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    v1.0.30
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyDC Medicaid EAPG Never-Pay Coverage | OpenPayer
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    CurrentDistrict of Columbia Department of Health Care FinancePolicy DCO19018

    DC Medicaid EAPG Never Pay List

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    This document lists HCPCS procedures that are designated as not used or never payable under the District of Columbia Medicaid EAPG payment system. It applies to providers billing DC Medicaid under EAPG Grouper Version 3.13, effective October 1, 2019.

    Policy Summary
    PayerDistrict of Columbia Department of Health Care Finance
    PolicyDC Medicaid EAPG Never Pay List
    Policy CodePolicy DCO19018
    Change TypeNo material change
    Effective DateOctober 1, 2019
    Next Review DateN/A
    Key ActionDo not submit or expect payment for HCPCS procedures designated on the DC Medicaid EAPG List of Not Used / Never Pay Procedures.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    2019-10-01Effective date
    3.13EAPG grouper
    Never payPayment status
    HCPCS T-codesCode system
    4 pagesDocument length

    DC Medicaid EAPG Never-Pay Determination

    Never-Pay Procedure Determination

    A procedure is subject to the DC Medicaid EAPG never-pay determination when the billed HCPCS code appears on the DC EAPGs List of Not Used / Never Pay Procedures.

    ALL of the following

    • The procedure is reported with an HCPCS code.
    • The HCPCS code appears on the DC EAPGs List of Not Used / Never Pay Procedures.
    • The list is effective October 1, 2019, for EAPG Grouper Version 3.13.

    DC EAPG Never-Pay Procedure Criteria

    The DC EAPG never-pay rule applies based on the procedure’s inclusion on the applicable list, regardless of the procedure description shown in the source list.

    ALL of the following

    Policy Summary
    PayerDistrict of Columbia Department of Health Care Finance
    PolicyDC Medicaid EAPG Never Pay List
    Policy CodePolicy DCO19018
    Change TypeNo material change
    Effective DateOctober 1, 2019
    Next Review DateN/A
    Key ActionDo not submit or expect payment for HCPCS procedures designated on the DC Medicaid EAPG List of Not Used / Never Pay Procedures.
    SourceLink
    On This Page
    DC Medicaid EAPG Never-Pay DeterminationNever-Pay HCPCS Procedure ListBilling and Payment ImplicationsKey Terms
    • The procedure is identified by an HCPCS code on the claim.
    • That HCPCS code is included on the DC EAPGs List of Not Used / Never Pay Procedures.

    DC EAPG Not Used / Never Pay Procedures

    Procedures appearing on the DC EAPGs List of Not Used / Never Pay Procedures are not payable under the DC Medicaid EAPG outpatient hospital payment method.

    ALL of the following

    • The procedure appears on the DC EAPGs List of Not Used / Never Pay Procedures.
    • The procedure is billed under the DC Medicaid outpatient hospital EAPG payment method.
    • The procedure is not payable under that EAPG payment method.

    Payment Treatment for Listed Procedures

    For the DC Medicaid EAPG outpatient hospital payment method, inclusion on the not used / never pay list establishes that the procedure is not payable.

    ALL of the following

    • The billed HCPCS procedure code is included on the DC EAPGs List of Not Used / Never Pay Procedures.
    • The code is evaluated under the applicable DC Medicaid outpatient hospital EAPG payment method.
    • The listed procedure is not payable through the EAPG payment method.

    Never-Pay HCPCS Procedure List

    Never-pay HCPCS procedures, codes 0042T–0212THCPCSNot Covered
    0042TCT perfusion with contrast, cerebral blood flow
    0058TCryopreservation of ovarian tissue
    0071TUltrasound ablation of uterine leiomyomata, less than 200
    0072TUltrasound ablation of uterine leiomyomata, greater than 200
    0085TBreath test for heart rejection
    0100TProsthetic retina, receipt and generation
    0101TExtracorporeal shock wave therapy, high energy
    0102TExtracorporeal shock wave therapy, anesthesia
    0106TQuantitative touch sensory testing
    0107TQuantitative vibration sensory testing
    1–10 of 26
    1/3
    Never-pay HCPCS procedures, codes 0213T–0265THCPCSNot Covered
    0213TParavertebral injection with ultrasound, cervical/thoracic
    0214TParavertebral injection with ultrasound, cervical/thoracic
    0215TParavertebral injection with ultrasound, cervical/thoracic
    0216TParavertebral injection with ultrasound, lumbar/sacral
    0217TParavertebral injection with ultrasound, lumbar/sacral
    0218TParavertebral injection with ultrasound, lumbar/sacral
    0221TPlacement of posterior facet implant, lumbar
    0222TAdditional posterior facet implant
    0228TTransforaminal epidural injection with ultrasound, cervical/thoracic
    0229TTransforaminal epidural injection with ultrasound, cervical/thoracic
    1–10 of 24
    1/3
    Never-pay HCPCS procedures, codes 0266T–0342THCPCSNot Covered
    0266TImplant or replacement of cardiac sensory device, total
    0267TImplant or replacement of cardiac sensory device, lead
    0268TImplant or replacement of cardiac sensory device, generator
    0269TRevision or removal of cardiac sensory device, total
    0270TRevision or removal of cardiac sensory device, lead
    0271TRevision or removal of cardiac sensory device, generator
    0272TInterrogation of cardiac sensory device
    0273TInterrogation of cardiac sensory device with programming
    0274TPercutaneous laminotomy/laminectomy, cervical/thoracic
    0275TPercutaneous laminotomy/laminectomy, lumbar
    1–10 of 31
    1/4
    Never-pay HCPCS procedures, codes 0347T–0386THCPCSNot Covered
    0347TInsertion of bone device for RSA
    0348TRSA spine examination
    0349TRSA upper extremity examination
    0350TRSA lower extremity examination
    0355TGastrointestinal tract capsule endoscopy
    0356TInsertion of drug delivery device for intraocular pressure
    0357TCryopreservation of oocyte(s)
    0358TBioelectrical impedance analysis, whole body
    0376TInsertion of anterior segment drainage device
    0377TAnoscopy with injection agent for incontinence
    1–10 of 19
    1/2
    Never-pay HCPCS procedures, codes 0394T–0399THCPCSNot Covered
    0394THDR electronic skin surface brachytherapy
    0395THDR electronic interstitial/intercavitary brachytherapy
    0397TERCP with optical endomicroscopy
    0398TMR-guided focused ultrasound ablation of a malignant stricture lesion
    0399TMyocardial strain imaging
    Procedures listed as not used or never payHCPCSNot Covered
    0384TEx h rate sz 30 day ri only
    0385TEx h rate for sz ovr 30 day
    0386TEx h rate sz 30+ day ri only
    0394THdr elctrnc skn surf brchytx
    0395THdr elctr ntrst/ntrcv brchtx
    0397TErcp w/optical endomicroscpy
    0398TMrgfus strtctc les abltj
    0399TMyocardial strain imaging
    0400TMltispectrl digital les alys
    0401TMltispectrl digital les alys
    1–10 of 13
    1/2
    Cardiac modulation system proceduresHCPCSNot Covered
    0408TInsj/rplc cardiac modulj sys
    0409TInsj/rplc car modulj pls gn
    0410TInsj/rplc car modulj atr elt
    0411TInsj/rplc car modulj vnt elt
    0412TRmvl cardiac modulj pls gen
    0413TRmvl car modulj tranvns elt
    0414TRmvl & rpl car modulj pls gn
    Cardiac, diagnostic, prostate, breast imaging, and apnea proceduresHCPCSNot Covered
    0415TRepos car modulj tranvns elt
    0416TReloc skin pocket pls gen
    0417TPrgrmg eval cardiac modulj
    0418TInterro eval cardiac modulj
    0419TDstrj neurofibroma xtnsv
    0420TDstrj neurofibroma xtnsv
    0421TWaterjet prostate abltj cmpl
    0422TTactile breast img uni/bi
    0423TAssay secretory type ii pla2
    0424TInsj/rplc nstim apnea compl
    1–10 of 12
    1/2
    Neurostimulator apnea and cardiac imaging proceduresHCPCSNot Covered
    0427TInsj/rplc nstim apnea pls gn
    0428TRmvl nstim apnea pls gen
    0429TRmvl nstim apnea sen ld
    0430TRmvl nstim apnea stimj ld
    0431TRmvl/rplc nstim apnea pls gn
    0432TRepos nstim apnea stimj ld
    0433TRepos nstim apnea sensing ld
    0434TInterro eval npgs apnea
    0435TPrgrmg eval npgs apnea 1 ses
    0436TPrgrmg eval npgs apnea study
    1–10 of 11
    1/2
    Nerve ablation, prostate tissue analysis, glucose sensor, and aqueous drainage proceduresHCPCSNot Covered
    0440TAbltj perc uxtr/perph nrv
    0441TAbltj perc lxtr/perph nrv
    0442TAbltj perc plex/trncl nrv
    0443TR-t spctrl alys prst8 tiss
    0446TInsj impltbl glucose sensor
    0447TRmvl impltbl glucose sensor
    0448TRemvl insj impltbl gluc sens
    0449TInsj aqueous drain dev 1st
    0450TInsj aqueous drain dev each
    Electrode, interface, aqueous drainage, and aortic ventricular device proceduresHCPCSNot Covered
    0453TInsj/rplcmt mech-elec ntrfce
    0454TInsj/rplcmt subq electrode
    0457TRemvl mech-elec skin ntrfce
    0458TRemvl subq electrode
    0460TRepos aortic ventr dev eltrd
    DC EAPGs list of not used / never pay proceduresCPTNot Covered
    0449TInsj aqueous drain dev 1st
    0450TInsj aqueous drain dev each
    0453TInsj/rplcmt mech-elec ntrfce
    0454TInsj/rplcmt subq electrode
    0457TRemvl mech-elec skin ntrfce
    0458TRemvl subq electrode
    0460TRepos aortic ventr dev eltrd
    0462TPrgrmg eval aortic ventr sys
    0463TInterrog aortic ventr sys
    0464TVisual ep test for glaucoma
    1–10 of 19
    1/2
    DC EAPG not used/never pay procedures 0467T–0471TCPTNot Covered
    0467TRevision/replacement of chest respiratory electrode
    0468TRemoval of chest wall respiratory electrode/array
    0469TRetinal polarization scan, optical coherence scan, bilateral
    0470TOcular skin imaging and acquisition, interpretation and report, first
    0471TOcular skin imaging and acquisition, interpretation and report, each additional
    DC EAPG not used/never pay procedures 0472T–0476TCPTNot Covered
    0472TProgramming of right atrial electronic device
    0473TReprogramming of right atrial electronic device
    0474TInsertion of aqueous drainage device into reservoir
    0475TRecording fetal cardiac single 3-channel interpretation and report
    0476TRecording fetal cardiac single electronic tracing data
    DC EAPG not used/never pay procedures 0477T–0478TCPTNot Covered
    0477TRecording fetal cardiac single X-ray tomography analysis
    0478TRecording fetal cardiac three-channel review and interpretation
    DC EAPG not used/never pay procedures 0479T–0480TCPTNot Covered
    0479TFractional laser ablation, first 100 square centimeters
    0480TFractional laser ablation, each additional 100 square centimeters
    DC EAPG not used/never pay procedures 0481T–0482TCPTNot Covered
    0481TNoninvasive autologous white blood cell concentrate
    0482TAbsolute quantification of myocardial blood flow by PET
    DC EAPG not used/never pay procedures 0485T–0486TCPTNot Covered
    0485TOtoendoscopy of middle ear, unilateral
    0486TOtoendoscopy of middle ear, bilateral
    Initial procedures in the DC EAPG list of not used or never pay proceduresHCPCSNot Covered
    0478TRec ftl car 3 ch rev i&r
    0479TFxjl abl lsr 1st 100 sq cm
    0480TFxjl abl lsr ea addl 100sqcm
    0481TNjx autol wbc concentrate
    0482TAbsl quan myocrd bld flo pet
    0485TOct mid ear i&r unilateral
    0486TOct mid ear i&r bilateral
    HCPCS procedures listed as not used or never payHCPCSNot Covered
    0487TTrvg biomchn mapg w/reprt
    0488TDiabetes prev online/elec
    0489TRegn cell tx scldr hands
    0490TRegn cell tx scldr h mlt inj
    0491TAbl lsr opn wnd 1st 20 sqcm
    0492TAbl lsr opn wnd addl 20 sqcm
    0493TNear ifr spectrsc of wounds
    0497TXtrnl pt act ecg in-off conn
    0498TXtrnl pt act ecg r&i pr 30 d
    0499TCysto f/urtl strix/stenosis
    1–10 of 24
    1/3
    HCPCS procedures listed as not used or never payHCPCSNot Covered
    0515TInsj wcs lv compl sys
    0516TInsj wcs lv eltrd only
    0517TInsj wcs lv pg compnt
    0518TRmvl pg compnt wcs
    0519TRmvl & rplcmt pg compnt wcs
    0520TRmvl&rplcmt pg wcs new eltrd
    0521TInterrog dev eval wcs ip
    0522TPrgrmg dev eval wcs ip
    0524TEv cath dir chem abltj w/img
    0525TInsj/rplcmt compl iims
    1–10 of 23
    1/3
    Coding
    EAPG grouper version3.13
    Payment systemDistrict of Columbia Medicaid EAPG payment system
    FunctionUsed for EAPG grouping
    Coding
    Effective dateOctober 1, 2019
    DocumentDC Medicaid EAPG Never Pay List
    Control log numberDCO19018

    Billing and Payment Implications

    Billing Rule

    DC EAPG Never-Pay Procedures: Do Not Bill as Payable

    Under the DC Medicaid outpatient hospital EAPG payment method, providers must not submit designated HCPCS procedures on the DC EAPG Never Pay List as payable services and should not expect reimbursement for them. Apply the list effective October 1, 2019, using EAPG Grouper Version 3.13, and verify each procedure against the complete list before billing.

    • The list identifies procedures defined by the District of Columbia Health Care Finance as not used/never pay under DC EAPGs.
    • Do not bill listed procedures as payable EAPG services; payment is not expected for those procedures.
    • The source list includes HCPCS procedures reported with Category III codes, including examples such as 0042T, 0058T, 0071T, 0274T, 0395T, 0415T, 0460T, 0474T, 0486T, 0500T, 0537T, 0540T, 0541T, and 0542T. Consult the complete DC Medicaid list for all designated codes.

    Key Terms

    Definitions
    DesignationA procedure identified in the DC EAPG list as not used or never pay
    Payment statusNot payable under the listed DC EAPG payment designation
    Code basisThe procedure is identified by its HCPCS code on the list
    Definitions
    DesignationProcedures designated by the DC EAPG list as not used or never pay
    Reimbursement statusNot payable under the applicable EAPG reimbursement logic
    ApplicationApplies when the procedure appears on the DC EAPG list
    Definitions
    List ownerDistrict of Columbia Health Care Finance
    List purposeIdentifies procedures designated as not used or never pay
    Payment methodEAPG outpatient hospital payment method
    Definitions
    SoftwareProprietary computer software
    Owner and licensor3M Company
    PurposeUsed for EAPG grouping