Mass General Brigham MA coding Coverage & Prior Auth

Representative codes and device qualification

Covered with prior authorizationmixedCovered

C1607	Neurostimulator, integrated (implantable), rechargeable with all implantable and external components including charging system.
C1608	Prosthesis, total, dual mobility, first carpometacarpal joint (implantable).
C7566	Arthrodesis, interphalangeal joints, with or without internal fixation, with autografts (includes obtaining grafts).
C7570	Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation with intraprocedural coronary fractional flow reserve (ffr) with 3d functional mapping of color-coded ffr values for the coronary tree, derived from coronary angiogram data, for real-time review and interpretation of possible atherosclerotic stenosis(es) intervention (list separately in addition to code for primary procedure).
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 (e.g. pads, console, disposable parts), 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).
C9813	Perforated continuous infusion catheter set (e.g. infiltralong), including all 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).
C9814	Continuous anesthesia echogenic conduction catheter set (e.g. sonolong), 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).

1–10 of 38

1/4

Covered without prior authorizationmixedCovered

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.
C7567	Bronchoscopy, rigid or flexible, including fluoroscopic guidance when performed, with transbronchial needle aspiration biopsy(s), trachea, main stem and/or lobar bronchus(i), with computer-assisted image-guided naviagation.
C7568	Catheter placement in coronary artery(ies) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation, with intravascular doppler velocity and/or pressure derived coronary flow reserve measurement (initial coronary vessel or graft) during coronary angiography including pharmacologically induced stress.
C7569	Percutaneous transluminal coronary angioplasty, single major coronary artery or branch with endoluminal imaging of initial coronary vessel or graft using intravascular ultrasound (ivus) or optical coherence tomography (oct) during diagnostic evaluation and/or therapeutic intervention including imaging supervision, interpretation and report.
C9176	Tc-99m from domestically produced non-heu mo-99, [minimum 50 percent], full cost recovery add-on, per study dose.
G0568	Initial psychiatric collaborative care management, in the first calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional, with the following required elements: outreach to and engagement in treatment of a patient directed by the treating physician or other qualified health care professional, initial assessment of the patient, including administration of validated rating scales, with the development of an individualized treatment plan, review by the psychiatric consultant with modifications of the plan if recommended, entering patient in a registry and tracking patient follow-up and progress.

Reportable only (not reimbursable)mixed

G0660	Team remote e/m new pt 10mins.
G0661	Team remote e/m new pt 20mins.
G0662	Team remote e/m new pt 30 mins.
G0663	Team remote e/m new pt 45mins.
G0664	Team remote e/m new pt 60mins.
G0665	Team remote e/m est. pt 10mins.
G0666	Team remote e/m est. pt 15mins.
G0667	Team remote e/m est. pt 25mins.
G0668	Team remote e/m est. pt 40mins.
M1426	Encounters conducted via telehealth.

1–10 of 17

1/2

inv-03: Non-opioid device qualification

RequirementC98xx codes listed (e.g., C9810–C9817) must be a qualifying Medicare non-opioid medical device for post-surgical pain relief in accordance with section 4135 of the Consolidated Appropriations Act, 2023.

Example codesC9810 (water circulating motorized cold therapy device), C9811 (electronic ambulatory infusion pump), C9812 (echogenic nerve block needles).

Additional examplesC9814 (continuous anesthesia echogenic conduction catheter set), C9815 (linear peristaltic infusion pump), C9816 (rotary peristaltic infusion pump), C9817 (electronic cryo-pneumatic compression pain management system).

Prior authorization, billing, and reporting actions for providers

Prior Authorization

Covered with prior authorization (partial list)

Covered with prior authorization required for Medicare Advantage: C1607, 1 = Neurostimulator, integrated (implantable), rechargeable with all implantable and external components including charging system. C1608, 1 = Prosthesis, total, dual mobility, first carpometacarpal joint (implantable). C7566, 1 = Arthrodesis, interphalangeal joints, with or without internal fixation, with autografts (includes obtaining grafts). C7570, 1 = Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation with intraprocedural coronary fractional flow reserve (FFR) with 3D functional mapping of color-coded FFR values for the coronary tree, derived from coronary angiogram data, for real-time review and interpretation of possible atherosclerotic stenosis(es) intervention (list separately in addition to code for primary procedure). C7571, 1 = Percutaneous transluminal coronary angioplasty, single major coronary artery or branch with percutaneous transluminal coronary lithotripsy. C9810, 1 = Water circulating motorized cold therapy device (e.g., iceman) including all system components (e.g. pads, console, disposable parts), 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, 1 = 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, 1 = 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). C9813, 1 = Perforated continuous infusion catheter set (e.g. InfiltraLong), including all 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).

C1607
C1608
C7566
C7570
C7571
C9810
C9811
C9812
C9813

Prior Authorization

Covered with prior authorization (continued)

Covered with prior authorization required for Medicare Advantage (continued): C9814, 1 = Continuous anesthesia echogenic conduction catheter set (e.g. Sonolong), 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). C9815, 1 = Linear peristaltic pain management infusion pump (e.g. CADD-Solis ambulatory infusion pump), and all disposable 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). C9816, 1 = Rotary peristaltic infusion pump (e.g., reusable Ambit pump) including all disposable system components, reusable 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). C9817, 1 = Electronic cryo-pneumatic compression, pain management system (e.g. Game Ready GRPro 2.1 system), including control unit, anatomically correct wrap(s), and other system component(s), 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). G0571, 1 = Intraoperative nerve(s) cryoablation for post-surgical pain relief (list separately in addition to code for primary service).

C9814
C9815
C9816
C9817
G0571

Prior Authorization

Covered with prior authorization (Q-codes skin substitutes)

Covered with prior authorization required for Medicare Advantage: Q4398, 1 = Summit AC, per square centimeter (add-on, list separately in addition to primary procedure). Q4399, 1 = Summit FX, per square centimeter (add-on, list separately in addition to primary procedure). Q4400, 1 = Polygon3 membrane, per square centimeter (add-on, list separately in addition to primary procedure). Q4402, 1 = Xwrap 2.0, per square centimeter (add-on, list separately in addition to primary procedure). Q4403, 1 = Xwrap Dual Plus, per square centimeter (add-on, list separately in addition to primary procedure). Q4404, 1 = Xwrap Hydro Plus, per square centimeter (add-on, list separately in addition to primary procedure). Q4405, 1 = Xwrap Fenestra Plus, per square centimeter (add-on, list separately in addition to primary procedure). Q4406, 1 = Xwrap Fenestra, per square centimeter (add-on, list separately in addition to primary procedure). Q4407, 1 = Xwrap Tribus, per square centimeter (add-on, list separately in addition to primary procedure). Q4408, 1 = Xwrap Hydro, per square centimeter (add-on, list separately in addition to primary procedure). Q4409, 1 = AmniomatrixF3X, per square centimeter (add-on, list separately in addition to primary procedure). Q4410, 1 = AmniomatrixDL, per square centimeter (add-on, list separately in addition to primary procedure). Q4411, 1 = AmniomatrixF4X, per square centimeter (add-on, list separately in addition to primary procedure). Q4412, 1 = ChorioFix, per square centimeter (add-on, list separately in addition to primary procedure). Q4413, 1 = Cygnus Solo, per square centimeter (add-on, list separately in addition to primary procedure). Q4414, 1 = SimpliChor, per square centimeter (add-on, list separately in addition to primary procedure). Q4415, 1 = AlexiGuard SL-T, per square centimeter (add-on, list separately in addition to primary procedure). Q4416, 1 = AlexiGuard TL-T, per square centimeter (add-on, list separately in addition to primary procedure). Q4417, 1 = AlexiGuard DL-T, per square centimeter (add-on, list separately in addition to primary procedure). Q4420, 1 = NuForm, per square centimeter (add-on, list separately in addition to primary procedure).

Note

Covered without prior authorization

Covered with no prior authorization required for Medicare Advantage: A4295, 1 = Intermittent urinary catheter; straight tip, hydrophilic coating, each. A4296, 1 = Intermittent urinary catheter; coude (curved) tip, hydrophilic coating, each. A4297, 1 = Intermittent urinary catheter; hydrophilic coating, with insertion supplies. C7567, 1 = Bronchoscopy, rigid or flexible, including fluoroscopic guidance when performed, with transbronchial needle aspiration biopsy(s), trachea, main stem and/or lobar bronchus(es), with computer-assisted image-guided navigation. C7568, 1 = Catheter placement in coronary artery(ies) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation, with intravascular Doppler velocity and/or pressure derived coronary flow reserve measurement (initial coronary vessel or graft) during coronary angiography including pharmacologically induced stress. C7569, 1 = Percutaneous transluminal coronary angioplasty, single major coronary artery or branch with endoluminal imaging of initial coronary vessel or graft using intravascular ultrasound (IVUS) or optical coherence tomography (OCT) during diagnostic evaluation and/or therapeutic intervention including imaging supervision, interpretation and report. C9176, 1 = Tc-99m from domestically produced non-HEU Mo-99, [minimum 50 percent], full cost recovery add-on, per study dose. G0568, 1 = Initial psychiatric collaborative care management, in the first calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional, with the following required elements: outreach to and engagement in treatment of a patient directed by the treating physician or other qualified health care professional, initial assessment of the patient, including administration of validated rating scales, with the development of an individualized treatment plan, review by the psychiatric consultant with modifications of the plan if recommended, entering patient in a registry and tracking patient follow-up and progress.

A4295
A4296

Documentation Required

Reportable-only (not reimbursable)

Reportable only, not reimbursable for Medicare Advantage: G0660, 1 = Team remote E/M new pt 10 mins. G0661, 1 = Team remote E/M new pt 20 mins. G0662, 1 = Team remote E/M new pt 30 mins. G0663, 1 = Team remote E/M new pt 45 mins. G0664, 1 = Team remote E/M new pt 60 mins. G0665, 1 = Team remote E/M est. pt 10 mins. G0666, 1 = Team remote E/M est. pt 15 mins. G0667, 1 = Team remote E/M est. pt 25 mins. G0668, 1 = Team remote E/M est. pt 40 mins. M1426, 1 = Encounters conducted via telehealth. M1427, 1 = Documentation of medical reason(s) for performing a bone scan (including documented pain related to prostate cancer, salvage therapy, other medical reasons). M1428, 1 = Patients who have bilateral absence of eyes any time during the patient's history through the end of the measurement period. M1429, 1 = Retinal exam finding with evidence of retinopathy in left, right or both eyes with severity level documented. M1430, 1 = Retinal exam finding without evidence of retinopathy in both eyes with severity level documented (in measurement year or in the prior year). M1431, 1 = Encounters conducted via telehealth. M1432, 1 = Encounters conducted via telehealth. M1433, 1 = Patient on oral chemotherapy on or within 30 days before denominator eligible encounter.

G0660
G0661
G0662
G0663
G0664
G0665
G0666
G0667
G0668

OpenPayer

Medicare Advantage coding coverage and reporting list

Coverage stances and applicability

Representative codes and device qualification

Prior authorization, billing, and reporting actions for providers

Terminology and statutory references