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| Short Descr | DILAT RTA XM EVC RTNOPTHY | Medium Descr | DILATED RETINAL EXAM W/EVIDENCE OF RETINOPATHY | Long Descr | Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; with evidence of retinopathy (DM) | Status Code | Measurement Code | Global Days | XXX - Global Concept Does Not Apply | PC/TC Indicator (26, TC) | 9 - Not Applicable | Multiple Procedures (51) | 9 - Concept does not apply. | Bilateral Surgery (50) | 9 - Concept does not apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 9 - Concept does not apply. | Co-Surgeons (62) | 9 - Concept does not apply. | Team Surgery (66) | 9 - Concept does not apply. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Items and Services Not Billable to the MAC | Type of Service (TOS) | 1 - Medical Care | Berenson-Eggers TOS (BETOS) | Z2 - Undefined codes | MUE | Not applicable/unspecified. | CCS Clinical Classification | 159 - Other diagnostic procedures on musculoskeletal system |
| 95 | Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system: synchronous telemedicine service is defined as a real-time interaction between a physician or other qualified health care professional and a patient who is located at a distant site from the physician or other qualified health care professional. the totality of the communication of information exchanged between the physician or other qualified health care professional and the patient during the course of the synchronous telemedicine service must be of an amount and nature that would be sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction. modifier 95 may only be appended to the services listed in appendix p. appendix p is the list of cpt codes for services that are typically performed face-to-face, but may be rendered via a real-time (synchronous) interactive audio and video telecommunications system. | GW | Service not related to the hospice patient's terminal condition | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | GV | Attending physician not employed or paid under arrangement by the patient's hospice provider | CR | Catastrophe/disaster related | GC | This service has been performed in part by a resident under the direction of a teaching physician | GY | Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit | X1 | Continuous/broad services: for reporting services by clinicians, who provide the principal care for a patient, with no planned endpoint of the relationship; services in this category represent comprehensive care, dealing with the entire scope of patient problems, either directly or in a care coordination role; reporting clinician service examples include, but are not limited to: primary care, and clinicians providing comprehensive care to patients in addition to specialty care | Q6 | Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area | 25 | Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service: it may be necessary to indicate that on the day a procedure or service identified by a cpt code was performed, the patient's condition required a significant, separately identifiable e/m service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. a significant, separately identifiable e/m service is defined or substantiated by documentation that satisfies the relevant criteria for the respective e/m service to be reported (see evaluation and management services guidelines for instructions on determining level of e/m service). the e/m service may be prompted by the symptom or condition for which the procedure and/or service was provided. as such, different diagnoses are not required for reporting of the e/m services on the same date. this circumstance may be reported by adding modifier 25 to the appropriate level of e/m service. note: this modifier is not used to report an e/m service that resulted in a decision to perform surgery. see modifier 57 for significant, separately identifiable non-e/m services, see modifier 59. | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | BP | The beneficiary has been informed of the purchase and rental options and has elected to purchase the item | CC | Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) | E1 | Upper left, eyelid | FS | Split (or shared) evaluation and management visit | GF | Non-physician (e.g. nurse practitioner (np), certified registered nurse anesthetist (crna), certified registered nurse (crn), clinical nurse specialist (cns), physician assistant (pa)) services in a critical access hospital | GT | Via interactive audio and video telecommunication systems | JZ | Zero drug amount discarded/not administered to any patient | LT | Left side (used to identify procedures performed on the left side of the body) | PD | Diagnostic or related non diagnostic item or service provided in a wholly owned or operated entity to a patient who is admitted as an inpatient within 3 days | PO | Excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Q1 | Routine clinical service provided in a clinical research study that is in an approved clinical research study | RT | Right side (used to identify procedures performed on the right side of the body) | SA | Nurse practitioner rendering service in collaboration with a physician | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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| 2020-01-01 | Changed | First appearance of change in code book. |
| 2019-10-01 | Changed | Description changed |
| 2009-01-01 | Changed | Code description changed |
| 2007-01-01 | Added | First appearance in code book in 2007. |
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