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UnlistedCodes

VIEWS: 9 PAGES: 24

  • pg 1
									Last Updated: 02/18/11.                                           5567839 Unlisted Codes - System Structure
                                                                         Unlisted Codes Categories
                                                                                                              Req Doc
                                                                                                               (Doc,
                                        Are                         Text                                       Text,
 Proc   Effective                       Docs         Doc            Notes                                      Both,
 Code     Date         Short Desc       Req?       Type Req         Req?          Text Note Req Info          Either)
                                                                            Describe the anesthesia
                                                                            procedure performed and
                 unlisted anesth                                            explain the use of the unlisted
01999   8/9/2010 procedure              Y      Operative Report    Y        code.                             Both

                                                                            Describe the surgical procedure
                 removal of pressure                                        performed and explain the use of
15999   8/9/2010 sore                   Y      Operative Report    Y        the unlisted code.               Both

                                                                            Describe the surgical procedure
                                                                            performed and explain the use of
17999   8/9/2010 skin tissue procedure Y       Operative Report    Y        the unlisted code.               Both

                                                                            Describe the surgical procedure
                 breast surgery                                             performed and explain the use of
19499   8/9/2010 procedure              Y      Operative Report    Y        the unlisted code.               Both

                                                                            Describe the surgical procedure
                 musculoskeletal                                            performed and explain the use of
20999   8/9/2010 surgery                Y      Operative Report    Y        the unlisted code.               Both

                                                                            Describe the surgical procedure
                 prepare face/oral                                          performed and explain the use of
21089   8/9/2010 prosthesis             Y      Operative Report    Y        the unlisted code.               Both

                                                                            Describe the surgical procedure
                 cranio/maxillofacial                                       performed and explain the use of
21299   8/9/2010 surgery                Y      Operative Report    Y        the unlisted code.               Both

                                                                            Describe the surgical procedure
                 head surgery                                               performed and explain the use of
21499   8/9/2010 procedure              Y      Operative Report    Y        the unlisted code.               Both




783ac578-3c0e-416d-8adf-38b07bc6a39a.xls
Detail Table Information                                                           Page 1 of 24                         Last Printed: 5/19/2012
Last Updated: 02/18/11.                                          5567839 Unlisted Codes - System Structure
                                                                        Unlisted Codes Categories
                                                                                                           Req Doc
                                                                                                            (Doc,
                                       Are                         Text                                     Text,
 Proc   Effective                      Docs         Doc            Notes                                    Both,
 Code     Date         Short Desc      Req?       Type Req         Req?         Text Note Req Info         Either)

                                                                           Describe the surgical procedure
                 neck/chest surgery                                        performed and explain the use of
21899   8/9/2010 procedure             Y      Operative Report    Y        the unlisted code.               Both

                                                                           Describe the surgical procedure
                 spine surgery                                             performed and explain the use of
22899   8/9/2010 procedure             Y      Operative Report    Y        the unlisted code.               Both

                                                                           Describe the surgical procedure
                 abdomen surgery                                           performed and explain the use of
22999   8/9/2010 procedure             Y      Operative Report    Y        the unlisted code.               Both

                                                                           Describe the surgical procedure
                 shoulder surgery                                          performed and explain the use of
23929   8/9/2010 procedure             Y      Operative Report    Y        the unlisted code.               Both

                                                                           Describe the surgical procedure
                 upper arm/elbow                                           performed and explain the use of
24999   8/9/2010 surgery               Y      Operative Report    Y        the unlisted code.               Both

                                                                           Describe the surgical procedure
                 forearm or wrist                                          performed and explain the use of
25999   8/9/2010 surgery               Y      Operative Report    Y        the unlisted code.               Both

                                                                           Describe the surgical procedure
                                                                           performed and explain the use of
26989   8/9/2010 hand/finger surgery   Y      Operative Report    Y        the unlisted code.               Both

                                                                           Describe the surgical procedure
                 pelvis/hip joint                                          performed and explain the use of
27299   8/9/2010 surgery               Y      Operative Report    Y        the unlisted code.               Both




783ac578-3c0e-416d-8adf-38b07bc6a39a.xls
Detail Table Information                                                          Page 2 of 24                       Last Printed: 5/19/2012
Last Updated: 02/18/11.                                           5567839 Unlisted Codes - System Structure
                                                                         Unlisted Codes Categories
                                                                                                            Req Doc
                                                                                                             (Doc,
                                        Are                         Text                                     Text,
 Proc   Effective                       Docs         Doc            Notes                                    Both,
 Code     Date         Short Desc       Req?       Type Req         Req?         Text Note Req Info         Either)

                                                                            Describe the surgical procedure
                                                                            performed and explain the use of
27599   8/9/2010 leg surgery procedure Y       Operative Report    Y        the unlisted code.               Both

                                                                            Describe the surgical procedure
                 leg/ankle surgery                                          performed and explain the use of
27899   8/9/2010 procedure              Y      Operative Report    Y        the unlisted code.               Both

                                                                            Describe the surgical procedure
                 foot/toes surgery                                          performed and explain the use of
28899   8/9/2010 procedure              Y      Operative Report    Y        the unlisted code.               Both

                                                                            Describe the surgical procedure
                                                                            performed and explain the use of
29999   8/9/2010 arthroscopy of joint   Y      Operative Report    Y        the unlisted code.               Both

                                                                            Describe the surgical procedure
                 vascular endoscopy                                         performed and explain the use of
37501   8/9/2010 procedure              Y      Operative Report    Y        the unlisted code.               Both

                                                                            Describe the surgical procedure
                 vascular surgery                                           performed and explain the use of
37799   8/9/2010 procedure              Y      Operative Report    Y        the unlisted code.               Both

                                                                            Describe the surgical procedure
                 laparoscope proc                                           performed and explain the use of
38129   8/9/2010 spleen                 Y      Operative Report    Y        the unlisted code.               Both

                                                                            Describe the surgical procedure
                 laparoscope proc                                           performed and explain the use of
38589   8/9/2010 lymphatic              Y      Operative Report    Y        the unlisted code.               Both




783ac578-3c0e-416d-8adf-38b07bc6a39a.xls
Detail Table Information                                                           Page 3 of 24                       Last Printed: 5/19/2012
Last Updated: 02/18/11.                                           5567839 Unlisted Codes - System Structure
                                                                         Unlisted Codes Categories
                                                                                                            Req Doc
                                                                                                             (Doc,
                                        Are                         Text                                     Text,
 Proc   Effective                       Docs         Doc            Notes                                    Both,
 Code     Date         Short Desc       Req?       Type Req         Req?         Text Note Req Info         Either)

                                                                            Describe the surgical procedure
                                                                            performed and explain the use of
40799   8/9/2010 lip surgery procedure Y       Operative Report    Y        the unlisted code.               Both

                                                                            Describe the surgical procedure
                 mouth surgery                                              performed and explain the use of
40899   8/9/2010 procedure              Y      Operative Report    Y        the unlisted code.               Both

                                                                            Describe the surgical procedure
                 tongue and mouth                                           performed and explain the use of
41599   8/9/2010 surgery                Y      Operative Report    Y        the unlisted code.               Both

                                                                            Describe the surgical procedure
                                                                            performed and explain the use of
42299   8/9/2010 palate/uvula surgery   Y      Operative Report    Y        the unlisted code.               Both

                                                                            Describe the surgical procedure
                 salivary surgery                                           performed and explain the use of
42699   8/9/2010 procedure              Y      Operative Report    Y        the unlisted code.               Both

                                                                            Describe the surgical procedure
                 throat surgery                                             performed and explain the use of
42999   8/9/2010 procedure              Y      Operative Report    Y        the unlisted code.               Both

                                                                            Describe the surgical procedure
                 laparoscope proc                                           performed and explain the use of
43289   8/9/2010 esoph                  Y      Operative Report    Y        the unlisted code.               Both

                                                                            Describe the surgical procedure
                 esophagus surgery                                          performed and explain the use of
43499   8/9/2010 procedure              Y      Operative Report    Y        the unlisted code.               Both




783ac578-3c0e-416d-8adf-38b07bc6a39a.xls
Detail Table Information                                                           Page 4 of 24                       Last Printed: 5/19/2012
Last Updated: 02/18/11.                                         5567839 Unlisted Codes - System Structure
                                                                       Unlisted Codes Categories
                                                                                                          Req Doc
                                                                                                           (Doc,
                                      Are                         Text                                     Text,
 Proc   Effective                     Docs         Doc            Notes                                    Both,
 Code     Date        Short Desc      Req?       Type Req         Req?         Text Note Req Info         Either)

                                                                          Describe the surgical procedure
                 laparoscope proc                                         performed and explain the use of
43659   8/9/2010 stom                 Y      Operative Report    Y        the unlisted code.               Both

                                                                          Describe the surgical procedure
                 stomach surgery                                          performed and explain the use of
43999   8/9/2010 procedure            Y      Operative Report    Y        the unlisted code.               Both

                                                                          Describe the surgical procedure
                 laparoscope proc                                         performed and explain the use of
44238   8/9/2010 intestine            Y      Operative Report    Y        the unlisted code.               Both

                                                                          Describe the surgical procedure
                 unlisted procedure                                       performed and explain the use of
44799   8/9/2010 intestine            Y      Operative Report    Y        the unlisted code.               Both

                                                                          Describe the surgical procedure
                                                                          performed and explain the use of
44979   8/9/2010 laparoscope proc app Y      Operative Report    Y        the unlisted code.               Both

                                                                          Describe the surgical procedure
                 laparoscope proc                                         performed and explain the use of
45499   8/9/2010 rectum               Y      Operative Report    Y        the unlisted code.               Both

                                                                          Describe the surgical procedure
                 rectum surgery                                           performed and explain the use of
45999   8/9/2010 procedure            Y      Operative Report    Y        the unlisted code.               Both

                                                                          Describe the surgical procedure
                 anus surgery                                             performed and explain the use of
46999   8/9/2010 procedure            Y      Operative Report    Y        the unlisted code.               Both




783ac578-3c0e-416d-8adf-38b07bc6a39a.xls
Detail Table Information                                                         Page 5 of 24                       Last Printed: 5/19/2012
Last Updated: 02/18/11.                                         5567839 Unlisted Codes - System Structure
                                                                       Unlisted Codes Categories
                                                                                                          Req Doc
                                                                                                           (Doc,
                                      Are                         Text                                     Text,
 Proc   Effective                     Docs         Doc            Notes                                    Both,
 Code     Date         Short Desc     Req?       Type Req         Req?         Text Note Req Info         Either)

                                                                          Describe the surgical procedure
                 laparoscope                                              performed and explain the use of
47379   8/9/2010 procedure liver      Y      Operative Report    Y        the unlisted code.               Both

                                                                          Describe the surgical procedure
                 liver surgery                                            performed and explain the use of
47399   8/9/2010 procedure            Y      Operative Report    Y        the unlisted code.               Both

                                                                          Describe the surgical procedure
                 laparoscope proc                                         performed and explain the use of
47579   8/9/2010 biliary              Y      Operative Report    Y        the unlisted code.               Both

                                                                          Describe the surgical procedure
                 bile tract surgery                                       performed and explain the use of
47999   8/9/2010 procedure            Y      Operative Report    Y        the unlisted code.               Both

                                                                          Describe the surgical procedure
                 pancreas surgery                                         performed and explain the use of
48999   8/9/2010 procedure            Y      Operative Report    Y        the unlisted code.               Both

                                                                          Describe the surgical procedure
                 laparo proc                                              performed and explain the use of
49329   8/9/2010 abdm/per/oment       Y      Operative Report    Y        the unlisted code.               Both

                                                                          Describe the surgical procedure
                 laparo proc hernia                                       performed and explain the use of
49659   8/9/2010 repair               Y      Operative Report    Y        the unlisted code.               Both

                                                                          Describe the surgical procedure
                 abdomen surgery                                          performed and explain the use of
49999   8/9/2010 procedure            Y      Operative Report    Y        the unlisted code.               Both




783ac578-3c0e-416d-8adf-38b07bc6a39a.xls
Detail Table Information                                                         Page 6 of 24                       Last Printed: 5/19/2012
Last Updated: 02/18/11.                                          5567839 Unlisted Codes - System Structure
                                                                        Unlisted Codes Categories
                                                                                                           Req Doc
                                                                                                            (Doc,
                                       Are                         Text                                     Text,
 Proc   Effective                      Docs         Doc            Notes                                    Both,
 Code     Date         Short Desc      Req?       Type Req         Req?         Text Note Req Info         Either)

                                                                           Describe the surgical procedure
                 laparoscope proc                                          performed and explain the use of
50549   8/9/2010 renal                Y       Operative Report    Y        the unlisted code.               Both

                                                                           Describe the surgical procedure
                 laparoscope proc                                          performed and explain the use of
50949   8/9/2010 ureter               Y       Operative Report    Y        the unlisted code.               Both

                                                                           Describe the surgical procedure
                                                                           performed and explain the use of
51999   8/9/2010 laparoscope proc bla Y       Operative Report    Y        the unlisted code.               Both

                                                                           Describe the surgical procedure
                 urology surgery                                           performed and explain the use of
53899   8/9/2010 procedure            Y       Operative Report    Y        the unlisted code.               Both

                                                                           Describe the surgical procedure
                 laparoscope proc                                          performed and explain the use of
54699   8/9/2010 testis               Y       Operative Report    Y        the unlisted code.               Both

                                                                           Describe the surgical procedure
                 laparo proc spermatic                                     performed and explain the use of
55559   8/9/2010 cord                  Y      Operative Report    Y        the unlisted code.               Both

                                                                           Describe the surgical procedure
                 genital surgery                                           performed and explain the use of
55899   8/9/2010 procedure            Y       Operative Report    Y        the unlisted code.               Both

                                                                           Describe the surgical procedure
                                                                           performed and explain the use of
58578   8/9/2010 laparo proc uterus   Y       Operative Report    Y        the unlisted code.               Both




783ac578-3c0e-416d-8adf-38b07bc6a39a.xls
Detail Table Information                                                          Page 7 of 24                       Last Printed: 5/19/2012
Last Updated: 02/18/11.                                           5567839 Unlisted Codes - System Structure
                                                                         Unlisted Codes Categories
                                                                                                            Req Doc
                                                                                                             (Doc,
                                        Are                         Text                                     Text,
 Proc   Effective                       Docs         Doc            Notes                                    Both,
 Code     Date         Short Desc       Req?       Type Req         Req?         Text Note Req Info         Either)

                                                                            Describe the surgical procedure
                 hysteroscope                                               performed and explain the use of
58579   8/9/2010 procedure              Y      Operative Report    Y        the unlisted code.               Both

                                                                            Describe the surgical procedure
                 laparo proc oviduct-                                       performed and explain the use of
58679   8/9/2010 ovary                  Y      Operative Report    Y        the unlisted code.               Both

                                                                            Describe the surgical procedure
                 genital surgery                                            performed and explain the use of
58999   8/9/2010 procedure              Y      Operative Report    Y        the unlisted code.               Both

                                                                            Describe the surgical procedure
                 laparo proc ob                                             performed and explain the use of
59898   8/9/2010 care/deliver           Y      Operative Report    Y        the unlisted code.               Both

                                                                            Describe the surgical procedure
                                                                            performed and explain the use of
60659   8/9/2010 laparo proc endocrine Y       Operative Report    Y        the unlisted code.               Both

                                                                            Describe the surgical procedure
                 endocrine surgery                                          performed and explain the use of
60699   8/9/2010 procedure              Y      Operative Report    Y        the unlisted code.               Both

                                                                            Describe the surgical procedure
                 nervous system                                             performed and explain the use of
64999   8/9/2010 surgery                Y      Operative Report    Y        the unlisted code.               Both

                                                                            Describe the surgical procedure
                 outer ear surgery                                          performed and explain the use of
69399   8/9/2010 procedure              Y      Operative Report    Y        the unlisted code.               Both




783ac578-3c0e-416d-8adf-38b07bc6a39a.xls
Detail Table Information                                                           Page 8 of 24                       Last Printed: 5/19/2012
Last Updated: 02/18/11.                                         5567839 Unlisted Codes - System Structure
                                                                       Unlisted Codes Categories
                                                                                                             Req Doc
                                                                                                              (Doc,
                                      Are                         Text                                        Text,
 Proc   Effective                     Docs         Doc            Notes                                       Both,
 Code     Date         Short Desc     Req?       Type Req         Req?          Text Note Req Info           Either)

                                                                          Describe the surgical procedure
                 middle ear surgery                                       performed and explain the use of
69799   8/9/2010 procedure            Y      Operative Report    Y        the unlisted code.               Both

                                                                          Describe the surgical procedure
                 inner ear surgery                                        performed and explain the use of
69949   8/9/2010 procedure            Y      Operative Report    Y        the unlisted code.               Both

                                                                          Describe the surgical procedure
                 temporal bone                                            performed and explain the use of
69979   8/9/2010 surgery              Y      Operative Report    Y        the unlisted code.                 Both
                                                                          Describe the procedure
                 casting/strapping                                        performed and explain the use of
29799   8/9/2010 procedure            X      Procedure report    X        the unlisted code.                 Either
                                                                          Describe the procedure
                 nasal surgery                                            performed and explain the use of
30999   8/9/2010 procedure            X      Procedure report    X        the unlisted code.                 Either
                                                                          Describe the procedure
                 sinus surgery                                            performed and explain the use of
31299   8/9/2010 procedure            X      Procedure report    X        the unlisted code.                 Either
                                                                          Describe the procedure
                 larynx surgery                                           performed and explain the use of
31599   8/9/2010 procedure            X      Procedure report    X        the unlisted code.                 Either
                                                                          Describe the procedure
                 airways surgical                                         performed and explain the use of
31899   8/9/2010 procedure            X      Procedure report    X        the unlisted code.                 Either
                                                                          Describe the procedure
                 chest surgery                                            performed and explain the use of
32999   8/9/2010 procedure            X      Procedure report    X        the unlisted code.                 Either
                                                                          Describe the procedure
                 cardiac surgery                                          performed and explain the use of
33999   8/9/2010 procedure            X      Procedure report    X        the unlisted code.                 Either




783ac578-3c0e-416d-8adf-38b07bc6a39a.xls
Detail Table Information                                                         Page 9 of 24                          Last Printed: 5/19/2012
Last Updated: 02/18/11.                                          5567839 Unlisted Codes - System Structure
                                                                        Unlisted Codes Categories
                                                                                                              Req Doc
                                                                                                               (Doc,
                                       Are                         Text                                        Text,
 Proc   Effective                      Docs         Doc            Notes                                       Both,
 Code     Date         Short Desc      Req?       Type Req         Req?          Text Note Req Info           Either)
                                                                           Describe the procedure
                 vessel injection                                          performed and explain the use of
36299   8/9/2010 procedure             X      Procedure report    X        the unlisted code.                 Either
                                                                           Describe the procedure
                 blood/lymph system                                        performed and explain the use of
38999   8/9/2010 procedure             X      Procedure report    X        the unlisted code.                 Either
                                                                           Describe the procedure
                                                                           performed and explain the use of
59897   8/9/2010 fetal invas px w/us   X      Procedure report    X        the unlisted code.                 Either
                                                                           Describe the procedure
                 maternity care                                            performed and explain the use of
59899   8/9/2010 procedure             X      Procedure report    X        the unlisted code.                 Either
                                                                           Describe the procedure
                                                                           performed and explain the use of
66999   8/9/2010 eye surgery procedure X      Procedure report    X        the unlisted code.                 Either
                                                                           Describe the procedure
                                                                           performed and explain the use of
67299   8/9/2010 eye surgery procedure X      Procedure report    X        the unlisted code.                 Either
                                                                           Describe the procedure
                 eye muscle surgery                                        performed and explain the use of
67399   8/9/2010 procedure             X      Procedure report    X        the unlisted code.                 Either
                                                                           Describe the procedure
                 orbit surgery                                             performed and explain the use of
67599   8/9/2010 procedure             X      Procedure report    X        the unlisted code.                 Either
                                                                           Describe the procedure
                                                                           performed and explain the use of
67999   8/9/2010 revision of eyelid    X      Procedure report    X        the unlisted code.                 Either
                                                                           Describe the procedure
                                                                           performed and explain the use of
68399   8/9/2010 eyelid lining surgery X      Procedure report    X        the unlisted code.                 Either
                                                                           Describe the procedure
                 tear duct system                                          performed and explain the use of
68899   8/9/2010 surgery               X      Procedure report    X        the unlisted code.                 Either




783ac578-3c0e-416d-8adf-38b07bc6a39a.xls
Detail Table Information                                                         Page 10 of 24                          Last Printed: 5/19/2012
Last Updated: 02/18/11.                                            5567839 Unlisted Codes - System Structure
                                                                          Unlisted Codes Categories
                                                                                                                Req Doc
                                                                                                                 (Doc,
                                         Are                         Text                                        Text,
 Proc   Effective                        Docs         Doc            Notes                                       Both,
 Code     Date         Short Desc        Req?       Type Req         Req?          Text Note Req Info           Either)
                                                                             Describe the procedure
                                                                             performed and explain the use of
86999   8/9/2010 transfusion procedure X        Procedure report    X        the unlisted code.                 Either
                                                                             Describe the procedure
                                                                             performed and explain the use of
90399   8/9/2010 immune globulin        X       Procedure report    X        the unlisted code.                 Either
                                                                             Describe the procedure
                                                                             performed and explain the use of
90999   8/9/2010 dialysis procedure     X       Procedure report    X        the unlisted code.                 Either
                                                                             Describe the procedure
                 gastroenterology                                            performed and explain the use of
91299   8/9/2010 procedure              X       Procedure report    X        the unlisted code.                 Either
                                                                             Describe the procedure
                 eye service or                                              performed and explain the use of
92499   8/9/2010 procedure              X       Procedure report    X        the unlisted code.                 Either
                                                                             Describe the procedure
                                                                             performed and explain the use of
92700   8/9/2010 ent procedure/service X        Procedure report    X        the unlisted code.                 Either
                                                                             Describe the procedure
                 cardiovascular                                              performed and explain the use of
93799   8/9/2010 procedure               X      Procedure report    X        the unlisted code.                 Either
                 respiratory services in                                     Describe the procedure
                 the outpatient                                              performed and explain the use of
94799   8/9/2010 hospital                X      Procedure report    X        the unlisted code.                 Either
                                                                             Describe the procedure
                 allergy immunology                                          performed and explain the use of
95199   8/9/2010 services               X       Procedure report    X        the unlisted code.                 Either
                                                                             Describe the procedure
                 neurological                                                performed and explain the use of
95999   8/9/2010 procedure              X       Procedure report    X        the unlisted code.                 Either
                                                                             Describe the procedure
                 ther/prop/diag inj/inf                                      performed and explain the use of
96379   8/9/2010 proc                   X       Procedure report    X        the unlisted code.                 Either




783ac578-3c0e-416d-8adf-38b07bc6a39a.xls
Detail Table Information                                                           Page 11 of 24                          Last Printed: 5/19/2012
Last Updated: 02/18/11.                                           5567839 Unlisted Codes - System Structure
                                                                         Unlisted Codes Categories
                                                                                                               Req Doc
                                                                                                                (Doc,
                                        Are                         Text                                        Text,
 Proc   Effective                       Docs         Doc            Notes                                       Both,
 Code     Date         Short Desc       Req?       Type Req         Req?          Text Note Req Info           Either)
                                                                            Describe the procedure
                                                                            performed and explain the use of
96549   8/9/2010 chemotherapy           X      Procedure report    X        the unlisted code.                 Either
                                                                            Describe the procedure
                 dermatological                                             performed and explain the use of
96999   8/9/2010 procedure              X      Procedure report    X        the unlisted code.                 Either
                                                                            Describe the procedure
                 physical therapy                                           performed and explain the use of
97039   8/9/2010 treatment              X      Procedure report    X        the unlisted code.                 Either
                                                                            Describe the procedure
                 physical medicine                                          performed and explain the use of
97139   8/9/2010 procedure              X      Procedure report    X        the unlisted code.                 Either
                                                                            Describe the procedure
                 physical medicine                                          performed and explain the use of
97799   8/9/2010 procedure              X      Procedure report    X        the unlisted code.                 Either
                                                                            Describe the procedure
                 other oral pathology                                       performed and explain the use of
D0502   8/9/2010 procedu                X      Procedure report    X        the unlisted code.                 Either
                                                                            Describe the procedure
                 unspecified                                                performed and explain the use of
D0999   8/9/2010 diagnostic proce       X      Procedure report    X        the unlisted code.                 Either
                                                                            Describe the procedure
                 dental unspec                                              performed and explain the use of
D2999   8/9/2010 restorative pr         X      Procedure report    X        the unlisted code.                 Either
                                                                            Describe the procedure
                                                                            performed and explain the use of
D3999   8/9/2010 endodontic procedure X        Procedure report    X        the unlisted code.                 Either
                                                                            Describe the procedure
                 unspecified                                                performed and explain the use of
D4999   8/9/2010 periodontal proc       X      Procedure report    X        the unlisted code.                 Either
                                                                            Describe the procedure
                 removable                                                  performed and explain the use of
D5899   8/9/2010 prosthodontic proc     X      Procedure report    X        the unlisted code.                 Either




783ac578-3c0e-416d-8adf-38b07bc6a39a.xls
Detail Table Information                                                          Page 12 of 24                          Last Printed: 5/19/2012
Last Updated: 02/18/11.                                          5567839 Unlisted Codes - System Structure
                                                                        Unlisted Codes Categories
                                                                                                              Req Doc
                                                                                                               (Doc,
                                       Are                         Text                                        Text,
 Proc   Effective                      Docs         Doc            Notes                                       Both,
 Code     Date         Short Desc      Req?       Type Req         Req?          Text Note Req Info           Either)
                                                                           Describe the procedure
                 maxillofacial                                             performed and explain the use of
D5999   8/9/2010 prosthesis            X      Procedure report    X        the unlisted code.                 Either
                                                                           Describe the procedure
                                                                           performed and explain the use of
D6199   8/9/2010 implant procedure     X      Procedure report    X        the unlisted code.                 Either
                                                                           Describe the procedure
                 fixed prosthodontic                                       performed and explain the use of
D6999   8/9/2010 proc                  X      Procedure report    X        the unlisted code.                 Either
                                                                           Describe the procedure
                 tmj unspecified                                           performed and explain the use of
D7899   8/9/2010 therapy               X      Procedure report    X        the unlisted code.                 Either
                                                                           Describe the procedure
                 oral surgery                                              performed and explain the use of
D7999   8/9/2010 procedure             X      Procedure report    X        the unlisted code.                 Either
                                                                           Describe the procedure
                 orthodontic                                               performed and explain the use of
D8999   8/9/2010 procedure             X      Procedure report    X        the unlisted code.                 Either
                                                                           Describe the procedure
                                                                           performed and explain the use of
D9999   8/9/2010 adjunctive procedure X       Procedure report    X        the unlisted code.                 Either
                                                                           Describe the procedure
                 miscellaneous vision                                      performed and explain the use of
V2799   8/9/2010 service              X       Procedure report    X        the unlisted code.                 Either
                                                                           Describe the procedure
                                                                           performed and explain the use of
V5299   8/9/2010 hearing service       X      Procedure report    X        the unlisted code.                 Either
                                                                           Describe the radiology
                                                                           procedure performed and
                 fluoroscopic                                              explain the use of the unlisted
76496   8/9/2010 procedure             X      Radiology Report    X        code.                              Either
                                                                           Describe the radiology
                                                                           procedure performed and
                                                                           explain the use of the unlisted
76497   8/9/2010 ct procedure          X      Radiology Report    X        code.                              Either

783ac578-3c0e-416d-8adf-38b07bc6a39a.xls
Detail Table Information                                                         Page 13 of 24                          Last Printed: 5/19/2012
Last Updated: 02/18/11.                                          5567839 Unlisted Codes - System Structure
                                                                        Unlisted Codes Categories
                                                                                                             Req Doc
                                                                                                              (Doc,
                                       Are                         Text                                       Text,
 Proc   Effective                      Docs         Doc            Notes                                      Both,
 Code     Date         Short Desc      Req?       Type Req         Req?          Text Note Req Info          Either)
                                                                           Describe the radiology
                                                                           procedure performed and
                                                                           explain the use of the unlisted
76498   8/9/2010 mri procedure         X      Radiology Report    X        code.                             Either
                                                                           Describe the radiology
                                                                           procedure performed and
                 other x-rays in the                                       explain the use of the unlisted
76499   8/9/2010 outpatient hospital   X      Radiology Report    X        code.                             Either
                                                                           Describe the radiology
                                                                           procedure performed and
                 echo examination                                          explain the use of the unlisted
76999   8/9/2010 procedure             X      Radiology Report    X        code.                             Either
                                                                           Describe the radiology
                 other medical testing                                     procedure performed and
                 in the outpatient                                         explain the use of the unlisted
78999   8/9/2010 hospital              X      Radiology Report    X        code.                             Either

                                                                           Describe the radiation therapy
                 radiation therapy            Radiation Therapy            performed and explain the use of
77299   8/9/2010 planning              Y      Report            Y          the unlisted code.               Both

                                                                           Describe the radiation therapy
                 external radiation           Radiation Therapy            performed and explain the use of
77399   8/9/2010 dosimetry             Y      Report            Y          the unlisted code.               Both

                                                                           Describe the radiation therapy
                                              Radiation Therapy            performed and explain the use of
77499   8/9/2010 radiation therapy     Y      Report            Y          the unlisted code.               Both

                                                                           Describe the radiation therapy
                 radium/radioisotope          Radiation Therapy            performed and explain the use of
77799   8/9/2010 therapy               Y      Report            Y          the unlisted code.               Both




783ac578-3c0e-416d-8adf-38b07bc6a39a.xls
Detail Table Information                                                          Page 14 of 24                        Last Printed: 5/19/2012
Last Updated: 02/18/11.                                      5567839 Unlisted Codes - System Structure
                                                                    Unlisted Codes Categories
                                                                                                       Req Doc
                                                                                                        (Doc,
                                       Are                     Text                                     Text,
 Proc   Effective                      Docs         Doc        Notes                                    Both,
 Code     Date         Short Desc      Req?       Type Req     Req?         Text Note Req Info         Either)

                                                                       Describe the radiation therapy
                 endocrine nuclear            Radiation Therapy        performed and explain the use of
78099   8/9/2010 procedure             Y      Report            Y      the unlisted code.               Both

                                                                       Describe the radiation therapy
                 blood/lymph nuclear          Radiation Therapy        performed and explain the use of
78199   8/9/2010 exam                Y        Report            Y      the unlisted code.               Both

                                                                       Describe the radiation therapy
                                              Radiation Therapy        performed and explain the use of
78299   8/9/2010 gi nuclear procedure Y       Report            Y      the unlisted code.               Both

                                                                       Describe the radiation therapy
                 musculoskeletal              Radiation Therapy        performed and explain the use of
78399   8/9/2010 nuclear exam          Y      Report            Y      the unlisted code.               Both

                                                                       Describe the radiation therapy
                 cardiovascular               Radiation Therapy        performed and explain the use of
78499   8/9/2010 nuclear exam          Y      Report            Y      the unlisted code.               Both

                                                                       Describe the radiation therapy
                 respiratory nuclear          Radiation Therapy        performed and explain the use of
78599   8/9/2010 exam                  Y      Report            Y      the unlisted code.               Both

                                                                       Describe the radiation therapy
                 nervous system               Radiation Therapy        performed and explain the use of
78699   8/9/2010 nuclear exam          Y      Report            Y      the unlisted code.               Both

                                                                       Describe the radiation therapy
                 genitourinary nuclear        Radiation Therapy        performed and explain the use of
78799   8/9/2010 exam                  Y      Report            Y      the unlisted code.               Both




783ac578-3c0e-416d-8adf-38b07bc6a39a.xls
Detail Table Information                                                     Page 15 of 24                       Last Printed: 5/19/2012
Last Updated: 02/18/11.                                        5567839 Unlisted Codes - System Structure
                                                                      Unlisted Codes Categories
                                                                                                            Req Doc
                                                                                                             (Doc,
                                        Are                      Text                                        Text,
 Proc   Effective                       Docs         Doc         Notes                                       Both,
 Code     Date         Short Desc       Req?       Type Req      Req?          Text Note Req Info           Either)

                                                                         Describe the radiation therapy
                 nuclear medicine              Radiation Therapy         performed and explain the use of
79999   8/9/2010 therapy               Y       Report             Y      the unlisted code.                 Both
                                               Supplier's invoice        Describe the implant used and
                                               and Operative             explain the use of the unlisted
L8699   8/9/2010 prosthetic implant nos Y      Report             Y      code.                              Both
                                                                         Describe the lab service
                 quantitative assay                                      performed and explain the use of
80299   8/9/2010 drug                  X       Lab Report        X       the unlisted code.                 Either
                                                                         Describe the lab service
                 urinalysis test                                         performed and explain the use of
81099   8/9/2010 procedure             X       Lab Report        X       the unlisted code.                 Either
                                                                         Describe the lab service
                 other labs in the                                       performed and explain the use of
84999   8/9/2010 outpatient hospital   X       Lab Report        X       the unlisted code.                 Either
                                                                         Describe the lab service
                 hematology                                              performed and explain the use of
85999   8/9/2010 procedure             X       Lab Report        X       the unlisted code.                 Either
                                                                         Describe the lab service
                 immunology                                              performed and explain the use of
86849   8/9/2010 procedure             X       Lab Report        X       the unlisted code.                 Either
                                                                         Describe the lab service
                 antibody detection                                      performed and explain the use of
87299   8/9/2010 nos if                X       Lab Report        X       the unlisted code.                 Either
                                                                         Describe the lab service
                 agent nos assay                                         performed and explain the use of
87899   8/9/2010 w/optic               X       Lab Report        X       the unlisted code.                 Either
                                                                         Describe the lab service
                 microbiology                                            performed and explain the use of
87999   8/9/2010 procedure             X       Lab Report        X       the unlisted code.                 Either
                                                                         Describe the lab service
                 cytopathology                                           performed and explain the use of
88199   8/9/2010 procedure             X       Lab Report        X       the unlisted code.                 Either


783ac578-3c0e-416d-8adf-38b07bc6a39a.xls
Detail Table Information                                                       Page 16 of 24                          Last Printed: 5/19/2012
Last Updated: 02/18/11.                                            5567839 Unlisted Codes - System Structure
                                                                          Unlisted Codes Categories
                                                                                                                Req Doc
                                                                                                                 (Doc,
                                         Are                         Text                                        Text,
 Proc   Effective                        Docs         Doc            Notes                                       Both,
 Code     Date         Short Desc        Req?       Type Req         Req?          Text Note Req Info           Either)
                                                                             Describe the lab service
                                                                             performed and explain the use of
88299   8/9/2010 cytogenetic study       X      Lab Report          X        the unlisted code.                 Either
                                                                             Describe the lab service
                                                                             performed and explain the use of
88749   1/1/2011 in vivo lab service     X      Lab Report          X        the unlisted code.                 Either
                                                                             Describe the lab service
                 unlisted reprod med                                         performed and explain the use of
89398   8/9/2010 lab proc                X      Lab Report          X        the unlisted code.                 Either
                                                                             Describe the lab service
                 drug screen multi                                           performed and explain the use of
G0434   1/1/2011 drug class              X      Lab Report          X        the unlisted code.                 Either
                                                                             Describe the pathology
                 surgical pathology                                          performed and explain the use of   Documen
88399   8/9/2010 procedure               Y      Pathology Report    N        the unlisted code.                 t
                                                                             Describe the pathology
                 pathology lab                                               performed and explain the use of   Documen
89240   8/9/2010 procedure               Y      Pathology Report    N        the unlisted code.                 t
                                                                             Enter NDC quantity, unit of
90749   8/9/2010 vaccine toxoid          N                          Y        measure, and common name.          Text
                 radiopharm dx agent                                         Enter NDC quantity, unit of
A4641   8/9/2010 noc                     N                          Y        measure, and common name.          Text
                 non-rad contrast                                            Enter NDC quantity, unit of
A9698   8/9/2010 materialnoc             N                          Y        measure, and common name.          Text
                 radiopharm rx agent                                         Enter NDC quantity, unit of
A9699   8/9/2010 noc                     N                          Y        measure, and common name.          Text
                 unclassified drugs or                                       Enter NDC quantity, unit of
C9399   8/9/2010 biolog                  N                          Y        measure, and common name.          Text
                 other                                                       Enter NDC quantity, unit of
D9630   8/9/2010 drugs/medicaments       N                          Y        measure, and common name.          Text
                 drug charges not                                            Enter NDC quantity, unit of
J3490   8/9/2010 otherwise specified     N                          Y        measure, and common name.          Text
                                                                             Enter NDC quantity, unit of
J3590   8/9/2010 unclassified biologics N                           Y        measure, and common name.          Text



783ac578-3c0e-416d-8adf-38b07bc6a39a.xls
Detail Table Information                                                           Page 17 of 24                          Last Printed: 5/19/2012
Last Updated: 02/18/11.                                               5567839 Unlisted Codes - System Structure
                                                                             Unlisted Codes Categories
                                                                                                                   Req Doc
                                                                                                                    (Doc,
                                              Are                       Text                                        Text,
 Proc   Effective                             Docs         Doc          Notes                                       Both,
 Code     Date            Short Desc          Req?       Type Req       Req?           Text Note Req Info          Either)
                    hemophilia clot factor                                      Enter NDC quantity, unit of
J7199   8/9/2010    noc                       N                        Y        measure, and common name.          Text
                    immunosuppressive                                           Enter NDC quantity, unit of
J7599   8/9/2010    drug noc                  N                        Y        measure, and common name.          Text
                    inhalation solution for                                     Enter NDC quantity, unit of
J7699   8/9/2010    dme                       N                        Y        measure, and common name.          Text
                    non-inhalation drug                                         Enter NDC quantity, unit of
J7799   8/9/2010    for dme                   N                        Y        measure, and common name.          Text
                    antiemetic rectal/supp                                      Enter NDC quantity, unit of
J8498   8/9/2010    nos                       N                        Y        measure, and common name.          Text
                    oral prescrip drug                                          Enter NDC quantity, unit of
J8499   8/9/2010    non chemo                 N                        Y        measure, and common name.          Text
                    antiemetic drug oral                                        Enter NDC quantity, unit of
J8597   8/9/2010    nos                       N                        Y        measure, and common name.          Text
                    oral prescription drug                                      Enter NDC quantity, unit of
J8999   8/9/2010    chemo                     N                        Y        measure, and common name.          Text
                                                                                Enter NDC quantity, unit of
J9999  8/9/2010 chemotherapy drug N                                    Y        measure, and common name.          Text
                nos flu vacc, 3 yrs &                                           Enter NDC quantity, unit of
Q2039 10/1/2010 >, im                 N                                Y        measure, and common name.          Text
                drug/bio noc part b                                             Enter NDC quantity, unit of
Q4082 8/9/2010 drug cap               N                                Y        measure, and common name.          Text
                                                                                Describe the psychiatric service
                 psychiatric                                                    performed and explain the use of
90899   8/9/2010 service/therapy              N                        Y        the unlisted code.                 Text
                                                                                Describe the preventive service
                 unlisted preventive                                            performed and explain the use of
99429   8/9/2010 service                      N                        Y        the unlisted code.                 Text
                                                                                Describe the evaluation and
                 other ancillary                                                management service performed
                 charges in the                                                 and explain the use of the
99499   8/9/2010 outpatient hospital          N                        Y        unlisted code.                     Text
                                                                                Describe the home service
                                                                                performed and explain the use of
99600   8/9/2010 home visit nos               N      Progress Notes    Y        the unlisted code.                 Text

783ac578-3c0e-416d-8adf-38b07bc6a39a.xls
Detail Table Information                                                              Page 18 of 24                          Last Printed: 5/19/2012
Last Updated: 02/18/11.                                             5567839 Unlisted Codes - System Structure
                                                                           Unlisted Codes Categories
                                                                                                                Req Doc
                                                                                                                 (Doc,
                                        Are                           Text                                       Text,
 Proc   Effective                       Docs         Doc              Notes                                      Both,
 Code     Date         Short Desc       Req?       Type Req           Req?          Text Note Req Info          Either)
                                                                              Describe the supplies or DME
                                                                              provided and explain the use of
A4335   8/9/2010 incontinence supply   Y       Supplier's invoice    Y        the unlisted code.                Both
                                                                              Describe the supplies or DME
                                                                              provided and explain the use of
A4421   8/9/2010 ostomy supply misc    Y       Supplier's invoice    Y        the unlisted code.                Both
                                                                              Describe the supplies or DME
                                                                              provided and explain the use of
A4649   8/9/2010 surgical supplies     Y       Supplier's invoice    Y        the unlisted code.                Both
                                                                              Describe the supplies or DME
                 misc dialysis supplies                                       provided and explain the use of
A4913   8/9/2010 noc                    Y      Supplier's invoice    Y        the unlisted code.                Both
                                                                              Describe the supplies or DME
                 compres burn                                                 provided and explain the use of
A6512   8/9/2010 garment, noc          Y       Supplier's invoice    Y        the unlisted code.                Both
                                                                              Describe the supplies or DME
                 g compression                                                provided and explain the use of
A6549   8/9/2010 stocking              Y       Supplier's invoice    Y        the unlisted code.                Both
                                                                              Describe the supplies or DME
                 supply/accessory/serv                                        provided and explain the use of
A9900   8/9/2010 ice                   Y       Supplier's invoice    Y        the unlisted code.                Both
                                                                              Describe the supplies or DME
                 dme supply or                                                provided and explain the use of
A9999   8/9/2010 accessory, nos        Y       Supplier's invoice    Y        the unlisted code.                Both
                                                                              Describe the supplies or DME
                 patient lift bathroom                                        provided and explain the use of
E0625   8/9/2010 or toi                Y       Supplier's invoice    Y        the unlisted code.                Both
                                                                              Describe the supplies or DME
                 inter limb compress                                          provided and explain the use of
E0676   8/9/2010 dev nos               Y       Supplier's invoice    Y        the unlisted code.                Both
                                                                              Describe the supplies or DME
                 electric wound                                               provided and explain the use of
E0769   8/9/2010 treatment dev         Y       Supplier's invoice    Y        the unlisted code.                Both




783ac578-3c0e-416d-8adf-38b07bc6a39a.xls
Detail Table Information                                                            Page 19 of 24                         Last Printed: 5/19/2012
Last Updated: 02/18/11.                                             5567839 Unlisted Codes - System Structure
                                                                           Unlisted Codes Categories
                                                                                                                Req Doc
                                                                                                                 (Doc,
                                        Are                           Text                                       Text,
 Proc   Effective                       Docs         Doc              Notes                                      Both,
 Code     Date         Short Desc       Req?       Type Req           Req?          Text Note Req Info          Either)
                                                                              Describe the supplies or DME
                 pediatric wheelchair                                         provided and explain the use of
E1229   8/9/2010 nos                    Y      Supplier's invoice    Y        the unlisted code.                Both
                                                                              Describe the supplies or DME
                 ped power wheelchair                                         provided and explain the use of
E1239   8/9/2010 nos                  Y        Supplier's invoice    Y        the unlisted code.                Both
                                                                              Describe the supplies or DME
                 durable medical                                              provided and explain the use of
E1399   8/9/2010 equipment mi           Y      Supplier's invoice    Y        the unlisted code.                Both
                                                                              Describe the supplies or DME
                 dialysis equipment                                           provided and explain the use of
E1699   8/9/2010 noc                    Y      Supplier's invoice    Y        the unlisted code.                Both
                                                                              Describe the supplies or DME
                                                                              provided and explain the use of
E2599   8/9/2010 sgd accessory noc      Y      Supplier's invoice    Y        the unlisted code.                Both
                                                                              Describe the supplies or DME
                 w/c component-                                               provided and explain the use of
K0108   8/9/2010 accessory nos          Y      Supplier's invoice    Y        the unlisted code.                Both
                                                                              Describe the supplies or DME
                 power operated                                               provided and explain the use of
K0812   8/9/2010 vehicle noc            Y      Supplier's invoice    Y        the unlisted code.                Both
                                                                              Describe the supplies or DME
                                                                              provided and explain the use of
K0898   8/9/2010 power wheelchair noc Y        Supplier's invoice    Y        the unlisted code.                Both
                                                                              Describe the supplies or DME
                 pow mobil dev no                                             provided and explain the use of
K0899   8/9/2010 dme pdac               Y      Supplier's invoice    Y        the unlisted code.                Both
                                                                              Describe the supplies or DME
                 add to spinal orthosis                                       provided and explain the use of
L0999   8/9/2010 nos                    Y      Supplier's invoice    Y        the unlisted code.                Both
                                                                              Describe the supplies or DME
                                                                              provided and explain the use of
L1499   8/9/2010 spinal orthosis nos    Y      Supplier's invoice    Y        the unlisted code.                Both




783ac578-3c0e-416d-8adf-38b07bc6a39a.xls
Detail Table Information                                                            Page 20 of 24                         Last Printed: 5/19/2012
Last Updated: 02/18/11.                                             5567839 Unlisted Codes - System Structure
                                                                           Unlisted Codes Categories
                                                                                                                Req Doc
                                                                                                                 (Doc,
                                        Are                           Text                                       Text,
 Proc   Effective                       Docs         Doc              Notes                                      Both,
 Code     Date         Short Desc       Req?       Type Req           Req?          Text Note Req Info          Either)
                                                                              Describe the supplies or DME
                 lower extremity                                              provided and explain the use of
L2999   8/9/2010 orthosis nos          Y       Supplier's invoice    Y        the unlisted code.                Both
                                                                              Describe the supplies or DME
                 upper limb orthosis                                          provided and explain the use of
L3999   8/9/2010 nos                   Y       Supplier's invoice    Y        the unlisted code.                Both
                                                                              Describe the supplies or DME
                 lowr extremity                                               provided and explain the use of
L5999   8/9/2010 prosthes nos          Y       Supplier's invoice    Y        the unlisted code.                Both
                                                                              Describe the supplies or DME
                 upper extremity                                              provided and explain the use of
L7499   8/9/2010 prosthes nos          Y       Supplier's invoice    Y        the unlisted code.                Both
                                                                              Describe the supplies or DME
                                                                              provided and explain the use of
L8039   8/9/2010 breast prosthesis nos Y       Supplier's invoice    Y        the unlisted code.                Both
                                                                              Describe the supplies or DME
                 unspec maxillofacial                                         provided and explain the use of
L8048   8/9/2010 prosth               Y        Supplier's invoice    Y        the unlisted code.                Both
                                                                              Describe the supplies or DME
                 unlisted misc                                                provided and explain the use of
L8499   8/9/2010 prosthetic ser        Y       Supplier's invoice    Y        the unlisted code.                Both
                                                                              Describe the supplies or DME
                 miscl                                                        provided and explain the use of
Q0505   8/9/2010 supply/accessory vad Y        Supplier's invoice    Y        the unlisted code.                Both
                                                                              Describe the supplies or DME
                                                                              provided and explain the use of
Q4050   8/9/2010 cast supplies unlisted Y      Supplier's invoice    Y        the unlisted code.                Both
                                                                              Describe the supplies or DME
                 noc retail items                                             provided and explain the use of
T1999   8/9/2010 andsupplies           Y       Supplier's invoice    Y        the unlisted code.                Both
                                                                              Describe the supplies or DME
                 lens single vision not                                       provided and explain the use of
V2199   8/9/2010 oth c                  Y      Supplier's invoice    Y        the unlisted code.                Both




783ac578-3c0e-416d-8adf-38b07bc6a39a.xls
Detail Table Information                                                            Page 21 of 24                         Last Printed: 5/19/2012
Last Updated: 02/18/11.                                               5567839 Unlisted Codes - System Structure
                                                                             Unlisted Codes Categories
                                                                                                                  Req Doc
                                                                                                                   (Doc,
                                          Are                           Text                                       Text,
 Proc   Effective                         Docs         Doc              Notes                                      Both,
 Code     Date          Short Desc        Req?       Type Req           Req?          Text Note Req Info          Either)
                                                                                Describe the supplies or DME
                                                                                provided and explain the use of
V2299   8/9/2010 lens bifocal speciality Y       Supplier's invoice    Y        the unlisted code.                Both
                                                                                Describe the supplies or DME
                                                                                provided and explain the use of
V2399   8/9/2010 lens trifocal speciality Y      Supplier's invoice    Y        the unlisted code.                Both
                                                                                Describe the supplies or DME
                 variable asphericity                                           provided and explain the use of
V2499   8/9/2010 lens                    Y       Supplier's invoice    Y        the unlisted code.                Both
                                                                                Describe the supplies or DME
                 contact lens/es other                                          provided and explain the use of
V2599   8/9/2010 type                    Y       Supplier's invoice    Y        the unlisted code.                Both
                                                                                Describe the supplies or DME
                 prosthetic eye other                                           provided and explain the use of
V2629   8/9/2010 type                    Y       Supplier's invoice    Y        the unlisted code.                Both
                                                                                Describe the supplies or DME
                                                                                provided and explain the use of
V5298   8/9/2010 hearing aid noc         Y       Supplier's invoice    Y        the unlisted code.                Both
                                                                                Describe the supplies or DME
                 enteral supp not                                               provided and explain the use of
B9998   8/9/2010 otherwise c             Y       Supplier's invoice    Y        the unlisted code.                Both
                                                                                Describe the supplies or DME
                 parenteral supp not                                            provided and explain the use of
B9999   8/9/2010 othrws c                Y       Supplier's invoice    Y        the unlisted code.                Both
                                                                                Describe the ambulance service
                 unlisted ambulance                                             provided and explain the use of
A0999   8/9/2010 service                 N                             Y        the unlisted code.                Text
TBD                                      N                             N




783ac578-3c0e-416d-8adf-38b07bc6a39a.xls
Detail Table Information                                                              Page 22 of 24                         Last Printed: 5/19/2012
Last Updated: 02/16/11                                       5567839 Unlisted Code - System Structure
                                                                     Unlisted Code Summary


                                                                      Req Doc
                         Doc                      Are Docs Text Notes (Doc, Text,
Cat Desc                 Type Req                 Req?     Req?       Both, Either) EOB/Eloquance Verbiage
                                                                                    Please code using standard industry coding. If no code is available please
                                                                                    provide a copy of the surgeon's operative report or a detailed description
(A) Anesthesia           Op report                Y        Y          Both          of the anesthesia procedure
                                                                                    Please recode this surgery using standard industry coding or provide an
                                                                                    operative report which points out why this surgery does not meet the
(B) Surgery              Op report                Y        Y          Both          requirements of the standard coding.
                                                                                    Please recode using standard industry listed procedure codes or provide a
(C) Procedures           Procedure report         X        X          Either        copy of the procedure report detailing the service.
                                                                                    Please recode using standard industry coding or provide a detailed
(D) Radiology            Radiology Report         X        X          Either        radiology report.
                                                                                    Please recode this using standard industry coding or provide a radiation
                                                                                    therapy report signed by the physician indicating what services were
(E) Rad Therapy          Radiation Therapy Report Y        Y          Both          performed.
                                                                                    Please recode with a standard industry listed code or provide a
                         Supplier's invoice and                                     description of services,manufacturer's or supplier's invoice and Operative
(F) Implants             Operative Report         Y        Y          Both          Report
                                                                                    Please recode using standard industry coding or provide a lab report
(G) Lab Report           Lab Report               X        X          Either        indicating what services were performed.
                                                                                    Please recode using standard industry coding or provide the Pathology
(H) Pathology            Pathology Report         Y        N          Document      report detailing the services provided.
                                                                                    Please recode with a standard industry listed code or provide the
                                                                                    National Drug Code, Drug Quantity, Drug Measurement and the English
(J) Drugs                None                     N        Y          Text          name of this drug.

                                                                                          Please provide the Psychiatric Progress Notes and the description of the
(K) Psych                None                     N          Y            Text            services performed or recode using standard psychiatric procedure codes.
                                                                                          Please use standard industry evaluation and management codes or
(L) E M Codes            None                     N          Y            Text            provide detailed office notes.
                                                                                          Please recode with a standard industry listed code or provide detailed
(M) Home Health          Progress Notes           N          Y            Text            progress notes.

783ac578-3c0e-416d-8adf-38b07bc6a39a.xls
783ac578-3c0e-416d-8adf-38b07bc6a39a.xls                                  Page 23 of 24                                                       Last Printed: 5/19/2012
Last Updated: 02/16/11                                 5567839 Unlisted Code - System Structure
                                                               Unlisted Code Summary


                                                                  Req Doc
                         Doc                  Are Docs Text Notes (Doc, Text,
Cat Desc                 Type Req             Req?     Req?       Both, Either) EOB/Eloquance Verbiage

                                                                                    Please recode with a standard industry listed code or provide a
(N) Supply/DME           Supplier's invoice   Y        Y           Both             description of services and a manufacturer's or supplier's invoice.

                                                                                    Please recode with a standard industry listed code or provide a
(O) Other                Supplier's invoice   Y        Y           Both             description of services and a manufacturer's or supplier's invoice.
                                                                                    Please recode the claim with standard industry ambulance codes and
(X) Ambulance            None                 N        Y           Text             modifiers or provide detailed Trip report.
(ZZ) Exceptions          None                 N        N           None             (blank)
Grand Total




783ac578-3c0e-416d-8adf-38b07bc6a39a.xls
783ac578-3c0e-416d-8adf-38b07bc6a39a.xls                            Page 24 of 24                                                          Last Printed: 5/19/2012

								
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