Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 46
CPT code lookup
Each row is one code from the public prior authorization list. The description is the procedure or service name on that source row. This is not a coverage decision.
Prior authorization codes
| Code | Description | Source |
|---|---|---|
| 96933 | Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; interpretation and report only, first lesion | New Hampshire Precertification List, Pg 198 Original policy |
| 97010 | Application of a modality to 1 or more areas; hot or cold packs | New Hampshire Precertification List, Pg 198 Original policy |
| 97012 | Application of a modality to 1 or more areas; traction, mechanical | New Hampshire Precertification List, Pg 198 Original policy |
| 97014 | Application of a modality to 1 or more areas; electrical stimulation (unattended) | New Hampshire Precertification List, Pg 198 Original policy |
| 97016 | Application of a modality to 1 or more areas; vasopneumatic devices | New Hampshire Precertification List, Pg 198 Original policy |
| 97018 | Application of a modality to 1 or more areas; paraffin bath | New Hampshire Precertification List, Pg 198 Original policy |
| 97022 | Application of a modality to 1 or more areas; whirlpool | New Hampshire Precertification List, Pg 198 Original policy |
| 97024 | Application of a modality to 1 or more areas; diathermy (eg, microwave) | New Hampshire Precertification List, Pg 198 Original policy |
| 97026 | Application of a modality to 1 or more areas; infrared | New Hampshire Precertification List, Pg 198 Original policy |
| 97028 | Application of a modality to 1 or more areas; ultraviolet | New Hampshire Precertification List, Pg 198 Original policy |
| 97032 | Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes | New Hampshire Precertification List, Pg 198 Original policy |
| 97033 | Application of a modality to 1 or more areas; iontophoresis, each 15 minutes | New Hampshire Precertification List, Pg 198 Original policy |
| 97034 | Application of a modality to 1 or more areas; contrast baths, each 15 minutes | New Hampshire Precertification List, Pg 198 Original policy |
| 97035 | Application of a modality to 1 or more areas; ultrasound, each 15 minutes | New Hampshire Precertification List, Pg 198 Original policy |
| 97036 | Application of a modality to 1 or more areas; Hubbard tank, each 15 minutes | New Hampshire Precertification List, Pg 198 Original policy |
| 97110 | Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility | New Hampshire Precertification List, Pg 198 Original policy |
| 97112 | Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities | New Hampshire Precertification List, Pg 198 Original policy |
| 97113 | Therapeutic procedure, 1 or more areas, each 15 minutes; aquatic therapy with therapeutic exercises | New Hampshire Precertification List, Pg 198 Original policy |
| 97116 | Therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing) | New Hampshire Precertification List, Pg 199 Original policy |
| 97124 | Therapeutic procedure, 1 or more areas, each 15 minutes; massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion) | New Hampshire Precertification List, Pg 199 Original policy |
| 97129 | Therapeutic interventions that focus on cognitive function (eg, attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (eg, managing time or schedules, initiating, organizing, and sequencing tasks), direct (one-on-one) patient contact; initial 15 minutes | New Hampshire Precertification List, Pg 199 Original policy |
| 97130 | Therapeutic interventions that focus on cognitive function (eg, attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (eg, managing time or schedules, initiating, organizing, and sequencing tasks), direct (one-on-one) patient contact; each additional 15 minutes (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 199 Original policy |
| 97140 | Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes | New Hampshire Precertification List, Pg 199 Original policy |
| 97150 | Therapeutic procedure(s), group (2 or more individuals) | New Hampshire Precertification List, Pg 199 Original policy |
| 97151 | Behavior identification assessment, administered by a physician or other qualified health care professional, each 15 minutes of the physician's or other qualified health care professional's time face-to-face with patient and/or guardian(s)/caregiver(s) administering assessments and discussing findings and recommendations, and non-face-to-face analyzing past data, scoring/interpreting the assessment, and preparing the report/treatment plan | New Hampshire Precertification List, Pg 199 Original policy |
| 97152 | Behavior identification-supporting assessment, administered by one technician under the direction of a physician or other qualified health care professional, face-to-face with the patient, each 15 minutes | New Hampshire Precertification List, Pg 199 Original policy |
| 97153 | Adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with one patient, each 15 minutes | New Hampshire Precertification List, Pg 200 Original policy |
| 97154 | Group adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with two or more patients, each 15 minutes | New Hampshire Precertification List, Pg 200 Original policy |
| 97155 | Adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, which may include simultaneous direction of technician, face- to-face with one patient, each 15 minutes | New Hampshire Precertification List, Pg 200 Original policy |
| 97156 | Family adaptive behavior treatment guidance, administered by physician or other qualified health care professional (with or without the patient present), face- to-face with guardian(s)/caregiver(s), each 15 minutes | New Hampshire Precertification List, Pg 200 Original policy |
| 97157 | Multiple-family group adaptive behavior treatment guidance, administered by physician or other qualified health care professional (without the patient present), face-to-face with multiple sets of guardians/caregivers, each 15 minutes | New Hampshire Precertification List, Pg 200 Original policy |
| 97158 | Group adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, face-to-face with multiple patients, each 15 minutes | New Hampshire Precertification List, Pg 200 Original policy |
| 97161 | Physical therapy evaluation: low complexity, requiring these components: A history with no personal factors and/or comorbidities that impact the plan of care; An examination of body system(s) using standardized tests and measures addressing 1-2 elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; A clinical presentation with stable and/or uncomplicated characteristics; and Clinical decision making of low complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 20 minutes are spent face-to- face with the patient and/or family. | New Hampshire Precertification List, Pg 201 Original policy |
| 97162 | Physical therapy evaluation: moderate complexity, requiring these components: A history of present problem with 1-2 personal factors and/or comorbidities that impact the plan of care; An examination of body systems using standardized tests and measures in addressing a total of 3 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; An evolving clinical presentation with changing characteristics; and Clinical decision making of moderate complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 30 minutes are spent face-to- face with the patient and/or family. | New Hampshire Precertification List, Pg 201 Original policy |
| 97163 | Physical therapy evaluation: high complexity, requiring these components: A history of present problem with 3 or more personal factors and/or comorbidities that impact the plan of care; An examination of body systems using standardized tests and measures addressing a total of 4 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; A clinical presentation with unstable and unpredictable characteristics; and Clinical decision making of high complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 45 minutes are spent face-to- face with the patient and/or family. | New Hampshire Precertification List, Pg 202 Original policy |
| 97164 | Re-evaluation of physical therapy established plan of care, requiring these components: An examination including a review of history and use of standardized tests and measures is required; and Revised plan of care using a standardized patient assessment instrument and/or measurable assessment of functional outcome Typically, 20 minutes are spent face-to- face with the patient and/or family. | New Hampshire Precertification List, Pg 202 Original policy |
| 97165 | Occupational therapy evaluation, low complexity, requiring these components: An occupational profile and medical and therapy history, which includes a brief history including review of medical and/or therapy records relating to the presenting problem; An assessment(s) that identifies 1-3 performance deficits (ie, relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and Clinical decision making of low complexity, which includes an analysis of the occupational profile, analysis of data from problem- focused assessment(s), and consideration of a limited number of treatment options. Patient presents with no comorbidities that affect occupational performance. Modification of tasks or assistance (eg, physical or verbal) with assessment(s) is not necessary to enable completion of evaluation component. Typically, 30 minutes are spent face-to- face with the patient and/or family. | New Hampshire Precertification List, Pg 203 Original policy |
| 97166 | Occupational therapy evaluation, moderate complexity, requiring these components: An occupational profile and medical and therapy history, which includes an expanded review of medical and/or therapy records and additional review of physical, cognitive, or psychosocial history related to current functional performance; An assessment(s) that identifies 3-5 performance deficits (ie, relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and Clinical decision making of moderate analytic complexity, which includes an analysis of the occupational profile, analysis of data from detailed assessment(s), and consideration of several treatment options. Patient may present with comorbidities that affect occupational performance. Minimal to moderate modification of tasks or assistance (eg, physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component. Typically, 45 minutes are spent face-to-face with the patient and/or family. | New Hampshire Precertification List, Pg 203 Original policy |
| 97167 | Occupational therapy evaluation, high complexity, requiring these components: An occupational profile and medical and therapy history, which includes review of medical and/or therapy records and extensive additional review of physical, cognitive, or psychosocial history related to current functional performance; An assessment(s) that identifies 5 or more performance deficits (ie, relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and Clinical decision making of high analytic complexity, which includes an analysis of the patient profile, analysis of data from comprehensive assessment(s), and consideration of multiple treatment options. Patient presents with comorbidities that affect occupational performance. Significant modification of tasks or assistance (eg, physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component. Typically, 60 minutes are spent face-to-face with the patient and/or family. | New Hampshire Precertification List, Pg 204 Original policy |
| 97168 | Re-evaluation of occupational therapy established plan of care, requiring these components: An assessment of changes in patient functional or medical status with revised plan of care; An update to the initial occupational profile to reflect changes in condition or environment that affect future interventions and/or goals; and A revised plan of care. A formal reevaluation is performed when there is a documented change in functional status or a significant change to the plan of care is required. Typically, 30 minutes are spent face-to-face with the patient and/or family. | New Hampshire Precertification List, Pg 204 Original policy |
| 97530 | Therapeutic activities, direct (one-on- one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes | New Hampshire Precertification List, Pg 204 Original policy |
| 97533 | Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on- one) patient contact, each 15 minutes | New Hampshire Precertification List, Pg 204 Original policy |
| 97535 | Self-care/home management training (eg, activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one- on-one contact, each 15 minutes | New Hampshire Precertification List, Pg 205 Original policy |
| 97537 | Community/work reintegration training (eg, shopping, transportation, money management, avocational activities and/or work environment/modification analysis, work task analysis, use of assistive technology device/adaptive equipment), direct one-on-one contact, each 15 minutes | New Hampshire Precertification List, Pg 205 Original policy |
| 97542 | Wheelchair management (eg, assessment, fitting, training), each 15 minutes | New Hampshire Precertification List, Pg 205 Original policy |
| 97545 | Work hardening/conditioning; initial 2 hours | New Hampshire Precertification List, Pg 205 Original policy |
| 97546 | Work hardening/conditioning; each additional hour (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 205 Original policy |
| 97610 | Low frequency, non-contact, non-thermal ultrasound, including topical application(s), when performed, wound assessment, and instruction(s) for ongoing care, per day | New Hampshire Precertification List, Pg 205 Original policy |
| 97750 | Physical performance test or measurement (eg, musculoskeletal, functional capacity), with written report, each 15 minutes | New Hampshire Precertification List, Pg 205 Original policy |
| 97755 | Assistive technology assessment (eg, to restore, augment or compensate for existing function, optimize functional tasks and/or maximize environmental accessibility), direct one-on-one contact, with written report, each 15 minutes | New Hampshire Precertification List, Pg 205 Original policy |