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MVP Health Care 2022 Payment Policies (selected sections)

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This document provides MVP Health Care's reimbursement and billing policies for multiple service areas (e.g., After-Hours, Allergy Testing and Serum Preparation, Evaluation and Management), including coding rules, reimbursement limits, and prior authorization/notification guidance for providers submitting claims to MVP.

Policy Summary

PayerMVP Health Care

PolicyMVP Health Care 2022 Payment Policies (selected sections)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJun 1, 2022

Last ReviewJun 1, 2022

Next Review DateMar 1, 2022

Key ActionProviders must check member eligibility and consult the Member Benefits Display and MVP Utilization Management Guides for prior authorization requirements.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4095165 first year (per claim)

16095165 first year (per year)

8095004 annual limit

1/dayOne E&M per day rule

Z23 reqImmunization billing

75%Audio-only reimbursement rate (VT)

Coverage Criteria and Clinical Billing Rules

E&M coverage criteria

Covered when ALL of the following are met:

Service is 'Medically Necessary' as defined by MVP/AMA/CMS (services necessary to prevent, diagnose, or treat illness and consistent with accepted standards).

Service is an Evaluation & Management (E&M) service reported with an appropriate E&M CPT code and supported by documentation meeting CMS 1995/1997 or 2021 Office and Other Outpatient Services guidelines.

Member eligibility and benefit specifics have been verified prior to providing the service.

Medical records support the level of service billed and may be requested for audit or medical review.

Allergy testing coverage criteria

Covered when ALL of the following are met:

Allergy testing and serum preparation services are medically necessary and ordered by an appropriate provider.

The claim specifies the number of units/tests/doses performed.

Unit limits

95165 (supervision of preparation/provision of antigens): First year limited to 40 units per claim and 160 units per calendar year; subsequent years limited to 30 units per claim and 120 units per calendar year.
95004 (percutaneous skin tests): Reimbursement limited to 80 units per calendar year.
95024 and 95027 (intradermal tests / sequential airborne tests): Reimbursement limited to 40 units per calendar year.
95028 (intracutaneous delayed reaction tests): Reimbursement limited to 30 units per calendar year.

Allergy injections (95115–95149 series) require modifier 25 and an accompanying E&M/Inpatient/ER visit to be reimbursed (per Modifier 25 policy).

After-Hours billing criteria

After-hours E/M codes may be billed only under the following conditions:

An after-hours CPT code (99050–99060) must be billed with an appropriate E&M code to be reimbursable.

After-hours codes (99051, 99053, 99056, 99058, 99060) are considered inclusive to the E&M and generally are not reimbursed separately for Commercial and Medicare products; 99051 may be reimbursed at Medicaid rate for Medicaid/HARP products as specified.

After-hours codes are not payable if they are the only CPT procedure(s) listed on the claim (must accompany an E&M).

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E&M reimbursement criteria

Reimbursed when ALL applicable rules below are satisfied:

Only one E&M CPT code is allowed per day per physician group per specialty.

Preventive medicine E&M codes (99381-99387, 99391-99397) are reimbursable, but certain office procedures listed (e.g., 99201-99215, selected diagnostic tests) performed same day are not reimbursed separately when done with a preventive visit.

Routine screening/lab procedures (e.g., G0102, 36415/36416, 99000/99001, Q0091, 92567) are not reimbursable separately on the same day as 99202-99215 when performed in-office unless they are the sole service or an external lab modifier (CG) is used as specified.

E&M services during a global surgical period are not reimbursed separately for major procedures unless the E&M addresses a significant, unrelated problem; modifier 24 must be appended for unrelated post-operative E&M.

Diabetes education codes (e.g., 98960) are reimbursed only when billed alone and will deny if billed with an E&M office visit (bundled).

Immunization administration codes (90460–90474, G0008–G0010) are reimbursed only when billed with diagnosis code Z23.

When two inpatient physician E&M codes are billed on the same date for the same/related condition by the same provider, the second E&M will be denied.

After-hours codes refer to the MVP After-Hours Payment Policy; 99050 is reimbursed unless submitted with preventive visit codes 99381-99397 as specified by contract.

Coverage criteria and billing rules

Provider reimbursement rules, limitations, and billing expectations (applies when listed conditions are met):

Inpatient: When two inpatient physician E&M codes are billed on the same date for the same/related condition by the same provider, the second E&M code will be denied.

Critical care (99291/99292): 99291 reimbursed only if ≥30 minutes; additional 99292 units are allowed per the defined time blocks (e.g., 75–104 minutes = one 99292). Procedures such as intubation or central line placement do NOT count toward critical care time and may be billed separately.

Arthroscopic/Endoscopic scope procedures within the same CPT family: highest RVU procedure reimbursed; payment for additional procedures follows Medicare methodology reducing payment for secondary procedures.

Split billing (Article 28): allowed only when billing entity meets Article 28 requirements (NY) or equivalent; Commercial/ASO and Exchange products are not eligible; this methodology combines professional and technical components as described in split billing rules.

Providers must verify member eligibility, benefits, and prior authorization requirements; MVP payment policies are not guarantees of payment.

Article 28 split billing criteria

Split billing (Article 28) is permitted only when ALL of the following conditions are met:

Billing entity is structured to meet Article 28 guidelines in New York or an equivalent standard in other states.

The arrangement is limited to Article 28 providers participating with MVP Medicare and/or Medicaid/Government programs (Medicaid Managed Care and Child Health Plus); Commercial/ASO and Exchange products are not eligible for split billing.

When billing under split billing, the hospital/facility bears employed provider expenses and receives the technical reimbursement while provider claims are submitted with a facility place of service (e.g., POS 22) rather than an office POS.

Procedure codes on the MVP In-Office Only list will not be reimbursed under split billing unless authorization is obtained; if authorized, reimbursement may be allowed for Medicare and Medicaid products.

If global reimbursement methodology is used (one bill combining professional and technical components), no additional payments will be made to facilities under split billing methodology.

Audiology coverage and billing rules

Audiology services are covered when the following conditions are met:

Services are performed for prevention, identification, evaluation, selection/evaluation of hearing aids, rehabilitation, or medical diagnosis/treatment of the auditory system.

Audiologists may not bill E&M CPT codes 99201–99499.

Audiologists may not bill cerumen removal codes 69209/69210; cerumen removal is included in diagnostic test relative value. If a physician removes impacted cerumen same day as a diagnostic test, bill G0268.

If only one ear is tested, modifier 52 should be reported to indicate less than the normal bilateral procedure.

Timed audiology CPT codes (92620, 92621, 92626, 92627, 92640) are billable only when testing time is at least 51% of the code's designated time; CPT descriptors without time are billed as a session regardless of time.

15-minute unit guidance applies to designated CPT codes (e.g., 1 unit = 8 to <23 minutes; 2 units = 23 to <38 minutes; 3 units = 38 to <53 minutes) per policy examples.

Clinical examples (appropriate reasons to order diagnostic testing)

Evaluation of suspected change in hearing, tinnitus, or balance.
Evaluation of cause of hearing/tinnitus/balance disorders or effect of medication, surgery, or other treatment.

Vermont audio-only and supervised billing criteria

Vermont-specific audio-only and supervised billing rules apply when ALL applicable conditions are met:

Audio-only (telephone) services are covered in Vermont and may be reimbursed equivalent to in-person codes when delivered via audio-only means.

For in-person CPT codes performed via audio-only, use Place of Service 99 and append Modifier V3 (Modifier V3 must be the first (left-most) modifier for non-physician/APRN behavioral health codes where required).

Non-Physician/APRN Behavioral Health providers will be reimbursed for contract codes delivered audio-only but are not eligible to bill CPT codes 99441–99443.

Reimbursement for covered audio-only services is at 75% of the medical provider fee schedule for covered services delivered audio-only (Vermont only).

In Vermont, services supplied by a Qualified Non-Licensed Psychotherapist may be billed and reimbursed when performed under direct supervision of a Qualified Licensed Psychotherapist (MVP Medicare Advantage excluded).

Supervised billing instructions: list supervising clinician NPI and taxonomy in Box 24J and supervising provider name/degree in Box 31 of the CMS-1500; append modifier HO for master's-level supervisee or HP for doctorate-level supervisee.

Services performed by non-licensed providers who cannot practice independently and are not actively working toward licensure are non-reimbursable; MVP Medicare members are excluded even under supervision.

Timed audiology CPT codes listed (92620, 92621, 92626, 92627, 92640) are billed only when testing comprises at least 51% of the code's designated time; CPT descriptors without time are billed as a session regardless of time.

Coverage and exclusion criteria (partial document)

Coverage and exclusions — apply as stated below:

Contrast materials (ionic and non-ionic) are considered included in the fee for CT and other contrast-enhanced exams; additional payment for contrast materials will be denied for Commercial, Exchange, and Medicaid products.

COVID-19 diagnostic and antibody testing is covered when medically appropriate for diagnosis and treatment of the member; testing ordered solely for pandemic control, surveillance, employer/school requirements, or member self-assessment is not covered unless required by law.

Claims for services requiring prior authorization per MVP Utilization Management Guides that are provided without prior approval will be administratively denied (technical, professional, global and/or facility claims) as specified.

Claims are subject to post-payment review and audit; commercial members may be held liable for denied claims and providers bear responsibility for denials for Medicare Advantage and Medicaid Managed Care members.

Coverage criteria and exclusions for COVID-19 testing

COVID-19 testing is covered when ALL of the following are satisfied:

Testing is medically appropriate for diagnosis and treatment of the individual member (clinical determination by provider).

Tests ordered solely for pandemic surveillance, reopening, employer/school screening, or member self-assessment are excluded from coverage unless required by law or regulation.

Providers are encouraged to use reliable FDA-authorized tests and must follow applicable ICD-10-CM coding guidance when selecting diagnosis codes.

Claims are subject to post-payment review; inappropriate primary diagnosis codes listed in policy examples will be denied and providers are responsible for denials for Medicare Advantage and Medicaid Managed Care members.

Coverage criteria for nutritional counseling and diabetic management

Nutritional counseling and diabetic management are covered when ALL of the following are met:

Services are medically necessary for chronic disease management where dietary adjustment has a therapeutic role (e.g., diabetes) and are prescribed by a physician or qualified non-physician practitioner.

Services are furnished by recognized providers: licensed nutritionist, registered dietitian, registered nurse, or other qualified licensed health professional; diabetic self-management education (DSME) must be provided by a certified diabetes educator (CDE).

Documentation for DSME includes assessment of education needs, self-management goals, education/behavioral interventions, and evaluation of goal attainment.

Reimbursable codes and limits

Medical nutrition therapy codes 97802–97804 and G0270–G0271 are reimbursable per policy.
For Medicare MSA plans only, reimbursement for 97802–97804 and G0270–G0271 is limited to specified ICD-10 diagnoses; other plans have no diagnosis restrictions.

Reimbursement criteria and exclusions

Reimbursable diabetic management services and exclusions:

G0108 (individual) and G0109 (group) diabetes outpatient self-management training services are reimbursable when medically necessary and properly documented.

For Medicare MSA plans only, reimbursement for G0108 and G0109 is limited to the specified ICD-10 diagnoses listed in the policy; all other plans will reimburse for ICD-10 in range E08–E13 per policy statements.

Nutritional counseling exclusions apply (non-reimbursable services such as commercial diet plans, gym memberships, resort programs, and other listed non-covered items); these services are not reimbursable under the policy.

Diagnosis matching and claim denial criteria

Claims for the listed procedures must meet the diagnosis-matching requirements below:

Submit the correct diagnosis with the claim that aligns with the referenced Medicare Local Coverage Determination (LCD) or National Coverage Determination (NCD) for the procedure codes listed; failure to submit the required diagnosis will result in denial for lack of medical necessity.

Procedure groups referenced

Transthoracic echocardiography codes (e.g., 93303–93308, 93350–93352): claims require diagnoses per Document ID #L33577/#A56781; Pediatric Cardiology specialty is excluded from this edit.
Facet joint procedures (64490–64495, 64625, 64633–64636): claims require diagnoses per Document ID #L33577/#A57826.
Corneal pachymetry (76514) and visual fields testing (92081–92083): claims require diagnoses per their respective LCD Document IDs (#L33630, #L33574) or will be denied for medical necessity.
Nerve conduction studies and EMG procedure codes require appropriate diagnoses per Document ID #L35098 or will be denied for medical necessity.

Providers must verify member eligibility and prior authorization requirements and submit appropriate diagnosis codes per the referenced CMS documents or specialty society guidance as cited in the policy.

Diagnosis linkage and medical necessity requirement

Claims for the listed laboratory and diagnostic procedures require an appropriate diagnosis for medical necessity:

Submit an appropriate diagnosis consistent with the referenced Medicare LCD/NCD or specialty society guidance for the specific laboratory or diagnostic procedure code (e.g., corneal pachymetry 76514; visual fields 92081–92083; herpes simplex antibody 86695/86696; vitamin D 82306/82652; ESR 85652; folic acid 82746; vitamin B12 82607; FSH 83001; TSH/thyroxine/T3 codes 84436/84439/84479/84480/84481).

If the claim does not include the required diagnosis as specified by the referenced LCD/NCD or clinical guidance, MVP will deny the claim for lack of medical necessity.

Refer to the policy Appendix for reimbursable diagnosis codes associated with the listed laboratory services.

Reimbursable diagnosis codes (Appendix)

Appendix — reimbursable diagnosis codes (examples):

The Appendix contains reimbursable ICD-10 diagnosis codes for laboratory services listed (Follicle Stimulating Hormone, Herpes Simplex Virus, Gammaglobulin IgE, Erythrocyte Sedimentation Rate, Folic Acid, Triiodothyronine/T3).

Providers should reference the Appendix to select appropriate diagnosis codes when submitting claims for the listed laboratory tests to avoid denials for medical necessity.

Code Lists and Billing Limits

After-Hours CPT codesCPTCovered

99050	After-hours office services; must be billed with an E&M; not reimbursable when submitted with preventive visit codes.
99051	After-hours evening/weekend; must be billed with an E&M; considered inclusive to the E&M; not reimbursed separately for Commercial and Medicare (Medicaid/HARP reimbursed at Medicaid rate).
99053	Services between 10:00 pm and 8:00 am at 24-hour facility; must be billed with an E&M; considered inclusive to the E&M; not reimbursed separately.
99056	Services provided out of office at patient request; must be billed with an E&M; considered inclusive to the E&M; not reimbursed separately.
99058	Emergency basis in office disrupting scheduled services; must be billed with an E&M; considered inclusive to the E&M; not reimbursed separately.
99060	Emergency basis out of office disrupting scheduled services; must be billed with an E&M; considered inclusive to the E&M; not reimbursed separately.

Allergy testing and serum preparation CPT codes and limitsCPTCovered

95165	Supervision of preparation and provision of antigens for allergen immunotherapy; units/doses must be specified on claim; first year limited to 40 units per claim and 160 units per calendar year; subsequent years limited to 30 units per claim and 120 units per calendar year.
95004	Percutaneous tests (scratch, puncture, prick) with allergenic extracts, immediate type reaction, including interpretation and report; number of tests must be specified; reimbursement limited to 80 units per calendar year.
95024	Intracutaneous (intradermal) tests with allergenic extracts, immediate type reaction, including interpretation and report; number of tests must be specified; reimbursement limited to 40 units per calendar year.
95027	Intracutaneous sequential/incremental tests for airborne allergens, immediate type reaction, including interpretation and report; number of tests must be specified; reimbursement limited to 40 units per calendar year.
95028	Intracutaneous tests with allergenic extracts, delayed type reaction, including reading; number of tests must be specified; reimbursement limited to 30 units per calendar year.

E&M coding guidancemixedCovered

No codes listed

E&M-related code groupsCPTCovered

99201-99499	E&M visit codes (general rules on bundling, duplicates, inpatient rules).
99381-99387, 99391-99397	Preventive medicine E&M codes (preventive visits; certain same-day procedures not reimbursed separately).
G0102	Manual rectal neoplasm screening — not reimbursed same day as 99202-99215 unless sole service.
36415, 36416, 99000, 99001, Q0091, 92567, 94760, 94761	Routine screening/lab procedures — generally not reimbursed separately same day as 99202-99215 unless sole service or external lab with modifier CG as specified.
99406, 99407, G0376, G0375, S9453, S9075	Smoking cessation counseling — not reimbursed unless member benefit indicates coverage.
98960	Diabetes education — reimbursed when billed alone; denied/bundled when billed with E&M office visit.
98925-98929	Osteopathic manipulation — not reimbursed unless contract exception.
90460-90474, G0008-G0010	Immunization administration — reimbursed only when billed with Z23 diagnosis.
95115-95149 series	Allergy injections — reimbursable only with an E&M/Inpatient/ER visit billed with modifier 25.
96900-96922 series	PUVA/UVA dermatologic treatments — reimbursable only with modifier 25 alongside E&M/Inpatient/ER visit.

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E&M generalCPTCovered

99201-99499

Evaluation and Management codes (inpatient and other E&M ranges).

After-hoursCPT

99050-99060

After-hours/E&M after-hour procedure codes; refer to After-Hours Payment Policy and contractual agreements for applicability.

Critical careCPT

99291	Critical care, first 30-74 minutes; reimbursed only if time ≥30 minutes per MVP rules (30-74 min = 99291 once).
99292	Critical care add-on unit(s) for additional time beyond initial period; additional 99292 units allowed per specified time blocks (75-104 min = 1 x 99292, 105-134 min = 2 x 99292, etc.).

Arthroscopic/Endoscopic scope proceduresmixed

arthroscopy/endoscopy families

Scope procedure code families (e.g., colonoscopy, cystoscopy, arthroscopy); when multiple within same family on same date, highest RVU procedure reimbursed and secondary procedures follow Medicare methodology reducing payment for additional procedures.

Audiology coding limitations and timed-code rulesCPT | HCPCS | mixedCovered

99201-99499	E&M CPT codes that audiologists may not bill.
69209	Cerumen removal code — audiologists may not bill; included in diagnostic test RVUs.
69210	Cerumen removal code — audiologists may not bill; included in diagnostic test RVUs.
G0268	Physician code to bill when physician removes impacted cerumen same day as diagnostic test.

Audiology timed codes and telephone E/M codesCPT

92620	Evaluation of central auditory function, with report; initial 60 minutes (timed code billed only if testing ≥51% of designated time).
92621	Evaluation of central auditory function, with report; each additional 15 minutes.
92626	Evaluation of auditory rehabilitation status; first hour.
92627	Evaluation of auditory rehabilitation status; each additional 15 minutes.
92640	Diagnostic analysis with programming of auditory brainstem implant, per hour.
99441	Telephone E/M service; 5-10 minutes of medical discussion (audio-only POS 99, Modifier V3).
99442	Telephone E/M service; 11-20 minutes of medical discussion (audio-only POS 99, Modifier V3).
99443	Telephone E/M service; 21-30 minutes of medical discussion (audio-only POS 99, Modifier V3).

Contrast material HCPCS codesHCPCSNot Covered

A9579	Injection, gadolinium-based magnetic resonance contrast agent, per ml (not reimbursed separately).
Q9951	Low osmolar contrast material, 400+ mg/ml iodine concentration, per ml (not reimbursed separately).
Q9965	Low osmolar contrast material, 200-299 mg/ml iodine concentration, per ml (not reimbursed separately).
Q9966	Low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml (not reimbursed separately).
Q9967	Low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml (not reimbursed separately).
Q9958	High osmolar contrast material, up to 149 mg/ml iodine concentration, per ml (not reimbursed separately).
Q9959	High osmolar contrast material, 150-199 mg/ml iodine concentration, per ml (not reimbursed separately).
Q9960	High osmolar contrast material, 200-249 mg/ml iodine concentration, per ml (not reimbursed separately).
Q9961	High osmolar contrast material, 250-299 mg/ml iodine concentration, per ml (not reimbursed separately).
Q9962	High osmolar contrast material, 300-349 mg/ml iodine concentration, per ml (not reimbursed separately).

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COVID-19 testing codes and coding guidancemixed

Applicable COVID-19 procedure codes as published in CPT by AMA or HCPCS by CMS; providers should follow CDC ICD-10-CM Official Coding Guidelines when selecting diagnosis codes.

Denied/ inappropriate diagnosis codesICD-10Not Covered

Z02.0, Z02.1, Z02.4, Z02.5, Z02.79, Z02.89	Examples of primary diagnosis codes that will be denied when submitted for COVID-19 testing (administrative/exam reasons).
Z02.9, Z56.89, Z56.9, Z03.818, Z76, Z01.89, Z13.9, Z71.89, Z71.82, R68.89, B34.9, E55.9, Z03.89, E03.9, Z56.5, Z00.00, K21.9, E11.9, R10.9, N23	Additional example diagnosis codes considered inappropriate for COVID-19 testing reimbursement.
N39.0, R73.03, M54.5, E78.2, R07.89, K62.89, N89.8, M25.50, Z20.818, R42, Z09, K80.00, R07.9, N93.9, K29.00, I24.9, O24.419, E78.5, E16.2, J11.1, Z29.9, Z11.9	Further examples of diagnosis codes listed as non-reimbursable for COVID-19 testing.

Reimbursable nutritional counseling codesCPT | HCPCSCovered

97802	Medical nutritional therapy; initial assessment and intervention, individual, face-to-face, each 15 minutes.
97803	Medical nutritional therapy; reassessment and intervention, individual, face-to-face, each 15 minutes.
97804	Medical nutritional therapy; group (2+ individuals), each 30 minutes.
G0270	Medical nutritional therapy; reassessment and subsequent intervention(s) following second referral in same year, individual, each 15 minutes.
G0271	Medical nutritional therapy; reassessment and subsequent intervention(s) following second referral in same year, group, each 30 minutes.

Drug/chemical induced diabetes mellitus codesICD-10

E09.*

Drug or chemical induced diabetes mellitus and associated complication subcodes (multiple specific codes listed).

Type 1 diabetes mellitus codesICD-10

E10.*

Type 1 diabetes mellitus and associated complication subcodes (multiple specific codes listed).

Type 2 diabetes mellitus codesICD-10

E11.*

Type 2 diabetes mellitus and associated complication subcodes (multiple specific codes listed).

Other specified diabetes mellitus codesICD-10

E13.*

Other specified diabetes mellitus and associated complication subcodes (multiple specific codes listed).

ICD-10 diagnosis groups for nutritional counseling and diabetic managementICD-10Covered

E11.*	Type 2 diabetes mellitus codes with multiple complication subcodes listed (see policy excerpts).
E13.*	Other specified diabetes mellitus codes with multiple complication subcodes listed (see policy excerpts).
N18.*	Chronic kidney disease stages listed (N18.1, N18.2, N18.31, N18.32, N18.4, N18.5).
O24.*	Pregnancy-related diabetes codes (multiple O24 codes listed).
Z48.22	Encounter for aftercare following kidney transplant.

Reimbursable Diabetic Management CPT/HCPCSHCPCSCovered

G0108	Diabetes outpatient self-management training services, individual, per 30 minutes.
G0109	Diabetes outpatient self-management training services, group session (2 or more), per 30 minutes.

Diabetes ICD-10 code groupsICD-10

E09.*	Drug or chemical induced diabetes mellitus and complications (multiple specific codes listed).
E10.*	Type 1 diabetes mellitus and complications (multiple specific codes listed).
E11.*	Type 2 diabetes mellitus and complications (multiple specific codes listed).
E13.*	Other specified diabetes mellitus and complications (multiple specific codes listed).

Transthoracic echocardiographyCPTCovered

93303-93308	Transthoracic echocardiography for congenital cardiac anomalies and real-time transthoracic echocardiography groups referenced for diagnosis matching edits (93303-93308).
93350-93352	Transthoracic echocardiography during rest and cardiovascular stress testing (93350-93352).
93308	Echocardiography, transthoracic, real-time with image documentation (93308).
93306-93308	Real time transthoracic echocardiography code group (93306-93308) referenced for edits.

NCS and EMGCPTCovered

51785	Cystometrogram and related code listed in NCS/EMG group (included in group references).
92265	Ophthalmic diagnostic code referenced in NCS/EMG group (included in group references).
95860-95874	EMG and NCS procedure codes referenced for diagnosis matching edits.
95885-95887	Additional EMG/NCS related codes referenced.
95905-95913	NCS/EMG related procedure codes referenced.
95933	NCS/EMG group code referenced.
G0255	NCS-related code referenced.
95937	Neuromuscular junction testing code referenced for diagnosis matching edits.

Corneal pachymetryCPTCovered

76514

Ophthalmic ultrasound, diagnostic; corneal pachymetry, unilateral or bilateral (determination of corneal thickness).

Visual fields testingCPTCovered

92081	Visual field examination, extended quantitative.
92082	Visual field examination, intermediate.
92083	Visual field examination, standard.

Facet joint proceduresCPTCovered

64490-64495	Facet joint injections and related diagnostic/therapeutic injection codes (cervical, thoracic, lumbar, sacral).
64625	Destruction by neurolytic agent, paravertebral facet joint nerve; Cervical, Thoracic, Lumbar, or Sacral.
64633-64636	Medial branch radiofrequency neurotomy and related codes.

Corneal pachymetryCPTCovered

76514

Ophthalmic ultrasound, diagnostic; corneal pachymetry, unilateral or bilateral (determination of corneal thickness).

Visual field testingCPTCovered

92081	Visual field examination, extended quantitative.
92082	Visual field examination, intermediate.
92083	Visual field examination, standard.

Herpes simplex antibody testingCPTCovered

86695	Herpes simplex, type 1 antibody.
86696	Herpes simplex, type 2 antibody.

Vitamin D testingCPTCovered

82306	Vitamin D, 25 hydroxy.
82652	Vitamin D, 1,25-dihydroxy.

Sedimentation rateCPTCovered

85652

Erythrocyte sedimentation rate; automated.

Allergen/IgE assaysCPTCovered

82785	Assay of gammaglobulin IgE.
86003	Allergen specific IgE; crude allergen extract, each.
86008	Allergen specific IgE; recombinant/purified component, each.

Folic acid assayCPTCovered

82746

Assay of folic acid, serum.

Vitamin B12 testingCPTCovered

82607

Cyanocobalamin (Vitamin B12) assay.

Follicle stimulating hormone assayCPTCovered

83001

Gonadotropin, follicle stimulating (FSH).

Thyroid function testsCPTCovered

84436	Thyroid stimulating hormone (TSH).
84439	Thyroxine; total.
84479	Thyroxine tests (other).
84480	Triiodothyronine (T3) total.
84481	Triiodothyronine (Free T3).

Sample Follicle Stimulating Hormone-associated ICD-10 codesICD-10

Z79899	Other long term (current) drug therapy.
Z853	Personal history of malignant neoplasm of breast.
E1165	Type 2 diabetes mellitus with hyperglycemia.

Sample Herpes Simplex Virus-associated ICD-10 codesICD-10

B009	Herpesviral infection, unspecified.
B0052	Herpesviral keratitis.
Z01411	Encounter for gynecological examination with abnormal findings.

Sample Gammaglobulin IGE-associated ICD-10 codesICD-10

J309	Allergic rhinitis, unspecified.
L500	Allergic urticaria.
T7800XA	Anaphylactic reaction due to unspecified food, initial encounter.

Gammaglobulin IgE related ICD-10 codesICD-10

T63481A	Toxic effect of venom of wasps, accidental (unintentional), subsequent encounter.
T6391XA	Toxic effect of venom of other arthropod, accidental (unintentional), initial encounter.
T6391XS	Toxic effect of contact with unspecified venomous animal, accidental (unintentional), sequela.
T65811A	Toxic effect of latex, accidental (unintentional), initial encounter.
T7800XA	Anaphylactic reaction due to unspecified food, initial encounter.
T7801XA	Anaphylactic reaction due to peanuts, initial encounter.
T7801XD	Anaphylactic reaction due to peanuts, subsequent encounter.
Z0182	Encounter for allergy testing.
Z91010	Allergy to peanuts.
Z91030	Bee allergy status.

ESR related ICD-10 codes (excerpts)ICD-10

C029	Malignant neoplasm of tongue, unspecified.
C220	Liver cell carcinoma.
C3411	Malignant neoplasm of upper lobe, right bronchus, or lung.
C9000	Multiple myeloma not having achieved remission.
C9110	Chronic lymphocytic leukemia of B-cell type not having achieved remission.
D550	Anemia due to glucose-6-phosphate dehydrogenase [G6PD] deficiency.
D630	Anemia in neoplastic disease.
D689	Sarcoidosis, unspecified.
D824	Hyperimmunoglobulin E [IgE] syndrome.
D891	Cryoglobulinemia.

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95165 limits and claim requirements

95165 — per-claim first-year limitFirst year reimbursement limited to 40 units per claim (160 units per calendar year).

95165 — subsequent-year per-claim limitSubsequent years limited to 30 units per claim (120 units per calendar year).

Claim requirementNumber of units/doses must be specified on the claim for 95165 and skin testing codes.

Allergy testing unit limits

95165 (first year calendar limit)First year reimbursement limited to 160 units per calendar year (40 units per claim first year).

95165 (subsequent years)Subsequent years reimbursement limited to 120 units per calendar year (30 units per claim).

95004 (annual limit)Reimbursement is limited to 80 units per calendar year; number of tests must be specified on the claim.

95024 (annual limit)Intracutaneous immediate-type tests limited to 40 units per calendar year; number of tests must be specified on the claim.

95027 (annual limit)Sequential/incremental intracutaneous tests for airborne allergens limited to 40 units per calendar year; number of tests must be specified on the claim.

95028 (annual limit)Intracutaneous delayed-type tests limited to 30 units per calendar year; number of tests must be specified on the claim.

Critical care timing and add-on units

99291 minimum time rule99291 reimbursed only if time spent is at least 30 minutes; 30–74 minutes = 99291 once.

Incremental 99292 units75–104 minutes = 99291 + 1 × 99292; 105–134 = 99291 + 2 × 99292; 135–164 = 99291 + 3 × 99292; 165–194 = 99291 + 4 × 99292.

Procedures excluded from critical care timeProcedures such as routine ECG interpretation (93010) do not count toward critical care time and may be reimbursed separately.

Timed-code billing thresholds and 15-minute unit guidance

Timed-code billing threshold (general)A timed code is billable only when testing comprises at least 51% of the time designated in the code descriptor.

15-minute CPT unit mapping (policy examples)Example mappings: 1 unit = 8 to <23 minutes; 2 units = 23 to <38 minutes; 3 units = 38 to <53 minutes (additional ranges provided for higher unit counts).

Audiology timed-code ruleFor audiology timed CPT codes (92620, 92621, 92626, 92627, 92640), bill timed code only if testing time meets the 51% threshold; non-timed CPT descriptors billed as a session.

Unit counting guidanceWhen calculating audiology test time, counseling/goal-setting or non-diagnostic activities should not be included in test time used to meet timed-code thresholds.

15-minute CPT unit definitions (examples)

1-unit (15-minute CPT) definition1 unit = 8 minutes to <23 minutes per policy examples.

2-units definition2 units = 23 minutes to <38 minutes.

3-units definition3 units = 38 minutes to <53 minutes.

Higher-unit examplesPolicy provides examples extending ranges for 4–6 units (e.g., 68–83 minutes = 4–5 unit example ranges shown).

15-minute CPT unit time ranges (general guidance)

General 15-minute unit rangesPolicy guidance: 1 unit = 8 to <23 minutes; 2 units = 23 to <38 minutes; 3 units = 38 to <53 minutes; additional higher ranges described for successive units.

ApplicationThese ranges apply to CPT codes designated in 15-minute increments; use provided thresholds when determining units to report.

Example extensionPolicy includes extended examples for higher unit counts (e.g., 5–6 unit ranges shown in text).

Inclusion of contrast cost in primary exam fee

Contrast material reimbursement stanceCost of ionic and non-ionic contrast is considered included in the primary exam fee; additional payment for contrast materials will be denied for Commercial, Exchange, and Medicaid products.

RationaleNon-ionic contrast cost parity and routine use removed the basis for separate payment; MVP considers contrast part of the underlying exam.

Applicable servicesApplies to CT and other contrast-enhanced exams listed in the policy's HCPCS/code tables.

COVID-19 testing — FDA-authorized tests and coding guidance

FDA-authorized tests encouragedProviders are encouraged to use reliable FDA-authorized tests for COVID-19 viral/antigen and antibody testing.

Coding guidanceApplicable COVID-19 codes are those published by the AMA (CPT) or CMS (HCPCS); follow CDC ICD-10-CM Official Coding Guidelines when selecting diagnosis codes.

Test purpose distinctionVirus/antigen tests determine current infection; antibody (serology) tests may determine prior exposure and should not be used to diagnose current infection per FDA guidance.

Nutritional counseling / Diabetic management coding and Medicare MSA restriction

Reimbursable MNT/MNT reassessment codes97802, 97803, 97804, G0270, G0271 are considered reimbursable for Nutritional Counseling/Medical Nutrition Therapy.

Medicare MSA diagnosis restrictionFor Medicare MSA plans only, codes 97802-97804 and G0270-G0271 are limited to the listed ICD-10 diagnoses; other plans have no diagnosis restrictions.

Diabetic management ICD-10 listingsDiabetic Management section lists extensive ICD-10 codes (E09.*, E10.*, E11.*, E13.*) used for diagnosis matching and plan-specific restrictions.

Exhaustiveness of diabetic complication ICD-10 variants

Exhaustive diabetic complication listingsDocument enumerates numerous 7-character and laterality-specific ICD-10 variants for diabetic complications (retinopathy, macular edema, nephropathy, neuropathy, etc.).

Use in diagnosis matchingThese detailed ICD-10 entries support diagnosis matching for reimbursement of Nutritional Counseling and Diabetic Management services.

Reference scopeThe listed codes span E09.*, E10.*, E11.*, E13.* and related pregnancy/CKD codes used across the Diabetic Management section.

Provider Responsibilities, Prior Authorization, and Documentation

Prior Authorization

Verify eligibility and check UM guides before providing services

Providers must check member eligibility, refer to the Member Benefits Display, review MVP's Utilization Management Guides to determine if prior authorization is required, and consult the Benefit Interpretation Manual; resources are accessible by signing into your provider account at mvphealthcare.com.

Prior Authorization

Confirm member eligibility and UM requirements for allergy testing

For allergy testing, providers must confirm Member eligibility and refer to the Member Benefits Display; they must also review MVP's Utilization Management Guides to determine if prior authorization is required. Access these resources by signing into your provider account at mvphealthcare.com.

Prior Authorization

Check eligibility and UM guides for prior authorization/notification

Providers must check member eligibility, refer to the Member Benefits Display, and review MVP's Utilization Management Guides to determine if prior authorization or notification is required; resources are available via the provider account at mvphealthcare.com.

Prior Authorization

Verify eligibility and required authorizations using MVP resources

Providers must check member eligibility, consult the Member Benefits Display, review MVP's Utilization Management Guides for prior authorization requirements, and consult the Benefit Interpretation Manual for clinical guidance; access these resources by signing into your account at mvphealthcare.com.

Documentation Required

Use After‑Hours Payment Policy and contract to determine applicability

Refer to the MVP After-Hours Payment Policy for guidance on billing and reimbursement of after‑hours E/M codes (99051–99060) and consult your contractual agreement to determine applicability of the rule.

Prior Authorization

Verify eligibility and prior authorization requirements via MVP resources

Providers must check Member eligibility, consult the Member Benefits Display, and review MVP's Utilization Management Guides and Benefit Interpretation Manual to determine prior authorization requirements before providing services; these resources are available via the provider portal.

Prior Authorization

Obtain authorization for In‑Office Only codes to be eligible for split billing reimbursement

Procedure codes on the MVP In‑Office Only list will not be reimbursed under a split billing arrangement unless authorization is obtained; if authorized, reimbursement may be allowed for Medicare and Medicaid products.

Prior Authorization

Confirm eligibility and authorization requirements before delivering services

Providers must check member eligibility, refer to the Member Benefits Display, and review MVP's Utilization Management Guides and Benefit Interpretation Manual to determine if prior authorization is required prior to rendering services; access via provider account.

Denial Risk

Obtain required authorizations to avoid administrative denials

Authorizations are required for select services identified in MVP's Utilization Management Guides; when authorization is required and not obtained, all technical, professional, global and/or facility claims associated with those services will be administratively denied (applies to outpatient surgical services and the Radiology code set). Providers must check member eligibility and the UM guides for authorization requirements.

Prior Authorization

Verify eligibility and prior authorization requirements prior to service

Providers must check member eligibility and review MVP's Utilization Management Guides and Benefit Interpretation Manual to determine whether prior authorization is required before performing services; resources accessed by signing into the provider account at mvphealthcare.com.

Prior Authorization

Confirm eligibility and authorization; policies do not guarantee payment

Note

ICD‑10 diagnosis listings for Nutritional Counseling (no authorization rules here)

This section provides ICD‑10 diagnosis code listings used in the Nutritional Counseling section; no prior authorization, denial risk, documentation, billing rule, or step therapy actions are specified in this excerpt.

Billing Rule

Billing restriction for G0108/G0109 — diagnosis limitation for Medicare MSA plans

G0108 and G0109 are considered reimbursable for Diabetic Management; reimbursement for these codes is limited to specified diagnoses for Medicare MSA plans (all other plans reimburse ICD‑10 in range E08–E09).

Documentation Required

Refer to ICD‑10 mappings for drug/chemical‑induced diabetes diagnoses

Listings of ICD‑10 codes for drug/chemical‑induced diabetes mellitus are provided for diabetic management coding and reference in the policy.

Prior Authorization

Verify eligibility and submit correct diagnosis per LCD/NCD to avoid denial

Providers must check member eligibility, consult the Member Benefits Display, and review MVP's Utilization Management Guides to determine if prior authorization is required; MVP requires the correct diagnosis be submitted with the claim per Medicare LCD/NCD or the claim will be denied for medical necessity.

Denial Risk

Submit correct diagnosis for corneal pachymetry (76514) per LCD

MVP requires the correct diagnosis be submitted with claims for corneal pachymetry (76514) in accordance with the applicable Medicare Local Coverage Determination; failure to submit the correct diagnosis will result in denial for medical necessity.

Denial Risk

Submit correct diagnosis for visual field testing (92081–92083) per LCD

MVP requires the correct diagnosis be submitted with claims for visual field testing (92081–92083) in accordance with the Medicare Local Coverage Determination; failure to submit the correct diagnosis will result in denial for medical necessity.

Denial Risk

Use appropriate diagnoses for Herpes Simplex antibody tests (86695/86696) or claim will deny

MVP requires the correct diagnosis be submitted with claims for Herpes Simplex antibody testing (86695, 86696) in accordance with USPSTF and AAFP or clinical guidance; claims without an appropriate diagnosis will be denied for medical necessity. See the Appendix for appropriate diagnosis codes.

Denial Risk

Submit appropriate diagnosis for Vitamin D tests (82306/82652) per LCD

MVP requires the correct diagnosis be submitted with claims for Vitamin D testing (82306, 82652) in accordance with the Medicare LCD; claims submitted without the appropriate diagnosis will be denied for medical necessity.

Denial Risk

Provide appropriate diagnosis for ESR automated test (85652) or claim will be denied

MVP requires the correct diagnosis be submitted with claims for the erythrocyte sedimentation rate automated test (85652) in accordance with ASCP guidance; claims lacking the appropriate diagnosis will be denied for medical necessity.

Documentation Required

Refer to AAAAI guidance and Appendix for appropriate diagnoses for Allergen/IgE tests

For allergen and IgE testing (82785, 86003, 86008), providers should refer to guidance from the American Academy of Allergy, Asthma & Immunology and the policy Appendix to identify appropriate diagnoses to submit with claims.

Denial Risk

Submit correct diagnosis for folic acid assay (82746) per clinical guidance

MVP requires the correct diagnosis be submitted with claims for folic acid assay (82746) in accordance with clinical guidance; submit appropriate diagnoses from the Appendix to avoid denial.

Denial Risk

Provide correct diagnosis for Vitamin B12 testing (82607) per LCD

MVP requires the correct diagnosis be submitted with claims for Vitamin B12 testing (82607) in accordance with the Medicare Local Coverage Determination; failure to submit the appropriate diagnosis will result in denial for medical necessity.

Denial Risk

Submit appropriate diagnosis for FSH testing (83001) per ASRM guidance

MVP requires the correct diagnosis be submitted with claims for follicle stimulating hormone testing (83001) in accordance with American Society for Reproductive Medicine guidance; claims without an appropriate diagnosis will be denied for medical necessity. Refer to the Appendix for appropriate diagnosis codes.

Denial Risk

Ensure correct diagnoses for TSH/thyroxine tests (84436/84439/84479) per LCD

MVP requires the correct diagnosis be submitted with claims for thyroid function tests (84436, 84439, 84479) according to Medicare LCDs; claims submitted without the appropriate diagnosis will be denied for medical necessity.

Denial Risk

Provide correct diagnosis for T3 tests (84480/84481) or expect denial

MVP requires the correct diagnosis be submitted with claims for T3 testing (84480, 84481) or the claim will be denied due to medical necessity; refer to the Appendix for appropriate diagnosis codes.

Documentation Required

Use listed ICD‑10 diagnoses associated with FSH therapy when appropriate

The policy lists ICD‑10 diagnosis codes and descriptions associated with Follicle Stimulating Hormone therapy (examples include Z79899, Z853, E11.65, E11.9); consult these codes when submitting claims related to FSH testing or therapy.

Documentation Required

Use Appendix ICD‑10 codes for Herpes Simplex Virus claims

The Appendix lists ICD‑10 diagnosis codes associated with Herpes Simplex Virus conditions and encounters (examples shown in the policy); use these listed diagnoses when submitting claims for related services.

Documentation Required

Refer to listed ICD‑10 codes for Gammaglobulin IgE indications

The policy lists ICD‑10 diagnosis codes associated with Gammaglobulin IgE indications (examples include allergic and respiratory codes J30‑J309 and L50‑L509); refer to these codes in the Appendix when submitting claims for 82785/86003/86008.

Documentation Required

Use Appendix ICD‑10 codes for Gammaglobulin IgE and allergy testing

The policy provides additional ICD‑10 codes describing toxic effects, anaphylactic reactions, allergies, and encounters for allergy testing (e.g., T7800XA, Z0182); consult these codes in the Appendix when billing related services.

Documentation Required

Consult Appendix ICD‑10 list when submitting ESR (85652) claims

An extensive list of ICD‑10 codes associated with indications for erythrocyte sedimentation rate testing is provided in the policy Appendix; consult the Appendix to select an appropriate diagnosis when submitting claims for ESR (85652).

Definitions and Key Terms

Medical Necessity (MVP/CMS/AMA definitions)

MVP definition — Medically NecessaryServices necessary to prevent, diagnose, correct or cure conditions; recommended by treating provider and meeting criteria for appropriateness, not convenience; supported by evidence and provided in a safe, cost‑effective setting

AMA definitionHealth care services a prudent physician would provide to prevent, diagnose, or treat illness in accordance with accepted medical practice

CMS/Medicare noteMedical necessity is the overarching criterion for payment; documentation must support the level of service reported and billing a higher level when a lower level is warranted is inappropriate

Medical Necessity — MVP adopts AMA/CMS definitions

Adoption of AMA and CMS definitionsMVP adopts AMA’s and CMS’s concepts of medical necessity and documentation guidelines for E&M services

Documentation expectationMedical records may be requested periodically to ensure services billed are appropriately documented per CMS 1995/1997 and 2021 Office and Other Outpatient Services guidelines

ApplicationApplies to reimbursement of Evaluation & Management services under MVP policy

New Patient — definition

New patient definitionA new patient is one who has not received professional services from the same provider or another provider of the same specialty within the same group (same tax ID) in the past three years

SourceMVP follows the American Medical Association definition

Billing impactUse this definition to determine new vs established patient E&M coding eligibility

Significant E&M Service — definition

Significant E&M Service — minimum standardRequires at minimum an expanded problem‑focused examination

Not considered significantRoutine reassurance, medication refills, monitoring, or minor problem‑focused services are not significant E&M services

Billing implicationSignificant designation supports billing higher‑level E&M when documentation meets criteria

Critically ill — definition

Critically ill — definitionA condition acutely impairing one or more vital organ systems with high probability of imminent or life‑threatening deterioration (e.g., CNS, circulatory, respiratory, renal failure)

Time attributionCritical care time includes bedside care, chart review, discussion with staff; time need not be continuous and is billed per calendar day

Documentation requirementTime must be documented in the medical record

Split billing / reimbursement — definition and explanation

Split billing — conceptTwo separate charges: professional (physician/provider) and technical (facility) reimbursement

Professional componentBillable physician services (consultation, interpretation) paid to provider group

Technical componentFacility‑based services (labs, imaging, procedures) reimbursed to the hospital

Professional component — definition

Professional component — definitionBillable services provided by the physician such as consultation and interpretation; payment is made to the provider group

ContextUsed when services are split between professional and technical components (split billing)

ExampleInterpretation of imaging studies billed as professional component separate from facility technical charge

Technical component — definition

Technical component — definitionBillable services provided in a facility setting (e.g., labs, imaging, procedures); reimbursement paid to the facility/hospital

ContextOften paired with a professional component when split billing is used

ExampleImaging equipment use and technician services billed as technical component separate from physician interpretation

Global — definition

Global reimbursement — definitionA single bill representing both professional and technical services with one global payment

ImplicationWhen billed globally, no separate professional or technical payments are made

Typical flowGlobal reimbursement often results in reimbursements going to the physician practice unless providers are hospital‑employed

CPT — definition

CPT — definitionCurrent Procedural Terminology (CPT) is the medical code set used to report medical, surgical, and diagnostic procedures and services

UseCPT codes are used for claims submission and to determine reimbursement and documentation requirements

AuthorityCPT codes are published and maintained by the American Medical Association (AMA)

E&M Codes — definition

E&M Codes — definitionEvaluation & Management (E&M) CPT codes (range 99202–99499) used to represent services that involve evaluation and management of patient health

ApplicationUsed for office, inpatient, ER, SNF, and other visit types with specific documentation guidelines

Guidance referencedMVP follows CMS 1995/1997 and 2021 Office and Other Outpatient Services guidelines for E&M documentation

Qualified Licensed Practitioner — definition

Qualified Licensed Practitioner — definitionA provider who is licensed and credentialed by MVP and acting within scope of practice

Supervision roleA qualified licensed practitioner may supervise and bill for services provided by a qualified non‑licensed practitioner when applicable

Use caseRelevant for supervised billing and Vermont audio‑only supervised billing rules

Qualified Non‑Licensed Practitioner — definition

Qualified Non‑Licensed Practitioner — definitionA provider actively working toward licensure as specified by their profession

Supervision requirementServices by such practitioners may be billed under supervised billing when direct supervision by a licensed practitioner is documented

LimitationServices by non‑licensed practitioners who cannot practice independently are non‑reimbursable for MVP Medicare members

Supervised Billing — definition

Supervised Billing — definitionBilling by a licensed practitioner for covered services provided by a non‑licensed practitioner under direct supervision

Billing fieldsFor supervised billing, supervising clinician NPI and taxonomy must be listed and appropriate modifiers (e.g., HO/HP) appended per policy guidance

ExclusionsMVP Medicare members are excluded from receiving services provided by non‑licensed providers even under supervision

Non‑reimbursable services for non‑licensed providers — policy note

Non‑licensed provider services — policy noteServices performed by a non‑licensed provider who cannot practice independently and is not actively working toward licensure are non‑reimbursable

Medicare exceptionMVP Medicare members are not eligible to receive services from non‑licensed providers even when supervised

ContextApplies across service lines where licensure is required for independent practice

Contrast material reimbursement rationale

Contrast inclusion rationaleNon‑ionic contrast considered inclusive to the primary procedure fee because its cost has approached ionic contrast and is routinely used; separate payment not warranted

Policy outcomeMVP will deny separate claims for contrast materials; contrast cost considered part of the exam fee

ApplicabilityThis rationale supports the denial of separate contrast material reimbursement across affected product lines

Diagnostic vs antibody testing — definition and distinction

Diagnostic vs antibody testing distinctionVirus/antigen detection (diagnostic) tests identify current infection; antibody (serology) tests may indicate prior exposure and per FDA should not be used to diagnose current infection

Policy coverageMVP covers COVID‑19 diagnostic/viral and antibody testing when medically appropriate for diagnosis and treatment

Coding practiceUse applicable CPT or HCPCS codes and follow CDC ICD‑10‑CM Official Coding Guidelines for diagnosis selection

Medical appropriateness — COVID‑19 testing requirement

Medical appropriateness requirementCOVID‑19 testing is covered only when medically appropriate for diagnosis and treatment of the member

Excluded reasonsTesting ordered solely for pandemic control, surveillance, employer/school screening, or member self‑assessment is not covered unless required by law

Audit riskClaims are subject to post‑payment review and audit; providers and members may be liable for denied claims

Nutritional Counseling — definition and provider requirements

Nutritional Counseling — when reimbursableReimbursable when medically necessary for chronic diseases where dietary adjustment has therapeutic role and when prescribed by a physician or qualified non‑physician practitioner

Qualified providersMust be furnished by recognized providers (licensed nutritionist, registered dietitian, or other qualified licensed health professionals trained in nutrition)

Service componentsMedical nutrition therapy includes assessment of nutritional status, individualized diet, counseling, and specialized nutrition therapies

Diabetic Management / DSME — definition and CMS/CDE requirements

Diabetic Management / DSME — definitionEducation and management for diabetes; DSME is medically necessary when member has a diabetes diagnosis and services are prescribed by a physician or qualified non‑physician practitioner

Provider qualificationsServices must be provided by licensed healthcare professionals who are certified diabetes educators (CDEs) such as registered dietitians or registered nurses

Reimbursable CPT/HCPCSG0108 and G0109 are reimbursable for diabetic management; 97802–97804 and G0270–G0271 apply for nutritional counseling as noted

Medical Nutrition Therapy — definition

Medical Nutrition Therapy — definitionAssessment of overall nutritional status and individualized diet/counseling by a registered dietitian to treat chronic illness

Billing codesReimbursable codes include 97802–97804 and G0270–G0271 when criteria met

DocumentationServices must be prescribed and furnished by qualified providers; Medicare MSA diagnosis restrictions may apply as specified

E09 series — drug/chemical induced diabetes mellitus (definition)

E09 series — definitionE09.* denotes drug or chemical‑induced diabetes mellitus and associated complications (retinopathy, neuropathy, circulatory, skin, oral complications)

Use caseE09 codes are listed extensively in the nutritional counseling/diabetic management appendices for diagnosis linkage

ExamplesExamples in policy include E09.3513, E09.3521, E09.3541 and many other complication‑specific subcodes

E10 series — Type 1 diabetes mellitus (definition)

E10 series — definitionE10.* denotes Type 1 diabetes mellitus and associated complications (retinopathy, nephropathy, neuropathy, skin complications, etc.)

Examples includedPolicy lists many E10 subcodes specifying laterality and complication details (e.g., E10.3211, E10.3311, E10.3511)

Billing linkageUsed to support medical necessity and reimbursement for DSME and nutritional counseling services when applicable

E11 series — Type 2 diabetes mellitus (definition)

E11 series — definitionE11.* denotes Type 2 diabetes mellitus and associated complications (retinopathy, neuropathy, chronic kidney disease, etc.)

Examples includedPolicy shows numerous E11 subcodes with laterality and complication specifications (e.g., E11.3211, E11.3311, E11.3411)

Use in policyE11 codes are referenced for eligibility of nutritional counseling and diabetic management services

E13 series — Other specified diabetes mellitus (definition)

E13 series — definitionE13.* denotes Other specified diabetes mellitus and associated complications

Examples includedPolicy lists many E13 subcodes including retinopathy, kidney disease, and pregnancy‑related codes (O24.*) in appendices

ImplicationUsed alongside E09–E11 code groups to determine diagnosis eligibility for nutrition/DSME services

Non‑reimbursable services — definition

Non‑reimbursable services — definitionServices not covered include commercial diet plans, gym memberships, holistic therapy, services offered by health resorts, supplemental fasting, and PT for weight loss

ScopeThese exclusions apply to nutritional counseling reimbursement determinations

Provider noteEnsure offered services meet reimbursable medical nutrition therapy criteria and are not excluded categories

Diabetes complication code entries — examples

Diabetes complication code examplesICD‑10 examples include codes for diabetic retinopathy, proliferative/nonproliferative variants, macular edema, nephropathy, CKD stages, neuropathy and oral complications

Appendix linkageThese code entries are used in the Appendix and diagnostic mapping sections to establish medical necessity for related services

Sample codesPolicy excerpts show E09.3521, E10.3511, E11.3411, E13.3211 among many others

Medical Necessity — CMS Medicare definition and documentation expectation

CMS Medicare medical necessity — payment criterionMedical necessity is the overarching payment criterion; documentation must support the level of service reported and billing a higher level when a lower level is warranted is inappropriate

Documentation expectationVolume of documentation should not be the primary influence for level of service; record must support billed service level

Application to claimsClaims may be denied if documentation does not support medical necessity per CMS/MVP guidance

Appendix — reference

Appendix referenceAppendix contains reimbursable diagnosis codes for listed laboratory services

UseConsult Appendix when submitting claims for laboratory services to ensure appropriate diagnosis linkage

LocationAppendix is part of the policy document and referenced in coding and diagnosis matching sections

Medicare Coverage Database — reference

Medicare Coverage Database — referencePolicy references CMS Medicare Coverage Database Advanced Search for diagnosis/procedure matching and LCD/NCD lookups

Use caseProviders should consult the Medicare Coverage Database when determining appropriate diagnosis codes for procedure claims

URL noteCMS Medicare Coverage Database Advanced Search link provided in policy references

Z79899 — code definition example

Z79899 — code meaningZ79899 = Other long term (current) drug therapy

ContextListed under Follicle Stimulating Hormone diagnosis examples in the Appendix

UseMay be used as an associated diagnosis for reproductive/endocrine evaluations referenced in policy appendix

Z170 — code definition example

Z170 — code meaningZ170 = Estrogen receptor positive status [ER+]

ContextIncluded among Follicle Stimulating Hormone related diagnosis examples in Appendix

ApplicationServes as an example diagnosis in reproductive/endocrine code listings

T7800XA — code definition example

T7800XA — code meaningT7800XA = Anaphylactic reaction due to unspecified food, initial encounter (listed in Gammaglobulin IgE examples)

ContextIncluded in Appendix Gammaglobulin IgE diagnosis listings for allergy‑related testing

Billing implicationUse appropriate acute reaction diagnosis when linking allergy testing claims to medical necessity

Z0182 — code definition example

Z0182 — code meaningZ0182 = Encounter for allergy testing

ContextListed with Gammaglobulin IgE and allergy testing diagnosis examples in Appendix

Claim noteUse encounter code Z0182 when appropriate to reflect allergy testing encounters per policy guidance

D824 — code definition example

D824 — code meaningD824 = Hyperimmunoglobulin E [IgE] syndrome

ContextIncluded in ESR and Gammaglobulin IgE related ICD‑10 lists in the Appendix

Clinical relevanceUsed to support medical necessity for related immunologic laboratory testing when clinically indicated

Policy Summary

PayerMVP Health Care

PolicyMVP Health Care 2022 Payment Policies (selected sections)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJun 1, 2022

Last ReviewJun 1, 2022

Next Review DateMar 1, 2022

Key ActionProviders must check member eligibility and consult the Member Benefits Display and MVP Utilization Management Guides for prior authorization requirements.

SourceLink

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MVP Health Care 2022 Payment Policies (selected sections)

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Coverage Criteria and Clinical Billing Rules

E&M coverage criteria

Covered when ALL of the following are met:

Service is 'Medically Necessary' as defined by MVP/AMA/CMS (services necessary to prevent, diagnose, or treat illness and consistent with accepted standards).

Member eligibility and benefit specifics have been verified prior to providing the service.

Medical records support the level of service billed and may be requested for audit or medical review.

Allergy testing coverage criteria

Covered when ALL of the following are met:

Allergy testing and serum preparation services are medically necessary and ordered by an appropriate provider.

The claim specifies the number of units/tests/doses performed.

Unit limits

95165 (supervision of preparation/provision of antigens): First year limited to 40 units per claim and 160 units per calendar year; subsequent years limited to 30 units per claim and 120 units per calendar year.
95004 (percutaneous skin tests): Reimbursement limited to 80 units per calendar year.
95024 and 95027 (intradermal tests / sequential airborne tests): Reimbursement limited to 40 units per calendar year.
95028 (intracutaneous delayed reaction tests): Reimbursement limited to 30 units per calendar year.

Allergy injections (95115–95149 series) require modifier 25 and an accompanying E&M/Inpatient/ER visit to be reimbursed (per Modifier 25 policy).

After-Hours billing criteria

After-hours E/M codes may be billed only under the following conditions:

An after-hours CPT code (99050–99060) must be billed with an appropriate E&M code to be reimbursable.

After-hours codes are not payable if they are the only CPT procedure(s) listed on the claim (must accompany an E&M).

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E&M reimbursement criteria

Reimbursed when ALL applicable rules below are satisfied:

Only one E&M CPT code is allowed per day per physician group per specialty.

Diabetes education codes (e.g., 98960) are reimbursed only when billed alone and will deny if billed with an E&M office visit (bundled).

Immunization administration codes (90460–90474, G0008–G0010) are reimbursed only when billed with diagnosis code Z23.

When two inpatient physician E&M codes are billed on the same date for the same/related condition by the same provider, the second E&M will be denied.

After-hours codes refer to the MVP After-Hours Payment Policy; 99050 is reimbursed unless submitted with preventive visit codes 99381-99397 as specified by contract.

Coverage criteria and billing rules

Provider reimbursement rules, limitations, and billing expectations (applies when listed conditions are met):

Inpatient: When two inpatient physician E&M codes are billed on the same date for the same/related condition by the same provider, the second E&M code will be denied.

Providers must verify member eligibility, benefits, and prior authorization requirements; MVP payment policies are not guarantees of payment.

Article 28 split billing criteria

Split billing (Article 28) is permitted only when ALL of the following conditions are met:

Billing entity is structured to meet Article 28 guidelines in New York or an equivalent standard in other states.

If global reimbursement methodology is used (one bill combining professional and technical components), no additional payments will be made to facilities under split billing methodology.

Audiology coverage and billing rules

Audiology services are covered when the following conditions are met:

Services are performed for prevention, identification, evaluation, selection/evaluation of hearing aids, rehabilitation, or medical diagnosis/treatment of the auditory system.

Audiologists may not bill E&M CPT codes 99201–99499.

If only one ear is tested, modifier 52 should be reported to indicate less than the normal bilateral procedure.

15-minute unit guidance applies to designated CPT codes (e.g., 1 unit = 8 to <23 minutes; 2 units = 23 to <38 minutes; 3 units = 38 to <53 minutes) per policy examples.

Clinical examples (appropriate reasons to order diagnostic testing)

Evaluation of suspected change in hearing, tinnitus, or balance.
Evaluation of cause of hearing/tinnitus/balance disorders or effect of medication, surgery, or other treatment.

Vermont audio-only and supervised billing criteria

Vermont-specific audio-only and supervised billing rules apply when ALL applicable conditions are met:

Audio-only (telephone) services are covered in Vermont and may be reimbursed equivalent to in-person codes when delivered via audio-only means.

Non-Physician/APRN Behavioral Health providers will be reimbursed for contract codes delivered audio-only but are not eligible to bill CPT codes 99441–99443.

Reimbursement for covered audio-only services is at 75% of the medical provider fee schedule for covered services delivered audio-only (Vermont only).

Coverage and exclusion criteria (partial document)

Coverage and exclusions — apply as stated below:

Coverage criteria and exclusions for COVID-19 testing

COVID-19 testing is covered when ALL of the following are satisfied:

Testing is medically appropriate for diagnosis and treatment of the individual member (clinical determination by provider).

Tests ordered solely for pandemic surveillance, reopening, employer/school screening, or member self-assessment are excluded from coverage unless required by law or regulation.

Providers are encouraged to use reliable FDA-authorized tests and must follow applicable ICD-10-CM coding guidance when selecting diagnosis codes.

Coverage criteria for nutritional counseling and diabetic management

Nutritional counseling and diabetic management are covered when ALL of the following are met:

Documentation for DSME includes assessment of education needs, self-management goals, education/behavioral interventions, and evaluation of goal attainment.

Reimbursable codes and limits

Medical nutrition therapy codes 97802–97804 and G0270–G0271 are reimbursable per policy.
For Medicare MSA plans only, reimbursement for 97802–97804 and G0270–G0271 is limited to specified ICD-10 diagnoses; other plans have no diagnosis restrictions.

Reimbursement criteria and exclusions

Reimbursable diabetic management services and exclusions:

G0108 (individual) and G0109 (group) diabetes outpatient self-management training services are reimbursable when medically necessary and properly documented.

Diagnosis matching and claim denial criteria

Claims for the listed procedures must meet the diagnosis-matching requirements below:

Procedure groups referenced

Transthoracic echocardiography codes (e.g., 93303–93308, 93350–93352): claims require diagnoses per Document ID #L33577/#A56781; Pediatric Cardiology specialty is excluded from this edit.
Facet joint procedures (64490–64495, 64625, 64633–64636): claims require diagnoses per Document ID #L33577/#A57826.
Corneal pachymetry (76514) and visual fields testing (92081–92083): claims require diagnoses per their respective LCD Document IDs (#L33630, #L33574) or will be denied for medical necessity.
Nerve conduction studies and EMG procedure codes require appropriate diagnoses per Document ID #L35098 or will be denied for medical necessity.

Diagnosis linkage and medical necessity requirement

Claims for the listed laboratory and diagnostic procedures require an appropriate diagnosis for medical necessity:

If the claim does not include the required diagnosis as specified by the referenced LCD/NCD or clinical guidance, MVP will deny the claim for lack of medical necessity.

Refer to the policy Appendix for reimbursable diagnosis codes associated with the listed laboratory services.

Reimbursable diagnosis codes (Appendix)

Appendix — reimbursable diagnosis codes (examples):

Providers should reference the Appendix to select appropriate diagnosis codes when submitting claims for the listed laboratory tests to avoid denials for medical necessity.

Code Lists and Billing Limits

After-Hours CPT codesCPTCovered

99050	After-hours office services; must be billed with an E&M; not reimbursable when submitted with preventive visit codes.
99051	After-hours evening/weekend; must be billed with an E&M; considered inclusive to the E&M; not reimbursed separately for Commercial and Medicare (Medicaid/HARP reimbursed at Medicaid rate).
99053	Services between 10:00 pm and 8:00 am at 24-hour facility; must be billed with an E&M; considered inclusive to the E&M; not reimbursed separately.
99056	Services provided out of office at patient request; must be billed with an E&M; considered inclusive to the E&M; not reimbursed separately.
99058	Emergency basis in office disrupting scheduled services; must be billed with an E&M; considered inclusive to the E&M; not reimbursed separately.
99060	Emergency basis out of office disrupting scheduled services; must be billed with an E&M; considered inclusive to the E&M; not reimbursed separately.

Allergy testing and serum preparation CPT codes and limitsCPTCovered

95165	Supervision of preparation and provision of antigens for allergen immunotherapy; units/doses must be specified on claim; first year limited to 40 units per claim and 160 units per calendar year; subsequent years limited to 30 units per claim and 120 units per calendar year.
95004	Percutaneous tests (scratch, puncture, prick) with allergenic extracts, immediate type reaction, including interpretation and report; number of tests must be specified; reimbursement limited to 80 units per calendar year.
95024	Intracutaneous (intradermal) tests with allergenic extracts, immediate type reaction, including interpretation and report; number of tests must be specified; reimbursement limited to 40 units per calendar year.
95027	Intracutaneous sequential/incremental tests for airborne allergens, immediate type reaction, including interpretation and report; number of tests must be specified; reimbursement limited to 40 units per calendar year.
95028	Intracutaneous tests with allergenic extracts, delayed type reaction, including reading; number of tests must be specified; reimbursement limited to 30 units per calendar year.

E&M coding guidancemixedCovered

No codes listed

E&M-related code groupsCPTCovered

99201-99499	E&M visit codes (general rules on bundling, duplicates, inpatient rules).
99381-99387, 99391-99397	Preventive medicine E&M codes (preventive visits; certain same-day procedures not reimbursed separately).
G0102	Manual rectal neoplasm screening — not reimbursed same day as 99202-99215 unless sole service.
36415, 36416, 99000, 99001, Q0091, 92567, 94760, 94761	Routine screening/lab procedures — generally not reimbursed separately same day as 99202-99215 unless sole service or external lab with modifier CG as specified.
99406, 99407, G0376, G0375, S9453, S9075	Smoking cessation counseling — not reimbursed unless member benefit indicates coverage.
98960	Diabetes education — reimbursed when billed alone; denied/bundled when billed with E&M office visit.
98925-98929	Osteopathic manipulation — not reimbursed unless contract exception.
90460-90474, G0008-G0010	Immunization administration — reimbursed only when billed with Z23 diagnosis.
95115-95149 series	Allergy injections — reimbursable only with an E&M/Inpatient/ER visit billed with modifier 25.
96900-96922 series	PUVA/UVA dermatologic treatments — reimbursable only with modifier 25 alongside E&M/Inpatient/ER visit.

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E&M generalCPTCovered

99201-99499

Evaluation and Management codes (inpatient and other E&M ranges).

After-hoursCPT

99050-99060

After-hours/E&M after-hour procedure codes; refer to After-Hours Payment Policy and contractual agreements for applicability.

Critical careCPT

99291	Critical care, first 30-74 minutes; reimbursed only if time ≥30 minutes per MVP rules (30-74 min = 99291 once).
99292	Critical care add-on unit(s) for additional time beyond initial period; additional 99292 units allowed per specified time blocks (75-104 min = 1 x 99292, 105-134 min = 2 x 99292, etc.).

Arthroscopic/Endoscopic scope proceduresmixed

arthroscopy/endoscopy families

Audiology coding limitations and timed-code rulesCPT | HCPCS | mixedCovered

99201-99499	E&M CPT codes that audiologists may not bill.
69209	Cerumen removal code — audiologists may not bill; included in diagnostic test RVUs.
69210	Cerumen removal code — audiologists may not bill; included in diagnostic test RVUs.
G0268	Physician code to bill when physician removes impacted cerumen same day as diagnostic test.

Audiology timed codes and telephone E/M codesCPT

92620	Evaluation of central auditory function, with report; initial 60 minutes (timed code billed only if testing ≥51% of designated time).
92621	Evaluation of central auditory function, with report; each additional 15 minutes.
92626	Evaluation of auditory rehabilitation status; first hour.
92627	Evaluation of auditory rehabilitation status; each additional 15 minutes.
92640	Diagnostic analysis with programming of auditory brainstem implant, per hour.
99441	Telephone E/M service; 5-10 minutes of medical discussion (audio-only POS 99, Modifier V3).
99442	Telephone E/M service; 11-20 minutes of medical discussion (audio-only POS 99, Modifier V3).
99443	Telephone E/M service; 21-30 minutes of medical discussion (audio-only POS 99, Modifier V3).

Contrast material HCPCS codesHCPCSNot Covered

A9579	Injection, gadolinium-based magnetic resonance contrast agent, per ml (not reimbursed separately).
Q9951	Low osmolar contrast material, 400+ mg/ml iodine concentration, per ml (not reimbursed separately).
Q9965	Low osmolar contrast material, 200-299 mg/ml iodine concentration, per ml (not reimbursed separately).
Q9966	Low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml (not reimbursed separately).
Q9967	Low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml (not reimbursed separately).
Q9958	High osmolar contrast material, up to 149 mg/ml iodine concentration, per ml (not reimbursed separately).
Q9959	High osmolar contrast material, 150-199 mg/ml iodine concentration, per ml (not reimbursed separately).
Q9960	High osmolar contrast material, 200-249 mg/ml iodine concentration, per ml (not reimbursed separately).
Q9961	High osmolar contrast material, 250-299 mg/ml iodine concentration, per ml (not reimbursed separately).
Q9962	High osmolar contrast material, 300-349 mg/ml iodine concentration, per ml (not reimbursed separately).

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COVID-19 testing codes and coding guidancemixed

Applicable COVID-19 procedure codes as published in CPT by AMA or HCPCS by CMS; providers should follow CDC ICD-10-CM Official Coding Guidelines when selecting diagnosis codes.

Denied/ inappropriate diagnosis codesICD-10Not Covered

Z02.0, Z02.1, Z02.4, Z02.5, Z02.79, Z02.89	Examples of primary diagnosis codes that will be denied when submitted for COVID-19 testing (administrative/exam reasons).
Z02.9, Z56.89, Z56.9, Z03.818, Z76, Z01.89, Z13.9, Z71.89, Z71.82, R68.89, B34.9, E55.9, Z03.89, E03.9, Z56.5, Z00.00, K21.9, E11.9, R10.9, N23	Additional example diagnosis codes considered inappropriate for COVID-19 testing reimbursement.
N39.0, R73.03, M54.5, E78.2, R07.89, K62.89, N89.8, M25.50, Z20.818, R42, Z09, K80.00, R07.9, N93.9, K29.00, I24.9, O24.419, E78.5, E16.2, J11.1, Z29.9, Z11.9	Further examples of diagnosis codes listed as non-reimbursable for COVID-19 testing.

Reimbursable nutritional counseling codesCPT | HCPCSCovered

97802	Medical nutritional therapy; initial assessment and intervention, individual, face-to-face, each 15 minutes.
97803	Medical nutritional therapy; reassessment and intervention, individual, face-to-face, each 15 minutes.
97804	Medical nutritional therapy; group (2+ individuals), each 30 minutes.
G0270	Medical nutritional therapy; reassessment and subsequent intervention(s) following second referral in same year, individual, each 15 minutes.
G0271	Medical nutritional therapy; reassessment and subsequent intervention(s) following second referral in same year, group, each 30 minutes.

Drug/chemical induced diabetes mellitus codesICD-10

E09.*

Drug or chemical induced diabetes mellitus and associated complication subcodes (multiple specific codes listed).

Type 1 diabetes mellitus codesICD-10

E10.*

Type 1 diabetes mellitus and associated complication subcodes (multiple specific codes listed).

Type 2 diabetes mellitus codesICD-10

E11.*

Type 2 diabetes mellitus and associated complication subcodes (multiple specific codes listed).

Other specified diabetes mellitus codesICD-10

E13.*

Other specified diabetes mellitus and associated complication subcodes (multiple specific codes listed).

ICD-10 diagnosis groups for nutritional counseling and diabetic managementICD-10Covered

E11.*	Type 2 diabetes mellitus codes with multiple complication subcodes listed (see policy excerpts).
E13.*	Other specified diabetes mellitus codes with multiple complication subcodes listed (see policy excerpts).
N18.*	Chronic kidney disease stages listed (N18.1, N18.2, N18.31, N18.32, N18.4, N18.5).
O24.*	Pregnancy-related diabetes codes (multiple O24 codes listed).
Z48.22	Encounter for aftercare following kidney transplant.

Reimbursable Diabetic Management CPT/HCPCSHCPCSCovered

G0108	Diabetes outpatient self-management training services, individual, per 30 minutes.
G0109	Diabetes outpatient self-management training services, group session (2 or more), per 30 minutes.

Diabetes ICD-10 code groupsICD-10

E09.*	Drug or chemical induced diabetes mellitus and complications (multiple specific codes listed).
E10.*	Type 1 diabetes mellitus and complications (multiple specific codes listed).
E11.*	Type 2 diabetes mellitus and complications (multiple specific codes listed).
E13.*	Other specified diabetes mellitus and complications (multiple specific codes listed).

Transthoracic echocardiographyCPTCovered

93303-93308	Transthoracic echocardiography for congenital cardiac anomalies and real-time transthoracic echocardiography groups referenced for diagnosis matching edits (93303-93308).
93350-93352	Transthoracic echocardiography during rest and cardiovascular stress testing (93350-93352).
93308	Echocardiography, transthoracic, real-time with image documentation (93308).
93306-93308	Real time transthoracic echocardiography code group (93306-93308) referenced for edits.

NCS and EMGCPTCovered

51785	Cystometrogram and related code listed in NCS/EMG group (included in group references).
92265	Ophthalmic diagnostic code referenced in NCS/EMG group (included in group references).
95860-95874	EMG and NCS procedure codes referenced for diagnosis matching edits.
95885-95887	Additional EMG/NCS related codes referenced.
95905-95913	NCS/EMG related procedure codes referenced.
95933	NCS/EMG group code referenced.
G0255	NCS-related code referenced.
95937	Neuromuscular junction testing code referenced for diagnosis matching edits.

Corneal pachymetryCPTCovered

76514

Ophthalmic ultrasound, diagnostic; corneal pachymetry, unilateral or bilateral (determination of corneal thickness).

Visual fields testingCPTCovered

92081	Visual field examination, extended quantitative.
92082	Visual field examination, intermediate.
92083	Visual field examination, standard.

Facet joint proceduresCPTCovered

64490-64495	Facet joint injections and related diagnostic/therapeutic injection codes (cervical, thoracic, lumbar, sacral).
64625	Destruction by neurolytic agent, paravertebral facet joint nerve; Cervical, Thoracic, Lumbar, or Sacral.
64633-64636	Medial branch radiofrequency neurotomy and related codes.

Corneal pachymetryCPTCovered

76514

Ophthalmic ultrasound, diagnostic; corneal pachymetry, unilateral or bilateral (determination of corneal thickness).

Visual field testingCPTCovered

92081	Visual field examination, extended quantitative.
92082	Visual field examination, intermediate.
92083	Visual field examination, standard.

Herpes simplex antibody testingCPTCovered

86695	Herpes simplex, type 1 antibody.
86696	Herpes simplex, type 2 antibody.

Vitamin D testingCPTCovered

82306	Vitamin D, 25 hydroxy.
82652	Vitamin D, 1,25-dihydroxy.

Sedimentation rateCPTCovered

85652

Erythrocyte sedimentation rate; automated.

Allergen/IgE assaysCPTCovered

82785	Assay of gammaglobulin IgE.
86003	Allergen specific IgE; crude allergen extract, each.
86008	Allergen specific IgE; recombinant/purified component, each.

Folic acid assayCPTCovered

82746

Assay of folic acid, serum.

Vitamin B12 testingCPTCovered

82607

Cyanocobalamin (Vitamin B12) assay.

Follicle stimulating hormone assayCPTCovered

83001

Gonadotropin, follicle stimulating (FSH).

Thyroid function testsCPTCovered

84436	Thyroid stimulating hormone (TSH).
84439	Thyroxine; total.
84479	Thyroxine tests (other).
84480	Triiodothyronine (T3) total.
84481	Triiodothyronine (Free T3).

Sample Follicle Stimulating Hormone-associated ICD-10 codesICD-10

Z79899	Other long term (current) drug therapy.
Z853	Personal history of malignant neoplasm of breast.
E1165	Type 2 diabetes mellitus with hyperglycemia.

Sample Herpes Simplex Virus-associated ICD-10 codesICD-10

B009	Herpesviral infection, unspecified.
B0052	Herpesviral keratitis.
Z01411	Encounter for gynecological examination with abnormal findings.

Sample Gammaglobulin IGE-associated ICD-10 codesICD-10

J309	Allergic rhinitis, unspecified.
L500	Allergic urticaria.
T7800XA	Anaphylactic reaction due to unspecified food, initial encounter.

Gammaglobulin IgE related ICD-10 codesICD-10

T63481A	Toxic effect of venom of wasps, accidental (unintentional), subsequent encounter.
T6391XA	Toxic effect of venom of other arthropod, accidental (unintentional), initial encounter.
T6391XS	Toxic effect of contact with unspecified venomous animal, accidental (unintentional), sequela.
T65811A	Toxic effect of latex, accidental (unintentional), initial encounter.
T7800XA	Anaphylactic reaction due to unspecified food, initial encounter.
T7801XA	Anaphylactic reaction due to peanuts, initial encounter.
T7801XD	Anaphylactic reaction due to peanuts, subsequent encounter.
Z0182	Encounter for allergy testing.
Z91010	Allergy to peanuts.
Z91030	Bee allergy status.

ESR related ICD-10 codes (excerpts)ICD-10

C029	Malignant neoplasm of tongue, unspecified.
C220	Liver cell carcinoma.
C3411	Malignant neoplasm of upper lobe, right bronchus, or lung.
C9000	Multiple myeloma not having achieved remission.
C9110	Chronic lymphocytic leukemia of B-cell type not having achieved remission.
D550	Anemia due to glucose-6-phosphate dehydrogenase [G6PD] deficiency.
D630	Anemia in neoplastic disease.
D689	Sarcoidosis, unspecified.
D824	Hyperimmunoglobulin E [IgE] syndrome.
D891	Cryoglobulinemia.