ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
10060
Incision and drainage of abscess (e.g., carbuncle, suppurative hidradenitis,
cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia)
3,640
840
2,800
10080
Incision and drainage of pilonidal cyst
3,640
840
2,800
10120
Incision and removal of foreign body, subcutaneous tissues
3,640
840
2,800
10140
10160
10180
11000
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
3,640
3,640
5,560
10,540
840
840
1,260
5,040
2,800
2,800
4,300
5,500
11010
Debridement including removal of foreign material associated w/ open
fracture(s) and/or dislocation(s); skin and subcutaneous tissues
10,540
5,040
5,500
11,980
5,880
6,100
12,120
6,720
5,400
3,640
3,640
5,680
8,020
8,020
840
840
1,680
2,520
2,520
2,800
2,800
4,000
5,500
5,500
3,640
840
2,800
5,560
1,260
4,300
5,680
1,680
4,000
3,640
840
2,800
5,560
1,260
4,300
3,700
1,344
2,356
8,020
2,520
5,500
8,440
2,940
5,500
5,560
1,260
4,300
3,700
1,344
2,356
8,020
2,520
5,500
8,440
2,940
5,500
3,700
1,344
2,356
8,020
2,520
5,500
8,440
2,940
5,500
8,260
3,360
4,900
3,640
840
2,800
3,640
840
2,800
3,640
840
2,800
3,640
840
2,800
3,640
840
2,800
11011
11012
11040
11041
11042
11043
11044
11050
11051
11052
11100
11300
11301
11302
11303
11305
11306
11307
11308
11310
11311
11312
11313
11400
11401
11402
11403
11404
Debridement including removal of foreign material associated w/ open
fracture(s) and/or dislocation(s); skin, subcutaneous tissue, muscle fascia,
and muscle
Debridement including removal of foreign material associated w/ 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 curettement of benign hyperkeratotic skin lesion w/ or w/o
chemical cauterization (such as verrucae or clavi) not extending through the
stratum corneum (e.g., callus or wart) w/ or w/o local anesthesia; single
lesion
Paring or curettement of benign hyperkeratotic skin lesion w/ or w/o
chemical cauterization (such as verrucae or clavi) not extending through the
stratum corneum (e.g., callus or wart) w/ or w/o local anesthesia; two to
four lesions
Paring or curettement of benign hyperkeratotic skin lesion w/ or w/o
chemical cauterization (such as verrucae or clavi) not extending through the
stratum corneum (e.g., callus or wart) w/ or w/o local anesthesia; more
than four lesions
Biopsy of skin, subcutaneous tissue and/or mucous membrane (including
simple closure), unless otherwise listed; single or multiple lesion
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
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, except skin tag (unless listed elsewhere), trunk, arms
or legs; lesion diameter 0.5 cm or less
Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms
or legs; lesion diameter 0.6 to 1.0 cm
Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms
or legs; lesion diameter 1.1 to 2.0 cm
Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms
or legs; lesion diameter 2.1 to 3.0 cm
Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms
or legs; lesion diameter 3.1 to 4.0 cm
Page 1 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
11406
11420
11421
11422
11423
11424
11426
11440
11441
11442
11443
11444
11446
11450
11462
11470
11600
DESCRIPTION
Case Rate
Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms
or legs; lesion diameter over 4.0 cm
Excision, benign lesion, except skin tag (unless listed elsewhere), scalp, neck,
hands, feet, genitalia; lesion diameter 0.5 cm or less
Excision, benign lesion, except skin tag (unless listed elsewhere), scalp, neck,
hands, feet, genitalia; lesion diameter 0.6 to 1.0 cm
Excision, benign lesion, except skin tag (unless listed elsewhere), scalp, neck,
hands, feet, genitalia; lesion diameter 1.1 to 2.0 cm
Excision, benign lesion, except skin tag (unless listed elsewhere), scalp, neck,
hands, feet, genitalia; lesion diameter 2.1 to 3.0 cm
Excision, benign lesion, except skin tag (unless listed elsewhere), scalp, neck,
hands, feet, genitalia; lesion diameter 3.1 to 4.0 cm
Excision, benign lesion, except skin tag (unless listed elsewhere), scalp, neck,
hands, feet, genitalia; lesion diameter over 4.0 cm
Excision, other benign lesion (unless listed elsewhere), face, ears, eyelids,
nose, lips, mucous membrane; lesion diameter 0.5 cm or less
Excision, other benign lesion (unless listed elsewhere), face, ears, eyelids,
nose, lips, mucous membrane; lesion diameter 0.6 to 1.0 cm
Excision, other benign lesion (unless listed elsewhere), face, ears, eyelids,
nose, lips, mucous membrane; lesion diameter 1.1 to 2.0 cm
Excision, other benign lesion (unless listed elsewhere), face, ears, eyelids,
nose, lips, mucous membrane; lesion diameter 2.1 to 3.0 cm
Excision, other benign lesion (unless listed elsewhere), face, ears, eyelids,
nose, lips, mucous membrane; lesion diameter 3.1 to 4.0 cm
Excision, other benign lesion (unless listed elsewhere), face, ears, eyelids,
nose, lips, mucous membrane; lesion diameter over 4.0 cm
Excision of skin and subcutaneous tissue for hidradenitis, axillary
Excision of skin and subcutaneous tissue for hidradenitis, inguinal
Excision of skin and subcutaneous tissue for hidradenitis, perianal, perineal
or umbilical
Excision, malignant lesion, trunk, arms, or legs; lesion diameter 0.5 cm or
less
Professional Fee
Health Care
Institution Fee
3,640
840
2,800
3,640
840
2,800
3,640
840
2,800
3,640
840
2,800
3,640
840
2,800
3,640
840
2,800
3,640
840
2,800
4,108
1,008
3,100
4,108
1,008
3,100
4,108
1,008
3,100
4,108
1,008
3,100
4,108
1,008
3,100
4,108
1,008
3,100
8,020
8,020
2,520
2,520
5,500
5,500
8,020
2,520
5,500
5,560
1,260
4,300
11601
Excision, malignant lesion, trunk, arms, or legs; lesion diameter 0.6 to 1.0 cm
5,560
1,260
4,300
11602
Excision, malignant lesion, trunk, arms, or legs; lesion diameter 1.1 to 2.0 cm
5,560
1,260
4,300
11603
Excision, malignant lesion, trunk, arms, or legs; lesion diameter 2.1 to 3.0 cm
5,560
1,260
4,300
11604
Excision, malignant lesion, trunk, arms, or legs; lesion diameter 3.1 to 4.0 cm
5,560
1,260
4,300
11606
Excision, malignant lesion, trunk, arms, or legs; lesion diameter over 4.0 cm
5,560
1,260
4,300
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
3,640
5,560
3,640
3,640
840
1,260
840
840
2,800
4,300
2,800
2,800
3,640
840
2,800
9,300
2,100
7,200
11620
11621
11622
11623
11624
11626
11640
11641
11642
11643
11644
11646
11720
11721
11730
11740
11750
11752
Excision, malignant lesion, scalp, neck, hands, feet, genitalia; lesion diameter
0.5 cm or less
Excision, malignant lesion, scalp, neck, hands, feet, genitalia; lesion diameter
0.6 to 1.0 cm
Excision, malignant lesion, scalp, neck, hands, feet, genitalia; lesion diameter
1.1 to 2.0 cm
Excision, malignant lesion, scalp, neck, hands, feet, genitalia; lesion diameter
2.1 to 3.0 cm
Excision, malignant lesion, scalp, neck, hands, feet, genitalia; lesion diameter
3.1 to 4.0 cm
Excision, malignant lesion, scalp, neck, hands, feet, genitalia; lesion diameter
over 4.0 cm
Excision, malignant lesion, face, ears, eyelids, nose, lips; lesion diameter 0.5
cm or less
Excision, malignant lesion, face, ears, eyelids, nose, lips; lesion diameter 0.6
to 1.0 cm
Excision, malignant lesion, face, ears, eyelids, nose, lips; lesion diameter 1.1
to 2.0 cm
Excision, malignant lesion, face, ears, eyelids, nose, lips; lesion diameter 2.1
to 3.0 cm
Excision, malignant lesion, face, ears, eyelids, nose, lips; lesion diameter 3.1
to 4.0 cm
Excision, malignant lesion, face, ears, eyelids, nose, lips; lesion diameter
over 4.0 cm
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
Evacuation of subungual hematoma
Excision of nail and nail matrix, partial or complete (e.g., ingrown or
deformed nail) for permanent removal
Excision of nail and nail matrix, partial or complete (e.g., ingrown or
deformed nail) for permanent removal w/ amputation of tuft of distal
phalanx
Page 2 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
11755
11760
11762
11765
11770
DESCRIPTION
Case Rate
Biopsy of nail unit, any method (e.g., plate, bed, matrix, hyponychium,
proximal and lateral nail folds)
Repair of nail bed
Reconstruction of nail bed w/ graft
Wedge excision of skin of nail fold (e.g., for ingrown toenail)
Excision of pilonidal cyst or sinus
Professional Fee
Health Care
Institution Fee
3,640
840
2,800
5,560
9,300
3,640
5,680
1,260
2,100
840
1,680
4,300
7,200
2,800
4,000
12001
Simple repair of superficial wounds of scalp, neck, axillae, external genitalia,
trunk and/or extremities (including hands and feet); 2.5 cm or less
3,640
840
2,800
12002
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
5,560
1,260
4,300
12004
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
5,680
1,680
4,000
12005
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
5,680
1,680
4,000
12006
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
5,680
1,680
4,000
12007
Simple repair of superficial wounds of scalp, neck, axillae, external genitalia,
trunk and/or extremities (including hands and feet); over 30.0 cm
5,680
1,680
4,000
5,680
1,680
4,000
9,300
2,100
7,200
9,552
2,352
7,200
8,020
2,520
5,500
8,020
2,520
5,500
8,020
2,520
5,500
8,020
2,520
5,500
3,640
840
2,800
5,560
1,260
4,300
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
9,300
2,100
7,200
8,020
2,520
5,500
8,440
2,940
5,500
8,260
3,360
4,900
10,880
3,780
7,100
5,680
1,680
4,000
5,680
1,680
4,000
8,020
2,520
5,500
8,020
2,520
5,500
8,260
3,360
4,900
8,260
3,360
4,900
9,700
4,200
5,500
12011
12013
12014
12015
12016
12017
12018
12031
12032
12034
12035
12036
12037
12041
12042
12044
12045
12046
12047
12051
12052
12053
12054
12055
12056
12057
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
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
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
membrances; 2.5 cm or less
Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous
membrances; 2.6 cm to 5.0 cm
Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous
membrances; 5.1 cm to 7.5 cm
Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous
membrances; 7.6 cm to 12.5 cm
Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous
membrances; 12.6 cm to 20.0 cm
Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous
membrances; 20.1 cm to 30.0 cm
Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous
membrances; over 30.0 cm
Page 3 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
14000
14001
14020
14021
DESCRIPTION
Case Rate
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
Professional Fee
Health Care
Institution Fee
12,120
6,720
5,400
12,120
6,720
5,400
10,540
5,040
5,500
11,980
5,880
6,100
14040
Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth,
neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less
12,120
6,720
5,400
14041
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
18,000
8,400
9,600
18,000
8,400
9,600
18,000
8,400
9,600
18,000
8,400
9,600
27,120
15,120
12,000
8,260
3,360
4,900
8,260
3,360
4,900
21,940
9,240
12,700
21,940
9,240
12,700
21,940
9,240
12,700
30,740
13,440
17,300
30,300
16,800
13,500
30,300
30,300
18,000
16,800
16,800
8,400
13,500
13,500
9,600
30,740
13,440
17,300
30,740
13,440
17,300
30,300
16,800
13,500
21,940
9,240
12,700
21,940
9,240
12,700
47,340
26,040
21,300
47,340
47,340
47,340
38,640
38,640
38,640
38,640
38,640
26,040
26,040
26,040
21,840
21,840
21,840
21,840
21,840
21,300
21,300
21,300
16,800
16,800
16,800
16,800
16,800
21,940
9,240
12,700
21,940
10,120
10,120
11,980
9,240
4,620
4,620
5,880
12,700
5,500
5,500
6,100
14060
14061
14300
14350
15050
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
Pinch graft, single or multiple, to cover small ulcer, tip or digit, or other
minimal open area (except on face), up to defect size 2 cm diameter
15350
15400
15570
Split graft, trunk, scalp, arms, legs, hands, and/or feet (except multiple
digits); 100 sq cm or less, or each one percent of body area of infants and
children (except 15050)
Split graft, face, eyelids, mouth, neck, ears, orbits, genitalia, and/or multiple
digits; 100 sq cm or less, or each one percent of body area of infants and
children (except 15050)
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, scalp, arms,
and/or legs; 20 sq cm or less
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
Full thickness graft, free, including direct closure of donor site, nose, ears,
eyelids, and/or lips; 20 sq cm or less
Application of allograft, skin
Application of xenograft, skin
Formation of direct or tubed pedicle, w/ or w/o transfer; trunk
15572
Formation of direct or tubed pedicle, w/ or w/o transfer; scalp, arms, or legs
15100
15120
15200
15220
15240
15260
15770
15820
15822
15823
Formation of direct or tubed pedicle, w/ or w/o transfer; forehead, cheeks,
chin, mouth, neck, axillae, genitalia, hands or feet
Formation of direct or tubed pedicle, w/ or w/o transfer; eyelids, nose, ears,
lips or intraoral
Cross finger flap, including free graft to donor site
Transfer, intermediate, of any pedicle flap (e.g., abdomen to wrist,
"Walking" tube), any location
Muscle, myocutaneous, or fasciocutaneous flap; head and neck (e.g.,
temporalis, masseter, 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 flap w/ or w/o skin graft w/ microvascular anastomosis
Free skin flap w/ microvascular anastomosis
Free fascial flap w/ microvascular anastomosis
Graft; composite (e.g., full thickness of external ear or nasal ala), including
primary closure, donor area
Graft; derma-fat-fascia
Blepharoplasty, lower eyelid
Blepharoplasty, upper eyelid;
Blepharoplasty, upper eyelid; with excessive skin weighting down lid
15840
Graft for facial nerve paralysis; free fascia graft (including obtaining fascia)
30,300
16,800
13,500
15841
Graft for facial nerve paralysis; free muscle graft (including obtaining graft)
30,300
16,800
13,500
15842
Graft for facial nerve paralysis; free muscle graft by microsurgical technique
38,640
21,840
16,800
15845
Graft for facial nerve paralysis; regional muscle transfer
30,300
16,800
13,500
15920
Excision, coccygeal pressure ulcer, w/ coccygectomy; w/ primary suture
30,740
13,440
17,300
15922
Excision, coccygeal pressure ulcer, w/ coccygectomy; w/ flap closure
30,300
16,800
13,500
15574
15576
15580
15650
15732
15734
15736
15738
15740
15750
15756
15757
15758
15760
Page 4 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
DESCRIPTION
15931
15933
15934
15935
Excision, sacral pressure ulcer, w/ primary suture;
Excision, sacral pressure ulcer, w/ primary suture; w/ ostectomy
Excision, sacral pressure ulcer, w/ skin flap closure;
Excision, sacral pressure ulcer, w/ skin flap closure; w/ ostectomy
21,940
30,740
12,120
30,300
9,240
13,440
6,720
16,800
Health Care
Institution Fee
12,700
17,300
5,400
13,500
15936
Excision, sacral pressure ulcer, w/ muscle or myocutaneous flap closure;
38,440
19,740
18,700
37,800
21,000
16,800
12,120
6,720
5,400
21,940
9,240
12,700
30,740
30,300
13,440
16,800
17,300
13,500
38,440
19,740
18,700
11,980
5,880
6,100
9,240
12,700
Case Rate
Professional Fee
15950
Excision, sacral pressure ulcer, w/ muscle or myocutaneous flap closure; w/
ostectomy
Excision, ischial pressure ulcer, w/ primary suture;
Excision, ischial pressure ulcer, w/ primary suture; w/ ostectomy
(ischiectomy)
Excision, ischial pressure ulcer, w/ skin flap closure;
Excision, ischial pressure ulcer, w/ skin flap closure; w/ ostectomy
Excision, ischial pressure ulcer, w/ ostectomy, w/ muscle or myocutaneous
flap closure
Excision, trochanteric pressure ulcer, w/ primary suture;
15951
Excision, trochanteric pressure ulcer, w/ primary suture; w/ ostectomy
21,940
15952
Excision, trochanteric pressure ulcer, w/ skin flap closure;
21,940
9,240
12,700
15953
Excision, trochanteric pressure ulcer, w/ skin flap closure; w/ ostectomy
30,740
13,440
17,300
31,140
17,640
13,500
38,440
19,740
18,700
8,260
30,740
3,360
13,440
4,900
17,300
9,700
4,200
5,500
8,020
2,520
5,500
15937
15940
15941
15944
15945
15946
15956
15958
16010
16035
16040
17000
Excision, trochanteric pressure ulcer, w/ muscle or myocutaneous flap
closure;
Excision, trochanteric pressure ulcer, w/ muscle or myocutaneous flap
closure; w/ ostectomy
Dressings and/or debridement, initial or subsequent
Escharotomy
Excision burn wound, w/o skin grafting, employing alloplastic dressing (e.g.,
synthetic mesh), any anatomic site
Destruction by any method, including laser, w/ or w/o surgical curettement,
all benign facial lesions or premalignant lesions in any location, or benign
lesions other than cutaneous vascular proliferative lesions, including local
anesthesia; any number of
17100
Destruction by any method, including laser, of benign skin lesions other than
cutaneous vascular proliferative lesions on any area other than the face,
including local anesthesia; any number of lesions
8,020
2,520
5,500
17106
Destruction of cutaneous vascular proliferative lesions (e.g., laser technique)
18,000
8,400
9,600
17110
Destruction by any method of flat warts or molluscum contagiosum, milia,
all lesions
5,680
1,680
4,000
17200
Electosurgical destruction of multiple fibrocutaneous tags; all lesions
8,020
2,520
5,500
17250
Chemical cauterization of granulation tissue (proud flesh, sinus or fistula)
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
9,300
2,100
7,200
9,300
2,100
7,200
9,300
2,100
7,200
9,300
2,100
7,200
17260
17261
17262
17263
17264
17266
17270
17271
17272
17273
17274
17276
17280
17281
17282
17283
Destruction, malignant lesion, any method, trunk, arms or legs; lesion
diameter 0.5 cm or less
Destruction, malignant lesion, any method, trunk, arms or legs; lesion
diameter 0.6 to 1.0 cm
Destruction, malignant lesion, any method, trunk, arms or legs; lesion
diameter 1.1 to 2.0 cm
Destruction, malignant lesion, any method, trunk, arms or legs; lesion
diameter 2.1 to 3.0 cm
Destruction, malignant lesion, any method, trunk, arms or legs; lesion
diameter 3.1 to 4.0 cm
Destruction, malignant lesion, any method, trunk, arms or legs; lesion
diameter over 4.0 cm
Destruction, malignant lesion, any method, scalp, neck, hands, feet,
genitalia; lesion diameter 0.5 cm or less
Destruction, malignant lesion, any method, scalp, neck, hands, feet,
genitalia; lesion diameter 0.6 to 1.0 cm
Destruction, malignant lesion, any method, scalp, neck, hands, feet,
genitalia; lesion diameter 1.1 to 2.0 cm
Destruction, malignant lesion, any method, scalp, neck, hands, feet,
genitalia; lesion diameter 2.1 to 3.0 cm
Destruction, malignant lesion, any method, scalp, neck, hands, feet,
genitalia; lesion diameter 3.1 to 4.0 cm
Destruction, malignant lesion, any method, scalp, neck, hands, feet,
genitalia; lesion diameter over 4.0 cm
Destruction, malignant lesion, any method, face, ears, eyelids, nose, lips,
mucous membrane; lesion diameter 0.5 cm or less
Destruction, malignant lesion, any method, face, ears, eyelids, nose, lips,
mucous membrane; lesion diameter 0.6 to 1.0 cm
Destruction, malignant lesion, any method, face, ears, eyelids, nose, lips,
mucous membrane; lesion diameter 1.1 to 2.0 cm
Destruction, malignant lesion, any method, face, ears, eyelids, nose, lips,
mucous membrane; lesion diameter 2.1 to 3.0 cm
Page 5 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
DESCRIPTION
Case Rate
19140
19160
19162
19180
19182
Destruction, malignant lesion, any method, face, ears, eyelids, nose, lips,
mucous membrane; lesion diameter 3.1 to 4.0 cm
Destruction, malignant lesion, any method, face, ears, eyelids, nose, lips,
mucous membrane; lesion diameter over 4.0 cm
Chemosurgery (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
complete histopathologic preparation; first stage, fresh tissue technique, up
to 5 specimens
Puncture aspiration of cyst of breast;
Mastotomy w/ exploration or drainage of abscess, deep
Biopsy of breast; needle core
Biopsy of breast; incisional
Nipple exploration, w/ or w/o 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 or nipple lesion (except 19140), male or female,
one or more lesions
Excision of breast lesion identified by preoperative placement of radiological
marker; single lesion
Mastectomy for gynecomastia
Mastectomy, partial;
Mastectomy, partial; with axillary lymphadenectomy
Mastectomy, simple, complete
Mastectomy, subcutaneous
19200
Mastectomy, radical, icnluding pectoral muscles, axillary lymph nodes
17284
17286
17304
19000
19020
19100
19101
19110
19112
19120
19125
19220
19240
19260
19271
19272
19340
19342
19350
19357
19361
19364
19366
Mastectomy, radical, including pectoral muscles, axillary and internal
mammary lymph nodes (Urban type operation)
Mastectomy, modified radical, including axillary lymph nodes, w/ or w/o
pectoralis minor muscle, but excluding pectoralis major muscle
Excision of chest wall tumor including ribs
Excision of chest wall tumor involving ribs, w/ plastic reconstruction; w/o
mediastinal lymphadenectomy
Excision of chest wall tumor involving ribs, w/ plastic reconstruction; w/
mediastinal lymphadenectomy
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
Breast reconstruction with latissimus dorsi flap, with or without prosthetic
implant
Breast reconstruction with free flap
Breast reconstruction with other technique
Professional Fee
Health Care
Institution Fee
9,300
2,100
7,200
9,300
2,100
7,200
8,020
2,520
5,500
3,640
9,700
3,640
5,560
840
4,200
840
1,260
2,800
5,500
2,800
4,300
8,440
2,940
5,500
8,260
3,360
4,900
8,020
2,520
5,500
8,020
2,520
5,500
22,000
22,000
22,000
22,000
22,000
8,800
8,800
8,800
8,800
8,800
13,200
13,200
13,200
13,200
13,200
22,000
8,800
13,200
22,000
8,800
13,200
22,000
8,800
13,200
46,500
25,200
21,300
55,000
33,600
21,400
58,800
37,800
21,000
37,800
21,000
16,800
37,800
21,000
16,800
30,300
16,800
13,500
37,800
21,000
16,800
55,000
33,600
21,400
55,000
55,000
33,600
33,600
21,400
21,400
19367
Breast reconstruction with transverse rectus abdominis myocutaneous flap
(TRAM), single pedicle, including closure of donor site;
55,000
33,600
21,400
19369
Breast reconstruction with transverse rectus abdominis myocutaneous flap
(TRAM), double pedicle, including closure of donor site
55,000
33,600
21,400
30,300
37,800
4,108
3,504
16,800
21,000
1,008
504
13,500
16,800
3,100
3,000
10,880
3,780
7,100
18,000
8,400
9,600
9,700
4,200
5,500
12,540
23,300
30,740
8,020
7,140
12,600
13,440
2,520
5,400
10,700
17,300
5,500
5,560
1,260
4,300
9,300
2,100
7,200
9,300
2,100
7,200
8,260
3,360
4,900
8,020
2,520
5,500
19370
19371
20200
20206
20615
Open periprosthetic capsulotomy, breast
Periprosthetic capsulectomy, breast
Biopsy, muscle
Biopsy, muscle, percutaneous needle
Biopsy, bone, trocar, or needle; superficial (e.g., ilium, sternum, spinous
process, ribs)
Biopsy, bone, trocar, or needle; deep (vertebral body, femur)
Biopsy, excisional; superficial (e.g., ilium, sternum, spinous process, ribs,
trochanter of femur)
Biopsy, excisional; deep (e.g., humerus, ischium, femur)
Biopsy, vertebral body, open; thoracic
Biopsy, vertebral body, open; lumbar or cervical
Removal of foreign body in muscle or tendon sheath
Arthrocentesis, aspiration and/or injection; small joint, bursa or ganglion
cyst (e.g., fingers, toes)
Arthrocentesis, aspiration and/or injection; intermediate joint, bursa or
ganglion cyst (e.g., temporomandibular, acromioclavicular, wrist, elbow or
ankle, olecranon bursa)
Arthrocentesis, aspiration and/or injection; major joint or bursa (e.g.,
shoulder, hip, knee joint, subacromial bursa)
Aspiration and injection for treatment of bone cyst
20650
Insertion of wire or pin w/ application of skeletal traction, including removal
20220
20225
20240
20245
20250
20251
20520
20600
20605
20610
Page 6 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
20660
Application of cranial tongs, caliper, or stereotactic frame, including removal
9,868
4,368
5,500
20661
20662
20663
20670
Application of halo, including removal; cranial
Application of halo, including removal; pelvic
Application of halo, including removal; femoral
Removal of implant; superficial (e.g., buried wire, pin or rod)
Removal of implant; deep (e.g., 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 multiplane (pins or wires in more than one plane), unilateral,
external fixation system (e.g., llizarov, Monticelli type)
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 joint(s),
complete amputation
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
8,608
23,300
21,940
10,540
3,108
12,600
9,240
5,040
5,500
10,700
12,700
5,500
11,980
5,880
6,100
12,120
6,720
5,400
39,280
20,580
18,700
9,300
2,100
7,200
40,320
23,520
16,800
40,320
23,520
16,800
23,300
12,600
10,700
23,300
12,600
10,700
30,300
16,800
13,500
20827
Replantation, thumb (includes distal tip to MP joint), complete amputation
23,300
12,600
10,700
20838
20900
20902
20910
20912
20920
20922
20924
20926
20930
20931
Replantation, foot, complete amputation
Bone graft, any donor area; minor or small (e.g., 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, form a distance (e.g., palmaris, toe extensor, plantaris)
Tissue grafts, other (e.g., paratenon, fat, dermis)
Allograft for spine surgery only; morselized
Allograft for spine surgery only; structural
37,800
10,540
18,000
12,120
12,120
9,700
12,120
10,960
9,700
12,120
18,420
21,000
5,040
8,400
6,720
6,720
4,200
6,720
5,460
4,200
6,720
8,820
16,800
5,500
9,600
5,400
5,400
5,500
5,400
5,500
5,500
5,400
9,600
20936
Autograft for spine surgery only (includes harvesting the graft); local (e.g.,
ribs, spinous process, or laminar fragments) obtained from same incision
10,540
5,040
5,500
20937
Autograft for spine surgery only (includes harvesting the graft); morselized
(thorugh separate skin or fascial incision)
10,540
5,040
5,500
20938
Autograft for spine surgery only (includes harvesting the graft); structural,
bicortical or tricortial (through separate skin or fascial incision)
18,000
8,400
9,600
37,800
37,800
20,980
21,000
21,000
10,080
16,800
16,800
10,900
27,120
15,120
12,000
37,800
21,000
16,800
20970
Bone graft w/ microvascular anastomosis; fibula
Bone graft w/ microvascular anastomosis; iliac crest
Bone graft w/ microvascular anastomosis; metatarsal
Bone graft w/ microvascular anastomosis; other than fibula, iliac crest, or
metatarsal
Free osteocutaneous flap w/ microvascular anastomosis; other than iliac
crest, metatarsal, or great toe
Free osteocutaneous flap w/ microvascular anastomosis; iliac crest
30,300
16,800
13,500
20972
Free osteocutaneous flap w/ microvascular anastomosis; metatarsal
23,300
12,600
10,700
20973
Free osteocutaneous flap w/ microvascular anastomosis; great toe w/ web
space
27,120
15,120
12,000
20982
Ablation, bone tumor(s) (e.g., osteoid osteoma, metastasis) radiofrequency,
percutaneous, including computed tomographic guidance
9,700
4,200
5,500
20680
20690
20692
20802
20805
20808
20816
20822
20824
20955
20956
20957
20962
20969
21010
9,700
4,200
5,500
23,300
12,600
10,700
21025
Arthrotomy, temporomandibular joint
Radical resection of tumor (e.g., malignant neoplasm), soft tissue of face or
scalp
Excision of bone (e.g., for osteomyelitis or bone abscess); mandible
18,000
8,400
9,600
21026
Excision of bone (e.g., for osteomyelitis or bone abscess); facial bone(s)
18,000
8,400
9,600
18,000
8,400
9,600
18,000
18,000
18,000
23,300
18,000
21,940
23,300
30,300
30,300
8,400
8,400
8,400
12,600
8,400
9,240
12,600
16,800
16,800
9,600
9,600
9,600
10,700
9,600
12,700
10,700
13,500
13,500
21015
21029
21030
21031
21032
21034
21040
21041
21044
21045
21050
Removal by contouring of benign tumor of facial bone (e.g., fibrous
dysplasia)
Excision of benign tumor or cyst of facial bone other than mandible
Excision of torus mandibularis
Excision of maxillary torus palatinus
Excision of malignant tumor of facial bone other than mandible
Excision of benign cyst or tumor of mandible; simple
Excision of benign cyst or tumor of mandible; complex
Excision of malignant tumor of mandible;
Excision of malignant tumor of mandible; radical resection
Condylectomy, temporomandibular joint
Page 7 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
21060
21070
21120
21121
21122
21123
21125
21127
21137
21138
21139
21141
21142
21143
21145
21146
21147
21150
21151
21154
21155
21159
21160
DESCRIPTION
Meniscectomy, partial or complete, temporomandibular joint
Coronoidectomy
Genioplasty; augmentation (autograft, allograft, prosthetic material)
Genioplasty; sliding osteotomy, single piece
Genioplasty; sliding osteotomies, two or more osteotomies (e.g., wedge
excision or bone wedge reversal for asymmetrical chin)
Genioplasty; sliding, augmentation w/ interpositional bone grafts (includes
obtaining autografts)
Augmentation, mandibular body or angle; prosthetic material
Augmentation, mandibular body or angle; w/ 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)
30,300
30,300
18,000
46,500
16,800
16,800
8,400
25,200
Health Care
Institution Fee
13,500
13,500
9,600
21,300
30,300
16,800
13,500
30,300
16,800
13,500
30,300
16,800
13,500
46,500
25,200
21,300
18,000
8,400
9,600
46,500
25,200
21,300
Reduction forehead; contouring and setback of anterior frontal sinus wall
30,300
16,800
13,500
53,400
29,400
24,000
46,500
25,200
21,300
46,500
25,200
21,300
46,500
25,200
21,300
46,500
25,200
21,300
55,000
33,600
21,400
55,000
33,600
21,400
55,000
33,600
21,400
58,800
37,800
21,000
55,000
33,600
21,400
55,000
33,600
21,400
46,500
25,200
21,300
Case Rate
Reconstruction midface, LeFort I; single piece, segment movement in any
direction (e.g., for Long Face Syndrome), w/o bone graft
Reconstruction midface, LeFort I; two pieces, segment movement in any
direction, w/o bone graft
Reconstruction midface, LeFort I; three or more pieces, segment movement
in any direction, w/o 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) (e.g.,
ungrafted unilateral alveolar cleft)
Reconstruction midface, LeFort I; three or more pieces, segment movement
in any direction, requiring bone grafts (includes obtaining autografts) (e.g.,
ungrafted bilateral alveolar cleft or multiple osteotomies)
Reconstruction midface, LeFort II; anterior intrusion (e.g., 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); w/o LeFort I
Reconstruction midface, LeFort III (extracranial), any type, requiring bone
grafts (includes obtaining autografts); w/ LeFort I
Reconstruction midface, LeFort III (extra and intracranial) w/ forehead
advancement (e.g., mono bloc), requiring bone grafts (includes obtaining
autografts); w/o LeFort I
Reconstruction midface, LeFort III (extra and intracranial) w/ forehead
advancement (e.g., mono bloc), requiring bone grafts (includes obtaining
autografts); w/ LeFort I
Professional Fee
21172
Reconstruction superior-lateral orbital rim and lower forehead,
advancement or alteration, w/ or w/o grafts (includes obtaining autografts)
55,000
33,600
21,400
21175
Reconstruction, bifrontal, superior-lateral orbital rims and lower forehead,
advancement or alteration (e.g., plagiocephaly, trigonocephaly,
brachycephaly), w/ or w/o grafts (includes obtaining autografts)
55,000
33,600
21,400
55,000
33,600
21,400
55,000
33,600
21,400
53,400
29,400
24,000
46,500
25,200
21,300
53,400
29,400
24,000
55,000
33,600
21,400
55,000
33,600
21,400
46,500
25,200
21,300
21179
21180
21181
21182
21183
21184
21188
21193
Reconstruction, entire or majority of forehead and/or supraorbital rims; w/
grafts (allograft or prosthetic material)
Reconstruction, entire or majority of forehead and/or supraorbital rims; w/
autograft (includes obtaining grafts)
Reconstruction by contouring of benign tumor of cranial bones (e.g., fibrous
dysplasia), extracranial
Reconstruction of orbital walls, rims, forehead, nasoethmoid complex
following intra-and extracranial excision of benign tumor of cranial bone
(e.g., fibrous dysplasia), w/ multiple autografts (includes obtaining grafts);
total area of bone grafting less
Reconstruction of orbital walls, rims, forehead, nasoethmoid complex
following intra-and extracranial excision of benign tumor of cranial bone
(e.g., fibrous dysplasia), w/ multiple autografts (includes obtaining grafts);
total area of bone grafting greater than 40 cm2 but less than 80 cm2
Reconstruction of orbital walls, rims, forehead, nasoethmoid complex
following intra-and extracranial excision of benign tumor of cranial bone
(e.g., fibrous dysplasia), w/ multiple autografts (includes obtaining grafts);
total area of bone grafting greater than 80 cm2
Reconstruction midface, osteotomies (other than LeFort type) and bone
grafts (includes obtaining autografts)
Reconstruction of mandibular rami, horizontal, vertical, "C", or "L"
osteotomy; w/o bone graft
Page 8 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
21198
21206
Reconstruction of mandibular rami, horizontal, vertical, "C", or "L"
osteotomy; w/ bone graft (includes obtaining graft)
Reconstruction of mandibular rami and/or body, sagittal split; w/o internal
rigid fixation
Reconstruction of mandibular rami and/or body, sagittal split; w/ internal
rigid fixation
Osteotomy, mandible, segmental
Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)
21210
Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)
46,500
25,200
21,300
21215
Graft, bone; mandible (includes obtaining graft)
Graft; rib cartilage, autogenous, to face, chin, nose or ear (includes obtaining
graft)
55,000
33,600
21,400
46,500
25,200
21,300
Graft; ear cartilage, autogenous, to nose or ear (includes obtaining graft)
30,300
16,800
13,500
46,500
25,200
21,300
46,500
25,200
21,300
21194
21195
21196
21230
21235
55,000
33,600
21,400
46,500
25,200
21,300
55,000
33,600
21,400
30,300
46,500
16,800
25,200
13,500
21,300
21242
Arthroplasty, temporomandibular joint, w/ or w/o autograft (includes
obtaining graft)
Arthroplasty, temporomandibular joint, w/ allograft
21243
Arthroplasty, temporomandibular joint, w/ prosthetic joint replacement
55,000
33,600
21,400
21244
Reconstruction of mandible, extraoral, w/ transosteal bone plate (e.g.,
mandibular staple bone plate)
46,500
25,200
21,300
21245
Reconstruction of mandible or maxilla, subperiosteal implant; partial
53,400
29,400
24,000
21246
Reconstruction of mandible or maxilla, subperiosteal implant; complete
55,000
33,600
21,400
21247
Reconstruction of mandibular condyle w/ bone and cartilage autografts
(includes obtaining grafts) (e.g., for hemifacial microsomia)
55,000
33,600
21,400
55,000
33,600
21,400
63,000
42,000
21,000
55,000
33,600
21,400
55,000
33,600
21,400
55,000
33,600
21,400
55,000
33,600
21,400
10,540
10,540
12,120
5,040
5,040
6,720
5,500
5,500
5,400
12,120
6,720
5,400
12,120
6,720
5,400
12,120
10,540
12,120
18,000
6,720
5,040
6,720
8,400
5,400
5,500
5,400
9,600
21,940
9,240
12,700
21,940
9,240
12,700
23,300
12,600
10,700
22,660
11,760
10,900
23,300
12,600
10,700
30,300
16,800
13,500
37,800
21,000
16,800
21,940
9,240
12,700
21240
21248
21249
21255
21256
21260
21267
21300
21315
21325
21330
21335
21336
21337
21338
21339
21340
21343
21344
21345
21346
21347
21348
21355
Reconstruction of mandible or maxilla, endosteal implant (e.g. blade,
cylinder); partial
Reconstruction of mandible or maxilla, endosteal implant (e.g. blade,
cylinder); complete
Reconstruction of zygomatic arch and glenoid fossa w/ bone and cartilage
(includes obtaining autografts)
Reconstruction of orbit w/ osteotomies (extracranial) and w/ bone grafts
(includes obtaining autografts) (e.g., micro-ophthalmia)
Periorbital osteotomies for orbital hypertelorism, w/ bone grafts
Orbital repositioning, periorbital osteotomies, unilateral, w/ bone grafts;
extracranial approach
Closed treatment of skull fracture w/o operation
Closed treatment of nasal bone fracture
Open treatment of nasal fracture; uncomplicated
Open treatment of nasal fracture; complicated, w/ internal and/or external
skeletal fixation
Open treatment of nasal fracture; w/ concomitant open treatment of
fractured septum
Open treatment of nasal septal fracture, w/ or w/o stabilization
Closed treatment of nasal septal fracture
Open treatment of nasoethmoid fracture; w/o external fixation
Open treatment of nasoethmoid fracture; w/ external fixation
Percutaneous treatment of nasoethmoid complex fracture, w/ 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 (e.g., comminuted or involving posterior
wall) frontal sinus fracture, via coronal or multiple approaches
Closed treatment of nasomaxillary complex fracture (LeFort II type), w/
interdental wire fixation or fixation of denture or splint
Open treatment of nasomaxillary complex fracture (LeFort II type); w/
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); w/ bone
grafting (includes obtaining graft)
Percutaneous treatment of fracture of malar area, including zygomatic arch
and malar tripod, w/ manipulation
21356
Open treatment of depressed zygomatic arch fracture (e.g., Gilles approach)
23,300
12,600
10,700
21360
Open treatment of depressed malar fracture, including zygomatic arch and
malar tripod
30,300
16,800
13,500
21365
Open treatment of complicated (e.g., comminuted or involving cranial nerve
foramina) fracture(s) of malar area, including zygomatic arch and malar
tripod; w/ internal fixation and multiple surgical approaches
37,800
21,000
16,800
Page 9 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
21366
Open treatment of complicated (e.g., comminuted or involving cranial nerve
foramina) fracture(s) of malar area, including zygomatic arch and malar
tripod; w/ bone grafting (includes obtaining graft)
46,500
25,200
21,300
21385
Open treatment of orbital floor "blowout" fracture; transantral approach
(Caldwell-Luc type operation)
20,980
10,080
10,900
21386
Open treatment of orbital floor "blowout" fracture; periorbital approach
18,000
8,400
9,600
21387
Open treatment of orbital floor "blowout" fracture; combined approach
37,800
21,000
16,800
31,580
14,280
17,300
31,580
14,280
17,300
18,000
20,980
31,580
8,400
10,080
14,280
9,600
10,900
17,300
31,580
14,280
17,300
12,120
6,720
5,400
20,980
10,080
10,900
23,300
12,600
10,700
12,120
6,720
5,400
23,300
12,600
10,700
18,000
8,400
9,600
23,300
12,600
10,700
46,500
25,200
21,300
12,120
18,000
18,000
23,300
14,960
22,660
22,660
23,300
30,300
6,720
8,400
8,400
12,600
7,560
11,760
11,760
12,600
16,800
5,400
9,600
9,600
10,700
7,400
10,900
10,900
10,700
13,500
37,800
21,000
16,800
9,700
4,200
5,500
20,980
10,080
10,900
30,300
18,000
23,300
12,120
16,800
8,400
12,600
6,720
13,500
9,600
10,700
5,400
5,680
1,680
4,000
8,020
2,520
5,500
4,108
1,008
3,100
5,680
8,020
1,680
2,520
4,000
5,500
9,700
4,200
5,500
30,300
16,800
13,500
10,540
20,980
37,180
37,800
27,120
12,288
5,040
10,080
18,480
21,000
15,120
6,888
5,500
10,900
18,700
16,800
12,000
5,400
21390
21395
21400
21406
21407
21408
21421
21422
21423
21431
21432
21433
21435
21436
21440
21445
21450
21452
21453
21454
21461
21462
21465
21470
Open treatment of orbital floor "blowout" fracture; periorbital approach, w/
alloplastic or other implant
Open treatment of orbital floor "blowout" fracture; periorbital approach w/
bone graft (includes obtaining graft)
Closed treatment of fracture of orbit, except "blowout"
Open treatment of fracture of orbit, except "blowout"; w/o implant
Open treatment of fracture of orbit, except "blowout"; w/ implant
Open treatment of fracture of orbit, except "blowout"; w/ bone grafting
(includes obtaining graft)
Closed treatment of palatal or maxillary fracture (LeFort I type), w/
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); w/ wiring and/or
internal fixation
Open treatment of craniofacial separation (LeFort III type); complicated
(e.g., 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 (e.g., head cap, halo
device, and/or intermaxillary fixation)
Open treatment of craniofacial separation (LeFort III type); complicated,
multiple surgical approaches, internal fixation, w/ bone grafting (includes
obtaining graft)
Closed treatment of mandibular or maxillary alveolar ridge fracture
Open treatment of mandibular or maxillary alveolar ridge fracture
Closed treatment of mandibular fracture
Percutaneous treatment of mandibular fractue, w/ external fixation
Closed treatment of mandibular fracture; w/ interdental fixation
Open treatment of mandibular fracture; w/ external fixation
Open treatment of mandibular fracture; w/o interdental fixation
Open treatment of mandibular fracture; w/ 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
21480
Closed treatment of temporomandibular dislocation; initial or subsequent
21485
Closed treatment of temporomandibular dislocation; complicated (e.g.,
recurrent requiring intermaxillary fixation or splinting), initial or subsequent
21490
21493
21495
21497
21550
21555
Open treatment of temporomandibular dislocation
Closed treatment of hyoid fracture
Open treatment of hyoid fracture
Interdental wiring, for condition other than fracture
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; w/ partial rib ostectomy
Incision, deep, w/ opening of bone cortex (e.g., for osteomyelitis or bone
abscess), thorax
Biopsy, soft tissue of neck or thorax
Excision tumor, soft tissue of neck or thorax; subcutaneous
21556
Excision tumor, soft tissue of neck or thorax; deep, subfascial, intramuscular
21501
21502
21510
21557
21600
21610
21615
21616
21620
21627
Radical resection of tumor (e.g., malignant neoplasm), soft tissue of neck or
thorax
Excision of rib, partial
Costotransversectomy
Excision first and/or cervical rib;
Excision first and/or cervical rib; w/ sympathectomy
Ostectomy of sternum, partial
Sternal debridement
Page 10 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
21630
21700
21705
21720
21740
21750
21800
21805
21810
21820
21825
21920
21930
21935
DESCRIPTION
37,800
18,000
23,300
18,000
27,120
23,300
8,020
10,960
20,980
9,868
21,940
3,504
5,680
21,000
8,400
12,600
8,400
15,120
12,600
2,520
5,460
10,080
4,368
9,240
504
1,680
Health Care
Institution Fee
16,800
9,600
10,700
9,600
12,000
10,700
5,500
5,500
10,900
5,500
12,700
3,000
4,000
23,300
12,600
10,700
Case Rate
Radical resection of sternum;
Division of scalenus anticus; w/o resection of cervical rib
Division of scalenus anticus; w/ resection of cervical rib
Division of sternocleidomastoid for torticollis, open operation
Reconstructive repair of pectus excavatum or carinatum
Closure of sternotomy separation w/ or w/o debridement
Closed treatment of rib fracture
Open treatment of rib fracture w/o fixation
Treatment of rib fracture requiring external fixation ("flail chest")
Closed treatment of sternum fracture
Open treatment of sternum fracture w/ or w/o skeletal fixation
Biopsy, soft tissue of back or flank
Excision, tumor, soft tissue of back or flank
Radical resection of tumor (e.g., malignant neoplasm), soft tissue of back or
flank
Professional Fee
22100
Partial excision of posterior vertebral component (e.g., spinous process,
lamina or facet) for intrinsic bony lesion, single vertebral segment; cervical
27,120
15,120
12,000
22101
Partial excision of posterior vertebral component (e.g., spinous process,
lamina or facet) for intrinsic bony lesion, single vertebral segment; thoracic
27,120
15,120
12,000
22102
Partial excision of posterior vertebral component (e.g., spinous process,
lamina or facet) for intrinsic bony lesion, single vertebral segment; lumbar
27,120
15,120
12,000
46,500
25,200
21,300
30,300
16,800
13,500
30,300
16,800
13,500
46,500
25,200
21,300
46,500
25,200
21,300
46,500
25,200
21,300
53,400
29,400
24,000
53,400
29,400
24,000
53,400
29,400
24,000
23,300
12,600
10,700
30,740
13,440
17,300
38,860
20,160
18,700
38,640
21,840
16,800
37,800
21,000
16,800
40,320
23,520
16,800
22110
22112
22114
22210
22212
22214
22220
22222
22224
22305
22310
22325
22326
22327
22548
Partial excision of vertebral body, for intrinsic bony lesion, w/o
decompression of spinal cord or nerve root(s), single vertebral segment;
cervical
Partial excision of vertebral body, for intrinsic bony lesion, w/o
decompression of spinal cord or nerve root(s), single vertebral segment;
thoracic
Partial excision of vertebral body, for intrinsic bony lesion, w/o
decompression of spinal cord or nerve root(s), single vertebral segment;
lumbar
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
Osteotomy of spine, including diskectomy, anterior approach, single
vertebral segment; cervical
Osteotomy of spine, including diskectomy, anterior approach, single
vertebral segment; thoracic
Osteotomy of spine, including diskectomy, anterior approach, single
vertebral segment; lumbar
Closed treatment of vertebral process fracture(s)
Closed treatment of vertebral body fracture(s), requiring and including
casting or bracing
Open treatment and/or reduction of vertebral fracture(s) and/or
dislocation(s), posterior approach, one fractured vertebrae or dislocated
segment; lumbar
Open treatment and/or reduction of vertebral fracture(s) and/or
dislocation(s), posterior approach, one fractured vertebrae or dislocated
segment; cervical
Open treatment and/or reduction of vertebral fracture(s) and/or
dislocation(s), posterior approach, one fractured vertebrae or dislocated
segment; thoracic
Arthrodesis, anterior transoral or extraoral technique, clivus-C1-C2 (atlasaxis), w/ or w/o excision of odontoid process
22554
Arthrodesis, anterior interbody technique, including minimal diskectomy to
prepare interspace (other than for decompression); cervical below C2
53,400
29,400
24,000
22556
Arthrodesis, anterior interbody technique, including minimal diskectomy to
prepare interspace (other than for decompression); thoracic
46,500
25,200
21,300
22558
Arthrodesis, anterior interbody technique, including minimal diskectomy to
prepare interspace (other than for decompression); lumbar
46,500
25,200
21,300
53,400
53,400
29,400
29,400
24,000
24,000
53,400
29,400
24,000
30,300
16,800
13,500
22590
22595
22600
22610
Arthrodesis; posterior technique, craniocervical (occiput-C2)
Arthrodesis, posterior technique, atlas-axis (C1-C2)
Arthrodesis, posterior or posterolateral technique, single level; cervical
below C2 segment;
Arthrodesis, posterior or posterolateral technique, single level; cervical
below C2 segment; thoracic (w/ or w/o lateral transverse technique)
Page 11 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
22612
Arthrodesis, posterior or posterolateral technique, single level; cervical
below C2 segment; lumbar (w/ or w/o lateral transverse technique)
30,300
16,800
13,500
22630
Arthrodesis, posterior interbody technique, single interspace; lumbar
40,320
23,520
16,800
58,800
37,800
21,000
63,000
42,000
21,000
67,200
46,200
21,000
55,000
33,600
21,400
58,800
37,800
21,000
67,200
46,200
21,000
55,000
33,600
21,400
22800
22802
22804
22808
22810
22812
22840
22841
Arthrodesis, posterior, for spinal deformity, w/ or w/o cast; up to 6 vertebral
segments
Arthrodesis, posterior, for spinal deformity, w/ or w/o cast; 7 to 12 vertebral
segments
Arthrodesis, posterior, for spinal deformity, w/ or w/o cast; 13 or more
vertebral segments
Arthrodesis, anterior, for spinal deformity, w/ or w/o cast; 2 to 3 vertebral
segments
Arthrodesis, anterior, for spinal deformity, w/ or w/o cast; 4 to 7 vertebral
segments
Arthrodesis, anterior, for spinal deformity, w/ or w/o cast; 8 or more
vertebral segments
Posterior non-segmental instrumentation (e.g., single Harrington rod
technique)
Internal spinal fixation by wiring of spinous processes
53,400
29,400
24,000
22842
Posterior segmental instrumentation (e.g., pedicle fixation, dual rods w/
multiple hooks and sublaminal wires); 3 to 6 vertebral segments
54,660
30,660
24,000
22843
Posterior segmental instrumentation (e.g., pedicle fixation, dual rods w/
multiple hooks and sublaminal wires); 7 to 12 vertebral segments
58,800
37,800
21,000
22844
Posterior segmental instrumentation (e.g., pedicle fixation, dual rods w/
multiple hooks and sublaminal wires); 13 or more vertebral segments
67,200
46,200
21,000
55,000
58,800
67,200
33,600
37,800
46,200
21,400
21,000
21,000
55,000
33,600
21,400
22849
Anterior instrumentation; 2 to 3 vertebral segments
Anterior instrumentation; 4 to 7 vertebral segments
Anterior instrumentation; 8 or more vertebral segments
Pelvic fixation (attachment of caudal end of instrumentation to pelvic bony
structures) other than sacrum
Reinsertion of spinal fixation device
53,400
29,400
24,000
22850
Removal of posterior nonsegmental instrumentation (e.g., Harrington rod)
21,940
9,240
12,700
58,800
37,800
21,000
27,120
30,300
23,300
15,120
16,800
12,600
12,000
13,500
10,700
20,980
10,080
10,900
27,120
18,000
14,960
15,120
8,400
7,560
12,000
9,600
7,400
20,980
10,080
10,900
23,300
12,600
10,700
20,980
10,080
10,900
3,504
5,680
8,020
504
1,680
2,520
3,000
4,000
5,500
37,800
21,000
16,800
23,300
12,600
10,700
27,120
15,120
12,000
27,120
21,820
15,120
10,920
12,000
10,900
30,740
13,440
17,300
23,300
27,960
27,540
12,600
15,960
15,540
10,700
12,000
12,000
20,980
10,080
10,900
22,240
11,340
10,900
22,240
11,340
10,900
30,740
13,440
17,300
22845
22846
22847
22848
23120
23125
23130
Application of prosthetic device (e.g., metal cages, methylmethacrylate) to
vertebral defect or interspace
Removal of posterior segmental instrumentation
Removal of anterior instrumentation
Excision, abdominal wall tumor, subfascial (e.g., desmoid)
Removal of subdeltoid (or intratendinous) calcareous deposits, open
method
Capsular contracture release (Sever type procedure)
Incision and drainage, shoulder area; deep abscess or hematoma
Incision and drainage, shoulder area; infected bursa
Incision, deep, w/ opening of cortex (e.g., for osteomyelitis or bone
abscess), shoulder area
Arthrotomy, glenohumeral joint, for infection, w/ exploration, drainage, or
removal of foreign body
Arthrotomy, acromioclavicular, sternoclavicular joint, for infection, w/
exploration, drainage, or removal of foreign body
Biopsy, soft tissue of shoulder area
Excision, tumor, shoulder area; subcutaneous
Excision, tumor, shoulder area; deep, subfascial, or intramuscular
Radical resection of tumor (e.g., malignant neoplasm), soft tissue of
shoulder area
Arthrotomy w/ biopsy, glenohumeral joint
Arthrotomy w/ biopsy, or w/ excision of torn cartilage, acromioclavicular,
sternoclavicular joint
Arthrotomy w/ synovectomy; glenohumeral joint
Arthrotomy w/ synovectomy; sternoclavicular joint
Arthrotomy, glenohumeral joint, w/ joint exploration, w/ or w/o removal of
loose or foreign body
Claviculectomy; partial
Claviculectomy; total
Acromioplasty or acromionectomy, partial
23140
Excision or curettage of bone cyst or benign tumor of clavicle or scapula;
22851
22852
22855
22900
23000
23020
23030
23031
23035
23040
23044
23065
23075
23076
23077
23100
23101
23105
23106
23107
23145
23146
23150
Excision or curettage of bone cyst or benign tumor of clavicle or scapula; w/
autograft (includes obtaining graft)
Excision or curettage of bone cyst or benign tumor of clavicle or scapula; w/
allograft
Excision or curettage of bone cyst or benign tumor of proximal humerus;
Page 12 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
23155
23156
23170
23172
23174
23180
23182
23184
23190
23195
23200
23210
23220
23221
DESCRIPTION
Case Rate
Excision or curettage of bone cyst or benign tumor of proximal humerus; w/
autograft (includes obtaining graft)
Excision or curettage of bone cyst or benign tumor of proximal humerus; w/
allograft
Sequestrectomy (e.g., for osteomyelitis or bone abscess), clavicle
Sequestrectomy (e.g., for osteomyelitis or bone abscess), scapula
Sequestrectomy (e.g., for osteomyelitis or bone abscess), humeral head to
surgical neck
Partial excision (craterization, saucerization,or diaphysectomy) of bone (e.g.,
for osteomyelitis), clavicle
Partial excision (craterization, saucerization,or diaphysectomy) of bone (e.g.,
for osteomyelitis), scapula
Partial excision (craterization, suacerization, or diaphysectomy) of bone
(e.g., for osteomyelitis), proximal humerus
Ostectomy of scapula, partial (e.g., superior medial angle)
Resection humeral head
Radical resection for tumor; clavicle
Radical resection for tumor; scapula
Radical resection for tumor; proximal humerus;
Radical resection for tumor; proximal humerus; w/ autograft (includes
obtaining graft)
Professional Fee
Health Care
Institution Fee
31,580
14,280
17,300
31,580
14,280
17,300
20,980
21,820
10,080
10,920
10,900
10,900
23,300
12,600
10,700
21,400
10,500
10,900
21,652
10,752
10,900
21,820
10,920
10,900
21,820
27,120
27,120
27,540
37,180
10,920
15,120
15,120
15,540
18,480
10,900
12,000
12,000
12,000
18,700
40,320
23,520
16,800
53,400
29,400
24,000
23222
Radical resection for tumor; proximal humerus; w/ prosthetic replacement
23330
Removal of foreign body, shoulder; subcutaneous
5,560
1,260
4,300
23331
Removal of foreign body, shoulder; deep (e.g., Neer prosthesis removal)
12,900
6,300
6,600
23332
Removal of foreign body, shoulder; complicated , including "total shoulder"
14,960
7,560
7,400
23395
23397
23400
23405
23406
23410
23412
23415
22,240
23,300
27,120
21,940
23,080
20,980
22,240
21,148
11,340
12,600
15,120
9,240
12,180
10,080
11,340
10,248
10,900
10,700
12,000
12,700
10,900
10,900
10,900
10,900
23,300
12,600
10,700
21,940
20,980
9,240
10,080
12,700
10,900
37,800
21,000
16,800
23455
23460
23462
Muscle transfer, any type, shoulder or upper arm; single
Muscle transfer, any type, shoulder or upper arm; multiple
Scapulopexy (e.g., Sprengels deformity or for paralysis)
Tenomyotomy, shoulder area; single
Tenomyotomy, shoulder area; multiple through same incision
Repair of ruptured musculotendinous cuff (e.g., rotator cuff); acute
Repair of ruptured musculotendinous cuff (e.g., rotator cuff); chronic
Coracoacromial ligament release, w/ or w/o acromioplasty
Repair 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; Bankart type operation w/ or w/o stapling
Capsulorrhaphy, anterior, any type; w/ bone block
Capsulorrhaphy, anterior, any type; w/ coracoid process transfer
38,860
38,860
37,180
20,160
20,160
18,480
18,700
18,700
18,700
23465
Capsulorrhaphy for recurrent dislocation, posterior, w/ or w/o bone block
37,800
21,000
16,800
23466
23470
Capsulorrhaphy w/ any type multi-directional instability
Arthroplasty w/ proximal humeral implant (e.g., Neer type operation)
Arthroplasty w/ glenoid and proximal humeral replacement (e.g. total
shoulder)
Osteotomy, clavicle, w/ or w/o internal fixation;
40,320
48,180
23,520
26,880
16,800
21,300
53,400
29,400
24,000
27,120
15,120
12,000
28,380
16,380
12,000
27,120
15,120
12,000
27,120
15,120
12,000
8,020
2,520
5,500
12,456
7,056
5,400
10,880
20,980
3,780
10,080
7,100
10,900
27,120
15,120
12,000
8,020
21,940
2,520
9,240
5,500
12,700
20,980
10,080
10,900
8,020
2,520
5,500
20,980
10,080
10,900
10,540
5,040
5,500
23420
23430
23440
23450
23472
23480
23485
23490
23491
23500
23515
23520
23530
23532
23540
23550
23552
23570
23585
23600
Osteotomy, clavicle, w/ or w/o internal fixation; w/ bone graft for nonunion
or malunion (includes obtaining graft and/or necessary fixation)
Prophylactic treatment (nailing, pinning, plating or wiring) w/ or w/o
methylmethacrylate; clavicle
Prophylactic treatment (nailing, pinning, plating or wiring) w/ or w/o
methylmethacrylate; proximal humerus and humeral head
Closed treatment of clavicular fracture
Open treatment of clavicular fracture, w/ or w/o internal or external
fixation
Closed treatment of sternoclavicular dislocation
Open treatment of sternoclavicular disloction, acute or chronic;
Open treatment of sternoclavicular disloction, w/ fascial graft (includes
obtaining graft)
Closed treatment of acromioclavicular dislocation
Open treatment of acromioclavicular dislocation, acute or chronic;
Open treatment of acromioclavicular dislocation, acute or chronic; w/
fascial graft (includes obtaining graft)
Closed treatment of scapular fracture
Open treatment of scapular fracture (body, glenoid or acromion) w/ or w/o
internal fixation
Closed treatment of proximal humeral (surgical or anatomical neck) fracture
Page 13 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
23615
DESCRIPTION
Case Rate
Open treatment of proximal humeral (surgical or anatomical neck) fracture,
w/ or w/o internal or external fixation, w/ or w/o repair of tuberosity(-ies);
Professional Fee
Health Care
Institution Fee
23,300
12,600
10,700
47,340
26,040
21,300
23650
Open treatment of proximal humeral (surgical or anatomical neck) fracture,
w/ or w/o internal or external fixation, w/ or w/o repair of tuberosity(-ies);
w/ proximal humeral prosthetic replacement
Closed treatment of greater tuberosity fracture
Open treatment of greater tuberosity fracture, w/ or w/o internal or
external fixation
Closed treatment of shoulder dislocation
10,540
5,040
5,500
23657
Thoracoscopy, surgical; w/ wedge resection of lung, single or mutiple
41,160
24,360
16,800
23660
Open treatment of acute shoulder dislocation
27,120
15,120
12,000
23665
Closed treatment of shoulder dislocation,/ fracture of greater tuberosity
11,980
5,880
6,100
27,120
15,120
12,000
12,120
6,720
5,400
27,120
15,120
12,000
9,700
4,200
5,500
23616
23620
23630
9,700
4,200
5,500
23,300
12,600
10,700
23900
23920
Open treatment of shoulder dislocation, w/ fracture of greater tuberosity,
w/ or w/o internal or external fixation
Closed treatment of shoulder dislocation, w/ surgical or anatomical neck
fracture
Open treatment of shoulder dislocation, w/ surgical or anatomical neck
fracture, w/ or w/o internal or external fixation
Manipulation under anesthesia, shoulder joint, including application of
fixation apparatus (dislocation excluded)
Arthrodesis, shoulder joint; w/ or w/o local bone graft
Arthrodesis, shoulder joint; w/ primary autogenous graft (includes obtaining
graft)
Interthoracoscapular amputation (forequarter)
Disarticulation of shoulder;
23930
Incision and drainage, upper arm or elbow area; deep abscess or hematoma
4,108
1,008
23931
5,560
1,260
4,300
21,940
9,240
12,700
22,360
9,660
12,700
24006
24065
24075
Incision and drainage, upper arm or elbow area; infected bursa
Incision, deep, w/ opening of bone cortex (e.g., for osteomyelitis of bone
abscess), humerus or elbow
Arthrotomy, elbow, for infection, w/ exploration, drainage or removal of
foreign body
Arthrotomy of the elbow, w/ capsular excision for capsular release
Biopsy, soft tissue of upper arm or elbow area
Excision, tumor, upper arm or elbow area; subcutaneous
20,980
3,504
5,680
10,080
504
1,680
10,900
3,000
4,000
24076
Excision, tumor, upper arm or elbow area; deep, subfascial or intramuscular
8,020
2,520
5,500
23,300
12,600
10,700
20,980
10,080
10,900
21,820
10,920
10,900
23,300
8,260
20,980
12,600
3,360
10,080
10,700
4,900
10,900
23,080
12,180
10,900
23,080
12,180
10,900
21,148
10,248
10,900
21,820
10,920
10,900
21,820
10,920
10,900
20,980
10,080
10,900
20,980
10,080
10,900
20,980
10,080
10,900
20,980
10,080
10,900
20,980
10,080
10,900
20,980
10,080
10,900
20,980
10,080
10,900
21,400
10,500
10,900
23,080
12,180
10,900
30,300
16,800
13,500
23,300
12,600
10,700
23670
23675
23680
23700
23800
23802
23935
24000
24077
24100
24101
24102
24105
24110
24115
24116
24120
24125
24126
24130
24134
24136
24138
24140
24145
24147
24149
24150
24151
24152
Radical resection of tumor (e.g., malignant neoplasm), soft tissue of upper
arm or elbow area
Arthrotomy, elbow; w/ synovial biopsy only
Arthrotomy, elbow; w/ joint exploration, w/ or w/o biopsy, w/ or w/o
removal of loose or foreign body
Arthrotomy, elbow; w/ synovectomy
Excision, olecranon bursa
Excision or curettage of bone cyst or benign tumor, humerus;
Excision or curettage of bone cyst or benign tumor, humerus; w/ autograft
(includes obtaining graft)
Excision or curettage of bone cyst or benign tumor, humerus; w/ allograft
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; w/ autograft (includes obtaining graft)
Excision or curettage of bone cyst or benign tumor of head or neck of radius
or olecranon process; w/ allograft
Excision, radial head
Sequestrectomy (e.g., for osteomyelitis or bone abscess), shaft or distal
humerus
Sequestrectomy (e.g., for osteomyelitis or bone abscess), radial head or
neck
Sequestrectomy (e.g., for osteomyelitis or bone abscess), olecranon process
Partial excision (craterization, saucerization, or diaphysectomy) of bone
(e.g., for osteomyelitis), humerus
Partial excision (craterization, saucerization, or diaphysectomy) of bone
(e.g., for osteomyelitis), radial head or neck
Partial excision (craterization, saucerization, or diaphysectomy) of bone
(e.g., for osteomyelitis), olecranon process
Radical resection of capsule, soft tissue, and heterotopic bone, elbow, w/
contracture release
Radical resection for tumor, shaft or distal humerus;
Radical resection for tumor, shaft or distal humerus; w/ autograft (includes
obtaining graft)
Radical resection for tumor, radial head or neck;
Page 14 of 98
12,456
7,056
5,400
37,180
18,480
18,700
30,300
27,120
16,800
15,120
13,500
12,000
3,100
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
24153
24155
24160
24164
24200
24301
24305
24310
24320
24330
24331
24340
24341
24342
24350
24351
24352
24354
24356
24360
24361
24362
24363
24365
24366
24400
24410
24420
24430
DESCRIPTION
Case Rate
Radical resection for tumor, radial head or neck; w/ 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
Muscle or tendon transfer, any type, upper arm or elbow, single
Tendon lengthening, upper arm or elbow, single, each
Tenotomy, open, elbow to shoulder, single, each
Tenoplasty, w/ muscle transfer, w/ or w/o free graft, elbow to shoulder,
single (Seddon-Brookes type procedure)
Flexor-plasty, elbow (e.g., Steindler type advancement);
Flexor-plasty, elbow (e.g., Steindler type advancement); w/ extensor
advancement
Tenodesis of biceps tendon at elbow
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, w/ or w/o tendon
graft
Fasciotomy, lateral or medial (e.g., "tennis elbow" or epicondylitis);
Fasciotomy, lateral or medial (e.g., "tennis elbow" or epicondylitis); w/
extensor origin detachment
Fasciotomy, lateral or medial (e.g., "tennis elbow" or epicondylitis); w/
annular ligament resection
Fasciotomy, lateral or medial (e.g., "tennis elbow" or epicondylitis); w/
stripping
Fasciotomy, lateral or medial (e.g., "tennis elbow" or epicondylitis); w/
partial ostectomy
Arthroplasty, elbow; w/ membrane;
Arthroplasty, elbow; w/ membrane; w/ distal humeral prosthetic
replacement
Arthroplasty, elbow; w/ membrane; w/ implant and fascia lata ligament
reconstruction
Arthroplasty, elbow; w/ membrane; w/ distal humerus and proximal ulnar
prosthetic replacement ("total elbow")
Arthroplasty, radial head;
Arthroplasty, radial head; w/ implant
Osteotomy, humerus, w/ or w/o internal fixation
Multiple osteotomies w/ realignment on intramedullary rod, humeral shaft
(Sofield type procedure)
Osteoplasty, humerus (e.g., shortening or lengthening)
Repair of non-union or malunion, humerus; w/o graft (e.g., compression
technique);
Professional Fee
Health Care
Institution Fee
27,120
15,120
12,000
27,120
21,940
22,360
8,272
23,300
20,980
21,940
15,120
9,240
9,660
2,772
12,600
10,080
9,240
12,000
12,700
12,700
5,500
10,700
10,900
12,700
27,120
15,120
12,000
30,740
13,440
17,300
27,120
15,120
12,000
8,260
3,360
4,900
20,980
10,080
10,900
12,120
6,720
5,400
10,540
5,040
5,500
12,120
6,720
5,400
12,120
6,720
5,400
12,120
6,720
5,400
12,120
6,720
5,400
27,120
15,120
12,000
37,180
18,480
18,700
27,120
15,120
12,000
38,640
21,840
16,800
21,940
27,120
20,980
9,240
15,120
10,080
12,700
12,000
10,900
20,980
10,080
10,900
23,300
12,600
10,700
23,080
12,180
10,900
15,120
12,000
24435
Repair of non-union or malunion, humerus; w/o graft (e.g., compression
technique); w/ iliac or other autograft (includes obtaining graft)
27,120
24470
Hemiepiphyseal arrest (e.g., for cubitus varus or valgus, distal humerus)
22,360
9,660
12,700
24495
Decompression fasciotomy, forearm, w/ brachial artery exploration
Prophylactic treatment (nailing, pinning, plating or wiring), w/ or w/o
methylmethacrylate, humerus
Closed treatment of humeral shaft fracture
Open treatment of humeral shaft fracture w/ plate/screws, w/ or w/o
cerclage
Open treatment of humeral shaft fracture, w/ insertion of intramedullary
implant, w/ or w/o cerclage and/or locking screws
Closed treatment of supracondylar or transcondylar humeral fracture, w/ or
w/o intercondylar extension
Percutaneous skeletal fixation of supracondylar or transcondylar humeral
fracture, w/ or w/o intercondylar extension
27,120
15,120
12,000
20,980
10,080
10,900
10,120
4,620
5,500
30,740
13,440
17,300
30,740
13,440
17,300
10,120
4,620
5,500
27,120
15,120
12,000
24498
24500
24515
24516
24530
24538
24545
Open treatment of humeral supracondylar or transcondylar fracture, w/ or
w/o internal or external fixation; w/o intercondylar extension
12,456
7,056
5,400
24546
Open treatment of humeral supracondylar or transcondylar fracture, w/ or
w/o internal or external fixation; w/ intercondylar extension
32,000
14,700
17,300
24560
24566
24575
24576
24579
24582
Closed treatment of humeral epicondylar fracture, medial or lateral;
Percutaneous skeletal fixation of humeral epicondylar fracture, medial or
lateral, w/ manipulation
Open treatment of humeral epicondylar fracture, medial or lateral, w/ or
w/o internal or external fixation
Closed treatment of humeral condylar fracture, medial or lateral
Open treatment of humeral condylar fracture, medial or lateral, w/ or w/o
internal or external fixation
Percutaneous skeletal fixation of humeral condylar fracture, medial or
lateral, w/ manipulation
Page 15 of 98
10,880
3,780
7,100
27,120
15,120
12,000
18,000
8,400
9,600
10,880
3,780
7,100
18,000
8,400
9,600
27,120
15,120
12,000
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
24586
24587
24600
24615
24620
24635
DESCRIPTION
Case Rate
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); w/
implant arthroplasty
Treatment of closed elbow dislocation
Open treatment of acute or chronic elbow dislocation
Closed treatment of Monteggia type of fracture dislocation at elbow
(fracture proximal end of ulna w/ dislocation of radial head)
Open treatment of Monteggia type of fracture dislocation at elbow (fracture
proximal end of ulna w/ dislocation of radial head), w/ or w/o internal or
external fixation
Professional Fee
Health Care
Institution Fee
22,660
11,760
10,900
37,800
21,000
16,800
10,540
23,300
5,040
12,600
5,500
10,700
10,880
3,780
7,100
21,940
9,240
12,700
4,000
24640
Closed treatment of radial head subluxation in child, "nursemaid elbow"
5,680
1,680
24650
Closed treatment of radial head or neck fracture
Open treatment of radial head or neck fracture, w/ or w/o internal fixation
or radial head excision;
Open treatment of periarticular fracture and/or dislocation of the elbow
(fracture distal humerus and proximal ulna and/or proximal radius); w/
radial head prosthetic replacement
10,880
3,780
7,100
20,980
10,080
10,900
27,120
15,120
12,000
Closed treatment of ulnar fracture, proximal end (olecranon process)
10,880
3,780
7,100
21,940
9,240
12,700
27,120
15,120
12,000
28,380
16,380
12,000
18,000
12,120
8,400
6,720
9,600
5,400
24665
24666
24670
24900
24920
Open treatment of ulnar fracture proximal end (olecranon process), w/ or
w/o internal or external fixation
Arthrodesis, elbow joint; w/ or w/o local autograft or allograft
Arthrodesis, elbow joint; w/ autograft (includes obtaining graft other than
locally obtained)
Amputation, arm through humerus; w/ primary closure
Amputation, arm through humerus; open, circular (guillotine)
24925
Amputation, arm through humerus; secondary closure or scar revision
10,960
5,460
5,500
24930
24931
24935
24940
Amputation, arm through humerus; re-amputation
Amputation, arm through humerus; w/ implant
Stump elongation, upper extremity
Cineplasty, upper extremity, complete procedure
14,960
14,960
12,120
27,120
7,560
7,560
6,720
15,120
7,400
7,400
5,400
12,000
25000
Tendon sheath incision; at radial styloid (e.g., for deQuervains disease)
10,540
5,040
5,500
18,000
8,400
9,600
14,960
7,560
7,400
24685
24800
24802
25020
25023
Decompression fasciotomy, forearm and/or wrist; flexor or extensor
compartment
Decompression fasciotomy, forearm and/or wrist; w/ debridement of
nonviable muscle and/or nerve
25028
Incision and drainage, forearm and/or wrist; deep abscess or hematoma
10,880
3,780
7,100
25031
10,120
4,620
5,500
12,120
6,720
5,400
10,120
4,620
5,500
3,504
5,680
504
1,680
3,000
4,000
8,020
2,520
5,500
23,300
12,600
10,700
15,380
11,044
7,980
5,544
7,400
5,500
25105
Incision and drainage, forearm and/or wrist; infected bursa
Incision, deep, w/ opening of bone cortex (e.g., for osteomyelitis or bone
abscess), forearm and/or wrist
Arthrotomy, radiocarpal or midcarpal joint, w/ exploration, drainage, or
removal of foreign body
Biopsy, soft tissue of forearm and/or wrist
Excision, tumor, forearm and/or wrist area; subcutaneous
Excision, tumor, forearm and/or wrist area; deep, subfascial or
intramuscular
Radical resection of tumor (e.g., malignant neoplasm), soft tissue of forearm
and/or wrist area
Capsulotomy, wrist (e.g., for contracture)
Arthrotomy, wrist joint; w/ biopsy
Arthrotomy, wrist joint; w/ joint exploration, w/ or w/o biopsy, w/ or w/o
removal of loose or foreign body
Arthrotomy, wrist joint; w/ synovectomy
25107
Arthrotomy, distal radioulnar joint for repair of triangle cartilage complex
25110
25111
Excision, lesion of tendon sheath, forearm and/or wrist
Excision of ganglion, wrist (dorsal or volar)
Radical excision of bursa, synovia of wrist, or forearm tendon sheaths (e.g.,
tenosynovitis, fungus, Tbc, or other granulomas, rheumatoid arthritis);
flexors
25035
25040
25065
25075
25076
25077
25085
25100
25101
25115
25116
25118
25119
25120
Radical excision of bursa, synovia of wrist, or forearm tendon sheaths (e.g.,
tenosynovitis, fungus, Tbc, or other granulomas, rheumatoid arthritis);
extensors, w/ or w/o transposition of dorsal retinaculum
Synovectomy, extensor tendon sheath, wrist, single compartment;
Synovectomy, extensor tendon sheath, wrist, single compartment; w/
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);
Page 16 of 98
12,540
7,140
5,400
20,980
10,080
10,900
20,980
10,080
10,900
8,020
8,260
2,520
3,360
5,500
4,900
21,820
10,920
10,900
18,420
8,820
9,600
9,952
4,452
5,500
21,940
9,240
12,700
20,980
10,080
10,900
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
25125
Excision or curettage of bone cyst or benign tumor of radius or ulna
(excluding head or neck of radius and olecranon process); w/ autograft
(includes obtaining graft)
21,820
10,920
10,900
25126
Excision or curettage of bone cyst or benign tumor of radius or ulna
(excluding head or neck of radius and olecranon process); w/ allograft
21,820
10,920
10,900
25130
25135
25136
25145
25150
25151
25170
25210
25215
25230
25240
25248
25250
25251
25260
25263
25265
25270
25272
25274
25280
25290
25295
25300
25301
25310
25312
25315
25316
25320
25332
25335
25337
25350
25355
25360
25365
25370
25375
25390
25391
Excision or curettage of bone cyst or benign tumor of carpal bones;
Excision or curettage of bone cyst or benign tumor of carpal bones; w/
autograft (includes obtaining graft)
Excision or curettage of bone cyst or benign tumor of carpal bones; w/
allograft
Sequestrectomy (e.g., for osteomyelitis or bone abscess), forearm and/or
wrist
Partial excision (craterization, saucerization, or diaphysectomy) of bone
(e.g., for osteomyelitis); ulna
Partial excision (craterization, saucerization, or diaphysectomy) of bone
(e.g., for osteomyelitis); radius
Radical resection for tumor, radius or ulna
Carpectomy; one bone
Carpectomy; all bones of proximal row
Radial styloidectomy
Excision distal ulna partial or complete (e.g., Darrach type or matched
resection)
Exploration w/ removal of deep foreign body, forearm or wrist
Removal of wrist prosthesis;
Removal of wrist prosthesis; complicated, including "total wrist"
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, w/ free
graft (includes obtaining graft), each tendon or muscle
Repair, tendon or muslce, extensor, forearm and/or wrist; primary, single,
each tendon or muscle
Repair, tendon or muslce, extensor, forearm and/or wrist; secondary, single,
each tendon or muscle
Repair, tendon or muscle, extensor, secondary, w/ tendon graft (includes
obtaining graft), forearm and/or wrist, each tendon or muscle
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; w/ tendon graft(s) (includes obtaining graft), each tendon
Flexor origin slide (e.g., for cerebral palsy, Volkmann contracture), forearm
and/or wrist;
Flexor origin slide (e.g., for cerebral palsy, Volkmann contracture), forearm
and/or wrist; w/ tendon(s) transfer
Capsulorrhaphy or reconstruction, wrist, any method (e.g., capsulodesis,
ligament repair, tendon transfer or graft) (includes synovectomy,
capsulotomy and open reduction) for carpal instability
Arthroplasty, wrist, w/ or w/o interposition, w/ or w/o external or internal
fixation
Centralization of wrist on ulna (e.g., radial club hand)
Reconstruction for stabilization of unstable distal ulna or distal radioulnar
joint, secondary by soft tissue stabilization (e.g., tendon transfer, tendon
graft or weave, or tenodesis) w/ or w/o open reduction of distal radioulnar
joint
Osteotomy, radius; distal third
Osteotomy, radius; middle or proximal third
Osteotomy; ulna
Osteotomy; radius and ulna
Multiple osteotomies, w/ realignment on intramedullary rod (Sofield type
procedure); radius or ulna
Multiple osteotomies, w/ realignment on intramedullary rod (Sofield type
procedure); radius and ulna
Osteoplasty, radius or ulna; shortening
Osteoplasty, radius or ulna; lengthening w/ autograft
Page 17 of 98
9,952
4,452
5,500
12,900
6,300
6,600
12,900
6,300
6,600
21,940
9,240
12,700
21,940
9,240
12,700
21,940
9,240
12,700
27,120
5,932
22,360
10,540
15,120
1,932
9,660
5,040
12,000
4,000
12,700
5,500
10,540
5,040
5,500
8,260
21,940
30,740
3,360
9,240
13,440
4,900
12,700
17,300
10,540
5,040
5,500
8,260
3,360
4,900
10,120
4,620
5,500
10,540
5,040
5,500
8,260
3,360
4,900
10,540
5,040
5,500
10,880
3,780
7,100
10,880
3,780
7,100
8,260
3,360
4,900
10,960
10,540
5,460
5,040
5,500
5,500
20,980
10,080
10,900
21,820
10,920
10,900
30,300
16,800
13,500
37,180
18,480
18,700
27,120
15,120
12,000
30,300
16,800
13,500
31,140
17,640
13,500
27,960
15,960
12,000
18,000
21,940
18,420
23,300
8,400
9,240
8,820
12,600
9,600
12,700
9,600
10,700
30,740
13,440
17,300
27,960
15,960
12,000
27,120
27,960
15,120
15,960
12,000
12,000
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
DESCRIPTION
27,120
27,960
15,120
15,960
20,980
10,080
10,900
23,300
12,600
10,700
30,740
13,440
17,300
27,960
15,960
12,000
21,940
30,740
9,240
13,440
12,700
17,300
23,720
13,020
10,700
30,300
27,120
27,120
27,120
31,580
16,800
15,120
15,120
15,120
14,280
13,500
12,000
12,000
12,000
17,300
37,800
21,000
16,800
27,960
15,960
12,000
25449
Osteoplasty, radius and ulna; shortening
Osteoplasty, radius and ulna; lengthening w/ autograft
Repair of nonunion or malunion, radius or ulna; w/o graft (compression
technique)
Repair of nonunion or malunion, radius or ulna; w/ iliac or other autograft
(includes obtaining graft)
Repair of nonunion or malunion, radius and ulna; w/o graft (e.g.
compression technique)
Repair of nonunion or malunion, radius and ulna; w/ iliac or other autograft
(includes obtaining graft)
Repair of defect w/ autograft; radius or ulna
Repair of defect w/ autograft; radius and ulna
Repair of nonunion, scaphoid (navicular) bone, w/ or w/o radial
styloidectomy (includes obtaining graft and necessary fixation)
Arthroplasty w/ prosthetic replacement; distal radius
Arthroplasty w/ prosthetic replacement; distal ulna
Arthroplasty w/ prosthetic replacement; scaphoid (navicular)
Arthroplasty w/ prosthetic replacement; lunate
Arthroplasty w/ prosthetic replacement; trapezium
Arthroplasty w/ prosthetic replacement; distal radius and partial or entire
carpus ("total wrist")
Arthroplasty w/ prosthetic replacement; Interposition arthroplasty,
intercarpal or carpometacarpal joints
Revision of arthroplasty, including removal of implant, wrist joint
Health Care
Institution Fee
12,000
12,000
40,320
23,520
16,800
25450
Epiphyseal arrest by epiphysiodesis or stapling; distal radius or ulna
20,980
10,080
10,900
25455
Epiphyseal arrest by epiphysiodesis or stapling; distal radius and ulna
30,740
13,440
17,300
21,940
9,240
12,700
21,940
9,240
12,700
37,180
18,480
18,700
9,700
4,200
5,500
21,940
9,240
12,700
9,700
4,200
5,500
20,980
10,080
10,900
22,660
11,760
10,900
25392
25393
25400
25405
25415
25420
25425
25426
25440
25441
25442
25443
25444
25445
25446
25447
25490
25491
25492
25500
25515
25520
25525
25526
25530
25545
25560
25574
25575
25600
25611
25620
25622
25628
25630
25645
25650
25660
Case Rate
Prophylactic treatment (nailing, pinning, plating or wiring) w/ or w/o
methylmethacrylate; radius
Prophylactic treatment (nailing, pinning, plating or wiring) w/ or w/o
methylmethacrylate; ulna
Prophylactic treatment (nailing, pinning, plating or wiring) w/ or w/o
methylmethacrylate; radius and ulna
Closed treatment of radial shaft fracture
Open treatment of radial shaft fracture, w/ or w/o internal or external
fixation
Closed treatment of radial shaft fracture, w/ dislocation of distal radio-ulnar
joint (Galeazzi fracture/dislocation)
Open treatment of radial shaft fracture, w/ internal and/or external fixation
and closed treatment of dislocation of distal radio-ulnar joint (Galeazzi
fracture/dislocation), w/ or w/o percutaneous skeletal fixation
Open treatment of radial shaft fracture, w/ internal and/or external fixation
and open treatment, w/ or w/o internal or external fixation of distal radioulnar joint (Galleazi fracture/dislocation), includes repair of triangular
cartilage
Closed treatment of ulnar shaft fracture
Open treatment of ulnar shaft fracture, w/ or w/o internal or external
fixation
Closed treatment of radial and ulnar shaft fractures
Open treatment of radial and ulnar shaft fractures, w/ internal or external
fixation; of radius or ulna
Open treatment of radial and ulnar shaft fractures, w/ internal or external
fixation; of radius and ulna
Closed treatment of distal radial fracture (e.g., Colles or Smith type) or
epiphyseal separation, w/ or w/o fracture of ulnar styloid
Percutaneous skeletal fixation of distal radial fracture (e.g., Colles or Smith
type) or epiphyseal separation, w/ or w/o fracture of ulnar styloid , requiring
manipulation, w/ or w/o external fixation
Open treatment of distal radial fracture (e.g., Colles or Smith type) or
epiphyseal separation, w/ or w/o fracture of ulnar styloid, w/ or w/o
internal or external fixation
Closed treatment of carpal scaphoid (navicular) fracture
Open treatment of carpal scaphoid (navicular) fracture, w/ or w/o internal
or external fixation
Closed treatment of carpal bone fracture (excluding carpal scaphoid
(navicular))
Open treatment of carpal bone fracture (excluding carpal scaphoid
(navicular)), each bone
Closed treatment of ulnar styloid fracture
Closed treatment of radiocarpal or intercarpal dislocation, one or more
bones
Professional Fee
8,260
3,360
4,900
18,000
8,400
9,600
9,700
4,200
5,500
27,960
15,960
12,000
27,120
15,120
12,000
8,260
3,360
4,900
23,300
12,600
10,700
23,300
12,600
10,700
8,260
3,360
4,900
21,820
10,920
10,900
8,260
3,360
4,900
21,904
11,004
10,900
8,440
2,940
5,500
8,260
3,360
4,900
25670
Open treatment of radiocarpal or intercarpal dislocation, one or more bones
18,000
8,400
9,600
25675
25676
Closed treatment of distal radioulnar dislocation
Open treatment of distal radioulnar dislocation, acute or chronic
8,260
21,820
3,360
10,920
4,900
10,900
Page 18 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
DESCRIPTION
Case Rate
25680
Closed treatment of trans-scaphoperilunar type of fracture dislocation
25685
25690
25695
Professional Fee
Health Care
Institution Fee
8,260
3,360
4,900
Open treatment of trans-scaphoperilunar type of fracture dislocation
20,980
10,080
10,900
Closed treatment of lunate dislocation
Open treatment of lunate dislocation
Arthrodesis, wrist joint (including radiocarpal and/or ulnocarpal fusion); w/o
bone graft
Arthrodesis, wrist joint (including radiocarpal and/or ulnocarpal fusion); w/
sliding graft
Arthrodesis, wrist joint (including radiocarpal and/or ulnocarpal fusion); w/
iliac or other autograft (includes obtaining graft)
Intercarpal fusion; w/o bone graft
Intercarpal fusion; w/ autograft (includes obtaining graft)
Distal radioulnar joint arthrodesis and segmental resection of ulna (e.g.
Sauve-Kapandji procedure), w/ or w/o bone graft
Amputation, forearm, through, radius and ulna;
Amputation, forearm, through, open, circular (guillotine)
Amputation, forearm, through, secondary closure or scar revision
Amputation, forearm, through, 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
Drainage of finger abscess; simple
Drainage of finger abscess; complicated (e.g., felon)
Drainage of tendon sheath, one digit and/or palm
Drainage of palmar bursa; single, ulnar or radial
Drainage of palmar bursa; single, multiple or complicated
Inicision, deep, w/ opening of bone cortex (e.g., for osteomyelitis or bone
abscess), hand or finger
8,260
21,940
3,360
9,240
4,900
12,700
18,000
8,400
9,600
21,820
10,920
10,900
21,820
10,920
10,900
12,900
14,960
6,300
7,560
6,600
7,400
21,820
10,920
10,900
18,000
12,120
10,960
14,960
37,800
14,960
8,440
14,960
14,960
8,440
14,960
3,504
4,108
8,020
10,880
10,540
8,400
6,720
5,460
7,560
21,000
7,560
2,940
7,560
7,560
2,940
7,560
504
1,008
2,520
3,780
5,040
9,600
5,400
5,500
7,400
16,800
7,400
5,500
7,400
7,400
5,500
7,400
3,000
3,100
5,500
7,100
5,500
21,940
9,240
12,700
26035
Decompression fingers and/or hand, injection injury (e.g., grease gun)
14,960
7,560
7,400
26037
26040
26045
26055
26060
21,940
12,120
12,120
10,540
9,700
9,240
6,720
6,720
5,040
4,200
12,700
5,400
5,400
5,500
5,500
10,880
3,780
7,100
10,880
3,780
7,100
8,260
3,360
4,900
26100
26105
26110
Decompressive fasciotomy, hand (excludes 26035)
Fasciotomy, palmar, for Dupuytrens contracture; percutaneous
Fasciotomy, palmar, for Dupuytrens contracture; open, partial
Tendon sheath incision (e.g., for trigger finger)
Tenotomy, percutaneous, single, each digit
Arthrotomy, w/ exploration, drainage, or removal of foreign body;
carpometacarpal joint
Arthrotomy, w/ exploration, drainage, or removal of foreign body;
metacarpophalangeal joint
Arthrotomy, w/ exploration, drainage, or removal of foreign body;
interphalangeal joint, each
Arthrotomy w/ synovial biopsy, carpometacarpal joint
Arthrotomy w/ synovial biopsy, metacarpophalangeal joint
Arthrotomy w/ synovial biopsy, interphalangeal joint, each
12,120
12,900
11,980
6,720
6,300
5,880
5,400
6,600
6,100
26115
Excision, tumor or vascular malformation, hand or finger; subcutaneous
20,980
10,080
10,900
23,300
12,600
10,700
27,120
15,120
12,000
27,120
15,120
12,000
22,660
11,760
10,900
8,260
3,360
4,900
22,660
11,760
10,900
12,984
6,384
6,600
12,984
6,384
6,600
15,380
7,980
7,400
11,980
5,880
6,100
8,440
8,260
2,940
3,360
5,500
4,900
25800
25805
25810
25820
25825
25830
25900
25905
25907
25909
25915
25920
25922
25924
25927
25929
25931
26010
26011
26020
26025
26030
26034
26070
26075
26080
26116
26117
26121
26123
26125
26130
26135
26140
26145
26160
26170
26180
Excision, tumor or vascular malformation, hand or finger; deep, subfascial,
intramuscular
Radical resection of tumor (e.g., malignant neoplasm), soft tissue of hand or
finger
Fasciectomy, palm only, w/ or w/o Z-plasty, other local tissue
rearrangement, or skin grafting (includes obtaining graft)
Fasciectomy, partial palmar w/ release of single digit including proximal
interphalangeal joint, w/ or w/o Z-plasty, other local tissue rearrangement,
or skin grafting (includes obtaining graft);
Fasciectomy, partial palmar w/ release of single digit including proximal
interphalangeal joint, w/ or w/o 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, capometacarpal joint
Synovectomy, metacarpophalangeal joint including intrinsic release and
extensor hood reconstruction, each digit
Synovectomy, proximal interphalangeal joint, including extensor
reconstruction, each interphalangeal joint
Synovectomy tendon sheath, radical (tenosynovectomy), flexor, palm or
finger, single, each digit
Excision of lesion of tendon sheath or capsule (e.g., cyst, mucous cyst, or
ganglion), hand or finger
Excision of tendon, palm, flexor, single , each
Excision of tendon, finger, flexor
Page 19 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
26185
26200
26205
26210
26215
26230
26235
26236
26250
26255
26260
26261
26262
26350
26352
26356
26357
26358
26370
26372
26373
26390
26392
26410
26412
26415
26416
26418
26420
26426
26428
26432
26433
26434
26437
26440
26442
26445
26449
26450
26455
26460
26471
26474
26476
DESCRIPTION
15,380
12,624
7,980
7,224
Health Care
Institution Fee
7,400
5,400
21,940
9,240
12,700
12,120
6,720
5,400
15,380
7,980
7,400
21,940
9,240
12,700
15,380
7,980
7,400
Case Rate
Sesamoidectomy, thumb or finger
Excision or curettage of bone cyst or benign tumor of metacarpal;
Excision or curettage of bone cyst or benign tumor of metacarpal; w/
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; w/ autograft (includes obtaining graft)
Partial excision (craterization, saucerization, or diaphysectomy) of bone
(e.g., for osteomyelitis); metacarpal
Partial excision (craterization, saucerization, or diaphysectomy) of bone
(e.g., for osteomyelitis); proximal or middle phalanx of finger
Partial excision (craterization, saucerization, or diaphysectomy) of bone
(e.g., for osteomyelitis); distal phalanx of finger
Radical resection (ostectomy) for tumor, metacarpal;
Radical resection (ostectomy) for tumor, metacarpal; w/ autograft (includes
obtaining graft)
Radical resection (ostectomy) for tumor, proximal or middle phalanx of
finger;
Radical resection (ostectomy) for tumor, proximal or middle phalanx of
finger; w/ autograft (includes obtaining graft)
Radical resection (ostectomy) for tumor, distal phalanx of finger
Flexor tendon repair or advancement, single, not in "no mans land", primary
or secondary w/o free graft, each tendon
Flexor tendon repair or advancement, single, not in "no mans land",
secondary w/ free graft (includes obtaining graft), each tendon
Flexor tendon repair or advancement, single, in "no mans land"; primary,
each tendon
Flexor tendon repair or advancement, single, in "no mans land"; secondary,
each tendon
Flexor tendon repair or advancement, single, in "no mans land"; secondary
w/ free graft (includes obtaining graft), each tendon
Profundus tendon repair or advancement, w/ intact sublimis; primary
Profundus tendon repair or advancement, w/ intact sublimis; secondary w/
free graft (includes obtaining graft)
Profundus tendon repair or advancement, w/ intact sublimis; secondary w/o
free graft
Flexor tendon excision, implantation of plastic tube or rod for delayed
tendon graft, hand or finger
Removal of tube or rod and insertion of flexor tendon graft (includes
obtaining graft), hand or finger
Extensor tendon repair, dorsum of hand, single, primary or secondary; w/o
free graft, each tendon
Extensor tendon repair, dorsum of hand, single, primary or secondary; w/
free graft (includes obtaining graft), each tendon
Extensor tendon excision, implantation of plastic tube or rod for delayed
extensor tendon graft, hand or finger
Removal of tube or rod and insertion of extensor tendon graft (includes
obtaining graft), hand or finger
Extensor tendon repair, dorsum of finger, single, primary or secondary; w/o
free graft, each tendon
Extensor tendon repair, dorsum of finger, single, primary or secondary; w/
free graft (includes obtaining graft), each tendon
Extensor tendon repair, central slip repair, secondary (boutonniere
deformity); using local tissues
Extensor tendon repair, central slip repair, secondary (boutonniere
deformity); w/ free graft (includes obtaining graft)
Extensor tendon repair, distal insertion ("mallet finger"), closed splinting w/
or w/o percutaneous pinning
Extensor tendon repair, distal insertion ("mallet finger"), open, primary or
secondary repair; w/o graft
Extensor tendon repair, distal insertion ("mallet finger"), open, primary or
secondary repair; w/ free graft (includes obtaining graft)
Extensor tendon realignment, hand
Tenolysis, simple, flexor tendon; palm or finger, single, each tendon
Tenolysis, simple, flexor tendon; palm and finger, each tendon
Tenolysis, extensor tendon, dorsum of hand or finger; each tendon
Tenolysis, complex, extensor tendon, dorsum of hand or finger, including
hand and forearm
Tenotomy, flexor, single, palm, open, each
Tenotomy, flexor, single, finger, open, each
Tenotomy, extensor, hand or finger, single, open, each
Tenodesis; for proximal interphalangeal joint stabilization
Tenodesis; for distal joint stabilizaton
Tendon lengthening, extensor, hand or finger, single, each
Page 20 of 98
Professional Fee
12,120
6,720
5,400
23,636
12,936
10,700
32,000
14,700
17,300
30,740
13,440
17,300
31,580
14,280
17,300
23,080
12,180
10,900
12,120
6,720
5,400
10,540
5,040
5,500
10,880
3,780
7,100
10,880
3,780
7,100
10,880
3,780
7,100
10,880
3,780
7,100
10,540
5,040
5,500
11,132
4,032
7,100
10,880
3,780
7,100
10,880
3,780
7,100
8,260
3,360
4,900
8,260
3,360
4,900
10,880
3,780
7,100
8,692
3,192
5,500
8,260
3,360
4,900
8,260
3,360
4,900
8,260
3,360
4,900
8,260
3,360
4,900
8,260
3,360
4,900
8,260
3,360
4,900
10,880
3,780
7,100
10,540
8,020
8,440
8,020
5,040
2,520
2,940
2,520
5,500
5,500
5,500
5,500
8,440
2,940
5,500
8,440
8,440
8,440
8,260
10,880
8,440
2,940
2,940
2,940
3,360
3,780
2,940
5,500
5,500
5,500
4,900
7,100
5,500
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
26477
26478
26479
26480
26483
DESCRIPTION
8,440
8,440
8,440
2,940
2,940
2,940
Health Care
Institution Fee
5,500
5,500
5,500
8,440
2,940
5,500
10,880
3,780
7,100
8,260
3,360
4,900
Case Rate
Tendon shortening, extensor, hand or finger, single, each
Tendon lengthening, flexor, hand or finger, single, each
Tendon shortening, flexor, hand or finger, single, each
Tendon transfer or transplant, carpometacarpal area or dorsum of hand,
single; w/o free graft, each
Tendon transfer or transplant, carpometacarpal area or dorsum of hand,
single; w/ free tendon graft (includes obtaining graft), each tendon
Professional Fee
26530
Tendon transfer or transplant, palmar, single, each tendon; w/o free tendon
graft
Tendon transfer or transplant, palmar, single, each tendon; w/ free tendon
graft (includes obtaining graft), each tendon
Opponensplasty; sublimis tendon transfer type
Opponensplasty; tendon transfer w/ graft (includes obtaining graft)
Opponensplasty; hypothenar muscle transfer
Opponensplasty; other methods
Tendon trasfer to restore intrinsic function; ring and small finger
Tendon trasfer to restore intrinsic function; all four fingers
Correction claw finger,other methods
Tendon pulley reconstruction; w/ local tissues
Tendon pulley reconstruction; w/ tendon or fascial graft (includes obtaining
graft)
Tendon pulley reconstruction; w/ tendon prosthesis
Thenar muscle release for thumb contracture
Cross intrinsic transfer
Capsulodesis for M-P joint stabilization; single digit
Capsulodesis for M-P joint stabilization; two digits
Capsulodesis for M-P joint stabilization; three or four digits
Capsulectomy or capsulotomy for contracture; metacarpophalangeal joint,
single, each
Capsulectomy or capsulotomy for contracture; interphalangeal joint, single,
each
Arthroplasty, metacarpophalangeal joint; single, each
26531
Arthroplasty, metacarpophalangeal joint; w/ prosthetic implant, single, each
26535
Arthroplasty interphalangeal joint, single, each
18,000
8,400
9,600
26536
Arthroplasty interphalangeal joint, w/ prosthetic implant, single, each
20,980
10,080
10,900
26540
Repair of collateral ligament, metacarpophalangeal or interphalangeal joint
8,428
3,528
4,900
8,428
3,528
4,900
8,428
3,528
4,900
10,880
3,780
7,100
10,540
5,040
5,500
8,428
20,980
3,528
10,080
4,900
10,900
30,300
16,800
13,500
30,740
13,440
17,300
27,120
15,120
12,000
14,960
27,120
18,000
7,560
15,120
8,400
7,400
12,000
9,600
20,980
10,080
10,900
30,740
13,440
17,300
23,300
23,300
23,300
20,980
20,980
23,300
30,740
30,740
20,980
21,820
12,600
12,600
12,600
10,080
10,080
12,600
13,440
13,440
10,080
10,920
10,700
10,700
10,700
10,900
10,900
10,700
17,300
17,300
10,900
10,900
21,820
10,920
10,900
10,120
4,620
5,500
26485
26489
26490
26492
26494
26496
26497
26498
26499
26500
26502
26504
26508
26510
26516
26517
26518
26520
26525
26555
26556
26560
Reconstruction, collateral ligament, metacarpophalangeal joint, single, w/
tendon or fascial graft (includes obtainig graft)
Reconstruction, collateral ligament, metacarpophalangeal joint, single, w/
local tissue (e.g., adductor advancement)
Reconstruction, collateral ligament, interphalangeal joint, single, including
graft, each joint
Repair non-union, metacarpal or phalanx, (includes obtaining bone graft w/
or w/o external or internal fixation)
Repair and reconstruction, finger, volar plate, interphalangeal joint
Pollicization of a digit
Toe-to-hand transfer w/ microvascular anastmosis; great toe "wraparound" w/ bone graft
Toe-to-hand transfer w/ microvascular anastmosis; other than great toe,
single
Toe-to-hand transfer w/ microvascular anastmosis; other than great toe,
double
Positional change of other finger
Free toe joint transfer w/ microvascular anastomosis
Repair of syndactyly (web finger) each web space; w/ skin flaps
26561
Repair of syndactyly (web finger) each web space; w/ skin flaps and grafts
26541
26542
26545
26546
26548
26550
26551
26553
26554
26562
26565
26567
26568
26580
26585
26587
26590
26591
26593
26596
26597
26600
Repair of syndactyly (web finger) each web space; complex (e.g., involving
bone, nails)
Osteotomy for correction of deformity; metacarpal
Osteotomy for correction of deformity; phalanx of finger
Osteoplasty for lengthening of metacarpal or phalanx
Repair cleft hand
Repair bifid digit
Reconstruction of supernumerary digit, soft tissue and bone
Repair macrodactylia
Repair, intrinsic muscles of hand (specify)
Release, intrinsic muscles of hand (specify)
Excision of constricting ring of finger, w/ multiple Z-plasties
Release of scar contracture, flexor or extensor, w/ skin grafts,
rearrangement flaps, or Z-plasties, hand and/or finger
Closed treatment of metacarpal fracture, single
Page 21 of 98
8,260
3,360
4,900
10,540
10,960
10,540
10,540
8,428
18,000
21,940
10,880
5,040
5,460
5,040
5,040
3,528
8,400
9,240
3,780
5,500
5,500
5,500
5,500
4,900
9,600
12,700
7,100
10,120
4,620
5,500
12,900
8,428
10,960
10,540
12,120
18,000
6,300
3,528
5,460
5,040
6,720
8,400
6,600
4,900
5,500
5,500
5,400
9,600
10,880
3,780
7,100
5,628
3,752
1,876
4,788
3,192
1,596
8,020
2,520
5,500
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
26607
Closed treatment of metacarpal fracture, w/ internal or external fixation
12,900
6,300
6,600
26608
Percutaneous skeletal fixation of metacarpal fracture, each bone
Open treatment of metacarpal fracture, single, w/ or w/o internal or
external fixation, each bone
Closed treatment of carpometacarpal dislocation, thumb
Closed tratment of carpometacarpal fracture dislocation, thumb (Bennett
fracture)
12,120
6,720
5,400
12,120
6,720
5,400
10,540
5,040
5,500
12,120
6,720
5,400
14,960
7,560
7,400
14,960
7,560
7,400
10,540
5,040
5,500
14,960
7,560
7,400
10,540
5,040
5,500
11,980
5,880
6,100
10,540
5,040
5,500
14,960
7,560
7,400
12,540
7,140
5,400
26615
26641
26645
26650
26665
26670
26676
26685
26686
26700
26706
26715
26720
Percutaneous skeletal fixation of carpometacarpal fracture dislocation,
thumb (Bennett fracture), w/ manipulation, w/ or w/o external fixation
Open treatment of carpometacarpal fracture dislocation, thumb (Bennett
fracture), w/ or w/o internal or external fixation
Closed treatment of carpometacarpal dislocation, other than thumb
(Bennett fracture); single
Percutaneous skeletal fixation of carpometacarpal dislocation, other than
thumb (Bennett fracture), single, w/ manipulation
Open treatment of carpometacarpal dislocation, other than thumb (Bennett
fracture); single, w/ or w/o Open treatment of carpometacarpal dislocation,
other than thumb (Bennett fracture); single, internal or external fixation
Open treatment of carpometacarpal dislocation, other than thumb (Bennett
fracture); single, complex, multiple or delayed reduction
Closed treatment of metacarpophalangeal dislocation, single
Percutaneous skeletal fixation of metacarpophalangeal dislocation, single,
w/ manipulation
Open treatment of metacarpophalangeal dislocation, single, w/ or w/o
internal or external fixation
Closed treatment of phalangeal shaft fracture, proximal or middle phalanx,
finger or thumb
10,120
4,620
5,500
26727
Percutaneous skeletal fixation of unstable phalangeal shaft fracture,
proximal or middle phalanx, finger or thumb, w/ manipulation, each
14,960
7,560
7,400
26735
Open treatment of phalangeal shaft fracture, proximal or middle phalanx,
finger or thumb, w/ or w/o internal or external fixation, each
14,960
7,560
7,400
26740
Closed treatment of articular fracture, involving metacarpophalangeal or
interphalangeal joint
10,120
4,620
5,500
26746
Open treatment of articular fracture, involving metacarpophalangeal or
interphalangeal joint, w/ or w/o internal or external fixation, each
12,540
7,140
5,400
Closed treatment of distal phalangeal fracture, finger or thumb
Percutaneous skeletal fixation of distal phalangeal fracture, finger or thumb,
each
Open treatment of distal phalangeal fracture, finger or thumb, w/ or w/o
internal or external fixation, each
Closed treatment of interphalangeal joint dislocation, single
Percutaneous skeletal fixation of interphalangeal joint dislocation, single, w/
manipulation
Open treatment of interphalangeal joint dislocation, w/ or w/o internal or
external fixation, single
10,120
4,620
5,500
14,960
7,560
7,400
12,120
6,720
5,400
10,880
3,780
7,100
12,540
7,140
5,400
12,540
7,140
5,400
26820
Fusion in opposition, thumb, w/ autogenous graft (includes obtaining graft)
21,820
10,920
10,900
26841
Arthrodesis, carpometacarpal joint, thumb, w/ or w/o internal fixation;
20,980
10,080
10,900
20,980
10,080
10,900
21,940
9,240
12,700
20,980
10,080
10,900
20,980
10,080
10,900
21,820
10,920
10,900
20,980
10,080
10,900
21,820
10,920
10,900
12,120
6,720
5,400
11,980
5,880
6,100
26750
26756
26765
26770
26776
26785
26842
26843
26844
26850
26852
26860
26862
26910
26951
Arthrodesis, carpometacarpal joint, thumb, w/ or w/o internal fixation; w/
autograft (includes obtaining graft)
Arthrodesis, carpometacarpal joint, digits, other than thumb;
Arthrodesis, carpometacarpal joint, digits, other than thumb; w/ autograft
(includes obtaining graft)
Arthrodesis, metacarpophalangeal joint, w/ or w/o internal fixation;
Arthrodesis, metacarpophalangeal joint, w/ or w/o internal fixation; w/
autograft (includes obtaining graft)
Arthrodesis, interphalangeal joint, w/ or w/o internal fixation;
Arthrodesis, interphalangeal joint, w/ or w/o internal fixation; w/ autograft
(includes obtaining graft)
Amputation, metacarpal, w/ finger or thumb (ray amputation), single, w/ or
w/o interosseous transfer
Amputation, finger or thumb, primary or secondary, any joint or phalanx,
single, including neurectomies; w/ direct closure
26952
Amputation, finger or thumb, primary or secondary, any joint or phalanx,
single, including neurectomies; w/ local advancement flaps (V-Y, hood)
21,940
9,240
12,700
26990
Incision and drainage, pelvis or hip joint area; deep abscess or hematoma
12,120
6,720
5,400
26991
Incision and drainage, pelvis or hip joint area; infected bursa
12,120
6,720
5,400
Page 22 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
26992
27000
27001
27003
27005
27006
27025
27030
27033
27035
DESCRIPTION
Case Rate
Incision, deep, w/ opening of bone cortex (e.g., for osteomyelitis or bone
abscess), pelvis and/or hip joint
Tenotomy, adductor of hip, subcutaneous, closed
Tenotomy, adductor of hip, subcutaneous, open
Tenotomy, adductor, subcutaneous, open, w/ obturator neurectomy
Tenotomy, iliopsoas, open
Tenotomy, abductors of hip, open
Fasciotomy, hip or thigh, any type
Arthrotomy, hip, for infection, w/ drainage
Arthrotomy, hip, w/ exploration or removal of loose or foreign body
Hip joint denervation, intrapelvic or extrapelvic intra-articular branches of
sciatic, femoral, or obturator nerves
Professional Fee
Health Care
Institution Fee
23,300
12,600
10,700
12,120
14,960
30,740
23,300
23,300
21,820
30,740
30,740
6,720
7,560
13,440
12,600
12,600
10,920
13,440
13,440
5,400
7,400
17,300
10,700
10,700
10,900
17,300
17,300
30,300
16,800
13,500
37,800
21,000
16,800
27036
Capsulectomy or capsulotomy of hip, w/ or w/o excision of heterotopic
bone, w/ release of hip flexor muscles (ie, gluteus medius, gluteus minimus,
tensor fascia latae, rectus femoris, sartorius, iliopsoas)
27040
27047
Biopsy, soft tissue of pelvis and hip area
Excision, tumor, pelvis and hip area; subcutaneous
3,504
5,680
504
1,680
3,000
4,000
27048
Excision, tumor, pelvis and hip area; deep, subfascial, intramuscular
8,260
3,360
4,900
37,800
21,000
16,800
27,960
37,180
31,140
27,120
27,120
15,960
18,480
17,640
15,120
15,120
12,000
18,700
13,500
12,000
12,000
27,960
15,960
12,000
30,300
16,800
13,500
31,140
17,640
13,500
46,500
25,200
21,300
46,500
25,200
21,300
38,860
20,160
18,700
38,860
20,160
18,700
37,180
18,480
18,700
31,140
17,640
13,500
31,560
18,060
13,500
15,380
14,960
30,300
7,980
7,560
16,800
7,400
7,400
13,500
38,020
19,320
18,700
22,660
23,300
11,760
12,600
10,900
10,700
30,740
13,440
17,300
27049
27050
27052
27054
27060
27062
27065
27066
27067
27070
27071
27075
27076
27077
27078
27079
27080
27086
27090
27091
27097
27098
27100
Radical resection of tumor (e.g., malignant neoplasm), soft tissue of pelvis
and hip area
Arthrotomy, w/ biopsy; sacroiliac joint
Arthrotomy, w/ biopsy; hip joint
Arthrotomy w/ 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) w/ or w/o autograft
Excision of bone cyst or benign tumor; deep, w/ or w/o autograft
Excision of bone cyst or benign tumor; w/ autograft requiring separate
incision
Partial excision (craterization, saucerization) (e.g., for osteomyelitis);
superficial (e.g., wing of ilium, symphysis pubis or greater trochanter of
femur)
Partial excision (craterization, saucerization) (e.g., for osteomyelitis); deep
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, w/ skin flaps
Coccygectomy, primary
Removal of foreign body, pelvis or hip
Removal of hip prosthesis;
Removal of hip prosthesis; complicated, including "total hip" and
methlmethacrylate, when applicable
Hamstring recession, proximal
Adductor transfer to ischium
Transfer external oblique muscle to greater trochanter including fascial or
tendon extension (graft)
27105
Transfer paraspinal muscle to hip (includes fascial or tendon extension graft)
30,740
13,440
17,300
27110
27111
27120
27122
30,740
30,740
37,180
37,180
13,440
13,440
18,480
18,480
17,300
17,300
18,700
18,700
37,180
18,480
18,700
53,400
29,400
24,000
55,080
31,080
24,000
55,000
33,600
21,400
38,640
21,840
16,800
38,640
21,840
16,800
27140
27146
Transfer iliopsoas; to greater trochanter
Transfer iliopsoas; to femoral neck
Acetabuloplasty; (e.g., Whitman, Colonna, Haygroves, or cup type)
Acetabuloplasty; resection femoral head (Girdlestone procedure)
Partial hip replacement, prosthesis (e.g., femoral stem prosthesis, bipolar
arthroplasty)
Arthroplasty, acetabular and proximal femoral prosthetic replacement (total
hip replacement), w/ or w/o autograft or allograft
Conversion of previous hip surgery to total hip replacement, w/ or w/o
autograft or allograft
Revision of total hip arthroplasty; both components, w/ or w/o autograft or
allograft
Revision of total hip arthroplasty; acetabular component only, w/ or w/o
autograft or allograft
Revision of total hip arthroplasty; femoral component only, w/ or w/o
allograft
Osteotomy and transfer of greater trochanter
Osteotomy , iliac, acetabular or innominate bone;
27,960
30,300
15,960
16,800
12,000
13,500
27147
Osteotomy , iliac, acetabular or innominate bone; w/ open reduction of hip
31,140
17,640
13,500
27125
27130
27132
27134
27137
27138
Page 23 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
27151
DESCRIPTION
Case Rate
Osteotomy , iliac, acetabular or innominate bone; w/ femoral osteotomy
27175
Osteotomy , iliac, acetabular or innominate bone; w/ femoral osteotomy
and w/ open reduction of hip
Osteotomy, pelvis, bilateral (e.g., for congenital malformation)
Osteotomy, femoral neck
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, w/o reduction
27176
Treatment of slipped femoral epiphysis; by single or multiple pinning, in situ
27156
27158
27161
27165
27170
27177
27178
27179
27181
27185
27187
Open treatment of slipped femoral epiphysis; single of multiple pinning or
bone graft (includes obtaining graft)
Open treatment of slipped femoral epiphysis; closed manipulation w/ 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
Prophylactic treatment (nailing, pinning, plating, or wiring) w/ or w/o
methylmethacrylate, femoral neck and proximal femur
Professional Fee
Health Care
Institution Fee
37,180
18,480
18,700
38,020
19,320
18,700
37,800
31,140
21,000
17,640
16,800
13,500
37,180
18,480
18,700
31,140
17,640
13,500
23,300
12,600
10,700
30,300
16,800
13,500
31,140
17,640
13,500
31,140
17,640
13,500
31,140
17,640
13,500
37,180
18,480
18,700
27,960
15,960
12,000
31,140
17,640
13,500
27193
Closed treatment of pelvic ring fracture, dislocation, diastasis or subluxation
27,960
15,960
12,000
27200
27202
Closed treatment of coccygeal fracture
Open treatment of coccygeal fracture
Open treatment of iliac spine(s), tuberosity avulsion, or iliac wing fracture(s)
(e.g., pelvic fracture(s) w/c do not disrupt the pelvic ring), w/ 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 w/ internal
fixation (includes pubic symphysis and/or rami)
Open treatment of posterior ring fracture and/or dislocation w/ internal
fixation (includes ilium, sacroiliac joint and/or sacrum)
Closed treatment of acetabulum (hip socket) fracture(s)
Open treatment of posterior or anterior acetabular wall fracture, w/
internal fixation
Open treatment of acetabular fracture(s) involving anterior or posterior
(one) column, or a fracture running transversely across the acetabulum, w/
internal fixation
Open treatment of acetabular fracture(s) involving anterior and posterior
(two) columns, includes T-fracture and both column fracture w/ complete
articular detachment, or single column or transverse fracture w/ associated
acetabular wall fracture, w/ inte
Closed treatment of femoral fracture, proximal end, neck
Percutaneous skeletal fixation of femoral fracture, proximal end, neck,
undisplaced, mildly displaced, or impacted fracture
Open treatment of femoral fracture, proximal end, neck, internal fixation or
prosthetic replacement (direct fracture exposure)
Closed treatment of intertrochanteric, pertrochanteric, or subtrochanteric
femoral fracture
14,960
22,660
7,560
11,760
7,400
10,900
37,800
21,000
16,800
40,320
23,520
16,800
46,500
25,200
21,300
46,500
25,200
21,300
30,740
13,440
17,300
38,640
21,840
16,800
40,320
23,520
16,800
46,500
25,200
21,300
23,300
12,600
10,700
46,500
25,200
21,300
46,500
25,200
21,300
23,300
12,600
10,700
46,500
25,200
21,300
31,140
17,640
13,500
23,300
12,600
10,700
27,120
15,120
12,000
23,300
37,180
12,600
18,480
10,700
18,700
40,320
23,520
16,800
30,300
16,800
13,500
37,180
18,480
18,700
18,000
37,800
27,960
37,800
8,400
21,000
15,960
21,000
9,600
16,800
12,000
16,800
27215
27216
27217
27218
27220
27226
27227
27228
27230
27235
27236
27238
27244
27245
27246
27248
27250
27253
27254
27258
27259
27265
27280
27282
27284
Open treatment of intertrochanteric, pertrochanteric, or subtrochanteric
femoral fracture; w/ plate/screw type implant, w/ or w/o cerclage
Open treatment of intertrochanteric, pertrochanteric, or subtrochanteric
femoral fracture; w/ intramedullary implant, w/ or w/o interlocking screws
and/or cerclage
Closed treatment of greater trochanteric fracture
Open treatment of greater trochanteric fracture, w/ or w/o internal or
external fixation
Closed treatment of hip dislocation, traumatic
Open treatment of hip dislocation, traumatic, w/o internal fixation
Open treatment of hip dislocation, traumatic w/ acetabular wall and
femoral head fracture, w/ or w/o internal or external fixation
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); w/ femoral shaft shortening
Closed treatment of post hip arthroplasty dislocation
Arthrodesis, sacroiliac joint (including obtaining graft)
Arthrodesis, symphysis pubis (including obtaining graft)
Arthrodesis, hip joint (includes obtaining graft);
Page 24 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
DESCRIPTION
Case Rate
27315
27320
27323
27327
Arthrodesis, hip joint (includes obtaining graft); w/ subtrochanteric
osteotomy
Interpelviabdominal amputation (hindquarter amputation)
Disarticulation of hip
Incision and drainage of deep abscess, infected bursa, or hematoma, thigh
or knee region
Incision, deep, w/ opening of bone cortex (e.g., for osteomyelitis or bone
abscess), femur or knee
Fasciotomy, iliotibial (tenotomy), open
Tenotomy, subcutaneous, closed, adductor or hamstring; single
Tenotomy, subcutaneous, closed, adductor or hamstring; multiple
Arthrotomy, knee, for infection, w/ exploration, drainage or removal of
foreign body
Neurectomy, hamstring muscle
Neurectomy, popliteal (gastrocnemius)
Biopsy, soft tissue of thigh or knee area
Excision, tumor, thigh or knee area; subcutaneous
27328
Excision, tumor, thigh or knee area; deep, subfascial, or intramuscular
27286
27290
27295
27301
27303
27305
27306
27307
27310
27340
27345
27350
27355
Radical resection of tumor (e.g., malignant neoplasm), soft tissue of thigh or
knee area
Arthrotomy, knee; w/ synovial biopsy only
Arthrotomy, knee; w/ joint exploration, w/ or w/o biopsy, w/ or w/o
removal of loose or foreign bodies
Arthrotomy, knee, w/ excision of semilunar cartilage (meniscectomy);
medial or lateral
Arthrotomy, knee, w/ excision of semilunar cartilage (meniscectomy);
medial and lateral
Arthrotomy, knee, w/ synovectomy; anterior or posterior
Arthrotomy, knee, w/ synovectomy; anterior and posterior including
popliteal area
Excision, prepatellar bursa
Excision of synovial cyst of popliteal space (Bakers cyst)
Patellectomy or hemipatellectomy
Excision or curettage of bone cyst or benign tumor of femur;
27356
Excision or curettage of bone cyst or benign tumor of femur; w/ allograft
27329
27330
27331
27332
27333
27334
27335
Professional Fee
Health Care
Institution Fee
40,320
23,520
16,800
46,500
30,300
25,200
16,800
21,300
13,500
8,260
3,360
4,900
23,300
12,600
10,700
18,000
18,000
21,820
8,400
8,400
10,920
9,600
9,600
10,900
27,120
15,120
12,000
23,300
23,300
3,504
5,680
12,600
12,600
504
1,680
10,700
10,700
3,000
4,000
8,020
2,520
5,500
27,120
15,120
12,000
20,980
10,080
10,900
23,300
12,600
10,700
31,580
14,280
17,300
27,960
15,960
12,000
13,152
6,552
6,600
23,300
12,600
10,700
14,960
20,980
30,740
22,240
7,560
10,080
13,440
11,340
7,400
10,900
17,300
10,900
23,720
13,020
10,700
23,720
13,020
10,700
27,120
15,120
12,000
23,720
13,020
10,700
27,120
18,000
23,300
15,120
8,400
12,600
12,000
9,600
10,700
27,120
15,120
12,000
32,000
14,700
17,300
27,120
15,120
12,000
18,000
21,940
20,980
23,300
21,940
20,980
23,300
22,360
8,400
9,240
10,080
12,600
9,240
10,080
12,600
9,660
9,600
12,700
10,900
10,700
12,700
10,900
10,700
12,700
27390
27391
27392
27393
27394
27395
27396
27397
Excision or curettage of bone cyst or benign tumor of femur; w/ autograft
(includes obtaining graft)
Excision or curettage of bone cyst or benign tumor of femur; w/ internal
fixation
Partial excision (craterization, saucerization, or diaphysectomy) of bone
(e.g., for osteomyelitis), femur, proximal tibia and/or fibula
Radical resection of tumor, bone, femur or knee
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
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
Tenotomy, open, hamstring, knee to hip; multiple, one leg
Tenotomy, open, hamstring, knee to hip; multiple, bilateral
Lengthening of hamstring tendon; single
Lengthening of hamstring tendon; multiple, one leg
Lengthening of hamstring tendon; multiple, bilateral
Transplant, hamstring tendon to patella; single
Transplant, hamstring tendon to patella; multiple
27400
Tendon or muscle transfer, hamstrings to femur (e.g.gers type procedure)
23,300
12,600
10,700
27403
27405
27407
27,960
27,120
30,300
15,960
15,120
16,800
12,000
12,000
13,500
37,800
21,000
16,800
27418
Arthrotomy w/ open meniscus repair
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
Anterior tibial tubercleplasty (e.g., for chondromalacia patellae)
22,660
11,760
10,900
27420
Reconstruction for recurrent dislocating patella; (Hauser type procedure)
23,080
12,180
10,900
30,740
13,440
17,300
30,740
21,820
30,300
13,440
10,920
16,800
17,300
10,900
13,500
31,140
17,640
13,500
27357
27358
27360
27365
27372
27380
27381
27385
27386
27409
27424
27425
27427
Reconstruction for recurrent dislocating patella; w/ extensor realignment
and/or muscle advancement or release (Campbell, Goldwaite type
procedure)
Reconstruction for recurrent dislocating patella; w/ patellectomy
Lateral retinacular release (any method)
Ligamentous reconstruction (augmentation), knee; extra-articular
27428
Ligamentous reconstruction (augmentation), knee; intra-articular (open)
27422
Page 25 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
DESCRIPTION
Case Rate
27430
27435
27437
27438
27440
Ligamentous reconstruction (augmentation), knee; intra-articular (open)
and extra-articular
Quadricepsplasty (Bennett or Thompson type)
Capsulotomy, knee, posterior capsular release
Arthroplasty, patella; w/o prosthesis
Arthroplasty, patella; w/ prosthesis
Arthroplasty, knee, tibial plateau;
27441
27442
27429
Professional Fee
Health Care
Institution Fee
37,180
18,480
18,700
27,120
30,740
30,740
31,140
37,800
15,120
13,440
13,440
17,640
21,000
12,000
17,300
17,300
13,500
16,800
Arthroplasty, knee, tibial plateau; w/ debridement and partial synovectomy
38,640
21,840
16,800
38,640
21,840
16,800
39,480
22,680
16,800
27445
Arthroplasty, knee, femoral condyles or tibial plateaus;
Arthroplasty, knee, femoral condyles or tibial plateaus; w/ debridement and
partial synovectomy
Arthroplasty, knee, constrained prosthesis (e.g., Walldius type)
46,500
25,200
21,300
27446
Arthroplasty, knee, condyle and plateau; medial or lateral compartment
39,480
22,680
16,800
27447
Arthroplasty, knee, condyle and plateau; medial and lateral compartments
w/ or w/o patella resurfacing ("total knee replacement")
40,320
23,520
16,800
18,420
23,300
8,820
12,600
9,600
10,700
27,120
15,120
12,000
27,120
15,120
12,000
27,120
15,120
12,000
27,120
27,120
15,120
15,120
12,000
12,000
37,180
18,480
18,700
31,580
14,280
17,300
27,960
15,960
12,000
27475
Osteotomy, femur, shaft or supracondylar; w/o fixation
Osteotomy, femur, shaft or supracondylar; w/ fixation
Osteotomy, multiple, femoral shaft, w/ realignment on intramedullary rod
(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 w/ femoral
segment transfer
Repair, nonunion or malunion, femur, distal to head and neck; w/o graft
(e.g., compression technique)
Repair, nonunion or malunion, femur, distal to head and neck; w/ iliac or
other autogenous bone graft (includes obtaining graft)
Epiphyseal arrest by epiphysiodesis or stapling; distal femur
30,740
13,440
17,300
27477
Epiphyseal arrest by epiphysiodesis or stapling; tibia and fibula, proximal
23,300
12,600
10,700
27,120
15,120
12,000
30,740
13,440
17,300
27443
27448
27450
27454
27455
27457
27465
27466
27468
27470
27472
27479
27485
Epiphyseal arrest by epiphysiodesis or stapling; combined distal femur,
proximal tibia and fibula
Arrest, hemiepiphyseal, distal femur or proximal leg (e.g., for genu varus or
valgus)
27486
Revision of total knee arthroplasty, w/ or w/o allograft; one component
53,400
29,400
24,000
27487
Revision of total knee arthroplasty, w/ or w/o allograft; all components
55,000
33,600
21,400
37,180
18,480
18,700
30,740
13,440
17,300
20,980
10,080
10,900
27488
27495
27496
Removal of knee prosthesis, including "total knee" methylmethacrylate and
insertion of spacer, when applicable
Prophylactic treatment (nailing, pinning, plating or writing) w/ or w/o
methylmethacrylate, femur
Decompression fasciotomy, thigh and/or knee, one compartment (flexor or
extensor or adductor);
27497
Decompression fasciotomy, thigh and/or knee, one compartment (flexor or
extensor or adductor); w/ debridement of nonviable muscle and/or nerve
21,820
10,920
10,900
27498
Decompression fasciotomy, thigh and/or knee, multiple compartments;
21,820
10,920
10,900
23,300
12,600
10,700
14,960
7,560
7,400
18,420
8,820
9,600
18,420
8,820
9,600
30,740
13,440
17,300
30,740
13,440
17,300
37,180
18,480
18,700
27499
27501
27502
27503
27506
27507
27509
Decompression fasciotomy, thigh and/or knee, multiple compartments; w/
debridement of nonviable muscle and/or nerve
Closed treatment of supracondylar or transcondylar femoral fracture w/ or
w/o intercondylar extension
Closed treatment of femoral shaft fracture, w/ or w/o skin or skeletal
traction
Closed treatment of supracondylar or transcondylar femoral fracture w/ or
w/o intercondylar extension, w/ or w/o skin or skeletal traction
Open treatment of femoral shaft fracture, w/ or w/o external fixation, w/
insertion of intramedullary implant, w/ or w/o cerclage and/or locking
screws
Open treatment of femoral shaft fracture w/ plate/screws, w/ or w/o
cerclage
Percutaneous skeletal fixation of femoral fracture, distal end, medial or
lateral condyle, or supracondylar or transcondylar, w/ or w/o intercondylar
extension, or distal femoral epiphyseal separation
Page 26 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
27510
27511
27513
27514
27516
27519
27520
27524
27530
27535
27536
27538
27540
27550
DESCRIPTION
Case Rate
Closed treatment of femoral fracture, distal end, medial or lateral condyle
Open treatment of femoral supracondylar or transcondylar fracture w/o
intercondylar extension, w/ or w/o internal or external fixation
Open treatment of femoral supracondylar or transcondylar fracture w/
intercondylar extension, w/ or w/o internal or external fixation
Open treatment of femoral fracture, distal end, medial or lateral condyle,
w/ or w/o internal or external fixation
Closed treatment of distal femoral epiphyseal separation
Open treatment of distal femoral epiphyseal separation, w/ or w/o internal
or external fixation
Closed treatment of patellar fracture
Open treatment of patellar fracture, w/ internal fixation and/or partial or
complete patellectomy and soft tissue repair
Closed treatment of tibial fracture, proximal (plateau)
Open treatment of tibial fracture, proximal (plateau); unicondylar, w/ or
w/o internal or external fixation
Open treatment of tibial fracture, proximal (plateau); bicondylar, w/ or w/o
internal fixation
Closed treatment of intercondylar spine(s) and/or tuberosity fracture(s) of
knee
Open treatment of intercondylar spine(s) and/or tuberosity fracture(s) of
the knee, w/ or w/o internal or external fixation
Closed treatment of knee dislocation
Professional Fee
Health Care
Institution Fee
18,420
8,820
9,600
37,180
18,480
18,700
37,800
21,000
16,800
30,740
13,440
17,300
23,300
12,600
10,700
22,660
11,760
10,900
20,980
10,080
10,900
20,980
10,080
10,900
18,420
8,820
9,600
30,740
13,440
17,300
27,120
15,120
12,000
10,540
5,040
5,500
21,820
10,920
10,900
10,540
5,040
5,500
27556
Open treatment of knee dislocation, w/ or w/o internal or external fixation;
w/o primary ligamentous repair or augmentation/reconstruction
27,120
15,120
12,000
27557
Open treatment of knee dislocation, w/ or w/o internal or external fixation;
w/ primary ligamentous repair
27,960
15,960
12,000
27558
Open treatment of knee dislocation, w/ or w/o internal or external fixation;
w/ primary ligamentous repair, w/ augmentation/reconstruction
37,800
21,000
16,800
Closed treatment of patellar dislocation
Open treatment of patellar dislocation, w/ or w/o partial or total
patellectomy
Fusion of knee, any technique
Amputation, thigh, through femur, any level;
Amputation, thigh, through femur, any level; immediate fitting technique
including first cast
20,980
10,080
10,900
27,120
15,120
12,000
30,740
30,300
13,440
16,800
17,300
13,500
23,300
12,600
10,700
Amputation, thigh, through femur, any level; open, circular (guillotine)
23,300
12,600
10,700
27560
27566
27580
27590
27591
27592
27596
27598
Amputation, thigh, through femur, any level; secondary closure or scar
revision
Amputation, thigh, through femur, any level; re-amputaion
Disarticulation at knee
27600
27601
27594
27602
27603
27604
27605
27606
27607
27610
27612
27613
27615
27618
27619
27620
27625
27626
27630
27635
27637
27638
11,980
5,880
6,100
22,660
27,120
11,760
15,120
10,900
12,000
Decompression fasciotomy, leg; anterior and/or lateral compartments only
8,020
2,520
5,500
Decompression fasciotomy, leg; posterior compartments(s) only
Decompression fasciotomy, leg; anterior and/or lateral, and posterior
compartment(s)
Incision and drainage, leg or ankle; deep abscess or hematoma
Incision and drainage, leg or ankle; infected bursa
Tenotomy, Achilles tendon, subcutaneous ; local anesthesia;
Tenotomy, Achilles tendon, subcutaneous ; local anesthesia; general
anesthesia
Incision, deep, w/ opening of bone cortex (e.g., for osteomyelitis or bone
abscess), leg or ankle
Arthrotomy, ankle, for infection, w/ exploration, drainage, or removal of
foreign body
Arthrotomy, ankle, posterior capsular release, w/ or w/o Achilles tendon
lengthening
Biopsy, soft tissue of leg or ankle area
Radical resection of tumor (e.g., malignant neoplasm), soft tissue of leg or
ankle area
Excision, tumor, leg or ankle area; subcutaneous
Excision, tumor, leg or ankle area; deep, subfascial or intramuscular
Arthrotomy, ankle, w/ joint exploration, w/ or w/o biopsy, w/ or w/o
removal of loose or foreign body
Arthrotomy, ankle, w/ synovectomy;
Arthrotomy, ankle, w/ synovectomy; including tenosynovectomy
Excision of lesion of tendon sheath or capsule (e.g., 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; w/
autograft(includes obtaining graft)
Excision or curettage of bone cyst or benign tumor, tibia or fibula; w/
allograft
8,020
2,520
5,500
8,260
3,360
4,900
4,108
5,680
12,540
1,008
1,680
7,140
3,100
4,000
5,400
18,420
8,820
9,600
20,980
10,080
10,900
21,940
9,240
12,700
22,660
11,760
10,900
3,504
504
3,000
20,980
10,080
10,900
5,680
8,020
1,680
2,520
4,000
5,500
12,900
6,300
6,600
18,420
21,940
8,820
9,240
9,600
12,700
4,000
Page 27 of 98
5,680
1,680
14,960
7,560
7,400
21,940
9,240
12,700
21,940
9,240
12,700
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
27654
27656
Partial excision (craterization, saucerization, or diaphysectomy) of bone
(e.g., for osteomyelitis or exostosis); tibia
Partial excision (craterization, saucerization, or diaphysectomy) of bone
(e.g., for osteomyelitis or exostosis); fibula
Radical resection of tumor, bone; tibia
Radical resection of tumor, bone; fibula
Radical resection of tumor, bone; talus or calcaneus
Repair, primary, open or percutaneous, ruptured Achilles tendon;
Repair, primary, open or percutaneous, ruptured Achilles tendon; w/ graft
(includes obtaining graft)
Repair, secondary, ruptured Achilles tendon, w/ or w/o graft
Repair, fascial defect of leg
27658
Repair or suture of flexor tendon of leg; primary, w/o graft, single, each
15,380
7,980
7,400
27659
Repair or suture of flexor tendon of leg; secondary w/ or w/o graft, single
tendon, each
18,000
8,400
9,600
27664
Repair or suture of extensor tendon of leg; primary, w/o graft, single, each
15,380
7,980
7,400
18,000
8,400
9,600
18,000
22,360
18,000
8,400
9,660
8,400
9,600
12,700
9,600
21,940
9,240
12,700
18,000
8,400
9,600
18,000
8,400
9,600
14,960
7,560
7,400
18,420
8,820
9,600
15,380
7,980
7,400
18,000
8,400
9,600
23,300
12,600
10,700
27640
27641
27645
27646
27647
27650
27652
27665
27675
27676
27680
27681
27685
27686
27687
27690
27692
27695
27696
27698
27700
27702
27703
27704
27705
27707
27709
27712
27715
27720
27722
27724
Repair or suture of extensor tendon of leg; secondary w/ or w/o graft, single
tendon, each
Repair for dislocating peroneal tendons; w/o fibular osteotomy
Repair for dislocating peroneal tendons; w/ fibular osteotomy
Tenolysis, including tibia, fibula, and ankle flexor; single
Tenolysis, including tibia, fibula, and ankle flexor; multiple (through same
incision), each
Lengthening or shortening of tendon, leg or ankle; single
Lengthening or shortening of tendon, leg or ankle; multiple (through same
incision), each
Gastrocnemius recession (e.g., Strayer procedure)
Transfer or transplant of single tendon (w/ muscle redirection or rerouting);
superficial (e.g., anterior tibial extensors into midfoot)
Transfer or transplant of single tendon (w/ muscle redirection or rerouting);
each additional tendon
Suture, primary, torn, ruptured or severed ligament, ankle; collateral
Suture, primary, torn, ruptured or severed ligament, ankle; both collateral
ligaments
Suture, secondary repair, torn, ruptured or severed ligament, ankle,
collateral (Watson-Jones procedure)
Arthroplasty, ankle;
Arthroplasty, ankle; w/ implant ("total ankle")
Arthroplasty, ankle; secondary reconstruction, total ankle
Removal of ankle implant
Osteotomy; tibia
Osteotomy; fibula
Osteotomy; tibia and fibula
Osteotomy; multiple, w/ realignment on intramedullary rod (Sofield type
procedure)
Osteoplasty, tibia and fibula, lengthening
Repair of nonunion or malunion, tibia; w/o graft, (e.g., compression
technique)
Repair of nonunion or malunion, tibia; w/ sliding graft
Repair of nonunion or malunion, tibia; w/ iliac or other autograft (includes
obtaining graft)
18,420
8,820
9,600
18,000
8,400
9,600
23,300
22,660
23,300
21,940
12,600
11,760
12,600
9,240
10,700
10,900
10,700
12,700
23,300
12,600
10,700
21,820
5,680
10,920
1,680
10,900
4,000
18,000
8,400
9,600
27,120
31,140
37,180
21,820
21,940
18,000
22,660
15,120
17,640
18,480
10,920
9,240
8,400
11,760
12,000
13,500
18,700
10,900
12,700
9,600
10,900
23,720
13,020
10,700
27,960
15,960
12,000
18,000
8,400
9,600
20,980
10,080
10,900
21,820
10,920
10,900
27725
Repair of nonunion or malunion, tibia; by synostosis, w/ fibula, any method
22,660
11,760
10,900
27727
27730
27732
Repair of congenital pseudarthrosis, tibia
Epiphyseal arrest by epiphysiodesis or stapling; distal tibia
Epiphyseal arrest by epiphysiodesis or stapling; distal fibula
23,300
21,820
20,980
12,600
10,920
10,080
10,700
10,900
10,900
27734
Epiphyseal arrest by epiphysiodesis or stapling; distal tibia and fibula
23,300
12,600
10,700
23,300
12,600
10,700
22,660
11,760
10,900
31,160
13,860
17,300
12,120
6,720
5,400
12,120
6,720
5,400
21,820
10,920
10,900
22,660
11,760
10,900
27740
27742
27745
27750
27752
27756
27758
Epiphyseal arrest by epiphysiodesis or stapling, combined, proximal and
distal tibia and fibula;
Epiphyseal arrest by epiphysiodesis or stapling, combined, proximal and
distal tibia and fibula; and distal femur
Prophylactic treatment (nailing, pinning, plating or wiring) w/ or w/o
methylmethacrylate, tibia
Closed treatment of tibial shaft fracture (w/ or w/o fibular fracture)
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 (w/ or w/o fibular
fracture) (e.g., pins or screws)
Open treatment of tibial shaft fracture (w/ or w/o fibular fracture) w/
plate/screws, w/ or w/o cerclage
27759
Open treatment of tibial shaft fracture (w/ or w/o fibular fracture) by
intramedullary implant, w/ or w/o interlocking screws and/or cerclage
27,120
15,120
12,000
27760
Closed treatment of medial malleolus fracture
10,960
5,460
5,500
Page 28 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
27766
27780
27784
27786
27792
27808
27814
27816
27822
27823
DESCRIPTION
Case Rate
Open treatment of medial malleolus fracture, w/ or w/o internal or external
fixation
Closed treatment of proximal fibula or shaft fracture
Open treatment of proximal fibula or shaft fracture, w/ or w/o internal or
external fixation
Closed treatment of distal fibular fracture (lateral malleolus)
Open treatment of distal fibular fracture (lateral malleolus), w/ or w/o
internal or external fixation w/o manipulation
Closed treatment of bimalleolar ankle fracture, (including Potts)
Open treatment of bimalleolar ankle fracture, w/ or w/o internal or external
fixation
Closed treatment of trimalleolar ankle fracture
Open treatment of trimalleolar ankle fracture, w/ or w/o internal or
external fixation, medial and/or lateral malleolus; w/o fixation of posterior
lip
Open treatment of trimalleolar ankle fracture, w/ or w/o internal or
external fixation, medial and/or lateral malleolus; w/ fixation of posterior lip
Professional Fee
Health Care
Institution Fee
12,120
6,720
10,960
5,460
5,400
5,500
22,660
11,760
10,900
10,540
5,040
5,500
20,980
10,080
10,900
12,900
6,300
6,600
23,300
12,600
10,700
23,300
12,600
10,700
23,300
12,600
10,700
23,300
12,600
10,700
10,540
5,040
5,500
20,980
10,080
10,900
21,940
9,240
12,700
21,820
10,920
10,900
20,980
10,080
10,900
10,960
5,460
5,500
11,980
5,880
6,100
10,960
5,460
5,500
22,660
11,760
10,900
23,720
13,020
10,700
18,000
21,400
30,300
8,400
10,500
16,800
9,600
10,900
13,500
30,740
13,440
17,300
18,000
8,400
9,600
27882
Closed treatment of fracture of weight bearing articular portion of distal
tibia (e.g., pilon or tibial plafond)
Open treatment of fracture of weight bearing articular surface/portion of
distal tibia (e.g., pilon or tibial plafond), w/ internal or external fixation; of
fibula only
Open treatment of fracture of weight bearing articular surface/portion of
distal tibia (e.g., pilon or tibial plafond), w/ internal or external fixation; of
tibia only
Open treatment of fracture of weight bearing articular surface/portion of
distal tibia (e.g., pilon or tibial plafond), w/ internal or external fixation; of
both tibia and fibula
Open treatment of distal tibiofibular joint (syndesmosis) disruption, w/ or
w/o internal or external fixation
Closed treatment of proximal tibiofibular joint dislocation
Open treatment of proximal tibiofibular joint dislocation, w/ or w/o internal
or external fixation, or w/ excision of proximal fibula
Closed treatment of ankle dislocation
Open treatment of ankle dislocation, w/ or w/o percutaneous skeletal
fixation; w/o repair or internal fixation
Open treatment of ankle dislocation, w/ or w/o percutaneous skeletal
fixation; w/ repair or internal or external fixation
Arthrodesis, ankle, any method
Arthrodesis, tibiofibular joint, proximal or distal
Amputation, leg, through tibia and fibula;
Amputation, leg, through tibia and fibula; w/ immediate fitting technique
including application of first cast
Amputation, leg, through tibia and fibula; open, circular (guillotine)
27884
Amputation, leg, through tibia and fibula; secondary closure or scar revision
12,120
6,720
5,400
27886
Amputation, leg, through tibia and fibula; re-amputation
Amputation, ankle, through malleoli of tibia and fibula (Syme, Pirogoff type
procedures), w/ plastic closure and resection of nerves
Ankle disarticulation
23,300
12,600
10,700
23,300
12,600
10,700
21,940
9,240
12,700
27892
Decompression fasciotomy, leg; anterior and/or lateral compartments only,
w/ debridement of nonviable muscle and/or nerve
18,000
8,400
9,600
27893
Decompression fasciotomy, leg; posterior compartment(s) only, w/
debridement of nonviable muscle and/or nerve
18,000
8,400
9,600
27894
Decompression fasciotomy, leg; anterior and/or lateral, and posterior
compartment(s), w/ debridement of nonviable muscle and/or nerve
18,420
8,820
9,600
5,680
1,680
4,000
8,260
3,360
4,900
9,700
4,200
5,500
10,540
5,040
5,500
12,120
8,260
10,540
6,720
3,360
5,040
5,400
4,900
5,500
12,900
6,300
6,600
8,260
3,360
4,900
8,260
3,360
4,900
11,132
4,032
7,100
27824
27826
27827
27828
27829
27830
27832
27840
27846
27848
27870
27871
27880
27881
27888
27889
28001
28002
28003
28005
28008
28010
28011
28020
28022
28024
28030
Incision and drainage, infected bursa, foot
Deep dissection below fascia, for deep infection of foot, w/ or w/o tendon
sheath involvement; single bursal space, specify;
Deep dissection below fascia, for deep infection of foot, w/ or w/o tendon
sheath involvement; single bursal space, specify; multiple areas
Incision, deep, w/ opening of bone cortex (e.g. for osteomyelitis or bone
abscess), foot
Fasciotomy, foot and/or toe
Tenotomy, subcutaneous, toe; single
Tenotomy, subcutaneous, toe; multiple
Arthrotomy, w/ exploration, drainage, or removal of loose or foreign body;
intertarsal or tarsometatarsal joint
Arthrotomy, w/ exploration, drainage, or removal of loose or foreign body;
metatarsophalangeal joint
Arthrotomy, w/ exploration, drainage, or removal of loose or foreign body;
interphalangeal joint
Neurectomy of intrinsic musculature of foot
Page 29 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
DESCRIPTION
28035
28043
28045
Tarsal tunnel release (posterior tibial nerve decompression)
Excision, tumor, foot; subcutaneous
Excision, tumor, foot; deep, subfascial, intramuscular
18,000
5,680
8,020
8,400
1,680
2,520
Health Care
Institution Fee
9,600
4,000
5,500
28046
Radical resection of tumor (e.g., malignant neoplasm), soft tissue of foot
37,800
21,000
16,800
28050
28052
28054
28060
28062
28070
28072
28080
28086
28088
Arthrotomy for synovial biopsy; intertarsal or tarsometatarsal joint
Arthrotomy for synovial biopsy; metatarsophalangeal joint
Arthrotomy for synovial biopsy; interphalangeal joint
Fasciectomy, excision of plantar fascia; partial
Fasciectomy, excision of plantar fascia; radical
Synovectomy; intertarsal or tarsometatarsal joint, each
Synovectomy; metatarsophalangeal joint, each
Excision of interdigital (Morton) neuroma, single, each
Synovectomy, tendon sheath, foot; flexor
Synovectomy, tendon sheath, foot; extensor
Excision of lesion of tendon or fibrous sheath or capsule (including
synovectomy) (cyst or ganglion); foot
Excision of lesion of tendon or fibrous sheath or capsule (including
synovectomy) (cyst or ganglion); toes
10,120
10,120
9,700
9,700
10,960
11,980
10,960
5,680
10,960
10,960
4,620
4,620
4,200
4,200
5,460
5,880
5,460
1,680
5,460
5,460
5,500
5,500
5,500
5,500
5,500
6,100
5,500
4,000
5,500
5,500
8,440
2,940
5,500
8,260
3,360
4,900
Excision or curettage of bone cyst or benign tumor, talus or calcaneus;
15,380
7,980
7,400
21,940
9,240
12,700
21,940
9,240
12,700
15,380
7,980
7,400
21,940
9,240
12,700
21,940
9,240
12,700
14,960
21,940
18,420
7,560
9,240
8,820
7,400
12,700
9,600
18,420
8,820
9,600
18,000
8,400
9,600
20,980
10,080
10,900
15,380
15,380
14,960
7,980
7,980
7,560
7,400
7,400
7,400
21,940
9,240
12,700
18,000
8,400
9,600
18,000
8,400
9,600
28126
28130
28140
28150
28153
Ostectomy, excision of tarsal coalition
Ostectomy, calcaneus;
Ostectomy, calcaneus; for spur, w/ or w/o plantar fascial release
Partial excision (craterization, saucerization, sequestrectomy, or
diaphysectomy) of bone (e.g., for osteomyelitis or talar bossing); talus or
calcaneus
Partial excision (craterization, saucerization, or diaphysectomy) of bone
(e.g., for osteomyelitis or tarsal bossing), tarsal or metatarsal bone, except
talus or calcaneus
Partial excision (craterization, saucerization, or diaphysectomy) of bone
(e.g., for osteomyelitis or dorsal bossing), phalanx of toe
Resection, partial or complete, phalangeal base, single toe, each
Talectomy (astragalectomy)
Metatarsectomy
Phalangectomy of toe, single, each
Resection, head of phalanx, toe
12,540
22,660
18,000
12,120
12,120
7,140
11,760
8,400
6,720
6,720
5,400
10,900
9,600
5,400
5,400
28160
Hemiphalangectomy or interphalangeal joint excision, toe, single, each
10,540
5,040
5,500
28171
28173
28175
Radical resection of tumor, bone; tarsal (except talus or calcaneus)
Radical resection of tumor, bone; metatarsal
Radical resection of tumor, bone; phalanx of toe
Repair or suture of tendon, foot, flexor, single; primary or secondary, w/o
free graft, each tendon
Repair or suture of tendon, foot, flexor, single; secondary w/ free graft, each
tendon (includes obtaining graft)
Repair or suture of tendon, foot, extensor, single; primary or secondary,
each tendon
Repair or suture of tendon, foot, extensor, single; secondary w/ free graft,
each tendon (includes obtaining graft)
Tenolysis, flexor, foot; single
Tenolysis, flexor, foot; multiple (through same incision)
Tenolysis, extensor, foot; single
Tenolysis, extensor, foot; multiple (through same incision)
Tenotomy, open, flexor; foot, single or multiple;
Tenotomy, open, flexor; foot, single or multiple; toe, single
Tenotomy, open, extensor, foot or toe
30,740
22,660
21,940
13,440
11,760
9,240
17,300
10,900
12,700
18,000
8,400
9,600
18,000
8,400
9,600
12,540
7,140
5,400
12,540
7,140
5,400
10,880
10,960
10,880
10,960
10,960
10,880
11,132
3,780
5,460
3,780
5,460
5,460
3,780
4,032
7,100
5,500
7,100
5,500
5,500
7,100
7,100
28090
28092
28100
28102
28103
28104
28106
28107
28108
28110
28111
28112
28113
28114
28116
28118
28119
28120
28122
28124
28200
28202
28208
28210
28220
28222
28225
28226
28230
28232
28234
Case Rate
Excision or curettage of bone cyst or benign tumor, talus or calcaneus; w/
iliac or other autograft (includes obtaining graft)
Excision or curettage of bone cyst or benign tumor, talus or calcaneus; w/
allograft
Excision or curettage of bone cyst or benign tumor, talus or metatarsal
bones, except tarsal or calcaneus;
Excision or curettage of bone cyst or benign tumor, talus or metatarsal
bones, except tarsal or calcaneus; w/ iliac or other autograft (includes
obtaining graft)
Excision or curettage of bone cyst or benign tumor, talus or metatarsal
bones, except tarsal or calcaneus; w/ allograft
Excision or curettage of bone cyst or benign tumor, phalanges of foot
Ostectomy, partial excision, fifth metatarsal head (bunionette)
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, w/ partial proximal
phalangectomy, excluding first metatarsal (Clayton type procedure)
Page 30 of 98
Professional Fee
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
28238
DESCRIPTION
Case Rate
Advancement of posterior tibial tendon w/ excision of accessory navicular
bone (Kidner type procedure)
Tenotomy, lengthening, or release, abductor hallucis muscle
Division of plantar fascia and muscle ("Steindler stripping")
Capsulotomy, midfoot; medial release only
Capsulotomy, midfoot; w/ tendon lengthening
Professional Fee
Health Care
Institution Fee
18,420
8,820
9,600
12,540
12,540
12,540
18,000
7,140
7,140
7,140
8,400
5,400
5,400
5,400
9,600
20,980
10,080
10,900
12,120
6,720
5,400
12,120
6,720
5,400
28272
Capsulotomy, midtarsal (Heyman type procedure)
Capsulotomy; metatarsophalangeal joint, w/ or w/o tenorrhaphy, single,
each joint
Capsulotomy; interphalangeal joint, single each joint
12,900
6,300
6,600
28280
Webbing operation (create syndactylism of toes) (Kelikian type procedure)
20,980
10,080
10,900
15,380
7,980
7,400
21,940
9,240
12,700
15,380
7,980
7,400
20,980
10,080
10,900
21,820
10,920
10,900
21,820
10,920
10,900
22,660
11,760
10,900
22,660
11,760
10,900
22,660
11,760
10,900
23,080
12,180
10,900
23,080
12,180
10,900
21,400
10,500
10,900
20,980
15,380
10,080
7,980
10,900
7,400
18,420
8,820
9,600
22,360
9,660
12,700
22,360
9,660
12,700
22,360
9,660
12,700
21,940
9,240
12,700
18,420
8,820
9,600
14,960
7,560
7,400
22,360
9,660
12,700
12,540
21,940
7,140
9,240
5,400
12,700
14,960
7,560
7,400
12,120
12,540
21,940
22,360
15,380
10,960
6,720
7,140
9,240
9,660
7,980
5,460
5,400
5,400
12,700
12,700
7,400
5,500
11,980
5,880
6,100
18,000
8,400
9,600
22,360
9,660
12,700
10,960
9,700
5,460
4,200
5,500
5,500
28240
28250
28260
28261
28262
28264
28270
28285
28286
28288
28290
28292
28293
28294
28296
28297
28298
28299
28300
28302
28304
28305
28306
28307
28308
28309
Capsulotomy, midfoot; extensive, including posterior talotibial capsulotomy
and tendon(s) lengthening as for resistant clubfoot deformity
Hammertoe operation, one toe (e.g., interphalangeal fusion, filleting,
phalangectomy)
Cock-up fifth toe operation w/ plastic skin closure (Ruiz-Mora type
procedure)
Ostectomy, partial, exostectomy or condylectomy, single, metatarsal head,
first through fifth, each metatarsal head
Hallux valgus (bunion) correction, w/ or w/o sesamoidectomy; simple
exostectomy (Silver type procedure)
Hallux valgus (bunion) correction, w/ or w/o sesamoidectomy; Keller,
McBride, or Mayo type procedure
Hallux valgus (bunion) correction, w/ or w/o sesamoidectomy; resection of
joint w/ implant
Hallux valgus (bunion) correction, w/ or w/o sesamoidectomy; w/ tendon
transplants (Joplin type procedure)
Hallux valgus (bunion) correction, w/ or w/o sesamoidectomy; w/
metatarsal osteotomy (e.g., Mitchell, Chevron, or concentric type
procedures)
Hallux valgus (bunion) correction, w/ or w/o sesamoidectomy; Lapidus type
procedure
Hallux valgus (bunion) correction, w/ or w/o sesamoidectomy; by phalanx
osteotomy
Hallux valgus (bunion) correction, w/ or w/o sesamoidectomy; by other
methods (e.g., double osteotomy)
Osteotomy; calcaneus (Dwyer or Chambers type procedure), w/ or w/o
internal fixation
Osteotomy; talus
Osteotomy, midtarsal bones, other than calcaneus or talus;
Osteotomy, midtarsal bones, other than calcaneus or talus; w/ autograft
(includes obtaining graft)(Fowler type)
Osteotomy, metatarsal, base or shaft, single, w/ or w/o lenghtening, for
shortening or angular correction; first metatarsal
Osteotomy, metatarsal, base or shaft, single, w/ or w/o lenghtening, for
shortening or angular correction; first metatarsal w/ autograft
Osteotomy, metatarsal, base or shaft, single, w/ or w/o lenghtening, for
shortening or angular correction; other than first metatarsal
Osteotomy, metatarsals, multiple, for cavus foot (Swanson type procedure)
28340
28341
28344
28345
28360
28400
Osteotomy for shortening, angular or rotational correction; proximal
phalanx, first toe
Osteotomy for shortening, angular or rotational correction; other
phalanges, any toe
Reconstruction, angular deformity of toe (overlapping second toe, fifth toe,
curly toes), soft tissue procedures only
Sesamoidectomy, first toe
Repair of nonunion or malunion; tarsal bones (e.g., calcaneus, talus)
Repair of nonunion or malunion; metatarsal, w/ or w/o 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, w/ or w/o skin graft(s)
Reconstruction, cleft foot
Closed treatment of calcaneal fracture
28406
Percutaneous skeletal fixation of calcaneal fracture, w/ manipulation
28310
28312
28313
28315
28320
28322
28415
28420
28430
28436
Open treatment of calcaneal fracture, w/ or w/o internal or external
fixation;
Open treatment of calcaneal fracture, w/ or w/o internal or external
fixation; w/ primary iliac or other autogenous bone graft (includes obtaining
graft)
Closed treatment of talus fracture
Percutaneous skeletal fixation of talus fracture, w/ manipulation
Page 31 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
28445
Open treatment of talus fracture, w/ or w/o internal or external fixation
15,380
7,980
7,400
28450
11,132
4,032
7,100
11,980
5,880
6,100
10,120
4,620
5,500
28470
Treatment of tarsal bone fracture (except talus and calcaneus)
Percutaneous skeletal fixation of tarsal bone fracture (except talus and
calcaneus), w/ manipulation
Open treatment of tarsal bone fracture (except talus and calcaneus), w/ or
w/o internal or external fixation
Closed treatment of metatarsal fracture
10,880
3,780
7,100
28476
Percutaneous skeletal fixation of metatarsal fracture, w/ manipulation
8,260
3,360
4,900
10,880
3,780
7,100
10,120
4,620
5,500
10,540
5,040
5,500
12,120
6,720
5,400
10,120
4,620
5,500
12,120
6,720
5,400
8,260
10,120
8,260
3,360
4,620
3,360
4,900
5,500
4,900
12,540
7,140
5,400
12,540
7,140
5,400
10,880
3,780
7,100
12,540
7,140
5,400
18,000
8,400
9,600
10,960
5,460
5,500
12,540
7,140
5,400
18,000
8,400
9,600
8,260
3,360
4,900
12,540
7,140
5,400
18,000
8,400
9,600
10,880
3,780
7,100
12,540
7,140
5,400
28456
28465
28485
28490
28496
28505
28510
Open treatment of metatarsal fracture, w/ or w/o internal or external
fixation
Closed treatment of fracture great toe, phalanx or phalanges
Percutaneous skeletal fixation of fracture great toe, phalanx or phalanges,
w/ manipulation
Open treatment of fracture great toe, phalanx or phalanges, w/ or w/o
internal or external fixation
Closed treatment of fracture, phalanx or phalanges, other than great toe
28810
28820
28825
29000
29010
29015
29020
29025
29035
Open treatment of fracture, phalanx or phalanges, other than great toe, w/
or w/o internal or external fixation
Closed treatment of sesamoid fracture
Open treatment of sesamoid fracture, w/ or w/o internal fixation
Closed treatment of tarsal bone dislocation, other than talotarsal
Percutaneous skeletal fixation of tarsal bone dislocation, other than
talotarsal ,w/ manipulation
Open treatment of tarsal bone dislocation, w/ or w/o internal or external
fixation
Closed treatment of talotarsal joint dislocation
Percutaneous skeletal fixation of talotarsal joint dislocation, w/
manipulation
Open treatment of talotarsal joint dislocation, w/ or w/o internal or external
fixation
Closed treatment of tarsometatarsal joint dislocation
Percutaneous skeletal fixation of tarsometatarsal joint dislocation, w/
manipulation
Open treatment of tarsometatarsal joint dislocation, w/ or w/o internal or
external fixation
Closed treatment of metatarsophalangeal joint dislocation
Percutaneous skeletal fixation of metatarsophalangeal joint dislocation, w/
manipulation
Open treatment of metatarsophalangeal joint dislocation, w/ or w/o
internal or external fixation
Closed treatment of interphalangeal joint dislocation
Percutaneous skeletal fixation of interphalangeal joint dislocation, w/
manipulation
Open treatment of interphalangeal joint dislocation, w/ or w/o internal or
external fixation
Pantalar arthrodesis
Triple arthrodesis
Subtalar arthrodesis
Arthrodesis, midtarsal or tarsometatarsal, multiple or transverse;
Arthrodesis, midtarsal or tarsometatarsal, multiple or transverse; w/
osteotomy as for flatfoot correction
Arthrodesis, midtarsal navicular-cuneiform, w/ tendon lengthening and
advancement (Miller type procedure)
Arthrodesis, midtarsal or tarsometatarsal, single joint
Arthrodesis, great toe; metatarsophalangeal joint
Arthrodesis, great toe; interphalangeal joint
Arthrodesis, great toe, interphalangeal joint, w/ extensor hallucis longus
transfer to first metatarsal neck (Jones type procedure)
Amputation, foot; midtarsal (Chopart type procedure)
Deep disection below fascia, for deep infection of foot, w/ or w/o tendon
shealth involvement; single bursal space specify
Deep disection below fascia, for deep infection of foot, w/ or w/o tendon
shealth involvement; transmetatarsal
Amputation, metatarsal, w/ toe, single
Amputation, toe; metatarsophalangeal joint
Amputation, toe; interphalangeal joint
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;
29040
Application of body cast, shoulder to hips; including head, Minerva type
28525
28530
28531
28540
28546
28555
28570
28576
28585
28600
28606
28615
28630
28636
28645
28660
28666
28675
28705
28715
28725
28730
28735
28737
28740
28750
28755
28760
28800
28802
28805
Page 32 of 98
18,000
8,400
9,600
27,120
27,960
27,120
23,300
15,120
15,960
15,120
12,600
12,000
12,000
12,000
10,700
23,080
12,180
10,900
21,940
9,240
12,700
18,420
18,420
15,380
8,820
8,820
7,980
9,600
9,600
7,400
22,240
11,340
10,900
23,300
12,600
10,700
8,260
3,360
4,900
21,820
10,920
10,900
12,120
18,000
12,120
10,540
10,540
10,540
10,540
10,540
10,540
6,720
8,400
6,720
5,040
5,040
5,040
5,040
5,040
5,040
5,400
9,600
5,400
5,500
5,500
5,500
5,500
5,500
5,500
10,540
5,040
5,500
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
DESCRIPTION
12,120
12,120
9,300
5,560
6,720
6,720
2,100
1,260
Health Care
Institution Fee
5,400
5,400
7,200
4,300
Application of body cast, shoulder to hips; shoulder to hand (long arm)
5,680
1,680
4,000
Application of body cast, shoulder to hips; elbow to finger (short arm)
5,560
1,260
4,300
5,560
1,260
4,300
8,020
8,440
8,020
2,520
2,940
2,520
5,500
5,500
5,500
Case Rate
29044
29046
29055
29058
Application of body cast, shoulder to hips; including one thigh
Application of body cast, shoulder to hips; including both thighs
Application of body cast, shoulder to hips; shoulder spica
Application of body cast, shoulder to hips; plaster Velpeau
29065
29075
Professional Fee
29305
29325
29345
Application of body cast, shoulder to hips; hand and lower forearm
(gauntlet)
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);
29355
Application of long leg cast (thigh to toes); walker or ambulatory type
8,440
2,940
5,500
29358
29365
29405
8,440
8,020
8,020
2,940
2,520
2,520
5,500
5,500
5,500
8,020
2,520
5,500
29435
29445
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
Application of rigid total contact leg cast
8,020
5,680
2,520
1,680
5,500
4,000
29450
Application of clubfoot cast w/ molding or manipulation, long or short leg
5,680
1,680
4,000
18,000
8,400
9,600
20,980
18,000
10,080
8,400
10,900
9,600
29085
29425
29804
29815
Arthroscopy, temporomandibular joint, diagnostic, w/ or w/o synovial
biopsy
Arthroscopy, temporomandibular joint, surgical
Arthroscopy, shoulder, diagnostic, w/ or w/o synovial biopsy
29819
Arthroscopy, shoulder, surgical; w/ removal of loose body or foreign body
21,940
9,240
12,700
29820
29821
29822
29823
20,980
21,820
20,980
23,300
10,080
10,920
10,080
12,600
10,900
10,900
10,900
10,700
30,740
13,440
17,300
27,120
15,120
12,000
29830
Arthroscopy, shoulder, surgical; synovectomy, partial
Arthroscopy, shoulder, surgical; synovectomy, complete
Arthroscopy, shoulder, surgical; debridement, limited
Arthroscopy, shoulder, surgical; debridement, extensive
Arthroscopy, shoulder, surgical; w/ lysis and resection of adhesions, w/ or
w/o manipulation
Arthroscopy, shoulder, surgical; decompression of subacromial space w/
partial acromioplasty, w/ or w/o coracoacromial release
Arthroscopy, elbow, dianostic, w/ or w/o synovial biopsy
18,000
8,400
9,600
29834
Arthroscopy, elbow, surgical; w/ removal of loose body or foreign body
21,940
9,240
12,700
29835
29836
29837
29838
29840
29843
29844
29845
Arthroscopy, elbow, surgical; synovectomy, partial
Arthroscopy, elbow, surgical; synovectomy, complete
Arthroscopy, elbow, surgical; debridement, limited
Arthroscopy, elbow, surgical; debridement, extensive
Arthroscopy, wrist, diagnostic, w/ or w/o synovial biopsy
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
20,980
21,820
20,980
23,300
12,120
21,940
20,980
21,820
10,080
10,920
10,080
12,600
6,720
9,240
10,080
10,920
10,900
10,900
10,900
10,700
5,400
12,700
10,900
10,900
23,300
12,600
10,700
29847
Arthroscopy, wrist, surgical; internal fixation for fracture or instability
23,300
12,600
10,700
29848
Arthroscopy, wrist, surgical; w/ release of transverse carpal ligament
23,300
12,600
10,700
27,120
15,120
12,000
27,120
15,120
12,000
29800
29825
29826
29846
29850
29851
Arthroscopically aided treatment of intercondylar spine(s) and/or tuberosity
fracture(s) of the knee, w/ or w/o manipulation; w/o internal or external
fixation (includes arthroscopy)
Arthroscopically aided treatment of intercondylar spine(s) and/or tuberosity
fracture(s) of the knee, w/ or w/o manipulation; w/ internal or external
fixation (includes arthroscopy)
29855
Arthroscopically aided treatment of tibial fracture, proximal (plateau);
unicondylar, w/ or w/o internal or external fixation (includes arthroscopy)
27,120
15,120
12,000
29856
Arthroscopically aided treatment of tibial fracture, proximal (plateau);
bicondylar, w/ or w/o internal or external fixation (includes arthroscopy)
27,960
15,960
12,000
29870
29871
Arthroscopy, knee, diagnostic, w/ or w/o synovial biopsy
Arthroscopy, knee, surgical; for infection, lavage and drainage
18,000
20,980
8,400
10,080
9,600
10,900
29874
Arthroscopy, knee, surgical; for removal of loose body or foreign body (e.g.,
osteochondritis dissecans fragmentation, chondral fragmentation)
21,940
9,240
12,700
30,740
13,440
17,300
31,580
14,280
17,300
29875
29876
Arthroscopy, knee, surgical; synovectomy, limited (e.g., plica or shelf
resection)
Arthroscopy, knee, surgical; synovectomy, major, two or more
compartments (e.g., medial or lateral)
Page 33 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
DESCRIPTION
Case Rate
29882
29883
Arthroscopy, knee, surgical; debridement/shaving of articular cartilage
(chondroplasty)
Arthroscopy, knee, surgical; abrasion arthroplasty (includes chondroplasty
where necessary) or multiple drilling
Arthroscopy, knee, surgical; w/ meniscectomy (medial and lateral, including
any meniscal shaving)
Arthroscopy, knee, surgical; w/ meniscectomy (medial or lateral, including
any meniscal shaving)
Arthroscopy, knee, surgical; w/ meniscus repair (medial or lateral)
Arthroscopy, knee, surgical; w/ meniscus repair (medial and lateral)
29884
Arthroscopy, knee, surgical; w/ lysis of adhesions, w/ or w/o manipulation
29877
29879
29880
29881
29885
29886
29887
29888
29889
29894
29895
29897
29898
30000
30020
30100
30110
30115
30117
30118
Arthroscopy, knee, surgical; drilling for osteochondritis dissecans w/ bone
grafting, w/ or w/o 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 w/ internal fixation
Arthroscopically aided anterior cruciate ligament repair/augmentation or
reconstruction
Arthroscopically aided posterior cruciate ligament repair/augmentation or
reconstruction
Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; w/ 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
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, any method (including laser), intranasal lesion;
internal approach
Excision or destruction, any method (including laser), intranasal lesion;
external approach (lateral rhinotomy)
Excision turbinate, partial or complete
Submucous resection turbinate, partial or complete
Removal foreign body, intranasal; requiring general anesthesia
Removal foreign body, intranasal; by lateral rhinotomy
Rhinoplasty for nasal deformity secondary to congenital cleft tip and/or
palate, including columellar lengthening; tip only
Professional Fee
Health Care
Institution Fee
23,300
12,600
10,700
23,300
12,600
10,700
30,740
13,440
17,300
30,740
13,440
17,300
27,120
30,300
15,120
16,800
12,000
13,500
23,300
12,600
10,700
23,300
12,600
10,700
27,120
15,120
12,000
23,300
12,600
10,700
37,180
18,480
18,700
38,860
20,160
18,700
21,940
9,240
12,700
20,980
10,080
10,900
20,980
10,080
10,900
21,820
10,920
10,900
5,560
5,560
5,680
8,020
9,700
1,260
1,260
1,680
2,520
4,200
4,300
4,300
4,000
5,500
5,500
9,700
4,200
5,500
9,700
4,200
5,500
12,900
12,900
8,020
8,020
6,300
6,300
2,520
2,520
6,600
6,600
5,500
5,500
30,300
16,800
13,500
30,300
16,800
13,500
37,800
21,000
16,800
12,900
6,300
6,600
30540
30545
30560
Rhinoplasty for nasal vestibular stenosis
Septoplasty or submucous resection, w/ or w/o cartilage scoring, contouring
or replacement w/ graft
Repair choanal atresia; intranasal
Repair choanal atresia; transpalatine
Lysis intranasal synechia
12,900
18,000
8,260
6,300
8,400
3,360
6,600
9,600
4,900
30580
Repair fistula; oromaxillary (combine w/ 31030 if antrotomy is included)
12,120
6,720
5,400
30600
30630
12,120
12,120
6,720
6,720
5,400
5,400
9,700
4,200
5,500
9,700
4,200
5,500
8,020
2,520
5,500
30915
30920
30930
Repair fistula; oronasal
Repair nasal septal perforations
Cauterization and/or ablation, mucosa of turbinates, unilateral or bilateral,
any method, ; superficial
Cauterization and/or ablation, mucosa of turbinates, unilateral or bilateral,
any method, ; intramural
Control nasal hemorrhage, posterior, w/ posterior nasal packs and/or
cauterization, any method; initial
Ligation arteries; ethmoidal
Ligation arteries; internal maxillary artery, transantral
Fracture nasal turbinate(s), therapeutic
12,120
12,120
9,700
6,720
6,720
4,200
5,400
5,400
5,500
31000
Lavage by cannulation; maxillary sinus (antrum puncture or natural ostium)
9,300
2,100
7,200
31002
31020
Lavage by cannulation; sphenoid sinus
Sinusotomy, maxillary (antrotomy); intranasal
Sinusotomy, maxillary (antrotomy); radical (Caldwell-Luc) w/o removal of
antrochoanal polyps
Sinusotomy, maxillary (antrotomy); radical (Caldwell-Luc) w/ removal of
antrochoanal polyps
Pterygomaxillary fossa surgery, any approach
8,020
9,700
2,520
4,200
5,500
5,500
12,120
6,720
5,400
30130
30140
30310
30320
30460
30462
30465
30520
30801
30802
30905
31030
31032
31040
Rhinoplasty for nasal deformity secondary to congenital cleft tip and/or
palate, including columellar lengthening; tip, septum, osteotomies
Page 34 of 98
12,120
6,720
5,400
23,300
12,600
10,700
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
DESCRIPTION
23,300
12,600
23,300
12,600
10,700
12,120
6,720
5,400
12,120
6,720
5,400
12,120
6,720
5,400
12,120
6,720
5,400
31084
Sinusotomy, sphenoid, w/ or w/o biopsy;
Sinusotomy, sphenoid, w/ or w/o biopsy; w/ 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 w/o osteoplastic flap, brow incision
(includes ablation)
Sinusotomy frontal; obliterative, w/o osteoplastic flap, coronal inicision
(includes ablation)
Sinusotomy frontal; obliterative, w/ osteoplastic flap, brow incision
Health Care
Institution Fee
10,700
12,120
6,720
5,400
31085
Sinusotomy frontal; obliterative, w/ osteoplastic flap, coronal incision
23,300
12,600
10,700
31086
Sinusotomy frontal; nonobliterative, w/ osteoplastic flap, brow incision
23,300
12,600
10,700
31087
Sinusotomy frontal; nonobliterative, w/ osteoplastic flap, coronal incision
23,300
12,600
10,700
31090
31200
31201
31205
31225
31230
31231
Sinusotomy combined, three or more sinuses
Ethmoidectomy; intranasal, anterior
Ethmoidectomy; intranasal, total
Ethmoidectomy; extranasal, total
Maxillectomy; w/o orbital exenteration
Maxillectomy; w/ orbital exenteration (en bloc)
Nasal endoscopy, diagnostic, unilateral or bilateral
Nasal/sinus endoscopy, diagnostic w/ maxillary sinusoscopy (via inferior
meatus or canine fossa puncture)
Nasal/sinus endoscopy, diagnostic w/ sphenoid sinusoscopy (via puncture of
sphenoidal face or cannulation of ostium)
23,300
12,120
12,120
12,120
46,500
53,400
10,540
12,600
6,720
6,720
6,720
25,200
29,400
5,040
10,700
5,400
5,400
5,400
21,300
24,000
5,500
10,540
5,040
5,500
10,540
5,040
5,500
31237
Nasal/sinus endoscopy, surgical; w/ biopsy, polypectomy or debridement
12,120
6,720
5,400
31238
31239
31240
Nasal/sinus endoscopy, surgical; w/ control of epistaxis
Nasal/sinus endoscopy, surgical; w/ dacrylocystorhinostomy
Nasal/sinus endoscopy, surgical; w/ concha bullosa resection
12,120
12,120
18,000
6,720
6,720
8,400
5,400
5,400
9,600
31254
Nasal/sinus endoscopy, surgical; w/ ethmoidectomy, partial (anterior)
18,000
8,400
9,600
18,000
8,400
9,600
18,000
8,400
9,600
18,000
8,400
9,600
18,000
8,400
9,600
18,000
8,400
9,600
18,000
8,400
9,600
18,000
8,400
9,600
18,000
8,400
9,600
18,000
8,400
9,600
31050
31051
31070
31075
31080
31081
31233
31235
Case Rate
31256
Nasal/sinus endoscopy, surgical; w/ ethmoidectomy, total (anterior and
posterior)
Nasal/sinus endoscopy, surgical, w/ maxillary antrostomy
31267
Nasal/sinus endoscopy, surgical, w/ removal of tissue from maxillary sinus
31255
31360
31365
31367
31368
31370
31375
31380
31382
Nasal/sinus endoscopy, surgical w/ frontal sinus exploration, w/ or w/o
removal of tissue from frontal sinus
Nasal/sinus endoscopy, surgical, w/ sphenoidotomy
Nasal/sinus endoscopy, surgical, w/ removal of tissure from the sphenoid
sinus
Nasal/sinus endoscopy, surgical, w/ repair of cerebrospinal fluid leak;
ethmoid region
Nasal/sinus endoscopy, surgical, sphenoid region
Nasal/sinus endoscopy, surgical; w/ medial or inferior orbital wall
decompression
Nasal/sinus endoscopy, surgical; w/ medial orbital wall and inferior orbital
wall decompression
Nasal/sinus endoscopy, surgical; w/ optic nerve decompression
Laryngotomy (thyrotomy, laryngofissure); w/ removal of tumor or
laryngocele, cordectomy
Laryngectomy; total, w/o radical neck dissection
Laryngectomy; total, w/ radical neck dissection
Laryngectomy; subtotal supraglottic, w/o radical neck dissection
Laryngectomy; subtotal supraglottic, w/ radical neck dissection
Partial laryngectomy (hemilaryngectomy); horizontal
Partial laryngectomy (hemilaryngectomy); laterovertical
Partial laryngectomy (hemilaryngectomy); anterovertical
Partial laryngectomy (hemilaryngectomy); antero-latero-vertical
31390
31276
31287
31288
31290
31291
31292
31293
31294
31300
Professional Fee
18,000
8,400
9,600
23,300
12,600
10,700
18,000
8,400
9,600
31,140
37,800
37,180
38,860
31,140
31,140
31,140
31,140
17,640
21,000
18,480
20,160
17,640
17,640
17,640
17,640
13,500
16,800
18,700
18,700
13,500
13,500
13,500
13,500
Pharyngolaryngectomy, w/ radical neck dissection; w/o reconstruction
37,800
21,000
16,800
31395
Pharyngolaryngectomy, w/ radical neck dissection; w/ reconstruction
46,500
25,200
21,300
31400
31420
31500
31515
31520
Arytenoidectomy or arytenoidopexy, external approach
Epiglottidectomy
Intubation, endotracheal, emergency emergency procedure
Laryngoscopy direct, w/ or w/o tracheoscopy; for aspiration
Laryngoscopy direct, w/ or w/o tracheoscopy; diagnostic, newborn
30,300
23,300
16,800
12,600
13,500
10,700
31525
31526
0
0
0
8,020
9,700
2,520
4,200
5,500
5,500
Laryngoscopy direct, w/ or w/o tracheoscopy; diagnostic, except newborn
8,020
2,520
5,500
Laryngoscopy direct, w/ or w/o tracheoscopy; diagnostic, w/ operating
microscope
9,700
4,200
5,500
Page 35 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
31527
Laryngoscopy direct, w/ or w/o tracheoscopy; w/ insertion of obturator
8,020
2,520
5,500
31528
Laryngoscopy direct, w/ or w/o tracheoscopy; w/ dilatation, initial
8,020
2,520
5,500
31529
Laryngoscopy direct, w/ or w/o tracheoscopy; w/ dilatation, subsequent
8,020
2,520
5,500
31530
12,120
6,720
5,400
12,120
6,720
5,400
12,120
12,120
6,720
6,720
5,400
5,400
12,120
6,720
5,400
31575
31576
31577
31578
31579
Laryngoscopy, direct, operative, w/ foreign body removal;
Laryngoscopy, direct, operative, w/ foreign body removal; w/ operating
microscope
Laryngoscopy, direct, operative, w/ biopsy;
Laryngoscopy, direct, operative, w/ biopsy; w/ operating microscope
Laryngoscopy, direct, operative, w/ excision of tumor and/or stripping of
vocal cords or epiglottis;
Laryngoscopy, direct, operative, w/ excision of tumor and/or stripping of
vocal cords or epiglottis; w/ operating microscope
Laryngoscopy, direct, operative, w/ arytenoidectomy;
Laryngoscopy, direct, operative, w/ arytenoidectomy; w/ operating
microscope
Laryngoscopy, direct, w/ injection into vocal cord(s), therapeutic;
Laryngoscopy, direct, w/ injection into vocal cord(s), therapeutic; w/
operating microscope
Laryngoscopy, flexible fiberoptic; diagnostic
Laryngoscopy, flexible fiberoptic; w/ biopsy
Laryngoscopy, flexible fiberoptic; w/ removal of foreign body
Laryngoscopy, flexible fiberoptic; w/ removal of lesion
Laryngoscopy, flexible or rigid fiberoptic, w/ stroboscopy
31580
Laryngoplasty; for laryngeal web, two stage, w/ keel insertion and removal
31531
31535
31536
31540
31541
31560
31561
31570
31571
31582
31584
31586
31587
31588
31590
31595
31600
31601
31603
31605
31610
31611
31612
31613
31614
31615
31622
31625
31628
31629
31630
31631
31635
31636
31640
31641
31643
31645
31710
31717
31750
31755
31760
31766
31770
31775
Laryngoplasty; for laryngeal stenosis, w/ graft or core mold, including
tracheotomy
Laryngoplasty; w/ open reduction of fracture
Laryngoplasty; w/ closed manipulative reduction
Laryngoplasty, cricoid split
Laryngoplasty, not otherwise specified (e.g., for burns, reconstruction after
partial laryngectomy)
Laryngeal reinnervation by neuromuscular pedicle
Section recurrent laryngeal nerve, therapeutic , unilateral
Tracheostomy, planned ;
Tracheostomy, planned ; under two years
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 (e.g., voice button, Blom-Singer prosthesis)
Tracheal puncture, percutaneous w/ transtracheal aspiration and/or
injection
Tracheostoma revision; simple, w/o flap rotation
Tracheostoma revision; complex, w/ flap rotation
Tracheobronchoscopy through established tracheostomy incision
Bronchoscopy; diagnostic, (flexible or rigid), w/ or w/o cell washing or
brushing
Bronchoscopy; w/ biopsy
Bronchoscopy; w/ transbronchial lung biopsy, w/ or w/o fluoroscopic
guidance
Bronchoscopy; w/ transbronchial needle aspiration biopsy
Bronchoscopy; w/ tracheal or bronchial dilation or closed reduction of
fracture
Bronchoscopy; w/ tracheal dilation and placement of tracheal stent
Bronchoscopy; w/ removal of foreign body
Bronchoscopy; diagnostic, (flexible or rigid),w/ placement of bronchial
stents
Bronchoscopy; w/ excision of tumor
Bronchoscopy; w/ destruction of tumor or relief of stenosis by any method
other than excision (e.g., laser)
Bronchoscopy; w/ placement of catheters for intracavitary radioelement
application
Bronchoscopy; w/ therapeutic aspiration of tracheobronchial tree, (e.g.,
drainage of lung abscess)
Catheterization for bronchography, w/ or w/o instillation of contrast
material
Catheterization w/ bronchial brush biopsy
Tracheoplasty; cervical
Tracheoplasty; tracheopharyngeal fistulization, each stage
Tracheoplasty; intrathoracic
Carinal reconstruction
Bronchoplasty; graft repair
Bronchoplasty; excision stenosis and anastomosis
Page 36 of 98
12,120
6,720
5,400
30,300
16,800
13,500
30,300
16,800
13,500
12,120
6,720
5,400
12,120
6,720
5,400
12,120
12,120
12,120
12,120
12,120
6,720
6,720
6,720
6,720
6,720
5,400
5,400
5,400
5,400
5,400
30,300
16,800
13,500
30,300
16,800
13,500
30,300
30,300
30,300
16,800
16,800
16,800
13,500
13,500
13,500
30,300
16,800
13,500
30,300
23,300
12,120
12,540
7,140
12,540
12,540
16,800
12,600
6,720
7,140
4,760
7,140
7,140
13,500
10,700
5,400
5,400
2,380
5,400
5,400
14,960
7,560
7,400
12,900
6,300
6,600
12,120
14,960
12,120
6,720
7,560
6,720
5,400
7,400
5,400
10,960
5,460
5,500
10,960
5,460
5,500
10,960
5,460
5,500
10,960
5,460
5,500
18,000
8,400
9,600
18,000
18,000
8,400
8,400
9,600
9,600
18,000
8,400
9,600
30,300
16,800
13,500
30,300
16,800
13,500
18,000
8,400
9,600
23,300
12,600
10,700
5,560
1,260
4,300
23,300
37,800
37,800
53,400
55,000
55,000
55,000
12,600
21,000
21,000
29,400
33,600
33,600
33,600
10,700
16,800
16,800
24,000
21,400
21,400
21,400
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
DESCRIPTION
31780
31781
31785
31786
31800
31805
31820
31825
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 w/o plastic repair
Surgical closure tracheostomy or fistula with plastic repair
32000
Thoracentesis, puncture of pleural cavity for aspiration, initial or subsequent
32002
Thoracentesis w/ insertion of tube w/ or w/o water seal (e.g., for
pneumothorax)
32005
Chemical pleurodesis (e.g., for recurrent or persistent pneumothorax)
32120
32124
Tube thoracostomy w/ or w/o water seal (e.g., for abscess, hemothorax,
empyema)
Thoracostomy; w/ rib resection for empyema
Thoracostomy; w/ open flap drainage for empyema
Thoracotomy, limited, for biopsy of lung or pleura
Thoracotomy, major; w/ exploration and biopsy
Thoracotomy, major; w/ control of traumatic hemorrhage and/or repair of
lung tear
Thoracotomy, major; for postoperative complications
Thoracotomy, major; w/ open intrapleural pneumonolysis
32140
Thoracotomy, major; w/ cyst(s) removal, w/ or w/o a pleural procedure
32020
32035
32036
32095
32100
32110
32445
Thoracotomy, major; w/ excision-plication of bullae, w/ or w/o a pleural
procedure
Thoracotomy, major; w/ removal of intrapleural foreign body or fibrin
deposit
Thoracotomy, major; w/ removal of intrapulmonary foreign body
THORACOTOMY, MAJOR; w/ cardiac massage
Pneumonostomy, w/ open drainage of abscess or cyst
Pleural scarification for repeat pneumothorax
Decortication, pulmonary ; total
Decortication, pulmonary ; partial
Pleurectomy, parietal
Decortication and parietal pleurectomy
Biopsy, pleura; percutaneous needle
Biopsy, pleura; open
Biopsy, lung or mediastinum, percutaneous needle
Pneumonocentesis, puncture of lung for aspiration
Removal of lung, total pneumonectomy
Removal of lung, w/ resection of segment of trachea followed by bronchotracheal anastomosis (sleeve pneumonectomy)
Removal of lung, extrapleural
32480
Removal of lung, other than total pneumonectomy; single lobe (lobectomy)
32141
32150
32151
32160
32200
32215
32220
32225
32310
32320
32400
32402
32405
32420
32440
32442
32482
32484
32486
32488
32491
46,500
53,400
37,800
55,000
23,300
37,800
8,440
9,700
25,200
29,400
21,000
33,600
12,600
21,000
2,940
4,200
Health Care
Institution Fee
21,300
24,000
16,800
21,400
10,700
16,800
5,500
5,500
1,260
840
420
10,540
5,040
5,500
10,540
5,040
5,500
Case Rate
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; w/ 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)
Removal of lung, other than total pneumonectomy; excision-plication of
emphysematous lung(s) (bullous or non-bullous) for lung volumeRemoval of
lung, other than total pneumonectomy; reduction, sternal split or
transthoracic approach, w/ or w/o any pleural procedure
Professional Fee
7,980
5,320
2,660
12,120
18,420
31,140
37,800
6,720
8,820
17,640
21,000
5,400
9,600
13,500
16,800
37,800
21,000
16,800
37,800
37,800
21,000
21,000
16,800
16,800
37,800
21,000
16,800
41,160
24,360
16,800
38,440
19,740
18,700
38,440
38,440
10,120
38,640
38,440
30,300
37,800
37,800
5,560
37,180
8,440
5,560
46,500
19,740
19,740
4,620
21,840
19,740
16,800
21,000
21,000
1,260
18,480
2,940
1,260
25,200
18,700
18,700
5,500
16,800
18,700
13,500
16,800
16,800
4,300
18,700
5,500
4,300
21,300
55,080
31,080
24,000
55,080
31,080
24,000
41,160
24,360
16,800
46,500
25,200
21,300
46,500
25,200
21,300
55,080
31,080
24,000
53,400
29,400
24,000
41,160
24,360
16,800
40,320
23,520
16,800
53,400
53,400
29,400
29,400
24,000
24,000
32520
32522
Removal of lung, other than total pneumonectomy; wedge resection, single
or multiple
Resection of lung; w/ resection of chest wall
Resection of lung; w/ reconstruction of chest wall, w/o prothesis
32525
Resection of lung; w/ major reconstruction of chest wall, w/ prosthesis
53,400
29,400
24,000
32540
32601
32602
32603
32604
32605
32606
32650
Extrapleural enucleation of empyema (empyemectomy)
Thoracoscopy, diagnostic ; lungs and pleural space, w/o biopsy
Thoracoscopy, diagnostic ; lungs and pleural space, w/ biopsy
Thoracoscopy, diagnostic ; pericardial sac, w/o biopsy
Thoracoscopy, diagnostic ; pericardial sac, w/ biopsy
Thoracoscopy, diagnostic ; mediastinal space, w/o biopsy
Thoracoscopy, diagnostic ; mediastinal space, w/ biopsy
Thoracoscopy, surgical; w/ pleurodesis, any method
38,440
11,980
12,900
12,120
12,120
12,120
12,120
12,120
19,740
5,880
6,300
6,720
6,720
6,720
6,720
6,720
18,700
6,100
6,600
5,400
5,400
5,400
5,400
5,400
32500
Page 37 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
DESCRIPTION
12,120
6,720
12,120
6,720
5,400
32660
Thoracoscopy, surgical; w/ partial pulmonary decortication
Thoracoscopy, surgical; w/ total pulmonary decortication, including
intrapleural pneumonolysis
Thoracoscopy, surgical; w/ removal of intrapleural foreign body or firbin
deposit
Thoracoscopy, surgical; w/ control of traumatic hemorrhage
Thoracoscopy, surgical; w/ excision-plication of bullae, including any pleural
procedure
Thoracoscopy, surgical; w/ parietal pleurectomy
Thoracoscopy, surgical; w/ removal of clot or foreign body from pericardial
sac
Thoracoscopy, surgical; w/ creation of percardial window or partial
resection of pericardial sac for drainage
Thoracoscopy, surgical; w/ total pericardiectomy
Health Care
Institution Fee
5,400
32661
32651
32652
32653
Case Rate
Professional Fee
12,120
6,720
5,400
30,300
16,800
13,500
41,160
24,360
16,800
38,640
21,840
16,800
38,640
21,840
16,800
38,640
21,840
16,800
41,160
24,360
16,800
Thoracoscopy, surgical; w/ excision of pericardial cyst, tumor, or mass
41,160
24,360
16,800
32662
Thoracoscopy, surgical; w/ excision of mediastinal cyst, tumor, or mass
41,160
24,360
16,800
32663
32664
32665
32800
Thoracoscopy, surgical; w/ lobectomy, total or segmental
Thoracoscopy, surgical; w/ thoracic sympathectomy
Thoracoscopy, surgical; w/ 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)
Donor pneumonectomy(ies) w/ preparation and maintenance of allograft
(cadaver)
Lung transplant, single; w/o cardiopulmonary bypass
Lung transplant, single; w/ cardiopulmonary bypass
Lung transplant, double (bilateral sequential or en bloc); w/o
cardiopulmonary bypass
Lung transplant, double (bilateral sequential or en bloc); w/
cardiopulmonary bypass
Resection of ribs, extrapleural, all stages
Thoracoplasty, Schede type or extrapleural (all stages);
Thoracoplasty, Schede type or extrapleural (all stages); w/ closure of
bronchial fistula
46,500
41,160
41,160
23,300
25,200
24,360
24,360
12,600
21,300
16,800
16,800
10,700
23,300
12,600
10,700
46,500
46,500
25,200
25,200
21,300
21,300
55,000
33,600
21,400
63,000
64,680
42,000
43,680
21,000
21,000
65,520
44,520
21,000
65,520
44,520
21,000
46,500
46,500
25,200
25,200
21,300
21,300
46,500
25,200
21,300
32940
Pneumonolysis, extraperiosteal, including filling or packing procedures
30,300
16,800
13,500
32960
33010
33015
Pneumothorax, therapeutic, intrapleural injection of air
Pericardiocentesis
Tube pericardiostomy
5,560
8,020
9,700
1,260
2,520
4,200
4,300
5,500
5,500
33020
Pericardiotomy for removal of clot or foreign body (primary procedure)
18,000
8,400
9,600
33025
Creation of pericardial window or partial resection for drainage
32,000
14,700
17,300
33030
Pericardiectomy, subtotal or complete; w/o cardiopulmonary bypass
46,500
25,200
21,300
33031
33050
Pericardiectomy, subtotal or complete; w/ cardiopulmonary bypass
Excision of pericardial cyst or tumor
58,800
37,800
37,800
21,000
21,000
16,800
33120
Excision of intracardiac tumor, resection w/ cardiopulmonary bypass
60,900
39,900
21,000
33130
Resection of external cardiac tumor
Insertion of permanent pacemaker w/ epicardial electrode(s); by
thoracotomy
Insertion of permanent pacemaker w/ epicardial electrode(s); by xiphoid
approach
Insertion or replacement of permanent pacemaker w/ transvenous
electrode(s); atrial
Insertion or replacement of permanent pacemaker w/ transvenous
electrode(s); ventricular
Insertion or replacement of permanent pacemaker w/ transvenous
electrode(s); atrial and ventricular
Insertion or placement of temporary transvenous single chamber cardiac
electrodes
Insertion or replacement of temporary transvenous dual chamber cardiac
electrodes
Insertion or replacement of pacemaker pulse generator only; single
chamber
39,900
23,100
16,800
21,400
10,500
10,900
21,400
10,500
10,900
18,000
8,400
9,600
18,000
8,400
9,600
21,400
10,500
10,900
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
33213
Insertion or replacement of pacemaker pulse generator only; dual chamber
12,900
6,300
6,600
33214
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)
32,000
14,700
17,300
32654
32655
32656
32658
32659
32810
32815
32820
32850
32851
32852
32853
32854
32900
32905
32906
33200
33201
33206
33207
33208
33210
33211
33212
Page 38 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
33216
Insertion, replacement or repositioning of permanent transvenous
electrode(s) only (15 days or more after initial insertion); single chamber,
atrial or ventricular
12,900
6,300
6,600
33217
Insertion, replacement or repositioning of permanent transvenous
electrode(s) only (15 days or more after initial insertion); dual chamber
18,000
8,400
9,600
33218
Repair of single transvenous electrode for a single chamber, permanent
pacemaker or single chamber pacing cardioverter-defibrillator
23,300
12,600
10,700
23,300
12,600
10,700
18,000
8,400
9,600
18,000
8,400
9,600
12,900
6,300
6,600
23,300
12,600
10,700
32,000
14,700
17,300
30,300
16,800
13,500
37,600
18,900
18,700
30,300
16,800
13,500
18,000
8,400
9,600
33220
33222
33223
33233
33234
33235
33236
33237
33238
33240
33241
33243
33244
33245
33246
33249
Repair of two transvenous electrode for a dual chamber, permanent
pacemaker or dual chamber pacing cardioverter-defibrillator
Revision or relocation of skin pocket for pacemaker
Revision or relocation of skin pocket for single or dual chamber pacing
cardioverter-defibrillator
Removal of transvenous pacemaker pulse generator
Removal of permanent of transvenous pacemaker electrode(s); single lead
system, atrial or ventricular
Removal of permanent of transvenous pacemaker electrode(s); dual lead
chamber
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 chamber
Removal of permanent transvenous electrode(s) by thoracotomy
Insertion or replacement of implantable cardioverter-defibrillator pulse
generator
Removal of implantable cardioverter-defibrillator pulse generator
Removal of implantable cardioverter-defibrillator pulse generator and/or
lead system; by thoracotomy
Removal of implantable cardioverter-defibrillator pulse generator and/or
lead system; by transvenous extraction
Implantation or replacement of implantable cardioverter-defibrillator pads
by thoracotomy, w/ or w/o sensing electrodes;
Implantation or replacement of implantable cardioverter-defibrillator pads
by thoracotomy, w/ insertion of implantable cardioverter-defibrillator pulse
generator
Implantation or replacement of implantable cardioverter-defibrillator pads
by thoracotomy, w/ insertion of cardio-defibrillator pulse generator
33300
33305
Operative ablation of supraventicular arrhythmogenic focus or pathway
(e.g., Wolff-Parkinson-White, A-V node reentry), tract(s) and/or focus (foci);
w/o cardiopulmonary bypass
Operative ablation of supraventicular arrhythmogenic focus or pathway
(e.g., Wolff-Parkinson-White, A-V node reentry), tract(s) and/or focus (foci);
w/ cardiopulmonary bypass
Operative incisions and reconstruction of atria for treatment of atrial
fibrillation or atrial flutter (e.g., maze procedure)
Operative ablation of ventricular arrhythmogenic focus w/ cardiopulmonary
bypass
Repair of cardiac wound; w/o bypass
Repair of cardiac wound; w/ cardiopulmonary bypass
33310
Cardiotomy, exploratory (includes removal of foreign body); w/o bypass
33250
33251
33253
33261
18,000
8,400
9,600
30,300
16,800
13,500
30,300
16,800
13,500
12,900
6,300
6,600
21,400
10,500
10,900
18,000
8,400
9,600
37,600
18,900
18,700
53,400
29,400
24,000
58,800
37,800
21,000
58,800
37,800
21,000
46,500
58,800
25,200
37,800
21,300
21,000
46,500
25,200
21,300
58,800
37,800
21,000
30,300
16,800
13,500
58,800
58,800
37,800
37,800
21,000
21,000
46,500
25,200
21,300
63,000
42,000
21,000
33332
Cardiotomy, exploratory (includes removal of foreign body); w/
cardiopulmonary bypass
Suture repair of aorta or great vessels; w/o shunt or cardiopulmonary
bypass
Suture repair of aorta or great vessels; w/ shunt bypass
Suture repair of aorta or great vessels; w/ cardiopulmonary bypass
Insertion of graft, aorta or great vessels; w/o shunt, or cardiopulmonary
bypass
Insertion of graft, aorta or great vessels; w/ shunt bypass
33335
Insertion of graft, aorta or great vessels; w/ cardiopulmonary bypass
63,000
42,000
21,000
33400
33401
Valvuloplasty, aortic valve; open, w/ cardiopulmonary bypass
Valvuloplasty, aortic valve; open, w/ inflow occlusion
Valvuloplasty, aortic valve; using transventricular dilation, w/
cardiopulmonary bypass
Construction of apica-aortic conduit
Replacement, aortic valve, w/ cardiopulmonary bypass; w/ prosthetic valve
other than homograft
Replacement, aortic valve, w/ cardiopulmonary bypass; w/ homograft valve
(freehand)
Replacement, aortic valve; w/ aortic annulus enlargement, noncoronary
cusp
Replacement, aortic valve; w/ transventricular aortic annulus enlargement
(Konno procedure)
53,400
53,400
29,400
29,400
24,000
24,000
55,000
33,600
21,400
58,800
37,800
21,000
53,400
29,400
24,000
58,800
37,800
21,000
55,000
33,600
21,400
58,800
37,800
21,000
33315
33320
33321
33322
33330
33403
33404
33405
33406
33411
33412
Page 39 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
33413
DESCRIPTION
Case Rate
Replacement, aortic valve; w/ translocation of autologous pulmonary valve
w/ hemograft repacement of pulmonary valve (Ross procedure)
33417
33420
33422
33425
Repair of left ventricular outflow tract obtruction by patch enlargement of
the outflow tract
Resection or incision of subvalvular tissue for discrete subaortic stenosis
(e.g., asymmetric septal hypertrophy)
Ventriculomyotomy (-myectomy) for idiopathic hypertrophic subaortic
stenosis (e.g., asymmetric septal hypertrophy)
Aortoplasty (gusset) for supravalvular stenosis
Valvotomy, mitral valve; closed heart
Valvotomy, mitral valve; open heart, w/ cardiopulmonary bypass
Valvuloplasty, mitral valve, w/ cardiopulmonary bypass;
33426
Valvuloplasty, mitral valve, w/ cardiopulmonary bypass; w/ prosthetic ring
33414
33415
33416
Professional Fee
Health Care
Institution Fee
71,400
50,400
21,000
46,500
25,200
21,300
46,500
25,200
21,300
55,000
33,600
21,400
46,500
37,800
53,400
55,000
25,200
21,000
29,400
33,600
21,300
16,800
24,000
21,400
57,100
35,700
21,400
58,800
37,800
21,000
46,500
46,500
53,400
55,000
53,400
58,800
30,300
23,300
46,500
25,200
25,200
29,400
33,600
29,400
37,800
16,800
12,600
25,200
21,300
21,300
24,000
21,400
24,000
21,000
13,500
10,700
21,300
33430
33460
33463
33464
33465
33468
33470
33471
33472
Valvuloplasty, mitral valve, w/ cardiopulmonary bypass; radical
reconstruction, w/ or w/o ring
Replacement, mitral valve, w/ cardiopulmonary bypass
Valvectomy, tricuspid valve, w/ cardiopulmonary bypass
Valvuloplasty, tricuspid valve; w/o ring insertion
Valvuloplasty, tricuspid valve; w/ ring insertion
Replacement, tricuspid valve, w/ 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; w/ inflow occlusion
33474
Valvotomy, pulmonary valve, open heart; w/ cardiopulmonary bypass
46,500
25,200
21,300
33475
53,400
29,400
24,000
46,500
25,200
21,300
53,400
29,400
24,000
46,500
25,200
21,300
30,300
16,800
13,500
33502
Replacement, pulmonary valve
Right ventricular resection for infundibular stenosis, with or without
commisurotomy
Outflow tract augmentation (gusset), w/ or w/o commissurotomy or
infundibular resection
Repair of coronary arteriovenous or arteriocardiac chamber fistula; w/
cardiopulmonary bypass
Repair of coronary arteriovenous or arteriocardiac chamber fistula; w/o
cardiopulmonary bypass
Repair of anomalous coronary artery; by ligation
30,300
16,800
13,500
33503
Repair of anomalous coronary artery; by graft, w/o cardiopulmonary bypass
46,500
25,200
21,300
33504
Repair of anomalous coronary artery; by graft, w/ cardiopulmonary bypass
53,400
29,400
24,000
53,400
29,400
24,000
53,400
29,400
24,000
53,400
53,400
55,000
58,800
58,800
29,400
29,400
33,600
37,800
37,800
24,000
24,000
21,400
21,000
21,000
33427
33476
33478
33500
33501
33510
33511
33512
33513
33514
Repair of anomalous coronary artery; with construction of intrapulmonary
artery tunnel (Takeuchi procedure)
Repair of anomalous coronary artery; by translocation from pulmonary
artery to aorta
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
33516
Coronary artery bypass, vein only; six or more coronary venous grafts
58,800
37,800
21,000
33517
Coronary artery bypass, using venous graft(s) and arterial graft(s); single
vein graft (list separately in addition to code for arterial graft)
53,400
29,400
24,000
33518
Coronary artery bypass, using venous graft(s) and arterial graft(s); two
venous grafts (list separately in addition to code for arterial graft)
53,400
29,400
24,000
33519
Coronary artery bypass, using venous graft(s) and arterial graft(s); three
venous grafts (list separately in addition to code for arterial graft)
55,000
33,600
21,400
33521
Coronary artery bypass, using venous graft(s) and arterial graft(s); four
venous grafts (list separately in addition to code for arterial graft)
58,800
37,800
21,000
33522
Coronary artery bypass, using venous graft(s) and arterial graft(s); five
venous grafts (list separately in addition to code for arterial graft)
58,800
37,800
21,000
33523
Coronary artery bypass, using venous graft(s) and arterial graft(s); six or
more venous grafts (list separately in addition to code for arterial graft)
58,800
37,800
21,000
63,000
42,000
21,000
53,400
29,400
24,000
53,400
29,400
24,000
33505
33506
33533
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
33534
Coronary artery bypass, using arterial graft(s); two coronary arterial grafts
33530
Page 40 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
33535
33536
33542
33545
33572
DESCRIPTION
Case Rate
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 (e.g., ventricular aneurysmectomy)
Repair of postinfarction ventricular septal defect, w/ or w/o myocardial
resection
Coronary endarterectomy, open, any method, of left anterior descending,
circumflex, or right coronary artery performed in conjuction w/ coronary
artery bypass graft procedure, each vessel (list separately in addition to
primary procedure)
Professional Fee
Health Care
Institution Fee
55,000
33,600
21,400
58,800
37,800
21,000
63,000
42,000
21,000
63,000
42,000
21,000
9,700
4,200
5,500
33600
Closure of atrioventricular valve (mitral or tricuspid) by suture or patch
46,500
25,200
21,300
33602
Closure of semilunar valve (aortic or pulmonary) by suture or patch
46,500
25,200
21,300
33606
Anastomosis of pulmonary artery to aorta (Damus-Kaye-Stansel procedure)
53,400
29,400
24,000
33608
Repair of complex cardiac anomaly other than pulmonary atresia with
ventricular septal defect by construction or replacemnet of conduit from
right or left ventricle to pulmonary artery
55,000
33,600
21,400
33610
Repair of complex cardiac anomalies (e.g., single ventricle with subaortic
obstruction) by surgical enlargement of interventricular septal defect
55,000
33,600
21,400
33611
Repair of double outlet right ventricle with intraventricular tunnel repair
55,000
33,600
21,400
55,000
33,600
21,400
55,000
33,600
21,400
55,000
33,600
21,400
63,000
42,000
21,000
46,500
25,200
21,300
53,400
29,400
24,000
55,000
33,600
21,400
55,000
33,600
21,400
55,000
33,600
21,400
33612
33615
33617
33619
33641
33645
33647
33660
33665
Repair of double outlet right ventricle with intraventricular tunnel repair
with repair of right ventricular outflow tract obstruction
Repair of complex cardiac anomalies (e.g., 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 (e.g., single ventricle) by modified
Fontan procedure
Repair of single ventricle w/ aortic outflow obstruction and aortic arch
hypoplasia (hypoplastic left heart syndrome) (e.g., Norwood procedure)
Repair atrial septal defect, secundum, w/ cardiopulmonary bypass, w/ or
w/o patch
Direct or patch closure, sinus venosus, w/ or w/o anomalous pulmonary
venous drainage
Repair of atrial septal defect and ventricular septal defect, w/ direct or
patch closure
Repair of incomplete or partial atrioventricular canal (ostium primum atrial
septal defect), w/ or w/o atrioventricular valve repair
Repair of intermediate or transitional atrioventricular canal, w/ or w/o
atrioventricular valve repair
33670
Repair of complete atrioventricular canal, w/ or w/o prosthetic valve
58,800
37,800
21,000
33681
46,500
25,200
21,300
55,000
33,600
21,400
55,000
33,600
21,400
21,400
55,000
10,500
33,600
10,900
21,400
55,000
33,600
21,400
55,000
33,600
21,400
33702
Closure of ventricular septal defect, w/ or w/o patch;
Closure of ventricular septal defect, w/ or w/o patch; with pulmonary
valvotomy or infundibular resection (acyanotic)
Closure of ventricular septal defect, w/ or w/o patch; with removal of
pulmonary artery band, w/ or w/o gusset
Banding of pulmonary artery
Complete repair of tetralogy of Fallot w/o pulmonary atresia;
Complete repair of tetralogy of Fallot w/o pulmonary atresia; with
transannular patch
Complete repair of tetralogy of Fallot w/ pulmonary atresia including
construction of conduit right ventricle to pulmonary artery and closure of
ventricular septal defect
Repair sinus of Valsalva fistula, w/ cardiopulmonary bypass
46,500
25,200
21,300
33710
Repair sinus of Valsalva fistula, with repair of ventricular septal defect
55,000
33,600
21,400
33720
33722
Repair sinus of Valsalva aneurysm, with cardiopulmonary bypass
Closure of aortico-left ventricular tunnel
Complete repair of anomalous venous return (supracardiac, intracardiac, or
infracardiac types)
Repair of cor triatum or supravalvular mitra ring by resection of left atrial
membrane
Atrial septectomy or septostomy; closed heart (Blalock-Hanlon type
operation)
53,400
53,400
29,400
29,400
24,000
24,000
55,000
33,600
21,400
55,000
33,600
21,400
21,400
10,500
10,900
33736
Atrial septectomy or septostomy; open heart w/ cardiopulmonary bypass
46,500
25,200
21,300
33737
Atrial septectomy or septostomy; open heart w/ inflow occlusion
46,500
25,200
21,300
33750
Shunt; subclavian to pulmonary artery (Blalock- Taussig type operation)
30,300
16,800
13,500
33764
Shunt; central, w/ prosthetic graft
Shunt; superior vena cava to pulmonary artery for flow to one lung (classical
Glenn procedure)
23,300
12,600
10,700
30,300
16,800
13,500
33684
33688
33690
33692
33694
33697
33730
33732
33735
33766
Page 41 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
33767
33770
33771
33774
33775
33776
33777
33778
33779
DESCRIPTION
Case Rate
Shunt; superior vena cava to pulmonary artery for flow to both lungs
(bidirectional Glenn procedure)
Repair of transposition of great arteries w/ ventricular septal defect and
subpulmonary stenosis; w/o surgical enlargement of ventricular septal
defect
Repair of transposition of great arteries w/ ventricular septal defect and
subpulmonary stenosis; with surgical enlagement of ventricular septal
defect
Repair of transposition of the great arteries, atrial baffle procedure (e.g.,
Mustard or Senning type) w/ cardiopulmonary bypass
Repair of transposition of the great arteries, atrial baffle procedure (e.g.,
Mustard or Senning type) w/ removal of pulmonary band
Repair of transposition of the great arteries, atrial baffle procedure (e.g.,
Mustard or Senning type) w/ closure of ventricular septal defect
Repair of transposition of the great arteries, atrial baffle procedure (e.g.,
Mustard or Senning type) w/ repair of subpulmonic obstruction
Repair of transposition of the great arteries, aortic pulmonary artery
reconstruction (e.g., Jatene type)
Repair of transposition of the great arteries, aortic pulmonary artery
reconstruction (e.g., Jatene type) w/ removal of pulmonary band
Professional Fee
Health Care
Institution Fee
46,500
25,200
21,300
58,800
37,800
21,000
58,800
37,800
21,000
58,800
37,800
21,000
60,900
39,900
21,000
60,900
39,900
21,000
60,900
39,900
21,000
63,000
42,000
21,000
65,100
44,100
21,000
33780
Repair of transposition of the great arteries, aortic pulmonary artery
reconstruction (e.g., Jatene type) w/ closure of ventricular septal defect
71,400
50,400
21,000
33781
Repair of transposition of the great arteries, aortic pulmonary artery
reconstruction (e.g., Jatene type) w/ repair of subpulmonic obstruction
71,400
50,400
21,000
58,800
55,000
37,800
33,600
21,000
21,400
21,400
10,500
10,900
33802
33803
Total repair, truncus arteriosus (Rastelli type operation)
Reimplantation of an anomalous pulmonary artery
Aortic suspension (aortopexy) for tracheal decompression (e.g., for
tracheomalacia)
Division of aberrant vessel (vascular ring)
Division of aberrant vessel (vascular ring) w/ reanastomosis
21,400
23,300
10,500
12,600
10,900
10,700
33814
Division of aberrant vessel (vascular ring) w/ cardiopulmonary bypass
46,500
25,200
21,300
33820
33822
33824
Repair of patent ductus arteriosus; by ligation
Repair of patent ductus arteriosus; by division, under 18 years
Repair of patent ductus arteriosus; by division, 18 years and older
Excision of coarctation of aorta, w/ or w/o associated patent ductus
arteriosus; w/ direct anastomosis
Excision of coarctation of aorta, w/ or w/o associated patent ductus
arteriosus; with graft
Excision of coarctation of aorta, w/ or w/o 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; w/o cardiopulmonary bypass
Repair of hypoplastic or interrupted aortic arch using autogenous or
prosthetic material; w/ cardiopulmonary bypass
Ascending aorta graft, w/ cardiopulmonary bypass, w/ or w/o valve
suspension;
Ascending aorta graft, w/ cardiopulmonary bypass, w/ or w/o valve
suspension; w/ coronary reconstruction
Ascending aorta graft, w/ cardiopulmonary bypass, w/ or w/o valve
suspension; w/ aortic root replacement using composite prosthesis and
coronary reconstruction
Transverse arch graft, w/ cardiopulmonary bypass
Descending thoracic aorta graft, w/ or w/o bypass
Repair of thoracoabdominal aortic aneurysm w/ graft, w/ or w/o
cardiopulmonary bypass
Pulmonary artery embolectomy; w/ cardiopulmonary bypass
Pulmonary artery embolectomy; w/o cardiopulmonary bypass
Pulmonary endarterectomy, w/ or w/o embolectomy, w/ cardiopulmonary
bypass
32,000
30,300
30,300
14,700
16,800
16,800
17,300
13,500
13,500
30,300
16,800
13,500
30,300
16,800
13,500
30,300
16,800
13,500
30,300
16,800
13,500
46,500
25,200
21,300
55,000
33,600
21,400
58,800
37,800
21,000
71,400
50,400
21,000
71,400
63,000
50,400
42,000
21,000
21,000
71,400
50,400
21,000
46,500
30,300
25,200
16,800
21,300
13,500
53,400
29,400
24,000
Repair of pulmonary artery stenosis by reconstruction w/ patch or graft
53,400
29,400
24,000
30,300
16,800
13,500
46,500
25,200
21,300
58,800
37,800
21,000
46,500
25,200
21,300
18,000
8,400
9,600
33786
33788
33800
33840
33845
33851
33852
33853
33860
33861
33863
33870
33875
33877
33910
33915
33916
33917
33918
33919
33920
33922
33924
Repair of pulmonary atresia w/ ventricular septal defect, by unifocalization
of pulmonary arteries; w/o cardiopulmonary bypass
Repair of pulmonary atresia w/ ventricular septal defect, by unifocalization
of pulmonary arteries; w/ cardiopulmonary bypass
Repair of pulmonary atresia w/ ventricular septal defect, by construction or
replacement of conduit from right or left ventricle to pulmonary artery
Transection of pulmonary artery w/ cardiopulmonary bypass
Ligation and takedown of a systemic-to-pulmonary artery shunt, performed
in conjuction w/ a congenital heart procedure (List separately in addition to
code for primary procedure)
Page 42 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
33930
33935
33940
33945
33970
33971
33973
33974
33975
33976
33977
33978
34001
34051
34101
34111
34151
34201
34203
34401
34421
34451
34471
34490
34501
34502
34510
34520
34530
35001
35002
35005
35011
35013
35021
35022
35045
35081
DESCRIPTION
Case Rate
Donor cardiectomy-pneumonectomy, w/ preparation and maintenance of
allograft
Heart-lung transplant w/ recipient cardiectomy-pneumonectomy
Donor cardiectomy, w/ preparation and maintenance of allograft
Heart transplant, w/ or w/o recipient cardiectomy
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 w/ or w/o 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, w/ or w/o graft
Implantation of ventricular assist device; single ventricle support
Implantation of ventricular assist device; biventricular support
Removal of ventricular assist device; single ventricle support
Removal of ventricular assist device; biventricular support
Embolectomy or thrombectomy, w/ or w/o catheter; carotid, subclavian or
innominate artery, by neck incision
Embolectomy or thrombectomy, w/ or w/o catheter; innominate,
subclavian artery, by thoracic incision
Embolectomy or thrombectomy, w/ or w/o catheter; axillary, brachial,
innominate, subclavian artery, by arm incision
Embolectomy or thrombectomy, w/ or w/o catheter; radial or ulnar artery,
by arm incision
Embolectomy or thrombectomy, w/ or w/o catheter; renal, celiac,
mesentery, aortoiliac artery, by abdominal incision
Embolectomy or thrombectomy, w/ or w/o catheter; femoropopliteal,
aortoiliac artery, by leg incision
Embolectomy or thrombectomy, w/ or w/o catheter; popliteal-tibioperoneal artery, by leg incision
Thrombectomy, direct or w/ catheter; vena cava, iliac vein, by abdominal
incision
Thrombectomy, direct or w/ catheter; vena cava, iliac, femoropopliteal vein,
by leg incision
Thrombectomy, direct or w/ catheter; vena cava, iliac, femoropopliteal vein,
by abdominal and leg incision
Thrombectomy, direct or w/ catheter; subclavian vein, by neck incision
Thrombectomy, direct or w/ 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 sytem
Saphenopopliteal vein anastomosis
Direct repair of aneurysm, false aneurysm, or excision (partial or total) and
graft insertion, w/ or w/o patch graft; for aneurysm and associated occlusive
disease, carotid, subclavian artery, by neck incision
Direct repair of aneurysm, false aneurysm, or excision (partial or total) and
graft insertion, w/ or w/o patch graft; for ruptured aneurysm, carotid,
subclavian artery, by neck incision
Direct repair of aneurysm, false aneurysm, or excision (partial or total) and
graft insertion, w/ or w/o patch graft; for aneurysm, false aneurysm, and
associated occlusive disease, vertebral artery
Direct repair of aneurysm, false aneurysm, or excision (partial or total) and
graft insertion, w/ or w/o patch graft; for aneurysm and associated occlusive
disease, axillary-brachial artery, by arm incision
Direct repair of aneurysm, false aneurysm, or excision (partial or total) and
graft insertion, w/ or w/o patch graft; for ruptured aneurysm, axillarybrachial artery, by arm incision
Direct repair of aneurysm, false aneurysm, or excision (partial or total) and
graft insertion, w/ or w/o patch graft; for aneurysm, false aneurysm, and
associated occlusive disease, innominate, subclavian artery, by thoracic
incision
Direct repair of aneurysm, false aneurysm, or excision (partial or total) and
graft insertion, w/ or w/o patch graft; for ruptured aneurysm, innominate,
subclavian artery, by thoracic insertion
Direct repair of aneurysm, false aneurysm, or excision (partial or total) and
graft insertion, w/ or w/o patch graft; for aneurysm, false aneurysm, and
associated occlusive disease, radial or ulnar artery
Direct repair of aneurysm, false aneurysm, or excision (partial or total) and
graft insertion, w/ or w/o patch graft; for aneurysm, false aneurysm, and
associated occlusive disease, abdominal aorta
Page 43 of 98
Professional Fee
Health Care
Institution Fee
46,500
25,200
21,300
75,600
46,500
75,600
54,600
25,200
54,600
21,000
21,300
21,000
12,900
6,300
6,600
9,700
4,200
5,500
21,400
10,500
10,900
30,300
16,800
13,500
46,500
55,000
37,800
46,500
25,200
33,600
21,000
25,200
21,300
21,400
16,800
21,300
32,000
14,700
17,300
32,000
14,700
17,300
23,300
12,600
10,700
23,300
12,600
10,700
30,300
16,800
13,500
23,300
12,600
10,700
23,300
12,600
10,700
30,300
16,800
13,500
32,000
14,700
17,300
37,600
18,900
18,700
32,000
14,700
17,300
23,300
12,600
10,700
30,300
30,300
30,300
30,300
30,300
16,800
16,800
16,800
16,800
16,800
13,500
13,500
13,500
13,500
13,500
23,300
12,600
10,700
30,300
16,800
13,500
30,300
16,800
13,500
18,000
8,400
9,600
23,300
12,600
10,700
23,300
12,600
10,700
30,300
16,800
13,500
18,000
8,400
9,600
46,500
25,200
21,300
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
35082
35091
DESCRIPTION
Case Rate
Direct repair of aneurysm, false aneurysm, or excision (partial or total) and
graft insertion, w/ or w/o patch graft; for ruptured aneurysm, abdominal
aorta
Direct repair of aneurysm, false aneurysm, or excision (partial or total) and
graft insertion, w/ or w/o patch graft; for aneurysm, false aneurysm, and
associated occlusive disease, abdominal aorta involving visceral vessels
(mesenteric, celiac, renal)
Professional Fee
Health Care
Institution Fee
53,400
29,400
24,000
53,400
29,400
24,000
35092
Direct repair of aneurysm, false aneurysm, or excision (partial or total) and
graft insertion, w/ or w/o patch graft; for ruptured aneurysm, abdominal
aorta involving visceral vessels (mesenteric, celiac, renal)
55,000
33,600
21,400
35102
Direct repair of aneurysm, false aneurysm, or excision (partial or total) and
graft insertion, w/ or w/o patch graft; for aneurysm, false aneurysm, and
associated occlusive disease, abdominal aorta involving iliac vessels
(common, hypogastric, external)
46,500
25,200
21,300
35103
Direct repair of aneurysm, false aneurysm, or excision (partial or total) and
graft insertion, w/ or w/o patch graft; for ruptured aneurysm, abdominal
aorta involving iliac vessels (common, hypogastric, external)
53,400
29,400
24,000
35111
Direct repair of aneurysm, false aneurysm, or excision (partial or total) and
graft insertion, w/ or w/o patch graft; for aneurysm, false aneurysm, and
associated occlusive disease, splenic artery
46,500
25,200
21,300
35112
Direct repair of aneurysm, false aneurysm, or excision (partial or total) and
graft insertion, w/ or w/o patch graft; for ruptured aneurysm, splenic artery
53,400
29,400
24,000
35121
Direct repair of aneurysm, false aneurysm, or excision (partial or total) and
graft insertion, w/ or w/o patch graft; for aneurysm, false aneurysm, and
associated occlusive disease, hepatic, celiac, renal, or mesenteric artery
46,500
25,200
21,300
35122
Direct repair of aneurysm, false aneurysm, or excision (partial or total) and
graft insertion, w/ or w/o patch graft; for ruptured aneurysm, hepatic,
celiac, renal, or mesenteric artery
53,400
29,400
24,000
35131
Direct repair of aneurysm, false aneurysm, or excision (partial or total) and
graft insertion, w/ or w/o patch graft; for aneurysm, false aneurysm, and
associated occlusive disease, iliac artery (common, hypogastric, external)
23,300
12,600
10,700
30,300
16,800
13,500
23,300
12,600
10,700
30,300
16,800
13,500
30,300
16,800
13,500
37,800
21,000
16,800
30,300
16,800
13,500
35132
35141
35142
35151
35152
35161
Direct repair of aneurysm, false aneurysm, or excision (partial or total) and
graft insertion, w/ or w/o patch graft; for ruptured aneurysm, iliac artery
(common, hypogastric, external)
Direct repair of aneurysm, false aneurysm, or excision (partial or total) and
graft insertion, w/ or w/o patch graft; for aneurysm, false aneurysm, and
associated occlusive disease, common femoral artery (profunda femoris,
superficial femoral)
Direct repair of aneurysm, false aneurysm, or excision (partial or total) and
graft insertion, w/ or w/o patch graft; for ruptured aneurysm, common
femoral artery (profunda femoris, superficial femoral)
Direct repair of aneurysm, false aneurysm, or excision (partial or total) and
graft insertion, w/ or w/o patch graft; for aneurysm, false aneurysm, and
associated occlusive disease, popliteal artery
Direct repair of aneurysm, false aneurysm, or excision (partial or total) and
graft insertion, w/ or w/o patch graft; for ruptured aneurysm, popliteal
artery
Direct repair of aneurysm, false aneurysm, or excision (partial or total) and
graft insertion, w/ or w/o patch graft; for aneurysm, false aneurysm, and
associated occlusive disease, other arteries
35162
Direct repair of aneurysm, false aneurysm, or excision (partial or total) and
graft insertion, w/ or w/o patch graft; for ruptured aneurysm, other arteries
37,800
21,000
16,800
35180
35182
35184
35188
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
23,300
30,300
23,300
23,300
12,600
16,800
12,600
12,600
10,700
13,500
10,700
10,700
35189
Repair, acquired or traumatic arteriovenous fistula; thorax and abdomen
30,300
16,800
13,500
35190
35201
35206
35207
35211
35216
35221
35226
35231
35236
35241
35246
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, w/ bypass
Repair blood vessel, direct; intrathoracic, w/o bypass
Repair blood vessel, direct; intra-abdominal
Repair blood vessel, direct; lower extremity
Repair blood vessel w/ vein graft; neck
Repair blood vessel w/ vein graft; upper extremity
Repair blood vessel w/ vein graft; intrathoracic, w/ bypass
Repair blood vessel w/ vein graft; intrathoracic, w/o bypass
23,300
18,000
18,000
18,000
46,500
30,300
18,000
18,000
23,300
18,000
46,500
30,300
12,600
8,400
8,400
8,400
25,200
16,800
8,400
8,400
12,600
8,400
25,200
16,800
10,700
9,600
9,600
9,600
21,300
13,500
9,600
9,600
10,700
9,600
21,300
13,500
Page 44 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
DESCRIPTION
35251
35256
35261
35266
Repair blood vessel w/ vein graft; intra-abdominal
Repair blood vessel w/ vein graft; lower extremity
Repair blood vessel w/ graft other than vein; neck
Repair blood vessel w/ graft other than vein; upper extremity
23,300
18,000
23,300
18,000
12,600
8,400
12,600
8,400
Health Care
Institution Fee
10,700
9,600
10,700
9,600
35271
Repair blood vessel w/ graft other than vein; intrathoracic, w/ bypass
46,500
25,200
21,300
35276
Repair blood vessel w/ graft other than vein; intrathoracic, w/o bypass
30,300
16,800
13,500
35281
35286
23,300
18,000
12,600
8,400
10,700
9,600
37,600
18,900
18,700
37,600
18,900
18,700
35321
35331
Repair blood vessel w/ graft other than vein; intra-abdominal
Repair blood vessel w/ graft other than vein; lower extremity
Thromboendarterectomy, w/ or w/o patch graft; carotid, vertebral,
subclavian, by neck incision
Thromboendarterectomy, w/ or w/o patch graft; subclavian, innominate, by
thoracic incision
Thromboendarterectomy, w/ or w/o patch graft; axillary-brachial
Thromboendarterectomy, w/ or w/o patch graft; abdominal aorta
37,600
37,600
18,900
18,900
18,700
18,700
35341
Thromboendarterectomy, w/ or w/o patch graft; mesenteric, celiac, or renal
37,600
18,900
18,700
35351
35355
35361
Thromboendarterectomy, w/ or w/o patch graft; iliac
Thromboendarterectomy, w/ or w/o patch graft; iliofemoral
Thromboendarterectomy, w/ or w/o patch graft; combined aortoiliac
30,300
30,300
46,500
16,800
16,800
25,200
13,500
13,500
21,300
35363
Thromboendarterectomy, w/ or w/o patch graft; combined aortoiliofemoral
23,300
12,600
10,700
35371
Thromboendarterectomy, w/ or w/o patch graft; common femoral
23,300
12,600
10,700
35372
Thromboendarterectomy, w/ or w/o patch graft; deep (profunda) femoral
23,300
12,600
10,700
35381
Thromboendarterectomy, w/ or w/o patch graft; femoral and/or popliteal,
and/or tibioperoneal
30,300
16,800
13,500
35450
Transluminal balloon angioplasty, open; renal or other visceral artery
21,400
10,500
10,900
35452
35454
35456
Transluminal balloon angioplasty, open; aortic
Transluminal balloon angioplasty, open; iliac
Transluminal balloon angioplasty, open; femoral-popliteal
Transluminal balloon angioplasty, open; brachiocephalic trunk or branches,
each vessel
21,400
21,400
21,400
10,500
10,500
10,500
10,900
10,900
10,900
21,400
10,500
10,900
35459
Transluminal balloon angioplasty, open; tibioperoneal trunk and branches
21,400
10,500
10,900
35460
Transluminal balloon angioplasty, open; venous
Transluminal balloon angioplasty, percutaneous; tibioperoneal trunk or
branches, each vessel
21,400
10,500
10,900
12,900
6,300
6,600
35471
Transluminal balloon angioplasty, percutaneous; renal or visceral artery
12,900
6,300
6,600
35472
35473
35474
12,900
12,900
12,900
6,300
6,300
6,300
6,600
6,600
6,600
12,900
6,300
6,600
35476
Transluminal balloon angioplasty, percutaneous; aortic
Transluminal balloon angioplasty, percutaneous; iliac
Transluminal balloon angioplasty, percutaneous; femoral-popliteal
Transluminal balloon angioplasty, percutaneous; branchiocephalic trunk or
branches, each vessel
Transluminal balloon angioplasty, percutaneous; venous
12,900
6,300
6,600
35480
Transluminal peripheral atherectomy, open; renal or other visceral artery
23,300
12,600
10,700
35481
35482
35483
23,300
23,300
23,300
12,600
12,600
12,600
10,700
10,700
10,700
23,300
12,600
10,700
23,300
12,600
10,700
21,400
10,500
10,900
35491
35492
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
21,400
21,400
10,500
10,500
10,900
10,900
35493
Transluminal peripheral atherectomy, percutaneous; femoral-popliteal
21,400
10,500
10,900
21,400
10,500
10,900
21,400
10,500
10,900
37,600
37,600
37,600
37,600
37,600
37,600
37,600
37,600
37,600
37,600
18,900
18,900
18,900
18,900
18,900
18,900
18,900
18,900
18,900
18,900
18,700
18,700
18,700
18,700
18,700
18,700
18,700
18,700
18,700
18,700
35301
35311
35458
35470
35475
35484
35485
35490
35494
35495
35501
35506
35507
35508
35509
35511
35515
35516
35518
35521
Case Rate
Transluminal peripheral atherectomy, percutaneous; branchiocephalic trunk
or branches, each vessel
Transluminal peripheral atherectomy, percutaneous; tibioperoneal trunk
and branches
Bypass graft, w/ vein; carotid
Bypass graft, w/ vein; carotid-subclavian
Bypass graft, w/ vein; subclavian-carotid
Bypass graft, w/ vein; carotid-vertebral
Bypass graft, w/ vein; carotid-carotid
Bypass graft, w/ vein; subclavian-subclavian
Bypass graft, w/ vein; subclavian-vertebral
Bypass graft, w/ vein; subclavian-axillary
Bypass graft, w/ vein; axillary-axillary
Bypass graft, w/ vein; axillary-femoral
Page 45 of 98
Professional Fee
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
35526
35531
35533
35536
35541
35546
35548
35549
35551
35556
35558
35560
35563
35565
35566
35571
DESCRIPTION
Bypass graft, w/ vein; aortosubclavian or carotid
Bypass graft, w/ vein; aortoceliac or aortomesenteric
Bypass graft, w/ vein; axillary-femoral-femoral
Bypass graft, w/ vein; splenorenal
Bypass graft, w/ vein; aortoiliac or bi-iliac
Bypass graft, w/ vein; aortofemoral or bifemoral
Bypass graft, w/ vein; aortoilliofemoral, unilateral
Bypass graft, w/ vein; aortoilliofemoral, bilateral
Bypass graft, w/ vein; aortofemoral - popliteal
Bypass graft, w/ vein; femoral - popliteal
Bypass graft, w/ vein; femoral-femoral
Bypass graft, w/ vein; aortorenal
Bypass graft, w/ vein; ilioiliac
Bypass graft, w/ vein; iliofemoral
Bypass graft, w/ vein; femoral - anterior tibial, posterior tibial, peroneal
artery or other distal vessels
46,500
46,500
46,500
46,500
46,500
46,500
46,500
46,500
46,500
30,300
23,300
37,800
30,300
30,300
25,200
25,200
25,200
25,200
25,200
25,200
25,200
25,200
25,200
16,800
12,600
21,000
16,800
16,800
Health Care
Institution Fee
21,300
21,300
21,300
21,300
21,300
21,300
21,300
21,300
21,300
13,500
10,700
16,800
13,500
13,500
30,300
16,800
13,500
Bypass graft, w/ vein; popliteal-tibial, peroneal artery or other distal vessels
23,300
12,600
10,700
46,500
25,200
21,300
37,800
21,000
16,800
37,800
21,000
16,800
37,800
37,600
37,600
37,600
37,600
37,600
37,600
46,500
21,000
18,900
18,900
18,900
18,900
18,900
18,900
25,200
16,800
18,700
18,700
18,700
18,700
18,700
18,700
21,300
46,500
25,200
21,300
46,500
25,200
21,300
46,500
37,600
37,600
46,500
37,600
46,500
37,600
30,300
23,300
30,300
30,300
25,200
18,900
18,900
25,200
18,900
25,200
18,900
16,800
12,600
16,800
16,800
21,300
18,700
18,700
21,300
18,700
21,300
18,700
13,500
10,700
13,500
13,500
30,300
16,800
13,500
Case Rate
35587
35601
35606
35612
35616
35621
35623
35626
In-situ vein bypass; aortofemoral-popliteal (only femoral-popliteal portion insitu)
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
Bypass graft, with other than vein; carotid
Bypass graft, with other than vein; carotid-subclavian
Bypass graft, with other than vein; subclavian-subclavian
Bypass graft, with other than vein; subclavian-axillary
Bypass graft, with other than vein; axillary-femoral
Bypass graft, with other than vein; axillary-popliteal or -tibial
Bypass graft, with other than vein; aortosubclavian or carotid
35631
Bypass graft, with other than vein; aortoceliac, aortomesenteric, aortorenal
35582
35583
35585
35636
35641
35642
35645
35646
35650
35651
35654
35656
35661
35663
35665
35666
Bypass graft, with other than vein; splenorenal (splenic to renal arterial
anastomosis)
Bypass graft, with other than vein; aortoiliac or bi-iliac
Bypass graft, with other than vein; carotid-vertebral
Bypass graft, with other than vein; subclavian-vertebral
Bypass graft, with other than vein; aortofemoral or bifemoral
Bypass graft, with other than vein; axillary-axillary
Bypass graft, with other than vein; aortofemoral-popliteal
Bypass graft, with other than vein; 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
Professional Fee
35671
Bypass graft, with other than vein; popliteal-tibial or -peroneal artery
23,300
12,600
10,700
35681
35691
35693
35694
35695
Bypass graft, composite
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
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), w/ or w/o lysis of artery;
carotid artery
Exploration (not followed by surgical repair), w/ or w/o lysis of artery;
femoral artery
Exploration (not followed by surgical repair), w/ or w/o lysis of artery;
popliteal artery
Exploration (not followed by surgical repair), w/ or w/o lysis of artery; other
vessels
46,500
37,600
37,600
37,600
37,600
25,200
18,900
18,900
18,900
18,900
21,300
18,700
18,700
18,700
18,700
18,000
8,400
9,600
18,000
8,400
9,600
18,000
8,400
9,600
18,000
8,400
9,600
18,000
8,400
9,600
35700
35701
35721
35741
35761
35800
Exploration for postoperative hemorrhage, thrombosis or infection; neck
9,700
4,200
5,500
35820
Exploration for postoperative hemorrhage, thrombosis or infection; chest
18,000
8,400
9,600
18,000
8,400
9,600
35840
35860
35870
35875
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;
Page 46 of 98
9,700
4,200
5,500
23,300
23,300
12,600
12,600
10,700
10,700
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
36013
36014
Thrombectomy of arterial or venous graft; w/ revision of arterial or venous
graft
Excision of infected graft; neck
Excision of infected graft; extremity
Excision of infected graft; thorax
Excision of infected graft; abdomen
Introduction of catheter, superior or inferior vena cava
Selective catheter placement, venous system; first order branch (e.g., renal
vein, jugular vein)
Selective catheter placement, venous system; second order, or more
selective, branch (e.g., left adrenal vein, petrosal sinus)
Introduction of catheter, right heart or main pulmonary artery
Selective catheter placement, left or right pulmonary artery
36015
Selective catheter placement, segmental or subsegmental pulmonary artery
8,440
2,940
5,500
36100
36120
36140
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 catheter, aorta
Selective catheter placement, arterial system; each first order thoracic or
brachiocephalic branch, w/in a vascular family
Selective catheter placement, arterial system; initial second order thoracic
or brachiocephalic branch, w/in a vascular family
8,440
9,300
9,300
2,940
2,100
2,100
5,500
7,200
7,200
8,260
3,360
4,900
9,300
2,100
7,200
9,300
2,100
7,200
9,300
2,100
7,200
35876
35901
35903
35905
35907
36010
36011
36012
36145
36200
36215
36216
23,300
12,600
10,700
30,300
30,300
37,800
30,300
3,640
16,800
16,800
21,000
16,800
840
13,500
13,500
16,800
13,500
2,800
9,300
2,100
7,200
8,020
2,520
5,500
8,020
8,020
2,520
2,520
5,500
5,500
36217
Selective catheter placement, arterial system; initial third order or more
selective thoracic or brachiocephalic branch, w/in a vascular family
8,020
2,520
5,500
36245
Selective catheter placement, arterial system; each first order abdominal,
pelvic, or lower extremity artery branch, w/in a vascular family
9,300
2,100
7,200
36246
Selective catheter placement, arterial system; initial second order
abdominal, pelvic or lower extremity artery branch, w/in a vascular family
9,300
2,100
7,200
8,020
2,520
5,500
23,300
12,600
10,700
9,700
9,700
4,200
4,200
5,500
5,500
36261
36262
Selective catheter placement, arterial system; initial third order or more
selective abdominal, pelvic or lower extremity artery branch, w/in a vascular
family
Insertion of implantable intra-arterial infusion pump (e.g., for chemotherapy
of liver)
Revision of implanted intra-arterial infusion pump
Removal of implanted intra-arterial infusion pump
36430
Outpatient Transfusion of Blood or Blood Products; one or more units
3,640
840
2,800
36450
36481
Exchange transfusion, blood
Percutaneous portal vein catheterization by any method
Placement of central venous catheter (subclavian, jugular, or other vein)
(e.g., for central venous pressure, hyperalimentation, hemodialysis, or
chemotherapy); percutaneous or cutdown
Catheterization of umbilical vein for diagnosis or therapy, newborn
Therapeutic apheresis
Insertion of peripherally inserted central venous catheter (PICC)
Arterial catheterization for prolonged infusion therapy (chemotherapy),
cutdown
Catheterization, umbilical artery, newborn, for diagnosis or therapy
Percutaneousportal vein catheterization by any method
Insertion of cannula for hemodialysis, other purpose ; vein to vein
Insertion of cannula for hemodialysis, other purpose ; arteriovenous,
external (Scribner type)
Insertion of cannula for hemodialysis, other purpose ; arteriovenous,
external revision, or closure
Arteriovenous anastomosis, direct, any site (e.g., Cimino type)
Insertion of cannula(s) for prolonged extracorporeal circulation for
cardiopulmonary insufficiency (ECMO)
Creation of arteriovenous fistula by other than direct arteriovenous
anastomosis ; autogenous graft
Creation of arteriovenous fistula by other than direct arteriovenous
anastomosis ; nonautogenous graft
Revision of an arteriovenous fistula, w/ or w/o thrombectomy, autogenous
or nonautogenous graft
Plastic repair of arteriovenous aneurysm
Insertion of Thomas shunt
Venous anastomosis; portocaval
Venous anastomosis; renoportal
Venous anastomosis; caval-mesenteric
Venous anastomosis; splenorenal, proximal
Venous anastomosis; splenorenal, distal (selective decompression of
esophagogastric varices, any technique)
5,680
9,300
1,680
2,100
4,000
7,200
9,700
4,200
5,500
3,640
3,640
9,700
840
840
4,200
2,800
2,800
5,500
3,640
840
2,800
5,680
9,300
9,300
1,680
2,100
2,100
4,000
7,200
7,200
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
18,000
8,400
9,600
12,900
6,300
6,600
12,900
6,300
6,600
9,700
4,200
5,500
8,260
9,300
30,300
37,800
30,300
37,600
3,360
2,100
16,800
21,000
16,800
18,900
4,900
7,200
13,500
16,800
13,500
18,700
37,800
21,000
16,800
36247
36260
36488
36510
36511
36568
36640
36660
36781
36800
36810
36815
36821
36822
36825
36830
36832
36834
36835
37140
37145
37160
37180
37181
Page 47 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
DESCRIPTION
Case Rate
37200
Insertion of transvenous intrahepatic portosystemic shunt(s) (TIPS) includes
venous access, hepatic and portal vein catheterization, portography,
hemodynamic evaluation, intrahepatic tract formation/dilatation, stent
placement and all associated imaging g
Primary percutaneous transluminal mechanical thrombectomy, noncoronary, arterial or arterial bypass graft including fluoroscopic guidance
and intraprocedural pharmacological thrombolytic injections; one or more
vessels
Percutaneous transluminal mechanical thrombectomy, veins, including
intraprocedural pharmacological thrombolytic injections and fluoroscopic
guidance; one or more vessels
Transcatheter biopsy
37201
Transcatheter therapy, infusion for thrombolysis other than coronary
37182
37184
37187
37202
37203
37204
37205
37207
37565
37600
37605
37606
37607
37609
37615
37616
37617
37618
37620
37650
37660
37700
37720
37730
Transchatheter therapy, infusion other than for thrombolysis, any type (e.g.,
spasmolytic, vasoconstrictive)
Transcatheter retrieval, percutaneous, of intravascular foreign body (e.g.,
fractured venous or arterial catheter)
Transcatheter occlusion or embolization (e.g., 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), (non-coronary vessel),
percutaneous; initial vessel
Transcatheter placement of an intravascular stent(s), (non-coronary vessel),
open; initial vessel
Ligation, internal jugular vein
Ligation; external carotid artery
Ligation; internal or common carotid artery
Ligation; internal or common carotid artery, w/ gradual occlusion, as w/
Selverstone or Crutchfield camp
Ligation or banding of angioaccess arteriovenous fistula
Ligation or biopsy, temporal artery
Ligation, major artery (e.g., post-traumatic, rupture); neck
Ligation, major artery (e.g., post-traumatic, rupture); chest
Ligation, major artery (e.g., post-traumatic, rupture); abdomen
Ligation, major artery (e.g., 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 and division and complete stripping of long or short saphenous
veins
Ligation and division and complete stripping of long and short saphenous
veins
Professional Fee
Health Care
Institution Fee
53,400
29,400
24,000
46,500
25,200
21,300
46,500
25,200
21,300
8,260
3,360
4,900
8,020
2,520
5,500
8,020
2,520
5,500
9,700
4,200
5,500
46,500
25,200
21,300
46,500
25,200
21,300
23,300
12,600
10,700
5,680
5,680
18,000
1,680
1,680
8,400
4,000
4,000
9,600
21,940
9,240
12,700
9,300
9,300
18,000
21,400
18,000
12,900
2,100
2,100
8,400
10,500
8,400
6,300
7,200
7,200
9,600
10,900
9,600
6,600
23,300
12,600
10,700
9,300
12,900
2,100
6,300
7,200
6,600
9,300
2,100
7,200
12,900
6,300
6,600
18,000
8,400
9,600
37735
Ligation and division and complete stripping of long or short saphenous
veins w/ radical excision of ulcer and skin graft and/or interruption of
communicating veins of lower leg, w/ excision of deep fascia
21,400
10,500
10,900
37760
Ligation of perforators, subfascial, radical (Linton type), w/ or w/o skin graft
21,400
10,500
10,900
37780
Ligation and division of short saphenous vein at saphenopopliteal junction
9,700
4,200
5,500
37788
37790
38100
38101
Penile revascularization, artery, w/ or w/o vein graft
Penile venous occlusive procedure
Splenectomy; total
Splenectomy; partial
Splenectomy; total, en bloc for extensive disease, in conjuction w/ other
procedure
46,500
23,300
30,740
23,300
25,200
12,600
13,440
12,600
21,300
10,700
17,300
10,700
32,000
14,700
17,300
38115
Repair of ruptured spleen (splenorrhaphy) w/ or w/o partial splenectomy
30,300
16,800
13,500
38120
Laparoscopy, surgical; splenectomy
30,740
13,440
17,300
38205
Blood-derived hematopoietic progenitor cell harvesting for transplantation
10,880
3,780
7,100
38220
38230
Bone marrow aspiration or biopsy
Bone marrow harvesting for transplantation
Bone marrow or peripheral blood derived peripheral stem cell
transplantation
Drainage of lymph node abscess or lymphadenitis
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 or lymph node(s); superficial
10,880
18,000
3,780
8,400
7,100
9,600
37,800
21,000
16,800
8,260
30,300
30,300
30,300
5,680
3,360
16,800
16,800
16,800
1,680
4,900
13,500
13,500
13,500
4,000
38102
38240
38300
38380
38381
38382
38500
Page 48 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
38505
38510
38520
38525
38530
38542
38550
38555
38570
38571
38572
38700
38720
38724
38740
38745
38746
38747
38760
38765
38770
38780
39000
39010
39200
39220
39400
39501
39502
39503
39520
39530
DESCRIPTION
Case Rate
Biopsy or excision or lymph node(s); by needle, superficial (e.g., cervical,
inguinal, axillary)
Biopsy or excision or lymph node(s); deep cervical node(s)
Biopsy or excision or lymph node(s); deep cervical node(s) w/ excision
scalene fat pad
Biopsy or excision or lymph node(s); deep axillary node(s)
Biopsy or excision or lymph node(s); internal mammary node(s)
Dissection, deep jugular node(s)
Excision of cystic hygroma, axillary or cervical; w/o deep neurovascular
dissection
Excision of cystic hygroma, axillary or cervical; w/ deep neurovascular
dissection
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 periaortic lymph node sampling (biopsy), single or multiple
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
Abdominal lymphadenectomy, regional, including celiac, para-aortic and
venal caval nodes
Inguinofemoral lymphadenectomy, superficial, including Cloquets node
Inguinofemoral lymphadenectomy, superficial, in continuity w/ pelvic
lymphadenectomy, including external iliac, hypogastric, and obturator
nodes
Pelvic lymphadenectomy, including external iliac, hypogastric, and obturator
nodes
Retroperitoneal transabdominal lymphadenectomy, extensive, including
pelvic, aortic, and renal nodes
Mediastinotomy with exploration, drainage, removal of foreign body, or
biopsy; cervical approach
Transthoracic approach, including either transthoracic or median
sternotomy
Excision of mediastinal cyst
Excision of mediastinal tumor
Mediastinoscopy, with or without biopsy
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
Professional Fee
Health Care
Institution Fee
5,680
1,680
4,000
8,260
3,360
4,900
9,300
2,100
7,200
9,300
9,300
21,940
2,100
2,100
9,240
7,200
7,200
12,700
37,800
21,000
16,800
46,500
25,200
21,300
27,120
15,120
12,000
30,300
16,800
13,500
58,800
37,800
21,000
27,120
30,300
30,300
23,300
30,300
15,120
16,800
16,800
12,600
16,800
12,000
13,500
13,500
10,700
13,500
37,800
21,000
16,800
23,300
12,600
10,700
23,300
12,600
10,700
23,300
12,600
10,700
37,800
21,000
16,800
37,800
21,000
16,800
18,000
8,400
9,600
23,300
12,600
10,700
37,800
41,160
14,960
37,800
21,000
24,360
7,560
21,000
16,800
16,800
7,400
16,800
40,320
23,520
16,800
40,320
23,520
16,800
40,320
23,520
16,800
40,320
23,520
16,800
39531
Repair, diaphragmatic hernia (esophageal hiatal); combined,
thoracoabdominal, with dilation of stricture (with or without gastroplasty)
40,320
23,520
16,800
39540
Repair, diaphragmatic hernia (other than neonatal), traumatic; acute
40,320
23,520
16,800
39541
Repair, diaphragmatic hernia (other than neonatal), traumatic; chronic
46,500
25,200
21,300
40,320
23,520
16,800
5,560
8,020
8,020
8,020
1,260
2,520
2,520
2,520
4,300
5,500
5,500
5,500
23,300
12,600
10,700
30,740
13,440
17,300
8,260
9,700
9,700
9,700
3,360
4,200
4,200
4,200
4,900
5,500
5,500
5,500
37,800
21,000
16,800
37,800
21,000
16,800
39545
40490
40500
40510
40520
40525
40527
40530
40650
40652
40654
40700
40701
Imbrication of diaphragm for eventration, transthoracic or transabdominal,
paralytic or nonparalytic
Biopsy of lip
Vermilionectomy (lip shave), w/ mucosal advancement
Excision of lip; transverse wedge excision w/ primary closure
V-excision w/ primary defect linear closure;
V-excision w/ primary defect linear closure; full thickness, reconstruction w/
local flap (e.g., Estlander or fan)
V-excision w/ primary defect linear closure; full thickness, reconstruction w/
cross lip flap (Abbe-Estlander)
Resection of lip, more than one-fourth, w/o 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
Page 49 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
DESCRIPTION
Case Rate
40830
40831
40840
40842
40843
40844
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; w/ cross lip pedicle flap (AbbeEstlander type), including sectioning and inserting of pedicle
Drainage of abscess, cyst, hematoma, vestibule of mouth
Biopsy, vestibule of mouth
Excision of lesion of mucosa and submucosa, vestibule of mouth
Excision of mucosa of vestibule of mouth as donor graft
Excision of frenum, labial or buccal (frenumectomy, frenulectomy,
frenectomy)
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
40845
Vestibuloplasty; complex (including ridge extension, muscle repositioning)
40702
40720
40761
40800
40808
40810
40818
40819
Professional Fee
Health Care
Institution Fee
30,300
16,800
13,500
30,300
16,800
13,500
37,800
21,000
16,800
5,680
5,680
5,680
8,440
1,680
1,680
1,680
2,940
4,000
4,000
4,000
5,500
9,300
2,100
7,200
5,680
5,680
12,120
12,120
12,120
18,000
1,680
1,680
6,720
6,720
6,720
8,400
4,000
4,000
5,400
5,400
5,400
9,600
18,000
8,400
9,600
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
5,680
1,680
4,000
5,560
5,560
5,560
9,300
9,300
9,300
9,300
9,300
9,300
8,260
10,880
37,800
1,260
1,260
1,260
2,100
2,100
2,100
2,100
2,100
2,100
3,360
3,780
21,000
4,300
4,300
4,300
7,200
7,200
7,200
7,200
7,200
7,200
4,900
7,100
16,800
37,800
21,000
16,800
37,800
21,000
16,800
40,320
23,520
16,800
46,500
25,200
21,300
53,400
29,400
24,000
9,700
4,200
5,500
9,700
4,200
5,500
41251
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
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
Biopsy of tongue; anterior two-thirds
Biopsy of tongue; posterior one-third
Biopsy of floor of mouth
Excision of lesion of tongue w/o closure
Excision of lesion of tongue w/ closure; anterior two-thirds
Excision of lesion of tongue w/ closure; posterior one-third
Excision of lesion of tongue w/ closure; w/ local tongue flap
Excision of lingual frenum (frenectomy)
Excision, lesion of floor of mouth
Glossectomy; less than one-half tongue
Glossectomy; hemiglossectomy
Glossectomy; partial, w/ unilateral radical neck dissection
Glossectomy; complete or total, w/ or w/o tracheostomy, w/o radical neck
dissection
Glossectomy; complete or total, w/ or w/o tracheostomy, w/ unilateral
radical neck dissection
Glossectomy; composite procedure w/ resection floor of mouth and
mandibular resection, w/o radical neck dissection
Glossectomy; composite procedure w/ resection floor of mouth, w/
suprahyoid neck dissection
Glossectomy; composite procedure w/ 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 twothirds of tongue
Repair of laceration 2.5 cm or less; posterior one-third of tongue
41252
Repair of laceration of tongue, floor of mouth, over 2.6 cm or complex
9,700
4,200
5,500
41500
41510
41520
41800
Frenoplasty (surgical revision of frenum, eg, w/ Z-plasty)
Suture of tongue to lip for micrognathia (Douglas type procedure)
Frenoplasty (surgical revision of frenum, eg, w/ Z-plasty)
Drainage of abscess, cyst, hematoma from dentoalveolar structures
Removal of embedded foreign body from dentoalveolar structures; soft
tissues
9,700
9,700
9,700
5,680
4,200
4,200
4,200
1,680
5,500
5,500
5,500
4,000
3,640
840
2,800
41806
Removal of embedded foreign body from dentoalveolar structures; bone
3,640
840
2,800
41820
41821
Gingivectomy, excision gingiva
Operculectomy, excision pericoronal tissues
8,020
8,020
2,520
2,520
5,500
5,500
41000
41005
41006
41007
41008
41009
41015
41016
41017
41018
41100
41105
41108
41110
41112
41113
41114
41115
41116
41120
41130
41135
41140
41145
41150
41153
41155
41250
41805
Page 50 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
DESCRIPTION
41822
41823
Excision of fibrous tuberosities, dentoalveolar structures
Excision of osseous tuberosities, dentoalveolar structures
8,020
8,020
2,520
2,520
Health Care
Institution Fee
5,500
5,500
41825
Excision of lesion or or tumor (except listed above), dentoalveolar structures
8,020
2,520
5,500
41828
41830
41850
41870
41872
41874
42000
42100
42104
42106
42107
42120
42140
8,020
8,260
8,260
8,260
18,000
18,000
8,020
5,560
5,680
9,300
9,300
20,980
12,120
2,520
3,360
3,360
3,360
8,400
8,400
2,520
1,260
1,680
2,100
2,100
10,080
6,720
5,500
4,900
4,900
4,900
9,600
9,600
5,500
4,300
4,000
7,200
7,200
10,900
5,400
23,300
12,600
10,700
42160
42180
42182
42200
Excision of hyperplastic alveolar mucosa
Alveolectomy, including curettage of osteitis or sequestrectomy
Destruction of lesion (except excision), dentoalveolar structures
Periodontal mucosal grafting
Gingivoplasty
Alveoloplasty
Drainage of abscess of palate, uvula
Biopsy of palate, uvula
Excision, lesion of palate , uvula; w/o closure
Excision, lesion of palate , uvula; w/ simple primary closure
Excision, lesion of palate , uvula; w/ local flap closure
Resection of palate or extensive resection of lesion
Uvulectomy, excision of uvula
Palatopharyngoplasty (e.g., 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
10,540
12,120
18,000
20,980
5,040
6,720
8,400
10,080
5,500
5,400
9,600
10,900
42205
Palatoplasty for cleft palate, w/ closure of alveolar ridge; soft tissue only
21,820
10,920
10,900
22,660
11,760
10,900
23,300
23,300
30,740
23,300
23,300
23,300
12,120
5,680
5,680
5,680
5,680
9,300
12,600
12,600
13,440
12,600
12,600
12,600
6,720
1,680
1,680
1,680
1,680
2,100
10,700
10,700
17,300
10,700
10,700
10,700
5,400
4,000
4,000
4,000
4,000
7,200
9,300
2,100
7,200
5,560
5,560
9,300
9,300
1,260
1,260
2,100
2,100
4,300
4,300
7,200
7,200
23,300
12,600
10,700
30,300
16,800
13,500
30,300
16,800
13,500
30,300
16,800
13,500
37,800
21,000
16,800
18,000
18,000
18,000
8,400
8,400
8,400
9,600
9,600
9,600
42145
Case Rate
42400
42405
42408
42409
Palatoplasty for cleft palate, w/ closure of alveolar ridge; w/ 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, w/ island flap
Repair of anterior palate, including vomer flap
Repair of nasolabial fistula
Drainage of abscess; parotid
Drainage of abscess; submaxillary or sublingual, intraoral
Drainage of abscess; submaxillary, external
Fistulization of sublingual salivary cyst (ranula);
Fistulization of sublingual salivary cyst (ranula); w/ prosthesis
Sialolithotomy; submandibular (submaxillary), sublingual or parotid,
intraoral
Biopsy of salivary gland; needle
Biopsy of salivary gland; incisional
Excision of sublingual salivary cyst (ranula)
Marsupialization of sublingual salivary cyst (ranula)
42410
Excision of parotid tumor or parotid gland; lateral lobe, w/o nerve dissection
42210
42215
42220
42225
42226
42227
42235
42260
42300
42310
42320
42325
42326
42330
Professional Fee
42440
42450
42500
Excision of parotid tumor or parotid gland; lateral lobe, w/ dissection and
preservation of facial nerve
Excision of parotid tumor or parotid gland; total, w/ dissection and
preservation of facial nerve
Excision of parotid tumor or parotid gland; total, en bloc removal w/
sacrifice of facial nerve
Excision of parotid tumor or parotid gland; total, w/ unilateral radical neck
dissection
Excision of submandibular (submaxillary) gland
Excision of sublingual gland
Plastic repair of salivary duct, sialodochoplasty; primary or simple
42505
Plastic repair of salivary duct, sialodochoplasty; secondary or complicated
18,000
8,400
9,600
42507
Parotid duct diversion, bilateral (Wilke type procedure);
Parotid duct diversion, bilateral (Wilke type procedure); w/ excision of one
submandibular gland
Parotid duct diversion, bilateral (Wilke type procedure); w/ excision of both
submandibular glands
Parotid duct diversion, bilateral (Wilke type procedure); w/ ligation of both
submandibular (Whartons) ducts
Closure salivary fistula
Ligation salivary duct, intraoral
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
18,000
8,400
9,600
18,000
8,400
9,600
18,000
8,400
9,600
18,000
8,400
9,600
8,260
8,260
8,260
3,360
3,360
3,360
4,900
4,900
4,900
8,260
3,360
4,900
8,260
3,360
4,900
8,020
8,020
8,020
2,520
2,520
2,520
5,500
5,500
5,500
42415
42420
42425
42426
42508
42509
42510
42600
42665
42700
42720
42725
42800
42802
42804
Page 51 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
42806
42808
42809
42810
42815
42820
42825
42830
42835
42842
42844
42845
42860
42870
42890
42892
DESCRIPTION
8,020
8,020
8,020
2,520
2,520
2,520
Health Care
Institution Fee
5,500
5,500
5,500
18,000
8,400
9,600
18,000
8,400
9,600
18,000
18,000
18,000
18,000
8,400
8,400
8,400
8,400
9,600
9,600
9,600
9,600
10,540
5,040
5,500
12,120
6,720
5,400
12,120
6,720
5,400
8,020
8,020
37,800
2,520
2,520
21,000
5,500
5,500
16,800
46,500
25,200
21,300
Case Rate
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
Tonsillectomy, primary or secondary
Adenoidectomy, primary
Adenoidectomy, secondary
Radical resection of tonsil, tonsillar pillars, and/or retromolar trigone; w/o
closure
Radical resection of tonsil, tonsillar pillars, and/or retromolar trigone;
closure w/ local flap (e.g., tongue, buccal)
Radical resection of tonsil, tonsillar pillars, and/or retromolar trigone;
closure w/ other flap
Excision of tonsil tags
Excision or destruction lingual tonsil, any method
Limited pharyngectomy
Resection of lateral pharyngeal wall or pyriform sinus, direct closure by
advancement of lateral and posterior pharyngeal walls
Professional Fee
42894
Resection of pharyngeal wall requiring closure w/ myocutaneous flap
53,400
29,400
24,000
42900
42950
42953
42955
43020
43030
43045
43100
Suture pharynx for wound or injury
Pharyngoplasty (plastic or reconstructive operation on pharynx)
Pharyngoesophageal repair
Pharyngostomy (fistulization of pharynx, external for feeding)
Esophagotomy, cervical approach, w/ removal of foreign body
Cricopharyngeal myotomy
Esophagotomy, thoracic approach, w/ removal of foreign body
Excision of lesion, esophagus, w/ primary repair; cervical approach
Excision of lesion, esophagus, w/ primary repair; thoracic or abdominal
approach
20,980
20,980
23,300
8,020
12,120
18,000
37,800
23,300
10,080
10,080
12,600
2,520
6,720
8,400
21,000
12,600
10,900
10,900
10,700
5,500
5,400
9,600
16,800
10,700
37,800
21,000
16,800
55,000
33,600
21,400
58,800
37,800
21,000
59,640
38,640
21,000
63,000
42,000
21,000
55,000
33,600
21,400
55,000
33,600
21,400
58,800
37,800
21,000
55,000
33,600
21,400
55,000
33,600
21,400
58,800
37,800
21,000
46,500
25,200
21,300
23,300
12,600
10,700
37,800
21,000
16,800
10,540
5,040
5,500
10,540
5,040
5,500
14,960
7,560
7,400
43101
43107
43108
43112
43113
43116
43117
43118
43121
43122
Total or near esophagectomy, w/o thoracotomy; w/ pharyngogastrostomy
or cervical esophagogastrostomy, w/ or w/o pyloroplasty (transhiatal)
Total or near esophagectomy, w/o thoracotomy; w/ colon interposition or
small bowel reconstruction, including bowel mobilization, preparation and
anastomosis(es)
Total or near total esophagectomy, w/ thoracotomy; w/
pharyngogastrostomy, or cervical esophagogastrostomy, w/ or w/o
pyloroplasty
Total or near total esophagectomy, w/ thoracotomy; w/ colon interposition
or small bowel reconstruction, including bowel mobilization, preparation
and anastomosis(es)
Partial esophagectomy, cervical, w/ free intestinal graft, including
microvascular anastomosis, obtaining the graft and intestinal reconstruction
Partial esophagectomy, distal two-thirds, w/ thoracotomy and separate
abdominal incision, w/ or w/o proximal gastrectomy; w/ thoracic
esophagogastrotomy, w/ or w/o pyloroplasty (Ivor Lewis)
Partial esophagectomy, distal two-thirds, w/ thoracotomy and separate
abdominal incision, w/ or w/o proximal gastrectomy; w/ colon interposition
or small bowel reconstruction, including bowel mobilization, preparation,
and anastomosis(ses)
Partial esophagectomy, distal two-thirds, w/ thoracotomy only, w/ or w/o
proximal gastrectomy, w/ thoracic esophagogastrostomy, w/ or w/o
pyloroplasty
Partial esophagectomy, thoracoabdominal or abdominal approach, w/ or
w/o proximal gastrectomy; w/ esophagogastrotomy, w/ or w/o pyloroplasty
43202
Partial esophagectomy, thoracoabdominal or abdominal approach, w/ or
w/o proximal gastrectomy; w/ colon interposition or small bowel
reconstruction, including bowel mobilization, preparation, and
anastomosis(ses)
Total or partial esophagectomy, w/o reconstruction (any approach), w/
cervical esophagostomy
Diverticulectomy of hypopharynx, or esophagus, w/ or w/o myotomy;
cervical approach
Diverticulectomy of hypopharynx, or esophagus, w/ or w/o myotomy;
thoracic approach
Esophagoscopy, rigid or flexible; diagnostic, w/ or w/o collection of
specimen(s) by brushing or washing
Esophagoscopy, rigid or flexible; w/ biopsy, single or multiple
43204
Esophagoscopy, rigid or flexible; w/ injection sclerosis of esophageal varices
43123
43124
43130
43135
43200
Page 52 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
43205
Esophagoscopy, rigid or flexible; w/ band ligation of esophageal varices
14,960
7,560
7,400
43215
Esophagoscopy, rigid or flexible; w/ removal of foreign body
Esophagoscopy, rigid or flexible; w/ removal of tumor(s), polyp(s), or other
lesion(s) by hot biopsy forceps or bipolar cautery
Esophagoscopy, rigid or flexible; w/ removal of tumor(s), polyp(s), or other
lesion(s) by snare technique
Esophagoscopy, rigid or flexible; w/ insertion of plastic tube or stent
Esophagoscopy, rigid or flexible; w/ balloon dilation (less than 30 mm
diameter)
Esophagoscopy, rigid or flexible; w/ insertion of guide wire followed by
dilation over guide wire
Esophagoscopy, rigid or flexible; w/ control of bleeding, any method
Esophagoscopy, rigid or flexible; w/ 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, simple primary examination ( e.g. w/
small diameter flexible endoscope)
14,960
7,560
7,400
11,980
5,880
6,100
12,120
6,720
5,400
18,000
8,400
9,600
18,000
8,400
9,600
18,000
8,400
9,600
14,960
7,560
7,400
18,000
8,400
9,600
10,540
5,040
5,500
43216
43217
43219
43220
43226
43227
43228
43234
43235
Upper gastrointestinal endoscopy including esophagus, stomach, and either
the duodenum and/or jejunum as appropriate; diagnostic, w/ or w/o
collection of specimen(s) by brushing or washing
10,540
5,040
5,500
43239
Upper gastrointestinal endoscopy including esophagus, stomach, and either
the duodenum and/or jejunum as appropriate; w/ biopsy, single or multiple
10,540
5,040
5,500
12,120
6,720
5,400
14,960
7,560
7,400
14,960
7,560
7,400
18,000
8,400
9,600
18,000
8,400
9,600
43241
43243
43244
43245
43246
Upper gastrointestinal endoscopy including esophagus, stomach, and either
the duodenum and/or jejunum as appropriate; w/ transendoscopic tube or
catheter placement
Upper gastrointestinal endoscopy including esophagus, stomach, and either
the duodenum and/or jejunum as appropriate; w/ injection sclerosis of
esophageal and/or gastric varices
Upper gastrointestinal endoscopy including esophagus, stomach, and either
the duodenum and/or jejunum as appropriate; w/ band ligation of
esophageal and/or gastric varices
Upper gastrointestinal endoscopy including esophagus, stomach, and either
the duodenum and/or jejunum as appropriate; w/ dilation of gastric outlet
for obstruction, any method
Upper gastrointestinal endoscopy including esophagus, stomach, and either
the duodenum and/or jejunum as appropriate; w/ directed placement of
percutaneous gastrostomy tube
43247
Upper gastrointestinal endoscopy including esophagus, stomach, and either
the duodenum and/or jejunum as appropriate; w/ removal or foreign body
14,960
7,560
7,400
43248
Upper gastrointestinal endoscopy including esophagus, stomach, and either
the duodenum and/or jejunum as appropriate; w/ insertion of guide wire
followed by dilation of esophagus over guide wire
18,000
8,400
9,600
43249
Upper gastrointestinal endoscopy including esophagus, stomach, and either
the duodenum and/or jejunum as appropriate; w/ ballon dilation of
esophagus (less than 30 mm diameter)
18,000
8,400
9,600
43250
Upper gastrointestinal endoscopy including esophagus, stomach, and either
the duodenum and/or jejunum as appropriate; w/ removal of tumor(s),
polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery
11,980
5,880
6,100
12,120
6,720
5,400
14,960
7,560
7,400
18,000
8,400
9,600
14,960
7,560
7,400
20,980
10,080
10,900
20,980
10,080
10,900
21,820
10,920
10,900
21,820
10,920
10,900
43251
43255
43258
43259
43260
43261
43262
43263
Upper gastrointestinal endoscopy including esophagus, stomach, and either
the duodenum and/or jejunum as appropriate; w/ 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; w/ control of bleeding, any
method
Upper gastrointestinal endoscopy including esophagus, stomach, and either
the duodenum and/or jejunum as appropriate; w/ 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; w/ endoscopic ultrasound
examination
Endoscopic retrograde cholangiopancreatography (ERCP); diagnostic, w/ or
w/o collection of specimen(s) by brushing or washing
Endoscopic retrograde cholangiopancreatography (ERCP); w/ biopsy, single
or multiple
Endoscopic retrograde cholangiopancreatography (ERCP); w/
sphincterotomy/papillotomy
Endoscopic retrograde cholangiopancreatography (ERCP); w/ pressure
measurement of sphincter of Oddi (pancreatic duct or common bile duct)
Page 53 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
43264
Endoscopic retrograde cholangiopancreatography (ERCP); w/ endoscopic
retrograde removal of stone(s) from biliary and/or pancreatic ducts
23,300
12,600
10,700
43265
Endoscopic retrograde cholangiopancreatography (ERCP); w/ endoscopic
retrograde destruction, lithotripsy of stone(s), any method
30,740
13,440
17,300
43267
Endoscopic retrograde cholangiopancreatography (ERCP); w/ endoscopic
retrograde insertion of nasobiliary or nasopancreatic drainage tube
22,660
11,760
10,900
43268
Endoscopic retrograde cholangiopancreatography (ERCP); w/ endoscopic
retrograde insertion of tube or stent into bile or pancreatic duct
22,660
11,760
10,900
43269
Endoscopic retrograde cholangiopancreatography (ERCP); w/ endoscopic
retrograde removal of foreign body and/or change of tube or stent
22,660
11,760
10,900
43271
Endoscopic retrograde cholangiopancreatography (ERCP); w/ endoscopic
retrograde balloon dilation of ampulla, biliary and/or pancreatic duct(s)
23,300
12,600
10,700
23,300
12,600
10,700
46,500
25,200
21,300
30,300
16,800
13,500
30,300
16,800
13,500
46,500
25,200
21,300
53,400
29,400
24,000
46,500
25,200
21,300
43272
43280
43300
43305
43310
43312
43320
Endoscopic retrograde cholangiopancreatography (ERCP); w/ 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, esophagogastic fundoplasty (e.g., Nissen, Toupet
procedures)
Esophagoplasty, (plastic repair or reconstruction), cervical approach; w/o
repair of tracheoesophageal fistula
Esophagoplasty, (plastic repair or reconstruction), cervical approach; w/
repair of tracheoesophageal fistula
Esophagoplasty, (plastic repair or reconstruction), thoracic approach; w/o
repair of tracheoesophageal fistula
Esophagoplasty, (plastic repair or reconstruction), thoracic approach; w/
repair of tracheoesophageal fistula
Esophagogastrostomy (cardioplasty), w/ or w/o vagotomy and pyloroplasty,
transabdominal or transthoracic approach
43324
Esophagogastric fundoplasty (e.g., Nissen, Belsey IV, Hill procedures)
46,500
25,200
21,300
43325
Esophagogastric fundoplasty; w/ fundic patch (Thal-Nissen procedure)
46,500
25,200
21,300
43326
43330
43331
43340
43341
Esophagogastric fundoplasty; w/ gastroplasty (e.g., Collis)
Esophagomyotomy (Heller type); abdominal approach
Esophagomyotomy (Heller type); thoracic approach
Esophagojejunostomy (w/o total gastrectomy); abdominal approach
Esophagojejunostomy (w/o total gastrectomy); thoracic approach
48,600
37,800
46,500
37,800
46,500
27,300
21,000
25,200
21,000
25,200
21,300
16,800
21,300
16,800
21,300
43350
Esophagostomy, fistulization of esophagus, external; abdominal approach
23,300
12,600
10,700
43351
Esophagostomy, fistulization of esophagus, external; thoracic approach
30,300
16,800
13,500
43352
Esophagostomy, fistulization of esophagus, external; cervical approach
12,120
6,720
5,400
58,800
37,800
21,000
63,000
42,000
21,000
37,800
37,800
21,000
21,000
16,800
16,800
37,800
21,000
16,800
12,120
6,720
5,400
37,800
21,000
16,800
43453
43456
Gastrointestinal reconstruction for previous esophagectomy, for obstructing
esophageal lesion or fistula, or for previous esophageal exclusion; w/
stomach, w/ or w/o pyloroplasty
Gastrointestinal reconstruction for previous esophagectomy, for obstructing
esophageal lesion or fistula, or for previous esophageal exclusion; w/ colon
interposition or small bowel reconstruction, including bowel mobilization,
preparation, and anastomosis(es)
Ligation, direct, esophageal varices
Transection of esophagus w/ repair, for esophageal varices
Ligation or stapling at gastroesophageal junction for pre-existing esophageal
perforation
Suture of esophageal wound or injury; cervical approach
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
43458
Dilation of esophagus w/ balloon (30 mm diameter or larger) for achalasia
43460
43496
43500
43501
Esophagogastric tamponade, w/ balloon (Sengstaaken type)
Free jejunum transfer w/ microvascular anastomosis
Gastrotomy; w/ exploration or foreign body removal
Gastrotomy; w/ suture repair of bleeding ulcer
Gastrotomy; w/ suture repair of pre-existing esophagogastric laceration
(e.g., Mallory-Weiss)
43360
43361
43400
43401
43405
43410
43415
43420
43425
43450
43502
Page 54 of 98
12,120
6,720
5,400
37,800
21,000
16,800
8,260
3,360
4,900
8,260
8,260
3,360
3,360
4,900
4,900
8,260
3,360
4,900
9,700
58,800
30,300
38,020
4,200
37,800
16,800
19,320
5,500
21,000
13,500
18,700
38,020
19,320
18,700
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
43510
Gastrotomy; w/ esophageal dilation and insertion of permanent
intraluminal tube (e.g., Celestin or Mousseaux-Barbin)
38,020
19,320
18,700
43520
Pyloromyotomy, cutting of pyloric muscle (Fredet-Ramstedt type operation)
38,020
19,320
18,700
43600
Biopsy of stomach; by capsule, tube, peroral (one or more specimens)
43605
43610
43611
43620
43621
43622
43631
43632
43633
43634
Biopsy of stomach; by laparotomy
Excision, local; ulcer or benign tumor of stomach
Excision, local; malignant tumor of stomach
Gastrectomy, total; w/ esophagoenterostomy
Gastrectomy, total; w/ Roux-en-Y reconstruction
Gastrectomy, total; w/ formation of intestinal pouch, any type
Gastrectomy, partial, distal; w/ gastroduodenostomy
Gastrectomy, partial, distal; w/ gastrojejunostomy
Gastrectomy, partial, distal; w/ Roux-en-Y reconstruction
Gastrectomy, partial, distal; w/ formation of intestinal pouch
Gastrectomy, partial, proximal, thoracic or abdominal approach including
esophagogastrostomy, w/ vagotomy;
43638
43639
Gastrectomy, partial, proximal, thoracic or abdominal approach including
esophagogastrostomy, w/ vagotomy; w/ pyloroplasty or pyloromyotomy
8,260
3,360
4,900
30,300
38,020
38,020
63,000
67,200
67,200
55,000
55,000
63,000
63,000
16,800
19,320
19,320
42,000
46,200
46,200
33,600
33,600
42,000
42,000
13,500
18,700
18,700
21,000
21,000
21,000
21,400
21,400
21,000
21,000
63,000
42,000
21,000
67,200
46,200
21,000
37,800
21,000
16,800
46,500
25,200
21,300
18,000
8,400
9,600
21,940
9,240
12,700
18,000
8,400
9,600
8,020
5,560
37,800
63,000
46,500
53,400
37,800
2,520
1,260
21,000
42,000
25,200
29,400
21,000
5,500
4,300
16,800
21,000
21,300
24,000
16,800
43750
43760
43800
43810
43820
43825
43830
Vagotomy including pyloroplasty, w/ or w/o gastrostomy; truncal or
selective
Vagotomy including pyloroplasty, w/ or w/o gastrostomy; parietal cell
(highly selective)
Laparoscopy, surgical; transection of vagus nerves, truncal
Laparoscopy, surgical; transection of vagus nerve, selective or highly
selective
Laparoscopy, surgical; gastrostomy, without construction of gastric tube
(e.g., Stamm Procedure)
Percutaneous placement of gastrostomy tube
Change of gastrostomy tube
Pyloroplasty
Gastroduodenostomy
Gastrojejunostomy; w/o vagotomy
Gastrojejunostomy; w/ vagotomy, any type
Gastrostomy, temporary (tube, rubber or plastic) ;
43831
Gastrostomy, temporary (tube, rubber or plastic) ; neonatal, for feeding
37,800
21,000
16,800
43832
Gastrostomy, permanent, w/ construction of gastric tube
Gastrorrhaphy, suture of perforated duodenal or gastric ulcer, wound, or
injury
Gastric restrictive procedure, w/o gastric bypass, for morbid obesity;
vertical-banded gastroplasty
Gastric restrictive procedure, w/o gastric bypass, for morbid obesity; other
than vertical-banded gastroplasty
Gastric restrictive procedure, w/ gastric bypass for morbid obesity; w/ short
limb (less than 100 cm) Roux-en-Y gastroenterostomy
Gastric restrictive procedure, w/ gastric bypass for morbid obesity; w/ small
bowel reconstruction to limit absorption
Revision of gastric restrictive procedure for morbid obesity
Revision of gastroduodenal anastomosis (gastroduodenostomy) w/
reconstruction; w/o vagotomy
Revision of gastroduodenal anastomosis (gastroduodenostomy) w/
reconstruction; w/ vagotomy
Revision of gastrojejunal anastomosis (gastrojejunostomy) w/
reconstruction, w/ or w/o partial gastrectomy or bowel resection; w/o
vagotomy
Revision of gastrojejunal anastomosis (gastrojejunostomy) w/
reconstruction, w/ or w/o partial gastrectomy or bowel resection; w/
vagotomy
Closure of gastrostomy, surgical
Closure of gastrocolic fistula
Enterolysis (freeing of intestinal adhesion)
Duodenotomy, for exploration, biopsy(s), or foreign body removal
Enterotomy, small bowel, other than duodenum; for exploration, biopsy(s),
or foreign body removal;
37,800
21,000
16,800
46,500
25,200
21,300
55,000
33,600
21,400
58,800
37,800
21,000
58,800
37,800
21,000
58,800
37,800
21,000
58,800
37,800
21,000
58,800
37,800
21,000
63,000
42,000
21,000
58,800
37,800
21,000
63,000
42,000
21,000
46,500
58,800
58,800
53,400
25,200
37,800
37,800
29,400
21,300
21,000
21,000
24,000
37,800
21,000
16,800
43640
43641
43651
43652
43653
43840
43842
43843
43846
43847
43848
43850
43855
43860
43865
43870
43880
44005
44010
44020
44021
Enterotomy, small bowel, other than duodenum; for exploration, biopsy(s),
or foreign body removal; for decompression (e.g., Baker tube)
37,800
21,000
16,800
44025
Colotomy, for exploration, biopsy(s), or foreign body removal
37,800
21,000
16,800
44050
Reduction of volvulus, intussusception, internal hernia, by laparotomy
53,400
29,400
24,000
44055
Correction of malrotation by lysis of duodenal bands and/or reduction of
midgut volvulus (e.g., Ladd procedure)
55,000
33,600
21,400
44100
Biopsy of intestine by capsule, tube, peroral (one or more specimens)
18,000
8,400
9,600
Page 55 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
44110
Excision of one or more lessions of small or large bowel not requiring
anastomosis, exteriorization, or fistulization; single enterotomy
37,800
21,000
16,800
44111
Excision of one or more lessions of small or large bowel not requiring
anastomosis, exteriorization, or fistulization; multiple enterotomies
46,500
25,200
21,300
44120
Enterectomy, resection of small intestine; single resection and anastomosis
46,500
25,200
21,300
44125
Enterectomy, resection of small intestine; w/ enterostomy
Enteroenterostomy, anastomosis of intestine, w/ or w/o cutaneous
enterostomy
Colectomy, partial; w/ anastomosis
Colectomy, partial; w/ skin level cecostomy or colostomy
Colectomy, partial; w/ end colostomy and closure of distal segment
(Hartmann type procedure)
Colectomy, partial; w/ resection, w/ colostomy or ileostomy and creation of
mucofistula
Colectomy, partial; w/ coloproctostomy (low pelvic anastomosis)
Colectomy, partial; w/ coloproctostomy (low pelvic anastomosis), w/
colostomy
Colectomy, partial; abdominal and transanal approach
Colectomy, total, abdominal, w/o proctectomy; w/ ileostomy or
ileoproctostomy
46,500
25,200
21,300
53,400
29,400
24,000
58,800
58,800
37,800
37,800
21,000
21,000
58,800
37,800
21,000
58,800
37,800
21,000
56,680
35,280
21,400
58,800
37,800
21,000
63,000
42,000
21,000
63,000
42,000
21,000
Colectomy, total, abdominal, w/o proctectomy; w/ continent ileostomy
63,000
42,000
21,000
67,200
46,200
21,000
67,200
46,200
21,000
44130
44140
44141
44143
44144
44145
44146
44147
44150
44151
44155
Colectomy, total, abdominal, w/o proctectomy; w/ rectal mucosectomy,
ileoanal anastomosis, w/ or w/o loop ileostomy
Colectomy, total, abdominal, w/o proctectomy; w/ rectal mucosectomy,
ileoanal anastomosis, creation of ileal reservior (S or J), w/ or w/o loop
ileostomy
Colectomy, total, abdominal, w/ proctectomy; w/ ileostomy
67,200
46,200
21,000
44156
Colectomy, total, abdominal, w/ proctectomy; w/ continent ileostomy
67,200
46,200
21,000
44160
44180
Colectomy w/ removal of terminal ileum and ileocolostomy
Laparoscopy, surgical, enterolysis (freeing of intestinal adhesion)
67,200
18,000
46,200
8,400
21,000
9,600
44186
Laparoscopy, surgical; jejunostomy (e.g., for decompression or feeding;
12,120
6,720
5,400
12,120
6,720
5,400
18,000
8,400
9,600
23,300
12,600
10,700
37,800
21,000
16,800
58,800
37,800
21,000
37,800
21,000
16,800
55,000
33,600
21,400
58,800
37,800
21,000
55,000
33,600
21,400
58,800
37,800
21,000
55,000
33,600
21,400
23,300
12,600
10,700
18,000
21,820
23,300
21,820
30,300
23,300
8,400
10,920
12,600
10,920
16,800
12,600
9,600
10,900
10,700
10,900
13,500
10,700
30,300
16,800
13,500
23,300
30,300
30,300
12,600
16,800
16,800
10,700
13,500
13,500
14,960
7,560
7,400
14,960
7,560
7,400
44152
44153
44187
44188
44202
44204
44205
44206
44207
44208
44210
44211
44212
44227
44300
44310
44312
44314
44316
44320
44322
44340
44345
44346
44360
44361
Laparoscopy, surgical; jejunostomy (e.g., for decompression or feeding);
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; 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 protectomy,
with ileostomy or ileoproctostomy
Laparoscopy, surgical; colectomy, total, abdominal, with protectomy, with
ileo-anal anastomosis, creation of ileal reservoir (S or J), with loop
ileostomy, with or without rectal mucosectomy
Laparoscopy, surgical; colectomy, total, abdominal, with protectomy, with
ileostomy
Laparoscopy, surgical; closure of enterostomy, large or small intestine, with
resection and anastomosis
Enterostomy or cecostomy, tube (e.g., for decompression or feeding)
Ileostomy or jejunostomy, non- tube
Revision of ileostomy; simple (release of superficial scar)
Revision of ileostomy; complicated (reconstruction in-depth)
Continent ileostomy (Koch procedure)
Colostomy or skin level cecostomy;
Colostomy or skin level cecostomy; w/ multiple biopsies (e.g., for
Hirschsprung disease)
Revision of colostomy; simple (release of superficial scar)
Revision of colostomy; complicated (reconstruction in - depth )
Revision of colostomy; w/ repair of paracolostomy hernia
Small intestinal endoscopy, enteroscopy, beyond second portion of
duodenum, not including ileum; diagnostic, w/ or w/o collection of
specimen(s) by brushing or washing
Small intestinal endoscopy, enteroscopy, beyond second portion of
duodenum, not including ileum; w/ biopsy, single or multiple
Page 56 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
44363
44364
44365
44366
44369
44372
44373
44376
44377
44378
44380
44382
44385
44386
44388
44389
44390
44391
44392
44393
44394
44500
44602
44603
DESCRIPTION
Case Rate
Small intestinal endoscopy, enteroscopy, beyond second portion of
duodenum, not including ileum; w/ removal of foreign body
Small intestinal endoscopy, enteroscopy, beyond second portion of
duodenum, not including ileum; w/ removal of tumor(s), polyp(s), or other
lesions(s) by snare technique
Small intestinal endoscopy, enteroscopy, beyond second portion of
duodenum, not including ileum; w/ 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; w/ control of bleeding, any method
Small intestinal endoscopy, enteroscopy, beyond second portion of
duodenum, not including ileum; w/ ablation of tumor(s), polyp(s), or other
lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or
snare tenchnique
Small intestinal endoscopy, enteroscopy, beyond second portion of
duodenum, not including ileum; w/ placement of percutaneous jejunostomy
tube
Small intestinal endoscopy, enteroscopy, beyond second portion of
duodenum, not including ileum; w/ conversion of percutaneous gastrostomy
tube to percutaneous jejunostomy tube
Small intestinal endoscopy, enteroscopy beyond second portion of
duodenum, including ileum; diagnostic, w/ or w/o collection of specimen(s)
by brushing or washing
Small intestinal endoscopy, enteroscopy beyond second portion of
duodenum, including ileum;w/ biopsy, single or multiple
Small intestinal endoscopy, enteroscopy beyond second portion of
duodenum, including ileum;w/ control of bleeding, any method
Ileoscopy, through stoma; diagnostic, w/ or w/o collection of specimen(s) by
brushing or washing
Ileoscopy, through stoma; w/ biopsy, single or multiple
Endoscopic evaluation of small intestinal (abdominal or pelvic) pouch;
diagnostic, w/ or w/o collection of specimen(s) by brushing or washing
Endoscopic evaluation of small intestinal (abdominal or pelvic) pouch; w/
biopsy, single or multiple
Colonoscopy through stoma; diagnostic, w/ or w/o collection of specimen(s)
by brushing or washing
Colonoscopy through stoma; w/ biopsy, single or multiple
Colonoscopy through stoma; w/ removal of foreign body
Colonoscopy through stoma; w/ control of bleeding, any method
Colonoscopy through stoma; w/ removal of tumor(s), polyp(s), or other
lesion(s) by hot biopsy forceps or bipolar cautery
Colonoscopy through stoma; w/ ablation of tumor(s), polyp(s), or other
lesion(s) not amenable to removal by hot biopsy forceps, bipolar caurtery
or snare technique
Colonoscopy through stoma; w/ removal of tumor(s), polyp(s), or other
lesion(s) by snare technique
Introduction of long gastrointestinal tube (e.g., Miller-Abbott)
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 perforation
Professional Fee
Health Care
Institution Fee
18,000
8,400
9,600
18,000
8,400
9,600
18,000
8,400
9,600
18,000
8,400
9,600
21,940
9,240
12,700
21,940
9,240
12,700
21,940
9,240
12,700
18,000
8,400
9,600
18,000
8,400
9,600
21,940
9,240
12,700
14,960
7,560
7,400
14,960
7,560
7,400
14,960
7,560
7,400
14,960
7,560
7,400
14,960
7,560
7,400
14,960
18,000
18,000
7,560
8,400
8,400
7,400
9,600
9,600
18,000
8,400
9,600
21,940
9,240
12,700
21,940
9,240
12,700
8,020
2,520
5,500
37,800
21,000
16,800
37,800
21,000
16,800
44604
Suture of large intestine (colorrhaphy) for perforated ulcer, diverticulum,
wound, injury or rupture (single or multiple perforations); w/o colostomy
37,800
21,000
16,800
44605
Suture of large intestine (colorrhaphy) for perforated ulcer, diverticulum,
wound, injury or rupture (single or multiple perforations); w/ colostomy
37,800
21,000
16,800
37,800
21,000
16,800
30,300
16,800
13,500
30,300
16,800
13,500
30,300
30,300
37,800
37,800
16,800
16,800
21,000
21,000
13,500
13,500
16,800
16,800
18,000
8,400
9,600
18,000
12,120
10,540
24,000
8,400
6,720
5,040
9,600
9,600
5,400
5,500
14,400
44820
44850
44900
44950
Intestinal stricturoplasty (enterotomy and enterorrhaphy) w/ or w/o
dilation, for intestinal obstruction
Closure of enterostomy, large or small intestine;
Closure of enterostomy, large or small intestine; w/ resection and
anastomosis
Closure of intestinal cutaneous fistula
Closure of enteroenteric or enterocolic fistula
Closure of enterovesical fistula; w/o intestinal or bladder resection
Closure of enterovesical fistula; w/ bowel and/or bladder resection
Excision of Meckels diverticulum (diverticulectomy) or omphalomesenteric
duct
Excision of lesion of mesentery
Suture of mesentery
Incision and drainage of appendiceal abscess, transabdominal
Appendectomy;
44960
Appendectomy; for ruptured appendix w/ abscess or generalized peritonitis
24,000
9,600
14,400
44970
45000
Laparoscopy, surgical; appendectomy
Transrectal drainage of pelvic abscess
24,000
30,300
9,600
16,800
14,400
13,500
44615
44620
44625
44640
44650
44660
44661
44800
Page 57 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
45005
45020
45100
45108
45110
45111
45112
45113
45114
45116
45120
45121
45123
45130
45135
45150
45160
45170
45190
45300
45303
45305
45307
45308
45309
45315
45317
45320
45321
45330
45331
45332
45333
45334
45337
45338
45339
45355
45378
45379
45380
45382
45383
DESCRIPTION
Incision and drainage of submucosal abscess, rectum
Incision and drainage of deep supralevator, pelvirectal, or retrorectal
abscess
Biopsy of anorectal wall, anal approach (e.g., congenital megacolon)
Anorectal myomectomy
Proctectomy; complete, combined abdominoperineal, w/ colostomy
Proctectomy; partial resection of rectum, transabdominal approach
Proctectomy, combined abdominoperineal, pull-through procedure (e.g.,
colo-anal anastomosis)
Proctectomy, partial, w/ rectal mucosectomy, ileoanal anastomosis,
creation of ileal reservoir (S or J), w/ or w/o loop ileostomy
18,000
8,400
Health Care
Institution Fee
9,600
30,300
16,800
13,500
23,300
30,300
55,000
55,000
12,600
16,800
33,600
33,600
10,700
13,500
21,400
21,400
55,000
33,600
21,400
58,800
37,800
21,000
Proctectomy, partial, w/ anastomosis; abdominal and transsacral approach
58,800
37,800
21,000
55,000
33,600
21,400
58,800
37,800
21,000
58,800
37,800
21,000
55,000
53,400
33,600
29,400
21,400
24,000
55,000
33,600
21,400
Case Rate
Proctectomy, partial, w/ anastomosis; transsacral approach only (Kraske
type)
Proctectomy, complete (for congenital megacolon), abdominal and perineal
approach; w/ pull-through procedure and anastomosis (e.g., Swenson,
Duhamel, or Soave type operation)
Proctectomy, complete (for congenital megacolon), abdominal and perineal
approach; w/ subtotal or total colectomy, w/ multiple biopsies
Proctectomy, partial, w/o anastomosis, perineal approach
Excision of rectal procidentia, w/ anatomosis; perineal approach
Excision of rectal procidentia, w/ anatomosis; abdominal and perineal
approach
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, any method (e.g., electrodesiccation) transanal
approach
Proctosigmoidoscopy, rigid; diagnostic, w/ or w/o collection of specimen(s)
by brushing or washing
Proctosigmoidoscopy, rigid; w/ dilation, any method
Proctosigmoidoscopy, rigid; w/ biopsy, single or multiple
Proctosigmoidoscopy, rigid; w/ removal of foreign body
Proctosigmoidoscopy, rigid; w/ removal of single tumor, polyp, or other
lesion by hot biopsy forceps or bipolar cautery
Proctosigmoidoscopy, rigid; w/ removal of single tumor, polyp, or other
lesion by snare technique
Proctosigmoidoscopy, rigid; w/ removal of multiple tumors, polyps or other
lesions by hot biopsy forceps, bipolar cautery or snare technique
Proctosigmoidoscopy, rigid; w/ control of bleeding, any method
Proctosigmoidoscopy, rigid; w/ ablation of tumor(s), polyp(s), or other
lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or
snare technique (e.g., laser)
Proctosigmoidoscopy, rigid; w/ decompression of volvulus
Sigmoidoscopy, flexible; diagnostic, w/ or w/o collection of specimen(s) by
brushing or washing
Sigmoidoscopy, flexible; w/ biopsy, single or multiple
Sigmoidoscopy, flexible; w/ removal of foreign body
Sigmoidoscopy, flexible; w/ removal of tumor(s), polyp(s), or other lesion(s)
by hot biopsy forceps or bipolar cautery
Sigmoidoscopy, flexible; w/ control of bleeding, any method
Sigmoidoscopy, flexible; w/ decompression of volvulus, any method
Sigmoidoscopy, flexible; w/ removal of tumor(s), polyp(s), or other lesion(s)
by snare technique
Sigmoidoscopy, flexible; w/ ablation of tumor(s), polyp(s), or other lesion(s)
not amenable to removal by hot biopsy forceps, bipolar cautery or snare
technique
Colonoscopy, rigid or flexible, transabdominal via colotomy, single or
multiple
Colonoscopy, flexible, proximal to splenic flexure; diagnostic, w/ or w/o
collection of specimen(s) by brushing or washing, w/ or w/o colon
decompression
Colonoscopy, flexible, proximal to splenic flexure; w/ removal of foreign
body
Colonoscopy, flexible, proximal to splenic flexure; w/ biopsy, single or
multiple
Colonoscopy, flexible, proximal to splenic flexure; w/ control of bleeding,
any method
Colonoscopy, flexible, proximal to splenic flexure; w/ ablation of tumor(s),
polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps,
bipolar cautery or snare technique
Page 58 of 98
Professional Fee
12,120
6,720
5,400
55,000
33,600
21,400
18,000
8,400
9,600
18,000
8,400
9,600
8,020
2,520
5,500
9,700
8,020
8,260
4,200
2,520
3,360
5,500
5,500
4,900
9,700
4,200
5,500
9,700
4,200
5,500
10,540
5,040
5,500
10,540
5,040
5,500
10,540
5,040
5,500
10,540
5,040
5,500
8,260
3,360
4,900
8,260
9,700
3,360
4,200
4,900
5,500
9,700
4,200
5,500
10,540
12,120
5,040
6,720
5,500
5,400
10,540
5,040
5,500
11,980
5,880
6,100
10,540
5,040
5,500
12,120
6,720
5,400
12,120
6,720
5,400
12,120
6,720
5,400
18,000
8,400
9,600
14,960
7,560
7,400
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
45384
45385
45395
DESCRIPTION
Case Rate
Colonoscopy, flexible, proximal to splenic flexure; w/ removal of tumor(s),
polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery
Colonoscopy, flexible, proximal to splenic flexure; w/ removal of tumor(s),
polyp(s), or other lesion(s) by snare technique
Laparoscopy, surgical; proctectomy, complete combined abdominoperineal,
with colostomy
Professional Fee
Health Care
Institution Fee
14,960
7,560
7,400
18,000
8,400
9,600
55,000
33,600
21,400
45397
Laparoscopy, surgical; protectomy, combined abdominoperineal pull
through procedure (e.g., colo-anal anastomosis), with creation of colonic
reservoir (e.g., J-pouch), with diverting enterostomy, when performed
55,000
33,600
21,400
45400
Laparoscopy, surgical; proctopexy (for prolapse)
27,120
15,120
12,000
45402
Laparoscopy, surgical; proctopexy (for prolapse), with sigmoid resection
30,300
16,800
13,500
45500
45505
45540
45541
45550
45560
45562
Proctoplasty; for stenosis
Proctoplasty; for prolapse of mucous membrane
Proctopexy for prolapse; abdominal approach
Proctopexy for prolapse; perineal approach
Proctopexy combined w/ sigmoid resection, abdominal approach
Repair of rectocele
Exploration, repair and presacral drainage for rectal injury;
18,000
18,000
27,120
27,120
30,300
18,000
23,300
8,400
8,400
15,120
15,120
16,800
8,400
12,600
9,600
9,600
12,000
12,000
13,500
9,600
10,700
45563
Exploration, repair and presacral drainage for rectal injury; w/ colostomy
27,120
15,120
12,000
45800
45805
45820
45825
45905
45910
45915
46040
Closure of rectovesical fistula;
Closure of rectovesical fistula; w/ colostomy
Closure of rectourethral fistula;
Closure of rectourethral fistula; w/ colostomy
Dilation of anal sphincter under anesthesia other than local
Dilation of rectal stricture under anesthesia other than local
Removal of fecal impaction or foreign body under anesthesia
Incision and drainage of ischiorectal and/or perirectal abscess
Incision and drainage of intramural, intramuscular, or submucosal abscess,
transanal, under anesthesia
Incision and drainage, perianal abscess, superficial
30,300
37,800
30,300
37,800
8,260
8,260
8,260
8,260
16,800
21,000
16,800
21,000
3,360
3,360
3,360
3,360
13,500
16,800
13,500
16,800
4,900
4,900
4,900
4,900
9,700
4,200
5,500
8,260
3,360
4,900
9,700
4,200
5,500
Incision, anal septum (infant)
Sphincterotomy, anal, division of sphincter
Incision of thrombosed hemorrhoid, external
Fissurectomy, w/ or w/o sphincterotomy
Cryptectomy; single
Cryptectomy; multiple
Papillectomy or excision of single tag, anus
Hemorrhoidectomy, by simple ligature (e.g., rubber band)
Excision of external hemorrhoid tags and/or multiple papillae
Hemorrhoidectomy, external, complete
Hemorrhoidectomy, internal and external, simple;
Hemorrhoidectomy, internal and external, simple; w/ fissurectomy
Hemorrhoidectomy, internal and external, simple; w/ fistulectomy, w/ or
w/o fissurectomy
Hemorrhoidectomy, internal and external, complex or extensive;
Hemorrhoidectomy, internal and external, complex or extensive; w/
fissurectomy
Hemorrhoidectomy, internal and external, complex or extensive; w/
fistulectomy, w/ or w/o fissurectomy
9,700
9,700
8,020
8,260
8,260
9,700
8,260
12,120
12,120
12,120
12,120
12,120
4,200
4,200
2,520
3,360
3,360
4,200
3,360
6,720
6,720
6,720
6,720
6,720
5,500
5,500
5,500
4,900
4,900
5,500
4,900
5,400
5,400
5,400
5,400
5,400
12,120
6,720
5,400
12,120
6,720
5,400
12,120
6,720
5,400
12,120
6,720
5,400
46270
Surgical treatment of anal fistula (fistulectomy/fistulotomy); subcutaneous
12,120
6,720
5,400
46275
Surgical treatment of anal fistula (fistulectomy/fistulotomy); submuscular
12,120
6,720
5,400
46280
Surgical treatment of anal fistula (fistulectomy/fistulotomy); complex or
multiple, w/ or w/o placement of seton
12,120
6,720
5,400
46285
Surgical treatment of anal fistula (fistulectomy/fistulotomy); second stage
12,120
6,720
5,400
46288
46320
Closure of anal fistula w/ rectal advancement flap
Enucleation or excision of external thrombotic hemorrhoid
Anoscopy; diagnostic, w/ or w/o collection of specimen(s) by brushing or
washing
Anoscopy; w/ dilation, any method
Anoscopy; w/ biopsy, single or multiple
Anoscopy; w/ removal of foreign body
Anoscopy; w/ removal of single tumor, polyp, or other lesion by hot biopsy
forceps or bipolar cautery
Anoscopy; w/ removal of single tumor, polyp or other lesion by snare
technique
Anoscopy; w/ removal of multiple tumor, polyps, or other lesions by hot
biopsy forceps, bipolar cautery or snare technique
18,000
12,120
8,400
6,720
9,600
5,400
5,680
1,680
4,000
5,680
5,680
5,680
1,680
1,680
1,680
4,000
4,000
4,000
8,020
2,520
5,500
8,260
3,360
4,900
8,260
3,360
4,900
46045
46050
46060
46070
46080
46083
46200
46210
46211
46220
46221
46230
46250
46255
46257
46258
46260
46261
46262
46600
46604
46606
46608
46610
46611
46612
Incision and drainage of ischiorectal or intramural abscess, w/ fistulectomy
or fistulotomy, submuscular, w/ or w/o placement of seton
Page 59 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
DESCRIPTION
46614
Anoscopy; w/ control of bleeding, any method
8,020
2,520
Health Care
Institution Fee
5,500
46615
Anoscopy; w/ ablation of tumor(s), polyp(s), or other lesion(s) not amenable
to removal by hot biopsy forceps, bipolar cautery or snare technique
9,700
4,200
5,500
12,900
23,300
6,300
12,600
6,600
10,700
23,300
12,600
10,700
37,800
21,000
16,800
37,800
21,000
16,800
46,500
25,200
21,300
30,300
16,800
13,500
53,400
29,400
24,000
58,800
37,800
21,000
63,000
42,000
21,000
63,000
42,000
21,000
14,960
23,300
9,700
8,260
40,320
7,560
12,600
4,200
3,360
23,520
7,400
10,700
5,500
4,900
16,800
20,980
10,080
10,900
40,320
23,520
16,800
8,260
3,360
4,900
8,260
3,360
4,900
8,260
3,360
4,900
8,260
3,360
4,900
8,260
3,360
4,900
9,700
4,200
5,500
9,700
9,700
9,700
9,700
9,700
4,200
4,200
4,200
4,200
4,200
5,500
5,500
5,500
5,500
5,500
46700
46705
46715
46716
46730
46735
46740
46742
46744
46746
46748
46750
46751
46753
46754
46760
46761
46762
46900
46910
Case Rate
Anoplasty, plastic operation for stricture; adult
Anoplasty, plastic operation for stricture; infant
Repair of low imperforate anus; w/ anoperineal fistula ("cut-back"
procedure)
Repair of low imperforate anus; w/ transportation of anoperineal or
anovestibular fistula
Repair of high imperforate anus w/o fistula; perineal or sacroperineal
approach
Repair of high imperforate anus w/o fistula; combined transabdominal and
sacroperineal approaches
Repair of high imperforate anus w/ rectourethral or rectovaginal fistula;
perineal or sacroperineal approach
Repair of high imperforate anus w/ 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; w/ 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 (e.g., condyloma, papilloma, molluscum
contagiosum, herpetic vesicle), simple; chemical
Destruction of lesion(s), anus (e.g., condyloma, papilloma, molluscum
contagiosum, herpetic vesicle), simple; electrodesiccation
Professional Fee
46934
46935
46936
46937
46938
Destruction of lesion(s), anus (e.g., condyloma, papilloma, molluscum
contagiosum, herpetic vesicle), simple; cryosurgery
Destruction of lesion(s), anus (e.g., condyloma, papilloma, molluscum
contagiosum, herpetic vesicle), simple; laser surgery
Destruction of lesion(s), anus (e.g., condyloma, papilloma, molluscum
contagiosum, herpetic vesicle), simple; surgical excision
Destruction of lesion(s), anus (e.g., condyloma, papilloma, molluscum
contagiosum, herpetic vesicle), extensive, any method
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
46940
Curettage or cauterization of anal fissure, including dilation of anal sphincter
9,700
4,200
5,500
46945
47000
47010
8,260
8,020
18,000
3,360
2,520
8,400
4,900
5,500
9,600
18,000
8,400
9,600
18,000
53,400
55,000
46,500
53,400
8,400
29,400
33,600
25,200
29,400
9,600
24,000
21,400
21,300
24,000
46,500
25,200
21,300
55,000
33,600
21,400
55,000
33,600
21,400
47300
Ligation of internal hemorrhoids
Biopsy of liver, needle; percutaneous
Hepatotomy for drainage of abscess or cyst, one or two stages
Laparotomy, w/ aspiration and/or injection of hepatic parasitic (e.g.,
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, w/ preparation and maintenance of allograft; partial,
from living 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
Marsupialization of cyst or abscess of liver
18,000
8,400
9,600
47350
Management of liver hemorrhage; simple suture of liver wound or injury
23,300
12,600
10,700
47360
Management of liver hemorrhage; complex suture of liver wound or injury,
w/ or w/o hepatic artery ligation
46,500
25,200
21,300
46916
46917
46922
46924
47015
47100
47120
47122
47125
47130
47134
47135
47136
Page 60 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
47361
47362
47370
DESCRIPTION
Case Rate
Management of liver hemorrhage; exploration of hepatic wound, extensive
debridement, coagulation and/or suture, w/ or w/o 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
47371
Laparoscopy, surgical, ablation of one or more liver tumor(s); cryosurgical
47380
47381
47382
47490
Ablation, open, of or more liver tumor(s); radiofrequency
Ablation, open, of or more liver tumor(s); cryosurgical
Ablation, one or more liver tumor(s), percutaneous radiofrequency
Hepaticotomy or hepaticostomy w/ exploration, drainage, or removal of
calculus
Choledochotomy or choledochostomy w/ exploration, drainage, or removal
of calculus, w/ or w/o cholecystotomy; w/o transduodenal sphincterotomy
or sphincteroplasty
Choledochotomy or choledochostomy w/ exploration, drainage, or removal
of calculus, w/ or w/o cholecystotomy; w/ transduodenal sphincterotomy or
sphincteroplasty
Transduodenal sphincterotomy or sphincteroplasty, w/ or w/o
transduodenal extraction of calculus
Cholecystotomy or cholecystostomy w/ exploration, drainage, or removal of
calculus
Percutaneous cholecystostomy
47510
Introduction of percutaneous transhepatic catheter for biliary drainage
47400
47420
47425
47460
47480
47511
47525
47530
47552
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, percutaneous via T- tube or other tract; diagnostic, w/ or
w/o collection of specimen(s) by brushing and/or washing
Professional Fee
Health Care
Institution Fee
37,800
21,000
16,800
37,800
21,000
16,800
18,000
8,400
9,600
18,000
8,400
9,600
9,700
9,700
9,700
4,200
4,200
4,200
5,500
5,500
5,500
53,400
29,400
24,000
37,800
21,000
16,800
46,500
25,200
21,300
46,500
25,200
21,300
30,300
16,800
13,500
30,300
16,800
13,500
30,300
16,800
13,500
30,300
16,800
13,500
8,020
8,260
2,520
3,360
5,500
4,900
23,300
12,600
10,700
23,300
12,600
10,700
23,300
12,600
10,700
23,300
12,600
10,700
23,300
12,600
10,700
31,000
12,400
18,600
31,000
12,400
18,600
31,000
31,000
12,400
12,400
18,600
18,600
47562
47563
Biliary endoscopy, percutaneous via T- tube or other tract; w/ biopsy, single
or multiple
Biliary endoscopy, percutaneous via T- tube or other tract; w/ removal of
stone(s)
Biliary endoscopy, percutaneous via T- tube or other tract; w/ dilation of
biliary duct stricture(s) w/o stent
Biliary endoscopy, percutaneous via T- tube or other tract; w/ dilation of
biliary duct stricture(s) w/ stent
Laparoscopy, surgical; with guided transhepatic cholangiography, without
biopsy
Laparoscopy, surgical; with guided transhepatic cholangiography, with
biopsy
Laparoscopy, surgical; cholecystectomy (any method)
Laparoscopy, surgical; cholecystectomy with cholangiography
47564
Laparoscopy, surgical; cholecystectomy with exploration of common duct
46,500
25,200
21,300
47570
47600
47605
47610
Laparoscopy, surgical; cholecystoenterostomy
Cholecystectomy;
Cholecystectomy; w/ cholangiography
Cholecystectomy w/ exploration of common duct;
Cholecystectomy w/ exploration of common duct; w/
choledochoenterostomy
Cholecystectomy w/ exploration of common duct; w/ transduodenal
sphincterotomy or sphincteroplasty, w/ or w/o cholangiography
Biliary duct stone extraction, percutaneous via T-tube tract, basket, or
snare (e.g., Burhenne technique)
Exploration for congenital atresia of bile ducts, w/o repair, w/ or w/o liver
biopsy, w/ or w/o cholangiography
Portoenterostomy (e.g., Kasai procedure)
Excision of bile duct tumor, w/ or w/o primary repair of bile duct;
extrahepatic
Excision of bile duct tumor, w/ or w/o primary repair of bile duct;
intrahepatic
Excision of choledochal cyst
Anastomosis, choledochal cyst, w/o excision
Cholecystoenterostomy; direct
Cholecystoenterostomy; w/ gastroenterostomy
Roux-en-Y
Roux-en-Y w/ gastroenterostomy
Anastomosis, of extrahepatic biliary ducts and gastrointestinal tract
Anastomosis, of intrahepatic ducts and gastrointestinal tract
Anastomosis, Roux-en-Y, of extrahepatic biliary ducts and gastrointestinal
tract
31,000
31,000
31,000
46,500
12,400
12,400
12,400
25,200
18,600
18,600
18,600
21,300
53,400
29,400
24,000
46,500
25,200
21,300
23,300
12,600
10,700
53,400
29,400
24,000
55,000
33,600
21,400
55,000
33,600
21,400
58,800
37,800
21,000
55,000
46,500
37,800
46,500
53,400
53,400
46,500
53,400
33,600
25,200
21,000
25,200
29,400
29,400
25,200
29,400
21,400
21,300
16,800
21,300
24,000
24,000
21,300
24,000
46,500
25,200
21,300
47553
47554
47555
47556
47560
47561
47612
47620
47630
47700
47701
47711
47712
47715
47716
47720
47721
47740
47741
47760
47765
47780
Page 61 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
47785
47800
47801
47802
47900
48000
48001
48005
48020
48100
48102
48120
48140
48145
48146
48148
48150
48152
48153
48154
48155
48160
DESCRIPTION
Case Rate
Anastomosis, Roux-en-Y, of intrahepatic biliary ducts and gastrointestinal
tract
Reconstruction, plastic, of extrahepatic biliary ducts w/ end-to-end
anastomosis
Placement of choledochal stent
U-tube hepaticoenterostomy
Suture of extrahepatic biliary duct for pre-existing injury
Placement of drains, peripancreatic, for acute pancreatitis;
Placement of drains, peripancreatic, for acute pancreatitis; w/
cholecystostomy, gastrostomy, and jejunostomy
Resection or debridement of pancreas and peripancreatic tissue for acute
necrotizing pancreatitis
Removal of pancreatic calculus
Biopsy of pancreas, open, any method (e.g., fine needle aspiration, needle
core biopsy, wedge biopsy)
Biopsy of pancreas, percutaneous needle
Excision of lesion of pancreas (e.g., cyst, adenoma)
Pancreatectomy, distal subtotal, w/ or w/o splenectomy; w/o
pancreaticojejunostomy
Pancreatectomy, distal subtotal, w/ or w/o splenectomy; w/
pancreaticojejunostomy
Pancreatectomy, distal, near-total w/ preservation of duodenum (Child-type
procedure)
Excision of ampulla of Vater
Pancreatectomy, proximal subtotal w/ total duodenectomy, partial
gastrectomy, choledochoenterostomy and gastrojejunostomy (Whippletype procedure); w/ pancreatojejunostomy
Pancreatectomy, proximal subtotal w/ total duodenectomy, partial
gastrectomy, choledochoenterostomy and gastrojejunostomy (Whippletype procedure); w/o pancreatojejunostomy
Pancreatectomy, proximal subtotal w/ near total duodenectomy,
choledochoenterostomy and duodenojejunostomy (pylorus-sparing,
Whipple-type procedure); w/ pancreatojejunostomy
Pancreatectomy, proximal subtotal w/ near total duodenectomy,
choledochoenterostomy and duodenojejunostomy (pylorus-sparing,
Whipple-type procedure); w/o pancreatojejunostomy
Pancreatectomy, total
Pancreatectomy, total or subtotal, w/ autologous transplantation of
pancreas or pancreatic islets
Professional Fee
Health Care
Institution Fee
53,400
29,400
24,000
46,500
25,200
21,300
37,800
37,800
46,500
23,300
21,000
21,000
25,200
12,600
16,800
16,800
21,300
10,700
46,500
25,200
21,300
46,500
25,200
21,300
37,800
21,000
16,800
12,120
6,720
5,400
9,700
30,300
4,200
16,800
5,500
13,500
46,500
25,200
21,300
53,400
29,400
24,000
53,400
29,400
24,000
46,500
25,200
21,300
58,800
37,800
21,000
55,000
33,600
21,400
63,000
42,000
21,000
58,800
37,800
21,000
63,000
42,000
21,000
63,000
42,000
21,000
48180
Pancreaticojejunostomy, side-to-side anastomosis (Puestow-type operation)
55,000
33,600
21,400
48500
48510
Marsupialization of cyst of pancreas
External drainage, psuedocyst of pancreas
30,300
23,300
16,800
12,600
13,500
10,700
48520
Internal anastomosis of pacreatic cyst to gastrointestinal tract; direct
46,500
25,200
21,300
48540
Internal anastomosis of pacreatic cyst to gastrointestinal tract; Roux-en-Y
46,500
25,200
21,300
48545
48547
Pancreatorrhaphy for trauma
Duodenal exclusion w/ gastrojejunostomy for pancreatic trauma
53,400
53,400
29,400
29,400
24,000
24,000
48550
Donor pancreatectomy, w/ preparation and maintenance of allograft from
cadaver donor, w/ or w/o duodenal segment for transplantation
30,300
16,800
13,500
30,300
23,300
23,300
23,300
16,800
12,600
12,600
12,600
13,500
10,700
10,700
10,700
23,300
12,600
10,700
48554
48556
49000
49010
49020
49021
49040
49060
49080
49085
49180
49200
49201
49215
49220
49250
49255
Transplantation of pancreatic allograft
Removal of transplanted pancreatic allograft
Exploratory laparotomy, exploratory celiotomy w/ or w/o biopsy(s)
Exploration, retroperitoneal area w/ or w/o biopsy(s)
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 subdiaphargmatic or subphrenic abscess
Drainage of retroperitoneal abscess
Peritoneocentesis, abdominal paracentesis, or peritoneal lavage (diagnostic
or therapeutic)
Removal of peritoneal foreign body from peritoneal cavity
Biopsy, abdominal or retroperitoneal mass, percutaneous needle
Excision or destruction by any method of intra-abdominal or retroperitoneal
tumors or cysts or endometriomas;
Excision or destruction by any method of intra-abdominal or retroperitoneal
tumors or cysts or endometriomas; extensive
Excision of presacral or sacrococcygeal tumor
Staging celiotomy (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
Omentectomy, epiploectomy, resection of omentum
Page 62 of 98
8,260
3,360
4,900
23,300
23,300
12,600
12,600
10,700
10,700
8,020
2,520
5,500
23,300
8,260
12,600
3,360
10,700
4,900
37,800
21,000
16,800
53,400
29,400
24,000
46,500
25,200
21,300
23,300
12,600
10,700
9,700
9,700
4,200
4,200
5,500
5,500
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
DESCRIPTION
Case Rate
49321
Laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or
without collection of specimen(s) by brushing or washing
Laparoscopy, surgical; with biopsy (single or multiple)
49322
Laparoscopy, surgical; with aspiration of cavity or cyst (single or multiple)
49323
Laparoscopy, surgical; with drainage of lymphocele to peritoneal cavity
49420
Insertion of intraperitoneal cannula or catheter for drainage or dialysis
49425
Insertion of peritoneal-venous shunt
Repair initial inguinal hernia, under age 6 months, w/ or w/o
hydrocelectomy; reducible
Repair initial inguinal hernia, under age 6 months, w/ or w/o
hydrocelectomy; incarcerated
Repair initial inguinal hernia, under age 6 months, w/ or w/o
hydrocelectomy; strangulated
Repair initial inguinal hernia, age 6 months to under 5 years, w/ or w/o
hydrocelectomy; reducible
Repair initial inguinal hernia, age 6 months to under 5 years, w/ or w/o
hydrocelectomy; incarcerated
Repair initial inguinal hernia, age 6 months to under 5 years, w/ or w/o
hydrocelectomy; strangulated
Repair initial inguinal hernia, age 5 years or over; reducible
Repair initial inguinal hernia, age 5 years or over; incarcerated
Repair initial inguinal hernia, age 5 years or over; strangulated
Repair recurrent inguinal hernia, any age; reducible
Repair recurrent inguinal hernia, any age; incarcerated
Repair recurrent inguinal hernia, any age; strangulated
Repair inguinal hernia, sliding, any age
Repair lumbar hernia
Repair initial femoral hernia, any age; reducible
Repair initial femoral hernia, any age; incarcerated
Repair initial femoral hernia, any age; strangulated
Repair recurrent femoral hernia; reducible
Repair recurrent femoral hernia; incarcerated
Repair recurrent femoral hernia; strangulated
Repair initial incisional hernia; reducible
Repair initial incisional hernia; incarcerated
Repair initial incisional hernia; strangulated
Repair recurrent incisional hernia; reducible
Repair recurrent incisional hernia; incarcerated
Repair recurrent incisional hernia; strangulated
Repair epigastric hernia (e.g., preperitoneal fat); reducible
Repair epigastric hernia (e.g., preperitoneal fat); incarcerated
Repair epigastric hernia (e.g., preperitoneal fat); strangulated
Repair umbilical hernia, under age 5 years; reducible
Repair umbilical hernia, under age 5 years; incarcerated
Repair umbilical hernia, under age 5 years; strangulated
Repair umbilical hernia, age 5 years or over; reducible
Repair umbilical hernia, age 5 years or over; incarcerated
Repair umbilical hernia, age 5 years or over; strangulated
Repair spigelian hernia
Repair of small omphalocele, w/ primary closure
Repair large omphalocele or gastroschisis; w/ or w/o prosthesis
Repair large omphalocele or gastroschisis; w/ 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
Laparoscopy, surgical; repair of initial inguinal hernia
Laparoscopy, surgical; repair of recurrent inguinal hernia
Suture, secondary, of abdominal wall for evisceration or dehiscence
Omental flap (e.g., for reconstruction of sternal and chest wall defects) (list
separately in addition to code for primary procedure)
Free omental flap w/ microvascular anastomosis
Renal exploration, not necessitating other specific procedures
Drainage of perirenal or renal abscess
Nephrostomy, nephrotomy w/ drainage
Nephrotomy, w/ 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)
49320
49495
49496
49497
49500
49501
49502
49505
49507
49509
49520
49521
49522
49525
49540
49550
49553
49554
49555
49557
49558
49560
49561
49562
49565
49566
49567
49570
49572
49573
49580
49582
49583
49585
49587
49588
49590
49600
49605
49606
49610
49611
49650
49651
49900
49905
49906
50010
50020
50040
50045
50060
50065
50070
50075
50080
Percutaneous nephrostolithotomy or pyelostolithotomy, w/ or w/o dilation,
endoscopy, lithotripsy, stenting, or basket extraction; up to 2 cm
Page 63 of 98
Professional Fee
Health Care
Institution Fee
5,680
1,680
4,000
9,700
4,200
5,500
12,120
6,720
5,400
8,260
3,360
4,900
4,900
8,260
3,360
18,000
8,400
9,600
21,000
8,400
12,600
21,000
8,400
12,600
21,000
8,400
12,600
21,000
8,400
12,600
21,000
8,400
12,600
21,000
8,400
12,600
21,000
21,000
21,000
21,000
21,000
21,000
21,000
21,000
21,000
21,000
21,000
21,000
21,000
21,000
21,000
21,000
21,000
21,000
21,000
21,000
21,000
21,000
21,000
21,000
21,000
21,000
21,000
21,000
21,000
21,000
23,300
37,800
8,400
8,400
8,400
8,400
8,400
8,400
8,400
8,400
8,400
8,400
8,400
8,400
8,400
8,400
8,400
8,400
8,400
8,400
8,400
8,400
8,400
8,400
8,400
8,400
8,400
8,400
8,400
8,400
8,400
8,400
12,600
21,000
12,600
12,600
12,600
12,600
12,600
12,600
12,600
12,600
12,600
12,600
12,600
12,600
12,600
12,600
12,600
12,600
12,600
12,600
12,600
12,600
12,600
12,600
12,600
12,600
12,600
12,600
12,600
12,600
12,600
12,600
10,700
16,800
30,300
16,800
13,500
23,300
30,300
21,000
21,000
18,000
12,600
16,800
8,400
8,400
8,400
10,700
13,500
12,600
12,600
9,600
23,300
12,600
10,700
30,300
20,980
18,000
18,000
18,000
27,120
30,300
27,120
16,800
10,080
8,400
8,400
8,400
15,120
16,800
15,120
13,500
10,900
9,600
9,600
9,600
12,000
13,500
12,000
37,800
21,000
16,800
30,300
16,800
13,500
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
50081
50100
50120
50125
50130
50135
50200
50205
50220
50225
50230
50234
50236
50240
50250
50280
50290
50320
50340
50360
DESCRIPTION
Case Rate
Percutaneous nephrostolithotomy or pyelostolithotomy, w/ or w/o dilation,
endoscopy, lithotripsy, stenting, or basket extraction; over 2 cm
Transection or repositioning of aberrant renal vessels
Pyelotomy; w/ exploration
Pyelotomy; w/ drainage, pyelostomy
Pyelotomy; w/ removal of calculus (pyelolithotomy, pelviolithotomy,
including coagulum pyelolithotomy)
Pyelotomy; complicated (e.g., secondary operation, congenital kidney
abnormality)
Renal biopsy; percutaneous, by trocar or needle
Renal biopsy; by surgical exposure of kidney
Nephrectomy, including partial ureterectomy, any approach including rib
resection;
Nephrectomy, including partial ureterectomy, any approach including rib
resection; complicated because of previous surgery on same kidney
Nephrectomy, including partial ureterectomy, any approach including rib
resection; radical, w/ regional lymphadenectomy and/or vena caval
thrombectomy
Nephrectomy w/ total ureterectomy and bladder cuff; through same
incision
Nephrectomy w/ 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
Donor nephrectomy, w/ preparation and maintenance of allograft; from
living donor
Recipient nephrectomy
Renal allotransplantation, implantation of graft; excluding donor and
recipient nephrectomy
Professional Fee
Health Care
Institution Fee
30,300
16,800
13,500
30,300
18,000
18,000
16,800
8,400
8,400
13,500
9,600
9,600
23,300
12,600
10,700
31,580
14,280
17,300
8,020
18,000
2,520
8,400
5,500
9,600
27,120
15,120
12,000
30,300
16,800
13,500
30,300
16,800
13,500
30,300
16,800
13,500
30,300
16,800
13,500
27,120
15,120
12,000
9,700
4,200
5,500
20,980
20,980
10,080
10,080
10,900
10,900
27,120
15,120
12,000
23,300
12,600
10,700
46,500
25,200
21,300
50365
Renal allotransplantation, implantation of graft; w/ recipient nephrectomy
61,320
40,320
21,000
50370
50380
Removal of transplanted renal allograft
Renal autotransplantation, reimplantation of kidney
30,300
53,400
16,800
29,400
13,500
24,000
50390
Aspiration and/or injection of renal cyst or pelvis by needle, percutaneous
5,680
1,680
4,000
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
8,260
3,360
4,900
30,300
16,800
13,500
37,180
18,480
18,700
23,300
18,000
12,600
8,400
10,700
9,600
23,300
12,600
10,700
30,300
16,800
13,500
30,300
16,800
13,500
10,540
9,700
30,300
27,120
5,040
4,200
16,800
15,120
5,500
5,500
13,500
12,000
27,120
15,120
12,000
23,300
12,600
10,700
23,300
12,600
10,700
30,300
16,800
13,500
8,692
3,192
5,500
50391
50392
50393
50395
50400
50405
50500
50520
50525
50526
50540
50541
50542
50543
50544
50545
50546
50547
50548
50551
Instillation of therapeutic agent into renal pelvis and/or ureter through
established nephrostomy, pyelostomy or ureterostomy tube
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
Introduction of guide into renal pelvis and/or ureter w/ dilation to establish
nephrostomy tract, percutaneous
Pyeloplasty (Foley Y-pyeloplasty), plastic operation on renal pelvis, w/ or
w/o plastic operation on ureter, nephropexy, nephrostomy, pyelostomy, or
ureteral splinting; simple
Pyeloplasty (Foley Y-pyeloplasty), plastic operation on renal pelvis, w/ or
w/o 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
Closure of nephrovisceral fistula (e.g., renocolic), including visceral repair;
abdominal approach
Closure of nephrovisceral fistula (e.g., renocolic), including visceral repair;
thoracic approach
Symphysiotomy for horseshoe kidney w/ or w/o 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 Gerotas
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
Renal endoscopy through established nephrostomy or pyelostomy, w/ or
w/o irrigation, instillation, or ureteropyelography, exclusive of radiologic
service;
Page 64 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
50553
Renal endoscopy through established nephrostomy or pyelostomy, w/ or
w/o irrigation, instillation, or ureteropyelography, exclusive of radiologic
service; w/ ureteral catheterization, w/ or w/o dilation of ureter
8,260
3,360
4,900
50555
Renal endoscopy through established nephrostomy or pyelostomy, w/ or
w/o irrigation, instillation, or ureteropyelography, exclusive of radiologic
service; w/ biopsy
10,880
3,780
7,100
50557
Renal endoscopy through established nephrostomy or pyelostomy, w/ or
w/o irrigation, instillation, or ureteropyelography, exclusive of radiologic
service; w/ fulguration and/or incision, w/ or w/o biopsy
8,104
2,604
5,500
8,356
2,856
5,500
9,700
4,200
5,500
50559
50561
Renal endoscopy through established nephrostomy or pyelostomy, w/ or
w/o irrigation, instillation, or ureteropyelography, exclusive of radiologic
service; w/ insertion of radioactive substance w/ or w/out biopsy and/or
fulguration
Renal endoscopy through established nephrostomy or pyelostomy, w/ or
w/o irrigation, instillation, or ureteropyelography, exclusive of radiologic
service; w/ removal of foreign body or calculus
50570
Renal endoscopy through nephrotomy or pyelotomy, w/ or w/o irrigation,
instillation, or ureteropyelography, exclusive of radiologic service;
8,260
3,360
4,900
50572
Renal endoscopy through nephrotomy or pyelotomy, w/ or w/o irrigation,
instillation, or ureteropyelography, exclusive of radiologic service; w/
ureteral catheterization, w/ or w/o dilation of ureter
8,260
3,360
4,900
50574
Renal endoscopy through nephrotomy or pyelotomy, w/ or w/o irrigation,
instillation, or ureteropyelography, exclusive of radiologic service; w/ biopsy
8,260
3,360
4,900
50575
Renal endoscopy through nephrotomy or pyelotomy, w/ or w/o irrigation,
instillation, or ureteropyelography, exclusive of radiologic service; w/
endopyelotomy (includes cystoscopy, ureteroscopy, dilation of ureter and
ureteral pelvic junction, incision of ureteral pelvic junction and insertion of
endopyelotomy stent)
9,700
4,200
5,500
50576
Renal endoscopy through nephrotomy or pyelotomy, w/ or w/o irrigation,
instillation, or ureteropyelography, exclusive of radiologic service; w/
fulguration and/or incision, w/ or w/o biopsy
9,700
4,200
5,500
50578
Renal endoscopy through nephrotomy or pyelotomy, w/ or w/o irrigation,
instillation, or ureteropyelography, exclusive of radiologic service; w/
insertion of radioactive substance, w/ or w/o biopsy and/or fulguration
9,700
4,200
5,500
9,700
4,200
5,500
18,000
8,400
9,600
9,700
4,200
5,500
50590
Renal endoscopy through nephrotomy or pyelotomy, w/ or w/o irrigation,
instillation, or ureteropyelography, exclusive of radiologic service; w/
removal of foreign body or calculus
Lithotripsy, extracorporeal shock wave
50592
Ablation, one or more renal tumor(s), percutaneous, unilateral frequency
50600
50605
50610
50620
50630
50650
12,120
12,120
21,820
20,980
21,820
21,820
6,720
6,720
10,920
10,080
10,920
10,920
5,400
5,400
10,900
10,900
10,900
10,900
20,980
10,080
10,900
50700
Ureterotomy w/ exploration or drainage
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, w/ bladder cuff
Ureterectomy, total, ectopic ureter, combination abdominal, vaginal and/or
perineal approach
Ureteroplasty, plastic operation on ureter (e.g., stricture)
21,820
10,920
10,900
50715
Ureterolysis, w/ or w/o repositioning of ureter for retroperitoneal fibrosis
21,820
10,920
10,900
50722
20,980
10,080
10,900
23,300
12,600
10,700
22,660
11,760
10,900
22,660
11,760
10,900
50740
50750
50760
Ureterolysis for ovarian vein syndrome
Ureterolysis for retrocaval ureter, w/ reanastomosis of upper urinary tract
or vena cava
Revision of urinary-cutaneous anastomosis (any type urostomy);
Revision of urinary-cutaneous anastomosis (any type urostomy); w/ repair
of fascial defect and hernia
Ureteropyelostomy, anastomosis of ureter and renal pelvis
Ureterocalycostomy, anastomosis of ureter to renal calyx
Ureteroureterostomy
23,300
27,120
21,820
12,600
15,120
10,920
10,700
12,000
10,900
50770
Transureteroureterostomy, anastomosis of ureter to contralateral ureter
27,120
15,120
12,000
50780
50782
50783
50785
50800
Ureteroneocystostomy; anastomosis of single ureter to bladder
Ureteroneocystostomy; anastomosis of duplicated ureter to bladder
Ureteroneocystostomy; w/ extensive ureteral tailoring
Ureteroneocystostomy; w/ vesico-psoas hitch or bladder flap
Ureteroenterostomy, direct anastomosis of ureter to intestine
27,120
30,300
37,800
30,300
30,740
15,120
16,800
21,000
16,800
13,440
12,000
13,500
16,800
13,500
17,300
50810
Ureterosigmoidostomy, w/ creation of sigmoid bladder and establishment
of abdominal or perineal colostomy, including bowel anastomosis
37,800
21,000
16,800
50580
50660
50725
50727
50728
Page 65 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
50815
50820
50825
50830
50840
50845
50860
50900
50920
50930
50940
50945
50947
50948
DESCRIPTION
37,800
21,000
Health Care
Institution Fee
16,800
40,320
23,520
16,800
46,500
25,200
21,300
37,800
21,000
16,800
37,800
21,000
16,800
30,300
20,980
18,000
20,980
23,300
21,820
21,940
16,800
10,080
8,400
10,080
12,600
10,920
9,240
13,500
10,900
9,600
10,900
10,700
10,900
12,700
23,300
12,600
10,700
23,300
12,600
10,700
Case Rate
Ureterocolon conduit, including bowel anastomosis
Ureteroileal conduit (ileal bladder), including bowel anastomosis (Bricker
operation)
Continent diversion, including bowel anastomosis using any segment of
small and/or large bowel (Kock pouch or Camey enterocystoplasty
Urinary undiversion (e.g., taking down of ureteroileal conduit,
ureterosigmoidostomy or ureteroenterostomy w/ ureteroureterostomy or
ureteroneocystostomy)
Replacement of all or part of ureter by bowel segment, including bowel
anastomosis
Cutaneous appendico-vesicostomy
Ureterostomy, transplantation of ureter to skin
Ureterorrhaphy, suture of ureter
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
Professional Fee
50951
Ureteral endoscopy through established ureterostomy, w/ or w/o irrigation,
instillation, or ureteropyelography, exclusive of radiologic service;
8,260
3,360
4,900
50953
Ureteral endoscopy through established ureterostomy, w/ or w/o irrigation,
instillation, or ureteropyelography, exclusive of radiologic service; w/
ureteral catheterization, w/ or w/o dilation of ureter
8,260
3,360
4,900
50955
Ureteral endoscopy through established ureterostomy, w/ or w/o irrigation,
instillation, or ureteropyelography, exclusive of radiologic service; w/ biopsy
8,260
3,360
4,900
10,880
3,780
7,100
9,700
4,200
5,500
11,980
5,880
6,100
8,260
3,360
4,900
50957
50959
50961
50970
Ureteral endoscopy through established ureterostomy, w/ or w/o irrigation,
instillation, or ureteropyelography, exclusive of radiologic service; w/
fulguration and/or incision, w/ or w/o biopsy
Ureteral endoscopy through established ureterostomy, w/ or w/o irrigation,
instillation, or ureteropyelography, exclusive of radiologic service; w/
insertion of radioactive substance, w/ or w/o biopsy and/or fulguration (not
including provision of material)
Ureteral endoscopy through established ureterostomy, w/ or w/o irrigation,
instillation, or ureteropyelography, exclusive of radiologic service; w/
removal of foreign body or calculus
Ureteral endoscopy through ureterotomy, w/ or w/o irrigation, instillation,
or ureteropyelography, exclusive of radiologic service;
50972
Ureteral endoscopy through established ureterostomy, w/ or w/o irrigation,
instillation, or ureteropyelography, exclusive of radiologic service; w/
ureteral catheterization, w/ or w/o dilation of ureter
8,260
3,360
4,900
50974
Ureteral endoscopy through established ureterostomy, w/ or w/o irrigation,
instillation, or ureteropyelography, exclusive of radiologic service; w/ biopsy
8,260
3,360
4,900
10,880
3,780
7,100
9,700
4,200
5,500
11,980
5,880
6,100
5,680
1,680
4,000
9,700
4,200
5,500
50976
50978
50980
51010
51020
Ureteral endoscopy through established ureterostomy, w/ or w/o irrigation,
instillation, or ureteropyelography, exclusive of radiologic service; w/
fulguration and/or incision, w/ or w/o biopsy
Ureteral endoscopy through established ureterostomy, w/ or w/o irrigation,
instillation, or ureteropyelography, exclusive of radiologic service; w/
insertion of radioactive substance, w/ or w/o biopsy and/or fulguration (not
including provision of material)
Ureteral endoscopy through established ureterostomy, w/ or w/o irrigation,
instillation, or ureteropyelography, exclusive of radiologic service; w/
removal of foreign body or calculus
Aspiration of bladder; by trocar or intracatheter w/ insertion of suprapubic
catheter
Cystotomy or cystostomy; w/ fulguration and/or insertion of radioactive
material
51030
Cystotomy or cystostomy; w/ cryosurgical destruction of intravesical lesion
9,700
4,200
5,500
51040
51045
Cystostomy, cystotomy w/ drainage
Cystotomy, w/ insertion of ureteral catheter or stent
Cystolithotomy, cystotomy w/ removal of calculus, w/o vesical neck
resection
Transvesical ureterolithotomy
Cystotomy, w/ stone basket extraction and/or ultrasonic or electrohydraulic
fragmentation of ureteral calculus
Drainage of perivesical or prevesical space abscess
Excision of urachal cyst or sinus, w/ or w/o umbilical hernia repair
Cystotomy; for simple excision of vesical neck
9,700
10,540
4,200
5,040
5,500
5,500
51050
51060
51065
51080
51500
51520
Page 66 of 98
12,540
7,140
5,400
21,820
10,920
10,900
21,820
10,920
10,900
10,540
30,300
20,980
5,040
16,800
10,080
5,500
13,500
10,900
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
51525
51530
51535
51550
51555
51565
51570
51575
51580
51585
51590
51595
51596
51597
51600
51720
51800
51820
51840
51841
51845
51860
51880
51900
51920
51925
51940
51960
51980
51990
51992
52000
52005
52007
DESCRIPTION
27,120
27,120
23,300
30,740
15,120
15,120
12,600
13,440
Health Care
Institution Fee
12,000
12,000
10,700
17,300
37,800
21,000
16,800
30,300
16,800
13,500
37,800
21,000
16,800
46,500
25,200
21,300
40,320
23,520
16,800
53,400
29,400
24,000
55,920
31,920
24,000
55,840
34,440
21,400
58,800
37,800
21,000
71,400
50,400
21,000
8,020
8,020
2,520
2,520
5,500
5,500
20,980
10,080
10,900
27,120
15,120
12,000
20,980
10,080
10,900
30,740
13,440
17,300
20,980
10,080
10,900
12,120
10,880
23,300
23,300
30,300
30,300
30,740
12,120
30,300
6,720
3,780
12,600
12,600
16,800
16,800
13,440
6,720
16,800
5,400
7,100
10,700
10,700
13,500
13,500
17,300
5,400
13,500
30,300
16,800
13,500
8,260
3,360
4,900
9,700
4,200
5,500
8,260
3,360
4,900
8,260
3,360
4,900
Case Rate
Cystotomy; for excision of bladder diverticulum, single or multiple
Cystotomy; for excision of bladder tumor
Cystotomy for excision, incision, or repair of ureterocele
Cystectomy, partial
Cystectomy, complicated (e.g., postradiation, previous surgery, difficult
location)
Cystectomy, partial, w/ reimplantation of ureter(s) into bladder
(ureteroneocystostomy)
Cystectomy, complete;
Cystectomy, complete; w/ bilateral pelvic lymphadenectomy, including
external iliac, hypogastric, and obturator nodes
Cystectomy, complete, w/ ureterosigmoidostomy or ureterocutaneous
transplantations;
Cystectomy, complete, w/ ureterosigmoidostomy or ureterocutaneous
transplantations; w/ bilateral pelvic lymphadenectomy, including external
iliac, hypogastric, and obturator nodes
Cystectomy, complete, w/ ureteroileal conduit or sigmoid bladder, including
bowel anastomosis;
Cystectomy, complete, w/ ureteroileal conduit or sigmoid bladder, including
bowel anastomosis; w/ bilateral pelvic lymphadenectomy, including external
iliac, hypogastric, and obturator nodes
Cystectomy, complete, w/ continent diversion, any technique, using any
segment of small and/or large bowel to construct neobladder
Pelvic exenteration, complete, for vesical, prostatic or urethral malignancy,
w/ removal of bladder and ureteral transplantations, w/ or w/o
hysterectomy and/or abdominoperineal resection of rectum and colon and
colostomy, or any combination thereof
Injection procedure for cystography or voiding urethrocystography
Bladder instillation of anticarcinogenic agent
Cystoplasty or cystourethroplasty, plastic operation on bladder and/or
vesical neck (anterior Y-plasty, vesical fundus resection), any procedure, w/
or w/o wedge resection of posterior vesical neck
Cystourethroplasty w/ unilateral or bilateral ureteroneocystostomy
Anterior vesicourethropexy, or urethropexy (Marshall-Marchetti-Krantz
type)
complicated (e.g., secondary repair)
Abdomino-vaginal vesical neck suspension, w/ or w/o endoscopic control
(e.g., Stamey, Raz, modified Pereyra)
Cystorrhaphy, suture of bladder wound, injury or rupture
Closure of cystostomy
Closure of vesicovaginal fistula, abdominal approach
Closure of vesicouterine fistula;
Closure of vesicouterine fistula; w/ hysterectomy
Closure of bladder exstrophy
Enterocystoplasty, including bowel anastomosis
Cutaneous vesicostomy
Laparoscopy, surgical; urethral suspension for stress incontinence
Laparoscopy, surgical; sling operation for stress incontinence (e.g., fascia or
synthetic)
Cystourethroscopy
Cystourethroscopy, w/ ureteral catheterization, w/ or w/o irrigation,
instillation, or ureteropyelography, exclusive of radiologic service;
Cystourethroscopy, w/ ureteral catheterization, w/ or w/o irrigation,
instillation, or ureteropyelography, exclusive of radiologic service; w/ brush
biopsy of ureter and/or renal pelvis
Professional Fee
52010
Cystourethroscopy, w/ ejaculatory duct catheterization, w/ or w/o
irrigation, instillation, or duct radiography, exclusive of radiologic service
52204
Cystourethroscopy, w/ biopsy
10,540
5,040
5,500
52214
Cystourethroscopy, w/ fulguration (including cryosurgery or laser surgery) of
trigone, bladder neck, prostatic fossa, urethra, or periurethral glands
11,980
5,880
6,100
52224
Cystourethroscopy, w/ fulguration (including cryosurgery or laser surgery) or
treatment of MINOR (less than 0.5 cm) lesion(s) w/ or w/o biopsy
11,980
5,880
6,100
52234
Cystourethroscopy, w/ fulguration (including cryosurgery or laser surgery)
and/or resection of; SMALL bladder tumor(s) (0.5 cm to 2.0 cm)
20,980
10,080
10,900
52235
Cystourethroscopy, w/ fulguration (including cryosurgery or laser surgery)
and/or resection of MEDIUM bladder tumor(s) (2.0 to 5.0 cm)
22,240
11,340
10,900
23,300
12,600
10,700
30,740
13,440
17,300
11,980
5,880
6,100
52240
52250
52260
LARGE bladder tumor(s)
Cystourethroscopy w/ insertionof radioactive substance, w/ or w/o biopsy
or fulguration
Cystourethroscopy, w/ dilation of bladder for insterstitial cystitis; general or
conduction (spinal) anesthesia
Page 67 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
DESCRIPTION
52265
52270
52275
52276
local anesthesia
Cystourethroscopy, w/ internal urethrotomy; female
Cystourethroscopy, w/ internal urethrotomy; male
Cystourethroscopy w/ direct vision internal urethrotomy
8,020
12,900
12,900
12,540
2,520
6,300
6,300
7,140
Health Care
Institution Fee
5,500
6,600
6,600
5,400
52277
Cystourethroscopy, w/ resection of external sphincter (sphincterotomy)
12,120
6,720
5,400
8,020
2,520
5,500
8,020
2,520
5,500
10,540
5,040
5,500
11,980
5,880
6,100
21,940
9,240
12,700
21,940
9,240
12,700
12,120
6,720
5,400
10,540
5,040
5,500
52281
52283
52285
52290
52300
52301
52305
52310
Case Rate
Cystourethroscopy, w/ calibration and/or dilation of urethral stricture or
stenosis, w/ or w/o meatotomy and injection procedure for cystography,
male or female
Cystourethroscopy, w/ steroid injection into stricture
Cystourethroscopy, for treatment of the female urethral syndrome w/ 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 of polyp(s) of urethra, bladder neck, and/or
trigone
Cystourethroscopy; w/ ureteral meatotomy, unilateral or bilateral
Cystourethroscopy; w/ resection or fulguration of orthotopic ureterocele(s),
unilateral or bilateral
Cystourethroscopy; w/ resection or fulguration of ectopic ureterocele(s),
unilateral or bilateral
Cystourethroscopy; w/ incision or resection of orifice of bladder
diverticulum, single or multiple
Cystourethroscopy, w/ removal of foreign body, calculus, or ureteral stent
from urethra or bladder
Professional Fee
52317
Litholapaxy: crushing or fragmentation of calculus by any means in bladder
and removal of fragments; simple or small (less than 2.5 cm)
18,000
8,400
9,600
52318
Litholapaxy: crushing or fragmentation of calculus by any means in bladder
and removal of fragments; complicated or large (over 2.5 cm)
21,940
9,240
12,700
52320
Cystourethroscopy (including ureteral catheterization); w/ removal of
ureteral calculus
11,980
5,880
6,100
52325
Cystourethroscopy (including ureteral catheterization); w/ fragmentation of
ureteral calculus (e.g., ultrasonic or electro-hydraulic technique)
18,000
8,400
9,600
9,700
4,200
5,500
10,540
5,040
5,500
10,540
5,040
5,500
9,700
4,200
5,500
12,120
6,720
5,400
12,120
6,720
5,400
21,940
9,240
12,700
21,940
9,240
12,700
12,120
6,720
5,400
21,940
9,240
12,700
23,300
23,300
12,120
12,600
12,600
6,720
10,700
10,700
5,400
37,800
21,000
16,800
18,000
8,400
9,600
21,940
9,240
12,700
21,940
9,240
12,700
20,980
10,080
10,900
52327
52330
52332
52334
52335
52336
52337
52338
52339
52340
52450
52500
52510
52601
52606
52612
52614
52620
Cystourethroscopy (including ureteral catheterization); w/ subureteric
injection of implant material
Cystourethroscopy (including ureteral catheterization); w/ manipulation,
w/o removal of ureteral calculus
Cystourethroscopy, w/ insertion of indwelling ureteral stent (e.g., Gibbons
or double-J type)
Cystourethroscopy w/ insertion of ureteral guide wire through kidney to
establish a percutaneous nephrostomy, retrograde
Cystourethroscopy, w/ ureteroscopy and/or pyeloscopy (includes dilation of
the ureter and/or pyeloureteral junction by any method);
Cystourethroscopy, w/ ureteroscopy and/or pyeloscopy (includes dilation of
the ureter and/or pyeloureteral junction by any method); w/ removal or
manipulation of calculus (ureteral catheterization is included)
Cystourethroscopy, w/ ureteroscopy and/or pyeloscopy (includes dilation of
the ureter and/or pyeloureteral junction by any method); w/ lithotripsy
(ureteral catheterization is included)
Cystourethroscopy, w/ ureteroscopy and/or pyeloscopy (includes dilation of
the ureter and/or pyeloureteral junction by any method); w/ biopsy and/or
fulguration of lesion
Cystourethroscopy, w/ ureteroscopy and/or pyeloscopy (includes dilation of
the ureter and/or pyeloureteral junction by any method); w/ resection of
tumor
Cystourethroscopy w/ incision, fulguration, or resection of congenital
posterior urethral valves, or congenital obstructive hypertrophic mucosal
folds
Transurethral incision of prostate
Transurethral resection of bladder neck
Transurethral balloon dilation of the prostatic urethra, any method
Transurethral electrosurgical resection of prostate, including control of
postoperative bleeding, complete (vasectomy, meatomy,
cystourethroscopy, urethral calibration and/or dilation, and internal
urethrotomy are included)
Transurethral fulguration for postoperative bleeding occuring 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
Page 68 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
52630
52640
52647
52648
52649
52700
53000
53010
53020
53025
53040
53060
53080
53200
53210
53215
53220
53230
53235
53240
53250
53260
53265
53270
53275
53400
53405
53410
53415
53420
53425
53430
53440
53442
53443
53445
53447
DESCRIPTION
Case Rate
Transurethral resection; of regrowth of obstructive tissue longer than one
year postoperative
Transurethral resection; of postoperative bladder neck contracture
Non-contact laser coagulation of prostate, including control of
postoperative bleeding, complete (vasectomy, meatotomy,
cystourethroscopy, urethral calibration and/or dilation, and internal
urethrotomy are included)
Contact laser vaporization w/ or w/o transurethral resection of prostate,
including control of postoperative bleeding, complete (vasectomy,
meatotomy, cystourethroscopy, urethral calibration and/or dilation, and
internal urethrotomy are included)
High intensity focused ultrasound (HIFU) of the prostate including
transurethral resection of the prostate (TURP)
Transurethral drainage of prostatic abscess
Urethrotomy or urethrostomy, external ; pendulous urethra
Urethrotomy or urethrostomy, external ; perineal urethra, external
Meatotomy, cutting of meatus ; except infant
Meatotomy, cutting of meatus ; infant
Drainage of deep periurethral abscess
Drainage of Skenes gland abscess or cyst
Drainage of perineal urinary extravasation
Biopsy of urethra
Urethrectomy, total, including cystostomy; female
Urethrectomy, total, including cystostomy; male
Excision of fulguration of carcinoma of urethra
Excision of urethral diverticulum ; female
Excision of urethral diverticulum ; male
Marsupialization of urethral diverticulum, male or female
Excision of bulbourethral gland (Cowpers gland)
Excision or fulguration; urethral polyp(s), distal urethra
Excision or fulguration; urethral caruncle
Skenes glands
Skenes glands urethral prolapse
Urethroplasty; first stage, for fistula, diverticulum, or stricture (e.g.,
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
Operation for correction of male urinary incontinence, w/ or w/o
introduction of prosthesis
Removal of perineal prosthesis introduced for continence
Urethroplasty w/ tubularization of posterior urethra and/or lower bladder
for incontinence (e.g., Tenago, Leadbetter procedure)
Operation for correction of urinary incontinence w/ placement of inflatable
urethral or bladder neck sphincter, including placement of pump and/or
reservoir
Removal, repair, or replacement of inflatable sphincter including pump
and/or reservoir and/or cuff
Professional Fee
Health Care
Institution Fee
37,800
21,000
16,800
20,980
10,080
10,900
27,120
15,120
12,000
27,120
15,120
12,000
37,800
21,000
16,800
18,000
5,680
8,260
5,560
8,260
9,300
5,560
8,020
5,560
21,940
21,820
9,700
18,000
14,960
9,300
12,120
5,560
5,560
5,560
9,300
8,400
1,680
3,360
1,260
3,360
2,100
1,260
2,520
1,260
9,240
10,920
4,200
8,400
7,560
2,100
6,720
1,260
1,260
1,260
2,100
9,600
4,000
4,900
4,300
4,900
7,200
4,300
5,500
4,300
12,700
10,900
5,500
9,600
7,400
7,200
5,400
4,300
4,300
4,300
7,200
30,300
16,800
13,500
27,120
15,120
12,000
14,960
7,560
7,400
40,320
23,520
16,800
37,800
21,000
16,800
27,120
15,120
12,000
18,000
8,400
9,600
18,000
8,400
9,600
18,000
8,400
9,600
31,140
17,640
13,500
37,180
18,480
18,700
40,320
23,520
16,800
18,000
8,400
9,600
8,260
3,360
4,900
53449
Surgical correction of hydraulic abnormality of inflatable sphincter device
53450
8,260
3,360
4,900
53502
53505
53510
Urethromeatoplasty, w/ mucosal advancement
Urethromeatoplasty, w/ partial excision of distal urethral segment
(Richardson type procedure)
Urethrorrhaphy, suture of urethral wound or injury, female
Urethrorrhaphy, suture of urethral wound or injury; penile
Urethrorrhaphy, suture of urethral wound or injury; perineal
9,700
9,700
10,540
4,200
4,200
5,040
5,500
5,500
5,500
53515
Urethrorrhaphy, suture of urethral wound or injury; prostatomembranous
10,540
5,040
5,500
53520
Closure of urethrostomy or urethrocutaneous fistula, male
8,020
2,520
5,500
53600
Dilation of urethral stricture by passage of sound or urethral dilator, male
5,680
1,680
4,000
53605
Dilation of urethral stricture or vesical neck, male, general or conduction
(spinal) anesthesia
5,680
1,680
4,000
53665
Dilation of female urethra, general or conduction (spinal) anesthesia
5,680
1,680
4,000
37,800
21,000
16,800
37,800
21,000
16,800
53460
53850
53852
Transurethral destruction of prostate tissue; by microwave thermotherapy
i.e. Transurethral Microwave Thermotherapy (TUMT)
Transurethral destruction of prostate tissue; by radiofrequncy ablation i.e.,
Transurethral Needle Ablation (TUNA), transurethral laser incision of the
prostate (TULIP)
Page 69 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
DESCRIPTION
3,640
840
3,640
840
2,800
54100
54110
Incision and drainage of penis
Destruction of lesion(s), penis (e.g., condyloma, papilloma, molluscum
contagiosum, herpetic vesicle), any method
Biopsy of penis
Excision of penile plaque (Peyronie disease);
Health Care
Institution Fee
2,800
3,504
9,300
504
2,100
3,000
7,200
54111
Excision of penile plaque (Peyronie disease); w/ graft to 5 cm in length
10,540
5,040
5,500
54112
Excision of penile plaque (Peyronie disease); w/ graft greater than 5 cm in
length
11,980
5,880
6,100
54115
Removal of foreign body from deep penile tissue (e.g., plastic implant)
8,260
3,360
4,900
54120
54125
Amputation of penis; partial
Amputation of penis; complete
10,540
21,400
5,040
10,500
5,500
10,900
54130
Amputation of penis, radical; w/ bilateral inguinofemoral lymphadenectomy
37,800
21,000
16,800
54135
Amputation of penis, radical; in continuity w/ bilateral pelvic
lymphadenectomy, including external iliac, hypogastric and obturator nodes
46,500
25,200
21,300
1,260
1,260
840
840
420
420
1,260
840
420
1,260
840
420
54200
Circumcision, using clamp or other device; newborn
Circumcision, using clamp or other device; except newborn
Circumcision, surgical excision other than clamp, device or dorsal slit;
newborn
Circumcision, surgical excision other than clamp, device or dorsal slit; except
newborn
Injection procedure for Peyronie disease;
5,560
1,260
4,300
54205
Injection procedure for Peyronie disease;w/ surgical exposure of plaque
5,680
1,680
4,000
54220
Irrigation of corpora cavernosa for priapism
Plastic operation of penis for straightening of chordee (e.g., hypospadias),
w/ or w/o mobilization of urethra
8,020
2,520
5,500
9,700
4,200
5,500
14,960
7,560
7,400
23,300
12,600
10,700
23,300
12,600
10,700
23,300
12,600
10,700
12,120
6,720
5,400
27,120
15,120
12,000
54015
54050
54150
54152
54160
54161
54300
54304
54308
54312
54316
54318
54322
Case Rate
Plastic operation on penis for correction of chordee or for first stage
hypospadias repair w/ or w/o 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
Urethroplasty for second stage hypospadias repair (including urinary
diversion) w/ free skin graft obtained from site other than genitalia
Urethroplasty for third stage hypospadias repair to release penis from
scrotum (e.g., third stage Cecil repair)
One stage distal hypospadias repair (w/ or w/o chordee or circumcision); w/
simple meatal advancement (e.g., Magpi, V-flap)
Professional Fee
54324
One stage distal hypospadias repair (w/ or w/o chordee or circumcision); w/
urethroplasty by local skin flaps (e.g., flip-flap, prepucial flap)
27,120
15,120
12,000
54326
One stage distal hypospadias repair (w/ or w/o chordee or circumcision); w/
urethroplasty by local skin flaps and mobilization of urethra
27,120
15,120
12,000
54328
One stage distal hypospadias repair (w/ or w/o chordee or circumcision); w/
extensive dissection to correct chordee and urethroplasty w/ local skin
flaps, skin graft patch, and/or island flap
30,300
16,800
13,500
37,180
18,480
18,700
37,180
18,480
18,700
37,180
18,480
18,700
18,000
8,400
9,600
20,980
10,080
10,900
37,800
21,000
16,800
54332
54336
54340
54344
54348
54352
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 w/ flap or patch graft
Repair of hypospadias complications (ie, fistula, stricture, diverticula);
requiring extensive dissection and urethroplasty w/ 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
54380
Plastic operation on penis for epispadias distal to external sphincter;
30,300
16,800
13,500
54385
Plastic operation on penis for epispadias distal to external sphincter;w/
incontinence
37,180
18,480
18,700
Page 70 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
54670
Plastic operation on penis for epispadias distal to external sphincter;w/
exstrophy of bladder
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 (e.g., biopsy needle, Winter
procedure, rongeur, or punch) for priapism
Plastic operation of penis for injury
Biopsy of testis, needle
Biopsy of testis, incisional
Excision of local lesion of testis
Orchiectomy, simple (including subcapsular), w/ or w/o testicular
prosthesis, scrotal or inguinal approach
Orchiectomy, radical, for tumor; inguinal approach
Orchiectomy, radical, for tumor; w/ abdominal exploration
Exploration for undescended testis (inguinal or scrotal area)
Exploration for undescended testis w/ abdominal exploration
Reduction of torsion of testis, surgical, w/ or w/o fixation of contralateral
testis
Fixation of contralateral testis
Orchiopexy, inguinal approach, w/ or w/o hernia repair
Orchiopexy, abdominal approach, for intra-abdominal testis (e.g., FowlerStephens)
Suture or repair of testicular injury
54680
Transplantation of testis(es) to thigh (because of scrotal destruction)
54690
54692
9,700
11,980
4,200
5,880
5,500
6,100
4,108
1,008
3,100
54800
54820
54830
54840
54860
54861
Laparoscopy, surgical; orchiectomy
Laparoscopy, surgical; orchiopexy for intra-abdominal testis
Incision and drainage of epididymis, testis and/or scrotal space (e.g., abscess
or hematoma)
Biopsy of epididymis, needle
Exploration of epididymis, w/ or w/o biopsy
Excision of local lesion of epidydimis
Excision of spermatocele, w/ or w/o epididymectomy
Epididymectomy; unilateral
Epididymectomy; bilateral
3,504
9,300
5,680
8,020
9,300
8,440
504
2,100
1,680
2,520
2,100
2,940
3,000
7,200
4,000
5,500
7,200
5,500
54900
Epididymovasostomy, anastomosis of epididymis to vas deferens; unilateral
10,540
5,040
5,500
54901
Epididymovasostomy, anastomosis of epididymis to vas deferens; bilateral
18,000
8,400
9,600
54390
54420
54430
54435
54440
54500
54505
54510
54520
54530
54535
54550
54560
54600
54620
54640
54650
54700
37,800
21,000
16,800
12,120
6,720
5,400
12,120
6,720
5,400
8,260
3,360
4,900
12,120
3,504
5,680
5,680
6,720
504
1,680
1,680
5,400
3,000
4,000
4,000
10,540
5,040
5,500
10,960
12,540
10,540
12,540
5,460
7,140
5,040
7,140
5,500
5,400
5,500
5,400
10,960
5,460
5,500
9,300
10,540
2,100
5,040
7,200
5,500
12,540
7,140
5,400
9,700
4,200
5,500
8,260
3,360
4,900
3,504
504
3,000
55040
55041
55060
55100
55101
55110
55120
55150
55175
Puncture aspiration of hydrocele, tunica vaginalis, w/ or w/o injection of
medication
Excision of hydrocele; unilateral
Excision of hydrocele; bilateral
Repair of tunica vaginalis hydrocele (Bottle type)
Drainage of scrotal wall abscess
Drainage and debridement of Fourniers gangrene of the scrotum
Scrotal exploration
Removal of foreign body in scrotum
Resection of scrotum
Scrotoplasty
9,700
18,000
9,700
3,504
9,300
9,300
4,108
5,560
5,680
4,200
8,400
4,200
504
2,100
2,100
1,008
1,260
1,680
5,500
9,600
5,500
3,000
7,200
7,200
3,100
4,300
4,000
55200
Vasotomy, cannulization w/ or w/o incision of vas, unilateral or bilateral
5,680
1,680
4,000
55250
55400
55500
55520
55530
Vasectomy, unilateral or bilateral
Vasovasostomy, vasovasorrhaphy
Excision of hydrocele of spermatic cord, unilateral
Excision of lesion of spermatic cord
Excision of varicocele or ligation of spermatic veins for varicocele;
Excision of varicocele or ligation of spermatic veins for varicocele;
abdominal approach
Excision of varicocele or ligation of spermatic veins for varicocele; w/ hernia
repair
4,000
10,540
9,700
8,260
12,900
1,000
5,040
4,200
3,360
6,300
3,000
5,500
5,500
4,900
6,600
14,960
7,560
7,400
14,960
7,560
7,400
55550
Laparoscopy, surgical; with ligation of spermatic veins for varicocele
14,960
7,560
7,400
55600
55650
55680
55700
55720
Vesiculotomy;
Vesiculectomy, any approach
Excision of Mullerian duct cyst
Biopsy, prostate; needle or punch, single or multiple, any approach
Prostatotomy, external drainage of prostatic abscess, any approach
Prostatectomy, perineal, subtotal (including control of postoperative
bleeding, vasectomy, meatotomy, urethral calibration and/or dilation, and
internal urethrotomy)
Prostatectomy, perineal radical;
Prostatectomy, perineal radical; w/ lymph node biopsy(s) (limited pelvic
lymphadenectomy)
10,120
18,000
18,000
9,300
5,680
4,620
8,400
8,400
2,100
1,680
5,500
9,600
9,600
7,200
4,000
38,860
20,160
18,700
46,500
25,200
21,300
48,180
26,880
21,300
55000
55535
55540
55801
55810
55812
Page 71 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
55815
55821
55831
55840
55842
55845
55859
DESCRIPTION
Case Rate
Prostatectomy, perineal radical; w/ 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, w/ or w/o nerve sparing;
Prostatectomy, retropubic radical, w/ or w/o nerve sparing; w/ lymph node
biopsy(s) (limited pelvic lymphadenectomy)
Prostatectomy, retropubic radical, w/ or w/o nerve sparing; w/ bilateral
pelvic lymphadenectomy, including external iliac, hypogastric, and obturator
nodes
Transperineal placement of needles, catheters or pellets into prostate for
interstitial radioelement application, with or without cystoscopy, ultrasound
or CT scan guidance
Professional Fee
Health Care
Institution Fee
48,180
26,880
21,300
38,860
20,160
18,700
30,300
16,800
13,500
46,500
25,200
21,300
48,180
26,880
21,300
48,180
26,880
21,300
18,000
8,400
9,600
55860
Exposure of prostate, any approach, for insertion of radioactive substance;
9,700
4,200
5,500
55862
Exposure of prostate, any approach, for insertion of radioactive substance;
w/ lymph node biopsy(s) (limited pelvic lymphadenectomy)
18,000
8,400
9,600
23,300
12,600
10,700
46,500
25,200
21,300
55,000
5,560
9,300
9,700
9,300
9,300
9,300
12,120
23,300
27,120
33,600
1,260
2,100
4,200
2,100
2,100
2,100
6,720
12,600
15,120
21,400
4,300
7,200
5,500
7,200
7,200
7,200
5,400
10,700
12,000
55873
56405
56420
56440
56441
56501
56605
56620
56625
56630
Exposure of prostate, any approach, for insertion of radioactive substance;
w/ bilateral pelvic lymphadenectomy, including external iliac, hypogastric
and obturator nodes
Laparoscopy, surgical prostatectomy, retropubic radical, including nerve
sparing
Cryosurgical ablation of the prostate (cryotherapy of the prostate)
Incision and drainage of vulva or perineal abscess
Incision and drainage of Bartholins gland abscess
Marsupialization of Bartholins gland cyst
Lysis of labial adhesions
Destruction of lesion(s), vulva; any method
Biopsy of vulva or perineum ; one lesion
Vulvectomy simple; partial
Vulvectomy simple; complete
Vulvectomy, radical, partial;
56631
Vulvectomy, radical, partial; w/ unilateral inguinofemoral lymphadenectomy
30,300
16,800
13,500
56632
Vulvectomy, radical, partial; w/ bilateral inguinofemoral lymphadenectomy
37,800
21,000
16,800
56633
46,500
25,200
21,300
53,400
29,400
24,000
55,000
33,600
21,400
58,800
37,800
21,000
9,700
9,300
9,700
12,120
5,680
5,680
5,680
23,300
30,300
27,120
9,300
9,700
4,200
2,100
4,200
6,720
1,680
1,680
1,680
12,600
16,800
15,120
2,100
4,200
5,500
7,200
5,500
5,400
4,000
4,000
4,000
10,700
13,500
12,000
7,200
5,500
9,700
4,200
5,500
8,020
2,520
5,500
10,540
5,040
5,500
12,120
6,720
5,400
57230
Vulvectomy, radical, complete;
Vulvectomy, radical, complete; w/ unilateral inguinofemoral
lymphadenectomy
Vulvectomy, radical, complete; w/ bilateral inguinofemoral
lymphadenectomy
Vulvectomy, radical, complete, w/ inguinofemoral, iliac, and pelvic
lymphadenectomy
Partial hymenectomy or revision of hymenal ring
Hymenotomy, simple incision
Excision of Bartholins gland or cyst
Colpotomy; w/ exploration
Colpocentesis
Destruction of vaginal lesion(s)
Biopsy of vaginal mucosa
Colpectomy, obliteration of vagina; partial
Colpectomy, obliteration of vagina; complete
Colpocleisis (Le Fort type)
Excision of vaginal septum
Excision of vaginal cyst or tumor
Insertion of uterine tandems and/or vaginal ovoids for clinical
brachytherapy
Colporrhaphy, suture of injury of vagina (nonobsterical)
Colpoperineorrhaphy, suture of injury of vagina and/or perineum
(nonobstetrical)
Plastic operation on urethral sphincter, vaginal approach (e.g., Kelly urethral
plication)
Plastic repair of urethrocele
12,120
6,720
5,400
57240
Anterior colporrhaphy, repair of cystocele w/ or w/o repair of urethrocele
20,980
10,080
10,900
57250
Posterior colporrhaphy, repair of rectocele w/ or w/o perineorrhaphy
20,980
10,080
10,900
57260
57265
57268
57270
Combined anteroposterior colporrhaphy;
Combined anteroposterior colporrhaphy; w/ enterocele repair
Repair of enterocele, vaginal approach
Repair of enterocele, abdominal approach
23,300
30,300
23,300
27,120
12,600
16,800
12,600
15,120
10,700
13,500
10,700
12,000
55865
55866
56634
56637
56640
56700
56720
56740
57000
57020
57061
57100
57108
57110
57120
57130
57135
57155
57200
57210
57220
Page 72 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
57280
57282
DESCRIPTION
27,120
27,120
15,120
15,120
Health Care
Institution Fee
12,000
12,000
27,120
15,120
12,000
30,300
30,300
20,980
23,300
16,800
16,800
10,080
12,600
13,500
13,500
10,900
10,700
30,300
16,800
13,500
20,980
30,300
23,300
30,300
8,260
27,120
8,020
8,260
9,700
10,080
16,800
12,600
16,800
3,360
15,120
2,520
3,360
4,200
10,900
13,500
10,700
13,500
4,900
12,000
5,500
4,900
5,500
Case Rate
Professional Fee
57310
57311
57320
57330
57415
57425
57452
57454
57460
Colpopexy, abdominal approach
Sacrospinous ligament fixation for prolapse of vagina
Paravaginal defect repair (including repair of cystocele, stress urinary
incontinence, and/or incomplete vaginal prolapse)
Sling operation for stress incontinence (e.g., fascia or synthetic)
Pereyra procedure, including anterior colporrhaphy
Closure of rectovaginal fistula; vaginal or transanal approach
Closure of rectovaginal fistula; abdominal approach
Closure of rectovaginal fistula; abdominal approach, w/ concomitant
colostomy
Closure of urethrovaginal fistula;
Closure of urethrovaginal fistula; w/ bulbocavernosus transplant
Closure of vesicovaginal fistula; vaginal approach
Closure of vesicovaginal fistula; transvesical and vaginal approach
Removal of impacted vaginal foreign body under anesthesia
Laparoscopy, surgical, colpopexy (suspension of vaginal apex)
Colposcopy (Vaginoscopy)
Colposcopy; w/ biopsy(s) of the cervix and/or endocervical curettage
Colposcopy; w/ loop electrode excision procedure of the cervix
57500
Biopsy, single or multiple, or local excision of lesion, w/ or w/o fulguration
5,680
1,680
4,000
57510
5,680
1,680
4,000
9,700
4,200
5,500
12,900
6,300
6,600
57530
57540
Cauterization of cervix; any method
Conization of cervix, w/ or w/o fulguration, w/ or w/o dilation and
curettage, w/ or w/o repair; cold knife or laser
Conization of cervix, w/ or w/o fulguration, w/ or w/o dilation and
curettage, w/ or w/o repair; loop electrode excision
Trachelectomy (cervicectomy), amputation of cervix
Excision of cervical stump, abdominal approach;
18,000
30,300
8,400
16,800
9,600
13,500
57545
Excision of cervical stump, abdominal approach; w/ pelvic floor repair
37,800
21,000
16,800
57550
Excision of cervical stump, vaginal approach;
Excision of cervical stump, vaginal approach; w/ anterior and/or posterior
repair
23,300
12,600
10,700
37,800
21,000
16,800
57556
Excision of cervical stump, vaginal approach; w/ repair of enterocele
39,900
23,100
16,800
57700
57720
Cerclage of uterine cervix, nonobstetrical
Trachelorrhaphy, plastic repair of uterine cervix, vaginal approach
Endometrial sampling (biopsy) w/ or w/o endocervical sampling (biopsy),
w/o cervical dilation, any method
Dilation and curettage
Myomectomy, excision of fibroid tumor of uterus, single or multiple ;
abdominal approach
Myomectomy, excision of fibroid tumor of uterus, single or multiple ; vaginal
approach
Total abdominal hysterectomy (corpus and cervix), w/ or w/o removal of
tube(s), w/ or w/o removal of ovary(s);
Total abdominal hysterectomy (corpus and cervix), w/ or w/o removal of
tube(s), w/ or w/o removal of ovary(s); w/ colpo-urethrocystopexy (MarshallMarchetti-Krantz type)
Supracervical abdominal hysterectomy (subtotal hysterectomy), w/ or w/o
removal of tube(s), w/ or w/o removal of ovary(s)
Total abdominal hysterectomy, including partial vaginectomy, w/ paraaortic and pelvic lymph node sampling, w/ or w/o removal of tube(s), w/ or
w/o removal of ovary(s)
Radical abdominal hysterectomy, w/ bilateral total pelvic lymphadenectomy
and para-aortic lymph node sampling (biopsy), w/ or w/o removal of
tube(s), w/ or w/o removal of ovary(s)
Pelvic exenteration for gynecologic malignancy, w/ total abdominal
hysterectomy or cervicectomy, w/ or w/o removal of tube(s), w/ or w/o
removal of ovary(s), w/ removal of bladder and ureteral transplantations,
and/or abdominoperineal resection of rectum and colon and colostomy, or
any combination thereof
Vaginal hysterectomy;
Vaginal hysterectomy; w/ removal of tube(s), and/or ovary(s)
Vaginal hysterectomy; w/ removal of tube(s), and/or ovary(s), w/ repair of
enterocele
Vaginal hysterectomy; w/ colpo-urethrocystopexy (Marshall-MarchettiKrantz type, Pereyra type, w/ or w/o endoscopic control)
Vaginal hysterectomy; w/ repair of enterocele
Vaginal hysterectomy, w/ total or partial colpectomy;
Vaginal hysterectomy, w/ total or partial colpectomy; w/ repair of
enterocele
Vaginal hysterectomy, radical (Schauta type operation)
Insertion of intrauterine device (IUD)
9,700
18,000
4,200
8,400
5,500
9,600
11,000
4,200
6,800
11,000
4,200
6,800
23,300
12,600
10,700
18,000
8,400
9,600
30,000
12,000
18,000
30,000
12,000
18,000
30,000
12,000
18,000
30,000
12,000
18,000
55,000
33,600
21,400
71,400
50,400
21,000
30,300
30,300
16,800
16,800
13,500
13,500
37,800
21,000
16,800
46,500
25,200
21,300
46,500
37,800
25,200
21,000
21,300
16,800
46,500
25,200
21,300
46,500
2,000
25,200
800
21,300
1,200
18,000
8,400
9,600
57284
57288
57289
57300
57305
57307
57520
57522
57555
58100
58120
58140
58145
58150
58152
58180
58200
58210
58240
58260
58262
58263
58267
58270
58275
58280
58285
58300
58345
Transcervical introduction of fallopian tube catheter for diagnosis and/or reestablishing patency (any method), w/ or w/o hysterosalpingography
Page 73 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
58346
58400
58410
58520
58540
58545
58550
58552
58555
58558
58559
58560
58561
58562
58563
58565
58600
58660
DESCRIPTION
9,700
4,200
Health Care
Institution Fee
5,500
23,300
12,600
10,700
27,120
15,120
12,000
Hysterorrhaphy, repair of ruptured uterus (nonobstetrical)
Hysteroplasty, repair of uterine anomaly (Strassman type)
Laparoscopy, surgical, myomectomy, excision; intramural myomas and/or
removal of surface myomas
Laparoscopy surgical, with vaginal hysterectomy;
Laparoscopy surgical, with vaginal hysterectomy; with removal of tube(s)
and/or ovary(s)
Hysteroscopy, diagnostic
Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or
polypectomy, with or without D&C
23,300
37,800
12,600
21,000
10,700
16,800
23,300
12,600
10,700
30,300
16,800
13,500
30,300
16,800
13,500
9,700
4,200
5,500
12,900
6,300
6,600
Hysteroscopy, surgical; with lysis of intrauterine adhesions (any method)
18,000
8,400
9,600
18,000
8,400
9,600
23,300
12,900
12,600
6,300
10,700
6,600
12,120
6,720
5,400
5,680
1,680
4,000
4,000
1,000
3,000
21,400
10,500
10,900
53,400
29,400
24,000
14,960
7,560
7,400
14,960
7,560
7,400
Case Rate
Insertion of heyman capsules for brachytherapy
Uterine suspension, w/ or w/o shortening of round ligaments, w/ or w/o
shortening of sacrouterine ligaments;
Uterine suspension, w/ or w/o shortening of round ligaments, w/ or w/o
shortening of sacrouterine ligaments; w/ presacral sympathectomy
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 (e.g., endometrial
resection, electrosurgical ablation thermoablation)
Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce
occlusion by placement of permanent implants
Ligation or transection of fallopian tube(s), abdominal or vaginal approach,
unilateral or bilateral
Laparoscopy, surgical; with lysis of adhesions (salphingolysis, ovariolysis)
58672
58673
58700
58720
58740
58750
58760
58770
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 (e.g., band, clip,
or Falope ring)
Laparoscopy, surgical; with fimbrioplasty
Laparoscopy, surgical; with salphingostomy (salpingoneostomy)
Salpingectomy, complete or partial, unilateral or bilateral
Salpingo-oophorectomy, complete or partial, unilateral or bilateral
Lysis of adhesions (salpingolysis, ovariolysis)
Tubotubal anastomosis
Fimbrioplasty
Salpingostomy (salpingoneostomy)
58800
58661
58662
58670
58671
Professional Fee
12,900
6,300
6,600
21,400
23,300
20,980
23,300
23,300
18,000
23,300
23,300
10,500
12,600
10,080
12,600
12,600
8,400
12,600
12,600
10,900
10,700
10,900
10,700
10,700
9,600
10,700
10,700
Drainage of ovarian cyst(s), unilateral or bilateral ; vaginal approach
20,980
10,080
10,900
58805
Drainage of ovarian cyst(s), unilateral or bilateral ; abdominal approach
20,980
10,080
10,900
58820
58822
58825
58900
58920
58925
58940
Drainage of ovarian abscess; vaginal approach
Drainage of ovarian abscess; abdominal approach
Transposition, ovary(s)
Biopsy of ovary, unilateral or bilateral
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
malignancy, w/ para-aortic and pelvic lymph node biopsies, peritoneal
washings, peritoneal biopsies, diaphragmatic assessments, w/ or w/o
salpingectomy(s), w/ or w/o omentectomy
Resection of ovarian malignancy w/ bilateral salpingo-oophorectomy and
omentectomy;
Resection of ovarian malignancy w/ bilateral salpingo-oophorectomy and
omentectomy; w/ total abdominal hysterectomy, pelvic and limited paraaortic lymphadenectomy
20,980
20,980
20,980
18,000
18,000
23,300
18,000
10,080
10,080
10,080
8,400
8,400
12,600
8,400
10,900
10,900
10,900
9,600
9,600
10,700
9,600
30,300
16,800
13,500
53,400
29,400
24,000
55,000
33,600
21,400
58,800
37,800
21,000
27,120
15,120
12,000
23,300
12,600
10,700
27,120
15,120
12,000
58943
58950
58951
58952
58960
59100
59120
Resection of ovarian malignancy w/ bilateral salpingo-oophorectomy and
omentectomy; w/ radical dissection for debulking
Laparotomy, for staging or restaging of ovarian malignancy ("second look"),
w/ or w/o omentectomy, peritoneal washing, biopsy of abdominal and
pelvic peritoneum, diaphragmatic assessment w/ pelvic and limited paraaortic lymphadenectomy
Hysterotomy, abdominal (e.g., for hydatidiform mole, abortion)
Surgical treatment of ectopic pregnancy; tubal or ovarian, requiring
salpingectomy and/or oophorectomy, abdominal or vaginal approach
Page 74 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
59121
59130
59135
59136
59140
59150
59151
59320
59325
59350
DESCRIPTION
Case Rate
Surgical treatment of ectopic pregnancy; tubal or ovarian, w/o
salpingectomy and/or oophorectomy
Surgical treatment of ectopic pregnancy; abdominal pregnancy
Surgical treatment of ectopic pregnancy; interstitial, uterine pregnancy
requiring total hysterectomy
Surgical treatment of ectopic pregnancy; interstitial, uterine pregnancy w/
partial resection of uterus
Surgical treatment of ectopic pregnancy; cervical, w/ evacuation
Laparoscopic treatment of ectopic pregnancy; w/o salpingectomy and/or
oophorectomy
Laparoscopic treatment of ectopic pregnancy; w/ salpingectomy and/or
oophorectomy
Cerclage of cervix, during pregnancy; vaginal
Cerclage of cervix, during pregnancy; abdominal
Hysterorrhaphy of ruptured uterus
Professional Fee
Health Care
Institution Fee
27,120
15,120
12,000
46,500
25,200
21,300
37,800
21,000
16,800
37,600
18,900
18,700
30,300
16,800
13,500
27,120
15,120
12,000
27,120
15,120
12,000
18,000
18,000
30,300
8,400
8,400
16,800
9,600
9,600
13,500
59400
Routine obstetric care including antepartum care, vaginal delivery and/or
postpartum care (Normal Spontaneous Delivery Package) for hospitals
6,500
2,000
3,000
59401
Routine Obstetric care including prenatal, delivery and newborn services of
non-hospital facilities (Maternity Care Package), 1st claim
8,000
2,600
3,900
10,500
3,600
5,400
9,700
12,120
19,000
19,000
30,000
4,200
6,720
7,600
7,600
12,000
5,500
5,400
11,400
11,400
18,000
12,120
6,720
5,400
19,000
7,600
11,400
59402
59409
59411
59513
59514
59525
59612
59620
Routine obstetric care including antepartum care, vaginal delivery and/or
postpartum care for hospitals; with bilateral tubal ligation
Vaginal delivery only (w/ episiotomy)
Breech extraction
Caesarian section, primary
Cesarian delivery
Subtotal or total hysterectomy after cesarean delivery
Vaginal delivery only, after previous cesarean delivery (w/ or w/o
episiotomy)
Cesarean delivery only, following attempted vaginal delivery after previous
cesarean delivery;
59812
Treatment of incomplete abortion, any trimester, completed surgically
11,000
4,200
6,800
59814
59870
60000
60001
60100
60200
60210
11,000
12,120
3,504
8,260
8,260
20,980
31,000
4,400
6,720
504
3,360
3,360
10,080
12,400
6,600
5,400
3,000
4,900
4,900
10,900
18,600
31,000
12,400
18,600
31,000
12,400
18,600
31,000
12,400
18,600
60240
Manual vacuum aspiration for spontaneous abortion
Uterine evacuation and curettage for hydatidiform mole
Incision and drainage of thyroglossal cyst, infected
Aspiration and/or injection, thyroid cyst
Biopsy thyroid, percutaneous core needle
Excision of cyst or adenoma of thyroid , or transection of isthmus
Partial thyroid lobectomy, unilateral; w/ or w/o isthmusectomy
Partial thyroid lobectomy, unilateral; w/ contralateral subtotal lobectomy,
including isthmusectomy
Total thyroid lobectomy, unilateral; w/ or w/o isthmusectomy
Total thyroid lobectomy, unilateral; w/ contralateral subtotal lobectomy,
including isthmusectomy
Thyroidectomy, total or complete
31,000
12,400
18,600
60252
Thyroidectomy, total or subtotal for malignancy; w/ limited neck dissection
31,000
12,400
18,600
60254
Thyroidectomy, total or subtotal for malignancy; w/ radical neck dissection
46,500
25,200
21,300
31,000
12,400
18,600
46,500
25,200
21,300
60212
60220
60225
60260
60270
Thyroidectomy, removal of all remaining thyroid tissue following previous
removal of a portion of thyroid
Thyroidectomy, including substernal thyroid gland; sternal split or
transhoracic approach
60271
Thyroidectomy, including substernal thyroid gland; cervical approach
46,500
25,200
21,300
60280
60281
60500
60502
Excision of thyroglossal duct cyst or sinus;
Excision of thyroglossal duct cyst or sinus; recurrent
Parathyroidectomy or exploration of parathyroid(s);
Parathyroidectomy or exploration of parathyroid(s); re-exploration
Parathyroidectomy or exploration of parathyroid(s); w/ mediastinal
exploration, sternal split or transthoracic approach
Parathyroid autotransplantation
Thymectomy, partial or total; transcervical approach
Thymectomy, partial or total; sternal split or transthoracic approach, w/o
radical mediastinal dissection
Thymectomy, partial or total; sternal split or transthoracic approach, w/
radical mediastinal dissection
Adrenalectomy, partial or complete, or exploration of adrenal gland w/ or
w/o biopsy, transabdominal, lumbar or dorsal;
Adrenalectomy, partial or complete, or exploration of adrenal gland w/ or
w/o biopsy, transabdominal, lumbar or dorsal; w/ excision of adjacent
retroperitoneal tumor
Excision of carotid body tumor; w/o excision of carotid artery
Excision of carotid body tumor; w/ excision of carotid artery
20,980
23,300
30,740
27,120
10,080
12,600
13,440
15,120
10,900
10,700
17,300
12,000
39,900
23,100
16,800
30,300
39,900
16,800
23,100
13,500
16,800
39,900
23,100
16,800
39,900
23,100
16,800
30,300
16,800
13,500
37,600
18,900
18,700
30,300
37,800
16,800
21,000
13,500
16,800
60505
60512
60520
60521
60522
60540
60545
60600
60605
Page 75 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
DESCRIPTION
Case Rate
60650
Laparoscopy, surgical, with adrenalectomy, partial or complete, or
exploration of adrenal gland with or without biopsy, transabdominal, lumbar
or dorsal
61000
Subdural tap through fontanelle, or suture, infant, unilateral or bilateral
61020
61050
61105
61106
61107
61108
Ventricular puncture through previous burr hole, fontanelle, suture, or
implanted ventricular catheter/reservoir
Cisternal or lateral cervical (C1-C2) puncture
Twist drill hole for subdural or ventricular puncture; not followed by other
surgery
Twist drill hole for subdural or ventricular puncture; followed by other
surgery
Twist drill hole for subdural or ventricular puncture; for implanting
venticular catheter or pressure recording device
Twist drill hole for subdural or ventricular puncture; for evacuation and/or
drainage of subdural hematoma
Professional Fee
Health Care
Institution Fee
30,300
16,800
13,500
5,680
1,680
4,000
5,680
1,680
4,000
10,540
5,040
5,500
18,000
8,400
9,600
18,420
8,820
9,600
30,300
16,800
13,500
37,800
21,000
16,800
61120
Burr hole(s) for ventricular puncture (including injection of gas, contrast
media, dye, or radioactive material); not followed by other surgery
23,300
12,600
10,700
61130
Burr hole(s) for ventricular puncture (including injection of gas, contrast
media, dye, or radioactive material); followed by other surgery
22,240
11,340
10,900
37,800
37,800
21,000
21,000
16,800
16,800
37,800
21,000
16,800
61156
61250
61253
61304
Burr hole(s) or trephine; w/ biopsy of brain or intracranial lesion
Burr hole(s) or trephine; w/ drainage of brain abscess or cyst
Burr hole(s) w/ evacuation and/or drainage of hematoma, extradural or
subdural
Burr hole(s); w/ aspiration of hematoma or cyst, intracerebral
Burr hole(s) or trephine, supratentorial
Burr hole(s) or trephine, infratentorial, unilateral or bilateral
Craniectomy or craniotomy, exploratory; supratentorial
37,800
23,300
30,300
37,800
21,000
12,600
16,800
21,000
16,800
10,700
13,500
16,800
61305
Craniectomy or craniotomy, exploratory; infratentorial (posterior fossa)
46,500
25,200
21,300
46,500
25,200
21,300
46,500
25,200
21,300
53,400
29,400
24,000
53,400
29,400
24,000
61140
61150
61154
61312
61313
61314
61315
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
61320
Craniectomy or craniotomy, drainage of intracranial abscess; supratentorial
46,500
25,200
21,300
61321
Craniectomy or craniotomy, drainage of intracranial abscess; infratentorial
53,400
29,400
24,000
61330
61332
61333
Decompression of orbit only, transcranial approach
Exploration of orbit (transcranial approach); w/ biopsy
Exploration of orbit (transcranial approach); w/ removal of lesion
46,500
53,400
53,400
25,200
29,400
29,400
21,300
24,000
24,000
61334
Exploration of orbit (transcranial approach); w/ removal of foreign body
53,400
29,400
24,000
61340
37,800
21,000
16,800
53,400
29,400
24,000
46,500
46,500
25,200
25,200
21,300
21,300
53,400
29,400
24,000
53,400
29,400
24,000
61460
61470
Other cranial decompression (e.g., subtemporal), supratentorial
Craniectomy, suboccipital w/ cervical laminectomy for decompression of
medulla and spinal cord, w/ or w/o dural graft (e.g., Arnold-Chiari
malformation)
Other cranial decompression, posterior fossa
Craniotomy for section of tentorium cerebelli
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
55,000
55,000
33,600
33,600
21,400
21,400
61480
Craniectomy, suboccipital; for mesencephalic tractotomy or pedunculotomy
55,000
33,600
21,400
61490
61500
61501
Craniotomy for lobotomy, including cingulotomy
Craniectomy; w/ 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
Craniectomy for excision of brain tumor, infratentorial or posterior fossa;
except meningioma, cerebellopontine angle tumor, or midline tumor at
base of skull
46,500
55,000
37,800
25,200
33,600
21,000
21,300
21,400
16,800
55,000
33,600
21,400
63,000
42,000
21,000
53,400
29,400
24,000
53,400
29,400
24,000
65,100
44,100
21,000
61343
61345
61440
61450
61458
61510
61512
61514
61516
61518
Page 76 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
61519
61520
61521
61522
61524
61526
61530
61531
61533
61534
61535
61536
61538
61539
DESCRIPTION
Case Rate
Craniectomy for excision of brain tumor, infratentorial or posterior fossa;
meningioma
Craniectomy for excision of brain tumor, infratentorial or posterior fossa;
cerebellopontine angle tumor
Craniectomy for excision 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 w/ 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 w/ elevation of bone flap; for subdural implantation of an
electrode array, for long term seizure monitoring
Craniotomy w/ elevation of bone flap; for excision of epileptogenic focus
w/o electrocorticography during surgery
Craniotomy w/ elevation of bone flap; for removal of epidural or subdural
electrode array, w/o excision of cerebral tissue
Craniotomy w/ elevation of bone flap; for excision of cerebral epileptogenic
focus, w/ electrocorticography during surgery (includes removal of
electrode array)
Craniotomy w/ elevation of bone flap; for lobectomy w/
electrocorticography during surgery, temporal lobe
Craniotomy w/ elevation of bone flap; for lobectomy w/
electrocorticography during surgery, other than temporal lobe, partial or
total
Professional Fee
Health Care
Institution Fee
67,200
46,200
21,000
71,400
50,400
21,000
71,400
50,400
21,000
55,000
33,600
21,400
55,000
33,600
21,400
75,600
54,600
21,000
75,600
54,600
21,000
53,400
29,400
24,000
53,400
29,400
24,000
53,400
29,400
24,000
53,400
29,400
24,000
55,000
33,600
21,400
53,400
29,400
24,000
53,400
29,400
24,000
61541
Craniotomy w/ elevation of bone flap; for transection of corpus callosum
53,400
29,400
24,000
61542
Craniotomy w/ elevation of bone flap; for total hemispherectomy
Craniotomy w/ elevation of bone flap; for partial or subtotal
hemispherectomy
Craniotomy w/ elevation of bone flap; for excision of coagulation of choroid
plexus
67,200
46,200
21,000
63,000
42,000
21,000
53,400
29,400
24,000
Craniotomy w/ elevation of bone flap; for excision of craniopharyngioma
63,000
42,000
21,000
63,000
42,000
21,000
63,000
42,000
21,000
37,800
46,500
46,500
46,500
21,000
25,200
25,200
25,200
16,800
21,300
21,300
21,300
58,800
37,800
21,000
58,800
37,800
21,000
58,800
37,800
21,000
58,800
37,800
21,000
53,400
29,400
24,000
55,500
31,500
24,000
75,600
54,600
21,000
75,600
54,600
21,000
63,000
42,000
21,000
63,000
42,000
21,000
63,000
42,000
21,000
61543
61544
61545
61546
61548
61550
61552
61556
61557
61558
61559
Craniotomy for hypophysectomy or excision of pituitary tumor, intracranial
approach
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 (e.g.,
cloverleaf skull); not requiring bone grafts
Extensive craniectomy for multiple cranial suture craniosynostosis (e.g.,
cloverleaf skull); recontouring w/ multiple osteotomies and bone autografts
(e.g., barrel-stave procedure) (includes obtaining grafts)
61570
Excision, intra and extracranial, benign tumor of cranial bone (e.g., fibrous
dysplasia); w/o optic nerve decompression
Excision, intra and extracranial, benign tumor of cranial bone (e.g., fibrous
dysplasia); w/ optic nerve decompression
Craniectomy or craniotomy; w/ excision of foreign body from brain
61571
Craniectomy or craniotomy; w/ treatment of penetrating wound of brain
61563
61564
61575
61576
61580
61581
61582
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, w/o 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
Page 77 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
61583
61584
61585
61586
61590
61591
61592
61595
61596
61597
DESCRIPTION
Case Rate
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
Orbitocranial approach to anterior cranial fossa, extradural, including
supraorbital ridge osteotomy and elevation of frontal and/or temporal
lobe(s); w/o orbital exenteration
Orbitocranial approach to anterior cranial fossa, extradural, including
supraorbital ridge osteotomy and elevation of frontal and/or temporal
lobe(s); w/ orbital exenteration
Bicoronal, transzygomatic and/or LeFort I osteotomy approach to anterior
cranial fossa w/ or w/o internal fixation, w/o bone graft
Infratemporal pre-auricular approach to middle cranial fossa
(parapharyngeal space, infratemporal and midline skull base, nasopharynx),
w/ or w/o disarticulation of the mandible, including parotidectomy,
craniotomy, decompression and/or mobilization of th
Infratemporal post-auricular approach to middle cranial fossa (internal
auditory meatus, petrous apex, tentorium, cavernous sinus, parasellar area,
infratemporal fossa) inlcuding mastoidectomy, resection of sigmoid sinus,
w/ or w/o decompression and/or mo
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, w/ or w/o mobilization
Transcochlear approach to posterior cranial fossa, jugular foramen or
midline skull base, including labyrinthectomy, decompression, w/ or w/o
mobilization of facial nerve and/or petrous carotid artery
Transcondylar (far lateral) approach to posterior cranial fossa, jugular
foramen or midline skull base, including occiptal condylectomy,
mastoidectomy, resection of C1-C3 vertebral body(s), decompression of
vertebral artery, w/ or w/o mobilization
Professional Fee
Health Care
Institution Fee
63,000
42,000
21,000
63,000
42,000
21,000
63,000
42,000
21,000
63,000
42,000
21,000
71,400
50,400
21,000
71,400
50,400
21,000
67,200
46,200
21,000
71,400
50,400
21,000
71,400
50,400
21,000
71,400
50,400
21,000
61598
Transpetrosal approach to posterior cranial fossa, clivus or framen magnum,
including ligation of superior petrosal sinus and/or sigmoid sinus
71,400
50,400
21,000
61600
Resection or excision of neoplastic, vascular or infectious lesion of base of
anterior cranial fossa; extradural
67,200
46,200
21,000
61601
Resection or excision of neoplastic, vascular or infectious lesion of base of
anterior cranial fossa; intradural, including dural repair,w/ or w/o graft
67,200
46,200
21,000
61605
Resection or excision of neoplastic, vascular or infectious lesion of
infratemporal fossa, parapharyngeal space, petrous apex; extradural
71,400
50,400
21,000
61606
Resection or excision of neoplastic, vascular or infectious lesion of
infratemporal fossa, parapharyngeal space, petrous apex; intradural,
including dural repair, w/ or w/o graft
71,400
50,400
21,000
61607
Resection or excision of neoplastic, vascular or infectious lesion of parasellar
area, cavernous sinus, clivus or midline skull base; extradural
71,400
50,400
21,000
61608
Resection or excision of neoplastic, vascular or infectious lesion of parasellar
area, cavernous sinus, clivus or midline skull base; intradural, including dural
repair, w/ or w/o graft
71,400
50,400
21,000
61609
Transection or ligation, carotid artery in cavernous sinus; w/o repair
71,400
50,400
21,000
71,400
50,400
21,000
63,000
42,000
21,000
71,400
50,400
21,000
71,400
50,400
21,000
71,400
50,400
21,000
61610
61611
61612
61613
61615
Transection or ligation, carotid artery in cavernous sinus; w/ repair by
anastomosis or graft
Transection or ligation , carotid artery in petrous canal; w/o repair
Transection or ligation , carotid artery in petrous canal; w/ repair by
anastomosis or graft
Obliteration of carotid aneurysm, arteriovenous malformation, or carotidcavernous fistula by dissection w/in cavernous sinus
Resection or excision of neoplastic, vascular or infectious lesion of base of
posterior cranial fossa, jugular foramen, foramen magnum, or CI-C3
vertebral bodies; extradural
61616
Resection or excision of neoplastic, vascular or infectious lesion of base of
posterior cranial fossa, jugular foramen, foramen magnum, or CI-C3
vertebral bodies; intradural, including dural repair, w/ or w/o graft
71,400
50,400
21,000
61618
Secondary repair of dura for CSF leak, anterior, middle or posterior cranial
fossa following surgery of the skull base; by free tissue graft (e.g.,
pericranium, fascia, tensor fascia lata, adipose tissue, homologous or
synthetic grafts)
67,200
46,200
21,000
Page 78 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
61619
Secondary repair of dura for CSF 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)
63,000
42,000
21,000
61624
Transcatheter oclussion or embolization (e.g., for tumor destruction, to
achieve hemostasis, to occlude a vascular malformation), percutaneous, any
method; central nervous system (intracranial, spinal cord)
71,400
50,400
21,000
61626
Transcatheter oclussion or embolization (e.g., for tumor destruction, to
achieve hemostasis, to occlude a vascular malformation), percutaneous, any
method; non-central nervous system, head or neck (extracranial,
brachiocephalic branch)
55,000
33,600
21,400
61680
Surgery of intracranial arteriovenous malformation; supratentorial, simple
63,000
42,000
21,000
61682
Surgery of intracranial arteriovenous malformation; supratentorial, complex
71,400
50,400
21,000
61684
Surgery of intracranial arteriovenous malformation; infratentorial, simple
63,000
42,000
21,000
61686
Surgery of intracranial arteriovenous malformation; infratentorial, complex
71,400
50,400
21,000
61690
61692
Surgery of intracranial arteriovenous malformation; dural, simple
Surgery of intracranial arteriovenous malformation; dural, complex
55,000
63,000
33,600
42,000
21,400
21,000
61700
Surgery of intracranial aneurysm, intracranial approach; carotid circulation
71,400
50,400
21,000
61702
Surgery of intracranial aneurysm, intracranial approach; vertebral-basilar
circulation
75,600
54,600
21,000
61703
Surgery of intracranial aneurysm, cervical approach by application of
occluding clamp to cervical carotid artery (Selverstone-Crutchfield type)
23,300
12,600
10,700
71,400
50,400
21,000
37,800
21,000
16,800
63,000
42,000
21,000
67,200
46,200
21,000
67,200
46,200
21,000
67,200
46,200
21,000
63,000
42,000
21,000
63,000
42,000
21,000
63,000
42,000
21,000
63,000
42,000
21,000
30,300
16,800
13,500
61705
61708
61710
61711
61712
61720
61735
61750
61751
61760
61770
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 (e.g., middle
cerebral/cortical) arteries
Microdissection, intracranial or spinal procedure (list separately in addition
to code for primary procedure)
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; w/ computerized axial tomography
Stereotactic implantation of depth electrodes into the cerebrum for long
term seizure monitoring
Stereotactic localization , any method, including burr hole(s), w/ insertion of
catheter(s) for brachytherapy
61790
Creation of lesion by stereotactic method, percutaneous, by neurolytic
agent (e.g., alcohol, thermal, electrical, radiofrequency); gasserian ganglion
37,800
21,000
16,800
61791
Creation of lesion by stereotactic method, percutaneous, by neurolytic
agent (e.g., alcohol, thermal, electrical, radiofrequency); trigeminal
medullary tract
37,800
21,000
16,800
61793
Stereotactic radiosurgery (particle beam,gamma ray or linear accelerator)
63,000
42,000
21,000
61795
Stereotactic computer assisted volumetric intracranial procedure
Twist drill or burr hole(s) for implantation of neurostimulator electrodes;
cortical
Twist drill or burr hole(s) for implantation of neurostimulator electrodes;
subcortical
Craniectomy or craniotomy for implantation of neurostimulator electrodes,
cerebral; cortical
Craniectomy or craniotomy for implantation of neurostimulator electrodes,
cerebral; subcortical
Craniectomy for implantation of neurostimulator electrodes, cerebellar;
cortical
Craniectomy for implantation of neurostimulator electrodes, cerebellar;
subcortical
Incision and subcutaneous placement of cranial neurostimulator pulse
generator or receiver, direct or inductive coupling
63,000
42,000
21,000
53,400
29,400
24,000
67,200
46,200
21,000
58,800
37,800
21,000
46,500
25,200
21,300
58,800
37,800
21,000
67,200
46,200
21,000
37,800
21,000
16,800
61850
61855
61860
61865
61870
61875
61885
Page 79 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
DESCRIPTION
62000
Elevation of depressed skull fracture; simple, extradural
30,300
16,800
Health Care
Institution Fee
13,500
62005
Elevation of depressed skull fracture; compound or comminuted, extradural
37,800
21,000
16,800
46,500
25,200
21,300
71,400
50,400
21,000
37,800
21,000
16,800
46,500
25,200
21,300
53,400
29,400
24,000
58,800
55,000
30,300
30,300
30,300
30,300
53,400
37,800
33,600
16,800
16,800
16,800
16,800
29,400
21,000
21,400
13,500
13,500
13,500
13,500
24,000
53,400
29,400
24,000
55,000
33,600
21,400
62010
62100
62115
62116
62117
62120
62121
62140
62141
62142
62143
62145
62146
62147
Case Rate
Elevation of depressed skull fracture; w/ repair of dura and /or debridement
of brain
Craniotomy for repair of dural /CSF leak, including surgery for
rhinorrhea/otorrhea
Reduction of craniomegalic skull (e.g., treated hydrocephalus); not requiring
bone grafts or cranioplasty
Reduction of craniomegalic skull (e.g., treated hydrocephalus); w/ simple
cranioplasty
Reduction of craniomegalic skull (e.g., treated hydrocephalus); requiring
craniotomy and reconstruction w/ or w/o 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
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 w/ reparative brain surgery
Cranioplasty w/ autograft (includes obtaining bone grafts); up to 5 cm
diameter
Cranioplasty w/ autograft (includes obtaining bone grafts); larger than 5 cm
diameter
Professional Fee
62160
Neuroendoscopy, intracranial, for placement or replacement of ventricular
catheter and attachment to shunt system or external drainage
37,800
21,000
16,800
62161
Neuroendoscopy, intracranial; with dissection of adhesions, fenestration of
septum pellucidum or intraventricular cyst (including placement,
replacement or removal of ventricular catheter)
46,500
25,200
21,300
62162
Neuroendoscopy, intracranial; with fenestration or excision of colloid cyst,
including placement of external ventricular catheter for drainage
46,500
25,200
21,300
46,500
25,200
21,300
46,500
25,200
21,300
62180
Neuroendoscopy, intracranial; with retrieval of foreign body
Neuroendoscopy, intracranial; with excision of pituitary tumor, transnasal or
transphenoidal approach
Ventriculocisternostomy (Torkildsen type operation)
37,800
21,000
16,800
62190
Creation of shunt; subarachnoid/subdural-atrial, -jugular, -auricular
23,300
12,600
10,700
23,300
12,600
10,700
37,800
46,500
30,300
30,300
21,000
25,200
16,800
16,800
16,800
21,300
13,500
13,500
23,300
12,600
10,700
12,900
12,900
5,680
6,300
6,300
1,680
6,600
6,600
4,000
5,560
1,260
4,300
23,300
12,600
10,700
62163
62165
62192
62200
62201
62220
62223
62230
62268
62269
62270
62272
62287
Creation of shunt; subarachnoid/subdural-peritonial, -pleural, other
terminus
Ventriculocisternostomy, third ventricle;
Ventriculocisternostomy, third ventricle; stereotactic method
Creation of shunt; ventriculo-atrial, -jugular,-auricular
Creation of shunt; ventriculo-peritonial,-pleural, other terminus
Replacement or revision of CSF (VP) shunt, obstructed valve, or distal
catheter in shunt system
Percutaneous aspiration, spinal cord cyst or syrinx
Biopsy of spinal cord, percutaneous needle
Spinal puncture, lumbar, diagnostic
Spinal puncture , therapeutic, for drainage of spinal fluid (by needle or
catheter)
Aspiration procedure, percutaneous, of nucleus pulposus of intervertebral
disk, any method, single or multiple levels, lumbar
62350
Implantation, revision or repositioning of intrathecal or epidural catheter,
for implantable reservoir or implantable infusion pump; w/o laminectomy
18,000
8,400
9,600
62351
Implantation, revision or repositioning of intrathecal or epidural catheter,
for implantable reservoir or implantable infusion pump; w/ laminectomy
37,800
21,000
16,800
9,700
4,200
5,500
18,000
8,400
9,600
23,300
12,600
10,700
46,500
25,200
21,300
55,000
33,600
21,400
62360
62361
62362
62464
63001
Implantation or replacement of device for intrathecal or epidural drug
infusion; subcutaneous reservoir
Implantation or replacement of device for intrathecal or epidural drug
infusion; non-programmable pump
Implantation or replacement of device for intrathecal or epidural drug
infusion; programmable pump, including preparation of pump, w/ or w/o
programming
Implantation or replacement of device for intrathecal or epidural drug
infusion; with excision of brain tumor, including placement of external
ventricular catheter for drainage
Laminectomy w/ exploration and/or decompression of spinal cord and/or
cauda equina, w/o facetectomy, foraminotomy or diskectomy, (e.g., spinal
stenosis), one or two vertebral segments; cervical
Page 80 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
63003
Laminectomy w/ exploration and/or decompression of spinal cord and/or
cauda equina, w/o facetectomy, foraminotomy or diskectomy, (e.g., spinal
stenosis), one or two vertebral segments; thoracic
53,400
29,400
24,000
63005
Laminectomy w/ exploration and/or decompression of spinal cord and/or
cauda equina, w/o facetectomy, foraminotomy or diskectomy, (e.g., spinal
stenosis), one or two vertebral segments; lumbar,except for
spondylolisthesis
37,800
21,000
16,800
63011
Laminectomy w/ exploration and/or decompression of spinal cord and/or
cauda equina, w/o facetectomy, foraminotomy or diskectomy, (e.g., spinal
stenosis), one or two vertebral segments; sacral
37,800
21,000
16,800
63012
Laminectomy w/ removal of abnormal facets and/or pars inter-articularis
w/ decompression of cauda equina and nerve roots for spondylolisthesis,
lumbar (Gill type procedure)
53,400
29,400
24,000
63015
Laminectomy w/ exploration and/or decompression of spinal cord and/or
cauda equina, w/o facetectomy, foraminotomy or diskectomy, (e.g., spinal
stenosis) , more than 2 vertebral segments; cervical
55,000
33,600
21,400
63016
Laminectomy w/ exploration and/or decompression of spinal cord and/or
cauda equina, w/o facetectomy, foraminotomy or diskectomy, (e.g., spinal
stenosis) , more than 2 vertebral segments; thoracic
53,400
29,400
24,000
63017
Laminectomy w/ exploration and/or decompression of spinal cord and/or
cauda equina, w/o facetectomy, foraminotomy or diskectomy, (e.g., spinal
stenosis) , more than 2 vertebral segments; lumbar
46,500
25,200
21,300
55,000
33,600
21,400
46,500
25,200
21,300
53,400
29,400
24,000
46,500
25,200
21,300
63020
63030
63040
63042
Laminotomy (hemilaminectomy), w/ decompression of nerve root (s),
including partial facetectomy , foraminotomy and/or excision of herniated
intervertebral disk; one interspace, cervical
Laminotomy (hemilaminectomy), w/ decompression of nerve root (s),
including partial facetectomy , foraminotomy and/or excision of herniated
intervertebral disk; one interspace,lumbar
Laminotomy (hemilaminectomy), w/ decompression of nerve root (s),
including partial facetectomy , foraminotomy and/or excision or herniated
intervertebral disk; re-exploration; cervical
Laminotomy (hemilaminectomy), w/ decompression of nerve root (s),
including partial facetectomy , foraminotomy and/or excision or herniated
intervertebral disk; re-exploration; lumbar
63045
Laminectomy, facetectomy and foraminotomy (unilateral or bilateral w/
decompression of spinal cord, cauda equina and/or nerve root(s), ( eg,
spinal or lateral recess stenosis), single vertebral segment; cervical
55,000
33,600
21,400
63046
Laminectomy, facetectomy and foraminotomy (unilateral or bilateral w/
decompression of spinal cord, cauda equina and/or nerve root(s), ( eg,
spinal or lateral recess stenosis), single vertebral segment; thoracic
53,400
29,400
24,000
63047
Laminectomy, facetectomy and foraminotomy (unilateral or bilateral w/
decompression of spinal cord, cauda equina and/or nerve root(s), ( eg,
spinal or lateral recess stenosis), single vertebral segment; lumbar
46,500
25,200
21,300
63055
Transpedicular approach w/ decompression of spinal cord, equina and/ or
nerve root(s) (e.g., herniated intervetebral disk), single segment; thoracic
53,400
29,400
24,000
63056
Transpedicular approach w/ decompression of spinal cord, equina and/ or
nerve root(s) (e.g., herniated intervetebral disk), single segment; lumbar
46,500
25,200
21,300
53,400
29,400
24,000
55,000
33,600
21,400
37,800
21,000
16,800
55,000
33,600
21,400
53,400
29,400
24,000
63064
63075
63077
63081
63085
Costovertebral approach w/ decompression of spinal cord or nerve root(s),
(e.g., herniated intervertebral disk), thoracic; single segment
Diskectomy, anterior, w/ decompression of spinal cord and/ or nerve
root(s), including osteophytectomy; cervical, single interspace
Diskectomy, anterior, w/ decompression of spinal cord and/ or nerve
root(s), including osteophytectomy; thoracic, single interspace
Vertebral corpectomy (vertebral body resection), partial or complete,
anterior approach w/ decompression of spinal cord and/ or nerve root(s);
cervical, single segment
Vertebral corpectomy (vertebral body resection), partial or complete,
transthoracic approach w/ decompression of spinal cord and/ or nerve
root(s); thoracic, single segment
63087
Vertebral corpectomy (vertebral body resection), partial or complete,
combined thoracolumbar approach w/ decompression of spinal cord, cauda
equina or nerve root(s), lower thoracic or lumbar; single segment
46,500
25,200
21,300
63090
Vertebral corpectomy (vertebral body resection), partial or complete,
transperitoneal or retroperitoneal approach w/ decompression of spinal
cord, cauda equina or nerve root(s), lower thoracic, lumbar, or sacral; single
segment
53,400
29,400
24,000
Page 81 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
63170
63172
63173
63180
63182
63185
63190
63191
63194
63195
63196
63197
63198
63199
63200
63250
63251
63252
63265
63266
63267
63268
63270
63271
63272
63273
63275
63276
63277
63278
63280
63281
63282
63283
63285
63286
63287
63290
63300
DESCRIPTION
Case Rate
Laminectomy w/ myelotomy (e.g., Bischof or DREZ type), cervical thoracic,
or thoracolumbar
Laminectomy w/ drainage of intramedullary cyst/ syrinx; to subarachnoid
space
Laminectomy w/ drainage of intramedullary cyst/ syrinx; to peritoneal space
Laminectomy and section of dentate ligaments, w/ or w/o dural graft,
cervical; one of two segments
Laminectomy and section of dentate ligaments, w/ or w/o dural graft,
cervical; more than two segments
Laminectomy w/ rhizotomy; one or two segments
Laminectomy w/ rhizotomy; more than two segments
Laminectomy w/ section of spinal accessory nerve
Laminectomy w/ cordotomy, w/ section of one spinothalamic tract, one
stage; cervical
Laminectomy w/ cordotomy, w/ section of one spinothalamic tract, one
stage; thoracic
Laminectomy w/ cordotomy w/ section of both spinothalamic tracts, one
stage; cervical
Laminectomy w/ cordotomy w/ section of both spinothalamic tracts, one
stage; thoracic
Laminectomy w/ cordotomy w/ section of both spinothalamic tracts, two
stages w/in 14 days; cervical
Laminectomy w/ cordotomy w/ section of both spinothalamic tracts, two
stages w/in 14 days; thoracic
Laminectomy, w/ release of tethered spinal cord, lumbar
Laminectomy for excision or occlusion of arteriovenous malformation of
spinal cord; cervical
Laminectomy for excision or occlusion of arteriovenous malformation of
spinal cord; thoracic
Laminectomy for excision 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
Laminectomy for 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,
extradural, thoracic
Laminectomy for biopsy/ excision of intraspinal neoplasm; extradural,
extradural, lumbar
Laminectomy for biopsy/ excision of intraspinal neoplasm; extradural,
extradural, sacral
Laminectomy for biopsy/ excision of intraspinal neoplasm; extradural,
intradural, extramedullary, cervical
Laminectomy for biopsy/ excision of intraspinal neoplasm; extradural,
intradural, extramedullarry, thoracic
Laminectomy for biopsy/ excision of intraspinal neoplasm; extradural,
intradural, extramedullary, lumbar
Laminectomy for biopsy/ excision of intraspinal neoplasm; extradural,
intradural, sacral
Laminectomy for biopsy/ excision of intraspinal neoplasm; extradural,
intradural, intramedullary, cervical
Laminectomy for biopsy/ excision of intraspinal neoplasm; extradural,
intradural, intramedullary, thoracic
Laminectomy for biopsy/ excision of intraspinal neoplasm; extradural,
intradural, intramedullary, thoracolumbar
Laminectomy for biopsy/ excision of intraspinal neoplasm; extradural,
combined extradural-intradural lesion, any level
Vertebral corpectomy (vertebral body resection), partial or complete, for
excision of intraspinal lesion, single segment; extradural, cervical
Page 82 of 98
Professional Fee
Health Care
Institution Fee
58,800
37,800
21,000
53,400
29,400
24,000
55,000
33,600
21,400
55,000
33,600
21,400
55,000
33,600
21,400
53,400
53,400
57,520
29,400
29,400
36,120
24,000
24,000
21,400
55,000
33,600
21,400
53,400
29,400
24,000
55,000
33,600
21,400
53,400
29,400
24,000
55,000
33,600
21,400
53,400
29,400
24,000
49,020
27,720
21,300
55,000
33,600
21,400
53,400
29,400
24,000
46,500
25,200
21,300
55,000
33,600
21,400
53,400
29,400
24,000
46,500
25,200
21,300
37,800
21,000
16,800
55,000
33,600
21,400
53,400
29,400
24,000
46,500
25,200
21,300
37,800
21,000
16,800
55,000
33,600
21,400
53,400
29,400
24,000
46,500
25,200
21,300
37,800
21,000
16,800
58,800
37,800
21,000
55,000
33,600
21,400
53,400
29,400
24,000
46,500
25,200
21,300
58,800
37,800
21,000
55,000
33,600
21,400
53,400
29,400
24,000
46,500
25,200
21,300
55,000
33,600
21,400
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
63301
63302
DESCRIPTION
Case Rate
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
Professional Fee
Health Care
Institution Fee
53,400
29,400
24,000
53,400
29,400
24,000
63303
Vertebral corpectomy (vertebral body resection), partial or complete, for
excision of intraspinal lesion, single segment; extradural, lumbar or sacral by
transperitoneal or retroperitoneal approach
53,400
29,400
24,000
63304
Vertebral corpectomy (vertebral body resection), partial or complete, for
excision of intraspinal lesion, single segment; intradural, cervical
55,000
33,600
21,400
53,400
29,400
24,000
53,400
29,400
24,000
63305
63306
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
63307
Vertebral corpectomy (vertebral body resection), partial or complete, for
excision of intraspinal lesion, single segment; intradural, lumbar or sacral by
transperitoneal or retroperitoneal approach
53,400
29,400
24,000
63600
Creation of lesion of spinal cord by stereotactic method, percutaneous, any
modality (including stimulation and/ or recording)
30,300
16,800
13,500
30,300
16,800
13,500
37,600
8,020
18,900
2,520
18,700
5,500
46,500
25,200
21,300
21,820
10,920
10,900
30,300
37,180
37,800
46,500
30,300
46,500
46,500
16,800
18,480
21,000
25,200
16,800
25,200
25,200
13,500
18,700
16,800
21,300
13,500
21,300
21,300
30,300
16,800
13,500
23,300
12,600
10,700
12,120
12,120
6,720
6,720
5,400
5,400
63615
63650
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 electrodes; epidural
63655
Laminectomy for implantation of neurostimulator electrodes; epidural
63610
64702
64704
Incision and subscutaneous placement of spinal neurostimulator pulse
generator or receiver, direct or inductive coupling
Repair of meningocele; less than 5 cm diameter
Repair of meningocele; larger than 5 diameter
Repair of myelomeningocele; less than 5 cm diameter
Repair of myelomeningocele; larger than 5 diameter
Repair of dural/ CSF leak, not requiring laminectomy
Repair of dural/ CSF leak or pseudomeningocele, w/ 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
Neuroplasty; digital, one or both, same digit
Neuroplasty; nerve of hand or foot
64708
Neuroplasty, major peripheral nerve, arm or leg; other than specified
18,000
8,400
9,600
64712
64713
64714
64716
64718
64719
64721
64722
64726
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
20,980
20,980
20,980
37,800
18,000
18,000
18,000
18,000
18,000
10,080
10,080
10,080
21,000
8,400
8,400
8,400
8,400
8,400
10,900
10,900
10,900
16,800
9,600
9,600
9,600
9,600
9,600
64727
Internal neurolysis, requiring use of operating microscope (list separately in
addition to code for neuroplasty) (Neuroplasty inlcudes external neurolysis)
30,300
16,800
13,500
9,700
9,700
9,700
9,700
9,700
12,120
9,700
12,120
21,940
4,200
4,200
4,200
4,200
4,200
6,720
4,200
6,720
9,240
5,500
5,500
5,500
5,500
5,500
5,400
5,500
5,400
12,700
21,940
9,240
12,700
18,000
9,700
8,400
4,200
9,600
5,500
18,000
8,400
9,600
63685
63700
63702
63704
63706
63707
63709
63710
63740
63741
64732
64734
64736
64738
64740
64742
64744
64746
64752
64755
64760
64761
64763
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; vagi 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, w/ or w/o adductor
tenotomy
Page 83 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
64858
64859
64861
64862
64864
64865
64866
64868
64870
Transection or avulsion of obturator nerve, intrapelvic, w/ or w/o adductor
tenotomy
Transection or avulsion of other cranial nerve, intradural
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; hand or foot, except digital nerve
Excision of neuroma; major peripheral nerve, except sciatic
Excision of neuroma; sciatic nerve
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, w/ magnification, each digit
Microdissection and/or microrepair of nerve (list separately in addition to
code for nerve repair)
Suture of digital nerve, hand or foot; one nerve
Suture of digital nerve, hand or foot; each additional digital nerve
Suture of one nerve, hand or foot; common sensory nerve
Suture of one nerve, hand or foot; median motor thenar
Suture of one nerve, hand or foot; ulnar motor
Suture of each additional nerve, hand or foot
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; w/o
transposition
Suture of sciatic nerve
Suture of each additional major peripheral nerve
Suture of; brachial plexus
Suture of; lumbar plexus
Suture of facial nerve; extracranial
Suture of facial nerve; infratemporal, w/ or w/o grafting
Anastomosis; facial-spinal accessory
Anastomosis; facial-hypoglossal
Anastomosis; facial-phrenic
64885
Nerve graft (includes obtaining graft), head or neck; up to 4cm in length
23,300
12,600
10,700
64886
Nerve graft (includes obtaining graft), head or neck; more than 4 cm length
31,580
14,280
17,300
30,300
16,800
13,500
30,300
16,800
13,500
23,300
12,600
10,700
31,580
14,280
17,300
27,120
15,120
12,000
30,300
16,800
13,500
23,300
12,600
10,700
31,580
14,280
17,300
8,020
8,020
20,980
20,980
12,120
12,120
12,120
12,120
12,120
2,520
2,520
10,080
10,080
6,720
6,720
6,720
6,720
6,720
5,500
5,500
10,900
10,900
5,400
5,400
5,400
5,400
5,400
37,800
21,000
16,800
38,640
21,840
16,800
39,480
22,680
16,800
10,960
5,460
5,500
64766
64771
64772
64774
64776
64782
64784
64786
64788
64790
64792
64795
64802
64804
64809
64818
64820
64830
64831
64832
64834
64835
64836
64837
64840
64856
64857
64901
64902
64905
64907
65091
65093
65101
65103
65105
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
Nerve graft, each additional nerve; multiple strands (cable)
Nerve pedicle transfer; first stage
Nerve pedicle transfer; second stage
Evisceration of ocular contents; w/o implant
Evisceration of ocular contents; w/ implant
Enucleation of eye; w/o implant
Enucleation of eye; w/ implant, muscles not attached to implant
Enucleation of eye; w/ implant, muscles attached to implant
65110
Exenteration of orbit without skin graft, removal of orbital contents; only
64890
64891
64892
64893
64895
64896
64897
64898
65112
65114
65130
Exenteration of orbit without skin graft, removal of orbital contents; w/
therapeutic removal of bone
Exenteration of orbit without skin graft, removal of orbital contents; w/
muscle or myocutaneous flap
Insertion of ocular implant; after evisceration, in scleral shell
Page 84 of 98
18,000
8,400
9,600
37,800
30,300
8,020
8,020
8,020
8,020
9,700
8,020
8,020
21,000
16,800
2,520
2,520
2,520
2,520
4,200
2,520
2,520
16,800
13,500
5,500
5,500
5,500
5,500
5,500
5,500
5,500
9,700
4,200
5,500
8,020
18,000
18,000
18,000
18,000
12,120
2,520
8,400
8,400
8,400
8,400
6,720
5,500
9,600
9,600
9,600
9,600
5,400
20,980
10,080
10,900
18,000
8,020
18,000
18,000
18,000
8,020
18,000
8,400
2,520
8,400
8,400
8,400
2,520
8,400
9,600
5,500
9,600
9,600
9,600
5,500
9,600
20,980
10,080
10,900
18,000
8,400
9,600
18,000
8,020
20,980
20,980
20,980
20,980
23,300
23,300
23,300
8,400
2,520
10,080
10,080
10,080
10,080
12,600
12,600
12,600
9,600
5,500
10,900
10,900
10,900
10,900
10,700
10,700
10,700
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
65135
Insertion of ocular implant; after enucleation, muscles not attached to
implant
10,960
5,460
5,500
65140
Insertion of ocular implant; after enucleation, muscles attached to implant
11,980
5,880
6,100
65150
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; subconjunctival or scleral, with slit
lamp
Removal of foreign body, external eye; cornea, with slit lamp
Removal of foreign body, intraocular; from anterior chamber 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, w/ or w/o nonperforating laceration
sclera, direct closure
11,980
5,880
6,100
11,980
5,880
6,100
9,700
3,640
4,200
840
5,500
2,800
8,020
2,520
5,500
8,020
18,000
2,520
8,400
5,500
9,600
53,400
29,400
24,000
55,000
33,600
21,400
8,020
2,520
5,500
8,020
2,520
5,500
9,700
4,200
5,500
20,980
10,080
10,900
23,300
12,600
10,700
9,700
4,200
5,500
65155
65175
65205
65210
65222
65235
65260
65265
65270
65273
65275
65280
65285
65286
Repair of laceration; conjunctiva, by mobilization and rearrangement
Repair of laceration; cornea, nonperforating, w/ or w/o removal foreign
body
Repair of laceration; cornea and/or sclera, perforating, not involving uveal
tissue
Repair of laceration; cornea and/or sclera, perforating, w/ reposition or
resection of uveal tissue
Repair of laceration; application of tissue glue, wounds of cornea and/or
sclera
65290
Repair of wound, extraocular muscle, tendon and/ or Tenons capsule
9,700
4,200
5,500
65400
Excision of lesion, cornea (keratectomy, lamellar, partial), except pterygium
8,260
3,360
4,900
65410
65420
65426
8,020
8,260
9,700
2,520
3,360
4,200
5,500
4,900
5,500
8,020
2,520
5,500
65710
65730
65750
65755
65760
65765
65767
65770
65771
Biopsy of cornea
Excision or transposition of pterygium; without graft
Excision or transposition of pterygium; with graft
Destruction of lesion of cornea by cryotherapy, photocoagulation or
thermocauterization
Keratoplasty (corneal transplant); lamellar
Keratoplasty (corneal transplant); penetrating (except in aphakia)
Keratoplasty (corneal transplant); penetrating (in aphakia)
Keratoplasty (corneal transplant); penetrating (in pseudophakia)
Keratomileusis
Keratophakia
Epikeratoplasty
Keratoprosthesis
Radial keratotomy
30,300
30,300
30,300
30,300
18,000
10,540
18,000
30,300
14,960
16,800
16,800
16,800
16,800
8,400
5,040
8,400
16,800
7,560
13,500
13,500
13,500
13,500
9,600
5,500
9,600
13,500
7,400
65772
Corneal relaxing incision for correction of surgically induced astigmatism
14,960
7,560
7,400
65775
Corneal wedge resection for correction of surgically induced astigmatism
14,960
7,560
7,400
65780
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)
30,300
16,800
13,500
30,300
16,800
13,500
30,300
16,800
13,500
65450
65781
65782
65805
Paracentesis of anterior chamber of eye; w/ therapeutic release of aqueous
8,020
2,520
5,500
65810
Paracentesis of anterior chamber of eye; w/ removal of vitreous and/or
discission of anterior hyaloid membrane, w/ or w/o air injection
9,700
4,200
5,500
65815
65820
65850
65855
65860
65865
65870
65875
65880
Paracentesis of anterior chamber of eye; w/ removal of blood, w/ or w/o
irrigation and/or air injection
Goniotomy
Trabeculotomy ab externo
Trabeculoplasty by laser surgery, one or more sessions (defined treatment
series)
Severing adhesions of anterior segment, laser technique
Severing adhesions of anterior segment of eye, incisional technique (w/ or
w/o injection of air or liquid); goniosynechiae
Severing adhesions of anterior segment of eye, incisional technique (w/ or
w/o injection of air or liquid); anterior synechiae, except goniosynechiae
Severing adhesions of anterior segment of eye, incisional technique (w/ or
w/o injection of air or liquid); posterior synechiae
Severing adhesions of anterior segment of eye, incisional technique (w/ or
w/o injection of air or liquid); corneovitreal adhesions
Page 85 of 98
9,700
4,200
5,500
23,300
23,300
12,600
12,600
10,700
10,700
12,120
6,720
5,400
10,540
5,040
5,500
10,540
5,040
5,500
10,540
5,040
5,500
10,540
5,040
5,500
10,540
5,040
5,500
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
DESCRIPTION
65900
65920
65930
66130
66150
Removal of epithelial material, anterior segment eye
Removal of implanted material, anterior segment eye
Removal of blood clot, anterior segment eye
Excision of lesion, sclera
Fistulization of scalera for glaucoma; trephination w/ iridectomy
10,540
12,120
8,020
8,260
18,000
5,040
6,720
2,520
3,360
8,400
Health Care
Institution Fee
5,500
5,400
5,500
4,900
9,600
66155
Fistulization of scalera for glaucoma; thermocauterization w/ iridectomy
18,000
8,400
9,600
18,000
8,400
9,600
18,000
8,400
9,600
18,000
8,400
9,600
27,120
15,120
12,000
30,300
16,800
13,500
30,300
12,120
23,300
16,800
6,720
12,600
13,500
5,400
10,700
14,960
7,560
7,400
10,540
10,540
5,040
5,040
5,500
5,500
Case Rate
Professional Fee
66500
66505
Fistulization of scalera for glaucoma; sclerectomy w/ punch or scissors, w/
iridectomy
Fistulization of scalera for glaucoma; iridencleisis or iridotasis
Fistulization of scalera for glaucoma; trabeculectomy ab externo in absence
of previous surgery
Fistulization of scalera for glaucoma; trabeculectomy ab externo w/ scarring
from previous ocular surgery or trauma (includes injection of antifibrotic
agents)
Aquenous shunt to extraocular reservoir (e.g., Molteno, Schocket, DenverKrupin)
Revision of aqueous shunt to extraocular reservoir
Repair of scleral staphyloma; w/o graft
Repair of scleral staphyloma; w/ graft
Revision or repair of operative wound of anterior segment, any type, early
or late, major or minor procedure
Iridotomy by stab incision; except transfixion
Iridotomy by stab incision; w/ transfixion as for iris bombe
66600
Iridectomy, w/ corneoscleral or corneal section; for removal of lesion
12,120
6,720
5,400
66605
Iridectomy, w/ corneoscleral or corneal section; w/ cyclectomy
18,000
8,400
9,600
66625
Iridectomy, w/ corneoscleral or corneal section; peripheral for glaucoma
12,120
6,720
5,400
66630
66680
Iridectomy, w/ corneoscleral or corneal section; sector for glaucoma
Repair of iris, ciliary body (as for iridodialysis)
Suture of iris, ciliary body w/ retrieval of suture through small incision (e.g.,
McCannel suture)
Ciliary body destruction; diathermy
Ciliary body destruction; cyclophotocoagulation
Ciliary body destruction; cryotherapy
Ciliary body destruction; cyclodialysis
Iridotomy/iridectomy by laser surgery (e.g., for glaucoma) ( one or more
sessions)
Iridoplasty by photocoagulation (one or more sessions) (e.g., for
improvement of vision, for widening of anterior chamber angle)
12,120
18,000
6,720
8,400
5,400
9,600
14,960
7,560
7,400
11,980
11,980
11,980
11,980
5,880
5,880
5,880
5,880
6,100
6,100
6,100
6,100
10,540
5,040
5,500
12,120
6,720
5,400
Destruction of cyst or lesion iris or ciliary body (nonexcisional procedure)
10,540
5,040
5,500
12,120
6,720
5,400
8,260
3,360
4,900
18,000
8,400
9,600
12,120
6,720
5,400
16,000
6,400
9,600
16,000
6,400
9,600
66160
66165
66170
66172
66180
66185
66220
66225
66250
66682
66700
66710
66720
66740
66761
66762
66770
66820
66821
66825
66830
66840
66850
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 (e.g., YAG laser) (one or more stages)
Repositioning of intraocular lens prosthesis, requiring an incision
Removal of secondary membranous cataract (opacified posterior lens
capsule and/or anterior hyaloid) w/ corneo-scleral section, w/ or w/o
iridectomy (iridocapsulotomy, iridocapsulectomy)
Removal of lens material; aspiration technique, one or more stages
Removal of lens material; phacofragmentation technique (mechanical or
ultrasonic) (e.g., phacoemulsification), w/ aspiration
66852
Removal of lens material; pars plana approach, with or without vitrectomy
16,000
6,400
9,600
66920
66930
66940
Removal of lens material; intracapsular
Removal of lens material; intracapsular, for dislocated lens
Removal of lens material; extracapsular
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 rout
Intracapsular cataract extraction w/ insertion of intraocular lens prosthesis
(one stage procedure)
Extracapsular cataract removal w/ insertion of intraocular lens prosthesis
(one stage procedure), (e.g., irrigation and aspiration)
Insertion of intraocular lens prosthesis, not associated with cataract
removal
Exchange of intraocular lens
Extracapsular cataract removal w/ insertion of intraocular lens prosthesis
(one stage procedure), (e.g., phacoemulsification)
16,000
16,000
16,000
6,400
6,400
6,400
9,600
9,600
9,600
16,000
6,400
9,600
16,000
6,400
9,600
16,000
6,400
9,600
16,000
6,400
9,600
16,000
6,400
9,600
16,000
6,400
9,600
66991
Revision of failed filter; with or without explantation/exchange of shunt
37,800
21,000
16,800
66992
Revision of failed filter; with excision of bleb cyst
37,800
21,000
16,800
66982
66983
66984
66985
66986
66987
Page 86 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
66993
66994
66995
66996
66997
66998
66999
67005
67010
67015
67025
67027
67030
67031
67036
67038
67039
67040
67041
67042
67043
67044
67045
67046
67047
67048
67049
67050
67051
67052
67101
67105
DESCRIPTION
Revision of failed filter; with choroidal tap
Revision of failed filter; with posterior sclerotomy
Revision of failed filter; with anterior chamber reformation
Revision of filtering bleb, needling technique; without injection of antimetabolite
Revision of filtering bleb, needling technique; with injection of antimetabolite
Release of scleral flap suture by laser suture lysis (new code)
Revision of overfiltering bleb (includes autologous blood injection,
cryotherapy, mattress sutures, etc.)
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 w/ 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), w/ or w/o aspiration
Implantation of intravitreal drug delivery system (eg, ganciclovir implant),
includes concomitant removal of vitreous
Discission of vitreous strands (w/o 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; w/ epiretinal membrane
stripping
Vitrectomy, mechanical, pars plana approach; w/ focal endolaser
photocoagulation
Vitrectomy, mechanical, pars plana approach; w/ endolaser panretinal
photocoagulation
Vitrectomy, mechanical, pars plana approach; with internal limiting
membrane (ILM) peeling
Vitrectomy, mechanical, pars plana approach; with radial optic nerve
neurotomy (RON)
Vitrectomy, mechanical, pars plana approach; with sheathotomy for branch
retinal vein occlusion
Vitrectomy, mechanical, pars plana approach; with macular translocation
(limited by retinotomy and/or scleral imbrication)
Vitrectomy, mechanical, pars plana approach; with macular translocation
(total)
Vitrectomy, mechanical, pars plana approach; with removal of subretinal
membranes
Vitrectomy, mechanical, pars plana approach; with removal of choroidal
neovascular membrane
Vitrectomy, mechanical, pars plana approach; with endodrainage of
subretinal hemorrhage (with or without tPA injection)
30,300
30,300
30,300
16,800
16,800
16,800
Health Care
Institution Fee
13,500
13,500
13,500
12,120
6,720
5,400
18,000
8,400
9,600
9,700
4,200
5,500
18,000
8,400
9,600
37,800
21,000
16,800
53,400
29,400
24,000
9,700
4,200
5,500
12,120
6,720
5,400
31,580
14,280
17,300
12,900
6,300
6,600
10,540
5,040
5,500
46,500
25,200
21,300
46,500
25,200
21,300
46,500
25,200
21,300
46,500
25,200
21,300
46,500
25,200
21,300
46,500
25,200
21,300
46,500
25,200
21,300
46,500
25,200
21,300
46,500
25,200
21,300
46,500
25,200
21,300
46,500
25,200
21,300
46,500
25,200
21,300
Vitrectomy, mechanical, pars plana approach; with removal of dropped IOL
46,500
25,200
21,300
46,500
25,200
21,300
46,500
25,200
21,300
37,800
21,000
16,800
46,500
25,200
21,300
37,180
18,480
18,700
Case Rate
Vitrectomy, mechanical, pars plana approach; with phacofragmentation for
dropped lens material
Vitrectomy, mechanical, pars plana approach; with internal tamponade with
air, gas, silicone oil, perfluorocarbon liquid
Vitrectomy, mechanical, pars plana approach; with insertion of scleral
fixated intraocular lens, with or without anterior vitrectomy
Repair of retinal detachment, one or more sessions; cryotherapy or
diathermy, w/ or w/o drainage of subretinal fluid
Repair of retinal detachment, one or more sessions; photocoagulation, w/
or w/o drainage of subretinal fluid
Professional Fee
67107
Repair of retinal detachment; scleral buckling (such as lamellar scleral
dissection, imbrication or encircling procedure), w/ or w/o implant, w/ or
w/o cryotherapy, photocoagulation, and drainage of subretinal fluid
46,500
25,200
21,300
67108
Repair of retinal detachment; w/ vitrectomy, any method, w/ or w/o air or
gas tamponade, focal endolaser photocoagulation, cryotherapy, drainage of
subretinal fluid, scleral buckling, and/or removal of lens by same technique
46,500
25,200
21,300
30,300
16,800
13,500
46,500
25,200
21,300
12,120
12,120
20,980
6,720
6,720
10,080
5,400
5,400
10,900
12,120
6,720
5,400
67110
67112
67115
67120
67121
67208
Repair of retinal detachment; by injection of air or other gas (e.g.,
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
Release of encircling material (posterior segment)
Removal of implanted material, posterior segment; extraocular
Removal of implanted material, posterior segment; intraocular
Destruction of localized lesion of retina (e.g., maculopathy, choroidopathy,
small tumors), one or more sessions; cryotherapy, diathermy
Page 87 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
67210
Destruction of localized lesion of retina (e.g., maculopathy, choroidopathy,
small tumors), one or more sessions; photocoagulation (laser or xenon arc)
12,120
6,720
5,400
67218
Destruction of localized lesion of retina (e.g., maculopathy, choroidopathy,
small tumors), one or more sessions; radiation by implantation of source
(includes removal of source)
12,120
6,720
5,400
67220
Destruction of localized lesion of choroid (e.g., choroidal
neovascularization); photocoagulation (e.g., laser), one or more sessions
12,120
6,720
5,400
67221
Destruction of localized lesion of choroid (e.g., choroidal
neovascularization); photodynamic therapy (includes intravenous infusions
12,120
6,720
5,400
12,120
6,720
5,400
12,120
6,720
5,400
12,120
6,720
5,400
12,120
6,720
5,400
10,120
4,620
5,500
12,120
6,720
5,400
67222
67227
67228
67250
67311
67312
Destruction of localized lesion of choroid (e.g., choroidal
neovascularization); transpupillary thermotherapy
Destruction of extensive or progressive retinopathy (e.g., diabetic
retinopathy), one or more sessions; cryotherapy, diathermy
Destruction of extensive or progressive retinopathy (e.g., diabetic
retinopathy), one or more sessions; photocoagulation (laser or xenon arc)
Scleral reinforcement
Strabismus surgery, recession or resection procedure (patient not previously
operated on); one horizontal muscle
Strabismus surgery, recession or resection procedure (patient not previously
operated on); two horizontal muscles
67314
Strabismus surgery, recession or resection procedure (patient not previously
operated on); one vertical muscle (excluding superior oblique)
12,120
6,720
5,400
67316
Strabismus surgery, recession or resection procedure (patient not previously
operated on); two or more vertical muscles (excluding superior oblique)
18,000
8,400
9,600
18,000
8,400
9,600
18,000
8,400
9,600
18,000
8,400
9,600
21,940
9,240
12,700
11,980
5,880
6,100
22,660
11,760
10,900
18,000
9,700
9,700
8,400
4,200
4,200
9,600
5,500
5,500
46,500
25,200
21,300
46,500
25,200
21,300
46,500
25,200
21,300
46,500
25,200
21,300
46,500
25,200
21,300
46,500
25,200
21,300
46,500
25,200
21,300
46,500
25,200
21,300
46,500
25,200
21,300
46,500
25,200
21,300
10,960
10,960
5,460
5,460
5,500
5,500
53,400
29,400
24,000
67318
67320
67331
67332
67334
67340
67343
67345
67350
67400
67405
67412
67413
67414
67415
67420
67430
67440
67445
67550
67560
67570
67580
67581
67582
67583
Strabismus surgery, any procedure (patient not previously operated on),
superior oblique muscle
Transposition procedure (e.g., for paretic extraocular muscle), any
extraocular muscle (specify)
Strabismus surgery on patient w/ previous eye surgery or injury that did not
involve the extraocular muscles
Strabismus surgery on patient w/ scaring of extraocular muscles (e.g., prior
ocular injury, strabismus or retinal detachment surgery) or restrictive
myopathy (e.g., dysthyroid ophthalmopathy)
Strabismus surgery by posterior fixation suture technique, w/ or w/o muscle
recession
Strabismus surgery involving exploration and/or repair of detached
extraocular muscle(s)
Release of extensive scar tissue w/o detaching extraocular muscle
Chemodenervation of extraocular muscle
Biopsy of extraocular muscle
Orbitotomy w/o bone flap (frontal or transconjunctival approach); for
exploration, w/ or w/o biopsy
Orbitotomy w/o bone flap (frontal or transconjunctival approach); w/
drainage only
Orbitotomy w/o bone flap (frontal or transconjunctival approach); w/
removal of lesion
Orbitotomy w/o bone flap (frontal or transconjunctival approach); w/
removal of foreign body
Orbitotomy w/o bone flap (frontal or transconjunctival approach); w/
removal of bone for decompression
Fine needle aspiration of orbital contents
Orbitotomy w/ bone flap or window, lateral approach (e.g., Kroenlein); w/
removal of lesion
Orbitotomy w/ bone flap or window, lateral approach (e.g., Kroenlein); w/
removal of foreign body
Orbitotomy w/ bone flap or window, lateral approach (e.g., Kroenlein); w/
drainage
Orbitotomy w/ bone flap or window, lateral approach (e.g., Kroenlein); w/
removal of bone for decompression
Orbital implant (implant outside muscle cone); insertion
Orbital implant (implant outside muscle cone); removal or revision
Optic nerve decompression (e.g., incision or fenestration of optic nerve
sheath)
Repair of anophthalmic socket; with insertion or removal of orbital implant
within muscle cone
Repair of anophthalmic socket; with exchange or orbital implant
Repair of anophthalmic socket; with exchange of orbital implant and
reattachment of muscles
Repair of anophthalmic socket; with fornix reconstruction using sutures
Page 88 of 98
12,120
6,720
5,400
20,980
10,080
10,900
20,980
10,080
10,900
20,980
10,080
10,900
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
DESCRIPTION
Case Rate
67830
Repair of anophthalmic socket; with fornix reconstruction using buccal
mucosal graft or amnion graft, including harvesting of graft
Repair of anophthalmic socket; with revision of implant and fornix
reconstruction using sutures
Repair of anophthalmic socket; with revision of implant and fornix
reconstruction using buccal mucosal graft, or amnion graft (including
harvesting of graft)
Blepharotomy, drainage of abscess, eyelid
Severing of tarsorrhaphy
Canthotomy
Excision of chalazion
Biopsy of eyelid
Repair of trichiasis; by electroepilation, electrosurgery, cryotherapy or laser
surgery
Repair of trichiasis; incision of lid margin
67835
Repair of trichiasis; incision of lid margin, with free mucous membrane graft
67584
67585
67586
67700
67710
67715
67800
67810
67825
67840
67875
67880
67882
67900
67901
67902
67903
67904
67906
67908
67911
67912
67914
67915
67916
67917
67921
67922
67923
67924
67930
67935
67950
67961
67966
Excision of lesion of eyelid (except chalazion) without closure or with simple
direct closure
Temporary closure of eyelids suture (e.g., frost suture)
Construction of intermargin adhesions, median tarsorrhaphy, or
canthorrhaphy;
Construction of intermargin adhesions, median tarsorrhaphy, or
canthorrhaphy; with transportation of tarsal plate
Repair of brow ptosis (supraciliary, midforehead or coronal approach)
Repair of blepharoptosis; frontalis muscle technique with suture or other
material
Repair of blepharoptosis; frontalis muscle technique with fascial sling
(includes obtaining fascia)
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-Mullers muscle-levator
resection (Fasanella-Servat type)
Repair of lid retraction (eyelid recession); without spacer
Correction of lagophthalmos, with implantation of upper eyelid load
Repair of ectropion; suture
Repair of ectropion; thermocauterization
Blepharoplasty, excision tarsal wedge
Blepharoplasty, extensive (e.g., Kuhnt-Szymanowski or tarsal strip
operations)
Repair of entropion; suture
Repair of entropion; thermocauterization
Blepharoplasty, excision tarsal wedge
Blepharoplasty, extensive (e.g., Wheeler 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
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
Professional Fee
Health Care
Institution Fee
20,980
10,080
10,900
20,980
10,080
10,900
20,980
10,080
10,900
5,680
5,680
5,680
5,680
5,680
1,680
1,680
1,680
1,680
1,680
4,000
4,000
4,000
4,000
4,000
5,680
1,680
4,000
3,640
840
2,800
9,300
2,100
7,200
5,560
1,260
4,300
5,680
1,680
4,000
5,680
1,680
4,000
8,020
2,520
5,500
18,000
8,400
9,600
18,000
8,400
9,600
20,980
10,080
10,900
18,000
8,400
9,600
18,000
8,400
9,600
18,000
8,400
9,600
18,000
8,400
9,600
21,400
32,000
8,020
8,020
9,700
10,500
14,700
2,520
2,520
4,200
10,900
17,300
5,500
5,500
5,500
12,900
6,300
6,600
5,680
5,680
9,700
12,900
1,680
1,680
4,200
6,300
4,000
4,000
5,500
6,600
9,700
4,200
5,500
12,120
6,720
5,400
12,120
6,720
5,400
30,740
13,440
17,300
27,120
15,120
12,000
67971
Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap
from opposing eyelid; up to two-thirds of eyelid, one stage or first stage
30,300
16,800
13,500
67973
Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap
from opposing eyelid; total eyelid, lower, one stage or first stage
37,800
21,000
16,800
67974
Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap
from opposing eyelid; total eyelid, upper, one stage or first stage
37,800
21,000
16,800
30,300
16,800
13,500
5,680
8,020
8,020
8,020
1,680
2,520
2,520
2,520
4,000
5,500
5,500
5,500
67975
68100
68110
68115
68130
Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap
from opposing eyelid; second stage
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
Page 89 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
68320
DESCRIPTION
Case Rate
Conjunctivoplasty; with conjunctival graft or extensive rearrangement
Professional Fee
Health Care
Institution Fee
10,540
5,040
5,500
12,120
6,720
5,400
14,960
7,560
7,400
18,000
8,400
9,600
14,960
7,560
7,400
21,940
9,240
12,700
18,000
8,400
9,600
11,980
5,880
6,100
68360
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
68362
Conjunctival flap; total (such as Gunderson thin flap or purse string flap)
11,980
5,880
6,100
68371
68400
68420
68440
68500
68510
68520
68525
68530
68540
68550
68700
68705
Harvesting conjunctival allograft, living donor
Incision, drainage of lacrimal gland
Incision, drainage of lacrimal sac (dacryocystostomy)
Snip incision of lacrimal punctum
Excision of lacrimal gland (dacryoadenectomy), except for tumor
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
20,980
5,680
5,680
5,680
12,120
5,680
12,120
5,680
5,680
18,000
18,000
9,700
3,640
10,080
1,680
1,680
1,680
6,720
1,680
6,720
1,680
1,680
8,400
8,400
4,200
840
10,900
4,000
4,000
4,000
5,400
4,000
5,400
4,000
4,000
9,600
9,600
5,500
2,800
68720
Dacryocystorhinostomy (fistulization of lacrimal sac to nasal cavity)
18,000
8,400
9,600
18,000
8,400
9,600
20,980
10,080
10,900
68325
68326
68328
68330
68335
68340
68770
68811
68815
69000
69020
69100
69105
69110
69120
69140
69145
69150
69155
Conjunctivorhinostomy (fistulization of conjunctiva to nasal cavity); without
tube
Conjunctivorhinostomy (fistulization of conjunctiva to nasal cavity); with
insertion of tube or stent
Closure of the lacrimal punctum; by thermocauterization, ligation, or laser
surgery
Closure of lacrimal fistula
Probing of nasolacrimal duct; requiring general anesthesia
Probing of nasolacrimal duct; with insertion of tube or stent
Drainage external ear, abscess or hematoma
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; w/o neck dissection
Radical excision external auditory canal lesion; w/ neck dissection
69200
69220
68745
68750
68760
69222
69310
8,020
2,520
5,500
10,880
8,020
9,700
3,672
3,472
5,680
5,680
8,260
12,120
9,700
9,700
23,300
30,300
3,780
2,520
4,200
672
252
1,680
1,680
3,360
6,720
4,200
4,200
12,600
16,800
7,100
5,500
5,500
3,000
3,220
4,000
4,000
4,900
5,400
5,500
5,500
10,700
13,500
Removal foreign body from external auditory canal; w/ general anesthesia
9,300
2,100
7,200
Debridement, mastoidectomy cavity, simple (e.g., routine cleaning)
Debridement, mastoidectomy cavity, complex (e.g., w/ anesthesia or more
than routine cleaning)
Reconstruction of external auditory canal (meatoplasty) (e.g., for stenosis
due to trauma, infection)
8,020
2,520
5,500
9,700
4,200
5,500
23,300
12,600
10,700
23,300
12,600
10,700
5,812
5,680
5,680
1,512
1,680
1,680
4,300
4,000
4,000
8,020
2,520
5,500
8,260
3,360
4,900
8,260
3,360
4,900
18,000
9,700
20,980
23,300
23,300
23,300
23,300
46,500
8,020
8,400
4,200
10,080
12,600
12,600
12,600
12,600
25,200
2,520
9,600
5,500
10,900
10,700
10,700
10,700
10,700
21,300
5,500
69320
Reconstruction external auditory canal for congenital atresia, single stage
69400
69405
69420
Eustachian tube inflation, transnasal; w/ catheterization
Eustachian tube catheterization, transtympanic
Myringotomy including aspiration and/or eustachian tube inflation
Myringotomy including aspiration and/or eustachian tube inflation requiring
general anesthesia
Tympanostomy (requiring insertion of ventilating tube), local or topical
anesthesia
Tympanostomy (requiring insertion of ventilating tube), w/ general
anesthesia
Middle ear exploration through postauricular or ear canal incision
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
69421
69433
69436
69440
69450
69501
69502
69505
69511
69530
69535
69540
Page 90 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
DESCRIPTION
69550
69552
69554
69601
Excision aural glomus tumor; transcanal
Excision aural glomus tumor; transmastoid
Excision aural glomus tumor; extended (extratemporal)
Revision mastoidectomy; resulting in complete mastoidectomy
30,300
30,300
30,300
23,300
16,800
16,800
16,800
12,600
Health Care
Institution Fee
13,500
13,500
13,500
10,700
69602
Revision mastoidectomy; resulting in modified radical mastoidectomy
31,580
14,280
17,300
69603
69604
69605
Revision mastoidectomy; resulting in radical mastoidectomy
Revision mastoidectomy; resulting in tympanoplasty
Revision mastoidectomy; w/ apicectomy
Tympanic membrane repair, w/ or w/o site preparation or perforation for
closure, w/ or w/o patch
Myringoplasty (surgery confined to drumhead and donor area)
23,300
23,300
23,300
12,600
12,600
12,600
10,700
10,700
10,700
69610
69620
Case Rate
Professional Fee
12,120
6,720
5,400
20,980
10,080
10,900
69631
Tympanoplasty w/o mastoidectomy (including canalplasty, atticotomy and/
or middle ear surgery), initial or revision; w/o ossicular chain reconstruction
30,740
13,440
17,300
69632
Tympanoplasty w/o mastoidectomy (including canalplasty, atticotomy and/
or middle ear surgery), initial or revision; w/ ossicular chain reconstruction
(e.g., postfenestration)
30,740
13,440
17,300
69633
Tympanoplasty w/o mastoidectomy (including canalplasty, atticotomy and/
or middle ear surgery), initial or revision; w/ ossicular chain reconstruction
and synthetic prosthesis (e.g., partial ossicular replacement prosthesis,
(PORP), total ossicular replacement prosthesis (TORP)
30,740
13,440
17,300
46,500
25,200
21,300
47,340
26,040
21,300
47,340
26,040
21,300
46,500
25,200
21,300
47,340
26,040
21,300
48,180
26,880
21,300
49,020
27,720
21,300
46,500
25,200
21,300
46,500
25,200
21,300
37,800
21,000
16,800
38,640
21,840
16,800
38,640
21,840
16,800
38,640
38,640
38,640
31,580
30,300
10,540
21,840
21,840
21,840
14,280
16,800
5,040
16,800
16,800
16,800
17,300
13,500
5,500
30,300
16,800
13,500
30,300
16,800
13,500
37,800
21,000
16,800
37,800
21,000
16,800
38,640
21,840
16,800
39,480
22,680
16,800
69635
69636
69637
69641
69642
Tympanoplasty w/ antrotomy or mastoidotomy (including canalplasty,
atticotomy, middle ear surgery, and/ or tympanic membrane repair); w/o
ossicular chain reconstruction
Tympanoplasty w/ antrotomy or mastoidotomy (including canalplasty,
atticotomy, middle ear surgery, and/ or tympanic membrane repair); w/
ossicular chain reconstruction
Tympanoplasty w/ antrotomy or mastoidotomy (including canalplasty,
atticotomy, middle ear surgery, and/ or tympanic membrane repair); w/
ossicular chain reconstruction and synthetic prosthesis (e.g. partial ossicular
replacement prosthesis, (PORP), total ossicular replacement prosthesis
(TORP)
Tympanoplasty w/ mastoidectomy (including canalplasty, middle ear
surgery, tympanic membrane repair); w/o ossicular chain reconstruction
Tympanoplasty w/ mastoidectomy (including canalplasty, middle ear
surgery, tympanic membrane repair); w/ ossicular chain reconstruction
69662
69666
69667
69670
69676
69700
Tympanoplasty w/ mastoidectomy (including canalplasty, middle ear
surgery, tympanic membrane repair); w/ intact or reconstructed wall, w/o
ossicular chain reconstruction
Tympanoplasty w/ mastoidectomy (including canalplasty, middle ear
surgery, tympanic membrane repair); w/ intact or reconstructed canal wall,
w/ ossicular chain reconstruction
Tympanoplasty w/ mastoidectomy (including canalplasty, middle ear
surgery, tympanic membrane repair); radical or complete, w/o ossicular
chain reconstruction
Tympanoplasty w/ mastoidectomy (including canalplasty, middle ear
surgery, tympanic membrane repair); radical or complete, w/ ossicular chain
reconstruction
Stapes mobilization
Stapedectomy or stapedotomy w/ reestablishment of ossicular continuity,
w/ or w/o use of foreign material;
Stapedectomy or stapedotomy w/ reestablishment of ossicular continuity,
w/ or w/o use of foreign material; w/ footplate drill out
Revision of stapedectomy or stapedotomy
Repair oval window fistula
Repair round window fistula
Mastoid obliteration
Tympanic neurectomy
Closure postauricular fistula, mastoid
69720
Decompression facial nerve, intratemporal; lateral to geniculate ganglion
69643
69644
69645
69646
69650
69660
69661
69725
69740
69745
69801
69802
Decompression facial nerve, intratemporal; including medial to geniculate
ganglion
Suture facial nerve, intratemporal, w/ or w/o graft or decompression;
lateral to geniculate ganglion
Suture facial nerve, intratemporal, w/ or w/o graft or decompression;
including medial to geniculate ganglion
Labyrinthotomy, w/ or w/o cryosurgery including other nonexcisional
destructive procedures or perfusion of vestbuloactive drugs (single or
multiple perfusions); transcanal
Labyrinthotomy, w/ or w/o cryosurgery including other nonexcisional
destructive procedures or perfusion of vestbuloactive drugs (single or
multiple perfusions); w/ mastoidectomy
Page 91 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
69805
69806
69820
69840
69905
69910
69915
69930
69950
69955
69960
69970
70010
70390
71090
72240
74300
74328
74329
74330
74340
74350
74355
74360
74363
74475
DESCRIPTION
46,500
53,400
46,500
53,400
46,500
53,400
53,400
55,000
55,000
55,000
53,400
46,500
25,200
29,400
25,200
29,400
25,200
29,400
29,400
33,600
33,600
33,600
29,400
25,200
Health Care
Institution Fee
21,300
24,000
21,300
24,000
21,300
24,000
24,000
21,400
21,400
21,400
24,000
21,300
8,020
2,520
5,500
8,020
2,520
5,500
8,020
2,520
5,500
8,020
2,520
5,500
8,020
2,520
5,500
8,020
2,520
5,500
8,020
2,520
5,500
8,020
2,520
5,500
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
18,000
8,400
9,600
18,000
8,400
9,600
18,000
8,400
9,600
8,020
2,520
5,500
9,700
4,200
5,500
Case Rate
Endolymphatic sac operation; w/o shunt
Endolymphatic sac operation; w/ shunt
Fenestration semicircular canal
Revision fenestration operation
Labyrinthectomy; transcanal
Labyrinthectomy; w/ mastoidectomy
Vestibular nerve section, translabyrinthine approach
Cochlear device implantation, w/ or w/o mastoidectomy
Vestibular nerve section, transcranial approach
Total facial nerve decompression and/or repair (may include graft)
Decompression internal auditory canal
Removal of tumor, temporal bone
Myelography, brain, including spinal puncture and radiological supervision
and interpretation
Sialography; including duct catheterization and radiological supervision and
interpretation
Insertion pacemaker, fluoroscopy and radiography, radiological supervision
and interpretation
Myelography, spine, including spinal puncture and radiological supervision
and interpretation
Cholangiography and/or pancreatography, intraoperative, 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
system, radiological supervision and interpretation
Introduction of long gastrointestinal tube (e.g., Miller-Abbott ), radiological
supervision and interpretation
Percutaneous placement of gastrostomy tube, radiological supervision and
interpretation
Percutaneous placement of enteroclysis tube, radiological supervision and
interpretation
Intraluminal dilation of strictures and/or obstructions, radiological
supervision and interpretation
Percutaneous transhepatic dilation of sbiliary duct stricture, radiological
supervision and interpretation
Introduction of intracatheter or catheter into renal pelvis for drainage
and/or injection, percutaneous, radiological supervision and interpretation
Professional Fee
75600
Introduction of ureteral catheter or stent into ureter through renal pelvis
for drainage and/or injection, percutaneous, radiological supervision and
interpretation
Transcervical catheterization of fallopian tube, radiological supervision and
interpretation
Aortography, thoracic, radiological supervision and interpretation
75625
Aortography, abdominal, radiological supervision and interpretation
9,700
4,200
5,500
75630
Aortography, abdominal plus bilateral iliofemoral lower extremity,
radiological supervision and interpretation
9,700
4,200
5,500
75635
Computed tomographic angiography, abdominal aorta and bilateral
iliofemoral lower extremity, radiological supervision and interpretation
9,700
4,200
5,500
75650
Angiography, cervicocerebral, radiological supervision and interpretation
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
74480
74742
75658
75660
75662
75665
75671
75676
75680
75685
75705
75710
75716
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, cerebral, 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, radiological supervision and interpretation
Angiography, extremity, unilateral, radiological supervision and
interpretation
Angiography, extremity, bilateral, radiological supervision and interpretation
Page 92 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
75722
Angiography, renal, unilateral, radiological supervision and interpretation
9,700
4,200
5,500
75724
Angiography, renal, bilateral, radiological supervision and interpretation
9,700
4,200
5,500
75726
Angiography, visceral, radiological supervision and interpretation
9,700
4,200
5,500
75731
Angiography, adrenal, unilateral, radiological supervision and interpretation
9,700
4,200
5,500
75733
Angiography, adrenal, bilateral, radiological supervision and interpretation
9,700
4,200
5,500
75736
Angiography, pelvis, radiological supervision and interpretation
Angiography, pulmonary, unilateral, radiological supervision and
interpretation
Angiography, pulmonary, bilateral, radiological supervision and
interpretation
Angiography, pulmonary, nonselective, radiological supervision and
interpretation
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
75756
Angiography, internal mammary, radiological supervision and interpretation
9,700
4,200
5,500
75757
Angiography, fluorescein (eye)
Angiography, arteriovenous shunt (e.g., dialysis patient), radiological
supervision and interpretation
Lymphangiography, extremity, unilateral, radiological supervision and
interpretation
Lymphangiography, extremity, bilateral, radiological supervision and
interpretation
Lymphangiography, pelvic/abdominal, unilateral , radiological supervision
and interpretation
Lymphangiography, pelvic/abdominal, bilateral, radiological supervision and
interpretation
Splenoportography, radiological supervision and interpretation
Venography, extremity, unilateral or bilateral, radiological supervision and
interpretation
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
75825
Venography, caval, inferior, radiological supervision and interpretation
9,700
4,200
5,500
75827
Venography, caval, superior, radiological supervision and interpretation
9,700
4,200
5,500
75831
Venography, renal, unilateral, radiological supervision and interpretation
9,700
4,200
5,500
75833
Venography, renal, bilateral, radiological supervision and interpretation
9,700
4,200
5,500
75840
Venography, adrenal, unilateral, radiological supervision and interpretation
9,700
4,200
5,500
75842
Venography, adrenal, bilateral, radiological supervision and interpretation
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
9,700
9,700
4,200
4,200
5,500
5,500
12,900
6,300
6,600
12,900
6,300
6,600
30,300
16,800
13,500
9,700
4,200
5,500
9,700
4,200
5,500
23,300
12,600
10,700
9,700
4,200
5,500
53,400
29,400
24,000
75741
75743
75746
75790
75801
75803
75805
75807
75810
75820
75860
75870
75872
75880
75885
75889
75900
75901
75902
75940
75945
75952
Venography, venous sinus(e.g., petrosal and inferior sagittal) or jugular,
radiological supervision and interpretation
Venography, superior sagittal sinus, radiological supervision and
interpretation
Venography, epidural, radiological supervision and interpretation
Venography, orbital, radiological supervision and interpretation
Percutaneous transhepatic portography, radiological supervision and
interpretation
Hepatic venography, radiological supervision and interpretation
Exchanged of a previously placed intravascular catheter during thrombolytic
therapy with contrast monitoring, radiological supervision and
interpretation
Mechanical removal of pericatheter obstructive material (e.g., 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
Percutaneous placement of IVC filter, radiologic supervision and
interpretation
Intravascular ultrasound (non-coronary-vessel), radiological supervision and
interpretation; initial vessel
Endovascular repair of infrarenal abdominal aortic aneurysm or dissection,
radiological supervision and interpretation
75953
Placement of proximal or distal extension prosthesis for endovascular repair
of infrarenal aortic or iliac artery aneurysm, pseudoanuerysm, or dissection,
radiological supervision and interpretation
55,000
33,600
21,400
75954
Endovascular repair of iliac artery aneurysm, pseudoaneurysm,
arteriovenous malformation, or trauma, radiological supervision and
interpretation
53,400
29,400
24,000
Page 93 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
75956
75957
75958
75959
75960
75961
75962
75966
75970
75978
75980
75982
75984
75989
75992
75994
75995
76003
76012
DESCRIPTION
Case Rate
Endovascular repair of descending thoracic aorta (e.g., aneurysm,
psuedoaneurysm, 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, radiologic supervision and interpretation
Endovascular repair of descending thoracic aorta (e.g., aneurysm,
psuedoaneurysm, 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, radiologic supervision and
interpretation
Placement of proximal extension prosthesis for endovascular repair of
descending thoracic aorta (e.g., aneurysm, pseudoaneurysm, dissection,
penetrating ulcer, intramural hematoma, or traumatic disruption),
radiologic 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 induction of intravascular stent(s), (except coronary, carotid,
and vertebral vessel), percutaneous and/ or open, radiological supervision
and interpretation
Transcatheter retrieval, percutaneous, of intravascular foreign body (e.g.,
fractured venous or arterial catheter), radiological supervision and
interpretation
Transluminal balloon angioplasty, peripheral artery, radiological supervision
and interpretation
Transluminal balloon angioplasty, renal or other visceral artery, radiological
supervision and interpretation
Transcatheter biopsy, radiological supervision and interpretation
Transluminal balloon angioplasty, venous (e.g., subclavian stenosis)
radiological supervision and interpretation
Percutaneous transhepatic biliary drainage with contrast monitoring,
radiological supervision and interpretation
Percutaneous placement of drainagecatheter combined internal and
external billiary drainage or of a drainage stent for internal billiary drainage
in patients with an inoperable mechanical billiary obstruction, radiologic
supervision and interpretation.
Change of percutaneous tube or drainage catheter with contrast
monitoring (e.g., gastrointestinal system, genitourinary system, abscess),
radiologic supervision and interpretation
Radiological guidance for percutaneous drainage (abscess, cyst, fluid
collection), with placement of catheter and radiological supervision and
interpretation
Transluminal atherectomy, peripheral artery, radiological supervision and
interpretation
Transluminal atherectomy, renal, radiological supervision and interpretation
Transluminal atherectomy, visceral, radiological supervision and
interpretation
Fluoroscopic guidance for needle placement (e.g., biopsy, aspiration,
injection, localization device)
Radiological supervision and interpretation, percutaneous vertebroplasty or
vertebral augmentation including cavity creation; under fluoroscopic
guidance
76013
Radiological supervision and interpretation, percutaneous vertebroplasty or
vertebral augmentation including cavity creation; under CT guidance
76080
Radiologic examination, abscess, fistula or sinus tract study, including
catheterization of lesion and radiological supervision and interpretation
76086
76095
76096
76355
76360
76362
76393
Mammary ductogram or galactogram, 1 or multiple duct, injection and
radiological supervision and interpretation
Stereotactic localization guidance for breast biopsy or needle placement
(e.g., for wire localization or for injection), one or more lesion, radiological
supervision and interpretation
Mammographic guidance for needle placement, breast (e.g., for wire
localization or for injection), each lesion, radiological supervision and
interpretation
Computed tomography guidance for stereotactic localization
Computed tomography guidance for needle placement (e.g., biopsy,
aspiration, injection, localization device), radiological supervision and
interpretation
Computed tomography guidance for visceral tissue ablation
Magnetic resonance guidance for needle placement (e.g., for biopsy, needle
aspiration, injection, or placement of localization device) radiological
supervision and interpretation
Page 94 of 98
Professional Fee
Health Care
Institution Fee
55,000
33,600
21,400
53,400
29,400
24,000
55,000
33,600
21,400
55,000
33,600
21,400
46,500
25,200
21,300
46,500
25,200
21,300
23,300
12,600
10,700
23,300
12,600
10,700
23,300
12,600
10,700
23,300
12,600
10,700
37,800
21,000
16,800
46,500
25,200
21,300
8,020
2,520
5,500
8,020
2,520
5,500
23,300
12,600
10,700
23,300
12,600
10,700
23,300
12,600
10,700
8,020
2,520
5,500
30,300
16,800
13,500
30,300
16,800
13,500
8,020
2,520
5,500
8,020
2,520
5,500
8,020
2,520
5,500
8,020
2,520
5,500
8,020
2,520
5,500
8,020
2,520
5,500
8,020
2,520
5,500
8,020
2,520
5,500
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
76394
76930
76932
76936
76940
76942
76965
76986
77261
77401
77401
77418
77421
77432
DESCRIPTION
Magnetic resonance guidance for visceral tissue ablation
Ultrasonic guidance for pericardiocentesis, imaging supervision and
interpretation
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)
Ultrasonic guidance for visceral tissue ablation
Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection,
localization device), imaging supervision and interpretation
Ultrasonic guidance for interstitial radioelement application
Ultrasonic guidance, intraoperative
Therapeutic radiology treatment planning; simple, intermediate or complex,
(Only one may be reported for a given course of therapy)
Radiation treatment delivery (Linear Accelerator)
Radiation treatment delivery (Cobalt Accelerator)
Intensity modulated treatment delivery, single or multiple fields/arcs, via
narrow spatially and temporally modulated beams, binary, dynamic MLC per
session
Stereoscopic X-ray guidance for localization of target volume for the delivery
of radiation therapy
Stereotactic radiation treatment management of cerebral lesion(s)
77600
Hyperthermia for treatment of malignancy, one or more sessions during the
course of therapy including follow-up care for 90 days after procedure
77750
Infusion or instillation of radioelement solution
77761
Intracavitary radiation source application, 1 or more sources/ribbons
(Brachytherapy), one or more sessions during the course of therapy
including follow-up care for 90 days after procedure
79440
Interstitial radiation source application, 1 or more sources/ribbons
(Brachytherapy), one or more sessions during the course of therapy
including follow-up care for 90 days after procedure
Remote after loading high intensity brachytherapy (RAHIB); 1 or more
source position or catheters per session
Surface application of radiation source (Brachytherapy), one or more
sessions during the course of therapy including follow-up care for 90 days
after procedure
Radiopharmaceutical (radioactive iodine) therapy
Radiopharmaceutical ablation of gland for thyroid carcinoma or metastases
of thyroid carcinoma
Radiopharmaceutical therapy, by intracavitary administration
Radiopharmaceutical therapy, by interstitial radioactive colloid
administration
Radiopharmaceutical therapy, by radiolabeled monoclonal antibody by
intravenous infusion
Radiopharmaceutical therapy, by intra-articular administration
79445
Radiopharmaceutical therapy, by intra-arterial particulate administration
87207
88174
Outpatient Malaria Package
Evaluation of aspirate (CT-guided biopsy) with or without preparation of
smears; immediate cytologic study to determine adequacy of specimen(s),
interpretation and report
88331
Pathology consultation during surgery; with frozen section(s), single block
77776
77781
77789
79000
79005
79200
79300
79403
89221
89222
90375
90935
Pathology consultation during surgery; with frozen section(s), two (2) or
more blocks
Directly Observed Treatment Short-course; intensive phase
Directly Observed Treatment Short-course; maintenance phase
Animal bite
Hemodialysis procedure
90945
Dialysis procedure other than hemodialysis (e.g. peritoneal, hemofiltration)
88332
91034
91037
91100
91105
92973
92975
8,020
2,520
Health Care
Institution Fee
5,500
8,020
2,520
5,500
8,020
2,520
5,500
8,020
2,520
5,500
8,020
2,520
5,500
8,020
2,520
5,500
8,020
8,020
2,520
2,520
5,500
5,500
18,000
8,400
9,600
3,000
2,000
1,200
800
1,800
1,200
5,680
1,680
4,000
30,300
16,800
13,500
30,300
16,800
13,500
12,120
6,720
5,400
5,680
1,680
4,000
18,000
8,400
9,600
18,000
8,400
9,600
5,680
1,680
4,000
9,700
4,200
5,500
3,640
840
2,800
8,020
2,520
5,500
9,700
4,200
5,500
9,700
4,200
5,500
8,020
2,520
5,500
8,020
2,520
5,500
8,020
2,520
5,500
Case Rate
Esophagus, gastroesophageal reflux test; with nasal catheter pH
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;
Intestinal bleeding tube, passage, positioning and monitoring
Gastric intubation, and aspiration or lavage for treatment (e.g., for ingested
poisons)
Percutaneous transluminal coronary thrombectomy
Thrombolysis, coronary; by intracoronary infusion, including coronary
angiography
Page 95 of 98
Professional Fee
600
600
5,680
1,680
4,000
5,680
1,680
4,000
9,700
4,200
5,500
2,500
1,500
3,000
4,000
500
2,500
1,500
3,000
3,500
4,000
500
3,500
8,260
3,360
4,900
8,260
3,360
4,900
8,260
3,360
4,900
8,260
3,360
4,900
30,300
16,800
13,500
23,300
12,600
10,700
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
92980
Transcatheter placement of an intracoronary stent(s), percutaneous, with or
without other therapeutic interventions, any method; single vessel
30,300
16,800
13,500
92981
Transcatheter placement of an intracoronary stent(s), percutaneous, with or
without other therapeutic interventions, any method; each additional vessel
30,300
16,800
13,500
92982
Percutaneous transluminal coronary balloon angioplasty, one or more vessel
30,300
16,800
13,500
92986
92987
92990
Percutaneous balloon valvuloplasty; aortic
Percutaneous balloon valvuloplasty; mitral
Percutaneous balloon valvuloplasty; pulmonary valve
Atrial septectomy or septostomy; transvenous method, balloon (e.g.,
Rashkind type) (includes cardiac catheterization)
Atrial septectomy or septostomy; blade method (Park septostomy) (includes
cardiac catheterization)
53,400
53,400
53,400
29,400
29,400
29,400
24,000
24,000
24,000
21,400
10,500
10,900
21,400
10,500
10,900
30,300
16,800
13,500
12,900
6,300
6,600
18,000
8,400
9,600
9,700
4,200
5,500
23,300
12,600
10,700
9,700
4,200
5,500
18,000
8,400
9,600
18,000
8,400
9,600
18,000
23,300
8,400
12,600
9,600
10,700
23,300
12,600
10,700
23,300
12,600
10,700
23,300
12,600
10,700
23,300
12,600
10,700
92992
92993
92995
92997
93501
93503
93505
93508
93510
93511
93514
93524
93526
93527
93528
93529
93530
93531
93532
93533
93539
93540
93541
93542
Percutaneous transluminal coronary atherectomy, by mechanical or other
method, with or without balloon angioplasty, one or more vessel
Percutaneous transluminal pulmonary balloon angioplasty, one or more
vessel
Right heart catheterization
Insertion and placement of flow directed catheter (e.g., Swan-Ganz) for
monitoring purposes
Endomyocardial biopsy
Catheter placement in coronary artery(s), arterial coronary conduits and/or
venous coronary bypass grafts 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 (e.g., internal mammary), whether native
or used 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
18,000
8,400
9,600
23,300
12,600
10,700
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
93543
Injection procedure during cardiac catheterization; for selective coronary
angiography (injection of radiopaque material may be by hand)
93544
Injection procedure during cardiac catheterization; for aortography
23,300
12,600
10,700
93545
Injection procedure during cardiac catheterization; for selective coronary
angiography (injection of radiopaque material may be by hand)
9,700
4,200
5,500
93555
Imaging supervision, interpretation and report for injection procedure(s)
during cardiac catheterization; ventricular and/or atrial angiography
9,700
4,200
5,500
Page 96 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
DESCRIPTION
Case Rate
Professional Fee
Health Care
Institution Fee
93556
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)
9,700
4,200
5,500
93580
Percutaneous transcatheter closure of congenital interatrial
communications (i.e., Fontan fenestration, atrial septal defect) with implant
55,000
33,600
21,400
55,000
33,600
21,400
9,700
9,700
9,700
9,700
9,700
4,200
4,200
4,200
4,200
4,200
5,500
5,500
5,500
5,500
5,500
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
93581
93600
93602
93603
93610
93612
93615
93616
93618
93619
93620
93624
Percutaneous transcatheter closure of congenital ventricular septal defect
with implant
Bundle of His recording
Intra-atrial recording
Right ventricular recording
Intra-atrial pacing
Intraventricular pacing
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
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 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, His bundle
recording
Electrophysiologic follow-up study with pacing and recording to test
effectiveness of therapy, including induction or attempted induction of
arrhythmia
93631
Intra-operative epicardial and endocardial pacing and mapping to localize
the site tachycardia or zone of slow conduction for surgical correction
9,700
4,200
5,500
93640
Electrophysiologic evaluation of single or dual chamber pacing cardioverterdefibrillator leads including defibrillation threshold evaluation (induction of
arrhythmia, evaluation of sensing and pacing for arrhythmia termination) at
time of initial implantation or replacement;
9,700
4,200
5,500
93641
Electrophysiologic evaluation of single or dual chamber pacing cardioverterdefibrillator leads including defibrillation threshold evaluation (induction of
arrhythmia, evaluation of sensing and pacing for arrhythmia termination) at
time of initial implantation or replacement; with testing of single or dual
chamber pacing cardioverter-defribrillator pulse generator
9,700
4,200
5,500
93642
Electrophysiologic evaluation of single or dual chamber pacing cardioverterdefibrillator (includes defibrillation threshold evaluation, induction of
arrhythmia, evaluation of sensing and pacing for arrhythmia termination,
and programming or reprogramming
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
9,700
4,200
5,500
7,280
1,680
5,600
5,560
1,260
4,300
8,020
2,520
5,500
5,560
1,260
4,300
3,640
840
2,800
93650
93651
93652
93660
96408
96440
96445
96450
96542
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
Chemotherapy administration
Chemotherapy administration into pleural cavity, requiring and including
thoracentesis
Chemotherapy administration into peritoneal cavity, requiring and including
peritoneocentesis
Chemotherapy administration into CNS, requiring and including spinal
puncture
Chemotherapy injection, subarachnoid or interventricular via subcutaneous
reservoir
Page 97 of 98
ANNEX 2. LIST OF PROCEDURE CASE RATES
FIRST CASE RATE
RVS CODE
96567
99246
99256
99360
99432
P00001
DESCRIPTION
Case Rate
Photodynamic therapy by external application of light to destroy
premalignant and/or malignant lesions of the skin and adjacent mucosa
(e.g., lip) by activation of photosensitive drug(s), 1 or more phototherapy
exposure session
Outpatient HIV / AIDS Packages
Preoperative inpatient consultation for a new or established patient which
requires: an expanded problem focused history, examination and medical
decision making. This service is requested by another physician or an
appropriate source; the consultant advices the requesting physician about
the management of specific problem including follow-up care for 90 days
after procedure (CP Clearance)
Physician standby service, requiring physician attendance (e.g., operative
standby), including preoperative inpatient consultation for high-risk patients
or those with severe systemic disease including follow-up care for 90 days
after procedure
Normal newborn care package
Referral package
Page 98 of 98
Professional Fee
8,020
Health Care
Institution Fee
2,520
5,500
30,000
30,000
0
0
0
0
0
0
1,750
4,000
500
1,200
1,250
2,800