apc_fee_schedule03202007

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					State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
00100       Anesth, salivary gland               N           N        0000       0.0000           0.00         0.00         0.00
00102       Anesth, repair of cleft lip          N           N        0000       0.0000           0.00         0.00         0.00
00103       Anesth, blepharoplasty               N           N        0000       0.0000           0.00         0.00         0.00
00104       Anesth, electroshock                 N           N        0000       0.0000           0.00         0.00         0.00
00120       Anesth, ear surgery                  N           N        0000       0.0000           0.00         0.00         0.00
00124       Anesth, ear exam                     N           N        0000       0.0000           0.00         0.00         0.00
00126       Anesth, tympanotomy                  N           N        0000       0.0000           0.00         0.00         0.00
00140       Anesth, procedures on eye            N           N        0000       0.0000           0.00         0.00         0.00
00142       Anesth, lens surgery                 N           N        0000       0.0000           0.00         0.00         0.00
00144       Anesth, corneal transplant           N           N        0000       0.0000           0.00         0.00         0.00
00145       Anesth, vitreoretinal surg           N           N        0000       0.0000           0.00         0.00         0.00
00147       Anesth, iridectomy                   N           N        0000       0.0000           0.00         0.00         0.00
00148       Anesth, eye exam                     N           N        0000       0.0000           0.00         0.00         0.00
00160       Anesth, nose/sinus surgery           N           N        0000       0.0000           0.00         0.00         0.00
00162       Anesth, nose/sinus surgery           N           N        0000       0.0000           0.00         0.00         0.00
00164       Anesth, biopsy of nose               N           N        0000       0.0000           0.00         0.00         0.00
00170       Anesth, procedure on mouth           N           N        0000       0.0000           0.00         0.00         0.00
00172       Anesth, cleft palate repair          N           N        0000       0.0000           0.00         0.00         0.00
00174       Anesth, pharyngeal surgery           N           N        0000       0.0000           0.00         0.00         0.00
00176       Anesth, pharyngeal surgery           C           C        0000       0.0000           0.00         0.00         0.00
00190       Anesth, face/skull bone surg         N           N        0000       0.0000           0.00         0.00         0.00
00192       Anesth, facial bone surgery          C           C        0000       0.0000           0.00         0.00         0.00
00210       Anesth, open head surgery            N           N        0000       0.0000           0.00         0.00         0.00
00212       Anesth, skull drainage               N           N        0000       0.0000           0.00         0.00         0.00
00214       Anesth, skull drainage               C           C        0000       0.0000           0.00         0.00         0.00
00215       Anesth, skull repair/fract           C           C        0000       0.0000           0.00         0.00         0.00
00216       Anesth, head vessel surgery          N           N        0000       0.0000           0.00         0.00         0.00
00218       Anesth, special head surgery         N           N        0000       0.0000           0.00         0.00         0.00
00220       Anesth, intrcrn nerve                N           N        0000       0.0000           0.00         0.00         0.00
00222       Anesth, head nerve surgery           N           N        0000       0.0000           0.00         0.00         0.00
00300       Anesth, head/neck/ptrunk             N           N        0000       0.0000           0.00         0.00         0.00
00320       Anesth, neck organ, 1 & over         N           N        0000       0.0000           0.00         0.00         0.00
00322       Anesth, biopsy of thyroid            N           N        0000       0.0000           0.00         0.00         0.00
00326       Anesth, larynx/trach, < 1 yr         N           N        0000       0.0000           0.00         0.00         0.00
00350       Anesth, neck vessel surgery          N           N        0000       0.0000           0.00         0.00         0.00
00352       Anesth, neck vessel surgery          N           N        0000       0.0000           0.00         0.00         0.00
00400       Anesth, skin, ext/per/atrunk         N           N        0000       0.0000           0.00         0.00         0.00
00402       Anesth, surgery of breast            N           N        0000       0.0000           0.00         0.00         0.00
00404       Anesth, surgery of breast            N           N        0000       0.0000           0.00         0.00         0.00
00406       Anesth, surgery of breast            N           N        0000       0.0000           0.00         0.00         0.00
00410       Anesth, correct heart rhythm         N           N        0000       0.0000           0.00         0.00         0.00
00450       Anesth, surgery of shoulder          N           N        0000       0.0000           0.00         0.00         0.00
00452       Anesth, surgery of shoulder          C           C        0000       0.0000           0.00         0.00         0.00
00454       Anesth, collar bone biopsy           N           N        0000       0.0000           0.00         0.00         0.00
00470       Anesth, removal of rib               N           N        0000       0.0000           0.00         0.00         0.00
00472       Anesth, chest wall repair            N           N        0000       0.0000           0.00         0.00         0.00
00474       Anesth, surgery of rib(s)            C           C        0000       0.0000           0.00         0.00         0.00
00500       Anesth, esophageal surgery           N           N        0000       0.0000           0.00         0.00         0.00
00520       Anesth, chest procedure              N           N        0000       0.0000           0.00         0.00         0.00
00522       Anesth, chest lining biopsy          N           N        0000       0.0000           0.00         0.00         0.00
00524       Anesth, chest drainage               C           C        0000       0.0000           0.00         0.00         0.00
00528       Anesth, chest partition view         N           N        0000       0.0000           0.00         0.00         0.00
00529       Anesth, chest partition view         N           N        0000       0.0000           0.00         0.00         0.00
00530       Anesth, pacemaker insertion          N           N        0000       0.0000           0.00         0.00         0.00
00532       Anesth, vascular access              N           N        0000       0.0000           0.00         0.00         0.00
00534       Anesth, cardioverter/defib           N           N        0000       0.0000           0.00         0.00         0.00
00537       Anesth, cardiac electrophys          N           N        0000       0.0000           0.00         0.00         0.00
00539       Anesth, trach-bronch reconst         N           N        0000       0.0000           0.00         0.00         0.00
00540       Anesth, chest surgery                C           C        0000       0.0000           0.00         0.00         0.00
00541       Anesth, one lung ventilation         N           N        0000       0.0000           0.00         0.00         0.00
00542       Anesth, release of lung              C           C        0000       0.0000           0.00         0.00         0.00
00546       Anesth, lung,chest wall surg         C           C        0000       0.0000           0.00         0.00         0.00
00548       Anesth, trachea,bronchi surg         N           N        0000       0.0000           0.00         0.00         0.00
00550       Anesth, sternal debridement          N           N        0000       0.0000           0.00         0.00         0.00
00560       Anesth, heart surg w/o pump          C           C        0000       0.0000           0.00         0.00         0.00
00561       Anesth, heart surg < age 1           C           C        0000       0.0000           0.00         0.00         0.00
00562       Anesth, heart surg w/pump            C           C        0000       0.0000           0.00         0.00         0.00
00563       Anesth, heart surg w/arrest          N           N        0000       0.0000           0.00         0.00         0.00
00566       Anesth, cabg w/o pump                N           N        0000       0.0000           0.00         0.00         0.00
00580       Anesth, heart/lung transplnt         C           C        0000       0.0000           0.00         0.00         0.00
00600       Anesth, spine, cord surgery          N           N        0000       0.0000           0.00         0.00         0.00
00604       Anesth, sitting procedure            C           C        0000       0.0000           0.00         0.00         0.00
00620       Anesth, spine, cord surgery          N           N        0000       0.0000           0.00         0.00         0.00
00622       Anesth, removal of nerves            C           C        0000       0.0000           0.00         0.00         0.00
00625       Anes spine tranthor w/o vent         N           N        0000       0.0000           0.00         0.00         0.00
00626       Anes, spine transthor w/vent         N           N        0000       0.0000           0.00         0.00         0.00
00630       Anesth, spine, cord surgery          N           N        0000       0.0000           0.00         0.00         0.00
00632       Anesth, removal of nerves            C           C        0000       0.0000           0.00         0.00         0.00
00634       Anesth for chemonucleolysis          N           N        0000       0.0000           0.00         0.00         0.00
00635       Anesth, lumbar puncture              N           N        0000       0.0000           0.00         0.00         0.00
00640       Anesth, spine manipulation           N           N        0000       0.0000           0.00         0.00         0.00
00670       Anesth, spine, cord surgery          C           C        0000       0.0000           0.00         0.00         0.00
00700       Anesth, abdominal wall surg          N           N        0000       0.0000           0.00         0.00         0.00
00702       Anesth, for liver biopsy             N           N        0000       0.0000           0.00         0.00         0.00
00730       Anesth, abdominal wall surg          N           N        0000       0.0000           0.00         0.00         0.00
00740       Anesth, upper gi visualize           N           N        0000       0.0000           0.00         0.00         0.00
00750       Anesth, repair of hernia             N           N        0000       0.0000           0.00         0.00         0.00
00752       Anesth, repair of hernia             N           N        0000       0.0000           0.00         0.00         0.00
00754       Anesth, repair of hernia             N           N        0000       0.0000           0.00         0.00         0.00
00756       Anesth, repair of hernia             N           N        0000       0.0000           0.00         0.00         0.00
00770       Anesth, blood vessel repair          N           N        0000       0.0000           0.00         0.00         0.00
00790       Anesth, surg upper abdomen           N           N        0000       0.0000           0.00         0.00         0.00
00792       Anesth, hemorr/excise liver          C           C        0000       0.0000           0.00         0.00         0.00
00794       Anesth, pancreas removal             C           C        0000       0.0000           0.00         0.00         0.00
00796       Anesth, for liver transplant         C           C        0000       0.0000           0.00         0.00         0.00
00797       Anesth, surgery for obesity          N           N        0000       0.0000           0.00         0.00         0.00
00800       Anesth, abdominal wall surg          N           N        0000       0.0000           0.00         0.00         0.00
00802       Anesth, fat layer removal            C           C        0000       0.0000           0.00         0.00         0.00
00810       Anesth, low intestine scope          N           N        0000       0.0000           0.00         0.00         0.00
00820       Anesth, abdominal wall surg          N           N        0000       0.0000           0.00         0.00         0.00
00830       Anesth, repair of hernia             N           N        0000       0.0000           0.00         0.00         0.00
00832       Anesth, repair of hernia             N           N        0000       0.0000           0.00         0.00         0.00
00834       Anesth, hernia repair< 1 yr          N           N        0000       0.0000           0.00         0.00         0.00
00836       Anesth hernia repair preemie         N           N        0000       0.0000           0.00         0.00         0.00
00840       Anesth, surg lower abdomen           N           N        0000       0.0000           0.00         0.00         0.00



                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 1 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
00842       Anesth, amniocentesis                N           N        0000       0.0000           0.00         0.00         0.00
00844       Anesth, pelvis surgery               C           C        0000       0.0000           0.00         0.00         0.00
00846       Anesth, hysterectomy                 C           C        0000       0.0000           0.00         0.00         0.00
00848       Anesth, pelvic organ surg            C           C        0000       0.0000           0.00         0.00         0.00
00851       Anesth, tubal ligation               N           N        0000       0.0000           0.00         0.00         0.00
00860       Anesth, surgery of abdomen           N           N        0000       0.0000           0.00         0.00         0.00
00862       Anesth, kidney/ureter surg           N           N        0000       0.0000           0.00         0.00         0.00
00864       Anesth, removal of bladder           C           C        0000       0.0000           0.00         0.00         0.00
00865       Anesth, removal of prostate          C           C        0000       0.0000           0.00         0.00         0.00
00866       Anesth, removal of adrenal           C           C        0000       0.0000           0.00         0.00         0.00
00868       Anesth, kidney transplant            C           C        0000       0.0000           0.00         0.00         0.00
00870       Anesth, bladder stone surg           N           N        0000       0.0000           0.00         0.00         0.00
00872       Anesth kidney stone destruct         N           N        0000       0.0000           0.00         0.00         0.00
00873       Anesth kidney stone destruct         N           N        0000       0.0000           0.00         0.00         0.00
00880       Anesth, abdomen vessel surg          N           N        0000       0.0000           0.00         0.00         0.00
00882       Anesth, major vein ligation          C           C        0000       0.0000           0.00         0.00         0.00
00902       Anesth, anorectal surgery            N           N        0000       0.0000           0.00         0.00         0.00
00904       Anesth, perineal surgery             C           C        0000       0.0000           0.00         0.00         0.00
00906       Anesth, removal of vulva             N           N        0000       0.0000           0.00         0.00         0.00
00908       Anesth, removal of prostate          C           C        0000       0.0000           0.00         0.00         0.00
00910       Anesth, bladder surgery              N           N        0000       0.0000           0.00         0.00         0.00
00912       Anesth, bladder tumor surg           N           N        0000       0.0000           0.00         0.00         0.00
00914       Anesth, removal of prostate          N           N        0000       0.0000           0.00         0.00         0.00
00916       Anesth, bleeding control             N           N        0000       0.0000           0.00         0.00         0.00
00918       Anesth, stone removal                N           N        0000       0.0000           0.00         0.00         0.00
00920       Anesth, genitalia surgery            N           N        0000       0.0000           0.00         0.00         0.00
00921       Anesth, vasectomy                    N           N        0000       0.0000           0.00         0.00         0.00
00922       Anesth, sperm duct surgery           N           N        0000       0.0000           0.00         0.00         0.00
00924       Anesth, testis exploration           N           N        0000       0.0000           0.00         0.00         0.00
00926       Anesth, removal of testis            N           N        0000       0.0000           0.00         0.00         0.00
00928       Anesth, removal of testis            N           N        0000       0.0000           0.00         0.00         0.00
00930       Anesth, testis suspension            N           N        0000       0.0000           0.00         0.00         0.00
00932       Anesth, amputation of penis          C           C        0000       0.0000           0.00         0.00         0.00
00934       Anesth, penis, nodes removal         C           C        0000       0.0000           0.00         0.00         0.00
00936       Anesth, penis, nodes removal         C           C        0000       0.0000           0.00         0.00         0.00
00938       Anesth, insert penis device          N           N        0000       0.0000           0.00         0.00         0.00
00940       Anesth, vaginal procedures           N           N        0000       0.0000           0.00         0.00         0.00
00942       Anesth, surg on vag/urethral         N           N        0000       0.0000           0.00         0.00         0.00
00944       Anesth, vaginal hysterectomy         C           C        0000       0.0000           0.00         0.00         0.00
00948       Anesth, repair of cervix             N           N        0000       0.0000           0.00         0.00         0.00
00950       Anesth, vaginal endoscopy            N           N        0000       0.0000           0.00         0.00         0.00
00952       Anesth, hysteroscope/graph           N           N        0000       0.0000           0.00         0.00         0.00
01112       Anesth, bone aspirate/bx             N           N        0000       0.0000           0.00         0.00         0.00
01120       Anesth, pelvis surgery               N           N        0000       0.0000           0.00         0.00         0.00
01130       Anesth, body cast procedure          N           N        0000       0.0000           0.00         0.00         0.00
01140       Anesth, amputation at pelvis         C           C        0000       0.0000           0.00         0.00         0.00
01150       Anesth, pelvic tumor surgery         C           C        0000       0.0000           0.00         0.00         0.00
01160       Anesth, pelvis procedure             N           N        0000       0.0000           0.00         0.00         0.00
01170       Anesth, pelvis surgery               N           N        0000       0.0000           0.00         0.00         0.00
01173       Anesth, fx repair, pelvis            N           N        0000       0.0000           0.00         0.00         0.00
01180       Anesth, pelvis nerve removal         N           N        0000       0.0000           0.00         0.00         0.00
01190       Anesth, pelvis nerve removal         N           N        0000       0.0000           0.00         0.00         0.00
01200       Anesth, hip joint procedure          N           N        0000       0.0000           0.00         0.00         0.00
01202       Anesth, arthroscopy of hip           N           N        0000       0.0000           0.00         0.00         0.00
01210       Anesth, hip joint surgery            N           N        0000       0.0000           0.00         0.00         0.00
01212       Anesth, hip disarticulation          C           C        0000       0.0000           0.00         0.00         0.00
01214       Anesth, hip arthroplasty             C           C        0000       0.0000           0.00         0.00         0.00
01215       Anesth, revise hip repair            N           N        0000       0.0000           0.00         0.00         0.00
01220       Anesth, procedure on femur           N           N        0000       0.0000           0.00         0.00         0.00
01230       Anesth, surgery of femur             N           N        0000       0.0000           0.00         0.00         0.00
01232       Anesth, amputation of femur          C           C        0000       0.0000           0.00         0.00         0.00
01234       Anesth, radical femur surg           C           C        0000       0.0000           0.00         0.00         0.00
01250       Anesth, upper leg surgery            N           N        0000       0.0000           0.00         0.00         0.00
01260       Anesth, upper leg veins surg         N           N        0000       0.0000           0.00         0.00         0.00
01270       Anesth, thigh arteries surg          N           N        0000       0.0000           0.00         0.00         0.00
01272       Anesth, femoral artery surg          C           C        0000       0.0000           0.00         0.00         0.00
01274       Anesth, femoral embolectomy          C           C        0000       0.0000           0.00         0.00         0.00
01320       Anesth, knee area surgery            N           N        0000       0.0000           0.00         0.00         0.00
01340       Anesth, knee area procedure          N           N        0000       0.0000           0.00         0.00         0.00
01360       Anesth, knee area surgery            N           N        0000       0.0000           0.00         0.00         0.00
01380       Anesth, knee joint procedure         N           N        0000       0.0000           0.00         0.00         0.00
01382       Anesth, dx knee arthroscopy          N           N        0000       0.0000           0.00         0.00         0.00
01390       Anesth, knee area procedure          N           N        0000       0.0000           0.00         0.00         0.00
01392       Anesth, knee area surgery            N           N        0000       0.0000           0.00         0.00         0.00
01400       Anesth, knee joint surgery           N           N        0000       0.0000           0.00         0.00         0.00
01402       Anesth, knee arthroplasty            C           C        0000       0.0000           0.00         0.00         0.00
01404       Anesth, amputation at knee           C           C        0000       0.0000           0.00         0.00         0.00
01420       Anesth, knee joint casting           N           N        0000       0.0000           0.00         0.00         0.00
01430       Anesth, knee veins surgery           N           N        0000       0.0000           0.00         0.00         0.00
01432       Anesth, knee vessel surg             N           N        0000       0.0000           0.00         0.00         0.00
01440       Anesth, knee arteries surg           N           N        0000       0.0000           0.00         0.00         0.00
01442       Anesth, knee artery surg             C           C        0000       0.0000           0.00         0.00         0.00
01444       Anesth, knee artery repair           C           C        0000       0.0000           0.00         0.00         0.00
01462       Anesth, lower leg procedure          N           N        0000       0.0000           0.00         0.00         0.00
01464       Anesth, ankle/ft arthroscopy         N           N        0000       0.0000           0.00         0.00         0.00
01470       Anesth, lower leg surgery            N           N        0000       0.0000           0.00         0.00         0.00
01472       Anesth, achilles tendon surg         N           N        0000       0.0000           0.00         0.00         0.00
01474       Anesth, lower leg surgery            N           N        0000       0.0000           0.00         0.00         0.00
01480       Anesth, lower leg bone surg          N           N        0000       0.0000           0.00         0.00         0.00
01482       Anesth, radical leg surgery          N           N        0000       0.0000           0.00         0.00         0.00
01484       Anesth, lower leg revision           N           N        0000       0.0000           0.00         0.00         0.00
01486       Anesth, ankle replacement            C           C        0000       0.0000           0.00         0.00         0.00
01490       Anesth, lower leg casting            N           N        0000       0.0000           0.00         0.00         0.00
01500       Anesth, leg arteries surg            N           N        0000       0.0000           0.00         0.00         0.00
01502       Anesth, lwr leg embolectomy          C           C        0000       0.0000           0.00         0.00         0.00
01520       Anesth, lower leg vein surg          N           N        0000       0.0000           0.00         0.00         0.00
01522       Anesth, lower leg vein surg          N           N        0000       0.0000           0.00         0.00         0.00
01610       Anesth, surgery of shoulder          N           N        0000       0.0000           0.00         0.00         0.00
01620       Anesth, shoulder procedure           N           N        0000       0.0000           0.00         0.00         0.00
01622       Anes dx shoulder arthroscopy         N           N        0000       0.0000           0.00         0.00         0.00
01630       Anesth, surgery of shoulder          N           N        0000       0.0000           0.00         0.00         0.00
01632       Anesth, surgery of shoulder          C           C        0000       0.0000           0.00         0.00         0.00
01634       Anesth, shoulder joint amput         C           C        0000       0.0000           0.00         0.00         0.00
01636       Anesth, forequarter amput            C           C        0000       0.0000           0.00         0.00         0.00
01638       Anesth, shoulder replacement         C           C        0000       0.0000           0.00         0.00         0.00
01650       Anesth, shoulder artery surg         N           N        0000       0.0000           0.00         0.00         0.00


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 2 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
01652       Anesth, shoulder vessel surg         C           C        0000        0.0000          0.00          0.00         0.00
01654       Anesth, shoulder vessel surg         C           C        0000        0.0000          0.00          0.00         0.00
01656       Anesth, arm-leg vessel surg          C           C        0000        0.0000          0.00          0.00         0.00
01670       Anesth, shoulder vein surg           N           N        0000        0.0000          0.00          0.00         0.00
01680       Anesth, shoulder casting             N           N        0000        0.0000          0.00          0.00         0.00
01682       Anesth, airplane cast                N           N        0000        0.0000          0.00          0.00         0.00
01710       Anesth, elbow area surgery           N           N        0000        0.0000          0.00          0.00         0.00
01712       Anesth, uppr arm tendon surg         N           N        0000        0.0000          0.00          0.00         0.00
01714       Anesth, uppr arm tendon surg         N           N        0000        0.0000          0.00          0.00         0.00
01716       Anesth, biceps tendon repair         N           N        0000        0.0000          0.00          0.00         0.00
01730       Anesth, uppr arm procedure           N           N        0000        0.0000          0.00          0.00         0.00
01732       Anesth, dx elbow arthroscopy         N           N        0000        0.0000          0.00          0.00         0.00
01740       Anesth, upper arm surgery            N           N        0000        0.0000          0.00          0.00         0.00
01742       Anesth, humerus surgery              N           N        0000        0.0000          0.00          0.00         0.00
01744       Anesth, humerus repair               N           N        0000        0.0000          0.00          0.00         0.00
01756       Anesth, radical humerus surg         C           C        0000        0.0000          0.00          0.00         0.00
01758       Anesth, humeral lesion surg          N           N        0000        0.0000          0.00          0.00         0.00
01760       Anesth, elbow replacement            N           N        0000        0.0000          0.00          0.00         0.00
01770       Anesth, uppr arm artery surg         N           N        0000        0.0000          0.00          0.00         0.00
01772       Anesth, uppr arm embolectomy         N           N        0000        0.0000          0.00          0.00         0.00
01780       Anesth, upper arm vein surg          N           N        0000        0.0000          0.00          0.00         0.00
01782       Anesth, uppr arm vein repair         N           N        0000        0.0000          0.00          0.00         0.00
01810       Anesth, lower arm surgery            N           N        0000        0.0000          0.00          0.00         0.00
01820       Anesth, lower arm procedure          N           N        0000        0.0000          0.00          0.00         0.00
01829       Anesth, dx wrist arthroscopy         N           N        0000        0.0000          0.00          0.00         0.00
01830       Anesth, lower arm surgery            N           N        0000        0.0000          0.00          0.00         0.00
01832       Anesth, wrist replacement            N           N        0000        0.0000          0.00          0.00         0.00
01840       Anesth, lwr arm artery surg          N           N        0000        0.0000          0.00          0.00         0.00
01842       Anesth, lwr arm embolectomy          N           N        0000        0.0000          0.00          0.00         0.00
01844       Anesth, vascular shunt surg          N           N        0000        0.0000          0.00          0.00         0.00
01850       Anesth, lower arm vein surg          N           N        0000        0.0000          0.00          0.00         0.00
01852       Anesth, lwr arm vein repair          N           N        0000        0.0000          0.00          0.00         0.00
01860       Anesth, lower arm casting            N           N        0000        0.0000          0.00          0.00         0.00
01905       Anes, spine inject, x-ray/re         N           N        0000        0.0000          0.00          0.00         0.00
01916       Anesth, dx arteriography             N           N        0000        0.0000          0.00          0.00         0.00
01920       Anesth, catheterize heart            N           N        0000        0.0000          0.00          0.00         0.00
01922       Anesth, cat or MRI scan              N           N        0000        0.0000          0.00          0.00         0.00
01924       Anes, ther interven rad, art         N           N        0000        0.0000          0.00          0.00         0.00
01925       Anes, ther interven rad, car         N           N        0000        0.0000          0.00          0.00         0.00
01926       Anes, tx interv rad hrt/cran         N           N        0000        0.0000          0.00          0.00         0.00
01930       Anes, ther interven rad, vei         N           N        0000        0.0000          0.00          0.00         0.00
01931       Anes, ther interven rad, tip         N           N        0000        0.0000          0.00          0.00         0.00
01932       Anes, tx interv rad, th vein         N           N        0000        0.0000          0.00          0.00         0.00
01933       Anes, tx interv rad, cran v          N           N        0000        0.0000          0.00          0.00         0.00
01951       Anesth, burn, less 4 percent         N           N        0000        0.0000          0.00          0.00         0.00
01952       Anesth, burn, 4-9 percent            N           N        0000        0.0000          0.00          0.00         0.00
01953       Anesth, burn, each 9 percent         N           N        0000        0.0000          0.00          0.00         0.00
01958       Anesth, antepartum manipul           N           N        0000        0.0000          0.00          0.00         0.00
01960       Anesth, vaginal delivery             N           N        0000        0.0000          0.00          0.00         0.00
01961       Anesth, cs delivery                  N           N        0000        0.0000          0.00          0.00         0.00
01962       Anesth, emer hysterectomy            N           N        0000        0.0000          0.00          0.00         0.00
01963       Anesth, cs hysterectomy              N           N        0000        0.0000          0.00          0.00         0.00
01965       Anesth, inc/missed ab proc           N           N        0000        0.0000          0.00          0.00         0.00
01966       Anesth, induced ab procedure         N           N        0000        0.0000          0.00          0.00         0.00
01967       Anesth/analg, vag delivery           N           N        0000        0.0000          0.00          0.00         0.00
01968       Anes/analg cs deliver add-on         N           N        0000        0.0000          0.00          0.00         0.00
01969       Anesth/analg cs hyst add-on          N           N        0000        0.0000          0.00          0.00         0.00
01990       Support for organ donor              C           C        0000        0.0000          0.00          0.00         0.00
01991       Anesth, nerve block/inj              N           N        0000        0.0000          0.00          0.00         0.00
01992       Anesth, n block/inj, prone           N           N        0000        0.0000          0.00          0.00         0.00
01996       Hosp manage cont drug admin          N           N        0000        0.0000          0.00          0.00         0.00
01999       Unlisted anesth procedure            N           1        0000        0.0000          0.00          0.00         0.00
10021       Fna w/o image                        T           T        0002        1.0995         50.69        115.57       132.47
10022       Fna w/image                          T           T        0036        2.0738         95.60        217.98       249.85
10040       Acne surgery                         T           T        0010        0.4760         21.94         50.03        57.35
10060       Drainage of skin abscess             T           T        0006        1.4392         66.35        151.27       173.39
10061       Drainage of skin abscess             T           T        0006        1.4392         66.35        151.27       173.39
10080       Drainage of pilonidal cyst           T           T        0006        1.4392         66.35        151.27       173.39
10081       Drainage of pilonidal cyst           T           T        0007       11.1535        514.18       1,172.34     1,343.77
10120       Remove foreign body                  T           T        0006        1.4392         66.35        151.27       173.39
10121       Remove foreign body                  T           T        0021       15.1024        696.22       1,587.41     1,819.54
10140       Drainage of hematoma/fluid           T           T        0007       11.1535        514.18       1,172.34     1,343.77
10160       Puncture drainage of lesion          T           T        0018        1.0259         47.29        107.83       123.60
10180       Complex drainage, wound              T           T        0008       17.5086        807.15       1,840.33     2,109.44
11000       Debride infected skin                T           T        0013        1.0918         50.33        114.76       131.54
11001       Debride infected skin add-on         T           T        0012        0.8432         38.87         88.63       101.59
11004       Debride genitalia & perineum         C           C        0000        0.0000          0.00          0.00         0.00
11005       Debride abdom wall                   C           C        0000        0.0000          0.00          0.00         0.00
11006       Debride genit/per/abdom wall         C           C        0000        0.0000          0.00          0.00         0.00
11008       Remove mesh from abd wall            C           C        0000        0.0000          0.00          0.00         0.00
11010       Debride skin, fx                     T           T        0019        4.0919        188.64        430.10       492.99
11011       Debride skin/muscle, fx              T           T        0019        4.0919        188.64        430.10       492.99
11012       Debride skin/muscle/bone, fx         T           T        0019        4.0919        188.64        430.10       492.99
11040       Debride skin, partial                T           T        0015        1.6241         74.87        170.71       195.67
11041       Debride skin, full                   T           T        0015        1.6241         74.87        170.71       195.67
11042       Debride skin/tissue                  T           T        0016        2.6749        123.31        281.16       322.27
11043       Debride tissue/muscle                T           T        0016        2.6749        123.31        281.16       322.27
11044       Debride tissue/muscle/bone           T           T        0682        6.8832        317.32        723.49       829.29
11055       Trim skin lesion                     T           T        0012        0.8432         38.87         88.63       101.59
11056       Trim skin lesions, 2 to 4            T           T        0012        0.8432         38.87         88.63       101.59
11057       Trim skin lesions, over 4            T           T        0013        1.0918         50.33        114.76       131.54
11100       Biopsy, skin lesion                  T           T        0018        1.0259         47.29        107.83       123.60
11101       Biopsy, skin add-on                  T           T        0018        1.0259         47.29        107.83       123.60
11200       Removal of skin tags                 T           T        0013        1.0918         50.33        114.76       131.54
11201       Remove skin tags add-on              T           T        0015        1.6241         74.87        170.71       195.67
11300       Shave skin lesion                    T           T        0012        0.8432         38.87         88.63       101.59
11301       Shave skin lesion                    T           T        0012        0.8432         38.87         88.63       101.59
11302       Shave skin lesion                    T           T        0013        1.0918         50.33        114.76       131.54
11303       Shave skin lesion                    T           T        0015        1.6241         74.87        170.71       195.67
11305       Shave skin lesion                    T           T        0013        1.0918         50.33        114.76       131.54
11306       Shave skin lesion                    T           T        0013        1.0918         50.33        114.76       131.54
11307       Shave skin lesion                    T           T        0013        1.0918         50.33        114.76       131.54
11308       Shave skin lesion                    T           T        0013        1.0918         50.33        114.76       131.54
11310       Shave skin lesion                    T           T        0013        1.0918         50.33        114.76       131.54
11311       Shave skin lesion                    T           T        0013        1.0918         50.33        114.76       131.54
11312       Shave skin lesion                    T           T        0013        1.0918         50.33        114.76       131.54


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 3 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
11313       Shave skin lesion                    T           T        0016        2.6749         123.31       281.16       322.27
11400       Exc tr-ext b9+marg 0.5 < cm          T           T        0019        4.0919         188.64       430.10       492.99
11401       Exc tr-ext b9+marg 0.6-1 cm          T           T        0019        4.0919         188.64       430.10       492.99
11402       Exc tr-ext b9+marg 1.1-2 cm          T           T        0019        4.0919         188.64       430.10       492.99
11403       Exc tr-ext b9+marg 2.1-3 cm          T           T        0020        6.8083         313.86       715.62       820.26
11404       Exc tr-ext b9+marg 3.1-4 cm          T           T        0021       15.1024         696.22      1,587.41     1,819.54
11406       Exc tr-ext b9+marg > 4.0 cm          T           T        0021       15.1024         696.22      1,587.41     1,819.54
11420       Exc h-f-nk-sp b9+marg 0.5 <          T           T        0020        6.8083         313.86       715.62       820.26
11421       Exc h-f-nk-sp b9+marg 0.6-1          T           T        0020        6.8083         313.86       715.62       820.26
11422       Exc h-f-nk-sp b9+marg 1.1-2          T           T        0020        6.8083         313.86       715.62       820.26
11423       Exc h-f-nk-sp b9+marg 2.1-3          T           T        0021       15.1024         696.22      1,587.41     1,819.54
11424       Exc h-f-nk-sp b9+marg 3.1-4          T           T        0021       15.1024         696.22      1,587.41     1,819.54
11426       Exc h-f-nk-sp b9+marg > 4 cm         T           T        0022       20.0656         925.02      2,109.10     2,417.50
11440       Exc face-mm b9+marg 0.5 < cm         T           T        0019        4.0919         188.64       430.10       492.99
11441       Exc face-mm b9+marg 0.6-1 cm         T           T        0019        4.0919         188.64       430.10       492.99
11442       Exc face-mm b9+marg 1.1-2 cm         T           T        0020        6.8083         313.86       715.62       820.26
11443       Exc face-mm b9+marg 2.1-3 cm         T           T        0020        6.8083         313.86       715.62       820.26
11444       Exc face-mm b9+marg 3.1-4 cm         T           T        0020        6.8083         313.86       715.62       820.26
11446       Exc face-mm b9+marg > 4 cm           T           T        0022       20.0656         925.02      2,109.10     2,417.50
11450       Removal, sweat gland lesion          T           T        0022       20.0656         925.02      2,109.10     2,417.50
11451       Removal, sweat gland lesion          T           T        0022       20.0656         925.02      2,109.10     2,417.50
11462       Removal, sweat gland lesion          T           T        0022       20.0656         925.02      2,109.10     2,417.50
11463       Removal, sweat gland lesion          T           T        0022       20.0656         925.02      2,109.10     2,417.50
11470       Removal, sweat gland lesion          T           T        0022       20.0656         925.02      2,109.10     2,417.50
11471       Removal, sweat gland lesion          T           T        0022       20.0656         925.02      2,109.10     2,417.50
11600       Exc tr-ext mlg+marg 0.5 < cm         T           T        0019        4.0919         188.64       430.10       492.99
11601       Exc tr-ext mlg+marg 0.6-1 cm         T           T        0019        4.0919         188.64       430.10       492.99
11602       Exc tr-ext mlg+marg 1.1-2 cm         T           T        0019        4.0919         188.64       430.10       492.99
11603       Exc tr-ext mlg+marg 2.1-3 cm         T           T        0020        6.8083         313.86       715.62       820.26
11604       Exc tr-ext mlg+marg 3.1-4 cm         T           T        0020        6.8083         313.86       715.62       820.26
11606       Exc tr-ext mlg+marg > 4 cm           T           T        0021       15.1024         696.22      1,587.41     1,819.54
11620       Exc h-f-nk-sp mlg+marg 0.5 <         T           T        0020        6.8083         313.86       715.62       820.26
11621       Exc h-f-nk-sp mlg+marg 0.6-1         T           T        0019        4.0919         188.64       430.10       492.99
11622       Exc h-f-nk-sp mlg+marg 1.1-2         T           T        0020        6.8083         313.86       715.62       820.26
11623       Exc h-f-nk-sp mlg+marg 2.1-3         T           T        0021       15.1024         696.22      1,587.41     1,819.54
11624       Exc h-f-nk-sp mlg+marg 3.1-4         T           T        0021       15.1024         696.22      1,587.41     1,819.54
11626       Exc h-f-nk-sp mlg+mar > 4 cm         T           T        0022       20.0656         925.02      2,109.10     2,417.50
11640       Exc face-mm malig+marg 0.5 <         T           T        0020        6.8083         313.86       715.62       820.26
11641       Exc face-mm malig+marg 0.6-1         T           T        0020        6.8083         313.86       715.62       820.26
11642       Exc face-mm malig+marg 1.1-2         T           T        0020        6.8083         313.86       715.62       820.26
11643       Exc face-mm malig+marg 2.1-3         T           T        0020        6.8083         313.86       715.62       820.26
11644       Exc face-mm malig+marg 3.1-4         T           T        0021       15.1024         696.22      1,587.41     1,819.54
11646       Exc face-mm mlg+marg > 4 cm          T           T        0022       20.0656         925.02      2,109.10     2,417.50
11719       Trim nail(s)                         T           T        0009        0.7744          35.70        81.40        93.30
11720       Debride nail, 1-5                    T           T        0009        0.7744          35.70        81.40        93.30
11721       Debride nail, 6 or more              T           T        0009        0.7744          35.70        81.40        93.30
11730       Removal of nail plate                T           T        0013        1.0918          50.33       114.76       131.54
11732       Remove nail plate, add-on            T           T        0012        0.8432          38.87        88.63       101.59
11740       Drain blood from under nail          T           T        0009        0.7744          35.70        81.40        93.30
11750       Removal of nail bed                  T           T        0019        4.0919         188.64       430.10       492.99
11752       Remove nail bed/finger tip           T           T        0022       20.0656         925.02      2,109.10     2,417.50
11755       Biopsy, nail unit                    T           T        0019        4.0919         188.64       430.10       492.99
11760       Repair of nail bed                   T           T        0024        1.4843          68.43       156.01       178.83
11762       Reconstruction of nail bed           T           T        0024        1.4843          68.43       156.01       178.83
11765       Excision of nail fold, toe           T           T        0015        1.6241          74.87       170.71       195.67
11770       Removal of pilonidal lesion          T           T        0022       20.0656         925.02      2,109.10     2,417.50
11771       Removal of pilonidal lesion          T           T        0022       20.0656         925.02      2,109.10     2,417.50
11772       Removal of pilonidal lesion          T           T        0022       20.0656         925.02      2,109.10     2,417.50
11900       Injection into skin lesions          T           T        0012        0.8432          38.87        88.63       101.59
11901       Added skin lesions injection         T           T        0012        0.8432          38.87        88.63       101.59
11920       Correct skin color defects           T           1        0000        0.0000           0.00         0.00         0.00
11921       Correct skin color defects           T           1        0000        0.0000           0.00         0.00         0.00
11922       Correct skin color defects           T           1        0000        0.0000           0.00         0.00         0.00
11950       Therapy for contour defects          T           1        0000        0.0000           0.00         0.00         0.00
11951       Therapy for contour defects          T           1        0000        0.0000           0.00         0.00         0.00
11952       Therapy for contour defects          T           1        0000        0.0000           0.00         0.00         0.00
11954       Therapy for contour defects          T           1        0000        0.0000           0.00         0.00         0.00
11960       Insert tissue expander(s)            T           T        0027       21.4302         987.93      2,252.53     2,581.91
11970       Replace tissue expander              T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
11971       Remove tissue expander(s)            T           T        0022       20.0656         925.02      2,109.10     2,417.50
11975       Insert contraceptive cap             E           3        0000        0.0000           M01          M01          M01
11976       Removal of contraceptive cap         T           T        0019        4.0919         188.64       430.10       492.99
11977       Removal/reinsert contra cap          E           3        0000        0.0000           M01          M01          M01
11980       Implant hormone pellet(s)            X           X        0340        0.6102          28.13        64.14        73.52
11981       Insert drug implant device           X           X        0340        0.6102          28.13        64.14        73.52
11982       Remove drug implant device           X           X        0340        0.6102          28.13        64.14        73.52
11983       Remove/insert drug implant           X           X        0340        0.6102          28.13        64.14        73.52
12001       Repair superficial wound(s)          T           T        0024        1.4843          68.43       156.01       178.83
12002       Repair superficial wound(s)          T           T        0024        1.4843          68.43       156.01       178.83
12004       Repair superficial wound(s)          T           T        0024        1.4843          68.43       156.01       178.83
12005       Repair superficial wound(s)          T           T        0024        1.4843          68.43       156.01       178.83
12006       Repair superficial wound(s)          T           T        0024        1.4843          68.43       156.01       178.83
12007       Repair superficial wound(s)          T           T        0024        1.4843          68.43       156.01       178.83
12011       Repair superficial wound(s)          T           T        0024        1.4843          68.43       156.01       178.83
12013       Repair superficial wound(s)          T           T        0024        1.4843          68.43       156.01       178.83
12014       Repair superficial wound(s)          T           T        0024        1.4843          68.43       156.01       178.83
12015       Repair superficial wound(s)          T           T        0024        1.4843          68.43       156.01       178.83
12016       Repair superficial wound(s)          T           T        0024        1.4843          68.43       156.01       178.83
12017       Repair superficial wound(s)          T           T        0024        1.4843          68.43       156.01       178.83
12018       Repair superficial wound(s)          T           T        0024        1.4843          68.43       156.01       178.83
12020       Closure of split wound               T           T        0024        1.4843          68.43       156.01       178.83
12021       Closure of split wound               T           T        0024        1.4843          68.43       156.01       178.83
12031       Layer closure of wound(s)            T           T        0024        1.4843          68.43       156.01       178.83
12032       Layer closure of wound(s)            T           T        0024        1.4843          68.43       156.01       178.83
12034       Layer closure of wound(s)            T           T        0024        1.4843          68.43       156.01       178.83
12035       Layer closure of wound(s)            T           T        0024        1.4843          68.43       156.01       178.83
12036       Layer closure of wound(s)            T           T        0024        1.4843          68.43       156.01       178.83
12037       Layer closure of wound(s)            T           T        0025        5.2594         242.46       552.82       633.65
12041       Layer closure of wound(s)            T           T        0024        1.4843          68.43       156.01       178.83
12042       Layer closure of wound(s)            T           T        0024        1.4843          68.43       156.01       178.83
12044       Layer closure of wound(s)            T           T        0024        1.4843          68.43       156.01       178.83
12045       Layer closure of wound(s)            T           T        0024        1.4843          68.43       156.01       178.83
12046       Layer closure of wound(s)            T           T        0024        1.4843          68.43       156.01       178.83
12047       Layer closure of wound(s)            T           T        0025        5.2594         242.46       552.82       633.65
12051       Layer closure of wound(s)            T           T        0024        1.4843          68.43       156.01       178.83
12052       Layer closure of wound(s)            T           T        0024        1.4843          68.43       156.01       178.83


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 4 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
12053       Layer closure of wound(s)            T           T        0024        1.4843         68.43        156.01       178.83
12054       Layer closure of wound(s)            T           T        0024        1.4843         68.43        156.01       178.83
12055       Layer closure of wound(s)            T           T        0024        1.4843         68.43        156.01       178.83
12056       Layer closure of wound(s)            T           T        0024        1.4843         68.43        156.01       178.83
12057       Layer closure of wound(s)            T           T        0025        5.2594        242.46        552.82       633.65
13100       Repair of wound or lesion            T           T        0025        5.2594        242.46        552.82       633.65
13101       Repair of wound or lesion            T           T        0025        5.2594        242.46        552.82       633.65
13102       Repair wound/lesion add-on           T           T        0024        1.4843         68.43        156.01       178.83
13120       Repair of wound or lesion            T           T        0024        1.4843         68.43        156.01       178.83
13121       Repair of wound or lesion            T           T        0024        1.4843         68.43        156.01       178.83
13122       Repair wound/lesion add-on           T           T        0024        1.4843         68.43        156.01       178.83
13131       Repair of wound or lesion            T           T        0024        1.4843         68.43        156.01       178.83
13132       Repair of wound or lesion            T           T        0024        1.4843         68.43        156.01       178.83
13133       Repair wound/lesion add-on           T           T        0024        1.4843         68.43        156.01       178.83
13150       Repair of wound or lesion            T           T        0025        5.2594        242.46        552.82       633.65
13151       Repair of wound or lesion            T           T        0025        5.2594        242.46        552.82       633.65
13152       Repair of wound or lesion            T           T        0025        5.2594        242.46        552.82       633.65
13153       Repair wound/lesion add-on           T           T        0024        1.4843         68.43        156.01       178.83
13160       Late closure of wound                T           T        0027       21.4302        987.93       2,252.53     2,581.91
14000       Skin tissue rearrangement            T           T        0686       14.0346        647.00       1,475.18     1,690.89
14001       Skin tissue rearrangement            T           T        0027       21.4302        987.93       2,252.53     2,581.91
14020       Skin tissue rearrangement            T           T        0686       14.0346        647.00       1,475.18     1,690.89
14021       Skin tissue rearrangement            T           T        0686       14.0346        647.00       1,475.18     1,690.89
14040       Skin tissue rearrangement            T           T        0686       14.0346        647.00       1,475.18     1,690.89
14041       Skin tissue rearrangement            T           T        0686       14.0346        647.00       1,475.18     1,690.89
14060       Skin tissue rearrangement            T           T        0686       14.0346        647.00       1,475.18     1,690.89
14061       Skin tissue rearrangement            T           T        0686       14.0346        647.00       1,475.18     1,690.89
14300       Skin tissue rearrangement            T           T        0027       21.4302        987.93       2,252.53     2,581.91
14350       Skin tissue rearrangement            T           T        0027       21.4302        987.93       2,252.53     2,581.91
15002       Wnd prep, ch/inf, trk/arm/lg         T           T        0025        5.2594        242.46        552.82       633.65
15003       Wnd prep, ch/inf addl 100 cm         T           T        0025        5.2594        242.46        552.82       633.65
15004       Wnd prep ch/inf, f/n/hf/g            T           T        0025        5.2594        242.46        552.82       633.65
15005       Wnd prep, f/n/hf/g, addl cm          T           T        0025        5.2594        242.46        552.82       633.65
15040       Harvest cultured skin graft          T           T        0024        1.4843         68.43        156.01       178.83
15050       Skin pinch graft                     T           T        0025        5.2594        242.46        552.82       633.65
15100       Skin split graft                     T           T        0027       21.4302        987.93       2,252.53     2,581.91
15101       Skin split graft add-on              T           T        0027       21.4302        987.93       2,252.53     2,581.91
15110       Epidrm autogrft trnk/arm/leg         T           T        0027       21.4302        987.93       2,252.53     2,581.91
15111       Epidrm autogrft t/a/l add-on         T           T        0027       21.4302        987.93       2,252.53     2,581.91
15115       Epidrm a-grft face/nck/hf/g          T           T        0027       21.4302        987.93       2,252.53     2,581.91
15116       Epidrm a-grft f/n/hf/g addl          T           T        0027       21.4302        987.93       2,252.53     2,581.91
15120       Skin split graft                     T           T        0027       21.4302        987.93       2,252.53     2,581.91
15121       Skin split graft add-on              T           T        0027       21.4302        987.93       2,252.53     2,581.91
15130       Derm autograft, trnk/arm/leg         T           T        0027       21.4302        987.93       2,252.53     2,581.91
15131       Derm autograft t/a/l add-on          T           T        0027       21.4302        987.93       2,252.53     2,581.91
15135       Derm autograft face/nck/hf/g         T           T        0027       21.4302        987.93       2,252.53     2,581.91
15136       Derm autograft, f/n/hf/g add         T           T        0027       21.4302        987.93       2,252.53     2,581.91
15150       Cult epiderm grft t/arm/leg          T           T        0027       21.4302        987.93       2,252.53     2,581.91
15151       Cult epiderm grft t/a/l addl         T           T        0027       21.4302        987.93       2,252.53     2,581.91
15152       Cult epiderm graft t/a/l +%          T           T        0027       21.4302        987.93       2,252.53     2,581.91
15155       Cult epiderm graft, f/n/hf/g         T           T        0027       21.4302        987.93       2,252.53     2,581.91
15156       Cult epidrm grft f/n/hfg add         T           T        0027       21.4302        987.93       2,252.53     2,581.91
15157       Cult epiderm grft f/n/hfg +%         T           T        0027       21.4302        987.93       2,252.53     2,581.91
15170       Acell graft trunk/arms/legs          T           T        0025        5.2594        242.46        552.82       633.65
15171       Acell graft t/arm/leg add-on         T           T        0025        5.2594        242.46        552.82       633.65
15175       Acellular graft, f/n/hf/g            T           T        0025        5.2594        242.46        552.82       633.65
15176       Acell graft, f/n/hf/g add-on         T           T        0025        5.2594        242.46        552.82       633.65
15200       Skin full graft                      T           T        0686       14.0346        647.00       1,475.18     1,690.89
15201       Skin full graft add-on               T           T        0025        5.2594        242.46        552.82       633.65
15220       Skin full graft                      T           T        0686       14.0346        647.00       1,475.18     1,690.89
15221       Skin full graft add-on               T           T        0025        5.2594        242.46        552.82       633.65
15240       Skin full graft                      T           T        0686       14.0346        647.00       1,475.18     1,690.89
15241       Skin full graft add-on               T           T        0025        5.2594        242.46        552.82       633.65
15260       Skin full graft                      T           T        0686       14.0346        647.00       1,475.18     1,690.89
15261       Skin full graft add-on               T           T        0025        5.2594        242.46        552.82       633.65
15300       Apply skinallogrft, t/arm/lg         T           T        0025        5.2594        242.46        552.82       633.65
15301       Apply sknallogrft t/a/l addl         T           T        0025        5.2594        242.46        552.82       633.65
15320       Apply skin allogrft f/n/hf/g         T           T        0025        5.2594        242.46        552.82       633.65
15321       Aply sknallogrft f/n/hfg add         T           T        0025        5.2594        242.46        552.82       633.65
15330       Aply acell alogrft t/arm/leg         T           T        0025        5.2594        242.46        552.82       633.65
15331       Aply acell grft t/a/l add-on         T           T        0025        5.2594        242.46        552.82       633.65
15335       Apply acell graft, f/n/hf/g          T           T        0025        5.2594        242.46        552.82       633.65
15336       Aply acell grft f/n/hf/g add         T           T        0025        5.2594        242.46        552.82       633.65
15340       Apply cult skin substitute           T           T        0025        5.2594        242.46        552.82       633.65
15341       Apply cult skin sub add-on           T           T        0025        5.2594        242.46        552.82       633.65
15360       Apply cult derm sub, t/a/l           T           T        0025        5.2594        242.46        552.82       633.65
15361       Aply cult derm sub t/a/l add         T           T        0025        5.2594        242.46        552.82       633.65
15365       Apply cult derm sub f/n/hf/g         T           T        0025        5.2594        242.46        552.82       633.65
15366       Apply cult derm f/hf/g add           T           T        0025        5.2594        242.46        552.82       633.65
15400       Skin heterograft                     T           T        0025        5.2594        242.46        552.82       633.65
15401       Skin heterograft add-on              T           T        0025        5.2594        242.46        552.82       633.65
15420       Apply skin xgraft, f/n/hf/g          T           T        0025        5.2594        242.46        552.82       633.65
15421       Apply skn xgrft f/n/hf/g add         T           T        0025        5.2594        242.46        552.82       633.65
15430       Apply acellular xenograft            T           T        0025        5.2594        242.46        552.82       633.65
15431       Apply acellular xgraft add           T           T        0025        5.2594        242.46        552.82       633.65
15570       Form skin pedicle flap               T           T        0027       21.4302        987.93       2,252.53     2,581.91
15572       Form skin pedicle flap               T           T        0027       21.4302        987.93       2,252.53     2,581.91
15574       Form skin pedicle flap               T           T        0027       21.4302        987.93       2,252.53     2,581.91
15576       Form skin pedicle flap               T           T        0686       14.0346        647.00       1,475.18     1,690.89
15600       Skin graft                           T           T        0027       21.4302        987.93       2,252.53     2,581.91
15610       Skin graft                           T           T        0027       21.4302        987.93       2,252.53     2,581.91
15620       Skin graft                           T           T        0027       21.4302        987.93       2,252.53     2,581.91
15630       Skin graft                           T           T        0027       21.4302        987.93       2,252.53     2,581.91
15650       Transfer skin pedicle flap           T           T        0027       21.4302        987.93       2,252.53     2,581.91
15731       Forehead flap w/vasc pedicle         T           1        0000        0.0000          0.00         0.00         0.00
15732       Muscle-skin graft, head/neck         T           T        0027       21.4302        987.93       2,252.53     2,581.91
15734       Muscle-skin graft, trunk             T           T        0027       21.4302        987.93       2,252.53     2,581.91
15736       Muscle-skin graft, arm               T           T        0027       21.4302        987.93       2,252.53     2,581.91
15738       Muscle-skin graft, leg               T           T        0027       21.4302        987.93       2,252.53     2,581.91
15740       Island pedicle flap graft            T           T        0686       14.0346        647.00       1,475.18     1,690.89
15750       Neurovascular pedicle graft          T           T        0027       21.4302        987.93       2,252.53     2,581.91
15756       Free myo/skin flap microvasc         C           C        0000        0.0000          0.00         0.00         0.00
15757       Free skin flap, microvasc            C           C        0000        0.0000          0.00         0.00         0.00
15758       Free fascial flap, microvasc         C           C        0000        0.0000          0.00         0.00         0.00
15760       Composite skin graft                 T           T        0027       21.4302        987.93       2,252.53     2,581.91
15770       Derma-fat-fascia graft               T           T        0027       21.4302        987.93       2,252.53     2,581.91


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 5 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
15775       Hair transplant punch grafts         T           1        0000        0.0000          0.00          0.00         0.00
15776       Hair transplant punch grafts         T           1        0000        0.0000          0.00          0.00         0.00
15780       Abrasion treatment of skin           T           T        0022       20.0656        925.02       2,109.10     2,417.50
15781       Abrasion treatment of skin           T           1        0000        0.0000          0.00          0.00         0.00
15782       Abrasion treatment of skin           T           1        0000        0.0000          0.00          0.00         0.00
15783       Abrasion treatment of skin           T           1        0000        0.0000          0.00          0.00         0.00
15786       Abrasion, lesion, single             T           1        0000        0.0000          0.00          0.00         0.00
15787       Abrasion, lesions, add-on            T           1        0000        0.0000          0.00          0.00         0.00
15788       Chemical peel, face, epiderm         T           1        0000        0.0000          0.00          0.00         0.00
15789       Chemical peel, face, dermal          T           1        0000        0.0000          0.00          0.00         0.00
15792       Chemical peel, nonfacial             T           1        0000        0.0000          0.00          0.00         0.00
15793       Chemical peel, nonfacial             T           1        0000        0.0000          0.00          0.00         0.00
15819       Plastic surgery, neck                T           1        0000        0.0000          0.00          0.00         0.00
15820       Revision of lower eyelid             T           T        0027       21.4302        987.93       2,252.53     2,581.91
15821       Revision of lower eyelid             T           T        0027       21.4302        987.93       2,252.53     2,581.91
15822       Revision of upper eyelid             T           T        0027       21.4302        987.93       2,252.53     2,581.91
15823       Revision of upper eyelid             T           T        0686       14.0346        647.00       1,475.18     1,690.89
15824       Removal of forehead wrinkles         T           1        0000        0.0000          0.00          0.00         0.00
15825       Removal of neck wrinkles             T           1        0000        0.0000          0.00          0.00         0.00
15826       Removal of brow wrinkles             T           1        0000        0.0000          0.00          0.00         0.00
15828       Removal of face wrinkles             T           1        0000        0.0000          0.00          0.00         0.00
15829       Removal of skin wrinkles             T           1        0000        0.0000          0.00          0.00         0.00
15830       Exc skin abd                         T           T        0022       20.0656        925.02       2,109.10     2,417.50
15832       Excise excessive skin tissue         T           1        0000        0.0000          0.00          0.00         0.00
15833       Excise excessive skin tissue         T           1        0000        0.0000          0.00          0.00         0.00
15834       Excise excessive skin tissue         T           1        0000        0.0000          0.00          0.00         0.00
15835       Excise excessive skin tissue         T           1        0000        0.0000          0.00          0.00         0.00
15836       Excise excessive skin tissue         T           1        0000        0.0000          0.00          0.00         0.00
15837       Excise excessive skin tissue         T           1        0000        0.0000          0.00          0.00         0.00
15838       Excise excessive skin tissue         T           1        0000        0.0000          0.00          0.00         0.00
15839       Excise excessive skin tissue         T           1        0000        0.0000          0.00          0.00         0.00
15840       Graft for face nerve palsy           T           T        0027       21.4302        987.93       2,252.53     2,581.91
15841       Graft for face nerve palsy           T           T        0027       21.4302        987.93       2,252.53     2,581.91
15842       Flap for face nerve palsy            T           T        0686       14.0346        647.00       1,475.18     1,690.89
15845       Skin and muscle repair, face         T           T        0027       21.4302        987.93       2,252.53     2,581.91
15847       Exc skin abd add-on                  T           T        0022       20.0656        925.02       2,109.10     2,417.50
15850       Removal of sutures                   T           T        0016        2.6749        123.31        281.16       322.27
15851       Removal of sutures                   T           T        0016        2.6749        123.31        281.16       322.27
15852       Dressing change not for burn         X           X        0340        0.6102         28.13         64.14        73.52
15860       Test for blood flow in graft         X           X        0340        0.6102         28.13         64.14        73.52
15876       Suction assisted lipectomy           T           1        0000        0.0000          0.00          0.00         0.00
15877       Suction assisted lipectomy           T           1        0000        0.0000          0.00          0.00         0.00
15878       Suction assisted lipectomy           T           1        0000        0.0000          0.00          0.00         0.00
15879       Suction assisted lipectomy           T           1        0000        0.0000          0.00          0.00         0.00
15920       Removal of tail bone ulcer           T           T        0019        4.0919        188.64        430.10       492.99
15922       Removal of tail bone ulcer           T           T        0027       21.4302        987.93       2,252.53     2,581.91
15931       Remove sacrum pressure sore          T           T        0022       20.0656        925.02       2,109.10     2,417.50
15933       Remove sacrum pressure sore          T           T        0022       20.0656        925.02       2,109.10     2,417.50
15934       Remove sacrum pressure sore          T           T        0027       21.4302        987.93       2,252.53     2,581.91
15935       Remove sacrum pressure sore          T           T        0027       21.4302        987.93       2,252.53     2,581.91
15936       Remove sacrum pressure sore          T           T        0027       21.4302        987.93       2,252.53     2,581.91
15937       Remove sacrum pressure sore          T           T        0027       21.4302        987.93       2,252.53     2,581.91
15940       Remove hip pressure sore             T           T        0022       20.0656        925.02       2,109.10     2,417.50
15941       Remove hip pressure sore             T           T        0022       20.0656        925.02       2,109.10     2,417.50
15944       Remove hip pressure sore             T           T        0027       21.4302        987.93       2,252.53     2,581.91
15945       Remove hip pressure sore             T           T        0027       21.4302        987.93       2,252.53     2,581.91
15946       Remove hip pressure sore             T           T        0027       21.4302        987.93       2,252.53     2,581.91
15950       Remove thigh pressure sore           T           T        0022       20.0656        925.02       2,109.10     2,417.50
15951       Remove thigh pressure sore           T           T        0022       20.0656        925.02       2,109.10     2,417.50
15952       Remove thigh pressure sore           T           T        0027       21.4302        987.93       2,252.53     2,581.91
15953       Remove thigh pressure sore           T           T        0027       21.4302        987.93       2,252.53     2,581.91
15956       Remove thigh pressure sore           T           T        0027       21.4302        987.93       2,252.53     2,581.91
15958       Remove thigh pressure sore           T           T        0027       21.4302        987.93       2,252.53     2,581.91
15999       Removal of pressure sore             T           1        0000        0.0000          0.00          0.00         0.00
16000       Initial treatment of burn(s)         T           T        0012        0.8432         38.87         88.63       101.59
16020       Treatment of burn(s)                 T           T        0013        1.0918         50.33        114.76       131.54
16025       Treatment of burn(s)                 T           T        0013        1.0918         50.33        114.76       131.54
16030       Treatment of burn(s)                 T           T        0015        1.6241         74.87        170.71       195.67
16035       Incision of burn scab, initi         T           T        0016        2.6749        123.31        281.16       322.27
16036       Escharotomy; add’l incision          C           C        0000        0.0000          0.00          0.00         0.00
17000       Destroy benign/premlg lesion         T           T        0010        0.4760         21.94         50.03        57.35
17003       Destroy lesions, 2-14                T           T        0010        0.4760         21.94         50.03        57.35
17004       Destroy lesions, 15 or more          T           T        0011        2.5665        118.32        269.76       309.21
17106       Destruction of skin lesions          T           T        0011        2.5665        118.32        269.76       309.21
17107       Destruction of skin lesions          T           T        0011        2.5665        118.32        269.76       309.21
17108       Destruction of skin lesions          T           T        0011        2.5665        118.32        269.76       309.21
17110       Destruct lesion, 1-14                T           T        0012        0.8432         38.87         88.63       101.59
17111       Destruct lesion, 15 or more          T           T        0013        1.0918         50.33        114.76       131.54
17250       Chemical cautery, tissue             T           T        0013        1.0918         50.33        114.76       131.54
17260       Destruction of skin lesions          T           T        0015        1.6241         74.87        170.71       195.67
17261       Destruction of skin lesions          T           T        0015        1.6241         74.87        170.71       195.67
17262       Destruction of skin lesions          T           T        0015        1.6241         74.87        170.71       195.67
17263       Destruction of skin lesions          T           T        0015        1.6241         74.87        170.71       195.67
17264       Destruction of skin lesions          T           T        0015        1.6241         74.87        170.71       195.67
17266       Destruction of skin lesions          T           T        0016        2.6749        123.31        281.16       322.27
17270       Destruction of skin lesions          T           T        0015        1.6241         74.87        170.71       195.67
17271       Destruction of skin lesions          T           T        0013        1.0918         50.33        114.76       131.54
17272       Destruction of skin lesions          T           T        0015        1.6241         74.87        170.71       195.67
17273       Destruction of skin lesions          T           T        0015        1.6241         74.87        170.71       195.67
17274       Destruction of skin lesions          T           T        0016        2.6749        123.31        281.16       322.27
17276       Destruction of skin lesions          T           T        0016        2.6749        123.31        281.16       322.27
17280       Destruction of skin lesions          T           T        0015        1.6241         74.87        170.71       195.67
17281       Destruction of skin lesions          T           T        0015        1.6241         74.87        170.71       195.67
17282       Destruction of skin lesions          T           T        0015        1.6241         74.87        170.71       195.67
17283       Destruction of skin lesions          T           T        0015        1.6241         74.87        170.71       195.67
17284       Destruction of skin lesions          T           T        0016        2.6749        123.31        281.16       322.27
17286       Destruction of skin lesions          T           T        0015        1.6241         74.87        170.71       195.67
17311       Mohs, 1 stage, h/n/hf/g              T           T        0694        3.7292        171.92        391.98       449.29
17312       Mohs addl stage                      T           T        0694        3.7292        171.92        391.98       449.29
17313       Mohs, 1 stage, t/a/l                 T           T        0694        3.7292        171.92        391.98       449.29
17314       Mohs, addl stage, t/a/l              T           T        0694        3.7292        171.92        391.98       449.29
17315       Mohs surg, addl block                T           T        0694        3.7292        171.92        391.98       449.29
17340       Cryotherapy of skin                  T           T        0016        2.6749        123.31        281.16       322.27
17360       Skin peel therapy                    T           1        0000        0.0000          0.00          0.00         0.00
17380       Hair removal by electrolysis         T           1        0000        0.0000          0.00          0.00         0.00
17999       Skin tissue procedure                T           1        0000        0.0000          0.00          0.00         0.00


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 6 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                              Critical
                                               January                                              General     Children's
                                                          WY 2007                                                             Access
  CPT/                                           2007                           APC Relative        Hospital     Hospital
                    Description (short)                     Status    APC                                                     Hospital
 HCPCS                                          Status                            Weight           Outpatient   Outpatient
                                                          Indicator                                                          Outpatient
                                              Indicator                                               Fee          Fee
                                                                                                                                Fee
                                             (FYI Only)
19000       Drainage of breast lesion            T           T        0004        2.0687              95.37       217.44       249.24
19001       Drain breast lesion add-on           T           T        0002        1.0995              50.69       115.57       132.47
19020       Incision of breast lesion            T           T        0008       17.5086             807.15      1,840.33     2,109.44
19030       Injection for breast x-ray           N           N        0000        0.0000               0.00         0.00         0.00
19100       Bx breast percut w/o image           T           T        0005        3.9045             180.00       410.40       470.41
19101       Biopsy of breast, open               T           T        0028       19.2788             888.75      2,026.39     2,322.71
19102       Bx breast percut w/image             T           T        0005        3.9045             180.00       410.40       470.41
19103       Bx breast percut w/device            T           T        0658        6.4387             296.82       676.77       775.73
19105       Cryosurg ablate fa, each             T           T        0029       28.0166            1,291.57     2,944.82     3,375.44
19110       Nipple exploration                   T           T        0028       19.2788             888.75      2,026.39     2,322.71
19112       Excise breast duct fistula           T           T        0028       19.2788             888.75      2,026.39     2,322.71
19120       Removal of breast lesion             T           T        0028       19.2788             888.75      2,026.39     2,322.71
19125       Excision, breast lesion              T           T        0028       19.2788             888.75      2,026.39     2,322.71
19126       Excision, addl breast lesion         T           T        0028       19.2788             888.75      2,026.39     2,322.71
19260       Removal of chest wall lesion         T           T        0021       15.1024             696.22      1,587.41     1,819.54
19271       Revision of chest wall               C           C        0000        0.0000               0.00         0.00         0.00
19272       Extensive chest wall surgery         C           C        0000        0.0000               0.00         0.00         0.00
19290       Place needle wire, breast            N           N        0000        0.0000               0.00         0.00         0.00
19291       Place needle wire, breast            N           N        0000        0.0000               0.00         0.00         0.00
19295       Place breast clip, percut            S           S        0657        1.7369              80.07       182.57       209.26
19296       Place po breast cath for rad         T           T        0648       51.2269            2,361.56     5,384.46     6,171.82
19297       Place breast cath for rad            T           T        0648       51.2269            2,361.56     5,384.46     6,171.82
19298       Place breast rad tube/caths          S           S        1524       52.8730       *    2,437.45     5,557.49     6,370.14
19300       Removal of breast tissue             T           T        0028       19.2788             888.75      2,026.39     2,322.71
19301       Partical mastectomy                  T           T        0028       19.2788             888.75      2,026.39     2,322.71
19302       P-mastectomy w/ln removal            T           T        0693       36.9988            1,705.64     3,888.94     4,457.62
19303       Mast, simple, complete               T           T        0029       28.0166            1,291.57     2,944.82     3,375.44
19304       Mast, subq                           T           T        0029       28.0166            1,291.57     2,944.82     3,375.44
19305       Mast, radical                        C           C        0000        0.0000               0.00         0.00         0.00
19306       Mast, rad, urban type                C           C        0000        0.0000               0.00         0.00         0.00
19307       Mast, mod rad                        T           T        0030       37.8692            1,745.77     3,980.43     4,562.48
19316       Suspension of breast                 T           T        0029       28.0166            1,291.57     2,944.82     3,375.44
19318       Reduction of large breast            T           T        0693       36.9988            1,705.64     3,888.94     4,457.62
19324       Enlarge breast                       T           1        0000        0.0000               0.00         0.00         0.00
19325       Enlarge breast with implant          T           T        0648       51.2269            2,361.56     5,384.46     6,171.82
19328       Removal of breast implant            T           T        0029       28.0166            1,291.57     2,944.82     3,375.44
19330       Removal of implant material          T           T        0029       28.0166            1,291.57     2,944.82     3,375.44
19340       Immediate breast prosthesis          T           T        0030       37.8692            1,745.77     3,980.43     4,562.48
19342       Delayed breast prosthesis            T           T        0648       51.2269            2,361.56     5,384.46     6,171.82
19350       Breast reconstruction                T           T        0028       19.2788             888.75      2,026.39     2,322.71
19355       Correct inverted nipple(s)           T           1        0000        0.0000               0.00         0.00         0.00
19357       Breast reconstruction                T           T        0648       51.2269            2,361.56     5,384.46     6,171.82
19361       Breast reconstruction                C           C        0000        0.0000               0.00         0.00         0.00
19364       Breast reconstruction                C           C        0000        0.0000               0.00         0.00         0.00
19366       Breast reconstruction                T           T        0029       28.0166            1,291.57     2,944.82     3,375.44
19367       Breast reconstruction                C           C        0000        0.0000               0.00         0.00         0.00
19368       Breast reconstruction                C           C        0000        0.0000               0.00         0.00         0.00
19369       Breast reconstruction                C           C        0000        0.0000               0.00         0.00         0.00
19370       Surgery of breast capsule            T           T        0029       28.0166            1,291.57     2,944.82     3,375.44
19371       Removal of breast capsule            T           T        0029       28.0166            1,291.57     2,944.82     3,375.44
19380       Revise breast reconstruction         T           T        0030       37.8692            1,745.77     3,980.43     4,562.48
19396       Design custom breast implant         T           T        0029       28.0166            1,291.57     2,944.82     3,375.44
19499       Breast surgery procedure             T           1        0000        0.0000               0.00         0.00         0.00
20000       Incision of abscess                  T           T        0006        1.4392              66.35       151.27       173.39
20005       Incision of deep abscess             T           T        0049       20.8706             962.13      2,193.71     2,514.49
20100       Explore wound, neck                  T           T        0023        4.2212             194.60       443.69       508.57
20101       Explore wound, chest                 T           T        0027       21.4302             987.93      2,252.53     2,581.91
20102       Explore wound, abdomen               T           T        0027       21.4302             987.93      2,252.53     2,581.91
20103       Explore wound, extremity             T           T        0023        4.2212             194.60       443.69       508.57
20150       Excise epiphyseal bar                T           T        0051       41.0893            1,894.22     4,318.90     4,950.44
20200       Muscle biopsy                        T           T        0021       15.1024             696.22      1,587.41     1,819.54
20205       Deep muscle biopsy                   T           T        0021       15.1024             696.22      1,587.41     1,819.54
20206       Needle biopsy, muscle                T           T        0005        3.9045             180.00       410.40       470.41
20220       Bone biopsy, trocar/needle           T           T        0019        4.0919             188.64       430.10       492.99
20225       Bone biopsy, trocar/needle           T           T        0020        6.8083             313.86       715.62       820.26
20240       Bone biopsy, excisional              T           T        0022       20.0656             925.02      2,109.10     2,417.50
20245       Bone biopsy, excisional              T           T        0022       20.0656             925.02      2,109.10     2,417.50
20250       Open bone biopsy                     T           T        0049       20.8706             962.13      2,193.71     2,514.49
20251       Open bone biopsy                     T           T        0049       20.8706             962.13      2,193.71     2,514.49
20500       Injection of sinus tract             T           T        0251        2.4520             113.04       257.73       295.42
20501       Inject sinus tract for x-ray         N           N        0000        0.0000               0.00         0.00         0.00
20520       Removal of foreign body              T           T        0019        4.0919             188.64       430.10       492.99
20525       Removal of foreign body              T           T        0022       20.0656             925.02      2,109.10     2,417.50
20526       Ther injection, carp tunnel          T           T        0204        2.2614             104.25       237.70       272.45
20550       Inj tendon sheath/ligament           T           T        0204        2.2614             104.25       237.70       272.45
20551       Inj tendon origin/insertion          T           T        0204        2.2614             104.25       237.70       272.45
20552       Inj trigger point, 1/2 muscl         T           T        0204        2.2614             104.25       237.70       272.45
20553       Inject trigger points, =/> 3         T           T        0204        2.2614             104.25       237.70       272.45
20600       Drain/inject, joint/bursa            T           T        0204        2.2614             104.25       237.70       272.45
20605       Drain/inject, joint/bursa            T           T        0204        2.2614             104.25       237.70       272.45
20610       Drain/inject, joint/bursa            T           T        0204        2.2614             104.25       237.70       272.45
20612       Aspirate/inj ganglion cyst           T           T        0204        2.2614             104.25       237.70       272.45
20615       Treatment of bone cyst               T           T        0004        2.0687              95.37       217.44       249.24
20650       Insert and remove bone pin           T           T        0049       20.8706             962.13      2,193.71     2,514.49
20660       Apply, rem fixation device           C           C        0000        0.0000               0.00         0.00         0.00
20661       Application of head brace            C           C        0000        0.0000               0.00         0.00         0.00
20662       Application of pelvis brace          T           T        0049       20.8706             962.13      2,193.71     2,514.49
20663       Application of thigh brace           T           T        0049       20.8706             962.13      2,193.71     2,514.49
20664       Halo brace application               C           C        0000        0.0000               0.00         0.00         0.00
20665       Removal of fixation device           X           X        0340        0.6102              28.13        64.14        73.52
20670       Removal of support implant           T           T        0021       15.1024             696.22      1,587.41     1,819.54
20680       Removal of support implant           T           T        0022       20.0656             925.02      2,109.10     2,417.50
20690       Apply bone fixation device           T           T        0050       25.1296            1,158.47     2,641.37     3,027.61
20692       Apply bone fixation device           T           T        0050       25.1296            1,158.47     2,641.37     3,027.61
20693       Adjust bone fixation device          T           T        0049       20.8706             962.13      2,193.71     2,514.49
20694       Remove bone fixation device          T           T        0049       20.8706             962.13      2,193.71     2,514.49
20802       Replantation, arm, complete          C           C        0000        0.0000               0.00         0.00         0.00
20805       Replant forearm, complete            C           C        0000        0.0000               0.00         0.00         0.00
20808       Replantation hand, complete          C           C        0000        0.0000               0.00         0.00         0.00
20816       Replantation digit, complete         C           C        0000        0.0000               0.00         0.00         0.00
20822       Replantation digit, complete         T           T        0054       25.8758            1,192.87     2,719.81     3,117.52
20824       Replantation thumb, complete         C           C        0000        0.0000               0.00         0.00         0.00
20827       Replantation thumb, complete         C           C        0000        0.0000               0.00         0.00         0.00
20838       Replantation foot, complete          C           C        0000        0.0000               0.00         0.00         0.00
20900       Removal of bone for graft            T           T        0050       25.1296            1,158.47     2,641.37     3,027.61
20902       Removal of bone for graft            T           T        0050       25.1296            1,158.47     2,641.37     3,027.61


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                     7 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
20910       Remove cartilage for graft           T           T        0027       21.4302         987.93      2,252.53     2,581.91
20912       Remove cartilage for graft           T           T        0027       21.4302         987.93      2,252.53     2,581.91
20920       Removal of fascia for graft          T           T        0686       14.0346         647.00      1,475.18     1,690.89
20922       Removal of fascia for graft          T           T        0027       21.4302         987.93      2,252.53     2,581.91
20924       Removal of tendon for graft          T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
20926       Removal of tissue for graft          T           T        0686       14.0346         647.00      1,475.18     1,690.89
20930       Spinal bone allograft                C           C        0000        0.0000           0.00         0.00         0.00
20931       Spinal bone allograft                C           C        0000        0.0000           0.00         0.00         0.00
20936       Spinal bone autograft                C           C        0000        0.0000           0.00         0.00         0.00
20937       Spinal bone autograft                C           C        0000        0.0000           0.00         0.00         0.00
20938       Spinal bone autograft                C           C        0000        0.0000           0.00         0.00         0.00
20950       Fluid pressure, muscle               T           T        0006        1.4392          66.35       151.27       173.39
20955       Fibula bone graft, microvasc         C           C        0000        0.0000           0.00         0.00         0.00
20956       Iliac bone graft, microvasc          C           C        0000        0.0000           0.00         0.00         0.00
20957       Mt bone graft, microvasc             C           C        0000        0.0000           0.00         0.00         0.00
20962       Other bone graft, microvasc          C           C        0000        0.0000           0.00         0.00         0.00
20969       Bone/skin graft, microvasc           C           C        0000        0.0000           0.00         0.00         0.00
20970       Bone/skin graft, iliac crest         C           C        0000        0.0000           0.00         0.00         0.00
20972       Bone/skin graft, metatarsal          T           T        0056       40.8559        1,883.46     4,294.36     4,922.32
20973       Bone/skin graft, great toe           T           T        0056       40.8559        1,883.46     4,294.36     4,922.32
20974       Electrical bone stimulation          A           3        0000        0.0000           M01          M01          M01
20975       Electrical bone stimulation          X           X        0340        0.6102          28.13        64.14        73.52
20979       Us bone stimulation                  X           X        0340        0.6102          28.13        64.14        73.52
20982       Ablate, bone tumor(s) perq           T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
20999       Musculoskeletal surgery              T           1        0000        0.0000           0.00         0.00         0.00
21010       Incision of jaw joint                T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
21015       Resection of facial tumor            T           T        0253       16.4266         757.27      1,726.60     1,979.08
21025       Excision of bone, lower jaw          T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21026       Excision of facial bone(s)           T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21029       Contour of face bone lesion          T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21030       Excise max/zygoma b9 tumor           T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
21031       Remove exostosis, mandible           T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
21032       Remove exostosis, maxilla            T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
21034       Excise max/zygoma mlg tumor          T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21040       Excise mandible lesion               T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
21044       Removal of jaw bone lesion           T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21045       Extensive jaw surgery                C           C        0000        0.0000           0.00         0.00         0.00
21046       Remove mandible cyst complex         T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21047       Excise lwr jaw cyst w/repair         T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21048       Remove maxilla cyst complex          T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21049       Excis uppr jaw cyst w/repair         T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21050       Removal of jaw joint                 T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21060       Remove jaw joint cartilage           T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21070       Remove coronoid process              T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21076       Prepare face/oral prosthesis         T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
21077       Prepare face/oral prosthesis         T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21079       Prepare face/oral prosthesis         T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21080       Prepare face/oral prosthesis         T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21081       Prepare face/oral prosthesis         T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21082       Prepare face/oral prosthesis         T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21083       Prepare face/oral prosthesis         T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21084       Prepare face/oral prosthesis         T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21085       Prepare face/oral prosthesis         T           T        0253       16.4266         757.27      1,726.60     1,979.08
21086       Prepare face/oral prosthesis         T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21087       Prepare face/oral prosthesis         T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21088       Prepare face/oral prosthesis         T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21089       Prepare face/oral prosthesis         T           1        0000        0.0000           0.00         0.00         0.00
21100       Maxillofacial fixation               T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21110       Interdental fixation                 T           T        0252        7.5511         348.11       793.70       909.76
21116       Injection, jaw joint x-ray           N           N        0000        0.0000           0.00         0.00         0.00
21120       Reconstruction of chin               T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
21121       Reconstruction of chin               T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
21122       Reconstruction of chin               T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
21123       Reconstruction of chin               T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
21125       Augmentation, lower jaw bone         T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
21127       Augmentation, lower jaw bone         T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21137       Reduction of forehead                T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
21138       Reduction of forehead                T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21139       Reduction of forehead                T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21141       Reconstruct midface, lefort          C           C        0000        0.0000           0.00         0.00         0.00
21142       Reconstruct midface, lefort          C           C        0000        0.0000           0.00         0.00         0.00
21143       Reconstruct midface, lefort          C           C        0000        0.0000           0.00         0.00         0.00
21145       Reconstruct midface, lefort          C           C        0000        0.0000           0.00         0.00         0.00
21146       Reconstruct midface, lefort          C           C        0000        0.0000           0.00         0.00         0.00
21147       Reconstruct midface, lefort          C           C        0000        0.0000           0.00         0.00         0.00
21150       Reconstruct midface, lefort          T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21151       Reconstruct midface, lefort          C           C        0000        0.0000           0.00         0.00         0.00
21154       Reconstruct midface, lefort          C           C        0000        0.0000           0.00         0.00         0.00
21155       Reconstruct midface, lefort          C           C        0000        0.0000           0.00         0.00         0.00
21159       Reconstruct midface, lefort          C           C        0000        0.0000           0.00         0.00         0.00
21160       Reconstruct midface, lefort          C           C        0000        0.0000           0.00         0.00         0.00
21172       Reconstruct orbit/forehead           C           C        0000        0.0000           0.00         0.00         0.00
21175       Reconstruct orbit/forehead           T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21179       Reconstruct entire forehead          C           C        0000        0.0000           0.00         0.00         0.00
21180       Reconstruct entire forehead          C           C        0000        0.0000           0.00         0.00         0.00
21181       Contour cranial bone lesion          T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
21182       Reconstruct cranial bone             C           C        0000        0.0000           0.00         0.00         0.00
21183       Reconstruct cranial bone             C           C        0000        0.0000           0.00         0.00         0.00
21184       Reconstruct cranial bone             C           C        0000        0.0000           0.00         0.00         0.00
21188       Reconstruction of midface            C           C        0000        0.0000           0.00         0.00         0.00
21193       Reconst lwr jaw w/o graft            C           C        0000        0.0000           0.00         0.00         0.00
21194       Reconst lwr jaw w/graft              C           C        0000        0.0000           0.00         0.00         0.00
21195       Reconst lwr jaw w/o fixation         T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21196       Reconst lwr jaw w/fixation           C           C        0000        0.0000           0.00         0.00         0.00
21198       Reconstr lwr jaw segment             T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21199       Reconstr lwr jaw w/advance           T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21206       Reconstruct upper jaw bone           T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21208       Augmentation of facial bones         T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21209       Reduction of facial bones            T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21210       Face bone graft                      T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21215       Lower jaw bone graft                 T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21230       Rib cartilage graft                  T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21235       Ear cartilage graft                  T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
21240       Reconstruction of jaw joint          T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21242       Reconstruction of jaw joint          T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21243       Reconstruction of jaw joint          T           T        0256       38.1991        1,760.98     4,015.11     4,602.23


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 8 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
21244       Reconstruction of lower jaw          T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21245       Reconstruction of jaw                T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21246       Reconstruction of jaw                T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21247       Reconstruct lower jaw bone           C           C        0000        0.0000           0.00        0.00         0.00
21248       Reconstruction of jaw                T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21249       Reconstruction of jaw                T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21255       Reconstruct lower jaw bone           C           C        0000        0.0000           0.00        0.00         0.00
21256       Reconstruction of orbit              C           C        0000        0.0000           0.00        0.00         0.00
21260       Revise eye sockets                   T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21261       Revise eye sockets                   T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21263       Revise eye sockets                   T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21267       Revise eye sockets                   T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21268       Revise eye sockets                   C           C        0000        0.0000           0.00        0.00         0.00
21270       Augmentation, cheek bone             T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21275       Revision, orbitofacial bones         T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21280       Revision of eyelid                   T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21282       Revision of eyelid                   T           T        0253       16.4266         757.27      1,726.60     1,979.08
21295       Revision of jaw muscle/bone          T           T        0252        7.5511         348.11       793.70       909.76
21296       Revision of jaw muscle/bone          T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
21299       Cranio/maxillofacial surgery         T           1        0000        0.0000           0.00        0.00         0.00
21310       Treatment of nose fracture           T           T        0251        2.4520         113.04       257.73       295.42
21315       Treatment of nose fracture           T           T        0251        2.4520         113.04       257.73       295.42
21320       Treatment of nose fracture           T           T        0252        7.5511         348.11       793.70       909.76
21325       Treatment of nose fracture           T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
21330       Treatment of nose fracture           T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
21335       Treatment of nose fracture           T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
21336       Treat nasal septal fracture          T           T        0063       37.5382        1,730.51     3,945.64     4,522.60
21337       Treat nasal septal fracture          T           T        0253       16.4266         757.27      1,726.60     1,979.08
21338       Treat nasoethmoid fracture           T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
21339       Treat nasoethmoid fracture           T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
21340       Treatment of nose fracture           T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21343       Treatment of sinus fracture          C           C        0000        0.0000           0.00        0.00         0.00
21344       Treatment of sinus fracture          C           C        0000        0.0000           0.00        0.00         0.00
21345       Treat nose/jaw fracture              T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
21346       Treat nose/jaw fracture              C           C        0000        0.0000           0.00        0.00         0.00
21347       Treat nose/jaw fracture              C           C        0000        0.0000           0.00        0.00         0.00
21348       Treat nose/jaw fracture              C           C        0000        0.0000           0.00        0.00         0.00
21355       Treat cheek bone fracture            T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21356       Treat cheek bone fracture            T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
21360       Treat cheek bone fracture            C           C        0000        0.0000           0.00        0.00         0.00
21365       Treat cheek bone fracture            C           C        0000        0.0000           0.00        0.00         0.00
21366       Treat cheek bone fracture            C           C        0000        0.0000           0.00        0.00         0.00
21385       Treat eye socket fracture            C           C        0000        0.0000           0.00        0.00         0.00
21386       Treat eye socket fracture            C           C        0000        0.0000           0.00        0.00         0.00
21387       Treat eye socket fracture            C           C        0000        0.0000           0.00        0.00         0.00
21390       Treat eye socket fracture            T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21395       Treat eye socket fracture            C           C        0000        0.0000           0.00        0.00         0.00
21400       Treat eye socket fracture            T           T        0252        7.5511         348.11       793.70       909.76
21401       Treat eye socket fracture            T           T        0253       16.4266         757.27      1,726.60     1,979.08
21406       Treat eye socket fracture            T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21407       Treat eye socket fracture            T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21408       Treat eye socket fracture            T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21421       Treat mouth roof fracture            T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
21422       Treat mouth roof fracture            C           C        0000        0.0000           0.00        0.00         0.00
21423       Treat mouth roof fracture            C           C        0000        0.0000           0.00        0.00         0.00
21431       Treat craniofacial fracture          C           C        0000        0.0000           0.00        0.00         0.00
21432       Treat craniofacial fracture          C           C        0000        0.0000           0.00        0.00         0.00
21433       Treat craniofacial fracture          C           C        0000        0.0000           0.00        0.00         0.00
21435       Treat craniofacial fracture          C           C        0000        0.0000           0.00        0.00         0.00
21436       Treat craniofacial fracture          C           C        0000        0.0000           0.00        0.00         0.00
21440       Treat dental ridge fracture          T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
21445       Treat dental ridge fracture          T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
21450       Treat lower jaw fracture             T           T        0251        2.4520         113.04       257.73       295.42
21451       Treat lower jaw fracture             T           T        0252        7.5511         348.11       793.70       909.76
21452       Treat lower jaw fracture             T           T        0253       16.4266         757.27      1,726.60     1,979.08
21453       Treat lower jaw fracture             T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21454       Treat lower jaw fracture             T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
21461       Treat lower jaw fracture             T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21462       Treat lower jaw fracture             T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21465       Treat lower jaw fracture             T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21470       Treat lower jaw fracture             T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21480       Reset dislocated jaw                 T           T        0251        2.4520         113.04       257.73       295.42
21485       Reset dislocated jaw                 T           T        0253       16.4266         757.27      1,726.60     1,979.08
21490       Repair dislocated jaw                T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
21495       Treat hyoid bone fracture            T           T        0253       16.4266         757.27      1,726.60     1,979.08
21497       Interdental wiring                   T           T        0253       16.4266         757.27      1,726.60     1,979.08
21499       Head surgery procedure               T           1        0000        0.0000           0.00        0.00         0.00
21501       Drain neck/chest lesion              T           T        0008       17.5086         807.15      1,840.33     2,109.44
21502       Drain chest lesion                   T           T        0049       20.8706         962.13      2,193.71     2,514.49
21510       Drainage of bone lesion              C           C        0000        0.0000           0.00        0.00         0.00
21550       Biopsy of neck/chest                 T           T        0020        6.8083         313.86       715.62       820.26
21555       Remove lesion, neck/chest            T           T        0022       20.0656         925.02      2,109.10     2,417.50
21556       Remove lesion, neck/chest            T           T        0022       20.0656         925.02      2,109.10     2,417.50
21557       Remove tumor, neck/chest             T           T        0022       20.0656         925.02      2,109.10     2,417.50
21600       Partial removal of rib               T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
21610       Partial removal of rib               T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
21615       Removal of rib                       C           C        0000        0.0000           0.00        0.00         0.00
21616       Removal of rib and nerves            C           C        0000        0.0000           0.00        0.00         0.00
21620       Partial removal of sternum           C           C        0000        0.0000           0.00        0.00         0.00
21627       Sternal debridement                  C           C        0000        0.0000           0.00        0.00         0.00
21630       Extensive sternum surgery            C           C        0000        0.0000           0.00        0.00         0.00
21632       Extensive sternum surgery            C           C        0000        0.0000           0.00        0.00         0.00
21685       Hyoid myotomy & suspension           T           T        0252        7.5511         348.11       793.70       909.76
21700       Revision of neck muscle              T           T        0049       20.8706         962.13      2,193.71     2,514.49
21705       Revision of neck muscle/rib          C           C        0000        0.0000           0.00        0.00         0.00
21720       Revision of neck muscle              T           T        0049       20.8706         962.13      2,193.71     2,514.49
21725       Revision of neck muscle              T           T        0006        1.4392          66.35       151.27       173.39
21740       Reconstruction of sternum            C           C        0000        0.0000           0.00        0.00         0.00
21742       Repair stern/nuss w/o scope          T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
21743       Repair sternum/nuss w/scope          T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
21750       Repair of sternum separation         C           C        0000        0.0000           0.00        0.00         0.00
21800       Treatment of rib fracture            T           T        0043        1.6857          77.71       177.18       203.09
21805       Treatment of rib fracture            T           T        0062       25.5264        1,176.77     2,683.08     3,075.42
21810       Treatment of rib fracture(s)         C           C        0000        0.0000           0.00        0.00         0.00
21820       Treat sternum fracture               T           T        0043        1.6857          77.71       177.18       203.09
21825       Treat sternum fracture               C           C        0000        0.0000           0.00        0.00         0.00


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 9 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
21899       Neck/chest surgery procedure         T           1        0000        0.0000           0.00        0.00         0.00
21920       Biopsy soft tissue of back           T           T        0020        6.8083         313.86       715.62       820.26
21925       Biopsy soft tissue of back           T           T        0022       20.0656         925.02      2,109.10     2,417.50
21930       Remove lesion, back or flank         T           T        0022       20.0656         925.02      2,109.10     2,417.50
21935       Remove tumor, back                   T           T        0022       20.0656         925.02      2,109.10     2,417.50
22010       I&d, p-spine, c/t/cerv-thor          C           C        0000        0.0000           0.00        0.00         0.00
22015       I&d, p-spine, l/s/ls                 C           C        0000        0.0000           0.00        0.00         0.00
22100       Remove part of neck vertebra         T           T        0208       44.1489        2,035.26     4,640.49     5,319.06
22101       Remove part, thorax vertebra         T           T        0208       44.1489        2,035.26     4,640.49     5,319.06
22102       Remove part, lumbar vertebra         T           T        0208       44.1489        2,035.26     4,640.49     5,319.06
22103       Remove extra spine segment           T           T        0208       44.1489        2,035.26     4,640.49     5,319.06
22110       Remove part of neck vertebra         C           C        0000        0.0000           0.00        0.00         0.00
22112       Remove part, thorax vertebra         C           C        0000        0.0000           0.00        0.00         0.00
22114       Remove part, lumbar vertebra         C           C        0000        0.0000           0.00        0.00         0.00
22116       Remove extra spine segment           C           C        0000        0.0000           0.00        0.00         0.00
22210       Revision of neck spine               C           C        0000        0.0000           0.00        0.00         0.00
22212       Revision of thorax spine             C           C        0000        0.0000           0.00        0.00         0.00
22214       Revision of lumbar spine             C           C        0000        0.0000           0.00        0.00         0.00
22216       Revise, extra spine segment          C           C        0000        0.0000           0.00        0.00         0.00
22220       Revision of neck spine               C           C        0000        0.0000           0.00        0.00         0.00
22222       Revision of thorax spine             T           T        0208       44.1489        2,035.26     4,640.49     5,319.06
22224       Revision of lumbar spine             C           C        0000        0.0000           0.00        0.00         0.00
22226       Revise, extra spine segment          C           C        0000        0.0000           0.00        0.00         0.00
22305       Treat spine process fracture         T           T        0043        1.6857          77.71       177.18       203.09
22310       Treat spine fracture                 T           T        0043        1.6857          77.71       177.18       203.09
22315       Treat spine fracture                 T           T        0043        1.6857          77.71       177.18       203.09
22318       Treat odontoid fx w/o graft          C           C        0000        0.0000           0.00        0.00         0.00
22319       Treat odontoid fx w/graft            C           C        0000        0.0000           0.00        0.00         0.00
22325       Treat spine fracture                 C           C        0000        0.0000           0.00        0.00         0.00
22326       Treat neck spine fracture            C           C        0000        0.0000           0.00        0.00         0.00
22327       Treat thorax spine fracture          C           C        0000        0.0000           0.00        0.00         0.00
22328       Treat each add spine fx              C           C        0000        0.0000           0.00        0.00         0.00
22505       Manipulation of spine                T           T        0045       14.5947         672.82      1,534.05     1,758.37
22520       Percut vertebroplasty thor           T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
22521       Percut vertebroplasty lumb           T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
22522       Percut vertebroplasty add’l          T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
22523       Percut kyphoplasty, thor             T           T        0052       66.5800        3,069.34     6,998.22     8,021.56
22524       Percut kyphoplasty, lumbar           T           T        0052       66.5800        3,069.34     6,998.22     8,021.56
22525       Percut kyphoplasty, add-on           T           T        0052       66.5800        3,069.34     6,998.22     8,021.56
22526       Idet, single level                   T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
22527       Idet, 1 or more levels               T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
22532       Lat thorax spine fusion              C           C        0000        0.0000           0.00        0.00         0.00
22533       Lat lumbar spine fusion              C           C        0000        0.0000           0.00        0.00         0.00
22534       Lat thor/lumb, add’l seg             C           C        0000        0.0000           0.00        0.00         0.00
22548       Neck spine fusion                    C           C        0000        0.0000           0.00        0.00         0.00
22554       Neck spine fusion                    C           C        0000        0.0000           0.00        0.00         0.00
22556       Thorax spine fusion                  C           C        0000        0.0000           0.00        0.00         0.00
22558       Lumbar spine fusion                  C           C        0000        0.0000           0.00        0.00         0.00
22585       Additional spinal fusion             C           C        0000        0.0000           0.00        0.00         0.00
22590       Spine & skull spinal fusion          C           C        0000        0.0000           0.00        0.00         0.00
22595       Neck spinal fusion                   C           C        0000        0.0000           0.00        0.00         0.00
22600       Neck spine fusion                    C           C        0000        0.0000           0.00        0.00         0.00
22610       Thorax spine fusion                  C           C        0000        0.0000           0.00        0.00         0.00
22612       Lumbar spine fusion                  T           T        0208       44.1489        2,035.26     4,640.49     5,319.06
22614       Spine fusion, extra segment          T           T        0208       44.1489        2,035.26     4,640.49     5,319.06
22630       Lumbar spine fusion                  C           C        0000        0.0000           0.00        0.00         0.00
22632       Spine fusion, extra segment          C           C        0000        0.0000           0.00        0.00         0.00
22800       Fusion of spine                      C           C        0000        0.0000           0.00        0.00         0.00
22802       Fusion of spine                      C           C        0000        0.0000           0.00        0.00         0.00
22804       Fusion of spine                      C           C        0000        0.0000           0.00        0.00         0.00
22808       Fusion of spine                      C           C        0000        0.0000           0.00        0.00         0.00
22810       Fusion of spine                      C           C        0000        0.0000           0.00        0.00         0.00
22812       Fusion of spine                      C           C        0000        0.0000           0.00        0.00         0.00
22818       Kyphectomy, 1-2 segments             C           C        0000        0.0000           0.00        0.00         0.00
22819       Kyphectomy, 3 or more                C           C        0000        0.0000           0.00        0.00         0.00
22830       Exploration of spinal fusion         C           C        0000        0.0000           0.00        0.00         0.00
22840       Insert spine fixation device         C           C        0000        0.0000           0.00        0.00         0.00
22841       Insert spine fixation device         C           C        0000        0.0000           0.00        0.00         0.00
22842       Insert spine fixation device         C           C        0000        0.0000           0.00        0.00         0.00
22843       Insert spine fixation device         C           C        0000        0.0000           0.00        0.00         0.00
22844       Insert spine fixation device         C           C        0000        0.0000           0.00        0.00         0.00
22845       Insert spine fixation device         C           C        0000        0.0000           0.00        0.00         0.00
22846       Insert spine fixation device         C           C        0000        0.0000           0.00        0.00         0.00
22847       Insert spine fixation device         C           C        0000        0.0000           0.00        0.00         0.00
22848       Insert pelv fixation device          C           C        0000        0.0000           0.00        0.00         0.00
22849       Reinsert spinal fixation             C           C        0000        0.0000           0.00        0.00         0.00
22850       Remove spine fixation device         C           C        0000        0.0000           0.00        0.00         0.00
22851       Apply spine prosth device            T           T        0049       20.8706         962.13      2,193.71     2,514.49
22852       Remove spine fixation device         C           C        0000        0.0000           0.00        0.00         0.00
22855       Remove spine fixation device         C           C        0000        0.0000           0.00        0.00         0.00
22857       Lumbar artif diskectomy              C           C        0000        0.0000           0.00        0.00         0.00
22862       Revise lumbar artif disc             C           C        0000        0.0000           0.00        0.00         0.00
22865       Remove lumb artif disc               C           C        0000        0.0000           0.00        0.00         0.00
22899       Spine surgery procedure              T           T        0049       20.8706         962.13      2,193.71     2,514.49
22900       Remove abdominal wall lesion         T           T        0022       20.0656         925.02      2,109.10     2,417.50
22999       Abdomen surgery procedure            T           1        0000        0.0000           0.00        0.00         0.00
23000       Removal of calcium deposits          T           T        0021       15.1024         696.22      1,587.41     1,819.54
23020       Release shoulder joint               T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
23030       Drain shoulder lesion                T           T        0008       17.5086         807.15      1,840.33     2,109.44
23031       Drain shoulder bursa                 T           T        0008       17.5086         807.15      1,840.33     2,109.44
23035       Drain shoulder bone lesion           T           T        0049       20.8706         962.13      2,193.71     2,514.49
23040       Exploratory shoulder surgery         T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
23044       Exploratory shoulder surgery         T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
23065       Biopsy shoulder tissues              T           T        0020        6.8083         313.86       715.62       820.26
23066       Biopsy shoulder tissues              T           T        0022       20.0656         925.02      2,109.10     2,417.50
23075       Removal of shoulder lesion           T           T        0021       15.1024         696.22      1,587.41     1,819.54
23076       Removal of shoulder lesion           T           T        0022       20.0656         925.02      2,109.10     2,417.50
23077       Remove tumor of shoulder             T           T        0022       20.0656         925.02      2,109.10     2,417.50
23100       Biopsy of shoulder joint             T           T        0049       20.8706         962.13      2,193.71     2,514.49
23101       Shoulder joint surgery               T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
23105       Remove shoulder joint lining         T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
23106       Incision of collarbone joint         T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
23107       Explore treat shoulder joint         T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
23120       Partial removal, collar bone         T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
23125       Removal of collar bone               T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
23130       Remove shoulder bone, part           T           T        0051       41.0893        1,894.22     4,318.90     4,950.44


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 10 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
23140       Removal of bone lesion               T           T        0049       20.8706         962.13      2,193.71     2,514.49
23145       Removal of bone lesion               T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
23146       Removal of bone lesion               T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
23150       Removal of humerus lesion            T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
23155       Removal of humerus lesion            T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
23156       Removal of humerus lesion            T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
23170       Remove collar bone lesion            T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
23172       Remove shoulder blade lesion         T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
23174       Remove humerus lesion                T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
23180       Remove collar bone lesion            T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
23182       Remove shoulder blade lesion         T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
23184       Remove humerus lesion                T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
23190       Partial removal of scapula           T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
23195       Removal of head of humerus           T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
23200       Removal of collar bone               C           C        0000        0.0000           0.00        0.00         0.00
23210       Removal of shoulder blade            C           C        0000        0.0000           0.00        0.00         0.00
23220       Partial removal of humerus           C           C        0000        0.0000           0.00        0.00         0.00
23221       Partial removal of humerus           C           C        0000        0.0000           0.00        0.00         0.00
23222       Partial removal of humerus           C           C        0000        0.0000           0.00        0.00         0.00
23330       Remove shoulder foreign body         T           T        0020        6.8083         313.86       715.62       820.26
23331       Remove shoulder foreign body         T           T        0022       20.0656         925.02      2,109.10     2,417.50
23332       Remove shoulder foreign body         C           C        0000        0.0000           0.00        0.00         0.00
23350       Injection for shoulder x-ray         N           N        0000        0.0000           0.00        0.00         0.00
23395       Muscle transfer,shoulder/arm         T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
23397       Muscle transfers                     T           T        0052       66.5800        3,069.34     6,998.22     8,021.56
23400       Fixation of shoulder blade           T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
23405       Incision of tendon & muscle          T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
23406       Incise tendon(s) & muscle(s)         T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
23410       Repair rotator cuff, acute           T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
23412       Repair rotator cuff, chronic         T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
23415       Release of shoulder ligament         T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
23420       Repair of shoulder                   T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
23430       Repair biceps tendon                 T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
23440       Remove/transplant tendon             T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
23450       Repair shoulder capsule              T           T        0052       66.5800        3,069.34     6,998.22     8,021.56
23455       Repair shoulder capsule              T           T        0052       66.5800        3,069.34     6,998.22     8,021.56
23460       Repair shoulder capsule              T           T        0052       66.5800        3,069.34     6,998.22     8,021.56
23462       Repair shoulder capsule              T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
23465       Repair shoulder capsule              T           T        0052       66.5800        3,069.34     6,998.22     8,021.56
23466       Repair shoulder capsule              T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
23470       Reconstruct shoulder joint           T           T        0425      107.1942        4,941.65    11,267.18    12,914.76
23472       Reconstruct shoulder joint           C           C        0000        0.0000           0.00        0.00         0.00
23480       Revision of collar bone              T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
23485       Revision of collar bone              T           T        0052       66.5800        3,069.34     6,998.22     8,021.56
23490       Reinforce clavicle                   T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
23491       Reinforce shoulder bones             T           T        0052       66.5800        3,069.34     6,998.22     8,021.56
23500       Treat clavicle fracture              T           T        0043        1.6857          77.71       177.18       203.09
23505       Treat clavicle fracture              T           T        0043        1.6857          77.71       177.18       203.09
23515       Treat clavicle fracture              T           T        0064       57.2172        2,637.71     6,014.10     6,893.53
23520       Treat clavicle dislocation           T           T        0043        1.6857          77.71       177.18       203.09
23525       Treat clavicle dislocation           T           T        0043        1.6857          77.71       177.18       203.09
23530       Treat clavicle dislocation           T           T        0063       37.5382        1,730.51     3,945.64     4,522.60
23532       Treat clavicle dislocation           T           T        0062       25.5264        1,176.77     2,683.08     3,075.42
23540       Treat clavicle dislocation           T           T        0043        1.6857          77.71       177.18       203.09
23545       Treat clavicle dislocation           T           T        0043        1.6857          77.71       177.18       203.09
23550       Treat clavicle dislocation           T           T        0063       37.5382        1,730.51     3,945.64     4,522.60
23552       Treat clavicle dislocation           T           T        0063       37.5382        1,730.51     3,945.64     4,522.60
23570       Treat shoulder blade fx              T           T        0043        1.6857          77.71       177.18       203.09
23575       Treat shoulder blade fx              T           T        0043        1.6857          77.71       177.18       203.09
23585       Treat scapula fracture               T           T        0064       57.2172        2,637.71     6,014.10     6,893.53
23600       Treat humerus fracture               T           T        0043        1.6857          77.71       177.18       203.09
23605       Treat humerus fracture               T           T        0043        1.6857          77.71       177.18       203.09
23615       Treat humerus fracture               T           T        0064       57.2172        2,637.71     6,014.10     6,893.53
23616       Treat humerus fracture               T           T        0064       57.2172        2,637.71     6,014.10     6,893.53
23620       Treat humerus fracture               T           T        0043        1.6857          77.71       177.18       203.09
23625       Treat humerus fracture               T           T        0043        1.6857          77.71       177.18       203.09
23630       Treat humerus fracture               T           T        0064       57.2172        2,637.71     6,014.10     6,893.53
23650       Treat shoulder dislocation           T           T        0043        1.6857          77.71       177.18       203.09
23655       Treat shoulder dislocation           T           T        0045       14.5947         672.82      1,534.05     1,758.37
23660       Treat shoulder dislocation           T           T        0063       37.5382        1,730.51     3,945.64     4,522.60
23665       Treat dislocation/fracture           T           T        0043        1.6857          77.71       177.18       203.09
23670       Treat dislocation/fracture           T           T        0064       57.2172        2,637.71     6,014.10     6,893.53
23675       Treat dislocation/fracture           T           T        0043        1.6857          77.71       177.18       203.09
23680       Treat dislocation/fracture           T           T        0063       37.5382        1,730.51     3,945.64     4,522.60
23700       Fixation of shoulder                 T           T        0045       14.5947         672.82      1,534.05     1,758.37
23800       Fusion of shoulder joint             T           T        0052       66.5800        3,069.34     6,998.22     8,021.56
23802       Fusion of shoulder joint             T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
23900       Amputation of arm & girdle           C           C        0000        0.0000           0.00        0.00         0.00
23920       Amputation at shoulder joint         C           C        0000        0.0000           0.00        0.00         0.00
23921       Amputation follow-up surgery         T           T        0025        5.2594         242.46       552.82       633.65
23929       Shoulder surgery procedure           T           1        0000        0.0000           0.00        0.00         0.00
23930       Drainage of arm lesion               T           T        0008       17.5086         807.15      1,840.33     2,109.44
23931       Drainage of arm bursa                T           T        0008       17.5086         807.15      1,840.33     2,109.44
23935       Drain arm/elbow bone lesion          T           T        0049       20.8706         962.13      2,193.71     2,514.49
24000       Exploratory elbow surgery            T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
24006       Release elbow joint                  T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
24065       Biopsy arm/elbow soft tissue         T           T        0021       15.1024         696.22      1,587.41     1,819.54
24066       Biopsy arm/elbow soft tissue         T           T        0021       15.1024         696.22      1,587.41     1,819.54
24075       Remove arm/elbow lesion              T           T        0021       15.1024         696.22      1,587.41     1,819.54
24076       Remove arm/elbow lesion              T           T        0022       20.0656         925.02      2,109.10     2,417.50
24077       Remove tumor of arm/elbow            T           T        0022       20.0656         925.02      2,109.10     2,417.50
24100       Biopsy elbow joint lining            T           T        0049       20.8706         962.13      2,193.71     2,514.49
24101       Explore/treat elbow joint            T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
24102       Remove elbow joint lining            T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
24105       Removal of elbow bursa               T           T        0049       20.8706         962.13      2,193.71     2,514.49
24110       Remove humerus lesion                T           T        0049       20.8706         962.13      2,193.71     2,514.49
24115       Remove/graft bone lesion             T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
24116       Remove/graft bone lesion             T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
24120       Remove elbow lesion                  T           T        0049       20.8706         962.13      2,193.71     2,514.49
24125       Remove/graft bone lesion             T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
24126       Remove/graft bone lesion             T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
24130       Removal of head of radius            T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
24134       Removal of arm bone lesion           T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
24136       Remove radius bone lesion            T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
24138       Remove elbow bone lesion             T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
24140       Partial removal of arm bone          T           T        0050       25.1296        1,158.47     2,641.37     3,027.61


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 11 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
24145       Partial removal of radius            T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
24147       Partial removal of elbow             T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
24149       Radical resection of elbow           T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
24150       Extensive humerus surgery            T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
24151       Extensive humerus surgery            T           T        0052       66.5800        3,069.34     6,998.22     8,021.56
24152       Extensive radius surgery             T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
24153       Extensive radius surgery             T           T        0052       66.5800        3,069.34     6,998.22     8,021.56
24155       Removal of elbow joint               T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
24160       Remove elbow joint implant           T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
24164       Remove radius head implant           T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
24200       Removal of arm foreign body          T           T        0019        4.0919         188.64       430.10       492.99
24201       Removal of arm foreign body          T           T        0021       15.1024         696.22      1,587.41     1,819.54
24220       Injection for elbow x-ray            N           N        0000        0.0000           0.00        0.00         0.00
24300       Manipulate elbow w/anesth            T           T        0045       14.5947         672.82      1,534.05     1,758.37
24301       Muscle/tendon transfer               T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
24305       Arm tendon lengthening               T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
24310       Revision of arm tendon               T           T        0049       20.8706         962.13      2,193.71     2,514.49
24320       Repair of arm tendon                 T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
24330       Revision of arm muscles              T           T        0052       66.5800        3,069.34     6,998.22     8,021.56
24331       Revision of arm muscles              T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
24332       Tenolysis, triceps                   T           T        0049       20.8706         962.13      2,193.71     2,514.49
24340       Repair of biceps tendon              T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
24341       Repair arm tendon/muscle             T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
24342       Repair of ruptured tendon            T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
24343       Repr elbow lat ligmnt w/tiss         T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
24344       Reconstruct elbow lat ligmnt         T           T        0052       66.5800        3,069.34     6,998.22     8,021.56
24345       Repr elbw med ligmnt w/tissu         T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
24346       Reconstruct elbow med ligmnt         T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
24350       Repair of tennis elbow               T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
24351       Repair of tennis elbow               T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
24352       Repair of tennis elbow               T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
24354       Repair of tennis elbow               T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
24356       Revision of tennis elbow             T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
24360       Reconstruct elbow joint              T           T        0047       33.4505        1,542.07     3,515.98     4,030.12
24361       Reconstruct elbow joint              T           T        0425      107.1942        4,941.65    11,267.18    12,914.76
24362       Reconstruct elbow joint              T           T        0048       47.4378        2,186.88     4,986.19     5,715.31
24363       Replace elbow joint                  T           T        0425      107.1942        4,941.65    11,267.18    12,914.76
24365       Reconstruct head of radius           T           T        0047       33.4505        1,542.07     3,515.98     4,030.12
24366       Reconstruct head of radius           T           T        0425      107.1942        4,941.65    11,267.18    12,914.76
24400       Revision of humerus                  T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
24410       Revision of humerus                  T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
24420       Revision of humerus                  T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
24430       Repair of humerus                    T           T        0052       66.5800        3,069.34     6,998.22     8,021.56
24435       Repair humerus with graft            T           T        0052       66.5800        3,069.34     6,998.22     8,021.56
24470       Revision of elbow joint              T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
24495       Decompression of forearm             T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
24498       Reinforce humerus                    T           T        0052       66.5800        3,069.34     6,998.22     8,021.56
24500       Treat humerus fracture               T           T        0043        1.6857          77.71       177.18       203.09
24505       Treat humerus fracture               T           T        0043        1.6857          77.71       177.18       203.09
24515       Treat humerus fracture               T           T        0064       57.2172        2,637.71     6,014.10     6,893.53
24516       Treat humerus fracture               T           T        0064       57.2172        2,637.71     6,014.10     6,893.53
24530       Treat humerus fracture               T           T        0043        1.6857          77.71       177.18       203.09
24535       Treat humerus fracture               T           T        0043        1.6857          77.71       177.18       203.09
24538       Treat humerus fracture               T           T        0062       25.5264        1,176.77     2,683.08     3,075.42
24545       Treat humerus fracture               T           T        0064       57.2172        2,637.71     6,014.10     6,893.53
24546       Treat humerus fracture               T           T        0064       57.2172        2,637.71     6,014.10     6,893.53
24560       Treat humerus fracture               T           T        0043        1.6857          77.71       177.18       203.09
24565       Treat humerus fracture               T           T        0043        1.6857          77.71       177.18       203.09
24566       Treat humerus fracture               T           T        0062       25.5264        1,176.77     2,683.08     3,075.42
24575       Treat humerus fracture               T           T        0064       57.2172        2,637.71     6,014.10     6,893.53
24576       Treat humerus fracture               T           T        0043        1.6857          77.71       177.18       203.09
24577       Treat humerus fracture               T           T        0043        1.6857          77.71       177.18       203.09
24579       Treat humerus fracture               T           T        0064       57.2172        2,637.71     6,014.10     6,893.53
24582       Treat humerus fracture               T           T        0062       25.5264        1,176.77     2,683.08     3,075.42
24586       Treat elbow fracture                 T           T        0064       57.2172        2,637.71     6,014.10     6,893.53
24587       Treat elbow fracture                 T           T        0064       57.2172        2,637.71     6,014.10     6,893.53
24600       Treat elbow dislocation              T           T        0043        1.6857          77.71       177.18       203.09
24605       Treat elbow dislocation              T           T        0045       14.5947         672.82      1,534.05     1,758.37
24615       Treat elbow dislocation              T           T        0064       57.2172        2,637.71     6,014.10     6,893.53
24620       Treat elbow fracture                 T           T        0043        1.6857          77.71       177.18       203.09
24635       Treat elbow fracture                 T           T        0064       57.2172        2,637.71     6,014.10     6,893.53
24640       Treat elbow dislocation              T           T        0043        1.6857          77.71       177.18       203.09
24650       Treat radius fracture                T           T        0043        1.6857          77.71       177.18       203.09
24655       Treat radius fracture                T           T        0043        1.6857          77.71       177.18       203.09
24665       Treat radius fracture                T           T        0063       37.5382        1,730.51     3,945.64     4,522.60
24666       Treat radius fracture                T           T        0064       57.2172        2,637.71     6,014.10     6,893.53
24670       Treat ulnar fracture                 T           T        0043        1.6857          77.71       177.18       203.09
24675       Treat ulnar fracture                 T           T        0043        1.6857          77.71       177.18       203.09
24685       Treat ulnar fracture                 T           T        0063       37.5382        1,730.51     3,945.64     4,522.60
24800       Fusion of elbow joint                T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
24802       Fusion/graft of elbow joint          T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
24900       Amputation of upper arm              C           C        0000        0.0000           0.00        0.00         0.00
24920       Amputation of upper arm              C           C        0000        0.0000           0.00        0.00         0.00
24925       Amputation follow-up surgery         T           T        0049       20.8706         962.13      2,193.71     2,514.49
24930       Amputation follow-up surgery         C           C        0000        0.0000           0.00        0.00         0.00
24931       Amputate upper arm & implant         C           C        0000        0.0000           0.00        0.00         0.00
24935       Revision of amputation               T           T        0052       66.5800        3,069.34     6,998.22     8,021.56
24940       Revision of upper arm                C           C        0000        0.0000           0.00        0.00         0.00
24999       Upper arm/elbow surgery              T           1        0000        0.0000           0.00        0.00         0.00
25000       Incision of tendon sheath            T           T        0049       20.8706         962.13      2,193.71     2,514.49
25001       Incise flexor carpi radialis         T           T        0049       20.8706         962.13      2,193.71     2,514.49
25020       Decompress forearm 1 space           T           T        0049       20.8706         962.13      2,193.71     2,514.49
25023       Decompress forearm 1 space           T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
25024       Decompress forearm 2 spaces          T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
25025       Decompress forearm 2 spaces          T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
25028       Drainage of forearm lesion           T           T        0049       20.8706         962.13      2,193.71     2,514.49
25031       Drainage of forearm bursa            T           T        0049       20.8706         962.13      2,193.71     2,514.49
25035       Treat forearm bone lesion            T           T        0049       20.8706         962.13      2,193.71     2,514.49
25040       Explore/treat wrist joint            T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
25065       Biopsy forearm soft tissues          T           T        0020        6.8083         313.86       715.62       820.26
25066       Biopsy forearm soft tissues          T           T        0022       20.0656         925.02      2,109.10     2,417.50
25075       Removal forearm lesion subcu         T           T        0021       15.1024         696.22      1,587.41     1,819.54
25076       Removal forearm lesion deep          T           T        0022       20.0656         925.02      2,109.10     2,417.50
25077       Remove tumor, forearm/wrist          T           T        0022       20.0656         925.02      2,109.10     2,417.50
25085       Incision of wrist capsule            T           T        0049       20.8706         962.13      2,193.71     2,514.49
25100       Biopsy of wrist joint                T           T        0049       20.8706         962.13      2,193.71     2,514.49


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 12 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
25101       Explore/treat wrist joint            T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
25105       Remove wrist joint lining            T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
25107       Remove wrist joint cartilage         T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
25109       Excise tendon forearm/wrist          T           T        0049       20.8706         962.13      2,193.71     2,514.49
25110       Remove wrist tendon lesion           T           T        0049       20.8706         962.13      2,193.71     2,514.49
25111       Remove wrist tendon lesion           T           T        0053       16.1540         744.70      1,697.95     1,946.23
25112       Reremove wrist tendon lesion         T           T        0053       16.1540         744.70      1,697.95     1,946.23
25115       Remove wrist/forearm lesion          T           T        0049       20.8706         962.13      2,193.71     2,514.49
25116       Remove wrist/forearm lesion          T           T        0049       20.8706         962.13      2,193.71     2,514.49
25118       Excise wrist tendon sheath           T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
25119       Partial removal of ulna              T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
25120       Removal of forearm lesion            T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
25125       Remove/graft forearm lesion          T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
25126       Remove/graft forearm lesion          T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
25130       Removal of wrist lesion              T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
25135       Remove & graft wrist lesion          T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
25136       Remove & graft wrist lesion          T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
25145       Remove forearm bone lesion           T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
25150       Partial removal of ulna              T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
25151       Partial removal of radius            T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
25170       Extensive forearm surgery            T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
25210       Removal of wrist bone                T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
25215       Removal of wrist bones               T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
25230       Partial removal of radius            T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
25240       Partial removal of ulna              T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
25246       Injection for wrist x-ray            N           N        0000        0.0000           0.00        0.00         0.00
25248       Remove forearm foreign body          T           T        0049       20.8706         962.13      2,193.71     2,514.49
25250       Removal of wrist prosthesis          T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
25251       Removal of wrist prosthesis          T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
25259       Manipulate wrist w/anesthes          T           T        0043        1.6857          77.71       177.18       203.09
25260       Repair forearm tendon/muscle         T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
25263       Repair forearm tendon/muscle         T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
25265       Repair forearm tendon/muscle         T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
25270       Repair forearm tendon/muscle         T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
25272       Repair forearm tendon/muscle         T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
25274       Repair forearm tendon/muscle         T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
25275       Repair forearm tendon sheath         T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
25280       Revise wrist/forearm tendon          T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
25290       Incise wrist/forearm tendon          T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
25295       Release wrist/forearm tendon         T           T        0049       20.8706         962.13      2,193.71     2,514.49
25300       Fusion of tendons at wrist           T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
25301       Fusion of tendons at wrist           T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
25310       Transplant forearm tendon            T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
25312       Transplant forearm tendon            T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
25315       Revise palsy hand tendon(s)          T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
25316       Revise palsy hand tendon(s)          T           T        0052       66.5800        3,069.34     6,998.22     8,021.56
25320       Repair/revise wrist joint            T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
25332       Revise wrist joint                   T           T        0047       33.4505        1,542.07     3,515.98     4,030.12
25335       Realignment of hand                  T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
25337       Reconstruct ulna/radioulnar          T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
25350       Revision of radius                   T           T        0052       66.5800        3,069.34     6,998.22     8,021.56
25355       Revision of radius                   T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
25360       Revision of ulna                     T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
25365       Revise radius & ulna                 T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
25370       Revise radius or ulna                T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
25375       Revise radius & ulna                 T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
25390       Shorten radius or ulna               T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
25391       Lengthen radius or ulna              T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
25392       Shorten radius & ulna                T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
25393       Lengthen radius & ulna               T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
25394       Repair carpal bone, shorten          T           T        0053       16.1540         744.70      1,697.95     1,946.23
25400       Repair radius or ulna                T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
25405       Repair/graft radius or ulna          T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
25415       Repair radius & ulna                 T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
25420       Repair/graft radius & ulna           T           T        0052       66.5800        3,069.34     6,998.22     8,021.56
25425       Repair/graft radius or ulna          T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
25426       Repair/graft radius & ulna           T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
25430       Vasc graft into carpal bone          T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
25431       Repair nonunion carpal bone          T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
25440       Repair/graft wrist bone              T           T        0052       66.5800        3,069.34     6,998.22     8,021.56
25441       Reconstruct wrist joint              T           T        0425      107.1942        4,941.65    11,267.18    12,914.76
25442       Reconstruct wrist joint              T           T        0425      107.1942        4,941.65    11,267.18    12,914.76
25443       Reconstruct wrist joint              T           T        0048       47.4378        2,186.88     4,986.19     5,715.31
25444       Reconstruct wrist joint              T           T        0048       47.4378        2,186.88     4,986.19     5,715.31
25445       Reconstruct wrist joint              T           T        0048       47.4378        2,186.88     4,986.19     5,715.31
25446       Wrist replacement                    T           T        0425      107.1942        4,941.65    11,267.18    12,914.76
25447       Repair wrist joint(s)                T           T        0047       33.4505        1,542.07     3,515.98     4,030.12
25449       Remove wrist joint implant           T           T        0047       33.4505        1,542.07     3,515.98     4,030.12
25450       Revision of wrist joint              T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
25455       Revision of wrist joint              T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
25490       Reinforce radius                     T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
25491       Reinforce ulna                       T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
25492       Reinforce radius and ulna            T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
25500       Treat fracture of radius             T           T        0043        1.6857          77.71       177.18       203.09
25505       Treat fracture of radius             T           T        0043        1.6857          77.71       177.18       203.09
25515       Treat fracture of radius             T           T        0063       37.5382        1,730.51     3,945.64     4,522.60
25520       Treat fracture of radius             T           T        0043        1.6857          77.71       177.18       203.09
25525       Treat fracture of radius             T           T        0063       37.5382        1,730.51     3,945.64     4,522.60
25526       Treat fracture of radius             T           T        0063       37.5382        1,730.51     3,945.64     4,522.60
25530       Treat fracture of ulna               T           T        0043        1.6857          77.71       177.18       203.09
25535       Treat fracture of ulna               T           T        0043        1.6857          77.71       177.18       203.09
25545       Treat fracture of ulna               T           T        0063       37.5382        1,730.51     3,945.64     4,522.60
25560       Treat fracture radius & ulna         T           T        0043        1.6857          77.71       177.18       203.09
25565       Treat fracture radius & ulna         T           T        0043        1.6857          77.71       177.18       203.09
25574       Treat fracture radius & ulna         T           T        0064       57.2172        2,637.71     6,014.10     6,893.53
25575       Treat fracture radius/ulna           T           T        0064       57.2172        2,637.71     6,014.10     6,893.53
25600       Treat fracture radius/ulna           T           T        0043        1.6857          77.71       177.18       203.09
25605       Treat fracture radius/ulna           T           T        0043        1.6857          77.71       177.18       203.09
25606       Treat fx distal radial               T           T        0062       25.5264        1,176.77     2,683.08     3,075.42
25607       Treat fx rad extra-articul           T           T        0064       57.2172        2,637.71     6,014.10     6,893.53
25608       Treat fx rad intra-articul           T           T        0064       57.2172        2,637.71     6,014.10     6,893.53
25609       Treat fx radial 3+ frag              T           T        0064       57.2172        2,637.71     6,014.10     6,893.53
25622       Treat wrist bone fracture            T           T        0043        1.6857          77.71       177.18       203.09
25624       Treat wrist bone fracture            T           T        0043        1.6857          77.71       177.18       203.09
25628       Treat wrist bone fracture            T           T        0063       37.5382        1,730.51     3,945.64     4,522.60
25630       Treat wrist bone fracture            T           T        0043        1.6857          77.71       177.18       203.09


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 13 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
25635       Treat wrist bone fracture            T           T        0043        1.6857          77.71       177.18       203.09
25645       Treat wrist bone fracture            T           T        0063       37.5382        1,730.51     3,945.64     4,522.60
25650       Treat wrist bone fracture            T           T        0043        1.6857          77.71       177.18       203.09
25651       Pin ulnar styloid fracture           T           T        0062       25.5264        1,176.77     2,683.08     3,075.42
25652       Treat fracture ulnar styloid         T           T        0063       37.5382        1,730.51     3,945.64     4,522.60
25660       Treat wrist dislocation              T           T        0043        1.6857          77.71       177.18       203.09
25670       Treat wrist dislocation              T           T        0062       25.5264        1,176.77     2,683.08     3,075.42
25671       Pin radioulnar dislocation           T           T        0062       25.5264        1,176.77     2,683.08     3,075.42
25675       Treat wrist dislocation              T           T        0043        1.6857          77.71       177.18       203.09
25676       Treat wrist dislocation              T           T        0062       25.5264        1,176.77     2,683.08     3,075.42
25680       Treat wrist fracture                 T           T        0043        1.6857          77.71       177.18       203.09
25685       Treat wrist fracture                 T           T        0062       25.5264        1,176.77     2,683.08     3,075.42
25690       Treat wrist dislocation              T           T        0043        1.6857          77.71       177.18       203.09
25695       Treat wrist dislocation              T           T        0062       25.5264        1,176.77     2,683.08     3,075.42
25800       Fusion of wrist joint                T           T        0052       66.5800        3,069.34     6,998.22     8,021.56
25805       Fusion/graft of wrist joint          T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
25810       Fusion/graft of wrist joint          T           T        0052       66.5800        3,069.34     6,998.22     8,021.56
25820       Fusion of hand bones                 T           T        0053       16.1540         744.70      1,697.95     1,946.23
25825       Fuse hand bones with graft           T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
25830       Fusion, radioulnar jnt/ulna          T           T        0052       66.5800        3,069.34     6,998.22     8,021.56
25900       Amputation of forearm                C           C        0000        0.0000           0.00        0.00         0.00
25905       Amputation of forearm                C           C        0000        0.0000           0.00        0.00         0.00
25907       Amputation follow-up surgery         T           T        0049       20.8706         962.13      2,193.71     2,514.49
25909       Amputation follow-up surgery         C           C        0000        0.0000           0.00        0.00         0.00
25915       Amputation of forearm                C           C        0000        0.0000           0.00        0.00         0.00
25920       Amputate hand at wrist               C           C        0000        0.0000           0.00        0.00         0.00
25922       Amputate hand at wrist               T           T        0049       20.8706         962.13      2,193.71     2,514.49
25924       Amputation follow-up surgery         C           C        0000        0.0000           0.00        0.00         0.00
25927       Amputation of hand                   C           C        0000        0.0000           0.00        0.00         0.00
25929       Amputation follow-up surgery         T           T        0686       14.0346         647.00      1,475.18     1,690.89
25931       Amputation follow-up surgery         C           C        0000        0.0000           0.00        0.00         0.00
25999       Forearm or wrist surgery             T           1        0000        0.0000           0.00        0.00         0.00
26010       Drainage of finger abscess           T           T        0006        1.4392          66.35       151.27       173.39
26011       Drainage of finger abscess           T           T        0007       11.1535         514.18      1,172.34     1,343.77
26020       Drain hand tendon sheath             T           T        0053       16.1540         744.70      1,697.95     1,946.23
26025       Drainage of palm bursa               T           T        0053       16.1540         744.70      1,697.95     1,946.23
26030       Drainage of palm bursa(s)            T           T        0053       16.1540         744.70      1,697.95     1,946.23
26034       Treat hand bone lesion               T           T        0053       16.1540         744.70      1,697.95     1,946.23
26035       Decompress fingers/hand              T           T        0053       16.1540         744.70      1,697.95     1,946.23
26037       Decompress fingers/hand              T           T        0053       16.1540         744.70      1,697.95     1,946.23
26040       Release palm contracture             T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26045       Release palm contracture             T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26055       Incise finger tendon sheath          T           T        0053       16.1540         744.70      1,697.95     1,946.23
26060       Incision of finger tendon            T           T        0053       16.1540         744.70      1,697.95     1,946.23
26070       Explore/treat hand joint             T           T        0053       16.1540         744.70      1,697.95     1,946.23
26075       Explore/treat finger joint           T           T        0053       16.1540         744.70      1,697.95     1,946.23
26080       Explore/treat finger joint           T           T        0053       16.1540         744.70      1,697.95     1,946.23
26100       Biopsy hand joint lining             T           T        0053       16.1540         744.70      1,697.95     1,946.23
26105       Biopsy finger joint lining           T           T        0053       16.1540         744.70      1,697.95     1,946.23
26110       Biopsy finger joint lining           T           T        0053       16.1540         744.70      1,697.95     1,946.23
26115       Removal hand lesion subcut           T           T        0022       20.0656         925.02      2,109.10     2,417.50
26116       Removal hand lesion, deep            T           T        0022       20.0656         925.02      2,109.10     2,417.50
26117       Remove tumor, hand/finger            T           T        0022       20.0656         925.02      2,109.10     2,417.50
26121       Release palm contracture             T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26123       Release palm contracture             T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26125       Release palm contracture             T           T        0053       16.1540         744.70      1,697.95     1,946.23
26130       Remove wrist joint lining            T           T        0053       16.1540         744.70      1,697.95     1,946.23
26135       Revise finger joint, each            T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26140       Revise finger joint, each            T           T        0053       16.1540         744.70      1,697.95     1,946.23
26145       Tendon excision, palm/finger         T           T        0053       16.1540         744.70      1,697.95     1,946.23
26160       Remove tendon sheath lesion          T           T        0053       16.1540         744.70      1,697.95     1,946.23
26170       Removal of palm tendon, each         T           T        0053       16.1540         744.70      1,697.95     1,946.23
26180       Removal of finger tendon             T           T        0053       16.1540         744.70      1,697.95     1,946.23
26185       Remove finger bone                   T           T        0053       16.1540         744.70      1,697.95     1,946.23
26200       Remove hand bone lesion              T           T        0053       16.1540         744.70      1,697.95     1,946.23
26205       Remove/graft bone lesion             T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26210       Removal of finger lesion             T           T        0053       16.1540         744.70      1,697.95     1,946.23
26215       Remove/graft finger lesion           T           T        0053       16.1540         744.70      1,697.95     1,946.23
26230       Partial removal of hand bone         T           T        0053       16.1540         744.70      1,697.95     1,946.23
26235       Partial removal, finger bone         T           T        0053       16.1540         744.70      1,697.95     1,946.23
26236       Partial removal, finger bone         T           T        0053       16.1540         744.70      1,697.95     1,946.23
26250       Extensive hand surgery               T           T        0053       16.1540         744.70      1,697.95     1,946.23
26255       Extensive hand surgery               T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26260       Extensive finger surgery             T           T        0053       16.1540         744.70      1,697.95     1,946.23
26261       Extensive finger surgery             T           T        0053       16.1540         744.70      1,697.95     1,946.23
26262       Partial removal of finger            T           T        0053       16.1540         744.70      1,697.95     1,946.23
26320       Removal of implant from hand         T           T        0021       15.1024         696.22      1,587.41     1,819.54
26340       Manipulate finger w/anesth           T           T        0043        1.6857          77.71       177.18       203.09
26350       Repair finger/hand tendon            T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26352       Repair/graft hand tendon             T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26356       Repair finger/hand tendon            T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26357       Repair finger/hand tendon            T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26358       Repair/graft hand tendon             T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26370       Repair finger/hand tendon            T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26372       Repair/graft hand tendon             T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26373       Repair finger/hand tendon            T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26390       Revise hand/finger tendon            T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26392       Repair/graft hand tendon             T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26410       Repair hand tendon                   T           T        0053       16.1540         744.70      1,697.95     1,946.23
26412       Repair/graft hand tendon             T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26415       Excision, hand/finger tendon         T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26416       Graft hand or finger tendon          T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26418       Repair finger tendon                 T           T        0053       16.1540         744.70      1,697.95     1,946.23
26420       Repair/graft finger tendon           T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26426       Repair finger/hand tendon            T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26428       Repair/graft finger tendon           T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26432       Repair finger tendon                 T           T        0053       16.1540         744.70      1,697.95     1,946.23
26433       Repair finger tendon                 T           T        0053       16.1540         744.70      1,697.95     1,946.23
26434       Repair/graft finger tendon           T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26437       Realignment of tendons               T           T        0053       16.1540         744.70      1,697.95     1,946.23
26440       Release palm/finger tendon           T           T        0053       16.1540         744.70      1,697.95     1,946.23
26442       Release palm & finger tendon         T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26445       Release hand/finger tendon           T           T        0053       16.1540         744.70      1,697.95     1,946.23
26449       Release forearm/hand tendon          T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26450       Incision of palm tendon              T           T        0053       16.1540         744.70      1,697.95     1,946.23
26455       Incision of finger tendon            T           T        0053       16.1540         744.70      1,697.95     1,946.23


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 14 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
26460       Incise hand/finger tendon            T           T        0053       16.1540         744.70      1,697.95     1,946.23
26471       Fusion of finger tendons             T           T        0053       16.1540         744.70      1,697.95     1,946.23
26474       Fusion of finger tendons             T           T        0053       16.1540         744.70      1,697.95     1,946.23
26476       Tendon lengthening                   T           T        0053       16.1540         744.70      1,697.95     1,946.23
26477       Tendon shortening                    T           T        0053       16.1540         744.70      1,697.95     1,946.23
26478       Lengthening of hand tendon           T           T        0053       16.1540         744.70      1,697.95     1,946.23
26479       Shortening of hand tendon            T           T        0053       16.1540         744.70      1,697.95     1,946.23
26480       Transplant hand tendon               T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26483       Transplant/graft hand tendon         T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26485       Transplant palm tendon               T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26489       Transplant/graft palm tendon         T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26490       Revise thumb tendon                  T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26492       Tendon transfer with graft           T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26494       Hand tendon/muscle transfer          T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26496       Revise thumb tendon                  T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26497       Finger tendon transfer               T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26498       Finger tendon transfer               T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26499       Revision of finger                   T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26500       Hand tendon reconstruction           T           T        0053       16.1540         744.70      1,697.95     1,946.23
26502       Hand tendon reconstruction           T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26508       Release thumb contracture            T           T        0053       16.1540         744.70      1,697.95     1,946.23
26510       Thumb tendon transfer                T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26516       Fusion of knuckle joint              T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26517       Fusion of knuckle joints             T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26518       Fusion of knuckle joints             T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26520       Release knuckle contracture          T           T        0053       16.1540         744.70      1,697.95     1,946.23
26525       Release finger contracture           T           T        0053       16.1540         744.70      1,697.95     1,946.23
26530       Revise knuckle joint                 T           T        0047       33.4505        1,542.07     3,515.98     4,030.12
26531       Revise knuckle with implant          T           T        0048       47.4378        2,186.88     4,986.19     5,715.31
26535       Revise finger joint                  T           T        0047       33.4505        1,542.07     3,515.98     4,030.12
26536       Revise/implant finger joint          T           T        0048       47.4378        2,186.88     4,986.19     5,715.31
26540       Repair hand joint                    T           T        0053       16.1540         744.70      1,697.95     1,946.23
26541       Repair hand joint with graft         T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26542       Repair hand joint with graft         T           T        0053       16.1540         744.70      1,697.95     1,946.23
26545       Reconstruct finger joint             T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26546       Repair nonunion hand                 T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26548       Reconstruct finger joint             T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26550       Construct thumb replacement          T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26551       Great toe-hand transfer              C           C        0000        0.0000           0.00        0.00         0.00
26553       Single transfer, toe-hand            C           C        0000        0.0000           0.00        0.00         0.00
26554       Double transfer, toe-hand            C           C        0000        0.0000           0.00        0.00         0.00
26555       Positional change of finger          T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26556       Toe joint transfer                   C           C        0000        0.0000           0.00        0.00         0.00
26560       Repair of web finger                 T           T        0053       16.1540         744.70      1,697.95     1,946.23
26561       Repair of web finger                 T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26562       Repair of web finger                 T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26565       Correct metacarpal flaw              T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26567       Correct finger deformity             T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26568       Lengthen metacarpal/finger           T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26580       Repair hand deformity                T           T        0053       16.1540         744.70      1,697.95     1,946.23
26587       Reconstruct extra finger             T           T        0053       16.1540         744.70      1,697.95     1,946.23
26590       Repair finger deformity              T           T        0053       16.1540         744.70      1,697.95     1,946.23
26591       Repair muscles of hand               T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26593       Release muscles of hand              T           T        0053       16.1540         744.70      1,697.95     1,946.23
26596       Excision constricting tissue         T           T        0053       16.1540         744.70      1,697.95     1,946.23
26600       Treat metacarpal fracture            T           T        0043        1.6857          77.71       177.18       203.09
26605       Treat metacarpal fracture            T           T        0043        1.6857          77.71       177.18       203.09
26607       Treat metacarpal fracture            T           T        0043        1.6857          77.71       177.18       203.09
26608       Treat metacarpal fracture            T           T        0062       25.5264        1,176.77     2,683.08     3,075.42
26615       Treat metacarpal fracture            T           T        0063       37.5382        1,730.51     3,945.64     4,522.60
26641       Treat thumb dislocation              T           T        0043        1.6857          77.71       177.18       203.09
26645       Treat thumb fracture                 T           T        0043        1.6857          77.71       177.18       203.09
26650       Treat thumb fracture                 T           T        0062       25.5264        1,176.77     2,683.08     3,075.42
26665       Treat thumb fracture                 T           T        0063       37.5382        1,730.51     3,945.64     4,522.60
26670       Treat hand dislocation               T           T        0043        1.6857          77.71       177.18       203.09
26675       Treat hand dislocation               T           T        0043        1.6857          77.71       177.18       203.09
26676       Pin hand dislocation                 T           T        0062       25.5264        1,176.77     2,683.08     3,075.42
26685       Treat hand dislocation               T           T        0063       37.5382        1,730.51     3,945.64     4,522.60
26686       Treat hand dislocation               T           T        0064       57.2172        2,637.71     6,014.10     6,893.53
26700       Treat knuckle dislocation            T           T        0043        1.6857          77.71       177.18       203.09
26705       Treat knuckle dislocation            T           T        0043        1.6857          77.71       177.18       203.09
26706       Pin knuckle dislocation              T           T        0043        1.6857          77.71       177.18       203.09
26715       Treat knuckle dislocation            T           T        0063       37.5382        1,730.51     3,945.64     4,522.60
26720       Treat finger fracture, each          T           T        0043        1.6857          77.71       177.18       203.09
26725       Treat finger fracture, each          T           T        0043        1.6857          77.71       177.18       203.09
26727       Treat finger fracture, each          T           T        0062       25.5264        1,176.77     2,683.08     3,075.42
26735       Treat finger fracture, each          T           T        0063       37.5382        1,730.51     3,945.64     4,522.60
26740       Treat finger fracture, each          T           T        0043        1.6857          77.71       177.18       203.09
26742       Treat finger fracture, each          T           T        0043        1.6857          77.71       177.18       203.09
26746       Treat finger fracture, each          T           T        0063       37.5382        1,730.51     3,945.64     4,522.60
26750       Treat finger fracture, each          T           T        0043        1.6857          77.71       177.18       203.09
26755       Treat finger fracture, each          T           T        0043        1.6857          77.71       177.18       203.09
26756       Pin finger fracture, each            T           T        0062       25.5264        1,176.77     2,683.08     3,075.42
26765       Treat finger fracture, each          T           T        0063       37.5382        1,730.51     3,945.64     4,522.60
26770       Treat finger dislocation             T           T        0043        1.6857          77.71       177.18       203.09
26775       Treat finger dislocation             T           T        0045       14.5947         672.82      1,534.05     1,758.37
26776       Pin finger dislocation               T           T        0062       25.5264        1,176.77     2,683.08     3,075.42
26785       Treat finger dislocation             T           T        0062       25.5264        1,176.77     2,683.08     3,075.42
26820       Thumb fusion with graft              T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26841       Fusion of thumb                      T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26842       Thumb fusion with graft              T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26843       Fusion of hand joint                 T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26844       Fusion/graft of hand joint           T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26850       Fusion of knuckle                    T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26852       Fusion of knuckle with graft         T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26860       Fusion of finger joint               T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26861       Fusion of finger jnt, add-on         T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26862       Fusion/graft of finger joint         T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26863       Fuse/graft added joint               T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26910       Amputate metacarpal bone             T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
26951       Amputation of finger/thumb           T           T        0053       16.1540         744.70      1,697.95     1,946.23
26952       Amputation of finger/thumb           T           T        0053       16.1540         744.70      1,697.95     1,946.23
26989       Hand/finger surgery                  T           1        0000        0.0000           0.00        0.00         0.00
26990       Drainage of pelvis lesion            T           T        0049       20.8706         962.13      2,193.71     2,514.49
26991       Drainage of pelvis bursa             T           T        0049       20.8706         962.13      2,193.71     2,514.49
26992       Drainage of bone lesion              C           C        0000        0.0000           0.00        0.00         0.00


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 15 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
27000       Incision of hip tendon               T           T        0049       20.8706         962.13      2,193.71     2,514.49
27001       Incision of hip tendon               T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
27003       Incision of hip tendon               T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
27005       Incision of hip tendon               C           C        0000        0.0000           0.00        0.00         0.00
27006       Incision of hip tendons              C           C        0000        0.0000           0.00        0.00         0.00
27025       Incision of hip/thigh fascia         C           C        0000        0.0000           0.00        0.00         0.00
27030       Drainage of hip joint                C           C        0000        0.0000           0.00        0.00         0.00
27033       Exploration of hip joint             T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
27035       Denervation of hip joint             T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
27036       Excision of hip joint/muscle         C           C        0000        0.0000           0.00        0.00         0.00
27040       Biopsy of soft tissues               T           T        0020        6.8083         313.86       715.62       820.26
27041       Biopsy of soft tissues               T           T        0020        6.8083         313.86       715.62       820.26
27047       Remove hip/pelvis lesion             T           T        0022       20.0656         925.02      2,109.10     2,417.50
27048       Remove hip/pelvis lesion             T           T        0022       20.0656         925.02      2,109.10     2,417.50
27049       Remove tumor, hip/pelvis             T           T        0022       20.0656         925.02      2,109.10     2,417.50
27050       Biopsy of sacroiliac joint           T           T        0049       20.8706         962.13      2,193.71     2,514.49
27052       Biopsy of hip joint                  T           T        0049       20.8706         962.13      2,193.71     2,514.49
27054       Removal of hip joint lining          C           C        0000        0.0000           0.00        0.00         0.00
27060       Removal of ischial bursa             T           T        0049       20.8706         962.13      2,193.71     2,514.49
27062       Remove femur lesion/bursa            T           T        0049       20.8706         962.13      2,193.71     2,514.49
27065       Removal of hip bone lesion           T           T        0049       20.8706         962.13      2,193.71     2,514.49
27066       Removal of hip bone lesion           T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
27067       Remove/graft hip bone lesion         T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
27070       Partial removal of hip bone          C           C        0000        0.0000           0.00        0.00         0.00
27071       Partial removal of hip bone          C           C        0000        0.0000           0.00        0.00         0.00
27075       Extensive hip surgery                C           C        0000        0.0000           0.00        0.00         0.00
27076       Extensive hip surgery                C           C        0000        0.0000           0.00        0.00         0.00
27077       Extensive hip surgery                C           C        0000        0.0000           0.00        0.00         0.00
27078       Extensive hip surgery                C           C        0000        0.0000           0.00        0.00         0.00
27079       Extensive hip surgery                C           C        0000        0.0000           0.00        0.00         0.00
27080       Removal of tail bone                 T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
27086       Remove hip foreign body              T           T        0020        6.8083         313.86       715.62       820.26
27087       Remove hip foreign body              T           T        0049       20.8706         962.13      2,193.71     2,514.49
27090       Removal of hip prosthesis            C           C        0000        0.0000           0.00        0.00         0.00
27091       Removal of hip prosthesis            C           C        0000        0.0000           0.00        0.00         0.00
27093       Injection for hip x-ray              N           N        0000        0.0000           0.00        0.00         0.00
27095       Injection for hip x-ray              N           N        0000        0.0000           0.00        0.00         0.00
27096       Inject sacroiliac joint              B           B        0000        0.0000           0.00        0.00         0.00
27097       Revision of hip tendon               T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
27098       Transfer tendon to pelvis            T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
27100       Transfer of abdominal muscle         T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
27105       Transfer of spinal muscle            T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
27110       Transfer of iliopsoas muscle         T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
27111       Transfer of iliopsoas muscle         T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
27120       Reconstruction of hip socket         C           C        0000        0.0000           0.00        0.00         0.00
27122       Reconstruction of hip socket         C           C        0000        0.0000           0.00        0.00         0.00
27125       Partial hip replacement              C           C        0000        0.0000           0.00        0.00         0.00
27130       Total hip arthroplasty               C           C        0000        0.0000           0.00        0.00         0.00
27132       Total hip arthroplasty               C           C        0000        0.0000           0.00        0.00         0.00
27134       Revise hip joint replacement         C           C        0000        0.0000           0.00        0.00         0.00
27137       Revise hip joint replacement         C           C        0000        0.0000           0.00        0.00         0.00
27138       Revise hip joint replacement         C           C        0000        0.0000           0.00        0.00         0.00
27140       Transplant femur ridge               C           C        0000        0.0000           0.00        0.00         0.00
27146       Incision of hip bone                 C           C        0000        0.0000           0.00        0.00         0.00
27147       Revision of hip bone                 C           C        0000        0.0000           0.00        0.00         0.00
27151       Incision of hip bones                C           C        0000        0.0000           0.00        0.00         0.00
27156       Revision of hip bones                C           C        0000        0.0000           0.00        0.00         0.00
27158       Revision of pelvis                   C           C        0000        0.0000           0.00        0.00         0.00
27161       Incision of neck of femur            C           C        0000        0.0000           0.00        0.00         0.00
27165       Incision/fixation of femur           C           C        0000        0.0000           0.00        0.00         0.00
27170       Repair/graft femur head/neck         C           C        0000        0.0000           0.00        0.00         0.00
27175       Treat slipped epiphysis              C           C        0000        0.0000           0.00        0.00         0.00
27176       Treat slipped epiphysis              C           C        0000        0.0000           0.00        0.00         0.00
27177       Treat slipped epiphysis              C           C        0000        0.0000           0.00        0.00         0.00
27178       Treat slipped epiphysis              C           C        0000        0.0000           0.00        0.00         0.00
27179       Revise head/neck of femur            C           C        0000        0.0000           0.00        0.00         0.00
27181       Treat slipped epiphysis              C           C        0000        0.0000           0.00        0.00         0.00
27185       Revision of femur epiphysis          C           C        0000        0.0000           0.00        0.00         0.00
27187       Reinforce hip bones                  C           C        0000        0.0000           0.00        0.00         0.00
27193       Treat pelvic ring fracture           T           T        0043        1.6857          77.71       177.18       203.09
27194       Treat pelvic ring fracture           T           T        0045       14.5947         672.82      1,534.05     1,758.37
27200       Treat tail bone fracture             T           T        0043        1.6857          77.71       177.18       203.09
27202       Treat tail bone fracture             T           T        0063       37.5382        1,730.51     3,945.64     4,522.60
27215       Treat pelvic fracture(s)             C           C        0000        0.0000           0.00        0.00         0.00
27216       Treat pelvic ring fracture           T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
27217       Treat pelvic ring fracture           C           C        0000        0.0000           0.00        0.00         0.00
27218       Treat pelvic ring fracture           C           C        0000        0.0000           0.00        0.00         0.00
27220       Treat hip socket fracture            T           T        0043        1.6857          77.71       177.18       203.09
27222       Treat hip socket fracture            C           C        0000        0.0000           0.00        0.00         0.00
27226       Treat hip wall fracture              C           C        0000        0.0000           0.00        0.00         0.00
27227       Treat hip fracture(s)                C           C        0000        0.0000           0.00        0.00         0.00
27228       Treat hip fracture(s)                C           C        0000        0.0000           0.00        0.00         0.00
27230       Treat thigh fracture                 T           T        0043        1.6857          77.71       177.18       203.09
27232       Treat thigh fracture                 C           C        0000        0.0000           0.00        0.00         0.00
27235       Treat thigh fracture                 T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
27236       Treat thigh fracture                 C           C        0000        0.0000           0.00        0.00         0.00
27238       Treat thigh fracture                 T           T        0043        1.6857          77.71       177.18       203.09
27240       Treat thigh fracture                 C           C        0000        0.0000           0.00        0.00         0.00
27244       Treat thigh fracture                 C           C        0000        0.0000           0.00        0.00         0.00
27245       Treat thigh fracture                 C           C        0000        0.0000           0.00        0.00         0.00
27246       Treat thigh fracture                 T           T        0043        1.6857          77.71       177.18       203.09
27248       Treat thigh fracture                 C           C        0000        0.0000           0.00        0.00         0.00
27250       Treat hip dislocation                T           T        0043        1.6857          77.71       177.18       203.09
27252       Treat hip dislocation                T           T        0045       14.5947         672.82      1,534.05     1,758.37
27253       Treat hip dislocation                C           C        0000        0.0000           0.00        0.00         0.00
27254       Treat hip dislocation                C           C        0000        0.0000           0.00        0.00         0.00
27256       Treat hip dislocation                T           T        0043        1.6857          77.71       177.18       203.09
27257       Treat hip dislocation                T           T        0045       14.5947         672.82      1,534.05     1,758.37
27258       Treat hip dislocation                C           C        0000        0.0000           0.00        0.00         0.00
27259       Treat hip dislocation                C           C        0000        0.0000           0.00        0.00         0.00
27265       Treat hip dislocation                T           T        0043        1.6857          77.71       177.18       203.09
27266       Treat hip dislocation                T           T        0045       14.5947         672.82      1,534.05     1,758.37
27275       Manipulation of hip joint            T           T        0045       14.5947         672.82      1,534.05     1,758.37
27280       Fusion of sacroiliac joint           C           C        0000        0.0000           0.00        0.00         0.00
27282       Fusion of pubic bones                C           C        0000        0.0000           0.00        0.00         0.00
27284       Fusion of hip joint                  C           C        0000        0.0000           0.00        0.00         0.00


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 16 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
27286       Fusion of hip joint                  C           C        0000        0.0000           0.00        0.00         0.00
27290       Amputation of leg at hip             C           C        0000        0.0000           0.00        0.00         0.00
27295       Amputation of leg at hip             C           C        0000        0.0000           0.00        0.00         0.00
27299       Pelvis/hip joint surgery             T           1        0000        0.0000           0.00        0.00         0.00
27301       Drain thigh/knee lesion              T           T        0008       17.5086         807.15      1,840.33     2,109.44
27303       Drainage of bone lesion              C           C        0000        0.0000           0.00        0.00         0.00
27305       Incise thigh tendon & fascia         T           T        0049       20.8706         962.13      2,193.71     2,514.49
27306       Incision of thigh tendon             T           T        0049       20.8706         962.13      2,193.71     2,514.49
27307       Incision of thigh tendons            T           T        0049       20.8706         962.13      2,193.71     2,514.49
27310       Exploration of knee joint            T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
27323       Biopsy, thigh soft tissues           T           T        0020        6.8083         313.86       715.62       820.26
27324       Biopsy, thigh soft tissues           T           T        0022       20.0656         925.02      2,109.10     2,417.50
27325       Neurectomy, hamstring                T           T        0220       17.8499         822.88      1,876.20     2,150.56
27326       Neurectomy, popliteal                T           T        0220       17.8499         822.88      1,876.20     2,150.56
27327       Removal of thigh lesion              T           T        0022       20.0656         925.02      2,109.10     2,417.50
27328       Removal of thigh lesion              T           T        0022       20.0656         925.02      2,109.10     2,417.50
27329       Remove tumor, thigh/knee             T           T        0022       20.0656         925.02      2,109.10     2,417.50
27330       Biopsy, knee joint lining            T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
27331       Explore/treat knee joint             T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
27332       Removal of knee cartilage            T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
27333       Removal of knee cartilage            T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
27334       Remove knee joint lining             T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
27335       Remove knee joint lining             T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
27340       Removal of kneecap bursa             T           T        0049       20.8706         962.13      2,193.71     2,514.49
27345       Removal of knee cyst                 T           T        0049       20.8706         962.13      2,193.71     2,514.49
27347       Remove knee cyst                     T           T        0049       20.8706         962.13      2,193.71     2,514.49
27350       Removal of kneecap                   T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
27355       Remove femur lesion                  T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
27356       Remove femur lesion/graft            T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
27357       Remove femur lesion/graft            T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
27358       Remove femur lesion/fixation         T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
27360       Partial removal, leg bone(s)         T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
27365       Extensive leg surgery                C           C        0000        0.0000           0.00        0.00         0.00
27370       Injection for knee x-ray             N           N        0000        0.0000           0.00        0.00         0.00
27372       Removal of foreign body              T           T        0022       20.0656         925.02      2,109.10     2,417.50
27380       Repair of kneecap tendon             T           T        0049       20.8706         962.13      2,193.71     2,514.49
27381       Repair/graft kneecap tendon          T           T        0049       20.8706         962.13      2,193.71     2,514.49
27385       Repair of thigh muscle               T           T        0049       20.8706         962.13      2,193.71     2,514.49
27386       Repair/graft of thigh muscle         T           T        0049       20.8706         962.13      2,193.71     2,514.49
27390       Incision of thigh tendon             T           T        0049       20.8706         962.13      2,193.71     2,514.49
27391       Incision of thigh tendons            T           T        0049       20.8706         962.13      2,193.71     2,514.49
27392       Incision of thigh tendons            T           T        0049       20.8706         962.13      2,193.71     2,514.49
27393       Lengthening of thigh tendon          T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
27394       Lengthening of thigh tendons         T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
27395       Lengthening of thigh tendons         T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
27396       Transplant of thigh tendon           T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
27397       Transplants of thigh tendons         T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
27400       Revise thigh muscles/tendons         T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
27403       Repair of knee cartilage             T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
27405       Repair of knee ligament              T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
27407       Repair of knee ligament              T           T        0052       66.5800        3,069.34     6,998.22     8,021.56
27409       Repair of knee ligaments             T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
27412       Autochondrocyte implant knee         T           T        0042       45.5027        2,097.67     4,782.79     5,482.17
27415       Osteochondral knee allograft         T           T        0042       45.5027        2,097.67     4,782.79     5,482.17
27418       Repair degenerated kneecap           T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
27420       Revision of unstable kneecap         T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
27422       Revision of unstable kneecap         T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
27424       Revision/removal of kneecap          T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
27425       Lat retinacular release open         T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
27427       Reconstruction, knee                 T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
27428       Reconstruction, knee                 T           T        0052       66.5800        3,069.34     6,998.22     8,021.56
27429       Reconstruction, knee                 T           T        0052       66.5800        3,069.34     6,998.22     8,021.56
27430       Revision of thigh muscles            T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
27435       Incision of knee joint               T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
27437       Revise kneecap                       T           T        0047       33.4505        1,542.07     3,515.98     4,030.12
27438       Revise kneecap with implant          T           T        0048       47.4378        2,186.88     4,986.19     5,715.31
27440       Revision of knee joint               T           T        0047       33.4505        1,542.07     3,515.98     4,030.12
27441       Revision of knee joint               T           T        0047       33.4505        1,542.07     3,515.98     4,030.12
27442       Revision of knee joint               T           T        0047       33.4505        1,542.07     3,515.98     4,030.12
27443       Revision of knee joint               T           T        0047       33.4505        1,542.07     3,515.98     4,030.12
27445       Revision of knee joint               C           C        0000        0.0000           0.00        0.00         0.00
27446       Revision of knee joint               T           T        0681      205.6815        9,481.92    21,619.18    24,780.51
27447       Total knee arthroplasty              C           C        0000        0.0000           0.00        0.00         0.00
27448       Incision of thigh                    C           C        0000        0.0000           0.00        0.00         0.00
27450       Incision of thigh                    C           C        0000        0.0000           0.00        0.00         0.00
27454       Realignment of thigh bone            C           C        0000        0.0000           0.00        0.00         0.00
27455       Realignment of knee                  C           C        0000        0.0000           0.00        0.00         0.00
27457       Realignment of knee                  C           C        0000        0.0000           0.00        0.00         0.00
27465       Shortening of thigh bone             C           C        0000        0.0000           0.00        0.00         0.00
27466       Lengthening of thigh bone            C           C        0000        0.0000           0.00        0.00         0.00
27468       Shorten/lengthen thighs              C           C        0000        0.0000           0.00        0.00         0.00
27470       Repair of thigh                      C           C        0000        0.0000           0.00        0.00         0.00
27472       Repair/graft of thigh                C           C        0000        0.0000           0.00        0.00         0.00
27475       Surgery to stop leg growth           T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
27477       Surgery to stop leg growth           C           C        0000        0.0000           0.00        0.00         0.00
27479       Surgery to stop leg growth           C           C        0000        0.0000           0.00        0.00         0.00
27485       Surgery to stop leg growth           C           C        0000        0.0000           0.00        0.00         0.00
27486       Revise/replace knee joint            C           C        0000        0.0000           0.00        0.00         0.00
27487       Revise/replace knee joint            C           C        0000        0.0000           0.00        0.00         0.00
27488       Removal of knee prosthesis           C           C        0000        0.0000           0.00        0.00         0.00
27495       Reinforce thigh                      C           C        0000        0.0000           0.00        0.00         0.00
27496       Decompression of thigh/knee          T           T        0049       20.8706         962.13      2,193.71     2,514.49
27497       Decompression of thigh/knee          T           T        0049       20.8706         962.13      2,193.71     2,514.49
27498       Decompression of thigh/knee          T           T        0049       20.8706         962.13      2,193.71     2,514.49
27499       Decompression of thigh/knee          T           T        0049       20.8706         962.13      2,193.71     2,514.49
27500       Treatment of thigh fracture          T           T        0043        1.6857          77.71       177.18       203.09
27501       Treatment of thigh fracture          T           T        0043        1.6857          77.71       177.18       203.09
27502       Treatment of thigh fracture          T           T        0043        1.6857          77.71       177.18       203.09
27503       Treatment of thigh fracture          T           T        0043        1.6857          77.71       177.18       203.09
27506       Treatment of thigh fracture          C           C        0000        0.0000           0.00        0.00         0.00
27507       Treatment of thigh fracture          C           C        0000        0.0000           0.00        0.00         0.00
27508       Treatment of thigh fracture          T           T        0043        1.6857          77.71       177.18       203.09
27509       Treatment of thigh fracture          T           T        0062       25.5264        1,176.77     2,683.08     3,075.42
27510       Treatment of thigh fracture          T           T        0043        1.6857          77.71       177.18       203.09
27511       Treatment of thigh fracture          C           C        0000        0.0000           0.00        0.00         0.00
27513       Treatment of thigh fracture          C           C        0000        0.0000           0.00        0.00         0.00


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 17 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
27514       Treatment of thigh fracture          C           C        0000        0.0000           0.00        0.00         0.00
27516       Treat thigh fx growth plate          T           T        0043        1.6857          77.71       177.18       203.09
27517       Treat thigh fx growth plate          T           T        0043        1.6857          77.71       177.18       203.09
27519       Treat thigh fx growth plate          C           C        0000        0.0000           0.00        0.00         0.00
27520       Treat kneecap fracture               T           T        0043        1.6857          77.71       177.18       203.09
27524       Treat kneecap fracture               T           T        0063       37.5382        1,730.51     3,945.64     4,522.60
27530       Treat knee fracture                  T           T        0043        1.6857          77.71       177.18       203.09
27532       Treat knee fracture                  T           T        0043        1.6857          77.71       177.18       203.09
27535       Treat knee fracture                  C           C        0000        0.0000           0.00        0.00         0.00
27536       Treat knee fracture                  C           C        0000        0.0000           0.00        0.00         0.00
27538       Treat knee fracture(s)               T           T        0043        1.6857          77.71       177.18       203.09
27540       Treat knee fracture                  C           C        0000        0.0000           0.00        0.00         0.00
27550       Treat knee dislocation               T           T        0043        1.6857          77.71       177.18       203.09
27552       Treat knee dislocation               T           T        0045       14.5947         672.82      1,534.05     1,758.37
27556       Treat knee dislocation               C           C        0000        0.0000           0.00        0.00         0.00
27557       Treat knee dislocation               C           C        0000        0.0000           0.00        0.00         0.00
27558       Treat knee dislocation               C           C        0000        0.0000           0.00        0.00         0.00
27560       Treat kneecap dislocation            T           T        0043        1.6857          77.71       177.18       203.09
27562       Treat kneecap dislocation            T           T        0045       14.5947         672.82      1,534.05     1,758.37
27566       Treat kneecap dislocation            T           T        0063       37.5382        1,730.51     3,945.64     4,522.60
27570       Fixation of knee joint               T           T        0045       14.5947         672.82      1,534.05     1,758.37
27580       Fusion of knee                       C           C        0000        0.0000           0.00        0.00         0.00
27590       Amputate leg at thigh                C           C        0000        0.0000           0.00        0.00         0.00
27591       Amputate leg at thigh                C           C        0000        0.0000           0.00        0.00         0.00
27592       Amputate leg at thigh                C           C        0000        0.0000           0.00        0.00         0.00
27594       Amputation follow-up surgery         T           T        0049       20.8706         962.13      2,193.71     2,514.49
27596       Amputation follow-up surgery         C           C        0000        0.0000           0.00        0.00         0.00
27598       Amputate lower leg at knee           C           C        0000        0.0000           0.00        0.00         0.00
27599       Leg surgery procedure                T           1        0000        0.0000           0.00        0.00         0.00
27600       Decompression of lower leg           T           T        0049       20.8706         962.13      2,193.71     2,514.49
27601       Decompression of lower leg           T           T        0049       20.8706         962.13      2,193.71     2,514.49
27602       Decompression of lower leg           T           T        0049       20.8706         962.13      2,193.71     2,514.49
27603       Drain lower leg lesion               T           T        0008       17.5086         807.15      1,840.33     2,109.44
27604       Drain lower leg bursa                T           T        0049       20.8706         962.13      2,193.71     2,514.49
27605       Incision of achilles tendon          T           T        0055       20.4263         941.65      2,147.01     2,460.96
27606       Incision of achilles tendon          T           T        0049       20.8706         962.13      2,193.71     2,514.49
27607       Treat lower leg bone lesion          T           T        0049       20.8706         962.13      2,193.71     2,514.49
27610       Explore/treat ankle joint            T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
27612       Exploration of ankle joint           T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
27613       Biopsy lower leg soft tissue         T           T        0020        6.8083         313.86       715.62       820.26
27614       Biopsy lower leg soft tissue         T           T        0022       20.0656         925.02      2,109.10     2,417.50
27615       Remove tumor, lower leg              T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
27618       Remove lower leg lesion              T           T        0021       15.1024         696.22      1,587.41     1,819.54
27619       Remove lower leg lesion              T           T        0022       20.0656         925.02      2,109.10     2,417.50
27620       Explore/treat ankle joint            T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
27625       Remove ankle joint lining            T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
27626       Remove ankle joint lining            T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
27630       Removal of tendon lesion             T           T        0049       20.8706         962.13      2,193.71     2,514.49
27635       Remove lower leg bone lesion         T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
27637       Remove/graft leg bone lesion         T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
27638       Remove/graft leg bone lesion         T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
27640       Partial removal of tibia             T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
27641       Partial removal of fibula            T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
27645       Extensive lower leg surgery          C           C        0000        0.0000           0.00        0.00         0.00
27646       Extensive lower leg surgery          C           C        0000        0.0000           0.00        0.00         0.00
27647       Extensive ankle/heel surgery         T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
27648       Injection for ankle x-ray            N           N        0000        0.0000           0.00        0.00         0.00
27650       Repair achilles tendon               T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
27652       Repair/graft achilles tendon         T           T        0052       66.5800        3,069.34     6,998.22     8,021.56
27654       Repair of achilles tendon            T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
27656       Repair leg fascia defect             T           T        0049       20.8706         962.13      2,193.71     2,514.49
27658       Repair of leg tendon, each           T           T        0049       20.8706         962.13      2,193.71     2,514.49
27659       Repair of leg tendon, each           T           T        0049       20.8706         962.13      2,193.71     2,514.49
27664       Repair of leg tendon, each           T           T        0049       20.8706         962.13      2,193.71     2,514.49
27665       Repair of leg tendon, each           T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
27675       Repair lower leg tendons             T           T        0049       20.8706         962.13      2,193.71     2,514.49
27676       Repair lower leg tendons             T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
27680       Release of lower leg tendon          T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
27681       Release of lower leg tendons         T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
27685       Revision of lower leg tendon         T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
27686       Revise lower leg tendons             T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
27687       Revision of calf tendon              T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
27690       Revise lower leg tendon              T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
27691       Revise lower leg tendon              T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
27692       Revise additional leg tendon         T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
27695       Repair of ankle ligament             T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
27696       Repair of ankle ligaments            T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
27698       Repair of ankle ligament             T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
27700       Revision of ankle joint              T           T        0047       33.4505        1,542.07     3,515.98     4,030.12
27702       Reconstruct ankle joint              C           C        0000        0.0000           0.00        0.00         0.00
27703       Reconstruction, ankle joint          C           C        0000        0.0000           0.00        0.00         0.00
27704       Removal of ankle implant             T           T        0049       20.8706         962.13      2,193.71     2,514.49
27705       Incision of tibia                    T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
27707       Incision of fibula                   T           T        0049       20.8706         962.13      2,193.71     2,514.49
27709       Incision of tibia & fibula           T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
27712       Realignment of lower leg             C           C        0000        0.0000           0.00        0.00         0.00
27715       Revision of lower leg                C           C        0000        0.0000           0.00        0.00         0.00
27720       Repair of tibia                      C           C        0000        0.0000           0.00        0.00         0.00
27722       Repair/graft of tibia                C           C        0000        0.0000           0.00        0.00         0.00
27724       Repair/graft of tibia                C           C        0000        0.0000           0.00        0.00         0.00
27725       Repair of lower leg                  C           C        0000        0.0000           0.00        0.00         0.00
27727       Repair of lower leg                  C           C        0000        0.0000           0.00        0.00         0.00
27730       Repair of tibia epiphysis            T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
27732       Repair of fibula epiphysis           T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
27734       Repair lower leg epiphyses           T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
27740       Repair of leg epiphyses              T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
27742       Repair of leg epiphyses              T           T        0051       41.0893        1,894.22     4,318.90     4,950.44
27745       Reinforce tibia                      T           T        0052       66.5800        3,069.34     6,998.22     8,021.56
27750       Treatment of tibia fracture          T           T        0043        1.6857          77.71       177.18       203.09
27752       Treatment of tibia fracture          T           T        0043        1.6857          77.71       177.18       203.09
27756       Treatment of tibia fracture          T           T        0062       25.5264        1,176.77     2,683.08     3,075.42
27758       Treatment of tibia fracture          T           T        0063       37.5382        1,730.51     3,945.64     4,522.60
27759       Treatment of tibia fracture          T           T        0064       57.2172        2,637.71     6,014.10     6,893.53
27760       Treatment of ankle fracture          T           T        0043        1.6857          77.71       177.18       203.09
27762       Treatment of ankle fracture          T           T        0043        1.6857          77.71       177.18       203.09
27766       Treatment of ankle fracture          T           T        0063       37.5382        1,730.51     3,945.64     4,522.60


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 18 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
27780       Treatment of fibula fracture         T           T        0043        1.6857          77.71       177.18       203.09
27781       Treatment of fibula fracture         T           T        0043        1.6857          77.71       177.18       203.09
27784       Treatment of fibula fracture         T           T        0063       37.5382        1,730.51     3,945.64     4,522.60
27786       Treatment of ankle fracture          T           T        0043        1.6857          77.71       177.18       203.09
27788       Treatment of ankle fracture          T           T        0043        1.6857          77.71       177.18       203.09
27792       Treatment of ankle fracture          T           T        0063       37.5382        1,730.51     3,945.64     4,522.60
27808       Treatment of ankle fracture          T           T        0043        1.6857          77.71       177.18       203.09
27810       Treatment of ankle fracture          T           T        0043        1.6857          77.71       177.18       203.09
27814       Treatment of ankle fracture          T           T        0063       37.5382        1,730.51     3,945.64     4,522.60
27816       Treatment of ankle fracture          T           T        0043        1.6857          77.71       177.18       203.09
27818       Treatment of ankle fracture          T           T        0043        1.6857          77.71       177.18       203.09
27822       Treatment of ankle fracture          T           T        0063       37.5382        1,730.51     3,945.64     4,522.60
27823       Treatment of ankle fracture          T           T        0064       57.2172        2,637.71     6,014.10     6,893.53
27824       Treat lower leg fracture             T           T        0043        1.6857          77.71       177.18       203.09
27825       Treat lower leg fracture             T           T        0043        1.6857          77.71       177.18       203.09
27826       Treat lower leg fracture             T           T        0063       37.5382        1,730.51     3,945.64     4,522.60
27827       Treat lower leg fracture             T           T        0064       57.2172        2,637.71     6,014.10     6,893.53
27828       Treat lower leg fracture             T           T        0064       57.2172        2,637.71     6,014.10     6,893.53
27829       Treat lower leg joint                T           T        0063       37.5382        1,730.51     3,945.64     4,522.60
27830       Treat lower leg dislocation          T           T        0043        1.6857          77.71       177.18       203.09
27831       Treat lower leg dislocation          T           T        0043        1.6857          77.71       177.18       203.09
27832       Treat lower leg dislocation          T           T        0063       37.5382        1,730.51     3,945.64     4,522.60
27840       Treat ankle dislocation              T           T        0043        1.6857          77.71       177.18       203.09
27842       Treat ankle dislocation              T           T        0045       14.5947         672.82      1,534.05     1,758.37
27846       Treat ankle dislocation              T           T        0063       37.5382        1,730.51     3,945.64     4,522.60
27848       Treat ankle dislocation              T           T        0063       37.5382        1,730.51     3,945.64     4,522.60
27860       Fixation of ankle joint              T           T        0045       14.5947         672.82      1,534.05     1,758.37
27870       Fusion of ankle joint, open          T           T        0052       66.5800        3,069.34     6,998.22     8,021.56
27871       Fusion of tibiofibular joint         T           T        0052       66.5800        3,069.34     6,998.22     8,021.56
27880       Amputation of lower leg              C           C        0000        0.0000           0.00        0.00         0.00
27881       Amputation of lower leg              C           C        0000        0.0000           0.00        0.00         0.00
27882       Amputation of lower leg              C           C        0000        0.0000           0.00        0.00         0.00
27884       Amputation follow-up surgery         T           T        0049       20.8706         962.13      2,193.71     2,514.49
27886       Amputation follow-up surgery         C           C        0000        0.0000           0.00        0.00         0.00
27888       Amputation of foot at ankle          C           C        0000        0.0000           0.00        0.00         0.00
27889       Amputation of foot at ankle          T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
27892       Decompression of leg                 T           T        0049       20.8706         962.13      2,193.71     2,514.49
27893       Decompression of leg                 T           T        0049       20.8706         962.13      2,193.71     2,514.49
27894       Decompression of leg                 T           T        0049       20.8706         962.13      2,193.71     2,514.49
27899       Leg/ankle surgery procedure          T           1        0000        0.0000           0.00        0.00         0.00
28001       Drainage of bursa of foot            T           T        0007       11.1535         514.18      1,172.34     1,343.77
28002       Treatment of foot infection          T           T        0049       20.8706         962.13      2,193.71     2,514.49
28003       Treatment of foot infection          T           T        0049       20.8706         962.13      2,193.71     2,514.49
28005       Treat foot bone lesion               T           T        0055       20.4263         941.65      2,147.01     2,460.96
28008       Incision of foot fascia              T           T        0055       20.4263         941.65      2,147.01     2,460.96
28010       Incision of toe tendon               T           T        0055       20.4263         941.65      2,147.01     2,460.96
28011       Incision of toe tendons              T           T        0055       20.4263         941.65      2,147.01     2,460.96
28020       Exploration of foot joint            T           T        0055       20.4263         941.65      2,147.01     2,460.96
28022       Exploration of foot joint            T           T        0055       20.4263         941.65      2,147.01     2,460.96
28024       Exploration of toe joint             T           T        0055       20.4263         941.65      2,147.01     2,460.96
28035       Decompression of tibia nerve         T           T        0220       17.8499         822.88      1,876.20     2,150.56
28043       Excision of foot lesion              T           T        0022       20.0656         925.02      2,109.10     2,417.50
28045       Excision of foot lesion              T           T        0055       20.4263         941.65      2,147.01     2,460.96
28046       Resection of tumor, foot             T           T        0055       20.4263         941.65      2,147.01     2,460.96
28050       Biopsy of foot joint lining          T           T        0055       20.4263         941.65      2,147.01     2,460.96
28052       Biopsy of foot joint lining          T           T        0055       20.4263         941.65      2,147.01     2,460.96
28054       Biopsy of toe joint lining           T           T        0055       20.4263         941.65      2,147.01     2,460.96
28055       Neurectomy, foot                     T           T        0220       17.8499         822.88      1,876.20     2,150.56
28060       Partial removal, foot fascia         T           T        0055       20.4263         941.65      2,147.01     2,460.96
28062       Removal of foot fascia               T           T        0055       20.4263         941.65      2,147.01     2,460.96
28070       Removal of foot joint lining         T           T        0055       20.4263         941.65      2,147.01     2,460.96
28072       Removal of foot joint lining         T           T        0055       20.4263         941.65      2,147.01     2,460.96
28080       Removal of foot lesion               T           T        0055       20.4263         941.65      2,147.01     2,460.96
28086       Excise foot tendon sheath            T           T        0055       20.4263         941.65      2,147.01     2,460.96
28088       Excise foot tendon sheath            T           T        0055       20.4263         941.65      2,147.01     2,460.96
28090       Removal of foot lesion               T           T        0055       20.4263         941.65      2,147.01     2,460.96
28092       Removal of toe lesions               T           T        0055       20.4263         941.65      2,147.01     2,460.96
28100       Removal of ankle/heel lesion         T           T        0055       20.4263         941.65      2,147.01     2,460.96
28102       Remove/graft foot lesion             T           T        0056       40.8559        1,883.46     4,294.36     4,922.32
28103       Remove/graft foot lesion             T           T        0056       40.8559        1,883.46     4,294.36     4,922.32
28104       Removal of foot lesion               T           T        0055       20.4263         941.65      2,147.01     2,460.96
28106       Remove/graft foot lesion             T           T        0056       40.8559        1,883.46     4,294.36     4,922.32
28107       Remove/graft foot lesion             T           T        0056       40.8559        1,883.46     4,294.36     4,922.32
28108       Removal of toe lesions               T           T        0055       20.4263         941.65      2,147.01     2,460.96
28110       Part removal of metatarsal           T           T        0055       20.4263         941.65      2,147.01     2,460.96
28111       Part removal of metatarsal           T           T        0055       20.4263         941.65      2,147.01     2,460.96
28112       Part removal of metatarsal           T           T        0055       20.4263         941.65      2,147.01     2,460.96
28113       Part removal of metatarsal           T           T        0055       20.4263         941.65      2,147.01     2,460.96
28114       Removal of metatarsal heads          T           T        0055       20.4263         941.65      2,147.01     2,460.96
28116       Revision of foot                     T           T        0055       20.4263         941.65      2,147.01     2,460.96
28118       Removal of heel bone                 T           T        0055       20.4263         941.65      2,147.01     2,460.96
28119       Removal of heel spur                 T           T        0055       20.4263         941.65      2,147.01     2,460.96
28120       Part removal of ankle/heel           T           T        0055       20.4263         941.65      2,147.01     2,460.96
28122       Partial removal of foot bone         T           T        0055       20.4263         941.65      2,147.01     2,460.96
28124       Partial removal of toe               T           T        0055       20.4263         941.65      2,147.01     2,460.96
28126       Partial removal of toe               T           T        0055       20.4263         941.65      2,147.01     2,460.96
28130       Removal of ankle bone                T           T        0055       20.4263         941.65      2,147.01     2,460.96
28140       Removal of metatarsal                T           T        0055       20.4263         941.65      2,147.01     2,460.96
28150       Removal of toe                       T           T        0055       20.4263         941.65      2,147.01     2,460.96
28153       Partial removal of toe               T           T        0055       20.4263         941.65      2,147.01     2,460.96
28160       Partial removal of toe               T           T        0055       20.4263         941.65      2,147.01     2,460.96
28171       Extensive foot surgery               T           T        0055       20.4263         941.65      2,147.01     2,460.96
28173       Extensive foot surgery               T           T        0055       20.4263         941.65      2,147.01     2,460.96
28175       Extensive foot surgery               T           T        0055       20.4263         941.65      2,147.01     2,460.96
28190       Removal of foot foreign body         T           T        0019        4.0919         188.64       430.10       492.99
28192       Removal of foot foreign body         T           T        0021       15.1024         696.22      1,587.41     1,819.54
28193       Removal of foot foreign body         T           T        0020        6.8083         313.86       715.62       820.26
28200       Repair of foot tendon                T           T        0055       20.4263         941.65      2,147.01     2,460.96
28202       Repair/graft of foot tendon          T           T        0055       20.4263         941.65      2,147.01     2,460.96
28208       Repair of foot tendon                T           T        0055       20.4263         941.65      2,147.01     2,460.96
28210       Repair/graft of foot tendon          T           T        0056       40.8559        1,883.46     4,294.36     4,922.32
28220       Release of foot tendon               T           T        0055       20.4263         941.65      2,147.01     2,460.96
28222       Release of foot tendons              T           T        0055       20.4263         941.65      2,147.01     2,460.96
28225       Release of foot tendon               T           T        0055       20.4263         941.65      2,147.01     2,460.96
28226       Release of foot tendons              T           T        0055       20.4263         941.65      2,147.01     2,460.96
28230       Incision of foot tendon(s)           T           T        0055       20.4263         941.65      2,147.01     2,460.96


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 19 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
28232       Incision of toe tendon               T           T        0055       20.4263         941.65      2,147.01     2,460.96
28234       Incision of foot tendon              T           T        0055       20.4263         941.65      2,147.01     2,460.96
28238       Revision of foot tendon              T           T        0056       40.8559        1,883.46     4,294.36     4,922.32
28240       Release of big toe                   T           T        0055       20.4263         941.65      2,147.01     2,460.96
28250       Revision of foot fascia              T           T        0055       20.4263         941.65      2,147.01     2,460.96
28260       Release of midfoot joint             T           T        0055       20.4263         941.65      2,147.01     2,460.96
28261       Revision of foot tendon              T           T        0055       20.4263         941.65      2,147.01     2,460.96
28262       Revision of foot and ankle           T           T        0055       20.4263         941.65      2,147.01     2,460.96
28264       Release of midfoot joint             T           T        0056       40.8559        1,883.46     4,294.36     4,922.32
28270       Release of foot contracture          T           T        0055       20.4263         941.65      2,147.01     2,460.96
28272       Release of toe joint, each           T           T        0055       20.4263         941.65      2,147.01     2,460.96
28280       Fusion of toes                       T           T        0055       20.4263         941.65      2,147.01     2,460.96
28285       Repair of hammertoe                  T           T        0055       20.4263         941.65      2,147.01     2,460.96
28286       Repair of hammertoe                  T           T        0055       20.4263         941.65      2,147.01     2,460.96
28288       Partial removal of foot bone         T           T        0055       20.4263         941.65      2,147.01     2,460.96
28289       Repair hallux rigidus                T           T        0055       20.4263         941.65      2,147.01     2,460.96
28290       Correction of bunion                 T           T        0057       28.2349        1,301.63     2,967.77     3,401.74
28292       Correction of bunion                 T           T        0057       28.2349        1,301.63     2,967.77     3,401.74
28293       Correction of bunion                 T           T        0057       28.2349        1,301.63     2,967.77     3,401.74
28294       Correction of bunion                 T           T        0057       28.2349        1,301.63     2,967.77     3,401.74
28296       Correction of bunion                 T           T        0057       28.2349        1,301.63     2,967.77     3,401.74
28297       Correction of bunion                 T           T        0057       28.2349        1,301.63     2,967.77     3,401.74
28298       Correction of bunion                 T           T        0057       28.2349        1,301.63     2,967.77     3,401.74
28299       Correction of bunion                 T           T        0057       28.2349        1,301.63     2,967.77     3,401.74
28300       Incision of heel bone                T           T        0056       40.8559        1,883.46     4,294.36     4,922.32
28302       Incision of ankle bone               T           T        0055       20.4263         941.65      2,147.01     2,460.96
28304       Incision of midfoot bones            T           T        0056       40.8559        1,883.46     4,294.36     4,922.32
28305       Incise/graft midfoot bones           T           T        0056       40.8559        1,883.46     4,294.36     4,922.32
28306       Incision of metatarsal               T           T        0055       20.4263         941.65      2,147.01     2,460.96
28307       Incision of metatarsal               T           T        0055       20.4263         941.65      2,147.01     2,460.96
28308       Incision of metatarsal               T           T        0055       20.4263         941.65      2,147.01     2,460.96
28309       Incision of metatarsals              T           T        0056       40.8559        1,883.46     4,294.36     4,922.32
28310       Revision of big toe                  T           T        0055       20.4263         941.65      2,147.01     2,460.96
28312       Revision of toe                      T           T        0055       20.4263         941.65      2,147.01     2,460.96
28313       Repair deformity of toe              T           T        0055       20.4263         941.65      2,147.01     2,460.96
28315       Removal of sesamoid bone             T           T        0055       20.4263         941.65      2,147.01     2,460.96
28320       Repair of foot bones                 T           T        0056       40.8559        1,883.46     4,294.36     4,922.32
28322       Repair of metatarsals                T           T        0056       40.8559        1,883.46     4,294.36     4,922.32
28340       Resect enlarged toe tissue           T           T        0055       20.4263         941.65      2,147.01     2,460.96
28341       Resect enlarged toe                  T           T        0055       20.4263         941.65      2,147.01     2,460.96
28344       Repair extra toe(s)                  T           T        0055       20.4263         941.65      2,147.01     2,460.96
28345       Repair webbed toe(s)                 T           T        0055       20.4263         941.65      2,147.01     2,460.96
28360       Reconstruct cleft foot               T           T        0056       40.8559        1,883.46     4,294.36     4,922.32
28400       Treatment of heel fracture           T           T        0043        1.6857          77.71       177.18       203.09
28405       Treatment of heel fracture           T           T        0043        1.6857          77.71       177.18       203.09
28406       Treatment of heel fracture           T           T        0062       25.5264        1,176.77     2,683.08     3,075.42
28415       Treat heel fracture                  T           T        0063       37.5382        1,730.51     3,945.64     4,522.60
28420       Treat/graft heel fracture            T           T        0063       37.5382        1,730.51     3,945.64     4,522.60
28430       Treatment of ankle fracture          T           T        0043        1.6857          77.71       177.18       203.09
28435       Treatment of ankle fracture          T           T        0043        1.6857          77.71       177.18       203.09
28436       Treatment of ankle fracture          T           T        0062       25.5264        1,176.77     2,683.08     3,075.42
28445       Treat ankle fracture                 T           T        0063       37.5382        1,730.51     3,945.64     4,522.60
28450       Treat midfoot fracture, each         T           T        0043        1.6857          77.71       177.18       203.09
28455       Treat midfoot fracture, each         T           T        0043        1.6857          77.71       177.18       203.09
28456       Treat midfoot fracture               T           T        0062       25.5264        1,176.77     2,683.08     3,075.42
28465       Treat midfoot fracture, each         T           T        0063       37.5382        1,730.51     3,945.64     4,522.60
28470       Treat metatarsal fracture            T           T        0043        1.6857          77.71       177.18       203.09
28475       Treat metatarsal fracture            T           T        0043        1.6857          77.71       177.18       203.09
28476       Treat metatarsal fracture            T           T        0062       25.5264        1,176.77     2,683.08     3,075.42
28485       Treat metatarsal fracture            T           T        0063       37.5382        1,730.51     3,945.64     4,522.60
28490       Treat big toe fracture               T           T        0043        1.6857          77.71       177.18       203.09
28495       Treat big toe fracture               T           T        0043        1.6857          77.71       177.18       203.09
28496       Treat big toe fracture               T           T        0062       25.5264        1,176.77     2,683.08     3,075.42
28505       Treat big toe fracture               T           T        0063       37.5382        1,730.51     3,945.64     4,522.60
28510       Treatment of toe fracture            T           T        0043        1.6857          77.71       177.18       203.09
28515       Treatment of toe fracture            T           T        0043        1.6857          77.71       177.18       203.09
28525       Treat toe fracture                   T           T        0063       37.5382        1,730.51     3,945.64     4,522.60
28530       Treat sesamoid bone fracture         T           T        0043        1.6857          77.71       177.18       203.09
28531       Treat sesamoid bone fracture         T           T        0063       37.5382        1,730.51     3,945.64     4,522.60
28540       Treat foot dislocation               T           T        0043        1.6857          77.71       177.18       203.09
28545       Treat foot dislocation               T           T        0062       25.5264        1,176.77     2,683.08     3,075.42
28546       Treat foot dislocation               T           T        0062       25.5264        1,176.77     2,683.08     3,075.42
28555       Repair foot dislocation              T           T        0063       37.5382        1,730.51     3,945.64     4,522.60
28570       Treat foot dislocation               T           T        0043        1.6857          77.71       177.18       203.09
28575       Treat foot dislocation               T           T        0043        1.6857          77.71       177.18       203.09
28576       Treat foot dislocation               T           T        0062       25.5264        1,176.77     2,683.08     3,075.42
28585       Repair foot dislocation              T           T        0063       37.5382        1,730.51     3,945.64     4,522.60
28600       Treat foot dislocation               T           T        0043        1.6857          77.71       177.18       203.09
28605       Treat foot dislocation               T           T        0043        1.6857          77.71       177.18       203.09
28606       Treat foot dislocation               T           T        0062       25.5264        1,176.77     2,683.08     3,075.42
28615       Repair foot dislocation              T           T        0063       37.5382        1,730.51     3,945.64     4,522.60
28630       Treat toe dislocation                T           T        0043        1.6857          77.71       177.18       203.09
28635       Treat toe dislocation                T           T        0045       14.5947         672.82      1,534.05     1,758.37
28636       Treat toe dislocation                T           T        0062       25.5264        1,176.77     2,683.08     3,075.42
28645       Repair toe dislocation               T           T        0063       37.5382        1,730.51     3,945.64     4,522.60
28660       Treat toe dislocation                T           T        0043        1.6857          77.71       177.18       203.09
28665       Treat toe dislocation                T           T        0045       14.5947         672.82      1,534.05     1,758.37
28666       Treat toe dislocation                T           T        0062       25.5264        1,176.77     2,683.08     3,075.42
28675       Repair of toe dislocation            T           T        0063       37.5382        1,730.51     3,945.64     4,522.60
28705       Fusion of foot bones                 T           T        0056       40.8559        1,883.46     4,294.36     4,922.32
28715       Fusion of foot bones                 T           T        0056       40.8559        1,883.46     4,294.36     4,922.32
28725       Fusion of foot bones                 T           T        0056       40.8559        1,883.46     4,294.36     4,922.32
28730       Fusion of foot bones                 T           T        0056       40.8559        1,883.46     4,294.36     4,922.32
28735       Fusion of foot bones                 T           T        0056       40.8559        1,883.46     4,294.36     4,922.32
28737       Revision of foot bones               T           T        0056       40.8559        1,883.46     4,294.36     4,922.32
28740       Fusion of foot bones                 T           T        0056       40.8559        1,883.46     4,294.36     4,922.32
28750       Fusion of big toe joint              T           T        0056       40.8559        1,883.46     4,294.36     4,922.32
28755       Fusion of big toe joint              T           T        0055       20.4263         941.65      2,147.01     2,460.96
28760       Fusion of big toe joint              T           T        0056       40.8559        1,883.46     4,294.36     4,922.32
28800       Amputation of midfoot                C           C        0000        0.0000           0.00        0.00         0.00
28805       Amputation thru metatarsal           C           C        0000        0.0000           0.00        0.00         0.00
28810       Amputation toe & metatarsal          T           T        0055       20.4263         941.65      2,147.01     2,460.96
28820       Amputation of toe                    T           T        0055       20.4263         941.65      2,147.01     2,460.96
28825       Partial amputation of toe            T           T        0055       20.4263         941.65      2,147.01     2,460.96
28890       High energy eswt, plantar f          T           T        0050       25.1296        1,158.47     2,641.37     3,027.61
28899       Foot/toes surgery procedure          T           1        0000        0.0000           0.00        0.00         0.00


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 20 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
29000       Application of body cast             S           S        0058        1.0607          48.90       111.49       127.79
29010       Application of body cast             S           S        0426        2.2777         105.00       239.41       274.42
29015       Application of body cast             S           S        0426        2.2777         105.00       239.41       274.42
29020       Application of body cast             S           S        0058        1.0607          48.90       111.49       127.79
29025       Application of body cast             S           S        0058        1.0607          48.90       111.49       127.79
29035       Application of body cast             S           S        0426        2.2777         105.00       239.41       274.42
29040       Application of body cast             S           S        0058        1.0607          48.90       111.49       127.79
29044       Application of body cast             S           S        0426        2.2777         105.00       239.41       274.42
29046       Application of body cast             S           S        0426        2.2777         105.00       239.41       274.42
29049       Application of figure eight          S           S        0058        1.0607          48.90       111.49       127.79
29055       Application of shoulder cast         S           S        0426        2.2777         105.00       239.41       274.42
29058       Application of shoulder cast         S           S        0058        1.0607          48.90       111.49       127.79
29065       Application of long arm cast         S           S        0426        2.2777         105.00       239.41       274.42
29075       Application of forearm cast          S           S        0426        2.2777         105.00       239.41       274.42
29085       Apply hand/wrist cast                S           S        0058        1.0607          48.90       111.49       127.79
29086       Apply finger cast                    S           S        0058        1.0607          48.90       111.49       127.79
29105       Apply long arm splint                S           S        0058        1.0607          48.90       111.49       127.79
29125       Apply forearm splint                 S           S        0058        1.0607          48.90       111.49       127.79
29126       Apply forearm splint                 S           S        0058        1.0607          48.90       111.49       127.79
29130       Application of finger splint         S           S        0058        1.0607          48.90       111.49       127.79
29131       Application of finger splint         S           S        0058        1.0607          48.90       111.49       127.79
29200       Strapping of chest                   S           S        0058        1.0607          48.90       111.49       127.79
29220       Strapping of low back                S           S        0058        1.0607          48.90       111.49       127.79
29240       Strapping of shoulder                S           S        0058        1.0607          48.90       111.49       127.79
29260       Strapping of elbow or wrist          S           S        0058        1.0607          48.90       111.49       127.79
29280       Strapping of hand or finger          S           S        0058        1.0607          48.90       111.49       127.79
29305       Application of hip cast              S           S        0426        2.2777         105.00       239.41       274.42
29325       Application of hip casts             S           S        0426        2.2777         105.00       239.41       274.42
29345       Application of long leg cast         S           S        0426        2.2777         105.00       239.41       274.42
29355       Application of long leg cast         S           S        0426        2.2777         105.00       239.41       274.42
29358       Apply long leg cast brace            S           S        0426        2.2777         105.00       239.41       274.42
29365       Application of long leg cast         S           S        0426        2.2777         105.00       239.41       274.42
29405       Apply short leg cast                 S           S        0426        2.2777         105.00       239.41       274.42
29425       Apply short leg cast                 S           S        0426        2.2777         105.00       239.41       274.42
29435       Apply short leg cast                 S           S        0426        2.2777         105.00       239.41       274.42
29440       Addition of walker to cast           S           S        0058        1.0607          48.90       111.49       127.79
29445       Apply rigid leg cast                 S           S        0426        2.2777         105.00       239.41       274.42
29450       Application of leg cast              S           S        0058        1.0607          48.90       111.49       127.79
29505       Application, long leg splint         S           S        0058        1.0607          48.90       111.49       127.79
29515       Application lower leg splint         S           S        0058        1.0607          48.90       111.49       127.79
29520       Strapping of hip                     S           S        0058        1.0607          48.90       111.49       127.79
29530       Strapping of knee                    S           S        0058        1.0607          48.90       111.49       127.79
29540       Strapping of ankle and/or ft         S           S        0058        1.0607          48.90       111.49       127.79
29550       Strapping of toes                    S           S        0058        1.0607          48.90       111.49       127.79
29580       Application of paste boot            S           S        0058        1.0607          48.90       111.49       127.79
29590       Application of foot splint           S           S        0058        1.0607          48.90       111.49       127.79
29700       Removal/revision of cast             S           S        0058        1.0607          48.90       111.49       127.79
29705       Removal/revision of cast             S           S        0058        1.0607          48.90       111.49       127.79
29710       Removal/revision of cast             S           S        0426        2.2777         105.00       239.41       274.42
29715       Removal/revision of cast             S           S        0058        1.0607          48.90       111.49       127.79
29720       Repair of body cast                  S           S        0058        1.0607          48.90       111.49       127.79
29730       Windowing of cast                    S           S        0058        1.0607          48.90       111.49       127.79
29740       Wedging of cast                      S           S        0058        1.0607          48.90       111.49       127.79
29750       Wedging of clubfoot cast             S           S        0058        1.0607          48.90       111.49       127.79
29799       Casting/strapping procedure          S           1        0000        0.0000           0.00        0.00         0.00
29800       Jaw arthroscopy/surgery              T           T        0041       28.6245        1,319.59     3,008.72     3,448.68
29804       Jaw arthroscopy/surgery              T           T        0041       28.6245        1,319.59     3,008.72     3,448.68
29805       Shoulder arthroscopy, dx             T           T        0041       28.6245        1,319.59     3,008.72     3,448.68
29806       Shoulder arthroscopy/surgery         T           T        0042       45.5027        2,097.67     4,782.79     5,482.17
29807       Shoulder arthroscopy/surgery         T           T        0042       45.5027        2,097.67     4,782.79     5,482.17
29819       Shoulder arthroscopy/surgery         T           T        0041       28.6245        1,319.59     3,008.72     3,448.68
29820       Shoulder arthroscopy/surgery         T           T        0041       28.6245        1,319.59     3,008.72     3,448.68
29821       Shoulder arthroscopy/surgery         T           T        0041       28.6245        1,319.59     3,008.72     3,448.68
29822       Shoulder arthroscopy/surgery         T           T        0041       28.6245        1,319.59     3,008.72     3,448.68
29823       Shoulder arthroscopy/surgery         T           T        0041       28.6245        1,319.59     3,008.72     3,448.68
29824       Shoulder arthroscopy/surgery         T           T        0041       28.6245        1,319.59     3,008.72     3,448.68
29825       Shoulder arthroscopy/surgery         T           T        0041       28.6245        1,319.59     3,008.72     3,448.68
29826       Shoulder arthroscopy/surgery         T           T        0042       45.5027        2,097.67     4,782.79     5,482.17
29827       Arthroscop rotator cuff repr         T           T        0042       45.5027        2,097.67     4,782.79     5,482.17
29830       Elbow arthroscopy                    T           T        0041       28.6245        1,319.59     3,008.72     3,448.68
29834       Elbow arthroscopy/surgery            T           T        0041       28.6245        1,319.59     3,008.72     3,448.68
29835       Elbow arthroscopy/surgery            T           T        0041       28.6245        1,319.59     3,008.72     3,448.68
29836       Elbow arthroscopy/surgery            T           T        0041       28.6245        1,319.59     3,008.72     3,448.68
29837       Elbow arthroscopy/surgery            T           T        0041       28.6245        1,319.59     3,008.72     3,448.68
29838       Elbow arthroscopy/surgery            T           T        0041       28.6245        1,319.59     3,008.72     3,448.68
29840       Wrist arthroscopy                    T           T        0041       28.6245        1,319.59     3,008.72     3,448.68
29843       Wrist arthroscopy/surgery            T           T        0041       28.6245        1,319.59     3,008.72     3,448.68
29844       Wrist arthroscopy/surgery            T           T        0041       28.6245        1,319.59     3,008.72     3,448.68
29845       Wrist arthroscopy/surgery            T           T        0041       28.6245        1,319.59     3,008.72     3,448.68
29846       Wrist arthroscopy/surgery            T           T        0041       28.6245        1,319.59     3,008.72     3,448.68
29847       Wrist arthroscopy/surgery            T           T        0041       28.6245        1,319.59     3,008.72     3,448.68
29848       Wrist endoscopy/surgery              T           T        0041       28.6245        1,319.59     3,008.72     3,448.68
29850       Knee arthroscopy/surgery             T           T        0041       28.6245        1,319.59     3,008.72     3,448.68
29851       Knee arthroscopy/surgery             T           T        0042       45.5027        2,097.67     4,782.79     5,482.17
29855       Tibial arthroscopy/surgery           T           T        0042       45.5027        2,097.67     4,782.79     5,482.17
29856       Tibial arthroscopy/surgery           T           T        0041       28.6245        1,319.59     3,008.72     3,448.68
29860       Hip arthroscopy, dx                  T           T        0041       28.6245        1,319.59     3,008.72     3,448.68
29861       Hip arthroscopy/surgery              T           T        0041       28.6245        1,319.59     3,008.72     3,448.68
29862       Hip arthroscopy/surgery              T           T        0042       45.5027        2,097.67     4,782.79     5,482.17
29863       Hip arthroscopy/surgery              T           T        0042       45.5027        2,097.67     4,782.79     5,482.17
29866       Autgrft implnt, knee w/scope         T           T        0042       45.5027        2,097.67     4,782.79     5,482.17
29867       Allgrft implnt, knee w/scope         T           T        0042       45.5027        2,097.67     4,782.79     5,482.17
29868       Meniscal trnspl, knee w/scpe         T           T        0042       45.5027        2,097.67     4,782.79     5,482.17
29870       Knee arthroscopy, dx                 T           T        0041       28.6245        1,319.59     3,008.72     3,448.68
29871       Knee arthroscopy/drainage            T           T        0041       28.6245        1,319.59     3,008.72     3,448.68
29873       Knee arthroscopy/surgery             T           T        0041       28.6245        1,319.59     3,008.72     3,448.68
29874       Knee arthroscopy/surgery             T           T        0041       28.6245        1,319.59     3,008.72     3,448.68
29875       Knee arthroscopy/surgery             T           T        0041       28.6245        1,319.59     3,008.72     3,448.68
29876       Knee arthroscopy/surgery             T           T        0041       28.6245        1,319.59     3,008.72     3,448.68
29877       Knee arthroscopy/surgery             T           T        0041       28.6245        1,319.59     3,008.72     3,448.68
29879       Knee arthroscopy/surgery             T           T        0041       28.6245        1,319.59     3,008.72     3,448.68
29880       Knee arthroscopy/surgery             T           T        0041       28.6245        1,319.59     3,008.72     3,448.68
29881       Knee arthroscopy/surgery             T           T        0041       28.6245        1,319.59     3,008.72     3,448.68
29882       Knee arthroscopy/surgery             T           T        0041       28.6245        1,319.59     3,008.72     3,448.68
29883       Knee arthroscopy/surgery             T           T        0041       28.6245        1,319.59     3,008.72     3,448.68
29884       Knee arthroscopy/surgery             T           T        0041       28.6245        1,319.59     3,008.72     3,448.68


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 21 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
29885       Knee arthroscopy/surgery             T           T        0042       45.5027        2,097.67     4,782.79     5,482.17
29886       Knee arthroscopy/surgery             T           T        0041       28.6245        1,319.59     3,008.72     3,448.68
29887       Knee arthroscopy/surgery             T           T        0041       28.6245        1,319.59     3,008.72     3,448.68
29888       Knee arthroscopy/surgery             T           T        0042       45.5027        2,097.67     4,782.79     5,482.17
29889       Knee arthroscopy/surgery             T           T        0042       45.5027        2,097.67     4,782.79     5,482.17
29891       Ankle arthroscopy/surgery            T           T        0041       28.6245        1,319.59     3,008.72     3,448.68
29892       Ankle arthroscopy/surgery            T           T        0041       28.6245        1,319.59     3,008.72     3,448.68
29893       Scope, plantar fasciotomy            T           T        0055       20.4263         941.65      2,147.01     2,460.96
29894       Ankle arthroscopy/surgery            T           T        0041       28.6245        1,319.59     3,008.72     3,448.68
29895       Ankle arthroscopy/surgery            T           T        0041       28.6245        1,319.59     3,008.72     3,448.68
29897       Ankle arthroscopy/surgery            T           T        0041       28.6245        1,319.59     3,008.72     3,448.68
29898       Ankle arthroscopy/surgery            T           T        0041       28.6245        1,319.59     3,008.72     3,448.68
29899       Ankle arthroscopy/surgery            T           T        0042       45.5027        2,097.67     4,782.79     5,482.17
29900       Mcp joint arthroscopy, dx            T           T        0053       16.1540         744.70      1,697.95     1,946.23
29901       Mcp joint arthroscopy, surg          T           T        0053       16.1540         744.70      1,697.95     1,946.23
29902       Mcp joint arthroscopy, surg          T           T        0053       16.1540         744.70      1,697.95     1,946.23
29999       Arthroscopy of joint                 T           1        0000        0.0000           0.00         0.00         0.00
30000       Drainage of nose lesion              T           T        0251        2.4520         113.04       257.73       295.42
30020       Drainage of nose lesion              T           T        0251        2.4520         113.04       257.73       295.42
30100       Intranasal biopsy                    T           T        0252        7.5511         348.11       793.70       909.76
30110       Removal of nose polyp(s)             T           T        0253       16.4266         757.27      1,726.60     1,979.08
30115       Removal of nose polyp(s)             T           T        0253       16.4266         757.27      1,726.60     1,979.08
30117       Removal of intranasal lesion         T           T        0253       16.4266         757.27      1,726.60     1,979.08
30118       Removal of intranasal lesion         T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
30120       Revision of nose                     T           T        0253       16.4266         757.27      1,726.60     1,979.08
30124       Removal of nose lesion               T           T        0252        7.5511         348.11       793.70       909.76
30125       Removal of nose lesion               T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
30130       Removal of turbinate bones           T           T        0253       16.4266         757.27      1,726.60     1,979.08
30140       Removal of turbinate bones           T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
30150       Partial removal of nose              T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
30160       Removal of nose                      T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
30200       Injection treatment of nose          T           T        0252        7.5511         348.11       793.70       909.76
30210       Nasal sinus therapy                  T           T        0252        7.5511         348.11       793.70       909.76
30220       Insert nasal septal button           T           T        0252        7.5511         348.11       793.70       909.76
30300       Remove nasal foreign body            X           X        0340        0.6102          28.13        64.14        73.52
30310       Remove nasal foreign body            T           T        0253       16.4266         757.27      1,726.60     1,979.08
30320       Remove nasal foreign body            T           T        0253       16.4266         757.27      1,726.60     1,979.08
30400       Reconstruction of nose               T           1        0000        0.0000           0.00         0.00         0.00
30410       Reconstruction of nose               T           1        0000        0.0000           0.00         0.00         0.00
30420       Reconstruction of nose               T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
30430       Revision of nose                     T           1        0000        0.0000           0.00         0.00         0.00
30435       Revision of nose                     T           1        0000        0.0000           0.00         0.00         0.00
30450       Revision of nose                     T           1        0000        0.0000           0.00         0.00         0.00
30460       Revision of nose                     T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
30462       Revision of nose                     T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
30465       Repair nasal stenosis                T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
30520       Repair of nasal septum               T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
30540       Repair nasal defect                  T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
30545       Repair nasal defect                  T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
30560       Release of nasal adhesions           T           T        0251        2.4520         113.04       257.73       295.42
30580       Repair upper jaw fistula             T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
30600       Repair mouth/nose fistula            T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
30620       Intranasal reconstruction            T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
30630       Repair nasal septum defect           T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
30801       Cauterization, inner nose            T           T        0252        7.5511         348.11       793.70       909.76
30802       Cauterization, inner nose            T           T        0252        7.5511         348.11       793.70       909.76
30901       Control of nosebleed                 T           T        0250        1.1791          54.36       123.94       142.06
30903       Control of nosebleed                 T           T        0250        1.1791          54.36       123.94       142.06
30905       Control of nosebleed                 T           T        0250        1.1791          54.36       123.94       142.06
30906       Repeat control of nosebleed          T           T        0250        1.1791          54.36       123.94       142.06
30915       Ligation, nasal sinus artery         T           T        0092       24.8809        1,147.01     2,615.23     2,997.65
30920       Ligation, upper jaw artery           T           T        0092       24.8809        1,147.01     2,615.23     2,997.65
30930       Therapy, fracture of nose            T           T        0253       16.4266         757.27      1,726.60     1,979.08
30999       Nasal surgery procedure              T           1        0000        0.0000           0.00         0.00         0.00
31000       Irrigation, maxillary sinus          T           T        0251        2.4520         113.04       257.73       295.42
31002       Irrigation, sphenoid sinus           T           T        0252        7.5511         348.11       793.70       909.76
31020       Exploration, maxillary sinus         T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
31030       Exploration, maxillary sinus         T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
31032       Explore sinus, remove polyps         T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
31040       Exploration behind upper jaw         T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
31050       Exploration, sphenoid sinus          T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
31051       Sphenoid sinus surgery               T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
31070       Exploration of frontal sinus         T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
31075       Exploration of frontal sinus         T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
31080       Removal of frontal sinus             T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
31081       Removal of frontal sinus             T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
31084       Removal of frontal sinus             T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
31085       Removal of frontal sinus             T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
31086       Removal of frontal sinus             T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
31087       Removal of frontal sinus             T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
31090       Exploration of sinuses               T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
31200       Removal of ethmoid sinus             T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
31201       Removal of ethmoid sinus             T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
31205       Removal of ethmoid sinus             T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
31225       Removal of upper jaw                 C           C        0000        0.0000           0.00         0.00         0.00
31230       Removal of upper jaw                 C           C        0000        0.0000           0.00         0.00         0.00
31231       Nasal endoscopy, dx                  T           T        0072        1.4054          64.79       147.72       169.32
31233       Nasal/sinus endoscopy, dx            T           T        0072        1.4054          64.79       147.72       169.32
31235       Nasal/sinus endoscopy, dx            T           T        0074       14.7928         681.95      1,554.87     1,782.24
31237       Nasal/sinus endoscopy, surg          T           T        0074       14.7928         681.95      1,554.87     1,782.24
31238       Nasal/sinus endoscopy, surg          T           T        0074       14.7928         681.95      1,554.87     1,782.24
31239       Nasal/sinus endoscopy, surg          T           T        0075       21.9512        1,011.95     2,307.29     2,644.68
31240       Nasal/sinus endoscopy, surg          T           T        0074       14.7928         681.95      1,554.87     1,782.24
31254       Revision of ethmoid sinus            T           T        0075       21.9512        1,011.95     2,307.29     2,644.68
31255       Removal of ethmoid sinus             T           T        0075       21.9512        1,011.95     2,307.29     2,644.68
31256       Exploration maxillary sinus          T           T        0075       21.9512        1,011.95     2,307.29     2,644.68
31267       Endoscopy, maxillary sinus           T           T        0075       21.9512        1,011.95     2,307.29     2,644.68
31276       Sinus endoscopy, surgical            T           T        0075       21.9512        1,011.95     2,307.29     2,644.68
31287       Nasal/sinus endoscopy, surg          T           T        0075       21.9512        1,011.95     2,307.29     2,644.68
31288       Nasal/sinus endoscopy, surg          T           T        0075       21.9512        1,011.95     2,307.29     2,644.68
31290       Nasal/sinus endoscopy, surg          C           C        0000        0.0000           0.00         0.00         0.00
31291       Nasal/sinus endoscopy, surg          C           C        0000        0.0000           0.00         0.00         0.00
31292       Nasal/sinus endoscopy, surg          T           T        0075       21.9512        1,011.95     2,307.29     2,644.68
31293       Nasal/sinus endoscopy, surg          T           T        0075       21.9512        1,011.95     2,307.29     2,644.68
31294       Nasal/sinus endoscopy, surg          T           T        0075       21.9512        1,011.95     2,307.29     2,644.68
31299       Sinus surgery procedure              T           1        0000        0.0000           0.00         0.00         0.00


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 22 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
31300       Removal of larynx lesion             T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
31320       Diagnostic incision, larynx          T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
31360       Removal of larynx                    C           C        0000        0.0000           0.00         0.00         0.00
31365       Removal of larynx                    C           C        0000        0.0000           0.00         0.00         0.00
31367       Partial removal of larynx            C           C        0000        0.0000           0.00         0.00         0.00
31368       Partial removal of larynx            C           C        0000        0.0000           0.00         0.00         0.00
31370       Partial removal of larynx            C           C        0000        0.0000           0.00         0.00         0.00
31375       Partial removal of larynx            C           C        0000        0.0000           0.00         0.00         0.00
31380       Partial removal of larynx            C           C        0000        0.0000           0.00         0.00         0.00
31382       Partial removal of larynx            C           C        0000        0.0000           0.00         0.00         0.00
31390       Removal of larynx & pharynx          C           C        0000        0.0000           0.00         0.00         0.00
31395       Reconstruct larynx & pharynx         C           C        0000        0.0000           0.00         0.00         0.00
31400       Revision of larynx                   T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
31420       Removal of epiglottis                T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
31500       Insert emergency airway              S           S        0094        2.4233         111.71       254.71       291.96
31502       Change of windpipe airway            T           T        0121        2.3587         108.74       247.92       284.18
31505       Diagnostic laryngoscopy              T           T        0071        0.7698          35.49        80.91        92.75
31510       Laryngoscopy with biopsy             T           T        0074       14.7928         681.95      1,554.87     1,782.24
31511       Remove foreign body, larynx          T           T        0072        1.4054          64.79       147.72       169.32
31512       Removal of larynx lesion             T           T        0074       14.7928         681.95      1,554.87     1,782.24
31513       Injection into vocal cord            T           T        0072        1.4054          64.79       147.72       169.32
31515       Laryngoscopy for aspiration          T           T        0074       14.7928         681.95      1,554.87     1,782.24
31520       Diagnostic laryngoscopy              T           T        0072        1.4054          64.79       147.72       169.32
31525       Diagnostic laryngoscopy              T           T        0074       14.7928         681.95      1,554.87     1,782.24
31526       Diagnostic laryngoscopy              T           T        0075       21.9512        1,011.95     2,307.29     2,644.68
31527       Laryngoscopy for treatment           T           T        0075       21.9512        1,011.95     2,307.29     2,644.68
31528       Laryngoscopy and dilation            T           T        0074       14.7928         681.95      1,554.87     1,782.24
31529       Laryngoscopy and dilation            T           T        0074       14.7928         681.95      1,554.87     1,782.24
31530       Operative laryngoscopy               T           T        0075       21.9512        1,011.95     2,307.29     2,644.68
31531       Operative laryngoscopy               T           T        0075       21.9512        1,011.95     2,307.29     2,644.68
31535       Operative laryngoscopy               T           T        0075       21.9512        1,011.95     2,307.29     2,644.68
31536       Operative laryngoscopy               T           T        0075       21.9512        1,011.95     2,307.29     2,644.68
31540       Operative laryngoscopy               T           T        0075       21.9512        1,011.95     2,307.29     2,644.68
31541       Operative laryngoscopy               T           T        0075       21.9512        1,011.95     2,307.29     2,644.68
31545       Remove vc lesion w/scope             T           T        0075       21.9512        1,011.95     2,307.29     2,644.68
31546       Remove vc lesion scope/graft         T           T        0075       21.9512        1,011.95     2,307.29     2,644.68
31560       Operative laryngoscopy               T           T        0075       21.9512        1,011.95     2,307.29     2,644.68
31561       Operative laryngoscopy               T           T        0075       21.9512        1,011.95     2,307.29     2,644.68
31570       Laryngoscopy with injection          T           T        0074       14.7928         681.95      1,554.87     1,782.24
31571       Laryngoscopy with injection          T           T        0075       21.9512        1,011.95     2,307.29     2,644.68
31575       Diagnostic laryngoscopy              T           T        0072        1.4054          64.79       147.72       169.32
31576       Laryngoscopy with biopsy             T           T        0075       21.9512        1,011.95     2,307.29     2,644.68
31577       Remove foreign body, larynx          T           T        0073        3.8463         177.31       404.28       463.40
31578       Removal of larynx lesion             T           T        0075       21.9512        1,011.95     2,307.29     2,644.68
31579       Diagnostic laryngoscopy              T           T        0073        3.8463         177.31       404.28       463.40
31580       Revision of larynx                   T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
31582       Revision of larynx                   T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
31584       Treat larynx fracture                C           C        0000        0.0000           0.00         0.00         0.00
31587       Revision of larynx                   C           C        0000        0.0000           0.00         0.00         0.00
31588       Revision of larynx                   T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
31590       Reinnervate larynx                   T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
31595       Larynx nerve surgery                 T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
31599       Larynx surgery procedure             T           1        0000        0.0000           0.00         0.00         0.00
31600       Incision of windpipe                 T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
31601       Incision of windpipe                 T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
31603       Incision of windpipe                 T           T        0252        7.5511         348.11       793.70       909.76
31605       Incision of windpipe                 T           T        0252        7.5511         348.11       793.70       909.76
31610       Incision of windpipe                 T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
31611       Surgery/speech prosthesis            T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
31612       Puncture/clear windpipe              T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
31613       Repair windpipe opening              T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
31614       Repair windpipe opening              T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
31615       Visualization of windpipe            T           T        0076        9.5228         439.00      1,000.94     1,147.31
31620       Endobronchial us add-on              S           S        0670       32.2854        1,488.36     3,393.52     3,889.74
31622       Dx bronchoscope/wash                 T           T        0076        9.5228         439.00      1,000.94     1,147.31
31623       Dx bronchoscope/brush                T           T        0076        9.5228         439.00      1,000.94     1,147.31
31624       Dx bronchoscope/lavage               T           T        0076        9.5228         439.00      1,000.94     1,147.31
31625       Bronchoscopy w/biopsy(s)             T           T        0076        9.5228         439.00      1,000.94     1,147.31
31628       Bronchoscopy/lung bx, each           T           T        0076        9.5228         439.00      1,000.94     1,147.31
31629       Bronchoscopy/needle bx, each         T           T        0076        9.5228         439.00      1,000.94     1,147.31
31630       Bronchoscopy dilate/fx repr          T           T        0415       22.0099        1,014.66     2,313.46     2,651.75
31631       Bronchoscopy, dilate w/stent         T           T        0415       22.0099        1,014.66     2,313.46     2,651.75
31632       Bronchoscopy/lung bx, add’l          T           T        0076        9.5228         439.00      1,000.94     1,147.31
31633       Bronchoscopy/needle bx add’l         T           T        0076        9.5228         439.00      1,000.94     1,147.31
31635       Bronchoscopy w/fb removal            T           T        0076        9.5228         439.00      1,000.94     1,147.31
31636       Bronchoscopy, bronch stents          T           T        0415       22.0099        1,014.66     2,313.46     2,651.75
31637       Bronchoscopy, stent add-on           T           T        0076        9.5228         439.00      1,000.94     1,147.31
31638       Bronchoscopy, revise stent           T           T        0415       22.0099        1,014.66     2,313.46     2,651.75
31640       Bronchoscopy w/tumor excise          T           T        0415       22.0099        1,014.66     2,313.46     2,651.75
31641       Bronchoscopy, treat blockage         T           T        0415       22.0099        1,014.66     2,313.46     2,651.75
31643       Diag bronchoscope/catheter           T           T        0076        9.5228         439.00      1,000.94     1,147.31
31645       Bronchoscopy, clear airways          T           T        0076        9.5228         439.00      1,000.94     1,147.31
31646       Bronchoscopy, reclear airway         T           T        0076        9.5228         439.00      1,000.94     1,147.31
31656       Bronchoscopy, inj for x-ray          T           T        0076        9.5228         439.00      1,000.94     1,147.31
31715       Injection for bronchus x-ray         N           N        0000        0.0000           0.00         0.00         0.00
31717       Bronchial brush biopsy               T           T        0073        3.8463         177.31       404.28       463.40
31720       Clearance of airways                 T           T        0071        0.7698          35.49        80.91        92.75
31725       Clearance of airways                 C           C        0000        0.0000           0.00         0.00         0.00
31730       Intro, windpipe wire/tube            T           T        0073        3.8463         177.31       404.28       463.40
31750       Repair of windpipe                   T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
31755       Repair of windpipe                   T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
31760       Repair of windpipe                   C           C        0000        0.0000           0.00         0.00         0.00
31766       Reconstruction of windpipe           C           C        0000        0.0000           0.00         0.00         0.00
31770       Repair/graft of bronchus             C           C        0000        0.0000           0.00         0.00         0.00
31775       Reconstruct bronchus                 C           C        0000        0.0000           0.00         0.00         0.00
31780       Reconstruct windpipe                 C           C        0000        0.0000           0.00         0.00         0.00
31781       Reconstruct windpipe                 C           C        0000        0.0000           0.00         0.00         0.00
31785       Remove windpipe lesion               T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
31786       Remove windpipe lesion               C           C        0000        0.0000           0.00         0.00         0.00
31800       Repair of windpipe injury            C           C        0000        0.0000           0.00         0.00         0.00
31805       Repair of windpipe injury            C           C        0000        0.0000           0.00         0.00         0.00
31820       Closure of windpipe lesion           T           T        0253       16.4266         757.27      1,726.60     1,979.08
31825       Repair of windpipe defect            T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
31830       Revise windpipe scar                 T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
31899       Airways surgical procedure           T           1        0000        0.0000           0.00         0.00         0.00
32000       Drainage of chest                    T           T        0070        3.6244         167.08       380.96       436.67


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 23 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
32002       Treatment of collapsed lung          T           T        0070        3.6244         167.08       380.96       436.67
32005       Treat lung lining chemically         T           T        0070        3.6244         167.08       380.96       436.67
32019       Insert pleural catheter              T           T        0652       29.5416        1,361.87     3,105.12     3,559.17
32020       Insertion of chest tube              T           T        0070        3.6244         167.08       380.96       436.67
32035       Exploration of chest                 C           C        0000        0.0000          0.00         0.00         0.00
32036       Exploration of chest                 C           C        0000        0.0000          0.00         0.00         0.00
32095       Biopsy through chest wall            C           C        0000        0.0000          0.00         0.00         0.00
32100       Exploration/biopsy of chest          C           C        0000        0.0000          0.00         0.00         0.00
32110       Explore/repair chest                 C           C        0000        0.0000          0.00         0.00         0.00
32120       Re-exploration of chest              C           C        0000        0.0000          0.00         0.00         0.00
32124       Explore chest free adhesions         C           C        0000        0.0000          0.00         0.00         0.00
32140       Removal of lung lesion(s)            C           C        0000        0.0000          0.00         0.00         0.00
32141       Remove/treat lung lesions            C           C        0000        0.0000          0.00         0.00         0.00
32150       Removal of lung lesion(s)            C           C        0000        0.0000          0.00         0.00         0.00
32151       Remove lung foreign body             C           C        0000        0.0000          0.00         0.00         0.00
32160       Open chest heart massage             C           C        0000        0.0000          0.00         0.00         0.00
32200       Drain, open, lung lesion             C           C        0000        0.0000          0.00         0.00         0.00
32201       Drain, percut, lung lesion           T           T        0070        3.6244         167.08       380.96       436.67
32215       Treat chest lining                   C           C        0000        0.0000          0.00         0.00         0.00
32220       Release of lung                      C           C        0000        0.0000          0.00         0.00         0.00
32225       Partial release of lung              C           C        0000        0.0000          0.00         0.00         0.00
32310       Removal of chest lining              C           C        0000        0.0000          0.00         0.00         0.00
32320       Free/remove chest lining             C           C        0000        0.0000          0.00         0.00         0.00
32400       Needle biopsy chest lining           T           T        0685        6.1384         282.98       645.21       739.55
32402       Open biopsy chest lining             C           C        0000        0.0000          0.00         0.00         0.00
32405       Biopsy, lung or mediastinum          T           T        0685        6.1384         282.98       645.21       739.55
32420       Puncture/clear lung                  T           T        0070        3.6244         167.08       380.96       436.67
32440       Removal of lung                      C           C        0000        0.0000          0.00         0.00         0.00
32442       Sleeve pneumonectomy                 C           C        0000        0.0000          0.00         0.00         0.00
32445       Removal of lung                      C           C        0000        0.0000          0.00         0.00         0.00
32480       Partial removal of lung              C           C        0000        0.0000          0.00         0.00         0.00
32482       Bilobectomy                          C           C        0000        0.0000          0.00         0.00         0.00
32484       Segmentectomy                        C           C        0000        0.0000          0.00         0.00         0.00
32486       Sleeve lobectomy                     C           C        0000        0.0000          0.00         0.00         0.00
32488       Completion pneumonectomy             C           C        0000        0.0000          0.00         0.00         0.00
32491       Lung volume reduction                C           C        0000        0.0000          0.00         0.00         0.00
32500       Partial removal of lung              C           C        0000        0.0000          0.00         0.00         0.00
32501       Repair bronchus add-on               C           C        0000        0.0000          0.00         0.00         0.00
32503       Resect apical lung tumor             C           C        0000        0.0000          0.00         0.00         0.00
32504       Resect apical lung tum/chest         C           C        0000        0.0000          0.00         0.00         0.00
32540       Removal of lung lesion               C           C        0000        0.0000          0.00         0.00         0.00
32601       Thoracoscopy, diagnostic             T           T        0069       31.9442        1,472.63     3,357.65     3,848.64
32602       Thoracoscopy, diagnostic             T           T        0069       31.9442        1,472.63     3,357.65     3,848.64
32603       Thoracoscopy, diagnostic             T           T        0069       31.9442        1,472.63     3,357.65     3,848.64
32604       Thoracoscopy, diagnostic             T           T        0069       31.9442        1,472.63     3,357.65     3,848.64
32605       Thoracoscopy, diagnostic             T           T        0069       31.9442        1,472.63     3,357.65     3,848.64
32606       Thoracoscopy, diagnostic             T           T        0069       31.9442        1,472.63     3,357.65     3,848.64
32650       Thoracoscopy, surgical               C           C        0000        0.0000          0.00         0.00         0.00
32651       Thoracoscopy, surgical               C           C        0000        0.0000          0.00         0.00         0.00
32652       Thoracoscopy, surgical               C           C        0000        0.0000          0.00         0.00         0.00
32653       Thoracoscopy, surgical               C           C        0000        0.0000          0.00         0.00         0.00
32654       Thoracoscopy, surgical               C           C        0000        0.0000          0.00         0.00         0.00
32655       Thoracoscopy, surgical               C           C        0000        0.0000          0.00         0.00         0.00
32656       Thoracoscopy, surgical               C           C        0000        0.0000          0.00         0.00         0.00
32657       Thoracoscopy, surgical               C           C        0000        0.0000          0.00         0.00         0.00
32658       Thoracoscopy, surgical               C           C        0000        0.0000          0.00         0.00         0.00
32659       Thoracoscopy, surgical               C           C        0000        0.0000          0.00         0.00         0.00
32660       Thoracoscopy, surgical               C           C        0000        0.0000          0.00         0.00         0.00
32661       Thoracoscopy, surgical               C           C        0000        0.0000          0.00         0.00         0.00
32662       Thoracoscopy, surgical               C           C        0000        0.0000          0.00         0.00         0.00
32663       Thoracoscopy, surgical               C           C        0000        0.0000          0.00         0.00         0.00
32664       Thoracoscopy, surgical               C           C        0000        0.0000          0.00         0.00         0.00
32665       Thoracoscopy, surgical               C           C        0000        0.0000          0.00         0.00         0.00
32800       Repair lung hernia                   C           C        0000        0.0000          0.00         0.00         0.00
32810       Close chest after drainage           C           C        0000        0.0000          0.00         0.00         0.00
32815       Close bronchial fistula              C           C        0000        0.0000          0.00         0.00         0.00
32820       Reconstruct injured chest            C           C        0000        0.0000          0.00         0.00         0.00
32850       Donor pneumonectomy                  C           C        0000        0.0000          0.00         0.00         0.00
32851       Lung transplant, single              C           C        0000        0.0000          0.00         0.00         0.00
32852       Lung transplant with bypass          C           C        0000        0.0000          0.00         0.00         0.00
32853       Lung transplant, double              C           C        0000        0.0000          0.00         0.00         0.00
32854       Lung transplant with bypass          C           C        0000        0.0000          0.00         0.00         0.00
32855       Prepare donor lung, single           C           C        0000        0.0000          0.00         0.00         0.00
32856       Prepare donor lung, double           C           C        0000        0.0000          0.00         0.00         0.00
32900       Removal of rib(s)                    C           C        0000        0.0000          0.00         0.00         0.00
32905       Revise & repair chest wall           C           C        0000        0.0000          0.00         0.00         0.00
32906       Revise & repair chest wall           C           C        0000        0.0000          0.00         0.00         0.00
32940       Revision of lung                     C           C        0000        0.0000          0.00         0.00         0.00
32960       Therapeutic pneumothorax             T           T        0070        3.6244         167.08       380.96       436.67
32997       Total lung lavage                    C           C        0000        0.0000          0.00         0.00         0.00
32998       Perq rf ablate tx, pul tumor         T           T        0423       37.3604        1,722.31     3,926.95     4,501.18
32999       Chest surgery procedure              T           1        0000        0.0000          0.00         0.00         0.00
33010       Drainage of heart sac                T           T        0070        3.6244         167.08       380.96       436.67
33011       Repeat drainage of heart sac         T           T        0070        3.6244         167.08       380.96       436.67
33015       Incision of heart sac                C           C        0000        0.0000          0.00         0.00         0.00
33020       Incision of heart sac                C           C        0000        0.0000          0.00         0.00         0.00
33025       Incision of heart sac                C           C        0000        0.0000          0.00         0.00         0.00
33030       Partial removal of heart sac         C           C        0000        0.0000          0.00         0.00         0.00
33031       Partial removal of heart sac         C           C        0000        0.0000          0.00         0.00         0.00
33050       Removal of heart sac lesion          C           C        0000        0.0000          0.00         0.00         0.00
33120       Removal of heart lesion              C           C        0000        0.0000          0.00         0.00         0.00
33130       Removal of heart lesion              C           C        0000        0.0000          0.00         0.00         0.00
33140       Heart revascularize (tmr)            C           C        0000        0.0000          0.00         0.00         0.00
33141       Heart tmr w/other procedure          C           C        0000        0.0000          0.00         0.00         0.00
33202       Insert epicard eltrd, open           C           C        0000        0.0000          0.00         0.00         0.00
33203       Insert epicard eltrd, endo           C           C        0000        0.0000          0.00         0.00         0.00
33206       Insertion of heart pacemaker         T           T        0089      123.6693        5,701.15    12,998.88    14,899.68
33207       Insertion of heart pacemaker         T           T        0089      123.6693        5,701.15    12,998.88    14,899.68
33208       Insertion of heart pacemaker         T           T        0655      152.6392        7,036.67    16,043.91    18,389.97
33210       Insertion of heart electrode         T           T        0106       58.8594        2,713.42     6,186.71     7,091.38
33211       Insertion of heart electrode         T           T        0106       58.8594        2,713.42     6,186.71     7,091.38
33212       Insertion of pulse generator         T           T        0090       98.3023        4,531.74    10,332.55    11,843.46
33213       Insertion of pulse generator         T           T        0654      112.7719        5,198.78    11,853.45    13,586.76
33214       Upgrade of pacemaker system          T           T        0655      152.6392        7,036.67    16,043.91    18,389.97
33215       Reposition pacing-defib lead         T           T        0105       25.6142        1,180.81     2,692.31     3,086.00
33216       Insert lead pace-defib, one          T           T        0106       58.8594        2,713.42     6,186.71     7,091.38


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 24 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
33217       Insert lead pace-defib, dual         T           T        0106       58.8594        2,713.42     6,186.71     7,091.38
33218       Repair lead pace-defib, one          T           T        0105       25.6142        1,180.81     2,692.31     3,086.00
33220       Repair lead pace-defib, dual         T           T        0105       25.6142        1,180.81     2,692.31     3,086.00
33222       Revise pocket, pacemaker             T           T        0027       21.4302         987.93      2,252.53     2,581.91
33223       Revise pocket, pacing-defib          T           T        0027       21.4302         987.93      2,252.53     2,581.91
33224       Insert pacing lead & connect         T           T        0418      307.2828       14,165.74    32,298.50    37,021.43
33225       L ventric pacing lead add-on         T           T        0418      307.2828       14,165.74    32,298.50    37,021.43
33226       Reposition l ventric lead            T           T        0105       25.6142        1,180.81     2,692.31     3,086.00
33233       Removal of pacemaker system          T           T        0105       25.6142        1,180.81     2,692.31     3,086.00
33234       Removal of pacemaker system          T           T        0105       25.6142        1,180.81     2,692.31     3,086.00
33235       Removal pacemaker electrode          T           T        0105       25.6142        1,180.81     2,692.31     3,086.00
33236       Remove electrode/thoracotomy         C           C        0000        0.0000          0.00         0.00         0.00
33237       Remove electrode/thoracotomy         C           C        0000        0.0000          0.00         0.00         0.00
33238       Remove electrode/thoracotomy         C           C        0000        0.0000          0.00         0.00         0.00
33240       Insert pulse generator               B           B        0000        0.0000          0.00         0.00         0.00
33241       Remove pulse generator               T           T        0105       25.6142        1,180.81     2,692.31     3,086.00
33243       Remove eltrd/thoracotomy             C           C        0000        0.0000          0.00         0.00         0.00
33244       Remove eltrd, transven               T           T        0105       25.6142        1,180.81     2,692.31     3,086.00
33249       Eltrd/insert pace-defib              B           B        0000        0.0000          0.00         0.00         0.00
33250       Ablate heart dysrhythm focus         C           C        0000        0.0000          0.00         0.00         0.00
33251       Ablate heart dysrhythm focus         C           C        0000        0.0000          0.00         0.00         0.00
33254       Ablate atria, lmtd                   C           C        0000        0.0000          0.00         0.00         0.00
33255       Ablate atria w/o bypass, ext         C           C        0000        0.0000          0.00         0.00         0.00
33256       Ablate atria w/bypass, exten         C           C        0000        0.0000          0.00         0.00         0.00
33261       Ablate heart dysrhythm focus         C           C        0000        0.0000          0.00         0.00         0.00
33265       Ablate atria w/bypass, endo          C           C        0000        0.0000          0.00         0.00         0.00
33266       Ablate atria w/o bypass endo         C           C        0000        0.0000          0.00         0.00         0.00
33282       Implant pat-active ht record         S           S        0680       72.6022        3,346.96     7,631.22     8,747.11
33284       Remove pat-active ht record          T           T        0109       10.9918         506.72      1,155.35     1,324.29
33300       Repair of heart wound                C           C        0000        0.0000          0.00         0.00         0.00
33305       Repair of heart wound                C           C        0000        0.0000          0.00         0.00         0.00
33310       Exploratory heart surgery            C           C        0000        0.0000          0.00         0.00         0.00
33315       Exploratory heart surgery            C           C        0000        0.0000          0.00         0.00         0.00
33320       Repair major blood vessel(s)         C           C        0000        0.0000          0.00         0.00         0.00
33321       Repair major vessel                  C           C        0000        0.0000          0.00         0.00         0.00
33322       Repair major blood vessel(s)         C           C        0000        0.0000          0.00         0.00         0.00
33330       Insert major vessel graft            C           C        0000        0.0000          0.00         0.00         0.00
33332       Insert major vessel graft            C           C        0000        0.0000          0.00         0.00         0.00
33335       Insert major vessel graft            C           C        0000        0.0000          0.00         0.00         0.00
33400       Repair of aortic valve               C           C        0000        0.0000          0.00         0.00         0.00
33401       Valvuloplasty, open                  C           C        0000        0.0000          0.00         0.00         0.00
33403       Valvuloplasty, w/cp bypass           C           C        0000        0.0000          0.00         0.00         0.00
33404       Prepare heart-aorta conduit          C           C        0000        0.0000          0.00         0.00         0.00
33405       Replacement of aortic valve          C           C        0000        0.0000          0.00         0.00         0.00
33406       Replacement of aortic valve          C           C        0000        0.0000          0.00         0.00         0.00
33410       Replacement of aortic valve          C           C        0000        0.0000          0.00         0.00         0.00
33411       Replacement of aortic valve          C           C        0000        0.0000          0.00         0.00         0.00
33412       Replacement of aortic valve          C           C        0000        0.0000          0.00         0.00         0.00
33413       Replacement of aortic valve          C           C        0000        0.0000          0.00         0.00         0.00
33414       Repair of aortic valve               C           C        0000        0.0000          0.00         0.00         0.00
33415       Revision, subvalvular tissue         C           C        0000        0.0000          0.00         0.00         0.00
33416       Revise ventricle muscle              C           C        0000        0.0000          0.00         0.00         0.00
33417       Repair of aortic valve               C           C        0000        0.0000          0.00         0.00         0.00
33420       Revision of mitral valve             C           C        0000        0.0000          0.00         0.00         0.00
33422       Revision of mitral valve             C           C        0000        0.0000          0.00         0.00         0.00
33425       Repair of mitral valve               C           C        0000        0.0000          0.00         0.00         0.00
33426       Repair of mitral valve               C           C        0000        0.0000          0.00         0.00         0.00
33427       Repair of mitral valve               C           C        0000        0.0000          0.00         0.00         0.00
33430       Replacement of mitral valve          C           C        0000        0.0000          0.00         0.00         0.00
33460       Revision of tricuspid valve          C           C        0000        0.0000          0.00         0.00         0.00
33463       Valvuloplasty, tricuspid             C           C        0000        0.0000          0.00         0.00         0.00
33464       Valvuloplasty, tricuspid             C           C        0000        0.0000          0.00         0.00         0.00
33465       Replace tricuspid valve              C           C        0000        0.0000          0.00         0.00         0.00
33468       Revision of tricuspid valve          C           C        0000        0.0000          0.00         0.00         0.00
33470       Revision of pulmonary valve          C           C        0000        0.0000          0.00         0.00         0.00
33471       Valvotomy, pulmonary valve           C           C        0000        0.0000          0.00         0.00         0.00
33472       Revision of pulmonary valve          C           C        0000        0.0000          0.00         0.00         0.00
33474       Revision of pulmonary valve          C           C        0000        0.0000          0.00         0.00         0.00
33475       Replacement, pulmonary valve         C           C        0000        0.0000          0.00         0.00         0.00
33476       Revision of heart chamber            C           C        0000        0.0000          0.00         0.00         0.00
33478       Revision of heart chamber            C           C        0000        0.0000          0.00         0.00         0.00
33496       Repair, prosth valve clot            C           C        0000        0.0000          0.00         0.00         0.00
33500       Repair heart vessel fistula          C           C        0000        0.0000          0.00         0.00         0.00
33501       Repair heart vessel fistula          C           C        0000        0.0000          0.00         0.00         0.00
33502       Coronary artery correction           C           C        0000        0.0000          0.00         0.00         0.00
33503       Coronary artery graft                C           C        0000        0.0000          0.00         0.00         0.00
33504       Coronary artery graft                C           C        0000        0.0000          0.00         0.00         0.00
33505       Repair artery w/tunnel               C           C        0000        0.0000          0.00         0.00         0.00
33506       Repair artery, translocation         C           C        0000        0.0000          0.00         0.00         0.00
33507       Repair art, intramural               C           C        0000        0.0000          0.00         0.00         0.00
33508       Endoscopic vein harvest              N           N        0000        0.0000          0.00         0.00         0.00
33510       CABG, vein, single                   C           C        0000        0.0000          0.00         0.00         0.00
33511       CABG, vein, two                      C           C        0000        0.0000          0.00         0.00         0.00
33512       CABG, vein, three                    C           C        0000        0.0000          0.00         0.00         0.00
33513       CABG, vein, four                     C           C        0000        0.0000          0.00         0.00         0.00
33514       CABG, vein, five                     C           C        0000        0.0000          0.00         0.00         0.00
33516       Cabg, vein, six or more              C           C        0000        0.0000          0.00         0.00         0.00
33517       CABG, artery-vein, single            C           C        0000        0.0000          0.00         0.00         0.00
33518       CABG, artery-vein, two               C           C        0000        0.0000          0.00         0.00         0.00
33519       CABG, artery-vein, three             C           C        0000        0.0000          0.00         0.00         0.00
33521       CABG, artery-vein, four              C           C        0000        0.0000          0.00         0.00         0.00
33522       CABG, artery-vein, five              C           C        0000        0.0000          0.00         0.00         0.00
33523       Cabg, art-vein, six or more          C           C        0000        0.0000          0.00         0.00         0.00
33530       Coronary artery, bypass/reop         C           C        0000        0.0000          0.00         0.00         0.00
33533       CABG, arterial, single               C           C        0000        0.0000          0.00         0.00         0.00
33534       CABG, arterial, two                  C           C        0000        0.0000          0.00         0.00         0.00
33535       CABG, arterial, three                C           C        0000        0.0000          0.00         0.00         0.00
33536       Cabg, arterial, four or more         C           C        0000        0.0000          0.00         0.00         0.00
33542       Removal of heart lesion              C           C        0000        0.0000          0.00         0.00         0.00
33545       Repair of heart damage               C           C        0000        0.0000          0.00         0.00         0.00
33548       Restore/remodel, ventricle           C           C        0000        0.0000          0.00         0.00         0.00
33572       Open coronary endarterectomy         C           C        0000        0.0000          0.00         0.00         0.00
33600       Closure of valve                     C           C        0000        0.0000          0.00         0.00         0.00
33602       Closure of valve                     C           C        0000        0.0000          0.00         0.00         0.00
33606       Anastomosis/artery-aorta             C           C        0000        0.0000          0.00         0.00         0.00
33608       Repair anomaly w/conduit             C           C        0000        0.0000          0.00         0.00         0.00


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 25 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
33610       Repair by enlargement                C           C        0000       0.0000           0.00         0.00         0.00
33611       Repair double ventricle              C           C        0000       0.0000           0.00         0.00         0.00
33612       Repair double ventricle              C           C        0000       0.0000           0.00         0.00         0.00
33615       Repair, modified fontan              C           C        0000       0.0000           0.00         0.00         0.00
33617       Repair single ventricle              C           C        0000       0.0000           0.00         0.00         0.00
33619       Repair single ventricle              C           C        0000       0.0000           0.00         0.00         0.00
33641       Repair heart septum defect           C           C        0000       0.0000           0.00         0.00         0.00
33645       Revision of heart veins              C           C        0000       0.0000           0.00         0.00         0.00
33647       Repair heart septum defects          C           C        0000       0.0000           0.00         0.00         0.00
33660       Repair of heart defects              C           C        0000       0.0000           0.00         0.00         0.00
33665       Repair of heart defects              C           C        0000       0.0000           0.00         0.00         0.00
33670       Repair of heart chambers             C           C        0000       0.0000           0.00         0.00         0.00
33675       Close mult vsd                       C           C        0000       0.0000           0.00         0.00         0.00
33676       Close mult vsd w/resection           C           C        0000       0.0000           0.00         0.00         0.00
33677       Cl mult vsd w/rem pul band           C           C        0000       0.0000           0.00         0.00         0.00
33681       Repair heart septum defect           C           C        0000       0.0000           0.00         0.00         0.00
33684       Repair heart septum defect           C           C        0000       0.0000           0.00         0.00         0.00
33688       Repair heart septum defect           C           C        0000       0.0000           0.00         0.00         0.00
33690       Reinforce pulmonary artery           C           C        0000       0.0000           0.00         0.00         0.00
33692       Repair of heart defects              C           C        0000       0.0000           0.00         0.00         0.00
33694       Repair of heart defects              C           C        0000       0.0000           0.00         0.00         0.00
33697       Repair of heart defects              C           C        0000       0.0000           0.00         0.00         0.00
33702       Repair of heart defects              C           C        0000       0.0000           0.00         0.00         0.00
33710       Repair of heart defects              C           C        0000       0.0000           0.00         0.00         0.00
33720       Repair of heart defect               C           C        0000       0.0000           0.00         0.00         0.00
33722       Repair of heart defect               C           C        0000       0.0000           0.00         0.00         0.00
33724       Repair venous anomaly                C           C        0000       0.0000           0.00         0.00         0.00
33726       Repair pul venous stenosis           C           C        0000       0.0000           0.00         0.00         0.00
33730       Repair heart-vein defect(s)          C           C        0000       0.0000           0.00         0.00         0.00
33732       Repair heart-vein defect             C           C        0000       0.0000           0.00         0.00         0.00
33735       Revision of heart chamber            C           C        0000       0.0000           0.00         0.00         0.00
33736       Revision of heart chamber            C           C        0000       0.0000           0.00         0.00         0.00
33737       Revision of heart chamber            C           C        0000       0.0000           0.00         0.00         0.00
33750       Major vessel shunt                   C           C        0000       0.0000           0.00         0.00         0.00
33755       Major vessel shunt                   C           C        0000       0.0000           0.00         0.00         0.00
33762       Major vessel shunt                   C           C        0000       0.0000           0.00         0.00         0.00
33764       Major vessel shunt & graft           C           C        0000       0.0000           0.00         0.00         0.00
33766       Major vessel shunt                   C           C        0000       0.0000           0.00         0.00         0.00
33767       Major vessel shunt                   C           C        0000       0.0000           0.00         0.00         0.00
33768       Cavopulmonary shunting               C           C        0000       0.0000           0.00         0.00         0.00
33770       Repair great vessels defect          C           C        0000       0.0000           0.00         0.00         0.00
33771       Repair great vessels defect          C           C        0000       0.0000           0.00         0.00         0.00
33774       Repair great vessels defect          C           C        0000       0.0000           0.00         0.00         0.00
33775       Repair great vessels defect          C           C        0000       0.0000           0.00         0.00         0.00
33776       Repair great vessels defect          C           C        0000       0.0000           0.00         0.00         0.00
33777       Repair great vessels defect          C           C        0000       0.0000           0.00         0.00         0.00
33778       Repair great vessels defect          C           C        0000       0.0000           0.00         0.00         0.00
33779       Repair great vessels defect          C           C        0000       0.0000           0.00         0.00         0.00
33780       Repair great vessels defect          C           C        0000       0.0000           0.00         0.00         0.00
33781       Repair great vessels defect          C           C        0000       0.0000           0.00         0.00         0.00
33786       Repair arterial trunk                C           C        0000       0.0000           0.00         0.00         0.00
33788       Revision of pulmonary artery         C           C        0000       0.0000           0.00         0.00         0.00
33800       Aortic suspension                    C           C        0000       0.0000           0.00         0.00         0.00
33802       Repair vessel defect                 C           C        0000       0.0000           0.00         0.00         0.00
33803       Repair vessel defect                 C           C        0000       0.0000           0.00         0.00         0.00
33813       Repair septal defect                 C           C        0000       0.0000           0.00         0.00         0.00
33814       Repair septal defect                 C           C        0000       0.0000           0.00         0.00         0.00
33820       Revise major vessel                  C           C        0000       0.0000           0.00         0.00         0.00
33822       Revise major vessel                  C           C        0000       0.0000           0.00         0.00         0.00
33824       Revise major vessel                  C           C        0000       0.0000           0.00         0.00         0.00
33840       Remove aorta constriction            C           C        0000       0.0000           0.00         0.00         0.00
33845       Remove aorta constriction            C           C        0000       0.0000           0.00         0.00         0.00
33851       Remove aorta constriction            C           C        0000       0.0000           0.00         0.00         0.00
33852       Repair septal defect                 C           C        0000       0.0000           0.00         0.00         0.00
33853       Repair septal defect                 C           C        0000       0.0000           0.00         0.00         0.00
33860       Ascending aortic graft               C           C        0000       0.0000           0.00         0.00         0.00
33861       Ascending aortic graft               C           C        0000       0.0000           0.00         0.00         0.00
33863       Ascending aortic graft               C           C        0000       0.0000           0.00         0.00         0.00
33870       Transverse aortic arch graft         C           C        0000       0.0000           0.00         0.00         0.00
33875       Thoracic aortic graft                C           C        0000       0.0000           0.00         0.00         0.00
33877       Thoracoabdominal graft               C           C        0000       0.0000           0.00         0.00         0.00
33880       Endovasc taa repr incl subcl         C           C        0000       0.0000           0.00         0.00         0.00
33881       Endovasc taa repr w/o subcl          C           C        0000       0.0000           0.00         0.00         0.00
33883       Insert endovasc prosth, taa          C           C        0000       0.0000           0.00         0.00         0.00
33884       Endovasc prosth, taa, add-on         C           C        0000       0.0000           0.00         0.00         0.00
33886       Endovasc prosth, delayed             C           C        0000       0.0000           0.00         0.00         0.00
33889       Artery transpose/endovas taa         C           C        0000       0.0000           0.00         0.00         0.00
33891       Car-car bp grft/endovas taa          C           C        0000       0.0000           0.00         0.00         0.00
33910       Remove lung artery emboli            C           C        0000       0.0000           0.00         0.00         0.00
33915       Remove lung artery emboli            C           C        0000       0.0000           0.00         0.00         0.00
33916       Surgery of great vessel              C           C        0000       0.0000           0.00         0.00         0.00
33917       Repair pulmonary artery              C           C        0000       0.0000           0.00         0.00         0.00
33920       Repair pulmonary atresia             C           C        0000       0.0000           0.00         0.00         0.00
33922       Transect pulmonary artery            C           C        0000       0.0000           0.00         0.00         0.00
33924       Remove pulmonary shunt               C           C        0000       0.0000           0.00         0.00         0.00
33925       Rpr pul art unifocal w/o cpb         C           C        0000       0.0000           0.00         0.00         0.00
33926       Repr pul art, unifocal w/cpb         C           C        0000       0.0000           0.00         0.00         0.00
33930       Removal of donor heart/lung          C           C        0000       0.0000           0.00         0.00         0.00
33933       Prepare donor heart/lung             C           C        0000       0.0000           0.00         0.00         0.00
33935       Transplantation, heart/lung          C           C        0000       0.0000           0.00         0.00         0.00
33940       Removal of donor heart               C           C        0000       0.0000           0.00         0.00         0.00
33944       Prepare donor heart                  C           C        0000       0.0000           0.00         0.00         0.00
33945       Transplantation of heart             C           C        0000       0.0000           0.00         0.00         0.00
33960       External circulation assist          C           C        0000       0.0000           0.00         0.00         0.00
33961       External circulation assist          C           C        0000       0.0000           0.00         0.00         0.00
33967       Insert ia percut device              C           C        0000       0.0000           0.00         0.00         0.00
33968       Remove aortic assist device          C           C        0000       0.0000           0.00         0.00         0.00
33970       Aortic circulation assist            C           C        0000       0.0000           0.00         0.00         0.00
33971       Aortic circulation assist            C           C        0000       0.0000           0.00         0.00         0.00
33973       Insert balloon device                C           C        0000       0.0000           0.00         0.00         0.00
33974       Remove intra-aortic balloon          C           C        0000       0.0000           0.00         0.00         0.00
33975       Implant ventricular device           C           C        0000       0.0000           0.00         0.00         0.00
33976       Implant ventricular device           C           C        0000       0.0000           0.00         0.00         0.00
33977       Remove ventricular device            C           C        0000       0.0000           0.00         0.00         0.00
33978       Remove ventricular device            C           C        0000       0.0000           0.00         0.00         0.00
33979       Insert intracorporeal device         C           C        0000       0.0000           0.00         0.00         0.00


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 26 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
33980       Remove intracorporeal device         C           C        0000        0.0000          0.00         0.00         0.00
33999       Cardiac surgery procedure            T           1        0000        0.0000          0.00         0.00         0.00
34001       Removal of artery clot               C           C        0000        0.0000          0.00         0.00         0.00
34051       Removal of artery clot               C           C        0000        0.0000          0.00         0.00         0.00
34101       Removal of artery clot               T           T        0088       37.7391        1,739.77     3,966.76     4,546.81
34111       Removal of arm artery clot           T           T        0088       37.7391        1,739.77     3,966.76     4,546.81
34151       Removal of artery clot               C           C        0000        0.0000          0.00         0.00         0.00
34201       Removal of artery clot               T           T        0088       37.7391        1,739.77     3,966.76     4,546.81
34203       Removal of leg artery clot           T           T        0088       37.7391        1,739.77     3,966.76     4,546.81
34401       Removal of vein clot                 C           C        0000        0.0000          0.00         0.00         0.00
34421       Removal of vein clot                 T           T        0088       37.7391        1,739.77     3,966.76     4,546.81
34451       Removal of vein clot                 C           C        0000        0.0000          0.00         0.00         0.00
34471       Removal of vein clot                 T           T        0088       37.7391        1,739.77     3,966.76     4,546.81
34490       Removal of vein clot                 T           T        0088       37.7391        1,739.77     3,966.76     4,546.81
34501       Repair valve, femoral vein           T           T        0088       37.7391        1,739.77     3,966.76     4,546.81
34502       Reconstruct vena cava                C           C        0000        0.0000          0.00         0.00         0.00
34510       Transposition of vein valve          T           T        0088       37.7391        1,739.77     3,966.76     4,546.81
34520       Cross-over vein graft                T           T        0088       37.7391        1,739.77     3,966.76     4,546.81
34530       Leg vein fusion                      T           T        0088       37.7391        1,739.77     3,966.76     4,546.81
34800       Endovas aaa repr w/sm tube           C           C        0000        0.0000          0.00         0.00         0.00
34802       Endovas aaa repr w/2-p part          C           C        0000        0.0000          0.00         0.00         0.00
34803       Endovas aaa repr w/3-p part          C           C        0000        0.0000          0.00         0.00         0.00
34804       Endovas aaa repr w/1-p part          C           C        0000        0.0000          0.00         0.00         0.00
34805       Endovas aaa repr w/long tube         C           C        0000        0.0000          0.00         0.00         0.00
34808       Endovas iliac a device addon         C           C        0000        0.0000          0.00         0.00         0.00
34812       Xpose for endoprosth, femorl         C           C        0000        0.0000          0.00         0.00         0.00
34813       Femoral endovas graft add-on         C           C        0000        0.0000          0.00         0.00         0.00
34820       Xpose for endoprosth, iliac          C           C        0000        0.0000          0.00         0.00         0.00
34825       Endovasc extend prosth, init         C           C        0000        0.0000          0.00         0.00         0.00
34826       Endovasc exten prosth, add’l         C           C        0000        0.0000          0.00         0.00         0.00
34830       Open aortic tube prosth repr         C           C        0000        0.0000          0.00         0.00         0.00
34831       Open aortoiliac prosth repr          C           C        0000        0.0000          0.00         0.00         0.00
34832       Open aortofemor prosth repr          C           C        0000        0.0000          0.00         0.00         0.00
34833       Xpose for endoprosth, iliac          C           C        0000        0.0000          0.00         0.00         0.00
34834       Xpose, endoprosth, brachial          C           C        0000        0.0000          0.00         0.00         0.00
34900       Endovasc iliac repr w/graft          C           C        0000        0.0000          0.00         0.00         0.00
35001       Repair defect of artery              C           C        0000        0.0000          0.00         0.00         0.00
35002       Repair artery rupture, neck          C           C        0000        0.0000          0.00         0.00         0.00
35005       Repair defect of artery              C           C        0000        0.0000          0.00         0.00         0.00
35011       Repair defect of artery              T           T        0653       32.3818        1,492.80     3,403.65     3,901.36
35013       Repair artery rupture, arm           C           C        0000        0.0000          0.00         0.00         0.00
35021       Repair defect of artery              C           C        0000        0.0000          0.00         0.00         0.00
35022       Repair artery rupture, chest         C           C        0000        0.0000          0.00         0.00         0.00
35045       Repair defect of arm artery          C           C        0000        0.0000          0.00         0.00         0.00
35081       Repair defect of artery              C           C        0000        0.0000          0.00         0.00         0.00
35082       Repair artery rupture, aorta         C           C        0000        0.0000          0.00         0.00         0.00
35091       Repair defect of artery              C           C        0000        0.0000          0.00         0.00         0.00
35092       Repair artery rupture, aorta         C           C        0000        0.0000          0.00         0.00         0.00
35102       Repair defect of artery              C           C        0000        0.0000          0.00         0.00         0.00
35103       Repair artery rupture, groin         C           C        0000        0.0000          0.00         0.00         0.00
35111       Repair defect of artery              C           C        0000        0.0000          0.00         0.00         0.00
35112       Repair artery rupture,spleen         C           C        0000        0.0000          0.00         0.00         0.00
35121       Repair defect of artery              C           C        0000        0.0000          0.00         0.00         0.00
35122       Repair artery rupture, belly         C           C        0000        0.0000          0.00         0.00         0.00
35131       Repair defect of artery              C           C        0000        0.0000          0.00         0.00         0.00
35132       Repair artery rupture, groin         C           C        0000        0.0000          0.00         0.00         0.00
35141       Repair defect of artery              C           C        0000        0.0000          0.00         0.00         0.00
35142       Repair artery rupture, thigh         C           C        0000        0.0000          0.00         0.00         0.00
35151       Repair defect of artery              C           C        0000        0.0000          0.00         0.00         0.00
35152       Repair artery rupture, knee          C           C        0000        0.0000          0.00         0.00         0.00
35180       Repair blood vessel lesion           T           T        0093       22.8653        1,054.09     2,403.37     2,754.81
35182       Repair blood vessel lesion           C           C        0000        0.0000          0.00         0.00         0.00
35184       Repair blood vessel lesion           T           T        0093       22.8653        1,054.09     2,403.37     2,754.81
35188       Repair blood vessel lesion           T           T        0088       37.7391        1,739.77     3,966.76     4,546.81
35189       Repair blood vessel lesion           C           C        0000        0.0000          0.00         0.00         0.00
35190       Repair blood vessel lesion           T           T        0093       22.8653        1,054.09     2,403.37     2,754.81
35201       Repair blood vessel lesion           T           T        0093       22.8653        1,054.09     2,403.37     2,754.81
35206       Repair blood vessel lesion           T           T        0093       22.8653        1,054.09     2,403.37     2,754.81
35207       Repair blood vessel lesion           T           T        0088       37.7391        1,739.77     3,966.76     4,546.81
35211       Repair blood vessel lesion           C           C        0000        0.0000          0.00         0.00         0.00
35216       Repair blood vessel lesion           C           C        0000        0.0000          0.00         0.00         0.00
35221       Repair blood vessel lesion           C           C        0000        0.0000          0.00         0.00         0.00
35226       Repair blood vessel lesion           T           T        0093       22.8653        1,054.09     2,403.37     2,754.81
35231       Repair blood vessel lesion           T           T        0093       22.8653        1,054.09     2,403.37     2,754.81
35236       Repair blood vessel lesion           T           T        0093       22.8653        1,054.09     2,403.37     2,754.81
35241       Repair blood vessel lesion           C           C        0000        0.0000          0.00         0.00         0.00
35246       Repair blood vessel lesion           C           C        0000        0.0000          0.00         0.00         0.00
35251       Repair blood vessel lesion           C           C        0000        0.0000          0.00         0.00         0.00
35256       Repair blood vessel lesion           T           T        0093       22.8653        1,054.09     2,403.37     2,754.81
35261       Repair blood vessel lesion           T           T        0653       32.3818        1,492.80     3,403.65     3,901.36
35266       Repair blood vessel lesion           T           T        0653       32.3818        1,492.80     3,403.65     3,901.36
35271       Repair blood vessel lesion           C           C        0000        0.0000          0.00         0.00         0.00
35276       Repair blood vessel lesion           C           C        0000        0.0000          0.00         0.00         0.00
35281       Repair blood vessel lesion           C           C        0000        0.0000          0.00         0.00         0.00
35286       Repair blood vessel lesion           T           T        0653       32.3818        1,492.80     3,403.65     3,901.36
35301       Rechanneling of artery               C           C        0000        0.0000          0.00         0.00         0.00
35302       Rechanneling of artery               C           C        0000        0.0000          0.00         0.00         0.00
35303       Rechanneling of artery               C           C        0000        0.0000          0.00         0.00         0.00
35304       Rechanneling of artery               C           C        0000        0.0000          0.00         0.00         0.00
35305       Rechanneling of artery               C           C        0000        0.0000          0.00         0.00         0.00
35306       Rechanneling of artery               C           C        0000        0.0000          0.00         0.00         0.00
35311       Rechanneling of artery               C           C        0000        0.0000          0.00         0.00         0.00
35321       Rechanneling of artery               T           T        0093       22.8653        1,054.09     2,403.37     2,754.81
35331       Rechanneling of artery               C           C        0000        0.0000          0.00         0.00         0.00
35341       Rechanneling of artery               C           C        0000        0.0000          0.00         0.00         0.00
35351       Rechanneling of artery               C           C        0000        0.0000          0.00         0.00         0.00
35355       Rechanneling of artery               C           C        0000        0.0000          0.00         0.00         0.00
35361       Rechanneling of artery               C           C        0000        0.0000          0.00         0.00         0.00
35363       Rechanneling of artery               C           C        0000        0.0000          0.00         0.00         0.00
35371       Rechanneling of artery               C           C        0000        0.0000          0.00         0.00         0.00
35372       Rechanneling of artery               C           C        0000        0.0000          0.00         0.00         0.00
35390       Reoperation, carotid add-on          C           C        0000        0.0000          0.00         0.00         0.00
35400       Angioscopy                           C           C        0000        0.0000          0.00         0.00         0.00
35450       Repair arterial blockage             C           C        0000        0.0000          0.00         0.00         0.00
35452       Repair arterial blockage             C           C        0000        0.0000          0.00         0.00         0.00
35454       Repair arterial blockage             C           C        0000        0.0000          0.00         0.00         0.00


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 27 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
35456       Repair arterial blockage             C           C        0000        0.0000          0.00         0.00         0.00
35458       Repair arterial blockage             T           T        0081       42.9360        1,979.35     4,513.00     5,172.93
35459       Repair arterial blockage             T           T        0081       42.9360        1,979.35     4,513.00     5,172.93
35460       Repair venous blockage               T           T        0081       42.9360        1,979.35     4,513.00     5,172.93
35470       Repair arterial blockage             T           T        0081       42.9360        1,979.35     4,513.00     5,172.93
35471       Repair arterial blockage             T           T        0081       42.9360        1,979.35     4,513.00     5,172.93
35472       Repair arterial blockage             T           T        0081       42.9360        1,979.35     4,513.00     5,172.93
35473       Repair arterial blockage             T           T        0081       42.9360        1,979.35     4,513.00     5,172.93
35474       Repair arterial blockage             T           T        0081       42.9360        1,979.35     4,513.00     5,172.93
35475       Repair arterial blockage             T           T        0081       42.9360        1,979.35     4,513.00     5,172.93
35476       Repair venous blockage               T           T        0081       42.9360        1,979.35     4,513.00     5,172.93
35480       Atherectomy, open                    C           C        0000        0.0000          0.00         0.00         0.00
35481       Atherectomy, open                    C           C        0000        0.0000          0.00         0.00         0.00
35482       Atherectomy, open                    C           C        0000        0.0000          0.00         0.00         0.00
35483       Atherectomy, open                    C           C        0000        0.0000          0.00         0.00         0.00
35484       Atherectomy, open                    T           T        0081       42.9360        1,979.35     4,513.00     5,172.93
35485       Atherectomy, open                    T           T        0081       42.9360        1,979.35     4,513.00     5,172.93
35490       Atherectomy, percutaneous            T           T        0081       42.9360        1,979.35     4,513.00     5,172.93
35491       Atherectomy, percutaneous            T           T        0081       42.9360        1,979.35     4,513.00     5,172.93
35492       Atherectomy, percutaneous            T           T        0081       42.9360        1,979.35     4,513.00     5,172.93
35493       Atherectomy, percutaneous            T           T        0081       42.9360        1,979.35     4,513.00     5,172.93
35494       Atherectomy, percutaneous            T           T        0081       42.9360        1,979.35     4,513.00     5,172.93
35495       Atherectomy, percutaneous            T           T        0081       42.9360        1,979.35     4,513.00     5,172.93
35500       Harvest vein for bypass              T           T        0081       42.9360        1,979.35     4,513.00     5,172.93
35501       Artery bypass graft                  C           C        0000        0.0000          0.00         0.00         0.00
35506       Artery bypass graft                  C           C        0000        0.0000          0.00         0.00         0.00
35508       Artery bypass graft                  C           C        0000        0.0000          0.00         0.00         0.00
35509       Artery bypass graft                  C           C        0000        0.0000          0.00         0.00         0.00
35510       Artery bypass graft                  C           C        0000        0.0000          0.00         0.00         0.00
35511       Artery bypass graft                  C           C        0000        0.0000          0.00         0.00         0.00
35512       Artery bypass graft                  C           C        0000        0.0000          0.00         0.00         0.00
35515       Artery bypass graft                  C           C        0000        0.0000          0.00         0.00         0.00
35516       Artery bypass graft                  C           C        0000        0.0000          0.00         0.00         0.00
35518       Artery bypass graft                  C           C        0000        0.0000          0.00         0.00         0.00
35521       Artery bypass graft                  C           C        0000        0.0000          0.00         0.00         0.00
35522       Artery bypass graft                  C           C        0000        0.0000          0.00         0.00         0.00
35525       Artery bypass graft                  C           C        0000        0.0000          0.00         0.00         0.00
35526       Artery bypass graft                  C           C        0000        0.0000          0.00         0.00         0.00
35531       Artery bypass graft                  C           C        0000        0.0000          0.00         0.00         0.00
35533       Artery bypass graft                  C           C        0000        0.0000          0.00         0.00         0.00
35536       Artery bypass graft                  C           C        0000        0.0000          0.00         0.00         0.00
35537       Artery bypass graft                  C           C        0000        0.0000          0.00         0.00         0.00
35538       Artery bypass graft                  C           C        0000        0.0000          0.00         0.00         0.00
35539       Artery bypass graft                  C           C        0000        0.0000          0.00         0.00         0.00
35540       Artery bypass graft                  C           C        0000        0.0000          0.00         0.00         0.00
35548       Artery bypass graft                  C           C        0000        0.0000          0.00         0.00         0.00
35549       Artery bypass graft                  C           C        0000        0.0000          0.00         0.00         0.00
35551       Artery bypass graft                  C           C        0000        0.0000          0.00         0.00         0.00
35556       Artery bypass graft                  C           C        0000        0.0000          0.00         0.00         0.00
35558       Artery bypass graft                  C           C        0000        0.0000          0.00         0.00         0.00
35560       Artery bypass graft                  C           C        0000        0.0000          0.00         0.00         0.00
35563       Artery bypass graft                  C           C        0000        0.0000          0.00         0.00         0.00
35565       Artery bypass graft                  C           C        0000        0.0000          0.00         0.00         0.00
35566       Artery bypass graft                  C           C        0000        0.0000          0.00         0.00         0.00
35571       Artery bypass graft                  C           C        0000        0.0000          0.00         0.00         0.00
35572       Harvest femoropopliteal vein         N           N        0000        0.0000          0.00         0.00         0.00
35583       Vein bypass graft                    C           C        0000        0.0000          0.00         0.00         0.00
35585       Vein bypass graft                    C           C        0000        0.0000          0.00         0.00         0.00
35587       Vein bypass graft                    C           C        0000        0.0000          0.00         0.00         0.00
35600       Harvest artery for cabg              C           C        0000        0.0000          0.00         0.00         0.00
35601       Artery bypass graft                  C           C        0000        0.0000          0.00         0.00         0.00
35606       Artery bypass graft                  C           C        0000        0.0000          0.00         0.00         0.00
35612       Artery bypass graft                  C           C        0000        0.0000          0.00         0.00         0.00
35616       Artery bypass graft                  C           C        0000        0.0000          0.00         0.00         0.00
35621       Artery bypass graft                  C           C        0000        0.0000          0.00         0.00         0.00
35623       Bypass graft, not vein               C           C        0000        0.0000          0.00         0.00         0.00
35626       Artery bypass graft                  C           C        0000        0.0000          0.00         0.00         0.00
35631       Artery bypass graft                  C           C        0000        0.0000          0.00         0.00         0.00
35636       Artery bypass graft                  C           C        0000        0.0000          0.00         0.00         0.00
35637       Artery bypass graft                  C           C        0000        0.0000          0.00         0.00         0.00
35638       Artery bypass graft                  C           C        0000        0.0000          0.00         0.00         0.00
35642       Artery bypass graft                  C           C        0000        0.0000          0.00         0.00         0.00
35645       Artery bypass graft                  C           C        0000        0.0000          0.00         0.00         0.00
35646       Artery bypass graft                  C           C        0000        0.0000          0.00         0.00         0.00
35647       Artery bypass graft                  C           C        0000        0.0000          0.00         0.00         0.00
35650       Artery bypass graft                  C           C        0000        0.0000          0.00         0.00         0.00
35651       Artery bypass graft                  C           C        0000        0.0000          0.00         0.00         0.00
35654       Artery bypass graft                  C           C        0000        0.0000          0.00         0.00         0.00
35656       Artery bypass graft                  C           C        0000        0.0000          0.00         0.00         0.00
35661       Artery bypass graft                  C           C        0000        0.0000          0.00         0.00         0.00
35663       Artery bypass graft                  C           C        0000        0.0000          0.00         0.00         0.00
35665       Artery bypass graft                  C           C        0000        0.0000          0.00         0.00         0.00
35666       Artery bypass graft                  C           C        0000        0.0000          0.00         0.00         0.00
35671       Artery bypass graft                  C           C        0000        0.0000          0.00         0.00         0.00
35681       Composite bypass graft               C           C        0000        0.0000          0.00         0.00         0.00
35682       Composite bypass graft               C           C        0000        0.0000          0.00         0.00         0.00
35683       Composite bypass graft               C           C        0000        0.0000          0.00         0.00         0.00
35685       Bypass graft patency/patch           T           T        0093       22.8653        1,054.09     2,403.37     2,754.81
35686       Bypass graft/av fist patency         T           T        0093       22.8653        1,054.09     2,403.37     2,754.81
35691       Arterial transposition               C           C        0000        0.0000          0.00         0.00         0.00
35693       Arterial transposition               C           C        0000        0.0000          0.00         0.00         0.00
35694       Arterial transposition               C           C        0000        0.0000          0.00         0.00         0.00
35695       Arterial transposition               C           C        0000        0.0000          0.00         0.00         0.00
35697       Reimplant artery each                C           C        0000        0.0000          0.00         0.00         0.00
35700       Reoperation, bypass graft            C           C        0000        0.0000          0.00         0.00         0.00
35701       Exploration, carotid artery          C           C        0000        0.0000          0.00         0.00         0.00
35721       Exploration, femoral artery          C           C        0000        0.0000          0.00         0.00         0.00
35741       Exploration popliteal artery         C           C        0000        0.0000          0.00         0.00         0.00
35761       Exploration of artery/vein           T           T        0115       29.2133        1,346.73     3,070.61     3,519.62
35800       Explore neck vessels                 C           C        0000        0.0000          0.00         0.00         0.00
35820       Explore chest vessels                C           C        0000        0.0000          0.00         0.00         0.00
35840       Explore abdominal vessels            C           C        0000        0.0000          0.00         0.00         0.00
35860       Explore limb vessels                 T           T        0093       22.8653        1,054.09     2,403.37     2,754.81
35870       Repair vessel graft defect           C           C        0000        0.0000          0.00         0.00         0.00
35875       Removal of clot in graft             T           T        0088       37.7391        1,739.77     3,966.76     4,546.81
35876       Removal of clot in graft             T           T        0088       37.7391        1,739.77     3,966.76     4,546.81


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 28 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
35879       Revise graft w/vein                  T           T        0088       37.7391        1,739.77     3,966.76     4,546.81
35881       Revise graft w/vein                  T           T        0088       37.7391        1,739.77     3,966.76     4,546.81
35883       Revise graft w/nonauto graft         T           T        0088       37.7391        1,739.77     3,966.76     4,546.81
35884       Revise graft w/vein                  T           T        0088       37.7391        1,739.77     3,966.76     4,546.81
35901       Excision, graft, neck                C           C        0000        0.0000           0.00         0.00         0.00
35903       Excision, graft, extremity           T           T        0115       29.2133        1,346.73     3,070.61     3,519.62
35905       Excision, graft, thorax              C           C        0000        0.0000           0.00         0.00         0.00
35907       Excision, graft, abdomen             C           C        0000        0.0000           0.00         0.00         0.00
36000       Place needle in vein                 N           N        0000        0.0000           0.00         0.00         0.00
36002       Pseudoaneurysm injection trt         S           S        0267        2.4606         113.43       258.63       296.45
36005       Injection ext venography             N           N        0000        0.0000           0.00         0.00         0.00
36010       Place catheter in vein               N           N        0000        0.0000           0.00         0.00         0.00
36011       Place catheter in vein               N           N        0000        0.0000           0.00         0.00         0.00
36012       Place catheter in vein               N           N        0000        0.0000           0.00         0.00         0.00
36013       Place catheter in artery             N           N        0000        0.0000           0.00         0.00         0.00
36014       Place catheter in artery             N           N        0000        0.0000           0.00         0.00         0.00
36015       Place catheter in artery             N           N        0000        0.0000           0.00         0.00         0.00
36100       Establish access to artery           N           N        0000        0.0000           0.00         0.00         0.00
36120       Establish access to artery           N           N        0000        0.0000           0.00         0.00         0.00
36140       Establish access to artery           N           N        0000        0.0000           0.00         0.00         0.00
36145       Artery to vein shunt                 N           N        0000        0.0000           0.00         0.00         0.00
36160       Establish access to aorta            N           N        0000        0.0000           0.00         0.00         0.00
36200       Place catheter in aorta              N           N        0000        0.0000           0.00         0.00         0.00
36215       Place catheter in artery             N           N        0000        0.0000           0.00         0.00         0.00
36216       Place catheter in artery             N           N        0000        0.0000           0.00         0.00         0.00
36217       Place catheter in artery             N           N        0000        0.0000           0.00         0.00         0.00
36218       Place catheter in artery             N           N        0000        0.0000           0.00         0.00         0.00
36245       Place catheter in artery             N           N        0000        0.0000           0.00         0.00         0.00
36246       Place catheter in artery             N           N        0000        0.0000           0.00         0.00         0.00
36247       Place catheter in artery             N           N        0000        0.0000           0.00         0.00         0.00
36248       Place catheter in artery             N           N        0000        0.0000           0.00         0.00         0.00
36260       Insertion of infusion pump           T           T        0623       28.5032        1,314.00     2,995.97     3,434.07
36261       Revision of infusion pump            T           T        0623       28.5032        1,314.00     2,995.97     3,434.07
36262       Removal of infusion pump             T           T        0622       22.6665        1,044.93     2,382.48     2,730.86
36299       Vessel injection procedure           N           1        0000        0.0000           0.00         0.00         0.00
36400       Bl draw < 3 yrs fem/jugular          N           N        0000        0.0000           0.00         0.00         0.00
36405       Bl draw < 3 yrs scalp vein           N           N        0000        0.0000           0.00         0.00         0.00
36406       Bl draw < 3 yrs other vein           N           N        0000        0.0000           0.00         0.00         0.00
36410       Non-routine bl draw > 3 yrs          N           N        0000        0.0000           0.00         0.00         0.00
36415       Routine venipuncture                 A           3        0000        0.0000           M01          M01          M01
36416       Capillary blood draw                 N           N        0000        0.0000           0.00         0.00         0.00
36420       Vein access cutdown < 1 yr           T           T        0035        0.1999           9.22        21.01        24.08
36425       Vein access cutdown > 1 yr           T           T        0035        0.1999           9.22        21.01        24.08
36430       Blood transfusion service            S           S        0110        3.4584         159.43       363.51       416.67
36440       Bl push transfuse, 2 yr or <         S           S        0110        3.4584         159.43       363.51       416.67
36450       Bl exchange/transfuse, nb            S           S        0110        3.4584         159.43       363.51       416.67
36455       Bl exchange/transfuse non-nb         S           S        0110        3.4584         159.43       363.51       416.67
36460       Transfusion service, fetal           S           S        0110        3.4584         159.43       363.51       416.67
36468       Injection(s), spider veins           T           1        0000        0.0000           0.00         0.00         0.00
36469       Injection(s), spider veins           T           1        0000        0.0000           0.00         0.00         0.00
36470       Injection therapy of vein            T           1        0000        0.0000           0.00         0.00         0.00
36471       Injection therapy of veins           T           1        0000        0.0000           0.00         0.00         0.00
36475       Endovenous rf, 1st vein              T           T        0091       34.7288        1,601.00     3,650.34     4,184.13
36476       Endovenous rf, vein add-on           T           T        0091       34.7288        1,601.00     3,650.34     4,184.13
36478       Endovenous laser, 1st vein           T           T        0092       24.8809        1,147.01     2,615.23     2,997.65
36479       Endovenous laser vein addon          T           T        0092       24.8809        1,147.01     2,615.23     2,997.65
36481       Insertion of catheter, vein          N           N        0000        0.0000           0.00         0.00         0.00
36500       Insertion of catheter, vein          N           N        0000        0.0000           0.00         0.00         0.00
36510       Insertion of catheter, vein          N           N        0000        0.0000           0.00         0.00         0.00
36511       Apheresis wbc                        S           S        0111       11.7134         539.99      1,231.20     1,411.23
36512       Apheresis rbc                        S           S        0111       11.7134         539.99      1,231.20     1,411.23
36513       Apheresis platelets                  S           S        0111       11.7134         539.99      1,231.20     1,411.23
36514       Apheresis plasma                     S           S        0111       11.7134         539.99      1,231.20     1,411.23
36515       Apheresis, adsorp/reinfuse           S           S        0112       30.2231        1,393.28     3,176.75     3,641.28
36516       Apheresis, selective                 S           S        0112       30.2231        1,393.28     3,176.75     3,641.28
36522       Photopheresis                        S           S        0112       30.2231        1,393.28     3,176.75     3,641.28
36540       Collect blood venous device          Q           Q        0624        0.5145          23.72        54.08        61.99
36550       Declot vascular device               T           T        0676        2.0726          95.55       217.85       249.71
36555       Insert non-tunnel cv cath            T           T        0621        8.7846         404.97       923.35      1,058.37
36556       Insert non-tunnel cv cath            T           T        0621        8.7846         404.97       923.35      1,058.37
36557       Insert tunneled cv cath              T           T        0622       22.6665        1,044.93     2,382.48     2,730.86
36558       Insert tunneled cv cath              T           T        0622       22.6665        1,044.93     2,382.48     2,730.86
36560       Insert tunneled cv cath              T           T        0623       28.5032        1,314.00     2,995.97     3,434.07
36561       Insert tunneled cv cath              T           T        0623       28.5032        1,314.00     2,995.97     3,434.07
36563       Insert tunneled cv cath              T           T        0623       28.5032        1,314.00     2,995.97     3,434.07
36565       Insert tunneled cv cath              T           T        0623       28.5032        1,314.00     2,995.97     3,434.07
36566       Insert tunneled cv cath              T           T        0625       83.4609        3,847.55     8,772.58    10,055.37
36568       Insert picc cath                     T           T        0621        8.7846         404.97       923.35      1,058.37
36569       Insert picc cath                     T           T        0621        8.7846         404.97       923.35      1,058.37
36570       Insert picvad cath                   T           T        0622       22.6665        1,044.93     2,382.48     2,730.86
36571       Insert picvad cath                   T           T        0622       22.6665        1,044.93     2,382.48     2,730.86
36575       Repair tunneled cv cath              T           T        0621        8.7846         404.97       923.35      1,058.37
36576       Repair tunneled cv cath              T           T        0621        8.7846         404.97       923.35      1,058.37
36578       Replace tunneled cv cath             T           T        0622       22.6665        1,044.93     2,382.48     2,730.86
36580       Replace cvad cath                    T           T        0621        8.7846         404.97       923.35      1,058.37
36581       Replace tunneled cv cath             T           T        0622       22.6665        1,044.93     2,382.48     2,730.86
36582       Replace tunneled cv cath             T           T        0623       28.5032        1,314.00     2,995.97     3,434.07
36583       Replace tunneled cv cath             T           T        0623       28.5032        1,314.00     2,995.97     3,434.07
36584       Replace picc cath                    T           T        0621        8.7846         404.97       923.35      1,058.37
36585       Replace picvad cath                  T           T        0622       22.6665        1,044.93     2,382.48     2,730.86
36589       Removal tunneled cv cath             T           T        0621        8.7846         404.97       923.35      1,058.37
36590       Removal tunneled cv cath             T           T        0621        8.7846         404.97       923.35      1,058.37
36595       Mech remov tunneled cv cath          T           T        0622       22.6665        1,044.93     2,382.48     2,730.86
36596       Mech remov tunneled cv cath          T           T        0621        8.7846         404.97       923.35      1,058.37
36597       Reposition venous catheter           T           T        0621        8.7846         404.97       923.35      1,058.37
36598       Inj w/fluor, eval cv device          X           X        0340        0.6102          28.13        64.14        73.52
36600       Withdrawal of arterial blood         Q           Q        0035        0.1999           9.22        21.01        24.08
36620       Insertion catheter, artery           N           N        0000        0.0000           0.00         0.00         0.00
36625       Insertion catheter, artery           N           N        0000        0.0000           0.00         0.00         0.00
36640       Insertion catheter, artery           T           T        0623       28.5032        1,314.00     2,995.97     3,434.07
36660       Insertion catheter, artery           C           C        0000        0.0000           0.00         0.00         0.00
36680       Insert needle, bone cavity           T           T        0002        1.0995          50.69       115.57       132.47
36800       Insertion of cannula                 T           T        0115       29.2133        1,346.73     3,070.61     3,519.62
36810       Insertion of cannula                 T           T        0115       29.2133        1,346.73     3,070.61     3,519.62
36815       Insertion of cannula                 T           T        0115       29.2133        1,346.73     3,070.61     3,519.62
36818       Av fuse, uppr arm, cephalic          T           T        0088       37.7391        1,739.77     3,966.76     4,546.81


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 29 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
36819       Av fuse, uppr arm, basilic           T           T        0088       37.7391        1,739.77     3,966.76     4,546.81
36820       Av fusion/forearm vein               T           T        0088       37.7391        1,739.77     3,966.76     4,546.81
36821       Av fusion direct any site            T           T        0088       37.7391        1,739.77     3,966.76     4,546.81
36822       Insertion of cannula(s)              C           C        0000        0.0000           0.00        0.00         0.00
36823       Insertion of cannula(s)              C           C        0000        0.0000           0.00        0.00         0.00
36825       Artery-vein autograft                T           T        0088       37.7391        1,739.77     3,966.76     4,546.81
36830       Artery-vein nonautograft             T           T        0088       37.7391        1,739.77     3,966.76     4,546.81
36831       Open thrombect av fistula            T           T        0088       37.7391        1,739.77     3,966.76     4,546.81
36832       Av fistula revision, open            T           T        0088       37.7391        1,739.77     3,966.76     4,546.81
36833       Av fistula revision                  T           T        0088       37.7391        1,739.77     3,966.76     4,546.81
36834       Repair A-V aneurysm                  T           T        0088       37.7391        1,739.77     3,966.76     4,546.81
36835       Artery to vein shunt                 T           T        0115       29.2133        1,346.73     3,070.61     3,519.62
36838       Dist revas ligation, hemo            T           T        0088       37.7391        1,739.77     3,966.76     4,546.81
36860       External cannula declotting          T           T        0676        2.0726          95.55       217.85       249.71
36861       Cannula declotting                   T           T        0115       29.2133        1,346.73     3,070.61     3,519.62
36870       Percut thrombect av fistula          T           T        0653       32.3818        1,492.80     3,403.65     3,901.36
37140       Revision of circulation              C           C        0000        0.0000           0.00        0.00         0.00
37145       Revision of circulation              C           C        0000        0.0000           0.00        0.00         0.00
37160       Revision of circulation              C           C        0000        0.0000           0.00        0.00         0.00
37180       Revision of circulation              C           C        0000        0.0000           0.00        0.00         0.00
37181       Splice spleen/kidney veins           C           C        0000        0.0000           0.00        0.00         0.00
37182       Insert hepatic shunt (tips)          C           C        0000        0.0000           0.00        0.00         0.00
37183       Remove hepatic shunt (tips)          T           T        0229       68.4697        3,156.45     7,196.85     8,249.23
37184       Prim art mech thrombectomy           T           T        0088       37.7391        1,739.77     3,966.76     4,546.81
37185       Prim art m-thrombect add-on          T           T        0088       37.7391        1,739.77     3,966.76     4,546.81
37186       Sec art m-thrombect add-on           T           T        0088       37.7391        1,739.77     3,966.76     4,546.81
37187       Venous mech thrombectomy             T           T        0088       37.7391        1,739.77     3,966.76     4,546.81
37188       Venous m-thrombectomy add-on         T           T        0088       37.7391        1,739.77     3,966.76     4,546.81
37195       Thrombolytic therapy, stroke         T           T        0676        2.0726          95.55       217.85       249.71
37200       Transcatheter biopsy                 T           T        0685        6.1384         282.98       645.21       739.55
37201       Transcatheter therapy infuse         T           T        0676        2.0726          95.55       217.85       249.71
37202       Transcatheter therapy infuse         T           T        0676        2.0726          95.55       217.85       249.71
37203       Transcatheter retrieval              T           T        0103       16.2375         748.55      1,706.72     1,956.29
37204       Transcatheter occlusion              T           T        0115       29.2133        1,346.73     3,070.61     3,519.62
37205       Transcath iv stent, percut           T           T        0229       68.4697        3,156.45     7,196.85     8,249.23
37206       Transcath iv stent/perc addl         T           T        0229       68.4697        3,156.45     7,196.85     8,249.23
37207       Transcath iv stent, open             T           T        0229       68.4697        3,156.45     7,196.85     8,249.23
37208       Transcath iv stent/open addl         T           T        0229       68.4697        3,156.45     7,196.85     8,249.23
37209       Exchange arterial catheter           T           T        0103       16.2375         748.55      1,706.72     1,956.29
37210       Embolization uterine fibroid         T           T        0202       42.9896        1,981.82     4,518.64     5,179.39
37215       Transcath stent, cca w/eps           C           C        0000        0.0000           0.00        0.00         0.00
37216       Transcath stent, cca w/o eps         E           3        0000        0.0000           M01         M01          M01
37250       Iv us first vessel add-on            S           S        0416       32.5472        1,500.43     3,421.04     3,921.29
37251       Iv us each add vessel add-on         S           S        0416       32.5472        1,500.43     3,421.04     3,921.29
37500       Endoscopy ligate perf veins          T           T        0091       34.7288        1,601.00     3,650.34     4,184.13
37501       Vascular endoscopy procedure         T           1        0000        0.0000           0.00        0.00         0.00
37565       Ligation of neck vein                T           T        0093       22.8653        1,054.09     2,403.37     2,754.81
37600       Ligation of neck artery              T           T        0093       22.8653        1,054.09     2,403.37     2,754.81
37605       Ligation of neck artery              T           T        0091       34.7288        1,601.00     3,650.34     4,184.13
37606       Ligation of neck artery              T           T        0092       24.8809        1,147.01     2,615.23     2,997.65
37607       Ligation of a-v fistula              T           T        0092       24.8809        1,147.01     2,615.23     2,997.65
37609       Temporal artery procedure            T           T        0021       15.1024         696.22      1,587.41     1,819.54
37615       Ligation of neck artery              T           T        0092       24.8809        1,147.01     2,615.23     2,997.65
37616       Ligation of chest artery             C           C        0000        0.0000           0.00        0.00         0.00
37617       Ligation of abdomen artery           C           C        0000        0.0000           0.00        0.00         0.00
37618       Ligation of extremity artery         C           C        0000        0.0000           0.00        0.00         0.00
37620       Revision of major vein               T           T        0091       34.7288        1,601.00     3,650.34     4,184.13
37650       Revision of major vein               T           T        0092       24.8809        1,147.01     2,615.23     2,997.65
37660       Revision of major vein               C           C        0000        0.0000           0.00        0.00         0.00
37700       Revise leg vein                      T           T        0091       34.7288        1,601.00     3,650.34     4,184.13
37718       Ligate/strip short leg vein          T           T        0091       34.7288        1,601.00     3,650.34     4,184.13
37722       Ligate/strip long leg vein           T           T        0091       34.7288        1,601.00     3,650.34     4,184.13
37735       Removal of leg veins/lesion          T           T        0091       34.7288        1,601.00     3,650.34     4,184.13
37760       Ligation, leg veins, open            T           T        0092       24.8809        1,147.01     2,615.23     2,997.65
37765       Phleb veins - extrem - to 20         T           T        0092       24.8809        1,147.01     2,615.23     2,997.65
37766       Phleb veins - extrem 20+             T           T        0092       24.8809        1,147.01     2,615.23     2,997.65
37780       Revision of leg vein                 T           T        0092       24.8809        1,147.01     2,615.23     2,997.65
37785       Ligate/divide/excise vein            T           T        0092       24.8809        1,147.01     2,615.23     2,997.65
37788       Revascularization, penis             C           C        0000        0.0000           0.00        0.00         0.00
37790       Penile venous occlusion              T           T        0181       32.9873        1,520.71     3,467.30     3,974.31
37799       Vascular surgery procedure           T           1        0000        0.0000           0.00        0.00         0.00
38100       Removal of spleen, total             C           C        0000        0.0000           0.00        0.00         0.00
38101       Removal of spleen, partial           C           C        0000        0.0000           0.00        0.00         0.00
38102       Removal of spleen, total             C           C        0000        0.0000           0.00        0.00         0.00
38115       Repair of ruptured spleen            C           C        0000        0.0000           0.00        0.00         0.00
38120       Laparoscopy, splenectomy             T           T        0131       43.5488        2,007.60     4,577.41     5,246.76
38129       Laparoscope proc, spleen             T           1        0000        0.0000           0.00        0.00         0.00
38200       Injection for spleen x-ray           N           N        0000        0.0000           0.00        0.00         0.00
38204       Bl donor search management           N           N        0000        0.0000           0.00        0.00         0.00
38205       Harvest allogenic stem cells         S           S        0111       11.7134         539.99      1,231.20     1,411.23
38206       Harvest auto stem cells              S           S        0111       11.7134         539.99      1,231.20     1,411.23
38207       Cryopreserve stem cells              E           3        0000        0.0000           M01         M01          M01
38208       Thaw preserved stem cells            E           3        0000        0.0000           M01         M01          M01
38209       Wash harvest stem cells              E           1        0000        0.0000           0.00        0.00         0.00
38210       T-cell depletion of harvest          E           1        0000        0.0000           0.00        0.00         0.00
38211       Tumor cell deplete of harvst         E           1        0000        0.0000           0.00        0.00         0.00
38212       Rbc depletion of harvest             E           1        0000        0.0000           0.00        0.00         0.00
38213       Platelet deplete of harvest          E           1        0000        0.0000           0.00        0.00         0.00
38214       Volume deplete of harvest            E           1        0000        0.0000           0.00        0.00         0.00
38215       Harvest stem cell concentrte         E           1        0000        0.0000           0.00        0.00         0.00
38220       Bone marrow aspiration               T           T        0003        2.4011         110.69       252.38       289.28
38221       Bone marrow biopsy                   T           T        0003        2.4011         110.69       252.38       289.28
38230       Bone marrow collection               S           S        0123       20.3582         938.51      2,139.85     2,452.76
38240       Bone marrow/stem transplant          S           S        0123       20.3582         938.51      2,139.85     2,452.76
38241       Bone marrow/stem transplant          S           S        0123       20.3582         938.51      2,139.85     2,452.76
38242       Lymphocyte infuse transplant         S           S        0111       11.7134         539.99      1,231.20     1,411.23
38300       Drainage, lymph node lesion          T           T        0007       11.1535         514.18      1,172.34     1,343.77
38305       Drainage, lymph node lesion          T           T        0008       17.5086         807.15      1,840.33     2,109.44
38308       Incision of lymph channels           T           T        0113       21.2621         980.18      2,234.86     2,561.66
38380       Thoracic duct procedure              C           C        0000        0.0000           0.00        0.00         0.00
38381       Thoracic duct procedure              C           C        0000        0.0000           0.00        0.00         0.00
38382       Thoracic duct procedure              C           C        0000        0.0000           0.00        0.00         0.00
38500       Biopsy/removal, lymph nodes          T           T        0113       21.2621         980.18      2,234.86     2,561.66
38505       Needle biopsy, lymph nodes           T           T        0005        3.9045         180.00       410.40       470.41
38510       Biopsy/removal, lymph nodes          T           T        0113       21.2621         980.18      2,234.86     2,561.66
38520       Biopsy/removal, lymph nodes          T           T        0113       21.2621         980.18      2,234.86     2,561.66


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 30 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
38525       Biopsy/removal, lymph nodes          T           T        0113       21.2621         980.18      2,234.86     2,561.66
38530       Biopsy/removal, lymph nodes          T           T        0113       21.2621         980.18      2,234.86     2,561.66
38542       Explore deep node(s), neck           T           T        0114       37.7224        1,739.00     3,965.00     4,544.79
38550       Removal, neck/armpit lesion          T           T        0113       21.2621         980.18      2,234.86     2,561.66
38555       Removal, neck/armpit lesion          T           T        0113       21.2621         980.18      2,234.86     2,561.66
38562       Removal, pelvic lymph nodes          C           C        0000        0.0000           0.00         0.00         0.00
38564       Removal, abdomen lymph nodes         C           C        0000        0.0000           0.00         0.00         0.00
38570       Laparoscopy, lymph node biop         T           T        0131       43.5488        2,007.60     4,577.41     5,246.76
38571       Laparoscopy, lymphadenectomy         T           T        0132       70.5066        3,250.35     7,410.95     8,494.64
38572       Laparoscopy, lymphadenectomy         T           T        0131       43.5488        2,007.60     4,577.41     5,246.76
38589       Laparoscope proc, lymphatic          T           1        0000        0.0000           0.00         0.00         0.00
38700       Removal of lymph nodes, neck         T           T        0113       21.2621         980.18      2,234.86     2,561.66
38720       Removal of lymph nodes, neck         T           T        0113       21.2621         980.18      2,234.86     2,561.66
38724       Removal of lymph nodes, neck         C           C        0000        0.0000           0.00         0.00         0.00
38740       Remove armpit lymph nodes            T           T        0114       37.7224        1,739.00     3,965.00     4,544.79
38745       Remove armpit lymph nodes            T           T        0114       37.7224        1,739.00     3,965.00     4,544.79
38746       Remove thoracic lymph nodes          C           C        0000        0.0000           0.00         0.00         0.00
38747       Remove abdominal lymph nodes         C           C        0000        0.0000           0.00         0.00         0.00
38760       Remove groin lymph nodes             T           T        0113       21.2621         980.18      2,234.86     2,561.66
38765       Remove groin lymph nodes             C           C        0000        0.0000           0.00         0.00         0.00
38770       Remove pelvis lymph nodes            C           C        0000        0.0000           0.00         0.00         0.00
38780       Remove abdomen lymph nodes           C           C        0000        0.0000           0.00         0.00         0.00
38790       Inject for lymphatic x-ray           N           N        0000        0.0000           0.00         0.00         0.00
38792       Identify sentinel node               Q           Q        0389        1.3754          63.41       144.57       165.71
38794       Access thoracic lymph duct           N           N        0000        0.0000           0.00         0.00         0.00
38999       Blood/lymph system procedure         S           1        0000        0.0000           0.00         0.00         0.00
39000       Exploration of chest                 C           C        0000        0.0000           0.00         0.00         0.00
39010       Exploration of chest                 C           C        0000        0.0000           0.00         0.00         0.00
39200       Removal chest lesion                 C           C        0000        0.0000           0.00         0.00         0.00
39220       Removal chest lesion                 C           C        0000        0.0000           0.00         0.00         0.00
39400       Visualization of chest               T           T        0069       31.9442        1,472.63     3,357.65     3,848.64
39499       Chest procedure                      C           1        0000        0.0000           0.00         0.00         0.00
39501       Repair diaphragm laceration          C           C        0000        0.0000           0.00         0.00         0.00
39502       Repair paraesophageal hernia         C           C        0000        0.0000           0.00         0.00         0.00
39503       Repair of diaphragm hernia           C           C        0000        0.0000           0.00         0.00         0.00
39520       Repair of diaphragm hernia           C           C        0000        0.0000           0.00         0.00         0.00
39530       Repair of diaphragm hernia           C           C        0000        0.0000           0.00         0.00         0.00
39531       Repair of diaphragm hernia           C           C        0000        0.0000           0.00         0.00         0.00
39540       Repair of diaphragm hernia           C           C        0000        0.0000           0.00         0.00         0.00
39541       Repair of diaphragm hernia           C           C        0000        0.0000           0.00         0.00         0.00
39545       Revision of diaphragm                C           C        0000        0.0000           0.00         0.00         0.00
39560       Resect diaphragm, simple             C           C        0000        0.0000           0.00         0.00         0.00
39561       Resect diaphragm, complex            C           C        0000        0.0000           0.00         0.00         0.00
39599       Diaphragm surgery procedure          C           1        0000        0.0000           0.00         0.00         0.00
40490       Biopsy of lip                        T           T        0251        2.4520         113.04       257.73       295.42
40500       Partial excision of lip              T           T        0253       16.4266         757.27      1,726.60     1,979.08
40510       Partial excision of lip              T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
40520       Partial excision of lip              T           T        0253       16.4266         757.27      1,726.60     1,979.08
40525       Reconstruct lip with flap            T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
40527       Reconstruct lip with flap            T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
40530       Partial removal of lip               T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
40650       Repair lip                           T           T        0252        7.5511         348.11       793.70       909.76
40652       Repair lip                           T           T        0252        7.5511         348.11       793.70       909.76
40654       Repair lip                           T           T        0252        7.5511         348.11       793.70       909.76
40700       Repair cleft lip/nasal               T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
40701       Repair cleft lip/nasal               T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
40702       Repair cleft lip/nasal               T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
40720       Repair cleft lip/nasal               T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
40761       Repair cleft lip/nasal               T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
40799       Lip surgery procedure                T           1        0000        0.0000           0.00         0.00         0.00
40800       Drainage of mouth lesion             T           T        0006        1.4392          66.35       151.27       173.39
40801       Drainage of mouth lesion             T           T        0252        7.5511         348.11       793.70       909.76
40804       Removal, foreign body, mouth         X           X        0340        0.6102          28.13        64.14        73.52
40805       Removal, foreign body, mouth         T           T        0252        7.5511         348.11       793.70       909.76
40806       Incision of lip fold                 T           T        0251        2.4520         113.04       257.73       295.42
40808       Biopsy of mouth lesion               T           T        0251        2.4520         113.04       257.73       295.42
40810       Excision of mouth lesion             T           T        0253       16.4266         757.27      1,726.60     1,979.08
40812       Excise/repair mouth lesion           T           T        0253       16.4266         757.27      1,726.60     1,979.08
40814       Excise/repair mouth lesion           T           T        0253       16.4266         757.27      1,726.60     1,979.08
40816       Excision of mouth lesion             T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
40818       Excise oral mucosa for graft         T           T        0251        2.4520         113.04       257.73       295.42
40819       Excise lip or cheek fold             T           T        0252        7.5511         348.11       793.70       909.76
40820       Treatment of mouth lesion            T           T        0253       16.4266         757.27      1,726.60     1,979.08
40830       Repair mouth laceration              T           T        0251        2.4520         113.04       257.73       295.42
40831       Repair mouth laceration              T           T        0252        7.5511         348.11       793.70       909.76
40840       Reconstruction of mouth              T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
40842       Reconstruction of mouth              T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
40843       Reconstruction of mouth              T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
40844       Reconstruction of mouth              T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
40845       Reconstruction of mouth              T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
40899       Mouth surgery procedure              T           1        0000        0.0000           0.00         0.00         0.00
41000       Drainage of mouth lesion             T           T        0253       16.4266         757.27      1,726.60     1,979.08
41005       Drainage of mouth lesion             T           T        0251        2.4520         113.04       257.73       295.42
41006       Drainage of mouth lesion             T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
41007       Drainage of mouth lesion             T           T        0253       16.4266         757.27      1,726.60     1,979.08
41008       Drainage of mouth lesion             T           T        0253       16.4266         757.27      1,726.60     1,979.08
41009       Drainage of mouth lesion             T           T        0251        2.4520         113.04       257.73       295.42
41010       Incision of tongue fold              T           T        0252        7.5511         348.11       793.70       909.76
41015       Drainage of mouth lesion             T           T        0251        2.4520         113.04       257.73       295.42
41016       Drainage of mouth lesion             T           T        0252        7.5511         348.11       793.70       909.76
41017       Drainage of mouth lesion             T           T        0252        7.5511         348.11       793.70       909.76
41018       Drainage of mouth lesion             T           T        0252        7.5511         348.11       793.70       909.76
41100       Biopsy of tongue                     T           T        0252        7.5511         348.11       793.70       909.76
41105       Biopsy of tongue                     T           T        0253       16.4266         757.27      1,726.60     1,979.08
41108       Biopsy of floor of mouth             T           T        0252        7.5511         348.11       793.70       909.76
41110       Excision of tongue lesion            T           T        0253       16.4266         757.27      1,726.60     1,979.08
41112       Excision of tongue lesion            T           T        0253       16.4266         757.27      1,726.60     1,979.08
41113       Excision of tongue lesion            T           T        0253       16.4266         757.27      1,726.60     1,979.08
41114       Excision of tongue lesion            T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
41115       Excision of tongue fold              T           T        0252        7.5511         348.11       793.70       909.76
41116       Excision of mouth lesion             T           T        0253       16.4266         757.27      1,726.60     1,979.08
41120       Partial removal of tongue            T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
41130       Partial removal of tongue            C           C        0000        0.0000           0.00         0.00         0.00
41135       Tongue and neck surgery              C           C        0000        0.0000           0.00         0.00         0.00
41140       Removal of tongue                    C           C        0000        0.0000           0.00         0.00         0.00
41145       Tongue removal, neck surgery         C           C        0000        0.0000           0.00         0.00         0.00


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 31 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
41150       Tongue, mouth, jaw surgery           C           C        0000        0.0000           0.00         0.00         0.00
41153       Tongue, mouth, neck surgery          C           C        0000        0.0000           0.00         0.00         0.00
41155       Tongue, jaw, & neck surgery          C           C        0000        0.0000           0.00         0.00         0.00
41250       Repair tongue laceration             T           T        0251        2.4520         113.04       257.73       295.42
41251       Repair tongue laceration             T           T        0251        2.4520         113.04       257.73       295.42
41252       Repair tongue laceration             T           T        0252        7.5511         348.11       793.70       909.76
41500       Fixation of tongue                   T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
41510       Tongue to lip surgery                T           T        0253       16.4266         757.27      1,726.60     1,979.08
41520       Reconstruction, tongue fold          T           T        0252        7.5511         348.11       793.70       909.76
41599       Tongue and mouth surgery             T           1        0000        0.0000           0.00         0.00         0.00
41800       Drainage of gum lesion               T           T        0006        1.4392          66.35       151.27       173.39
41805       Removal foreign body, gum            T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
41806       Removal foreign body,jawbone         T           T        0253       16.4266         757.27      1,726.60     1,979.08
41820       Excision, gum, each quadrant         T           T        0252        7.5511         348.11       793.70       909.76
41821       Excision of gum flap                 T           T        0252        7.5511         348.11       793.70       909.76
41822       Excision of gum lesion               T           T        0253       16.4266         757.27      1,726.60     1,979.08
41823       Excision of gum lesion               T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
41825       Excision of gum lesion               T           T        0253       16.4266         757.27      1,726.60     1,979.08
41826       Excision of gum lesion               T           T        0253       16.4266         757.27      1,726.60     1,979.08
41827       Excision of gum lesion               T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
41828       Excision of gum lesion               T           T        0253       16.4266         757.27      1,726.60     1,979.08
41830       Removal of gum tissue                T           T        0253       16.4266         757.27      1,726.60     1,979.08
41850       Treatment of gum lesion              T           T        0253       16.4266         757.27      1,726.60     1,979.08
41870       Gum graft                            T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
41872       Repair gum                           T           T        0253       16.4266         757.27      1,726.60     1,979.08
41874       Repair tooth socket                  T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
                                                                                                APC by       APC by       APC by
41899       Dental surgery procedure             T           2        0000        0.0000         Report       Report       Report
42000       Drainage mouth roof lesion           T           T        0251        2.4520         113.04       257.73       295.42
42100       Biopsy roof of mouth                 T           T        0252        7.5511         348.11       793.70       909.76
42104       Excision lesion, mouth roof          T           T        0253       16.4266         757.27      1,726.60     1,979.08
42106       Excision lesion, mouth roof          T           T        0253       16.4266         757.27      1,726.60     1,979.08
42107       Excision lesion, mouth roof          T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
42120       Remove palate/lesion                 T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
42140       Excision of uvula                    T           T        0252        7.5511         348.11       793.70       909.76
42145       Repair palate, pharynx/uvula         T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
42160       Treatment mouth roof lesion          T           T        0253       16.4266         757.27      1,726.60     1,979.08
42180       Repair palate                        T           T        0251        2.4520         113.04       257.73       295.42
42182       Repair palate                        T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
42200       Reconstruct cleft palate             T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
42205       Reconstruct cleft palate             T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
42210       Reconstruct cleft palate             T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
42215       Reconstruct cleft palate             T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
42220       Reconstruct cleft palate             T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
42225       Reconstruct cleft palate             T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
42226       Lengthening of palate                T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
42227       Lengthening of palate                T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
42235       Repair palate                        T           T        0253       16.4266         757.27      1,726.60     1,979.08
42260       Repair nose to lip fistula           T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
42280       Preparation, palate mold             T           T        0251        2.4520         113.04       257.73       295.42
42281       Insertion, palate prosthesis         T           T        0253       16.4266         757.27      1,726.60     1,979.08
42299       Palate/uvula surgery                 T           1        0000        0.0000           0.00         0.00         0.00
42300       Drainage of salivary gland           T           T        0253       16.4266         757.27      1,726.60     1,979.08
42305       Drainage of salivary gland           T           T        0253       16.4266         757.27      1,726.60     1,979.08
42310       Drainage of salivary gland           T           T        0251        2.4520         113.04       257.73       295.42
42320       Drainage of salivary gland           T           T        0251        2.4520         113.04       257.73       295.42
42330       Removal of salivary stone            T           T        0253       16.4266         757.27      1,726.60     1,979.08
42335       Removal of salivary stone            T           T        0253       16.4266         757.27      1,726.60     1,979.08
42340       Removal of salivary stone            T           T        0253       16.4266         757.27      1,726.60     1,979.08
42400       Biopsy of salivary gland             T           T        0005        3.9045         180.00       410.40       470.41
42405       Biopsy of salivary gland             T           T        0253       16.4266         757.27      1,726.60     1,979.08
42408       Excision of salivary cyst            T           T        0253       16.4266         757.27      1,726.60     1,979.08
42409       Drainage of salivary cyst            T           T        0253       16.4266         757.27      1,726.60     1,979.08
42410       Excise parotid gland/lesion          T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
42415       Excise parotid gland/lesion          T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
42420       Excise parotid gland/lesion          T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
42425       Excise parotid gland/lesion          T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
42426       Excise parotid gland/lesion          C           C        0000        0.0000           0.00         0.00         0.00
42440       Excise submaxillary gland            T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
42450       Excise sublingual gland              T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
42500       Repair salivary duct                 T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
42505       Repair salivary duct                 T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
42507       Parotid duct diversion               T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
42508       Parotid duct diversion               T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
42509       Parotid duct diversion               T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
42510       Parotid duct diversion               T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
42550       Injection for salivary x-ray         N           N        0000        0.0000           0.00         0.00         0.00
42600       Closure of salivary fistula          T           T        0253       16.4266         757.27      1,726.60     1,979.08
42650       Dilation of salivary duct            T           T        0252        7.5511         348.11       793.70       909.76
42660       Dilation of salivary duct            T           T        0251        2.4520         113.04       257.73       295.42
42665       Ligation of salivary duct            T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
42699       Salivary surgery procedure           T           1        0000        0.0000           0.00         0.00         0.00
42700       Drainage of tonsil abscess           T           T        0251        2.4520         113.04       257.73       295.42
42720       Drainage of throat abscess           T           T        0253       16.4266         757.27      1,726.60     1,979.08
42725       Drainage of throat abscess           T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
42800       Biopsy of throat                     T           T        0252        7.5511         348.11       793.70       909.76
42802       Biopsy of throat                     T           T        0253       16.4266         757.27      1,726.60     1,979.08
42804       Biopsy of upper nose/throat          T           T        0253       16.4266         757.27      1,726.60     1,979.08
42806       Biopsy of upper nose/throat          T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
42808       Excise pharynx lesion                T           T        0253       16.4266         757.27      1,726.60     1,979.08
42809       Remove pharynx foreign body          X           X        0340        0.6102          28.13        64.14        73.52
42810       Excision of neck cyst                T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
42815       Excision of neck cyst                T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
42820       Remove tonsils and adenoids          T           T        0258       22.1165        1,019.57     2,324.67     2,664.60
42821       Remove tonsils and adenoids          T           T        0258       22.1165        1,019.57     2,324.67     2,664.60
42825       Removal of tonsils                   T           T        0258       22.1165        1,019.57     2,324.67     2,664.60
42826       Removal of tonsils                   T           T        0258       22.1165        1,019.57     2,324.67     2,664.60
42830       Removal of adenoids                  T           T        0258       22.1165        1,019.57     2,324.67     2,664.60
42831       Removal of adenoids                  T           T        0258       22.1165        1,019.57     2,324.67     2,664.60
42835       Removal of adenoids                  T           T        0258       22.1165        1,019.57     2,324.67     2,664.60
42836       Removal of adenoids                  T           T        0258       22.1165        1,019.57     2,324.67     2,664.60
42842       Extensive surgery of throat          T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
42844       Extensive surgery of throat          T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
42845       Extensive surgery of throat          C           C        0000        0.0000           0.00         0.00         0.00
42860       Excision of tonsil tags              T           T        0258       22.1165        1,019.57     2,324.67     2,664.60
42870       Excision of lingual tonsil           T           T        0258       22.1165        1,019.57     2,324.67     2,664.60


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 32 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
42890       Partial removal of pharynx           T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
42892       Revision of pharyngeal walls         T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
42894       Revision of pharyngeal walls         C           C        0000        0.0000           0.00        0.00         0.00
42900       Repair throat wound                  T           T        0252        7.5511         348.11       793.70       909.76
42950       Reconstruction of throat             T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
42953       Repair throat, esophagus             C           C        0000        0.0000           0.00        0.00         0.00
42955       Surgical opening of throat           T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
42960       Control throat bleeding              T           T        0250        1.1791          54.36       123.94       142.06
42961       Control throat bleeding              C           C        0000        0.0000           0.00        0.00         0.00
42962       Control throat bleeding              T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
42970       Control nose/throat bleeding         T           T        0250        1.1791          54.36       123.94       142.06
42971       Control nose/throat bleeding         C           C        0000        0.0000           0.00        0.00         0.00
42972       Control nose/throat bleeding         T           T        0253       16.4266         757.27      1,726.60     1,979.08
42999       Throat surgery procedure             T           1        0000        0.0000           0.00        0.00         0.00
43020       Incision of esophagus                T           T        0252        7.5511         348.11       793.70       909.76
43030       Throat muscle surgery                T           T        0253       16.4266         757.27      1,726.60     1,979.08
43045       Incision of esophagus                C           C        0000        0.0000           0.00        0.00         0.00
43100       Excision of esophagus lesion         C           C        0000        0.0000           0.00        0.00         0.00
43101       Excision of esophagus lesion         C           C        0000        0.0000           0.00        0.00         0.00
43107       Removal of esophagus                 C           C        0000        0.0000           0.00        0.00         0.00
43108       Removal of esophagus                 C           C        0000        0.0000           0.00        0.00         0.00
43112       Removal of esophagus                 C           C        0000        0.0000           0.00        0.00         0.00
43113       Removal of esophagus                 C           C        0000        0.0000           0.00        0.00         0.00
43116       Partial removal of esophagus         C           C        0000        0.0000           0.00        0.00         0.00
43117       Partial removal of esophagus         C           C        0000        0.0000           0.00        0.00         0.00
43118       Partial removal of esophagus         C           C        0000        0.0000           0.00        0.00         0.00
43121       Partial removal of esophagus         C           C        0000        0.0000           0.00        0.00         0.00
43122       Partial removal of esophagus         C           C        0000        0.0000           0.00        0.00         0.00
43123       Partial removal of esophagus         C           C        0000        0.0000           0.00        0.00         0.00
43124       Removal of esophagus                 C           C        0000        0.0000           0.00        0.00         0.00
43130       Removal of esophagus pouch           T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
43135       Removal of esophagus pouch           C           C        0000        0.0000           0.00        0.00         0.00
43200       Esophagus endoscopy                  T           T        0141        8.3175         383.44       874.25      1,002.09
43201       Esoph scope w/submucous inj          T           T        0141        8.3175         383.44       874.25      1,002.09
43202       Esophagus endoscopy, biopsy          T           T        0141        8.3175         383.44       874.25      1,002.09
43204       Esoph scope w/sclerosis inj          T           T        0141        8.3175         383.44       874.25      1,002.09
43205       Esophagus endoscopy/ligation         T           T        0141        8.3175         383.44       874.25      1,002.09
43215       Esophagus endoscopy                  T           T        0141        8.3175         383.44       874.25      1,002.09
43216       Esophagus endoscopy/lesion           T           T        0141        8.3175         383.44       874.25      1,002.09
43217       Esophagus endoscopy                  T           T        0141        8.3175         383.44       874.25      1,002.09
43219       Esophagus endoscopy                  T           T        0384       22.9475        1,057.88     2,412.01     2,764.71
43220       Esoph endoscopy, dilation            T           T        0141        8.3175         383.44       874.25      1,002.09
43226       Esoph endoscopy, dilation            T           T        0141        8.3175         383.44       874.25      1,002.09
43227       Esoph endoscopy, repair              T           T        0141        8.3175         383.44       874.25      1,002.09
43228       Esoph endoscopy, ablation            T           T        0422       25.7552        1,187.31     2,707.13     3,102.99
43231       Esoph endoscopy w/us exam            T           T        0141        8.3175         383.44       874.25      1,002.09
43232       Esoph endoscopy w/us fn bx           T           T        0141        8.3175         383.44       874.25      1,002.09
43234       Upper GI endoscopy, exam             T           T        0141        8.3175         383.44       874.25      1,002.09
43235       Uppr gi endoscopy, diagnosis         T           T        0141        8.3175         383.44       874.25      1,002.09
43236       Uppr gi scope w/submuc inj           T           T        0141        8.3175         383.44       874.25      1,002.09
43237       Endoscopic us exam, esoph            T           T        0141        8.3175         383.44       874.25      1,002.09
43238       Uppr gi endoscopy w/us fn bx         T           T        0141        8.3175         383.44       874.25      1,002.09
43239       Upper GI endoscopy, biopsy           T           T        0141        8.3175         383.44       874.25      1,002.09
43240       Esoph endoscope w/drain cyst         T           T        0141        8.3175         383.44       874.25      1,002.09
43241       Upper GI endoscopy with tube         T           T        0141        8.3175         383.44       874.25      1,002.09
43242       Uppr gi endoscopy w/us fn bx         T           T        0141        8.3175         383.44       874.25      1,002.09
43243       Upper gi endoscopy & inject          T           T        0141        8.3175         383.44       874.25      1,002.09
43244       Upper GI endoscopy/ligation          T           T        0141        8.3175         383.44       874.25      1,002.09
43245       Uppr gi scope dilate strictr         T           T        0141        8.3175         383.44       874.25      1,002.09
43246       Place gastrostomy tube               T           T        0141        8.3175         383.44       874.25      1,002.09
43247       Operative upper GI endoscopy         T           T        0141        8.3175         383.44       874.25      1,002.09
43248       Uppr gi endoscopy/guide wire         T           T        0141        8.3175         383.44       874.25      1,002.09
43249       Esoph endoscopy, dilation            T           T        0141        8.3175         383.44       874.25      1,002.09
43250       Upper GI endoscopy/tumor             T           T        0141        8.3175         383.44       874.25      1,002.09
43251       Operative upper GI endoscopy         T           T        0141        8.3175         383.44       874.25      1,002.09
43255       Operative upper GI endoscopy         T           T        0141        8.3175         383.44       874.25      1,002.09
43256       Uppr gi endoscopy w/stent            T           T        0384       22.9475        1,057.88     2,412.01     2,764.71
43257       Uppr gi scope w/thrml txmnt          T           T        0422       25.7552        1,187.31     2,707.13     3,102.99
43258       Operative upper GI endoscopy         T           T        0141        8.3175         383.44       874.25      1,002.09
43259       Endoscopic ultrasound exam           T           T        0141        8.3175         383.44       874.25      1,002.09
43260       Endo cholangiopancreatograph         T           T        0151       19.8381         914.54      2,085.18     2,390.09
43261       Endo cholangiopancreatograph         T           T        0151       19.8381         914.54      2,085.18     2,390.09
43262       Endo cholangiopancreatograph         T           T        0151       19.8381         914.54      2,085.18     2,390.09
43263       Endo cholangiopancreatograph         T           T        0151       19.8381         914.54      2,085.18     2,390.09
43264       Endo cholangiopancreatograph         T           T        0151       19.8381         914.54      2,085.18     2,390.09
43265       Endo cholangiopancreatograph         T           T        0151       19.8381         914.54      2,085.18     2,390.09
43267       Endo cholangiopancreatograph         T           T        0151       19.8381         914.54      2,085.18     2,390.09
43268       Endo cholangiopancreatograph         T           T        0384       22.9475        1,057.88     2,412.01     2,764.71
43269       Endo cholangiopancreatograph         T           T        0384       22.9475        1,057.88     2,412.01     2,764.71
43271       Endo cholangiopancreatograph         T           T        0151       19.8381         914.54      2,085.18     2,390.09
43272       Endo cholangiopancreatograph         T           T        0151       19.8381         914.54      2,085.18     2,390.09
43280       Laparoscopy, fundoplasty             T           T        0132       70.5066        3,250.35     7,410.95     8,494.64
43289       Laparoscope proc, esoph              T           1        0000        0.0000           0.00        0.00         0.00
43300       Repair of esophagus                  C           C        0000        0.0000           0.00        0.00         0.00
43305       Repair esophagus and fistula         C           C        0000        0.0000           0.00        0.00         0.00
43310       Repair of esophagus                  C           C        0000        0.0000           0.00        0.00         0.00
43312       Repair esophagus and fistula         C           C        0000        0.0000           0.00        0.00         0.00
43313       Esophagoplasty congenital            C           C        0000        0.0000           0.00        0.00         0.00
43314       Tracheo-esophagoplasty cong          C           C        0000        0.0000           0.00        0.00         0.00
43320       Fuse esophagus & stomach             C           C        0000        0.0000           0.00        0.00         0.00
43324       Revise esophagus & stomach           C           C        0000        0.0000           0.00        0.00         0.00
43325       Revise esophagus & stomach           C           C        0000        0.0000           0.00        0.00         0.00
43326       Revise esophagus & stomach           C           C        0000        0.0000           0.00        0.00         0.00
43330       Repair of esophagus                  C           C        0000        0.0000           0.00        0.00         0.00
43331       Repair of esophagus                  C           C        0000        0.0000           0.00        0.00         0.00
43340       Fuse esophagus & intestine           C           C        0000        0.0000           0.00        0.00         0.00
43341       Fuse esophagus & intestine           C           C        0000        0.0000           0.00        0.00         0.00
43350       Surgical opening, esophagus          C           C        0000        0.0000           0.00        0.00         0.00
43351       Surgical opening, esophagus          C           C        0000        0.0000           0.00        0.00         0.00
43352       Surgical opening, esophagus          C           C        0000        0.0000           0.00        0.00         0.00
43360       Gastrointestinal repair              C           C        0000        0.0000           0.00        0.00         0.00
43361       Gastrointestinal repair              C           C        0000        0.0000           0.00        0.00         0.00
43400       Ligate esophagus veins               C           C        0000        0.0000           0.00        0.00         0.00
43401       Esophagus surgery for veins          C           C        0000        0.0000           0.00        0.00         0.00
43405       Ligate/staple esophagus              C           C        0000        0.0000           0.00        0.00         0.00
43410       Repair esophagus wound               C           C        0000        0.0000           0.00        0.00         0.00


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 33 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
43415       Repair esophagus wound               C           C        0000        0.0000           0.00        0.00         0.00
43420       Repair esophagus opening             C           C        0000        0.0000           0.00        0.00         0.00
43425       Repair esophagus opening             C           C        0000        0.0000           0.00        0.00         0.00
43450       Dilate esophagus                     T           T        0140        5.4566         251.55       573.54       657.41
43453       Dilate esophagus                     T           T        0140        5.4566         251.55       573.54       657.41
43456       Dilate esophagus                     T           T        0140        5.4566         251.55       573.54       657.41
43458       Dilate esophagus                     T           T        0140        5.4566         251.55       573.54       657.41
43460       Pressure treatment esophagus         C           C        0000        0.0000           0.00        0.00         0.00
43496       Free jejunum flap, microvasc         C           C        0000        0.0000           0.00        0.00         0.00
43499       Esophagus surgery procedure          T           1        0000        0.0000           0.00        0.00         0.00
43500       Surgical opening of stomach          C           C        0000        0.0000           0.00        0.00         0.00
43501       Surgical repair of stomach           C           C        0000        0.0000           0.00        0.00         0.00
43502       Surgical repair of stomach           C           C        0000        0.0000           0.00        0.00         0.00
43510       Surgical opening of stomach          T           T        0141        8.3175         383.44       874.25      1,002.09
43520       Incision of pyloric muscle           C           C        0000        0.0000           0.00        0.00         0.00
43600       Biopsy of stomach                    T           T        0141        8.3175         383.44       874.25      1,002.09
43605       Biopsy of stomach                    C           C        0000        0.0000           0.00        0.00         0.00
43610       Excision of stomach lesion           C           C        0000        0.0000           0.00        0.00         0.00
43611       Excision of stomach lesion           C           C        0000        0.0000           0.00        0.00         0.00
43620       Removal of stomach                   C           C        0000        0.0000           0.00        0.00         0.00
43621       Removal of stomach                   C           C        0000        0.0000           0.00        0.00         0.00
43622       Removal of stomach                   C           C        0000        0.0000           0.00        0.00         0.00
43631       Removal of stomach, partial          C           C        0000        0.0000           0.00        0.00         0.00
43632       Removal of stomach, partial          C           C        0000        0.0000           0.00        0.00         0.00
43633       Removal of stomach, partial          C           C        0000        0.0000           0.00        0.00         0.00
43634       Removal of stomach, partial          C           C        0000        0.0000           0.00        0.00         0.00
43635       Removal of stomach, partial          C           C        0000        0.0000           0.00        0.00         0.00
43640       Vagotomy & pylorus repair            C           C        0000        0.0000           0.00        0.00         0.00
43641       Vagotomy & pylorus repair            C           C        0000        0.0000           0.00        0.00         0.00
43644       Lap gastric bypass/roux-en-y         C           C        0000        0.0000           0.00        0.00         0.00
43645       Lap gastr bypass incl smll i         C           C        0000        0.0000           0.00        0.00         0.00
43647       Lap impl electrode, antrum           T           T        0130       32.1241        1,480.92     3,376.56     3,870.31
43648       Lap revise/remv eltrd antrum         T           T        0130       32.1241        1,480.92     3,376.56     3,870.31
43651       Laparoscopy, vagus nerve             T           T        0132       70.5066        3,250.35     7,410.95     8,494.64
43652       Laparoscopy, vagus nerve             T           T        0132       70.5066        3,250.35     7,410.95     8,494.64
43653       Laparoscopy, gastrostomy             T           T        0131       43.5488        2,007.60     4,577.41     5,246.76
43659       Laparoscope proc, stom               T           1        0000        0.0000           0.00        0.00         0.00
43750       Place gastrostomy tube               T           T        0141        8.3175         383.44       874.25      1,002.09
43752       Nasal/orogastric w/stent             X           X        0272        1.2908          59.51       135.68       155.52
43760       Change gastrostomy tube              T           T        0121        2.3587         108.74       247.92       284.18
43761       Reposition gastrostomy tube          T           T        0122        7.4800         344.83       786.22       901.19
43770       Lap, place gastr adjust band         C           C        0000        0.0000           0.00        0.00         0.00
43771       Lap, revise adjust gast band         C           C        0000        0.0000           0.00        0.00         0.00
43772       Lap, remove adjust gast band         C           C        0000        0.0000           0.00        0.00         0.00
43773       Lap, change adjust gast band         C           C        0000        0.0000           0.00        0.00         0.00
43774       Lap remov adj gast band/port         C           C        0000        0.0000           0.00        0.00         0.00
43800       Reconstruction of pylorus            C           C        0000        0.0000           0.00        0.00         0.00
43810       Fusion of stomach and bowel          C           C        0000        0.0000           0.00        0.00         0.00
43820       Fusion of stomach and bowel          C           C        0000        0.0000           0.00        0.00         0.00
43825       Fusion of stomach and bowel          C           C        0000        0.0000           0.00        0.00         0.00
43830       Place gastrostomy tube               T           T        0422       25.7552        1,187.31     2,707.13     3,102.99
43831       Place gastrostomy tube               T           T        0141        8.3175         383.44       874.25      1,002.09
43832       Place gastrostomy tube               C           C        0000        0.0000           0.00        0.00         0.00
43840       Repair of stomach lesion             C           C        0000        0.0000           0.00        0.00         0.00
43842       V-band gastroplasty                  E           C        0000        0.0000           0.00        0.00         0.00
43843       Gastroplasty w/o v-band              C           C        0000        0.0000           0.00        0.00         0.00
43845       Gastroplasty duodenal switch         C           C        0000        0.0000           0.00        0.00         0.00
43846       Gastric bypass for obesity           C           C        0000        0.0000           0.00        0.00         0.00
43847       Gastric bypass incl small i          C           C        0000        0.0000           0.00        0.00         0.00
43848       Revision gastroplasty                C           C        0000        0.0000           0.00        0.00         0.00
43850       Revise stomach-bowel fusion          C           C        0000        0.0000           0.00        0.00         0.00
43855       Revise stomach-bowel fusion          C           C        0000        0.0000           0.00        0.00         0.00
43860       Revise stomach-bowel fusion          C           C        0000        0.0000           0.00        0.00         0.00
43865       Revise stomach-bowel fusion          C           C        0000        0.0000           0.00        0.00         0.00
43870       Repair stomach opening               T           T        0141        8.3175         383.44       874.25      1,002.09
43880       Repair stomach-bowel fistula         C           C        0000        0.0000           0.00        0.00         0.00
43881       Impl/redo electrd, antrum            C           C        0000        0.0000           0.00        0.00         0.00
43882       Revise/remove electrd antrum         C           C        0000        0.0000           0.00        0.00         0.00
43886       Revise gastric port, open            T           T        0025        5.2594         242.46       552.82       633.65
43887       Remove gastric port, open            T           T        0025        5.2594         242.46       552.82       633.65
43888       Change gastric port, open            T           T        0686       14.0346         647.00      1,475.18     1,690.89
43999       Stomach surgery procedure            T           1        0000        0.0000           0.00        0.00         0.00
44005       Freeing of bowel adhesion            C           C        0000        0.0000           0.00        0.00         0.00
44010       Incision of small bowel              C           C        0000        0.0000           0.00        0.00         0.00
44015       Insert needle cath bowel             C           C        0000        0.0000           0.00        0.00         0.00
44020       Explore small intestine              C           C        0000        0.0000           0.00        0.00         0.00
44021       Decompress small bowel               C           C        0000        0.0000           0.00        0.00         0.00
44025       Incision of large bowel              C           C        0000        0.0000           0.00        0.00         0.00
44050       Reduce bowel obstruction             C           C        0000        0.0000           0.00        0.00         0.00
44055       Correct malrotation of bowel         C           C        0000        0.0000           0.00        0.00         0.00
44100       Biopsy of bowel                      T           T        0141        8.3175         383.44       874.25      1,002.09
44110       Excise intestine lesion(s)           C           C        0000        0.0000           0.00        0.00         0.00
44111       Excision of bowel lesion(s)          C           C        0000        0.0000           0.00        0.00         0.00
44120       Removal of small intestine           C           C        0000        0.0000           0.00        0.00         0.00
44121       Removal of small intestine           C           C        0000        0.0000           0.00        0.00         0.00
44125       Removal of small intestine           C           C        0000        0.0000           0.00        0.00         0.00
44126       Enterectomy w/o taper, cong          C           C        0000        0.0000           0.00        0.00         0.00
44127       Enterectomy w/taper, cong            C           C        0000        0.0000           0.00        0.00         0.00
44128       Enterectomy cong, add-on             C           C        0000        0.0000           0.00        0.00         0.00
44130       Bowel to bowel fusion                C           C        0000        0.0000           0.00        0.00         0.00
44132       Enterectomy, cadaver donor           C           1        0000        0.0000           0.00        0.00         0.00
44133       Enterectomy, live donor              C           1        0000        0.0000           0.00        0.00         0.00
44135       Intestine transplnt, cadaver         C           1        0000        0.0000           0.00        0.00         0.00
44136       Intestine transplant, live           C           1        0000        0.0000           0.00        0.00         0.00
44137       Remove intestinal allograft          C           1        0000        0.0000           0.00        0.00         0.00
44139       Mobilization of colon                C           C        0000        0.0000           0.00        0.00         0.00
44140       Partial removal of colon             C           C        0000        0.0000           0.00        0.00         0.00
44141       Partial removal of colon             C           C        0000        0.0000           0.00        0.00         0.00
44143       Partial removal of colon             C           C        0000        0.0000           0.00        0.00         0.00
44144       Partial removal of colon             C           C        0000        0.0000           0.00        0.00         0.00
44145       Partial removal of colon             C           C        0000        0.0000           0.00        0.00         0.00
44146       Partial removal of colon             C           C        0000        0.0000           0.00        0.00         0.00
44147       Partial removal of colon             C           C        0000        0.0000           0.00        0.00         0.00
44150       Removal of colon                     C           C        0000        0.0000           0.00        0.00         0.00
44151       Removal of colon/ileostomy           C           C        0000        0.0000           0.00        0.00         0.00
44155       Removal of colon/ileostomy           C           C        0000        0.0000           0.00        0.00         0.00


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 34 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
44156       Removal of colon/ileostomy           C           C        0000        0.0000          0.00         0.00         0.00
44157       Colectomy w/ileoanal anast           C           C        0000        0.0000          0.00         0.00         0.00
44158       Colectomy w/neo-rectum pouch         C           C        0000        0.0000          0.00         0.00         0.00
44160       Removal of colon                     C           C        0000        0.0000          0.00         0.00         0.00
44180       Lap, enterolysis                     T           T        0131       43.5488        2,007.60     4,577.41     5,246.76
44186       Lap, jejunostomy                     T           T        0131       43.5488        2,007.60     4,577.41     5,246.76
44187       Lap, ileo/jejuno-stomy               C           C        0000        0.0000          0.00         0.00         0.00
44188       Lap, colostomy                       C           C        0000        0.0000          0.00         0.00         0.00
44202       Lap resect s/intestine singl         C           C        0000        0.0000          0.00         0.00         0.00
44203       Lap resect s/intestine, addl         C           C        0000        0.0000          0.00         0.00         0.00
44204       Laparo partial colectomy             C           C        0000        0.0000          0.00         0.00         0.00
44205       Lap colectomy part w/ileum           C           C        0000        0.0000          0.00         0.00         0.00
44206       Lap part colectomy w/stoma           T           T        0132       70.5066        3,250.35     7,410.95     8,494.64
44207       L colectomy/coloproctostomy          T           T        0132       70.5066        3,250.35     7,410.95     8,494.64
44208       L colectomy/coloproctostomy          T           T        0132       70.5066        3,250.35     7,410.95     8,494.64
44210       Laparo total proctocolectomy         C           C        0000        0.0000          0.00         0.00         0.00
44211       Laparo total proctocolectomy         C           C        0000        0.0000          0.00         0.00         0.00
44212       Laparo total proctocolectomy         C           C        0000        0.0000          0.00         0.00         0.00
44213       Lap, mobil splenic fl add-on         T           T        0130       32.1241        1,480.92     3,376.56     3,870.31
44227       Lap, close enterostomy               C           C        0000        0.0000          0.00         0.00         0.00
44238       Laparoscope proc, intestine          T           1        0000        0.0000          0.00         0.00         0.00
44300       Open bowel to skin                   C           C        0000        0.0000          0.00         0.00         0.00
44310       Ileostomy/jejunostomy                C           C        0000        0.0000          0.00         0.00         0.00
44312       Revision of ileostomy                T           T        0027       21.4302         987.93      2,252.53     2,581.91
44314       Revision of ileostomy                C           C        0000        0.0000          0.00         0.00         0.00
44316       Devise bowel pouch                   C           C        0000        0.0000          0.00         0.00         0.00
44320       Colostomy                            C           C        0000        0.0000          0.00         0.00         0.00
44322       Colostomy with biopsies              C           C        0000        0.0000          0.00         0.00         0.00
44340       Revision of colostomy                T           T        0027       21.4302         987.93      2,252.53     2,581.91
44345       Revision of colostomy                C           C        0000        0.0000          0.00         0.00         0.00
44346       Revision of colostomy                C           C        0000        0.0000          0.00         0.00         0.00
44360       Small bowel endoscopy                T           T        0142        9.4946         437.70       997.98      1,143.91
44361       Small bowel endoscopy/biopsy         T           T        0142        9.4946         437.70       997.98      1,143.91
44363       Small bowel endoscopy                T           T        0142        9.4946         437.70       997.98      1,143.91
44364       Small bowel endoscopy                T           T        0142        9.4946         437.70       997.98      1,143.91
44365       Small bowel endoscopy                T           T        0142        9.4946         437.70       997.98      1,143.91
44366       Small bowel endoscopy                T           T        0142        9.4946         437.70       997.98      1,143.91
44369       Small bowel endoscopy                T           T        0142        9.4946         437.70       997.98      1,143.91
44370       Small bowel endoscopy/stent          T           T        0384       22.9475        1,057.88     2,412.01     2,764.71
44372       Small bowel endoscopy                T           T        0142        9.4946         437.70       997.98      1,143.91
44373       Small bowel endoscopy                T           T        0142        9.4946         437.70       997.98      1,143.91
44376       Small bowel endoscopy                T           T        0142        9.4946         437.70       997.98      1,143.91
44377       Small bowel endoscopy/biopsy         T           T        0142        9.4946         437.70       997.98      1,143.91
44378       Small bowel endoscopy                T           T        0142        9.4946         437.70       997.98      1,143.91
44379       S bowel endoscope w/stent            T           T        0384       22.9475        1,057.88     2,412.01     2,764.71
44380       Small bowel endoscopy                T           T        0142        9.4946         437.70       997.98      1,143.91
44382       Small bowel endoscopy                T           T        0142        9.4946         437.70       997.98      1,143.91
44383       Ileoscopy w/stent                    T           T        0384       22.9475        1,057.88     2,412.01     2,764.71
44385       Endoscopy of bowel pouch             T           T        0143        8.7686         404.23       921.67      1,056.44
44386       Endoscopy, bowel pouch/biop          T           T        0143        8.7686         404.23       921.67      1,056.44
44388       Colonoscopy                          T           T        0143        8.7686         404.23       921.67      1,056.44
44389       Colonoscopy with biopsy              T           T        0143        8.7686         404.23       921.67      1,056.44
44390       Colonoscopy for foreign body         T           T        0143        8.7686         404.23       921.67      1,056.44
44391       Colonoscopy for bleeding             T           T        0143        8.7686         404.23       921.67      1,056.44
44392       Colonoscopy & polypectomy            T           T        0143        8.7686         404.23       921.67      1,056.44
44393       Colonoscopy, lesion removal          T           T        0143        8.7686         404.23       921.67      1,056.44
44394       Colonoscopy w/snare                  T           T        0143        8.7686         404.23       921.67      1,056.44
44397       Colonoscopy w/stent                  T           T        0384       22.9475        1,057.88     2,412.01     2,764.71
44500       Intro, gastrointestinal tube         T           T        0121        2.3587         108.74       247.92       284.18
44602       Suture, small intestine              C           C        0000        0.0000          0.00         0.00         0.00
44603       Suture, small intestine              C           C        0000        0.0000          0.00         0.00         0.00
44604       Suture, large intestine              C           C        0000        0.0000          0.00         0.00         0.00
44605       Repair of bowel lesion               C           C        0000        0.0000          0.00         0.00         0.00
44615       Intestinal stricturoplasty           C           C        0000        0.0000          0.00         0.00         0.00
44620       Repair bowel opening                 C           C        0000        0.0000          0.00         0.00         0.00
44625       Repair bowel opening                 C           C        0000        0.0000          0.00         0.00         0.00
44626       Repair bowel opening                 C           C        0000        0.0000          0.00         0.00         0.00
44640       Repair bowel-skin fistula            C           C        0000        0.0000          0.00         0.00         0.00
44650       Repair bowel fistula                 C           C        0000        0.0000          0.00         0.00         0.00
44660       Repair bowel-bladder fistula         C           C        0000        0.0000          0.00         0.00         0.00
44661       Repair bowel-bladder fistula         C           C        0000        0.0000          0.00         0.00         0.00
44680       Surgical revision, intestine         C           C        0000        0.0000          0.00         0.00         0.00
44700       Suspend bowel w/prosthesis           C           C        0000        0.0000          0.00         0.00         0.00
44701       Intraop colon lavage add-on          N           N        0000        0.0000          0.00         0.00         0.00
44715       Prepare donor intestine              C           1        0000        0.0000          0.00         0.00         0.00
44720       Prep donor intestine/venous          C           1        0000        0.0000          0.00         0.00         0.00
44721       Prep donor intestine/artery          C           1        0000        0.0000          0.00         0.00         0.00
44799       Unlisted procedure intestine         T           1        0000        0.0000          0.00         0.00         0.00
44800       Excision of bowel pouch              C           C        0000        0.0000          0.00         0.00         0.00
44820       Excision of mesentery lesion         C           C        0000        0.0000          0.00         0.00         0.00
44850       Repair of mesentery                  C           C        0000        0.0000          0.00         0.00         0.00
44899       Bowel surgery procedure              C           1        0000        0.0000          0.00         0.00         0.00
44900       Drain app abscess, open              C           C        0000        0.0000          0.00         0.00         0.00
44901       Drain app abscess, percut            T           T        0037       10.2655         473.24      1,079.01     1,236.79
44950       Appendectomy                         C           C        0000        0.0000          0.00         0.00         0.00
44955       Appendectomy add-on                  C           C        0000        0.0000          0.00         0.00         0.00
44960       Appendectomy                         C           C        0000        0.0000          0.00         0.00         0.00
44970       Laparoscopy, appendectomy            T           T        0131       43.5488        2,007.60     4,577.41     5,246.76
44979       Laparoscope proc, app                T           1        0000        0.0000          0.00         0.00         0.00
45000       Drainage of pelvic abscess           T           T        0148        5.0770         234.05       533.64       611.68
45005       Drainage of rectal abscess           T           T        0155       12.7389         587.26      1,338.99     1,534.78
45020       Drainage of rectal abscess           T           T        0155       12.7389         587.26      1,338.99     1,534.78
45100       Biopsy of rectum                     T           T        0149       22.2682        1,026.56     2,340.61     2,682.87
45108       Removal of anorectal lesion          T           T        0149       22.2682        1,026.56     2,340.61     2,682.87
45110       Removal of rectum                    C           C        0000        0.0000          0.00         0.00         0.00
45111       Partial removal of rectum            C           C        0000        0.0000          0.00         0.00         0.00
45112       Removal of rectum                    C           C        0000        0.0000          0.00         0.00         0.00
45113       Partial proctectomy                  C           C        0000        0.0000          0.00         0.00         0.00
45114       Partial removal of rectum            C           C        0000        0.0000          0.00         0.00         0.00
45116       Partial removal of rectum            C           C        0000        0.0000          0.00         0.00         0.00
45119       Remove rectum w/reservoir            C           C        0000        0.0000          0.00         0.00         0.00
45120       Removal of rectum                    C           C        0000        0.0000          0.00         0.00         0.00
45121       Removal of rectum and colon          C           C        0000        0.0000          0.00         0.00         0.00
45123       Partial proctectomy                  C           C        0000        0.0000          0.00         0.00         0.00
45126       Pelvic exenteration                  C           C        0000        0.0000          0.00         0.00         0.00
45130       Excision of rectal prolapse          C           C        0000        0.0000          0.00         0.00         0.00


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 35 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
45135       Excision of rectal prolapse          C           C        0000        0.0000           0.00         0.00         0.00
45136       Excise ileoanal reservior            C           C        0000        0.0000           0.00         0.00         0.00
45150       Excision of rectal stricture         T           T        0149       22.2682        1,026.56     2,340.61     2,682.87
45160       Excision of rectal lesion            T           T        0149       22.2682        1,026.56     2,340.61     2,682.87
45170       Excision of rectal lesion            T           T        0149       22.2682        1,026.56     2,340.61     2,682.87
45190       Destruction, rectal tumor            T           T        0149       22.2682        1,026.56     2,340.61     2,682.87
45300       Proctosigmoidoscopy dx               T           T        0146        4.8683         224.43       511.71       586.53
45303       Proctosigmoidoscopy dilate           T           T        0147        8.5477         394.05       898.45      1,029.83
45305       Proctosigmoidoscopy w/bx             T           T        0147        8.5477         394.05       898.45      1,029.83
45307       Proctosigmoidoscopy fb               T           T        0428       20.6375         951.39      2,169.21     2,486.41
45308       Proctosigmoidoscopy removal          T           T        0147        8.5477         394.05       898.45      1,029.83
45309       Proctosigmoidoscopy removal          T           T        0147        8.5477         394.05       898.45      1,029.83
45315       Proctosigmoidoscopy removal          T           T        0147        8.5477         394.05       898.45      1,029.83
45317       Proctosigmoidoscopy bleed            T           T        0147        8.5477         394.05       898.45      1,029.83
45320       Proctosigmoidoscopy ablate           T           T        0428       20.6375         951.39      2,169.21     2,486.41
45321       Proctosigmoidoscopy volvul           T           T        0428       20.6375         951.39      2,169.21     2,486.41
45327       Proctosigmoidoscopy w/stent          T           T        0384       22.9475        1,057.88     2,412.01     2,764.71
45330       Diagnostic sigmoidoscopy             T           T        0146        4.8683         224.43       511.71       586.53
45331       Sigmoidoscopy and biopsy             T           T        0146        4.8683         224.43       511.71       586.53
45332       Sigmoidoscopy w/fb removal           T           T        0146        4.8683         224.43       511.71       586.53
45333       Sigmoidoscopy & polypectomy          T           T        0147        8.5477         394.05       898.45      1,029.83
45334       Sigmoidoscopy for bleeding           T           T        0147        8.5477         394.05       898.45      1,029.83
45335       Sigmoidoscopy w/submuc inj           T           T        0146        4.8683         224.43       511.71       586.53
45337       Sigmoidoscopy & decompress           T           T        0146        4.8683         224.43       511.71       586.53
45338       Sigmoidoscopy w/tumr remove          T           T        0147        8.5477         394.05       898.45      1,029.83
45339       Sigmoidoscopy w/ablate tumr          T           T        0147        8.5477         394.05       898.45      1,029.83
45340       Sig w/balloon dilation               T           T        0147        8.5477         394.05       898.45      1,029.83
45341       Sigmoidoscopy w/ultrasound           T           T        0147        8.5477         394.05       898.45      1,029.83
45342       Sigmoidoscopy w/us guide bx          T           T        0147        8.5477         394.05       898.45      1,029.83
45345       Sigmoidoscopy w/stent                T           T        0384       22.9475        1,057.88     2,412.01     2,764.71
45355       Surgical colonoscopy                 T           T        0143        8.7686         404.23       921.67      1,056.44
45378       Diagnostic colonoscopy               T           T        0143        8.7686         404.23       921.67      1,056.44
45379       Colonoscopy w/fb removal             T           T        0143        8.7686         404.23       921.67      1,056.44
45380       Colonoscopy and biopsy               T           T        0143        8.7686         404.23       921.67      1,056.44
45381       Colonoscopy, submucous inj           T           T        0143        8.7686         404.23       921.67      1,056.44
45382       Colonoscopy/control bleeding         T           T        0143        8.7686         404.23       921.67      1,056.44
45383       Lesion removal colonoscopy           T           T        0143        8.7686         404.23       921.67      1,056.44
45384       Lesion remove colonoscopy            T           T        0143        8.7686         404.23       921.67      1,056.44
45385       Lesion removal colonoscopy           T           T        0143        8.7686         404.23       921.67      1,056.44
45386       Colonoscopy dilate stricture         T           T        0143        8.7686         404.23       921.67      1,056.44
45387       Colonoscopy w/stent                  T           T        0384       22.9475        1,057.88     2,412.01     2,764.71
45391       Colonoscopy w/endoscope us           T           T        0143        8.7686         404.23       921.67      1,056.44
45392       Colonoscopy w/endoscopic fnb         T           T        0143        8.7686         404.23       921.67      1,056.44
45395       Lap, removal of rectum               C           C        0000        0.0000           0.00         0.00         0.00
45397       Lap, remove rectum w/pouch           C           C        0000        0.0000           0.00         0.00         0.00
45400       Laparoscopic proctopexy              C           C        0000        0.0000           0.00         0.00         0.00
45402       Lap proctopexy w/sig resect          C           C        0000        0.0000           0.00         0.00         0.00
45499       Laparoscope proc, rectum             T           1        0000        0.0000           0.00         0.00         0.00
45500       Repair of rectum                     T           T        0149       22.2682        1,026.56     2,340.61     2,682.87
45505       Repair of rectum                     T           T        0150       29.6189        1,365.43     3,113.24     3,568.49
45520       Treatment of rectal prolapse         T           T        0098        1.0798          49.78       113.50       130.09
45540       Correct rectal prolapse              C           C        0000        0.0000           0.00         0.00         0.00
45541       Correct rectal prolapse              T           T        0150       29.6189        1,365.43     3,113.24     3,568.49
45550       Repair rectum/remove sigmoid         C           C        0000        0.0000           0.00         0.00         0.00
45560       Repair of rectocele                  T           T        0150       29.6189        1,365.43     3,113.24     3,568.49
45562       Exploration/repair of rectum         C           C        0000        0.0000           0.00         0.00         0.00
45563       Exploration/repair of rectum         C           C        0000        0.0000           0.00         0.00         0.00
45800       Repair rect/bladder fistula          C           C        0000        0.0000           0.00         0.00         0.00
45805       Repair fistula w/colostomy           C           C        0000        0.0000           0.00         0.00         0.00
45820       Repair rectourethral fistula         C           C        0000        0.0000           0.00         0.00         0.00
45825       Repair fistula w/colostomy           C           C        0000        0.0000           0.00         0.00         0.00
45900       Reduction of rectal prolapse         T           T        0148        5.0770         234.05       533.64       611.68
45905       Dilation of anal sphincter           T           T        0149       22.2682        1,026.56     2,340.61     2,682.87
45910       Dilation of rectal narrowing         T           T        0149       22.2682        1,026.56     2,340.61     2,682.87
45915       Remove rectal obstruction            T           T        0148        5.0770         234.05       533.64       611.68
45990       Surg dx exam, anorectal              T           T        0148        5.0770         234.05       533.64       611.68
45999       Rectum surgery procedure             T           1        0000        0.0000           0.00         0.00         0.00
46020       Placement of seton                   T           T        0149       22.2682        1,026.56     2,340.61     2,682.87
46030       Removal of rectal marker             T           T        0148        5.0770         234.05       533.64       611.68
46040       Incision of rectal abscess           T           T        0149       22.2682        1,026.56     2,340.61     2,682.87
46045       Incision of rectal abscess           T           T        0149       22.2682        1,026.56     2,340.61     2,682.87
46050       Incision of anal abscess             T           T        0148        5.0770         234.05       533.64       611.68
46060       Incision of rectal abscess           T           T        0149       22.2682        1,026.56     2,340.61     2,682.87
46070       Incision of anal septum              T           T        0155       12.7389         587.26      1,338.99     1,534.78
46080       Incision of anal sphincter           T           T        0149       22.2682        1,026.56     2,340.61     2,682.87
46083       Incise external hemorrhoid           T           T        0164        2.1393          98.62       224.86       257.74
46200       Removal of anal fissure              T           T        0149       22.2682        1,026.56     2,340.61     2,682.87
46210       Removal of anal crypt                T           T        0149       22.2682        1,026.56     2,340.61     2,682.87
46211       Removal of anal crypts               T           T        0149       22.2682        1,026.56     2,340.61     2,682.87
46220       Removal of anal tag                  T           T        0149       22.2682        1,026.56     2,340.61     2,682.87
46221       Ligation of hemorrhoid(s)            T           T        0148        5.0770         234.05       533.64       611.68
46230       Removal of anal tags                 T           T        0149       22.2682        1,026.56     2,340.61     2,682.87
46250       Hemorrhoidectomy                     T           T        0149       22.2682        1,026.56     2,340.61     2,682.87
46255       Hemorrhoidectomy                     T           T        0149       22.2682        1,026.56     2,340.61     2,682.87
46257       Remove hemorrhoids & fissure         T           T        0149       22.2682        1,026.56     2,340.61     2,682.87
46258       Remove hemorrhoids & fistula         T           T        0149       22.2682        1,026.56     2,340.61     2,682.87
46260       Hemorrhoidectomy                     T           T        0149       22.2682        1,026.56     2,340.61     2,682.87
46261       Remove hemorrhoids & fissure         T           T        0149       22.2682        1,026.56     2,340.61     2,682.87
46262       Remove hemorrhoids & fistula         T           T        0149       22.2682        1,026.56     2,340.61     2,682.87
46270       Removal of anal fistula              T           T        0149       22.2682        1,026.56     2,340.61     2,682.87
46275       Removal of anal fistula              T           T        0149       22.2682        1,026.56     2,340.61     2,682.87
46280       Removal of anal fistula              T           T        0149       22.2682        1,026.56     2,340.61     2,682.87
46285       Removal of anal fistula              T           T        0149       22.2682        1,026.56     2,340.61     2,682.87
46288       Repair anal fistula                  T           T        0149       22.2682        1,026.56     2,340.61     2,682.87
46320       Removal of hemorrhoid clot           T           T        0155       12.7389         587.26      1,338.99     1,534.78
46500       Injection into hemorrhoid(s)         T           T        0155       12.7389         587.26      1,338.99     1,534.78
46505       Chemodenervation anal musc           T           T        0148        5.0770         234.05       533.64       611.68
46600       Diagnostic anoscopy                  X           X        0340        0.6102          28.13        64.14        73.52
46604       Anoscopy and dilation                T           T        0147        8.5477         394.05       898.45      1,029.83
46606       Anoscopy and biopsy                  T           T        0146        4.8683         224.43       511.71       586.53
46608       Anoscopy, remove for body            T           T        0147        8.5477         394.05       898.45      1,029.83
46610       Anoscopy, remove lesion              T           T        0428       20.6375         951.39      2,169.21     2,486.41
46611       Anoscopy                             T           T        0147        8.5477         394.05       898.45      1,029.83
46612       Anoscopy, remove lesions             T           T        0428       20.6375         951.39      2,169.21     2,486.41
46614       Anoscopy, control bleeding           T           T        0146        4.8683         224.43       511.71       586.53
46615       Anoscopy                             T           T        0428       20.6375         951.39      2,169.21     2,486.41


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 36 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
46700       Repair of anal stricture             T           T        0149       22.2682        1,026.56     2,340.61     2,682.87
46705       Repair of anal stricture             C           C        0000        0.0000           0.00        0.00         0.00
46706       Repr of anal fistula w/glue          T           T        0150       29.6189        1,365.43     3,113.24     3,568.49
46710       Repr per/vag pouch sngl proc         C           C        0000        0.0000           0.00        0.00         0.00
46712       Repr per/vag pouch dbl proc          C           C        0000        0.0000           0.00        0.00         0.00
46715       Rep perf anoper fistu                C           C        0000        0.0000           0.00        0.00         0.00
46716       Rep perf anoper/vestib fistu         C           C        0000        0.0000           0.00        0.00         0.00
46730       Construction of absent anus          C           C        0000        0.0000           0.00        0.00         0.00
46735       Construction of absent anus          C           C        0000        0.0000           0.00        0.00         0.00
46740       Construction of absent anus          C           C        0000        0.0000           0.00        0.00         0.00
46742       Repair of imperforated anus          C           C        0000        0.0000           0.00        0.00         0.00
46744       Repair of cloacal anomaly            C           C        0000        0.0000           0.00        0.00         0.00
46746       Repair of cloacal anomaly            C           C        0000        0.0000           0.00        0.00         0.00
46748       Repair of cloacal anomaly            C           C        0000        0.0000           0.00        0.00         0.00
46750       Repair of anal sphincter             T           T        0171       37.8991        1,747.15     3,983.57     4,566.08
46751       Repair of anal sphincter             C           C        0000        0.0000           0.00        0.00         0.00
46753       Reconstruction of anus               T           T        0149       22.2682        1,026.56     2,340.61     2,682.87
46754       Removal of suture from anus          T           T        0149       22.2682        1,026.56     2,340.61     2,682.87
46760       Repair of anal sphincter             T           T        0171       37.8991        1,747.15     3,983.57     4,566.08
46761       Repair of anal sphincter             T           T        0171       37.8991        1,747.15     3,983.57     4,566.08
46762       Implant artificial sphincter         T           T        0171       37.8991        1,747.15     3,983.57     4,566.08
46900       Destruction, anal lesion(s)          T           T        0016        2.6749         123.31       281.16       322.27
46910       Destruction, anal lesion(s)          T           T        0017       17.4423         804.09      1,833.36     2,101.45
46916       Cryosurgery, anal lesion(s)          T           T        0013        1.0918          50.33       114.76       131.54
46917       Laser surgery, anal lesions          T           T        0695       20.4276         941.71      2,147.15     2,461.12
46922       Excision of anal lesion(s)           T           T        0695       20.4276         941.71      2,147.15     2,461.12
46924       Destruction, anal lesion(s)          T           T        0695       20.4276         941.71      2,147.15     2,461.12
46934       Destruction of hemorrhoids           T           T        0155       12.7389         587.26      1,338.99     1,534.78
46935       Destruction of hemorrhoids           T           T        0155       12.7389         587.26      1,338.99     1,534.78
46936       Destruction of hemorrhoids           T           T        0149       22.2682        1,026.56     2,340.61     2,682.87
46937       Cryotherapy of rectal lesion         T           T        0149       22.2682        1,026.56     2,340.61     2,682.87
46938       Cryotherapy of rectal lesion         T           T        0150       29.6189        1,365.43     3,113.24     3,568.49
46940       Treatment of anal fissure            T           T        0149       22.2682        1,026.56     2,340.61     2,682.87
46942       Treatment of anal fissure            T           T        0148        5.0770         234.05       533.64       611.68
46945       Ligation of hemorrhoids              T           T        0155       12.7389         587.26      1,338.99     1,534.78
46946       Ligation of hemorrhoids              T           T        0155       12.7389         587.26      1,338.99     1,534.78
46947       Hemorrhoidopexy by stapling          T           T        0150       29.6189        1,365.43     3,113.24     3,568.49
46999       Anus surgery procedure               T           1        0000        0.0000           0.00        0.00         0.00
47000       Needle biopsy of liver               T           T        0685        6.1384         282.98       645.21       739.55
47001       Needle biopsy, liver add-on          N           N        0000        0.0000           0.00        0.00         0.00
47010       Open drainage, liver lesion          C           C        0000        0.0000           0.00        0.00         0.00
47011       Percut drain, liver lesion           T           T        0037       10.2655         473.24      1,079.01     1,236.79
47015       Inject/aspirate liver cyst           C           C        0000        0.0000           0.00        0.00         0.00
47100       Wedge biopsy of liver                C           C        0000        0.0000           0.00        0.00         0.00
47120       Partial removal of liver             C           C        0000        0.0000           0.00        0.00         0.00
47122       Extensive removal of liver           C           C        0000        0.0000           0.00        0.00         0.00
47125       Partial removal of liver             C           C        0000        0.0000           0.00        0.00         0.00
47130       Partial removal of liver             C           C        0000        0.0000           0.00        0.00         0.00
47133       Removal of donor liver               C           C        0000        0.0000           0.00        0.00         0.00
47135       Transplantation of liver             C           C        0000        0.0000           0.00        0.00         0.00
47136       Transplantation of liver             C           C        0000        0.0000           0.00        0.00         0.00
47140       Partial removal, donor liver         C           C        0000        0.0000           0.00        0.00         0.00
47141       Partial removal, donor liver         C           C        0000        0.0000           0.00        0.00         0.00
47142       Partial removal, donor liver         C           C        0000        0.0000           0.00        0.00         0.00
47143       Prep donor liver, whole              C           C        0000        0.0000           0.00        0.00         0.00
47144       Prep donor liver, 3-segment          C           C        0000        0.0000           0.00        0.00         0.00
47145       Prep donor liver, lobe split         C           C        0000        0.0000           0.00        0.00         0.00
47146       Prep donor liver/venous              C           C        0000        0.0000           0.00        0.00         0.00
47147       Prep donor liver/arterial            C           C        0000        0.0000           0.00        0.00         0.00
47300       Surgery for liver lesion             C           C        0000        0.0000           0.00        0.00         0.00
47350       Repair liver wound                   C           C        0000        0.0000           0.00        0.00         0.00
47360       Repair liver wound                   C           C        0000        0.0000           0.00        0.00         0.00
47361       Repair liver wound                   C           C        0000        0.0000           0.00        0.00         0.00
47362       Repair liver wound                   C           C        0000        0.0000           0.00        0.00         0.00
47370       Laparo ablate liver tumor rf         T           T        0132       70.5066        3,250.35     7,410.95     8,494.64
47371       Laparo ablate liver cryosurg         T           T        0131       43.5488        2,007.60     4,577.41     5,246.76
47379       Laparoscope procedure, liver         T           1        0000        0.0000           0.00        0.00         0.00
47380       Open ablate liver tumor rf           C           C        0000        0.0000           0.00        0.00         0.00
47381       Open ablate liver tumor cryo         C           C        0000        0.0000           0.00        0.00         0.00
47382       Percut ablate liver rf               T           T        0423       37.3604        1,722.31     3,926.95     4,501.18
47399       Liver surgery procedure              T           1        0000        0.0000           0.00        0.00         0.00
47400       Incision of liver duct               C           C        0000        0.0000           0.00        0.00         0.00
47420       Incision of bile duct                C           C        0000        0.0000           0.00        0.00         0.00
47425       Incision of bile duct                C           C        0000        0.0000           0.00        0.00         0.00
47460       Incise bile duct sphincter           C           C        0000        0.0000           0.00        0.00         0.00
47480       Incision of gallbladder              C           C        0000        0.0000           0.00        0.00         0.00
47490       Incision of gallbladder              T           T        0152       20.2682         934.36      2,130.39     2,441.91
47500       Injection for liver x-rays           N           N        0000        0.0000           0.00        0.00         0.00
47505       Injection for liver x-rays           N           N        0000        0.0000           0.00        0.00         0.00
47510       Insert catheter, bile duct           T           T        0152       20.2682         934.36      2,130.39     2,441.91
47511       Insert bile duct drain               T           T        0152       20.2682         934.36      2,130.39     2,441.91
47525       Change bile duct catheter            T           T        0427       11.6575         537.41      1,225.32     1,404.50
47530       Revise/reinsert bile tube            T           T        0427       11.6575         537.41      1,225.32     1,404.50
47550       Bile duct endoscopy add-on           C           C        0000        0.0000           0.00        0.00         0.00
47552       Biliary endoscopy thru skin          T           T        0152       20.2682         934.36      2,130.39     2,441.91
47553       Biliary endoscopy thru skin          T           T        0152       20.2682         934.36      2,130.39     2,441.91
47554       Biliary endoscopy thru skin          T           T        0152       20.2682         934.36      2,130.39     2,441.91
47555       Biliary endoscopy thru skin          T           T        0152       20.2682         934.36      2,130.39     2,441.91
47556       Biliary endoscopy thru skin          T           T        0152       20.2682         934.36      2,130.39     2,441.91
47560       Laparoscopy w/cholangio              T           T        0130       32.1241        1,480.92     3,376.56     3,870.31
47561       Laparo w/cholangio/biopsy            T           T        0130       32.1241        1,480.92     3,376.56     3,870.31
47562       Laparoscopic cholecystectomy         T           T        0131       43.5488        2,007.60     4,577.41     5,246.76
47563       Laparo cholecystectomy/graph         T           T        0131       43.5488        2,007.60     4,577.41     5,246.76
47564       Laparo cholecystectomy/explr         T           T        0131       43.5488        2,007.60     4,577.41     5,246.76
47570       Laparo cholecystoenterostomy         C           C        0000        0.0000           0.00        0.00         0.00
47579       Laparoscope proc, biliary            T           1        0000        0.0000           0.00        0.00         0.00
47600       Removal of gallbladder               C           C        0000        0.0000           0.00        0.00         0.00
47605       Removal of gallbladder               C           C        0000        0.0000           0.00        0.00         0.00
47610       Removal of gallbladder               C           C        0000        0.0000           0.00        0.00         0.00
47612       Removal of gallbladder               C           C        0000        0.0000           0.00        0.00         0.00
47620       Removal of gallbladder               C           C        0000        0.0000           0.00        0.00         0.00
47630       Remove bile duct stone               T           T        0152       20.2682         934.36      2,130.39     2,441.91
47700       Exploration of bile ducts            C           C        0000        0.0000           0.00        0.00         0.00
47701       Bile duct revision                   C           C        0000        0.0000           0.00        0.00         0.00
47711       Excision of bile duct tumor          C           C        0000        0.0000           0.00        0.00         0.00
47712       Excision of bile duct tumor          C           C        0000        0.0000           0.00        0.00         0.00


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 37 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
47715       Excision of bile duct cyst           C           C        0000        0.0000          0.00         0.00         0.00
47719       Fusion of bile duct cyst             C           C        0000        0.0000          0.00         0.00         0.00
47720       Fuse gallbladder & bowel             C           C        0000        0.0000          0.00         0.00         0.00
47721       Fuse upper gi structures             C           C        0000        0.0000          0.00         0.00         0.00
47740       Fuse gallbladder & bowel             C           C        0000        0.0000          0.00         0.00         0.00
47741       Fuse gallbladder & bowel             C           C        0000        0.0000          0.00         0.00         0.00
47760       Fuse bile ducts and bowel            C           C        0000        0.0000          0.00         0.00         0.00
47765       Fuse liver ducts & bowel             C           C        0000        0.0000          0.00         0.00         0.00
47780       Fuse bile ducts and bowel            C           C        0000        0.0000          0.00         0.00         0.00
47785       Fuse bile ducts and bowel            C           C        0000        0.0000          0.00         0.00         0.00
47800       Reconstruction of bile ducts         C           C        0000        0.0000          0.00         0.00         0.00
47801       Placement, bile duct support         C           C        0000        0.0000          0.00         0.00         0.00
47802       Fuse liver duct & intestine          C           C        0000        0.0000          0.00         0.00         0.00
47900       Suture bile duct injury              C           C        0000        0.0000          0.00         0.00         0.00
47999       Bile tract surgery procedure         T           1        0000        0.0000          0.00         0.00         0.00
48000       Drainage of abdomen                  C           C        0000        0.0000          0.00         0.00         0.00
48001       Placement of drain, pancreas         C           C        0000        0.0000          0.00         0.00         0.00
48020       Removal of pancreatic stone          C           C        0000        0.0000          0.00         0.00         0.00
48100       Biopsy of pancreas, open             C           C        0000        0.0000          0.00         0.00         0.00
48102       Needle biopsy, pancreas              T           T        0685        6.1384         282.98       645.21       739.55
48105       Resect/debride pancreas              C           C        0000        0.0000          0.00         0.00         0.00
48120       Removal of pancreas lesion           C           C        0000        0.0000          0.00         0.00         0.00
48140       Partial removal of pancreas          C           C        0000        0.0000          0.00         0.00         0.00
48145       Partial removal of pancreas          C           C        0000        0.0000          0.00         0.00         0.00
48146       Pancreatectomy                       C           C        0000        0.0000          0.00         0.00         0.00
48148       Removal of pancreatic duct           C           C        0000        0.0000          0.00         0.00         0.00
48150       Partial removal of pancreas          C           C        0000        0.0000          0.00         0.00         0.00
48152       Pancreatectomy                       C           C        0000        0.0000          0.00         0.00         0.00
48153       Pancreatectomy                       C           C        0000        0.0000          0.00         0.00         0.00
48154       Pancreatectomy                       C           C        0000        0.0000          0.00         0.00         0.00
48155       Removal of pancreas                  C           C        0000        0.0000          0.00         0.00         0.00
48160       Pancreas removal/transplant          E           3        0000        0.0000          M01          M01          M01
48400       Injection, intraop add-on            C           C        0000        0.0000          0.00         0.00         0.00
48500       Surgery of pancreatic cyst           C           C        0000        0.0000          0.00         0.00         0.00
48510       Drain pancreatic pseudocyst          C           C        0000        0.0000          0.00         0.00         0.00
48511       Drain pancreatic pseudocyst          T           T        0037       10.2655         473.24      1,079.01     1,236.79
48520       Fuse pancreas cyst and bowel         C           C        0000        0.0000          0.00         0.00         0.00
48540       Fuse pancreas cyst and bowel         C           C        0000        0.0000          0.00         0.00         0.00
48545       Pancreatorrhaphy                     C           C        0000        0.0000          0.00         0.00         0.00
48547       Duodenal exclusion                   C           C        0000        0.0000          0.00         0.00         0.00
48548       Fuse pancreas and bowel              C           C        0000        0.0000          0.00         0.00         0.00
48550       Donor pancreatectomy                 E           3        0000        0.0000          M01          M01          M01
48551       Prep donor pancreas                  C           C        0000        0.0000          0.00         0.00         0.00
48552       Prep donor pancreas/venous           C           C        0000        0.0000          0.00         0.00         0.00
48554       Transpl allograft pancreas           C           C        0000        0.0000          0.00         0.00         0.00
48556       Removal, allograft pancreas          C           C        0000        0.0000          0.00         0.00         0.00
48999       Pancreas surgery procedure           T           1        0000        0.0000          0.00         0.00         0.00
49000       Exploration of abdomen               C           C        0000        0.0000          0.00         0.00         0.00
49002       Reopening of abdomen                 C           C        0000        0.0000          0.00         0.00         0.00
49010       Exploration behind abdomen           C           C        0000        0.0000          0.00         0.00         0.00
49020       Drain abdominal abscess              C           C        0000        0.0000          0.00         0.00         0.00
49021       Drain abdominal abscess              T           T        0037       10.2655         473.24      1,079.01     1,236.79
49040       Drain, open, abdom abscess           C           C        0000        0.0000          0.00         0.00         0.00
49041       Drain, percut, abdom abscess         T           T        0037       10.2655         473.24      1,079.01     1,236.79
49060       Drain, open, retrop abscess          C           C        0000        0.0000          0.00         0.00         0.00
49061       Drain, percut, retroper absc         T           T        0037       10.2655         473.24      1,079.01     1,236.79
49062       Drain to peritoneal cavity           C           C        0000        0.0000          0.00         0.00         0.00
49080       Puncture, peritoneal cavity          T           T        0070        3.6244         167.08       380.96       436.67
49081       Removal of abdominal fluid           T           T        0070        3.6244         167.08       380.96       436.67
49180       Biopsy, abdominal mass               T           T        0685        6.1384         282.98       645.21       739.55
49200       Removal of abdominal lesion          T           T        0130       32.1241        1,480.92     3,376.56     3,870.31
49201       Remove abdom lesion, complex         C           C        0000        0.0000          0.00         0.00         0.00
49215       Excise sacral spine tumor            C           C        0000        0.0000          0.00         0.00         0.00
49220       Multiple surgery, abdomen            C           C        0000        0.0000          0.00         0.00         0.00
49250       Excision of umbilicus                T           T        0153       22.0832        1,018.04     2,321.17     2,660.58
49255       Removal of omentum                   C           C        0000        0.0000          0.00         0.00         0.00
49320       Diag laparo separate proc            T           T        0130       32.1241        1,480.92     3,376.56     3,870.31
49321       Laparoscopy, biopsy                  T           T        0130       32.1241        1,480.92     3,376.56     3,870.31
49322       Laparoscopy, aspiration              T           T        0130       32.1241        1,480.92     3,376.56     3,870.31
49323       Laparo drain lymphocele              T           T        0130       32.1241        1,480.92     3,376.56     3,870.31
49324       Lap insertion perm ip cath           T           T        0130       32.1241        1,480.92     3,376.56     3,870.31
49325       Lap revision perm ip cath            T           T        0130       32.1241        1,480.92     3,376.56     3,870.31
49326       Lap w/omentopexy add-on              T           T        0130       32.1241        1,480.92     3,376.56     3,870.31
49329       Laparo proc, abdm/per/oment          T           1        0000        0.0000          0.00         0.00         0.00
49400       Air injection into abdomen           N           N        0000        0.0000          0.00         0.00         0.00
49402       Remove foreign body, adbomen         T           T        0153       22.0832        1,018.04     2,321.17     2,660.58
49419       Insrt abdom cath for chemotx         T           T        0115       29.2133        1,346.73     3,070.61     3,519.62
49420       Insert abdom drain, temp             T           T        0652       29.5416        1,361.87     3,105.12     3,559.17
49421       Insert abdom drain, perm             T           T        0652       29.5416        1,361.87     3,105.12     3,559.17
49422       Remove perm cannula/catheter         T           T        0105       25.6142        1,180.81     2,692.31     3,086.00
49423       Exchange drainage catheter           T           T        0427       11.6575         537.41      1,225.32     1,404.50
49424       Assess cyst, contrast inject         N           N        0000        0.0000          0.00         0.00         0.00
49425       Insert abdomen-venous drain          C           C        0000        0.0000          0.00         0.00         0.00
49426       Revise abdomen-venous shunt          T           T        0153       22.0832        1,018.04     2,321.17     2,660.58
49427       Injection, abdominal shunt           N           N        0000        0.0000          0.00         0.00         0.00
49428       Ligation of shunt                    C           C        0000        0.0000          0.00         0.00         0.00
49429       Removal of shunt                     T           T        0105       25.6142        1,180.81     2,692.31     3,086.00
49435       Insert subq exten to ip cath         T           1        0000        0.0000          0.00         0.00         0.00
49436       Embedded ip cath exit-site           T           T        0427       11.6575         537.41      1,225.32     1,404.50
49491       Rpr hern preemie reduc               T           T        0154       29.2182        1,346.96     3,071.13     3,520.21
49492       Rpr ing hern premie, blocked         T           T        0154       29.2182        1,346.96     3,071.13     3,520.21
49495       Rpr ing hernia baby, reduc           T           T        0154       29.2182        1,346.96     3,071.13     3,520.21
49496       Rpr ing hernia baby, blocked         T           T        0154       29.2182        1,346.96     3,071.13     3,520.21
49500       Rpr ing hernia, init, reduce         T           T        0154       29.2182        1,346.96     3,071.13     3,520.21
49501       Rpr ing hernia, init blocked         T           T        0154       29.2182        1,346.96     3,071.13     3,520.21
49505       Prp i/hern init reduc >5 yr          T           T        0154       29.2182        1,346.96     3,071.13     3,520.21
49507       Prp i/hern init block >5 yr          T           T        0154       29.2182        1,346.96     3,071.13     3,520.21
49520       Rerepair ing hernia, reduce          T           T        0154       29.2182        1,346.96     3,071.13     3,520.21
49521       Rerepair ing hernia, blocked         T           T        0154       29.2182        1,346.96     3,071.13     3,520.21
49525       Repair ing hernia, sliding           T           T        0154       29.2182        1,346.96     3,071.13     3,520.21
49540       Repair lumbar hernia                 T           T        0154       29.2182        1,346.96     3,071.13     3,520.21
49550       Rpr rem hernia, init, reduce         T           T        0154       29.2182        1,346.96     3,071.13     3,520.21
49553       Rpr fem hernia, init blocked         T           T        0154       29.2182        1,346.96     3,071.13     3,520.21
49555       Rerepair fem hernia, reduce          T           T        0154       29.2182        1,346.96     3,071.13     3,520.21
49557       Rerepair fem hernia, blocked         T           T        0154       29.2182        1,346.96     3,071.13     3,520.21
49560       Rpr ventral hern init, reduc         T           T        0154       29.2182        1,346.96     3,071.13     3,520.21


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 38 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
49561       Rpr ventral hern init, block         T           T        0154       29.2182        1,346.96     3,071.13     3,520.21
49565       Rerepair ventrl hern, reduce         T           T        0154       29.2182        1,346.96     3,071.13     3,520.21
49566       Rerepair ventrl hern, block          T           T        0154       29.2182        1,346.96     3,071.13     3,520.21
49568       Hernia repair w/mesh                 T           T        0154       29.2182        1,346.96     3,071.13     3,520.21
49570       Rpr epigastric hern, reduce          T           T        0154       29.2182        1,346.96     3,071.13     3,520.21
49572       Rpr epigastric hern, blocked         T           T        0154       29.2182        1,346.96     3,071.13     3,520.21
49580       Rpr umbil hern, reduc < 5 yr         T           T        0154       29.2182        1,346.96     3,071.13     3,520.21
49582       Rpr umbil hern, block < 5 yr         T           T        0154       29.2182        1,346.96     3,071.13     3,520.21
49585       Rpr umbil hern, reduc > 5 yr         T           T        0154       29.2182        1,346.96     3,071.13     3,520.21
49587       Rpr umbil hern, block > 5 yr         T           T        0154       29.2182        1,346.96     3,071.13     3,520.21
49590       Repair spigelian hernia              T           T        0154       29.2182        1,346.96     3,071.13     3,520.21
49600       Repair umbilical lesion              T           T        0154       29.2182        1,346.96     3,071.13     3,520.21
49605       Repair umbilical lesion              C           C        0000        0.0000           0.00        0.00         0.00
49606       Repair umbilical lesion              C           C        0000        0.0000           0.00        0.00         0.00
49610       Repair umbilical lesion              C           C        0000        0.0000           0.00        0.00         0.00
49611       Repair umbilical lesion              C           C        0000        0.0000           0.00        0.00         0.00
49650       Laparo hernia repair initial         T           T        0131       43.5488        2,007.60     4,577.41     5,246.76
49651       Laparo hernia repair recur           T           T        0131       43.5488        2,007.60     4,577.41     5,246.76
49659       Laparo proc, hernia repair           T           1        0000        0.0000           0.00        0.00         0.00
49900       Repair of abdominal wall             C           C        0000        0.0000           0.00        0.00         0.00
49904       Omental flap, extra-abdom            C           C        0000        0.0000           0.00        0.00         0.00
49905       Omental flap, intra-abdom            C           C        0000        0.0000           0.00        0.00         0.00
49906       Free omental flap, microvasc         C           C        0000        0.0000           0.00        0.00         0.00
49999       Abdomen surgery procedure            T           1        0000        0.0000           0.00        0.00         0.00
50010       Exploration of kidney                C           C        0000        0.0000           0.00        0.00         0.00
50020       Renal abscess, open drain            T           T        0162       23.8700        1,100.41     2,508.98     2,875.86
50021       Renal abscess, percut drain          T           T        0037       10.2655         473.24      1,079.01     1,236.79
50040       Drainage of kidney                   C           C        0000        0.0000           0.00        0.00         0.00
50045       Exploration of kidney                C           C        0000        0.0000           0.00        0.00         0.00
50060       Removal of kidney stone              C           C        0000        0.0000           0.00        0.00         0.00
50065       Incision of kidney                   C           C        0000        0.0000           0.00        0.00         0.00
50070       Incision of kidney                   C           C        0000        0.0000           0.00        0.00         0.00
50075       Removal of kidney stone              C           C        0000        0.0000           0.00        0.00         0.00
50080       Removal of kidney stone              T           T        0429       43.1004        1,986.93     4,530.28     5,192.74
50081       Removal of kidney stone              T           T        0429       43.1004        1,986.93     4,530.28     5,192.74
50100       Revise kidney blood vessels          C           C        0000        0.0000           0.00        0.00         0.00
50120       Exploration of kidney                C           C        0000        0.0000           0.00        0.00         0.00
50125       Explore and drain kidney             C           C        0000        0.0000           0.00        0.00         0.00
50130       Removal of kidney stone              C           C        0000        0.0000           0.00        0.00         0.00
50135       Exploration of kidney                C           C        0000        0.0000           0.00        0.00         0.00
50200       Biopsy of kidney                     T           T        0685        6.1384         282.98       645.21       739.55
50205       Biopsy of kidney                     C           C        0000        0.0000           0.00        0.00         0.00
50220       Remove kidney, open                  C           C        0000        0.0000           0.00        0.00         0.00
50225       Removal kidney open, complex         C           C        0000        0.0000           0.00        0.00         0.00
50230       Removal kidney open, radical         C           C        0000        0.0000           0.00        0.00         0.00
50234       Removal of kidney & ureter           C           C        0000        0.0000           0.00        0.00         0.00
50236       Removal of kidney & ureter           C           C        0000        0.0000           0.00        0.00         0.00
50240       Partial removal of kidney            C           C        0000        0.0000           0.00        0.00         0.00
50250       Cryoablate renal mass open           C           C        0000        0.0000           0.00        0.00         0.00
50280       Removal of kidney lesion             C           C        0000        0.0000           0.00        0.00         0.00
50290       Removal of kidney lesion             C           C        0000        0.0000           0.00        0.00         0.00
50300       Remove cadaver donor kidney          C           C        0000        0.0000           0.00        0.00         0.00
50320       Remove kidney, living donor          C           C        0000        0.0000           0.00        0.00         0.00
50323       Prep cadaver renal allograft         C           C        0000        0.0000           0.00        0.00         0.00
50325       Prep donor renal graft               C           C        0000        0.0000           0.00        0.00         0.00
50327       Prep renal graft/venous              C           C        0000        0.0000           0.00        0.00         0.00
50328       Prep renal graft/arterial            C           C        0000        0.0000           0.00        0.00         0.00
50329       Prep renal graft/ureteral            C           C        0000        0.0000           0.00        0.00         0.00
50340       Removal of kidney                    C           C        0000        0.0000           0.00        0.00         0.00
50360       Transplantation of kidney            C           C        0000        0.0000           0.00        0.00         0.00
50365       Transplantation of kidney            C           C        0000        0.0000           0.00        0.00         0.00
50370       Remove transplanted kidney           C           C        0000        0.0000           0.00        0.00         0.00
50380       Reimplantation of kidney             C           C        0000        0.0000           0.00        0.00         0.00
50382       Change ureter stent, percut          T           T        0161       19.2251         886.28      2,020.75     2,316.24
50384       Remove ureter stent, percut          T           T        0161       19.2251         886.28      2,020.75     2,316.24
50387       Change ext/int ureter stent          T           T        0122        7.4800         344.83       786.22       901.19
50389       Remove renal tube w/fluoro           T           T        0156        3.4079         157.10       358.20       410.58
50390       Drainage of kidney lesion            T           T        0685        6.1384         282.98       645.21       739.55
50391       Instll rx agnt into rnal tub         T           T        0126        1.0887          50.19       114.43       131.17
50392       Insert kidney drain                  T           T        0161       19.2251         886.28      2,020.75     2,316.24
50393       Insert ureteral tube                 T           T        0161       19.2251         886.28      2,020.75     2,316.24
50394       Injection for kidney x-ray           N           N        0000        0.0000           0.00        0.00         0.00
50395       Create passage to kidney             T           T        0161       19.2251         886.28      2,020.75     2,316.24
50396       Measure kidney pressure              T           T        0164        2.1393          98.62       224.86       257.74
50398       Change kidney tube                   T           T        0122        7.4800         344.83       786.22       901.19
50400       Revision of kidney/ureter            C           C        0000        0.0000           0.00        0.00         0.00
50405       Revision of kidney/ureter            C           C        0000        0.0000           0.00        0.00         0.00
50500       Repair of kidney wound               C           C        0000        0.0000           0.00        0.00         0.00
50520       Close kidney-skin fistula            C           C        0000        0.0000           0.00        0.00         0.00
50525       Repair renal-abdomen fistula         C           C        0000        0.0000           0.00        0.00         0.00
50526       Repair renal-abdomen fistula         C           C        0000        0.0000           0.00        0.00         0.00
50540       Revision of horseshoe kidney         C           C        0000        0.0000           0.00        0.00         0.00
50541       Laparo ablate renal cyst             T           T        0130       32.1241        1,480.92     3,376.56     3,870.31
50542       Laparo ablate renal mass             T           T        0132       70.5066        3,250.35     7,410.95     8,494.64
50543       Laparo partial nephrectomy           T           T        0131       43.5488        2,007.60     4,577.41     5,246.76
50544       Laparoscopy, pyeloplasty             T           T        0130       32.1241        1,480.92     3,376.56     3,870.31
50545       Laparo radical nephrectomy           C           C        0000        0.0000           0.00        0.00         0.00
50546       Laparoscopic nephrectomy             C           C        0000        0.0000           0.00        0.00         0.00
50547       Laparo removal donor kidney          C           C        0000        0.0000           0.00        0.00         0.00
50548       Laparo remove w/ureter               C           C        0000        0.0000           0.00        0.00         0.00
50549       Laparoscope proc, renal              T           1        0000        0.0000           0.00        0.00         0.00
50551       Kidney endoscopy                     T           T        0160        6.4951         299.42       682.70       782.53
50553       Kidney endoscopy                     T           T        0161       19.2251         886.28      2,020.75     2,316.24
50555       Kidney endoscopy & biopsy            T           T        0160        6.4951         299.42       682.70       782.53
50557       Kidney endoscopy & treatment         T           T        0162       23.8700        1,100.41     2,508.98     2,875.86
50561       Kidney endoscopy & treatment         T           T        0161       19.2251         886.28      2,020.75     2,316.24
50562       Renal scope w/tumor resect           T           T        0160        6.4951         299.42       682.70       782.53
50570       Kidney endoscopy                     T           T        0160        6.4951         299.42       682.70       782.53
50572       Kidney endoscopy                     T           T        0160        6.4951         299.42       682.70       782.53
50574       Kidney endoscopy & biopsy            T           T        0160        6.4951         299.42       682.70       782.53
50575       Kidney endoscopy                     T           T        0163       34.9261        1,610.09     3,671.08     4,207.90
50576       Kidney endoscopy & treatment         T           T        0161       19.2251         886.28      2,020.75     2,316.24
50580       Kidney endoscopy & treatment         C           C        0000        0.0000           0.00        0.00         0.00
50590       Fragmenting of kidney stone          T           T        0169       43.5398        2,007.18     4,576.47     5,245.68
50592       Perc rf ablate renal tumor           T           T        0423       37.3604        1,722.31     3,926.95     4,501.18
50600       Exploration of ureter                C           C        0000        0.0000           0.00        0.00         0.00


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 39 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
50605       Insert ureteral support              C           C        0000        0.0000           0.00         0.00         0.00
50610       Removal of ureter stone              C           C        0000        0.0000           0.00         0.00         0.00
50620       Removal of ureter stone              C           C        0000        0.0000           0.00         0.00         0.00
50630       Removal of ureter stone              C           C        0000        0.0000           0.00         0.00         0.00
50650       Removal of ureter                    C           C        0000        0.0000           0.00         0.00         0.00
50660       Removal of ureter                    C           C        0000        0.0000           0.00         0.00         0.00
50684       Injection for ureter x-ray           N           N        0000        0.0000           0.00         0.00         0.00
50686       Measure ureter pressure              T           T        0126        1.0887          50.19       114.43       131.17
50688       Change of ureter tube                T           T        0122        7.4800         344.83       786.22       901.19
50690       Injection for ureter x-ray           N           N        0000        0.0000           0.00         0.00         0.00
50700       Revision of ureter                   C           C        0000        0.0000           0.00         0.00         0.00
50715       Release of ureter                    C           C        0000        0.0000           0.00         0.00         0.00
50722       Release of ureter                    C           C        0000        0.0000           0.00         0.00         0.00
50725       Release/revise ureter                C           C        0000        0.0000           0.00         0.00         0.00
50727       Revise ureter                        C           C        0000        0.0000           0.00         0.00         0.00
50728       Revise ureter                        C           C        0000        0.0000           0.00         0.00         0.00
50740       Fusion of ureter & kidney            C           C        0000        0.0000           0.00         0.00         0.00
50750       Fusion of ureter & kidney            C           C        0000        0.0000           0.00         0.00         0.00
50760       Fusion of ureters                    C           C        0000        0.0000           0.00         0.00         0.00
50770       Splicing of ureters                  C           C        0000        0.0000           0.00         0.00         0.00
50780       Reimplant ureter in bladder          C           C        0000        0.0000           0.00         0.00         0.00
50782       Reimplant ureter in bladder          C           C        0000        0.0000           0.00         0.00         0.00
50783       Reimplant ureter in bladder          C           C        0000        0.0000           0.00         0.00         0.00
50785       Reimplant ureter in bladder          C           C        0000        0.0000           0.00         0.00         0.00
50800       Implant ureter in bowel              C           C        0000        0.0000           0.00         0.00         0.00
50810       Fusion of ureter & bowel             C           C        0000        0.0000           0.00         0.00         0.00
50815       Urine shunt to intestine             C           C        0000        0.0000           0.00         0.00         0.00
50820       Construct bowel bladder              C           C        0000        0.0000           0.00         0.00         0.00
50825       Construct bowel bladder              C           C        0000        0.0000           0.00         0.00         0.00
50830       Revise urine flow                    C           C        0000        0.0000           0.00         0.00         0.00
50840       Replace ureter by bowel              C           C        0000        0.0000           0.00         0.00         0.00
50845       Appendico-vesicostomy                C           C        0000        0.0000           0.00         0.00         0.00
50860       Transplant ureter to skin            C           C        0000        0.0000           0.00         0.00         0.00
50900       Repair of ureter                     C           C        0000        0.0000           0.00         0.00         0.00
50920       Closure ureter/skin fistula          C           C        0000        0.0000           0.00         0.00         0.00
50930       Closure ureter/bowel fistula         C           C        0000        0.0000           0.00         0.00         0.00
50940       Release of ureter                    C           C        0000        0.0000           0.00         0.00         0.00
50945       Laparoscopy ureterolithotomy         T           T        0131       43.5488        2,007.60     4,577.41     5,246.76
50947       Laparo new ureter/bladder            T           T        0131       43.5488        2,007.60     4,577.41     5,246.76
50948       Laparo new ureter/bladder            T           T        0131       43.5488        2,007.60     4,577.41     5,246.76
50949       Laparoscope proc, ureter             T           1        0000        0.0000           0.00         0.00         0.00
50951       Endoscopy of ureter                  T           T        0160        6.4951         299.42       682.70       782.53
50953       Endoscopy of ureter                  T           T        0160        6.4951         299.42       682.70       782.53
50955       Ureter endoscopy & biopsy            T           T        0161       19.2251         886.28      2,020.75     2,316.24
50957       Ureter endoscopy & treatment         T           T        0161       19.2251         886.28      2,020.75     2,316.24
50961       Ureter endoscopy & treatment         T           T        0161       19.2251         886.28      2,020.75     2,316.24
50970       Ureter endoscopy                     T           T        0160        6.4951         299.42       682.70       782.53
50972       Ureter endoscopy & catheter          T           T        0160        6.4951         299.42       682.70       782.53
50974       Ureter endoscopy & biopsy            T           T        0161       19.2251         886.28      2,020.75     2,316.24
50976       Ureter endoscopy & treatment         T           T        0161       19.2251         886.28      2,020.75     2,316.24
50980       Ureter endoscopy & treatment         T           T        0161       19.2251         886.28      2,020.75     2,316.24
51000       Drainage of bladder                  T           T        0164        2.1393          98.62       224.86       257.74
51005       Drainage of bladder                  T           T        0126        1.0887          50.19       114.43       131.17
51010       Drainage of bladder                  T           T        0165       18.1679         837.54      1,909.63     2,188.87
51020       Incise & treat bladder               T           T        0162       23.8700        1,100.41     2,508.98     2,875.86
51030       Incise & treat bladder               T           T        0162       23.8700        1,100.41     2,508.98     2,875.86
51040       Incise & drain bladder               T           T        0162       23.8700        1,100.41     2,508.98     2,875.86
51045       Incise bladder/drain ureter          T           T        0160        6.4951         299.42       682.70       782.53
51050       Removal of bladder stone             T           T        0162       23.8700        1,100.41     2,508.98     2,875.86
51060       Removal of ureter stone              C           C        0000        0.0000           0.00         0.00         0.00
51065       Remove ureter calculus               T           T        0162       23.8700        1,100.41     2,508.98     2,875.86
51080       Drainage of bladder abscess          T           T        0008       17.5086         807.15      1,840.33     2,109.44
51500       Removal of bladder cyst              T           T        0154       29.2182        1,346.96     3,071.13     3,520.21
51520       Removal of bladder lesion            T           T        0162       23.8700        1,100.41     2,508.98     2,875.86
51525       Removal of bladder lesion            C           C        0000        0.0000           0.00         0.00         0.00
51530       Removal of bladder lesion            C           C        0000        0.0000           0.00         0.00         0.00
51535       Repair of ureter lesion              C           C        0000        0.0000           0.00         0.00         0.00
51550       Partial removal of bladder           C           C        0000        0.0000           0.00         0.00         0.00
51555       Partial removal of bladder           C           C        0000        0.0000           0.00         0.00         0.00
51565       Revise bladder & ureter(s)           C           C        0000        0.0000           0.00         0.00         0.00
51570       Removal of bladder                   C           C        0000        0.0000           0.00         0.00         0.00
51575       Removal of bladder & nodes           C           C        0000        0.0000           0.00         0.00         0.00
51580       Remove bladder/revise tract          C           C        0000        0.0000           0.00         0.00         0.00
51585       Removal of bladder & nodes           C           C        0000        0.0000           0.00         0.00         0.00
51590       Remove bladder/revise tract          C           C        0000        0.0000           0.00         0.00         0.00
51595       Remove bladder/revise tract          C           C        0000        0.0000           0.00         0.00         0.00
51596       Remove bladder/create pouch          C           C        0000        0.0000           0.00         0.00         0.00
51597       Removal of pelvic structures         C           C        0000        0.0000           0.00         0.00         0.00
51600       Injection for bladder x-ray          N           N        0000        0.0000           0.00         0.00         0.00
51605       Preparation for bladder xray         N           N        0000        0.0000           0.00         0.00         0.00
51610       Injection for bladder x-ray          N           N        0000        0.0000           0.00         0.00         0.00
51700       Irrigation of bladder                T           T        0164        2.1393          98.62       224.86       257.74
51701       Insert bladder catheter              X           X        0340        0.6102          28.13        64.14        73.52
51702       Insert temp bladder cath             X           X        0340        0.6102          28.13        64.14        73.52
51703       Insert bladder cath, complex         T           T        0126        1.0887          50.19       114.43       131.17
51705       Change of bladder tube               T           T        0121        2.3587         108.74       247.92       284.18
51710       Change of bladder tube               T           T        0122        7.4800         344.83       786.22       901.19
51715       Endoscopic injection/implant         T           T        0168       29.0253        1,338.07     3,050.85     3,496.97
51720       Treatment of bladder lesion          T           T        0164        2.1393          98.62       224.86       257.74
51725       Simple cystometrogram                T           T        0164        2.1393          98.62       224.86       257.74
51726       Complex cystometrogram               T           T        0156        3.4079         157.10       358.20       410.58
51736       Urine flow measurement               T           T        0126        1.0887          50.19       114.43       131.17
51741       Electro-uroflowmetry, first          T           T        0126        1.0887          50.19       114.43       131.17
51772       Urethra pressure profile             T           T        0164        2.1393          98.62       224.86       257.74
51784       Anal/urinary muscle study            T           T        0126        1.0887          50.19       114.43       131.17
51785       Anal/urinary muscle study            T           T        0126        1.0887          50.19       114.43       131.17
51792       Urinary reflex study                 T           T        0126        1.0887          50.19       114.43       131.17
51795       Urine voiding pressure study         T           T        0164        2.1393          98.62       224.86       257.74
51797       Intraabdominal pressure test         T           T        0164        2.1393          98.62       224.86       257.74
51798       Us urine capacity measure            X           X        0340        0.6102          28.13        64.14        73.52
51800       Revision of bladder/urethra          C           C        0000        0.0000           0.00         0.00         0.00
51820       Revision of urinary tract            C           C        0000        0.0000           0.00         0.00         0.00
51840       Attach bladder/urethra               C           C        0000        0.0000           0.00         0.00         0.00
51841       Attach bladder/urethra               C           C        0000        0.0000           0.00         0.00         0.00
51845       Repair bladder neck                  C           C        0000        0.0000           0.00         0.00         0.00
51860       Repair of bladder wound              C           C        0000        0.0000           0.00         0.00         0.00


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 40 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
51865       Repair of bladder wound              C           C        0000        0.0000          0.00         0.00         0.00
51880       Repair of bladder opening            T           T        0162       23.8700        1,100.41     2,508.98     2,875.86
51900       Repair bladder/vagina lesion         C           C        0000        0.0000          0.00         0.00         0.00
51920       Close bladder-uterus fistula         C           C        0000        0.0000          0.00         0.00         0.00
51925       Hysterectomy/bladder repair          C           C        0000        0.0000          0.00         0.00         0.00
51940       Correction of bladder defect         C           C        0000        0.0000          0.00         0.00         0.00
51960       Revision of bladder & bowel          C           C        0000        0.0000          0.00         0.00         0.00
51980       Construct bladder opening            C           C        0000        0.0000          0.00         0.00         0.00
51990       Laparo urethral suspension           T           T        0131       43.5488        2,007.60     4,577.41     5,246.76
51992       Laparo sling operation               T           T        0131       43.5488        2,007.60     4,577.41     5,246.76
51999       Laparoscope proc, bladder            T           1        0000        0.0000          0.00         0.00         0.00
52000       Cystoscopy                           T           T        0160        6.4951         299.42       682.70       782.53
52001       Cystoscopy, removal of clots         T           T        0160        6.4951         299.42       682.70       782.53
52005       Cystoscopy & ureter catheter         T           T        0161       19.2251         886.28      2,020.75     2,316.24
52007       Cystoscopy and biopsy                T           T        0161       19.2251         886.28      2,020.75     2,316.24
52010       Cystoscopy & duct catheter           T           T        0160        6.4951         299.42       682.70       782.53
52204       Cystoscopy                           T           T        0161       19.2251         886.28      2,020.75     2,316.24
52214       Cystoscopy and treatment             T           T        0162       23.8700        1,100.41     2,508.98     2,875.86
52224       Cystoscopy and treatment             T           T        0162       23.8700        1,100.41     2,508.98     2,875.86
52234       Cystoscopy and treatment             T           T        0162       23.8700        1,100.41     2,508.98     2,875.86
52235       Cystoscopy and treatment             T           T        0162       23.8700        1,100.41     2,508.98     2,875.86
52240       Cystoscopy and treatment             T           T        0162       23.8700        1,100.41     2,508.98     2,875.86
52250       Cystoscopy and radiotracer           T           T        0162       23.8700        1,100.41     2,508.98     2,875.86
52260       Cystoscopy and treatment             T           T        0161       19.2251         886.28      2,020.75     2,316.24
52265       Cystoscopy and treatment             T           T        0160        6.4951         299.42       682.70       782.53
52270       Cystoscopy & revise urethra          T           T        0161       19.2251         886.28      2,020.75     2,316.24
52275       Cystoscopy & revise urethra          T           T        0161       19.2251         886.28      2,020.75     2,316.24
52276       Cystoscopy and treatment             T           T        0161       19.2251         886.28      2,020.75     2,316.24
52277       Cystoscopy and treatment             T           T        0162       23.8700        1,100.41     2,508.98     2,875.86
52281       Cystoscopy and treatment             T           T        0161       19.2251         886.28      2,020.75     2,316.24
52282       Cystoscopy, implant stent            T           T        0163       34.9261        1,610.09     3,671.08     4,207.90
52283       Cystoscopy and treatment             T           T        0161       19.2251         886.28      2,020.75     2,316.24
52285       Cystoscopy and treatment             T           T        0161       19.2251         886.28      2,020.75     2,316.24
52290       Cystoscopy and treatment             T           T        0161       19.2251         886.28      2,020.75     2,316.24
52300       Cystoscopy and treatment             T           T        0161       19.2251         886.28      2,020.75     2,316.24
52301       Cystoscopy and treatment             T           T        0161       19.2251         886.28      2,020.75     2,316.24
52305       Cystoscopy and treatment             T           T        0161       19.2251         886.28      2,020.75     2,316.24
52310       Cystoscopy and treatment             T           T        0160        6.4951         299.42       682.70       782.53
52315       Cystoscopy and treatment             T           T        0161       19.2251         886.28      2,020.75     2,316.24
52317       Remove bladder stone                 T           T        0162       23.8700        1,100.41     2,508.98     2,875.86
52318       Remove bladder stone                 T           T        0162       23.8700        1,100.41     2,508.98     2,875.86
52320       Cystoscopy and treatment             T           T        0162       23.8700        1,100.41     2,508.98     2,875.86
52325       Cystoscopy, stone removal            T           T        0162       23.8700        1,100.41     2,508.98     2,875.86
52327       Cystoscopy, inject material          T           T        0162       23.8700        1,100.41     2,508.98     2,875.86
52330       Cystoscopy and treatment             T           T        0162       23.8700        1,100.41     2,508.98     2,875.86
52332       Cystoscopy and treatment             T           T        0162       23.8700        1,100.41     2,508.98     2,875.86
52334       Create passage to kidney             T           T        0162       23.8700        1,100.41     2,508.98     2,875.86
52341       Cysto w/ureter stricture tx          T           T        0162       23.8700        1,100.41     2,508.98     2,875.86
52342       Cysto w/up stricture tx              T           T        0162       23.8700        1,100.41     2,508.98     2,875.86
52343       Cysto w/renal stricture tx           T           T        0162       23.8700        1,100.41     2,508.98     2,875.86
52344       Cysto/uretero, stricture tx          T           T        0162       23.8700        1,100.41     2,508.98     2,875.86
52345       Cysto/uretero w/up stricture         T           T        0162       23.8700        1,100.41     2,508.98     2,875.86
52346       Cystouretero w/renal strict          T           T        0162       23.8700        1,100.41     2,508.98     2,875.86
52351       Cystouretero & or pyeloscope         T           T        0161       19.2251         886.28      2,020.75     2,316.24
52352       Cystouretero w/stone remove          T           T        0162       23.8700        1,100.41     2,508.98     2,875.86
52353       Cystouretero w/lithotripsy           T           T        0163       34.9261        1,610.09     3,671.08     4,207.90
52354       Cystouretero w/biopsy                T           T        0162       23.8700        1,100.41     2,508.98     2,875.86
52355       Cystouretero w/excise tumor          T           T        0162       23.8700        1,100.41     2,508.98     2,875.86
52400       Cystouretero w/congen repr           T           T        0162       23.8700        1,100.41     2,508.98     2,875.86
52402       Cystourethro cut ejacul duct         T           T        0162       23.8700        1,100.41     2,508.98     2,875.86
52450       Incision of prostate                 T           T        0162       23.8700        1,100.41     2,508.98     2,875.86
52500       Revision of bladder neck             T           T        0162       23.8700        1,100.41     2,508.98     2,875.86
52510       Dilation prostatic urethra           T           T        0161       19.2251         886.28      2,020.75     2,316.24
52601       Prostatectomy (TURP)                 T           T        0163       34.9261        1,610.09     3,671.08     4,207.90
52606       Control postop bleeding              T           T        0162       23.8700        1,100.41     2,508.98     2,875.86
52612       Prostatectomy, first stage           T           T        0163       34.9261        1,610.09     3,671.08     4,207.90
52614       Prostatectomy, second stage          T           T        0163       34.9261        1,610.09     3,671.08     4,207.90
52620       Remove residual prostate             T           T        0163       34.9261        1,610.09     3,671.08     4,207.90
52630       Remove prostate regrowth             T           T        0163       34.9261        1,610.09     3,671.08     4,207.90
52640       Relieve bladder contracture          T           T        0162       23.8700        1,100.41     2,508.98     2,875.86
52647       Laser surgery of prostate            T           T        0429       43.1004        1,986.93     4,530.28     5,192.74
52648       Laser surgery of prostate            T           T        0429       43.1004        1,986.93     4,530.28     5,192.74
52700       Drainage of prostate abscess         T           T        0162       23.8700        1,100.41     2,508.98     2,875.86
53000       Incision of urethra                  T           T        0166       18.3960         848.06      1,933.60     2,216.35
53010       Incision of urethra                  T           T        0166       18.3960         848.06      1,933.60     2,216.35
53020       Incision of urethra                  T           T        0166       18.3960         848.06      1,933.60     2,216.35
53025       Incision of urethra                  T           T        0166       18.3960         848.06      1,933.60     2,216.35
53040       Drainage of urethra abscess          T           T        0166       18.3960         848.06      1,933.60     2,216.35
53060       Drainage of urethra abscess          T           T        0166       18.3960         848.06      1,933.60     2,216.35
53080       Drainage of urinary leakage          T           T        0166       18.3960         848.06      1,933.60     2,216.35
53085       Drainage of urinary leakage          T           T        0166       18.3960         848.06      1,933.60     2,216.35
53200       Biopsy of urethra                    T           T        0166       18.3960         848.06      1,933.60     2,216.35
53210       Removal of urethra                   T           T        0168       29.0253        1,338.07     3,050.85     3,496.97
53215       Removal of urethra                   T           T        0166       18.3960         848.06      1,933.60     2,216.35
53220       Treatment of urethra lesion          T           T        0168       29.0253        1,338.07     3,050.85     3,496.97
53230       Removal of urethra lesion            T           T        0168       29.0253        1,338.07     3,050.85     3,496.97
53235       Removal of urethra lesion            T           T        0166       18.3960         848.06      1,933.60     2,216.35
53240       Surgery for urethra pouch            T           T        0168       29.0253        1,338.07     3,050.85     3,496.97
53250       Removal of urethra gland             T           T        0166       18.3960         848.06      1,933.60     2,216.35
53260       Treatment of urethra lesion          T           T        0166       18.3960         848.06      1,933.60     2,216.35
53265       Treatment of urethra lesion          T           T        0166       18.3960         848.06      1,933.60     2,216.35
53270       Removal of urethra gland             T           T        0166       18.3960         848.06      1,933.60     2,216.35
53275       Repair of urethra defect             T           T        0166       18.3960         848.06      1,933.60     2,216.35
53400       Revise urethra, stage 1              T           T        0168       29.0253        1,338.07     3,050.85     3,496.97
53405       Revise urethra, stage 2              T           T        0168       29.0253        1,338.07     3,050.85     3,496.97
53410       Reconstruction of urethra            T           T        0168       29.0253        1,338.07     3,050.85     3,496.97
53415       Reconstruction of urethra            C           C        0000        0.0000          0.00         0.00         0.00
53420       Reconstruct urethra, stage 1         T           T        0168       29.0253        1,338.07     3,050.85     3,496.97
53425       Reconstruct urethra, stage 2         T           T        0168       29.0253        1,338.07     3,050.85     3,496.97
53430       Reconstruction of urethra            T           T        0168       29.0253        1,338.07     3,050.85     3,496.97
53431       Reconstruct urethra/bladder          T           T        0168       29.0253        1,338.07     3,050.85     3,496.97
53440       Male sling procedure                 S           S        0385       79.2092        3,651.54     8,325.68     9,543.12
53442       Remove/revise male sling             T           T        0168       29.0253        1,338.07     3,050.85     3,496.97
53444       Insert tandem cuff                   S           S        0385       79.2092        3,651.54     8,325.68     9,543.12
53445       Insert uro/ves nck sphincter         S           S        0386      137.3897        6,333.67    14,441.03    16,552.71
53446       Remove uro sphincter                 T           T        0168       29.0253        1,338.07     3,050.85     3,496.97


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 41 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
53447       Remove/replace ur sphincter          S           S        0386      137.3897        6,333.67    14,441.03    16,552.71
53448       Remov/replc ur sphinctr comp         C           C        0000        0.0000           0.00         0.00        0.00
53449       Repair uro sphincter                 T           T        0168       29.0253        1,338.07     3,050.85     3,496.97
53450       Revision of urethra                  T           T        0168       29.0253        1,338.07     3,050.85     3,496.97
53460       Revision of urethra                  T           T        0166       18.3960         848.06      1,933.60     2,216.35
53500       Urethrlys, transvag w/ scope         T           T        0168       29.0253        1,338.07     3,050.85     3,496.97
53502       Repair of urethra injury             T           T        0166       18.3960         848.06      1,933.60     2,216.35
53505       Repair of urethra injury             T           T        0168       29.0253        1,338.07     3,050.85     3,496.97
53510       Repair of urethra injury             T           T        0166       18.3960         848.06      1,933.60     2,216.35
53515       Repair of urethra injury             T           T        0168       29.0253        1,338.07     3,050.85     3,496.97
53520       Repair of urethra defect             T           T        0168       29.0253        1,338.07     3,050.85     3,496.97
53600       Dilate urethra stricture             T           T        0156        3.4079         157.10       358.20       410.58
53601       Dilate urethra stricture             T           T        0126        1.0887          50.19       114.43       131.17
53605       Dilate urethra stricture             T           T        0161       19.2251         886.28      2,020.75     2,316.24
53620       Dilate urethra stricture             T           T        0165       18.1679         837.54      1,909.63     2,188.87
53621       Dilate urethra stricture             T           T        0164        2.1393          98.62       224.86       257.74
53660       Dilation of urethra                  T           T        0126        1.0887          50.19       114.43       131.17
53661       Dilation of urethra                  T           T        0126        1.0887          50.19       114.43       131.17
53665       Dilation of urethra                  T           T        0166       18.3960         848.06      1,933.60     2,216.35
53850       Prostatic microwave thermotx         T           T        0675       41.1375        1,896.44     4,323.96     4,956.25
53852       Prostatic rf thermotx                T           T        0675       41.1375        1,896.44     4,323.96     4,956.25
53853       Prostatic water thermother           T           T        0162       23.8700        1,100.41     2,508.98     2,875.86
53899       Urology surgery procedure            T           1        0000        0.0000           0.00         0.00        0.00
54000       Slitting of prepuce                  T           T        0166       18.3960         848.06      1,933.60     2,216.35
54001       Slitting of prepuce                  T           T        0166       18.3960         848.06      1,933.60     2,216.35
54015       Drain penis lesion                   T           T        0008       17.5086         807.15      1,840.33     2,109.44
54050       Destruction, penis lesion(s)         T           T        0013        1.0918          50.33       114.76       131.54
54055       Destruction, penis lesion(s)         T           T        0017       17.4423         804.09      1,833.36     2,101.45
54056       Cryosurgery, penis lesion(s)         T           T        0012        0.8432          38.87        88.63       101.59
54057       Laser surg, penis lesion(s)          T           T        0017       17.4423         804.09      1,833.36     2,101.45
54060       Excision of penis lesion(s)          T           T        0017       17.4423         804.09      1,833.36     2,101.45
54065       Destruction, penis lesion(s)         T           T        0695       20.4276         941.71      2,147.15     2,461.12
54100       Biopsy of penis                      T           T        0021       15.1024         696.22      1,587.41     1,819.54
54105       Biopsy of penis                      T           T        0022       20.0656         925.02      2,109.10     2,417.50
54110       Treatment of penis lesion            T           T        0181       32.9873        1,520.71     3,467.30     3,974.31
54111       Treat penis lesion, graft            T           T        0181       32.9873        1,520.71     3,467.30     3,974.31
54112       Treat penis lesion, graft            T           T        0181       32.9873        1,520.71     3,467.30     3,974.31
54115       Treatment of penis lesion            T           T        0008       17.5086         807.15      1,840.33     2,109.44
54120       Partial removal of penis             T           T        0181       32.9873        1,520.71     3,467.30     3,974.31
54125       Removal of penis                     C           C        0000        0.0000           0.00         0.00        0.00
54130       Remove penis & nodes                 C           C        0000        0.0000           0.00         0.00        0.00
54135       Remove penis & nodes                 C           C        0000        0.0000           0.00         0.00        0.00
54150       Circumcision                         T           T        0180       20.5513         947.41      2,160.15     2,476.02
54160       Circumcision                         T           T        0180       20.5513         947.41      2,160.15     2,476.02
54161       Circumcision                         T           T        0180       20.5513         947.41      2,160.15     2,476.02
54162       Lysis penil circumic lesion          T           T        0180       20.5513         947.41      2,160.15     2,476.02
54163       Repair of circumcision               T           T        0180       20.5513         947.41      2,160.15     2,476.02
54164       Frenulotomy of penis                 T           T        0180       20.5513         947.41      2,160.15     2,476.02
54200       Treatment of penis lesion            T           T        0164        2.1393          98.62       224.86       257.74
54205       Treatment of penis lesion            T           T        0181       32.9873        1,520.71     3,467.30     3,974.31
54220       Treatment of penis lesion            T           T        0164        2.1393          98.62       224.86       257.74
54230       Prepare penis study                  N           N        0000        0.0000           0.00         0.00        0.00
54231       Dynamic cavernosometry               T           T        0165       18.1679         837.54      1,909.63     2,188.87
54235       Penile injection                     T           T        0164        2.1393          98.62       224.86       257.74
54240       Penis study                          T           1        0000        0.0000           0.00         0.00        0.00
54250       Penis study                          T           1        0000        0.0000           0.00         0.00        0.00
54300       Revision of penis                    T           T        0181       32.9873        1,520.71     3,467.30     3,974.31
54304       Revision of penis                    T           T        0181       32.9873        1,520.71     3,467.30     3,974.31
54308       Reconstruction of urethra            T           T        0181       32.9873        1,520.71     3,467.30     3,974.31
54312       Reconstruction of urethra            T           T        0181       32.9873        1,520.71     3,467.30     3,974.31
54316       Reconstruction of urethra            T           T        0181       32.9873        1,520.71     3,467.30     3,974.31
54318       Reconstruction of urethra            T           T        0181       32.9873        1,520.71     3,467.30     3,974.31
54322       Reconstruction of urethra            T           T        0181       32.9873        1,520.71     3,467.30     3,974.31
54324       Reconstruction of urethra            T           T        0181       32.9873        1,520.71     3,467.30     3,974.31
54326       Reconstruction of urethra            T           T        0181       32.9873        1,520.71     3,467.30     3,974.31
54328       Revise penis/urethra                 T           T        0181       32.9873        1,520.71     3,467.30     3,974.31
54332       Revise penis/urethra                 C           C        0000        0.0000           0.00         0.00        0.00
54336       Revise penis/urethra                 C           C        0000        0.0000           0.00         0.00        0.00
54340       Secondary urethral surgery           T           T        0181       32.9873        1,520.71     3,467.30     3,974.31
54344       Secondary urethral surgery           T           T        0181       32.9873        1,520.71     3,467.30     3,974.31
54348       Secondary urethral surgery           T           T        0181       32.9873        1,520.71     3,467.30     3,974.31
54352       Reconstruct urethra/penis            T           T        0181       32.9873        1,520.71     3,467.30     3,974.31
54360       Penis plastic surgery                T           T        0181       32.9873        1,520.71     3,467.30     3,974.31
54380       Repair penis                         T           T        0181       32.9873        1,520.71     3,467.30     3,974.31
54385       Repair penis                         T           T        0181       32.9873        1,520.71     3,467.30     3,974.31
54390       Repair penis and bladder             C           C        0000        0.0000           0.00         0.00        0.00
54400       Insert semi-rigid prosthesis         S           1        0000        0.0000           0.00         0.00        0.00
54401       Insert self-contd prosthesis         S           1        0000        0.0000           0.00         0.00        0.00
54405       Insert multi-comp penis pros         S           1        0000        0.0000           0.00         0.00        0.00
54406       Remove muti-comp penis pros          T           1        0000        0.0000           0.00         0.00        0.00
54408       Repair multi-comp penis pros         T           1        0000        0.0000           0.00         0.00        0.00
54410       Remove/replace penis prosth          S           1        0000        0.0000           0.00         0.00        0.00
54411       Remov/replc penis pros, comp         C           1        0000        0.0000           0.00         0.00        0.00
54415       Remove self-contd penis pros         T           1        0000        0.0000           0.00         0.00        0.00
54416       Remv/repl penis contain pros         S           1        0000        0.0000           0.00         0.00        0.00
54417       Remv/replc penis pros, compl         C           1        0000        0.0000           0.00         0.00        0.00
54420       Revision of penis                    T           T        0181       32.9873        1,520.71     3,467.30     3,974.31
54430       Revision of penis                    C           C        0000        0.0000           0.00         0.00        0.00
54435       Revision of penis                    T           T        0181       32.9873        1,520.71     3,467.30     3,974.31
54440       Repair of penis                      T           T        0181       32.9873        1,520.71     3,467.30     3,974.31
54450       Preputial stretching                 T           T        0156        3.4079         157.10       358.20       410.58
54500       Biopsy of testis                     T           T        0037       10.2655         473.24      1,079.01     1,236.79
54505       Biopsy of testis                     T           T        0183       23.5310        1,084.78     2,473.34     2,835.01
54512       Excise lesion testis                 T           T        0183       23.5310        1,084.78     2,473.34     2,835.01
54520       Removal of testis                    T           T        0183       23.5310        1,084.78     2,473.34     2,835.01
54522       Orchiectomy, partial                 T           T        0183       23.5310        1,084.78     2,473.34     2,835.01
54530       Removal of testis                    T           T        0154       29.2182        1,346.96     3,071.13     3,520.21
54535       Extensive testis surgery             C           C        0000        0.0000           0.00         0.00        0.00
54550       Exploration for testis               T           T        0154       29.2182        1,346.96     3,071.13     3,520.21
54560       Exploration for testis               T           T        0183       23.5310        1,084.78     2,473.34     2,835.01
54600       Reduce testis torsion                T           T        0183       23.5310        1,084.78     2,473.34     2,835.01
54620       Suspension of testis                 T           T        0183       23.5310        1,084.78     2,473.34     2,835.01
54640       Suspension of testis                 T           T        0154       29.2182        1,346.96     3,071.13     3,520.21
54650       Orchiopexy (Fowler-Stephens)         C           C        0000        0.0000           0.00         0.00        0.00
54660       Revision of testis                   T           1        0000        0.0000           0.00         0.00        0.00
54670       Repair testis injury                 T           T        0183       23.5310        1,084.78     2,473.34     2,835.01


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 42 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
54680       Relocation of testis(es)             T           T        0183       23.5310        1,084.78     2,473.34     2,835.01
54690       Laparoscopy, orchiectomy             T           T        0131       43.5488        2,007.60     4,577.41     5,246.76
54692       Laparoscopy, orchiopexy              T           T        0132       70.5066        3,250.35     7,410.95     8,494.64
54699       Laparoscope proc, testis             T           1        0000        0.0000           0.00        0.00         0.00
54700       Drainage of scrotum                  T           T        0183       23.5310        1,084.78     2,473.34     2,835.01
54800       Biopsy of epididymis                 T           T        0004        2.0687          95.37       217.44       249.24
54830       Remove epididymis lesion             T           T        0183       23.5310        1,084.78     2,473.34     2,835.01
54840       Remove epididymis lesion             T           T        0183       23.5310        1,084.78     2,473.34     2,835.01
54860       Removal of epididymis                T           T        0183       23.5310        1,084.78     2,473.34     2,835.01
54861       Removal of epididymis                T           T        0183       23.5310        1,084.78     2,473.34     2,835.01
54865       Explore epididymis                   T           T        0183       23.5310        1,084.78     2,473.34     2,835.01
54900       Fusion of spermatic ducts            T           T        0183       23.5310        1,084.78     2,473.34     2,835.01
54901       Fusion of spermatic ducts            T           T        0183       23.5310        1,084.78     2,473.34     2,835.01
55000       Drainage of hydrocele                T           T        0004        2.0687          95.37       217.44       249.24
55040       Removal of hydrocele                 T           T        0154       29.2182        1,346.96     3,071.13     3,520.21
55041       Removal of hydroceles                T           T        0154       29.2182        1,346.96     3,071.13     3,520.21
55060       Repair of hydrocele                  T           T        0183       23.5310        1,084.78     2,473.34     2,835.01
55100       Drainage of scrotum abscess          T           T        0007       11.1535         514.18      1,172.34     1,343.77
55110       Explore scrotum                      T           T        0183       23.5310        1,084.78     2,473.34     2,835.01
55120       Removal of scrotum lesion            T           T        0183       23.5310        1,084.78     2,473.34     2,835.01
55150       Removal of scrotum                   T           T        0183       23.5310        1,084.78     2,473.34     2,835.01
55175       Revision of scrotum                  T           T        0183       23.5310        1,084.78     2,473.34     2,835.01
55180       Revision of scrotum                  T           T        0183       23.5310        1,084.78     2,473.34     2,835.01
55200       Incision of sperm duct               T           T        0183       23.5310        1,084.78     2,473.34     2,835.01
55250       Removal of sperm duct(s)             T           T        0183       23.5310        1,084.78     2,473.34     2,835.01
55300       Prepare, sperm duct x-ray            N           N        0000        0.0000           0.00        0.00         0.00
55400       Repair of sperm duct                 T           T        0183       23.5310        1,084.78     2,473.34     2,835.01
55450       Ligation of sperm duct               T           T        0183       23.5310        1,084.78     2,473.34     2,835.01
55500       Removal of hydrocele                 T           T        0183       23.5310        1,084.78     2,473.34     2,835.01
55520       Removal of sperm cord lesion         T           T        0183       23.5310        1,084.78     2,473.34     2,835.01
55530       Revise spermatic cord veins          T           T        0183       23.5310        1,084.78     2,473.34     2,835.01
55535       Revise spermatic cord veins          T           T        0154       29.2182        1,346.96     3,071.13     3,520.21
55540       Revise hernia & sperm veins          T           T        0154       29.2182        1,346.96     3,071.13     3,520.21
55550       Laparo ligate spermatic vein         T           T        0131       43.5488        2,007.60     4,577.41     5,246.76
55559       Laparo proc, spermatic cord          T           1        0000        0.0000           0.00        0.00         0.00
55600       Incise sperm duct pouch              T           T        0183       23.5310        1,084.78     2,473.34     2,835.01
55605       Incise sperm duct pouch              C           C        0000        0.0000           0.00        0.00         0.00
55650       Remove sperm duct pouch              C           C        0000        0.0000           0.00        0.00         0.00
55680       Remove sperm pouch lesion            T           T        0183       23.5310        1,084.78     2,473.34     2,835.01
55700       Biopsy of prostate                   T           T        0184        5.6262         259.37       591.37       677.84
55705       Biopsy of prostate                   T           T        0184        5.6262         259.37       591.37       677.84
55720       Drainage of prostate abscess         T           T        0162       23.8700        1,100.41     2,508.98     2,875.86
55725       Drainage of prostate abscess         T           T        0162       23.8700        1,100.41     2,508.98     2,875.86
55801       Removal of prostate                  C           C        0000        0.0000           0.00        0.00         0.00
55810       Extensive prostate surgery           C           C        0000        0.0000           0.00        0.00         0.00
55812       Extensive prostate surgery           C           C        0000        0.0000           0.00        0.00         0.00
55815       Extensive prostate surgery           C           C        0000        0.0000           0.00        0.00         0.00
55821       Removal of prostate                  C           C        0000        0.0000           0.00        0.00         0.00
55831       Removal of prostate                  C           C        0000        0.0000           0.00        0.00         0.00
55840       Extensive prostate surgery           C           C        0000        0.0000           0.00        0.00         0.00
55842       Extensive prostate surgery           C           C        0000        0.0000           0.00        0.00         0.00
55845       Extensive prostate surgery           C           C        0000        0.0000           0.00        0.00         0.00
55860       Surgical exposure, prostate          T           T        0165       18.1679         837.54      1,909.63     2,188.87
55862       Extensive prostate surgery           C           C        0000        0.0000           0.00        0.00         0.00
55865       Extensive prostate surgery           C           C        0000        0.0000           0.00        0.00         0.00
55866       Laparo radical prostatectomy         C           C        0000        0.0000           0.00        0.00         0.00
55870       Electroejaculation                   T           1        0000        0.0000           0.00        0.00         0.00
55873       Cryoablate prostate                  T           T        0674      108.7566        5,013.68    11,431.41    13,103.00
55875       Transperi needle place, pros         T           T        0163       34.9261        1,610.09     3,671.08     4,207.90
55876       Place rt device/marker, pros         T           T        0156        3.4079         157.10       358.20       410.58
55899       Genital surgery procedure            T           1        0000        0.0000           0.00        0.00         0.00
55970       Sex transformation, M to F           E           1        0000        0.0000           0.00        0.00         0.00
55980       Sex transformation, F to M           E           1        0000        0.0000           0.00        0.00         0.00
56405       I & D of vulva/perineum              T           T        0189        2.8966         133.53       304.46       348.98
56420       Drainage of gland abscess            T           T        0188        1.2900          59.47       135.59       155.42
56440       Surgery for vulva lesion             T           T        0194       20.5081         945.42      2,155.61     2,470.82
56441       Lysis of labial lesion(s)            T           T        0193       14.8489         684.53      1,560.77     1,789.00
56442       Hymenotomy                           T           T        0193       14.8489         684.53      1,560.77     1,789.00
56501       Destroy, vulva lesions, sim          T           T        0017       17.4423         804.09      1,833.36     2,101.45
56515       Destroy vulva lesion/s compl         T           T        0695       20.4276         941.71      2,147.15     2,461.12
56605       Biopsy of vulva/perineum             T           T        0019        4.0919         188.64       430.10       492.99
56606       Biopsy of vulva/perineum             T           T        0019        4.0919         188.64       430.10       492.99
56620       Partial removal of vulva             T           T        0195       28.5095        1,314.29     2,996.63     3,434.82
56625       Complete removal of vulva            T           T        0195       28.5095        1,314.29     2,996.63     3,434.82
56630       Extensive vulva surgery              C           C        0000        0.0000           0.00        0.00         0.00
56631       Extensive vulva surgery              C           C        0000        0.0000           0.00        0.00         0.00
56632       Extensive vulva surgery              C           C        0000        0.0000           0.00        0.00         0.00
56633       Extensive vulva surgery              C           C        0000        0.0000           0.00        0.00         0.00
56634       Extensive vulva surgery              C           C        0000        0.0000           0.00        0.00         0.00
56637       Extensive vulva surgery              C           C        0000        0.0000           0.00        0.00         0.00
56640       Extensive vulva surgery              C           C        0000        0.0000           0.00        0.00         0.00
56700       Partial removal of hymen             T           T        0194       20.5081         945.42      2,155.61     2,470.82
56740       Remove vagina gland lesion           T           T        0194       20.5081         945.42      2,155.61     2,470.82
56800       Repair of vagina                     T           T        0194       20.5081         945.42      2,155.61     2,470.82
56805       Repair clitoris                      T           T        0193       14.8489         684.53      1,560.77     1,789.00
56810       Repair of perineum                   T           T        0194       20.5081         945.42      2,155.61     2,470.82
56820       Exam of vulva w/scope                T           T        0188        1.2900          59.47       135.59       155.42
56821       Exam/biopsy of vulva w/scope         T           T        0189        2.8966         133.53       304.46       348.98
57000       Exploration of vagina                T           T        0193       14.8489         684.53      1,560.77     1,789.00
57010       Drainage of pelvic abscess           T           T        0193       14.8489         684.53      1,560.77     1,789.00
57020       Drainage of pelvic fluid             T           T        0192        6.6592         306.99       699.95       802.30
57022       I & d vaginal hematoma, pp           T           T        0007       11.1535         514.18      1,172.34     1,343.77
57023       I & d vag hematoma, non-ob           T           T        0008       17.5086         807.15      1,840.33     2,109.44
57061       Destroy vag lesions, simple          T           T        0194       20.5081         945.42      2,155.61     2,470.82
57065       Destroy vag lesions, complex         T           T        0194       20.5081         945.42      2,155.61     2,470.82
57100       Biopsy of vagina                     T           T        0192        6.6592         306.99       699.95       802.30
57105       Biopsy of vagina                     T           T        0194       20.5081         945.42      2,155.61     2,470.82
57106       Remove vagina wall, partial          T           T        0194       20.5081         945.42      2,155.61     2,470.82
57107       Remove vagina tissue, part           T           T        0195       28.5095        1,314.29     2,996.63     3,434.82
57109       Vaginectomy partial w/nodes          T           T        0195       28.5095        1,314.29     2,996.63     3,434.82
57110       Remove vagina wall, complete         C           C        0000        0.0000           0.00        0.00         0.00
57111       Remove vagina tissue, compl          C           C        0000        0.0000           0.00        0.00         0.00
57112       Vaginectomy w/nodes, compl           C           C        0000        0.0000           0.00        0.00         0.00
57120       Closure of vagina                    T           T        0195       28.5095        1,314.29     2,996.63     3,434.82
57130       Remove vagina lesion                 T           T        0194       20.5081         945.42      2,155.61     2,470.82
57135       Remove vagina lesion                 T           T        0194       20.5081         945.42      2,155.61     2,470.82


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 43 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
57150       Treat vagina infection               T           T        0191        0.1468           6.77        15.43        17.69
57155       Insert uteri tandems/ovoids          T           T        0192        6.6592         306.99       699.95       802.30
57160       Insert pessary/other device          T           T        0188        1.2900          59.47       135.59       155.42
57170       Fitting of diaphragm/cap             T           T        0191        0.1468           6.77        15.43        17.69
57180       Treat vaginal bleeding               T           T        0189        2.8966         133.53       304.46       348.98
57200       Repair of vagina                     T           T        0194       20.5081         945.42      2,155.61     2,470.82
57210       Repair vagina/perineum               T           T        0194       20.5081         945.42      2,155.61     2,470.82
57220       Revision of urethra                  T           T        0202       42.9896        1,981.82     4,518.64     5,179.39
57230       Repair of urethral lesion            T           T        0195       28.5095        1,314.29     2,996.63     3,434.82
57240       Repair bladder & vagina              T           T        0195       28.5095        1,314.29     2,996.63     3,434.82
57250       Repair rectum & vagina               T           T        0195       28.5095        1,314.29     2,996.63     3,434.82
57260       Repair of vagina                     T           T        0195       28.5095        1,314.29     2,996.63     3,434.82
57265       Extensive repair of vagina           T           T        0202       42.9896        1,981.82     4,518.64     5,179.39
57267       Insert mesh/pelvic flr addon         T           T        0195       28.5095        1,314.29     2,996.63     3,434.82
57268       Repair of bowel bulge                T           T        0195       28.5095        1,314.29     2,996.63     3,434.82
57270
57280       Repair of bowel pouch
            Suspension of vagina                 C           C        0000        0.0000           0.00         0.00         0.00
57282       Colpopexy, extraperitoneal           T           T        0202       42.9896        1,981.82     4,518.64     5,179.39
57283       Colpopexy, intraperitoneal           T           T        0202       42.9896        1,981.82     4,518.64     5,179.39
57284       Repair paravaginal defect            T           T        0202       42.9896        1,981.82     4,518.64     5,179.39
57287       Revise/remove sling repair           T           T        0195       28.5095        1,314.29     2,996.63     3,434.82
57288       Repair bladder defect                T           T        0202       42.9896        1,981.82     4,518.64     5,179.39
57289       Repair bladder & vagina              T           T        0195       28.5095        1,314.29     2,996.63     3,434.82
57291       Construction of vagina               T           1        0000        0.0000           0.00         0.00         0.00
57292       Construct vagina with graft          T           1        0000        0.0000           0.00         0.00         0.00
57295       Change vaginal graft                 T           1        0000        0.0000           0.00         0.00         0.00
57296       Revise vag graft, open abd           C           C        0000        0.0000           0.00         0.00         0.00
57300       Repair rectum-vagina fistula         T           T        0195       28.5095        1,314.29     2,996.63     3,434.82
57305       Repair rectum-vagina fistula         C           C        0000        0.0000           0.00         0.00         0.00
57307       Fistula repair & colostomy           C           C        0000        0.0000           0.00         0.00         0.00
57308       Fistula repair, transperine          C           C        0000        0.0000           0.00         0.00         0.00
57310       Repair urethrovaginal lesion         T           T        0202       42.9896        1,981.82     4,518.64     5,179.39
57311       Repair urethrovaginal lesion         C           C        0000        0.0000           0.00         0.00         0.00
57320       Repair bladder-vagina lesion         T           T        0195       28.5095        1,314.29     2,996.63     3,434.82
57330       Repair bladder-vagina lesion         T           T        0195       28.5095        1,314.29     2,996.63     3,434.82
57335       Repair vagina                        T           T        0195       28.5095        1,314.29     2,996.63     3,434.82
57400       Dilation of vagina                   T           T        0194       20.5081         945.42      2,155.61     2,470.82
57410       Pelvic examination                   T           T        0193       14.8489         684.53      1,560.77     1,789.00
57415       Remove vaginal foreign body          T           T        0194       20.5081         945.42      2,155.61     2,470.82
57420       Exam of vagina w/scope               T           T        0189        2.8966         133.53       304.46       348.98
57421       Exam/biopsy of vag w/scope           T           T        0189        2.8966         133.53       304.46       348.98
57425       Laparoscopy, surg, colpopexy         T           T        0130       32.1241        1,480.92     3,376.56     3,870.31
57452       Exam of cervix w/scope               T           T        0188        1.2900          59.47       135.59       155.42
57454       Bx/curett of cervix w/scope          T           T        0189        2.8966         133.53       304.46       348.98
57455       Biopsy of cervix w/scope             T           T        0189        2.8966         133.53       304.46       348.98
57456       Endocerv curettage w/scope           T           T        0189        2.8966         133.53       304.46       348.98
57460       Bx of cervix w/scope, leep           T           T        0193       14.8489         684.53      1,560.77     1,789.00
57461       Conz of cervix w/scope, leep         T           T        0194       20.5081         945.42      2,155.61     2,470.82
57500       Biopsy of cervix                     T           T        0189        2.8966         133.53       304.46       348.98
57505       Endocervical curettage               T           T        0189        2.8966         133.53       304.46       348.98
57510       Cauterization of cervix              T           T        0193       14.8489         684.53      1,560.77     1,789.00
57511       Cryocautery of cervix                T           T        0188        1.2900          59.47       135.59       155.42
57513       Laser surgery of cervix              T           T        0193       14.8489         684.53      1,560.77     1,789.00
57520       Conization of cervix                 T           T        0194       20.5081         945.42      2,155.61     2,470.82
57522       Conization of cervix                 T           T        0195       28.5095        1,314.29     2,996.63     3,434.82
57530       Removal of cervix                    T           T        0195       28.5095        1,314.29     2,996.63     3,434.82
57531       Removal of cervix, radical           C           C        0000        0.0000           0.00         0.00         0.00
57540       Removal of residual cervix           C           C        0000        0.0000           0.00         0.00         0.00
57545       Remove cervix/repair pelvis          C           C        0000        0.0000           0.00         0.00         0.00
57550       Removal of residual cervix           T           T        0195       28.5095        1,314.29     2,996.63     3,434.82
57555       Remove cervix/repair vagina          T           T        0195       28.5095        1,314.29     2,996.63     3,434.82
57556       Remove cervix, repair bowel          T           T        0202       42.9896        1,981.82     4,518.64     5,179.39
57558       D&c of cervical stump                T           T        0196       17.7499         818.27      1,865.69     2,138.51
57700       Revision of cervix                   T           T        0194       20.5081         945.42      2,155.61     2,470.82
57720       Revision of cervix                   T           T        0194       20.5081         945.42      2,155.61     2,470.82
57800       Dilation of cervical canal           T           T        0193       14.8489         684.53      1,560.77     1,789.00
58100       Biopsy of uterus lining              T           T        0188        1.2900          59.47       135.59       155.42
58110       Bx done w/colposcopy add-on          T           T        0188        1.2900          59.47       135.59       155.42
58120       Dilation and curettage               T           T        0196       17.7499         818.27      1,865.69     2,138.51
58140       Myomectomy abdom method              C           C        0000        0.0000           0.00         0.00         0.00
58145       Myomectomy vag method                T           T        0195       28.5095        1,314.29     2,996.63     3,434.82
58146       Myomectomy abdom complex             C           C        0000        0.0000           0.00         0.00         0.00
58150       Total hysterectomy                   C           C        0000        0.0000           0.00         0.00         0.00
58152       Total hysterectomy                   C           C        0000        0.0000           0.00         0.00         0.00
58180       Partial hysterectomy                 C           C        0000        0.0000           0.00         0.00         0.00
58200       Extensive hysterectomy               C           C        0000        0.0000           0.00         0.00         0.00
58210       Extensive hysterectomy               C           C        0000        0.0000           0.00         0.00         0.00
58240       Removal of pelvis contents           C           C        0000        0.0000           0.00         0.00         0.00
58260       Vaginal hysterectomy                 T           T        0195       28.5095        1,314.29     2,996.63     3,434.82
58262       Vag hyst including t/o               T           T        0195       28.5095        1,314.29     2,996.63     3,434.82
58263       Vag hyst w/t/o & vag repair          T           T        0195       28.5095        1,314.29     2,996.63     3,434.82
58267       Vag hyst w/urinary repair            C           C        0000        0.0000           0.00         0.00         0.00
58270       Vag hyst w/enterocele repair         T           T        0195       28.5095        1,314.29     2,996.63     3,434.82
58275       Hysterectomy/revise vagina           C           C        0000        0.0000           0.00         0.00         0.00
58280       Hysterectomy/revise vagina           C           C        0000        0.0000           0.00         0.00         0.00
58285       Extensive hysterectomy               C           C        0000        0.0000           0.00         0.00         0.00
58290       Vag hyst complex                     T           T        0202       42.9896        1,981.82     4,518.64     5,179.39
58291       Vag hyst incl t/o, complex           T           T        0202       42.9896        1,981.82     4,518.64     5,179.39
58292       Vag hyst t/o & repair, compl         T           T        0202       42.9896        1,981.82     4,518.64     5,179.39
58293       Vag hyst w/uro repair, compl         C           C        0000        0.0000           0.00         0.00         0.00
58294       Vag hyst w/enterocele, compl         T           T        0202       42.9896        1,981.82     4,518.64     5,179.39
58300       Insert intrauterine device           E           3        0000        0.0000           M01          M01          M01
58301       Remove intrauterine device           T           T        0188        1.2900          59.47       135.59       155.42
58321       Artificial insemination              T           1        0000        0.0000           0.00         0.00         0.00
58322       Artificial insemination              T           1        0000        0.0000           0.00         0.00         0.00
58323       Sperm washing                        T           1        0000        0.0000           0.00         0.00         0.00
58340       Catheter for hysterography           N           1        0000        0.0000           0.00         0.00         0.00
58345       Reopen fallopian tube                T           1        0000        0.0000           0.00         0.00         0.00
58346       Insert heyman uteri capsule          T           1        0000        0.0000           0.00         0.00         0.00
58350       Reopen fallopian tube                T           1        0000        0.0000           0.00         0.00         0.00
58353       Endometr ablate, thermal             T           T        0195       28.5095        1,314.29     2,996.63     3,434.82
58356       Endometrial cryoablation             T           T        0202       42.9896        1,981.82     4,518.64     5,179.39
58400       Suspension of uterus                 C           C        0000        0.0000           0.00         0.00         0.00
58410       Suspension of uterus                 C           C        0000        0.0000           0.00         0.00         0.00
58520       Repair of ruptured uterus            C           C        0000        0.0000           0.00         0.00         0.00
58540       Revision of uterus                   C           C        0000        0.0000           0.00         0.00         0.00



                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 44 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
58541       Lsh, uterus 250 g or less            T           T        0131       43.5488        2,007.60     4,577.41     5,246.76
58542       Lsh w/t/o ut 250 g or less           T           T        0131       43.5488        2,007.60     4,577.41     5,246.76
58543       Lsh uterus above 250 g               T           T        0131       43.5488        2,007.60     4,577.41     5,246.76
58544       Lsh w/t/o uterus above 250 g         T           T        0131       43.5488        2,007.60     4,577.41     5,246.76
58545       Laparoscopic myomectomy              T           T        0130       32.1241        1,480.92     3,376.56     3,870.31
58546       Laparo-myomectomy, complex           T           T        0131       43.5488        2,007.60     4,577.41     5,246.76
58548       Lap radical hyst                     C           C        0000        0.0000           0.00        0.00         0.00
58550       Laparo-asst vag hysterectomy         T           T        0132       70.5066        3,250.35     7,410.95     8,494.64
58552       Laparo-vag hyst incl t/o             T           T        0131       43.5488        2,007.60     4,577.41     5,246.76
58553       Laparo-vag hyst, complex             T           T        0131       43.5488        2,007.60     4,577.41     5,246.76
58554       Laparo-vag hyst w/t/o, compl         T           T        0131       43.5488        2,007.60     4,577.41     5,246.76
58555       Hysteroscopy, dx, sep proc           T           T        0190       21.3586         984.63      2,245.00     2,573.28
58558       Hysteroscopy, biopsy                 T           T        0190       21.3586         984.63      2,245.00     2,573.28
58559       Hysteroscopy, lysis                  T           T        0190       21.3586         984.63      2,245.00     2,573.28
58560       Hysteroscopy, resect septum          T           T        0387       34.0155        1,568.11     3,575.37     4,098.19
58561       Hysteroscopy, remove myoma           T           T        0387       34.0155        1,568.11     3,575.37     4,098.19
58562       Hysteroscopy, remove fb              T           T        0190       21.3586         984.63      2,245.00     2,573.28
58563       Hysteroscopy, ablation               T           T        0387       34.0155        1,568.11     3,575.37     4,098.19
58565       Hysteroscopy, sterilization          T           T        0202       42.9896        1,981.82     4,518.64     5,179.39
58578       Laparo proc, uterus                  T           1        0000        0.0000           0.00        0.00         0.00
58579       Hysteroscope procedure               T           1        0000        0.0000           0.00        0.00         0.00
58600       Division of fallopian tube           T           T        0195       28.5095        1,314.29     2,996.63     3,434.82
58605       Division of fallopian tube           C           C        0000        0.0000           0.00        0.00         0.00
58611       Ligate oviduct(s) add-on             C           C        0000        0.0000           0.00        0.00         0.00
58615       Occlude fallopian tube(s)            T           T        0194       20.5081         945.42      2,155.61     2,470.82
58660       Laparoscopy, lysis                   T           T        0131       43.5488        2,007.60     4,577.41     5,246.76
58661       Laparoscopy, remove adnexa           T           T        0131       43.5488        2,007.60     4,577.41     5,246.76
58662       Laparoscopy, excise lesions          T           T        0131       43.5488        2,007.60     4,577.41     5,246.76
58670       Laparoscopy, tubal cautery           T           T        0131       43.5488        2,007.60     4,577.41     5,246.76
58671       Laparoscopy, tubal block             T           T        0131       43.5488        2,007.60     4,577.41     5,246.76
58672       Laparoscopy, fimbrioplasty           T           T        0131       43.5488        2,007.60     4,577.41     5,246.76
58673       Laparoscopy, salpingostomy           T           T        0131       43.5488        2,007.60     4,577.41     5,246.76
58679       Laparo proc, oviduct-ovary           T           1        0000        0.0000           0.00        0.00         0.00
58700       Removal of fallopian tube            C           C        0000        0.0000           0.00        0.00         0.00
58720       Removal of ovary/tube(s)             C           C        0000        0.0000           0.00        0.00         0.00
58740       Revise fallopian tube(s)             C           C        0000        0.0000           0.00        0.00         0.00
58750       Repair oviduct                       C           1        0000        0.0000           0.00        0.00         0.00
58752       Revise ovarian tube(s)               C           1        0000        0.0000           0.00        0.00         0.00
58760       Remove tubal obstruction             C           1        0000        0.0000           0.00        0.00         0.00
58770       Create new tubal opening             T           1        0000        0.0000           0.00        0.00         0.00
58800       Drainage of ovarian cyst(s)          T           T        0193       14.8489         684.53      1,560.77     1,789.00
58805       Drainage of ovarian cyst(s)          C           C        0000        0.0000           0.00        0.00         0.00
58820       Drain ovary abscess, open            T           T        0195       28.5095        1,314.29     2,996.63     3,434.82
58822       Drain ovary abscess, percut          C           C        0000        0.0000           0.00        0.00         0.00
58823       Drain pelvic abscess, percut         T           T        0193       14.8489         684.53      1,560.77     1,789.00
58825       Transposition, ovary(s)              C           C        0000        0.0000           0.00        0.00         0.00
58900       Biopsy of ovary(s)                   T           T        0193       14.8489         684.53      1,560.77     1,789.00
58920       Partial removal of ovary(s)          T           T        0195       28.5095        1,314.29     2,996.63     3,434.82
58925       Removal of ovarian cyst(s)           T           T        0195       28.5095        1,314.29     2,996.63     3,434.82
58940       Removal of ovary(s)                  C           C        0000        0.0000           0.00        0.00         0.00
58943       Removal of ovary(s)                  C           C        0000        0.0000           0.00        0.00         0.00
58950       Resect ovarian malignancy            C           C        0000        0.0000           0.00        0.00         0.00
58951       Resect ovarian malignancy            C           C        0000        0.0000           0.00        0.00         0.00
58952       Resect ovarian malignancy            C           C        0000        0.0000           0.00        0.00         0.00
58953       Tah, rad dissect for debulk          C           C        0000        0.0000           0.00        0.00         0.00
58954       Tah rad debulk/lymph remove          C           C        0000        0.0000           0.00        0.00         0.00
58956       Bso, omentectomy w/tah               C           C        0000        0.0000           0.00        0.00         0.00
58957       Resect recurrent gyn mal             C           C        0000        0.0000           0.00        0.00         0.00
58958       Resect recur gyn mal w/lym           C           C        0000        0.0000           0.00        0.00         0.00
58960       Exploration of abdomen               C           C        0000        0.0000           0.00        0.00         0.00
58970       Retrieval of oocyte                  T           1        0000        0.0000           0.00        0.00         0.00
58974       Transfer of embryo                   T           1        0000        0.0000           0.00        0.00         0.00
58976       Transfer of embryo                   T           1        0000        0.0000           0.00        0.00         0.00
58999       Genital surgery procedure            T           1        0000        0.0000           0.00        0.00         0.00
59000       Amniocentesis, diagnostic            T           T        0198        1.4222          65.56       149.49       171.35
59001       Amniocentesis, therapeutic           T           T        0192        6.6592         306.99       699.95       802.30
59012       Fetal cord puncture,prenatal         T           T        0198        1.4222          65.56       149.49       171.35
59015       Chorion biopsy                       T           T        0198        1.4222          65.56       149.49       171.35
59020       Fetal contract stress test           T           T        0189        2.8966         133.53       304.46       348.98
59025       Fetal non-stress test                T           T        0198        1.4222          65.56       149.49       171.35
59030       Fetal scalp blood sample             T           T        0198        1.4222          65.56       149.49       171.35
59050       Fetal monitor w/report               M           1        0000        0.0000           0.00        0.00         0.00
59051       Fetal monitor/interpret only         B           B        0000        0.0000           0.00        0.00         0.00
59070       Transabdom amnioinfus w/us           T           T        0198        1.4222          65.56       149.49       171.35
59072       Umbilical cord occlud w/us           T           T        0198        1.4222          65.56       149.49       171.35
59074       Fetal fluid drainage w/us            T           T        0198        1.4222          65.56       149.49       171.35
59076       Fetal shunt placement, w/us          T           T        0198        1.4222          65.56       149.49       171.35
59100       Remove uterus lesion                 T           T        0195       28.5095        1,314.29     2,996.63     3,434.82
59120       Treat ectopic pregnancy              C           C        0000        0.0000           0.00        0.00         0.00
59121       Treat ectopic pregnancy              C           C        0000        0.0000           0.00        0.00         0.00
59130       Treat ectopic pregnancy              C           C        0000        0.0000           0.00        0.00         0.00
59135       Treat ectopic pregnancy              C           C        0000        0.0000           0.00        0.00         0.00
59136       Treat ectopic pregnancy              C           C        0000        0.0000           0.00        0.00         0.00
59140       Treat ectopic pregnancy              C           C        0000        0.0000           0.00        0.00         0.00
59150       Treat ectopic pregnancy              T           T        0131       43.5488        2,007.60     4,577.41     5,246.76
59151       Treat ectopic pregnancy              T           T        0131       43.5488        2,007.60     4,577.41     5,246.76
59160       D & c after delivery                 T           T        0196       17.7499         818.27      1,865.69     2,138.51
59200       Insert cervical dilator              T           T        0189        2.8966         133.53       304.46       348.98
59300       Episiotomy or vaginal repair         T           T        0193       14.8489         684.53      1,560.77     1,789.00
59320       Revision of cervix                   T           T        0194       20.5081         945.42      2,155.61     2,470.82
59325       Revision of cervix                   C           C        0000        0.0000           0.00        0.00         0.00
59350       Repair of uterus                     C           C        0000        0.0000           0.00        0.00         0.00
59400       Obstetrical care                     B           B        0000        0.0000           0.00        0.00         0.00
59409       Obstetrical care                     T           T        0194       20.5081         945.42      2,155.61     2,470.82
59410       Obstetrical care                     B           B        0000        0.0000           0.00        0.00         0.00
59412       Antepartum manipulation              T           T        0700        2.3864         110.01       250.83       287.51
59414       Deliver placenta                     T           T        0193       14.8489         684.53      1,560.77     1,789.00
59425       Antepartum care only                 B           B        0000        0.0000           0.00        0.00         0.00
59426       Antepartum care only                 B           B        0000        0.0000           0.00        0.00         0.00
59430       Care after delivery                  B           B        0000        0.0000           0.00        0.00         0.00
59510       Cesarean delivery                    B           B        0000        0.0000           0.00        0.00         0.00
59514       Cesarean delivery only               C           C        0000        0.0000           0.00        0.00         0.00
59515       Cesarean delivery                    B           B        0000        0.0000           0.00        0.00         0.00
59525       Remove uterus after cesarean         C           C        0000        0.0000           0.00        0.00         0.00
59610       Vbac delivery                        B           B        0000        0.0000           0.00        0.00         0.00
59612       Vbac delivery only                   T           T        0194       20.5081         945.42      2,155.61     2,470.82


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 45 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
59614       Vbac care after delivery             B           B        0000        0.0000           0.00        0.00         0.00
59618       Attempted vbac delivery              B           B        0000        0.0000           0.00        0.00         0.00
59620       Attempted vbac delivery only         C           C        0000        0.0000           0.00        0.00         0.00
59622       Attempted vbac after care            B           B        0000        0.0000           0.00        0.00         0.00
59812       Treatment of miscarriage             T           T        0201       18.5201         853.78      1,946.65     2,231.30
59820       Care of miscarriage                  T           T        0201       18.5201         853.78      1,946.65     2,231.30
59821       Treatment of miscarriage             T           T        0201       18.5201         853.78      1,946.65     2,231.30
59830       Treat uterus infection               C           C        0000        0.0000           0.00        0.00         0.00
59840       Abortion                             T           T        0200       16.9328         780.60      1,779.81     2,040.06
59841       Abortion                             T           T        0200       16.9328         780.60      1,779.81     2,040.06
59850       Abortion                             C           C        0000        0.0000           0.00        0.00         0.00
59851       Abortion                             C           C        0000        0.0000           0.00        0.00         0.00
59852       Abortion                             C           C        0000        0.0000           0.00        0.00         0.00
59855       Abortion                             C           C        0000        0.0000           0.00        0.00         0.00
59856       Abortion                             C           C        0000        0.0000           0.00        0.00         0.00
59857       Abortion                             C           C        0000        0.0000           0.00        0.00         0.00
59866       Abortion (mpr)                       T           T        0198        1.4222          65.56       149.49       171.35
59870       Evacuate mole of uterus              T           T        0201       18.5201         853.78      1,946.65     2,231.30
59871       Remove cerclage suture               T           T        0194       20.5081         945.42      2,155.61     2,470.82
59897       Fetal invas px w/us                  T           1        0000        0.0000           0.00        0.00         0.00
59898       Laparo proc, ob care/deliver         T           1        0000        0.0000           0.00        0.00         0.00
59899       Maternity care procedure             T           1        0000        0.0000           0.00        0.00         0.00
60000       Drain thyroid/tongue cyst            T           T        0252        7.5511         348.11       793.70       909.76
60001       Aspirate/inject thyriod cyst         T           T        0004        2.0687          95.37       217.44       249.24
60100       Biopsy of thyroid                    T           T        0004        2.0687          95.37       217.44       249.24
60200       Remove thyroid lesion                T           T        0114       37.7224        1,739.00     3,965.00     4,544.79
60210       Partial thyroid excision             T           T        0114       37.7224        1,739.00     3,965.00     4,544.79
60212       Partial thyroid excision             T           T        0114       37.7224        1,739.00     3,965.00     4,544.79
60220       Partial removal of thyroid           T           T        0114       37.7224        1,739.00     3,965.00     4,544.79
60225       Partial removal of thyroid           T           T        0114       37.7224        1,739.00     3,965.00     4,544.79
60240       Removal of thyroid                   T           T        0114       37.7224        1,739.00     3,965.00     4,544.79
60252       Removal of thyroid                   T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
60254       Extensive thyroid surgery            C           C        0000        0.0000           0.00        0.00         0.00
60260       Repeat thyroid surgery               T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
60270       Removal of thyroid                   C           C        0000        0.0000           0.00        0.00         0.00
60271       Removal of thyroid                   C           C        0000        0.0000           0.00        0.00         0.00
60280       Remove thyroid duct lesion           T           T        0114       37.7224        1,739.00     3,965.00     4,544.79
60281       Remove thyroid duct lesion           T           T        0114       37.7224        1,739.00     3,965.00     4,544.79
60500       Explore parathyroid glands           T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
60502       Re-explore parathyroids              T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
60505       Explore parathyroid glands           C           C        0000        0.0000           0.00        0.00         0.00
60512       Autotransplant parathyroid           T           1        0000        0.0000           0.00        0.00         0.00
60520       Removal of thymus gland              T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
60521       Removal of thymus gland              C           C        0000        0.0000           0.00        0.00         0.00
60522       Removal of thymus gland              C           C        0000        0.0000           0.00        0.00         0.00
60540       Explore adrenal gland                C           C        0000        0.0000           0.00        0.00         0.00
60545       Explore adrenal gland                C           C        0000        0.0000           0.00        0.00         0.00
60600       Remove carotid body lesion           C           C        0000        0.0000           0.00        0.00         0.00
60605       Remove carotid body lesion           C           C        0000        0.0000           0.00        0.00         0.00
60650       Laparoscopy adrenalectomy            C           C        0000        0.0000           0.00        0.00         0.00
60659       Laparo proc, endocrine               T           1        0000        0.0000           0.00        0.00         0.00
60699       Endocrine surgery procedure          T           1        0000        0.0000           0.00        0.00         0.00
61000       Remove cranial cavity fluid          T           T        0212        2.9907         137.87       314.35       360.32
61001       Remove cranial cavity fluid          T           T        0212        2.9907         137.87       314.35       360.32
61020       Remove brain cavity fluid            T           T        0212        2.9907         137.87       314.35       360.32
61026       Injection into brain canal           T           T        0212        2.9907         137.87       314.35       360.32
61050       Remove brain canal fluid             T           T        0212        2.9907         137.87       314.35       360.32
61055       Injection into brain canal           T           T        0212        2.9907         137.87       314.35       360.32
61070       Brain canal shunt procedure          T           T        0212        2.9907         137.87       314.35       360.32
61105       Twist drill hole                     C           C        0000        0.0000           0.00        0.00         0.00
61107       Drill skull for implantation         C           C        0000        0.0000           0.00        0.00         0.00
61108       Drill skull for drainage             C           C        0000        0.0000           0.00        0.00         0.00
61120       Burr hole for puncture               C           C        0000        0.0000           0.00        0.00         0.00
61140       Pierce skull for biopsy              C           C        0000        0.0000           0.00        0.00         0.00
61150       Pierce skull for drainage            C           C        0000        0.0000           0.00        0.00         0.00
61151       Pierce skull for drainage            C           C        0000        0.0000           0.00        0.00         0.00
61154       Pierce skull & remove clot           C           C        0000        0.0000           0.00        0.00         0.00
61156       Pierce skull for drainage            C           C        0000        0.0000           0.00        0.00         0.00
61210       Pierce skull, implant device         C           C        0000        0.0000           0.00        0.00         0.00
61215       Insert brain-fluid device            T           T        0224       47.0342        2,168.28     4,943.76     5,666.68
61250       Pierce skull & explore               C           C        0000        0.0000           0.00        0.00         0.00
61253       Pierce skull & explore               C           C        0000        0.0000           0.00        0.00         0.00
61304       Open skull for exploration           C           C        0000        0.0000           0.00        0.00         0.00
61305       Open skull for exploration           C           C        0000        0.0000           0.00        0.00         0.00
61312       Open skull for drainage              C           C        0000        0.0000           0.00        0.00         0.00
61313       Open skull for drainage              C           C        0000        0.0000           0.00        0.00         0.00
61314       Open skull for drainage              C           C        0000        0.0000           0.00        0.00         0.00
61315       Open skull for drainage              C           C        0000        0.0000           0.00        0.00         0.00
61316       Implt cran bone flap to abdo         C           C        0000        0.0000           0.00        0.00         0.00
61320       Open skull for drainage              C           C        0000        0.0000           0.00        0.00         0.00
61321       Open skull for drainage              C           C        0000        0.0000           0.00        0.00         0.00
61322       Decompressive craniotomy             C           C        0000        0.0000           0.00        0.00         0.00
61323       Decompressive lobectomy              C           C        0000        0.0000           0.00        0.00         0.00
61330       Decompress eye socket                T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
61332       Explore/biopsy eye socket            C           C        0000        0.0000           0.00        0.00         0.00
61333       Explore orbit/remove lesion          C           C        0000        0.0000           0.00        0.00         0.00
61334       Explore orbit/remove object          T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
61340       Subtemporal decompression            C           C        0000        0.0000           0.00        0.00         0.00
61343       Incise skull (press relief)          C           C        0000        0.0000           0.00        0.00         0.00
61345       Relieve cranial pressure             C           C        0000        0.0000           0.00        0.00         0.00
61440       Incise skull for surgery             C           C        0000        0.0000           0.00        0.00         0.00
61450       Incise skull for surgery             C           C        0000        0.0000           0.00        0.00         0.00
61458       Incise skull for brain wound         C           C        0000        0.0000           0.00        0.00         0.00
61460       Incise skull for surgery             C           C        0000        0.0000           0.00        0.00         0.00
61470       Incise skull for surgery             C           C        0000        0.0000           0.00        0.00         0.00
61480       Incise skull for surgery             C           C        0000        0.0000           0.00        0.00         0.00
61490       Incise skull for surgery             C           C        0000        0.0000           0.00        0.00         0.00
61500       Removal of skull lesion              C           C        0000        0.0000           0.00        0.00         0.00
61501       Remove infected skull bone           C           C        0000        0.0000           0.00        0.00         0.00
61510       Removal of brain lesion              C           C        0000        0.0000           0.00        0.00         0.00
61512       Remove brain lining lesion           C           C        0000        0.0000           0.00        0.00         0.00
61514       Removal of brain abscess             C           C        0000        0.0000           0.00        0.00         0.00
61516       Removal of brain lesion              C           C        0000        0.0000           0.00        0.00         0.00
61517       Implt brain chemotx add-on           C           C        0000        0.0000           0.00        0.00         0.00
61518       Removal of brain lesion              C           C        0000        0.0000           0.00        0.00         0.00
61519       Remove brain lining lesion           C           C        0000        0.0000           0.00        0.00         0.00


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 46 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
61520       Removal of brain lesion              C           C        0000        0.0000          0.00         0.00         0.00
61521       Removal of brain lesion              C           C        0000        0.0000          0.00         0.00         0.00
61522       Removal of brain abscess             C           C        0000        0.0000          0.00         0.00         0.00
61524       Removal of brain lesion              C           C        0000        0.0000          0.00         0.00         0.00
61526       Removal of brain lesion              C           C        0000        0.0000          0.00         0.00         0.00
61530       Removal of brain lesion              C           C        0000        0.0000          0.00         0.00         0.00
61531       Implant brain electrodes             C           C        0000        0.0000          0.00         0.00         0.00
61533       Implant brain electrodes             C           C        0000        0.0000          0.00         0.00         0.00
61534       Removal of brain lesion              C           C        0000        0.0000          0.00         0.00         0.00
61535       Remove brain electrodes              C           C        0000        0.0000          0.00         0.00         0.00
61536       Removal of brain lesion              C           C        0000        0.0000          0.00         0.00         0.00
61537       Removal of brain tissue              C           C        0000        0.0000          0.00         0.00         0.00
61538       Removal of brain tissue              C           C        0000        0.0000          0.00         0.00         0.00
61539       Removal of brain tissue              C           C        0000        0.0000          0.00         0.00         0.00
61540       Removal of brain tissue              C           C        0000        0.0000          0.00         0.00         0.00
61541       Incision of brain tissue             C           C        0000        0.0000          0.00         0.00         0.00
61542       Removal of brain tissue              C           C        0000        0.0000          0.00         0.00         0.00
61543       Removal of brain tissue              C           C        0000        0.0000          0.00         0.00         0.00
61544       Remove & treat brain lesion          C           C        0000        0.0000          0.00         0.00         0.00
61545       Excision of brain tumor              C           C        0000        0.0000          0.00         0.00         0.00
61546       Removal of pituitary gland           C           C        0000        0.0000          0.00         0.00         0.00
61548       Removal of pituitary gland           C           C        0000        0.0000          0.00         0.00         0.00
61550       Release of skull seams               C           C        0000        0.0000          0.00         0.00         0.00
61552       Release of skull seams               C           C        0000        0.0000          0.00         0.00         0.00
61556       Incise skull/sutures                 C           C        0000        0.0000          0.00         0.00         0.00
61557       Incise skull/sutures                 C           C        0000        0.0000          0.00         0.00         0.00
61558       Excision of skull/sutures            C           C        0000        0.0000          0.00         0.00         0.00
61559       Excision of skull/sutures            C           C        0000        0.0000          0.00         0.00         0.00
61563       Excision of skull tumor              C           C        0000        0.0000          0.00         0.00         0.00
61564       Excision of skull tumor              C           C        0000        0.0000          0.00         0.00         0.00
61566       Removal of brain tissue              C           C        0000        0.0000          0.00         0.00         0.00
61567       Incision of brain tissue             C           C        0000        0.0000          0.00         0.00         0.00
61570       Remove foreign body, brain           C           C        0000        0.0000          0.00         0.00         0.00
61571       Incise skull for brain wound         C           C        0000        0.0000          0.00         0.00         0.00
61575       Skull base/brainstem surgery         C           C        0000        0.0000          0.00         0.00         0.00
61576       Skull base/brainstem surgery         C           C        0000        0.0000          0.00         0.00         0.00
61580       Craniofacial approach, skull         C           C        0000        0.0000          0.00         0.00         0.00
61581       Craniofacial approach, skull         C           C        0000        0.0000          0.00         0.00         0.00
61582       Craniofacial approach, skull         C           C        0000        0.0000          0.00         0.00         0.00
61583       Craniofacial approach, skull         C           C        0000        0.0000          0.00         0.00         0.00
61584       Orbitocranial approach/skull         C           C        0000        0.0000          0.00         0.00         0.00
61585       Orbitocranial approach/skull         C           C        0000        0.0000          0.00         0.00         0.00
61586       Resect nasopharynx, skull            C           C        0000        0.0000          0.00         0.00         0.00
61590       Infratemporal approach/skull         C           C        0000        0.0000          0.00         0.00         0.00
61591       Infratemporal approach/skull         C           C        0000        0.0000          0.00         0.00         0.00
61592       Orbitocranial approach/skull         C           C        0000        0.0000          0.00         0.00         0.00
61595       Transtemporal approach/skull         C           C        0000        0.0000          0.00         0.00         0.00
61596       Transcochlear approach/skull         C           C        0000        0.0000          0.00         0.00         0.00
61597       Transcondylar approach/skull         C           C        0000        0.0000          0.00         0.00         0.00
61598       Transpetrosal approach/skull         C           C        0000        0.0000          0.00         0.00         0.00
61600       Resect/excise cranial lesion         C           C        0000        0.0000          0.00         0.00         0.00
61601       Resect/excise cranial lesion         C           C        0000        0.0000          0.00         0.00         0.00
61605       Resect/excise cranial lesion         C           C        0000        0.0000          0.00         0.00         0.00
61606       Resect/excise cranial lesion         C           C        0000        0.0000          0.00         0.00         0.00
61607       Resect/excise cranial lesion         C           C        0000        0.0000          0.00         0.00         0.00
61608       Resect/excise cranial lesion         C           C        0000        0.0000          0.00         0.00         0.00
61609       Transect artery, sinus               C           C        0000        0.0000          0.00         0.00         0.00
61610       Transect artery, sinus               C           C        0000        0.0000          0.00         0.00         0.00
61611       Transect artery, sinus               C           C        0000        0.0000          0.00         0.00         0.00
61612       Transect artery, sinus               C           C        0000        0.0000          0.00         0.00         0.00
61613       Remove aneurysm, sinus               C           C        0000        0.0000          0.00         0.00         0.00
61615       Resect/excise lesion, skull          C           C        0000        0.0000          0.00         0.00         0.00
61616       Resect/excise lesion, skull          C           C        0000        0.0000          0.00         0.00         0.00
61618       Repair dura                          C           C        0000        0.0000          0.00         0.00         0.00
61619       Repair dura                          C           C        0000        0.0000          0.00         0.00         0.00
61623       Endovasc tempory vessel occl         T           T        0081       42.9360        1,979.35     4,513.00     5,172.93
61624       Transcath occlusion, cns             C           C        0000        0.0000          0.00         0.00         0.00
61626       Transcath occlusion, non-cns         T           T        0081       42.9360        1,979.35     4,513.00     5,172.93
61630       Intracranial angioplasty             E           3        0000        0.0000          M01          M01          M01
61635       Intracran angioplsty w/stent         E           3        0000        0.0000          M01          M01          M01
61640       Dilate ic vasospasm, init            E           3        0000        0.0000          M01          M01          M01
61641       Dilate ic vasospasm add-on           E           3        0000        0.0000          M01          M01          M01
61642       Dilate ic vasospasm add-on           E           3        0000        0.0000          M01          M01          M01
61680       Intracranial vessel surgery          C           C        0000        0.0000          0.00         0.00         0.00
61682       Intracranial vessel surgery          C           C        0000        0.0000          0.00         0.00         0.00
61684       Intracranial vessel surgery          C           C        0000        0.0000          0.00         0.00         0.00
61686       Intracranial vessel surgery          C           C        0000        0.0000          0.00         0.00         0.00
61690       Intracranial vessel surgery          C           C        0000        0.0000          0.00         0.00         0.00
61692       Intracranial vessel surgery          C           C        0000        0.0000          0.00         0.00         0.00
61697       Brain aneurysm repr, complx          C           C        0000        0.0000          0.00         0.00         0.00
61698       Brain aneurysm repr, complx          C           C        0000        0.0000          0.00         0.00         0.00
61700       Brain aneurysm repr, simple          C           C        0000        0.0000          0.00         0.00         0.00
61702       Inner skull vessel surgery           C           C        0000        0.0000          0.00         0.00         0.00
61703       Clamp neck artery                    C           C        0000        0.0000          0.00         0.00         0.00
61705       Revise circulation to head           C           C        0000        0.0000          0.00         0.00         0.00
61708       Revise circulation to head           C           C        0000        0.0000          0.00         0.00         0.00
61710       Revise circulation to head           C           C        0000        0.0000          0.00         0.00         0.00
61711       Fusion of skull arteries             C           C        0000        0.0000          0.00         0.00         0.00
61720       Incise skull/brain surgery           T           T        0221       33.1520        1,528.31     3,484.61     3,994.15
61735       Incise skull/brain surgery           C           C        0000        0.0000          0.00         0.00         0.00
61750       Incise skull/brain biopsy            C           C        0000        0.0000          0.00         0.00         0.00
61751       Brain biopsy w/ct/mr guide           C           C        0000        0.0000          0.00         0.00         0.00
61760       Implant brain electrodes             C           C        0000        0.0000          0.00         0.00         0.00
61770       Incise skull for treatment           C           C        0000        0.0000          0.00         0.00         0.00
61790       Treat trigeminal nerve               T           T        0220       17.8499         822.88      1,876.20     2,150.56
61791       Treat trigeminal tract               T           T        0206        5.7253         263.94       601.79       689.78
61793       Focus radiation beam                 B           B        0000        0.0000          0.00         0.00         0.00
61795       Brain surgery using computer         S           S        0302        4.9138         226.53       516.49       592.01
61850       Implant neuroelectrodes              C           C        0000        0.0000          0.00         0.00         0.00
61860       Implant neuroelectrodes              C           C        0000        0.0000          0.00         0.00         0.00
61863       Implant neuroelectrode               C           C        0000        0.0000          0.00         0.00         0.00
61864       Implant neuroelectrde, add’l         C           C        0000        0.0000          0.00         0.00         0.00
61867       Implant neuroelectrode               C           C        0000        0.0000          0.00         0.00         0.00
61868       Implant neuroelectrde, add’l         C           C        0000        0.0000          0.00         0.00         0.00
61870       Implant neuroelectrodes              C           C        0000        0.0000          0.00         0.00         0.00
61875       Implant neuroelectrodes              C           C        0000        0.0000          0.00         0.00         0.00


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 47 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
61880       Revise/remove neuroelectrode         T           T        0687       17.8334         822.12      1,874.47     2,148.57
61885       Insrt/redo neurostim 1 array         S           S        0039      187.3821        8,638.31    19,695.73    22,575.80
61886       Implant neurostim arrays             T           T        0315      242.9363       11,199.36    25,535.03    29,268.97
61888       Revise/remove neuroreceiver          T           T        0688       35.5702        1,639.79     3,738.78     4,285.50
62000       Treat skull fracture                 T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
62005       Treat skull fracture                 C           C        0000        0.0000          0.00         0.00         0.00
62010       Treatment of head injury             C           C        0000        0.0000          0.00         0.00         0.00
62100       Repair brain fluid leakage           C           C        0000        0.0000          0.00         0.00         0.00
62115       Reduction of skull defect            C           C        0000        0.0000          0.00         0.00         0.00
62116       Reduction of skull defect            C           C        0000        0.0000          0.00         0.00         0.00
62117       Reduction of skull defect            C           C        0000        0.0000          0.00         0.00         0.00
62120       Repair skull cavity lesion           C           C        0000        0.0000          0.00         0.00         0.00
62121       Incise skull repair                  C           C        0000        0.0000          0.00         0.00         0.00
62140       Repair of skull defect               C           C        0000        0.0000          0.00         0.00         0.00
62141       Repair of skull defect               C           C        0000        0.0000          0.00         0.00         0.00
62142       Remove skull plate/flap              C           C        0000        0.0000          0.00         0.00         0.00
62143       Replace skull plate/flap             C           C        0000        0.0000          0.00         0.00         0.00
62145       Repair of skull & brain              C           C        0000        0.0000          0.00         0.00         0.00
62146       Repair of skull with graft           C           C        0000        0.0000          0.00         0.00         0.00
62147       Repair of skull with graft           C           C        0000        0.0000          0.00         0.00         0.00
62148       Retr bone flap to fix skull          C           C        0000        0.0000          0.00         0.00         0.00
62160       Neuroendoscopy add-on                T           T        0122        7.4800         344.83       786.22       901.19
62161       Dissect brain w/scope                C           C        0000        0.0000          0.00         0.00         0.00
62162       Remove colloid cyst w/scope          C           C        0000        0.0000          0.00         0.00         0.00
62163       Neuroendoscopy w/fb removal          C           C        0000        0.0000          0.00         0.00         0.00
62164       Remove brain tumor w/scope           C           C        0000        0.0000          0.00         0.00         0.00
62165       Remove pituit tumor w/scope          C           C        0000        0.0000          0.00         0.00         0.00
62180       Establish brain cavity shunt         C           C        0000        0.0000          0.00         0.00         0.00
62190       Establish brain cavity shunt         C           C        0000        0.0000          0.00         0.00         0.00
62192       Establish brain cavity shunt         C           C        0000        0.0000          0.00         0.00         0.00
62194       Replace/irrigate catheter            T           T        0427       11.6575         537.41      1,225.32     1,404.50
62200       Establish brain cavity shunt         C           C        0000        0.0000          0.00         0.00         0.00
62201       Brain cavity shunt w/scope           C           C        0000        0.0000          0.00         0.00         0.00
62220       Establish brain cavity shunt         C           C        0000        0.0000          0.00         0.00         0.00
62223       Establish brain cavity shunt         C           C        0000        0.0000          0.00         0.00         0.00
62225       Replace/irrigate catheter            T           T        0427       11.6575         537.41      1,225.32     1,404.50
62230       Replace/revise brain shunt           T           T        0224       47.0342        2,168.28     4,943.76     5,666.68
62252       Csf shunt reprogram                  S           S        0691        2.8942         133.42       304.21       348.69
62256       Remove brain cavity shunt            C           C        0000        0.0000          0.00         0.00         0.00
62258       Replace brain cavity shunt           C           C        0000        0.0000          0.00         0.00         0.00
62263       Epidural lysis mult sessions         T           T        0203       12.1702         561.05      1,279.21     1,466.27
62264       Epidural lysis on single day         T           T        0203       12.1702         561.05      1,279.21     1,466.27
62268       Drain spinal cord cyst               T           T        0212        2.9907         137.87       314.35       360.32
62269       Needle biopsy, spinal cord           T           T        0685        6.1384         282.98       645.21       739.55
62270       Spinal fluid tap, diagnostic         T           T        0204        2.2614         104.25       237.70       272.45
62272       Drain cerebro spinal fluid           T           T        0204        2.2614         104.25       237.70       272.45
62273       Inject epidural patch                T           T        0206        5.7253         263.94       601.79       689.78
62280       Treat spinal cord lesion             T           T        0207        6.3603         293.21       668.53       766.29
62281       Treat spinal cord lesion             T           T        0207        6.3603         293.21       668.53       766.29
62282       Treat spinal canal lesion            T           T        0207        6.3603         293.21       668.53       766.29
62284       Injection for myelogram              N           N        0000        0.0000          0.00         0.00         0.00
62287       Percutaneous diskectomy              T           T        0221       33.1520        1,528.31     3,484.61     3,994.15
62290       Inject for spine disk x-ray          N           N        0000        0.0000          0.00         0.00         0.00
62291       Inject for spine disk x-ray          N           N        0000        0.0000          0.00         0.00         0.00
62292       Injection into disk lesion           T           T        0212        2.9907         137.87       314.35       360.32
62294       Injection into spinal artery         T           T        0212        2.9907         137.87       314.35       360.32
62310       Inject spine c/t                     T           T        0207        6.3603         293.21       668.53       766.29
62311       Inject spine l/s (cd)                T           T        0207        6.3603         293.21       668.53       766.29
62318       Inject spine w/cath, c/t             T           T        0207        6.3603         293.21       668.53       766.29
62319       Inject spine w/cath l/s (cd)         T           T        0207        6.3603         293.21       668.53       766.29
62350       Implant spinal canal cath            T           T        0223       30.8394        1,421.70     3,241.53     3,715.53
62351       Implant spinal canal cath            T           T        0208       44.1489        2,035.26     4,640.49     5,319.06
62355       Remove spinal canal catheter         T           T        0203       12.1702         561.05      1,279.21     1,466.27
62360       Insert spine infusion device         T           T        0226      112.6322        5,192.34    11,838.77    13,569.93
62361       Implant spine infusion pump          T           T        0227      174.4056        8,040.10    18,331.77    21,012.39
62362       Implant spine infusion pump          T           T        0227      174.4056        8,040.10    18,331.77    21,012.39
62365       Remove spine infusion device         T           T        0221       33.1520        1,528.31     3,484.61     3,994.15
62367       Analyze spine infusion pump          S           S        0691        2.8942         133.42       304.21       348.69
62368       Analyze spine infusion pump          S           S        0691        2.8942         133.42       304.21       348.69
63001       Removal of spinal lamina             T           T        0208       44.1489        2,035.26     4,640.49     5,319.06
63003       Removal of spinal lamina             T           T        0208       44.1489        2,035.26     4,640.49     5,319.06
63005       Removal of spinal lamina             T           T        0208       44.1489        2,035.26     4,640.49     5,319.06
63011       Removal of spinal lamina             T           T        0208       44.1489        2,035.26     4,640.49     5,319.06
63012       Removal of spinal lamina             T           T        0208       44.1489        2,035.26     4,640.49     5,319.06
63015       Removal of spinal lamina             T           T        0208       44.1489        2,035.26     4,640.49     5,319.06
63016       Removal of spinal lamina             T           T        0208       44.1489        2,035.26     4,640.49     5,319.06
63017       Removal of spinal lamina             T           T        0208       44.1489        2,035.26     4,640.49     5,319.06
63020       Neck spine disk surgery              T           T        0208       44.1489        2,035.26     4,640.49     5,319.06
63030       Low back disk surgery                T           T        0208       44.1489        2,035.26     4,640.49     5,319.06
63035       Spinal disk surgery add-on           T           T        0208       44.1489        2,035.26     4,640.49     5,319.06
63040       Laminotomy, single cervical          T           T        0208       44.1489        2,035.26     4,640.49     5,319.06
63042       Laminotomy, single lumbar            T           T        0208       44.1489        2,035.26     4,640.49     5,319.06
63043       Laminotomy, add’l cervical           C           C        0000        0.0000          0.00         0.00         0.00
63044       Laminotomy, add’l lumbar             C           C        0000        0.0000          0.00         0.00         0.00
63045       Removal of spinal lamina             T           T        0208       44.1489        2,035.26     4,640.49     5,319.06
63046       Removal of spinal lamina             T           T        0208       44.1489        2,035.26     4,640.49     5,319.06
63047       Removal of spinal lamina             T           T        0208       44.1489        2,035.26     4,640.49     5,319.06
63048       Remove spinal lamina add-on          T           T        0208       44.1489        2,035.26     4,640.49     5,319.06
63050       Cervical laminoplasty                C           C        0000        0.0000          0.00         0.00         0.00
63051       C-laminoplasty w/graft/plate         C           C        0000        0.0000          0.00         0.00         0.00
63055       Decompress spinal cord               T           T        0208       44.1489        2,035.26     4,640.49     5,319.06
63056       Decompress spinal cord               T           T        0208       44.1489        2,035.26     4,640.49     5,319.06
63057       Decompress spine cord add-on         T           T        0208       44.1489        2,035.26     4,640.49     5,319.06
63064       Decompress spinal cord               T           T        0208       44.1489        2,035.26     4,640.49     5,319.06
63066       Decompress spine cord add-on         T           T        0208       44.1489        2,035.26     4,640.49     5,319.06
63075       Neck spine disk surgery              T           T        0208       44.1489        2,035.26     4,640.49     5,319.06
63076       Neck spine disk surgery              C           C        0000        0.0000          0.00         0.00         0.00
63077       Spine disk surgery, thorax           C           C        0000        0.0000          0.00         0.00         0.00
63078       Spine disk surgery, thorax           C           C        0000        0.0000          0.00         0.00         0.00
63081       Removal of vertebral body            C           C        0000        0.0000          0.00         0.00         0.00
63082       Remove vertebral body add-on         C           C        0000        0.0000          0.00         0.00         0.00
63085       Removal of vertebral body            C           C        0000        0.0000          0.00         0.00         0.00
63086       Remove vertebral body add-on         C           C        0000        0.0000          0.00         0.00         0.00
63087       Removal of vertebral body            C           C        0000        0.0000          0.00         0.00         0.00
63088       Remove vertebral body add-on         C           C        0000        0.0000          0.00         0.00         0.00
63090       Removal of vertebral body            C           C        0000        0.0000          0.00         0.00         0.00


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 48 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
63091       Remove vertebral body add-on         C           C        0000        0.0000          0.00         0.00         0.00
63101       Removal of vertebral body            C           C        0000        0.0000          0.00         0.00         0.00
63102       Removal of vertebral body            C           C        0000        0.0000          0.00         0.00         0.00
63103       Remove vertebral body add-on         C           C        0000        0.0000          0.00         0.00         0.00
63170       Incise spinal cord tract(s)          C           C        0000        0.0000          0.00         0.00         0.00
63172       Drainage of spinal cyst              C           C        0000        0.0000          0.00         0.00         0.00
63173       Drainage of spinal cyst              C           C        0000        0.0000          0.00         0.00         0.00
63180       Revise spinal cord ligaments         C           C        0000        0.0000          0.00         0.00         0.00
63182       Revise spinal cord ligaments         C           C        0000        0.0000          0.00         0.00         0.00
63185       Incise spinal column/nerves          C           C        0000        0.0000          0.00         0.00         0.00
63190       Incise spinal column/nerves          C           C        0000        0.0000          0.00         0.00         0.00
63191       Incise spinal column/nerves          C           C        0000        0.0000          0.00         0.00         0.00
63194       Incise spinal column & cord          C           C        0000        0.0000          0.00         0.00         0.00
63195       Incise spinal column & cord          C           C        0000        0.0000          0.00         0.00         0.00
63196       Incise spinal column & cord          C           C        0000        0.0000          0.00         0.00         0.00
63197       Incise spinal column & cord          C           C        0000        0.0000          0.00         0.00         0.00
63198       Incise spinal column & cord          C           C        0000        0.0000          0.00         0.00         0.00
63199       Incise spinal column & cord          C           C        0000        0.0000          0.00         0.00         0.00
63200       Release of spinal cord               C           C        0000        0.0000          0.00         0.00         0.00
63250       Revise spinal cord vessels           C           C        0000        0.0000          0.00         0.00         0.00
63251       Revise spinal cord vessels           C           C        0000        0.0000          0.00         0.00         0.00
63252       Revise spinal cord vessels           C           C        0000        0.0000          0.00         0.00         0.00
63265       Excise intraspinal lesion            C           C        0000        0.0000          0.00         0.00         0.00
63266       Excise intraspinal lesion            C           C        0000        0.0000          0.00         0.00         0.00
63267       Excise intraspinal lesion            C           C        0000        0.0000          0.00         0.00         0.00
63268       Excise intraspinal lesion            C           C        0000        0.0000          0.00         0.00         0.00
63270       Excise intraspinal lesion            C           C        0000        0.0000          0.00         0.00         0.00
63271       Excise intraspinal lesion            C           C        0000        0.0000          0.00         0.00         0.00
63272       Excise intraspinal lesion            C           C        0000        0.0000          0.00         0.00         0.00
63273       Excise intraspinal lesion            C           C        0000        0.0000          0.00         0.00         0.00
63275       Biopsy/excise spinal tumor           C           C        0000        0.0000          0.00         0.00         0.00
63276       Biopsy/excise spinal tumor           C           C        0000        0.0000          0.00         0.00         0.00
63277       Biopsy/excise spinal tumor           C           C        0000        0.0000          0.00         0.00         0.00
63278       Biopsy/excise spinal tumor           C           C        0000        0.0000          0.00         0.00         0.00
63280       Biopsy/excise spinal tumor           C           C        0000        0.0000          0.00         0.00         0.00
63281       Biopsy/excise spinal tumor           C           C        0000        0.0000          0.00         0.00         0.00
63282       Biopsy/excise spinal tumor           C           C        0000        0.0000          0.00         0.00         0.00
63283       Biopsy/excise spinal tumor           C           C        0000        0.0000          0.00         0.00         0.00
63285       Biopsy/excise spinal tumor           C           C        0000        0.0000          0.00         0.00         0.00
63286       Biopsy/excise spinal tumor           C           C        0000        0.0000          0.00         0.00         0.00
63287       Biopsy/excise spinal tumor           C           C        0000        0.0000          0.00         0.00         0.00
63290       Biopsy/excise spinal tumor           C           C        0000        0.0000          0.00         0.00         0.00
63295       Repair of laminectomy defect         C           C        0000        0.0000          0.00         0.00         0.00
63300       Removal of vertebral body            C           C        0000        0.0000          0.00         0.00         0.00
63301       Removal of vertebral body            C           C        0000        0.0000          0.00         0.00         0.00
63302       Removal of vertebral body            C           C        0000        0.0000          0.00         0.00         0.00
63303       Removal of vertebral body            C           C        0000        0.0000          0.00         0.00         0.00
63304       Removal of vertebral body            C           C        0000        0.0000          0.00         0.00         0.00
63305       Removal of vertebral body            C           C        0000        0.0000          0.00         0.00         0.00
63306       Removal of vertebral body            C           C        0000        0.0000          0.00         0.00         0.00
63307       Removal of vertebral body            C           C        0000        0.0000          0.00         0.00         0.00
63308       Remove vertebral body add-on         C           C        0000        0.0000          0.00         0.00         0.00
63600       Remove spinal cord lesion            T           T        0220       17.8499         822.88      1,876.20     2,150.56
63610       Stimulation of spinal cord           T           T        0220       17.8499         822.88      1,876.20     2,150.56
63615       Remove lesion of spinal cord         T           T        0220       17.8499         822.88      1,876.20     2,150.56
63650       Implant neuroelectrodes              S           S        0040       56.5705        2,607.90     5,946.13     6,815.61
63655       Implant neuroelectrodes              S           S        0061       84.1967        3,881.47     8,849.92    10,144.02
63660       Revise/remove neuroelectrode         T           T        0687       17.8334         822.12      1,874.47     2,148.57
63685       Insrt/redo spine n generator         T           T        0222      181.6249        8,372.91    19,090.59    21,882.17
63688       Revise/remove neuroreceiver          T           T        0688       35.5702        1,639.79     3,738.78     4,285.50
63700       Repair of spinal herniation          C           C        0000        0.0000          0.00         0.00         0.00
63702       Repair of spinal herniation          C           C        0000        0.0000          0.00         0.00         0.00
63704       Repair of spinal herniation          C           C        0000        0.0000          0.00         0.00         0.00
63706       Repair of spinal herniation          C           C        0000        0.0000          0.00         0.00         0.00
63707       Repair spinal fluid leakage          C           C        0000        0.0000          0.00         0.00         0.00
63709       Repair spinal fluid leakage          C           C        0000        0.0000          0.00         0.00         0.00
63710       Graft repair of spine defect         C           C        0000        0.0000          0.00         0.00         0.00
63740       Install spinal shunt                 C           C        0000        0.0000          0.00         0.00         0.00
63741       Install spinal shunt                 T           T        0228       39.2633        1,810.04     4,126.97     4,730.44
63744       Revision of spinal shunt             T           T        0228       39.2633        1,810.04     4,126.97     4,730.44
63746       Removal of spinal shunt              T           T        0109       10.9918         506.72      1,155.35     1,324.29
64400       N block inj, trigeminal              T           T        0204        2.2614         104.25       237.70       272.45
64402       N block inj, facial                  T           T        0204        2.2614         104.25       237.70       272.45
64405       N block inj, occipital               T           T        0204        2.2614         104.25       237.70       272.45
64408       N block inj, vagus                   T           T        0204        2.2614         104.25       237.70       272.45
64410       N block inj, phrenic                 T           T        0206        5.7253         263.94       601.79       689.78
64412       N block inj, spinal accessor         T           T        0206        5.7253         263.94       601.79       689.78
64413       N block inj, cervical plexus         T           T        0204        2.2614         104.25       237.70       272.45
64415       N block inj, brachial plexus         T           T        0204        2.2614         104.25       237.70       272.45
64416       N block cont infuse, b plex          T           T        0204        2.2614         104.25       237.70       272.45
64417       N block inj, axillary                T           T        0204        2.2614         104.25       237.70       272.45
64418       N block inj, suprascapular           T           T        0204        2.2614         104.25       237.70       272.45
64420       N block inj, intercost, sng          T           T        0204        2.2614         104.25       237.70       272.45
64421       N block inj, intercost, mlt          T           T        0206        5.7253         263.94       601.79       689.78
64425       N block inj, ilio-ing/hypogi         T           T        0204        2.2614         104.25       237.70       272.45
64430       N block inj, pudendal                T           T        0204        2.2614         104.25       237.70       272.45
64435       N block inj, paracervical            T           T        0204        2.2614         104.25       237.70       272.45
64445       N block inj, sciatic, sng            T           T        0204        2.2614         104.25       237.70       272.45
64446       N blk inj, sciatic, cont inf         T           T        0206        5.7253         263.94       601.79       689.78
64447       N block inj fem, single              T           T        0204        2.2614         104.25       237.70       272.45
64448       N block inj fem, cont inf            T           T        0204        2.2614         104.25       237.70       272.45
64449       N block inj, lumbar plexus           T           T        0204        2.2614         104.25       237.70       272.45
64450       N block, other peripheral            T           T        0204        2.2614         104.25       237.70       272.45
64470       Inj paravertebral c/t                T           T        0207        6.3603         293.21       668.53       766.29
64472       Inj paravertebral c/t add-on         T           T        0206        5.7253         263.94       601.79       689.78
64475       Inj paravertebral l/s                T           T        0207        6.3603         293.21       668.53       766.29
64476       Inj paravertebral l/s add-on         T           T        0206        5.7253         263.94       601.79       689.78
64479       Inj foramen epidural c/t             T           T        0207        6.3603         293.21       668.53       766.29
64480       Inj foramen epidural add-on          T           T        0207        6.3603         293.21       668.53       766.29
64483       Inj foramen epidural l/s             T           T        0207        6.3603         293.21       668.53       766.29
64484       Inj foramen epidural add-on          T           T        0207        6.3603         293.21       668.53       766.29
64505       N block, spenopalatine gangl         T           T        0204        2.2614         104.25       237.70       272.45
64508       N block, carotid sinus s/p           T           T        0204        2.2614         104.25       237.70       272.45
64510       N block, stellate ganglion           T           T        0207        6.3603         293.21       668.53       766.29
64517       N block inj, hypogas plxs            T           T        0204        2.2614         104.25       237.70       272.45
64520       N block, lumbar/thoracic             T           T        0207        6.3603         293.21       668.53       766.29


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 49 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
64530       N block inj, celiac pelus            T           T        0207        6.3603         293.21       668.53       766.29
64550       Apply neurostimulator                A           3        0000        0.0000          M01          M01          M01
64553       Implant neuroelectrodes              S           S        0225      221.1512       10,195.07    23,245.20    26,644.30
64555       Implant neuroelectrodes              S           S        0040       56.5705        2,607.90     5,946.13     6,815.61
64560       Implant neuroelectrodes              S           S        0040       56.5705        2,607.90     5,946.13     6,815.61
64561       Implant neuroelectrodes              S           S        0040       56.5705        2,607.90     5,946.13     6,815.61
64565       Implant neuroelectrodes              S           S        0040       56.5705        2,607.90     5,946.13     6,815.61
64573       Implant neuroelectrodes              S           S        0225      221.1512       10,195.07    23,245.20    26,644.30
64575       Implant neuroelectrodes              S           S        0061       84.1967        3,881.47     8,849.92    10,144.02
64577       Implant neuroelectrodes              S           S        0061       84.1967        3,881.47     8,849.92    10,144.02
64580       Implant neuroelectrodes              S           S        0061       84.1967        3,881.47     8,849.92    10,144.02
64581       Implant neuroelectrodes              S           S        0061       84.1967        3,881.47     8,849.92    10,144.02
64585       Revise/remove neuroelectrode         T           T        0687       17.8334         822.12      1,874.47     2,148.57
64590       Insrt/redo perph n generator         T           T        0222      181.6249        8,372.91    19,090.59    21,882.17
64595       Revise/remove neuroreceiver          T           T        0688       35.5702        1,639.79     3,738.78     4,285.50
64600       Injection treatment of nerve         T           T        0203       12.1702         561.05      1,279.21     1,466.27
64605       Injection treatment of nerve         T           T        0203       12.1702         561.05      1,279.21     1,466.27
64610       Injection treatment of nerve         T           T        0203       12.1702         561.05      1,279.21     1,466.27
64612       Destroy nerve, face muscle           T           T        0204        2.2614         104.25       237.70       272.45
64613       Destroy nerve, spine muscle          T           T        0204        2.2614         104.25       237.70       272.45
64614       Destroy nerve, extrem musc           T           T        0204        2.2614         104.25       237.70       272.45
64620       Injection treatment of nerve         T           T        0203       12.1702         561.05      1,279.21     1,466.27
64622       Destr paravertebrl nerve l/s         T           T        0203       12.1702         561.05      1,279.21     1,466.27
64623       Destr paravertebral n add-on         T           T        0207        6.3603         293.21       668.53       766.29
64626       Destr paravertebrl nerve c/t         T           T        0203       12.1702         561.05      1,279.21     1,466.27
64627       Destr paravertebral n add-on         T           T        0207        6.3603         293.21       668.53       766.29
64630       Injection treatment of nerve         T           T        0206        5.7253         263.94       601.79       689.78
64640       Injection treatment of nerve         T           T        0206        5.7253         263.94       601.79       689.78
64650       Chemodenerv eccrine glands           T           T        0204        2.2614         104.25       237.70       272.45
64653       Chemodenerv eccrine glands           T           T        0204        2.2614         104.25       237.70       272.45
64680       Injection treatment of nerve         T           T        0207        6.3603         293.21       668.53       766.29
64681       Injection treatment of nerve         T           T        0203       12.1702         561.05      1,279.21     1,466.27
64702       Revise finger/toe nerve              T           T        0220       17.8499         822.88      1,876.20     2,150.56
64704       Revise hand/foot nerve               T           T        0220       17.8499         822.88      1,876.20     2,150.56
64708       Revise arm/leg nerve                 T           T        0220       17.8499         822.88      1,876.20     2,150.56
64712       Revision of sciatic nerve            T           T        0220       17.8499         822.88      1,876.20     2,150.56
64713       Revision of arm nerve(s)             T           T        0220       17.8499         822.88      1,876.20     2,150.56
64714       Revise low back nerve(s)             T           T        0220       17.8499         822.88      1,876.20     2,150.56
64716       Revision of cranial nerve            T           T        0220       17.8499         822.88      1,876.20     2,150.56
64718       Revise ulnar nerve at elbow          T           T        0220       17.8499         822.88      1,876.20     2,150.56
64719       Revise ulnar nerve at wrist          T           T        0220       17.8499         822.88      1,876.20     2,150.56
64721       Carpal tunnel surgery                T           T        0220       17.8499         822.88      1,876.20     2,150.56
64722       Relieve pressure on nerve(s)         T           T        0220       17.8499         822.88      1,876.20     2,150.56
64726       Release foot/toe nerve               T           T        0220       17.8499         822.88      1,876.20     2,150.56
64727       Internal nerve revision              T           T        0220       17.8499         822.88      1,876.20     2,150.56
64732       Incision of brow nerve               T           T        0220       17.8499         822.88      1,876.20     2,150.56
64734       Incision of cheek nerve              T           T        0220       17.8499         822.88      1,876.20     2,150.56
64736       Incision of chin nerve               T           T        0220       17.8499         822.88      1,876.20     2,150.56
64738       Incision of jaw nerve                T           T        0220       17.8499         822.88      1,876.20     2,150.56
64740       Incision of tongue nerve             T           T        0220       17.8499         822.88      1,876.20     2,150.56
64742       Incision of facial nerve             T           T        0220       17.8499         822.88      1,876.20     2,150.56
64744       Incise nerve, back of head           T           T        0220       17.8499         822.88      1,876.20     2,150.56
64746       Incise diaphragm nerve               T           T        0220       17.8499         822.88      1,876.20     2,150.56
64752       Incision of vagus nerve              C           C        0000        0.0000          0.00         0.00         0.00
64755       Incision of stomach nerves           C           C        0000        0.0000          0.00         0.00         0.00
64760       Incision of vagus nerve              C           C        0000        0.0000          0.00         0.00         0.00
64761       Incision of pelvis nerve             T           T        0220       17.8499         822.88      1,876.20     2,150.56
64763       Incise hip/thigh nerve               T           T        0220       17.8499         822.88      1,876.20     2,150.56
64766       Incise hip/thigh nerve               T           T        0221       33.1520        1,528.31     3,484.61     3,994.15
64771       Sever cranial nerve                  T           T        0220       17.8499         822.88      1,876.20     2,150.56
64772       Incision of spinal nerve             T           T        0220       17.8499         822.88      1,876.20     2,150.56
64774       Remove skin nerve lesion             T           T        0220       17.8499         822.88      1,876.20     2,150.56
64776       Remove digit nerve lesion            T           T        0220       17.8499         822.88      1,876.20     2,150.56
64778       Digit nerve surgery add-on           T           T        0220       17.8499         822.88      1,876.20     2,150.56
64782       Remove limb nerve lesion             T           T        0220       17.8499         822.88      1,876.20     2,150.56
64783       Limb nerve surgery add-on            T           T        0220       17.8499         822.88      1,876.20     2,150.56
64784       Remove nerve lesion                  T           T        0220       17.8499         822.88      1,876.20     2,150.56
64786       Remove sciatic nerve lesion          T           T        0221       33.1520        1,528.31     3,484.61     3,994.15
64787       Implant nerve end                    T           T        0220       17.8499         822.88      1,876.20     2,150.56
64788       Remove skin nerve lesion             T           T        0220       17.8499         822.88      1,876.20     2,150.56
64790       Removal of nerve lesion              T           T        0220       17.8499         822.88      1,876.20     2,150.56
64792       Removal of nerve lesion              T           T        0221       33.1520        1,528.31     3,484.61     3,994.15
64795       Biopsy of nerve                      T           T        0220       17.8499         822.88      1,876.20     2,150.56
64802       Remove sympathetic nerves            T           T        0220       17.8499         822.88      1,876.20     2,150.56
64804       Remove sympathetic nerves            T           T        0220       17.8499         822.88      1,876.20     2,150.56
64809       Remove sympathetic nerves            C           C        0000        0.0000          0.00         0.00         0.00
64818       Remove sympathetic nerves            C           C        0000        0.0000          0.00         0.00         0.00
64820       Remove sympathetic nerves            T           T        0220       17.8499         822.88      1,876.20     2,150.56
64821       Remove sympathetic nerves            T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
64822       Remove sympathetic nerves            T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
64823       Remove sympathetic nerves            T           T        0054       25.8758        1,192.87     2,719.81     3,117.52
64831       Repair of digit nerve                T           T        0221       33.1520        1,528.31     3,484.61     3,994.15
64832       Repair nerve add-on                  T           T        0221       33.1520        1,528.31     3,484.61     3,994.15
64834       Repair of hand or foot nerve         T           T        0221       33.1520        1,528.31     3,484.61     3,994.15
64835       Repair of hand or foot nerve         T           T        0221       33.1520        1,528.31     3,484.61     3,994.15
64836       Repair of hand or foot nerve         T           T        0221       33.1520        1,528.31     3,484.61     3,994.15
64837       Repair nerve add-on                  T           T        0221       33.1520        1,528.31     3,484.61     3,994.15
64840       Repair of leg nerve                  T           T        0221       33.1520        1,528.31     3,484.61     3,994.15
64856       Repair/transpose nerve               T           T        0221       33.1520        1,528.31     3,484.61     3,994.15
64857       Repair arm/leg nerve                 T           T        0221       33.1520        1,528.31     3,484.61     3,994.15
64858       Repair sciatic nerve                 T           T        0221       33.1520        1,528.31     3,484.61     3,994.15
64859       Nerve surgery                        T           T        0221       33.1520        1,528.31     3,484.61     3,994.15
64861       Repair of arm nerves                 T           T        0221       33.1520        1,528.31     3,484.61     3,994.15
64862       Repair of low back nerves            T           T        0221       33.1520        1,528.31     3,484.61     3,994.15
64864       Repair of facial nerve               T           T        0221       33.1520        1,528.31     3,484.61     3,994.15
64865       Repair of facial nerve               T           T        0221       33.1520        1,528.31     3,484.61     3,994.15
64866       Fusion of facial/other nerve         C           C        0000        0.0000          0.00         0.00         0.00
64868       Fusion of facial/other nerve         C           C        0000        0.0000          0.00         0.00         0.00
64870       Fusion of facial/other nerve         T           T        0221       33.1520        1,528.31     3,484.61     3,994.15
64872       Subsequent repair of nerve           T           T        0221       33.1520        1,528.31     3,484.61     3,994.15
64874       Repair & revise nerve add-on         T           T        0221       33.1520        1,528.31     3,484.61     3,994.15
64876       Repair nerve/shorten bone            T           T        0221       33.1520        1,528.31     3,484.61     3,994.15
64885       Nerve graft, head or neck            T           T        0221       33.1520        1,528.31     3,484.61     3,994.15
64886       Nerve graft, head or neck            T           T        0221       33.1520        1,528.31     3,484.61     3,994.15
64890       Nerve graft, hand or foot            T           T        0221       33.1520        1,528.31     3,484.61     3,994.15
64891       Nerve graft, hand or foot            T           T        0221       33.1520        1,528.31     3,484.61     3,994.15


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 50 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
64892       Nerve graft, arm or leg              T           T        0221       33.1520        1,528.31     3,484.61     3,994.15
64893       Nerve graft, arm or leg              T           T        0221       33.1520        1,528.31     3,484.61     3,994.15
64895       Nerve graft, hand or foot            T           T        0221       33.1520        1,528.31     3,484.61     3,994.15
64896       Nerve graft, hand or foot            T           T        0221       33.1520        1,528.31     3,484.61     3,994.15
64897       Nerve graft, arm or leg              T           T        0221       33.1520        1,528.31     3,484.61     3,994.15
64898       Nerve graft, arm or leg              T           T        0221       33.1520        1,528.31     3,484.61     3,994.15
64901       Nerve graft add-on                   T           T        0221       33.1520        1,528.31     3,484.61     3,994.15
64902       Nerve graft add-on                   T           T        0221       33.1520        1,528.31     3,484.61     3,994.15
64905       Nerve pedicle transfer               T           T        0221       33.1520        1,528.31     3,484.61     3,994.15
64907       Nerve pedicle transfer               T           T        0221       33.1520        1,528.31     3,484.61     3,994.15
64910       Nerve repair w/allograft             T           1        0000        0.0000           0.00        0.00         0.00
64911       Neurorraphy w/vein autograft         T           T        0220       17.8499         822.88      1,876.20     2,150.56
64999       Nervous system surgery               T           1        0000        0.0000           0.00        0.00         0.00
65091       Revise eye                           T           T        0242       35.2292        1,624.07     3,702.94     4,244.41
65093       Revise eye with implant              T           T        0242       35.2292        1,624.07     3,702.94     4,244.41
65101       Removal of eye                       T           T        0242       35.2292        1,624.07     3,702.94     4,244.41
65103       Remove eye/insert implant            T           T        0242       35.2292        1,624.07     3,702.94     4,244.41
65105       Remove eye/attach implant            T           T        0242       35.2292        1,624.07     3,702.94     4,244.41
65110       Removal of eye                       T           T        0242       35.2292        1,624.07     3,702.94     4,244.41
65112       Remove eye/revise socket             T           T        0242       35.2292        1,624.07     3,702.94     4,244.41
65114       Remove eye/revise socket             T           T        0242       35.2292        1,624.07     3,702.94     4,244.41
65125       Revise ocular implant                T           T        0240       17.1243         789.43      1,799.94     2,063.14
65130       Insert ocular implant                T           T        0241       25.2550        1,164.26     2,654.55     3,042.72
65135       Insert ocular implant                T           T        0241       25.2550        1,164.26     2,654.55     3,042.72
65140       Attach ocular implant                T           T        0242       35.2292        1,624.07     3,702.94     4,244.41
65150       Revise ocular implant                T           T        0241       25.2550        1,164.26     2,654.55     3,042.72
65155       Reinsert ocular implant              T           T        0242       35.2292        1,624.07     3,702.94     4,244.41
65175       Removal of ocular implant            T           T        0240       17.1243         789.43      1,799.94     2,063.14
65205       Remove foreign body from eye         S           S        0698        1.1607          53.51       122.00       139.84
65210       Remove foreign body from eye         S           S        0698        1.1607          53.51       122.00       139.84
65220       Remove foreign body from eye         S           S        0698        1.1607          53.51       122.00       139.84
65222       Remove foreign body from eye         S           S        0698        1.1607          53.51       122.00       139.84
65235       Remove foreign body from eye         T           T        0233       15.2259         701.91      1,600.39     1,834.42
65260       Remove foreign body from eye         T           T        0236       16.5239         761.75      1,736.83     1,990.80
65265       Remove foreign body from eye         T           T        0237       27.6020        1,272.45     2,901.25     3,325.49
65270       Repair of eye wound                  T           T        0240       17.1243         789.43      1,799.94     2,063.14
65272       Repair of eye wound                  T           T        0234       22.9970        1,060.16     2,417.21     2,770.68
65273       Repair of eye wound                  C           C        0000        0.0000           0.00        0.00         0.00
65275       Repair of eye wound                  T           T        0234       22.9970        1,060.16     2,417.21     2,770.68
65280       Repair of eye wound                  T           T        0236       16.5239         761.75      1,736.83     1,990.80
65285       Repair of eye wound                  T           T        0672       37.4290        1,725.48     3,934.16     4,509.45
65286       Repair of eye wound                  T           T        0232        6.0673         279.70       637.73       730.99
65290       Repair of eye socket wound           T           T        0243       21.2801         981.01      2,236.75     2,563.83
65400       Removal of eye lesion                T           T        0233       15.2259         701.91      1,600.39     1,834.42
65410       Biopsy of cornea                     T           T        0233       15.2259         701.91      1,600.39     1,834.42
65420       Removal of eye lesion                T           T        0233       15.2259         701.91      1,600.39     1,834.42
65426       Removal of eye lesion                T           T        0234       22.9970        1,060.16     2,417.21     2,770.68
65430       Corneal smear                        S           S        0698        1.1607          53.51       122.00       139.84
65435       Curette/treat cornea                 T           T        0239        7.2819         335.70       765.40       877.32
65436       Curette/treat cornea                 T           T        0233       15.2259         701.91      1,600.39     1,834.42
65450       Treatment of corneal lesion          S           S        0231        2.1451          98.89       225.47       258.44
65600       Revision of cornea                   T           T        0240       17.1243         789.43      1,799.94     2,063.14
65710       Corneal transplant                   T           T        0244       38.2707        1,764.28     4,022.63     4,610.85
65730       Corneal transplant                   T           T        0244       38.2707        1,764.28     4,022.63     4,610.85
65750       Corneal transplant                   T           T        0244       38.2707        1,764.28     4,022.63     4,610.85
65755       Corneal transplant                   T           T        0244       38.2707        1,764.28     4,022.63     4,610.85
65760       Revision of cornea                   E           1        0000        0.0000           0.00        0.00         0.00
65765       Revision of cornea                   E           1        0000        0.0000           0.00        0.00         0.00
65767       Corneal tissue transplant            E           1        0000        0.0000           0.00        0.00         0.00
65770       Revise cornea with implant           T           T        0293       51.9894        2,396.71     5,464.61     6,263.68
65771       Radial keratotomy                    E           1        0000        0.0000           0.00        0.00         0.00
65772       Correction of astigmatism            T           1        0000        0.0000           0.00        0.00         0.00
65775       Correction of astigmatism            T           1        0000        0.0000           0.00        0.00         0.00
65780       Ocular reconst, transplant           T           1        0000        0.0000           0.00        0.00         0.00
65781       Ocular reconst, transplant           T           1        0000        0.0000           0.00        0.00         0.00
65782       Ocular reconst, transplant           T           1        0000        0.0000           0.00        0.00         0.00
65800       Drainage of eye                      T           T        0233       15.2259         701.91      1,600.39     1,834.42
65805       Drainage of eye                      T           T        0233       15.2259         701.91      1,600.39     1,834.42
65810       Drainage of eye                      T           T        0234       22.9970        1,060.16     2,417.21     2,770.68
65815       Drainage of eye                      T           T        0234       22.9970        1,060.16     2,417.21     2,770.68
65820       Relieve inner eye pressure           T           T        0232        6.0673         279.70       637.73       730.99
65850       Incision of eye                      T           T        0234       22.9970        1,060.16     2,417.21     2,770.68
65855       Laser surgery of eye                 T           T        0247        5.0839         234.37       534.37       612.51
65860       Incise inner eye adhesions           T           T        0247        5.0839         234.37       534.37       612.51
65865       Incise inner eye adhesions           T           T        0233       15.2259         701.91      1,600.39     1,834.42
65870       Incise inner eye adhesions           T           T        0234       22.9970        1,060.16     2,417.21     2,770.68
65875       Incise inner eye adhesions           T           T        0234       22.9970        1,060.16     2,417.21     2,770.68
65880       Incise inner eye adhesions           T           T        0233       15.2259         701.91      1,600.39     1,834.42
65900       Remove eye lesion                    T           T        0233       15.2259         701.91      1,600.39     1,834.42
65920       Remove implant of eye                T           T        0234       22.9970        1,060.16     2,417.21     2,770.68
65930       Remove blood clot from eye           T           T        0234       22.9970        1,060.16     2,417.21     2,770.68
66020       Injection treatment of eye           T           T        0233       15.2259         701.91      1,600.39     1,834.42
66030       Injection treatment of eye           T           T        0232        6.0673         279.70       637.73       730.99
66130       Remove eye lesion                    T           T        0234       22.9970        1,060.16     2,417.21     2,770.68
66150       Glaucoma surgery                     T           T        0234       22.9970        1,060.16     2,417.21     2,770.68
66155       Glaucoma surgery                     T           T        0234       22.9970        1,060.16     2,417.21     2,770.68
66160       Glaucoma surgery                     T           T        0234       22.9970        1,060.16     2,417.21     2,770.68
66165       Glaucoma surgery                     T           T        0234       22.9970        1,060.16     2,417.21     2,770.68
66170       Glaucoma surgery                     T           T        0234       22.9970        1,060.16     2,417.21     2,770.68
66172       Incision of eye                      T           T        0234       22.9970        1,060.16     2,417.21     2,770.68
66180       Implant eye shunt                    T           T        0673       37.8967        1,747.04     3,983.32     4,565.79
66185       Revise eye shunt                     T           T        0673       37.8967        1,747.04     3,983.32     4,565.79
66220       Repair eye lesion                    T           T        0672       37.4290        1,725.48     3,934.16     4,509.45
66225       Repair/graft eye lesion              T           T        0673       37.8967        1,747.04     3,983.32     4,565.79
66250       Follow-up surgery of eye             T           T        0233       15.2259         701.91      1,600.39     1,834.42
66500       Incision of iris                     T           T        0232        6.0673         279.70       637.73       730.99
66505       Incision of iris                     T           T        0232        6.0673         279.70       637.73       730.99
66600       Remove iris and lesion               T           T        0234       22.9970        1,060.16     2,417.21     2,770.68
66605       Removal of iris                      T           T        0234       22.9970        1,060.16     2,417.21     2,770.68
66625       Removal of iris                      T           T        0232        6.0673         279.70       637.73       730.99
66630       Removal of iris                      T           T        0234       22.9970        1,060.16     2,417.21     2,770.68
66635       Removal of iris                      T           T        0234       22.9970        1,060.16     2,417.21     2,770.68
66680       Repair iris & ciliary body           T           T        0234       22.9970        1,060.16     2,417.21     2,770.68
66682       Repair iris & ciliary body           T           T        0234       22.9970        1,060.16     2,417.21     2,770.68
66700       Destruction, ciliary body            T           T        0233       15.2259         701.91      1,600.39     1,834.42
66710       Ciliary transsleral therapy          T           T        0233       15.2259         701.91      1,600.39     1,834.42


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 51 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
66711       Ciliary endoscopic ablation          T           T        0233       15.2259         701.91      1,600.39     1,834.42
66720       Destruction, ciliary body            T           T        0233       15.2259         701.91      1,600.39     1,834.42
66740       Destruction, ciliary body            T           T        0234       22.9970        1,060.16     2,417.21     2,770.68
66761       Revision of iris                     T           T        0247        5.0839         234.37       534.37       612.51
66762       Revision of iris                     T           T        0247        5.0839         234.37       534.37       612.51
66770       Removal of inner eye lesion          T           T        0247        5.0839         234.37       534.37       612.51
66820       Incision, secondary cataract         T           T        0232        6.0673         279.70       637.73       730.99
66821       After cataract laser surgery         T           T        0247        5.0839         234.37       534.37       612.51
66825       Reposition intraocular lens          T           T        0234       22.9970        1,060.16     2,417.21     2,770.68
66830       Removal of lens lesion               T           T        0232        6.0673         279.70       637.73       730.99
66840       Removal of lens material             T           T        0245       14.8702         685.52      1,563.01     1,791.56
66850       Removal of lens material             T           T        0249       29.2281        1,347.42     3,072.17     3,521.40
66852       Removal of lens material             T           T        0249       29.2281        1,347.42     3,072.17     3,521.40
66920       Extraction of lens                   T           T        0249       29.2281        1,347.42     3,072.17     3,521.40
66930       Extraction of lens                   T           T        0249       29.2281        1,347.42     3,072.17     3,521.40
66940       Extraction of lens                   T           T        0245       14.8702         685.52      1,563.01     1,791.56
66982       Cataract surgery, complex            T           T        0246       23.6313        1,089.40     2,483.89     2,847.10
66983       Cataract surg w/iol, 1 stage         T           T        0246       23.6313        1,089.40     2,483.89     2,847.10
66984       Cataract surg w/iol, 1 stage         T           T        0246       23.6313        1,089.40     2,483.89     2,847.10
66985       Insert lens prosthesis               T           T        0246       23.6313        1,089.40     2,483.89     2,847.10
66986       Exchange lens prosthesis             T           T        0246       23.6313        1,089.40     2,483.89     2,847.10
66990       Ophthalmic endoscope add-on          N           N        0000        0.0000           0.00        0.00         0.00
66999       Eye surgery procedure                T           1        0000        0.0000           0.00        0.00         0.00
67005       Partial removal of eye fluid         T           T        0237       27.6020        1,272.45     2,901.25     3,325.49
67010       Partial removal of eye fluid         T           T        0237       27.6020        1,272.45     2,901.25     3,325.49
67015       Release of eye fluid                 T           T        0237       27.6020        1,272.45     2,901.25     3,325.49
67025       Replace eye fluid                    T           T        0237       27.6020        1,272.45     2,901.25     3,325.49
67027       Implant eye drug system              T           T        0672       37.4290        1,725.48     3,934.16     4,509.45
67028       Injection eye drug                   T           T        0235        3.9333         181.33       413.43       473.88
67030       Incise inner eye strands             T           T        0236       16.5239         761.75      1,736.83     1,990.80
67031       Laser surgery, eye strands           T           T        0247        5.0839         234.37       534.37       612.51
67036       Removal of inner eye fluid           T           T        0672       37.4290        1,725.48     3,934.16     4,509.45
67038       Strip retinal membrane               T           T        0672       37.4290        1,725.48     3,934.16     4,509.45
67039       Laser treatment of retina            T           T        0672       37.4290        1,725.48     3,934.16     4,509.45
67040       Laser treatment of retina            T           T        0672       37.4290        1,725.48     3,934.16     4,509.45
67101       Repair detached retina               T           T        0236       16.5239         761.75      1,736.83     1,990.80
67105       Repair detached retina               T           T        0248        5.0841         234.38       534.39       612.53
67107       Repair detached retina               T           T        0672       37.4290        1,725.48     3,934.16     4,509.45
67108       Repair detached retina               T           T        0672       37.4290        1,725.48     3,934.16     4,509.45
67110       Repair detached retina               T           T        0236       16.5239         761.75      1,736.83     1,990.80
67112       Rerepair detached retina             T           T        0672       37.4290        1,725.48     3,934.16     4,509.45
67115       Release encircling material          T           T        0236       16.5239         761.75      1,736.83     1,990.80
67120       Remove eye implant material          T           T        0236       16.5239         761.75      1,736.83     1,990.80
67121       Remove eye implant material          T           T        0237       27.6020        1,272.45     2,901.25     3,325.49
67141       Treatment of retina                  T           T        0235        3.9333         181.33       413.43       473.88
67145       Treatment of retina                  T           T        0248        5.0841         234.38       534.39       612.53
67208       Treatment of retinal lesion          T           T        0236       16.5239         761.75      1,736.83     1,990.80
67210       Treatment of retinal lesion          T           T        0248        5.0841         234.38       534.39       612.53
67218       Treatment of retinal lesion          T           T        0236       16.5239         761.75      1,736.83     1,990.80
67220       Treatment of choroid lesion          T           T        0235        3.9333         181.33       413.43       473.88
67221       Ocular photodynamic ther             T           T        0235        3.9333         181.33       413.43       473.88
67225       Eye photodynamic ther add-on         T           T        0235        3.9333         181.33       413.43       473.88
67227       Treatment of retinal lesion          T           T        0237       27.6020        1,272.45     2,901.25     3,325.49
67228       Treatment of retinal lesion          T           T        0248        5.0841         234.38       534.39       612.53
67250       Reinforce eye wall                   T           T        0240       17.1243         789.43      1,799.94     2,063.14
67255       Reinforce/graft eye wall             T           T        0237       27.6020        1,272.45     2,901.25     3,325.49
67299       Eye surgery procedure                T           1        0000        0.0000           0.00        0.00         0.00
67311       Revise eye muscle                    T           T        0243       21.2801         981.01      2,236.75     2,563.83
67312       Revise two eye muscles               T           T        0243       21.2801         981.01      2,236.75     2,563.83
67314       Revise eye muscle                    T           T        0243       21.2801         981.01      2,236.75     2,563.83
67316       Revise two eye muscles               T           T        0243       21.2801         981.01      2,236.75     2,563.83
67318       Revise eye muscle(s)                 T           T        0243       21.2801         981.01      2,236.75     2,563.83
67320       Revise eye muscle(s) add-on          T           T        0243       21.2801         981.01      2,236.75     2,563.83
67331       Eye surgery follow-up add-on         T           T        0243       21.2801         981.01      2,236.75     2,563.83
67332       Rerevise eye muscles add-on          T           T        0243       21.2801         981.01      2,236.75     2,563.83
67334       Revise eye muscle w/suture           T           T        0243       21.2801         981.01      2,236.75     2,563.83
67335       Eye suture during surgery            T           T        0243       21.2801         981.01      2,236.75     2,563.83
67340       Revise eye muscle add-on             T           T        0243       21.2801         981.01      2,236.75     2,563.83
67343       Release eye tissue                   T           T        0243       21.2801         981.01      2,236.75     2,563.83
67345       Destroy nerve of eye muscle          T           T        0238        2.8954         133.48       304.34       348.84
67346       Biopsy, eye muscle                   T           T        0699       14.3845         663.13      1,511.95     1,733.04
67399       Eye muscle surgery procedure         T           1        0000        0.0000           0.00        0.00         0.00
67400       Explore/biopsy eye socket            T           T        0241       25.2550        1,164.26     2,654.55     3,042.72
67405       Explore/drain eye socket             T           T        0241       25.2550        1,164.26     2,654.55     3,042.72
67412       Explore/treat eye socket             T           T        0241       25.2550        1,164.26     2,654.55     3,042.72
67413       Explore/treat eye socket             T           T        0241       25.2550        1,164.26     2,654.55     3,042.72
67414       Explr/decompress eye socket          T           T        0242       35.2292        1,624.07     3,702.94     4,244.41
67415       Aspiration, orbital contents         T           T        0240       17.1243         789.43      1,799.94     2,063.14
67420       Explore/treat eye socket             T           T        0242       35.2292        1,624.07     3,702.94     4,244.41
67430       Explore/treat eye socket             T           T        0242       35.2292        1,624.07     3,702.94     4,244.41
67440       Explore/drain eye socket             T           T        0242       35.2292        1,624.07     3,702.94     4,244.41
67445       Explr/decompress eye socket          T           T        0242       35.2292        1,624.07     3,702.94     4,244.41
67450       Explore/biopsy eye socket            T           T        0242       35.2292        1,624.07     3,702.94     4,244.41
67500       Inject/treat eye socket              S           S        0231        2.1451          98.89       225.47       258.44
67505       Inject/treat eye socket              T           T        0238        2.8954         133.48       304.34       348.84
67515       Inject/treat eye socket              T           T        0238        2.8954         133.48       304.34       348.84
67550       Insert eye socket implant            T           T        0242       35.2292        1,624.07     3,702.94     4,244.41
67560       Revise eye socket implant            T           T        0241       25.2550        1,164.26     2,654.55     3,042.72
67570       Decompress optic nerve               T           T        0242       35.2292        1,624.07     3,702.94     4,244.41
67599       Orbit surgery procedure              T           1        0000        0.0000           0.00        0.00         0.00
67700       Drainage of eyelid abscess           T           T        0238        2.8954         133.48       304.34       348.84
67710       Incision of eyelid                   T           T        0239        7.2819         335.70       765.40       877.32
67715       Incision of eyelid fold              T           T        0240       17.1243         789.43      1,799.94     2,063.14
67800       Remove eyelid lesion                 T           T        0238        2.8954         133.48       304.34       348.84
67801       Remove eyelid lesions                T           T        0239        7.2819         335.70       765.40       877.32
67805       Remove eyelid lesions                T           T        0238        2.8954         133.48       304.34       348.84
67808       Remove eyelid lesion(s)              T           T        0240       17.1243         789.43      1,799.94     2,063.14
67810       Biopsy of eyelid                     T           T        0238        2.8954         133.48       304.34       348.84
67820       Revise eyelashes                     S           S        0698        1.1607          53.51       122.00       139.84
67825       Revise eyelashes                     T           T        0238        2.8954         133.48       304.34       348.84
67830       Revise eyelashes                     T           T        0239        7.2819         335.70       765.40       877.32
67835       Revise eyelashes                     T           T        0240       17.1243         789.43      1,799.94     2,063.14
67840       Remove eyelid lesion                 T           T        0239        7.2819         335.70       765.40       877.32
67850       Treat eyelid lesion                  T           T        0239        7.2819         335.70       765.40       877.32
67875       Closure of eyelid by suture          T           T        0239        7.2819         335.70       765.40       877.32
67880       Revision of eyelid                   T           T        0233       15.2259         701.91      1,600.39     1,834.42


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 52 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
67882       Revision of eyelid                   T           T        0240       17.1243         789.43      1,799.94     2,063.14
67900       Repair brow defect                   T           T        0240       17.1243         789.43      1,799.94     2,063.14
67901       Repair eyelid defect                 T           T        0240       17.1243         789.43      1,799.94     2,063.14
67902       Repair eyelid defect                 T           T        0240       17.1243         789.43      1,799.94     2,063.14
67903       Repair eyelid defect                 T           T        0240       17.1243         789.43      1,799.94     2,063.14
67904       Repair eyelid defect                 T           T        0240       17.1243         789.43      1,799.94     2,063.14
67906       Repair eyelid defect                 T           T        0240       17.1243         789.43      1,799.94     2,063.14
67908       Repair eyelid defect                 T           T        0240       17.1243         789.43      1,799.94     2,063.14
67909       Revise eyelid defect                 T           T        0240       17.1243         789.43      1,799.94     2,063.14
67911       Revise eyelid defect                 T           T        0240       17.1243         789.43      1,799.94     2,063.14
67912       Correction eyelid w/implant          T           T        0240       17.1243         789.43      1,799.94     2,063.14
67914       Repair eyelid defect                 T           T        0240       17.1243         789.43      1,799.94     2,063.14
67915       Repair eyelid defect                 T           T        0240       17.1243         789.43      1,799.94     2,063.14
67916       Repair eyelid defect                 T           T        0240       17.1243         789.43      1,799.94     2,063.14
67917       Repair eyelid defect                 T           T        0240       17.1243         789.43      1,799.94     2,063.14
67921       Repair eyelid defect                 T           T        0240       17.1243         789.43      1,799.94     2,063.14
67922       Repair eyelid defect                 T           T        0240       17.1243         789.43      1,799.94     2,063.14
67923       Repair eyelid defect                 T           T        0240       17.1243         789.43      1,799.94     2,063.14
67924       Repair eyelid defect                 T           T        0240       17.1243         789.43      1,799.94     2,063.14
67930       Repair eyelid wound                  T           T        0240       17.1243         789.43      1,799.94     2,063.14
67935       Repair eyelid wound                  T           T        0240       17.1243         789.43      1,799.94     2,063.14
67938       Remove eyelid foreign body           S           S        0698        1.1607          53.51       122.00       139.84
67950       Revision of eyelid                   T           T        0240       17.1243         789.43      1,799.94     2,063.14
67961       Revision of eyelid                   T           T        0240       17.1243         789.43      1,799.94     2,063.14
67966       Revision of eyelid                   T           T        0240       17.1243         789.43      1,799.94     2,063.14
67971       Reconstruction of eyelid             T           T        0241       25.2550        1,164.26     2,654.55     3,042.72
67973       Reconstruction of eyelid             T           T        0241       25.2550        1,164.26     2,654.55     3,042.72
67974       Reconstruction of eyelid             T           T        0241       25.2550        1,164.26     2,654.55     3,042.72
67975       Reconstruction of eyelid             T           T        0240       17.1243         789.43      1,799.94     2,063.14
67999       Revision of eyelid                   T           1        0000        0.0000           0.00         0.00         0.00
68020       Incise/drain eyelid lining           T           T        0240       17.1243         789.43      1,799.94     2,063.14
68040       Treatment of eyelid lesions          S           S        0698        1.1607          53.51       122.00       139.84
68100       Biopsy of eyelid lining              T           T        0232        6.0673         279.70       637.73       730.99
68110       Remove eyelid lining lesion          T           T        0699       14.3845         663.13      1,511.95     1,733.04
68115       Remove eyelid lining lesion          T           T        0240       17.1243         789.43      1,799.94     2,063.14
68130       Remove eyelid lining lesion          T           T        0233       15.2259         701.91      1,600.39     1,834.42
68135       Remove eyelid lining lesion          T           T        0239        7.2819         335.70       765.40       877.32
68200       Treat eyelid by injection            S           S        0230        0.7898          36.41        83.02        95.16
68320       Revise/graft eyelid lining           T           T        0240       17.1243         789.43      1,799.94     2,063.14
68325       Revise/graft eyelid lining           T           T        0241       25.2550        1,164.26     2,654.55     3,042.72
68326       Revise/graft eyelid lining           T           T        0241       25.2550        1,164.26     2,654.55     3,042.72
68328       Revise/graft eyelid lining           T           T        0241       25.2550        1,164.26     2,654.55     3,042.72
68330       Revise eyelid lining                 T           T        0234       22.9970        1,060.16     2,417.21     2,770.68
68335       Revise/graft eyelid lining           T           T        0241       25.2550        1,164.26     2,654.55     3,042.72
68340       Separate eyelid adhesions            T           T        0240       17.1243         789.43      1,799.94     2,063.14
68360       Revise eyelid lining                 T           T        0234       22.9970        1,060.16     2,417.21     2,770.68
68362       Revise eyelid lining                 T           T        0234       22.9970        1,060.16     2,417.21     2,770.68
68371       Harvest eye tissue, alograft         T           1        0000        0.0000           0.00         0.00         0.00
68399       Eyelid lining surgery                T           1        0000        0.0000           0.00         0.00         0.00
68400       Incise/drain tear gland              T           T        0238        2.8954         133.48       304.34       348.84
68420       Incise/drain tear sac                T           T        0240       17.1243         789.43      1,799.94     2,063.14
68440       Incise tear duct opening             T           T        0238        2.8954         133.48       304.34       348.84
68500       Removal of tear gland                T           T        0241       25.2550        1,164.26     2,654.55     3,042.72
68505       Partial removal, tear gland          T           T        0241       25.2550        1,164.26     2,654.55     3,042.72
68510       Biopsy of tear gland                 T           T        0240       17.1243         789.43      1,799.94     2,063.14
68520       Removal of tear sac                  T           T        0241       25.2550        1,164.26     2,654.55     3,042.72
68525       Biopsy of tear sac                   T           T        0240       17.1243         789.43      1,799.94     2,063.14
68530       Clearance of tear duct               T           T        0240       17.1243         789.43      1,799.94     2,063.14
68540       Remove tear gland lesion             T           T        0241       25.2550        1,164.26     2,654.55     3,042.72
68550       Remove tear gland lesion             T           T        0241       25.2550        1,164.26     2,654.55     3,042.72
68700       Repair tear ducts                    T           T        0241       25.2550        1,164.26     2,654.55     3,042.72
68705       Revise tear duct opening             T           T        0238        2.8954         133.48       304.34       348.84
68720       Create tear sac drain                T           T        0241       25.2550        1,164.26     2,654.55     3,042.72
68745       Create tear duct drain               T           T        0241       25.2550        1,164.26     2,654.55     3,042.72
68750       Create tear duct drain               T           T        0241       25.2550        1,164.26     2,654.55     3,042.72
68760       Close tear duct opening              S           S        0231        2.1451          98.89       225.47       258.44
68761       Close tear duct opening              S           S        0231        2.1451          98.89       225.47       258.44
68770       Close tear system fistula            T           T        0240       17.1243         789.43      1,799.94     2,063.14
68801       Dilate tear duct opening             S           S        0698        1.1607          53.51       122.00       139.84
68810       Probe nasolacrimal duct              S           S        0231        2.1451          98.89       225.47       258.44
68811       Probe nasolacrimal duct              T           T        0240       17.1243         789.43      1,799.94     2,063.14
68815       Probe nasolacrimal duct              T           T        0240       17.1243         789.43      1,799.94     2,063.14
68840       Explore/irrigate tear ducts          S           S        0698        1.1607          53.51       122.00       139.84
68850       Injection for tear sac x-ray         N           N        0000        0.0000           0.00         0.00         0.00
68899       Tear duct system surgery             T           1        0000        0.0000           0.00         0.00         0.00
69000       Drain external ear lesion            T           T        0006        1.4392          66.35       151.27       173.39
69005       Drain external ear lesion            T           T        0008       17.5086         807.15      1,840.33     2,109.44
69020       Drain outer ear canal lesion         T           T        0006        1.4392          66.35       151.27       173.39
69090       Pierce earlobes                      E           1        0000        0.0000           0.00         0.00         0.00
69100       Biopsy of external ear               T           T        0019        4.0919         188.64       430.10       492.99
69105       Biopsy of external ear canal         T           T        0253       16.4266         757.27      1,726.60     1,979.08
69110       Remove external ear, partial         T           T        0021       15.1024         696.22      1,587.41     1,819.54
69120       Removal of external ear              T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
69140       Remove ear canal lesion(s)           T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
69145       Remove ear canal lesion(s)           T           T        0021       15.1024         696.22      1,587.41     1,819.54
69150       Extensive ear canal surgery          T           T        0252        7.5511         348.11       793.70       909.76
69155       Extensive ear/neck surgery           C           C        0000        0.0000           0.00         0.00         0.00
69200       Clear outer ear canal                X           X        0340        0.6102          28.13        64.14        73.52
69205       Clear outer ear canal                T           T        0022       20.0656         925.02      2,109.10     2,417.50
69210       Remove impacted ear wax              X           X        0340        0.6102          28.13        64.14        73.52
69220       Clean out mastoid cavity             T           T        0012        0.8432          38.87        88.63       101.59
69222       Clean out mastoid cavity             T           T        0252        7.5511         348.11       793.70       909.76
69300       Revise external ear                  T           1        0000        0.0000           0.00         0.00         0.00
69310       Rebuild outer ear canal              T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
69320       Rebuild outer ear canal              T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
69399       Outer ear surgery procedure          T           1        0000        0.0000           0.00         0.00         0.00
69400       Inflate middle ear canal             T           T        0251        2.4520         113.04       257.73       295.42
69401       Inflate middle ear canal             T           T        0251        2.4520         113.04       257.73       295.42
69405       Catheterize middle ear canal         T           T        0252        7.5511         348.11       793.70       909.76
69420       Incision of eardrum                  T           T        0251        2.4520         113.04       257.73       295.42
69421       Incision of eardrum                  T           T        0253       16.4266         757.27      1,726.60     1,979.08
69424       Remove ventilating tube              T           T        0252        7.5511         348.11       793.70       909.76
69433       Create eardrum opening               T           T        0252        7.5511         348.11       793.70       909.76
69436       Create eardrum opening               T           T        0253       16.4266         757.27      1,726.60     1,979.08
69440       Exploration of middle ear            T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
69450       Eardrum revision                     T           T        0256       38.1991        1,760.98     4,015.11     4,602.23


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 53 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
69501       Mastoidectomy                        T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
69502       Mastoidectomy                        T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
69505       Remove mastoid structures            T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
69511       Extensive mastoid surgery            T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
69530       Extensive mastoid surgery            T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
69535       Remove part of temporal bone         C           C        0000        0.0000           0.00         0.00         0.00
69540       Remove ear lesion                    T           T        0253       16.4266         757.27      1,726.60     1,979.08
69550       Remove ear lesion                    T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
69552       Remove ear lesion                    T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
69554       Remove ear lesion                    C           C        0000        0.0000           0.00         0.00         0.00
69601       Mastoid surgery revision             T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
69602       Mastoid surgery revision             T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
69603       Mastoid surgery revision             T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
69604       Mastoid surgery revision             T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
69605       Mastoid surgery revision             T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
69610       Repair of eardrum                    T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
69620       Repair of eardrum                    T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
69631       Repair eardrum structures            T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
69632       Rebuild eardrum structures           T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
69633       Rebuild eardrum structures           T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
69635       Repair eardrum structures            T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
69636       Rebuild eardrum structures           T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
69637       Rebuild eardrum structures           T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
69641       Revise middle ear & mastoid          T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
69642       Revise middle ear & mastoid          T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
69643       Revise middle ear & mastoid          T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
69644       Revise middle ear & mastoid          T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
69645       Revise middle ear & mastoid          T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
69646       Revise middle ear & mastoid          T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
69650       Release middle ear bone              T           T        0254       23.3299        1,075.51     2,452.21     2,810.79
69660       Revise middle ear bone               T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
69661       Revise middle ear bone               T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
69662       Revise middle ear bone               T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
69666       Repair middle ear structures         T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
69667       Repair middle ear structures         T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
69670       Remove mastoid air cells             T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
69676       Remove middle ear nerve              T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
69700       Close mastoid fistula                T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
69710       Implant/replace hearing aid          E           3        0000        0.0000           M01          M01          M01
69711       Remove/repair hearing aid            T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
69714       Implant temple bone w/stimul         T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
69715       Temple bne implnt w/stimulat         T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
69717       Temple bone implant revision         T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
69718       Revise temple bone implant           T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
69720       Release facial nerve                 T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
69725       Release facial nerve                 T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
69740       Repair facial nerve                  T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
69745       Repair facial nerve                  T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
69799       Middle ear surgery procedure         T           1        0000        0.0000           0.00         0.00         0.00
69801       Incise inner ear                     T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
69802       Incise inner ear                     T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
69805       Explore inner ear                    T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
69806       Explore inner ear                    T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
69820       Establish inner ear window           T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
69840       Revise inner ear window              T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
69905       Remove inner ear                     T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
69910       Remove inner ear & mastoid           T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
69915       Incise inner ear nerve               T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
69930       Implant cochlear device              T           T        0259      414.8455       19,124.38    43,604.41    49,980.59
69949       Inner ear surgery procedure          T           1        0000        0.0000           0.00         0.00         0.00
69950       Incise inner ear nerve               C           C        0000        0.0000           0.00         0.00         0.00
69955       Release facial nerve                 T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
69960       Release inner ear canal              T           T        0256       38.1991        1,760.98     4,015.11     4,602.23
69970       Remove inner ear lesion              C           C        0000        0.0000           0.00         0.00         0.00
69979       Temporal bone surgery                T           1        0000        0.0000           0.00         0.00         0.00
69990       Microsurgery add-on                  N           N        0000        0.0000           0.00         0.00         0.00
70010       Contrast x-ray of brain              S           S        0274        2.5544         117.76       268.49       307.75
70015       Contrast x-ray of brain              S           S        0274        2.5544         117.76       268.49       307.75
70030       X-ray eye for foreign body           X           X        0260        0.7093          32.70        74.55        85.46
70100       X-ray exam of jaw                    X           X        0260        0.7093          32.70        74.55        85.46
70110       X-ray exam of jaw                    X           X        0260        0.7093          32.70        74.55        85.46
70120       X-ray exam of mastoids               X           X        0260        0.7093          32.70        74.55        85.46
70130       X-ray exam of mastoids               X           X        0260        0.7093          32.70        74.55        85.46
70134       X-ray exam of middle ear             X           X        0261        1.2224          56.35       128.49       147.27
70140       X-ray exam of facial bones           X           X        0260        0.7093          32.70        74.55        85.46
70150       X-ray exam of facial bones           X           X        0260        0.7093          32.70        74.55        85.46
70160       X-ray exam of nasal bones            X           X        0260        0.7093          32.70        74.55        85.46
70170       X-ray exam of tear duct              X           X        0264        2.9586         136.39       310.98       356.45
70190       X-ray exam of eye sockets            X           X        0260        0.7093          32.70        74.55        85.46
70200       X-ray exam of eye sockets            X           X        0260        0.7093          32.70        74.55        85.46
70210       X-ray exam of sinuses                X           X        0260        0.7093          32.70        74.55        85.46
70220       X-ray exam of sinuses                X           X        0260        0.7093          32.70        74.55        85.46
70240       X-ray exam, pituitary saddle         X           X        0260        0.7093          32.70        74.55        85.46
70250       X-ray exam of skull                  X           X        0260        0.7093          32.70        74.55        85.46
70260       X-ray exam of skull                  X           X        0261        1.2224          56.35       128.49       147.27
70300       X-ray exam of teeth                  X           X        0262        0.6550          30.20        68.85        78.91
70310       X-ray exam of teeth                  X           X        0262        0.6550          30.20        68.85        78.91
70320       Full mouth x-ray of teeth            X           X        0262        0.6550          30.20        68.85        78.91
70328       X-ray exam of jaw joint              X           X        0260        0.7093          32.70        74.55        85.46
70330       X-ray exam of jaw joints             X           X        0260        0.7093          32.70        74.55        85.46
70332       X-ray exam of jaw joint              S           S        0275        3.6915         170.18       388.01       444.75
70336       Magnetic image, jaw joint            S           S        0335        4.5523         209.86       478.49       548.46
70350       X-ray head for orthodontia           X           X        0260        0.7093          32.70        74.55        85.46
70355       Panoramic x-ray of jaws              X           X        0260        0.7093          32.70        74.55        85.46
70360       X-ray exam of neck                   X           X        0260        0.7093          32.70        74.55        85.46
70370       Throat x-ray & fluoroscopy           X           X        0272        1.2908          59.51       135.68       155.52
70371       Speech evaluation, complex           X           X        0272        1.2908          59.51       135.68       155.52
70373       Contrast x-ray of larynx             X           X        0263        1.6956          78.17       178.22       204.29
70380       X-ray exam of salivary gland         X           X        0260        0.7093          32.70        74.55        85.46
70390       X-ray exam of salivary duct          X           X        0263        1.6956          78.17       178.22       204.29
70450       Ct head/brain w/o dye                S           S        0332        3.0908         142.49       324.87       372.38
70460       Ct head/brain w/dye                  S           S        0283        4.0825         188.20       429.11       491.86
70470       Ct head/brain w/o & w/dye            S           S        0333        4.8405         223.15       508.78       583.18
70480       Ct orbit/ear/fossa w/o dye           S           S        0332        3.0908         142.49       324.87       372.38
70481       Ct orbit/ear/fossa w/dye             S           S        0283        4.0825         188.20       429.11       491.86
70482       Ct orbit/ear/fossa w/o&w/dye         S           S        0333        4.8405         223.15       508.78       583.18


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 54 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
70486       Ct maxillofacial w/o dye             S           S        0332        3.0908        142.49        324.87       372.38
70487       Ct maxillofacial w/dye               S           S        0283        4.0825        188.20        429.11       491.86
70488       Ct maxillofacial w/o & w/dye         S           S        0333        4.8405        223.15        508.78       583.18
70490       Ct soft tissue neck w/o dye          S           S        0332        3.0908        142.49        324.87       372.38
70491       Ct soft tissue neck w/dye            S           S        0283        4.0825        188.20        429.11       491.86
70492       Ct sft tsue nck w/o & w/dye          S           S        0333        4.8405        223.15        508.78       583.18
70496       Ct angiography, head                 S           S        0662        4.8552        223.82        510.33       584.95
70498       Ct angiography, neck                 S           S        0662        4.8552        223.82        510.33       584.95
70540       Mri orbit/face/neck w/o dye          S           S        0336        5.6745        261.59        596.45       683.66
70542       Mri orbit/face/neck w/dye            S           S        0284        6.1231        282.27        643.60       737.71
70543       Mri orbt/fac/nck w/o & w/dye         S           S        0337        8.1155        374.12        853.02       977.76
70544       Mr angiography head w/o dye          S           S        0336        5.6745        261.59        596.45       683.66
70545       Mr angiography head w/dye            S           S        0284        6.1231        282.27        643.60       737.71
70546       Mr angiograph head w/o&w/dye         S           S        0337        8.1155        374.12        853.02       977.76
70547       Mr angiography neck w/o dye          S           S        0336        5.6745        261.59        596.45       683.66
70548       Mr angiography neck w/dye            S           S        0284        6.1231        282.27        643.60       737.71
70549       Mr angiograph neck w/o&w/dye         S           S        0337        8.1155        374.12        853.02       977.76
70551       Mri brain w/o dye                    S           S        0336        5.6745        261.59        596.45       683.66
70552       Mri brain w/dye                      S           S        0284        6.1231        282.27        643.60       737.71
70553       Mri brain w/o & w/dye                S           S        0337        8.1155        374.12        853.02       977.76
70554       Fmri brain by tech                   S           S        0336        5.6745        261.59        596.45       683.66
70555       Fmri brain by phys/psych             S           S        0336        5.6745        261.59        596.45       683.66
70557       Mri brain w/o dye                    S           S        0336        5.6745        261.59        596.45       683.66
70558       Mri brain w/dye                      S           S        0284        6.1231        282.27        643.60       737.71
70559       Mri brain w/o & w/dye                S           S        0337        8.1155        374.12        853.02       977.76
71010       Chest x-ray                          X           X        0260        0.7093         32.70         74.55        85.46
71015       Chest x-ray                          X           X        0260        0.7093         32.70         74.55        85.46
71020       Chest x-ray                          X           X        0260        0.7093         32.70         74.55        85.46
71021       Chest x-ray                          X           X        0260        0.7093         32.70         74.55        85.46
71022       Chest x-ray                          X           X        0260        0.7093         32.70         74.55        85.46
71023       Chest x-ray and fluoroscopy          X           X        0272        1.2908         59.51        135.68       155.52
71030       Chest x-ray                          X           X        0260        0.7093         32.70         74.55        85.46
71034       Chest x-ray and fluoroscopy          X           X        0272        1.2908         59.51        135.68       155.52
71035       Chest x-ray                          X           X        0260        0.7093         32.70         74.55        85.46
71040       Contrast x-ray of bronchi            X           X        0263        1.6956         78.17        178.22       204.29
71060       Contrast x-ray of bronchi            X           X        0263        1.6956         78.17        178.22       204.29
71090       X-ray & pacemaker insertion          X           X        0272        1.2908         59.51        135.68       155.52
71100       X-ray exam of ribs                   X           X        0260        0.7093         32.70         74.55        85.46
71101       X-ray exam of ribs/chest             X           X        0260        0.7093         32.70         74.55        85.46
71110       X-ray exam of ribs                   X           X        0260        0.7093         32.70         74.55        85.46
71111       X-ray exam of ribs/chest             X           X        0261        1.2224         56.35        128.49       147.27
71120       X-ray exam of breastbone             X           X        0260        0.7093         32.70         74.55        85.46
71130       X-ray exam of breastbone             X           X        0260        0.7093         32.70         74.55        85.46
71250       Ct thorax w/o dye                    S           S        0332        3.0908        142.49        324.87       372.38
71260       Ct thorax w/dye                      S           S        0283        4.0825        188.20        429.11       491.86
71270       Ct thorax w/o & w/dye                S           S        0333        4.8405        223.15        508.78       583.18
71275       Ct angiography, chest                S           S        0662        4.8552        223.82        510.33       584.95
71550       Mri chest w/o dye                    S           S        0336        5.6745        261.59        596.45       683.66
71551       Mri chest w/dye                      S           S        0284        6.1231        282.27        643.60       737.71
71552       Mri chest w/o & w/dye                S           S        0337        8.1155        374.12        853.02       977.76
71555       Mri angio chest w or w/o dye         B           B        0000        0.0000          0.00          0.00         0.00
72010       X-ray exam of spine                  X           X        0260        0.7093         32.70         74.55        85.46
72020       X-ray exam of spine                  X           X        0260        0.7093         32.70         74.55        85.46
72040       X-ray exam of neck spine             X           X        0260        0.7093         32.70         74.55        85.46
72050       X-ray exam of neck spine             X           X        0261        1.2224         56.35        128.49       147.27
72052       X-ray exam of neck spine             X           X        0261        1.2224         56.35        128.49       147.27
72069       X-ray exam of trunk spine            X           X        0260        0.7093         32.70         74.55        85.46
72070       X-ray exam of thoracic spine         X           X        0260        0.7093         32.70         74.55        85.46
72072       X-ray exam of thoracic spine         X           X        0260        0.7093         32.70         74.55        85.46
72074       X-ray exam of thoracic spine         X           X        0260        0.7093         32.70         74.55        85.46
72080       X-ray exam of trunk spine            X           X        0260        0.7093         32.70         74.55        85.46
72090       X-ray exam of trunk spine            X           X        0261        1.2224         56.35        128.49       147.27
72100       X-ray exam of lower spine            X           X        0260        0.7093         32.70         74.55        85.46
72110       X-ray exam of lower spine            X           X        0261        1.2224         56.35        128.49       147.27
72114       X-ray exam of lower spine            X           X        0261        1.2224         56.35        128.49       147.27
72120       X-ray exam of lower spine            X           X        0261        1.2224         56.35        128.49       147.27
72125       Ct neck spine w/o dye                S           S        0332        3.0908        142.49        324.87       372.38
72126       Ct neck spine w/dye                  S           S        0283        4.0825        188.20        429.11       491.86
72127       Ct neck spine w/o & w/dye            S           S        0333        4.8405        223.15        508.78       583.18
72128       Ct chest spine w/o dye               S           S        0332        3.0908        142.49        324.87       372.38
72129       Ct chest spine w/dye                 S           S        0283        4.0825        188.20        429.11       491.86
72130       Ct chest spine w/o & w/dye           S           S        0333        4.8405        223.15        508.78       583.18
72131       Ct lumbar spine w/o dye              S           S        0332        3.0908        142.49        324.87       372.38
72132       Ct lumbar spine w/dye                S           S        0283        4.0825        188.20        429.11       491.86
72133       Ct lumbar spine w/o & w/dye          S           S        0333        4.8405        223.15        508.78       583.18
72141       Mri neck spine w/o dye               S           S        0336        5.6745        261.59        596.45       683.66
72142       Mri neck spine w/dye                 S           S        0284        6.1231        282.27        643.60       737.71
72146       Mri chest spine w/o dye              S           S        0336        5.6745        261.59        596.45       683.66
72147       Mri chest spine w/dye                S           S        0284        6.1231        282.27        643.60       737.71
72148       Mri lumbar spine w/o dye             S           S        0336        5.6745        261.59        596.45       683.66
72149       Mri lumbar spine w/dye               S           S        0284        6.1231        282.27        643.60       737.71
72156       Mri neck spine w/o & w/dye           S           S        0337        8.1155        374.12        853.02       977.76
72157       Mri chest spine w/o & w/dye          S           S        0337        8.1155        374.12        853.02       977.76
72158       Mri lumbar spine w/o & w/dye         S           S        0337        8.1155        374.12        853.02       977.76
72159       Mr angio spine w/o&w/dye             E           3        0000        0.0000          M01           M01          M01
72170       X-ray exam of pelvis                 X           X        0260        0.7093         32.70         74.55        85.46
72190       X-ray exam of pelvis                 X           X        0260        0.7093         32.70         74.55        85.46
72191       Ct angiograph pelv w/o&w/dye         S           S        0662        4.8552        223.82        510.33       584.95
72192       Ct pelvis w/o dye                    S           S        0332        3.0908        142.49        324.87       372.38
72193       Ct pelvis w/dye                      S           S        0283        4.0825        188.20        429.11       491.86
72194       Ct pelvis w/o & w/dye                S           S        0333        4.8405        223.15        508.78       583.18
72195       Mri pelvis w/o dye                   S           S        0336        5.6745        261.59        596.45       683.66
72196       Mri pelvis w/dye                     S           S        0284        6.1231        282.27        643.60       737.71
72197       Mri pelvis w/o & w/dye               S           S        0337        8.1155        374.12        853.02       977.76
72198       Mr angio pelvis w/o & w/dye          B           B        0000        0.0000          0.00          0.00         0.00
72200       X-ray exam sacroiliac joints         X           X        0260        0.7093         32.70         74.55        85.46
72202       X-ray exam sacroiliac joints         X           X        0260        0.7093         32.70         74.55        85.46
72220       X-ray exam of tailbone               X           X        0260        0.7093         32.70         74.55        85.46
72240       Contrast x-ray of neck spine         S           S        0274        2.5544        117.76        268.49       307.75
72255       Contrast x-ray, thorax spine         S           S        0274        2.5544        117.76        268.49       307.75
72265       Contrast x-ray, lower spine          S           S        0274        2.5544        117.76        268.49       307.75
72270       Contrast x-ray, spine                S           S        0274        2.5544        117.76        268.49       307.75
72275       Epidurography                        S           S        0274        2.5544        117.76        268.49       307.75
72285       X-ray c/t spine disk                 S           S        0388       15.9758        736.48       1,679.22     1,924.76
72291       Perq vertebroplasty, fluor           S           S        0274        2.5544        117.76        268.49       307.75
72292       Perq vertebroplasty, ct              S           S        0274        2.5544        117.76        268.49       307.75


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 55 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
72295       X-ray of lower spine disk            S           S        0388       15.9758        736.48       1,679.22     1,924.76
73000       X-ray exam of collar bone            X           X        0260        0.7093         32.70         74.55        85.46
73010       X-ray exam of shoulder blade         X           X        0260        0.7093         32.70         74.55        85.46
73020       X-ray exam of shoulder               X           X        0260        0.7093         32.70         74.55        85.46
73030       X-ray exam of shoulder               X           X        0260        0.7093         32.70         74.55        85.46
73040       Contrast x-ray of shoulder           S           S        0275        3.6915        170.18        388.01       444.75
73050       X-ray exam of shoulders              X           X        0260        0.7093         32.70         74.55        85.46
73060       X-ray exam of humerus                X           X        0260        0.7093         32.70         74.55        85.46
73070       X-ray exam of elbow                  X           X        0260        0.7093         32.70         74.55        85.46
73080       X-ray exam of elbow                  X           X        0260        0.7093         32.70         74.55        85.46
73085       Contrast x-ray of elbow              S           S        0275        3.6915        170.18        388.01       444.75
73090       X-ray exam of forearm                X           X        0260        0.7093         32.70         74.55        85.46
73092       X-ray exam of arm, infant            X           X        0260        0.7093         32.70         74.55        85.46
73100       X-ray exam of wrist                  X           X        0260        0.7093         32.70         74.55        85.46
73110       X-ray exam of wrist                  X           X        0260        0.7093         32.70         74.55        85.46
73115       Contrast x-ray of wrist              S           S        0275        3.6915        170.18        388.01       444.75
73120       X-ray exam of hand                   X           X        0260        0.7093         32.70         74.55        85.46
73130       X-ray exam of hand                   X           X        0260        0.7093         32.70         74.55        85.46
73140       X-ray exam of finger(s)              X           X        0260        0.7093         32.70         74.55        85.46
73200       Ct upper extremity w/o dye           S           S        0332        3.0908        142.49        324.87       372.38
73201       Ct upper extremity w/dye             S           S        0283        4.0825        188.20        429.11       491.86
73202       Ct uppr extremity w/o&w/dye          S           S        0333        4.8405        223.15        508.78       583.18
73206       Ct angio upr extrm w/o&w/dye         S           S        0662        4.8552        223.82        510.33       584.95
73218       Mri upper extremity w/o dye          S           S        0336        5.6745        261.59        596.45       683.66
73219       Mri upper extremity w/dye            S           S        0284        6.1231        282.27        643.60       737.71
73220       Mri uppr extremity w/o&w/dye         S           S        0337        8.1155        374.12        853.02       977.76
73221       Mri joint upr extrem w/o dye         S           S        0336        5.6745        261.59        596.45       683.66
73222       Mri joint upr extrem w/dye           S           S        0284        6.1231        282.27        643.60       737.71
73223       Mri joint upr extr w/o&w/dye         S           S        0337        8.1155        374.12        853.02       977.76
73225       Mr angio upr extr w/o&w/dye          E           3        0000        0.0000          M01           M01          M01
73500       X-ray exam of hip                    X           X        0260        0.7093         32.70         74.55        85.46
73510       X-ray exam of hip                    X           X        0260        0.7093         32.70         74.55        85.46
73520       X-ray exam of hips                   X           X        0261        1.2224         56.35        128.49       147.27
73525       Contrast x-ray of hip                S           S        0275        3.6915        170.18        388.01       444.75
73530       X-ray exam of hip                    X           X        0261        1.2224         56.35        128.49       147.27
73540       X-ray exam of pelvis & hips          X           X        0260        0.7093         32.70         74.55        85.46
73542       X-ray exam, sacroiliac joint         S           S        0275        3.6915        170.18        388.01       444.75
73550       X-ray exam of thigh                  X           X        0260        0.7093         32.70         74.55        85.46
73560       X-ray exam of knee, 1 or 2           X           X        0260        0.7093         32.70         74.55        85.46
73562       X-ray exam of knee, 3                X           X        0260        0.7093         32.70         74.55        85.46
73564       X-ray exam, knee, 4 or more          X           X        0260        0.7093         32.70         74.55        85.46
73565       X-ray exam of knees                  X           X        0260        0.7093         32.70         74.55        85.46
73580       Contrast x-ray of knee joint         S           S        0275        3.6915        170.18        388.01       444.75
73590       X-ray exam of lower leg              X           X        0260        0.7093         32.70         74.55        85.46
73592       X-ray exam of leg, infant            X           X        0260        0.7093         32.70         74.55        85.46
73600       X-ray exam of ankle                  X           X        0260        0.7093         32.70         74.55        85.46
73610       X-ray exam of ankle                  X           X        0260        0.7093         32.70         74.55        85.46
73615       Contrast x-ray of ankle              S           S        0275        3.6915        170.18        388.01       444.75
73620       X-ray exam of foot                   X           X        0260        0.7093         32.70         74.55        85.46
73630       X-ray exam of foot                   X           X        0260        0.7093         32.70         74.55        85.46
73650       X-ray exam of heel                   X           X        0260        0.7093         32.70         74.55        85.46
73660       X-ray exam of toe(s)                 X           X        0260        0.7093         32.70         74.55        85.46
73700       Ct lower extremity w/o dye           S           S        0332        3.0908        142.49        324.87       372.38
73701       Ct lower extremity w/dye             S           S        0283        4.0825        188.20        429.11       491.86
73702       Ct lwr extremity w/o&w/dye           S           S        0333        4.8405        223.15        508.78       583.18
73706       Ct angio lwr extr w/o&w/dye          S           S        0662        4.8552        223.82        510.33       584.95
73718       Mri lower extremity w/o dye          S           S        0336        5.6745        261.59        596.45       683.66
73719       Mri lower extremity w/dye            S           S        0284        6.1231        282.27        643.60       737.71
73720       Mri lwr extremity w/o&w/dye          S           S        0337        8.1155        374.12        853.02       977.76
73721       Mri jnt of lwr extre w/o dye         S           S        0336        5.6745        261.59        596.45       683.66
73722       Mri joint of lwr extr w/dye          S           S        0284        6.1231        282.27        643.60       737.71
73723       Mri joint lwr extr w/o&w/dye         S           S        0337        8.1155        374.12        853.02       977.76
73725       Mr ang lwr ext w or w/o dye          B           B        0000        0.0000          0.00          0.00         0.00
74000       X-ray exam of abdomen                X           X        0260        0.7093         32.70         74.55        85.46
74010       X-ray exam of abdomen                X           X        0260        0.7093         32.70         74.55        85.46
74020       X-ray exam of abdomen                X           X        0260        0.7093         32.70         74.55        85.46
74022       X-ray exam series, abdomen           X           X        0261        1.2224         56.35        128.49       147.27
74150       Ct abdomen w/o dye                   S           S        0332        3.0908        142.49        324.87       372.38
74160       Ct abdomen w/dye                     S           S        0283        4.0825        188.20        429.11       491.86
74170       Ct abdomen w/o & w/dye               S           S        0333        4.8405        223.15        508.78       583.18
74175       Ct angio abdom w/o & w/dye           S           S        0662        4.8552        223.82        510.33       584.95
74181       Mri abdomen w/o dye                  S           S        0336        5.6745        261.59        596.45       683.66
74182       Mri abdomen w/dye                    S           S        0284        6.1231        282.27        643.60       737.71
74183       Mri abdomen w/o & w/dye              S           S        0337        8.1155        374.12        853.02       977.76
74185       Mri angio, abdom w orw/o dye         B           B        0000        0.0000          0.00          0.00         0.00
74190       X-ray exam of peritoneum             X           X        0264        2.9586        136.39        310.98       356.45
74210       Contrst x-ray exam of throat         S           S        0276        1.4294         65.90        150.24       172.21
74220       Contrast x-ray, esophagus            S           S        0276        1.4294         65.90        150.24       172.21
74230       Cine/vid x-ray, throat/esoph         S           S        0276        1.4294         65.90        150.24       172.21
74235       Remove esophagus obstruction         S           S        0257        1.0974         50.59        115.35       132.21
74240       X-ray exam, upper gi tract           S           S        0276        1.4294         65.90        150.24       172.21
74241       X-ray exam, upper gi tract           S           S        0276        1.4294         65.90        150.24       172.21
74245       X-ray exam, upper gi tract           S           S        0277        2.2176        102.23        233.09       267.18
74246       Contrst x-ray uppr gi tract          S           S        0276        1.4294         65.90        150.24       172.21
74247       Contrst x-ray uppr gi tract          S           S        0276        1.4294         65.90        150.24       172.21
74249       Contrst x-ray uppr gi tract          S           S        0277        2.2176        102.23        233.09       267.18
74250       X-ray exam of small bowel            S           S        0276        1.4294         65.90        150.24       172.21
74251       X-ray exam of small bowel            S           S        0277        2.2176        102.23        233.09       267.18
74260       X-ray exam of small bowel            S           S        0276        1.4294         65.90        150.24       172.21
74270       Contrast x-ray exam of colon         S           S        0276        1.4294         65.90        150.24       172.21
74280       Contrast x-ray exam of colon         S           S        0277        2.2176        102.23        233.09       267.18
74283       Contrast x-ray exam of colon         S           S        0276        1.4294         65.90        150.24       172.21
74290       Contrast x-ray, gallbladder          S           S        0276        1.4294         65.90        150.24       172.21
74291       Contrast x-rays, gallbladder         S           S        0276        1.4294         65.90        150.24       172.21
74300       X-ray bile ducts/pancreas            X           X        0263        1.6956         78.17        178.22       204.29
74301       X-rays at surgery add-on             X           X        0263        1.6956         78.17        178.22       204.29
74305       X-ray bile ducts/pancreas            X           X        0263        1.6956         78.17        178.22       204.29
74320       Contrast x-ray of bile ducts         X           X        0264        2.9586        136.39        310.98       356.45
74327       X-ray bile stone removal             S           S        0296        2.6802        123.56        281.72       322.91
74328       X-ray bile duct endoscopy            N           N        0000        0.0000          0.00          0.00         0.00
74329       X-ray for pancreas endoscopy         N           N        0000        0.0000          0.00          0.00         0.00
74330       X-ray bile/panc endoscopy            N           N        0000        0.0000          0.00          0.00         0.00
74340       X-ray guide for GI tube              X           X        0272        1.2908         59.51        135.68       155.52
74350       X-ray guide, stomach tube            X           X        0263        1.6956         78.17        178.22       204.29
74355       X-ray guide, intestinal tube         X           X        0263        1.6956         78.17        178.22       204.29
74360       X-ray guide, GI dilation             S           S        0257        1.0974         50.59        115.35       132.21


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 56 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
74363       X-ray, bile duct dilation            S           S        0297        3.6392        167.77        382.52       438.45
74400       Contrst x-ray, urinary tract         S           S        0278        2.4159        111.37        253.94       291.07
74410       Contrst x-ray, urinary tract         S           S        0278        2.4159        111.37        253.94       291.07
74415       Contrst x-ray, urinary tract         S           S        0278        2.4159        111.37        253.94       291.07
74420       Contrst x-ray, urinary tract         S           S        0278        2.4159        111.37        253.94       291.07
74425       Contrst x-ray, urinary tract         S           S        0278        2.4159        111.37        253.94       291.07
74430       Contrast x-ray, bladder              S           S        0278        2.4159        111.37        253.94       291.07
74440       X-ray, male genital tract            S           S        0278        2.4159        111.37        253.94       291.07
74445       X-ray exam of penis                  S           S        0278        2.4159        111.37        253.94       291.07
74450       X-ray, urethra/bladder               S           S        0278        2.4159        111.37        253.94       291.07
74455       X-ray, urethra/bladder               S           S        0278        2.4159        111.37        253.94       291.07
74470       X-ray exam of kidney lesion          X           X        0263        1.6956         78.17        178.22       204.29
74475       X-ray control, cath insert           S           S        0297        3.6392        167.77        382.52       438.45
74480       X-ray control, cath insert           S           S        0296        2.6802        123.56        281.72       322.91
74485       X-ray guide, GU dilation             S           S        0296        2.6802        123.56        281.72       322.91
74710       X-ray measurement of pelvis          X           X        0261        1.2224         56.35        128.49       147.27
74740       X-ray, female genital tract          X           X        0264        2.9586        136.39        310.98       356.45
74742       X-ray, fallopian tube                X           X        0264        2.9586        136.39        310.98       356.45
74775       X-ray exam of perineum               S           S        0278        2.4159        111.37        253.94       291.07
75552       Heart mri for morph w/o dye          S           S        0336        5.6745        261.59        596.45       683.66
75553       Heart mri for morph w/dye            S           S        0284        6.1231        282.27        643.60       737.71
75554       Cardiac MRI/function                 S           S        0336        5.6745        261.59        596.45       683.66
75555       Cardiac MRI/limited study            S           S        0336        5.6745        261.59        596.45       683.66
75556       Cardiac MRI/flow mapping             E           3        0000        0.0000          M01          M01          M01
75600       Contrast x-ray exam of aorta         S           S        0280       20.8225        959.92       2,188.65     2,508.69
75605       Contrast x-ray exam of aorta         S           S        0280       20.8225        959.92       2,188.65     2,508.69
75625       Contrast x-ray exam of aorta         S           S        0280       20.8225        959.92       2,188.65     2,508.69
75630       X-ray aorta, leg arteries            S           S        0280       20.8225        959.92       2,188.65     2,508.69
75635       Ct angio abdominal arteries          S           S        0662        4.8552        223.82        510.33       584.95
75650       Artery x-rays, head & neck           S           S        0280       20.8225        959.92       2,188.65     2,508.69
75658       Artery x-rays, arm                   S           S        0279        9.5061        438.23        999.19      1,145.29
75660       Artery x-rays, head & neck           S           S        0668        6.2463        287.95        656.55       752.55
75662       Artery x-rays, head & neck           S           S        0280       20.8225        959.92       2,188.65     2,508.69
75665       Artery x-rays, head & neck           S           S        0280       20.8225        959.92       2,188.65     2,508.69
75671       Artery x-rays, head & neck           S           S        0280       20.8225        959.92       2,188.65     2,508.69
75676       Artery x-rays, neck                  S           S        0280       20.8225        959.92       2,188.65     2,508.69
75680       Artery x-rays, neck                  S           S        0280       20.8225        959.92       2,188.65     2,508.69
75685       Artery x-rays, spine                 S           S        0280       20.8225        959.92       2,188.65     2,508.69
75705       Artery x-rays, spine                 S           S        0668        6.2463        287.95        656.55       752.55
75710       Artery x-rays, arm/leg               S           S        0280       20.8225        959.92       2,188.65     2,508.69
75716       Artery x-rays, arms/legs             S           S        0280       20.8225        959.92       2,188.65     2,508.69
75722       Artery x-rays, kidney                S           S        0280       20.8225        959.92       2,188.65     2,508.69
75724       Artery x-rays, kidneys               S           S        0280       20.8225        959.92       2,188.65     2,508.69
75726       Artery x-rays, abdomen               S           S        0280       20.8225        959.92       2,188.65     2,508.69
75731       Artery x-rays, adrenal gland         S           S        0280       20.8225        959.92       2,188.65     2,508.69
75733       Artery x-rays, adrenals              S           S        0668        6.2463        287.95        656.55       752.55
75736       Artery x-rays, pelvis                S           S        0280       20.8225        959.92       2,188.65     2,508.69
75741       Artery x-rays, lung                  S           S        0279        9.5061        438.23        999.19      1,145.29
75743       Artery x-rays, lungs                 S           S        0280       20.8225        959.92       2,188.65     2,508.69
75746       Artery x-rays, lung                  S           S        0279        9.5061        438.23        999.19      1,145.29
75756       Artery x-rays, chest                 S           S        0279        9.5061        438.23        999.19      1,145.29
75774       Artery x-ray, each vessel            S           S        0279        9.5061        438.23        999.19      1,145.29
75790       Visualize A-V shunt                  S           S        0279        9.5061        438.23        999.19      1,145.29
75801       Lymph vessel x-ray, arm/leg          X           X        0264        2.9586        136.39        310.98       356.45
75803       Lymph vessel x-ray,arms/legs         X           X        0264        2.9586        136.39        310.98       356.45
75805       Lymph vessel x-ray, trunk            X           X        0264        2.9586        136.39        310.98       356.45
75807       Lymph vessel x-ray, trunk            X           X        0264        2.9586        136.39        310.98       356.45
75809       Nonvascular shunt, x-ray             X           X        0263        1.6956         78.17        178.22       204.29
75810       Vein x-ray, spleen/liver             S           S        0279        9.5061        438.23        999.19      1,145.29
75820       Vein x-ray, arm/leg                  S           S        0668        6.2463        287.95        656.55       752.55
75822       Vein x-ray, arms/legs                S           S        0668        6.2463        287.95        656.55       752.55
75825       Vein x-ray, trunk                    S           S        0279        9.5061        438.23        999.19      1,145.29
75827       Vein x-ray, chest                    S           S        0279        9.5061        438.23        999.19      1,145.29
75831       Vein x-ray, kidney                   S           S        0279        9.5061        438.23        999.19      1,145.29
75833       Vein x-ray, kidneys                  S           S        0279        9.5061        438.23        999.19      1,145.29
75840       Vein x-ray, adrenal gland            S           S        0280       20.8225        959.92       2,188.65     2,508.69
75842       Vein x-ray, adrenal glands           S           S        0280       20.8225        959.92       2,188.65     2,508.69
75860       Vein x-ray, neck                     S           S        0668        6.2463        287.95        656.55       752.55
75870       Vein x-ray, skull                    S           S        0668        6.2463        287.95        656.55       752.55
75872       Vein x-ray, skull                    S           S        0279        9.5061        438.23        999.19      1,145.29
75880       Vein x-ray, eye socket               S           S        0668        6.2463        287.95        656.55       752.55
75885       Vein x-ray, liver                    S           S        0280       20.8225        959.92       2,188.65     2,508.69
75887       Vein x-ray, liver                    S           S        0279        9.5061        438.23        999.19      1,145.29
75889       Vein x-ray, liver                    S           S        0280       20.8225        959.92       2,188.65     2,508.69
75891       Vein x-ray, liver                    S           S        0279        9.5061        438.23        999.19      1,145.29
75893       Venous sampling by catheter          Q           Q        0668        6.2463        287.95        656.55       752.55
75894       X-rays, transcath therapy            S           S        0298        8.3906        386.81        881.94      1,010.90
75896       X-rays, transcath therapy            S           S        0298        8.3906        386.81        881.94      1,010.90
75898       Follow-up angiography                X           X        0263        1.6956         78.17        178.22       204.29
75900       Arterial catheter exchange           C           C        0000        0.0000          0.00         0.00         0.00
75901       Remove cva device obstruct           X           X        0263        1.6956         78.17        178.22       204.29
75902       Remove cva lumen obstruct            X           X        0263        1.6956         78.17        178.22       204.29
75940       X-ray placement, vein filter         S           S        0298        8.3906        386.81        881.94      1,010.90
75945       Intravascular us                     S           S        0267        2.4606        113.43        258.63       296.45
75946       Intravascular us add-on              S           S        0266        1.5607         71.95        164.05       188.03
75952       Endovasc repair abdom aorta          C           C        0000        0.0000          0.00         0.00         0.00
75953       Abdom aneurysm endovas rpr           C           C        0000        0.0000          0.00         0.00         0.00
75954       Iliac aneurysm endovas rpr           C           C        0000        0.0000          0.00         0.00         0.00
75956       Xray, endovasc thor ao repr          C           C        0000        0.0000          0.00         0.00         0.00
75957       Xray, endovasc thor ao repr          C           C        0000        0.0000          0.00         0.00         0.00
75958       Xray, place prox ext thor ao         C           C        0000        0.0000          0.00         0.00         0.00
75959       Xray, place dist ext thor ao         C           C        0000        0.0000          0.00         0.00         0.00
75960       Transcath iv stent rs&i              S           S        0668        6.2463        287.95        656.55       752.55
75961       Retrieval, broken catheter           S           S        0668        6.2463        287.95        656.55       752.55
75962       Repair arterial blockage             S           S        0668        6.2463        287.95        656.55       752.55
75964       Repair artery blockage, each         S           S        0668        6.2463        287.95        656.55       752.55
75966       Repair arterial blockage             S           S        0668        6.2463        287.95        656.55       752.55
75968       Repair artery blockage, each         S           S        0668        6.2463        287.95        656.55       752.55
75970       Vascular biopsy                      S           S        0668        6.2463        287.95        656.55       752.55
75978       Repair venous blockage               S           S        0668        6.2463        287.95        656.55       752.55
75980       Contrast xray exam bile duct         S           S        0297        3.6392        167.77        382.52       438.45
75982       Contrast xray exam bile duct         S           S        0297        3.6392        167.77        382.52       438.45
75984       Xray control catheter change         X           X        0263        1.6956         78.17        178.22       204.29
75989       Abscess drainage under x-ray         N           N        0000        0.0000          0.00         0.00         0.00
75992       Atherectomy, x-ray exam              S           S        0668        6.2463        287.95        656.55       752.55
75993       Atherectomy, x-ray exam              S           S        0668        6.2463        287.95        656.55       752.55


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 57 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
75994       Atherectomy, x-ray exam              S           S        0668       6.2463         287.95       656.55       752.55
75995       Atherectomy, x-ray exam              S           S        0668       6.2463         287.95       656.55       752.55
75996       Atherectomy, x-ray exam              S           S        0668       6.2463         287.95       656.55       752.55
76000       Fluoroscope examination              X           X        0272       1.2908          59.51       135.68       155.52
76001       Fluoroscope exam, extensive          N           N        0000       0.0000           0.00         0.00         0.00
76010       X-ray, nose to rectum                X           X        0260       0.7093          32.70        74.55        85.46
76080       X-ray exam of fistula                X           X        0263       1.6956          78.17       178.22       204.29
76098       X-ray exam, breast specimen          X           X        0260       0.7093          32.70        74.55        85.46
76100       X-ray exam of body section           X           X        0261       1.2224          56.35       128.49       147.27
76101       Complex body section x-ray           X           X        0263       1.6956          78.17       178.22       204.29
76102       Complex body section x-rays          X           X        0264       2.9586         136.39       310.98       356.45
76120       Cine/video x-rays                    X           X        0272       1.2908          59.51       135.68       155.52
76125       Cine/video x-rays add-on             X           X        0260       0.7093          32.70        74.55        85.46
76140       X-ray consultation                   E           1        0000       0.0000           0.00         0.00         0.00
76150       X-ray exam, dry process              X           X        0260       0.7093          32.70        74.55        85.46
76350       Special x-ray contrast study         N           N        0000       0.0000           0.00         0.00         0.00
76376       3d render w/o postprocess            X           X        0340       0.6102          28.13        64.14        73.52
76377       3d rendering w/postprocess           S           S        0282       1.5379          70.90       161.65       185.29
76380       CAT scan follow-up study             S           S        0282       1.5379          70.90       161.65       185.29
76390       Mr spectroscopy                      E           3        0000       0.0000           M01          M01          M01
76496       Fluoroscopic procedure               X           1        0000       0.0000           0.00         0.00         0.00
76497       Ct procedure                         S           1        0000       0.0000           0.00         0.00         0.00
76498       Mri procedure                        S           1        0000       0.0000           0.00         0.00         0.00
76499       Radiographic procedure               X           1        0000       0.0000           0.00         0.00         0.00
76506       Echo exam of head                    S           S        0265       0.9923          45.75       104.30       119.55
76510       Ophth us, b & quant a                S           S        0266       1.5607          71.95       164.05       188.03
76511       Ophth us, quant a only               S           S        0266       1.5607          71.95       164.05       188.03
76512       Ophth us, b w/non-quant a            S           S        0266       1.5607          71.95       164.05       188.03
76513       Echo exam of eye, water bath         S           S        0266       1.5607          71.95       164.05       188.03
76514       Echo exam of eye, thickness          X           X        0340       0.6102          28.13        64.14        73.52
76516       Echo exam of eye                     S           S        0265       0.9923          45.75       104.30       119.55
76519       Echo exam of eye                     S           S        0266       1.5607          71.95       164.05       188.03
76529       Echo exam of eye                     S           S        0265       0.9923          45.75       104.30       119.55
76536       Us exam of head and neck             S           S        0266       1.5607          71.95       164.05       188.03
76604       Us exam, chest, b-scan               S           S        0265       0.9923          45.75       104.30       119.55
76645       Us exam, breast(s)                   S           S        0265       0.9923          45.75       104.30       119.55
76700       Us exam, abdom, complete             S           S        0266       1.5607          71.95       164.05       188.03
76705       Echo exam of abdomen                 S           S        0266       1.5607          71.95       164.05       188.03
76770       Us exam abdo back wall, comp         S           S        0266       1.5607          71.95       164.05       188.03
76775       Us exam abdo back wall, lim          S           S        0266       1.5607          71.95       164.05       188.03
76776       Us exam k transpl w/doppler          S           S        0266       1.5607          71.95       164.05       188.03
76800       Us exam, spinal canal                S           S        0266       1.5607          71.95       164.05       188.03
76801       Ob us < 14 wks, single fetus         S           S        0266       1.5607          71.95       164.05       188.03
76802       Ob us < 14 wks, add’l fetus          S           S        0265       0.9923          45.75       104.30       119.55
76805       Ob us >/= 14 wks, sngl fetus         S           S        0266       1.5607          71.95       164.05       188.03
76810       Ob us >/= 14 wks, addl fetus         S           S        0266       1.5607          71.95       164.05       188.03
76811       Ob us, detailed, sngl fetus          S           S        0267       2.4606         113.43       258.63       296.45
76812       Ob us, detailed, addl fetus          S           S        0265       0.9923          45.75       104.30       119.55
76813       Ob us nuchal meas, 1 gest            S           S        0266       1.5607          71.95       164.05       188.03
76814       Ob us nuchal meas, add-on            S           S        0265       0.9923          45.75       104.30       119.55
76815       Ob us, limited, fetus(s)             S           S        0265       0.9923          45.75       104.30       119.55
76816       Ob us, follow-up, per fetus          S           S        0265       0.9923          45.75       104.30       119.55
76817       Transvaginal us, obstetric           S           S        0265       0.9923          45.75       104.30       119.55
76818       Fetal biophys profile w/nst          S           S        0266       1.5607          71.95       164.05       188.03
76819       Fetal biophys profil w/o nst         S           S        0266       1.5607          71.95       164.05       188.03
76820       Umbilical artery echo                S           S        0096       1.5303          70.55       160.85       184.37
76821       Middle cerebral artery echo          S           S        0096       1.5303          70.55       160.85       184.37
76825       Echo exam of fetal heart             S           S        0697       1.5973          73.64       167.89       192.44
76826       Echo exam of fetal heart             S           S        0697       1.5973          73.64       167.89       192.44
76827       Echo exam of fetal heart             S           S        0697       1.5973          73.64       167.89       192.44
76828       Echo exam of fetal heart             S           S        0697       1.5973          73.64       167.89       192.44
76830       Transvaginal us, non-ob              S           S        0266       1.5607          71.95       164.05       188.03
76831       Echo exam, uterus                    S           S        0267       2.4606         113.43       258.63       296.45
76856       Us exam, pelvic, complete            S           S        0266       1.5607          71.95       164.05       188.03
76857       Us exam, pelvic, limited             S           S        0265       0.9923          45.75       104.30       119.55
76870       Us exam, scrotum                     S           S        0266       1.5607          71.95       164.05       188.03
76872       Us, transrectal                      S           S        0266       1.5607          71.95       164.05       188.03
76873       Echograp trans r, pros study         S           S        0266       1.5607          71.95       164.05       188.03
76880       Us exam, extremity                   S           S        0266       1.5607          71.95       164.05       188.03
76885       Us exam infant hips, dynamic         S           S        0265       0.9923          45.75       104.30       119.55
76886       Us exam infant hips, static          S           S        0265       0.9923          45.75       104.30       119.55
76930       Echo guide, cardiocentesis           S           S        0268       1.1882          54.78       124.89       143.15
76932       Echo guide for heart biopsy          S           S        0309       2.1012          96.87       220.86       253.15
76936       Echo guide for artery repair         S           S        0309       2.1012          96.87       220.86       253.15
76937       Us guide, vascular access            N           N        0000       0.0000           0.00         0.00         0.00
76940       Us guide, tissue ablation            S           S        0268       1.1882          54.78       124.89       143.15
76941       Echo guide for transfusion           S           S        0268       1.1882          54.78       124.89       143.15
76942       Echo guide for biopsy                S           S        0268       1.1882          54.78       124.89       143.15
76945       Echo guide, villus sampling          S           S        0268       1.1882          54.78       124.89       143.15
76946       Echo guide for amniocentesis         S           S        0268       1.1882          54.78       124.89       143.15
76948       Echo guide, ova aspiration           S           S        0309       2.1012          96.87       220.86       253.15
76950       Echo guidance radiotherapy           S           S        0268       1.1882          54.78       124.89       143.15
76965       Echo guidance radiotherapy           S           S        0309       2.1012          96.87       220.86       253.15
76970       Ultrasound exam follow-up            S           S        0265       0.9923          45.75       104.30       119.55
76975       GI endoscopic ultrasound             S           S        0266       1.5607          71.95       164.05       188.03
76977       Us bone density measure              X           X        0340       0.6102          28.13        64.14        73.52
76998       Us guide, intraop                    S           S        0266       1.5607          71.95       164.05       188.03
76999       Echo examination procedure           S           1        0000       0.0000           0.00         0.00         0.00
77001       Fluoroguide for vein device          N           N        0000       0.0000           0.00         0.00         0.00
77002       Needle localization by xray          N           N        0000       0.0000           0.00         0.00         0.00
77003       Fluoroguide for spine inject         N           N        0000       0.0000           0.00         0.00         0.00
77011       Ct scan for localization             S           S        0283       4.0825         188.20       429.11       491.86
77012       Ct scan for needle biopsy            S           S        0283       4.0825         188.20       429.11       491.86
77013       Ct guide for tissue ablation         S           S        0333       4.8405         223.15       508.78       583.18
77014       Ct scan for therapy guide            S           S        0282       1.5379          70.90       161.65       185.29
77021       Mr guidance for needle place         S           S        0335       4.5523         209.86       478.49       548.46
77022       Mri for tissue ablation              S           S        0335       4.5523         209.86       478.49       548.46
77031       Stereotact guide for brst bx         X           X        0264       2.9586         136.39       310.98       356.45
77032       Guidance for needle, breast          X           X        0263       1.6956          78.17       178.22       204.29
77051       Computer dx mammogram add-on         A           3        0000       0.0000           M01          M01          M01
77052       Comp screen mammogram add-on         A           3        0000       0.0000           M01          M01          M01
77053       X-ray of mammary duct                X           X        0263       1.6956          78.17       178.22       204.29
77054       X-ray of mammary ducts               X           X        0263       1.6956          78.17       178.22       204.29
77055       Mammogram, one breast                A           3        0000       0.0000           M01          M01          M01
77056       Mammogram, both breasts              A           3        0000       0.0000           M01          M01          M01
77057       Mammogram, screening                 A           3        0000       0.0000           M01          M01          M01


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 58 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
77058       Mri, one breast                      B           B        0000        0.0000           0.00         0.00         0.00
77059       Mri, both breasts                    B           B        0000        0.0000           0.00         0.00         0.00
77071       X-ray stress view                    X           X        0260        0.7093          32.70        74.55        85.46
77072       X-rays for bone age                  X           X        0260        0.7093          32.70        74.55        85.46
77073       X-rays, bone length studies          X           X        0260        0.7093          32.70        74.55        85.46
77074       X-rays, bone survey, limited         X           X        0261        1.2224          56.35       128.49       147.27
77075       X-rays, bone survey complete         X           X        0261        1.2224          56.35       128.49       147.27
77076       X-rays, bone survey, infant          X           X        0260        0.7093          32.70        74.55        85.46
77077       Joint survey, single view            X           X        0260        0.7093          32.70        74.55        85.46
77078       Ct bone density, axial               S           S        0288        1.1755          54.19       123.56       141.62
77079       Ct bone density, peripheral          S           S        0282        1.5379          70.90       161.65       185.29
77080       Dxa bone density, axial              S           S        0288        1.1755          54.19       123.56       141.62
77081       Dxa bone density/peripheral          S           S        0665        0.5497          25.34        57.78        66.23
77082       Dxa bone density, vert fx            X           X        0260        0.7093          32.70        74.55        85.46
77083       Radiographic absorptiometry          X           X        0261        1.2224          56.35       128.49       147.27
77084       Magnetic image, bone marrow          S           S        0335        4.5523         209.86       478.49       548.46
77261       Radiation therapy planning           B           B        0000        0.0000           0.00         0.00         0.00
77262       Radiation therapy planning           B           B        0000        0.0000           0.00         0.00         0.00
77263       Radiation therapy planning           B           B        0000        0.0000           0.00         0.00         0.00
77280       Set radiation therapy field          X           X        0304        1.5735          72.54       165.39       189.58
77285       Set radiation therapy field          X           X        0305        3.9723         183.12       417.53       478.58
77290       Set radiation therapy field          X           X        0305        3.9723         183.12       417.53       478.58
77295       Set radiation therapy field          X           X        0310       13.8081         636.55      1,451.37     1,663.60
77299       Radiation therapy planning           X           1        0000        0.0000           0.00         0.00         0.00
77300       Radiation therapy dose plan          X           X        0304        1.5735          72.54       165.39       189.58
77301       Radiotherapy dose plan, imrt         X           X        0310       13.8081         636.55      1,451.37     1,663.60
77305       Teletx isodose plan simple           X           X        0304        1.5735          72.54       165.39       189.58
77310       Teletx isodose plan intermed         X           X        0305        3.9723         183.12       417.53       478.58
77315       Teletx isodose plan complex          X           X        0305        3.9723         183.12       417.53       478.58
77321       Special teletx port plan             X           X        0305        3.9723         183.12       417.53       478.58
77326       Brachytx isodose calc simp           X           X        0304        1.5735          72.54       165.39       189.58
77327       Brachytx isodose calc interm         X           X        0305        3.9723         183.12       417.53       478.58
77328       Brachytx isodose plan compl          X           X        0305        3.9723         183.12       417.53       478.58
77331       Special radiation dosimetry          X           X        0304        1.5735          72.54       165.39       189.58
77332       Radiation treatment aid(s)           X           X        0303        2.9430         135.67       309.34       354.57
77333       Radiation treatment aid(s)           X           X        0303        2.9430         135.67       309.34       354.57
77334       Radiation treatment aid(s)           X           X        0303        2.9430         135.67       309.34       354.57
77336       Radiation physics consult            X           X        0304        1.5735          72.54       165.39       189.58
77370       Radiation physics consult            X           X        0304        1.5735          72.54       165.39       189.58
77371       Srs, multisource                     S           S        0127      138.4486        6,382.48    14,552.33    16,680.29
77372       Srs, linear based                    B           B        0000        0.0000           0.00         0.00         0.00
77373       Sbrt delivery                        B           B        0000        0.0000           0.00         0.00         0.00
77399       External radiation dosimetry         X           1        0000        0.0000           0.00         0.00         0.00
77401       Radiation treatment delivery         S           S        0300        1.4826          68.35       155.84       178.62
77402       Radiation treatment delivery         S           S        0300        1.4826          68.35       155.84       178.62
77403       Radiation treatment delivery         S           S        0300        1.4826          68.35       155.84       178.62
77404       Radiation treatment delivery         S           S        0300        1.4826          68.35       155.84       178.62
77406       Radiation treatment delivery         S           S        0300        1.4826          68.35       155.84       178.62
77407       Radiation treatment delivery         S           S        0300        1.4826          68.35       155.84       178.62
77408       Radiation treatment delivery         S           S        0300        1.4826          68.35       155.84       178.62
77409       Radiation treatment delivery         S           S        0300        1.4826          68.35       155.84       178.62
77411       Radiation treatment delivery         S           S        0301        2.2295         102.78       234.34       268.61
77412       Radiation treatment delivery         S           S        0301        2.2295         102.78       234.34       268.61
77413       Radiation treatment delivery         S           S        0301        2.2295         102.78       234.34       268.61
77414       Radiation treatment delivery         S           S        0301        2.2295         102.78       234.34       268.61
77416       Radiation treatment delivery         S           S        0301        2.2295         102.78       234.34       268.61
77417       Radiology port film(s)               X           X        0260        0.7093          32.70        74.55        85.46
77418       Radiation tx delivery, imrt          S           S        0412        5.4731         252.31       575.28       659.40
77421       Stereoscopic x-ray guidance          S           S        0257        1.0974          50.59       115.35       132.21
77422       Neutron beam tx, simple              S           S        0301        2.2295         102.78       234.34       268.61
77423       Neutron beam tx, complex             S           S        0301        2.2295         102.78       234.34       268.61
77427       Radiation tx management, x5          B           B        0000        0.0000           0.00         0.00         0.00
77431       Radiation therapy management         B           B        0000        0.0000           0.00         0.00         0.00
77432       Stereotactic radiation trmt          B           B        0000        0.0000           0.00         0.00         0.00
77435       Sbrt management                      N           N        0000        0.0000           0.00         0.00         0.00
77470       Special radiation treatment          S           S        0299        5.8839         271.25       618.46       708.89
77499       Radiation therapy management         B           1        0000        0.0000           0.00         0.00         0.00
77520       Proton trmt, simple w/o comp         S           S        0664       18.8926         870.95      1,985.80     2,276.18
77522       Proton trmt, simple w/comp           S           S        0664       18.8926         870.95      1,985.80     2,276.18
77523       Proton trmt, intermediate            S           S        0667       22.6031        1,042.00     2,375.81     2,723.22
77525       Proton treatment, complex            S           S        0667       22.6031        1,042.00     2,375.81     2,723.22
77600       Hyperthermia treatment               S           S        0314        3.3461         154.26       351.71       403.14
77605       Hyperthermia treatment               S           S        0314        3.3461         154.26       351.71       403.14
77610       Hyperthermia treatment               S           S        0314        3.3461         154.26       351.71       403.14
77615       Hyperthermia treatment               S           S        0314        3.3461         154.26       351.71       403.14
77620       Hyperthermia treatment               S           S        0314        3.3461         154.26       351.71       403.14
77750       Infuse radioactive materials         S           S        0301        2.2295         102.78       234.34       268.61
77761       Apply intrcav radiat simple          S           S        0312        4.8569         223.90       510.51       585.16
77762       Apply intrcav radiat interm          S           S        0312        4.8569         223.90       510.51       585.16
77763       Apply intrcav radiat compl           S           S        0312        4.8569         223.90       510.51       585.16
77776       Apply interstit radiat simpl         S           S        0312        4.8569         223.90       510.51       585.16
77777       Apply interstit radiat inter         S           S        0312        4.8569         223.90       510.51       585.16
77778       Apply interstit radiat compl         S           S        0651       16.8462         776.61      1,770.70     2,029.63
77781       High intensity brachytherapy         S           S        0313       12.8473         592.26      1,350.38     1,547.84
77782       High intensity brachytherapy         S           S        0313       12.8473         592.26      1,350.38     1,547.84
77783       High intensity brachytherapy         S           S        0313       12.8473         592.26      1,350.38     1,547.84
77784       High intensity brachytherapy         S           S        0313       12.8473         592.26      1,350.38     1,547.84
77789       Apply surface radiation              S           S        0300        1.4826          68.35       155.84       178.62
77790       Radiation handling                   N           N        0000        0.0000           0.00         0.00         0.00
77799       Radium/radioisotope therapy          S           1        0000        0.0000           0.00         0.00         0.00
78000       Thyroid, single uptake               S           S        0389        1.3754          63.41       144.57       165.71
78001       Thyroid, multiple uptakes            S           S        0389        1.3754          63.41       144.57       165.71
78003       Thyroid suppress/stimul              S           S        0392        2.0057          92.46       210.82       241.65
78006       Thyroid imaging with uptake          S           S        0390        2.3432         108.02       246.29       282.31
78007       Thyroid image, mult uptakes          S           S        0391        2.7146         125.14       285.33       327.06
78010       Thyroid imaging                      S           S        0390        2.3432         108.02       246.29       282.31
78011       Thyroid imaging with flow            S           S        0390        2.3432         108.02       246.29       282.31
78015       Thyroid met imaging                  S           S        0406        3.9934         184.10       419.75       481.12
78016       Thyroid met imaging/studies          S           S        0406        3.9934         184.10       419.75       481.12
78018       Thyroid met imaging, body            S           S        0406        3.9934         184.10       419.75       481.12
78020       Thyroid met uptake                   S           S        0399        1.5054          69.40       158.23       181.37
78070       Parathyroid nuclear imaging          S           S        0391        2.7146         125.14       285.33       327.06
78075       Adrenal nuclear imaging              S           S        0391        2.7146         125.14       285.33       327.06
78099       Endocrine nuclear procedure          S           1        0000        0.0000           0.00         0.00         0.00
78102       Bone marrow imaging, ltd             S           S        0400        3.9073         180.13       410.70       470.75
78103       Bone marrow imaging, mult            S           S        0400        3.9073         180.13       410.70       470.75


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 59 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
78104       Bone marrow imaging, body            S           S        0400        3.9073        180.13        410.70       470.75
78110       Plasma volume, single                S           S        0393        3.7562        173.16        394.81       452.55
78111       Plasma volume, multiple              S           S        0393        3.7562        173.16        394.81       452.55
78120       Red cell mass, single                S           S        0393        3.7562        173.16        394.81       452.55
78121       Red cell mass, multiple              S           S        0393        3.7562        173.16        394.81       452.55
78122       Blood volume                         S           S        0393        3.7562        173.16        394.81       452.55
78130       Red cell survival study              S           S        0393        3.7562        173.16        394.81       452.55
78135       Red cell survival kinetics           S           S        0393        3.7562        173.16        394.81       452.55
78140       Red cell sequestration               S           S        0393        3.7562        173.16        394.81       452.55
78185       Spleen imaging                       S           S        0400        3.9073        180.13        410.70       470.75
78190       Platelet survival, kinetics          S           S        0392        2.0057         92.46        210.82       241.65
78191       Platelet survival                    S           S        0392        2.0057         92.46        210.82       241.65
78195       Lymph system imaging                 S           S        0400        3.9073        180.13        410.70       470.75
78199       Blood/lymph nuclear exam             S           1        0000        0.0000          0.00         0.00         0.00
78201       Liver imaging                        S           S        0394        4.3774        201.80        460.11       527.39
78202       Liver imaging with flow              S           S        0394        4.3774        201.80        460.11       527.39
78205       Liver imaging (3D)                   S           S        0394        4.3774        201.80        460.11       527.39
78206       Liver image (3d) with flow           S           S        0394        4.3774        201.80        460.11       527.39
78215       Liver and spleen imaging             S           S        0394        4.3774        201.80        460.11       527.39
78216       Liver & spleen image/flow            S           S        0394        4.3774        201.80        460.11       527.39
78220       Liver function study                 S           S        0394        4.3774        201.80        460.11       527.39
78223       Hepatobiliary imaging                S           S        0394        4.3774        201.80        460.11       527.39
78230       Salivary gland imaging               S           S        0395        3.6526        168.38        383.92       440.07
78231       Serial salivary imaging              S           S        0395        3.6526        168.38        383.92       440.07
78232       Salivary gland function exam         S           S        0395        3.6526        168.38        383.92       440.07
78258       Esophageal motility study            S           S        0395        3.6526        168.38        383.92       440.07
78261       Gastric mucosa imaging               S           S        0395        3.6526        168.38        383.92       440.07
78262       Gastroesophageal reflux exam         S           S        0395        3.6526        168.38        383.92       440.07
78264       Gastric emptying study               S           S        0395        3.6526        168.38        383.92       440.07
78267       Breath tst attain/anal c-14          A           3        0000        0.0000          M01          M01          M01
78268       Breath test analysis, c-14           A           3        0000        0.0000          M01          M01          M01
78270       Vit B-12 absorption exam             S           S        0392        2.0057         92.46        210.82       241.65
78271       Vit b-12 absrp exam, int fac         S           S        0392        2.0057         92.46        210.82       241.65
78272       Vit B-12 absorp, combined            S           S        0392        2.0057         92.46        210.82       241.65
78278       Acute GI blood loss imaging          S           S        0395        3.6526        168.38        383.92       440.07
78282       GI protein loss exam                 S           S        0395        3.6526        168.38        383.92       440.07
78290       Meckel’s divert exam                 S           S        0395        3.6526        168.38        383.92       440.07
78291       Leveen/shunt patency exam            S           S        0395        3.6526        168.38        383.92       440.07
78299       GI nuclear procedure                 S           1        0000        0.0000          0.00         0.00         0.00
78300       Bone imaging, limited area           S           S        0396        3.9174        180.59        411.76       471.97
78305       Bone imaging, multiple areas         S           S        0396        3.9174        180.59        411.76       471.97
78306       Bone imaging, whole body             S           S        0396        3.9174        180.59        411.76       471.97
78315       Bone imaging, 3 phase                S           S        0396        3.9174        180.59        411.76       471.97
78320       Bone imaging (3D)                    S           S        0396        3.9174        180.59        411.76       471.97
78350       Bone mineral, single photon          E           3        0000        0.0000          M01          M01          M01
78351       Bone mineral, dual photon            E           3        0000        0.0000          M01          M01          M01
78399       Musculoskeletal nuclear exam         S           1        0000        0.0000          0.00         0.00         0.00
78414       Non-imaging heart function           S           S        0398        4.1265        190.23        433.74       497.16
78428       Cardiac shunt imaging                S           S        0398        4.1265        190.23        433.74       497.16
78445       Vascular flow imaging                S           S        0397        2.4204        111.58        254.41       291.61
78456       Acute venous thrombus image          S           S        0397        2.4204        111.58        254.41       291.61
78457       Venous thrombosis imaging            S           S        0397        2.4204        111.58        254.41       291.61
78458       Ven thrombosis images, bilat         S           S        0397        2.4204        111.58        254.41       291.61
78459       Heart muscle imaging (PET)           S           S        0307       11.8963        548.42       1,250.42     1,433.27
78460       Heart muscle blood, single           S           S        0398        4.1265        190.23        433.74       497.16
78461       Heart muscle blood, multiple         S           S        0377        6.5012        299.71        683.34       783.26
78464       Heart image (3d), single             S           S        0398        4.1265        190.23        433.74       497.16
78465       Heart image (3d), multiple           S           S        0377        6.5012        299.71        683.34       783.26
78466       Heart infarct image                  S           S        0398        4.1265        190.23        433.74       497.16
78468       Heart infarct image (ef)             S           S        0398        4.1265        190.23        433.74       497.16
78469       Heart infarct image (3D)             S           S        0398        4.1265        190.23        433.74       497.16
78472       Gated heart, planar, single          S           S        0398        4.1265        190.23        433.74       497.16
78473       Gated heart, multiple                S           S        0376        4.9832        229.73        523.78       600.38
78478       Heart wall motion add-on             S           S        0399        1.5054         69.40        158.23       181.37
78480       Heart function add-on                S           S        0399        1.5054         69.40        158.23       181.37
78481       Heart first pass, single             S           S        0398        4.1265        190.23        433.74       497.16
78483       Heart first pass, multiple           S           S        0376        4.9832        229.73        523.78       600.38
78491       Heart image (pet), single            S           S        0307       11.8963        548.42       1,250.42     1,433.27
78492       Heart image (pet), multiple          S           S        0307       11.8963        548.42       1,250.42     1,433.27
78494       Heart image, spect                   S           S        0398        4.1265        190.23        433.74       497.16
78496       Heart first pass add-on              S           S        0399        1.5054         69.40        158.23       181.37
78499       Cardiovascular nuclear exam          S           1        0000        0.0000          0.00         0.00         0.00
78580       Lung perfusion imaging               S           S        0401        3.1802        146.61        334.27       383.15
78584       Lung V/Q image single breath         S           S        0378        5.0975        234.99        535.80       614.15
78585       Lung V/Q imaging                     S           S        0378        5.0975        234.99        535.80       614.15
78586       Aerosol lung image, single           S           S        0401        3.1802        146.61        334.27       383.15
78587       Aerosol lung image, multiple         S           S        0401        3.1802        146.61        334.27       383.15
78588       Perfusion lung image                 S           S        0378        5.0975        234.99        535.80       614.15
78591       Vent image, 1 breath, 1 proj         S           S        0401        3.1802        146.61        334.27       383.15
78593       Vent image, 1 proj, gas              S           S        0401        3.1802        146.61        334.27       383.15
78594       Vent image, mult proj, gas           S           S        0401        3.1802        146.61        334.27       383.15
78596       Lung differential function           S           S        0378        5.0975        234.99        535.80       614.15
78599       Respiratory nuclear exam             S           1        0000        0.0000          0.00         0.00         0.00
78600       Brain imaging, ltd static            S           S        0402        4.6418        213.99        487.90       559.24
78601       Brain imaging, ltd w/flow            S           S        0402        4.6418        213.99        487.90       559.24
78605       Brain imaging, complete              S           S        0402        4.6418        213.99        487.90       559.24
78606       Brain imaging, compl w/flow          S           S        0402        4.6418        213.99        487.90       559.24
78607       Brain imaging (3D)                   S           S        0402        4.6418        213.99        487.90       559.24
78608       Brain imaging (PET)                  S           S        0308       13.9166        641.56       1,462.77     1,676.67
78609       Brain imaging (PET)                  E           1        0000        0.0000          0.00         0.00         0.00
78610       Brain flow imaging only              S           S        0402        4.6418        213.99        487.90       559.24
78615       Cerebral vascular flow image         S           S        0402        4.6418        213.99        487.90       559.24
78630       Cerebrospinal fluid scan             S           S        0403        3.4923        161.00        367.08       420.75
78635       CSF ventriculography                 S           S        0403        3.4923        161.00        367.08       420.75
78645       CSF shunt evaluation                 S           S        0403        3.4923        161.00        367.08       420.75
78647       Cerebrospinal fluid scan             S           S        0403        3.4923        161.00        367.08       420.75
78650       CSF leakage imaging                  S           S        0403        3.4923        161.00        367.08       420.75
78660       Nuclear exam of tear flow            S           S        0403        3.4923        161.00        367.08       420.75
78699       Nervous system nuclear exam          S           1        0000        0.0000          0.00         0.00         0.00
78700       Kidney imaging, static               S           S        0404        3.4209        157.70        359.57       412.15
78701       Kidney imaging with flow             S           S        0404        3.4209        157.70        359.57       412.15
78707       Kidney flow/function image           S           S        0404        3.4209        157.70        359.57       412.15
78708       Kidney flow/function image           S           S        0405        4.0378        186.14        424.41       486.47
78709       Kidney flow/function image           S           S        0405        4.0378        186.14        424.41       486.47
78710       Kidney imaging (3D)                  S           S        0404        3.4209        157.70        359.57       412.15
78725       Kidney function study                S           S        0389        1.3754         63.41        144.57       165.71


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 60 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                              Critical
                                               January                                              General     Children's
                                                          WY 2007                                                             Access
  CPT/                                           2007                           APC Relative        Hospital     Hospital
                    Description (short)                     Status    APC                                                     Hospital
 HCPCS                                          Status                            Weight           Outpatient   Outpatient
                                                          Indicator                                                          Outpatient
                                              Indicator                                               Fee          Fee
                                                                                                                                Fee
                                             (FYI Only)
78730       Urinary bladder retention            X           X        0340        0.6102             28.13         64.14        73.52
78740       Ureteral reflux study                S           S        0404        3.4209            157.70        359.57       412.15
78761       Testicular imaging/flow              S           S        0404        3.4209            157.70        359.57       412.15
78799       Genitourinary nuclear exam           S           1        0000        0.0000              0.00          0.00         0.00
78800       Tumor imaging, limited area          S           S        0406        3.9934            184.10        419.75       481.12
78801       Tumor imaging, mult areas            S           S        0406        3.9934            184.10        419.75       481.12
78802       Tumor imaging, whole body            S           S        0406        3.9934            184.10        419.75       481.12
78803       Tumor imaging (3D)                   S           S        0406        3.9934            184.10        419.75       481.12
78804       Tumor imaging, whole body            S           S        0408        5.9245            273.12        622.72       713.78
78805       Abscess imaging, ltd area            S           S        0406        3.9934            184.10        419.75       481.12
78806       Abscess imaging, whole body          S           S        0406        3.9934            184.10        419.75       481.12
78807       Nuclear localization/abscess         S           S        0406        3.9934            184.10        419.75       481.12
78811       Tumor imaging (pet), limited         S           S        0308       13.9166            641.56       1,462.77     1,676.67
78812       Tumor image (pet)/skul-thigh         S           S        0308       13.9166            641.56       1,462.77     1,676.67
78813       Tumor image (pet) full body          S           S        0308       13.9166            641.56       1,462.77     1,676.67
78814       Tumor image pet/ct, limited          S           S        1511       15.4552       *    712.48       1,624.50     1,862.04
78815       Tumorimage pet/ct skul-thigh         S           S        1511       15.4552       *    712.48       1,624.50     1,862.04
78816       Tumor image pet/ct full body         S           S        1511       15.4552       *    712.48       1,624.50     1,862.04
78890       Nuclear medicine data proc           N           N        0000        0.0000              0.00          0.00         0.00
78891       Nuclear med data proc                N           N        0000        0.0000              0.00          0.00         0.00
78999       Nuclear diagnostic exam              S           1        0000        0.0000              0.00          0.00         0.00
79005       Nuclear rx, oral admin               S           S        0407        3.1779            146.50        334.03       382.87
79101       Nuclear rx, iv admin                 S           S        0407        3.1779            146.50        334.03       382.87
79200       Nuclear rx, intracav admin           S           S        0413        5.2957            244.13        556.63       638.03
79300       Nuclr rx, interstit colloid          S           S        0407        3.1779            146.50        334.03       382.87
79403       Hematopoietic nuclear tx             S           1        0000        0.0000              0.00          0.00         0.00
79440       Nuclear rx, intra-articular          S           S        0413        5.2957            244.13        556.63       638.03
79445       Nuclear rx, intra-arterial           S           S        0407        3.1779            146.50        334.03       382.87
79999       Nuclear medicine therapy             S           1        0000        0.0000              0.00          0.00         0.00
80048       Basic metabolic panel                A           3        0000        0.0000              M01           M01          M01
80050       General health panel                 E           3        0000        0.0000              M01           M01          M01
80051       Electrolyte panel                    A           3        0000        0.0000              M01           M01          M01
80053       Comprehen metabolic panel            A           3        0000        0.0000              M01           M01          M01
80055       Obstetric panel                      E           3        0000        0.0000              M01           M01          M01
80061       Lipid panel                          A           3        0000        0.0000              M01           M01          M01
80069       Renal function panel                 A           3        0000        0.0000              M01           M01          M01
80074       Acute hepatitis panel                A           3        0000        0.0000              M01           M01          M01
80076       Hepatic function panel               A           3        0000        0.0000              M01           M01          M01
80100       Drug screen, qualitate/multi         A           3        0000        0.0000              M01           M01          M01
80101       Drug screen, single                  A           3        0000        0.0000              M01           M01          M01
80102       Drug confirmation                    A           3        0000        0.0000              M01           M01          M01
80103       Drug analysis, tissue prep           N           N        0000        0.0000              0.00          0.00         0.00
80150       Assay of amikacin                    A           3        0000        0.0000              M01           M01          M01
80152       Assay of amitriptyline               A           3        0000        0.0000              M01           M01          M01
80154       Assay of benzodiazepines             A           3        0000        0.0000              M01           M01          M01
80156       Assay, carbamazepine, total          A           3        0000        0.0000              M01           M01          M01
80157       Assay, carbamazepine, free           A           3        0000        0.0000              M01           M01          M01
80158       Assay of cyclosporine                A           3        0000        0.0000              M01           M01          M01
80160       Assay of desipramine                 A           3        0000        0.0000              M01           M01          M01
80162       Assay of digoxin                     A           3        0000        0.0000              M01           M01          M01
80164       Assay, dipropylacetic acid           A           3        0000        0.0000              M01           M01          M01
80166       Assay of doxepin                     A           3        0000        0.0000              M01           M01          M01
80168       Assay of ethosuximide                A           3        0000        0.0000              M01           M01          M01
80170       Assay of gentamicin                  A           3        0000        0.0000              M01           M01          M01
80172       Assay of gold                        A           3        0000        0.0000              M01           M01          M01
80173       Assay of haloperidol                 A           3        0000        0.0000              M01           M01          M01
80174       Assay of imipramine                  A           3        0000        0.0000              M01           M01          M01
80176       Assay of lidocaine                   A           3        0000        0.0000              M01           M01          M01
80178       Assay of lithium                     A           3        0000        0.0000              M01           M01          M01
80182       Assay of nortriptyline               A           3        0000        0.0000              M01           M01          M01
80184       Assay of phenobarbital               A           3        0000        0.0000              M01           M01          M01
80185       Assay of phenytoin, total            A           3        0000        0.0000              M01           M01          M01
80186       Assay of phenytoin, free             A           3        0000        0.0000              M01           M01          M01
80188       Assay of primidone                   A           3        0000        0.0000              M01           M01          M01
80190       Assay of procainamide                A           3        0000        0.0000              M01           M01          M01
80192       Assay of procainamide                A           3        0000        0.0000              M01           M01          M01
80194       Assay of quinidine                   A           3        0000        0.0000              M01           M01          M01
80195       Assay of sirolimus                   A           3        0000        0.0000              M01           M01          M01
80196       Assay of salicylate                  A           3        0000        0.0000              M01           M01          M01
80197       Assay of tacrolimus                  A           3        0000        0.0000              M01           M01          M01
80198       Assay of theophylline                A           3        0000        0.0000              M01           M01          M01
80200       Assay of tobramycin                  A           3        0000        0.0000              M01           M01          M01
80201       Assay of topiramate                  A           3        0000        0.0000              M01           M01          M01
80202       Assay of vancomycin                  A           3        0000        0.0000              M01           M01          M01
80299       Quantitative assay, drug             A           1        0000        0.0000              0.00          0.00         0.00
80400       Acth stimulation panel               A           3        0000        0.0000              M01           M01          M01
80402       Acth stimulation panel               A           3        0000        0.0000              M01           M01          M01
80406       Acth stimulation panel               A           3        0000        0.0000              M01           M01          M01
80408       Aldosterone suppression eval         A           3        0000        0.0000              M01           M01          M01
80410       Calcitonin stimul panel              A           3        0000        0.0000              M01           M01          M01
80412       CRH stimulation panel                A           3        0000        0.0000              M01           M01          M01
80414       Testosterone response                A           3        0000        0.0000              M01           M01          M01
80415       Estradiol response panel             A           3        0000        0.0000              M01           M01          M01
80416       Renin stimulation panel              A           3        0000        0.0000              M01           M01          M01
80417       Renin stimulation panel              A           3        0000        0.0000              M01           M01          M01
80418       Pituitary evaluation panel           A           3        0000        0.0000              M01           M01          M01
80420       Dexamethasone panel                  A           3        0000        0.0000              M01           M01          M01
80422       Glucagon tolerance panel             A           3        0000        0.0000              M01           M01          M01
80424       Glucagon tolerance panel             A           3        0000        0.0000              M01           M01          M01
80426       Gonadotropin hormone panel           A           3        0000        0.0000              M01           M01          M01
80428       Growth hormone panel                 A           3        0000        0.0000              M01           M01          M01
80430       Growth hormone panel                 A           3        0000        0.0000              M01           M01          M01
80432       Insulin suppression panel            A           3        0000        0.0000              M01           M01          M01
80434       Insulin tolerance panel              A           3        0000        0.0000              M01           M01          M01
80435       Insulin tolerance panel              A           3        0000        0.0000              M01           M01          M01
80436       Metyrapone panel                     A           3        0000        0.0000              M01           M01          M01
80438       TRH stimulation panel                A           3        0000        0.0000              M01           M01          M01
80439       TRH stimulation panel                A           3        0000        0.0000              M01           M01          M01
80440       TRH stimulation panel                A           3        0000        0.0000              M01           M01          M01
80500       Lab pathology consultation           X           X        0433        0.2557             11.79         26.88        30.81
80502       Lab pathology consultation           X           X        0342        0.0824              3.80          8.66         9.93
81000       Urinalysis, nonauto w/scope          A           3        0000        0.0000              M01           M01          M01
81001       Urinalysis, auto w/scope             A           3        0000        0.0000              M01           M01          M01
81002       Urinalysis nonauto w/o scope         A           3        0000        0.0000              M01           M01          M01
81003       Urinalysis, auto, w/o scope          A           3        0000        0.0000              M01           M01          M01
81005       Urinalysis                           A           3        0000        0.0000              M01           M01          M01


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                     61 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
81007       Urine screen for bacteria            A           3        0000       0.0000           M01          M01          M01
81015       Microscopic exam of urine            A           3        0000       0.0000           M01          M01          M01
81020       Urinalysis, glass test               A           3        0000       0.0000           M01          M01          M01
81025       Urine pregnancy test                 A           3        0000       0.0000           M01          M01          M01
81050       Urinalysis, volume measure           A           3        0000       0.0000           M01          M01          M01
81099       Urinalysis test procedure            X           1        0000       0.0000           0.00         0.00         0.00
82000       Assay of blood acetaldehyde          A           3        0000       0.0000           M01          M01          M01
82003       Assay of acetaminophen               A           3        0000       0.0000           M01          M01          M01
82009       Test for acetone/ketones             A           3        0000       0.0000           M01          M01          M01
82010       Acetone assay                        A           3        0000       0.0000           M01          M01          M01
82013       Acetylcholinesterase assay           A           3        0000       0.0000           M01          M01          M01
82016       Acylcarnitines, qual                 A           3        0000       0.0000           M01          M01          M01
82017       Acylcarnitines, quant                A           3        0000       0.0000           M01          M01          M01
82024       Assay of acth                        A           3        0000       0.0000           M01          M01          M01
82030       Assay of adp & amp                   A           3        0000       0.0000           M01          M01          M01
82040       Assay of serum albumin               A           3        0000       0.0000           M01          M01          M01
82042       Assay of urine albumin               A           3        0000       0.0000           M01          M01          M01
82043       Microalbumin, quantitative           A           3        0000       0.0000           M01          M01          M01
82044       Microalbumin, semiquant              A           3        0000       0.0000           M01          M01          M01
82045       Albumin, ischemia modified           A           3        0000       0.0000           M01          M01          M01
82055       Assay of ethanol                     A           3        0000       0.0000           M01          M01          M01
82075       Assay of breath ethanol              A           3        0000       0.0000           M01          M01          M01
82085       Assay of aldolase                    A           3        0000       0.0000           M01          M01          M01
82088       Assay of aldosterone                 A           3        0000       0.0000           M01          M01          M01
82101       Assay of urine alkaloids             A           3        0000       0.0000           M01          M01          M01
82103       Alpha-1-antitrypsin, total           A           3        0000       0.0000           M01          M01          M01
82104       Alpha-1-antitrypsin, pheno           A           3        0000       0.0000           M01          M01          M01
82105       Alpha-fetoprotein, serum             A           3        0000       0.0000           M01          M01          M01
82106       Alpha-fetoprotein, amniotic          A           3        0000       0.0000           M01          M01          M01
82107       Alpha-fetoprotein l3                 A           3        0000       0.0000           M01          M01          M01
82108       Assay of aluminum                    A           3        0000       0.0000           M01          M01          M01
82120       Amines, vaginal fluid qual           A           3        0000       0.0000           M01          M01          M01
82127       Amino acid, single qual              A           3        0000       0.0000           M01          M01          M01
82128       Amino acids, mult qual               A           3        0000       0.0000           M01          M01          M01
82131       Amino acids, single quant            A           3        0000       0.0000           M01          M01          M01
82135       Assay, aminolevulinic acid           A           3        0000       0.0000           M01          M01          M01
82136       Amino acids, quant, 2-5              A           3        0000       0.0000           M01          M01          M01
82139       Amino acids, quan, 6 or more         A           3        0000       0.0000           M01          M01          M01
82140       Assay of ammonia                     A           3        0000       0.0000           M01          M01          M01
82143       Amniotic fluid scan                  A           3        0000       0.0000           M01          M01          M01
82145       Assay of amphetamines                A           3        0000       0.0000           M01          M01          M01
82150       Assay of amylase                     A           3        0000       0.0000           M01          M01          M01
82154       Androstanediol glucuronide           A           3        0000       0.0000           M01          M01          M01
82157       Assay of androstenedione             A           3        0000       0.0000           M01          M01          M01
82160       Assay of androsterone                A           3        0000       0.0000           M01          M01          M01
82163       Assay of angiotensin II              A           3        0000       0.0000           M01          M01          M01
82164       Angiotensin I enzyme test            A           3        0000       0.0000           M01          M01          M01
82172       Assay of apolipoprotein              A           3        0000       0.0000           M01          M01          M01
82175       Assay of arsenic                     A           3        0000       0.0000           M01          M01          M01
82180       Assay of ascorbic acid               A           3        0000       0.0000           M01          M01          M01
82190       Atomic absorption                    A           3        0000       0.0000           M01          M01          M01
82205       Assay of barbiturates                A           3        0000       0.0000           M01          M01          M01
82232       Assay of beta-2 protein              A           3        0000       0.0000           M01          M01          M01
82239       Bile acids, total                    A           3        0000       0.0000           M01          M01          M01
82240       Bile acids, cholylglycine            A           3        0000       0.0000           M01          M01          M01
82247       Bilirubin, total                     A           3        0000       0.0000           M01          M01          M01
82248       Bilirubin, direct                    A           3        0000       0.0000           M01          M01          M01
82252       Fecal bilirubin test                 A           3        0000       0.0000           M01          M01          M01
82261       Assay of biotinidase                 A           3        0000       0.0000           M01          M01          M01
82270       Test for blood, feces                A           3        0000       0.0000           M01          M01          M01
82271       Occult blood, feces, single          A           3        0000       0.0000           M01          M01          M01
82272       Blood occult peroxidase              A           3        0000       0.0000           M01          M01          M01
82274       Assay test for blood, fecal          A           3        0000       0.0000           M01          M01          M01
82286       Assay of bradykinin                  A           3        0000       0.0000           M01          M01          M01
82300       Assay of cadmium                     A           3        0000       0.0000           M01          M01          M01
82306       Assay of vitamin D                   A           3        0000       0.0000           M01          M01          M01
82307       Assay of vitamin D                   A           3        0000       0.0000           M01          M01          M01
82308       Assay of calcitonin                  A           3        0000       0.0000           M01          M01          M01
82310       Assay of calcium                     A           3        0000       0.0000           M01          M01          M01
82330       Assay of calcium                     A           3        0000       0.0000           M01          M01          M01
82331       Calcium infusion test                A           3        0000       0.0000           M01          M01          M01
82340       Assay of calcium in urine            A           3        0000       0.0000           M01          M01          M01
82355       Calculus analysis, qual              A           3        0000       0.0000           M01          M01          M01
82360       Calculus assay, quant                A           3        0000       0.0000           M01          M01          M01
82365       Calculus spectroscopy                A           3        0000       0.0000           M01          M01          M01
82370       X-ray assay, calculus                A           3        0000       0.0000           M01          M01          M01
82373       Assay, c-d transfer measure          A           3        0000       0.0000           M01          M01          M01
82374       Assay, blood carbon dioxide          A           3        0000       0.0000           M01          M01          M01
82375       Assay, blood carbon monoxide         A           3        0000       0.0000           M01          M01          M01
82376       Test for carbon monoxide             A           3        0000       0.0000           M01          M01          M01
82378       Carcinoembryonic antigen             A           3        0000       0.0000           M01          M01          M01
82379       Assay of carnitine                   A           3        0000       0.0000           M01          M01          M01
82380       Assay of carotene                    A           3        0000       0.0000           M01          M01          M01
82382       Assay, urine catecholamines          A           3        0000       0.0000           M01          M01          M01
82383       Assay, blood catecholamines          A           3        0000       0.0000           M01          M01          M01
82384       Assay, three catecholamines          A           3        0000       0.0000           M01          M01          M01
82387       Assay of cathepsin-d                 A           3        0000       0.0000           M01          M01          M01
82390       Assay of ceruloplasmin               A           3        0000       0.0000           M01          M01          M01
82397       Chemiluminescent assay               A           3        0000       0.0000           M01          M01          M01
82415       Assay of chloramphenicol             A           3        0000       0.0000           M01          M01          M01
82435       Assay of blood chloride              A           3        0000       0.0000           M01          M01          M01
82436       Assay of urine chloride              A           3        0000       0.0000           M01          M01          M01
82438       Assay, other fluid chlorides         A           3        0000       0.0000           M01          M01          M01
82441       Test for chlorohydrocarbons          A           3        0000       0.0000           M01          M01          M01
82465       Assay, bld/serum cholesterol         A           3        0000       0.0000           M01          M01          M01
82480       Assay, serum cholinesterase          A           3        0000       0.0000           M01          M01          M01
82482       Assay, rbc cholinesterase            A           3        0000       0.0000           M01          M01          M01
82485       Assay, chondroitin sulfate           A           3        0000       0.0000           M01          M01          M01
82486       Gas/liquid chromatography            A           3        0000       0.0000           M01          M01          M01
82487       Paper chromatography                 A           3        0000       0.0000           M01          M01          M01
82488       Paper chromatography                 A           3        0000       0.0000           M01          M01          M01
82489       Thin layer chromatography            A           3        0000       0.0000           M01          M01          M01
82491       Chromotography, quant, sing          A           3        0000       0.0000           M01          M01          M01
82492       Chromotography, quant, mult          A           3        0000       0.0000           M01          M01          M01
82495       Assay of chromium                    A           3        0000       0.0000           M01          M01          M01
82507       Assay of citrate                     A           3        0000       0.0000           M01          M01          M01


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 62 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
82520       Assay of cocaine                     A           3        0000       0.0000           M01          M01          M01
82523       Collagen crosslinks                  A           3        0000       0.0000           M01          M01          M01
82525       Assay of copper                      A           3        0000       0.0000           M01          M01          M01
82528       Assay of corticosterone              A           3        0000       0.0000           M01          M01          M01
82530       Cortisol, free                       A           3        0000       0.0000           M01          M01          M01
82533       Total cortisol                       A           3        0000       0.0000           M01          M01          M01
82540       Assay of creatine                    A           3        0000       0.0000           M01          M01          M01
82541       Column chromotography, qual          A           3        0000       0.0000           M01          M01          M01
82542       Column chromotography, quant         A           3        0000       0.0000           M01          M01          M01
82543       Column chromotograph/isotope         A           3        0000       0.0000           M01          M01          M01
82544       Column chromotograph/isotope         A           3        0000       0.0000           M01          M01          M01
82550       Assay of ck (cpk)                    A           3        0000       0.0000           M01          M01          M01
82552       Assay of cpk in blood                A           3        0000       0.0000           M01          M01          M01
82553       Creatine, MB fraction                A           3        0000       0.0000           M01          M01          M01
82554       Creatine, isoforms                   A           3        0000       0.0000           M01          M01          M01
82565       Assay of creatinine                  A           3        0000       0.0000           M01          M01          M01
82570       Assay of urine creatinine            A           3        0000       0.0000           M01          M01          M01
82575       Creatinine clearance test            A           3        0000       0.0000           M01          M01          M01
82585       Assay of cryofibrinogen              A           3        0000       0.0000           M01          M01          M01
82595       Assay of cryoglobulin                A           3        0000       0.0000           M01          M01          M01
82600       Assay of cyanide                     A           3        0000       0.0000           M01          M01          M01
82607       Vitamin B-12                         A           3        0000       0.0000           M01          M01          M01
82608       B-12 binding capacity                A           3        0000       0.0000           M01          M01          M01
82615       Test for urine cystines              A           3        0000       0.0000           M01          M01          M01
82626       Dehydroepiandrosterone               A           3        0000       0.0000           M01          M01          M01
82627       Dehydroepiandrosterone               A           3        0000       0.0000           M01          M01          M01
82633       Desoxycorticosterone                 A           3        0000       0.0000           M01          M01          M01
82634       Deoxycortisol                        A           3        0000       0.0000           M01          M01          M01
82638       Assay of dibucaine number            A           3        0000       0.0000           M01          M01          M01
82646       Assay of dihydrocodeinone            A           3        0000       0.0000           M01          M01          M01
82649       Assay of dihydromorphinone           A           3        0000       0.0000           M01          M01          M01
82651       Assay of dihydrotestosterone         A           3        0000       0.0000           M01          M01          M01
82652       Assay of dihydroxyvitamin d          A           3        0000       0.0000           M01          M01          M01
82654       Assay of dimethadione                A           3        0000       0.0000           M01          M01          M01
82656       Pancreatic elastase, fecal           A           3        0000       0.0000           M01          M01          M01
82657       Enzyme cell activity                 A           3        0000       0.0000           M01          M01          M01
82658       Enzyme cell activity, ra             A           3        0000       0.0000           M01          M01          M01
82664       Electrophoretic test                 A           3        0000       0.0000           M01          M01          M01
82666       Assay of epiandrosterone             A           3        0000       0.0000           M01          M01          M01
82668       Assay of erythropoietin              A           3        0000       0.0000           M01          M01          M01
82670       Assay of estradiol                   A           3        0000       0.0000           M01          M01          M01
82671       Assay of estrogens                   A           3        0000       0.0000           M01          M01          M01
82672       Assay of estrogen                    A           3        0000       0.0000           M01          M01          M01
82677       Assay of estriol                     A           3        0000       0.0000           M01          M01          M01
82679       Assay of estrone                     A           3        0000       0.0000           M01          M01          M01
82690       Assay of ethchlorvynol               A           3        0000       0.0000           M01          M01          M01
82693       Assay of ethylene glycol             A           3        0000       0.0000           M01          M01          M01
82696       Assay of etiocholanolone             A           3        0000       0.0000           M01          M01          M01
82705       Fats/lipids, feces, qual             A           3        0000       0.0000           M01          M01          M01
82710       Fats/lipids, feces, quant            A           3        0000       0.0000           M01          M01          M01
82715       Assay of fecal fat                   A           3        0000       0.0000           M01          M01          M01
82725       Assay of blood fatty acids           A           3        0000       0.0000           M01          M01          M01
82726       Long chain fatty acids               A           3        0000       0.0000           M01          M01          M01
82728       Assay of ferritin                    A           3        0000       0.0000           M01          M01          M01
82731       Assay of fetal fibronectin           A           3        0000       0.0000           M01          M01          M01
82735       Assay of fluoride                    A           3        0000       0.0000           M01          M01          M01
82742       Assay of flurazepam                  A           3        0000       0.0000           M01          M01          M01
82746       Blood folic acid serum               A           3        0000       0.0000           M01          M01          M01
82747       Assay of folic acid, rbc             A           3        0000       0.0000           M01          M01          M01
82757       Assay of semen fructose              A           3        0000       0.0000           M01          M01          M01
82759       Assay of rbc galactokinase           A           3        0000       0.0000           M01          M01          M01
82760       Assay of galactose                   A           3        0000       0.0000           M01          M01          M01
82775       Assay galactose transferase          A           3        0000       0.0000           M01          M01          M01
82776       Galactose transferase test           A           3        0000       0.0000           M01          M01          M01
82784       Assay of gammaglobulin igm           A           3        0000       0.0000           M01          M01          M01
82785       Assay of gammaglobulin ige           A           3        0000       0.0000           M01          M01          M01
82787       Igg 1, 2, 3 or 4, each               A           3        0000       0.0000           M01          M01          M01
82800       Blood pH                             A           3        0000       0.0000           M01          M01          M01
82803       Blood gases: pH, pO2 & pCO2          A           3        0000       0.0000           M01          M01          M01
82805       Blood gases W/02 saturation          A           3        0000       0.0000           M01          M01          M01
82810       Blood gases, O2 sat only             A           3        0000       0.0000           M01          M01          M01
82820       Hemoglobin-oxygen affinity           A           3        0000       0.0000           M01          M01          M01
82926       Assay of gastric acid                A           3        0000       0.0000           M01          M01          M01
82928       Assay of gastric acid                A           3        0000       0.0000           M01          M01          M01
82938       Gastrin test                         A           3        0000       0.0000           M01          M01          M01
82941       Assay of gastrin                     A           3        0000       0.0000           M01          M01          M01
82943       Assay of glucagon                    A           3        0000       0.0000           M01          M01          M01
82945       Glucose other fluid                  A           3        0000       0.0000           M01          M01          M01
82946       Glucagon tolerance test              A           3        0000       0.0000           M01          M01          M01
82947       Assay, glucose, blood quant          A           3        0000       0.0000           M01          M01          M01
82948       Reagent strip/blood glucose          A           3        0000       0.0000           M01          M01          M01
82950       Glucose test                         A           3        0000       0.0000           M01          M01          M01
82951       Glucose tolerance test (GTT)         A           3        0000       0.0000           M01          M01          M01
82952       GTT-added samples                    A           3        0000       0.0000           M01          M01          M01
82953       Glucose-tolbutamide test             A           3        0000       0.0000           M01          M01          M01
82955       Assay of g6pd enzyme                 A           3        0000       0.0000           M01          M01          M01
82960       Test for G6PD enzyme                 A           3        0000       0.0000           M01          M01          M01
82962       Glucose blood test                   A           3        0000       0.0000           M01          M01          M01
82963       Assay of glucosidase                 A           3        0000       0.0000           M01          M01          M01
82965       Assay of gdh enzyme                  A           3        0000       0.0000           M01          M01          M01
82975       Assay of glutamine                   A           3        0000       0.0000           M01          M01          M01
82977       Assay of GGT                         A           3        0000       0.0000           M01          M01          M01
82978       Assay of glutathione                 A           3        0000       0.0000           M01          M01          M01
82979       Assay, rbc glutathione               A           3        0000       0.0000           M01          M01          M01
82980       Assay of glutethimide                A           3        0000       0.0000           M01          M01          M01
82985       Glycated protein                     A           3        0000       0.0000           M01          M01          M01
83001       Gonadotropin (FSH)                   A           3        0000       0.0000           M01          M01          M01
83002       Gonadotropin (LH)                    A           3        0000       0.0000           M01          M01          M01
83003       Assay, growth hormone (hgh)          A           3        0000       0.0000           M01          M01          M01
83008       Assay of guanosine                   A           3        0000       0.0000           M01          M01          M01
83009       H pylori (c-13), blood               A           3        0000       0.0000           M01          M01          M01
83010       Assay of haptoglobin, quant          A           3        0000       0.0000           M01          M01          M01
83012       Assay of haptoglobins                A           3        0000       0.0000           M01          M01          M01
83013       H pylori (c-13), breath              A           3        0000       0.0000           M01          M01          M01
83014       H pylori drug admin                  A           3        0000       0.0000           M01          M01          M01
83015       Heavy metal screen                   A           3        0000       0.0000           M01          M01          M01


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 63 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
83018       Quantitative screen, metals          A           3        0000       0.0000           M01          M01          M01
83020       Hemoglobin electrophoresis           A           3        0000       0.0000           M01          M01          M01
83021       Hemoglobin chromotography            A           3        0000       0.0000           M01          M01          M01
83026       Hemoglobin, copper sulfate           A           3        0000       0.0000           M01          M01          M01
83030       Fetal hemoglobin, chemical           A           3        0000       0.0000           M01          M01          M01
83033       Fetal hemoglobin assay, qual         A           3        0000       0.0000           M01          M01          M01
83036       Glycated hemoglobin test             A           3        0000       0.0000           M01          M01          M01
83037       Glycosylated hb, home device         A           3        0000       0.0000           M01          M01          M01
83045       Blood methemoglobin test             A           3        0000       0.0000           M01          M01          M01
83050       Blood methemoglobin assay            A           3        0000       0.0000           M01          M01          M01
83051       Assay of plasma hemoglobin           A           3        0000       0.0000           M01          M01          M01
83055       Blood sulfhemoglobin test            A           3        0000       0.0000           M01          M01          M01
83060       Blood sulfhemoglobin assay           A           3        0000       0.0000           M01          M01          M01
83065       Assay of hemoglobin heat             A           3        0000       0.0000           M01          M01          M01
83068       Hemoglobin stability screen          A           3        0000       0.0000           M01          M01          M01
83069       Assay of urine hemoglobin            A           3        0000       0.0000           M01          M01          M01
83070       Assay of hemosiderin, qual           A           3        0000       0.0000           M01          M01          M01
83071       Assay of hemosiderin, quant          A           3        0000       0.0000           M01          M01          M01
83080       Assay of b hexosaminidase            A           3        0000       0.0000           M01          M01          M01
83088       Assay of histamine                   A           3        0000       0.0000           M01          M01          M01
83090       Assay of homocystine                 A           3        0000       0.0000           M01          M01          M01
83150       Assay of for hva                     A           3        0000       0.0000           M01          M01          M01
83491       Assay of corticosteroids             A           3        0000       0.0000           M01          M01          M01
83497       Assay of 5-hiaa                      A           3        0000       0.0000           M01          M01          M01
83498       Assay of progesterone                A           3        0000       0.0000           M01          M01          M01
83499       Assay of progesterone                A           3        0000       0.0000           M01          M01          M01
83500       Assay, free hydroxyproline           A           3        0000       0.0000           M01          M01          M01
83505       Assay, total hydroxyproline          A           3        0000       0.0000           M01          M01          M01
83516       Immunoassay, nonantibody             A           3        0000       0.0000           M01          M01          M01
83518       Immunoassay, dipstick                A           3        0000       0.0000           M01          M01          M01
83519       Immunoassay, nonantibody             A           3        0000       0.0000           M01          M01          M01
83520       Immunoassay, RIA                     A           3        0000       0.0000           M01          M01          M01
83525       Assay of insulin                     A           3        0000       0.0000           M01          M01          M01
83527       Assay of insulin                     A           3        0000       0.0000           M01          M01          M01
83528       Assay of intrinsic factor            A           3        0000       0.0000           M01          M01          M01
83540       Assay of iron                        A           3        0000       0.0000           M01          M01          M01
83550       Iron binding test                    A           3        0000       0.0000           M01          M01          M01
83570       Assay of idh enzyme                  A           3        0000       0.0000           M01          M01          M01
83582       Assay of ketogenic steroids          A           3        0000       0.0000           M01          M01          M01
83586       Assay 17- ketosteroids               A           3        0000       0.0000           M01          M01          M01
83593       Fractionation, ketosteroids          A           3        0000       0.0000           M01          M01          M01
83605       Assay of lactic acid                 A           3        0000       0.0000           M01          M01          M01
83615       Lactate (LD) (LDH) enzyme            A           3        0000       0.0000           M01          M01          M01
83625       Assay of ldh enzymes                 A           3        0000       0.0000           M01          M01          M01
83630       Lactoferrin, fecal (qual)            A           3        0000       0.0000           M01          M01          M01
83631       Lactoferrin, fecal (quant)           A           3        0000       0.0000           M01          M01          M01
83632       Placental lactogen                   A           3        0000       0.0000           M01          M01          M01
83633       Test urine for lactose               A           3        0000       0.0000           M01          M01          M01
83634       Assay of urine for lactose           A           3        0000       0.0000           M01          M01          M01
83655       Assay of lead                        A           3        0000       0.0000           M01          M01          M01
83661       L/s ratio, fetal lung                A           3        0000       0.0000           M01          M01          M01
83662       Foam stability, fetal lung           A           3        0000       0.0000           M01          M01          M01
83663       Fluoro polarize, fetal lung          A           3        0000       0.0000           M01          M01          M01
83664       Lamellar bdy, fetal lung             A           3        0000       0.0000           M01          M01          M01
83670       Assay of lap enzyme                  A           3        0000       0.0000           M01          M01          M01
83690       Assay of lipase                      A           3        0000       0.0000           M01          M01          M01
83695       Assay of lipoprotein(a)              A           3        0000       0.0000           M01          M01          M01
83698       Assay lipoprotein pla2               A           3        0000       0.0000           M01          M01          M01
83700       Lipopro bld, electrophoretic         A           3        0000       0.0000           M01          M01          M01
83701       Lipoprotein bld, hr fraction         A           3        0000       0.0000           M01          M01          M01
83704       Lipoprotein, bld, by nmr             A           3        0000       0.0000           M01          M01          M01
83718       Assay of lipoprotein                 A           3        0000       0.0000           M01          M01          M01
83719       Assay of blood lipoprotein           A           3        0000       0.0000           M01          M01          M01
83721       Assay of blood lipoprotein           A           3        0000       0.0000           M01          M01          M01
83727       Assay of lrh hormone                 A           3        0000       0.0000           M01          M01          M01
83735       Assay of magnesium                   A           3        0000       0.0000           M01          M01          M01
83775       Assay of md enzyme                   A           3        0000       0.0000           M01          M01          M01
83785       Assay of manganese                   A           3        0000       0.0000           M01          M01          M01
83788       Mass spectrometry qual               A           3        0000       0.0000           M01          M01          M01
83789       Mass spectrometry quant              A           3        0000       0.0000           M01          M01          M01
83805       Assay of meprobamate                 A           3        0000       0.0000           M01          M01          M01
83825       Assay of mercury                     A           3        0000       0.0000           M01          M01          M01
83835       Assay of metanephrines               A           3        0000       0.0000           M01          M01          M01
83840       Assay of methadone                   A           3        0000       0.0000           M01          M01          M01
83857       Assay of methemalbumin               A           3        0000       0.0000           M01          M01          M01
83858       Assay of methsuximide                A           3        0000       0.0000           M01          M01          M01
83864       Mucopolysaccharides                  A           3        0000       0.0000           M01          M01          M01
83866       Mucopolysaccharides screen           A           3        0000       0.0000           M01          M01          M01
83872       Assay synovial fluid mucin           A           3        0000       0.0000           M01          M01          M01
83873       Assay of csf protein                 A           3        0000       0.0000           M01          M01          M01
83874       Assay of myoglobin                   A           3        0000       0.0000           M01          M01          M01
83880       Natriuretic peptide                  A           3        0000       0.0000           M01          M01          M01
83883       Assay, nephelometry not spec         A           3        0000       0.0000           M01          M01          M01
83885       Assay of nickel                      A           3        0000       0.0000           M01          M01          M01
83887       Assay of nicotine                    A           3        0000       0.0000           M01          M01          M01
83890       Molecule isolate                     A           3        0000       0.0000           M01          M01          M01
83891       Molecule isolate nucleic             A           3        0000       0.0000           M01          M01          M01
83892       Molecular diagnostics                A           3        0000       0.0000           M01          M01          M01
83893       Molecule dot/slot/blot               A           3        0000       0.0000           M01          M01          M01
83894       Molecule gel electrophor             A           3        0000       0.0000           M01          M01          M01
83896       Molecular diagnostics                A           3        0000       0.0000           M01          M01          M01
83897       Molecule nucleic transfer            A           3        0000       0.0000           M01          M01          M01
83898       Molecule nucleic ampli               A           3        0000       0.0000           M01          M01          M01
83900       Molecule nucleic ampli 2 seq         A           3        0000       0.0000           M01          M01          M01
83901       Molecule nucleic ampli               A           3        0000       0.0000           M01          M01          M01
83902       Molecular diagnostics                A           3        0000       0.0000           M01          M01          M01
83903       Molecule mutation scan               A           3        0000       0.0000           M01          M01          M01
83904       Molecule mutation identify           A           3        0000       0.0000           M01          M01          M01
83905       Molecule mutation identify           A           3        0000       0.0000           M01          M01          M01
83906       Molecule mutation identify           A           3        0000       0.0000           M01          M01          M01
83907       Lyse cells for nucleic ext           A           3        0000       0.0000           M01          M01          M01
83908       Nucleic acid, signal ampli           A           3        0000       0.0000           M01          M01          M01
83909       Nucleic acid, high resolute          A           3        0000       0.0000           M01          M01          M01
83912       Genetic examination                  A           3        0000       0.0000           M01          M01          M01
83913       Molecular, rna stabilization         A           3        0000       0.0000           M01          M01          M01
83914       Mutation ident ola/sbce/aspe         A           3        0000       0.0000           M01          M01          M01


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 64 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
83915       Assay of nucleotidase                A           3        0000       0.0000           M01          M01          M01
83916       Oligoclonal bands                    A           3        0000       0.0000           M01          M01          M01
83918       Organic acids, total, quant          A           3        0000       0.0000           M01          M01          M01
83919       Organic acids, qual, each            A           3        0000       0.0000           M01          M01          M01
83921       Organic acid, single, quant          A           3        0000       0.0000           M01          M01          M01
83925       Assay of opiates                     A           3        0000       0.0000           M01          M01          M01
83930       Assay of blood osmolality            A           3        0000       0.0000           M01          M01          M01
83935       Assay of urine osmolality            A           3        0000       0.0000           M01          M01          M01
83937       Assay of osteocalcin                 A           3        0000       0.0000           M01          M01          M01
83945       Assay of oxalate                     A           3        0000       0.0000           M01          M01          M01
83950       Oncoprotein, her-2/neu               A           3        0000       0.0000           M01          M01          M01
83970       Assay of parathormone                A           3        0000       0.0000           M01          M01          M01
83986       Assay of body fluid acidity          A           3        0000       0.0000           M01          M01          M01
83992       Assay for phencyclidine              A           3        0000       0.0000           M01          M01          M01
84022       Assay of phenothiazine               A           3        0000       0.0000           M01          M01          M01
84030       Assay of blood pku                   A           3        0000       0.0000           M01          M01          M01
84035       Assay of phenylketones               A           3        0000       0.0000           M01          M01          M01
84060       Assay acid phosphatase               A           3        0000       0.0000           M01          M01          M01
84061       Phosphatase, forensic exam           A           3        0000       0.0000           M01          M01          M01
84066       Assay prostate phosphatase           A           3        0000       0.0000           M01          M01          M01
84075       Assay alkaline phosphatase           A           3        0000       0.0000           M01          M01          M01
84078       Assay alkaline phosphatase           A           3        0000       0.0000           M01          M01          M01
84080       Assay alkaline phosphatases          A           3        0000       0.0000           M01          M01          M01
84081       Amniotic fluid enzyme test           A           3        0000       0.0000           M01          M01          M01
84085       Assay of rbc pg6d enzyme             A           3        0000       0.0000           M01          M01          M01
84087       Assay phosphohexose enzymes          A           3        0000       0.0000           M01          M01          M01
84100       Assay of phosphorus                  A           3        0000       0.0000           M01          M01          M01
84105       Assay of urine phosphorus            A           3        0000       0.0000           M01          M01          M01
84106       Test for porphobilinogen             A           3        0000       0.0000           M01          M01          M01
84110       Assay of porphobilinogen             A           3        0000       0.0000           M01          M01          M01
84119       Test urine for porphyrins            A           3        0000       0.0000           M01          M01          M01
84120       Assay of urine porphyrins            A           3        0000       0.0000           M01          M01          M01
84126       Assay of feces porphyrins            A           3        0000       0.0000           M01          M01          M01
84127       Assay of feces porphyrins            A           3        0000       0.0000           M01          M01          M01
84132       Assay of serum potassium             A           3        0000       0.0000           M01          M01          M01
84133       Assay of urine potassium             A           3        0000       0.0000           M01          M01          M01
84134       Assay of prealbumin                  A           3        0000       0.0000           M01          M01          M01
84135       Assay of pregnanediol                A           3        0000       0.0000           M01          M01          M01
84138       Assay of pregnanetriol               A           3        0000       0.0000           M01          M01          M01
84140       Assay of pregnenolone                A           3        0000       0.0000           M01          M01          M01
84143       Assay of 17-hydroxypregneno          A           3        0000       0.0000           M01          M01          M01
84144       Assay of progesterone                A           3        0000       0.0000           M01          M01          M01
84146       Assay of prolactin                   A           3        0000       0.0000           M01          M01          M01
84150       Assay of prostaglandin               A           3        0000       0.0000           M01          M01          M01
84152       Assay of psa, complexed              A           3        0000       0.0000           M01          M01          M01
84153       Assay of psa, total                  A           3        0000       0.0000           M01          M01          M01
84154       Assay of psa, free                   A           3        0000       0.0000           M01          M01          M01
84155       Assay of protein, serum              A           3        0000       0.0000           M01          M01          M01
84156       Assay of protein, urine              A           3        0000       0.0000           M01          M01          M01
84157       Assay of protein, other              A           3        0000       0.0000           M01          M01          M01
84160       Assay of protein, any source         A           3        0000       0.0000           M01          M01          M01
84163       Pappa, serum                         A           3        0000       0.0000           M01          M01          M01
84165       Protein e-phoresis, serum            A           3        0000       0.0000           M01          M01          M01
84166       Protein e-phoresis/urine/csf         A           3        0000       0.0000           M01          M01          M01
84181       Western blot test                    A           3        0000       0.0000           M01          M01          M01
84182       Protein, western blot test           A           3        0000       0.0000           M01          M01          M01
84202       Assay RBC protoporphyrin             A           3        0000       0.0000           M01          M01          M01
84203       Test RBC protoporphyrin              A           3        0000       0.0000           M01          M01          M01
84206       Assay of proinsulin                  A           3        0000       0.0000           M01          M01          M01
84207       Assay of vitamin b-6                 A           3        0000       0.0000           M01          M01          M01
84210       Assay of pyruvate                    A           3        0000       0.0000           M01          M01          M01
84220       Assay of pyruvate kinase             A           3        0000       0.0000           M01          M01          M01
84228       Assay of quinine                     A           3        0000       0.0000           M01          M01          M01
84233       Assay of estrogen                    A           3        0000       0.0000           M01          M01          M01
84234       Assay of progesterone                A           3        0000       0.0000           M01          M01          M01
84235       Assay of endocrine hormone           A           3        0000       0.0000           M01          M01          M01
84238       Assay, nonendocrine receptor         A           3        0000       0.0000           M01          M01          M01
84244       Assay of renin                       A           3        0000       0.0000           M01          M01          M01
84252       Assay of vitamin b-2                 A           3        0000       0.0000           M01          M01          M01
84255       Assay of selenium                    A           3        0000       0.0000           M01          M01          M01
84260       Assay of serotonin                   A           3        0000       0.0000           M01          M01          M01
84270       Assay of sex hormone globul          A           3        0000       0.0000           M01          M01          M01
84275       Assay of sialic acid                 A           3        0000       0.0000           M01          M01          M01
84285       Assay of silica                      A           3        0000       0.0000           M01          M01          M01
84295       Assay of serum sodium                A           3        0000       0.0000           M01          M01          M01
84300       Assay of urine sodium                A           3        0000       0.0000           M01          M01          M01
84302       Assay of sweat sodium                A           3        0000       0.0000           M01          M01          M01
84305       Assay of somatomedin                 A           3        0000       0.0000           M01          M01          M01
84307       Assay of somatostatin                A           3        0000       0.0000           M01          M01          M01
84311       Spectrophotometry                    A           3        0000       0.0000           M01          M01          M01
84315       Body fluid specific gravity          A           3        0000       0.0000           M01          M01          M01
84375       Chromatogram assay, sugars           A           3        0000       0.0000           M01          M01          M01
84376       Sugars, single, qual                 A           3        0000       0.0000           M01          M01          M01
84377       Sugars, multiple, qual               A           3        0000       0.0000           M01          M01          M01
84378       Sugars, single, quant                A           3        0000       0.0000           M01          M01          M01
84379       Sugars multiple quant                A           3        0000       0.0000           M01          M01          M01
84392       Assay of urine sulfate               A           3        0000       0.0000           M01          M01          M01
84402       Assay of testosterone                A           3        0000       0.0000           M01          M01          M01
84403       Assay of total testosterone          A           3        0000       0.0000           M01          M01          M01
84425       Assay of vitamin b-1                 A           3        0000       0.0000           M01          M01          M01
84430       Assay of thiocyanate                 A           3        0000       0.0000           M01          M01          M01
84432       Assay of thyroglobulin               A           3        0000       0.0000           M01          M01          M01
84436       Assay of total thyroxine             A           3        0000       0.0000           M01          M01          M01
84437       Assay of neonatal thyroxine          A           3        0000       0.0000           M01          M01          M01
84439       Assay of free thyroxine              A           3        0000       0.0000           M01          M01          M01
84442       Assay of thyroid activity            A           3        0000       0.0000           M01          M01          M01
84443       Assay thyroid stim hormone           A           3        0000       0.0000           M01          M01          M01
84445       Assay of tsi                         A           3        0000       0.0000           M01          M01          M01
84446       Assay of vitamin e                   A           3        0000       0.0000           M01          M01          M01
84449       Assay of transcortin                 A           3        0000       0.0000           M01          M01          M01
84450       Transferase (AST) (SGOT)             A           3        0000       0.0000           M01          M01          M01
84460       Alanine amino (ALT) (SGPT)           A           3        0000       0.0000           M01          M01          M01
84466       Assay of transferrin                 A           3        0000       0.0000           M01          M01          M01
84478       Assay of triglycerides               A           3        0000       0.0000           M01          M01          M01
84479       Assay of thyroid (t3 or t4)          A           3        0000       0.0000           M01          M01          M01
84480       Assay, triiodothyronine (t3)         A           3        0000       0.0000           M01          M01          M01


                                             7eebdaa4-31a7-446d-a122-2a9cd0a2ef7a.xls                                                 65 of 128
State of Wyoming Oupatient Prospective Payment System                 Updated    3/20/07
Procedure Code List
Effective Date: 2007

Conversion Factors:
   $46.10 General Acute Care Hospitals
  $105.11 Children's Hospitals
  $120.48 Critical Access Hospitals

Medicare's 2007 National Conversion Factor   $61.468



                                             Medicare
                                                                                                                          Critical
                                               January                                          General     Children's
                                                          WY 2007                                                         Access
  CPT/                                           2007                           APC Relative    Hospital     Hospital
                    Description (short)                     Status    APC                                                 Hospital
 HCPCS                                          Status                            Weight       Outpatient   Outpatient
                                                          Indicator                                                      Outpatient
                                              Indicator                                           Fee          Fee
                                                                                                                            Fee
                                             (FYI Only)
84481       Free assay (FT-3)                    A           3        0000       0.0000           M01          M01          M01
84482       T3 reverse                           A           3        0000       0.0000           M01          M01          M01
84484       Assay of troponin, quant             A           3        0000       0.0000           M01          M01          M01
84485       Assay duodenal fluid trypsin         A           3        0000       0.0000           M01          M01          M01
84488       Test feces for trypsin               A           3        0000       0.0000           M01          M01          M01
84490       Assay of feces for trypsin           A           3        0000       0.0000           M01          M01          M01
84510       Assay of tyrosine                    A           3        0000       0.0000           M01          M01          M01
84512       Assay of troponin, qual              A           3        0000       0.0000           M01          M01          M01
84520       Assay of urea nitrogen               A           3        0000       0.0000           M01          M01          M01
84525       Urea nitrogen semi-quant             A           3        0000       0.0000           M01          M01          M01
84540       Assay of urine/urea-n                A           3        0000       0.0000           M01          M01          M01
84545       Urea-N clearance test                A           3        0000       0.0000           M01          M01          M01
84550       Assay of blood/uric acid             A           3        0000       0.0000           M01          M01          M01
84560       Assay of urine/uric acid             A           3        0000       0.0000           M01          M01          M01
84577       Assay of feces/urobilinogen          A           3        0000       0.0000           M01          M01          M01
84578       Test urine urobilinogen              A           3        0000       0.0000           M01          M01          M01
84580       Assay of urine urobilinogen          A           3        0000       0.0000           M01          M01          M01
84583       Assay of urine urobilinogen          A           3        0000       0.0000           M01          M01          M01
84585       Assay of urine vma                   A           3        0000       0.0000           M01          M01          M01
84586       Assay of vip                         A           3        0000       0.0000           M01          M01          M01
84588       Assay of vasopressin                 A           3        0000       0.0000           M01          M01          M01
84590       Assay of vitamin a                   A           3        0000       0.0000           M01          M01          M01
84591       Assay of nos vitamin                 A           3        0000       0.0000           M01          M01          M01
84597       Assay of vitamin k                   A           3        0000       0.0000           M01          M01          M01
84600       Assay of volatiles                   A           3        0000       0.0000           M01          M01