D4999 priced per prior authorization

D4999 is identified in the fee schedule as “Priced per prior authorization.” Providers must obtain prior authorization to determine the reimbursement amount for D4999 before billing.

Prior authorization required for pricing on flagged codes

Several listed codes are marked as “***” or explicitly noted as “Priced per prior authorization,” meaning providers must obtain prior authorization for price determination prior to submission.

• Examples include D5899, D5912, D5919 (marked/priced per prior authorization) and other entries noted with ***.

Surgical and prosthetic codes flagged for prior authorization

Multiple surgical and prosthetic procedure codes in the schedule are flagged “Priced per prior authorization”; providers must secure prior authorization to establish the payable amount for these codes.

• Examples in the schedule include D5933, D5937, D5983, D5984, D5985 (listed as priced per prior authorization).

Miscellaneous (open) codes priced per prior authorization

Miscellaneous and unlisted (open) codes such as D7999 and D8999 are shown as priced per prior authorization; providers must request authorization to determine reimbursement for these miscellaneous codes.

• D7999 is shown with *** and marked “Priced per prior authorization.”
• D8999 is shown with *** and marked “Priced per prior authorization.”

Open-code prior authorization and pricing references

Open codes (e.g., D8999, D9999) are priced per prior authorization and referenced in Gainwell Technologies/BMS Edit 225; providers must obtain prior authorization to determine payment amounts for these open codes.

• D8999 and D9999 are explicitly listed as *** / Priced per prior authorization.
• The schedule notes that open codes priced per prior authorization are located in Gainwell Technologies/BMS Edit 225.