HCPCS Range Miscellaneous Services

• 1 Molecular pathology procedure; physician interpretation and report ( G0452 )

• 2 Continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby), per patient, (attention directed exclusively to one patient) each 15 minutes (list in addition to primary procedure) ( G0453 )

• 3 Physician documentation of face-to-face visit for durable medical equipment determination performed by nurse practitioner, physician assistant or clinical nurse specialist ( G0454 )

• 4 Preparation with instillation of fecal microbiota by any method, including assessment of donor specimen ( G0455 )

• 5 Low dose rate (LDR) prostate brachytherapy services, composite rate ( G0458 )

• 6 Inpatient telehealth pharmacologic management, including prescription, use, and review of medication with no more than minimal medical psychotherapy ( G0459 )

• 7 Autologous platelet rich plasma or other blood-derived product for non-diabetic chronic wounds/ulcers, including as applicable phlebotomy, centrifugation or mixing, and all other preparatory procedures, administration and dressings, per treatment ( G0460 )

• 8 Hospital outpatient clinic visit for assessment and management of a patient ( G0463 )

• 9 Autologous platelet rich plasma (PRP) or other blood-derived product for diabetic chronic wounds/ulcers, using an FDA-cleared device for this indication, (includes as applicable administration, dressings, phlebotomy, centrifugation or mixing, and all other preparatory procedures, per treatment)  ( G0465 )