Never Pay Procedures - New York State Department of Health · 0152U Nfct bct fng prst dna >1000 No 07/01/20 0223U Nfct ds 22 trgt sars-cov-2 Yes 04/01/20 0224U Antibody sars-cov-2

NYS DOH - Never Pay Procedures Under APG Reimbursement Revised for January 1, 2021 Updates:

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List 0001A ADM SARSCOV2 30MCG/0.3ML 1ST Yes 01/01/21 0002A ADM SARSCOV2 30MCG/0.3ML 2ND Yes 01/01/21 0011A ADM SARSCOV2 100MCG/0.5ML1ST Yes 01/01/21 0012A ADM SARSCOV2 100MCG/0.5ML2ND Yes 01/01/21 0006U Rx mntr 120+ drugs & sbsts No 07/01/18 0007U Rx test prsmv ur w/def conf No 07/01/18 0008U Hpylori detcj abx rstnc dna No 07/01/18 0011U Rx mntr lc-ms/ms oral fluid No 07/01/18 0020U Rx test prsmv ur w/def conf No 07/01/18 0038U Vitamin d srm microsamp quan No 07/01/19 0041U B brgdrferi antb 5 prtn igm No 07/01/19 0042U B brgdrferi antb 12 prtn igg No 07/01/19 0043U Tbrf b grp antb 4 prtn igm No 07/01/19 0044U Tbrf b grp antb 4 prtn igg No 07/01/19 0058U Onc merkel cll carc srm quan No 07/01/19 0059U Onc merkel cll carc srm +/- No 07/01/19 0061U Tc meas 5 bmrk sfdi m-s alys No 07/01/19 0064U Antb tp total&rpr ia qual No 07/01/19 0066U Pamg-1 ia cervico-vag fluid No 07/01/19 0077U Ig paraprotein qual bld/ur No 07/01/19 0086U Nfct ds bact&fng org id 6+ No 07/01/20 0091U Onc clrct scr whl bld alg No 07/01/20 0096U Hpv hi risk types male urine No 07/01/20 0097U Gi pathogen 22 targets No 07/01/20 0098U Respir pathogen 14 targets No 07/01/20 0099U Respir pathogen 20 targets No 07/01/20 0100U Respir pathogen 21 targets No 07/01/20 0106U Gstr emptg 7 timed brth spec No 07/01/20 0109U Id aspergillus dna 4 species No 07/01/20 0112U Iadi 16s&18s rrna genes No 07/01/20 0115U Respir iadna 18 viral&2 bact No 07/01/20 0121U Sc dis vcam-1 whole blood No 07/01/20 0122U Sc dis p-selectin whl blood No 07/01/20 0140U Nfct ds fungi dna 15 trgt No 07/01/20 0141U Nfct ds bact&fng gram pos No 07/01/20 0142U Nfct ds bact&fng gram neg No 07/01/20 0143U Drug assay 120+ rx/metablt No 07/01/20 0144U Drug assay 160+ rx/metablt No 07/01/20 0145U Drug assay 65+ rx/metablt No 07/01/20 0146U Drug assay 80+ rx/metablt No 07/01/20 0147U Drug assay 85+ rx/metablt No 07/01/20 0148U Drug assay 100+ rx/metablt No 07/01/20 0149U Drug assay 60+ rx/metablt No 07/01/20 0150U Drug assay 120+ rx/metablt No 07/01/20 0151U Nfct bct/vir resp nfctj 33 No 07/01/20 0152U Nfct bct fng prst dna >1000 No 07/01/20 0223U Nfct ds 22 trgt sars-cov-2 Yes 04/01/20 0224U Antibody sars-cov-2 titer(s) Yes 04/01/20 0225U Infectious disease (bacterial or viral respiratory tract infec TBD 07/01/20 0226U Surrogate viral neutralization test (sVNT), severe acute re TBD 07/01/20 0227U RX ASY PRSMV30+RX/METABLT No 01/01/21 0240U Infectious disease (viral respiratory tract infection), patho TBD 07/01/20 0241U Infectious disease (viral respiratory tract infection), patho TBD 07/01/20 P9099 Blood component/product noc No 07/01/20 20696 Comp multiplane ext fixation No 01/01/13 20697 Comp ext fixate strut change No 01/01/13 20983 Ablate bone tumor(s) perq No 07/01/16 20985 Cptr-asst dir ms px No 12/01/08 20986 Cptr-asst dir ms px io img No 12/01/08

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List 20987 Cptr-asst dir ms px pre img No 12/01/08 22867 Insj stablj dev w/dcmprn No 01/01/17 22868 Insj stablj dev w/dcmprn No 01/01/17 22869 Insj stablj dev w/o dcmprn No 01/01/17 22870 Insj stablj dev w/o dcmprn No 01/01/17 27412 Autochondrocyte implant knee No 07/01/10 28890 High energy eswt, plantar f No 12/01/08 32994 Ablate pulm tumor perq crybl TBD 07/01/18 36473 Endovenous mchnchem 1st vein No 01/01/17 36474 Endovenous mchnchem add-on No 01/01/17 36482 Endoven ther chem adhes 1st TBD 07/01/18 36483 Endoven ther chem adhes sbsq TBD 07/01/18 43257 Uppr gi scope w/thrml txmnt No 07/01/10 43284 Laps esophgl sphnctr agmntj No 01/01/17 43285 Rmvl esophgl sphnctr dev No 01/01/17 55400 Repair of sperm duct No 04/01/13 55706 Prostate saturation sampling No 07/01/10 55874 Tprnl plmt biodegrdabl matrl TBD 07/01/18 58750 Repair oviduct No 10/01/09 59610 Vbac delivery No 01/01/20 62380 Ndsc dcmprn 1 ntrspc lumbar No 01/01/17 64912 Nrv rpr w/nrv algrft 1st TBD 07/01/18 64913 Nrv rpr w/nrv algrft ea addl TBD 07/01/18 65785 Impltj ntrstrml crnl rng seg No 01/01/18 70554 Fmri brain by tech No 12/01/08 74261 Ct colonography dx No 04/01/11 74262 Ct colonography dx w/dye No 04/01/11 74263 Ct colonography screening No 04/01/11 75571 Ct hrt w/o dye w/ca test No 04/01/11 75572 Ct hrt w/3d image No 04/01/11 75573 Ct hrt w/3d image congen No 04/01/11 75574 Ct angio hrt w/3d image No 04/01/11 07/01/16 77082 Dxa bone density vert fx No 10/01/12 01/01/15 77422 Neutron beam tx, simple No 04/01/09 07/01/10 77423 Neutron beam tx, complex No 04/01/09 07/01/10 81161 Dmd dup/delet analysis No 01/01/15 81200 Aspa gene Yes 01/01/16 81201 Apc gene full sequence Yes 01/01/16 81202 Apc gene known fam variants Yes 01/01/16 81203 Apc gene dup/delet variants Yes 01/01/16 81205 Bckdhb gene Yes 01/01/16 81206 Bcr/abl1 gene major bp Yes 01/01/16 81207 Bcr/abl1 gene minor bp Yes 01/01/16 81208 Bcr/abl1 gene other bp Yes 01/01/16 81209 Blm gene Yes 01/01/16 81210 Braf gene Yes 01/01/16 81211 Brca1&2 seq & com dup/del Yes 01/01/16 81212 Brca1&2 185&5385&6174 var Yes 01/01/16 81213 Brca1&2 uncom dup/del var Yes 01/01/16 81214 Brca1 full seq & com dup/del Yes 01/01/16 81215 Brca1 gene known fam variant Yes 01/01/16 81216 Brca2 gene full sequence Yes 01/01/16 81217 Brca2 gene known fam variant Yes 01/01/16 81220 Cftr gene com variants Yes 01/01/16 81221 Cftr gene known fam variants Yes 01/01/16 81222 Cftr gene dup/delet variants Yes 01/01/16 81223 Cftr gene full sequence Yes 01/01/16 81224 Cftr gene intron poly t Yes 01/01/16 81225 Cyp2c19 gene com variants No 01/01/16 81226 Cyp2d6 gene com variants Yes 01/01/16 81227 Cyp2c9 gene com variants No 01/01/16 81228 Cytogen micrarray copy nmbr Yes 01/01/16 81229 Cytogen m array copy no&snp Yes 01/01/16 81235 Egfr gene com variants Yes 01/01/16



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List 81240 F2 gene Yes 01/01/16 81241 F5 gene Yes 01/01/16 81242 Fancc gene Yes 01/01/16 81243 Fmr1 gene detection Yes 01/01/16 81244 Fmr1 gene characterization Yes 01/01/16 81245 Flt3 gene Yes 01/01/16 81246 Flt3 gene analysis No 01/01/16 81250 G6pc gene Yes 01/01/16 81251 Gba gene Yes 01/01/16 81252 Gjb2 gene full sequence Yes 01/01/16 81253 Gjb2 gene known fam variants Yes 01/01/16 81254 Gjb6 gene com variants Yes 01/01/16 81255 Hexa gene Yes 01/01/16 81256 Hfe gene No 01/01/16 81257 Hba1/hba2 gene Yes 01/01/16 81260 Ikbkap gene Yes 01/01/16 81261 Igh gene rearrange amp meth No 01/01/16 81262 Igh gene rearrang dir probe No 01/01/16 81263 Igh vari regional mutation No 01/01/16 81264 Igk rearrangeabn clonal pop No 01/01/16 81265 Str markers specimen anal No 01/01/16 81266 Str markers spec anal addl No 01/01/16 81267 Chimerism anal no cell selec No 01/01/16 81268 Chimerism anal w/cell select No 01/01/16 81270 Jak2 gene No 01/01/16 81275 Kras gene Yes 01/01/16 81280 Long qt synd gene full seq Yes 01/01/16 81281 Long qt synd known fam var Yes 01/01/16 81282 Long qt syn gene dup/dlt var Yes 01/01/16 81287 Mgmt gene methylation anal Yes 01/01/16 81288 Mlh1 gene No 01/01/16 81290 Mcoln1 gene Yes 01/01/16 81291 Mthfr gene No 01/01/16 81292 Mlh1 gene full seq Yes 01/01/16 81293 Mlh1 gene known variants Yes 01/01/16 81294 Mlh1 gene dup/delete variant Yes 01/01/16 81295 Msh2 gene full seq Yes 01/01/16 81296 Msh2 gene known variants Yes 01/01/16 81297 Msh2 gene dup/delete variant Yes 01/01/16 81298 Msh6 gene full seq Yes 01/01/16 81299 Msh6 gene known variants Yes 01/01/16 81300 Msh6 gene dup/delete variant Yes 01/01/16 81301 Microsatellite instability Yes 01/01/16 81302 Mecp2 gene full seq Yes 01/01/16 81303 Mecp2 gene known variant Yes 01/01/16 81304 Mecp2 gene dup/delet variant Yes 01/01/16 81310 Npm1 gene Yes 01/01/16 81313 Pca3/klk3 antigen No 01/01/16 81315 Pml/raralpha com breakpoints Yes 01/01/16 81316 Pml/raralpha 1 breakpoint Yes 01/01/16 81317 Pms2 gene full seq analysis Yes 01/01/16 81318 Pms2 known familial variants Yes 01/01/16 81319 Pms2 gene dup/delet variants Yes 01/01/16 81321 Pten gene full sequence Yes 01/01/16 81322 Pten gene known fam variant Yes 01/01/16 81323 Pten gene dup/delet variant Yes 01/01/16 81324 Pmp22 gene dup/delet No 01/01/16 81325 Pmp22 gene full sequence No 01/01/16 81326 Pmp22 gene known fam variant No 01/01/16 81327 Sept9 methylation analysis TBD 01/01/17 07/01/18 81330 Smpd1 gene common variants Yes 01/01/16 81331 Snrpn/ube3a gene Yes 01/01/16 81332 Serpina1 gene Yes 01/01/16 81340 Trb@ gene rearrange amplify No 01/01/16



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List 81341 Trb@ gene rearrange dirprobe No 01/01/16 81342 Trg gene rearrangement anal No 01/01/16 81350 Ugt1a1 gene Yes 01/01/16 81355 Vkorc1 gene Yes 01/01/16 81370 Hla i & ii typing lr No 01/01/16 81371 Hla i & ii type verify lr No 01/01/16 81372 Hla i typing complete lr No 01/01/16 81373 Hla i typing 1 locus lr No 01/01/16 81374 Hla i typing 1 antigen lr No 01/01/16 81375 Hla ii typing ag equiv lr No 01/01/16 81376 Hla ii typing 1 locus lr No 01/01/16 81377 Hla ii type 1 ag equiv lr No 01/01/16 81378 Hla i & ii typing hr No 01/01/16 81379 Hla i typing complete hr No 01/01/16 81380 Hla i typing 1 locus hr No 01/01/16 81381 Hla i typing 1 allele hr No 01/01/16 81382 Hla ii typing 1 loc hr No 01/01/16 81383 Hla ii typing 1 allele hr No 01/01/16 81400 Mopath procedure level 1 Yes 01/01/16 81401 Mopath procedure level 2 Yes 01/01/16 81402 Mopath procedure level 3 Yes 01/01/16 81403 Mopath procedure level 4 Yes 01/01/16 81404 Mopath procedure level 5 Yes 01/01/16 81405 Mopath procedure level 6 Yes 01/01/16 81406 Mopath procedure level 7 Yes 01/01/16 81407 Mopath procedure level 8 Yes 01/01/16 81408 Mopath procedure level 9 Yes 01/01/16 81410 Aortic dysfunction/dilation No 01/01/16 81411 Aortic dysfunction/dilation No 01/01/16 81415 Exome sequence analysis No 01/01/16 81416 Exome sequence analysis No 01/01/16 81417 Exome re-evaluation No 01/01/16 81420 Fetal chrmoml aneuploidy Yes 01/01/16 81422 Fetal chrmoml microdeltj TBD 01/01/17 07/01/18 81425 Genome sequence analysis No 01/01/16 81426 Genome sequence analysis No 01/01/16 81427 Genome re-evaluation No 01/01/16 81430 Hearing loss sequence analys No 01/01/16 81431 Hearing loss dup/del analys No 01/01/16 81435 Hereditary colon cancer No 01/01/16 81436 Hereditary colon ca synd No 01/01/16 81439 Inherited cardmypthy 5 gns TBD 01/01/17 07/01/18 81440 Mitochondrial gene No 01/01/16 81445 Targeted genomic seq analys No 01/01/16 81450 Targeted genomic seq analys No 01/01/16 81455 Targeted genomic seq analys No 01/01/16 81460 Whole mitochondrial genome No 01/01/16 81465 Whole mitochondrial genome No 01/01/16 81470 X-linked intellectual dblt No 01/01/16 81471 X-linked intellectual dblt No 01/01/16 81479 Unlisted molecular pathology Yes 01/01/16 81500 Onco (ovar) two proteins No 01/01/16 81503 Onco (ovar) five proteins No 01/01/16 81504 Oncology tissue of origin No 01/01/16 81506 Endo assay seven anal No 01/01/16 81507 Fetal aneuploidy trisom risk Yes 01/01/16 81508 Ftl cgen abnor two proteins Yes 01/01/16 81509 Ftl cgen abnor 3 proteins Yes 01/01/16 81510 Ftl cgen abnor three anal Yes 01/01/16 81511 Ftl cgen abnor four anal Yes 01/01/16 81512 Ftl cgen abnor five anal Yes 01/01/16 81519 Oncology breast mrna Yes 01/01/16 81539 Oncology prostate prob score TBD 01/01/17 07/01/18 81599 Unlisted maaa No 01/01/16



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List 83655 Assay of lead Yes 12/01/08 83722 Lipoprtn dir meas sd ldl chl No 07/01/19 83890 Molecule isolate Yes 01/01/10 83891 Molecule isolate nucleic Yes 01/01/10 83892 Molecular diagnostics Yes 01/01/10 83893 Molecule dot/slot/blot Yes 01/01/10 83894 Molecule gel electrophor Yes 01/01/10 83896 Molecular diagnostics Yes 01/01/10 83897 Molecule nucleic transfer Yes 01/01/10 83898 Molecule nucleic ampli, each Yes 01/01/10 83900 Molecule nucleic ampli 2 seq Yes 01/01/10 83901 Molecule nucleic ampli addon Yes 01/01/10 83902 Molecular diagnostics Yes 01/01/10 83903 Molecule mutation scan Yes 01/01/10 83904 Molecule mutation identify Yes 01/01/10 83905 Molecule mutation identify Yes 01/01/10 83906 Molecule mutation identify Yes 01/01/10 83907 Lyse cells for nucleic ext Yes 01/01/10 83908 Nucleic acid, signal ampli Yes 01/01/10 83909 Nucleic acid, high resolute Yes 01/01/10 83912 Genetic examination Yes 01/01/10 83913 Molecular, rna stabilization Yes 01/01/10 83914 Mutation ident ola/sbce/aspe Yes 01/01/10 84410 Testosterone bioavailable TBD 01/01/17 07/01/18 85004 Automated diff wbc count Yes 10/01/09 85610 Prothrombin time Yes 10/01/09 86008 Allg spec ige recomb ea Yes 07/01/18 86328 Ia nfct ab sarscov2 covid 19 Yes 04/01/20 86408 Neutralizing antibody, severe acute respiratory syndrome TBD 07/01/20 86409 Neutralizing antibody, severe acute respiratory syndrome TBD 07/01/20 86413 Severe acute respiratory syndrome coronavirus 2 (SARSCo Yes 07/01/20 86769 Sars-cov-2 covid-19 antibody Yes 04/01/20 86794 Zika virus igm antibody Yes 07/01/18 86849 Immunology procedure Yes 04/01/12 87426 Coronavirus ag ia Yes 04/01/20 87483 Cns dna amp probe type 12-25 No 01/01/17 87536 Hiv-1, dna, quant Yes 12/01/08 87539 Hiv-2, dna, quant No 04/01/10 87634 Rsv dna/rna amp probe Yes 07/01/18 87635 Sars-cov-2 covid-19 amp prb Yes 01/01/20 87636 Infectious agent detection by nucleic acid (DNA orRNA); s TBD 07/01/20 87637 Infectious agent detection by nucleic acid (DNA orRNA); s TBD 07/01/20 87662 Zika virus dna/rna amp probe Yes 07/01/18 87811 Infectious agent antigen detection by immunoassay withd TBD 07/01/20 87900 Virtual phenotype Yes 01/01/10 87901 GeNo - APG Carve Outtype, dna, hiv reverse t Yes 12/01/08 87902 GeNo - APG Carve Outtype, dna, hepatitis C Yes 12/01/08 87903 PheNo - APG Carve Outtype, dna hiv w/culture Yes 12/01/08 87904 PheNo - APG Carve Outtype, dna hiv w/clt add Yes 10/01/09 87999 Microbiology procedure Yes 12/01/08 88230 Tissue culture, lymphocyte Yes 01/01/10 88233 Tissue culture, skin/biopsy Yes 01/01/10 88235 Tissue culture, placenta Yes 01/01/10 88237 Tissue culture, bone marrow Yes 01/01/10 88239 Tissue culture, tumor Yes 01/01/10 88240 Cell cryopreserve/storage Yes 01/01/10 88241 Frozen cell preparation Yes 01/01/10 88245 Chromosome analysis, 20-25 Yes 01/01/10 88248 Chromosome analysis, 50-100 Yes 01/01/10 88249 Chromosome analysis, 100 Yes 01/01/10 88261 Chromosome analysis, 5 No 01/01/10 88262 Chromosome analysis, 15-20 Yes 01/01/10 88263 Chromosome analysis, 45 Yes 01/01/10 88264 Chromosome analysis, 20-25 No 01/01/10



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List 88267 Chromosome analys, placenta Yes 01/01/10 88269 Chromosome analys, amniotic Yes 01/01/10 88271 Cytogenetics, dna probe Yes 01/01/10 88272 Cytogenetics, 3-5 Yes 01/01/10 88273 Cytogenetics, 10-30 Yes 01/01/10 88274 Cytogenetics, 25-99 Yes 01/01/10 88275 Cytogenetics, 100-300 Yes 01/01/10 88280 Chromosome karyotype study Yes 01/01/10 88283 Chromosome banding study No 01/01/10 88285 Chromosome count, additional Yes 01/01/10 88289 Chromosome study, additional No 01/01/10 88291 Cyto/molecular report Yes 01/01/10 88299 Cytogenetic study No 01/01/16 88323 Microslide consultation No 01/01/21 88325 Comprehensive review of data No 01/01/21 88331 Path consult intraop 1 bloc No 01/01/21 88332 Path consult intraop addl No 01/01/21 88333 Intraop cyto path consult 1 No 01/01/21 88334 Intraop cyto path consult 2 No 01/01/21 88375 Optical endomicroscpy interp No 01/01/21 89250 Cultr oocyte/embryo <4 days No 01/01/21 89251 Cultr oocyte/embryo <4 days No 01/01/21 89253 Embryo hatching No 01/01/21 89254 Oocyte identification No 01/01/21 89255 Prepare embryo for transfer No 01/01/21 89257 Sperm identification No 01/01/21 89258 Cryopreservation embryo(s) No 01/01/21 89259 Cryopreservation sperm No 01/01/21 89260 Sperm isolation simple No 01/01/21 89261 Sperm isolation complex No 01/01/21 89264 Identify sperm tissue No 01/01/21 89268 Insemination of oocytes No 01/01/21 89272 Extended culture of oocytes No 01/01/21 89280 Assist oocyte fertilization No 01/01/21 89281 Assist oocyte fertilization No 01/01/21 89290 Biopsy oocyte polar body No 01/01/21 89291 Biopsy oocyte polar body No 01/01/21 89335 Cryopreserve testicular tiss No 01/01/21 89337 Cryopreservation oocyte(s) No 01/01/21 89342 Storage/year embryo(s) No 01/01/21 89343 Storage/year sperm/semen No 01/01/21 89344 Storage/year reprod tissue No 01/01/21 89346 Storage/year oocyte(s) No 01/01/21 89352 Thawing cryopresrved embryo No 01/01/21 89353 Thawing cryopresrved sperm No 01/01/21 89354 Thaw cryoprsvrd reprod tiss No 01/01/21 89356 Thawing cryopresrved oocyte No 01/01/21 90375 Rabies ig im/sc Yes 07/01/17 90376 Rabies ig heat treated Yes 07/01/17 90470 H1N1 Administration Yes 10/01/09 07/01/11 90473 Immune admin oral/nasal Yes 10/01/09 04/01/11 90655 Flu vaccine no preserv 6-35m Yes 10/01/09 04/01/11 90656 Flu vaccine no preserv 3 & > Yes 10/01/09 04/01/11 90657 Flu vaccine, 3 yrs, im Yes 10/01/09 04/01/11 90658 Flu vaccine, 3 yrs & >, im Yes 10/01/09 04/01/11 90660 Flu vaccine, nasal Yes 10/01/09 04/01/11 90663 Flu vacc pandemic Yes 10/01/09 07/01/11 90669 Pneumococcal vacc, ped <5 Yes 10/01/09 04/01/11 90732 Pneumococcal vaccine Yes 10/01/09 04/01/11 90750 Hzv vacc recombinant im njx TBD 01/01/17 07/01/18 90785 Psytx complex interactive No 01/01/21 90863 Pharmacologic mgmt w/psytx No 04/01/13 90875 Psychophysiological therapy No 07/01/10 90876 Psychophysiological therapy No 07/01/10



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List 90880 Hypnotherapy No 04/01/09 90901 Biofeedback train, any meth No 07/01/10 90911 Biofeedback peri/uro/rectal No 07/01/10 01/01/20 90951 Esrd serv 4 visits p mo <2yr No 01/01/20 90952 Esrd serv 2-3 vsts p mo <2yr No 01/01/20 90953 Esrd serv 1 visit p mo <2yrs No 01/01/20 90954 Esrd serv 4 vsts p mo 2-11 No 01/01/20 90955 Esrd srv 2-3 vsts p mo 2-11 No 01/01/20 90956 Esrd srv 1 visit p mo 2-11 No 01/01/20 90957 Esrd srv 4 vsts p mo 12-19 No 01/01/20 90958 Esrd srv 2-3 vsts p mo 12-19 No 01/01/20 90959 Esrd serv 1 vst p mo 12-19 No 01/01/20 90960 Esrd srv 4 visits p mo 20+ No 01/01/20 90961 Esrd srv 2-3 vsts p mo 20+ No 01/01/20 90962 Esrd serv 1 visit p mo 20+ No 01/01/20 90963 Esrd home pt serv p mo <2yrs No 01/01/20 90964 Esrd home pt serv p mo 2-11 No 01/01/20 90965 Esrd home pt serv p mo 12-19 No 01/01/20 90966 Esrd home pt serv p mo 20+ No 01/01/20 91300 SARSCOV2 VAC 30MCG/0.3ML IM Yes 01/01/21 91301 SARSCOV2 VAC 100MCG/0.5ML IM Yes 01/01/21 92145 Corneal hysteresis deter No 07/01/16 92973 Prq coronary mech thrombect No 01/01/20 93702 Bis xtracell fluid analysis No 07/01/16 93895 Carotid intima atheroma eval No 07/01/16 94664 Evaluate pt use of inhaler No 10/01/16 95012 Exhaled nitric oxide meas No 12/01/08 95800 Slp stdy unattended No 01/01/13 95801 Slp stdy unatnd w/anal No 01/01/13 95806 Sleep study unatt&resp efft No 01/01/13 95965 Meg, spontaneous No 12/01/08 07/01/16 95966 Meg, evoked, single No 12/01/08 07/01/16 96102 Psycho testing by technician No 04/01/09 04/01/10 96119 Neuropsych testing by tec No 04/01/09 04/01/10 96127 Brief emotional/behav assmt No 07/01/16 96131 Psycl tst eval phys/qhp ea No 07/01/19 96133 Nrpsyc tst eval phys/qhp ea No 07/01/19 96146 Psycl/nrpsyc tst auto result No 07/01/19 96373 Ther/proph/diag inj ia No 01/01/20 96374 Ther/proph/diag inj iv push No 01/01/20 96375 Tx/pro/dx inj new drug addon No 01/01/20 96376 Tx/pro/dx inj same drug adon No 01/01/20 97012 Mechanical traction therapy No 04/01/13 97124 Massage therapy No 04/01/09 07/01/10 97150 Group therapeutic procedures No 04/01/09 04/01/10 97169 Athletic trn eval low cmplx No 01/01/17 97170 Athletic trn eval mod cmplx No 01/01/17 97171 Athletic trn eval high cmplx No 01/01/17 97172 Athletic trn re-eval plan cr No 01/01/17 97610 Low frequency non-thermal us No 07/01/16 97810 Acupunct w/o stimul 15 min No 04/01/09 97811 Acupunct w/o stimul addl 15m No 04/01/09 97813 Acupunct w/stimul 15 min No 04/01/09 97814 Acupunct w/stimul addl 15m No 04/01/09 98940 Chiropractic manipulation No 01/01/12 98941 Chiropractic manipulation No 04/01/11 98942 Chiropractic manipulation No 01/01/12 98943 Chiropractic manipulation No 01/01/12 99002 Device Handling No 04/01/11 99072 Additional supplies, materials, and clinical staff time over No 07/01/20 0004M Scoliosis dna alys No 01/01/16 0006M Onc hep gene risk classifier No 01/01/16 0007M Onc gastro 51 gene nomogram No 01/01/16 0008M Onc breast risk score No 01/01/16



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List 0009M Fetal aneuploidy trisom risk No 01/01/16 01/01/20 0010M Onc Prostate prob score No 01/01/16 0019T Extracorp shock wv tx,ms nos No 04/01/10 1/1/17** 0126T Chd risk imt study No 01/01/13 0216T Njx paravert w/us lumb/sac No 01/01/13 0217T Njx paravert w/us lumb/sac No 01/01/13 0218T Njx paravert w/us lumb/sac No 01/01/13 0310T Motor function mapping ntms No 04/01/13 0311T Cal & alys cntrl artl press No 04/01/13 1000F Tobacco use assessed No 12/01/08 4000F Tobacco use txmnt counseling No 12/01/08 A4459 Manual pump enema, reusable No 07/01/16 C9055 Injection, brexanolone, 1mg No 01/01/20 10/01/20 C9137 Adynovate Factor VIII recom No 07/01/16 1/1/17** C9138 Nuwiq Factor VIII recomb No 07/01/16 1/1/17** C9140 Afstyla factor viii recomb No 01/01/18 C9257 Bevacizumab injection No 01/01/18 C9259 Injection, pralatrexate, 1 mg Yes 01/01/11 C9287 Inj, brentuximab vedotin Yes 07/01/12 C9471 Hymovis, 1 mg No 07/01/16 1/1/17** C9716 Radiofrequency energy to anu No 07/01/10 C9803 Hopd covid-19 spec collect No 01/01/20 D0414 Lab process microbial spec No 01/01/17 D0421 Gen tst suscept oral disease Yes 01/01/16 D0484 Consult slides prep elsewher No 01/01/21 D0485 Consult inc prep of slides No 01/01/21 D0600 Non-ionizing diag proc No 01/01/17 D0601 Caries risk assess low risk No 01/01/21 D0602 Caries risk assess mod risk No 01/01/21 D0603 Caries risk assess high risk No 01/01/21 D1354 Int caries med app per tooth No 01/01/18 01/01/21 D1575 Dist space maint, fixed unil TBD 01/01/17 07/01/18 D1999 Unspecified preventive proc No 01/01/21 D4346 Scaling gingiv inflammation TBD 01/01/17 07/01/18 D6081 Scale & debride, single imp TBD 01/01/17 07/01/18 D6085 Provisional implant crown No 01/01/17 D9210 Dent anesthesia w/o surgery No 01/01/16 D9211 Regional block anesthesia No 01/01/16 D9212 Trigeminal block anesthesia No 01/01/16 D9215 Local anesthesia No 01/01/16 D9220 General anesthesia No 01/01/18 D9221 General anesthesia ea ad 15m No 07/01/11 D9241 Intravenous sedation No 01/01/18 D9242 IV sedation ea ad 30 m No 07/01/11 D9311 Consult w/med hlth care prof TBD 01/01/17 D9920 Behavior management No 12/01/08 07/01/11 07/01/20 D9991 Case mgmt, appt barriers No 01/01/17 D9992 Case mgmt, care coordination No 01/01/17 D9993 Case mgmt, interviewing No 01/01/17 D9994 Case mgmt, pt education No 01/01/17 D9995 Teledentistry real-time No 01/01/20 D9996 Teledentistry dent review No 01/01/20 G0008 Admin influenza virus vac Yes 10/01/09 04/01/11 G0009 Admin pneumococcal vaccine Yes 10/01/09 04/01/11 G0398 Home sleep test/type 2 Porta No 01/01/13 G0399 Home sleep test/type 3 Porta No 01/01/13 G0400 Home sleep test/type 4 Porta No 01/01/13 G0464 Colorec ca scr, sto bas dna Yes 01/01/16 G0493 Rn care ea 15 min hh/hospice No 01/01/17 G0494 Lpn care ea 15min hh/hospice No 01/01/17 G0495 Rn care train/edu in hh No 01/01/17 G0496 Lpn care train/edu in hh No 01/01/17 G2025 Dis site tele svcs rhc/fqhc No 01/01/20 G8402 Smoke preven interven counse No 12/01/08



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List


List G8403 Smoke preven Outcounsel No 12/01/08 G9013 Esrd demo bundle level i No 01/01/20 G9014 Esrd demo bundle-level ii No 01/01/20 G9016 Demo-smoking cessation coun No 12/01/08 G9141 Influenza A (H1N1) - administration No 10/01/09 07/01/11 G9142 Influenza A (H1N1) - vaccine No 10/01/09 07/01/11 G9143 Warfarin respon genetic test Yes 01/01/16 G9481 Remote E/M new pt 10mins No 07/01/16 G9482 Remote E/M new pt 20mins No 07/01/16 G9483 Remote E/M new pt 30mins No 07/01/16 G9484 Remote E/M new pt 45mins No 07/01/16 G9485 Remote E/M new pt 60mins No 07/01/16 G9486 Remote E/M est. pt 10mins No 07/01/16 G9487 Remote E/M est. pt 15mins No 07/01/16 G9488 Remote E/M est. pt 25mins No 07/01/16 G9489 Remote E/M est. pt 40mins No 07/01/16 G9490 Joint replac mod home visit No 07/01/16 G9678 Oncology Care Model service No 07/01/16 H0018 Alcohol and/or drug services No 07/01/10 H0023 Behavioral health outreach service - planned approach to No 10/01/10 H0031 Mh health assess by non-md No 01/01/20 H0032 MH svc plan dev by non-md No 07/01/10 H0037 Comm psy sup tx pgm per diem No 07/01/10 H0046 Mental health service, nos No 01/01/20 H2029 Sex offend tx svc, per diem No 07/01/10 J0128 Injection, abarelix, 10 mg Yes 01/01/11 J0365 Injection, aprotonin, 10,000 kiu Yes 01/01/11 J0480 Injection, basiliximab, 20 mg Yes 01/01/11 J0585 Botulinum toxin a per unit Yes 12/01/08 01/01/15 J0587 Botulinum toxin type B Yes 12/01/08 J0740 Injection, cidofovir, 375 mg Yes 01/01/11 J0882 Darbepoetin alfa, esrd use Yes 12/01/08 01/01/12 J0886 Epoetin alfa 1000 units ESRD Yes 12/01/08 01/01/12 10/01/13 J0890 Peginesatide injection No 07/01/13 J1440 Filgrastim 300 mcg injection Yes 12/01/08 J1441 Filgrastim 480 mcg injection Yes 12/01/08 J1442 Inj filgrastim excl biosimil Yes 01/01/18 J1566 Injection, immune globulin, intravenous, lyophilized (e.g. Yes 01/01/11 J1675 Injection, histrelin acetate, 10 micrograms Yes 01/01/11 J1725 Hydroxyprogesterone caproate Yes 04/01/12 J1726 Makena, 10 mg Yes 01/01/18 J1931 Injection, laronidase, 0.1 mg Yes 01/01/11 J2315 Naltrexone, depot form Yes - Only for

Article 32 providers 01/01/10 07/01/11

J2323 Natalizumab injection Yes - only for TOUCH providers

01/01/10 01/01/11

J2358 Olanzapine long-acting inj Yes 04/01/11 J2426 Paliperidone palmitate inj Yes 04/01/11 J2505 Injection, pegfilgrastim 6mg Yes 12/01/08 J2562 Injection, plerixafor, 1 mg Yes 01/01/11 J2783 Rasburicase Yes 01/01/21 J2794 Risperidone, long acting Yes 04/01/09 J2997 Alteplase recombinant Yes 04/01/10 04/01/11 J3110 Injection, teriparatide, 10 mcg Yes 01/01/11 J3285 Injection, treprostinil, 1 mg Yes 01/01/11 J3490 Drugs unclassified injection Yes 04/01/10 J3590 Unclassified biologics Yes 04/01/10 J7175 Inj, factor x, (human), 1iu Yes 01/01/18 J7178 Human fibrinogen conc inj Yes 01/01/18 J7179 Vonvendi inj 1 iu vwf:rco Yes 01/01/18 J7180 Factor xiii anti-hem factor Yes 01/01/21 J7181 Factor xiii recomb a-subunit Yes 01/01/18 J7182 Factor viii recomb novoeight Yes 01/01/18



Payment Available*



List


List J7183 Wilate injection Yes 01/01/18 J7185 Xyntha inj Yes 01/01/18 J7186 Antihemophilic viii/vwf comp Yes 01/01/18 J7187 Humate-P, inj Yes 12/01/08 J7188 Factor viii recomb obizur Yes 01/01/18 J7189 Factor viia Yes 12/01/08 J7190 Factor viii Yes 12/01/08 J7191 Factor VIII (porcine) Yes 12/01/08 J7192 Factor viii recombinant Yes 12/01/08 J7193 Factor IX No - APG Carve Outn-recombinant Yes 12/01/08 J7194 Factor ix complex Yes 12/01/08 J7195 Factor IX recombinant Yes 12/01/08 J7196 Antithrombin recombinant Yes 01/01/18 J7197 Antithrombin iii injection Yes 12/01/08 J7198 Anti-inhibitor Yes 12/01/08 J7199 Hemophilia clot factor No - APG Carve Outc Yes 12/01/08 J7200 Factor ix recombinan rixubis Yes 01/01/18 J7201 Factor ix alprolix recomb Yes 01/01/18 J7202 Factor ix idelvion inj Yes 01/01/18 J7203 Factor ix recomb gly rebinyn Yes 01/01/21 J7204 Inj recombin esperoct per iu Yes 01/01/21 J7205 Factor viii fc fusion recomb Yes 01/01/18 J7207 Factor viii pegylated recomb Yes 01/01/18 J7208 Inj. jivi 1 iu Yes 01/01/21 J7209 Factor viii nuwiq recomb 1iu Yes 01/01/18 J7210 Inj, afstyla, 1 i.u. Yes 01/01/21 J7211 Inj, kovaltry, 1 i.u. Yes 01/01/21 J7296 Kyleena, 19.5 mg Yes 01/01/18 J7297 Levonorgestrel iu 52mg 3 yr Yes 07/01/16 J7298 Levonorgestrel iu 52mg 5 yr Yes 07/01/16 J7300 Intraut copper contraceptive Yes 12/01/08 J7301 Levonorgestrel iu 13.5 mg Yes 07/01/16 J7302 LevoNo - APG Carve Outrgestrel iu contracept Yes 12/01/08 J7306 Levonorgestrel implant sys Yes 07/01/16 J7307 EtoNo - APG Carve Outgestrel implant system Yes 12/01/08 J7320 Genvisc 850, inj, 1mg No 01/01/17 J7322 Hymovis injection 1 mg No 01/01/17 J8520 Capecitabine, oral, 150 mg Yes 01/01/11 J9001 Injection, doxorubicin hydrochloride, all lipid formulations Yes 01/01/11 J9019 Erwinaze injection Yes 07/01/14 J9022 Inj, atezolizumab,10 mg Yes 01/01/21 J9023 Injection, avelumab, 10 mg Yes 01/01/21 J9027 Clofarabine injection Yes 12/01/08 J9032 Injection, belinostat, 10mg Yes 01/01/21 J9033 Injection, bendamustine hcl, 1 mg Yes 01/01/11 J9034 Inj., bendeka 1 mg Yes 01/01/21 J9035 Injection, bevacizumab, 10 mg Yes 01/01/11 J9036 Inj. belrapzo/bendamustine Yes 01/01/21 J9039 Injection, blinatumomab Yes 01/01/18 J9042 Brentuximab vedotin inj Yes 01/01/21 J9043 Cabazitaxel injection Yes 01/01/21 J9044 Inj, bortezomib, nos, 0.1 mg Yes 01/01/21 J9047 Injection, carfilzomib, 1 mg Yes 01/01/21 J9050 Carmustine injection Yes 01/01/21 J9055 Injection, cetuximab, 10 mg Yes 01/01/11 J9057 Inj., copanlisib, 1 mg Yes 01/01/21 J9098 Injection, cytarabine liposome, 10 mg Yes 01/01/11 J9118 Inj. Calaspargase pegol-mknl Yes 01/01/21 J9119 Inj., cemiplimab-rwlc, 1 mg Yes 01/01/21 J9120 Injection, dactinomycin, 0.5 mg Yes 01/01/11 J9145 Injection, daratumumab 10 mg Yes 01/01/21 J9153 Inj daunorubicin, cytarabine Yes 01/01/21 J9160 Injection, denileukin diftitox, 300 micrograms Yes 01/01/11 J9173 Inj., durvalumab, 10 mg Yes 01/01/21



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List


List J9176 Injection, elotuzumab, 1mg Yes 01/01/21 J9177 Inj enfort vedo-ejfv 0.25mg Yes 01/01/21 J9202 Goserelin acetate implant Yes 01/01/18 J9203 Gemtuzumab ozogamicin 0.1 mg Yes 01/01/21 J9204 Inj mogamulizumab-kpkc, 1 mg Yes 01/01/21 J9205 Inj irinotecan liposome 1 mg Yes 01/01/21 J9207 Injection, ixabepilone, 1 mg Yes 01/01/11 J9210 Inj., emapalumab-lzsg, 1 mg Yes 01/01/21 J9219 Leuprolide acetate implant, 65 mg Yes 01/01/11 J9225 Histrelin implant (vantas), 50 mg Yes 01/01/11 J9226 Supprelin LA implant Yes 10/01/10 J9227 Inj. isatuximab-irfc 10 mg Yes 01/01/21 J9228 Ipilimumab injection Yes 01/01/21 J9229 Inj inotuzumab ozogam 0.1 mg Yes 01/01/21 J9245 Injection, melphalan hydrochloride, 50 mg Yes 01/01/11 J9246 Inj., evomela, 1 mg Yes 01/01/21 J9261 Nelarabine injection Yes 01/01/21 J9263 Injection, oxaliplatin, 0.5 mg Yes 01/01/11 J9264 Injection, paclitaxel protein-bound particles, 1 mg Yes 01/01/11 J9266 Injection, pegaspargase, per single dose vial Yes 01/01/11 J9268 Injection, pentostatin, 10 mg Yes 01/01/11 J9269 Inj. tagraxofusp-erzs 10 mcg Yes 01/01/21 J9271 Inj pembrolizumab Yes 01/01/18 J9285 Inj, olaratumab, 10 mg Yes 01/01/21 J9295 Injection, necitumumab, 1 mg Yes 01/01/21 J9299 Injection, nivolumab Yes 01/01/18 J9301 Obinutuzumab inj Yes 01/01/18 J9302 Ofatumumab injection Yes 01/01/21 J9303 Injection, panitumumab, 10 mg Yes 01/01/11 J9305 Injection, pemetrexed, 10 mg Yes 01/01/11 J9307 Pralatrexate injection Yes 01/01/18 J9308 Injection, ramucirumab Yes 01/01/18 J9309 Inj, polatuzumab vedotin 1mg Yes 01/01/21 J9310 Injection, rituximab, 100 mg Yes 01/01/11 J9311 Inj rituximab, hyaluronidase Yes 01/01/21 J9312 Inj., rituximab, 10 mg Yes 01/01/21 J9313 Inj., lumoxiti, 0.01 mg Yes 01/01/21 J9325 Inj talimogene laherparepvec Yes 01/01/21 J9328 Temozolomide injection Yes 01/01/21 J9350 Injection, topotecan, 4 mg Yes 01/01/11 J9352 Injection trabectedin 0.1mg Yes 01/01/21 J9354 Inj, ado-trastuzumab emt 1mg Yes 01/01/18 J9355 Injection, trastuzumab, 10 mg Yes 01/01/11 J9356 Inj. herceptin hylecta, 10mg Yes 01/01/21 J9357 Valrubicin injection Yes 01/01/21 J9358 Inj fam-trastu deru-nxki 1mg Yes 01/01/21 J9371 Inj, vincristine sul lip 1mg Yes 01/01/21 J9400 Inj, ziv-aflibercept, 1mg Yes 01/01/18 J9600 Injection, porfimer sodium, 75 mg Yes 01/01/11

M0239 Intravenous infusion, bamlanivimab-xxxx, includes infusio Yes 01/01/21 M0243 Casirivi and imdevi infusion Yes 01/01/21 P9603 One-way allow prorated miles No 01/01/20 P9604 One-way allow prorated trip No 01/01/20 Q0091 Obtaining screen pap smear No 01/01/12 Q0239 Injection, bamlanivimab, 700 mg Yes 01/01/21 Q0243 Casirivimab and imdevimab Yes 01/01/21 Q2017 Teniposide, 50 mg Yes 01/01/21 Q2043 Provenge Yes 07/01/14 Q2049 Imported lipodox inj No 01/01/16 Q2050 Doxorubicin inj 10mg Yes 01/01/18 Q4074 Iloprost, inhalation solution, fda-approved final product, n Yes 01/01/11 Q5108 Injection, fulphila Yes 01/01/21 Q5111 Injection, udenyca 0.5 mg Yes 01/01/21 Q5112 Inj ontruzant 10 mg Yes 01/01/21



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List


List Q5113 Inj herzuma 10 mg Yes 01/01/21 Q5114 Inj ogivri 10 mg Yes 01/01/21 Q5115 Inj truxima 10 mg Yes 01/01/21 Q5116 Inj., trazimera, 10 mg Yes 01/01/21 Q5117 Inj., kanjinti, 10 mg Yes 01/01/21 Q5119 Inj ruxience, 10 mg Yes 01/01/21 Q5120 Inj pegfilgrastim-bmez 0.5mg Yes 01/01/21 S0166 Inj olanzapine 2.5mg No 04/01/11 S0190 Mifepristone, oral, 200 mg Yes 12/01/08 S0191 Misoprostol, oral, 200 mcg Yes 12/01/08 S0199 Med abortion inc all ex drug No 01/01/20 S2202 Echosclerotherapy No 01/01/20 S3800 Genetic testing als No 01/01/16 S3818 BRCA1 gene anal Yes 01/01/10 S3819 BRCA2 gene anal Yes 01/01/10 S3820 Comp BRCA1/BRCA2 Yes 01/01/10 S3822 Sing mutation brst/ovar Yes 01/01/10 S3823 3 mutation brst/ovar Yes 01/01/10 S3828 Comp MLH1 gene Yes 01/01/10 S3829 Comp MLH2 gene Yes 01/01/10 S3830 Gene test HNPCC comp Yes 01/01/10 S3831 Gene test HNPCC single Yes 01/01/10 S3833 Comp APC sequence Yes 01/01/10 S3834 Sing mutation APC Yes 01/01/10 S3835 Gene test cystic fibrosis Yes 01/01/10 S3840 DNA analysis RET-oncogene Yes 01/01/10 S3841 Gene test retinoblastoma No 01/01/16 S3842 Gene test Hippel-Lindau Yes 01/01/10 S3843 DNA analysis factor v Yes 01/01/10 S3844 DNA analysis deafness Yes 01/01/10 S3845 Gene test alpha-thalassemia No 01/01/10 S3846 Gene test beta-thalassemia Yes 01/01/10 S3847 Gene test Tay-Sachs Yes 01/01/10 S3848 Gene test Gaucher Yes 01/01/10 S3849 Gene test Niemann-Pick Yes 01/01/10 S3850 Gene test sickle cell Yes 01/01/10 S3851 Gene test canavan Yes 01/01/10 S3852 DNA analysis APOE alzheimer Yes 01/01/10 S3853 Gene test myo musclr dyst Yes 01/01/10 S3854 Gene profile panel breast No 01/01/16 S3861 Genetic test brugada Yes 01/01/16 S3865 Comp genet test hyp cardiomy Yes 01/01/16 S3866 Spec gene test hyp cardiomy Yes 01/01/16 S3870 Cgh test developmental delay No 01/01/16 S3890 Fecal dna analysis No 01/01/16 S4989 Contracept IUD Yes 12/01/08 S8940 Hippotherapy per session No 12/01/08 S9075 Smoking cessation treatment No 12/01/08 S9128 Speech therapy, in the home, No 12/01/08 S9129 Occupational therapy, in the No 12/01/08 S9131 PT in the home per diem No 12/01/08 S9453 Smoking cessation class No 12/01/08 S9480 Intensive outpatient psychia No 07/01/10 01/01/11 S9529 Venipuncture home/snf No 01/01/20 T1040 Comm bh clinic svc per diem No 01/01/17 T1041 Comm bh clinic svc per month No 01/01/17 U0002 Covid-19 lab test non-cdc Yes 01/01/20 U0003 Infectious agent detection Yes 04/01/20 U0004 2019-nCoV Coronavirus, SARS Yes 04/01/20 V5014 Hearing aid repair/modifying Yes 04/01/12 V5362 Speech screening No 04/01/11 V5364 Dysphagia screening No 04/01/11

*Procedure codes listed as carve outs should not be billed using APGs. Indication as a carve out does not guarantee alternative payment.



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List


List ** Procedure codes became obsolete effective 1/1/2017. Yes = Procedure code is not payable in APGs but is available for billing on ordered ambulatory fee schedule.

No = Procedure code is not reimbursable by Medicaid. Service may be billable under an alternative procedure code.

TBD= At this time Medicaid Policy has not made a final determination regarding these procedures. Once a final determination has been made, they will be adjusted on this list or just added into the general APG logic.


Documents

Never Pay Procedures - New York State Department of Health · 0152U Nfct bct fng prst dna >1000 No 07/01/20 0223U Nfct ds 22 trgt sars-cov-2 Yes 04/01/20 0224U Antibody sars-cov-2