Highmark Medical Policy Bulletin

Section: Visits
Number: V-31
Topic: Medical Visits and Associated Services
Effective Date: January 1, 2003
Issued Date: January 13, 2003
Date Last Reviewed:

General Policy Guidelines

The services on the Text Attachment are considered an integral part of a doctor's medical or surgical care. They are not eligible as distinct and separate services when performed with medical or surgical care.

Procedure Codes

158521725020500206902110029130
291312920029220292402926029280
295202953029540295502958029590
315023150532005354003600036410
437524660050688542355445057150
571605835065430692108716887169
910609112392100922609250492511
947609476194762958319583295833
958349585195852958759690299050
990529905499056990709917299173
993549935599356993579935899359
993749937599377993789937999380
G0179G0180G0181G0182G0268G0272
S0395S0820S9092S9441S9474 

Traditional (UCR/Fee Schedule) Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Code 92260 may be paid in addition to medical care reported on the same day.

Also refer to General Policy Guidelines

Comprehensive/Wraparound/PPO Guidelines

Refer to General Policy Guidelines

Managed Care (HMO/POS) Guidelines

Refer to General Policy Guidelines

Publications

References

View Previous Versions

[Version 006 of V-31]
[Version 005 of V-31]
[Version 004 of V-31]
[Version 003 of V-31]
[Version 002 of V-31]
[Version 001 of V-31]

Table Attachment


Text Attachment

Services

  1. Administration of IV Innovar
  2. Amsler Grid Test
  3. Analysis of data from Swan-Ganz Catheterization
  4. Anoscopy without biopsy (46600)
  5. Angioscopy (non-coronary vessels or grafts) during therapeutic intervention (35400)
  6. Application of external fixation system (20690)
  7. Application of halo type appliance for maxillofacial fixation, includes removal (21100)
  8. Application of splint (29130-29131)
  9. Application of traction, suspension, or corrective appliance (non-fracture care)
  10. Asthma education, non-physician provider, per session (S9441)
  11. Blood pressure check
  12. Blue field entoptoscopic exam
  13. Breast exam
  14. Brightness Acuity Test
  15. Canalith repositioning procedure (a.k.a., Epley maneuvers, Otolith repositioning)(S9092)
  16. Care plan oversight services (99374-99380)
  17. Catheter site inspection by physician
  18. Changing of tubes
    1. connecting tube
    2. tracheostomy tube
    3. tracheotomy tube (31502)
    4. ureterostomy tube (50688)
  19. Chemical cauterization of granulation tissue (17250)
  20. Chemical pleurodesis (e.g., for recurrent or persistent pneumothorax) (32005)
  21. Corneal scrapings (65430)
  22. Corneal topography/corneal-assisted photokeratoscopy (S0820)
  23. Dressing change (for other than burns) under anesthesia (other than local) (15852)
  24. Ear/pulse oximetry (94760-94762)
  25. Enterostomal therapy (S9474)
  26. Eye tonometry (92100)
  27. Foreskin manipulation including lysis of preputial adhesions and stretching (54450)
  28. Gastric saline load test (91060)
  29. Grenz ray therapy
  30. Hydrotubation of oviduct (tubal lavage), including materials (58350)
  31. Impression casting of a foot performed by a practitioner other than the manufacturer of the orthotic (S0395)
  32. Injection of corpora cavernosa with pharmacologic agent(s), e.g., papaverine, phentolamine, etc. (54235)
  33. Injection of sinus tract (therapeutic) (20500)
  34. Insertion of pessary (57160)
  35. Irrigation and/or application of medicament for treatment of bacterial, parasitic, or fungoid disease (57150)
  36. IV therapy for severe or intractable allergic disease in physician's office or institution with theophyllines, corticosteroids, antihistamines (excludes cost of the drug)
  37. Laryngoscopy, indirect/mirror, without biopsy (31505)
  38. Laser interferometry or retinometry
  39. Macroscopic examination of arthropod or parasite (87168, 87169)
  40. Magnified penile surface scanning (penoscopy)
  41. Manual, gross visual fields
  42. Microscopic examination of hairs plucked or clipped by the examiner (excluding hair collected by the patient) to determine telogen and anagen counts, or structural hair shaft abnormality (96902)
  43. Miller-Nadler Glare Test
  44. Muscle testing (95831-95834, 95851-95852, 95875)
  45. Naso- or oro-gastric tube placement, necessitating physician's skill (43752, G0272)
  46. Nasopharyngolaryngoscopy (indirect)
  47. Nasopharyngoscopy (92511)
  48. Ophthalmodynamometry (92260)
  49. Otoscopy (no removal of foreign body)
  50. Phototherapy (for neonatal jaundice)
  51. Physician certification services for Medicare-covered services provided by a participating home health agency (patient not present)(G0180)
  52. Physician recertification services for Medicare-covered services provided by a participating home health agency (patient not present)(G0179)
  53. Physician supervision of a patient receiving Medicare-approved hospice (patient not present) requiring complex and multidisciplinary care modalities (G0182)
  54. Physician supervision of a patient receiving Medicare-covered services provided by a participating home health agency (patient not present) requiring complex and multidisciplinary care modalities (G0181)
  55. Placement of nasogastric feeding tube
  56. Potential acuity testing (visual)
    1. PAM (potential acuity meter)
    2. Guyton - Minkowski test
    3. visometer or retinometer
    4. macular integrity or electro-laser test
  57. Prolonged services (99354-99359)
  58. Prostatic massage
  59. Pulsed irrigation of fecal impaction (91123)
  60. Removal of cerumen (69210, G0268)
  61. Removal non-contraceptive pellets or capsules (FEP and Special Contracts Only-Noncovered under Standard Contracts)
  62. Rhinoscopy (no removal of foreign body)
  63. Schirmer test
  64. Screening test, visual acuity (99173)
  65. Slit lamp test (biomicroscopy, binocular microscopy and fluorescein staining) (92504)
  66. *Special Services (99050-99056)
  67. Starting of an IV (See MPB G-16 for information on starting of an IV under the chemotherapy benefit) (36000)
  68. Stat charges for laboratory services
  69. Strapping of joint, including flexible, gel, and soft casts (29200-29280, 29520-29590)
  70. Supplies and materials (except spectacles), provided by the physician over and above those usually included with the office visit or other services rendered (99070)
  71. Telemetry
  72. Tuning fork test
  73. Venipuncture (36410)
  74. Visual function screening, automated or semiautomated (99172)

Procedure Code Attachment


Glossary

TermDescription






Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.