CurrentMass General Brigham Health PlanPolicy N/A

DSNP Duals HCPCS/CPT code coverage list

Lists HCPCS/CPT codes that are covered, covered with prior authorization, covered without prior authorization, or reportable-only (not reimbursable) for DSNP Duals members of Mass General Brigham Health Plan.

Policy Summary

PayerMass General Brigham Health Plan

PolicyDSNP Duals HCPCS/CPT code coverage list

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization for listed HCPCS/CPT codes that require prior authorization before billing for DSNP Duals members.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~100+listed HCPCS/CPT codes and modifiers across sections

3coverage categories

DSNP Dualspopulation governed

Coverage Criteria for DSNP Duals

inv-01: Covered when prior authorized

Codes covered when prior authorized for DSNP Duals.

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ALL of the following

List
- C1607 — Neurostimulator, integrated (implantable), rechargeable with all implantable and external components including charging system.
- C1608 — Prosthesis, total, dual mobility, first carpometacarpal joint (implantable).
- C7570 — Catheter placement in coronary artery(s) for coronary angiography with intraprocedural coronary FFR with 3D functional mapping (list separately in addition to primary procedure).
- C7571 — Percutaneous transluminal coronary angioplasty with percutaneous transluminal coronary lithotripsy.
- C9810 — Water circulating motorized cold therapy device (non-opioid medical device; must be a qualifying Medicare non-opioid medical device for post-surgical pain relief per section 4135 of the CAA, 2023).
- C9811 — Electronic ambulatory infusion pump (non-opioid medical device; must be a qualifying Medicare non-opioid medical device for post-surgical pain relief per section 4135 of the CAA, 2023).
- C9812 — Echogenic nerve block needles (non-opioid medical device; must be a qualifying Medicare non-opioid medical device for post-surgical pain relief per section 4135 of the CAA, 2023).
- C9813 — Perforated continuous infusion catheter set (non-opioid medical device; must be a qualifying Medicare non-opioid medical device for post-surgical pain relief per section 4135 of the CAA, 2023).
- C9814 — Continuous anesthesia echogenic conduction catheter set (non-opioid medical device; must be a qualifying Medicare non-opioid medical device for post-surgical pain relief per section 4135 of the CAA, 2023).
- C9815 — Linear peristaltic pain management infusion pump and disposable components (non-opioid medical device; must be a qualifying Medicare non-opioid medical device for post-surgical pain relief per section 4135 of the CAA, 2023).
- C9816 — Rotary peristaltic infusion pump, including disposable components (reusable non-opioid medical device; must be a qualifying Medicare non-opioid medical device for post-surgical pain relief per section 4135 of the CAA, 2023).
- C9817 — Electronic cryo-pneumatic compression pain management system, including control unit and wraps (non-opioid medical device; must be a qualifying Medicare non-opioid medical device for post-surgical pain relief per section 4135 of the CAA, 2023).
- G0571 — Intraoperative nerve(s) cryoablation for post-surgical pain relief (list separately in addition to primary service).
- Q4398 — Summit AC, per square centimeter (add-on, list separately in addition to primary procedure).
- Q4399 — Summit FX, per square centimeter (add-on, list separately in addition to primary procedure).
- Q4400 — Polygon3 membrane, per square centimeter (add-on, list separately in addition to primary procedure).
- Q4401 — Absolv3 membrane, per square centimeter (add-on, list separately in addition to primary procedure).
- Q4402 — Xwrap 2.0, per square centimeter (add-on, list separately in addition to primary procedure).
- Q4403 — Xwrap dual plus, per square centimeter (add-on, list separately in addition to primary procedure).
- Q4404 — Xwrap hydro plus, per square centimeter (add-on, list separately in addition to primary procedure).
- Q4405 — Xwrap fenestra plus, per square centimeter (add-on, list separately in addition to primary procedure).
- Q4406 — Xwrap fenestra, per square centimeter (add-on, list separately in addition to primary procedure).
- Q4407 — Xwrap tribus, per square centimeter (add-on, list separately in addition to primary procedure).
- Q4408 — Xwrap hydro, per square centimeter (add-on, list separately in addition to primary procedure).
- Q4409 — AmniomatrixF3X, per square centimeter (add-on, list separately in addition to primary procedure).
- Q4410 — AmchomatrixDL, per square centimeter (add-on, list separately in addition to primary procedure).
- Q4411 — AmniomatrixF4X, per square centimeter (add-on, list separately in addition to primary procedure).
- Q4412 — Choriofix, per square centimeter (add-on, list separately in addition to primary procedure).
- Q4413 — Cygnus Solo, per square centimeter (add-on, list separately in addition to primary procedure).
- Q4414 — SimpliChor, per square centimeter (add-on, list separately in addition to primary procedure).
- Q4415 — Alexiguard SL-T, per square centimeter (add-on, list separately in addition to primary procedure).
- Q4416 — Alexiguard TL-T, per square centimeter (add-on, list separately in addition to primary procedure).
- Q4417 — Alexiguard DL-T, per square centimeter (add-on, list separately in addition to primary procedure).
- Q4420 — Nuform, per square centimeter (add-on, list separately in addition to primary procedure).
- Q4431 — PMA skin substitute product, not otherwise specified (list in addition to primary procedure).
- Q4432 — 510(k) skin substitute product, not otherwise specified (list in addition to primary procedure).
- Q4433 — 361 HCT/P skin substitute product, not otherwise specified (list in addition to primary procedure).

inv-03: Reportable only (not reimbursable)

Codes covered with no prior authorization required for DSNP Duals.

ALL of the following

List
- A4295 — Intermittent urinary catheter; straight tip, hydrophilic coating, each.
- A4296 — Intermittent urinary catheter; coude (curved) tip, hydrophilic coating, each.
- A4297 — Intermittent urinary catheter; hydrophilic coating, with insertion supplies.
- C7566 — Arthrodesis, interphalangeal joints, with or without internal fixation, with autografts (includes obtaining grafts).
- C7567 — Bronchoscopy with transbronchial needle aspiration biopsy(s) with computer-assisted image-guided navigation.
- C7568 — Catheter placement in coronary artery(ies) for coronary angiography with intravascular Doppler velocity and/or pressure-derived coronary flow reserve measurement (initial vessel or graft).
- C7569 — Percutaneous transluminal coronary angioplasty with endoluminal imaging using IVUS or OCT during evaluation/intervention.
- C9176 — Tc-99m from domestically produced non-HEU Mo-99 add-on, per study dose.
- G0568 — Initial psychiatric collaborative care management (first calendar month) with required elements including outreach, assessment, registry enrollment, and treatment planning.
- G0569 — Subsequent psychiatric collaborative care management (subsequent month) with required elements including registry tracking, weekly consultation, and brief interventions.
- G0570 — Care management services for behavioral health conditions, per calendar month (list separately in addition to advanced primary care management).
- G9871 — Behavioral counseling for diabetes prevention, online, 60 minutes.

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CPT / HCPCS Coding Lists

Prior authorization covered codes (sample)HCPCSCovered

C1607	Neurostimulator, integrated (implantable), rechargeable with all implantable and external components including charging system
C1608	Prosthesis, total, dual mobility, first carpometacarpal joint (implantable)
C7570	Catheter placement in coronary artery(s) for coronary angiography...with intraprocedural coronary fractional flow reserve (FFR) with 3D functional mapping
C7571	Percutaneous transluminal coronary angioplasty, single major coronary artery or branch with percutaneous transluminal coronary lithotripsy
C9810	Water circulating motorized cold therapy device (e.g., iceman) including all system components, non-opioid medical device (must be a qualifying Medicare non-opioid medical device for post-surgical pain relief in accordance with section 4135 of the CAA, 2023)
C9811	Electronic ambulatory infusion pump (e.g., sapphire pump), including all pump components, including disposable components, non-opioid medical device (must be a qualifying Medicare non-opioid medical device for post-surgical pain relief in accordance with section 4135 of the CAA, 2023)
C9812	Echogenic nerve block needles (e.g., sonoplex, sonoblock, sonotap), non-opioid medical device (must be a qualifying Medicare non-opioid medical device for post-surgical pain relief in accordance with section 4135 of the CAA, 2023)

No prior authorization required - coveredHCPCSCovered

A4295	Intermittent urinary catheter; straight tip, hydrophilic coating, each
A4296	Intermittent urinary catheter; coude (curved) tip, hydrophilic coating, each
A4297	Intermittent urinary catheter; hydrophilic coating, with insertion supplies
G0568	Initial psychiatric collaborative care management
G0569	Subsequent psychiatric collaborative care management

Provider Actions and Billing Guidance

Prior Authorization

Prior authorization required for listed covered services

The following HCPCS/CPT codes are covered only when prior authorization has been obtained for DSNP Duals members: C1607, C1608, C7570, C7571, C9810–C9817, G0571, Q4398–Q4401, Q4402–Q4417, Q4420, Q4431–Q4433. Prior authorization is required because these services are listed under “Covered when prior authorized for DSNP Duals.”

Includes non-opioid medical devices C9810–C9817 which must be qualifying Medicare non-opioid medical devices per section 4135 of the CAA, 2023.
Includes add-on and skin substitute product codes that must be listed separately in addition to the primary procedure.

Billing Rule

No prior authorization required for listed covered services

The following HCPCS/CPT codes are covered for DSNP Duals members without prior authorization: A4295, A4296, A4297, C7566–C7569, C9176, G0568–G0570, G9871. These services are explicitly listed as “Covered with no prior authorization required for DSNP Duals.”

Behavioral health care management codes (G0568, G0569, G0570) include required elements such as initial assessment, registry enrollment, weekly caseload consultation, and documentation as described in the code descriptors.
A4295–A4297 are intermittent urinary catheter codes covered without prior authorization.

Documentation Required

Reportable-only codes — must be reported but not reimbursed

The codes listed under “Reportable only, not reimbursable for DSNP Duals” must still be reported on claims but are not reimbursable (examples include G0660–G0668, M1426–M1503 series and many M1xxx codes). Providers must report these codes where applicable, recognizing they will not trigger reimbursement.

Examples: Team remote E/M codes (G0660–G0668) and multiple M14xx–M15xx measures are reportable-only.
Reportable-only codes include telehealth encounter indicators (e.g., M1426, M1431–M1432, M1436–M1437) and numerous measure-status codes (M1459–M1503).

Definitions and Code Notes

Qualifying Medicare non-opioid medical device

HCPCS codes designated as qualifying Medicare non-opioid medical devicesC9810, C9811, C9812, C9813, C9814, C9815, C9816, C9817 (each must be a qualifying Medicare non-opioid medical device for post-surgical pain relief per section 4135 of the CAA, 2023)

Additional related procedure codeG0571 — Intraoperative nerve(s) cryoablation for post-surgical pain relief (list separately in addition to code for primary service)

Examples of device descriptionsC9810 = Water circulating motorized cold therapy device; C9811 = Electronic ambulatory infusion pump; C9812 = Echogenic nerve block needles

Pump and infusion device examplesC9815 = Linear peristaltic pain management infusion pump; C9816 = Rotary peristaltic infusion pump (reusable)

Cryo-compression system exampleC9817 = Electronic cryo-pneumatic compression pain management system (includes control unit and wraps)

Reportable only

DefinitionReportable-only codes are codes that must be reported for DSNP Duals but are not reimbursable under this policy.

Examples — team-based remote E/M codesG0660, G0661, G0662, G0663, G0664, G0665, G0666, G0667, G0668 (team remote E/M codes for new and established patients)

Examples — telehealth/documentation encounter codesM1426, M1431, M1432 (encounters conducted via telehealth) and other M-series reporting codes listed

Provider actionThese codes should be reported for documentation/quality reporting purposes only and will not result in reimbursement under DSNP Duals coverage