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Q0138 |
 |
Injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg (non-esrd use)
| short | Ferumoxytol, non-esrd |
| RVU | | CPT Modifier | Physician Component | Facility Practice | Nonfacility Practice | Professional Liability Insurance | Total Facility | Total Nonfacility | Global Period |
|---|
| 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | XXX |
|
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 510.0 | 3 Date of Service Edit: Clinical | Prescribing Information | | OPH | 510.0 | 3 Date of Service Edit: Clinical | Prescribing Information |
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Q0139 |
|
Injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg (for esrd on dialysis)
| short | Ferumoxytol, esrd use |
| RVU | | CPT Modifier | Physician Component | Facility Practice | Nonfacility Practice | Professional Liability Insurance | Total Facility | Total Nonfacility | Global Period |
|---|
| 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | XXX |
|
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 510.0 | 3 Date of Service Edit: Clinical | Prescribing Information | | OPH | 510.0 | 3 Date of Service Edit: Clinical | Prescribing Information |
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Q0144 |
|
Azithromycin dihydrate, oral, capsules/powder, 1 gram
| short | Azithromycin dihydrate, oral |
| RVU | | CPT Modifier | Physician Component | Facility Practice | Nonfacility Practice | Professional Liability Insurance | Total Facility | Total Nonfacility | Global Period |
|---|
| 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | XXX |
|
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | DME | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy |
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Q0161 |
|
Chlorpromazine hydrochloride, 5 mg, oral, fda approved prescription anti-emetic, for use as a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen
| short | Chlorpromazine hcl 5mg oral |
| RVU | | CPT Modifier | Physician Component | Facility Practice | Nonfacility Practice | Professional Liability Insurance | Total Facility | Total Nonfacility | Global Period |
|---|
| 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | XXX |
|
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 66.0 | 3 Date of Service Edit: Clinical | Clinical: Data | | DME | 66.0 | 3 Date of Service Edit: Clinical | Clinical: Data |
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Q0162 |
|
Ondansetron 1 mg, oral, fda approved prescription anti-emetic, for use as a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen
| short | Ondansetron oral |
| RVU | | CPT Modifier | Physician Component | Facility Practice | Nonfacility Practice | Professional Liability Insurance | Total Facility | Total Nonfacility | Global Period |
|---|
| 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | XXX |
|
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | Oral Medication; Not Payable | | OPH | 24.0 | 3 Date of Service Edit: Clinical | Prescribing Information | | DME | 40.0 | 3 Date of Service Edit: Clinical | CMS Policy |
|
|
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Q0163 |
|
Diphenhydramine hydrochloride, 50 mg, oral, fda approved prescription anti-emetic, for use as a complete therapeutic substitute for an iv anti-emetic at time of chemotherapy treatment not to exceed a 48 hour dosage regimen
| short | Diphenhydramine hcl 50mg |
| RVU | | CPT Modifier | Physician Component | Facility Practice | Nonfacility Practice | Professional Liability Insurance | Total Facility | Total Nonfacility | Global Period |
|---|
| 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | XXX |
|
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | Oral Medication; Not Payable | | OPH | 6.0 | 3 Date of Service Edit: Clinical | Prescribing Information | | DME | 13.0 | 3 Date of Service Edit: Clinical | CMS Policy |
|
|
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Q0164 |
|
Prochlorperazine maleate, 5 mg, oral, fda approved prescription anti-emetic, for use as a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen
| short | Prochlorperazine maleate 5mg |
| RVU | | CPT Modifier | Physician Component | Facility Practice | Nonfacility Practice | Professional Liability Insurance | Total Facility | Total Nonfacility | Global Period |
|---|
| 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | XXX |
|
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | Oral Medication; Not Payable | | OPH | 8.0 | 3 Date of Service Edit: Clinical | Prescribing Information | | DME | 18.0 | 3 Date of Service Edit: Clinical | CMS Policy |
|
|
|
|
Q0166 |
|
Granisetron hydrochloride, 1 mg, oral, fda approved prescription anti-emetic, for use as a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 24 hour dosage regimen
| short | Granisetron hcl 1 mg oral |
| RVU | | CPT Modifier | Physician Component | Facility Practice | Nonfacility Practice | Professional Liability Insurance | Total Facility | Total Nonfacility | Global Period |
|---|
| 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | XXX |
|
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | Oral Medication; Not Payable | | OPH | 2.0 | 3 Date of Service Edit: Clinical | Prescribing Information | | DME | 2.0 | 3 Date of Service Edit: Clinical | Prescribing Information |
|
|
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|
Q0167 |
|
Dronabinol, 2.5 mg, oral, fda approved prescription anti-emetic, for use as a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen
| short | Dronabinol 2.5mg oral |
| RVU | | CPT Modifier | Physician Component | Facility Practice | Nonfacility Practice | Professional Liability Insurance | Total Facility | Total Nonfacility | Global Period |
|---|
| 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | XXX |
|
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | Oral Medication; Not Payable | | OPH | 108.0 | 3 Date of Service Edit: Clinical | Prescribing Information | | DME | 108.0 | 3 Date of Service Edit: Clinical | Prescribing Information |
|
|
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Q0169 |
|
Promethazine hydrochloride, 12.5 mg, oral, fda approved prescription anti-emetic, for use as a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen
| short | Promethazine hcl 12.5mg oral |
| RVU | | CPT Modifier | Physician Component | Facility Practice | Nonfacility Practice | Professional Liability Insurance | Total Facility | Total Nonfacility | Global Period |
|---|
| 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | XXX |
|
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | Oral Medication; Not Payable | | OPH | 12.0 | 3 Date of Service Edit: Clinical | Prescribing Information | | DME | 26.0 | 3 Date of Service Edit: Clinical | CMS Policy |
|
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Q0173 |
|
Trimethobenzamide hydrochloride, 250 mg, oral, fda approved prescription anti-emetic, for use as a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen
| short | Trimethobenzamide hcl 250mg |
| RVU | | CPT Modifier | Physician Component | Facility Practice | Nonfacility Practice | Professional Liability Insurance | Total Facility | Total Nonfacility | Global Period |
|---|
| 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | XXX |
|
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | Oral Medication; Not Payable | | OPH | 5.0 | 3 Date of Service Edit: Clinical | Prescribing Information | | DME | 11.0 | 3 Date of Service Edit: Clinical | CMS Policy |
|
|
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Q0174 |
|
Thiethylperazine maleate, 10 mg, oral, fda approved prescription anti-emetic, for use as a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen
| short | Thiethylperazine maleate10mg |
| RVU | | CPT Modifier | Physician Component | Facility Practice | Nonfacility Practice | Professional Liability Insurance | Total Facility | Total Nonfacility | Global Period |
|---|
| 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | XXX |
|
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | Drug discontinued | | OPH | 0.0 | 3 Date of Service Edit: Clinical | Drug discontinued | | DME | 0.0 | 3 Date of Service Edit: Clinical | Drug discontinued |
|
|
|
|
Q0175 |
|
Perphenazine, 4 mg, oral, fda approved prescription anti-emetic, for use as a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen
| short | Perphenazine 4mg oral |
| RVU | | CPT Modifier | Physician Component | Facility Practice | Nonfacility Practice | Professional Liability Insurance | Total Facility | Total Nonfacility | Global Period |
|---|
| 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | XXX |
|
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | Oral Medication; Not Payable | | OPH | 6.0 | 3 Date of Service Edit: Clinical | Prescribing Information | | DME | 14.0 | 3 Date of Service Edit: Clinical | CMS Policy |
|
|
|
|
Q0177 |
|
Hydroxyzine pamoate, 25 mg, oral, fda approved prescription anti-emetic, for use as a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen
| short | Hydroxyzine pamoate 25mg |
| RVU | | CPT Modifier | Physician Component | Facility Practice | Nonfacility Practice | Professional Liability Insurance | Total Facility | Total Nonfacility | Global Period |
|---|
| 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | XXX |
|
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | Oral Medication; Not Payable | | OPH | 16.0 | 3 Date of Service Edit: Clinical | Prescribing Information | | DME | 36.0 | 3 Date of Service Edit: Clinical | CMS Policy |
|
|
|
|
Q0180 |
|
Dolasetron mesylate, 100 mg, oral, fda approved prescription anti-emetic, for use as a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 24 hour dosage regimen
| short | Dolasetron mesylate oral |
| RVU | | CPT Modifier | Physician Component | Facility Practice | Nonfacility Practice | Professional Liability Insurance | Total Facility | Total Nonfacility | Global Period |
|---|
| 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | XXX |
|
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | Oral Medication; Not Payable | | OPH | 1.0 | 3 Date of Service Edit: Clinical | Prescribing Information | | DME | 1.0 | 3 Date of Service Edit: Clinical | Prescribing Information |
|
|
|
|
Q0181 |
|
Unspecified oral dosage form, fda approved prescription anti-emetic, for use as a complete therapeutic substitute for a iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen
| short | Unspecified oral anti-emetic |
| RVU | | CPT Modifier | Physician Component | Facility Practice | Nonfacility Practice | Professional Liability Insurance | Total Facility | Total Nonfacility | Global Period |
|---|
| 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | XXX |
|
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 2.0 | 3 Date of Service Edit: Clinical | CMS Policy |
|
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