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					                ACTION: Final                                           ENACTED                  DATE: 03/19/2010 8:53 AM
                                                                          Appendix
           5101:3-2-21                                                   5101:3-2-21                                                        Page 1 of 81




                                                                               APPENDIX C

                                                              AMBULATORY SURGERY FEE SCHEDULE

                                           Effective 10/1/2009                                        Effective 1/1/2010

                                                    Level 1        Level 2                                Level 1          Level 2

                           GROUP A                    $177              $198                GROUP A          $131               $147

                           GROUP B                    $310              $315                GROUP B          $233               $236

                           GROUP 1                    $469              $512                GROUP 1          $408               $445

                           GROUP 2                    $707              $718                GROUP 2          $716               $728

                           GROUP 3                  $1,424          $1,683                  GROUP 3        $1,062          $1,255

                           GROUP 4                  $1,893          $2,208                  GROUP 4        $1,401          $1,634

                           GROUP 5                  $2,710          $2,804                  GROUP 5        $1,818          $1,881

                           GROUP 6                  $2,882          $2,882                  GROUP 6        $1,759          $1,759

                           GROUP 7                  $3,091          $3,146                  GROUP 7        $2,304          $2,345

                           GROUP 8                  $1,569          $1,610                  GROUP 8        $1,530          $1,570

                           GROUP 9                  $2,328          $2,444                  GROUP 9        $2,224          $2,335

                           **UNLISTED                 69 % of Charges                       **UNLISTED       69 % of Charges


                           LEVEL 1----- CHILDREN'S HOSPITALS
                           LEVEL 2----- ALL OTHER HOSPITALS SUBJECT TO PROSPECTIVE PAYMENT




APPENDIX p(60317) pa(105740) d(272321) ra(229551)                                                                              print date: 03/19/2010 9:13 PM
5101:3-2-21                                                                                                       Page 2 of 81

                                                             APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                                                     GROUP NOTE
10021     Fine needle aspiration, w/o imaging guidance                                                            A
10022     Fine needle aspiration, with imaging guidance                                                           A
10040     Acne surg remove milia,comedones,cysts,pustules                                                         A
10060     Incis/drain abcesses,simple/single                                                                      A
10061     Incis/drain abcesses, comp/multiple                                                                     A
10080     Incis/drain pilonidal cyst;simple                                                                       A
10081     Incis/drain pilonidal cyst;complex                                                                      A
10120     Incis/remove subcutaneous tissues, simple                                                               A
10121     Incis/remove subcutaneous tissues, complex                                                               1
10140     Incis/drain hematoma, simple                                                                            A
10160     Puncture abcess, hematoma, bulla, cyst                                                                  A
10180     I&D Post Op complex wound infection                                                                      2
11000     Debridement eczematous infected skin 10% body                                                           A
11001     Additional 10% body                                                                                     A
11004     Debride of skin, subcuta tissue, muscle, fascia for necrotizing soft tissue, ext genitalia               3
11005     Debride of skin, subcuta tissue, muscle, fascia for necrotizing soft tissue, abdomin wall                3
11006     Debride of skin, subcuta tissue, muscle, fascia for necrotizing soft tissue, ext genita & abdom wall     2
11008     Removal of prosthetic material or mesh, abdominal wall                                                   1
11010     Debridement of musculoskeletal injury                                                                    2
11011     Debridement of musculoskeletal injury                                                                    2
11012     Debridement of musculoskeletal injury                                                                    2
11040     Debridement;skin partial thickness                                                                      A
11041     Debridement;skin full thickness                                                                         A
11042     Debridement;skin,subcutaneous tissue                                                                     2
11043     Debridement;skin,tissue/muscle                                                                           1
11044     Debridement;skin,subQ tissue,muscle,bone                                                                 1
11055     Paring or cutting of benign lesion                                                                      A
11056     Paring or cutting of benign lesions                                                                     A
11057     Paring or cutting of benign lesions                                                                     A
11100     Bx of skin/subq tissue,mucous membrane,closure,1 lesion                                                 A
11101     Biopsy of skin tissue, mucous membrane, addl lesion                                                     A
11200     Excis,skin tags multi fibrocutaneous tags up to 15                                                       2
11201     Excis,skin tags fibrocutaneous tags additional ten lesions                                               1
11300     Shaving lesion,single;trunk,arms,0.5/or<                                                                A
11301     Shaving lesion 0.6-1 cm                                                                                 A
11302     Shaving lesion 1.1-2 cm                                                                                 A
11303     Shaving lesion>2 cm                                                                                     B
11305     Shaving lesion,single;scalp,neck,0.5/or<                                                                A
11306     Shaving lesion 0.6-1 cm                                                                                 A
11307     Shaving lesion 1.1-2 cm                                                                                 A
11308     Shaving lesion >2 cm                                                                                    B
11310     Shaving lesion,single;face,ears,0.5/or<                                                                 A
11311     Shaving lesion 0.6-1 cm                                                                                 A
11312     Shaving lesion 1.1-2 cm                                                                                 B
11313     Shaving lesion >2 cm                                                                                    B
11400     Excis,benign lesion,diameter 0.5 cm                                                                     B
11401     Excis,benign lesion,diameter 0.6 to 1.0 cm                                                               1
11402     Excis benign lesion,diameter 1.1 to 2.0 cm                                                               1
11403     Excis benign lesion,diameter 2.1 to 3.0 cm                                                               1
11404     Excis benign lesion,diameter 3.1 to 4.0 cm                                                               1
11406     Excis benign lesion,diameter over 4.0 cm                                                                 2
5101:3-2-21                                                             Page 3 of 81

                                                          APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                           GROUP NOTE
11420     Excis benign lesion,diameter 0.5 cm                            1
11421     Excis benign lesion,diameter 0.6 to 1.0 cm                     1
11422     Excis benign lesion,diameter 1.1 to 2.0 cm                     1
11423     Excis benign lesion,diameter 2.1 to 3.0 cm                     1
11424     Excis benign lesion,diameter 3.1 to 4.0 cm                     2
11426     Excis benign lesion,diameter over 4.0 cm                       2
11440     Excis benign lesion,diameter 0.5 cm                            1
11441     Excis benign lesion,diameter 0.6 to 1.0 cm                     1
11442     Excis benign lesion,diameter 1.1 to 2.0 cm                     1
11443     Excis benign lesion,diameter 2.1 to 3.0 cm                     1
11444     Excis benign lesion,diameter 3.1 to 4.0 cm                     1
11446     Excis benign lesion,diameter over 4.0 cm                       2
11450     Excis skin,axillary w/simple/inter repair                      2
11451     Excis skin,axillary w/complex repair                           2
11462     Excis skin,inguinal w/simple/inter repair                      2
11463     Excis skin,inguinal w/complex repair                           2
11470     Excis skin,hidradenitis w/simple/inter repair                  2
11471     Excis skin,hidradenitis w/complex repair                       2
11600     Excis,malignant lesion,diameter 0.5                            1
11601     Excis malignant lesion,diameter 0.6-1.0 cm                     1
11602     Excis malignant lesion,diameter 1.1-2.0 cm                     1
11603     Excis malignant lesion,diameter 2.1-3.0 cm                     1
11604     Excis malignant lesion,diameter 3.1-4.0 cm                     2
11606     Excis malignant lesion,diameter>4.0 cm                         2
11620     Excis malignant lesion,diameter 0.5 cm                         1
11621     Excis malignant lesion,diameter 0.6-1.0 cm                     1
11622     Excis malignant lesion,diameter 1.1-2.0 cm                     1
11623     Excis malignant lesion,diameter 2.1-3.0 cm                     1
11624     Excis malignant lesion,diameter 3.1-4.0 cm                     2
11626     Excis malignant lesion,diameter>4.0 cm                         2
11640     Excis malignant lesion,diameter 0.5 cm                         1
11641     Excis malignant lesion,diameter 0.6-1.0 cm                     1
11642     Excis malignant lesion,diameter 1.1-2.0 cm                     1
11643     Excis malignant lesion,diameter 2.1-3.0 cm                     1
11644     Excis malignant lesion,diameter 3.1-4.0 cm                     2
11646     Excis malignant lesion,diameter>4.0 cm                         2
11720     Debridement of nail                                           A
11721     Debridement of nail                                           A
11730     Avulsion nail plate,simple,single                             A
11732     Avulsion nails plate,additional nail plate                    A
11740     Evacuation sublingual hematoma                                A
11750     Excis nail/nail matrix permanent removal                       1
11752     Excis nail/nail matrix amputation tuft                        B
11755     Biopsy of nail unit, any method                               A
11760     Repair nail bed                                               A
11762     Reconstruction nail bed w/graft                               B
11765     Wedge excision skin;nail fold                                 B
11770     Excis pilonidal cyst/sinus;simple                              3
11771     Excis pilonidal cyst/sinus;extensive                           3
11772     Excis pilonidal cyst/sinus;complicated                         3
11900     Inj,intralesional;up to seven lesions                         A
5101:3-2-21                                                               Page 4 of 81

                                                            APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                             GROUP NOTE
11901     Inj,intralesional;>seven lesions                                A
11960     Insertion tissue expanders,except breast                         2
11970     Replacement tissue expander w permanent prosthesis               3    PA
11971     Remove tissue expander w/o insert prosthesis                     1
11975     Insertion implant contraceptive capsules                        A
11976     Removal contraceptive capsules                                  A
11977     Removal w reinsert contraceptive capsules                       B
11980     Subcutaneous hormonepellet implantation                         A
11981     Insertion of drug delivery implant device                       A
11982     Removal of drug delivery implant device                         A
11983     Removal & reinsertion of drug delivery implant device           B
12001     Simple Repair wounds(scalp, extremitities,etc.) 2.5 cm          A
12002     Simple Repair wounds(scalp, extremitities,etc.)2.6-7.5cm        A
12004     Simple Repair wounds(scalp, extremitities,etc.)7.6-12.5cm       A
12005     Simple Repair wounds(scalp, extremitities,etc.)12.6-20 cm        2
12006     Simple Repair wounds(scalp, extremitities,etc.)20.0-30 cm        2
12007     Simple Repair wounds(scalp, extremitities,etc.)>30 cm            2
12011     Simple Repair wound(face,ears, etc.)2.5 cm                      A
12013     Simple Repair wound (face,ears, etc.)2.6 cm -5.0 cm             A
12014     Simple Repair wound (face,ears, etc.)5.1 - 7.5 cm               A
12015     Simple Repair wound (face,ears, etc.)7.6 - 12.5 cm              B
12016     Simple Repair wound (face,ears, etc.)12.6 cm -20 cm              2
12017     Simple Repair wound (face,ears, etc.)20 - 30 cm                  2
12018     Simple Repair wound (face,ears, etc.) > 30 cm                    2
12020     Treatment of dehiscence; simple                                  1
12021     Treatment of dehiscence; simple with packing                     1
12031     Layer closure of wounds 2.5 cm                                  A
12032     Layer closure of wounds 2.6 cm to 7.5 cm                        B
12034     Layer closure of wounds 7.6 cm to 12.5 cm                        2
12035     Layer closure of wounds 12.6 cm to 20.0 cm                       2
12036     Layer closure of wounds 20.1 cm to 30.0 cm                       2
12037     Layer closure of wounds over 30.0 cm                             2
12041     Layer closure of wounds 2.5 cm                                  A
12042     Layer closure of wounds 2.6 cm to 7.5 cm                        B
12044     Layer closure of wounds 7.6 cm to 12.5 cm                        2
12045     Layer closure of wounds 12.6 cm to 20.0 cm                       2
12046     Layer closure of wounds 20.1 cm to 30.0 cm                       2
12047     Layer closure of wounds over 30.0 cm                             2
12051     Layer closure of wounds 2.5 cm                                  A
12052     Layer closure of wounds 2.6 cm to 5.0 cm                        B
12053     Layer closure of wounds 5.1 cm to 7.5 cm                        B
12054     Layer closure of wounds 7.6 cm to 12.5 cm                        2
12055     Layer closure of wounds 12.6 cm to 20.0 cm                       2
12056     Layer closure of wounds 20.1 cm to 30.0 cm                       2
12057     Layer closure of wounds over 30.0 cm                             2
13100     Repair, complex trunk; 1.1 cm to 2.5 cm                          2
13101     Repair, complex trunk; 2.6 cm to 7.5 cm                          3
13102     Each additional 5cm or less                                      2
13120     Repair, complex scalp; 1.1 cm to 2.5 cm                          2
13121     Repair, complex scalp; 2.6 cm to 7.5 cm                          3
13122     Each additional 5cm or less                                      2
5101:3-2-21                                                                                             Page 5 of 81

                                                               APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                                           GROUP NOTE
13131     Repair, complex forehead; 1.1 cm to 2.5 cm                                                     2
13132     Repair, complex forehead; 2.6 cm to 7.5 cm                                                     3
13133     Each additional 5cm or less                                                                    2
13150     Repair, complex eyelids; 1.0 cm                                                                3
13151     Repair, complex eyelids; 1.1 cm to 2.5 cm                                                      3
13152     Repair, complex eyelids; 2.6 cm to 7.5 cm                                                      3
13153     Each additional 5cm or less                                                                    2
13160     Secondary closure of dehiscence, extensive or complicated                                      2
14000     Tissue transfer trunk; defect 10 sq cm                                                         2
14001     Tissue transfer trunk; defect 10.1 sq cm to 30.0 sq cm                                         3
14020     Tissue transfer scalp; defect 10 sq cm                                                         3
14021     Tissue transfer scalp; defect 10.1 sq cm to 30.0 sq cm                                         3
14040     Tissue transfer forehead; 10 sq cm                                                             2
14041     Tissue transfer forehead; defect 10.1 sq cm to 30.0 sq cm                                      3
14060     Tissue transfer eyelids; 10 sq cm                                                              3
14061     Tissue transfer eyelids; defect 10.1 sq cm to 30.0 sq cm                                       3
14301     Skin tissue rearrangement; DEFECT 30.1 SQ CM TO 60.0 SQ CM                                     4
14302     Skin tissue rearrangement; EACH ADDITIONAL 30.0 SQ CM                                          2
14350     Fillet finger, toe flap preparation recipient site                                             3
15002     Preparation recipient site; trunk, arms, legs; first 100 sq cm                                 2
15003     Preparation recipient site; trunk, arms, legs; each additional 100 sq cm                       1
15004     Preparation recipient site; face, scalp, neck, hands, feet, etc; first 100 sq cm               2
15005     Preparation recipient site; face, scalp, neck, hands, feet, etc; each additional 100 sq cm     1
15040     Harvest of skin for tissue cultured skin autograft; 100 sq cm or less                          1
15050     Pinch graft; single or multi; defect 2 cm diameter                                             2
15100     Split graft trunk, 100 sq cm                                                                   2
15101     Split graft trunk, 100 sq cm, 100 additonal sq cm                                              3
15110     Epidermal autograft; first 100 sq cm or less                                                   2
15111     Epidermal autograft; each addition 100 sq. cm                                                 A
15115     Epidermal autograft, face, scalp; first 100 sq cm or less                                      2
15116     Epidermal autograft, face, scalp; each additional 100 sq cm                                   A
15120     Split graft face, 100 sq cm                                                                    2
15121     Split graft face, 100 sq cm, 100 additional sq cm                                              3
15130     Dermal autograft, trunk, arms, legs; first 100 sq cm                                           2
15131     Dermal autograft; each additional sq cm                                                       A
15135     Dermal autograft, face, scalp; first 100 sq cm or less                                         2
15136     Dermal autograft, face, scalp; additional 100 sq cm                                           A
15150     Tissue cultured epidermal autograft, trunk, arms legs; first 25 sq cm or less                  2
15151     Tissue cultured epidermal autograft, trunk, arms legs; additional 1-75 sq cm                  A
15152     Tissue cultured epidermal autograft, trunk, arms, legs; each additional 100 sq cm             A
15155     Tissue cultured epidermal autograft, face, scalp; first 25 sq cm or less                       2
15156     Tissue cultured epidermal autograft, face, scalp; additional 1-75 sq cm                       A
15157     Tissue cultured epidermal autograft, face, scalp; each additional 100 sq cm                   A
15170     Acellular dermal replacement, trunk, arms, legs; first 100 sq cm                              B
15171     Acellular dermal replacement, trunk, arms, legs; additional 100 sq cm                         A
15175     Acellular dermal replacement, face, scalp, etc…; first 100 sq cm                               1
15176     Acellular dermal replacement, face, scalp, etc…; additional 100 sq cm                         A
15200     Full thickness graft, trunk, 20 sq cm                                                          3
15201     Full thickness graft, trunk 20 sq cm additional 20 sq cm                                       2
15220     Full thickness graft, scalp, 20 sq cm                                                          2
15221     Full thickness graft, scalp 20 sq cm additional 20                                             2
5101:3-2-21                                                                                       Page 6 of 81

                                                               APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                                     GROUP NOTE
15240     Full thickness graft, feet, 20 sq cm                                                     3
15241     Full thickness graft, feet 20 sq cm additional 20                                        3
15260     Full thickness graft, nose, 20 sq cm                                                     2
15261     Full thickness graft, nose 20 sq cm additional 20 sq cm                                  2
15300     Allograft skin for temporary wound closure, trunk, arms, legs; first 100 sq cm          B
15301     Allograft skin for temporary wound closure, trunk, arms, legs; additional 100 sq cm     A
15320     Allograft skin for temporary wound closure, face, scalp; first 100 sq cm                B
15321     Allograft skin for temporary wound closure face, scalp; additional 100 sq cm            A
15330     Acellular dermal allograft, trunk, arms, legs; first 100 sq cm                          B
15331     Acellular dermal allograft, trunk, arms, legs; additional 100 sq cm                     A
15335     Acellular dermal allograft, face, scalp; first 100 sq cm                                B
15336     Acellular dermal allograft, face, scalp; additional 100 sq cm                           A
15340     Tissue cultured allogenic skin substitute; first 25 sq cm or less                       B
15341     Tissue cultured allogenic skin substitute; additional 25 sq cm                          A
15360     Tissue cultured allogenic dermal substitute; trunk, arms, legs; first 100 sq cm         B
15361     Tissue cultured allogenic dermal substitute; trunk, arms, legs; additional 100 sq cm    A
15365     Tissue cultured allogenic dermal substitute, face, scalp; first 100 sq cm               B
15366     Tissue cultured allogenic dermal substitute, face, scalp; additional 100 sq cm          A
15400     Application of xenograft (heterograft) skin, 100 sq cm or less                           2
15401     Application of xenograft, skin; each additional 100 sq cm                                1
15420     Xenograft skin, for temp. wound closure, face, scalp; first 100 sq cm                   B
15421     Xenograft skin, for temp. wound closure, face, scalp; additional 100 sq cm              A
15430     Acellular xenograft implant; first 100 sq cm                                             1
15431     Acellular xenograft implant; additional 100 sq cm                                       A
15570     Formation pedicle,w/wo transfer;trunk                                                    3
15572     Formation pedicle,w/wo transfer;arm,leg                                                  3
15574     Formation pedicle,w/wo transfer;cheek,hand,feet                                          3
15576     Formation pedicle,w/wo transfer;ear,nose                                                 3
15600     Delay flap/sectioning;trunk                                                              3
15610     Delay flap/sectioning;arm,leg                                                            3
15620     Delay flap/sectioning;cheek,hand,feet                                                    4
15630     Delay flap/sectioning;eyelid,nose,ear                                                    3
15650     Transfer, intermediate, pedicle flap                                                     5
15731     Forehead flap with preservation of vascular pedicle                                      2
15732     Muscle, myocutaneous/fasciocutaneous flap;head neck                                      3
15734     Muscle, myocutaneous/fasciocutaneous flap;trunk                                          3
15736     Muscle, myocutaneous/fasciocutaneous flap;upper extremity                                3
15738     Muscle, myocutaneous/fasciocutaneous flap;lower extremity                                3
15740     Flap; island pedicle                                                                     2
15750     Flap;neurovascular pedicle                                                               2
15756     Microvascular free muscle flap                                                           3
15757     Microvascular free skin flap                                                             3
15758     Microvascular free fascial flap                                                          3
15760     Graft;composite incl primary closure donor                                               2
15770     Graft; derma-fat-fascia                                                                  3
15786     Abrasion; single lesion (eg. keratosis, scar)                                           A
15787     Abrasion; each additional four lesions or less                                          A
15821     Blepharoplasty, lower eyelid; with extensive herniated fat pad                           3
15840     Graft for facial nerve paralysis free facia graft                                        4
15841     Graft for facial nerve paralysis free muscle graft                                       4
15842     Graft for paralysis by microsurgical technique                                           4
5101:3-2-21                                                                  Page 7 of 81

                                                               APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                GROUP NOTE
15845     Graft for facial, regional muscle transfer                          4
15850     Removal sutures w anesthesia, same surgeon                         B      ***
15851     Removal of sutures under anesthesia, surgeon                        1     ***
15852     Dressing change;o.t. burns w anesthesia                            B      ***
15860     Intravenous injection of agent, to test blood flow in flap         A
15920     Excis coccygeal,coccygectomy, with primary sutures                  3
15922     Excis, coccygeal ulcer;w flap closure                               4
15931     Excis, sacral pressure ulcer, with primary suture                   3
15933     Excis, sacral pressure ulcer, with ostectomy                        3
15934     Excis,sacral ulcer;w muscle/myocutaneous flap closure               3
15935     Excis, sacral ulcer,w ostectomy                                     4
15936     Excis,sacral ulcer,w muscle/myocutaneous flap closure               4
15937     Excis, sacral ulcer,w other colsure,w ostectomy                     4
15940     Excis, ischial pressure ulcer, with primary suture                  3
15941     Excis, ischial pressure ulcer, with ostectomy                       3
15944     Excis,ischial,w skin flap closure                                   3
15945     Excis, ischial, with ostectomy                                      4
15946     Excis ischial w ostectomy w muscle/myocutaneous flap closure        4
15950     Excis, trochanteric ulcer with primary suture                       3
15951     Excis, trochanteric ulcer with ostectomy                            4
15952     Excis, trochanteric ulcer;w skin flap closure                       3
15953     Excis, trochanteric ulcer;w ostectomy                               4
15956     Excis trochanteric with muscle or myocutaneous                      3
15958     Excis, trochanteric pressure ulcer with ostectomy                   4
15999     Unlisted procedure, Excision pressure ulcer                        U
16000     Initial, burn, local, treatment is required                        A
16020     Dressings, w/o anesthesia, office or hospital                      A
16025     Dressings, w/o anesthesia, medium                                  A
16030     Dressings, w/o anesthesia, large                                    1
16035     Escharotomy                                                         2
16036     Escharotomy; each additional incision                               1
17000     Destruct any method, benign facial lesions,any loc,1 lesion        B
17003     Destruction of benign lesions                                      A
17004     Destruction of benign lesions                                      A
17106     Destruct cutaneous vascular proliferative lesions<10 sq cm         A
17107     Destruct cutaneous lesions>10.0-50.0 sq cm                         B
17108     Destruct cutaneous lesions>50.0 sq cm                              B
17110     Destruct of warts up to 15 lesions                                 B
17111     Destruction of flat warts                                          B
17250     Chemical cauterization;granulation tissue                          A
17260     Dest;malig lesion;any method;trunk,arms;0.5 cm or<                 A
17261     Dest;malig lesion;any method;trunk,arms;0.6-1 cm                   A
17262     Dest;malig lesion;any method;trunk,arms;1.1-2 cm                   A
17263     Dest;malig lesion;any method;trunk,arms;2.1-3 cm                   A
17264     Dest;malig lesion;any method;trunk,arms;3.1-4 cm                   A
17266     Dest;malig lesion;any method;trunk,arms;>4.0 cm                    B
17270     Dest;malig lesion;any method;scalp,neck 0.5 cm or <                A
17271     Dest;malig lesion;any method;scalp,neck 0.6-1 cm                   A
17272     Dest;malig lesion;any method;scalp,neck 1.1-2 cm                   A
17273     Dest;malig lesion;any method;scalp,neck 2.1-3 cm                   A
17274     Dest;malig lesion;any method;scalp,neck 3.1-4 cm                   A
5101:3-2-21                                                                                                  Page 8 of 81

                                                               APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                                                GROUP NOTE
17276     Dest;malig lesion;any method;scalp,neck >4.0 cm                                                    B
17280     Dest;malig lesion;any method;face, ear, 0.5 cm or <                                                A
17281     Dest;malig lesion;any method;face, ear, 0.6-1 cm                                                   A
17282     Dest;malig lesion;any method;face, ear, 1.1-2 cm                                                   A
17283     Dest;malig lesion;any method;face, ear, 2.1-3 cm                                                   B
17284     Dest;malig lesion;any method;face, ear, 3.1-4 cm                                                   B
17286     Dest;malig lesion;any method;face, ear, >4.0 cm                                                    B
17311     Mohs micrographic technique; head, neck, hands, feet, etc., first stage                            B
17312     Mohs micrographic technique; head, neck, hands, feet, etc., each additional stage                  B
17313     Mohs micrographic technique; trunk, arms, legs, first stage                                        B
17314     Mohs micrographic technique; trunk, arms, legs, each additional stage                              B
17315     Mohs micrographic technique, each additional block after the first 5 tissue blocks                 B
17360     Chemical exfoliation for acne (eg. acne paste, acid)                                               A
17999     Unlisted procedure skin mucous membranes/subcutaneous tissue                                       U
19000     Puncture asp cyst breast;                                                                          A
19001     Puncture asp addl cyst                                                                             A
19020     Mastotomy w exp/drg abscess deep                                                                    2
19030     Inject proced for mammary ductogram/galactogram                                                    A
19100     Bx breast;needle(separate procedure)                                                                1
19101     Incisional                                                                                          2
19102     Biopsy of breast; percutaneous, needle core, imaging guidance                                       2
19103     Biopsy of breast; percutaneous, automated vacuum assist, imaging                                    3
19105     Ablation, cryosurgical, each fibroadenoma, including ultrasound guidance                            4
19110     Nipple exploration excis solitary lactiferous duct                                                  2
19112     Excis, of lactiferous duct fistula                                                                  3
19120     Excis cyst fibroadenoma benign one or more lesions                                                  3
19125     Excis breast lesion, single lesion                                                                  3
19126     Excision,add'l breast lesion                                                                        3
19260     Excision chest wall tumor,incl ribs                                                                 5
19290     Preop plcmt needle local wire,breast                                                               A
19291     Preop plcmt, ea addl lesion                                                                        A
19295     Image guided placement, metallic localizn clip, during breast biopsy                                1
19296     Placemt of radiotherapy after loading balloon catheter into breast                                  2
19297     Placemt of radiotherapy after loading balloon catheter into breast following partial mastectomy     7
19298     Placemt of radiotherapy after loading brachytherapy catheters into breast                           7
19300     Mastectomy for gynecomastia                                                                         4
19301     Partial mastectomy                                                                                  3
19302     Mastectomy, partial, with axillary lymphadenectomy                                                  7
19303     Mastectomy, simple, complete                                                                        4
19304     Mastectomy, subcutaneous                                                                            4
19307     Mastectomy, modified radical, including axillary lymph nodes                                        4
19316     Mastopexy                                                                                           3    PA
19318     Reduction mammaplasty                                                                               4    PA
19328     Removal of intact mammary implant                                                                   1
19330     Removal of mammary implant material                                                                 1
19340     Immediate insert breast prosthesis follow mastopexy,mastectomy                                      2    PA
19342     Delayed insert breast prosthesis follow mastopexy,mastectomy                                        3    PA
19350     Nipple/areola reconstruction                                                                        4    PA
19357     Breast reconst;w tissue expander                                                                    5    PA
19361     Breast reconst;w latissimus dorsi flap                                                              5    PA
19364     Breast reconst w free flap                                                                          5    PA
5101:3-2-21                                                                Page 9 of 81

                                                             APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                              GROUP NOTE
19366     Breast reconst w other technique                                  5    PA
19370     Open periprosthetic capsulectomy,breast                           4    PA
19371     Periprosthetic capsulectomy,breast                                4    PA
19380     Revision reconst breast                                           5    PA
19396     Prep moulage;custom breast implant                               B     PA
19499     Unlisted procedure, breast                                       U     PA
20000     Incision soft tissue abscess                                     A
20005     Incision soft tissue abscess deep/complicated                     2
20100     Explore wound, neck                                               2
20101     Explore wound, chest                                              2
20102     Explore wound, ab/flank/back                                      2
20103     Explore wound, extremity                                          2
20150     Excision of epiphyseal bar                                        2
20200     Biopsy,muscle;superficial                                         2
20205     Biopsy, muscle; deep                                              3
20206     Biopsy,muscle,percutaneous needle                                 1
20220     Biopsy,bone,trocar/needle;superficial                             1
20225     Biopsy,bone,trocar/needle;deep                                    2
20240     Biopsy,excisional;superficial                                     2
20245     Biopsy,excisional;deep                                            3
20250     Biopsy,vertebral body,open;thoracic                               3
20251     Biopsy,lumbar/cervical                                            3
20500     Injection sinus tract;therapeutic                                A
20501     Injection sinus tract;diagnostic                                 A
20520     Removal foreign body;muscle;simple                               B
20525     Removal foreign body;muscle;complicated                           3
20526     Carpel tunnel therapeutic injection                              A
20550     Injection,tendon sheath,ligament,trigger points                   1
20551     Injection, tendon origin/insertion                               A
20552     Trigger point injection, 1 or more muscle groups                 B
20553     Trigger point injection, 3 or more muscle groups                  1
20555     Place NDL musc/tis for rt                                         4
20600     Arthrocentesis,aspiration/injection;                             A
20605     Intermediate joint,bursa/ganglion cyst                           A
20610     Arthrocentesis,major joint/bursa                                 A
20612     Aspirate/inj ganglion cyst                                       A
20615     Asp/inj treatment bone cyst                                      A
20650     Insertion wire/pin                                                3
20660     Application cranial tongs,caliper/stereotactic                    2
20661     Application halo,incl removal;cranial                             3
20662     Application halo,incl removal;pelvic                              3
20663     Application halo,incl removal;femoral                             3
20664     Application of halo brace                                         3
20665     Removal tongs/halo,by another physician                           0    *****
20670     Removal implant;superficial                                       1
20680     Removal implant;deep                                              3
20690     Application uniplane,unilat ext fixation system                   2
20692     Application multiplane,unilat,ext fixation                        2
20693     Adjustment/revision ext fixation sys req anesthesia               1     ***
20694     Removal under anesth ext fixation system                          1     ***
20696     Computer-assisted multiplane external fixation                    6
5101:3-2-21                                                                       Page 10 of 81

                                                              APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                      GROUP NOTE
20697     Computer-assisted external fixation, strut change                         3
20822     Replant Digit; exclud thumb comp amput                                    6
20900     Bone graft,any donor area,minor                                           3
20902     Bone graft,any donor area,major                                           4
20910     Cartilage graft;costochondral                                             3
20912     Cartilage graft;nasal septum                                              3
20920     Fascia lata graft;by stripper                                             4
20922     Fascia lata graft;by incision/area exposure,complex                       3
20924     Tendon graft,distance                                                     4
20926     Tissue graft,other                                                        4
20950     Monitor interstitial fluid pressure,e.g.,wick catheter                   B
20955     Bone graft w microvascular anastomosis;fibula                             4
20956     Microvascular iliac crest bone graft                                      4
20962     Bone graft w microvascular anastomosis;other bone graft                   4
20969     Free osteocutaneous flap w/microvascular anastomosis;                     4
20970     Free osteocutaneous flap w/microvascular anastomosis;iliac crest          4
20972     Free osteocutaneous flap w/microvascular anastomosis;metatarsal           4
20973     Free osteocutaneous flap w/microvascular anastomosis;great toe            4
20974     Electrical stimulation;aid bone healing;noninvasive                      A
20975     Electrical stimulation;aid bone healing;invasive                          2
20976     Electrical stimulation to aid bone healing;percutaneous                   1
20979     Low intensity ultrasound stim. to aid bone healing, noninvasive          A
20982     Ablation, bone tumor(s) (osteoid osteoma, metastasis) radiofreq, perq     2
20985     CPTR-ASST DIR MS PX                                                      A
20999     Unlisted procedure,musculoskeletal system,general                        U
21010     Arthrotomy,temporomandibular joint                                        2
21011     Exc face les sc < 2 cm                                                    1
21012     Exc face les sc = 2 cm                                                    1
21013     Exc face tum deep < 2 cm                                                  1
21014     Exc face tum deep = 2 cm                                                  1
21016     Resect face tum < 2 cm                                                    8
21015     Resect face tum = 2 cm                                                    3
21025     Excision bone; mandible                                                   2
21026     Excision bone;facial bone(s)                                              2
21029     Removal by contouring benign tumor facial bone                            2
21030     Exc benign tumor/cyst;facial bone o.t. mandible                           2
21031     Excision torus mandibularis                                               2
21032     Excision maxillary torus palantinus                                       2
21034     Exc malignant tumor/cyst facial bone o.t. mandible                        3
21040     Excision benign tumor/cyst mandible;simple                                2
21044     Excision malignant tumor;mandible                                         2
21046     Remove mandible cyst complex                                              3
21047     Excise lwr jaw cyst w/repair                                              4
21048     Remove maxilla cyst complex                                               3
21049     Excis uppr jaw cyst w/repair                                              4
21050     Condylectomy,temporomandibular joint                                      3
21060     Meniscetomy, partial/complete,temporomandibular joint                     2
21070     Coronoidectomy                                                            3
21073     MNPJ OF TMJ W/ANESTH                                                      1     ***
21079     Impression and custom preparation; interim obturator prosthesis           5
21080     Impression and custom preparation; definitive obturator prosthesis        5
5101:3-2-21                                                                             Page 11 of 81

                                                              APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                            GROUP NOTE
21081     Impression and custom preparation; mandibular obturator prosthesis              5
21082     Impression and custom preparation; palatal augmentation prosthesis              5
21083     Impression and custom preparation; palatal lift prosthesis                      5
21084     Impression and custom preparation; speech aid prosthesis                        5
21085     Impression and custom preparation; oral surgical splint                         2
21086     Impression and custom preparation; auricular prosthesis                         5
21087     Impression and custom preparation; nasal prosthesis                             5
21088     Impression and custom preparation; facial prosthesis                            5
21089     Unlisted maxillofacial prosthetic procedure                                    A
21100     Appl halo type appliance;maxillofacial,incl remov                               2
21110     Appl interdental fixation o.t. fx/dislocation                                   2
21116     Inj proc temporomandibular joint arthrography                                  A
21120     Genioplasty; augmentation (autograft, allograft, prosthetic material)           3
21121     Genioplasty; slid osteotomy, SGL piece                                          3
21122     Genioplasty; sliding osteotomies, two or more osteotomies                       3
21123     Genioplasty; sliding, augmentation with interpositional bone grafts             3
21125     Augmentation, mandibular body or angle; prosthetic material                     3
21127     Augmentation, mandibular body or angle; with bone graft                         5
21137     Reduction of forehead; contouring only                                          3
21138     Reduction of forehead, contouing and application of prothetic material          5
21139     Reduction of forehead, contouing and setback of anterior frontal sinus wall     5
21141     Reconstruct midface, LeFort                                                     5
21142     Reconstruct midface, LeFort                                                     5
21143     Reconstruction midface, 3 or more pieces                                        6
21145     Reconstruct midface LeFort I; single piece, bone grafts                         5
21146     Reconstruct midface LeFort I; two pieces, bone grafts                           5
21147     Reconstruct midface LeFort I; three or more pieces, bone grafts                 5
21150     Reconstruct midface LeFort II; anterior intrusion                               5
21151     Reconstruct midface LeFort II; requiring bone grafts                            5
21154     Reconstruct midface, LeFort III, bone grafts, w/o LeFort I                      5
21155     Reconstruct midface, LeFort III, bone grafts, with LeFort I                     5
21159     Reconstruct midface,LeFort III,forehead advance,bone grafts,w/o LeFort I        5
21160     Reconstruct midface,LeFort III,forehead advance,bone grafts,with LeFort I       5
21172     Reconstruct supper lat orbit rim/low fore                                       7
21175     Reconstruct bifront super lat orbit rims                                        7
21181     Reconstruct by contouring of benign tumor of cranial bones, extracranial        3
21193     Reconstruct mandibular ramus, w/o bone graft                                    5
21194     Reconstruct mandibular ramus, with bone graft                                   5
21195     Reconstruct mandibular ramus, w/o int rigid fixation                            5
21196     Reconstruct mandibular ramus, with int rigid fixation                           5
21198     Osteotomy, mandible, segmental                                                  5
21199     Osteotomy, mandible, segment; with genioglossus advancement                     6
21206     Osteotomy,maxilla,segmental                                                     5
21208     Osteoplasty, facial bones;augmentation                                          7
21209     Osteoplasty, facial bones;reduction                                             5
21210     Graft bone;nasal,maxillary/malar areas,incl obt graft                           7
21215     Graft bone;mandible,incl obt graft                                              7
21230     Graft;rib cartilage,autogenous to face,chin,nose,ear,incl obt graft             7
21235     Graft;ear cartilage,autograft to nose,ear,incl obt graft                        7
21240     Arthroplasty,temporomandibular joint w/wo autograft                             4
21242     Arthroplasty,temporomandibular joint w allograft                                5
5101:3-2-21                                                                                                Page 12 of 81

                                                             APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                                               GROUP NOTE
21243     Arthroplasty,temporomandibular joint w prosthetic joint replacement                                5
21244     Reconst mandible,extraoral w transosteal bone plate                                                7
21245     Reconst mandible/maxilla,subperiosteal implant;partial                                             7
21246     Reconst mandible/maxilla,subperiosteal implant;complete                                            7
21247     Reconst mandibular condyle w bone/cartilage autografts                                             7
21248     Reconst mandible/maxilla,endosteal implant;partial                                                 7
21249     Reconst mandible/maxilla,endosteal implant;complete                                                7
21256     Reconstruct orbit; bone graft                                                                      7
21260     Periorbital osteotomies for orbital hypertelorism, with bone grafts; extracranial approach         5
21261     Orbit osteotom bilat intra extracranial                                                            7
21263     Periorbital osteotomies for orbital hypertelorism, with bone grafts; with forehead advancement     5
21267     Orbital repositioning,periorbital osteotomies,unilateral w bone grafts;estracranial approach       7
21270     Malar augmentation prosthetic material                                                             5
21275     Secondary revision orbitocraniofacial reconst                                                      7
21280     Medial canthopexy                                                                                  5
21282     Lateral canthopexy                                                                                 5
21295     Reduction of masseter muscle and bone; extraoral approach                                         B
21296     Reduction of masseter muscle and bone; intraoral approach                                          3
21299     Unlisted procedure                                                                                U
21310     Closed trt nasal fx w/o manipulation                                                               2
21315     Closed trt,nasal bone fx;w/o stabilization                                                         2
21320     Manipulative trt, nasal bone fx;w/ stabilizatio                                                    2
21325     Open trt nasal fx; uncomplicated                                                                   4
21330     Open trt nasal fx;complicated w/skeletal fixat                                                     5
21335     Open trt nasal fx; w/concomitant of fx septum                                                      7
21336     Open trt nasal fx; w/wo stabilization                                                              2
21337     Closed trt nasal septal fx,w/wo stabilization                                                      2
21338     Open trt nasoethmoid fx;w/o ext fixation                                                           4
21339     Open trt nasoethmoid fx;w/ ext fixation                                                            5
21340     Percutaneous trt nasoethmoid complex fx,w/splint, wire, headcap                                    4
21343     Open trt depressed frontal sinus fx                                                                5
21344     Open trt comp fontal sinus fx,mult approaches                                                      5
21345     Closed trt nasomaxillary comp fx,w/wiring or fixation                                              5
21346     Open trt nasomaxillary comp fx w/wiring/fixation                                                   5
21347     Open trt nasomaxillary comp fx req/mult approach                                                   5
21348     Open trt nasomaxillary comp fx w bone graft                                                        6
21355     Percutaneous trt malar area,towel clip tech                                                        3
21356     Open trt depressed zygomatic arch fx                                                               3
21360     Open trt depressed malar fx/zygomatic arch/malar tripod                                            4
21365     Open trt complicated fx of malar area                                                              5
21366     Open trt comp fx malar area w bone graft                                                           6
21385     Opn trt "blowout" fx,transantral approach                                                          5
21386     Opn trt "blowout" fx,periorbital approach                                                          5
21387     Opn trt "blowout" fx,combined approach                                                             5
21390     Opn trt "blowout" fx,periorbital approach,alloplastic/other implant                                7
21395     Opn trt "blowout" fx,periorbital approach,bone graft                                               7
21400     Open trt fx orbit,except"blowout"w/o manipulation                                                  2
21401     Trt fx orbit,except"blowout",w manipulation                                                        3
21406     Trt fx orbit,except"blowout",w/o implant                                                           4
21407     Trt fx orbit,except"blowout",w implant                                                             5
21408     Trt fx orbit,except"blowout",w bone graft                                                          6
5101:3-2-21                                                                  Page 13 of 81

                                                                APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                 GROUP NOTE
21421     Closed trt palatal/maxillary fx,interdental wire fixation            4
21422     Open trt of 21421                                                    5
21423     Open trt of 21421,comp,mult approaches                               6
21440     Closed trt mandibular/max alveolar ridge fx                          3
21445     Open trt of 21440                                                    4
21450     Closed trt mandibular fx;w/o manipulation                            3
21451     Closed trt mandibular fx;w/manipulation                              4
21452     Percuatneous trt mandibular fx;w ext fixation                        2
21453     Closed trt mandibular fx;w/interdental fixation                      3
21454     Open trt mandibular fx w/ext fixation                                5
21461     Open trt mandibular fx;w/o interdental fixation                      4
21462     Open trt mandibular fx;w/interdental fixation                        5
21465     Open trt mandibular condylar fracture                                4
21470     Open trt comp mandibular fx mult surgical app                        5
21480     Closed trt temporomandibular dislocation,initial/subsequent          1
21485     Closed trt comp temporomandibular dislocation,initial/subsequent     2
21490     Open trt temporomandibular dislocation                               3
21495     Open trt hyoid fx                                                    4
21497     Interdental wiring, for condition o.t. fx                            2
21499     Unlisted orthopedic procedure, head                                 U
21501     I&D,soft tissues of neck/thorax                                      2
21502     I&D,soft tissue neck/thorax,w/part rib ostectomy                     2
21510     Incision,deep,opening bone cortex,thorax                             3
21550     Bx,soft tissue neck/thorax                                           1
21552     Exc neck les sc = 3 cm                                               3
21554     Exc neck tum deep = 5 cm                                             3
21555     Exc neck les sc < 3 cm                                               2
21556     Exc neck tum deep < 5 cm                                             2
21557     Resect neck tum < 5 cm                                               2
21558     Resect neck tum = 5 cm                                               3
21600     Excision of rib, partial                                             2
21610     Costotransversectomy                                                 2
21620     Ostectomy sternum,partial                                            2
21685     Hyoid myotomy and suspension                                        B
21700     Division scalenus anticus;w/o resection cervical rib                 2
21720     Division sternocleidomastoid for torticollis,w/o cast                3
21725     Division sternocleidomastoid for torticollis,w cast                  3
21742     Repair stern/nuss w/o scope                                          2
21743     Repair sternum/nuss w/scope                                          3
21750     Closure sternotomy separation;w/wo debridement                       3
21800     Closed trt rib fx;uncomplicated,each                                 1
21805     Open trt rib fx; w/o fixation,each                                   2
21810     Trt rib fx; req ext fixation                                         2
21820     Closed trt sternum fx                                                1
21825     Open trt of 21820, w/wo skeletal fixation                            3
21899     Unlisted procedure, neck or thorax                                  U
21920     Bx,soft tissue back/flank;superficial                                1
21925     Bx,soft tissue back/flank;deep                                       2
21930     Exc back les sc < 3 cm                                               2
21931     Exc back les sc = 3 cm                                               3
21932     Exc back tum deep < 5 cm                                             2
5101:3-2-21                                                                                                   Page 14 of 81

                                                            APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                                                  GROUP NOTE
21933     Exc back tum deep = 5 cm                                                                              3
21935     Resect back tum < 5 cm                                                                                3
21936     Resect back tum = 5 cm                                                                                8
22010     Incision&drainage, open, of deep abscess, posterior spine, cervical, thoracic, or cervicothoracic     3
22015     Incision and drainage, lumbar sacral or lumbrosacral                                                  3
22100     Partial resection vertebral component spinous process,cervical                                        3
22101     Partial resection vertebral component spinous process,thoracic                                        3
22102     Partial resection vertebral component spinous process,lumbar                                          3
22103     Remove extra spine segment                                                                            3
22222     Ostomy spine ante for cor defor s seq; tho                                                            7
22305     Cl trt vertebral process fx                                                                           1
22310     Cl trt vertebral body fx w/o manipulation                                                             1
22315     Cl trt vertebral fx by manipulation/tx each                                                           2
22318     Open trt odontoid fx, without grafting                                                                3
22319     Open trt odontoid fx, with grafting                                                                   4
22325     Open trt vertebral fx,lumbar                                                                          3
22326     Open trt vertebral fx,cervical                                                                        3
22327     Open trt vertebral fx,thoracic                                                                        3
22328     Repair each add. spine fx                                                                             3
22505     Manipulation spine req anesth,any region                                                              2     ***
22520     Percutaneous vertabroplasty, one vertebral body, thoracic                                             3
22521     Percutaneous vertabroplasty, one vertebral body, lumbar                                               3
22522     Percutaneous vertabroplasty, one vertebral body, each additional                                      2
22523     Percut kyphoplasty, thor                                                                              7
22524     Percut kyphoplasty, lumbar                                                                            7
22525     Percut kyphoplasty, add-on                                                                            7
22526     Percutaneous intradiscal electrothermal annuloplasty, 1 level                                         4
22527     Percutaneous intradiscal electrothermal annuloplasty, additional levels                               3
22612     Lumbar spine fusion                                                                                   7
22614     Spine fusion, extra segment                                                                           7
22899     Unlisted procedure,spine                                                                             U
22900     Exc back tum deep < 5 cm                                                                              4
22901     Exc back tum deep = 5 cm                                                                              4
22902     Exc abd les sc < 3 cm                                                                                 3
22903     Exc abd les sc > 3 cm                                                                                 8
22904     Resect abd tum < 5 cm                                                                                 3
22905     Resect abd tum > 5 cm                                                                                 8
22999     Unlisted procedure, abdomen, musculoskeletal system                                                  U
23000     Removal of subdeltoid calcareous deposits open method                                                 2
23020     Capsular contracture release for Erb's palsy                                                          2
23030     I&D,shoulder area;deep abscess or hematoma                                                            1
23031     I&D,shoulder area;infected bursa                                                                     B
23035     Incision,deep,with opening of cortex,shoulder area                                                    3
23040     Arthrotomy,glenohumeral joint,for infection,w/ exploration                                            3
23044     Arthrotomy,acromioclavicular,sternoclavicular joint,infect                                            4
23065     Bx,soft tissue of shoulder area;superficial                                                           1
23066     Bx,soft tissue of shoulder area;deep                                                                  2
23071     Exc shoulder les sc > 3 cm                                                                            8
23073     Exc shoulder tum deep > 5 cm                                                                          8
23075     Exc shoulder les sc < 3 cm                                                                            2
23076     Exc shoulder tum deep < 5 cm                                                                          2
5101:3-2-21                                                                              Page 15 of 81

                                                            APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                             GROUP NOTE
23077     Resect shoulder tum < 5 cm                                                       3
23078     Resect shoulder tum > 5 cm                                                       8
23100     Arthrotomy for bx,glenohumeral joint                                             2
23101     Arthrotomy torn cartilage,acromio/steroclavicular jnt                            7
23105     Arthrotomy for synovectomy;glenohumeral joint                                    4
23106     Arthrotomy for synovectomy;sternoclavicular joint                                4
23107     Arthrotomy glenohumeral joint w exploration                                      4
23120     Claviculectomy;partial                                                           5
23125     Claviculectomy;total                                                             5
23130     Acromioplasty/Acromionectomy,partial                                             5
23140     Excis/curettage bone cyst or benign tumor clavicle/scapula                       4
23145     Exc/curettage bone cyst/tumor,clavical w autograft                               5
23146     Exc/curettage bone cyst/tumor,clavical w allograft                               5
23150     Excis/curettage bone cyst or benign tumor proximal humerus                       4
23155     Exc/curettage bone cyst/tumor,prox humerus w autograft                           5
23156     Exc/curettage bone cyst/tumor,prox humerus w allograft                           5
23170     Sequestrectomy,clavicle                                                          2
23172     Sequestrectomy,scapula                                                           2
23174     Sequestrectomy,humeral head to surgical neck                                     2
23180     Partial excision of bone, clavicle                                               4
23182     Partial excision of bone, scapula                                                4
23184     Partial excision of bone, proximal humerus                                       4
23190     Ostectomy of scapula,partial                                                     4
23195     Resection humeral head                                                           5
23330     Removal of foreign body, shoulder; subcutaneous                                  1
23331     Removal of foreign body, shoulder; deep                                          1
23350     Injection procedure for shoulder arthrography                                   A
23395     Muscle transfer paralysis shoulder/arm,single                                    5
23397     Muscle transfer paralysis shoulder/arm,mult                                      7
23400     Scapulopexy                                                                      7
23405     Tenomyotomy, shoulder area;single                                                2
23406     Tenomyotomy, shoulder area;multiple through same incision                        2
23410     Repair ruptured supraspinatus tendon, acute                                      5
23412     Repair as 23410, chronic                                                         7
23415     Coracoacromial ligament release;w/wo acromioplasty                               5
23420     Repair complete shoulder, chronic                                                7
23430     Tenodesis for rupture of long tendon of biceps                                   4
23440     Resection/transplantaion long tendon of biceps                                   4
23450     Capsulorrhaphy recurrent dislocation, ant putti-platt proc                       5
23455     Capsulorrhaphy recurrent dislocation, ant bankart type,w/wo stapling             7
23460     Capsulorrhaphy recurrent dislocation, ant any type,bone block                    5
23462     Capsulorrhaphy recurrent dislocation, ant any type, coracoid process transfr     7
23465     Capsulorrhaphy recurrent dislocation, post,w/wo bone block                       5
23466     Capsulorrhaphy recurrent dislocation, any type,multi directional instability     7
23470     Arthroplasty, glenohumeral joint; hemiarthroplasty                               7
23480     Osteotomy,clavicle,w/ or w/o internal fixation                                   4
23485     Osteotomy,clavicle,w/ or w/o internal fixat;w/ bone graft                        7
23490     Prophylactic trt clavicle                                                        3
23491     Prophylactic proximal humerus and humeral head                                   3
23500     Closed trt clavicular fx;w/o manipulation                                        1
23505     Closed trt clavicular fx;w manipulation                                          1
5101:3-2-21                                                                     Page 16 of 81

                                                              APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                    GROUP NOTE
23515     Open trt clavicular fx;w/or w/o fixati                                  3
23520     Closed trt sternoclavicular dislocation;w/o manipulati                  1
23525     Closed trt sternoclavicular dislocation;w manipulati                    1
23530     Open trt sternoclavicular dislocat,acute/chronic                        3
23532     Open trt sternoclavi dislocat,acut/chron;w/fascial graft                4
23540     Closed trt acromioclavicular dislocat;w/o manipulation                  1
23545     Closed trt acromioclavicular dislocat;w manipulation                    1
23550     Open trt acromioclavicular dislocat,acute/chronic                       3
23552     Open trt acromioclavi dislocat,acut/chroni;w/fascial graf               4
23570     Closed trt scapular fx;w/o manipulation                                 1
23575     Closed trt scapular fx;w manipulation                                   1
23585     Open trt scapular fx w/wo int fix                                       3
23600     Closed trt proximal humeral fx;w/o manipulation                         1
23605     Closed trt proximal humeral fx;w manipulation                           2
23615     Open trt proximal humeral fx w/wo int/ext fix                           4
23616     Repair humerus fracture                                                 4
23620     Closed trt greater tuberosity fx;w/o manipulation                       1
23625     Closed trt greater tuberosity fx;w manipulation                         2
23630     Open trt greater tuberosity fx,w/wo int/ext fixat                       5
23650     Closed trt shoulder dislocation,w/manipulat;w/o anesthesia              1
23655     Closed trt shoulder dislocation,w/manipulat;w anesthesia                1     ***
23660     Open trt acute shoulder dislocation                                     3
23665     Closed trt shoulder disloc,w/fx gr tuberosity,w/manip                   2
23670     Open trt shoulder disloc,w/fx gr tuberosity,w/wo int/ext fix            3
23675     Closed trt shoulder disloc,w/surg/anatomic neck fx,w manipulation       2
23680     Open trt shoulder disloc,w/ surg/anatomic neck fx, w/wo int/ext fix     3
23700     Manipulat under anesth,shoulder joint,incl fixat apparat                1     ***
23800     Arthrodesis shoulder joint,w/wo local bone graft                        4
23802     Arthrodesis shoulder joint,w primary autogenous graft                   7
23921     Disarticulation shoulder, secondary closure/scar revision               3
23929     Unlisted procedure,shoulder                                            U
23930     I&D,upper arm or elbow area;deep abscess/hematoma                       1
23931     I&D,upper arm or elbow area;infected bursa                              2
23935     Incision,deep,w/ opening of bone cortex,humerus or elbow                2
24000     Arthrotomy,elbow,for infection,w/ explorat,drain/removal                4
24006     Arthrotomy,elbow,w/cap exc for cap release                              4
24065     Bx,soft tissue upper arm/elbow area;superficial                         1
24066     Bx,soft tissue upper arm/elbow area;deep                                2
24071     Exc arm/elbow les sc = 3 cm                                             8
24073     Ex arm/elbow tum deep > 5 cm                                            8
24075     Exc arm/elbow les sc < 3 cm                                             2
24076     Ex arm/elbow tum deep < 5 cm                                            2
24077     Resect arm/elbow tum < 5 cm                                             3
24079     Resect arm/elbow tum > 5 cm                                             8
24100     Arthrotomy,elbow;for synovial bx only                                   1
24101     Arthrotomy,elbow;w/ joint explorat,w/ or w/o biopsy                     4
24102     Arthrotomy,elbow;for synovectomy                                        4
24105     Excision,olecranon bursa                                                3
24110     Excision/curettage of bone cyst/benign tumor,humerus                    2
24115     Excis/curett bone cyst/benign tumor,humerus;w/autogen graft             3
24116     Excis/curett bone cyst/benign tumor,humerus;o.t.autogen graft           3
5101:3-2-21                                                                          Page 17 of 81

                                                             APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                         GROUP NOTE
24120     Excis cyst/bgn tumor,head/neck,radius/olecranon process                      3
24125     Excis cyst/bgn tumor,head/neck,radius/olecranon;auto graft                   3
24126     Exci cyst/bgn tumor,head/neck,radius/olecranon;nonaut graft                  3
24130     Excis cyst/bgn tumor,head/neck,radius/olecranon process                      3
24134     Sequestrectomy shaft or distal humerus                                       2
24136     Sequestrectomy,radial head or neck                                           2
24138     Sequestrectomy,olecranon process                                             2
24140     Partial excision of bone,humerus                                             3
24145     Partial excision of bone,radial head or neck                                 3
24147     Partial excision of bone,olecranon process                                   2
24149     Radical resection and release of elbow joint                                 3
24150     Radical resection tumor,shaft/distal humerus                                 3
24152     Radical resection tumor,radial head/neck                                     3
24155     Resection of elbow joint                                                     3
24160     Implant removal; elbow joint                                                 2
24164     Implant removal; radial head                                                 3
24200     Removal of foreign body,upper arm/elbow area;subcutaneous                   A
24201     Removal of foreign body,upper arm/elbow area;deep                            2
24220     Injection procedure for elbow arthrography                                  A
24300     Manipulation, elbow, under anesthesia                                        2
24301     Muscle or tendon transfer,any type,upper arm/elbow,single                    4
24305     Tendon lenghtening,upper arm/elbow,single,each                               3
24310     Tenotomy,open,elbow to shoulder,single each                                  3
24320     Tenoplasty,w/muscle transf,w/or w/o free graft,elbow to shoulder             3
24330     Flexor-plasty,elbow;                                                         3
24331     Flexor-plasty,elbow;w/ extensor advancement                                  3
24332     Tenolysis or triceps                                                         2
24340     Tenodesis for rupture of biceps tendon at elbow                              3
24341     Muscle or tendon repair of upper arm or elbow                                3
24342     Reinsert ruptured biceps/triceps,distal,w/ w/o tendon graft                  3
24343     Repair, elbow ligament, w. local tissue                                      3
24344     Repair, elbow ligament, with tendon graft                                    8
24345     Repair, medial ligament, with local tissue                                   3
24346     Reconstruct elbow ligament                                                   8
24357     Repair elbow, perc                                                           3
24358     Repair elbow w/deb, open                                                     3
24359     Repair elbow deb/ attch open                                                 3
24360     Arthroplasty, elbow w membrane                                               5
24361     Arthroplasty, elbow w distal humeral prosthetic replacement                  5
24362     Arthroplasty,elbow;w implant/fascia lata ligament reconst                    5
24363     Arthroplasty, elbow distal humerus/proximal ulnar prosthetic replacement     7
24365     Arthroplasty, radial head                                                    5
24366     Arthroplasty,radial head w implant                                           5
24400     Osteotomy,humerus,w/ or w/o internal fixation                                4
24410     Multiple osteotomies humeral shaft                                           4
24420     Osteoplasty,humerus                                                          3
24430     Repair nonunion humerus, w/o graft                                           3
24435     Repair nonunion humerus, w iliac/other autograft                             4
24470     Hemiepiphyseal arrest                                                        3
24495     Decompression fasciotomy,forearm,w/brachial artery explorat                  2
24498     Prophylactic trt w/wo methyl methacrylate,humerus                            3
5101:3-2-21                                                                    Page 18 of 81

                                                              APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                   GROUP NOTE
24500     Closed trt humeral shaft fx;w/o manipulat                              1
24505     Closed trt humeral shaft fx;w manipulat,w/wo tx                        1
24515     Open trt humeral shaft fx,w plate/screws w/wo cerclage                 4
24516     Open trt humeral shaft fx,w plate/screws w/wo cerclage                 4
24530     Closed trt humeral supracondylar/transcondylar fx,w/o manip;           1
24535     Closed trt humeral supracondylar/transcondylar fx,w manip;             1
24538     Perc skel fix supracondylar/transcondylar fx,w/wo ext                  2
24545     Open trt humeral supracondylar/transcondylar fx,w/o ext                4
24546     Open trt humeral supracondylar/transcondylar fx,w/ext                  5
24560     Closed trt humeral epicondylar fx,med/lat,w/o mani                     1
24565     Trt cls humeral epicondylar fxt,medial/lateral,w/ manip                2
24566     Perc skel fix humeral epicondylar fx                                   2
24575     Open trt humeral epicondylar fx,med/lat,w/wo int/ext fix               3
24576     Closed trt humeral condylar fx,med/lat;w/o manipul                     1
24577     Closed trt humeral condylar fx,med/lat;w manipul                       1
24579     Open trt humeral condylar fx,med/lat,w/wo int/ext fix                  3
24582     Perc skel fix humeral condylar fx                                      2
24586     Open trt periarticular fx &/or/disloc elbow                            4
24587     Implant arthroplasty in 24586                                          5
24600     Trt closed elbow dislocation;w/o anesthesia                            1
24605     Trt closed elbow dislocation;req anesthesia                            2     ***
24615     Open trt acute/chronic elbow dislocation                               3
24620     Closed trt monteggia type fx dislocat elbow, w manipulation            2
24635     Open trt monteggia type fx dislocat elbow,w/wo int/ext fix             3
24640     Closed trt radial head subluxation in child,w manipulation             2
24650     Closed trt radial head/neck fx,w/o manipulation                       A
24655     Closed trt radial head/neck fx,w manipulation                          1
24665     Open trt radial head/neck fx,w/wo int fix/exc                          4
24666     Open trt radial head/neck fx;w/prosthetic replacement                  4
24670     Closed trt ulnar fx,proximal end;w/o manipulation                      1
24675     Closed trt ulnar fx,proximal end;w manipulation                        1
24685     Open trt ulnar fx proximal end,w/wo int/ext fix                        3
24800     Arthrodesis, elbow joint,w/wo autograft/allograft                      4
24802     Arthrodesis, elbow joint,w/wo autograft                                5
24925     Amputation,arm humerous,secondary closure,scar revision                3
24935     Stump elongation, upper extremity                                      7
24999     Unlisted procedure,humerus or elbow                                   U
25000     Tendon sheath incision;radial styloid for deQuervain's                 3
25001     Incision of flexor tendon sheath, wrist                                2
25020     Decompression fasciotomy,forearm/wrist,flexor extensor compartment     3
25023     Decompress fasciotomy,forearm/wrist,flexor extensor;w/debridement      3
25024     Decompression fasciotomy, forearm/wrist, w/o debridement               3
25025     Decompression fasciotomy, forearm/wrist, with debridement              3
25028     I&D,forearm/wrist;deep abscess or hematoma                             1
25031     I&D,forearm/wrist;infected bursa                                       2
25035     Incision into bone cortex, wrist/forearm                               2
25040     Arthrotomy,radiscarpal/mediocarpal,inf                                 5
25065     Bx,soft tissue of forearm/wrist;superficial                            1
25066     Bx,soft tissue of forearm/wrist;deep                                   2
25071     Exc forearm les sc > 3 cm                                              8
25073     Exc forearm tum deep = 3 cm                                            8
5101:3-2-21                                                                    Page 19 of 81

                                                              APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                   GROUP NOTE
25075     Exc forearm les sc < 3 cm                                              2
25076     Exc forearm tum deep < 3 cm                                            3
25077     Resect forearm/wrist tum<3cm                                           3
25078     Resect forearm/wrist tum=3cm                                           8
25085     Capsulotomy,wrist                                                      3
25100     Arthrotomy,wrist joint;for biopsy                                      2
25101     Arthrotomy,wrist joint;w/ exploration                                  3
25105     Arthrotomy,wrist joint;for synovectomy                                 4
25107     Arthrotomy,distal radioulnar joint;complex                             3
25109     Excision of tendon, forearm and/or wrist, flexor or extensor, each     3
25110     Excision,lesion of tendon sheath,forearm/wrist                         3
25111     Excision of ganglion wrist;primary                                     3
25112     Excision of ganglion wrist;recurrent                                   4
25115     Radi excis bursa,synovia wrist,frearm tendon sheaths;flexors           4
25116     Radi excis bursa,synovia wrist,frearm tendon sheaths;extensor          4
25118     Synovectomy,extensor tendon sheath,wrist,sngl compart                  2
25119     Synovectomy,extensor tendon sheath,wrist,sngl compart;w/res            3
25120     Excis/curet bone cyst/benign tumor of radius/ulna;                     3
25125     Excis/curet bone cyst/benign tumor radius/ulna;w/auto graft            3
25126     Excis/curet bone cyst/benign tumor radius/ulna;w/homo graft            3
25130     Excis,curet bone cyst/benign tumor carpal bones;                       3
25135     Excis,curet bone cyst/benign tmor carpal bones;w/auto graft            3
25136     Excis,curet bone cyst/benign tmor carpal bones;w/homo graft            3
25145     Sequestrectomy,forearm/wrist                                           2
25150     Partial excision of bone;ulna                                          2
25151     Partial excision of bone;radius                                        2
25170     Radical resection tumor, radius/ulna                                   3
25210     Carpectomy;one bone                                                    3
25215     Carpectomy;all bones of proximal row                                   4
25230     Radial styloidectomy                                                   4
25240     Excision distal ulna                                                   4
25246     Inj proc wrist arthrography                                            2
25248     Exploration removeal deep foreign body,forearm/wrist                   2
25250     Removal wrist prosthesis;                                              1
25251     Removal wrist prosthesis;Complicated,incl total wrist                  1
25259     Manipulation of wrist under anesthesia                                 2
25260     Repair,tendon/muscle,flexor,forearm/wrist;primary,single               4
25263     Repair,tendon/muscle,flexor,forearm/wrist;secondary,single             2
25265     Repair,tendon/muscle,flexor,forearm/wrist;secondary,w/graft            3
25270     Repair,tendon/muscle,extensor,forearm/wrist;primary,single             4
25272     Repair,tendon/muscle,extensor,forearm/wrist;secndary,single            3
25274     Repair,tendon/muscle,extensor,secondary,w/ tendon graft                4
25275     Repair tendon sheath, forearm/wrist                                    2
25280     Length/short flexor/extensor tendon,forearm/wrist,single               4
25290     Tenotomy,open,flexor/extensor tendon,forearm,wrist,single              3
25295     Tenolysis,flexor/extensor tendon,forearm,wrist,single                  3
25300     Tenodesis at wrist;flexors of fingers                                  3
25301     Tenodesis at wrist;extensors of fingers                                3
25310     Tendon transpl/transfer,flexor/extensor,forearm,wrist,sgl              3
25312     Tendon transpl/transf,flexor/extensor,frarm,wrst,sgl;w/graf            4
25315     Flexor origin slide cerebral palsy,forearm,wrist;                      3
5101:3-2-21                                                                  Page 20 of 81

                                                                APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                 GROUP NOTE
25316     Flexor origin slide cerebral palsy,frarm,wrst;w/tend transf          3
25320     Capsulorrhaphy/reconst,capsulectomy,wrist                            3
25332     Arthroplasty, wrist,pseudoarthrosis type w int fixation              5
25335     Centralization of wrist on ulna                                      3
25337     Reconstruct ulna/radioulnar                                          3
25350     Osteotomy, radius, distal third                                      3
25355     Osteotomy, radius, middle or proximal third                          3
25360     Osteotomy, ulna                                                      3
25365     Osteotomy, radius and ulna                                           3
25370     Multiple osteotomies, radius or ulna                                 3
25375     Multiple osteotomies, radius and ulna                                4
25390     Osteiplasty,radius OR ulna;shortening                                3
25391     Osteiplasty,radius OR ulna;length w. auto bone graft                 4
25392     Osteoplasty,radius & ulna;shortening                                 3
25393     Osteoplasty,radius & ulna;Length w. auto bone graft                  4
25394     Osteoplasty of carpal bone                                           2
25400     Repair nonunion radius or ulna w/o graft                             3
25405     Repair nonunion radius or ulna w iliac/other autograft               4
25415     Repair nonunion radius and ulna w/o graft                            3
25420     Repair nonunion radius and ulna w iliac/other autograft              4
25425     Repair defect w autograft,radius,ulna                                3
25426     Repair defect w autograft,radius & ulna                              4
25430     Vascular pedicle graft for carpal bone                               2
25431     Repair of nonunion carpal bone                                       2
25440     Repair nonunion scaphoid,w/wo radial styloidectomy                   4
25441     Arthroplasty w prosthetic replacement distal radius                  5
25442     Arthroplasty w prosthetic replacement distal ulna                    5
25443     Arthroplasty w prosthetic replacement distal scaphoid                5
25444     Arthroplasty w prosthetic replacement distal lunate                  5
25445     Arthroplasty w prosthetic replacement distal trapezium               5
25446     Arthroplasty w prosthetic replacement distal radius & carpus         7
25447     Interposition arthroplasty, intercarpal/carpometacarpal joints       5
25449     Revision arthroplasty incl removal implant,wrist                     5
25450     Epiphyseal arrest by epiphysiode/stapl;dista radius or ulna          3
25455     Epiphyseal arrest by epiphysiode/stapl;dista radiu and ulna          3
25490     Prophylactic trt w/w/o methyl methacrylate;radius                    3
25491     Prophylactic trt w/w/o methyl methacrylate;ulna                      3
25492     Prophylactic trt w/w/o methyl methacrylate;radiu & ulna              3
25500     Closed trt radial shaft fx;w/o manipulation                         A
25505     Closed trt radial shaft fx;w manipulation                            1
25515     Open trt radial shaft fx,w/wo int/ext fix                            3
25520     Closed trt radial shaft fx w disloc distal joint                     1
25525     Open trt radial shaft fx w int/ext fix                               4
25526     Open trt radial shaft fx w int/ext fix,w/wo percutaneous fix         5
25530     Closed trt ulnar shaft fx;w/o manipulation                          A
25535     Closed trt ulnar shaft fx;w manipulation                             1
25545     Open trt ulnar shaft fx,w/wo int/ext fix                             3
25560     Closed trt radial/ulnar shaft fx;w/o manipulation                   B
25565     Closed trt radial/ulnar shaft fx;w manipulation                      2
25574     Open trt radial/ulnar shaft fx, int/ext fix radius or ulna           3
25575     Open trt radial/ulnar shaft fx,w int/ext fix radius and ulna         3
5101:3-2-21                                                                                                Page 21 of 81

                                                              APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                                               GROUP NOTE
25600     Closed trt distal radial fx/epiphyseal separat;w/o manipula                                       B
25605     Closed trt distal radial fx/epiphyseal separat;w manipula                                          3
25606     Percutaneous skeletal fixation of distal radial fracture or epiphyseal separation                  3
25607     Open treatment, distal radial extra-articular fracture with internal fixation                      5
25608     Open treatment, distal radial intra-articular fracture; internal fixation, 2 fragments             5
25609     Open treatment, distal radial intra-articular fracture; internal fixation, 3 or more fragments     5
25622     Closed trt carpal scaphoid fx;w/o manipulation                                                    A
25624     Closed trt carpal scaphoid fx;w manipulation                                                       2
25628     Open trt carpal scaphoid fx,w/wo int/ext fix                                                       3
25630     Closed trt carpal bone fx;w/o manip,each bone                                                     B
25635     Closed trt carpal bone fx;w manip,each bone                                                        1
25645     Open trt carpal bone fx,each bone                                                                  3
25650     Closed trt ulnar styloid fx                                                                        1
25651     Percutaneous skeletal fixation of ulnar styloid fracture                                           2
25652     Open treatment of ulnarstyloid fracture                                                            3
25660     Closed trt radiocarpal/intercarpal disloc,w/ manipulat                                             1
25670     Open trt radiocarpal/intercarpal disloc 1 or> bones                                                3
25671     Percutaneous skeltion fixation of distal radioulnar dislocation                                    2
25675     Closed trt distal radioulnar disloc w manipulat                                                    1
25676     Open trt distal radioulnar disloc,acute/chronic                                                    2
25680     Closed trt trans-scaphoperilunar type fx disloc, w manip                                           2
25685     Open trt trans-scaphoperilunar type fx disloc                                                      3
25690     Closed trt lunate disloc,w/manipulation                                                            1
25695     Open trt lunate dislocation                                                                        2
25800     Arthrodesis,wrist joint,w/o bone graft                                                             4
25805     Arthrodesis,wrist joint,w sliding graft                                                            5
25810     Arthrodesis,wrist joint,w iliac/other autograft                                                    5
25820     Intercarpal fusion w/o bone graft                                                                  4
25825     Intercarpal fusion w autograft                                                                     5
25830     Fusion radioulnar joint/ulna                                                                       3
25907     Amputation forearm thru radius/ulna, secondary closure                                             3
25922     Disarticulation thru wrist, secondary closure                                                      3
25929     Transmetacarpal amputation, secondary closure                                                      3
25931     Amputation follow-up surgery                                                                       3
25999     Unlisted procedure,forearm or wrist                                                               U
26010     Drainage finger abscess;simple                                                                    A
26011     Drainage finger abscess;complicated                                                                1
26020     Drainage tendon sheath,one digit and/or palm                                                       2
26025     Drainage palmar bursa;single,ulnar or radial                                                       1
26030     Drainage palmar bursa;multiple or complicated                                                      2
26034     Incision,deep,w/opening of bone cortex,hand/finger                                                 2
26035     Decompression fingers and/or hand,inj injury                                                       4
26037     Decompressive fasciotomy, hand(exclude 26035)                                                      4
26040     Fasciotomy,palmar,for Dupuytren's contracture;closed                                               4
26045     Fasciotomy,palmar,for Dupuytren's contracture;open,partial                                         3
26055     Tendon sheath incision for trigger finger                                                          2
26060     Tenotomy,subQ,single,each digit                                                                    2
26070     Arthrotomy,infect,explor,drain/remov;carpometacarpal joint                                         2
26075     Arthrotomy,infect,explor,drain/remov;metacarpophalangeal joint                                     4
26080     Arthrotomy,infect,explor,drain/remov;interphalangeal joint,each                                    4
26100     Arthrotomy synovial bx carpometacarpal joint                                                       2
5101:3-2-21                                                                Page 22 of 81

                                                              APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                               GROUP NOTE
26105     Arthrotomy synovial bx;metacarpophalangeal joint                   1
26110     Arthrotomy synovial bx;interphalangeal joint,each                  1
26111     Exc hand les sc > 1.5 cm                                           8
26113     Exc hand tum deep > 1.5 cm                                         8
26115     Exc hand les sc < 1.5 cm                                           2
26116     Exc hand tum deep < 1.5 cm                                         2
26117     Exc hand tum ra < 3 cm                                             3
26118     Exc hand tum ra > 3 cm                                             8
26121     Fasciectomy,palmer only w/wo zplasty,skin grafting                 4
26123     Partial palmar excision w release of single digit                  4
26125     partial palmar excision w release each additional digit            4
26130     Synovectomy,carpometacarpal joint                                  3
26135     Synovectomy,metacarpophalangeal joint,each digit                   4
26140     Synovectomy,proximal interphalangeal jnt,incl exten reconst        2
26145     Synovectomy,proximal interphalangeal jnt,incl exten reconst        3
26160     Excision lesion tendon sheath or capsule,hand or finger            3
26170     Excision tendon,palm,flexor,sgl,each                               3
26180     Excision tendon,finger,flexor                                      3
26185     Sesamoidectomy of thumb or finger                                  3
26200     Excision/curettage bone cyst/benign tumor metacarpal               2
26205     Excis/curet bone cyst/benign tumor metacarpal;w/ auto graft        3
26210     Exci/curret bone cyst/bgn tumor proximal,mid/distal phalanx        2
26215     Excis/curret cyst/bgn tumor proximal,phalanx,w/ auto graft         3
26230     Partial excision of bone;metacarpal                                7
26235     Partial excision of bone;prominal/middle phalanx of finger         3
26236     Partial excision of bone;distal phalanx of finger                  3
26250     Radical resection for tumor, metacarpal;                           3
26260     Radical resection for tumor,proximal/mid phalanx of finger         3
26262     Radical resection for tumor,distal phalanx of finger               2
26320     Removal implant from finger/hand                                   2
26340     Manipulation of finger joint under anestheia                       1
26350     Flexor tendon repair/advancement,single,w/o free graft             1
26352     Flexor tendon repair/advancement;secondary w/free graft            4
26356     Flexor tendon repair/advancement,single;primary                    4
26357     Flexor tendon repair/advancement,single;secondary                  4
26358     Flexor tendon repair/advancement,sgl;second w/free graft           4
26370     Profundus tendon repair/advance,w/ intact sublimis;primary         4
26372     Profundus tendon repair,w/intact sublimis;sec w/free graft         4
26373     Profundus tendon repair,w/intact sublimis;sec w/ofree graft        3
26390     Flexor tendon excis,implant tube/rod,tendon graft,hand/fing        4
26392     Removal tube/rod;insertion tendon graft,hand/fing                  3
26410     Extensor tendon repair,dorsum hand,sgl;w/o free graft              3
26412     Extensor tendon repair,dorsum hand,sgl;w/ free graft               3
26415     Excision extenson tendon,implantation tube                         4
26416     Removal tube,insertion tendon graft                                3
26418     Extensor tendon repair,dorsum finger,sgl,w/o free graft            4
26420     Extensor tendon repair,dorsum finger,sgl,w/ free graft             4
26426     Extensor tendon repair,central slip repair,sec;use loc tiss        3
26428     Extensor tendon repair,central slip repair,sec;w/free graft        3
26432     Extensor tendon repair,distal insert,closed,splinting              3
26433     Extensor tendon repair,open,hand/finger;w/o graft                  3
5101:3-2-21                                                                 Page 23 of 81

                                                               APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                GROUP NOTE
26434     Extensor tendon repair,open,hand/finger;w/ graft                    3
26437     Extensor tendon realignment,hand                                    3
26440     Tenolysis,simple,flexor tendon;palm/finger,single                   3
26442     Tenolysis,simple,flexor tendon;palm&finger                          3
26445     Tenolysis,extensor tendon,dorsum hand/finger;each tendon            3
26449     Tenolysis,compl,extensor tendon,dorsum hand/fing                    3
26450     Tenotomy,flexor,single,palm,open,each                               3
26455     Tenotomy,flexor,single,finger,open,each                             3
26460     Tenotomy,extensor,hand or finger,single,open                        3
26471     Tenodesis;proximal interphalangeal joint stabilization              2
26474     Tenodesis;for distal joint stabilization                            2
26476     Tendon lengthening,extensor,hand/finger,single                      1
26477     Tendon shortening,extensor,hand/finger,single                       1
26478     Tendon lengthening,flexor,hand/finger,single                        1
26479     Tendon short,flexor,hand/finger,single                              1
26480     Tendon transf/transp,carpometacarpal/dorsum,sgl;w/o graft           3
26483     Tendon transf/transp,carpometacarpal/dorsum,sgl;w/ graft            3
26485     Tendon transf/transp,palmar,sgl;w/o free graft                      2
26489     Tendon transf/transp,palmar,sgl;w/ free graft                       3
26490     Opponens plasty;sublimis tendon transfer type                       3
26492     Opponens plasty;tendon transfer w graft                             3
26494     Opponens plasty;hypothenar muscle transfer                          3
26496     Opponens plasty;other methods                                       3
26497     Tendon tranf;restore intrinsic funct;ring&small finger              3
26498     Tendon tranf;restore intrinsic funct;4 fingers                      4
26499     Correction claw finger,other methods                                3
26500     Tendon pulley reconstruct;w/local tissues                           4
26502     Tendon pulley reconstruct;w/tendon/fascial graft                    4
26508     Thenar muscle release;thumb contracture                             3
26510     Cross intrinsic transfer                                            3
26516     Capsulodesis for M-P joint stabilization;sgl digit                  1
26517     Capsulodesis for M-P joint stabilization;Two digits                 3
26518     Capsulodesis for M-P joint stabilization;3/4digits                  3
26520     Capsulectomy/capsulotomy;metacarpophalangeal jnt,sgl                3
26525     Capsulectomy/capsulotomy;interphalangeal joint,single               3
26530     Arthroplasty,metacarpophalangeal joint;single,each                  3
26531     Arthroplasty,metacarpophalangeal jnt;prosthetic implnt,sgl          7
26535     Arthroplasty interphalangeal joint;single,each                      5
26536     Arthroplasty interphalangeal joint;w/prosthetic implant,sgl         5
26540     Repair collateral ligament,metacarpophalangeal jnt;                 4
26541     Repair collateral ligament,metacarpophalangeal jnt;graft            7
26542     Repair collateral ligament,metacarpophalangeal jnt;loc tiss         4
26545     Reconst,collateral ligament,interphalangeal jnt,sgl,graft           4
26546     Repair of metacarpal or phalanx non-union                           4
26548     Repair & reconstruct,finger,volar plate,interphalangeal jnt         4
26550     Pollicization of a digit                                            2
26551     Microvascular toe-to-hand transfer                                  4
26553     Microvascular toe-to-hand transfer                                  4
26554     Microvascular toe-to-hand transfer                                  4
26555     Positional change of other finger                                   3
26556     Microvascular toe joint transfer                                    4
5101:3-2-21                                                                     Page 24 of 81

                                                              APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                    GROUP NOTE
26560     Repair syndactyly, ea space, skin flaps                                 2
26561     Repair syndactyly, skin flaps and grafts                                3
26562     Repair syndactyly complex, bone/nails                                   4
26565     Osteotomy deformity, metacarpal                                         5
26567     Osteotomy for correction of deformity;phalanx of finger                 5
26568     Osteoplasty for lengthing of metacarpal or phalanx                      3
26580     Repair cleft hand                                                       5
26587     Repair supernumerary digit, soft tissue & bone                          5
26590     Repair macrodactylia                                                    5
26591     Repair intrinsic muscles of hand                                        3
26593     Release intrinsic muscles of hand                                       3
26596     Excis of constricting ring of finger,w/multiple Z-plasties              2
26600     Closed trt metacarpal fx, single,w/o manipulation, ea bone             A
26605     Closed trt metacarpal fx, single,w manipulation, ea bone                2
26607     Closed trt metacarpal fx,sgl w/manip,int/ext fix,ea bone                2
26608     Percutaneous skeletal fix metacarpal fx,ea bone                         3
26615     Open trt metacarpal fx,sgl,w/wo int/ext fix,ea bone                     4
26641     Closed trt carpometacarpal dislocation,thumb,w manip                   B
26645     Closed trt carpometacarpal fx disloc,thumb,w manip                      1
26650     Percutaneous skeletal fix carpometacarpal fx,w manip;w/wo ext fix       2
26665     Open trt carpometacarpal fx disloc,w/wo int/ext fix                     4
26670     Closed trt carpometacarpal disloc,sgl manip;w/o anesthesia              1
26675     Closed trt carpometacarpal disloc,sgl manip;req anesthesia              2     ***
26676     Percutaneous skeletal fix carpometacarpal disloc,sgl,w manip            2
26685     Open trt carpometacarpal disloc;sgl,w/wo int/ext fix                    3
26686     Open trt carpometacarpal disloc;complex,mult delay reduct               3
26700     Closed trt metacarpophalangeal disloc,sgl,manip;w/o anesthesia         A
26705     Closed trt metacarpophalangeal disloc,sgl,manip;req anesthesia          2     ***
26706     Percutaneous skeletal fix metacarpophalangeal disloc,sgl,manip          2
26715     Open trt metacarpophalangeal disloc,sgl,w/wo int/ext fix                4
26720     Closed trt phalangeal shaft fx,proximal/mid phalanx,w/o manip.         A
26725     Closed trt phalangeal shaft fx,proximal/mid phalanx,w manip.           B
26727     Percutaneous skeletal fix unstable phalangeal shaft fx,w manip each     7
26735     Open trt phalangeal shaft fx,proximal/mid phalanx,w/wo ext/int fix      4
26740     Closed trt articular fx,w/o manipulation,each                          A
26742     Trt cls articular fx,metacarpo/interphalangeal jnt,manip                2
26746     Open trt articular fx,metacarpo/interphalangeal jnt,ea                  5
26750     Closed trt distal phalangeal fx,w/o manipulation                       A
26755     Closed trt distal phalangeal fx,w manipulation                         B
26756     Percutaneous skeletal fix distal phalangeal fx,finger/thumb             2
26765     Open trt distal phalangeal fx,finger/thumb,w/wo int/ext fix             4
26770     Closed trt interphalangeal jnt disloc,sgl,manip;w/o anesthesia         B
26775     Closed trt interphalangeal jnt disloc,sgl,manip;req anesthesia          1     ***
26776     Percutaneous skeletal fix interphalangeal jnt disloc,sgl,manip          2
26785     Open trt interphalangeal jnt disloc,w/wo int/ext fix,sgl                2
26820     Fusion in opposition,thumb,w/ autogenous graft                          5
26841     Arthrodesis carpometacarpal joint, thumb                                4
26842     Arthrodesis,carpometacarpal jnt,thumb,fixat;autogenus graft             4
26843     Arthrodesis,carpometacarpal jnt,digits,o.t. thumb;                      3
26844     Arthrodesis,carpometacarpal jnt,digits,o.t.thumb;auto graft             3
26850     Arthrodesis,metacarpophalangeal jnt;                                    4
5101:3-2-21                                                                  Page 25 of 81

                                                             APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                 GROUP NOTE
26852     Arthrodesis,metacarpophalangeal jnt;autogenous graft                 4
26860     Arthrodesis,interphalangeal joint;                                   3
26861     Arthrodesis,interphalangeal jnt;ea add interphalangeal jnt           2
26862     Arthrodesis,interphalangeal joint;w/ autogenous graft                4
26863     Arthrodesis,interphalangeal jnt;autogenous graft,ea add jnt          3
26910     Amputation,metacarpal,w/ finger or thumb,sgl                         3
26951     Amputation finger/thumb with direct closure                          2
26952     Amputat,finger/thumb,any jnt or phalanx,sgl;direct cls               4
26989     Unlisted procedure                                                  U
26990     I&D pelvis/hip joint, deep abscess                                   1
26991     I&D,pelvis/hip jnt area;deep abscess/hematoma                        1
26992     I&D opening bone cortex, pelvis/hip                                  2
27000     Tenotomy,adductor hip,subcutaneous,cls                               2
27001     Tenotomy,adductor hip,subcutaneous,open                              3
27003     Tenotomy,adductor,subcut,open obturator neurectomy                   3
27005     Tenotomy, iliopsoas, open                                            3
27006     Tenotomy, abductors hip, open                                        3
27025     Fasciotomy, hip/thigh, any type                                      5
27027     Fasciotomy, buttock, unilateral                                      3
27030     Arthrotomy,hip,infection,w drg                                       3
27033     Arthrotomy,hip,exploration/remov loose foreign body                  3
27035     Hip jnt denervation,intra-articular branches nerves                  4
27036     Release of hip flexion contracture                                   4
27040     Biopsy,soft tissue pelvis/hip area;superficial                       1
27041     Biopsy, pelvis/hip deep                                              2
27043     Exc hip pelvis les sc > 3 cm                                         8
27045     Exc hip/pelv tum deep > 5 cm                                         8
27047     Excision, tumor pelvis/hip SubQ                                      2
27048     Bx,sft tis pelvis&hip area;deep subfascial,intramuscula              3
27049     Radical resection tumor soft tissue pelvis/hip                       3
27050     Arthrotomy,biopsy;sacroiliac joint                                   3
27052     Arthrotomy,biopsy;hip joint                                          3
27054     Arthrotomy,synovectomy, hip joint                                    3
27057     Fasciotomy, buttock, with debridement, unilateral                    3
27059     Resect hip/pelv tum > 5 cm                                           8
27060     Excision;ischial bursa                                               5
27062     Excision;trochanteric bursa/calcification                            5
27065     Excision bone cyst/benign tumor;superficial                          5
27066     Excision bone cyst/benign tumor;deep                                 5
27067     Excision bone cyst/benign tumor;w/ bone graft                        5
27070     Partial excision;superficial                                         4
27071     Partial excision;deep                                                5
27080     Coccygectomy,primary                                                 2
27086     Remov foreign body,pelvis/hip;subcutaneous tissue                    1
27087     Removal foreign body, pelvis/hip deep                                3
27090     Removal hip prosthesis                                               3
27093     Inj proc hip arthrography;w/o anesthesia                            A
27095     Inj proc hip arthrography;w/anesthesia                               1     ***
27096     Inj proc sacroiliac joint, arthography and/or anesthetic/steroid    B
27097     Hamstring recession, proximal                                        3
27098     Abductor transfer to ischium                                         3
5101:3-2-21                                                                                        Page 26 of 81

                                                            APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                                       GROUP NOTE
27100     Transfer ext oblique muscle great trochanter                                               4
27105     Transfer paraspinal muscle to hip                                                          4
27110     Transfer iliopsoas to great torchanter                                                     4
27111     Transfer iliopsoas to femoral neck                                                         4
27187     Prophylactic trt femoral neck/proximal femur                                               3
27193     Closed trt pelvic ring fx,w/o manipulation                                                 1
27194     Closed trt pelvic ring fx,w manipulation,req anesthesia                                    2
27200     Closed trt coccygeal fracture                                                             B
27202     Open trt coccygeal fracture                                                                2
27215     Treat pelvic fracture(s)                                                                   7
27216     Treat pelvic ring fracture                                                                 2
27220     Closed treatment of acetabulum (hip socket) fracture(s); without manipulation             A
27230     Closed trt femoral fx,proximal neck w/o manipulation                                       1
27232     Closed trt femoral fx,proximal neck,w manip,w/wo skeletal tx                               1
27235     Percutaneous skeletal fixation of femoral fracture, proximal end, neck                     3
27238     Closed trt intertrochanteric femoral fx w/o manipulation                                   1
27240     Closed trt intertrochanteric femoral fx,w manip,w/wo skeletal tx                           1
27246     Closed trt gr trochanteric fx w/o manipulation                                             1
27250     Closed trt hip dislocation,traumatic w/o anesthesia                                        1
27252     Closed trt hip dislocation,traumatic,req anesthesia                                        2     ***
27256     Trt spont hip dislocat,splint/tx;w/o manip,w/o anesthesia                                 B
27257     Trt spont hip dislocat,splint/tx;w manip,req anesthesia                                    1     ***
27265     Closed trt post hip arthroplasty dislocation, w/o anesthesia                               1
27266     Closed trt post hip arthroplasty dislocation,req anesthesia                                2     ***
27267     Cltx thigh FX                                                                             A
27275     Manipulation,hip jnt,req general anesthesia                                                2     ***
27299     Unlisted procedure pelvis/hip joint                                                       U
27301     I&D deep abscess,inf bursa/hematoma,thigh/knee                                             3
27303     I&D deep into bone cortex, femur/knee                                                      2
27305     Fasciotomy iliotibial, open                                                                2
27306     Tenotomy,subQ,cls,adductor/hamstring;single                                                3
27307     Tenotomy,subQ,cls,adductor/hamstring;multiple                                              3
27310     Arthrotomy,knee,inf,explore,drain foreign body                                             4
27323     Bx,soft tissue thigh/knee area;superficial                                                 1
27324     Bx soft tissue knee/thigh deep                                                             1
27325     Neurectomy, hamstring muscle                                                               2
27326     Neurectomy, popliteal (gastrocnemius)                                                      2
27327     Excision,tumor,thigh/knee area;subQ                                                        2
27328     Exc,tumor,thigh/knee area;deep,subfascial,intramuscular                                    3
27329     Radical resection of tumor (eg. malignant neoplasm), soft tissue of thigh or knee area     3
27330     Arthrotomy,knee;synovial bx only                                                           4
27331     Arthrotomy with joint exploration                                                          4
27332     Arthrotomy knee excision semilunar cartilage                                               4
27333     Arthrotomy knee medial/lateral                                                             4
27334     Arthrotomy knee synovectomy ant or post                                                    4
27335     Arthrotomy knee ant&post                                                                   4
27337     Exc thigh/knee les sc > 3 cm                                                               8
27339     Exc thigh/knee tum deep >5cm                                                               8
27340     Excision prepatellar bursa                                                                 3
27345     Excision synovial cyst popliteal space                                                     4
27347     Excision of lesion of meniscus or capsule, knee                                            4
5101:3-2-21                                                                                Page 27 of 81

                                                              APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                               GROUP NOTE
27350     Patellectomy/hemipatellectomy                                                      4
27355     Excis curettage bone cyst/benign tumor femur                                       3
27356     Excis/curet bone cyst/benign tumor femur;homo graft                                4
27357     Excis/curet bone cyst/benign tumor femur;auto graft                                5
27358     Excis/curet bone cyst/benign tumor femur;inter fixat                               5
27360     Partial excision bone,femur,proximal tibia/fibula                                  5
27364     Resect thigh/knee tum >5 cm                                                        8
27370     Inj proc knee arthrography                                                        A
27372     Removal foreign body deep thigh/knee                                               7
27380     Suture infrapatellar tendon;primary                                                1
27381     Infrapetellar tendon, secondary reconstruction incl graft                          3
27385     Suture quadriceps/hamstring muscle rupture;primary                                 3
27386     Suture quadriceps/hamstring muscle rupture;secondary                               3
27390     Tenotomy,open,hamstring,knee to hip;single                                         1
27391     Tenotomy,open,hamstring,knee to hip;mult,one leg                                   2
27392     Tenotomy,open,hamstring,knee to hip;mult,bilateral                                 3
27393     Lengthening hamstring tendon to patella;single                                     2
27394     Lengthening hamstring tendon to patella;mult,one leg                               3
27395     Lengthening hamstring tendon to patella;mult,bilateral                             3
27396     Transplant,hamstring tendon to patella;single                                      3
27397     Transplant,hamstring tendon to patella;multiple                                    3
27400     Tendon/muscle transfer,hamstring to femur;                                         3
27403     Arthrotomy with open meniscus repair                                               4
27405     Repair primary torn ligament/capsule knee, collateral                              4
27407     Repair primary torn ligament knee, cruciate                                        4
27409     Repair primary torn ligament knee, collateral & cruciate                           4
27412     Autologous chondrocyte implantation knee                                           6
27415     Osteochondral allograft, knee, open                                                5
27416     Osteochondral knee autograft                                                       5
27418     Ant tibial tubercle plasty;chondromalacia patellae                                 3
27420     Reconstruction recurrent dislocating patella;                                      3
27422     Reconstr recurrent dislocating patella;realignment/advancem                        7
27424     Reconstr for recurrent dislocating patella;w/patellectomy                          3
27425     Lateral retinacular release                                                        7
27427     Ligamentous reconstruction, knee, extra-articular                                  3
27428     Ligamentous reconstruction knee, intra-articular                                   4
27429     Ligamentous reconstruction intra&extra articular                                   4
27430     Quadriceps plasty                                                                  4
27435     Capsulotomy,knee,posterior capsular release                                        4
27437     Arthroplasty,patella w/o prosthesis                                                4
27438     Arthroplasty,patella w prosthesis                                                  5
27440     Arthroplasty,knee tibial plateau                                                   5
27441     Arthroplasty,knee tibial plateau debridement/part synovectomyu                     5
27442     Arthroplasty knee,femoral condyles/tibial plateaus                                 5
27443     Arthroplasty knee,femoral condyles/tibial plateaus w debridement                   5
27470     Repair malunion femur w/o graft                                                    4
27475     Arrest, epiphyseal, any method (eg. epiphysiodesis); distal femur                  3
27479     Surgery to stop leg growth                                                         4
27495     Prophylactic trt w/wo methyl methacrylate,femur                                    5
27496     Decompression fasciotomy, thigh and/or knee, one compartment                       3
27497     Decompression fasciotomy, thigh and/or knee, one compartment; with debridement     3
5101:3-2-21                                                                     Page 28 of 81

                                                               APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                    GROUP NOTE
27498     Decompression of thigh/knee                                             4
27499     Decompression of thigh/knee                                             4
27500     Closed trt femoral shaft fx. w/o manipulation                           1
27501     Closed trt supra/transcondylar femoral fx,w/o manipulation              2
27502     Closed trt femoral shaft fx,w manip,w/wo skeletal tx                    2
27503     Closed trt supra/transcondylar femoral fx,w manipulation                3
27506     Open trt femoral shaft fx,w/w/o ext fix,w/wo cerclage                   4
27507     Open trt femoral shaft fx,w plate/screws,w/wo cerclage                  4
27508     Closed trt femoral fx, distal end w/o manipulation                      1
27509     Perc skel fix femoral fx,distal end,supra/transcondylar femoral fx      3
27510     Closed trt femoral fx, distal end w manipulation                        1
27511     Open trt femoral supra/transcondylar fx,w/o intercondylar extension     4
27513     Open trt femoral supra/transcondylar fx,w intercondylar extension       5
27514     Open trt femoral fx,distal end w/wo ext/int fixation                    4
27516     Closed trt distal femoral epiphyseal separation w/o manipulation        1
27517     Closed trt distal femoral epiphyseal separation w manipulation          1
27520     Closed trt patellar fx w/o manipulation                                 1
27524     Open trt patellar fx,w int fix,patellectomy soft tissue repair          3
27530     Closed trt tibial fx,proximal;w/o manipulation                          1
27532     Closed trt tibial fx,proximal;w/o manipulation,w skeletal tx            1
27535     Open trt fibial fx,proximal unicondylar,w/wo int/ext fix                3
27536     Open trt tibial fx, bicondylar,w/w/o fixation                           4
27538     Closed trt intercondylar spine fx knee,w/wo manipulation                1
27540     Open trt intercondylar spine fx knee,w/wo int/ext fix                   2
27550     Closed trt knee dislocation;w/o anesthesia                              1
27552     Closed trt knee dislocation;w anesthesia                                1     ***
27556     Open trt knee disloc,w/o primary ligamentous repair/reconstruction      2
27557     Open trt knee disloc,w primary ligamentous repair                       3
27558     Open trt knee disloc,w primary ligamentous repair/reconstruction        4
27560     Closed trt patellar dislocation;w/o anesthesia                          1
27562     Closed trt patellar dislocation;w anesthesia                            1     ***
27566     Open trt patellar dislocation,w/wo patellectomy                         2
27570     Manipulation knee joint under gen anesthesia                            1     ***
27594     Amputation follow-up surgery                                            3
27599     Unlisted procedure,femur or knee                                       U
27600     Decompression fasciotomy,leg,ant/lat compartmnt only                    4
27601     Decompression fasciotomy,leg,post compartmnt only                       4
27602     Decompression fasciotomy,leg,ant/lat/post compartmnt                    4
27603     I&D,leg/ankle;deep abscess/hematoma                                     2
27604     I&D,leg/ankle;infected bursa                                            2
27605     Tenotomy,achilles tendon,subQ;local anesthesia                          1     ***
27606     Tenotomy,achilles tendon,subQ;gen anesthesia                            1     ***
27607     Incision,deep,w/opening bone cortex,leg/ankle                           2
27610     Arthrotomy,ankle,inf w/explorat,drain/remov foreign body                2
27612     Arthrotomy,ankle,post capsular release                                  3
27613     Bx,soft tissue leg/ankle area;superficial                               1
27614     Bx,soft tissue leg/ankle area;deep                                      2
27615     Resect leg/ankle tum < 5 cm                                             3
27616     Resect leg/ankle tum > 5 cm                                             8
27618     Exc leg/ankle tum < 3 cm                                                2
27619     Exc leg/ankle tum deep <5 cm                                            3
5101:3-2-21                                                                   Page 29 of 81

                                                                 APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                  GROUP NOTE
27620     Arthrotomy,ankle,biopsy                                               4
27625     Arthrotomy,ankle,synovectomy                                          4
27626     Arthrotomy,ankle,synovectomy;incl tenosynovectomy                     4
27630     Excis lesion tendon sheath/capsule,leg/ankle                          3
27632     Exc leg/ankle les sc > 3 cm                                           8
27634     Exc leg/ankle tum deep >5 cm                                          8
27635     Excis/curet bone cyst/benign tumor,tibia/fibula;                      3
27637     Excis bone cyst/benign tumor,tibia/fibula;autogen graft               3
27638     Excis bone cyst/benign tumor,tibia/fibula;homogen graft               3
27640     Partial excis bone;tibia                                              2
27641     Partial excis bone;fibula                                             2
27647     Radical resection of tumor, talus or calcaneus                        6
27648     Inj proc ankle arthrography                                          A
27650     Repair,primary,open/percutaneous,ruptured achilles tendon             3
27652     Repair,prim,opn/percutaneous,ruptured achilles tendon;graft           3
27654     Repair,secondary,ruptured achilles tendon,w/w/o graft                 3
27656     Repair,fascial defect;leg                                             2
27658     Repair suture flexor tendon;leg;primary,w/o graft,sgl,ea              1
27659     Repair suture flexor tendon;leg;secondary,sgl tendon,ea               2
27664     Repair suture extensor tendon leg;primary,w/o graft,sgl,ea            2
27665     Repair suture extensor tendon;leg;secondry,sgl tendon,ea              2
27675     Repair dislocatng peroneal tendons,w/o fibular osteotomy              2
27676     Repair dislocat peroneal tendons,w/fibular osteotomy                  3
27680     Tenolysis,incl tibia,fibula/ankle flexor;single                       3
27681     Tenolysis,incl tibia,fibula/ankle flexor;multiple,ea                  2
27685     Lengthening/shortening tendon,leg/ankle;single                        3
27686     Lengthening/shortening tendon,leg/ankle;mult,ea                       3
27687     Gastrocnemius recession                                               3
27690     Transfer/transplant single tendon;superficial                         4
27691     Transfer/transplant sgl tendon;anterior/posterior tibial              4
27692     Transfer/transplant sgl tendon;each addl tendon                       3
27695     Suture,prim,torn,ruptured,severed ligament,ankle;collateral           2
27696     Suture,prim,torn,ruptur,sever ligament,ankle;both collatera           2
27698     Suture,second repair,torn,severed ligament,ankle collateral           2
27700     Arthroplasty, ankle                                                   5
27704     Removal of ankle implant                                              2
27705     Osteotomy;tibia                                                       2
27707     Osteotomy;fibula                                                      2
27709     Osteotomy;tibia and fibula                                            2
27712     Osteotomy, multiple with realignment                                  5
27715     Osteotomy,tibia/fibula;lengthen                                       4
27720     Repair nonuntion tibia w/o graft                                      3
27722     Repair/graft of tibia                                                 7
27724     Repair of nonunion or malunion, tibia; w/ autograft                   4
27726     Repair fibula nonunion                                                3
27730     Ephyseal arrest;epiphysiodesis;distal tibia                           2
27732     Ephyseal arrest;epiphysiodesis;distal fibula                          2
27734     Ephyseal arrest;epiphysiodesis;distal tibia/fibula                    2
27740     Ephyseal arrest;epiphysiodesis;prox/distal tibia/fibula               2
27742     Ephyseal arrest;epiphysiodesis;prox/distal tibia/fibula/femur         2
27745     Prophylactic trt tibia                                                3
5101:3-2-21                                                                            Page 30 of 81

                                                                 APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                           GROUP NOTE
27750     Closed trt tibial shaft fx;w/o manipulation                                    1
27752     Closed trt tibial shaft fx;w manipulation,w/wo skeletal tx                     1
27756     Percutaneous skeletal fix tibial shaft fx                                      3
27758     Open trt tibial shaft fx,w plate/screws,w/wo cerclage                          4
27759     Open trt tibial shaft fx,intramedullary implant                                4
27760     Closed trt medial malleolus fx;w/o manipulation                                1
27762     Closed trt medial malleolus fx;w manipulation,w/wo skin tx                     1
27766     Open trt medial malleolus fx,w/wo int/ext fixation                             3
27767     Cltx post ankle FX                                                            A
27768     Cltx post ankle FX w/ MNPJ                                                    A
27769     Optx post ankle FX                                                             5
27780     Closed trt proximal fibula/shaft fx;w/o manipula                               1
27781     Closed trt proximal fibula/shaft fx;w manipula                                 1
27784     Open trt proximal fibula/shaft fx,w/wo ext/int fix                             3
27786     Closed trt distal fibular fx;w manipulation                                    1
27788     Closed trt distal fibular fx;w/o manipulation                                  1
27792     Open trt distal fibular fx,w/wo int/ext fixation                               3
27808     Closed trt bimalleolar ankle fx;w/o manipulation                               1
27810     Trt closed bimalleolar ankle fx;w/manipulation                                 1
27814     Open trt bimalleolar ankle fx,w/wo int/ext fix                                 3
27816     Closed trt trimalleolar ankle fx;w/o manipulation                              1
27818     Closed trt trimalleolar ankle fx;w manipulation                                1
27822     Open trt trimalleolar ankle fx;w/o fix post lip                                3
27823     Open trt trimalleolar ankle fx;w fix post lip                                  3
27824     Closed trt wt bear articular portion distal tibia,w/o manipulation             1
27825     Closed trt wt bear articular portion distal tibia,w manipulation               2
27826     Open trt wt bear articular portion distal tibia,w int/ext fix fibula           3
27827     Open trt wt bear articular portion distal tibia,w int/ext fix tibia            3
27828     Open trt wt bear articular portion distal tibia,w int/ext fix tibia/fibula     4
27829     Open trt distal tibiofibular joint,w/wo int/ext fix                            2
27830     Closed trt proximal tibiofibullar jnt dislocat;w/o anesthesia                  1
27831     Closed trt proximal tibiofibullar jnt dislocat;req anesthesia                  1     ***
27832     Open trt proximal tibiofibular jnt dislocat,w/wo int/ext fix                   2
27840     Closed trt ankle dislocation;w/o anesthesia                                    1
27842     Closed trt ankle dislocation;req anesthesia                                    1     ***
27846     Open trt ankle dislocation;w/wo percutaneous skeletal fix                      3
27848     Open trt ankle dislocation;w repair/int/ext fix                                3
27860     Manipulation ankle under gen anesthesia                                        1     ***
27870     Arthrodesis,ankle,any method                                                   4
27871     Arthrodesis,tibiofibular joint,proximal/distal                                 4
27884     Amputation leg thru tibia/fibula                                               3
27889     Amputation of foot at ankle                                                    5
27892     Decompression fasciotomy leg;ant/lat;w debridement                             4
27893     Decompression fasciotomy leg;post;w debridement                                5
27894     Decompression fasciotomy leg;ant/lat/post;w debridement                        5
27899     Unlisted procedure,leg/ankle                                                  U
28001     I&D,infected bursa,foot                                                        1
28002     Deep disect below fascia,deep infect foot;sgl bursal space                     3
28003     Deep disection below fascia,deep infect foot;multiple areas                    3
28005     Incision,deep,w/ opening bone cortex,foot                                      3
28008     Fasciotomy,foot and/or toe                                                     3
5101:3-2-21                                                               Page 31 of 81

                                                             APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                              GROUP NOTE
28010     Tenotomy,subcutaneous,toe;single                                  2
28011     Tenotomy,subcutaneous,toe;multiple                                2
28020     Arthrotomy,explor,remov forgn body;intertarsal/tarsometatar       2
28022     Arthrotomy,explorat,remov foreign body;metatarsophalangeal        2
28024     Arthrotomy,explorat,remov foreign body;interphalangeal jnt        2
28035     Tarsal tunnel release                                             4
28039     Exc foot/toe tum sc > 1.5 cm                                      8
28041     Exc foot/toe tum deep >1.5cm                                      8
28043     Exc foot/toe tum sc < 1.5 cm                                      2
28045     Exc foot/toe tum deep <1.5cm                                      3
28046     Resect foot/toe tumor < 3 cm                                      3
28047     Resect foot/toe tumor > 3 cm                                      8
28050     Arthrotomy synovial bx;intertarsal/tarsometatarsal jnt            2
28052     Arthrotomy synovial bx;metatarsophalangeal joint                  3
28054     Arthrotomy synovial bx;interphalangeal joint                      2
28055     Neurectomy, intrinsic musculature of foot                         4
28060     Fasciectomy,excision plantar fascia;partial                       2
28062     Fasciectomy,excision of plantar fascia;radical                    3
28070     Synovectomy;interarsal/tarsometatarsal joint,each                 3
28072     Synovectomy;metatarsophalangeal joint,each                        3
28080     Excision Morton neuroma,single,each                               3
28086     Synovectomy,tendon sheath,foot;flexor                             2
28088     Synovectomy,tendon sheath,foot;extensor                           2
28090     Excis lesion tendon/fibrous sheath/capsule;foot                   3
28092     Excis lesion tendon/fibrous sheath/capsule;toes                   3
28100     Excis/curet bone cyst/benign tumor,talus/calcaneus                2
28102     Exc bone cyst/benign tumor,talus/calcaneus;iliac/auto graft       3
28103     Exc bone cyst/benign tumor,talus/calcaneus;w/homogen graft        3
28104     Exc bone cyst/benign tumor,tarsal/metatarsal bones;               2
28106     Exc cyst/tumor,tarsal/metatarsal bones;iliac or auto graft        3
28107     Exc bone cyst/benign tumor,tarsal/metatarsal bones;homo graft     3
28108     Excis/curet bone cyst/benign tumor,phalanges foot                 3
28110     Ostectomy,partial excision,fifth metatarsal head                  3
28111     Ostectomy,complete excision;first metatarsal head                 3
28112     Ostectomy,complete excision;other metatarsal head                 3
28113     Ostectomy,complete excision;fifth metatarsal head                 3
28114     Ostectomy,complete excision;all metatarsal head,excl first        3
28116     Ostectomy,excision/tarsal coalition                               3
28118     Ostectomy,clacaneus;partial                                       4
28119     Ostectomy,clacaneus;for spur                                      4
28120     Partial excision bone,talus/calcaneus                             7
28122     Partial exc bone,tarsal/metatarsal bone,exc talus/calcaneus       3
28124     Partial excision of bone,phalanx toe                              3
28126     Condylectomy,phalangeal base,single toe,each                      3
28130     Talectomy                                                         3
28140     Metatarsectomy                                                    3
28150     Phalangectomy toe,single,each                                     3
28153     Resection,head phalanx,toe                                        2
28160     Hemiphalangectomy/interphalangeal joint excis,toe,sgl,ea          1
28171     Radical resection for tumor;tarsal                                3
28173     Radical resection for tumor;metatarsal                            3
5101:3-2-21                                                                  Page 32 of 81

                                                            APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                 GROUP NOTE
28175     Radical resection for tumor;phalanx toe                              3
28190     Removal foreign body,foot;subcutaneous                              A
28192     Removal foreign body,foot;deep                                       2
28193     Removal foreign body,foot;complicated                                4
28200     Repair/suture tendon,foot,flexor,sgl;w/o free graft,ea               3
28202     Repair/suture tendon,foot,flexor,sgl;second,free graft               3
28208     Repair/suture tendon,foot,extensor,sgl;each tendon                   3
28210     Repair/suture tendon,foot,extensor,sgl;second,free graft,ea          3
28220     Tenolysis,flexor,foot;single                                         1
28222     Tenolysis,flexor,foot;multiple                                       1
28225     Tenolysis,extensor,foot;single                                       1
28226     Tenolysis,extensor,foot;multiple                                     1
28230     Tenotomy,open,flexor;foot,single or multiple                         1
28232     Tenotomy,open,flexor;toe,single                                      4
28234     Tenotomy,open,extensor,foot or toe                                   3
28236     Transfer of foot tendon                                              2
28238     Advancement post tibial tendon w/exc navicular bone                  3
28240     Tenotomy/release,abductor hallucis muscle                            2
28250     Division plantar fascia/muscle                                       3
28260     Capsulotomy,midfoot;medial release only                              3
28261     Capsulotomy,midfoot;with tendon lengthing                            3
28262     Capsulotomy,midfoot;extensive                                        4
28264     Capsulotomy                                                          1
28270     Capsulotomy contracture;metatarsophalangeal joint,sgl                2
28272     Capsulotomy contracture;interphalangeal joint,sgl,each               3
28280     Webbing operation soft corn                                          2
28285     Hammertoe op;one toe                                                 3
28286     Hammertoe operation;cock-up 5th toe w/plastic skin cls               4
28288     Ostectomy,part,exostectomy/condylectomy,sgl,metatarsal head,ea       3
28289     Hallux rigidus correction with cheilectomy, debridement and caps     3
28290     Hallux valgus correction;simple exostectomy                          2
28292     Hallux valgus correction;Keller,McBride or Mayo type proced          2
28293     Hallux valgus correction;resection of joint w/implant                3
28294     Hallux valgus correction;w/tendon transplant                         3
28296     Hallux valgus correction;w/metatarsal osteotomy                      3
28297     Hallux valgus correction;Laoidus type procedure                      3
28298     Hallux valgus correction;by phalanx osteotomy                        3
28299     Hallux valgus correction;by other methods                            5
28300     Osteotomy;calcaneus,w/wo int fixation                                2
28302     Osteotomy;talus                                                      2
28304     Osteotomy,midtarsal bones,o.t. calcaneus/talus                       2
28305     Osteotomy,midtarsal bones,o.t.calcaneus/talus;auto graft             3
28306     Osteotomy,metatarsal,base or shaft,sgl;first metatarsal              4
28307     Osteotomy, first metatarsal with bone graft                          4
28308     Osteotomy,metatarsal,base/shaft,sgl;o.t.1st metatarsal               2
28309     Osteotomy,metatarsals,multiple,cavus foot                            4
28310     Osteotomy,angular/rotational correct,proximl phalanx,1sttoe          3
28312     Osteotomy,angular/rotationl correct;other phalanges,any toe          3
28313     Reconstruction soft tissue deformity toe                             2
28315     Sesamoidectomy,first toe                                             4
28320     Repair nonunion/malunion;tarsal bones                                4
5101:3-2-21                                                                          Page 33 of 81

                                                                APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                         GROUP NOTE
28322     Repair nonunion/malunion;metatarsal                                          4
28340     Reconstruction toe, macrodactyly, soft tissue                                4
28341     Reconstruction toe req. bone resection                                       4
28344     Reconstruction toe polydactyly                                               4
28345     Reconstruction toe syndactyly ea web                                         4
28360     Reconstruction cleft foot                                                    5
28400     Closed trt calcaneal fx;w/o manipulation                                     1
28405     Closed trt calcaneal fx;w manipulation                                       2
28406     Percutaneous skeletal fix calcaneal fx;w manipulation                        2
28415     Open trt calcaneal fx;w/wo int/ext fix                                       3
28420     Open trt calcaneal fx;primary iliac/or auto graft                            4
28430     Closed trt talus fx;w/o manipulation                                        B
28435     Closed trt talus fx;w manipulation                                           2
28436     Percutaneous skeletal fix talus fx;w/manipulation                            2
28445     Open trt talus fx;w/wo int/ext fix                                           3
28446     Osteochondral talus autogrft                                                 9
28450     Closed trt tarsal bone fx;w/o manipulation,each                             B
28455     Closed trt tarsal bone fx;w manipulation,each                                1
28456     Percutaneous skeletal fix tarsal bone fx;w manipulation                      2
28465     Open trt tarsal bone fx,w/wo int/ext fix each                                3
28470     Closed trt metatarsal fx,w/o manipulation,each                              A
28475     Closed trt metatarsal fx,w manipulation,each                                 1
28476     Percutaneous skeletal fix metatarsal fx,w manipulation                       2
28485     Open trt metatarsal fx,w/wo int/ext fix,each                                 4
28490     Closed trt fx great toe,phalanx/phalanges;w/o manip                         A
28495     Closed trt fx great toe,phalanx/phalanges;w manip                           B
28496     Percutaneous skeletal fix fx great toe,phalanx/phalanges;w manip             2
28505     Open trt fx great toe,phalanx/phalanges,w/wo int/ext fix                     3
28510     Closed trt fx,phalanx/phalanges,o.t. great toe,w/o manip                    A
28515     Closed trt fx,phalanx/phalanges,o.t. great toe,w manip                       1
28525     Open trt fx,phalanx/phalanges,w/wo int/ext fix each                          3
28530     Closed trt sesamoid fx                                                      B
28531     Open trt sesamoid fx, w/wo int fix                                           1
28540     Closed trt tarsal bone dislocat;w/o anesthesia                              A
28545     Closed trt tarsal bone dislocat;w anesthesia                                 1     ***
28546     Percutaneous skeletal fix tarsal bone dislocat,w manipulation                2
28555     Open trt tarsal bone dislocation,w/wo int/ext fix                            2
28570     Closed trt talotarsal joint dislocat,w/o anesthesia                         B
28575     Closed trt talotarsal joint dislocat,req anesthesia                          1     ***
28576     Percutaneous skeletal fix talotarsal jnt;w manipulation                      3
28585     Open trt talotarsal joint dislocation,w/wo int/ext fix                       3
28600     Closed trt tarsometatarsal joint dislocat;w/o anesthesia                    B
28605     Closed trt tarsometatarsla joint dislocat;req anesthesia                     1     ***
28606     Percutaneous skeletal fix tarsometatarsal jnt dislocat,w manipulation        2
28615     Open trt tarsometatarsal joint disloc,w/wo int/ext fix                       3
28630     Closed trt metatarsophalangeal joint dislocat;w/o anesthesia                B
28635     Closed trt metatarsophalangeal joint dislocat;req anesthesia                 1     ***
28636     Percutaneous skeletal fix metatarsophalangeal jnt disloc; w manipulation     3
28645     Open trt metatarsophalangeal joint dislocat;w/wo int/ext fix                 3
28660     Closed trt interphalangeal joint dislocat;req anesthesia                    B
28665     Closed trt interphalangeal joint dislocat;w/o anesthesia                     1     ***
5101:3-2-21                                                                                      Page 34 of 81

                                                               APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                                     GROUP NOTE
28666     Percutaneous skeletal fix interphalangeal jnt;w manipulation                             3
28675     Open trt interphalangeal joint dislocat;w/wo int/ext fix                                 3
28705     Pantalar arthrodesis                                                                     4
28715     Triple arthrodesis                                                                       4
28725     Subtalar arthrodesis                                                                     4
28730     Arthrodesis,midtarsal/tarsometatarsal,mult/transverse                                    4
28735     Arthrodesis,midtarsal/tarsometatarsal,mult/transverse;osteo                              4
28737     Arthrodesis,midtarsal navicular-cuneiform,tendon lengthenin                              5
28740     Arthrodesis,midtarsal/tarsometatarsal,sgl joint                                          4
28750     Arthrodesis,great toe;metatarsophalangeal joint                                          4
28755     Arthrodesis,great toe;interphalangeal joint                                              4
28760     Arthrodesis,great toe,interphalangeal jnt,extensor transfer                              4
28805     Amputation thru metatarsal                                                               3
28810     Amputation,metatarsal,with toe single                                                    2
28820     Amputation,toe;metatarsophalangeal joint                                                 2
28825     Amputation,toe;interphalangeal joint                                                     2
28890     Extracorporeal shock wave, high energy,including ultrasound guidance, plantar fascia     1     ***
28899     Unlisted procedure,foot or toes                                                         U
29000     Application halo type body cast                                                         A
29010     Application Risser jacket,localizer,body;only                                           B
29015     Application Risser jacket,localizer,body;incl head                                      B
29020     Application turnbuckle jacket,body;only                                                 B
29025     Application turnbuckle jacket,body;incl head                                            B
29035     Application body cast,shoulder to hips;                                                 B
29040     Appl body cast,shoulder to hips;incl head,Minerva type                                  B
29044     Appl body cast,shoulder to hips;incl one thigh                                          B
29046     Appl body cast,shoulder to hips;incl both thigh                                         B
29049     Application;plaster figure of eight                                                     B
29055     Application;shoulder spica                                                              B
29058     Application;plaster Velpeau                                                             B
29065     Application;shoulder to hand                                                            B
29075     Application;elbow to finger                                                             A
29085     Application;hand and lower forearm                                                      A
29086     Application of finger cast                                                              A
29105     Application of long arm splint                                                          A
29125     Application of short arm splint;static                                                  A
29126     Application of short arm splint;dynamic                                                 A
29130     Application of finger splint;static                                                     A
29131     Application of finger splint;dynamic                                                    A
29200     Strapping;thorax                                                                        A
29240     Strapping;shoulder                                                                      A
29260     Strapping;elbow or wrist                                                                A
29280     Strapping;hand or finger                                                                A
29305     Application hip spica cast;one leg                                                      B
29325     Appl hip spica cast;1&1/2 spica/both legs                                               B
29345     Application long leg cast;                                                              B
29355     Application long leg cast;walker/ambulatory type                                        B
29358     Application long leg cast brace                                                         B
29365     Application of cylinder cast                                                            B
29405     Application of short leg cast;                                                          B
29425     Appl short leg cast;walking/ambulatory type                                             A
5101:3-2-21                                                                      Page 35 of 81

                                                             APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                     GROUP NOTE
29435     Application patellar tendon bearing cast                                A
29440     Adding walker to previously applied cast                                A
29445     Apply rigid leg cast                                                    A
29450     Application of clubfoot cast                                            A
29505     Application of long leg splint                                          B
29515     Application of short leg splint                                         A
29520     Strapping;hip                                                           A
29530     Strapping;knee                                                          A
29540     Strapping;ankle                                                         A
29550     Strapping;toes                                                          A
29580     Strapping;Unna boot                                                     A
29581     Apply multlay comprs lwr leg                                            A
29590     Denis-Browne splint strapping                                           A
29700     Remov or bivalving;gauntlet,boot or body cast                            0    *****
29705     Remov or bivalving;full arm or full leg cast                             0    *****
29710     Remov or bivalving;shoulder to hip spica,Minerva,or Risser               0    *****
29715     Remov or bivalving;turnbuckle jacket                                     0    *****
29720     Repair of spica,body cast or jacket                                     A
29730     Windowing of cast                                                       A
29740     Wedging of cast                                                         A
29750     Wedging of clubfoot cast                                                A
29799     Unlisted procedure,casting or strapping                                 U
29800     Arthroscopy,temporomandibular jnt,dx w/wo bx                             3
29804     Arthroscopy,temporomandibular jnt,surgical                               3
29805     Shoulder arthroscopy, w or w/o synovial biopsy                           2
29806     Shoulder arthroscopy,capsulorrhaphy                                      6
29807     Repair of slap lesion                                                    6
29819     Arthroscopy,shoulder,surg;w/remov loose foreign body                     3
29820     Arthroscopy,shoulder,surg;synovectomy,partial                            3
29821     Arthroscopy,shoulder,surg;synovectomy,complete                           3
29822     Arthroscopy,shoulder,surg;debridement,limited                            3
29823     Arthroscopy,shoulder,surg;debridement,extensive                          3
29824     Shoulder arthroscopy, distal claviculectomy                              3
29825     Arthroscopy,shoulder,surg;w/lysis&resection adhesions                    3
29826     Arthroscopy,shoulder,decomp subacromial space w part acromioplasty       3
29827     Arthroscop rotator cuff repr                                             5
29828     Arthroscopy biceps tenodesis                                             9
29830     Arthroscopy,elbow,diagnostic                                             3
29834     Arthroscopy,elbow,surg;w/remov loose foreign body                        3
29835     Arthroscopy,elbow,surg;synovectomy,partial                               3
29836     Arthroscopy,elbow,surg;synovectomy,complete                              3
29837     Arthroscopy,elbow,surg;debridement,limited                               3
29838     Arthroscopy,elbow,surg;debridement,extensive                             3
29840     Arthroscopy,wrist,diagnostic                                             3
29843     Arthroscopy,wrist,surg;infection,lavage&drainage                         3
29844     Arthroscopy,wrist,surg;synovectomy,partial                               3
29845     Arthroscopy,wrist,surg;synovectomy,complete                              3
29846     Arthroscopy,wrist,surg;excis triangular fibrocartilage                   3
29847     Arthroscopy,wrist,surg;internal fixation;fx                              3
29848     Arthroscopy,wrist,release transverse carpal lig                          3
29850     Arthroscop aided trt intercondylar spine;w/wo manip;w/wo int/ext fix     4
5101:3-2-21                                                                                  Page 36 of 81

                                                              APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                                 GROUP NOTE
29851     Arthroscop aided trt intercondylar spine;w/wo manip;w int/ext fix                    4
29855     Arthroscop aided trt tibial fx,unicondylar;w/wo int/ext fix                          4
29856     Arthroscop aided trt tibial fx,bicondylar;w/wo int/ext fix                           4
29860     Arthroscopy, hip, diagnostic                                                         3
29861     Arthroscopy, hip, surgery                                                            3
29862     Arthroscopy, hip, surgery; debridement/shav articular cartilage                      4
29863     Arthroscopy, hip, surgical; with synovectomy                                         4
29866     Arthroscopy, knee, surgical: osteochondral autografts                                4
29867     Arthroscopy, knee, surgical: osteochondral allograft                                 5
29868     Arthroscopy, knee, surgical: meniscal transplantation, medial or lateral             6
29870     Arthroscopy,knee,diagnostic                                                          3
29871     Arthroscopy,knee,surg;inf,lavage&drainage                                            3
29873     Knee arthroscopy/surgery                                                             3
29874     Arthroscopy,knee,surg;remov loose foreign body                                       3
29875     Arthroscopy,knee,surg;synovectomy,limited                                            4
29876     Arthroscopy,knee,surg;synovectomy,major,2 or > compartm                              4
29877     Arthroscopy,knee,surg;debridement/shav articular cartil                              4
29879     Arthroscopy,knee,surg;abrasion arthroplasty                                          3
29880     Arthroscopy,knee,surg;with meniscectomy,medial&lateral                               4
29881     Arthroscopy,knee,surg;w/meniscectomy,medial/lateral                                  4
29882     Arthroscopy,knee,surg;meniscus repair,medial/lateral                                 3
29883     Arthroscopy,knee,surg;meniscus repair,medial&lateral                                 3
29884     Arthroscopy,knee,surg;w/lysis adhesions                                              3
29885     Arthroscopy,knee,surg;drill dissecans w/bone graft                                   3
29886     Arthroscopy,knee,surg;drill intact dissecans lesion                                  3
29887     Arthroscopy,knee,surg;drill intact dissecans lesion,fix                              3
29888     Arthroscopically aided anterior cruciate ligament repair                             3
29889     Arthroscopically aided posterior cruciate ligament repair                            3
29891     Arthroscopy, ankle, surgical, excision of osteo defect, including drilling           3
29892     Arthroscopy, ankle, surgical                                                         3
29893     Endoscopic plantar fasciotomy                                                        3
29894     Arthroscopy,ankle,(tibiotalar/fibulotalar)surgical;w/remov of loose foreign body     3
29895     Arthroscopy,ankle,surg;synovectomy,partial                                           3
29897     Arthroscopy,ankle,surg;debridement,limited                                           3
29898     Arthroscopy,ankle,surg;debridement,extensive                                         3
29899     Ankle arthroscopy/surgery                                                            4
29900     Metacarpophalangeal joint arthroscopy,w synovial biopsy                              3
29901     Metacarpophalangeal joint arthroscopy w debridement                                  3
29902     Metacarpophalangeal joint arthroscopy, w reduction ligament                          3
29904     Subtalar arthro w/FB rmvl                                                            3
29905     Subtalar arthro w/EXC                                                                3
29906     Subtalar arthro w/DEB                                                                3
29907     Subtalar arthro w/fusion                                                             9
29999     Unlisted arthroscopy procedure                                                      U
30000     Drainage abscess/hematoma,nasal,int approach                                        B
30020     Drainage abscess/hematoma,nasal septum                                              B
30100     Biopsy, intranasal                                                                  B
30110     Excision,nasal polyp,simple                                                         B
30115     Excision,nasal polyp,extensive                                                       2
30117     Excision/destruction,any method,intranasal lesion;int approach                       3
30118     Excision,intranasal lesion;ext approach                                              3
5101:3-2-21                                                                        Page 37 of 81

                                                                APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                       GROUP NOTE
30120     Excision/surg planing skin nose;rhinophyma                                 1
30124     Excision dermoid cyst,nose;simple,skin,subcutaneous                        1
30125     Excision dermoid cyst,nose;complex,under bone/cartilage                    2
30130     Excision turbinate,partial/complete                                        3
30140     Submucous resection turbinate,partial/complete                             2
30150     Rhinectomy;partial                                                         3
30160     Rhinectomy;total                                                           4
30200     Injection into turbinate,therapeutic                                      A
30210     Displacement therapy                                                      A
30220     Insertion,nasal septal prothesis                                          B
30300     Remov foreign body,intranasal;office type procedure                       A
30310     Remov foreign body,intranasal;req gen anesth                               1     ***
30320     Remov foreign body,intranasal;by lateral rhinotomy                         2
30400     Rinoplasty,primary,lat/alar cartilage/elevation tip                        4     PA
30410     Rhinoplasty,complete,est part incl bony pyramid                            5     PA
30420     Rhinoplasty,incl major septal repair                                       5     PA
30430     Rhinoplasty,secondary,minor rev                                            3     PA
30435     Rhinoplasty,intermediate rev                                               5     PA
30450     Rhinoplasty,major rev                                                      7     PA
30460     Rhinoplasty nasal deformity secondary cleft lip,tip only                   5
30462     Rhinoplasty nasal deformity secondary cleft lip,tip/septum/osteotomies     6
30465     Repair of nasal vestibular stenosis                                        6
30520     Septoplasty/submucous resection                                            4
30540     Repair choanal atresia;intranasal                                          5
30545     Repair choanal atresia;transpalatine                                       3
30560     Lysis intranasal synechia                                                  2
30580     Repair fistula;oromaxillary                                                4
30600     Repair fistula;oronasal                                                    4
30620     Septal/other intranasal dermatoplasty                                      7
30630     Repair nasal septal perforations                                           7
30801     Caut/ablation mucosa turbinates,superficial                                1
30802     Caut/ablation mucosa turbinates,intramural                                 1
30901     Control nasal hemorrhage,ant,simple,any method                            A
30903     Control nasal hemorrhage,ant,complex,any method                            1
30905     Cntrl nasal hemorrhage,post,packs/cauteriz,any method,initial              1
30906     Cntrl nasal hemorrhage,post,nasal packs/cauteriz,subse                     1
30915     Ligation arteries;ethmoidal                                                2
30920     Ligation arteries;int maxillary artery,transantral                         3
30930     Fx nasal turbinate,therapeutic                                             4
30999     Unlisted procedure, nose                                                  U
31000     Lavage by cannulation;maxillary sinus                                     B
31002     Lavage by cannulation;sphenoid sinus                                      B
31020     Sinusotomy,maxillary;intranasal                                            2
31030     Sinusotomy,maxillary;radical, w/o remov polyps                             3
31032     Sinusotomy,maxillary;radical,w/remov polyps                                4
31040     Surgery;pterygomaxillary fossa contents,transantral appr                   4
31050     Sinusotomy,sphenoid,w/w/o biopsy                                           2
31051     Sinusotomy,sphenoid;w/mucosal stripping/remov polyps                       4
31070     Sinusotomy,frontal;intranasal                                              2
31075     Sinusotomy,frontal;transorbital,unilateral                                 4
31080     Sinusotomy,frontal;obliterative w/o flap,brow incision                     4
5101:3-2-21                                                               Page 38 of 81

                                                             APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                              GROUP NOTE
31081     Sinusotomy,frontal;obliterative w/o flap,coronal incision         3
31084     Sinusotomy,frontal;obliterative w/ flap,brow incision             4
31085     Sinusotomy,frontal;obliterative w/ flap,coronal incision          4
31086     Sinusotomy,frontal;nonobliterative,w/ flap,brow incision          4
31087     Sinusotomy,frontal;nonobliterative,w/ flap,coronal incision       4
31090     Sinusotomy combined,three or more sinuses                         5
31200     Ethmoidectomy;intranasal,anterior                                 2
31201     Ethmoidectomy;intranasal,total                                    5
31205     Ethmoidectomy;extranasal,total                                    3
31231     Nasal endo, dx unilat/bilat                                       1
31233     Nasal/sinus endo,dx w maxillary sinusoscopy                       2
31235     Nasal/sinus endo,dx w sphenoid sinusoscopy                        1
31237     Nasal/sinus endo, surg;w bx,polypectomy/debridement               2
31238     Nasal/sinus endo, surg;w control epistaxis                        1
31239     Nasal/sinus endo, surg;w dacryocystorhinostomy                    4
31240     Nasal/sinus endo, surg;w concha bullosa resect                    2
31254     Revision of ethmoid sinus                                         3
31255     Removal of ethmoid sinus                                          5
31256     Exploration of maxillary sinus                                    3
31267     Endoscopy, maxillary sinus                                        3
31276     Sinus surgical endoscopy                                          3
31287     Nasal/sinus endo, surg;w sphenoidotomy                            3
31288     Nasal/sinus endo, surg;w sphenoid,tissue                          3
31290     Nasal/sinus endo, surg;w repair fluid leak,ethmoid region         2
31291     Nasal/sinus endo, surg;w repair fluid leak,sphenoid region        2
31292     Nasal/sinus endo, surg;w med/inf orbital wall decompression       3
31293     Nasal/sinus endo, surg;w med&inf orbital wall decompression       3
31294     Nasal/sinus endo, surg;w optic nerve decompression                3
31299     Unlisted procedure,accessory sinuses                             U
31300     Laryngotomy;remov tumor/laryngocele,cordectomy                    5
31320     Laryngotomy;diagnostic                                            2
31400     Arytenoidectomy or arytenoidopexy, external approach              5
31420     Epiglottidectomy                                                  5
31500     Intubation, endotracheal, emergency procedure                     1
31502     Tracheotomy tube chg prior estab fistula tract                   A
31505     Laryngoscopy,indirect;diagnostic                                  1
31510     Laryngoscopy,indirect;with biopsy                                 2
31511     Laryngoscopy,indirect;w/remov foreign body                        2
31512     Laryngoscopy,indirect;w/remov lesion                              2
31513     Laryngoscopy,indirect;w/vocal cord inj                            2
31515     Laryngoscopy direct,w/w/o tracheoscopy;aspiration                 1
31520     Laryngoscopy direct;dx newborn                                    1
31525     Laryngoscopy direct;dx,except newborn                             1
31526     Laryngoscopy direct;dx,with operating microscope                  2
31527     Laryngoscopy direct;with insertion obturator                      1
31528     Laryngoscopy direct;with dilatation,initial                       2
31529     Laryngoscopy direct;with dilatation,subsequent                    2
31530     Laryngoscopy,direct,operative,w/foreign body remov;               2
31531     Laryngoscopy,direct,operative,foreign body remov;microscope       3
31535     Laryngoscopy,direct,operative,w/biopsy;                           2
31536     Laryngoscopy,direct,operative,w/biopsy;operating microscope       3
5101:3-2-21                                                                                                  Page 39 of 81

                                                            APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                                                 GROUP NOTE
31540     Laryngoscopy,direct,operative,exc tumor/strip vocal cords                                            3
31541     Laryngoscopy,direct,operat,exc tumor/strip cords;microscope                                          4
31545     Laryngoscopy,direct;operat,w operat microscope or telescope, reconst tissue                          4
31546     Laryngoscopy,direct;operat,w operat microscope or telescope, reconst graft                           4
31560     Laryngoscopy,direct,operative,w/arytenoidectomy                                                      5
31561     Laryngoscopy,direct,operative,w/arytenoidectomy;microscope                                           5
31570     Laryngoscopy,direct,inj into vocal chords,therapeutic;                                               2
31571     Laryngoscopy,direct,inj vocal chords,therapeutic;microsc                                             2
31575     Laryngoscopy,flexible fiberscopic;diagnostic                                                         1
31576     Laryngoscopy,flexible fiberscopic;w/biopsy                                                           2
31577     Laryngoscopy,flexible fiberscopic;w/removal foreign body                                             2
31578     Laryngoscopy,flexible fiberscopic;w/removal lesion                                                   2
31579     Laryngoscopy with stroboscopy                                                                        2
31580     Laryngoplasty;laryngeal web,two stage,keel insert&remov                                              5
31582     Laryngoplasty;laryngeal stenosis,graft/core mold,tracheotom                                          5
31584     Laryngoplasty;with open reduction fx                                                                 4
31587     Laryngoplasty, cricoid split                                                                         4
31588     Laryngoplasty,not otherwise specified                                                                5
31590     Laryngeal reinnervation by neuromuscular pedicle                                                     5
31595     Section recurrent laryngeal nerve,therapeutic,unilateral                                             2
31599     Unlisted procedure,larynx                                                                           U
31600     Tracheostomy,planned;                                                                                2
31601     Tracheostomy,planned;under two years                                                                 2
31603     Tracheostomy,emergency procedure;transtracheal                                                       2
31605     Tracheostomy,emergency procedure;cricothyroid                                                        2
31610     Tracheostomy,fenestration procedure w/skin flaps                                                     2
31611     Const tracheoesophageal fistula,insert alaryngeal speech prosthesis                                  3
31612     Tracheal puncture,percutaneous asp mucus                                                             1
31613     Tracheostoma revision;simple,w/o flap rotation                                                       2
31614     Tracheostoma revision;complex,w/flap rotation                                                        2
31615     Tracheobronchoscopy through estab trach incis                                                        1
31620     Endobronchial ultrasound (EBUS), bronchoscopic diagn or therapeutic intervent                        1
31622     Bronchoscopy;diagnostic                                                                              1
31623     Bronchoscopy; with brushing or protected brushings                                                   1
31624     Bronchoscopy; with bronchial alveolar lavage                                                         1
31625     Bronchoscopy;with biopsy                                                                             2
31626     Bronchoscopy w/markers                                                                               1
31627     Navigational bronchoscopy                                                                           A
31628     Bronchoscopy;w/transbronchial lung biopsy                                                            2
31629     Bronchoscopy;w/transbronchial needle asp biopsy                                                      2
31630     Bronchoscopy;tracheal/bronchial dilatin/cls reduct fx                                                2
31631     Bronchoscopy;tracheal dilation&placement tracheal stent                                              2
31632     Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; with lung biopsy(s)          2
31633     Bronchoscopy, rigid or flexible, w/w/out fluoroscopic guidance; with needle aspiration biopsy(s)     2
31635     Bronchoscopy;w/removal foreign body                                                                  2
31636     Bronchoscopy;w/placemt bronchial stent; initial bronchus                                             2
31637     Bronchoscopy;w/placemt bronchial stent; major bronchus                                              B
31638     Bronchoscopy;w/placemt bronchial stent; revisional bronchial stent                                   2
31640     Bronchoscopy;w/excision tumor                                                                        2
31641     Bronchoscopy;w/destruction tumor/relief stenosis                                                     2
31643     Bronchoscopy;w/placement of catheter                                                                 2
5101:3-2-21                                                                                Page 40 of 81

                                                            APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                               GROUP NOTE
31645     Bronchoscopy;therapeutic aspirat tracheobron tree,initial                          1
31646     Bronchoscopy;therapeutic asp tracheobronchial tree,subsequen                       1
31656     Bronchoscopy;inj contrast material segmental bronchography                         1
31715     Transtracheal inj bronchography                                                    1
31717     Catheterization with bronchial brush biopsy                                        1
31720     Catheter asp;nasotracheobronchial                                                  1
31730     Transtracheal intro needle wire dialtor for oxygen therapy                         1
31750     Tracheoplasty; cervical                                                            5
31755     Tracheoplasty; tracheopharyngeal fistulization, each stage                         2
31785     Excision tracheal tumor/CA;cervical                                                4
31800     Suture ext tracheal wound/injury;cervical                                          2
31805     Suture ext tracheal wound/injury;intrathoracic                                    B
31820     Surgical closure tracheostomy/fistula;w/o plastic repair                           1
31825     Surgical closure tracheostomy/fistula;w/plastic repair                             2
31830     Revision of tracheostomy scar                                                      2
31899     Unlisted procedure,trachea,bronchi                                                U
32400     Biopsy,pleura;percutaneous needle                                                  1
32405     Biopsy,lung,percutaneous needle                                                    1
32420     Pneumonocentesis,puncture lung;aspiration                                          1
32421     Thoracentesis for aspiration                                                       1
32422     Thoracentesis w/tube insert                                                        2
32550     Insert pleural cath                                                                2
32551     Insertion of chest tube                                                            2
32552     Remove lung catheter                                                              A
32553     Ins mark thor for rt perq                                                          2
32560     Treat lung lining chemically                                                       2
32561     Lyse chest fibrin init day                                                        B
32562     Lyse chest fibrin subq day                                                        B
32601     Thoracoscopy,dx,lung/plural space,w/o bx                                           1
32602     Thoracoscopy,dx,lung/plural space,w bx                                             1
32603     Thoracoscopy,dx,pericardial sac,w/o bx                                             1
32604     Thoracoscopy,dx,pericardial sac,w bx                                               1
32605     Thoracoscopy,dx,mediastinal space,w/o bx                                           1
32606     Thoracoscopy,dx,mediastinal space,w bx                                             1
32650     Thoracoscopy,surg,w pleurodesis,any method                                         3
32653     Thoracoscopy,surg,w removal intrapleural foreign body                              4
32655     Thoracoscopy,surg,w exc-plication bullae                                           4
32960     Pneumothorax,therapeutic intrapleural inj air                                     A
32997     Total lung lavage                                                                  1
32998     Ablation therapy, pulmonary tumor(s); percutaneous, radiofrequency, unilateral     5
32999     Unlisted procedure                                                                U
33010     Pericardiocentesis, initial                                                        2
33011     Pericardiocentesis, subsequent                                                     2
33206     Insertion or replacement of pacemaker; atrial                                      3
33207     Insertion or replacement of pacemaker; ventricular                                 3
33208     Insertion or replacement of pacemaker; atrial and ventricular                      3
33210     Insert temp transvenous sgl chamber,cardiac electrode                              3
33211     Insert temp transvenous dual chamber                                               4
33212     Insert/replace,sgl chamber,pulse generator only                                    3
33213     Insert/replace,dual chamber,pulse generator only                                   3
33214     Upgrade implanted pacemaker system                                                 5
5101:3-2-21                                                                                         Page 41 of 81

                                                            APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                                        GROUP NOTE
33215     Reposition pacing-defib lead                                                                3
33216     Insert/reposition perm transvenous electrodes,sgl chamber                                   4
33217     Insert/reposition perm transvenous electrodes,dual chamber                                  4
33218     Repair of pacemaker;sgl chamber,electrodes only                                             3
33220     Repair of pacemaker;dual chamber,electrodes only                                            3
33222     Revision or relocation of skin pocket for pacemaker                                         3
33223     Revision of skin pocket for single or dual chamber pacing cardioverter                      3
33224     Insert pacing lead & connect                                                                4
33225     L ventric pacing lead add-on                                                                3
33226     Reposition l ventric lead                                                                   4
33233     Removal perm pacemaker;pulse generator only                                                 2
33234     Removal perm pacemaker;sgl lead sys,transvenous electrodes                                  2
33235     Removal perm pacemaker;dual lead sys,transvenous electrodes                                 3
33240     Insertion or replacement of cardioverter-defibrulator pulse generator                       3
33241     Removal of cardioverter-defibrulator pulse generator only                                   3
33244     Removal of single or dual chamber pacing cardio defibrill systm; by transvenous extract     5
33249     Insert/ reposition of electrode lead for single or dual chamber                             5
33282     Implant patient activated cardiac recorder                                                  2
33284     Removal implantable, patient activated cardiac recorder                                     2
33886     Replacement of distal extension prosthesis delayed after endovascular repair                4
33999     Unlisted procedure, cardiac surgery                                                        A
34101     Embolectomy/thrombectomy;axillary,brachial,innominate,subclavian                            3
34111     Embolectomy/thrombectomy;radical/ulnar artery,arm incis                                     3
34201     Embolectomy,femoropopliteal,aortoiliac;leg incision                                         3
34203     Embolectomy popliteal-tibio-peroneal;leg incision                                           3
34421     Thrombectomy vena cava,illiac;leg incision                                                  3
34471     Thrombectomy, direct or with catheter; subclavian vein, by neck incision                    5
34490     Thrombectomy,direct/w/catheter;axillary&subclavian vein                                     2
34501     Valvuloplasty, femoral vein                                                                 5
34510     Venous valve transposition, any vein donor                                                  5
34520     Cross-over vein graft to venous system                                                      5
34530     Saphenopopliteal vein anastomosis                                                           5
35011     Direct repair of aneurysm, pseudoaneurysm, or excision and graft insertion                  6
35180     Repair, congenital arteriovenous fistula; head and neck                                     3
35184     Repair, congenital arteriovenous fistula; extremities                                       3
35188     Repair, acquired or traumatic arteriovenous fistula; head and neck                          5
34803     Endovascular repair of infrarenal abdominal aortic aneurysm                                 6
35190     Repair arteriovenous fistula, extremities                                                   5
35201     Repair blood vessel,direct;neck                                                             3
35206     Repair blood vessel,direct;upper extremity                                                  3
35207     Repair blood vessel,direct;hand,finger                                                      3
35226     Repair blood vessel,direct;lower extremity                                                  3
35231     Repair blood vessel with vein graft; neck                                                   3
35236     Repair blood vessel with vein graft; upper extremity                                        3
35256     Repair blood vessel with vein graft; lower extremity                                        3
35261     Repair blood vessel with graft other than vein; neck                                        6
35266     Repair blood vessel with graft other than vein; upper extremity                             6
35286     Repair blood vessel with graft other than vein; lower extremity                             6
35321     Thromoendarterectomy                                                                        6
35458     Transluminal balloon angioplasty, open; brachiocephalic trunk or branches                   5
35459     Transluminal balloon angioplasty, open; tibioperoneal trunk or branches                     5
5101:3-2-21                                                                                          Page 42 of 81

                                                                APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                                         GROUP NOTE
35460     Repair venous blockage                                                                       2
35470     Transluminal balloon angioplasty, percutaneous; tibioperoneal trunk or branches              5
35471     Repair arterial blockage                                                                     4
35472     Transluminal balloon angioplasty, percutaneous; aortic                                       5
35473     Repair arterial blockage                                                                     3
35474     Repair arterial blockage                                                                     4
35475     Repair arterial blockage                                                                     4
35476     Repair venous blockage                                                                       2
35484     Transluminal peripheral atherectomy, open; brachiocephalic trunk or branches                 5
35485     Transluminal peripheral atherectomy, open; tibioperoneal trunk or branches                   5
35490     Transluminal peripheral atherectomy, percutaneous; renal or other visceral artery            5
35491     Transluminal peripheral atherectomy, percutaneous; aortic                                    5
35492     Atherectomy, percutaneous                                                                    3
35493     Transluminal peripheral atherectomy, percutaneous; femoral-popliteal                         5
35494     Transluminal peripheral atherectomy, percutaneous; brachiocephalic trunk or branches         5
35495     Transluminal peripheral atherectomy, percutaneous; tibioperoneal trunk or branches           5
35500     Harvest vein for bypass                                                                      2
35685     Placement of vein patch or cuff at distal anastomosis of bypass graft, synthetic conduit     3
35686     Bypass graft/av fist patency                                                                 5
35697     Reimplantation, visceral artery-infrarenal aortic prosthesis, ea artery                     B
35761     Exploration with or without lysis of artery; other vessels                                   4
35860     Exploration for postoperative hemorrhage, thrombosis or infection; extremity                 3
35875     Thrombectomy of arterial or venous graft                                                     4
35876     Thrombectomy of arterial or venous graft; with revision of arterial or venous graft          4
35879     Revision, lower extremity arterial bypass, w/out thrombectomy, open                          4
35881     With segmental vein interposition                                                            4
35883     Revision graft with nonautogenous patch graft                                                5
35884     Revision graft with autogenous vein patch graft                                              5
35903     Excision, graft, extremity                                                                   4
36000     Introduction of needle or intracatheter,vein                                                A
36002     Pseudoaneurysm injection                                                                    B
36005     Inj proc contrast venography                                                                A
36010     Intro catheter;sup/inf vena cava                                                            A
36011     Select cath placemt, venous;1st order branch                                                B
36012     Select cath placemt, venous;2nd order branch                                                B
36013     Intro cath rt heart/main pulmonary art                                                       1
36014     Select cath placemt;lft/rt pulmonary art                                                     1
36015     Select cath placemt;seg/subseg pulmonary art                                                 1
36100     Intro needle/intracatheter,carotid/vertebral artery                                         A
36120     Intro needle/intracatheter,retrograde brachial artery                                       A
36140     Intro needle/intracatheter;extremity artery                                                 A
36147     Access av dial grft for eval                                                                A
36148     Access av dial grft for proc                                                                A
36160     Intro needle/intracatheter,aortic,translumbar                                               A
36200     Intro catheter,aorta                                                                        A
36215     Select cath placemt;art sys;ea 1st order thoracic                                           A
36216     Select cath placemt;init 2nd order thoracic branch                                          A
36217     Select cath placemt;init 3rd order/more select thoracic branch                              B
36218     Select cath placemt;addl 2nd,3rd order & beyond                                             A
36245     Select cath placemt,art sys,ea 1st order abd, pelvic                                        A
36246     Select cath placemt,art sys,init 2nd order abd, pelvic                                      A
5101:3-2-21                                                                                                 Page 43 of 81

                                                            APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                                                GROUP NOTE
36247     Select cath placemt,art sys,addl 3rd order abd, pelvic                                             B
36248     Select cath placemt,art sys,addl 2nd,3rd order & beyond abd, pelvic                                A
36260     Insertion of intra-arterial infusion pump                                                           4
36261     Revision implanted intra-arterial infusion pump                                                     2
36262     Removal implanted intra-arterial infusion pump                                                      1
36299     Unlisted procedure,vascular injection                                                              U
36430     Transfusion,blood/blood components                                                                  1
36440     Push transfusion,blood,2 yrs or under                                                               1
36450     Exchange transfusion service                                                                        1
36455     Exchange transfusion service                                                                        1
36460     Transfusion intrauterine, fetal                                                                     5
36468     Single/mult inj sclerosing solu limb/trunk                                                         A      PA
36469     Single/mult inj sclerosing solu face                                                               A      PA
36470     Inj sclerosing solution;single vein                                                                A      PA
36471     Inj sclerosing solu;multiple vein,same leg                                                         A      PA
36475     Endov ablation therapy of incompetent vein, extremity, raidofrequency; first vein treated           4     PA
36476     Endov ablation therapy of incompetent vein, extremity, raidofrequency; second and subsequ veins     1     PA
36478     Endov ablation therapy of incompetent vein, extremity, laser; first vein treated                    4     PA
36479     Endov ablation therapy of incompetent vein, extremity, laser; second and subsequ veins              1     PA
36481     Percutaneous portal vein cath;any method                                                            1
36500     Venous cath;selective organ blood sampling                                                          2
36510     Catheterization umbilical vein;dx/therapy,newborn                                                  A
36511     Apheresis wbc                                                                                       2
36512     Apheresis rbc                                                                                       2
36513     Apheresis platelets                                                                                 2
36514     Apheresis plasma                                                                                    2
36515     Apheresis, adsorp/reinfuse                                                                          2
36516     Apheresis, selective                                                                                2
36522     Photopheresis, extracorporeal                                                                       2
36555     Insert non-tunneled centrally inserted central venous catheter; <5 yrs.                             1
36556     Insert non-tunneled centrally inserted central venous catheter; 5 yrs.or older                      1
36557     Insert tunneled centrally inserted venous catheter, w/o subq port/pump; <5 years                    3
36558     Insert tunneled w/o subq port/pump; 5 yrs. Or older                                                 3
36560     Insert tunneled centrally inserted CVA device, with subq port <5 years                              3
36561     Insert tunneled centrally inserted CVA device, with subq port 5 yrs or older                        3
36563     Insert tunneled centrally inserted CVA device, with subq pump                                       3
36565     Insert tunneled centrally inserted CVA device, requiring two catheters                              3
36566     Insert tunneled centrally inserted CVA device, requiring two catheters, with subq port(s)           7
36568     Insertion, Peripheral CV Cath; w/o subq port/pump, <5 years                                         1
36569     Insertion, Peripheral CV Cath; w/o subq Port/Pump, 5 yrs or older                                   1
36570     Insertion, Peripheral CVA Device; w/subq Port; <5 years                                             3
36571     Insertion, Peripheral CV Cath; w subq Port/Pump, 5 yrs or older                                     3
36576     Repair of CVA device, with subq port or pump, central or peripheral insertion site                  3
36578     Replacement, catheter only, of CVA device with subq port or pump                                    3
36580     Replacement, complete, non-tunneled centrally inserted CV catheter, without subq port               3
36581     Replacement, complete, tunneled CVA device w/ subq port                                             3
36582     Replacement, complete, tunneled CVA device, w/subq port                                             3
36583     Replacement, complete, tunneled CVA device, w/subq pump                                             3
36584     Replace, comp. periph. CV cath; (PICC) w/o subq port or pump, same access                           1
36585     Replacement, complete, peripheral CVA device, w/ subq port                                          3
36589     Removal of tunneled central venous catheter, w/o subq port/pump                                     1
5101:3-2-21                                                                                                     Page 44 of 81

                                                             APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                                                    GROUP NOTE
36590     Remove tunneled CVA device, with subq port or pump, central or peripheral insertion                     1
36593     Declot vascular device                                                                                 A
36595     Mech. removal, pericatheter obstructive material, CV device, via venous access                         2
36596     Mech. removal, intraluminal obstructive material, CV device, through device lumen                       1
36597     Repositioning, previously placed CV catheter, w/flouroscopic guidance                                  B
36620     Arterial catheterization/cannulation percutaneous                                                      B
36625     Same as 36620, except cutdown                                                                          B
36640     Arterial cath,cutdown for prolonged infusion                                                            1
36800     Insert cannula;hemodialysis,other purpose;vein to vein                                                  3
36810     Insert cannula;hemodialysis;arteriovenous,external                                                      3
36815     Insert cannula;hemodialysis;arteriovenous,ext rev/cls                                                   3
36818     Arteriovenous anastomosis, open; by open arm vein                                                       3
36819     Arteriovenous anastomosis, open; by basilic vein transposition                                          3
36820     Anastomosis forearm vein transposition                                                                  3
36821     Arteriovenous anastamosis,direct,any site                                                               3
36825     Creation arteriovenous fistula;autogenous graft                                                         4
36830     Creation arteriovenous fistula;nonautogenous graft                                                      4
36831     Thrombectomy, arteriovenous fistula without revision, graft                                             4
36832     Revision arteriovenous fistula w/wo thrombectomy,graft                                                  4
36833     Revision, arteriovenous fistula; with thrombectomy, graft                                               4
36835     Insertion Thomas shunt                                                                                  4
36838     Distal revascularization & interval ligation, upper extremity hemodialysis access                       7
36860     Cannula declotting;w/o balloon catheter                                                                 2
36861     Cannula declotting;w/balloon catheter                                                                   3
36870     Thrombectomy, percutaneous, arteriovenous                                                               6
37183     Insert hepatic shunt (tips)                                                                             3
37184     Prim. percut thrmbect,artrl grft,1st vsl                                                                1
37185     Prim. percut thrmbect,artrl grft,add vsl                                                               A
37186     Sec thrmbct artrl grft,w/o prim.thrmbct                                                                B
37187     Perc transluminal thrmbct, vein, initial                                                                1
37188     Perc transluminal thrmbct, vein, subsqnt                                                               B
37195     Thrombolysis, cerebral, by IV infusion                                                                 B
37200     Transcatheter biopsy                                                                                    1
37201     Transcath therapy, infusion thrombolysis                                                               B
37202     Transcath therapy,infusion o.t. thrombolysis                                                           B
37203     Transcath retrieval, percutaneous intravascular foreign body                                            1
37204     Transcath occlusion/embolization,non-central nervous                                                    2
37205     Transcatheter plcmnt intravascular stent;percutaneous,initial vessel                                   A
37206     Transcatheter plcmnt intravascular stent,ea addl vessel                                                A
37207     Transcatheter plcmnt intravascular stent;open,initial vessel                                           A
37208     Transcatheter plcmnt intravascular stent;open,ea addl vessel                                           A
37209     Exchange arterial catheter                                                                             A
37210     Uterine fibroid embolization, percutaneous approach                                                     7
37215     Transcatheter plmnt of intravascular stents, cervical carotid artery; w/ distal embolic protection      4
37216     Transcatheter plmnt of intravascular stents, cervical carotid artery; w/o distal embolic protection     4
37250     Intravascular Ultrasound, non-coronary                                                                 A
37251     Intravascular Ultrasound, non-coronary                                                                 A
37500     Endoscopy ligate perf veins                                                                             3
37501     Vascular endoscopy procedure                                                                           U
37565     Ligation, internal jugular vein                                                                         3
37600     Ligation, external carotid artery                                                                       3
5101:3-2-21                                                                             Page 45 of 81

                                                              APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                            GROUP NOTE
37605     Ligation of neck artery                                                         7
37606     Ligation of neck artery                                                         8
37607     Ligation of banding of angioaccess                                              2
37609     Ligation/biopsy,temporal artery                                                 2
37615     Ligation of neck artery                                                         8
37618     Ligation of extremity artery                                                    2
37620     Interruption of inferior vena cava by suture, ligation                          2
37650     Ligation of femoral vein                                                        3
37700     Ligation&division long saphenous vein                                           2
37718     Ligtn,divsn,stripng,short saphenous vein                                        3
37722     Ligtn,divsn,stripng,long saphenous vein                                         3
37735     Ligatin&divis&complete stripping saphenous veins                                3
37760     Ligation perforators,subfascial,radical,w/wo skin graft                         3
37761     Ligate leg veins open                                                           4
37765     Stab phlebectomy of varicose veins, one extrem. 10 - 20 stab incisions          3     PA
37766     Stab phlebectomy of varicose veins, one extrem. more than 20 stab incisions     3     PA
37780     Ligat&divis shrt saphenous vein at saphenopopliteal jct                         3
37785     Ligat,divis,and/or excis second varicose veins leg                              3
37790     Penile venous occlusive procedure                                               3
37799     Unlisted procedure,vascular surgery                                            U
38120     Laparoscopy, surgical, splenectomy                                              5
38129     Unlisted laparoscopy procedure, spleen                                          6
38200     Inj proc;splenoportography                                                     A
38205     Harvest allogenic stem cells                                                   B
38206     Harvest auto stem cells                                                        B
38220     Bone marrow aspiration                                                         B
38221     Bone marrow biopsy, needle/ trocar                                             B
38230     Bone marrow harvesting for transplantation                                      2     PA
38240     Bone marrow or blood-derived peripheral stem cell transplant; allogenic        B      PA
38241     Bone marrow/stem transplant                                                     5     PA
38242     Lymphocyte infuse transplant                                                   B
38300     Drainage lymph node abscess/lymphadenitis;simple                                1
38305     Drainage lymph node abscess/lymphadenitis;extensive                             2
38308     Lymphangiotomy/other operations;lymphatic channels                              2
38500     Bx or excision lymph node(s);superficial                                        2
38505     Bx or excision lymph node(s);by needle,superficial                              1
38510     Bx or excision lymph node(s);deep cervical node(s)                              2
38520     Bx/exc lymph node(s);deep cervical node(s),exci scalene                         2
38525     Bx or excision lymph node(s);deep axillary node                                 2
38530     Bx or excision lymph node(s);internal mammary node                              2
38542     Dissection,deep jugular node                                                    2
38550     Exc cystic hygroma,axillary/cervical w/o neurov dissec;simp                     3
38555     Exc cystic hygroma,axillary/cervical w/o neurov dissec;comp                     4
38570     Laparoscopy, surgical; w/ retroperitoneal lymph node sampling                   3
38571     With bilateral total pelvic lymphadenectomy                                     4
38572     W/ bilateral ttl pelvic lymphadenectomy & peri-aortic lymph nde biop            4
38589     Unlisted laparoscopy, procedure, lymphatic system                              U
38700     Suprahyoid lymphadenectomy                                                      2
38720     Cervical lymphadenectomy(complete)                                              4
38740     Axillary lymphadenectomy;superficial                                            2
38745     Axillary lymphadenectomy;complete                                               4
5101:3-2-21                                                                          Page 46 of 81

                                                                 APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                         GROUP NOTE
38746     Thoracic lymphadenectomy,incl mediastinal/peritracheal nodes                 5
38747     Abd lymphadenectomy, incl celiac, para-aortic                                5
38760     Inguinofemoral lymphadenectomy,superficia,inc Cloquet's                      2
38790     Inj proc;lymphangiography                                                    1
38792     Injection procedure; for identification of sentinel node                     1
38999     Unlisted procedure,hemic/lymphatic system                                   U
39010     Mediastinotomy w/ explore, drain; transthoracic                              2
39400     Mediastinoscopy,w/wo biopsy                                                  2
39499     Unlisted procedure,mediastinum                                              U
39599     Unlisted procedure,diaphragm                                                U
40490     Biopsy of lip                                                               A
40500     Vermilionectomy,w/mucosal advancement                                        2
40510     Excision lip;transverse wedge excision w/primary closure                     2
40520     Excision lip;v-excision w/primary direct linear cls                          2
40525     Excision lip;full thickness,reconstruction w/local flap                      2
40527     Excis lip;full thickness,reconstruction w/cross lip flap                     2
40530     Resection lip,more than one-fourth,w/o reconstruction                        2
40650     Repair lip,full thickness;vermilion only                                     3
40652     Repair lip,full thickness;up to half vertical height                         3
40654     Repair lip,full thickness;over 1/2 vertical hght,or complex                  3
40700     Plastic rep cleft lip/nasal deform,primary,unilat                            5
40701     Plastic rep cleft lip/nasal deform,primary,bilat                             6
40702     Plastic rep cleft lip/nasal deform,primary,bilt,1 of 2 stages                6
40720     Plastic rep cleft lip/nasal deform,second,recreat defect                     6
40761     Plastic repair of cleft lip/nasal deformity; with cross lip pedicle flap     6
40799     Unlisted procedure,lips                                                     U
40800     Drain abscess,cyst,hematoma,vestibule mouth;simple                          A
40801     Drain abscess,cyst,hematoma,vestibule mouth;comp                             2
40804     Removal embedded foreign body,vestibule mouth;simple                        A
40805     Removal embedded foreign body,vestibule mouth;comp                           2
40806     Incision labial frenum                                                       1
40808     Biopsy,vestibule mouth                                                      A
40810     Excis lesion mucosa&submucosa,vestibule mouth;w/o repair                    A
40812     Excis lesion mucosa&submucosa,vestibule mouth;w/simp repair                 B
40814     Excis lesion mucosa&submucosa,vestibule mouth;w/comp repair                  2
40816     Exc lesion mucosa&submucosa,vestibule mouth;comp,exc muscle                  2
40818     Excision mucosa vestibule mouth as donor graft                               1
40819     Excision frenum,labial/buccal                                                1
40820     Destruct lesion/scar vestibule mouth;physical methods                        1
40830     Closure laceration,vestibule mouth;2.5cm or<                                A
40831     Closure laceration,vestibule mouth;over 2.6cm/complex                        1
40840     Vestibuloplasty;anterior                                                     2
40842     Vestibuloplasty;posterior,unilateral                                         3
40843     Vestibuloplasty;posterior,bilateral                                          3
40844     Vestibuloplasty;entire arch                                                  5
40845     Vestibuloplasty;complex                                                      5
40899     Unlisted procedure,vestibule of mouth                                       U
41000     Intraoral incis abscess,cyst,hematoma tongue/mouth;lingual                   1
41005     Intraoral incis abscess,cyst,hematoma tongue/mouth;sublingual                1
41006     Intraoral inc abscess,cyst,hematoma tongue/mouth;subling deep                1
41007     Intraoral incis abscess,cyst,hematoma tongue/mouth;lingual                   1
5101:3-2-21                                                                Page 47 of 81

                                                              APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                               GROUP NOTE
41008     Intraoral inc abscess,cyst,hematoma tongue/mouth;submandibula      1
41009     Intraoral incis abscess,cyst,hematoma tongue/mouth;masticator      1
41010     Incision lingual frenum                                            1
41015     Extraoral inc abscess,cyst,hematoma floor mouth;sublingual         1
41016     Extraoral inc abscess,cyst,hematoma floor mouth;submental          1
41017     Extraoral inc abscess,cyst,hematoma floor mouth;submandibul        1
41018     Extraoral inc abscess,cyst,hematoma floor mouth;masticator         1
41019     Place needles H&N for RT                                           3
41100     Biopsy tongue,anterior two-thirds                                  2
41105     Biopsy tongue;posterior one-third                                  2
41108     Biopsy floor mouth                                                 1
41110     Excision lesion tongue w/o closure                                 1
41112     Excision lesion tongue w/closure;anterior two-thirds               2
41113     Excision lesion tongue w/closure;posterior 1/3                     2
41114     Excision lesion tongue w/closure;w/local tongue flap               2
41115     Excision lingual frenum                                            1
41116     Excision,lesion floor mouth                                        1
41120     Glossectomy;less than one-half tongue                              5
41130     Glossectomy;hemiglossectomy                                        5
41250     Repair lacerat 2.5cm or<;floor mouth/ant 2/3 tongue                2
41251     Repair laceration 2.5cm or<;post 1/3 tongue                        2
41252     Repair lacerat tongue,floor mouth,>2.6cm/complex                   2
41500     Fixation of tongue,mechanical,other than suture                    1
41510     Suture tongue lip for micrognathia                                 1
41512     Tongue base suspension, permanent suture technique                B
41520     Frenoplasty                                                        2
41530     Ablation of the tongue base, radiofrequency, one or more sites     2
41599     Unlisted procedure,tongue,floor mouth                             U
41800     Drain/abscess,cyst,hematoma from dentoalveolar structures          1
41805     Remov embedded forgn body from dentoalveolar struct;sft tis        1
41806     Remov embedded forgn body from dentoalveolar struct;bone           1
41820     Gingivectomy,excision gingiva,each quadrant                        1
41821     Operculectomy,excision pericoronal tissues                         1
41822     Excision fibrous tuberosities,dentoalveolar structures             1
41823     Excision osseous tuberosities,dentoalveolar structures             1
41825     Excis lesion/tumor,dentoalveolar structure;w/o repair              1
41826     Excis lesion/tumor;dentoalveolar structure;w/simp repair           2
41827     Excis lesion/tumor;dentoalveolar structure;w/comp repair           2
41828     Excis hyperplastic alveolar mucosa,each sextant/quadrant           1
41830     Alveolectomy,incl curettage osteitis/sequestrectomy                2
41850     Destruction of lesion,dentoalveolar structures                    B
41870     Periodontal mucosal grafting                                       1
41872     Gingivoplasty                                                      1
41874     Alveoplasty                                                        1
41899     Unlisted procedure,dentoalveolar structures                       U
42000     Drainage abscess palate,uvula                                      2
42100     Biopsy palate,uvula                                                2
42104     Excision,lesion palate,uvula;w/o closure                           2
42106     Excision,lesion palate,uvula;w/simple primary closure              2
42107     Excision,lesion palate,uvula;w/local flap closure                  2
42120     Resection palate/extensive resection lesion                        4
5101:3-2-21                                                                         Page 48 of 81

                                                             APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                        GROUP NOTE
42140     Uvulectomy,excision uvula                                                   2
42145     Palatopharyngoplasty                                                        5
42160     Destruction lesion,palate/uvula                                             1
42180     Repair,laceration palate;up to 2cm                                          1
42182     Repair,laceration palate;over 2 cm/complex                                  2
42200     Platoplasty cleft palate,soft &/or hard palate                              5
42205     Palatoplasty cleft palate,closure alveolar ridge,soft tissue                5
42210     Palatoplasty cleft palate,bone graft to alveolar ridge                      5
42215     Palatoplasty cleft palate,major revision                                    7
42220     Palatoplasty cleft palate,secondary lengthening proc                        5
42225     Palatoplasty cleft palate,attach pharyngeal flap                            5
42226     Lengthening of palate, and pharyngeal flap                                  5
42227     Lengthening of palate, with island flap                                     5
42235     Repair ant palate,incl vomer flap                                           5
42260     Repair nasolabial fistuls                                                   4
42280     Maxillary impression for palatal prosthesis                                A
42281     Insertion of pin-retained palatal prosthesis                                3
42299     Unlisted procedure,palate,uvula                                            U
42300     Drainage abscess;parotid,simple                                             1
42305     Drainage abscess;parotid,complicated                                        2
42310     Drainage abscess;submaxillary/sublingual,intraoral                          1
42320     Drainage abscess;submaxillary,external                                      1
42330     Sialolithotomy;submandibular,sublingual/parotid,uncomp                      1
42335     Sialolithotomy;submandibular,complicated,intraoral                          3
42340     Sialolithotomy;parotid,extraoral/complicated intraoral                      2
42400     Biopsy of salivary gland;needle                                            A
42405     Biopsy of salivary gland;incisional                                         2
42408     Excision of sublingual salivary cyst                                        3
42409     Marsupialization sublingual salivary cyst                                   3
42410     Exc parotid tumor/gland;lateral lobe w/o nerve dissectio                    3
42415     Exc parotid tumor/gland;lateral lobe w/dissect/preserve of facial nerve     7
42420     Exc parotid tumor/gland;tot w disection/preservation facial nerve           7
42425     Exc parotid tumor gland;tot en bloc removal w sacrifice facial nerve        7
42440     Excision submandibular gland                                                3
42450     Excision sublingual gland                                                   2
42500     Plastic repair salivary duct,sialodochoplasty;                              3
42505     Plastic repair salivary duct,sialodochoplasty;second/comp                   4
42507     Parotid duct diversion,bilateral;                                           3
42508     Parotid duct diversion,bilat;w/exc 1 submandibular gland                    4
42509     Parotid duct diversion,bilat;w/exc 2 submandibular gland                    4
42510     Parotid duct diversion,bilat;w/ligat 2 submandibular duct                   4
42550     Injection procedure;sialography                                            A
42600     Closure salivary fistula                                                    1
42650     Dilation salivary duct                                                     A
42660     Dilation&cath salivary duct,w/wo inj                                       A
42665     Ligation salivary duct,intraoral                                            1
42699     Unlisted procedure,salivary glands/ducts                                   U
42700     I&D abscess;peritonsillar                                                   1
42720     I&D abscess;retropharyngeal/parapharyngeal,intraoral                        1
42725     I&D abscess;retropharyngeal/parapharyngeal,external                         2
42800     Biopsy;oropharynx                                                          B
5101:3-2-21                                                                                                   Page 49 of 81

                                                               APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                                                  GROUP NOTE
42802     Biopsy;hypopharynx                                                                                    1
42804     Biopsy;nasopharynx,visible lesion,simple                                                              1
42806     Bx;nasopharynx,survey;unknown primary lesion                                                          2
42808     Excision/destruction lesion pharynx,any method                                                        2
42809     Removal foreign body;pharynx                                                                         B
42810     Exc branchial cleft cyst/vestige;confine to skin&subcut tis                                           3
42815     Exc branchial cleft cyst/vestige;extend beneath subcuta tis                                           5
42820     Tonsillectomy/adenoidectomy;<age 12                                                                   4
42821     Tonsillectomy/adenoidectomy;>age 12                                                                   5
42825     Tonsillectomy,primary/secondary;<age 12                                                               4
42826     Tonsillectomy,primary/secondary;>age 12                                                               4
42830     Adenoidectomy,primary;<age 12                                                                         4
42831     Adenoidectomy,primary;age 12 or>                                                                      4
42835     Adenoidectomy,secondary;<age 12                                                                       4
42836     Adenoidectomy,secondary;age 12 or>                                                                    4
42842     Radical resection of tonsil, tonsillar pillars and/or retromolar trigone; without closure             3
42844     Radical resection of tonsil, tonsillar pillars and/or retromolar trigone; closure with local flap     5
42860     Excision tonsil tags                                                                                  3
42870     Excision/destruction lingual tonsil,any method,separate proc                                          3
42890     Partial removal of pharynx                                                                            7
42892     Revision of pharyngeal walls                                                                          7
42900     Suture pharynx;wound/injury                                                                           1
42950     Pharynpolasty                                                                                         2
42953     Pharyngoesophageal repair                                                                             2
42955     Pharyngostomy                                                                                         2
42960     Control oropharyngeal hemorrhage;simple                                                               1
42962     Control oropharyngeal hemorrhage;secondary surg intervention                                          2
42970     Contrl nasopharyngeal hemorrhage;simp,post nasal packs                                               A
42972     Control nasopharyngeal hemorrhage, primary or secondary; with secondary surgical intervention         2
42999     Unlisted procedure,pharynx,adenoids,or tonsils                                                       U
43020     Incision of esophagus                                                                                 1
43030     Throat muscle surgery                                                                                 2
43130     Removal of esophagus pouch                                                                            7
43200     Esophagoscopy,rigid/flexible;dx,w/wo spec                                                             1
43201     Esoph scope w/submucous inj                                                                           1
43202     Esophagoscopy,rigid/flexible;bx,sgl/mult                                                              1
43204     Esophagoscopy,rigid/flexible;inj sclerosis                                                            1
43205     Esophagoscopy,rigid/flexible;band ligation                                                            1
43215     Esophagoscopy,rigid/flexible;removal foreign body                                                     1
43216     Esophagoscopy,rigid/flexible;remove by hot bx forceps                                                 1
43217     Esophagoscopy,rigid/flexible;remove by snare tech                                                     1
43219     Esophagoscopy,rigid/flexible;insert tube/stent                                                        1
43220     Esophagoscopy,rigid/flexible;balloon dilation                                                         1
43226     Esophagoscopy,rigid/flexible;insert wire w dilation                                                   1
43227     Esophagoscopy,rigid/flexible;contrl hemorrhage                                                        2
43228     Esophagoscopy,rigid/flexible;ablation tumor/lesi                                                      2
43231     Esophagoscopy,rigid/flexible; with endoscopic ultrasound exam                                         2
43232     Esophagoscopy,rigid/flexible; with transendoscopic ultrasound guided                                  2
43234     Upper GI endoscopy,simple primary examination                                                         1
43235     Upper GI endoscopy incl esophagus,stomach;comp                                                        1
43236     Uppr gi scope w/submuc inj                                                                            2
5101:3-2-21                                                                                   Page 50 of 81

                                                              APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                                  GROUP NOTE
43237     Upper GI endoscopy; w/endoscopic u/s esophageal exam                                  2
43238     Upper GI endoscopy; w/transendoscopic u/s-guided needle aspiration/bx, esophagus      2
43239     Upper GI endoscopy;biopsy,sgl/multiple                                                2
43240     Upper GI endoscopy;including esophagus, stomach                                       2
43241     Upper GI endoscopy;w/tube/catheter plcmt                                              2
43242     Upper GI endoscopy;includ esophogas, stomach, ultrsound guided                        2
43243     Upper GI endoscopy,inj sclerosis of varices                                           2
43244     Upper GI endoscopy,band ligation of varices                                           2
43245     Upper GI endoscopy;dilation gastic outlet                                             2
43246     Upper GI endoscopy;plcmt gastrostomy tube                                             2
43247     Upper GI endoscopy;removal foreign body                                               2
43248     Upper GI endoscopy;insert guide wire w dilation                                       2
43249     Upper GI endoscopy;w/ balloon dilation of esophagus                                   2
43250     Upper GI endoscopy;removal tumor w hot bx forceps                                     2
43251     Upper GI endoscopy;remov lesion by snare technique                                    2
43255     Upper GI endoscopy;control hemorrhage                                                 2
43256     Upper GI endoscopy;includ esophogas, stomach, stent placement                         2
43257     Upper GI endoscopy;include esophogas, stomach and either duodem or jejunum            2
43258     Upper GI endoscopy;ablation tumor/lesion                                              3
43259     Upper GI endoscopy;endo ultrasound                                                    3
43260     ERCP,w/wo specimen collect;                                                           2
43261     ERCP w biopsy,sgl/multi                                                               2
43262     ERCP;sphincterotomy/papillotomy                                                       2
43263     ERCP;pressure measure sphincter Oddi                                                  2
43264     ERCP;endo retro remov stone biliary/pancreatic ducts                                  2
43265     ERCP;endo retro destruct,lithotripsy stone                                            2
43267     ERCP;endo retro insert nasobiliary/nasopancreatic drain tube                          2
43268     ERCP;endo retro insert tube/stent into bile/pancreatic duct                           2
43269     ERCP;endo retro removal foreign body&/or change tube/stent                            2
43271     ERCP;endo retro balloon dil ampulla,biliary/pancreatic duct                           2
43272     ERCP;ablation tumor/mucosal lesion                                                    2
43273     Endoscopic pancreatoscopy                                                             3
43280     Laparoscopy, surg; esophagogastric fundoplasty                                        4
43289     Unlisted laparoscopy, procedure, esophagus                                           U
43420     Repair esophagus opening                                                              8
43450     Dilation esophagus,by sound/bougie;initial session                                    1
43453     Dilation esophagus,over guide wire                                                    1
43456     Dilation esophagus,balloon/dilator;retrograde                                         2
43458     Dilation esophagus,balloon                                                            2
43460     Esophagogastric tamponade,w/balloon                                                   1
43496     Microvascular free jejunum transfer                                                   1
43499     Unlisted procedure,esophagus                                                         U
43500     Gastrotomy, exploration/foreign body removal                                         B
43510     Gastrotomy; with esophageal dilation and insertion of permanent intraluminal tube    B
43600     Bx stomach;by capsule,tube,peroral                                                    1
43605     Bx stomach;by laparotomy                                                              2
43647     Laparoscopy, surgical; implant/replace gastric neurostimulator electrodes             5
43648     Laparoscopy, surgical; revise/remove gastric neurostimulator electrodes               6
43651     Laparoscopy, surgical; transection of vagus nerves, truncal                           4
43652     Transection of vagus, selective or highly selective                                   5
43653     Gastrostomy, without construction of gastric tube                                     4
5101:3-2-21                                                                                     Page 51 of 81

                                                            APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                                    GROUP NOTE
43659     Unlisted laparoscopy, procedure, stomach                                               U
43760     Change gastrostomy tube                                                                 1
43761     Reposition gastric feed tube thru duodenum                                             B
43830     Gastrostomy                                                                             3
43831     Gastrostomy, open; neonatal for feeding                                                B
43870     Closure gastrostomy,surgical                                                            1
43999     Unlisted procedure,stomach                                                             U
44100     Bx intestine by capsule,tube,peroral                                                    1
44180     Laparoscopy, surgical, enterolysis                                                      4
44186     Laparoscopy, surgical, jejunostomy                                                      4
44187     Laparoscopy, surgical; ileostomy or jejunostomy, non tube                               4
44188     Laparoscopy, surgical, colostomy or skin level cecostomy                                4
44202     Intestinal resection, with anastomosis                                                  4
44203     Laparoscopic resection of small intestine                                               1
44204     Laparoscopic partial colectomy,w amastomosis                                            8
44205     Laparoscopic partial colectomy, w. removal ileum                                        4
44206     Laparoscopy, surgical; colectomy, partial with end colostomy                            7
44207     Laparoscopy, surgical; colectomy, partial with anastomosis, with coloproctostomy        7
44213     Laparoscopy, surgical, mobilization of splenic flexure in conj w/ partial colectomy    B
44227     Laparoscopy, surgical, closure of jejunostomy, large or small intestine                 7
44238     Laparoscope proc, intestine                                                            U
44312     Revision ileostomy;simple                                                               1
44340     Revision colostomy;simple                                                               3
44345     Revision colostomy;complicated                                                          4
44346     Revision colostomy;w/repair paracolostomy hernia                                        4
44360     Sm intestine endo,not illium;diagnostic                                                 2
44361     Sm intestine endo,not illium;bx,sgl/multi                                               2
44363     Sm intestine endo,not illium;removal foreign body                                       2
44364     Sm intestine endo,not illium;remove tumor,snare technique                               2
44365     Sm intestine endo,not illium;remove tumor,hot bx forceps                                2
44366     Sm intestine endo,not illium;control bleeding                                           2
44369     Sm intestine endo,not illium;ablation tumor/mucosal lesion                              2
44370     Sm intestine endo,enteroscopy, with stent placement                                     2
44372     Sm intestine endo,not illium,placemt percutaneous jujunostomy                           2
44373     Sm intestine endo,not illium;convert percut gastrostomy to jujuno                       2
44376     Sm intestine endo,illium;diagnostic                                                     3
44377     Sm intestine endo,illium;bx,sgl/multi                                                   3
44378     Sm intestine endo,illium;control bleeding                                               3
44379     Sm intestine endo,enteroscopy, including ileum, with stent placement                    2
44380     Ileoscopy thru stoma;dx                                                                 1
44382     Ileoscopy thru stoma;bx,sgl/multi                                                       1
44383     Ileoscopy thru stoma;with transendoscopic stent placement                               1
44385     Endo eval sm intestine;dx                                                               1
44386     Endo eval sm intestine;bx,sgl/multi                                                     1
44388     Colonoscopy thru stoma;dx                                                               1
44389     Colonoscopy thru stoma;bx,sgl/multi                                                     1
44390     Colonoscopy thru stoma;remove foreign body                                              1
44391     Colonoscopy thru stoma;control bleeding                                                 1
44392     Colonoscopy thru stoma;remove tumor,hot bx forceps                                      1
44393     Colonoscopy thru stoma;ablation tumor                                                   1
44394     Colonoscopy thru stoma;remove tumor,snare technique                                     1
5101:3-2-21                                                                 Page 52 of 81

                                                             APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                GROUP NOTE
44397     Colonoscopy thru stoma, with transendoscopic stent placement        2
44500     Intro long gastrointestinal tube                                   A
44701     Intraop colon lavage add-on                                         2
44799     Unlisted procedure,intestine                                       U
44800     Excision Meckel's diverticulum/omphalomesenteric duct               4
44820     Excision lesion mesentery                                           3
44850     Suture mesentery                                                    3
44899     Unlisted procedure,Meckel's diverticulum/mesentery                 U
44900     I&D appendiceal abscess,transabdominal                              1
44901     Percutaneous I & D of appendiceal abscess                           1
44950     Appendectomy                                                        4
44955     Appendectomy w/ other major procedure                               4
44960     Appendectomy, ruptured appendix                                     4
44970     Laparoscopy, surgical, appendectomy                                 4
44979     Unlisted laparoscopy, procedure, appendix                          U
45000     Transrectal drainage pelvic abscess                                 1
45005     I&D submucosal abscess,rectum                                       2
45020     I&D deep supralevator,pelvirectal,retrorectal abscess               2
45100     Bx anorectal wall,anal approach                                     1
45108     Anorectal myomectomy                                                2
45150     Division stricture rectum                                           2
45160     Excision rectal tumor by proctotomy                                 3
45171     Exc rect tum transanal part                                         2
45172     Exc rect tum transanal full                                         8
45190     Destruction rectal tumor                                            3
45300     Proctosigmoidoscopy,rigid;diagnostic                               A
45303     Proctosigmoidoscopy,rigid;dilation                                 B
45305     Proctosigmoidoscopy,rigid;biopsy                                    1
45307     Proctosigmoidoscopy,rigid;removal foreign body                      1
45308     Proctosigmoidoscopy,rigid;remove sgl tumor,hot bx forceps           1
45309     Proctosigmoidoscopy,rigid;remove sgl tumor,snare technique          1
45315     Proctosigmoidoscopy,rigid;remov mult tumors                         1
45317     Proctosigmoidoscopy,rigid;control bleeding                          1
45320     Proctosigmoidoscopy,rigid;ablation tumor                            1
45321     Proctosigmoidoscopy,rigid;decompression volvulus                    1
45327     Protosigmoidoscopy, rigid; with transendoscopic stent placement     1
45330     Sigmoidoscopy,flexible;diagnostic                                   1
45331     Sigmoidoscopy,flexible;bx,sgl/multi                                 1
45332     Sigmoidoscopy,flexible;remov foreign body                           1
45333     Sigmoidoscopy,flexible;remov tumor,hot bx forceps                   1
45334     Sigmoidoscopy,flexible;control bleeding                             1
45335     Sigmoidoscope w/submuc inj                                          1
45337     Sigmoidoscopy,flexible;decompression volvulus                       1
45338     Sigmoidoscopy,flexible;remov tumor,snare technique                  1
45339     Sigmoidoscopy,flexible;ablation tumor                               1
45340     Sig w/balloon dilation                                              1
45341     Sigmoidoscopy,flexible, with endoscopic ultrasound exam             2
45342     Sigmoidoscopy,flexible w/ transendoscopic ultrasound guided         2
45345     Sigmoidoscopy,flexible w/ transendoscopic stent placement           1
45355     Colonoscopy,rigid/flexible,transabd via colotomy                    1
45378     Colonoscopy,flexible,prox to splenic flexure;diagnostic             2
5101:3-2-21                                                                                                      Page 53 of 81

                                                              APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                                                     GROUP NOTE
45379     Colonoscopy,flexible;remov foreign body                                                                  2
45380     Colonoscopy,flexible;bx,sgl/multi                                                                        2
45381     Colonoscope, submucous inj                                                                               2
45382     Colonoscopy,flexible;control bleeding                                                                    2
45383     Colonoscopy,flexible;ablation tumor/polyps                                                               2
45384     Colonoscopy,flexible;remove tumor,hot bx forceps                                                         2
45385     Colonoscopy,flexible;remov tumor,snare technique                                                         2
45386     Colonoscope dilate stricture                                                                             2
45387     Colonoscopy, flexible, w/ transendoscopic stent placement                                                2
45391     Colonoscopy, flexible, proximal to splenic flexure;diagnostic w/endo ultrasound exam                     2
45392     Colonoscopy, flexible, proximal to splenic flexure;diagnostic, w/ transendo ultra guided fine needle     2
45400     Laparoscopy, surgical; proctopexy                                                                        4
45402     Laparoscopy, surgical; proctopexy, with sigmoid resection                                                6
45499     Unlisted laparoscopy procedure, rectum                                                                  U
45500     Proctoplasty;for stenosis                                                                                2
45505     Proctoplasty;prolapse mucous membrane                                                                    2
45520     Perirectal inj sclerosing sol,prolapse                                                                   2
45541     Proctopexy; perineal approach                                                                            6
45560     Repair of rectocele                                                                                      2
45562     Exploration/ repair of rectum                                                                            4
45563     Exploration/ repair of rectum                                                                            5
45800     Closure of rectovesical fistula;                                                                         5
45820     Closure of rectourethral fistula;                                                                        5
45900     Reduction procidentia under anesthesia                                                                   1     ***
45905     Dilation anal sphincter under anesthesia ot local                                                        1     ***
45910     Dilation rectal stricture under anesthesia o.t. local                                                    1     ***
45915     Removal fecal impaction/foreign body under anesthesia                                                    1     ***
45990     Anorectal exam,surg,anesthesia,diagnostc                                                                B      ***
45999     Unlisted procedure,rectum                                                                               U
46020     Placement of anal seton                                                                                  2
46030     Removal anal seton,other marker                                                                          1
46040     I&D ischio &/or perirectal abscess                                                                       3
46045     I&D intramural,intramuscular/abscess,transanal,anesth                                                    2     ***
46050     I&D,perianal abscess,superficial                                                                         1
46060     I&D ischiorectal/intramural abscess,w fistulectomy                                                       2
46070     Incision,anal septum                                                                                     3
46080     Sphincterotomy,anal,division sphincter                                                                   3
46083     Incision thrombosed hemorrhoid,external                                                                  1
46200     Fissurectomy,w/wo sphincterotomy                                                                         2
46220     Papillectomy/excision single tag,anus                                                                    1
46221     Hemorrhoidectomy,by simple ligature                                                                      2
46230     Excis ext hemorrhoid tags and/or multi papillae                                                          2
46250     Hemorrhoidectomy,external ,complete                                                                      3
46255     Hemorrhoidectomy,ext & int,simple;                                                                       3
46257     Hemorrhoidectomy,ext & int,simple;w/fissurectomy                                                         3
46258     Hemorrhoidectomy,ext & int,simple;w/fistulectomy                                                         3
46260     Hemorrhoid,complex or extensive;                                                                         3
46261     Hemorrhoid,complex/extensive;w/fissurectomy                                                              4
46262     Hemorrhoid,complex/extensive;w/fistulectomy                                                              4
46270     Surg trt anal fistula;subctaneous                                                                        3
46275     Surg trt anal fistula;submuscular                                                                        3
5101:3-2-21                                                                     Page 54 of 81

                                                                   APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                    GROUP NOTE
46280     Surg trt anal fistula;complex/multi                                     4
46285     Closure anal fistula,second stage                                       1
46288     Repair anal fistula                                                     5
46320     Enucleation/excision external thrombotic hemorrhoid                     2
46500     Inj sclerosing solution,hemorrhoids                                    B
46505     Chemodenervation,internal anal sphincter                               A
46600     Anoscopy;diagnostic                                                     1
46604     Anoscopy;dilation,any method                                           A
46606     Anoscopy;biopsy,sgl/multi                                              A
46608     Anoscopy;removal foreign body                                           1
46610     Anoscopy;remove tumor,hot bx forceps                                    1
46611     Anoscopy;remove tumor,snare technique                                   1
46612     Anoscopy;multiple tumor removal                                         1
46614     Anoscopy;control bleeding                                              B
46615     Anoscopy;ablation tumor                                                 1
46700     Anoplasty,plastic op structure;adult                                    3
46705     Anoplasty,plastic op structure;infant                                   3
46706     Repr of anal fistula w/glue                                             1
46707     Repair anorectal fist w/plug                                            5
46710     Rpr ileoanal,fistula/sinus;transprnl app                                4
46712     Rpr ileoanal fist/sin;trnsprnl& trnsabd                                 9
46750     Sphincteroplasty,anal,incontinence/prolapse;adult                       3
46751     Sphincteroplasty,anal,incontinence/prolapse;child                       3
46753     Graft rectal incontinence and/or prolapse                               3
46754     Removal thiersch wire/suture,anal canal                                 2
46760     Sphincteroplasty,anal,incontinence,adult;muscle transpl                 2
46761     Sphincteroplasty,anal,incontinence,adult;muscle imbrication             3
46762     Sphincteroplasty,anal,incontinence,adult;implant sphincter              4
46900     Destruction lesion,anus,simple;chemical                                A
46910     Destruction lesion,anus,simple;electrodesiccation                      A
46916     Destruction lesion,anus,simple;cryosurgery                             A
46917     Destruction lesion,anus,simple;laser surgery                           A
46922     Destruction lesion,anus,simple;surgical excision                        1
46924     Destruction lesion,anus,extensive,any method                            1
46930     Destruction of internal hemorrhoids                                     1
46940     Curet/cauterization anal fissure,incl dilation;initial                  2
46942     Curet/cauterization anal fissure,incl dilation;subsequen                2
46945     Ligation internal hemorrhoids;single procedure                          2
46946     Ligation internal hemorrhoids;multile procedures                        2
46947     Hemorrhoidopexy by stapling                                             2
46999     Unlisted procedure,anus                                                U
47000     Biopsy of liver,percutaneous needle                                     1
47001     Bx liver, w other major procedure                                      B
47010     Hepatotomy drg abscess/cyst,one/two stages                              5
47011     Hepatotomy for percutaneous drainage                                    5
47015     Inject/aspirate liver cyst                                              3
47100     Biopsy liver,wedge                                                      2
47370     Laparoscopic radiofrequency ablation of liver tumor, radiofrequency     3
47371     Laparoscopic radiofrequency ablation of liver tumor, cyrosurgical       3
47379     Unlisted laproscopy procedure, liver                                   U
47380         Ablation of liver tumor, 1 or more                                  4
5101:3-2-21                                                                  Page 55 of 81

                                                              APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                 GROUP NOTE
47381     Open cryosurgical ablation of liver tumor                            4
47382     Percutaneous radiofrequency ablation of liver tumor                  2
47399     Unlisted procedure,liver                                            U
47490     Percutaneous cholecystostomy                                        A
47500     Inj proc percutaneous transhepatic cholangiography                  A
47505     Inj proc cholangiography thru existing catheter                     A
47510     Intro percutaneous transhepatic catheter/biliary drg                 2
47511     Intro percutaneous transhepatic stent;int/ext drg                    2
47525     Change percutaneous biliary drg catheter                             1
47530     Revision &/or reinsertion transhepatic T-tube                        1
47552     Biliary endoscopy,via T-tube;dx                                      2
47553     Biliary endoscopy,via T-tube;bx,sgl/multi                            3
47554     Biliary endoscopy,via T-tube;remove stone                            3
47555     Biliary endoscopy,via T-tube;dilat wo stent                          3
47556     Biliary endoscopy,via T-tube;dilat w stent                           3
47560     Laparoscopy, surg; with guided transhepatic cholangiography          3
47561     With guided transhepatic cholangiography with biopshy                3
47562     Cholecystectomy                                                      4
47563     Cholecystectomy with cholangiography                                 5
47564     Cholecystectomy with exploration of common duct                      5
47570     Cholecystoenterostomy                                                4
47579     Unlisted laparoscopy, procedure, biliary duct                       U
47630     Biliary duct stone extraction,percutaneous via t-tube, etc.          3
47999     Unlisted procedure,biliary tract                                    U
48100     Biopsy of pancreas,open                                             B
48102     Biopsy pacnreas,percutaneous needle                                  1
48999     Unlisted procedure,pancreas                                         U
49000     Exploratory lap;explore ceiliotomy                                   4
49002     Reopening recent lap incis explore,remov hematoma                    4
49010     Exploration,retroperitoneal area                                     4
49020     Drain peritoneal abscess/local peritonitis,transabd                  1
49021     Percutaneous drainage of peritoneal abscess                          1
49040     Drg subdiaphragmatic/subphrenic                                      1
49041     Drainage of abdominal abscess                                        1
49060     Drain retroperitoneal abscess                                        1
49061     Drainage of retroperitoneal abscess                                  1
49062     Drainage of extraperitoneal lymphocele to peritoneal cavity          2
49080     Peritoneocentesis,abd paracentisis,lavage;initial,dx                 2
49081     Peritoneocentesis,abd paracentisis,lavage;subsequent,dx              2
49180     Bx,abd/retroperitoneal mass,percutaneous needle                      1
49250     Umbilectomy, omphalectomy                                            4
49255     Omentectomy, epiploectomy                                            2
49320     Laparoscopy, surg; abdomen, peritoneeum, omentum; diagnostic         3
49321     Wtih biopsy                                                          4
49322     With aspiration of cavity or cyst                                    4
49323     With drainage of lymphocele to peritoneal cavity                     4
49324     Laparoscopy, surgical; insert permanent intraperitoneal catheter     4
49325     Laparoscopy, surgical; revision of intraperitoneal catheter          4
49326     Laparoscopy, surgical; with omentopexy                               4
49329     Unlisted laparoscopy procedure, abdomen, peritoneum, omentum        U
49400     Inj air/contrast in peritoneal cavity                                1
5101:3-2-21                                                                         Page 56 of 81

                                                             APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                        GROUP NOTE
49402     Removal of peritoneal foreign body from peritoneal cavity                   2
49411     Ins mark abd/pel for rt perq                                                2
49419     Insrt abdom cath for chemotx                                                2
49420     Insert intraperitoneal cannula/catheter,drain/dialysis;temp                 1
49421     Insert intraperitoneal cannula/catheter,drain/dialysis;perm                 1
49422     Remove perm cannula/catheter                                               B
49423     Exhange of previously places drainage catheter                             B
49424     Contrast injection for abscess assessment via previously placed cathet.    B
49425     Peritoneal-venous shunt                                                     2
49426     Revision of peritoneal-venous shunt                                         2
49427     Inj proc eval peritoneal-venous shunt                                      A
49428     Ligation of shunt                                                          A
49429     Removal of shunt                                                           B
49435     Insert subcutaneous extension to intraperitoneal catheter                   2
49436     Delayed creation exit site, embedded catheter                               2
49440     Place gastrotomy tube perc                                                  1
49441     Place duod/jej tube perc                                                    1
49442     Place cecostomy tube perc                                                   1
49446     Change G-tube to G-J perc                                                   1
49450     Replace G/C tube perc                                                      B
49451     Replace duod/ jej tube perc                                                B
49452     Replace G-J tube perc                                                      B
49460     Fix G/colon tube w/device                                                  B
49465     Fluoro exam of G/colon tube                                                A
49491     Inguinal hernia repair on preterm infant,w or w/o hydrocelectomy            4
49492     Inguinal hernia repair on preterm infant,incarcerated                       8
49495     Repair inguinal hernia,<6 mo;reducible                                      2
49496     Repair inguinal hernia,<6 mo;incarcerated                                   3
49500     Repair inguinal hernia,6 mo-<5yrs;reducibla                                 4
49501     Repair inguinal hernia,6 mo-<5yrs;incarcerated                              4
49505     Repair inguinal hernia,>age 5;reducible                                     4
49507     Repair inguinal hernia,>age 5;incarcerated                                  5
49520     Repair recurrent inguinal hernia,any age;reducible                          7
49521     Repair recurrent inguinal hernia,any age;incarcerated                       7
49525     Repair inguinal hernia,any age;sliding                                      4
49540     Repair lumbar hernia                                                        2
49550     Repair femoral hernia,any age;reducible                                     4
49553     Repair femoral hernia,any age;incarcerated                                  5
49555     Repair femoral hernia,recurrent;reducible                                   5
49557     Repair femoral hernia,recurrent;incarcerated                                6
49560     Repair incisional hernia;reducible                                          4
49561     Repair incisional hernia;incarcerated                                       5
49565     Repair incisional recurrent hernia;reducible                                4
49566     Repair incisional recurrent hernia;incarcerated                             5
49568     Implantation prosthesis for incisional hernia repair                       A
49570     Repair epigastric hernia,reducible                                          4
49572     Repair epigastric hernia,incarcerated                                       5
49580     Repair umbilical hernia;<age 5 yrs,reducible                                4
49582     Repair umbilical hernia;<age 5 yrs,incarcerated                             4
49585     Repair umbilical hernia;age 5 or>,reducible                                 4
49587     Repair umbilical hernia;age 5 or >,incarcerated                             5
5101:3-2-21                                                                   Page 57 of 81

                                                                 APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                  GROUP NOTE
49590     Repair spigelian hernia                                               3
49600     Repair omphalocele;sm w primary closure                               6
49650     Laparoscopy, surgical, repair initial inguinal hernia                 4
49651     Repair recurrent inguinal hernia                                      7
49652     Laparoscopic repair, ventral hernia                                   7
49653     Laparoscopic repair, ventral hernia, strangulated                     7
49654     Laparoscopic repair, incisional hernia                                7
49655     Laparoscopic repair, incisional hernia, strangulated                  7
49656     Laparoscopic repair, recurrent incisional hernia                      7
49657     Laparoscopic repair, recurrent incisional hernia, strangulated        7
49659     Unlisted laparoscopy proc, hernioplasty, herniorraphy, herniotomy    U
49900     Suture, secondary abd wall, evisceration/dehiscence                   1
49904     Omental flap, extra-abdom                                             6
49999     Unlisted procedure,abdomen,peritoneum/omentum                        U
50010     Renal exp,not necessitating other specific proc                       4
50020     Drg perirenal/renal abscess                                           2
50021     Drainage of perirenal or renal abscess                                2
50040     Nephrostomy,nephrotomy w/ drainage                                    3
50080     Percutaneous nephrostolithotomy/pyelostolithotomy;< 2cm              A
50081     Percutaneous nephrostolithotomy/pyelostolithotomy;> 2cm              A
50200     Renal bx;percutaneous,trocar/needle                                   1
50205     Biopsy of kidney                                                      3
50382     Removal and replacement internl uretrl stent, percut app             B
50384     Removal internl ureteral stent, percut app                           B
50385     Change stent via transureth                                           2
50386     Remove stent via transureth                                          B
50387     Removal and replacement of ext transnephric uretrl stent             A
50389     Removal of nephrostomy tube, fluoroscopic guide                      A
50390     Asp/inj renal cyst/pelvis by needle,percutaneous                      1
50391     Instillations of therapeutic agent into renal pelvis                  1
50392     Intro intra/catheter into renal pelvis;drg/inj                        1
50393     Intro ureteral cath/stent ureter;drg/inject                           1
50394     Inj proc pyelography thru nephrostomy/pyelostomy tube                 1
50395     Intro guide; renal pelvis/ureter w/dialation                          1
50396     Mamometric studies thru nephrostomy/pyelostomy tube                   1
50398     Change nephrostomy/pyelostomy tube                                    1
50520     Closure nephrocutaneous/pyelocutaneous fistula                        1
50541     Laparoscopy, surgical; ablation of renal cysts                        4
50542     Laparo ablate renal mass                                              5
50543     Laparo partial nephrectomy                                            6
50544     Pyeloplasty                                                           5
50546     Nephrectomy                                                           5
50549     Unlisted laparoscopy procedure, renal                                U
50551     Renal endoscopy thru estab nephrostomy/pyelostomy;                    1
50553     Renal endoscopy thru nephrostomy/pyelostomy;ureteral cath             1
50555     Renal endoscopy thru nephrostomy/pyelostomy;w/biopsy                  1
50557     Renal endoscopy thru nephrostomy/pyelostomy;fulgurat/incis            1
50561     Renal endoscopy thru nephrostomy/pyelostomy;remov foreign body        1
50562     Renal scope w/tumor resect                                            2
50570     Renal endoscopy thru nephrotomy/pyelotomy;                            1
50572     Renal endoscopy thru nephrotomy/pyelotomy;ureteral cath               1
5101:3-2-21                                                                                       Page 58 of 81

                                                               APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                                      GROUP NOTE
50574     Renal endoscopy thru nephrotomy/pyelotomy;w/biopsy                                        1
50575     Renal endoscopy thru nephrotomy w endopyelotomy                                           2
50576     Renal endoscopy thru nephrotomy/pyelotomy;fulgurat/incis                                  1
50580     Renal endoscopy thru nephrotomy/pyelotomy;remov foreign body                              1
50590     Lithotripsy,extracorporeal                                                                9
50592     Abltn,1or+ renal tumr,perc,unilat,radfrq                                                  1
50593     Perc cryo ablate renal tum                                                                6
50684     Inj proc ureterography/ureteropyelography thru ureterostomy                               1
50686     Manometric studies thru ureterostomy/ureteral cath                                       A
50688     Change ureterostomy tube                                                                  1
50690     Inj proc visual ilial conduit/ureteropyelography,excl rad                                 1
50727     Revise ureter                                                                             3
50945     Laparoscopy, surgical, ureterolithotomy                                                   4
50947     Laparoscopy, surgical, ureteroneocystostomy w/ cystoscopy and stent                       9
50948     Laparoscopy, surg, ureteroneocystostomy w/out cystoscopy and stent                        9
50949     Unlisted laparoscopy procedure, ureter                                                   U
50951     Ureteral endoscopy thru estab ureterostomy                                                1
50953     Ureteral endoscopy thru ureterostomy;ureteral cath                                        1
50955     Ureteral endoscopy thru ureterostomy;w/biopsy                                             1
50957     Ureteral endoscopy thru ureterostomy;fulguration/incision                                 1
50961     Ureteral endoscopy thru ureterostomy;remov foreign body                                   1
50970     Ureteral endoscopy thru ureterotomy;                                                      1
50972     Ureteral endoscopy thru ureterotomy;ureteral cath                                         1
50974     Ureteral endoscopy thru ureterotomy;w/biopsy                                              1
50976     Ureteral endoscopy thru ureterotomy;fluguration/incision                                  1
50980     Ureteral endoscopy thru ureterotomy;remov foreign body                                    1
51020     Cystotomy/cystostomy;fulgurat/insert radioactive material                                 4
51030     Cystotomy/cystostomy;cryosurgical destruct intravesical les                               4
51040     Incise & drain bladder                                                                    4
51045     Cystotomy,w/insert ureteral catheter/stent                                                4
51050     Cystolithotomy, cystotomy with removal of calculus, without vesical neck resection        4
51060     Removal of ureter stone                                                                   5
51065     Cystotomy, with calculus basket extraction and/or ultrasonic or electrohydraulic frag     4
51080     Drainage of perivesical or prevesical space abcess                                        2
51100     Drain bladder by needle                                                                  A
51101     Drain bladder by trocar/cath                                                             A
51102     Drain bl w/cath insertion                                                                 2
51500     Exc urachal cyst/sinus,w/wo umbilical hernia repair                                       4
51520     Cystotomy; for simple excision of vesical neck                                            4
51535     Repair of ureter lesion                                                                   4
51600     Inj proc cystography/voiding urethrocystography                                           1
51605     Inj proc & plcmnt chain;contrast/urethrocystography                                       1
51610     Inj proc;retrograde urethrocystography                                                    1
51700     Bladder irrigation,simple,lavage &/or instillation                                       A
51701     Insert bladder catheter                                                                  A
51702     Insert temp bladder cath                                                                 A
51703     Insert bladder cath, complex                                                              1
51705     Change cystostomy tube;simple                                                            B
51710     Change cystostomy tube;complicated                                                        1
51715     Encoscopic inj implant urethra/bladder neck                                               1
51720     Bladder instillation anticarcinogenic agent                                              B
5101:3-2-21                                                                    Page 59 of 81

                                                             APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                   GROUP NOTE
51725     Simple cystometrogram                                                  1
51726     Complex cystometrogram                                                 1
51727     Cystometrogram w/up                                                   A
51728     Cystometrogram w/vp                                                   A
51729     Cystometrogram w/vp&up                                                A
51736     Simple uroflowmetry                                                   A
51741     Complex uroflowmetry                                                  A
51784     Anal/urinary muscle study                                              1
51785     Needle electromyography studies anal/urethral sphincter                1
51792     Stimulus evoked response                                              A
51797     Voiding pressure studies;intra-abdominal voiding pressure             A
51798     Us urine capacity measure                                             A
51840     Anterior vesicourethropexy                                             4
51841     Anterior vesicourethropexy, complicated                                4
51845     Repair bladder neck                                                    7
51860     Cystorrhaphy,suture bladder wound,injury,rupture;simp                  3
51865     Cystorrhaphy,suture bladder wound,injury,rupture;comp                  4
51880     Closure of cystostomy                                                  1
51900     Closure vesicovaginal fistula,abd approach                             4
51920     Closure vesicouterine fistula                                          3
51990     Laparoscopy, surgical; urethral suspension for stress incontinence     4
51992     Sling operation for stress incontinence                                4
51999     Unlisted laparoscopy procedure, bladder                               U
52000     Cystourethroscopy                                                      1
52001     Cystourethroscopy with removal of clots                                2
52005     Cystourethroscopy,w/ureteral catheterization                           2
52007     Cystourethroscopy,w/ureteral cath,w/brush biopsy                       2
52010     Cystourethroscopy,w/ejaculatory duct catheterization                   2
52204     Cystourethroscopy,w/ biopsy                                            2
52214     Cystourethroscopy,w/ fulguration                                       2
52224     Cystourethroscopy,w/fulguration/treat of minor<.5cm lesion             2
52234     Cystourethroscopy,fulgurat/resect;sm bladder tumor(.5-2cm)             2
52235     Cystourethroscopy,fulgurat/resect;med bladder tumor(2-5cm)             3
52240     Cystourethroscopy,fulgurat/resect;lrg bladder tumor                    3
52250     Cystourethroscopy w/insert radioactive substance                       4
52260     Cystourethroscopy,dilat bladder;cystitis;anesth                        2     ***
52265     Cystourethroscopy,dilat bladder;cystitis;local                         3     ***
52270     Cystourethroscopy,w/internal urethrotomy;female                        2
52275     Cystourethroscopy,w/internal urethrotomy;male                          2
52276     Cystourethroscopy w/direct vision int urethrotomy                      3
52277     Cystourethroscopy,w/resection ext sphincter                            2
52281     Cystourethroscopy,calibrat/dilat urethral sticture/stenosis            2
52282     Cystourethroscopy, with insertion of urethral stent                    2
52283     Cystourethroscopy,w/steroid inj;stricture                              2
52285     Cystourethroscopy trt female urethral syndorme                         2
52290     Cystourethroscopy;w/ureteral meatotomy                                 2
52300     Cystourethroscopy;w/resection/fulguration;ureterocele                  2
52301     Cystourethroscopy for resection of extopic ureterocele                 2
52305     Cystourethroscopy incision/resect orifice bladder diverticulum         2
52310     Cystourethroscopy,w/remov foreign body;urethra/bladder;simple          2
52315     Cystourethroscopy,w/remov foreign body urethra/bladder;comp            2
5101:3-2-21                                                                              Page 60 of 81

                                                               APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                             GROUP NOTE
52317     Litholapaxy;crushing calculus;bladder,simp;sm<2.5cm                              1
52318     Litholapaxy;crushing calculus;bladder,comp;lg>2.5cm                              2
52320     Cystourethroscopy;w/removal ureteral calculus                                    5
52325     Cystourethroscopy;w/fragmentation ureteral calculus                              4
52327     Cytoscopy, inject material                                                       2
52330     Cystourethroscopy;w/manipul,w/o remov ureteral calculus                          2
52332     Cystourethroscopy,w/insert indwelling ureteral stent                             2
52334     Cystourethroscopy w/insert ureteral guide wire thru kidney                       3
52341     Cystourethroscopy with treatment of ureteral stricture                           2
52342     Cystourethroscopy with treatment of uretero pelvic juncture stricture            3
52343     Cystourethroscopy with treatment of intra-renal stricture                        3
52344     Cystourethroscopy with ureteroscopy; treatment uretheral stricture               4
52345     Cystourethroscopy, ureteroscopy; trmt of pelvic juncture stricture               4
52346     Cystourethroscopy with ureteroscopy; treatment intra-renal stricture             4
52351     Cystourethroscopy with ureteroscopy; and/or pyleoscopy; diagnostic               3
52352     Cystourethroscopy w ureteroscopy; and/or pyleoscopy; w removal                   4
52353     Cystourethroscopy with ureteroscopy; and/or pyleoscopy; w lithotripsy            4
52354     Cystourethroscopy w ureteroscopy; and/or pyleoscopy; w biopsy                    4
52355     Cystourethroscopy with ureteroscopy; and/or pyleoscopy; w resection              4
52400     Cystourethroscopy w incision, fulguration, or resection of valves                4
52402     Cystourethroscopy w transurethral resection or incision of ejaculatory ducts     2
52450     Transurethral incision prostate                                                  3
52500     Transurethral resection bladder neck                                             3
52601     Transurethral resect prostate,cntrl of postop bleeding                           4
52630     Transurethral resect;regrowth of obstructive tissue                              2
52640     Transurethral resect;postop bladder neck contracture                             2
52647     Laser surgery of prostate                                                        3
52648     Laser surgery of prostate                                                        3
52649     Prostate laser enucleation                                                       4
52700     Transurethral drainage prostatic abscess                                         2
53000     Urethrotomy/urethrostomy,ext;pendulous urethra                                   1
53010     Urethrotomy urethrostomy;perineal urethra,ext                                    1
53020     Meatotomy,cutting meatus;except infant                                           1
53025     Meatotomy,cutting meatus;infant                                                  1
53040     Drg deep periurethral abscess                                                    2
53060     Drg Skene's gland abscess/cyst                                                   2
53080     Drg perineal urinary extravasation;uncomp                                        2
53085     Drg perineal urinary extravasation;complicated                                   3
53200     Biopsy of urethra                                                                1
53210     Urethrectomy,tot,incl cystostomy,female                                          5
53215     Urethrectomy,tot,incl cystostomy,male                                            5
53220     Excision/fulguration carcimona/urethra                                           2
53230     Excision urethral diverticulum;female                                            2
53235     Excision urethral diverticulum;male                                              3
53240     Marsupialization urethral diverticulum,male/female                               2
53250     Excision bulbourethral gland                                                     2
53260     Excision/fulguration;urethral polyp,distal urethra                               2
53265     Excision/fulguration;urethral caruncle                                           2
53270     Excision/fulguration;Skene's gland                                               2
53275     Excision/fulguration;urethral prolapse                                           2
53400     Urethroplasty;frst stage,fistula,diverticulum,stricture                          3
5101:3-2-21                                                                  Page 61 of 81

                                                                APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                 GROUP NOTE
53405     Urethroplasty,second stage,incl urinary diversion                    2
53410     Urethroplasty;1 stage reconst;male ant urethra                       2
53415     Urethroplasty;transpubic,one stage,repair prostatic/urethra          3
53420     Urethroplasty,repair postatic/membranous urethra;frst stage          3
53425     Urethroplasty,repair postatic/membranous urethra;scnd stage          2
53430     Urethroplasty,reconstruction female urethra                          2
53431     Urethroplasty                                                        2
53440     Op;correction male urinary incontinence                              2
53442     Removal perineal prosthesis introduced for continence                1
53444     Insertion of tandem cuff                                             1
53445     Op correct urinary incontinence w/placement sphincter                5
53446     Removal of urethral/bladder neck sphincter                           1
53447     Removal,repair inflatable sphincter inc pump,reservoir               1
53448     Removal/replacement of urethral/bladder neck sphincter               3
53449     Surgical correct hydraulic abnormality sphincter device              1
53450     Urethromeatoplasty,w/mucosal advancement                             1
53460     Urethromeatoplasty,w/part excis distal urethral segment              1
53500     Urethrolysis, transvaginal, secondary, open, w/cystourethroscopy     2
53502     Urethrorrhaphy,suture urethral wound/injury;female                   2
53505     Urethrorrhaphy,suture urethral wound/injury;penile                   2
53510     Urethrorrhaphy,suture urethral wound/injury;perineal                 2
53515     Urethrorrhaphy,suture urethral injury;prostatomembranous             2
53520     Closure urethrostomy/urethrocutaneous fistula,male                   2
53600     Dilat urethral stricture;passage sound,male initial                  1
53601     Dilat urethral stricture passage sound,male;subsequent               1
53605     Dilat urethral stricture/vesical neck;passage sound,male             2     ***
53620     Dilat urethral stricture;passage filiform,male;initial               1
53621     Dilat urethral stricture;passage filiform,male;subsequent            1
53660     Dilation of female urethra;initial                                   1
53661     Dilation of female urethra;subsequent                                1
53665     Dilation female urethra,gen/conduction anesthesia                    1     ***
53850     Prostatic microwave thermotherapy                                    3
53852     Prostatic RF thermotherapy                                           3
53855     Insert prost urethral stent                                         A
53899     Unlisted procedure,urinary system                                   U
54000     Slitting prepuce,dorsal/lat;newborn                                 A
54001     Slitting prepuce,dorsal/lat;except newborn                           2
54015     Drain penis lesion                                                   4
54050     Destruction lesion,penis,simple;chemical                            A
54055     Destruction lesion,penis,simple;electrodesiccation                  A
54056     Destruction lesion,penis,simple;cryosurgery                         A
54057     Destruction lesion,penis,simple;laser surgery                        1
54060     Destruction lesion,penis,simple;surgical excision                    1
54065     Destruction lesion,penis,extensive,any method                        1
54100     Biopsy penis;cutaneous                                               1
54105     Biopsy penis;deep structures                                         1
54110     Excision penile plaque;                                              2
54111     Excision penile plaque; to 5 cm                                      3
54112     Excision penile plaque; greater than 5 cm                            3
54115     Removal foreign body;deep penile tissue                              1
54120     Amputation penis;partial                                             2
5101:3-2-21                                                                                                 Page 62 of 81

                                                             APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                                                GROUP NOTE
54125     Amputation penis;complete                                                                           2
54150     Circumcision,clamp/other device;newborn                                                            B
54160     Circumcision,surg exc o.t. clamp/device/dorsal slit;newborn                                        B
54161     Circumcis,surg exc o.t.clamp/dorsal slit;except newborn                                             2
54162     Lysis of penile circumcision adhesions                                                              2
54163     Repair of incomplete circumcision                                                                   2
54164     Frenulotomy of the penis                                                                            2
54200     Inj proc Peyronie disease;                                                                         A
54205     Inj proc Peyronie dis;w/surg exposure;plaque                                                        4
54220     Irrigation corpora cavernosa;priapism                                                               1
54230     Inj proc corpora cavernosography                                                                    3
54231     Dynamic cavernosometry,incl inj drugs                                                               1
54235     Inj corpora cavernosa w/pharmacologic agent                                                        A
54240     Penile plethysmography                                                                             A
54250     Nocturnal penile tumescence                                                                        A
54300     Plastic op penis;straightening chordee                                                              3
54304     Plastic op penis, correction chordee, hypospadias repair                                            7
54308     Urethroplasty second stage hypospadias repair<3 cm.                                                 3
54312     Urethroplasty second stage hypoospadias repair>3 cm.                                                4
54316     Urethroplasty for second stage hypospadias repair                                                   4
54318     Urethroplasty for third stage hypospadias repair to release penis from scrotum                      4
54322     Distal hypospadias repair simple meatal advancement                                                 5
54324     Distal hypospadias repair,urethroplasty,local skin flaps                                            6
54326     Distal hypospadias repair,urethroplasty,mobilization urethra                                        6
54328     Distal hypospadias repair,ext dissection to correct chordee                                         6
54332     One stage proximal penile hypospadias repair req extensive dissection,graft                         6
54336     One stage perineal hypospadias repair, skin graft tube                                              6
54340     Repair of hypospadias complications; by closure, incision, or excision, simple                      4
54344     Repair of hypospadias complications; requiring mobilization of skin flaps and urethroplasty         6
54348     Repair of hypospadias complications; requiring extensive dissection and urethroplasty with flap     6
54352     Repair hypospadias cripple req ext dissection                                                       7
54360     Plastic op;penis;correct angulation                                                                 3
54380     Plastic op penis epispadias distal;ext sphincter                                                    5
54385     Plastic op penis epispadias,incontinence                                                            5
54406     Removal of penile prosthesis                                                                        4     PA
54408     Repair of penile prosthesis                                                                         4     PA
54410     Removal/replacement, penile prosthesis, same oper. session                                          8     PA
54411     Removal/replacement, penile prosthesis, incl irrigation/debridement                                 6     PA
54415     Removal penile prosthesis, w/o replacement                                                          3     PA
54416     Removal/replacement, penile prosthesis, same op. sesson                                             4     PA
54417     Removal/replace, penile prosthesis, incl irrigation/debridement                                     8     PA
54420     Corpora cavernosa-saphenous vein shunt                                                              4
54435     Corpora cavernosa-glans penis fistulization for priapism                                            4
54440     Plastic operation penis;injury                                                                      4
54450     Foreskin manipul incl lysis preputial adhesion/stretching                                           1
54500     Biopsy testis,needle                                                                                1
54505     Biopsy testis,incisional                                                                            1
54512     Excision of extra parenchymal lesion of testis                                                      3
54520     Orchiectomy,simple,scrotal inguinal approach                                                        3
54522     Oriectomy, partial                                                                                  4
54530     Orchiectomy,radical,tumor;inguinal approach                                                         4
5101:3-2-21                                                                  Page 63 of 81

                                                              APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                 GROUP NOTE
54535     Extensive testis surgery                                             5
54550     Exploration undescented testis                                       4
54560     Exploration for testis                                               3
54600     Reduction torsion testis,surg,w/wo fixation contralateral testis     4
54620     Fixation contralateral testis                                        3
54640     Orchiopexy,inguinal approach,w/wo hernia repair                      4
54650     Orchiopexy, abd approach for intra-abd testis                        4
54660     Insertion testicular prosthesis                                      2     PA
54670     Suture/repair testicular injury                                      3
54680     Transplantation testis to thigh                                      3
54690     Laparoscopy, surgical; orchiectomy                                   4
54692     Orchiopexy for intra-abdominal testis                                4
54699     Unlisted laparoscopy procedure, testis                              U
54700     I&D epididymis,testis/scrotal space                                  2
54800     Biopsy epididymis,needle                                             1
54830     Excision local lesion;epididymis                                     3
54840     Excision spermatocele, w/wo epididymectomy                           4
54860     Epididymectomy;unilateral                                            3
54861     Epididymectomy;bilateral                                             4
54865     Exploration of epididymis, with or without biopsy                    1
54900     Epididymovasostomy,anastomosis epididymis vas deferens;unil          4
54901     Epididymovasostomy,anastomosis epididymis vas deferens;bila          4
55000     Puncture asp hydrocele,tunica vaginalis                             B
55040     Excision hydrocele;unilateral                                        3
55041     Excision hydrocele;bilateral                                         5
55060     Repair tunica vaginalis hydrocele                                    4
55100     Drainage scrotal wall abscess                                        1
55110     Scrotal exploration                                                  2
55120     Removal foreign body;scrotum                                         2
55150     Resection of scrotum                                                 1
55175     Scrotoplasty;simple                                                  1
55180     Scrotoplasty;complicated                                             2
55200     Vasotomy,cannulization w/wo incision vas                             2     PA
55250     Vasectomy,unilat/bilat,incl postop semen exam                        2
55300     Vasotomy vasograms,seminal vesiculograms/epididymograms             A      PA
55400     Vasovasostomy,vasovasorrhaphy                                        1     PA
55450     Ligation vas deferens,unilat/bilat                                   3
55500     Excision hydrocele spermatic cord,unilateral                         3
55520     Excis lesion spermatic cord                                          4
55530     Excis varicocele/ligat spermatic veins;varicocele                    4
55535     Exc varicocele/ligat spermatic veins;varicocele;abd approach         4
55540     Exc varicocele/ligat spermatic veins;varicocele;hernia repair        5
55550     Laparoscopy, surgical, with ligation of spermatic veins              4
55559     Unlisted laparoscopy procedure, spermatic cord                      U
55600     Vesiculotomy                                                         1
55605     Vesiculotomy;complicated                                             1
55650     Vesiculectomy,any approach                                           1
55680     Excision Mullerian duct cyst                                         1
55700     Bx,prostate;needle/punch,singl/mult,any approach                     2
55705     Bx,prostate;incisional,any approach                                  2
55706     Prostate saturation sampling                                         2
5101:3-2-21                                                                       Page 64 of 81

                                                            APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                      GROUP NOTE
55720     Prostatotomy,ext drain prostatic abscess,any appr;simp                    1
55725     Drainage of prostate abscess                                              3
55873     Cryosurgical ablation of the prostate                                     8
55875     Transperineal placement of needle/cath into prostate                      4
55876     Placement of interstitial device for radiation therapy guidance          A
55899     Unlisted procedure,male genital system                                   U
55920     Place needles pelvic for rt                                               3
56405     I&D vulva/perineal abscess                                                2
56420     I&D Bartholin's gland abscess                                            A
56440     Marsupialization Bartholin's gland cyst                                   2
56441     Lysis labial adhesions                                                    1
56442     Hymenotomy, simple incision                                               1
56501     Destruction lesion,vulva;simple,any method                               B
56515     Destruction lesion,vulva;extensive,any method                             3
56605     Biopsy vulva/perineum;one lesion                                          1
56606     Biopsy vulva/perineum;ea addl lesion                                     A
56620     Vulvectomy;simple,partial                                                 5
56625     Vulvectomy;simple,complete                                                7
56630     Vulvectomy,radical;partial                                                3
56700     Partial hymenectomy/revision hymenal ring                                 1
56740     Excision Bartholin's gland/cyst                                           3
56800     Plastic repair introitus                                                  3
56805     Clitoroplasty for adrenogenital syndrome                                  3
56810     Perineoplasty, repair, non-obstetrical                                    5
56820     Exam of vulva w/scope                                                     1
56821     Exam/biopsy of vulva w/scope                                              1
57000     Colpotomy;w/exploration                                                   1
57010     Colpotomy;w/drg pelvic abscess                                            2
57020     Colpocentesis                                                             2
57022     Incision and drainage of vaginal hematoma, post-obstetrical               2
57023     Incision and drainage of vaginal hematoma, non-obstetrical                2
57061     Destruction vaginal lesion;simple,any method                             A
57065     Destruction vaginal lesion;extensive,any method                           1
57100     Biopsy vaginal mucosa;simple                                             A
57105     Biopsy vaginal mucosa;extensive,req suture                                2
57106     Vaginectomy, partial removal of vaginal wall                              2
57107     Vaginectomy, with removal of paravaginal tissue                           4
57109     Vaginectomy partial w/nodes                                               5
57110     Colpectomy,obliteration vagina;complete                                   2
57120     Colpocleisis                                                              2
57130     Excision vaginal septum                                                   2
57135     Excision vaginal cyst/tumor                                               2
57150     Irrigation vagina/application medicament                                 A
57155     Insertion of uterine tandems/vaginal ovoid for clinical brachytherapy     2
57160     Insertion of pessary                                                     A
57170     Diaphragm/cx cap fitting w/instructions                                  A
57180     Intro hemostatic agent/pack,vaginal hemorrhage                            1
57200     Colporrhaphy,suture injury;vagina                                         1
57210     Colpoperineorrhaphy,suture injury;vagina/perineum                         2
57220     Plastic op urethral sphincter,vaginal approach                            3
57230     Plastic repair urethrocele                                                3
5101:3-2-21                                                                         Page 65 of 81

                                                             APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                        GROUP NOTE
57240     Ant colporrhaphy, repair cystocele w/wo repair urethrocele                  5
57250     Post colporrhaphy,repair rectocele w/wo perineorrhaphy                      5
57260     Combined ant/post colporrhaphy                                              5
57265     Combined ant/post colporrhaphy;enterocele repair                            7
57267     Insertion of mesh or other prosthesis for repair of plevic floor defect     2
57268     Repair enterocele,vaginal approach                                          3
57282     Colpopexy, vaginal; extra-peritoneal approach                               5
57283     Colpopexy, intraperitoneal                                                  7
57284     Paravaginal defect repair                                                   5
57285     Repair paravag defect, vag                                                  4
57287     Removal or revision of sling for stress incontinence                        4
57288     Sling operation for stress incontinence                                     6
57289     Pereyra procedure, including anterior colporrhaphy                          4
57291     Construction of vagina                                                      5
57292     Construct vagina with graft                                                 5
57295     Revision o prosthetic vaginal graft, vaginal approach                       1
57300     Closure rectovaginal fistula;vaginal approach                               3
57310     Closure urethrovaginal fistula                                              3
57311     Closure urethrovaginal fistula;bulbocavernosus transplant                   4
57320     Colsure vesicovaginal fistula;vag approach                                  3
57330     Closure of vesicovaginal fistula; transvesical and vaginal approach         4
57335     Vaginoplasty for adrenogenital syndrome                                     3
57400     Dilation vagina under anesthesia                                            2   ***/****
57410     Pelvic examination under anesthesia                                         2   ***/****
57415     Removal impacted vaginal foreign body                                      B
57420     Exam of vagina w/scope                                                     B
57421     Exam/biopsy of vag w/scope                                                 B
57423     Repair paravag defect, lap                                                  5
57425     Laparoscopy, surgical, colpopexy                                            5
57426     Revise prosth vag graft lap                                                 3
57452     Colposcopy;                                                                A
57454     Colposcopy;w bx cervix &/or curettage                                      B
57455     Biopsy of cervix w/scope                                                   B
57456     Endocerv curettage w/scope                                                 B
57460     Colposcopy;loop electrosurgical excision of cx                             B
57461     Conz of cervix w/scope, leep                                               B
57500     Bx,singl/mult/local excision lesion                                        B
57505     Endocervical curettage                                                     B
57510     Cauterization cervix;electro/thermal                                        1
57511     Cauterization cervix;cryocautery,initial/repeat                            A
57513     Cauterization cervix;laser ablation                                         2
57520     Conization cx,w/wo fulguration,w/woD&C,w/wo repair                          2
57522     Conization of cervix                                                        2
57530     Trachelectomy,amputation cervix                                             3
57531     Radical trachelectomy                                                       3
57540     Excision cervical stump,abd approach                                        3
57545     Excision cervical stump,abd approach;w/pelvic floor repair                  3
57550     Excision cervical stump,vaginal approach;                                   3
57555     Excision cervical stump,vaginal appr;ant/post repair                        3
57556     Excision cervical stump,vaginal approach;repair enterocele                  3
57558     Dilation & curettage of cervical stump                                      3
5101:3-2-21                                                                                             Page 66 of 81

                                                              APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                                            GROUP NOTE
57700     Cerclage uterine cervix,nonobstetrical                                                          1
57720     Trachelorrhapy,plastic repair uterine cervix,vaginal app                                        3
57800     Dilation cervical canal,instrumental                                                            1
58100     Endometrial sampling;w/o cervical dilation                                                     A
58110     Endometrial biopsy with colposcopy                                                             A
58120     Dilation & curettage,dx and/or therapeutic                                                      2
58140     Myomectomy,abdominal approach                                                                   6
58145     Myomectomy,excision fibroid tumor;uterus;vag approach                                           5
58146     Myomectomy abdom complex                                                                        6
58260     Vag hyst; uterus 250 grams or less                                                              4     PA
58262     Vag hyst w/ removal of tubes and/or ovary                                                       4     PA
58263     Vag hyst w/ removal of tubes and/or ovary, with repair                                          5     PA
58267     Vag hyst w/urinary repair                                                                       5     PA
58270     Vag hyst w/enterocele repair                                                                    4     PA
58275     Hysterectomy/revise vagina                                                                      5     PA
58280     Hysterectomy/revise vagina                                                                      5     PA
58290     Vag hyst complex                                                                                6
58291     Vag hyst incl t/o, complex                                                                      6
58292     Vag hyst t/o & repair, compl                                                                    6
58293     Vag hyst w/uro repair, compl                                                                    7
58294     Vag hyst w/enterocele, compl                                                                    6
58300     Insertion intrauterine device                                                                  A
58301     Removal intrauterine device                                                                     0    *****
58346     Insertion of Heyman capsulses, clinical brachytherapy                                           2
58353     Endometrial ablation, thermal, w/out hysteroscopic guidance                                     2
58356     Endometrial cryoablation with ultrasonic guidance, inlcuding endometrial curettage              2
58400     Uterine suspension                                                                              6
58541     Laparoscopy, surgical, supracervical hysterectomy; 250 g or less                                7
58542     Laparoscopy, surgical, supracervical hysterectomy; 250 g or less, remove tubes/ovaries          7
58543     Laparoscopy, surgical, supracervical hysterectomy; >250 g                                       7
58544     Laparoscopy, surgical, supracervical hysterectomy; >250 g, remove tubes/ovaries                 7
58545     Laparoscopic myomectomy                                                                         5
58546     Laparo-myomectomy, complex                                                                      6
58550     Laparo-asst vag hysterectomy                                                                    5
58552     Laparo-vag hyst incl t/o                                                                        5
58553     Laparo-vag hyst, complex                                                                        6
58554     Laparo-vag hyst w/t/o, compl                                                                    6
58555     Hysteroscopy, diagnostic                                                                        1
58558     Hysteroscopy, surgical; with sampling of endometrium                                            3
58559     With lysis of intrauterine septum                                                               2
58560     With division or resection of intrauterine septum                                               2
58561     With removal of leiomyomata                                                                     3
58562     With removal of impacted foreign body                                                           1
58563     With endometrial ablation                                                                       4
58565     With bilateral fallopian tube cannulation to induce occlusion by placments of perm implants     4
58570     TLH, uterus 250 G or less                                                                       5
58571     TLH w/t/o 250 G or less                                                                         5
58572     TLH, uterus over 250 G                                                                          5
58573     TLH w/t/o uterus over 250 G                                                                     5
58578     Unlisted laparoscopy procedure, uterus                                                         U
58579     Unlisted hysterectomy procedure, uterus                                                        U
5101:3-2-21                                                                           Page 67 of 81

                                                             APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                          GROUP NOTE
58600     Ligation/transection fallopian tube                                           4
58615     Occlusion fallopian tube by device,vaginal/suprapubic appro                   4
58660     Laparoscopy, surgical; with lysis of adhesions                                5     PA
58661     With removal of adnexal structures                                            5
58662     With fulgration/excision of lesions, ovary, pelvic, or peritoneal surface     5
58670     With fulgration of oviducts                                                   4
58671     With occlusion of oviducts by device                                          4
58672     With fimbrioplasty                                                            5
58673     With salpingostomy                                                            5
58679     Unlisted laparoscopy procedure, oviduct, ovary                               U
58700     Salpingectomy,part/comp,unilat/bilat                                          3
58720     Salpinto-oophorecrtomy,comp/part,unilat/bilat                                 4
58740     Lysis of adhesions                                                            3     PA
58770     Salpingostomy                                                                 4
58800     Drg ovarian cyst,unilat/bilat;vaginal approach                                3
58805     Drg ovarian cyst,unilat/bilat;abd approach                                    4
58820     Drg ovarian abscess;vaginal approach                                          3
58822     Drg ovarian abscess;abd approach                                              4
58823     Drainage of pelvic abscess, transvaginal or transrectal, percutaneous         4
58825     Transposition, ovary                                                          4
58900     Biopsy ovary,unilat/bilat                                                     3
58920     Wedge resection ovary,unilat/bilat                                            5
58925     Ovarian cystectomy,unilat/bilat                                               3
58940     Oophorectomy,part/tot unilat/bilat                                            4
58950     Resection ovarian malignancy, bilat S&O                                       5
58999     Unlisted proc,female genital system                                          U
59000     Amniocentesis,any method                                                     A
59001     Therapeutic amniotic fluid reduction                                         A
59012     Cordocentesis;intrauterine,any method                                        A
59015     Chorionic villus sampling,any method                                         B
59020     Fetal contraction stress test                                                A
59025     Fetal non-stress test                                                        A
59030     Fetal scalp blood sampling;                                                  A
59050     Int fetal monitoring during labor                                            A
59070     Transabdominal amnioinfusion, including ultrasound guidance                   2
59072     Fetal umbilical cord occlusion, w/ultrasound guidance                         2
59074     Fetal fluid drainage, w/ultrasound guidance                                   2
59076     Fetal shunt placement, w/ultrasound guidance                                  2
59100     Hysterotomy,abd;hydatidiform mole,AB                                          3
59120     Surg trt ectopic pregnancy,tubal/ovarian                                      3
59121     Surg trt ectopic,tubal/ovarian w/o salpingectomy                              3
59130     Surg trt abd pregnancy                                                        3
59140     Surg trt ectopic pregnancy,cervical,w evacuation                              1
59150     Laparoscopic trt ectopic preg w/o S&/or O                                     3
59151     Laparoscopic trt ectopic preg w S&/or O                                       3
59160     Curettage, postpartum;separate procedure                                      2
59200     Insert cervical dilator;laminaria,prostaglandin,separate proc                A
59300     Episiotomy/vaginal repair only,by o.t.attend physician                       B
59320     Cerclage cervix during preg;vaginal                                          A
59325     Cerclage cervix during preg;abdominal                                         3
59409     Vaginal delivery only                                                         2
5101:3-2-21                                                                                   Page 68 of 81

                                                               APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                                  GROUP NOTE
59412     External cephalic version (vaginal delivery)                                          1
59414     Delivery placenta, separate procedure                                                A
59612     VBAC delivery only                                                                    2
59812     Trt incomplete AB completed surgically                                                2
59820     Trt missed abortion,surg,first trimester                                              2
59821     Trt missed abortion,surg,second trimester                                             2
59830     Trt septic abortion,completed surgically                                              2
59840     Induced abortion,by D&C                                                               2
59841     Induced abortion,by D&E                                                               2
59855     Abortion                                                                              2
59856     Abortion                                                                              2
59857     Abortion                                                                              2
59870     Uterine evac/curettage hydatiform mole                                                2
59871     Removal of cerclage suture under anesthesia (other than local)                        2
59897     Unlisted fetal invasive procedure, w/us guidance                                     U
59898     Unlisted laparoscopy procedure, maternity care and delivery                          U
59899     Unlisted procedure,maternity care & delivery                                         U
60000     I&D thyroglossal cyst,infected                                                        1
60100     Biopsy thyroid,percutaneous needle                                                   B
60200     Excision cyst/adenoma thyroid/transection isthmus                                     2
60210     Partial excision thyroid                                                              1
60212     Partial thyroid excision                                                              1
60220     Total thyroid lobectomy,unilateral;                                                   2
60225     Tot thyroid lobectomy,unilat;contralat subtot lobectomy                               3
60240     Thyroidectomy                                                                         5
60252     Thyroidectomy, total or subtotal for malignancy                                       5
60260     Thyroidectomy, removal of all remaining thyroid tissue following previous removal     5
60271     Removal of thyroid                                                                    9
60280     Excision thyroglossal duct cyst/sinus;                                                4
60281     Excision thyroglossal duct cyst/sinus;recurrent                                       4
60300     Aspir/inj thyroid cyst                                                               B
60500     Parathyroidectomy                                                                     5
60502     Parathyroidectomy or exploration of parathyroid(s)                                    5
60512     Parathyroid autotransplantation                                                       3
60520     Removal of thymus gland                                                               9
60650     Laparoscopy, surgical, with adenalectomy, or explor adrenal gland                     4
60659     Unlisted laparoscopy procedure, endocrine system                                     U
60699     Unlisted procedure,endocrine system                                                  U
61000     Subdural tap thru fontanelle/suture,infant;initial                                    1
61001     Subdural tap thru fontanelle/suture,infant;subseq taps                                1
61020     Ventricular puncture thru previous burr hole;w/o inject                               1
61026     Ventricular puncture thru previous burr hole;w/inject                                 1
61050     Cisternal/lat cervical (C1-C2) puncture;w/o injection                                 1
61055     Cisternal/lat cervical (C1-C2) puncture;w/injection                                   1
61070     Puncture shunt tubing/reservoir;aspiration/inj proc                                   1
61210     Burr holes; implant ventricular catheter                                              2
61215     Insertion SubQ reservoir,pump,cont infusion system                                    3
61316     Implt cran bone flap to abdo                                                          1
61330     Decompress eye socket                                                                 9
61334     Explore orbit/remove object                                                           9
61623     Endovasc tempory vessel occl                                                          4
5101:3-2-21                                                                                    Page 69 of 81

                                                                APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                                   GROUP NOTE
61626     Transcatheter permanent occlusion or embolization                                      5
61720     Incise skull/brain surgery                                                             5
61770     Incise skull for treatment                                                             5
61790     Creation lesion,stereotactic method;gasserian ganglion                                 3
61791     Creation lesion,stereotactic method;trigeminal medullary tract                         3
61795     Stereotactic computer assisted volumetric procedure                                   B
61796     Stereotactic radiosurgery, 1 simple cranial lesion                                     2
61797     Stereotactic radiosurgery, each add'l simple cranial lesion                            1
61798     Stereotactic radiosurgery, 1 complex cranial lesion                                    3
61799     Stereotactic radiosurgery, each add'l complex cranial lesion                           1
61800     Application of stereotactic radiosurgery headframe, add-on                            B
61880     Revision or removal of intracranial neurostimulator electrodes                         4
61885     Incision/subQ placement cranial neurostim pulse gen/receiver                           4
61886     With connection to two or more electrode arrays                                        4
61888     Revision/removal cranial neurostim pulse gen/receiver                                  1
62000     Elevation of depressed skull fracture; simple, extradural                              3
62160     Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter    B
62194     Replacement irrigation,subarachnoid/subdural catheter                                  1
62223     Creation of a shunt; ventriculo-peritoneal                                             1
62225     Replacement irrigation,ventricular                                                     1
62230     Replacement/revision CSF shunt                                                         2
62252     Reprogramming of programmable csf shunt                                                1
62256     Removal complete CSF shunt w/o replacement                                             2
62258     As in 62256 but with replacement                                                       5
62263     Percutaneous lysis of epidual adhesions using solution injection                       2
62264     Epidural lysis on single day                                                           2
62267     Interdiscal percutaneous aspiration for diagnostic purposes                           B
62268     Percutaneous aspiration,spinal cord cyst/syrinx                                        1
62269     Biopsy spinal cord,percutaneous needle                                                 1
62270     Spinal puncture,lumbar,diagnostic                                                      1
62272     Spinal puncture,therapeutic,drg spinal fluid                                           1
62273     Inj,lumbar epidural;blood/clot patch                                                   1
62280     Inj neurolytic sub;subarachnoid                                                        1
62281     Inj neurolytic sub;epi,cervical/thoracic                                               1
62282     Inj neurolytic sub;epi/lumbar/caudal                                                   1
62284     Inj proc myelography/CAT o.t. C1-C2/post fossa                                         1
62287     Asp proc,percutaneous intervertebral disk,sgl/mult                                     1
62290     Inj proc diskography,each level;lumbar                                                A
62291     Inj proc diskography;cervical                                                         A
62292     Inj proc chemonucleolysis,intervertebral disk,lumbar                                  A
62294     Inj proc,arterial,occlus arteriovenous malformat,spinal                                3
62310     Inj, single, diag or ther substance; epi, cervical or thoracic                         1
62311     Lumbar, sacral                                                                         1
62318     Inj, inc cath place, cont bolus; cervical, thoracic                                    1
62319     Lumbar, sacral                                                                         1
62350     Implant spinal canal catheter                                                          1    ****
62351     Implant spinal canal catheter                                                          1    ****
62355     Remove spinal canal catheter                                                           1    ****
62360     Insert spine infusion device                                                           1    ****
62361     Implant spine infusion pump                                                            1    ****
62362     Implant spine infusion pump                                                            1    ****
5101:3-2-21                                                                                    Page 70 of 81

                                                            APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                                   GROUP NOTE
62365     Remove spine infusion device                                                           1    ****
62367     Analyze spine infusion pump                                                            1    ****
62368     Analyze spine infusion pump                                                            1    ****
63001     Laminectomy with exploration and/or decompression of spinal cord                       5
63003     Laminectomy with exploration and/or decompression of spinal cord                       5
63005     Laminectomy with exploration and/or decompression of spinal cord                       5
63011     Laminectomy with exploration and/or decompression of spinal cord                       5
63012     Removal of spinal lamina                                                               7
63015     Removal of spinal lamina                                                               7
63016     Laminectomy with exploration and/or decompression of spinal cord                       5
63017     Removal of spinal lamina                                                               7
63020     Laminotomy, with decompression of nerve root(s)                                        6
63030     Laminotomy w/decompression; one interspace, lumbar                                     6
63035     Laminotomy w/decompression; each additional interspace, cervical or lumbar            B
63040     Laminotomy, with decompression of nerve root(s)                                        6
63042     Hemilacminect lumbar extensive                                                         6
63044     Each additional lumbar                                                                 6
63045     Removal of spinal lamina                                                               7
63046     Removal of spinal lamina                                                               7
63047     Removal of spinal lamina                                                               7
63048     Remove spinal lamina add-on                                                            7
63055     Decompress spinal cord                                                                 7
63056     Decompress spinal cord                                                                 7
63057     Decompress spine cord add-on                                                           7
63064     Decompress spinal cord                                                                 7
63066     Decompress spine cord add-on                                                           7
63075     Diskectomy, anterior, with decompression of spinal cord and/or nerve root(s)           6
63076     Neck spine disk surgery                                                                7
63600     Creation lesion spinal cord,sterotactic method                                         5
63610     Sterotactic stim spinal cord,separate proc,not follow other surg                       1
63615     Stereotactic biopsy                                                                    5
63620     Stereotactic radiosurgery, 1 spinal lesion                                             2
63621     Stereotactic radiosurgery, each add'l spinal lesion                                    1
63650     Percutaneous implantation nrurostimulator electrodes;epi                               2
63655     Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural     7
63661     Remove spine eltrd perq aray                                                           3
63662     Remove spine eltrd plate                                                               3
63663     Revise spine eltrd perq aray                                                           3
63664     Revise spine eltrd plate                                                               3
63685     Incision/subQ placement spinal neurostim;direct/inductive coupling                     2
63688     Revision/removal spinal neurostim pulse gen/receiver                                   1
63741     Creation shunt percutaneous,not req laminectomy                                        3
63744     Replacement,irrigation lumbosubarachnoid shunt                                         3
63746     Removal lumbosubarachnoid shunt system w/o replacement                                 2
63750     Insert spinal canal catheter                                                           4
63780     Insert spinal canal catheter                                                           2
64400     Inj anesth agent;trigeminal nerve,any division/branch                                  1    ****
64402     Inj anesth agent;facial nerve                                                          1    ****
64405     Inj anesth agent;greater occipital nerve                                               1    ****
64408     Inj anesth agent;vagus nerve                                                           1    ****
64410     Inj anesth agent;phrenic nerve                                                         1    ****
5101:3-2-21                                                                           Page 71 of 81

                                                               APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                          GROUP NOTE
64412     Inj anesth agent;spinal accessory nerve                                       1    ****
64413     Inj anesth agent;cervical plexus                                              1    ****
64415     Inj anesth agent;brachial plexus                                              1    ****
64416     N block cont infuse, b plex                                                   1
64417     Inj anesth agent;axillary nerve                                               1    ****
64418     Inj anesth agent;suprascapular nerve                                          1    ****
64420     Inj anesth agent;intercostal nerve,single                                     1    ****
64421     Inj anesth agent;intercostal nerves,mult,region bloc                          1    ****
64425     Inj anesth agent;ilioinguinal,iliohypogastric nerves                          1    ****
64430     Inj anesth agent;pudendal nerve                                               1    ****
64435     Inj anesth agent;paracervical nerve                                           1    ****
64445     Inj anesth agent;sciatic nerve                                                1    ****
64446     N blk inj, sciatic, cont inf                                                  1
64447     N block inj fem, single                                                       1
64448     N block inj fem, cont inf                                                     1
64449     Injection, anesthetic agent; lumbar plexus, posterior approach               A
64450     Inj anesth agent;other peripheral nerve/branch                               A     ****
64455     N block injection, plantar common digital                                    A
64479     Inj anesth agent, transfor epidural; cervical or thoracic, sgl lvl            1    ****
64480     Inj anesth agent, transfor epidural; cervical or thoracic, ea addtl level     1    ****
64483     Inj anesth agent, transfor epidural; lumbar or sacral, sgl lvl                1    ****
64484     Inj anesth agent, transfor epidural; lumbar or sacral, ea addtl level         1    ****
64490     Inj paravert f jnt c/t 1 lev                                                  1
64491     Inj paravert f jnt c/t 2 lev                                                 A
64492     Inj paravert f jnt c/t 3 lev                                                 A
64493     Inj paravert f jnt l/s 1 lev                                                  1
64494     Inj paravert f jnt l/s 2 lev                                                 A
64495     Inj paravert f jnt l/s 3 lev                                                 A
64505     Inj anesth agent;sphenopalatine ganglion                                      1    ****
64508     Inj anesth agent;carotid sinus                                                1    ****
64510     Inj anesth agent;stellate ganglion                                            1    ****
64517     Inj anesth agent; sphenopalatine ganglion, superior hypogastric plexus        2
64520     Inj anesth agent;lumbar/thoracic                                              1    ****
64530     Inj anesth agent;celiac plexus,w/wo radiologic mont                           1    ****
64550     Application surface neurostimulator                                          A
64553     Percutaneous implant neurostim electrode;cranial nerve                        3
64555     Percutaneous implant neurostim electrode;peripheral nerve                     3
64560     Percutaneous implant neurostim electrode;autonomic nerve                      3
64561     Percutaneous implantaton neurostimular electrodes                             3
64565     Percutaneous implant neurostim electrode;neuromuscular                        3
64573     Incision;implant neurostim electrode;carnial nerve                            3
64575     Incision;implant neurostim electrode;peripheral nerve                         1
64577     Incision;implant neurostim electrode;autonomic nerve                          3
64580     Incision implant neurostim electrode;neuromuscular                            3
64581     Incision neurostimulator electrode implant                                    3
64585     Revision/removal peripheral neurostimu electrodes                             2
64590     Incis/subQ plcmnt peripheral neurostim receiver,direct/inductive coupling     2
64595     Revision/removal peripheral neurostim pulse gen/receiver                      1
64600     Destruct;neurolytic agent,trigeminal nerve;supraorbital                       1
64605     Destruct;neurolytic agent,trigeminal nerve;2nd&3rd divis                      1
64610     Destruct;neurolytic agent,trigeminal nerve;radiologic                         1
5101:3-2-21                                                                                  Page 72 of 81

                                                              APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                                 GROUP NOTE
64612     Dest neurolytic agent muscles enervated by facial nerve                              1
64613     Dest neurolytic agent;cervical spinal muscles                                        1
64614     Chemodenervation of muscules, extremity and trunk muscle                             2
64620     Destruct;neurolytic agent;intercostal nerve                                          1
64622     Destruct;neurolytic agent;paravertebral facet nerve,sgl                              1
64623     Destruct;neurolytic agent;paravertebral facet nerve,ea                               1
64626     Destruct;neurolytic agent;paravert nerve, cervical/thoracic,sgl                      1
64627     Destruct;neurolytic agent;paravert nerve, cervical/thoracic, ea addtl                1
64630     Destruct;neurolytic agent;pudendal nerve                                             2
64632     Destruct; neurolytic agent; plantar digital nerve                                   A
64640     Destruct;neurolytic agent;other peripheral nerve                                     1
64650     Chemodenrvatn eccrine glnds;both axillae                                            A
64653     Chemodenervatn,eccrine glnds;other area                                             A
64680     Destruction;neurolytic agent,celiac plexus                                           2
64681     Destruct;neurolytic agent;w/wo radiologic monitoring;superior hypogastric plexus     2
64702     Neurolysis;digital,one/both,same digit                                               1
64704     Neurolysis;nerve;hand/foot                                                           1
64708     Neurolysis,major peripheral nerve,arm/leg;ot specified                               2
64712     Neurolysis,major peripheral nerve,arm/leg;sciatic nerve                              2
64713     Neurolysis,major peripheral nerve,arm/leg;brachial plexus                            2
64714     Neurolysis,major peripheral nerve,arm/leg;lumbar plexus                              2
64716     Neurolysis and/or transposition;cranial nerve                                        3
64718     Neurolysis and/or transposition;ulnar nerve;elbow                                    2
64719     Neurolysis and/or transposition;ulnar nerve;wrist                                    2
64721     Neurolysis/transposition;median nerve;carpal tunnel                                  2
64722     Decompression;unspecified nerve                                                      1
64726     Decompression;plantar digital nerve                                                  1
64727     Internal neurolysis;dissection w/wo microdissection                                  1
64732     Transection/avulsion of;supraorbital nerve                                           2
64734     Transection/avulsion of;infraorbital nerve                                           2
64736     Transection/avulsion of;mental nerve                                                 2
64738     Transection/avulsion of;inferior alveolar nerve                                      2
64740     Transection/avulsion of;lingual nerve                                                2
64742     Transection/avulsion of;facial nerve                                                 2
64744     Transection/avulsion of;greater occipital nerve                                      2
64746     Transection/avulsion of;phrenic nerve                                                2
64752     Transection/avulsion of;vagus nerve,transthoracic                                    2
64755     Transection/avulsion of;vagi limited to proximal stomach                             2
64760     Transection/avulsion of;vagus nerve,abdominal                                        2
64761     Transection/avulsion of;pudendal nerve                                               2
64763     Transect/avulsion obturator nerve,extrapelvic                                        2
64766     Transect/avulsion obturator nerve,intrapelvic                                        2
64771     Transection/avulsion other cranial nerve,extradural                                  2
64772     Transection/avulsion other spinal nerve,extradural                                   2
64774     Excision neuroma;cutaneous nerve surgically identifiable                             2
64776     Excision neuroma;digital nerve,one/both,same digit                                   3
64778     Excision neuroma;digital nerve,ea addl nerve                                         2
64782     Excision neuroma;hand/foot,except digital nerve                                      3
64783     Excision neuroma;hand/foot,ea addl nerve                                             2
64784     Excision neuroma;major peripheral nerve,except sciatic                               3
64786     Excision neuroma;sciatic nerve                                                       3
5101:3-2-21                                                               Page 73 of 81

                                                            APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                              GROUP NOTE
64787     Implant nerve end into bone/muscle                                2
64788     Excision neurofibroma/neurolemmoma;cutaneous nerve                3
64790     Excision neurofibroma/neurolemmoma;major peripheral nerve         3
64792     Excision neurofibroma/neurolemmoma;extensive                      3
64795     Biopsy of nerve                                                   2
64802     Sympathectomy,cervical                                            2
64804     Sympathectomy,cervicothoracic                                     4
64809     Sympathectomy,thoracolumbar                                       4
64818     Sympathectomy,lumbar                                              4
64821     Sympathectomy,radial artery                                       4
64822     Sympathectomy,ulnar artery                                        4
64823     Sympathectomy, superficial palmar arch                            4
64831     Suture digital nerve,hand/foot;one nerve                          4
64832     Suture digital nerve,hand/foot;ea addl nerve                      1
64834     Suture one nerve,hand/foot;common sensory nerve                   2
64835     Suture one nerve,hand/foot;median motor thenar                    3
64836     Suture one nerve,hand/foot;ulnar motor                            3
64837     Suture ea addl nerve,hand/foot                                    1
64840     Suture posterior tibial nerve                                     2
64856     Suture major peripheral nerve,arm/leg;incl transposition          2
64857     Suture major peripheral nerve,arm/leg;w/o transposition           2
64858     Suture of sciatic nerve                                           2
64859     Suture ea addl major peripheral nerve                             1
64861     Suture of;brachial plexus                                         3
64862     Suture of;lumbar plexus                                           3
64864     Suture of facial nerve;extracranial                               3
64865     Suture facial nerve;intratemporal,w/wo grafting                   4
64866     Anastomosis;facial-spinal accessory                               3
64868     Anastomosis;facial-hypoglossal                                    3
64870     Anastomosis;facial-phrenic                                        4
64872     Suture nerve;req secondary/delayed suture                         2
64874     Suture nerve;req extensive proximal mobilizat/transposit          3
64876     Suture nerve;req shortening bone;extremity                        3
64885     Nerve graft,head/neck;up to 4 cm                                  2
64886     Nerve graft,head/neck;> 4 cm                                      2
64890     Nerve graft,sgl strand,hand/foot;up to 4cm length                 2
64891     Nerve graft,sgl strand,hand/foot;>4cm length                      2
64892     Nerve graft,sgl strand,arm/leg;up to 4cm length                   2
64893     Nerve graft,sgl strand,arm/leg;>4cm length                        2
64895     Nerve graft,mult strands,hand/foot;up to 4cm length               3
64896     Nerve graft,mult strands,hand/foot;>4cm length                    3
64897     Nerve graft,mult strands,arm/leg;up to 4cm length                 3
64898     Nerve graft,mult strands,arm/leg;>4cm length                      3
64901     Nerve graft,ea addl nerve;single strand                           2
64902     Nerve graft,ea addl nerve;multiple strands                        2
64905     Nerve pedicle transfer;first stage                                2
64907     Nerve pedicle transfer;second stage                               1
64910     Nerve repair; synthetic conduit or vein allograft, each nerve     2
64911     Nerve repair; autogenous vein graft, each nerve                   2
64999     Unlisted procedure,nervous system                                U
65091     Evisceration ocular contents;w/o implant                          3
5101:3-2-21                                                                        Page 74 of 81

                                                             APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                       GROUP NOTE
65093     Evisceration ocular contents;w/implant                                     3
65101     Enucleation eye;w/o implant                                                3
65103     Enucleation eye;implant,muscles not attached to implant                    3
65105     Enucleation eye;w/implant,muscles attached to implant                      4
65110     Exenteration orbit,removal orbital contents;only                           5
65112     Exenteration orbit,removal orbital contents;removal bone                   7
65114     Exenteration orbit,remove contents;muscle/myocutaneous flap                7
65125     Modification ocular implant                                                1
65130     Insert ocular implant secondary;after evisceration,scleral shell           3     PA
65135     Insert ocular implant secondary;after enucleation,muscles not attached     2     PA
65140     Insert ocular implant secondary;after enucleation,muscles attached         3     PA
65150     Reinsert ocular implant;w/wo conjunctival graft                            2     PA
65155     Reinsert ocular implant;w use foreign mat;reinforcement                    3     PA
65175     Removal of ocular implant                                                  1
65205     Remove foreign body,ext eye;conjunctival superficial                      A
65210     Remove foreign body,ext eye;conjunctival embedded                          1
65220     Remove foreign body,ext eye;w/o slit lamp                                 A
65222     Remove foreign body,ext eye;corneal,w/slit lamp                           A
65235     Remove foreign body,intraocular;ant chamber/lens                           2
65260     Remove foreign body,intraocular;post segment,magnetic                      3
65265     Remove foreign body,intraocular;post segment,nonmagneti                    4
65270     Repair laceration;conjunctiva,direct closure                               2
65272     Repair lac;conjunctiva,by mobilization & rearrangement                     2
65275     Repair lac;cornea,nonperforating                                           4
65280     Repair lac;cornea/sclera,perforating,not involing uveal tissue             4
65285     Repair lac;cornea/sclera,perforating,resection uveal tissue                4
65286     Repair lac conjunctiva,application tissue glue                             2
65290     Repair wound,extraocular muscle,tendon/Tendon's capsule                    3
65400     Excision lesion,cornea,except pterygium                                    1
65410     Biopsy of cornea                                                           2
65420     Excision/transposition pterygium;w/o graft                                 2
65426     Excision/transposition pterygium;w/graft                                   5
65430     Scraping cornea,diagnostic;smear &/or culture                             A
65435     Removal corneal epithelium;w/wo chemocauterization                        B
65436     Removal corneal epithelium;w/applicat chelating agent                     B
65450     Destruction lesion cornea by cryotherapy                                  B
65600     Multi punctures anterior conrnea                                           3
65710     Keratoplasty,(corneal transplant)lamellar                                  7
65730     Keratoplasty,penetrating(excp aphakia)                                     7
65750     Keratoplasty,penetrating,in aphakia                                        7
65755     Keratoplasty penetrating(in pseudophakia)                                  7
65756     Keratoplasty, endothelial                                                  7
65757     Preparation of corneal endothelial allograft prior to transplantation      2
65765     Keratophakia                                                               5     PA
65767     Epikeratoplasty                                                            5
65770     Keratoprosthesis                                                           7
65772     Corneal relaxing incis correct surgical induced astigmatism                5
65775     Corneal wedge resect correct surgical induced astigmatism                  5
65780     Ocular surface reconstruction; amniotic membrane transplantation           5
65781     Ocular surface reconstruction; limbal stem cell allograft                  7
65782     Ocular surface reconstruction; limbal conjunctival autograft               7
5101:3-2-21                                                                      Page 75 of 81

                                                             APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                     GROUP NOTE
65800     Paracentesis ant chamber eye;diagnostic asp                              1
65805     Paracentesis ant chamber eye;therapeutic release                         1
65810     Paracentesis ant chamber eye;remov vitreous                              3
65815     Paracentesis ant chamber eye;removal blood                               2
65820     Goniotomy                                                                2
65850     Trabeculotomy ab externo                                                 4
65855     Trabeculoplasty;laser surgery,1 or > session                             1
65860     Severing adhesions;ant segment,laser technique                          B
65865     Severing adhesions ant segment eye;goniosynechiae                        1
65870     Severing adhesions ant segment eye;ant synechie                          4
65875     Severing adhesions ant segment eye;post synechiae                        4
65880     Severing adhesions ant segment eye;corneovitreal adhesions               4
65900     Removal epithelial downgrowth,ant chamber eye                            5
65920     Remov of implanted material,anterior segment eye                         7
65930     Removal blood clot,ant segment eye                                       5
66020     Inj,anterior chamber;air/liquid                                          1
66030     Inj,anterior chamber;medication                                          1
66130     Excision lesion,sclera                                                   7
66150     Fistulization sclera glaucoma;trephination iridectomy                    4
66155     Fistulization sclera glaucoma;thermocauterizat iridectomy                4
66160     Fistulization sclera glaucoma;sclerectomy,w/iridectomy                   2
66165     Fistulization sclera glaucoma;iridencleisis/iridotasis                   4
66170     Fistulization sclera glaucoma;trabeculectomy ab externo                  4
66172     Fistulization sclera glaucoma;trabeculectomy w scarring                  4
66180     Aqueous shunt to extraocular reservoir                                   5
66185     Revision aqueous shunt to extraocular reservoir                          2
66220     Repair scleral staphyloma;w/o graft                                      3
66225     Repair scleral staphyloma;w/graft                                        4
66250     Revision/repair operative wound;anterior segment                         2
66500     Iridotomy by stab incision;except transfixion                            1
66505     Iridotomy;stab incision;w/transfixion;for iris bombe                     1
66600     Iridectomy,w/corneoscleral/corneal section;remov lesion                  3
66605     Iridectomy,w/corneoscleral/corneal section;w/cyclectomy                  3
66625     Iridectomy,corneoscleral/corneal sect;peripheral glaucoma                3
66630     Iridectomy,corneoscleral/corneal sect;sector;glaucoma                    3
66635     Iridectomy,corneoscleral/corneal sect;optical                            3
66680     Repair iris,ciliary body                                                 3
66682     Suture iris,ciliary body w/retrieval suture                              2
66700     Ciliary body dest;diathermy                                              2
66710     Ciliary body dest;cyclophotocoagulation                                  2
66711     Cillary body dest; cyclophotocagulation, endoscopic                      3
66720     Ciliary body dest;cryotherapy                                            2
66740     Ciliary body dest;cyclodialysis                                          2
66761     Iridotomy by laser surgery                                               1
66762     Iridoplasty by photocoagulation;1 or >sessions                           1
66770     Destruction cyst/lesion iris/ciliary body;nonexcisional                  3
66820     Discisssion secondary membraneous cataract/ant hyaloid;stab incision     1
66821     Discisssion secondary membraneous cataract/ant hyaloid;laser             2
66825     Repositioning intraocular lens prosthesis,req incision                   3
66830     Removal secondary membranous cataract,w/corneoscleral section            4
66840     Removal lens material;aspiration tech,1 or >stages                       4
5101:3-2-21                                                                             Page 76 of 81

                                                              APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                            GROUP NOTE
66850     Removal lens material;phacofragmentation tech,aspiration                        7
66852     Removal lens material;pars plana approach w/wo vitrectomy                       4
66920     Removal lens material;intracapsular                                             4
66930     Removal lens material;intracapsular dislocated lens                             5
66940     Removal lens material;extracapsular                                             5
66982     Extra capsular cataract removal w insertion of intra ocular lens prosthesis     8
66983     Intracapsular cataract extract,insert lens prosthesis                           8
66984     Extracapsular cataract remov/insert prosthesis lens man/mech                    8
66985     Insert intraocular lens(secondary implant)                                      6
66986     Exchange intraocular lens                                                       6
66990     Ophthalmic endoscope add-on                                                    B
66999     Unlisted procedure,anterior segment eye                                        U
67005     Removal vitreous,ant approach;partial removal                                   4
67010     Removal vitreous,ant approach;subtotal remov,vitrectomy                         4
67015     Asp/release vitreous,subretinal/choroidal fluid                                 1
67025     Inj vitreous substitute,pars plana/limbal approach                              1
67027     Implant or replace intravitreal drug delivery system                            9
67028     Intravitreal inj pharmacologic agent                                           A
67030     Discission vitreous strands,pars plana approach                                 1
67031     Sever vitreous strands,adhesions,sheets,membranes,opacities                     2
67036     Vitrectomy,mechanical,pars plana approach                                       4
67039     Vitrectomy,mechanical;focal endolaser photocoagulation                          7
67040     Vitrectomy,mechanical;endolaser panretinal photocoagulation                     7
67041     Vit for macular pucker                                                          6
67042     Vit for macular hole                                                            6
67043     Vit for membrane dissect                                                        6
67101     Repair retinal detachment;cryotherapy/diathermy                                 4
67105     Repair retinal detachment;photocoagulation,w/drainage                           5
67107     Repair retinal detachment;scleral bucking                                       5
67108     Repair retinal detachment;w/vitrectomy,any method                               7
67110     Repair retinal detachment;by inj air/other gas                                  4
67112     Repair retinal detachment;previously operated upon,any tech                     7
67113     Repair retinal detach, cplx                                                     6
67115     Release encircling material                                                     2
67120     Removal implanted material post segment;extraocular                             2
67121     Removal implanted material post segment;intraocular                             2
67141     Prophylaxis retinal detach w/o drain;cryotherapy diathermy                      2
67145     Prophylaxis retinal detach w/o drain;photocoagulation                          B
67208     Destruct localized lesion retina;cryotherapy,diathermy                          1
67210     Destruct localized lesion retina;photocoagulation                               1
67218     Destruct localized lesion retina;radiation by implant                           5
67220     Destruction of localized lesion of choroid                                      1
67221     Destruction of localized lesion of choroid                                      2
67225     Ocular photodynamic therapy                                                    A
67227     Destruct extensive/progressive retinopathy;cryotherapy,diathermy                1
67228     Destruct extensive/progressive retinopathy;photocoagulation                     1
67229     Tr retinal les preterm inf                                                     B
67250     Scleral reinforcement;w/o graft                                                 3
67255     Scleral reinforcement;w/graft                                                   3
67299     Unlisted procedure,posterior segment                                           U
67311     Strabismus surg,recession/resection proc;1 horizontal muscle                    3
5101:3-2-21                                                                     Page 77 of 81

                                                              APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                    GROUP NOTE
67312     Strabismus surg,recession/resection proc;2 horizontal muscle            4
67314     Strabismus surg,recession/resection proc;1 vert muscle                  4
67316     Strabismus surg,recession/resection proc;2 or >vert muscle              4
67318     Strabismus surg,any proc,superior oblique muscle                        4
67320     Transposition procedure                                                 4
67331     Strabismus surg pt w previous eye surg,not extraocular muscles          4
67332     Strabismus surgery;pt w scarring extraocular muscles                    4
67334     Strabismus surg post fixation suture tech w/wo muscle recession         3
67335     Placement adjustable suture during strabismus surgery                  A
67340     Strabismus surg exploration &/or repair detached extraocular muscle     4
67343     Release extensive scar tissue wo detaching extraocular muscle           3
67345     Chemodenervation extraocular muscle                                     1
67346     Biopsy extraocular muscle                                               1
67399     Unlisted procedure,ocular muscle                                       U
67400     Orbitotomy w/o bone flap;for exploration,w/wo biopsy                    3
67405     Orbitotomy w/o bone flap;with drainge only                              4
67412     Orbitotomy w/o bone flap;with removal lesion                            5
67413     Orbitotomy w/o bone flap;with removal foreign body                      5
67414     Orbitotomy w/o bone flap;w removal bone for decompression               5
67415     Fine needle asp orbital contents                                        1
67420     Orbitotomy w bone flap,lat;w removal lesion                             5
67430     Orbitotomy w bone flap,lat;w removal foreign body                       5
67440     Orbitotomy w bone flap,lat;w drg                                        5
67445     Orbitotomy w bone flap,lat;w removal bone for decompression             5
67450     Orbitotomy w bone flap,lat;exploration,w/wo bx                          5
67500     Retrobulbar injection;medication                                       A
67505     Retrobulbar injection;alcohol                                          A
67515     Inj therapeutic agent into Tenon's capsule                             A
67550     Orbital implant;insertion                                               4
67560     Orbital implant;removal/revision                                        2
67570     Optic nerve decompression                                               3
67599     Unlisted procedure,orbit                                               U
67700     Blepharotomy,drainage abscess,eyelid                                   A
67710     Severing of tarsorrhapy                                                A
67715     Canthotomy                                                              1
67800     Excision chalazion;single                                              B
67801     Excision chalazion;multiple,same lid                                    2
67805     Excision chalazion;multiple,different lids                              2
67808     Excision chalazion;under gen anesth,sgl/mult                            2     ***
67810     Biopsy of eyelid                                                       B
67820     Correction trichiasis;epilation,by forceps only                        B
67825     Correction trichiasis;epilation                                        B
67830     Correction trichiasis;incision lid margin                               2
67835     Correction trichiasis;incision lid margin,w/graft                       2
67840     Excision lesion eyelid w/o closure or w/simple direct closure           1
67850     Destruction lesion lid margin                                          B
67875     Temporary closure eyelids by suture                                     1
67880     Construction intermarginal adhesions;                                   3
67882     Construction intermarginal adhesion;transposition tarsal plate          3
67900     Repair brow ptosis                                                      4     PA
67901     Repair blepharoptosis;frontalis muscle technique w suture               5     PA
5101:3-2-21                                                                  Page 78 of 81

                                                            APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                 GROUP NOTE
67902     Repair blepharoptosis;frontalis muscle technique w fascial sling     5     PA
67903     Repair blepharoptosis;levator resection/advance,int approach         4     PA
67904     Repair blepharoptosis;levator resection/advance,ext approach         4     PA
67906     Repair blepharoptosis;superior rectus technique w fascial sling      5     PA
67908     Repair blepharoptosis;conjunctivo-tarso-levator resection            4     PA
67909     Reduction overcorrection ptosis                                      4
67911     Correction lid retraction                                            3     PA
67912     Correction, lagophthalmos, w/implant, upper eyelid lid load          3
67914     Repair of ectropion;suture                                           3
67915     Repair ectropion;thermocauterization                                 2
67916     Repair ectropion;blepharoplasty,excision tarsal wedge                4
67917     Repair ectropion;blepharoplasty,extensive                            4
67921     Repair entropion;suture                                              3
67922     Repair entropion;thermocauterization                                 2
67923     Repair entropion;blepharoplasty                                      4
67924     Repair entropion;blepharoplasty,extensive                            4
67930     Suture recent wound,eyelid;partial thickness                         2
67935     Suture recent wound,eyelid;full thickness                            2
67938     Removal embedded foreign body,eyelid                                 2
67950     Canthoplasty                                                         2
67961     Excision & repair eyelid;up to one-fourth lid margin                 3
67966     Excision & repair eyelid;>one-fourth lid margin                      3
67971     Reconstruct eyelid;up to 2/3 eyelid,1 stage/1st stage                3
67973     Reconstruct eyelid;total eyelid,lower,1 stage/1st stage              3
67974     Reconstruct eyelid;total eyelid,upper,1 stage/1st stage              3
67975     Reconstruction eyelid;second stage                                   3
67999     Unlisted procedure,eyelids                                          U
68020     Incision conjunctiva,drainage cyst                                  A
68040     Expression conjucnctival follicles                                  A
68100     Biopsy of conjunctiva                                               A
68110     Excision lesion,conjunctiva;up to 1 cm                               1
68115     Excision lesion,conjunctiva;> 1 cm                                   2
68130     Excision lesion,conjunctiva;w adjacent sclera                        2
68135     Destruction lesion,conjunctiva                                       2
68200     Subconjunctival injection                                           A
68320     Conjunctivoplasty;conjunctival graft/extensive rearrangment          4
68325     Conjunctivoplasty;buccal mucous membrane graft                       4
68326     Conjunctivoplasty;reconst cul-de-sac;w/graft/rearrangement           4
68328     Conjunctivoplasty;w/buccal mucous membrane graft                     4
68330     Repair symblepharon;conjunctivoplasty,w/o graft                      4
68335     Repair symblepharon;graft conjunctiva/buccal mucous memb             4
68340     Repair symblepharon;division symblepharon                            4
68360     Conjunctival flap;bridge/partial                                     2
68362     Conjunctival flap;total                                              2
68371     Harvesting conjunctival allograft, living donor                      2
68399     Unlisted procedure,conjunctiva                                      U
68400     Incision,drainage;lacrimal gland                                    B
68420     Incision,drainage;lacrimal sac                                      B
68440     Snip incision lacrimal punctum                                      B
68500     Excision lacrimal gland,except tumor;total                           3
68505     Excision lacrimal gland,except tumor;partial                         3
5101:3-2-21                                                                           Page 79 of 81

                                                              APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                          GROUP NOTE
68510     Biopsy of lacrimal gland                                                      1
68520     Excision of lacrimal sac                                                      3
68525     Biopsy of lacrimal sac                                                        1
68530     Removal foreign body/dacryolith,lacrimal passages                            B
68540     Excision lacrimal gland tumor;frontal approach                                3
68550     Excision lacrimal gland tumor;involving osteotomy                             3
68700     Plastic repair canaliculi                                                     2
68705     Correction everted punctum,cautery                                            1
68720     Dacryocystorhinostomy                                                         4
68745     Conjunctivorhinostomy;w/o tube                                                4
68750     Conjunctivorhinostomy;w insertion tube/stent                                  4
68760     Closure lacrimal punctum,thermocauterization,laser                            2
68761     Closure lacrimal punctum,plug,each                                            1
68770     Closure of lacrimal fistula                                                   2
68801     Dilation of lacrimal punctum                                                  1
68810     Probing of nasolacrimal duct                                                  1
68811     Probing of nasolacrimal duct                                                  2
68815     Probing of nasolacrimal duct                                                  2
68816     Probe NL duct w/balloon                                                       2
68840     Probing lacrimal canaliculi,w/wo irrigation                                   1
68850     Injection contrast medium;dacryocystography                                  A
68899     Unlisted procedures,lacrimal system                                          U
69000     Drainage ext ear,abscess/hematoma;simple                                     A
69005     Drainage ext ear,abscess/hematoma;complicated                                B
69020     Drainage ext auditory canal,abscess                                          A
69100     Biopsy external ear                                                          A
69105     Biopsy external auditory canal                                                1
69110     Excision ext ear;partial,simple repair                                        1
69120     Excision ext ear;complete amputation                                          2
69140     Excision exostosis,ext auditory canal                                         2
69145     Excision soft tissue lesion,external auditory canal                           2
69150     Radical excision ext auditory canal lesion;w/o neck dissect                   3
69200     Removal foriegn body;ext auditory canal;w/o anesth                           A
69205     Removal foriegn body ext auditory canal;w/anesthesia                          1     ***
69210     Removal impacted cerumen                                                     A
69220     Debridement,mastoidectomy cavity,simple                                      A
69222     Debridement,mastoidectomy cavity,complex                                     B
69300     Otoplasty,protruding ear,w/wo size reduction                                  3     PA
69310     Reconstruct external auditory canal                                           3
69320     Reconstruct ext auditory canal;congenital atresia                             7
69399     Unlisted procedure,external ear                                              U
69400     Eustachian tube inflation,transnasal;w/catheterization                        1
69401     Eustachian tube inflation,transnasal;w/o catheterization                      1
69405     Eustachian tube catheterization,transtympanic                                 2
69420     Myringotomy incl asp &/or eustachian tube                                     1
69421     Myringotomy incl asp/eustachian tube;req anesthesia                           3     ***
69424     Ventilating tube removal originally insert by another dr.; req anesthesia     1     ***
69433     Tympanostomy,local/topical anesthesia                                         1
69436     Tympanostomy,general anesthesia                                               3     ***
69440     Middle ear exploration thru postauricular/ear canal incis                     3
69450     Tympanolysis,transcanal                                                       1
5101:3-2-21                                                                  Page 80 of 81

                                                            APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                 GROUP NOTE
69501     Transmastoid antrotomy                                               7
69502     Mastoidectomy;complete                                               7
69505     Mastoidectomy;modified radical                                       7
69511     Mastoidectomy;radical                                                7
69530     Petrous apicectomy incl radical mastoidectomy                        7
69540     Excision aural polyp                                                 3
69550     Excision aural glomus tumor;transcanal                               5
69552     Excision aural glomus tumor;transmastoid                             7
69554     Excision aural glomus tumor;extended                                 7
69601     Revision mastoidectomy;resulting comp mastoidectomy                  7
69602     Revision mastoidectomy;resulting mod rad mastoidectomy               7
69603     Revision mastoidectomy;resulting rad mastoidectomy                   7
69604     Revision mastoidectomy;resulting in tympanoplasty                    7
69605     Revision mastoidectomy;w apicectomy                                  7
69610     Tympanic membrane repair                                             2
69620     Myringoplasty                                                        2
69631     Tympanoplasty w/o mastoidectomy;w/o ossicular chain reconst          5
69632     Tympanoplasty w/o mastoidectomy;w/ossicular chain reconst            5
69633     Tympanoplsty w/o mastoidectmy;chain reconst & synthetic prosthe      5
69635     Tympanoplasty w/antrotomy/mastoidotomy;w/o chain reconst             7
69636     Tympanoplasty w/antrotomy/mastoidotomy;w/chain reconst               7
69637     Tympanoplasty w/antrotomy/mastoidotomy;w/reconst&prosthesis          7
69641     Tympanoplasty w mastoidectomy;w/o ossicular chain                    7
69642     Tympanoplasty w/mastoidectomy;w/ossicular chain reconstruct          7
69643     Tympanoplasty w/mastoidectomy;intact wall,w/o chain reconst          7
69644     Tympanoplasty w/mastoidectomy;w/intact wall,w/chain reconst          7
69645     Tympanoplasty w/mastoidectomy;radical/complet,w/o reconst            7
69646     Tympanoplasty w/mastoidectomy;radical/complete,w/reconst             7
69650     Stapes mobilization                                                  7
69660     Stapedectomy/stapedotomy w/reestablishment ossicular continuity      5
69661     Stapedectomy/stapedotomy w/footplate drill out                       5
69662     Revision stapedectomy/stapedotomy                                    5
69666     Repair oval window fistula                                           4
69667     Repair round window fistula                                          4
69670     Mastoid obliteration                                                 3
69676     Tympanic neurectomy                                                  3
69700     Closure postauricular fistula,mastoid                                3
69710     Implant/replace electromagnetic bone conduction hear device          3
69711     Remov/repair electromagnetic bone conduction hear device             1
69714     Implantation, osseointegrated implant w/out mastoidectomy            6
69715     Implantation, osseointegrated implant w/ mastoidectomy               9
69717     Replacement osseointegrated implant, speech processor,w/out mast     8
69718     Replacement osseointegrated implant, speech processor,w/ mastoid     9
69720     Decompres facial nerve,intratemporal;lateral to ganglion             5
69725     Decompres facial nerve,intratemporal;medial to ganglion              5
69740     Suture facial nerve,intratemporal;lateral to ganglion                5
69745     Suture facial nerve,intratemporal;medial to ganglion                 5
69799     Unlisted procedure,middle ear                                       U
69801     Labyrinthotomy w/wo cryosurg;transcanal                              5
69802     Labyrinthotomy w/wo cryosurg;w mastoidectomy                         7
69805     Endolymphatic sac operation w/o shunt                                7
5101:3-2-21                                                                      Page 81 of 81

                                                              APPENDIX C
CPT
CODE      CPT CODE DESCRIPTION (ABBREVIATED)                                     GROUP NOTE
69806     Endolymphatic sac operation w shunt                                      7
69820     Fenestration semicircular canal                                          5
69840     Revision fenestration op                                                 5
69905     Labyrinthectomy;transcanal                                               7
69910     Labyrinthectomy;w mastoidectomy                                          7
69915     Vestibular nerve section,translabyrinthine approach                      7
69930     Cochlear device implantation w/wo mastoidectomy                          7
69949     Unlisted procedure inner ear                                            U
69955     Total facial nerve decompression and/or repair                           5
69960     Release inner ear canal                                                  9
69970     Remove inner ear lesion                                                  9
69979     Unlisted procedure temporal bone, middle fossa approach                 U
***       Paid only if billed with an anesthesia CPT code.
****      Paid only if no other surgical CPT code on claim.
*****     Procedure not considered a surgery or is incident to another surgery
PA        Procedure requires prior authorization for payment.
U         Unlisted procedure.

				
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