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Crosswalk to CPT/HCPCS Codes and Associated Coverage Determinations

The following table lists the Coverage Determinations that WPS GHA currently has available and the CPT/HCPCS codes that can be found within each document. This list assists you with determining whether a procedure code has local coverage limits. All codes are also subject to National Coverage rules, medical necessity and other regulations such as CCI, MUE, ASC, National Lab restrictions, documentation/ signature requirements and other provisions. If a code is available on this list, the Coverage Determination that is associated with the code will present guidance on coverage. This listing is intended to be a helpful tool for search and document retrieval.

If you are unable to find the code(s) you are specifically looking for, please review the CMS Coverage Center Website to research additional resources they have available.

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LCD Title CMS ID# Coverage Determination Type Associated CPT/HCPCS Codes
Allergy Immunotherapy
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L36408 Local 95115, 95117, 95144, 95145, 95146, 95147, 95148, 95149, 95165, 95170, 95180
Allergy Testing
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L36402 Local 82785, 86001, 86003, 86005, 95004, 95017, 95018, 95024, 95027, 95028, 95044, 95052, 95056, 95060, 95065, 95070, 95071, 95076, 95079
Autonomic Function Testing
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L35124 Local 95921, 95922, 95923, 95924, 95943
Bisphosphonate Drug Therapy
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34648 Local J1436, J1740, J2430, J3489
Blepharoplasty, Blepharoptosis and Brow Lift
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34528 Local 15820, 15821, 15822, 15823, 67900, 67901, 67902, 67903, 67904, 67906, 67908
Botulinum Toxin Type A & Type B
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34635 Local 31513, 31570, 31571, 43201, 43236, 46505, 52287, 64611, 64612, 64615, 64616, 64617, 64642, 64643, 64644, 64645, 64646, 64647, 64650, 64653, 67345, 92265, 95873, 95874, J0585, J0586, J0587, J0588
Category III Codes
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L35490 Local 0075T, 0076T, 0171T, 0172T, 0184T, 0191T, 0249T, 0275T, 0281T, 0295T, 0296T, 0297T, 0298T, 0308T, 0394T, 0395T
Chemotherapy Drugs and their Adjuncts
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L35053 Local A9606, A9699, C9399, C9472, C9474, C9475, C9476, C9477, C9480, J0640, J0641, J0894, J2353, J3490, J3590, J7315, J9000, J9015, J9017, J9019, J9020, J9025, J9031, J9032, J9033, J9035, J9039, J9040, J9041, J9042, J9043, J9045, J9047, J9050, J9055, J9060, J9065, J9070, J9098, J9100, J9120, J9130, J9150, J9151, J9160, J9165, J9171, J9178, J9179, J9181, J9185, J9190, J9200, J9201, J9206, J9207, J9208, J9209, J9211, J9214, J9215, J9228, J9230, J9245, J9250, J9260, J9261, J9262, J9263, J9264, J9266, J9267, J9268, J9270, J9271, J9280, J9293, J9299, J9300, J9301, J9302, J9303, J9305, J9306, J9307, J9308, J9310, J9315, J9320, J9330, J9340, J9351, J9354, J9355, J9357, J9360, J9370, J9371, J9390, J9395, J9400, J9600, J9999, Q2043, Q2048, Q2049, Q2050
Chiropractic Services
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34585 Local 98940, 98941, 98942
Colonoscopy and Sigmoidoscopy-Diagnostic
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34614 Local 44388, 44389, 44390, 44391, 44392, 44394, 44401, 44402, 44403, 44404, 44405, 44406, 44407, 44408, 45330, 45331, 45332, 45333, 45334, 45335, 45337, 45338, 45340, 45341, 45342, 45378, 45379, 45380, 45381, 45382, 45384, 45385, 45386, 45391, 45392
Coronary Computed Tomography Angiography (CCTA)
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L35121 Local 75571, 75572, 75573, 75574
Cosmetic and Reconstructive Surgery
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34698 Local 11920, 11921, 11922, 11950, 11951, 11952, 11954, 15775, 15776, 15781, 15782, 15783, 15788, 15789, 15792, 15793, 15819, 15824, 15825, 15826, 15828, 15829, 15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15876, 15877, 15878, 15879, 17340, 17360, 17380, 19300, 19316, 19318, 19324, 19325, 19328, 19330, 19340, 19342, 19350, 19355, 19357, 19361, 19364, 19366, 19367, 19368, 19369, 19370, 19371, 19380, 19396, 30400, 30410, 30420, 30430, 30435, 30450, 69300, C9800, G0429, Q2026, Q2028
Drug Testing
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34645 Local 80300, 80301, 80302, 80303, 80304, 80320, 80321, 80322, 80323, 80324, 80325, 80326, 80327, 80328, 80329, 80330, 80331, 80332, 80333, 80334, 80335, 80336, 80337, 80338, 80339, 80340, 80341, 80342, 80343, 80344, 80345, 80346, 80347, 80348, 80349, 80350, 80351, 80352, 80353, 80354, 80355, 80356, 80357, 80358, 80359, 80360, 80361, 80362, 80363, 80364, 80365, 80366, 80367, 80368, 80369, 80370, 80371, 80372, 80373, 80374, 80375, 80376, 80377, G0477, G0478, G0479, G0480, G0481, G0482, G0483
Drugs and Biologics (Non-chemotherapy)
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34741 Local 96401, C9257, C9399, J0129, J0178, J0180, J0256, J0257, J0364, J0490, J1300, J1745, J1931, J2001, J2323, J2357, J2503, J2562, J2778, J2796, J3396, J3490, J3590, J7999, J9999
Electrocardiographic (EKG or ECG) Monitoring (Holter or Real-Time Monitoring)
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34636 Local 0295T, 0296T, 0297T, 0298T, 93224, 93225, 93226, 93227, 93228, 93229, 93268, 93270, 93271, 93272
Endoscopic Treatment of GERD
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34659 Local 43257, 43499, 43999, 49999
Erythropoiesis Stimulating Agents (ESAs)
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34633 Local 99211, A4657, J0881, J0882, J0885, J0887, J0888, J0890, Q4081
Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L35996 Local 64490, 64491, 64492, 64493, 64494, 64495, 64633, 64634, 64635, 64636
Flow Cytometry
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34651 Local 88182, 88184, 88185, 88187, 88188, 88189
Foot Care
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L36404 Local 11055, 11056, 11057, 11719, 11720, 11721, G0127
Genetic Testing for CYP2C19, CYP2D6, CYP2C9, and VKORC1
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L36398 Local 81225, 81226, 81227, 81355
Genetic Testing for Hypercoagulability/Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR)
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L36400 Local 81240, 81241, 81291
Human Granulocyte/Macrophage Colony Stimulating Factors
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34699 Local J1442, J1447, J2505, J2820
Immune Globulins
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34771 Local 90371, 90375, 90376, 90393, 90396, 96365, 96366, 96372, J0840, J0850, J1459, J1460, J1556, J1557, J1560, J1561, J1566, J1568, J1569, J1571, J1572, J1573, J1599, J1670
Immunizations
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34596 Local 90296, 90476, 90477, 90581, 90585, 90586, 90620, 90621, 90625, 90632, 90633, 90634, 90636, 90644, 90647, 90648, 90649, 90650, 90675, 90676, 90679, 90680, 90681, 90690, 90691, 90696, 90698, 90700, 90702, 90707, 90710, 90713, 90714, 90715, 90716, 90717, 90723, 90733, 90734, 90736, 90738, 90749
Intra-articular Injections of Hyaluronan
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34525 Local 20610, 20611, C9471, J3490, J7321, J7323, J7324, J7325, J7326, J7327, J7378, Q9980
Intraoperative Neurophysiological Testing
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34623 Local 95940, 95941, G0453
Lumbar Epidural Injections
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L36521 Local 62281, 62282, 62284, 62287, 62290, 62291, 62292, 62294, 62302, 62303, 62304, 62305, 62310, 62311, 62318, 62319, 64483, 64484, 78630
Mohs Micrographic Surgery
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L35494 Local 17311, 17312, 17313, 17314, 17315, 88300, 88302, 88304, 88304, 88307, 88309, 88331, 88332, 88342
MolDX: Biomarkers in Cardiovascular Risk Assessment
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L36523 Local 82172, 82610, 83090, 83695, 83698, 83700, 83701, 83704, 83719, 83721, 83880, 86141
Molecular Diagnostic Testing
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34762 Local 81162, 81200, 81201, 81202, 81203, 81205, 81206, 81207, 81208, 81209, 81210, 81211, 81212, 81213, 81214, 81215, 81216, 81217, 81220, 81221, 81223, 81224, 81227, 81228, 81229, 81235, 81242, 81243, 81244, 81250, 81251, 81252, 81253, 81254, 81255, 81257, 81260, 81270, 81275, 81276, 81280, 81281, 81282, 81290, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81301, 81302, 81303, 81304, 81317, 81318, 81319, 81324, 81325, 81326, 81355, 81381, 81330, 81331, 81403, 81405, 81406, 88341, 88342, 88363, G9143
Nerve Blocks for Peripheral Neuropathy
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L35222 Local 64450, 76881, 76882, 76942, 76999, 97032, 97139, G0282, G0283
Nerve Conduction Studies and Electromyography
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34594 Local 51785, 92265, 95860, 95861, 95863, 95864, 95865, 95866, 95867, 95868, 95869, 95870, 95872, 95873, 95874, 95885, 95886, 95887, 95905, 95907, 95908, 95909, 95910, 95911, 95912, 95913, 95933, 95937, 95999, G0255
Non-Coronary Vascular Stents
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L35998 Local 37221, 37223, 37226, 37227, 37230, 37231, 37234, 37235, 37236, 37237, 37238, 37239
Non-Invasive Abdominal / Visceral Vascular Studies
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L35755 Local 55899, 76936, 93975, 93976, 93978, 93979, 93980, 93981
Non-Invasive Cerebrovascular Studies
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L35753 Local 93880, 93882, 93886, 93888, 93890, 93892, 93893, 93895
Non-Invasive Peripheral Arterial Vascular Studies
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L35761 Local 93922, 93923, 93924, 93925, 93926, 93930, 93931
Non-Invasive Peripheral Venous Vascular Studies including Hemodialysis Access
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L35751 Local 93965, 93970, 93971, 93990, 90995, G0365
Pelvic Floor Dysfunction: Anorectal Manometry and EMG
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L35486 Local 51784, 51785, 91122
Percutaneous Coronary Interventions (PCI)
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34761 Local 92920, 92921, 92924, 92925, 92928, 92929, 92933, 92934, 92937, 92938, 92941, 92943, 92944, 92973, 92974, 92975, 92978, 92979, 93571, 93572, C9600, C9601, C9602, C9603, C9604, C9605, C9606, C9607, C9608
Percutaneous minimally invasive fusion/stabilization of the sacroiliac joint for the treatment of back pain
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L36000 Local 27279
Polysomnography and Other Sleep Studies
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34535 Local 95782, 95783, 95800, 95801, 95805, 95806, 95807, 95808, 95810, 95811, G0398, G0399, G0400
Posterior Tibial Nerve Stimulation PTNS
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34436 Local 64566
Proton Beam Therapy
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34634 Local 77520, 77522, 77523, 77524, 77525
Psychiatry and Psychology Services
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34616 Local 90785, 90791, 90792, 90804, 90805, 90806, 90807, 90808, 90909, 90810, 90811, 90812, 90813, 90814, 90815, 90816, 90817, 90818, 90819, 90821, 90822, 90823, 90824, 90826, 90827, 90828, 90829, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90845, 90846, 90847, 90849, 90853, 90857, 90862, 90863, 90865, 90880, 90885, 90887, 90889, 908997
Psychological and Neuropsychological Testing
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34646 Local 96101, 96102, 96103, 96105, 96110, 96111, 96116, 96118, 96119, 96120, 96125
Removal of Benign Skin Lesions
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L35498 Local 11200, 11201, 11300, 11301, 11302, 11303, 11305, 11306, 11307, 11308, 11310, 11311, 11312, 11313, 11400, 11401, 11402, 11403, 11404, 11406, 11420, 11421, 11422, 11423, 11424, 11426, 11440, 11441, 11442, 11443, 11444, 11446, 17106, 17107, 17108, 17110, 17111
Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34760 Local 76512, 92132, 92133, 92134, 92225, 92226, 92235, 92250
Somatosensory Testing
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34624 Local 95860, 95861, 95863, 95864, 95865, 95866, 95867, 95868, 95869, 95870, 95872, 95873, 95874, 95875, 95885, 95886, 95887, 95905, 95907, 95908, 95909, 95910, 95911, 95912, 95913, 95921, 95922, 95923, 95924, 95925, 95926, 95927, 95928, 95929, 95930, 95933, 95937, 95938
Surgical Treatment of Obstructive Sleep Apnea (OSA)
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34526 Local 21110, 21141, 21145, 21196, 21199, 21685, 30140, 30802, 31600, 31610, 41512, 41530, 42145, 42299,
Transcranial Magnetic Stimulation (TMS)
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34641 Local 90867, 90868, 90869
Treatment of Varicose Veins of the Lower Extremities
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34536 Local 36468, 36470, 36471, 36475, 36476, 36478, 36479, 37500, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785, 37799, 93965, 93970, 93971
Trigger Points, Local Injections
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34588 Local 20552, 20553
Vertebroplasty (Percutaneous) and Vertebral Augmentation including cavity creation
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34592 Local 20225, 20250, 20251, 22325, 22326, 22327, 22328, 22510, 22511, 22512, 22513, 22514, 22515, 22899, 62292, 63003, 63005, 63011, 63012, 63015, 63016, 63017, 63020, 63030, 63035, 63040, 63042, 63043, 63044, 63045, 63046, 63047, 63048, 63050, 63051, 63055, 63056, 63057, 63064, 63066, 63075, 63076, 63077, 63078, 63081, 63082, 63085, 63086, 63087, 63088, 63090, 63091
Visual Fields
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34615 Local 92081, 92082, 92083
Vitamin D Assay Testing
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34658 Local 82306, 82652
Wound Care
Iowa ¦ Kansas ¦ Missouri ¦ Nebraska
L34587 Local 11042, 11043, 11044, 11045, 11046, 11047, 97026, 97028, 97035, 97597, 97598, 97602, 97605, 97606, 97607, 97608, 97610, G0281, G0329