Phoenix Health Plan Procedures to be Performed in an ASC or Office Setting Whenever Medically Appropriate Effective May 1, 2011

Phoenix Health Plan Procedures to be Performed in an ASC or Office Setting Whenever Medically Appropriate Effective May 1, 2011 This listing is not in...
Author: Quentin Lamb
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Phoenix Health Plan Procedures to be Performed in an ASC or Office Setting Whenever Medically Appropriate Effective May 1, 2011 This listing is not intended to represent all services that can appropriately be performed in an ASC or office setting, but a listing of procedures frequently performed in a hospital outpatient setting that are far more cost effective if done in the alternative ASC or office setting

NOTE: Most of these procedures do not require Prior Authorization when performed in ASC/Office setting. Please consult PHP Prior Authorization guidelines to determine when PA is needed. Updated 5.19.11

Procedure Code 10021 10022 10060 10061 10081 10120 10121 10140 10160 10180 11011 11012 11042 11044 11100 11101 11200 11310 11406 11462 11602 11603 11606 11621 11622 11623 11626 11641 11642 11643 11730 11750 11760 11765 11770 11771 11772 11960 11971 11981 11983 12001 12002 12011 12013 12031 12032 12036 12041 12042 12051 12052

Description 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 DEBRIDEMENT; SKIN AND SUBCUTANEOUS TISSUE DEBRIDEMENT; SKIN SUBCUT TISSUE MUSCLE&BONE BX SKIN SUBQ TISS&/MUCOUS MEMB (SEP PRO); 1 LES BX SKIN SUBQ TISS&/MUCOUS MEMB (SEP PRO); EA ADD REMOVAL SKIN TAGS ANY AREA;TO & INCL 15 LESION 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 INSRT EXPANDER NOT BREAST INCL SUBSQT EXPANSION REMOVAL TISSUE EXPANDER WITHOUT INSERTION PROSTH 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 NOSE&/MUCOUS MEMB; < 2.5 CM SIMPL REPR FACE ERS NOSE&/MUCOUS 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 FT&/GENIT; < 2.5 CM LAYER CLOS WNDS NCK HNDS FT&/GENIT; 2.6-7.5 CM LAYER CLOS WNDS FACE EARS NOSE&/LIPS; < 2.5 CM LAYER CLOS WNDS FACE EARS NOSE&/LIPS; 2.6-5.0 CM Page 1 of 13

Updated 5.19.11

Procedure Code 13101 13121 13122 13131 13132 13133 13160 14000 14001 14020 14040 14041 14060 14061 15002 15003 15004 15005 15100 15200 15240 15241 15365 15430 15431 15732 15760 15770 15852 16020 16025 17000 17003 17110 17250 17281 19020 19100 19101 19102 19103 19110 19120 19290 19291 19295 19304 19316 19328 19340 19342 19350 19357 19370 19371 19380 20103 20200 20205 20206 20220 20225 20240 20245 20520 20525

Description REPAIR COMPLEX TRUNK; 2.6 TO 7.5 CM REPAIR COMPLEX SCALP ARMS &/ LEGS; 2.6 TO 7.5 CM REPR CMPLX SCLP ARMS &OR LEGS; EA ADD 5 CM/LESS 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 WOUND/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 ARMS&/LEGS; 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 NOSE&/LIPS; 10 SQ CM/LESS ADJ TISS TRANS EYELDS NOSE&/LIPS;10.1-30.0 SQ CM WND PREP, CH/INF, TRK/ARM/LG WND PREP, CH/INF ADDL 100 CM WND PREP CH/INF, F/N/HF/G WND 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 HAND&/FT; 20 SQ CM/LESS FTG FOREHEAD CHIN NCK AX HAND&/FT;EA ADD 20 SQCM APPLY CULT DERM SUB F/N/HF/G APPLY ACELLULAR XENOGRAFT APPLY ACELLULAR XGRAFT ADD MUSCLE MYOCUT/FASCIOCUT FLAP; HEAD&NECK GRAFT; COMPOS INCLUDING PRIMARY CLOS DONOR AREA GRAFT; DERMA-FAT-FASCIA DRESSING CHANGE UNDER ANESTHESIA DRSG &OR DEBRID INIT/SUBSQT; W/O ANES-OFC/HOS SM DRSG &OR DEBRID INIT/SUBSEQUENT; W/O ANES-MEDIUM DESTRUC BEN/PREMALIG LES OTH THAN SKN TAG; 1 LES DESTRUC BEN/PREMALIG LES OTH THN SKN TAG;2-14 EA DESTRUC FLAT WARTS MOLLUSC CONTAG/MILIA; UP 14 CHEMICAL CAUTERIZATION OF GRANULATION TISSUE DESTRUC MAL LES FCE ERS EYELD NSE LPS;0.6-1.0 CM MASTOTOMY W/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 BX BREAST; PERC-VACUUM/ROTATING DEV W/IMAG GUID NIPPLE EXPL W/WO 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 REMOVAL OF INTACT MAMMARY IMPLANT IMMED INSRT BREAST PROSTH FLW MASTOPXY/MASTECT DELAY INSRT BREAST PROSTH FLW MASTOPXY/MASTECT NIPPLE/AREOLA RECONSTRUCTION BREAST RECON IMMED/DELAY W/EXPANDR W/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 Page 2 of 13

Updated 5.19.11

Procedure Code 20526 20550 20551 20552 20553 20600 20605 20610 20612 20670 20690 20693 20694 20900 20902 20924 21030 21046 21048 21235 21320 21330 21337 21356 21501 21550 21555 21556 21930 22520 22900 23076 23130 23410 23412 23415 23430 23440 23462 23466 23500 23515 23550 23552 23700 24075 24076 24101 24105 24110 24116 24200 24300 24343 24359 24498 24530 24535 24538 24575 24579 24640 24665 24685 25000 25075

Description INJECTION THERAPEUTIC CARPAL TUNNEL INJECTION; TENDON SHEATH LIGAMENT INJECTION; TENDON ORIGIN/INSERTION INJ; SINGLE/MX TRIGGER POINT 1/TWO MUSCLE INJ; SINGLE/MX TRIGGER POINT 3/MORE MUSCLE ARTHROCEN ASPIRATION &OR INJ; SM JOINT/BURSA ARTHROCEN ASPIRATION &OR INJ; INTERMED JNT/BURSA ARTHROCEN ASPIR&/INJ; MAJOR JNT BURSA/GANG CYST ASPIR &OR INJECTION GANG CYSTS ANY LOCATION REMOVAL OF IMPLANT; SUPERFICIAL-SEP PROC APPLICATION UNIPLANE UNILAT EXTERNAL FIX SYSTEM ADJ/REV EXTERNAL FIX SYSTEM REQUIRING ANESTHESIA REMOVAL UNDER ANES-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 CLOSED TX NASAL BONE FRACTURE; W/STABLZATION OPEN TX NASL FX; COMPLICATED W/INT&/EXT SKEL FIX CLOSED TX NASAL SEPTAL FX W/WO STABILIZATION OPEN TREATMENT DEPRESSED ZYGOMATIC ARCH FRACTURE I&D DEEP ABSC/HEMATOMA SOFT TISSUES NECK/THORAX; BIOPSY SOFT TISSUE OF NECK OR THORAX EXCISION TUMOR SOFT TISSUE NECK/THORAX; SUBCUT EXC TUMR SOFT TISSUE NCK/THOR; DP SUBFASCL IM EXCISION TUMOR SOFT TISSUE OF BACK OR FLANK PERQ VERTPLSTY 1 VERT BODY UNI/BIL INJ; THORACIC EXCISION ABDOMINAL WALL TUMOR SUBFASCIAL 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 REMOVAL FOREIGN BODY UPPER ARM/ELB AREA; SUBCUT 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 EXC TUMR SFT TISSUE FORARM &OR WRST AREA; SUBCUT Page 3 of 13

Updated 5.19.11

Procedure Code 25076 25111 25112 25115 25248 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 26727 26735 26746 26765 26910 26951 26952 26990 27250 27324

Description EXC TUMR SOFT TISSUE FOREARM &OR WRST AREA; DEEP EXCISION OF GANGLION WRIST ; PRIMARY EXCISION OF GANGLION WRIST ; RECURRENT RADL EXC BURSA WRIST TENDON SHEATHS; FLEXORS EXPL W/REMOVAL DEEP FOREIGN BODY FOREARM/WRIST 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 W/WO INTRL/EXT FIX CLOS TX RADIAL&ULNAR SHAFT FX; W/MANIPULATION CLOS TX DIST RADIAL FX W/WO FX STYLOID; WO MANIP CLOS TX DIST RADIAL FX W/WO FX STYLOID; W/MANIP TREAT FX DISTAL RADIAL TREAT FX RAD EXTRA-ARTICUL TREAT FX RAD INTRA-ARTICUL OPEN TX CARPAL SCAPHOID FX W/WO 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; IP JNT EA EXC TUMR/VASC MALFORM SFT TISSUE HND/FNGR; SUBQ EXC TUMR/VASC MALFORM SOFT TISSUE HND/FNGR; DEEP FASCECT PART PALMAR W/REL 1 DIGT W/WO Z-PLASTY; SYNOVECT SHEATH RADL FLEX TENDON PALM&/FINGR EA PARTIAL EXCISION BONE ; METACARPAL REP/ADV FLX TEND ZONE 2 DIGTL; W/O FREE GFT EA REP/ADV FLX TEND ZONE 2 DIGTL; SEC W/FREE GFT EA REPR PROFUNDUS TENDON; PRIMARY EA TENDON EXC FLX TEND W/IMPL ROD DELAY TEND GFT HND/FNGR REPR EXT TEND HND PRIM/SEC; W/O FREE GFT EA TEND REP EXT TEND FNGR PRIM/SEC; W/O FREE GFT EA TEND REP EXT TEND CNTRL SLIP SEC;LOC TISS LAT BAND EA REPR EXT TENDON DIST INSERTION PRIM/SEC; W/O GFT TENOLYSIS FLEXOR TENDON; PALM/FINGER EACH TENDON TENOLYSIS EXTENSOR TENDON HAND/FINGER; EA TENDON TRNSF/TPLNT TEND CMC/DORSUM HAND; WO GFT EA TEND CAPSLDSIS MCP JOINT; SINGLE DIGIT REPAIR COLLAT LIGAMENT MCP/IP JOINT RECON COLLAT LIG MCP JNT 1; W/TENDON/FASCL GFT REPAIR&RECONSTRUCT FINGER VOLAR PLATE IP 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 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 Page 4 of 13

Updated 5.19.11

Procedure Code 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 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

Description 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 REALIGN&/MUSC 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 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 OTH 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 Page 5 of 13

Updated 5.19.11

Procedure Code 29065 29075 29085 29125 29130 29365 29405 29425 29505 29515 29580 29805 29806 29807 29819 29820 29821 29822 29823 29824 29825 29826 29827 29828 29834 29835 29837 29838 29848 29850 29862 29866 29870 29873 29874 29875 29876 29877 29879 29880 29881 29882 29883 29884 29888 29895 29897 29898 30100 30117 30130 30310 30465 30801 30802 30930 31030 31231 31238 31240 31254 31256 31267 31287 31515 31525

Description APPLICATION CAST; SHOULDER TO HAND APPLICATION CAST; ELBOW TO FINGER APPLICATION CAST; HAND AND LOWER FOREARM APPLICATION OF SHORT ARM SPLINT ; STATIC APPLICATION OF FINGER SPLINT; STATIC APPLICATION OF CYLINDER CAST APPLICATION OF SHORT LEG CAST ; 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 SCOPE SHOULDER SURGICAL; REPAIR SLAP LESION SCOPE SHOULDER SURGICAL; W/REMOVAL LOOSE BODY/FB ARTHROSCOPY SHOULDER SURG; SYNOVECTOMY PARTIAL ARTHROSCOPY SHLDR SURG; SYNOVECTECTOMY COMPLETE ARTHROSCOPY SHOULDER SURG; DEBRIDEMENT LIMITED ARTHROSCOPY SHOULDER SURG; DEBRIDEMENT EXTENSIVE SCOPE SHLDR SURG;DIST CLAVICULECT W/ARTICLR SURF SCOPE SHLDR SURG; W/LYSIS&RES ADHES W/WO MANIP ARTHROSCOPY SHOULDER SURG; DECOMP SUBACROM SPACE SCOPE SHOULDER SURGICAL; W/ROTATOR CUFF REPAIR ARTHROSCOPY BICEPS TENODESIS 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 SCOPE KNEE; OSTEOCHONDRAL AUTOGRAFT ARTHROSCOPY KNEE DX W/WO SYNOVIAL BX SEP PROC ARTHROSCOPY KNEE SURGICAL; WITH LATERAL RELEASE ARTHROSCOPY KNEE SURG; REMOVAL LOOSE BODY/FB ARTHROSCOPY KNEE SURG; SYNOVECT LIMITED SEP PROC ARTHROSCOPY KNEE; SYNOVECT MAJ 2/MORE CMPRTMTS ARTHROSCOPY KNEE SURG; DEBRID/SHAV ARTICLR CART ARTHROSCOPY KNEE; ABRAS ARTHPLASTY/DRILL/MICROFX ARTHROSCOPY KNEE; W/MENISCECTOMY MED&LAT ARTHROSCOPY KNEE; W/MENISCECTOMY MED/LAT ARTHROSCOPY KNEE; W/MENISCUS REPAIR MED/LAT ARTHROSCOPY KNEE; W/MENISCUS REPAIR MED&LAT ARTHROSCOPY KNEE; W/LYSIS ADHESION SEP PROC ARTHSCPY AIDED ACL REPAIR/AUG/RECONSTRUCTION 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 CAUT&/ABLAT MUCOS TURBINS UNI/BIL SEP PROC; SUP CAUT&/ABLAT MUCOS TURB UNI/BIL SEP PROC;INTRMURL FRACTURE NASAL TURBINATE THERAPEUTIC SINUSOT MAX; RADL W/O REMOVL ANTROCHOANAL POLYPS 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 Page 6 of 13

Updated 5.19.11

Procedure Code 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 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

Description 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 FLUORO 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 TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER 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 CENTRAL VENOUS ACCESS DEVICE 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 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 ACCESS REPLACEMENT, COMPLETE, OF A TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS 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 Page 7 of 13

Updated 5.19.11

Procedure Code 40805 40812 40816 40819 41010 41105 41112 41113 41115 41806 42104 42140 42408 42415 42505 42725 42806 42821 42825 42826 42830 42831 42962 43200 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

Description 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 REMOVAL EMBEDDED FB FROM DENTOALVEOL STRCT; BONE EXCISION LESION OF PALATE UVULA; WITHOUT CLOSURE UVULECTOMY EXCISION OF UVULA 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 TONSILLECTOMY AND ADENOIDECTOMY; AGE 12 OR OVER TONSILLECTOMY PRIMARY OR SECONDARY; UNDER AGE 12 TONSILLECTOMY PRIMARY OR SEC; AGE 12 OR OVER ADENOIDECTOMY PRIMARY; UNDER AGE 12 ADENOIDECTOMY PRIMARY; AGE 12 OR OVER CONTRL OROPHARYNG HEMORR; W/SECNDRY SURG INTERV ESOPHGSCPY RIGD/FLEX; DX W/WO CLCT BRSH/WSH-SP 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 ENDO; 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 ENDO; W/BX 1/MX UGI ENDO; W/TRANSMURAL DRAIN PSEUDOCYST UGI EG DUO JEJUN W/TRNSENDO INTRLUMNL CATH PLCMT UGI ENDO; W/US GUID FINE NEEDLE ASPIR/BX UGI ENDO; W/INJ SCLEROSIS-ESOPH/GASTRIC VARICES UGI ENDO; W/BAND LIG ESOPH &/OR GASTRIC VARICES UP GI ENDO; W/DILAT GASTR OUTLET OBST UGI ENDO; W/DIRECTED PLCMT PERQ GASTROSTOMY TUBE UGI ENDO; W/REMOVAL FB UGI ENDO; W/INSRT GUIDE WIRE-DILAT ESOPHAGUS UGI ENDO; W/BALLOON DILAT ESOPHAGUS UGI ENDO; W/REMV TUMOR/POLYP/LES-HOT BX FORCEPS UGI ENDO; W/REMV TUMOR/POLYP/OTHER LES-SNARE UGI ENDO; W/CONTRL BLEEDING ANY METHD UGI ENDO W/TRNSENDO STENT PLCMNT INC PREDILA UP GI ENDO;THRM ENRGY MUSC LW ESOPH UGI ENDO; 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 BILI&/PANC DUCTS ERCP; W/ENDO RETRO DESTRUC LITH CALCU/CALCU METH ERCP; W/ENDO RETRO INSRT TUBE/STNT BILE/PANC DCT Page 8 of 13

Updated 5.19.11

Procedure Code 43450 43760 43870 44361 44388 45300 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 46600 46615 46910 46924 46947 47000 47001

Description 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 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 ANOSCPY; DX W/WO COLLCT SPECIMEN BRUSH/WASH-SP ANOSCOPY; W/ABLAT TUMOR/LES NOT AMENABLE-FORCEPS DESTRUC LESION ANUS SIMPLE; ELECTRODESICCATION DESTRUCTION OF LESION ANUS EXTENSIVE HEMORRHOIDOPEXY BY STAPLING BIOPSY OF LIVER NEEDLE; PERCUTANEOUS BX LIVER NEEDLE; DONE @ TIME W/OTH MAJ PROC Page 9 of 13

Updated 5.19.11

Procedure Code 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 51701 51703 51725 51741 51784 51797 51798 52000 52005 52007 52204 52224 52234 52235 52240 52260 52281 52282 52285 52310 52317 52318 52320 52327 52330 52332 52334 52344 52345 52351 52352 52500 52648 53020 53060 53450 54001 54057 54060

Description 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; W/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 INCI/VENTRAL HERNIA; REDUCIBLE REPAIR RECURRENT INCI/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 LAVAGE&/INSTILLATION INSERTION NON-INDWELLING BLADDER CATHETER INSERTION TEMP INDWELLING BLADDER CATHETER; COMP SIMPLE CYSTOMETROGRAM COMPLEX UROFLOWMETRY EMG STDY ANAL/URETH SPHNCTR OTH THAN NDLE TECH VOIDING PRESS STUDIES; INTRA-ABD VOIDING PRESS MEASUREMENT PVR URIN&/BLADD CAPACTY US NON-IMAG CYSTOURETHROSCOPY-SEP PROC CYSTOURETHROSCOPY W/URETERAL CATH 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 &/OR DILAT URETHRAL CYSTOURETHROSCOPY W/INSERTION OF URETHRAL STENT CYSTOURETHROSCOPY TX FE URETHRAL SYNDROME 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 TURP 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 Page 10 of 13

Updated 5.19.11

Procedure Code 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 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

Description 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 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/

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