Miscellaneous Services – Claim Documentation Requirements

CodeDescriptionDocumentation Required
J0208Injection, sodium thiosulfate, 100 mgClinical notes
J0666Injection, bupivacaine liposome, 1 mgClinical Notes
J0691Injection, Lefamulin, 1 MgClinical notes
J0724INJECTION, IMIPENEM 4 MG, CILASTATIN 4 MG AND RELEBACTAM 2 MGClinical notes
J0742Injection, Imipenem 4 Mg, Cilastatin 4 Mg And Relebactam 2 MgClinical notes
J0841Injection, crotalidae immune f(ab')2 (equine), 120 mgClinical notes
J1411Injection, etranacogene dezaparvovec-drlb, per therapeutic doseClinical notes
J1414Injection, fidanacogene elaparvovec-dzkt, per therapeutic doseClinical Notes
J2406Injection, Oritavancin (Kimyrsa), 10 MgClinical notes
J7336Capsaicin 8% Patch, Per Square CentimeterClinical notes
J7351Injection, Bimatoprost, Intracameral Implant, 1 MicrogramClinical notes
J7402Mometasone Furoate Sinus Implant, (Sinuva), 10 MicrogramsClinical notes
Q2053Brexucabtagene Autoleucel, Up To 200 Million Autologous Anti-Cd19 Car Positive Viable T Cells, Including Leukapheresis And Dose Preparation Procedures, Per Therapeutic DoseClinical notes
Q2054Lisocabtagene Maraleucel, Up To 110 Million Autologous Anti-Cd19 Car-Positive Viable T Cells, Including Leukapheresis And Dose Preparation Procedures, Per Therapeutic DoseClinical notes
Q4186Epifix, per square centimeterHistory and Physical
31295Nasal/sinus endoscopy, surgical; with dilation of maxillary sinus ostium (eg, balloon dilation), transnasal or via canine fossa Note: this code denies for patients older than 18 years or youngerClinical notes or History and Physical
31296Nasal/sinus endoscopy, surgical; with dilation of frontal sinus ostium (eg, balloon dilation) Note: this code denies for patients older than 18 years or youngerClinical notes or History and Physical
31297Nasal/sinus endoscopy, surgical; with dilation of sphenoid sinus ostium (eg, balloon dilation) Note: this code denies for patients older than 18 years or youngerClinical notes or History and Physical
42280Maxillary impression for palatal prosthesisClinical notes
49327Laparoscopy, surgical; with placement of interstitial device(s) for radiation therapy guidance (eg., fiducial markers, dosimeter), intra-abdominal, intrapelvic, and/or retroperitoneum, including imaging guidance, if performed, single or multiple (list separately in addition to code for primary procedure)Clinical notes
49412Placement of interstitial device(s) for radiation therapy guidance (eg., fiducial markers, dosimeter), open intra-abdominal, intrapelvic, and/or retroperitoneum, including image guidance, if performed, single or multiple (list separately in addition to code for primary procedure)Clinical notes
65778Placement of amniotic membrane on the ocular surface; without sutures) describes this procedureClinical notes
66179Aqueous shunt eye w/o graftClinical notes
66183Insertion of an aqueous drainage device without an extraocular reservoir into the anterior segment via an external approachClinical notes
66184Revision of aqueous shuntClinical notes
76981Ultrasound, elastography; parenchyma (eg, organ) - This code may also require precertification if performed more than once on same member.Clinical notes
77293Respiratory motion management simulationClinical notes
81190Cstb (cystatin b) (eg, unverricht-lundborg disease) gene analysis; known familial variant(s)Clinical notes
81337Smn1 (survival of motor neuron 1, telomeric) (eg, spinal muscular atrophy) gene analysis; known familial sequence variant(s)Clinical notes
81596Infectious disease, chronic hepatitis c virus (hcv) infection, six biochemical assays (alt, a2-macroglobulin, apolipoprotein a-1, total bilirubin, ggt, and haptoglobin) utilizing serum, prognostic algorithm reported as scores for fibrosis and necroinflammatory activity in liverClinical notes
87662Infectious agent detection by nucleic acid (dna or rna); zika virus, amplified probe techniqueClinical notes
90865Narcosynthesis for psychiatric diagnostic and therapeutic purposes [e.g., sodium amobarbital (Amytal) interview]Clinical notes
93260Programming Device Evaluation (In Person) With Iterative Adjustment Of The Implantable Device To Test The Function Of The Device And Select Optimal Permanent Programmed Values With Analysis, Review And Report By A Physician Or Other Qualified Health Care Professional; Implantable Subcutaneous Lead Defibrillator SystemClinical notes
93261Interrogation Device Evaluation (In Person) With Analysis, Review And Report By A Physician Or Other Qualified Health Care Professional, Includes Connection, Recording And Disconnection Per Patient Encounter; Implantable Subcutaneous Lead Defibrillator SystemClinical notes
93644Electrophysiologic Evaluation Of Subcutaneous Implantable Defibrillator (Includes Defibrillation Threshold Evaluation, Induction Of Arrhythmia, Evaluation Of Sensing For Arrhythmia Termination, And Programming Or Reprogramming Of Sensing Or Therapeutic Parameters)Clinical notes
93895Quantitative carotid intima media thickness and carotid atheroma evaluation, bilateralClinical notes
94660CPAP initiation and managementSleep study report
94662CPAP initiation and managementSleep study report
95836Electrocorticogram from an implanted brain neurostimulator pulse generator/transmitter, including recording, with interpretation and written report, up to 30 daysSleep study report
95965Magnetoencephalography (MEG), recording and analysis; for spontaneous brain magnetic activity (e.g., epileptic cerebral cortex localization).Clinical notes
95966Magnetoencephalography (MEG), recording and analysis; for evoked magnetic fields, single modality (e.g., sensory, motor, language, or visual cortex localization).Clinical notes
95967Magnetoencephalography (MEG), recording and analysis; for evoked magnetic fields, each additional modality (e.g., sensory, motor, language, or visual cortex localization).Clinical notes
96020Neurofunctional testingClinical notes
96125Standardized cognitive performance testing (e.g., Ross Information Processing Assessment) per hour of a qualified health care professional's time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the reportClinical notes
99184Initiation of selective head or total body hypothermia in the critically ill neonate, includes appropriate patient selection by review of clinical, imaging and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitudeClinical notes
99485Supervision by a control physician of interfacility transport care of the critically ill or critically injured pediatric patient, 24 months of age or younger, includes two-way communication with transport team before transport, at the referring facility and during the transport, including data interpretation and report; first 30 minutesClinical notes
99486Supervision by a control physician of interfacility transport care of the critically ill or critically injured pediatric patient, 24 months of age or younger, includes two-way communication with transport team before transport, at the referring facility and during the transport, including data interpretation and report; each additional 30 minutes (list separately in addition to code for primary procedure)Clinical notes
0058TCryopreservation; reproductive tissue, ovarianClinical notes
0650TProgramming device evaluation (remote) of subcutaneous cardiac rhythm monitor system, with iterative adjustment of the implantable device to test the function of the device and select optimal permanently programmed values with analysis, review and report by a physician or other qualified health care professionalClinical Notes
0106UGastric emptying, serial collection of 7 timed breath specimens, non-radioisotope carbon-13 (13c) spirulina substrate, analysis of each specimen by gas isotope ratio mass spectrometry, reported as rate of 13co2 excretionClinical Notes
0121USickle cell disease, microfluidic flow adhesion (vcam-1), whole bloodClinical Notes
0122USickle cell disease, microfluidic flow adhesion (p-selectin), whole bloodClinical Notes
A0998Ambulance response and treatment provided without transportDescription of Service document
E0766Electrical stimulation device used for cancer treatment, includes all accessories, any typeClinical notes
G0330Facility services for dental rehabilitation procedure(s) performed on a patient who requires monitored anesthesia (e.g., general, intravenous sedation (monitored anesthesia care) and use of an operating roomClinical notes
J0600Chelation therapyClinical notes
J1952Leuprolide Injectable, Camcevi, 1 MgClinical notes
J3520Chelation therapyClinical notes
J7309Methyl aminolevulinate (MAL) for topical administration, 16.8%, 1 gramClinical notes
J7336Capsaicin 8% patch, per square centimeterClinical notes
K1001Electronic positional obstructive sleep apnea treatment, with sensor, includes all components and accessories, any typeClinical notes
Q4107Graftjacket, per sq cm (effective 8/1/11)Clinical notes
Q4113Graftjacket express, injectable, 1cc (effective 8/1/11)Clinical notes
Q4115Skin SubstituteClinical notes
S2152Solid organ(s), complete or segmental, single organ or combination of organs; deceased or living donor (s), procurement, transplantation, and related complications; including: drugs; supplies; hospitalization with outpatient follow-up; medical/surgical, diagnostic, emergency, and rehabilitative services, and the number of days of pre and posttransplant care in the global definition (effective 09/01/2014)Clinical notes
S2404Repair, myelomeningocele in the fetus, procedure performed in uteroClinical notes
S5501Catheter care/maintenance, home infusion therapyDescription of Service document
S9055ProcurenClinical notes
V2790Amniotic membrane for surgical reconstruction per procedureClinical notes
Baldness. For services relating to diagnosing the condition, a copy of the clinical note describing the findings that led to the diagnosis along with any supporting documentation must accompany the claim. See Hair Loss – Alopecia for additional information on coverage and limitations.
Donor services. See Organ Donor Services
Polysomnography and Home Sleep Apnea Testing Polysomnography/sleep study should be performed with the intent to complete the study with titration of positive airway pressure (i.e., CPT code 95811). One polysomnogram/sleep study will be covered every five years unless there is a significant change in patient status. A repeat polysomnogram before five years will be covered only when criteria outlined in the policy are met.
Temporomandibular joint (TMJ) syndrome. Services rendered to determine the diagnosis are a benefit of HMSA’s HMO plans and Federal Plan 87. A copy of the clinical note describing the findings that led to the diagnosis along with any supporting radiology reports must accompany the claim.
Unlisted and Miscellaneous Codes – Claim Documentation Requirements

In addition, HMSA may require submission of clinical records before or after payment of claims for the purpose of investigating potential fraudulent, abusive or other inappropriate billing practices, but only as long as there is a reasonable basis for believing such investigation is warranted.


Revision History

Date Nature of Revision
08/03/2026 Migrated to new platform.