Low Back Pain(LBP) ECR Summary Description
Version: 5.4.005
Low Back Pain is a chronic condition open from 30 days prior to the date of the trigger service until the end of the study period, or until the patient's date of death. The trigger service can be an inpatient service with a low back pain-specific principal diagnosis code or an outpatient or professional E&M; service with a low back pain-specific diagnosis code in any position. The professional trigger also requires a confirming inpatient, outpatient or professional low back pain-related E&M; service at least 30 days later. Services with diagnosis codes for signs and symptoms related to Low Back Pain such as lumbago or sciatica have been defined as typical care for Low Back Pain, and conditions such as electrolyte disturbances or GI bleed due to use of pain medicines without proper protection have been labeled as complications.Patients who undergo a Lumbar Laminectomy (LBRLAM) are included in a separate procedural episode but are linked back to the Low Back Pain episode to understand the frequency and consequently the appropriateness of these procedures in Low Back Pain patients. In addition, the Low Back Pain episode is related back to the underlying Osteoarthritis episode (if one exists) as typical care at the patient level, and is compared to similar Low Back Pain episodes as part of the risk adjustment methodology.
Episode Components
| Trigger Codes | Codes that, when meeting the trigger criteria, indicate an episode exists (See Table A) |
| SubTypes | Episodes often have sub-types or variants, which are useful to adjust for the severity of that episode, and reduce the need to have multiple episodes of the same type. |
| Relevant Diagnoses | These are diagnosis codes that could serve as a proxy to the trigger diagnosis codes in order to steer services to an episode. There are two types of relevant diagnosis: 1) those that are for routine and typical care for an episode and include codes that represent signs and symptoms related to the episode, diagnosis codes for similar conditions, status codes, family history codes or for aftercare (See Table B); and 2) those that indicate the occurrence of a PAC (potentially avoidable complication) during the episode time window (See Table C) |
| Relevant Procedures | These include all services that are relevant to a given episode but would only be included in the episode if they have a relevant diagnosis code on the claim (See Tables D and E) |
| Relevant Pharmacy | These include all pharmacy codes that are relevant to a given episode. Pharmacy codes are grouped into Prometheus Drug Groups for inclusion in the episode (See Table H). All relevant pharmacy codes in this episode are classified as typical. |
SubTypes
| SubType Groups | Inflammatory spondylopathies, Low Back Pain, Radiculopathy, Low Back Pain, Radiculopathy, Myelopathy, Obstructive sleep apnea, Orthostatic Hypotension / Dizziness, Other arthropathies, Other Back Pain, Radiculopathy, Myelopathy, Other bone infections, Other Spine Problems, Sleep Apnea, Spina Bifida, Stiff Spine |
Code Tables
In accordance with WHO and AMA respective licenses, the specific codes for ICD-10, HCPCS, and CPT have been redacted as “***” below. The specific ICD-10, HCPCS, and CPT code definitions for each episode-of-care are available to authorized users of the TrustHub platform.Table A: Trigger Codes
| Trigger Type | Codes |
| ICD-9-CM (DX) Triggers | *** |
| ICD-10-CM (DX) Triggers | *** |
*** Specific ICD/HCPCS/CPT codes will be shared upon execution of a license agreement
Trigger Codes will be used to identify patients with this episode.
Table B: ICD-9 Relevant Typical Diagnosis Codes:
| Group ID | Group Name | ICD-9-CM (DX) |
| DX0102 | ID - syphilis | *** |
| DX0104 | ID - other herpes zoster | *** |
| DX01130 | NS - autonomic ns ds | *** |
| DX01146 | NS - hereditary polyneuropathy | *** |
| DX01147 | NS - idiopathic polyneuropathy | *** |
| DX01183 | NS - acute pain - other | *** |
| DX01186 | NS - chronic pain - other | *** |
| DX01208 | MS - soft tissue - nos- symptoms / findings | *** |
| DX01343 | Inj - cauda equina | *** |
| DX01398 | Mild - Moderate Neurological Deficit | *** |
| DX01399 | Major Neurological Deficit | *** |
| DX05345 | Orthostatic Hypotension / Dizziness | *** |
| DX06335 | Retroperitoneal Abscess | *** |
| DX081038 | Post Laminectomy Syndrome | *** |
| DX081045 | Deformities, lower limb | *** |
| DX081048 | Hip / Pelvis deformities | *** |
| DX081050 | Inflammatory Arthropathies | *** |
| DX081051 | Inflammatory spondylopathies | *** |
| DX081054 | Low Back Pain, Radiculopathy | *** |
| DX081055 | Low Back Pain, Radiculopathy, Myelopathy | *** |
| DX081062 | Other arthropathies | *** |
| DX081063 | Other Back Pain, Radiculopathy, Myelopathy | *** |
| DX081092 | Backache | *** |
| DX081093 | Sprain Lower Back | *** |
| DX081094 | Sprains and Strains | *** |
| DX081095 | Stiff Spine | *** |
| DX081096 | Other Spine Problems | *** |
| DX08195 | MS - spine - ccyx - hypermobility | *** |
| DX08196 | MS - spine - ccyx - ds of ccyx | *** |
| DX08218 | MS - spine - fx - w/o cord injury - closed | *** |
| DX08219 | MS - spine - fx - w/o cord injury - open | *** |
| DX08220 | MS - spine - fx - w/ cord injury - closed | *** |
| DX08221 | MS - spine - fx - w/ cord injury - open | *** |
| DX08224 | MS - spine - deformity | *** |
| DX08225 | MS - spine - anomaly | *** |
| DX0853 | Immune sys - screening for rheumatoid arthritis | *** |
| DX0873 | MS - head / neck - ossification of ligament | *** |
| DX08892 | MS - joint nos - arthropathy - nos | *** |
| DX08931 | MS - soft tissue - nos- nec / nos | *** |
| DX08948 | MS - muscle - nos - spasm of muscle | *** |
| DX08949 | MS - muscle - nos - muscle weakness | *** |
| DX08950 | MS - muscle - nos - myalgia | *** |
| DX08960 | MS - nos - aftercare | *** |
| DX1765 | NS - chronic pain - cancer | *** |
| DX1923 | BH - other ds | *** |
| DX1963 | Anxiety Disorders | *** |
| DX2159 | Toxic Effects of Radiation | *** |
| DX2307 | NS - acute pain - other | *** |
| DX2337 | Prvn - routine medical exam | *** |
| DX2338 | Prvn - routine exam - other | *** |
| DX2339 | Prvn - admin exam / visit | *** |
| DX2341 | Prvn - encounter for x-ray | *** |
| DX2342 | Prvn - encounter for lab test | *** |
| DX2345 | Othr - fitting - other device | *** |
| DX2346 | Othr - rehabilitation | *** |
| DX2352 | Othr - other | *** |
*** Specific ICD/HCPCS/CPT codes will be shared upon execution of a license agreement
Table B: ICD-10 Relevant Typical Diagnosis Codes:
| Group ID | Group Name | ICD-10-CM (DX) |
| DXX0012 | Other injuries and conditions due to external | *** |
| DXX0102 | ID - syphilis | *** |
| DXX0104 | ID - other herpes zoster | *** |
| DXX01130 | NS - autonomic ns ds | *** |
| DXX01146 | NS - hereditary polyneuropathy | *** |
| DXX01147 | NS - idiopathic polyneuropathy | *** |
| DXX01152 | NS - polyneuropathy - other diseases | *** |
| DXX01183 | NS - acute pain - other | *** |
| DXX01186 | NS - chronic pain - other | *** |
| DXX01208 | MS - soft tissue - nos- symptoms / findings | *** |
| DXX01343 | Inj - cauda equina | *** |
| DXX01399 | Major Neurological Deficit | *** |
| DXX05345 | Orthostatic Hypotension / Dizziness | *** |
| DXX06335 | Retroperitoneal Abscess | *** |
| DXX081038 | Post Laminectomy Syndrome | *** |
| DXX081045 | Deformities, lower limb | *** |
| DXX081048 | Hip / Pelvis deformities | *** |
| DXX081050 | Inflammatory Arthropathies | *** |
| DXX081051 | Inflammatory spondylopathies | *** |
| DXX081054 | Low Back Pain, Radiculopathy | *** |
| DXX081055 | Low Back Pain, Radiculopathy, Myelopathy | *** |
| DXX081062 | Other arthropathies | *** |
| DXX081063 | Other Back Pain, Radiculopathy, Myelopathy | *** |
| DXX08107 | MS - pelvis - sprn/strn | *** |
| DXX081070 | Other bone infections | *** |
| DXX081092 | Backache | *** |
| DXX081093 | Sprain Lower Back | *** |
| DXX081094 | Sprains and Strains | *** |
| DXX081095 | Stiff Spine | *** |
| DXX081096 | Other Spine Problems | *** |
| DXX081104 | Other injuries to spine | *** |
| DXX081105 | Spinal cord injury | *** |
| DXX08186 | MS - spine - scrm / ccyx - fx - w/o cord injury - closed | *** |
| DXX08187 | MS - spine - scrm / ccyx - fx - w/o cord injury - open | *** |
| DXX08224 | MS - spine - deformity | *** |
| DXX0873 | MS - head / neck - ossification of ligament | *** |
| DXX08897 | MS - joint nos - jnt derangmnt - other | *** |
| DXX08931 | MS - soft tissue - nos- nec / nos | *** |
| DXX08948 | MS - muscle - nos - spasm of muscle | *** |
| DXX08949 | MS - muscle - nos - muscle weakness | *** |
| DXX08950 | MS - muscle - nos - myalgia | *** |
| DXX08960 | MS - nos - aftercare | *** |
| DXX0990 | MS - head / neck - infection | *** |
| DXX1554 | Spina Bifida | *** |
| DXX1765 | NS - chronic pain - cancer | *** |
| DXX1923 | BH - other ds | *** |
| DXX1963 | Anxiety Disorders | *** |
| DXX2159 | Toxic Effects of Radiation | *** |
| DXX2337 | Prvn - routine medical exam | *** |
| DXX2338 | Prvn - routine exam - other | *** |
| DXX2339 | Prvn - admin exam / visit | *** |
| DXX2345 | Othr - fitting - other device | *** |
| DXX2352 | Othr - other | *** |
| DXX2378 | Pain, unspecified | *** |
| DXX2379 | Observation/Examination | *** |
| DXX2381 | Aftercare | *** |
| DXX2382 | Preventive Screening | *** |
| XX0000 | Ungrouped Codes | *** |
*** Specific ICD/HCPCS/CPT codes will be shared upon execution of a license agreement
Diagnosis Codes which will be used in combination with Procedure codes to identify relevant typical services.
Table C: ICD-9 Relevant Potentially Avoidable Complication Codes:
| Group ID | Group Name | ICD-9-CM (DX) |
| DX01391 | Meningitis / Encephalitis | *** |
| DX04142 | Respiratory Failure | *** |
| DX05274 | transfusion, infusion related complications | *** |
| DX05275 | phlebitis, deep vein thrombosis (dvt) | *** |
| DX05297 | Hypotension / Syncope | *** |
| DX05298 | Fluid Electrolyte Acid Base Problems | *** |
| DX05308 | Pulmonary Embolism | *** |
| DX05309 | IVC & other intra-abd venous thrombosis | *** |
| DX05311 | Other Phlebitis, Lymphangitis, varices | *** |
| DX05342 | Acute cor pulmonale | *** |
| DX06306 | GI Bleed | *** |
| DX06307 | Intestinal Obstruction | *** |
| DX06314 | Digestive system complications | *** |
| DX06317 | Acute esophagitis, acute gastritis, duodenitis | *** |
| DX081039 | Intraspinal abscess | *** |
| DX081082 | Compl of joint prosthesis, orthopedic proced | *** |
| DX09191 | Decubitus Ulcer | *** |
| DX09192 | Dermatitis, Urticaria | *** |
| DX09193 | Cellulitis, Skin Infection | *** |
| DX11143 | Urinary Tract Infection | *** |
| DX11147 | Complication of genitourinary device | *** |
| DX11150 | Bladder Dysfunction, hemorrhage | *** |
| DX11153 | Urinary Incontinence | *** |
| DX2164 | Accidental Falls | *** |
| DX2171 | Adverse effects of drugs | *** |
| DX2172 | Overdose, Poisonings | *** |
| DX2360 | Complication of Implanted device, graft | *** |
| DX2361 | complications of surgical procedures | *** |
| DX2362 | complications of medical care | *** |
| DX9910 | HAC 02: Air Embolism | *** |
| DX9912 | HAC 04: Stage III and IV Pressure Ulcers | *** |
| DX9915 | HAC: Catheter Associated UTIs | *** |
| DX9916 | HAC: Infection due to central venous catheter | *** |
*** Specific ICD/HCPCS/CPT codes will be shared upon execution of a license agreement
Table C: ICD-10 Relevant Potentially Avoidable Complication Codes:
| Group ID | Group Name | ICD-10-CM (DX) |
| DXX01392 | Delirium, Encephalopathy | *** |
| DXX01403 | Complication of nervous system device | *** |
| DXX02119 | Cmplctns - eye - graft/implant | *** |
| DXX02147 | Complications after eye surgery | *** |
| DXX04142 | Respiratory Failure | *** |
| DXX05274 | transfusion, infusion related complications | *** |
| DXX05275 | phlebitis, deep vein thrombosis (dvt) | *** |
| DXX05297 | Hypotension / Syncope | *** |
| DXX05298 | Fluid Electrolyte Acid Base Problems | *** |
| DXX05308 | Pulmonary Embolism | *** |
| DXX05309 | IVC & other intra-abd venous thrombosis | *** |
| DXX05311 | Other Phlebitis, Lymphangitis, varices | *** |
| DXX05342 | Acute cor pulmonale | *** |
| DXX06306 | GI Bleed | *** |
| DXX06307 | Intestinal Obstruction | *** |
| DXX06314 | Digestive system complications | *** |
| DXX06317 | Acute esophagitis, acute gastritis, duodenitis | *** |
| DXX06372 | Ulc Colitis w Obstruction | *** |
| DXX081039 | Intraspinal abscess | *** |
| DXX081082 | Compl of joint prosthesis, orthopedic proced | *** |
| DXX09191 | Decubitus Ulcer | *** |
| DXX09192 | Dermatitis, Urticaria | *** |
| DXX09193 | Cellulitis, Skin Infection | *** |
| DXX11143 | Urinary Tract Infection | *** |
| DXX11147 | Complication of genitourinary device | *** |
| DXX11150 | Bladder Dysfunction, hemorrhage | *** |
| DXX11153 | Urinary Incontinence | *** |
| DXX1948 | Suicide or Self-inflicted Injury | *** |
| DXX2156 | adverse effects of drugs, correct use | *** |
| DXX2164 | Accidental Falls | *** |
| DXX2171 | Adverse effects of drugs | *** |
| DXX2360 | Complication of Implanted device, graft | *** |
| DXX2361 | complications of surgical procedures | *** |
| DXX2362 | complications of medical care | *** |
| DXX2367 | Malfunction / Complication of Heart Device, H | *** |
| DXX9910 | HAC 02: Air Embolism | *** |
| DXX9912 | HAC 04: Stage III and IV Pressure Ulcers | *** |
| DXX9916 | HAC: Infection due to central venous catheter | *** |
| XX0000 | Ungrouped Codes | *** |
*** Specific ICD/HCPCS/CPT codes will be shared upon execution of a license agreement
PAC Codes which will be used in combination with Procedure codes to identify relevant PAC services.
Table D: ICD-9 Relevant Procedure Codes
| Group ID | Group Name | ICD-9-PCS (PX) |
| PX01198 | Magnetic resonance imaging - 198 | *** |
| PX03215 | Other physical therapy and rehabilitation - 215 | *** |
| PX03231 | Other therapeutic procedures - 231 | *** |
| PX05197 | Other diagnostic ultrasound - 197 | *** |
| PX05226 | Other diagnostic radiology and related techniques - 226 | *** |
| PX05227 | Other diagnostic procedures (interview, evaluation, consultation) - 227 | *** |
| PX08156 | Injections and aspirations of muscles, tendons, bursa, joints and soft tis - 156 | *** |
| PX08159 | Other diagnostic procedures on musculoskeletal system - 159 | *** |
| PX08162 | Other OR therapeutic procedures on joints - 162 | *** |
| PX08163 | Other non-OR therapeutic procedures on musculoskeletal system - 163 | *** |
| PX08181 | Myelogram - 181 | *** |
| PX08207 | Radioisotope bone scan - 207 | *** |
| PX08212 | Diagnostic physical therapy - 212 | *** |
| PX08213 | Physical therapy exercises, manipulation, and other procedures - 213 | *** |
| PX08214 | Traction, splints, and other wound care - 214 | *** |
| PX08217 | Biologic Infusions | *** |
| PX08227 | Spinal Instrumentation / Stabilization | *** |
| PX09168 | Incision and drainage, skin and subcutaneous tissue - 168 | *** |
| PX09169 | Debridement of wound, infection or burn - 169 | *** |
| PX09171 | Suture of skin and subcutaneous tissue - 171 | *** |
| PX11180 | Other CT scan - 180 | *** |
*** Specific ICD/HCPCS/CPT codes will be shared upon execution of a license agreement
Table D: ICD-10 Relevant Procedure Codes
| Group ID | Group Name | ICD-10-PCS (PX) |
| PXX0101 | Incision and excision of CNS - 001 | *** |
| PXX0105 | Insertion of catheter or spinal stimulator and injection into spinal canal - 005 | *** |
| PXX0108 | Other non-OR or closed therapeutic nervous system procedures - 008 | *** |
| PXX01198 | Magnetic resonance imaging - 198 | *** |
| PXX0219 | Other therapeutic procedures on eyelids, conjunctiva, cornea - 019 | *** |
| PXX02220 | Ophthalmologic and otologic diagnosis and treatment - 220 | *** |
| PXX03215 | Other physical therapy and rehabilitation - 215 | *** |
| PXX03231 | Other therapeutic procedures - 231 | *** |
| PXX04183 | Routine chest X-ray - 183 | *** |
| PXX0441 | Other non-OR therapeutic procedures on respiratory system - 041 | *** |
| PXX05197 | Other diagnostic ultrasound - 197 | *** |
| PXX05226 | Other diagnostic radiology and related techniques - 226 | *** |
| PXX05227 | Other diagnostic procedures (interview, evaluation, consultation) - 227 | *** |
| PXX0686 | Other hernia repair - 086 | *** |
| PXX0696 | Other OR lower GI therapeutic procedures - 096 | *** |
| PXX0697 | Other gastrointestinal diagnostic procedures - 097 | *** |
| PXX08149 | Arthroscopy - 149 | *** |
| PXX08156 | Injections and aspirations of muscles, tendons, bursa, joints and soft tis - 156 | *** |
| PXX08159 | Other diagnostic procedures on musculoskeletal system - 159 | *** |
| PXX08160 | Other therapeutic procedures on muscles and tendons - 160 | *** |
| PXX08162 | Other OR therapeutic procedures on joints - 162 | *** |
| PXX08163 | Other non-OR therapeutic procedures on musculoskeletal system - 163 | *** |
| PXX08164 | Other OR therapeutic procedures on musculoskeletal system - 164 | *** |
| PXX08181 | Myelogram - 181 | *** |
| PXX08207 | Radioisotope bone scan - 207 | *** |
| PXX08212 | Diagnostic physical therapy - 212 | *** |
| PXX08213 | Physical therapy exercises, manipulation, and other procedures - 213 | *** |
| PXX08214 | Traction, splints, and other wound care - 214 | *** |
| PXX08217 | Biologic Infusions | *** |
| PXX08227 | Spinal Instrumentation / Stabilization | *** |
| PXX08239 | Removal From Hip Joint | *** |
| PXX09168 | Incision and drainage, skin and subcutaneous tissue - 168 | *** |
| PXX09171 | Suture of skin and subcutaneous tissue - 171 | *** |
| PXX11180 | Other CT scan - 180 | *** |
| PXX17225 | CHEMOTHERAPY | *** |
*** Specific ICD/HCPCS/CPT codes will be shared upon execution of a license agreement
Procedure Codes which will be used in combination with diagnosis codes to identify relevant services.
Table E: Relevant Procedure Codes CPT/HCPCS
| Group ID | Group Name | CPT / HCPCS |
| CT0007 | X-Ray Thoracolumbar Spine / Pelvis | *** |
| CT0025 | Preventive Medicine, Care Coordination | *** |
| CT0078 | Prosthetic Implant | *** |
| CT0080 | Imaging Abdomen | *** |
| CT0082 | Opioid Administration / Dispensing (OTP) | *** |
| CT0089 | Metabolic Renal Hepatic Chemistry Panel | *** |
| CT0090 | Physical Therapy / Rehab | *** |
| CT0091 | Physician Services - Outpatient | *** |
| CT0092 | Physician Services - Inpatient | *** |
| CT0111 | Procedure - spinal neurostimulator | *** |
| CT0112 | Procedure - spinal canal - injection into spinal canal | *** |
| CT0113 | Procedure - spinal canal - other | *** |
| CT0118 | Procedure - peripheral nerve - decompression - other | *** |
| CT0119 | Procedure - block - nerve | *** |
| CT0120 | Procedure - destruction - nerve | *** |
| CT0124 | Procedure - other or rx - peripheral neurostimulator procedures | *** |
| CT0125 | Procedure - neuro - other or rx | *** |
| CT0126 | Procedure - neuro - other non - or rx | *** |
| CT0131 | Procedure - anesthesia | *** |
| CT01395 | DME and supplies | *** |
| CT0158 | Imaging - other imaging - epidurography | *** |
| CT0161 | Tests - neuro - muscle testing | *** |
| CT0162 | Tests - neuro - ncv / emg | *** |
| CT0163 | Tests - neuro - evoked potentials | *** |
| CT0165 | Tests - neuro - other | *** |
| CT03396 | Other OR therapeutic procedures on nose, mouth and pharynx | *** |
| CT0442 | Other care - respiratory - equipment / supplies | *** |
| CT0444 | Other care - prevention - smoking cessation | *** |
| CT0446 | Imaging - cta - chest | *** |
| CT0453 | Tests - pulmonary - peak flow | *** |
| CT05141 | Procedure - graft | *** |
| CT05171 | Procedure - central venous catheter - insertion | *** |
| CT05176 | Procedure - peripheral venous catheter | *** |
| CT05184 | Procedure - vascular access - port / pump - insertion | *** |
| CT05191 | Procedure - related supplies - other | *** |
| CT05202 | Rx - diuretics, loop diuretics | *** |
| CT05210 | Other care - other - pvd - compressor | *** |
| CT05257 | Tests - vascular - arterial - extremity | *** |
| CT05258 | Tests - vascular - venous | *** |
| CT0692 | Therapy - neurostimulator - nausea / vomiting | *** |
| CT0694 | Rx - gi - antiemetics | *** |
| CT0697 | Rx - gi - ppis | *** |
| CT0809 | Procedure - other spine - rx / dx - injection | *** |
| CT08111 | Imaging - other imaging - bone density - dexa | *** |
| CT08113 | DME - heat/cold application | *** |
| CT08114 | DME - traction | *** |
| CT08115 | DME - trapeze / other orthopedic device | *** |
| CT08118 | Prosthetics - lower extremity | *** |
| CT08120 | Prosthetics - external power | *** |
| CT08121 | Orthotics - spine | *** |
| CT08122 | Orthotics - upper extremity | *** |
| CT08123 | Orthotics - lower extremity | *** |
| CT08124 | Orthotics - orthopedic shoes | *** |
| CT08125 | Orthotics - other | *** |
| CT0831 | Procedure - removal of pins or fixation | *** |
| CT0833 | Procedure - casting / splinting - application | *** |
| CT0834 | Procedure - casting / splinting - supplies | *** |
| CT0835 | Procedure - injection - tendons / joints / etc. | *** |
| CT0840 | Procedure - other dx on musculoskeletal system | *** |
| CT0841 | Procedure - other rx on muscles and tendons | *** |
| CT0849 | Procedure - anesthesia | *** |
| CT0851 | Therapy - chiropractic / osteopathic manipulation | *** |
| CT0855 | Therapy - neurostimulator - muscle training | *** |
| CT0857 | Rx - muscle relaxants - muscle relax, skeletal central | *** |
| CT0860 | Imaging - ct - abdomen - pelvis | *** |
| CT0863 | Imaging - ct - lumbar spine | *** |
| CT0866 | Imaging - ct - study | *** |
| CT0867 | Imaging - mri - pelvis | *** |
| CT0870 | Imaging - mri - lumbar spine | *** |
| CT0873 | Imaging - mra - spinal canal | *** |
| CT0874 | Imaging - mra - pelvis | *** |
| CT0878 | Imaging - nuclear - other musculoskeletal | *** |
| CT0887 | Imaging - x-ray - si joints - arthrogram | *** |
| CT0889 | Imaging - x-ray - discography | *** |
| CT0890 | Imaging - x-ray - myelogram | *** |
| CT0920 | Procedure - injection of skin lesion | *** |
| CT0929 | Procedure - excision - skin - shave skin lesion | *** |
| CT0969 | Other care - chronic edema - surgical stockings | *** |
| CT0970 | Other care - chronic edema - appliance - limb compression | *** |
| CT0971 | Other care - chronic edema - appliance - non - segmental | *** |
| CT0972 | Other care - chronic edema - appliance - segmental | *** |
| CT0973 | Other care - chronic edema - compression stocking | *** |
| CT0974 | Other care - chronic edema - compressor - non - segmental | *** |
| CT0975 | Other care - chronic edema - compressor - segmental | *** |
| CT0976 | Other care - chronic edema - compressor | *** |
| CT0977 | Other care - chronic edema - sleeve | *** |
| CT0978 | Other care - chronic edema - glove | *** |
| CT0979 | Other care - chronic edema - gauntlet | *** |
| CT0980 | Other care - chronic edema - exterior wrap | *** |
| CT0981 | Other care - chronic edema - complex therapy | *** |
| CT0991 | Tests - skin | *** |
| CT1021 | Rx - vitamins - multivit prep | *** |
| CT1026 | Other care - diabetes care - glucose monitoring - lancet | *** |
| CT10296 | Low dose steroids | *** |
| CT1036 | Other care - nutrition - assessment | *** |
| CT1044 | Other care - nutrition - parenteral - pump | *** |
| CT1045 | Other care - nutrition - parenteral - all - inclusive | *** |
| CT1046 | Other care - nutrition - education | *** |
| CT1047 | Other care - nutrition - medical food | *** |
| CT1048 | Other care - nutrition - counseling - dietician | *** |
| CT1049 | Other care - other - weight management | *** |
| CT14389 | Other Laboratory | *** |
| CT1620 | Therapy - phlebotomy | *** |
| CT16296 | Lipid Level Monitoring | *** |
| CT16297 | Blood Count | *** |
| CT16298 | NewBorn Blood Tests | *** |
| CT16299 | Bleeding Status | *** |
| CT1638 | Rx - administration - injection | *** |
| CT1639 | Rx - administration - infusion | *** |
| CT1646 | Lab - hematology - coagulation | *** |
| CT1647 | Lab - hematology - blood count | *** |
| CT18300 | Microscopic examination (bacterial smear, culture, toxicology) | *** |
| CT1901 | Therapy - behavior - evaluation and therapy | *** |
| CT1903 | Therapy - behavior - medication management | *** |
| CT1905 | Therapy - behavior - partial hospilization | *** |
| CT1907 | Tests - neuro - sleep studies | *** |
| CT19303 | Psychiatry Evaluations | *** |
| CT19304 | Psychiatry Services | *** |
| CT19378 | Laboratory - Chemistry and Hematology | *** |
| CT19381 | Smoking / Tobacco Cessation | *** |
| CT2009 | Alcohol / Drug Use Screening | *** |
| CT20376 | Other Laboratory | *** |
| CT2302 | Therapy - behavior - other | *** |
| CT2304 | Therapy - pt - exercises / activities | *** |
| CT2305 | Therapy - pt - modalities | *** |
| CT2308 | Therapy - biofeedback | *** |
| CT2309 | Therapy - activity therapy | *** |
| CT2325 | Other care - ostomy - supplies | *** |
| CT2326 | Other care - bladder / bowel care - other supplies | *** |
| CT2327 | Other care - bladder / bowel care - catheter | *** |
| CT2328 | Other care - bladder / bowel care - drainage bag | *** |
| CT2329 | Other care - bladder / bowel care - other supplies - diaper / related | *** |
| CT2330 | Other care - bladder / bowel care - other supplies - skin barrier | *** |
| CT2331 | Other care - observation | *** |
| CT2332 | Other care - child care - foster care | *** |
| CT2333 | Other care - child care - education | *** |
| CT2336 | Other care - case / disease management - case management | *** |
| CT2339 | Other care - other - geriatric care | *** |
| CT23398 | Ancillary Services | *** |
| CT2341 | Other care - other - exercise classes | *** |
| CT2352 | DME - mobility aids | *** |
| CT2353 | DME - patient lifts | *** |
| CT9902 | E & M - consultation | *** |
| CT9903 | E & M - hospital | *** |
| CT9904 | E & M - emergency care | *** |
| CT9905 | E & M - home visit | *** |
| CT9906 | E & M - nursing home | *** |
| CT9907 | E & M - prevention | *** |
| CT9908 | E & M - other | *** |
| CT9909 | Procedure - maintenance - cns / spinal pump / port | *** |
| CT9910 | Procedure - anesthesia | *** |
| CT99100 | Other care - other - personal care services | *** |
| CT99101 | Other care - other - lead assessment | *** |
| CT99102 | Other care - other | *** |
| CT99103 | Imaging - ct - follow - up | *** |
| CT99104 | Imaging - ct - other | *** |
| CT99105 | Imaging - ct - guidance | *** |
| CT99106 | Imaging - cta - other | *** |
| CT99107 | Imaging - mri - other | *** |
| CT99108 | Imaging - mri - guidance | *** |
| CT99109 | Imaging - mri - contrast agent | *** |
| CT9911 | Procedure - sedation | *** |
| CT99113 | Imaging - us - guide - biopsy | *** |
| CT99114 | Imaging - us - guide - other | *** |
| CT99115 | Imaging - us - other | *** |
| CT99116 | Imaging - nuclear - bone scan | *** |
| CT99125 | Imaging - nuclear - localization of inflammation | *** |
| CT99133 | Imaging - other imaging - fluoroscopy | *** |
| CT99134 | Imaging - other imaging - fluoroscopy - guidance | *** |
| CT99136 | Imaging - other imaging | *** |
| CT99139 | Imaging - supplies - contrast agent - low osmolar | *** |
| CT99140 | Imaging - supplies - contrast agent - high osmolar | *** |
| CT99142 | Lab - pathology consultation | *** |
| CT99143 | Lab - chemistry | *** |
| CT99148 | Lab - surgical pathology | *** |
| CT9915 | Procedure - microsurgery | *** |
| CT99169 | Lab - specimen collection - blood - venous - venipuncture | *** |
| CT9917 | Procedure - related supplies - access catheter | *** |
| CT99171 | Lab - specimen collection - blood - venous - venous port | *** |
| CT99172 | Lab - specimen collection - blood - arterial - arterial puncture | *** |
| CT99173 | Lab - specimen collection - specimen handling | *** |
| CT99176 | Lab - stat request | *** |
| CT9918 | Procedure - related supplies - ablation - catheter | *** |
| CT99182 | Transportation - paramedic | *** |
| CT99183 | Transportation - other transportation | *** |
| CT99184 | DME - other | *** |
| CT99185 | DME - bath / toilet aids | *** |
| CT99186 | DME - beds / accessories | *** |
| CT99187 | DME - safety equipment | *** |
| CT99188 | DME - restraints | *** |
| CT99189 | DME - whirlpool - equipment | *** |
| CT99190 | DME - repair / maintenance | *** |
| CT99191 | Supplies | *** |
| CT99192 | Prosthetics - implant | *** |
| CT99195 | Prosthetics - other | *** |
| CT99196 | Prosthetics - repair | *** |
| CT99197 | Other - non - covered | *** |
| CT99198 | PQRI | *** |
| CT9927 | Procedure - related supplies - other | *** |
| CT9928 | Therapy - accupuncture | *** |
| CT9930 | Therapy - habilitation | *** |
| CT99309 | Physician Services | *** |
| CT99316 | Physician Services - Inpatient | *** |
| CT9935 | Therapy - hyperbaric oxygen | *** |
| CT9936 | Therapy - neurostimulator - tens - device | *** |
| CT9937 | Therapy - neurostimulator - tens - leads | *** |
| CT9938 | Therapy - neurostimulator - tens - supplies | *** |
| CT99392 | Other diagnostic procedures (interview, evaluation, consultation) | *** |
| CT9940 | Therapy - other | *** |
| CT9947 | Rx - analg/antipy/nsaids - narcotics | *** |
| CT9950 | Rx - electrolytic, caloric, water - potassium supp | *** |
| CT9951 | Rx - electrolytic, caloric, water - multi-mineral prep | *** |
| CT9955 | Rx - electrolytic, caloric, water - caloric rx dextrose / rel | *** |
| CT9956 | Rx - electrolytic, caloric, water - hydration - unspecfied | *** |
| CT9957 | Rx - miscellaneous rx | *** |
| CT9958 | Rx - miscellaneous rx - enzymes | *** |
| CT9960 | Rx - miscellaneous rx - anesthetics, local | *** |
| CT9961 | Rx - diagnostic rx - roentgenography | *** |
| CT9962 | Rx - other | *** |
| CT9963 | Rx - pharmacy fee | *** |
| CT9964 | Other care - home care - specialized visit | *** |
| CT9965 | Other care - home care - physician supervision | *** |
| CT9966 | Other care - home care - nursing care | *** |
| CT9967 | Other care - home care - nursing care - rn | *** |
| CT9968 | Other care - home care - nursing care - lpn | *** |
| CT9969 | Other care - home care - nursing care - np | *** |
| CT9970 | Other care - home care - rehabilitation - physical therapy | *** |
| CT9971 | Other care - home care - rehabilitation - occupational therapy | *** |
| CT9972 | Other care - home care - rehabilitation - speech therapy | *** |
| CT9973 | Other care - home care - social worker | *** |
| CT9974 | Other care - home care - home health aide | *** |
| CT9975 | Other care - home care - other care - day care | *** |
| CT9976 | Other care - home care - other care - chore care | *** |
| CT9977 | Other care - home care - other care - attendant care | *** |
| CT9978 | Other care - home care - other care - homemaker | *** |
| CT9979 | Other care - home care - other care - companion care | *** |
| CT9980 | Other care - home care - other care - respite care | *** |
| CT9981 | Other care - home care - other care | *** |
| CT9982 | Other care - home care - training | *** |
| CT9983 | Other care - home care - emergency response system | *** |
| CT9984 | Other care - home care - meals | *** |
| CT9985 | Other care - pain management - pca / related | *** |
| CT9986 | Other care - hospice | *** |
| CT9987 | Other care - long term care - residential care | *** |
| CT9988 | Other care - long term care - assisted living | *** |
| CT9990 | Other care - other - ancillary services | *** |
| CT9993 | Other care - other - therapeutic riding | *** |
| CT9994 | Other care - other - back care | *** |
| CT9996 | Other care - other - lodging | *** |
| CT9997 | Other care - other - meals | *** |
| CT9998 | Other care - other - medical records | *** |
| XX0000 | Ungrouped Codes | *** |
*** Specific ICD/HCPCS/CPT codes will be shared upon execution of a license agreement
CPT / HCPCS / ICD-9-PCS (PX) Codes which will be used in combination with ICD-9 diagnosis codes to identify relevant services.
Table H: Relevant Typical Drug Groups
| Group ID | Group Name |
| RX001 | contrast media |
| RX002 | diagnostic agents |
| RX017 | hypnotics and sedatives |
| RX018 | other nervous system drugs |
| RX0543 | peripheral vasodilators |
| RX0544 | statins and lipid modifying agents |
| RX0546 | Antiplatelet Agents Thrombin Inhibitors |
| RX0645 | antacids |
| RX0647 | antiemetics and antinauseants |
| RX0648 | digestives incl. enzymes |
| RX0649 | drugs for constipation |
| RX0650 | drugs for functional gastrointestinal disorders |
| RX0651 | drugs for peptic ulcer and gerd |
| RX0856 | antigout preparations |
| RX0857 | antiinflammatory and antirheumatic products |
| RX0858 | antipsoriatics for systemic use |
| RX0859 | antipsoriatics for topical use |
| RX0860 | muscle relaxants |
| RX0861 | opioids |
| RX0862 | other analgesics and antipyretics |
| RX0863 | other drugs for disorders of the musculo-skeletal system |
| RX0864 | topical products for joint and muscular pain |
| RX0965 | agents for treatment of hemorrhoids and anal fissures for topical use |
| RX0968 | antibiotics and chemotherapeutics for dermatological use |
| RX0969 | antifungals for dermatological use |
| RX0970 | antipruritics incl. antihistamines anesthetics etc. |
| RX0971 | antiseptics and disinfectants |
| RX0973 | corticosteroids dermatological preparations |
| RX0974 | ectoparasiticides incl. scabicides insecticides and repellents |
| RX0976 | irrigating solutions |
| RX0977 | medicated dressings |
| RX0978 | other dermatological preparations |
| RX0979 | preparations for treatment of wounds and ulcers |
| RX0980 | Moisturizers and skin protective agents |
| RX1082 | antiobesity preparations excl. diet products |
| RX1086 | corticosteroids for systemic use |
| RX16106 | iron preparations |
| RX16109 | vitamin b12 and folic acid |
| RX18121 | antimycobacterials |
| RX19123 | antidepressants |
| RX19125 | anxiolytics |
| RX23130 | immunosuppressants |
| RX23131 | mineral supplements |
| RX23133 | other nutrients |
| RX23135 | vitamins |
| RX99137 | anesthetics local |