The services on the Text Attachment are considered an integral part of a doctor’s medical care. If any of the services on the Text Attachment are reported on the same day as medical care, and the charges are itemized, combine the charges and pay only the medical care. Payment for the medical care performed on the same date of service includes the allowance for these procedures. A participating, preferred, or network provider cannot bill the member separately for these services in this case.

If any of the services on the Text Attachment are reported independently, process it for payment under the appropriate code.

Modifier 25 may be reported with medical care to identify it as a significant, separately identifiable service from the integral service. When the 25 modifier is reported, the patient’s records must clearly document that separately identifiable medical care has been rendered.

This medical policy may not apply to FEP.  Medical policy is not an authorization, certification, explanation of benefits, or a contract.  Benefits are determined by the Federal Employee Program.

1. Administration of IV Innovar



2. Amsler Grid Test



3. Analysis of data from Swan-Ganz Catheterization



4. Anoscopy without biopsy (46600)



5. Application of splint (29130-29131)



6. Application of traction, suspension, or corrective appliance (non-fracture care)



7. Asthma education, non-physician provider, per session (S9441)



8. Blood pressure check



9. Blue field entoptoscopic exam



10. Breast exam



11. Brightness Acuity Test



12. Canalith repositioning procedure (a.k.a., Epley maneuvers, Otolith repositioning)(S9092)



13. Care plan oversight services (94005, 99339, 99340, 99374-99380)



14. Catheter site inspection by physician



15. Changing of tubes
    
    
    
    
    1. connecting tube
    
    
    
    2. tracheostomy tube
    
    
    
    3. tracheotomy tube (31502)
    
    
    
    4. ureterostomy tube (50688)
    
    
    
    



16. Chemical cauterization of granulation tissue (17250)



17. Collection and interpretation of physiologic data (EG, ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified healthcare professional, requiring a minimum of 30 minutes of time (99091) 



18. Dressing change (for other than burns) under anesthesia (other than local) (15852)



19. Ear/pulse oximetry (94760, 94761)



20. Enterostomal therapy (S9474)



21. Eye tonometry (92100)



22. Foreskin manipulation including lysis of preputial adhesions and stretching (54450)



23. Grenz ray therapy



24. Hydrotubation of oviduct (tubal lavage), including materials (58350)



25. Impression casting of a foot performed by a practitioner other than the manufacturer of the orthotic (S0395)



26. Injection of corpora cavernosa with pharmacologic agent(s), e.g., papaverine, phentolamine, etc. (54235)



27. Insertion of pessary (57160)



28. Irrigation and/or application of medicament for treatment of bacterial, parasitic, or fungoid disease (57150)



29. IV therapy for severe or intractable allergic disease in physician's office or institution with theophyllines, corticosteroids, antihistamines (excludes cost of the drug)



30. Laryngoscopy, indirect/mirror, without biopsy (31505)



31. Laser interferometry or retinometry



32. Macroscopic examination of arthropod or parasite (87168, 87169)



33. Magnified penile surface scanning (penoscopy)



34. Manual, gross visual fields



35. Microscopic examination of hairs plucked or clipped by the examiner (excluding hair collected by the patient) to determine telogen and anagen counts, or structural hair shaft abnormality (96902)



36. Miller-Nadler Glare Test



37. Muscle testing (95831-95834, 95851-95852, 95875)



38. Naso- or oro-gastric tube placement, requiring physician's skill (43752)



39. Nasopharyngolaryngoscopy (indirect)



40. Nasopharyngoscopy (92511)



41. Ophthalmodynamometry (92260)



42. Otoscopy (no removal of foreign body)



43. Phototherapy (for neonatal jaundice)



44. Physician certification services for Medicare-covered services provided by a participating home health agency (patient not present)(G0180)



45. Physician recertification services for Medicare-covered services provided by a participating home health agency (patient not present)(G0179)



46. Physician supervision of a patient receiving Medicare-approved hospice (patient not present) requiring complex and multidisciplinary care modalities (G0182)



47. Physician supervision of a patient receiving Medicare-covered services provided by a participating home health agency (patient not present) requiring complex and multidisciplinary care modalities (G0181)



48. Placement of nasogastric feeding tube



49. Potential acuity testing (visual)
    
    
    
    
    1. PAM (potential acuity meter)
    
    
    
    2. Guyton - Minkowski test
    
    
    
    3. visometer or retinometer
    
    
    
    4. macular integrity or electro-laser test
    
    
    
    



50. Prolonged services (99354-99359)



51. Prostatic massage



52. Pulsed irrigation of fecal impaction (91123)



53. Removal of cerumen (69210, G0268)



54. Removal non-contraceptive pellets or capsules (FEP and Special Contracts Only-Noncovered under Standard Contracts)



55. Rhinoscopy (no removal of foreign body)



56. Schirmer test



57. Screening test, visual acuity (99173)



58. Slit lamp test (biomicroscopy, binocular microscopy and fluorescein staining) (92504)



59. Special Services (99050-99060)



60. Starting of an IV (See MPB G-16 for information on starting of an IV under the chemotherapy benefit) (36000)



61. Stat charges for laboratory services



62. Strapping of joint, including flexible, gel, and soft casts (29200-29280, 29520-29590)



63. Telemetry



64. Tuning fork test



65. Venipuncture (36410)



66. Visual function screening, automated or semiautomated (99172)