| Column 1 |
Column 2 |
STD Policy Statement |
B Mods Allowed |
| 87801 |
87653 |
HCPCS/CPT procedure code definition |
1 |
| 87490 |
83913 |
More extensive procedure |
1 |
| 87472 |
83913 |
More extensive procedure |
1 |
| 87641 |
83893 |
Misuse of column two code with column one code |
1 |
| 87498 |
83896 |
Misuse of column two code with column one code |
1 |
| 87562 |
83913 |
More extensive procedure |
1 |
| 87550 |
83913 |
More extensive procedure |
1 |
| 83913 |
80502 |
Standards of medical / surgical practice |
1 |
| 88305 |
89060 |
HCPCS/CPT coding manual instruction / guidelin |
1 |
| 87581 |
83913 |
More extensive procedure |
1 |
| 87801 |
87498 |
Misuse of column two code with column one code |
1 |
| 87498 |
83894 |
Misuse of column two code with column one code |
1 |
| 87498 |
83912 |
Misuse of column two code with column one code |
1 |
| 0146T |
0150T |
Misuse of column two code with column one code |
0 |
| 87640 |
83892 |
Misuse of column two code with column one code |
1 |
| 87529 |
83913 |
More extensive procedure |
1 |
| 87492 |
83913 |
More extensive procedure |
1 |
| 0151T |
0144T |
HCPCS/CPT coding manual instruction / guideline |
0 |
| 0149T |
0145T |
More extensive procedure |
0 |
| 87486 |
83913 |
More extensive procedure |
1 |
| 87653 |
83902 |
Misuse of column two code with column one code |
1 |
| 87653 |
83912 |
Misuse of column two code with column one code |
1 |
| 87498 |
83908 |
Misuse of column two code with column one code |
|
| 87253 |
87498 |
Misuse of column two code with column one code |
1 |
| 87538 |
83913 |
More extensive procedure |
1 |
| 87517 |
83913 |
More extensive procedure |
1 |
| 87641 |
83891 |
Misuse of column two code with column one code |
1 |
| 87653 |
83891 |
Misuse of column two code with column one code |
1 |
| 87512 |
83913 |
More extensive procedure |
1 |
| 87651 |
83913 |
More extensive procedure |
1 |
| 87800 |
83913 |
More extensive procedure |
1 |
| 87470 |
83913 |
More extensive procedure |
1 |
| 0148T |
0145T |
More extensive procedure |
0 |
| 87561 |
83913 |
More extensive procedure |
1 |
| 87641 |
83897 |
Misuse of column two code with column one code |
1 |
| 87640 |
83890 |
Misuse of column two code with column one code |
1 |
| 87641 |
83909 |
Misuse of column two code with column one code |
1 |
| 87653 |
80502 |
Standards of medical / surgical practice |
1 |
| 87640 |
83898 |
Misuse of column two code with column one code |
1 |
| 87552 |
83913 |
More extensive procedure |
1 |
| 87653 |
80500 |
Standards of medical / surgical practice |
1 |
| 87498 |
83907 |
Misuse of column two code with column one code |
1 |
| 87149 |
87498 |
Misuse of column two code with column one code |
1 |
| 87640 |
83896 |
Misuse of column two code with column one code |
1 |
| 87641 |
83894 |
Misuse of column two code with column one code |
1 |
| 87498 |
83892 |
Misuse of column two code with column one code |
1 |
| 87498 |
83891 |
Misuse of column two code with column one code |
1 |
| 83950 |
83913 |
More extensive procedure |
1 |
| 87653 |
83892 |
Misuse of column two code with column one code |
1 |
| 0145T |
0147T |
Misuse of column two code with column one code |
0 |
| 87536 |
83913 |
More extensive procedure |
1 |
| 87640 |
83900 |
Misuse of column two code with column one code |
1 |
| 87903 |
83913 |
More extensive procedure |
1 |
| 87641 |
83907 |
Misuse of column two code with column one code |
1 |
| 87542 |
83913 |
More extensive procedure |
1 |
| 88309 |
89060 |
HCPCS/CPT coding manual instruction / guideline |
1 |
| 87592 |
83913 |
More extensive procedure |
1 |
| 87522 |
83913 |
More extensive procedure |
1 |
| 87590 |
83913 |
More extensive procedure |
1 |
| 87525 |
83913 |
More extensive procedure |
1 |
| 87653 |
83896 |
Misuse of column two code with column one code |
1 |
| 0148T |
0146T |
HCPCS/CPT procedure code definition |
0 |
| 87653 |
83913 |
More extensive procedure |
1 |
| 87498 |
83902 |
Misuse of column two code with column one code |
1 |
| 0147T |
0150T |
Misuse of column two code with column one code |
0 |
| 87498 |
83901 |
Misuse of column two code with column one code |
1 |
| 87640 |
83893 |
Misuse of column two code with column one code |
1 |
| 87798 |
83913 |
More extensive procedure |
1 |
| 87527 |
83913 |
More extensive procedure |
1 |
| 0145T |
0144T |
HCPCS/CPT coding manual instruction / guideline |
0 |
| 87521 |
83913 |
More extensive procedure |
1 |
| 87498 |
83913 |
More extensive procedure |
1 |
| 87901 |
83913 |
More extensive procedure |
1 |
| 0148T |
0144T |
HCPCS/CPT coding manual instruction / guideline |
0 |
| 0149T |
0150T |
Misuse of column two code with column one code |
0 |
| 87653 |
83908 |
Misuse of column two code with column one code |
1 |
| 87640 |
83891 |
Misuse of column two code with column one code |
1 |
| 87485 |
83913 |
More extensive procedure |
1 |
| 87498 |
80500 |
Standards of medical / surgical practice |
1 |
| 83913 |
80500 |
Standards of medical / surgical practice |
1 |
| 87556 |
83913 |
More extensive procedure |
1 |
| 87557 |
83913 |
More extensive procedure |
1 |
| 87641 |
83896 |
Misuse of column two code with column one code |
1 |
| 87621 |
83913 |
More extensive procedure |
1 |
| 87641 |
83900 |
Misuse of column two code with column one code |
1 |
| 87641 |
80502 |
Standards of medical / surgical practice |
1 |
| 87528 |
83913 |
More extensive procedure |
1 |
| 87620 |
83913 |
More extensive procedure |
1 |
| 87622 |
83913 |
More extensive procedure |
1 |
| 87539 |
83913 |
More extensive procedure |
1 |
| 0154T |
0153T |
HCPCS/CPT coding manual instruction / guideline |
1 |
| 87652 |
83913 |
More extensive procedure |
1 |
| 87653 |
83909 |
Misuse of column two code with column one code |
0 |
| 0149T |
0146T |
Misuse of column two code with column one code |
1 |
| 87902 |
83913 |
More extensive procedure |
1 |
| 87495 |
83913 |
More extensive procedure |
1 |
| 87808 |
80500 |
Standards of medical / surgical practice |
1 |
| 87650 |
83913 |
More extensive procedure |
1 |
| 87555 |
83913 |
More extensive procedure |
1 |
| 87641 |
83890 |
Misuse of column two code with column one code |
1 |
| 87640 |
83907 |
Misuse of column two code with column one code |
1 |
| 0148T |
0147T |
Misuse of column two code with column one code |
0 |
| 87653 |
83907 |
Misuse of column two code with column one code |
1 |
| 87641 |
83908 |
Misuse of column two code with column one code |
1 |
| 0148T |
0150T |
Misuse of column two code with column one code |
0 |
| 0149T |
0148T |
More extensive procedure |
0 |
| 87496 |
83913 |
More extensive procedure |
1 |
| 87640 |
83901 |
Misuse of column two code with column one code |
1 |
| 87640 |
80500 |
Standards of medical / surgical practice |
1 |
| 0147T |
0144T |
HCPCS/CPT coding manual instruction / guideline |
0 |
| 87641 |
80500 |
Standards of medical / surgical practice |
1 |
| 87533 |
83913 |
More extensive procedure |
1 |
| 87491 |
83913 |
More extensive procedure |
1 |
| 87641 |
83913 |
More extensive procedure |
1 |
| 87653 |
83898 |
Misuse of column two code with column one code |
1 |
| 87481 |
83913 |
More extensive procedure |
1 |
| 87531 |
83913 |
More extensive procedure |
1 |
| 0145T |
0146T |
Misuse of column two code with column one code |
0 |
| 87641 |
83902 |
More extensive procedure |
1 |
| 87487 |
83913 |
Misuse of column two code with column one code |
1 |
| 87640 |
83897 |
More extensive procedure |
1 |
| 87534 |
83913 |
Misuse of column two code with column one code |
1 |
| 87498 |
83900 |
More extensive procedure |
1 |
| 87149 |
83913 |
Misuse of column two code with column one code |
1 |
| 87591 |
83913 |
More extensive procedure |
1 |
| 88307 |
89060 |
HCPCS/CPT coding manual instruction / guideline |
1 |
| 87498 |
83909 |
Misuse of column two code with column one code |
1 |
| 87540 |
83913 |
More extensive procedure |
1 |
| 87541 |
83913 |
More extensive procedure |
1 |
| 87498 |
83898 |
Misuse of column two code with column one code |
1 |
| 87582 |
83913 |
More extensive procedure |
1 |
| 88304 |
89060 |
HCPCS/CPT coding manual instruction / guideline |
1 |
| 0149T |
0144T |
HCPCS/CPT coding manual instruction / guideline |
0 |
| 87551 |
83913 |
More extensive procedure |
1 |
| 87640 |
83913 |
More extensive procedure |
1 |
| 87498 |
83897 |
More extensive procedure |
1 |
| 87532 |
83913 |
Misuse of column two code with column one code |
1 |
| 87530 |
83913 |
More extensive procedure |
1 |
| 87640 |
83912 |
More extensive procedure |
1 |
| 87477 |
83913 |
More extensive procedure |
1 |
| 87641 |
83901 |
Misuse of column two code with column one code |
1 |
| 87511 |
83913 |
More extensive procedure |
1 |
| 87482 |
83913 |
More extensive procedure |
1 |
| 87560 |
83913 |
More extensive procedure |
1 |
| 0147T |
0146T |
More extensive procedure |
0 |
| 87475 |
83913 |
More extensive procedure |
|
| 87537 |
83913 |
More extensive procedure |
1 |
| 87797 |
83913 |
More extensive procedure |
1 |
| 87471 |
83913 |
More extensive procedure |
1 |
| 87516 |
83913 |
More extensive procedure |
1 |
| 87640 |
83894 |
Misuse of column two code with column one code |
1 |
| 87653 |
83901 |
Misuse of column two code with column one code |
1 |
| 87653 |
83897 |
Misuse of column two code with column one code |
1 |
| 87476 |
83913 |
More extensive procedure |
1 |
| 87480 |
83913 |
More extensive procedure |
1 |
| 87498 |
83893 |
Misuse of column two code with column one code |
1 |
| 88302 |
89060 |
HCPCS/CPT coding manual instruction / guideline |
1 |
| 87640 |
80502 |
Standards of medical / surgical practice |
1 |
| 0149T |
0147T |
HCPCS/CPT procedure code definition |
0 |
| 87641 |
83912 |
Misuse of column two code with column one code |
1 |
| 87641 |
87640 |
More extensive procedure |
1 |
| 87640 |
83909 |
Misuse of column two code with column one code |
1 |
| 87497 |
83913 |
More extensive procedure |
1 |
| 87653 |
83893 |
Misuse of column two code with column one code |
1 |
| 87653 |
83894 |
Misuse of column two code with column one code |
1 |
| 87498 |
83890 |
Misuse of column two code with column one code |
1 |
| 87653 |
83900 |
Misuse of column two code with column one code |
1 |
| 87801 |
87640 |
Misuse of column two code with column one code |
1 |
| 87515 |
83913 |
More extensive procedure |
1 |
| 87653 |
83890 |
Misuse of column two code with column one code |
1 |
| 0150T |
0144T |
HCPCS/CPT coding manual instruction / guideline |
0 |
| 87799 |
83913 |
More extensive procedure |
1 |
| 87149 |
87640 |
Misuse of column two code with column one code |
1 |
| 87641 |
83898 |
Misuse of column two code with column one code |
1 |
| 87640 |
83902 |
Misuse of column two code with column one code |
1 |
| 87640 |
83908 |
Misuse of column two code with column one code |
1 |
| 87580 |
83913 |
More extensive procedure |
1 |
| 87526 |
83913 |
More extensive procedure |
1 |
| 87535 |
83913 |
More extensive procedure |
1 |
| 0146T |
0144T |
HCPCS/CPT coding manual instruction / guideline |
0 |
| 87660 |
83913 |
More extensive procedure |
1 |
| 87498 |
80502 |
Standards of medical / surgical practice |
1 |
| 87520 |
83913 |
More extensive procedure |
1 |
| 87641 |
83892 |
Misuse of column two code with column one code |
1 |
| 87808 |
80502 |
Standards of medical / surgical practice |
1 |
| 87801 |
83913 |
More extensive procedure |
1 |