2004 CPT-4 and HCPCS Updates

The 2004 updates to the Current Procedural Terminology – 4th Edition (CPT-4) and Healthcare Common Procedure Coding System (HCPCS) National Level II and local Level III codes will become effective October 18, 2004 for Medi-Cal. Some of the policy changes follow:

Pathology / Laboratory

The following are deleted CPT-4 codes and their 2004 replacement codes. The policy of the deleted codes applies to the replacement codes.

The updated information is reflected on manual replacement page rates max lab 8 (Part 2).

The following new CPT–4 and HCPCS pathology codes are split-billable and must be billed with the appropriate modifier (–26, –99, –TC or –ZS): 84156 – 84157, 85055, 85396, 87269, 87329, 87660, 88112, 88361, 89220, 89225, 89230, 89235, 89240 and S3820.

Radiology

The following new CPT–4 radiology codes are split-billable and must be billed with the appropriate modifier (–26, –99, –TC or –ZS): 70557 – 70559, 75998, 76937, 76940, 78804 and 79403.

Maximum Reimbursement – Code Combinations:
Reimbursement for the following combinations of CPT–4 codes will be paid only up to the amount of the code with the highest maximum allowable amount if billed for the same date of service, any provider:

• 70250 vs. 70260
• 70557 vs. 70558 vs. 70559
• 78802 vs. 78804

Duplicate Payment – Combination Codes:
Reimbursement will be made for only one CPT-4 code or set of codes in the following combinations when billed for the same date of service, any provider:

• 70557 – 70559 vs. 61751, 76393, 76394
• 76003 vs. 75998
• 76937 vs. 76942
• 76940 vs. 76986
• 76942 vs. 43232, 43237, 43238, 43242, 45341, 45342 or 76975
• 76975 vs. 43231, 43232, 43237, 43238, 43242, 43259, 45341, 45342 or 76942
• 79403 vs. 79400
• 76975 vs. 43231, 43232, 43237, 43238, 43242, 43259, 45341, 45342 or 76942
• 79403 vs. 79400

Add-on Codes

The following CPT-4 codes are “add-on” codes and must be billed on the same claim with the corresponding code: