Jan 8th - 2013 CPT Codes - No Auth Required
CareOregon Advantage Plus/Star AND CareOregon OHP Plus NO AUTHORIZATION REQUIRED - CPT CODE LIST Revised November 25, 2015 PLEASE NOTE: See Authorization Overview document for details regarding CPT code changes occur annually and occasionally through out the year. It's important INSTRUCTIONS 1. Use this code list in conjuction with the Authorization Guidelines based on the member's 2. This list only applies when the services are performed in following settings: a) office , b) ancillary, c) ASC for ASC approved procedures, and d) facility day patient/surgery OHP MEMBERS - additional instructions: 1. For diagnostic (dx) procedures - diagnosis does NOT need to pair with CPT code. 2. For treatment (tx) procedures - diagnosis DOES need to pair with CPT code unless otherwise 3. Services are held to Prioritized List and Excluded Code rules (OAR 410-120-1140) unless Procedure Code Dx or Tx Procedure 10021-10022 10060-10180 11000-11057 11100-11101 Dx & Tx Tx Tx Dx 11200-11201 11300-11313 11600-11646 11719-11765 11770-11772 11960-11976 11981-11983 12001-13160 14000-14350 15271-15276 Tx Tx Tx Tx Tx Tx Tx Tx Tx Tx 15277 15278 17000-17315 19000-19030 19100-19101 Tx Tx Tx Tx Dx 19105 19110-19120 19125-19272 19296-19298 20005-20150 Tx Tx Dx Tx Tx Limitations or Special Instructions For Tx procedure, diagnosis does NOT need to pair, but must be ATL. No auth applies to COA mbrs only! Excluded svc for OHP mbrs. No auth applies to COA mbrs only! Excluded svc for OHP mbrs. Biopsy Codes; 19102 & 19103 terminated in 2014. No auth applies to COA mbrs only! Excluded svc for OHP mbrs. 19290, 19291, & 19295 terminated in 2014. CareOregon NO authorization required CPT Code List - Revised 11/25/14- Page 1 of 10 20200-20251 20600-20610 Dx Tx 20650-20696 Tx 20697 20900 21116 21310-21497 21501-21550 21557-21632 21800 - 21825 22010-22015 22305-22328 23065-23066 23077-23220 23350 23500-23680 23700 23930-23931 24065-24066 24077-24155 24500-24685 25000-25040 25065-25066 25077-25107 25246 25500-25695 26010-26037 26100-26110 26600-26785 26990-26991 27040-27041 27093-27095 27193 - 27269 27275 27280-27286 27290-27295 27301-27303 27323 27370 27372 27500-27566 27570 27580 27590-27598 27600-27612 27613-27614 27615-27616 Tx Tx Dx Tx Tx Tx Tx Tx Tx Dx Tx Dx Tx Tx Tx Dx Tx Tx Tx Dx Tx Dx Tx Tx Dx Tx Tx Dx Dx Tx Tx Tx Tx Tx Dx Dx Tx Tx Tx Tx Tx Tx Dx Tx Biopsy Codes For Tx procedure, diagnosis does NOT need to pair, but must be ATL. No auth applies to COA mbrs only! Excluded svc for OHP mbrs. Inj proc for TMJ arthrography Biopsy Codes Inj proc for shoulder arthrography Biopsy Codes Biopsy Codes Inj proc for wrist arthrography Biopsy Codes Injection procedures. Biopsy Code Inj proc for knee arthrography Biopsy Codes CareOregon NO authorization required CPT Code List - Revised 11/25/14- Page 2 of 10 27645-27647 27648 27750-27848 27860 27870-27871 27880-27889 28001-28005 28400-28675 28705-28760 28800-28825 Tx Dx Tx Tx Tx Tx Tx Tx Tx Tx 29000-29515 29700-29750 29805-29863 29870-29907 30901-30920 31231-31235 Tx Tx Dx Dx Tx Dx 31502 Tx 31505-31579 Dx & Tx 31615-31661 Dx & Tx 31717-31730 32550-32557 32607-32609 Dx & Tx Tx Dx 33202-33249 35471-35476 Tx Tx 36000-36015 Dx or Tx 36100-36262 Dx or Tx 36400-36460 Dx or Tx 36555-36598 Tx 36600-36660 Dx or Tx 36800-36870 37184-37200 37211- 37217 Tx Tx Tx 37250-37251 38220-38221 38300 38500-38530 40490 40800 40808-40816 Dx Dx Tx Dx Dx Tx Dx Inj proc for ankle arthrography For Tx procedure, diagnosis does NOT need to pair, but must be ATL. Arthroscopy Arthroscopy Diagnostic endoscopy For Tx procedure, diagnosis does NOT need to pair, but must be ATL. For Tx procedure, diagnosis does NOT need to pair, but must be ATL. For Tx procedure, diagnosis does NOT need to pair, but must be ATL. 31661 is ex cluded for OHP For Tx procedure, diagnosis does NOT need to pair, but must be ATL. For Tx procedure, diagnosis does NOT need to pair, but must be ATL. For Tx procedure, diagnosis does must be ATL. For Tx procedure, diagnosis does must be ATL. For Tx procedure, diagnosis does must be ATL. For Tx procedure, diagnosis does must be ATL. For Tx procedure, diagnosis does must be ATL. For Tx procedure, diagnosis does must be ATL. NOT need to pair, but NOT need to pair, but NOT need to pair, but NOT need to pair, but NOT need to pair, but NOT need to pair, but Biopsy Codes Biopsy Code No auth applies to COA mbrs only! Biopsy Codes CareOregon NO authorization required CPT Code List - Revised 11/25/14- Page 3 of 10 40830-40831 Tx 41019 41100-41108 41250-41252 41800-41806 41820-41850 42100 42180-42182 42300-42320 42700 Tx Dx Tx Tx Tx Dx Tx Tx Tx 43200-43255 Dx & Tx 43257 Tx 43258-43273 Dx & Tx 43752-43761 44388-44397 44970 45300-45387 Tx Dx Tx Dx 45391-45392 46600-46615 46900-46924 47000-47001 47100 48400 Dx Dx Tx Dx Dx Dx 49082-49084 49180 Dx & Tx Dx 49400 - 49436 Dx & Tx 49440-49465 50200 50551-50580 50590 50684-50690 50951-50980 51020-51597 Tx Dx Dx Tx Dx Dx Tx 51600-51720 51725-51798 52000-52010 52204-52318 Dx & Tx Dx Dx Dx 52320-52356 52400 Dx & Tx Dx For Tx procedure, diagnosis does NOT need to pair, but must be ATL. Biopsy Codes Biopsy Code For Tx procedure, diagnosis does NOT need to pair, but must be ATL. CP T code 43256 term inated in 2014. No auth applies to COA mbrs only! Excluded svc for OHP mbrs. For Tx procedure, diagnosis does NOT need to pair, but must be ATL. For Tx procedure, diagnosis does NOT need to pair, but must be ATL. Colonoscopy through stoma Endoscopy procedures including colonscopy No auth applies to COA mbrs only! Excluded svc for OHP mbrs. Endoscopy procedures Biopsy Codes Biopsy Code Inj proc for pancreatography For Tx procedure, diagnosis does NOT need to pair, but must be ATL. Biopsy Code For Tx procedure, diagnosis does NOT need to pair, but must be ATL. For Tx procedure, diagnosis does NOT need to pair, but must be ATL. Biopsy Code Endoscopy procedures Inj proc for ureterography/ureterophyelography Endoscopy procedures For Tx procedure, diagnosis does NOT need to pair, but must be ATL. For Tx procedure, diagnosis does NOT need to pair, but must be ATL. CareOregon NO authorization required CPT Code List - Revised 11/25/14- Page 4 of 10 52402 52450-52640 52647-52648 52649 53600-53601 53620-53661 54050-54055 54065 54100 54500-54505 54512-54535 54640-54650 54670 55250 Dx Tx Tx Tx Tx Tx Tx Tx Dx Dx Tx Tx Tx Tx 55300-55400 55700-55706 Tx Dx 55875-55876 56405-56440 56501-56515 56605-56606 56820-56821 57022-57023 57061-57065 57100-57105 57150-57180 57420-57421 57423-57452 57454-57460 57461 57500 57505-57522 57530-57531 57800 58100-58110 Tx Tx Tx Dx Dx Tx Tx Dx Tx Dx Tx Dx Tx Dx Tx Tx Tx Dx 58120 Dx & Tx 58300 Tx 58301 Tx 58340 Dx 58565 Tx No auth applies to COA mbrs only! Excluded svc for OHP mbrs. Biopsy Code Biopsy Codes Vasectomy - No auth applies to OHP mbrs only! No auth applies to COA mbrs only! Excluded svc for OHP mbrs. Biopsy Codes For Tx procedure, diagnosis does NOT need to pair, but must be ATL. Biopsy Codes Endoscopy procedures Biopsy Codes Biopsy Codes For Tx procedure, diagnosis does NOT need to pair, but must be ATL. No auth applies to OHP mbrs only. Excluded svc for COA mbrs. No auth applies to OHP mbrs only-for Tx procedure, diagnosis does NOT need to pair, but must be ATL. Auth required for COA mbrs. Cath/intro of saline/contrast for sonohysterography or hysterosalpingography Sterilization proc- No auth applies to #1) OHP mbrs only AND #2) when done in an office setting! Auth required if done in ASC or hospital setting! Sterilization consent is required. CareOregon NO authorization required CPT Code List - Revised 11/25/14- Page 5 of 10 58600-58615 Tx 58670-58671 58673 Tx Tx 59000-59070 59100-59160 Dx & Tx Tx 59412 59812-59830 59840-59866 Tx Tx Tx 59870 60000 60100 60200-60281 60500-60650 61070 61796-61800 62267 62270 Tx Tx Dx Tx Tx Tx Tx Dx Dx 62272-62273 62284 62290-62291 62365 62367-62370 63620-63621 63661-63664 Dx & Tx Dx Dx Tx Tx Tx Tx 64718-64721 65270-65286 66761-66762 66820-66825 66830-66986 67005-67040 67220-67229 67311-67340 67810 69000-69020 69100-69105 69990 Tx Tx Tx Tx Tx Tx Tx Tx Dx Tx Dx Dx Sterilization proc- No auth applies to OHP mbrs only! Sterilization consent is required. Auth required for COA mbrs. No auth applies to OHP mbrs only! Auth required for COA mbrs. For Tx procedure, diagnosis does NOT need to pair, but must be ATL. For Tx procedure, diagnosis does NOT need to pair, but must be ATL. Abortions Biopsy Code For Tx procedure, diagnosis does NOT need to pair, but must be ATL. Inj procedure for myelography Inj procedure for discography Biopsy Code Biopsy Codes Radiology including Nuclear Medicine and Diagnostic Ultrasound CPT Codes 70010-70553 Dx Diagnostic radiology No auth applies to COA mbrs only! Excluded svc for 70554, 70555 Dx OHP mbrs. 70557-72158 Dx Diagnostic radiology. No auth applies to OHP mbrs only! Excluded svc for 72159 Dx COA mbrs. CareOregon NO authorization required CPT Code List - Revised 11/25/14- Page 6 of 10 72170-73223 Dx 73225 73500- 74260 Dx Dx 74270-74740 Dx 74742 74775-76376 Dx Dx 76377 76380-77082 Dx Dx 77084 77261-77372 Dx Tx 77373 77399-77432 Tx Tx 77435 77469-77799 78012-78350 Tx Tx Dx 78351 78414-78458 78466-78483 78494-78607 78610-78808 78999 79005-79999 Dx Dx Dx Dx Dx Dx Tx Diagnostic radiology No auth applies to OHP mbrs only! Excluded svc for COA mbrs. Diagnostic radiology/ultrasound/mammography/bone studies. No auth applies to COA mbrs only! Excluded svc for OHP mbrs. No auth applies to COA mbrs only! Excluded svc for OHP mbrs. No auth applies to COA mbrs only! OHP mbrs. Radiation oncology procedures No auth applies to COA mbrs only! OHP mbrs. Radiation oncology procedures No auth applies to COA mbrs only! OHP mbrs. Radiation oncology procedures Nuclear medicine No auth applies to COA mbrs only! OHP mbrs. Nuclear medicine Nuclear medicine Nuclear medicine Nuclear medicine Nuclear medicine Radiopharmaceutical therapy Excluded svc for Excluded svc for Excluded svc for Excluded svc for Pathology and Laboratory CPT Codes to occur! 80047-80102 Dx 80104 80150-80412 Dx Dx 80414, 80415 80416-81099 81206-81208 81210 81220-81224 81240-81251 81255-81257 81261-81264 81267-81275 81292-81342 81370-82106 Dx Dx Dx Dx Dx Dx Dx Dx Dx Dx Dx 82107 82108-82608 Dx DX No auth applies to OHP mbrs only as of 4/15/12! Not a valid code for COA mbrs. No auth applies to COA mbrs only! Excluded svc for OHP mbrs. Genetic Testing for Cystic Fibrosis No auth applies to COA mbrs only! Excluded svc for OHP mbrs. CareOregon NO authorization required CPT Code List - Revised 11/25/14- Page 7 of 10 82610 82615-82747 Dx Dx 82757 82759-83690 Dx Dx 83695-83704 83718-83887 83915-83986 Dx Dx 83987 83992-84022 Dx Dx 84030 84035-84144 Dx Dx 84145 84146-84430 Dx Dx 84431 84432-84704 Dx Dx 84830 84999-86304 Dx Dx 86305 86308-86355 Dx Dx 86356 86357-86384 Dx Dx 86386 86403-86431 86485-86890 Dx Dx Dx 86891 86900-86906 86920-86950 Dx Dx Dx 86960 86965-87149 Dx Dx 87150 87152 Dx Dx 87153 87158-87807 Dx Dx 87808 87809-87999 88104-88121 Dx Dx Dx Dx No auth applies to COA mbrs only! Excluded svc for OHP mbrs. No auth applies to COA mbrs only! Excluded svc for OHP mbrs. No auth applies to COA mbrs only! Excluded svc for OHP mbrs. No auth applies to COA mbrs only! Excluded svc for OHP mbrs. No auth applies to COA mbrs only! Excluded svc for OHP mbrs. No auth applies to COA mbrs only! Excluded svc for OHP mbrs. No auth applies to COA mbrs only! Excluded svc for OHP mbrs. No auth applies to COA mbrs only! Excluded svc for OHP mbrs. No auth applies to COA mbrs only! Excluded svc for OHP mbrs. No auth applies to COA mbrs only! Excluded svc for OHP mbrs. No auth applies to COA mbrs only! Excluded svc for OHP mbrs. No auth applies to COA mbrs only! Excluded svc for OHP mbrs. No auth applies to COA mbrs only! Excluded svc for OHP mbrs. No auth applies to COA mbrs only! Excluded svc for OHP mbrs. No auth applies to COA mbrs only! Excluded svc for OHP mbrs. No auth applies to COA mbrs only! Excluded svc for OHP mbrs. CareOregon NO authorization required CPT Code List - Revised 11/25/14- Page 8 of 10 88125 88130-88241 88280-88381 88387-88720 Dx Dx Dx Dx 88738-88741 89049-89230 Dx Dx 89240 Dx 91000-91299 90935-90997 Dx Tx 90999 91010-91110 Tx Dx 91111, 91117 91120-91122 92002-92014 Dx Dx Dx & Tx 92015 92018-92020 92025 92060 92065 92081-92287 92502-92504 92511-92524 92531-92534 92540-92558 92560-92588 Dx Dx & Tx Dx Dx Tx Dx Dx Dx Dx Dx Dx 92590-92591 Dx 92592-92593 Dx 92594-92595 92610-92617 92960-92961 92973-93668 Dx Dx Tx Dx & Tx 93701 93724-93790 93880-93888 Dx Dx Dx 93890-93893 93922-93998 94010-94450 Dx Dx Dx No auth applies to COA mbrs only! Excluded svc for OHP mbrs. No auth applies to COA mbrs only! Excluded svc for OHP mbrs. No auth applies to COA mbrs only! Excluded svc for OHP mbrs. Medicine CPT Codes Dialysis/End Stage Renal Disease Services For Tx procedure, diagnosis does NOT need to pair, but must be ATL . Gastroenterology studies No auth applies to COA mbrs only! Excluded svc for OHP mbrs. For Tx visits, diagnosis does need to pair! Refractive exam - No auth applies to CareOregon Advantage members, OHP Plus children (<21) and OHP Plus adults who are pregnant or have a diagnosis of aphakia or keratonconus. For Tx visits, diagnosis does need to pair! Vestibular function tests Audiologic function tests Audiologic function tests Hearing Aid exams - No auth applies to OHP Plus children (<21) and pregnant adults. No auth applies to COA mbrs only! Excluded svc for OHP mbrs. Hearing Aid exams - No auth applies to OHP Plus children (<21) and pregnant adults Cardioversion For Tx procedure, diagnosis does NOT need to pair! No auth applies to COA mbrs only! Excluded svc for OHP mbrs. No auth applies to COA mbrs only! Excluded svc for OHP mbrs. Pulmonary studies CareOregon NO authorization required CPT Code List - Revised 11/25/14- Page 9 of 10 94452-94453 94620-94621 94640-94668 94680-94799 95250-95830 95831-95852 95857-95927 Dx Dx Tx Dx Dx Dx Dx 95928-95929 95939-95975 Dx Dx 95978-95982 95990-96004 Dx Dx 96360-96549 Tx 96365-96379 Tx 96401-96425 96440-96549 Tx Tx 97597-97602 Tx 97760-97761 98925-98929 Tx Tx 99143-99150 99170-99175 Dx & Tx Dx No auth applies to COA mbrs only! Excluded svc for OHP mbrs. Pulmonary studies Pulmonary tx procedures Pulmonary studies Diagnostic tests No auth applies to COA mbrs only! Excluded svc for OHP mbrs. No auth applies to COA mbrs only! Excluded svc for OHP mbrs. For hydration codes within this range; no auth applies to ALL diagnosis, regardless of whether they are ATL or BLT or don't pair. Injections and infusions. For Tx procedure, diagnosis does NOT need to pair, but must be ATL. Chemotherapy for FDA approved agent only! For Tx procedure, diagnosis does NOT need to pair, but must be ATL. Other injection & infusion services For Tx procedure, diagnosis does NOT need to pair, but must be ATL. Orthotic management & prosthetic training by orthopedic surgeon only! All other providers, authorization is required! For Tx procedure, diagnosis does NOT need to pair, but must be ATL. CareOregon NO authorization required CPT Code List - Revised 11/25/14- Page 10 of 10
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