PRIOR AUTHORIZATION GUIDELINES
For authorization, use Fax: (602) 674-6678
To check the status of a prior authorization request, use website:
www.phoenixhealthplan.com
For information or for urgent requests, use Phone: (602) 824-3760 or (800) 747-7997
All by-report codes regardless of place of service (POS) and any professional services,
except hospital-based pathologists, radiologists and anesthesiologist, provided by a noncontracted provider or facility requires a prior authorization (PA).
Inpatient Services Requiring Prior Authorization
INPATIENT SRVICES REQUIRING PRIOR AUTHORIZATIONS REQUIRING of
1. All admissions, inpatient hospice admissions, skilled nursing facility admissions
and rehab admissions.
2. Transplants
3. All observations services (except for OB)
Additional Services Requiring Prior Authorization (regardless of place of service)
1. Dialysis – initial start only
2. Durable Medical Equipment (DME) – any code over $500 in AHCCCS allowed
charges, by report codes, and any identified service requiring medical review. PA
requests should be submitted to Preferred Homecare our DME vendor. (See
Ancillary Directory located under the Provider Directory tab.)
3. Nutritional feedings – Except for B4100 for children under 4 months old
4. Transportation – Ambulance non emergent inter-facility transports.
5. Orthotics and Prosthetics – over $500 in AHCCCS allowed charges, by report
codes and any identified services requiring medical review and all use of orthotics
and prosthetics from any vendor other than Hanger.
6. Sleep studies
7. Chiropractic services – members under the age of 21 are covered for codes 9894098943 when medically necessary and require prior authorization. Chiropractic
Services are not covered for members 21 years of age and older.
8. Home Health - request should be submitted to Professional Cares our Home
Health vendor. (See Ancillary Directory located under the Provider Directory
tab.)
9. Physical/Occupational/Speech Therapy
a. All follow-up visits
b. Evaluation visits for OT/ST and all non-contracted PT/OT/ST providers.
10. Prior Authorization is not required for evaluation and re-evaluation visits with
contracted PT/OT providers. Lists of contracted PT/OT/ST providers are found in
the PT Ancillary Directory. (See Ancillary Directory located under the Provider
Directory tab.)
1
Revised 1/1/2014
11. Radiology services
a. CT scans, MRAs, MRIs, and PET scans in all counties
b. For Maricopa County only:
i. Radiologic outpatient services performed in a hospital.
12. Sterilization - must be submitted with a Federal Consent Form thirty (30) days
prior to the procedure.
Pharmacy Services Requiring Prior Authorization
1. Non-formulary drugs
Outpatient Services (facility and provider) Requiring Prior Authorization
1. Outpatient services (contracted provider)
a. Both the facility and provider for all elective surgeries and procedures
performed in an outpatient hospital setting (POS 22) EXCEPT for
pathologist, radiologist and anesthesiologist and those procedures listed on
Attachment IV, which require NO authorization.
b. Surgeries performed at an ambulatory surgical center (POS 24) EXCEPT
those listed on Attachment III, which require NO authorization.
2. Pregnancy Termination – request must include the AHCCCS Certificate of
Necessity for Pregnancy Termination. Procedure codes: 59830, 59840, 59841,
59850, 59851, 59852, 59855, 59856, 59857
3. Pain Management Epidural Injections
4. Infusion Services
Services Performed in an Office Setting (POS 11) Requiring Prior Authorization
1. J Codes/In Office injections, infusions and inhalations (see Attachment II)
2. Requires prior-authorization: Procedures over $500 in AHCCCS-allowed charges
EXCEPT those listed in Attachment III. Also, all codes listed in Attachment I
require prior-authorization, regardless of cost.
3. Total OB care must be submitted with a complete standardized obstetrical risk
assessment tool using either the America College of Obstetricians and
Gynecologist (ACOG) or MICA form. Total OB authorizations will include two
(2) medically necessary, routine ultrasounds (2D) per OB case.
4. Consultations and/or follow up office visits for Specialist listed below;
2
Revised 1/1/2014
Office Services Requiring Prior Authorization, by Specialty
Specialty
Allergy
Cardiology
Dermatology
Developmental Pediatrics
Endocrinology
General Surgery
Genetics
Gastrointestinal (GI)
Hematology/Oncology
Neurology/Neurosurgery
Ophthalmology
Orthopedics
ENT (Otolaryngology)
Oral Surgery
Pain Management
Plastic Surgery
Podiatry
Pulmonology
Rheumatology
Surgical Consult for Gastric
Bypass
Urology
PA Required for Consults
Yes – all ages
Yes – ages 0-21
Yes – all ages
Yes – ages 0-21
No
No
Yes – all ages
No
No
No
No
No
No
Yes – all ages
No
Yes – all ages
Yes – all ages
No
No
Yes – all ages
PA Required for Follow up
Visits
Yes – all ages
Yes – ages 0-21
Yes – all ages
Yes – ages 0-21
Yes – ages 0-21
Yes – ages 0-21
Yes – all ages
Yes – ages 0-21
Yes – ages 0-21
Yes – ages 0-21
Yes – ages 0-21
Yes – ages 0-21
Yes – ages 0-21
Yes – all ages
Yes – all ages
Yea – all ages
Yes – all ages
Yes – ages 0-21
Yes – ages 0-21
Yes – all ages
No
Yes – ages 0-21
3
Revised 1/1/2014
Attachment I: Additional codes requiring PA when performed in office settings:
Service Type
Allergy Testing and Immunotherapy
Cardiology
Dermatology
Gastrointestinal
Orthopedics
Pain Management
Podiatry
Rheumatology
Urology
Miscellaneous
Codes
95004, 95010, 95012, 95015, 95024, 95027, 95028,
95044, 95052, 95056, 95060, 95065, 95070, 95071,
95075, 95115, 95117, 95120, 95125, 95130, 95132,
95133, 95134, 95144, 95145, 95146, 95147, 95148,
95149, 91565, 95170, 95180, 95199
93016, 93017, 93018, 93024
11772, 11200, 11201, 11400, 11444, 11719, 11721,
11900, 11901, 17315, 17250, 17340
91100-Covered for Medicare primary members
only-requires PA
20974, 20975, 20979
Codes listed in Attachment II
Services rendered for diabetics (250.XX) and/or
peripheral vascular disease (433.XX) and/or
immunocompromised (279.XX) do not require PA.
All other procedures rendered in relation to podiatry
services require PA 11719, 11720, 11721, G0127
Infusions/J codes listed on Attachment II
54161, 54235, 54250, 55200, 55250
(54450 except when performed by an Urologist)
Insertion of implantable contraceptives or hormonerelated agents: 11975, 11977, 11980, 11983.
3D rendering/interpretation of imaging: 76376,
76377.
Various psychiatric or therapy services: 90804,
90802, 90804, 90805, 90806, 90807, 90808, 90809,
90810, 90811, 90812, 90813, 90814, 90815, 90816,
90817, 90818, 90819, 90821, 90822, 90823, 90824,
90826, 90827, 90828, 90829, 90845, 90846, 90847,
90849, 90853, 90857, 90865, 90870, 90875, 90876,
90882, 90885, 90887, 90889.
CNS Testing/Assessment: 96101, 96102, 96103,
96105, 96111, 96116, 96118, 96119, 96120.
Dialysis Procedure Code: 90999-initial start only.
HCPCS: A6531, A6532, A6550, A8000, A8001,
A8002, A8003, A8004, L0112, L0130, A0150,
L0160, L0172, L0174, L0180, L0200, L3100.
4
Revised 1/1/2014
Attachment II: J and Q Codes REQUIRING PA when performed in the office; *denotes
2008 Code
Code
J0256
J0585
J0587
J0637
J0881
J0882
J0885
J0886
J0894
J1460J1560
J1561*
J1562
J1565
J1566
J1568*
J1569*
J1572*
J1740
J1745
J1825J1830
J1950
J2357
J2469
J2505
J2805
J3488*
J3490
J3590
J7187
Description
INJECTION, ALPHA I – PROTEINASE INHIBITOR
BOTULINUM TOXIN
BOTULINUM TOXIN TYPE B, PER 100 UNITS
INJECTION, CASPOFUNGIN ACETATE, 5MG
INJECTION, DARBEPOETIN ALFA 1 MCG (NON-ERSD USE) –
Aransep
INJECTION, DARBEPOETIN ALFA, 1 MCG (FOR ESRD ON
DIALYSIS)
INJECTION, EPOETIN ALFA, (FOR NON-ESRD USE), 1000 UNITS
INJECTION, EPOETIN ALFA, 1000 UNITS (FOR ESRD ON
DIALYSIS)
INJECTION, DECITABINE, 1 MG
INJECTION HAMMA GLOBULIN, INTRAMUSCULAR
INJECTION, IMMUNE GLOBULIN, IV, NON-LYPPHILIZED 500 MG
(gamunex)
INJECTION, IMMUNE GLOBULIN SUBQ 100 MG (Vivaglobin)
INJECTION, RESPIRATORY SYNCYTIAL VIRUS IMMUNE
GLOBULIN,
INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, NOT
OTHERWISE SPECIFIED, 500 MG
INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, NONLYOPHILIZED, 500 MG (Octagam)
INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, NONLYOPHILIZED, 500 MG (Gammagard)
INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, NONLYOPHILIZED, 500 MG (Flebogamma)
INJECTION, IBANDRONATE SODIUM, 1 MG (Bonisa)
INJECTION INFLIXIMAB, 10 MG
INJECTION, INTERFERON BETA-IA, 33MCG
INJECTION, LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION)
INJECTION, OMALIZUMAB, 5 MG
INJECTION, PALONOSETRON HCL, 25 MCG
INJECTION, PEGFILGRASTIM, 6 MG
INJECTION, SINCALIDE, 5 MICROGRAMS
INJECTION, ZOLEDRONIC ACID, 1 MG (Reclast)
UNCLASSIFIED DRUGS
UNCLASSIFIED BIOLOGICS
INJ VONWILLBRAND FCT CMPLX HUMAN 1 I.U.
5
Revised 1/1/2014
J7189
J7190
J7191
J7192
J7193
J7194
J7195
J7197
J7198
J7199
J7322*
J7323*
J7324*
J7599
J7799
J8499
J8597
Q3025
Q3026
FACTOR VIIA (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PER 1
MCG
FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) PER I.U.
FACTOR VIII (ANTIHEMOPHILIC FACTOR (PORCINE), PER I.U.
FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U.
FACTOR IX (ANTIHEMOPHILIC FACTOR, PURIFIED, NONRECOMBINANT) PER I.U.
FACTOR IX, COMPLEX, PER I.U.
FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U.
ANTITHROMBIN III (HUMAN), PER I.U.
ANTI-INHIBITOR, PER I.U.
HEMOPHILIA CLOTTING FACTOR, NOT OTHERWISE CLASSIFIED
HYALURONAN OR DERIVATIVE, SYNVISC, FOR INTRA-ARTICULAR
INJECTION, PER DOSE
HYALURONAN OR DERIVATIVE, EUFLEXXA, FOR INTRAARTICULAR INJECTION, PER DOSE
HYALURONAN OR DERIVATIVE, ORTHOVISC, FOR INTRAARTICULAR INJECTION, PER DOSE
IMMUNOSUPPRESSIVE DRUG, NOT OTHERWISE CLASSIFIED
NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED
THROUGH DME
PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, NOS
ANTIEMETIC DRUG, ORAL, NOT OTHERWISE SPECIFIED
INJECTION, INTERFERON BETA-1A, 11 MCG FOR INTRAMUSCULAR
USE
INJECTION, INTERFERON BETA-1A, 11 MCG FOR SUBCUTANEOUS
USE
6
Revised 1/1/2014
New Attachment III: Listed codes do not require PA when performed in an Ambulatory Surgery Ctr or Office Setting.
13122
Procedure
Code
10021
10022
10060
10061
10081
10120
10121
10140
10160
10180
11011
11012
11100
11101
11310
11406
11462
11602
11603
11606
11621
11622
11623
11626
11641
11642
11643
11730
11750
11760
11765
11770
11771
11772
11981
11983
12001
12002
12011
12013
12031
12032
12036
12041
12042
12051
12052
13101
13121
Description
REPR
CMPLX SCLP ARMS &OR LEGS; EA ADD 5 CM/LESS
FINE NEEDLE ASPIRATION; WITHOUT IMAGING GUIDANCE
FINE NEEDLE ASPIRATION; WITH IMAGING GUIDANCE
I&D OF ABSCESS ; SIMPLE OR SINGLE
I&D OF ABSCESS; COMPLICATED OR MULTIPLE
I&D OF PILONIDAL CYST; COMPLICATED
INCISION&REMOVAL FB SUBCUT TISSUES; SIMPLE
INCISION&REMOVAL FB SUBCUT TISSUES; COMP
I&D OF HEMATOMA SEROMA OR FLUID COLLECTION
PUNCTURE ASPIRATION ABSCESS HEMATOMA BULLA/CYST
I&D COMPLEX POSTOPERATIVE WOUND INFECTION
DEBRID ASSOC W/OPEN FX&/DISLOC;SKIN SUBQ&MUSC
DEBRID ASSOC W/OPEN FX&/DISLOC;SKIN SUBQ MUSC&BN
BX SKIN SUBQ TISSWMUCOUS MEMB (SEP PRO); 1 LES
BX SKIN SUBQ TISS&/MUCOUS MEMB (SEP PRO); EA ADD
SHAV 1 LES FACE EARS EYELD NOSE LPS; 0.5 CM/LESS
EXC BEN LES MARG NO TAG TRNK ARM/LEG;OVR 4.0 CM
EXC SKN&SUBQ HIDRADENITIS ING;SMPL/INTERMED REPR
EXC MAL LES MARG TRNK ARMS/LEGS; DIAM 1.1-2.0 CM
EXC MAL LES MARG TRNK ARMS/LEGS; DIAM 2.1-3.0 CM
EXC MAL LES MARG TRNK ARMS/LEGS; DIAM OVR 4.0 CM
EXC MAL LES MARG SCLP NCK HND FT GNT; 0.6-1.0 CM
EXC MAL LES MARG SCLP NCK HND FT GNT; 1.1-2.0 CM
EXC MAL LES MARG SCLP NCK HND FT GNT; 2.1-3.0 CM
EXC MAL LES MARG SCLP NCK HND FT GNT; OVR 4.0 CM
EXC MAL LES MARG FCE ERS EYELD NSE LP;0.6-1.0 CM
EXC MAL LES MARG FCE ERS EYELD NSE LP;1.1-2.0 CM
EXC MAL LES MARG FCE ERS EYELD NSE LP;2.1-3.0 CM
AVUL NAIL PLATE PARTIAL/COMPLETE SIMPLE; SINGLE
EXC NAIL&NAIL MATRIX PART/CMPL PERM REMOVAL;
REPAIR OF NAIL BED
WEDGE EXCISION OF SKIN OF NAIL FOLD
EXCISION OF PILONIDAL CYST OR SINUS; SIMPLE
EXCISION OF PILONIDAL CYST OR SINUS; EXTENSIVE
EXCISION OF PILONIDAL CYST OR SINUS; COMPLICATED
INSERTION NON-BIODEGRADABLE DRUG DELIV IMPLANT
REMOVAL W/REINS NON-BIODEGRADABLE RX DELIV IMPL
SIMPL REPR SCLP AX GENIT TRNK&/EXTREM; <2.5 CM
SIMPL REPR SCLP AX GENIT TRNK&/EXTREM;2.6-7.5 CM
SIMPL REPR FACE EARS NOSEWMUCOUS MEMB; < 2.5 CM
SIMPL REPR FACE ERS NOSEWMUCOUS MEMB;2.6-5.0 CM
LAYER CLOS WNDS SCLP AX TRNK&/EXTREM; <2.5 CM
LAYER CLOS WNDS SCLP AX TRNK&/EXTREM; 2.6-7.5 CM
LAYER CLOS WNDS SCLP AX TRNK&/EXTREM;20.1-30. CM
LAYER CLOS WNDS NCK HNDS FTWGENIT; <2.5 CM
LAYER CLOS WNDS NCK HNDS FTWGENIT; 2.6-7.5 CM
LAYER CLOS WNDS FACE EARS NOSEWLIPS; <2.5 CM
LAYER CLOS WNDS FACE EARS NOSEWLIPS; 2.6-5.0 CM
REPAIR COMPLEX TRUNK; 2.6 TO 7.5 CM
REPAIR COMPLEX SCALP ARMS &/ LEGS; 2.6 TO 7.5 CM
7
Revised 1/1/2014
13131
13132
13133
13160
14000
14001
14020
14040
14041
14060
14061
15002
15003
15004
15005
15100
15200
15240
15241
15430
15431
15732
15760
15770
17000
17003
17110
19020
19100
19101
19102
19103
19110
19120
19290
19291
19295
19304
19316
19357
19370
19371
19380
20103
20200
20205
20206
20220
20225
20240
20245
20520
20525
REPR CMPLX FOREHEAD CHIN AX GENIT&/FT;1.1-2.5 CM
REPE CMPLX FOREHEAD CHIN AX GENIT&/FT;2.6-7.5 CM
REPR CMPLX FOREGEAD CHIN GENIT&/FT; EA ADD 5 CM
SEC CLOS SURGICAL VVOUND/DEHIS EXTENSIVE/COMP
ADJACENT TISS TRANS TRUNK; DEFECT 10 SQ CM/LESS
ADJACENT TISS TRANS TRUNK; DEFEC 10.1-30.0 SQ CM
ADJ TISS TRANS SCALP ARMSWLEGS; 10 SQ CM/LESS
ADJ TISS TRANS FOREHEAD NCK AX&/FT;10 SQ CM/LESS
ADJ TISS TRANS FOREHEAD NCK AX&/FT;10.1-30.0 CM
ADJ TISS TRANS EYELDS NOSEWLIPS; 10 SQ CM/LESS
ADJ TISS TRANS EYELDS NOSE&LIPS;10.1-30.0 SQ CM
VVND PREP, CH/INF, TRK/ARM/LG
VVND PREP, CH/INF ADDL 100 CM
VVND PREP CH/INF, F/N/HF/G
VVND PREP, F/N/HF/G, ADDL CM
SPLIT GFT TRUNK; 1ST 100 SQ CM/LESS/1% CHILD
FULL THICKNESS GRAFT FREE TRUNK; 20 SQ CM/LESS
FTG FOREHEAD CHIN NCK AX HANDWFT; 20 SQ CM/LESS
FTG FOREHEAD CHIN NCK AX HAND&/FT;EA ADD 20 SQCM
APPLY ACELLULAR XENOGRAFT
APPLY ACELLULAR XGRAFT ADD
MUSCLE MYOCUT/FASCIOCUT FLAP; HEAD&NECK
GRAFT; COMPOS INCLUDING PRIMARY CLOS DONOR AREA
GRAFT; DERMA-FAT-FASCIA
DESTRUC BEN/PREMALIG LES 0TH THAN SKN TAG; 1 LES
DESTRUC BEN/PREMALIG LES 0TH THN SKN TAG;2-14 EA
DESTRUC FLAT WARTS MOLLUSC CONTAG/MILIA; UP 14
MASTOTOMY VV/EXPLORATION OR DRAINAGE ABSCESS DEEP
BX BREAST; PERQ NDLE CORE W/O IMAG GUID-SEP PROC
BIOPSY OF BREAST; OPEN INCISIONAL
BX BREAST; PERCUT NEEDLE CORE USING IMAGING GUID
EX BREAST; PERC-VACUUM/ROTATING DEV VV/IMAG GUID
NIPPLE EXPL VV/VVO EXC SOLITARY/PAPIL LACT DUCT
EXC BREAST CYST TUMR/LES OPEN MALE/FEMALE 1/>
PREOPERATIVE PLACEMENT NEEDLE LOC WIRE BREAST
PREOP PLACMT NDLE LOC WIRE BREAST; ES ADD LESION
IMAG GUID PLCMT METAL CLIP PERQ DURING BREAST BX
MAST, SUBQ
MASTOPEXY
BREAST RECON IMMED/DELAY VV/EXPANDR VV/SUBSQT EXPA
OPEN PERIPROSTHETIC CAPSULOTOMY BREAST
PERIPROSTHETIC CAPSULECTOMY BREAST
REVISION OF RECONSTRUCTED BREAST
EXPLORATION PENETRATING WOUND-SEP PROC; EXTREM
BIOPSY MUSCLE; SUPERFICIAL
BIOPSY MUSCLE; DEEP
BIOPSY MUSCLE PERCUTANEOUS NEEDLE
BIOPSY BONE TROCAR OR NEEDLE; SUPERFICIAL
BIOPSY BONE TROCAR OR NEEDLE; DEEP
BIOPSY BONE EXCISIONAL; SUPERFICIAL
BIOPSY BONE EXCISIONAL; DEEP
REMOVAL FB MUSCLE/TENDON SHEATH; SIMPLE
REMOVAL FB MUSCLE/TENDON SHEATH; DEEP/COMP
8
Revised 1/1/2014
20526
20550
20551
20694
20900
20902
20924
21030
21046
21048
21235
21330
21356
21501
22520
23076
23130
23410
23412
23415
23430
23440
23462
23466
23500
23515
23550
23552
23700
24075
24076
24101
24105
24110
24116
24300
24343
24359
24498
24530
24535
24538
24575
24579
24640
24665
24685
25000
25111
INJECTION THERAPEUTIC CARPAL TUNNEL
INJECTION; TENDON SHEATH LIGAMENT
INJECTION; TENDON ORIGIN/INSERTION
REMOVAL UNDER AN ES-EXTERNAL FIXATION SYSTEM
BONE GRAFT ANY DONOR AREA; MINOR OR SMALL
BONE GRAFT ANY DONOR AREA; MAJOR OR LARGE
TENDON GRAFT FROM A DISTANCE
EXCISION BEN TUMR/CYST MAX/ZYGOMA ENUCLEAT&CURET
EXC BEN TUMR/CYST MANDIBLE; RQR INTRA-ORL OSTEOT
EXC BEN TUMR/CYST MAXILLA; RQR INTRA-ORL OSTEOT
GRAFT; EAR CARTILAGE AUTOGENOUS TO NOSE OR EAR
OPEN TX NASL FX; COMPLICATED W/INTWEXT SKEL FIX
OPEN TREATMENT DEPRESSED ZYGOMATIC ARCH FRACTURE
I&D DEEP ABSC/HEMATOMA SOFT TISSUES NECK/THORAX;
PERQ VERTPLSTY 1 VERT BODY UNI/BIL INJ; THORACIC
EXC SOFT TISSUE TUMR SHLDR AREA; DP SUBFASCL/IM
ACROMPLST/ACROMNECT PART W/WO LIGAMENT RELEASE
REP RUPTURED MUSCULOTENDINOUS CUFF OPEN; ACUTE
REP RUPTURED MUSCULOTENDINOUS CUFF OPEN; CHRONIC
CORACOACROMIAL LIGAMENT RELEASE W/WO ACROMPLSTY
TENODESIS OF LONG TENDON OF BICEPS
RESECTION OR TRANSPLANTATION LONG TENDON BICEPS
CPSLORR ANT ANY TYPE; W/CORACOID PROCESS TRNSF
CPSLORR GLENOHUM JNT ANY TYPE MX DIR INSTABILITY
CLOSED TX CLAVICULAR FX; W/O MANIPULATION
OPEN TX CLAVICULAR FX W/WO INTERNAL/EXTERNAL FIX
OPEN TX AC DISLOCATION ACUTE/CHRONIC;
OPEN TX AC DISLOC ACUT/CHRON; W/FASCIAL GRAFT
MANIP UNDER ANES-SHLDR JNT W/APPLIC FIX APPARAT
EXC TUMR SOFT TISSUE UPPER ARM/ELB AREA; SUBCUT
EXC TUMR SOFT TISSUE UPPER ARM/ELB AREA; DEEP
ARTHROT ELBOW; W/JNT EXPL W/WO BX W/WO REMV FB
EXCISION OLECRANON BURSA
EXCISION/CURETTAGE BONE CYST/BEN TUMOR HUMERUS;
EXC/CURET BONE CYST/BEN TUMR HUM; WITH ALLOGFT
MANIPULATION ELBOW UNDER ANESTHESIA
REPAIR LAT COLLAT LIGAMENT ELB W/LOCAL TISSUE
REPAIR ELBOW DEB/ATTCH OPEN
PROPHYLACTIC TX W/WO MMC HUM SHAFT
CLOSED TX SPRCOND/TRNSCOND HUM FX; W/O MANIP
CLOSED TX SPR/TRNSCOND HUM FX; W/MANIP W/WO TRAC
PERQ FIX SPRCOND/TRNSCOND HUM FX W/WO EXTENSION
OPEN TX HUMERAL EPICOND FX MED/LAT W/WO FIXATION
OPN TX HUM CONDYLR FX MED/LAT W/WO INTRL/EXT FIX
CLO TX RADIAL HEAD SUBLUXATION CHILD W/MANIP
OPEN TX RADIAL HEAD/NCK FX W/WO INTRL FIX/EXC
OPEN TX ULNAR FX PROX END W/WO INTRL/EXT FIX
INCISION EXTENSOR TENDON SHEATH WRIST
EXCISION OF GANGLION WRIST; PRIMARY
9
Revised 1/1/2014
25112
25115
25295
25310
25430
25440
25447
25515
25565
25600
25605
25606
25607
25608
25628
25645
25800
25825
26055
26075
26080
26115
26116
26123
26145
26230
26356
26358
26370
26390
26410
26418
26426
26433
26440
26445
26480
26516
26540
26541
26548
26555
26567
26600
26605
26607
26608
26615
26676
26685
26686
26715
26725
EXCISION OF GANGLION WRIST; RECURRENT
RADL EXC BURSA WRIST TENDON SHEATHS; FLEXORS
TENOLYSIS FLX/EXT TEND FORARM &OR WRST 1 EA TEND
TEND TPLNT/TRNSF FLEX/EXT FOREARM&/WRIST 1; EA
INSERTION VASCULAR PEDICLE IN CARPAL BONE
REP NONUNION SCAPHOID CARPAL BN W/WO STYLOIDECT
ARTHPLSTY INTERPOSITION INTERCARPAL/CMC JOINTS
OPEN TX RADIAL SHAFT FRACTURE VV/VVO INTRL/EXT FIX
CLOS TX RADIAL&ULNAR SHAFT FX; VV/MANIPULATION
CLOS TX DIST RADIAL FX VV/VVO FX STYLOID; WO MANIP
CLOS TX DIST RADIAL FX VV/VVO FX STYLOID; VV/MANIP
TREAT FX DISTAL RADIAL
TREAT FX RAD EXTRA-ARTICUL
TREAT FX RAD INTRA-ARTICUL
OPEN TX CARPAL SCAPHOID FX VV/VVO INTRL/EXT FIX
OPEN TREATMENT CARPAL BONE FRACTURE EACH BONE
ARTHRODESIS WRIST; COMPLETE WITHOUT BONE GRAFT
ARTHRODESIS WRIST; WITH AUTOGRAFT
TENDON SHEATH INCISION
ARTHROT W/EXPL DRAIN/REMOVL LOOSE/FB; MCP JNT EA
ARTHROT W/EXPL DRAIN/REMOVAL LOOSE/FB; IF JNT EA
EXC TUMR/VASC MALFORM SET TISSUE HND/FNGR; SUBQ
EXC TUMRNASC MALFORM SOFT TISSUE HND/FNGR; DEEP
FASCECT PART PALMAR VV/REL 1 DIGT VV/VVO Z-PLASTY;
SYNOVECT SHEATH RADL FLEX TENDON PALM/FINGR EA
PARTIAL EXCISION BONE; METACARPAL
REP/ADV FLX TEND ZONE 2 DIGTL; W/O FREE GET EA
REP/ADV FLX TEND ZONE 2 DIGTL; SEC W/FREE GET EA
REPR PROFUNDUS TENDON; PRIMARY EA TENDON
EXC FLX TEND W/IMPL ROD DELAY TEND GET HND/FNGR
REPR EXT TEND HND PRIM/SEC; W/O FREE GET EA TEND
REP EXT TEND FNGR PRIM/SEC; W/O FREE GET EA TEND
REP EXT TEND CNTRL SLIP SEC;LOC TISS LAT BAND EA
REPR EXT TENDON DIST INSERTION PRIM/SEC; W/O GET
TENOLYSIS FLEXOR TENDON; PALM/FINGER EACH TENDON
TENOLYSIS EXTENSOR TENDON HAND/FINGER; EA TENDON
TRNSF/TPLNT TEND CMC/DORSUM HAND; WO GET EA TEND
CAPSLDSIS MCP JOINT; SINGLE DIGIT
REPAIR COLLAT LIGAMENT MCP/IP JOINT
RECON COLLAT LIG MCP JNT 1; W/TENDON/FASCL GET
REPAIR&RECONSTRUCT FINGER VOLAR PLATE IF JOINT
TRANSFER FNGR ANOTH POSITION W/O MICVASC ANASTOM
OSTEOTOMY; PHALANX OF FINGER EACH
CLOS TX MC FX SINGLE; W/O MANIPULATION EA BN
CLOS TX MC FRACTURE SINGLE; W/MANIPULATION EA BN
CLOS TX MC FX W/MANIPULATION W/EXT FIX EA BN
PERCUT SKELETAL FIX METACARPAL FRACTURE EA BONE
OPEN TX MC FX SINGLE W/WO INTRL/EXT FIX EA BN
PERQ SKEL FIX CMC DISLOC NOT THUMB W/MANIP EA JT
OPEN TX CMC DISLOC NOT THUMB; W/WO FIX EA JNT
OPEN TX CMC DISLOC NOT THUMB;CMPLX MX/DELAY RDUC
OPEN TX MCP DISLOC SINGLE W/WO INTRL/EXT FIX
CLOS TX PHALANG FX PROX/MID; W/MANIP W/WO TRAC
10
Revised 1/1/2014
26727
26735
26746
26765
26910
26951
26952
26990
27250
27324
27327
27328
27331
27347
27360
27380
27405
27418
27422
27425
27427
27562
27570
27606
27618
27619
27635
27641
27650
27652
27654
27658
27675
27680
27685
27687
27691
27695
27698
27756
27766
27784
27786
27792
27824
27827
27829
27842
27870
PERQ FIX PHALANG SHAFT FX PROX/MID W/MANIP EA
OPN TX PHALANG FX PROX/MID W/WO INTRL/EXT FIX EA
OPEN TX ARTICULR FX INVLV MCP/IP JNT W/WO FIX EA
OPEN TX DIST PHALANGEAL FX W/WO INTRL/EXT FIX EA
AMP MC W/FNGR/THUMB 1 W/WO INTEROSSEOUS TRANSFER
AMP FNGR/THUMB ANY JNT INCL NEURECT; W/DIR CLOS
AMP FNGR/THUMB ANY JNT W/NEURECT; W/LOC ADV FLAP
I&D PELVIS/HIP JOINT AREA; DEEP ABSCESS/HEMATOMA
CLOS TX HIP DISLOC TRAUMATIC; WITHOUT ANESTHESIA
BIOPSY SOFT TISSUE OF THIGH OR KNEE AREA; DEEP
EXCISION TUMOR THIGH OR KNEE AREA; SUBCUTANEOUS
EXCISION TUMOR THIGH/KNEE AREA; DEEP SUBFASCL/IM
ARTHROTOMY KNEE; JOINT EXPL BX/REMV LOOSE/FB
EXCISION OF LESION OF MENISCUS OR CAPSULE KNEE
PARTIAL EXCISION BONE FEM PROXIMAL TIBIA &OR FIB
SUTURE OF INFRAPATELLAR TENDON; PRIMARY
REPR PRIM TORN LIGAMENT &OR CAPSULE KNEE; COLLAT
ANTERIOR TIBIAL TUBERCLEPLASTY
RECON DISLOC PATELLA; EXT REALIGN8IMUSC ADV/REL
LATERAL RETINACULAR RELEASE OPEN
LIGAMENTOUS RECONSTRUCTION KNEE; EXTRA-ARTICULAR
CLOS TX PATELLAR DISLOC; REQUIRING ANESTHESIA
MANIPULATION KNEE JOINT UNDER GENERAL ANESTHESIA
TENOT PERCUT ACHILLES TENDON SEP PROC; GEN ANES
EXCISION TUMOR LEG/ANK AREA; SUBCUTANEOUS TISSUE
EXCISION TUMOR LEG OR ANKLE AREA; DEEP
EXCISION/CURET BONE CYST/BEN TUMOR TIBIA/FIBULA;
PARTIAL EXCISION BONE; FIBULA
REPAIR PRIM OPEN/PERCUT RUP ACHILLES TENDON;
REPR PRIM OPEN/PERCUT RUP ACHILLES TENDON; W/GFT
REPAIR SECONDARY ACHILLES TENDON W/WO GRAFT
REPR FLEX TENDON LEG; PRIM W/O GRAFT EA TENDON
REPAIR DISLOC PERONEAL TEND; WITHOUT FIBR OSTEOT
TENOLYSIS FLX/EXT TEND LEG &OR ANK; 1 EA TEND
LEN/SHRT TENDON LEG/ANK; SINGLE TENDON SEP PROC
GASTROCNEMIUS RECESSION
TRANSFER OR TRANSPLANT OF SINGLE TENDON; DEEP
REPAIR PRIMARY DISRUPTED LIGAMENT ANK; COLLAT
REPAIR SEC DISRUPTED LIGAMENT ANKLE COLLATERAL
PERCUT SKELETAL FIXATION TIBIAL SHAFT FRACTURE
OPEN TX MED MALLEOLUS FX W/WO INTRL/EXT FIX
OPEN TX PROX FIB/SHAFT FX W/WO INTRL/EXT FIX
CLOS TX DIST FIB FRACTURE; WITHOUT MANIPULATION
OPEN TX DIST FIB FRACTURE W/WO INTRL/EXT FIX
CLOS TX FX WT BEARING ARTIC DIST TIB; W/O MANIP
OPEN TX FX WT BEARING DIST TIB W/FIX; TIBIA ONLY
OPEN TX DIST TIBIOFIBULAR JNT DISRUPT W/WO FIX
CLOS TX ANK DISLOC; RQR ANES-W/WO PERQ SKEL FIX
ARTHRODESIS, ANKLE, OPEN
11
Revised 1/1/2014
28035
28043
28045
28080
28086
28100
28108
28113
28119
28120
28122
28124
28193
28415
28470
28485
28490
28515
28525
28606
28615
28645
28725
28730
28750
28755
28825
29425
29505
29515
29580
29805
29806
29828
29834
29835
29837
29838
29848
29850
29862
29895
29897
29898
30100
30117
30130
30310
30465
30801
30802
30930
31030
RELEASE TARSAL TUNNEL
EXCISION TUMOR FOOT; SUBCUTANEOUS TISSUE
EXCISION TUMOR FOOT; DEEP SUBFASCL INTRAMUSCULAR
EXCISION INTERDIGITAL NEUROMA SINGLE EACH
SYNOVECTOMY TENDON SHEATH FOOT; FLEXOR
EXCISION/CURET BONE CYST/BEN TUMOR TALUS/CALCAN;
EXCISION/CURET BONE CYST/BEN TUMOR PHALANG FOOT
OSTECTOMY COMPLETE EXCISION; 1/5 METATARSAL HEAD
OSTEC CALCAN; SPUR W/WO PLANTAR FASCL RELEASE
PARTIAL EXCISION BONE ; TALUS OR CALCANEUS
PART EXCISION BN; TARSAL/MT BN NO TALUS/CALCAN
PARTIAL EXCISION BONE; PHALANX OF TOE
REMOVAL OF FOREIGN BODY FOOT; COMPLICATED
OPEN TX CALCAN FRACTURE W/WO INTRL/EXTERNAL FIX;
CLOS TX MT FRACTURE; WITHOUT MANIPULATION EA
OPEN TX MT FRACTURE W/WO INTRL/EXTERNAL FIX EA
CLOS TX FX GT TOE PHALNX/PHALANG; W/O MANIP
CLOS TX FX PHALANX 0TH THAN GREAT TOE; W/MANIP
OPEN TX FX PHALNX NOT GT TOE W/WO INTRL/EXT FIX
PERCUT SKEL FIX TARSOMT JNT DISLOC W/MANIP
OPEN TX TARSOMT JOINT DISLOC W/WO INTRL/EXT FIX
OPEN TX MTP JOINT DISLOC W/WO INTRL/EXTERNAL FIX
ARTHRODESIS; SUBTALAR
ARTHRDSIS MIDTARSAL/TARSOMT MULTIPLE/TRANSVERSE;
ARTHRODESIS GREAT TOE; METATARSOPHALANGEAL JOINT
ARTHRODESIS GREAT TOE; INTERPHALANGEAL JOINT
AMPUTATION TOE; INTERPHALANGEAL JOINT
APPLICATION SHORT LEG CAST; WALKING/AMB TYPE
APPLICATION OF LONG LEG SPLINT
APPLICATION OF SHORT LEG SPLINT
STRAPPING; UNNA BOOT
SCOPE SHOULDER DX W/WO SYNOVIAL BX SEP PROC
ARTHROSCOPY SHOULDER SURGICAL; CAPSULORRHAPHY
ARTHROSCOPY BICEPS TEN ODESIS
SCOPE ELB SURGICAL; W/REMOVAL LOOSE BODY/FB
ARTHROSCOPY ELBOW SURGICAL; SYNOVECTOMY PARTIAL
ARTHROSCOPY ELBOW SURGICAL; DEBRIDEMENT LIMITED
ARTHROSCOPY ELBOW SURG; DEBRIDEMENT EXTENSIVE
ENDO WRIST SURG W/RLSE TRNS CARPAL LIGAMENT
ARTHSCPY AIDED TX FX KNEE; W/O INTRL/EXT FIX
ARTHROSCOPY HIP SURG; DEBRID/SHAV ARTIC CART
ARTHROSCOPY ANKLE SURGICAL; SYNOVECTOMY PARTIAL
ARTHROSCOPY ANKLE SURGICAL; DEBRIDEMENT LIMITED
ARTHROSCOPY ANK SURGICAL; DEBRIDEMENT EXTENSIVE
BIOPSY INTRANASAL
EXCISION/DESTRUC INTRANASAL LESION; INTRL APPRCH
EXCISION TURBINATE PARTIAL/COMPLETE ANY METHOD
REMOVAL FB INTRANASL; RQR GENERAL ANESTHESIA
REPAIR OF NASAL VESTIBULAR STENOSIS
CAUTWABLAT MUCOS TURBINS UNI/BIL SEP PROC; SUP
CAUTWABLAT MUCOS TURB UNI/BIL SEP PROC;INTRMURL
FRACTURE NASAL TURBINATE THERAPEUTIC
SINUSOT MAX; RADL W/O REMOVL ANTROCHOANAL POLYPS
12
Revised 1/1/2014
31231
31238
31240
31254
31256
31267
31287
31515
31525
31526
31535
31536
31541
31571
31575
31622
31623
31624
31625
31628
31632
31641
32400
32405
32420
32421
32422
33010
35207
35761
36555
36556
36557
36558
36560
36561
36563
36565
36566
36568
36569
36570
36571
NASAL ENDOSCOPY DX UNILATERAL/BILATERAL SEP PROC
NASL/SINUS ENDO SURGICAL; W/CONTROL NASL HEMORR
NASL/SINUS ENDO SURG; W/CONCHA BULLOSA RESECTION
NASAL/SINUS ENDO SURGICAL; W/ETHMOECT PARTIAL
NASAL/SINUS ENDOSCOPY SURGICAL W/MAX ANTROST;
NASAL/SINUS ENDO W/MAXIL ANTROST; W/TISS REMV
NASAL/SINUS ENDOSCOPY SURGICAL W/SPHENOIDOTOMY;
LARYNGSCPY DIRECT W/WO TRACHEOSCOPY; ASPIRATION
LARYNGSCPY DIRECT W/WO TRACHEOSCOPY; DX NO NB
LARYNGOSCPY DIR W/WO TRCHEOSCPY; DX W/OPER MICRO
LARYNGOSCOPY DIRECT OPERATIVE WITH BIOPSY;
LARYNGSCPY DIRECT OPERATIVE W/BX; W/OP MIC
LARYNGOSCOPY DIR OP W/EXC TUMOR; W/OP MIC
LARYNGSCPY DIR W/INJ IN VOCAL CORD TX; W/OP MIC
LARYNGOSCOPY FLEXIBLE FIBEROPTIC; DIAGNOSTIC
BRONCHOSCOPY; DX W/WO CELL WASHING SEP PROC
BRONCHOSCOPY; W/BRUSHING/PROTECTED BRUSHINGS
BRONCHOSCOPY ; WITH BRONCHIAL ALVEOLAR LAVAGE
BRONCHOSCOPY ; WITH BIOPSY
BRONCHOSCOPY; W/TRANSBRONCH LUNG BX W/WO FLUOR°
BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR WITH
BRNCHSCPY; W/DESTRUC TUMR/RELIEF STENOS NOT EXC
BIOPSY PLEURA; PERCUTANEOUS NEEDLE
BIOPSY LUNG OR MEDIASTINUM PERCUTANEOUS NEEDLE
PNEUMOCENTESIS PUNCTURE OF LUNG FOR ASPIRATION
THORACENTESIS FOR ASPIRATION
THORACENTESIS W/TUBE INSERT
PERICARDIOCENTESIS; INITIAL
REPAIR BLOOD VESSEL DIRECT; HAND FINGER
EXPLORATION W/WO LYSIS OF ARTERY; OTHER VESSELS
INSERTION OF NON-TUNNELED CENTRALLY INSERTED
INSERTION OF NON-TUNNELED CENTRALLY INSERTED
INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS
CATHETER,WITHOUT
INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS
CATHETER,WITHOUT
INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS
ACCESS DEVICE
INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS
ACCESS DEVICE
INSERTION OF TUNNELED CENTRALLY INSERTED CENT
INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS
ACCESS DEVICE
INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS
ACCESS DEVICE
INSERTION OF PERIPHERALLY INSERTED CENTRAL VE
INSERTION OF PERIPHERALLY INSERTED CENTRAL VE
INSERTION OF PERIPHERALLY INSERTED CENTRAL VE
INSERTION OF PERIPHERALLY INSERTED CENTRAL VE
13
Revised 1/1/2014
36575
36576
36578
36580
36581
36582
36583
36584
36585
36589
36590
36597
36598
36819
36820
36821
36830
37186
37250
37607
37609
38220
38221
38500
38505
38510
38525
38700
38792
40490
40530
40650
40805
40812
40816
40819
41010
41105
41112
41113
41115
42408
42415
42505
42725
42806
42962
43200
REPAIR OF TUNNELED OR NON-TUNNELED CENTRAL VENOUS ACCESS
CATHETER
REPAIR OF CENTRAL VENOUS ACCESS DEVICE,WITH SUBCUTANEOUS
PORT OR PUMP
REPLACEMENT, CATHETER ONLY, OF CENTRAL VENOUS
REPLACEMENT, COMPLETE, OF A NON-TUNNELED CENT
REPLACEMENT, COMPLETE, OF A TUNNELED CENTRALLY INSERTED
CENTRAL VENOUS
REPLACEMENT, COMPLETE, OF A TUNNELED CENTRALLY INSERTED
CENTRAL VENOUS AC(
REPLACEMENT, COMPLETE, OF A TUNNELED CENTRALLY INSERTED
CENTRAL VENOUS AC(
REPLACEMENT, COMPLETE, OF A PERIPHERALLY INSE
REPLACEMENT, COMPLETE, OF A PERIPHERALLY INSE
REMOVAL OF TUNNELED CENTRAL VENOUS CATHETER,
REMOVAL OF TUNNELED CENTRAL VENOUS ACCESS DEV
REPOSITIONING OF PREVIOUSLY PLACED CENTRAL VE
INJ W/FLUOR, EVAL CV DEVICE
AV ANASTOM OPEN; UPPER ARM BASILIC VEIN TRNSPSTN
AV ANASTOM OPEN; FOREARM VEIN TRANSPOSITION
ARTERIOVENOUS ANASTOM OPEN; DIRECT ANY SITE-SP
CREAT AV FIST NOT DIR ANAST SEP PROC; NONAUTOGEN
SEC ART M-THROMBECT ADD-ON
INTRAVASC US DUR DX&/TX INTRVN; INIT VES
LIGATION/BANDING ANGIOACCESS AV FISTULA
LIGATION OR BIOPSY TEMPORAL ARTERY
BONE MARROW; ASPIRATION ONLY
BONE MARROW; BIOPSY NEEDLE OR TROCAR
BIOPSY OR EXCISION LYMPH NODE; OPEN SUPERFICIAL
BIOPSY/EXCISION LYMPH NODE; NEEDLE SUPERFICIAL
BX/EXCISION LYMPH NODE; OPEN DEEP CERVICAL NODE
BIOPSY/EXCISION LYMPH NODE; OPEN DEEP AX NODE
SUPRAHYOID LYMPHADENECTOMY
INJECTION PROC; IDENTIFICATION SENTINEL NODE
BIOPSY OF LIP
RESECTION LIP MORE THAN 1/4 W/O RECONSTRUCT
REPAIR LIP FULL THICKNESS; VERMILION ONLY
REMOVAL EMBEDDED FB VESTIBULE MOUTH; COMP
EXC LES-MUCOS/SUBMUCOSA-MOUTH; W/SMPL REPR
EXC LES-VESTIBULE-MOUTH; COMPLEX/EXC MUSCLE
EXCISION OF FRENUM LABIAL OR BUCCAL
INCISION OF LINGUAL FRENUM
BIOPSY OF TONGUE; POSTERIOR ONE-THIRD
EXCISION LESION TONGUE WITH CLOSURE; ANT 2/3
EXCISION LESION TONGUE WITH CLOS; POSTERIOR 1/3
EXCISION OF LINGUAL FRENUM
EXCISION OF SUBLINGUAL SALIVARY CYST
EXC PAROTID TUMOR; LAT LOBE W/DISSECTION NERVE
PLSTC REPR SALIV DUCT SIALODOCHOPLASTY; SEC/COMP
I&D ABSC; RETROPHARYNG/PARAPHARYNG EXT APPRCH
BX; NASOPHARYNX SURVEY UNKNOWN PRIMARY LESION
CONTRL OROPHARYNG HEMORR; W/SECNDRY SURG INTERV
ESOPHGSCPY RIGD/FLEX; DX W/WO CLCT BRSH/WSH-SP
14
Revised 1/1/2014
43201
43202
43204
43205
43215
43216
43217
43219
43220
43226
43227
43228
43231
43232
43234
43235
43236
43237
43238
43239
43240
43241
43242
43243
43244
43245
43246
43247
43248
43249
43250
43251
43255
43256
43257
43258
43259
43260
43261
43264
43265
43268
43450
43760
43870
44361
44388
45300
ESOPHGSCPY RIGD/FLXIBLE; DIR SUBMUCOS INJ SBSTNC
ESOPHGSCPY RIGID/FLEXIBLE; W/BX SINGLE/MULTIPLE
ESOPHAGOSCOPY RIGID/FLEX; W/INJ-SCLEROSIS VARICE
ESOPHAGOSCOPY RIGID/FLEX; W/BAND LIG VARICES
ESOPHGSCPY RIGID/FLEXIBLE; W/REMOVAL FB
ESOPHAGOSCOPY RIGID/FLEX; REMV TUMOR/POLYP/LES
ESOPHAGOSCOPY RIGID/FLEX; W/REMV LES-SNARE TECH
ESOPHAGOSCOPY RIGID/FLEX; W/INSRT TUBE/STENT
ESOPHAGOSCOPY RIGID/FLEXIBLE; W/BALLOON DILATION
ESOPHAGOSCOPY RIGID/FLEX; W/INSRT GUIDE WIRE
ESOPHAGOSCOPY RIGID/FLEXIBLE; W/CONTROL BLEEDING
ESOPHAGOSCOPY RIGID/FLEX; W/ABLAT TUMOR
ESOPHGSCPY RIGID/FLEXIBLE; W/ENDO US EXAMINATION
ESOPHSCOPY; W/TRANSENDO US GUID NEEDLE ASPIR/BX
UPPER GI ENDO SMPL PRIM EXAMINATION-SEP PROC
UGI EN DO; DX W/WO CLCT SPECMN-BRUSH/WASH-SP
UP GI ENDO ESOPH STOMACH; W/DIR SUBMUCOS INJ ANY
UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ES
UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ES
UGI EN DO; W/BX 1/MX
UGI EN DO; W/TRANSMURAL DRAIN PSEUDOCYST
UGI EG DUO JEJUN W/TRNSENDO INTRLUMNL CATH PLCMT
UGI ENDO; W/US GUID FINE NEEDLE ASPIR/BX
UGI EN DO; W/INJ SCLEROSIS-ESOPH/GASTRIC VARICES
UGI ENDO; W/BAND LIG ESOPH WOR GASTRIC VARICES
UP GI EN DO; W/DILAT GASTR OUTLET OBST
UGI EN DO; W/DIRECTED PLCMT PERQ GASTROSTOMY TUBE
UGI ENDO; W/REMOVAL FB
UGI EN DO; W/INSRT GUIDE WIRE-DILAT ESOPHAGUS
UGI ENDO; W/BALLOON DILAT ESOPHAGUS
UGI EN DO; W/REMV TUMOR/POLYP/LES-HOT BX FORCEPS
UGI ENDO; W/REMV TUMOR/POLYP/OTHER LES-SNARE
UGI EN DO; W/CONTRL BLEEDING ANY METHD
UGI ENDO W/TRNSENDO STENT PLCMNT INC PREDILA
UP GI ENDO;THRM ENRGY MUSC LW ESOPH
UGI EN DO; W/ABLAT LES NOT AMENABLE TO CAUT/SNARE
UGI ENDO; W/ENDO ULTRASOUND EXAM
ERCP; DX W/WO CLCT SPECIMEN BRUSH/WASH SEP PROC
ERCP; WITH BIOPSY SINGLE OR MULTIPLE
ERCP; W/ENDO RETRO REMV CALCU BILIWPANC DUCTS
ERCP; W/ENDO RETRO DESTRUC LITH CALCU/CALCU METH
ERCP; W/ENDO RETRO INSRT TUBE/STNT BILE/PANC DCT
DILAT ESOPH UNGUID SOUND/BOUGIE SINGLE/MX PASSES
CHANGE OF GASTROSTOMY TUBE
CLOSURE OF GASTROSTOMY SURGICAL
SM INTESTINAL ENDO NOT ILEUM; W/BX 1/MX
COLONOSCOPY THRU STOMA; DIAGNOSTIC-SEP PROC
PROCTSIGMODSCPY RIGD; DIAGNOSTIC-SEP PROC
15
Revised 1/1/2014
45303
45305
45307
45308
45309
45315
45317
45320
45321
45327
45330
45331
45332
45333
45334
45335
45337
45338
45339
45340
45341
45342
45345
45355
45378
45379
45380
45381
45382
45383
45384
45385
45386
45387
45391
45392
45990
46020
46040
46045
46050
46083
46200
46220
46221
46250
46255
46257
46260
46270
46275
46280
46505
PROCTOSIGMOIDOSCOPY RIGID; WITH DILATION
PROCTOSIGMOIDOSCOPY RIGID; W/BX SINGLE/MULTIPLE
PROCTOSIGMOIDOSCOPY RIGID; W/REMOVAL FB
PROCTOSIGMOIDOSCOPY RIGID; REMV LES-HOT FORCEPS
PROCTOSIGMOIDOSCOPY RIGID; REMV LES-SNARE
PROCTOSIGMOIDOS RIGID; W/REMV LES-FORCEPS/SNARE
PROCTOSIGMOIDOSCOPY RIGID; W/CONTROL OF BLEEDING
PROCTOSIGMOIDOSCOPY RIGID; W/ABLAT LES-NOT SNARE
PROCTOSIGMOIDOSCOPY RIGID; W/DECOMPRS VOLVULUS
PROCTSIGMOIDSCPY RIGID; W/TRANSENDO STENT PLCMT
SIGMOIDSCPY FLXIBLE; DIAGNOSTIC-SEP PROC
SIGMOIDOSCOPY FLEXIBLE; W/BX SINGLE OR MULTIPLE
SIGMOIDOSCOPY FLEXIBLE; W/REMOVAL FOREIGN BODY
SIGMOIDOSCOPY FLEX; W/REMV LES-FORCEPS/CAUT
SIGMOIDOSCOPY FLEXIBLE; WITH CONTROL OF BLEEDING
SIGMOIDSCPY FLXIBLE; W/DIR SUBMUCOS INJ SBSTNC
SIGMOIDSCPY FLXIBLE; W/DECOMPRS VOLVULUS METH
SIGMOIDOSCOPY FLEX; REMV LES-SNARE
SIGMOIDOSCOPY FLEX; ABLAT TUMOR/LES-NOT AMENABLE
SIGMOIDSCPY FLXIBLE; W/DILAT BALLN 1/MORE STRICT
SIGMOIDOSCOPY FLEXIBLE; W/ENDO US EXAMINATION
SIGMOIDSCPY FLEX; W/US GUID NEEDLE ASPIR/BX
SIGMOIDOSCOPY FLEXIBLE; W/TRANSENDO STENT PLCMT
COLONSCPY RIGD/FLXIBLE TRANSABD VIA COLOT 1/MX
COLONOSCOPY FLEX-PROX SPLEN FLEX; DX-SEP PROC
COLONOSCOPY FLEX-PROX SPLEN FLEX; W/REMV FB
COLONSCPY FLXIBLE PROX SPLENIC FLXURE; W/BX 1/MX
COLNSCPY FLX PROX SPLENIC FLXR; DIR SUBMUCOS INJ
COLNSCPY FLEX PROX SPLENIC FLXURE; W/CNTRL BLEED
COLONOSCOPY FLEX; W/ABLAT LES NOT AMENABLE-SNARE
COLONOSCOPY FLEX; REMV TUMOR/LES HOT BX FORCEPS
COLONOSCOPY FLEX; W/REMV TUMOR/LES BY SNARE
COLNSCPY FLX PROX SPLENIC FLXUR; DILAT BALLN 1/>
COLONOSCOPY FLEX-PROX SPLEN FLEX; W/STENT PLCMT
COLONSCOPY FLEX; W/ENDO US EXAM
COLNSCPY FLX;INTRA/TRNSMURL FNA/BXS
SURG DX EXAM, ANORECTAL
PLACEMENT OF SETON
I&D OF ISCHIORECTAL&PERIRECTAL ABSCESS-SEP PROC
I&D INTRAMURAL/IM ABSCESS TRANSANAL UNDER ANES
I&D PERIANAL ABSCESS SUPERFICIAL
INCISION OF THROMBOSED HEMORRHOID EXTERNAL
FISSURECTOMY WITH OR WITHOUT SPHINCTEROTOMY
PAPILLECTOMY/EXCISION-SINGLE TAG ANUS-SEP PROC
HEMORRHOIDECTOMY BY SIMPLE LIGATURE
HEMORRHOIDECTOMY EXTERNAL COMPLETE
HEMORRHOIDECTOMY INTERNAL AND EXTERNAL SIMPLE;
HEMORRHOIDECT INTRL&EXTERNAL SIMPLE; W/FISSURECT
HEMORRHOIDECTOMY INTERNAL&EXTERNAL COMPLEX/EXT;
SURGICAL TREATMENT OF ANAL FISTULA; SUBCUTANEOUS
SURGICAL TREATMENT OF ANAL FISTULA; SUBMUSCULAR
SURG TX ANAL FIST; COMPLEX/MX W/WO PLCMT SETON
CHEMODENERVATION ANAL MUSC
16
Revised 1/1/2014
46910
46924
46947
47000
47001
49080
49081
49320
49321
49322
49402
49421
49422
49426
49500
49520
49525
49550
49560
49565
49570
49580
49585
49590
49650
49651
50200
50392
50398
50590
51102
51700
51725
51741
51784
51797
51798
52000
52005
52007
52204
52224
52234
52235
52240
52260
52281
52282
52285
DESTRUC LESION ANUS SIMPLE; ELECTRODESICCATION
DESTRUCTION OF LESION ANUS EXTENSIVE
HEMORRHOIDOPEXY BY STAPLING
BIOPSY OF LIVER NEEDLE; PERCUTANEOUS
BX LIVER NEEDLE; DONE G TIME W/OTH MAJ PROC
PERITONEOCENTESIS-ABD PARACENTESIS; INIT
PERITONEOCENTESIS-ABD PARACENTESIS; SUBSQT
LAP ABD PERIT&OMENTM DX W/WO COLLECT BRSH/WSH-SP
LAPAROSCOPY SURGICAL; WITH BIOPSY
LAPAROSCOPY SURGICAL; VV/ASPIRATION CAVITY/CYST
REMOVE FOREIGN BODY, ADBOMEN
INSRT INTRAPER CANNULA/CATH DRAIN/DIALYSIS; PERM
REMOVAL PERMANENT INTRAPER CANNULA/CATHETER
REVISION OF PERITONEAL-VENOUS SHUNT
REPR INIT ING HERNIA 6 MO-< 5 YR; REDUCIBLE
REPAIR RECURRENT ING HERNIA ANY AGE; REDUCIBLE
REPAIR INGUINAL HERNIA SLIDING ANY AGE
REPAIR INITIAL FEMORAL HERNIA ANY AGE; REDUCIBLE
REPAIR INITIAL INCL/VENTRAL HERNIA; REDUCIBLE
REPAIR RECURRENT INCL/VENTRAL HERNIA; REDUCIBLE
REPAIR EPIGASTRIC HERNIA; REDUCIBLE-SEP PROC
REPAIR UMB HERNIA UNDER AGE 5 YEARS; REDUCIBLE
REPAIR UMB HERNIA AGE 5 YEARS/OVER; REDUCIBLE
REPAIR SPIGELIAN HERNIA
LAPAROSCOPY SURGICAL; REPAIR INITIAL ING HERNIA
LAPARSCPY SURGICAL; REPAIR RECURRENT ING HERNIA
RENAL BIOPSY; PERCUTANEOUS BY TROCAR OR NEEDLE
INTRO INTRACATH/CATH-RENAL PELVIS-DRAIN PERQ
CHANGE OF NEPHROSTOMY OR PYELOSTOMY TUBE
LITHOTRIPSY EXTRACORPOREAL SHOCK WAVE
DRAIN BL W/CATH INSERTION
BLADD IRRIGATION SIMPLE LAVAGEWINSTILLATION
SIMPLE CYSTOMETROGRAM
COMPLEX UROFLOWMETRY
EMG STDY ANAL/URETH SPHNCTR 0TH THAN NDLE TECH
VOIDING PRESS STUDIES; INTRA-ABD VOIDING PRESS
MEASUREMENT PVR URIN&/BLADD CAPACTY US NON-IMAG
CYSTOURETHROSCOPY-SEP PROC
CYSTOURETHROSCOPY W/URETERAL OATH EXCLUS-RAD
CYSTOURETHROSCOPY EXCLUS-RAD SERV; W/BRUSH BX
CYSTOURETHROSCOPY WITH BIOPSY
CYSTURETHRSCPY W/FULG/TX MINOR LESION W/WO BX
CYSTURETHRSCOPY W/FULG & RES; SM BLADDER TUMOR
CYSTURETHRSCOPY W/FULG &/ RES; MED BLADDER TUMOR
CYSTURETHRSCOPY W/FULG &/ RES; LG BLADDER TUMOR
CYSTOURETHROSCOPY W/DILAT BLADDER; GEN ANES
CYSTOURETHROSCOPY W/CALIBRAT WOR DILAT URETHRAL
CYSTOURETHROSCOPY W/INSERTION OF URETHRAL STENT
CYSTOURETHROSCOPY TX FE URETHRAL SYNDROME
17
Revised 1/1/2014
52310
52317
52318
52320
52327
52330
52332
52334
52344
52345
52351
52352
52500
52648
53020
53060
53450
54001
54057
54060
54100
54162
54235
54300
54322
54326
54500
54505
54512
54520
54530
54550
54640
54692
54700
54830
54840
55040
55041
55060
55175
55500
55520
55700
55705
56405
56420
56501
56515
56605
56606
56820
56821
CYSTOURETHROSCOPY W/REMV FB-SEP PROC; SIMPLE
LITH: CRUSH CALCU-BLADDER; SMPL/SM <2.5 CM
LITH: CRUSH CALCU-BLADDER; COMP/LG >2.5 CM
CYSTOURETHROSCOPY; W/REMOVAL URETERAL CALCULUS
CYSTURETHRSCPY; W/SUBURETERIC INJ IMPL MATERIAL
CYSTURETHRSCPY; W/MANIP W/O REMOVAL URETRL CALCU
CYSTURETHRSCPY W/INSERTION INDWELL URETRL STENT
CYSTOURETHROSCOPY W/INSRT GUIDE WIRE THRU KIDNEY
CYSTURETHRSCPY W/URETERSCPY; W/TX URETRL STRICT
CYSTURETHSCPY W/URETEROSCOPY; W/TX UPJ STRICT
CYSTURETHRSCOPY W/URETEROSCOPY&/PYELOSCOPY; DX
CYSTOURETHSCOPY W/URETERO&PYELOSCPY; REMOV CALC
TRANSURETHRAL RESECTION OF BLADDER NECK
CNTCT LASR VAPRIZ PROS W/WO TURF CNTRL BLD COMPL
MEATOTOMY CUTTING OF MEATUS; EXCEPT INFANT
DRAINAGE OF SKENES GLAND ABSCESS OR CYST
URETHROMEATOPLASTY WITH MUCOSAL ADVANCEMENT
SLITTING PREPUCE DORSAL/LATERAL; EXCEPT NEWBORN
DESTRUCTION LESION PENIS SIMPLE; LASER SURGERY
DESTRUC LESION PENIS SIMPLE; SURGICAL EXCISION
BIOPSY OF PENIS;
LYSIS/EXCISION PENILE POST-CIRCUMCISION ADHES
INJECTION CORPORA CAVERNOSA W/PHARMACOLOGIC AGT
PLSTC OP PENIS-STRAIT CHORDEE W/WO MOBILIZ URETH
1 STAGE DISTAL HYPOSPAD REPR; W/SIMPL MEATAL ADV
1 STAGE DISTAL HYPOSPAD REPR;URETHROPLST MOBILIZ
BIOPSY OF TESTIS NEEDLE
BIOPSY OF TESTIS INCISIONAL
EXCISION OF EXTRAPARENCHYMAL LESION OF TESTIS
ORCHIECTOMY SIMPL W/WO TESTICULAR PROSTH
ORCHIECTOMY RADICAL FOR TUMOR; INGUINAL APPROACH
EXPLORATION FOR UNDESCENDED TESTIS
ORCHIOPEXY INGUINAL APPROACH W/WO HERNIA REPAIR
LAPAROSCOPY SURGICAL;ORCHIOPEXY INTRA-ABD TESTIS
I&D OF EPIDIDYMIS TESTIS AND/OR SCROTAL SPACE
EXCISION OF LOCAL LESION OF EPIDIDYMIS
EXCISION OF SPERMATOCELE W/WO EPIDIDYMECTOMY
EXCISION OF HYDROCELE; UNILATERAL
EXCISION OF HYDROCELE; BILATERAL
REPAIR OF TUNICA VAGINALIS HYDROCELE
SCROTOPLASTY; SIMPLE
EXC HYDROCELE SPERMATIC CORD UNI-SEP PROC
EXCISION OF LESION OF SPERMATIC CORD-SEP PROC
BX PROSTATE; NEEDLE/PUNCH SINGLE/MX ANY APPRCH
BIOPSY PROSTATE;INCISIONAL ANY APPROACH
I&D OF VULVA OR PERINEAL ABSCESS
I&D OF BARTHOLINS GLAND ABSCESS
DESTRUCTION OF LESION VULVA; SIMPLE
DESTRUCTION OF LESION VULVA; EXTENSIVE
BIOPSY OF VULVA OR PERINEUM; ONE LESION
BIOPSY VULVA/PERINEUM; EA SEPARATE ADD LESION
COLPOSCOPY OF THE VULVA;
COLPOSCOPY OF THE VULVA; WITH BIOPSY
18
Revised 1/1/2014
57200
57260
57267
57300
57410
57420
57421
57452
57454
57455
57456
57460
57461
57500
57505
57510
57511
57513
57520
57522
57700
57800
58100
58120
58301
58353
58545
58555
58558
58561
58562
58563
58600
58671
58805
58900
59025
59150
59160
59200
59412
60100
61070
62269
62270
62272
62287
64795
65855
66761
66770
66821
66982
COLPORRHAPHY SUTURE OF INJURY OF VAGINA
COMBINED ANTEROPOSTERIOR COLPORRHAPHY;
INSRT MESH REPR PLV FLR EA SITE VAG
CLOS RECTOVAGINAL FISTULA; VAG/TRNSANAL APPRCH
PELVIC EXAMINATION UNDER ANESTHESIA
COLPOSCOPY ENTIRE VAGINA W/CERVIX IF PRESENT;
COLPOSCOPY ENTIRE VAG W/CERV IF PRESENT; W/BX
COLPOSCOPY CERVIX INCLUDING UPPER/ADJ VAGINA;
COLPSCPY CERV UP/ADJ VAG; BX CERV&ENDOCERV CURET
COLPOSCOPY CERV INCL UP/ADJ VAGINA; W/BX CERVIX
COLPSCPY CERV INCL UP/ADJ VAG; W/ENDOCERV CURET
COLPSCPY CERV W/UP/ADJ VAG; W/LOOP ELEC BX CERV
COLPSCPY CERV W/UP VAG; W/LOOP ELEC CONIZAT CERV
BX SINGLE/MX/LOCAL EXCISION LESION W/WO FULG
ENDOCERVICAL CURETTAGE
CAUTERY OF CERVIX; ELECTRO OR THERMAL
CAUTERY OF CERVIX; CRYOCAUTERY INITIAL OR REPEAT
CAUTERY OF CERVIX; LASER ABLATION
CONIZATION CERV W/WO D&C W/WO REPR; KNIFE/LASER
CONIZATN CERV W/WO D&C W/WO REPR; LOOP ELEC EXC
CERCLAGE OF UTERINE CERVIX NONOBSTETRICAL
DILATION OF CERVICAL CANAL INSTRUMENTAL
ENDOMETRIAL BX W/WO ENDOCERV BX-SEP PROC
DILATION & CURETTAGE DIAGNOSTIC &/ THERAPEUTIC
REMOVAL OF INTRAUTERINE DEVICE
ENDOMETRIAL ABLAT THERMAL W/O HYSTEROSCOPIC GUID
LAP MYOMECT; 1-4 MYOM TOT 250 GMS/<&/SURFCE MYOM
HYSTEROSCOPY DIAGNOSTIC
HYSTEROSCPY SURG;W/BX ENDOMETWPOLYPECT W/WO D&C
HYSTEROSCOPY SURGICAL; W/REMOVAL OF LEIOMYOMATA
HYSTEROSCOPY SURGICAL; W/REMOVAL IMPACTED FB
HYSTEROSCOPY SURGICAL; WITH ENDOMETRIAL ABLATION
LIG/TRANSECTION FALLOPIAN TUBE ABD/VAG UNI/BILAT
LAPAROSCOPY SURG; W/OCCLUSION OVIDUCTS-DEVICE
DRAIN OVARIAN CYST UNI/BIL-SEP PROC; ABD APPRCH
BIOPSY OF OVARY UNILATERAL OR BILATERAL-SEP PROC
FETAL NON-STRESS TEST
LAP TX ECTOPIC PG; W/O SALPINGECT &OR OOPHORECT
CURETTAGE POSTPARTUM
INSERTION OF CERVICAL DILATOR
EXTERNAL CEPHALIC VERSION W/WO TOCOLYSIS
BIOPSY THYROID PERCUTANEOUS CORE NEEDLE
PUNCT SHNT TUBING/RESRVOR ASPIR/INJECTION PROC
BIOPSY OF SPINAL CORD PERCUTANEOUS NEEDLE
SPINAL PUNCTURE LUMBAR DIAGNOSTIC
SPINAL PUNCTURE THERAPEUTIC DRAIN CEREBROSP FL
ASPIR/DECOMPRESS-PERQ-NUCLEUS PULPOS 1/MX-LUMB
BIOPSY OF NERVE
TRABECULOPLASTY LASER SURGERY 1 OR MORE SESSIONS
IRIDOTOMY/IRIDECTOMY BY LASER SURGERY
DESTRUCTION CYST OR LESION IRIS OR CILIARY BODY
DISCISSION SEC MEMB CATARACT; LASER SURGERY
EXTRACAP CATARACT REMV W/I0L-COMPLX-DIFF TECH
19
Revised 1/1/2014
66984
67010
67040
67113
67120
67311
67515
67800
67810
67961
68020
68110
68720
68761
68811
68815
69145
69205
69210
69310
69424
69436
69440
69540
69666
76942
77002
77003
77012
77021
77031
77032
EXTRACAPSULAR CATARACT REMV W/INSRT IOL PROSTH
REMV VITREOUS ANT; SUBTL REMV W/MECH VITRECT
VITRECTOMY MECH; W/ENDOLASER PANRETINAL PHOTOCOA
REPAIR RETINAL DETACH, CPLX
REMOVAL IMPL MATERIAL POST SEGMENT; XTRAOCULR
STRABISMUS SURGERY R/R PROC; 1 HORIZONTAL MUSCLE
INJECTION MEDICATION/OTH SUBSTANCE IN TENONS CAP
EXCISION OF CHALAZION; SINGLE
BIOPSY OF EYELID
EXC & REPR EYELID; UP TO 1/4 LID MARGIN
INCISION OF CONJUNCTIVA DRAINAGE OF CYST
EXCISION OF LESION CONJUNCTIVA; UP TO 1 CM
DACRYOCYSTORHINOSTOMY
CLOSURE OF THE LACRIMAL PUNCTUM; BY PLUG EACH
PROBING NLD W/WO IRRIGATION; RQR GEN ANESTHESIA
PROBING NLD W/WO IRRIG; W/INSRTION TUBE/STENT
EXC SOFT TISSUE LESION EXTERNAL AUDITRY CANAL
REMOVL FB EXT AUDITRY CANAL; W/GEN ANESTHESIA
REMOVAL IMPACTED CERUMEN ONE OR BOTH EARS
RECON OF EXTERNAL AUDITORY CANAL SEP PROC
VENTILATING TUBE REMOVAL RQR GENERAL ANESTHESIA
TYMPANOSTOMY GENERAL ANESTHESIA
MID EAR EXPL THRU POSTAURICULAR/EAR CANAL INCI
EXCISION AURAL POLYP
REPAIR OVAL WINDOW FISTULA
US GUID NDLE PLCMT IMAGING SUPERVIS&INTEPR
NEEDLE LOCALIZATION BY XRAY
FLUOROGUIDE FOR SPINE INJECT
CT SCAN FOR NEEDLE BIOPSY
MR GUIDANCE FOR NEEDLE PLACE
STEREOTACT GUIDE FOR BRST BX
GUIDANCE FOR NEEDLE, BREAST
20
Revised 1/1/2014