Fees

(1) Acupuncture. Fee 40.06(1) Acupuncture Description Unlisted modality (specify type and time if constant attendance) Therapeutic procedure, one or more areas, each 15 minutes; massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion) 97139 13.17 Unlisted therapeutic procedure (specify) Acupuncture, one or more needles; without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient Acupuncture, one or more needles; without electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s) (List separately in addition to code for primary procedure) Acupuncture, one or more needles; with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient Acupuncture, one or more needles; with electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s) (List separately in addition to code for primary procedure) Special reports such as insurance forms, more than the information conveyed in the usual medical communications or standard reporting form Fee 40.06(1) Acupuncture Description (continued) Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a problem focused history; a problem focused examination; straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually the presenting problems are self limited or minor. Physicians typically spend ten minutes face-to-face with the patient and/or family Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: an expanded problem focused history; an expanded problem focused examination; straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually the presenting problems are of low to moderate severity. Physicians typically spend 20 minutes face-to-face with the patient and/or family Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a detailed history; a detailed examination; medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually the presenting problems are of moderate severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a comprehensive history; a comprehensive examination; medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually the presenting problems are of moderate to high severity. Physicians typically spend 45 minutes face-to-face with the patient and/or family Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, five minutes are spent performing or supervising these services Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem focused history; a problem focused examination; straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually the presenting problem(s) are self limited or minor. Physicians typically spend ten minutes face-to-face with the patient and/or family. Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually the presenting problem(s) are of low to moderate complexity. Physicians typically spend 15 minutes face-to-face with the patient and/or family. Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a detailed history; a detailed examination; medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually the presenting problem(s) are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family. (2) Anesthesia. PAYMENT EQUALS : (TIME UNITS + BASE UNITS + MODIFYING UNITS) TIMES $39.00 (Rate per UNIT) Base Code Unit 40.06(2) - Anesthesia Description Anesthesia for procedures on salivary glands, including biopsy Anesthesia for procedures involving plastic repair of cleft lip Anesthesia for reconstructive procedures of eyelid (eg, blepharoplasty, ptosis surgery) Anesthesia for electroconvulsive therapy Anesthesia for procedures on external, middle, and inner ear including biopsy; not otherwise specified Anesthesia for procedures on external, middle, and inner ear including biopsy; otoscopy Anesthesia for procedures on external, middle, and inner ear including biopsy; tympanotomy Anesthesia for procedures on eye; not otherwise specified Anesthesia for procedures on eye; lens surgery Anesthesia for procedures on eye; corneal transplant Anesthesia for procedures on eye; vitreoretinal surgery Anesthesia for procedures on eye; iridectomy Anesthesia for procedures on eye; ophthalmoscopy Anesthesia for procedures on nose and accessory sinuses; not otherwise specified Anesthesia for procedures on nose and accessory sinuses; radical surgery Anesthesia for procedures on nose and accessory sinuses; biopsy, soft tissue Anesthesia for intraoral procedures, including biopsy; not otherwise specified Anesthesia for intraoral procedures, including biopsy; repair of cleft palate Anesthesia for intraoral procedures, including biopsy; excision of retropharyngeal tumor Anesthesia for intraoral procedures, including biopsy; radical surgery Anesthesia for procedures on facial bones or skull; not otherwise specified Anesthesia for procedures on facial bones or skull; radical surgery (including prognathism) 00210 11 Anesthesia for intracranial procedures; not otherwise specified Anesthesia for intracranial procedures; subdural taps Anesthesia for intracranial procedures; burr holes, including ventriculography Anesthesia for intracranial procedures; cranioplasty or elevation of depressed skull fracture, extradural (simple or compound) 00216 15 Anesthesia for intracranial procedures; vascular procedures 00218 13 Anesthesia for intracranial procedures; procedures in sitting position 00220 10 Anesthesia for intracranial procedures; cerebrospinal fluid shunting procedures Anesthesia for intracranial procedures; electrocoagulation of intracranial nerve Anesthesia for all procedures on the integumentary system, muscles and nerves of head, neck, and posterior trunk, not otherwise specified Anesthesia for all procedures on esophagus, thyroid, larynx, trachea and lymphatic system of neck; not otherwise specified, age 1 year or older Anesthesia for all procedures on esophagus, thyroid, larynx, trachea and lymphatic system of neck; needle biopsy of thyroid 00350 10 Anesthesia for procedures on major vessels of neck; not otherwise specified Anesthesia for procedures on major vessels of neck; simple ligation Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; not otherwise specified Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; reconstructive procedures on breast (eg, reduction or augmentation mammoplasty, muscle flaps) Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; radical or modified radical procedures on breast 00406 13 Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; radical or modified radical procedures on breast with internal mammary node dissection Base Code Unit 40.06(2) - Anesthesia Description (continued) Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; electrical conversion of arrhythmias Anesthesia for procedures on clavicle and scapula; not otherwise specified Anesthesia for procedures on clavicle and scapula; radical surgery Anesthesia for procedures on clavicle and scapula; biopsy of clavicle Anesthesia for partial rib resection; not otherwise specified 00472 10 Anesthesia for partial rib resection; thoracoplasty (any type) 00474 13 Anesthesia for partial rib resection; radical procedures (eg, pectus excavatum) 00500 15 Anesthesia for all procedures on esophagus Anesthesia for closed chest procedures; (including bronchoscopy) not otherwise specified Anesthesia for closed chest procedures; needle biopsy of pleura Anesthesia for closed chest procedures; pneumocentesis Anesthesia for closed chest procedures; mediastinoscopy and diagnostic thoracoscopy not utilizing one lung ventilation 00529 11 Anesthesia for closed chest procedures; mediastinoscopy and diagnostic thoracoscopy utilizing one lung ventilation Anesthesia for permanent transvenous pacemaker insertion Anesthesia for access to central venous circulation Anesthesia for transvenous insertion or replacement of pacing cardioverter-defibrillator Anesthesia for cardiac electrophysiologic procedures including radiofrequency ablation 00539 18 Anesthesia for tracheobronchial reconstruction 00540 12 Anesthesia for thoracotomy procedures involving lungs, pleura, diaphragm, and mediastinum (including surgical thoracoscopy); not otherwise specified 00542 15 Anesthesia for thoracotomy procedures involving lungs, pleura, diaphragm, and mediastinum (including surgical thoracoscopy); decortication 00541 15 Anesthesia for thoracotomy procedures involving lungs, pleura, diaphragm, and mediastinum (including surgical thoracoscopy); utilizing one lung ventilation 00546 15 Anesthesia for thoracotomy procedures involving lungs, pleura, diaphragm, and mediastinum (including surgical thoracoscopy); pulmonary resection with thoracoplasty 00548 17 Anesthesia for thoracotomy procedures involving lungs, pleura, diaphragm, and mediastinum (including surgical thoracoscopy); intrathoracic procedures on the trachea and bronchi 00550 10 Anesthesia for sternal debridement 00560 15 Anesthesia for procedures on heart, pericardial sac, and great vessels of chest; without pump oxygenator 00562 20 Anesthesia for procedures on heart, pericardial sac, and great vessels of chest; with pump oxygenator 00563 25 Anesthesia for procedures on heart, pericardial sac, and great vessels of chest; with pump oxygenator with hypothermic circulatory arrest 00566 25 Anesthesia for direct coronary artery bypass grafting without pump oxygenator 00580 20 Anesthesia for heart transplant or heart/lung transplant 00600 10 Anesthesia for procedures on cervical spine and cord; not otherwise specified 00604 13 Anesthesia for procedures on cervical spine and cord; procedures with patient in the sitting position 00620 10 Anesthesia for procedures on thoracic spine and cord; not otherwise specified 00622 13 Anesthesia for procedures on thoracic spine and cord; thoracolumbar sympathectomy 00625 13 Anesthesia for procedures on the thoracic spine and cord, via an anterior transthoracic approach; not utilizing one lung ventilation 00626 15 Anesthesia for procedures on the thoracic spine and cord, via an anterior transthoracic approach; utilizing one lung ventilation Anesthesia for procedures in lumbar region; not otherwise specified Anesthesia for procedures in lumbar region; lumbar sympathectomy 00634 10 Anesthesia for procedures in lumbar region; chemonucleolysis Anesthesia for procedures in lumbar region; diagnostic or therapeutic lumbar puncture Base Code Unit 40.06(2) - Anesthesia Description (continued) Anesthesia for manipulation of the spine or for closed procedures on the cervical, thoracic or lumbar spine 00670 13 Anesthesia for extensive spine and spinal cord procedures (eg, spinal instrumentation or vascular procedures) Anesthesia for procedures on upper anterior abdominal wall; not otherwise specified Anesthesia for procedures on upper anterior abdominal wall; percutaneous liver biopsy Anesthesia for procedures on upper posterior abdominal wall Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum Anesthesia for hernia repairs in upper abdomen; not otherwise specified Anesthesia for hernia repairs in upper abdomen; lumbar and ventral (incisional) hernias and/or wound dehiscence Anesthesia for hernia repairs in upper abdomen; omphalocele Anesthesia for hernia repairs in upper abdomen; transabdominal repair of diaphragmatic hernia 00770 15 Anesthesia for all procedures on major abdominal blood vessels Anesthesia for intraperitoneal procedures in upper abdomen including laparoscopy; not otherwise specified 00792 13 Anesthesia for intraperitoneal procedures in upper abdomen including laparoscopy; partial hepatectomy or management of liver hemorrhage (excluding liver biopsy) Anesthesia for intraperitoneal procedures in upper abdomen including laparoscopy; pancreatectomy, partial or total (eg, Whipple procedure) 00796 30 Anesthesia for intraperitoneal procedures in upper abdomen including laparoscopy; liver transplant (recipient) 00797 11 Anesthesia for intraperitoneal procedures in upper abdomen including laparoscopy; gastric restrictive procedure for morbid obesity Anesthesia for procedures on lower anterior abdominal wall; not otherwise specified Anesthesia for procedures on lower anterior abdominal wall; panniculectomy Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum Anesthesia for procedures on lower posterior abdominal wall Anesthesia for hernia repairs in lower abdomen; not otherwise specified Anesthesia for hernia repairs in lower abdomen; ventral and incisional hernias Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; not otherwise specified Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; amniocentesis Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; abdominoperineal resection Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; radical hysterectomy Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; pelvic exenteration Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; tubal ligation/transection Anesthesia for extraperitoneal procedures in lower abdomen, including urinary tract; not otherwise specified Anesthesia for extraperitoneal procedures in lower abdomen, including urinary tract; renal procedures, including upper one-third of ureter, or donor nephrectomy Anesthesia for extraperitoneal procedures in lower abdomen, including urinary tract; total cystectomy Anesthesia for extraperitoneal procedures in lower abdomen, including urinary tract; radical prostatectomy (suprapubic, retropubic) 00866 10 Anesthesia for extraperitoneal procedures in lower abdomen, including urinary tract; adrenalectomy Base Code Unit 40.06(2) - Anesthesia Description (continued) 00868 10 Anesthesia for extraperitoneal procedures in lower abdomen, including urinary tract; renal transplant (recipient) Anesthesia for extraperitoneal procedures in lower abdomen, including urinary tract; cystolithotomy Anesthesia for lithotripsy, extracorporeal shock wave; with water bath Anesthesia for lithotripsy, extracorporeal shock wave; without water bath 00880 15 Anesthesia for procedures on major lower abdominal vessels; not otherwise specified 00882 10 Anesthesia for procedures on major lower abdominal vessels; inferior vena cava ligation Anesthesia for; anorectal procedure Anesthesia for; radical perineal procedure Anesthesia for; vulvectomy Anesthesia for; perineal prostatectomy Anesthesia for transurethral procedures (including urethrocystoscopy); not otherwise specified Anesthesia for transurethral procedures (including urethrocystoscopy); transurethral resection of bladder tumor(s) Anesthesia for transurethral procedures (including urethrocystoscopy); transurethral resection of prostate Anesthesia for transurethral procedures (including urethrocystoscopy); post-transurethral resection bleeding Anesthesia for transurethral procedures (including urethrocystoscopy); with fragmentation, manipulation and/or removal of ureteral calculus Anesthesia for procedures on male genitalia (including open urethral procedures); not otherwise specified Anesthesia for procedures on male genitalia (including open urethral procedures); vasectomy, unilateral or bilateral Anesthesia for procedures on male genitalia (including open urethral procedures); seminal vesicles Anesthesia for procedures on male genitalia (including open urethral procedures); undescended testis, unilateral or bilateral Anesthesia for procedures on male genitalia (including open urethral procedures); radical orchiectomy, inguinal Anesthesia for procedures on male genitalia (including open urethral procedures); radical orchiectomy, abdominal Anesthesia for procedures on male genitalia (including open urethral procedures); orchiopexy, unilateral or bilateral Anesthesia for procedures on male genitalia (including open urethral procedures); complete amputation of penis Anesthesia for procedures on male genitalia (including open urethral procedures); radical amputation of penis with bilateral inguinal lymphadenectomy Anesthesia for procedures on male genitalia (including open urethral procedures); radical amputation of penis with bilateral inguinal and iliac lymphadenectomy Anesthesia for procedures on male genitalia (including open urethral procedures); insertion of penile prosthesis (perineal approach) Anesthesia for vaginal procedures (including biopsy of labia, vagina, cervix or endometrium); not otherwise specified Anesthesia for vaginal procedures (including biopsy of labia, vagina, cervix or endometrium); colpotomy, vaginectomy, colporrhaphy, and open urethral procedures Anesthesia for vaginal procedures (including biopsy of labia, vagina, cervix or endometrium); vaginal hysterectomy Anesthesia for vaginal procedures (including biopsy of labia, vagina, cervix or endometrium); cervical cerclage Anesthesia for vaginal procedures (including biopsy of labia, vagina, cervix or endometrium); culdoscopy Base Code Unit 40.06(2) - Anesthesia Description (continued) Anesthesia for vaginal procedures (including biopsy of labia, vagina, cervix or endometrium); hysteroscopy and/or hysterosalpingography Anesthesia for bone marrow aspiration and/or biopsy, anterior or posterior iliac crest Anesthesia for procedures on bony pelvis Anesthesia for body cast application or revision 01140 15 Anesthesia for interpelviabdominal (hindquarter) amputation 01150 10 Anesthesia for radical procedures for tumor of pelvis, except hindquarter amputation Anesthesia for closed procedures involving symphysis pubis or sacroiliac joint Anesthesia for open procedures involving symphysis pubis or sacroiliac joint 01173 12 Anesthesia for open repair of fracture disruption of pelvis or column fracture involving acetabulum Anesthesia for obturator neurectomy; extrapelvic Anesthesia for obturator neurectomy; intrapelvic Anesthesia for all closed procedures involving hip joint Anesthesia for arthroscopic procedures of hip joint Anesthesia for open procedures involving hip joint; not otherwise specified 01212 10 Anesthesia for open procedures involving hip joint; hip disarticulation Anesthesia for open procedures involving hip joint; total hip arthroplasty 01215 10 Anesthesia for open procedures involving hip joint; revision of total hip arthroplasty Anesthesia for all closed procedures involving upper two-thirds of femur Anesthesia for open procedures involving upper two-thirds of femur; not otherwise specified Anesthesia for open procedures involving upper two-thirds of femur; amputation Anesthesia for open procedures involving upper two-thirds of femur; radical resection Anesthesia for all procedures on nerves, muscles, tendons, fascia, and bursae of upper leg Anesthesia for all procedures involving veins of upper leg, including exploration Anesthesia for procedures involving arteries of upper leg, including bypass graft; not otherwise specified Anesthesia for procedures involving arteries of upper leg, including bypass graft; femoral artery ligation Anesthesia for procedures involving arteries of upper leg, including bypass graft; femoral artery embolectomy Anesthesia for all procedures on nerves, muscles, tendons, fascia, and bursae of knee and/or popliteal area Anesthesia for all closed procedures on lower one-third of femur Anesthesia for all open procedures on lower one-third of femur Anesthesia for all closed procedures on knee joint Anesthesia for diagnostic arthroscopic procedures of knee joint Anesthesia for all closed procedures on upper ends of tibia, fibula, and/or patella Anesthesia for all open procedures on upper ends of tibia, fibula, and/or patella Anesthesia for open or surgical arthroscopic procedures on knee joint; not otherwise specified Anesthesia for open or surgical arthroscopic procedures on knee joint; total knee arthroplasty Anesthesia for open or surgical arthroscopic procedures on knee joint; disarticulation at knee Anesthesia for all cast applications, removal, or repair involving knee joint Anesthesia for procedures on veins of knee and popliteal area; not otherwise specified Anesthesia for procedures on veins of knee and popliteal area; arteriovenous fistula Anesthesia for procedures on arteries of knee and popliteal area; not otherwise specified Anesthesia for procedures on arteries of knee and popliteal area; popliteal thromboendarterectomy, with or without patch graft Anesthesia for procedures on arteries of knee and popliteal area; popliteal excision and graft or repair for occlusion or aneurysm Base Code Unit 40.06(2) - Anesthesia Description (continued) Anesthesia for all closed procedures on lower leg, ankle, and foot Anesthesia for arthroscopic procedures of ankle and/or foot Anesthesia for procedures on nerves, muscles, tendons, and fascia of lower leg, ankle, and foot; not otherwise specified Anesthesia for procedures on nerves, muscles, tendons, and fascia of lower leg, ankle, and foot; repair of ruptured Achilles tendon, with or without graft Anesthesia for procedures on nerves, muscles, tendons, and fascia of lower leg, ankle, and foot; gastrocnemius recession (eg, Strayer procedure) Anesthesia for open procedures on bones of lower leg, ankle, and foot; not otherwise specified Anesthesia for open procedures on bones of lower leg, ankle, and foot; radical resection (including below knee amputation) Anesthesia for open procedures on bones of lower leg, ankle, and foot; osteotomy or osteoplasty of tibia and/or fibula Anesthesia for open procedures on bones of lower leg, ankle, and foot; total ankle replacement Anesthesia for lower leg cast application, removal, or repair Anesthesia for procedures on arteries of lower leg, including bypass graft; not otherwise specified Anesthesia for procedures on arteries of lower leg, including bypass graft; embolectomy, direct or with catheter Anesthesia for procedures on veins of lower leg; not otherwise specified Anesthesia for procedures on veins of lower leg; venous thrombectomy, direct or with catheter Anesthesia for all procedures on nerves, muscles, tendons, fascia, and bursae of shoulder and axilla Anesthesia for all closed procedures on humeral head and neck, sternoclavicular joint, acromioclavicular joint, and shoulder joint Anesthesia for diagnostic arthroscopic procedures of shoulder joint Anesthesia for open or surgical arthroscopic procedures on humeral head and neck, sternoclavicular joint, acromioclavicular joint, and shoulder joint; not otherwise specified Anesthesia for open or surgical arthroscopic procedures on humeral head and neck, sternoclavicular joint, acromioclavicular joint, and shoulder joint; radical resection Anesthesia for open or surgical arthroscopic procedures on humeral head and neck, sternoclavicular joint, acromioclavicular joint, and shoulder joint; shoulder disarticulation 01636 15 Anesthesia for open or surgical arthroscopic procedures on humeral head and neck, sternoclavicular joint, acromioclavicular joint, and shoulder joint; interthoracoscapular (forequarter) amputation 01638 10 Anesthesia for open or surgical arthroscopic procedures on humeral head and neck, sternoclavicular joint, acromioclavicular joint, and shoulder joint; total shoulder replacement Anesthesia for procedures on arteries of shoulder and axilla; not otherwise specified 01652 10 Anesthesia for procedures on arteries of shoulder and axilla; axillary-brachial aneurysm Anesthesia for procedures on arteries of shoulder and axilla; bypass graft 01656 10 Anesthesia for procedures on arteries of shoulder and axilla; axillary-femoral bypass graft Anesthesia for all procedures on veins of shoulder and axilla Anesthesia for shoulder cast application, removal or repair; not otherwise specified Anesthesia for shoulder cast application, removal or repair; shoulder spica Anesthesia for procedures on nerves, muscles, tendons, fascia, and bursae of upper arm and elbow; not otherwise specified Anesthesia for procedures on nerves, muscles, tendons, fascia, and bursae of upper arm and elbow; tenotomy, elbow to shoulder, open Anesthesia for procedures on nerves, muscles, tendons, fascia, and bursae of upper arm and elbow; tenoplasty, elbow to shoulder Base Code Unit 40.06(2) - Anesthesia Description (continued) Anesthesia for procedures on nerves, muscles, tendons, fascia, and bursae of upper arm and elbow; tenodesis, rupture of long tendon of biceps Anesthesia for all closed procedures on humerus and elbow Anesthesia for diagnostic arthroscopic procedures of elbow joint Anesthesia for open or surgical arthroscopic procedures of the elbow; not otherwise specified Anesthesia for open or surgical arthroscopic procedures of the elbow; osteotomy of humerus Anesthesia for open or surgical arthroscopic procedures of the elbow; repair of nonunion or malunion of humerus Anesthesia for open or surgical arthroscopic procedures of the elbow; radical procedures Anesthesia for open or surgical arthroscopic procedures of the elbow; excision of cyst or tumor of humerus Anesthesia for open or surgical arthroscopic procedures of the elbow; total elbow replacement Anesthesia for procedures on arteries of upper arm and elbow; not otherwise specified Anesthesia for procedures on arteries of upper arm and elbow; embolectomy Anesthesia for procedures on veins of upper arm and elbow; not otherwise specified Anesthesia for procedures on veins of upper arm and elbow; phleborrhaphy Anesthesia for all procedures on nerves, muscles, tendons, fascia, and bursae of forearm, wrist, and hand Anesthesia for all closed procedures on radius, ulna, wrist, or hand bones Anesthesia for diagnostic arthroscopic procedures on the wrist Anesthesia for open or surgical arthroscopic/endoscopic procedures on distal radius, distal ulna, wrist, or hand joints; not otherwise specified Anesthesia for open or surgical arthroscopic/endoscopic procedures on distal radius, distal ulna, wrist, or hand joints; total wrist replacement Anesthesia for procedures on arteries of forearm, wrist, and hand; not otherwise specified Anesthesia for procedures on arteries of forearm, wrist, and hand; embolectomy Anesthesia for vascular shunt, or shunt revision, any type (eg, dialysis) Anesthesia for procedures on veins of forearm, wrist, and hand; not otherwise specified Anesthesia for procedures on veins of forearm, wrist, and hand; phleborrhaphy Anesthesia for forearm, wrist, or hand cast application, removal, or repair Anesthesia for diagnostic arteriography/venography Anesthesia for cardiac catheterization including coronary angiography and ventriculography (not to include Swan-Ganz catheter) Anesthesia for non-invasive imaging or radiation therapy Anesthesia for therapeutic interventional radiological procedures involving the arterial system; not otherwise specified Anesthesia for therapeutic interventional radiological procedures involving the arterial system; carotid or coronary Anesthesia for therapeutic interventional radiological procedures involving the arterial system; intracranial, intracardiac, or aortic Anesthesia for therapeutic interventional radiological procedures involving the venous/lymphatic system (not to include access to the central circulation); not otherwise specified Anesthesia for therapeutic interventional radiological procedures involving the venous/lymphatic system (not to include access to the central circulation); intrahepatic or portal circulation (eg, transvenous intrahepatic portosystemic shunt[s] [TIPS]) Anesthesia for therapeutic interventional radiological procedures involving the venous/lymphatic system (not to include access to the central circulation); intrathoracic or jugular Anesthesia for therapeutic interventional radiological procedures involving the venous/lymphatic system (not to include access to the central circulation); intracranial Base Code Unit 40.06(2) - Anesthesia Description (continued) Anesthesia for percutaneous image guided procedures on the spine and spinal cord; diagnostic Anesthesia for percutaneous image guided procedures on the spine and spinal cord; therapeutic Anesthesia for second- and third-degree burn excision or debridement with or without skin grafting, any site, for total body surface area (TBSA) treated during anesthesia and surgery; less than 4% total body surface area Anesthesia for second- and third-degree burn excision or debridement with or without skin grafting, any site, for total body surface area (TBSA) treated during anesthesia and surgery; between 4% and 9% of total body surface area Anesthesia for second- and third-degree burn excision or debridement with or without skin grafting, any site, for total body surface area (TBSA) treated during anesthesia and surgery; each additional 9% total body surface area or part thereof (List separately in addition to code for primary procedure performed) Anesthesia for external cephalic version procedure Anesthesia for vaginal delivery only Anesthesia for cesarean delivery only Anesthesia for urgent hysterectomy following delivery Anesthesia for cesarean hysterectomy without any labor analgesia/anesthesia care Anesthesia for incomplete or missed abortion procedures Anesthesia for induced abortion procedures Neuraxial labor analgesia/anesthesia for planned vaginal delivery (this includes any repeat subarachnoid needle placement and drug injection and/or any necessary replacement of an epidural catheter during labor) Anesthesia for cesarean delivery following neuraxial labor analgesia/anesthesia (List separately in addition to code for primary procedure performed) Anesthesia for cesarean hysterectomy following neuraxial labor analgesia/anesthesia (List separately in addition to code for primary procedure performed) Physiological support for harvesting of organ(s) from brain-dead patient Anesthesia for diagnostic or therapeutic nerve blocks and injections (when block or injection is performed by a different provider); other than the prone position Anesthesia for diagnostic or therapeutic nerve blocks and injections (when block or injection is performed by a different provider); prone position Daily hospital management of epidural or subarachnoid continuous drug administration Unlisted anesthesia procedure(s) (3) Chiropractors. Fee 40.06(3) - Chiropractic Description Chiropractic manipulative treatment (CMT); spinal, one to two regions Chiropractic manipulative treatment (CMT); spinal, three to four regions Chiropractic manipulative treatment (CMT); spinal, five regions Chiropractic manipulative treatment (CMT); extraspinal, one or more regions Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend ten minutes face-to-face with the patient and/or family. Fee 40.06(3) - Chiropractic Description (continued) Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 20 minutes face-to-face with the patient and/or family. Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: A detailed history; A detailed examination; Medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family. Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 45 minutes face-to-face with the patient and/or family. 9921 1 17.97 Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, five minutes are spent performing or supervising these services. Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend ten minutes face-to-face with the patient and/or family. Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family. Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family. Prolonged evaluation and management service before and/or after direct (face-to-face) patient care (eg, review of extensive records and tests, communication with other professionals and/or the patient/family); first hour (List separately in addition to code for other physician service(s) and/or inpatient or outpatient Evaluation and Management service) Prolonged evaluation and management service before and/or after direct (face-to-face) patient care (eg, review of extensive records and tests, communication with other professionals and/or the patient/family); each additional 30 minutes (List separately in addition to code for prolonged physician service) Medical team conference with interdisciplinary team of health care professionals, patient and/or family not present, 30 minutes or more; participation by nonphysician qualified health care professional Fee 40.06(4) - Clinical Lab Description 30.51 Basic metabolic panel (Calcium, ionized) This panel must include the following: Calcium, ionized (82330) Carbon dioxide (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Potassium (84132) Sodium (84295) Urea Nitrogen (BUN) (84520) 11.83 Basic metabolic panel (Calcium, total) This panel must include the following: Calcium (82310) Carbon dioxide (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Potassium (84132) Sodium (84295) Urea nitrogen (BUN) (84520) Electrolyte panel This panel must include the following: Carbon dioxide (82374) Chloride (82435) Potassium (84132) Sodium (84295) 14.77 Comprehensive metabolic panel This panel must include the following: Albumin (82040) Bilirubin, total (82247) Calcium (82310) Carbon dioxide (bicarbonate) (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Phosphatase, alkaline (84075) Potassium (84132) Protein, total (84155) Sodium (84295) Transferase, alanine amino (ALT) (SGPT) (84460) Transferase, aspartate amino (AST) (SGOT) (84450) 18.72 Lipid panel This panel must include the following: Cholesterol, serum, total (82465) Lipoprotein, direct measurement, high density cholesterol (HDL cholesterol) (83718) Triglycerides (84478) 12.13 Renal function panel This panel must include the following: Albumin (82040) Calcium (82310) Carbon dioxide (bicarbonate) (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Phosphorus inorganic (phosphate) (84100) Potassium (84132) Sodium (84295) 62.84 Acute hepatitis panel This panel must include the following: Hepatitis A antibody (HAAb), IgM antibody (86709) Hepatitis B core antibody (HBcAb), IgM antibody (86705) Hepatitis B surface antigen (HBsAg) (87340) Hepatitis C antibody (86803) 11.42 Hepatic function panel This panel must include the following: Albumin (82040) Bilirubin, total (82247) Bilirubin, direct (82248) Phosphatase, alkaline (84075) Protein, total (84155) Transferase, alanine amino (ALT) (SGPT) (84460) Transferase, aspartate amino (AST) (SGOT) (84450) 16.32 Drug screen, qualitative; multiple drug classes chromatographic method, each procedure 19.24 Drug screen, qualitative; single drug class method (eg, immunoassay, enzyme assay), each drug class 18.51 Drug confirmation, each procedure 21.06 Amikacin 25.01 Amitriptyline 25.84 Benzodiazepines 20.34 Carbamazepine; total 18.52 Carbamazepine; free 25.23 Cyclosporine 24.05 Desipramine 18.55 Digoxin 18.93 Dipropylacetic acid (valproic acid) 21.66 Doxepin 22.83 Ethosuximide 22.90 Gentamicin 22.76 Gold 20.34 Haloperidol 24.05 Imipramine 20.52 Lidocaine Lithium 18.93 Nortriptyline 16.01 Phenobarbital 18.52 Phenytoin; total 19.23 Phenytoin; free 23.18 Primidone 23.41 Procainamide; 23.41 Procainamide; with metabolites (eg, n-acetyl procainamide) 20.39 Quinidine Fee 40.06(4) - Clinical Lab Description (continued) 10.18 Sirolimus Salicylate 10.18 Tacrolimus 19.77 Theophylline 22.52 Tobramycin 16.66 Topiramate 18.93 Vancomycin 19.13 Quantitation of drug, not elsewhere specified 45.56 ACTH stimulation panel; for adrenal insufficiency This panel must include the following: Cortisol (82533 x 2) 121.46 ACTH stimulation panel; for 21 hydroxylase deficiency This panel must include the following: Cortisol (82533 x 2) 17 hydroxyprogesterone (83498 x 2) 106.06 ACTH stimulation panel; for 3 beta-hydroxydehydrogenase deficiency This panel must include the following: Cortisol (82533 x 2) 17 hydroxypregnenolone (84143 x 2) 175.34 Aldosterone suppression evaluation panel (eg, saline infusion) This panel must include the following: Aldosterone (82088 x 2) Renin (84244 x 2) 112.23 Calcitonin stimulation panel (eg, calcium, pentagastrin) This panel must include the following: Calcitonin (82308 x 3) 460.50 Corticotropic releasing hormone (CRH) stimulation panel This panel must include the following: Cortisol (82533 x 6) Adrenocorticotropic hormone (ACTH) (82024 x 6) 72.16 Chorionic gonadotropin stimulation panel; testosterone response This panel must include the following: Testosterone (84403 x 2 on three pooled blood samples) 78.08 Chorionic gonadotropin stimulation panel; estradiol response This panel must include the following: Estradiol (82670 x 2 on three pooled blood samples) 184.38 Renal vein renin stimulation panel (eg, captopril) This panel must include the following: Renin (84244 x 6) 61.46 Peripheral vein renin stimulation panel (eg, captopril) This panel must include the following: Renin (84244 x 2) 809.76 Combined rapid anterior pituitary evaluation panel This panel must include the following: Adrenocorticotropic hormone (ACTH) (82024 x 4) Luteinizing hormone (LH) (83002 x 4) Follicle stimulating hormone (FSH) (83001 x 4) Prolactin (84146 x 4) Human growth hormone (HGH) (93003x4) Cortisol (82533 x 4) Thyroid stimulating hormone (TSH) (84443 x 4) 100.64 Dexamethasone suppression panel, 48 hour This panel must include the following: Free cortisol, urine (82530 x 2) Cortisol (82533 x 2) Volume measurement for timed collection (81050 x 2) 64.38 Glucagon tolerance panel; for insulinoma This panel must include the following: Glucose (82947 x 3) Insulin (83525 x 3) 70.56 Glucagon tolerance panel; for pheochromocytoma This panel must include the following: Catecholamines, fractionated (82384 x 2) 207.40 Gonadotropin releasing hormone stimulation panel This panel must include the following: Follicle stimulating hormone (FSH) (83001 x 4) Luteinizing hormone (LH) (83002 x 4) 93.16 Growth hormone stimulation panel (eg, arginine infusion, l-dopa administration) This panel must include the following: Human growth hormone (HGH) (83003 x 4) 109.60 Growth hormone suppression panel (glucose administration) This panel must include the following: Glucose (82947 x 3) Human growth hormone (HGH) (83003 x 4) 188.73 Insulin-induced C-peptide suppression panel This panel must include the following: Insulin (83525) C-peptide (84681 x 5) Glucose (82947 x 5) 141.30 Insulin tolerance panel; for ACTH insufficiency This panel must include the following: Cortisol (82533 x 5) Glucose (82947 x 5) 143.85 Insulin tolerance panel; for growth hormone deficiency This panel must include the following: Glucose (82947 x 5) Human growth hormone (HGH) (83003 x 5) 127.36 Metyrapone panel This panel must include the following: Cortisol (82533 x 2) 11 deoxycortisol (82634 x 2) 70.41 Thyrotropin releasing hormone (TRH) stimulation panel; one hour This panel must include the following: Thyroid stimulating hormone (TSH) (84443 x 3) Fee 40.06(4) - Clinical Lab Description (continued) Thyrotropin releasing hormone (TRH) stimulation panel; two hour This panel must include the following: Thyroid stimulating hormone (TSH) (84443 x 4) Thyrotropin releasing hormone (TRH) stimulation panel; for hyperprolactinemia This panel must include the following: Prolactin (84146 x 3) Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, with microscopy Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, with microscopy Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, without microscopy Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, without microscopy Urinalysis; qualitative or semiquantitative, except immunoassays Urinalysis; bacteriuria screen, except by culture or dipstick Urinalysis; microscopic only Urinalysis; two or three glass test Urine pregnancy test, by visual color comparison methods Volume measurement for timed collection, each Acetaldehyde, blood Acetaminophen Acetone or other ketone bodies, serum; qualitative Acetone or other ketone bodies, serum; quantitative Acetylcholinesterase Acylcarnitines; qualitative, each specimen Acylcarnitines; quantitative, each specimen Adrenocorticotropic hormone (ACTH) Adenosine, 5-monophosphate, cyclic (cyclic AMP) Albumin; serum Albumin; urine or other source, quantitative, each specimen Albumin; urine, microalbumin, quantitative Albumin; urine, microalbumin, semiquantitative (eg, reagent strip assay) Albumin; ischemia modified Alcohol (ethanol); any specimen except breath Alcohol (ethanol); breath Aldolase Aldosterone Alkaloids, urine, quantitative Alpha-1-antitrypsin; total Alpha-1-antitrypsin; phenotype Alpha-fetoprotein (AFP); serum Alpha-fetoprotein (AFP); amniotic fluid Alpha-fetoprotein (AFP); AFP-L3 fraction isoform and total AFP (including ratio) Aluminum Amines, vaginal fluid, qualitative Amino acids; single, qualitative, each specimen Amino acids; multiple, qualitative, each specimen Amino acids; single, quantitative, each specimen Aminolevulinic acid, delta (ALA) Amino acids, two to five amino acids, quantitative, each specimen Amino acids, six or more amino acids, quantitative, each specimen Ammonia Amniotic fluid scan (spectrophotometric) Fee 40.06(4) - Clinical Lab Description (continued) Amphetamine or methamphetamine Amylase Androstanediol glucuronide Androstenedione Androsterone Angiotensin II Angiotensin I - converting enzyme (ACE) Apolipoprotein, each Arsenic Ascorbic acid (Vitamin C), blood Atomic absorption spectroscopy, each analyte Barbiturates, not elsewhere specified Beta-2 microglobulin Bile acids; total Bile acids; cholylglycine Bilirubin; total Bilirubin; direct Bilirubin; feces, qualitative Biotinidase, each specimen Blood, occult, by peroxidase activity (eg, guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (ie, patient was provided three cards or single triple card for consecutive collection) Blood, occult, by peroxidase activity (eg, guaiac), qualitative; other sources Blood, occult, by peroxidase activity (eg, guaiac), qualitative, feces, one-three simultaneous determinations, performed for other than colorectal neoplasm screening Blood, occult, by fecal hemoglobin determination by immunoassay, qualitative, feces, one-three simultaneous determinations Bradykinin Cadmium Calcifediol (25-OH Vitamin D-3) Calciferol (Vitamin D) Calcitonin Calcium; total Calcium; ionized Calcium; after calcium infusion test Calcium; urine quantitative, timed specimen Calculus; qualitative analysis Calculus; quantitative analysis, chemical Calculus; infrared spectroscopy Calculus; X-ray diffraction Carbohydrate deficient transferrin Carbon dioxide (bicarbonate) Carbon monoxide (carboxyhemoglobin); quantitative Carbon monoxide (carboxyhemoglobin); qualitative Carcinoembryonic antigen (CEA) Carnitine (total and free), quantitative, each specimen Carotene Catecholamines; total urine Catecholamines; blood Catecholamines; fractionated Cathepsin-D Ceruloplasmin Chemiluminescent assay Chloramphenicol Chloride; blood Chloride; urine Fee 40.06(4) - Clinical Lab Description (continued) Chloride; other source Chlorinated hydrocarbons, screen Cholesterol, serum or whole blood, total Cholinesterase; serum Cholinesterase; RBC Chondroitin B sulfate, quantitative Chromatography, qualitative; column (eg, gas liquid or HPLC), analyte not elsewhere specified Chromatography, qualitative; paper, 1-dimensional, analyte not elsewhere specified Chromatography, qualitative; paper, 2-dimensional, analyte not elsewhere specified Chromatography, qualitative; thin layer, analyte not elsewhere specified Chromatography, quantitative, column (eg, gas liquid or HPLC); single analyte not elsewhere specified, single stationary and mobile phase Chromatography, quantitative, column (eg, gas liquid or HPLC); multiple analytes, single stationary and mobile phase Chromium Citrate Cocaine or metabolite Collagen cross links, any method Copper Corticosterone Cortisol; free Cortisol; total Creatine Column chromatography/mass spectrometry (eg, GC/MS, or HPLC/MS), analyte not elsewhere specified; qualitative, single stationary and mobile phase Column chromatography/mass spectrometry (eg, GC/MS, or HPLC/MS), analyte not elsewhere specified; quantitative, single stationary and mobile phase Column chromatography/mass spectrometry (eg, GC/MS, or HPLC/MS), analyte not elsewhere specified; stable isotope dilution, single analyte, quantitative, single stationary and mobile phase Column chromatography/mass spectrometry (eg, GC/MS, or HPLC/MS), analyte not elsewhere specified; stable isotope dilution, multiple analytes, quantitative, single stationary and mobile phase Creatine kinase (CK), (CPK); total Creatine kinase (CK), (CPK); isoenzymes Creatine kinase (CK), (CPK); MB fraction only Creatine kinase (CK), (CPK); isoforms Creatinine; blood Creatinine; other source Creatinine; clearance Cryofibrinogen Cryoglobulin, qualitative or semi-quantitative (eg, cryocrit) Cyanide Cyanocobalamin (Vitamin B-12); Cyanocobalamin (Vitamin B-12); unsaturated binding capacity Cystatin C Cystine and homocystine, urine, qualitative Dehydroepiandrosterone (DHEA) Dehydroepiandrosterone-sulfate (DHEA-S) Desoxycorticosterone, 11­ Deoxycortisol, 11­ Dibucaine number Dihydrocodeinone Dihydromorphinone Dihydrotestosterone (DHT) Fee 40.06(4) - Clinical Lab Description (continued) Dihydroxyvitamin D, 1,25­ Dimethadione Elastase, pancreatic (EL-1), fecal, qualitative or semi-quantitative Enzyme activity in blood cells, cultured cells, or tissue, not elsewhere specified; nonradioactive substrate, each specimen Enzyme activity in blood cells, cultured cells, or tissue, not elsewhere specified; radioactive substrate, each specimen Electrophoretic technique, not elsewhere specified Epiandrosterone Erythropoietin Estradiol Estrogens; fractionated Estrogens; total Estriol Estrone Ethchlorvynol Ethylene glycol Etiocholanolone Fat or lipids, feces; qualitative Fat or lipids, feces; quantitative Fat differential, feces, quantitative Fatty acids, nonesterified Very long chain fatty acids Ferritin Fetal fibronectin, cervicovaginal secretions, semi-quantitative Fluoride Flurazepam Folic acid; serum Folic acid; RBC Fructose, semen Galactokinase, RBC Galactose Galactose-1-phosphate uridyl transferase; quantitative Galactose-1-phosphate uridyl transferase; screen Gammaglobulin; IgA, IgD, IgG, IgM, each Gammaglobulin; IgE Gammaglobulin; immunoglobulin subclasses (IgG1, 2, 3, or 4), each Gases, blood, pH only Gases, blood, any combination of pH, pCO2, pO2, CO2, HCO3 (including calculated O2 saturation); Gases, blood, any combination of pH, pCO2, pO2, CO2, HCO3 (including calculated O2 saturation); with O2 saturation, by direct measurement, except pulse oximetry Gases, blood, O2 saturation only, by direct measurement, except pulse oximetry Hemoglobin-oxygen affinity (pO2 for 50% hemoglobin saturation with oxygen) Gastric acid, free and total, each specimen Gastric acid, free or total, each specimen Gastrin after secretin stimulation Gastrin Glucagon Glucose, body fluid, other than blood Glucagon tolerance test Glucose; quantitative, blood (except reagent strip) Glucose; blood, reagent strip Glucose; post glucose dose (includes glucose) Glucose; tolerance test (GTT), three specimens (includes glucose) Glucose; tolerance test, each additional beyond three specimens Fee 40.06(4) - Clinical Lab Description (continued) Glucose; tolbutamide tolerance test Glucose-6-phosphate dehydrogenase (G6PD); quantitative Glucose-6-phosphate dehydrogenase (G6PD); screen Glucose, blood by glucose monitoring device(s) cleared by the FDA specifically for home use Glucosidase, beta Glutamate dehydrogenase Glutamine (glutamic acid amide) Glutamyltransferase, gamma (GGT) Glutathione Glutathione reductase, RBC Glutethimide Glycated protein Gonadotropin; follicle stimulating hormone (FSH) Gonadotropin; luteinizing hormone (LH) Growth hormone, human (HGH) (somatotropin) Guanosine monophosphate (GMP), cyclic Helicobacter pylori, blood test analysis for urease activity, non-radioactive isotope (eg, C-13) Haptoglobin; quantitative Haptoglobin; phenotypes Helicobacter pylori; breath test analysis for urease activity, non-radioactive isotope (eg, C-13) Helicobacter pylori; drug administration Heavy metal (eg, arsenic, barium, beryllium, bismuth, antimony, mercury); screen Heavy metal (eg, arsenic, barium, beryllium, bismuth, antimony, mercury); quantitative, each Hemoglobin fractionation and quantitation; electrophoresis (eg, A2, S, C, and/or F) Hemoglobin fractionation and quantitation; chromatography (eg, A2, S, C, and/or F) Hemoglobin; by copper sulfate method, non-automated Hemoglobin; F (fetal), chemical Hemoglobin; F (fetal), qualitative Hemoglobin; glycosylated (A1C) Hemoglobin; glycosylated (A1C) by device cleared by FDA for home use Hemoglobin; methemoglobin, qualitative Hemoglobin; methemoglobin, quantitative Hemoglobin; plasma Hemoglobin; sulfhemoglobin, qualitative Hemoglobin; sulfhemoglobin, quantitative Hemoglobin; thermolabile Hemoglobin; unstable, screen Hemoglobin; urine Hemosiderin; qualitative Hemosiderin; quantitative b-Hexosaminidase, each assay Histamine Homocysteine Homovanillic acid (HVA) Hydroxycorticosteroids, 17- (17-OHCS) Hydroxyindolacetic acid, 5-(HIAA) Hydroxyprogesterone, 17-d Hydroxyprogesterone, 20­ Hydroxyproline; free Hydroxyproline; total Immunoassay for analyte other than infectious agent antibody or infectious agent antigen, qualitative or semiquantitative; multiple step method Fee 40.06(4) - Clinical Lab Description (continued) 10.68 Immunoassay for analyte other than infectious agent antibody or infectious agent antigen, qualitative or semiquantitative; single step method (eg, reagent strip) 18.88 Immunoassay, analyte, quantitative; by radiopharmaceutical technique (eg, RIA) 18.09 Immunoassay, analyte, quantitative; not otherwise specified 15.98 Insulin; total 17.68 Insulin; free 22.22 Intrinsic factor Iron 12.21 Iron binding capacity Isocitric dehydrogenase (IDH) Ketogenic steroids, fractionation 17.89 Ketosteroids, 17- (17-KS); total 36.75 Ketosteroids, 17- (17-KS); fractionation 14.92 Lactate (lactic acid) Lactate dehydrogenase (LD), (LDH); 17.88 Lactate dehydrogenase (LD), (LDH); isoenzymes, separation and quantitation 27.42 Lactoferrin, fecal; qualitative 27.42 Lactoferrin, fecal; quantitative 28.24 Lactogen, human placental (HPL) human chorionic somatomammotropin Lactose, urine; qualitative 16.10 Lactose, urine; quantitative 16.91 Lead 30.71 Fetal lung maturity assessment; lecithin sphingomyelin (L/S) ratio 26.43 Fetal lung maturity assessment; foam stability test 26.43 Fetal lung maturity assessment; fluorescence polarization 26.43 Fetal lung maturity assessment; lamellar body density 11.77 Leucine aminopeptidase (LAP) Lipase 18.09 Lipoprotein (a) 47.43 Lipoprotein-associated phospholipase A2 (Lp-PLA2) 15.73 Lipoprotein, blood; electrophoretic separation and quantitation 34.68 Lipoprotein, blood; high resolution fractionation and quantitation of lipoproteins including lipoprotein subclasses when performed (eg, electrophoresis, ultracentrifugation) 44.08 Lipoprotein, blood; quantitation of lipoprotein particle numbers and lipoprotein particle subclasses (eg, by nuclear magnetic resonance spectroscopy) 11.44 Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol) 16.26 Lipoprotein, direct measurement; VLDL cholesterol 12.81 Lipoprotein, direct measurement; LDL cholesterol 24.02 Luteinizing releasing factor (LRH) Magnesium Malate dehydrogenase 34.36 Manganese 25.23 Mass spectrometry and tandem mass spectrometry (MS, MS/MS), analyte not elsewhere specified; qualitative, each specimen 25.23 Mass spectrometry and tandem mass spectrometry (MS, MS/MS), analyte not elsewhere specified; quantitative, each specimen 24.63 Meprobamate 22.72 Mercury, quantitative 23.67 Metanephrines 22.81 Methadone 10.97 Methemalbumin 20.71 Methsuximide 27.82 Mucopolysaccharides, acid; quantitative 13.76 Mucopolysaccharides, acid; screen Mucin, synovial fluid (Ropes test) 24.04 Myelin basic protein, cerebrospinal fluid Fee 40.06(4) - Clinical Lab Description (continued) Myoglobin Natriuretic peptide Nephelometry, each analyte not elsewhere specified Nickel Nicotine Molecular diagnostics; molecular isolation or extraction Molecular diagnostics; isolation or extraction of highly purified nucleic acid Molecular diagnostics; enzymatic digestion Molecular diagnostics; dot/slot blot production Molecular diagnostics; separation by gel electrophoresis (eg, agarose, polyacrylamide) Molecular diagnostics; nucleic acid probe, each Molecular diagnostics; nucleic acid transfer (eg, Southern, Northern) Molecular diagnostics; amplification, target, each nucleic acid sequence Molecular diagnostics; amplification, target, multiplex, first two nucleic acid sequences Molecular diagnostics; amplification, target, multiplex, each additional nucleic acid sequence beyond two (List separately in addition to code for primary procedure) Molecular diagnostics; reverse transcription Molecular diagnostics; mutation scanning, by physical properties (eg, single strand conformational polymorphisms (SSCP), heteroduplex, denaturing gradient gel electrophoresis (DGGE), RNA'ase A), single segment, each Molecular diagnostics; mutation identification by sequencing, single segment, each segment Molecular diagnostics; mutation identification by allele specific transcription, single segment, each segment Molecular diagnostics; mutation identification by allele specific translation, single segment, each segment Molecular diagnostics; lysis of cells prior to nucleic acid extraction (eg, stool specimens, paraffin embedded tissue) Molecular diagnostics; amplification, signal, each nucleic acid sequence Molecular diagnostics; separation and identification by high resolution technique (eg, capillary electrophoresis) Molecular diagnostics; interpretation and report Molecular diagnostics; RNA stabilization Mutation identification by enzymatic ligation or primer extension, single segment, each segment (eg, oligonucleotide ligation assay (OLA), single base chain extension (SBCE), or allele-specific primer extension (ASPE)) Nucleotidase 5'­ Oligoclonal immune (oligoclonal bands) Organic acids; total, quantitative, each specimen Organic acids; qualitative, each specimen Organic acid, single, quantitative Opiates (eg, morphine, meperidine) Osmolality; blood Osmolality; urine Osteocalcin (bone g1a protein) Oxalate Oncoprotein, HER-2/neu Parathormone (parathyroid hormone) pH, body fluid, except blood Phencyclidine (PCP) Calprotectin, fecal Phenothiazine Phenylalanine (PKU), blood Phenylketones, qualitative Phosphatase, acid; total Phosphatase, acid; forensic examination Phosphatase, acid; prostatic Fee 40.06(4) - Clinical Lab Description (continued) Phosphatase, alkaline; Phosphatase, alkaline; heat stable (total not included) Phosphatase, alkaline; isoenzymes Phosphatidylglycerol Phosphogluconate, 6-, dehydrogenase, RBC Phosphohexose isomerase Phosphorus inorganic (phosphate); Phosphorus inorganic (phosphate); urine Porphobilinogen, urine; qualitative Porphobilinogen, urine; quantitative Porphyrins, urine; qualitative Porphyrins, urine; quantitation and fractionation Porphyrins, feces; quantitative Porphyrins, feces; qualitative Potassium; serum Potassium; urine Prealbumin Pregnanediol Pregnanetriol Pregnenolone 17-hydroxypregnenolone Progesterone Prolactin Prostaglandin, each Prostate specific antigen (PSA); complexed (direct measurement) Prostate specific antigen (PSA); total Prostate specific antigen (PSA); free Protein, total, except by refractometry; serum Protein, total, except by refractometry; urine Protein, total, except by refractometry; other source (eg, synovial fluid, cerebrospinal fluid) Protein, total, by refractometry, any source Pregnancy-associated plasma protein-A (PAPP-A) Protein; electrophoretic fractionation and quantitation, serum Protein; electrophoretic fractionation and quantitation, other fluids with concentration (eg, urine, CSF) Protein; Western Blot, with interpretation and report, blood or other body fluid Protein; Western Blot, with interpretation and report, blood or other body fluid, immunological probe for band identification, each Protoporphyrin, RBC; quantitative Protoporphyrin, RBC; screen Proinsulin Pyridoxal phosphate (Vitamin B-6) Pyruvate Pyruvate kinase Quinine Receptor assay; estrogen Receptor assay; progesterone Receptor assay; endocrine, other than estrogen or progesterone (specify hormone) Receptor assay; non-endocrine (specify receptor) Renin Riboflavin (Vitamin B-2) Selenium Serotonin Sex hormone binding globulin (SHBG) Sialic acid Silica Fee 40.06(4) - Clinical Lab Description (continued) Sodium; serum Sodium; urine Sodium; other source Somatomedin Somatostatin Spectrophotometry, analyte not elsewhere specified Specific gravity (except urine) Sugars, chromatographic, TLC or paper chromatography Sugars (mono-, di-, and oligosaccharides); single qualitative, each specimen Sugars (mono-, di-, and oligosaccharides); multiple qualitative, each specimen Sugars (mono-, di-, and oligosaccharides); single quantitative, each specimen Sugars (mono-, di-, and oligosaccharides); multiple quantitative, each specimen Sulfate, urine Testosterone; free Testosterone; total Thiamine (Vitamin B-1) Thiocyanate Thyroglobulin Thyroxine; total Thyroxine; requiring elution (eg, neonatal) Thyroxine; free Thyroxine binding globulin (TBG) Thyroid stimulating hormone (TSH) Thyroid stimulating immune globulins (TSI) Tocopherol alpha (Vitamin E) Transcortin (cortisol binding globulin) Transferase; aspartate amino (AST) (SGOT) Transferase; alanine amino (ALT) (SGPT) Transferrin Triglycerides Thyroid hormone (T3 or T4) uptake or thyroid hormone binding ratio (THBR) Triiodothyronine T3; total (TT-3) Triiodothyronine T3; free Triiodothyronine T3; reverse Troponin, quantitative Trypsin; duodenal fluid Trypsin; feces, qualitative Trypsin; feces, quantitative, 24-hour collection Tyrosine Troponin, qualitative Urea nitrogen; quantitative Urea nitrogen; semiquantitative (eg, reagent strip test) Urea nitrogen, urine Urea nitrogen, clearance Uric acid; blood Uric acid; other source Urobilinogen, feces, quantitative Urobilinogen, urine; qualitative Urobilinogen, urine; quantitative, timed specimen Urobilinogen, urine; semiquantitative Vanillylmandelic acid (VMA), urine Vasoactive intestinal peptide (VIP) Vasopressin (antidiuretic hormone, ADH) Vitamin A Vitamin, not otherwise specified Vitamin K Fee 40.06(4) - Clinical Lab Description (continued) Volatiles (eg, acetic anhydride, carbon tetrachloride, dichloroethane, dichloromethane, diethylether, isopropyl alcohol, methanol) Xylose absorption test, blood and/or urine Zinc C-peptide Gonadotropin, chorionic (hCG); quantitative Gonadotropin, chorionic (hCG); qualitative Gonadotropin, chorionic (hCG); free beta chain Ovulation tests, by visual color comparison methods for human luteinizing hormone Bleeding time Blood count; automated differential WBC count Blood count; blood smear, microscopic examination with manual differential WBC count Blood count; blood smear, microscopic examination without manual differential WBC count Blood count; manual differential WBC count, buffy coat Blood count; spun microhematocrit Blood count; hematocrit (Hct) Blood count; hemoglobin (Hgb) Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC count Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) Blood count; manual cell count (erythrocyte, leukocyte, or platelet) each Blood count; red blood cell (RBC), automated Blood count; reticulocyte, manual Blood count; reticulocyte, automated Blood count; reticulocytes, automated, including one or more cellular parameters (eg, reticulocyte hemoglobin content (CHr), immature reticulocyte fraction (IRF), reticulocyte volume (MRV), RNA content), direct measurement Blood count; leukocyte (WBC), automated Blood count; platelet, automated Reticulated platelet assay Chromogenic substrate assay Clot retraction Clot lysis time, whole blood dilution Clotting; factor II, prothrombin, specific Clotting; factor V (AcG or proaccelerin), labile factor Clotting; factor VII (proconvertin, stable factor) Clotting; factor VIII (AHG), one stage Clotting; factor VIII related antigen Clotting; factor VIII, VW factor, ristocetin cofactor Clotting; factor VIII, VW factor antigen Clotting; factor VIII, von Willebrand factor, multimetric analysis Clotting; factor IX (PTC or Christmas) Clotting; factor X (Stuart-Prower) Clotting; factor XI (PTA) Clotting; factor XII (Hageman) Clotting; factor XIII (fibrin stabilizing) Clotting; factor XIII (fibrin stabilizing), screen solubility Clotting; prekallikrein assay (Fletcher factor assay) Clotting; high molecular weight kininogen assay (Fitzgerald factor assay) Clotting inhibitors or anticoagulants; antithrombin III, activity Clotting inhibitors or anticoagulants; antithrombin III, antigen assay Clotting inhibitors or anticoagulants; protein C, antigen Clotting inhibitors or anticoagulants; protein C, activity Clotting inhibitors or anticoagulants; protein S, total Clotting inhibitors or anticoagulants; protein S, free Fee 40.06(4) - Clinical Lab Description (continued) Activated Protein C (APC) resistance assay Factor inhibitor test Thrombomodulin Coagulation time; Lee and White Coagulation time; activated Coagulation time; other methods Euglobulin lysis Fibrin(ogen) degradation (split) products (FDP) (FSP); agglutination slide, semiquantitative Fibrin(ogen) degradation (split) products (FDP) (FSP); paracoagulation Fibrin(ogen) degradation (split) products (FDP) (FSP); quantitative Fibrin degradation products, D-dimer; qualitative or semiquantitative Fibrin degradation products, D-dimer; quantitative Fibrin degradation products, D-dimer; ultrasensitive (eg, for evaluation for venous thromboembolism), qualitative or semiquantitative Fibrinogen; activity Fibrinogen; antigen Fibrinolysins or coagulopathy screen, interpretation and report Fibrinolytic factors and inhibitors; plasmin Fibrinolytic factors and inhibitors; alpha-2 antiplasmin Fibrinolytic factors and inhibitors; plasminogen activator Fibrinolytic factors and inhibitors; plasminogen, except antigenic assay Fibrinolytic factors and inhibitors; plasminogen, antigenic assay Heinz bodies; direct Heinz bodies; induced, acetyl phenylhydrazine Hemoglobin or RBCs, fetal, for fetomaternal hemorrhage; differential lysis (Kleihauer-Betke) Hemoglobin or RBCs, fetal, for fetomaternal hemorrhage; rosette Hemolysin, acid Heparin assay Heparin neutralization Heparin-protamine tolerance test Iron stain, peripheral blood Leukocyte alkaline phosphatase with count Mechanical fragility, RBC Muramidase Osmotic fragility, RBC; unincubated Osmotic fragility, RBC; incubated Platelet, aggregation (in vitro), each agent Platelet, aggregation (in vitro), each agent Platelet neutralization Prothrombin time; Prothrombin time; substitution, plasma fractions, each Russell viper venom time (includes venom); undiluted Russell viper venom time (includes venom); diluted Reptilase test Sedimentation rate, erythrocyte; non-automated Sedimentation rate, erythrocyte; automated Sickling of RBC, reduction Thrombin time; plasma Thrombin time; titer Thromboplastin inhibition, tissue Thromboplastin time, partial (PTT); plasma or whole blood Thromboplastin time, partial (PTT); substitution, plasma fractions, each Viscosity Agglutinins, febrile (eg, Brucella, Francisella, Murine typhus, Q fever, Rocky Mountain spotted fever, scrub typhus), each antigen Fee 40.06(4) - Clinical Lab Description (continued) Allergen specific IgG quantitative or semiquantitative, each allergen Allergen specific IgE; quantitative or semiquantitative, each allergen Allergen specific IgE; qualitative, multiallergen screen (dipstick, paddle, or disk) Antibody identification; leukocyte antibodies Antibody identification; platelet antibodies Antibody identification; platelet associated immunoglobulin assay Antinuclear antibodies (ANA); Antinuclear antibodies (ANA); titer Antistreptolysin 0; titer Antistreptolysin 0; screen C-reactive protein; C-reactive protein; high sensitivity (hsCRP) Beta 2 Glycoprotein I antibody, each Cardiolipin (phospholipid) antibody, each Ig class Anti-phosphatidylserine (phospholipid) antibody Chemotaxis assay, specify method Cold agglutinin; screen Cold agglutinin; titer Complement; antigen, each component Complement; functional activity, each component Complement; total hemolytic (CH50) Complement fixation tests, each antigen Counterimmunoelectrophoresis, each antigen Cyclic citrullinated peptide (CCP), antibody Deoxyribonuclease, antibody Deoxyribonucleic acid (DNA) antibody; native or double stranded Deoxyribonucleic acid (DNA) antibody; single stranded Extractable nuclear antigen, antibody to, any method (eg, nRNP, SS-A, SS-B, Sm, RNP, Sc170, J01), each antibody Fc receptor Fluorescent noninfectious agent antibody; screen, each antibody Fluorescent noninfectious agent antibody; titer, each antibody Growth hormone, human (HGH), antibody Hemagglutination inhibition test (HAI) Immunoassay for tumor antigen, qualitative or semiquantitative (eg, bladder tumor antigen) Immunoassay for tumor antigen, quantitative; CA 15-3 (27.29) Immunoassay for tumor antigen, quantitative; CA 19-9 Immunoassay for tumor antigen, quantitative; CA 125 Heterophile antibodies; screening Heterophile antibodies; titer Heterophile antibodies; titers after absorption with beef cells and guinea pig kidney Immunoassay for tumor antigen, other antigen, quantitative (eg, CA 50, 72-4, 549), each Immunoassay for infectious agent antibody, quantitative, not otherwise specified Immunoassay for infectious agent antibody, qualitative or semiquantitative, single step method (eg, reagent strip) Immunoelectrophoresis; serum Immunoelectrophoresis; other fluids (eg, urine, cerebrospinal fluid) with concentration Immunoelectrophoresis; crossed (2-dimensional assay) Immunodiffusion; not elsewhere specified Immunodiffusion; gel diffusion, qualitative (Ouchterlony), each antigen or antibody Immune complex assay Immunofixation electrophoresis; serum Immunofixation electrophoresis; other fluids with concentration (eg, urine, CSF) Inhibin A Insulin antibodies Intrinsic factor antibodies Fee 40.06(4) - Clinical Lab Description (continued) 27.65 Islet cell antibody 17.41 Leukocyte histamine release test (LHR) 11.16 Leukocyte phagocytosis 68.49 Lymphocyte transformation, mitogen (phytomitogen) or antigen induced blastogenesis 16.01 B cells, total count 15.37 Mononuclear cell antigen, quantitative (eg, flow cytometry), not otherwise specified, each antigen 16.01 Natural killer (NK) cells, total count 16.01 T cells; total count 19.21 T cells; absolute CD4 and CD8 count, including ratio 15.37 T cells; absolute CD4 count 16.01 Stem cells (ie, CD34), total count 20.33 Microsomal antibodies (eg, thyroid or liver-kidney), each 27.51 Migration inhibitory factor test (MIF) 23.62 Neutralization test, viral 15.91 Nitroblue tetrazolium dye test (NTD) 14.24 Particle agglutination; screen, each antibody 14.87 Particle agglutination; titer, each antibody Rheumatoid factor; qualitative Rheumatoid factor; quantitative 86.59 Tuberculosis test, cell mediated immunity measurement of gamma interferon antigen response 15.41 Streptokinase, antibody Syphilis test; qualitative (eg, VDRL, RPR, ART) Syphilis test; quantitative 13.64 Antibody; actinomyces 14.58 Antibody; adenovirus 20.59 Antibody; Aspergillus 13.64 Antibody; bacterium, not elsewhere specified 13.64 Antibody; Bartonella 18.03 Antibody; Blastomyces 18.43 Antibody; Bordetella 21.64 Antibody; Borrelia burgdorferi (Lyme disease) confirmatory test (eg, Western Blot or immunoblot) 19.97 Antibody; Borrelia burgdorferi (Lyme disease) 18.69 Antibody; Borrelia (relapsing fever) 12.14 Antibody; Brucella 13.64 Antibody; Campylobacter 16.78 Antibody; Candida 16.52 Antibody; Chlamydia 17.74 Antibody; Chlamydia, IgM 16.03 Antibody; Coccidioides 16.94 Antibody; Coxiella burnetii (Q fever) 12.14 Antibody; Cryptococcus 20.11 Antibody; cytomegalovirus (CMV) 19.97 Antibody; cytomegalovirus (CMV), IgM 13.64 Antibody; Diphtheria 18.43 Antibody; encephalitis, California (La Crosse) 18.43 Antibody; encephalitis, Eastern equine 18.43 Antibody; encephalitis, St. Louis 18.43 Antibody; encephalitis, Western equine 14.58 Antibody; enterovirus (eg, coxsackie, echo, polio) 18.33 Antibody; Epstein-Barr (EB) virus, early antigen (EA) 19.97 Antibody; Epstein-Barr (EB) virus, nuclear antigen (EBNA) 19.97 Antibody; Epstein-Barr (EB) virus, viral capsid (VCA) 13.64 Antibody; Ehrlichia 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY Fee 40.06(4) - Clinical Lab Description (continued) Antibody; Francisella tularensis Antibody; fungus, not elsewhere specified Antibody; Giardia lamblia Antibody; Helicobacter pylori Antibody; helminth, not elsewhere specified Antibody; Haemophilus influenza Antibody; HTLV-I Antibody; HTLV-II Antibody; HTLV or HIV antibody, confirmatory test (eg, Western Blot) Antibody; hepatitis, delta agent Antibody; herpes simplex, non-specific type test Antibody; herpes simplex, type 1 Antibody; herpes simplex, type 2 Antibody; histoplasma Antibody; HIV-1 Antibody; HIV-2 Antibody; HIV-1 and HIV-2, single assay Hepatitis B core antibody (HBcAb); total Hepatitis B core antibody (HBcAb); IgM antibody Hepatitis B surface antibody (HBsAb) Hepatitis Be antibody (HBeAb) Hepatitis A antibody (HAAb); total Hepatitis A antibody (HAAb); IgM antibody Antibody; influenza virus Antibody; Legionella Antibody; Leishmania Antibody; Leptospira Antibody; Listeria monocytogenes Antibody; lymphocytic choriomeningitis Antibody; lymphogranuloma venereum Antibody; mucormycosis Antibody; mumps Antibody; mycoplasma Antibody; Neisseria meningitides Antibody; Nocardia Antibody; parvovirus Antibody; Plasmodium (malaria) Antibody; protozoa, not elsewhere specified Antibody; respiratory syncytial virus Antibody; Rickettsia Antibody; rotavirus Antibody; rubella Antibody; rubeola Antibody; Salmonella Antibody; Shigella Antibody; tetanus Antibody; Toxoplasma Antibody; Toxoplasma, IgM Antibody; Treponema pallidum, confirmatory test (eg, FTA-abs) Antibody; Trichinella Antibody; varicella-zoster Antibody; West Nile virus, IgM Antibody; West Nile virus Antibody; virus, not elsewhere specified Antibody; Yersinia Thyroglobulin antibody Fee 40.06(4) - Clinical Lab Description (continued) Hepatitis C antibody; Hepatitis C antibody; confirmatory test (eg, immunoblot) Lymphocytotoxicity assay, visual crossmatch; with titration Lymphocytotoxicity assay, visual crossmatch; without titration Serum screening for cytotoxic percent reactive antibody (PRA); standard method Serum screening for cytotoxic percent reactive antibody (PRA); quick method HLA typing; A, B, or C (eg, A10, B7, B27), single antigen HLA typing; A, B, or C, multiple antigens HLA typing; DR/DQ, single antigen HLA typing; DR/DQ, multiple antigens HLA typing; lymphocyte culture, mixed (MLC) HLA typing; lymphocyte culture, primed (PLC) Antihuman globulin test (Coombs test); direct, each antiserum Antihuman globulin test (Coombs test); indirect, qualitative, each reagent red cell Antihuman globulin test (Coombs test); indirect, each antibody titer Blood typing; ABO Blood typing; Rh (D) Blood typing; antigen screening for compatible blood unit using reagent serum, per unit screened Blood typing; antigen screening for compatible unit using patient serum, per unit screened Blood typing; RBC antigens, other than ABO or Rh (D), each Blood typing; Rh phenotyping, complete Hemolysins and agglutinins; auto, screen, each Hemolysins and agglutinins; incubated Animal inoculation, small animal; with observation Animal inoculation, small animal; with observation and dissection Concentration (any type), for infectious agents Culture, bacterial; blood, aerobic, with isolation and presumptive identification of isolates (includes anaerobic culture, if appropriate) Culture, bacterial; stool, aerobic, with isolation and preliminary examination (eg, KIA, LIA), Salmonella and Shigella species Culture, bacterial; stool, aerobic, additional pathogens, isolation and presumptive identification of isolates, each plate Culture, bacterial; any other source except urine, blood or stool, aerobic, with isolation and presumptive identification of isolates Culture, bacterial; quantitative, aerobic with isolation and presumptive identification of isolates, any source except urine, blood or stool Culture, bacterial; quantitative, anaerobic with isolation and presumptive identification of isolates, any source except urine, blood or stool Culture, bacterial; any source, except blood, anaerobic with isolation and presumptive identification of isolates Culture, bacterial; anaerobic isolate, additional methods required for definitive identification, each isolate Culture, bacterial; aerobic isolate, additional methods required for definitive identification, each isolate Culture, presumptive, pathogenic organisms, screening only; Culture, presumptive, pathogenic organisms, screening only; with colony estimation from density chart Culture, bacterial; quantitative colony count, urine Culture, bacterial; with isolation and presumptive identification of each isolate, urine Culture, fungi (mold or yeast) isolation, with presumptive identification of isolates; skin, hair, or nail Culture, fungi (mold or yeast) isolation, with presumptive identification of isolates; other source (except blood) Culture, fungi (mold or yeast) isolation, with presumptive identification of isolates; blood Culture, fungi, definitive identification, each organism; yeast Fee 40.06(4) - Clinical Lab Description (continued) Culture, fungi, definitive identification, each organism; mold Culture, mycoplasma, any source Culture, chlamydia, any source Culture, tubercle or other acid-fast bacilli (eg, TB, AFB, mycobacteria) any source, with isolation and presumptive identification of isolates Culture, mycobacterial, definitive identification, each isolate Culture, typing; immunofluorescent method, each antiserum Culture, typing; gas liquid chromatography (GLC) or high pressure liquid chromatography (HPLC) method Culture, typing; immunologic method, other than immunofluoresence (eg, agglutination grouping), per antiserum Culture, typing; identification by nucleic acid probe Culture, typing; identification by pulse field gel typing Culture, typing; other methods Dark field examination, any source (eg, penile, vaginal, oral, skin); includes specimen collection Dark field examination, any source (eg, penile, vaginal, oral, skin); without collection Macroscopic examination; arthropod Macroscopic examination; parasite Pinworm exam (eg, cellophane tape prep) Homogenization, tissue, for culture Ova and parasites, direct smears, concentration and identification Susceptibility studies, antimicrobial agent; agar dilution method, per agent (eg, antibiotic gradient strip) Susceptibility studies, antimicrobial agent; disk method, per plate (12 or fewer agents) Susceptibility studies, antimicrobial agent; enzyme detection (eg, beta lactamase), per enzyme Susceptibility studies, antimicrobial agent; microdilution or agar dilution (minimum inhibitory concentration (MIC) or breakpoint), each multi-antimicrobial, per plate Susceptibility studies, antimicrobial agent; microdilution or agar dilution, minimum lethal concentration (MLC), each plate (List separately in addition to code for primary procedure) Susceptibility studies, antimicrobial agent; macrobroth dilution method, each agent Susceptibility studies, antimicrobial agent; mycobacteria, proportion method, each agent Serum bactericidal titer (Schlicter test) Smear, primary source with interpretation; Gram or Giemsa stain for bacteria, fungi, or cell types Smear, primary source with interpretation; fluorescent and/or acid fast stain for bacteria, fungi, parasites, viruses or cell types Smear, primary source with interpretation; special stain for inclusion bodies or parasites (eg, malaria, coccidia, microsporidia, trypanosomes, herpes viruses) Smear, primary source with interpretation; complex special stain (eg, trichrome, iron hemotoxylin) for ova and parasites Smear, primary source with interpretation; wet mount for infectious agents (eg, saline, India ink, KOH preps) Tissue examination by KOH slide of samples from skin, hair, or nails for fungi or ectoparasite ova or mites (eg, scabies) Toxin or antitoxin assay, tissue culture (eg, Clostridium difficile toxin) Virus isolation; inoculation of embryonated eggs, or small animal, includes observation and dissection Virus isolation; tissue culture inoculation, observation, and presumptive identification by cytopathic effect Virus isolation; tissue culture, additional studies or definitive identification (eg, hemabsorption, neutralization, immunofluoresence stain), each isolate Virus isolation; centrifuge enhanced (shell vial) technique, includes identification with immunofluorescence stain, each virus Fee 40.06(4) - Clinical Lab Description (continued) 47.31 Virus isolation; including identification by non-immunologic method, other than by cytopathic effect (eg, virus specific enzymatic activity) 16.01 Infectious agent antigen detection by immunofluorescent technique; adenovirus 16.01 Infectious agent antigen detection by immunofluorescent technique; Bordetella pertussis/parapertussis 16.01 Infectious agent antigen detection by immunofluorescent technique; Enterovirus, direct fluorescent antibody (DFA) 16.01 Infectious agent antigen detection by immunofluorescent technique; giardia 16.01 Infectious agent antigen detection by immunofluorescent technique; Chlamydia trachomatis 16.01 Infectious agent antigen detection by immunofluorescent technique; Cytomegalovirus, direct fluorescent antibody (DFA) 16.01 Infectious agent antigen detection by immunofluorescent technique; cryptosporidium 16.01 Infectious agent antigen detection by immunofluorescent technique; Herpes simplex virus type 2 16.01 Infectious agent antigen detection by immunofluorescent technique; Herpes simplex virus type 1 16.01 Infectious agent antigen detection by immunofluorescent technique; influenza B virus 16.01 Infectious agent antigen detection by immunofluorescent technique; influenza A virus 16.01 Infectious agent antigen detection by immunofluorescent technique; Legionella micdadei 16.01 Infectious agent antigen detection by immunofluorescent technique; Legionella pneumophila 16.01 Infectious agent antigen detection by immunofluorescent technique; Parainfluenza virus, each type 16.01 Infectious agent antigen detection by immunofluorescent technique; respiratory syncytial virus 16.01 Infectious agent antigen detection by immunofluorescent technique; Pneumocystis carinii 16.01 Infectious agent antigen detection by immunofluorescent technique; Rubeola 16.01 Infectious agent antigen detection by immunofluorescent technique; Treponema pallidum 16.01 Infectious agent antigen detection by immunofluorescent technique; Varicella zoster virus 16.01 Infectious agent antigen detection by immunofluorescent technique; not otherwise specified, each organism 16.01 Infectious agent antigen detection by immunofluorescent technique, polyvalent for multiple organisms, each polyvalent antiserum 16.01 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; adenovirus enteric types 40/41 16.01 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; Aspergillus 16.01 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; Chlamydia trachomatis 16.01 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; Clostridium difficile toxin(s) 16.01 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; Cryptococcus neoformans 16.01 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; cryptosporidium 16.01 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; giardia 16.01 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; cytomegalovirus 16.01 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; Escherichia coli 0157 16.01 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; Entamoeba histolytica dispar group 16.01 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; Entamoeba histolytica group Fee 40.06(4) - Clinical Lab Description (continued) 16.04 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; Helicobacter pylori, stool 16.01 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; Helicobacter pylori 14.43 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; hepatitis B surface antigen (HBsAg) 14.43 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; hepatitis B surface antigen (HBsAg) neutralization 16.10 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; hepatitis Be antigen (HBeAg) 15.54 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; hepatitis, delta agent 16.01 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; Histoplasma capsulatum 24.65 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; HIV-1 24.65 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; HIV-2 16.01 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; Influenza, A or B, each 16.01 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; respiratory syncytial virus 16.01 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; rotavirus 16.01 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; Shiga-like toxin 16.01 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; Streptococcus, group A 16.01 Infectious agent antigen detection by enzyme immunoassay technique qualitative or semiquantitative; multiple step method, not otherwise specified, each organism 10.68 Infectious agent antigen detection by enzyme immunoassay technique qualitative or semiquantitative; single step method, not otherwise specified, each organism 10.68 Infectious agent antigen detection by enzyme immunoassay technique qualitative or semiquantitative; multiple step method, polyvalent for multiple organisms, each polyvalent antiserum 28.02 Infectious agent detection by nucleic acid (DNA or RNA); Bartonella henselae and Bartonella quintana, direct probe technique 36.39 Infectious agent detection by nucleic acid (DNA or RNA); Bartonella henselae and Bartonella quintana, amplified probe technique 59.85 Infectious agent detection by nucleic acid (DNA or RNA); Bartonella henselae and Bartonella quintana, quantification 28.02 Infectious agent detection by nucleic acid (DNA or RNA); Borrelia burgdorferi, direct probe technique 36.39 Infectious agent detection by nucleic acid (DNA or RNA); Borrelia burgdorferi, amplified probe technique 59.85 Infectious agent detection by nucleic acid (DNA or RNA); Borrelia burgdorferi, quantification 28.02 Infectious agent detection by nucleic acid (DNA or RNA); Candida species, direct probe technique 36.39 Infectious agent detection by nucleic acid (DNA or RNA); Candida species, amplified probe technique 58.33 Infectious agent detection by nucleic acid (DNA or RNA); Candida species, quantification 28.02 Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia pneumoniae, direct probe technique 36.39 Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia pneumoniae, amplified probe technique Fee 40.06(4) - Clinical Lab Description (continued) 59.85 Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia pneumoniae, quantification 28.02 Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, direct probe technique 36.39 Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique 22.93 Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, quantification 28.02 Infectious agent detection by nucleic acid (DNA or RNA); cytomegalovirus, direct probe technique 36.39 Infectious agent detection by nucleic acid (DNA or RNA); cytomegalovirus, amplified probe technique 59.85 Infectious agent detection by nucleic acid (DNA or RNA); cytomegalovirus, quantification 36.39 Infectious agent detection by nucleic acid (DNA or RNA); enterovirus, amplified probe technique 36.39 Infectious agent detection by nucleic acid (DNA or RNA); vancomycin resistance (eg, enterococcus species van A, van B), amplified probe technique 28.02 Infectious agent detection by nucleic acid (DNA or RNA); Gardnerella vaginalis, direct probe technique 36.39 Infectious agent detection by nucleic acid (DNA or RNA); Gardnerella vaginalis, amplified probe technique 58.33 Infectious agent detection by nucleic acid (DNA or RNA); Gardnerella vaginalis, quantification 28.02 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis B virus, direct probe technique 36.39 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis B virus, amplified probe technique 59.85 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis B virus, quantification 28.02 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, direct probe technique 36.39 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, amplified probe technique 59.85 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, quantification 28.02 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis G, direct probe technique 36.39 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis G, amplified probe technique 58.33 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis G, quantification 28.02 Infectious agent detection by nucleic acid (DNA or RNA); Herpes simplex virus, direct probe technique 36.39 Infectious agent detection by nucleic acid (DNA or RNA); Herpes simplex virus, amplified probe technique 59.85 Infectious agent detection by nucleic acid (DNA or RNA); Herpes simplex virus, quantification 28.02 Infectious agent detection by nucleic acid (DNA or RNA); Herpes virus-6, direct probe technique 36.39 Infectious agent detection by nucleic acid (DNA or RNA); Herpes virus-6, amplified probe technique 58.33 Infectious agent detection by nucleic acid (DNA or RNA); Herpes virus-6, quantification 28.02 Infectious agent detection by nucleic acid (DNA or RNA); HIV-1, direct probe technique 36.39 Infectious agent detection by nucleic acid (DNA or RNA); HIV-1, amplified probe technique 78.52 Infectious agent detection by nucleic acid (DNA or RNA); HIV-1, quantification 28.02 Infectious agent detection by nucleic acid (DNA or RNA); HIV-2, direct probe technique 36.39 Infectious agent detection by nucleic acid (DNA or RNA); HIV-2, amplified probe technique Fee 40.06(4) - Clinical Lab Description (continued) Infectious agent detection by nucleic acid (DNA or RNA); HIV-2, quantification Infectious agent detection by nucleic acid (DNA or RNA); Legionella pneumophila, direct probe technique Infectious agent detection by nucleic acid (DNA or RNA); Legionella pneumophila, amplified probe technique Infectious agent detection by nucleic acid (DNA or RNA); Legionella pneumophila, quantification Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria species, direct probe technique Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria species, amplified probe technique Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria species, quantification Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria tuberculosis, direct probe technique Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria tuberculosis, amplified probe technique Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria tuberculosis, quantification Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria avium-intracellulare, direct probe technique Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria avium-intracellulare, amplified probe technique Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria avium-intracellulare, quantification Infectious agent detection by nucleic acid (DNA or RNA); Mycoplasma pneumoniae, direct probe technique Infectious agent detection by nucleic acid (DNA or RNA); Mycoplasma pneumoniae, amplified probe technique Infectious agent detection by nucleic acid (DNA or RNA); Mycoplasma pneumoniae, quantification Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, direct probe technique Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, amplified probe technique Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, quantification Infectious agent detection by nucleic acid (DNA or RNA); papillomavirus, human, direct probe technique Infectious agent detection by nucleic acid (DNA or RNA); papillomavirus, human, amplified probe technique Infectious agent detection by nucleic acid (DNA or RNA); papillomavirus, human, quantification Infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, amplified probe technique Infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, methicillin resistant, amplified probe technique Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, direct probe technique Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, amplified probe technique Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, quantification Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group B, amplified probe technique Fee 40.06(4) - Clinical Lab Description (continued) 28.02 Infectious agent detection by nucleic acid (DNA or RNA); Trichomonas vaginalis, direct probe technique 28.02 Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; direct probe technique, each organism 36.39 Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, each organism 59.85 Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; quantification, each organism 56.03 Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; direct probe(s) technique 72.78 Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; amplified probe(s) technique 16.01 Infectious agent antigen detection by immunoassay with direct optical observation; Streptococcus, group B 16.01 Infectious agent antigen detection by immunoassay with direct optical observation; Clostridium difficile toxin A 16.01 Infectious agent antigen detection by immunoassay with direct optical observation; Influenza 16.01 Infectious agent antigen detection by immunoassay with direct optical observation; Influenza 16.01 Infectious agent antigen detection by immunoassay with direct optical observation; respiratory syncytial virus 16.01 Infectious agent antigen detection by immunoassay with direct optical observation; Trichomonas vaginalis 16.01 Infectious agent antigen detection by immunoassay with direct optical observation; adenovirus 16.01 Infectious agent detection by immunoassay with direct optical observation; Chlamydia trachomatis 16.01 Infectious agent detection by immunoassay with direct optical observation; Neisseria gonorrhoeae 16.01 Infectious agent detection by immunoassay with direct optical observation; Streptococcus, group A 16.01 Infectious agent detection by immunoassay with direct optical observation; not otherwise specified 182.11 Infectious agent drug susceptibility phenotype prediction using regularly updated genotypic bioinformatics 114.95 Infectious agent genotype analysis by nucleic acid (DNA or RNA); HIV 1, reverse transcriptase and protease 114.95 Infectious agent genotype analysis by nucleic acid (DNA or RNA); Hepatitis C virus 682.72 Infectious agent phenotype analysis by nucleic acid (DNA or RNA) with drug resistance tissue culture analysis, HIV 1; first through ten drugs tested 36.42 Infectious agent phenotype analysis by nucleic acid (DNA or RNA) with drug resistance tissue culture analysis, HIV 1; each additional drug tested (List separately in addition to code for primary procedure) 21.02 Sex chromatin identification; Barr bodies 11.17 Sex chromatin identification; peripheral blood smear, polymorphonuclear drumsticks 28.31 Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; manual screening under physician supervision 28.31 Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; with manual screening and rescreening under physician supervision 15.90 Cytopathology smears, cervical or vaginal; screening by automated system under physician supervision 21.23 Cytopathology smears, cervical or vaginal; screening by automated system with manual rescreening under physician supervision 14.76 Cytopathology, slides, cervical or vaginal; manual screening under physician supervision Fee 40.06(4) - Clinical Lab Description (continued) 14.76 Cytopathology, slides, cervical or vaginal; with manual screening and computer-assisted rescreening under physician supervision 14.76 Cytopathology, slides, cervical or vaginal; with manual screening and rescreening under physician supervision 14.76 Cytopathology, slides, cervical or vaginal; with manual screening and computer-assisted rescreening using cell selection and review under physician supervision Cytopathology, slides, cervical or vaginal, definitive hormonal evaluation (eg, maturation index, karyopyknotic index, estrogenic index) (List separately in addition to code(s) for other technical and interpretation services) 14.76 Cytopathology, slides, cervical or vaginal (the Bethesda System); manual screening under physician supervision 14.76 Cytopathology, slides, cervical or vaginal (the Bethesda System); with manual screening and rescreening under physician supervision 14.76 Cytopathology, slides, cervical or vaginal (the Bethesda System); with manual screening and computer-assisted rescreening under physician supervision 14.76 Cytopathology, slides, cervical or vaginal (the Bethesda System); with manual screening and computer-assisted rescreening using cell selection and review under physician supervision 29.85 Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; screening by automated system, under physician supervision 37.01 Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; with screening by automated system and manual rescreening or review, under physician supervision 48.38 Tissue culture for non-neoplastic disorders; lymphocyte 122.81 Tissue culture for non-neoplastic disorders; skin or other solid tissue biopsy 122.81 Tissue culture for non-neoplastic disorders; amniotic fluid or chorionic villus cells 55.83 Tissue culture for neoplastic disorders; bone marrow, blood cells 206.12 Tissue culture for neoplastic disorders; solid tumor 14.11 Cryopreservation, freezing and storage of cells, each cell line 14.11 Thawing and expansion of frozen cells, each aliquot 207.98 Chromosome analysis for breakage syndromes; baseline Sister Chromatid Exchange (SCE), 20-25 cells 241.96 Chromosome analysis for breakage syndromes; baseline breakage, score 50-100 cells, count 20 cells, two karyotypes (eg, for ataxia telangiectasia, Fanconi anemia, fragile X) 241.96 Chromosome analysis for breakage syndromes; score 100 cells, clastogen stress (eg, diepoxybutane, mitomycin C, ionizing radiation, UV radiation) 246.93 Chromosome analysis; count five cells, one karyotype, with banding 174.14 Chromosome analysis; count 15-20 cells, two karyotypes, with banding 204.68 Chromosome analysis; count 45 cells for mosaicism, two karyotypes, with banding 174.14 Chromosome analysis; analyze 20-25 cells 251.17 Chromosome analysis, amniotic fluid or chorionic villus, count 15 cells, one karyotype, with banding 232.38 Chromosome analysis, in situ for amniotic fluid cells, count cells from six-12 colonies, one karyotype, with banding 29.93 Molecular cytogenetics; DNA probe, each (eg, FISH) 37.41 Molecular cytogenetics; chromosomal in situ hybridization, analyze three-five cells (eg, for derivatives and markers) 44.89 Molecular cytogenetics; chromosomal in situ hybridization, analyze ten-30 cells (eg, for microdeletions) 48.63 Molecular cytogenetics; interphase in situ hybridization, analyze 25-99 cells 56.11 Molecular cytogenetics; interphase in situ hybridization, analyze 100-300 cells 35.07 Chromosome analysis; additional karyotypes, each study 95.84 Chromosome analysis; additional specialized banding technique (eg, NOR, C-banding) 26.54 Chromosome analysis; additional cells counted, each study 48.11 Chromosome analysis; additional high resolution study Fee 40.06(4) - Clinical Lab Description (continued) Protein analysis of tissue by Western Blot, with interpretation and report; Protein analysis of tissue by Western Blot, with interpretation and report; immunological probe for band identification, each Bilirubin, total, transcutaneous Cell count, miscellaneous body fluids (eg, cerebrospinal fluid, joint fluid), except blood; Cell count, miscellaneous body fluids (eg, cerebrospinal fluid, joint fluid), except blood; with differential count Leukocyte assessment, fecal, qualitative or semiquantitative Crystal identification by light microscopy with or without polarizing lens analysis, tissue or any body fluid (except urine) Fat stain, feces, urine, or respiratory secretions Meat fibers, feces Nasal smear for eosinophils Starch granules, feces Water load test Semen analysis; presence and/or motility of sperm including Huhner test (post coital) Semen analysis; motility and count (not including Huhner test) Semen analysis; volume, count, motility, and differential Semen analysis; sperm presence and motility of sperm, if performed Semen analysis; volume, count, motility, and differential using strict morphologic criteria (eg, Kruger) Sperm antibodies Sperm evaluation; hamster penetration test Sperm evaluation; cervical mucus penetration test, with or without spinnbarkeit test Sperm evaluation, for retrograde ejaculation, urine (sperm concentration, motility, and morphology, as indicated) (5) Dental Services. Fee 40.06(5) - Dental Service Description Periodic oral evaluation - established patient Limited oral evaluation - problem focused Comprehensive oral evaluation - new or established patient Detailed and extensive oral evaluation - problem focused, by report Re-evaluation - limited, problem focused (established patient; not postoperative visit) Comprehensive periodontal evaluation - new or established patient 100.00 Intraoral - complete series (including bitewings) Intraoral - periapical, first film Intraoral - periapical, each additional film Intraoral - occlusal film Extraoral - first film Extraoral - each additional film Bitewing - single film Bitewings - two films Bitewings - three films Bitewings - four films Vertical bitewings - seven to eight films Posterior-anterior or lateral skull and facial bone survey film 132.00 Sialography 104.00 Other temporomandibular joint films, by report 220.00 Tomographic survey Panoramic film Cephalometric film Oral/facial photographic images Pulp vitality tests Fee 40.06(5) - Dental Service Description (continued) Diagnostic casts 112.00 Accession of tissue, gross examination, preparation, and transmission of written report 264.00 Accession of tissue, gross and microscopic examination, preparation and transmission of written report 12.00 Accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation and transmission of written report 12.00 Accession of exfoliative cytologic smears, microscopic examination, preparation and transmission of written report 69.60 Prophylaxis - adult 26.40 Topical application of fluoride (prophylaxis not included) - adult 28.80 Topical fluoride varnish; therapeutic application for moderate to high caries risk patients 41.60 Sealant - per tooth 280.00 Space maintainer - fixed-unilateral 424.00 Space maintainer - fixed-bilateral 128.00 Space maintainer - removable-unilateral 180.00 Space maintainer - removable-bilateral 80.00 Recementation of space maintainer 44.00 Removal of fixed space maintainer 88.00 Amalgam-one surface, primary or permanent 110.40 Amalgam-two surfaces, primary or permanent 132.00 Amalgam-three surfaces, primary or permanent 156.00 Amalgam-four or more surfaces, primary or permanent 104.00 Resin - one surface, anterior 129.60 Resin - two surfaces, anterior 157.60 Resin - three surfaces, anterior 200.00 Resin - four or more surfaces or involving incisal angle (anterior) 176.80 Resin-based composite crown, anterior 116.00 Resin-based composite - one surface, posterior 151.20 Resin-based composite - two surfaces, posterior 184.00 Resin-based composite - three surfaces, posterior 216.00 Resin-based composite - four or more surfaces, posterior 240.00 Inlay - metallic -one surface 680.00 Inlay - metallic - two surfaces 756.00 Inlay - metallic - three or more surfaces 720.00 Onlay - metallic - two surfaces 772.00 Onlay - metallic - three surfaces 880.00 Onlay - metallic - four or more surfaces 288.00 Inlay - porcelain/ceramic - one surface 389.60 Inlay - porcelain/ceramic - two surfaces 632.00 Inlay - porcelain/ceramic - three or more surfaces 748.00 Onlay - porcelain/ceramic - two surfaces 796.00 Onlay - porcelain/ceramic - three surfaces 912.00 Onlay - porcelain/ceramic - four or more surfaces D2662 1,016.00 Onlay - resin-based composite - two surfaces 960.00 Onlay - resin-based composite - three surfaces D2664 1,016.00 Onlay - resin-based composite - four or more surfaces 240.00 Crown - resin-based composite (indirect) 300.00 Crown - ¾ resin-based composite (indirect) D2720 1,120.00 Crown - resin with high noble metal 640.00 Crown - resin with predominantly base metal 960.00 Crown - porcelain/ceramic substrate 880.00 Crown - porcelain fused to high noble metal 796.00 Crown - porcelain fused to predominantly base metal 800.00 Crown - porcelain fused to noble metal 920.00 Crown - ¾ cast high noble metal D2782 1,100.00 Crown - ¾ cast noble metal Fee 40.06(5) - Dental Service Description (continued) D2783 1,005.60 Crown - 3/4 porcelain/ceramic 918.40 Crown - full cast high noble metal 744.00 Crown - full cast predominantly base metal 856.00 Crown - full cast noble metal D2794 1,120.00 Crown - titanium 200.00 Provisional crown Recement inlay, onlay or partial coverage restoration Recement cast or prefabricated post and core Recement crown 208.00 Prefabricated stainless steel crown - primary tooth 240.00 Prefabricated stainless steel crown - permanent tooth 200.00 Prefabricated resin crown 232.00 Stainless steel crown - primary Sedative filling 227.20 Core buildup, including any pins Pin retention - per tooth, in addition to restoration 316.00 Post and core in addition to crown, indirectly fabricated 256.00 Prefabricated post and core in addition to crown 224.80 Temporary crown (fractured tooth) 224.80 Additional procedures to construct new crown under existing partial denture framework 150.40 Crown repair, by report Pulp cap - direct (excluding final restoration) Pulp cap - indirect (excluding final restoration) 132.00 Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament 145.60 Pulpal debridement, primary and permanent teeth 560.00 Anterior (excluding final restoration) 660.00 Bicuspid (excluding final restoration) 840.00 Molar (excluding final restoration) 260.00 Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth 312.00 Internal root repair of perforation defects 640.00 Retreatment of previous root canal therapy - anterior 760.00 Retreatment of previous root canal therapy - bicuspid 921.60 Retreatment of previous root canal therapy - molar 156.00 Apexification/recalcification - initial visit (apical closure/calcific repair of perforations, root resorption, etc.) 169.60 Apexification/recalcification - interim medication replacement (apical closure/calcific repair of perforations, root resorption, etc.) 639.20 Apicoectomy/periradicular surgery - anterior 560.00 Apicoectomy/periradicular surgery - bicuspid (first root) 656.00 Apicoectomy/periradicular surgery - molar (first root) 120.00 Retrograde filling - per root 420.00 Root amputation - per root 313.60 Hemisection (including any root removal), not including root canal therapy 304.00 Gingivectomy or gingivoplasty - Four or more contiguous teeth or bounded teeth spaces per quadrant 140.00 Gingivectomy or gingivoplasty - one to three contiguous teeth or bounded teeth spaces per quadrant 560.00 Gingival flap procedure, including root planing - four or more contiguous teeth or bounded teeth spaces per quadrant 240.00 Gingival flap procedure, including root planing - one to three contiguous teeth or bounded teeth spaces per quadrant 625.60 Clinical crown lengthening - hard tissue 880.00 Osseous surgery (including flap entry and closure) - four or more contiguous teeth or bounded teeth spaces per quadrant Fee 40.06(5) - Dental Service Description (continued) 760.00 Osseous surgery (including flap entry and closure) - one to three contiguous teeth or bounded teeth spaces per quadrant 269.60 Bone replacement graft - first site in quadrant 180.00 Bone replacement graft - each additional site in quadrant 236.00 Biologic materials to aid in soft and osseous tissue regeneration 360.00 Guided tissue regeneration - resorbable barrier, per site 743.20 Pedicle soft tissue graft procedure 718.40 Free soft tissue graft procedure (including donor site surgery) 928.00 Subepithelial connective tissue graft procedures, per tooth 460.00 Distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area) 780.00 Soft tissue allograft 180.00 Periodontal scaling and root planing - four or more teeth per quadrant 124.00 Periodontal scaling and root planing - one to three teeth, per quadrant 116.00 Full mouth debridement to enable comprehensive evaluation and diagnosis 29.60 Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth, by report Periodontal maintenance 88.00 Unscheduled dressing change (by someone other than treating dentist) 960.00 Complete denture - maxillary 960.00 Complete denture - mandibular D5130 1,040.00 Immediate denture - maxillary D5140 1,040.00 Immediate denture - mandibular 760.00 Maxillary partial denture - resin base (including any conventional clasps, rests and teeth) 780.00 Mandibular partial denture - resin base (including any conventional clasps, rests and teeth) D5213 1,040.00 Maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) D5214 1,040.00 Mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) D5225 1,000.00 Maxillary partial denture - flexible base (including any clasps, rests and teeth) 960.00 Mandibular partial denture - flexible base (including any clasps, rests and teeth) 520.00 Removable unilateral partial denture - one piece cast metal (including clasps and teeth) 60.00 Adjust complete denture - maxillary 36.00 Adjust complete denture - mandibular 68.00 Adjust partial denture - maxillary 60.00 Adjust partial denture - mandibular 132.00 Repair broken complete denture base 116.00 Replace missing or broken teeth - complete denture (each tooth) 124.00 Repair resin denture base 168.00 Repair cast framework 140.00 Repair or replace broken clasp 112.00 Replace broken teeth - per tooth 128.00 Add tooth to existing partial denture 132.80 Add clasp to existing partial denture 340.00 Replace all teeth and acrylic on cast metal framework (maxillary) 480.00 Replace all teeth and acrylic on cast metal framework (mandibular) 280.00 Rebase complete maxillary denture 378.40 Rebase complete mandibular denture 320.00 Rebase maxillary partial denture 316.00 Rebase mandibular partial denture 240.00 Reline complete maxillary denture (chairside) 211.20 Reline lower complete mandibular denture (chairside) 180.00 Reline maxillary partial denture (chairside) 200.00 Reline mandibular partial denture (chairside) 285.60 Reline complete maxillary denture (laboratory) 300.00 Reline complete mandibular denture (laboratory) Fee 40.06(5) - Dental Service Description (continued) 285.60 Reline maxillary partial denture (laboratory) 267.20 Reline mandibular partial denture (laboratory) 380.00 Interim partial denture (maxillary) 428.00 Interim partial denture (mandibular) 110.40 Tissue conditioning, maxillary 134.40 Tissue conditioning, mandibular 360.00 Precision attachment, by report D6010 1,560.00 Surgical placement of implant body: endosteal implant D6040 1,200.00 Surgical placement: eposteal implant 360.00 Surgical placement: transosteal implant D6055 1,040.00 Dental implant supported connecting bar 420.00 Prefabricated abutment - includes placement 560.00 Custom abutment - includes placement D6058 1,000.00 Abutment supported porcelain/ceramic crown D6059 1,036.00 Abutment supported porcelain fused to metal crown (high noble metal) 960.00 Abutment supported porcelain fused to metal crown (predominantly base metal) 920.00 Abutment supported porcelain fused to metal crown (noble metal) D6062 1,050.40 Abutment supported cast metal crown (high noble metal) 360.00 Abutment supported cast metal crown (predominantly base metal) 820.00 Abutment supported cast metal crown (noble metal) D6065 1,040.00 Implant supported porcelain/ceramic crown D6066 1,120.00 Implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal) D6067 1,480.00 Implant supported metal crown (titanium, titanium alloy, high noble metal) 480.00 Abutment supported retainer for porcelain/ceramic FPD 960.00 Abutment supported retainer for porcelain fused to metal FPD (high noble metal) 528.80 Abutment supported retainer for porcelain fused to metal FPD (noble metal) D6072 1,360.00 Abutment supported retainer for cast metal FPD (high noble metal) D6077 1,120.00 Implant supported retainer for cast metal FPD (titanium, titanium alloy, or high noble metal) Recement implant/abutment supported crown Recement implant/abutment supported fixed partial denture 240.00 Pontic - indirect resin based composite 880.00 Pontic - cast high noble metal 520.00 Pontic - cast predominantly base metal 704.00 Pontic - cast noble metal 872.00 Pontic - porcelain fused to high noble metal 760.00 Pontic - porcelain fused to predominantly base metal 798.40 Pontic - porcelain fused to noble metal 904.00 Pontic - resin with high noble metal 616.00 Pontic - resin with predominantly base metal 480.00 Pontic - resin with noble metal 240.00 Provisional pontic 320.00 Retainer - cast metal for resin bonded fixed prosthesis 676.00 Inlay - cast high noble metal, two surfaces 600.00 Inlay - cast noble metal, two surfaces 720.00 Onlay - cast high noble metal, two surfaces 860.00 Onlay - cast high noble metal, three or more surfaces 920.00 Onlay - cast noble metal, three or more surfaces 276.00 Crown - indirect resin based composite 764.00 Crown - resin with high noble metal 604.00 Crown - resin with predominantly base metal 640.00 Crown - resin with noble metal 877.60 Crown - porcelain fused to high noble metal 756.80 Crown - porcelain fused to predominantly base metal 800.00 Crown - porcelain fused to noble metal Fee 40.06(5) - Dental Service Description (continued) 800.00 Crown - ¾ cast high noble metal 840.00 Crown - ¾ noble metal 864.00 Crown - full cast high noble metal 560.00 Crown - full cast predominantly base metal 680.00 Crown - full cast noble metal 240.00 Provisional retainer crown 100.00 Recement bridge 360.00 Precision attachment 200.00 Post and core in addition to fixed partial denture retainer, indirectly fabricated 280.00 Prefabricated post and core in addition to bridge retainer 216.00 Core build up for retainer, including any pins 168.80 Bridge repair, by report Extraction, coronal remnants - deciduous tooth 112.00 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) 200.00 Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth 247.20 Removal of impacted tooth - soft tissue 320.00 Removal of impacted tooth - partially bony 400.00 Removal of impacted tooth - completely bony 476.00 Removal of impacted tooth - completely bony, with unusual surgical complications 214.40 Surgical removal of residual tooth roots (cutting procedure) 460.00 Primary closure of a sinus perforation 320.00 Surgical access of an unerupted tooth 120.00 Placement of device to facilitate eruption of impacted tooth 312.00 Biopsy of oral tissue - hard (bone, tooth) 277.60 Biopsy of oral tissue - soft Exfoliative cytological sample collection 104.00 Brush biopsy - transepithelial sample collection 171.20 Transseptal fiberotomy/supra crestal fiberotomy, by report 200.00 Alveoloplasty in conjunction with extractions-four or more teeth or tooth spaces, per quadrant 224.00 Alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant 200.00 Alveoloplasty not in conjunction with extractions-four or more teeth or tooth spaces, per quadrant 160.80 Alveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quadrant 357.60 Vestibuloplasty - ridge extension (second epithelialization) D7350 1,760.00 Vestibuloplasty - ridge extension (including soft tissue grafts, muscle reattachments, revision of soft tissue attachment and management of hytrophied and hyperplastic tissue 200.00 Excision of benign lesion up to 1.25 cm 400.80 Excision of benign lesion greater than 1.25 cm Destruction of lesion(s) by physical or chemical method, by report 236.00 Removal of lateral exostosis (maxilla or mandible) 400.00 Removal of torus mandibularis 148.00 Incision and drainage of abscess - intraoral soft tissue 236.00 Incision and drainage of abscess - intraoral soft tissue - complicated (includes drainage of multiple fascial spaces) Incision and drainage of abscess - extraoral soft tissue Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue 244.00 Partial ostectomy/sequestrectomy for removal of nonvital bone Alveolus-closed reduction, may include stabilization of teeth 796.00 Mandible-closed reduction 192.00 Closed reduction of dislocation 960.00 Manipulation under anesthesia 356.00 Occlusal orthotic appliance Fee 40.06(5) - Dental Service Description (continued) 380.00 TMD therapy 12.00 Complicated suture - up to 5 cm 380.00 Frenulectomy (frenectomy or frenotomy) - separate procedure 557.60 Frenuloplasty 243.20 Limited orthodontic treatment of the primary dentition 353.60 Limited orthodontic treatment of the transitional dentition 200.00 Limited orthodontic treatment of the adolescent dentition 333.60 Limited orthodontic treatment of the adult dentition 333.60 Interceptive orthodontic treatment of the primary dentition 373.60 Interceptive orthodontic treatment of the transitional dentition 316.80 Comprehensive orthodontic treatment of the transitional dentition 323.20 Comprehensive orthodontic treatment of the adolescent dentition 323.20 Comprehensive orthodontic treatment of the adult dentition 280.00 Removable appliance therapy 360.00 Fixed appliance therapy 244.00 Preorthodontic treatment visit 300.00 Periodic orthodontic treatment visit (as part of contract) 308.00 Orthodontic retention (removal of appliances, construction and placement of retainer(s)) 200.00 Orthodontic treatment (alternative billing to a contract fee) 76.00 Repair of orthodontic appliance 200.00 Replacement of lost or broken retainer 75.20 Palliative (emergency) treatment of dental pain - minor procedure 120.00 Fixed partial denture sectioning 248.00 Deep sedation/general anesthesia - first 30 minutes 132.00 Deep sedation/general anesthesia - each additional 15 minutes 52.00 Analgesia, anxiolysis, inhalation of nitrous oxide 240.00 Intravenous conscious sedation/analgesia - first 30 minutes 116.00 Intravenous conscious sedation/analgesia - each additional 15 minutes 64.00 Consultation-diagnostic service provided by dentist or physician other than requesting dentist or physician 27.20 Application of desensitizing medicament 333.60 Occlusal guards, by report 100.00 Repair and/or reline of occlusal guard 220.00 Occlusal adjustment - complete (6) Durable Medical Equipment, Prosthetics/Orthotics, and Supplies. Fee Nu Fee Ue Fee RR 114.3 CMR 40.06(6) - DMEPOS Description Sterile water, saline and/or dextrose, diluent/flush, 10 ml Sterile water/saline, 500 ml Supplies for maintenance of drug infusion catheter, per week (list drug separately) Infusion supplies for external drug infusion pump, per cassette or bag (list drugs separately) Replacement battery, alkaline (other than J cell), for use with medically necessary home blood glucose monitor owned by patient, each Replacement battery, alkaline, J cell, for use with medically necessary home blood glucose monitor owned by patient, each Replacement battery, lithium, for use with medically necessary home blood glucose monitor owned by patient, each Fee Nu Fee Ue Fee RR 114.3 CMR 40.06(6) - DMEPOS Description (con’t) Replacement battery, silver oxide, for use with medically necessary home blood glucose monitor owned by patient, each Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips Platforms for home blood glucose monitor, 50 per box Normal, low, and high calibrator solution/chips Replacement lens shield cartridge for use with laser skin piercing device, each Spring-powered device for lancet, each Lancets, per box of 100 Paraffin, per pound Adhesive skin support attachment for use with external breast prosthesis, each Insertion tray without drainage bag and without catheter (accessories only) Insertion tray without drainage bag with indwelling catheter, Foley type, two-way latex with coating (Teflon, silicone, silicone elastomer or hydrophilic, etc.) Insertion tray without drainage bag with indwelling catheter, Foley type, two-way, all silicone Insertion tray without drainage bag with indwelling catheter, Foley type, three-way, for continuous irrigation Insertion tray with drainage bag with indwelling catheter, Foley type, two-way latex with coating (Teflon, silicone, silicone elastomer or hydrophilic, etc.) Insertion tray with drainage bag with indwelling catheter, Foley type, two-way, all silicone Insertion tray with drainage bag with indwelling catheter, Foley type, three-way, for continuous irrigation Irrigation tray with bulb or piston syringe, any purpose A4321 I.C Therapeutic agent for urinary catheter irrigation Irrigation syringe, bulb or piston, each Male external catheter with integral collection chamber, any type, each Female external urinary collection device; meatal cup, each Female external urinary collection device; pouch, each Perianal fecal collection pouch with adhesive, each Extension drainage tubing, any type, any length, with connector/adaptor, for use with urinary leg bag or urostomy pouch, each Lubricant, individual sterile packet, each Urinary catheter anchoring device, adhesive skin attachment, each Urinary catheter anchoring device, leg strap, each Indwelling catheter; Foley type, two-way latex with coating (Teflon, silicone, silicone elastomer, or hydrophilic, etc.), each Indwelling catheter; specialty type, (eg, Coude, mushroom, wing, etc.), each Fee Nu Fee Ue Fee RR 114.3 CMR 40.06(6) - DMEPOS Description (con’t) Indwelling catheter, Foley type, two-way, all silicone, each Indwelling catheter; Foley type, three-way for continuous irrigation, each Male external catheter, with or without adhesive, disposable, each Intermittent urinary catheter; straight tip, with or without coating (Teflon, silicone, silicone elastomer, or hydrophilic, etc.), each Intermittent urinary catheter; Coude (curved) tip, with or without coating (Teflon, silicone, silicone elastomeric, or hydrophilic, etc.), each Intermittent urinary catheter, with insertion supplies Insertion tray with drainage bag but without catheter Irrigation tubing set for continuous bladder irrigation through a three-way indwelling Foley catheter, each External urethral clamp or compression device (not to be used for catheter clamp), each Bedside drainage bag, day or night, with or without anti-reflux device, with or without tube, each Urinary drainage bag, leg or abdomen, vinyl, with or without tube, with straps, each Ostomy faceplate, each Skin barrier; solid, 4 x 4 or equivalent; each Ostomy clamp, any type, replacement only, each Adhesive, liquid, or equal, any type, per oz. Adhesive remover wipes, any type, per 50 Ostomy vent, any type, each Ostomy belt, each Ostomy filter, any type, each Ostomy skin barrier, liquid (spray, brush, etc.), per oz. Ostomy skin barrier, powder, per oz. Ostomy skin barrier, solid 4 x 4 or equivalent, standard wear, with built-in convexity, each Ostomy skin barrier, with flange (solid, flexible or accordion), with built-in convexity, any size, each Ostomy pouch, drainable, with faceplate attached, plastic, each Ostomy pouch, drainable, with faceplate attached, rubber, each Ostomy pouch, drainable, for use on faceplate, plastic, each Ostomy pouch, drainable, for use on faceplate, rubber, each Ostomy pouch, urinary, with faceplate attached, plastic, each Ostomy pouch, urinary, with faceplate attached, rubber, each Ostomy pouch, urinary, for use on faceplate, plastic, each Ostomy pouch, urinary, for use on faceplate, heavy plastic, each Ostomy pouch, urinary, for use on faceplate, rubber, each Ostomy faceplate equivalent, silicone ring, each Fee Nu Fee Ue Fee RR A4387 I.C 114.3 CMR 40.06(6) - DMEPOS Description (con’t) Ostomy skin barrier, solid 4 x 4 or equivalent, extended wear, without built-in convexity, each Ostomy pouch, closed, with barrier attached, with built-in convexity (one piece), each Ostomy pouch, drainable, with extended wear barrier attached, (one piece), each Ostomy pouch, drainable, with barrier attached, with built-in convexity (one piece), each Ostomy pouch, drainable, with extended wear barrier attached, with built-in convexity (one piece), each Ostomy pouch, urinary, with extended wear barrier attached (one piece), each Ostomy pouch, urinary, with standard wear barrier attached, with built-in convexity (one piece), each Ostomy pouch, urinary, with extended wear barrier attached, with built-in convexity (one piece), each Ostomy deodorant, with or without lubricant, for use in ostomy pouch, per fluid ounce Ostomy deodorant for use in ostomy pouch, solid, per tablet Ostomy belt with peristomal hernia support Irrigation supply; sleeve, each Ostomy irrigation supply; bag, each Ostomy irrigation supply; cone/catheter, including brush Ostomy irrigation set Lubricant, per oz. Ostomy ring, each Ostomy skin barrier, nonpectin-based, paste, per oz. Ostomy skin barrier, pectin-based, paste, per oz. Ostomy skin barrier, with flange (solid, flexible, or accordion), extended wear, with built-in convexity, 4 x 4 in. or smaller, each Ostomy skin barrier, with flange (solid, flexible or accordion), extended wear, with built-in convexity, larger than 4 x 4 in., each Ostomy skin barrier, with flange (solid, flexible or accordion), extended wear, without built-in convexity, 4 x 4 in. or smaller, each Ostomy skin barrier, with flange (solid, flexible or accordion), extended wear, without built-in convexity, larger than 4 x 4 in., each Ostomy skin barrier, solid 4 x 4 or equivalent, extended wear, with built-in convexity, each Ostomy pouch, drainable, high output, for use on a barrier with flange (two piece system), without filter, each Ostomy pouch, drainable, high output, for use on a barrier with flange (two piece system), with filter, each Ostomy skin barrier, with flange (solid, flexible or accordion), without built-in convexity, 4 x 4 in. or smaller, each Ostomy skin barrier, with flange (solid, flexible or accordion), without built-in convexity, larger than 4 x 4 in., each Fee Nu Fee Ue Fee RR 114.3 CMR 40.06(6) - DMEPOS Description (con’t) Ostomy pouch, closed, with barrier attached, with filter (one piece), each Ostomy pouch, closed, with barrier attached, with built-in convexity, with filter (one piece), each Ostomy pouch, closed; without barrier attached, with filter (one piece), each Ostomy pouch, closed; for use on barrier with nonlocking flange, with filter (two piece), each A4420 I.C Ostomy pouch, closed; for use on barrier with locking flange (two piece), each Ostomy absorbent material (sheet/pad/crystal packet) for use in ostomy pouch to thicken liquid stomal output, each Ostomy pouch, closed; for use on barrier with locking flange, with filter (two piece), each Ostomy pouch, drainable, with barrier attached, with filter (one piece), each Ostomy pouch, drainable; for use on barrier with nonlocking flange, with filter (two piece system), each Ostomy pouch, drainable; for use on barrier with locking flange (two piece system), each Ostomy pouch, drainable; for use on barrier with locking flange, with filter (two piece system), each Ostomy pouch, urinary, with extended wear barrier attached, with faucet-type tap with valve (one piece), each Ostomy pouch, urinary, with barrier attached, with built-in convexity, with faucet-type tap with valve (one piece), each Ostomy pouch, urinary, with extended wear barrier attached, with built-in convexity, with faucet-type tap with valve (one piece), each Ostomy pouch, urinary; with barrier attached, with faucet-type tap with valve (one piece), each Ostomy pouch, urinary; for use on barrier with nonlocking flange, with faucet-type tap with valve (two piece), each Ostomy pouch, urinary; for use on barrier with locking flange (two piece), each Ostomy pouch, urinary; for use on barrier with locking flange, with faucet-type tap with valve (two piece), each Adhesive remover or solvent (for tape, cement or other adhesive), per oz. Surgical dressing holder, nonreusable, each Surgical dressing holder, reusable, each Tracheostoma filter, any type, any size, each A4483 I.C Moisture exchanger, disposable, for use with invasive mechanical ventilation Electrodes (eg, apnea monitor), per pair Lead wires (eg, apnea monitor), per pair Conductive gel or paste, for use with electrical device (eg, TENS, NMES), per oz. Coupling gel or paste, for use with ultrasound device, per oz. Pessary, rubber, any type Fee Nu Fee Ue A4638 I.C I.C Fee RR I.C 114.3 CMR 40.06(6) - DMEPOS Description (con’t) Pessary, nonrubber, any type Electrical stimulator supplies, two lead, per month, (eg, TENS, NMES) Tubing with integrated heating element for use with positive airway pressure device Tracheal suction catheter, closed system, each Transtracheal oxygen catheter, each Battery, heavy duty; replacement for patient-owned ventilator Battery cables; replacement for patient-owned ventilator Battery charger; replacement for patient-owned ventilator Peak expiratory flow rate meter, hand held Cannula, nasal Tubing (oxygen), per foot Mouthpiece Breathing circuits Face tent Variable concentration mask Tracheostomy, inner cannula Tracheal suction catheter, any type other than closed system, each Tracheostomy care kit for new tracheostomy Tracheostomy cleaning brush, each Oropharyngeal suction catheter, each Tracheostomy care kit for established tracheostomy Replacement batteries, medically necessary, transcutaneous electrical stimulator, owned by patient Replacement bulb/lamp for ultraviolet light therapy system, each Underarm pad, crutch, replacement, each Replacement, handgrip, cane, crutch, or walker, each Replacement, tip, cane, crutch, walker, each Replacement battery for patient-owned ear pulse generator, each Replacement pad for infrared heating pad system, each Replacement pad for use with medically necessary alternating pressure pad owned by patient Ostomy pouch, closed; with barrier attached (one piece), each Ostomy pouch, closed; without barrier attached (one piece), each Ostomy pouch, closed; for use on faceplate, each Ostomy pouch, closed; for use on barrier with flange (two piece), each Stoma cap Ostomy pouch, drainable; with barrier attached, (one piece), each Ostomy pouch, drainable; without barrier attached (one piece), each Ostomy pouch, drainable; for use on barrier with flange (two piece system), each Ostomy pouch, urinary; with barrier attached (one piece), each Ostomy pouch, urinary; without barrier attached (one piece), each Fee Nu Fee Ue Fee RR A5083 I.C. 114.3 CMR 40.06(6) - DMEPOS Description (con’t) Ostomy pouch, urinary; for use on barrier with flange (two piece), each Continent device; plug for continent stoma Continent device; catheter for continent stoma Continent device, stoma absorptive cover for continent stoma Ostomy accessory; convex insert Bedside drainage bottle, with or without tubing, rigid or expandable, each Urinarysuspensory with leg bag, with or without tube, each Urinary leg bag; latex Leg strap; latex, replacement only, per set Leg strap; foam or fabric, replacement only, per set Skin barrier; solid, 6 x 6 or equivalent, each Skin barrier; solid, 8 x 8 or equivalent, each Adhesive or nonadhesive; disk or foam pad Appliance cleaner, incontinence and ostomy appliances, per 16 oz. Percutaneous catheter/tube anchoring device, adhesive skin attachment For diabetics only, fitting (including follow-up), custom preparation and supply of off-the-shelf depth-inlay shoe manufactured to accommodate multi-density insert(s), per shoe For diabetics only, fitting (including follow-up), custom preparation and supply of shoe molded from cast(s) of patient's foot (custom molded shoe), per shoe For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with roller or rigid rocker bottom, per shoe For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with wedge(s), per shoe For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with metatarsal bar, per shoe For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with off-set heel(s), per shoe For diabetics only, not otherwise specified modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe, per shoe For diabetics only, multiple density insert, direct formed, molded to foot after external heat source of 230 degrees Fahrenheit or higher, total contact with patient's foot, including arch, base layer minimum of ¼ inch material of shore a 35 durometer or 3/16 inch material For diabetics only, multiple density insert, custom molded from model of patient's foot, total contact with patient's foot, including arch, base layer minimum of 3/16 inch material of shore a 35 durometer or higher, includes arch filler and other shaping Fee Nu Fee Ue Fee RR A6217 I.C. 114.3 CMR 40.06(6) - DMEPOS Description (con’t) Collagen based wound filler, dry form, per gram of collagen Collagen based wound filler, gel/paste, per gram of collagen Collagen dressing, pad size 16 sq. in. or less, each Collagen dressing, pad size more than 16 sq. in. but less than or equal to 48 sq. in., each Collagen dressing, pad size more than 48 square inches, each Collagen dressing wound filler, per 6 in. Wound pouch, each Alginate or other fiber gelling dressing, wound cover, pad size 16 sq. in. or less, each dressing Alginate or other fiber gelling dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in., each dressing Alginate or other fiber gelling dressing, wound filler, per 6 in. Composite dressing, pad size 16 sq. in. or less, with any size adhesive border, each dressing Composite dressing, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing Contact layer, more than 16 sq. in. but less than or equal to 48 sq. in., each dressing Foam dressing, wound cover, pad size 16 sq. in. or less, without adhesive border, each dressing Foam dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing Foam dressing, wound cover, pad size more then 48 sq. in., without adhesive border, each dressing Foam dressing, wound cover, pad size 16 sq. in. or less, with any size adhesive border, each dressing Foam dressing, wound cover, pad size more than 48 sq. in., with any size adhesive border, each dressing Gauze, nonimpregnated, nonsterile, pad size 16 sq. in. or less, without adhesive border, each dressing Gauze, nonimpregnated, nonsterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing Gauze, nonimpregnated, pad size 16 sq. in. or less, with any size adhesive border, each dressing Gauze, nonimpregnated, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing Gauze, impregnated with other than water, normal saline, or hydrogel, pad size 16 sq. in. or less, without adhesive border, each dressing Gauze, impregnated with other than water, normal saline, or hydrogel, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing Gauze, impregnated with other than water, normal saline, or hydrogel, pad size more than 48 sq. in., without adhesive border, each dressing Fee Nu Fee Ue Fee RR 114.3 CMR 40.06(6) - DMEPOS Description (con’t) Gauze, impregnated, water or normal saline, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing Gauze, impregnated, hydrogel, for direct wound contact, pad size 16 sq. in. or less, each dressing Gauze, impregnated, hydrogel, for direct wound contact, pad size greater than 16 sq. in., but less than or equal to 48 sq. in., each dressing Gauze, impregnated, hydrogel for direct wound contact, pad size more than 48 sq. in., each dressing Hydrocolloid dressing, wound cover, pad size 16 sq. in. or less, without adhesive border, each dressing Hydrocolloid dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing Hydrocolloid dressing, wound cover, pad size more than 48 sq. in., without adhesive border, each dressing Hydrocolloid dressing, wound cover, pad size 16 sq. in. or less, with any size adhesive border, each dressing Hydrocolloid dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing Hydrocolloid dressing, wound filler, paste, per fl. oz. Hydrocolloid dressing, wound filler, dry form, per gm Hydrogel dressing, wound cover, pad size 16 sq. in. or less, without adhesive border, each dressing Hydrogel dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing Hydrogel dressing, wound cover, pad size more than 48 sq. in., without adhesive border, each dressing Hydrogel dressing, wound cover, pad size 16 sq. in. or less, with any size adhesive border, each dressing Hydrogel dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing Hydrogel dressing, wound cover, pad size more than 48 sq. in., with any size adhesive border, each dressing Hydrogel dressing, wound filler, gel, per fl. oz. Specialty absorptive dressing, wound cover, pad size 16 sq. in. or less, without adhesive border, each dressing Specialty absorptive dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing Specialty absorptive dressing, wound cover, pad size more than 48 sq. in., without adhesive border, each dressing Specialty absorptive dressing, wound cover, pad size 16 sq. in. or less, with any size adhesive border, each dressing Specialty absorptive dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing Fee Nu Fee Ue Fee RR 114.3 CMR 40.06(6) - DMEPOS Description (con’t) Transparent film, 16 sq. in. or less, each dressing Transparent film, more than 16 sq. in. but less than or equal to 48 sq. in., each dressing Transparent film, more than 48 sq. in., each dressing Gauze, impregnated, other than water, normal saline, or zinc paste, any width, per linear yd. Gauze, nonimpregnated, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing Gauze, nonimpregnated, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing Packing strips, nonimpregnated, up to two in. in width, per linear yd. Eye pad, sterile, each A6411 I.C. Eye pad, non-sterile, each Padding bandage, nonelastic, nonwoven/nonknitted, width greater than or equal to three in. and less than five in., per yd. Conforming bandage, nonelastic, knitted/woven, nonsterile, width less than three in., per yd. Conforming bandage, nonelastic, knitted/woven, nonsterile, width greater than or equal to three in. and less than five in., per yd. Conforming bandage, nonelastic, knitted/woven, nonsterile, width greater than or equal to five in., per yd. Conforming bandage, nonelastic, knitted/woven, sterile, width less than three in., per yd. Conforming bandage, nonelastic, knitted/woven, sterile, width greater than or equal to three in. and less than five in., per yd. Conforming bandage, nonelastic, knitted/woven, sterile, width greater than or equal to five in., per yd. Light compression bandage, elastic, knitted/woven, width less than three in., per yd. Light compression bandage, elastic, knitted/woven, width greater than or equal to three in. and less than five in., per yd. A6450 I.C. Light compression bandage, elastic, knitted/woven, width greater than or equal to five inches, per yard A6451 I.C. Moderate compression bandage, elastic, knitted/woven, load resistance of 1.25 to 1.34 foot pounds at 50% maximum stretch, width greater than or equal to three in. and less than five in., per yd. High compression bandage, elastic, knitted/woven, load resistance greater than or equal to 1.35 foot pounds at 50% maximum stretch, width greater than or equal to three in. and less than five in., per yd. Self-adherent bandage, elastic, nonknitted/nonwoven, width less than three in., per yd. Self-adherent bandage, elastic, nonknitted/nonwoven, width greater than or equal to three in. and less than five in., per yard Self-adherent bandage, elastic, nonknitted/nonwoven, width greater than or equal to five in., per yd. Fee Nu Fee Ue Fee RR 114.3 CMR 40.06(6) - DMEPOS Description (con’t) Zinc paste impregnated bandage, nonelastic, knitted/woven, width greater than or equal to 3 in. and less than 5 in., per yd. Tubular dressing with or without elastic, any width, per linear yard A6501 AI +20% Compression burn garment, bodysuit (head to foot), custom fabricated A6502 AI +20% Compression burn garment, chin strap, custom fabricated A6503 AI +20% Compression burn garment, facial hood, custom fabricated A6504 AI +20% Compression burn garment, glove to wrist, custom fabricated A6505 AI +20% Compression burn garment, glove to elbow, custom fabricated A6506 AI +20% Compression burn garment, glove to axilla, custom fabricated A6507 AI +20% Compression burn garment, foot to knee length, custom fabricated A6508 AI +20% Compression burn garment, foot to thigh length, custom fabricated A6509 AI +20% Compression burn garment, upper trunk to waist including arm openings (vest), custom fabricated A6510 AI +20% Compression burn garment, trunk, including arms down to leg openings (leotard), custom fabricated A6511 AI +20% Compression burn garment, lower trunk including leg openings (panty), custom fabricated A6513 AI +20% Compression burn mask, face and/or neck, plastic or equal, custom fabricated Gradient compression stocking, below knee, 30-40 mm Hg, each Gradient compression stocking, below knee, 40-50 mm Hg, each Wound care set, for negative pressure wound therapy electrical pump, includes all supplies and accessories Canister, disposable, used with suction pump, each Canister, nondisposable, used with suction pump, each Tubing, used with suction pump, each Administration set, with small volume nonfiltered pneumatic nebulizer, disposable Small volume nonfiltered pneumatic nebulizer, disposable Administration set, with small volume nonfiltered pneumatic nebulizer, nondisposable Administration set, with small volume filtered pneumatic nebulizer Large volume nebulizer, disposable, unfilled, used with aerosol compressor Large volume nebulizer, disposable, prefilled, used with aerosol compressor Reservoir bottle, nondisposable, used with large volume ultrasonic nebulizer Corrugated tubing, disposable, used with large volume nebulizer, 100 ft. Water collection device, used with large volume nebulizer Fee Nu Fee Ue Fee RR 114.3 CMR 40.06(6) - DMEPOS Description (con’t) Filter, disposable, used with aerosol compressor Filter, nondisposable, used with aerosol compressor or ultrasonic generator Aerosol mask, used with DME nebulizer Dome and mouthpiece, used with small volume ultrasonic nebulizer Nebulizer, durable, glass or autoclavable plastic, bottle type, not used with oxygen Water, distilled, used with large volume nebulizer, 1000 ml High frequency chest wall oscillation system vest, replacement for use with patient owned equipment, each High frequency chest wall oscillation system hose, replacement for use with patient owned equipment, each Combination oral/nasal mask, used with continuous positive airway pressure device, each Oral cushion for combination oral/nasal mask, replacement only, each Nasal pillows for combination oral/nasal mask, replacement only, pair Full face mask used with positive airway pressure device, each Face mask interface, replacement for full face mask, each Cushion for use on nasal mask interface, replacement only, each Pillow for use on nasal cannula type interface, replacement only, pair Nasal interface (mask or cannula type) used with positive airway pressure device, with or without head strap Headgear used with positive airway pressure device Chinstrap used with positive airway pressure device Tubing used with positive airway pressure device Filter, disposable, used with positive airway pressure device Filter, nondisposable, used with positive airway pressure device One way chest drain valve Water seal drainage container and tubing for use with implanted chest tube Implanted pleural catheter, each Vacuum drainage bottle and tubing for use with implanted catheter Oral interface used with positive airway pressure device, each Exhalation port with or without swivel used with accessories for positive airway devices, replacement only Water chamber for humidifier, used with positive airway pressure device, replacement, each Tracheostoma valve, including diaphragm, each Replacement diaphragm/faceplate for tracheostoma valve, each Fee Nu Fee Ue Fee RR 114.3 CMR 40.06(6) - DMEPOS Description (con’t) Filter holder or filter cap, reusable, for use in a tracheostoma heat and moisture exchange system, each Filter for use in a tracheostoma heat and moisture exchange system, each Housing, reusable without adhesive, for use in a heat and moisture exchange system and/or with a tracheostoma valve, each Adhesive disc for use in a heat and moisture exchange system and/or with tracheostoma valve, any type each Filter holder and integrated filter without adhesive, for use in a tracheostoma heat and moisture exchange system, each Housing and integrated adhesive, for use in a tracheostoma heat and moisture exchange system and/or with a tracheostoma valve, each Filter holder and integrated filter housing, and adhesive, for use as a tracheostoma heat and moisture exchange system, each Tracheostomy/laryngectomy tube, noncuffed, polyvinylchloride (PVC), silicone or equal, each Tracheostomy/laryngectomy tube, cuffed, polyvinylchloride (PVC), silicone or equal, each Tracheostomy/laryngectomy tube, stainless steel or equal (sterilizable and reusable), each Tracheostoma stent/stud/button, each Tracheostomy mask, each Tracheostomy tube collar/holder, each Tracheostomy/laryngectomy tube plug/stop, each Helmet, protective, soft, prefabricated, includes all components and accessories Helmet, protective, hard, prefabricated, includes all components and accessories A8002 AI +70% Helmet, protective, soft, custom fabricated, includes all components and accessories A8003 AI +70% Helmet, protective, hard, custom fabricated, includes all components and accessories A8004 I.C. I.C. I.C. Soft interface for helmet, replacement only E0100 20.29 Cane, includes canes of all materials, adjustable or fixed, with tip E0105 48.46 Cane, quad or three-prong, includes canes of all materials, adjustable or fixed, with tips E0110 77.59 Crutches, forearm, includes crutches of various materials, adjustable or fixed, pair, complete with tips and handgrips E0111 53.26 Crutch, forearm, includes crutches of various materials, adjustable or fixed, each, with tip and handgrip E0112 31.45 Crutches, underarm, wood, adjustable or fixed, pair, with pads, tips and handgrips E0113 21.13 Crutch, underarm, wood, adjustable or fixed, each, with pad, tip and handgrip E0114 40.11 Crutches, underarm, other than wood, adjustable or fixed, pair, with pads, tips and handgrips Fee Nu Fee Ue E0116 27.74 E0117 192.71 E0130 64.70 E0135 83.84 E0140 360.71 E0141 114.09 E0143 120.23 E0144 318.45 E0147 574.81 E0148 127.05 E0149 223.20 E0153 58.97 E0154 65.40 E0155 31.56 E0156 26.43 E0157 81.92 E0158 32.18 E0159 17.81 E0160 33.06 E0161 22.30 E0162 145.70 E0163 102.25 E0165 E0167 12.00 E0168 150.92 E0170 E0171 E0175 64.98 E0181 E0182 E0184 194.70 E0185 319.86 E0186 E0187 E0188 22.47 E0189 51.96 E0191 9.99 E0193 E0194 E0196 Fee RR 114.3 CMR 40.06(6) - DMEPOS Description (con’t) Crutch, underarm, other than wood, adjustable or fixed, with pad, tip, handgrip, with or without shock absorber, each Crutch, underarm, articulating, spring assisted, each Walker, rigid (pickup), adjustable or fixed height Walker, folding (pickup), adjustable or fixed height Walker, with trunk support, adjustable or fixed height, any type Walker, rigid, wheeled, adjustable or fixed height Walker, folding, wheeled, adjustable or fixed height Walker, enclosed, four sided framed, rigid or folding, wheeled with posterior seat Walker, heavy duty, multiple braking system, variable wheel resistance Walker, heavy duty, without wheels, rigid or folding, any type, each Walker, heavy duty, wheeled, rigid or folding, any type Platform attachment, forearm crutch, each Platform attachment, walker, each Wheel attachment, rigid pick-up walker, per pair Seat attachment, walker Crutch attachment, walker, each Leg extensions for walker, per set of four Brake attachment for wheeled walker, replacement, each Sitz type bath or equipment, portable, used with or without commode Sitz type bath or equipment, portable, used with or without commode, with faucet attachment(s) Sitz bath chair Commode chair, mobile or stationary, with fixed arms Commode chair, mobile or stationary, with detachable arms Pail or pan for use with commode chair, replacement only Commode chair, extra wide and/or heavy duty, stationary or mobile, with or without arms, any type, each Commode chair with integrated seat lift mechanism, electric, any type Commode chair with integrated seat lift mechanism, non-electric, any type Foot rest, for use with commode chair, each Powered pressure reducing mattress overlay/pad, alternating, with pump, includes heavy duty Pump for alternating pressure pad, for replacement only Dry pressure mattress Gel or gel-like pressure pad for mattress, standard mattress length and width Air pressure mattress Water pressure mattress Synthetic sheepskin pad Lambswool sheepskin pad, any size Heel or elbow protector, each Powered air flotation bed (low air loss therapy) Air fluidized bed Gel pressure mattress Fee Nu Fee Ue E0197 188.34 E0198 188.34 E0199 28.30 E0200 67.39 E0202 E0205 164.95 E0210 32.64 E0215 60.21 E0217 496.47 E0220 7.20 E0225 330.35 E0230 7.21 E0235 E0236 E0238 22.98 E0239 449.83 E0249 99.60 E0250 E0251 E0255 E0256 E0260 E0261 E0265 E0266 E0271 222.04 E0272 202.37 E0275 14.57 E0276 11.31 E0277 E0280 36.58 E0290 E0291 E0292 E0293 E0294 Fee RR 114.3 CMR 40.06(6) - DMEPOS Description (con’t) Air pressure pad for mattress, standard mattress length and width Water pressure pad for mattress, standard mattress length and width Dry pressure pad for mattress, standard mattress length and width Heat lamp, without stand (table model), includes bulb, or infrared element Phototherapy (bilirubin) light with photometer Heat lamp, with stand, includes bulb, or infrared element Electric heat pad, standard Electric heat pad, moist Water circulating heat pad with pump Hot water bottle Hydrocollator unit, includes pads Ice cap or collar Paraffin bath unit, portable (see medical supply code A4265 for paraffin) Pump for water circulating pad Nonelectric heat pad, moist Hydrocollator unit, portable Pad for water circulating heat unit Hospital bed, fixed height, with any type side rails, with mattress Hospital bed, fixed height, with any type side rails, without mattress Hospital bed, variable height, hi-lo, with any type side rails, with mattress Hospital bed, variable height, hi-lo, with any type side rails, without mattress Hospital bed, semi-electric (head and foot adjustment), with any type side rails, with mattress Hospital bed, semi-electric (head and foot adjustment), with any type side rails, without mattress Hospital bed, total electric (head, foot, and height adjustments), with any type side rails, with mattress Hospital bed, total electric (head, foot, and height adjustments), with any type side rails, without mattress Mattress, innerspring Mattress, foam rubber Bed pan, standard, metal or plastic Bed pan, fracture, metal or plastic Powered pressure-reducing air mattress Bed cradle, any type Hospital bed, fixed height, without side rails, with mattress Hospital bed, fixed height, without side rails, without mattress Hospital bed, variable height, hi-lo, without side rails, with mattress Hospital bed, variable height, hi-lo, without side rails, without mattress Hospital bed, semi-electric (head and foot adjustment), without side rails, with mattress Fee Nu Fee Ue Fee RR E0295 E0296 E0297 E0300 2,838.62 E0301 E0302 E0303 E0304 E0305 E0310 185.02 E0316 E0325 10.11 E0326 10.50 E0371 E0372 E0373 E0424 E0431 E0434 E0439 E0441 77.45 E0442 77.45 E0443 77.45 114.3 CMR 40.06(6) - DMEPOS Description (con’t) Hospital bed, semi-electric (head and foot adjustment), without side rails, without mattress Hospital bed, total electric (head, foot, and height adjustments), without side rails, with mattress Hospital bed, total electric (head, foot, and height adjustments), without side rails, without mattress Pediatric crib, hospital grade, fully enclosed Hospital bed, heavy duty, extra wide, with weight capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type side rails, without mattress Hospital bed, extra heavy duty, extra wide, with weight capacity greater than 600 pounds, with any type side rails, without mattress Hospital bed, heavy duty, extra wide, with weight capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type side rails, with mattress Hospital bed, extra heavy duty, extra wide, with weight capacity greater than 600 pounds, with any type side rails, with mattress Bedside rails, half-length Bedside rails, full-length Safety enclosure frame/canopy for use with hospital bed, any type Urinal; male, jug-type, any material Urinal; female, jug-type, any material Nonpowered advanced pressure reducing overlay for mattress, standard mattress length and width Powered air overlay for mattress, standard mattress length and width Nonpowered advanced pressure reducing mattress Stationary compressed gaseous oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing Portable gaseous oxygen system, rental; includes portable container, regulator, flowmeter, humidifier, cannula or mask, and tubing Portable liquid oxygen system, rental; includes portable container, supply reservoir, humidifier, flowmeter, refill adaptor, contents gauge, cannula or mask, and tubing Stationary liquid oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, & tubing Oxygen contents, gaseous (for use with owned gaseous stationary systems or when both a stationary and portable gaseous system are owned), one month's supply = 1 unit Oxygen contents, liquid (for use with owned liquid stationary systems or when both a stationary and portable liquid system are owned), one month's supply = 1 unit Portable oxygen contents, gaseous (for use only with portable gaseous systems when no stationary gas or liquid system is used), one month's supply = 1 unit Fee Nu Fee Ue Fee RR E0444 77.45 E0450 E0457 614.51 E0459 E0460 E0462 E0463 E0464 E0470 E0471 E0472 E0480 E0482 E0483 E0484 36.92 E0485 AI + 50% E0486 AI + 70% E0486 AI + 70% E0486 AI + 70% E0500 E0550 114.3 CMR 40.06(6) - DMEPOS Description (con’t) Portable oxygen contents, liquid (for use only with portable liquid systems when no stationary gas or liquid system is used), one month's supply = 1 unit Volume control ventilator, without pressure support mode, may include pressure control mode, used with invasive interface (eg, tracheostomy tube) Chest shell (cuirass) Chest wrap Negative pressure ventilator; portable or stationary Rocking bed, with or without side rails Pressure support ventilator with volume control mode, may include pressure control mode, used with invasive interface (eg, tracheostomy tube) Pressure support ventilator with volume control mode, may include pressure control mode, used with noninvasive interface (eg, mask) Respiratory assist device, bi-level pressure capability, without backup rate feature, used with noninvasive interface, eg, nasal or facial mask (intermittent assist device with continuous positive airway pressure device) Respiratory assist device, bi-level pressure capability, with back-up rate feature, used with noninvasive interface, eg, nasal or facial mask (intermittent assist device with continuous positive airway pressure device) Respiratory assist device, bi-level pressure capability, with backup rate feature, used with invasive interface, eg, tracheostomy tube (intermittent assist device with continuous positive airway pressure device) Percussor, electric or pneumatic, home model Cough stimulating device, alternating positive and negative airway pressure High frequency chest wall oscillation air-pulse generator system, (includes hoses and vest), each Oscillatory positive expiratory pressure device, nonelectric, any type, each Oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, prefabricated, includes fitting and adjustment Oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, custom fabricated, includes fitting and adjustment Oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, custom fabricated, includes fitting and adjustment Oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, custom fabricated, includes fitting and adjustment IPPB machine, all types, with built-in nebulization; manual or automatic valves; internal or external power source Humidifier, durable for extensive supplemental humidification during IPPB treatments or oxygen delivery Fee Nu Fee Ue E0560 171.52 E0561 107.00 E0562 301.22 E0565 E0570 E0571 E0572 E0574 E0575 E0580 134.04 E0585 E0600 E0601 E0602 29.52 E0605 26.43 E0606 E0607 66.82 E0610 202.18 E0615 478.82 E0617 E0617 E0618 E0619 E0620 874.39 E0621 95.99 E0627 337.32 E0628 337.32 E0629 330.71 E0630 E0635 E0636 E0650 720.22 E0651 780.66 E0652 5,301.45 Fee RR I.C. 114.3 CMR 40.06(6) - DMEPOS Description (con’t) Humidifier, durable for supplemental humidification during IPPB treatment or oxygen delivery Humidifier, nonheated, used with positive airway pressure device Humidifier, heated, used with positive airway pressure device Compressor, air power source for equipment which is not self-contained or cylinder driven Nebulizer, with compressor Aerosol compressor, battery powered, for use with small volume nebulizer Aerosol compressor, adjustable pressure, light duty for intermittent use Ultrasonic/electronic aerosol generator with small volume nebulizer Nebulizer, ultrasonic, large volume Nebulizer, durable, glass or autoclavable plastic, bottle type, for use with regulator or flowmeter Nebulizer, with compressor and heater Respiratory suction pump, home model, portable or stationary, electric Continuous airway pressure (CPAP) device Breast pump, manual, any type Vaporizer, room type Postural drainage board Home blood glucose monitor Pacemaker monitor, self-contained, (checks battery depletion, includes audible and visible check systems) Pacemaker monitor, self-contained, checks battery depletion and other pacemaker components, includes digital/visible check systems Ex ternal defibrillator with integrated electrocardiogram analysis Ex t er nal def i bri llator with integrated electrocardiogram analysis Apnea monitor, without recording feature Apnea monitor, with recording feature Skin piercing device for collection of capillary blood, laser, each Sling or seat, patient lift, canvas or nylon Seat lift mechanism incorporated into a combination lift-chair mechanism Separate seat lift mechanism for use with patient owned furniture - electric Separate seat lift mechanism for use with patient owned furniture - nonelectric Patient lift, hydraulic or mechanical, includes any seat, sling, strap(s), or pad(s) Patient lift, electric, with seat or sling Multipositional patient support system, with integrated lift, patient accessible controls Pneumatic compressor, nonsegmental home model Pneumatic compressor, segmental home model without calibrated gradient pressure Pneumatic compressor, segmental home model with calibrated gradient pressure Fee Nu Fee Ue E0655 101.75 E0660 158.24 E0665 136.99 E0666 138.08 E0667 275.20 E0668 441.88 E0669 174.06 E0671 415.35 E0672 322.73 E0673 268.17 E0675 E0691 898.59 E0692 1,128.37 E0693 1,390.98 E0694 4,427.34 E0705 54.89 E0720 367.58 E0730 370.56 E0731 303.19 E0740 522.87 E0744 E0745 E0747 3,328.66 E0748 3,890.70 E0749 E0760 3,233.10 E0762 934.63 Fee RR 114.3 CMR 40.06(6) - DMEPOS Description (con’t) Nonsegmental pneumatic appliance for use with pneumatic compressor, half arm Nonsegmental pneumatic appliance for use with pneumatic compressor, full leg Nonsegmental pneumatic appliance for use with pneumatic compressor, full arm Nonsegmental pneumatic appliance for use with pneumatic compressor, half leg Segmental pneumatic appliance for use with pneumatic compressor, full leg Segmental pneumatic appliance for use with pneumatic compressor, full arm Segmental pneumatic appliance for use with pneumatic compressor, half leg Segmental gradient pressure pneumatic appliance, full leg Segmental gradient pressure pneumatic appliance, full arm Segmental gradient pressure pneumatic appliance, half leg Pneumatic compression device, high pressure, rapid inflation/deflation cycle, for arterial insufficiency (unilateral or bilateral system) Ultraviolet light therapy system panel, includes bulbs/lamps, timer, and eye protection; treatment area 2 sq. ft. or less Ultraviolet light therapy system panel, includes bulbs/lamps, timer, and eye protection, 4 ft. panel Ultraviolet light therapy system panel, includes bulbs/lamps, timer, and eye protection, 6 ft. panel Ultraviolet multidirectional light therapy system in 6 ft. cabinet, includes bulbs/lamps, timer, and eye protection Transfer device, any type, each Transcutaneous electrical nerve stimulation (TENS) device, two lead, localized stimulation Transcutaneous electrical nerve stimulation (TENS) device, four or more leads, for multiple nerve stimulation Form-fitting conductive garment for delivery of TENS or NMES (with conductive fibers separated from the patient's skin by layers of fabric) Incontinence treatment system, pelvic floor stimulator, monitor, sensor, and/or trainer Neuromuscular stimulator for scoliosis Neuromuscular stimulator, electronic shock unit Osteogenesis stimulator, electrical, noninvasive, other than spinal applications Osteogenesis stimulator, electrical, noninvasive, spinal applications Osteogenesis stimulator, electrical, surgically implanted Osteogenesis stimulator, low intensity ultrasound, noninvasive Transcutaneous electrical joint stimulation device system, includes all accessories Fee Nu Fee Ue E0764 11,066.82 E0765 84.13 E0776 143.16 E0779 E0780 10.37 E0781 E0782 3,649.40 E0783 8,186.91 E0784 E0785 472.50 E0786 7,697.60 E0791 E0840 73.28 E0849 515.31 E0850 105.06 E0855 502.63 E0856 I.C. I.C. E0860 38.53 E0870 116.31 E0880 125.54 E0890 120.41 E0900 128.12 E0910 E0911 E0912 E0920 E0930 Fee RR I.C. 114.3 CMR 40.06(6) - DMEPOS Description (con’t) Functional neuromuscular stimulator, transcutaneous stimulation of muscles of ambulation with computer control, used for walking by spinal cord injured, entire system, after completion of training program FDA approved nerve stimulator, with replaceable batteries, for treatment of nausea and vomiting IV pole Ambulatory infusion pump, mechanical, reusable, for infusion eight hours or greater Ambulatory infusion pump, mechanical, reusable, for infusion less than eight hours Ambulatory infusion pump, single or multiple channels, electric or battery operated, with administrative equipment, worn by patient Infusion pump, implantable, non-programmable (includes all components, eg, pump, catheter, connectors, etc.) Infusion pump system, implantable, programmable (includes all components, eg, pump, catheter, connectors, etc.) External ambulatory infusion pump, insulin Implantable intraspinal (epidural/intrathecal) catheter used with implantable infusion pump, replacement Implantable programmable infusion pump, replacement (excludes implantable intraspinal catheter) Parenteral infusion pump, stationary, single, or multi-channel Traction frame, attached to headboard, cervical traction Traction equipment, cervical, free-standing stand/frame, pneumatic, applying traction force to other than mandible Traction stand, freestanding, cervical traction Cervical traction equipment not requiring additional stand or frame Cervical traction device, cervical collar with inflatable air bladder Traction equipment, overdoor, cervical Traction frame, attached to footboard, extremity traction (eg, Buck's) Traction stand, freestanding, extremity traction (eg, Buck's) Traction frame, attached to footboard, pelvic traction Traction stand, freestanding, pelvic traction (eg, Buck's) Trapeze bars, also known as Patient Helper, attached to bed, with grab bar Trapeze bar, heavy duty, for patient weight capacity greater than 250 pounds, attached to bed, with grab bar Trapeze bar, heavy duty, for patient weight capacity greater than 250 pounds, free standing, complete with grab bar Fracture frame, attached to bed, includes weights Fracture frame, freestanding, includes weights Fee Nu Fee Ue E0935 E0940 E0941 E0942 19.85 E0944 45.88 E0945 44.32 E0946 E0947 606.46 E0948 586.59 E0950 88.36 E0951 17.08 E0952 16.89 E0955 202.18 E0956 98.58 E0957 137.93 E0958 E0959 44.21 E0960 90.98 E0961 29.74 E0966 71.37 E0967 65.69 E0968 E0969 156.63 E0971 43.39 E0973 114.97 E0974 74.07 E0978 42.70 E0980 33.06 E0981 47.15 E0982 51.53 E0983 E0984 1,760.94 E0985 202.85 E0986 4,864.24 Fee RR 114.3 CMR 40.06(6) - DMEPOS Description (con’t) Continuous passive motion exercise device for use on knee only Trapeze bar, freestanding, complete with grab bar Gravity assisted traction device, any type Cervical head harness/halter Pelvic belt/harness/boot Extremity belt/harness Fracture frame, dual with cross bars, attached to bed (eg, Balken, Four Poster) Fracture frame, attachments for complex pelvic traction Fracture frame, attachments for complex cervical traction Wheelchair accessory, tray, each Heel loop/holder, any type, with or without ankle strap, each Toe loop/holder, any type, each Wheelchair accessory, headrest, cushioned, any type, including fixed mounting hardware, each Wheelchair accessory, lateral trunk or hip support, any type, including fixed mounting hardware, each Wheelchair accessory, medial thigh support, any type, including fixed mounting hardware, each Manual wheelchair accessory, one-arm drive attachment, each Manual wheelchair accessory, adapter for amputee, each Wheelchair accessory, shoulder harness/straps or chest strap, including any type mounting hardware Manual wheelchair accessory, wheel lock brake extension (handle), each Manual wheelchair accessory, headrest extension, each Manual wheelchair accessory, hand rim with projections, any type, each Commode seat, wheelchair Narrowing device, wheelchair Manual wheelchair accessory, anti-tipping device, each Wheelchair accessory, adjustable height, detachable armrest, complete assembly, each Manual wheelchair accessory, anti-rollback device, each Wheelchair accessory, positioning belt/safety belt/pelvic strap, each Safety vest, wheelchair Wheelchair accessory, seat upholstery, replacement only, each Wheelchair accessory, back upholstery, replacement only, each Manual wheelchair accessory, power add-on to convert manual wheelchair to motorized wheelchair, joystick control Manual wheelchair accessory, power add-on to convert manual wheelchair to motorized wheelchair, tiller control Wheelchair accessory, seat lift mechanism Manual wheelchair accessory, push activated power assist, each Fee Nu Fee Ue E0990 117.43 E0992 95.15 E0994 17.63 E0995 25.84 E1002 4,053.21 E1003 4,391.30 E1004 4,869.05 E1005 5,270.36 E1006 6,455.70 E1007 8,741.27 E1008 8,742.05 E1009 AI + 35% I.C. E1010 1,143.79 E1011 I.C. I.C. E1014 365.14 E1015 114.70 E1016 131.31 E1017 AI + 35% I.C. E1018 AI + 35% I.C. E1020 243.41 E1028 206.54 E1029 369.54 E1030 1,165.27 E1031 E1035 E1037 E1038 E1039 E1050 E1060 Fee RR I.C. I.C. I.C. I.C. 114.3 CMR 40.06(6) - DMEPOS Description (con’t) Wheelchair accessory, elevating leg rest, complete assembly, each Manual wheelchair accessory, solid seat insert Armrest, each Wheelchair accessory, calf rest/pad, each Wheelchair accessory, power seating system, tilt only Wheelchair accessory, power seating system, recline only, without shear reduction Wheelchair accessory, power seating system, recline only, with mechanical shear reduction Wheelchair accessory, power seatng System, recline only, with power shear reduction Wheelchair accessory, power seating system, combination tilt and recline, without shear reduction Wheelchair accessory, power seating system, combination tilt and recline, with mechanical shear reduction Wheelchair accessory, power seating system, combination tilt and recline, with power shear reduction Wheelchair accessory, addition to power seating system, mechanically linked leg elevation system, including pushrod and leg rest, each Wheelchair accessory, addition to power seating system, power leg elevation system, including leg rest, pair Modification to pediatric size wheelchair, width adjustment package (not to be dispensed with initial chair) Reclining back, addition to pediatric size wheelchair Shock absorber for manual wheelchair, each Shock absorber for power wheelchair, each Heavy duty shock absorber for heavy duty or extra heavy duty manual wheelchair, each Heavy duty shock absorber for heavy duty or extra heavy duty power wheelchair, each Residual limb support system for wheelchair Wheelchair accessory, manual swingaway, retractable or removable mounting hardware for joystick, other control interface or positioning accessory Wheelchair accessory, ventilator tray, fixed Wheelchair accessory, ventilator tray, gimbaled Rollabout chair, any and all types with castors five in. or greater Multi-positional patient transfer system, with integrated seat, operated by care giver Transport chair, pediatric size Transport chair, adult size, patient weight capacity up to and including 300 pounds Transport chair, adult size, heavy duty, patient weight capacity greater than 300 pounds Fully reclining wheelchair; fixed full-length arms, swing-away, detachable, elevating legrests Fully reclining wheelchair; detachable arms, desk, or full-length, swing-away, detachable, elevating leg rests Fee Nu Fee Ue Fee RR 114.3 CMR 40.06(6) - DMEPOS Description (con’t) E1070 Fully reclining wheelchair; detachable arms, desk or full-length, swing-away, detachable footrests E1083 Hemi-wheelchair; fixed full-length arms, swing-away, detachable, elevating legrests E1084 Hemi-wheelchair; detachable arms, desk, or full-length, swing-away, detachable, elevating leg rests E1087 High-strength lightweight wheelchair; fixed full-length arms, swing-away, detachable, elevating legrests E1088 High strength lightweight wheelchair, detachable arms desk or full length, swing away detachable elevating leg rests E1092 Wide heavy duty wheel chair, detachable arms (desk or full length), swing away detachable elevating leg rests E1093 Wide, heavy-duty wheelchair; detachable arms, desk or full-length arms, swing-away, detachable footrests E1100 Semi-reclining wheelchair, fixed full-length arms, swing away detachable elevating leg rests E1110 Semi-reclining wheelchair; detachable arms, desk or full-length, elevating legrest E1150 Wheelchair, detachable arms, desk or full-length swing away detachable elevating leg rests E1160 Wheelchair, fixed full-length arms, swing away detachable elevating leg rests E1161 2,366.09 Manual adult size wheelchair, includes tilt in space E1170 Amputee wheelchair, fixed full-length arms, swing away detachable elevating leg rests E1171 Amputee wheelchair, fixed full-length arms, without footrests or leg rest E1172 Amputee wheelchair, detachable arms (desk or full-length) without footrests or leg rest E1180 Amputee wheelchair, detachable arms (desk or full-length) swing away detachable foot rests E1190 Amputee wheelchair, detachable arms (desk or full-length) swing away detachable elevating leg rests E1195 Heavy duty wheelchair, fixed full-length arms, swing away detachable elevating leg rests E1200 Amputee wheelchair, fixed full-length arms, swing away detachable footrest E1221 Wheelchair with fixed arm, footrests E1222 Wheelchair with fixed arm, elevating leg rests E1223 Wheelchair with detachable arms, footrests E1224 Wheelchair with detachable arms, elevating leg rests E1225 Wheelchair accessory, manual semi-reclining back, (recline greater than 15 degrees, but less than 80 degrees), each E1226 463.80 Wheelchair accessory, manual fully reclining back, (recline greater than 80 degrees), each E1227 235.88 Special height arms for wheelchair E1228 Special back height for wheelchair E1230 2,261.79 Power operated vehicle (three­ or four-wheel nonhighway), specify brand name and model number E1240 Lightweight wheelchair, detachable arms, (desk or full length) swing away detachable, elevating leg rest Fee Nu Fee Ue E1270 E1280 E1295 E1296 491.67 E1297 88.92 E1298 360.10 E1310 1,825.29 E1353 32.87 E1355 24.75 E1372 163.03 E1390 E1391 E1392 E1405 E1406 E1700 312.39 E1701 10.37 E1702 22.57 E1800 E1801 E1802 E1805 E1806 E1810 E1811 E1812 E1815 E1816 Fee RR 114.3 CMR 40.06(6) - DMEPOS Description (con’t) Lightweight wheelchair, fixed full length arms, swing away detachable elevating leg rests Heavy duty wheelchair, detachable arms (desk or full length) elevating leg rests Heavy duty wheelchair, fixed full length arms, elevating leg rest Special wheelchair seat height from floor Special wheelchair seat depth, by upholstery Special wheelchair seat depth and/or width, by construction Whirlpool, nonportable (built-in type) Regulator Stand/rack Immersion external heater for nebulizer Oxygen concentrator, single delivery port, capable of delivering 85% or greater oxygen concentration at the prescribed flow rate Oxygen concentrator, dual delivery port, capable of delivering 85% or greater oxygen concentration at the prescribed flow rate, each Portable oxygen concentrator, rental Oxygen and water vapor enriching system with heated delivery Oxygen and water vapor enriching system without heated delivery Jaw motion rehabilitation system Replacement cushions for jaw motion rehabilitation system, package of six Replacement measuring scales for jaw motion rehabilitation system, package of 200 Dynamic adjustable elbow extension/flexion device, includes soft interface material Static progressive stretch elbow device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories Dynamic adjustable forearm pronation/supination device, includes soft interface material Dynamic adjustable wrist extension/flexion device, includes soft interface material Static progressive stretch wrist device, flexion and/or extension, with or without range of motion adjustment, includes all components and accessories Dynamic adjustable knee extension/flexion device, includes soft interface material Static progressive stretch knee device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories Dynamic knee, extension/flexion device with active resistance control Dynamic adjustable ankle extension/flexion device, includes soft interface material Static progressive stretch ankle device, flexion and/or extension, with or without range of motion adjustment, includes all components and accessories Fee Nu Fee Ue E1818 E1820 81.74 E1821 105.25 E1825 E1830 E1840 E1841 E2000 E2100 643.19 E2101 188.56 E2120 E2201 373.10 E2202 473.98 E2203 479.05 E2204 813.40 E2205 32.67 E2206 40.68 E2207 43.35 E2208 118.78 E2209 107.16 E2210 6.55 E2211 40.91 E2212 5.88 E2213 30.41 E2214 36.00 E2215 9.60 Fee RR 114.3 CMR 40.06(6) - DMEPOS Description (con’t) S t a t i c p r o g r e s s i v e s t r e t c h f o r e a r m pronation/supination device, with or without range of motion adjustment, includes all components and accessories Replacement soft interface material, dynamic adjustable extension/flexion device Replacement soft interface material/cuffs for bi-directional static progressive stretch device Dynamic adjustable finger extension/flexion device, includes soft interface material Dynamic adjustable toe extension/flexion device, includes soft interface material Dynamic adjustable shoulder flexion/abduction/ rotation device, includes soft interface material Static progressive stretch shoulder device, with or without range of motion adjustment, includes all components and accessories Gastric suction pump, home model, portable or stationary, electric Blood glucose monitor with integrated voice synthesizer Blood glucose monitor with integrated lancing/blood sample Pulse generator system for tympanic treatment of inner ear endolymphatic fluid Manual wheelchair accessory, nonstandard seat frame, width greater than or equal to 20 inches and less than 24 inches Manual wheelchair accessory, nonstandard seat frame width, 24-27 in. Manual wheelchair accessory, nonstandard seat frame depth, 20 to less than 22 inches Manual wheelchair accessory, nonstandard seat frame depth, 22 to 25 inches Manual wheelchair accessory, handrim without projections (includes ergonomic or contoured), any type, replacement only, each Manual wheelchair accessory, wheel Lock assembly, complete, each Wheelchair accessory, crutch and cane holder, each Wheelchair accessory, cylinder tank carrier, each Accessory, arm trough, with or without hand support, each Wheelchair accessory, bearings, any type, replacement only, each Manual wheelchair accessory, pneumatic propulsion tire, any size, each Manual wheelchair accessory, tube for pneumatic propulsion tire, any size, each Manual wheelchair accessory, insert for pneumatic propulsion tire (removable), any type, any size, each Manual wheelchair accessory, pneumatic caster tire, any size, each Manual wheelchair accessory, tube for pneumatic caster tire, any size, each Fee Nu Fee Ue E2216 AI + 30% I.C. E2217 AI + 30% I.C. E2218 AI + 30% I.C. E2219 40.31 E2220 28.52 E2221 25.55 E2222 21.06 E2223 5.61 E2224 98.06 E2225 17.40 E2226 37.94 E2227 AI + 35% I.C. E2228 AI + 35% I.C. E2310 1,170.24 E2311 2,369.20 E2312 2,473.18 E2312 1,939.18 E2313 307.93 E2321 2,231.00 E2322 1,410.36 E2323 69.16 Fee RR I.C. I.C. I.C. I.C. I.C. 114.3 CMR 40.06(6) - DMEPOS Description (con’t) Manual wheelchair accessory, foam filled propulsion tire, any size, each Manual wheelchair accessory, foam filled caster tire, any size, each Manual wheelchair accessory, foam propulsion tire, any size, each Manual wheelchair accessory, foam caster tire, any size, each Manual wheelchair accessory, solid (rubber/plastic) propulsion tire, any size, each Manual wheelchair accessory, solid (rubber/plastic) caster tire (removable), any size, each Manual wheelchair accessory, solid (rubber/plastic) caster tire with integrated wheel, any size, each Manual wheelchair accessory, valve, any type, replacement only, each Manual wheelchair accessory, propulsion wheel excludes tire, any size, each Manual wheelchair accessory, caster wheel excludes tire, any size, replacement only, each Manual wheelchair accessory, caster fork, any size, replacement only, each Manual wheelchair accessory, gear reduction drive wheel, each Manual wheelchair accessory, wheel braking system and lock, complete, each Power wheelchair accessory, electronic connection between wheelchair controller and one power seating system motor, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware Power wheelchair accessory, electronic connection between wheelchair controller and two or more power seating system motors, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware Power wheelchair accessory, hand or chin control interface, mini-proportional remote joystick, proportional, including fixed mounting hardware Power wheelchair accessory, hand or chin control interface, mini-proportional remote joystick, proportional, including fixed mounting hardware Power wheelchair accessory, harness for upgrade to expandable controller, including all fasteners, connectors and mounting hardware, each Power wheelchair accessory, hand control interface, remote joystick, nonproportional, including all related electronics, mechanical stop switch, and fixed mounting hardware Power wheelchair accessory, hand control interface, multiple mechanical switches, nonproportional, including all related electronics, mechanical stop switch, and fixed mounting hardware Power wheelchair accessory, specialty joystick handle for hand control interface, prefabricated Fee Nu Fee Ue E2323 69.16 E2323 69.16 E2324 43.82 E2324 43.82 E2324 43.82 E2325 1,346.83 E2325 1,346.83 E2325 1,346.83 E2326 347.14 E2326 347.14 E2326 347.14 E2327 3,420.77 E2328 4,955.32 E2329 1,766.13 E2330 3,422.09 E2340 358.36 E2341 537.58 E2342 447.98 E2343 716.78 Fee RR 114.3 CMR 40.06(6) - DMEPOS Description (con’t) Power wheelchair accessory, specialty joystick handle for hand control interface, prefabricated Power wheelchair accessory, specialty joystick handle for hand control interface, prefabricated Power wheelchair accessory, chin cup for chin control interface Power wheelchair accessory, chin cup for chin control interface Power wheelchair accessory, chin cup for chin control interface Power wheelchair accessory, sip and puff interface, nonproportional, including all related electronics, mechanical stop switch, and manual swingaway mounting hardware Power wheelchair accessory, sip and puff interface, nonproportional, including all related electronics, mechanical stop switch, and manual swingaway mounting hardware Power wheelchair accessory, sip and puff interface, nonproportional, including all related electronics, mechanical stop switch, and manual swingaway mounting hardware Power wheelchair accessory, breath tube kit for sip and puff interface Power wheelchair accessory, breath tube kit for sip and puff interface Power wheelchair accessory, breath tube kit for sip and puff interface Power wheelchair accessory, head control interface, mechanical, proportional, including all related electronics, mechanical direction change switch, and fixed mounting hardware Power wheelchair accessory, head control or extremity control interface, electronic, proportional, including all related electronics and fixed mounting hardware Power wheelchair accessory, head control interface, contact switch mechanism, nonproportional, including all related electronics, mechanical stop switch, mechanical direction change switch, head array, and fixed mounting hardware Power wheelchair accessory, head control interface, proximity switch mechanism, nonproportional, including all related electronics, mechanical stop switch, mechanical direction change switch, head array, and fixed mounting hardware Power wheelchair accessory, nonstandard seat frame width, 20-23 in. Power wheelchair accessory, nonstandard seat frame width, 24-27 in. Power wheelchair accessory, nonstandard seat frame depth, 20 or 21 in. Power wheelchair accessory, nonstandard seat frame depth, 22-25 in. Fee Nu Fee Ue E2351 698.63 E2360 112.34 E2361 139.47 E2362 91.98 E2363 186.00 E2364 112.34 E2365 112.17 E2366 263.62 E2367 419.08 E2368 516.57 E2369 449.94 E2370 802.84 E2371 150.74 E2372 AI + 35% I.C. E2373 1,209.93 E2374 534.02 E2375 856.56 E2376 1,342.27 E2377 485.71 E2381 76.18 E2382 20.77 E2383 151.88 E2384 80.91 Fee RR I.C. 114.3 CMR 40.06(6) - DMEPOS Description (con’t) Power wheelchair accessory, electronic interface to operate speech generating device using power wheelchair control interface Power wheelchair accessory, 22 NF nonsealed lead acid battery, each Power wheelchair accessory, 22 NF sealed lead acid battery, each, (e.g., gel cell, absorbed glassmat) Power wheelchair accessory, group 24 nonsealed lead acid battery, each Power wheelchair accessory, group 24 sealed lead acid battery, each (e.g., gel cell, absorbed glassmat) Power wheelchair accessory, U-1 nonsealed lead acid battery, each Power wheelchair accessory, U-1 sealed lead acid battery, each (e.g., gel cell, absorbed glassmat) Power wheelchair accessory, battery charger, single mode, for use with only one battery type, sealed or non-sealed, each Power wheelchair accessory, battery charger, dual mode, for use with either battery type, sealed or nonsealed, each Power wheelchair component, motor, replacement only Power wheelchair component, gear box, replacement only Power wheelchair component, motor and gear box combination, replacement only Power wheelchair accessory, group 27 sealed lead acid battery, (e.g., gel cell, absorbed glassmat), each Power wheelchair accessory, group 27 nonsealed lead acid battery, each Power wheelchair accessory, hand or chin control interface, compact remote joystick, proportional, including fixed mounting hardware Power wheelchair accessory, hand or chin control interface, standard remote joystick (not including controller), proportional, including all related electronics and fixed mounting hardware, replacement only Power wheelchair accessory, nonexpandable controller, including all related electronics and mounting hardware, replacement only Power wheelchair accessory, expandable controller, including all related electronics and mounting hardware, replacement only Power wheelchair accessory, expandable controller, including all related electronics and mounting hardware, upgrade provided at initial issue Power wheelchair accessory, pneumatic drive wheel tire, any size, replacement only, each Power wheelchair accessory, tube for pneumatic drive wheel tire, any size, replacement only, each Power wheelchair accessory, insert for pneumatic drive wheel tire (removable), any type, any size, replacement only, each Power wheelchair accessory, pneumatic caster tire, any size, replacement only, each Fee Nu Fee Ue E2385 49.50 E2386 150.51 E2387 67.49 E2388 50.39 E2389 27.36 E2390 42.79 E2391 20.50 E2392 53.88 E2393 AI + 35% I.C E2394 76.75 E2395 54.55 E2396 64.07 E2397 AI + 35% I.C E2402 E2500 391.06 E2502 1,195.80 E2504 1,577.42 E2506 2,312.96 E2508 3,576.61 E2510 6,768.25 E2511 AI + 30% I.C E2512 AI + 30% I.C E2601 61.16 E2602 119.40 Fee RR I.C I.C I.C I.C 114.3 CMR 40.06(6) - DMEPOS Description (con’t) Power wheelchair accessory, tube for pneumatic caster tire, any size, replacement only, each Power wheelchair accessory, foam filled drive wheel tire, any size, replacement only, each Power wheelchair accessory, foam filled caster tire, any size, replacement only, each Power wheelchair accessory, foam drive wheel tire, any size, replacement only, each Power wheelchair accessory, foam caster tire, any size, replacement only, each Power wheelchair accessory, solid (rubber/plastic) drive wheel tire, any size, replacement only, each Power wheelchair accessory, solid (rubber/plastic) caster tire (removable), any size, replacement only, each Power wheelchair accessory, solid (rubber/plastic) caster tire with integrated wheel, any size, replacement only, each Power wheelchair accessory, valve for pneumatic tire tube, any type, replacement only, each Power wheelchair accessory, drive wheel excludes tire, any size, replacement only, each Power wheelchair accessory, caster wheel excludes tire, any size, replacement only, each Power wheelchair accessory, caster fork, any size, replacement only, each Power wheelchair accessory, lithium-based battery, each Negative pressure wound therapy electrical pump, stationary or portable Speech generating device, digitized speech, using pre-recorded messages, less than or equal to eight minutes recording time Speech generating device, digitized speech, using prerecorded messages, greater than eight minutes but less than or equal to 20 minutes recording time Speech generating device, digitized speech, using prerecorded messages, greater than 20 minutes but less than or equal to 40 minutes recording time Speech generating device, digitized speech, using prerecorded messages, greater than 40 minutes recording time Speech generating device, synthesized speech, requiring message formulation by spelling and access by physical contact with the device Speech generating device, synthesized speech, permitting multiple methods of message formulation and multiple methods of device access Speech generating software program, for personal computer or personal digital assistant Accessory for speech generating device, mounting system General use wheelchair seat cushion, width less than 22 in., any depth General use wheelchair seat cushion, width 22 in. or greater, any depth Fee Nu Fee Ue E2603 151.59 E2604 188.41 E2605 269.17 E2606 419.93 E2607 289.85 E2608 348.09 E2611 312.35 E2612 422.54 E2613 393.04 E2614 543.93 E2615 452.32 E2616 608.58 E2619 51.32 E2620 547.70 E2621 574.76 Fee RR 114.3 CMR 40.06(6) - DMEPOS Description (con’t) Skin protection wheelchair seat cushion, width less than 22 in., any depth Skin protection wheelchair seat cushion, width 22 in. or greater, any depth Positioning wheelchair seat cushion, width less than 22 in., any depth Positioning wheelchair seat cushion, width 22 in. or greater, any depth Skin protection and positioning wheelchair seat cushion, width less than 22 in., any depth Skin protection and positioning wheelchair seat cushion, width 22 in. or greater, any depth General use wheelchair back cushion, width less than 22 in., any height, including any type mounting hardware General use wheelchair back cushion, width 22 in. or greater, any height, including any type mounting hardware Positioning wheelchair back cushion, posterior, width less than 22 in., any height, including any type mounting hardware Positioning wheelchair back cushion, posterior, width 22 in. or greater, any height, including any type mounting hardware Positioning wheelchair back cushion, posterior-lateral, width less than 22 in., any height, including any type mounting hardware Positioning wheelchair back cushion, posterior-lateral, width 22 in. or greater, any height, including any type mounting hardware Replacement cover for wheelchair seat cushion or back cushion, each Positioning wheelchair back cushion, planar back with lateral supports, width less than 22 in., any height, including any type mounting hardware Positioning wheelchair back cushion, planar back with lateral supports, width 22 in. or greater, any height, including any type mounting hardware Cranial cervical orthosis, congenital torticollis type, with or without soft interface material, adjustable range of motion joint, custom fabricated Cervical, flexible, nonadjustable (foam collar) Cervical, flexible, thermoplastic collar, molded to patient Cervical, semi-rigid, adjustable (plastic collar) Cervical, semi-rigid, adjustable molded chin cup (plastic collar with mandibular/occipital piece) Cervical, semi-rigid, wire frame occipital/mandibular support Cervical, collar, molded to patient model Cervical, collar, semi-rigid thermoplastic foam, two piece Cervical, collar, semi-rigid, thermoplastic foam, two piece with thoracic extension Cervical, multiple post collar, occipital/mandibular supports, adjustable Fee Nu Fee Ue Fee RR L0452 AI + 70%. 114.3 CMR 40.06(6) - DMEPOS Description (con’t) Cervical, multiple post collar, occipital/mandibular supports, adjustable cervical bars (SOMI, Guilford, Taylor types) Cervical, multiple post collar, occipital/mandibular supports, adjustable cervical bars, and thoracic extension Thoracic, rib belt Thoracic, rib belt, custom fabricated Spinal orthosis, anterior-posterior-lateral control, with interface material, custom fitted (DeWall Posture Protector only) TLSO, flexible, provides trunk support, upper thoracic region, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and closures, prefabricated, includes fitting and adjustment TLSO, flexible, provides trunk support, upper thoracic region, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and closures, custom fabricated TLSO flexible, provides trunk support, extends from sacrococcygeal junction to above T-9 vertebra, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder TLSO, flexible, provides trunk support, thoracic region, rigid posterior panel and soft anterior apron, extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, restricts gross trunk motion in the sagittal plane, produces intracavitary TLSO, triplanar control, modular segmented spinal system, two rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner restricts gross trunk motion in the sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment TLSO, triplanar control, modular segmented spinal system, two rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in the sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment Fee Nu Fee Ue Fee RR 114.3 CMR 40.06(6) - DMEPOS Description (con’t) TLSO, triplanar control, modular segmented spinal system, three rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in the sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment TLSO, triplanar control, modular segmented spinal system, four rigid plastic shells, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in the sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment TLSO, sagittal control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, restricts gross trunk motion in sagittal plane, produces intracavitary pressure to reduce load on intervertebral disks, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment TLSO, sagittal-coronal control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, extends from sacrococcygeal junction over scapulae, lateral strength provided by pelvic, thoracic, and lateral frame pieces, restricts gross trunk motion in sagittal, and coronal planes, produces intracavitary pressure to reduce load on intravertebral disks, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment TLSO, triplanar control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, extends from sacrococcygeal junction to scapula, lateral strength provided by pelvic, thoracic, and lateral frame pieces, rotational strength provided by subclavicular extensions, restricts gross trunk motion in the sagittal, coronal, and transverse planes, produces intracavitary pressure to reduce load on intravertebral disks, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment TLSO, triplanar control, hyperextension, rigid anterior and lateral frame extends from symphysis pubis to sternal notch with two anterior components (one pubic and one sternal), posterior and lateral pads with straps and closures, limits spinal flexion, restricts gross trunk motion in the sagittal, coronal, and transverse planes, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment Fee Nu Fee Ue Fee RR 114.3 CMR 40.06(6) - DMEPOS Description (con’t) TLSO, triplanar control, one piece rigid plastic shell without interface liner, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in the sagittal, coronal, and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated TLSO, triplanar control, one piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in the sagittal, coronal, and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated TLSO, triplanar control, two piece rigid plastic shell without interface liner, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, lateral strength is enhanced by overlapping plastic, restricts gross trunk motion in the sagittal, coronal, and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated TLSO, triplanar control, two piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, lateral strength is enhanced by overlapping plastic, restricts gross trunk motion in the sagittal, coronal, and transverse planes, includes a carved plaster or CAD­ CAM model, custom fabricated TLSO, triplanar control, one piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal, and transverse planes, prefabricated, includes fitting and adjustment TLSO, sagittal-coronal control, one piece rigid plastic shell, with overlapping reinforced anterior, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates at or before the T-9 vertebra, anterior extends from symphysis pubis to xiphoid, anterior opening, restricts gross trunk motion in sagittal and coronal planes, prefabricated, includes fitting and adjustment Fee Nu Fee Ue Fee RR L0623 AI + 50%. L0624 AI + 70% 114.3 CMR 40.06(6) - DMEPOS Description (con’t) TLSO, sagittal-coronal control, modular segmented spinal System, two rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal and coronal planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment TLSO, sagittal-coronal control, modular segmented spinal system, three rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal and coronal planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment Sacroiliac orthosis, flexible, provides pelvic-sacral support, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, prefabricated, includes fitting and adjustment Sacroiliac orthosis, flexible, provides pelvic-sacral support, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, custom fabricated Sacroiliac orthosis, provides pelvic-sacral support, with rigid or semi-rigid panels over the sacrum and abdomen, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, prefabricated, includes fitting and adjustment Sacroiliac orthosis, provides pelvic-sacral support, with rigid or semi-rigid panels placed over the sacrum and abdomen, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, custom fabricated Lumbar orthosis, flexible, provides lumbar support, posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include pendulous abdomen design, shoulder straps, stays, prefabricated, includes fitting and adjustment Lumbar orthosis, sagittal control, with rigid posterior panel(s), posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder Fee Nu Fee Ue Fee RR L0629 AI + 70% L0632 AI + 70%. L0634 AI + 70%. 114.3 CMR 40.06(6) - DMEPOS Description (con’t) Lumbar orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from L-1 to below L-5 vertebra, produces intracavitarypressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment Lumbar-sacral orthosis, flexible, provides lumbo­ sacral support, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include stays, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment Lumbar-sacral orthosis, flexible, provides lumbo­ sacral support, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include stays, shoulder straps, pendulous abdomen design, custom fabricated Lumbar-sacral orthosis, sagittal control, with rigid posterior panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment Lumbar-sacral orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment LSO, sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, custom fabricated LSO, sagittal-coronal control, with rigid posterior frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment LSO, sagittal-coronal control, with rigid posterior frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, custom fabricated Fee Nu Fee Ue Fee RR 114.3 CMR 40.06(6) - DMEPOS Description (con’t) LSO, sagittal-coronal control, lumbar flexion, rigid posterior frame/panel(s), lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, anterior panel, pendulous abdomen design, prefabricated, includes fitting and adjustment LSO, sagittal-coronal control, lumbar flexion, rigid posterior frame/panels, lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, anterior panel, pendulous abdomen design, custom fabricated LSO, sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment LSO, sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, custom fabricated LSO, sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xyphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength is provided by overlapping rigid material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, prefabricated, includes fitting and adjustment LSO, sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xyphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength is provided by overlapping rigid material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, custom fabricated CTLSO, anterior-posterior-lateral control, molded to patient model (Minerva type) CTLSO, anterior-posterior-lateral control, molded to patient model, with interface material (Minerva type) Halo procedure, cervical halo incorporated into jacket vest Fee Nu Fee Ue Fee RR 114.3 CMR 40.06(6) - DMEPOS Description (con’t) Halo procedure, cervical halo incorporated into plaster body jacket Halo procedure, cervical halo incorporated into Milwaukee type orthosis Addition to halo procedure, magnetic resonance image compatible systems, rings and pins, any material Addition to halo procedure, replacement liner/interface material TLSO, corset front LSO, corset front TLSO, full corset LSO, full corset Axillary crutch extension Peroneal straps, pair Stocking supporter grips, set of four Protective body sock, each CTLSO (Milwaukee), inclusive of furnishing initial orthosis, including model Tension based scoliosis orthosis and accessory pads, includes fitting and adjustment Addition to CTLSO or scoliosis orthosis, axilla sling Addition to CTLSO or scoliosis orthosis, kyphosis pad Addition to CTLSO or scoliosis orthosis, kyphosis pad, floating Addition to CTLSO or scoliosis orthosis, lumbar bolster pad Addition to CTLSO or scoliosis orthosis, lumbar or lumbar rib pad Addition to CTLSO or scoliosis orthosis, sternal pad Addition to CTLSO or scoliosis orthosis, thoracic pad Addition to CTLSO or scoliosis orthosis, trapezius sling Addition to CTLSO or scoliosis orthosis, outrigger Addition to CTLSO or scoliosis orthosis, outrigger, bilateral with vertical extensions Addition to CTLSO or scoliosis orthosis, lumbar sling Addition to CTLSO or scoliosis orthosis, ring flange, plastic or leather Addition to CTLSO or scoliosis orthosis, ring flange, plastic or leather, molded to patient model Addition to CTLSO, scoliosis orthosis, cover for upright, each TLSO, inclusive of furnishing initial orthosis only Addition to TLSO, (low profile), lateral thoracic extension Addition to TLSO, (low profile), anterior thoracic extension Addition to TLSO, (low profile), Milwaukee type superstructure Addition to TLSO, (low profile), lumbar derotation pad Addition to TLSO, (low profile), anterior ASIS pad Addition to TLSO, (low profile), anterior thoracic derotation pad Addition to TLSO, (low profile), abdominal pad Addition to TLSO, (low profile), rib gusset (elastic), each Fee Nu Fee Ue Fee RR 114.3 CMR 40.06(6) - DMEPOS Description (con’t) Addition to TLSO, (low profile), lateral trochanteric pad Other scoliosis procedure, body jacket molded to patient model Other scoliosis procedure, postoperative body jacket THKAO, mobility frame (Newington, Parapodium types) THKAO, standing frame, with or without tray and accessories THKAO, swivel walker HO, abduction control of hip joints, flexible, Frejka type with cover, prefabricated, includes fitting and adjustment HO, abduction control of hip joints, flexible, (Frejka cover only), prefabricated, includes fitting and adjustment HO, abduction control of hip joints, flexible, (Pavlik harness), prefabricated, includes fitting and adjustment HO, abduction control of hip joints, semi-flexible (Von Rosen type), custom fabricated HO, abduction control of hip joints, static, pelvic band or spreader bar, thigh cuffs, custom fabricated HO, abduction control of hip joints, static, adjustable (Ilfled type), prefabricated, includes fitting and adjustment Hip orthosis, bilateral thigh cuffs with adjustable abductor spreader bar, adult size, prefabricated, includes fitting and adjustment, any type HO, abduction control of hip joints, static, plastic, prefabricated, includes fitting and adjustment HO, abduction control of hip joints, dynamic, pelvic control, adjustable hip motion control, thigh cuffs (Rancho hip action type), custom fabricated HO, abduction control of hip joint, postoperative hip abduction type, custom fabricated HO, abduction control of hip joint, postoperative hip abduction type, prefabricated, includes fitting and adjustments Combination, bilateral, lumbo-sacral, hip, femur orthosis providing adduction and internal rotation control, prefabricated, includes fitting and adjustment Legg Perthes orthosis, (Toronto type), custom fabricated Legg Perthes orthosis, (Newington type), custom fabricated Legg Perthes orthosis, trilateral, (Tachdijan type), custom fabricated Legg Perthes orthosis, (Scottish Rite type), custom fabricated Legg Perthes orthosis, (Patten bottom type), custom fabricated KO, elastic with stays, prefabricated, includes fitting and adjustment KO, elastic with joints, prefabricated, includes fitting and adjustment Fee Nu Fee Ue Fee RR 114.3 CMR 40.06(6) - DMEPOS Description (con’t) KO, elastic or other elastic type material with condylar pad(s), prefabricated, includes fitting and adjustment Knee orthosis, elastic with condylar pads and joints, with or without patellar control, prefabricated, includes fitting and adjustment KO, elastic knee cap, prefabricated, includes fitting and adjustment KO, immobilizer, canvas longitudinal, prefabricated, includes fitting and adjustment Knee orthosis, locking knee joint(s), positional orthosis, prefabricated, includes fitting and adjustment Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, includes fitting and adjustment KO, without knee joint, rigid, custom fabricated Knee orthosis, rigid, without joint(s), includes soft interface material, prefabricated, includes fitting and adjustment KO, derotation, medial-lateral, anterior cruciate ligament, custom fabricated Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, includes fitting and adjustment Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated Knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, includes fitting and adjustment Knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated KO, double upright with adjustable joint, with inflatable air support chamber(s), prefabricated, includes fitting and adjustment KO, Swedish type, prefabricated, includes fitting and adjustment KO, modification of supracondylar prosthetic socket, custom fabricated (SK) AFO, spring wire, dorsiflexion assist calf band, custom fabricated Ankle orthosis, elastic, prefabricated, includes fitting and adjustment (e.g., neoprene, Lycra) AFO, ankle gauntlet, prefabricated, includes fitting and adjustment AFO, molded ankle gauntlet, custom fabricated AFO, multiligamentus ankle support, prefabricated, includes fitting and adjustment Fee Nu Fee Ue Fee RR 114.3 CMR 40.06(6) - DMEPOS Description (con’t) AFO, supramalleolar with straps, with or without interface/pads, custom fabricated AFO, posterior, single bar, clasp attachment to shoe counter, prefabricated, includes fitting and adjustment AFO, single upright with static or adjustable stop (Phelps or Perlstein type), custom fabricated AFO, plastic or other material, prefabricated, includes fitting and adjustment AFO, rigid anterior tibial section, total carbon fiber or equal material, prefabricated, includes fitting and adjustment AFO, plastic or other material, custom-fabricated AFO, molded to patient model, plastic, rigid anterior tibial section (floor reaction), custom fabricated AFO, spiral, (Institute of Rehabilitative Medicine type), plastic, custom fabricated AFO, spiral, (Institute of Rehabilitative Medicine type), plastic or other material, prefabricated, includes fitting and adjustment AFO, posterior solid ankle, plastic, custom fabricated AFO, plastic, with ankle joint, custom fabricated AFO, plastic or other material with ankle joint, prefabricated, includes fitting and adjustment AFO, single upright free plantar dorsiflexion, solid stirrup, calf band/cuff (single bar BK orthosis), custom fabricated AFO, double upright free plantar dorsiflexion, solid stirrup, calf band/cuff (double bar BK orthosis), custom fabricated KAFO, single upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs (single bar AK orthosis), custom fabricated Knee ankle foot orthosis, any material, single or double upright, stance control, automatic lock and swing phase release, mechanical activation, includes ankle joint, any type, custom fabricated KAFO, single upright, free ankle, solid stirrup, thigh and calf bands/cuffs (single bar AK orthosis), without knee joint, custom fabricated KAFO, double upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs (double bar AK orthosis), custom fabricated KAFO, double upright, free ankle, solid stirrup, thigh and calf bands/cuffs, (double bar AK orthosis), without knee joint, custom fabricated Knee ankle foot orthosis, full plastic, single upright, with or without free motion knee, medial lateral rotation control, with or without free motion ankle, custom fabricated Knee ankle foot orthosis, full plastic, static (pediatric size), without free motion ankle, prefabricated, includes fitting and adjustment Knee ankle foot orthosis, full plastic, double upright, with or without free motion knee, with or without free motion ankle, custom fabricated Fee Nu Fee Ue Fee RR 114.3 CMR 40.06(6) - DMEPOS Description (con’t) Knee ankle foot orthosis, full plastic, single upright, with or without free motion knee, with or without free motion ankle, custom fabricated Knee ankle foot orthosis, full plastic, with or without free motion knee, multi-axis ankle, custom fabricated HKAFO, torsion control, bilateral rotation straps, pelvic band/belt, custom fabricated HKAFO, torsion control, bilateral torsion cables, hip joint, pelvic band/belt, custom fabricated HKAFO, torsion control, bilateral torsion cables, ball bearing hip joint, pelvic band/ belt, custom fabricated HKAFO, torsion control, unilateral rotation straps, pelvic band/belt, custom fabricated HKAFO, torsion control, unilateral torsion cable, hip joint, pelvic band/belt, custom fabricated HKAFO, torsion control, unilateral torsion cable, ball bearing hip joint, pelvic band/belt, custom fabricated AFO, fracture orthosis, tibial fracture cast orthosis, thermoplastic type casting material, custom fabricated AFO, fracture orthosis, tibial fracture cast orthosis, custom fabricated AFO, fracture orthosis, tibial fracture orthosis, soft, prefabricated, includes fitting and adjustment AFO, fracture orthosis, tibial fracture orthosis, semi-rigid, prefabricated, includes fitting and adjustment AFO, fracture orthosis, tibial fracture orthosis, rigid, prefabricated, includes fitting and adjustment KAFO, fracture orthosis, femoral fracture cast orthosis, thermoplastic type casting material, custom fabricated KAFO, fracture orthosis, femoral fracture cast orthosis, custom fabricated Knee ankle foot orthosis (KAFO), fracture orthosis, femoral fracture cast orthosis, soft, prefabricated, includes fitting and adjustment Knee ankle foot orthosis (KAFO), fracture orthosis, femoral fracture cast orthosis, semi-rigid, prefabricated, includes fitting and adjustment KAFO, fracture orthosis, femoral fracture cast orthosis, rigid, prefabricated, includes fitting and adjustment Addition to lower extremity fracture orthosis, plastic shoe insert with ankle joints Addition to lower extremity fracture orthosis, drop lock knee joint Addition to lower extremity fracture orthosis, limited motion knee joint Addition to lower extremity fracture orthosis, adjustable motion knee joint, Lerman type Addition to lower extremity fracture orthosis, quadrilateral brim Addition to lower extremity fracture orthosis, waist belt Addition to lower extremity fracture orthosis, hip joint, pelvic band, thigh flange, and pelvic belt Fee Nu Fee Ue Fee RR 114.3 CMR 40.06(6) - DMEPOS Description (con’t) Addition to lower extremity, limited ankle motion, each joint Addition to lower extremity, dorsiflexion assist (plantar flexion resist), each joint Addition to lower extremity, dorsiflexion and plantar flexion assist/resist, each joint Addition to lower extremity, split flat caliper stirrups and plate attachment Addition to lower extremity orthosis, rocker bottom for total contact ankle foot orthosis, for custom fabricated orthosis only Addition to lower extremity, round caliper and plate attachment Addition to lower extremity, foot plate, molded to patient model, stirrup attachment Addition to lower extremity, reinforced solid stirrup (Scott-Craig type) Addition to lower extremity, long tongue stirrup Addition to lower extremity, varus/valgus correction (T) strap, padded/lined or malleolus pad Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined Addition to lower extremity, molded inner boot Addition to lower extremity, abduction bar (bilateral hip involvement), jointed, adjustable Addition to lower extremity, abduction bar, straight Addition to lower extremity, non-molded lacer, for custom fabricated orthosis only Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis only Addition to lower extremity, anterior swing band Addition to lower extremity, pretibial shell, molded to patient model Addition to lower extremity, prosthetic type, (BK) socket, molded to patient model, (used for PTB, AFO orthoses) Addition to lower extremity, extended steel shank Addition to lower extremity, Patten bottom Addition to lower extremity, torsion control, ankle joint and half solid stirrup Addition to lower extremity, torsion control, straight knee joint, each joint Addition to lower extremity, straight knee joint, heavy duty, each joint Addition to lower extremity, polycentric knee joint, for custom fabricated knee ankle foot orthosis, each joint Addition to lower extremity, offset knee joint, each joint Addition to lower extremity, offset knee joint, heavy duty, each joint Addition to lower extremity orthosis, suspension sleeve Addition to knee joint, drop lock, each Addition to knee lock with integrated release mechanism (bail, cable, or equal), any material, each joint Fee Nu Fee Ue Fee RR 114.3 CMR 40.06(6) - DMEPOS Description (con’t) Addition to knee joint, disc or dial lock for adjustable knee flexion, each joint Addition to knee joint, ratchet lock for active and progressive knee extension, each joint Addition to knee joint, lift loop for drop lock ring Addition to lower extremity, thigh/weight bearing, gluteal/ischial weight bearing, ring Addition to lower extremity, thigh/weight bearing, quadri-lateral brim, molded to patient model Addition to lower extremity, thigh/weight bearing, quadri-lateral brim, custom fitted Addition to lower extremity, thigh/weight bearing, ischial containment/narrow M-L brim molded to patient model Addition to lower extremity, thigh/weight bearing, ischial containment/narrow M-L brim, custom fitted Addition to lower extremity, thigh/weight bearing, lacer, nonmolded Addition to lower extremity, thigh/weight bearing, lacer, molded to patient model Addition to lower extremity, thigh/weight bearing, high roll cuff Addition to lower extremity, pelvic control, hip joint, Clevis type, two position joint, each Addition to lower extremity, pelvic control, pelvic sling Addition to lower extremity, pelvic control, hip joint, Clevis type, or thrust bearing, free, each Addition to lower extremity, pelvic control, hip joint, Clevis or thrust bearing, lock, each Addition to lower extremity, pelvic control, hip joint, heavy-duty, each Addition to lower extremity, pelvic control, hip joint, adjustable flexion, each Addition to lower extremity, pelvic control, hip joint, adjustable flexion, extension, abduction control, each Addition to lower extremity, pelvic control, plastic, molded to patient model, reciprocating hip joint and cables Addition to lower extremity, pelvic control, metal frame, reciprocating hip joint and cables Addition to lower extremity, pelvic control, band and belt, unilateral Addition to lower extremity, pelvic control, band and belt, bilateral Addition to lower extremity, pelvic and thoracic control, gluteal pad, each Addition to lower extremity, thoracic control, thoracic band Addition to lower extremity, thoracic control, paraspinal uprights Addition to lower extremity, thoracic control, lateral support uprights Addition to lower extremity orthosis, plating chrome or nickel, per bar Fee Nu Fee Ue Fee RR 114.3 CMR 40.06(6) - DMEPOS Description (con’t) Addition to lower extremity orthosis, high strength, lightweight material, all hybrid lamination/prepreg composite, per segment, for custom fabricated orthosis only Addition to lower extremity orthosis, extension, per extension, per bar (for lineal adjustment for growth) Orthotic side bar disconnect device, per bar Addition to lower extremity orthosis, any material, per bar or joint Addition to lower extremity orthosis, noncorrosive finish, per bar Addition to lower extremity orthosis, drop lock retainer, each Addition to lower extremity orthosis, knee control, full kneecap Addition to lower extremity orthosis, knee control, knee cap, medial or lateral pull, for use with custom fabricated orthosis only Addition to lower extremity orthosis, knee control, condylar pad Addition to lower extremity orthosis, soft interface for molded plastic, below knee section Addition to lower extremity orthosis, soft interface for molded plastic, above knee section Addition to lower extremity orthosis, tibial length sock, fracture or equal, each Addition to lower extremity orthosis, femoral length sock, fracture or equal, each L2999 A.I. + 50% Unlisted procedure for lower extremity orthosis Foot insert, removable, molded to patient model, UCB type, Berkeley shell, each Foot insert, removable, molded to patient model, Spenco, each Foot insert, removable, molded to patient model, Plastazote or equal, each Foot insert, removable, molded to patient model, silicone gel, each Foot insert, removable, molded to patient model, longitudinal arch support, each Foot insert, removable, molded to patient model, longitudinal/metatarsal support, each Foot insert, removable, formed to patient foot, each Foot, insert/plate, removable, addition to lower extremity orthosis, high strength, lightweight material, all hybrid lamination/prepreg composite, each Foot, arch support, removable, premolded, longitudinal, each Foot, arch support, removable, premolded, metatarsal, each Foot, arch support, removable, premolded, longitudinal/metatarsal, each Foot, arch support, nonremovable, attached to shoe, longitudinal, each Foot, arch support, nonremovable, attached to shoe, metatarsal, each Fee Nu Fee Ue Fee RR 114.3 CMR 40.06(6) - DMEPOS Description (con’t) Foot, arch support, nonremovable, attached to shoe, longitudinal/metatarsal, each Hallus-valgus night dynamic splint Foot, abduction rotation bar, including shoes Foot, abduction rotation bar, without shoes L3160 AI + 50% Foot, adjustable shoe style positioning device Foot, plastic, silicone, or equal, heel stabilizer, each Orthopedic shoe, oxford wit supinator or pronator, junior L3207 AI + 50% Orthopedic shoe, hightop with supinator or pronator, junior Surgical boot, each, junior L3214 AI + 50% Benesch boot, pair, junior Orthopedic footwear, ladies shoes, oxford, "each" Orthopedic footwear, ladies shoes, depth inlay "each" L3217 AI + 50% Orthopedic footwear, ladies shoes, hightop, depth inlay "each" Orthopedic footwear, mens shoes, oxford, "each" Orthopedic footwear, mens shoes, depth inlay "each" Orthopedic footwear, mens shoes, hightop, depth inlay "each" Orthopedic footwear, woman's shoe, oxford, used as an integral part of a brace (orthosis) Orthopedic footwear, man's shoe, oxford, used as an integral part of a brace (orthosis) Orthopedic footwear, custom shoes, depth inlay "each" Orthopedic footwear, custom molded shoe, removable inner mold, prosthetic shoe, each L3251 Foot, shoe molded to patient model, silicone shoe, each Foot, shoe molded to patient model, plastazote (or similar), custom fabricated, each Foot, molded shoe, plastazote (or similar) custom fitted, each Non-standard size or width L3255 AI + 70% Non-standard size or length Orthopedic footware, additional charge for split size Ambulatory surgical boot, each Plastazote sandal, each Lift, elevation, heel, tapered to metatarsals, per inch Lift, elevation, heel and sole, neoprene, per inch Lift, elevation, metal extension (skate) Lift, elevation, inside shoe, tapered, up to one-half in. Lift, elevation, heel, per in. Heel wedge, SACH Heel wedge Sole wedge, outside sole Sole wedge, between sole Clubfoot wedge Outflare wedge Metatarsal bar wedge, rocker Metatarsal bar wedge, between sole Full sole and heel wedge, between sole Heel, counter, plastic reinforced Heel, counter, leather reinforced Heel, SACH cushion type Heel, new leather, standard Fee Nu Fee Ue Fee RR L3649 AI + 70% 114.3 CMR 40.06(6) - DMEPOS Description (con’t) Heel, new rubber, standard Heel, Thomas with wedge Heel, Thomas extended to ball Heel, pad and depression for spur Heel, pad-removeable for spur Orthopedic shoe addition, insole, leather Orthopedic shoe addition, insole, rubber Orthopedic shoe addition, insole, felt covered with leather Orthopedic shoe addition, sole, half Orthopedic shoe addition, sole, full Orthopedic shoe addition, toe tap, standard Orthopedic shoe addition, toe tap, horseshoe Orthopedic shoe addition, special extension to instep (leather with eyelets) Orthopedic shoe addition, convert instep to Velcro closure Orthopedic shoe addition, convert firm shoe counter to soft counter Orthopedic shoe addition, March bar Transfer of an orthosis from one shoe to another, caliper plate, existing Transfer of an orthosis from one shoe to another, caliper plate, new Transfer of an orthosis from one shoe to another, solid stirrup, existing Transfer of an orthosis from one shoe to another, solid stirrup, new Transfer of an orthosis from one shoe to another, Dennis Browne splint (Riveton), both shoes Orthopedic shoe modification, addition or transfer not otherwise specified SO, figure of eight design abduction restrainer, prefabricated, includes fitting and adjustment SO, single shoulder, elastic, prefabricated, includes fitting and adjustment (e.g., neoprene, Lycra) SO, double shoulder, elastic, prefabricated, includes fitting and adjustment (e.g., neoprene, Lycra) SO, figure of eight design abduction restrainer, canvas and webbing, prefabricated, includes fitting and adjustment SO, acromio/clavicular (canvas and webbing type), prefabricated, includes fitting and adjustment Shoulder orthosis (SO), shoulder cap design, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment SO, abduction positioning (airplane design), thoracic component and support bar, without joints, may inlcude soft interface, straps, custom fabricated, includes fitting and adjustment Shoulder orthosis (SO), abduction positioning (airplane design), thoracic component and support bar, includes nontorsion joint/turnbuckle, may include soft interface, straps, custom fabricated, includes fitting and adjustment Fee Nu Fee Ue Fee RR 114.3 CMR 40.06(6) - DMEPOS Description (con’t) SO, vest type abduction restrainer, canvas webbing type, or equal, prefabricated, includes fitting and adjustment EO, elastic with stays, prefabricated, includes fitting and adjustment Elbow orthosis (EO), elastic, prefabricated, includes fitting and adjustment (e.g., neoprene, Lycra) Elbow orthosis (EO), without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment EO, elastic with metal joints, prefabricated, includes fitting and adjustment Elbow orthosis (EO), double upright with forearm/arm cuffs, free motion, custom fabricated EO, double upright with forearm/arm cuffs, extension/flexion assist, custom fabricated Elbow orthosis (EO), double upright with forearm/arm cuffs, adjustable position Lock with active control, custom fabricated Elbow orthosis (EO), with adjustable position locking joint(s), prefabricated, includes fitting and adjustments, any type Elbow orthosis (EO), rigid, without joints, includes soft interface material, prefabricated, includes fitting and adjustment Elbow wrist hand orthosis (EWHO), rigid, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment Elbow wrist hand orthosis (EWHO), includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment Elbow wrist hand finger orthosis (EWHFO), rigid, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment Elbow wrist hand finger orthosis (EWHFO), includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment WHFO, includes one or more nontorsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, custom fabricated, includes fitting and adjustment Wrist hand finger orthosis (WHFO), without joint(s), prefabricated, includes fitting and adjustments, any type Wrist hand finger orthosis (WHFO), rigid without joints, may include soft interface material; straps, custom fabricated, includes fitting and adjustment WHFO, dynamic flexor hinge, reciprocal wrist extension/flexion, finger flexion/extension, wrist or finger driven, custom fabricated WHFO, dynamic flexor hinge, reciprocal wrist extension/flexion, finger flexion/extension, cable driven, custom fabricated WHFO, external powered, electric, custom fabricated Fee Nu Fee Ue Fee RR L3927 AI + 50% 114.3 CMR 40.06(6) - DMEPOS Description (con’t) Wrist hand finger orthosis (WHFO), includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment Wrist hand orthosis (WHO), without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment WHO, wrist extension control cock-up, nonmolded, prefabricated, includes fitting and adjustment WO, elastic, prefabricated, includes fitting and adjustment (e.g., neoprene, Lycra) Wrist hand finger orthosis (WHFO), elastic, prefabricated, includes fitting and adjustment (e.g., neoprene, Lycra) HFO, flexion glove with elastic finger control, prefabricated, includes fitting and adjustment Hand finger orthosis (HFO), without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment Wrist hand orthosis (WHO), includes one or more nontorsion joint(s), elastic bands, turnbuckles, may include soft interface, straps, prefabricated, includes fitting and adjustment Hand orthosis (HO), metacarpal fracture orthosis, prefabricated, includes fitting and adjustment Hand orthosis (HO), without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment Hand finger orthosis (HFO), includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment Hand finger orthosis (HFO), without joints, may include soft interface, straps, prefabricated, includes fitting and adjustment FO, proximal interphalangeal (PIP)/distal interphalangeal (DIP), nontorsion joint/spring, extension/flexion, may include soft interface material, prefabricated, includes fitting and adjustment FO, proximal interphalangeal (PIP)/distal interphalangeal (DIP), without joint/spring, extension/flexion (e.g., static or ring type), may include soft interface material, prefabricated, includes fitting and adjustment HFO, includes one or more nontorsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, prefabricated, includes fitting and adjustment WHFO, includes one or more nontorsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, prefabricated, includes fitting and adjustment Finger orthosis (FO), without joints, may include soft interface, custom fabricated, includes fitting and adjustment Fee Nu Fee Ue L3956 I.C. Fee RR 114.3 CMR 40.06(6) - DMEPOS Description (con’t) Finger orthosis, nontorsion joint, may include soft interface, custom fabricated, includes fitting and adjustment Addition of joint to upper extremity orthosis, any material; per joint SEWHO, abduction positioning, airplane design, prefabricated, includes fitting and adjustment Shoulder elbow wrist hand orthosis (SEWHO), shoulder cap design, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment SEWHO, abduction positioning, Erb's palsy design, prefabricated, includes fitting and adjustment SEO, mobile arm support attached to wheelchair, balanced, adjustable, prefabricated, includes fitting and adjustment SEO, mobile arm support attached to wheelchair, balanced, adjustable, prefabricated, includes fitting and adjustment SEO, mobile arm support attached to wheelchair, balanced, adjustable, prefabricated, includes fitting and adjustment SEO, mobile arm support attached to wheelchair, balanced, adjustable Rancho type, prefabricated, includes fitting and adjustment SEO, mobile arm support attached to wheelchair, balanced, adjustable Rancho type, prefabricated, includes fitting and adjustment SEO, mobile arm support attached to wheelchair, balanced, adjustable Rancho type, prefabricated, includes fitting and adjustment SEO, mobile arm support attached to wheelchair, balanced, reclining, prefabricated, includes fitting and adjustment SEO, mobile arm support attached to wheelchair, balanced, reclining, prefabricated, includes fitting and adjustment SEO, mobile arm support attached to wheelchair, balanced, reclining, prefabricated, includes fitting and adjustment Shoulder elbow wrist hand orthosis (SEWHO), abduction positioning (airplane design), thoracic component and support bar, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment SEO, mobile arm support attached to wheelchair, balanced, friction arm support (friction dampening to proximal and distal joints), prefabricated, includes fitting and adjustment SEO, mobile arm support attached to wheelchair, balanced, friction arm support (friction dampening to proximal and distal joints), prefabricated, includes fitting and adjustment Fee Nu Fee Ue Fee RR 114.3 CMR 40.06(6) - DMEPOS Description (con’t) SEO, mobile arm support attached to wheelchair, balanced, friction arm support (friction dampening to proximal and distal joints), prefabricated, includes fitting and adjustment SEO, mobile arm support, monosuspension arm and hand support, overhead elbow forearm hand sling support, yoke type arm suspension support, prefabricated, includes fitting and adjustment SEO, mobile arm support, monosuspension arm and hand support, overhead elbow forearm hand sling support, yoke type arm suspension support, prefabricated, includes fitting and adjustment SEO, mobile arm support, monosuspension arm and hand support, overhead elbow forearm hand sling support, yoke type arm suspension support, prefabricated, includes fitting and adjustment Shoulder elbow orthosis (SEO), addition to mobile arm support, elevating proximal arm Shoulder elbow orthosis (SEO), addition to mobile arm support, elevating proximal arm Shoulder elbow orthosis (SEO), addition to mobile arm support, elevating proximal arm Shoulder elbow wrist hand orthosis (SEWHO), shoulder cap design, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment Shoulder elbow orthosis (SEO), addition to mobile arm support, offset or lateral rocker arm with elastic balance control Shoulder elbow orthosis (SEO), addition to mobile arm support, offset or lateral rocker arm with elastic balance control Shoulder elbow orthosis (SEO), addition to mobile arm support, offset or lateral rocker arm with elastic balance control Shoulder elbow wrist hand orthosis (SEWHO), abduction positioning (airplane design), thoracic component and support bar, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment Shoulder elbow orthosis (SEO), addition to mobile arm support, supinator Shoulder elbow orthosis (SEO), addition to mobile arm support, supinator Shoulder elbow orthosis (SEO), addition to mobile arm support, supinator Shoulder elbow wrist hand finger orthosis (SEWHO), shoulder cap design, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment Fee Nu Fee Ue Fee RR 114.3 CMR 40.06(6) - DMEPOS Description (con’t) Shoulder elbow wrist hand finger orthosis (SEWHO), abduction positioning (airplane design), thoracic component and support bar, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment Shoulder elbow wrist hand finger orthosis (SEWHO), shoulder cap design, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment Shoulder elbow wrist hand finger orthosis (SEWHO), abduction positioning (airplane design), thoracic component and support bar, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, incl Upper extremity fracture orthosis, humeral, prefabricated, includes fitting and adjustment Upper extremity fracture orthosis, radius/ulnar, prefabricated, includes fitting and adjustment Upper extremity fracture orthosis, wrist, prefabricated, includes fitting and adjustment Addition to upper extremity orthosis, sock, fracture or equal, each Replace girdle for spinal orthosis (CTLSO or SO) L4002 AI + 70% Replacement strap, any orthosis, includes all components, any length, any type Replace trilateral socket brim Replace quadrilateral socket brim, molded to patient model Replace quadrilateral socket brim, custom fitted Replace molded thigh lacer, for custom fabricated orthosis only Replace non-molded thigh lacer, for custom fabricated orthosis only Replace molded calf lacer, for custom fabricated orthosis only Replace non-molded calf lacer, for custom fabricated orthosis only Replace high roll cuff Replace proximal and distal upright for KAFO Replace metal bands KAFO, proximal thigh Replace metal bands KAFO-AFO, calf or distal thigh Replace leather cuff KAFO, proximal thigh Replace leather cuff KAFO-AFO, calf or distal thigh Replace pretibial shell Ankle control orthosis, stirrup style, rigid, includes any type interface (e.g., pneumatic, gel), prefabricated, includes fitting and adjustment Walking boot, pneumatic, with or without joints, with or without interface material, prefabricated, includes fitting and adjustment Pneumatic full leg splint, prefabricated, includes fitting and adjustment Pneumatic knee splint, prefabricated, includes fitting and adjustment Fee Nu Fee Ue Fee RR 114.3 CMR 40.06(6) - DMEPOS Description (con’t) Walking boot, non-pneumatic, with or without joints, with or without interface material, prefabricated, includes fitting and adjustment Replacement, soft interface material, static AFO Replace soft interface material, foot drop splint Static ankle foot orthosis, including soft interface material, adjustable for fit, for positioning, pressure reduction, may be used for minimal ambulation, prefabricated, includes fitting and adjustment Foot drop splint, recumbent positioning device, prefabricated, includes fitting and adjustment Partial foot, shoe insert with longitudinal arch, toe filler Partial foot, molded socket, ankle height, with toe filler Partial foot, molded socket, tibial tubercle height, with toe filler Ankle, Symes, molded socket, SACH foot Ankle, Symes, metal frame, molded leather socket, articulated ankle/foot Below knee, molded socket, shin, SACH foot Below knee, plastic socket, joints and thigh lacer, SACH foot Knee disarticulation (or through knee), molded socket, external knee joints, shin, SACH foot Knee disarticulation (or through knee), molded socket, bent knee configuration, external knee joints, shin, SACH foot Above knee, molded socket, single axis constant friction knee, shin, SACH foot Above knee, short prosthesis, no knee joint (stubbies), with foot blocks, no ankle joints, each Above knee, short prosthesis, no knee joint (stubbies), with articulated ankle/foot, dynamically aligned, each Above knee, for proximal femoral focal deficiency, constant friction knee, shin, SACH foot Hip disarticulation, Canadian type; molded socket, hip joint, single axis constant friction knee, shin, SACH foot Hip disarticulation, tilt table type; molded socket, locking hip joint, single axis constant friction knee, shin, SACH foot Hemipelvectomy, Canadian type; molded socket, hip joint, single axis constant friction knee, shin, SACH foot Below knee, molded socket, shin, SACH foot, endoskeletal system Knee disarticulation (or through knee), molded socket, external knee joints, shin, SACH foot, endoskeletal system Above knee, molded socket, open end, SACH foot, endoskeletal system, single axis knee Hip disarticulation, Canadian type, molded socket, endoskeletal system, hip joint, single axis knee, SACH foot Fee Nu Fee Ue Fee RR 114.3 CMR 40.06(6) - DMEPOS Description (con’t) Hemipelvectomy, Canadian type, molded socket, endoskeletal system, hip joint, single axis knee, SACH foot Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting, alignment, suspension, and one cast change, below knee Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting, alignment and suspension, below knee, each additional cast change and realignment Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting, alignment and suspension and one cast change AK or knee disarticulation Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting, alignment and suspension, AK or knee disarticulation, each additional cast change and realignment Immediate postsurgical or early fitting, application of nonweight bearing rigid dressing, below knee Immediate postsurgical or early fitting, application of nonweight bearing rigid dressing, above knee Initial, below knee PTB type socket, nonalignable system, pylon, no cover, SACH foot, plaster socket, direct formed Initial, above knee - knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, SACH foot plaster socket, direct formed Preparatory, below knee PTB type socket, nonalignable system, pylon, no cover, SACH foot, plaster socket, molded to model Preparatory, below knee PTB type socket, nonalignable system, pylon, no cover, SACH foot, thermoplastic or equal, direct formed Preparatory, below knee PTB type socket, nonalignable system, pylon, no cover, SACH foot, thermoplastic or equal, molded to model Preparatory, below knee PTB type socket, nonalignable system, pylon, no cover, SACH foot, prefabricated, adjustable open end socket Preparatory, below knee PTB type socket, nonalignable system, pylon, no cover, SACH foot, laminated socket, molded to model Preparatory, above knee - knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, SACH foot, plaster socket, molded to model Preparatory, above knee - knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, SACH foot, thermoplastic or equal, direct formed Preparatory, above knee - knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, SACH foot, thermoplastic or equal, molded to model Preparatory, above knee - knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, SACH foot, prefabricated adjustable open end socket Fee Nu Fee Ue Fee RR 114.3 CMR 40.06(6) - DMEPOS Description (con’t) Preparatory, above knee - knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, SACH foot, laminated socket, molded to model Preparatory, hip disarticulation - hemipelvectomy, pylon, no cover, SACH foot, thermoplastic or equal, molded to patient model Preparatory, hip disarticulation - hemipelvectomy, pylon, no cover, SACH foot, laminated socket, molded to patient model Addition to lower extremity, endoskeletal system, above knee, hydracadence system Addition to lower extremity, endoskeletal system, above knee - knee disarticulation, 4-bar linkage, with friction swing phase control Addition to lower extremity, endoskeletal system, above knee - knee disarticulation, 4-bar linkage, with hydraulic swing phase control Addition to lower extremity, endoskeletal system, above knee - knee disarticulation, 4-bar linkage, with pneumatic swing phase control Addition to lower extremity, endoskeletal system, above knee, universal multiplex system, friction swing phase control Addition to lower extremity, quick change self-aligning unit, above or below knee, each Addition to lower extremity, test socket, Symes Addition to lower extremity, test socket, below knee Addition to lower extremity, test socket, knee disarticulation Addition to lower extremity, test socket, above knee Addition to lower extremity, test socket, hip disarticulation Addition to lower extremity, test socket, hemipelvectomy Addition to lower extremity, below knee, acrylic socket Addition to lower extremity, Symes type, expandable wall socket Addition to lower extremity, above knee or knee disarticulation, acrylic socket Addition to lower extremity, Symes type, PTB brim design socket Addition to lower extremity, Symes type, posterior opening (Canadian) socket Addition to lower extremity, Symes type, medial opening socket Addition to lower extremity, below knee, total contact Addition to lower extremity, below knee, leather socket Addition to lower extremity, below knee, wood socket Addition to lower extremity, knee disarticulation, leather socket Addition to lower extremity, above knee, leather socket Addition to lower extremity, hip disarticulation, flexible inner socket, external frame Addition to lower extremity, above knee, wood socket Addition to lower extremity, below knee, flexible inner socket, external frame Fee Nu Fee Ue Fee RR 114.3 CMR 40.06(6) - DMEPOS Description (con’t) Addition to lower extremity, below knee, air, fluid, gel or equal, cushion socket Addition to lower extremity, below knee, suction socket Addition to lower extremity, above knee, air, fluid, gel or equal, cushion socket Addition to l o we r ex t re m i t y, ischial containment/narrow M-L socket Addition to lower extremity, total contact, above knee or knee disarticulation socket Addition to lower extremity, above knee, flexible inner socket, external frame Addition to lower extremity, suction suspension, above knee or knee disarticulation socket Addition to lower extremity, knee disarticulation, expandable wall socket Addition to lower extremity, socket insert, Symes (Kemblo, Pelite, Aliplast, Plastazote or equal) Addition to lower extremity, socket insert, below knee (Kemblo, Pelite, Aliplast, Plastazote or equal) Addition to lower extremity, socket insert, knee disarticulation (Kemblo, Pelite, Aliplast, Plastazote or equal) Addition to lower extremity, socket insert, above knee (Kemblo, Pelite, Aliplast, Plastazote or equal) Addition to lower extremity, socket insert, multidurometer, Symes Addition to lower extremity, socket insert, multidurometer, below knee Addition to lower extremity, below knee, cuff suspension Addition to lower extremity, below knee, molded distal cushion Addition to lower extremity, below knee, molded supracondylar suspension (PTS or similar) Addition to lower extremity, below knee/above knee suspension locking mechanism (shuttle, lanyard or equal), excludes socket insert Addition to lower extremity, below knee, removable medial brim suspension Addition to lower extremity, below knee/above knee, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, for use with locking mechanism Addition to lower extremity, below knee, knee joints, single axis, pair Addition to lower extremity, below knee, knee joints, polycentric, pair Addition to lower extremity, below knee joint covers, pair Addition to lower extremity, below knee/above knee, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, not for use with locking mechanism Addition to lower extremity, below knee, thigh lacer, nonmolded Fee Nu Fee Ue Fee RR 114.3 CMR 40.06(6) - DMEPOS Description (con’t) Addition to lower extremity, below knee/above knee, custom fabricated socket insert for congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or without locking mechanism, initial only (for other than initial, use code L5673 or L5679) Addition to lower extremity, below knee, thigh lacer, gluteal/ischial, molded Addition to lower extremity, below knee/above knee, custom fabricated socket insert for other than congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or without locking mechanism, initial only (for other than initial, use code L5673 or L5679) Addition to lower extremity, below knee, fork strap Addition to lower extremity prosthesis, below knee, suspension/sealing sleeve, with or without valve, any material, each Addition to lower extremity, below knee, back check (extension control) Addition to lower extremity, below knee, waist belt, webbing Addition to lower extremity, below knee, waist belt, padded and lined Addition to lower extremity, above knee, pelvic control belt, light Addition to lower extremity, above knee, pelvic control belt, padded and lined Addition to lower extremity, above knee, pelvic control, sleeve suspension, neoprene or equal, each Addition to lower extremity, above knee or knee disarticulation, pelvic joint Addition to lower extremity, above knee or knee disarticulation, pelvic band Addition to lower extremity, above knee or knee disarticulation, Silesian bandage All lower extremity prostheses, shoulder harness Replacement, socket, below knee, molded to patient model Replacement, socket, above knee/knee disarticulation, including attachment plate, molded to patient model Replacement, socket, hip disarticulation, including hip joint, molded to patient model Ankle, Symes, molded to patient model, socket without solid ankle cushion heel (SACH) foot, replacement only Custom shaped protective cover, below knee Custom shaped protective cover, above knee Custom shaped protective cover, knee disarticulation Custom shaped protective cover, hip disarticulation Addition, exoskeletal knee-shin system, single axis, manual lock Addition, exoskeletal knee-shin system, single axis, manual lock, ultra-light material Addition, exoskeletal knee-shin system, single axis, friction swing and stance phase control (safety knee) Addition, exoskeletal knee-shin system, single axis, variable friction swing phase control Fee Nu Fee Ue Fee RR 114.3 CMR 40.06(6) - DMEPOS Description (con’t) Addition, exoskeletal knee-shin system, polycentric, mechanical stance phase lock Addition, exoskeletal knee-shin system, polycentric, friction swing and stance phase control Addition, exoskeletal knee-shin system, single axis, pneumatic swing, friction stance phase control Addition, exoskeletal knee-shin system, single axis, fluid swing phase control Addition, exoskeletal knee-shin system, single axis, external joints, fluid swing phase control Addition, exoskeletal knee-shin system, single axis, fluid swing and stance phase control Addition, exoskeletal knee-shin system, single axis, pneumatic/hydra pneumatic swing phase control Addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system Addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system, heavy duty Addition, exoskeletal system, below knee, ultra-light material (titanium, carbon fiber or equal) Addition, exoskeletal system, above knee, ultra-light material (titanium, carbon fiber or equal) Addition, exoskeletal system, hip disarticulation, ultra-light material (titanium, carbon fiber or equal) Addition, endoskeletal knee-shin system, single axis, manual lock Addition, endoskeletal knee-shin system, single axis, manual lock, ultra-light material Addition, endoskeletal knee-shin system, single axis, friction swing and stance phase control (safety knee) Addition, endoskeletal knee-shin system, polycentric, hydraulic swing phase control, mechanical stance phase lock Addition, endoskeletal knee-shin system, polycentric, mechanical stance phase lock Addition, endoskeletal knee-shin system, polycentric, friction swing and stance phase control Addition, endoskeletal knee-shin system, single axis, pneumatic swing, friction stance phase control Addition, endoskeletal knee-shin system, single axis, fluid swing phase control Addition, endoskeletal knee-shin system, single axis, hydraulic swing phase control, with miniature high activity frame Addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase control Addition, endoskeletal knee-shin system, single axis, pneumatic/swing phase control Addition, endoskeletal knee-shin system, 4-bar linkage or multiaxial, pneumatic swing phase control Addition, endoskeletal knee-shin system, stance flexion feature, adjustable Fee Nu Fee Ue Fee RR 114.3 CMR 40.06(6) - DMEPOS Description (con’t) Addition to endoskeletal knee-shin system, fluid stance extension, dampening feature, with or without adjustability Addition, endoskeletal system, above knee or hip disarticulation, knee extension assist Addition, endoskeletal system, hip disarticulation, mechanical hip extension assist Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing phase only, includes electronic sensor(s), any type Addition to lower extremity prosthesis, endoskeletal knee shin system, microprocessor control feature, stance phase only, includes electronic sensor(s), any type Addition, endoskeletal system, below knee, alignable system Addition, endoskeletal system, above knee or hip disarticulation, alignable system Addition, endoskeletal system, above knee, knee disarticulation or hip disarticulation, manual lock Addition, endoskeletal system, high activity knee control frame Addition, endoskeletal system, below knee, ultra-light material (titanium, carbon fiber or equal) Addition, endoskeletal system, above knee, ultra-light material (titanium, carbon fiber or equal) Addition, endoskeletal system, hip disarticulation, ultra-light material (titanium, carbon fiber or equal) Addition, endoskeletal system, below knee, flexible protective outer surface covering system Addition, endoskeletal system, above knee, flexible protective outer surface covering system Addition, endoskeletal system, hip disarticulation, flexible protective outer surface covering system Addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion feature All lower extremity prostheses, foot, external keel, SACH foot All lower extremity prosthesis, solid ankle cushion heel (SACH) foot, replacement only All lower extremity prostheses, flexible keel foot (SAFE, STEN, Bock Dynamic or equal) All lower extremity prostheses, foot, single axis ankle/foot All lower extremity prosthesis, combination single axis ankle and flexible keel foot All lower extremity prostheses, energy storing foot (Seattle Carbon Copy II or equal) All lower extremity prostheses, foot, multiaxial ankle/foot Fee Nu Fee Ue Fee RR 114.3 CMR 40.06(6) - DMEPOS Description (con’t) All lower extremity prostheses, multiaxial ankle, dynamic response foot, one piece system All lower extremity prostheses, flex-foot system All lower extremity prostheses, flex-walk system or equal All exoskeletal lower extremity prostheses, axial rotation unit All endoskeletal lower extremity prosthesis, axial rotation unit, with or without adjustability All endoskeletal lower extremity prostheses, dynamic prosthetic pylon All lower extremity prostheses, multiaxial rotation unit (MCP or equal) All lower extremity prosthesis, shank foot system with vertical loading pylon Addition to lower limb prosthesis, vertical shock reducing pylon feature Addition to lower extremity prosthesis, user adjustable heel height L5993 AI + 70% Addition to lower extremity prosthesis, heavy duty feature, foot only, (for patient weight greater than 300 lbs) L5994 AI + 70% Addition to lower extremity prosthesis, heavy duty feature, knee only, (for patient weight greater than 300 lbs) L5995 AI + 70% Addition to lower extremity prosthesis, heavy duty feature, other than foot or knee, (for patient weight greater than 300 lbs) Partial hand, Robin-Aids, thumb remaining (or equal) Partial hand, Robin-Aids, little and/or ring finger remaining (or equal) Partial hand, Robin-Aids, no finger remaining (or equal) Transcarpal/metacarpal or partial hand disarticulation prosthesis, external power, self-suspended, inner socket with removable forearm section, electrodes and cables, two batteries, charger, myoelectric control of terminal device Wrist disarticulation, molded socket, flexible elbow hinges, triceps pad Wrist disarticulation, molded socket with expandable interface, flexible elbow hinges, triceps pad Below elbow, molded socket, flexible elbow hinge, triceps pad Below elbow, molded socket (Muenster or Northwestern suspension types) Below elbow, molded double wall split socket, step-up hinges, half cuff Below elbow, molded double wall split socket, stump activated locking hinge, half cuff Elbow disarticulation, molded socket, outside locking hinge, forearm Elbow disarticulation, molded socket with expandable interface, outside locking hinges, forearm Above elbow, molded double wall socket, internal locking elbow, forearm Fee Nu Fee Ue Fee RR 114.3 CMR 40.06(6) - DMEPOS Description (con’t) Shoulder disarticulation, molded socket, shoulder bulkhead, humeral section, internal locking elbow, forearm Shoulder disarticulation, passive restoration (complete prosthesis) Shoulder disarticulation, passive restoration (shoulder cap only) Interscapular thoracic, molded socket, shoulder bulkhead, humeral section, internal locking elbow, forearm Interscapular thoracic, passive restoration (complete prosthesis) Interscapular thoracic, passive restoration (shoulder cap only) Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting alignment and suspension of components, and one cast change, wrist disarticulation or below elbow Immediate postsurgical or early fitting, application of initial rigid dressing including fitting alignment and suspension of components, and one cast change, elbow disarticulation or above elbow Immediate postsurgical or early fitting, application of initial rigid dressing including fitting alignment and suspension of components, and one cast change, shoulder disarticulation or interscapular thoracic Immediate postsurgical or early fitting, each additional cast change and realignment Immediate postsurgical or early fitting, application of rigid dressing only Below elbow, molded socket, endoskeletal system, including soft prosthetic tissue shaping Elbow disarticulation, molded socket, endoskeletal system, including soft prosthetic tissue shaping Above elbow, molded socket, endoskeletal system, including soft prosthetic tissue shaping Shoulder disarticulation, molded socket, endoskeletal system, including soft prosthetic tissue shaping Interscapular thoracic, molded socket, endoskeletal system, including soft prosthetic tissue shaping Preparatory, wrist disarticulation or below elbow, single wall plastic socket, friction wrist, flexible elbow hinges, figure of eight harness, humeral cuff, Bowden cable control, USMC or equal pylon, no cover, molded to patient model Preparatory, wrist disarticulation or below elbow, single wall socket, friction wrist, flexible elbow hinges, figure of eight harness, humeral cuff, Bowden cable control, USMC or equal pylon, no cover, direct formed Preparatory, elbow disarticulation or above elbow, single wall plastic socket, friction wrist, locking elbow, figure of eight harness, fair lead cable control, USMC or equal pylon, no cover, molded to patient model Fee Nu Fee Ue Fee RR 114.3 CMR 40.06(6) - DMEPOS Description (con’t) Preparatory, elbow disarticulation or above elbow, single wall socket, friction wrist, locking elbow, figure of eight harness, fair lead cable control, USMC or equal pylon, no cover, direct formed Preparatory, shoulder disarticulation or interscapular thoracic, single wall plastic socket, shoulder joint, locking elbow, friction wrist, chest strap, fair lead cable control, USMC or equal pylon, no cover, molded to patient model Preparatory, shoulder disarticulation or interscapular thoracic, single wall socket, shoulder joint, locking elbow, friction wrist, chest strap, fair lead cable control, USMC or equal pylon, no cover, direct formed Upper extremity additions, polycentric hinge, pair Upper extremity additions, single pivot hinge, pair Upper extremity additions, flexible metal hinge, pair Addition to upper extremity prosthesis, external powered, additional switch, any type Upper extremity addition, disconnect locking wrist unit Upper extremity addition, additional disconnect insert for locking wrist unit, each Upper extremity addition, flexion/extension wrist unit, with or without friction Upper extremity prosthesis addition, flexion/extension wrist with or without friction, for use with external powered terminal device Upper extremity addition, spring assisted rotational wrist unit with latch release Upper extremity addition, flexion/extension and rotation wrist unit Upper extremity addition, rotation wrist unit with cable lock Upper extremity addition, quick disconnect hook adapter, Otto Bock or equal Upper extremity addition, quick disconnect lamination collar with coupling piece, Otto Bock or equal Upper extremity addition, stainless steel, any wrist Upper extremity addition, latex suspension sleeve, each Upper extremity addition, lift assist for elbow Upper extremity addition, nudge control elbow lock Upper extremity addition to prosthesis, electric locking feature, only for use with manually powered elbow Upper extremity addition, heavy duty feature, any elbow Upper extremity additions, shoulder abduction joint, pair Upper extremity addition, excursion amplifier, pulley type Upper extremity addition, excursion amplifier, lever type Upper extremity addition, shoulder flexion-abduction joint, each Fee Nu Fee Ue Fee RR 114.3 CMR 40.06(6) - DMEPOS Description (con’t) Upper extremity addition, shoulder joint, multipositional locking, flexion, adjustable abduction friction control, for use with body powered or external powered system Upper extremity addition, shoulder lock mechanism, body powered actuator Upper extremity addition, shoulder lock mechanism, external powered actuator Upper extremity addition, shoulder universal joint, each Upper extremity addition, standard control cable, extra Upper extremity addition, heavy duty control cable Upper extremity addition, Teflon, or equal, cable lining Upper extremity addition, hook to hand, cable adapter Upper extremity addition, harness, chest or shoulder, saddle type Upper extremity addition, harness, (e.g. figure of eight type), single cable design Upper extremity addition, harness, (e.g. figure of eight type), dual cable design Upper extremity addition, harness, triple control, simultaneous operation of terminal device and elbow Upper extremity addition, test socket, wrist disarticulation or below elbow Upper extremity addition, test socket, elbow disarticulation or above elbow Upper extremity addition, test socket, shoulder disarticulation or interscapular thoracic Upper extremity addition, suction socket Upper extremity addition, frame type socket, below elbow or wrist disarticulation Upper extremity addition, frame type socket, above elbow or elbow disarticulation Upper extremity addition, frame type socket, shoulder disarticulation Upper extremity addition, frame type socket, interscapular-thoracic Upper extremity addition, removable insert, each Upper extremity addition, silicone gel insert or equal, each Upper extremity addition, locking elbow, forearm counterbalance Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, for use with locking mechanism Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, not for use with locking mechanism Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated socket insert for congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or without locking mechanism, initial only (for other than initial, use code L6694 or L6695) Fee Nu Fee Ue Fee RR 114.3 CMR 40.06(6) - DMEPOS Description (con’t) Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated socket insert for other than congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or without locking mechanism, initial only (for other than initial, use code L6694 or L6695) Addition to upper extremity prosthesis, below elbow/above elbow, lock mechanism, excludes socket insert Terminal device, passive hand/mitt, any material, any size Terminal device, sport/recreational/work attachment, any material, any size Terminal device, hook, mechanical, voluntary opening, any material, any size, lined or unlined Terminal device, hook, mechanical, voluntary closing, any material, any size, lined or unlined Terminal device, hand, mechanical, voluntary opening, any material, any size Terminal device, hand, mechanical, voluntary closing, any material, any size Addition to terminal device, modifier wrist unit Addition to terminal device, precision pinch device Automatic grasp feature, addition to upper limb electric prosthetic terminal device Microprocessor control feature, addition to upper limb prosthetic terminal device Replacement socket, below elbow/wrist disarticulation, molded to patient model, for use with or without external power Replacement socket, above elbow/elbow disarticulation, molded to patient model, for use with or without external power Replacement socket, shoulder disarticulation/ interscapular thoracic, molded to patient model, for use with or without external power Addition to upper extremity prosthesis, glove for terminal device, any material, prefabricated, includes fitting and adjustment Addition to upper extremity prosthesis, glove for terminal device, any material, custom fabricated Hand restoration (casts, shading and measurements included), partial hand, with glove, thumb or one finger remaining Hand restoration (casts, shading and measurements included), partial hand, with glove, multiple fingers remaining Hand restoration (casts, shading and measurements included), partial hand, with glove, no fingers remaining Hand restoration (shading and measurements included), replacement glove for above Wrist disarticulation, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal switch, cables, two batteries and one charger, switch control of terminal device Fee Nu Fee Ue Fee RR 114.3 CMR 40.06(6) - DMEPOS Description (con’t) Wrist disarticulation, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device Below elbow, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal switch, cables, two batteries and one charger, switch control of terminal device Below elbow, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device Elbow disarticulation, external power, molded inner socket, removable humeral shell, outside locking hinges, forearm, Otto Bock or equal switch, cables, two batteries and one charger, switch control of terminal device Elbow disarticulation, external power, molded inner socket, removable humeral shell, outside locking hinges, forearm, Otto Bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device Above elbow, external power, molded inner socket, removable humeral shell, internal locking elbow, forearm, Otto Bock or equal switch, cables, two batteries and one charger, switch control of terminal device Above elbow, external power, molded inner socket, removable humeral shell, internal locking elbow, forearm, Otto Bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device Shoulder disarticulation, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal switch, cables, two batteries and one charger, switch control of terminal device Shoulder disarticulation, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device Interscapular-thoracic, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal switch, cables, two batteries and one charger, switch control of terminal device Interscapular-thoracic, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device Electric hand, switch or myoelectric controlled, adult Fee Nu Fee Ue Fee RR 114.3 CMR 40.06(6) - DMEPOS Description (con’t) Electric hand, switch or myoelectric, controlled, pediatric Electric hook, switch or myoelectric controlled, adult Prehensile actuator, switch controlled Electric hook, switch or myoelectric controlled, pediatric Electronic elbow, Hosmer or equal, switch controlled Electronic elbow, microprocessor sequential control of elbow and terminal device Electronic elbow, microprocessor simultaneous control of elbow and terminal device Electronic elbow, adolescent, Variety Village or equal, switch controlled Electronic elbow, child, Variety Village or equal, switch controlled Electronic elbow, adolescent, Variety Village or equal, myoelectronically controlled Electronic elbow, child, Variety Village or equal, myoelectronically controlled Electronic wrist rotator, Otto Bock or equal Electronic wrist rotator, for Utah arm Servo control, Steeper or equal Analogue control, UNB or equal Proportional control, six-12 volt, Liberty, Utah or equal Six volt battery, each Battery charger, six volt, each Twelve volt battery, each Battery charger, twelve volt, each Lithium ion battery, replacement Lithium ion battery charger Addition to upper extremity prosthesis, below elbow/wrist disarticulation, ultralight material (titanium, carbon fiber or equal) Addition to upper extremity prosthesis, above elbow disarticulation, ultralight material (titanium, carbon fiber or equal) Addition to upper extremity prosthesis, shoulder disarticulation/interscapular thoracic, ultralight material (titanium, carbon fiber or equal) Addition to upper extremity prosthesis, below elbow/wrist disarticulation, acrylic material Addition to upper extremity prosthesis, above elbow disarticulation, acrylic material Addition to upper extremity prosthesis, shoulder disarticulation/interscapular thoracic, acrylic material L7621 I.C. Terminal device, hook or hand, heavy duty, mechanical, voluntary opening, any material, any size, lined or unlined L7622 I.C. Terminal device, hook or hand, heavy duty, mechanical, voluntary closing, any material, any size, lined or unlined Male vacuum erection system Breast prosthesis, mastectomy bra Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, unilateral Fee Nu Fee Ue Fee RR 114.3 CMR 40.06(6) - DMEPOS Description (con’t) Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, bilateral External breast prosthesis garment, with mastectomy form, post-mastectomy Breast prosthesis, mastectomy form Breast prosthesis, silicone or equal Custom breast prosthesis, post mastectomy, molded to patient model Nasal prosthesis, provided by a nonphysician Nasal prosthesis, provided by a nonphysician Nasal prosthesis, provided by a nonphysician Midfacial prosthesis, provided by a nonphysician Midfacial prosthesis, provided by a nonphysician Midfacial prosthesis, provided by a nonphysician Orbital prosthesis, provided by a nonphysician Orbital prosthesis, provided by a nonphysician Orbital prosthesis, provided by a nonphysician Upper facial prosthesis, provided by a nonphysician Upper facial prosthesis, provided by a nonphysician Upper facial prosthesis, provided by a nonphysician Hemi-facial prosthesis, provided by a nonphysician Hemi-facial prosthesis, provided by a nonphysician Hemi-facial prosthesis, provided by a nonphysician Auricular prosthesis, provided by a nonphysician Auricular prosthesis, provided by a nonphysician Auricular prosthesis, provided by a nonphysician Partial facial prosthesis, provided by a nonphysician Partial facial prosthesis, provided by a nonphysician Partial facial prosthesis, provided by a nonphysician Nasal septal prosthesis, provided by a nonphysician Nasal septal prosthesis, provided by a nonphysician Nasal septal prosthesis, provided by a nonphysician Truss, single with standard pad Truss, double with standard pads Truss, addition to standard pad, water pad Truss, addition to standard pad, scrotal pad Prosthetic sheath, below knee, each Prosthetic sheath, above knee, each Prosthetic sheath, upper limb, each Prosthetic sheath/sock, including a gel cushion layer, below knee or above knee, each Prosthetic sock, multiple ply, below knee, each Prosthetic sock, multiple ply, above knee, each Prosthetic sock, multiple ply, upper limb, each Prosthetic shrinker, below knee, each Prosthetic shrinker, above knee, each Prosthetic shrinker, upper limb, each Prosthetic sock, single ply, fitting, below knee, each Prosthetic sock, single ply, fitting, above knee, each Prosthetic sock, single ply, fitting, upper limb, each Artificial larynx, any type Tracheostomy speaking valve Tracheo-esophageal voice prosthesis, patient inserted, any type, each Tracheo-esophageal voice prosthesis, inserted by a licensed health care provider, any type Fee Nu Fee Ue Fee RR 114.3 CMR 40.06(6) - DMEPOS Description (con’t) Voice amplifier Insert for indwelling tracheoesophageal prosthesis, with or without valve, replacement only, each Gelatin capsules or equivalent, for use with tracheoesophageal voice prosthesis, replacement only, per ten Cleaning device used with tracheoesophageal voice prosthesis, pipet, brush, or equal, replacement only, each Tracheoesophageal puncture dilator, replacement only, each Gelatin capsule, application device for use with tracheoesophageal voice prosthesis, each Implantable breast prosthesis, silicone or equal Injectable bulking agent, collagen implant, urinary tract, 2.5 ml syringe, includes shipping and necessary supplies Injectable bulking agent, synthetic implant, urinary tract, 1 ml syringe, includes shipping and necessary supplies Artificial cornea Ocular implant Aqueous shunt Ossicula implant Cochlear device, includes all internal and external components Headset/headpiece for use with cochlear implant device, replacement Microphone for use with cochlear implant device, replacement Transmitting coil for use with cochlear implant device, replacement Transmitter cable for use with cochlear implant device, replacement Cochlear implant external speech processor, replacement Zinc air battery for use with cochlear implant device, replacement, each Alkaline battery for use with cochlear implant device, any size, replacement, each Lithium ion battery for use with cochlear implant device speech processor, other than ear level, replacement, each Lithium ion battery for use with cochlear implant device speech processor, ear level, replacement, each Metacarpophalangeal joint implant Metacarpal phalangeal joint replacement, two or more pieces, metal (e.g., stainless steel or cobalt chrome), ceramic-like material (e.g., pyrocarbon), for surgical implantation (all sizes, includes entire system) Metatarsal joint implant Hallux implant Interphalangeal joint spacer, silicone or equal, each Fee Nu Fee Ue Fee RR 114.3 CMR 40.06(6) - DMEPOS Description (con’t) Interphalangeal finger joint replacement, two or more pieces, metal (e.g., stainless steel or cobalt chrome), ceramic-like material (e.g., pyrocarbon) for surgical implantation, any size Vascular graft material, synthetic, implant Implantable neurostimulator electrode, each Patient programmer (external) for use with implantable programmable neurostimulator pulse generator Implantable neurostimulator radiofrequency receiver Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver Radiofrequency transmitter (external) for use with implantable sacral root neurostimulator receiver for bowel and bladder management, replacement Implantable neurostimulator pulse generator, single array, rechargeable, includes extension Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension External recharging system for battery (internal) for use with implantable neurostimulator Auditory osseointegrated device, includes all internal and external components Auditory osseointegrated device, external sound processor, replacement External recharging system for battery (external) for use with implantable neurostimulator L7614 I.C. Terminal device, hand, mechanical, voluntary closing, any material, any size, pediatric L7621 I.C. Terminal device, hook or hand, heavy duty, mechanical, voluntary opening, any material, any size, lined or unlined L7622 I.C. Terminal device, hook or hand, heavy duty, mechanical, voluntary closing, any material, any size, lined or unlined Male vacuum erection system Breast prosthesis, mastectomy bra Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, unilateral Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, bilateral External breast prosthesis garment, with mastectomy form, post-mastectomy Breast prosthesis, mastectomy form Breast prosthesis, silicone or equal Custom breast prosthesis, post mastectomy, molded to patient model Nasal prosthesis, provided by a nonphysician Midfacial prosthesis, provided by a nonphysician Orbital prosthesis, provided by a nonphysician Upper facial prosthesis, provided by a nonphysician Hemi-facial prosthesis, provided by a nonphysician Fee Nu Fee Ue Fee RR 114.3 CMR 40.06(6) - DMEPOS Description (con’t) Auricular prosthesis, provided by a nonphysician Partial facial prosthesis, provided by a nonphysician Nasal septal prosthesis, provided by a nonphysician Truss, single with standard pad Truss, double with standard pads Truss, addition to standard pad, water pad Truss, addition to standard pad, scrotal pad Prosthetic sheath, below knee, each Prosthetic sheath, above knee, each Prosthetic sheath, upper limb, each Prosthetic sheath/sock, including a gel cushion layer, below knee or above knee, each Prosthetic sock, multiple ply, below knee, each Prosthetic sock, multiple ply, above knee, each Prosthetic sock, multiple ply, upper limb, each Prosthetic shrinker, below knee, each Prosthetic shrinker, above knee, each Prosthetic shrinker, upper limb, each Prosthetic sock, single ply, fitting, below knee, each Prosthetic sock, single ply, fitting, above knee, each Prosthetic sock, single ply, fitting, upper limb, each Artificial larynx, any type Tracheostomy speaking valve Tracheo-esophageal voice prosthesis, patient inserted, any type, each Tracheo-esophageal voice prosthesis, inserted by a licensed health care provider, any type Voice amplifier Insert for indwelling tracheoesophageal prosthesis, with or without valve, replacement only, each Gelatin capsules or equivalent, for use with tracheoesophageal voice prosthesis, replacement only, per ten Cleaning device used with tracheoesophageal voice prosthesis, pipet, brush, or equal, replacement only, each Tracheoesophageal puncture dilator, replacement only, each Gelatin capsule, application device for use with tracheoesophageal voice prosthesis, each Implantable breast prosthesis, silicone or equal Injectable bulking agent, collagen implant, urinary tract, 2.5 ml syringe, includes shipping and necessary supplies Injectable bulking agent, synthetic implant, urinary tract, 1 ml syringe, includes shipping and necessary supplies Artificial cornea Ocular implant Aqueous shunt Ossicula implant Cochlear device, includes all internal and external components Headset/headpiece for use with cochlear implant device, replacement Fee Nu Fee Ue Fee RR 114.3 CMR 40.06(6) - DMEPOS Description (con’t) Microphone for use with cochlear implant device, replacement Transmitting coil for use with cochlear implant device, replacement Transmitter cable for use with cochlear implant device, replacement Cochlear implant external speech processor, replacement Zinc air battery for use with cochlear implant device, replacement, each Alkaline battery for use with cochlear implant device, any size, replacement, each Lithium ion battery for use with cochlear implant device speech processor, other than ear level, replacement, each Lithium ion battery for use with cochlear implant device speech processor, ear level, replacement, each Metacarpophalangeal joint implant Metacarpal phalangeal joint replacement, two or more pieces, metal (e.g., stainless steel or cobalt chrome), ceramic-like material (e.g., pyrocarbon), for surgical implantation (all sizes, includes entire system) Metatarsal joint implant Hallux implant Interphalangeal joint spacer, silicone or equal, each Interphalangeal finger joint replacement, two or more pieces, metal (e.g., stainless steel or cobalt chrome), ceramic-like material (e.g., pyrocarbon) for surgical implantation, any size Vascular graft material, synthetic, implant Implantable neurostimulator electrode, each Patient programmer (external) for use with implantable programmable neurostimulator pulse generator Implantable neurostimulator radiofrequency receiver Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver Radiofrequency transmitter (external) for use with implantable sacral root neurostimulator receiver for bowel and bladder management, replacement Implantable neurostimulator pulse generator, single array, rechargeable, includes extension Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension External recharging system for battery (internal) for use with implantable neurostimulator Auditory osseointegrated device, includes all internal and external components Auditory osseointegrated device, external sound processor, replacement External recharging system for battery (external) for use with implantable neurostimulator (7) Freestanding Diagnostic Facilities/Radiology. Global PC I.C. TC I.C. 40.06(7) - Radiologic Service Description Myelography, posterior fossa, radiological supervision and interpretation Cisternography, positive contrast, radiological supervision and interpretation Radiologic examination, eye, for detection of foreign body Radiologic examination, mandible; partial, less than four views Radiologic examination, mandible; complete, minimum of four views Radiologic examination, mastoids; less than three views per side Radiologic examination, mastoids; complete, minimum of three views per side Radiologic examination, internal auditory meati, complete Radiologic examination, facial bones; less than three views Radiologic examination, facial bones; complete, minimum of three views Radiologic examination, nasal bones, complete, minimum of three views Dacryocystography, nasolacrimal duct, radiological supervision and interpretation Radiologic examination; optic foramina Radiologic examination; orbits, complete, minimum of four views Radiologic examination, sinuses, paranasal, less than three views Radiologic examination, sinuses, paranasal, complete, minimum of three views Radiologic examination, sella turcica Radiologic examination, skull; less than four views Radiologic examination, skull; complete, minimum of four views Radiologic examination, teeth; single view Radiologic examination, teeth; partial examination, less than full mouth Radiologic examination, teeth; complete, full mouth Radiologic examination, temporomandibular joint, open and closed mouth; unilateral Radiologic examination, temporomandibular joint, open and closed mouth; bilateral Temporomandibular joint arthrography, radiological supervision and interpretation Magnetic resonance (eg, proton) imaging, temporomandibular joint(s) Cephalogram, orthodontic Orthopantogram Radiologic examination; neck, soft tissue Radiologic examination; pharynx or larynx, including fluoroscopy and/or magnification technique Complex dynamic pharyngeal and speech evaluation by cine or video recording Global PC TC 40.06(7) - Radiologic Service Description (con’t) Laryngography, contrast, radiological supervision and interpretation Radiologic examination, salivary gland for calculus Sialography, radiological supervision and interpretation Computed tomography, head or brain; without contrast material Computed tomography, head or brain; with contrast material(s) Computed tomography, head or brain; without contrast material, followed by contrast material(s) and further sections Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; with contrast material(s) Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material, followed by contrast material(s) and further sections Computed tomography, maxillofacial area; without contrast material Computed tomography, maxillofacial area; with contrast material(s) Computed tomography, maxillofacial area; without contrast material, followed by contrast material(s) and further sections Computed tomography, soft tissue neck; without contrast material Computed tomography, soft tissue neck; with contrast material(s) Computed tomography, soft tissue neck; without contrast material followed by contrast material(s) and further sections Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image postprocessing Computed tomographic angiography, neck, with contrast material(s), including noncontrast images, if performed, and image postprocessing Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; without contrast material(s) Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; with contrast material(s) Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; without contrast material(s), followed by contrast material(s) and further sequences Magnetic resonance angiography, head; without contrast material(s) Magnetic resonance angiography, head; with contrast material(s) Magnetic resonance angiography, head; without contrast material(s), followed by contrast material(s) and further sequences Magnetic resonance angiography, neck; without contrast material(s) Global PC I.C. I.C. I.C. I.C. TC I.C. I.C. I.C. I.C. 40.06(7) - Radiologic Service Description (con’t) Magnetic resonance angiography, neck; with contrast material(s) Magnetic resonance angiography, neck; without contrast material(s), followed by contrast material(s) and further sequences Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material Magnetic resonance (eg, proton) imaging, brain (including brain stem); with contrast material(s) Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material, followed by contrast material(s) and further sequences Magnetic resonance imaging, brain, functional MRI; including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration Magnetic resonance imaging, brain, functional MRI; requiring physician or psychologist administration of entire neurofunctional testing Magnetic resonance (eg, proton) imaging, brain (including brain stem and skull base), during open intracranial procedure (eg, to assess for residual tumor or residual vascular malformation); without contrast material Magnetic resonance (eg, proton) imaging, brain (including brain stem and skull base), during open intracranial procedure (eg, to assess for residual tumor or residual vascular malformation); with contrast material(s) Magnetic resonance (eg, proton) imaging, brain (including brain stem and skull base), during open intracranial procedure (eg, to assess for residual tumor or residual vascular malformation); without contrast material(s), followed by contrast material(s) and further sequences Radiologic examination, chest; single view, frontal Radiologic examination, chest; stereo, frontal Radiologic examination, chest, two views, frontal and lateral; Radiologic examination, chest, two views, frontal and lateral; with apical lordotic procedure Radiologic examination, chest, two views, frontal and lateral; with oblique projections Radiologic examination, chest, two views, frontal and lateral; with fluoroscopy Radiologic examination, chest, complete, minimum of four views; Radiologic examination, chest, complete, minimum of four views; with fluoroscopy Radiologic examination, chest, special views (eg, lateral decubitus, Bucky studies) Bronchography, unilateral, radiological supervision and interpretation Bronchography, bilateral, radiological supervision and interpretation Global PC I.C. TC I.C. 40.06(7) - Radiologic Service Description (con’t) Insertion pacemaker, fluoroscopy and radiography, radiological supervision and interpretation Radiologic examination, ribs, unilateral; two views Radiologic examination, ribs, unilateral; including posteroanterior chest, minimum of three views Radiologic examination, ribs, bilateral; three views Radiologic examination, ribs, bilateral; including posteroanterior chest, minimum of four views Radiologic examination; sternum, minimum of two views Radiologic examination; sternoclavicular joint or joints, minimum of three views Computed tomography, thorax; without contrast material Computed tomography, thorax; with contrast material(s) Computed tomography, thorax; without contrast material, followed by contrast material(s) and further sections Computed tomographic angiography, chest (noncoronary), with contrast material(s), including noncontrast images, if performed, and image postprocessing Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); without contrast material(s) Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); with contrast material(s) Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); without contrast material(s), followed by contrast material(s) and further sequences Magnetic resonance angiography, chest (excluding myocardium), with or without contrast material(s) Radiologic examination, spine, entire, survey study, anteroposterior and lateral Radiologic examination, spine, single view, specify level Radiologic examination, spine, cervical; two or three views Radiologic examination, spine, cervical; minimum of four views Radiologic examination, spine, cervical; complete, including oblique and flexion and/or extension studies Radiologic examination, spine, thoracolumbar, standing (scoliosis) Radiologic examination, spine; thoracic, two views Radiologic examination, spine; thoracic, three views Radiologic examination, spine; thoracic, minimum of four views Radiologic examination, spine; thoracolumbar, two views Radiologic examination, spine; scoliosis study, including supine and erect studies Radiologic examination, spine, lumbosacral; two or three views Global PC TC 40.06(7) - Radiologic Service Description (con’t) Radiologic examination, spine, lumbosacral; minimum of four views Radiologic examination, spine, lumbosacral; complete, including bending views Radiologic examination, spine, lumbosacral, bending views only, minimum of four views Computed tomography, cervical spine; without contrast material Computed tomography, cervical spine; with contrast material Computed tomography, cervical spine; without contrast material, followed by contrast material(s) and further sections Computed tomography, thoracic spine; without contrast material Computed tomography, thoracic spine; with contrast material Computed tomography, thoracic spine; without contrast material, followed by contrast material(s) and further sections Computed tomography, lumbar spine; without contrast material Computed tomography, lumbar spine; with contrast material Computed tomography, lumbar spine; without contrast material, followed by contrast material(s) and further sections Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; without contrast material Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; with contrast material(s) Magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; without contrast material Magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; with contrast material(s) Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; without contrast material Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; with contrast material(s) Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; cervical Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; thoracic Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; lumbar Magnetic resonance angiography, spinal canal and contents, with or without contrast material(s) Radiologic examination, pelvis; one or two views Radiologic examination, pelvis; complete, minimum of three views Computed tomographic angiography, pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing Global PC I.C. I.C. TC I.C. I.C. 40.06(7) - Radiologic Service Description (con’t) Computed tomography, pelvis; without contrast material Computed tomography, pelvis; with contrast material(s) Computed tomography, pelvis; without contrast material, followed by contrast material(s) and further sections Magnetic resonance (eg, proton) imaging, pelvis; without contrast material(s) Magnetic resonance (eg, proton) imaging, pelvis; with contrast material(s) Magnetic resonance (eg, proton) imaging, pelvis; without contrast material(s), followed by contrast material(s) and further sequences Magnetic resonance angiography, pelvis, with or without contrast material(s) Radiologic examination, sacroiliac joints; less than three views Radiologic examination, sacroiliac joints; three or more views Radiologic examination, sacrum and coccyx, minimum of two views Myelography, cervical, radiological supervision and interpretation Myelography, thoracic, radiological supervision and interpretation Myelography, lumbosacral, radiological supervision and interpretation M yel ography, t wo or m ore regi ons (eg, lumbar/thoracic, cervical/thoracic, lumbar/cervical, lumbar/thoracic/cervical), radiological supervision and interpretation Epidurography, radiological supervision and interpretation Discography, cervical or thoracic, radiological supervision and interpretation Radiological supervision and interpretation, percutaneous vertebroplasty or vertebral augmentation including cavity creation, per vertebral body; under fluoroscopic guidance Radiological supervision and interpretation, percutaneous vertebroplasty or vertebral augmentation including cavity creation, per vertebral body; under CT guidance Discography, lumbar, radiological supervision and interpretation Radiologic examination; clavicle, complete Radiologic examination; scapula, complete Radiologic examination, shoulder; one view Radiologic examination, shoulder; complete, minimum of two views Radiologic examination, shoulder, arthrography, radiological supervision and interpretation Radiologic examination; acromioclavicular joints, bilateral, with or without weighted distraction Radiologic examination; humerus, minimum of two views Global PC I.C. TC I.C. 40.06(7) - Radiologic Service Description (con’t) Radiologic examination, elbow; two views Radiologic examination, elbow; complete, minimum of three views Radiologic examination, elbow, arthrography, radiological supervision and interpretation Radiologic examination; forearm, two views Radiologic examination; upper extremity, infant, minimum of two views Radiologic examination, wrist; two views Radiologic examination, wrist; complete, minimum of three views Radiologic examination, wrist, arthrography, radiological supervision and interpretation Radiologic examination, hand; two views Radiologic examination, hand; minimum of three views Radiologic examination, finger(s), minimum of two views Computed tomography, upper extremity; without contrast material Computed tomography, upper extremity; with contrast material(s) Computed tomography, upper extremity; without contrast material, followed by contrast material(s) and further sections Computed tomographic angiography, upper extremity, with contrast material(s), including noncontrast images, if performed, and image postprocessing Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; without contrast material(s) Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; with contrast material(s) Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; without contrast material(s), followed by contrast material(s) and further sequences Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast material(s) Magnetic resonance (eg, proton) imaging, any joint of upper extremity; with contrast material(s) Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast material(s), followed by contrast material(s) and further sequences Magnetic resonance angiography, upper extremity, with or without contrast material(s) Radiologic examination, hip, unilateral; one view Radiologic examination, hip, unilateral; complete, minimum of two views Radiologic examination, hips, bilateral, minimum of two views of each hip, including anteroposterior view of pelvis Radiologic examination, hip, arthrography, radiological supervision and interpretation Radiologic examination, hip, during operative procedure Radiologic examination, pelvis and hips, infant or child, minimum of two views Global PC TC 40.06(7) - Radiologic Service Description (con’t) Radiological examination, sacroiliac joint arthrography, radiological supervision and interpretation Radiologic examination, femur, two views Radiologic examination, knee; one or two views Radiologic examination, knee; three views Radiologic examination, knee; complete, four or more views Radiologic examination, knee; both knees, standing, anteroposterior Radiologic examination, knee, arthrography, radiological supervision and interpretation Radiologic examination; tibia and fibula, two views Radiologic examination; lower extremity, infant, minimum of two views Radiologic examination, ankle; two views Radiologic examination, ankle; complete, minimum of three views Radiologic examination, ankle, arthrography, radiological supervision and interpretation Radiologic examination, foot; two views Radiologic examination, foot; complete, minimum of three views Radiologic examination; calcaneus, minimum of two views Radiologic examination; toe(s), minimum of two views Computed tomography, lower extremity; without contrast material Computed tomography, lower extremity; with contrast material(s) Computed tomography, lower extremity; without contrast material, followed by contrast material(s) and further sections Computed tomographic angiography, lower extremity, with contrast material(s), including noncontrast images, if performed, and image postprocessing Magnetic resonance (eg, proton) imaging, lower extremity other than joint; without contrast material(s) Magnetic resonance (eg, proton) imaging, lower extremity other than joint; with contrast material(s) Magnetic resonance (eg, proton) imaging, lower extremity other than joint; without contrast material(s), followed by contrast material(s) and further sequences Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material Magnetic resonance (eg, proton) imaging, any joint of lower extremity; with contrast material(s) Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material(s), followed by contrast material(s) and further sequences Magnetic resonance angiography, lower extremity, with or without contrast material(s) Radiologic examination, abdomen; single anteroposterior view Global PC I.C. I.C. TC I.C. I.C. 40.06(7) - Radiologic Service Description (con’t) Radiologic examination, abdomen; anteroposterior and additional oblique and cone views Radiologic examination, abdomen; complete, including decubitus and/or erect views Radiologic examination, abdomen; complete acute abdomen series, including supine, erect, and/or decubitus views, single view chest Computed tomography, abdomen; without contrast material Computed tomography, abdomen; with contrast material(s) Computed tomography, abdomen; without contrast material, followed by contrast material(s) and further sections Computed tomographic angiography, abdomen, with contrast material(s), including noncontrast images, if performed, and image postprocessing Magnetic resonance (eg, proton) imaging, abdomen; without contrast material(s) Magnetic resonance (eg, proton) imaging, abdomen; with contrast material(s) Magnetic resonance (eg, proton) imaging, abdomen; without contrast material(s), followed by with contrast material(s) and further sequences Magnetic resonance angiography, abdomen, with or without contrast material(s) Peritoneogram (eg, after injection of air or contrast), radiological supervision and interpretation Radiologic examination; pharynx and/or cervical esophagus Radiologic examination; esophagus Swallowing function, with cineradiography/ videoradiography Removal of foreign body(s), esophageal, with use of balloon catheter, radiological supervision and interpretation Radiologic examination, gastrointestinal tract, upper; with or without delayed films, without KUB Radiologic examination, gastrointestinal tract, upper; with or without delayed films, with KUB Radiologic examination, gastrointestinal tract, upper; with small intestine, includes multiple serial films Radiological examination, gastrointestinal tract, upper, air contrast, with specific high density barium, effervescent agent, with or without glucagon; with or without delayed films, without KUB Radiological examination, gastrointestinal tract, upper, air contrast, with specific high density barium, effervescent agent, with or without glucagon; with or without delayed films, with KUB Radiological examination, gastrointestinal tract, upper, air contrast, with specific high density barium, effervescent agent, with or without glucagon; with small intestine follow-through Radiologic examination, small intestine, includes multiple serial films; Global PC I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. TC I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. 40.06(7) - Radiologic Service Description (con’t) Radiologic examination, small intestine, includes multiple serial films; via enteroclysis tube Duodenography, hypotonic Radiologic examination, colon; barium enema, with or without KUB Radiologic examination, colon; air contrast with specific high density barium, with or without glucagon Therapeutic enema, contrast or air, for reduction of intussusception or other intraluminal obstruction (eg, meconium ileus) Cholecystography, oral contrast; Cholecystography, oral contrast; additional or repeat examination or multiple day examination Cholangiography and/or pancreatography; intraoperative, radiological supervision and interpretation Cholangiography and/or pancreatography; additional set intraoperative, radiological supervision and interpretation (List separately in addition to code for primary procedure) Cholangiography and/or pancreatography; through existing catheter, radiological supervision and interpretation Cholangiography, percutaneous, transhepatic, radiological supervision and interpretation Postoperative biliary duct calculus removal, percutaneous via T-tube tract, basket, or snare (eg, Burhenne technique), radiological supervision and interpretation Endoscopic catheterization of the biliary ductal system, radiological supervision and interpretation Endoscopic catheterization of the pancreatic ductal system, radiological supervision and interpretation Combined endoscopic catheterization of the biliary and pancreatic ductal systems, radiological supervision and interpretation Introduction of long gastrointestinal tube (eg, Miller-Abbott), including multiple fluoroscopies and films, radiological supervision and interpretation Percutaneous placement of enteroclysis tube, radiological supervision and interpretation Intraluminal dilation of strictures and/or obstructions (eg, esophagus), radiological supervision and interpretation Percutaneous transhepatic dilation of biliary duct stricture with or without placement of stent, radiological supervision and interpretation Urography (pyelography), intravenous, with or without KUB, with or without tomography Urography, infusion, drip technique and/or bolus technique; Urography, infusion, drip technique and/or bolus technique; with nephrotomography Urography, retrograde, with or without KUB Global I.C. I.C. I.C. I.C. I.C. I.C. PC TC I.C. I.C. I.C. I.C. I.C. I.C. 40.06(7) - Radiologic Service Description (con’t) Urography, antegrade (pyelostogram, nephrostogram, loopogram), radiological supervision and interpretation Cystography, minimum of thee views, radiological supervision and interpretation Vasography, vesiculography, or epididymography, radiological supervision and interpretation Corpora cavernosography, radiological supervision and interpretation Urethrocystography, retrograde, radiological supervision and interpretation Urethrocystography, voiding, radiological supervision and interpretation Radiologic examination, renal cyst study, translumbar, contrast visualization, radiological supervision and interpretation Introduction of intracatheter or catheter into renal pelvis for drainage and/or injection, percutaneous, radiological supervision and interpretation Introduction of ureteral catheter or stent into ureter through renal pelvis for drainage and/or injection, percutaneous, radiological supervision and interpretation Dilation of nephrostomy, ureters, or urethra, radiological supervision and interpretation Pelvimetry, with or without placental localization Hysterosalpingography, radiological supervision and interpretation Transcervical catheterization of fallopian tube, radiological supervision and interpretation Perineogram (eg, vaginogram, for sex determination or extent of anomalies) Cardiac magnetic resonance imaging for morphology and function without contrast material; Cardiac magnetic resonance imaging for morphology and function without contrast material; with flow/velocity quantification Cardiac magnetic resonance imaging for morphology and function without contrast material; with stress imaging Cardiac magnetic resonance imaging for morphology and function without contrast material; with flow/velocity quantification and stress Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; with flow/velocity quantification Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; with stress imaging Global PC TC 40.06(7) - Radiologic Service Description (con’t) Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; with flow/velocity quantification and stress Aortography, thoracic, without serialography, radiological supervision and interpretation Aortography, thoracic, by serialography, radiological supervision and interpretation Aortography, abdominal, by serialography, radiological supervision and interpretation Aortography, abdominal plus bilateral iliofemoral lower extremity, catheter, by serialography, radiological supervision and interpretation Computed tomographic angiography, abdominal aorta and bilateral iliofemoral lower extremity runoff, with contrast material(s), including noncontrast images, if performed, and image postprocessing Angiography, cervicocerebral, catheter, including vessel origin, radiological supervision and interpretation Angiography, brachial, retrograde, radiological supervision and interpretation Angiography, external carotid, unilateral, selective, radiological supervision and interpretation Angiography, external carotid, bilateral, selective, radiological supervision and interpretation Angiography, carotid, cerebral, unilateral, radiological supervision and interpretation Angiography, carotid, cerebral, bilateral, radiological supervision and interpretation Angiography, carotid, cervical, unilateral, radiological supervision and interpretation Angiography, carotid, cervical, bilateral, radiological supervision and interpretation Angiography, vertebral, cervical, and/or intracranial, radiological supervision and interpretation Angiography, spinal, selective, radiological supervision and interpretation Angiography, extremity, unilateral, radiological supervision and interpretation Angiography, extremity, bilateral, radiological supervision and interpretation Angiography, renal, unilateral, selective (including flush aortogram), radiological supervision and interpretation Angiography, renal, bilateral, selective (including flush aortogram), radiological supervision and interpretation Angiography, visceral, selective or supraselective (with or without flush aortogram), radiological supervision and interpretation Angiography, adrenal, unilateral, selective, radiological supervision and interpretation Angiography, adrenal, bilateral, selective, radiological supervision and interpretation 40.06: continued Global PC I.C. I.C. I.C. I.C. I.C. TC 40.06(7) - Radiologic Service Description (con’t) Angiography, pelvic, selective or supraselective, radiological supervision and interpretation Angiography, pulmonary, unilateral, selective, radiological supervision and interpretation Angiography, pulmonary, bilateral, selective, radiological supervision and interpretation Angiography, pulmonary, by nonselective catheter or venous injection, radiological supervision and interpretation Angiography, internal mammary, radiological supervision and interpretation Angiography, selective, each additional vessel studied after basic examination, radiological supervision and interpretation (List separately in addition to code for primary procedure) Angiography, arteriovenous shunt (eg, dialysis patient), radiological supervision and interpretation I.C. Lymphangiography, extremity only, unilateral, radiological supervision and interpretation I.C. Lymphangiography, extremity only, bilateral, radiological supervision and interpretation I.C. Lymphangiography, pelvic/abdominal, unilateral, radiological supervision and interpretation I.C. Lymphangiography, pelvic/abdominal, bilateral, radiological supervision and interpretation Shuntogram for investigation of previously placed indwelling nonvascular shunt (eg, LeVeen shunt, ventriculoperitoneal shunt, indwelling infusion pump), radiological supervision and interpretation I.C. Splenoportography, radiological supervision and interpretation Venography, extremity, unilateral, radiological supervision and interpretation Venography, extremity, bilateral, radiological supervision and interpretation Venography, caval, inferior, with serialography, radiological supervision and interpretation Venography, caval, superior, with serialography, radiological supervision and interpretation Venography, renal, unilateral, selective, radiological supervision and interpretation Venography, renal, bilateral, selective, radiological supervision and interpretation Venography, adrenal, unilateral, selective, radiological supervision and interpretation Venography, adrenal, bilateral, selective, radiological supervision and interpretation Venography, venous sinus (eg, petrosal and inferior sagittal) or jugular, catheter, radiological supervision and interpretation Venography, superior sagittal sinus, radiological supervision and interpretation Venography, epidural, radiological supervision and interpretation Venography, orbital, radiological supervision and interpretation 40.06: continued Global PC I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. TC 40.06(7) - Radiologic Service Description (con’t) Percutaneous transhepatic portography with hemodynamic evaluation, radiological supervision and interpretation Percutaneous transhepatic portography without hemodynamic evaluation, radiological supervision and interpretation Hepatic venography, wedged or free, with hemodynamic evaluation, radiological supervision and interpretation Hepatic venography, wedged or free, without hemodynamic evaluation, radiological supervision and interpretation Venous sampling through catheter, with or without angiography (eg, for parathyroid hormone, renin), radiological supervision and interpretation I.C. Transcatheter therapy, embolization, any method, radiological supervision and interpretation I.C. Transcatheter therapy, infusion, any method (eg, thrombolysis other than coronary), radiological supervision and interpretation I.C. Angiography through existing catheter for follow-up study for transcatheter therapy, embolization or infusion I.C. Exchange of a previously placed intravascular catheter during thrombolytic therapy with contrast monitoring, radiological supervision and interpretation Mechanical removal of pericatheter obstructive material (eg, fibrin sheath) from central venous device via separate venous access, radiologic supervision and interpretation Mechanical removal of intraluminal (intracatheter) obstructive material from central venous device through device lumen, radiologic supervision and interpretation I.C. Percutaneous placement of IVC filter, radiological supervision and interpretation I.C. Intravascular ultrasound (non-coronary vessel), radiological supervision and interpretation; initial vessel I.C. Intravascular ultrasound (non-coronary vessel), radiological supervision and interpretation; each additional non-coronary vessel (List separately in addition to code for primary procedure) I.C. Endovascular repair of infrarenal abdominal aortic aneurysm or dissection, radiological supervision and interpretation I.C. Placement of proximal or distal extension prosthesis for endovascular repair of infrarenal aortic or iliac artery aneurysm, pseudoaneurysm, or dissection, radiological supervision and interpretation I.C. Endovascular repair of iliac artery aneurysm, pseudoaneurysm, arteriovenous malformation, or trauma, radiological supervision and interpretation Global PC I.C. I.C. I.C. I.C. I.C. I.C. I.C. TC I.C. I.C. I.C. I.C. I.C. I.C. I.C. 40.06(7) - Radiologic Service Description (con’t) Endovascular repair of descending thoracic aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption); involving coverage of left subclavian artery origin, initial endoprosthesis plus descending thoracic aortic extension(s), if required, to level of celiac artery origin, radiological supervision and interpretation Endovascular repair of descending thoracic aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption); not involving coverage of left subclavian artery origin, initial endoprosthesis plus descending thoracic aortic extension(s), if required, to level of celiac artery origin, radiological supervision and interpretation Placement of proximal extension prosthesis for endovascular repair of descending thoracic aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption), radiological supervision and interpretation Placement of distal extension prosthesis(s) (delayed) after endovascular repair of descending thoracic aorta, as needed, to level of celiac origin, radiological supervision and interpretation Transcatheter introduction of intravascular stent(s) (except coronary, carotid, and vertebral vessel), percutaneous and/or open, radiological supervision and interpretation, each vessel Transcatheter retrieval, percutaneous, of intravascular foreign body (eg, fractured venous or arterial catheter), radiological supervision and interpretation Transluminal balloon angioplasty, peripheral artery, radiological supervision and interpretation Transluminal balloon angioplasty, each additional peripheral artery, radiological supervision and interpretation (List separately in addition to code for primary procedure) Transluminal balloon angioplasty, renal or other visceral artery, radiological supervision and interpretation Transluminal balloon angioplasty, each additional visceral artery, radiological supervision and interpretation (List separately in addition to code for primary procedure) Transcatheter biopsy, radiological supervision and interpretation Transluminal balloon angioplasty, venous (eg, subclavian stenosis), radiological supervision and interpretation Percutaneous transhepatic biliary drainage with contrast monitoring, radiological supervision and interpretation Percutaneous placement of drainage catheter for combined internal and external biliary drainage or of a drainage stent for internal biliary drainage in patients with an inoperable mechanical biliary obstruction, radiological supervision and interpretation Global PC I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. TC I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. 40.06(7) - Radiologic Service Description (con’t) Change of percutaneous tube or drainage catheter with contrast monitoring (eg, genitourinary system, abscess), radiological supervision and interpretation Radiological guidance (ie, fluoroscopy, ultrasound, or computed tomography), for percutaneous drainage (eg, abscess, specimen collection), with placement of catheter, radiological supervision and interpretation Transluminal atherectomy, peripheral artery, radiological supervision and interpretation Transluminal atherectomy, each additional peripheral artery, radiological supervision and interpretation (List separately in addition to code for primary procedure) Transluminal atherectomy, renal, radiological supervision and interpretation Transluminal atherectomy, visceral, radiological supervision and interpretation Transluminal atherectomy, each additional visceral artery, radiological supervision and interpretation (List separately in addition to code for primary procedure) Fluoroscopy (separate procedure), up to one hour physician time, other than 71023 or 71034 (eg, cardiac fluoroscopy) Fluoroscopy, physician time more than one hour, assisting a nonradiologic physician (eg, nephrostolithotomy, ERCP, bronchoscopy, transbronchial biopsy) Radiologic examination from nose to rectum for foreign body, single view, child Radiologic examination, abscess, fistula or sinus tract study, radiological supervision and interpretation Radiological examination, surgical specimen Radiologic examination, single plane body section (eg, tomography), other than with urography Radiologic examination, complex motion (ie, hypercycloidal) body section (eg, mastoid polytomography), other than with urography; unilateral Radiologic examination, complex motion (ie, hypercycloidal) body section (eg, mastoid polytomography), other than with urography; bilateral Cineradiography/videoradiography, except where specifically included Cineradiography/videoradiography to complement routine examination (List separately in addition to code for primary procedure) Consultation on X-ray examination made elsewhere, written report Xeroradiography Subtraction in conjunction with contrast studies 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; not requiring image postprocessing on an independent workstation 40.06: continued Global PC I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. TC 40.06(7) - Radiologic Service Description (con’t) 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; requiring image postprocessing on an independent workstation Computed tomography, limited or localized follow-up study Magnetic resonance spectroscopy I.C. Unlisted fluoroscopic procedure (eg, diagnostic, interventional) I.C. Unlisted computed tomography procedure (eg, diagnostic, interventional) I.C. Unlisted magnetic resonance procedure (eg, diagnostic, interventional) I.C. Unlisted diagnostic radiographic procedure Echoencephalography, real time with image documentation (gray scale) (for determination of ventricular size, delineation of cerebral contents, and detection of fluid masses or other intracranial abnormalities), including A-mode encephalography as secondary component where indicated Ophthalmic ultrasound, diagnostic; B-scan and quantitative A-scan performed during the same patient encounter Ophthalmic ultrasound, diagnostic; quantitative A-scan only Ophthalmic ultrasound, diagnostic; B-scan (with or without superimposed non-quantitative A-scan) Ophthalmic ultrasound, diagnostic; anterior segment ultrasound, immersion (water bath) B-scan or high resolution biomicroscopy Ophthalmic ultrasound, diagnostic; corneal pachymetry, unilateral or bilateral (determination of corneal thickness) Ophthalmic biometry by ultrasound echography, A-scan; Ophthalmic biometry by ultrasound echography, A-scan; with intraocular lens power calculation Ophthalmic ultrasonic foreign body localization Ultrasound, soft tissues of head and neck (eg, thyroid, parathyroid, parotid), real time with image documentation Ultrasound, chest (includes mediastinum), real time with image documentation Ultrasound, breast(s) (unilateral or bilateral), real time with image documentation Ultrasound, abdominal, real time with image documentation; complete Ultrasound, abdominal, real time with image documentation; limited (eg, single organ, quadrant, follow-up) Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; complete Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; limited Ultrasound, transplanted kidney, real time and duplex Doppler with image documentation Global PC TC 40.06(7) - Radiologic Service Description (con’t) Ultrasound, spinal canal and contents Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (< 14 weeks 0 days), transabdominal approach; single or first gestation Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (< 14 weeks 0 days), transabdominal approach; each additional gestation (List separately in addition to code for primary procedure) Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> or = 14 weeks 0 days), transabdominal approach; single or first gestation Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> or = 14 weeks 0 days), transabdominal approach; each additional gestation (List separately in addition to code for primary procedure) Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; each additional gestation (List separately in addition to code for primary procedure) Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; single or first gestation Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; each additional gestation (List separately in addition to code for primary procedure) Ultrasound, pregnant uterus, real time with image documentation, limited (eg, fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume), one or more fetuses Ultrasound, pregnant uterus, real time with image documentation, follow-up (eg, re-evaluation of fetal size by measuring standard growth parameters and amniotic fluid volume, re-evaluation of organ system(s) suspected or confirmed to be abnormal on a previous scan), transabdominal approach, per fetus Ultrasound, pregnant uterus, real time with image documentation, transvaginal Fetal biophysical profile; with non-stress testing Fetal biophysical profile; without non-stress testing Doppler velocimetry, fetal; umbilical artery Doppler velocimetry, fetal; middle cerebral artery 40.06: continued Global PC I.C. I.C. I.C. I.C. TC 40.06(7) - Radiologic Service Description (con’t) Echocardiography, fetal, cardiovascular system, real time with image documentation (2D), with or without M-mode recording; Echocardiography, fetal, cardiovascular system, real time with image documentation (2D), with or without M-mode recording; follow-up or repeat study Doppler echocardiography, fetal, pulsed wave and/or continuous wave with spectral display; complete Doppler echocardiography, fetal, pulsed wave and/or continuous wave with spectral display; follow-up or repeat study Ultrasound, transvaginal Saline infusion sonohysterography (SIS), including color flow Doppler, when performed Ultrasound, pelvic (nonobstetric), real time with image documentation; complete Ultrasound, pelvic (nonobstetric), real time with image documentation; limited or follow-up (eg, for follicles) Ultrasound, scrotum and contents Ultrasound, transrectal; Ultrasound, transrectal; prostate volume study for brachytherapy treatment planning (separate procedure) Ultrasound, extremity, nonvascular, real time with image documentation Ultrasound, infant hips, real time with imaging documentation; dynamic (requiring physician manipulation) Ultrasound, infant hips, real time with imaging documentation; limited, static (not requiring physician manipulation) Ultrasonic guidance for pericardiocentesis, imaging supervision and interpretation I.C. Ultrasonic guidance for endomyocardial biopsy, imaging supervision and interpretation Ultrasound guided compression repair of arterial pseudoaneurysm or arteriovenous fistulae (includes diagnostic ultrasound evaluation, compression of lesion and imaging) Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting (List separately in addition to code for primary procedure) I.C. Ultrasound guidance for, and monitoring of, parenchymal tissue ablation I.C. Ultrasonic guidance for intrauterine fetal transfusion or cordocentesis, imaging supervision and interpretation Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation I.C. Ultrasonic guidance for chorionic villus sampling, imaging supervision and interpretation Ultrasonic guidance for amniocentesis, imaging supervision and interpretation Global PC I.C. I.C. I.C. I.C. I.C. I.C. TC I.C. I.C. I.C. I.C. I.C. 40.06(7) - Radiologic Service Description (con’t) Ultrasonic guidance for aspiration of ova, imaging supervision and interpretation Ultrasonic guidance for placement of radiation therapy fields Ultrasonic guidance for interstitial radioelement application Ultrasound study follow-up (specify) Gastrointestinal endoscopic ultrasound, supervision and interpretation Ultrasound bone density measurement and interpretation, peripheral site(s), any method Ultrasonic guidance, intraoperative Unlisted ultrasound procedure (eg, diagnostic, interventional) Fluoroscopic guidance for central venous access device placement, replacement (catheter only or complete), or removal (includes fluoroscopic guidance for vascular access and catheter manipulation, any necessary contrast injections through access site or catheter with related venographyradiologic supervision and interpretation, and radiographic documentation of final catheter position) (List separately in addition to code for primary procedure) Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device) Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural, transforaminal epidural, subarachnoid, paravertebral facet joint, paravertebral facet joint nerve, or sacroiliac joint), including neurolytic agent destruction Computed tomography guidance for stereotactic localization Computed tomography guidance for needle placement (eg, biopsy, aspiration, injection, localization device), radiological supervision and interpretation Computed tomography guidance for, and monitoring of, parenchymal tissue ablation Computed tomography guidance for placement of radiation therapy fields Magnetic resonance guidance for needle placement (eg, for biopsy, needle aspiration, injection, or placement of localization device) radiological supervision and interpretation Magnetic resonance guidance for, and monitoring of, parenchymal tissue ablation Stereotactic localization guidance for breast biopsy or needle placement (eg, for wire localization or for injection), each lesion, radiological supervision and interpretation Mammographic guidance for needle placement, breast (eg, for wire localization or for injection), each lesion, radiological supervision and interpretation Global PC I.C. I.C. I.C. I.C. TC I.C. I.C. I.C. I.C. 40.06(7) - Radiologic Service Description (con’t) Computer-aided detection (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation, with or without digitization of film radiographic images; diagnostic mammography (List separately in addition to code for primary procedure) Computer-aided detection (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation, with or without digitization of film radiographic images; screening mammography (List separately in addition to code for primary procedure) Mammary ductogram or galactogram, single duct, radiological supervision and interpretation Mammary ductogram or galactogram, multiple ducts, radiological supervision and interpretation Mammography; unilateral Mammography; bilateral Screening mammography, bilateral (2-view film study of each breast) Magnetic resonance imaging, breast, without and/or with contrast material(s); unilateral Magnetic resonance imaging, breast, without and/or with contrast material(s); bilateral Manual application of stress performed by physician for joint radiography, including contralateral joint if indicated Bone age studies Bone length studies (orthoroentgenogram, scanogram) Radiologic examination, osseous survey; limited (eg, for metastases) Radiologic examination, osseous survey; complete (axial and appendicular skeleton) Radiologic examination, osseous survey, infant Joint survey, single view, two or more joints (specify) Computed tomography, bone mineral density study, one or more sites; axial skeleton (eg, hips, pelvis, spine) Computed tomography, bone mineral density study, one or more sites; appendicular skeleton (peripheral) (eg, radius, wrist, heel) Dual-energy X-ray absorptiometry (DXA), bone density study, one or more sites; axial skeleton (eg, hips, pelvis, spine) Dual-energy X-ray absorptiometry (DXA), bone density study, one or more sites; appendicular skeleton (peripheral) (eg, radius, wrist, heel) Dual-energy X-ray absorptiometry (DXA), bone density study, one or more sites; vertebral fracture assessment Radiographic absorptiometry (eg, photodensitometry, radiogrammetry), one or more sites Magnetic resonance (eg, proton) imaging, bone marrow blood supply Therapeutic radiology treatment planning; simple Therapeutic radiology treatment planning; intermediate Therapeutic radiology treatment planning; complex Global PC I.C. I.C. TC 40.06(7) - Radiologic Service Description (con’t) Therapeutic radiology simulation-aided field setting; simple Therapeutic radiology simulation-aided field setting; intermediate Therapeutic radiology simulation-aided field setting; complex Therapeutic radiology simulation-aided field setting; 3-dimensional I.C. Unlisted procedure, therapeutic radiology clinical treatment planning Basic radiation dosimetry calculation, central axis depth dose calculation, TDF, NSD, gap calculation, off axis factor, tissue inhomogeneity factors, calculation of non-ionizing radiation surface and depth dose, as required during course of treatment, only when prescribed by the treating physician Intensity modulated radiotherapy plan, including dose-volume histograms for target and critical structure partial tolerance specifications Teletherapy, isodose plan (whether hand or computer calculated); simple (one or two parallel opposed unmodified ports directed to a single area of interest) Teletherapy, isodose plan (whether hand or computer calculated); intermediate (three or more treatment ports directed to a single area of interest) Teletherapy, isodose plan (whether hand or computer calculated); complex (mantle or inverted Y, tangential ports, the use of wedges, compensators, complex blocking, rotational beam, or special beam considerations) Special teletherapy port plan, particles, hemibody, total body Brachytherapy isodose plan; simple (calculation made from single plane, one to four sources/ribbon application, remote afterloading brachytherapy, one to eight sources) Brachytherapy isodose plan; intermediate (multiplane dosage calculations, application involving five to ten sources/ribbons, remote afterloading brachytherapy, nine to 12 sources) Brachytherapy isodose plan; complex (multiplane isodose plan, volume implant calculations, over ten sources/ribbons used, special spatial reconstruction, remote afterloading brachytherapy, over 12 sources) Special dosimetry (eg, TLD, microdosimetry) (specify), only when prescribed by the treating physician Treatment devices, design and construction; simple (simple block, simple bolus) Treatment devices, design and construction; intermediate (multiple blocks, stents, bite blocks, special bolus) Stereotactic body radiation therapy, treatment delivery, per fraction to one or more lesions, including image guidance, entire course not to exceed five fractions Global PC TC I.C. 40.06(7) - Radiologic Service Description (con’t) Unlisted procedure, medical radiation physics, dosimetry and treatment devices, and special services Radiation treatment delivery, superficial and/or ortho voltage Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks; up to 5 MeV Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks; 6-10 MeV Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks; 11-19 MeV Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks; 20 MeV or greater Radiation treatment delivery, two separate treatment areas, three or more ports on a single treatment area, use of multiple blocks; up to 5 MeV Radiation treatment delivery, two separate treatment areas, three or more ports on a single treatment area, use of multiple blocks; 6-10 MeV Radiation treatment delivery, two separate treatment areas, three or more ports on a single treatment area, use of multiple blocks; 11-19 MeV Radiation treatment delivery, two separate treatment areas, three or more ports on a single treatment area, use of multiple blocks; 20 MeV or greater Radiation treatment delivery, three or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; up to 5 MeV Radiation treatment delivery, three or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 6-10 MeV Radiation treatment delivery, three or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 11-19 MeV Radiation treatment delivery, three or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 20 MeV or greater Therapeutic radiology port film(s) Intensity modulated treatment delivery, single or multiple fields/arcs, via narrow spatially and temporally modulated beams, binary, dynamic MLC, per treatment session Stereoscopic X-ray guidance for localization of target volume for the delivery of radiation therapy High energy neutron radiation treatment delivery; single treatment area using a single port or parallel-opposed ports with no blocks or simple blocking Global PC I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. TC 40.06(7) - Radiologic Service Description (con’t) High energy neutron radiation treatment delivery; one or more isocenter(s) with coplanar or non-coplanar geometry with blocking and/or wedge, and/or compensator(s) Radiation treatment management, five treatments Radiation therapy management with complete course of therapy consisting of one or two fractions only Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of one session) Stereotactic body radiation therapy, treatment management, per treatment course, to one or more lesions, including image guidance, entire course not to exceed five fractions Special treatment procedure (eg, total body irradiation, hemibody radiation, per oral, endocavitary or intraoperative cone irradiation) I.C. Unlisted procedure, therapeutic radiology treatment management Proton treatment delivery; simple, without compensation Proton treatment delivery; simple, with compensation Proton treatment delivery; intermediate Proton treatment delivery; complex Hyperthermia, externally generated; superficial (ie, heating to a depth of 4 cm or less) Hyperthermia, externally generated; deep (ie, heating to depths greater than 4 cm) Hyperthermia generated by interstitial probe(s); five or fewer interstitial applicators Hyperthermia generated by interstitial probe(s); more than five interstitial applicators Hyperthermia generated by intracavitary probe(s) Infusion or instillation of radioelement solution (includes three months follow-up care) Intracavitary radiation source application; simple Intracavitary radiation source application; intermediate Intracavitary radiation source application; complex Interstitial radiation source application; simple Interstitial radiation source application; intermediate Interstitial radiation source application; complex Remote afterloading high intensity brachytherapy; one - four source positions or catheters Remote afterloading high intensity brachytherapy; five - eight source positions or catheters Remote afterloading high intensity brachytherapy; nine-12 source positions or catheters Remote afterloading high intensity brachytherapy; over 12 source positions or catheters Surface application of radiation source Supervision, handling, loading of radiation source I.C. Unlisted procedure, clinical brachytherapy Thyroid uptake; single determination Thyroid uptake; multiple determinations Thyroid uptake; stimulation, suppression or discharge (not including initial uptake studies) Global PC I.C. I.C. I.C. I.C. TC 40.06(7) - Radiologic Service Description (con’t) Thyroid imaging, with uptake; single determination Thyroid imaging, with uptake; multiple determinations Thyroid imaging; only Thyroid imaging; with vascular flow Thyroid carcinoma metastases imaging; limited area (eg, neck and chest only) Thyroid carcinoma metastases imaging; with additional studies (eg, urinary recovery) Thyroid carcinoma metastases imaging; whole body Thyroid carcinoma metastases uptake (List separately in addition to code for primary procedure) Parathyroid imaging Adrenal imaging, cortex and/or medulla I.C. Unlisted endocrine procedure, diagnostic nuclear medicine Bone marrow imaging; limited area Bone marrow imaging; multiple areas Bone marrow imaging; whole body Plasma volume, radiopharmaceutical volume-dilution technique (separate procedure); single sampling Plasma volume, radiopharmaceutical volume-dilution technique (separate procedure); multiple samplings Red cell volume determination (separate procedure); single sampling Red cell volume determination (separate procedure); multiple samplings Whole blood volume determination, including separate measurement of plasma volume and red cell volume (radiopharmaceutical volume-dilution technique) Red cell survival study; Red cell survival study; differential organ/tissue kinetics (eg, splenic and/or hepatic sequestration) Labeled red cell sequestration, differential organ/tissue (eg, splenic and/or hepatic) Spleen imaging only, with or without vascular flow Kinetics, study of platelet survival, with or without differential organ/tissue localization Platelet survival study Lymphatics and lymph nodes imaging I.C. Unlisted hematopoietic, reticuloendothelial and lymphatic procedure, diagnostic nuclear medicine Liver imaging; static only Liver imaging; with vascular flow Liver imaging (SPECT); Liver imaging (SPECT); with vascular flow Liver and spleen imaging; static only Liver and spleen imaging; with vascular flow Liver function study with hepatobiliary agents, with serial images Hepatobiliary ductal system imaging, including gallbladder, with or without pharmacologic intervention, with or without quantitative measurement of gallbladder function Salivary gland imaging; Salivary gland imaging; with serial images Global PC I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. TC 40.06(7) - Radiologic Service Description (con’t) Salivary gland function study Esophageal motility Gastric mucosa imaging Gastroesophageal reflux study Gastric emptying study Urea breath test, C-14 (isotopic); acquisition for analysis Urea breath test, C-14 (isotopic); analysis Vitamin B-12 absorption study (eg, Schilling test); without intrinsic factor Vitamin B-12 absorption study (eg, Schilling test); with intrinsic factor Vitamin B-12 absorption studies combined, with and without intrinsic factor Acute gastrointestinal blood loss imaging I.C. Gastrointestinal protein loss Intestine imaging (eg, ectopic gastric mucosa, Meckel's localization, volvulus) Peritoneal-venous shunt patency test (eg, for LeVeen, Denver shunt) I.C. Unlisted gastrointestinal procedure, diagnostic nuclear medicine Bone and/or joint imaging; limited area Bone and/or joint imaging; multiple areas Bone and/or joint imaging; whole body Bone and/or joint imaging; three phase study Bone and/or joint imaging; tomographic (SPECT) Bone density (bone mineral content) study, one or more sites; single photon absorptiometry Bone density (bone mineral content) study, one or more sites; dual photon absorptiometry, one or more sites I.C. Unlisted musculoskeletal procedure, diagnostic nuclear medicine I.C. Determination of central c-v hemodynamics (non-imaging) (eg, ejection fraction with probe technique) with or without pharmacologic intervention or exercise, single or multiple determinations Cardiac shunt detection Non-cardiac vascular flow imaging (ie, angiography, venography) Acute venous thrombosis imaging, peptide Venous thrombosis imaging, venogram; unilateral Venous thrombosis imaging, venogram; bilateral I.C. Myocardial imaging, positron emission tomography (PET), metabolic evaluation Myocardial perfusion imaging; (planar) single study, at rest or stress (exercise and/or pharmacologic), with or without quantification Myocardial perfusion imaging; multiple studies (planar), at rest and/or stress (exercise and/or pharmacologic), and redistribution and/or rest injection, with or without quantification 40.06: continued Global PC I.C. I.C. I.C. I.C. TC 40.06(7) - Radiologic Service Description (con’t) Myocardial perfusion imaging; tomographic (SPECT), single study (including attenuation correction when performed), at rest or stress (exercise and/or pharmacologic), with or without quantification Myocardial perfusion imaging; tomographic (SPECT), multiple studies (including attenuation correction when performed), at rest and/or stress (exercise and/or pharmacologic) and redistribution and/or rest injection, with or without quantification Myocardial imaging, infarct avid, planar; qualitative or quantitative Myocardial imaging, infarct avid, planar; with ejection fraction by first pass technique Myocardial imaging, infarct avid, planar; tomographic SPECT with or without quantification Cardiac blood pool imaging, gated equilibrium; planar, single study at rest or stress (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without additional quantitative processing Cardiac blood pool imaging, gated equilibrium; multiple studies, wall motion study plus ejection fraction, at rest and stress (exercise and/or pharmacologic), with or without additional quantification Myocardial perfusion study with wall motion, qualitative or quantitative study (List separately in addition to code for primary procedure) Myocardial perfusion study with ejection fraction (List separately in addition to code for primary procedure) Cardiac blood pool imaging (planar), first pass technique; single study, at rest or with stress (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without quantification Cardiac blood pool imaging (planar), first pass technique; multiple studies, at rest and with stress (exercise and/ or pharmacologic), wall motion study plus ejection fraction, with or without quantification I.C. Myocardial imaging, positron emission tomography (PET), perfusion; single study at rest or stress I.C. Myocardial imaging, positron emission tomography (PET), perfusion; multiple studies at rest and/or stress Cardiac blood pool imaging, gated equilibrium, SPECT, at rest, wall motion study plus ejection fraction, with or without quantitative processing Cardiac blood pool imaging, gated equilibrium, single study, at rest, with right ventricular ejection fraction by first pass technique (List separately in addition to code for primary procedure) I.C. Unlisted cardiovascular procedure, diagnostic nuclear medicine Pulmonary perfusion imaging, particulate Pulmonary perfusion imaging, particulate, with ventilation; single breath Global PC I.C. I.C. I.C. I.C. I.C. TC 40.06(7) - Radiologic Service Description (con’t) Pulmonary perfusion imaging, particulate, with ventilation; rebreathing and washout, with or without single breath Pulmonary ventilation imaging, aerosol; single projection Pulmonary ventilation imaging, aerosol; multiple projections (eg, anterior, posterior, lateral views) Pulmonary perfusion imaging, particulate, with ventilation imaging, aerosol, one or multiple projections Pulmonary ventilation imaging, gaseous, single breath, single projection Pulmonary ventilation imaging, gaseous, with rebreathing and washout with or without single breath; single projection Pulmonary ventilation imaging, gaseous, with rebreathing and washout with or without single breath; multiple projections (eg, anterior, posterior, lateral views) Pulmonary quantitative differential function (ventilation/perfusion) study I.C. Unlisted respiratory procedure, diagnostic nuclear medicine Brain imaging, less than four static views; Brain imaging, less than four static views; with vascular flow Brain imaging, minimum four static views; Brain imaging, minimum four static views; with vascular flow Brain imaging, tomographic (SPECT) I.C. Brain imaging, positron emission tomography (PET); metabolic evaluation I.C. Brain imaging, positron emission tomography (PET); perfusion evaluation Brain imaging, vascular flow only Cerebrospinal fluid flow, imaging (not including introduction of material); cisternography Cerebrospinal fluid flow, imaging (not including introduction of material); ventriculography Cerebrospinal fluid flow, imaging (not including introduction of material); shunt evaluation Cerebrospinal fluid flow, imaging (not including introduction of material); tomographic (SPECT) Cerebrospinal fluid leakage detection and localization Radiopharmaceutical dacryocystography I.C. Unlisted nervous system procedure, diagnostic nuclear medicine Kidney imaging morphology; Kidney imaging morphology; with vascular flow Kidney imaging morphology; with vascular flow and function, single study without pharmacological intervention Kidney imaging morphology; with vascular flow and function, single study, with pharmacological intervention (eg, angiotensin converting enzyme inhibitor and/or diuretic) 40.06: continued Global PC I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. TC 40.06(7) - Radiologic Service Description (con’t) Kidney imaging morphology; with vascular flow and function, multiple studies, with and without pharmacological intervention (eg, angiotensin converting enzyme inhibitor and/or diuretic) Kidney imaging morphology; tomographic (SPECT) Kidneyfunction study, non-imaging radioisotopic study Urinary bladder residual study (List separately in addition to code for primary procedure) Ureteral reflux study (radiopharmaceutical voiding cystogram) Testicular imaging with vascular flow I.C. Unlisted genitourinary procedure, diagnostic nuclear medicine Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s); limited area Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s); multiple areas Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s); whole body, single day imaging Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s); tomographic (SPECT) Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s); whole body, requiring two or more days imaging Radiopharmaceutical localization of inflammatory process; limited area Radiopharmaceutical localization of inflammatory process; whole body Radiopharmaceutical localization of inflammatory process; tomographic (SPECT) I.C. Positron emission tomography (PET) imaging; limited area (eg, chest, head/neck) I.C. Positron emission tomography (PET) imaging; skull base to mid-thigh I.C. Positron emission tomography (PET) imaging; whole body I.C. Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; limited area (eg, chest, head/neck) I.C. Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh I.C. Positron emi ssion tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; whole body Generation of automated data: interactive process involving nuclear physician and/or allied health professional personnel; simple manipulations and interpretation, not to exceed 30 minutes Global PC TC 40.06(7) - Radiologic Service Description (con’t) Generation of automated data: interactive process involving nuclear physician and/or allied health professional personnel; complex manipulations and interpretation, exceeding 30 minutes I.C. I.C. I.C. Unlisted miscellaneous procedure, diagnostic nuclear medicine Radiopharmaceutical therapy, by oral administration Radiopharmaceutical therapy, by intravenous administration Radiopharmaceutical therapy, by intracavitary administration I.C. I.C. Radiopharmaceutical therapy, by interstitial radioactive colloid administration Radiopharmaceutical therapy, radiolabeled monoclonal antibody by intravenous infusion Radiopharmaceutical therapy, by intra-articular administration I.C. I.C. Radiopharmaceutical therapy, by intra-arterial particulate administration I.C. I.C. I.C. Radiopharmaceutical therapy, unlisted procedure (8) Freestanding Ambulatory Surgical Services / Surgery. ASC Incl PC TC 40.06(8) - Surgical Services Description Rate Fee Fee Fine needle aspiration; without imaging guidance Fine needle aspiration; with imaging guidance Acne surgery (eg, marsupialization, opening or removal of multiple milia, comedones, cysts, pustules) Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple Incision and drainage of pilonidal cyst; simple Incision and drainage of pilonidal cyst; complicated Incision and removal of foreign body, subcutaneous tissues; simple Incision and removal of foreign body, subcutaneous tissues; complicated Incision and drainage of hematoma, seroma or fluid collection Puncture aspiration of abscess, hematoma, bulla, or cyst Incision and drainage, complex, postoperative wound infection Debridement of extensive eczematous or infected skin; up to 10% of body surface Debridement of extensive eczematous or infected skin; each additional 10% of the body surface (List separately in addition to code for primary procedure) ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue infection; external genitalia and perineum Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue infection; abdominal wall, with or without fascial closure Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue infection; external genitalia, perineum and abdominal wall, with or without fascial closure Removal of prosthetic material or mesh, abdominal wall for infection (eg, for chronic or recurrent mesh infection or necrotizing soft tissue infection) (List separately in addition to code for primary procedure) Debridement including removal of foreign material associated with open fracture(s) and/or dislocation(s); skin and subcutaneous tissues Debridement including removal of foreign material associated with open fracture(s) and/or dislocation(s); skin, subcutaneous tissue, muscle fascia, and muscle Debridement including removal of foreign material associated with open fracture(s) and/or dislocation(s); skin, subcutaneous tissue, muscle fascia, muscle, and bone Debridement; skin, partial thickness Debridement; skin, full thickness Debridement; skin, and subcutaneous tissue Debridement; skin, subcutaneous tissue, and muscle Debridement; skin, subcutaneous tissue, muscle, and bone Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); single lesion Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); two to four lesions Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); more than four lesions Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed; single lesion Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed; each separate/additional lesion (List separately in addition to code for primary procedure) Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions Removal of skin tags, multiple fibrocutaneous tags, any area; each additional ten lesions (List separately in addition to code for primary procedure) Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.5 cm or less Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.6 to 1.0 cm Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 1.1 to 2.0 cm 40.06: continued ASC Incl Rate PC Fee TC Fee 40.06(8) - Surgical Services Description (con’t) Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter over 2.0 cm Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 0.5 cm or less Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 0.6 to 1.0 cm Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 1.1 to 2.0 cm Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter over 2.0 cm Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.5 cm or less Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.6 to 1.0 cm Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 1.1 to 2.0 cm Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter over 2.0 cm Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.5 cm or less Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.6 to 1.0 cm Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 1.1 to 2.0 cm Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 2.1 to 3.0 cm Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 3.1 to 4.0 cm Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter over 4.0 cm Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 0.5 cm or less Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 0.6 to 1.0 cm Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 1.1 to 2.0 cm ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 2.1 to 3.0 cm Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 3.1 to 4.0 cm Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter over 4.0 cm Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 0.5 cm or less Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 0.6 to 1.0 cm Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 1.1 to 2.0 cm Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 2.1 to 3.0 cm Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 3.1 to 4.0 cm Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter over 4.0 cm Excision of skin and subcutaneous tissue for hidradenitis, axillary; with simple or intermediate repair Excision of skin and subcutaneous tissue for hidradenitis, axillary; with complex repair Excision of skin and subcutaneous tissue for hidradenitis, inguinal; with simple or intermediate repair Excision of skin and subcutaneous tissue for hidradenitis, inguinal; with complex repair Excision of skin and subcutaneous tissue for hidradenitis, perianal, perineal, or umbilical; with simple or intermediate repair Excision of skin and subcutaneous tissue for hidradenitis, perianal, perineal, or umbilical; with complex repair Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 0.5 cm or less Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 0.6 to 1.0 cm Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 1.1 to 2.0 cm 40.06: continued ASC Incl Rate PC Fee TC Fee 40.06(8) - Surgical Services Description (con’t) Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 2.1 to 3.0 cm Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 3.1 to 4.0 cm Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter over 4.0 cm Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 0.5 cm or less Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 0.6 to 1.0 cm Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 1.1 to 2.0 cm Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 2.1 to 3.0 cm Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 3.1 to 4.0 cm Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter over 4.0 cm Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 0.5 cm or less Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 0.6 to 1.0 cm Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 1.1 to 2.0 cm Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 2.1 to 3.0 cm Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 3.1 to 4.0 cm Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter over 4.0 cm Trimming of nondystrophic nails, any number Debridement of nail(s) by any method(s); one to five Debridement of nail(s) by any method(s); six or more Avulsion of nail plate, partial or complete, simple; single Avulsion of nail plate, partial or complete, simple; each additional nail plate (List separately in addition to code for primary procedure) Evacuation of subungual hematoma Excision of nail and nail matrix, partial or complete (eg, ingrown or deformed nail), for permanent removal; ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Excision of nail and nail matrix, partial or complete (eg, ingrown or deformed nail), for permanent removal; with amputation of tuft of distal phalanx Biopsy of nail unit (eg, plate, bed, matrix, hyponychium, proximal and lateral nail folds) (separate procedure) Repair of nail bed Reconstruction of nail bed with graft Wedge excision of skin of nail fold (eg, for ingrown toenail) Excision of pilonidal cyst or sinus; simple Excision of pilonidal cyst or sinus; extensive Excision of pilonidal cyst or sinus; complicated Injection, intralesional; up to and including seven lesions Injection, intralesional; more than seven lesions Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.0 sq cm or less Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.1 to 20.0 sq cm Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; each additional 20.0 sq cm (List separately in addition to code for primary procedure) Subcutaneous injection of filling material (eg, collagen); 1 cc or less Subcutaneous injection of filling material (eg, collagen); 1.1 to 5.0 cc Subcutaneous injection of filling material (eg, collagen); 5.1 to 10.0 cc Subcutaneous injection of filling material (eg, collagen); over 10.0 cc Insertion of tissue expander(s) for other than breast, including subsequent expansion Replacement of tissue expander with permanent prosthesis Removal of tissue expander(s) without insertion of prosthesis Subcutaneous hormone pellet implantation (implantation of estradiol and/or testosterone pellets beneath the skin) Insertion, non-biodegradable drug delivery implant Removal, non-biodegradable drug delivery implant Removal with reinsertion, non-biodegradable drug delivery implant Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.6 cm to 7.5 cm ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 7.6 cm to 12.5 cm Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 12.6 cm to 20.0 cm Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 20.1 cm to 30.0 cm Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); over 30.0 cm Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 5.1 cm to 7.5 cm Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 7.6 cm to 12.5 cm Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 12.6 cm to 20.0 cm Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 20.1 cm to 30.0 cm Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; over 30.0 cm Treatment of superficial wound dehiscence; simple closure Treatment of superficial wound dehiscence; with packing Layer closure of wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.5 cm or less Layer closure of wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.6 cm to 7.5 cm Layer closure of wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 7.6 cm to 12.5 cm Layer closure of wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 12.6 cm to 20.0 cm Layer closure of wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 20.1 cm to 30.0 cm Layer closure of wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); over 30.0 cm Layer closure of wounds of neck, hands, feet and/or external genitalia; 2.5 cm or less ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Layer closure of wounds of neck, hands, feet and/or external genitalia; 2.6 cm to 7.5 cm Layer closure of wounds of neck, hands, feet and/or external genitalia; 7.6 cm to 12.5 cm Layer closure of wounds of neck, hands, feet and/or external genitalia; 12.6 cm to 20.0 cm Layer closure of wounds of neck, hands, feet and/or external genitalia; 20.1 cm to 30.0 cm Layer closure of wounds of neck, hands, feet and/or external genitalia; over 30.0 cm Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 5.1 cm to 7.5 cm Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 7.6 cm to 12.5 cm Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 12.6 cm to 20.0 cm Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 20.1 cm to 30.0 cm Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membranes; over 30.0 cm Repair, complex, trunk; 1.1 cm to 2.5 cm Repair, complex, trunk; 2.6 cm to 7.5 cm Repair, complex, trunk; each additional 5 cm or less (List separately in addition to code for primary procedure) Repair, complex, scalp, arms, and/or legs; 1.1 cm to 2.5 cm Repair, complex, scalp, arms, and/or legs; 2.6 cm to 7.5 cm Repair, complex, scalp, arms, and/or legs; each additional 5 cm or less (List separately in addition to code for primary procedure) Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 1.1 cm to 2.5 cm Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 2.6 cm to 7.5 cm Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; each additional 5 cm or less (List separately in addition to code for primary procedure) Repair, complex, eyelids, nose, ears and/or lips; 1.0 cm or less Repair, complex, eyelids, nose, ears and/or lips; 1.1 cm to 2.5 cm Repair, complex, eyelids, nose, ears and/or lips; 2.6 cm to 7.5 cm Repair, complex, eyelids, nose, ears and/or lips; each additional 5 cm or less (List separately in addition to code for primary procedure) Secondary closure of surgical wound or dehiscence, extensive or complicated 40.06: continued ASC Incl Rate PC Fee TC Fee 40.06(8) - Surgical Services Description (con’t) Adjacent tissue transfer or rearrangement, trunk; defect 10 sq cm or less Adjacent tissue transfer or rearrangement, trunk; defect 10.1 sq cm to 30.0 sq cm Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10 sq cm or less Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10.1 sq cm to 30.0 sq cm Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10.1 sq cm to 30.0 sq cm Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq cm or less Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10.1 sq cm to 30.0 sq cm Adjacent tissue transfer or rearrangement, more than 30 sq cm, unusual or complicated, any area Filleted finger or toe flap, including preparation of recipient site Harvest of skin for tissue cultured skin autograft, 100 sq cm or less Pinch graft, single or multiple, to cover small ulcer, tip of digit, or other minimal open area (except on face), up to defect size 2 cm diameter Tissue cultured epidermal autograft, trunk, arms, legs; first 25 sq cm or less Tissue cultured epidermal autograft, trunk, arms, legs; additional 1 sq cm to 75 sq cm (List separately in addition to code for primary procedure) Tissue cultured epidermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 25 sq cm or less Tissue cultured epidermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; additional 1 sq cm to 75 sq cm (List separately in addition to code for primary procedure) Full thickness graft, free, including direct closure of donor site, trunk; 20 sq cm or less Full thickness graft, free, including direct closure of donor site, trunk; each additional 20 sq cm (List separately in addition to code for primary procedure) Full thickness graft, free, including direct closure of donor site, scalp, arms, and/or legs; 20 sq cm or less Full thickness graft, free, including direct closure of donor site, scalp, arms, and/or legs; each additional 20 sq cm (List separately in addition to code for primary procedure) Full thickness graft, free, including direct closure of donor site, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, and/or feet; 20 sq cm or less ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Full thickness graft, free, including direct closure of donor site, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, and/or feet; each additional 20 sq cm (List separately in addition to code for primary procedure) Full thickness graft, free, including direct closure of donor site, nose, ears, eyelids, and/or lips; 20 sq cm or less Full thickness graft, free, including direct closure of donor site, nose, ears, eyelids, and/or lips; each additional 20 sq cm (List separately in addition to code for primary procedure) Tissue cultured allogeneic skin substitute; first 25 sq cm or less Tissue cultured allogeneic skin substitute; each additional 25 sq cm Formation of direct or tubed pedicle, with or without transfer; trunk Formation of direct or tubed pedicle, with or without transfer; scalp, arms, or legs Formation of direct or tubed pedicle, with or without transfer; forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands or feet Formation of direct or tubed pedicle, with or without transfer; eyelids, nose, ears, lips, or intraoral Delay of flap or sectioning of flap (division and inset); at trunk Delay of flap or sectioning of flap (division and inset); at scalp, arms, or legs Delay of flap or sectioning of flap (division and inset); at forehead, cheeks, chin, neck, axillae, genitalia, hands, or feet Delay of flap or sectioning of flap (division and inset); at eyelids, nose, ears, or lips Transfer, intermediate, of any pedicle flap (eg, abdomen to wrist, Walking tube), any location Forehead flap with preservation of vascular pedicle (eg, axial pattern flap, paramedian forehead flap) Muscle, myocutaneous, or fasciocutaneous flap; head and neck (eg, temporalis, masseter muscle, sternocleidomastoid, levator scapulae) Muscle, myocutaneous, or fasciocutaneous flap; trunk Muscle, myocutaneous, or fasciocutaneous flap; upper extremity Muscle, myocutaneous, or fasciocutaneous flap; lower extremity Flap; island pedicle Flap; neurovascular pedicle Free muscle or myocutaneous flap with microvascular anastomosis Free skin flap with microvascular anastomosis Free fascial flap with microvascular anastomosis Graft; composite (eg, full thickness of external ear or nasal ala), including primary closure, donor area Graft; derma-fat-fascia ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Punch graft for hair transplant; one to 15 punch grafts Punch graft for hair transplant; more than 15 punch grafts Dermabrasion; total face (eg, for acne scarring, fine wrinkling, rhytids, general keratosis) Dermabrasion; segmental, face Dermabrasion; regional, other than face Dermabrasion; superficial, any site (eg, tattoo removal) Abrasion; single lesion (eg, keratosis, scar) Abrasion; each additional four lesions or less (List separately in addition to code for primary procedure) Chemical peel, facial; epidermal Chemical peel, facial; dermal Chemical peel, nonfacial; epidermal Chemical peel, nonfacial; dermal Cervicoplasty Blepharoplasty, lower eyelid; Blepharoplasty, lower eyelid; with extensive herniated fat pad Blepharoplasty, upper eyelid; Blepharoplasty, upper eyelid; with excessive skin weighting down lid I.C. Rhytidectomy; forehead I.C. Rhytidectomy; neck with platysmal tightening (platysmal flap, P-flap) I.C. Rhytidectomy; glabellar frown lines I.C. Rhytidectomy; cheek, chin, and neck I.C. Rhytidectomy; superficial musculoaponeurotic system (SMAS) flap Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy Excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh Excision, excessive skin and subcutaneous tissue (includes lipectomy); leg Excision, excessive skin and subcutaneous tissue (includes lipectomy); hip Excision, excessive skin and subcutaneous tissue (includes lipectomy); buttock Excision, excessive skin and subcutaneous tissue (includes lipectomy); arm Excision, excessive skin and subcutaneous tissue (includes lipectomy); forearm or hand Excision, excessive skin and subcutaneous tissue (includes lipectomy); submental fat pad Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area Graft for facial nerve paralysis; free fascia graft (including obtaining fascia) Graft for facial nerve paralysis; free muscle graft (including obtaining graft) Graft for facial nerve paralysis; free muscle flap by microsurgical technique Graft for facial nerve paralysis; regional muscle transfer ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee I.C. Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (eg, abdominoplasty) (includes umbilical transposition and fascial plication) (List separately in addition to code for primary procedure) Removal of sutures under anesthesia (other than local), same surgeon Removal of sutures under anesthesia (other than local), other surgeon Dressing change (for other than burns) under anesthesia (other than local) Intravenous injection of agent (eg, fluorescein) to test vascular flow in flap or graft I.C. Suction assisted lipectomy; head and neck I.C. Suction assisted lipectomy; trunk I.C. Suction assisted lipectomy; upper extremity I.C. Suction assisted lipectomy; lower extremity Exc isi on , coccygeal p res su re ul cer, with coccygectomy; with primary suture Excis io n, coccygeal pres su re ulcer, wi th coccygectomy; with flap closure Excision, sacral pressure ulcer, with primary suture; Excision, sacral pressure ulcer, with primary suture; with ostectomy Excision, sacral pressure ulcer, with skin flap closure; Excision, sacral pressure ulcer, with skin flap closure; with ostectomy Excision, sacral pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft closure; Excision, sacral pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft closure; with ostectomy Excision, ischial pressure ulcer, with primary suture; Excision, ischial pressure ulcer, with primary suture; with ostectomy (ischiectomy) Excision, ischial pressure ulcer, with skin flap closure; Excision, ischial pressure ulcer, with skin flap closure; with ostectomy Excision, ischial pressure ulcer, with ostectomy, in preparation for muscle or myocutaneous flap or skin graft closure Excision, trochanteric pressure ulcer, with primary suture; Excision, trochanteric pressure ulcer, with primary suture; with ostectomy Excision, trochanteric pressure ulcer, with skin flap closure; Excision, trochanteric pressure ulcer, with skin flap closure; with ostectomy Excision, trochanteric pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft closure; Excision, trochanteric pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft closure; with ostectomy I.C. Unlisted procedure, excision pressure ulcer 40.06: continued ASC Incl Rate PC Fee TC Fee 40.06(8) - Surgical Services Description (con’t) Initial treatment, first degree burn, when no more than local treatment is required Dressings and/or debridement of partial-thickness burns, initial or subsequent; small (less than 5% total body surface area) Dressings and/or debridement of partial-thickness burns, initial or subsequent; medium (eg, whole face or whole extremity, or 5% to 10% total body surface area) Dressings and/or debridement of partial-thickness burns, initial or subsequent; large (eg, more than one extremity, or greater than 10% total body surface area) Escharotomy; initial incision Escharotomy; each additional incision (List separately in addition to code for primary procedure) Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses); first lesion Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses); second through 14 lesions, each (List separately in addition to code for first lesion) Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses), 15 or more lesions Destruction of cutaneous vascular proliferative lesions (eg, laser technique); less than 10 sq cm Destruction of cutaneous vascular proliferative lesions (eg, laser technique); 10.0 to 50.0 sq cm Destruction of cutaneous vascular proliferative lesions (eg, laser technique); over 50.0 sq cm Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; 15 or more lesions Chemical cauterization of granulation tissue (proud flesh, sinus or fistula) Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter 0.5 cm or less Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter 0.6 to 1.0 cm 40.06: continued ASC Incl Rate PC Fee TC Fee 40.06(8) - Surgical Services Description (con’t) Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter 1.1 to 2.0 cm Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter 2.1 to 3.0 cm Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter 3.1 to 4.0 cm Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter over 4.0 cm Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter 0.5 cm or less Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter 0.6 to 1.0 cm Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter 1.1 to 2.0 cm Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter 2.1 to 3.0 cm Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter 3.1 to 4.0 cm Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter over 4.0 cm Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.5 cm or less Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.6 to 1.0 cm Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 1.1 to 2.0 cm ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 2.1 to 3.0 cm Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 3.1 to 4.0 cm Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter over 4.0 cm Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (eg, hematoxylin and eosin, toluidine blue), head, neck, hands, feet, genitalia, or any location with surgery directly involving muscle, cartilage, bone, tendon, major nerves, or vessels; first stage, up to five tissue blocks Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (eg, hematoxylin and eosin, toluidine blue), head, neck, hands, feet, genitalia, or any location with surgery directly involving muscle, cartilage, bone, tendon, major nerves, or vessels; each additional stage after the first stage, up to five tissue blocks (List separately in addition to code for primary procedure) Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (eg, hematoxylin and eosin, toluidine blue), of the trunk, arms, or legs; first stage, up to five tissue blocks Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (eg, hematoxylin and eosin, toluidine blue), of the trunk, arms, or legs; each additional stage after the first stage, up to five tissue blocks (List separately in addition to code for primary procedure) ASC Rate Incl PC Fee TC Fee I.C. I.C. 40.06(8) - Surgical Services Description (con’t) Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (eg, hematoxylin and eosin, toluidine blue), each additional block after the first five tissue blocks, any stage (List separately in addition to code for primary procedure) Cryotherapy (CO2 slush, liquid N2) for acne Chemical exfoliation for acne (eg, acne paste, acid) Electrolysis epilation, each 30 minutes Unlisted procedure, skin, mucous membrane and subcutaneous tissue Puncture aspiration of cyst of breast; Puncture aspiration of cyst of breast; each additional cyst (List separately in addition to code for primary procedure) Mastotomy with exploration or drainage of abscess, deep Injection procedure only for mammary ductogram or galactogram Biopsy of breast; percutaneous, needle core, not using imaging guidance (separate procedure) Biopsy of breast; open, incisional Biopsy of breast; percutaneous, needle core, using imaging guidance Biopsy of breast; percutaneous, automated vacuum assisted or rotating biopsy device, using imaging guidance Ablation, cryosurgical, of fibroadenoma, including ultrasound guidance, each fibroadenoma Nipple exploration, with or without excision of a solitary lactiferous duct or a papilloma lactiferous duct Excision of lactiferous duct fistula Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion (except 19300), open, male or female, one or more lesions Excision of breast lesion identified by preoperative placement of radiological marker, open; single lesion Excision of breast lesion identified by preoperative placement of radiological marker, open; each additional lesion separately identified by a preoperative radiological marker (List separately in addition to code for primary procedure) Excision of chest wall tumor including ribs Excision of chest wall tumor involving ribs, with plastic reconstruction; without mediastinal lymphadenectomy Excision of chest wall tumor involving ribs, with plastic reconstruction; with mediastinal lymphadenectomy ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Preoperative placement of needle localization wire, breast; Preoperative placement of needle localization wire, breast; each additional lesion (List separately in addition to code for primary procedure) Image guided placement, metallic localization clip, percutaneous, during breast biopsy (List separately in addition to code for primary procedure) Placement of radiotherapy afterloading balloon catheter into the breast for interstitial radioelement application following partial mastectomy, includes imaging guidance; on date separate from partial mastectomy Placement of radiotherapy afterloading balloon catheter into the breast for interstitial radioelement application following partial mastectomy, includes imaging guidance; concurrent with partial mastectomy (List separately in addition to code for primary procedure) Placement of radiotherapy afterloading brachytherapy catheters (multiple tube and button type) into the breast for interstitial radioelement application following (at the time of or subsequent to) partial mastectomy, includes imaging guidance Mastectomy for gynecomastia Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy); Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy); with axillary lymphadenectomy Mastectomy, simple, complete Mastectomy, subcutaneous Mastectomy, radical, including pectoral muscles, axillary lymph nodes Mastectomy, radical, including pectoral muscles, axillary and internal mammary lymph nodes (Urban type operation) Mastectomy, modified radical, including axillary lymph nodes, with or without pectoralis minor muscle, but excluding pectoralis major muscle Mastopexy Reduction mammaplasty Mammaplasty, augmentation; without prosthetic implant Mammaplasty, augmentation; with prosthetic implant Removal of intact mammary implant Removal of mammary implant material Immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction Delayed insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction Nipple/areola reconstruction Breast reconstruction, immediate or delayed, with tissue expander, including subsequent expansion ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Breast reconstruction with latissimus dorsi flap, without prosthetic implant Breast reconstruction with free flap Breast reconstruction with other technique Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), single pedicle, including closure of donor site; Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), single pedicle, including closure of donor site; with microvascular anastomosis (supercharging) Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), double pedicle, including closure of donor site Open periprosthetic capsulotomy, breast Periprosthetic capsulectomy, breast Revision of reconstructed breast Preparation of moulage for custom breast implant I.C. Unlisted procedure, breast Incision of soft tissue abscess (eg, secondary to osteomyelitis); superficial Incision of soft tissue abscess (eg, secondary to osteomyelitis); deep or complicated Exploration of penetrating wound (separate procedure); neck Exploration of penetrating wound (separate procedure); chest Exploration of penetrating wound (separate procedure); abdomen/flank/back Exploration of penetrating wound (separate procedure); extremity Excision of epiphyseal bar, with or without autogenous soft tissue graft obtained through same fascial incision Biopsy, muscle; superficial Biopsy, muscle; deep Biopsy, muscle, percutaneous needle Biopsy, bone, trocar, or needle; superficial (eg, ilium, sternum, spinous process, ribs) Biopsy, bone, trocar, or needle; deep (eg, vertebral body, femur) Biopsy, bone, open; superficial (eg, ilium, sternum, spinous process, ribs, trochanter of femur) Biopsy, bone, open; deep (eg, humerus, ischium, femur) Biopsy, vertebral body, open; thoracic Biopsy, vertebral body, open; lumbar or cervical Injection of sinus tract; therapeutic (separate procedure) Injection of sinus tract; diagnostic (sinogram) Removal of foreign body in muscle or tendon sheath; simple Removal of foreign body in muscle or tendon sheath; deep or complicated Injection, therapeutic (eg, local anesthetic, corticosteroid), carpal tunnel ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar "fascia") Injection(s); single tendon origin/insertion Injection(s); single or multiple trigger point(s), one or two muscle(s) Injection(s); single or multiple trigger point(s), three or more muscle(s) Placement of needles or catheters into muscle and/or soft tissue for subsequent interstitial radioelement application (at the time of or subsequent to the procedure) Arthrocentesis, aspiration and/or injection; small joint or bursa (eg, fingers, toes) Arthrocentesis, aspiration and/or injection; intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa) Arthrocentesis, aspiration and/or injection; major joint or bursa (eg, shoulder, hip, knee joint, subacromial bursa) Aspiration and/or injection of ganglion cyst(s) any location Aspiration and injection for treatment of bone cyst Insertion of wire or pin with application of skeletal traction, including removal (separate procedure) Application of cranial tongs, caliper, or stereotactic frame, including removal (separate procedure) Application of halo, including removal; cranial Application of halo, including removal; pelvic Application of halo, including removal; femoral Application of halo, including removal, cranial, 6 or more pins placed, for thin skull osteology (eg, pediatric patients, hydrocephalus, osteogenesis imperfecta), requiring general anesthesia Removal of tongs or halo applied by another physician Removal of implant; superficial (eg, buried wire, pin or rod) (separate procedure) Removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate) Application of a uniplane (pins or wires in one plane), unilateral, external fixation system Application of a multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type) Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s)) Removal, under anesthesia, of external fixation system Replantation, arm (includes surgical neck of humerus through elbow joint), complete amputation Replantation, forearm (includes radius and ulna to radial carpal joint), complete amputation Replantation, hand (includes hand through metacarpophalangeal joints), complete amputation ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Replantation, digit, excluding thumb (includes metacarpophalangeal joint to insertion of flexor sublimis tendon), complete amputation Replantation, digit, excluding thumb (includes distal tip to sublimis tendon insertion), complete amputation Replantation, thumb (includes carpometacarpal joint to MP joint), complete amputation Replantation, thumb (includes distal tip to MP joint), complete amputation Replantation, foot, complete amputation Bone graft, any donor area; minor or small (eg, dowel or button) Bone graft, any donor area; major or large Cartilage graft; costochondral Cartilage graft; nasal septum Fascia lata graft; by stripper Fascia lata graft; by incision and area exposure, complex or sheet Tendon graft, from a distance (eg, palmaris, toe extensor, plantaris) Tissue grafts, other (eg, paratenon, fat, dermis) I.C. Allograft for spine surgery only; morselized (List separately in addition to code for primary procedure) Allograft for spine surgery only; structural (List separately in addition to code for primary procedure) I.C. Autograft for spine surgery only (includes harvesting the graft); local (eg, ribs, spinous process, or laminar fragments) obtained from same incision (List separately in addition to code for primary procedure) Autograft for spine surgery only (includes harvesting the graft); morselized (through separate skin or fascial incision) (List separately in addition to code for primary procedure) Autograft for spine surgery only (includes harvesting the graft); structural, bicortical or tricortical (through separate skin or fascial incision) (List separately in addition to code for primary procedure) Monitoring of interstitial fluid pressure (includes insertion of device, eg, wick catheter technique, needle manometer technique) in detection of muscle compartment syndrome Bone graft with microvascular anastomosis; fibula Bone graft with microvascular anastomosis; iliac crest Bone graft with microvascular anastomosis; metatarsal Bone graft with microvascular anastomosis; other than fibula, iliac crest, or metatarsal Free osteocutaneous flap with microvascular anastomosis; other than iliac crest, metatarsal, or great toe Free osteocutaneous flap with microvascular anastomosis; iliac crest Free osteocutaneous flap with microvascular anastomosis; metatarsal Free osteocutaneous flap with microvascular anastomosis; great toe with web space 40.06: continued ASC Incl Rate PC TC Fee Fee I.C. I.C. I.C. 40.06(8) - Surgical Services Description (con’t) Electrical stimulation to aid bone healing; noninvasive (nonoperative) Electrical stimulation to aid bone healing; invasive (operative) Low intensity ultrasound stimulation to aid bone healing, noninvasive (nonoperative) Ablation, bone tumor(s) (eg, osteoid osteoma, metastasis) radiofrequency, percutaneous, including computed tomographic guidance Computer-assisted surgical navigational procedure for musculoskeletal procedures; image-less (List separately in addition to code for primary procedure) Computer-assisted surgical navigational procedure for musculoskeletal procedures; with image guidance based on intraoperatively obtained images (eg, fluoroscopy, ultrasound) (List separately in addition to code for primary procedure) Computer-assisted surgical navigational procedure for musculoskeletal procedures; with image guidance based on preoperative images (List separately in addition to code for primary procedure) Unlisted procedure, musculoskeletal system, general Arthrotomy, temporomandibular joint Radical resection of tumor (eg, malignant neoplasm), soft tissue of face or scalp Excision of bone (eg, for osteomyelitis or bone abscess); mandible Excision of bone (eg, for osteomyelitis or bone abscess); facial bone(s) Removal by contouring of benign tumor of facial bone (eg, fibrous dysplasia) Excision of benign tumor or cyst of maxilla or zygoma by enucleation and curettage Excision of torus mandibularis Excision of maxillary torus palatinus Excision of malignant tumor of maxilla or zygoma Excision of benign tumor or cyst of mandible, by enucleation and/or curettage Excision of malignant tumor of mandible; Excision of malignant tumor of mandible; radical resection Excision of benign tumor or cyst of mandible; requiring intra-oral osteotomy (eg, locally aggressive or destructive lesion(s)) Excision of benign tumor or cyst of mandible; requiring extra-oral osteotomy and partial mandibulectomy (eg, locally aggressive or destructive lesion(s)) Excision of benign tumor or cyst of maxilla; requiring intra-oral osteotomy (eg, locally aggressive or destructive lesion(s)) Excision of benign tumor or cyst of maxilla; requiring extra-oral osteotomy and partial maxillectomy (eg, locally aggressive or destructive lesion(s)) ASC Rate Incl I.C. PC TC Fee Fee I.C. 40.06(8) - Surgical Services Description (con’t) Condylectomy, temporomandibular joint (separate procedure) M e n i s c e c t o m y , p a r t i a l o r c o m p l e t e , temporomandibular joint (separate procedure) Coronoidectomy (separate procedure) Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia service (ie, general or monitored anesthesia care) Impression and custom preparation; surgical obturator prosthesis Impression and custom preparation; orbital prosthesis Impression and custom preparation; interim obturator prosthesis Impression and custom preparation; definitive obturator prosthesis Impression and custom preparation; mandibular resection prosthesis Impression and custom preparation; palatal augmentation prosthesis Impression and custom preparation; palatal lift prosthesis Impression and custom preparation; speech aid prosthesis Impression and custom preparation; oral surgical splint Impression and custom preparation; auricular prosthesis Impression and custom preparation; nasal prosthesis Impression and custom preparation; facial prosthesis Unlisted maxillofacial prosthetic procedure Application of halo type appliance for maxillofacial fixation, includes removal (separate procedure) Application of interdental fixation device for conditions other than fracture or dislocation, includes removal Injection procedure for temporomandibular joint arthrography Genioplasty; augmentation (autograft, allograft, prosthetic material) Genioplasty; sliding osteotomy, single piece Genioplasty; sliding osteotomies, two or more osteotomies (eg, wedge excision or bone wedge reversal for asymmetrical chin) Genioplasty; sliding, augmentation with interpositional bone grafts (includes obtaining autografts) Augmentation, mandibular body or angle; prosthetic material Augmentation, mandibular body or angle; with bone graft, onlay or interpositional (includes obtaining autograft) Reduction forehead; contouring only Reduction forehead; contouring and application of prosthetic material or bone graft (includes obtaining autograft) Reduction forehead; contouring and setback of anterior frontal sinus wall ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Reconstruction midface, LeFort I; single piece, segment movement in any direction (eg, for Long Face Syndrome), without bone graft Reconstruction midface, LeFort I; two pieces, segment movement in any direction, without bone graft Reconstruction midface, LeFort I; three or more pieces, segment movement in any direction, without bone graft Reconstruction midface, LeFort I; single piece, segment movement in any direction, requiring bone grafts (includes obtaining autografts) Reconstruction midface, LeFort I; two pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (eg, ungrafted unilateral alveolar cleft) Reconstruction midface, LeFort I; three or more pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (eg, ungrafted bilateral alveolar cleft or multiple osteotomies) Reconstruction midface, LeFort II; anterior intrusion (eg, Treacher-Collins Syndrome) Reconstruction midface, LeFort II; any direction, requiring bone grafts (includes obtaining autografts) Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining autografts); without LeFort I Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining autografts); with LeFort I Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (eg, mono bloc), requiring bone grafts (includes obtaining autografts); without LeFort I Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (eg, mono bloc), requiring bone grafts (includes obtaining autografts); with LeFort I Reconstruction superior-lateral orbital rim and lower forehead, advancement or alteration, with or without grafts (includes obtaining autografts) Reconstruction, bifrontal, superior-lateral orbital rims and lower forehead, advancement or alteration (eg, plagiocephaly, trigonocephaly, brachycephaly), with or without grafts (includes obtaining autografts) Reconstruction, entire or majority of forehead and/or supraorbital rims; with grafts (allograft or prosthetic material) Reconstruction, entire or majority of forehead and/or supraorbital rims; with autograft (includes obtaining grafts) Reconstruction by contouring of benign tumor of cranial bones (eg, fibrous dysplasia), extracranial ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra­ and extracranial excision of benign tumor of cranial bone (eg, fibrous dysplasia), with multiple autografts (includes obtaining grafts); total area of bone grafting less than 40 sq cm Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra- and extracranial excision of benign tumor of cranial bone (eg, fibrous dysplasia), with multiple autografts (includes obtaining grafts); total area of bone grafting greater than 40 sq cm but less than 80 sq cm Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra- and extracranial excision of benign tumor of cranial bone (eg, fibrous dysplasia), with multiple autografts (includes obtaining grafts); total area of bone grafting greater than 80 sq cm Reconstruction midface, osteotomies (other than LeFort type) and bone grafts (includes obtaining autografts) Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; without bone graft Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; with bone graft (includes obtaining graft) Reconstruction of mandibular rami and/or body, sagittal split; without internal rigid fixation Reconstruction of mandibular rami and/or body, sagittal split; with internal rigid fixation Osteotomy, mandible, segmental; Osteotomy, mandible, segmental; with genioglossus advancement Osteotomy, maxilla, segmental (eg, Wassmund or Schuchard) Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant) Osteoplasty, facial bones; reduction Graft, bone; nasal, maxillary or malar areas (includes obtaining graft) Graft, bone; mandible (includes obtaining graft) Graft; rib cartilage, autogenous, to face, chin, nose or ear (includes obtaining graft) Graft; ear cartilage, autogenous, to nose or ear (includes obtaining graft) Arthroplasty, temporomandibular joint, with or without autograft (includes obtaining graft) Arthroplasty, temporomandibular joint, with allograft Arthroplasty, temporomandibular joint, with prosthetic joint replacement Reconstruction of mandible, extraoral, with transosteal bone plate (eg, mandibular staple bone plate) Reconstruction of mandible or maxilla, subperiosteal implant; partial ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Reconstruction of mandible or maxilla, subperiosteal implant; complete Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia) Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); partial Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); complete Reconstruction of zygomatic arch and glenoid fossa with bone and cartilage (includes obtaining autografts) Reconstruction of orbit with osteotomies (extracranial) and with bone grafts (includes obtaining autografts) (eg, micro-ophthalmia) Periorbital osteotomies for orbital hypertelorism, with bone grafts; extracranial approach Periorbital osteotomies for orbital hypertelorism, with bone grafts; combined intra- and extracranial approach Periorbital osteotomies for orbital hypertelorism, with bone grafts; with forehead advancement Orbital repositioning, periorbital osteotomies, unilateral, with bone grafts; extracranial approach Orbital repositioning, periorbital osteotomies, unilateral, with bone grafts; combined intra- and extracranial approach Malar augmentation, prosthetic material Sec o n d a r y r e v ision of or bitocraniofa cial reconstruction Medial canthopexy (separate procedure) Lateral canthopexy Reduction of masseter muscle and bone (eg, for treatment of benign masseteric hypertrophy); extraoral approach Reduction of masseter muscle and bone (eg, for treatment of benign masseteric hypertrophy); intraoral approach I.C. Unlisted craniofacial and maxillofacial procedure Closed treatment of nasal bone fracture without manipulation Closed treatment of nasal bone fracture; without stabilization Closed treatment of nasal bone fracture; with stabilization Open treatment of nasal fracture; uncomplicated Open treatment of nasal fracture; complicated, with internal and/or external skeletal fixation Open treatment of nasal fracture; with concomitant open treatment of fractured septum Open treatment of nasal septal fracture, with or without stabilization Closed treatment of nasal septal fracture, with or without stabilization Open treatment of nasoethmoid fracture; without external fixation ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Open treatment of nasoethmoid fracture; with external fixation Percutaneous treatment of nasoethmoid complex fracture, with splint, wire or headcap fixation, including repair of canthal ligaments and/or the nasolacrimal apparatus Open treatment of depressed frontal sinus fracture Open treatment of complicated (eg, comminuted or involving posterior wall) frontal sinus fracture, via coronal or multiple approaches Closed treatment of nasomaxillary complex fracture (LeFort II type), with interdental wire fixation or fixation of denture or splint Open treatment of nasomaxillary complex fracture (LeFort II type); with wiring and/or local fixation Open treatment of nasomaxillary complex fracture (LeFort II type); requiring multiple open approaches Open treatment of nasomaxillary complex fracture (LeFort II type); with bone grafting (includes obtaining graft) Percutaneous treatment of fracture of malar area, including zygomatic arch and malar tripod, with manipulation Open treatment of depressed zygomatic arch fracture (eg, Gillies approach) Open treatment of depressed malar fracture, including zygomatic arch and malar tripod Open treatment of complicated (eg, comminuted or involving cranial nerve foramina) fracture(s) of malar area, including zygomatic arch and malar tripod; with internal fixation and multiple surgical approaches Open treatment of complicated (eg, comminuted or involving cranial nerve foramina) fracture(s) of malar area, including zygomatic arch and malar tripod; with bone grafting (includes obtaining graft) Open treatment of orbital floor blowout fracture; transantral approach (Caldwell-Luc type operation) Open treatment of orbital floor blowout fracture; periorbital approach Open treatment of orbital floor blowout fracture; combined approach Open treatment of orbital floor blowout fracture; periorbital approach, with alloplastic or other implant Open treatment of orbital floor blowout fracture; periorbital approach with bone graft (includes obtaining graft) Closed treatment of fracture of orbit, except blowout; without manipulation Closed treatment of fracture of orbit, except blowout; with manipulation Open treatment of fracture of orbit, except blowout; without implant Open treatment of fracture of orbit, except blowout; with implant 40.06: continued ASC Incl Rate PC TC Fee Fee 40.06(8) - Surgical Services Description (con’t) Open treatment of fracture of orbit, except blowout; with bone grafting (includes obtaining graft) Closed treatment of palatal or maxillary fracture (LeFort I type), with interdental wire fixation or fixation of denture or splint Open treatment of palatal or maxillary fracture (LeFort I type); Open treatment of palatal or maxillary fracture (LeFort I type); complicated (comminuted or involving cranial nerve foramina), multiple approaches Closed treatment of craniofacial separation (LeFort III type) using interdental wire fixation of denture or splint Open treatment of craniofacial separation (LeFort III type); with wiring and/or internal fixation Open treatment of craniofacial separation (LeFort III type); complicated (eg, comminuted or involving cranial nerve foramina), multiple surgical approaches Open treatment of craniofacial separation (LeFort III type); complicated, utilizing internal and/or external fixation techniques (eg, head cap, halo device, and/or intermaxillary fixation) Open treatment of craniofacial separation (LeFort III type); complicated, multiple surgical approaches, internal fixation, with bone grafting (includes obtaining graft) Closed treatment of mandibular or maxillary alveolar ridge fracture (separate procedure) Open treatment of mandibular or maxillary alveolar ridge fracture (separate procedure) Closed treatment of mandibular fracture; without manipulation Closed treatment of mandibular fracture; with manipulation Percutaneous treatment of mandibular fracture, with external fixation Closed treatment of mandibular fracture with interdental fixation Open treatment of mandibular fracture with external fixation Open treatment of mandibular fracture; without interdental fixation Open treatment of mandibular fracture; with interdental fixation Open treatment of mandibular condylar fracture Open treatment of complicated mandibular fracture by multiple surgical approaches including internal fixation, interdental fixation, and/or wiring of dentures or splints Closed treatment of temporomandibular dislocation; initial or subsequent Closed treatment of temporomandibular dislocation; complicated (eg, recurrent requiring intermaxillary fixation or splinting), initial or subsequent ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Open treatment of temporomandibular dislocation Open treatment of hyoid fracture Interdental wiring, for condition other than fracture I.C. Unlisted musculoskeletal procedure, head Incision and drainage, deep abscess or hematoma, soft tissues of neck or thorax; Incision and drainage, deep abscess or hematoma, soft tissues of neck or thorax; with partial rib ostectomy Incision, deep, with opening of bone cortex (eg, for osteomyelitis or bone abscess), thorax Biopsy, soft tissue of neck or thorax Excision tumor, soft tissue of neck or thorax; subcutaneous Excision tumor, soft tissue of neck or thorax; deep, subfascial, intramuscular Radical resection of tumor (eg, malignant neoplasm), soft tissue of neck or thorax Excision of rib, partial Costotransversectomy (separate procedure) Excision first and/or cervical rib; Excision first and/or cervical rib; with sympathectomy Ostectomy of sternum, partial Sternal debridement Radical resection of sternum; Radical resection of sternum; with mediastinal lymphadenectomy Hyoid myotomy and suspension Division of scalenus anticus; without resection of cervical rib Division of scalenus anticus; with resection of cervical rib Division of sternocleidomastoid for torticollis, open operation; without cast application Division of sternocleidomastoid for torticollis, open operation; with cast application Reconstructive repair of pectus excavatum or carinatum; open I.C. Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), without thoracoscopy I.C. Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), with thoracoscopy Closure of median sternotomy separation with or without debridement (separate procedure) Closed treatment of rib fracture, uncomplicated, each Open treatment of rib fracture without fixation, each Treatment of rib fracture requiring external fixation (flail chest) Closed treatment of sternum fracture Open treatment of sternum fracture with or without skeletal fixation I.C. Unlisted procedure, neck or thorax Biopsy, soft tissue of back or flank; superficial Biopsy, soft tissue of back or flank; deep ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Excision, tumor, soft tissue of back or flank Radical resection of tumor (eg, malignant neoplasm), soft tissue of back or flank Incision and drainage, open, of deep abscess (subfascial), posterior spine; cervical, thoracic, or cervicothoracic Incision and drainage, open, of deep abscess (subfascial), posterior spine; lumbar, sacral, or lumbosacral Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; cervical Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; thoracic Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; lumbar Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; each additional segment (List separately in addition to code for primary procedure) Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal cord or nerve root(s), single vertebral segment; cervical Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal cord or nerve root(s), single vertebral segment; thoracic Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal cord or nerve root(s), single vertebral segment; lumbar Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal cord or nerve root(s), single vertebral segment; each additional vertebral segment (List separately in addition to code for primary procedure) Osteotomy of spine, posterior or posterolateral approach, three columns, one vertebral segment (eg, pedicle/vertebral body subtraction); thoracic Osteotomy of spine, posterior or posterolateral approach, three columns, one vertebral segment (eg, pedicle/vertebral body subtraction); lumbar Osteotomy of spine, posterior or posterolateral approach, three columns, one vertebral segment (eg, pedicle/vertebral body subtraction); each additional vertebral segment (List separately in addition to code for primary procedure) Osteotomy of spine, posterior or posterolateral approach, one vertebral segment; cervical Osteotomy of spine, posterior or posterolateral approach, one vertebral segment; thoracic Osteotomy of spine, posterior or posterolateral approach, one vertebral segment; lumbar 40.06: continued ASC Incl Rate PC Fee TC Fee 40.06(8) - Surgical Services Description (con’t) Osteotomy of spine, posterior or posterolateral approach, one vertebral segment; each additional vertebral segment (List separately in addition to primary procedure) Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; cervical Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; thoracic Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; lumbar Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; each additional vertebral segment (List separately in addition to code for primary procedure) Closed treatment of vertebral process fracture(s) Closed treatment of vertebral body fracture(s), without manipulation, requiring and including casting or bracing Closed treatment of vertebral fracture(s) and/or dislocation(s) requiring casting or bracing, with and including casting and/or bracing, with or without anesthesia, by manipulation or traction Open treatment and/or reduction of odontoid fracture(s) and or dislocation(s) (including os odontoideum), anterior approach, including placement of internal fixation; without grafting Open treatment and/or reduction of odontoid fracture(s) and or dislocation(s) (including os odontoideum), anterior approach, including placement of internal fixation; with grafting Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, one fractured vertebra or dislocated segment; lumbar Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, one fractured vertebra or dislocated segment; cervical Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, one fractured vertebra or dislocated segment; thoracic Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, one fractured vertebra or dislocated segment; each additional fractured vertebra or dislocated segment (List separately in addition to code for primary procedure) Manipulation of spine requiring anesthesia, any region Percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; thoracic Percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; lumbar Percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; each additional thoracic or lumbar vertebral body (List separately in addition to code for primary procedure) ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device, one vertebral body, unilateral or bilateral cannulation (eg, kyphoplasty); thoracic Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device, one vertebral body, unilateral or bilateral cannulation (eg, kyphoplasty); lumbar Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device, one vertebral body, unilateral or bilateral cannulation (eg, kyphoplasty); each additional thoracic or lumbar vertebral body (List separately in addition to code for primary procedure) Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; single level Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; one or more additional levels (List separately in addition to code for primary procedure) Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic or lumbar, each additional vertebral segment (List separately in addition to code for primary procedure) Arthrodesis, anterior transoral or extraoral technique, clivus-C1-C2 (atlas-axis), with or without excision of odontoid process Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); cervical below C2 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar I Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each additional interspace (List separately in addition to code for primary procedure) Arthrodesis, posterior technique, craniocervical (occiput-C2) Arthrodesis, posterior technique, atlas-axis (C1-C2) ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment Arthrodesis, posterior or posterolateral technique, single level; thoracic (with or without lateral transverse technique) I Arthrodesis, posterior or posterolateral technique, single level; lumbar (with or without lateral transverse technique) Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment (List separately in addition to code for primary procedure) Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; each additional interspace (List separately in addition to code for primary procedure) Arthrodesis, posterior, for spinal deformity, with or without cast; up to six vertebral segments Arthrodesis, posterior, for spinal deformity, with or without cast; seven to 12 vertebral segments Arthrodesis, posterior, for spinal deformity, with or without cast; 13 or more vertebral segments Arthrodesis, anterior, for spinal deformity, with or without cast; two to three vertebral segments Arthrodesis, anterior, for spinal deformity, with or without cast; four to seven vertebral segments Arthrodesis, anterior, for spinal deformity, with or without cast; eight or more vertebral segments Kyphectomy, circumferential exposure of spine and resection of vertebral segment(s) (including body and posterior elements); single or two segments Kyphectomy, circumferential exposure of spine and resection of vertebral segment(s) (including body and posterior elements); three or more segments Exploration of spinal fusion I Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across one interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation) (List separately in addition to code for primary procedure) I.C. Internal spinal fixation by wiring of spinous processes (List separately in addition to code for primary procedure) I Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); three to six vertebral segments (List separately in addition to code for primary procedure) Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); seven to 12 vertebral segments (List separately in addition to code for primary procedure) ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 13 or more vertebral segments (List separately in addition to code for primary procedure) I Anterior instrumentation; two to three vertebral segments (List separately in addition to code for primary procedure) Anterior instrumentation; four to seven vertebral segments (List separately in addition to code for primary procedure) Anterior instrumentation; eight or more vertebral segments (List separately in addition to code for primary procedure) Pelvic fixation (attachment of caudal end of instrumentation to pelvic bony structures) other than sacrum (List separately in addition to code for primary procedure) Reinsertion of spinal fixation device Removal of posterior nonsegmental instrumentation (eg, Harrington rod) I Application of intervertebral biomechanical device(s) (eg, synthetic cage(s), threaded bone dowel(s), methylmethacrylate) to vertebral defect or interspace (List separately in addition to code for primary procedure) Removal of posterior segmental instrumentation Removal of anterior instrumentation Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), lumbar, single interspace Revision including replacement of total disc arthroplasty (artificial disc) anterior approach, lumbar, single interspace Removal of total disc arthroplasty (artificial disc), anterior approach, lumbar, single interspace I.C. Unlisted procedure, spine Excision, abdominal wall tumor, subfascial (eg, desmoid) I.C. Unlisted procedure, abdomen, musculoskeletal system Removal of subdeltoid calcareous deposits, open Capsular contracture release (eg, Sever type procedure) Incision and drainage, shoulder area; deep abscess or hematoma Incision and drainage, shoulder area; infected bursa Incision, bone cortex (eg, osteomyelitis or bone abscess), shoulder area Arthrotomy, glenohumeral joint, including exploration, drainage, or removal of foreign body Arthrotomy, acromioclavicular, sternoclavicular joint, including exploration, drainage, or removal of foreign body Biopsy, soft tissue of shoulder area; superficial ASC Rate Incl PC TC Fee Fee 40.06(8) - Surgical Services Description (con’t) Biopsy, soft tissue of shoulder area; deep Excision, soft tissue tumor, shoulder area; subcutaneous Excision, soft tissue tumor, shoulder area; deep, subfascial, or intramuscular Radical resection of tumor (eg, malignant neoplasm), soft tissue of shoulder area Arthrotomy, glenohumeral joint, including biopsy Arthrotomy, acrom ioclavicular joint or sternoclavicular joint, including biopsy and/or excision of torn cartilage Arthrotomy; glenohumeral joint, with synovectomy, with or without biopsy Arthrotomy; sternoclavicular joint, with synovectomy, with or without biopsy Arthrotomy, glenohumeral joint, with joint exploration, with or without removal of loose or foreign body Claviculectomy; partial Claviculectomy; total Acromioplasty or acromionectomy, partial, with or without coracoacromial ligament release Excision or curettage of bone cyst or benign tumor of clavicle or scapula; Excision or curettage of bone cyst or benign tumor of clavicle or scapula; with autograft (includes obtaining graft) Excision or curettage of bone cyst or benign tumor of clavicle or scapula; with allograft Excision or curettage of bone cyst or benign tumor of proximal humerus; Excision or curettage of bone cyst or benign tumor of proximal humerus; with autograft (includes obtaining graft) Excision or curettage of bone cyst or benign tumor of proximal humerus; with allograft Sequestrectomy (eg, for osteomyelitis or bone abscess), clavicle Sequestrectomy (eg, for osteomyelitis or bone abscess), scapula Sequestrectomy (eg, for osteomyelitis or bone abscess), humeral head to surgical neck Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), clavicle Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), scapula Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), proximal humerus Ostectomy of scapula, partial (eg, superior medial angle) Resection, humeral head Radical resection for tumor; clavicle Radical resection for tumor; scapula Radical resection of bone tumor, proximal humerus; ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Radical resection of bone tumor, proximal humerus; with autograft (includes obtaining graft) Radical resection of bone tumor, proximal humerus; with prosthetic replacement Removal of foreign body, shoulder; subcutaneous Removal of foreign body, shoulder; deep (eg, Neer hemiarthroplasty removal) Removal of foreign body, shoulder; complicated (eg, total shoulder) Injection procedure for shoulder arthrography or enhanced CT/MRI shoulder arthrography Muscle transfer, any type, shoulder or upper arm; single Muscle transfer, any type, shoulder or upper arm; multiple Scapulopexy (eg, Sprengels deformity or for paralysis) Tenotomy, shoulder area; single tendon Tenotomy, shoulder area; multiple tendons through same incision Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; acute I Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; chronic Coracoacromial ligament release, with or without acromioplasty I Reconstruction of complete shoulder (rotator) cuff avulsion, chronic (includes acromioplasty) Tenodesis of long tendon of biceps Resection or transplantation of long tendon of biceps Capsulorrhaphy, anterior; Putti-Platt procedure or Magnuson type operation Capsulorrhaphy, anterior; with labral repair (eg, Bankart procedure) Capsulorrhaphy, anterior, any type; with bone block Capsulorrhaphy, anterior, any type; with coracoid process transfer Capsulorrhaphy, glenohumeral joint, posterior, with or without bone block Capsulorrhaphy, glenohumeral joint, any type multi-directional instability Arthroplasty, glenohumeral joint; hemiarthroplasty Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (eg, total shoulder)) Osteotomy, clavicle, with or without internal fixation; Osteotomy, clavicle, with or without internal fixation; with bone graft for nonunion or malunion (includes obtaining graft and/or necessary fixation) Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; clavicle Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; proximal humerus Closed treatment of clavicular fracture; without manipulation 40.06: continued ASC Incl Rate PC TC Fee Fee 40.06(8) - Surgical Services Description (con’t) Closed treatment of clavicular fracture; with manipulation Open treatment of clavicular fracture, includes internal fixation, when performed Closed treatment of sternoclavicular dislocation; without manipulation Closed treatment of sternoclavicular dislocation; with manipulation Open treatment of sternoclavicular dislocation, acute or chronic; Open treatment of sternoclavicular dislocation, acute or chronic; with fascial graft (includes obtaining graft) Closed treatment of acromioclavicular dislocation; without manipulation Closed treatment of acromioclavicular dislocation; with manipulation Open treatment of acromioclavicular dislocation, acute or chronic; Open treatment of acromioclavicular dislocation, acute or chronic; with fascial graft (includes obtaining graft) Closed treatment of scapular fracture; without manipulation Closed treatment of scapular fracture; with manipulation, with or without skeletal traction (with or without shoulder joint involvement) Open treatment of scapular fracture (body, glenoid or acromion) with or without internal fixation Closed treatment of proximal humeral (surgical or anatomical neck) fracture; without manipulation Closed treatment of proximal humeral (surgical or anatomical neck) fracture; with manipulation, with or without skeletal traction Open treatment of proximal humeral (surgical or anatomical neck) fracture, includes internal fixation, when performed, includes repair of tuberosity(s), when performed; Open treatment of proximal humeral (surgical or anatomical neck) fracture, includes internal fixation, when performed, includes repair of tuberosity(s), when performed; with proximal humeral prosthetic replacement Closed treatment of greater humeral tuberosity fracture; without manipulation Closed treatment of greater humeral tuberosity fracture; with manipulation Open treatment of greater humeral tuberosity fracture, includes internal fixation, when performed Closed treatment of shoulder dislocation, with manipulation; without anesthesia Closed treatment of shoulder dislocation, with manipulation; requiring anesthesia Open treatment of acute shoulder dislocation ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Closed treatment of shoulder dislocation, with fracture of greater humeral tuberosity, with manipulation Open treatment of shoulder dislocation, with fracture of greater humeral tuberosity, includes internal fixation, when performed Closed treatment of shoulder dislocation, with surgical or anatomical neck fracture, with manipulation Open treatment of shoulder dislocation, with surgical or anatomical neck fracture, includes internal fixation, when performed Manipulation under anesthesia, shoulder joint, including application of fixation apparatus (dislocation excluded) Arthrodesis, glenohumeral joint; Arthrodesis, glenohumeral joint; with autogenous graft (includes obtaining graft) Interthoracoscapular amputation (forequarter) Disarticulation of shoulder; Disarticulation of shoulder; secondary closure or scar revision I.C. Unlisted procedure, shoulder Incision and drainage, upper arm or elbow area; deep abscess or hematoma Incision and drainage, upper arm or elbow area; bursa Incision, deep, with opening of bone cortex (eg, for osteomyelitis or bone abscess), humerus or elbow Arthrotomy, elbow, including exploration, drainage, or removal of foreign body Arthrotomy of the elbow, with capsular excision for capsular release (separate procedure) Biopsy, soft tissue of upper arm or elbow area; superficial Biopsy, soft tissue of upper arm or elbow area; deep (subfascial or intramuscular) Excision, tumor, soft tissue of upper arm or elbow area; subcutaneous Excision, tumor, soft tissue of upper arm or elbow area; deep (subfascial or intramuscular) Radical resection of tumor (eg, malignant neoplasm), soft tissue of upper arm or elbow area Arthrotomy, elbow; with synovial biopsy only Arthrotomy, elbow; with joint exploration, with or without biopsy, with or without removal of loose or foreign body Arthrotomy, elbow; with synovectomy Excision, olecranon bursa Excision or curettage of bone cyst or benign tumor, humerus; Excision or curettage of bone cyst or benign tumor, humerus; with autograft (includes obtaining graft) Excision or curettage of bone cyst or benign tumor, humerus; with allograft ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Excision or curettage of bone cyst or benign tumor of head or neck of radius or olecranon process; Excision or curettage of bone cyst or benign tumor of head or neck of radius or olecranon process; with autograft (includes obtaining graft) Excision or curettage of bone cyst or benign tumor of head or neck of radius or olecranon process; with allograft Excision, radial head Sequestrectomy (eg, for osteomyelitis or bone abscess), shaft or distal humerus Sequestrectomy (eg, for osteomyelitis or bone abscess), radial head or neck Sequestrectomy (eg, for osteomyelitis or bone abscess), olecranon process Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), humerus Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), radial head or neck Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), olecranon process Radical resection of capsule, soft tissue, and heterotopic bone, elbow, with contracture release (separate procedure) Radical resection for tumor, shaft or distal humerus; Radical resection for tumor, shaft or distal humerus; with autograft (includes obtaining graft) Radical resection for tumor, radial head or neck; Radical resection for tumor, radial head or neck; with autograft (includes obtaining graft) Resection of elbow joint (arthrectomy) Implant removal; elbow joint Implant removal; radial head Removal of foreign body, upper arm or elbow area; subcutaneous Removal of foreign body, upper arm or elbow area; deep (subfascial or intramuscular) Injection procedure for elbow arthrography Manipulation, elbow, under anesthesia Muscle or tendon transfer, any type, upper arm or elbow, single (excluding 24320-24331) Tendon lengthening, upper arm or elbow, each tendon Tenotomy, open, elbow to shoulder, each tendon Tenoplasty, with muscle transfer, with or without free graft, elbow to shoulder, single (Seddon-Brookes type procedure) Flexor-plasty, elbow (eg, Steindler type advancement); Flexor-plasty, elbow (eg, Steindler type advancement); with extensor advancement Tenolysis, triceps Tenodesis of biceps tendon at elbow (separate procedure) ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Repair, tendon or muscle, upper arm or elbow, each tendon or muscle, primary or secondary (excludes rotator cuff) Reinsertion of ruptured biceps or triceps tendon, distal, with or without tendon graft Repair lateral collateral ligament, elbow, with local tissue Reconstruction lateral collateral ligament, elbow, with tendon graft (includes harvesting of graft) Repair medial collateral ligament, elbow, with local tissue Reconstruction medial collateral ligament, elbow, with tendon graft (includes harvesting of graft) Tenotomy, elbow, lateral or medial (eg, epicondylitis, tennis elbow, golfer's elbow); percutaneous Tenotomy, elbow, lateral or medial (eg, epicondylitis, tennis elbow, golfer's elbow); debridement, soft tissue and/or bone, open Tenotomy, elbow, lateral or medial (eg, epicondylitis, tennis elbow, golfer's elbow); debridement, soft tissue and/or bone, open with tendon repair or reattachment Arthroplasty, elbow; with membrane (eg, fascial) Arthroplasty, elbow; with distal humeral prosthetic replacement Arthroplasty, elbow; with implant and fascia lata ligament reconstruction Arthroplasty, elbow; with distal humerus and proximal ulnar prosthetic replacement (eg, total elbow) Arthroplasty, radial head; Arthroplasty, radial head; with implant Osteotomy, humerus, with or without internal fixation Multiple osteotomies with realignment on intramedullary rod, humeral shaft (Sofield type procedure) Osteoplasty, humerus (eg, shortening or lengthening) (excluding 64876) Repair of nonunion or malunion, humerus; without graft (eg, compression technique) Repair of nonunion or malunion, humerus; with iliac or other autograft (includes obtaining graft) Hemiepiphyseal arrest (eg, cubitus varus or valgus, distal humerus) Decompression fasciotomy, forearm, with brachial artery exploration Prophylactic treatment (nailing, pinning, plating or wiring), with or without methylmethacrylate, humeral shaft Closed treatment of humeral shaft fracture; without manipulation Closed treatment of humeral shaft fracture; with manipulation, with or without skeletal traction Open treatment of humeral shaft fracture with plate/screws, with or without cerclage 40.06: continued ASC Incl Rate PC TC Fee Fee 40.06(8) - Surgical Services Description (con’t) Treatment of humeral shaft fracture, with insertion of intramedullary implant, with or without cerclage and/or locking screws Closed treatment of supracondylar or transcondylar humeral fracture, with or without intercondylar extension; without manipulation Closed treatment of supracondylar or transcondylar humeral fracture, with or without intercondylar extension; with manipulation, with or without skin or skeletal traction Percutaneous skeletal fixation of supracondylar or transcondylar humeral fracture, with or without intercondylar extension Open treatment of humeral supracondylar or transcondylar fracture, includes internal fixation, when performed; without intercondylar extension Open treatment of humeral supracondylar or transcondylar fracture, includes internal fixation, when performed; with intercondylar extension Closed treatment of humeral epicondylar fracture, medial or lateral; without manipulation Closed treatment of humeral epicondylar fracture, medial or lateral; with manipulation Percutaneous skeletal fixation of humeral epicondylar fracture, medial or lateral, with manipulation Open treatment of humeral epicondylar fracture, medial or lateral, includes internal fixation, when performed Closed treatment of humeral condylar fracture, medial or lateral; without manipulation Closed treatment of humeral condylar fracture, medial or lateral; with manipulation Open treatment of humeral condylar fracture, medial or lateral, includes internal fixation, when performed Percutaneous skeletal fixation of humeral condylar fracture, medial or lateral, with manipulation Open treatment of periarticular fracture and/or dislocation of the elbow (fracture distal humerus and proximal ulna and/or proximal radius); Open treatment of periarticular fracture and/or dislocation of the elbow (fracture distal humerus and proximal ulna and/or proximal radius); with implant arthroplasty Treatment of closed elbow dislocation; without anesthesia Treatment of closed elbow dislocation; requiring anesthesia Open treatment of acute or chronic elbow dislocation Closed treatment of Monteggia type of fracture dislocation at elbow (fracture proximal end of ulna with dislocation of radial head), with manipulation Open treatment of Monteggia type of fracture dislocation at elbow (fracture proximal end of ulna with dislocation of radial head), includes internal fixation, when performed ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Closed treatment of radial head subluxation in child, nursemaid elbow, with manipulation Closed treatment of radial head or neck fracture; without manipulation Closed treatment of radial head or neck fracture; with manipulation Open treatment of radial head or neck fracture, includes internal fixation or radial head excision, when performed; Open treatment of radial head or neck fracture, includes internal fixation or radial head excision, when performed; with radial head prosthetic replacement Closed treatment of ulnar fracture, proximal end (eg, olecranon or coronoid process[es]); without manipulation Closed treatment of ulnar fracture, proximal end (eg, olecranon or coronoid process[es]); with manipulation Open treatment of ulnar fracture, proximal end (eg, olecranon or coronoid process[es]), includes internal fixation, when performed Arthrodesis, elbow joint; local Arthrodesis, elbow joint; with autogenous graft (includes obtaining graft) Amputation, arm through humerus; with primary closure Amputation, arm through humerus; open, circular (guillotine) Amputation, arm through humerus; secondary closure or scar revision Amputation, arm through humerus; re-amputation Amputation, arm through humerus; with implant Stump elongation, upper extremity I.C. Cineplasty, upper extremity, complete procedure I.C. Unlisted procedure, humerus or elbow Incision, extensor tendon sheath, wrist (eg, deQuervains disease) Incision, flexor tendon sheath, wrist (eg, flexor carpi radialis) Decompression fasciotomy, forearm and/or wrist, flexor OR extensor compartment; without debridement of nonviable muscle and/or nerve Decompression fasciotomy, forearm and/or wrist, flexor OR extensor compartment; with debridement of nonviable muscle and/or nerve Decompression fasciotomy, forearm and/or wrist, flexor AND extensor compartment; without debridement of nonviable muscle and/or nerve Decompression fasciotomy, forearm and/or wrist, flexor AND extensor compartment; with debridement of nonviable muscle and/or nerve Incision and drainage, forearm and/or wrist; deep abscess or hematoma Incision and drainage, forearm and/or wrist; bursa ASC Rate Incl PC TC Fee Fee 40.06(8) - Surgical Services Description (con’t) Incision, deep, bone cortex, forearm and/or wrist (eg, osteomyelitis or bone abscess) Arthrotomy, radiocarpal or midcarpal joint, with exploration, drainage, or removal of foreign body Biopsy, soft tissue of forearm and/or wrist; superficial Biopsy, soft tissue of forearm and/or wrist; deep (subfascial or intramuscular) Excision, tumor, soft tissue of forearm and/or wrist area; subcutaneous Excision, tumor, soft tissue of forearm and/or wrist area; deep (subfascial or intramuscular) Radical resection of tumor (eg, malignant neoplasm), soft tissue of forearm and/or wrist area Capsulotomy, wrist (eg, contracture) Arthrotomy, wrist joint; with biopsy Arthrotomy, wrist joint; with joint exploration, with or without biopsy, with or without removal of loose or foreign body Arthrotomy, wrist joint; with synovectomy Arthrotomy, distal radioulnar joint including repair of triangular cartilage, complex Excision of tendon, forearm and/or wrist, flexor or extensor, each Excision, lesion of tendon sheath, forearm and/or wrist Excision of ganglion, wrist (dorsal or volar); primary Excision of ganglion, wrist (dorsal or volar); recurrent Radical excision of bursa, synovia of wrist, or forearm tendon sheaths (eg, tenosynovitis, fungus, Tbc, or other granulomas, rheumatoid arthritis); flexors Radical excision of bursa, synovia of wrist, or forearm tendon sheaths (eg, tenosynovitis, fungus, Tbc, or other granulomas, rheumatoid arthritis); extensors, with or without transposition of dorsal retinaculum Synovectomy, extensor tendon sheath, wrist, single compartment; Synovectomy, extensor tendon sheath, wrist, single compartment; with resection of distal ulna Excision or curettage of bone cyst or benign tumor of radius or ulna (excluding head or neck of radius and olecranon process); Excision or curettage of bone cyst or benign tumor of radius or ulna (excluding head or neck of radius and olecranon process); with autograft (includes obtaining graft) Excision or curettage of bone cyst or benign tumor of radius or ulna (excluding head or neck of radius and olecranon process); with allograft Excision or curettage of bone cyst or benign tumor of carpal bones; Excision or curettage of bone cyst or benign tumor of carpal bones; with autograft (includes obtaining graft) Excision or curettage of bone cyst or benign tumor of carpal bones; with allograft Sequestrectomy (eg, for osteomyelitis or bone abscess), forearm and/or wrist ASC Rate Incl PC Fee TC Fee 40.06(8) - Surgical Services Description (con’t) Partial excision (craterization, saucerization, or diaphysectomy) of bone (eg, for osteomyelitis); ulna Partial excision (craterization, saucerization, or diaphysectomy) of bone (eg, for osteomyelitis); radius Radical resection for tumor, radius or ulna Carpectomy; one bone Carpectomy; all bones of proximal row Radial styloidectomy (separate procedure) Excision distal ulna partial or complete (eg, Darrach type or matched resection) Injection procedure for wrist arthrography Exploration with removal of deep foreign body, forearm or wrist Removal of wrist prosthesis; (separate procedure) Removal of wrist prosthesis; complicated, including total wrist Manipulation, wrist, under anesthesia Repair, tendon or muscle, flexor, forearm and/or wrist; primary, single, each tendon or muscle Repair, tendon or muscle, flexor, forearm and/or wrist; secondary, single, each tendon or muscle Repair, tendon or muscle, flexor, forearm and/or wrist; secondary, with free graft (includes obtaining graft), each tendon or muscle Repair, tendon or muscle, extensor, forearm and/or wrist; primary, single, each tendon or muscle Repair, tendon or muscle, extensor, forearm and/or wrist; secondary, single, each tendon or muscle Repair, tendon or muscle, extensor, forearm and/or wrist; secondary, with free graft (includes obtaining graft), each tendon or muscle Repair, tendon sheath, extensor, forearm and/or wrist, with free graft (includes obtaining graft) (eg, for extensor carpi ulnaris subluxation) Lengthening or shortening of flexor or extensor tendon, forearm and/or wrist, single, each tendon Tenotomy, open, flexor or extensor tendon, forearm and/or wrist, single, each tendon Tenolysis, flexor or extensor tendon, forearm and/or wrist, single, each tendon Tenodesis at wrist; flexors of fingers Tenodesis at wrist; extensors of fingers Tendon transplantation or transfer, flexor or extensor, forearm and/or wrist, single; each tendon Tendon transplantation or transfer, flexor or extensor, forearm and/or wrist, single; with tendon graft(s) (includes obtaining graft), each tendon Flexor origin slide (eg, for cerebral palsy, Volkmann contracture), forearm and/or wrist; Flexor origin slide (eg, for cerebral palsy, Volkmann contracture), forearm and/or wrist; with tendon(s) transfer ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Capsulorrhaphy or reconstruction, wrist, open (eg, capsulodesis, ligament repair, tendon transfer or graft) (includes synovectomy, capsulotomy and open reduction) for carpal instability Arthroplasty, wrist, with or without interposition, with or without external or internal fixation Centralization of wrist on ulna (eg, radial club hand) Reconstruction for stabilization of unstable distal ulna or distal radioulnar joint, secondary by soft tissue stabilization (eg, tendon transfer, tendon graft or weave, or tenodesis) with or without open reduction of distal radioulnar joint Osteotomy, radius; distal third Osteotomy, radius; middle or proximal third Osteotomy; ulna Osteotomy; radius AND ulna Multiple osteotomies, with realignment on intramedullary rod (Sofield type procedure); radius OR ulna Multiple osteotomies, with realignment on intramedullary rod (Sofield type procedure); radius AND ulna Osteoplasty, radius OR ulna; shortening Osteoplasty, radius OR ulna; lengthening with autograft Osteoplasty, radius AND ulna; shortening (excluding 64876) Osteoplasty, radius AND ulna; lengthening with autograft Osteoplasty, carpal bone, shortening Repair of nonunion or malunion, radius OR ulna; without graft (eg, compression technique) Repair of nonunion or malunion, radius OR ulna; with autograft (includes obtaining graft) Repair of nonunion or malunion, radius AND ulna; without graft (eg, compression technique) Repair of nonunion or malunion, radius AND ulna; with autograft (includes obtaining graft) Repair of defect with autograft; radius OR ulna Repair of defect with autograft; radius AND ulna Insertion of vascular pedicle into carpal bone (eg, Hori procedure) Repair of nonunion of carpal bone (excluding carpal scaphoid (navicular)) (includes obtaining graft and necessary fixation), each bone Repair of nonunion, scaphoid carpal (navicular) bone, with or without radial styloidectomy (includes obtaining graft and necessary fixation) Arthroplastywith prosthetic replacement; distal radius Arthroplasty with prosthetic replacement; distal ulna Arthroplasty with prosthetic replacement; scaphoid carpal (navicular) Arthroplasty with prosthetic replacement; lunate Arthroplasty with prosthetic replacement; trapezium 40.06: continued ASC Incl Rate PC TC Fee Fee 40.06(8) - Surgical Services Description (con’t) Arthroplastywith prosthetic replacement; distal radius and partial or entire carpus (total wrist) Arthroplasty, interposition, intercarpal or carpometacarpal joints Revision of arthroplasty, including removal of implant, wrist joint Epiphyseal arrest by epiphysiodesis or stapling; distal radius OR ulna Epiphyseal arrest by epiphysiodesis or stapling; distal radius AND ulna Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; radius Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; ulna Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; radius AND ulna Closed treatment of radial shaft fracture; without manipulation Closed treatment of radial shaft fracture; with manipulation Open treatment of radial shaft fracture, includes internal fixation, when performed Closed treatment of radial shaft fracture and closed treatment of dislocation of distal radioulnar joint (Galeazzi fracture/dislocation) Open treatment of radial shaft fracture, includes internal fixation, when performed, and closed treatment of distal radioulnar joint dislocation (Galeazzi fracture/ dislocation), includes percutaneous skeletal fixation, when performed Open treatment of radial shaft fracture, includes internal fixation, when performed, and open treatment of distal radioulnar joint dislocation (Galeazzi fracture/ dislocation), includes internal fixation, when performed, includes repair of triangular fibrocartilage complex Closed treatment of ulnar shaft fracture; without manipulation Closed treatment of ulnar shaft fracture; with manipulation Open treatment of ulnar shaft fracture, includes internal fixation, when performed Closed treatment of radial and ulnar shaft fractures; without manipulation Closed treatment of radial and ulnar shaft fractures; with manipulation Open treatment of radial AND ulnar shaft fractures, with internal fixation, when performed; of radius OR ulna Open treatment of radial AND ulnar shaft fractures, with internal fixation, when performed; of radius AND ulna 40.06: continued ASC Incl Rate PC TC Fee Fee 40.06(8) - Surgical Services Description (con’t) Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; without manipulation Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; with manipulation Percutaneous skeletal fixation of distal radial fracture or epiphyseal separation Open treatment of distal radial extra-articular fracture or epiphyseal separation, with internal fixation Open treatment of distal radial intra-articular fracture or epiphyseal separation; with internal fixation of 2 fragments Open treatment of distal radial intra-articular fracture or epiphyseal separation; with internal fixation of 3 or more fragments Closed treatment of carpal scaphoid (navicular) fracture; without manipulation Closed treatment of carpal scaphoid (navicular) fracture; with manipulation Open treatment of carpal scaphoid (navicular) fracture, includes internal fixation, when performed Closed treatment of carpal bone fracture (excluding carpal scaphoid (navicular)); without manipulation, each bone Closed treatment of carpal bone fracture (excluding carpal scaphoid (navicular)); with manipulation, each bone Open treatment of carpal bone fracture (other than carpal scaphoid (navicular)), each bone Closed treatment of ulnar styloid fracture Percutaneous skeletal fixation of ulnar styloid fracture Open treatment of ulnar styloid fracture Closed treatment of radiocarpal or intercarpal dislocation, one or more bones, with manipulation Open treatment of radiocarpal or intercarpal dislocation, one or more bones Percutaneous skeletal fixation of distal radioulnar dislocation Closed treatment of distal radioulnar dislocation with manipulation Open treatment of distal radioulnar dislocation, acute or chronic Closed treatment of trans-scaphoperilunar type of fracture dislocation, with manipulation Open treatment of trans-scaphoperilunar type of fracture dislocation Closed treatment of lunate dislocation, with manipulation Open treatment of lunate dislocation Arthrodesis, wrist; complete, without bone graft (includes radiocarpal and/or intercarpal and/or carpometacarpal joints) ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Arthrodesis, wrist; with sliding graft Arthrodesis, wrist; with iliac or other autograft (includes obtaining graft) Arthrodesis, wrist; limited, without bone graft (eg, intercarpal or radiocarpal) Arthrodesis, wrist; with autograft (includes obtaining graft) Arthrodesis, distal radioulnar joint with segmental resection of ulna, with or without bone graft (eg, Sauve-Kapandji procedure) Amputation, forearm, through radius and ulna; Amputation, forearm, through radius and ulna; open, circular (guillotine) Amputation, forearm, through radius and ulna; secondary closure or scar revision Amputation, forearm, through radius and ulna; re-amputation Krukenberg procedure Disarticulation through wrist; Disarticulation through wrist; secondary closure or scar revision Disarticulation through wrist; re-amputation Transmetacarpal amputation; Transmetacarpal amputation; secondary closure or scar revision Transmetacarpal amputation; re-amputation I.C. Unlisted procedure, forearm or wrist Drainage of finger abscess; simple Drainage of finger abscess; complicated (eg, felon) Drainage of tendon sheath, digit and/or palm, each Drainage of palmar bursa; single, bursa Drainage of palmar bursa; multiple bursa Incision, bone cortex, hand or finger (eg, osteomyelitis or bone abscess) Decompression fingers and/or hand, injection injury (eg, grease gun) Decompressive fasciotomy, hand (excludes 26035) Fasciotomy, palmar (eg, Dupuytren's contracture); percutaneous Fasciotomy, palmar (eg, Dupuytren's contracture); open, partial Tendon sheath incision (eg, for trigger finger) Tenotomy, percutaneous, single, each digit Arthrotomy, with exploration, drainage, or removal of loose or foreign body; carpometacarpal joint Arthrotomy, with exploration, drainage, or removal of loose or foreign body; metacarpophalangeal joint, each Arthrotomy, with exploration, drainage, or removal of loose or foreign body; interphalangeal joint, each Arthrotomy with biopsy; carpometacarpal joint, each Arthrotomy with biopsy; metacarpophalangeal joint, each Arthrotomy with biopsy; interphalangeal joint, each ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Excision, tumor or vascular malformation, soft tissue of hand or finger; subcutaneous Excision, tumor or vascular malformation, soft tissue of hand or finger; deep (subfascial or intramuscular) Radical resection of tumor (eg, malignant neoplasm), soft tissue of hand or finger Fasciectomy, palm only, with or without Z-plasty, other local tissue rearrangement, or skin grafting (includes obtaining graft) Fasciectomy, partial palmar with release of single digit including proximal interphalangeal joint, with or without Z-plasty, other local tissue rearrangement, or skin grafting (includes obtaining graft); Fasciectomy, partial palmar with release of single digit including proximal interphalangeal joint, with or without Z-plasty, other local tissue rearrangement, or skin grafting (includes obtaining graft); each additional digit (List separately in addition to code for primary procedure) Synovectomy, carpometacarpal joint Synovectomy, metacarpophalangeal joint including intrinsic release and extensor hood reconstruction, each digit Synovectomy, proximal interphalangeal joint, including extensor reconstruction, each interphalangeal joint S y n o v e c t o m y , t e n d o n s h e a t h , r a d i c a l (tenosynovectomy), flexor tendon, palm and/or finger, each tendon Excision of lesion of tendon sheath or joint capsule (eg, cyst, mucous cyst, or ganglion), hand or finger Excision of tendon, palm, flexor or extensor, single, each tendon Excision of tendon, finger, flexor or extensor, each tendon Sesamoidectomy, thumb or finger (separate procedure) Excision or curettage of bone cyst or benign tumor of metacarpal; Excision or curettage of bone cyst or benign tumor of metacarpal; with autograft (includes obtaining graft) Excision or curettage of bone cyst or benign tumor of proximal, middle, or distal phalanx of finger; Excision or curettage of bone cyst or benign tumor of proximal, middle, or distal phalanx of finger; with autograft (includes obtaining graft) Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis); metacarpal Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis); proximal or middle phalanx of finger Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis); distal phalanx of finger Radical resection, metacarpal (eg, tumor); ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Radical resection, metacarpal (eg, tumor); with autograft (includes obtaining graft) Radical resection, proximal or middle phalanx of finger (eg, tumor); Radical resection, proximal or middle phalanx of finger (eg, tumor); with autograft (includes obtaining graft) Radical resection, distal phalanx of finger (eg, tumor) Removal of implant from finger or hand Manipulation, finger joint, under anesthesia, each joint Repair or advancement, flexor tendon, not in zone 2 digital flexor tendon sheath (eg, no man's land); primary or secondary without free graft, each tendon Repair or advancement, flexor tendon, not in zone 2 digital flexor tendon sheath (eg, no man's land); secondary with free graft (includes obtaining graft), each tendon Repair or advancement, flexor tendon, in zone 2 digital flexor tendon sheath (eg, no man's land); primary, without free graft, each tendon Repair or advancement, flexor tendon, in zone 2 digital flexor tendon sheath (eg, no man's land); secondary, without free graft, each tendon Repair or advancement, flexor tendon, in zone 2 digital flexor tendon sheath (eg, no man's land); secondary, with free graft (includes obtaining graft), each tendon Repair or advancement of profundus tendon, with intact superficialis tendon; primary, each tendon Repair or advancement of profundus tendon, with intact superficialis tendon; secondary with free graft (includes obtaining graft), each tendon Repair or advancement of profundus tendon, with intact superficialis tendon; secondary without free graft, each tendon Excision flexor tendon, with implantation of synthetic rod for delayed tendon graft, hand or finger, each rod Removal of synthetic rod and insertion of flexor tendon graft, hand or finger (includes obtaining graft), each rod Repair, extensor tendon, hand, primary or secondary; without free graft, each tendon Repair, extensor tendon, hand, primary or secondary; with free graft (includes obtaining graft), each tendon Excision of extensor tendon, with implantation of synthetic rod for delayed tendon graft, hand or finger, each rod Removal of synthetic rod and insertion of extensor tendon graft (includes obtaining graft), hand or finger, each rod Repair, extensor tendon, finger, primary or secondary; without free graft, each tendon Repair, extensor tendon, finger, primary or secondary; with free graft (includes obtaining graft) each tendon ASC Rate Incl PC TC Fee Fee 40.06(8) - Surgical Services Description (con’t) Repair of extensor tendon, central slip, secondary (eg, boutonniere deformity); using local tissue(s), including lateral band(s), each finger Repair of extensor tendon, central slip, secondary (eg, boutonniere deformity); with free graft (includes obtaining graft), each finger Closed treatment of distal extensor tendon insertion, with or without percutaneous pinning (eg, mallet finger) Repair of extensor tendon, distal insertion, primary or secondary; without graft (eg, mallet finger) Repair of extensor tendon, distal insertion, primary or secondary; with free graft (includes obtaining graft) Realignment of extensor tendon, hand, each tendon Tenolysis, flexor tendon; palm OR finger, each tendon Tenolysis, flexor tendon; palm AND finger, each tendon Tenolysis, extensor tendon, hand OR finger, each tendon Tenolysis, complex, extensor tendon, finger, including forearm, each tendon Tenotomy, flexor, palm, open, each tendon Tenotomy, flexor, finger, open, each tendon Tenotomy, extensor, hand or finger, open, each tendon Tenodesis; of proximal interphalangeal joint, each joint Tenodesis; of distal joint, each joint Lengthening of tendon, extensor, hand or finger, each tendon Shortening of tendon, extensor, hand or finger, each tendon Lengthening of tendon, flexor, hand or finger, each tendon Shortening of tendon, flexor, hand or finger, each tendon Transfer or transplant of tendon, carpometacarpal area or dorsum of hand; without free graft, each tendon Transfer or transplant of tendon, carpometacarpal area or dorsum of hand; with free tendon graft (includes obtaining graft), each tendon Transfer or transplant of tendon, palmar; without free tendon graft, each tendon Transfer or transplant of tendon, palmar; with free tendon graft (includes obtaining graft), each tendon Opponensplasty; superficialis tendon transfer type, each tendon Opponensplasty; tendon transfer with graft (includes obtaining graft), each tendon Opponensplasty; hypothenar muscle transfer Opponensplasty; other methods Transfer of tendon to restore intrinsic function; ring and small finger Transfer of tendon to restore intrinsic function; all four fingers Correction claw finger, other methods 40.06: continued Code ASC Incl Rate 26520 735.73 26525 735.73 26540 735.73 26541 1,175.77 26542 735.73 26548 1,175.77 26567 1,175.77 PC TC 40.06(8) - Surgical Services Description (con’t) Fee Fee Reconstruction of tendon pulley, each tendon; with local tissues (separate procedure) Reconstruction of tendon pulley, each tendon; with tendon or fascial graft (includes obtaining graft) (separate procedure) Release of thenar muscle(s) (eg, thumb contracture) Cross intrinsic transfer, each tendon Capsulodesis, metacarpophalangeal joint; single digit Capsulodesis, metacarpophalangeal joint; two digits Capsulodesis, metacarpophalangeal joint; three or four digits Capsulectomy or capsulotomy; metacarpophalangeal joint, each joint Capsulectomy or capsulotomy; interphalangeal joint, each joint Arthroplasty, metacarpophalangeal joint; each joint Arthroplasty, metacarpophalangeal joint; with prosthetic implant, each joint Arthroplasty, interphalangeal joint; each joint Arthroplasty, interphalangeal joint; with prosthetic implant, each joint Repair of collateral ligament, metacarpophalangeal or interphalangeal joint R e c o n s t r u c t i o n , c o l l a t e r a l l i g a m e n t , metacarpophalangeal joint, single; with tendon or fascial graft (includes obtaining graft) R e c o n s t r u c t i o n , c o l l a t e r a l l i g a m e n t , metacarpophalangeal joint, single; with local tissue (eg, adductor advancement) Reconstruction, collateral ligament, interphalangeal joint, single, including graft, each joint Repair non-union, metacarpal or phalanx (includes obtaining bone graft with or without external or internal fixation) Repair and reconstruction, finger, volar plate, interphalangeal joint Pollicization of a digit Transfer, toe-to-hand with microvascular anastomosis; great toe wrap-around with bone graft Transfer, toe-to-hand with microvascular anastomosis; other than great toe, single Transfer, toe-to-hand with microvascular anastomosis; other than great toe, double Transfer, finger to another position without microvascular anastomosis Transfer, free toe joint, with microvascular anastomosis Repair of syndactyly (web finger) each web space; with skin flaps Repair of syndactyly (web finger) each web space; with skin flaps and grafts Repair of syndactyly (web finger) each web space; complex (eg, involving bone, nails) Osteotomy; metacarpal, each Osteotomy; phalanx of finger, each ASC Rate Incl PC TC Fee Fee 40.06(8) - Surgical Services Description (con’t) Osteoplasty, lengthening, metacarpal or phalanx Repair cleft hand Reconstruction of polydactylous digit, soft tissue and bone Repair macrodactylia, each digit Repair, intrinsic muscles of hand, each muscle Release, intrinsic muscles of hand, each muscle Excision of constricting ring of finger, with multiple Z-plasties Closed treatment of metacarpal fracture, single; without manipulation, each bone Closed treatment of metacarpal fracture, single; with manipulation, each bone Closed treatment of metacarpal fracture, with manipulation, with external fixation, each bone Percutaneous skeletal fixation of metacarpal fracture, each bone Open treatment of metacarpal fracture, single, includes internal fixation, when performed, each bone Closed treatment of carpometacarpal dislocation, thumb, with manipulation Closed treatment of carpometacarpal fracture dislocation, thumb (Bennett fracture), with manipulation Percutaneous skeletal fixation of carpometacarpal fracture dislocation, thumb (Bennett fracture), with manipulation Open treatment of carpometacarpal fracture dislocation, thumb (Bennett fracture), includes internal fixation, when performed Closed treatment of carpometacarpal dislocation, other than thumb, with manipulation, each joint; without anesthesia Closed treatment of carpometacarpal dislocation, other than thumb, with manipulation, each joint; requiring anesthesia Percutaneous skeletal fixation of carpometacarpal dislocation, other than thumb, with manipulation, each joint Open treatment of carpometacarpal dislocation, other than thumb; includes internal fixation, when performed, each joint Open treatment of carpometacarpal dislocation, other than thumb; complex, multiple, or delayed reduction Closed treatment of metacarpophalangeal dislocation, single, with manipulation; without anesthesia Closed treatment of metacarpophalangeal dislocation, single, with manipulation; requiring anesthesia Percutaneous skeletal fixation of metacarpophalangeal dislocation, single, with manipulation Open treatment of metacarpophalangeal dislocation, single, includes internal fixation, when performed Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; without manipulation, each ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; with manipulation, with or without skin or skeletal traction, each Percutaneous skeletal fixation of unstable phalangeal shaft fracture, proximal or middle phalanx, finger or thumb, with manipulation, each Open treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb, includes internal fixation, when performed, each Closed treatment of articular fracture, involving metacarpophalangeal or interphalangeal joint; without manipulation, each Closed treatment of articular fracture, involving metacarpophalangeal or interphalangeal joint; with manipulation, each Open treatment of articular fracture, involving metacarpophalangeal or interphalangeal joint, includes internal fixation, when performed, each Closed treatment of distal phalangeal fracture, finger or thumb; without manipulation, each Closed treatment of distal phalangeal fracture, finger or thumb; with manipulation, each Percutaneous skeletal fixation of distal phalangeal fracture, finger or thumb, each Open treatment of distal phalangeal fracture, finger or thumb, includes internal fixation, when performed, each Closed treatment of interphalangeal joint dislocation, single, with manipulation; without anesthesia Closed treatment of interphalangeal joint dislocation, single, with manipulation; requiring anesthesia Percutaneous skeletal fixation of interphalangeal joint dislocation, single, with manipulation Open treatment of interphalangeal joint dislocation, includes internal fixation, when performed, single Fusion in opposition, thumb, with autogenous graft (includes obtaining graft) Arthrodesis, carpometacarpal joint, thumb, with or without internal fixation; Arthrodesis, carpometacarpal joint, thumb, with or without internal fixation; with autograft (includes obtaining graft) Arthrodesis, carpometacarpal joint, digit, other than thumb, each; Arthrodesis, carpometacarpal joint, digit, other than thumb, each; with autograft (includes obtaining graft) Arthrodesis, metacarpophalangeal joint, with or without internal fixation; Arthrodesis, metacarpophalangeal joint, with or without internal fixation; with autograft (includes obtaining graft) Arthrodesis, interphalangeal joint, with or without internal fixation; ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Arthrodesis, interphalangeal joint, with or without internal fixation; each additional interphalangeal joint (List separately in addition to code for primary procedure) Arthrodesis, interphalangeal joint, with or without internal fixation; with autograft (includes obtaining graft) Arthrodesis, interphalangeal joint, with or without internal fixation; with autograft (includes obtaining graft), each additional joint (List separately in addition to code for primary procedure) Amputation, metacarpal, with finger or thumb (ray amputation), single, with or without interosseous transfer Amputation, finger or thumb, primary or secondary, any joint or phalanx, single, including neurectomies; with direct closure Amputation, finger or thumb, primary or secondary, any joint or phalanx, single, including neurectomies; with local advancement flaps (V-Y, hood) I.C. Unlisted procedure, hands or fingers Incision and drainage, pelvis or hip joint area; deep abscess or hematoma Incision and drainage, pelvis or hip joint area; infected bursa Incision, bone cortex, pelvis and/or hip joint (eg, osteomyelitis or bone abscess) Tenotomy, adductor of hip, percutaneous (separate procedure) Tenotomy, adductor of hip, open Tenotomy, adductor, subcutaneous, open, with obturator neurectomy Tenotomy, hip flexor(s), open (separate procedure) Tenotomy, abductors and/or extensor(s) of hip, open (separate procedure) Fasciotomy, hip or thigh, any type Arthrotomy, hip, with drainage (eg, infection) Arthrotomy, hip, including exploration or removal of loose or foreign body Denervation, hip joint, intrapelvic or extrapelvic intra-articular branches of sciatic, femoral, or obturator nerves Capsulectomy or capsulotomy, hip, with or without excision of heterotopic bone, with release of hip flexor muscles (ie, gluteus medius, gluteus minimus, tensor fascia latae, rectus femoris, sartorius, iliopsoas) Biopsy, soft tissue of pelvis and hip area; superficial Biopsy, soft tissue of pelvis and hip area; deep, subfascial or intramuscular Excision, tumor, pelvis and hip area; subcutaneous tissue Excision, tumor, pelvis and hip area; deep, subfascial, intramuscular Radical resection of tumor, soft tissue of pelvis and hip area (eg, malignant neoplasm) ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Arthrotomy, with biopsy; sacroiliac joint Arthrotomy, with biopsy; hip joint Arthrotomy with synovectomy, hip joint Excision; ischial bursa Excision; trochanteric bursa or calcification Excision of bone cyst or benign tumor; superficial (wing of ilium, symphysis pubis, or greater trochanter of femur) with or without autograft Excision of bone cyst or benign tumor; deep, with or without autograft Excision of bone cyst or benign tumor; with autograft requiring separate incision Partial excision (craterization, saucerization) (eg, osteomyelitis or bone abscess); superficial (eg, wing of ilium, symphysis pubis, or greater trochanter of femur) Partial excision (craterization, saucerization) (eg, osteomyelitis or bone abscess); deep (subfascial or intramuscular) Radical resection of tumor or infection; wing of ilium, one pubic or ischial ramus or symphysis pubis Radical resection of tumor or infection; ilium, including acetabulum, both pubic rami, or ischium and acetabulum Radical resection of tumor or infection; innominate bone, total Radical resection of tumor or infection; ischial tuberosity and greater trochanter of femur Radical resection of tumor or infection; ischial tuberosity and greater trochanter of femur, with skin flaps Coccygectomy, primary Removal of foreign body, pelvis or hip; subcutaneous tissue Removal of foreign body, pelvis or hip; deep (subfascial or intramuscular) Removal of hip prosthesis; (separate procedure) Removal of hip prosthesis; complicated, including total hip prosthesis, methylmethacrylate with or without insertion of spacer Injection procedure for hip arthrography; without anesthesia Injection procedure for hip arthrography; with anesthesia Injection procedure for sacroiliac joint, arthrography and/or anesthetic/steroid Release or recession, hamstring, proximal Transfer, adductor to ischium Transfer external oblique muscle to greater trochanter including fascial or tendon extension (graft) Transfer paraspinal muscle to hip (includes fascial or tendon extension graft) Transfer iliopsoas; to greater trochanter of femur Transfer iliopsoas; to femoral neck ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Acetabuloplasty; (eg, Whitman, Colonna, Haygroves, or cup type) Acetabuloplasty; resection, femoral head (eg, Girdlestone procedure) Hemiarthroplasty, hip, partial (eg, femoral stem prosthesis, bipolar arthroplasty) Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft Conversion of previous hip surgery to total hip arthroplasty, with or without autograft or allograft Revision of total hip arthroplasty; both components, with or without autograft or allograft Revision of total hip arthroplasty; acetabular component only, with or without autograft or allograft Revision of total hip arthroplasty; femoral component only, with or without allograft Osteotomy and transfer of greater trochanter of femur (separate procedure) Osteotomy, iliac, acetabular or innominate bone; Osteotomy, iliac, acetabular or innominate bone; with open reduction of hip Osteotomy, iliac, acetabular or innominate bone; with femoral osteotomy Osteotomy, iliac, acetabular or innominate bone; with femoral osteotomy and with open reduction of hip Osteotomy, pelvis, bilateral (eg, congenital malformation) Osteotomy, femoral neck (separate procedure) Osteotomy, intertrochanteric or subtrochanteric including internal or external fixation and/or cast Bone graft, femoral head, neck, intertrochanteric or subtrochanteric area (includes obtaining bone graft) Treatment of slipped femoral epiphysis; by traction, without reduction Treatment of slipped femoral epiphysis; by single or multiple pinning, in situ Open treatment of slipped femoral epiphysis; single or multiple pinning or bone graft (includes obtaining graft) Open treatment of slipped femoral epiphysis; closed manipulation with single or multiple pinning Open treatment of slipped femoral epiphysis; osteoplasty of femoral neck (Heyman type procedure) Open treatment of slipped femoral epiphysis; osteotomy and internal fixation Epiphyseal arrest by epiphysiodesis or stapling, greater trochanter of femur Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate, femoral neck and proximal femur Closed treatment of pelvic ring fracture, dislocation, diastasis or subluxation; without manipulation 40.06: continued ASC Incl Rate PC Fee TC Fee 40.06(8) - Surgical Services Description (con’t) Closed treatment of pelvic ring fracture, dislocation, diastasis or subluxation; with manipulation, requiring more than local anesthesia Closed treatment of coccygeal fracture Open treatment of coccygeal fracture Open treatment of iliac spine(s), tuberosity avulsion, or iliac wing fracture(s) (eg, pelvic fracture(s) which do not disrupt the pelvic ring), with internal fixation Percutaneous skeletal fixation of posterior pelvic ring fracture and/or dislocation (includes ilium, sacroiliac joint and/or sacrum) Open treatment of anterior ring fracture and/or dislocation with internal fixation (includes pubic symphysis and/or rami) Open treatment of posterior ring fracture and/or dislocation with internal fixation (includes ilium, sacroiliac joint and/or sacrum) Closed treatment of acetabulum (hip socket) fracture(s); without manipulation Closed treatment of acetabulum (hip socket) fracture(s); with manipulation, with or without skeletal traction Open treatment of posterior or anterior acetabular wall fracture, with internal fixation Open treatment of acetabular fracture(s) involving anterior or posterior (one) column, or a fracture running transversely across the acetabulum, with internal fixation Open treatment of acetabular fracture(s) involving anterior and posterior (two) columns, includes T-fracture and both column fracture with complete articular detachment, or single column or transverse fracture with associated acetabular wall fracture, with internal fixation Closed treatment of femoral fracture, proximal end, neck; without manipulation Closed treatment of femoral fracture, proximal end, neck; with manipulation, with or without skeletal traction Percutaneous skeletal fixation of femoral fracture, proximal end, neck Open treatment of femoral fracture, proximal end, neck, internal fixation or prosthetic replacement Closed treatment of intertrochanteric, peritrochanteric, or subtrochanteric femoral fracture; without manipulation Closed treatment of intertrochanteric, peritrochanteric, or subtrochanteric femoral fracture; with manipulation, with or without skin or skeletal traction Treatment of intertrochanteric, peritrochanteric, or subtrochanteric femoral fracture; with plate/screw type implant, with or without cerclage ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Treatment of intertrochanteric, peritrochanteric, or subtrochanteric femoral fracture; with intramedullary implant, with or without interlocking screws and/or cerclage Closed treatment of greater trochanteric fracture, without manipulation Open treatment of greater trochanteric fracture, includes internal fixation, when performed Closed treatment of hip dislocation, traumatic; without anesthesia Closed treatment of hip dislocation, traumatic; requiring anesthesia Open treatment of hip dislocation, traumatic, without internal fixation Open treatment of hip dislocation, traumatic, with acetabular wall and femoral head fracture, with or without internal or external fixation Treatment o f s p o n t an eo u s h ip dislocation (developmental, including congenital or pathological), by abduction, splint or traction; without anesthesia, without manipulation Treatment of spontaneous hip dislocation (developmental, including congenital or pathological), by abduction, splint or traction; with manipulation, requiring anesthesia Open treatment of spontaneous hip dislocation (developmental, including congenital or pathological), replacement of femoral head in acetabulum (including tenotomy, etc); Open treatment of spontaneous hip dislocation (developmental, including congenital or pathological), replacement of femoral head in acetabulum (including tenotomy, etc); with femoral shaft shortening Closed treatment of post hip arthroplasty dislocation; without anesthesia Closed treatment of post hip arthroplasty dislocation; requiring regional or general anesthesia Closed treatment of femoral fracture, proximal end, head; without manipulation Closed treatment of femoral fracture, proximal end, head; with manipulation Open treatment of femoral fracture, proximal end, head, includes internal fixation, when performed Manipulation, hip joint, requiring general anesthesia Arthrodesis, sacroiliac joint (including obtaining graft) Arthrodesis, symphysis pubis (including obtaining graft) Arthrodesis, hip joint (including obtaining graft); Arthrodesis, hip joint (including obtaining graft); with subtrochanteric osteotomy Interpelviabdominal amputation (hindquarter amputation) Disarticulation of hip I.C. Unlisted procedure, pelvis or hip joint Incision and drainage, deep abscess, bursa, or hematoma, thigh or knee region ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Incision, deep, with opening of bone cortex, femur or knee (eg, osteomyelitis or bone abscess) Fasciotomy, iliotibial (tenotomy), open Tenotomy, percutaneous, adductor or hamstring; single tendon (separate procedure) Tenotomy, percutaneous, adductor or hamstring; multiple tendons Arthrotomy, knee, with exploration, drainage, or removal of foreign body (eg, infection) Biopsy, soft tissue of thigh or knee area; superficial Biopsy, soft tissue of thigh or knee area; deep (subfascial or intramuscular) Neurectomy, hamstring muscle Neurectomy, popliteal (gastrocnemius) Excision, tumor, thigh or knee area; subcutaneous Excision, tumor, thigh or knee area; deep, subfascial, or intramuscular Radical resection of tumor (eg, malignant neoplasm), soft tissue of thigh or knee area Arthrotomy, knee; with synovial biopsy only Arthrotomy, knee; including joint exploration, biopsy, or removal of loose or foreign bodies Arthrotomy, with excision of semilunar cartilage (meniscectomy) knee; medial OR lateral Arthrotomy, with excision of semilunar cartilage (meniscectomy) knee; medial AND lateral Arthrotomy, with synovectomy, knee; anterior OR posterior Arthrotomy, with synovectomy, knee; anterior AND posterior including popliteal area Excision, prepatellar bursa Excision of synovial cyst of popliteal space (eg, Baker's cyst) Excision of lesion of meniscus or capsule (eg, cyst, ganglion), knee Patellectomy or hemipatellectomy Excision or curettage of bone cyst or benign tumor of femur; Excision or curettage of bone cyst or benign tumor of femur; with allograft Excision or curettage of bone cyst or benign tumor of femur; with autograft (includes obtaining graft) Excision or curettage of bone cyst or benign tumor of femur; with internal fixation (List in addition to code for primary procedure) Partial excision (craterization, saucerization, or diaphysectomy) bone, femur, proximal tibia and/or fibula (eg, osteomyelitis or bone abscess) Radical resection of tumor, bone, femur or knee Injection procedure for knee arthrography Removal of foreign body, deep, thigh region or knee area Suture of infrapatellar tendon; primary Suture of infrapatellar tendon; secondary reconstruction, including fascial or tendon graft ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Suture of quadriceps or hamstring muscle rupture; primary Suture of quadriceps or hamstring muscle rupture; secondary reconstruction, including fascial or tendon graft Tenotomy, open, hamstring, knee to hip; single tendon Tenotomy, open, hamstring, knee to hip; multiple tendons, one leg Tenotomy, open, hamstring, knee to hip; multiple tendons, bilateral Lengthening of hamstring tendon; single tendon Lengthening of hamstring tendon; multiple tendons, one leg Lengthening of hamstring tendon; multiple tendons, bilateral Transplant, hamstring tendon to patella; single tendon Transplant, hamstring tendon to patella; multiple tendons Transfer, tendon or muscle, hamstrings to femur (eg, Egger's type procedure) Arthrotomy with meniscus repair, knee Repair, primary, torn ligament and/or capsule, knee; collateral Repair, primary, torn ligament and/or capsule, knee; cruciate Repair, primary, torn ligament and/or capsule, knee; collateral and cruciate ligaments Autologous chondrocyte implantation, knee Osteochondral allograft, knee, open Osteochondral autograft(s), knee, open (eg, mosaicplasty) (includes harvesting of autograft[s]) Anterior tibial tubercleplasty (eg, Maquet type procedure) Reconstruction of dislocating patella; (eg, Hauser type procedure) Reconstruction of dislocating patella; with extensor realignment and/or muscle advancement or release (eg, Campbell, Goldwaite type procedure) Reconstruction of dislocating patella; with patellectomy Lateral retinacular release, open Ligamentous reconstruction (augmentation), knee; extra-articular Ligamentous reconstruction (augmentation), knee; intra-articular (open) Ligamentous reconstruction (augmentation), knee; intra-articular (open) and extra-articular Quadricepsplasty (eg, Bennett or Thompson type) Capsulotomy, posterior capsular release, knee Arthroplasty, patella; without prosthesis Arthroplasty, patella; with prosthesis Arthroplasty, knee, tibial plateau; Arthroplasty, knee, tibial plateau; with debridement and partial synovectomy 40.06: continued etc. Code ASC Incl Rate PC TC 40.06(8) - Surgical Services Description (con’t) Fee Fee Arthroplasty, femoral condyles or tibial plateau(s), knee; Arthroplasty, femoral condyles or tibial plateau(s), knee; with debridement and partial synovectomy Arthroplasty, knee, hinge prosthesis (eg, Walldius type) Arthroplasty, knee, condyle and plateau; medial OR lateral compartment Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty) Osteotomy, femur, shaft or supracondylar; without fixation Osteotomy, femur, shaft or supracondylar; with fixation Osteotomy, multiple, with realignment on intramedullary rod, femoral shaft (eg, Sofield type procedure) Osteotomy, proximal tibia, including fibular excision or osteotomy (includes correction of genu varus (bowleg) or genu valgus (knock-knee)); before epiphyseal closure Osteotomy, proximal tibia, including fibular excision or osteotomy (includes correction of genu varus (bowleg) or genu valgus (knock-knee)); after epiphyseal closure Osteoplasty, femur; shortening (excluding 64876) Osteoplasty, femur; lengthening Osteoplasty, femur; combined, lengthening and shortening with femoral segment transfer Repair, nonunion or malunion, femur, distal to head and neck; without graft (eg, compression technique) Repair, nonunion or malunion, femur, distal to head and neck; with iliac or other autogenous bone graft (includes obtaining graft) Arrest, epiphyseal, any method (eg, epiphysiodesis); distal femur Arrest, epiphyseal, any method (eg, epiphysiodesis); tibia and fibula, proximal Arrest, epiphyseal, any method (eg, epiphysiodesis); combined distal femur, proximal tibia and fibula Arrest, hemiepiphyseal, distal femur or proximal tibia or fibula (eg, genu varus or valgus) Revision of total knee arthroplasty, with or without allograft; one component Revision of total knee arthroplasty, with or without allograft; femoral and entire tibial component Removal of prosthesis, including total knee prosthesis, methylmethacrylate with or without insertion of spacer, knee Prophylactic treatment (nailing, pinning, plating, or wiring) with or without methylmethacrylate, femur Decompression fasciotomy, thigh and/or knee, one compartment (flexor or extensor or adductor); 40.06: continued ASC Incl Rate PC Fee TC Fee 40.06(8) - Surgical Services Description (con’t) Decompression fasciotomy, thigh and/or knee, one compartment (flexor or extensor or adductor); with debridement of nonviable muscle and/or nerve Decompression fasciotomy, thigh and/or knee, multiple compartments; Decompression fasciotomy, thigh and/or knee, multiple compartments; with debridement of nonviable muscle and/or nerve Closed treatment of femoral shaft fracture, without manipulation Closed treatment of supracondylar or transcondylar femoral fracture with or without intercondylar extension, without manipulation Closed treatment of femoral shaft fracture, with manipulation, with or without skin or skeletal traction Closed treatment of supracondylar or transcondylar femoral fracture with or without intercondylar extension, with manipulation, with or without skin or skeletal traction Open treatment of femoral shaft fracture, with or without external fixation, with insertion of intramedullary implant, with or without cerclage and/or locking screws Open treatment of femoral shaft fracture with plate/screws, with or without cerclage Closed treatment of femoral fracture, distal end, medial or lateral condyle, without manipulation Percutaneous skeletal fixation of femoral fracture, distal end, medial or lateral condyle, or supracondylar or transcondylar, with or without intercondylar extension, or distal femoral epiphyseal separation Closed treatment of femoral fracture, distal end, medial or lateral condyle, with manipulation Open treatment of femoral supracondylar or transcondylar fracture without intercondylar extension, includes internal fixation, when performed Open treatment of femoral supracondylar or transcondylar fracture with intercondylar extension, includes internal fixation, when performed Open treatment of femoral fracture, distal end, medial or lateral condyle, includes internal fixation, when performed Closed treatment of distal femoral epiphyseal separation; without manipulation Closed treatment of distal femoral epiphyseal separation; with manipulation, with or without skin or skeletal traction Open treatment of distal femoral epiphyseal separation, includes internal fixation, when performed Closed treatment of patellar fracture, without manipulation Open treatment of patellar fracture, with internal fixation and/or partial or complete patellectomy and soft tissue repair ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Closed treatment of tibial fracture, proximal (plateau); without manipulation Closed treatment of tibial fracture, proximal (plateau); with or without manipulation, with skeletal traction Open treatment of tibial fracture, proximal (plateau); unicondylar, includes internal fixation, when performed Open treatment of tibial fracture, proximal (plateau); bicondylar, with or without internal fixation Closed treatment of intercondylar spine(s) and/or tuberosity fracture(s) of knee, with or without manipulation Open treatment of intercondylar spine(s) and/or tuberosity fracture(s) of the knee, includes internal fixation, when performed Closed treatment of knee dislocation; without anesthesia Closed treatment of knee dislocation; requiring anesthesia Open treatment of knee dislocation, includes internal fixation, when performed; without primary ligamentous repair or augmentation/reconstruction Open treatment of knee dislocation, includes internal fixation, when performed; with primary ligamentous repair Open treatment of knee dislocation, includes internal fixation, when performed; with primary ligamentous repair, with augmentation/reconstruction Closed treatment of patellar dislocation; without anesthesia Closed treatment of patellar dislocation; requiring anesthesia Open treatment of patellar dislocation, with or without partial or total patellectomy Manipulation of knee joint under general anesthesia (includes application of traction or other fixation devices) Arthrodesis, knee, any technique Amputation, thigh, through femur, any level; Amputation, thigh, through femur, any level; immediate fitting technique including first cast Amputation, thigh, through femur, any level; open, circular (guillotine) Amputation, thigh, through femur, any level; secondary closure or scar revision Amputation, thigh, through femur, any level; re-amputation Disarticulation at knee I.C. Unlisted procedure, femur or knee Decompression fasciotomy, leg; anterior and/or lateral compartments only Decompressio n fasciotomy, leg; posterior compartment(s) only Decompression fasciotomy, leg; anterior and/or lateral, and posterior compartment(s) ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Incision and drainage, leg or ankle; deep abscess or hematoma Incision and drainage, leg or ankle; infected bursa Tenotomy, percutaneous, Achilles tendon (separate procedure); local anesthesia Tenotomy, percutaneous, Achilles tendon (separate procedure); general anesthesia Incision (eg, osteomyelitis or bone abscess), leg or ankle Arthrotomy, ankle, including exploration, drainage, or removal of foreign body Arthrotomy, posterior capsular release, ankle, with or without Achilles tendon lengthening Biopsy, soft tissue of leg or ankle area; superficial Biopsy, soft tissue of leg or ankle area; deep (subfascial or intramuscular) Radical resection of tumor (eg, malignant neoplasm), soft tissue of leg or ankle area Excision, tumor, leg or ankle area; subcutaneous tissue Excision, tumor, leg or ankle area; deep (subfascial or intramuscular) Arthrotomy, ankle, with joint exploration, with or without biopsy, with or without removal of loose or foreign body Arthrotomy, with synovectomy, ankle; Arthrotomy, with synovectomy, ankle; including tenosynovectomy Excision of lesion of tendon sheath or capsule (eg, cyst or ganglion), leg and/or ankle Excision or curettage of bone cyst or benign tumor, tibia or fibula; Excision or curettage of bone cyst or benign tumor, tibia or fibula; with autograft (includes obtaining graft) Excision or curettage of bone cyst or benign tumor, tibia or fibula; with allograft Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis or exostosis); tibia Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis or exostosis); fibula Radical resection of tumor, bone; tibia Radical resection of tumor, bone; fibula Radical resection of tumor, bone; talus or calcaneus Injection procedure for ankle arthrography Repair, primary, open or percutaneous, ruptured Achilles tendon; Repair, primary, open or percutaneous, ruptured Achilles tendon; with graft (includes obtaining graft) Repair, secondary, Achilles tendon, with or without graft Repair, fascial defect of leg Repair, flexor tendon, leg; primary, without graft, each tendon ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Repair, flexor tendon, leg; secondary, with or without graft, each tendon Repair, extensor tendon, leg; primary, without graft, each tendon Repair, extensor tendon, leg; secondary, with or without graft, each tendon Repair, dislocating peroneal tendons; without fibular osteotomy Repair, dislocating peroneal tendons; with fibular osteotomy Tenolysis, flexor or extensor tendon, leg and/or ankle; single, each tendon Tenolysis, flexor or extensor tendon, leg and/or ankle; multiple tendons (through separate incision(s)) Lengthening or shortening of tendon, leg or ankle; single tendon (separate procedure) Lengthening or shortening of tendon, leg or ankle; multiple tendons (through same incision), each Gastrocnemius recession (eg, Strayer procedure) Transfer or transplant of single tendon (with muscle redirection or rerouting); superficial (eg, anterior tibial extensors into midfoot) Transfer or transplant of single tendon (with muscle redirection or rerouting); deep (eg, anterior tibial or posterior tibial through interosseous space, flexor digitorum longus, flexor hallucis longus, or peroneal tendon to midfoot or hindfoot) Transfer or transplant of single tendon (with muscle redirection or rerouting); each additional tendon (List separately in addition to code for primary procedure) Repair, primary, disrupted ligament, ankle; collateral Repair, primary, disrupted ligament, ankle; both collateral ligaments Repair, secondary, disrupted ligament, ankle, collateral (eg, Watson-Jones procedure) Arthroplasty, ankle; Arthroplasty, ankle; with implant (total ankle) Arthroplasty, ankle; revision, total ankle Removal of ankle implant Osteotomy; tibia Osteotomy; fibula Osteotomy; tibia and fibula Osteo tomy; multiple, wi th real ignment on intramedullary rod (eg, Sofield type procedure) Osteoplasty, tibia and fibula, lengthening or shortening Repair of nonunion or malunion, tibia; without graft, (eg, compression technique) Repair of nonunion or malunion, tibia; with sliding graft Repair of nonunion or malunion, tibia; with iliac or other autograft (includes obtaining graft) Repair of nonunion or malunion, tibia; by synostosis, with fibula, any method Repair of fibula nonunion and/or malunion with internal fixation ASC Rate Incl PC TC Fee Fee 40.06(8) - Surgical Services Description (con’t) Repair of congenital pseudarthrosis, tibia Arrest, epiphyseal (epiphysiodesis), open; distal tibia Arrest, epiphyseal (epiphysiodesis), open; distal fibula Arrest, epiphyseal (epiphysiodesis), open; distal tibia and fibula Arrest, epiphyseal (epiphysiodesis), any method, combined, proximal and distal tibia and fibula; Arrest, epiphyseal (epiphysiodesis), any method, combined, proximal and distal tibia and fibula; and distal femur Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate, tibia Closed treatment of tibial shaft fracture (with or without fibular fracture); without manipulation Closed treatment of tibial shaft fracture (with or without fibular fracture); with manipulation, with or without skeletal traction Percutaneous skeletal fixation of tibial shaft fracture (with or without fibular fracture) (eg, pins or screws) Open treatment of tibial shaft fracture (with or without fibular fracture), with plate/screws, with or without cerclage Treatment of tibial shaft fracture (with or without fibular fracture) by intramedullary implant, with or without interlocking screws and/or cerclage Closed treatment of medial malleolus fracture; without manipulation Closed treatment of medial malleolus fracture; with manipulation, with or without skin or skeletal traction Open treatment of medial malleolus fracture, includes internal fixation, when performed Closed treatment of posterior malleolus fracture; without manipulation Closed treatment of posterior malleolus fracture; with manipulation Open treatment of posterior malleolus fracture, includes internal fixation, when performed Closed treatment of proximal fibula or shaft fracture; without manipulation Closed treatment of proximal fibula or shaft fracture; with manipulation Open treatment of proximal fibula or shaft fracture, includes internal fixation, when performed Closed treatment of distal fibular fracture (lateral malleolus); without manipulation Closed treatment of distal fibular fracture (lateral malleolus); with manipulation Open treatment of distal fibular fracture (lateral malleolus), includes internal fixation, when performed Closed treatment of bimalleolar ankle fracture (eg, lateral and medial malleoli, or lateral and posterior malleoli or medial and posterior malleoli); without manipulation 40.06: continued ASC Incl Rate PC Fee TC Fee 40.06(8) - Surgical Services Description (con’t) Closed treatment of bimalleolar ankle fracture (eg, lateral and medial malleoli, or lateral and posterior malleoli or medial and posterior malleoli); with manipulation Open treatment of bimalleolar ankle fracture (eg, lateral and medial malleoli, or lateral and posterior malleoli, or medial and posterior malleoli), includes internal fixation, when performed Closed treatment of trimalleolar ankle fracture; without manipulation Closed treatment of trimalleolar ankle fracture; with manipulation Open treatment of trimalleolar ankle fracture, includes internal fixation, when performed, medial and/or lateral malleolus; without fixation of posterior lip Open treatment of trimalleolar ankle fracture, includes internal fixation, when performed, medial and/or lateral malleolus; with fixation of posterior lip Closed treatment of fracture of weight bearing articular portion of distal tibia (eg, pilon or tibial plafond), with or without anesthesia; without manipulation Closed treatment of fracture of weight bearing articular portion of distal tibia (eg, pilon or tibial plafond), with or without anesthesia; with skeletal traction and/or requiring manipulation Open treatment of fracture of weight bearing articular surface/portion of distal tibia (eg, pilon or tibial plafond), with internal fixation, when performed; of fibula only Open treatment of fracture of weight bearing articular surface/portion of distal tibia (eg, pilon or tibial plafond), with internal fixation, when performed; of tibia only Open treatment of fracture of weight bearing articular surface/portion of distal tibia (eg, pilon or tibial plafond), with internal fixation, when performed; of both tibia and fibula Open treatment of distal tibiofibular joint (syndesmosis) disruption, includes internal fixation, when performed Closed treatment of proximal tibiofibular joint dislocation; without anesthesia Closed treatment of proximal tibiofibular joint dislocation; requiring anesthesia Open treatment of proximal tibiofibular joint dislocation, includes internal fixation, when performed, or with excision of proximal fibula Closed treatment of ankle dislocation; without anesthesia Closed treatment of ankle dislocation; requiring anesthesia, with or without percutaneous skeletal fixation ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Open treatment of ankle dislocation, with or without percutaneous skeletal fixation; without repair or internal fixation Open treatment of ankle dislocation, with or without percutaneous skeletal fixation; with repair or internal or external fixation Manipulation of ankle under general anesthesia (includes application of traction or other fixation apparatus) Arthrodesis, ankle, open Arthrodesis, tibiofibular joint, proximal or distal Amputation, leg, through tibia and fibula; Amputation, leg, through tibia and fibula; with immediate fitting technique including application of first cast Amputation, leg, through tibia and fibula; open, circular (guillotine) Amputation, leg, through tibia and fibula; secondary closure or scar revision Amputation, leg, through tibia and fibula; re-amputation Amputation, ankle, through malleoli of tibia and fibula (eg, Syme, Pirogoff type procedures), with plastic closure and resection of nerves Ankle disarticulation Decompression fasciotomy, leg; anterior and/or lateral compartments only, with debridement of nonviable muscle and/or nerve Decompression fas ci otomy, leg; posterior compartment(s) only, with debridement of nonviable muscle and/or nerve Decompression fasciotomy, leg; anterior and/or lateral, and posterior compartment(s), with debridement of nonviable muscle and/or nerve I.C. Unlisted procedure, leg or ankle Incision and drainage, bursa, foot Incision and drainage below fascia, with or without tendon sheath involvement, foot; single bursal space Incision and drainage below fascia, with or without tendon sheath involvement, foot; multiple areas Incision, bone cortex (eg, osteomyelitis or bone abscess), foot Fasciotomy, foot and/or toe Tenotomy, percutaneous, toe; single tendon Tenotomy, percutaneous, toe; multiple tendons Arthrotomy, including exploration, drainage, or removal of loose or foreign body; intertarsal or tarsometatarsal joint Arthrotomy, including exploration, drainage, or r e m o v a l o f l o o s e o r f o r e i gn b o d y; metatarsophalangeal joint Arthrotomy, including exploration, drainage, or removal of loose or foreign body; interphalangeal joint Release, tarsal tunnel (posterior tibial nerve decompression) ASC Rate Incl PC Fee TC Fee 40.06(8) - Surgical Services Description (con’t) Excision, tumor, foot; subcutaneous tissue Excision, tumor, foot; deep, subfascial, intramuscular Radical resection of tumor (eg, malignant neoplasm), soft tissue of foot Arthrotomy with biopsy; intertarsal or tarsometatarsal joint Arthrotomy with biopsy; metatarsophalangeal joint Arthrotomy with biopsy; interphalangeal joint Neurectomy, intrinsic musculature of foot Fasciectomy, plantar fascia; partial (separate procedure) Fasciectomy, plantar fascia; radical (separate procedure) Synovectomy; intertarsal or tarsometatarsal joint, each Synovectomy; metatarsophalangeal joint, each Excision, interdigital (Morton) neuroma, single, each Synovectomy, tendon sheath, foot; flexor Synovectomy, tendon sheath, foot; extensor Excision of lesion, tendon, tendon sheath, or capsule (including synovectomy) (eg, cyst or ganglion); foot Excision of lesion, tendon, tendon sheath, or capsule (including synovectomy) (eg, cyst or ganglion); toe(s), each Excision or curettage of bone cyst or benign tumor, talus or calcaneus; Excision or curettage of bone cyst or benign tumor, talus or calcaneus; with iliac or other autograft (includes obtaining graft) Excision or curettage of bone cyst or benign tumor, talus or calcaneus; with allograft Excision or curettage of bone cyst or benign tumor, tarsal or metatarsal, except talus or calcaneus; Excision or curettage of bone cyst or benign tumor, tarsal or metatarsal, except talus or calcaneus; with iliac or other autograft (includes obtaining graft) Excision or curettage of bone cyst or benign tumor, tarsal or metatarsal, except talus or calcaneus; with allograft Excision or curettage of bone cyst or benign tumor, phalanges of foot Ostectomy, partial excision, fifth metatarsal head (bunionette) (separate procedure) Ostectomy, complete excision; first metatarsal head Ostectomy, complete excision; other metatarsal head (second, third or fourth) Ostectomy, complete excision; fifth metatarsal head Ostectomy, complete excision; all metatarsal heads, with partial proximal phalangectomy, excluding first metatarsal (eg, Clayton type procedure) Ostectomy, excision of tarsal coalition Ostectomy, calcaneus; Ostectomy, calcaneus; for spur, with or without plantar fascial release Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (eg, osteomyelitis or bossing); talus or calcaneus ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (eg, osteomyelitis or bossing); tarsal or metatarsal bone, except talus or calcaneus Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (eg, osteomyelitis or bossing); phalanx of toe Resection, partial or complete, phalangeal base, each toe Talectomy (astragalectomy) Metatarsectomy Phalangectomy, toe, each toe Resection, condyle(s), distal end of phalanx, each toe Hemiphalangectomy or interphalangeal joint excision, toe, proximal end of phalanx, each Radical resection of tumor, bone; tarsal (except talus or calcaneus) Radical resection of tumor, bone; metatarsal Radical resection of tumor, bone; phalanx of toe Removal of foreign body, foot; subcutaneous Removal of foreign body, foot; deep Removal of foreign body, foot; complicated Repair, tendon, flexor, foot; primary or secondary, without free graft, each tendon Repair, tendon, flexor, foot; secondary with free graft, each tendon (includes obtaining graft) Repair, tendon, extensor, foot; primary or secondary, each tendon Repair, tendon, extensor, foot; secondary with free graft, each tendon (includes obtaining graft) Tenolysis, flexor, foot; single tendon Tenolysis, flexor, foot; multiple tendons Tenolysis, extensor, foot; single tendon Tenolysis, extensor, foot; multiple tendons Tenotomy, open, tendon flexor; foot, single or multiple tendon(s) (separate procedure) Tenotomy, open, tendon flexor; toe, single tendon (separate procedure) Tenotomy, open, extensor, foot or toe, each tendon Reconstruction (advancement), posterior tibial tendon with excision of accessory tarsal navicular bone (eg, Kidner type procedure) Tenotomy, lengthening, or release, abductor hallucis muscle Division of plantar fascia and muscle (eg, Steindler stripping) (separate procedure) Capsulotomy, midfoot; medial release only (separate procedure) Capsulotomy, midfoot; with tendon lengthening Capsulotomy, midfoot; extensive, including posterior talotibial capsulotomy and tendon(s) lengthening (eg, resistant clubfoot deformity) Capsulotomy, midtarsal (eg, Heyman type procedure) Capsulotomy; metatarsophalangeal joint, with or without tenorrhaphy, each joint (separate procedure) 40.06: continued ASC Incl Rate PC TC Fee Fee 40.06(8) - Surgical Services Description (con’t) Capsulotomy; interphalangeal joint, each joint (separate procedure) Syndactylization, toes (eg, webbing or Kelikian type procedure) Correction, hammertoe (eg, interphalangeal fusion, partial or total phalangectomy) Correction, cock-up fifth toe, with plastic skin closure (eg, Ruiz-Mora type procedure) Ostectomy, partial, exostectomy or condylectomy, metatarsal head, each metatarsal head Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint Correction, hallux valgus (bunion), with or without sesamoidectomy; simple exostectomy (eg, Silver type procedure) Correction, hallux valgus (bunion), with or without sesamoidectomy; Keller, McBride, or Mayo type procedure Correction, hallux valgus (bunion), with or without sesamoidectomy; resection of joint with implant Correction, hallux valgus (bunion), with or without sesamoidectomy; with tendon transplants (eg, Joplin type procedure) Correction, hallux valgus (bunion), with or without sesamoidectomy; with metatarsal osteotomy (eg, Mitchell, Chevron, or concentric type procedures) Correction, hallux valgus (bunion), with or without sesamoidectomy; Lapidus-type procedure Correction, hallux valgus (bunion), with or without sesamoidectomy; by phalanx osteotomy Correction, hallux valgus (bunion), with or without sesamoidectomy; by double osteotomy Osteotomy; calcaneus (eg, Dwyer or Chambers type procedure), with or without internal fixation Osteotomy; talus Osteotomy, tarsal bones, other than calcaneus or talus; Osteotomy, tarsal bones, other than calcaneus or talus; with autograft (includes obtaining graft) (eg, Fowler type) Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; first metatarsal Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; first metatarsal with autograft (other than first toe) Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; other than first metatarsal, each Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; multiple (eg, Swanson type cavus foot procedure) Osteotomy, shortening, angular or rotational correction; proximal phalanx, first toe (separate procedure) ASC Rate Incl PC TC Fee Fee 40.06(8) - Surgical Services Description (con’t) Osteotomy, shortening, angular or rotational correction; other phalanges, any toe Reconstruction, angular deformity of toe, soft tissue procedures only (eg, overlapping second toe, fifth toe, curly toes) Sesamoidectomy, first toe (separate procedure) Repair, nonunion or malunion; tarsal bones Repair, nonunion or malunion; metatarsal, with or without bone graft (includes obtaining graft) Reconstruction, toe, macrodactyly; soft tissue resection Reconstruction, toe, macrodactyly; requiring bone resection Reconstruction, toe(s); polydactyly Reconstruction, toe(s); syndactyly, with or without skin graft(s), each web Reconstruction, cleft foot Closed treatment of calcaneal fracture; without manipulation Closed treatment of calcaneal fracture; with manipulation Percutaneous skeletal fixation of calcaneal fracture, with manipulation Open treatment of calcaneal fracture, includes internal fixation, when performed; Open treatment of calcaneal fracture, includes internal fixation, when performed; with primary iliac or other autogenous bone graft (includes obtaining graft) Closed treatment of talus fracture; without manipulation Closed treatment of talus fracture; with manipulation Percutaneous skeletal fixation of talus fracture, with manipulation Open treatment of talus fracture, includes internal fixation, when performed Open osteochondral autograft, talus (includes obtaining graft[s]) Treatment of tarsal bone fracture (except talus and calcaneus); without manipulation, each Treatment of tarsal bone fracture (except talus and calcaneus); with manipulation, each Percutaneous skeletal fixation of tarsal bone fracture (except talus and calcaneus), with manipulation, each Open treatment of tarsal bone fracture (except talus and calcaneus), includes internal fixation, when performed, each Closed treatment of metatarsal fracture; without manipulation, each Closed treatment of metatarsal fracture; with manipulation, each Percutaneous skeletal fixation of metatarsal fracture, with manipulation, each Open treatment of metatarsal fracture, includes internal fixation, when performed, each Closed treatment of fracture great toe, phalanx or phalanges; without manipulation ASC Incl Rate PC TC Fee Fee 40.06(8) - Surgical Services Description (con’t) Closed treatment of fracture great toe, phalanx or phalanges; with manipulation Percutaneous skeletal fixation of fracture great toe, phalanx or phalanges, with manipulation Open treatment of fracture, great toe, phalanx or phalanges, includes internal fixation, when performed Closed treatment of fracture, phalanx or phalanges, other than great toe; without manipulation, each Closed treatment of fracture, phalanx or phalanges, other than great toe; with manipulation, each Open treatment of fracture, phalanx or phalanges, other than great toe, includes internal fixation, when performed, each Closed treatment of sesamoid fracture Open treatment of sesamoid fracture, with or without internal fixation Closed treatment of tarsal bone dislocation, other than talotarsal; without anesthesia Closed treatment of tarsal bone dislocation, other than talotarsal; requiring anesthesia Percutaneous skeletal fixation of tarsal bone dislocation, other than talotarsal, with manipulation Open treatment of tarsal bone dislocation, includes internal fixation, when performed Closed treatment of talotarsal joint dislocation; without anesthesia Closed treatment of talotarsal joint dislocation; requiring anesthesia Percutaneous skeletal fixation of talotarsal joint dislocation, with manipulation Open treatment of talotarsal joint dislocation, includes internal fixation, when performed Closed treatment of tarsometatarsal joint dislocation; without anesthesia Closed treatment of tarsometatarsal joint dislocation; requiring anesthesia Percutaneous skeletal fixation of tarsometatarsal joint dislocation, with manipulation Open treatment of tarsometatarsal joint dislocation, includes internal fixation, when performed Closed treatment of metatarsophalangeal joint dislocation; without anesthesia Closed treatment of metatarsophalangeal joint dislocation; requiring anesthesia Percutaneous skeletal fixation of metatarsophalangeal joint dislocation, with manipulation Open treatment of metatarsophalangeal joint dislocation, includes internal fixation, when performed Closed treatment of interphalangeal joint dislocation; without anesthesia Closed treatment of interphalangeal joint dislocation; requiring anesthesia Percutaneous skeletal fixation of interphalangeal joint dislocation, with manipulation ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Open treatment of interphalangeal joint dislocation, includes internal fixation, when performed Arthrodesis; pantalar Arthrodesis; triple Arthrodesis; subtalar Arthrodesis, midtarsal or tarsometatarsal, multiple or transverse; Arthrodesis, midtarsal or tarsometatarsal, multiple or transverse; with osteotomy (eg, flatfoot correction) Arthrodesis, with tendon lengthening and advancement, midtarsal, tarsal navicular-cuneiform (eg, Miller type procedure) Arthrodesis, midtarsal or tarsometatarsal, single joint Arthrodesis, great toe; metatarsophalangeal joint Arthrodesis, great toe; interphalangeal joint Arthrodesis, with extensor hallucis longus transfer to first metatarsal neck, great toe, interphalangeal joint (eg, Jones type procedure) Amputation, foot; midtarsal (eg, Chopart type procedure) Amputation, foot; transmetatarsal Amputation, metatarsal, with toe, single Amputation, toe; metatarsophalangeal joint Amputation, toe; interphalangeal joint Extracorporeal shock wave, high energy, performed by a physician, requiring anesthesia other than local, including ultrasound guidance, involving the plantar fascia I.C. Unlisted procedure, foot or toes Application of halo type body cast (see 20661-20663 for insertion) Application of Risser jacket, localizer, body; only Application of Risser jacket, localizer, body; including head Application of turnbuckle jacket, body; only Application of turnbuckle jacket, body; including head Application of body cast, shoulder to hips; Application of body cast, shoulder to hips; including head, Minerva type Application of body cast, shoulder to hips; including one thigh Application of body cast, shoulder to hips; including both thighs Application, cast; figure-of-eight Application, cast; shoulder spica Application, cast; plaster Velpeau Application, cast; shoulder to hand (long arm) Application, cast; elbow to finger (short arm) Application, cast; hand and lower forearm (gauntlet) Application, cast; finger (eg, contracture) Application of long arm splint (shoulder to hand) Application of short arm splint (forearm to hand); static Application of short arm splint (forearm to hand); dynamic Application of finger splint; static ASC Incl Rate I.C. I I I PC TC Fee Fee 40.06(8) - Surgical Services Description (con’t) Application of finger splint; dynamic Strapping; thorax Strapping; low back Strapping; shoulder (eg, Velpeau) Strapping; elbow or wrist Strapping; hand or finger Application of hip spica cast; one leg Application of hip spica cast; one and one-half spica or both legs Application of long leg cast (thigh to toes); Application of long leg cast (thigh to toes); walker or ambulatory type Application of long leg cast brace Application of cylinder cast (thigh to ankle) Application of short leg cast (below knee to toes); Application of short leg cast (below knee to toes); walking or ambulatory type Application of patellar tendon bearing (PTB) cast Adding walker to previously applied cast Application of rigid total contact leg cast Application of clubfoot cast with molding or manipulation, long or short leg Application of long leg splint (thigh to ankle or toes) Application of short leg splint (calf to foot) Strapping; hip Strapping; knee Strapping; ankle and/or foot Strapping; toes Strapping; Unna boot Denis-Browne splint strapping Removal or bivalving; gauntlet, boot or body cast Removal or bivalving; full arm or full leg cast Removal or bivalving; shoulder or hip spica, Minerva, or Risser jacket, etc. Removal or bivalving; turnbuckle jacket Repair of spica, body cast or jacket Windowing of cast Wedging of cast (except clubfoot casts) Wedging of clubfoot cast Unlisted procedure, casting or strapping Arthroscopy, temporomandibular joint, diagnostic, with or without synovial biopsy (separate procedure) Arthroscopy, temporomandibular joint, surgical Arthroscopy, shoulder, diagnostic, with or without synovial biopsy (separate procedure) Arthroscopy, shoulder, surgical; capsulorrhaphy Arthroscopy, shoulder, surgical; repair of SLAP lesion Arthroscopy, shoulder, surgical; with removal of loose body or foreign body Arthroscopy, shoulder, surgical; synovectomy, partial Arthroscopy, shoulder, surgical; synovectomy, complete Arthroscopy, shoulder, surgical; debridement, limited Arthroscopy, shoulder, surgical; debridement, extensive ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface (Mumford procedure) Arthroscopy, shoulder, surgical; with lysis and resection of adhesions, with or without manipulation I Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with or without coracoacromial release I Arthroscopy, shoulder, surgical; with rotator cuff repair Arthroscopy, shoulder, surgical; biceps tenodesis Arthroscopy, elbow, diagnostic, with or without synovial biopsy (separate procedure) Arthroscopy, elbow, surgical; with removal of loose body or foreign body Arthroscopy, elbow, surgical; synovectomy, partial Arthroscopy, elbow, surgical; synovectomy, complete Arthroscopy, elbow, surgical; debridement, limited Arthroscopy, elbow, surgical; debridement, extensive Arthroscopy, wrist, diagnostic, with or without synovial biopsy (separate procedure) Arthroscopy, wrist, surgical; for infection, lavage and drainage Arthroscopy, wrist, surgical; synovectomy, partial Arthroscopy, wrist, surgical; synovectomy, complete Arthroscopy, wrist, surgical; excision and/or repair of triangular fibrocartilage and/or joint debridement Arthroscopy, wrist, surgical; internal fixation for fracture or instability Endoscopy, wrist, surgical, with release of transverse carpal ligament Arthroscopically aided treatment of intercondylar spine(s) and/or tuberosity fracture(s) of the knee, with or without manipulation; without internal or external fixation (includes arthroscopy) Arthroscopically aided treatment of intercondylar spine(s) and/or tuberosity fracture(s) of the knee, with or without manipulation; with internal or external fixation (includes arthroscopy) Arthroscopically aided treatment of tibial fracture, proximal (plateau); unicondylar, includes internal fixation, when performed (includes arthroscopy) Arthroscopically aided treatment of tibial fracture, proximal (plateau); bicondylar, includes internal fixation, when performed (includes arthroscopy) Arthroscopy, hip, diagnostic with or without synovial biopsy (separate procedure) Arthroscopy, hip, surgical; with removal of loose body or foreign body Arthroscopy, hip, surgical; with debridement/shaving of articular cartilage (chondroplasty), abrasion arthroplasty, and/or resection of labrum Arthroscopy, hip, surgical; with synovectomy ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Arthroscopy, knee, surgical; osteochondral autograft(s) (eg, mosaicplasty) (includes harvesting of the autograft[s]) Arthroscopy, knee, surgical; osteochondral allograft (eg, mosaicplasty) Arthroscopy, knee, surgical; meniscal transplantation (includes arthrotomy for meniscal insertion), medial or lateral Arthroscopy, knee, diagnostic, with or without synovial biopsy (separate procedure) Arthroscopy, knee, surgical; for infection, lavage and drainage Arthroscopy, knee, surgical; with lateral release Arthroscopy, knee, surgical; for removal of loose body or foreign body (eg, osteochondritis dissecans fragmentation, chondral fragmentation) Arthroscopy, knee, surgical; synovectomy, limited (eg, plica or shelf resection) (separate procedure) Arthroscopy, knee, surgical; synovectomy, major, two or more compartments (eg, medial or lateral) I Arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty) Arthroscopy, knee, surgical; abrasion arthroplasty (includes chondroplasty where necessary) or multiple drilling or microfracture I Arthroscopy, knee, surgical; with meniscectomy (medial AND lateral, including any meniscal shaving) I Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral, including any meniscal shaving) Arthroscopy, knee, surgical; with meniscus repair (medial OR lateral) Arthroscopy, knee, surgical; with meniscus repair (medial AND lateral) Arthroscopy, knee, surgical; with lysis of adhesions, with or without manipulation (separate procedure) Arthroscopy, knee, surgical; drilling for osteochondritis dissecans with bone grafting, with or without internal fixation (including debridement of base of lesion) Arthroscopy, knee, surgical; drilling for intact osteochondritis dissecans lesion Arthroscopy, knee, surgical; drilling for intact osteochondritis dissecans lesion with internal fixation I Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction Arthroscopically aided posterior cruciate ligament repair/augmentation or reconstruction Arthroscopy, ankle, surgical, excision of osteochondral defect of talus and/or tibia, including drilling of the defect Arthroscopically aided repair of large osteochondritis dissecans lesion, talar dome fracture, or tibial plafond fracture, with or without internal fixation (includes arthroscopy) Endoscopic plantar fasciotomy ASC Rate Incl I.C. PC TC 40.06(8) - Surgical Services Description (con’t) Fee Fee Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; with removal of loose body or foreign body Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; synovectomy, partial Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; debridement, limited Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; debridement, extensive Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; with ankle arthrodesis Arthroscopy, metacarpophalangeal joint, diagnostic, includes synovial biopsy Arthroscopy, metacarpophalangeal joint, surgical; with debridement Arthroscopy, metacarpophalangeal joint, surgical; with reduction of displaced ulnar collateral ligament (eg, Stenar lesion) Arthroscopy, subtalar joint, surgical; with removal of loose body or foreign body Arthroscopy, subtalar joint, surgical; with synovectomy Arthroscopy, subtalar joint, surgical; with debridement Arthroscopy, subtalar joint, surgical; with subtalar arthrodesis Unlisted procedure, arthroscopy Drainage abscess or hematoma, nasal, internal approach Drainage abscess or hematoma, nasal septum Biopsy, intranasal Excision, nasal polyp(s), simple Excision, nasal polyp(s), extensive Excision or destruction (eg, laser), intranasal lesion; internal approach Excision or destruction (eg, laser), intranasal lesion; external approach (lateral rhinotomy) Excision or surgical planing of skin of nose for rhinophyma Excision dermoid cyst, nose; simple, skin, subcutaneous Excision dermoid cyst, nose; complex, under bone or cartilage Excision inferior turbinate, partial or complete, any method Submucous resection inferior turbinate, partial or complete, any method Rhinectomy; partial Rhinectomy; total Injection into turbinate(s), therapeutic Displacement therapy (Proetz type) Insertion, nasal septal prosthesis (button) Removal foreign body, intranasal; office type procedure Removal foreign body, intranasal; requiring general anesthesia Removal foreign body, intranasal; by lateral rhinotomy ASC Rate Incl I.C. PC TC Fee Fee 40.06(8) - Surgical Services Description (con’t) Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip Rhinoplasty, primary; including major septal repair Rhinoplasty, secondary; minor revision (small amount of nasal tip work) Rhinoplasty, secondary; intermediate revision (bony work with osteotomies) Rhinoplasty, secondary; major revision (nasal tip work and osteotomies) Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columellar lengthening; tip only Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columellar lengthening; tip, septum, osteotomies Repair of nasal vestibular stenosis (eg, spreader grafting, lateral nasal wall reconstruction) Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft Repair choanal atresia; intranasal Repair choanal atresia; transpalatine Lysis intranasal synechia Repair fistula; oromaxillary (combine with 31030 if antrotomy is included) Repair fistula; oronasal Septal or other intranasal dermatoplasty (does not include obtaining graft) Repair nasal septal perforations Cautery and/or ablation, mucosa of inferior turbinates, unilateral or bilateral, any method; superficial Cauteryand/or ablation, mucosa of inferior turbinates, unilateral or bilateral, any method; intramural Control nasal hemorrhage, anterior, simple (limited cautery and/or packing) any method Control nasal hemorrhage, anterior, complex (extensive cautery and/or packing) any method Control nasal hemorrhage, posterior, with posterior nasal packs and/or cautery, any method; initial Control nasal hemorrhage, posterior, with posterior nasal packs and/or cautery, any method; subsequent Ligation arteries; ethmoidal Ligation arteries; internal maxillary artery, transantral Fracture nasal inferior turbinate(s), therapeutic Unlisted procedure, nose Lavage by cannulation; maxillary sinus (antrum puncture or natural ostium) Lavage by cannulation; sphenoid sinus Sinusotomy, maxillary (antrotomy); intranasal Sinusotomy, maxillary (antrotomy); radical (Caldwell-Luc) without removal of antrochoanal polyps ASC Rate Incl PC Fee TC Fee 40.06(8) - Surgical Services Description (con’t) Sinusotomy, maxillary (antrotomy); radical (Caldwell-Luc) with removal of antrochoanal polyps Pterygomaxillary fossa surgery, any approach Sinusotomy, sphenoid, with or without biopsy; Sinusotomy, sphenoid, with or without biopsy; with mucosal stripping or removal of polyp(s) Sinusotomy frontal; external, simple (trephine operation) Sinusotomy frontal; transorbital, unilateral (for mucocele or osteoma, Lynch type) Sinusotomy frontal; obliterative without osteoplastic flap, brow incision (includes ablation) Sinusotomy frontal; obliterative, without osteoplastic flap, coronal incision (includes ablation) Sinusotomy frontal; obliterative, with osteoplastic flap, brow incision Sinusotomy frontal; obliterative, with osteoplastic flap, coronal incision Sinusotomyfrontal; nonobliterative, with osteoplastic flap, brow incision Sinusotomyfrontal; nonobliterative, with osteoplastic flap, coronal incision Sinusotomy, unilateral, three or more paranasal sinuses (frontal, maxillary, ethmoid, sphenoid) Ethmoidectomy; intranasal, anterior Ethmoidectomy; intranasal, total Ethmoidectomy; extranasal, total Maxillectomy; without orbital exenteration Maxillectomy; with orbital exenteration (en bloc) Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure) Nasal/sinus endoscopy, diagnostic with maxillary sinusoscopy (via inferior meatus or canine fossa puncture) Nasal/sinus endoscopy, diagnostic with sphenoid sinusoscopy (via puncture of sphenoidal face or cannulation of ostium) Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement (separate procedure) Nasal/sinus endoscopy, surgical; with control of nasal hemorrhage N as a l / s i n u s e n d o s c o p y, s u r gi c a l ; w i t h dacryocystorhinostomy Nasal/sinus endoscopy, surgical; with concha bullosa resection Nasal/sinus endoscopy, surgical; with ethmoidectomy, partial (anterior) Nasal/sinus endoscopy, surgical; with ethmoidectomy, total (anterior and posterior) Nasal/sinus endoscopy, surgical, with maxillary antrostomy; Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Nasal/sinus endoscopy, surgical with frontal sinus exploration, with or without removal of tissue from frontal sinus Nasal/sinus endoscopy, surgical, with sphenoidotomy; Nasal/sinus endoscopy, surgical, with sphenoidotomy; with removal of tissue from the sphenoid sinus Nasal/sinus endoscopy, surgical, with repair of cerebrospinal fluid leak; ethmoid region Nasal/sinus endoscopy, surgical, with repair of cerebrospinal fluid leak; sphenoid region Nasal/sinus endoscopy, surgical; with medial or inferior orbital wall decompression Nasal/sinus endoscopy, surgical; with medial orbital wall and inferior orbital wall decompression Nasal/sinus endoscopy, surgical; with optic nerve decompression I.C. Unlisted procedure, accessory sinuses Laryngotomy (thyrotomy, laryngofissure); with removal of tumor or laryngocele, cordectomy Laryngotomy (thyrotomy, laryngofissure); diagnostic Laryngectomy; total, without radical neck dissection Laryngectomy; total, with radical neck dissection Laryngectomy; subtotal supraglottic, without radical neck dissection Laryngectomy; subtotal supraglottic, with radical neck dissection Partial laryngectomy (hemilaryngectomy); horizontal Partial laryngectomy (hemilaryngectomy); laterovertical Partial laryngectomy (hemilaryngectomy); anterovertical Partial laryngectomy (h em ilaryngectomy); antero-latero-vertical Pharyngolaryngectomy, with radical neck dissection; without reconstruction Pharyngolaryngectomy, with radical neck dissection; with reconstruction Arytenoidectomy or arytenoidopexy, external approach Epiglottidectomy Intubation, endotracheal, emergency procedure Tracheotomy tube change prior to establishment of fistula tract Laryngoscopy, indirect; diagnostic (separate procedure) Laryngoscopy, indirect; with biopsy Laryngoscopy, indirect; with removal of foreign body Laryngoscopy, indirect; with removal of lesion Laryngoscopy, indirect; with vocal cord injection Laryngoscopy direct, with or without tracheoscopy; for aspiration Laryngoscopy direct, with or without tracheoscopy; diagnostic, except newborn Laryngoscopy direct, with or without tracheoscopy; diagnostic, with operating microscope or telescope Laryngoscopy direct, with or without tracheoscopy; with insertion of obturator ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Laryngoscopy direct, with or without tracheoscopy; with dilation, initial Laryngoscopy direct, with or without tracheoscopy; with dilation, subsequent Laryngoscopy, direct, operative, with foreign body removal; Laryngoscopy, direct, operative, with foreign body removal; with operating microscope or telescope Laryngoscopy, direct, operative, with biopsy; Laryngoscopy, direct, operative, with biopsy; with operating microscope or telescope Laryngoscopy, direct, operative, with excision of tumor and/or stripping of vocal cords or epiglottis; Laryngoscopy, direct, operative, with excision of tumor and/or stripping of vocal cords or epiglottis; with operating microscope or telescope Laryngoscopy, direct, operative, with operating microscope or telescope, with submucosal removal of non-neoplastic lesion(s) of vocal cord; reconstruction with local tissue flap(s) Laryngoscopy, direct, operative, with operating microscope or telescope, with submucosal removal of non-neoplastic lesion(s) of vocal cord; reconstruction with graft(s) (includes obtaining autograft) L a r y n g o s c o p y , d i r e c t , o p e r a t i v e , w i t h arytenoidectomy; L a r y n g o s c o p y , d i r e c t , o p e r a t i v e , w i t h arytenoidectomy; with operating microscope or telescope Laryngoscopy, direct, with injection into vocal cord(s), therapeutic; Laryngoscopy, direct, with injection into vocal cord(s), therapeutic; with operating microscope or telescope Laryngoscopy, flexible fiberoptic; diagnostic Laryngoscopy, flexible fiberoptic; with biopsy Laryngoscopy, flexible fiberoptic; with removal of foreign body Laryngoscopy, flexible fiberoptic; with removal of lesion Laryngoscopy, flexible or rigid fiberoptic, with stroboscopy Laryngoplasty; for laryngeal web, two stage, with keel insertion and removal Laryngoplasty; for laryngeal stenosis, with graft or core mold, including tracheotomy Laryngoplasty; with open reduction of fracture Laryngoplasty, cricoid split Laryngoplasty, not otherwise specified (eg, for burns, reconstruction after partial laryngectomy) Laryngeal reinnervation by neuromuscular pedicle Section recurrent laryngeal nerve, therapeutic (separate procedure), unilateral I.C. Unlisted procedure, larynx Tracheostomy, planned (separate procedure); ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Tracheostomy, emergency procedure; transtracheal Tracheostomy, emergency procedure; cricothyroid membrane Tracheostomy, fenestration procedure with skin flaps Construction of tracheoesophageal fistula and subsequent insertion of an alaryngeal speech prosthesis (eg, voice button, Blom-Singer prosthesis) Tracheal puncture, percutaneous with transtracheal aspiration and/or injection Tracheostoma revision; simple, without flap rotation Tracheostoma revision; complex, with flap rotation Tracheobronchoscopy through established tracheostomy incision Endobronchial ultrasound (EBUS) during bronchoscopic diagnostic or therapeutic intervention(s) (List separately in addition to code for primary procedure(s)) Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; diagnostic, with or without cell washing (separate procedure) Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; with brushing or protected brushings Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; with bronchial alveolar lavage Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; with bronchial or endobronchial biopsy(s), single or multiple sites Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; with transbronchial lung biopsy(s), single lobe Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; with transbronchial needle aspiration biopsy(s), trachea, main stem and/or lobar bronchus(i) Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; with tracheal/bronchial dilation or closed reduction of fracture Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; with placement of tracheal stent(s) (includes tracheal/bronchial dilation as required) Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; with transbronchial lung biopsy(s), each additional lobe (List separately in addition to code for primary procedure) Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; with transbronchial needle aspiration biopsy(s), each additional lobe (List separately in addition to code for primary procedure) Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; with removal of foreign body ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; with placement of bronchial stent(s) (includes tracheal/bronchial dilation as required), initial bronchus Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; each additional major bronchus stented (List separately in addition to code for primary procedure) Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; with revision of tracheal or bronchial stent inserted at previous session (includes tracheal/bronchial dilation as required) Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; with excision of tumor Bronchoscopy (rigid or flexible); with destruction of tumor or relief of stenosis by any method other than excision (eg, laser therapy, cryotherapy) Bronchoscopy (rigid or flexible); with placement of catheter(s) for intracavitary radioelement application Bronchoscopy (rigid or flexible); with therapeutic aspiration of tracheobronchial tree, initial (eg, drainage of lung abscess) Bronchoscopy (rigid or flexible); with therapeutic aspiration of tracheobronchial tree, subsequent Bronchoscopy (rigid or flexible); with injection of contrast material for segmental bronchography (fiberscope only) Transtracheal injection for bronchography Catheterization with bronchial brush biopsy Catheter aspiration (separate procedure); nasotracheal Catheter aspiration (separate procedure); tracheobronchial with fiberscope, bedside Transtracheal (percutaneous) introduction of needle wire dilator/stent or indwelling tube for oxygen therapy Tracheoplasty; cervical Tracheoplasty; tracheopharyngeal fistulization, each stage Tracheoplasty; intrathoracic Carinal reconstruction Bronchoplasty; graft repair Bronchoplasty; excision stenosis and anastomosis Excision tracheal stenosis and anastomosis; cervical Excision tracheal stenosis and anastomosis; cervicothoracic Excision of tracheal tumor or carcinoma; cervical Excision of tracheal tumor or carcinoma; thoracic Suture of tracheal wound or injury; cervical Suture of tracheal wound or injury; intrathoracic Surgical closure tracheostomy or fistula; without plastic repair Surgical closure tracheostomy or fistula; with plastic repair Revision of tracheostomy scar I.C. Unlisted procedure, trachea, bronchi ASC Rate Incl PC Fee TC Fee 40.06(8) - Surgical Services Description (con’t) Thoracostomy; with rib resection for empyema Thoracostomy; with open flap drainage for empyema Thoracotomy, limited, for biopsy of lung or pleura Thoracotomy, major; with exploration and biopsy Thoracotomy, major; with control of traumatic hemorrhage and/or repair of lung tear Thoracotomy, major; for postoperative complications Thoracotomy, major; with open intrapleural pneumonolysis Thoracotomy, major; with cyst(s) removal, with or without a pleural procedure Thoracotomy, major; with excision-plication of bullae, with or without any pleural procedure Thoracotomy, major; with removal of intrapleural foreign body or fibrin deposit Thoracotomy, major; with removal of intrapulmonary foreign body Thoracotomy, major; with cardiac massage Pneumonostomy; with open drainage of abscess or cyst Pneumonostomy; with percutaneous drainage of abscess or cyst Pleural scarification for repeat pneumothorax Decortication, pulmonary (separate procedure); total Decortication, pulmonary (separate procedure); partial Pleurectomy, parietal (separate procedure) Decortication and parietal pleurectomy Biopsy, pleura; percutaneous needle Biopsy, pleura; open Biopsy, lung or mediastinum, percutaneous needle Pneumocentesis, puncture of lung for aspiration Thoracentesis, puncture of pleural cavity for aspiration, initial or subsequent Thoracentesis with insertion of tube, includes water seal (eg, for pneumothorax), when performed (separate procedure) Removal of lung, total pneumonectomy; Removal of lung, total pneumonectomy; with resection of segment of trachea followed by broncho-tracheal anastomosis (sleeve pneumonectomy) Removal of lung, total pneumonectomy; extrapleural Removal of lung, other than total pneumonectomy; single lobe (lobectomy) Removal of lung, other than total pneumonectomy; two lobes (bilobectomy) Removal of lung, other than total pneumonectomy; single segment (segmentectomy) Removal of lung, other than total pneumonectomy; with circumferential resection of segment of bronchus followed by broncho-bronchial anastomosis (sleeve lobectomy) Removal of lung, other than total pneumonectomy; all remaining lung following previous removal of a portion of lung (completion pneumonectomy) ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Removal of lung, other than total pneumonectomy; excision-plication of emphysematous lung(s) (bullous or non-bullous) for lung volume reduction, sternal split or transthoracic approach, with or without any pleural procedure Removal of lung, other than total pneumonectomy; wedge resection, single or multiple Resection and repair of portion of bronchus (bronchoplasty) when performed at time of lobectomy or segmentectomy (List separately in addition to code for primary procedure) Resection of apical lung tumor (eg, Pancoast tumor), including chest wall resection, rib(s) resection(s), neurovascular dissection, when performed; without chest wall reconstruction(s) Resection of apical lung tumor (eg, Pancoast tumor), including chest wall resection, rib(s) resection(s), neurovascular dissection, when performed; with chest wall reconstruction E x t r a p l e u r a l e n u c l e a t i o n o f e m p y e m a (empyemectomy) Insertion of indwelling tunneled pleural catheter with cuff Tube thoracostomy, includes water seal (eg, for abscess, hemothorax, empyema), when performed (separate procedure) Chemical pleurodesis (eg, for recurrent or persistent pneumothorax) Thoracoscopy, diagnostic (separate procedure); lungs and pleural space, without biopsy Thoracoscopy, diagnostic (separate procedure); lungs and pleural space, with biopsy Thoracoscopy, diagnostic (separate procedure); pericardial sac, without biopsy Thoracoscopy, diagnostic (separate procedure); pericardial sac, with biopsy Thoracoscopy, diagnostic (separate procedure); mediastinal space, without biopsy Thoracoscopy, diagnostic (separate procedure); mediastinal space, with biopsy Thoracoscopy, surgical; with pleurodesis (eg, mechanical or chemical) Thoracoscopy, surgical; with partial pulmonary decortication Thoracoscopy, surgical; with total pulmonary decortication, including intrapleural pneumonolysis Thoracoscopy, surgical; with removal of intrapleural foreign body or fibrin deposit Thoracoscopy, surgical; with control of traumatic hemorrhage Thoracoscopy, surgical; with excision-plication of bullae, including any pleural procedure Thoracoscopy, surgical; with parietal pleurectomy Thoracoscopy, surgical; with wedge resection of lung, single or multiple ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Thoracoscopy, surgical; with removal of clot or foreign body from pericardial sac Thoracoscopy, surgical; with creation of pericardial window or partial resection of pericardial sac for drainage Thoracoscopy, surgical; with total pericardiectomy Thoracoscopy, surgical; with excision of pericardial cyst, tumor, or mass Thoracoscopy, surgical; with excision of mediastinal cyst, tumor, or mass Thoracoscopy, surgical; with lobectomy, total or segmental Thoracoscopy, surgical; with thoracic sympathectomy Thoracoscopy, surgical; with esophagomyotomy (Heller type) Repair lung hernia through chest wall Closure of chest wall following open flap drainage for empyema (Clagett type procedure) Open closure of major bronchial fistula Major reconstruction, chest wall (posttraumatic) I.C. Donor pneum on ect om y(s) (including cold preservation), from cadaver donor Lung transplant, single; without cardiopulmonary bypass Lung transplant, single; with cardiopulmonary bypass Lung transplant, double (bilateral sequential or en bloc); without cardiopulmonary bypass Lung transplant, double (bilateral sequential or en bloc); with cardiopulmonary bypass I.C. Backbench standard preparation of cadaver donor lung allograft prior to transplantation, including dissection of allograft from surrounding soft tissues to prepare pulmonary venous/atrial cuff, pulmonary artery, and bronchus; unilateral I.C. Backbench standard preparation of cadaver donor lung allograft prior to transplantation, including dissection of allograft from surrounding soft tissues to prepare pulmonary venous/atrial cuff, pulmonary artery, and bronchus; bilateral Resection of ribs, extrapleural, all stages Thoracoplasty, Schede type or extrapleural (all stages); Thoracoplasty, Schede type or extrapleural (all stages); with closure of bronchopleural fistula Pneumonolysis, extraperiosteal, including filling or packing procedures Pneumothorax, therapeutic, intrapleural injection of air Total lung lavage (unilateral) Ablation therapy for reduction or eradication of one or more pulmonary tumor(s) including pleura or chest wall when involved by tumor extension, percutaneous, radiofrequency, unilateral I.C. Unlisted procedure, lungs and pleura Pericardiocentesis; initial Pericardiocentesis; subsequent Tube pericardiostomy 40.06: continued ASC Incl Rate PC Fee TC Fee 40.06(8) - Surgical Services Description (con’t) Pericardiotomy for removal of clot or foreign body (primary procedure) Creation of pericardial window or partial resection for drainage Pericardiectomy, subtotal or complete; without cardiopulmonary bypass Pericardiectomy, subtotal or complete; with cardiopulmonary bypass Excision of pericardial cyst or tumor Excision of intracardiac tumor, resection with cardiopulmonary bypass Resection of external cardiac tumor Transmyocardial laser revascularization, by thoracotomy; (separate procedure) Transmyocardial laser revascularization, by thoracotomy; performed at the time of other open cardiac procedure(s) (List separately in addition to code for primary procedure) Insertion of epicardial electrode(s); open incision (eg, thoracotomy, median sternotomy, subxiphoid approach) Insertion of epicardial electrode(s); endoscopic approach (eg, thoracoscopy, pericardioscopy) Insertion or replacement of permanent pacemaker with transvenous electrode(s); atrial Insertion or replacement of permanent pacemaker with transvenous electrode(s); ventricular Insertion or replacement of permanent pacemaker with transvenous electrode(s); atrial and ventricular Insertion or replacement of temporary transvenous single chamber cardiac electrode or pacemaker catheter (separate procedure) Insertion or replacement of temporary transvenous dual chamber pacing electrodes (separate procedure) Insertion or replacement of pacemaker pulse generator only; single chamber, atrial or ventricular Insertion or replacement of pacemaker pulse generator only; dual chamber Upgrade of implanted pacemaker system, conversion of single chamber system to dual chamber system (includes removal of previously placed pulse generator, testing of existing lead, insertion of new lead, insertion of new pulse generator) Repositioning of previously implanted transvenous pacemaker or pacing cardioverter-defibrillator (right atrial or right ventricular) electrode Insertion of a transvenous electrode; single chamber (one electrode) permanent pacemaker or single chamber pacing cardioverter-defibrillator Insertion of a transvenous electrode; dual chamber (two electrodes) permanent pacemaker or dual chamber pacing cardioverter-defibrillator Repair of single transvenous electrode for a single chamber, permanent pacemaker or single chamber pacing cardioverter-defibrillator ASC Incl Rate PC TC Fee Fee 40.06(8) - Surgical Services Description (con’t) Repair of two transvenous electrodes for a dual chamber permanent pacemaker or dual chamber pacing cardioverter-defibrillator Revision or relocation of skin pocket for pacemaker Revision of skin pocket for single or dual chamber pacing cardioverter-defibrillator Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, with attachment to previously placed pacemaker or pacing cardioverter-defibrillator pulse generator (including revision of pocket, removal, insertion, and/or replacement of generator) Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of pacing cardioverter-defibrillator or pacemaker pulse generator (including upgrade to dual chamber system) (List separately in addition to code for primary procedure) Repositioning of previously implanted cardiac venous system (left ventricular) electrode (including removal, insertion and/or replacement of generator) Removal of permanent pacemaker pulse generator Removal of transvenous pacemaker electrode(s); single lead system, atrial or ventricular Removal of transvenous pacemaker electrode(s); dual lead system Removal of permanent epicardial pacemaker and electrodes by thoracotomy; single lead system, atrial or ventricular Removal of permanent epicardial pacemaker and electrodes by thoracotomy; dual lead system Removal of permanent transvenous electrode(s) by thoracotomy Insertion of single or dual chamber pacing cardioverter-defibrillator pulse generator Subcutaneous removal of single or dual chamber pacing cardioverter-defibrillator pulse generator Removal of single or dual chamber pacing cardioverter-defibrillator electrode(s); by thoracotomy Removal of single or dual chamber pacing cardioverter-defibrillator electrode(s); by transvenous extraction Insertion or repositioning of electrode lead(s) for s i n g l e o r d u a l c h a m b e r p a c i n g cardioverter-defibrillator and insertion of pulse generator Operative ablation of supraventricular arrhythmogenic focus or pathway (eg, Wolff-Parkinson-White, atrioventricular node re-entry), tract(s) and/or focus (foci); without cardiopulmonary bypass Operative ablation of supraventricular arrhythmogenic focus or pathway (eg, Wolff-Parkinson-White, atrioventricular node re-entry), tract(s) and/or focus (foci); with cardiopulmonary bypass ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Operative tissue ablation and reconstruction of atria, limited (eg, modified maze procedure) Operative tissue ablation and reconstruction of atria, extensive (eg, maze procedure); without cardiopulmonary bypass Operative tissue ablation and reconstruction of atria, extensive (eg, maze procedure); with cardiopulmonary bypass Operative tissue ablation and reconstruction of atria, performed at the time of other cardiac procedure(s), limited (eg, modified maze procedure) (List separately in addition to code for primary procedure) Operative tissue ablation and reconstruction of atria, performed at the time of other cardiac procedure(s), extensive (eg, maze procedure), without cardiopulmonary bypass (List separately in addition to code for primary procedure) Operative tissue ablation and reconstruction of atria, performed at the time of other cardiac procedure(s), extensive (eg, maze procedure), with cardiopulmonary bypass (List separately in addition to code for primary procedure) Operative ablation of ventricular arrhythmogenic focus with cardiopulmonary bypass Endoscopy, surgical; operative tissue ablation and reconstruction of atria, limited (eg, modified maze procedure), without cardiopulmonary bypass Endoscopy, surgical; operative tissue ablation and reconstruction of atria, extensive (eg, maze procedure), without cardiopulmonary bypass Implantation of patient-activated cardiac event recorder Removal of an implantable, patient-activated cardiac event recorder Repair of cardiac wound; without bypass Repair of cardiac wound; with cardiopulmonary bypass Cardiotomy, exploratory (includes removal of foreign body, atrial or ventricular thrombus); without bypass Cardiotomy, exploratory (includes removal of foreign body, atrial or ventricular thrombus); with cardiopulmonary bypass Suture repair of aorta or great vessels; without shunt or cardiopulmonary bypass Suture repair of aorta or great vessels; with shunt bypass Suture repair of aorta or great vessels; with cardiopulmonary bypass Insertion of graft, aorta or great vessels; without shunt, or cardiopulmonary bypass Insertion of graft, aorta or great vessels; with shunt bypass Insertion of graft, aorta or great vessels; with cardiopulmonary bypass Va lvu lo pl ast y , aort ic va lve ; op e n, wi th cardiopulmonary bypass Valvuloplasty, aortic valve; open, with inflow occlusion ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Valvuloplasty, aortic valve; using transventricular dilation, with cardiopulmonary bypass Construction of apical-aortic conduit Replacement, aortic valve, with cardiopulmonary bypass; with prosthetic valve other than homograft or stentless valve Replacement, aortic valve, with cardiopulmonary bypass; with allograft valve (freehand) Replacement, aortic valve, with cardiopulmonary bypass; with stentless tissue valve Replacement, aortic valve; with aortic annulus enlargement, noncoronary cusp Replacement, aortic valve; with transventricular aortic annulus enlargement (Konno procedure) Replacement, aortic valve; by translocation of autologous pulmonary valve with allograft replacement of pulmonary valve (Ross procedure) Repair of left ventricular outflow tract obstruction by patch enlargement of the outflow tract Resection or incision of subvalvular tissue for discrete subvalvular aortic stenosis Ventriculomyotomy (-myectomy) for idiopathic hypertrophic subaortic stenosis (eg, asymmetric septal hypertrophy) Aortoplasty (gusset) for supravalvular stenosis Valvotomy, mitral valve; closed heart Valvotomy, mitral valve; open heart, with cardiopulmonary bypass Valvuloplasty, mitral valve, with cardiopulmonary bypass; Valvuloplasty, mitral valve, with cardiopulmonary bypass; with prosthetic ring Valvuloplasty, mitral valve, with cardiopulmonary bypass; radical reconstruction, with or without ring Replacement, mitral valve, with cardiopulmonary bypass Valvectomy, tricuspid valve, with cardiopulmonary bypass Valvuloplasty, tricuspid valve; without ring insertion Valvuloplasty, tricuspid valve; with ring insertion Replacement, tricuspid valve, with cardiopulmonary bypass Tricuspid valve repositioning and plication for Ebstein anomaly Valvotomy, pulmonary valve, closed heart; transventricular Valvotomy, pulmonary valve, closed heart; via pulmonary artery Valvotomy, pulmonary valve, open heart; with inflow occlusion Valvotomy, pulmonary valve, open heart; with cardiopulmonary bypass Replacement, pulmonary valve Right ventricular resection for infundibular stenosis, with or without commissurotomy ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Outflow tract augmentation (gusset), with or without commissurotomy or infundibular resection Repair of non-structural prosthetic valve dysfunction with cardiopulmonary bypass (separate procedure) Repair of coronary arteriovenous or arteriocardiac chamber fistula; with cardiopulmonary bypass Repair of coronary arteriovenous or arteriocardiac chamber fistula; without cardiopulmonary bypass Repair of anomalous coronary artery from pulmonary artery origin; by ligation Repair of anomalous coronary artery from pulmonary artery origin; by graft, without cardiopulmonary bypass Repair of anomalous coronary artery from pulmonary artery origin; by graft, with cardiopulmonary bypass Repair of anomalous coronary artery from pulmonary artery origin; with construction of intrapulmonary artery tunnel (Takeuchi procedure) Repair of anomalous coronary artery from pulmonary artery origin; by translocation from pulmonary artery to aorta Repair of anomalous (eg, intramural) aortic origin of coronary artery by unroofing or translocation Endoscopy, surgical, including video-assisted harvest of vein(s) for coronary artery bypass procedure (List separately in addition to code for primary procedure) Coronary artery bypass, vein only; single coronary venous graft Coronary artery bypass, vein only; two coronary venous grafts Coronary artery bypass, vein only; three coronary venous grafts Coronary artery bypass, vein only; four coronary venous grafts Coronary artery bypass, vein only; five coronary venous grafts Coronary artery bypass, vein only; six or more coronary venous grafts Coronary artery bypass, using venous graft(s) and arterial graft(s); single vein graft (List separately in addition to code for primary procedure) Coronary artery bypass, using venous graft(s) and arterial graft(s); two venous grafts (List separately in addition to code for primary procedure) Coronary artery bypass, using venous graft(s) and arterial graft(s); three venous grafts (List separately in addition to code for primary procedure) Coronary artery bypass, using venous graft(s) and arterial graft(s); four venous grafts (List separately in addition to code for primary procedure) Coronary artery bypass, using venous graft(s) and arterial graft(s); five venous grafts (List separately in addition to code for primary procedure) ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Coronary artery bypass, using venous graft(s) and arterial graft(s); six or more venous grafts (List separately in addition to code for primary procedure) Reoperation, coronary artery bypass procedure or valve procedure, more than one month after original operation (List separately in addition to code for primary procedure) Coronary artery bypass, using arterial graft(s); single arterial graft Coronary artery bypass, using arterial graft(s); two coronary arterial grafts Coronary artery bypass, using arterial graft(s); three coronary arterial grafts Coronary artery bypass, using arterial graft(s); four or more coronary arterial grafts Myocardial resection (eg, ventricular aneurysmectomy) Repair of postinfarction ventricular septal defect, with or without myocardial resection Surgical ventricular restoration procedure, includes prosthetic patch, when performed (eg, ventricular remodeling, SVR, SAVER, Dor procedures) Coronary endarterectomy, open, any method, of left anterior descending, circumflex, or right coronary artery performed in conjunction with coronary artery bypass graft procedure, each vessel (List separately in addition to primary procedure) Closure of atrioventricular valve (mitral or tricuspid) by suture or patch Closure of semilunar valve (aortic or pulmonary) by suture or patch Anastom os is of pulmonary artery to aorta (Damus-Kaye-Stansel procedure) Repair of complex cardiac anomaly other than pulmonary atresia with ventricular septal defect by construction or replacement of conduit from right or left ventricle to pulmonary artery Repair of complex cardiac anomalies (eg, single ventricle with subaortic obstruction) by surgical enlargement of ventricular septal defect Repair of double outlet right ventricle with intraventricular tunnel repair; Repair of double outlet right ventricle with intraventricular tunnel repair; with repair of right ventricular outflow tract obstruction Repair of complex cardiac anomalies (eg, tricuspid atresia) by closure of atrial septal defect and anastomosis of atria or vena cava to pulmonary artery (simple Fontan procedure) Repair of complex cardiac anomalies (eg, single ventricle) by modified Fontan procedure Repair of single ventricle with aortic outflow obstruction and aortic arch hypoplasia (hypoplastic left heart syndrome) (eg, Norwood procedure) Repair atrial septal defect, secundum, with cardiopulmonary bypass, with or without patch ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Direct or patch closure, sinus venosus, with or without anomalous pulmonary venous drainage Repair of atrial septal defect and ventricular septal defect, with direct or patch closure Repair of incomplete or partial atrioventricular canal (ostium primum atrial septal defect), with or without atrioventricular valve repair Repair of intermediate or transitional atrioventricular canal, with or without atrioventricular valve repair Repair of complete atrioventricular canal, with or without prosthetic valve Closure of multiple ventricular septal defects; Closure of multiple ventricular septal defects; with pulmonary valvotomy or infundibular resection (acyanotic) Closure of multiple ventricular septal defects; with removal of pulmonary artery band, with or without gusset Closure of single ventricular septal defect, with or without patch; Closure of single ventricular septal defect, with or without patch; with pulmonary valvotomy or infundibular resection (acyanotic) Closure of single ventricular septal defect, with or without patch; with removal of pulmonary artery band, with or without gusset Banding of pulmonary artery Complete repair tetralogy of Fallot without pulmonary atresia; Complete repair tetralogy of Fallot without pulmonary atresia; with transannular patch Complete repair tetralogy of Fallot with pulmonary atresia including construction of conduit from right ventricle to pulmonary artery and closure of ventricular septal defect R e p a i r s i n u s o f V a l s a l v a f i s t u l a , w i t h cardiopulmonary bypass; R e p a i r s i n u s o f V a l s a l v a f i s t u l a , w i t h cardiopulmonary bypass; with repair of ventricular septal defect R ep ai r s i n u s o f V a lsalva aneurysm, wi th cardiopulmonary bypass Closure of aortico-left ventricular tunnel Repair of isolated partial anomalous pulmonary venous return (eg, Scimitar Syndrome) Repair of pulmonary venous stenosis Complete repair of anomalous pulmonary venous return (supracardiac, intracardiac, or infracardiac types) Repair of cor triatriatum or supravalvular mitral ring by resection of left atrial membrane Atrial septectomy or septostomy; closed heart (Blalock-Hanlon type operation) Atrial septectomy or septostomy; open heart with cardiopulmonary bypass ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Atrial septectomy or septostomy; open heart, with inflow occlusion S h u n t ; s u b c l a v i a n t o p u l m o n a r y a r t e r y (Blalock-Taussig type operation) Shunt; ascending aorta to pulmonary artery (Waterston type operation) Shunt; descending aorta to pulmonary artery (Potts-Smith type operation) Shunt; central, with prosthetic graft Shunt; superior vena cava to pulmonary artery for flow to one lung (classical Glenn procedure) Shunt; superior vena cava to pulmonary artery for flow to both lungs (bidirectional Glenn procedure) Anastomosis, cavopulmonary, second superior vena cava (List separately in addition to primary procedure) Repair of transposition of the great arteries with ventricular septal defect and subpulmonary stenosis; without surgical enlargement of ventricular septal defect Repair of transposition of the great arteries with ventricular septal defect and subpulmonary stenosis; with surgical enlargement of ventricular septal defect Repair of transposition of the great arteries, atrial baffle procedure (eg, Mustard or Senning type) with cardiopulmonary bypass; Repair of transposition of the great arteries, atrial baffle procedure (eg, Mustard or Senning type) with cardiopulmonary bypass; with removal of pulmonary band Repair of transposition of the great arteries, atrial baffle procedure (eg, Mustard or Senning type) with cardiopulmonary bypass; with closure of ventricular septal defect Repair of transposition of the great arteries, atrial baffle procedure (eg, Mustard or Senning type) with cardiopulmonary bypass; with repair of subpulmonic obstruction Repair of transposition of the great arteries, aortic pulmonary artery reconstruction (eg, Jatene type); Repair of transposition of the great arteries, aortic pulmonary artery reconstruction (eg, Jatene type); with removal of pulmonary band Repair of transposition of the great arteries, aortic pulmonary artery reconstruction (eg, Jatene type); with closure of ventricular septal defect Repair of transposition of the great arteries, aortic pulmonary artery reconstruction (eg, Jatene type); with repair of subpulmonic obstruction Total repair, truncus arteriosus (Rastelli type operation) Reimplantation of an anomalous pulmonary artery Aortic sus pension (aortopexy) for tracheal decompression (eg, for tracheomalacia) (separate procedure) Division of aberrant vessel (vascular ring); ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Division of aberrant vessel (vascular ring); with reanastomosis Obliteration of aortopulmonary septal defect; without cardiopulmonary bypass Obliteration of aortopulmonary septal defect; with cardiopulmonary bypass Repair of patent ductus arteriosus; by ligation Repair of patent ductus arteriosus; by division, younger than 18 years Repair of patent ductus arteriosus; by division, 18 years and older Excision of coarctation of aorta, with or without associated patent ductus arteriosus; with direct anastomosis Excision of coarctation of aorta, with or without associated patent ductus arteriosus; with graft Excision of coarctation of aorta, with or without associated patent ductus arteriosus; repair using either left subclavian artery or prosthetic material as gusset for enlargement Repair of hypoplastic or interrupted aortic arch using autogenous or prosthetic material; without cardiopulmonary bypass Repair of hypoplastic or interrupted aortic arch using autogenous or prosthetic material; with cardiopulmonary bypass Ascending aorta graft, with cardiopulmonary bypass, with or without valve suspension; Ascending aorta graft, with cardiopulmonary bypass, with or without valve suspension; with coronary reconstruction Ascending aorta graft, with cardiopulmonary bypass, with or without valve suspension; with aortic root replacement using composite prosthesis and coronary reconstruction Ascending aorta graft, with cardiopulmonary bypass with valve suspension, with coronary reconstruction and valve-sparing aortic annulus remodeling (eg, David Procedure, Yacoub Procedure) Transverse arch graft, with cardiopulmonary bypass Descending thoracic aorta graft, with or without bypass Repair of thoracoabdominal aortic aneurysm with graft, with or without cardiopulmonary bypass Endovascular repair of descending thoracic aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption); involving coverage of left subclavian artery origin, initial endoprosthesis plus descending thoracic aortic extension(s), if required, to level of celiac artery origin ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Endovascular repair of descending thoracic aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption); not involving coverage of left subclavian artery origin, initial endoprosthesis plus descending thoracic aortic extension(s), if required, to level of celiac artery origin Placement of proximal extension prosthesis for endovascular repair of descending thoracic aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption); initial extension Placement of proximal extension prosthesis for endovascular repair of descending thoracic aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption); each additional proximal extension (List separately in addition to code for primary procedure) Placement of distal extension prosthesis(s) delayed after endovascular repair of descending thoracic aorta Open subclavian to carotid artery transposition performed in conjunction with endovascular repair of descending thoracic aorta, by neck incision, unilateral Bypass graft, with other than vein, transcervical retropharyngeal carotid-carotid, performed in conjunction with endovascular repair of descending thoracic aorta, by neck incision P u l m o n a r y a r t e r y e m b o l e c t o m y ; w i t h cardiopulmonary bypass Pulmonary arte ry em b o l ec t o m y; wi thout cardiopulmonary bypass Pulmonary endarterectomy, with or without embolectomy, with cardiopulmonary bypass Repair of pulmonary artery stenosis by reconstruction with patch or graft Repair of pulmonary atresia with ventricular septal defect, by construction or replacement of conduit from right or left ventricle to pulmonary artery T r a n s e c t i o n o f p u l m o n a r y a r t e r y w i t h cardiopulmonary bypass Ligation and takedown of a systemic-to-pulmonary artery shunt, performed in conjunction with a congenital heart procedure (List separately in addition to code for primary procedure) Repair of pulmonary artery arborization anomalies by unifocalization; without cardiopulmonary bypass Repair of pulmonary artery arborization anomalies by unifocalization; with cardiopulmonary bypass I.C. Donor cardiectomy-pneumonectomy (including cold preservation) I.C. Backbench standard preparation of cadaver donor heart/lung allograft prior to transplantation, including dissection of allograft from surrounding soft tissues to prepare aorta, superior vena cava, inferior vena cava, and trachea for implantation ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee H e a r t - l u n g t r a n s p l a n t w i t h r e c i p i e n t cardiectomy-pneumonectomy I.C. Donor cardiectomy (including cold preservation) I.C. Backbench standard preparation of cadaver donor heart allograft prior to transplantation, including dissection of allograft from surrounding soft tissues to prepare aorta, superior vena cava, inferior vena cava, pulmonary artery, and left atrium for implantation Heart transplant, with or without recipient cardiectomy Prolonge d extracorpor eal circ u latio n for cardiopulmonary insufficiency; initial 24 hours Prolonge d extracorpor e a l c irc u lation for cardiopulmonary insufficiency; each additional 24 hours (List separately in addition to code for primary procedure) Insertion of intra-aortic balloon assist device, percutaneous Removal of intra-aortic balloon assist device, percutaneous Insertion of intra-aortic balloon assist device through the femoral artery, open approach Removal of intra-aortic balloon assist device including repair of femoral artery, with or without graft Insertion of intra-aortic balloon assist device through the ascending aorta Removal of intra-aortic balloon assist device from the ascending aorta, including repair of the ascending aorta, with or without graft Insertion of ventricular assist device; extracorporeal, single ventricle Insertion of ventricular assist device; extracorporeal, biventricular Removal of ventricular assist device; extracorporeal, single ventricle Removal of ventricular assist device; extracorporeal, biventricular Insertion of ventricular assist device, implantable intracorporeal, single ventricle Removal of ventricular assist device, implantable intracorporeal, single ventricle I.C. Unlisted procedure, cardiac surgery Embolectomy or thrombectomy, with or without catheter; carotid, subclavian or innominate artery, by neck incision Embolectomy or thrombectomy, with or without catheter; innominate, subclavian artery, by thoracic incision Embolectomy or thrombectomy, with or without catheter; axillary, brachial, innominate, subclavian artery, by arm incision Embolectomy or thrombectomy, with or without catheter; radial or ulnar artery, by arm incision ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Embolectomy or thrombectomy, with or without catheter; renal, celiac, mesentery, aortoiliac artery, by abdominal incision Embolectomy or thrombectomy, with or without catheter; femoropopliteal, aortoiliac artery, by leg incision Embolectomy or thrombectomy, with or without catheter; popliteal-tibio-peroneal artery, by leg incision Thrombectomy, direct or with catheter; vena cava, iliac vein, by abdominal incision Thrombectomy, direct or with catheter; vena cava, iliac, femoropopliteal vein, by leg incision Thrombectomy, direct or with catheter; vena cava, iliac, femoropopliteal vein, by abdominal and leg incision Thrombectomy, direct or with catheter; subclavian vein, by neck incision Thrombectomy, direct or with catheter; axillary and subclavian vein, by arm incision Valvuloplasty, femoral vein Reconstruction of vena cava, any method Venous valve transposition, any vein donor Cross-over vein graft to venous system Saphenopopliteal vein anastomosis Endovascular repair of infrarenal abdominal aortic aneurysm or dissection; using aorto-aortic tube prosthesis Endovascular repair of infrarenal abdominal aortic aneurysm or dissection; using modular bifurcated prosthesis (one docking limb) Endovascular repair of infrarenal abdominal aortic aneurysm or dissection; using modular bifurcated prosthesis (two docking limbs) Endovascular repair of infrarenal abdominal aortic aneurysm or dissection; using unibody bifurcated prosthesis Endovascular repair of infrarenal abdominal aortic aneurysm or dissection; using aorto-uniiliac or aorto-unifemoral prosthesis Transcatheter placement of wireless physiologic sensor in aneurysmal sac during endovascular repair, including radiological supervision and interpretation, instrument calibration, and collection of pressure data Endovascular placement of iliac artery occlusion device (List separately in addition to code for primary procedure) Open femoral artery exposure for delivery of endovascular prosthesis, by groin incision, unilateral Placement of femoral-femoral prosthetic graft during endovascular aortic aneurysm repair (List separately in addition to code for primary procedure) ASC Rate Incl PC Fee TC Fee 40.06(8) - Surgical Services Description (con’t) Open iliac artery exposure for delivery of endovascular prosthesis or iliac occlusion during endovascular therapy, by abdominal or retroperitoneal incision, unilateral Placement of proximal or distal extension prosthesis for endovascular repair of infrarenal abdominal aortic or iliac aneurysm, false aneurysm, or dissection; initial vessel Placement of proximal or distal extension prosthesis for endovascular repair of infrarenal abdominal aortic or iliac aneurysm, false aneurysm, or dissection; each additional vessel (List separately in addition to code for primary procedure) Open repair of infrarenal aortic aneurysm or dissection, plus repair of associated arterial trauma, following unsuccessful endovascular repair; tube prosthesis Open repair of infrarenal aortic aneurysm or dissection, plus repair of associated arterial trauma, following unsuccessful endovascular repair; aorto-bi-iliac prosthesis Open repair of infrarenal aortic aneurysm or dissection, plus repair of associated arterial trauma, following unsuccessful endovascular repair; aorto-bifemoral prosthesis Open iliac artery exposure with creation of conduit for delivery of aortic or iliac endovascular prosthesis, by abdominal or retroperitoneal incision, unilateral Open brachial artery exposure to assist in the deployment of aortic or iliac endovascular prosthesis by arm incision, unilateral Endovascular graft placement for repair of iliac artery (eg, aneurysm, pseudoaneurysm, arteriovenous malformation, trauma) Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm and associated occlusive disease, carotid, subclavian artery, by neck incision Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for ruptured aneurysm, carotid, subclavian artery, by neck incision Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, vertebral artery Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm and associated occlusive disease, axillary-brachial artery, by arm incision ASC Incl PC TC Rate Fee Fee 40.06(8) - Surgical Services Description (con’t) Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for ruptured aneurysm, axillary-brachial artery, by arm incision Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, innominate, subclavian artery, by thoracic incision Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for ruptured aneurysm, innominate, subclavian artery, by thoracic incision Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, radial or ulnar artery Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, abdominal aorta Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for ruptured aneurysm, abdominal aorta Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, abdominal aorta involving visceral vessels (mesenteric, celiac, renal) Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for ruptured aneurysm, abdominal aorta involving visceral vessels (mesenteric, celiac, renal) Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, abdominal aorta involving iliac vessels (common, hypogastric, external) Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for ruptured aneurysm, abdominal aorta involving iliac vessels (common, hypogastric, external) Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, splenic artery Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for ruptured aneurysm, splenic artery ASC Incl PC TC Rate Fee Fee 40.06(8) - Surgical Services Description (con’t) Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, hepatic, celiac, renal, or mesenteric artery Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for ruptured aneurysm, hepatic, celiac, renal, or mesenteric artery Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, iliac artery (common, hypogastric, external) Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for ruptured aneurysm, iliac artery (common, hypogastric, external) Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, common femoral artery (profunda femoris, superficial femoral) Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for ruptured aneurysm, common femoral artery (profunda femoris, superficial femoral) Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, popliteal artery Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for ruptured aneurysm, popliteal artery Repair, congenital arteriovenous fistula; head and neck Repair, congenital arteriovenous fistula; thorax and abdomen Repair, congenital arteriovenous fistula; extremities Repair, acquired or traumatic arteriovenous fistula; head and neck Repair, acquired or traumatic arteriovenous fistula; thorax and abdomen Repair, acquired or traumatic arteriovenous fistula; extremities Repair blood vessel, direct; neck Repair blood vessel, direct; upper extremity Repair blood vessel, direct; hand, finger Repair blood vessel, direct; intrathoracic, with bypass Repair blood vessel, direct; intrathoracic, without bypass Repair blood vessel, direct; intra-abdominal Repair blood vessel, direct; lower extremity Repair blood vessel with vein graft; neck ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Repair blood vessel with vein graft; upper extremity Repair blood vessel with vein graft; intrathoracic, with bypass Repair blood vessel with vein graft; intrathoracic, without bypass Repair blood vessel with vein graft; intra-abdominal Repair blood vessel with vein graft; lower extremity Repair blood vessel with graft other than vein; neck Repair blood vessel with graft other than vein; upper extremity Repair blood vessel with graft other than vein; intrathoracic, with bypass Repair blood vessel with graft other than vein; intrathoracic, without bypass Repair blood vessel with graft other than vein; intra-abdominal Repair blood vessel with graft other than vein; lower extremity Thromboendarterectomy, including patch graft, if performed; carotid, vertebral, subclavian, by neck incision Thromboendarterectomy, including patch graft, if performed; superficial femoral artery Thromboendarterectomy, including patch graft, if performed; popliteal artery Thromboendarterectomy, including patch graft, if performed; tibioperoneal trunk artery Thromboendarterectomy, including patch graft, if performed; tibial or peroneal artery, initial vessel Thromboendarterectomy, including patch graft, if performed; each additional tibial or peroneal artery (List separately in addition to code for primary procedure) Thromboendarterectomy, including patch graft, if performed; subclavian, innominate, by thoracic incision Thromboendarterectomy, including patch graft, if performed; axillary-brachial Thromboendarterectomy, including patch graft, if performed; abdominal aorta Thromboendarterectomy, including patch graft, if performed; mesenteric, celiac, or renal Thromboendarterectomy, including patch graft, if performed; iliac Thromboendarterectomy, including patch graft, if performed; iliofemoral Thromboendarterectomy, including patch graft, if performed; combined aortoiliac Thromboendarterectomy, including patch graft, if performed; combined aortoiliofemoral Thromboendarterectomy, including patch graft, if performed; common femoral Thromboendarterectomy, including patch graft, if performed; deep (profunda) femoral ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Reoperation, carotid, thromboendarterectomy, more than one month after original operation (List separately in addition to code for primary procedure) Angioscopy (non-coronary vessels or grafts) during therapeutic intervention (List separately in addition to code for primary procedure) Transluminal balloon angioplasty, open; renal or other visceral artery Transluminal balloon angioplasty, open; aortic Transluminal balloon angioplasty, open; iliac Transluminal balloon a n gioplasty, open; femoral-popliteal Transluminal balloon a n giopla sty, open; brachiocephalic trunk or branches, each vessel Transluminal balloon angioplasty, open; tibioperoneal trunk and branches Transluminal balloon angioplasty, open; venous Transluminal balloon angioplasty, percutaneous; tibioperoneal trunk or branches, each vessel Transluminal balloon angioplasty, percutaneous; renal or visceral artery Transluminal balloon angioplasty, percutaneous; aortic Transluminal balloon angioplasty, percutaneous; iliac Transluminal balloon angioplasty, percutaneous; femoral-popliteal Transluminal balloon angioplasty, percutaneous; brachiocephalic trunk or branches, each vessel Transluminal balloon angioplasty, percutaneous; venous Transluminal peripheral atherectomy, open; renal or other visceral artery Transluminal peripheral atherectomy, open; aortic Transluminal peripheral atherectomy, open; iliac Transluminal peripheral atherectomy, open; femoral-popliteal Transluminal peripheral atherectomy, open; brachiocephalic trunk or branches, each vessel Transluminal peripheral atherectomy, open; tibioperoneal trunk and branches Transluminal peripheral atherectomy, percutaneous; renal or other visceral artery Transluminal peripheral atherectomy, percutaneous; aortic Transluminal peripheral atherectomy, percutaneous; iliac Transluminal peripheral atherectomy, percutaneous; femoral-popliteal Transluminal peripheral atherectomy, percutaneous; brachiocephalic trunk or branches, each vessel Transluminal peripheral atherectomy, percutaneous; tibioperoneal trunk and branches Harvest of upper extremity vein, one segment, for lower extremity or coronary artery bypass procedure (List separately in addition to code for primary procedure) ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Bypass graft, with vein; common carotid-ipsilateral internal carotid Bypass graft, with vein; carotid-subclavian or subclavian-carotid Bypass graft, with vein; carotid-vertebral Bypass graft, with vein; carotid-contralateral carotid Bypass graft, with vein; carotid-brachial Bypass graft, with vein; subclavian-subclavian Bypass graft, with vein; subclavian-brachial Bypass graft, with vein; subclavian-vertebral Bypass graft, with vein; subclavian-axillary Bypass graft, with vein; axillary-axillary Bypass graft, with vein; axillary-femoral Bypass graft, with vein; axillary-brachial Bypass graft, with vein; brachial-ulnar or -radial Bypass graft, with vein; brachial-brachial Bypass graft, with vein; aortosubclavian or carotid Bypass graft, with vein; aortoceliac or aortomesenteric Bypass graft, with vein; axillary-femoral-femoral Bypass graft, with vein; splenorenal Bypass graft, with vein; aortoiliac Bypass graft, with vein; aortobi-iliac Bypass graft, with vein; aortofemoral Bypass graft, with vein; aortobifemoral Bypass graft, with vein; aortoiliofemoral, unilateral Bypass graft, with vein; aortoiliofemoral, bilateral Bypass graft, with vein; aortofemoral-popliteal Bypass graft, with vein; femoral-popliteal Bypass graft, with vein; femoral-femoral Bypass graft, with vein; aortorenal Bypass graft, with vein; ilioiliac Bypass graft, with vein; iliofemoral Bypass graft, with vein; femoral-anterior tibial, posterior tibial, peroneal artery or other distal vessels Bypass graft, with vein; popliteal-tibial, -peroneal artery or other distal vessels Harvest of femoropopliteal vein, one segment, for vascular reconstruction procedure (eg, aortic, vena caval, coronary, peripheral artery) (List separately in addition to code for primary procedure) In-situ vein bypass; femoral-popliteal In-situ vein bypass; femoral-anterior tibial, posterior tibial, or peroneal artery In-situ vein bypass; popliteal-tibial, peroneal Harvest of upper extremity artery, one segment, for coronary artery bypass procedure (List separately in addition to code for primary procedure) Bypass graft, with other than vein; common carotid-ipsilateral internal carotid Bypass graft, with other than vein; carotid-subclavian B y p a s s g r a f t , w i t h o t h e r t h a n v e i n ; subclavian-subclavian Bypass graft, with other than vein; subclavian-axillary Bypass graft, with other than vein; axillary-femoral ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Bypass graft, with other than vein; axillary-popliteal or -tibial Bypass graft, with other than vein; aortosubclavian or carotid Bypass graft, with other than vein; aortoceliac, aortomesenteric, aortorenal Bypass graft, with other than vein; splenorenal (splenic to renal arterial anastomosis) Bypass graft, with other than vein; aortoiliac Bypass graft, with other than vein; aortobi-iliac Bypass graft, with other than vein; carotid-vertebral Bypass graft, with other than vein; subclavian-vertebral Bypass graft, with other than vein; aortobifemoral Bypass graft, with other than vein; aortofemoral Bypass graft, with other than vein; axillary-axillary B y p a s s g r a f t , w i t h o t h e r t h a n v e i n ; aortofemoral-popliteal B y p a s s g r a f t , w i t h o t h e r t h a n v e i n ; axillary-femoral-femoral Bypass graft, with other than vein; femoral-popliteal Bypass graft, with other than vein; femoral-femoral Bypass graft, with other than vein; ilioiliac Bypass graft, with other than vein; iliofemoral Bypass graft, with other than vein; femoral-anterior tibial, posterior tibial, or peroneal artery Bypass graft, with other than vein; popliteal-tibial or -peroneal artery Bypass graft; composite, prosthetic and vein (List separately in addition to code for primary procedure) Bypass graft; autogenous composite, two segments of veins from two locations (List separately in addition to code for primary procedure) Bypass graft; autogenous composite, three or more segments of vein from two or more locations (List separately in addition to code for primary procedure) Placement of vein patch or cuff at distal anastomosis of bypass graft, synthetic conduit (List separately in addition to code for primary procedure) Creation of distal arteriovenous fistula during lower extremity bypass surgery (non-hemodialysis) (List separately in addition to code for primary procedure) Transposition and/or reimplantation; vertebral to carotid artery Transposition and/or reimplantation; vertebral to subclavian artery Transposition and/or reimplantation; subclavian to carotid artery Transposition and/or reimplantation; carotid to subclavian artery Reimplantation, visceral artery to infrarenal aortic prosthesis, each artery (List separately in addition to code for primary procedure) ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Reoperation, femoral-popliteal or femoral (popliteal)-anterior tibial, posterior tibial, peroneal artery, or other distal vessels, more than one month after original operation (List separately in addition to code for primary procedure) Exploration (not followed by surgical repair), with or without lysis of artery; carotid artery Exploration (not followed by surgical repair), with or without lysis of artery; femoral artery Exploration (not followed by surgical repair), with or without lysis of artery; popliteal artery Exploration (not followed by surgical repair), with or without lysis of artery; other vessels Exploration for postoperative hemorrhage, thrombosis or infection; neck Exploration for postoperative hemorrhage, thrombosis or infection; chest Exploration for postoperative hemorrhage, thrombosis or infection; abdomen Exploration for postoperative hemorrhage, thrombosis or infection; extremity Repair of graft-enteric fistula Thrombectomy of arterial or venous graft (other than hemodialysis graft or fistula); Thrombectomy of arterial or venous graft (other than hemodialysis graft or fistula); with revision of arterial or venous graft Revision, lower extremity arterial bypass, without thrombectomy, open; with vein patch angioplasty Revision, lower extremity arterial bypass, without thrombectomy, open; with segmental vein interposition Revision, femoral anastomosis of synthetic arterial bypass graft in groin, open; with nonautogenous patch graft (eg, Dacron, ePTFE, bovine pericardium) Revision, femoral anastomosis of synthetic arterial bypass graft in groin, open; with autogenous vein patch graft Excision of infected graft; neck Excision of infected graft; extremity Excision of infected graft; thorax Excision of infected graft; abdomen Introduction of needle or intracatheter, vein Injection procedures (eg, thrombin) for percutaneous treatment of extremity pseudoaneurysm Injection procedure for extremity venography (including introduction of needle or intracatheter) Introduction of catheter, superior or inferior vena cava Selective catheter placement, venous system; first order branch (eg, renal vein, jugular vein) Selective catheter placement, venous system; second order, or more selective, branch (eg, left adrenal vein, petrosal sinus) Introduction of catheter, right heart or main pulmonary artery ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Selective catheter placement, left or right pulmonary artery Selective catheter placement, segmental or subsegmental pulmonary artery Introduction of needle or intracatheter, carotid or vertebral artery Introduction of needle or intracatheter; retrograde brachial artery Introduction of needle or intracatheter; extremity artery Introduction of needle or intracatheter; arteriovenous shunt created for dialysis (cannula, fistula, or graft) Introduction of needle or intracatheter, aortic, translumbar Introduction of catheter, aorta Selective catheter placement, arterial system; each first order thoracic or brachiocephalic branch, within a vascular family Selective catheter placement, arterial system; initial second order thoracic or brachiocephalic branch, within a vascular family Selective catheter placement, arterial system; initial third order or more selective thoracic or brachiocephalic branch, within a vascular family Selective catheter placement, arterial system; additional second order, third order, and beyond, thoracic or brachiocephalic branch, within a vascular family (List in addition to code for initial second or third order vessel as appropriate) Selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery branch, within a vascular family Selective catheter placement, arterial system; initial second order abdominal, pelvic, or lower extremity artery branch, within a vascular family Selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or lower extremity artery branch, within a vascular family Selective catheter placement, arterial system; additional second order, third order, and beyond, abdominal, pelvic, or lower extremity artery branch, within a vascular family (List in addition to code for initial second or third order vessel as appropriate) Insertion of implantable intra-arterial infusion pump (eg, for chemotherapy of liver) Revision of implanted intra-arterial infusion pump Removal of implanted intra-arterial infusion pump I.C. Unlisted procedure, vascular injection Venipuncture, age 3 years or older, necessitating physician's skill (separate procedure), for diagnostic or therapeutic purposes (not to be used for routine venipuncture) I.C. Collection of venous blood by venipuncture I.C. Collection of capillary blood specimen (eg, finger, heel, ear stick) ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Venipuncture, cutdown; age one or over Exchange transfusion, blood; other than newborn Transfusion, intrauterine, fetal I.C. Single or multiple injections of sclerosing solutions, spider veins (telangiectasia); limb or trunk I.C. Single or multiple injections of sclerosing solutions, spider veins (telangiectasia); face Injection of sclerosing solution; single vein Injection of sclerosing solution; multiple veins, same leg Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; second and subsequent veins treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure) Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; first vein treated Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; second and subsequent veins treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure) Percutaneous portal vein catheterization by any method Venous catheterization for selective organ blood sampling Therapeutic apheresis; for white blood cells Therapeutic apheresis; for red blood cells Therapeutic apheresis; for platelets Therapeutic apheresis; for plasma pheresis Therapeutic apheresis; with extracorporeal immunoadsorption and plasma reinfusion Therapeutic apheresis; with extracorporeal selective adsorption or selective filtration and plasma reinfusion Photopheresis, extracorporeal Insertion of non-tunneled centrally inserted central venous catheter; age five years or older Insertion of tunneled centrally inserted central venous catheter, without subcutaneous port or pump; age five years or older Insertion of tunneled centrally inserted central venous access device, with subcutaneous port; age five years or older Insertion of tunneled centrally inserted central venous access device with subcutaneous pump 40.06: continued ASC Incl Rate 40.06(8) - Surgical Services Description (con’t) Insertion of tunneled centrally inserted central venous access device, requiring two catheters via two separate venous access sites; without subcutaneous port or pump (eg, Tesio type catheter) Insertion of tunneled centrally inserted central venous access device, requiring two catheters via two separate venous access sites; with subcutaneous port(s) Insertion of peripherally inserted central venous catheter (PICC), without subcutaneous port or pump; age five years or older Insertion of peripherally inserted central venous access device, with subcutaneous port; age five years or older Repair of tunneled or non-tunneled central venous access catheter, without subcutaneous port or pump, central or peripheral insertion site Repair of central venous access device, with subcutaneous port or pump, central or peripheral insertion site Replacement, catheter only, of central venous access device, with subcutaneous port or pump, central or peripheral insertion site Replacement, complete, of a non-tunneled centrally inserted central venous catheter, without subcutaneous port or pump, through same venous access Replacement, complete, of a tunneled centrally inserted central venous catheter, without subcutaneous port or pump, through same venous access Replacement, complete, of a tunneled centrally inserted central venous access device, with subcutaneous port, through same venous access Replacement, complete, of a tunneled centrally inserted central venous access device, with subcutaneous pump, through same venous access Replacement, complete, of a peripherally inserted central venous catheter (PICC), without subcutaneous port or pump, through same venous access Replacement, complete, of a peripherally inserted central venous access device, with subcutaneous port, through same venous access Removal of tunneled central venous catheter, without subcutaneous port or pump Removal of tunneled central venous access device, with subcutaneous port or pump, central or peripheral insertion Collection of blood specimen from a completely implantable venous access device Collection of blood specimen using established central or peripheral catheter, venous, not otherwise specified Declotting by thrombolytic agent of implanted vascular access device or catheter Mechanical removal of pericatheter obstructive material (eg, fibrin sheath) from central venous device via separate venous access PC TC Fee Fee 40.06: continued ASC Incl Rate PC Fee TC Fee 40.06(8) - Surgical Services Description (con’t) Mechanical removal of intraluminal (intracatheter) obstructive material from central venous device through device lumen Repositioning of previously placed central venous catheter under fluoroscopic guidance Contrast injection(s) for radiologic evaluation of existing central venous access device, including fluoroscopy, image documentation and report Arterial puncture, withdrawal of blood for diagnosis Arterial catheterization or cannulation for sampling, monitoring or transfusion (separate procedure); percutaneous Arterial catheterization or cannulation for sampling, monitoring or transfusion (separate procedure); cutdown Arterial catheterization for prolonged infusion therapy (chemotherapy), cutdown Catheterization, umbilical artery, newborn, for diagnosis or therapy Placement of needle for intraosseous infusion Insertion of cannula for hemodialysis, other purpose (separate procedure); vein to vein Insertion of cannula for hemodialysis, other purpose (separate procedure); arteriovenous, external (Scribner type) Insertion of cannula for hemodialysis, other purpose (separate procedure); arteriovenous, external revision, or closure Arteriovenous anastomosis, open; by upper arm cephalic vein transposition Arteriovenous anastomosis, open; by upper arm basilic vein transposition Arteriovenous anastomosis, open; by forearm vein transposition Arteriovenous anastomosis, open; direct, any site (eg, Cimino type) (separate procedure) Insertion of cannula(s) for prolonged extracorporeal circulation for cardiopulmonary insufficiency (ECMO) (separate procedure) Insertion of arterial and venous cannula(s) for isolated extracorporeal circulation including regional chemotherapy perfusion to an extremity, with or without hyperthermia, with removal of cannula(s) and repair of arteriotomy and venotomy sites Creation of arteriovenous fistula by other than direct arteriovenous anastomosis (separate procedure); autogenous graft Creation of arteriovenous fistula by other than direct arteriovenous anastomosis (separate procedure); nonautogenous graft (eg, biological collagen, thermoplastic graft) Thrombectomy, open, arteriovenous fistula without revision, autogenous or nonautogenous dialysis graft (separate procedure) 40.06: continued ASC Incl Rate PC TC Fee Fee 40.06(8) - Surgical Services Description (con’t) Revision, open, arteriovenous fistula; without thrombectomy, autogenous or nonautogenous dialysis graft (separate procedure) Revision, open, arteriovenous fistula; with thrombectomy, autogenous or nonautogenous dialysis graft (separate procedure) Plastic repair of arteriovenous aneurysm (separate procedure) Insertion of Thomas shunt (separate procedure) Distal revascularization and interval ligation (DRIL), upper extremity hemodialysis access (steal syndrome) External cannula declotting (separate procedure); without balloon catheter External cannuladeclotting (separate procedure); with balloon catheter Thrombectomy, percutaneous, arteriovenous fistula, autogenous or nonautogenous graft (includes mechanical thrombus extraction and intra-graft thrombolysis) Venous anastomosis, open; portocaval Venous anastomosis, open; renoportal Venous anastomosis, open; caval-mesenteric Venous anastomosis, open; splenorenal, proximal Venous anastomosis, open; splenorenal, distal (selective decompression of esophagogastric varices, any technique) Insertion of transvenous intrahepatic portosystemic shunt(s) (TIPS) (includes venous access, hepatic and portal vein catheterization, portography with hemodynamic evaluation, intrahepatic tract formation/dilatation, stent placement and all associated imaging guidance and documentation) Revision of transvenous intrahepatic portosystemic shunt(s) (TIPS) (includes venous access, hepatic and portal vein catheterization, portography with hemodynamic evaluation, intrahepatic tract recanulization/dilatation, stent placement and all associated imaging guidance and documentation) Primary percutaneous transluminal mechanical thrombectomy, noncoronary, arterial or arterial bypass graft, including fluoroscopic guidance and intraprocedural pharmacological thrombolytic injection(s); initial vessel Primary percutaneous transluminal mechanical thrombectomy, noncoronary, arterial or arterial bypass graft, including fluoroscopic guidance and intraprocedural pharmacological thrombolytic injection(s); second and all subsequent vessel(s) within the same vascular family (List separately in addition to code for primary mechanical thrombectomy procedure) ASC Incl PC TC Rate Fee Fee I.C. 40.06(8) - Surgical Services Description (con’t) Secondary percutaneous transluminal thrombectomy (eg, nonprimary mechanical, snare basket, suction technique), noncoronary, arterial or arterial bypass graft, including fluoroscopic guidance and intraprocedural pharmacological thrombolytic injections, provided in conjunction with another percutaneous intervention other than primary mechanical thrombectomy (List separately in addition to code for primary procedure) Percutaneous transluminal mechanical thrombectomy, vein(s), including intraprocedural pharmacological thrombolytic injections and fluoroscopic guidance Percutaneous transluminal mechanical thrombectomy, vein(s), including intraprocedural pharmacological thrombolytic injections and fluoroscopic guidance, repeat treatment on subsequent day during course of thrombolytic therapy Thrombolysis, cerebral, by intravenous infusion Transcatheter biopsy Transcatheter therapy, infusion for thrombolysis other than coronary Transcatheter therapy, infusion other than for thrombolysis, any type (eg, spasmolytic, vasoconstrictive) Transcatheter retrieval, percutaneous, of intravascular foreign body (eg, fractured venous or arterial catheter) Transcatheter occlusion or embolization (eg, for tumor destruction, to achieve hemostasis, to occlude a vascular malformation), percutaneous, any method, non-central nervous system, non-head or neck Transcatheter placement of an intravascular stent(s) (except coronary, carotid, and vertebral vessel), percutaneous; initial vessel Transcatheter placement of an intravascular stent(s) (except coronary, carotid, and vertebral vessel), percutaneous; each additional vessel (List separately in addition to code for primary procedure) Transcatheter placement of an intravascular stent(s) (non-coronary vessel), open; initial vessel Transcatheter placement of an intravascular stent(s) (non-coronary vessel), open; each additional vessel (List separately in addition to code for primary procedure) Exchange of a previously placed intravascular catheter during thrombolytic therapy Uterine fibroid embolization (UFE, embolization of the uterine arteries to treat uterine fibroids, leiomyomata), percutaneous approach inclusive of vascular access, vessel selection, embolization, and all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the procedure Transcatheter placement of intravascular stent(s), cervical carotid artery, percutaneous; with distal embolic protection ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Transcatheter placement of intravascular stent(s), cervical carotid artery, percutaneous; without distal embolic protection Intravascular ultrasound (non-coronary vessel) during diagnostic evaluation and/or therapeutic intervention; initial vessel (List separately in addition to code for primary procedure) Intravascular ultrasound (non-coronary vessel) during diagnostic evaluation and/or therapeutic intervention; each additional vessel (List separately in addition to code for primary procedure) Vascular endoscopy, surgical, with ligation of perforator veins, subfascial (SEPS) I.C. Unlisted vascular endoscopy procedure Ligation, internal jugular vein Ligation; external carotid artery Ligation; internal or common carotid artery Ligation; internal or common carotid artery, with gradual occlusion, as with Selverstone or Crutchfield clamp Ligation or banding of angioaccess arteriovenous fistula Ligation or biopsy, temporal artery Ligation, major artery (eg, post-traumatic, rupture); neck Ligation, major artery (eg, post-traumatic, rupture); chest Ligation, major artery (eg, post-traumatic, rupture); abdomen Ligation, major artery (eg, post-traumatic, rupture); extremity Interruption, partial or complete, of inferior vena cava by suture, ligation, plication, clip, extravascular, intravascular (umbrella device) Ligation of femoral vein Ligation of common iliac vein Ligation and division of long saphenous vein at saphenofemoral junction, or distal interruptions Ligation, division, and stripping, short saphenous vein Ligation, division, and stripping, long (greater) saphenous veins from saphenofemoral junction to knee or below Ligation and division and complete stripping of long or short saphenous veins with radical excision of ulcer and skin graft and/or interruption of communicating veins of lower leg, with excision of deep fascia Ligation of perforator veins, subfascial, radical (Linton type), with or without skin graft, open Stab phlebectomy of varicose veins, one extremity; ten - 20 stab incisions Stab phlebectomy of varicose veins, one extremity; more than 20 incisions Ligation and division of short saphenous vein at saphenopopliteal junction (separate procedure) Ligation, division, and/or excision of varicose vein cluster(s), one leg ASC Rate Incl PC Fee TC Fee I.C. I.C. 40.06(8) - Surgical Services Description (con’t) Penile revascularization, artery, with or without vein graft Penile venous occlusive procedure Unlisted procedure, vascular surgery Splenectomy; total (separate procedure) Splenectomy; partial (separate procedure) plenectomy; total, en bloc for extensive disease, in conjunction with other procedure (List in addition to code for primary procedure) Repair of ruptured spleen (splenorrhaphy) with or without partial splenectomy Laparoscopy, surgical, splenectomy Unlisted laparoscopy procedure, spleen Injection procedure for splenoportography Management of recipient hematopoietic progenitor cell donor search and cell acquisition Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; allogenic Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; autologous Transplant preparation of hematopoietic progenitor cells; cryopreservation and storage Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, with washing Transplant preparation of hematopoietic progenitor cells; specific cell depletion within harvest, T-cell depletion Transplant preparation of hematopoietic progenitor cells; tumor cell depletion Transplant preparation of hematopoietic progenitor cells; red blood cell removal Transplant preparation of hematopoietic progenitor cells; platelet depletion Transplant preparation of hematopoietic progenitor cells; plasma (volume) depletion Transplant preparation of hematopoietic progenitor cells; cell concentration in plasma, mononuclear, or buffy coat layer Bone marrow; aspiration only Bone marrow; biopsy, needle or trocar Bone marrow harvesting for transplantation Bone marrow or blood-derived peripheral stem cell transplantation; allogenic Bone marrow or blood-derived peripheral stem cell transplantation; autologous Bone marrow or blood-derived peripheral stem cell transplantation; allogeneic donor lymphocyte infusions ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Drainage of lymph node abscess or lymphadenitis; simple Drainage of lymph node abscess or lymphadenitis; extensive Lymphangiotomy or other operations on lymphatic channels Suture and/or ligation of thoracic duct; cervical approach Suture and/or ligation of thoracic duct; thoracic approach Suture and/or ligation of thoracic duct; abdominal approach Biopsy or excision of lymph node(s); open, superficial Biopsy or excision of lymph node(s); by needle, superficial (eg, cervical, inguinal, axillary) Biopsy or excision of lymph node(s); open, deep cervical node(s) Biopsy or excision of lymph node(s); open, deep cervical node(s) with excision scalene fat pad Biopsy or excision of lymph node(s); open, deep axillary node(s) Biopsy or excision of lymph node(s); open, internal mammary node(s) Dissection, deep jugular node(s) Excision of cystic hygroma, axillary or cervical; without deep neurovascular dissection Excision of cystic hygroma, axillary or cervical; with deep neurovascular dissection Limited lymphadenectomy for staging (separate procedure); pelvic and para-aortic Limited lymphadenectomy for staging (separate procedure); retroperitoneal (aortic and/or splenic) Laparoscopy, surgical; with retroperitoneal lymph node sampling (biopsy), single or multiple Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy and peri-aortic lymph node sampling (biopsy), single or multiple I.C. Unlisted laparoscopy procedure, lymphatic system Suprahyoid lymphadenectomy Cervical lymphadenectomy (complete) Cervical lymphadenectomy (modified radical neck dissection) Axillary lymphadenectomy; superficial Axillary lymphadenectomy; complete Thoracic lymphadenectomy, regional, including mediastinal and peritracheal nodes (List separately in addition to code for primary procedure) Abdominal lymphadenectomy, regional, including celiac, gastric, portal, peripancreatic, with or without para-aortic and vena caval nodes (List separately in addition to code for primary procedure) Inguinofemoral lymphadenectomy, superficial, including Cloquets node (separate procedure) ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Inguinofemoral lymphadenectomy, superficial, in continuity with pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes (separate procedure) Pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes (separate procedure) Retroperitoneal transabdominal lymphadenectomy, extensive, including pelvic, aortic, and renal nodes (separate procedure) Injection procedure; lymphangiography Injection procedure; for identification of sentinel node Cannulation, thoracic duct I.C. Unlisted procedure, hemic or lymphatic system Mediastinotomy with exploration, drainage, removal of foreign body, or biopsy; cervical approach Mediastinotomy with exploration, drainage, removal of foreign body, or biopsy; transthoracic approach, including either transthoracic or median sternotomy Excision of mediastinal cyst Excision of mediastinal tumor Mediastinoscopy, with or without biopsy I.C. Unlisted procedure, mediastinum Repair, laceration of diaphragm, any approach Repair, paraesophageal hiatus hernia, transabdominal, with or without fundoplasty, vagotomy, and/or pyloroplasty, except neonatal Repair, neonatal diaphragmatic hernia, with or without chest tube insertion and with or without creation of ventral hernia Repair, diaphragmatic hernia (esophageal hiatal); transthoracic Repair, diaphragmatic hernia (esophageal hiatal); combined, thoracoabdominal Repair, diaphragmatic hernia (esophageal hiatal); combined, thoracoabdominal, with dilation of stricture (with or without gastroplasty) Repair, diaphragmatic hernia (other than neonatal), traumatic; acute Repair, diaphragmatic hernia (other than neonatal), traumatic; chronic Imbrication of diaphragm for eventration, transthoracic or transabdominal, paralytic or nonparalytic Resection, diaphragm; with simple repair (eg, primary suture) Resection, diaphragm; with complex repair (eg, prosthetic material, local muscle flap) I.C. Unlisted procedure, diaphragm Biopsy of lip Vermilionectomy (lip shave), with mucosal advancement Excision of lip; transverse wedge excision with primary closure Excision of lip; V-excision with primary direct linear closure ASC Rate Incl I.C. PC TC Fee Fee 40.06(8) - Surgical Services Description (con’t) Excision of lip; full thickness, reconstruction with local flap (eg, Estlander or fan) Excision of lip; full thickness, reconstruction with cross lip flap (Abbe-Estlander) Resection of lip, more than one-fourth, without reconstruction Repair lip, full thickness; vermilion only Repair lip, full thickness; up to half vertical height Repair lip, full thickness; over one-half vertical height, or complex Plastic repair of cleft lip/nasal deformity; primary, partial or complete, unilateral Plastic repair of cleft lip/nasal deformity; primary bilateral, one stage procedure Plastic repair of cleft lip/nasal deformity; primary bilateral, one of two stages Plastic repair of cleft lip/nasal deformity; secondary, by recreation of defect and reclosure Plastic repair of cleft lip/nasal deformity; with cross lip pedicle flap (Abbe-Estlander type), including sectioning and inserting of pedicle Unlisted procedure, lips Drainage of abscess, cyst, hematoma, vestibule of mouth; simple Drainage of abscess, cyst, hematoma, vestibule of mouth; complicated Removal of embedded foreign body, vestibule of mouth; simple Removal of embedded foreign body, vestibule of mouth; complicated Incision of labial frenum (frenotomy) Biopsy, vestibule of mouth Excision of lesion of mucosa and submucosa, vestibule of mouth; without repair Excision of lesion of mucosa and submucosa, vestibule of mouth; with simple repair Excision of lesion of mucosa and submucosa, vestibule of mouth; with complex repair Excision of lesion of mucosa and submucosa, vestibule of mouth; complex, with excision of underlying muscle Excision of mucosa of vestibule of mouth as donor graft Excision of frenum, labial or buccal (frenumectomy, frenulectomy, frenectomy) Destruction of lesion or scar of vestibule of mouth by physical methods (eg, laser, thermal, cryo, chemical) Closure of laceration, vestibule of mouth; 2.5 cm or less Closure of laceration, vestibule of mouth; over 2.5 cm or complex Vestibuloplasty; anterior Vestibuloplasty; posterior, unilateral Vestibuloplasty; posterior, bilateral Vestibuloplasty; entire arch ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Vestibuloplasty; complex (including ridge extension, muscle repositioning) I.C. Unlisted procedure, vestibule of mouth Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; lingual Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; sublingual, superficial Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; sublingual, deep, supramylohyoid Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; submental space Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; submandibular space Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; masticator space Incision of lingual frenum (frenotomy) Extraoral incision and drainage of abscess, cyst, or hematoma of floor of mouth; sublingual Extraoral incision and drainage of abscess, cyst, or hematoma of floor of mouth; submental Extraoral incision and drainage of abscess, cyst, or hematoma of floor of mouth; submandibular Extraoral incision and drainage of abscess, cyst, or hematoma of floor of mouth; masticator space Placement of needles, catheters, or other device(s) into the head and/or neck region (percutaneous, transoral, or transnasal) for subsequent interstitial radioelement application Biopsy of tongue; anterior two-thirds Biopsy of tongue; posterior one-third Biopsy of floor of mouth Excision of lesion of tongue without closure Excision of lesion of tongue with closure; anterior two-thirds Excision of lesion of tongue with closure; posterior one-third Excision of lesion of tongue with closure; with local tongue flap Excision of lingual frenum (frenectomy) Excision, lesion of floor of mouth Glossectomy; less than one-half tongue Glossectomy; hemiglossectomy Glossectomy; partial, with unilateral radical neck dissection Glossectomy; complete or total, with or without tracheostomy, without radical neck dissection Glossectomy; complete or total, with or without tracheostomy, with unilateral radical neck dissection ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Glossectomy; composite procedure with resection floor of mouth and mandibular resection, without radical neck dissection Glossectomy; composite procedure with resection floor of mouth, with suprahyoid neck dissection Glossectomy; composite procedure with resection floor of mouth, mandibular resection, and radical neck dissection (Commando type) Repair of laceration 2.5 cm or less; floor of mouth and/or anterior two-thirds of tongue Repair of laceration 2.5 cm or less; posterior one-third of tongue Repair of laceration of tongue, floor of mouth, over 2.6 cm or complex Fixation of tongue, mechanical, other than suture (eg, K-wire) Suture of tongue to lip for micrognathia (Douglas type procedure) Frenoplasty (surgical revision of frenum, eg, with Z-plasty) I.C. Unlisted procedure, tongue, floor of mouth Drainage of abscess, cyst, hematoma from dentoalveolar structures Removal of embedded f o re i gn b o dy from dentoalveolar structures; soft tissues Remova l o f e mbe d d e d f o r e ign b o dy from dentoalveolar structures; bone I.C. Gingivectomy, excision gingiva, each quadrant I.C. Operculectomy, excision pericoronal tissues Excision of fibrous tuberosities, dentoalveolar structures Excision of osseous tuberosities, dentoalveolar structures Excision of lesion or tumor (except listed above), dentoalveolar structures; without repair Excision of lesion or tumor (except listed above), dentoalveolar structures; with simple repair Excision of lesion or tumor (except listed above), dentoalveolar structures; with complex repair Excision of hyperplastic alveolar mucosa, each quadrant (specify) Alveolectomy, including curettage of osteitis or sequestrectomy I.C. Destruction of lesion (except excision), dentoalveolar structures I.C. Periodontal mucosal grafting Gingivoplasty, each quadrant (specify) Alveoloplasty, each quadrant (specify) I.C. Unlisted procedure, dentoalveolar structures Drainage of abscess of palate, uvula Biopsy of palate, uvula Excision, lesion of palate, uvula; without closure Excision, lesion of palate, uvula; with simple primary closure Excision, lesion of palate, uvula; with local flap closure ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Resection of palate or extensive resection of lesion Uvulectomy, excision of uvula Palatopharyngoplasty (eg, uvulopalatopharyngoplasty, uvulopharyngoplasty) Destruction of lesion, palate or uvula (thermal, cryo or chemical) Repair, laceration of palate; up to 2 cm Repair, laceration of palate; over 2 cm or complex Palatoplasty for cleft palate, soft and/or hard palate only Palatoplasty for cleft palate, with closure of alveolar ridge; soft tissue only Palatoplasty for cleft palate, with closure of alveolar ridge; with bone graft to alveolar ridge (includes obtaining graft) Palatoplasty for cleft palate; major revision Palatoplasty for cleft palate; secondary lengthening procedure Palatoplasty for cleft palate; attachment pharyngeal flap Lengthening of palate, and pharyngeal flap Lengthening of palate, with island flap Repair of anterior palate, including vomer flap Repair of nasolabial fistula Maxillary impression for palatal prosthesis Insertion of pin-retained palatal prosthesis I.C. Unlisted procedure, palate, uvula Drainage of abscess; parotid, simple Drainage of abscess; parotid, complicated Drainage of abscess; submaxillary or sublingual, intraoral Drainage of abscess; submaxillary, external Sialolithotomy; submandibular (submaxillary), sublingual or parotid, uncomplicated, intraoral Sialolithotomy; submandibular (submaxillary), complicated, intraoral Sialolithotomy; parotid, extraoral or complicated intraoral Biopsy of salivary gland; needle Biopsy of salivary gland; incisional Excision of sublingual salivary cyst (ranula) Marsupialization of sublingual salivary cyst (ranula) Excision of parotid tumor or parotid gland; lateral lobe, without nerve dissection Excision of parotid tumor or parotid gland; lateral lobe, with dissection and preservation of facial nerve Excision of parotid tumor or parotid gland; total, with dissection and preservation of facial nerve Excision of parotid tumor or parotid gland; total, en bloc removal with sacrifice of facial nerve Excision of parotid tumor or parotid gland; total, with unilateral radical neck dissection Excision of submandibular (submaxillary) gland Excision of sublingual gland Plastic repair of salivary duct, sialodochoplasty; primary or simple ASC Rate Incl PC Fee TC Fee I.C. 40.06(8) - Surgical Services Description (con’t) Plastic repair of salivary duct, sialodochoplasty; secondary or complicated Parotid duct diversion, bilateral (Wilke type procedure); Parotid duct diversion, bilateral (Wilke type procedure); with excision of one submandibular gland Parotid duct diversion, bilateral (Wilke type procedure); with excision of both submandibular glands Parotid duct diversion, bilateral (Wilke type procedure); with ligation of both submandibular (Wharton's) ducts Injection procedure for sialography Closure salivary fistula Dilation salivary duct Dilation and catheterization of salivary duct, with or without injection Ligation salivary duct, intraoral Unlisted procedure, salivary glands or ducts Incision and drainage abscess; peritonsillar Incision and drainage abscess; retropharyngeal or parapharyngeal, intraoral approach Incision and drainage abscess; retropharyngeal or parapharyngeal, external approach Biopsy; oropharynx Biopsy; hypopharynx Biopsy; nasopharynx, visible lesion, simple Biopsy; nasopharynx, survey for unknown primary lesion Excision or destruction of lesion of pharynx, any method Removal of foreign body from pharynx Excision branchial cleft cyst or vestige, confined to skin and subcutaneous tissues Excision branchial cleft cyst, vestige, or fistula, extending beneath subcutaneous tissues and/or into pharynx Tonsillectomy and adenoidectomy; age 12 or over Tonsillectomy, primary or secondary; age 12 or over Adenoidectomy, primary; age 12 or over Adenoidectomy, secondary; age 12 or over Radical resection of tonsil, tonsillar pillars, and/or retromolar trigone; without closure Radical resection of tonsil, tonsillar pillars, and/or retromolar trigone; closure with local flap (eg, tongue, buccal) Radical resection of tonsil, tonsillar pillars, and/or retromolar trigone; closure with other flap Excision of tonsil tags Excision or destruction lingual tonsil, any method (separate procedure) Limited pharyngectomy Resection of lateral pharyngeal wall or pyriform sinus, direct closure by advancement of lateral and posterior pharyngeal walls 40.06: continued ASC Incl Rate PC TC Fee Fee I.C. 40.06(8) - Surgical Services Description (con’t) Resection of pharyngeal wall requiring closure with myocutaneous flap Suture pharynx for wound or injury Pharyngoplasty(plasticor reconstructive operation on pharynx) Pharyngoesophageal repair Pharyngostomy (fistulization of pharynx, external for feeding) Control oropharyngeal hemorrhage, primary or secondary (eg, post-tonsillectomy); simple Control oropharyngeal hemorrhage, primary or secondary (eg, post-tonsillectomy); complicated, requiring hospitalization Control oropharyngeal hemorrhage, primary or secondary (eg, post-tonsillectomy); with secondary surgical intervention Control of nasopharyngeal hemorrhage, primary or secondary (eg, postadenoidectomy); simple, with posterior nasal packs, with or without anterior packs and/or cautery Control of nasopharyngeal hemorrhage, primary or secondary (eg, postadenoidectomy); complicated, requiring hospitalization Control of nasopharyngeal hemorrhage, primary or secondary (eg, postadenoidectomy); with secondary surgical intervention Unlisted procedure, pharynx, adenoids, or tonsils Esophagotomy, cervical approach, with removal of foreign body Cricopharyngeal myotomy Esophagotomy, thoracic approach, with removal of foreign body Excision of lesion, esophagus, with primary repair; cervical approach Excision of lesion, esophagus, with primary repair; thoracic or abdominal approach Total or near total esophagectomy, without thoracotomy; with pharyngogastrostomy or cervical esophagogastrostomy, with or without pyloroplasty (transhiatal) Total or near total esophagectomy, without thoracotomy; with colon interposition or small intestine reconstruction, including intestine mobilization, preparation and anastomosis(es) Total or near total esophagectomy, with thoracotomy; with pharyngogastrostomy or cervical esophagogastrostomy, with or without pyloroplasty Total or near total esophagectomy, with thoracotomy; with colon interposition or small intestine reconstruction, including intestine mobilization, preparation, and anastomosis(es) Partial esophagectomy, cervical, with free intestinal graft, including microvascular anastomosis, obtaining the graft and intestinal reconstruction ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Partial esophagectomy, distal two-thirds, with thoracotomy and separate abdominal incision, with or without proximal gastrectomy; with thoracic esophagogastrostomy, with or without pyloroplasty (Ivor Lewis) Partial esophagectomy, distal two-thirds, with thoracotomy and separate abdominal incision, with or without proximal gastrectomy; with colon interposition or small intestine reconstruction, including intestine mobilization, preparation, and anastomosis(es) Partial esophagectomy, distal two-thirds, with thoracotomy only, with or without proximal gastrectomy, with thoracic esophagogastrostomy, with or without pyloroplasty Partial esophagectomy, thoracoabdominal or abdominal approach, with or without proximal gastrectomy; with esophagogastrostomy, with or without pyloroplasty Partial esophagectomy, thoracoabdominal or abdominal approach, with or without proximal gastrectomy; with colon interposition or small intestine reconstruction, including intestine mobilization, preparation, and anastomosis(es) Total or partial eso p h age ct o my, without reconstruction (any approach), with cervical esophagostomy Diverticulectomy of hypopharynx or esophagus, with or without myotomy; cervical approach Diverticulectomy of hypopharynx or esophagus, with or without myotomy; thoracic approach Esophagoscopy, rigid or flexible; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) Esophagoscopy, rigid or flexible; with directed submucosal injection(s), any substance Esophagoscopy, rigid or flexible; with biopsy, single or multiple Esophagoscopy, rigid or flexible; with injection sclerosis of esophageal varices Esophagoscopy, rigid or flexible; with band ligation of esophageal varices Esophagoscopy, rigid or flexible; with removal of foreign body Esophagoscopy, rigid or flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery Esophagoscopy, rigid or flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique Esophagoscopy, rigid or flexible; with insertion of plastic tube or stent Esophagoscopy, rigid or flexible; with balloon dilation (less than 30 mm diameter) 40.06: continued ASC Incl Rate PC Fee TC Fee 40.06(8) - Surgical Services Description (con’t) Esophagoscopy, rigid or flexible; with insertion of guide wire followed by dilation over guide wire Esophagoscopy, rigid or flexible; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator) Esophagoscopy, rigid or flexible; with ablation of tumor(s), polyp(s), or other lesion(s), not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique Esophagoscopy, rigid or flexible; with endoscopic ultrasound examination E s o p h ago s co p y, ri gi d or fl ex i b l e ; w i t h transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s) Upper gastrointestinal endoscopy, simple primary examination (eg, with small diameter flexible endoscope) (separate procedure) Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with directed submucosal injection(s), any substance Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with endoscopic ultrasound examination limited to the esophagus Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s), esophagus (includes endoscopic ultrasound examination limited to the esophagus) Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with biopsy, single or multiple Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with transmural drainage of pseudocyst Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with transendoscopic intraluminal tube or catheter placement ASC Rate Incl PC Fee TC Fee 40.06(8) - Surgical Services Description (con’t) Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s) (includes endoscopic ultrasound examination of the esophagus, stomach, and either the duodenum and/or jejunum as appropriate) Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with injection sclerosis of esophageal and/or gastric varices Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with band ligation of esophageal and/or gastric varices Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with dilation of gastric outlet for obstruction (eg, balloon, guide wire, bougie) Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with directed placement of percutaneous gastrostomy tube Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with removal of foreign body Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with insertion of guide wire followed by dilation of esophagus over guide wire Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with balloon dilation of esophagus (less than 30 mm diameter) Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with control of bleeding, any method Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with transendoscopic stent placement (includes predilation) ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with delivery of thermal energy to the muscle of lower esophageal sphincter and/or gastric cardia, for treatment of gastroesophageal reflux disease Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with endoscopic ultrasound examination, including the esophagus, stomach, and either the duodenum and/or jejunum as appropriate Endoscopic retrograde cholangiopancreatography (ERCP); diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) Endoscopic retrograde cholangiopancreatography (ERCP); with biopsy, single or multiple Endoscopic retrograde cholangiopancreatography (ERCP); with sphincterotomy/papillotomy Endoscopic retrograde cholangiopancreatography (ERCP); with pressure measurement of sphincter of Oddi (pancreatic duct or common bile duct) Endoscopic retrograde cholangiopancreatography (ERCP); with endoscopic retrograde removal of calculus/calculi from biliary and/or pancreatic ducts Endoscopic retrograde cholangiopancreatography (ERCP); with endoscopic retrograde destruction, lithotripsy of calculus/calculi, any method Endoscopic retrograde cholangiopancreatography (ERCP); with endoscopic retrograde insertion of nasobiliary or nasopancreatic drainage tube Endoscopic retrograde cholangiopancreatography (ERCP); with endoscopic retrograde insertion of tube or stent into bile or pancreatic duct Endoscopic retrograde cholangiopancreatography (ERCP); with endoscopic retrograde removal of foreign body and/or change of tube or stent Endoscopic retrograde cholangiopancreatography (ERCP); with endoscopic retrograde balloon dilation of ampulla, biliary and/or pancreatic duct(s) Endoscopic retrograde cholangiopancreatography (ERCP); with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique Laparoscopy, surgical, esophagogastric fundoplasty (eg, Nissen, Toupet procedures) I.C. Unlisted laparoscopy procedure, esophagus ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Esophagoplasty (plastic repair or reconstruction), cervical approach; wi thout repai r of tracheoesophageal fistula Esophagoplasty (plastic repair or reconstruction), cervical approach; with repair of tracheoesophageal fistula Esophagoplasty (plastic repair or reconstruction), thoracic approach; without repair of tracheoesophageal fistula Esophagoplasty (plastic repair or reconstruction), thoracic approach; with repair of tracheoesophageal fistula Esophagoplasty for congenital defect (plastic repair or reconstruction), thoracic approach; without repair of congenital tracheoesophageal fistula Esophagoplasty for congenital defect (plastic repair or reconstruction), thoracic approach; with repair of congenital tracheoesophageal fistula Esophagogastrostomy (cardioplasty), with or without vagotomy and pyloroplasty, transabdominal or transthoracic approach Esophagogastric fundoplasty (eg, Nissen, Belsey IV, Hill procedures) Esophagogastric fundoplasty; with fundic patch (Thal-Nissen procedure) Esophagogastric fundoplasty; with gastroplasty (eg, Collis) Esophagomyotomy (Heller type); abdominal approach Esophagomyotomy (Heller type); thoracic approach Esophagojejunostomy (without total gastrectomy); abdominal approach Esophagojejunostomy (without total gastrectomy); thoracic approach Esophagostomy, fistulization of esophagus, external; abdominal approach Esophagostomy, fistulization of esophagus, external; thoracic approach Esophagostomy, fistulization of esophagus, external; cervical approach Gastrointestinal reconstruction for previous esophagectomy, for obstructing esophageal lesion or fistula, or for previous esophageal exclusion; with stomach, with or without pyloroplasty Gastrointestinal reconstruction for previous esophagectomy, for obstructing esophageal lesion or fistula, or for previous esophageal exclusion; with colon interposition or small intestine reconstruction, including intestine mobilization, preparation, and anastomosis(es) Ligation, direct, esophageal varices Transection of esophagus with repair, for esophageal varices Ligation or stapling at gastroesophageal junction for pre-existing esophageal perforation Suture of esophageal wound or injury; cervical approach ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Suture of esophageal wound or injury; transthoracic or transabdominal approach Closure of esophagostomy or fistula; cervical approach Closure of esophagostomy or fistula; transthoracic or transabdominal approach Dilation of esophagus, by unguided sound or bougie, single or multiple passes Dilation of esophagus, over guide wire Dilation of esophagus, by balloon or dilator, retrograde Dilation of esophagus with balloon (30 mm diameter or larger) for achalasia Esophagogastric tamponade, w i t h b alloon (Sengstaaken type) I.C. Free jejunum transfer with microvascular anastomosis I.C. Unlisted procedure, esophagus Gastrotomy; with exploration or foreign body removal Gastrotomy; with suture repair of bleeding ulcer Gastrotomy; with suture repair of pre-existing esophagogastric laceration (eg, Mallory-Weiss) Gastrotomy; with esophageal dilation and insertion of permanent intraluminal tube (eg, Celestin or Mousseaux-Barbin) Pyloromyotomy, cutting of pyloric muscle (Fredet-Ramstedt type operation) Biopsy of stomach; by capsule, tube, peroral (one or more specimens) Biopsy of stomach; by laparotomy Excision, local; ulcer or benign tumor of stomach Excision, local; malignant tumor of stomach Gastrectomy, total; with esophagoenterostomy Gastrectomy, total; with Roux-en-Y reconstruction Gastrectomy, total; with formation of intestinal pouch, any type Gastrectomy, partial, distal; with gastroduodenostomy Gastrectomy, partial, distal; with gastrojejunostomy Gastrectomy, partial, distal; with Roux-en-Y reconstruction Gastrectomy, partial, distal; with formation of intestinal pouch Vagotomy when performed with partial distal gastrectomy (List separately in addition to code(s) for primary procedure) Vagotomy including pyloroplasty, with or without gastrostomy; truncal or selective Vagotomy including pyloroplasty, with or without gastrostomy; parietal cell (highly selective) Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less) Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and small intestine reconstruction to limit absorption I.C. Laparoscopy, surgical; implantation or replacement of gastric neurostimulator electrodes, antrum ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee I.C. Laparoscopy, surgical; revision or removal of gastric neurostimulator electrodes, antrum Laparoscopy, surgical; transection of vagus nerves, truncal Laparoscopy, surgical; transection of vagus nerves, selective or highly selective Laparoscopy, surgical; gastrostomy, without construction of gastric tube (eg, Stamm procedure) (separate procedure) I.C. Unlisted laparoscopy procedure, stomach Naso- or oro-gastric tube placement, requiring physician's skill and fluoroscopic guidance (includes fluoroscopy, image documentation and report) Change of gastrostomy tube, percutaneous, without imaging or endoscopic guidance Repositioning of the gastric feeding tube, through the duodenum for enteric nutrition Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (eg, gastric band and subcutaneous port components) Laparoscopy, surgical, gastric restrictive procedure; revision of adjustable gastric restrictive device component only Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device component only Laparoscopy, surgical, gastric restrictive procedure; removal and replacement of adjustable gastric restrictive device component only Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device and subcutaneous port components Pyloroplasty Gastroduodenostomy Gastrojejunostomy; without vagotomy Gastrojejunostomy; with vagotomy, any type Gastrostomy, open; without construction of gastric tube (eg, Stamm procedure) (separate procedure) Gastrostomy, open; neonatal, for feeding Gastrostomy, open; with construction of gastric tube (eg, Janeway procedure) Gastrorrhaphy, suture of perforated duodenal or gastric ulcer, wound, or injury Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical-banded gastroplasty Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than vertical-banded gastroplasty Gastric restrictive procedure with partial gastrectomy, pylorus-preserving duodenoileostomy and ileoileostomy (50 to 100 cm common channel) to limit absorption (biliopancreatic diversion with duodenal switch) ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less) Roux-en-Y gastroenterostomy Gastric restrictive procedure, with gastric bypass for morbid obesity; with small intestine reconstruction to limit absorption Revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric restrictive device (separate procedure) Re vis ion of g a str od uo den al ana sto mos is (gastroduodenostomy) with reconstruction; without vagotomy Re vis ion of g a str od uo de na l anas to mosis (gastroduodenostomy) with reconstruction; with vagotomy R e v i s i o n o f g a s t r o j e j u n a l a n a s t o m o s i s (gastrojejunostomy) with reconstruction, with or without partial gastrectomy or intestine resection; without vagotomy R e v i s i o n o f g a s t r o j e j u n a l a n a s t o m o s i s (gastrojejunostomy) with reconstruction, with or without partial gastrectomy or intestine resection; with vagotomy Closure of gastrostomy, surgical Closure of gastrocolic fistula I.C. I m p l a n t a t i o n o r r e p l a c e m e n t o f g a s t r i c neurostimulator electrodes, antrum, open I.C. Revision or removal of gastric neurostimulator electrodes, antrum, open Gastric restrictive procedure, open; revision of subcutaneous port component only Gastric restrictive procedure, open; removal of subcutaneous port component only Gastric restrictive procedure, open; removal and replacement of subcutaneous port component only I.C. Unlisted procedure, stomach Enterolysis (freeing of intestinal adhesion) (separate procedure) Duodenotomy, for exploration, biopsy(s), or foreign body removal Tube or needle catheter jejunostomy for enteral alimentation, intraoperative, any method (List separately in addition to primary procedure) Enterotomy, small intestine, other than duodenum; for exploration, biopsy(s), or foreign body removal Enterotomy, small intestine, other than duodenum; for decompression (eg, Baker tube) Colotomy, for exploration, biopsy(s), or foreign body removal Reduction of volvulus, intussusception, internal hernia, by laparotomy Correction of malrotation by lysis of duodenal bands and/or reduction of midgut volvulus (eg, Ladd procedure) ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Biopsy of intestine by capsule, tube, peroral (one or more specimens) Excision of one or more lesions of small or large intestine not requiring anastomosis, exteriorization, or fistulization; single enterotomy Excision of one or more lesions of small or large intestine not requiring anastomosis, exteriorization, or fistulization; multiple enterotomies Enterectomy, resection of small intestine; single resection and anastomosis Enterectomy, resection of small intestine; each additional resection and anastomosis (List separately in addition to code for primary procedure) Enterectomy, resection of small intestine; with enterostomy Enterectomy, resection of small intestine for congenital atresia, single resection and anastomosis of proximal segment of intestine; without tapering Enterectomy, resection of small intestine for congenital atresia, single resection and anastomosis of proximal segment of intestine; with tapering Enterectomy, resection of small intestine for congenital atresia, single resection and anastomosis of proximal segment of intestine; each additional resection and anastomosis (List separately in addition to code for primary procedure) Enteroenterostomy, anastomosis of intestine, with or without cutaneous enterostomy (separate procedure) I.C. Donor enterectomy (including cold preservation), open; from cadaver donor I.C. Donor enterectomy (including cold preservation), open; partial, from living donor I.C. Intestinal allotransplantation; from cadaver donor I.C. Intestinal allotransplantation; from living donor I.C. Removal of transplanted intestinal allograft, complete Mobilization (take-down) of splenic flexure performed in conjunction with partial colectomy (List separately in addition to primary procedure) Colectomy, partial; with anastomosis Colectomy, partial; with skin level cecostomy or colostomy Colectomy, partial; with end colostomy and closure of distal segment (Hartmann type procedure) Colectomy, partial; with resection, with colostomy or ileostomy and creation of mucofistula Colectomy, partial; with coloproctostomy (low pelvic anastomosis) Colectomy, partial; with coloproctostomy (low pelvic anastomosis), with colostomy Colectomy, partial; abdominal and transanal approach Colectomy, total, abdominal, without proctectomy; with ileostomy or ileoproctostomy Colectomy, total, abdominal, without proctectomy; with continent ileostomy ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Colectomy, total, abdominal, with proctectomy; with ileostomy Colectomy, total, abdominal, with proctectomy; with continent ileostomy Colectomy, total, abdominal, with proctectomy; with ileoanal anastomosis, includes loop ileostomy, and rectal mucosectomy, when performed Colectomy, total, abdominal, with proctectomy; with ileoanal anastomosis, creation of ileal reservoir (S or J), includes loop ileostomy, and rectal mucosectomy, when performed Colectomy, partial, with removal of terminal ileum with ileocolostomy Laparoscopy, surgical, enterolysis (freeing of intestinal adhesion) (separate procedure) Laparoscopy, surgical; jejunostomy (eg, for decompression or feeding) Laparoscopy, surgical; ileostomy or jejunostomy, non-tube Laparoscopy, surgical, colostomy or skin level cecostomy Laparoscopy, surgical; enterectomy, resection of small intestine, single resection and anastomosis Laparoscopy, surgical; each additional small intestine resection and anastomosis (List separately in addition to code for primary procedure) Laparoscopy, surgical; colectomy, partial, with anastomosis Laparoscopy, surgical; colectomy, partial, with removal of terminal ileum with ileocolostomy Laparoscopy, surgical; colectomy, partial, with end colostomy and closure of distal segment (Hartmann type procedure) Laparoscopy, surgical; colectomy, partial, with anastomosis, with coloproctostomy (low pelvic anastomosis) Laparoscopy, surgical; colectomy, partial, with anastomosis, with coloproctostomy (low pelvic anastomosis) with colostomy Laparoscopy, surgical; colectomy, total, abdominal, without proctectomy, with ileostomy or ileoproctostomy Laparoscopy, surgical; colectomy, total, abdominal, with proctectomy, with ileoanal anastomosis, creation of ileal reservoir (S or J), with loop ileostomy, includes rectal mucosectomy, when performed Laparoscopy, surgical; colectomy, total, abdominal, with proctectomy, with ileostomy Laparoscopy, surgical, mobilization (take-down) of splenic flexure performed in conjunction with partial colectomy (List separately in addition to primary procedure) Laparoscopy, surgical, closure of enterostomy, large or small intestine, with resection and anastomosis 40.06: continued ASC Incl Rate I.C. PC Fee TC Fee 40.06(8) - Surgical Services Description (con’t) Unlisted laparoscopy procedure, intestine (except rectum) Placement, enterostomy or cecostomy, tube open (eg, for feeding or decompression) (separate procedure) Ileostomy or jejunostomy, non-tube Revision of ileostomy; simple (release of superficial scar) (separate procedure) Revision of ileostomy; complicated (reconstruction in-depth) (separate procedure) Continent ileostomy (Kock procedure) (separate procedure) Colostomy or skin level cecostomy; Colostomy or skin level cecostomy; with multiple biopsies (eg, for congenital megacolon) (separate procedure) Revision of colostomy; simple (release of superficial scar) (separate procedure) Revision of colostomy; complicated (reconstruction in-depth) (separate procedure) Revision of colostomy; with repair of paracolostomy hernia (separate procedure) Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with biopsy, single or multiple Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with removal of foreign body Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator) Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with transendoscopic stent placement (includes predilation) 40.06: continued ASC Incl Rate PC Fee TC Fee 40.06(8) - Surgical Services Description (con’t) Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with placement of percutaneous jejunostomy tube Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with conversion of percutaneous gastrostomy tube to percutaneous jejunostomy tube Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; with biopsy, single or multiple Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator) Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; with transendoscopic stent placement (includes predilation) Ileoscopy, through stoma; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) Ileoscopy, through stoma; with biopsy, single or multiple Ileoscopy, through stoma; with transendoscopic stent placement (includes predilation) Endoscopic evaluation of small intestinal (abdominal or pelvic) pouch; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) Endoscopic evaluation of small intestinal (abdominal or pelvic) pouch; with biopsy, single or multiple Colonoscopy through stoma; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) Colonoscopy through stoma; with biopsy, single or multiple Colonoscopy through stoma; with removal of foreign body Colonoscopy through stoma; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator) Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery Colonoscopy through stoma; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Colonoscopy through stoma; with transendoscopic stent placement (includes predilation) Introduction of long gastrointestinal tube (eg, Miller-Abbott) (separate procedure) Suture of small intestine (enterorrhaphy) for perforated ulcer, diverticulum, wound, injury or rupture; single perforation Suture of small intestine (enterorrhaphy) for perforated ulcer, diverticulum, wound, injury or rupture; multiple perforations Suture of large intestine (colorrhaphy) for perforated ulcer, diverticulum, wound, injury or rupture (single or multiple perforations); without colostomy Suture of large intestine (colorrhaphy) for perforated ulcer, diverticulum, wound, injury or rupture (single or multiple perforations); with colostomy Intest i n al stricturoplasty (enterotomy and enterorrhaphy) with or without dilation, for intestinal obstruction Closure of enterostomy, large or small intestine; Closure of enterostomy, large or small intestine; with resection and anastomosis other than colorectal Closure of enterostomy, large or small intestine; with resection and colorectal anastomosis (eg, closure of Hartmann type procedure) Closure of intestinal cutaneous fistula Closure of enteroenteric or enterocolic fistula Closure of enterovesical fistula; without intestinal or bladder resection Closure of enterovesical fistula; with intestine and/or bladder resection Intestinal plication (separate procedure) Exclusion of small intestine from pelvis by mesh or other prosthesis, or native tissue (eg, bladder or omentum) Intraoperative colonic lavage (List separately in addition to code for primary procedure) I.C. Backbench standard preparation of cadaver or living donor intestine allograft prior to transplantation, including mobilization and fashioning of the superior mesenteric artery and vein Backbench reconstruction of cadaver or living donor intestine allograft prior to transplantation; venous anastomosis, each Backbench reconstruction of cadaver or living donor intestine allograft prior to transplantation; arterial anastomosis, each I.C. Unlisted procedure, intestine Excision of Meckel's diverticulum (diverticulectomy) or omphalomesenteric duct Excision of lesion of mesentery (separate procedure) Suture of mesentery (separate procedure) I.C. Unlisted procedure, Meckel's diverticulum and the mesentery Incision and drainage of appendiceal abscess; open ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Incision and drainage of appendiceal abscess; percutaneous Appendectomy; Appendectomy; when done for indicated purpose at time of other major procedure (not as separate procedure) (List separately in addition to code for primary procedure) Appendectomy; for ruptured appendix with abscess or generalized peritonitis Laparoscopy, surgical, appendectomy I.C. Unlisted laparoscopy procedure, appendix Transrectal drainage of pelvic abscess Incision and drainage of submucosal abscess, rectum Incision and drainage of deep supralevator, pelvirectal, or retrorectal abscess Biopsy of anorectal wall, anal approach (eg, congenital megacolon) Anorectal myomectomy Proctectomy; complete, combined abdominoperineal, with colostomy Proctectomy; partial resection of rectum, transabdominal approach Proctectomy, combined abdominoperineal, pull-through procedure (eg, colo-anal anastomosis) Proctectomy, partial, with rectal mucosectomy, ileoanal anastomosis, creation of ileal reservoir (S or J), with or without loop ileostomy Proctectomy, partial, with anastomosis; abdominal and transsacral approach Proctectomy, partial, with anastomosis; transsacral approach only (Kraske type) Proctectomy, combined abdominoperineal pull-through procedure (eg, colo-anal anastomosis), with creation of colonic reservoir (eg, J-pouch), with diverting enterostomy when performed Proctectomy, complete (for congenital megacolon), abdominal and perineal approach; with pull-through procedure and anastomosis (eg, Swenson, Duhamel, or Soave type operation) Proctectomy, complete (for congenital megacolon), abdominal and perineal approach; with subtotal or total colectomy, with multiple biopsies Proctectomy, partial, without anastomosis, perineal approach Pelvic exenteration for colorectal malignancy, with proctectomy (with or without colostomy), with removal of bladder and ureteral transplantations, and/or hysterectomy, or cervicectomy, with or without removal of tube(s), with or without removal of ovary(s), or any combination thereof Excision of rectal procidentia, with anastomosis; perineal approach Excision of rectal procidentia, with anastomosis; abdominal and perineal approach Excision of ileoanal reservoir with ileostomy ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Division of stricture of rectum Excision of rectal tumor by proctotomy, transsacral or transcoccygeal approach Excision of rectal tumor, transanal approach Destruction of rectal tumor (eg, electrodesiccation, electrosurgery, laser ablation, laser resection, cryosurgery) transanal approach Proctosigmoidoscopy, rigid; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) Proctosigmoidoscopy, rigid; with dilation (eg, balloon, guide wire, bougie) Proctosigmoidoscopy, rigid; with biopsy, single or multiple Proctosigmoidoscopy, rigid; with removal of foreign body Proctosigmoidoscopy, rigid; with removal of single tumor, polyp, or other lesion by hot biopsy forceps or bipolar cautery Proctosigmoidoscopy, rigid; with removal of single tumor, polyp, or other lesion by snare technique Proctosigmoidoscopy, rigid; with removal of multiple tumors, polyps, or other lesions by hot biopsy forceps, bipolar cautery or snare technique Proctosigmoidoscopy, rigid; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator) Proctosigmoidoscopy, rigid; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique (eg, laser) Proctosigmoidoscopy, rigid; with decompression of volvulus Proctosigmoidoscopy, rigid; with transendoscopic stent placement (includes predilation) Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) Sigmoidoscopy, flexible; with biopsy, single or multiple Sigmoidoscopy, flexible; with removal of foreign body Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery Sigmoidoscopy, flexible; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator) Sigmoidoscopy, flexible; with directed submucosal injection(s), any substance Sigmoidoscopy, flexible; with decompression of volvulus, any method Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Sigmoidoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique Sigmoidoscopy, flexible; with dilation by balloon, one or more strictures Sigmoidoscopy, flexible; with endoscopic ultrasound examination Sigmoidoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s) Sigmoidoscopy, flexible; with transendoscopic stent placement (includes predilation) Colonoscopy, rigid or flexible, transabdominal via colotomy, single or multiple Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression (separate procedure) Colonoscopy, flexible, proximal to splenic flexure; with removal of foreign body Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple Colonoscopy, flexible, proximal to splenic flexure; with directed submucosal injection(s), any substance Colonoscopy, flexible, proximal to splenic flexure; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator) Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique Colonoscopy, flexible, proximal to splenic flexure; with dilation by balloon, one or more strictures Colonoscopy, flexible, proximal to splenic flexure; with transendoscopic stent placement (includes predilation) Colonoscopy, flexible, proximal to splenic flexure; with endoscopic ultrasound examination Colonoscopy, flexible, proximal to splenic flexure; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s) Laparoscopy, surgical; proctectomy, complete, combined abdominoperineal, with colostomy ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Laparoscopy, surgical; proctectomy, combined abdominoperineal pull-through procedure (eg, colo-anal anastomosis), with creation of colonic reservoir (eg, J-pouch), with diverting enterostomy, when performed Laparoscopy, surgical; proctopexy (for prolapse) Laparoscopy, surgical; proctopexy (for prolapse), with sigmoid resection I.C. Unlisted laparoscopy procedure, rectum Proctoplasty; for stenosis Proctoplasty; for prolapse of mucous membrane Perirectal injection of sclerosing solution for prolapse Proctopexy (eg, for prolapse); abdominal approach Proctopexy (eg, for prolapse); perineal approach Proctopexy (eg, for prolapse); with sigmoid resection, abdominal approach Repair of rectocele (separate procedure) Exploration, repair, and presacral drainage for rectal injury; Exploration, repair, and presacral drainage for rectal injury; with colostomy Closure of rectovesical fistula; Closure of rectovesical fistula; with colostomy Closure of rectourethral fistula; Closure of rectourethral fistula; with colostomy Reduction of procidentia (separate procedure) under anesthesia Dilation of anal sphincter (separate procedure) under anesthesia other than local Dilation of rectal stricture (separate procedure) under anesthesia other than local Removal of fecal impaction or foreign body (separate procedure) under anesthesia Anorectal exam, surgical, requiring anesthesia (general, spinal, or epidural), diagnostic I.C. Unlisted procedure, rectum Placement of seton Removal of anal seton, other marker Incision and drainage of ischiorectal and/or perirectal abscess (separate procedure) Incision and drainage of intramural, intramuscular, or submucosal abscess, transanal, under anesthesia Incision and drainage, perianal abscess, superficial Incision and drainage of ischiorectal or intramural abscess, with fistulectomy or fistulotomy, submuscular, with or without placement of seton Incision, anal septum (infant) Sphincterotomy, anal, division of sphincter (separate procedure) Incision of thrombosed hemorrhoid, external Fissurectomy, with or without sphincterotomy Cryptectomy; single Cryptectomy; multiple (separate procedure) Papillectomy or excision of single tag, anus (separate procedure) ASC Rate Incl 40.06(8) - Surgical Services Description (con’t) Hemorrhoidectomy, by simple ligature (eg, rubber band) Excision of external hemorrhoid tags and/or multiple papillae Hemorrhoidectomy, external, complete Hemorrhoidectomy, internal and external, simple; Hemorrhoidectomy, internal and external, simple; with fissurectomy Hemorrhoidectomy, internal and external, simple; with fistulectomy, with or without fissurectomy Hemorrhoidectomy, internal and external, complex or extensive; Hemorrhoidectomy, internal and external, complex or extensive; with fissurectomy Hemorrhoidectomy, internal and external, complex or extensive; with fistulectomy, with or without fissurectomy S u r g i c a l t r e a t m e n t o f a n a l f i s t u l a (fistulectomy/fistulotomy); subcutaneous S u r g i c a l t r e a t m e n t o f a n a l f i s t u l a (fistulectomy/fistulotomy); submuscular S u r g i c a l t r e a t m e n t o f a n a l f i s t u l a (fistulectomy/fistulotomy); complex or multiple, with or without placement of seton S u r g i c a l t r e a t m e n t o f a n a l f i s t u l a (fistulectomy/fistulotomy); second stage Closure of anal fistula with rectal advancement flap Enucleation or excision of external thrombotic hemorrhoid Injection of sclerosing solution, hemorrhoids Chemodenervation of internal anal sphincter Anoscopy; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) Anoscopy; with dilation (eg, balloon, guide wire, bougie) Anoscopy; with biopsy, single or multiple Anoscopy; with removal of foreign body Anoscopy; with removal of single tumor, polyp, or other lesion by hot biopsy forceps or bipolar cautery Anoscopy; with removal of single tumor, polyp, or other lesion by snare technique Anoscopy; with removal of multiple tumors, polyps, or other lesions by hot biopsy forceps, bipolar cautery or snare technique Anoscopy; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator) Anoscopy; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique Anoplasty, plastic operation for stricture; adult Anoplasty, plastic operation for stricture; infant Repair of anal fistula with fibrin glue PC TC Fee Fee 40.06: continued ASC Incl Rate PC Fee TC Fee 40.06(8) - Surgical Services Description (con’t) Repair of ileoanal pouch fistula/sinus (eg, perineal or vaginal), pouch advancement; transperineal approach Repair of ileoanal pouch fistula/sinus (eg, perineal or vaginal), pouch advancement; combined transperineal and transabdominal approach Repair of low imperforate anus; with anoperineal fistula (cut-back procedure) Repair of low imperforate anus; with transposition of anoperineal or anovestibular fistula Repair of high imperforate anus without fistula; perineal or sacroperineal approach Repair of high imperforate anus without fistula; combined transabdominal and sacroperineal approaches Repair of high imperforate anus with rectourethral or rectovaginal fistula; perineal or sacroperineal approach Repair of high imperforate anus with rectourethral or rectovaginal fistula; combined transabdominal and sacroperineal approaches Repair of cloacal anomaly by anorectovaginoplasty and urethroplasty, sacroperineal approach Repair of cloacal anomaly by anorectovaginoplasty and urethroplasty, combined abdominal and sacroperineal approach; Repair of cloacal anomaly by anorectovaginoplasty and urethroplasty, combined abdominal and sacroperineal approach; with vaginal lengthening by intestinal graft or pedicle flaps Sphincteroplasty, anal, for incontinence or prolapse; adult Sphincteroplasty, anal, for incontinence or prolapse; child Graft (Thiersch operation) for rectal incontinence and/or prolapse Removal of Thiersch wire or suture, anal canal Sphincteroplasty, anal, for incontinence, adult; muscle transplant Sphincteroplasty, anal, for incontinence, adult; levator muscle imbrication (Park posterior anal repair) Sphincteroplasty, anal, for incontinence, adult; implantation artificial sphincter Destruction of lesion(s), anus (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; chemical Destruction of lesion(s), anus (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; electrodesiccation Destruction of lesion(s), anus (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; cryosurgery Destruction of lesion(s), anus (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; laser surgery ASC Rate Incl PC Fee TC Fee I.C. I.C. 40.06(8) - Surgical Services Description (con’t) Destruction of lesion(s), anus (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; surgical excision Destruction of lesion(s), anus (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), extensive (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery) Destruction of hemorrhoids, any method; internal Destruction of hemorrhoids, any method; external Destruction of hemorrhoids, any method; internal and external Cryosurgery of rectal tumor; benign Cryosurgery of rectal tumor; malignant Curettage or cautery of anal fissure, including dilation of anal sphincter (separate procedure); initial Curettage or cautery of anal fissure, including dilation of anal sphincter (separate procedure); subsequent Ligation of internal hemorrhoids; single procedure Ligation of internal hemorrhoids; multiple procedures Hemorrhoidopexy (eg, for prolapsing internal hemorrhoids) by stapling Unlisted procedure, anus Biopsy of liver, needle; percutaneous Biopsy of liver, needle; when done for indicated purpose at time of other major procedure (List separately in addition to code for primary procedure) Hepatotomy; for open drainage of abscess or cyst, one or two stages Hepatotomy; for percutaneous drainage of abscess or cyst, one or two stages Laparotomy, with aspiration and/or injection of hepatic parasitic (eg, amoebic or echinococcal) cyst(s) or abscess(es) Biopsy of liver, wedge Hepatectomy, resection of liver; partial lobectomy Hepatectomy, resection of liver; trisegmentectomy Hepatectomy, resection of liver; total left lobectomy Hepatectomy, resection of liver; total right lobectomy Donor hepatectomy (including cold preservation), from cadaver donor Liver allotransplantation; orthotopic, partial or whole, from cadaver or living donor, any age Liver allotransplantation; heterotopic, partial or whole, from cadaver or living donor, any age Donor hepatectomy (including cold preservation), from living donor; left lateral segment only (segments II and III) Donor hepatectomy (including cold preservation), from living donor; total left lobectomy (segments II, III and IV) Donor hepatectomy (including cold preservation), from living donor; total right lobectomy (segments V, VI, VII and VIII) Code ASC Incl PC TC Rate Fee Fee I.C. I.C. I.C. I.C. I.C. 40.06(8) - Surgical Services Description (con’t) Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation, including cholecystectomy, if necessary, and dissection and removal of surrounding soft tissues to prepare the vena cava, portal vein, hepatic artery, and common bile duct for implantation; without trisegment or lobe split Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation, including cholecystectomy, if necessary, and dissection and removal of surrounding soft tissues to prepare the vena cava, portal vein, hepatic artery, and common bile duct for implantation; with trisegment split of whole liver graft into two partial liver grafts (ie, left lateral segment (segments II and III) and right trisegment (segments I and IV through VIII)) Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation, including cholecystectomy, if necessary, and dissection and removal of surrounding soft tissues to prepare the vena cava, portal vein, hepatic artery, and common bile duct for implantation; with lobe split of whole liver graft into two partial liver grafts (ie, left lobe (segments II, III, and IV) and right lobe (segments I and V through VIII)) Backbench reconstruction of cadaver or living donor liver graft prior to allotransplantation; venous anastomosis, each Backbench reconstruction of cadaver or living donor liver graft prior to allotransplantation; arterial anastomosis, each Marsupialization of cyst or abscess of liver Management of liver hemorrhage; simple suture of liver wound or injury Management of liver hemorrhage; complex suture of liver wound or injury, with or without hepatic artery ligation Management of liver hemorrhage; exploration of hepatic wound, extensive debridement, coagulation and/or suture, with or without packing of liver Management of liver hemorrhage; re-exploration of hepatic wound for removal of packing Laparoscopy, surgical, ablation of one or more liver tumor(s); radiofrequency Laparoscopy, surgical, ablation of one or more liver tumor(s); cryosurgical Unlisted laparoscopic procedure, liver Ablation, open, of one or more liver tumor(s); radiofrequency Ablation, open, of one or more liver tumor(s); cryosurgical Ablation, one or more liver tumor(s), percutaneous, radiofrequency Unlisted procedure, liver ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Hepaticotomy or hepaticostomy with exploration, drainage, or removal of calculus Choledochotomy or choledochostomy with exploration, drainage, or removal of calculus, with or without cholecystotomy; without transduodenal sphincterotomy or sphincteroplasty Choledochotomy or choledochostomy with exploration, drainage, or removal of calculus, with or without cholecystotomy; with transduodenal sphincterotomy or sphincteroplasty Transduodenal sphincterotomy or sphincteroplasty, with or without transduodenal extraction of calculus (separate procedure) Cholecystotomy or cholecystostomy with exploration, drainage, or removal of calculus (separate procedure) Percutaneous cholecystostomy Injection procedure for percutaneous transhepatic cholangiography Injection procedure for cholangiography through an existing catheter (eg, percutaneous transhepatic or T-tube) Introduction of percutaneous transhepatic catheter for biliary drainage Introduction of percutaneous transhepatic stent for internal and external biliary drainage Change of percutaneous biliary drainage catheter Revision and/or reinsertion of transhepatic tube Biliary endoscopy, intraoperative (choledochoscopy) (List separately in addition to code for primary procedure) Biliary endoscopy, percutaneous via T-tube or other tract; diagnostic, with or without collection of specimen(s) by brushing and/or washing (separate procedure) Biliary endoscopy, percutaneous via T-tube or other tract; with biopsy, single or multiple Biliary endoscopy, percutaneous via T-tube or other tract; with removal of calculus/calculi Biliary endoscopy, percutaneous via T-tube or other tract; with dilation of biliary duct stricture(s) without stent Biliary endoscopy, percutaneous via T-tube or other tract; with dilation of biliary duct stricture(s) with stent Laparoscopy, surgical; with guided transhepatic cholangiography, without biopsy Laparoscopy, surgical; with guided transhepatic cholangiography with biopsy Laparoscopy, surgical; cholecystectomy Laparoscopy, surgical; cholecystectomy with cholangiography Laparoscopy, surgical; cholecystectomy with exploration of common duct Laparoscopy, surgical; cholecystoenterostomy I.C. Unlisted laparoscopy procedure, biliary tract ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Cholecystectomy; Cholecystectomy; with cholangiography Cholecystectomy with exploration of common duct; Cholecystectomy with exploration of common duct; with choledochoenterostomy Cholecystectomy with exploration of common duct; with transduodenal sphincterotomy or sphincteroplasty, with or without cholangiography Biliary duct stone extraction, percutaneous via T-tube tract, basket, or snare (eg, Burhenne technique) Exploration for congenital atresia of bile ducts, without repair, with or without liver biopsy, with or without cholangiography Portoenterostomy (eg, Kasai procedure) Excision of bile duct tumor, with or without primary repair of bile duct; extrahepatic Excision of bile duct tumor, with or without primary repair of bile duct; intrahepatic Excision of choledochal cyst Cholecystoenterostomy; direct Cholecystoenterostomy; with gastroenterostomy Cholecystoenterostomy; Roux-en-Y Chol ecys t o en t ero sto my; Rou x-e n-Y wi th gastroenterostomy Anastomosis, of extrahepatic biliary ducts and gastrointestinal tract Anastom osis, of intr a h e p atic ducts a nd gastrointestinal tract Anastomosis, Roux-en-Y, of extrahepatic biliary ducts and gastrointestinal tract Anastomosis, Roux-en-Y, of intrahepatic biliary ducts and gastrointestinal tract Reconstruction, plastic, of extrahepatic biliary ducts with end-to-end anastomosis Placement of choledochal stent U-tube hepaticoenterostomy Suture of extrahepatic biliary duct for pre-existing injury (separate procedure) I.C. Unlisted procedure, biliary tract Placement of drains, peripancreatic, for acute pancreatitis; Placement of drains, peripancreatic, for acute pancreatitis; with cholecystostomy, gastrostomy, and jejunostomy Removal of pancreatic calculus Biopsy of pancreas, open (eg, fine needle aspiration, needle core biopsy, wedge biopsy) Biopsy of pancreas, percutaneous needle Resection or debridement of pancreas and peripancreatic tissue for acute necrotizing pancreatitis Excision of lesion of pancreas (eg, cyst, adenoma) Pancreatectomy, distal subtotal, with or without splenectomy; without pancreaticojejunostomy Pancreatectomy, distal subtotal, with or without splenectomy; with pancreaticojejunostomy ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Pancreatectomy, distal, near-total with preservation of duodenum (Child-type procedure) Excision of ampulla of Vater Pancreatectomy, proximal subtotal with total d u o d e n e c t o m y , p a r t i a l g a s t r e c t o m y, choledochoenterostomy and gastrojejunostomy (Whipple-type procedure); with pancreatojejunostomy Pancreatectomy, proximal subtotal with total d u o d e n e c t o m y, p a r t i a l g a s t r e c t o m y, choledochoenterostomy and gastrojejunostomy ( W h i p p l e - t y p e p r o c e d u r e ) ; w i t h o u t pancreatojejunostomy Pancreatectomy, proximal subtotal with near-total duodenectomy, choledochoenterostomy and duodenojejunostomy (pylorus-sparing, Whipple-type procedure); with pancreatojejunostomy Pancreatectomy, proximal subtotal with near-total duodenectomy, choledochoenterostomy and duodenojejunostomy (pylorus-sparing, Whipple-type procedure); without pancreatojejunostomy Pancreatectomy, total I.C. Pancreatectomy, total or subtotal, with autologous transplantation of pancreas or pancreatic islet cells Injection procedure for intraoperative pancreatography (List separately in addition to code for primary procedure) Marsupialization of pancreatic cyst External drainage, pseudocyst of pancreas; open External drainage, pseudocyst of pancreas; percutaneous Internal anastomosis of pancreatic cyst to gastrointestinal tract; direct Internal anastomosis of pancreatic cyst to gastrointestinal tract; Roux-en-Y Pancreatorrhaphy for injury Duodenal exclusion with gastrojejunostomy for pancreatic injury Pancreaticojejunostomy, side-to-side anastomosis (Puestow-type operation) I.C. Donor pancreatectomy (including cold preservation), with or without duodenal segment for transplantation I.C. Backbench standard preparation of cadaver donor pancreas allograft prior to transplantation, including dissection of allograft from surrounding soft tissues, splenectomy, duodenotomy, ligation of bile duct, ligation of mesenteric vessels, and Y-graft arterial anastomoses from iliac artery to superior mesenteric artery and to splenic artery Backbench reconstruction of cadaver donor pancreas allograft prior to transplantation, venous anastomosis, each Transplantation of pancreatic allograft Removal of transplanted pancreatic allograft I.C. Unlisted procedure, pancreas Exploratory laparotomy, exploratory celiotomy with or without biopsy(s) (separate procedure) ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Reopening of recent laparotomy Exploration, retroperitoneal area with or without biopsy(s) (separate procedure) Drainage of peritoneal abscess or localized peritonitis, exclusive of appendiceal abscess; open Drainage of peritoneal abscess or localized peritonitis, exclusive of appendiceal abscess; percutaneous Drainage of subdiaphragmatic or subphrenic abscess; open Drainage of subdiaphragmatic or subphrenic abscess; percutaneous Drainage of retroperitoneal abscess; open Drainage of retroperitoneal abscess; percutaneous Drainage of extraperitoneal lymphocele to peritoneal cavity, open Peritoneocentesis, abdominal paracentesis, or peritoneal lavage (diagnostic or therapeutic); initial Peritoneocentesis, abdominal paracentesis, or peritoneal lavage (diagnostic or therapeutic); subsequent Biopsy, abdominal or retroperitoneal mass, percutaneous needle Excision or destruction, open, intra-abdominal tumors, cysts or endometriomas, one or more peritoneal, mesenteric, or retroperitoneal primary or secondary tumors; largest tumor five cm diameter or less Excision or destruction, open, intra-abdominal tumors, cysts or endometriomas, one or more peritoneal, mesenteric, or retroperitoneal primary or secondary tumors; largest tumor 5.1-10.0 cm diameter Excision or destruction, open, intra-abdominal tumors, cysts or endometriomas, one or more peritoneal, mesenteric, or retroperitoneal primary or secondary tumors; largest tumor greater than 10.0 cm diameter Excision of presacral or sacrococcygeal tumor Staging laparotomy for Hodgkins disease or lymphoma (includes splenectomy, needle or open biopsies of both liver lobes, possibly also removal of abdominal nodes, abdominal node and/or bone marrow biopsies, ovarian repositioning) Umbilectomy, omphalectomy, excision of umbilicus (separate procedure) Omentectomy, epiploectomy, resection of omentum (separate procedure) Laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) Laparoscopy, surgical; with biopsy (single or multiple) Laparoscopy, surgical; with aspiration of cavity or cyst (eg, ovarian cyst) (single or multiple) Laparoscopy, surgical; with drainage of lymphocele to peritoneal cavity Lapar o s co py, surg ical; with insertion of intraperitoneal cannula or catheter, permanent 40.06: continued ASC Incl Rate PC Fee TC Fee I.C. 40.06(8) - Surgical Services Description (con’t) Laparoscopy, surgical; with revision of previously placed intraperitoneal cannula or catheter, with removal of intraluminal obstructive material if performed Laparoscopy, surgical; with omentopexy (omental tacking procedure) (List separately in addition to code for primary procedure) Unlisted laparoscopy procedure, abdomen, peritoneum and omentum Injection of air or contrast into peritoneal cavity (separate procedure) Removal of peritoneal foreign body from peritoneal cavity Insertion of intraperitoneal cannula or catheter, with subcutaneous reservoir, permanent (ie, totally implantable) Insertion of intraperitoneal cannula or catheter for drainage or dialysis; temporary Insertion of intraperitoneal cannula or catheter for drainage or dialysis; permanent Removal of permanent intraperitoneal cannula or catheter Exchange of previously placed abscess or cyst drainage catheter under radiological guidance (separate procedure) Contrast injection for assessment of abscess or cyst via previously placed drainage catheter or tube (separate procedure) Insertion of peritoneal-venous shunt Revision of peritoneal-venous shunt Injection procedure (eg, contrast media) for evaluation of previously placed peritoneal-venous shunt Ligation of peritoneal-venous shunt Removal of peritoneal-venous shunt Insertion of subcutaneous extension to intraperitoneal cannula or catheter with remote chest exit site (List separately in addition to code for primary procedure) Delayed creation of exit site from embedded subcutaneous segment of intraperitoneal cannula or catheter Insertion of gastrostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report Insertion of duodenostomy or jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report Insertion of cecostomy or other colonic tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report Conversion of gastrostomy tube to gastro-jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Replacement of gastrostomy or cecostomy (or other colonic) tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report Replacement of duodenostomy or jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report Replacement of gastro-jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report Mechanical removal of obstructive material from gastrostomy, duodenostomy, jejunostomy, gastro-jejunostomy, or cecostomy (or other colonic) tube, any method, under fluoroscopic guidance including contrast injection(s), if performed, image documentation and report Contrast injection(s) for radiological evaluation of existing gastrostomy, duodenostomy, jejunostomy, gastro-jejunostomy, or cecostomy (or other colonic) tube, from a percutaneous approach including image documentation and report I Repair initial inguinal hernia, age five years or older; reducible Repair initial inguinal hernia, age five years or older; incarcerated or strangulated Repair recurrent inguinal hernia, any age; reducible Repair recurrent inguinal hernia, any age; incarcerated or strangulated Repair inguinal hernia, sliding, any age Repair lumbar hernia Repair initial femoral hernia, any age; reducible Repair initial femoral hernia, any age; incarcerated or strangulated Repair recurrent femoral hernia; reducible Repair recurrent femoral hernia; incarcerated or strangulated Repair initial incisional or ventral hernia; reducible Repair initial incisional or ventral hernia; incarcerated or strangulated Repair recurrent incisional or ventral hernia; reducible Repair recurrent incisional or ventral hernia; incarcerated or strangulated Implantation of mesh or other prosthesis for incisional or ventral hernia repair or mesh for closure of debridement for necrotizing soft tissue infection (List separately in addition to code for the incisional or ventral hernia repair) Repair epigastric hernia (eg, preperitoneal fat); reducible (separate procedure) Repair epigastric hernia (eg, preperitoneal fat); incarcerated or strangulated Repair umbilical hernia, age five years or older; reducible Repair umbilical hernia, age five years or older; incarcerated or strangulated Repair spigelian hernia ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Repair of small omphalocele, with primary closure Repair of large omphalocele or gastroschisis; with or without prosthesis Repair of large omphalocele or gastroschisis; with removal of prosthesis, final reduction and closure, in operating room Repair of omphalocele (Gross type operation); first stage Repair of omphalocele (Gross type operation); second stage 49650 2,034.73 I Laparoscopy, surgical; repair initial inguinal hernia Laparoscopy, surgical; repair recurrent inguinal hernia I.C. Unlisted laparoscopy procedure, hernioplasty, herniorrhaphy, herniotomy Suture, secondary, of abdominal wall for evisceration or dehiscence Omental flap, extra-abdominal (eg, for reconstruction of sternal and chest wall defects) Omental flap, intra-abdominal (List separately in addition to code for primary procedure) I.C. Free omental flap with microvascular anastomosis I.C. Unlisted procedure, abdomen, peritoneum and omentum Renal exploration, not necessitating other specific procedures Drainage of perirenal or renal abscess; open Drainage of perirenal or renal abscess; percutaneous Nephrostomy, nephrotomy with drainage Nephrotomy, with exploration Nephrolithotomy; removal of calculus Nephrolithotomy; secondary surgical operation for calculus Nephrolithotomy; complicated by congenital kidney abnormality Nephrolithotomy; removal of large staghorn calculus filling renal pelvis and calyces (including anatrophic pyelolithotomy) P e r c u t a n e o u s n e p h r o s t o l i t h o t o m y o r pyelostolithotomy, with or without dilation, endoscopy, lithotripsy, stenting, or basket extraction; up to 2 cm P e r c u t a n e o u s n e p h r o s t o l i t h o t o m y o r pyelostolithotomy, with or without dilation, endoscopy, lithotripsy, stenting, or basket extraction; over 2 cm Transection or repositioning of aberrant renal vessels (separate procedure) Pyelotomy; with exploration Pyelotomy; with drainage, pyelostomy Pyelotomy; with removal of calculus (pyelolithotomy, pelviolithotomy, including coagulum pyelolithotomy) Pyelotomy; complicated (eg, secondary operation, congenital kidney abnormality) Renal biopsy; percutaneous, by trocar or needle Renal biopsy; by surgical exposure of kidney ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Nephrectomy, including partial ureterectomy, any open approach including rib resection; Nephrectomy, including partial ureterectomy, any open approach including rib resection; complicated because of previous surgery on same kidney Nephrectomy, including partial ureterectomy, any open approach including rib resection; radical, with regional lymphadenectomy and/or vena caval thrombectomy Nephrectomy with total ureterectomy and bladder cuff; through same incision Nephrectomy with total ureterectomy and bladder cuff; through separate incision Nephrectomy, partial Ablation, open, one or more renal mass lesion(s), cryosurgical, including intraoperative ultrasound, if performed Excision or unroofing of cyst(s) of kidney Excision of perinephric cyst I.C. Donor nephrectomy (including cold preservation); from cadaver donor, unilateral or bilateral Donor nephrectomy (including cold preservation); open, from living donor I.C. Backbench standard preparation of cadaver donor renal allograft prior to transplantation, including dissection and removal of perinephric fat, diaphragmatic and retroperitoneal attachments, excision of adrenal gland, and preparation of ureter(s), renal vein(s), and renal artery(s), ligating branches, as necessary I.C. Backbench standard preparation of living donor renal allograft (open or laparoscopic) prior to transplantation, including dissection and removal of perinephric fat and preparation of ureter(s), renal vein(s), and renal artery(s), ligating branches, as necessary Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation; venous anastomosis, each Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation; arterial anastomosis, each Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation; ureteral anastomosis, each Recipient nephrectomy (separate procedure) Renal allotransplantation, implantation of graft; without recipient nephrectomy Renal allotransplantation, implantation of graft; with recipient nephrectomy Removal of transplanted renal allograft Renal autotransplantation, reimplantation of kidney ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Removal (via snare/capture) and replacement of internally dwelling ureteral stent via percutaneous approach, including radiological supervision and interpretation Removal (via snare/capture) of internally dwelling ureteral stent via percutaneous approach, including radiological supervision and interpretation Removal (via snare/capture) and replacement of internally dwelling ureteral stent via transurethral approach, without use of cystoscopy, including radiological supervision and interpretation Removal (via snare/capture) of internally dwelling ureteral stent via transurethral approach, without use of cystoscopy, including radiological supervision and interpretation Removal and replacement of externally accessible transnephric ureteral stent (eg, external/internal stent) requiring fluoroscopic guidance, including radiological supervision and interpretation Removal of nephrostomy tube, requiring fluoroscopic guidance (eg, with concurrent indwelling ureteral stent) Aspiration and/or injection of renal cyst or pelvis by needle, percutaneous Instillation(s) of therapeutic agent into renal pelvis and/or ureter through established nephrostomy, pyelostomy or ureterostomy tube (eg, anticarcinogenic or antifungal agent) Introduction of intracatheter or catheter into renal pelvis for drainage and/or injection, percutaneous Introduction of ureteral catheter or stent into ureter through renal pelvis for drainage and/or injection, percutaneous I njectio n p r o c edure for pyelog raphy (as nephrostogram, pyelostogram, antegrade pyeloureterograms) through nephrostomy or pyelostomy tube, or indwelling ureteral catheter Introduction of guide into renal pelvis and/or ureter with dilation to establish nephrostomy tract, percutaneous Manometric studies through nephrostomy or pyelostomy tube, or indwelling ureteral catheter Change of nephrostomy or pyelostomy tube Pyeloplasty (Foley Y-pyeloplasty), plastic operation on renal pelvis, with or without plastic operation on ureter, nephropexy, nephrostomy, pyelostomy, or ureteral splinting; simple Pyeloplasty (Foley Y-pyeloplasty), plastic operation on renal pelvis, with or without plastic operation on ureter, nephropexy, nephrostomy, pyelostomy, or ureteral splinting; complicated (congenital kidney abnormality, secondary pyeloplasty, solitary kidney, calycoplasty) Nephrorrhaphy, suture of kidney wound or injury Closure of nephrocutaneous or pyelocutaneous fistula 40.06: continued ASC Incl Rate PC Fee TC Fee I.C. 40.06(8) - Surgical Services Description (con’t) Closure of nephrovisceral fistula (eg, renocolic), including visceral repair; abdominal approach Closure of nephrovisceral fistula (eg, renocolic), including visceral repair; thoracic approach Symphysiotomy for horseshoe kidney with or without pyeloplasty and/or other plastic procedure, unilateral or bilateral (one operation) Laparoscopy, surgical; ablation of renal cysts Laparoscopy, surgical; ablation of renal mass lesion(s) Laparoscopy, surgical; partial nephrectomy Laparoscopy, surgical; pyeloplasty Laparoscopy, surgical; radical nephrectomy (includes removal of Gerota's fascia and surrounding fatty tissue, removal of regional lymph nodes, and adrenalectomy) Laparoscopy, surgical; nephrectomy, including partial ureterectomy Laparoscopy, surgical; donor nephrectomy (including cold preservation), from living donor Laparoscopy, surgical; nephrectomy with total ureterectomy Unlisted laparoscopy procedure, renal Renal endoscopy through established nephrostomy or pyelostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; Renal endoscopy through established nephrostomy or pyelostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with ureteral catheterization, with or without dilation of ureter Renal endoscopy through established nephrostomy or pyelostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with biopsy Renal endoscopy through established nephrostomy or pyelostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with fulguration and/or incision, with or without biopsy Renal endoscopy through established nephrostomy or pyelostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with removal of foreign body or calculus Renal endoscopy through established nephrostomy or pyelostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with resection of tumor Renal endoscopy through nephrotomy or pyelotomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; Renal endoscopy through nephrotomy or pyelotomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with ureteral catheterization, with or without dilation of ureter ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Renal endoscopy through nephrotomy or pyelotomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with biopsy Renal endoscopy through nephrotomy or pyelotomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with endopyelotomy (includes cystoscopy, ureteroscopy, dilation of ureter and ureteral pelvic junction, incision of ureteral pelvic junction and insertion of endopyelotomy stent) Renal endoscopy through nephrotomy or pyelotomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with fulguration and/or incision, with or without biopsy Renal endoscopy through nephrotomy or pyelotomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with removal of foreign body or calculus Lithotripsy, extracorporeal shock wave Ablation, one or more renal tumor(s), percutaneous, unilateral, radiofrequency Ablation, renal tumor(s), unilateral, percutaneous, cryotherapy Ureterotomy with exploration or drainage (separate procedure) Ureterotomy for insertion of indwelling stent, all types Ureterolithotomy; upper one-third of ureter Ureterolithotomy; middle one-third of ureter Ureterolithotomy; lower one-third of ureter Ureterectomy, with bladder cuff (separate procedure) Ureterectomy, total, ectopic ureter, combination abdominal, vaginal and/or perineal approach Injection proc edure f o r u r e ter og raphy or ureteropyelography through ureterostomy or indwelling ureteral catheter Manometric studies through ureterostomy or indwelling ureteral catheter Change of ureterostomy tube or externally accessible ureteral stent via ileal conduit Injection procedure for visualization of ileal conduit and/or ureteropyelography, exclusive of radiologic service Ureteroplasty, plastic operation on ureter (eg, stricture) Ureterolysis, with or without repositioning of ureter for retroperitoneal fibrosis Ureterolysis for ovarian vein syndrome Ureterolysis for retrocaval ureter, with reanastomosis of upper urinary tract or vena cava Revision of urinary-cutaneous anastomosis (any type urostomy); Revision of urinary-cutaneous anastomosis (any type urostomy); with repair of fascial defect and hernia ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Ureteropyelostomy, anastomosis of ureter and renal pelvis Ureterocalycostomy, anastomosis of ureter to renal calyx Ureteroureterostomy Transureteroureterostomy, anastomosis of ureter to contralateral ureter Ureteroneocystostomy; anastomosis of single ureter to bladder Ureteroneocystostomy; anastomosis of duplicated ureter to bladder Ureteroneocystostomy; with extensive ureteral tailoring Ureteroneocystostomy; with vesico-psoas hitch or bladder flap Ureteroenterostomy, direct anastomosis of ureter to intestine Ureterosigmoidostomy, with creation of sigmoid bladder and establishment of abdominal or perineal colostomy, including intestine anastomosis Ureterocolon conduit, including intestine anastomosis Ureteroileal conduit (ileal bladder), including intestine anastomosis (Bricker operation) Continent diversion, including intestine anastomosis using any segment of small and/or large intestine (Kock pouch or Camey enterocystoplasty) Urinary undiversion (eg, taking down of ureteroileal conduit, ureterosigmoidostomy or ureteroenterostomy with ureteroureterostomy or ureteroneocystostomy) Replacement of all or part of ureter by intestine segment, including intestine anastomosis Cutaneous appendico-vesicostomy Ureterostomy, transplantation of ureter to skin Ureterorrhaphy, suture of ureter (separate procedure) Closure of ureterocutaneous fistula Closure of ureterovisceral fistula (including visceral repair) Deligation of ureter Laparoscopy, surgical; ureterolithotomy Laparoscopy, surgical; ureteroneocystostomy with cystoscopy and ureteral stent placement Laparoscopy, surgical; ureteroneocystostomy without cystoscopy and ureteral stent placement I.C. Unlisted laparoscopy procedure, ureter Ureteral endoscopy through established ureterostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; Ureteral endoscopy through established ureterostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with ureteral catheterization, with or without dilation of ureter Ureteral endoscopy through established ureterostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with biopsy ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Ureteral endoscopy through established ureterostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with fulguration and/or incision, with or without biopsy Ureteral endoscopy through established ureterostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with removal of foreign body or calculus Ureteral endoscopy through ureterotomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; Ureteral endoscopy through ureterotomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with ureteral catheterization, with or without dilation of ureter Ureteral endoscopy through ureterotomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with biopsy Ureteral endoscopy through ureterotomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with fulguration and/or incision, with or without biopsy Ureteral endoscopy through ureterotomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with removal of foreign body or calculus Cystotomy or cystostomy; with fulguration and/or insertion of radioactive material Cystotomy or cystostomy; with cryosurgical destruction of intravesical lesion Cystostomy, cystotomy with drainage Cystotomy, with insertion of ureteral catheter or stent (separate procedure) Cystolithotomy, cystotomy with removal of calculus, without vesical neck resection Transvesical ureterolithotomy Cystotomy, with calculus basket extraction and/or ultrasonic or electrohydraulic fragmentation of ureteral calculus Drainage of perivesical or prevesical space abscess Aspiration of bladder; by needle Aspiration of bladder; by trocar or intracatheter Aspiration of bladder; with insertion of suprapubic catheter Excision of urachal cyst or sinus, with or without umbilical hernia repair Cystotomy; for simple excision of vesical neck (separate procedure) Cystotomy; for excision of bladder diverticulum, single or multiple (separate procedure) Cystotomy; for excision of bladder tumor Cystotomy for excision, incision, or repair of ureterocele Cystectomy, partial; simple ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Cystectomy, partial; complicated (eg, postradiation, previous surgery, difficult location) Cystectomy, partial, with reimplantation of ureter(s) into bladder (ureteroneocystostomy) Cystectomy, complete; (separate procedure) Cystectomy, complete; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes Cystectomy, complete, with ureterosigmoidostomy or ureterocutaneous transplantations; Cystectomy, complete, with ureterosigmoidostomy or ureterocutaneous transplantations; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes Cystectomy, complete, with ureteroileal conduit or sigmoid bladder, including intestine anastomosis; Cystectomy, complete, with ureteroileal conduit or sigmoid bladder, including intestine anastomosis; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes Cystectomy, complete, with continent diversion, any open technique, using any segment of small and/or large intestine to construct neobladder Pelvic exenteration, complete, for vesical, prostatic or urethral malignancy, with removal of bladder and ureteral transplantations, with or without hysterectomy and/or abdominoperineal resection of rectum and colon and colostomy, or any combination thereof Injection procedure for cystography or voiding urethrocystography Injection procedure and placement of chain for contrast and/or chain urethrocystography Injection procedure for retrograde urethrocystography Bladder irrigation, simple, lavage and/or instillation Insertion of non-indwelling bladder catheter (eg, straight catheterization for residual urine) Insertion of temporary indwelling bladder catheter; simple (eg, Foley) Insertion of temporary indwelling bladder catheter; complicated (eg, altered anatomy, fractured catheter/balloon) Change of cystostomy tube; simple Change of cystostomy tube; complicated Endoscopic injection of implant material into the submucosal tissues of the urethra and/or bladder neck Bladder instillation of anticarcinogenic agent (including retention time) 79.09 203.26 Simple cystometrogram (CMG) (eg, spinal manometer) 89.90 310.35 Complex cystometrogram (eg, calibrated electronic equipment) 32.45 25.15 Simple uroflowmetry (UFR) (eg, stop-watch flow rate, mechanical uroflowmeter) ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee 60.49 29.14 Complex uroflowmetry (eg, calibrated electronic equipment) 84.78 221.05 Urethral pressure profile studies (UPP) (urethral closure pressure profile), any technique 80.23 163.22 Electromyography studies (EMG) of anal or urethral sphincter, other than needle, any technique 79.93 183.93 Needle electromyography studies (EMG) of anal or urethral sphincter, any technique 58.07 239.56 Stimulus evoked response (eg, measurement of bulbocavernosus reflex latency time) 80.23 300.80 Voiding pressure studies (VP); bladder voiding pressure, any technique 49.78 171.80 Voiding pressure studies (VP); intra-abdominal voiding pressure (AP) (rectal, gastric, intraperitoneal) (List separately in addition to code for primary procedure) Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging Cystoplasty or cystourethroplasty, plastic operation on bladder and/or vesical neck (anterior Y-plasty, vesical fundus resection), any procedure, with or without wedge resection of posterior vesical neck Cystourethroplasty with unilateral or bilateral ureteroneocystostomy Anterior vesicourethropexy, or urethropexy (eg, Marshall-Marchetti-Krantz, Burch); simple Anterior vesicourethropexy, or urethropexy (eg, Marshall-Marchetti-Krantz, Burch); complicated (eg, secondary repair) Abdomino-vaginal vesical neck suspension, with or without endoscopic control (eg, Stamey, Raz, modified Pereyra) Cystorrhaphy, suture of bladder wound, injury or rupture; simple Cystorrhaphy, suture of bladder wound, injury or rupture; complicated Closure of cystostomy (separate procedure) Closure of vesicovaginal fistula, abdominal approach Closure of vesicouterine fistula; Closure of vesicouterine fistula; with hysterectomy Closure, exstrophy of bladder Enterocystoplasty, including intestinal anastomosis Cutaneous vesicostomy Laparoscopy, surgical; urethral suspension for stress incontinence Laparoscopy, surgical; sling operation for stress incontinence (eg, fascia or synthetic) I.C. Unlisted laparoscopy procedure, bladder Cystourethroscopy (separate procedure) Cystourethroscopy with irrigation and evacuation of multiple obstructing clots Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with brush biopsy of ureter and/or renal pelvis Cystourethroscopy, with ejaculatory duct catheterization, with or without irrigation, instillation, or duct radiography, exclusive of radiologic service Cystourethroscopy, with biopsy(s) Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) of trigone, bladder neck, prostatic fossa, urethra, or periurethral glands Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) or treatment of MINOR (less than 0.5 cm) lesion(s) with or without biopsy Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of SMALL bladder tumor(s) (0.5 up to 2.0 cm) Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of MEDIUM bladder tumor(s) (2.0 to 5.0 cm) Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of LARGE bladder tumor(s) Cystourethroscopy with insertion of radioactive substance, with or without biopsy or fulguration Cystourethroscopy, with dilation of bladder for interstitial cystitis; general or conduction (spinal) anesthesia Cystourethroscopy, with dilation of bladder for interstitial cystitis; local anesthesia Cystourethroscopy, with internal urethrotomy; female Cystourethroscopy, with internal urethrotomy; male Cystourethroscopy with direct vision internal urethrotomy Cystourethroscopy, with resection of external sphincter (sphincterotomy) Cystourethroscopy, with calibration and/or dilation of urethral stricture or stenosis, with or without meatotomy, with or without injection procedure for cystography, male or female Cystourethroscopy, with insertion of urethral stent Cystourethroscopy, with steroid injection into stricture Cystourethroscopyfor treatment of the female urethral syndrome with any or all of the following: urethral meatotomy, urethral dilation, internal urethrotomy, lysis of urethrovaginal septal fibrosis, lateral incisions of the bladder neck, and fulguration Cystourethroscopy; with ureteral meatotomy, unilateral or bilateral Cystourethroscopy; with resection or fulguration of orthotopic ureterocele(s), unilateral or bilateral Cystourethroscopy; with resection or fulguration of ectopic ureterocele(s), unilateral or bilateral Cystourethroscopy; with incision or resection of orifice of bladder diverticulum, single or multiple 40.06: continued ASC Incl Rate PC Fee TC Fee 40.06(8) - Surgical Services Description (con’t) Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder (separate procedure); simple Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder (separate procedure); complicated Litholapaxy: crushing or fragmentation of calculus by any means in bladder and removal of fragments; simple or small (less than 2.5 cm) Litholapaxy: crushing or fragmentation of calculus by any means in bladder and removal of fragments; complicated or large (over 2.5 cm) C ys t o u r e t h r o s c o p y ( i n c l u d i n g u r e t e r a l catheterization); with removal of ureteral calculus C ys t o u r e t h r o s c o p y ( i n c l u d i n g u r e t e r a l catheterization); with fragmentation of ureteral calculus (eg, ultrasonic or electro-hydraulic technique) C ys t o u r e t h r o s c o p y ( i n c l u d i n g u r e t e r a l catheterization); with subureteric injection of implant material C ys t o u r e t h r o s c o p y ( i n c l u d i n g u r e t e r a l catheterization); with manipulation, without removal of ureteral calculus Cystourethroscopy, with insertion of indwelling ureteral stent (eg, Gibbons or double-J type) Cystourethroscopy with insertion of ureteral guide wire through kidney to establish a percutaneous nephrostomy, retrograde Cystourethroscopy; with treatment of ureteral stricture (eg, balloon dilation, laser, electrocautery, and incision) Cystourethroscopy; with treatment of ureteropelvic junction stricture (eg, balloon dilation, laser, electrocautery, and incision) Cystourethroscopy; with treatment of intra-renal stricture (eg, balloon dilation, laser, electrocautery, and incision) Cystourethroscopy with ureteroscopy; with treatment of ureteral stricture (eg, balloon dilation, laser, electrocautery, and incision) Cystourethroscopy with ureteroscopy; with treatment of ureteropelvic junction stricture (eg, balloon dilation, laser, electrocautery, and incision) Cystourethroscopy with ureteroscopy; with treatment of intra-renal stricture (eg, balloon dilation, laser, electrocautery, and incision) Cystourethroscopy, with ureteroscopy and/or pyeloscopy; diagnostic Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with removal or manipulation of calculus (ureteral catheterization is included) Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy (ureteral catheterization is included) ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with biopsy and/or fulguration of ureteral or renal pelvic lesion Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with resection of ureteral or renal pelvic tumor Cystourethroscopy with incision, fulguration, or resection of congenital posterior urethral valves, or congenital obstructive hypertrophic mucosal folds Cystourethroscopy with transurethral resection or incision of ejaculatory ducts Transurethral incision of prostate Transurethral resection of bladder neck (separate procedure) Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included) Transurethral fulguration for postoperative bleeding occurring after the usual follow-up time Transurethral resection of prostate; first stage of two-stage resection (partial resection) Transurethral resection of prostate; second stage of two-stage resection (resection completed) Transurethral resection; of residual obstructive tissue after 90 days postoperative Transurethral resection; of regrowth of obstructive tissue longer than one year postoperative Transurethral resection; of postoperative bladder neck contracture Laser coagulation of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included if performed) Laser vaporization of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, internal urethrotomy and transurethral resection of prostate are included if performed) Laser enucleation of the prostate with morcellation, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, internal urethrotomy and transurethral resection of prostate are included if performed) Transurethral drainage of prostatic abscess Urethrotomy or urethrostomy, external (separate procedure); pendulous urethra Urethrotomy or urethrostomy, external (separate procedure); perineal urethra, external Meatotomy, cutting of meatus (separate procedure); except infant Drainage of deep periurethral abscess ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Drainage of Skene's gland abscess or cyst Drainage of perineal urinary extravasation; uncomplicated (separate procedure) Drainage of perineal urinary extravasation; complicated Biopsy of urethra Urethrectomy, total, including cystostomy; female Urethrectomy, total, including cystostomy; male Excision or fulguration of carcinoma of urethra Excision of urethral diverticulum (separate procedure); female Excision of urethral diverticulum (separate procedure); male Marsupialization of urethral diverticulum, male or female Excision of bulbourethral gland (Cowper's gland) Excision or fulguration; urethral polyp(s), distal urethra Excision or fulguration; urethral caruncle Excision or fulguration; Skene's glands Excision or fulguration; urethral prolapse Urethroplasty; first stage, for fistula, diverticulum, or stricture (eg, Johannsen type) Urethroplasty; second stage (formation of urethra), including urinary diversion Urethroplasty, one-stage reconstruction of male anterior urethra Urethroplasty, transpubic or perineal, one stage, for reconstruction or repair of prostatic or membranous urethra Urethroplasty, two-stage reconstruction or repair of prostatic or membranous urethra; first stage Urethroplasty, two-stage reconstruction or repair of prostatic or membranous urethra; second stage Urethroplasty, reconstruction of female urethra Urethroplasty with tubularization of posterior urethra and/or lower bladder for incontinence (eg, Tenago, Leadbetter procedure) Sling operation for correction of male urinary incontinence (eg, fascia or synthetic) Removal or revision of sling for male urinary incontinence (eg, fascia or synthetic) Insertion of tandem cuff (dual cuff) Insertion of inflatable urethral/bladder neck sphincter, including placement of pump, reservoir, and cuff Removal of inflatable urethral/bladder neck sphincter, including pump, reservoir, and cuff Re mov a l a n d rep l acem en t o f i n fl a ta ble urethral/bladder neck sphincter including pump, reservoir, and cuff at the same operative session R e m o v a l a n d r e p l a c e m e n t o f i n f l a t a b l e urethral/bladder neck sphincter including pump, reservoir, and cuff through an infected field at the same operative session including irrigation and debridement of infected tissue Repair of inflatable urethral/bladder neck sphincter, including pump, reservoir, and cuff ASC Rate Incl PC Fee TC Fee I.C. 40.06(8) - Surgical Services Description (con’t) Urethromeatoplasty, with mucosal advancement Urethromeatoplasty, with partial excision of distal urethral segment (Richardson type procedure) Urethrolysis, transvaginal, secondary, open, including cystourethroscopy (eg, postsurgical obstruction, scarring) Urethrorrhaphy, suture of urethral wound or injury, female Urethrorrhaphy, suture of urethral wound or injury; penile Urethrorrhaphy, suture of urethral wound or injury; perineal Urethrorrhaphy, suture of urethral wound or injury; prostatomembranous Closure of urethrostomy or urethrocutaneous fistula, male (separate procedure) Dilation of urethral stricture by passage of sound or urethral dilator, male; initial Dilation of urethral stricture by passage of sound or urethral dilator, male; subsequent Dilation of urethral stricture or vesical neck by passage of sound or urethral dilator, male, general or conduction (spinal) anesthesia Dilation of urethral stricture by passage of filiform and follower, male; initial Dilation of urethral stricture by passage of filiform and follower, male; subsequent Dilation of female urethra including suppository and/or instillation; initial Dilation of female urethra including suppository and/or instillation; subsequent Dilation of female urethra, general or conduction (spinal) anesthesia Transurethral destruction of prostate tissue; by microwave thermotherapy Transurethral destruction of prostate tissue; by radiofrequency thermotherapy Transurethral destruction of prostate tissue; by water-induced thermotherapy Unlisted procedure, urinary system Slitting of prepuce, dorsal or lateral (separate procedure); newborn Slitting of prepuce, dorsal or lateral (separate procedure); except newborn Incision and drainage of penis, deep Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; chemical Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; electrodesiccation Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; cryosurgery ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; laser surgery Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; surgical excision Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), extensive (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery) Biopsy of penis; (separate procedure) Biopsy of penis; deep structures Excision of penile plaque (Peyronie disease); Excision of penile plaque (Peyronie disease); with graft to 5 cm in length Excision of penile plaque (Peyronie disease); with graft greater than 5 cm in length Removal foreign body from deep penile tissue (eg, plastic implant) Amputation of penis; partial Amputation of penis; complete Amputation of penis, radical; with bilateral inguinofemoral lymphadenectomy Amputation of penis, radical; in continuity with bilateral pelvic lymphadenectomy, including external iliac, hypogastric and obturator nodes Circumcision, using clamp or other device with regional dorsal penile or ring block Circumcision, surgical excision other than clamp, device, or dorsal slit; older than 28 days of age Lysis or excision of penile post-circumcision adhesions Repair incomplete circumcision Frenulotomy of penis Injection procedure for Peyronie disease; Injection procedure for Peyronie disease; with surgical exposure of plaque Irrigation of corpora cavernosa for priapism Injection procedure for corpora cavernosography Dynamic cavernosometry, including intracavernosal injection of vasoactive drugs (eg, papaverine, phentolamine) Injection of corpora cavernosa with pharmacologic agent(s) (eg, papaverine, phentolamine) 68.74 39.08 Penile plethysmography 116.50 13.49 Nocturnal penile tumescence and/or rigidity test Plastic operation of penis for straightening of chordee (eg, hypospadias), with or without mobilization of urethra Plastic operation on penis for correction of chordee or for first stage hypospadias repair with or without transplantation of prepuce and/or skin flaps Urethroplasty for second stage hypospadias repair (including urinary diversion); less than 3 cm Urethroplasty for second stage hypospadias repair (including urinary diversion); greater than 3 cm ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Urethroplasty for second stage hypospadias repair (including urinary diversion) with free skin graft obtained from site other than genitalia Urethroplasty for third stage hypospadias repair to release penis from scrotum (eg, third stage Cecil repair) One stage distal hypospadias repair (with or without chordee or circumcision); with simple meatal advancement (eg, Magpi, V-flap) One stage distal hypospadias repair (with or without chordee or circumcision); with urethroplasty by local skin flaps (eg, flip-flap, prepucial flap) One stage distal hypospadias repair (with or without chordee or circumcision); with urethroplasty by local skin flaps and mobilization of urethra One stage distal hypospadias repair (with or without chordee or circumcision); with extensive dissection to correct chordee and urethroplasty with local skin flaps, skin graft patch, and/or island flap One stage proximal penile or penoscrotal hypospadias repair requiring extensive dissection to correct chordee and urethroplasty by use of skin graft tube and/or island flap One stage perineal hypospadias repair requiring extensive dissection to correct chordee and urethroplasty by use of skin graft tube and/or island flap Repair of hypospadias complications (ie, fistula, stricture, diverticula); by closure, incision, or excision, simple Repair of hypospadias complications (ie, fistula, stricture, diverticula); requiring mobilization of skin flaps and urethroplasty with flap or patch graft Repair of hypospadias complications (ie, fistula, stricture, diverticula); requiring extensive dissection and urethroplasty with flap, patch or tubed graft (includes urinary diversion) Repair of hypospadias cripple requiring extensive dissection and excision of previously constructed structures including re-release of chordee and reconstruction of urethra and penis by use of local skin as grafts and island flaps and skin brought in as flaps or grafts Plastic operation on penis to correct angulation Plastic operation on penis for epispadias distal to external sphincter; Plastic operation on penis for epispadias distal to external sphincter; with incontinence Plastic operation on penis for epispadias distal to external sphincter; with exstrophy of bladder Insertion of penile prosthesis; non-inflatable (semi-rigid) Insertion of penile prosthesis; inflatable (self-contained) ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Insertion of multi-component, inflatable penile prosthesis, including placement of pump, cylinders, and reservoir Removal of all components of a multi-component, inflatable penile prosthesis without replacement of prosthesis Repair of component(s) of a multi-component, inflatable penile prosthesis Removal and replacement of all component(s) of a multi-component, inflatable penile prosthesis at the same operative session Removal and replacement of all components of a multi-component inflatable penile prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue Removal of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis, without replacement of prosthesis Removal and replacement of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis at the same operative session Removal and replacement of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue Corpora cavernosa-saphenous vein shunt (priapism operation), unilateral or bilateral Corpora cavernosa-corpus spongiosum shunt (priapism operation), unilateral or bilateral Corpora cavernosa-glans penis fistulization (eg, biopsy needle, Winter procedure, rongeur, or punch) for priapism I.C. Plastic operation of penis for injury Foreskin manipulation including lysis of preputial adhesions and stretching Biopsy of testis, needle (separate procedure) Biopsy of testis, incisional (separate procedure) Excision of extraparenchymal lesion of testis Orchiectomy, simple (including subcapsular), with or without testicular prosthesis, scrotal or inguinal approach Orchiectomy, partial Orchiectomy, radical, for tumor; inguinal approach Orchiectomy, radical, for tumor; with abdominal exploration Exploration for undescended testis (inguinal or scrotal area) Exploration for undescended testis with abdominal exploration Reduction of torsion of testis, surgical, with or without fixation of contralateral testis Fixation of contralateral testis (separate procedure) Orchiopexy, inguinal approach, with or without hernia repair ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Orchiopexy, abdominal approach, for intra-abdominal testis (eg, Fowler-Stephens) Insertion of testicular prosthesis (separate procedure) Suture or repair of testicular injury Transplantation of testis(es) to thigh (because of scrotal destruction) Laparoscopy, surgical; orchiectomy Laparoscopy, surgical; orchiopexy for intra-abdominal testis I.C. Unlisted laparoscopy procedure, testis Incision and drainage of epididymis, testis and/or scrotal space (eg, abscess or hematoma) Biopsy of epididymis, needle Excision of local lesion of epididymis Ex cision of spermatocele, with or without epididymectomy Epididymectomy; unilateral Epididymectomy; bilateral Exploration of epididymis, with or without biopsy Epididymovasostomy, anastomosis of epididymis to vas deferens; unilateral Epididymovasostomy, anastomosis of epididymis to vas deferens; bilateral Puncture aspiration of hydrocele, tunica vaginalis, with or without injection of medication Excision of hydrocele; unilateral Excision of hydrocele; bilateral Repair of tunica vaginalis hydrocele (Bottle type) Drainage of scrotal wall abscess Scrotal exploration Removal of foreign body in scrotum Resection of scrotum Scrotoplasty; simple Scrotoplasty; complicated Vasotomy, cannulization with or without incision of vas, unilateral or bilateral (separate procedure) Vasectomy, unilateral or bilateral (separate procedure), including postoperative semen examination(s) Vasotomy for vasograms, seminal vesiculograms, or epididymograms, unilateral or bilateral Vasovasostomy, vasovasorrhaphy Ligation (percutaneous) of vas deferens, unilateral or bilateral (separate procedure) Excision of hydrocele of spermatic cord, unilateral (separate procedure) Excision of lesion of spermatic cord (separate procedure) Excision of varicocele or ligation of spermatic veins for varicocele; (separate procedure) Excision of varicocele or ligation of spermatic veins for varicocele; abdominal approach Excision of varicocele or ligation of spermatic veins for varicocele; with hernia repair ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Laparoscopy, surgical, with ligation of spermatic veins for varicocele I.C. Unlisted laparoscopy procedure, spermatic cord Vesiculotomy; Vesiculotomy; complicated Vesiculectomy, any approach Excision of Mullerian duct cyst Biopsy, prostate; needle or punch, single or multiple, any approach Biopsy, prostate; incisional, any approach Prostatotomy, external drainage of prostatic abscess, any approach; simple Prostatotomy, external drainage of prostatic abscess, any approach; complicated Prostatectomy, perineal, subtotal (including control of postoperative bleeding, vasectomy, meatotomy, urethral calibration and/or dilation, and internal urethrotomy) Prostatectomy, perineal radical; Prostatectomy, perineal radical; with lymph node biopsy(s) (limited pelvic lymphadenectomy) Prostatectomy, perineal radical; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric and obturator nodes Prostatectomy (including control of postoperative bleeding, vasectomy, meatotomy, urethral calibration and/or dilation, and internal urethrotomy); suprapubic, subtotal, one or two stages Prostatectomy (including control of postoperative bleeding, vasectomy, meatotomy, urethral calibration and/or dilation, and internal urethrotomy); retropubic, subtotal Prostatectomy, retropubic radical, with or without nerve sparing; Prostatectomy, retropubic radical, with or without nerve sparing; with lymph node biopsy(s) (limited pelvic lymphadenectomy) Prostatectomy, retropubic radical, with or without nerve sparing; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes Exposure of prostate, any approach, for insertion of radioactive substance; Exposure of prostate, any approach, for insertion of radioactive substance; with lymph node biopsy(s) (limited pelvic lymphadenectomy) Exposure of prostate, any approach, for insertion of radioactive substance; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric and obturator nodes Laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing Electroejaculation ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Cryosurgical ablation of the prostate (includes ultrasonic guidance for interstitial cryosurgical probe placement) Transperineal placement of needles or catheters into prostate for interstitial radioelement application, with or without cystoscopy Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), prostate (via needle, any approach), single or multiple I.C. Unlisted procedure, male genital system Placement of needles or catheters into pelvic organs and/or genitalia (except prostate) for subsequent interstitial radioelement application Incision and drainage of vulva or perineal abscess Incision and drainage of Bartholin's gland abscess Marsupialization of Bartholin's gland cyst Lysis of labial adhesions Hymenotomy, simple incision Destruction of lesion(s), vulva; simple (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery) Destruction of lesion(s), vulva; extensive (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery) Biopsyof vulva or perineum (separate procedure); one lesion Biopsy of vulva or perineum (separate procedure); each separate additional lesion (List separately in addition to code for primary procedure) Vulvectomy simple; partial Vulvectomy simple; complete Vulvectomy, radical, partial; Vulvectomy, radical, partial; with unilateral inguinofemoral lymphadenectomy Vulvectomy, radical, partial; with bilateral inguinofemoral lymphadenectomy Vulvectomy, radical, complete; Vulvectomy, radical, complete; with unilateral inguinofemoral lymphadenectomy Vulvectomy, radical, complete; with bilateral inguinofemoral lymphadenectomy Vulvectomy, radical, complete, with inguinofemoral, iliac, and pelvic lymphadenectomy Partial hymenectomy or revision of hymenal ring Excision of Bartholin's gland or cyst Plastic repair of introitus Clitoroplasty for intersex state Perineoplasty, repair of perineum, nonobstetrical (separate procedure) Colposcopy of the vulva; Colposcopy of the vulva; with biopsy(s) Colpotomy; with exploration Colpotomy; with drainage of pelvic abscess Colpocentesis (separate procedure) Incision and drainage of vaginal hematoma; obstetrical/postpartum ASC Rate Incl PC Fee TC Fee 40.06(8) - Surgical Services Description (con’t) Incision and drainage of vaginal hematoma; non-obstetrical (eg, post-trauma, spontaneous bleeding) Destruction of vaginal lesion(s); simple (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery) Destruction of vaginal lesion(s); extensive (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery) Biopsyof vaginal mucosa; simple (separate procedure) Biopsy of vaginal mucosa; extensive, requiring suture (including cysts) Vaginectomy, partial removal of vaginal wall; Vaginectomy, partial removal of vaginal wall; with removal of paravaginal tissue (radical vaginectomy) Vaginectomy, partial removal of vaginal wall; with removal of paravaginal tissue (radical vaginectomy) with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy) Vaginectomy, complete removal of vaginal wall; Vaginectomy, complete removal of vaginal wall; with removal of paravaginal tissue (radical vaginectomy) Vaginectomy, complete removal of vaginal wall; with removal of paravaginal tissue (radical vaginectomy) with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy) Colpocleisis (Le Fort type) Excision of vaginal septum Excision of vaginal cyst or tumor Irrigation of vagina and/or application of medicament for treatment of bacterial, parasitic, or fungoid disease Insertion of uterine tandems and/or vaginal ovoids for clinical brachytherapy Fitting and insertion of pessary or other intravaginal support device Diaphragm or cervical cap fitting with instructions Introduction of any hemostatic agent or pack for spontaneous or traumatic nonobstetrical vaginal hemorrhage (separate procedure) Colporrhaphy, suture of injury of vagina (nonobstetrical) Colpoperineorrhaphy, suture of injury of vagina and/or perineum (nonobstetrical) Plastic operation on urethral sphincter, vaginal approach (eg, Kelly urethral plication) Plastic repair of urethrocele Anterior colporrhaphy, repair of cystocele with or without repair of urethrocele Posterior colporrhaphy, repair of rectocele with or without perineorrhaphy Combined anteroposterior colporrhaphy; Combined anteroposterior colporrhaphy; with enterocele repair Insertion of mesh or other prosthesis for repair of pelvic floor defect, each site (anterior, posterior compartment), vaginal approach (List separately in addition to code for primary procedure) ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Repair of enterocele, vaginal approach (separate procedure) Repair of enterocele, abdominal approach (separate procedure) Colpopexy, abdominal approach Colpopexy, vaginal; extra-peritoneal approach (sacrospinous, iliococcygeus) Colpopexy, vaginal; intra-peritoneal approach (uterosacral, levator myorrhaphy) Paravaginal defect repair (including repair of cystocele, if performed); open abdominal approach Paravaginal defect repair (including repair of cystocele, if performed); vaginal approach Removal or revision of sling for stress incontinence (eg, fascia or synthetic) Sling operation for stress incontinence (eg, fascia or synthetic) Pereyra procedure, including anterior colporrhaphy Construction of artificial vagina; without graft Construction of artificial vagina; with graft Revision (including removal) of prosthetic vaginal graft; vaginal approach Revision (including removal) of prosthetic vaginal graft; open abdominal approach Closure of rectovaginal fistula; vaginal or transanal approach Closure of rectovaginal fistula; abdominal approach Closure of rectovaginal fistula; abdominal approach, with concomitant colostomy Closure of rectovaginal fistula; transperineal approach, with perineal body reconstruction, with or without levator plication Closure of urethrovaginal fistula; C l o s u r e o f u r e t h r o v a g i n a l f i s t u l a ; w i t h bulbocavernosus transplant Closure of vesicovaginal fistula; vaginal approach Closure of vesicovaginal fistula; transvesical and vaginal approach Vaginoplasty for intersex state Dilation of vagina under anesthesia Pelvic examination under anesthesia Removal of impacted vaginal foreign body (separate procedure) under anesthesia Colposcopy of the entire vagina, with cervix if present; Colposcopy of the entire vagina, with cervix if present; with biopsy(s) of vagina/cervix Paravaginal defect repair (including repair of cystocele, if performed), laparoscopic approach Laparoscopy, surgical, colpopexy (suspension of vaginal apex) Colposcopy of the cervix including upper/adjacent vagina; ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Colposcopy of the cervix including upper/adjacent vagina; with biopsy(s) of the cervix and endocervical curettage Colposcopy of the cervix including upper/adjacent vagina; with biopsy(s) of the cervix Colposcopy of the cervix including upper/adjacent vagina; with endocervical curettage Colposcopy of the cervix including upper/adjacent vagina; with loop electrode biopsy(s) of the cervix Colposcopy of the cervix including upper/adjacent vagina; with loop electrode conization of the cervix Biopsy of cervix, single or multiple, or local excision of lesion, with or without fulguration (separate procedure) Endocervical curettage (not done as part of a dilation and curettage) Cautery of cervix; electro or thermal Cautery of cervix; cryocautery, initial or repeat Cautery of cervix; laser ablation Conization of cervix, with or without fulguration, with or without dilation and curettage, with or without repair; cold knife or laser Conization of cervix, with or without fulguration, with or without dilation and curettage, with or without repair; loop electrode excision Trachelectomy (cervicectomy), amputation of cervix (separate procedure) Radical trachelectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling biopsy, with or without removal of tube(s), with or without removal of ovary(s) Excision of cervical stump, abdominal approach; Excision of cervical stump, abdominal approach; with pelvic floor repair Excision of cervical stump, vaginal approach; Excision of cervical stump, vaginal approach; with anterior and/or posterior repair Excision of cervical stump, vaginal approach; with repair of enterocele Dilation and curettage of cervical stump Cerclage of uterine cervix, nonobstetrical Trachelorrhaphy, plastic repair of uterine cervix, vaginal approach Dilation of cervical canal, instrumental (separate procedure) Endometrial sampling (biopsy) with or without endocervical sampling (biopsy), without cervical dilation, any method (separate procedure) Endometrial sampling (biopsy) performed in conjunction with colposcopy (List separately in addition to code for primary procedure) Dilation and curettage, diagnostic and/or therapeutic (nonobstetrical) ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Myomectomy, excision of fibroid tumor(s) of uterus, one to four intramural myoma(s) with total weight of 250 g or less and/or removal of surface myomas; abdominal approach Myomectomy, excision of fibroid tumor(s) of uterus, one to four intramural myoma(s) with total weight of 250 g or less and/or removal of surface myomas; vaginal approach Myomectomy, excision of fibroid tumor(s) of uterus, five or more intramural myomas and/or intramural myomas with total weight greater than 250 g, abdominal approach Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s); Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s); with colpo-urethrocystopexy (eg, Marshall-Marchetti-Krantz, Burch) Supracervical abdominal hysterectomy (subtotal hysterectomy), with or without removal of tube(s), with or without removal of ovary(s) Total abdominal hysterectomy, including partial vaginectomy, with para-aortic and pelvic lymph node sampling, with or without removal of tube(s), with or without removal of ovary(s) Radical abdominal hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy), with or without removal of tube(s), with or without removal of ovary(s) Pelvic exenteration for gynecologic malignancy, with total abdominal hysterectomy or cervicectomy, with or without removal of tube(s), with or without removal of ovary(s), with removal of bladder and ureteral transplantations, and/or abdominoperineal resection of rectum and colon and colostomy, or any combination thereof Vaginal hysterectomy, for uterus 250 g or less; Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s) Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s), with repair of enterocele Vaginal hysterectomy, for uterus 250 g or less; with colpo-urethrocystopexy (Marshall-Marchetti-Krantz type, Pereyra type) with or without endoscopic control Vaginal hysterectomy, for uterus 250 g or less; with repair of enterocele Vaginal hysterectomy, with total or partial vaginectomy; Vaginal hysterectomy, with total or partial vaginectomy; with repair of enterocele Vaginal hysterectomy, radical (Schauta type operation) Vaginal hysterectomy, for uterus greater than 250 g; 40.06: continued ASC Incl Rate PC Fee TC Fee 40.06(8) - Surgical Services Description (con’t) Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s) Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s), with repair of enterocele Vaginal hysterectomy, for uterus greater than 250 g; with colpo-urethrocystopexy (Marshall-Marchetti- Krantz type, Pereyra type) with or without endoscopic control Vaginal hysterectomy, for uterus greater than 250 g; with repair of enterocele Insertion of intrauterine device (IUD) Removal of intrauterine device (IUD) Catheterization and introduction of saline or contrast material for saline infusion sonohysterography (SIS) or hysterosalpingography Transcervical introduction of fallopian tube catheter for diagnosis and/or re-establishing patency (any method), with or without hysterosalpingography Insertion of Heyman capsules for clinical brachytherapy Chromotubation of oviduct, including materials Endometrial ablation, thermal, without hysteroscopic guidance Endometrial cryoablation with ultrasonic guidance, including endometrial curettage, when performed Uterine suspension, with or without shortening of round ligaments, with or without shortening of sacrouterine ligaments; (separate procedure) Uterine suspension, with or without shortening of round ligaments, with or without shortening of sacrouterine ligaments; with presacral sympathectomy Hysterorrhaphy, repair of ruptured uterus (nonobstetrical) Hysteroplasty, repair of uterine anomaly (Strassman type) Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less; Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s) Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g; Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s) Laparoscopy, surgical, myomectomy, excision; 1 to 4 intramural myomas with total weight of 250 g or less and/or removal of surface myomas Laparoscopy, surgical, myomectomy, excision; 5 or more intramural myomas and/or intramural myomas with total weight greater than 250 g Laparoscopy, surgical, with radical hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy), with removal of tube(s) and ovary(s), if performed ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less; Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s) Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g; Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s) Hysteroscopy, diagnostic (separate procedure) Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D & C Hysteroscopy, surgical; with lysis of intrauterine adhesions (any method) Hysteroscopy, surgical; with division or resection of intrauterine septum (any method) Hysteroscopy, surgical; with removal of leiomyomata Hysteroscopy, surgical; with removal of impacted foreign body Hysteroscopy, surgical; with endometrial ablation (eg, endometrial resection, electrosurgical ablation, thermoablation) Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s) Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g; Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s) I.C. Unlisted laparoscopy procedure, uterus I.C. Unlisted hysteroscopy procedure, uterus Ligation or transection of fallopian tube(s), abdominal or vaginal approach, unilateral or bilateral Laparoscopy, surgical; with lysis of adhesions (salpingolysis, ovariolysis) (separate procedure) Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy) Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method Laparoscopy, surgical; with fulguration of oviducts (with or without transection) Laparoscopy, surgical; with occlusion of oviducts by device (eg, band, clip, or Falope ring) Laparoscopy, surgical; with fimbrioplasty ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Laparoscopy, surgical; with salpingostomy (salpingoneostomy) I.C. Unlisted laparoscopy procedure, oviduct, ovary Salpingectomy, complete or partial, unilateral or bilateral (separate procedure) Salpingo-oophorectomy, complete or partial, unilateral or bilateral (separate procedure) Lysis of adhesions (salpingolysis, ovariolysis) Tubotubal anastomosis Tubouterine implantation Fimbrioplasty Salpingostomy (salpingoneostomy) Drainage of ovarian cyst(s), unilateral or bilateral (separate procedure); vaginal approach Drainage of ovarian cyst(s), unilateral or bilateral (separate procedure); abdominal approach Drainage of ovarian abscess; vaginal approach, open Drainage of ovarian abscess; abdominal approach Drainage of pelvic abscess, transvaginal or transrectal approach, percutaneous (eg, ovarian, pericolic) Transposition, ovary(s) Biopsy of ovary, unilateral or bilateral (separate procedure) Wedge resection or bisection of ovary, unilateral or bilateral Ovarian cystectomy, unilateral or bilateral Oophorectomy, partial or total, unilateral or bilateral; Oophorectomy, partial or total, unilateral or bilateral; for ovarian, tubal or primary peritoneal malignancy, with para-aortic and pelvic lymph node biopsies, peritoneal washings, peritoneal biopsies, diaphragmatic assessments, with or without salpingectomy(s), with or without omentectomy Resection (initial) of ovarian, tubal or primary perito n ea l m al i gn ancy with bilateral salpingo-oophorectomy and omentectomy; Resection (initial) of ovarian, tubal or primary peritoneal ma lign a n c y w ith b ila tera l salpingo-oophorectomy and omentectomy; with total abdominal hysterectomy, pelvic and limited para-aortic lymphadenectomy Resection (initial) of ovarian, tubal or primary p er i t o n ea l m al ignancy with bilateral salpingo-oophorectomy and omentectomy; with radical dissection for debulking (ie, radical excision or destruction, intra-abdominal or retroperitoneal tumors) Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical dissection for debulking; Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical dissection for debulking; with pelvic lymphadenectomy and limited para-aortic lymphadenectomy ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Bilateral salpingo-oophorectomy with total omentectomy, total abdominal hysterectomy for malignancy Resection (tumor debulking) of recurrent ovarian, tubal, primary peritoneal, uterine malignancy (intra-abdominal, retroperitoneal tumors), with omentectomy, if performed; Resection (tumor debulking) of recurrent ovarian, tubal, primary peritoneal, uterine malignancy (intra-abdominal, retroperitoneal tumors), with omentectomy, if performed; with pelvic lymphadenectomy and limited para-aortic lymphadenectomy Laparotomy, for staging or restaging of ovarian, tubal, or primary peritoneal malignancy (second look), with or without omentectomy, peritoneal washing, biopsy of abdominal and pelvic peritoneum, diaphragmatic assessment with pelvic and limited para-aortic lymphadenectomy Follicle puncture for oocyte retrieval, any method I.C. Embryo transfer, intrauterine Gamete, zygote, or embryo intrafallopian transfer, any method I.C. Unlisted pro cedure, female genital system (nonobstetrical) Amniocentesis; diagnostic Amniocentesis; therapeutic amniotic fluid reduction (includes ultrasound guidance) Cordocentesis (intrauterine), any method Chorionic villus sampling, any method 37.46 35.22 Fetal contraction stress test 30.28 17.17 Fetal non-stress test Fetal scalp blood sampling Fetal monitoring during labor by consulting physician (ie, non-attending physician) with written report; supervision and interpretation Fetal monitoring during labor by consulting physician (ie, non-attending physician) with written report; interpretation only Transabdominal amnioinfusion, including ultrasound guidance Fetal umbilical cord occlusion, including ultrasound guidance F e ta l f lui d d rainag e (eg , v e sicoc e ntesis, thoracocentesis, paracentesis), including ultrasound guidance Fetal shunt placement, including ultrasound guidance Hysterotomy, abdominal (eg, for hydatidiform mole, abortion) Surgical treatment of ectopic pregnancy; tubal or ovarian, without salpingectomy and/or oophorectomy Curettage, postpartum Insertion of cervical dilator (eg, laminaria, prostaglandin) (separate procedure) ASC Rate Incl PC Fee TC Fee 40.06(8) - Surgical Services Description (con’t) Episiotomy or vaginal repair, by other than attending physician Cerclage of cervix, during pregnancy; vaginal Cerclage of cervix, during pregnancy; abdominal Hysterorrhaphy of ruptured uterus Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care Vaginal delivery only (with or without episiotomy and/or forceps); Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care External cephalic version, with or without tocolysis Delivery of placenta (separate procedure) Routine obstetric care including antepartum care, cesarean delivery, and postpartum care Cesarean delivery only; Cesarean delivery only; including postpartum care Subtotal or total hysterectomy after cesarean delivery (List separately in addition to code for primary procedure) Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care, after previous cesarean delivery Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps); Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps); including postpartum care Routine obstetric care including antepartum care, cesarean delivery, and postpartum care, following attempted vaginal delivery after previous cesarean delivery Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery; Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery; including postpartum care Treatment of incomplete abortion, any trimester, completed surgically Treatment of missed abortion, completed surgically; first trimester Treatment of missed abortion, completed surgically; second trimester Treatment of septic abortion, completed surgically Induced abortion, by dilation and curettage Induced abortion, by dilation and evacuation Induced abortion, by one or more intra-amniotic injections (amniocentesis-injections), including hospital admission and visits, delivery of fetus and secundines; 40.06: continued ASC Incl Rate PC Fee TC Fee I.C. I.C. I.C. 40.06(8) - Surgical Services Description (con’t) Induced abortion, by one or more intra-amniotic injections (amniocentesis-injections), including hospital admission and visits, delivery of fetus and secundines; with dilation and curettage and/or evacuation Induced abortion, by one or more intra-amniotic injections (amniocentesis-injections), including hospital admission and visits, delivery of fetus and secundines; with hysterotomy (failed intra-amniotic injection) Induced abortion, by one or more vaginal suppositories (eg, prostaglandin) with or without cervical dilation (eg, laminaria), including hospital admission and visits, delivery of fetus and secundines; Induced abortion, by one or more vaginal suppositories (eg, prostaglandin) with or without cervical dilation (eg, laminaria), including hospital admission and visits, delivery of fetus and secundines; with dilation and curettage and/or evacuation Induced abortion, by one or more vaginal suppositories (eg, prostaglandin) with or without cervical dilation (eg, laminaria), including hospital admission and visits, delivery of fetus and secundines; with hysterotomy (failed medical evacuation) Multifetal pregnancy reduction(s) (MPR) Uterine evacuation and curettage for hydatidiform mole Removal of cerclage suture under anesthesia (other than local) Unlisted fetal invasive procedure, including ultrasound guidance Unlisted laparoscopy procedure, maternity care and delivery Unlisted procedure, maternity care and delivery Incision and drainage of thyroglossal duct cyst, infected Biopsy thyroid, percutaneous core needle Excision of cyst or adenoma of thyroid, or transection of isthmus Partial thyroid lobectomy, unilateral; with or without isthmusectomy Partial thyroid lobectomy, unilateral; with contralateral subtotal lobectomy, including isthmusectomy Total thyroid lobectomy, unilateral; with or without isthmusectomy Total thyroid lobectomy, unilateral; with contralateral subtotal lobectomy, including isthmusectomy Thyroidectomy, total or complete Thyroidectomy, total or subtotal for malignancy; with limited neck dissection Thyroidectomy, total or subtotal for malignancy; with radical neck dissection Thyroidectomy, removal of all remaining thyroid tissue following previous removal of a portion of thyroid ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Thyroidectomy, including substernal thyroid; sternal split or transthoracic approach Thyroidectomy, including substernal thyroid; cervical approach Excision of thyroglossal duct cyst or sinus; Excision of thyroglossal duct cyst or sinus; recurrent Aspiration and/or injection, thyroid cyst Parathyroidectomy or exploration of parathyroid(s); Parathyroidectomy or exploration of parathyroid(s); re-exploration Parathyroidectomy or exploration of parathyroid(s); with mediastinal exploration, sternal split or transthoracic approach Parathyroid autotransplantation (List separately in addition to code for primary procedure) Thymectomy, partial or total; transcervical approach (separate procedure) Thymectomy, partial or total; sternal split or transthoracic approach, without radical mediastinal dissection (separate procedure) Thymectomy, partial or total; sternal split or transthoracic approach, with radical mediastinal dissection (separate procedure) Adrenalectomy, partial or complete, or exploration of adrenal gland with or without biopsy, transabdominal, lumbar or dorsal (separate procedure); Adrenalectomy, partial or complete, or exploration of adrenal gland with or without biopsy, transabdominal, lumbar or dorsal (separate procedure); with excision of adjacent retroperitoneal tumor Excision of carotid body tumor; without excision of carotid artery Excision of carotid body tumor; with excision of carotid artery Laparoscopy, surgical, with adrenalectomy, partial or complete, or exploration of adrenal gland with or without biopsy, transabdominal, lumbar or dorsal I.C. Unlisted laparoscopy procedure, endocrine system I.C. Unlisted procedure, endocrine system Ventricular puncture through previous burr hole, fontanelle, suture, or implanted ventricular catheter/reservoir; without injection Ventricular puncture through previous burr hole, fontanelle, suture, or implanted ventricular catheter/reservoir; with injection of medication or other substance for diagnosis or treatment Cisternal or lateral cervical (C1-C2) puncture; without injection (separate procedure) Cisternal or lateral cervical (C1-C2) puncture; with injection of medication or other substance for diagnosis or treatment (eg, C1-C2) Puncture of shunt tubing or reservoir for aspiration or injection procedure Twist drill hole for subdural or ventricular puncture ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Twist drill hole(s) for subdural, intracerebral, or ventricular puncture; for implanting ventricular catheter, pressure recording device, or other intracerebral monitoring device Twist drill hole(s) for subdural, intracerebral, or ventricular puncture; for evacuation and/or drainage of subdural hematoma Burr hole(s) for ventricular puncture (including injection of gas, contrast media, dye, or radioactive material) Burr hole(s) or trephine; with biopsy of brain or intracranial lesion Burr hole(s) or trephine; with drainage of brain abscess or cyst Burr hole(s) or trephine; with subsequent tapping (aspiration) of intracranial abscess or cyst Burr hole(s) with evacuation and/or drainage of hematoma, extradural or subdural Burr hole(s); with aspiration of hematoma or cyst, intracerebral Burr hole(s); for implanting ventricular catheter, reservoir, EEG electrode(s), pressure recording device, or other cerebral monitoring device (separate procedure) Insertion of subcutaneous reservoir, pump or continuous infusion system for connection to ventricular catheter Burr hole(s) or trephine, supratentorial, exploratory, not followed by other surgery Burr hole(s) or trephine, infratentorial, unilateral or bilateral Craniectomy or craniotomy, exploratory; supratentorial Craniectomy or craniotomy, exploratory; infratentorial (posterior fossa) Craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural Craniectomy or craniotomy for evacuation of hematoma, supratentorial; intracerebral Craniectomy or craniotomy for evacuation of hematoma, infratentorial; extradural or subdural Craniectomy or craniotomy for evacuation of hematoma, infratentorial; intracerebellar Incision and subcutaneous placement of cranial bone graft (List separately in addition to code for primary procedure) Craniectomy or craniotomy, drainage of intracranial abscess; supratentorial Craniectomy or craniotomy, drainage of intracranial abscess; infratentorial Craniectomy or craniotomy, decompressive, with or without duraplasty, for treatment of intracranial hypertension, without evacuation of associated intraparenchymal hematoma; without lobectomy ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Craniectomy or craniotomy, decompressive, with or without duraplasty, for treatment of intracranial hypertension, without evacuation of associated intraparenchymal hematoma; with lobectomy Decompression of orbit only, transcranial approach Exploration of orbit (transcranial approach); with biopsy Exploration of orbit (transcranial approach); with removal of lesion Exploration of orbit (transcranial approach); with removal of foreign body Subtemporal cranial decompression (pseudotumor cerebri, slit ventricle syndrome) Craniectomy, suboccipital with cervical laminectomy for decompression of medulla and spinal cord, with or without dural graft (eg, Arnold-Chiari malformation) Other cranial decompression, posterior fossa Craniotomy for section of tentorium cerebelli (separate procedure) Craniectomy, subtemporal, for section, compression, or decompression of sensory root of gasserian ganglion Craniectomy, suboccipital; for exploration or decompression of cranial nerves Craniectomy, suboccipital; for section of one or more cranial nerves Craniectomy, suboccipital; for medullary tractotomy Craniectomy, suboccipital; for mesencephalic tractotomy or pedunculotomy Craniotomy for lobotomy, including cingulotomy Craniectomy; with excision of tumor or other bone lesion of skull Craniectomy; for osteomyelitis Craniectomy, trephination, bone flap craniotomy; for excision of brain tumor, supratentorial, except meningioma Craniectomy, trephination, bone flap craniotomy; for excision of meningioma, supratentorial Craniectomy, trephination, bone flap craniotomy; for excision of brain abscess, supratentorial Craniectomy, trephination, bone flap craniotomy; for excision or fenestration of cyst, supratentorial Implantation of brain intracavitary chemotherapy agent (List separately in addition to code for primary procedure) Craniectomy for ex cision of brain tumor, infratentorial or posterior fossa; except meningioma, cerebellopontine angle tumor, or midline tumor at base of skull Craniectomy for excision of brain tumor, infratentorial or posterior fossa; meningioma Craniectomy for excision of brain tumor, infratentorial or posterior fossa; cerebellopontine angle tumor ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Craniectomy for ex cision of brain tumor, infratentorial or posterior fossa; midline tumor at base of skull Craniectomy, infratentorial or posterior fossa; for excision of brain abscess Craniectomy, infratentorial or posterior fossa; for excision or fenestration of cyst Craniectomy, bone flap craniotomy, transtemporal (mastoid) for excision of cerebellopontine angle tumor; Craniectomy, bone flap craniotomy, transtemporal (mastoid) for excision of cerebellopontine angle tumor; combined with middle/posterior fossa craniotomy/craniectomy Subdural implantation of strip electrodes through one or more burr or trephine hole(s) for long-term seizure monitoring Craniotomy with elevation of bone flap; for subdural implantation of an electrode array, for long-term seizure monitoring Craniotomy with elevation of bone flap; for excision of epileptogenic focus without electrocorticography during surgery Craniotomy with elevation of bone flap; for removal of epidural or subdural electrode array, without excision of cerebral tissue (separate procedure) Craniotomy with elevation of bone flap; for excision of cerebral epileptogenic focus, with electrocorticography during surgery (includes removal of electrode array) Craniotomy with elevation of bone flap; for lobecto m y , t em p o ra l l o b e, without electrocorticography during surgery Craniotomy with elevation of bone flap; for lobectomy, temporal lobe, with electrocorticography during surgery Craniotomy with elevation of bone flap; for lobectomy, other than temporal lobe, partial or total, with electrocorticography during surgery Craniotomy with elevation of bone flap; for lobectomy, other than temporal lobe, partial or total, without electrocorticography during surgery Craniotomy with elevation of bone flap; for transection of corpus callosum Craniotomy with elevation of bone flap; for total hemispherectomy Craniotomy with elevation of bone flap; for partial or subtotal (functional) hemispherectomy Craniotomy with elevation of bone flap; for excision or coagulation of choroid plexus Craniotomy with elevation of bone flap; for excision of craniopharyngioma Craniotomy for hypophysectomy or excision of pituitary tumor, intracranial approach ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Hypophysectomy or excision of pituitary tumor, transnasal or transseptal approach, nonstereotactic Craniectomy for craniosynostosis; single cranial suture Craniectomy for craniosynostosis; multiple cranial sutures Craniotomy for craniosynostosis; frontal or parietal bone flap Craniotomy for craniosynostosis; bifrontal bone flap Extensive craniectomy for multiple cranial suture craniosynostosis (eg, cloverleaf skull); not requiring bone grafts Extensive craniectomy for multiple cranial suture craniosynostosis (eg, cloverleaf skull); recontouring with multiple osteotomies and bone autografts (eg, barrel-stave procedure) (includes obtaining grafts) Excision, intra and extracranial, benign tumor of cranial bone (eg, fibrous dysplasia); without optic nerve decompression Excision, intra and extracranial, benign tumor of cranial bone (eg, fibrous dysplasia); with optic nerve decompression Craniotomy with elevation of bone flap; for selective amygdalohippocampectomy Craniotomy with elevation of bone flap; for multiple subpial transections, with electrocorticography during surgery Craniectomy or craniotomy; with excision of foreign body from brain Craniectomy or craniotomy; with treatment of penetrating wound of brain Transoral approach to skull base, brain stem or upper spinal cord for biopsy, decompression or excision of lesion; Transoral approach to skull base, brain stem or upper spinal cord for biopsy, decompression or excision of lesion; requiring splitting of tongue and/or mandible (including tracheostomy) Craniofacial approach to anterior cranial fossa; extradural, including lateral rhinotomy, ethmoidectomy, sphenoidectomy, without maxillectomy or orbital exenteration Craniofacial approach to anterior cranial fossa; extradural, including lateral rhinotomy, orbital exenteration, ethmoidectomy, sphenoidectomy and/or maxillectomy Craniofacial approach to anterior cranial fossa; extradural, including unilateral or bifrontal craniotomy, elevation of frontal lobe(s), osteotomy of base of anterior cranial fossa Craniofacial approach to anterior cranial fossa; intradural, including unilateral or bifrontal craniotomy, elevation or resection of frontal lobe, osteotomy of base of anterior cranial fossa ASC Rate Incl PC Fee TC Fee 40.06(8) - Surgical Services Description (con’t) Orbitocranial approach to anterior cranial fossa, extradural, including supraorbital ridge osteotomy and elevation of frontal and/or temporal lobe(s); without orbital exenteration Orbitocranial approach to anterior cranial fossa, extradural, including supraorbital ridge osteotomy and elevation of frontal and/or temporal lobe(s); with orbital exenteration Bicoronal, transzygomatic and/or LeFort I osteotomy approach to anterior cranial fossa with or without internal fixation, without bone graft Infratemporal pre-auricular approach to middle cranial fossa (parapharyngeal space, infratemporal and midline skull base, nasopharynx), with or without disarticulation of the mandible, including parotidectomy, craniotomy, decompression and/or mobilization of the facial nerve and/or petrous carotid artery Infratemporal post-auricular approach to middle cranial fossa (internal auditory meatus, petrous apex, tentorium, cavernous sinus, parasellar area, infratemporal fossa) including mastoidectomy, resection of sigmoid sinus, with or without decompression and/or mobilization of contents of auditory canal or petrous carotid artery Orbitocranial zygomatic approach to middle cranial fossa (cavernous sinus and carotid artery, clivus, basilar artery or petrous apex) including osteotomy of zygoma, craniotomy, extra- or intradural elevation of temporal lobe Transtemporal approach to posterior cranial fossa, jugular foramen or midline skull base, including mastoidectomy, decompression of sigmoid sinus and/or facial nerve, with or without mobilization Transcochlear approach to posterior cranial fossa, jugular foramen or midline skull base, including labyrinthectomy, decompression, with or without mobilization of facial nerve and/or petrous carotid artery Transcondylar (far lateral) approach to posterior cranial fossa, jugular foramen or midline skull base, including occipital condylectomy, mastoidectomy, resection of C1-C3 vertebral body(s), decompression of vertebral artery, with or without mobilization Transpetrosal approach to posterior cranial fossa, clivus or foramen magnum, including ligation of superior petrosal sinus and/or sigmoid sinus Resection or excision of neoplastic, vascular or infectious lesion of base of anterior cranial fossa; extradural Resection or excision of neoplastic, vascular or infectious lesion of base of anterior cranial fossa; intradural, including dural repair, with or without graft ASC Rate Incl PC Fee TC Fee 40.06(8) - Surgical Services Description (con’t) Resection or excision of neoplastic, vascular or infectious lesion of infratemporal fossa, parapharyngeal space, petrous apex; extradural Resection or excision of neoplastic, vascular or infectious lesion of infratemporal fossa, parapharyngeal space, petrous apex; intradural, including dural repair, with or without graft Resection or excision of neoplastic, vascular or infectious lesion of parasellar area, cavernous sinus, clivus or midline skull base; extradural Resection or excision of neoplastic, vascular or infectious lesion of parasellar area, cavernous sinus, clivus or midline skull base; intradural, including dural repair, with or without graft Transection or ligation, carotid artery in cavernous sinus; without repair (List separately in addition to code for primary procedure) Transection or ligation, carotid artery in cavernous sinus; with repair by anastomosis or graft (List separately in addition to code for primary procedure) Transection or ligation, carotid artery in petrous canal; without repair (List separately in addition to code for primary procedure) Transection or ligation, carotid artery in petrous canal; with repair by anastomosis or graft (List separately in addition to code for primary procedure) Obliteration of carotid aneurysm, arteriovenous malformation, or carotid-cavernous fistula by dissection within cavernous sinus Resection or excision of neoplastic, vascular or infectious lesion of base of posterior cranial fossa, jugular foramen, foramen magnum, or C1-C3 vertebral bodies; extradural Resection or excision of neoplastic, vascular or infectious lesion of base of posterior cranial fossa, jugular foramen, foramen magnum, or C1-C3 vertebral bodies; intradural, including dural repair, with or without graft Secondary repair of dura for cerebrospinal fluid leak, anterior, middle or posterior cranial fossa following surgery of the skull base; by free tissue graft (eg, pericranium, fascia, tensor fascia lata, adipose tissue, homologous or synthetic grafts) Secondary repair of dura for cerebrospinal fluid leak, anterior, middle or posterior cranial fossa following surgery of the skull base; by local or regionalized vascularized pedicle flap or myocutaneous flap (including galea, temporalis, frontalis or occipitalis muscle) ASC Incl PC TC Rate Fee Fee 40.06(8) - Surgical Services Description (con’t) Endovascular temporary balloon arterial occlusion, head or neck (extracranial/intracranial) including selective catheterization of vessel to be occluded, positioning and inflation of occlusion balloon, concomitant neurological monitoring, and radiologic supervision and interpretation of all angiography required for balloon occlusion and to exclude vascular injury post occlusion Transcatheter permanent occlusion or embolization (eg, for tumor destruction, to achieve hemostasis, to occlude a vascular malformation), percutaneous, any method; central nervous system (intracranial, spinal cord) Transcatheter permanent occlusion or embolization (eg, for tumor destruction, to achieve hemostasis, to occlude a vascular malformation), percutaneous, any method; non-central nervous system, head or neck (extracranial, brachiocephalic branch) Balloon angioplasty, intracranial (eg, atherosclerotic stenosis), percutaneous Transcatheter placement of intravascular stent(s), intracranial (eg, atherosclerotic stenosis), including balloon angioplasty, if performed Balloon dilatation of intracranial vasospasm, percutaneous; initial vessel Balloon dilatation of intracranial vasospasm, percutaneous; each additional vessel in same vascular family (List separately in addition to code for primary procedure) Balloon dilatation of intracranial vasospasm, percutaneous; each additional vessel in different vascular family (List separately in addition to code for primary procedure) Surgery of intracranial arteriovenous malformation; supratentorial, simple Surgery of intracranial arteriovenous malformation; supratentorial, complex Surgery of intracranial arteriovenous malformation; infratentorial, simple Surgery of intracranial arteriovenous malformation; infratentorial, complex Surgery of intracranial arteriovenous malformation; dural, simple Surgery of intracranial arteriovenous malformation; dural, complex Surgery of complex intracranial aneurysm, intracranial approach; carotid circulation Surgery of complex intracranial aneurysm, intracranial approach; vertebrobasilar circulation Surgery of simple intracranial aneurysm, intracranial approach; carotid circulation Surgery of simple intracranial aneurysm, intracranial approach; vertebrobasilar circulation ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Surgery of intracranial aneurysm, cervical approach by application of occluding clamp to cervical carotid artery (Selverstone-Crutchfield type) Surgery of aneurysm, vascular malformation or carotid-cavernous fistula; by intracranial and cervical occlusion of carotid artery Surgery of aneurysm, vascular malformation or carotid-cavernous fistula; by intracranial electrothrombosis Surgery of aneurysm, vascular malformation or carotid-cavernous fistula; by intra-arterial embolization, injection procedure, or balloon catheter Anastomosis, arterial, extracranial-intracranial (eg, middle cerebral/cortical) arteries Creation of lesion by stereotactic method, including burr hole(s) and localizing and recording techniques, single or multiple stages; globus pallidus or thalamus Creation of lesion by stereotactic method, including burr hole(s) and localizing and recording techniques, single or multiple stages; subcortical structure(s) other than globus pallidus or thalamus Stereotactic biopsy, aspiration, or excision, including burr hole(s), for intracranial lesion; Stereotactic biopsy, aspiration, or excision, including burr hole(s), for intracranial lesion; with computed tomography and/or magnetic resonance guidance Stereotactic implantation of depth electrodes into the cerebrum for long-term seizure monitoring Stereotactic localization, including burr hole(s), with insertion of catheter(s) or probe(s) for placement of radiation source Creation of lesion by stereotactic method, percutaneous, by neurolytic agent (eg, alcohol, thermal, electrical, radiofrequency); gasserian ganglion Creation of lesion by stereotactic method, percutaneous, by neurolytic agent (eg, alcohol, thermal, electrical, radiofrequency); trigeminal medullary tract Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator), one or more sessions Stereotacti c computer-assisted volumetric (navigational) procedure, intracranial, extracranial, or spinal (List separately in addition to code for primary procedure) Twist drill or burr hole(s) for implantation of neurostimulator electrodes, cortical Craniectomy or craniotomy for implantation of neurostimulator electrodes, cerebral, cortical Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (eg, thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (eg, thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; each additional array (List separately in addition to primary procedure) Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (eg, thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (eg, thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; each additional array (List separately in addition to primary procedure) Craniectomy for implantation of neurostimulator electrodes, cerebellar; cortical Craniectomy for implantation of neurostimulator electrodes, cerebellar; subcortical Revision or removal of intracranial neurostimulator electrodes Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to two or more electrode arrays Revision or removal of cranial neurostimulator pulse generator or receiver Elevation of depressed skull fracture; simple, extradural Elevation of depressed skull fracture; compound or comminuted, extradural Elevation of depressed skull fracture; with repair of dura and/or debridement of brain Craniotomy for repair of dural/cerebrospinal fluid leak, including surgery for rhinorrhea/otorrhea Reduction of craniomegalic skull (eg, treated hydrocephalus); not requiring bone grafts or cranioplasty Reduction of craniomegalic skull (eg, treated hydrocephalus); with simple cranioplasty Reduction of craniomegalic skull (eg, treated hydrocephalus); requiring craniotomy and reconstruction with or without bone graft (includes obtaining grafts) Repair of encephalocele, skull vault, including cranioplasty Craniotomy for repair of encephalocele, skull base Cranioplasty for skull defect; up to 5 cm diameter ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Cranioplasty for skull defect; larger than 5 cm diameter Removal of bone flap or prosthetic plate of skull Replacement of bone flap or prosthetic plate of skull Cranioplasty for skull defect with reparative brain surgery Cranioplasty with autograft (includes obtaining bone grafts); up to 5 cm diameter Cranioplasty with autograft (includes obtaining bone grafts); larger than 5 cm diameter Incision and retrieval of subcutaneous cranial bone graft for cranioplasty (List separately in addition to code for primary procedure) Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure) Neuroendoscopy, intracranial; with dissection of adhesions, fenestration of septum pellucidum or intraventricular cysts (including placement, replacement, or removal of ventricular catheter) Neuroendoscopy, intracranial; with fenestration or excision of colloid cyst, including placement of external ventricular catheter for drainage Neuroendoscopy, intracranial; with retrieval of foreign body Neuroendoscopy, intracranial; with excision of brain tumor, including placement of external ventricular catheter for drainage Neuroendoscopy, intracranial; with excision of pituitary tumor, transnasal or trans-sphenoidal approach Ventriculocisternostomy (Torkildsen type operation) Creation of shunt; subarachnoid/subdural-atrial, -jugular, -auricular Creation of shunt; subarachnoid/subdural-peritoneal, -pleural, other terminus Replacement or irrigation, subarachnoid/subdural catheter Ventriculocisternostomy, third ventricle; Ventriculocisternostomy, third ventricle; stereotactic, neuroendoscopic method Creation of shunt; ventriculo-atrial, -jugular, -auricular Creation of shunt; ventriculo-peritoneal, -pleural, other terminus Replacement or irrigation, ventricular catheter Replacement or revision of cerebrospinal fluid shunt, obstructed valve, or distal catheter in shunt system 45.69 60.44 Reprogramming of programmable cerebrospinal shunt Removal of complete cerebrospinal fluid shunt system; without replacement Removal of complete cerebrospinal fluid shunt system; with replacement by similar or other shunt at same operation 40.06: continued ASC Incl Rate PC Fee TC Fee 40.06(8) - Surgical Services Description (con’t) Percutaneous lysis of epidural adhesions using solution injection (eg, hypertonic saline, enzyme) or mechanical means (eg, catheter) including radiologic localization (includes contrast when administered), multiple adhesiolysis sessions; 2 or more days Percutaneous lysis of epidural adhesions using solution injection (eg, hypertonic saline, enzyme) or mechanical means (eg, catheter) including radiologic localization (includes contrast when administered), multiple adhesiolysis sessions; 1 day Percutaneous aspiration, spinal cord cyst or syrinx Biopsy of spinal cord, percutaneous needle Spinal puncture, lumbar, diagnostic Spinal puncture, therapeutic, for drainage of cerebrospinal fluid (by needle or catheter) Injection, epidural, of blood or clot patch Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions), with or without other therapeutic substance; subarachnoid Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions), with or without other therapeutic substance; epidural, cervical or thoracic Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions), with or without other therapeutic substance; epidural, lumbar, sacral (caudal) Injection procedure for myelography and/or computed tomography, spinal (other than C1-C2 and posterior fossa) Aspiration or decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, any method, single or multiple levels, lumbar (eg, manual or automated percutaneous discectomy, percutaneous laser discectomy) Injection procedure for discography, each level; lumbar Injection procedure for discography, each level; cervical or thoracic Injection procedure for chemonucleolysis, including discography, intervertebral disc, single or multiple levels, lumbar Injection procedure, arterial, for occlusion of arteriovenous malformation, spinal Injection, single (not via indwelling catheter), not including neurolytic substances, with or without contrast (for either localization or epidurography), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), epidural or subarachnoid; cervical or thoracic ASC Incl Rate PC TC Fee Fee 40.06(8) - Surgical Services Description (con’t) Injection, single (not via indwelling catheter), not including neurolytic substances, with or without contrast (for either localization or epidurography), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), epidural or subarachnoid; lumbar, sacral (caudal) Injection, including catheter placement, continuous infusion or intermittent bolus, not including neurolytic substances, with or without contrast (for either localization or epidurography), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), epidural or subarachnoid; cervical or thoracic Injection, including catheter placement, continuous infusion or intermittent bolus, not including neurolytic substances, with or without contrast (for either localization or epidurography), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), epidural or subarachnoid; lumbar, sacral (caudal) Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; without laminectomy Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; with laminectomy Removal of previously implanted intrathecal or epidural catheter Implantation or replacement of device for intrathecal or epidural drug infusion; subcutaneous reservoir Implantation or replacement of device for intrathecal or epidural drug infusion; nonprogrammable pump Implantation or replacement of device for intrathecal or epidural drug infusion; programmable pump, including preparation of pump, with or without programming Removal of subcutaneous reservoir or pump, previously implanted for intrathecal or epidural infusion Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); without reprogramming Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); with reprogramming ASC Incl PC TC Rate Fee Fee I 40.06(8) - Surgical Services Description (con’t) Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; cervical Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; thoracic Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; lumbar, except for spondylolisthesis Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; sacral Laminectomy with removal of abnormal facets and/or pars inter-articularis with decompression of cauda equina and nerve roots for spondylolisthesis, lumbar (Gill type procedure) Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral segments; cervical Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral segments; thoracic Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral segments; lumbar Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; one interspace, cervical Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; one interspace, lumbar (including open or endoscopically-assisted approach) Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; each additional interspace, cervical or lumbar (List separately in addition to code for primary procedure) Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; cervical ASC Incl PC TC Rate Fee Fee I.C. I.C. I 40.06(8) - Surgical Services Description (con’t) Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; lumbar Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; each additional cervical interspace (List separately in addition to code for primary procedure) Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; each additional lumbar interspace (List separately in addition to code for primary procedure) Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; cervical Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; thoracic Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; each additional segment, cervical, thoracic, or lumbar (List separately in addition to code for primary procedure) Laminoplasty, cervical, with decompression of the spinal cord, two or more vertebral segments; Laminoplasty, cervical, with decompression of the spinal cord, two or more vertebral segments; with reconstruction of the posterior bony elements (including the application of bridging bone graft and non-segmental fixation devices (eg, wire, suture, mini-plates), when performed) Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; thoracic Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; lumbar (including transfacet, or lateral extraforaminal approach) (eg, far lateral herniated intervertebral disc) ASC Rate Incl PC Fee TC Fee 40.06(8) - Surgical Services Description (con’t) I Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; each additional segment, thoracic or lumbar (List separately in addition to code for primary procedure) Costovertebral approach with decompression of spinal cord or nerve root(s) (eg, herniated intervertebral disc), thoracic; single segment Costovertebral approach with decompression of spinal cord or nerve root(s) (eg, herniated intervertebral disc), thoracic; each additional segment (List separately in addition to code for primary procedure) Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, single interspace Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, each additional interspace (List separately in addition to code for primary procedure) Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; thoracic, single interspace Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; thoracic, each additional interspace (List separately in addition to code for primary procedure) Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, single segment Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, each additional segment (List separately in addition to code for primary procedure) Vertebral corpectomy (vertebral body resection), partial or complete, transthoracic approach with decompression of spinal cord and/or nerve root(s); thoracic, single segment Vertebral corpectomy (vertebral body resection), partial or complete, transthoracic approach with decompression of spinal cord and/or nerve root(s); thoracic, each additional segment (List separately in addition to code for primary procedure) Vertebral corpectomy (vertebral body resection), partial or complete, combined thoracolumbar approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic or lumbar; single segment Vertebral corpectomy (vertebral body resection), partial or complete, combined thoracolumbar approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic or lumbar; each additional segment (List separately in addition to code for primary procedure) ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Vertebral corpectomy (vertebral body resection), partial or complete, transperitoneal or retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic, lumbar, or sacral; single segment Vertebral corpectomy (vertebral body resection), partial or complete, transperitoneal or retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic, lumbar, or sacral; each additional segment (List separately in addition to code for primary procedure) Vertebral corpectomy (vertebral body resection), partial or complete, lateral extracavitary approach with decompression of spinal cord and/or nerve root(s) (eg, for tumor or retropulsed bone fragments); thoracic, single segment Vertebral corpectomy (vertebral body resection), partial or complete, lateral extracavitary approach with decompression of spinal cord and/or nerve root(s) (eg, for tumor or retropulsed bone fragments); lumbar, single segment Vertebral corpectomy (vertebral body resection), partial or complete, lateral extracavitary approach with decompression of spinal cord and/or nerve root(s) (eg, for tumor or retropulsed bone fragments); thoracic or lumbar, each additional segment (List separately in addition to code for primary procedure) Laminectomy with myelotomy (eg, Bischof or DREZ type), cervical, thoracic, or thoracolumbar Laminectomy with drainage of intramedullary cyst/syrinx; to subarachnoid space Laminectomy with drainage of intramedullary cyst/syrinx; to peritoneal or pleural space Laminectomy and section of dentate ligaments, with or without dural graft, cervical; one or two segments Laminectomy and section of dentate ligaments, with or without dural graft, cervical; more than two segments Laminectomy with rhizotomy; one or two segments Laminectomywith rhizotomy; more than two segments Laminectomy with section of spinal accessory nerve Laminectomy with cordotomy, with section of one spinothalamic tract, one stage; cervical Laminectomy with cordotomy, with section of one spinothalamic tract, one stage; thoracic Laminectomy with cordotomy, with section of both spinothalamic tracts, one stage; cervical Laminectomy with cordotomy, with section of both spinothalamic tracts, one stage; thoracic Laminectomy with cordotomy with section of both spinothalamic tracts, two stages within 14 days; cervical Laminectomy with cordotomy with section of both spinothalamic tracts, two stages within 14 days; thoracic ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Laminectomy, with release of tethered spinal cord, lumbar Laminectomy for ex cision or occlusion of arteriovenous malformation of spinal cord; cervical Laminectomy for excision or occlusion of arteriovenous malformation of spinal cord; thoracic Laminectomy for ex cision or occlusion of arteriovenous malformation of spinal cord; thoracolumbar Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; cervical Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; thoracic Laminectomyfor excision or evacuation of intraspinal lesion other than neoplasm, extradural; lumbar Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; sacral Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; cervical Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; thoracic Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; lumbar Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; sacral Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, cervical Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, thoracic Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, lumbar Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, sacral Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, extramedullary, cervical Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, extramedullary, thoracic Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, extramedullary, lumbar Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, sacral Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, intramedullary, cervical Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, intramedullary, thoracic Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, intramedullary, thoracolumbar Laminectomy for biopsy/excision of intraspinal neoplasm; combined extradural-intradural lesion, any level Osteoplastic reconstruction of dorsal spinal elements, following primary intraspinal procedure (List separately in addition to code for primary procedure) ASC Incl Rate PC Fee TC Fee 40.06(8) - Surgical Services Description (con’t) Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; extradural, cervical Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; extradural, thoracic by transthoracic approach Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; extradural, thoracic by thoracolumbar approach Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; extradural, lumbar or sacral by transperitoneal or retroperitoneal approach Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; intradural, cervical Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; intradural, thoracic by transthoracic approach Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; intradural, thoracic by thoracolumbar approach Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; intradural, lumbar or sacral by transperitoneal or retroperitoneal approach Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; each additional segment (List separately in addition to codes for single segment) Creation of lesion of spinal cord by stereotactic method, percutaneous, any modality (including stimulation and/or recording) Stereotactic stimulation of spinal cord, percutaneous, separate procedure not followed by other surgery Stereotactic biopsy, aspiration, or excision of lesion, spinal cord Percutaneous implantation of neurostimulator electrode array, epidural Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural Revision or removal of spinal neurostimulator electrode percutaneous array(s) or plate/paddle(s) Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling Revision or removal of implanted spinal neurostimulator pulse generator or receiver Repair of meningocele; less than 5 cm diameter Repair of meningocele; larger than 5 cm diameter Repair of myelomeningocele; less than 5 cm diameter ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Repair of myelomeningocele; larger than 5 cm diameter Repair of dural/cerebrospinal fluid leak, not requiring laminectomy Repair of dural/cerebrospinal fluid leak or pseudomeningocele, with laminectomy Dural graft, spinal Creation of shunt, lumbar, subarachnoid-peritoneal, -pleural, or other; including laminectomy Creation of shunt, lumbar, subarachnoid-peritoneal, -pleural, or other; percutaneous, not requiring laminectomy Re p la c e me n t, ir r iga ti o n or re vision of lumbosubarachnoid shunt Removal of entire lumbosubarachnoid shunt system without replacement Injection, anesthetic agent; trigeminal nerve, any division or branch Injection, anesthetic agent; facial nerve Injection, anesthetic agent; greater occipital nerve Injection, anesthetic agent; vagus nerve Injection, anesthetic agent; phrenic nerve Injection, anesthetic agent; spinal accessory nerve Injection, anesthetic agent; cervical plexus Injection, anesthetic agent; brachial plexus, single Injection, anesthetic agent; brachial plexus, continuous infusion by catheter (including catheter placement) including daily management for anesthetic agent administration Injection, anesthetic agent; axillary nerve Injection, anesthetic agent; suprascapular nerve Injection, anesthetic agent; intercostal nerve, single Injection, anesthetic agent; intercostal nerves, multiple, regional block Injec tion, anes th eti c agent ; i li oi ngui nal, iliohypogastric nerves Injection, anesthetic agent; pudendal nerve Injection, anesthetic agent; paracervical (uterine) nerve Injection, anesthetic agent; sciatic nerve, single Injection, anesthetic agent; sciatic nerve, continuous infusion by catheter (including catheter placement), including daily management for anesthetic agent administration Injection, anesthetic agent; femoral nerve, single Injection, anesthetic agent; femoral nerve, continuous infusion by catheter (including catheter placement) including daily management for anesthetic agent administration Injection, anesthetic agent; lumbar plexus, posterior approach, continuous infusion by catheter (including catheter placement) including daily management for anesthetic agent administration Injection, anesthetic agent; other peripheral nerve or branch 40.06: continued Code ASC Incl Rate 64470 315.26 64472 183.07 64475 315.26 64476 103.73 64479 315.26 64480 183.07 64530 315.26 PC TC Fee Fee 40.06(8) - Surgical Services Description (con’t) Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; cervical or thoracic, single level Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; cervical or thoracic, each additional level (List separately in addition to code for primary procedure) Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; lumbar or sacral, single level Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; lumbar or sacral, each additional level (List separately in addition to code for primary procedure) Injection, anesthetic agent and/or steroid, transforaminal epidural; cervical or thoracic, single level Injection, anesthetic agent and/or steroid, transforaminal epidural; cervical or thoracic, each additional level (List separately in addition to code for primary procedure) Injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, single level Injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, each additional level (List separately in addition to code for primary procedure) Injection, anesthetic agent; sphenopalatine ganglion Injection, anesthetic agent; carotid sinus (separate procedure) Injection, anesthetic agent; stellate ganglion (cervical sympathetic) Injection, anesthetic agent; superior hypogastric plexus Injection, anesthetic agent; lumbar or thoracic (paravertebral sympathetic) Injection, anesthetic agent; celiac plexus, with or without radiologic monitoring Application of surface (transcutaneous) neurostimulator Percutaneous implantation of neurostimulator electrodes; cranial nerve Percutaneous implantation of neurostimulator electrodes; peripheral nerve (excludes sacral nerve) Percutaneous implantation of neurostimulator electrodes; autonomic nerve Percutaneous implantation of neurostimulator electrodes; sacral nerve (transforaminal placement) Percutaneous implantation of neurostimulator electrodes; neuromuscular Incision for implantation of neurostimulator electrodes; cranial nerve Incision for implantation of neurostimulator electrodes; peripheral nerve (excludes sacral nerve) Incision for implantation of neurostimulator electrodes; autonomic nerve 40.06: continued Code ASC Incl Rate 64612 74.65 64623 315.26 64680 647.43 64681 647.43 PC TC Fee Fee 40.06(8) - Surgical Services Description (con’t) Incision for implantation of neurostimulator electrodes; neuromuscular Incision for implantation of neurostimulator electrodes; sacral nerve (transforaminal placement) Revision or removal of peripheral neurostimulator electrodes Insertion or replacement of peripheral or gastric neurostimulator pulse generator or receiver, direct or inductive coupling Revision or removal of peripheral or gastric neurostimulator pulse generator or receiver Destruction by neurolytic agent, trigeminal nerve; supraorbital, infraorbital, mental, or inferior alveolar branch Destruction by neurolytic agent, trigeminal nerve; second and third division branches at foramen ovale Destruction by neurolytic agent, trigeminal nerve; second and third division branches at foramen ovale under radiologic monitoring Chemodenervation of muscle(s); muscle(s) innervated by facial nerve (eg, for blepharospasm, hemifacial spasm) Chemodenervation of muscle(s); neck muscle(s) (eg, for spasmodic torticollis, spasmodic dysphonia) Chemodenervation of muscle(s); extremity(s) and/or trunk muscle(s) (eg, for dystonia, cerebral palsy, multiple sclerosis) Destruction by neurolytic agent, intercostal nerve Destruction by neurolytic agent, paravertebral facet joint nerve; lumbar or sacral, single level Destruction by neurolytic agent, paravertebral facet joint nerve; lumbar or sacral, each additional level (List separately in addition to code for primary procedure) Destruction by neurolytic agent, paravertebral facet joint nerve; cervical or thoracic, single level Destruction by neurolytic agent, paravertebral facet joint nerve; cervical or thoracic, each additional level (List separately in addition to code for primary procedure) Destruction by neurolytic agent; pudendal nerve Destruction by neurolytic agent; other peripheral nerve or branch Chemodenervation of eccrine glands; both axillae Chemodenervation of eccrine glands; other area(s) (eg, scalp, face, neck), per day Destruction by neurolytic agent, with or without radiologic monitoring; celiac plexus Destruction by neurolytic agent, with or without radiologic monitoring; superior hypogastric plexus Neuroplasty; digital, one or both, same digit Neuroplasty; nerve of hand or foot Neuroplasty, major peripheral nerve, arm or leg; other than specified ASC Rate Incl PC Fee TC Fee I I 40.06(8) - Surgical Services Description (con’t) Neuroplasty, major peripheral nerve, arm or leg; sciatic nerve Neuroplasty, major peripheral nerve, arm or leg; brachial plexus Neuroplasty, major peripheral nerve, arm or leg; lumbar plexus Neuroplasty and/or transposition; cranial nerve (specify) Neuroplasty and/or transposition; ulnar nerve at elbow Neuroplasty and/or transposition; ulnar nerve at wrist Neuroplasty and/or transposition; median nerve at carpal tunnel Decompression; unspecified nerve(s) (specify) Decompression; plantar digital nerve Internal neurolysis, requiring use of operating microscope (List separately in addition to code for neuroplasty) (Neuroplasty includes external neurolysis) Transection or avulsion of; supraorbital nerve Transection or avulsion of; infraorbital nerve Transection or avulsion of; mental nerve Transection or avulsion of; inferior alveolar nerve by osteotomy Transection or avulsion of; lingual nerve Transection or avulsion of; facial nerve, differential or complete Transection or avulsion of; greater occipital nerve Transection or avulsion of; phrenic nerve Transection or avulsion of; vagus nerve (vagotomy), transthoracic Transection or avulsion of; vagus nerves limited to proximal stomach (selective proximal vagotomy, proximal gastric vagotomy, parietal cell vagotomy, supra- or highly selective vagotomy) Transection or avulsion of; vagus nerve (vagotomy), abdominal Transection or avulsion of; pudendal nerve Transection or avulsion of obturator nerve, extrapelvic, with or without adductor tenotomy Transection or avulsion of obturator nerve, intrapelvic, with or without adductor tenotomy Transection or avulsion of other cranial nerve, extradural Transection or avulsion of other spinal nerve, extradural Excision of neuroma; cutaneous nerve, surgically identifiable Excision of neuroma; digital nerve, one or both, same digit Excision of neuroma; digital nerve, each additional digit (List separately in addition to code for primary procedure) Excision of neuroma; hand or foot, except digital nerve Excision of neuroma; hand or foot, each additional nerve, except same digit (List separately in addition to code for primary procedure) ASC Rate Incl PC Fee TC Fee 40.06(8) - Surgical Services Description (con’t) Excision of neuroma; major peripheral nerve, except sciatic Excision of neuroma; sciatic nerve Implantation of nerve end into bone or muscle (List separately in addition to neuroma excision) Excision of neurofibroma or neurolemmoma; cutaneous nerve Excision of neurofibroma or neurolemmoma; major peripheral nerve Excision of neurofibroma or neurolemmoma; extensive (including malignant type) Biopsy of nerve Sympathectomy, cervical Sympathectomy, cervicothoracic Sympathectomy, thoracolumbar Sympathectomy, lumbar Sympathectomy; digital arteries, each digit Sympathectomy; radial artery Sympathectomy; ulnar artery Sympathectomy; superficial palmar arch Suture of digital nerve, hand or foot; one nerve Suture of digital nerve, hand or foot; each additional digital nerve (List separately in addition to code for primary procedure) Suture of one nerve; hand or foot, common sensory nerve Suture of one nerve; median motor thenar Suture of one nerve; ulnar motor Suture of each additional nerve, hand or foot (List separately in addition to code for primary procedure) Suture of posterior tibial nerve Suture of major peripheral nerve, arm or leg, except sciatic; including transposition Suture of major peripheral nerve, arm or leg, except sciatic; without transposition Suture of sciatic nerve Suture of each additional major peripheral nerve (List separately in addition to code for primary procedure) Suture of brachial plexus Suture of lumbar plexus Suture of facial nerve; extracranial Suture of facial nerve; infratemporal, with or without grafting Anastomosis; facial-spinal accessory Anastomosis; facial-hypoglossal Anastomosis; facial-phrenic Suture of nerve; requiring secondary or delayed suture (List separately in addition to code for primary neurorrhaphy) Suture of nerve; requiring extensive mobilization, or transposition of nerve (List separately in addition to code for nerve suture) Suture of nerve; requiring shortening of bone of extremity (List separatelyin addition to code for nerve suture) ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Nerve graft (includes obtaining graft), head or neck; up to 4 cm in length Nerve graft (includes obtaining graft), head or neck; more than 4 cm length Nerve graft (includes obtaining graft), single strand, hand or foot; up to 4 cm length Nerve graft (includes obtaining graft), single strand, hand or foot; more than 4 cm length Nerve graft (includes obtaining graft), single strand, arm or leg; up to 4 cm length Nerve graft (includes obtaining graft), single strand, arm or leg; more than 4 cm length Nerve graft (includes obtaining graft), multiple strands (cable), hand or foot; up to 4 cm length Nerve graft (includes obtaining graft), multiple strands (cable), hand or foot; more than 4 cm length Nerve graft (includes obtaining graft), multiple strands (cable), arm or leg; up to 4 cm length Nerve graft (includes obtaining graft), multiple strands (cable), arm or leg; more than 4 cm length Nerve graft, each additional nerve; single strand (List separately in addition to code for primary procedure) Nerve graft, each additional nerve; multiple strands (cable) (List separately in addition to code for primary procedure) Nerve pedicle transfer; first stage Nerve pedicle transfer; second stage Nerve repair; with synthetic conduit or vein allograft (eg, nerve tube), each nerve Nerve repair; with autogenous vein graft (includes harvest of vein graft), each nerve I.C. Unlisted procedure, nervous system Evisceration of ocular contents; without implant Evisceration of ocular contents; with implant Enucleation of eye; without implant Enucleation of eye; with implant, muscles not attached to implant Enucleation of eye; with implant, muscles attached to implant Exenteration of orbit (does not include skin graft), removal of orbital contents; only Exenteration of orbit (does not include skin graft), removal of orbital contents; with therapeutic removal of bone Exenteration of orbit (does not include skin graft), removal of orbital contents; with muscle or myocutaneous flap Modification of ocular implant with placement or replacement of pegs (eg, drilling receptacle for prosthesis appendage) (separate procedure) Insertion of ocular implant secondary; after evisceration, in scleral shell Insertion of ocular implant secondary; after enucleation, muscles not attached to implant ASC Incl Rate PC TC Fee Fee 40.06(8) - Surgical Services Description (con’t) Insertion of ocular implant secondary; after enucleation, muscles attached to implant Reinsertion of ocular implant; with or without conjunctival graft Reinsertion of ocular implant; with use of foreign material for reinforcement and/or attachment of muscles to implant Removal of ocular implant Removal of foreign body, external eye; conjunctival superficial Removal of foreign body, external eye; conjunctival embedded (includes concretions), subconjunctival, or scleral nonperforating Removal of foreign body, external eye; corneal, without slit lamp Removal of foreign body, external eye; corneal, with slit lamp Removal of foreign body, intraocular; from anterior chamber of eye or lens Removal of foreign body, intraocular; from posterior segment, magnetic extraction, anterior or posterior route Removal of foreign body, intraocular; from posterior segment, nonmagnetic extraction Repair of laceration; conjunctiva, with or without nonperforating laceration sclera, direct closure Repair of laceration; conjunctiva, by mobilization and rearrangement, without hospitalization Repair of laceration; conjunctiva, by mobilization and rearrangement, with hospitalization Repair of laceration; cornea, nonperforating, with or without removal foreign body Repair of laceration; cornea and/or sclera, perforating, not involving uveal tissue Repair of laceration; cornea and/or sclera, perforating, with reposition or resection of uveal tissue Repair of laceration; application of tissue glue, wounds of cornea and/or sclera Repair of wound, extraocular muscle, tendon and/or Tenon's capsule Excision of lesion, cornea (keratectomy, lamellar, partial), except pterygium Biopsy of cornea Excision or transposition of pterygium; without graft Excision or transposition of pterygium; with graft Scraping of cornea, diagnostic, for smear and/or culture Removal of corneal epithelium; with or without chemocauterization (abrasion, curettage) Removal of corneal epithelium; with application of chelating agent (eg, EDTA) Destruction of lesion of cornea by cryotherapy, photocoagulation or thermocauterization Multiple punctures of anterior cornea (eg, for corneal erosion, tattoo) Keratoplasty (corneal transplant); lamellar ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Keratoplasty (corneal transplant); penetrating (except in aphakia) Keratoplasty (corneal transplant); penetrating (in aphakia) Keratoplasty (corneal transplant); penetrating (in pseudophakia) I.C. Keratomileusis I.C. Keratophakia I.C. Epikeratoplasty Keratoprosthesis I.C. Radial keratotomy Corneal relaxing incision for correction of surgically induced astigmatism Corneal wedge resection for correction of surgically induced astigmatism Ocular surface reconstruction; amniotic membrane transplantation Ocular surface reconstruction; limbal stem cell allograft (eg, cadaveric or living donor) Ocular surface reconstruction; limbal conjunctival autograft (includes obtaining graft) Paracentesis of anterior chamber of eye (separate procedure); with diagnostic aspiration of aqueous Paracentesis of anterior chamber of eye (separate procedure); with therapeutic release of aqueous Paracentesis of anterior chamber of eye (separate procedure); with removal of vitreous and/or discission of anterior hyaloid membrane, with or without air injection Paracentesis of anterior chamber of eye (separate procedure); with removal of blood, with or without irrigation and/or air injection Goniotomy Trabeculotomy ab externo Trabeculoplastybylaser surgery, one or more sessions (defined treatment series) Severing adhesions of anterior segment, laser technique (separate procedure) Severing adhesions of anterior segment of eye, incisional technique (with or without injection of air or liquid) (separate procedure); goniosynechiae Severing adhesions of anterior segment of eye, incisional technique (with or without injection of air or liquid) (separate procedure); anterior synechiae, except goniosynechiae Severing adhesions of anterior segment of eye, incisional technique (with or without injection of air or liquid) (separate procedure); posterior synechiae Severing adhesions of anterior segment of eye, incisional technique (with or without injection of air or liquid) (separate procedure); corneovitreal adhesions Removal of epithelial downgrowth, anterior chamber of eye ASC Rate Incl PC TC Fee Fee 40.06(8) - Surgical Services Description (con’t) Removal of implanted material, anterior segment of eye Removal of blood clot, anterior segment of eye Injection, anterior chamber of eye (separate procedure); air or liquid Injection, anterior chamber of eye (separate procedure); medication Excision of lesion, sclera Fistulization of sclera for glaucoma; trephination with iridectomy F istuliz ation of sclera fo r gl au co m a; thermocauterization with iridectomy Fistulization of sclera for glaucoma; sclerectomy with punch or scissors, with iridectomy Fistulization of sclera for glaucoma; iridencleisis or iridotasis Fistulization of sclera for glaucoma; trabeculectomy ab externo in absence of previous surgery Fistulization of sclera for glaucoma; trabeculectomy ab externo with scarring from previous ocular surgery or trauma (includes injection of antifibrotic agents) Aqueous shunt to extraocular reservoir (eg, Molteno, Schocket, Denver-Krupin) Revision of aqueous shunt to extraocular reservoir Repair of scleral staphyloma; without graft Repair of scleral staphyloma; with graft Revision or repair of operative wound of anterior segment, any type, early or late, major or minor procedure Iridotomy by stab incision (separate procedure); except transfixion Iridotomy by stab incision (separate procedure); with transfixion as for iris bombe Iridectomy, with corneoscleral or corneal section; for removal of lesion Iridectomy, with corneoscleral or corneal section; with cyclectomy Iridectomy, with corneoscleral or corneal section; peripheral for glaucoma (separate procedure) Iridectomy, with corneoscleral or corneal section; sector for glaucoma (separate procedure) Iridectomy, with corneoscleral or corneal section; optical (separate procedure) Repair of iris, ciliary body (as for iridodialysis) Suture of iris, ciliary body (separate procedure) with retrieval of suture through small incision (eg, McCannel suture) Ciliary body destruction; diathermy Ciliary body destruction; cyclophotocoagulation, transscleral Ciliary body destruction; cyclophotocoagulation, endoscopic Ciliary body destruction; cryotherapy Ciliary body destruction; cyclodialysis 40.06: continued ASC Incl Rate I.C. PC TC Fee Fee 40.06(8) - Surgical Services Description (con’t) Iridotomy/iridectomy by laser surgery (eg, for glaucoma) (one or more sessions) Iridoplasty by photocoagulation (one or more sessions) (eg, for improvement of vision, for widening of anterior chamber angle) Destruction of cyst or lesion iris or ciliary body (nonexcisional procedure) Discission of secondary membranous cataract (opacified posterior lens capsule and/or anterior hyaloid); stab incision technique (Ziegler or Wheeler knife) Discission of secondary membranous cataract (opacified posterior lens capsule and/or anterior hyaloid); laser surgery (eg, YAG laser) (one or more stages) Repositioning of intraocular lens prosthesis, requiring an incision (separate procedure) Removal of secondary membranous cataract (opacified posterior lens capsule and/or anterior hyaloid) with corneo-scleral section, with or without iridectomy (iridocapsulotomy, iridocapsulectomy) Removal of lens material; aspiration technique, one or more stages Removal of lens material; phacofragmentation technique (mechanical or ultrasonic) (eg, phacoemulsification), with aspiration Removal of lens material; pars plana approach, with or without vitrectomy Removal of lens material; intracapsular Removal of lens material; intracapsular, for dislocated lens Removal of lens material; extracapsular (other than 66840, 66850, 66852) Extracapsular cataract removal with insertion of intraocular lens prosthesis (one stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (eg, iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage Intracapsular cataract extraction with insertion of intraocular lens prosthesis (one stage procedure) Extracapsular cataract removal with insertion of intraocular lens prosthesis (one stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification) Insertion of intraocular lens prosthesis (secondary implant), not associated with concurrent cataract removal Exchange of intraocular lens Use of ophthalmic endoscope (List separately in addition to code for primary procedure) Unlisted procedure, anterior segment of eye 40.06: continued ASC Incl Rate PC TC Fee Fee 40.06(8) - Surgical Services Description (con’t) Removal of vitreous, anterior approach (open sky technique or limbal incision); partial removal Removal of vitreous, anterior approach (open sky technique or limbal incision); subtotal removal with mechanical vitrectomy Aspiration or release of vitreous, subretinal or choroidal fluid, pars plana approach (posterior sclerotomy) Injection of vitreous substitute, pars plana or limbal approach (fluid-gas exchange), with or without aspiration (separate procedure) Implantation of intravitreal drug delivery system (eg, ganciclovir implant), includes concomitant removal of vitreous Intravitreal injection of a pharmacologic agent (separate procedure) Discission of vitreous strands (without removal), pars plana approach Severing of vitreous strands, vitreous face adhesions, sheets, membranes or opacities, laser surgery (one or more stages) Vitrectomy, mechanical, pars plana approach; Vitrectomy, mechanical, pars plana approach; with focal endolaser photocoagulation Vitrectomy, mechanical, pars plana approach; with endolaser panretinal photocoagulation Vitrectomy, mechanical, pars plana approach; with removal of preretinal cellular membrane (eg, macular pucker) Vitrectomy, mechanical, pars plana approach; with removal of internal limiting membrane of retina (eg, for repair of macular hole, diabetic macular edema), includes, if performed, intraocular tamponade (ie, air, gas or silicone oil) Vitrectomy, mechanical, pars plana approach; with removal of subretinal membrane (eg, choroidal neovascularization), includes, if performed, intraocular tamponade (ie, air, gas or silicone oil) and laser photocoagulation Repair of retinal detachment, one or more sessions; cryotherapy or diathermy, with or without drainage of subretinal fluid Repair of retinal detachment, one or more sessions; photocoagulation, with or without drainage of subretinal fluid Repair of retinal detachment; scleral buckling (such as lamellar scleral dissection, imbrication or encircling procedure), with or without implant, with or without cryotherapy, photocoagulation, and drainage of subretinal fluid Repair of retinal detachment; with vitrectomy, any method, with or without air or gas tamponade, focal endolaser photocoagulation, cryotherapy, drainage of subretinal fluid, scleral buckling, and/or removal of lens by same technique ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Repair of retinal detachment; by injection of air or other gas (eg, pneumatic retinopexy) Repair of retinal detachment; by scleral buckling or vitrectomy, on patient having previous ipsilateral retinal detachment repair(s) using scleral buckling or vitrectomy techniques Repair of complex retinal detachment (eg, proliferative vitreoretinopathy, stage C-1 or greater, diabetic traction retinal detachment, retinopathy of prematurity, retinal tear of greater than 90 degrees), with vitrectomy and membrane peeling, may include air, gas, or silicone oil tamponade, cryotherapy, endolaser photocoagulation, drainage of subretinal fluid, scleral buckling, and/or removal of lens Release of encircling material (posterior segment) Removal of implanted material, posterior segment; extraocular Removal of implanted material, posterior segment; intraocular Prophylaxis of retinal detachment (eg, retinal break, lattice degeneration) without drainage, one or more sessions; cryotherapy, diathermy Prophylaxis of retinal detachment (eg, retinal break, lattice degeneration) without drainage, one or more sessions; photocoagulation (laser or xenon arc) Destruction of localized lesion of retina (eg, macular edema, tumors), one or more sessions; cryotherapy, diathermy Destruction of localized lesion of retina (eg, macular edema, tumors), one or more sessions; photocoagulation Destruction of localized lesion of retina (eg, macular edema, tumors), one or more sessions; radiation by implantation of source (includes removal of source) Destruction of localized lesion of choroid (eg, choroidal neovascularization); photocoagulation (eg, laser), one or more sessions Destruction of localized lesion of choroid (eg, choroidal neovascularization); photodynamic therapy (includes intravenous infusion) Destruction of localized lesion of choroid (eg, choroidal neovascularization); photodynamic therapy, second eye, at single session (List separately in addition to code for primary eye treatment) Destruction of extensive or progressive retinopathy (eg, diabetic retinopathy), one or more sessions, cryotherapy, diathermy Treatment of extensive or progressive retinopathy, one or more sessions; (eg, diabetic retinopathy), photocoagulation Scleral reinforcement (separate procedure); without graft Scleral reinforcement (separate procedure); with graft I.C. Unlisted procedure, posterior segment ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Strabismus surgery, recession or resection procedure; one horizontal muscle Strabismus surgery, recession or resection procedure; two horizontal muscles Strabismus surgery, recession or resection procedure; one vertical muscle (excluding superior oblique) Strabismus surgery, recession or resection procedure; two or more vertical muscles (excluding superior oblique) Strabismus surgery, any procedure, superior oblique muscle Transposition procedure (eg, for paretic extraocular muscle), any extraocular muscle (specify) (List separately in addition to code for primary procedure) Strabismus surgery on patient with previous eye surgery or injury that did not involve the extraocular muscles (List separately in addition to code for primary procedure) Strabismus surgery on patient with scarring of extraocular muscles (eg, prior ocular injury, strabismus or retinal detachment surgery) or restrictive myopathy (eg, dysthyroid ophthalmopathy) (List separately in addition to code for primary procedure) Strabismus surgery by posterior fixation suture technique, with or without muscle recession (List separately in addition to code for primary procedure) Placement of adjustable suture(s) during strabismus surgery, including postoperative adjustment(s) of suture(s) (List separately in addition to code for specific strabismus surgery) Strabismus surgery involving exploration and/or repair of detached extraocular muscle(s) (List separately in addition to code for primary procedure) Release of extensive scar tissue without detaching extraocular muscle (separate procedure) Chemodenervation of extraocular muscle Biopsy of extraocular muscle I.C. Unlisted procedure, ocular muscle Orbitotomy without bone flap (frontal or transconjunctival approach); for exploration, with or without biopsy Orbitotomy without bone flap (frontal or transconjunctival approach); with drainage only Orbitotomy without bone flap (frontal or transconjunctival approach); with removal of lesion Orbitotomy without bone flap (frontal or transconjunctival approach); with removal of foreign body Orbitotomy without bone flap (frontal or transconjunctival approach); with removal of bone for decompression Fine needle aspiration of orbital contents Orbitotomy with bone flap or window, lateral approach (eg, Kroenlein); with removal of lesion ASC Rate Incl PC Fee TC Fee I.C. 40.06(8) - Surgical Services Description (con’t) Orbitotomy with bone flap or window, lateral approach (eg, Kroenlein); with removal of foreign body Orbitotomy with bone flap or window, lateral approach (eg, Kroenlein); with drainage Orbitotomy with bone flap or window, lateral approach (eg, Kroenlein); with removal of bone for decompression Orbitotomy with bone flap or window, lateral approach (eg, Kroenlein); for exploration, with or without biopsy Retrobulbar injection; medication (separate procedure, does not include supply of medication) Retrobulbar injection; alcohol Injection of medication or other substance into Tenon's capsule Orbital implant (implant outside muscle cone); insertion Orbital implant (implant outside muscle cone); removal or revision Optic nerve decompression (eg, incision or fenestration of optic nerve sheath) Unlisted procedure, orbit Blepharotomy, drainage of abscess, eyelid Severing of tarsorrhaphy Canthotomy (separate procedure) Excision of chalazion; single Excision of chalazion; multiple, same lid Excision of chalazion; multiple, different lids Excision of chalazion; under general anesthesia and/or requiring hospitalization, single or multiple Biopsy of eyelid Correction of trichiasis; epilation, by forceps only Correction of trichiasis; epilation by other than forceps (eg, by electrosurgery, cryotherapy, laser surgery) Correction of trichiasis; incision of lid margin Correction of trichiasis; incision of lid margin, with free mucous membrane graft Excision of lesion of eyelid (except chalazion) without closure or with simple direct closure Destruction of lesion of lid margin (up to 1 cm) Temporaryclosureofeyelids by suture (eg, Frost suture) Construction of intermarginal adhesions, median tarsorrhaphy, or canthorrhaphy; Construction of intermarginal adhesions, median tarsorrhaphy, or canthorrhaphy; with transposition of tarsal plate Repair of brow ptosis (supraciliary, mid-forehead or coronal approach) Repair of blepharoptosis; frontalis muscle technique with suture or other material (eg, banked fascia) Repair of blepharoptosis; frontalis muscle technique with autologous fascial sling (includes obtaining fascia) ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Repair of blepharoptosis; (tarso) levator resection or advancement, internal approach Repair of blepharoptosis; (tarso) levator resection or advancement, external approach Repair of blepharoptosis; superior rectus technique with fascial sling (includes obtaining fascia) Repair of blepharoptosis; conjunctivo-tarso-Muller's muscle-levator resection (eg, Fasanella-Servat type) Reduction of overcorrection of ptosis Correction of lid retraction Correction of lagophthalmos, with implantation of upper eyelid lid load (eg, gold weight) Repair of ectropion; suture Repair of ectropion; thermocauterization Repair of ectropion; excision tarsal wedge Repair of ectropion; extensive (eg, tarsal strip operations) Repair of entropion; suture Repair of entropion; thermocauterization Repair of entropion; excision tarsal wedge Repair of entropion; extensive (eg, tarsal strip or capsulopalpebral fascia repairs operation) Suture of recent wound, eyelid, involving lid margin, tarsus, and/or palpebral conjunctiva direct closure; partial thickness Suture of recent wound, eyelid, involving lid margin, tarsus, and/or palpebral conjunctiva direct closure; full thickness Removal of embedded foreign body, eyelid Canthoplasty (reconstruction of canthus) Excision and repair of eyelid, involving lid margin, tarsus, conjunctiva, canthus, or full thickness, may include preparation for skin graft or pedicle flap with adjacent tissue transfer or rearrangement; up to one-fourth of lid margin Excision and repair of eyelid, involving lid margin, tarsus, conjunctiva, canthus, or full thickness, may include preparation for skin graft or pedicle flap with adjacent tissue transfer or rearrangement; over one-fourth of lid margin Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap from opposing eyelid; up to two-thirds of eyelid, one stage or first stage Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap from opposing eyelid; total eyelid, lower, one stage or first stage Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap from opposing eyelid; total eyelid, upper, one stage or first stage Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap from opposing eyelid; second stage I.C. Unlisted procedure, eyelids Incision of conjunctiva, drainage of cyst Expression of conjunctival follicles (eg, for trachoma) ASC Rate Incl I.C. PC TC Fee Fee 40.06(8) - Surgical Services Description (con’t) Biopsy of conjunctiva Excision of lesion, conjunctiva; up to 1 cm Excision of lesion, conjunctiva; over 1 cm Excision of lesion, conjunctiva; with adjacent sclera Destruction of lesion, conjunctiva Subconjunctival injection Conjunctivoplasty; with conjunctival graft or extensive rearrangement Conjunctivoplasty; with buccal mucous membrane graft (includes obtaining graft) Conjunctivoplasty, reconstruction cul-de-sac; with conjunctival graft or extensive rearrangement Conjunctivoplasty, reconstruction cul-de-sac; with buccal mucous membrane graft (includes obtaining graft) Repair of symblepharon; conjunctivoplasty, without graft Repair of symblepharon; with free graft conjunctiva or buccal mucous membrane (includes obtaining graft) Repair of symblepharon; division of symblepharon, with or without insertion of conformer or contact lens Conjunctival flap; bridge or partial (separate procedure) Conjunctival flap; total (such as Gunderson thin flap or purse string flap) Harvesting conjunctival allograft, living donor Unlisted procedure, conjunctiva Incision, drainage of lacrimal gland Incision, drainage of lacrimal sac (dacryocystotomy or dacryocystostomy) Snip incision of lacrimal punctum Excision of lacrimal gland (dacryoadenectomy), except for tumor; total Excision of lacrimal gland (dacryoadenectomy), except for tumor; partial Biopsy of lacrimal gland Excision of lacrimal sac (dacryocystectomy) Biopsy of lacrimal sac Removal of foreign body or dacryolith, lacrimal passages Excision of lacrimal gland tumor; frontal approach Excision of lacrimal gland tumor; involving osteotomy Plastic repair of canaliculi Correction of everted punctum, cautery Dacryocystorhinostomy (fistulization of lacrimal sac to nasal cavity) Conjunctivorhinostomy (fistulization of conjunctiva to nasal cavity); without tube Conjunctivorhinostomy (fistulization of conjunctiva to nasal cavity); with insertion of tube or stent C l o s u r e o f t h e l a c r i m a l p u n c t u m ; b y thermocauterization, ligation, or laser surgery Closure of the lacrimal punctum; by plug, each Closure of lacrimal fistula (separate procedure) ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Dilation of lacrimal punctum, with or without irrigation Probing of nasolacrimal duct, with or without irrigation; Probing of nasolacrimal duct, with or without irrigation; requiring general anesthesia Probing of nasolacrimal duct, with or without irrigation; with insertion of tube or stent Probing of nasolacrimal duct, with or without irrigation; with transluminal balloon catheter dilation Probing of lacrimal canaliculi, with or without irrigation Injection of contrast medium for dacryocystography I.C. Unlisted procedure, lacrimal system Drainage external ear, abscess or hematoma; simple Drainage external ear, abscess or hematoma; complicated Drainage external auditory canal, abscess Biopsy external ear Biopsy external auditory canal Excision external ear; partial, simple repair Excision external ear; complete amputation Excision exostosis(es), external auditory canal Excision soft tissue lesion, external auditory canal Radical excision external auditory canal lesion; without neck dissection Radical excision external auditory canal lesion; with neck dissection Removal foreign body from external auditory canal; without general anesthesia Removal foreign body from external auditory canal; with general anesthesia Removal impacted cerumen (separate procedure), one or both ears Debridement, mastoidectomy cavity, simple (eg, routine cleaning) Debridement, mastoidectomy cavity, complex (eg, with anesthesia or more than routine cleaning) Reconstruction of external auditory canal (meatoplasty) (eg, for stenosis due to injury, infection) (separate procedure) I.C. Unlisted procedure, external ear Eustachian tube inflation, transnasal; with catheterization Eustachian tube inflation, transnasal; without catheterization Eustachian tube catheterization, transtympanic Myringotomy including aspiration and/or eustachian tube inflation Myringotomy including aspiration and/or eustachian tube inflation requiring general anesthesia Ventilating tube removal requiring general anesthesia Tympanostomy (requiring insertion of ventilating tube), local or topical anesthesia Tympanostomy (requiring insertion of ventilating tube), general anesthesia Middle ear exploration through postauricular or ear canal incision ASC Rate Incl PC Fee TC Fee 40.06(8) - Surgical Services Description (con’t) Tympanolysis, transcanal Transmastoid antrotomy (simple mastoidectomy) Mastoidectomy; complete Mastoidectomy; modified radical Mastoidectomy; radical Petrous apicectomy including radical mastoidectomy Resection temporal bone, external approach Excision aural polyp Excision aural glomus tumor; transcanal Excision aural glomus tumor; transmastoid Ex cision aural glom us tumor; ex tended (extratemporal) Revision mastoidectomy; resulting in complete mastoidectomy Revision mastoidectomy; resulting in modified radical mastoidectomy Revision mastoidectomy; resulting in radical mastoidectomy Revision mastoidectomy; resulting in tympanoplasty Revision mastoidectomy; with apicectomy Tympanic membrane repair, with or without site preparation of perforation for closure, with or without patch Myringoplasty (surgery confined to drumhead and donor area) Tympanoplasty without mastoidectomy (including canalplasty, atticotomy and/or middle ear surgery), initial or revision; without ossicular chain reconstruction Tympanoplasty without mastoidectomy (including canalplasty, atticotomy and/or middle ear surgery), initial or revision; with ossicular chain reconstruction (eg, postfenestration) Tympanoplasty without mastoidectomy (including canalplasty, atticotomy and/or middle ear surgery), initial or revision; with ossicular chain reconstruction and synthetic prosthesis (eg, partial ossicular replacement prosthesis (PORP), total ossicular replacement prosthesis (TORP)) Tympanoplasty with antrotomy or mastoidotomy (including canalplasty, atticotomy, middle ear surgery, and/or tympanic membrane repair); without ossicular chain reconstruction Tympanoplasty with antrotomy or mastoidotomy (including canalplasty, atticotomy, middle ear surgery, and/or tympanic membrane repair); with ossicular chain reconstruction Tympanoplasty with antrotomy or mastoidotomy (including canalplasty, atticotomy, middle ear surgery, and/or tympanic membrane repair); with ossicular chain reconstruction and synthetic prosthesis (eg, partial ossicular replacement prosthesis (PORP), total Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repair); without ossicular chain reconstruction ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repair); with ossicular chain reconstruction Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repair); with intact or reconstructed wall, without ossicular chain reconstruction Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repair); with intact or reconstructed canal wall, with ossicular chain reconstruction Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repair); radical or complete, without ossicular chain reconstruction Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repair); radical or complete, with ossicular chain reconstruction Stapes mobilization Stapedectomy or stapedotomy with reestablishment of ossicular continuity, with or without use of foreign material; Stapedectomy or stapedotomy with reestablishment of ossicular continuity, with or without use of foreign material; with footplate drill out Revision of stapedectomy or stapedotomy Repair oval window fistula Repair round window fistula Mastoid obliteration (separate procedure) Tympanic neurectomy Closure postauricular fistula, mastoid (separate procedure) I.C. Implantation or replacement of electromagnetic bone conduction hearing device in temporal bone Removal or repair of electromagnetic bone conduction hearing device in temporal bone Implantation, osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; without mastoidectomy Implantation, osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; with mastoidectomy Replacement (including removal of existing device), osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; without mastoidectomy Replacement (including removal of existing device), osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; with mastoidectomy Decompression facial nerve, intratemporal; lateral to geniculate ganglion Decompression facial nerve, intratemporal; including medial to geniculate ganglion 40.06: continued Code ASC Incl Rate 69802 1,782.06 I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. PC TC Fee Fee 40.06(8) - Surgical Services Description (con’t) Suture facial nerve, intratemporal, with or without graft or decompression; lateral to geniculate ganglion Suture facial nerve, intratemporal, with or without graft or decompression; including medial to geniculate ganglion Unlisted procedure, middle ear Labyrinthotomy, with or without cryosurgery including other nonexcisional destructive procedures or perfusion of vestibuloactive drugs (single or multiple perfusions); transcanal Labyrinthotomy, with or without cryosurgery including other nonexcisional destructive procedures or perfusion of vestibuloactive drugs (single or multiple perfusions); with mastoidectomy Endolymphatic sac operation; without shunt Endolymphatic sac operation; with shunt Fenestration semicircular canal Revision fenestration operation Labyrinthectomy; transcanal Labyrinthectomy; with mastoidectomy Vestibular nerve section, translabyrinthine approach Cochlear device implantation, with or without mastoidectomy Unlisted procedure, inner ear Vestibular nerve section, transcranial approach Total facial nerve decompression and/or repair (may include graft) Decompression internal auditory canal Removal of tumor, temporal bone Unlisted procedure, temporal bone, middle fossa approach Microsurgical techniques, requiring use of operating microscope (List separately in addition to code for primary procedure) Necropsy (autopsy), gross examination only; without CNS Necropsy (autopsy), gross examination only; with brain Necropsy (autopsy), gross examination only; with brain and spinal cord Necropsy (autopsy), gross and microscopic; without CNS Necropsy (autopsy), gross and microscopic; with brain Necropsy (autopsy), gross and microscopic; with brain and spinal cord Necropsy (autopsy), limited, gross and/or microscopic; regional Necropsy (autopsy), limited, gross and/or microscopic; single organ Necropsy (autopsy); forensic examination Necropsy (autopsy); coroner's call Unlisted necropsy (autopsy) procedure Level I - Surgical pathology, gross examination only ASC Rate Incl PC Fee TC Fee 40.06(8) - Surgical Services Description (con’t) Level II - Surgical pathology, gross and microscopic examination Appendix, incidental Fallopian tube, sterilization Fingers/toes, amputation, traumatic Foreskin, newborn Hernia sac, any location Hydrocele sac Nerve Skin, plastic repair Sympathetic ganglion Testis, castration Vaginal mucosa, incidental Vas deferens, sterilization 11.03 61.36 Level III - Surgical pathology, gross and microscopic examination Abortion, induced Abscess Aneurysm ­ arterial/ventricular Anus, tag Appendix, other than incidental Artery, atheromatous plaque Bartholin's gland cyst Bone fragment(s), other than pathologic fracture Bursa/synovial cyst Carpal tunnel tissue Cartilage, shavings Cholesteatoma Colon, colostomy stoma Conjunctiva - biopsy/pterygium Cornea Diverticulum - esophagus/small intestine Dupuytren's contracture tissue Femoral head, other than fracture 38.47 79.91 Fissure/fistula Foreskin, other than newborn Gallbladder Ganglion cyst Hematoma Hemorrhoids Hydatid of Morgagni Intervertebral disc Joint, loose body Meniscus Mucocele, salivary Neuroma ­ Morton's/traumatic Pilonidal cyst/sinus Polyps, inflammatory - nasal/sinusoidal Skin - cyst/tag/debridement Soft tissue, debridement Soft tissue, lipoma Spermatocele Tendon/tendon sheath Testicular appendage Thrombus or embolus Tonsil and/or adenoids Varicocele Vas deferens, other than sterilization Vein, varicosity Level IV - Surgical pathology, gross and microscopic examination Abortion - spontaneous/missed Artery, biopsy Bone marrow, biopsy Bone exostosis Brain/meninges, other than for tumor resection Breast, biopsy, not requiring microscopic evaluation of surgical margins Breast, reduction mammoplasty Bronchus, biopsy Cell block, any source Cervix, biopsy Colon, biopsy Duodenum, biopsy Endocervix, curettings/biopsy Endometrium, curettings/biopsy Esophagus, biopsy Extremity, amputation, traumatic Fallopian tube, biopsy Fallopian tube, ectopic pregnancy Femoral head, fracture Fingers/toes, amputation, non-traumatic Gingiva/oral mucosa, biopsy Heart valve Joint, resection Kidney, biopsy Larynx, biopsy Leiomyoma(s), uterine myomectomy - without uterus Lip, biopsy/wedge resection Lung, transbronchial biopsy Lymph node, biopsy Muscle, b i o p s y N a s a l m u c o s a , b i o p s y Nasopharynx/oropharynx, biopsy Nerve, biopsy Odontogenic/dental cyst Omentum, biopsy Ovary with or without tube, non-neoplastic Ovary, biopsy/wedge resection Parathyroid gland Peritoneum, biopsy Pituitary tumor Placenta, other than third trimester Pleura/pericardium - biopsy/tissue Polyp, cervical/endometrial Polyp, colorectal Polyp, stomach/smallintestineProstate,needlebiopsy ASC Incl PC Rate Fee TC 40.06(8) - Surgical Services Description (con’t) Fee Prostate, TUR Salivary gland, biopsy Sinus, paranasal biopsy Skin, other than cyst/tag/debridement/plastic repair Small intestine, biopsy Soft tissue, other than tumor/mass/lipoma/debridement Spleen Stomach, bi o p s y S yn o v i u m T es t i s , other than tumor/biopsy/castration Thyroglossal duct/brachial cleft cyst Tongue, biopsy Tonsil, biopsy Trachea, biopsy Ureter, biopsy Urethra, biopsy Urinary bladder, biopsy Uterus, with or without tubes and ovaries, for prolapse Vagina, biopsy Vulva/labia, biopsy 149.55 Level V - Surgical pathology, gross and microscopic 139.42 203.40 12.18 7.20 27.32 79.47 examination Adrenal, resection Bone ­ biopsy/curettings Bone fragment(s), pathologic fracture Brain, biopsy Brain/meninges, tumor resection Breast, excision of lesion, requiring microscopic evaluation of surgical margins Breast, mastectomy - partial/simple Cervix, conization Colon, segmental resection, other than for tumor Extremity, amputation, non-traumatic Eye, enucleation Kidney, partial/total nephrectomy Larynx, partial/total resection Liver, biopsy - needle/wedge Liver, partial resection Lung, wedge biopsy Lymph nodes, regional resection Mediastinum, mass Myocardium, biopsy Odontogenic tumor Ovary with or without tube, neoplastic Pancreas, biopsy Placenta, third trimester Prostate, except radical resection Salivary gland Sentinel lymph node Small intestine, resection, other than for tumor Soft tissue mass (except lipoma) ­ biopsy/simple excision Stomach - subtotal/total resection, other than for tumor Testis, biopsy Thymus, tumor Thyroid, total/lobe Ureter, resection Urinary bladder, TUR Uterus, with or without tubes and ovaries, other than neoplastic/prolapse Level VI - Surgical pathology, gross and microscopic examination Bone resection Breast, mastectomy ­ with regional lymph nodes Colon, segmental resection for tumor Colon, total resection Esophagus, partial/total resection Extremity, disarticulation Fetus, with dissection Larynx, partial/total resection - with regional lymph nodes Lung - total/lobe/segment resection Pancreas, total/subtotal resection Prostate, radical resection Small intestine, resection for tumor Soft tissue tumor, extensive resection Stomach ­ subtotal/total resection for tumor Testis, tumor Tongue/tonsil -resection for tumor Urinary bladder, partial/total resection Uterus, with or without tubes and ovaries, neoplastic Vulva, total/subtotal resection Decalcification procedure (List separately in addition to code for surgical pathology examination) Special stains (List separately in addition to code for primary service); Group I for microorganisms (eg, Gridley, acid fast, methenamine silver), each ASC Incl PC TC 40.06(8) - Surgical Services Description (con’t) Rate Fee Fee 12.18 70.26 Special stains (List separately in addition to code for primary service); Group II, all other (eg, iron, trichrome), except immunocytochemistry and immunoperoxidase stains, each 23.33 85.75 Special stains (List separately in addition to code for primary service); histochemical staining with frozen section(s) 21.84 99.26 Determinative histochemistry to identify chemical components (eg, copper, zinc) 27.44 144.67 Determinative histochemistry or cytochemistry to identify enzyme constituents, each Consultation and report on referred slides prepared elsewhere 87.92 68.72 Consultation and report on referred material requiring preparation of slides Consultation, comprehensive, with review of records and specimens, with report on referred material Pathology consultation during surgery; 62.08 34.34 Pathology consultation during surgery; first tissue block, with frozen section(s), single specimen 30.87 12.11 Pathology consultation during surgery; each additional tissue block with frozen section(s) 62.88 35.72 Pathology consultation during surgery; cytologic examination (eg, touch prep, squash prep), initial site 36.57 21.31 Pathology consultation during surgery; cytologic examination (eg, touch prep, squash prep), each additional site 43.27 66.42 Immunohist ochemistry (includ i n g t i ssue immunoperoxidase), each antibody 43.61 67.34 Immunofluorescent study, each antibody; direct method 42.69 47.55 Immunofluorescent study, each antibody; indirect method 77.75 613.35 Electron microscopy; diagnostic 39.74 287.17 Electron microscopy; scanning 91.96 251.27 Morphometric analysis; skeletal muscle 149.06 179.31 Morphometric analysis; nerve 48.32 33.86 Morphometric analysis; tumor (eg, DNA ploidy) 56.39 74.70 Morphometric analysis, tumor immunohistochemistry (eg, Her-2/neu, estrogen receptor/progesterone receptor), quantitative or semiquantitative, each antibody; manual 60.78 118.55 Morphometric analysis, tumor immunohistochemistry (eg, Her-2/neu, estrogen receptor/progesterone receptor), quantitative or semiquantitative, each antibody; using computer-assisted technology 111.31 190.51 Nerve teasing preparations 60.28 107.85 In situ hybridization (eg, FISH), each probe 63.68 196.04 Morphometric analysis, in situ hybridization (quantitative or semi-quantitative) each probe; using computer-assisted technology 69.39 151.85 Morphometric analysis, in situ hybridization (quantitative or semi-quantitative) each probe; manual Protein analysis of tissue by Western Blot, with interpretation and report; ASC Incl PC Rate Fee I.C. I.C. I.C. I.C. (9) Homemakers. TC Fee 40.06(8) - Surgical Services Description (con’t) Protein analysis of tissue by Western Blot, with interpretation and report; immunological probe for band identification, each 104.74 Microdissection (ie, sample preparation of microscopically identified target); laser capture 191.62 Microdissection (ie, sample preparation of microscopically identified target); manual I.C. Array-based evaluation of multiple molecular probes; 11 through 50 probes 501.66 Array-based evaluation of multiple molecular probes; 51 through 250 probes 493.52 Array-based evaluation of multiple molecular probes; 251 through 500 probes I.C. Unlisted surgical pathology procedure Fee 40.06(9) Homemaker - Description S5130 Homemaker service, NOS; per 15 minutes (10) Medicine / Podiatric Care. PC Fee TC Fee 40.06(10) - Medical Service Description I.C. Immune globulin (Ig), human, for intramuscular use I.C. Immune globulin (IgIV), human, for intravenous use I.C. Immune globulin (SCIg), human, for use in subcutaneous infusions, 100 mg, each I.C. Botulinum antitoxin, equine, any route I.C. Botulism immune globulin, human, for intravenous use I.C. Cytomegalovirus immune globulin (CMV-IgIV), human, for intravenous use I.C. Diphtheria antitoxin, equine, any route I.C. Hepatitis B immune globulin (HBIg), human, for intramuscular use I.C. Rabies immune globulin (RIg), human, for intramuscular and/or subcutaneous use I.C. Rabies immune globulin, heat-treated (RIg-HT), human, for intramuscular and/or subcutaneous use I.C. Respiratory syncytial virus immune globulin (RSV-IgIM), for intramuscular use, 50 mg, each I.C. Respiratory syncytial virus immune globulin (RSV-IgIV), human, for intravenous use I.C. Rho(D) immune globulin (RhIg), human, full-dose, for intramuscular use I.C. Rho(D) immune globulin (RhIg), human, mini-dose, for intramuscular use I.C. Rho(D) immune globulin (RhIgIV), human, for intravenous use I.C. Tetanus immune globulin (TIg), human, for intramuscular use I.C. Vaccinia immune globulin, human, for intramuscular use I.C. Varicella-zoster immune globulin, human, for intramuscular use I.C. Unlisted immune globulin PC Fee TC Fee 40.06(10) - Medical Service Description (continued) Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); one vaccine (single or combination vaccine/toxoid) Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure) Immunization administration by intranasal or oral route; one vaccine (single or combination vaccine/toxoid) Immunization administration by intranasal or oral route; each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure) I.C. Adenovirus vaccine, type 4, live, for oral use I.C. Adenovirus vaccine, type 7, live, for oral use I.C. Anthrax vaccine, for subcutaneous use I.C. Bacillus Calmette-Guerin vaccine (BCG) for tuberculosis, live, for percutaneous use I.C. Bacillus Calmette-Guerin vaccine (BCG) for bladder cancer, live, for intravesical use I.C. Hepatitis A vaccine, adult dosage, for intramuscular use I.C. Hepatitis A vaccine, pediatric/adolescent dosage-2 dose schedule, for intramuscular use I.C. Hepatitis A vaccine, pediatric/adolescent dosage-3 dose schedule, for intramuscular use I.C. Hepatitis A and hepatitis B vaccine (HepA-HepB), adult dosage, for intramuscular use I.C. Hemophilus influenza b vaccine (Hib), HbOC conjugate (4 dose schedule), for intramuscular use I.C. Hemophilus influenza b vaccine (Hib), PRP-D conjugate, for booster use only, intramuscular use I.C. Hemophilus influenza b vaccine (Hib), PRP-OMP conjugate (3 dose schedule), for intramuscular use I.C. Hemophilus influenza b vaccine (Hib), PRP-T conjugate (4 dose schedule), for intramuscular use I.C. Human Papilloma virus (HPV) vaccine, types 6, 11, 16, 18 (quadrivalent), three dose schedule, for intramuscular use I.C. Rabies vaccine, for intramuscular use I.C. Rabies vaccine, for intradermal use I.C. Rotavirus vaccine, pentavalent, thee dose schedule, live, for oral use I.C. Tetanus toxoid adsorbed, for intramuscular use I.C. Varicella virus vaccine, live, for subcutaneous use I.C. Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (three dose schedule), for intramuscular use I.C. Hepatitis B vaccine, adolescent (two dose schedule), for intramuscular use I.C. Hepatitis B vaccine, pediatric/adolescent dosage (three dose schedule), for intramuscular use I.C. Hepatitis B vaccine, adult dosage, for intramuscular use I.C. Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (four dose schedule), for intramuscular use I.C. Hepatitis B and Hemophilus influenza b vaccine (HepB-Hib), for intramuscular use I.C. Unlisted vaccine/toxoid Intravenous infusion, hydration; initial, 31 minutes to one hour PC Fee TC Fee 40.06(10) - Medical Service Description (continued) Intravenous infusion, hydration; each additional hour (List separately in addition to code for primary procedure) Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to one hour Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure) Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); additional sequential infusion, up to 1 hour (List separately in addition to code for primary procedure) Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); concurrent infusion (List separately in addition to code for primary procedure) Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); initial, up to one hour, including pump set-up and establishment of subcutaneous infusion site(s) Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure) Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); additional pump set-up with establishment of new subcutaneous infusion site(s) (List separately in addition to code for primary procedure) Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular Therapeutic, prophylactic or diagnostic injection (specify substance or drug); intra-arterial Therapeutic, prophylactic or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug Therapeutic, prophylactic or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug (List separately in addition to code for primary procedure) I.C. Therapeutic, prophylactic or diagnostic injection (specify substance or drug); each additional sequential intravenous push of the same substance/drug provided in a facility (List separately in addition to code for primary procedure) I.C. Unlisted therapeutic, prophylactic or diagnostic intravenous or intra-arterial injection or infusion Pharmacologic management, including prescription, use, and review of medication with no more than minimal medical psychotherapy Biofeedback training by any modality Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry Hemodialysis procedure with single physician evaluation Hemodialysis procedure requiring repeated evaluation(s) with or without substantial revision of dialysis prescription I.C. Hemodialysis access flow study to determine blood flow in grafts and arteriovenous fistulae by an indicator method Dialysis procedure other than hemodialysis (eg, peritoneal dialysis, hemofiltration, or other continuous renal replacement therapies), with single physician evaluation PC Fee I.C. I.C. I.C. I.C. I.C. 1,115.00 194.64 I.C. I.C. I.C. TC Fee 40.06(10) - Medical Service Description (continued) Dialysis procedure other than hemodialysis (eg, peritoneal dialysis, hemofiltration, or other continuous renal replacement therapies) requiring repeated physician evaluations, with or without substantial revision of dialysis prescription Dialysis training, patient, including helper where applicable, any mode, completed course Dialysis training, patient, including helper where applicable, any mode, course not completed, per training session Hemoperfusion (eg, with activated charcoal or resin) Unlisted dialysis procedure, inpatient or outpatient Esophageal intubation and collection of washings for cytology, including preparation of specimens (separate procedure) Esophageal motility (manometric study of the esophagus and/or gastroesophageal junction) study; Esophageal motility (manometric study of the esophagus and/or gastroesophageal junction) study; with mecholyl or similar stimulant Esophageal motility (manometric study of the esophagus and/or gastroesophageal junction) study; with acid perfusion studies Gastric motility (manometric) studies Duodenal motility (manometric) study Esophagus, acid perfusion (Bernstein) test for esophagitis Esophagus, gastroesophageal reflux test; with nasal catheter pH electrode(s) placement, recording, analysis and interpretation Esophagus, gastroesophageal reflux test; with mucosal attached telemetry pH electrode placement, recording, analysis and interpretation Esophageal function test, gastroesophageal reflux test with nasal catheter intraluminal impedance electrode(s) placement, recording, analysis and interpretation; Esophageal function test, gastroesophageal reflux test with nasal catheter intraluminal impedance electrode(s) placement, recording, analysis and interpretation; prolonged (greater than one hour, up to 24 hours) Esophageal balloon distension provocation study Gastric analysis test with injection of stimulant of gastric secretion (eg, histamine, insulin, pentagastrin, calcium and secretin) Gastric intubation, washings, and preparing slides for cytology (separate procedure) Breath hydrogen test (eg, for detection of lactase deficiency, fructose intolerance, bacterial overgrowth, or oro-cecal gastrointestinal transit) I.C. Intestinal bleeding tube, passage, positioning and monitoring I.C. Gastric intubation, and aspiration or lavage for treatment (eg, for ingested poisons) Gastrointestinal tract imaging, intraluminal (eg, capsule endoscopy), esophagus through ileum, with physician interpretation and report Gastrointestinal tract imaging, intraluminal (eg, capsule endoscopy), esophagus with physician interpretation and report Rectal sensation, tone, and compliance test (ie, response to graded balloon distention) Anorectal manometry I.C. Pulsed irrigation of fecal impaction I.C. Electrogastrography, diagnostic, transcutaneous; PC Fee TC Fee I.C. I.C. I.C. I.C. I.C. 40.06(10) - Medical Service Description (continued) Electrogastrography, diagnostic, transcutaneous; with provocative testing Unlisted diagnostic gastroenterology procedure Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; intermediate, new patient Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, one or more visits Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, one or more visits Determination of refractive state Ophthalmological examination and evaluation, under general anesthesia, with or without manipulation of globe for passive range of motion or other manipulation to facilitate diagnostic examination; complete Ophthalmological examination and evaluation, under general anesthesia, with or without manipulation of globe for passive range of motion or other manipulation to facilitate diagnostic examination; limited Gonioscopy (separate procedure) Computerized corneal topography, unilateral or bilateral, with interpretation and report Sensorimotor examination with multiple measurements of ocular deviation (eg, restrictive or paretic muscle with diplopia) with interpretation and report (separate procedure) Orthoptic and/or pleoptic training, with continuing medical direction and evaluation Fitting of contact lens for treatment of disease, including supply of lens Visual field examination, unilateral or bilateral, with interpretation and report; limited examination (eg, tangent screen, Autoplot, arc perimeter, or single stimulus level automated test, such as Octopus three or seven equivalent) Visual field examination, unilateral or bilateral, with interpretation and report; intermediate examination (eg, at least two isopters on Goldmann perimeter, or semiquantitative, automated suprathreshold screening program, Humphrey suprathreshold automatic diagnostic test, Octopus program 33) Visual field examination, unilateral or bilateral, with interpretation and report; extended examination (eg, Goldmann visual fields with at least three isopters plotted and static determination within the central 30/, or quantitative, automated threshold periimetry, Octopus program G-1, 32 or 42, Humphrey Visual field analyzer full threshold programs; 30-2, 24-2, or 30/60-2) Serial tonometry (separate procedure) with multiple measurements of intraocular pressure over an extended time period with interpretation and report, same day (eg, diurnal curve or medical treatment of acute elevation of intraocular pressure) PC Fee TC Fee 40.06(10) - Medical Service Description (continued) Tonography with interpretation and report, recording indentation tonometer method or perilimbal suction method Tonography with water provocation Scanning computerized ophthalmic diagnostic imaging, posterior segment, (eg, scanning laser) with interpretation and report, unilateral Ophthalmic biometry by partial coherence interferometry with intraocular lens power calculation Provocative tests for glaucoma, with interpretation and report, without tonography Ophthalmoscopy, extended, with retinal drawing (eg, for retinal detachment, melanoma), with interpretation and report; initial Ophthalmoscopy, extended, with retinal drawing (eg, for retinal detachment, melanoma), with interpretation and report; subsequent Fluorescein angioscopy with interpretation and report Fluorescein angiography (includes multiframe imaging) with interpretation and report Indocyanine-green angiography (includes multiframe imaging) with interpretation and report Fundus photography with interpretation and report Ophthalmodynamometry Needle oculoelectromyography, one or more extraocular muscles, one or both eyes, with interpretation and report Electro-oculography with interpretation and report Electroretinography with interpretation and report Color vision examination, extended, eg, anomaloscope or equivalent Dark adaptation examination with interpretation and report External ocular photography with interpretation and report for documentation of medical progress (eg, close-up photography, slit lamp photography, goniophotography, stereo-photography) Special anterior segment photography with interpretation and report; with specular endothelial microscopy and cell count Special anterior segment photography with interpretation and report; with fluorescein angiography Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens for aphakia, one eye Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens for aphakia, both eyes Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneoscleral lens Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and direction of fitting by independent technician; corneal lens for aphakia, one eye Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and direction of fitting by independent technician; corneal lens for aphakia, both eyes Fitting of spectacle prosthesis for aphakia; monofocal Fitting of spectacle prosthesis for aphakia; multifocal PC Fee TC Fee I.C. I.C. I.C. I.C. I.C. I.C. I.C. 40.06(10) - Medical Service Description (continued) Fitting of spectacle mounted low vision aid; single element system Fitting of spectacle mounted low vision aid; telescopic or other compound lens system Prosthesis service for aphakia, temporary (disposable or loan, including materials) Repair and refitting spectacles; spectacle prosthesis for aphakia Unlisted ophthalmological service or procedure Otolaryngologic examination under general anesthesia Binocular microscopy (separate diagnostic procedure) Spontaneous nystagmus, including gaze Positional nystagmus test Caloric vestibular test, each irrigation (binaural, bithermal stimulation constitutes four tests) Optokinetic nystagmus test Spontaneous nystagmus test, including gaze and fixation nystagmus, with recording Positional nystagmus test, minimum of 4 positions, with recording Caloric vestibular test, each irrigation (binaural, bithermal stimulation constitutes four tests), with recording Optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, with recording Oscillating tracking test, with recording Sinusoidal vertical axis rotational testing Use of vertical electrodes (List separately in addition to code for primary procedure) Computerized dynamic posturography Diagnostic analysis of cochlear implant, age 7 years or older; with programming Diagnostic analysis of cochlear implant, age 7 years or older; subsequent reprogramming Evaluation for prescription of non-speech-generating augmentative and alternative communication device Therapeutic service(s) for the use of non-speech-generating device, including programming and modification Evaluation for prescription for speech-generating augmentative and alternative communication device, face-to-face with the patient; first hour Evaluation for prescription for speech-generating augmentative and alternative communication device, face-to-face with the patient; each additional 30 minutes (List separately in addition to code for primary procedure) Therapeutic services for the use of speech-generating device, including programming and modification Evaluation of oral and pharyngeal swallowing function Motion fluoroscopic evaluation of swallowing function by cine or video recording Flexible fiberoptic endoscopic evaluation of swallowing by cine or video recording; Flexible fiberoptic endoscopic evaluation of swallowing by cine or video recording; physician interpretation and report only Flexible fiberoptic endoscopic evaluation, laryngeal sensory testing by cine or video recording; PC Fee TC Fee 40.06(10) - Medical Service Description (continued) Flexible fiberoptic endoscopic evaluation, laryngeal sensory testing by cine or video recording; physician interpretation and report only Flexible fiberoptic endoscopic evaluation of swallowing and laryngeal sensory testing by cine or video recording; Flexible fiberoptic endoscopic evaluation of swallowing and laryngeal sensory testing by cine or video recording; physician interpretation and report only Evaluation of central auditory function, with report; initial 60 minutes Evaluation of central auditory function, with report; each additional 15 minutes Assessment of tinnitus (includes pitch, loudness matching, and masking) Evaluation of auditory rehabilitation status; first hour Evaluation of auditory rehabilitation status; each additional 15 minutes (List separately in addition to code for primary procedure) I.C. Auditory rehabilitation; prelingual hearing loss I.C. Auditory rehabilitation; postlingual hearing loss Diagnostic analysis with programming of auditory brainstem implant, per hour I.C. Unlisted otorhinolaryngological service or procedure Cardiopulmonary resuscitation (eg, in cardiac arrest) Temporary transcutaneous pacing Cardioversion, elective, electrical conversion of arrhythmia; external Cardioversion, elective, electrical conversion of arrhythmia; internal (separate procedure) Cardioassist-method of circulatory assist; internal Cardioassist-method of circulatory assist; external Percutaneous transluminal coronary thrombectomy (List separately in addition to code for primary procedure) Transcatheter placement of radiation delivery device for subsequent coronary intravascular brachytherapy (List separately in addition to code for primary procedure) Thrombolysis, coronary; by intracoronary infusion, including selective coronary angiography Thrombolysis, coronary; by intravenous infusion I.C. I.C. Intravascular ultrasound (coronary vessel or graft) during diagnostic evaluation and/or therapeutic intervention including imaging supervision, interpretation and report; initial vessel (List separately in addition to code for primary procedure) I.C. I.C. Intravascular ultrasound (coronary vessel or graft) during diagnostic evaluation and/or therapeutic intervention including imaging supervision, interpretation and report; each additional vessel (List separately in addition to code for primary procedure) Transcatheter placement of an intracoronary stent(s), percutaneous, with or without other therapeutic intervention, any method; single vessel Transcatheter placement of an intracoronary stent(s), percutaneous, with or without other therapeutic intervention, any method; each additional vessel (List separately in addition to code for primary procedure) PC Fee TC Fee 40.06(10) - Medical Service Description (continued) Percutaneous transluminal coronary balloon angioplasty; single vessel Percutaneous transluminal coronary balloon angioplasty; each additional vessel (List separately in addition to code for primary procedure) Percutaneous balloon valvuloplasty; aortic valve Percutaneous balloon valvuloplasty; mitral valve Percutaneous balloon valvuloplasty; pulmonary valve I.C. Atrial septectomy or septostomy; transvenous method, balloon (eg, Rashkind type) (includes cardiac catheterization) I.C. Atrial septectomy or septostomy; blade method (Park septostomy) (includes cardiac catheterization) Percutaneous transluminal coronary atherectomy, by mechanical or other method, with or without balloon angioplasty; single vessel Percutaneous transluminal coronary atherectomy, by mechanical or other method, with or without balloon angioplasty; each additional vessel (List separately in addition to code for primary procedure) Percutaneous transluminal pulmonary artery balloon angioplasty; single vessel Percutaneous transluminal pulmonary artery balloon angioplasty; each additional vessel (List separately in addition to code for primary procedure) Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only Telephonic transmission of post-symptom electrocardiogram rhythm strip(s), 24-hour attended monitoring, per 30 day period of time; tracing only Telephonic transmission of post-symptom electrocardiogram rhythm strip(s), 24-hour attended monitoring, per 30 day period of time; physician review with interpretation and report only Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with physician supervision, with interpretation and report Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; physician supervision only, without interpretation and report Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; tracing only, without interpretation and report Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; interpretation and report only Ergonovine provocation test Microvolt T-wave alternans for assessment of ventricular arrhythmias Rhythm ECG, one to three leads; with interpretation and report PC Fee TC Fee 40.06(10) - Medical Service Description (continued) Rhythm ECG, one to three leads; tracing only without interpretation and report Rhythm ECG, one to three leads; interpretation and report only Electrocardiographic monitoring for 24 hours by continuous original ECG waveform recording and storage, with visual superimposition scanning; includes recording, scanning analysis with report, physician review and interpretation Electrocardiographic monitoring for 24 hours by continuous original ECG waveform recording and storage, with visual superimposition scanning; recording (includes hook-up, recording, and disconnection) Electrocardiographic monitoring for 24 hours by continuous original ECG waveform recording and storage, with visual superimposition scanning; scanning analysis with report Electrocardiographic monitoring for 24 hours by continuous original ECG waveform recording and storage, with visual superimposition scanning; physician review and interpretation Electrocardiographic monitoring for 24 hours by continuous original ECG waveform recording and storage without superimposition scanning utilizing a device capable of producing a full miniaturized printout; includes recording, microprocessor-based analysis Electrocardiographic monitoring for 24 hours by continuous original ECG waveform recording and storage without superimposition scanning utilizing a device capable of producing a full miniaturized printout; recording (includes hook-up, recording, and disconnection) Electrocardiographic monitoring for 24 hours by continuous original ECG waveform recording and storage without superimposition scanning utilizing a device capable of producing a full miniaturized printout; microprocessor-based analysis with report Electrocardiographic monitoring for 24 hours by continuous original ECG waveform recording and storage without superimposition scanning utilizing a device capable of producing a full miniaturized printout; physician review and interpretation I.C. Electrocardiographic monitoring for 24 hours by continuous computerized monitoring and non-continuous recording, and real-time data analysis utilizing a device capable of producing intermittent full-sized waveform tracings, possibly patient activated; includes monitoring and real-time data analysis with report, physician review and interpretation I.C. Electrocardiographic monitoring for 24 hours by continuous computerized monitoring and non-continuous recording, and real-time data analysis utilizing a device capable of producing intermittent full-sized waveform tracings, possibly patient activated; includes monitoring and real-time data analysis with report, Electrocardiographic monitoring for 24 hours by continuous computerized monitoring and non-continuous recording, and real-time data analysis utilizing a device capable of producing intermittent full-sized waveform tracings, possibly patient activated; physician review and interpretation PC Fee I.C. I.C. I.C. TC Fee I.C. I.C. I.C. 40.06(10) - Medical Service Description (continued) Patient demand single or multiple event recording with presymptom memory loop, 24-hour attended monitoring, per 30 day period of time; includes transmission, physician review and interpretation Patient demand single or multiple event recording with presymptom memory loop, 24-hour attended monitoring, per 30 day period of time; recording (includes hook-up, recording, and disconnection) Patient demand single or multiple event recording with presymptom memory loop, 24-hour attended monitoring, per 30 day period of time; monitoring, receipt of transmissions, and analysis Patient demand single or multiple event recording with presymptom memory loop, 24-hour attended monitoring, per 30 day period of time; physician review and interpretation only Signal-averagedelectrocardiography(SAECG), with or without ECG Transthoracic echocardiography for congenital cardiac anomalies; complete Transthoracic echocardiography for congenital cardiac anomalies; follow-up or limited study Echocardiography, transthoracic, real-time with image documentation (2D) with or without M-mode recording; complete Echocardiography, transthoracic, real-time with image documentation (2D) with or without M-mode recording; follow-up or limited study Echocardiography, transesophageal, real time with image documentation (2D) (with or without M-mode recording); including probe placement, image acquisition, interpretation and report Echocardiography, transesophageal, real time with image documentation (2D) (with or without M-mode recording); placement of transesophageal probe only Echocardiography, transesophageal, real time with image documentation (2D) (with or without M-mode recording); image acquisition, interpretation and report only Transesophageal echocardiography for congenital cardiac anomalies; including probe placement, image acquisition, interpretation and report Transesophageal echocardiography for congenital cardiac anomalies; placement of transesophageal probe only Transesophageal echocardiography for congenital cardiac anomalies; image acquisition, interpretation and report only Echocardiography, transesophageal (TEE) for monitoring purposes, including probe placement, real time 2-dimensional image acquisition and interpretation leading to ongoing (continuous) assessment of (dynamically changing) cardiac pumping function and to therapeutic measures on an immediate time basis Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in addition to codes for echocardiographic imaging); complete PC Fee TC Fee 1,170.01 246.08 1,774.58 259.13 1,515.45 I.C. I.C. I.C. I.C. I.C. I.C. 2,288.94 354.39 1,934.55 I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. 40.06(10) - Medical Service Description (continued) Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in addition to codes for echocardiographic imaging); follow-up or limited study (List separately in addition to codes for echocardiographic imaging) Doppler echocardiography color flow velocity mapping (List separately in addition to codes for echocardiography) Echocardiography, transthoracic, real-time with image documentation (2D), with or without M-mode recording, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report Right heart catheterization Insertion and placement of flow directed catheter (eg, Swan-Ganz) for monitoring purposes Endomyocardial biopsy Catheter placement in coronary artery(s), arterial coronary conduit(s), and/or venous coronary bypass graft(s) for coronary angiography without concomitant left heart catheterization Left heart catheterization, retrograde, from the brachial artery, axillary artery or femoral artery; percutaneous Left heart catheterization, retrograde, from the brachial artery, axillary artery or femoral artery; by cutdown Left heart catheterization by left ventricular puncture Combined transseptal and retrograde left heart catheterization Combined right heart catheterization and retrograde left heart catheterization Combined right heart catheterization and transseptal left heart catheterization through intact septum (with or without retrograde left heart catheterization) Combined right heart catheterization with left ventricular puncture (with or without retrograde left heart catheterization) Combined right heart catheterization and left heart catheterization through existing septal opening (with or without retrograde left heart catheterization) Right heart catheterization, for congenital cardiac anomalies Combined right heart catheterization and retrograde left heart catheterization, for congenital cardiac anomalies Combined right heart catheterization and transseptal left heart catheterization through intact septum with or without retrograde left heart catheterization, for congenital cardiac anomalies Combined right heart catheterization and transseptal left heart catheterization through existing septal opening, with or without retrograde left heart catheterization, for congenital cardiac anomalies Injection procedure during cardiac catheterization; for selective opacification of arterial conduits (eg, internal mammary), whether native or used for bypass Injection procedure during cardiac catheterization; for selective opacification of aortocoronary venous bypass grafts, one or more coronary arteries Injection procedure during cardiac catheterization; for pulmonary angiography Injection procedure during cardiac catheterization; for selective right ventricular or right atrial angiography PC Fee I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. TC Fee I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. 40.06(10) - Medical Service Description (continued) Injection procedure during cardiac catheterization; for selective left ventricular or left atrial angiography Injection procedure during cardiac catheterization; for aortography Injection procedure during cardiac catheterization; for selective coronary angiography (injection of radiopaque material may be by hand) Imaging supervision, interpretation and report for injection procedure(s) during cardiac catheterization; ventricular and/or atrial angiography Imaging supervision, interpretation and report for injection procedure(s) during cardiac catheterization; pulmonary angiography, aortography, and/or selective coronary angiography including venous bypass grafts and arterial conduits (whether native or used in bypass) Indicator dilution studies such as dye or thermal dilution, including arterial and/or venous catheterization; with cardiac output measurement (separate procedure) Indicator dilution studies such as dye or thermal dilution, including arterial and/or venous catheterization; subsequent measurement of cardiac output Intravascular Doppler velocity and/or pressure derived coronary flow reserve measurement (coronary vessel or graft) during coronary angiography including pharmacologically induced stress; initial vessel (List separately in addition to code for primary procedure) Intravascular Doppler velocity and/or pressure derived coronary flow reserve measurement (coronary vessel or graft) during coronary angiography including pharmacologically induced stress; each additional vessel (List separatelyin addition to code for primary procedure) Percutaneous transcatheter closure of congenital interatrial communication (ie, Fontan fenestration, atrial septal defect) with implant Percutaneous transcatheter closure of a congenital ventricular septal defect with implant Bundle of His recording Intra-atrial recording Right ventricular recording Intraventricular and/or intra-atrial mapping of tachycardia site(s) with catheter manipulation to record from multiple sites to identify origin of tachycardia (List separately in addition to code for primary procedure) Intra-atrial pacing Intraventricular pacing Intracardiac electrophysiologic 3-dimensional mapping (List separately in addition to code for primary procedure) Esophageal recording of atrial electrogram with or without ventricular electrogram(s); Esophageal recording of atrial electrogram with or without ventricular electrogram(s); with pacing Induction of arrhythmia by electrical pacing PC Fee I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. 40.06(10) - Medical Service Description (continued) Comprehensive electrophysiologic evaluation with right atrial pacing and recording, right ventricular pacing and recording, His bundle recording, including insertion and repositioning of multiple electrode catheters, without induction or attempted induction of arrhythmia Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with right atrial pacing and recording, right ventricular pacing and recording, His bundle recording Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with left atrial pacing and recording from coronary sinus or left atrium (List separately in addition to code for primary procedure) Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with left ventricular pacing and recording (List separately in addition to code for primary procedure) Programmed stimulation and pacing after intravenous drug infusion (List separately in addition to code for primary procedure) Electrophysiologic follow-up study with pacing and recording to test effectiveness of therapy, including induction or attempted induction of arrhythmia Intra-operative epicardial and endocardial pacing and mapping to localize the site of tachycardia or zone of slow conduction for surgical correction Electrophysiologic evaluation of single or dual chamber pacing cardioverter-defibrillator leads including defibrillation threshold evaluation (induction of arrhythmia, evaluation of sensing and pacing for arrhythmia termination) at time of initial implant Electrophysiologic evaluation of single or dual chamber pacing cardioverter-defibrillator leads including defibrillation threshold evaluation (induction of arrhythmia, evaluation of sensing and pacing for arrhythmia termination) at time of initial implant Electrophysiologic evaluation of single or dual chamber pacing cardioverter-defibrillator (includes defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing and pacing for arrhythmia termination, and programming or reprogramming Intracardiac catheter ablation of atrioventricular node function, atrioventricular conduction for creation of complete heart block, with or without temporary pacemaker placement Intracardiac catheter ablation of arrhythmogenic focus; for treatment of supraventricular tachycardia by ablation of fast or slow atrioventricular pathways, accessory atrioventricular connections or other atrial foci, singly or in combination Intracardiac catheter ablation of arrhythmogenic focus; for treatment of ventricular tachycardia Evaluation of cardiovascular function with tilt table evaluation, with continuous ECG monitoring and intermittent blood pressure monitoring, with or without pharmacological intervention TC Fee I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. PC Fee I.C. TC Fee I.C. 40.06(10) - Medical Service Description (continued) Intracardiac echocardiography during therapeutic/diagnostic intervention, including imaging supervision and interpretation (List separately in addition to code for primary procedure) Peripheral arterial disease (PAD) rehabilitation, per session Bioimpedance, thoracic, electrical Plethysmography, total body; with interpretation and report Plethysmography, total body; tracing only, without interpretation and report Plethysmography, total body; interpretation and report only Electronic analysis of antitachycardia pacemaker system (includes electrocardiographic recording, programming of device, induction and termination of tachycardia via implanted pacemaker, and interpretation of recordings) Electronic analysis of implantable loop recorder (ILR) system (includes retrieval of recorded and stored ECG data, physician review and interpretation of retrieved ECG data and reprogramming) Electronic analysis of dual-chamber pacemaker system (includes evaluation of programmable parameters at rest and during activity where applicable, using electrocardiographic recording and interpretation of recordings at rest and during exercise, analysis of event markers and device response); without reprogramming Electronic analysis of dual-chamber pacemaker system (includes evaluation of programmable parameters at rest and during activity where applicable, using electrocardiographic recording and interpretation of recordings at rest and during exercise, analysis of event markers and device response); with reprogramming Electronic analysis of dual chamber internal pacemaker system (may include rate, pulse amplitude and duration, configuration of wave form, and/or testing of sensory function of pacemaker), telephonic analysis Electronic analysis of single chamber pacemaker system (includes evaluation of programmable parameters at rest and during activity where applicable, using electrocardiographic recording and interpretation of recordings at rest and during exercise, analysis of event markers and device response); without reprogramming Electronic analysis of single chamber pacemaker system (includes evaluation of programmable parameters at rest and during activity where applicable, using electrocardiographic recording and interpretation of recordings at rest and during exercise, analysis of event markers and device response); with reprogramming Electronic analysis of single chamber internal pacemaker system (may include rate, pulse amplitude and duration, configuration of wave form, and/or testing of sensory function of pacemaker), telephonic analysis Temperature gradient studies PC Fee TC Fee I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. 40.06(10) - Medical Service Description (continued) Electronic analysis of pacing cardioverter-defibrillator (includes interrogation, evaluation of pulse generator status, evaluation of programmable parameters at rest and during activity where applicable, using electrocardiographic recording and interpretation of recordings at rest and during exercise, analysis of event markers and device response); single chamber or wearable cardioverter-defibrillator system, without reprogramming Electronic analysis of pacing cardioverter-defibrillator (includes interrogation, evaluation of pulse generator status, evaluation of programmable parameters at rest and during activity where applicable, using electrocardiographic recording and interpretation of recordings at rest and during exercise, analysis of event markers and device response); single chamber or wearable cardioverter-defibrillator system, with reprogramming Electronic analysis of pacing cardioverter-defibrillator (includes interrogation, evaluation of pulse generator status, evaluation of programmable parameters at rest and during activity where applicable, using electrocardiographic recording and interpretation of recordings at rest and during exercise, analysis of event markers and device response); dual chamber or wearable cardioverter-defibrillator system, without reprogramming Electronic analysis of pacing cardioverter-defibrillator (includes interrogation, evaluation of pulse generator status, evaluation of programmable parameters at rest and during activity where applicable, using electrocardiographic recording and interpretation of recordings at rest and during exercise, analysis of event markers and device response); dual chamber or wearable cardioverter-defibrillator system, with reprogramming Initial set-up and programming by a physician of wearable cardioverter-defibrillator includes initial programming of system, establishing baseline electronic ECG, transmission of data to data repository, patient instruction in wearing system and patient reporting of problems or events Thermogram; cephalic Thermogram; peripheral Determination of venous pressure Ambulatory blood pressure monitoring, utilizing a system such as magnetic tape and/or computer disk, for 24 hours or longer; including recording, scanning analysis, interpretation and report Ambulatory blood pressure monitoring, utilizing a system such as magnetic tape and/or computer disk, for 24 hours or longer; recording only Ambulatory blood pressure monitoring, utilizing a system such as magnetic tape and/or computer disk, for 24 hours or longer; scanning analysis with report Ambulatory blood pressure monitoring, utilizing a system such as magnetic tape and/or computer disk, for 24 hours or longer; physician review with interpretation and report Physician services for outpatient cardiac rehabilitation; without continuous ECG monitoring (per session) Physician services for outpatient cardiac rehabilitation; with continuous ECG monitoring (per session) Unlisted cardiovascular service or procedure PC Fee TC Fee 40.06(10) - Medical Service Description (continued) Noninvasive physiologic studies of extracranial arteries, complete bilateral study (eg, periorbital flow direction with arterial compression, ocular pneumoplethysmography, Doppler ultrasound spectral analysis) Duplex scan of extracranial arteries; complete bilateral study Duplex scan of extracranial arteries; unilateral or limited study Transcranial Doppler study of the intracranial arteries; complete study Transcranial Doppler study of the intracranial arteries; limited study Transcranial Doppler study of the intracranial arteries; vasoreactivity study Transcranial Doppler study of the intracranial arteries; emboli detection without intravenous microbubble injection Transcranial Doppler study of the intracranial arteries; emboli detection with intravenous microbubble injection Noninvasive physiologic studies of upper or lower extremity arteries, single level, bilateral (eg, ankle/brachial indices, Doppler waveform analysis, volume plethysmography, transcutaneous oxygen tension measurement) Noninvasive physiologic studies of upper or lower extremity arteries, multiple levels or with provocative functional maneuvers, complete bilateral study (eg, segmental blood pressure measurements, segmental Doppler waveform analysis, segmental volume plethsmography, segmental transcutaneous oxygen tension measurements with postural provicative tests, measurements with reactive hyperemia) Noninvasive physiologic studies of lower extremity arteries, at rest and following treadmill stress testing, complete bilateral study Duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study Duplex scan of lower extremity arteries or arterial bypass grafts; unilateral or limited study Duplex scan of upper extremity arteries or arterial bypass grafts; complete bilateral study Duplex scan of upper extremity arteries or arterial bypass grafts; unilateral or limited study Noninvasive physiologic studies of extremity veins, complete bilateral study (eg, Doppler waveform analysis with responses to compression and other maneuvers, phleborheography, impedance plethysmography) Duplex scan of extremity veins including responses to compression and other maneuvers; complete bilateral study Duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; complete study Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; limited study Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; complete study Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; unilateral or limited study PC Fee TC Fee 40.06(10) - Medical Service Description (continued) Duplex scan of arterial inflow and venous outflow of penile vessels; complete study Duplex scan of arterial inflow and venous outflow of penile vessels; follow-up or limited study Noninvasive physiologic study of implanted wireless pressure sensor in aneurysmal sac following endovascular repair, complete study including recording, analysis of pressure and waveform tracings, interpretation and report Duplex scan of hemodialysis access (including arterial inflow, body of access and venous outflow) Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; hospital inpatient/observation, initial day Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; hospital inpatient/observation, each subsequent day Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; nursing facility, per day Home ventilator management care plan oversight of a patient (patient not present) in home, domiciliary or rest home (eg, assisted living) requiring review of status, review of laboratories and other studies and revision of orders and respiratory care plan Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement(s), with or without maximal voluntary ventilation Patient-initiated spirometric recording per 30-day period of time; includes reinforced education, transmission of spirometric tracing, data capture, analysis of transmitted data, periodic recalibration and physician review and interpretation Patient-initiated spirometric recording per 30-day period of time; recording (includes hook-up, reinforced education, data transmission, data capture, trend analysis, and periodic recalibration) Patient-initiated spirometric recording per 30-day period of time; physician review and interpretation only Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration Bronchospasm provocation evaluation, multiple spirometric determinations as in 94010, with administered agents (eg, antigen[s], cold air, methacholine) Vital capacity, total (separate procedure) Maximum breathing capacity, maximal voluntary ventilation Functional residual capacity or residual volume: helium method, nitrogen open circuit method, or other method Expired gas collection, quantitative, single procedure (separate procedure) Thoracic gas volume Determination of maldistribution of inspired gas: multiple breath nitrogen washout curve including alveolar nitrogen or helium equilibration time Determination of resistance to airflow, oscillatory or plethysmographic methods Determination of airway closing volume, single breath tests Respiratory flow volume loop PC Fee I.C. TC Fee 40.06(10) - Medical Service Description (continued) Breathing response to CO2 (CO2 response curve) Breathing response to hypoxia (hypoxia response curve) High altitude simulation test (HAST), with physician interpretation and report; High altitude simulation test (HAST), with physician interpretation and report; with supplemental oxygen titration Intrapulmonary surfactant administration by a physician through endotracheal tube Pulmonary stress testing; simple (eg, 6-minute walk test, prolonged exercise test for bronchospasm with pre- and post-spirometry and oximetry) Pulmonary stress testing; complex (including measurements of CO2 production, O2 uptake, and electrocardiographic recordings) Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes (eg, with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing [IPPB] device) Aerosol inhalation of pentamidine for pneumocystis carinii pneumonia treatment or prophylaxis Continuous inhalation treatment with aerosol medication for acute airway obstruction; first hour Continuous inhalation treatment with aerosol medication for acute airway obstruction; each additional hour (List separately in addition to code for primary procedure) Continuous positive airway pressure ventilation (CPAP), initiation and management Continuous negative pressure ventilation (CNP), initiation and management Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device Manipulation chest wall, such as cupping, percussing, and vibration to facilitate lung function; initial demonstration and/or evaluation Manipulation chest wall, such as cupping, percussing, and vibration to facilitate lung function; subsequent Oxygen uptake, expired gas analysis; rest and exercise, direct, simple Oxygen uptake, expired gas analysis; including CO2 output, percentage oxygen extracted Oxygen uptake, expired gas analysis; rest, indirect (separate procedure) Carbon monoxide diffusing capacity (eg, single breath, steady state) Membrane diffusion capacity Pulmonary compliance study (eg, plethysmography, volume and pressure measurements) Noninvasive ear or pulse oximetry for oxygen saturation; single determination Noninvasive ear or pulse oximetry for oxygen saturation; multiple determinations (eg, during exercise) Noninvasive ear or pulse oximetry for oxygen saturation; by continuous overnight monitoring (separate procedure) Carbon dioxide, expired gas determination by infrared analyzer PC Fee TC Fee 40.06(10) - Medical Service Description (continued) I.C. I.C. I.C. Unlisted pulmonary service or procedure Percutaneous tests (scratch, puncture, prick) with allergenic extracts, immediate type reaction, including test interpretation and report by a physician, specify number of tests Percutaneous tests (scratch, puncture, prick) sequential and incremental, with drugs, biologicals or venoms, immediate type reaction, specify number of tests Nitric oxide expired gas determination Intracutaneous (intradermal) tests, sequential and incremental, with drugs, biologicals, or venoms, immediate type reaction, specify number of tests Intracutaneous (intradermal) tests with allergenic extracts, immediate type reaction, including test interpretation and report by a physician, specify number of tests Intracutaneous (intradermal) tests, sequential and incremental, with allergenic extracts for airborne allergens, immediate type reaction, including test interpretation and report by a physician, specify number of tests Intracutaneous (intradermal) tests with allergenic extracts, delayed type reaction, including reading, specify number of tests Patch or application test(s) (specify number of tests) Photo patch test(s) (specify number of tests) Photo tests Ophthalmic mucous membrane tests Direct nasal mucous membrane test Inhalation bronchial challenge testing (not including necessary pulmonary function tests); with histamine, methacholine, or similar compounds Inhalation bronchial challenge testing (not including necessary pulmonary function tests); with antigens or gases, specify Ingestion challenge test (sequential and incremental ingestion of test items, eg, food, drug or other substance such as metabisulfite) Professional services for allergen immunotherapy not including provision of allergenic extracts; single injection Professional services for allergen immunotherapy not including provision of allergenic extracts; two or more injections I.C. Professional services for allergen immunotherapy in prescribing physicians office or institution, including provision of allergenic extract; single injection I.C. Professional services for allergen immunotherapy in prescribing physicians office or institution, including provision of allergenic extract; two or more injections I.C. Professional services for allergen immunotherapy in prescribing physicians office or institution, including provision of allergenic extract; single stinging insect venom I.C. Professional services for allergen immunotherapy in prescribing physicians office or institution, including provision of allergenic extract; two stinging insect venoms I.C. Professional services for allergen immunotherapy in prescribing physicians office or institution, including provision of allergenic extract; three stinging insect venoms I.C. Professional services for allergen immunotherapy in prescribing physicians office or institution, including provision of allergenic extract; four stinging insect venoms 40.06: continued I.C. PC Fee TC Fee I.C. 40.06(10) - Medical Service Description (continued) Professional services for allergen immunotherapy in prescribing physicians office or institution, including provision of allergenic extract; five stinging insect venoms Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy, single dose vial(s) (specify number of vials) Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy (specify number of doses); single stinging insect venom Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy (specify number of doses); two single stinging insect venoms Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy (specify number of doses); three single stinging insect venoms Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy (specify number of doses); four single stinging insect venoms Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy (specify number of doses); five single stinging insect venoms Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single or multiple antigens (specify number of doses) Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; whole body extract of biting insect or other arthropod (specify number of doses) Rapid desensitization procedure, each hour (eg, insulin, penicillin, equine serum) Unlisted allergy/clinical immunologic service or procedure Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for up to 72 hours; sensor placement, hook-up, calibration of monitor, patient training, removal of sensor, and printout of recording Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for up to 72 hours; physician interpretation and report Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, unattended by a technologist Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist Polysomnography; sleep staging with one - three additional parameters of sleep, attended by a technologist Polysomnography; sleep staging with four or more additional parameters of sleep, attended by a technologist Polysomnography; sleep staging with four or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist PC Fee TC Fee I.C. I.C. 1,510.86 319.97 1,190.89 I.C. I.C. 40.06(10) - Medical Service Description (continued) Electroencephalogram (EEG) extended monitoring; 41-60 minutes Electroencephalogram (EEG) extended monitoring; greater than one hour Electroencephalogram (EEG); including recording awake and drowsy Electroencephalogram (EEG); including recording awake and asleep Electroencephalogram (EEG); recording in coma or sleep only Electroencephalogram (EEG); cerebral death evaluation only Electroencephalogram (EEG); all night recording Electrocorticogram at surgery (separate procedure) Insertion by physician of sphenoidal electrodes for electroencephalographic (EEG) recording Muscle testing, manual (separate procedure) with report; extremity (excluding hand) or trunk Muscle testing, manual (separate procedure) with report; hand, with or without comparison with normal side Muscle testing, manual (separate procedure) with report; total evaluation of body, excluding hands Muscle testing, manual (separate procedure) with report; total evaluation of body, including hands Range of motion measurements and report (separate procedure); each extremity (excluding hand) or each trunk section (spine) Range of motion measurements and report (separate procedure); hand, with or without comparison with normal side Tensilon test for myasthenia gravis Needle electromyography; one extremity with or without related paraspinal areas Needle electromyography; two extremities with or without related paraspinal areas Needle electromyography; three extremities with or without related paraspinal areas Needle electromyography; four extremities with or without related paraspinal areas Needle electromyography; larynx Needle electromyography; hemidiaphragm Needle electromyography; cranial nerve supplied muscle(s), unilateral Needle electromyography; cranial nerve supplied muscles, bilateral Needle electromyography; thoracic paraspinal muscles (excluding T1 or T12) Needle electromyography; limited study of muscles in one extremity or non-limb (axial) muscles (unilateral or bilateral), other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters Needle electromyography using single fiber electrode, with quantitative measurement of jitter, blocking and/or fiber density, any/all sites of each muscle studied Electrical stimulation for guidance in conjunction with chemodenervation (List separately in addition to code for primary procedure) Needle electromyography for guidance in conjunction with chemodenervation (List separately in addition to code for primary procedure) PC Fee I.C. TC Fee I.C. 40.06(10) - Medical Service Description (continued) Ischemic limb exercise test with serial specimen(s) acquisition for muscle(s) metabolite(s) Nerve conduction, amplitude and latency/velocity study, each nerve; motor, without F-wave study Nerve conduction, amplitude and latency/velocity study, each nerve; motor, with F-wave study Nerve conduction, amplitude and latency/velocity study, each nerve; sensory Intraoperativeneurophysiologytesting, per hour (List separately in addition to code for primary procedure) Testing of autonomic nervous system function; cardiovagal innervation (parasympathetic function), including two or more of the following: heart rate response to deep breathing with recorded R-R interval, Valsalva ratio, and 30:15 ratio Testing of autonomic nervous system function; vasomotor adrenergic innervation (sympathetic adrenergic function), including beat-to-beat blood pressure and R-R interval changes during Valsalva maneuver and at least five minutes of passive tilt Testing of autonomic nervous system function; sudomotor, including one or more of the following: quantitative sudomotor axon reflex test (QSART), silastic sweat imprint, thermoregulatory sweat test, and changes in sympathetic skin potential Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper limbs Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in lower limbs Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in the trunk or head Central motor evoked potential study (transcranial motor stimulation); upper limbs Central motor evoked potential study (transcranial motor stimulation); lower limbs Visual evoked potential (VEP) testing central nervous system, checkerboard or flash Orbicularis oculi (blink) reflex, by electrodiagnostic testing H-reflex, amplitude and latency study; record gastrocnemius/soleus muscle H-reflex, amplitude and latency study; record muscle other than gastrocnemius/soleus muscle Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any one method Monitoring for identification and lateralization of cerebral seizure focus, electroencephalographic (eg, eight channel EEG) recording and interpretation, each 24 hours Monitoring for localization of cerebral seizure focus by cable or radio, 16 or more channel telemetry, combined electroencephalographic (EEG) and video recording and interpretation (eg, for presurgical localization), each 24 hours 40.06: continued PC Fee I.C. I.C. I.C. TC Fee 40.06(10) - Medical Service Description (continued) Monitoring for localization of cerebral seizure focus by computerized portable 16 or more channel EEG, electroencephalographic (EEG) recording and interpretation, each 24 hours I.C. I.C. I.C. Pharmacological or physical activation requiring physician attendance during EEG recording of activation phase (eg, thiopental activation test) Electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery) Monitoring for localization of cerebral seizure focus by cable or radio, 16 or more channel telemetry, electroencephalographic (EEG) recording and interpretation, each 24 hours Digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis) Wada activation test for hemispheric function, including electroencephalographic (EEG) monitoring Functional cortical and subcortical mapping by stimulation and/or recording of electrodes on brain surface, or of depth electrodes, to provoke seizures or identify vital brain structures; initial hour of physician attendance Functional cortical and subcortical mapping by stimulation and/or recording of electrodes on brain surface, or of depth electrodes, to provoke seizures or identify vital brain structures; each additional hour of physician attendance (List separately in addition to code for primary procedure) Magnetoencephalography (MEG), recording and analysis; for spontaneous brain magnetic activity (eg, epileptic cerebral cortex localization) Magnetoencephalography (MEG), recording and analysis; for evoked magnetic fields, single modality (eg, sensory, motor, language, or visual cortex localization) Magnetoencephalography (MEG), recording and analysis; for evoked magnetic fields, each additional modality (eg, sensory, motor, language, or visual cortex localization) (List separately in addition to code for primary procedure) Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements PC Fee TC Fee 40.06(10) - Medical Service Description (continued) Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient measurements) gastric neurostimulator pulse generator/transmitter; intraoperative, with programming Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient measurements) gastric neurostimulator pulse generator/transmitter; subsequent, without programming Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient measurements) gastric neurostimulator pulse generator/transmitter; subsequent, with programming Refilling and maintenance of implantable pump or reservoir for drug delivery, spinal (intrathecal, epidural) or brain (intraventricular); Refilling and maintenance of implantable pump or reservoir for drug delivery, spinal (intrathecal, epidural) or brain (intraventricular); administered by physician I.C. Unlisted neurological or neuromuscular diagnostic procedure Comprehensive computer-based motion analysis by video-taping and 3-D kinematics; Comprehensive computer-based motion analysis by video-taping and 3-D kinematics; with dynamic plantar pressure measurements during walking Dynamic surface electromyography, during walking or other functional activities, one - 12 muscles Dynamic fine wire electromyography, during walking or other functional activities, one muscle PC Fee TC Fee 40.06(10) - Medical Service Description (continued) Physician review and interpretation of comprehensive computer-based motion analysis, dynamic plantar pressure measurements, dynamic surface electromyography during walking or other functional activities, and dynamic fine wire electromyography, with written report I.C. I.C. Neurofunctional testing selection and administration during noninvasive imaging functional brain mapping, with test administered entirely by a physician or psychologist, with review of test results and report Medical genetics and genetic counseling services, each 30 minutes face-to-face with patient/family Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic Chemotherapy administration, subcutaneous or intramuscular; hormonal anti-neoplastic Chemotherapy administration; intralesional, up to and including seven lesions Chemotherapy administration; intralesional, more than seven lesions Chemotherapy administration; intravenous, push technique, single or initial substance/drug Chemotherapy administration; intravenous, push technique, each additional substance/drug (List separately in addition to code for primary procedure) Chemotherapy administration, intravenous infusion technique; up to one hour, single or initial substance/drug Chemotherapy administration, intravenous infusion technique; each additional hour (List separately in addition to code for primary procedure) Chemotherapy administration, intravenous infusion technique; initiation of prolonged chemotherapy infusion (more than eight hours), requiring use of a portable or implantable pump Chemotherapy administration, intravenous infusion technique; each additional sequential infusion (different substance/drug), up to one hour (List separately in addition to code for primary procedure) Chemotherapy administration, intra-arterial; push technique Chemotherapyadministration, intra-arterial; infusion technique, up to one hour Chemotherapyadministration, intra-arterial; infusion technique, each additional hour (List separately in addition to code for primary procedure) Chemotherapyadministration, intra-arterial; infusion technique, initiation of prolonged infusion (more than eight hours), requiring the use of a portable or implantable pump Chemotherapy administration into pleural cavity, requiring and including thoracentesis Chemotherapy administration into peritoneal cavity, requiring and including peritoneocentesis Chemotherapy administration, into CNS (eg, intrathecal), requiring and including spinal puncture Refilling and maintenance of portable pump Refilling and maintenance of implantable pump or reservoir for drug delivery, systemic (eg, intravenous, intra-arterial) Irrigation of implanted venous access device for drug delivery systems PC Fee TC Fee 40.06(10) - Medical Service Description (continued) Chemotherapy injection, subarachnoid or intraventricular via subcutaneous reservoir, single or multiple agents I.C. Unlisted chemotherapy procedure Photodynamic therapy by external application of light to destroy premalignant and/or malignant lesions of the skin and adjacent mucosa (eg, lip) by activation of photosensitive drug(s), each phototherapy exposure session Photodynamic therapy by endoscopic application of light to ablate abnormal tissue via activation of photosensitive drug(s); first 30 minutes (List separately in addition to code for endoscopy or bronchoscopy procedures of lung and esophagus) Photodynamic therapy by endoscopic application of light to ablate abnormal tissue via activation of photosensitive drug(s); each additional 15 minutes (List separately in addition to code for endoscopy or bronchoscopy procedures of lung and esophagus) Actinotherapy (ultraviolet light) Microscopic examination of hairs plucked or clipped by the examiner (excluding hair collected by the patient) to determine telogen and anagen counts, or structural hair shaft abnormality Whole body integumentary photography, for monitoring of high risk patients with dysplastic nevus syndrome or a history of dysplastic nevi, or patients with a personal or familial history of melanoma Photochemotherapy; tar and ultraviolet B (Goeckerman treatment) or petrolatum and ultraviolet B Photochemotherapy; psoralens and ultraviolet A (PUVA) Photochemotherapy (Goeckerman and/or PUVA) for severe photoresponsive dermatoses requiring at least four to eight hours of care under direct supervision of the physician (includes application of medication and dressings) Laser treatment for inflammatory skin disease (psoriasis); total area less than 250 sq cm Laser treatment for inflammatory skin disease (psoriasis); 250 sq cm to 500 sq cm Laser treatment for inflammatory skin disease (psoriasis); over 500 sq cm I.C. Unlisted special dermatological service or procedure Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes Medical nutrition therapy; re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes Medical nutrition therapy; group (two or more individual(s)), each 30 minutes Osteopathic manipulative treatment (OMT); one to two body regions involved Osteopathic manipulative treatment (OMT); three to four body regions involved Osteopathic manipulative treatment (OMT); five to six body regions involved Osteopathic manipulative treatment (OMT); seven to eight body regions involved Osteopathic manipulative treatment (OMT); nine to ten body regions involved PC Fee TC Fee 40.06(10) - Medical Service Description (continued) Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; two - four patients Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; five - eight patients Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous seven days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; five - ten minutes of medical discussion Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous seven days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous seven days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 21-30 minutes of medical discussion I.C. Online assessment and management service provided by a qualified nonphysician health care professional to an established patient, guardian, or health care provider not originating from a related assessment and management service provided within the previous seven days, using the internet or similar electronic communications network Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure I.C. Hospital mandated on call service; in-hospital, each hour I.C. Hospital mandated on call service; out-of-hospital, each hour Services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed (eg, holidays, Saturday or Sunday), in addition to basic service Service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service PC Fee TC Fee 40.06(10) - Medical Service Description (continued) Service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service Service(s) typically provided in the office, provided out of the office at request of patient, in addition to basic service Service(s) provided on an emergency basis in the office, which disrupts other scheduled office services, in addition to basic service Service(s) provided on an emergency basis, out of the office, which disrupts other scheduled office services, in addition to basic service I.C. Supplies and materials (except spectacles), provided by the physician over and above those usually included with the office visit or other services rendered (list drugs, trays, supplies, or materials provided) I.C. Educational supplies, such as books, tapes, and pamphlets, provided by the physician for the patient's education at cost to physician I.C. Medical testimony I.C. Special reports such as insurance forms, more than the information conveyed in the usual medical communications or standard reporting form I.C. Unusual travel (eg, transportation and escort of patient) I.C. Analysis of clinical data stored in computers (eg, ECGs, blood pressures, hematologic data) Collection and interpretation of physiologic data (eg, ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified health care professional, requiring a minimum of 30 min I.C. Moderate sedation services (other than those services described by codes 00100-01999) provided by the same physician performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological sattus; five years or older, first 30 minutes intra-service time I.C. Moderate sedation services (other than those services described by codes 00100-01999) provided by the same physician performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additinal 15 minutes intra-service time (list separately in addition to code for primary service) I.C. Moderate sedation services (other than those services described by codes 00100-01999), provided by a physician other than the health care professional performing the diagnostic or therapeutic service that the sedation supports; age five years or older, first 30 minutes intra-service time I.C. Moderate sedation services (other than those services described by codes 00100-01999), provided by a physician other than the health care professional performing the diagnostic or therapeutic service that the sedation supports; each additional 15 minutes (list separately in addition to code for primary service) PC Fee TC Fee 40.06(10) - Medical Service Description (continued) I.C. Visual function screening, automated or semi-automated bilateral quantitative determination of visual acuity, ocular alignment, color vision by pseudoisochromatic plates, and field of vision (may include all or some screening of the determination[s] for contrast sensitivity, vision under glare) Screening test of visual acuity, quantitative, bilateral I.C. Ocular photoscreening with interpretation and report, bilateral Ipecac or similar administration for individual emesis and continued observation until stomach adequately emptied of poison Physician attendance and supervision of hyperbaric oxygen therapy, per session Hypothermia; regional Hypothermia; total body I.C. Assembly and operation of pump with oxygenator or heat exchanger (with or without ECG and/or pressure monitoring); each hour I.C. Assembly and operation of pump with oxygenator or heat exchanger (with or without ECG and/or pressure monitoring); 45 minutes I.C. Assembly and operation of pump with oxygenator or heat exchanger (with or without ECG and/or pressure monitoring); 30 minutes Phlebotomy, therapeutic (separate procedure) I.C. Unlisted special service, procedure or report Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend ten minutes face-to-face with the patient and/or family. Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 20 minutes face-to-face with the patient and/or family. Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: A detailed history; A detailed examination; Medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family. PC Fee TC Fee 40.06(10) - Medical Service Description (continued) Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 45 minutes face-to-face with the patient and/or family. Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, five minutes are spent performing or supervising these services. Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend ten minutes face-to-face with the patient and/or family. Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family. Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family. PC Fee TC Fee 40.06(10) - Medical Service Description (continued) Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family. Observation care discharge day management (This code is to be utilized by the physician to report all services provided to a patient on discharge from "observation status" if the discharge is on other than the initial date of "observation status." To report services to a patient designated as "observation status" or "inpatient status" and discharged on the same date, use the codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-99236 as appropriate.]) A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity. Initial observation care, per day, for the evaluation and management of a patient which requires these three key components: Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission to "observation status" are of low severity. Initial observation care, per day, for the evaluation and management of a patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission to "observation status" are of moderate severity. Initial observation care, per day, for the evaluation and management of a patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission to "observation status" are of high severity. Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or or of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of low severity. Physicians typically spend 30 minutes at the bedside and on the patient's hospital floor or unit. PC Fee TC Fee 40.06(10) - Medical Service Description (continued) Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of moderate severity. Physicians typically spend 50 minutes at the bedside and on the patient's hospital floor or unit. Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Physicians typically spend 70 minutes at the bedside and on the patient's hospital floor or unit. Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: A problem focused interval history; A problem focused examination; Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is stable, recovering or improving. Physicians typically spend 15 minutes at the bedside and on the patient's hospital floor or unit. Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Physicians typically spend 25 minutes at the bedside and on the patient's hospital floor or unit. Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: A detailed interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Physicians typically spend 35 minutes at the bedside and on the patient's hospital floor or unit. PC Fee TC Fee 40.06(10) - Medical Service Description (continued) Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date which requires these three key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually the presenting problem(s) requiring admission are of low severity. Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually the presenting problem(s) requiring admission are of moderate severity. Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually the presenting problem(s) requiring admission are of high severity. Hospital discharge day management; 30 minutes or less Hospital discharge day management; more than 30 minutes Office consultation for a new or established patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other providers Office consultation for a new or established patient, which requires these three key components: An expanded problem focused history; An expanded problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care Office consultation for a new or established patient, which requires these three key components: A detailed history; A detailed examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies Office consultation for a new or established patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 60 minutes face-to-face with the patient and/or family. PC Fee TC Fee 40.06(10) - Medical Service Description (continued) Office consultation for a new or established patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 80 minutes face-to-face with the patient and/or family. Inpatient consultation for a new or established patient, which requires these three key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 20 minutes at the bedside and on the patient's hospital floor or unit. Inpatient consultation for a new or established patient, which requires these three key components: An expanded problem focused history; An expanded problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low severity. Physicians typically spend 40 minutes at the bedside and on the patient's hospital floor or unit. Inpatient consultation for a new or established patient, which requires these three key components: A detailed history; A detailed examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 55 minutes at the bedside and on the patient's hospital floor or unit. Inpatient consultation for a new or established patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 80 minutes at the bedside and on the patient's hospital floor or unit. Inpatient consultation for a new or established patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 110 minutes at the bedside and on the patient's hospital floor or unit. PC Fee TC Fee 40.06(10) - Medical Service Description (continued) Emergency department visit for the evaluation and management of a patient, which requires these three key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Emergency department visit for the evaluation and management of a patient, which requires these three key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Emergency department visit for the evaluation and management of a patient, which requires these three key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Emergency department visit for the evaluation and management of a patient, which requires these three key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity, and require urgent evaluation by the physician but do not pose an immediate significant threat to life or physiologic function. Emergency department visit for the evaluation and management of a patient, which requires these three key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function. I.C. Physician direction of emergency medical systems (EMS) emergency care, advanced life support Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service) PC Fee TC Fee 40.06(10) - Medical Service Description (continued) Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these three key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity.Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.Usually the problem(s) requiring admission are of low severity. Physicians typically spend 25 minutes with the patient and/or family or caregiver Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.Usually the problem(s) requiring admission are of moderate severity. Physicians typically spend 35 minutes with the patient and/or family or caregiver Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.Usually the problem(s) requiring admission are of high severity. Physicians typically spend 45 minutes with the patient and/or family or caregiver Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: A problem focused interval history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.Usually the patient is stable, recovering or improving. Physicians typically spend ten minutes with the patient and/or family or caregiver. Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of low complexity.Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually the patient is responding inadequately to therapy or has developed a minor complication.Physicians typically spend 15 minutes with the patient and/or family or caregiver. PC Fee TC Fee 40.06(10) - Medical Service Description (continued) Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: A detailed interval history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.Usually the patient has developed a significant complication or a significant new problem. Physicians typically spend 25 minutes with the patient and/or family or caregiver. Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: A comprehensive interval history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.The patient may be unstable or may have developed a significant new problem. Physicians typically spend 35 minutes with the patient and/or family or caregiver. Nursing facility discharge day management; 30 minutes or less Nursing facility discharge day management; more than 30 minutes Evaluation and management of a patient involving an annual nursing facility assessment, which requires these three key components: A detailed interval history; A comprehensive examination; and Medical decision making that is of low to moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.Usually the patient is stable, recovering or improving. Physicians typically spend 30 minutes with the patient and/or family or caregiver. Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these three key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.Usually the presenting problem(s) are of low severity. Physicians typically spend 20 minutes with the patient and/or family or caregiver Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these three key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually the problem(s) requiring admission are of low severity. Physicians typically spend 25 minutes with the patient and/or family or caregiver.Usually the presenting problem(s) are of moderate severity. Physicians typically spend 30 minutes with the patient and/or family or caregiver. PC Fee TC Fee 40.06(10) - Medical Service Description (continued) Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these three key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.Usually the presenting problem(s) are of moderate to high severity. Physicians typically spend 45 minutes with the patient and/or family or caregiver. Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.Usually the presenting problem(s) are of high severity. Physicians typically spend 60 minutes with the patient and/or family or caregiver. Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually the patient is unstable or has developed a significant new problem requiring immediate physician attention.Physicians typically spend 75 minutes with the patient and/or family or caregiver. Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least two of these three key components: A problem focused interval history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually the presenting problem(s) are self-limited or minor. Physicians typically spend 15 minutes with the patient and/or family or caregiver. Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least two of these three key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of low complexity.Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.Usually the presenting problem(s) are of low to moderate severity. Physicians typically spend 25 minutes with the patient and/or family or caregiver. PC Fee TC Fee 40.06(10) - Medical Service Description (continued) Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least two of these three key components: A detailed interval history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.Usually the presenting problem(s) are of moderate to high severity. Physicians typically spend 40 minutes with the patient and/or family or caregiver. Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least two of these three key components: A comprehensive interval history; A comprehensive examination; Medical decision making of moderate to high complexity.Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.Usually the presenting problem(s) are of moderate to high severity. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention.Physicians typically spend 60 minutes with the patient and/or family or caregiver. Individual physician supervision of a patient (patient not present) in home, domiciliary or rest home (eg, assisted living facility) requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans, review of subsequent reports of patient status, review of related laboratory and other studies, communication (including telephone calls) for purposes of assessment or care decisions with health care professional(s), family member(s), surrogate decision maker(s) (e.g., legal guardian) and/or key caregiver(s) involved inpatient's care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month, 15-29 minutes Individual physician supervision of a patient (patient not present) in home, domiciliary or rest home (eg, assisted living facility) requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans, review of subsequent reports of patient status, review of related laboratory and other studies, communication (including telephone calls) for purposes of assessment or care decisions with health care professional(s), family member(s), surrogate decision maker(s) (e.g., legal guardian) and/or key caregiver(s) involved inpatient's care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month, 30 minutes or more Home visit for the evaluation and management of a new patient, which requires these three key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.Usually the presenting problem(s) are of low severity. Physicians typically spend 20 minutes face-to-face with the patient and/or family. PC Fee TC Fee 40.06(10) - Medical Service Description (continued) Home visit for the evaluation and management of a new patient, which requires these three key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.Usually the presenting problem(s) are of moderate severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family. Home visit for the evaluation and management of a new patient, which requires these three key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.Usually the presenting problem(s) are of moderate to high severity. Physicians typically spend 45 minutes face-to-face with the patient and/or family. Home visit for the evaluation and management of a new patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.Usually the presenting problem(s) are of high severity. Physicians typically spend 60 minutes face -to-face with the patient and/or family. Home visit for the evaluation and management of a new patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually the patient is unstable or has developed a significant new problem requiring immediate physician attention.Physicians typically spend 75 minutes face-to-face with the patient and/or family. Home visit for the evaluation and management of an established patient, which requires at least two of these three key components: A problem focused interval history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Home visit for the evaluation and management of an established patient, which requires at least two of these three key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of low complexity. PC Fee TC Fee 40.06(10) - Medical Service Description (continued) Home visit for the evaluation and management of an established patient, which requires at least two of these three key components: A detailed interval history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.Usually the presenting problem(s) are self-limited or minor. Physicians typically spend 15 minutes with the patient and/or family. Home visit for the evaluation and management of an established patient, which requires at least two of these three key components: A comprehensive interval history; A comprehensive examination; Medical decision making of moderate to high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual service (eg, prolonged care and treatment of an acute asthmatic patient in an outpatient setting); first hour (List separately in addition to code for office or other Evaluation and Management procedure) Prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual service (eg, prolonged care and treatment of an acute asthmatic patient in an outpatient setting); each additional 30 minutes (List separately in addition to code for office or other Evaluation and Management procedure) Prolonged physician service in the inpatient setting, requiring direct (face-to-face) patient contact beyond the usual service (eg, maternal fetal monitoring for high risk delivery or other physiological monitoring, prolonged care of an acutely ill inpatient); first hour (List separately in addition to code for office or other Evaluation and Management procedure). Prolonged physician service in the inpatient setting, requiring direct (face-to-face) patient contact beyond the usual service (eg, maternal fetal monitoring for high risk delivery or other physiological monitoring, prolonged care of an acutely ill inpatient); each additional 30 minutes (List separately in addition to code for office or other Evaluation and Management procedure). Prolonged evaluation and management service before and/or after direct (face-to-face) patient care (eg, review of extensive records and tests, communication with other professionals and/or the patient/family); first hour (List separately in addition to code for other physician service(s) and/or inpatient or outpatient Evaluation and Management service) Prolonged evaluation and management service before and/or after direct (face-to-face) patient care (eg, review of extensive records and tests, communication with other professionals and/or the patient/family); each additional 30 minutes (List separately in addition to code for prolonged physician service) PC Fee TC Fee 40.06(10) - Medical Service Description (continued) Physician standby service, requiring prolonged physician attendance, each 30 minutes (eg, operative standby, standby for frozen section, for cesarean/high risk delivery, for monitoring EEG) Anticoagulant management for an outpatient taking warfarin, physician review and interpretation of International Normalized Ratio (INR) testing, patient instructions, dosage adjustment (as needed), and ordering of additional tests; initial 90 days of therapy (must include a minimum of 8 INR measurements) Anticoagulant management for an outpatient taking warfarin, physician review and interpretation of International Normalized Ratio (INR) testing, patient instructions, dosage adjustment (as needed), and ordering of additional tests; each subsequent 90 days of therapy (must include a minimum of three INR measurements) Medical team conference with interdisciplinary team of health care professionals, face-to-face with patient and/or family, 30 minutes or more, participation by nonphysician qualified health care professional Medical team conference with interdisciplinary team of health care professionals, patient and/or family not present, 30 minutes or more; participation by physician Medical team conference with interdisciplinary team of health care professionals, patient and/or family not present, 30 minutes or more; participation by nonphysician qualified health care professional Physician supervision of a patient under care of home health agency (patient not present) in home, domiciliary or equivalent environment (eg, Alzheimer's facility) requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans, review of subsequent reports of patient status, review of related laboratory and other studies, communication (includiing telephone calls) for purposes of assessment of care decisions with health care professional(s), family member(s), surrogate decision maker(s) (e.g., legal guardian) and/or key caregiver(s) involved in patient's care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 15-29 minutes Physician supervision of a patient under care of home health agency (patient not present) in home, domiciliary or equivalent environment (eg, Alzheimer's facility) requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans, review of subsequent reports of patient status, review of related laboratory and other studies, communication (includiing telephone calls) for purposes of assessment of care decisions with health care professional(s), family member(s), surrogate decision maker(s) (e.g., legal guardian) and/or key caregiver(s) involved in patient's care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 30 minutes or more PC Fee TC Fee 40.06(10) - Medical Service Description (continued) Physician supervision of a hospice patient (patient not present) requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans, review of subsequent reports of patient status, review of related laboratory and other studies, communication (includiing telephone calls) for purposes of assessment of care decisions with health care professional(s), family member(s), surrogate decision maker(s) (e.g., legal guardian) and/or key caregiver(s) involved in patient's care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 15-29 minutes Physician supervision of a hospice patient (patient not present) requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans, review of subsequent reports of patient status, review of related laboratory and other studies, communication (includiing telephone calls) for purposes of assessment of care decisions with health care professional(s), family member(s), surrogate decision maker(s) (e.g., legal guardian) and/or key caregiver(s) involved in patient's care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 30 minutes or more Physician supervision of a nursing facility patient (patient not present) requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans, review of subsequent reports of patient status, review of related laboratory and other studies, communication (includiing telephone calls) for purposes of assessment of care decisions with health care professional(s), family member(s), surrogate decision maker(s) (e.g., legal guardian) and/or key caregiver(s) involved in patient's care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 15-29 minutes Physician supervision of a nursing facility patient (patient not present) requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans, review of subsequent reports of patient status, review of related laboratory and other studies, communication (includiing telephone calls) for purposes of assessment of care decisions with health care professional(s), family member(s), surrogate decision maker(s) (e.g., legal guardian) and/or key caregiver(s) involved in patient's care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 30 minutes or more Telephone evaluation and management service provided by a physician to an established patient, parent, or guardian not originating from a related E/M service provided within the previous seven days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; five - ten minutes of medical discussion PC Fee TC Fee 40.06(10) - Medical Service Description (continued) Telephone evaluation and management service provided by a physician to an established patient, parent, or guardian not originating from a related E/M service provided within the previous seven days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion Telephone evaluation and management service provided by a physician to an established patient, parent, or guardian not originating from a related E/M service provided within the previous seven days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 21-30 minutes of medical discussion I.C. Online evaluation and management service provided by a physician to an established patient, guardian, or health care provider not originating from a related E/M service provided within the previous seven days, using the Internet or similar electronic communications network I.C. Basic life and/or disability examination that includes: Measurement of height, weight, and blood pressure; Completion of a medical history following a life insurance pro forma; Collection of blood sample and/or urinalysis complying with "chain of custody" protocols; and completion of necessary documentatioin/certificates I.C. Work related or medical disability examination by the treating physician that includes: Completion of a medical history commensurate with the patient's condition; Performance of an examination commensurate with the patient's condition; Formulation of a diagnosis, assessment of capabilities and stability, and calculation of impairment; development of future medical treatment plan; and completion of necessary documentation/certification and report. I.C. Work related or medical disability examination by other than the treating physician that includes: Completion of a medical history commensurate with the patient's condition; Performance of an examination commensurate with the patient's condition; Formulation of a diagnosis, assessment of capabilities and stability, and calculation of impairment; development of future medical treatment plan; and completion of necessary documentation/certification and report. I.C. Unlisted evaluation and management service I.C. Home visit for respiratory therapy care (eg, bronchodilator, oxygen therapy, respiratory assessment, apnea evaluation) I.C. Home visit for mechanical ventilation care I.C. Home visit for stoma care and maintenance including colostomy and cystostomy I.C. Home visit for intramuscular injections I.C. Home visit for care and maintenance of catheter(s) (eg, urinary, drainage, and enteral) I.C. Home visit for assistance with activities of daily living and personal care I.C. Home visit for fecal impaction management and enema administration I.C. Home visit for hemodialysis I.C. Unlisted home visit service or procedure (11) Psychological Services. Unit 40.06(11) - Psychological Services Description Psychiatric diagnostic interview examination Interactive psychiatric diagnostic interview examination using play equipment, physical devices, language interpreter, or other mechanisms of communication Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately20 to 30 minutes face-to-face with the patient; Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 20 to 30 minutes face-to-face with the patient; with medical evaluation and management services Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately45 to 50 minutes face-to-face with the patient; Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately45 to 50 minutes face-to-face with the patient; with medical evaluation and management services Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately75 to 80 minutes face-to-face with the patient; Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 75 to 80 minutes face-to-face with the patient; with medical evaluation and management services Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, approximately 20 to 30 minutes face-to-face with the patient; Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, approximately 20 to 30 minutes face-to-face with the patient; with medical evaluation Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, approximately 45 to 50 minutes face-to-face with the patient; Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, approximately 45 to 50 minutes face-to-face with the patient; with medical evaluation Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, approximately 75 to 80 minutes face-to-face with the patient; Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, approximately 75 to 80 minutes face-to-face with the patient; with medical evaluation Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 20 to 30 minutes face-to-face with the patient; Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 20 to 30 minutes face-to-face with the patient; with medical evaluation and management Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 45 to 50 minutes face-to-face with the patient; Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 45 to 50 minutes face-to-face with the patient; with medical evaluation and management Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 75 to 80 minutes face-to-face with the patient; Unit 40.06(11) - Psychological Services Description (continued) Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 75 to 80 minutes face-to-face with the patient; with medical evaluation and management Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 20 to 30 minutes face-to-face with the patient; Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 20 to 30 minutes face-to-face with the patient; Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 45 to 50 minutes face-to-face with the patient; Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 45 to 50 minutes face-to-face with the patient; Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 75 to 80 minutes face-to-face with the patient; Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 75 to 80 minutes face-to-face with the patient; Psychoanalysis Family psychotherapy (without the patient present) Family psychotherapy (conjoint psychotherapy) (with patient present) Multiple-family group psychotherapy Group psychotherapy (other than of a multiple-family group) Interactive group psychotherapy Pharmacologic management, including prescription, use, and review of medication with no more than minimal medical psychotherapy Narcosynthesis for psychiatric diagnostic and therapeutic purposes (eg, sodium amobarbital (Amytal) interview) Electroconvulsive therapy (includes necessary monitoring) Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy (eg, insight oriented, behavior modifying or supportive psychotherapy); approximately 20-30 minutes Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy (eg, insight oriented, behavior modifying or supportive psychotherapy); approximately 45-50 minutes Hypnotherapy Psychiatric evaluation of hospital records, other psychiatric reports, psychometric and/or projective tests, and other accumulated data for medical diagnostic purposes Interpretation or explanation of results of psychiatric, other medical examinations and procedures, or other accumulated data to family or other responsible persons, or advising them how to assist patient Preparation of report of patient's psychiatric status, history, treatment, or progress (other than for legal or consultative purposes) for other physicians, agencies, or insurance carriers Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, eg, MMPI, Rorschach, WAIS), per hour of the psychologist's or physician's time, both face-to-face time administering test Unit 40.06(11) - Psychological Services Description (continued) Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, eg, MMPI and WAIS), with qualified health care professional interpretation and report, administered by technician, per hour Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, eg, MMPI), administered by a computer, with qualified health care professional interpretation and report Assessment of aphasia (includes assessment of expressive and receptive speech and language function, language comprehension, speech production ability, reading, spelling, writing, eg, by Boston Diagnostic Aphasia Examination) with interpretation and report Developmental testing; limited (eg, Developmental Screening Test II, Early Language Milestone Screen), with interpretation and report Developmental testing; extended (includes assessment of motor, language, social, adaptive and/or cognitive functioning by standardized developmental instruments) with interpretation and report Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, eg, acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities), per hour of the psychologist's or physician's time, both face-to-face Neuropsychological testing (eg, Halstead-Reitan Neuropsychological Battery, Wechsler Memory Scales and Wisconsin Card Sorting Test), per hour of the psychologist's or physician's time, both face-to-face time administering tests to the patient and time interpreting Neuropsychological testing (eg, Halstead-Reitan Neuropsychological Battery, Wechsler Memory Scales and Wisconsin Card Sorting Test), with qualified health care professional interpretation and report, administered by technician, per hour of technician time Neuropsychological testing (eg, Wisconsin Card Sorting Test), administered by a computer, with qualified health care professional interpretation and report Standardized cognitive performance testing (eg, Ross Information Processing Assessment) per hour of a qualified health care professional's time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report Health and behavior assessment (eg, health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient; initial assessment Health and behavior assessment (eg, health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient; re-assessment Health and behavior intervention, each 15 minutes, face-to-face; individual Health and behavior intervention, each 15 minutes, face-to-face; group (two or more patients) Health and behavior intervention, each 15 minutes, face-to-face; family (with the patient present) Health and behavior intervention, each 15 minutes, face-to-face; family (without the patient present) Prolonged evaluation and management service before and/or after direct (face-to-face) patient care (eg, review of extensive records and tests, communication with other professionals and/or the patient/family); first hour (List separately in addition to code(s) for other physician service(s) and.or inpatient or outpatient evaluation and management service) Prolonged evaluation and management service before and/or after direct (face-to-face) patient care (eg, review of extensive records and tests, communication with other professionals and/or the patient/family); each additional 30 minutes (List separately in addition to code for prolonged physician service) Medical team conference with interdisciplinary team of health care professionals, patient and/or family not present, 30 minutes or more; participation by nonphysician qualified health care professional (12) Restorative Services. Unit 40.06(12) - Restorative Services Description Initial treatment, first degree burn, when no more than local treatment is required Dressings and/or debridement of partial-thickness burns, initial or subsequent; small (less than 5% total body surface area) Dressings and/or debridement of partial-thickness burns, initial or subsequent; medium (eg, whole face or whole extremity, or 5% to 10% total body surface area) Dressings and/or debridement of partial-thickness burns, initial or subsequent; large (eg, more than one extremity, or greater than 10% total body surface area) Evaluation of speech, language, voice, communication, and/or auditory processing Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, two or more individuals Nasopharyngoscopy with endoscope (separate procedure) Nasal function studies (eg, rhinomanometry) Facial nerve function studies (eg, electroneuronography) Laryngeal function studies (ie, aerodynamic testing and acoustic testing) Treatment of swallowing dysfunction and/or oral function for feeding I.C. Spontaneous nystagmus, including gaze I.C. Positional nystagmus test I.C. Caloric vestibular test, each irrigation (binaural, bithermal stimulation constitutes four tests) I.C. Optokinetic nystagmus test Physical therapy evaluation Physical therapy re-evaluation Occupational therapy evaluation Occupational therapy re-evaluation I.C. Athletic training evaluation I.C. Athletic training re-evaluation Application of a modality to one or more areas; traction, mechanical Application of a modality to one or more areas; electrical stimulation (unattended) Application of a modality to one or more areas; vasopneumatic devices Application of a modality to one or more areas; paraffin bath Application of a modality to one or more areas; whirlpool Application of a modality to one or more areas; diathermy (eg, microwave) Application of a modality to one or more areas; infrared Application of a modality to one or more areas; ultraviolet Application of a modality to one or more areas; electrical stimulation (manual), each 15 minutes Application of a modality to one or more areas; iontophoresis, each 15 minutes Application of a modality to one or more areas; contrast baths, each 15 minutes Application of a modality to one or more areas; ultrasound, each 15 minutes Application of a modality to one or more areas; Hubbard tank, each 15 minutes I.C. Unlisted modality (specify type and time if constant attendance) Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility Therapeutic procedure, one or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities Therapeutic procedure, one or more areas, each 15 minutes; aquatic therapy with therapeutic exercises Therapeutic procedure, one or more areas, each 15 minutes; gait training (includes stair climbing) Therapeutic procedure, one or more areas, each 15 minutes; massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion) Code Unit 40.06(12) - Restorative Services Description (continued) I.C. Unlisted therapeutic procedure (specify) Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes Therapeutic procedure(s), group (two or more individuals) Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact by the provider, each 15 minutes Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact by the provider, each 15 minutes 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 by provider, each 15 minutes 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 by provider each 15 minutes Wheelchair management (eg, assessment, fitting, training), each 15 minutes Work hardening/conditioning; initial two hours Work hardening/conditioning; each additional hour (List separately in addition to code for primary procedure) Removal of devitalized tissue from wound(s), selective debridement, without anesthesia (eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), with or without topical application(s), wound assessment and instruction(s) for ongoing care, may include use of a whirlpool, per session; total wound(s) surface area less than or equal to 20 square centimeters Removal of devitalized tissue from wound(s), selective debridement, without anesthesia (eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), with or without topical application(s), wound assessment and instruction(s) for ongoing care, may include use of a whirlpool, per session; total wound(s) surface area greater than 20 square centimeters I.C. Removal of devitalized tissue from wound(s), non-selective debridement, without anesthesia (eg, wet-to-moist dressings, enzymatic, abrasion), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session Negative pressure wound therapy (eg, vacuum assisted drainage collection), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters Negative pressure wound therapy (eg, vacuum assisted drainage collection), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area greater than 50 square centimeters Physical performance test or measurement (eg, musculoskeletal, functional capacity), with written report, each 15 minutes 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 by provider, with written report, each 15 minutes Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(s), lower extremity(s) and/or trunk, each 15 minutes Prosthetic training, upper and/or lower extremity(s), each 15 minutes Checkout for orthotic/prosthetic use, established patient, each 15 minutes I.C. Unlisted physical medicine/rehabilitation service or procedure G0237 Therapeutic procedures to increase strength or endurance of respiratory muscles, face-to-face, one-on-one, each 15 minutes (includes monitoring) CPT Codes 29000 through 29750 are incorporated by reference and shall be paid at the listed fee.