Description:
The purpose of this policy to provide direction on procedure codes the Plan will not separately reimburse. This policy was in effect from dates of service January 1, 2019 through December 31, 2019.
Policy:
The procedure codes listed below are considered not separately reimbursed by The Plan.
Reimbursement for these services is inherently included in the global allowance for other services not specified. If submitted, these services will be rejected and non-billable to the Member.
| 15850 |
20936 |
22841 |
36000 |
36416 |
69209 |
69210 |
90863 |
90887 |
92260 |
| 92531 |
92532 |
92533 |
92921 |
92925 |
92929 |
92934 |
92938 |
92944 |
92971 |
| 93770 |
94005 |
94150 |
94760 |
94761 |
96902 |
97010 |
97602 |
99000 |
99001 |
| 99002 |
99024 |
99070 |
99078 |
99090 |
99172 |
99173 |
99340 |
99374 |
99377 |
| 99378 |
99379 |
99380 |
99483 |
99484 |
99487 |
99489 |
99490 |
99491 |
99492 |
| 99493 |
99494 |
A4220 |
A4262 |
A4263 |
A4270 |
A4300 |
A4550 |
A4556 |
A4557 |
| A4558 |
A4565 |
A4570 |
A4580 |
A4590 |
G0269 |
Q4001 |
Q4002 |
Q4003 |
Q4004 |
| Q4005 |
Q4006 |
Q4007 |
Q4008 |
Q4009 |
Q4010 |
Q4011 |
Q4012 |
Q4013 |
Q4014 |
| Q4015 |
Q4016 |
Q4017 |
Q4018 |
Q4019 |
Q4020 |
Q4021 |
Q4022 |
Q4023 |
Q4024 |
| Q4025 |
Q4026 |
Q4027 |
Q4028 |
Q4029 |
Q4030 |
Q4031 |
Q4032 |
Q4033 |
Q4034 |
| Q4035 |
Q4036 |
Q4037 |
Q4038 |
Q4039 |
Q4040 |
Q4041 |
Q4042 |
Q4043 |
Q4044 |
| Q4045 |
Q4046 |
Q4047 |
Q4048 |
Q4049 |
Q4050 |
Q4051 |
S0395 |
S3600 |
S3601 |
| S8450 |
S8451 |
S8452 |
S9110 |
