36C10G20R0014-026.xlsx
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- Solicitation number
- 36C10G20R0014
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This document provides details on a forthcoming federal contract solicitation from the Department of Veterans Affairs for community care network services in Alaska. The solicitation will be for a single-award firm fixed price indefinite delivery indefinite quantity contract with a 9-month base period and seven 1-year option periods. The contractor will be responsible for establishing and maintaining a network of licensed healthcare providers to deliver medical, surgical, pharmacy, dental and other services to eligible Veterans throughout Alaska. Additional responsibilities will include exemplary customer service, quality monitoring and management, and claims processing and payment. Offers are due on or about June 1, 2020 and the contract is expected to be awarded under full and open competition. All interested parties must register in SAM under NAICS code 524292 in order to receive the solicitation, anticipated to be posted to beta.sam.gov on or about May 11, 2020.
36C10G20R0014 CCN Region 5 Attachment AO - ART Codes by SEOC.xlsx
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CPT Crosswalk 1.0.2 Episode of Care Infertility-ART-IVF Female 1.0.2
Included services CPT/HCPCS code Short Description
| Evaluation and Management | ||
| Initial outpatient evaluation and treatment for infertility | ||
| 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99354, 99355, 99356, 99357, 99358, 99359, 90024, 99078, 99217, 99218, 99219, 99220 | ||
| 99201 | New patient, which requires these 3 key components, problem focused history, problem focused exam, and medical decision making of straightforward presenting problems are usually self-limited or minor problem, typically 10 minutes | |
| 99202 | New patient, which requires these 3 key components, expanded problem focused history, expanded problem focused exam, and medical decision making of straightforward. Presenting problems are usually low to moderate severity problem, typically 20 minutes | |
| 99203 | New patient, which requires these 3 key components, detailed history, detailed exam, and medical decision making of low complexity. Presenting problems are usually moderate severity problem, typically 30 minutes | |
| 99204 | New patient, which requires these 3 key components, comprehensive history, comprehensive, and medical decision making of moderate. Presenting problems are usually moderate to high severity problem, typically 45 minutes | |
| 99205 | New patient, which requires these 3 key components, comprehensive history, comprehensive, and medical decision making of high. Presenting problems are usually high severity problem, typically 60 minutes | |
| 99211 | Established patient, may not require the presence of a physician or other qualifies health care professional. Minimal presenting problems, typically 5 minutes | |
| 99212 | Established patient, which requires at least 2 of these 3 key components: problem focused history, problem focused exam, and straight forward medical decision making. Presenting problems are usually self-limited or minor problem, typically 10 minutes | |
| 99213 | Established patient, which requires at least 2 of these 3 key components: expanded problem focused history, expanded problem focused exam, and low medical decision making. Presenting problems are usually low to moderate severity problem, typically 15 minutes | |
| 99214 | Established patient, which requires at least 2 of these 3 key components: detailed history, detailed exam, and moderate medical decision making. Presenting problems are usually moderate severity problem, typically 25 minutes | |
| 99215 | Established patient, which requires at least 2 of these 3 key components: comprehensive history, comprehensive exam, and high medical decision making. Presenting problems are usually Moderate to high severity problem, typically 40 minutes | |
| 99358 | Prolonged service without direct patient contact, any setting, must be during the same session as another evaluation and management service (may be reported on a different date than the primary service to which it is related) and is beyond the usual physical or other qualified health care profession service time, before and/or after direct patient care, first hour | |
| add-on 99354 | Prolonged evaluation and management or psychotherapy services in the office or other outpatient setting requiring direct patient contact beyond the usual service, does not have to be continuous but must be in the same day, first hour | |
| add-on 99355 | Prolonged evaluation and management or psychotherapy services in the office or other outpatient setting requiring direct patient contact beyond the usual service, does not have to be continuous but must be in the same day, each additional 30 minutes. | |
| add-on 99356 | Prolonged service without direct patient contact, any setting, must be during the same session as another evaluation and management service (may be reported on a different date than the primary service to which it is related) and is beyond the usual physical or other qualified health care profession service time, before and/or after direct patient care, each additional 30 minutes | |
| add-on 99357 | Prolonged service in the inpatient or observation setting requiring unit/floor time beyond the usual service, each additional 30 minutes | |
| add-on 99359 | Prolonged service without direct patient contact, any setting, must be during the same session as another evaluation and management service (may be reported on a different date than the primary service to which it is related) and is beyond the usual physical or other qualified health care profession service time, before and/or after direct patient care, each additional 30 minutes | |
| 99024 | Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure | |
| 99078 | Physician or other qualified health care professional qualified by education, training, licensure/regulation (when applicable) educational services rendered to patients in a group setting (eg, prenatal, obesity, or diabetic instructions) | |
| 99217 | Observation care discharge day management (This code is to be utilized to report all services provided to a patient on discharge from outpatient hospital "observation status" if the discharge is on other than the initial date of "observation status." To report services to a patient designated as "observation status" or "inpatient status" and discharged on the same date, use the codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-99236 as appropriate.]) | |
| 99218 | Initial observation care, per day, which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity. Typically, 30 minutes are spent at the bedside and on the patient's hospital floor or unit. | |
| 99219 | Initial observation care, per day, requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Typically, 50 minutes are spent at the bedside and on the patient's hospital floor or unit. | |
| 99220 | Initial observation care, per day, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit. | |
| Diagnostic imaging relevant to the referred condition on the consult | ||
| 70145 | Radiologic examination, chest; single view | |
| 71046 | Radiologic examination, chest; 2 views | |
| 71047 | Radiologic examination, chest; 3 views | |
| 71048 | Radiologic examination, chest; 4 or more views | |
| 74740 | Hysterosalpingography, radiological supervision and interpretation | |
| 74742 | Transcervical catheterization of fallopian tube, radiological supervision and interpretation | |
| 76830 | Ultrasound, transvaginal | |
| 76812 | Magnetic resonance (eg, proton) imaging, fetal, including placental and maternal pelvic imaging when performed; each additional gestation (List separately in addition to code for primary procedure) | |
| 76815 | Ultrasound, pregnant uterus, real time with image documentation, limited (eg, fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume), 1 or more fetuses | |
| 76816 | Ultrasound, pregnant uterus, real time with image documentation, follow-up (eg, re-evaluation of fetal size by measuring standard growth parameters and amniotic fluid volume, re-evaluation of organ system(s) suspected or confirmed to be abnormal on a prev | |
| 76830 | Ultrasound, transvaginal | |
| 76831 | Saline infusion sonohysterography (SIS), including color flow Doppler, when performed | |
| 76844 | Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation | |
| 76941 | Ultrasonic guidance for intrauterine fetal transfusion or cordocentesis, imaging supervision and interpretation | |
| 76948 | Ultrasonic guidance for aspiration of ova, imaging supervision and interpretation | |
| 93000 | Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report | |
| 93005 | Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report | |
| 93010 | Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only | |
| 99070 | Supplies and materials (except spectacles), provided by the physician or other qualified health care professional over and above those usually included with the office visit or other services rendered (list drugs, trays, supplies, or materials provided) | |
| Labs and pathology relevant to the referred condition on the consult | ||
| 36415, 36416, 80047, 80048, 80050, 80053, 80076, 80414, 80415, 80426, 81000, 81001, 81002, 81003, 81005, 81007, 81015, 81025, 82670, 83001, 83002, 84144, 84702, 84703, 84704, 85025, 85610, 85730 | 36415 | Collection of venous blood by venipuncture |
| 36416 | Collection of capillary blood specimen (eg, finger, heel, ear stick) | |
| 80047 | Basic metabolic panel (Calcium, ionized) This panel must include the following: Calcium, ionized (82330) Carbon dioxide (bicarbonate) (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Potassium (84132) Sodium (84295) Urea Nitrogen (BUN) (84520) | |
| 80048 | Basic metabolic panel (Calcium, total) This panel must include the following: Calcium, total (82310) Carbon dioxide (bicarbonate) (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Potassium (84132) Sodium (84295) Urea nitrogen (BUN) (84520) | |
| 80050 | General health panel This panel must include the following: Comprehensive metabolic panel (80053) Blood count, complete (CBC), automated and automated differential WBC count (85025 or 85027 and 85004) OR Blood count, complete (CBC), automated (85027) and appropriate manual differential WBC count (85007 or 85009) Thyroid stimulating hormone (TSH) (84443) | |
| 80053 | Comprehensive metabolic panel This panel must include the following: Albumin (82040) Bilirubin, total (82247) Calcium, total (82310) Carbon dioxide (bicarbonate) (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Phosphatase, alkaline (84075) Potassium (84132) Protein, total (84155) Sodium (84295) Transferase, alanine amino (ALT) (SGPT) (84460) Transferase, aspartate amino (AST) (SGOT) (84450) Urea nitrogen (BUN) (84520) | |
| 80076 | Hepatic function panel This panel must include the following: Albumin (82040) Bilirubin, total (82247) Bilirubin, direct (82248) Phosphatase, alkaline (84075) Protein, total (84155) Transferase, alanine amino (ALT) (SGPT) (84460) Transferase, aspartate amino (AST) (SGOT) (84450) | |
| 80414 | Chorionic gonadotropin stimulation panel; testosterone response This panel must include the following: Testosterone (84403 x 2 on 3 pooled blood samples) | |
| 80415 | Chorionic gonadotropin stimulation panel; estradiol response This panel must include the following: Estradiol (82670 x 2 on 3 pooled blood samples) | |
| 80426 | Gonadotropin releasing hormone stimulation panel This panel must include the following: Follicle stimulating hormone (FSH) (83001 x 4) Luteinizing hormone (LH) (83002 x 4) | |
| 81000 | Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, with microscopy | |
| 81001 | Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, with microscopy | |
| 81002 | Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, without microscopy | |
| 81003 | Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, without microscopy | |
| 81005 | Urinalysis; qualitative or semiquantitative, except immunoassays | |
| 81007 | Urinalysis; bacteriuria screen, except by culture or dipstick | |
| 81015 | Urinalysis; microscopic only | |
| 81025 | Urine pregnancy test, by visual color comparison methods | |
| 82670 | Estradiol | |
| 83001 | Gonadotropin; follicle stimulating hormone (FSH) | |
| 83002 | Gonadotropin; luteinizing hormone (LH) | |
| 84402 | Testosterone; free | |
| 84403 | Testosterone; total | |
| 84144 | Progesterone | |
| 84702 | Gonadotropin, chorionic (hCG); quantitative | |
| 84703 | Gonadotropin, chorionic (hCG); qualitative | |
| 84704 | Gonadotropin, chorionic (hCG); free beta chain | |
| 85025 | Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC count | |
| 85610 | Prothrombin time; | |
| 85730 | Thromboplastin time, partial (PTT); plasma or whole blood | |
| Diagnostic studies relevant to the referred condition on the consult | ||
| 84830, 88248, 88261, 88262, 88263, 88267, 88269, 88271, 88280, 88283, 88285 | 84830 | Ovulation tests, by visual color comparison methods for human luteinizing hormone Flow cytometry, cell cycle or DNA analysis |
| 88271 | Molecular cytogenetics; DNA probe, each (eg, FISH) | |
| 88280 | Chromosome analysis; additional karyotypes, each study | |
| 88263 | Chromosome analysis; count 45 cells for mosaicism, 2 karyotypes, with banding | |
| 88262 | Chromosome analysis; count 15-20 cells, 2 karyotypes, with banding | |
| 88248 | Chromosome analysis for breakage syndromes; baseline breakage, score 50-100 cells, count 20 cells, 2 karyotypes (eg, for ataxia telangiectasia, Fanconi anemia, fragile X) | |
| 88261 | Chromosome analysis; count 5 cells, 1 karyotype, with banding | |
| 88267 | Chromosome analysis, amniotic fluid or chorionic villus, count 15 cells, 1 karyotype, with banding | |
| 88269 | Chromosome analysis, in situ for amniotic fluid cells, count cells from 6-12 colonies, 1 karyotype, with banding | |
| 88283 | Chromosome analysis; additional specialized banding technique (eg, NOR, C-banding) | |
| 88285 | Chromosome analysis; additional cells counted, each study Culture of oocyte(s)/embryo(s), less than 4 days; | |
| Procedures to include: ovarian stimulation medications (oral and/or injectable), oocyte harvesting, In-vitro insemination (IVF) including intra-cytoplasmic sperm injection (ICSI), embryo culture, fresh or frozen embryo transfer, cryopreservation techniques and genetic testing as indicated. Ovarian stimulation with multiple labs and ultrasounds | ||
| 00965, 00842, 58321, 58322, 58323, 58340, 58345, 58350, 58558, 58559, 58560, 58561, 58970, 58974, 58976, 59160, 59812, 59820, 59821, 59830, 76376, 76700, 76856, 76857 89250, 89251, 89253, 89254, 89255, 89258, 89268, 89272, 89280, 89281, 89290, 89291, 89325, 89352, 89354, S3800, S4011 S4013, S4014, S4015, S4016, , S4017, S1018, S4020, S4021, S4022, S4037, S4042 | ||
| 01965 | Anesthesia for incomplete or missed abortion procedures | |
| 00842 | Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; amniocentesis | |
| 58321 | Artificial insemination; intra-cervical | |
| 58322 | Artificial insemination; intra-uterine | |
| 58323 | Sperm washing for artificial insemination | |
| 58340 | Catheterization and introduction of saline or contrast material for saline infusion sonohysterography (SIS) or hysterosalpingography | |
| 58345 | Transcervical introduction of fallopian tube catheter for diagnosis and/or re- establishing patency (any method), with or without hysterosalpingography | |
| 58350 | Chromotubation of oviduct, including materials | |
| 58558 | Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D & C | |
| 58559 | Hysteroscopy, surgical; with lysis of intrauterine adhesions (any method) | |
| 58560 | Hysteroscopy, surgical; with division or resection of intrauterine septum (any method) | |
| 58561 | Hysteroscopy, surgical; with removal of leiomyomata | |
| 58970 | Follicle puncture for oocyte retrieval, any method | |
| 58974 | Embryo transfer, intrauterine | |
| 58976 | Gamete, zygote, or embryo intrafallopian transfer, any method |
| 59812 | Treatment of incomplete abortion, any trimester, completed surgically | |
| 59820 | Treatment of missed abortion, completed surgically; first trimester | |
| 59821 | Treatment of missed abortion, completed surgically; second trimester | |
| 59830 | Treatment of septic abortion, completed surgically | |
| 59160 | Curettage, postpartum | |
| 76376 | 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; not requiring image postprocessing on an independent workstation | |
| 76700 | Ultrasound, abdominal, real time with image documentation; complete | |
| 76856 | Ultrasound, pelvic (nonobstetric), real time with image documentation; complete | |
| 76857 | Ultrasound, pelvic (nonobstetric), real time with image documentation; limited or follow-up (e.g., for follicles) | |
| 89250 | Culture of oocyte(s)/embryo(s), less than 4 days; | |
| 89251 | Culture of oocyte(s)/embryo(s), less than 4 days; with co-culture of oocyte(s)/embryos | |
| 89253 | Assisted embryo hatching, microtechniques (any method) | |
| 89254 | Oocyte identification from follicular fluid | |
| 89255 | Preparation of embryo for transfer (any method) | |
| 89258 | Cryopreservation; embryo(s) | |
| 89268 | Insemination of oocytes | |
| 89272 | Extended culture of oocyte(s)/embryo(s), 4-7 days | |
| 89280 | Assisted oocyte fertilization, microtechnique; less than or equal to 10 oocytes | |
| 89281 | Assisted oocyte fertilization, microtechnique; greater than 10 oocytes | |
| 89290 | Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); less than or equal to 5 embryos | |
| 89291 | Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); greater than 5 embryos | |
| 89325 | Sperm antibodies | |
| 89352 | Thawing of cryopreserved; embryo(s) | |
| 89354 | Thawing of cryopreserved; reproductive tissue, testicular/ovarian | |
| J0725 | Injection, chorionic gonadotropin, per 1,000 USP units | |
| J3355 | Injection, urofollitropin, 75 IU | |
| S0265 | Genetic counseling, under physician supervision, each 15 minutes | |
| S0610 | Annual gynecological examination, new patient | |
| S0612 | Annual gynecological examination, established patient | |
| S0122 | Injection, menotropins, 75 IU | |
| S0126 | Injection, follitropin alfa, 75 IU | |
| S0128 | Injection, follitropin beta, 75 IU | |
| S0132 | Injection, ganirelix acetate, 250 mcg | |
| s3800 | Genetic testing for amyotrophic lateral sclerosis (ALS) | |
| S4016 | Frozen in vitro fertilization cycle, case rate | |
| S4017 | Incomplete cycle, treatment cancelled prior to stimulation, case rate | |
| S4011 | In vitro fertilization; including but not limited to identification and incubation of mature oocytes, fertilization with sperm, incubation of embryo(s), and subsequent visualization for determination of development | |
| S4015 | Complete in vitro fertilization cycle, not otherwise specified, case rate | |
| S4020 | In vitro fertilization procedure cancelled before aspiration, case rate | |
| S4021 | In vitro fertilization procedure cancelled after aspiration, case rate | |
| S4018 | Frozen embryo transfer procedure cancelled before transfer, case rate | |
| S4022 | Assisted oocyte fertilization, case rate | |
| S4013 | Complete cycle, gamete intrafallopian transfer (GIFT), case rate | |
| S4014 | Complete cycle, zygote intrafallopian transfer (ZIFT), case rate | |
| S4037 | Cryopreserved embryo transfer, case rate | |
| S4042 | Management of ovulation induction (interpretation of diagnostic tests and studies, nonface-to-face medical management of the patient), per cycle | |
| ** Need to include codes for testing pap smear | ||
| 88141, 88142, 88143, 88147, 88148, 88150, 88152, 88153, 88155, 88164, 88165, 88166, 88167, 88174, 88175, G0101, G0123, G0124, G0141, G0143, G0144, G0145, G0147, G0148, P3000, P3001, Q0091 | ||
| 88147 | Cytopathology smears, cervical or vaginal; screening by automated system under physician supervision | |
| 88148 | Cytopathology smears, cervical or vaginal; screening by automated system with manual rescreening under physician supervision | |
| 88152 | Cytopathology, slides, cervical or vaginal; with manual screening and computer-assisted rescreening under physician supervision | |
| 88141 | Cytopathology, cervical or vaginal (any reporting system), requiring interpretation by physician | |
| 88142 | Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; manual screening under physician supervision | |
| 88150 | Cytopathology, slides, cervical or vaginal; manual screening under physician supervision | |
| 88153 | Cytopathology, slides, cervical or vaginal; with manual screening and rescreening under physician supervision | |
| 88155 | Cytopathology, slides, cervical or vaginal, definitive hormonal evaluation (eg, maturation index, karyopyknotic index, estrogenic index) (List separately in addition to code[s] for other technical and interpretation services) | |
| 88143 | Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; with manual screening and rescreening under physician supervision | |
| 88164 | Cytopathology, slides, cervical or vaginal (the Bethesda System); manual screening under physician supervision | |
| 88165 | Cytopathology, slides, cervical or vaginal (the Bethesda System); with manual screening and rescreening under physician supervision | |
| 88167 | Cytopathology, slides, cervical or vaginal (the Bethesda System); with manual screening and computer-assisted rescreening using cell selection and review under physician supervision | |
| 88166 | Cytopathology, slides, cervical or vaginal (the Bethesda System); with manual screening and computer-assisted rescreening under physician supervision | |
| 88174 | Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; screening by automated system, under physician supervision | |
| 88175 | Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; with screening by automated system and manual rescreening or review, under physician supervision | |
| P3000 | Screening Papanicolaou smear, cervical or vaginal, up to 3 smears, by technician under physician supervision | |
| P3001 | Screening Papanicolaou smear, cervical or vaginal, up to 3 smears, requiring interpretation by physician | |
| Q0091 | Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory | |
| G0101 | Cervical or vaginal cancer screening; pelvic and clinical breast examination | |
| G0123 | Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, screening by cytotechnologist under physician supervision | |
| G0124 | Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, requiring interpretation by physician | |
| G0148 | Screening cytopathology smears, cervical or vaginal, performed by automated system with manual rescreening | |
| G0147 | Screening cytopathology smears, cervical or vaginal, performed by automated system under physician supervision | |
| G0141 | Screening cytopathology smears, cervical or vaginal, performed by automated system, with manual rescreening, requiring interpretation by physician | |
| G0143 | Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and rescreening by cytotechnologist under physician supervision | |
| G0144 | Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with screening by automated system, under physician supervision | |
| G0145 | Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with screening by automated system and manual rescreening under physician supervision | |
| 00840 | Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; not otherwise specified | |
| 10021 | Fine needle aspiration; without imaging guidance | |
| 10022 | Fine needle aspiration; with imaging guidance | |
| 58140 | Myomectomy, excision of fibroid tumor(s) of uterus, 1 to 4 intramural myoma(s) with total weight of 250 g or less and/or removal of surface myomas; abdominal approach | |
| 58145 | Myomectomy, excision of fibroid tumor(s) of uterus, 1 to 4 intramural myoma(s) with total weight of 250 g or less and/or removal of surface myomas; vaginal approach | |
| 58146 | Myomectomy, excision of fibroid tumor(s) of uterus, 5 or more intramural myomas and/or intramural myomas with total weight greater than 250 g, abdominal approach | |
| 58540 | Hysteroplasty, repair of uterine anomaly (Strassman type) | |
| 58545 | Laparoscopy, surgical, myomectomy, excision; 1 to 4 intramural myomas with total weight of 250 grams or less and/or removal of surface myomas | |
| 58546 | Laparoscopy, surgical, myomectomy, excision; 5 or more intramural myomas and/or intramural myomas with total weight greater than 250 grams | |
| 58555 | Hysteroscopy, diagnostic (separate procedure) | |
| 58660 | Laparoscopy, surgical; with lysis of adhesions (salpingolysis, ovariolysis) (separate procedure) | |
| 58662 | Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method | |
| 58670 | Laparoscopy, surgical; with fulguration of oviducts (with or without transection) | |
| 58672 | Laparoscopy, surgical; with fimbrioplasty | |
| 58673 | Laparoscopy, surgical; with salpingostomy (salpingoneostomy) | |
| 58679 | Unlisted laparoscopy procedure, oviduct, ovary | |
| 58700 | Salpingectomy, complete or partial, unilateral or bilateral (separate procedure) | |
| 58740 | Lysis of adhesions (salpingolysis, ovariolysis) | |
| 58752 | Tubouterine implantation | |
| 58760 | Fimbrioplasty | |
| 58770 | Salpingostomy (salpingoneostomy) | |
| 58800 | Drainage of ovarian cyst(s), unilateral or bilateral, (separate procedure); vaginal approach | |
| 58805 | Drainage of ovarian cyst(s), unilateral or bilateral, (separate procedure); abdominal approach | |
| 58920 | Wedge resection or bisection of ovary, unilateral or bilateral | |
| 76942 | Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation | |
| 83498 | Hydroxyprogesterone, 17-d | |
| 83520 | Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative, not otherwise specified | |
| 88182 | Flow cytometry, cell cycle or DNA analysis | |
| 88273 | Molecular cytogenetics; chromosomal in situ hybridization, analyze 10-30 cells (e.g., for microdeletions) | |
| 89260 | Sperm isolation; simple prep (e.g., sperm wash and swim-up) for insemination or diagnosis with semen analysis | |
| 89261 | Sperm isolation; complex prep (e.g., Percoll gradient, albumin gradient) for insemination or diagnosis with semen analysis | |
| 89264 | Sperm identification from testis tissue, fresh or cryopreserved | |
| 89300 | Semen analysis; presence and/or motility of sperm including Huhner test (post coital) | |
| 89300 | Semen analysis; presence and/or motility of sperm including Huhner test (post coital) | |
| 89310 | Semen analysis; motility and count (not including Huhner test) | |
| 89320 | Semen analysis; volume, count, motility, and differential | |
| 89321 | Semen analysis; sperm presence and motility of sperm, if performed | |
| 89322 | Semen analysis; volume, count, motility, and differential using strict morphologic criteria (e.g., Kruger) | |
| 89331 | Sperm evaluation, for retrograde ejaculation, urine (sperm concentration, motility, and morphology, as indicated) | |
| 89353 | Thawing of cryopreserved; sperm/semen, each aliquot | |
| 99000 | Handling and/or conveyance of specimen for transfer from the office to a laboratory | |
| G0027 | Semen analysis; presence and/or motility of sperm excluding Huhner | |
| S3600 | Stat laboratory request (situations other than s3601) | |
| S3655 | Antisperm antibodies test (immunobead) | |
| S4027 | Storage of previously frozen embryos | |
| S4028 | Microsurgical epididymal sperm aspiration (mesa) | |
| S4030 | Sperm procurement and cryopreservation services; initial visit | |
| S4031 | Sperm procurement and cryopreservation services; subsequent visit | |
| S4035 | Stimulated intrauterine insemination (IUI), case rate |
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Episode of Care ART-IVF Male SEOC 1.1.2
| Included services | CPT/HCPCS code | Short Description |
| 1. Initial outpatient evaluation and treatment for infertility | ||
| 2. 10 visits for diagnostic imaging/studies, lab and pathology services relevant to the patient complaint/condition | ||
| 3. Procedures to obtain viable sperm for reproductive efforts to include: surgical procedures, sperm extraction techniques | ||
| 4. Cryopreservation techniques | ||
| 5. Sperm genetic testing related to sperm function and viability | ||
| 6. Please see attached consultation for number of cycles approved. | ||
| Evaluation and Management | ||
| 99201 | New patient, which requires these 3 key components, problem focused history, problem focused exam, and medical decision making of straightforward presenting problems are usually self-limited or minor problem, typically 10 minutes | |
| 99202 | New patient, which requires these 3 key components, expanded problem focused history, expanded problem focused exam, and medical decision making of straightforward. Presenting problems are usually low to moderate severity problem, typically 20 minutes | |
| 99203 | New patient, which requires these 3 key components, detailed history, detailed exam, and medical decision making of low complexity. Presenting problems are usually moderate severity problem, typically 30 minutes | |
| 99204 | New patient, which requires these 3 key components, comprehensive history, comprehensive, and medical decision making of moderate. Presenting problems are usually moderate to high severity problem, typically 45 minutes | |
| 99205 | New patient, which requires these 3 key components, comprehensive history, comprehensive, and medical decision making of high. Presenting problems are usually high severity problem, typically 60 minutes | |
| 99211 | Established patient, may not require the presence of a physician or other qualifies health care professional. Minimal presenting problems, typically 5 minutes | |
| 99212 | Established patient, which requires at least 2 of these 3 key components: problem focused history, problem focused exam, and straight forward medical decision making. Presenting problems are usually self-limited or minor problem, typically 10 minutes | |
| 99213 | Established patient, which requires at least 2 of these 3 key components: expanded problem focused history, expanded problem focused exam, and low medical decision making. Presenting problems are usually low to moderate severity problem, typically 15 minutes | |
| 99214 | Established patient, which requires at least 2 of these 3 key components: detailed history, detailed exam, and moderate medical decision making. Presenting problems are usually moderate severity problem, typically 25 minutes | |
| 99215 | Established patient, which requires at least 2 of these 3 key components: comprehensive history, comprehensive exam, and high medical decision making. Presenting problems are usually Moderate to high severity problem, typically 40 minutes | |
| 99358 | Prolonged service without direct patient contact, any setting, must be during the same session as another evaluation and management service (may be reported on a different date than the primary service to which it is related) and is beyond the usual physical or other qualified health care profession service time, before and/or after direct patient care, first hour | |
| add-on 99354 | Prolonged evaluation and management or psychotherapy services in the office or other outpatient setting requiring direct patient contact beyond the usual service, does not have to be continuous but must be in the same day, first hour | |
| add-on 99355 | Prolonged evaluation and management or psychotherapy services in the office or other outpatient setting requiring direct patient contact beyond the usual service, does not have to be continuous but must be in the same day, each additional 30 minutes. | |
| add-on 99356 | Prolonged service without direct patient contact, any setting, must be during the same session as another evaluation and management service (may be reported on a different date than the primary service to which it is related) and is beyond the usual physical or other qualified health care profession service time, before and/or after direct patient care, each additional 30 minutes | |
| add-on 99357 | Prolonged service in the inpatient or observation setting requiring unit/floor time beyond the usual service, each additional 30 minutes | |
| add-on 99359 | Prolonged service without direct patient contact, any setting, must be during the same session as another evaluation and management service (may be reported on a different date than the primary service to which it is related) and is beyond the usual physical or other qualified health care profession service time, before and/or after direct patient care, each additional 30 minutes | |
| 99024 | Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure | |
| 99217 | Observation care discharge day management (This code is to be utilized to report all services provided to a patient on discharge from outpatient hospital "observation status" if the discharge is on other than the initial date of "observation status." To report services to a patient designated as "observation status" or "inpatient status" and discharged on the same date, use the codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-99236 as appropriate.]) | |
| 99218 | Initial observation care, per day, which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity. Typically, 30 minutes are spent at the bedside and on the patient's hospital floor or unit. | |
| 99219 | Initial observation care, per day, requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Typically, 50 minutes are spent at the bedside and on the patient's hospital floor or unit. | |
| 99220 | Initial observation care, per day, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit. | |
| 54110 | Excision of penile plaque (Peyronie disease) | |
| 54111 | Excision of penile plaque (Peyronie disease); with graft to 5 cm in length | |
| 54112 | Excision of penile plaque (Peyronie disease); with graft greater than 5 cm in length | |
| 55400 | Vasovasostomy, vasovasorrhaphy | |
| 55530 | Excision of varicocele or ligation of spermatic veins for varicocele; (separate procedure) | |
| 55535 | Excision of varicocele or ligation of spermatic veins for varicocele; abdominal approach | |
| 55540 | The provider excises a varicocele, a dilation of the veins in the spermatic cord, often reaching into the scrotum, or ligates one or more spermatic veins and repairs a hernia. | |
| 55550 | Laparoscopy, surgical, with ligation of spermatic veins for varicocele | |
| 55870 | Electroejaculation | |
| 58323 | Sperm washing for artificial insemination | |
| S4028 | Microsurgical epididymal sperm aspiration (MESA) | |
| S4030 | Sperm procurement and cryopreservation services; initial visit | |
| S4031 | Sperm procurement and cryopreservation services; subsequent visit | |
| 76870 | Ultrasound, scrotum and contents | |
| 76872 | Ultrasound, transrectal | |
| 70145 | Radiologic examination, chest; single view | |
| 71046 | Radiologic examination, chest; 2 views | |
| 71047 | Radiologic examination, chest; 3 views | |
| 71048 | Radiologic examination, chest; 4 or more views | |
| 93000 | Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report | |
| 93005 | Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report | |
| 93010 | Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only | |
| 36415 | Collection of venous blood by venipuncture | |
| 80047 | Basic metabolic panel (Calcium, ionized) This panel must include the following: Calcium, ionized (82330) Carbon dioxide (bicarbonate) (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Potassium (84132) Sodium (84295) Urea Nitrogen (BUN) (84520) | |
| 80048 | Basic metabolic panel (Calcium, total) This panel must include the following: Calcium, total (82310) Carbon dioxide (bicarbonate) (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Potassium (84132) Sodium (84295) Urea nitrogen (BUN) (84520) | |
| 80050 | General health panel This panel must include the following: Comprehensive metabolic panel (80053) Blood count, complete (CBC), automated and automated differential WBC count (85025 or 85027 and 85004) OR Blood count, complete (CBC), automated (85027) and appropriate manual differential WBC count (85007 or 85009) Thyroid stimulating hormone (TSH) (84443) | |
| 80053 | Comprehensive metabolic panel This panel must include the following: Albumin (82040) Bilirubin, total (82247) Calcium, total (82310) Carbon dioxide (bicarbonate) (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Phosphatase, alkaline (84075) Potassium (84132) Protein, total (84155) Sodium (84295) Transferase, alanine amino (ALT) (SGPT) (84460) Transferase, aspartate amino (AST) (SGOT) (84450) Urea nitrogen (BUN) (84520) | |
| 80076 | Hepatic function panel This panel must include the following: Albumin (82040) Bilirubin, total (82247) Bilirubin, direct (82248) Phosphatase, alkaline (84075) Protein, total (84155) Transferase, alanine amino (ALT) (SGPT) (84460) Transferase, aspartate amino (AST) (SGOT) (84450) | |
| 80415 | Chorionic gonadotropin stimulation panel; estradiol response This panel must include the following: Estradiol (82670 x 2 on 3 pooled blood samples) | |
| 80414 | Chorionic gonadotropin stimulation panel; testosterone response This panel must include the following: Testosterone (84403 x 2 on 3 pooled blood samples) | |
| 80426 | Gonadotropin releasing hormone stimulation panel This panel must include the following: Follicle stimulating hormone (FSH) (83001 x 4) Luteinizing hormone (LH) (83002 x 4) | |
| 81000 | Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, with microscopy | |
| 81001 | Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, with microscopy | |
| 81002 | Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, without microscopy | |
| 81003 | Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, without microscopy | |
| 81005 | Urinalysis; qualitative or semiquantitative, except immunoassays | |
| 81007 | Urinalysis; bacteriuria screen, except by culture or dipstick | |
| 81015 | Urinalysis; microscopic only | |
| 81020 | Urinalysis; 2 or 3 glass test | |
| 81220 | CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; common variants (eg, ACMG/ACOG guidelines) | |
| 81221 | CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; known familial variants | |
| 81222 | CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; duplication/deletion variants | |
| 81223 | CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; full gene sequence | |
| 81224 | CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; intron 8 poly-T analysis (eg, male infertility) | |
| 82397 | Chemiluminescent assay | |
| 82670 | Estradiol | |
| 83001 | Gonadotropin; follicle stimulating hormone (FSH) | |
| 83002 | Gonadotropin; luteinizing hormone (LH) | |
| 84144 | Progesterone | |
| 84402 | Testosterone; free | |
| 84403 | Testosterone; total | |
| 84703 | Gonadotropin, chorionic (hCG); qualitative | |
| 84704 | Gonadotropin, chorionic (hCG); free beta chain | |
| 85025 | Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC count | |
| 85610 | Prothrombin time; | |
| 85730 | Thromboplastin time, partial (PTT); plasma or whole blood | |
| 88363 | 88363 Examination and selection of retrieved archival (ie, previously diagnosed) tissue(s) for molecular analysis (eg, KRAS mutational analysis) | |
| 88380 | 88380 Microdissection (ie, sample preparation of microscopically identified target); laser capture | |
| 88387 | 88387 Macroscopic examination, dissection, and preparation of tissue for non-microscopic analytical studies (eg, nucleic acid-based molecular studies); each tissue preparation (eg, a single lymph node) | |
| 88388 | 88388 Macroscopic examination, dissection, and preparation of tissue for non-microscopic analytical studies (eg, nucleic acid-based molecular studies); in conjunction with a touch imprint, intraoperative consultation, or frozen section, each tissue preparation (eg, a single lymph node) (List separately in addition to code for primary procedure) | |
| 89257 | Sperm identification from aspiration (other than seminal fluid) | |
| 89259 | Cryopreservation; sperm | |
| 89260 | Sperm isolation; simple prep (e.g., sperm wash and swim-up) for insemination or diagnosis with semen analysis | |
| 89261 | Sperm isolation; complex prep (e.g., Percoll gradient, albumin gradient) for insemination or diagnosis with semen analysis | |
| 89264 | Sperm identification from testis tissue, fresh or cryopreserved | |
| 89300 | Semen analysis; presence and/or motility of sperm including Huhner test (post coital) | |
| 89310 | Semen analysis; motility and count (not including Huhner test) | |
| 89320 | Semen analysis; volume, count, motility, and differential | |
| 89321 | Semen analysis; sperm presence and motility of sperm, if performed | |
| 89322 | Semen analysis; volume, count, motility, and differential using strict morphologic criteria (eg, Kruger) | |
| 89325 | Sperm antibodies | |
| 89329 | Sperm evaluation; hamster penetration test | |
| 89330 | Sperm evaluation; cervical mucus penetration test, with or without spinnbarkeit test | |
| 89331 | Sperm evaluation, for retrograde ejaculation, urine (sperm concentration, motility, and morphology, as indicated) | |
| 89335 | Cryopreservation; reproductive tissue, testicular | |
| 89353 | Thawing cryopreserved; sperm/semen each aliquot | |
| 89354 | Thawing of cryopreserved; reproductive tissue, testicular/ovarian | |
| 00840 | Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; not otherwise specified | |
| 10021 | Fine needle aspiration; without imaging guidance | |
| 10022 | Fine needle aspiration; with imaging guidance | |
| 52402 | Cystourethroscopy with transurethral resection or incision of ejaculatory ducts | |
| 54500 | Biopsy of testis, needle (separate procedure) | |
| 54505 | Biopsy of testis, incisional (separate procedure) | |
| 54800 | Biopsy of epididymis, needle | |
| 54900 | Epididymovasostomy, anastomosis of epididymis to vas deferens; unilateral | |
| 54901 | Epididymovasostomy, anastomosis of epididymis to vas deferens; bilatera | |
| G0027 | Semen analysis; presence and/or motility of sperm excluding Huhner | |
| G0452 | Molecular pathology procedure; physician interpretation and report | |
| S3655 | Antisperm antibodies test (immunobead) |
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| Included services | CPT/HCPCS code | Short Description |
| Initial outpatient evaluation and treatment for infertility | ||
| 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99354, 99355, 99356, 99357, 99358, 99359, 90078, 99024 | ||
| 99201 | New patient, which requires these 3 key components, problem focused history, problem focused exam, and medical decision making of straightforward presenting problems are usually self-limited or minor problem, typically 10 minutes | |
| 99202 | New patient, which requires these 3 key components, expanded problem focused history, expanded problem focused exam, and medical decision making of straightforward. Presenting problems are usually low to moderate severity problem, typically 20 minutes | |
| 99203 | New patient, which requires these 3 key components, detailed history, detailed exam, and medical decision making of low complexity. Presenting problems are usually moderate severity problem, typically 30 minutes | |
| 99204 | New patient, which requires these 3 key components, comprehensive history, comprehensive, and medical decision making of moderate. Presenting problems are usually moderate to high severity problem, typically 45 minutes | |
| 99205 | New patient, which requires these 3 key components, comprehensive history, comprehensive, and medical decision making of high. Presenting problems are usually high severity problem, typically 60 minutes | |
| 99211 | Established patient, may not require the presence of a physician or other qualifies health care professional. Minimal presenting problems, typically 5 minutes | |
| 99212 | Established patient, which requires at least 2 of these 3 key components: problem focused history, problem focused exam, and straight forward medical decision making. Presenting problems are usually self-limited or minor problem, typically 10 minutes | |
| 99213 | Established patient, which requires at least 2 of these 3 key components: expanded problem focused history, expanded problem focused exam, and low medical decision making. Presenting problems are usually low to moderate severity problem, typically 15 minutes | |
| 99214 | Established patient, which requires at least 2 of these 3 key components: detailed history, detailed exam, and moderate medical decision making. Presenting problems are usually moderate severity problem, typically 25 minutes | |
| 99215 | Established patient, which requires at least 2 of these 3 key components: comprehensive history, comprehensive exam, and high medical decision making. Presenting problems are usually Moderate to high severity problem, typically 40 minutes | |
| 99358 | Prolonged service without direct patient contact, any setting, must be during the same session as another evaluation and management service (may be reported on a different date than the primary service to which it is related) and is beyond the usual physical or other qualified health care profession service time, before and/or after direct patient care, first hour | |
| add-on 99354 | Prolonged evaluation and management or psychotherapy services in the office or other outpatient setting requiring direct patient contact beyond the usual service, does not have to be continuous but must be in the same day, first hour | |
| add-on 99355 | Prolonged evaluation and management or psychotherapy services in the office or other outpatient setting requiring direct patient contact beyond the usual service, does not have to be continuous but must be in the same day, each additional 30 minutes. | |
| add-on 99356 | Prolonged service without direct patient contact, any setting, must be during the same session as another evaluation and management service (may be reported on a different date than the primary service to which it is related) and is beyond the usual physical or other qualified health care profession service time, before and/or after direct patient care, each additional 30 minutes | |
| add-on 99357 | Prolonged service in the inpatient or observation setting requiring unit/floor time beyond the usual service, each additional 30 minutes | |
| add-on 99359 | Prolonged service without direct patient contact, any setting, must be during the same session as another evaluation and management service (may be reported on a different date than the primary service to which it is related) and is beyond the usual physical or other qualified health care profession service time, before and/or after direct patient care, each additional 30 minutes | |
| 99078 | Physician or other qualified health care professional qualified by education, training, licensure/regulation (when applicable) educational services rendered to patients in a group setting (eg, prenatal, obesity, or diabetic instructions) | |
| 99024 | Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure | |
| Six visits for diagnostic imaging relevant to the patient complaint/condition | ||
| 70145, 71046, 71047, 71048, 74740, 76830, 76831, 76815, 76856, 76857, 93000, 93005, 93010 | 70145 | Radiologic examination, chest; single view |
| 71046 | Radiologic examination, chest; 2 views | |
| 71047 | Radiologic examination, chest; 3 views | |
| 71048 | Radiologic examination, chest; 4 or more views | |
| 83520 | Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative, not otherwise specified | |
| 88182 | Flow cytometry, cell cycle or DNA analysis | |
| 74742 | Transcervical catheterization of fallopian tube, radiological supervision and interpretation | |
| 74740 | Hysterosalpingography, radiological supervision and interpretation | |
| 76376 | 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; not requiring image postprocessing on an independent workstation | |
| 76700 | Ultrasound, abdominal, real time with image documentation; complete | |
| 76830 | Ultrasound, transvaginal | |
| 76831 | Saline infusion sonohysterography (SIS), including color flow Doppler, when performed |
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