An Independent Licensee of the Blue Cross Blue Shield Association.

Assistant Surgery Not Medically Necessary (NMN) Last Updated 1/1/2016

Assistant surgery will be denied as not medically necessary for codes on the following list, unless indicated otherwise. Assistant surgery will be allowed for those codes marked with an asterisk (*) when performed in a physician's office.

Note: The presence of a code on this list does not guarantee its medical necessity and/or coverage.

Acknowledgement: Current Procedural Terminology (CPT®) is copyright 2015 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association

Assistant Surgery - Not Medically Necessary (NMN) Codes G0259

0262T

11011

11406

11641

11982

12055

G0260

0281T

11012

11420

11642

11983

12056

G0268

0282T

11042

11421

11643

12001

12057

G0269

0286T

11043

11422

11644

12002

13100

G0289

0288T

11044

11423

11646

12004

13101

G0364

0291T

11045

11424

11719

12005

13102

G0440

0292T

11046

11426

11720

12006

13120

G0455

0293T

11047

11440

11721

12007

13121

S0400

0294T

11055

11441

11730

12011

13122

S0812

0299T

11056

11442

11732

12013

13131

S2080

0300T

11057

11443

11740

12014

13132

S2083

0301T

11100

11444

11750

12015

13133

S2112

10021

11101

11446

11752

12016

13151

S2150

10022

11200

11450

11755

12017

13152

S2260

10030

11201

11451

11760

12018

13153

S2341

10035

11300

11462

11762

12020

13160

S2342

10036

11301

11463

11765

12021

14000

S2348

10040

11302

11470

11771

12031

14001

S2351

10080

11303

11471

11772

12032

14020

S4011

10081

11305

11600

11900

12034

14021

S4015

10120

11306

11601

11901

12035

14040

S4016

10121

11307

11602

11920

12037

14041

S4018

10140

11308

11603

11950

12041

14060

S4020

10160

11310

11604

11951

12042

14061

S4021

10180

11311

11606

11952

12044

15002

S4028

11000

11312

11620

11954

12045

15003

S4981

11001

11313

11621

11960

12046

15004

S8030

11004

11400

11622

11970

12047

15005

0019T

11005

11401

11623

11971

12051

15040

0075T

11006

11402

11624

11976

12052

15050

0076T

11008

11403

11626

11980

12053

15100

0222T

11010

11404

11640

11981

12054

15101

Key:

* Allowed when performed in a physician's office.

Current Procedural Terminology

© 2015 American Medical Association. All Rights Reserved

BCBSKS - CODE LIST - Assistant Surgery - NMN Last Updated: 1/1/2016 Contains Public Information

Page 2 of 15

Assistant Surgery - Not Medically Necessary (NMN) Codes 15110

15781

15878

17281

19283

20527

20979

15111

15782

15879

17282

19284

20550

20982

15115

15783

15920

17283

19285

20551

20985

15116

15786

15931

17284

19286

20552

21010

15130

15787

15934

17286

19287

20553

21011

15131

15788

15936

17311

19288

20555

21012

15135

15789

15950

17312

19296

20500

21013

15136

15792

16000

17313

19297

20600

21016

15150

15793

16020

17314

19298

20604

21025

15151

15819

16025

17315

19300

20605

21026

15152

15820

16030

17340

19301

20606

21030

15155

15821

17000

17360

19302

20610

21031

15156

15822

17003

17380

19324

20611

21032

15157

15823

17004

19000

19350

20612

21040

15200

15824

17106

19001

19355

20615

21070

15201

15825

17107

19020

19370

20650

21079

15220

15826

17108

19030

19396

20660

21080

15221

15828

17110

19081

20005

20661

21081

15240

15829

17250

19082

20150

20662

21082

15241

15833

17260

19083

20200

20663

21083

15260

15834

17261

19084

20205

20665

21084

15261

15835

17262

19085

20206

20670

21085

15600

15836

17263

19086

20220

20690

21086

15610

15837

17264

19100

20225

20694

21087

15620

15838

17266

19101

20240

20808

21100

15630

15839

17270

19110

20245

20900

21110

15650

15850

17271

19112

20250

20910

21116

15740

15851

17272

19120

20500

20912

21120

15760

15852

17273

19125

20501

20926

21121

15770

15860

17274

19126

20520

20950

21122

15775

15876

17276

19281

20525

20974

21123

15780

15877

17280

19282

20526

20975

21125

Key:

* Allowed when performed in a physician's office.

Current Procedural Terminology

© 2015 American Medical Association. All Rights Reserved

BCBSKS - CODE LIST - Assistant Surgery - NMN Last Updated: 1/1/2016 Contains Public Information

Page 3 of 15

Assistant Surgery - Not Medically Necessary (NMN) Codes 21127

21451

22532

23530

24305

24666

25126

21137

21452

22533

23540

24310

24670

25130

21138

21453

22534

23545

24330

24675

25145

21199

21480

22900

23570

24332

24685

25246

21230

21485

22902

23575

24341

24802

25248

21245

21495

22903

23600

24359

24925

25251

21246

21501

22904

23605

24362

24930

25259

21248

21510

23030

23620

24495

24931

25260

21249

21550

23031

23625

24500

24935

25270

21260

21552

23035

23650

24505

24940

25275

21310

21555

23065

23655

24516

25000

25290

21315

21556

23066

23660

24530

25001

25301

21320

21800

23071

23665

24535

25020

25316

21325

21810

23075

23675

24538

25023

25335

21330

21820

23076

23700

24545

25024

25355

21335

21920

23146

23921

24546

25025

25370

21336

21925

23156

23930

24560

25028

25392

21337

21930

23170

23931

24565

25031

25393

21339

21931

23172

23935

24566

25035

25394

21345

21932

23330

24006

24575

25065

25430

21355

22010

23333

24065

24576

25066

25443

21356

22015

23334

24066

24577

25071

25444

21386

22305

23335

24071

24579

25073

25450

21387

22310

23350

24075

24582

25075

25455

21400

22315

23400

24076

24600

25076

25490

21401

22505

23405

24105

24605

25077

25491

21421

22510

23406

24120

24620

25100

25492

21423

22511

23500

24126

24635

25109

25500

21433

22512

23505

24149

24640

25110

25505

21440

22513

23515

24200

24650

25111

25520

21445

22514

23520

24220

24655

25112

25525

21450

22515

23525

24300

24665

25125

25526

Key:

* Allowed when performed in a physician's office.

Current Procedural Terminology

© 2015 American Medical Association. All Rights Reserved

BCBSKS - CODE LIST - Assistant Surgery - NMN Last Updated: 1/1/2016 Contains Public Information

Page 4 of 15

Assistant Surgery - Not Medically Necessary (NMN) Codes 25530

26011

26210

26517

26742

27047

27324

25535

26020

26230

26546

26746

27048

27325

25560

26025

26235

26550

26750

27062

27327

25565

26030

26236

26555

26755

27086

27328

25600

26034

26250

26560

26756

27093

27331

25605

26037

26260

26562

26765

27095

27332

25606

26040

26340

26587

26770

27096

27337

25622

26045

26341

26590

26775

27158

27347

25624

26055

26350

26591

26776

27175

27370

25628

26060

26356

26593

26785

27193

27390

25630

26070

26357

26600

26820

27194

27391

25635

26075

26370

26605

26841

27200

27392

25645

26080

26410

26607

26842

27202

27397

25650

26100

26416

26608

26843

27215

27412

25651

26105

26418

26615

26844

27216

27415

25652

26110

26420

26641

26850

27220

27416

25660

26111

26428

26645

26852

27222

27425

25670

26113

26433

26650

26860

27230

27495

25671

26115

26434

26665

26861

27238

27496

25675

26116

26440

26670

26862

27246

27497

25680

26117

26442

26675

26863

27250

27498

25690

26118

26449

26676

26910

27252

27499

25905

26121

26450

26685

26951

27256

27500

25907

26123

26455

26700

26952

27257

27501

25920

26125

26460

26705

26990

27259

27502

25922

26145

26474

26706

26991

27265

27503

25924

26160

26476

26715

27000

27266

27508

25927

26170

26478

26720

27001

27275

27509

25929

26180

26479

26725

27006

27301

27510

25931

26185

26489

26727

27040

27306

27516

25999

26200

26497

26735

27041

27310

27517

26010

26205

26500

26740

27043

27323

27519

Key:

* Allowed when performed in a physician's office.

Current Procedural Terminology

© 2015 American Medical Association. All Rights Reserved

BCBSKS - CODE LIST - Assistant Surgery - NMN Last Updated: 1/1/2016 Contains Public Information

Page 5 of 15

Assistant Surgery - Not Medically Necessary (NMN) Codes 27520

27732

27893

*28222

28435

28635

29200

27530

27734

27894

*28230

28436

28636

29240

27532

27750

28001

*28232

28445

28645

29260

27535

27752

28002

28234

28450

28660

29280

27536

27756

28003

28240

28455

28665

29305

27538

27758

28005

28261

28456

28666

29325

27550

27759

28008

28264

28465

28675

29345

27552

27760

28010

28270

28470

28810

29355

27556

27762

28011

28272

28475

28820

29358

27557

27780

28022

28285

28476

28825

29365

27558

27781

28024

28288

28485

28890

29405

27560

27784

28039

28289

28490

29000

29425

27562

27786

28041

28290

28495

29010

29435

27570

27788

28043

28292

28496

29015

29440

27592

27792

28045

28293

28505

29020

29450

27594

27808

28080

28296

28510

29025

29505

27603

27810

28088

28298

28515

29035

29515

27604

27816

28090

28300

28525

29040

29520

27605

27818

28092

28306

28530

29044

29530

27606

27824

28102

28307

28531

29046

29540

27613

27825

28107

28308

28540

29049

29550

27614

27826

28110

28310

28545

29055

29580

27618

27827

28112

28313

28546

29058

29581

27619

27829

28113

28315

28570

29065

29582

27626

27830

28119

28340

28575

29075

29583

27630

27840

28126

28341

28576

29085

29584

27632

27842

28150

28345

28585

29086

29700

27648

27846

28153

28360

28600

29105

29705

27650

27848

28160

28400

28605

29125

29710

27664

27860

28190

28405

28606

29126

29715

27685

27884

*28192

28406

28615

29130

29720

27726

27892

*28193

28430

28630

29131

29730

Key:

* Allowed when performed in a physician's office.

Current Procedural Terminology

© 2015 American Medical Association. All Rights Reserved

BCBSKS - CODE LIST - Assistant Surgery - NMN Last Updated: 1/1/2016 Contains Public Information

Page 6 of 15

Assistant Surgery - Not Medically Necessary (NMN) Codes 29740

29886

31051

31520

31614

31627

32553

29750

29887

31070

31525

31615

31628

32554

29805

29900

31090

31526

31622

31629

32555

29824

29901

31200

31527

31623

31630

32556

29826

29902

31201

31528

31624

31631

32557

29840

30000

31233

31529

31625

31632

32560

29843

30020

31235

31530

31626

31633

32561

29844

30100

30462

31237

31531

31635

32607

29845

30110

30465

31238

31535

31636

32608

29846

30115

30520

31239

31536

31637

32609

29850

30117

30540

31240

31540

31638

32666

29851

30118

30545

31254

31541

31640

32667

29860

30120

30560

31255

31545

31641

32668

29861

30124

30580

31256

31546

31643

32701

29862

30125

30600

31267

31560

31645

32810

29863

30130

30620

31276

31561

31646

32855

29866

30140

30630

31287

31570

31652

32856

29867

30150

30801

31288

31571

31653

32960

29868

30160

30802

31290

31575

31654

32997

29870

30200

30901

31291

31576

31717

33010

29871

30210

30903

31292

31577

31720

33011

29873

30220

30905

31293

31578

31725

33015

29874

30300

30906

31320

31579

31730

33206

29875

30310

30915

31400

31595

31766

33207

29876

30320

30920

31500

31600

31781

33208

29877

30400

30930

31502

31601

31820

33210

29879

30410

31000

31505

31603

31825

33211

29881

30420

31002

31510

31605

31830

33212

29882

30430

31020

31511

31610

32400

33213

29883

30435

31030

31512

31611

32405

33214

29884

30450

31032

31513

31612

32550

33215

29885

30460

31050

31515

31613

32551

33216

Key:

* Allowed when performed in a physician's office.

Current Procedural Terminology

© 2015 American Medical Association. All Rights Reserved

BCBSKS - CODE LIST - Assistant Surgery - NMN Last Updated: 1/1/2016 Contains Public Information

Page 7 of 15

Assistant Surgery - Not Medically Necessary (NMN) Codes 33217

33361

33971

36245

36514

36597

37218

33218

33362

33984

36251

36515

36598

37609

33220

33363

33985

36252

36516

36600

37722

33221

33364

33986

36253

36555

36620

37765

33222

33365

33987

36254

36556

36625

37766

33223

33366

33988

36261

36557

36640

37780

33224

33508

33989

36262

36558

36660

37785

33225

33768

34471

36400

36560

36680

38200

33226

33884

34803

36405

36561

36800

38204

33227

33933

35306

36406

36563

36810

38205

33228

33944

35400

36410

36565

36815

38206

33229

33946

35450

36415

36566

36818

38207

33230

33947

35500

36416

36568

36819

38208

33231

33948

35600

36420

36569

36820

38209

33233

33949

35697

36425

36570

36830

38210

33234

33951

35820

36430

36571

36831

38211

33235

33952

36000

36440

36575

36832

38212

33240

33953

36002

36450

36576

36833

38213

33241

33954

36010

36455

36578

36860

38214

33244

33955

36100

36468

36580

36861

38215

33249

33956

36120

36470

36581

36870

38220

33250

33957

36140

36471

36582

37184

38221

33251

33958

36147

36475

36583

37185

38230

33262

33959

36160

36476

36584

37186

38232

33263

33960

36200

36478

36585

37187

38240

33264

33962

36215

36479

36589

37188

38242

33270

33963

36221

36481

36590

37191

38243

33271

33964

36222

36500

36591

37192

38300

33272

33965

36223

36510

36592

37193

38305

33273

33966

36224

36511

36593

37195

38308

33282

33968

36225

36512

36595

37215

38500

33284

33969

36226

36513

36596

37216

38505

Key:

* Allowed when performed in a physician's office.

Current Procedural Terminology

© 2015 American Medical Association. All Rights Reserved

BCBSKS - CODE LIST - Assistant Surgery - NMN Last Updated: 1/1/2016 Contains Public Information

Page 8 of 15

Assistant Surgery - Not Medically Necessary (NMN) Codes 38510

40816

41130

42180

42725

43198

43245

38520

40818

41250

42182

42800

43200

43246

38525

40819

41251

42200

42804

43201

43247

38790

40820

41252

42205

42806

43202

43248

38792

40830

41500

42215

42808

43204

43250

38794

40831

41510

42226

42809

43205

43251

39401

40840

41520

42227

42810

43206

43252

39402

40842

41530

42260

42820

43211

43253

40490

40843

41800

42280

42821

43212

43254

40500

40844

41805

42281

42825

43213

43255

40510

41000

41806

42300

42826

43214

43257

40520

41005

41820

42305

42830

43215

43259

40525

41006

41821

42320

42831

43216

43260

40527

41007

41822

42330

42835

43217

43261

40530

41008

41823

42335

42836

43220

43262

40650

41009

41825

42340

42860

42972

43263

40652

41010

41826

42400

42870

43226

43264

40654

41015

41827

42405

42900

43227

43265

40700

41016

41828

42408

42960

43229

43266

40701

41017

41830

42409

42961

43231

43270

40702

41018

41850

42410

42962

43232

43273

40720

41019

41870

42450

42970

43233

43274

40761

41100

41872

42500

42971

43235

43275

40800

41105

41874

42505

42972

43236

43276

40801

41108

42000

42507

43180

43237

43277

40804

41110

42100

42509

43191

43238

43278

40805

41112

42104

42550

43192

43239

43420

40806

41113

42106

42600

43193

43240

43450

40808

41114

42107

42650

43194

43241

43453

40810

41115

42140

42660

43195

43242

43460

40812

41116

42145

42700

43196

43243

43752

40814

41120

42160

42720

43197

43244

Key:

43760

* Allowed when performed in a physician's office.

Current Procedural Terminology

© 2015 American Medical Association. All Rights Reserved

BCBSKS - CODE LIST - Assistant Surgery - NMN Last Updated: 1/1/2016 Contains Public Information

Page 9 of 15

Assistant Surgery - Not Medically Necessary (NMN) Codes 44100

44401

45331

45393

46320

46947

49082

44213

44402

45332

45398

46500

47000

49083

44340

44403

45333

45499

46505

47143

49084

44360

44404

45334

45500

46600

47144

49180

44361

44405

45335

45520

46601

47145

49185

44363

44406

45337

45900

46604

47146

49320

44364

44407

45338

45905

46606

47147

49321

44365

44408

45339

45910

46607

47490

49322

44366

44500

45340

45915

46608

47530

49400

44369

44701

45341

45990

46610

47531

49402

44370

44705

45342

46020

46611

47532

49405

44372

44715

45345

46030

46612

47533

49406

44373

44720

45346

46040

46614

47534

49407

44376

44721

45347

46045

46615

47535

49411

44377

44970

45349

46050

46706

47536

49419

44378

45000

45350

46060

46715

47537

49421

44379

45005

45355

46070

46730

47538

49422

44380

45020

45378

46080

46751

47539

49423

44381

45100

45379

46083

46753

47540

49424

44382

45190

45380

46200

46754

47541

49428

44383

45300

45381

46220

46900

47542

49429

44384

45303

45382

46221

46910

47543

49435

44385

45305

45383

46230

46916

47544

49436

44386

45307

45384

46250

46917

47552

49440

44388

45308

45385

46255

46922

47553

49441

44389

45309

45386

46258

46924

47554

49442

44390

45315

45387

46260

46930

47555

49450

44391

45317

45388

46270

46938

48102

49451

44392

45320

45389

46275

46940

48400

49452

44393

45321

45390

46280

46942

48551

49460

44394

45327

45391

46285

46945

48552

49465

44397

45330

45392

46288

46946

49062

49491

Key:

* Allowed when performed in a physician's office.

Current Procedural Terminology

© 2015 American Medical Association. All Rights Reserved

BCBSKS - CODE LIST - Assistant Surgery - NMN Last Updated: 1/1/2016 Contains Public Information

Page 10 of 15

Assistant Surgery - Not Medically Necessary (NMN) Codes 49572

50555

51610

52235

52346

53275

54200

49582

50557

51700

52240

52351

53500

54220

49585

50561

51701

52250

52352

53502

54230

49587

50562

51702

52260

52353

53520

54231

49611

50590

51703

52265

52354

53600

54235

50080

50606

51705

52270

52355

53601

54240

50200

50684

51710

52275

52356

53605

54250

50323

50686

51715

52276

52400

53620

54318

50325

50688

51720

52277

52402

53621

54328

50327

50690

51725

52281

52441

53660

54340

50328

50693

51726

52282

52442

53661

54380

50329

50694

51727

52283

52450

53665

54385

50382

50695

51728

52285

52500

53850

54435

50384

50705

51729

52287

52601

53852

54450

50385

50706

51736

52290

52630

53855

54500

50386

50951

51741

52300

52640

54000

54505

50387

50953

51785

52301

52700

54001

54520

50389

50955

51792

52305

53000

54015

54522

50390

50957

51797

52310

53010

54050

54600

50391

50961

51798

52315

53020

54055

54620

50394

50970

51820

52317

53025

54056

54660

50395

50972

51940

52318

53040

54057

54670

50396

50974

51999

52320

53060

54060

54700

50430

50976

52000

52325

53080

54065

54800

50431

50980

52001

52330

53200

54100

54860

50432

51040

52005

52332

53220

54105

54900

50433

51065

52007

52334

53235

54150

55000

50434

51100

52010

52341

53240

54160

55040

50435

51101

52204

52342

53250

54161

55060

50548

51102

52214

52343

53260

54162

55100

50551

51600

52224

52344

53265

54163

55120

50553

51605

52234

52345

53270

54164

55180

Key:

* Allowed when performed in a physician's office.

Current Procedural Terminology

© 2015 American Medical Association. All Rights Reserved

BCBSKS - CODE LIST - Assistant Surgery - NMN Last Updated: 1/1/2016 Contains Public Information

Page 11 of 15

Assistant Surgery - Not Medically Necessary (NMN) Codes 55200

56820

57456

58600

59430

61250

62223

55250

56821

57461

58605

59812

61316

62252

55300

57000

57500

58611

59820

61334

62256

55400

57010

57505

58615

59821

61470

62258

55450

57020

57510

58660

59840

61517

62263

55500

57022

57511

58662

59841

61531

62264

55520

57023

57513

58670

59850

61535

62267

55550

57061

57520

58671

59851

61541

62268

55600

57065

57556

58672

59852

61542

62269

55700

57100

57558

58740

59855

61623

62270

55705

57105

57700

58800

59856

61630

62272

55706

57106

57720

58820

59857

61635

62273

55720

57135

57800

58953

59866

61640

62280

55870

57150

58100

58954

59870

61641

62284

55873

57155

58110

58970

59871

61642

62287

55876

57160

58120

59000

59897

61645

62290

55920

57170

58300

59001

59898

61650

62291

55980

57180

58301

59015

60000

61651

62292

56405

57267

58340

59020

60100

61750

62294

56420

57283

58345

59130

61000

61760

62302

56440

57287

58346

59135

61001

61790

62303

56441

57291

58350

59136

61020

61791

62304

56442

57311

58353

59140

61026

61800

62305

56501

57400

58356

59150

61050

61850

62310

56515

57410

58555

59160

61055

61864

62311

56605

57415

58558

59200

61070

61868

62318

56606

57420

58559

59300

61107

61870

62319

56700

57421

58560

59325

61120

61885

62369

56740

57425

58561

59409

61140

61888

62370

56800

57452

58562

59410

61151

62148

63103

56805

57454

58563

59412

61154

62194

63308

56810

57455

58565

59414

61156

62201

63600

Key:

* Allowed when performed in a physician's office.

Current Procedural Terminology

© 2015 American Medical Association. All Rights Reserved

BCBSKS - CODE LIST - Assistant Surgery - NMN Last Updated: 1/1/2016 Contains Public Information

Page 12 of 15

Assistant Surgery - Not Medically Necessary (NMN) Codes 63650

64483

64633

64823

65286

66150

66984

63661

64484

64634

64831

65400

66155

66985

63662

64486

64635

64832

65410

66160

66990

63663

64487

64636

64834

65420

66165

67015

63688

64488

64640

64837

65426

66170

67025

64400

64489

64642

64840

65430

66179

67027

64402

64490

64643

64858

65435

66183

67028

64405

64493

64644

64861

65436

66184

67101

64408

64505

64645

64870

65450

66500

67105

64410

64508

64646

64874

65600

66505

67110

64413

64510

64647

64876

65710

66600

67120

64415

64517

64650

64895

65730

66605

67141

64416

64520

64653

64896

65750

66625

67145

64417

64530

64680

64898

65755

66630

67208

64418

64550

64681

64901

65756

66635

67210

64420

64553

64718

64905

65757

66680

67220

64421

64555

64721

64907

65771

66682

67221

64425

64561

64726

65112

65772

66700

67225

64430

64565

64727

65125

65775

66710

67227

64435

64575

64732

65140

65780

66711

67228

64445

64580

64734

65150

65781

66720

67229

64446

64581

64736

65205

65782

66740

67345

64447

64585

64738

65210

65785

66761

67346

64448

64595

64761

65220

65800

66762

67405

64449

64600

64774

65222

65810

66770

67413

64450

64605

64776

65235

65815

66820

67415

64455

64610

64778

65260

65820

66830

67430

64461

64615

64782

65265

65850

66840

67500

64462

64616

64783

65270

65855

66920

67505

64463

64617

64795

65272

66020

66930

67515

64479

64630

64821

65275

66030

66940

67700

64480

64632

64822

65280

66130

66982

67710

Key:

* Allowed when performed in a physician's office.

Current Procedural Terminology

© 2015 American Medical Association. All Rights Reserved

BCBSKS - CODE LIST - Assistant Surgery - NMN Last Updated: 1/1/2016 Contains Public Information

Page 13 of 15

Assistant Surgery - Not Medically Necessary (NMN) Codes 67715

67971

68801

69436

69662

92924

93563

67800

67974

68810

69440

69666

92928

93564

67801

67975

68815

69450

69667

92933

93565

67805

68020

68816

69501

69676

92937

93566

67808

68040

68840

69502

69700

92941

93567

67810

68100

68850

69505

69710

92943

93568

67820

68110

69000

69511

69711

92961

93571

67825

68115

69005

69530

69714

92973

93572

67830

68130

69020

69540

69715

92974

93580

67835

68135

69090

69550

69717

92992

93581

67840

68200

69100

69554

69718

92993

93600

67850

68320

69105

69601

69725

92997

93602

67875

68325

69110

69602

69801

92998

93603

67880

68326

69120

69603

69805

93451

93609

67882

68328

69140

69604

69806

93452

93610

67900

68330

69145

69610

69820

93453

93612

67906

68335

69200

69620

69840

93454

93613

67909

68340

69205

69631

69905

93455

93615

67912

68360

69209

69632

69910

93456

93616

67914

68371

69210

69633

69930

93457

93618

67915

68400

69220

69635

69955

93458

93619

67916

68420

69222

69636

69960

93459

93620

67921

68440

69300

69637

69970

93460

93621

67922

68500

69310

69641

92018

93461

93622

67923

68510

69320

69642

92511

93462

93623

67924

68530

69400

69643

92601

93463

93624

67930

68700

69401

69644

92602

93464

93631

67935

68705

69405

69645

92603

93503

93640

67938

68750

69420

69646

92604

93530

93641

67950

68760

69421

69650

92620

93531

93642

67961

68761

69424

69660

92621

93532

93650

67966

68770

69433

69661

92920

93533

93653

Key: * Allowed when performed in a physician's office.

Current Procedural Terminology

© 2015 American Medical Association. All Rights Reserved

BCBSKS - CODE LIST - Assistant Surgery - NMN Last Updated: 1/1/2016 Contains Public Information

Page 14 of 15

Assistant Surgery - Not Medically Necessary (NMN) Codes 93654 93656 93660 93662 95970 95971 95972 95974 95975 96570 96571 96920 96921 96922 97597 97598 97602

Key:

* Allowed when performed in a physician's office.

Current Procedural Terminology

© 2015 American Medical Association. All Rights Reserved

BCBSKS - CODE LIST - Assistant Surgery - NMN Last Updated: 1/1/2016 Contains Public Information

Page 15 of 15