This prior authorization guide applies to the following lines of business

Transcription

This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health
Plan Plus (BH+), Washington Mediciad Integration Partnership (WMIP), Basic Health Plan (BHP)
CPT Code
00100
Prior Authorization Required Outpatient
Facility Place of Serivce 22, 24 Effective
July 2011
No
00102
00103
00104
00120
No
No
No
No
Code Description
ANES- SALIVARY GLANDS INCL BX
ANES-PROC INVOLVING PLASTIC REPAIR
CLEFT LIP
ANES-RECON PROCS EYELID
ANES- ELEC-CONVULS THERAP
ANES- EXT/MID/INNER EAR W/BX; NOS
00124
00126
00140
00142
00144
00145
00147
00148
00160
No
No
No
No
No
No
No
No
No
ANES- EXT/MID/INNER EAR W/BX; OTOSC
ANES- EXT/MID/INNER EAR W/BX; TYMP
ANES- EYE; NOS
ANES- EYE; LENS SURG
ANES- EYE; CORNEAL TRANSPL
ANES- EYE; VITRECTOMY
ANES- EYE; IRIDECTOMY
ANES- EYE; OPHTH
ANES- NOSE & ACCES SINUSES; NOS
No
No
No
No
No
No
No
No
No
00162
00164
00170
00172
00174
00176
00190
00192
00210
No
No
No
No
No
No
No
No
No
ANES- NOSE/ACCES SINUSES; RAD SURG
ANES- NOSE/ACCES SINUSES; BX TISS
ANES- INTRAORAL PROC, INCL BX; NOS
ANES- INTRAORAL W/BX; REPR CLEFT
ANES- INTRAORAL W/BX; EXC TUMOR
ANES- INTRAORAL W/BX; RAD SURG
ANES- FACIAL BONES; NOS
ANES- FACIAL BONES; RADICAL SURG
ANES- INTRACRAN PROC; NOS
No
No
No
No
No
No
No
No
No
00212
No
No
00214
00215
No
No
ANES- INTRACRAN PROC; SUBDURAL TAPS
ANES-CRAN; BURR HOLESVENTRICOGRPHY
ANES- INTRACRAN; ELEVAT SKULL FX
00216
00218
No
No
ANES- INTRACRAN PROC; VASCULAR PROC
ANES- INTRACRAN; PROC SITTING POSIT
No
No
00220
No
ANES- INTRACRAN; SPINAL FLUID SHUNT
No
00222
No
ANES- INTRACRAN; ELECTROCOAG NERV
No
Prior Authorization Required Office Setting
Place of Service 11, 20 Effective July 2011
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries.Claim
payment is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
CPT Code
July 2011
00300
No
ANES-INTEG-MUSC/NRV-HEAD/TRUNK-NOS
No
00320
No
ANES- PROC ESOPHA/THYROID/TRAC; NOS
No
00322
No
No
00326
00350
No
No
ANES- PROC ESOPHA/THYRO/TRACH; BX
ANES-ON THE LARYNX&TRACHEA
CHILDREN < 1 YEAR AGE
ANES- MAJOR VESSELS NECK; NOS
00352
No
ANES- MAJOR VESSELS NECK; SIMPL LIG
No
00400
00402
00404
No
No
No
ANES-INTEG-EXTREM/TRNK/PERINEM; NOS
ANES-INTEG-TRUNK; BREAST RECON
ANES-INTEG-TRUNK; RAD BREAST PROC
No
No
No
00406
No
ANES-INTEG; RAD BRST W/NODE DISSEC
No
00410
00450
No
No
ANES-INTEG SYS-TRNK; CONVERT ARRYTH
ANES- CLAV & SCAPULA; NOS
No
No
00452
00454
00470
No
No
No
ANES- CLAV & SCAPULA; RADICAL SURG
ANES- CLAV & SCAPULA; BX CLAV
ANES- PART RIB RESECT; NOS
No
No
No
00472
No
ANES- PART RIB RESECT; THORACOPLSTY
No
00474
00500
00520
00522
00524
No
No
No
No
No
ANES- PART RIB RESECT; RADICAL PROC
ANES- ALL PROC ESOPHAGUS
ANES-CLO CHEST; (INCL BRONCH) NOS
ANES-CLO CHEST; NEEDLE BX PLEURA
ANES-CLO CHEST; PNEUMOCENTESIS
No
No
No
No
No
00528
No
00529
00530
Code Description
No
No
No
ANES-CLO CHST;MEDIASTIN&THORACSCP
NO 1 LUNG VENT
ANES-CLOS CHST;MEDIASTN&DX
THORACSCP 1 LUNG VENT
No
No
ANES- TRANSVENOUS PACEMAKER INSRT
No
No
CPT Code
July 2011
00532
No
ANES- ACCES TO CENT VENOUS CIRCULAT
No
00534
No
No
00537
No
00539
00540
No
No
00541
00542
No
No
00546
No
ANES- TRANSVENOUS INSRT CARDIOVERT
ANES-CARDIAC ELECTROPHYSIOLOGIC
PROC
ANESTHESIA FOR TRACHEOBRONCHIAL
RECONSTRUCTION
ANES- THORACOT W/LUNGS; NOS
ANES-THORACOT PROC; UTILIZING 1 LUNG
VENTILATION
ANES- THORACOT W/LUNGS; DECORTIC
ANES- THORACOT W/LUNGS;
THORACOPLST
00548
00550
00560
00562
No
No
No
No
No
No
No
No
00563
No
00566
No
ANES- THORCOT W/LUNGS; INTHOR TRACH
ANES-STERNAL DEBRID
ANES- HEART; WO PUMP OXYGENATOR
ANES- HEART; W/ PUMP OXYGENATOR
ANES-W PUMP OXYGENATOR W
HYPOTHERM CIRCU ARREST
ANES-DIRECT CORONARY ARTERY BYPASS
GRAFT
00580
00600
No
No
ANES- HEART TRANSPL OR HEART/LUNG
ANES- CERV SPINE & CORD; NOS
No
No
00604
00620
No
No
No
No
00622
00625
00626
00630
No
No
No
No
ANES- CERV SPINE; POST LAMIN SITTNG
ANES- THORACIC SPINE & CORD; NOS
ANES- THORACIC; THORACOLUM
SYMPATHE
ANES SPINE TRANTHOR W/O VENT
ANES, SPINE TRANSTHOR W/VENT
ANES- PROC LUMBAR REGION; NOS
00632
No
No
00634
No
ANES- LUMBAR REGION; SYMPATHECTOMY
ANES- LUMBAR REGION;
CHEMONUCLEOLYS
Code Description
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
00635
No
00640
00670
00700
No
No
No
Code Description
ANES- LUMBAR REGION; DIAGN OR
THERAPEUTIC LUMB PUNCT
ANES-MANIP SPN/CLOS PROC CERV
THOR/LUMB SPN
ANES- EXTEN SPINE & SPINAL CORD
ANES- UPPER ANT ABD WALL; NOS
00702
00730
No
No
ANES- UP ANT ABD WALL;PERQ LIVER BX
ANES- UPPER POST ABD WALL
No
No
00740
00750
No
No
ANES-UGI ENDOSCOP-INTRO PROX DUOD
ANES- HERNIA REPR UPPER ABD; NOS
No
No
00752
No
ANES- HERNIA REPR UP ABD; & DEHISCE
No
00754
No
ANES- HERNIA REPR UP ABD; OMPHALOCE
No
00756
00770
00790
No
No
No
ANES- HERNIA REPR UP ABD; TRANSABD
ANES- ALL MAJOR ABD BLD VESSELS
ANES- INTRAPERITONEAL W/LAP; NOS
No
No
No
00792
No
ANES- INTRAPERITONL W/LAP;: HEPATEC
No
00794
No
ANES- INTRAPERITON W/LAP; PANCREATE
No
00796
No
ANES- INTRAPERITONEAL; LIVER TRANSP
No
00797
00800
Not Reimbursable
No
ANESTH - UPPER ABD GASTRIC RESTRICT
ANES- LOWER ANT ABD WALL; NOS
Not Reimbursable
No
00802
No
ANES- LO ANT ABD WALL; PANNICULECTO
No
00810
00820
00830
00832
No
No
No
No
No
No
No
No
00834
No
ANES-LO INTES ENDOSCOP-DIST TO DUOD
ANES- LOWER POST ABD WALL
ANES- HERNIA REPR LOWER ABD; NOS
ANES- HERNIA REPR; VENTRAL & INCS
ANES-HERNIA REPR LOWER ABD NOS
UNDER 1 YEAR AGE
No
No
No
No
No
CPT Code
July 2011
00836
00840
No
No
Code Description
ANES-HERN REP NOS INFNTS <37 WK
BRTH&<50 WK SURG
ANES- INTRAPERITONEAL LO ABD; NOS
00842
No
ANES- INTRAPERITONEAL LO ABD; AMNIO
No
00844
No
ANES- INTRAPERITONEAL; ABD-PERINEAL
No
00846
No
ANES- INTRAPERITONL W/LAP; RAD HYST
No
00848
00851
No
No
ANES- INTRAPERITONEAL; PELVIC EXENT
ANES- STERILIZATIONS
No
No
00860
00862
00864
No
No
No
No
No
No
00865
00866
00868
00870
No
No
No
No
ANES- EXTRAPERITONEAL URINARY; NOS
ANES- EXTRAPERIT; UP 1/3 URETER
ANES- EXTRAPERIT; TOT CYSTECTOMY
ANES- EXTRAPERIT; RAD
PROSTATECTOMY
ANES- EXTRAPERIT; ADRENALECTOMY
ANES- EXTRAPERIT; RENAL TRANSPL
ANES- EXTRAPERIT; CYSTOLITHTOMY
00872
No
ANES- LITH EXTRACORPOR; W/H2O BATH
No
00873
No
ANES- LITH EXTRACORPOR; WO H2O BATH
No
00880
00882
00902
00904
00906
No
No
No
No
No
ANES- MAJOR LOWER ABD VESSELS; NOS
ANES- MAJOR VESS; INFER VENA CAVA
ANES- PERINEAL INTEG; ANORECTAL
ANES- PERINEAL INTEG; RAD PERINEAL
ANES- PERINEAL INTEG; VULVECTOMY
No
No
No
No
No
00908
00910
No
No
No
No
00912
00914
No
No
ANES- PERINEAL INTEG; PROSTATECTOMY
ANES- TRANSURETHRAL PROC; NOS
ANES- TRANSURETH; RESEC BLADDER
TUM
ANES- TRANSURETHRAL; TURP
00916
No
ANES- TRANSURETHR; POST RESECT BLED
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
00918
00920
No
No
00921
00922
00924
00926
00928
00930
00932
Code Description
No
No
No
No
No
No
No
No
No
ANES-TRNSURETH; W/MANIP/REMOV CALC
ANES- MALE EXT GENIT; SEMINAL VESIC
ANES-MALE GNT INCL OP URETH; VASECT
UNILAT/BILAT
ANES- MALE EXT GENIT; SEMINAL VESIC
ANES- MALE; UNDESCEN TESTIS UNI/BIL
ANES- MALE; RAD ORCHIECTOMY ING
ANES- MALE; RAD ORCHIECTOMY ABD
ANES- MALE; ORCHIOPEXY UNI/BILAT
ANES- MALE; COMPLT AMPUT PENIS
00934
00936
00938
00940
No
No
No
No
ANES- MALE; RAD AMP PENIS ING LYMPH
ANES- MALE; AMP PENIS ING & ILIAC
ANES- MALE; INSRT PENILE PROSTH
ANES- VAG PROC; NOS
No
No
No
No
00942
00944
00948
00950
No
No
No
No
ANES- VAG; COLPOT, COLPEC, COLPORRH
ANES- VAG PROC; VAG HYST
ANES- VAG PROC; CERV CERCLAGE
ANES- VAG PROC; CULDOSCOPY
No
No
No
No
00952
No
No
01112
01120
01130
01140
No
No
No
No
ANES-VAG; HYSTEROSCOP/SALPINGRPHY
ANES- BONE MARROW ASPIRA &/OR BX,
ANTERIOR OR POSTERIOR
ANES- BONY PELVIS
ANES- BODY CAST APPLIC OR REVIS
ANES- INTERPELVIABDOMINAL AMPUTA
01150
No
ANES- RAD PROC TUMOR PELV EX AMPUT
No
01160
01170
No
No
No
No
01173
No
ANES- CLO PROC W/S PUBIS/SACROIL JT
ANES- OPEN PROC W/S PUBIS/SACILI JT
ANES-OPEN REP FX DISRUPT
PELV/COLUMN FX ACETAB
01180
No
ANES- OBTURATOR NEURECT; EXTRAPELV
No
01190
No
ANES- OBTURATOR NEURECT; INTRAPELV
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
01200
01202
01210
01212
01214
July 2011
No
No
No
No
No
01215
01220
No
No
Code Description
ANES- ALL CLO PROC INVOLV HIP JT
ANES- ARTHROSCOPIC PROC HIP JT
ANES- OPEN PROC INVOLV HIP JT; NOS
ANES- OPEN PROC INVOLV HIP; DISART
ANES- OPEN HIP; TOT HIP REPLC/REVIS
ANES- REVIS OF TOTAL HIP
ANTHROPSCOPY
ANES- ALL CLO INVOLV UP 2/3 FEMUR
01230
No
ANES- OPEN INVOLV UP 2/3 FEMUR; NOS
No
01232
No
ANES- OPEN UPPER 2/3 FEMUR; AMPUTA
No
01234
No
ANES- OPEN UP 2/3 FEMUR; RAD RESECT
No
01250
01260
01270
01272
No
No
No
No
ANES- ALL NERV/MUSCL/FASCIA UP LEG
ANES- ALL INVOLV VEIN UP LEG W/EXPL
ANES- INVOLV ART UP LEG W/GFT; NOS
ANES- INVOLV ART LEG W/GFT; FEM LIG
No
No
No
No
01274
No
ANES- INVOLV ART LEG W/GFT; FEM EMB
No
01320
No
ANES- NERV/MUSCL/BURSAE KNEE/POP
No
01340
No
ANES- ALL CLO PROC LOWER 1/3 FEMUR
No
01360
01380
01382
01390
01392
01400
No
No
No
No
No
No
ANES- ALL OPEN PROC LOWER 1/3 FEMUR
ANES- ALL CLO PROC KNEE JT
ANES- ARTHROSCOPIC PROC KNEE JT
ANES- ALL CLO UP ENDS TIB/FIB/PATEL
ANES- ALL OPEN UP END TIB/FIB/PATEL
ANES- OPEN PROC KNEE JT; NOS
No
No
No
No
No
No
01402
01404
01420
01430
No
No
No
No
ANES- OPEN KNEE JT; TOT KNEE REPLAC
ANES- OPEN KNEE JT; DISART AT KNEE
ANES- ALL CAST APPLIC/REPR W/KNEE
ANES- VEINS KNEE & POP AREA; NOS
No
No
No
No
01432
No
ANES- VEINS KNEE/POP AREA; AV FISTU
No
No
No
No
No
No
No
No
CPT Code
01440
July 2011
No
01442
No
ANES- ART KNEE; POP THROMBOENDART
No
01444
01462
01464
01470
01472
No
No
No
No
No
ANES- ART KNEE; POP EXC OCC/U/ANEUR
ANES- ALL CLO LOWER LEG/ANK/FT
ANES- ARTHROSCOPIC PROC ANK JT
ANES- NERV/FASCIA LO LEG/FT; NOS
ANES- NERV LO LEG; REPR ACHILLES
No
No
No
No
No
01474
No
ANES- NERV LO LEG; GASTROC RECESS
No
01480
No
ANES- OPEN BONES LO LEG/ANK/FT; NOS
No
01482
No
ANES- OPEN BONES LO LEG; RAD RESECT
No
01484
No
ANES- OPEN BONES LO LEG; OSTEOTOMY
No
01486
No
ANES- OPEN BON LO LEG; TOT ANK REPL
No
01490
No
ANES- LO LEG CAST APPLIC/REMOV/REPR
No
01500
01502
01520
No
No
No
ANES- ART LO LEG W/BYPASS GFT; NOS
ANES- ART LO LEG W/GFT; EMBOLEC
ANES- VEINS LOWER LEG; NOS
No
No
No
01522
No
ANES- VEINS LO LEG; THROMBEC DIRECT
No
01610
01620
No
No
No
No
01622
No
ANES- ALL PROC NERV, MUSCL, TENDONS
ANES- ALL CLO HUMERAL/AC/SHLDR JT
ANES- ARTHROSCOPIC PROC SHOULDER
JT
01630
No
ANES- OPEN HUMERAL/AC/SHLDR JT; NOS
No
01634
No
ANES- OPEN HUMER/AC JT; SHLDR DISAR
No
01636
No
ANES- OPEN HUMER/AC; INTERTHOR AMPU
No
Code Description
ANES- ART KNEE & POP AREA; NOS
No
No
CPT Code
July 2011
01638
01650
No
No
ANES- OPEN HUMER/AC; TOT SHLDR REPL
ANES- ART SHOULDER AXILLA; NOS
No
No
01652
01654
No
No
ANES- ART SHLDR/AX; AX-BRACH ANEURY
ANES- ART SHLDR & AXIL; BYPASS GFT
No
No
01656
01670
01680
No
No
No
ANES- ART SHLDR & AX; AX-FEM BYPASS
ANES- ALL VEINS SHLDR & AXILLA
ANES- SHLDR CAST APPLIC REPR; NOS
No
No
No
01682
No
ANES- SHLDR CAST REPR; SHLDR SPICA
No
01710
No
ANES- NERV/BURSAE UP ARM/ELBOW; NOS
No
01712
No
ANES- NERV UP ARM/ELBOW; TENOTOMY
No
01714
No
ANES- NERV UP ARM/ELBOW; TENOPLASTY
No
01716
No
ANES- NERV UP ARM/ELBOW; TENODESIS
No
01730
01732
No
No
ANES- ALL CLO PROC HUMERUS & ELBOW
ANES- ARTHROSCOPIC PROC ELBOW JT
No
No
01740
No
No
01742
No
ANES- OPEN PROC HUMERUS & ELBW; NOS
ANES- OPEN HUMERUS & ELBW;
OSTEOTMY
01744
No
ANES- OPEN HUMER/ELB; REPR NONUNION
No
01756
No
ANES- OPEN HUMERUS/ELB; RADICL PROC
No
01758
No
ANES- OPEN HUMERUS; EXC CYST HUMER
No
01760
01770
No
No
No
No
01772
No
ANES- OPEN HUMER; TOT ELBOW REPLAC
ANES- ART UPPER ARM & ELBOW; NOS
ANES- ART UP ARM/ELBOW;
EMBOLECTOMY
Code Description
No
No
CPT Code
July 2011
01780
No
ANES- VEINS UPPER ARM & ELBOW; NOS
No
01782
No
ANES- VEINS UP ARM; PHLEBORRHAPHY
No
01810
No
ANES- ALL NERV/MUSCL FOREARM/HAND
No
01820
No
No
01829
No
ANES- ALL CLO RADIUS/ULNA/HAND BONE
ANESTHESIA DIAGNOSTIC ARTHROSCOPIC
PROC WRIST
01830
No
ANES- OPEN RAD/ULNA/HAND BONES; NOS
No
01832
No
ANES- OPEN RAD/ULN BONES; TOT WRIST
No
01840
No
ANES- ART FOREARM/WRIST/HAND; NOS
No
01842
No
ANES- ART FOREARM/WRIST/HAND; EMBOL
No
01844
No
ANES- VASCULAR SHUNT/REVIS ANY TYPE
No
01850
No
ANES- VEINS FOREARM/WRIST/HAND; NOS
No
01852
No
ANES- VEINS FOREARM/HAND; PHLEBORRH
No
01860
No
ANES- FOREARM/HAND CAST APPLIC/REPR
No
01916
No
No
01920
No
ANES- ARTERIOGRAMS/NEEDLE; CAROTID
ANES- CARD CATH W/CORON
ARTERIOGPHY
01922
No
ANES- NON-INVASIVE IMAG/RAD THERAP
No
01924
01925
No
No
No
No
01926
No
01930
No
ANES- THERAP INTERVENT VENOUS/LYMPH
ANES- CAROTID OR CORONARY
ANES- INTRACRANIAL, INTRACARDIAC, OR
AORTIC
ANES- THERA INTERVENT INVOLV
VENOUS/LYMPH
Code Description
No
No
No
No
CPT Code
01931
01932
01933
July 2011
No
No
No
01951
No
01952
No
01953
No
01958
01960
01961
01962
01963
01965
01966
01967
No
No
No
No
No
No
No
No
01968
No
01969
No
01990
No
01991
01992
01996
01999
10021
10022
10040
10060
10061
10080
10081
10120
10121
Code Description
ANES- TRANSCUT PORTO CAV SHUNT
ANES- INTRATHOR OR JUGULR
ANES- INTRACRANIAL
ANES- BURN EXCIS OR DEBRID 2ND & 3RD
DEGREE
ANES- BURN EXCIS OR DEBRID 1-9% TOTAL
BODY SURFACE AREA
ANES- BURN EXCIS OR DEBRID EA ADDNL
9% TOTAL BODY SURFACE
ANESTHESIA EXTERNAL CEPHALIC
VERSION PROCEDURE
ANES- VAG DELIV ONLY
ANES- CES DELIV ONLY
ANES- URGE HYSTER FOLLOW DELIV
ANES- HYSTERECTOMIES
ANES INCOMPL/MISSED AB
ANES INDUCED AB
ANES- NEURAXIAL LABOR ANAGLESIA
ANES- CES DELIV FOLLOW NEURAXIAL
LABOR ANAGLESIA
ANES- CES HYSTER FOLLOW NEURAXIAL
LABOR ANAGLESIA
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
PHYSIOL SUPPORT - DONOR-BRAIN DEAD
ANES-DX/TX NRV BLKS&INJ; OTH THAN
PRONE PSTN
No
No
No
No
No
No
No
No
No
No
No
No
ANES-DX/TX NRV BLKS&INJ; PRONE PSTN
ANES- DA MGMT EPIDUR DRUG ADMIN
UNLISTED ANES PROC
FINE NDLE ASPIR; W/O IMAGING GUID
FINE NEEDLE ASPIR; W/IMAGING GUID
ACNE SURG
I&D ABSCESS; SIMPL/SNGL
I&D ABSCESS; COMPLIC/MX
I&D PILONIDAL CYST; SIMPL
I&D PILONIDAL CYST; COMPLIC
INCS & REMOV FB SUBQ TISS; SIMPL
INCS & REMOV FB SUBQ TISS; COMPLIC
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
10140
July 2011
No
10160
10180
11000
11001
No
No
No
No
11004
No
11005
No
11006
No
11008
11010
Code Description
I&D HEMATOMA/SEROMA/FLUID COLLEC
No
No
No
No
No
No
No
PUNCT ASPIR ABSCES/HEMAT/BULLA/CYST
I&D COMPLX POSTOP WOUND INFEC
DEBRID EXTEN INFEC SKIN; TO 10% SUR
DEBRID EXTEN INFEC SKIN; EA AD 10%
DEBRID SKN SUBQ TISS MUSC&FASC; EXT
GENITL&PERIN
DEBRID SKN SUBQ TISS MUSC&FASC; ABD
WALL
DEBRID SKN SUBQ TISS; EXT GENIT W/WO
FASCL CLOS
REMV PROS MATL/MESH ABD WALL
NECROT SFT TISS INF
DEBRID W/REMOV MAT; SKIN & SUBQ
11011
No
DEBRID W/REMOV MAT; SKIN-SUBQ-MUSC
No
11012
11042
11043
11044
11045
11046
11047
11055
11056
11057
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
11100
No
11101
11200
11201
11300
11301
11302
11303
11305
No
Non Reimbursable
Non Reimbursable
No
No
No
No
No
DEBRID W/REMOV MAT; SKIN-MUSC-BONE
DEBRID; SKIN & SUBQ TISS
DEBRID; SKIN-SUBQ TISS-MUSCL
DEBRID; SKIN-SUBQ TISS-MUSCL-BONE
DEB SUBQ TISSUE ADD-ON
DEB MUSC/FASCIA ADD-ON
DEB BONE ADD-ON
PARING/CUTTING BEN LES; 1 LES
PARING/CUTTING BEN LES; 2-4 LES
PARING/CUTTING BEN LES; > 4 LES
BX SKIN SUBQ TISSUE &/ MUCOUS
MEMBRANE; 1 LESION
BX SKIN SUBQ TISSUE &/ MUCOUS
MEMBRANE; EA ADD
REMOV SKIN TAGS; TO & INCL 15 LES
REMOV SKIN TAGS; EA ADD 10 LES
SHAVING 1 LES TRUNK; 0.5 CM/LESS
SHAVING 1 LES TRUNK; 0.6 TO 1.0 CM
SHAVING 1 LES TRUNK; 1.1 TO 2.0 CM
SHAVING 1 LES TRUNK; OVER 2.0 CM
SHAVING 1 LES SCALP; 0.5CM/LESS
No
No
No
No
No
No
No
Non Reimbursable
Non Reimbursable
No
No
No
No
No
CPT Code
11306
11307
11308
11310
11311
11312
11313
11400
11401
11402
11403
11404
11406
11420
11421
11422
11423
11424
11426
11440
11441
11442
11443
11444
11446
11450
11451
11462
11463
11470
July 2011
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Code Description
SHAVING 1 LES SCALP; 0.6 TO 1.0 CM
SHAVING 1 LES SCALP; 1.1 TO 2.0 CM
SHAVING 1 LES SCALP; OVER 2.0 CM
SHAVING 1 LES FACE; 0.5 CM/LESS
SHAVING 1 LES FACE; 0.6 TO 1.0 CM
SHAVING 1 LES FACE; 1.1 TO 2.0 CM
SHAVING 1 LES FACE; OVER 2.0 CM
EXC BEN LES TRUNK; 0.5 CM/LESS
EXC BEN LES TRUNK; 0.6 TO 1.0 CM
EXC BEN LES TRUNK; OVER 4.0 CM
EXC BEN LES SCALP; 0.5 CM/LESS
EXC BEN LES SCALP; 0.6 TO 1.0 CM
EXC BEN LES SCALP; OVER 4.0 CM
EXC BEN LES FACE; 0.5 CM/LESS
EXC BEN LES FACE; 0.6 TO 1.0 CM
EXC BEN LES FACE; OVER 4.0 CM
EXC SKIN HIDRADEN AX; SIMPL/INTERM
EXC SKIN HIDRADEN AX; COMPLX REPR
EXC SKIN HIDRADEN ING; SIMPL/INTERM
EXC SKIN HIDRADEN ING; COMPLX REPR
EXC SKIN HIDRADEN PERIANAL; SIMPL
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
11471
11600
11601
11602
11603
11604
11606
11620
No
No
No
No
No
No
No
No
EXC SKIN HIDRADEN PERIANAL; COMPLX
EXC MALIG LES TRUNK; 0.5 CM/LESS
EXC MALIG LES TRUNK; 0.6 TO 1.0 CM
EXC MALIG LES TRUNK; OVER 4.0 CM
EXC MALIG LES SCLP; 0.5 CM/LESS
No
No
No
No
No
No
No
No
CPT Code
11621
11622
11623
11624
11626
11640
11641
11642
11643
11644
11646
July 2011
No
No
No
No
No
No
No
No
No
No
No
11719
11720
11721
No
No
No
Code Description
EXC MALIG LES SCLP; 0.6 TO 1.0 CM
EXC MALIG LES SCLP; OVER 4.0 CM
EXC MALIG LES FACE; 0.5 CM/LESS
EXC MALIG LES FACE; 0.6 TO 1.0 CM
EXC MALIG LES FACE; OVER 4.0 CM
TRIM NONDYSTROPHIC NAILS-ANY
NUMBER
DEBRID NAIL(S) ANY METHD(S); 1 TO 5
DEBRID NAIL(S) ANY METHD(S); 6/MORE
11730
No
AVULSION PLATE PART/COMPLT SIMPL; 1
No
11732
11740
11750
11752
11755
11760
11762
11765
11770
11771
11772
11900
11901
No
No
No
No
No
No
No
No
No
No
No
No
No
AVULSION PLATE PART/COMPLT SMPL; EA
EVACUATION SUBUNGUAL HEMATOMA
EXC NAIL/MATRIX PART/COMPLT PERM
EXC NAIL/MATRIX PERM; AMPUT DISTAL
BX NAIL UNIT ANY METHD (SEP PRO)
REPR NAIL BED
RECON NAIL BED W/GFT
WEDGE EXC SKIN NAIL FOLD
EXC PILONIDAL CYST/SINUS; SIMPL
EXC PILONIDAL CYST/SINUS; EXTEN
EXC PILONIDAL CYST/SINUS; COMPLIC
INJ INTRALES; UP TO & INCL 7 LES
INJ INTRALES; MORE THAN 7 LES
No
No
No
No
No
No
No
No
No
No
No
No
No
11920
11921
No
YES
TATTOOING W/MICROPIGMEN; 6.0 SQ CM
TATTOOING W/MICROPIGMEN; 6.0-20 CM
No
YES
11922
11950
11951
11952
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
TATTOOING W/MICROPIGMEN; EA ADD 20.
SUBQ INJ FILLING MAT; 1 CC/LESS
SUBQ INJ FILLING MAT; 1.1 TO 5.0 CC
SUBQ INJ FILLING MAT; 5.1 TO 10 CC
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
11954
July 2011
Not Reimbursable
11960
Yes
INSRT EXPANDER NOT BREAST W/SUBSQT
No
11970
Yes
No
11971
Yes
REPLAC TISS EXPANDER W/PERM PROSTH
REMOV TISS EXPANDER WO INSRT
PROSTH
11975
Not Reimbursable
Not Reimbursable
11976
No
11977
11980
Not Reimbursable
No
INSRT IMPLNT CONTRACEPTIVE CAPSULES
REMOV IMPLNT CONTRACEPTIVE
CAPSULES
REMOV W/REINSRT CONTRACEPTIVE
CAPSU
SUBQ HORMONE PELLET IMPLNT
11981
Yes
INSRT NON-BIODEGRADABLE RX DEL IMPL
No
11982
No
REMV NON-BIODEGRADABLE RX DEL IMPL
No
11983
12001
12002
12004
12005
12006
Yes
No
No
No
No
No
REMV REINS NONBIODEGRAD RX DEL IMPL
SIMPL REPR SCLP/TRUNK; 2.5 CM/LESS
SIMPL REPR SCLP/TRUNK; 2.6-7.5 CM
No
No
No
No
No
No
12007
12011
12013
12014
No
No
No
No
SIMPL REPR SCLP/TRUNK; OVER 30.0 CM
SIMPL REPR FACE/MUCOUS; 2.5/LESS
SIMPL REPR FACE/MUCOUS; 2.6-5.0 CM
No
No
No
No
12015
12016
12017
12018
No
No
No
No
SIMPL REPR FACE/MUCOUS; 12.6-20.0
SIMPL REPR FACE/MUCOUS; 20.1-30.0
SIMPL REPR FACE/MUCOUS; OVER 30.0
No
No
No
No
12020
No
TX SUPERF WOUND DEHISCENCE; SIMPL
No
12021
No
TX SUPERF WOUND DEHISCENCE; W/PACK
No
Code Description
SUBQ INJ FILLING MAT; OVER 10.0 CC
Not Reimbursable
No
No
Not Reimbursable
No
CPT Code
12031
12032
12034
12035
12036
12037
July 2011
No
No
No
No
No
No
Code Description
LAYER CLO SCLP/TRUNK; 2.5 CM/LESS
LAYER CLO SCLP/TRUNK; 2.6 TO 7.5 CM
LAYER CLO SCLP/TRUNK; 7.6 TO 12.5
LAYER CLO SCLP/TRUNK; OVER 30.0 CM
No
No
No
No
No
No
12041
12042
12044
12045
12046
12047
12051
12052
12053
12054
12055
12056
12057
13100
13101
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
LAYER CLO NECK/FT/GENIT; 2.5CM/LESS
LAYER CLO NECK/FT/GENIT; 2.6 TO 7.5
LAYER CLO NECK/FT/GENIT; 7.6-12.5
LAYER CLO NECK/FT/GENIT; OVER 30.0
LAYER CLO FACE/LIPS; 2.5 CM/LESS
LAYER CLO FACE/LIPS; 2.6 TO 5.0 CM
LAYER CLO FACE/LIPS; 12.6 TO 20.0
LAYER CLO FACE/LIPS; 20.1 TO 30.0
LAYER CLO FACE/LIPS; OVER 30.0 CM
REPR COMPLX TRUNK; 1.1 CM TO 2.5 CM
REPR COMPLX TRUNK; 2.6 CM TO 7.5 CM
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
13102
No
REPR COMPLX-TRUNK; EA ADD 5 CM/LESS
No
13120
No
REPR COMPLX SCLP/EXTREM; 1.1-2.5 CM
No
13121
No
REPR COMPLX SCLP/EXTREM; 2.6-7.5 CM
No
13122
13131
13132
No
No
No
REPR CMPLX-SCLP/ARM/LEG; EA AD 5 CM
REPR COMPLX FOREHEAD/AX/FT; 1.1-2.5
REPR COMPLX FOREHEAD/AX/FT; 2.6-7.5
No
No
No
13133
13150
13151
13152
No
No
No
No
REPR CMPLX-FAC/HAND/FT; EA ADD 5 CM
REPR COMPLX LIDS/LIPS; 1.0/LESS
REPR COMPLX LIDS/LIPS; 1.1-2.5 CM
REPR COMPLX LIDS/LIPS; 2.6-7.5 CM
No
No
No
No
13153
No
REPR CMPLX-EYE/NOSE/EAR; EA AD 5 CM
No
CPT Code
13160
14000
14001
14020
14021
14040
14041
14060
14061
14301
14302
July 2011
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
14350
15002
15003
15004
15005
Yes
Yes
Yes
Yes
Yes
15040
15050
15100
15101
No
Yes
Yes
Yes
15110
No
15111
No
15115
No
15116
15120
No
Yes
15121
15130
15131
15135
Yes
No
No
No
15136
15150
No
No
Code Description
SECNDRY CLO DEHISCENCE COMPLIC
ADJAC TISS TRANSF TRUNK; 10 SQ CM
ADJAC TISS TRANSF TRUNK; 10.1-30.0
ADJAC TRANSF SCLP/LEGS; 10 SQ CM
ADJAC TRANSF SCLP/LEGS; 10.1-30.0
ADJAC TRANSF CHIN/AX/FT; 10 SQ CM
ADJAC TRANSF CHIN/AX/FT; 10.1- 30.0
ADJAC TRANSF LIDS/LIPS; 10 SQ CM
ADJAC TRANSF LIDS/LIPS; 10.1-30.0
SKIN TISSUE REARRANGEMENT
SKIN TISSUE REARRANGE ADD-ON
No
No
No
No
No
No
No
No
No
No
No
FILLETED FINGER/TOE FLP W/PREP SITE
WND PREP, CH/INF, TRK/ARM/LG
WND PREP, CH/INF ADDL 100 CM
WND PREP CH/INF, F/N/HF/G
WND PREP, F/N/HF/G, ADDL CM
HARVEST SKN TISS CLTR SKN AGRFT 100
CM/<
PINCH GFT 1/MX-SM AREA UP TO 2 CM
SPLIT GFT TRUNK; 1ST 100 SQ CM/1%
SPLIT GFT TRUNK; EA ADD 100 SQ/1%
EPIDRM AGRFT T/A/L 1ST 100 CM/</1% BDY
INFT/CHLD
EPIDRM AGRFT T/A/L EA 100 CM/EA 1% BDY
INFT/CHLD
EPIDRM AGRFT F/S/N/H/F/G/M/D GT 1ST 100
CM
EPIDRM AGRFT F/S/N/H/F/G/M/D GT EA 100
CM/EA
SPLIT GFT FACE; 1ST 100 SQ/1%
No
No
No
No
No
SPLT GFT FACE; EA ADD 100/EA ADD 1%
DRM AGRFT T/A/L 1ST 100 CM
DRM AGRFT T/A/L EA 100 CM/EA
DRM AGRFT F/S/N/H/F/G/M/D GT 1ST 100
DRM AGRFT F/S/N/H/F/G/M/D GT EA 100
CM/EA
CLTR EPIDRM AGRFT T/A/L 1ST 25 CM/<
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
15151
No
15152
No
15155
No
15156
No
15157
No
15170
No
15171
No
15175
No
15176
15200
15201
15220
15221
15240
15241
15260
15261
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
15300
No
15301
No
15320
No
15321
15330
15331
No
No
No
15335
No
Code Description
CLTR EPIDRM AGRFT T/A/L ADDL 1 CM-75
CM
CLTR EPIDRM AGRFT T/A/L EA 100 CM/EA 1
% BDY
CLTR EPIDRM AGRFT F/S/N/H/F/G/M/D GT
1ST 25CM/<
ADDL 1-75CM
EA 100 EA
ACLR DRM RPLCMT T/A/L 1ST 100 CM/</1 %
BDY
ACLR DRM RPLCMT T/A/L EA 100 CM/EA 1 %
BDY
ACLR DRM RPLCMT F/S/N/H/F/G/M/D GT 1ST
100 CM
ACLR DRM RPLCMT F/S/N/H/F/G/M/D GT EA
100 CM/EA
FULL THICK GFT TRUNK; 20 SQ CM/LESS
FULL THICK GFT TRUNK; EA AD 20 SQ
FULL THICK GFT SCLP; 20 SQ CM/LESS
FULL THICK GFT SCLP; EA AD 20 SQ CM
FULL THICK GFT CHIN/AX/FT; 20 SQ CM
FULL THICK GFT CHIN/AX/FT; EA AD 20
FULL THICK GFT NOSE/LIPS; 20 SQ CM
FULL THICK GFT NOSE/LIPS; EA AD 20
ALGRFT SKN F/TEMP CLSR T/A/L 1ST 100
CM/</1
ALGRFT SKN F/TEMP CLSR T/A/L EA 100
CM/EA
ALGRFT SKN F/TEMP CLSR F/S/N/H/F/G/M/D
1ST 100CM
ALGRFT SKN F/TEMP CLSR F/S/N/H/F/G/M/D
EA 100CM
ACLR DRM ALGRFT T/A/L 1ST 100 CM
ACLR DRM ALGRFT T/A/L EA 100 CM/EA
ACLR DRM ALGRFT F/S/N/H/F/G/M/D GT 1ST
100 CM
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
15336
15340
15341
15360
15361
No
No
No
No
No
15365
No
15366
No
15400
15401
Yes
Yes
15420
No
15421
15430
15431
Code Description
ACLR DRM ALGRFT F/S/N/H/F/G/M/D GT EA
100 CM/EA
TISS CLTR ALGC SKN 1ST 25 CM/<
TISS CLTR ALGC SKN EA 25 CM
TISS CLTR ALGC DRM T/A/L 1ST 100 CM
TISS CLTR ALGC DRM EA 100 CM/EA
TISS CLTR ALGC DRM F/S/N/H/F/G/M/D 1ST
100 CM
TISS CLTR ALGC DRM F/S/N/H/F/G/M/D EA
100 CM
No
No
No
No
No
No
No
No
No
Yes
APPLIC XENOGFT SKIN; 100 SQ CM/LESS
APPLIC XENOGFT; EA ADD 100 SQ CM
XENOGRF SKN TEMP CLSR F/S/N/H/F/G/M/D
1ST 100CM
XENOGRF SKN TEMP CLSR F/S/N/H/F/G/M/D
EA 100CM
ACLR XENOGRF IMPLT 1ST 100 CM
ACLR XENOGRF IMPLT EA 100 CM
No
No
Yes
15570
Yes
FORM DIR PEDICLE W/WO TRANSF; TRUNK
No
15572
15574
15576
15600
Yes
Yes
Yes
Yes
FORM DIR PEDICLE W/WO TRANSF; SCLP
FORM DIR PEDICLE; CHEEKS/CHIN/AX/FT
FORM DIR PEDICLE; LIDS/NOSE/EARS
DELAY FLAP/SECT FLAP; AT TRUNK
No
No
No
No
15610
15620
Yes
Yes
DELAY FLAP/SECT FLAP; SCLP/ARMS/LEG
DELAY FLAP/SECT; CHIN/AX/GENIT/FT
No
No
15630
15650
15731
Yes
Yes
Yes
DELAY FLAP/SECT; LIDS/NOSE/EARS/LIP
TRANSF INTERMED ANY PEDICLE FLAP
FOREHEAD FLAP W/VASC PEDICLE
No
No
No
15732
Yes
MUSCL MYOCUT/FASCIOCUT FLAP; HEAD
No
15734
Yes
MUSCL MYOCUT/FASCIOCUT FLAP; TRUNK
No
15736
Yes
MUSCL MYOCUT/FASCIOCUT; UP EXTREM
No
No
No
No
CPT Code
July 2011
15738
15740
15750
Yes
Yes
Yes
MUSCL MYOCUT/FASCIOCUT; LOW EXTREM
FLAP; ISLAND PEDICLE
FLAP; NEUROVASCULAR PEDICLE
No
No
No
15756
Yes
FREE MUSC FLAP W/MICROVASC ANASTOM
No
15757
Yes
FREE SKIN FLAP W/MICROVASC ANASTOM
No
15758
Yes
FREE FASCIAL FLAP W/MICROVASC ANAST
No
15760
15770
15775
15776
15780
15781
15782
15783
15786
15787
15788
15789
15792
15793
15819
15820
Yes
Yes
Not Reimbursable
Not Reimbursable
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Not Reimbursable
Not Reimbursable
GFT; COMPOSITE INCL PRIM CLO DONOR
GFT; DERM-FAT-FASCIA
PUNCH GFT HAIR TRANSPL; 1-15 GFTS
PUNCH GFT HAIR TRANSPL; > 15 GFTS
DERMABRASION; TOT FACE
DERMABRASION; SEGMT FACE
DERMABRASION; REGIONAL NOT FACE
DERMABRASION; SUPERF ANY SITE
ABRASION; SNGL LES
ABRASION; EA ADD 4 LES/LESS
CHEM PEEL FACIAL; EPIDERMAL
CHEM PEEL FACIAL; DERMAL
CHEM PEEL; NONFACIAL; EPIDERMAL
CHEM PEEL; NONFACIAL; DERMAL
CERVICOPLASTY
BLEPHAROPLASTY LOWER EYELID
No
No
Not Reimbursable
Not Reimbursable
No
No
No
No
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
15821
15822
Not Reimbursable
Yes
BLEPHAROPLASTY LOW; HERNIAT FAT PAD
BLEPHAROPLASTY UPPER EYELID
Not Reimbursable
No
15823
15824
Yes
Not Reimbursable
BLEPHAROPLASTY UPPER; W/EXCESS SKIN
RHYTIDECTOMY; FOREHEAD
No
Not Reimbursable
15825
Not Reimbursable
Not Reimbursable
15826
15828
15829
Not Reimbursable
Not Reimbursable
Not Reimbursable
RHYTIDECTOMY; NECK W/PLATYSM TIGHT
RHYTIDECTOMY; GLABELLAR FROWN
LINES
RHYTIDECTOMY; CHEEK/CHIN/NECK
RHYTIDECTOMY; SMAS FLAP
Code Description
Not Reimbursable
Not Reimbursable
Not Reimbursable
CPT Code
15830
15832
15833
15834
15835
15836
July 2011
Yes
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Code Description
EXC SKIN ABD
EXC EXCESS SKIN/SUBQ TISS; THIGH
EXC EXCESS SKIN/SUBQ TISS; LEG
EXC EXCESS SKIN/SUBQ TISS; HIP
EXC EXCESS SKIN/SUBQ TISS; BUTTOCK
EXC EXCESS SKIN/SUBQ TISS; ARM
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
15837
Not Reimbursable
EXC EXCESS SKIN/SUBQ TISS; FOREARM
Not Reimbursable
15838
15839
Not Reimbursable
Not Reimbursable
EXC EXCESS SKIN/SUBQ TISS; SUBMENTL
EXC EXCESS SKIN/SUBQ TISS; OTHER
Not Reimbursable
Not Reimbursable
15840
Yes
GFT FACE NERV PARALYSIS; FASCIA GFT
No
15841
Yes
GFT FACE NERV PARALYSIS; MUSCL GFT
No
15842
Yes
GFT FACE NERV PARALYS; MUSCL-MICRO
No
15845
15847
Yes
Not Reimbursable
15850
Bundled Prof/Paid OPPS
15851
15852
15860
No
Not Reimbursable
Yes
No
No
GFT FACE NERV PARALYS; MUSCL TRANSF
EXC SKIN ABD ADD-ON
REMOV SUTURES UNDER ANES SAME
SURG
REMOV SUTURES UNDER ANES OTHER
SURG
DSG CHANGE UNDER ANES
IV INJ AGENT-TEST BLD FLOW FLAP/GFT
15876
15877
Not Reimbursable
Not Reimbursable
SUCTION ASSIST LIPECTOMY; HEAD/NECK
SUCTION ASSISTED LIPECTOMY; TRUNK
Not Reimbursable
Not Reimbursable
15878
Not Reimbursable
SUCTION ASSIST LIPECTOMY; UP EXTREM
Not Reimbursable
15879
15920
15922
Not Reimbursable
Yes
Yes
SUCTION ASSIST LIPECTOMY; LO EXTREM
EXC COCCYGEAL ULCER; PRIM SUTURE
EXC COCCYGEAL ULCER; FLAP CLO
Not Reimbursable
No
No
15931
Yes
EXC SACRAL PRESS ULCER W/PRIM SUTUR
No
15933
Yes
EXC SACRAL ULCER W/SUTUR; W/OSTECT
No
Bundled
No
No
No
CPT Code
15934
July 2011
Yes
15935
Yes
EXC SACRAL ULCER W/FLAP; W/OSTECT
No
15936
Yes
EXC SACRAL ULCR PREP-FLAP/SKIN GFT;
No
15937
15940
Yes
Yes
EXC SACRL ULCR PREP-FLP/GFT; OSTECT
EXC ISCHIAL ULCER W/PRIM SUTURE
No
No
15941
15944
15945
Yes
Yes
Yes
EXC ISCHIAL ULCER W/SUTUR; W/OSTECT
EXC ISCHIAL ULCER W/SKIN FLAP CLO
EXC ISCHIAL ULCER W/FLAP; W/OSTECT
No
No
No
15946
Yes
No
15950
Yes
EXC ISCH ULCER-OSTECT PREP-FLAP/GFT
EXC TROCH PRESS ULCER W/PRIM
SUTURE
No
15951
15952
Yes
Yes
EXC TROCH ULCER W/PRIM SUT; W/OSTEC
EXC TROCH ULCER W/SKIN FLAP CLO
No
No
15953
Yes
EXC TROCH ULCER W/FLAP CLO; W/OSTEC
No
15956
Yes
EXC TROCH ULCER PREP-FLAP/SKIN GFT;
No
15958
15999
16000
Yes
Yes
No
EXC TROCH ULCR PREP-FLP/GFT; OSTECT
UNLISTED PROC EXC PRESS ULCER
INIT TX 1ST DEGREE BURN W/LOCAL TX
No
Yes
No
16020
No
DSG/DEBRID INIT/SUBSQT; WO ANES SM
No
16025
16030
16035
No
No
No
No
No
No
16036
No
DSG/DEBRID INIT/SUBSQT; WO ANES MED
DSG/DEBRID INIT/SUBSQT; WO ANES LG
ESCHAROTOMY; INITIAL INCISION
ESCHAROTOMY; EA ADD INCISION (IN
CONJCTN W/ CPT 16035)
17000
No
DESTRCT-ANY METHD-BEN LES; W/ANE; 1
No
17003
No
DESTRCT-ANY METHD-BEN LES; 2-14, EA
No
Code Description
EXC SACRAL ULCER W/SKIN FLAP CLO
No
No
CPT Code
July 2011
17004
17106
Yes
Yes
DESTRCT-ANY METHD-BEN LES 15/> LES
DESTRCT CUT VASCUL LES; < 10 SQ CM
No
No
17107
17108
Yes
Yes
DESTRCT CUT VASCUL LES; 10-50 SQ CM
DESTRCT CUT VASCUL LES; > 50 SQ CM
No
No
17110
No
DESTRCT WARTS/MOLLUSCUM TO 14 LES
No
17111
17250
17260
17261
17262
17263
17264
17266
No
No
No
No
No
No
No
No
DESTRCT WARTS/MOLLUSCUM; 15/> LES
CHEM CAUT GRANULATION TISS
DESTRCT MALIG LES TRUNK; 0.5/LESS
DESTRCT MALIG LES TRUNK; 0.6-1.0 CM
DESTRCT MALIG LES TRUNK; > 4.0 CM
No
No
No
No
No
No
No
No
17270
17271
17272
17273
17274
No
No
No
No
No
DESTRCT MALIG LES SCLP; 0.5 CM/LESS
DESTRCT MALIG LES SCLP; 0.6-1.0 CM
No
No
No
No
No
17276
No
DESTRCT MALIG LES SCLP; OVER 4.0 CM
No
17280
17281
17282
17283
17284
No
No
No
No
No
DESTRCT MALIG LES FACE; 0.5 CM/LESS
DESTRCT MALIG LES FACE; 0.6-1.0 CM
No
No
No
No
No
17286
17311
17312
17313
17314
17315
17340
No
No
No
No
No
No
Yes
DESTRCT MALIG LES FACE; OVER 4.0 CM
MOHS, 1 STAGE, H/N/HF/G
MOHS ADDL STAGE
MOHS, 1 STAGE, T/A/L
MOHS, ADDL STAGE, T/A/L
MOHS SURG, ADDL BLOCK
CRYOTHERAPY-ACNE
No
No
No
No
No
No
No
Code Description
CPT Code
17360
17380
July 2011
Not Reimbursable
Not Reimbursable
17999
19000
Yes
No
UNLISTED-SKIN/MUCOUS MEMB/SUBQ TISS
PUNCT ASPIRAT CYST BREAST
Yes
No
19001
No
PUNCT ASPIR CYST BREAST; EA AD CYST
No
19020
No
No
19030
19100
19101
No
No
No
19102
No
19103
19105
19110
19112
No
Not Reimbursable
No
No
MASTOTOMY W/EXPLOR/DRAIN ABSCESS
INJ PROC ONLY-MAMMARY
DUCT/GALACTGM
BX BREAST; NEEDLE CORE (SEP PROC)
BX BREAST; INCS
BX-BREAST; PERCUTANEOUS, NEEDLE
CORE
BX BREAST; PERCUTANEOUS, AUTO VAC
ASSIST OR ROT BX DEVICE
CRYOSURG ABLATE FA, EACH
NIPPLE EXPLOR W/WO EXC DUCT
EXC LACTIFEROUS DUCT FISTULA
No
Not Reimbursable
No
No
19120
No
EXC CYST/BEN-MALIG TISS/DUCT 1/MORE
No
19125
No
EXC BREAST LES-ID RAD MARKER; 1 LES
No
19126
19260
No
Yes
EXC BREAST LES; EA ADD-ID RAD MARKR
EXC CHEST WALL TUMOR INCL RIBS
No
No
19271
Yes
EXC CHEST WALL TUMOR; WO LYMPHADEN
No
19272
Yes
EXC CHEST WALL TUMOR; W/LYMPHADEN
No
19290
No
PREOP PLCMT NEEDL LOCAL WIRE BREAST
No
19291
No
No
19295
No
19296
Yes
PREOP PLCMT NEEDLE BREAST; ADD LES
IMAGE GUIDED PLCMT; DURING BREAST BX
(IN CONJTN W/ CPT 19102
PLCMT RT BALLN CATH BRST; DATE SEP
PART MASTECT
Code Description
CHEM EXFOLIATION ACNE
ELECTROLYSIS EPILATION EA 1/2 HR
Not Reimbursable
Not Reimbursable
No
No
No
No
No
No
CPT Code
July 2011
19297
No
19298
19300
19301
19302
19303
19304
19305
19306
19307
19316
19318
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
19324
Not Reimbursable
19325
19328
19330
Not Reimbursable
Yes
Yes
19340
Yes
19342
19350
19355
Code Description
PLCMT RT BALLN CATH BRST; CONCURRNT
PART MASTECT
PLCMT RT BRACHYTX CATH BRST FLW
PART MASTECT
REMOVAL OF BREAST TISSUE
PARTICAL MASTECTOMY
P-MASTECTOMY W/LN REMOVAL
MAST, SIMPLE, COMPLETE
MAST, SUBQ
MAST, RADICAL
MAST, RAD, URBAN TYPE
MAST, MOD RAD
MASTOPEXY
REDUCTION MAMMAPLASTY
MAMMAPLSTY AUGMEN; WO PROSTH
IMPLNT
MAMMAPLASTY AUGMEN; W/PROSTH
IMPLNT
REMOV INTACT MAMMARY IMPLNT
REMOV MAMMARY IMPLNT MAT
No
No
Yes
No
No
No
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
No
No
Yes
Yes
Yes
IMMED INSRT PROSTH AFTER MASTOPEX
DELAYED INSRT PROSTH AFTER
MASTOPEX
NIPPLE/AREOLA RECON
CORRECT INVERTED NIPPLES
No
No
No
19357
19361
19364
19366
Yes
Yes
Yes
Yes
BREAST RECON IMMED/DELAY W/EXPANDR
BREAST RECON W/FLAP W/WO PROSTH
BREAST RECON W/FREE FLAP
BREAST RECON W/OTHER TECH
No
No
No
No
19367
Yes
BREAST RECON W/TRAM FLAP-1 PEDICLE;
No
19368
Yes
BRST RECON W/TRAM FLP; W/MICRO ANAS
No
19369
Yes
No
19370
Yes
BREAST RECON W/TRAM FLAP-2 PEDICLE
OPEN PERIPROSTH CAPSULOTOMY
BREAST
No
No
CPT Code
July 2011
19371
19380
Yes
Yes
Code Description
PERIPROSTHETIC CAPSULECTOMY
BREAST
REVIS RECON BREAST
19396
19499
No
Yes
PREP MOULAGE CUSTOM BREAST IMPLNT
UNLISTED PROC BREAST
No
Yes
20005
No
INCS SOFT TISS ABSCESS; DEEP/COMPLI
No
20100
No
EXPLOR PENETR WOUND (SEP PRO); NECK
No
20101
No
EXPLOR PENETR WOUND (SEP PRO); CHST
No
20102
No
EXPLOR WOUND (SEP PRO); ABD/FLNK/BK
No
20103
No
EXPLO PENTR WOUND (SEP PRO); EXTREM
No
20150
20200
20205
20206
20220
20225
20240
20245
20250
No
No
No
No
No
No
No
No
No
EXC EPIPHYSEAL BAR W/WO AUTOG GFT
BX MUSCL; SUPERF
BX MUSCL; DEEP
BX MUSCL PERCUT NEEDLE
BX BONE TROCAR/NEEDLE; SUPERF
BX BONE TROCAR/NEEDLE; DEEP
BIOPSY BONE OPEN; SUPERFICIAL
BIOPSY BONE OPEN; DEEP
BX VERTEBRAL BODY OPEN; THORACIC
No
No
No
No
No
No
No
No
No
20251
20500
20501
20520
No
No
No
No
BX VERTEBRAL BODY OPEN; LUMBAR/CERV
INJ SINUS TRACT; THERAP (SEP PRO)
INJ SINUS TRACT; DX
REMOV FB MUSCL/TENDON; SIMPL
No
No
No
No
20525
No
REMOV FB MUSCL/TENDON; DEEP/COMPLI
No
20526
No
No
20550
No
20551
No
INJECTION THERAPEUTIC CARPAL TUNNEL
INJECTION; SINGLE TENDON SHEATH OR
LIGAMENT
INJECTION; SINGLE TENDON
ORIGIN/INSERTION
No
No
No
No
CPT Code
July 2011
20552
20553
20555
20600
20605
20610
No
No
Non Reim Prof/Paid OPPS
No
No
No
20612
20615
20650
20660
20661
20662
20663
No
No
No
No
No
No
No
Code Description
INJ; SINGLE/MX TRIGGER POINT 1/TWO
MUSCLE
INJ; 1/MX TRIG POINT 3/> MUSC GRP
PLACE NDL MUSC/TIS FOR RT
ARTHROCENTESIS/ASPIR/INJ; SM JT
ARTHROCENTESIS/ASPIR/INJ; INTERM JT
ARTHROCENTESIS/ASPIR/INJ; MAJOR JT
ASPIRATION AND/OR INJECT OF GANGLION
CYST(S)
ASPIRAT & INJ TX BONE CYST
INSRT WIRE W/TRACT (SEPART PROC)
APPLIC CRAN TONGS (SEPART PROC)
APPLIC HALO INCL REMOV; CRANIAL
APPLIC HALO INCL REMOV; PELVIC
APPLIC HALO INCL REMOV; FEMORAL
20664
No
APPLIC HALO INCL REMOV, CRAN W/ANES
No
20665
No
REMOV TONGS/HALO APPLIC BY ANOTHER
No
20670
20680
20690
20692
No
No
No
No
REMOV IMPLNT; SUPERF (SEPART PROC)
REMOV IMPLNT; DEEP
APPLIC UNIPLANE-UNILAT-EXT FIXA
APPLIC MULTIPLANE-UNILAT-EXT FIXA
No
No
No
No
20693
20694
20696
20697
20802
No
No
Yes
Yes
Yes
No
No
No
No
No
20805
20808
20816
20822
20824
20827
20838
Yes
Yes
Yes
Yes
Yes
Yes
Yes
ADJUST/REVIS EXT FIXA SYST REQ ANES
REMOV UNDER ANES EXT FIXA SYST
COMP MULTIPLANE EXT FIXATION
COMP EXT FIXATE STRUT CHANGE
REPLANTATION ARM; COMPLT AMPUTA
REPLANTATION FOREARM; COMPLT
AMPUTA
REPLANTATION HAND; COMPLT AMPUTA
REPLANTATION DIGIT (MCP JT); COMPLT
REPLANT DIGIT (DISTAL TIP); COMPLT
REPLANT THUMB (CM-MP JT); COMPLT
REPLANT THUMB (DISTAL TIP); COMPLT
REPLANTATION FT; COMPLT AMPUTA
No
No
Not Reimbursable
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
20900
Yes
BONE GFT ANY DONOR AREA; MINOR/SM
No
20902
20910
20912
20920
Yes
Yes
Yes
Yes
BONE GFT ANY DONOR AREA; MAJOR/LG
CARTILAGE GFT; COSTOCHONDRAL
CARTILAGE GFT; NASAL SEPTUM
FASCIA LATA GFT; BY STRIPPER
No
No
No
No
20922
20924
20926
Yes
Yes
Yes
FASCIA LATA GFT; INCS & AREA EXPOSU
TENDON GFT FROM A DISTANCE
TISS GFT OTHER
No
No
No
20930
Bundled
ALLOGFT SPINE SURG ONLY; MORSELIZED
Bundled
20931
Yes
ALLOGFT SPINE SURG ONLY; STRUCTURAL
No
20936
Bundled
20937
Yes
AUTOGFT SPINE SURG ONLY; MORSELIZED
No
20938
Yes
No
20950
Yes
AUTOGFT SPIN SURG; STRUC/BI-TRICORT
MONITOR PRESS-DETECT MUSCL
COMPARTM
20955
Yes
BONE GFT W/MICROVASC ANASTOM; FIBUL
No
20956
Yes
BONE GFT W/MICROVASC ANASTOM; ILIAC
No
20957
Yes
No
20962
Yes
BONE GFT W/MICROVAS ANAS; METATARSL
BONE GFT W/MICROVASC ANASTOM;
OTHER
20969
20970
20972
20973
Yes
Yes
Yes
Yes
FREE OSTEOCUT FLAP; NOT ILIAC CREST
FREE OSTEOCUT FLAP; ILIAC CREST
FREE OSTEOCUT FLAP; METATARS
FREE OSTEOCUT FLAP; GRT TOE
No
No
No
No
20974
20975
Yes
Yes
ELEC STIM-AID BONE HEAL; NONINVASIV
ELEC STIM-AID BONE HEAL; INVASIVE
No
No
Code Description
AUTOGFT SPIN SURG; LOCAL-SAME INCIS
Bundled
No
No
CPT Code
20979
July 2011
Yes
20982
20985
20999
Yes
Not Reimbursable
Yes
21010
21011
21012
21013
21014
Yes
Yes
Yes
Yes
Yes
ARTHROTOMY TEMPOROMANDIBULAR JT
EXC FACE LES SC < 2 CM
EXC FACE LES SC = 2 CM
EXC FACE TUM DEEP < 2 CM
EXC FACE TUM DEEP = 2 CM
No
No
No
No
No
21015
21016
21025
21026
Yes
Yes
Yes
Yes
No
No
No
No
21029
Yes
RAD RESEC TUMOR SOFT TISS FACE/SCLP
RESECT FACE TUM = 2 CM
EXC BONE; MANDIB
EXC BONE; FACIAL BONE
REMOV-CONTOURNG BEN TUMOR FACE
BONE
21030
21031
21032
Yes
Yes
Yes
EXC BEN TUMOR FACE BONE NOT MANDIB
EXC TORUS MANDIBULARIS
EXC MAXIL TORUS PALATINUS
No
No
No
21034
21040
21044
Yes
Yes
Yes
EXC MALIG TUM FACE BONE NOT MANDIB
EXC BEN CYST/TUMOR MANDIB; SIMPL
EXC MALIG TUMOR MANDIB
No
No
No
21045
Yes
No
21046
Yes
21047
Yes
21048
Yes
21049
21050
Yes
Yes
EXC MALIG TUMOR MANDIB; RAD RESECT
EXC BEN CYST/TUMOR MANDIB; INTRAORAL OSTEOTOMY
EXC BEN CYST/TUMOR MANDIB; EXTRAORAL OSTEOTOMY
EXC BEN CYST/TUMOR MAXILLA; INTRAORAL OSTEOTOMY
EXC BEN CYST/TUMOR MAXILLA; EXTRAORAL OSTEOTOMY
CONDYLECTOMY TMJ (SEPART PROC)
21060
Yes
MENISCECT PART/COMPLT (SEPART PROC)
No
Code Description
US STIM-AID BONE HEALING-NONINVAS
ABLATION BONE TUMOR RADIOFREQ PERQ
CT GUID
CPTR-ASST DIR MS PX
UNLISTED PROC MS SYST GEN
No
No
Not Reimbursable
Yes
No
No
No
No
No
No
CPT Code
21070
21073
July 2011
Yes
No
21076
Yes
IMPRES & CUSTM PREP; SUR OBTUR PROS
No
21077
Yes
IMPRESS & CUSTOM PREP; ORBIT PROSTH
No
21079
Yes
IMPRESS/CUST PREP; INTERIM OBTURATR
No
21080
21081
Yes
Yes
IMPRESS/CUST PREP; DEFINIT OBTURATR
IMPRESS/CUST PREP; MANDIB RESECT
No
No
21082
21083
21084
Yes
Yes
Yes
IMPRESS/CUST PREP; PALATAL AUGMEN
IMPRESS/CUST PREP; PALATAL LIFT
IMPRESS/CUST PREP; SPEECH AID
No
No
No
21085
Yes
IMPRESS/CUST PREP; ORAL SURG SPLINT
No
21086
21087
21088
Yes
Yes
Yes
IMPRESS/CUST PREP; AURICULAR PROSTH
IMPRESS/CUST PREP; NASAL PROSTH
IMPRESS/CUST PREP; FACIAL PROSTH
No
No
Yes
21089
21100
21110
21116
21120
21121
Yes
Yes
Yes
Yes
Yes
Yes
UNLISTED MAXILLOFACIAL PROSTH PROC
APPLIC HALO-MAXILLOFAC (SEP PRO)
APPLIC INTERDENTAL DEVICE-NOT FX
INJ PROC TMJ ARTHROGRAPHY
GENIOPLASTY; AUGMEN
GENIOPLASTY; SLIDING OSTEOTOMY 1
Yes
No
No
No
No
No
21122
21123
Yes
Yes
GENIOPLASTY; SLIDING OSTEOT 2/MORE
GENIOPLASTY; SLIDING AUGMEN W/GFT
No
No
21125
21127
Yes
Yes
No
No
21137
Yes
AUGMEN MANDIB BODY/ANGLE; PROSTH
AUGMEN MANDIB BODY; W/BONE GFT
REDUCTION FOREHEAD; CONTOURING
ONLY
21138
Yes
REDUCT FOREHEAD; CONTOUR/BONE GFT
No
Code Description
CORONOIDECTOMY (SEPART PROC)
MNPJ OF TMJ W/ANESTH
No
No
No
CPT Code
July 2011
21139
21141
21142
21143
21145
21146
21147
21150
21151
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Code Description
REDUCT FOREHEAD; SETBACK SINUS
WALL
RECON MIDFACE LEFORT I; 1 WO GFT
RECON MIDFACE LEFORT I; 2 WO GFT
RECON MIDFACE LEFORT I; 3/> WO GFT
RECON MIDFACE LEFORT I; 1 REQ GFT
RECON MIDFACE LEFORT I; 2 REQ GFT
RECON MIDFACE LEFORT I; 3/MORE-GFT
RECON MIDFACE LEFORT II; ANT INTRUS
RECON MIDFACE LEFORT II; REQ GFT
21154
21155
Yes
Yes
RECON MIDFACE REQ GFT; WO LEFORT I
RECON MIDFACE REQ GFT; W/LEFORT I
No
No
21159
Yes
RECON MIDFACE FOREHD ADV; WO LFRT I
No
21160
Yes
RECON MIDFACE FOREHD ADV; W/LFORT I
No
21172
Yes
RECON ORBITAL RIM/LO FORHD W/WO GFT
No
21175
21179
Yes
Yes
RECON BIFRONTL ORBIT RIMS W/WO GFTS
RECON MAJ FORHD/ORBIT RIMS; W/GFT
No
No
21180
Yes
RECON MAJ FORHD/ORBIT RIM; W/AUTOGT
No
21181
21182
Yes
Yes
RECON CONTOUR BEN TUMOR CRAN BONE
RECON ORBIT-EXC BONE; GFT < 40 CM2
No
No
21183
21184
Yes
Yes
RECON ORBIT; BONE GFT >40 BUT <80CM
RECON ORBIT-EXC BONE; GFT > 80 CM2
No
No
21188
21193
21194
21195
21196
21198
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
21199
Yes
RECON MIDFACE OSTEOTOMIES/BONE GFT
RECON MANDIB RAMI OSTEOT; WO GFT
RECON MANDIB RAMI OSTEOT; W/GFT
RECON MANDIB RAMI/BODY; WO INT FIX
RECON MANDIB RAMI/BODY; W/INT FIXA
OSTEOTOMY MANDIB SEGMT
OSTEOTOMY W/ GENIOGLOSSUS
ADVANCEMENT
No
No
No
No
No
No
No
No
No
No
CPT Code
21206
July 2011
Yes
21208
Yes
OSTEOPLASTY FACIAL BONES; AUGMEN
No
21209
21210
21215
21230
Yes
Yes
Yes
Yes
OSTEOPLASTY FACIAL BONES; REDUCTION
GFT BONE; NASAL/MAXIL/MALAR AREAS
GFT BONE; MANDIB
GFT; RIB CARTIL AUTOG-FACE/CHIN/EAR
No
No
No
No
21235
21240
21242
Yes
Yes
Yes
No
No
No
21243
Yes
21244
Yes
GFT; EAR CARTILAGE AUTOGEN NOSE/EAR
ARTHROPLASTY TMJ W/WO AUTOGFT
ARTHROPLASTY TMJ W/ALLOGFT
ARTHROPLASTY TMJ W/PROSTH JT
REPLAC
RECON MANDIB EXTRAORAL W/BONE
PLATE
21245
Yes
RECON MANDIB SUBPERIOST IMPLT; PART
No
21246
Yes
No
21247
Yes
RECON MANDIB SUBPERIOST IMPLT; COMP
RECON MANDIB CONDYLE W/BONE
AUTOGFT
21248
Yes
RECON MANDIB ENDOSTEAL IMPLT; PART
No
21249
Yes
RECON MANDIB ENDOSTEAL IMPLT; COMPL
No
21255
Yes
RECON ZYGOMATIC ARCH W/BONE CARTIL
No
21256
Yes
No
21260
Yes
RECON ORBIT W/OSTEOT & W/BONE GFT
PERIORBIT OSTEOTOM W/GFT;
EXTRACRAN
21261
Yes
No
21263
21267
21268
21270
Yes
Yes
Yes
Yes
PERIORBIT OSTEOTOM; INTRA-EXTRACRAN
PERIORBIT OSTEOTOM; W/FORHD
ADVANCE
ORBIT REPOSIT-UNILAT; EXTRACRANIAL
ORBIT REPOSIT-UNILAT; INTRA-EXTRACR
MALAR AUGMEN PROSTH MAT
Code Description
OSTEOTOMY MAXIL SEGMT
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
21275
21280
21282
Yes
Yes
Yes
Code Description
SECNDRY REVIS ORBITOCRAN-FACE
RECON
MEDIAL CANTHOPEXY (SEPART PROC)
LAT CANTHOPEXY
21295
21296
Yes
Yes
REDUCTION MASSETER MUSCL & BONE; EX
REDUCT MASSETER MUSCL; INTRAORAL
No
No
21299
21310
21315
21320
21325
21330
Yes
No
No
No
No
No
UNLISTED CRANIO-MAXILLOFACIAL PROC
CLO TX NASAL BONE FX WO MANIP
CLO TX NASAL BONE FX; WO STABILIZAT
CLO TX NASAL BONE FX; W/STABILIZAT
OPEN TX NASAL FX; UNCOMP
OPEN TX NAS FX; COMPL W/INT-EXT FIX
Yes
No
No
No
No
No
21335
21336
21337
No
No
No
OPEN TX NASAL FX; W/CONCOM TX SEPTM
OPEN TX SEPTAL FX; W/WO STABILIZAT
CLO TX SEPTAL FX W/WO STABILIZAT
No
No
No
21338
21339
No
No
OPEN TX NASOETHMOID FX; WO EXT FIXA
OPEN TX NASOETHMOID FX; W/EXT FIXA
No
No
21340
No
PERCUT TX NASOETH FX W/FIXA W/REPR
No
21343
21344
21345
21346
No
No
No
No
No
No
No
No
21347
21348
21355
No
No
No
21356
No
OPEN TX DEPRESSED FRONTAL SINUS FX
OPEN TX FRONT SINUS FX VIA CORONAL
CLO TX NASOMAXIL FX W/FIXA/SPLINT
OPEN TX NASOMAXIL FX; W/WIRING/FIXA
OPEN TX NASOMAX FX; REQ MX
APPROACH
OPEN TX NASOMAXIL FX; W/BONE GFT
PERCUT TX FX MALAR AREA W/MANIP
OPEN TX DEPRESSED ZYGOMATIC ARCH
FX
21360
21365
21366
No
No
No
OPEN TX DEPRESS MALAR FX INCL ZYGOM
OPEN TX FX MALAR AREA; W/INT FIX
OPEN TX FX MALAR AREA; W/GFT
No
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
21385
No
OPEN TX ORBIT BLOWOUT FX; TRNSANTRL
No
21386
21387
21390
21395
No
No
No
No
OPEN TX ORBIT BLOWOUT FX; PERIORBIT
OPEN TX ORBIT "BLOWOUT" FX; COMBO
OPEN TX ORBIT BLOWOUT FX; W/IMPLNT
OPEN TX ORBIT "BLOWOUT" FX; W/GFT
No
No
No
No
21400
No
CLO TX FX ORBIT EX BLOWOUT; WO MANI
No
21401
No
CLO TX FX ORBIT EX BLOWOUT; W/MANIP
No
21406
No
OPEN TX FX ORB EX BLOWOUT; WO IMPLT
No
21407
21408
21421
21422
21423
21431
No
No
No
No
No
No
OPEN TX FX ORB EX BLOWOUT; W/IMPLNT
OPEN TX FX ORBIT EX BLOWOUT; W/GFT
CLO TX PALATAL FX W/INTERDENT FIXA
OPEN TX PALATAL/MAXIL FX
OPEN TX PALATAL/MAXIL FX; COMPLIC
CLO TX CRANIOFAC SEPART W/WIRE FIX
No
No
No
No
No
No
21432
21433
21435
No
No
No
OPEN TX CRANIOFAC SEPAR; W/INT FIXA
OPEN TX CRANIOFAC SEPART; COMPLIC
OPEN TX CRANIFAC SEPAR; INT-EXT FIX
No
No
No
21436
21440
21445
21450
21451
21452
21453
21454
21461
21462
21465
No
No
No
No
No
No
No
No
No
No
No
OPEN TX CRANIFAC SEPAR; W/FIX W/GFT
CLO TX MAXIL RIDGE FX (SEP PRO)
OPEN TX MAXIL RIDGE FX (SEP PRO)
CLO TX MANDIB FX; WO MANIP
CLO TX MANDIB FX; W/MANIP
PERCUT TX MANDIB FX W/EXT FIXA
CLO TX MANDIB FX W/INTERDENTAL FIXA
OPEN TX MANDIB FX W/EXT FIXA
OPEN TX MANDIB FX; WO INTERDENT FIX
OPEN TX MANDIB FX; W/INTERDENT FIXA
OPEN TX MANDIB CONDYLAR FX
No
No
No
No
No
No
No
No
No
No
No
21470
21480
No
No
OPEN TX MANDIB FX MX APPROACH W/FIX
CLO TX TM DISLOC; INIT/SUBSQT
No
No
Code Description
CPT Code
21485
July 2011
No
21490
21495
21497
21499
21501
21502
No
No
No
Yes
No
No
21510
21550
21552
21554
21555
21556
21557
21558
21600
No
No
Yes
Yes
No
No
Yes
Yes
Yes
21610
21615
Yes
Yes
21616
21620
21627
21630
Yes
Yes
Yes
Yes
21632
21685
Code Description
CLO TX TM DISLOC; COMPLIC INIT/SUBS
No
OPEN TX TEMPOROMANDIBULAR DISLOC
OPEN TX HYOID FX
INTERDENT WIRING-CONDITION NOT FX
UNLISTED MS PROC HEAD
I&D DEEP ABSCESS SOFT TISS NECK
I&D DEEP ABSCESS NECK; W/PART RIB
INCS DEEP W/OPEN BONE CORTEX
THORAX
BX SOFT TISS NECK/THORAX
EXC NECK LES SC = 3 CM
EXC NECK TUM DEEP = 5 CM
EXC TUMOR SOFT TISS NECK; SUBQ
EXC TUMOR SOFT TISS NECK; DEEP/IM
RAD RESECT TUMOR SOFT TISS NECK
RESECT NECK TUM = 5 CM
EXC RIB PART
COSTOTRANSVERSECTOMY (SEPART
PROC)
EXC 1ST &/OR CERV RIB;
No
No
No
Yes
No
No
No
No
No
No
Yes
Yes
EXC 1ST &/OR CERV RIB; W/SYMPATHEC
OSTECTOMY STERNUM PART
STERNAL DEBRID
RADICAL RESECT STERNUM;
RAD RESECT STERNUM;
W/LYMPHADENECT
HYOID MYOTOMY AND SUSPENSION
21700
21705
Yes
Yes
DIVIS SCALENUS ANTICUS; WO CERV RIB
DIVIS SCALENUS ANTICUS; W/CERV RIB
No
No
21720
21725
Yes
Yes
No
No
21740
Yes
21742
Yes
DIVIS STERNOCLEIDOMASTOID; WO CAST
DIVIS STERNOCLEIDOMASTOID; W/CAST
RECON REPR PECTUS
EXCAVAT/CARINATUM
RECON REP PECTUS
EXCAVATM/CARINATM;NO THORACSCPY
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
CPT Code
July 2011
21743
Yes
Code Description
RECON REP PECTUS
EXCAVATM/CARINATM; W/THORACSCPY
21750
21800
21805
21810
21820
No
No
No
No
No
CLO STERNOTMY W/WO DEBRID (SEP PRO)
CLO TX RIB FX UNCOMP EA
OPEN TX RIB FX WO FIXA EA
TX RIB FX REQUIRING EXT FIXA
CLO TX STERNUM FX
No
No
No
No
No
21825
21899
21920
21925
21930
21931
21932
21933
21935
21936
22010
22015
No
Yes
No
No
No
Yes
Yes
Yes
Yes
Yes
No
No
OPEN TX STERNUM FX W/WO SKELET FIXA
UNLISTED PROC NECK/THORAX
BX SOFT TISS BACK/FLANK; SUPERF
BX SOFT TISS BACK/FLANK; DEEP
EXC TUMOR SOFT TISS BACK/FLANK
EXC BACK LES SC = 3 CM
EXC BACK TUM DEEP < 5 CM
EXC BACK TUM DEEP = 5 CM
RAD RESECT TUMOR TISS BACK/FLANK
RESECT BACK TUM = 5 CM
I&D, P-SPINE, C/T/CERV-THOR
I&d, P-SPINE, L/S/LS
No
Yes
No
No
No
No
No
No
No
No
No
No
22100
Yes
PART EXC POST VERTEB COMPON-1; CERV
No
22101
Yes
PART EXC POST VERTEB COMPON-1; THOR
No
22102
Yes
PART EXC POST VERTEB COMPON-1; LUMB
No
22103
Yes
PART EXC POST VERTEB COMPON; EA ADD
No
22110
Yes
PART EXC VERT BODY WO DECOM-1; CERV
No
22112
Yes
PART EXC VERT BODY WO DECOM-1; THOR
No
22114
22116
22206
22207
22208
Yes
Yes
Yes
Yes
Yes
PART EXC VERT BODY WO DECOM-1; LUMB
PART EXC VERT BODY; EA ADD SEGMT
CUT SPINE 3 COL, THOR
CUT SPINE 3 COL, LUMB
CUT SPINE 3 COL, ADDL SEG
No
No
No
No
No
Yes
CPT Code
22210
22212
22214
22216
22220
22222
22224
22226
22305
July 2011
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
22310
22315
22318
22319
22325
22326
22327
22328
No
No
No
No
No
No
No
No
CLO TX VERT BODY FX WO MANIP-W/CAST
CLO TX VERT FX/DISLOC W/CAST-MANIP
OP TX ODONTOID FX/DISLOC; WO GFT
OP TX ODONTOID FX/DISLOC; W/GFT
OPEN TX VERT FX/DISLOC-POST-1; LUMB
OPEN TX VERT FX/DISLOC-POST-1; CERV
OPEN TX VERT FX/DISLOC-POST-1; THOR
OP TX VERT FX/DISLOC-POST; EA ADD
No
No
No
No
No
No
No
No
22505
22520
22521
Yes
Not Reimbursable
Not Reimbursable
No
Not Reimbursable
Not Reimbursable
22522
Not Reimbursable
22523
Not Reimbursable
22524
Not Reimbursable
22525
22526
22527
Not Reimbursable
Yes
Yes
22532
Yes
22533
Yes
22534
Yes
MANIP SPINE REQUIR ANES ANY REGION
PERCTANEOUS VERTEBROPLASTY
PERC VERTEBROPLASTY-LUMBAR
PERC VERTEBROPLASTY-EA ADD
THORACIC OR LUMBAR VERT
PRQ VRT AGMNTJ MCHNL DEV 1 VRT BDY
THRC
LMBR
EA THRC/LMBR
IDET, SINGLE LEVEL
IDET, 1 OR MORE LEVELS
ARTHRDSIS LAT XTRACAVITARY MINI
DISKECT; THOR
ARTHRDSIS LAT XTRACAVITARY MINI
DISKECT; LUMB
ARTHRDSIS LAT XTRACAVTRY MINI
DISKECT;T/L EA ADD
Code Description
OSTEOT SPINE-VIA POST/LAT-1; CERV
OSTEOT SPINE-VIA POST/LAT-1; THOR
OSTEOT SPINE-VIA POST/LAT-1; LUMB
OSTEOT SPINE VIA POST/LAT; EA ADD
OSTEOT SPINE W/DISKECT-ANT-1; CERV
OSTEOT SPINE W/DISKECT-ANT-1; THOR
OSTEOT SPINE W/DISKECT-ANT-1; LUMB
OSTEOT SPINE W/DISKECT-ANT; EA ADD
CLO TX VERTEBRAL PROCESS FX
No
No
No
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
No
No
No
CPT Code
July 2011
22548
22551
Yes
Yes
22552
22554
22556
22558
22585
Yes
Yes
Yes
Yes
Yes
Code Description
ARTHRODESIS-C1 C2-W/WO EXC
ODONTOID
NECK SPINE FUSE&REMOVE ADDL
ARTHRODESIS WITH DISKECTOMY,
CERVICAL,
ARTHRODESIS W/MINI DISKECT; C3-C7
ARTHRODESIS W/MINI DISKECT; THOR
ARTHRODESIS W/MINI DISKECT; LUMB
ARTHRODESIS W/MINI DISKECT; EA ADD
22590
22595
22600
22610
22612
Yes
Yes
Yes
Yes
Yes
ARTHRODESIS-POST TECH, CRANIOCERV
ARTHRODESIS-POST TECH, ATLAS-AXIS
ARTHRODESIS-POST/POSTLAT-1; C3-C7
ARTHRODESIS-POST/POSTLAT-1; THOR
ARTHRODESIS-POST/POSTLAT-1; LUMB
No
No
No
No
No
22614
Yes
ARTHRODESIS-POST/LAT; EA ADD SEGMT
No
22630
Yes
ARTHRODESIS-POST-W/ LAMINEC-1; LUMB
No
22632
Yes
ARTHRODES-POST-W/ LAMINEC-1; EA ADD
No
22800
Yes
ARTHRODESIS-POST; 6/LESS VERT SEGMT
No
22802
Yes
ARTHRODESIS-POST; 7-12 VERTEB SEGMT
No
22804
22808
22810
Yes
Yes
Yes
ARTHRODESIS-POST; 13/> VERTEB SEGMT
ARTHRODESIS-ANT; 2 TO 3 VERT SEGMT
ARTHRODESIS-ANT; 4-7 VERTEB SEGMT
No
No
No
22812
Yes
ARTHRODESIS-ANT; 8/MORE VERT SEGMT
No
22818
Yes
KYPHECTOMY, RESECT VERT SEGMT; 1-2
No
22819
22830
Yes
Yes
KYPHECTOMY, RESECT VERT SEGMT; 3/>
EXPLOR SPINAL FUSION
No
No
22840
Yes
POST NON-SEG INSTRUM-PEDICLE/SCREW
No
No
No
No
No
No
No
No
CPT Code
July 2011
22841
Bundled
INT SPINAL FIX-WIRE SPINOUS PROCESS
Bundled
22842
Yes
POST SEGMT INSTRUM; 3 TO 6 VERT SEG
No
22843
Yes
POST SEGMT INSTRUM; 7-12 VERT SEGMT
No
22844
22845
22846
22847
22848
22849
Yes
Yes
Yes
Yes
Yes
Yes
POST SEGMT INSTRUM; 13/> VERT SEGMT
ANT INSTRUM; 2 TO 3 VERTEB SEGMT
ANT INSTRUM; 4 TO 7 VERTEB SEGMT
ANT INSTRUM; 8/MORE VERTEB SEGMT
PELV FIX OTH THAN SACRUM
REINSERTION SPINAL FIXA DEVICE
No
No
No
No
No
No
22850
22851
22852
22855
22856
22857
22861
22862
22864
22865
22899
22900
22901
22902
22903
22904
22905
22999
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
REMOV POST NONSEGMENTAL INSTRUM
APPLIC INTERVERT BIOMECHAN DEVICE
REMOV POST SEGMT INSTRUM
REMOV ANT INSTRUM
CERV ARTIFIC DISKECTOMY
LUMBAR ARTIF DISKECTOMY
REVISE CERV ARTIFIC DISC
REVISE LUMBAR ARTIF DISC
REMOVE CERV ARTIF DISC
REMOVE LUMB ARTIF DISC
UNLISTED PROC SPINE
EXC ABD WALL TUMOR SUBFASCIAL
EXC BACK TUM DEEP = 5 CM
EXC ABD LES SC < 3 CM
EXC ABD LES SC > 3 CM
RESECT ABD TUM < 5 CM
RESECT ABD TUM > 5 CM
UNLISTED PROC ABD MS SYST
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
Yes
23000
23020
No
Yes
No
No
23030
23031
23035
No
No
Yes
REMOV SUBDELT CALC DEPOS ANY METHD
CAPSULAR CONTRACTURE RELEASE
I&D SHOULDER; DEEP
ABSCESS/HEMATOMA
I&D SHOULDER AREA; INFEC BURSA
INCS BONE CORTEX SHLDR AREA
Code Description
No
No
No
CPT Code
July 2011
23040
Yes
ARTHROT GLENOHUMERAL JT W/EXPLOR
No
23044
Yes
ARTHROT AC/STERNOCLAV JT W/EXPLOR
No
23065
23066
23071
23073
23075
23076
No
No
Yes
Yes
No
No
No
No
No
No
No
No
23077
23078
23100
23101
Yes
Yes
Yes
Yes
23105
Yes
BX SOFT TISS SHOULDER AREA; SUPERF
BX SOFT TISS SHOULDER AREA; DEEP
EXC SHOULDER LES SC > 3 CM
EXC SHOULDER TUM DEEP > 5 CM
EXC SOFT TISS TUMOR SHLDR; SUBQ
EXC SOFT TISS TUMOR SHLDR; DEEP
RAD RESECT TUMOR SOFT TISS
SHOULDER
RESECT SHOULDER TUM > 5 CM
ARTHROT GLENOHUMERAL JT INCL BX
ARTHROT AC/SC JT W/BX/EXC CARTIL
ARTHROT; GLENOHUM JT-SYNVCT W/WO
BX
23106
Yes
No
23107
23120
23125
23130
Yes
Yes
Yes
Yes
23140
Yes
ARTHROT; SC JT W/SYNOVECT W/WO BX
ARTHROTOMY-GLENOHUMERAL JT
W/EXPLOR
CLAVICULECTOMY; PART
CLAVICULECTOMY; TOT
ACROMIOPLAS/ACROMIONECT PART
EXC/CURET BONE CYST/TUMOR
CLAV/SCAP
23145
Yes
EXC/CURET BONE CYST/CLAV; W/AUTOGFT
No
23146
Yes
No
23150
Yes
23155
Yes
23156
23170
23172
Yes
Yes
Yes
EXC/CURET BONE CYST CLAV; W/ALLOGFT
EXC/CURET BONE CYST/TUMOR PROX
HUME
EXC BONE CYST PROX HUMERUS;
W/AUTOG
EXC BONE CYST PROX HUMERUS;
W/ALLOG
SEQUESTRECTOMY CLAV
SEQUESTRECTOMY SCAPULA
Code Description
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
23174
23180
23182
23184
23190
23195
23200
23210
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
23220
23330
23331
Code Description
No
No
No
No
No
No
No
No
Yes
No
No
SEQUEST HUMERAL HEAD TO SURG NECK
PART EXC BONE CLAV
PART EXC BONE SCAPULA
PART EXC BONE PROX HUMERUS
OSTECTOMY SCAPULA PART
RESECT HUMERAL HEAD
RADICAL RESECT TUMOR; CLAV
RADICAL RESECT TUMOR; SCAPULA
RAD RESECT BONE TUMOR PROX
HUMERUS;
REMOV FB SHOULDER; SUBQ
REMOV FB SHLDR; DEEP
23332
23350
Yes
No
REMOV FB SHLDR; COMPLIC (TOT SHLDR)
INJ PROC SHOULDER ARTHROGRAPHY
No
No
23395
23397
23400
23405
23406
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
23410
Yes
23412
Yes
23415
23420
23430
Yes
Yes
Yes
MUSCL TRANSF-SHOULDER/UP ARM; SNGL
MUSCL TRANSF-SHOULDER/UP ARM; MX
SCAPULOPEXY
TENOT SHLDR AREA; SNGL TENDON
TENOT SHLDR; MX TENDONS-SAME INCS
REPR RUPT MUSCULOTENDIN CUFF;
ACUTE
REPR RUPT MUSCULOTENDIN CUFF;
CHRON
CORACOACROM LIG REL W/WO
ACROMIOPLA
RECONS SHLDR CUFF AVULS CHRONIC
TENODESIS LONG TENDON BICEPS
23440
Yes
RESECT/TRANSPL LONG TENDON BICEPS
No
23450
Yes
CAPSULORRHAPHY ANT; PUTTI-PLATT TYP
No
23455
Yes
CAPSULORRHAPHY ANT; W/LABRAL REPR
No
23460
Yes
CAPSULORRHAPHY ANT; W/BONE BLOCK
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
23462
23465
Yes
Yes
23466
Yes
23470
23472
23480
Yes
Yes
Yes
23485
Yes
23490
23491
23500
23505
23515
Yes
Yes
No
No
No
23520
23525
No
No
23530
Code Description
CAPSULORRHAPHY ANT; W/CORACOID
TRNS
CAPSULORRHAPY GH JT POST BLOCK
No
No
CAPSULORRHAPHY GH JT MX INSTABILITY
ARTHROPLASTY GH JT;
HEMIARTHROPLAST
ARTHROPLASTY GH JT; TOT SHLDR
OSTEOTOMY CLAV W/WO INT FIXA
No
OSTEOTOMY CLAV W/WO INT FIXA; W/GFT
PROPHYL TX W/WO
METHYLMETHACRY;CLAV
PROPHYLACTIC TX; PROX HUMERUS
CLO TX CLAV FX; WO MANIP
CLO TX CLAV FX; W/MANIP
OPEN TX CLAV FX W/WO INT/EXT FIXA
No
No
No
No
CLO TX STERNOCLAV DISLOC; W/O MANIP
CLO TX STERNOCLAV DISLOC; W/MANIP
OPEN TX STERNCLAV DISLOC
ACUTE/CHRO
23532
No
OPEN TX STRNCLAV DISLOC; W/FASC GFT
No
23540
No
CLO TX ACROMIOCLAV DISLOC; WO MANIP
No
23545
23550
23552
23570
No
No
No
No
CLO TX ACROMIOCLAV DISLOC; W/MANIP
OPEN TX AC DISLOC ACUTE/CHRONIC
OPEN TX AC DISLOC; W/FASCIAL GFT
CLO TX SCAPULAR FX; WO MANIP
No
No
No
No
23575
23585
23600
23605
No
No
No
No
CLO TX SCAP FX; W/MANIP W/WO TRACT
OPEN TX SCAPULAR FX W/WO INT FIXA
CLO TX PROX HUMERAL FX; WO MANIP
CLO TX PROX HUMER FX; W/MANIP
No
No
No
No
23615
No
OPEN TX PROX HUMER FX W/WO FIX-REPR
No
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
23616
23620
No
No
OPEN TX PROX HUMER FX; W/PROS REPLA
CLO TX GR HUMERAL TUBER FX; WO
No
No
23625
23630
No
No
CLO TX GR HUMERAL TUBER FX; W/MANIP
OP TX GR HUMERAL TUBER FX W/WO
No
No
23650
No
CLO TX SHLDR DISLOC W/MANIP;WO ANES
No
23655
23660
23665
23670
23675
No
No
No
No
No
CLO TX SHLDR DISLOC W/MANIP; W/ANES
OPEN TX ACUTE SHOULDER DISLOC
CLO TX SHLDR DISLOC-FX GR HUMERAL
OP TX SHLDR DISLC-FX GR HUMER
CLO TX SHLDR DISLOC W/FX W/MANIP
No
No
No
No
No
23680
23700
23800
23802
23900
23920
No
No
Yes
Yes
Yes
Yes
OPEN TX SHLDR DISLOC W/FX SURG NECK
MANIP W/ANES SHLDR JT INCL FIXA
ARTHRODESIS GLENOHUMERAL JOINT;
ARTHRODESIS GH JOINT; W/AUTOG GFT
INTERTHORACOSCAPULAR AMPUTA
DISART SHOULDER
No
No
No
No
No
No
23921
23929
Yes
Yes
DISART SHLDR; SECNDRY CLO/SCAR REVI
UNLISTED PROC SHOULDER
No
Yes
23930
23931
No
No
I&D UPPER ARM/ELBOW; DEEP ABSCESS
I&D UPPER ARM/ELBOW AREA; BURSA
No
No
23935
24000
No
Yes
INCS DEEP W/OPEN BONE CORTEX HUMER
ARTHROT ELBOW EXPLOR/REMOV FB
No
No
24006
24065
No
No
ARTHROTOMY ELBO W/CAP EXC (SEP PRO)
BX SOFT TISS UP ARM/ELBOW; SUPERF
No
No
24066
24071
24073
24075
No
Yes
Yes
No
BX SOFT TISS UPPER ARM/ELBOW; DEEP
EXC ARM/ELBOW LES SC = 3 CM
EX ARM/ELBOW TUM DEEP > 5 CM
EXC TUMOR UPPER ARM/ELBOW; SUBQ
No
No
No
No
Code Description
CPT Code
July 2011
24076
No
Code Description
EXC TUMOR UP ARM/ELBOW;
DEEP/SUBFAS
24077
24079
No
Yes
RAD RESECT TUMOR TISS UP ARM/ELBOW
RESECT ARM/ELBOW TUM > 5 CM
No
No
24100
24101
Yes
Yes
ARTHROTOMY ELB; W/SYNOVIAL BX ONLY
ARTHROTOMY ELBOW; W/JT EXPLOR
No
No
24102
24105
Yes
Yes
ARTHROTOMY ELBOW; W/SYNOVECTOMY
EXC OLECRANON BURSA
No
No
24110
Yes
EXC/CURET BONE CYST/TUMOR HUMERUS
No
24115
24116
24120
Yes
Yes
Yes
EXC BONE CYST HUMERUS; W/AUTOGFT
EXC BONE CYST HUMERUS; W/ALLOGFT
EXC BONE CYST-HEAD/NECK RADIUS
No
No
No
24125
Yes
EXC BONE CYST-HEAD RADIUS; W/AUTOGF
No
24126
24130
Yes
Yes
No
No
24134
24136
Yes
Yes
EXC BONE CYST-HEAD RADIUS; W/ALLOGF
EXC RADIAL HEAD
SEQUESTRECTOMY SHAFT/DISTAL
HUMERUS
SEQUESTRECTOMY RADIAL HEAD/NECK
24138
24140
24145
24147
Yes
Yes
Yes
Yes
SEQUESTRECTOMY OLECRANON PROCESS
PART EXC BONE HUMERUS
PART EXC BONE RADIAL HEAD/NECK
PART EXC BONE OLECRANON PROCESS
No
No
No
No
24149
Yes
No
24150
Yes
RAD RESECT TISS-BONE ELB (SEP PROC)
RAD RESEC TUMOR SHAFT/DISTAL
HUMERU
24152
24155
24160
24164
Yes
Yes
Yes
Yes
RAD RESECT TUMOR RADIAL HEAD/NECK
RESECT ELBOW JT
IMPLNT REMOV; ELBOW JT
IMPLNT REMOV; RADIAL HEAD
No
No
No
No
No
No
No
No
CPT Code
24200
24201
24220
July 2011
Yes
Yes
Yes
24300
Yes
Code Description
REMOV FB UPPER ARM/ELBOW; SUBQ
REMOV FB UPPER ARM/ELBOW; DEEP
INJ PROC ELBOW ARTHROGRAPHY
MANIPULATION ELBOW UNDER
ANESTHESIA
24301
Yes
MUSCL/TENDON TRANSF UP ARM/ELBOW 1
No
24305
24310
Yes
Yes
TENDON LENGTH UP ARM/ELBOW EA TEND
TENOT OP ELBOW-SHLDR EA TENDON
No
No
24320
24330
Yes
Yes
No
No
24331
24332
Yes
Yes
TENOPLSTY W/MUSCL TRNSF ELBO-SHDL 1
FLEXOR-PLASTY ELBOW
FLEXOR-PLASTY ELBOW; W/EXTENSOR
ADV
TENOLYSIS TRICEPS
24340
Yes
TENODESIS BICEPS TEND ELB (SEP PRO)
No
24341
24342
24343
Yes
Yes
Yes
REPR TEND/MUSC-ARM/ELB-EA-PRI/SECND
REINSRT RUPT BICEPS/TRICEPS DISTAL
REPR LAT COLLAT LIG ELB W/LOC TISS
No
No
No
24344
Yes
RECON LAT COLLAT LIG ELB W/TEND GFT
No
24345
Yes
No
24346
24357
24358
24359
24360
Yes
Yes
Yes
Yes
Yes
REPAIR MCL ELBOW WITH LOCAL TISSUE
RECONSTRUCT MCL ELB W/TENDON
GRAFT
REPAIR ELBOW, PERC
REPAIR ELBOW W/DEB, OPEN
REPAIR ELBOW DEB/ATTCH OPEN
ARTHROPLASTY ELBOW; W/MEMBRN
24361
Yes
ARTHROPLSTY ELBO; W/HUMERAL PROSTH
No
24362
24363
24365
Yes
Yes
Yes
ARTHROPLSTY ELBO; W/IMPLNT & RECON
ARTHROPLASTY ELBOW; (TOT ELBOW)
ARTHROPLASTY RADIAL HEAD
No
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
24366
24400
Yes
Yes
ARTHROPLASTY RADIAL HEAD; W/IMPLNT
OSTEOTOMY HUMERUS W/WO INT FIXA
No
No
24410
24420
Yes
Yes
MX OSTEOTOMIES W/REALIGN-HUMERAL
OSTEOPLASTY HUMERUS
No
No
24430
Yes
No
24435
24470
Yes
Yes
24495
24498
24500
Yes
Yes
No
REPR NON-MALUNION HUMERUS; WO GFT
REPR NON-MALUNION HUMERUS;
W/AUTOGF
HEMIEPIPHYSEAL ARREST
DECOMP FASCIOT FOREARM W/BRACH
ART
PROPHYLACTIC TX HUMERAL SHAFT
CLO TX HUMERAL SHAFT FX; WO MANIP
24505
No
No
24515
No
24516
No
24530
No
CLO TX HUMERAL FX; W/MANIP W/WO TRA
OPEN TX HUMER FX W/PLATE
W/CERCLAGE
OPEN TX HUMER FX W/IMPLNT W/WO
CERC
CLO TX SUPRACONDYL HUMER FX; WO
MAN
24535
No
CLO TX SUPRACONDYL HUMER FX; W/MANI
No
24538
No
No
24545
No
PERCUT FIX SUPRACOND FX; W/WO INTER
OPEN TX HUM SUPRACON FX; WO
INTERCO
24546
24560
24565
No
No
No
OPEN TX HUM SUPRACON FX; W/INTERCON
CLO TX HUMER EPICOND FX; WO MANIP
CLO TX HUMER EPICOND FX; W/MANIP
No
No
No
24566
No
PERQ SKELET FIX HUMRL EPICONDYL FX
No
24575
No
OPEN TX HUMER EPICOND FX; W/WO FIXA
No
24576
No
CLO TX HUMERAL CONDYL FX; WO MANIP
No
Code Description
No
No
No
No
No
No
No
No
No
CPT Code
24577
July 2011
No
24579
24582
No
No
OPEN TX HUMER CONDYL FX; W/WO FIXA
PERQ SKELET FIX HUMRL CONDYL FX
No
No
24586
No
OPEN TX PERIARTICUL FX/DISLOC ELBOW
No
24587
24600
No
No
OPEN TX PERIART FX ELB; W/ARTHROPLS
TX CLO ELBOW DISLOC; WO ANES
No
No
24605
No
TX CLO ELBOW DISLOC; REQUIRING ANES
No
24615
No
OPEN TX ACUTE/CHRONIC ELBOW DISLOC
No
24620
No
CLO TX MONTEGGIA FX ELBOW W/MANIP
No
24635
24640
No
No
OPEN TX MONTEGGIA FX ELBOW W/WO FIX
CLO TX RADIAL HEAD SUBLUXA CHILD
No
No
24650
No
CLO TX RADIAL HEAD/NECK FX;WO MANIP
No
24655
No
CLO TX RADIAL HEAD/NECK FX; W/MANIP
No
24665
No
OPEN TX RAD'L HEAD/NECK FX W/WO FIX
No
24666
24670
24675
No
No
No
OPEN TX RAD'L HEAD FX; PROSTH REPLC
CLO TX ULNAR FX PROX END; WO MANIP
CLO TX ULNAR FX PROX END; W/MANIP
No
No
No
24685
24800
No
Yes
OPEN TX ULNAR FX PROX END W/WO FIXA
ARTHRODESIS ELBOW JT; LOCAL
No
No
24802
Yes
No
24900
Yes
ARTHRODESIS ELBOW JT; W/AUTOG GFT
AMPUTA ARM THRU HUMERUS; W/PRIM
CLO
24920
Yes
No
24925
Yes
AMPUTA ARM THRU HUMERUS; OPEN CIRC
AMPUTA ARM THRU HUMERUS; SCAR
REVIS
Code Description
CLO TX HUMERAL CONDYL FX; W/MANIP
No
No
No
CPT Code
July 2011
24930
Yes
AMPUTA ARM THRU HUMERUS; RE-AMPUTA
No
24931
24935
Yes
Yes
No
No
24940
24999
25000
Yes
Yes
Yes
AMPUTA ARM THRU HUMERUS; W/IMPLNT
STUMP ELONGATION UPPER EXTREM
CINEPLASTY UPPER EXTREM COMPLT
PROC
UNLISTED PROC HUMERUS/ELBOW
INCIS EXTEN TENDON SHEATH WRIST
25001
Yes
25020
Yes
25023
Yes
25024
Yes
25025
Yes
25028
25031
Yes
Yes
25035
Yes
25040
Code Description
No
Yes
No
INCISION FLEXOR TENDON SHEATH WRIST
DECOMP FASCIOT FOREARM;
FLEX/EXTENS
DECOMP FASCIOT FOREARM; DEBRID
MUSC
DECOMP FASC FORARM FLX&EXT;NO
DEBRD
DECOMP FASC FORARM
FLX&EXT;W/DEBRID
No
No
No
No
I&D FOREARM; DEEP ABSCESS/HEMATOMA
I&D FOREARM &/OR WRIST; BURSA
INCS DEEP BONE CORTEX
FOREARM/WRIST
ARTHROT RADIO/MIDCARPAL
W/XPLOR/DRN
25065
25066
25071
25073
No
No
Yes
Yes
BX SOFT TISS FOREARM/WRIST; SUPERF
BX SOFT TISS FOREARM/WRIST; DEEP
EXC FOREARM LES SC > 3 CM
EXC FOREARM TUM DEEP = 3 CM
No
No
No
No
25075
25076
Yes
Yes
No
No
25077
25078
25085
25100
Yes
Yes
Yes
Yes
EXC TUMOR FOREARM/WRIST AREA; SUBQ
EXC TUMOR FOREARM/WRIST; DEEP/IM
RAD RESECT TUMOR TISS
FOREARM/WRIST
RESECT FOREARM/WRIST TUM=3CM
CAPSULOTOMY WRIST
ARTHROTOMY WRIST JT; W/BX
No
No
No
No
No
No
No
No
No
No
CPT Code
25101
July 2011
Yes
25105
25107
25109
Yes
Yes
Yes
25110
25111
25112
Yes
Yes
Yes
Code Description
ARTHROTOMY WRIST JT; W/EXPLOR
ARTHROTOMY WRIST JT;
W/SYNOVECTOMY
ARTHROT DIST RADIOULNAR JT
EXCISE TENDON FOREARM/WRIST
EXC LES TENDON SHEATH
FOREARM/WRIST
EXC GANGLION WRIST; PRIM
EXC GANGLION WRIST; RECURRENT
25115
25116
Yes
Yes
RAD EXC BURSA WRIST TENDON; FLEXORS
RAD EXC BURSA WRIST; EXTENSORS
No
No
25118
Yes
No
25119
25120
Yes
Yes
SYNOVECTOMY EXTENSOR WRIST SNGL
SYNOVECTMY EXTENSR WRIST; RESC
ULNA
EXC BONE CYST/TUMOR RADIUS/ULNA
No
No
25125
Yes
EXC BONE CYST RADIUS/ULNA; W/AUTOGF
No
25126
Yes
EXC BONE CYST RADIUS/ULNA; W/ALLOGF
No
25130
Yes
EXC BONE CYST/TUMOR CARPAL BONES
No
25135
Yes
EXC BONE CYST CARPAL BONES; W/AUTOG
No
25136
Yes
EXC BONE CYST CARPAL BONES; W/ALLOG
No
25145
25150
25151
25170
25210
25215
Yes
Yes
Yes
Yes
Yes
Yes
SEQUESTRECTOMY FOREARM &/OR WRIST
PART EXC BONE; ULNA
PART EXC BONE; RADIUS
RADICAL RESECT TUMOR RADIUS/ULNA
CARPECTOMY; 1 BONE
CARPECTOMY; ALL BONES PROX ROW
No
No
No
No
No
No
25230
25240
25246
Yes
Yes
No
RADIAL STYLOIDECTOMY (SEPART PROC)
EXC DISTAL ULNA PART/COMPLT
INJ PROC WRIST ARTHROGRAPHY
No
No
No
No
No
No
Yes
No
No
No
CPT Code
July 2011
25248
Yes
Code Description
EXPLOR W/REMOV DEEP FB
FORARM/WRIST
25250
25251
No
Yes
REMOV WRIST PROSTH; (SEPART PROC)
REMOV PROSTH; COMPLIC-"TOT WRIST"
No
No
25259
No
MANIPULATION WRIST UNDER ANESTHESIA
No
25260
Yes
REPR TENDON-FLEXOR-WRIST; PRIM SNGL
No
25263
Yes
REPR TENDON-FLEXOR-WRIST; 2ND 1 EA
No
25265
Yes
REPR TENDON-FLEXOR-WRIST; 2ND W/GFT
No
25270
Yes
No
25272
Yes
25274
Yes
REPR TENDON-EXTENSOR-WRIST; PRIM EA
REPR TENDON-EXTENSOR-WRIST;
SECNDRY
REPR TENDON EXTENSR 2ND W/GFT
WRIST
25275
Yes
REP TEND EXT FORARM&/WRST FREE GFT
No
25280
Yes
No
25290
Yes
LENGTH/SHORT TENDON-WRIST 1 EA TEND
TENOTOMY OPEN FLEX/EXTEN WRIST
SNGL
No
25295
Yes
TENOLYSIS FLEX/EXTEN-WRIST SNGL EA
No
25300
Yes
TENODESIS @ WRIST; FLEXORS FINGERS
No
25301
25310
Yes
Yes
TENODESIS @ WRIST; EXTENSORS FINGER
TENDON TRANSPL WRIST; SNGL EA
No
No
25312
25315
Yes
Yes
TENDON TRANSPL WRIST; W/TENDON GFT
FLEXOR ORIGIN SLIDE FOREARM/WRIST;
No
No
25316
25320
Yes
Yes
FLEXOR SLIDE WRIST; W/TENDON TRANSF
CAPSULOR/RECON WRIST ANY METHOD
No
No
No
No
No
CPT Code
July 2011
25332
25335
Yes
Yes
25337
25350
25355
25360
25365
25370
25375
Yes
Yes
Yes
Yes
Yes
Yes
Yes
25390
Yes
25391
Code Description
ARTHROPLASTY WRIST; W/WO INTERPOSIT
CENTRALIZATION WRIST ULNA
RECON WRST-SCND-W/WO OPEN RED RU
JT
OSTEOTOMY RADIUS; DISTAL THIRD
OSTEOTOMY RADIUS; MID/PROX THIRD
OSTEOTOMY; ULNA
OSTEOTOMY; RADIUS & ULNA
MX OSTEOTOMIES; RADIUS/ULNA
MX OSTEOTOMIES; RADIUS & ULNA
No
No
No
Yes
OSTEOPLASTY RADIUS/ULNA; SHORTENING
OSTEOPLSTY RAD/ULNA;LENGTH
W/AUTOGT
25392
Yes
OSTEOPLASTY RAD & ULNA; SHORTENING
No
25393
Yes
No
25394
Yes
OSTEOPLASTY RAD & ULNA; LENGTH W/GF
OSTEOPLASTY CARPAL BONE
SHORTENING
25400
Yes
REPR NON/MALUNION RAD/ULNA; WO GFT
No
25405
25415
Yes
Yes
REPR NON/MALUNION RAD/ULNA; W/AUTOG
REPR NONUNION RAD & ULNA; WO GFT
No
No
25420
Yes
REPR NONUNION RAD & ULNA; W/AUTOGFT
No
25425
Yes
REPR DEFECT W/AUTOGFT; RADIUS/ULNA
No
25426
Yes
REPR DEFECT W/AUTOGFT; RAD & ULNA
No
25430
Yes
INSERTION VASC PEDICLE IN CARPAL BN
No
25431
Yes
No
25440
Yes
REPAIR NONUNION CARPAL BONE EA BONE
REPR NONUNION SCAPHOID W/WO
STYLOID
No
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
25441
Yes
ARTHROPLSTY W/PROS REPLAC; DIST RAD
No
25442
Yes
No
25443
Yes
ARTHROPLSTY W/PROS REPLAC;DIST ULNA
ARTHROPLSTY W/PROS REPLAC;
SCAPHOID
25444
Yes
No
25445
Yes
ARTHROPLSTY W/PROS REPLAC; LUNATE
ARTHROPLSTY W/PROS
REPLAC;TRAPEZIUM
25446
Yes
No
25447
Yes
ARTHROPLASTY W/PROS; PART CARPUS
ARTHROPLAS INTERPOSITCARPOMETACAR
25449
Yes
REVIS ARTHROPLSTY REMOV IMPLT WRIST
No
25450
25455
Yes
Yes
No
No
25490
Yes
25491
Yes
EPIPHYSEAL ARREST; DIST RADIUS/ULNA
EPIPHYSEAL ARREST; RADIUS & ULNA
PROPHYLC TX W/WO
METHYLMETHACRY;RAD
PROPHYLC TX W/WO
METHYLMETHACR;ULNA
25492
25500
25505
25515
25520
25525
25526
25530
25535
25545
Yes
No
No
No
No
No
No
No
No
No
PROPHYLAC TX W/WO METHYL; RAD & ULN
CLO TX RADIAL SHAFT FX; WO MANIP
CLO TX RADIAL SHAFT FX; W/MANIP
OPEN TX RADIAL SHAFT FX W/WO FIXA
CLO TX RADIAL FX W/DISLOC RAD/ULNA
OPEN TX RAD FX W/FIX-CLO TX RU JT
OPEN TX RAD FX W/FIX-OPEN TX RU JT
CLO TX ULNAR SHAFT FX; WO MANIP
CLO TX ULNAR SHAFT FX; W/MANIP
OPEN TX ULNAR SHAFT FX W/WO FIXA
No
No
No
No
No
No
No
No
No
No
25560
25565
25574
25575
No
No
No
No
CLO TX RAD & ULNA SHAFT FX; WO MANI
CLO TX RAD & ULNA SHAFT FX; W/MANIP
OPEN TX RAD & ULNA FX; RADIUS/ULNA
OPEN TX RAD & ULNA FX; RAD & ULNA
No
No
No
No
Code Description
No
No
No
No
No
CPT Code
25600
25605
25606
25607
25608
25609
July 2011
No
No
No
No
No
No
25622
25624
No
No
CLO TX CARPAL SCAPHOID FX; WO MANIP
CLO TX CARPAL SCAPHOID FX; W/MANIP
No
No
25628
No
OPEN TX CARPAL SCAPHOID FX W/WO FIX
No
25630
25635
25645
25650
25651
25652
25660
25670
No
No
No
No
No
No
No
No
CLO TX CARPAL BONE FX; WO MANIP EA
CLO TX CARPAL BONE FX; W/MANIP EA
OPEN TX CARPAL BONE FX EA BONE
CLO TX ULNAR STYLOID FX
PERCUT SKEL FIX ULNAR STYLOID FX
OPEN TX ULNAR STYLOID FRACTURE
CLO TX RADIOCARPAL DISLOC W/MANIP
OPEN TX RADIOCARPAL DISLOC 1/MORE
No
No
No
No
No
No
No
No
25671
25675
No
No
PERQ SKEL FIX DIST RADIOULNR DISLOC
CLO TX RADIOULNAR DISLOC W/MANIP
No
No
25676
No
No
25680
No
OPEN TX RADIOULN DISLOC ACUTE/CHRON
CLO TX TRANS-SCAPHOPERILUNAR
W/MANI
25685
25690
25695
25800
25805
No
No
No
Yes
Yes
OPEN TX TRANS-SCAPHOPERILUN FX DISL
CLO TX LUNATE DISLOC W/MANIP
OPEN TX LUNATE DISLOC
ARTHRODESIS WRIST; COMPLT WO GFT
ARTHRODESIS WRIST;W/SLIDING GFT
No
No
No
No
No
25810
25820
25825
Yes
Yes
Yes
No
No
No
25830
Yes
ARTHRODESIS WRIST JT; W/ILIAC/AUTOG
ARTHRODESIS WRIST; LIMITED WO GFT
ARTHRODESIS WRIST; W/AUTOGFT
ARTHRODES DIST RADIOULNA-RESCT
ULNA
Code Description
CLO TX DIST RAD FX; WO MANIP
CLO TX DIST RAD FX; W/MANIP
TREAT FX DISTAL RADIAL
TREAT FX RAD EXTRA-ARTICUL
TREAT FX RAD INTRA-ARTICUL
TREAT FX RADIAL 3+ FRAG
No
No
No
No
No
No
No
No
CPT Code
July 2011
25900
25905
Yes
Yes
AMPUTA FOREARM THRU RADIUS & ULNA
AMPUTA FOREARM; OPEN CIRCULAR
No
No
25907
25909
25915
25920
Yes
Yes
Yes
Yes
AMPUTA FOREARM; 2ND CLO/SCAR REVIS
AMPUTA FOREARM; RE-AMPUTA
KRUKENBERG PROC
DISART THRU WRIST
No
No
No
No
25922
25924
25927
Yes
Yes
Yes
DISART THRU WRIST; 2ND CLO/SCAR REV
DISART THRU WRIST; RE-AMPUTA
TRANSMETACARPAL AMPUTA
No
No
No
25929
Yes
TRANSMETACARPAL AMPUT; SCAR REVIS
No
25931
25999
26010
26011
Yes
Yes
No
No
TRANSMETACARPAL AMPUTA; RE-AMPUTA
UNLISTED PROC FOREARM/WRIST
DRAINAGE FINGER ABSCESS; SIMPL
DRAINAGE FINGER ABSCESS; COMPLIC
No
Yes
No
No
26020
26025
26030
26034
No
No
No
No
DRAIN TENDON SHEATH/DIGIT &/PALM EA
DRAIN PALMAR BURSA; SNGL BURSA
DRAIN PALMAR BURSA; MX BURSA
INCS BONE CORTEX HAND/FINGR
No
No
No
No
26035
26037
26040
26045
26055
26060
No
No
Yes
Yes
Yes
Yes
DECOMP FINGERS &/OR HAND INJ INJURY
DECOMP FASCIOTOMY HAND
FASCIOT PALMAR; PERCUT
FASCIOT PALMAR; OP PART
TENDON SHEATH INCS
TENOTOMY PERCUT SNGL EA DIGIT
No
No
No
No
No
No
26070
26075
26080
26100
26105
No
No
No
Yes
Yes
ARTHROT W/EXPLOR; CARPOMETACARP JT
ARTHROT W/EXPLOR/DRAIN; MCP JT EA
ARTHROT W/EXPLOR/DRAIN; IP JT EA
ARTHROT-BX; CARPOMETACARP JT EA
ARTHROT W/BX; MCP JT EA
No
No
No
No
No
26110
Yes
ARTHROT W/BX; INTERPHALANGEAL JT EA
No
Code Description
CPT Code
26111
26113
26115
26116
26117
26118
26121
26123
26125
26130
26135
July 2011
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Code Description
EXC HAND LES SC > 1.5 CM
EXC HAND TUM DEEP > 1.5 CM
EXC TUMOR HAND/FINGER; SUBQ
EXC TUMOR HAND/FINGER; DEEP/IM
RAD RESECT TUMOR TISS HAND/FINGER
EXC HAND TUM RA > 3 CM
FASCIECT PALM W/WO Z-PLASTY/GFT
FASCIECT PART PALM W/REL 1 DIGIT;
FASCIECT PART PALM W/REL; EA ADD
SYNOVECTOMY CARPOMETACARPAL JT
SYNOVECTOMY MCP JT EA DIGIT
No
No
No
No
No
No
No
No
No
No
No
26140
Yes
SYNOVECTOMY PROX IP JT W/RECON EA
No
26145
Yes
SYNOVECT FLEX TENDON PALM/FINGR EA
No
26160
26170
26180
Yes
Yes
Yes
EXC LES TENDON SHEATH HAND/FINGER
EXC TENDON PALM SNGL (SEP PRO) EA
EXC TEND FINGR FLEX (SP) EA TEND
No
No
No
26185
Yes
No
26200
Yes
26205
Yes
SESAMOIDECTMY THUMB/FING (SEP PROC)
EXC/CURET BONE CYST/TUMOR
METACARPA
EXC BONE CYST METACARPAL;
W/AUTOGFT
26210
26215
26230
26235
26236
26250
26260
26262
26320
26340
26350
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
EXC BONE CYST PROX/MID/DIST PHALANX
EXC BONE CYST PHALANX; W/AUTOGFT
PART EXC BONE; METACARPAL
PART EXC BONE; PROX/MID PHAL-FINGR
PART EXC BONE; DIST PHALANX-FINGR
RAD RESECT METACARPAL; (TUMOR)
RAD RESECT PROX/MID FINGR (TUMOR);
RAD RESECT DISTAL FINGR (TUMOR)
REMOV IMPLNT FROM FINGER/HAND
MANIP FNGR JNT UNDER ANES-EA JNT
REPR FLEX TENDON; PRIM/2ND EA TEND
No
No
No
No
No
No
No
No
No
No
No
26352
Yes
REPR FLEX TEND; SECND W/GFT-EA TEND
No
No
No
CPT Code
July 2011
26356
Yes
26357
Yes
Code Description
REP/ADV FLX TEND ZONE 2 DIGTL; W/O
FREE GFT EA
REP/ADV FLX TEND ZONE 2 DIGTL; SEC
W/O GRAFT EA
26358
Yes
REPR FLEX TEND; SECND W/GFT EA TEND
No
26370
Yes
REPR PROFUNDUS TENDON; PRIM EA TEND
No
26372
Yes
REPR PROFND TEND; SECND FREE GFT EA
No
26373
26390
Yes
Yes
REPR PROFUND TEND; SECND WO GFT EA
EXC FLEX TEND W/ROD HAND/FINGR EA
No
No
26392
26410
26412
26415
26416
26418
26420
Yes
Yes
Yes
Yes
Yes
Yes
Yes
REMOV ROD-INSRT FLX GFT HND/FING EA
REPR EXTEN TEND HND PRIM/SEC; EA
REPR EXTEN TEND HAND PRIM; GFT-EA
EXC EXTEN TEND-ROD-GFT HAND/FINGR
REMOV ROD-INSRT TEND GFT HAND-EA
REPR EXTEN TEND FINGR; WO-EA TEND
REPR EXTEN TEND FINGR; GFT EA TEND
No
No
No
No
No
No
No
26426
Yes
REPR EXTEN TEND-CNTRL SLIP-SCND; EA
No
26428
26432
26433
26434
26437
26440
26442
26445
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
26449
26450
26455
26460
26471
26474
Yes
Yes
Yes
Yes
Yes
Yes
REPR EXTEN TEND-CENTRL-SEC; GFT EA
CLO TX DIST EXTEN TEND INSRT-PIN
REPR EXTEN TEND-DIST INSRT; WO GFT
REPR EXTEN TEND-DIST INSRT; W/GFT
REALIGN EXTEN TEND HAND EA TEND
TENOLYSIS FLEX; PALM/FINGR EA TEND
TENLYSIS FLEX; PALM & FINGR EA TEND
TENLYSIS EXTEN TEND HAND/FINGR EA
TENOLYS COMPLX-EXTEN-FINGRFOREARM
TENOT FLEX PALM OP EA TENDON
TENOT FLEX FINGR OP EA TENDON
TENOT EXTEN HAND/FINGR OP EA TEND
TENODESIS; PROX IP JT EA JT
TENODESIS; DIST JT EA JT
No
No
No
No
No
No
No
No
CPT Code
26476
July 2011
Yes
26477
26478
Yes
Yes
SHORTEN TENDON EXTEN HAND/FINGR EA
LENGTHEN TEND FLEX HAND/FINGR EA
No
No
26479
Yes
SHORTEN TENDON FLEX HAND/FINGR EA
No
26480
Yes
TRANSF/TEND DORSUM HAND; WO GFT EA
No
26483
Yes
TRANSF TEND DORSUM HAND; W/GFT EA
No
26485
Yes
TRANSF TEND PALMAR; WO GFT EA TEND
No
26489
Yes
TRANSF TENDON PALMAR; W/GFT EA TEND
No
26490
Yes
OPPONENSPLAS; SUPERFICIALIS TRANSF
No
26492
Yes
OPPONENSPLASTY; TEND TRANSF-GFT EA
No
26494
26496
Yes
Yes
OPPONENSPALSTY; HYPOTHENAR MUSCL
OPPONENSPLASTY; OTHER METHD
No
No
26497
Yes
TRANSF TEND-RESTORE; RING-SM FINGR
No
26498
26499
Yes
Yes
TRANSF TENDON -RESTORE; ALL 4 FINGR
CORRECT CLAW FINGER OTHER METHD
No
No
26500
26502
26508
26510
26516
Yes
Yes
Yes
Yes
Yes
RECONS TEND PULLEY EA; LOC TISS (SP
RECONS TENDON PULLEY EA; GFT (SP)
RELEASE THENAR MUSCL
CROSS INTRINSIC TRANSF
CAPSULODESIS MCP JT; SINGL DIGIT
No
No
No
No
No
26517
Yes
CAPSULODES METACARPOPHALANG JT; 2
No
26518
26520
26525
26530
Yes
Yes
Yes
Yes
CAPSULODES METACARPOPHAL JT; 3 OR 4
CAPSULECT/CAPSULOT; MCP JT EA JT
CAPSULECT/CAPSULOT; IP JT EA JT
ARTHROPLASTY MCP JT; EA JT
No
No
No
No
Code Description
LENGTHEN TEND EXTEN HAND/FINGR EA
No
CPT Code
26531
26535
26536
26540
26541
26542
26545
July 2011
Yes
Yes
Yes
Yes
Yes
Yes
Yes
26546
Yes
REPR NON-UNION METACARPAL/PHALYNX
No
26548
26550
26551
Yes
Yes
Yes
REPR & RECON FING VOLAR PLATE IP JT
POLLICIZATION A DIGIT
TRANSF TOE-HAND-ANASTOM; GR TOE
No
No
No
26553
26554
26555
Yes
Yes
Yes
TRANSF TOE-HAND-ANAS; NOT GR TOE-1
TRANS TOE-HAND-ANAS; NOT GR TOE-2
TRANSF FINGR OTH POSIT WO ANAS
No
No
No
26556
Yes
TRANSF FREE TOE JT W/MICROVAS ANAS
No
26560
Yes
REPR SYNDACTYLY EA WEB; W/SKIN FLAP
No
26561
Yes
No
26562
26565
26567
Yes
Yes
Yes
26568
26580
Yes
Yes
REPR SYNDACTYLY; W/SKIN FLAPS & GFT
REPR SYNDACTYLY EA WEB SPACE;
COMPL
OSTEOT; METACARPAL EA
OSTEOT; PHALANX FINGR EA
OSTEOPLAS LENGTHEN
METACARP/PHALANX
REPR CLEFT HAND
26587
26590
Yes
Yes
RECON SUPERNUMER DIGIT TISS & BONE
REPR MACRODACTYLIA
No
No
26591
Yes
REPR INTRINSIC MUSCL HAND EA MUSCL
No
26593
Yes
RELEASE INTRINS MUSCL HAND EA MUSCL
No
26596
Yes
EXC CONSTRICT OF FINGR W/Z-PLASTIES
No
Code Description
ARTHROPLASTY MCP JT; PROSTH EA JT
ARTHROPLASTY IP JT; EA JT
ARTHROPLASTY IP JT; W/PROSTH EA JT
REPR COLLAT LIGAMNT MCP/IP JT
RECON LIGAMNT MCP JT-1; W/TEND GFT
RECON LIGAMNT MCP JT-1; W/LOC TISS
RECON LIG IP JT SNGL INCL GFT EA JT
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
26600
26605
July 2011
No
No
26607
26608
No
No
CLO TX METACARPAL FX W/MANIP W/FIXA
PERCUT FIXA METACARPAL FX EA BONE
No
No
26615
No
No
26641
No
No
26645
No
OPEN TX METACARPAL FX SNGL W/WO FIX
CLO TX CARPOMETA DISLOC THUMB
W/MAN
CLO TX CARPOMETACAR FX THUMB
W/MANI
26650
26665
26670
26675
No
No
No
No
PERCUT SKELE FIX FX THUMB W/WO EXT
OPEN TX FX DISLOC THUMB W/WO FIXA
CLO TX DISLOC-NOT THUMB; WO ANES
CLO TX DISLOC-NOT THUMB; REQ ANES
No
No
No
No
26676
26685
No
No
PERCUT SKELET FIX-NOT THUMB; W/MANI
OPEN TX DISLOC-EX THUMB; 1 W/WO FIX
No
No
26686
No
OPEN TX DISLOC-NOT THUMB; COMPLX/MX
No
26700
No
CLO TX MCP DISLOC-1-W/MANIP; WO ANE
No
26705
No
CLO TX MCP DISLOC-1-W/MANIP; W/ANES
No
26706
26715
26720
26725
26727
No
No
No
No
No
PERCUT FIXA MCP DISLOC SNGL W/MANIP
OPEN TX MCP DISLOC SNGL W/WO FIXA
CLO TX PHALANGEAL FX; WO MANIP EA
CLO TX PHALANGEAL FX; W/WO TRACT
PERCUT FIXA FX PROX/MID W/MANIP EA
No
No
No
No
No
26735
26740
26742
26746
No
No
No
No
OPEN TX PHALANGEAL FX W/WO FIXA EA
CLO TX ARTIC FX MCP/IP JT; WO MANIP
CLO TX ARTIC FX MCP/IP JT; W/MANIP
OPEN TX ARTIC FX MCP/IP JT W/WO FIX
No
No
No
No
26750
26755
No
No
CLO TX DIST PHALANGEAL FX; WO MANIP
CLO TX DIST PHALANGEAL FX; W/MANIP
No
No
Code Description
CLO TX METACARP FX 1; WO MANIP EA
CLO TX METACARP FX 1; W/MANIP EA
No
No
No
CPT Code
July 2011
26756
No
PERCUT SKELETAL FIX DIST PHALANG FX
No
26765
26770
26775
26776
26785
26820
26841
26842
26843
26844
26850
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
OPEN TX DIST PHALANG FX W/WO FIX EA
CLO TX IP JT DISLOC W/MANIP; WO ANE
CLO TX IP JT DISLOC W/MANIP; W/ANES
PERCUT FIXA IP JT DISLOC 1 W/MANIP
OPEN TX IP JT DISLOC W/WO FIX SNGL
FUSION IN OPPOSIT THUMB W/AUTOGFT
ARTHRODESIS JT THUMB W/WO FIXA
ARTHRODESIS JT THUMB; W/AUTOGFT
ARTHRODESIS JT DIGITS NOT THUMB
ARTHRODESIS JT DIGITS; W/AUTOGFT
ARTHRODESIS MCP JT W/WO INT FIXA
No
No
No
No
No
No
No
No
No
No
No
26852
26860
26861
Yes
Yes
Yes
ARTHRODES MCP JT W/WO FIX; W/AUTOGF
ARTHRODESIS IP JT W/WO INT FIXA
ARTHRODESIS IP JT W/WO FIX; EA ADD
No
No
No
26862
Yes
ARTHRODESIS IP JT W/WO FIX; W/AUTOG
No
26863
26910
26951
Yes
Yes
Yes
ARTHRODESIS IP JT; W/AUTOGFT EA ADD
AMPUTA METACARPAL 1 W/WO TRANSF
AMPUTA FINGER ANY JT; W/DIRECT CLO
No
No
No
26952
26989
26990
26991
26992
27000
27001
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
No
No
No
No
27003
27005
27006
27025
27027
27030
Yes
Yes
Yes
Yes
Yes
Yes
AMPUTA FINGER ANY JT; W/ADVANC FLAP
UNLISTED PROC HANDS/FINGERS
I&D PELVIS/HIP JT; DEEP ABSCESS
I&D PELVIS/HIP JT AREA; INFEC BURSA
INCIS BONE CORTEX PELVIS &/HIP JT
TENOT ADDUCTOR HIP PERCUT (SP)
TENOT ADDUCTOR HIP OP
TENOTOMY ADDUCT OPEN
W/NEURECTOMY
TENOT HIP FLEX OP (SEPART PROC)
TENOT ABDUCT &/OR EXTEN HIP OP (SP)
FASCIOTOMY HIP/THIGH ANY TYPE
BUTTOCK FASCIOTOMY
ARTHROT HIP W/DRAINAGE
Code Description
No
No
No
No
No
No
CPT Code
27033
27035
July 2011
Yes
Yes
27036
27040
27041
27043
27045
27047
27048
27049
27050
27052
27054
27057
27059
27060
27062
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
CAPSULECT/CAPSULOT HIP-RELEASE FLEX
BX SOFT TISS PELVIS & HIP; SUPERF
BX SOFT TISS PELVIS & HIP; DEEP
EXC HIP PELVIS LES SC > 3 CM
EXC HIP/PELV TUM DEEP > 5 CM
EXC TUMOR PELVIS & HIP; SUBQ TISS
EXC TUMOR PELVIS & HIP; DEEP/IM
RAD RESECT TUMOR SOFT TISS PELVIS
ARTHROTOMY W/BX; SACROILIAC JT
ARTHROTOMY W/BX; HIP JT
ARTHROTOMY W/SYNOVECTOMY HIP JT
BUTTOCK FASCIOTOMY W/DBRDMT
RESECT HIP/PELV TUM > 5 CM
EXC; ISCHIAL BURSA
EXC; TROCH BURSA/CALCIFICATION
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
27065
27066
Yes
Yes
EXC BONE CYST; SUPERF W/WO AUTOGFT
EXC BONE CYST; DEEP W/WO AUTOGFT
No
No
27067
27070
27071
27075
Yes
Yes
Yes
Yes
EXC BONE CYST; W/AUTOGFT-SEPAR INCS
PART EXC; SUPERF
PART EXC; DEEP
RAD RESECT TUMOR; WING ILIUM/PUBIS
No
No
No
No
27076
Yes
RAD RESECT TUMOR; ILIUM W/ACETABULM
No
27077
Yes
RAD RESECT TUMOR; INNOMINATE BONE
No
27078
27080
27086
27087
27090
27091
Yes
Yes
No
No
Yes
Yes
RAD RESECT TUMOR; ISCH TUB GRT TROC
COCCYGECTOMY PRIM
REMOV FB PELVIS/HIP; SUBQ TISS
REMOV FB PELVIS/HIP; DEEP
REMOV HIP PROSTH; (SEPART PROC)
REMOV HIP PROSTH; COMPLIC TOT HIP
No
No
No
No
No
No
27093
Yes
INJ PROC HIP ARTHROGRAPHY; WO ANES
No
Code Description
ARTHROT HIP-EXPLOR/REMOV FB
DENERVAT HIP JT SCIATIC NERV
No
No
CPT Code
27095
27096
July 2011
Yes
Yes
Code Description
INJ PROC HIP ARTHROGRAPHY; W/ANES
INJ-S I JT ARTHROG &/ ANES/STEROID
No
No
27097
27098
27100
27105
Yes
Yes
Yes
Yes
RELEASE/RECESSION HAMSTRING PROX
TRANSF ADDUCTOR TO ISCHIUM
TRANSF EXT OBLIQ MUSCL-GR TROCH
TRANSF PARASPINAL MUSCL TO HIP
No
No
No
No
27110
27111
27120
Yes
Yes
Yes
TRANSF ILIOPSOAS; TO GREATER TROCH
TRANSF ILIOPSOAS; TO FEMORAL NECK
ACETABULOPLASTY
No
No
No
27122
27125
Yes
Yes
ACETABULOPLASTY; RESECT FEM HEAD
HEMIARTHROPLASTY HIP PART
No
No
27130
Yes
ARTHROPLASTY ACETAB & FEM PROSTH
No
27132
Yes
CONVERSION PREV HIP-TOT HIP W/WO GF
No
27134
Yes
REVIS TOT HIP; BOTH COMPON W/WO GFT
No
27137
Yes
REVIS TOT HIP ARTHROPLSTY; ACETABUL
No
27138
Yes
REVIS TOT HIP ARTHROPALSTY; FEMORAL
No
27140
Yes
OSTEOT & TRANSF GRT TROCH (SEP PRO)
No
27146
27147
27151
Yes
Yes
Yes
OSTEOTMY ILIAC/ACETAB/INNOMIN BONE
OSTEOTOMY ILIAC; W/OPEN REDUC HIP
OSTEOTOMY ILIAC; W/FEM OSTEOTOMY
No
No
No
27156
27158
Yes
Yes
OSTEOT; W/FEM OSTEOT/OPEN REDUC HIP
OSTEOT PELVIS BILAT
No
No
27161
Yes
OSTEOTOMY FEMORAL NECK (SEP PROC)
No
27165
27170
27175
Yes
Yes
Yes
OSTEOTOMY INTER-/SUBTROCH INCL FIXA
BONE GFT FEM HEAD/INTER-SUBTROCH
TX SLIPPED FEM EPIPHYSIS; BY TRACT
No
No
No
CPT Code
27176
27177
July 2011
Yes
Yes
27178
Yes
OPEN TX SLIP'D FEM EPIPHYS; CLO MAN
No
27179
27181
27185
27187
27193
27194
27200
27202
27215
27216
27217
27218
27220
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
OPEN TX SLIP'D FEM EPIPHYS; OSTEOPL
OPEN TX SLIP'D FEM EPIPHYS; OSTEOT
EPIPHYSEAL ARREST-EPIPHYSIODESIS
PROPHYLACTIC TX FEM NECK & FEMUR
CLO TX PELVIC RING FX; WO MANIP
CLO TX PELVIC RING FX; W/MANIP-ANES
CLO TX COCCYGEAL FX
OPEN TX COCCYGEAL FX
OPEN TX ILIAC SPI/WING FX W/INT FIX
PERCUT FIX POST PELVIC RING FX
OPEN TX ANT RING FX/DISLO W/INT FIX
OPEN TX POST RING FX/DISL W/INT FIX
CLO TX ACETABULUM FX; WO MANIP
No
No
No
No
No
No
No
No
No
No
No
No
No
27222
27226
27227
27228
No
No
No
No
CLO TX ACETAB FX; W/MANIP W/WO TRAC
OPEN TX POST/ANT ACETAB FX W/FIX
OPEN TX ACETAB FX W/INT FIX
OPEN TX ACETAB FX W/T-FX W/INT FIXA
No
No
No
No
27230
No
CLO TX FEM FX PROX END NECK; WO MAN
No
27232
No
CLO TX FEM FX PROX END NECK; W/MANI
No
27235
27236
27238
27240
No
No
No
No
PERCUT FIX FEM FX PROX END-DISPLACE
OPEN TX FEM FX PROX END FIX/PROSTH
CLO TX INTERTROCH FEM FX; WO MANIP
CLO TX -TROCHANTER FEM FX; W/MANIP
No
No
No
No
27244
No
OPEN TX FEM FX; W/IMPLNT W/WO CERCL
No
27245
27246
27248
27250
No
No
No
No
OPEN TX FEM FX; W/IMPLNT W/WO SCREW
CLO TX GREATER TROCH FX WO MANIP
OPEN TX GR TROC FX W/WO INT/EXT FIX
CLO TX HIP DISLOC TRAUMA; WO ANES
No
No
No
No
Code Description
TX SLIPPED FEM EPIPHYSIS; BY PIN
OPEN TX SLIP'D FEM EPIPHYS; PIN/GFT
No
No
CPT Code
27252
27253
27254
27256
27257
July 2011
No
No
No
No
No
Code Description
CLO TX HIP DISLOC TRAUMA; W/ANES
OPEN TX HIP DISLO TRAUMA WO INT FIX
OPEN TX HIP DISLOC TRAUMA W/FEM FX
TX SPON HIP DISLOC; WO ANES/MANIP
TX SPON HIP DISLOC; W/MANIP W/ANES
No
No
No
No
No
27258
No
OPEN TX SPON HIP DISLO RPL FEM HEAD
No
27259
No
OPEN TX SPON HIP DISLO; W/FEM SHORT
No
27265
27266
27267
27268
27269
27275
27280
27282
27284
No
No
No
No
No
No
Yes
Yes
Yes
CLO TX HIP ARTHROPL DISLOC; WO ANES
CLO TX HIP ARTHROPL DISLOC; W/ANES
CLTX THIGH FX
CLTX THIGH FX W/MNPJ
OPTX THIGH FX
MANIP HIP JT REQUIRING GEN ANES
ARTHRODESIS SACROILIAC JT
ARTHRODESIS SYMPHYSIS PUBIS
ARTHRODESIS HIP JT;
No
No
No
No
No
No
No
No
No
27286
27290
27295
27299
Yes
Yes
Yes
Yes
ARTHRODES HIP JT; W/SUBTROCH OSTEOT
INTERPELVIABDOMINAL AMPUTA
DIASART HIP
UNLISTED PROC PELVIS/HIP JT
No
No
No
Yes
27301
No
I&D DEEP ABSCESS BURSA THIGH/KNEE
No
27303
27305
No
No
INCS DEEP OP BONE CORTEX FEM/KNEE
FASCIOTOMY ILIOTIBIAL OPEN
No
No
27306
No
No
27307
No
TENOT PERCUT HAMSTRING; 1 TEND (SP)
TENOT PERCUT HAMSTRINGS; MX
TENDONS
27310
27323
27324
27325
27326
No
No
No
Yes
Yes
ARTHROT KNEE EXPLOR/DRAIN/REMOV FB
BX SOFT TISS THIGH/KNEE SUPERF
BX SOFT TISS THIGH/KNEE AREA; DEEP
NEURECTOMY, HAMSTRING
NEURECTOMY, POPLITEAL
No
No
No
No
No
No
CPT Code
27327
27328
July 2011
Yes
Yes
27329
Yes
RAD RESEC TUMOR SOFT TISS THIGH/KNE
No
27330
Yes
ARTHROTOMY KNEE; W/SYNOVIAL BX ONLY
No
27331
Yes
ARTHROT KNEE; JT EXPLOR BX/REMOV FB
No
27332
Yes
ARTHROT EXCIS SEMILUN-KNEE; MED/LAT
No
27333
Yes
ARTHROT EXCS SEMILUNR KNEE; MED-LAT
No
27334
Yes
No
27335
27337
27339
27340
27345
27347
27350
Yes
Yes
Yes
Yes
Yes
Yes
Yes
27355
Yes
ARTHROT W/SYNOVECT KNEE; ANT/POST
ARTHROT-SYNOVECT KNEE; ANT-POSTPOP
EXC THIGH/KNEE LES SC > 3 CM
EXC THIGH/KNEE TUM DEEP >5CM
EXC PREPATELLAR BURSA
EXC SYNOVIAL CYST POP SPACE
EXC LES MENISCUS/CAPSULE KNEE
PATELLECTOMY/HEMIPATELLECTOMY
EXC/CURET BONE CYST/BEN TUMOR
FEMUR
27356
Yes
EXC BONE CYST/TUM FEMUR; W/ALLOGFT
No
27357
27358
27360
27364
Yes
Yes
Yes
Yes
EXC BONE CYST/TUM FEMUR; W/AUTOGFT
EXC CYST/BENIGN TUMOR FEM; INT FIXA
PART EXC BONE FEM/PROX TIB/FIBULA
RESECT THIGH/KNEE TUM >5 CM
No
No
No
No
27365
27370
27372
27380
Yes
No
No
Yes
RAD RESECT TUMOR BONE FEMUR/KNEE
INJ PROC KNEE ARTHROGRAPHY
REMOV FB DEEP THIGH REGION/KNEE
SUTURE INFRAPATELLAR TENDON; PRIM
No
No
No
No
27381
27385
Yes
Yes
SUTURE INFRAPATELL TEND; 2ND RECON
SUTURE QUAD/HAM MUSCL RUPT; PRIM
No
No
Code Description
EXC TUMOR THIGH/KNEE AREA; SUBQ
EXC TUMOR THIGH/KNEE; DEEP/IM
No
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
27386
27390
Yes
Yes
SUTURE QUAD MUSCL RUPT; 2ND RECON
TENOT OP HAMSTRING KNEE TO HIP; 1
No
No
27391
Yes
TENOT OP HMSTRNG KNEE-HIP; MX 1 LEG
No
27392
Yes
TENOT OP HMSTRNG KNEE-HIP; MX BILAT
No
27393
27394
Yes
Yes
LENGTHEN HAMSTRING TENDON; 1 TEND
LENGTHEN HMSTRNG TEND; MX 1 LEG
No
No
27395
27396
Yes
Yes
LENGTHN HMSTRNG TEND; MX TEND BILAT
TRANSPL HAMSTRING TEND-PATELLA; 1
No
No
27397
Yes
TRANSPL HAMSTRING TEND-PATELLA; MX
No
27400
27403
Yes
Yes
TRANSF TEND/MUSCL HAMSTRINGS-FEM
ARTHROT W/MENISCUS REPR KNEE
No
No
27405
Yes
REPR PRIM TORN LIGAM KNEE; COLLATER
No
27407
Yes
REPR PRIM TORN LIGAM KNEE; CRUCIATE
No
27409
Yes
No
27412
Yes
REPR TORN LIG KNEE; COLLAT & CRUCIA
AUTOLOGOUS CHONDROCYTE
IMPLANTATION KNEE
No
27415
27416
27418
27420
Yes
Yes
Yes
Yes
OSTEOCHONDRAL ALLOGRAFT KNEE OPEN
OSTEOCHONDRAL KNEE AUTOGRAFT
ANT TIBIAL TUBERCLEPLASTY
RECON DISLOC PATELLA;
No
No
No
No
27422
Yes
RECON DISLOC PATLLA; EXTEN REALIGN
No
27424
27425
Yes
Yes
RECON RECUR DISL PATEL; W/PATELLECT
LAT RETINACULAR RELEASE
No
No
27427
Yes
LIGAMNT RECON KNEE; EXTRA-ARTICULAR
No
Code Description
CPT Code
July 2011
27428
27429
27430
Yes
Yes
Yes
27435
27437
27438
27440
Yes
Yes
Yes
Yes
27441
27442
Yes
Yes
27443
27445
Code Description
LIGAMNT RECON KNEE; INTRA-ARTICULAR
LIG RECON KNEE; INTRA/EXTRA-ARTICUL
QUADRICEPSPLASTY
CAPSULOT POST CAPSULAR RELEASE
KNEE
ARTHROPLASTY PATELLA; WO PROSTH
ARTHROPLASTY PATELLA; W/PROSTH
ARTHROPLASTY KNEE TIBIAL PLATEAU
No
No
No
No
No
Yes
Yes
ARTHROPLSTY TIB; W/DEBRID/SYNOVECT
ARTHROPLASTY FEM CONDYLE KNEES;
ARTHROPLAS FEM CONDYLE KNEE;
DEBRID
ARTHROPLASTY KNEE HINGE PROSTH
27446
Yes
ARTHROPLSTY KNEE CONDYL; MEDIAL/LAT
No
27447
27448
27450
Yes
Yes
Yes
No
No
No
27454
Yes
ARTHROPLSTY KNEE CONDYL; MED & LAT
OSTEOTOMY FEMUR SHAFT; WO FIXA
OSTEOTOMY FEMUR SHAFT; W/FIXA
OSTEOT MX REALGN INTRAMEDUL ROD
FEM
27455
27457
27465
27466
Yes
Yes
Yes
Yes
OSTEOT PROX TIB; BEFORE EPIPHYS CLO
OSTEOT PROX TIB; AFTER EPIPHYS CLO
OSTEOPLASTY FEMUR; SHORTENING
OSTEOPLASTY FEMUR; LENGTHENING
No
No
No
No
27468
27470
Yes
Yes
OSTEOPLSTY FEM; COMBO LENGTH/SHORT
REPR NON-MALUNION FEMUR; WO GFT
No
No
27472
27475
27477
Yes
Yes
Yes
REPR NON-/MALUNION FEM; W/ILIAC GFT
ARREST EPIPHYSEAL; DIST FEM
ARRST EPIPHYSEAL; TIBIA-FIBULA PROX
No
No
No
27479
27485
27486
Yes
Yes
Yes
ARRST EPIPHYSEAL; COMBO FEM-TIB/FIB
ARREST HEMIEPIPHYSEAL DIST FEM
REVIS TOT KNEE ARTHROPL; 1 COMPON
No
No
No
No
No
No
No
No
No
No
CPT Code
27487
July 2011
Yes
27488
Yes
27495
Yes
Code Description
REVIS TOT KNEE ARTHROPLAS; FEM-TIB
REMOV TOTAL KNEE PROSTH W/WO
SPACER
PROPHYLAC TX W/WO METHYLMETHACR
FEM
27496
Yes
DECOMP FASCIOT THIGH/KNEE 1 COMPART
No
27497
Yes
No
27498
Yes
27499
27500
Yes
No
DECOMP FASCIOT 1 COMPART; W/DEBRID
DECOMP FASCIOT THIGH/KNEE MX
COMPAR
DECOMP FASCIOT MX COMPART;
W/DEBRID
CLO TX FEMORAL SHAFT FX WO MANIP
27501
No
CLO TX SUPRACONDYL FEM FX WO MANIP
No
27502
27503
No
No
CLO TX FEM FX W/MANIP W/WO TRACTION
CLO TX CONDYLAR FEM FX W/MANIP
No
No
27506
No
OPEN TX FEM SHAFT FX W/WO FIX/SCREW
No
27507
27508
No
No
OPEN TX FEM SHAFT FX W/PLATE/SCREWS
CLO TX FEM FX DIST END WO MANIP
No
No
27509
27510
No
No
No
No
27511
No
PERQ FIX FEM FX DISTAL/FEM EPIPHYSL
CLO TX FEM FX DIST END W/MANIP
OPEN TX FEM SUPRACONDYL FX WO
EXTEN
27513
27514
No
No
OPEN TX FEM SUPRACONDYL FX W/EXTEN
OPEN TX FEM FX MED/LAT CONDYLE
No
No
27516
No
CLO TX FEM EPIPHYSEAL SEPAR; WO MAN
No
27517
No
CLO TX FEM EPIPHYSEAL SEP; W/MANIP
No
27519
27520
No
No
OPEN TX FEM EPIPHYS SEPAR W/WO FIXA
CLO TX PATELLAR FX WO MANIP
No
No
No
No
No
No
No
No
No
CPT Code
27524
27530
27532
27535
27536
27538
27540
27550
27552
27556
July 2011
No
No
No
No
No
No
No
No
No
No
Code Description
OPEN TX PATELLA FX W/FIX PATELLECT
CLO TX TIBIAL FX PROX; WO MANIP
CLO TX TIB FX; W/WO MANIP W/TRACT
OPEN TX TIB FX; UNICONDYL W/WO FIXA
OPEN TX TIB FX; BICONDYLAR W/WO FIX
CLO TX FX KNEE W/WO MANIP
OPEN TX FX KNEE W/WO FIX
CLO TX KNEE DISLOC; WO ANES
CLO TX KNEE DISLOC; REQUIRING ANES
OPEN TX KNEE DISLO; WO PRI LIG REPR
No
No
No
No
No
No
No
No
No
No
27557
No
OPEN TX KNEE DISLO; W/PRIM LIG REPR
No
27558
27560
27562
No
No
No
OPEN TX KNEE DISLO; W/LIG REPR/AUGM
CLO TX PATELLAR DISLOC; WO ANES
CLO TX PATELLAR DISLOC; REQ ANES
No
No
No
27566
27570
27580
No
No
Yes
OPEN TX PATEL DISLO W/WO PATELLECT
MANIP KNEE JT UNDER GEN ANES
ARTHRODESIS KNEE ANY TECH
No
No
No
27590
27591
Yes
Yes
AMPUTA THIGH THRU FEMUR ANY LEVEL
AMPUTA THIGH THRU FEMUR; IMMED FIT
No
No
27592
27594
Yes
Yes
AMPUTA THIGH THRU FEMUR; OPEN CIRC
AMPUTA THIGH FEMUR; 2ND CLO/REVIS
No
No
27596
27598
27599
Yes
Yes
Yes
AMPUTA THIGH THRU FEMUR; RE-AMPUTA
DIASART AT KNEE
UNLISTED PROC FEMUR/KNEE
No
No
Yes
27600
27601
27602
Yes
Yes
Yes
DECOMP FASCIOT LEG; ANT/LAT COMPART
DECOMP FASCIOT LEG; POST COMPART
DECOMP FASCIOT LEG; ANT/LAT/POST
No
No
No
27603
27604
No
No
I&D LEG/ANK; DEEP ABSCESS/HEMATOMA
I&D LEG/ANK; INFEC BURSA
No
No
27605
Yes
TENOT PERCUT ACHILLS (SP); LOC ANES
No
CPT Code
July 2011
27606
27607
Yes
Yes
TENOT PERCUT ACHLLES (SP); GEN ANES
INCIS LEG/ANK
No
No
27610
Yes
ARTHROT ANK-EXPLOR/DRAIN/REMOV FB
No
27612
27613
27614
Yes
No
No
ARTHROT POST CAPSULAR RELASE ANK
BX SOFT TISS LEG/ANK AREA; SUPERF
BX SOFT TISS LEG/ANK AREA; DEEP
No
No
No
27615
27616
27618
27619
Yes
Yes
Yes
Yes
RAD RESECT TUMOR SOFT TISS LEG/ANK
RESECT LEG/ANKLE TUM > 5 CM
EXC TUMOR LEG/ANK AREA; SUBQ TISS
EXC TUMOR LEG/ANK AREA; DEEP
No
No
No
No
27620
27625
Yes
Yes
No
No
27626
Yes
ARTHROTOMY ANK W/JT EXPLOR W/WO BX
ARTHROTOMY W/SYNOVECTOMY ANK;
ARTHROT W/SYNOVECT ANK;
TENOSYNOVEC
27630
27632
27634
27635
27637
27638
27640
27641
27645
27646
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
27647
27648
27650
27652
Yes
Yes
Yes
Yes
27654
27656
27658
Yes
Yes
Yes
EXC LES TENDON SHEATH/CAPSULE LEG
EXC LEG/ANKLE LES SC 3+ CM
EXC LEG/ANKLE TUM DEEP >5 CM
EXC/CURET BONE CYST/TUMOR TIB/FIB
EXC BONE CYST TIB/FIB; W/AUTOGFT
EXC BONE CYST TIB/FIB; W/ALLOGFT
PART EXC BONE; TIBIA
PART EXC BONE; FIBULA
RADICAL RESECT BONE TUMOR; TIBIA
RADICAL RESECT BONE TUMOR; FIBULA
RAD RESECT BONE TUMOR;
TALUS/CALCAN
INJ PROC ANK ARTHROGRAPHY
REPR PRIM OP/PERCUT RUPT ACHILLES
REPR PRIM OP RUPT ACHILLES; W/GFT
REPR SECNDRY ACHILLES TEND W/WO
GFT
REPR FASCIAL DEFECT LEG
REPR FLEX TEND LEG; PRIM WO GFT EA
Code Description
No
No
No
No
No
No
No
No
CPT Code
July 2011
27659
Yes
REPR FLEX TEND LEG; SECND EA TENDON
No
27664
Yes
REPR EXTEN TEND LEG; PRIM WO GFT EA
No
27665
Yes
REPR EXTEN TEND LEG; SECND EA TEND
No
27675
Yes
REPR DISLOC PERNEL TEND; WO OSTEOT
No
27676
27680
27681
Yes
Yes
Yes
REPR DISLOC PERONL TEND; FIB OSTEOT
TENOLYS FLEX/EXTEN-LEG ANK; 1 EA
TENLYS FLEX/EXTEN LEG-ANK; MX TEND
No
No
No
27685
Yes
LENGTH/SHORT TENDON LEG/ANK; 1 TEND
No
27686
27687
Yes
Yes
LENGTH/SHORT TEND LEG/ANK; MX TEND
GASTROCNEMIUS RECESSION
No
No
27690
27691
Yes
Yes
TRANSF/TRANSPL SNGL TENDON; SUPERF
TRANSF/TRANSPL SNGL TENDON; DEEP
No
No
27692
27695
27696
Yes
Yes
Yes
TRANSF/TRANSPL SNGL; EA ADD TENDON
REPR PRIM DISRUPT LIG ANK; COLLAT
REPR PRIM DISRUPT LIG ANK; BOTH
No
No
No
27698
27700
27702
27703
27704
27705
27707
27709
27712
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
REPR SECND DISRUPT LIG ANK COLLATER
ARTHROPLASTY ANK
ARTHROPLAS ANK; W/IMPLNT (TOT ANK)
ARTHROPLASTY ANK; REVIS TOT ANK
REMOV ANK IMPLNT
OSTEOTOMY; TIBIA
OSTEOTOMY; FIBULA
OSTEOTOMY; TIBIA & FIBULA
OSTEOT; MX REALIGN INTRAMEDUL ROD
No
No
No
No
No
No
No
No
No
27715
27720
27722
27724
Yes
Yes
Yes
Yes
OSTEOPLAS TIB-FIB LENGTHEN/SHORTEN
REPR NON/MALUNION TIBIA; WO GFT
REPR NON/MALUNION TIBIA; W/SLID GFT
REPR NON/MALUNION TIBIA; W/GFT
No
No
No
No
Code Description
CPT Code
July 2011
27725
27726
27727
Yes
Yes
Yes
REPR NONUNION TIB; SYNOSTOSIS W/FIB
REPAIR FIBULA NONUNION
REPR CONGEN PSEUDARTHROSIS TIBIA
No
No
No
27730
Yes
ARRST EPIPHYSEL ANY METHD; DIST TIB
No
27732
27734
27740
27742
Yes
Yes
Yes
Yes
No
No
No
No
27745
27750
27752
27756
Yes
No
No
No
ARRST EPIPHYSEL ANY METHD; DIST FIB
ARRST EPIPHYSEAL; DIST TIBIA-FIBULA
ARRST EPIPHYSEAL PROX-DIST TIB-FIB;
ARRST EPIP PROX-DIST TIB-FIB; FEM
PROPHYLAC TX W/WO METHYLMETHACR
TIB
CLO TX TIBIAL SHAFT FX; WO MANIP
CLO TX TIB FX; W/MANIP W/WO TRACT
PERCUT SKELETAL FIXA TIB SHAFT FX
27758
No
OPEN TX TIB SHAFT FX W/PLATE/SCREWS
No
27759
No
OPEN TX TIB FX-IMPLANT-W/WO SCREWS
No
27760
27762
No
No
CLO TX MEDIAL MALLEOLUS FX; WO MANI
CLO TX MED MALLEOLUS FX; W/MANIP
No
No
27766
27767
27768
27769
27780
27781
No
No
No
No
No
No
OPEN TX MED MALLEOLUS FX W/WO FIXA
CLTX POST ANKLE FX
CLTX POST ANKLE FX W/MNPJ
OPTX POST ANKLE FX
CLO TX PROX FIB/SHAFT FX; WO MANIP
CLO TX PROX FIB/SHAFT FX; W/MANIP
No
No
No
No
No
No
27784
27786
27788
27792
No
No
No
No
OPEN TX PROX FIB/SHAFT FX W/WO FIXA
CLO TX DISTAL FIBULAR FX; WO MANIP
CLO TX DISTAL FIBULAR FX; W/MANIP
OPEN TX DIS FIB FX W/WO INT/EXT FIX
No
No
No
No
27808
27810
No
No
CLO TX BIMALLEOLAR ANK FX; WO MANIP
CLO TX BIMALLEOLAR ANK FX; W/MANIP
No
No
Code Description
No
No
No
No
CPT Code
July 2011
27814
No
OPEN TX BIMALLEOLAR ANK FX W/WO FIX
No
27816
No
CLO TX TRIMALLEOLAR ANK FX; WO MANI
No
27818
27822
27823
27824
27825
27826
27827
27828
27829
27830
27831
27832
27840
27842
No
No
No
No
No
No
No
No
No
No
No
No
No
No
CLO TX TRIMALLEOLAR ANK FX; W/MANIP
OPEN TX TRIMALLEOLR FX; WO FIXA LIP
OPEN TX TRIMALLEOLAR FX; W/FIXA LIP
CLO TX FX ARTICUL-DIST TIB; WO ANES
CLO TX FX DIST TIB; W/TRACT/ANES
OPEN TX FX DIST TIB W/FIX; FIB ONLY
OPEN TX FX DIST TIB W/FIX; TIB ONLY
OPEN TX FX DIS TIB W/FIX; TIB & FIB
OPEN TX DIST TIBIOFIBULR JT DISRUPT
CLO TX PROX TIB-FIB JT DISL; WO ANE
CLO TX PROX TIB-FIB JT DISL; W/ANES
OPEN TX PROX TIB-FIB JT DISLO W/EXC
CLO TX ANK DISLOC; WO ANES
CLO TX ANK DISLOC; W/ANES W/WO FIX
No
No
No
No
No
No
No
No
No
No
No
No
No
No
27846
No
OPEN TX ANK DISLO W/WO FIX; WO REPR
No
27848
27860
27870
27871
27880
27881
27882
27884
27886
27888
27889
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
OPEN TX ANK DISLOC W/WO FIX; W/REPR
MANIP ANK UNDER GEN ANES
ARTHRODESIS ANK ANY METHD
ARTHRODESIS TIB-FIB JT PROX/DISTAL
AMPUTA LEG THRU TIBIA & FIBULA
AMPUT LEG-TIB & FIB; W/FIT & CAST
AMPUTA LEG-TIBIA & FIB; OPEN CIRC
AMPUTA LEG-TIB & FIB; 2ND CLO/REVIS
AMPUTA LEG-TIB & FIB; RE-AMPUTA
AMPUT ANK-MALLEOLI PLAS CLO
ANK DIASART
No
No
No
No
No
No
No
No
No
No
No
27892
27893
27894
27899
28001
Yes
Yes
Yes
Yes
No
DECOMP FASCIOT LEG; ANT/LAT COMPRT
DECOMP FASCIOT LEG; POST COMPRT
DECOMP FASCI LEG; A-P/LAT W/DEBRID
UNLISTED PROC LEG/ANK
I&D BURSA FT
No
No
No
Yes
No
Code Description
CPT Code
July 2011
28002
28003
28005
28008
28010
28011
28020
28022
28024
28035
28039
28041
28043
28045
28046
28047
28050
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
I&D BELOW FASCIA FT; 1 BURSAL SPACE
I&D BELOW FASCIA FT; MX AREAS
INCIS BONE CORTEX FT
FASCIOTOMY FT &/OR TOE
TENOT PERCUT TOE; SINGL TENDON
TENOT PERCUT TOE; MX TENDON
ARTHROT EXPLOR; INTERTARSAL JT
ARTHROT EXPLOR; METATARSOPHAL JT
ARTHROT EXPLOR/DRAIN; IP JT
RELEASE TARSAL TUNNEL
EXC FOOT/TOE TUM SC > 1.5 CM
EXC FOOT/TOE TUM DEEP >1.5CM
EXC TUMOR FT; SUBQ TISS
EXC TUMOR FT; DEEP/SUBFASCIAL/IM
RADICAL RESECT TUMOR SOFT TISS FT
RESECT FOOT/TOE TUMOR > 3 CM
ARTHROT W/BX; INTERTARSAL JT
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
28052
28054
28055
28060
28062
28070
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
28072
28080
Yes
Yes
ARTHROT W/BX; METATARSOPHALANG JT
ARTHROT W/BX; INTERPHALANGEAL JT
NEURECTOMY, FOOT
FASCIECTOMY PLANTAR; PART (SP)
FASCIECT PLANTAR FASCIA; RAD (SP)
SYNOVECTOMY; INTERTARSAL JT EA
SYNOVECT; METATARSOPHALANGEAL JT
EA
EXC INTERDIGITAL NEUROMA SNGL EA
28086
Yes
No
28088
28090
Yes
Yes
SYNOVECT TENDON SHEATH FT; FLEXOR
SYNOVECT TENDON SHEATH FT;
EXTENSOR
EXC LES TENDON/SHEATH/CAPSULE; FT
28092
Yes
EXC LES TEND/SHEATH/CAPSULE; TOE EA
No
28100
Yes
EXC/CURET BONE CYST/TUMOR TALUS/CAL
No
28102
Yes
EXC/CURET BONE CYST TALUS; W/AUTOGF
No
Code Description
No
No
No
No
CPT Code
July 2011
28103
Yes
EXC/CURET BONE CYST TALUS; W/ALLOGF
No
28104
28106
28107
Yes
Yes
Yes
No
No
No
28108
Yes
EXC/CURET BONE CYST TARSAL EX TALUS
EXC BONE CYST TARSAL/W/AUTOGFT
EXC BONE CYST TARSAL; W/ALLOGFT
EXC/CURET BONE CYST/TUMOR PHALAN
FT
28110
Yes
OSTEOTOMY 5TH METAR HEAD (SEP PRO)
No
28111
Yes
No
28112
Yes
OSTECT COMPL EXC; 1ST METATARS HEAD
OSTECT COMPL EXC; OTHR METATAR
HEAD
28113
28114
28116
28118
Yes
Yes
Yes
Yes
No
No
No
No
28119
28120
28122
28124
28126
28130
28140
28150
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
OSTECT COMPL EXC; 5TH METATARS HEAD
OSTEC; ALL METATARS HEADS-NOT 1ST
OSTECTOMY EXC TARSAL COALITION
OSTECTOMY CALCAN
OSTECTOMY CALCAN; W/WO PLANT
RELEAS
PART EXC BONE; TALUS/CALCAN
PART EXC BONE; TARSAL EX TALUS
PART EXC BONE; PHALANX TOE
RESECT PART/ALL PHAL BASE EA TOE
TALECTOMY
METATARSECTOMY
PHALANGECTOMY TOE EA TOE
28153
Yes
RESECT CONDYLE DIST PHALANX EA TOE
No
28160
Yes
HEMIPHALANGECT/TOE PROX PHALANX EA
No
28171
Yes
No
28173
Yes
RADICAL RESECT BONE TUMOR; TARSAL
RADICAL RESECT BONE TUMOR;
METATARS
28175
28190
Yes
No
RAD RESECT BONE TUMOR; PHALANX TOE
REMOV FB FT; SUBQ
No
No
Code Description
No
No
No
No
No
No
No
No
No
No
No
CPT Code
28192
28193
28200
July 2011
No
No
Yes
28202
28208
28210
28220
28222
28225
28226
28230
28232
28234
28238
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
REPR TENDON FLEX FT; SECND W/GFT EA
REPR TEND EXTEN FT; PRIM/SECND EA
REPR TEND EXTEN FT; SEC W/GFT EA
TENOLYSIS FLEX FT; SINGL TENDON
TENOLYSIS FLEX FT; MX TENDON
TENOLYSIS EXTEN FT; SINGL TENDON
TENOLYSIS EXTEN FT; MX TENDON
TENOT OP TEND FLEX; FT 1/MX (SP)
TENOT OP TEND FLEX; TOE 1 TEND (SP)
TENOT OP EXTEN FT/TOE EA TENDON
RECON POST TIBIAL TENDON
No
No
No
No
No
No
No
No
No
No
No
28240
28250
Yes
Yes
TENOT LENGTH/RELEAS ABDUCT HALLUCIS
DIVIS PLANTAR FASCIA & MUSC (SP)
No
No
28260
Yes
CAPSULOT MIDFT; MED RELEAS ONLY (SP
No
28261
28262
28264
28270
28272
28280
28285
28286
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
28288
Yes
CAPSULOT MIDFT; W/TENDON LENTHENING
CAPSULOT MIDFT; EXTEN
CAPSULOT MIDTARSAL
CAPSULOT; MTP JT-EA JT (SP)
CAPSULOT; IP JT-EA JT (SEPART PROC)
SYNDACTYLIZATION TOES
CORRECT HAMMERTOE
CORRECT COCK-UP 5TH TOE-PLSTC CLO
OSTECT PART EXOSTECT MTATRS HEADEA
28289
28290
Yes
Yes
HALLUX RIGIDIS CORRECT W/CHEILECTMY
HALLUX VALGUS; SIMPL EXOSTECT
No
No
28292
28293
28294
Yes
Yes
Yes
HALLUX VALGUS; KELLER/MAYO TYPE PRO
HALLUX VALGUS; RESEC JT W/IMPLNT
HALLUX VALGUS; W/TENDON TRANSPL
No
No
No
Code Description
REMOV FB FT; DEEP
REMOV FB FT; COMPLIC
REPR TEND FLEX FT; 1ST/2ND EA TEND
No
No
No
No
CPT Code
July 2011
28296
28297
28298
28299
28300
28302
Yes
Yes
Yes
Yes
Yes
Yes
HALLUX VALGUS; W/METATARSAL OSTEOT
HALLUX VALGUS; LAPIDUS TYPE PRO
HALLUX VALGUS; PHALANX OSTEOT
HALLUX VALGUS; OTH METHD
OSTEOT; CALCAN W/WO INT FIXA
OSTEOTOMY; TALUS
No
No
No
No
No
No
28304
28305
Yes
Yes
OSTEOT TARSL BONS NOT CALCAN/TALUS;
OSTEOT TARSAL BONES; W/AUTOGFT
No
No
28306
28307
28308
Yes
Yes
Yes
No
No
No
28309
28310
Yes
Yes
28312
Yes
OSTEOT METATARSAL; 1ST METATARSAL
OSTEOT METATARS; 1ST W/AUTOGFT
OSTEOT METATARSAL; NOT 1ST-EA
OSTEOT W/WO CORRECT METATARSAL;
MX
OSTEOT; PROX PHALANX 1ST TOE (SP)
OSTEOT-CORRECT; OTH PHALANG-ANY
TOE
28313
28315
28320
28322
Yes
Yes
Yes
Yes
No
No
No
No
28340
Yes
28341
28344
Yes
Yes
RECON ANGULAR DEFORM TOE SOFT TISS
SESAMOIDECTOMY 1ST TOE (SEP PRO)
REPR NON/MALUNION; TARSAL BONES
REPR NON/MALUNION; METATARSAL
RECON TOE MACRODACTYLY; TISS
RESECT
RECON TOE MACRODACT; REQ BONE
RESEC
RECON TOE; POLYDACTYLY
28345
28360
28400
28405
Yes
Yes
No
No
RECON TOE; SYNDAC W/WO SKIN GFT EA
RECON CLEFT FT
CLO TX CALCAN FX; WO MANIP
CLO TX CALCAN FX; W/MANIP
No
No
No
No
28406
28415
28420
28430
No
No
No
No
PERCUT SKELE FIX CALCAN FX W/MANIP
OPEN TX CALCAN FX W/WO INT/EXT FIXA
OPEN TX CALCAN FX; W/PRI AUTOG GFT
CLO TX TALUS FX; WO MANIP
No
No
No
No
Code Description
No
No
No
No
No
No
CPT Code
28435
July 2011
No
28436
28445
28446
28450
28455
28456
28465
28470
28475
No
No
No
No
No
No
No
No
No
PERCUT SKELETL FIXA TALUS FX W/MANI
OPEN TX TALUS FX W/WO INT/EXT FIXA
OSTEOCHONDRAL TALUS AUTOGRFT
TX TARSAL BONE FX; WO MANIP EA
TX TARSAL BONE FX; W/MANIP EA
PERCUT FIX TARSAL BONE FX W/MANIP
OPEN TX TARSAL BONE FX W/WO FIX EA
CLO TX METATARSAL FX; WO MANIP EA
CLO TX METATARSAL FX; W/MANIP EA
No
No
No
No
No
No
No
No
No
28476
28485
No
No
PERCUT FIX METATARSAL FX W/MANIP EA
OPEN TX METATARSAL FX W/WO FIX EA
No
No
28490
28495
No
No
CLO TX FX GRT TOE PHALANX; WO MANIP
CLO TX FX GRT TOE PHALANX; W/MANIP
No
No
28496
No
PERCUT FIX FX GRT TOE-PHALAN-W/MANI
No
28505
No
OPEN TX FX GRT TOE-PHALANX-W/WO FIX
No
28510
28515
No
No
CLO TX FX PHALNX NOT GR TOE; WO MAN
CLO TX FX PHALNX NOT GR TOE; W/MANI
No
No
28525
28530
28531
No
No
No
OPEN TX FX PHLNX EX GR TOE W/WO FIX
CLO TX SESAMOID FX
OPEN TX SESAMOID FX W/WO INT FIXA
No
No
No
28540
28545
28546
No
No
No
CLO TX TARSAL BONE DISLOC; WO ANES
CLO TX TARSAL BONE DISLOC; W/ANES
PERCUT FIX TARSAL DISLOC W/MANIP
No
No
No
28555
28570
28575
No
No
No
OPEN TX TARSAL BONE DISLOC W/WO FIX
CLO TX TALOTARS JT DISLOC; WO ANES
CLO TX TALOTAR JT DISLOC; REQ ANES
No
No
No
28576
No
PERCUT FIX TALOTARS JT DISLOC W/MAN
No
Code Description
CLO TX TALUS FX; W/MANIP
No
CPT Code
July 2011
28585
No
OPEN TX TALOTARS JT DISLOC W/WO FIX
No
28600
No
CLO TX TARSOMETAT JT DISLOC; WO ANE
No
28605
No
CLO TX TARSOMETAT JT DISLOC; W/ANES
No
28606
No
PERCU FIX TARSOMETAT JT DISL W/MANI
No
28615
No
OPEN TX TARSMETAT JT DISLO W/WO FIX
No
28630
No
CLO TX METATARSOPHAL JT DISL;WO ANE
No
28635
No
CLO TX METATARSOPHAL JT DISL; W/ANE
No
28636
28645
28660
28665
28666
28675
28705
28715
28725
No
No
No
No
No
No
Yes
Yes
Yes
PERCU FIX METATARSOPHAL JT W/MANIP
OPEN TX METATARSOPHAL JT DISLOC
CLO TX IP JT DISLOC; WO ANES
CLO TX IP JT DISLOC; REQUIRING ANES
PERCUT SKELET FIX IP JT DISL W/MANI
OPEN TX IP JT DISLOC W/WO FIXA
ARTHRODESIS; PANTALAR
ARTHRODESIS; TRIPLE
ARTHRODESIS; SUBTALAR
No
No
No
No
No
No
No
No
No
28730
28735
Yes
Yes
No
No
28737
28740
Yes
Yes
28750
28755
Yes
Yes
ARTHRODESIS MIDTARS/TARSOMETAT MX
ARTHRODESIS MIDTARS MX; W/OSTEOT
ARTHRODESIS TENDON LENGTH
MIDTARSAL
ARTHRODESIS MIDTARSAL SNGL JT
ARTHRODESIS GRT TOE; METATARSOPH
JT
ARTHRODESIS GREAT TOE; IP JT
28760
28800
28805
28810
Yes
Yes
Yes
Yes
ARTHRODESIS EXTEN HALLUCIS TRANSF
AMPUTA FT; MIDTARSAL
AMPUTA FT; TRANSMETATARSAL
AMPUTA METATARSAL W/TOE SNGL
No
No
No
No
Code Description
No
No
No
No
CPT Code
July 2011
28820
28825
Yes
Yes
28890
28899
29000
29010
29015
Code Description
Not Reimbursable
Yes
No
No
No
AMPUTA TOE; METATARSOPHALANGEAL JT
AMPUTA TOE; IP JT
ESWT HI NRG PFRMD PHYS W/US GDN
INVG PLNTAR FSCA
UNLISTED PROC FT/TOES
APPLIC HALO TYPE BODY CAST
APPLIC RISSER JACKET BODY; ONLY
APPL RISSER JACKET BODY; INCL HEAD
Not Reimbursable
Yes
No
No
No
29020
No
APPLIC TURNBUCKLE JACKET BODY; ONLY
No
29025
29035
No
No
APPLIC TURNBUCKLE JACKET BODY; W/HD
APPLIC BODY CAST SHOULDER TO HIPS
No
No
29040
29044
29046
29049
29055
29058
29065
29075
29085
29086
29105
29125
29126
29130
29131
29200
29240
29260
29280
29305
29325
29345
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
APPLIC BODY CAST; INCL HEAD-MINERVA
APPLIC BODY CAST; INCL 1 THIGH
APPLIC BODY CAST; INCL BOTH THIGHS
APPLIC; PLASTER FIGURE-8
APPLIC; SHOULDER SPICA
APPLIC; PLASTER VELPEAU
APPLIC; SHOULDER TO HAND
APPLIC; ELBOW TO FINGER
APPLIC; HAND & LOWER FOREARM
APPLICATION CAST; FINGER
APPLIC LONG ARM SPLINT
APPLIC SHORT ARM SPLINT; STATIC
APPLIC SHORT ARM SPLINT; DYNAMIC
APPLIC FINGER SPLINT; STATIC
APPLIC FINGER SPLINT; DYNAMIC
STRAPPING; THORAX
STRAPPING; SHOULDER
STRAPPING; ELBOW/WRIST
STRAPPING; HAND/FINGER
APPLIC HIP SPICA CAST; 1 LEG
APPLIC HIP SPICA CAST; 1-1/2 SPICA
APPLIC LONG LEG CAST
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
29355
No
APPLIC LONG LEG CAST;WALKER/AMB TYP
No
No
No
CPT Code
29358
29365
29405
July 2011
No
No
No
29425
No
APPLIC SHORT LEG CAST; WALKING/AMB
No
29435
29440
29445
No
No
No
APPLIC PATELLAR TENDON BEARING CAST
ADD WALKER TO PREV APPLIC CAST
APPLIC RIGID TOT CONTACT LEG CAST
No
No
No
29450
29505
29515
29520
29530
29540
29550
29580
29581
29590
29700
29705
29710
29715
29720
29730
29740
29750
29799
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
APPLIC CLUBFT CAST W/MOLDING/MANIP
APPLIC LONG LEG SPLINT
APPLIC SHORT LEG SPLINT
STRAPPING; HIP
STRAPPING; KNEE
STRAPPING; ANK
STRAPPING; TOES
STRAPPING; UNNA BOOT
APPLY MULTLAY COMPRS LWR LEG
DENIS-BROWNE SPLINT STRAPPING
REMOV/BIVALV; GAUNTLET/BOOT CAST
REMOV/BIVALV; FULL ARM/LEG CAST
REMOV/BIVALV; SHOULDR/HIP SPICA
REMOV/BIVALV; TURNBUCKLE JACKET
REPR SPICA BODY CAST/JACKET
WINDOWING CAST
WEDGING CAST
WEDGING CLUBFT CAST
UNLISTED PROC CASTING/STRAPPING
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
29800
29804
Yes
Yes
ARTHROSCOPY-TMJ-DX W/WO BX(SEP PRO
ARTHROSCOPY TMJ; SURG
No
No
29805
Yes
SCOPE SHLDR DX W/WO SYN BX SEP PROC
No
29806
Yes
SCOPE SHOULDER SURGICAL; CPSLORR
No
29807
Yes
SCOPE SHLDR SURG; REPR SLAP LESION
No
Code Description
APPLIC LONG LEG CAST BRACE
APPLIC CYLINDER CAST
APPLIC SHORT LEG CAST
No
No
No
CPT Code
July 2011
29819
Yes
29820
Yes
29821
Yes
29822
Yes
29823
29824
Yes
Yes
29825
Yes
29826
Yes
29827
29828
29830
Yes
Yes
Yes
29834
Yes
29835
Yes
29836
Yes
29837
Yes
29838
29840
Yes
Yes
29843
Yes
29844
Code Description
ARTHROSCOPY SHOULDR SURG; REMOV
FB
ARTHROSCPY SHOULDR SURG; SYNOV
PART
ARTHROSCPY SHLDR SURG; SYNOV
COMPLT
ARTHROSCPY SHOULDR SURG; DEBRID
LTD
ARTHROSCP SHOULDR SURG;DEBRID
EXTEN
SCOPE SHLDR SURG;DIST CLAVICULECT
ARTHROSCPY SHLDR; W/LYSIS ADHESIONS
ARTHROSCPY SHLDR; DECOMP
SUBACROM
SCOPE SHOULDER SURGICAL; W/ROTATOR
CUFF REPAIR
ARTHROSCOPY BICEPS TENODESIS
ARTHROSCPY ELBOW DX (SEP PRO)
No
No
No
No
No
No
No
No
No
No
No
ARTHROSCPY ELBOW SURG; W/REMOV FB
ARTHROSCPY ELBOW SURG; SYNOVEC
PART
ARTHROS ELBOW SURG; SYNOVEC
COMPLT
No
ARTHROSCOPY ELBOW SURG; DEBRID LTD
ARTHROSCPY ELBOW SURG; DEBRID
EXTEN
ARTHROSCPY WRIST DX (SEP PRO)
No
No
Yes
ARTHROSCPY WRIST SURG; INFEC/DRAIN
ARTHROSCPY WRIST SURG; SYNOVEC
PART
29845
Yes
ARTHROS WRIST SURG; SYNOVEC COMPLT
No
29846
29847
Yes
Yes
ARTHROS WRIST SURG; EXC/REPR FIBROC
ARTHROSCOPY WRIST SURG; INT FIX-FX
No
No
No
No
No
No
No
CPT Code
July 2011
29848
29850
29851
29855
29856
29860
Yes
Yes
Yes
Yes
Yes
Yes
ENDO WRST SURG-RELEAS TRNS CARP LIG
ARTHROSCOPIC AIDED TX KNEE; WO FIX
ARTHROSCOPIC AIDED TX KNEE; W/FIX
ARTHROSCOPIC AIDED TX TIB FX; UNICO
ARTHROSCOPIC AIDED TX TIB FX; BICON
ARTHROS HIP DX W/WO BX (SEP PROC)
No
No
No
No
No
No
29861
Yes
ARTHROSCOPY HIP SURG; W/REMOV FB
No
29862
Yes
No
29863
Yes
29867
Not Reimbursable
29868
29870
Not Reimbursable
Yes
ARTHROS HIP SURG; DEBRID/SHAV CART
ARTHROSCOPY HIP SURG;
W/SYNOVECTOMY
ARTHROSCOPY KNEE SURG;
OSTEOCHONDRAL ALLOGRAFT
ARTHROSCOPY KNEE SURG; MENISCAL
TPLNT MED/LAT
ARTHROS KNEE DX W/WO BX (SEP PRO)
29871
Yes
29873
29874
Yes
Yes
29875
Yes
29876
29877
Code Description
No
Not Reimbursable
Not Reimbursable
No
ARTHROSCOPY KNEE SURG; INFEC/DRAIN
ARTHROSCOPY KNEE SURGICAL; WITH
LATERAL RELEASE
ARTHROSCOPY KNEE SURG; REMOV FB
No
No
Yes
Yes
ARTHROS KNEE; SYNOVEC LTD (SEP PRO)
ARTHROSCOPY KNEE; SYNOVECTOMY
MAJOR
ARTHROS KNEE; DEBRID/SHAVE CARTIL
29879
Yes
ARTHROSCOP KNEE SURG; ABRAS PLASTY
No
29880
Yes
ARTHROS KNEE; W/MENISECT (MED & LAT
No
29881
Yes
ARTHROS KNEE; W/MENISECT (MED/LAT)
No
29882
Yes
ARTHROS KNEE W/MENISCUS (MED/LAT)
No
29883
Yes
ARTHROS KNEE; W/MENISCUS (MED & LAT
No
No
No
No
No
CPT Code
July 2011
29884
29885
Yes
Yes
ARTHROS KNEE; W/LYSIS ADH (SEP PRO)
ARTHROS KNEE; DRILL W/GFT W/WO FIX
No
No
29886
Yes
ARTHROS KNEE; DRILL-OSTEOCHON LES
No
29887
Yes
ARTHROS KNEE; DRILL-OSTEOCHON W/FIX
No
29888
Yes
ARTHROSCOPIC AIDED ACL REPAIR/RECON
No
29889
Yes
ARTHROSCOPIC AIDED PCL REPAIR/RECON
No
29891
Yes
ARTHROS ANK SURG; EXC DEFEC TAL/TIB
No
29892
29893
Yes
Yes
ARTHROS AIDED REPR OSTEO LES-TAL FX
ENDOSCOPIC PLANTAR FASCIOTOMY
No
No
29894
Yes
No
29895
29897
Yes
Yes
ARTHROSCOPY ANK SURG; W/REMOV FB
ARTHROS ANK SURG; SYNOVECTOMY
PART
ARTHROSCOPY ANK SURG; DEBRID LTD
29898
Yes
No
29899
Yes
ARTHROSCOPY ANK SURG; DEBRID EXTEN
ARTHROSCOPY ANKLE SURG; W/ANKLE
ARTHRODESIS
29900
Yes
SCOPE MCP JOINT DX INCL SYNOVIAL BX
No
29901
Yes
SCOPE MCP JOINT SURGICAL; W/DEBRID
No
29902
29904
29905
29906
29907
29914
29915
29916
29999
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
SCOPE MCP JNT;RDUC ULNAR COLLAT LIG
SUBTALAR ARTHRO W/FB RMVL
SUBTALAR ARTHRO W/EXC
SUBTALAR ARTHRO W/DEB
SUBTALAR ARTHRO W/FUSION
HIP ARTHRO W/FEMOROPLASTY
HIP ARTHRO ACETABULOPLASTY
HIP ARTHRO W/LABRAL REPAIR
UNLISTED PROCEDURE ARTHROSCOPY
No
No
No
No
No
No
No
No
Yes
Code Description
No
No
No
CPT Code
30000
July 2011
No
30020
30100
30110
30115
30117
30118
No
No
No
No
No
No
30120
30124
30125
No
No
No
30130
No
30140
30150
30160
30200
30210
30220
30300
Code Description
DRAIN ABSCESS/HEMATOMA-NASAL-INT
DRAIN ABSCESS/HEMATOMA NASAL
SEPTUM
BX INTRANASAL
EXC NASAL POLYP SIMPL
EXC NASAL POLYP EXTEN
EXC INTRANASAL LES; INT APPROACH
EXC INTRANASAL LES; EXT APPROACH
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
EXC/SURG PLANING NOSE RHINOPHYMA
EXC DERMOID CYST NOSE; SIMPL/SUBQ
EXC DERMOID CYST NOSE; COMPLX
EXC TURBINATE PART/COMPLT ANY
METHD
SMR TURBINATE PART/COMPLT ANY
METHD
RHINECTOMY; PART
RHINECTOMY; TOT
INJ INTO TURBINATE THERAP
DISPLACEMENT THERAP
INSRT NASAL SEPTAL PROSTH
REMOV FB INTRANASAL; OFFIC PROC
30310
No
REMOV FB INTRANASAL; REQ GEN ANES
No
30320
30400
No
Not Reimbursable
REMOV FB INTRANASAL; LAT RHINOTOMY
RHINOPLASTY PRIM; CARTIL/ELEV TIP
No
Not Reimbursable
30410
Not Reimbursable
RHINOPLASTY PRIM; COMPLT-EXT PARTS
Not Reimbursable
30420
30430
Not Reimbursable
Not Reimbursable
RHINOPLASTY PRIM; INCL MAJOR SEPTAL
RHINOPLASTY SECNDRY; MINOR REVIS
Not Reimbursable
Not Reimbursable
30435
30450
30460
Not Reimbursable
Not Reimbursable
Yes
RHINOPLASTY SECNDRY; INTERMED REVIS
RHINOPLASTY SECNDRY; MAJOR REVIS
RHINOPLASTY-DEFORM CLEFT LIP; TIP
Not Reimbursable
Not Reimbursable
No
30462
Yes
RHINOPLSTY-DEFORM; TIP/SEPTUM/OSTEO
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
30465
Yes
30520
30540
Yes
Yes
30545
30560
30580
30600
Yes
Yes
Yes
Yes
30620
30630
Code Description
REPR OF NASAL VESTIBULAR STENOSIS
SEPTOPLSTY/SMR W/WO
SCORING/REPLAC
REPR CHOANAL ATRESIA; INTRANASAL
No
No
No
No
No
Yes
Yes
REPR CHOANAL ATRESIA; TRANSPALATINE
LYSIS INTRANASAL SYNECHIA
REPR FISTULA; OROMAXILLARY
REPR FISTULA; ORONASAL
SEPTAL/OTHER INTRANASL
DERMATOPLSTY
REPR NASAL SEPTAL PERFORATIONS
30801
No
CAUT MUCOS TURBIN (SEP PRO); SUPERF
No
30802
30901
30903
30905
No
No
No
No
CAUT MUCOS TURBIN (SEP PRO); INTRAM
CONTRL NASAL HEMORR-ANT-SIMPL
CONTRL NASAL HEMORR-ANT-COMPLX
CONTRL NASAL HEMORR-POST; INIT
No
No
No
No
30906
30915
30920
30930
30999
31000
No
Yes
Yes
No
Yes
No
CONTRL NASAL HEMORR-POST; SUBSQT
LIG ART; ETHMO
LIG ART; INT MAXIL ART TRANSANTRAL
FX NASAL TURBINATE THERAP
UNLISTED PROC NOSE
LAVAGE BY CANNULATION; MAXIL SINUS
No
No
No
No
Yes
No
31002
31020
Yes
Yes
LAVAGE-CANNULATION; SPHENOID SINUS
SINUSOTOMY MAXIL; INTRANASAL
No
No
31030
Yes
SINUSOTMY MAXIL; RAD WO REMOV POLYP
No
31032
31040
31050
Yes
Yes
Yes
No
No
No
31051
31070
Yes
Yes
SINUSOTMY MAXIL; RAD W/REMOV POLYPS
PTERYGOMAXILLARY FOSSA SURG
SINUSOTOMY SPHENOID W/WO BX
SINUSOTMY SPHENOID W/WO MUCOS
STRIP
SINUSOTOMY FRONTAL; EXT SIMPL
No
No
No
No
No
No
CPT Code
July 2011
31075
Yes
SINUSOTOMY FRONT; TRANSORBIT UNILAT
No
31080
Yes
SINUSOTMY FRONT; OBLIT-WO FLAP-BROW
No
31081
Yes
SINUSOTOMY FRONT; WO FLAP-CORONAL
No
31084
Yes
SINUSOTOMY FRONT; OBLIT-W/FLAP-BROW
No
31085
Yes
No
31086
Yes
31087
31090
31200
31201
31205
Yes
Yes
Yes
Yes
Yes
31225
Yes
SINUSOTOMY FRONT; W/FLAP-CORONAL
SINUSOTMY FRONT; NONOBL-W/FLAPBROW
SINUSOTMY FRONT; NONBL-W/FLAPCORON
SINUSOT UNILAT 3/MORE PARANASAL
ETHMO; INTRANASAL ANT
ETHMO; INTRANASAL TOT
ETHMO; EXTRANASAL TOT
MAXILLECTOMY; WO ORBIT
EXENTERATION
31230
31231
Yes
No
MAXILLECTOMY; W/ORBIT EXENTERATION
NASAL ENDO DX UNI/BILAT (SEP PRO)
No
No
31233
31235
No
No
NASAL/SINUS ENDO DX W/MAX SINUSOSCP
NASAL/SINUS ENDO DX W/SPHENOID
No
No
31237
No
No
31238
No
31239
No
31240
No
NAS/SINUS ENDO SURG; W/BX (SEP PRO)
NASAL/SINUS ENDO SURG; CNTRL EPISTX
HEMORRHAGE
NASAL/SINUS ENDO SURG;
DACRYOCYSTOR
NASAL/SINUS ENDO SURG; CONCHA BULLO
RESECTION
31254
31255
No
No
NASAL/SINUS ENDO-OR; W/PART ETHMO
NASAL/SINUS ENDO-OR; W/TOT ETHMO
No
No
31256
No
NAS/SINUS ENDO-OR-W/MAXIL ANTROST;
No
Code Description
No
No
No
No
No
No
No
No
No
No
CPT Code
31267
31276
July 2011
No
No
31287
No
NASAL/SINUS ENDO SURG W/SPHENOIDOT
No
31288
No
NASAL ENDO W/SPHENOIDOT; REMOV TISS
No
31290
No
NASAL ENDO REPR CSF LEAK; ETHMOID
No
31291
No
NASAL ENDO REPR CSF LEAK; SPHENOID
No
31292
No
NASAL ENDO; MED/INFER ORBIT DECOMP
No
31293
No
NASAL ENDO; MED & INFER ORBIT DECOM
No
31294
31295
31296
31297
31299
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Yes
31300
31320
Yes
Yes
NASAL ENDO SURG; W/OPTIC NERV DECOM
SINUS ENDO W/BALLOON DIL
UNLISTED PROC ACCES SINUSES
LARYNGOTOMY; W/REMOV
TUMOR/CORDECT
LARYNGOTOMY; DX
31360
31365
31367
31368
31370
Yes
Yes
Yes
Yes
Yes
LARYNGECT; TOT WO RAD NECK DISSECT
LARYNGECT; TOT W/RAD NECK DISSECT
LARYNGECTOMY; SUBTL WO RAD NECK
LARYNGECTOMY; SUBTL W/RAD NECK
PART LARYNGECTOMY; HORIZONTAL
No
No
No
No
No
31375
Yes
PART LARYNGECTOMY; LATEROVERTICAL
No
31380
Yes
PART LARYNGECTOMY; ANTEROVERTICAL
No
31382
Yes
No
31390
Yes
31395
Yes
PART LARYNGEC; ANTERO-LAT-VERTICAL
PHARYNGOLARYNGEC W/RAD NEC; WO
RECN
PHARYNGOLARYNGEC W/RAD NEC;
W/RECON
Code Description
NAS/SINUS ENDO; W/TISS REMOV MAXIL
NAS/SINUS ENDO-OR-W/FRONT EXPLOR
No
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Yes
No
No
No
No
CPT Code
31400
31420
July 2011
Yes
Yes
31500
No
INTUBATION ENDOTRACHEAL EMER PROC
No
31502
No
TRACHEOT TUBE CHANGE BEFOR FISTULA
No
31505
31510
No
No
LARYNGOSCOPY INDIREC; DX (SEP PROC)
LARYNGOSCOPY INDIRECT; W/BX
No
No
31511
No
LARYNGOSCOPY INDIRECT; W/REMOV FB
No
31512
No
LARYNGOSCOPY INDIRECT; W/REMOV LES
No
31513
No
No
31515
No
LARYNGOSCOP INDIR; W/VOCAL CRD INJ
LARYNGOSCP DIR W/WO TRACHEO;
ASPIRA
31520
31525
31526
No
No
No
No
No
No
31527
31528
31529
No
No
No
LARYNGOSCP DIR W/WO TRACHEO; DX NB
LARYNGOSCOPY DIRECT; DX EX NB
LARYNGOSCOPY DIR; DX W/OR MICRO
LARYNGOSCOPY DIR; W/INSRT
OBTURATOR
LARYNGOSCOPY DIR W/DILAT INIT
LARYNGOSCP DIR; W/DILAT SUBSQT
31530
No
LARYNGOSCOPY DIRECT OR W/FB REMOV
No
31531
31535
No
No
LARYNGOSCP DIR W/FB REMOV; W/MICRO
LARYNGOSCOPY DIRECT OR W/BX
No
No
31536
31540
No
No
No
No
31541
No
31545
No
31546
No
LARYNGOSCPY DIRECT OR W/BX; W/MICRO
LARYNGOSCOPY DIR OR W/EXC TUMOR
LARYNGOSCP DIR W/EXC TUMOR;
W/MICRO
LARYN OP MIC REMV LES VC; RECNSTR
W/LOC TISS FLP
LARYN OP MIC REMV LES VOCAL CORD;
RECNSTR W/GFT
Code Description
ARYTENOIDECTOMY EXT APPROACH
EPIGLOTTIDECTOMY
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
31560
No
31561
No
31570
31571
31575
No
No
No
Code Description
LARYNGOSCPY DIR OR
W/ARYTENOIDECTMY
LARYNGOSCP W/ARYTENOIDEC; W/OR
MICR
LARYNGOSCOPY DIR W/INJ CORDS
THERAP
LARYNGOSCP W/INJ CORDS; W/MICRO
LARYNGOSCOPY FLEX FIBEROPTIC; DX
31576
No
LARYNGOSCOPY FLEX FIBEROPTIC; W/BX
No
31577
No
LARYNGOSCPY FIBEROPTIC; W/REMOV FB
No
31578
No
No
31579
No
LARYNGOSCPY FIBEROPTIC; W/REMOV LES
LARYNGOSCOPY-FLEX/RIGID
W/STROBOSCP
31580
31582
Yes
Yes
LARYNGOPLASTY; W/KEEL INSRT & REMOV
LARYNGOPLASTY; STENOSIS W/GFT
No
No
31584
31587
31588
Yes
Yes
Yes
No
No
No
31590
Yes
LARYNGOPLASTY; W/OPEN REDUCTION FX
LARYNGOPLASTY CRICOID SPLIT
LARYNGOPLASTY NOS
LARYNGEAL REINNERV-NEUROMUSCL
PEDIC
31595
31599
Yes
Yes
SECT RECUR LARYNGEAL NERV (SEP PRO)
UNLISTED PROC LARYNX
No
Yes
31600
Yes
TRACHEOSTOMY PLANNED (SEPART PROC)
No
31601
Yes
No
31603
No
31605
Yes
TRACH PLANNED (SEPART PROC); < 2 YR
TRACHEOSTOMY EMER PROC;
TRANSTRACH
TRACH EMER PROC; CRICOTHYROID
MEMBR
31610
Yes
TRACH FENESTRATION PROC W/SKIN FLAP
No
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
31611
Yes
CONSTRUCT TRACHEOESOPHAG FISTULA
No
31612
No
TRACH PUNCT-PERC-W/TRNSTRAC ASP/INJ
No
31613
Yes
TRACHEOSTOMA REVIS; SIMPL WO FLAP
No
31614
Yes
No
31615
No
31620
No
31622
No
31623
No
31624
No
TRACHEOSTOMA REVIS; COMPLX W/FLAP
TRACHEOBRONCHOSCOPY THRU TRACH
INCS
ENDOBRONCHIAL US DUR BRONCHOSCOP
DX/TX INTERVEN
BRONCHOSCOPY; DX W/WO CELL WASH
SEP PROC
BRONCHOSCPY W/WO FLOURO;
W/BRUSH/PROTECTED BRUSH
BRNCHSCPY W/WO FLOURO; W/BRONCHAL
ALVEOLR LAVAGE
31625
31626
31627
No
No
Yes
31628
No
31629
No
31630
No
31631
No
31632
No
31633
31634
No
Yes
31635
No
Code Description
BRONCHOSCOPY;
BRONCHIAL/ENDOBRNCHL BX 1/MX SITES
BRONCHOSCOPY W/MARKERS
NAVIGATIONAL BRONCHOSCOPY
BRNCHSCPY W/WO FLUORO; TRANSBRNCH
LUNG BX 1 LOBE
BRNCHSCPY;TRANSBRNCH NABX TRACH
STEM&/LOBR BRNCH
BRNCHSCPY; W/TRACHEAL/BRONCH
DILAT/CLOS RDUC FX
BRONCHOSCOPY RIGD/FLEX; W/PLCMT
TRACHEAL STENT
BRNCHSCPY W/WO FLUORO GUID; W/TBLB
EA ADD LOBE
BRNCHSCPY W/WO FLUORO GUID; TBNA
BX EA ADD LOBE
BRONCH W/BALLOON OCCLUSION
BRONCHOSCOPY W/WO FLOURO; W/REMV
OF FOREIGN BODY
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
31636
No
31637
No
31638
No
31640
31641
No
No
31643
31645
No
No
31646
No
31656
31715
31717
No
No
No
Code Description
BRNCHSCPY RIGD/FLX;PLCMT BRNCH
STNT INIT BRNCHUS
BRNCHSCPY RIGD/FLX; EA ADD MAJ
BRONCHUS STNTED
BRNCHSCPY; REV TRACH/BRNCH STNT
INSRT PREV SESS
BRONCHOSCOPY W/WO FLOURO; WITH
EXCISION OF TUMOR
BRONCHOSCOPY; W/DESTRUC TUMOR
BRONCHOSCP; W/PLCMT CATH RAD
APPLIC
BRONCHOSCOPY; W/THERAP ASPIR-INIT
BRONCHOSCOPY; W/THERAP ASPIRSUBSEQ
BRONCHOSCOPY; W/ INJ CMBRONCHGRPH
TRANSTRACHEAL INJ BRONCHOGRAPHY
CATH W/BRONCHIAL BRUSH BX
31720
No
CATH ASPIRA (SEP PRO); NASOTRACHEAL
No
31725
31730
31750
No
No
Yes
No
No
No
31755
31760
31766
31770
31775
31780
Yes
Yes
Yes
Yes
Yes
Yes
CATH ASPIRAT (SEP PRO);TRACHEOBRONC
TRANSTRACH INTRO TUBE-O2 THERAP
TRACHEOPLASTY; CERV
TRACHEOPLASTY; TRACHEOPHARY
FISTULA
TRACHEOPLASTY; INTRATHORACIC
CARINAL RECON
BRONCHOPLASTY; GFT REPR
BRONCHOPLASTY; EXC STENOSIS
EXC TRACHEAL STENOSIS; CERV
31781
Yes
EXC TRACH STENOSIS; CERVICOTHORACIC
No
31785
Yes
EXC TRACHEAL TUMOR/CARCINOMA; CERV
No
31786
Yes
EXC TRACHEAL TUMOR/CARCIN; THORACIC
No
31800
Yes
SUTURE TRACHEAL WOUND/INJURY; CERV
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
31805
Yes
SUTURE TRACH WOUND; INTRATHORACIC
No
31820
31825
31830
31899
Yes
Yes
Yes
Yes
No
No
No
Yes
32035
Yes
32036
32095
Yes
Yes
SURG CLO TRACH/FISTULA; WO PLASTIC
SURG CLO TRACH/FISTULA; W/PLASTIC
REVIS TRACHEOSTOMY SCAR
UNLISTED PROC TRACHEA BRONCHI
THORACOSTOMY; W/RIB RESECT
EMPYEMA
THORACOSTMY; W/OPEN FLAP-DRAIN
EMPY
THORACOTOMY LTD BX LUNG/PLEURA
32100
Yes
No
32110
Yes
THORACOTOMY MAJOR; W/EXPLOR & BX
THORACOTOMY MAJOR; W/CONTRL
HEMORR
No
32120
Yes
THORACOTOMY MAJOR; POSTOP COMPLIC
No
32124
32140
Yes
Yes
THORACOTOMY MAJ; W/PNEUMONOLYSIS
THORACOTOMY MAJ; W/CYST REMOV
No
No
32141
Yes
No
32150
Yes
32151
Yes
32160
Yes
32200
Yes
32201
Yes
THORACOTOMY MAJ; W/EXC-PLICAT BULLA
THORACOTOMY MAJ; REMOV INTRAPLEU
FB
THORACOTOMY MAJ; REMOV INTRAPULM
FB
THORACOTOMY MAJ; W/CARDIAC
MASSAGE
PNEUMONOSTOMY W/OPEN DRAIN
ABSCESS
PNEUMONOSTOMY; W/PERCUT DRAIN
ABSC
32215
32220
32225
Yes
Yes
Yes
PLEURAL SCARIFICATION REPEAT PNEUMO
DECORTIC PULM (SEPART PROC); TOT
DECORTIC PULM (SEPART PROC); PART
No
No
No
32310
Yes
PLEURECTOMY, PARIETAL (SEPART PROC)
No
Code Description
No
No
No
No
No
No
No
No
CPT Code
32320
32400
32402
July 2011
Yes
No
No
32405
No
32420
32421
32422
32440
No
No
No
Yes
32442
32445
Code Description
DECORTIC & PARIETAL PLEURECTOMY
BX PLEURA; PERCUT NEEDLE
BX PLEURA; OPEN
No
No
No
No
Yes
Yes
BX LUNG/MEDIASTINUM PERCUT NEEDLE
PNEUMONOCENTESIS-PUNCT LUNG
ASPIRAT
THORACENTESIS FOR ASPIRATION
THORACENTESIS W/TUBE INSERT
REMOV LUNG TOT PNEUMONECTOMY
REMOV LUNG; W/RESECT TRACH
W/ANASTM
REMOV LUNG; EXTRAPLEURAL
32480
Yes
REMOV LUNG NOT TOT PNEUMON; 1 LOBE
No
32482
Yes
REMOV LUNG OTHER THAN TOT; 2 LOBES
No
32484
Yes
No
32486
Yes
32488
Yes
REMOV LUNG OTHER THAN TOT; 1 SEGMT
REMOV LUNG NOT TOT; W/CIRCUM
RESECT
REMOV LUNG; AFTER PREV REMOVPORTIN
32491
Yes
REMOV LUNG NOT TOT; LUNG VOL REDUC
No
32500
Yes
REMOV LUNG NOT TOT; WEDG RESEC 1/MX
No
32501
Yes
No
32503
Yes
32504
Yes
RESECT & REPR BRONCH @ TIME LOBEC
RESCJ APICAL LNG TUM W/O CH WALL
RCNSTJ
RESCJ APICAL LNG TUM W/CH WALL
RCNSTJ
32540
32550
32551
32552
32553
Yes
No
No
No
No
EXTRAPLEURAL ENUCLEATION EMPYEMA
INSERT PLEURAL CATH
INSERTION OF CHEST TUBE
REMOVE LUNG CATHETER
INS MARK THOR FOR RT PERQ
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
32560
32561
32562
July 2011
No
No
No
32601
Yes
Code Description
TREAT LUNG LINING CHEMICALLY
LYSE CHEST FIBRIN INIT DAY
LYSE CHEST FIBRIN SUBQ DAY
THORACOSCPY DX; LUNGS/PLEURAL WO
BX
32602
Yes
THORACOSCPY DX; LUNGS/PLEURAL W/BX
No
32603
Yes
THORACOSCPY DX; PERICARD SAC WO BX
No
32604
Yes
THORACOSCPY DX; PERICARD SAC W/BX
No
32605
32606
Yes
Yes
THORACOSCPY DX; MEDIASTINAL WO BX
THORACOSCPY DX; MEDIASTINAL W/BX
No
No
32650
Yes
No
32651
Yes
32652
32653
Yes
Yes
32654
Yes
THORACOSCOPY SURG; W/PLEURODESIS
THORACOSCPY SURG; W/PART PULM
DECOR
THORACOSCPY SURG; W/TOT PULM
DECORT
THORACOSCPY SURG; W/REMOV FB
THORACOSCPY SURG; CONTRL TRAUM
HEMO
32655
Yes
No
32656
Yes
32657
Yes
THORACOSCPY SURG; W/EXC-PLICAT BULL
THORACOSCPY SURG; W/PARIETL
PLEUREC
THORACOSCPY SURG; WEDGE RESECT
1/MX
32658
Yes
No
32659
Yes
32660
Yes
32661
Yes
32662
Yes
THORACOSCPY SURG; REMOV FB-PERICAR
THORACOSCPY SURG; CREAT PERICAR
WIN
THORACOSCPY SURG; W/TOT
PERICARDECT
THORACOSCPY SURG; EXC PERICARD
CYST
THORACOSCPY SURG; EXC MEDIASTN
CYST
No
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
32663
Yes
32664
Yes
32665
32800
Yes
Yes
32810
32815
32820
Yes
Yes
Yes
32850
32851
32852
32853
32854
Yes
Yes
Yes
Yes
Yes
32856
Yes
32900
Yes
32905
Yes
32906
Code Description
THORACOSCPY SURG; W/LOBEC
TOT/SEGMT
THORACOSCPY SURG; THORAC
SYMPATHECT
THORACOSCPY SURG;
W/ESOPHAGOMYOTOMY
REPR LUNG HERNIA THRU CHEST WALL
CLO CHEST WALL FOLLOWING OPEN FLAP
OPEN CLO MAJOR BRONCHIAL FISTULA
MAJOR RECON CHEST WALL
DONOR PNEUMONECTOMY FROM
CADAVER DONOR
LUNG TRANSPL SNGL; WO CP BYPASS
LUNG TRANSPL SNGL; W/CP BYPASS
LUNG TRANSPL DBL; WO CP BYPASS
LUNG TRANSPL DBL; W/CP BYPASS
BACKBENCH STD PREP CADVR DONR LUNG
ALLOGFT; BIL
No
No
No
No
No
No
No
Yes
No
No
No
No
Yes
No
Yes
RESECT RIBS EXTRAPLEURAL ALL STAGES
THORACOPLSTY SCHEDE
TYPE/EXTRAPLEUR
THORACOPLSTY; W/CLO BRONCHOPLE
FIST
32940
Yes
PNEUMOLYSIS EXTRAPERIOSTEAL W/FILL
No
32960
32997
32998
32999
33010
33011
33015
33020
Yes
Yes
Not Reimbursable
Yes
Yes
Yes
Yes
Yes
No
No
Not Reimbursable
Yes
No
No
No
No
33025
Yes
PNEUMOT THERAP-INTRAPLEURAL INJ AIR
TOT LUNG LAVAGE (UNILAT)
PERQ RF ABLATE TX, PUL TUMOR
UNLISTED PROC LUNGS & PLEURA
PERICARDIOCENTESIS; INIT
PERICARDIOCENTESIS; SUBSQT
TUBE PERICARDIOSTOMY
PERICARDIOTOMY REMOV CLOT/FB
CREAT PERICARDIAL WINDOW/PART
RESEC
No
No
No
CPT Code
July 2011
33030
Yes
PERICARDIECTOMY SUBTL WO CP BYPASS
No
33031
33050
Yes
Yes
PERICARDIECTOMY SUBTL; W/CP BYPASS
EXC PERICARDIAL CYST/TUMOR
No
No
33120
33130
Yes
Yes
No
No
33140
Not Reimbursable
33141
33202
33203
Not Reimbursable
Yes
Yes
EXC INTRACARDIAC TUMOR W/CP BYPASS
RESECT EXT CARDIAC TUMOR
TRANSMYOCARD LASER REVAS (SEP
PROC)
TRANSMYOCARD PERF AT THE SAME TIME
W/OTHER CARD PROC
INSERT EPICARD ELTRD, OPEN
INSERT EPICARD ELTRD, ENDO
33206
Yes
INSRT/REPLAC PERM PACEMAKR; ATRIAL
No
33207
Yes
INSRT/REPLAC PERM PACEMAKR; VENTRIC
No
33208
33210
Yes
Yes
INSRT/REPLAC PACEMKR; ATRIL/VENTRIC
INSRT/REPLC TEMP 1 ELECT (SEP PRO)
No
No
33211
Yes
INSRT/REPLC TEMP ELECTROD (SEP PRO)
No
33212
Yes
INSRT/REPLAC PACEMKR GEN; 1 CHMBR
No
33213
Yes
INSRT/REPLC PACEMKR GEN; DUAL CHMBR
No
33214
Yes
No
33215
No
UPGRADE IMPLNT PACEMKR SYST 1-DUAL
REPSTN PREV IMPL PACEMKR/CARDIOVRTDFIB ELEC
33216
Yes
INSRT TRNSVEN ELECTROD; 1 CHMB-PERM
No
33217
Yes
INSRT TRNSVEN ELECTROD; 2 CHMB-PERM
No
33218
Yes
REPR ELECTRODE-1 CHMBR PACER/DEFIB
No
33220
Yes
REPR ELECTRODE-2 CHMBR PACER/DEFIB
No
Code Description
Not Reimbursable
Not Reimbursable
No
No
No
CPT Code
July 2011
33222
Yes
33223
Yes
33224
Yes
33225
Yes
33226
33233
Code Description
REVIS/RELOCAT SKIN POCKETPACEMAKER
No
No
Yes
Yes
REVIS SKIN POCKET CARDIOVERT-DEFIB
INSRT PACE ELEC PREV PLCD
PACEMKR/CARDIOVRT-DFIB
INSRT PACE ELEC @TM INSRT CARDIOVRTDFIB/PACEMKR
REPSTN PREV IMPL CARDIAC VENOUS SYS
ELECTRODE
REMOV PERM PACEMAKER PULSE GEN
33234
Yes
REMOV TRANSVEN PACEMKR ELEC; 1 LEAD
No
33235
Yes
REMOV TRANSVEN PACEMKR ELEC; 2 LEAD
No
33236
Yes
REMOV EPICARD PACEMKR-THORAC; 1 LED
No
33237
Yes
No
33238
33240
Yes
Yes
33241
Yes
33243
Yes
33244
33249
Yes
Yes
33250
Yes
REMOV EPICARD PACEMKR-THORAC; DUAL
REMOV PERM TRANSVEN ELECTTHORACOT
INSRT PACING CARDIOVERT-DEFIB GEN
SUBQ REMOV CARDIOVERT-DEFIB
GENERAT
REMOV CARDIOVERT ELECTROD;
THORACOT
REMOV CARDIOVERT ELECTROD;
TRNSVEN
INSRT/REPOS LEAD-DEFIB & INSRT GEN
OR ABLAT SUPRAVENT FOCUS; WO
BYPASS
33251
33254
33255
33256
33257
33258
33259
Yes
Yes
Yes
Yes
Yes
Yes
Yes
OR ABLAT SUPRAVENT FOCUS; W/BYPASS
ABLATE ATRIA, LMTD
ABLATE ATRIA W/O BYPASS, EXT
ABLATE ATRIA W/BYPASS, EXTEN
ABLATE ATRIA, LMTD, ADD-ON
ABLATE ATRIA, X10SV, ADD-ON
ABLATE ATRIA W/BYPASS ADD-ON
No
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
33261
33265
33266
Yes
Yes
Yes
OPER ABLAT VENT ARRHYTH FOCUS W/BP
ABLATE ATRIA W/BYPASS, ENDO
ABLATE ATRIA W/O BYPASS ENDO
No
No
Yes
33282
Yes
IMPLNT PT-ACTIV CARD EVENT RECORDER
No
33284
33300
33305
No
Yes
Yes
No
No
No
33310
Yes
33315
Yes
REMOV PT-ACTIV CARD EVENT RECORDER
REPR CARDIAC WOUND; WO BYPASS
REPR CARDIAC WOUND; W/CP BYPASS
CARDIOTOMY EXPLORATORY; WITHOUT
BYPASS
CARDIOTOMY EXPLORATORY;
W/CARDIOPULMONARY BYPASS
33320
Yes
SUT REPR AOR/GRT VESS; WO SHNT/BYPS
No
33321
33322
Yes
Yes
SUTURE REPR AOR/GRT VESS; W/SHUNT
SUTURE REPR AORTA; W/CP BYPASS
No
No
33330
33332
33335
Yes
Yes
Yes
INSRT GFT AO/GRT VESS; WO SHNT/BYPS
INSRT GFT AORTA/GRT VESS; W/SHUNT
INSRT GFT AORTA; W/CP BYPASS
No
No
No
33400
Yes
VALVPLSTY AORTIC; OPEN W/CP BYPASS
No
33401
Yes
VALVPLSTY AORTIC VALV; OPEN W/OCCL
No
33403
Yes
VALVULOPLSTY AORTIC; W/DILAT-CP BYP
No
33404
Yes
CONSTRUCTION APICAL-AORTIC CONDUIT
No
33405
Yes
REPLC AORT VALVE W/BYPASS; W/PROSTH
No
33406
Yes
REPLC AORTC VALV W/CP BYP; W/HOMOGF
No
33410
Yes
REPLCMT AORTIC VALVE; W/TISS VALVE
No
33411
Yes
REPLAC AORTIC VALV; W/AORT ANNULUS
No
Code Description
No
No
CPT Code
July 2011
33412
Yes
REPLAC AORTIC VALV; W/TRANSVEN AORT
No
33413
Yes
REPLC AORTC VALV; TRNSLOC PULM VALV
No
33414
Yes
REPR LT VENT OUTFLO OBSTRUC-PATCH
No
33415
Yes
No
33416
Yes
33417
33420
Yes
Yes
RESECT/INCS SUBVALVULAR TISS-STENOS
VENTRICULOMYOTOMY-IDIOPATHIC
STENOS
AORTOPLASTY SUPRAVALVULAR
STENOSIS
VALVOTOMY MITRAL VALV; CLO HEART
33422
33425
33426
Yes
Yes
Yes
VALVOT MITRAL; OPEN HEART W/BYPASS
VALVULOPLASTY-MITRAL W/CP BYPASS
VALVULOPL-MITRAL W/BYPASS; W/RING
No
No
No
33427
33430
Yes
Yes
VALVULOPL-MITRAL W/BYPAS; RAD RECON
REPLAC MITRAL VALV W/CP BYPASS
No
No
33460
Yes
VALVECTOMY TRICUSPID; W/CP BYPASS
No
33463
Yes
VALVULOPLSTY TRICUSPD; WO RING INSR
No
33464
Yes
VALCULOPLSTY TRICUSPD; W/RING INSRT
No
33465
Yes
REPLAC TRICUSPID VALV W/CP BYPASS
No
33468
Yes
No
33470
Yes
TRICUSP VALV REPOSIT-EBSTEIN ANOMLY
VALVOTOMY PULM CLO HRT;
TRNSVENTRIC
33471
Yes
VALVOTMY PULM CLO HRT; VIA PULM ART
No
33472
Yes
VALVOT PULM OPEN HRT; W/INFLO OCCLU
No
33474
33475
Yes
Yes
VALVOTMY PULM OPEN HRT; W/CP BYPASS
REPLAC PULM VALV
No
No
Code Description
No
No
No
No
CPT Code
July 2011
33476
Yes
33478
Code Description
No
Yes
RT VENTRIC RESECT-INFUNDIB STENOSIS
OUTFLOW TRACT AUGMEN W/WO
COMMISSUR
33496
Yes
REPR PROSTH VALV DYSFUNC W/CPB (SP)
No
33500
Yes
REPR CORON AV FISTULA; W/CP BYPASS
No
33501
Yes
REPR CORON AV FISTULA; WO CP BYPASS
No
33502
Yes
REPR ANOMALOUS CORONARY ART; LIG
No
33503
Yes
ANOMALOUS CORON ART; GFT WO BYPASS
No
33504
Yes
ANOMALOUS CORON ART; GFT W/BYPASS
No
33505
Yes
REPR CORON ART; CONSTRUC PULM ART
No
33506
Yes
No
33507
Yes
33508
33510
33511
33512
33513
33514
33516
33517
33518
33519
33521
33522
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
REPR CORON ART; TRNSLOC PULM-AORTA
RPR ANOM AORTIC ORIGIN C ART
UNROOFING/TLCJ
ENDO SURG W/VIDEO-ASSTD HARV VEINS
COR ART BYPS
CAB-VEIN ONLY; 1 CORON VENOUS GFT
CAB-VEIN ONLY; 6/MORE VENOUS GFT
CAB W/VENOUS & ART GFT; 1 VEIN GFT
33523
33530
33533
Yes
Yes
Yes
CAB W/VENOUS & ART GFT; 6/MORE GFT
REOPERAT CAB > 1 MO AFTER ORIG OR
CAB USING ART GFT; 1 ART GFT
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
33534
33535
July 2011
Yes
Yes
33536
33542
Yes
Yes
CAB W/ART GFT; 4/MORE CORON ART GFT
MYOCARDIAL RESECT
No
No
33545
Yes
No
33548
Not Reimbursable
33572
Yes
REPR POSTINFARCT VENT SEPTAL DEFECT
SURG VENTR RSTRJ PX W/PROSTC PATCH
PFRMD
CORON ENDARTERECT PERFMD W/CABGEA
33600
33602
33606
Yes
Yes
Yes
33608
Yes
33610
Code Description
CAB W/ART GFT; 2 CORON ART GFT
CAB W/ART GFT; 3 CORON ART GFT
No
No
Not Reimbursable
No
No
No
No
Yes
CLO ATRIOVENTRIC VALV-SUTURE/PATCH
CLO SEMILUNAR VALV-SUTURE/PATCH
ANASTOM PULM ART TO AORTA
REPR COMPLX CARD ANOMAL NOT
ATRESIA
REPR COMPLX CARD ANOMAL-ENLARG
DEFC
33611
Yes
REPR DBL OUTLET RT VENT W/TUNNL REP
No
33612
Yes
No
33615
Yes
REPR DBL OUTLET RT VENT; W/REPR OBS
REPR CARD ANOMAL-CLO DEFEC &
ANASTO
33617
Yes
REPR CARD ANOMAL-MODIF FONTAN PROC
No
33619
33620
33621
33622
Yes
Yes
Yes
Yes
REPR 1 VENT W/AORTIC OBSTRUC & ARCH
APPLY R&L PULM ART BANDS
TRANSTHOR CATH FOR STENT
REDO COMPL CARDIAC ANOMALY
No
No
No
No
33641
33645
33647
Yes
Yes
Yes
REPR ATRIAL SEPTAL DEFECT W/BYPASS
DIRECT/PATCH CLO-SINUS VENOSUS
REPR ATRIAL & VENT SEPTAL DEFECT
No
No
No
33660
Yes
REPR INCOMPL/PART ATRIOVENT CANAL
No
No
No
No
CPT Code
July 2011
33665
33670
33675
33676
33677
Yes
Yes
Yes
Yes
Yes
REPR INTERM/TRNSIT ATRIOVENT CANAL
REPR COMPLT ATRIOVENT CANAL
CLOSE MULT VSD
CLOSE MULT VSD W/RESECTION
CL MULT VSD W/REM PUL BAND
No
No
No
No
No
33681
Yes
CLO VENT SEPTAL DEFECT W/WO PATCH;
No
33684
Yes
CLO VSD W/WO PATCH; W/PULM VALVOT
No
33688
33690
Yes
Yes
No
No
33692
33694
33697
33702
Yes
Yes
Yes
Yes
CLO VSD W/WO PATCH; W/REMOV PA BAND
BANDING PULM ART
COMPLT REPR TETRALOGY WO PULM
ATRES
COMPLT REPR TETRALOGY; W/PATCH
COMPLT REPR TETRALOGY FALLOT
REPR SINUS VALSALVA FIST W/BYPASS
33710
Yes
REPR FISTULA W/BYPASS; W/REPR SEPTL
No
33720
33722
33724
33726
Yes
Yes
Yes
Yes
No
No
No
No
33730
Yes
REPR SINUS VALSALVA ANEURY W/BYPASS
CLO AORTICO-LT VENTRICULAR TUNNEL
REPAIR VENOUS ANOMALY
REPAIR PUL VENOUS STENOSIS
COMPLT REPR ANOMALOUS VENOUS
RETURN
33732
33735
Yes
Yes
REPR COR TRIATRIATUM/SUPRAVALV RING
ATRIAL SEPTECT/SEPTOST; CLO HEART
No
No
33736
Yes
ATRIAL SEPTEC/SEPTOS; OPEN HRT W/CP
No
33737
33750
33755
33762
33764
33766
Yes
Yes
Yes
Yes
Yes
Yes
ATRIAL SEPTEC/SEPTOS; OPEN HRT W/OC
SHUNT; SUBCLAVIAN PULM ART
SHUNT; ASCENDING AORTA PULM ART
SHUNT; DESCENDING AORTA PULM ART
SHUNT; CENTRAL W/PROSTH GFT
SHUNT; SUPER VENA CAVA-PULM ART 1
No
No
No
No
No
No
Code Description
No
No
No
No
No
CPT Code
July 2011
33767
33768
Yes
Yes
SHUNT; SUPER VENA CAVA-PULM ART FLO
ANAST CAVOPULM 2ND SUPRIOR V/C
No
No
33770
Yes
REPR TRNSPOSIT GRT ART; WO SURG ENL
No
33771
Yes
REPR TRNSPOSIT GRT ART; W/SURG ENLG
No
33774
Yes
REPR TRANSPOSIT GR ART W/CP BYPASS
No
33775
Yes
REPR TRANSPOSIT GR ART; W/REMOV BND
No
33776
Yes
REPR TRANSPOSIT; W/CLO SEPTAL DEFEC
No
33777
Yes
REPR TRANSPOSIT; W/REPR SUBPLUM OBS
No
33778
Yes
REPR TRANSPOSIT-AORTIC PULM RECON
No
33779
Yes
REPR TRANSPOSIT-AORTIC; W/REMOV BND
No
33780
Yes
REPR TRANSPOSIT-AORTIC; W/CLO DEFEC
No
33781
33782
33783
33786
Yes
Yes
Yes
Yes
REPR TRANSPOSIT AORTIC; W/REPR OBST
NIKAIDOH PROC
NIKAIDOH PROC W/OSTIA IMPLT
TOT REPR TRUNCUS ARTERIOSUS
No
No
No
No
33788
Yes
REIMPLANTATION ANOMALOUS PULM ART
No
33800
33802
Yes
Yes
AORTIC SUSP-TRACH DECOMP (SEP PRO)
DIVISION ABERRANT VESSEL
No
No
33803
Yes
DIVISION ABERRANT VESS; W/REANASTOM
No
33813
Yes
OBLIT AORTOPULM DEFEC; WO CP BYPASS
No
33814
Yes
OBLIT AORTOPULM DEFECT; W/CP BYPASS
No
33820
Yes
REPR PATENT DUCTUS ARTERIOSUS; LIG
No
Code Description
CPT Code
33822
July 2011
Yes
33824
Yes
33840
33845
Code Description
REPR PATENT DUCT ART; DIVIS < 18 YR
No
Yes
Yes
REPR PATENT DUCT ART; DIVIS 18&OLDR
EXC COARCTAT AORTA; W/DIREC
ANASTOM
EXC COARCTATION AORTA; W/GFT
No
No
33851
Yes
EXC COARCTAT AORTA; REPR W/LT SUBCL
No
33852
Yes
REPR HYPOPLST/INTER ARCH; WO CP BYP
No
33853
Yes
No
33860
Yes
33863
33864
33870
Yes
Yes
Yes
33875
Yes
33877
Yes
33880
Yes
33881
Yes
33883
Yes
33884
Yes
33886
Yes
33889
33891
Yes
Yes
REPR HYPOPLASTIC AORT ARCH; W/CP BP
ASCEND AORTA GFT W/BYPASS W/WO
VALV
ASCEND AORTA GFT; W/AORTC ROOT
REPL
ASCENDING AORTIC GRAFT
TRANSVERSE ARCH GFT W/CP BYPASS
DESCEND THORAC AORTA GFT W/WO
BYPAS
REPR THORACOABD AORTIC ANEURY
W/GFT
EVASC RPR DTA COVERAGE ART ORIGIN
1ST ENDOPROSTH
EVASC RPR DTA EXP COVERAGE W/O ART
ORIGIN
PLMT PROX XTN PROSTH EVASC RPR DTA
1ST XTN
EA PROX XTN
PLMT DSTL XTN PROSTH DLYD AFTER
EVASC RPR DTA
OPN SUBCLA CRTD ART TRPOS NCK INC
ULAT
BYP GRF W/DTA RPR NCK INC
33910
Yes
PULM ART EMBOLECTOMY; W/CP BYPASS
No
33915
Yes
PULM ART EMBOLECTOMY; WO CP BYPASS
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
33916
Yes
PULM ENDARTERECTOMY W/CP BYPASS
No
33917
Yes
No
33920
33922
Yes
Yes
REPR PULM ART STENOS-RECON W/PATCH
REPR PULM ATRESIA-CONSTRUCT
CONDUIT
TRANSECT PULM ART W/CP BYPASS
33924
Yes
No
33925
Yes
33926
Yes
LIG & TAKEDOWN SYST-PULM ART SHUNT
RPR P-ART ARBORIZJ ANOMAL UNIFCLIZJ
W/O CARD BYP
RPR P-ART ARBORIZJ ANOMAL UNIFCLIZJ
W/CARD BYP
33930
Yes
Yes
33933
33935
33940
Yes
Yes
Yes
33944
Yes
DONOR CARDIECTOMY-PNEUMONECTOMY
BACKBENCH STD PREP CADVER DONOR
HRT/LUNG ALLOGFT
HEART-LUNG TRANSPL W/RECIPIENT
DONOR CARDIECTOMY
HEART ALLOGFT
33945
Yes
HEART TRANSPL W/WO RECIPIN CARDIECT
No
33960
Yes
PROLONG XTRCORPOR CIRCUL; INIT 24HR
No
33961
33967
Yes
Yes
PROLONG XTRCORPOR CIRCUL; EA ADD 24
INSRT INTRA-AORTC BALLN DEVC PERQ
No
No
33968
Yes
REMOV INTRA-AO BALLOON ASST DEVICE
No
33970
Yes
INSRT INTRA-AORTIC BALLOON-FEM OPEN
No
33971
Yes
REMOV INTRA-AORTIC DEVICE-REPR FEM
No
33973
Yes
INSRT INTRA-AORT BALOON ASSIST DEVC
No
33974
33975
Yes
Yes
REMOV INTRA-AORT BALOON DEVIC W/REP
IMPLNT VENTRIC DEVICE; 1 VENT SUPPT
No
No
Code Description
No
No
No
No
Yes
No
Yes
Yes
CPT Code
July 2011
33976
Yes
IMPLNT VENTRIC DEVICE; BIVENT SUPPT
No
33977
Yes
REMOV VENT DEVICE; 1 VENTRIC SUPPRT
No
33978
33979
33980
33981
33982
33983
33999
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
Yes
34001
Yes
REMOV VENT DEVICE; BIVENTRIC SUPPRT
INSRT VENT DEVC IMPL INTRACORP 1
REMV VENT DEVC IMPL INTRACORP 1
REPLACE VAD PUMP EXT
REPLACE VAD INTRA W/O BP
REPLACE VAD INTRA W/BP
UNLISTED PROC CARDIAC SURG
EMBOLECT/THROMBEC; CAROTID ARTNECK
34051
34101
34111
34151
34201
Yes
Yes
Yes
Yes
Yes
EMBOLECT; INNOMINATE THORACIC INCS
EMBOLECT; AXILRY ART-ARM INCS
EMBOLECT; RADIAL ART BY ARM INCS
EMBOLECT; RENAL ART BY ABD INCS
EMBOLECT; FEMPOP ART BY LEG INCS
No
No
No
No
No
34203
34401
34421
Yes
Yes
Yes
EMBOLECT; POP-TIBIOPER ART LEG INCS
THROMBEC; VENA CAVA BY ABD INCS
THROMBEC; VENA CAVA BY LEG INCS
No
No
No
34451
34471
Yes
Yes
THROMBEC; VENA CAVA ABD & LEG INCS
THROMBEC; SUBCLAV VEIN NECK INCS
No
No
34490
34501
34502
Yes
Yes
Yes
THROMBEC; AX & SUBCLAV BY ARM INCS
VALVULOPLASTY FEMORAL VEIN
RECON VENA CAVA ANY METHD
No
No
No
34510
Yes
VENOUS VALV TRNSPOSIT ANY VEIN DONR
No
34520
34530
Yes
Yes
No
No
34800
Yes
CROSS-OVER VEIN GFT TO VENOUS SYST
SAPHENOPOPLITEAL VEIN ANASTOM
ENDOVSCLR REPR OF INFRARENAL ABD
AORTIC ANEUR OR DISSECT
Code Description
No
No
CPT Code
July 2011
34802
Yes
34803
Yes
34804
Yes
34805
34806
Yes
Yes
34808
Yes
34812
Yes
34813
Yes
34820
Yes
34825
Yes
34826
Yes
34830
34831
34832
Yes
Yes
Yes
34833
Yes
34834
Yes
34900
35001
Yes
Yes
Code Description
ENDOVSCLR REPR USING MODULAR
BIFURCATED PROSTH
ENDOVASC REPR AAA; BIFURCAT PROS 2
DOCK LIMBS
ENDOVSCLR REPR USING UNIBODY
BIFURCATED PROSTH
ENDOVASC REP AAA; USE AORTOUNIILIAC/UNIFEM PROS
ANEURYSM PRESS SENSOR ADD-ON
ENDOVSCLR PLACEMNT OF ILIAC ARTERY
OCCLU DEVICE
OPEN FEMORAL ARTERY EXPOSR FOR
DELIV OF AORTIC ENDOV PROSTH
PLACEMNT FEMORAL PROSTH GRAFT
DURING ENDOVSCLR REPR
OPEN ILIAC ARTERY EXPOSR FOR DEL OF
ENDOVSCLR PROSTH
PLACEMNT PROXIMAL/DISTAL EXT FOR
PROSTH ENDOVSCLR REPR
PLACEMNT PROXIMAL/DISTAL EXT-EA ADD
VESSEL
OPEN REPR OF INFRARENAL AORTIC
ANERY OR DISSECT, PLUS REPR
AORTO-BI-ILIAC PROSTHESIS
AORTO-BIFEMORAL PROSTHESIS
OPN ILIAC ART EXPS CONDUIT DEL
ENDOVSC PROS UNI
OPN BRACH ART EXPS ASST DEPLOY
ENDOVASC PROS UNI
ENDOVASCULAR GRAFT PLCMT REPAIR
ILIAC ARTERY
DIREC REPR ANEUR; CAROTID/SUBCLAV
35002
35005
Yes
Yes
DIREC REPR; RUPTD ANEURY-NECK INCS
DIREC REPR; ANEURY VERTEBRAL ART
No
No
35011
35013
Yes
Yes
DIREC REPR; ANEURY AX-BRACH-ARM INC
DIREC REPR; RUTP ANEURY AX-BRACH
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
35021
35022
Yes
Yes
DIR REPR; ANEUR INNOM/SUBCLAV-THORA
DIREC REPR; RUPT ANEURY INNOM ART
No
No
35045
Yes
DIREC REPR; ANEURY RADIAL/ULNAR ART
No
35081
Yes
DIREC REPR; ANEURY/OCCLUD ABD AORTA
No
35082
Yes
DIREC REPR; RUPT ANUERY ABD AORTA
No
35091
Yes
DIREC REPR; ANEURY ABD AORTA W/VISC
No
35092
35102
35103
35111
Yes
Yes
Yes
Yes
DIR REPR; RUPT ANEUR ABD AORT W/VIS
DIR REPR; ANEURY ABD AORTA W/ILIAC
DIR REPR; RUPT ANEUR ABD AORT W/ILI
DIREC REPR; ANEURY SPLENIC ART
No
No
No
No
35112
35121
Yes
Yes
DIREC REPR; RUPT ANEURY SPENIC ART
DIREC REPR; ANEURY VISCERAL ARTS
No
No
35122
35131
35132
Yes
Yes
Yes
DIREC REPR; RUPT ANEURY HEPATIC ART
DIREC REPR; ANEURY ILIAC ART
DIREC REPR; RUPT ANEURY ILIAC ART
No
No
No
35141
Yes
DIREC REPR; ANEURY COMMON FEM ART
No
35142
Yes
DIREC REPR; RUPT ANEURY COMMON FEM
No
35151
35152
Yes
Yes
DIREC REPR; ANEURY/OCCLUD POP ART
DIREC REPR; RUPT ANEURY POP ART
No
No
35180
Yes
REPR CONGEN AV FISTULA; HEAD & NECK
No
35182
35184
Yes
Yes
REPR CONGEN AV FISTULA; THORX & ABD
REPR CONGEN AV FISTULA; EXTREM
No
No
35188
35189
35190
Yes
Yes
Yes
REPR ACQUIR AV FISTULA; HEAD & NECK
REPR ACQUIR AV FIST; THORAX & ABD
REPR ACQUIRED AV FISTULA; EXTREM
No
No
No
Code Description
CPT Code
35201
July 2011
Yes
35206
Yes
REPR BLD VESSEL DIRECT; UPPR EXTREM
No
35207
Yes
REPR BLD VESSEL DIRECT; HAND-FINGER
No
35211
Yes
REPR VESS DIR; INTRATHORAC W/BYPASS
No
35216
35221
Yes
Yes
REPR VESS DIR; INTRATHORAC WO BYPAS
REPR BLD VESSEL DIRECT; INTRA-ABD
No
No
35226
35231
Yes
Yes
REPR BLD VESSEL DIRECT; LOWR EXTREM
REPR BLD VESSEL W/VEIN GFT; NECK
No
No
35236
Yes
REPR BLD VESS W/VEIN GFT; UP EXTREM
No
35241
Yes
REPR VESS W/GFT; INTRATHORAC W/BYPS
No
35246
Yes
REPR VESS W/GFT; INTRATHOR WO BYPAS
No
35251
Yes
REPR BLD VESS W/VEIN GFT; INTRA-ABD
No
35256
Yes
REPR VESS W/VEIN GFT; LOWER EXTREM
No
35261
Yes
REPR BLD VESS W/GFT NOT VEIN; NECK
No
35266
Yes
REPR VESS W/GFT NOT VEIN; UP EXTREM
No
35271
Yes
REPR VESS W/GFT NOT VEIN;INTRATH W/
No
35276
Yes
REPR VESS W/GFT NOT VEIN;INTRATH WO
No
35281
Yes
REPR VESS W/GFT NOT VEIN; INTRA-ABD
No
35286
Yes
No
35301
35302
35303
Yes
Yes
Yes
REPR VESS W/GFT NOT VEIN; LOWR EXTM
THROMBOENDARTEREC; CAROTID-NECK
INC
RECHANNELING OF ARTERY
Code Description
REPR BLD VESSEL DIRECT; NECK
No
No
No
No
CPT Code
35304
35305
35306
July 2011
Yes
Yes
Yes
35311
Yes
35321
Yes
Code Description
THROMBOENDART; SUBCLAV-THORAC
INCS
THROMBOENDARTERECT; AXILRYBRACHIAL
35331
Yes
THROMBOENDARTERECTOMY; ABD AORTA
No
35341
Yes
THROMBOENDART; MESENTERIC/CELIAC
No
35351
35355
Yes
Yes
No
No
35361
Yes
35363
Yes
35371
Yes
THROMBOENDARTERECT W/WO GFT; ILIAC
THROMBOENDARTERECT; ILIOFEMORAL
THROMBOENDARTEREC; COMBO
AORTOILIAC
THROMBOENDARTER; COMBO
AORTOILIOFEM
THROMBOENDARTERECT; COMMON
FEMORAL
35372
Yes
No
35390
Yes
35400
Yes
THROMBOENDARTERECT; DEEP FEMORAL
REOPER CAROTID THROMBOENDARTER
>1MO
ANGIOSCOPY DURING THERAP
INTERVENTN
35450
Yes
No
35452
Yes
35458
Yes
35460
Yes
TRNSLM BALOON ANGIOP OPEN; RENL ART
TRNSLUMNL BALOON ANGIOPL OPEN;
AORT
TRNSLM ANGPLS-OPEN;
BRACHCEPH/BRNCH
TRNSLUM BALOON ANGIOPL OPEN;
VENOUS
35471
Yes
TRNSLUMNL ANGIOPL PERCUT; RENAL ART
No
35472
Yes
TRNSLUM BALOON ANGIO PERCUT; AORTIC
No
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
35475
Yes
35476
Yes
Code Description
TRNSLM ANGPLST-PERC;
BRACHCEP/BRNCH
TRNSLUM BALOON ANGIO PERCUT;
VENOUS
35500
35501
Yes
Yes
HARVST UP EXTREM VEIN-L-EXTREM/CABG
BYPASS GFT W/VEIN; CAROTID
No
No
35506
35508
Yes
Yes
BYPASS GFT W/VEIN; CAROTID-SUBCLAV
BYPASS GFT W/VEIN; CAROTID-VERTEB
No
No
35509
Yes
No
35510
Yes
BYPASS GFT W/VEIN; CAROTID-CAROTID
BYPASS GRAFT WITH VEIN; CAROTIDBRACHIAL
35511
Yes
No
35512
Yes
BYPASS GFT W/VEIN; SUBCLAV-SUBCLAV
BYPASS GRAFT WITH VEIN; SUBCLAVIANBRACHIAL
35515
35516
35518
35521
Yes
Yes
Yes
Yes
No
No
No
No
35522
35523
Yes
Yes
35525
Yes
BYPASS GFT W/VEIN; SUBCLAV-VERTEB
BYPASS GFT W/VEIN; SUBCLAV-AXILRY
BYPASS GFT W/VEIN; AXILRY-AXILRY
BYPASS GFT W/VEIN; AXILRY-FEMORAL
BYPASS GRAFT WITH VEIN; AXILLARYBRACHIAL
ARTERY BYPASS GRAFT
BYPASS GRAFT WITH VEIN; BRACHIALBRACHIAL
35526
35531
35533
35535
35536
35537
35538
35539
35540
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
BYPASS GFT W/VEIN; AORTOSUBCLAVIAN
BYPASS GFT W/VEIN; AORTOCELIAC
BYPASS GFT W/VEIN; AXILRY-FEM-FEM
ARTERY BYPASS GRAFT
BYPASS GFT W/VEIN; SPLENORENAL
ARTERY BYPASS GRAFT
ARTERY BYPASS GRAFT
ARTERY BYPASS GRAFT
ARTERY BYPASS GRAFT
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
35548
Yes
BYPASS GFT W/VEIN; AORTOILIOFEM UNI
No
35549
Yes
BYPASS GFT W/VEIN; AORTOILIOFEM BIL
No
35551
35556
Yes
Yes
BYPASS GFT W/VEIN; AORTOFEMORAL-POP
BYPASS GFT W/VEIN; FEMORAL-POP
No
No
35558
35560
35563
35565
35566
35570
35571
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
35572
35583
35585
35587
Yes
Yes
Yes
Yes
35600
35601
Yes
Yes
BYPASS GFT W/VEIN; FEMORAL-FEMORAL
BYPASS GFT W/VEIN; AORTORENAL
BYPASS GFT W/VEIN; ILIOILIAC
BYPASS GFT W/VEIN; ILIOFEMORAL
BYPASS GFT W/VEIN; FEM-ANT TIB/DIST
ARTERY BYPASS GRAFT
BYPASS GFT W/VEIN; POP-TIB/DISTAL
HARVEST FEMPOP VEIN 1 SEGMENT VASC
RECNSTR PROC
IN-SITU VEIN BYPASS; FEMORAL-POP
IN-SITU VEIN BYPASS; FEM-ANT TIB
IN-SITU VEIN BYPASS; POP-TIB/PERONL
HARVEST OF UPPER EXTREMITY ARTERY
FOR BYPASS PROC
BYPASS GFT NOT VEIN; CAROTID
35606
Yes
BYPASS GFT NOT VEIN; CAROTID-SUBCLA
No
35612
Yes
BYPASS GFT NOT VEIN; SUBCLAV-SUBCLA
No
35616
Yes
BYPASS GFT NOT VEIN; SUBCLAV-AXILRY
No
35621
35623
Yes
Yes
BYPASS GFT NOT VEIN; AXILRY-FEMORAL
BYPASS GFT NOT VEIN; AX-POP/-TIB
No
No
35626
35631
35632
35633
35634
35636
Yes
Yes
Yes
Yes
Yes
Yes
BYPASS GFT NOT VEIN; AORTOSUBCLAV
BYPASS GFT NOT VEIN; AORTOCELIAC
ARTERY BYPASS GRAFT
ARTERY BYPASS GRAFT
ARTERY BYPASS GRAFT
BYPASS GFT NOT VEIN; SPLENORENAL
No
No
No
No
No
No
Code Description
No
No
No
No
No
No
CPT Code
35637
35638
July 2011
Yes
Yes
35642
Yes
BYPASS GFT NOT VEIN; CAROTID-VERTEB
No
35645
Yes
BYPASS GFT NOT VEIN; SUBCLAV-VERTEB
No
35646
Yes
BYPASS GFT NOT VEIN; AORTOFEB/BIFEM
No
35647
35650
Yes
Yes
BYPS GFT W/OTH THAN VEIN; AORTOFEM
BYPASS GFT NOT VEIN; AXILRY-AXILRY
No
No
35651
Yes
BYPASS GFT NOT VEIN; AORTOFEM-POP
No
35654
35656
Yes
Yes
BYPASS GFT NOT VEIN; AXILRY-FEM-FEM
BYPASS GFT NOT VEIN; FEMORAL-POP
No
No
35661
35663
35665
35666
Yes
Yes
Yes
Yes
BYPASS GFT NOT VEIN; FEMORAL-FEMORL
BYPASS GFT NOT VEIN; ILIOILIAC
BYPASS GFT NOT VEIN; ILIOFEMORAL
BYPASS GFT NOT VEIN; FEM-ANT-TIB
No
No
No
No
35671
Yes
BYPASS GFT NOT VEIN; POP-TIB/-PERON
No
35681
Yes
BYPASS GFT; COMPOSITE PROSTH VEIN
No
35682
Yes
BYPASS GFT; AUTOG-2 SEGMT 2 LOCATNS
No
35683
Yes
BYPASS GFT; AUTOG-3/> SEGMT 2/> LOC
No
35685
Yes
PLCMT VEIN PATCH@DIST ANASTOM GFT
No
35686
Yes
CREAT DIST AV FIST DUR LW EXTRM BYP
No
35691
Yes
TRANSPOSIT/REIMPLNT; VERTEB-CAROTID
No
35693
Yes
TRANSPOSIT/REIMPLNT; VERTEB-SUBCLAV
No
35694
Yes
TRANSPOSIT/REIMPLNT; SUBCLAV-CAROTD
No
Code Description
ARTERY BYPASS GRAFT
ARTERY BYPASS GRAFT
No
No
CPT Code
July 2011
35695
Yes
35697
Code Description
No
Yes
TRANSPOSIT/REIMPLNT; CAROTID-SUBCLV
REIMPL VISCERAL ART INFRARENL AORTC
PROS EA ART
35700
Yes
REOPER FEM-POP > 1 MO AFTER ORIG OR
No
35701
Yes
EXPLOR W/WO LYSIS ART; CAROTID ART
No
35721
35741
Yes
Yes
EXPLOR W/WO LYSIS ART; FEMORAL ART
EXPLOR W/WO LYSIS ART; POP ART
No
No
35761
35800
Yes
Yes
EXPLOR W/WO LYSIS ART; OTHER VESSEL
EXPLOR POSTOP HEMORR/INFEC; NECK
No
No
35820
35840
Yes
Yes
EXPLOR POSTOP HEMORR/INFEC; CHEST
EXPLOR POSTOP HEMORR/INFEC; ABD
No
No
35860
35870
35875
Yes
Yes
Yes
EXPLOR POSTOP HEMORR/INFEC; EXTREM
REPR GFT-ENTERIC FISTULA
THROMBECTOMY ART/VENOUS GFT;
No
No
No
35876
35879
Yes
Yes
THROMBECT ART/VENOUS GFT; W/REVIS
REVIS LO EXTR ART BYPASS; W/PATCH
No
No
35881
35883
35884
35901
35903
35905
35907
36000
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
36002
36005
No
No
REVIS LO EXTR ART BYPAS; W/INTERPOS
REVISE GRAFT W/NONAUTO GRAFT
REVISE GRAFT W/VEIN
EXC INFEC GFT; NECK
EXC INFEC GFT; EXTREM
EXC INFEC GFT; THORAX
EXC INFEC GFT; ABD
INTRO NEEDLE/INTRACATHETER VEIN
INJ PROC PERQ TX EXTREM
PSEUDOANEUR
INJ PROC CONTRAST VENOGRAPHY
36010
No
INTRO CATH SUPER/INFERIOR VENA CAVA
No
No
No
No
CPT Code
July 2011
36011
No
SELECT CATH PLCMT VENOUS; 1ST ORDER
No
36012
36013
36014
36015
No
No
No
No
SELECT CATH PLCMT VENOUS; 2ND ORDER
INTRO CATH RT HEART/MAIN PULM ART
SELECT CATH PLCMT LT/RT PULM ART
SELECT CATH PLCMT SEGMT PLUM ART
No
No
No
No
36100
No
INTRO NEEDLE/INTRACATH CAROTID ART
No
36120
No
INTRO NEEDLE; RETROGRADE BRACHIAL
No
36140
36147
36148
36160
36200
No
No
No
No
No
INTRO NEEDLE/INTRACATH; EXTREM ART
ACCESS AV DIAL GRFT FOR EVAL
ACCESS AV DIAL GRFT FOR PROC
INTRO NEEDLE/AORTIC TRANSLUMBAR
INTRO CATH AORTA
No
No
No
No
No
36215
36216
36217
No
No
No
SELECT CATH PLCMT ART; EA 1ST ORDER
SELECT CATH PLCMT ART; INIT 2ND ORD
SELECT CATH PLCMT ART; INIT 3RD ORD
No
No
No
36218
36245
36246
36247
36248
36260
36261
No
No
No
No
No
No
No
SELEC CATH PLCMT ART; ADD 2ND & 3RD
SELECT CATH PLCMT ART; EA 1ST ABD
SELECT CATH PLCMT ART; INIT 2ND ABD
SELECT CATH PLCMT ART; INIT 3RD ABD
SELECT CATH PLCMT; 2ND & 3RD ABD
INSRT IMPLNT INTRA-ART INFUSN PUMP
REVIS IMPLNT INTRA-ART INFUSN PUMP
No
No
No
No
No
No
No
36262
36299
No
Yes
No
Yes
36400
No
36405
No
36406
No
REMOV IMPLNT INTRA-ART INFUSN PUMP
UNLISTED PROC VASCULAR INJ
VENIPUNCTURE UNDER AGE 3 YEARS;
FEMORAL/JUGULAR
SCALP VEIN
OTHER VEIN
Code Description
No
No
No
CPT Code
July 2011
36410
No
36415
No
36416
36420
36425
36430
36440
36450
No
No
No
No
No
No
36455
36460
36468
36469
36470
36471
No
Yes
Not reimbursable
Not reimbursable
Not reimbursable
Not reimbursable
36475
Not reimbursable
36476
Not reimbursable
36478
Not reimbursable
36479
Not reimbursable
36481
Yes
PERCUT PORTAL VEIN CATH-ANY METHD
No
36500
36510
No
No
No
No
36511
No
36512
No
36513
No
36514
No
VENOUS CATH SELECT ORGAN BLD SAMPL
CATH UMBILICAL VEIN DX/THERAP NB
THERAPEUTIC APHERESIS; FOR WHITE
BLOOD CELLS
THERAPEUTIC APHERESIS; FOR RED
BLOOD CELLS
THERAPEUTIC APHERESIS; FOR
PLATELETS
THERAPEUTIC APHERESIS; FOR PLASMA
PHERESIS
Code Description
VENIPUNCT AGE 3 YR MD SKILL-SEP PROC
NOT ROUTINE
ROUTINE VENIPUNCT/FINGER/HEEL STICK
COLLECTION OF CAPILLARY BLOOD
SPECIMAN
VENIPUNCT CUTDOWN; < 1 YR
VENIPUNCT CUTDOWN; AGE 1/OVER
TRANSFUSION BLD/BLD COMPONENTS
PUSH TRANSFUSION BLD 2 YR/UNDER
EXCHG TRANSFUSION BLD; NB
EXCHG TRNSFUSION BLD; OTHER THAN NB
TRANSFUSION INTRAUTERINE FETAL
SNGL/MX INJ SCLEROS-VEINS; LIMB
SNGL/MX INJ SCLEROS-VEINS; FACE
INJ SCLEROSING SOLUTION; SNGL VEIN
INJ SCLEROS SOLUT; MX VEINS 1 LEG
ENDOVENUS ABLAT TX INCOMPETENT VEIN
EXT RF; 1 VN
ENDOVEN ABLAT TX VEIN EXT RF; 2&>VNS
1 EXT EA
ENDOVEN ABLAT TX INCMPETNT VEIN EXT
LASR;1 VEIN
ENDOVEN ABLAT TX VEIN EXT LASR;
2&>VNS 1 EXT EA
No
No
No
No
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
No
No
CPT Code
July 2011
36515
No
36516
36522
No
No
36555
No
36556
No
36557
No
36558
No
36560
No
36561
No
36563
Yes
36565
No
36566
Yes
36568
No
36569
No
36570
No
36571
No
36575
No
36576
No
36578
No
36580
No
Code Description
TX APHERES; W/XTRACORP
IMMUOADSORPT&PLAS REINFUS
TX APHERES; W/XTRACORP
ADSORPT/FILTRAT& REINFUS
PHOTOPHERESIS EXTRACORPOREAL
INSRTION NON-TUNNLD CNTRLLY INSRT
CVC; <5 YR AGE
INSRTION NON-TUNNLD CNTRLLY INSRT
CVC; AGE 5/>
INSRT TUNNLD CNTRLLY CVC NO
SUBQPORT/PUMP; <5 YR
INSRT TUNNLD CNTRLLY CVC NO
SUBQPORT/PUMP;5 YR/>
INSRT TUNNLD CNTRLLY INSRT CVAD
SUBQ PORT; <5 YR
INSRT TUNNLD CNTRLLY INSRT CVAD
SUBQ PORT;5 YR/>
INSRT TUNNLD CNTRLLY CV ACSS DEVC
W/SUBQ PUMP
INSRT TUNNL CNTRL CVAD 2 CATH-2 SITE;
W/O PORT
INSRT TUNNL CNTRL CVAD 2 CATH VIA 2
SITE; W/PORT
INSERTION PICC W/O SUBQ PORT/PUMP; <
5 YR AGE
INSERTION PICC W/O SUBQ PORT/PUMP;
AGE 5 YR/>
INSERTION PERIPHLY INSRT CVAD W/SUBQ
PORT; <5 YR
INSERTION PERIPHLY INSRT CVAD SUBQ
PORT; 5 YR/>
REP CV ACSS CATH NO SUBQ PORT/PUMP
CNTRL/PERIPH
REP CVAD SUBQ PORT/PUMP
CNTRL/PERIPH INSRT SITE
REPL CATH ONLY CVAD SUBQ PORT/PUMP
CNTRL/PERIPH
REPL CMPL NON-TUNNLD CNTRL CVC NO
SUBQ PORT/PUMP
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
36581
No
36582
Yes
36583
Yes
36584
No
36585
Yes
36589
No
36590
36591
36592
36593
No
No
No
No
36595
No
36596
No
36597
No
36598
36600
36620
36625
No
No
No
No
36640
36660
No
No
Code Description
REPL CMPL TUNNLD CNTRLLY CVC W/O
SUBQ PORT/PUMP
REPL CMPL TUNNLD CNTRLLY INSRT CVAD
W/SUBQ PORT
REPL CMPL TUNNLD CNTRLLY INSRT CVAD
W/SUBQ PUMP
REPL CMPL PICC NO SUBQ PORT/PUMP
THRU SAME ACSS
REPL CMPL PERIPHLY INSRT CVAD W/SUBQ
PORT
REMOVAL TUNNELED CVC WITHOUT SUBQ
PORT/PUMP
REMV TUNNLD CVAD W/SUBQ PORT/PUMP
CNTRL/PERIPH
DRAW BLOOD OFF VENOUS DEVICE
COLLECT BLOOD FROM PICC
DECLOT VASCULAR DEVICE
MECH REMV PERICATH OBST MATL CV
DEVC SEP ACSS
MECH REMV INTRALUMNL OBST MATL CV
DEVC THRU LUMN
REPSTN PREVIOUSLY PLCD CVC UNDER
FLUORO GUID
CNTRST NJX RAD EVAL CTR VAD FLUOR
IMG&REPRT
ART PUNCT WITHDRAWAL BLD DX
ART CATH-SAMPL (SEP PRO); PERQ
ART CATH-SAMPL (SEP PRO); CUTDN
ART CATH PROLONG INFUS THERAP
CUTDN
CATH UMBILICAL ART-NB-DX/THERAP
36680
36800
36810
No
Yes
Yes
PLCMT NEEDLE INTRAOSSEOUS INFUSION
INSRT CANNULA (SEP PROC); VEIN-VEIN
INSRT CANNULA (SEP PROC); AV-EXT
No
No
No
36815
Yes
No
36818
Yes
INSRT CANNULA (SEP PRO); AV-REV/CLO
AV ANASTOM OPEN; UP ARM CEPHALIC
VEIN TRNSPSTN
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
36819
Yes
Code Description
AV ANASTOMOSIS; BASILIC VEIN TRNSPO
No
36820
Yes
36821
Yes
INSERTION OF CANNULA FOR
HEMODIALYSIS, OTHER PURPOSE; ARTERI
ARTERIOVENOUS ANASTOMOSIS-OP;
DIREC
36822
36823
36825
Yes
Yes
Yes
INSRT CANNULA PROLNG EXTRACORP (SP)
INSRT ART & VEN CANNULA(S)-EXTREM
CREATE AV FISTULA (SP); AUTOG GFT
No
No
No
36830
Yes
CREATE AV FISTUL (SP); NONAUTOG GFT
No
36831
36832
Yes
Yes
THROMBECT AV FIST WO REVIS-DIAL GFT
REVIS-AV FIST DIALYSIS GFT (SP)
No
No
36833
36835
Yes
Yes
No
No
36838
36860
36861
Yes
Yes
Yes
36870
37140
37145
Yes
Yes
Yes
REVIS AV FIST; W/THROMBECT-DIAL GFT
INSRT THOMAS SHUNT (SEPART PROC)
DIST REVASC&INTRVL LIG UPPER EXTREM
HD ACSS
EXT CANNULA DECLOT (SP); WO CATH
EXT CANNULA DECLOT (SP); W/CATH
THROMBECTOMY, PERCUTANEOUS,
ARTERIOVENOUS FISTULA
VENOUS ANASTOM; PORTOCAVAL
VENOUS ANASTOM; RENOPORTAL
37160
Yes
VENOUS ANASTOM; CAVAL-MESENTERIC
No
37180
Yes
VENOUS ANASTOM; SPLENORENAL PROX
No
37181
Yes
No
37182
Yes
37183
Yes
37184
No
VENOUS ANASTOM; SPLENORENAL DISTAL
INSRTION TRANSVENOUS INTRAHEP
PORTOSYS SHNT-TIPS
REV TRANSVENOUS INTRAHEP PORTOSYS
SHUNT-TIPS
PRIM PRQ TRLUML MCHNL THRMBC 1ST
VSL
No
No
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
37185
37186
37187
No
No
No
37188
37195
37200
No
No
No
37201
No
37202
37203
37204
No
No
No
37205
No
37206
37207
No
No
37208
No
37209
37210
No
Yes
37215
No
37216
37220
37221
37222
37223
37224
37225
37226
37227
37228
37229
37230
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Code Description
PRIM PRQ TRLUML MCHNL THRMBC SBSQ
VSL
SEC PRQ TRLUML THRMBC
PRQ TRLUML MCHNL THRMBC VEIN
PRQ TRLUML MCHNL THRMBC VEIN
REPEAT TX
THROMBOLYSIS CEREBRAL BY IV INFUS
TRANSCATH BX
TRANSCATH THERAP INFUSTHROMBOLYSIS
TRANSCATH THERAP INFUS-NOT
THROMBOL
TRANSCATH RETRIEVAL PERCUT-IV FB
TRANSCATH OCCLUD-PERCUT-NON CNS
TRANSCATH PLCMT INTRAVASC STENT
PERQ; INIT VES
TRANSCATH PLCMT INTRAVASC STENT
PERQ; EA ADD VES
TRANSCATH PLCMT IV STENT OPEN; INIT
TRNSCTH PLCMT IV STENT OPEN; EA ADD
EXCHG PREV PLCD ART CATH DUR
THERAP
EMBOLIZATION UTERINE FIBROID
TRNSCATH PLCMT IVASC STNT; DIST
EMBOLIC PROTECT
TRNSCATH PLCMT IVASC STNT;NO DIST
EMBOLIC PROTCT
ILIAC REVASC
ILIAC REVASC W/STENT
ILIAC REVASC ADD-ON
ILIAC REVASC W/STENT ADD-ON
FEM/POPL REVAS W/TLA
FEM/POPL REVAS W/ATHER
FEM/POPL REVASC W/STENT
FEM/POPL REVASC STNT & ATHER
TIB/PER REVASC W/TLA
TIB/PER REVASC W/ATHER
TIB/PER REVASC W/STENT
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
37231
37232
37233
37234
37235
37250
37251
July 2011
Yes
Yes
Yes
Yes
Yes
Yes
Yes
37500
Yes
37501
37565
37600
37605
Yes
Yes
Yes
Yes
Code Description
TIB/PER REVASC STENT & ATHER
TIB/PER REVASC ADD-ON
TIBPER REVASC W/ATHER ADD-ON
REVSC OPN/PRQ TIB/PERO STENT
TIB/PER REVASC STNT & ATHER
VASC US (NON-CORN) DUR DX/TX; INIT
VASC US (NON-CORN) DX/TX; EA ADD
PHLEBORRHAPHY, SUTURE OF MAJOR
VEIN, WOUND OR INJURY
UNLISTED VASCULAR ENDOSCOPY
PROCEDURE
LIG INT JUGULAR VEIN
LIG; EXT CAROTID ART
LIG; INT/COMMON CAROTID ART
37606
Yes
LIG; INT CAROTID ART W/GRADUAL OCCL
No
37607
37609
37615
37616
37617
37618
Yes
No
Yes
Yes
Yes
Yes
LIG/BANDING ANGIO ACCESS AV FISTULA
LIG/BX TEMPORAL ART
LIG MAJOR ART; NECK
LIG MAJOR ART; CHEST
LIG MAJOR ART; ABD
LIG MAJOR ART; EXTREM
No
No
No
No
No
No
37620
37650
37660
Yes
Yes
Yes
No
No
No
37700
Yes
37718
Yes
37722
37735
37760
37761
Yes
Yes
Yes
Yes
37765
Not Reimbursable
INTERRUPT PART/COMPLT-INFER VENA CA
LIG FEMORAL VEIN
LIG COMMON ILIAC VEIN
LIG LONG SAPHENOUS VEIN @
SAPHENOFE
LIG DIV&STRIPPING SHORT SAPHENOUS
VEIN
LIG DIV&STRIP LONG SAPH SAPHFEM
JUNCT KNE/BELW
LIG & STRIP LNG/SHRT SAPHEN W/EXC
LIG PERFORATORS-RADICAL W/WO GFT
LIGATE LEG VEINS OPEN
STAB PHLEBECT VARICOS VNS 1 EXT; 10-20
STAB INCI
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
No
No
Not Reimbursable
CPT Code
July 2011
37766
Not Reimbursable
37780
Yes
37785
37788
37790
37799
38100
38101
Yes
Yes
Yes
Yes
Yes
Yes
38102
Yes
38115
38120
38129
38200
Yes
Yes
Yes
No
38204
Bundled Prof/OPPS Packaged
38205
Yes
38206
No
38207
Yes
38208
Yes
38209
Yes
38210
Yes
38211
Yes
38212
38213
Yes
Yes
38214
Yes
Code Description
STAB PHLEBECT VARICOSE VNS 1 EXTREM;
> 20 INCI
LIG SHORT SAPHENOUS VEIN (SEP PRO)
LIGATION DIV &/ EXC VARICOSE VEIN
CLUSTER 1 LEG
PENILE REVASCULARIZ ART W/WO GFT
PENILE VENOUS OCCLUD PROC
UNLISTED PROC VASCULAR SURG
SPLENECTOMY; TOT (SEPART PROC)
SPLENECTOMY; PART (SEPART PROC)
SPLENECTOMY; TOT EN BLOC W/OTH
PROC
REPR RUPT SPLEEN W/WO PART
SPLENECT
LAP SURG-SPLENECTOMY
UNLISTED LAP PROC-SPLEEN
INJ PROC SPLENOPORTOGRAPHY
MGMT RECIP HEM PROGNATOR CELLS
DONR SEARCH&ACQN
BLD-DERIV HEM PROGNATR CELL HARV
TPLNT; ALLOGNIC
BLD-DERIV HEM PROGNATOR CELL HARV
TPLNT; AUTOL
TPLNT PREP HEM PROGNATOR CELLS;
CRYOPRES&STOR
TPLNT PREP HEM PROGNTR CELL; THAW
HARV W/O WASH
TPLNT PREP HEMATOPOIET PROGNTOR
CELLS; THAW-WASH
TPLNT PREP HEM PROGNTR CELL; DEPLET
HARV T-CELL
TPLNT PREP HEM PROGNTOR CELLS;
TUMR CELL DEPLET
TPLNT PREP HEMATOPOIET PROGNTOR
CELLS; RBC REMV
PLATELET DEPLETION
TPLNT PREP HEMATOPOIET PROGNTR
CELL; PLAS DEPLET
Not Reimbursable
No
No
No
No
Yes
No
No
No
No
No
Yes
No
Bundled
No
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
38215
38220
Yes
No
38221
38230
No
Yes
38240
Yes
38241
Yes
38242
Yes
Code Description
TPLNT PREP HEM PROGNATOR CELLS;
CELL CONC PLAS
BONE MARROW ASPIRATION
BONE MARROW BIOPSY NEEDLE OR
TROCAR
BONE MARROW HARVESTING TRANSPL
BONE MARROW/STEM CELL TRANSPL;
ALLO
BONE MARROW/STEM CELL TRANSPL;
AUTO
BN MARROW/BLD-DERIV STEM CELL TPLNT;
ALLOGN DONR
38300
No
DRAINAGE LYMPH NODE ABSCESS; SIMPL
No
38305
No
No
38308
No
38380
Yes
DRAINAGE LYMPH NODE ABSCESS; EXTEN
LYMPHANGIOTOMY ON LYMPHATIC
CHANNEL
SUTURE THORACIC DUCT; CERV
APPROACH
38381
Yes
SUTURE THORACIC DUCT; THORACIC APPR
No
38382
Yes
SUTURE THORACIC DUCT; ABD APPROACH
No
38500
No
BX/EXC LYMPH NODE; SUPERF (SEP PRO)
No
38505
No
BX/EXC LYMPH NODE; BY NEEDLE SUPERF
No
38510
No
BX/EXC LYMPH NODE; DEEP CERV NODE
No
38520
No
BX/EXC LYMPH NODE; DEEP CERV W/EXC
No
38525
No
BX/EXC LYMPH NODE; DEEP AXILRY NODE
No
38530
38542
No
Yes
BX LYMPH NODE; INT MAMMARY (SEP PRO
DISSECTION DEEP JUGULAR NODE
No
No
38550
Yes
EXC CYST HYGROMA AX/CERV; WO DISSEC
No
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
38555
Yes
EXC CYST HYGROMA AX/CERV; W/DISSEC
No
38562
Yes
LTD LYMPHADENECT (SEP PRO); PELVIC
No
38564
Yes
LTD LYMPHADENEC (SEP PRO); RETROPER
No
38570
Yes
LAP SURG; W/RETRO LYMPH NODE SAMP
No
38571
Yes
LAP SURG; W/BIL TOT PELV LYMPHECTMY
No
38572
38589
38700
Yes
Yes
Yes
LAP SURG; PELV LYMPHEC-NODE SAMP
UNLISTED LAP PROC-LYMPHATIC SYST
SUPRAHYOID LYMPHADENECTOMY
No
Yes
No
38720
Yes
No
38724
38740
38745
Yes
Yes
Yes
CERV LYMPHADENECTOMY (COMPLETE)
CERV LYMPHADENECTOMY (MOD RAD
NECK)
AXILRY LYMPHADENECTOMY; SUPERF
AXILRY LYMPHADENECTOMY; COMPLT
38746
38747
Yes
Yes
THORACIC LYMPHADENECTOMY REGIONAL
ABD LYMPHADENECTOMY REGIONAL
No
No
38760
Yes
INGUINOFEM LYMPHADENECT (SEP PRO)
No
38765
Yes
INGUINFEM/PELV LYMPHADNEC (SEP PRO)
No
38770
Yes
PELVIC LYMPHADNECT W/ILIAC (SEP PRO
No
38780
38790
38792
38794
38900
38999
Yes
No
No
No
No
Yes
RETROPERIT TRANSABD LYMPH (SEP PRO)
INJ PROC; LYMPHANGIOGRAPHY
INJ PROC; ID SENTINEL NODE
CANNULATION THORACIC DUCT
IO MAP OF SENT LYMPH NODE
BLOOD/LYMPH SYSTEM PROCEDURE
No
No
No
No
Yes
39000
Yes
MEDIASTINOT W/EXPLOR/DRAIN/BX; CERV
No
Code Description
No
No
No
CPT Code
July 2011
39010
39200
39220
39400
39499
Yes
Yes
Yes
Yes
Yes
39501
39503
Yes
Yes
39540
Yes
39541
39545
39560
39561
39599
40490
Yes
Yes
Yes
Yes
Yes
No
40500
Code Description
No
No
No
No
Yes
Yes
MEDIASTINOT W/EXPLOR/BX; TRANSTHORA
EXC MEDIASTINAL CYST
EXC MEDIASTINAL TUMOR
MEDIASTINOSCOPY W/WO BX
UNLISTED PROC MEDIASTINUM
REPR LACERAT DIAPHRAGM ANY
APPROACH
REPR NEONAT DIAPHRAGMATIC HERNIA
REPR DIAPHRAGM HERNIA-TRAUMA;
ACUTE
REPR DIAPHRAGM HERNIA-TRAUMA;
CHRON
IMBRICAT DIAPHRAGM; PARALYTIC/NON
RESECT DIAPHRAGM; W/SIMP REPR
RESECT DIAPHRAGM; W/COMPLX REPR
UNLISTED PROC DIAPHRAGM
BX LIP
VERMILIONECTOMY W/MUCOS
ADVANCEMENT
40510
40520
40525
40527
40530
40650
40652
40654
40700
40701
40702
40720
40761
40799
Yes
Yes
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
EXC LIP; TRANSVERSE WEDGE EXC W/CLO
EXC LIP; V-EXC W/PRIM LINEAR CLO
EXC LIP; FULL THICK RECON W/FLAP
EXC LIP; FULL THICK RECON W/LIP FLP
RESECT LIP > 1/4 WO RECON
REPR LIP FULL THICK; VERMILION ONLY
REPR LIP FULL THICK; TO HALF VERTIC
REPR LIP FULL THICK; > 1/2 VERTICAL
PLASTIC REPR CLEFT LIP; PRIM UNILAT
PLASTIC REPR CLEFT LIP; BILAT-1 STG
PLASTIC REPR CLEFT LIP; 1 OF 2 STG
PLASTIC REPR CLEFT LIP; SECNDRY
PLASTIC REPR CLEFT LIP; W/PEDICLE
UNLISTED PROC LIPS
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
40800
No
DRAIN ABSCESS VESTIBULE MOUTH; SIMP
No
40801
No
DRAIN ABSCESS VESTIBULE MOUTH; COMP
No
No
No
No
No
No
No
No
Yes
No
No
CPT Code
40804
July 2011
No
40805
40806
40808
40810
40812
40814
No
No
No
No
No
No
REMOV EMBEDDED FB MOUTH; COMPLIC
INCS LABIAL FRENUM
BX VESTIBULE MOUTH
EXC LES-VESTIBULE MOUTH; WO REPR
EXC LES-MOUTH; W/SIMPL REPR
EXC LES-MOUTH; W/COMPLX REPR
No
No
No
No
No
No
40816
No
No
40818
40819
No
Yes
EXC LES-MOUTH; COMPLX W/EXC MUSCL
EXC MUCOS VESTIBULE MOUTH-DONOR
GFT
EXC FRENUM LABIAL/BUCCAL
40820
40830
40831
40840
40842
40843
40844
40845
40899
41000
41005
41006
41007
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
DESTRCT LES VESTIBULE MOUTH-PHYSICL
CLO LACERATION MOUTH; 2.5 CM/LESS
CLO LACERATION MOUTH; > 2.5/COMPLX
VESTIBULOPLASTY; ANT
VESTIBULOPLASTY; POST UNILAT
VESTIBULOPLASTY; POST BILAT
VESTIBULOPLASTY; ENTIRE ARCH
VESTIBULOPLASTY; COMPLX
UNLISTED PROC VESTIBULE MOUTH
INTRAORAL I&D ABSCESS; LINGUAL
INTRAORAL I&D ABSCESS; SUBLINGUAL
INTRAORAL I&D; SUPRAMYLOHYOID
INTRAORAL I&D ABSCESS; SUBMENTAL
No
No
No
No
No
No
No
No
Yes
No
No
No
No
41008
41009
41010
41015
41016
41017
41018
41019
41100
41105
41108
No
No
No
No
No
No
No
No
No
No
No
INTRAORAL I&D; SUBMANDIBULAR SPACE
INTRAORAL I&D; MASTICATOR SPACE
INCS LINGUAL FRENUM
EXTRAORAL I&D ABSCESS; SUBLINGUAL
EXTRAORAL I&D ABSCESS; SUBMENTAL
EXTRAORAL I&D; SUBMANDIBULAR
EXTRAORAL I&D; MASTICATOR SPACE
PLACE NEEDLES H&N FOR RT
BX TONGUE; ANT TWO-THIRDS
BX TONGUE; POST ONE-THIRD
BX FLOOR MOUTH
No
No
No
No
No
No
No
No
No
No
No
Code Description
REMOV EMBEDDED FB MOUTH; SIMPL
No
No
No
CPT Code
41110
41112
41113
July 2011
No
No
No
41114
41115
41116
41120
41130
No
Yes
No
Yes
Yes
EXC LES TONGUE W/CLO; W/TONGUE FLAP
EXC LINGUAL FRENUM
EXC LES FLOOR MOUTH
GLOSSECTOMY; < ONE-HALF TONGUE
GLOSSECTOMY; HEMIGLOSSECTOMY
No
No
No
No
No
41135
Yes
GLOSSECTOMY; PART W/UNILAT RAD NECK
No
41140
Yes
GLOSSECTOMY; COMPLT WO RAD NECK
No
41145
Yes
No
41150
Yes
GLOSSECTOMY; TOT W/UNILAT RAD NECK
GLOSSECTOMY; COMPOSITE WO RAD
NECK
41153
Yes
GLOSSECTOMY; W/SUPRAHYOID DISSECT
No
41155
Yes
GLOSSECTOMY; COMPOSITE & RAD NECK
No
41250
No
REPR LACERAT 2.5CM/LESS; ANT TONGUE
No
41251
No
REPR LACERAT 2.5CM/LESS; POST TONGU
No
41252
No
REPR LACERAT TONGUE > 2.6 CM/COMPLX
No
41500
41510
41512
41520
41530
No
No
Yes
No
Yes
FIXA TONGUE MECH OTHER THAN SUTURE
SUTURE TONGUE TO LIP MICROGNATHIA
TONGUE SUSPENSION
FRENOPLASTY
TONGUE BASE VOL REDUCTION
No
No
No
No
No
41599
Yes
UNLISTED PROC TONGUE FLOOR MOUTH
Yes
41800
Yes
DRAIN ABSCESS DENTOALVEOLAR STRUCT
No
41805
Yes
REMOV FB-DENTOALVEOLAR; SOFT TISS
No
Code Description
EXC LES TONGUE WO CLO
EXC LES TONGUE W/CLO; ANT 2-THIRDS
EXC LES TONGUE W/CLO; POST 1-THIRD
No
No
No
No
CPT Code
July 2011
41806
41820
Yes
Yes
REMOV EMBED FB-DENTOALVEOLAR; BONE
GINGIVECTOMY EA QUADRANT
No
Yes
41821
Yes
OPERCULECTOMY EXC PERICORONAL TISS
Yes
41822
Yes
No
41823
41825
Yes
Yes
EXC FIBROUS TUBEROSITIES DENTOALVEO
EXC OSSEOUS TUBEROSITIES
DENTOALVEO
EXC LES DENTOALVEOLAR; WO REPR
41826
Yes
No
41827
41828
41830
Yes
Yes
Yes
EXC LES DENTOALVEOLAR; W/SIMPL REPR
EXC LES DENTOALVEOLAR; W/COMPLX
REP
EXC HYPERPLASTIC ALVEOLAR MUCOS
ALVEOLECTOMY INCL CURET OSTEITIS
41850
41870
41872
41874
Yes
Yes
Yes
Yes
DESTRCT LES DENTOALVEOLAR STRUCT
PERIODONTAL MUCOS GFT
GINGIVOPLASTY EA QUADRANT
ALVEOLOPLASTY EA QUADRANT
Yes
Yes
No
No
41899
42000
42100
42104
42106
42107
42120
42140
42145
42160
42180
42182
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
UNLISTED PROC DENTOALVEOLAR STRUCT
DRAINAGE ABSCESS PALATE UVULA
BX PALATE UVULA
EXC LES PALATE UVULA; WO CLO
EXC LES PALATE UVULA; W/PRIM CLO
EXC LES PALATE UVULA; W/FLAP CLO
RESECT PALATE/EXTEN RESECT LES
UVULECTOMY EXC UVULA
PALATOPHARYNGOPLASTY
DESTRCT LES PALATE/UVULA
REPR LACERATION PALATE; UP TO 2 CM
REPR LACERATION PALATE; > 2 CM
Yes
No
No
No
No
No
No
No
No
No
No
No
42200
Yes
PALATOPLASTY-CLEFT PALATE SOFT/HARD
No
42205
42210
Yes
Yes
PALATOPLASTY-CLEFT PALATE; SOFT TIS
PALATOPLASTY CLEFT PALATE; W/GFT
No
No
Code Description
No
No
No
No
No
CPT Code
42215
July 2011
Yes
42220
Yes
PALATOPLASTY; SECNDRY LENGTHENING
No
42225
Yes
PALATOPLASTY; ATTACH PHARYNGEAL FLP
No
42226
42227
42235
42260
42280
42281
42299
42300
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
LENGTHENING PALATE & PHARYNGEAL FLP
LENGTHENING PALATE W/ISLAND FLAP
REPR ANT PALATE INCL VOMER FLAP
REPR NASOLABIAL FISTULA
MAXIL IMPRESSION PALATAL PROSTH
INSRT PIN-RETAINED PALATAL PROSTH
UNLISTED PROC PALATE UVULA
DRAINAGE ABSCESS; PAROTID SIMPL
No
No
No
No
No
No
Yes
No
42305
42310
No
No
DRAINAGE ABSCESS; PAROTID COMPLIC
DRAIN ABSCESS; SUBMAXIL INTRAORAL
No
No
42320
42330
No
No
DRAINAGE ABSCESS; SUBMAXILLARY EXT
SIALOLITHOTOMY; UNCOMP INTRAORAL
No
No
42335
42340
42400
42405
42408
42409
42410
No
No
No
No
No
No
No
SIALOLITHOTOMY; SUBMANDIB COMPLIC
SIALOLITHOTOMY; PAROTID COMPLIC
BX SALIVARY GLAND; NEEDLE
BX SALIVARY GLAND; INCS
EXC SUBLINGUAL SALIVARY CYST
MARSUPIALIZATION SUBLINGUAL CYST
EXC PAROTID TUMOR; LAT LOBE
No
No
No
No
No
No
No
42415
42420
42425
42426
42440
42450
42500
42505
42507
42508
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
EXC PAROTID TUMOR; LAT W/DISSECTION
EXC PAROTID TUMOR; TOT W/DISSECT
EXC PAROTID TUMOR; TOT W/NERVE
EXC PAROTID TUMOR; TOT W/RAD NECK
EXC SUBMANDIBULAR GLAND
EXC SUBLINGUAL GLAND
PLASTIC REPR SALIV DUCT; PRIM/SIMPL
PLASTIC REPR SALIV DUCT; SECNDRY
PAROTID DUCT DIVERSION BILAT
PAROTID DIVERS BILAT; W/EXC 1 GLAND
No
No
No
No
No
No
No
No
No
No
Code Description
PALATOPLASTY CLEFT PALATE; REVIS
No
CPT Code
42509
42510
42550
42600
42650
July 2011
Yes
Yes
No
No
No
Code Description
PAROTID DIVERS BILAT; W/EXC GLANDS
PAROTID DIVERS BILAT; W/LIG DUCTS
INJ PROC SIALOGRAPHY
CLO SALIVARY FISTULA
DILAT SALIVARY DUCT
No
No
No
No
No
42660
42665
No
No
DILAT & CATH SALIVARY DUCT W/WO INJ
LIG SALIVARY DUCT INTRAORAL
No
No
42699
42700
Yes
No
Yes
No
42720
42725
42800
42802
42804
No
No
No
No
No
UNLISTED PROC SALIVARY GLANDS/DUCTS
I&D ABSCESS; PERITONSILLAR
I&D ABSCESS; RETROPHARYNG
INTRAORAL
I&D ABSCESS; RETROPHARYNGEAL EXT
BX; OROPHARYNX
BX; HYPOPHARYNX
BX; NASOPHARYNX VISIBLE LES SIMPL
42806
No
BX; NASOPHARYNX SURVEY-UKN PRIM LES
No
42808
42809
No
No
EXC/DESTRCT LES PHARYNX ANY METHD
REMOV FB FROM PHARYNX
No
No
42810
No
EXC BRANCHIAL CLEFT CYST-SKIN/SUBQ
No
42815
42820
42821
No
No
No
EXC BRANCH CLEFT CYST-BENEATH SUBQ
T & A; UNDER AGE 12
T & A; AGE 12/OVER
No
No
No
42825
No
TONSILLECTMY PRIM/SECNDRY; < AGE 12
No
42826
42830
42831
No
No
No
No
No
No
42835
No
TONSILLECTOMY PRIM/SECNDRY; 12/OVER
ADENOIDECTOMY PRIM; UNDER AGE 12
ADENOIDECTOMY PRIM; AGE 12/OVER
ADENOIDECTOMY SECNDRY; UNDER AGE
12
42836
42842
No
No
ADENOIDECTOMY SECNDRY; AGE 12/OVER
RADICAL RESECT TONSIL; WO CLO
No
No
No
No
No
No
No
No
CPT Code
July 2011
42844
No
RAD RESECT TONSIL; CLO W/LOCAL FLAP
No
42845
42860
42870
42890
No
Yes
Yes
Yes
RAD RESECT TONSIL; CLO W/OTHER FLAP
EXC TONSIL TAGS
EXC/DESTRCT LING TONSIL (SEP PRO)
LTD PHARYNGECTOMY
No
No
No
No
42892
Yes
RESECT LAT PHARYNGEAL WALL DIRECT
No
42894
42900
42950
42953
42955
42960
Yes
No
Yes
Yes
Yes
No
RESECT PHARYNG WALL W/CLO W/FLAP
SUTURE PHARYNX WOUND/INJURY
PHARYNGOPLASTY
PHARYNGOESOPHAGEAL REPR
PHARYNGOSTOMY
CONTRL OROPHARYNG HEMORR; SIMPL
No
No
No
No
No
No
42961
No
CONTRL OROPHARYNG HEMORR; COMPLIC
No
42962
No
CONTRL OROPHARYNG HEMORR; W/SURG
No
42970
No
No
42971
No
42972
Yes
CONTRL NASOPHARYNG HEMORR; SIMPL
CONTRL NASOPHARYNG HEMORR;
COMPLIC
CONTRL NASOPHARYNG HEMORR;
W/SURG
42999
43020
43030
Yes
No
No
UNLISTED PROC PHARYNX/ADENOID/TONSI
ESOPHAGOTOMY CERV; W/REMOV FB
CRICOPHARYNGEAL MYOTOMY
Yes
No
No
43045
No
ESOPHAGOTOMY THORACIC, W/REMOV FB
No
43100
Yes
EXC LES ESOPHAGUS W/PRIM REPR; CERV
No
43101
Yes
No
43107
Yes
EXC LES ESOPHAG W/REPR; THORAC/ABD
ESOPHAGECT WO THORCTMY;
W/GASTROST
Code Description
No
No
No
CPT Code
July 2011
43108
Yes
Code Description
ESOPHAGECT WO THORCTMY; W/SB
RECON
43112
Yes
ESOPHAGECT W/THORCTMY; W/GASTROST
No
43113
Yes
No
43116
Yes
ESOPHAGECT W/THORCTMY; W/SB RECON
PART ESOPHAGECT-CERVW/GFT/ANASTOM
43117
Yes
No
43118
Yes
43121
Yes
43122
Yes
43123
43124
Yes
Yes
PART ESOPHAGECT; W/ESOPHGASTROST
PART ESOPHAGECT; W/INTRPOS/SB
RECON
PART ESOPHAGECT W/THORCTMY,
W/GASTR
PART ESOPHAGECT THORABD;
W/ESOGASTR
PART ESOPHAGECT THORABD; W/SB
RECON
TOT/PART ESOPHAGECT WO RECON
43130
Yes
No
43135
43200
Yes
No
43201
No
DIVERTICULECTOMY HYPOPHARYNX; CERV
DIVERTICULECTOMY HYPOPHARYNX;
THORA
ESOPHAGOSCOPY; DX (SEPART PROC)
ESOPHGSCPY RIGD/FLXIBLE; DIR
SUBMUCOS INJ SBSTNC
43202
No
No
43204
No
ESOPHAGOSCOPY RIGID/FLEX; W/BX 1/MX
ESOPHAGOSCOPY; W/INJ-SCLEROS
VARICE
43205
43215
No
No
No
No
43216
No
ESOPHAGOSCPY RIGID/FLEX; W/BAND LIG
ESOPHAGOSCOPY; W/REMOV FB
ESOPHAGOSCPY RIGID/FLEX; REMOV
TUMR
43217
43219
43220
No
No
No
ESOPHAGOSCOPY; W/REMOV LES-SNARE
ESOPHAGOSCOPY; INSRT TUBE/STENT
ESOPHAGOSCOPY; W/BALLOON DILAT
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
43226
No
ESOPHAGOSCOPY; W/INSRT GUIDE WIRE
No
43227
No
No
43228
No
43231
No
43232
43234
43235
No
No
No
43236
No
43237
No
43238
43239
No
No
43240
43241
No
No
43242
43243
43244
43245
No
No
No
No
ESOPHAGOSCOPY; W/CONTRL BLEEDING
ESOPHAGOSCOPY; W/ABLAT TUMR-NOT
AMN
ESOPHAGOSCOPY; W/ENDOSCOPIC
ULTRASOUND
ESOPHAGOSCOPY; W/TRANSENDOSCOPIC
ULTRASOUND
UGI ENDO SIMPL PRIM EXAM (SEP PRO)
UGI ENDO; DX W/WO COLLEC SPECMN
UP GI ENDO ESOPH STOMACH; W/DIR
SUBMUCOS INJ ANY
UPPER GI ENDO; W/ENDO US EXAM LTD
ESOPHAGUS
UP GI ENDO;TRANSENDO US FINE NDLE
ASPIR/BX ESOPH
UGI ENDO; W/BX 1/MX
ESOPHAGOSCOPY; W/TRANSMURAL
DRAINAGE OF PSEUDOCYST
UGI ENDO; W/TRANSENDOSCOPIC TUBE
UGI ENDO; W/US GUID FINE NEEDLE
ASPIR/BX
UGI ENDO; W/INJ SCLEROSIS-VARICES
UGI ENDO; W/BAND LIG VARICES
UGI ENDO; W/DILAT OUTLET-ANY METHD
43246
43247
43248
No
No
No
UGI ENDO; W/PLCMT GASTROSTOMY TUBE
UGI ENDO; W/REMOV FB
UGI ENDO; W/INSRT GUIDE WIRE
No
No
No
43249
No
UGI ENDO; W/BALLOON DILAT ESOPHAGUS
No
43250
No
UGI ENDO; W/REMOV TUMOR/POLYP/LES
No
43251
No
UGI ENDO; W/REMOV TUMOR/LES-SNARE
No
43255
No
UGI ENDO; W/CONTRL BLEED ANY METHD
No
Code Description
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
43256
No
43257
43258
43259
43260
43261
Not Reimbursable
No
No
No
No
43262
No
ERCP; W/SPHINCTEROTOMY/PAPILLOTOMY
No
43263
43264
43265
No
No
No
ERCP; W/PRESS MEASUR-SPHINCTER ODDI
ERCP; W/ENDO RETRO REMOV STONE
ERCP; W/ENDO RETRO DESTRCT-STONE
No
No
No
43267
No
ERCP; W/ENDO RETRO INSRT DRAIN TUBE
No
43268
No
ERCP; W/ENDO RETRO INSRT TUBE/STENT
No
43269
No
ERCP; W/ENDO RETRO REMOV FB/CHANGE
No
43271
No
ERCP; W/ENDO RETRO BALOON DILAT-DUC
No
43272
43273
43279
No
No
Yes
No
No
No
43280
43281
43282
43283
43289
Yes
Yes
Yes
Yes
Yes
ERCP; W/ABLAT TUMOR/LES NOT SNARE
ENDOSCOPIC PANCREATOSCOPY
LAP MYOTOMY, HELLER
LAP SURG-ESOPHAGOGASTRIC
FUNDOPLSTY
LAP PARAESOPHAG HERN REPAIR
LAP PARAESOPH HER RPR W/MESH
LAP ESOPH LENGTHENING
UNLISTED LAP PROC-ESOPHAGUS
43300
43305
Yes
Yes
43310
43312
Code Description
UGI ENDO; W/TRANSENDOSCOPIC STENT
PLACEMNT
UP GI ENDO;DEL THRML ENRGY MUSC LW
ESOPH SPHNCTR
UGI ENDO; W/ABLAT LES NOT SNARE
UGI ENDO; W/ENDO ULTRASOUND EXAM
ERCP; DX W/WO SPECMN (SEP PRO)
ERCP; W/BX 1/MX
No
Not Reimbursable
No
No
No
No
No
No
No
No
Yes
No
No
Yes
ESOPHAGOPLASTY CERV; WO REPR FIST
ESOPHAGOPLASTY CERV; W/REPR FIST
ESOPHAGOPLASTY THORACIC; WO
FISTULA
Yes
ESOPHAGOPLASTY THORACIC; W FISTULA
No
No
CPT Code
July 2011
43313
Yes
43314
Yes
43320
Yes
43325
43327
43328
43330
Yes
Yes
Yes
Yes
43331
43332
43333
43334
43335
43336
43337
43338
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
43340
43341
43350
Yes
Yes
Yes
43351
43352
Yes
Yes
43360
Yes
43361
43400
Code Description
ESOPHGPLSTY CONGN DEFEC;NO REP
FIST
No
ESOPHGPLSTY CONGN DEFEC; W/REP FIST
ESOPHAGOGASTROST THOR/ABD
APPROACH
ESOPHAGOGASTRIC FUNDOPLSTY;
W/PATCH
ESOPH FUNDOPLASTY LAP
ESOPH FUNDOPLASTY THOR
ESOPHAGOMYOTOMY; ABD APPROACH
ESOPHAGOMYOTOMY; THORACIC
APPROACH
TRANSAB ESOPH HIAT HERN RPR
TRANSAB ESOPH HIAT HERN RPR
TRANSTHOR DIAPHRAG HERN RPR
TRANSTHOR DIAPHRAG HERN RPR
THORABD DIAPHR HERN REPAIR
THORABD DIAPHR HERN REPAIR
ESOPH LENGTHENING
ESOPHAGOJEJUNOSTOMY; ABD
APPROACH
ESOPHAGOJEJUNOSTOMY; THORACIC
ESOPHAGOSTOMY FISTULIZ-EXT; ABD
No
No
No
Yes
Yes
ESOPHAGOSTOMY FISTULIZ-EXT; THORACI
ESOPHAGOSTOMY FISTULIZ-EXT; CERV
GI RECON-PREV ESOPHAGECT;
W/STOMACH
GI RECON-PREV ESOPHGEC; W/BOWEL
REC
LIG DIRECT ESOPH VARICES
43401
43405
Yes
Yes
TRANSECT ESOPHAGUS W/REPR VARICES
LIG/STAPLE GE JNCTN-EXIST ESO PERF
No
No
43410
Yes
No
43415
Yes
SUTURE ESOPH WOUND; CERV APPROACH
SUTURE ESOPH WOUND; THOR/ABD
APPROA
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
43420
July 2011
Yes
43425
Yes
43450
43453
43456
No
No
No
43458
No
43460
No
43496
43499
43500
Yes
Yes
Yes
43501
Yes
43502
Yes
43510
Yes
43520
43605
Yes
Yes
43610
43611
Yes
Yes
43620
Yes
43621
Yes
43622
Yes
43631
Yes
43632
43633
Code Description
CLO ESOPHAGOSTOMY/FISTULA; CERV
CLO ESOPHAGOSTOMY/FISTULA;
THOR/ABD
DILAT ESOPH-SOUND/BOUGIE-1/MX PASS
DILAT ESOPH OVER GUIDE WIRE
DILAT ESOPH BALLOON/DILAT RETRO
DILAT ESOPHAGUS W/BALLOONACHALASIA
ESOPHAGOGASTRIC TAMPONADE
W/BALLOON
FREE JEJUNUM TRANS W/MICROVAS
ANAST
UNLISTED PROC ESOPHAGUS
GASTROTOMY; W/EXPLOR/FB REMOV
No
No
No
No
No
No
No
Yes
Yes
No
GASTROTOMY; W/SUTURE BLEED ULCER
GASTROTOMY; W/SUTURE EXIST EG
LACER
No
GASTROT; W/ESO DIL, INSRT PERM TUBE
PYLOROMYOTOMY CUTTING PYLORIC
MUSCL
BX STOMACH; BY LAPAROTOMY
No
EXC LOCAL; ULCER/BEN TUMOR-STOMACH
EXC LOCAL; MALIG TUMOR STOMACH
GASTRECTOMY TOT;
W/ESOPHAGOENTEROST
No
No
GASTRECTOMY TOT; W/ROUX-EN-Y RECON
GASTRECT TOT; W/FORMAT INTEST
POUCH
No
No
Yes
GASTRECT PART DIST; W/GASTRODUODEN
GASTRECT PART DIST;
W/GASTROJEJUNOS
Yes
GASTRECT PART DIST; ROUX-EN-Y RECON
No
No
No
No
No
No
No
CPT Code
July 2011
43634
Yes
43635
Yes
43640
Yes
43641
Yes
43644
DSHS FFS Only
43645
43647
43648
DSHS FFS Only
Yes
Yes
43651
Yes
VAGOTOMY W/PYLOROPLASTY; PARIETAL
LAP GASTR RSTRCIV PROC; GASTR BYPS &
ROUX-EN-Y
LAP GASTR RSTRCIV PROC;GASTR
BYPS&SM INTST RECON
LAP IMPL ELECTRODE, ANTRUM
LAP REVISE/REMV ELTRD ANTRUM
LAP SURG; TRANSEC VAGUS NRVTRUNCAL
43652
Yes
LAP SURG; TRANSECT VAGUS NERVES-SEL
No
43653
43659
Yes
Yes
No
Yes
43752
43753
43754
43755
43756
43757
43760
No
No
No
No
No
No
No
LAP SURG; GASTROS WO TUBE (SEP PRO)
UNLISTED LAP PROC-STOMACH
NASO/ORO-GASTRC TUBE PLCMT RQR
PHYS SKILL&FLOURO
TX GASTRO INTUB W/ASP
DX GASTR INTUB W/ASP SPEC
DX GASTR INTUB W/ASP SPECS
DX DUOD INTUB W/ASP SPEC
DX DUOD INTUB W/ASP SPECS
CHANGE GASTROSTOMY TUBE
43761
43770
43771
43772
No
DSHS FFS Only
Yes
Yes
No
DSHS FFS Only
Yes
Yes
43773
Yes
REPOSIT GASTRIC FEED TUBE THRU DUOD
LAPS GSTR RSTCV PX PLMT BAND
LAPS GSTR RSTCV PX REVJ BAND
LAPS GSTR RSTCV PX RMVL BAND
LAPS GSTR RSTCV PX RMVL&RPLCMT
BAND
43774
43775
Yes
DSHS FFS Only
Code Description
GASTRECTOMY PART DIST; W/FORM
POUCH
VAGOTOMY PERFORM W/PART DIS
GASTRCT
VAGOTOMY INCL PYLOROPLASTY;
TRUNCAL
LAPS GSTR RSTCV PX RMVL BAND&PORT
LAP SLEEVE GASTRECTOMY
No
No
No
No
DSHS FFS Only
DSHS FFS Only
Yes
Yes
No
No
No
No
No
No
No
No
Yes
Yes
Yes
CPT Code
43800
43810
July 2011
Yes
Yes
43820
43825
Yes
Yes
GASTROJEJUNOSTOMY; WO VAGOTOMY
GASTROJEJUNOSTOMY; W/VAGOTOMY
No
No
43830
Yes
GASTROSTMY; WO GAST TUBE (SEP PRO)
No
43831
Yes
GASTROSTOMY-OP; NEONATAL FEEDING
No
43832
Yes
GASTROSTOMY; W/CONSTRUC GAST TUBE
No
43840
Yes
GASTRORRHAPHY SUTURE-ULCER/WOUND
No
43842
DSHS FFS Only
GASTRIC RESTRIC WO BYP; VERTCL BAND
DSHS FFS Only
43843
DSHS FFS Only
DSHS FFS Only
43845
DSHS FFS Only
43846
DSHS FFS Only
43847
DSHS FFS Only
GAST RESTRIC WO BYP; NOT VERT BAND
GASTRIC RESTRICTIVE PROC PARTIAL
GASTRECTOMY
GASTR RSTRC PROC W/GASTR BYPS;SHRT
LMB ROUX-EN-Y
GAST RESTRC W/BYP; W/SM BOWEL
RECON
43848
DSHS FFS Only
43850
Yes
43855
Yes
43860
Yes
43865
43870
43880
43881
43882
Yes
Yes
Yes
Yes
Yes
43886
Yes
Code Description
PYLOROPLASTY
GASTRODUODENOSTOMY
REVIS GASTR RESTRICT PROC (SEP PRO)
REVIS GASTRODUOD ANASTOM; WO
VAGOT
REVIS GASTRODUOD ANASTOM;
W/VAGOTMY
REVIS GASTROJEJUN ANASTOM; WO
VAGOT
REVIS GASTROJEJUN ANASTOM; W/VAGOT
CLO GASTROSTOMY SURG
CLO GASTROCOLIC FISTULA
IMPL/REDO ELECTRD, ANTRUM
REVISE/REMOVE ELECTRD ANTRUM
GSTR RSTCV PX OPN REVJ SUBQ PORT
COMPONENT ONLY
No
No
DSHS FFS Only
DSHS FFS Only
DSHS FFS Only
DSHS FFS Only
No
No
No
No
No
No
Yes
Yes
No
CPT Code
July 2011
43887
Yes
43888
43999
44005
44010
Yes
Yes
Yes
Yes
44015
Yes
44020
44021
44025
44050
Yes
Yes
Yes
Yes
Code Description
GSTR RSTCV PX OPN RMVL SUBQ PORT
COMPONENT ONLY
GSTR RSTCV OPN RMVL&RPLCMT SUBQ
PORT
UNLISTED PROC STOMACH
ENTEROLYSIS (SEPART PROC)
DUODENOTOMY-EXPLOR/BX/FB REMOV
TUBE/NEEDLE CATH JEJUNOSTMYINTRAOP
ENTEROT-SM BOWEL; EXPLO/BX/FB
REMOV
ENTEROTOMY-SM BOWEL; DECOMP
COLOTOMY EXPLOR BX/FB REMOV
REDUCT VOLVULUS BY LAPAROTOMY
44055
44100
Yes
No
CORRECT MALROTATION BY LYSIS BANDS
BX INTESTINE-CAPSULE/TUBE/PERORAL
No
No
44110
Yes
No
44111
44120
Yes
Yes
EXC 1/MORE LES-BOWEL; 1 ENTEROTOMY
EXC 1/MORE LES-BOWEL; MX
ENTEROTOMS
ENTERECT SM INTES; 1 RESECT & ANAS
44121
Yes
No
44125
Yes
ENTERECTOMY SM INTES; EA ADD RESECT
ENTERECTOMY SM INTES;
W/ENTEROSTOMY
44126
44127
44128
44130
Yes
Yes
Yes
Yes
No
No
No
No
44132
Yes
44133
Yes
44135
Not Reimbursable
44136
Not Reimbursable
ENTERECT RES SM INTST;W/O TAPERING
ENTERECT RES SM INTST; W/TAPERING
ENTERECT RES SM INTST; EA ADD RES
ENTEROENTEROSTOMY (SEP PROC)
DONOR ENTERECT INCL COLD PRES OPEN;
CADVR DONOR
DONOR ENTERECT W/PREP ALLOGFT;
PART- LIVE DONOR
INTESTINAL ALLOTRANSPLANTATION,
FROM CADAVER DONOR
INTESTINAL ALLTRANSPLANTATION FROM
LIVING DONOR
No
No
Yes
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
CPT Code
July 2011
44137
Yes
44139
44140
44141
44143
Yes
Yes
Yes
Yes
44144
Yes
44145
Yes
44146
44147
Yes
Yes
44150
Yes
44151
Code Description
REMOVAL TRANSPLANTED INTESTINAL
ALLOGFT COMPETE
Yes
No
No
No
No
Yes
MOBILIZA SPLENIC FLEX DUR COLECTOMY
COLECTOMY PART; W/ANASTOM
COLECTOMY PART; W/CECOSTOMY
COLECTOMY PART; W/END COLOSTOMY
COLECTOMY PART; W/RESECT &
MUCOFIST
COLECTOMY PART;
W/COLOPROCTOSTOMY
COLECTMY PART; W/COLOPROCTO
W/COLOS
COLECTOMY PART; ABD & TRANSANAL
COLECTOMY WO PROCTECT;
W/ILEOSTOMY
COLECTOMY WO PROCTECT;
W/CONTINENT
44155
Yes
COLECTOMY W/PROCTECT; W/ILEOSTOMY
No
44156
44157
44158
44160
Yes
Yes
Yes
Yes
No
No
No
No
44180
44186
44187
44188
Yes
Yes
Yes
Yes
COLECTOMY W/PROCTECT; W/CONTINENT
COLECTOMY W/ILEOANAL ANAST
COLECTOMY W/NEO-RECTUM POUCH
COLECTOMY W/REMOV TERM ILEUM
LAPS ENTEROLSS FRING INTSTINAL
ADHESION SPX
LAPS JEJUNOSTOMY
LAPS ILEOST/JEJUNOSTOMY NON-TUBE
LAPS CLST/SKN LVL CECOSTOMY
44202
Yes
LAP SURG; INTESTNL RESECT W/ANASTOM
No
44203
Yes
No
44204
Yes
LAPARSCPY SURG; EA ADD SM INTST RES
LAPARSCPY SURG; COLECT PART
W/ANAST
44205
Yes
LAP SURG; COLECT W/REMV TERM ILEUM
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
44206
Yes
44207
Yes
44208
Yes
44210
Yes
44211
Yes
44212
Yes
44213
Yes
44227
Yes
44238
44300
44310
44312
44314
44316
Yes
Yes
Yes
Yes
Yes
Yes
Code Description
LAP SURG; COLECT PART W/END
COLOST&CLOS DIST SEG
LAP SURG; COLECT PART W/ANASTOM
W/COLOPROCTOST
LAP SURG;COLECT PART W/ANAST
COLOPROCTOST&COLOST
LAP;COLECT TOT ABD NO PROCTECT
W/ILEOST/PROCTOST
LAP; COLECT TOT ABD W/PROCTECT
RESRVOR W/ILEOST
LAP SURG; COLECT TOTAL ABD
W/PROCTECT W/ILEOST
LAPS MOBLJ SPLENIC FLXR PFRMD W/PRTL
COLCT
LAPS CLSR NTRSTM LG/SM INT
W/RESCJ&ANAST
UNLISTED LAPAROSCOPY PROC INTESTINE
NO RECTUM
ENTEROSTOMY TUBE (SEPART PROC)
ILEOSTOMY NON-TUBE (SEPART PROC)
REVIS ILEOSTOMY; SIMPL (SEP PRO)
REVIS ILEOSTOMY; COMPLIC (SEP PRO)
CONTINENT ILEOSTOMY (SEPART PROC)
44320
44322
44340
Yes
Yes
Yes
COLOSTOMY/CECOSTOMY (SEPART PROC)
COLOSTOMY; W/MX BX (SEPART PROC)
REVIS COLOSTOMY; SIMPL (SEP PRO)
No
No
No
44345
Yes
REVIS COLOSTOMY; COMPLIC (SEP PRO)
No
44346
44360
44361
Yes
No
No
REVIS COLOSTOMY; W/HERNIA (SEP PRO)
SM INTEST ENDO NOT ILEUM; DX (SP)
SM INTEST ENDO NOT ILEUM; W/BX 1/MX
No
No
No
44363
No
SM INTEST ENDO NOT ILEUM;W/REMOV FB
No
44364
No
SM INTEST ENDO NOT ILEUM; REMOV LES
No
44365
No
SM INTEST ENDO WO ILEUM; REMOV TUMR
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No
CPT Code
July 2011
44366
44369
No
No
SM INTEST ENDO NOT ILEUM; CONTR BLD
SM INTEST ENDO; W/ABLAT TUMOR
No
No
44370
No
SM INTEST ENDO W/TRANSENDOSCOPIC
STENT PLACEMNT
No
44372
No
SM INTEST ENDO; W/PLCMT JEJUNO TUBE
No
44373
44376
44377
No
No
No
SM INTEST ENDO; W/GASTRO TO JEJUNO
SM INTEST ENDO W;ILEUM; DX (SP)
SM INTEST ENDO W/ILEUM; W/BX 1/MX
No
No
No
44378
No
No
44379
44380
44382
No
No
No
44383
44385
No
No
SM INTEST ENDO W/ILEM; CONTRL BLEED
SM INTEST ENDO W/TRANSENDO STENT
PLACEMNT
ILEOSCPY-STOMA; DX W/WO SPECMN
ILEOSCOPY-STOMA; W/BX 1/MX
ILEOSCOPY W/TRANSENDO STENT
PLACEMNT
ENDO EVAL SM INTEST POUCH; DX (SP)
44386
No
No
44388
44389
44390
No
No
No
ENDO EVAL SM INTEST POUC; W/BX 1/MX
COLONOSCOPY-STOMA; DX (SEPART
PROC)
COLONOSCOPY-STOMA; W/BX 1/MX
COLONOSCOPY-STOMA; W/REMOV FB
44391
No
No
44392
No
COLONOSCOPY-STOMA; W/CONTRL BLEED
COLONOSCPY-STOMA; W/REMOV
TUMOR/LES
44393
No
No
44394
No
44397
44500
44602
No
No
Yes
COLONOSCOPY-STOMA; W/ABLAT TUMOR
COLONSCPY-STMOA; REMOV
TUMOR/POLYP
COLONOSCOPY W/TRANSENDO STENT
PLACEMNT
INTRO LONG GI TUBE (SEPART PROC)
SUTURE SM INTESTINE; 1 PERFORATION
Code Description
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
44603
July 2011
Yes
44604
44605
44615
44620
Yes
Yes
Yes
Yes
44625
Yes
44626
44640
44650
Code Description
SUTURE SM INTEST; MX PERFORATIONS
No
No
No
No
No
Yes
Yes
Yes
SUTURE LG INTESTINE; WO COLOSTOMY
SUTURE LG INTESTINE; W/COLOSTOMY
INTEST STRICTUROPLASTY W/WO DILAT
CLO ENTEROSTOMY LG/SM INTEST
CLO ENTEROSTMY; W/RESEC NOT
COLOREC
CLO ENTEROSTOMY; W/RESECT
COLORECTL
CLO INTESTINAL CUT FISTULA
CLO ENTEROENTERIC FISTULA
44660
Yes
CLO ENTEROVESICAL FISTULA; WO RESEC
No
44661
44680
Yes
Yes
CLO ENTEROVESICAL FISTULA; W/RESECT
INTESTINAL PLICATION (SEPART PROC)
No
No
44700
44701
Yes
Yes
No
No
44715
Yes
44720
Yes
44721
44799
44800
44820
44850
44899
44900
44901
44950
44955
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
EXCLUS SM BOWEL FROM PELV-MESH/TISS
INTRAOPERATIVE COLONIC LAVAGE
BACKBENCH STD PREP CD/LD INTESTINE
ALLOGFT
BCKBNCH RECNSTR CD/LD INTST
ALLOGFT;VEN ANAST EA
BCKBNCH RECNSTR CD/LD INTST
ALLOGFT;ART ANAST EA
UNLISTED PROC INTESTINE
EXC MECKEL'S DIVERTIC
EXC LES MESENTERY (SEPART PROC)
SUTURE MESENTERY (SEPART PROC)
UNLISTED PROC MECKEL'S DIVERTIC
I&D APPENDICEAL ABSC; OPEN
I&D APPENDICEAL ABSC; PERCUT
APPENDECTOMY
APPY; DONE @ TIME OF OTH PROC
44960
44970
44979
No
No
No
APPY; RUPT W/ABSCESS/GEN PERITONITS
LAP SURG-APPENDECTOMY
UNLISTED LAP PROC-APPENDIX
No
No
No
No
Yes
No
No
Yes
No
No
No
Yes
No
No
No
No
No
No
Yes
CPT Code
July 2011
45000
45005
45020
45100
45108
No
No
No
No
Yes
45110
45111
Yes
Yes
45112
Yes
45113
45114
Yes
Yes
45116
Yes
45119
Yes
45120
Yes
45121
45123
45126
45130
Code Description
TRANSRECTAL DRAINAGE PELVIC
ABSCESS
I&D SUBMUCOSAL ABSCESS RECTUM
I&D DEEP SUPRALEVATOR ABSCESS
BX ANORECTAL WALL ANAL APPROACH
ANORECTAL MYOMECTOMY
PROCTECTOMY; COMPLT-ABDPERI
W/COLOS
PROCTECTOMY; PART RESECT RECTUM
PROCTECTOMY ABDOMPERINEAL PULLTHRU
PROCTECT PART W/RECTAL MUCOSECANAS
PROCTECTOMY PART W/ANASTOM; ABD
PROCTECTMY PART W/ANASTOM;
TRANSACR
PROCTECTOMY-COLON RESVOIR W/WO
OST
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
PROCTECT COMPLT; W/PULL-THRU & ANAS
PROCTECT COMP; W/SUBTL/TOT
COLECTMY
PROCTECTOMY PART WO ANASTOM
PELV EXENTERATION-COLOREC MALIG
EXC RECTAL PROCIDENTIA; PERIANAL
45135
Yes
EXC RECTAL PROCIDENT; ABD & PERINEL
No
45136
45150
Yes
Yes
No
No
45160
45171
45172
45190
Yes
Yes
Yes
Yes
EXCISION ILEOANAL RESRVOR W/ILEOST
DIVISION STRICT RECTUM
EXC RECTAL TUMOR-PROCTOTOMY
APPROCH
EXC RECT TUM TRANSANAL PART
EXC RECT TUM TRANSANAL FULL
DESTRCT RECTAL TUMOR ANY METHD
45300
No
PROCSIGMOSCOPY RIGID; DX (SEP PROC)
No
45303
No
PROCTOSIGMOIDOSCOPY RIGID; W/DILAT
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
45305
No
45307
Code Description
No
No
PROCTOSIGMOIDOSCPY RIGID; W/BX 1/MX
PROCTOSIGMOIDOSCPY RIGID;W/REMOV
FB
45308
No
PROCTOSIGMOID RIGID; REMOV LES-FORC
No
45309
No
PROCTOSIGMOID RIGID; REMOV LES-SNAR
No
45315
No
PROCTOSIGMOIDOS RIGID; W/REMOV LES
No
45317
No
PROCTOSIGMOIDOS RIGID; W/CONTRL BLD
No
45320
No
No
45321
No
45327
45330
45331
45332
No
No
No
No
PROCTOSIGMOIDOS RIDIG; W/ABLAT LES
PROCTOSIGMOIDOS RIGID; W/DECOMP
VOL
PROCTOSIGMOIDOSCOPY W/TRANSENDO
STENT PLACEMNT
SIGMOIDOSCOPY FLEX; DX (SEP PROC)
SIGMOIDOSCOPY FLEX; W/BX 1/MX
SIGMOIDOSCOPY FLEX; W/REMOV FB
45333
No
SIGMOIDOSCPY FLEX; W/REMOV LES-CAUT
No
45334
No
No
45335
No
45337
No
SIGMOIDOSCOPY FLEX; W/CONTRL BLEED
SIGMOIDSCPY FLXIBLE; W/DIR SUBMUCOS
INJ SBSTNC
SIGMOIDOSCOPY FLEX; W/DECOMP
VOLVUL
45338
No
SIGMOIDOSCOPY FLEX; REMOV LES-SNARE
No
45339
No
No
45340
No
45341
No
45342
No
SIGMOIDOS FLEX; ABLAT LES-NOT AMENA
SIGMOIDSCPY FLXIBLE; W/DILAT BALLN
1/MORE STRICT
SIGMOIDOSCOPY W/ENDO ULTRASOUND
EXAM
SIGMOIDOSCOPY W/TRANSENDO
ULTRASOUND
No
No
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
45345
45355
45378
45379
45380
No
No
No
No
No
45381
No
45382
45383
No
No
45384
No
45385
No
45386
No
45387
No
45391
No
45392
No
45395
Yes
45397
45400
Yes
Yes
45402
45499
45500
Yes
Yes
Yes
45505
Yes
COLONSCPY
FLEX;INTRAMURAL/TRANSMURAL FNA/BXS
LAPS PRCTECT COMPL CMBN
ABDOMINOPRNL W/CLST
LAPS PRCTECT CMBN PULL-THRU CRTJ
RSVR
LAPS PROCTOPEXY FOR PROLAPSE
LAPS PROCTOPEXY FOR PROLAPSE
SIGMOID RESCJ
UNLIS LAPS PX RECTUM
PROCTOPLASTY; STENOSIS
PROCTOPLASTY; PROLAPSE MUCOS
MEMBRN
45520
No
PERIRECTAL INJ SCLEROSING SOLUTION
No
45540
Yes
PROCTOPEXY PROLAPSE; ABD APPROACH
No
Code Description
SIGMOIDOSCOPY W/TRANSENDO STENT
PLACEMNT
COLONOSCPY RIGID/FLEX 1/MX
COLONOSCOPY FLEX; DX (SEP PRO)
COLONOSCOPY FLEX; W/REMOV FB
COLONOSCOPY FLEX; W/BX 1/MX
COLNSCPY FLX PROX SPLENIC FLXR; DIR
SUBMUCOS INJ
COLONOSCOPY FLEX; W/CONTRL BLEED
COLONOSCOPY FLEX; W/ABLAT LES
COLONOSOCPY FLEX; REMOV LESFORCEPS
COLONOSCOPY FLEX; W/REMOV LESSNARE
COLNSPY FIBRPTC BEYND SPLNC;
W/RETRGRDE LAVAGE
COLONOSCOPY W/TRANSENDO STENT
PLACEMNT
COLONSCPY FLEX PROX SPLENIC FLXURE;
W/ENDO US EX
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
CPT Code
45541
45550
45560
July 2011
Yes
Yes
Yes
45562
Yes
EXPLOR, REPR & DRAIN-RECTAL INJURY;
No
45563
45800
Yes
Yes
EXPLOR-REPR-DRAIN RECTAL; W/COLOST
CLO RECTOVESICAL FISTULA
No
No
45805
45820
Yes
Yes
No
No
45825
Yes
CLO RECTOVESICAL FIST; W/COLOSTOMY
CLO RECTOURETHRAL FISTULA
CLO RECTOURETHRAL FIST;
W/COLOSTOMY
45900
No
REDUCT PROCIDENTIA (SEP PRO) W/ANES
No
45905
45910
No
No
DILAT ANAL SPHINCT (SEP PRO) W/ANES
DILAT RECTAL STRICT (SEP PRO) W/ANE
No
No
45915
No
No
45990
45999
46020
46030
46040
46045
46050
No
Yes
No
No
No
No
No
REMOV FECAL IMPACT (SEP PRO) W/ANES
ANRCT XM SURG REQ ANES GENERAL
SPI/EDRL DX
UNLISTED PROC RECTUM
PLACEMENT OF SETON
REMOV ANAL SETON OTHER MARKER
I&D ISCHIORECTAL ABSCESS (SEP PRO)
I&D INTRAMURAL ABSCESS TRANSANAL
I&D PERIANAL ABSCESS SUPERF
No
Yes
No
No
No
No
No
46060
46070
46080
46083
No
No
No
No
I&D ISCHIORECTAL/INTRAMURAL ABSCESS
INCS ANAL SEPTUM (INFANT)
SPHINCTEROTOMY ANAL (SEP PRO)
INCS THROMBOSED HEMORRHOID EXT
No
No
No
No
46200
46220
46221
Yes
No
No
FISSURECTOMY W/WO SPHINCTEROTOMY
PAPILLECTOMY ANUS (SEPART PROC)
HEMORRHOIDECTOMY BY SIMPL LIG
No
No
No
46230
No
EXC EXT HEMORRHOID TAGS/MX PAPILLAE
No
Code Description
PROCTOPEXY PROLAPSE; PERINEAL
PROCTOPEXY COMBO W/RESECT-ABD
REPR RECTOCELE (SEPART PROC)
No
No
No
No
CPT Code
46250
46255
July 2011
Yes
Yes
46257
Yes
46258
46260
Yes
Yes
46261
Yes
46262
46270
46275
46280
46285
Yes
Yes
Yes
Yes
Yes
46288
Yes
46320
No
46500
46505
No
Yes
46600
46604
46606
46608
No
No
No
No
46610
No
46611
No
46612
Code Description
HEMORRHOIDECTOMY EXT COMPLT
HEMORRHOIDECTOMY INT & EXT SIMPL
HEMORRHOIDECTOMY SIMPL;
W/FISSURECT
HEMORRHOIDECTOMY SIMPL;
W/FISTULECT
HEMORRHOIDECTOMY COMPLX/EXTEN
HEMORRHOIDECT COMPLX;
W/FISSURECTMY
HEMORRHOIDECT COMPLX;
W/FISTULECTMY
SURG TX ANAL FISTULA; SUBQ
SURG TX ANAL FISTULA; SUBMUSCULAR
SURG TX ANAL FISTULA; COMPLX/MX
SURG TX ANAL FISTULA; 2ND STAGE
No
No
No
No
No
No
No
No
No
No
No
CLO ANAL FIST W/RECTAL ADVANC FLAP
ENUCLEATION EXT THROMBOTIC
HEMORRHO
INJ SCLEROSING SOLUTION
HEMORRHOIDS
CHEMODNRVTJ INT ANAL SPHNCTR
No
No
No
No
No
No
ANOSCOPY; DX W/WO SPECMN (SEP PRO)
ANOSCOPY; DILAT ANY METHD
ANOSCOPY; W/BX 1/MX
ANOSCOPY; W/REMOV FB
ANOSCOPY; W/REMOV 1 LESFORCEP/CAUT
ANOSCOPY; W/REMOV 1 TUMOR/LESSNARE
ANOSCOPY; W/REMOV MX LESCAUT/SNARE
46614
No
ANOSCOPY; W/CONTRL BLEED ANY METHD
No
46615
46700
No
Yes
ANOSCPY; ABLAT LES NOT AMENAB-FORCP
ANOPLASTY PLASTIC OR STRICT; ADULT
No
No
No
No
No
No
No
No
CPT Code
July 2011
46705
Yes
46706
46707
No
No
46710
Yes
46712
Yes
46715
Yes
46716
Code Description
ANOPLASTY PLASTIC OR STRICT; INFANT
REPAIR OF ANAL FISTULA WITH FIBRIN
GLUE
REPAIR ANORECTAL FIST W/PLUG
RPR ILEOANAL POUCH FSTL/POUCH
ADVMNT TPRNL APPR
RPR ILEOANAL POUCH FSTL/POUCH
ADVMNT CMBN APPR
No
No
Yes
REPR LO IMPERFORAT ANUS; W/FISTULA
REPR LO IMPERFORAT ANUS;
W/TRNSPOST
46730
Yes
REPR HI IMPERFORAT ANUS; PERINL/SAC
No
46735
Yes
REPR HIGH IMPERFORATE ANUS; COMBO
No
46740
Yes
REPR HI IMPERFOR ANUS W/FIST; PERIN
No
46742
Yes
No
46744
Yes
46746
Yes
REPR HI IMPERFOR ANUS; COMBO APPROC
REPR CLOACAL ANOMALYSACROPERINEAL
REPR CLOACAL ANOMALY-COMBO
APPROACH
46748
Yes
REPR CLOACAL ANOMALY; W/VAG LENGTH
No
46750
Yes
SPHINCTEROPLASTY-ANAL-INCONT; ADULT
No
46751
46753
46754
Yes
Yes
No
No
No
No
46760
Yes
46761
Yes
SPHINCTEROPLASTY-ANAL-INCONT; CHILD
GFT RECTAL INCONT &/OR PROLAPSE
REMOV THIERSCH WIRE ANAL CANAL
SPHINCTEROPLSTY-ANAL; MUSCL
TRANSPL
SPHINCTEROPLSTY-ANAL; LEVATOR
MUSCL
46762
Yes
SPHINCTEROPLSTY-ANAL; IMPLNT SPHINC
No
No
No
No
No
No
No
No
No
No
CPT Code
46900
July 2011
No
46910
No
46916
Code Description
DESTRCT LES ANUS SIMPL; CHEM
No
No
DESTRCT LES ANUS SIMP; ELECTRODESIC
DESTRCT LES ANUS SIMPL;
CRYOSURGERY
No
46917
46922
46924
46930
46940
No
No
No
No
No
DESTRCT LES ANUS SIMPL; LASER SURG
DESTRCT LES ANUS SIMPL; SURG EXC
DESTRCT LES ANUS EXTEN ANY METHD
DESTROY INTERNAL HEMORRHOIDS
CURET ANAL FISSURE (SEP PRO); INIT
No
No
No
No
No
46942
46945
46946
46947
46999
47000
No
No
No
No
Yes
No
CURET ANAL FISSURE (SEP PRO); SUBSQ
LIG INT HEMORRHOIDS; SNGL PROC
LIG INT HEMORRHOIDS; MX PROC
HEMORRHOIDOPEXY BY STAPLING
UNLISTED PROC ANUS
BX LIVER NEEDLE; PERCUT
No
No
No
No
Yes
No
47001
Yes
BX LIVER NEEDLE; DONE W/OTH MAJ PRO
No
47010
No
HEPATOT; OPEN DRAIN ABSC 1/2 STAGES
No
47011
No
HEPATOT; PERC DRAIN ABSC 1/2 STAGES
No
47015
47100
Yes
Yes
LAPAROT W/ASP/INJ HEPATIC CYST/ABSC
BX LIVER WEDGE
No
No
47120
47122
47125
47130
Yes
Yes
Yes
Yes
No
No
No
No
47133
Yes
HEPATECTOMY RESEC LIVER; PART LOBEC
HEPATECTOMY; TRISEGMENTECTOMY
HEPATECTOMY; TOT LT LOBEC
HEPATECTOMY; TOT RT LOBEC
DONOR HEPATECTOMY FROM CADAVER
DONOR
47135
47136
Yes
Yes
47140
Yes
LIVER ALLOTRANSPL; ORTHOTOP-PRT/ALL
LIVER ALLOTRANSPL; HETEROTOPIC
DONOR HEPATECTOMY LIVING DONOR; LT
LAT SEG ONLY
No
Yes
No
No
No
CPT Code
July 2011
47141
Yes
47142
Yes
47143
Yes
47144
Yes
47145
Yes
47146
Yes
47147
Yes
Code Description
DONOR HEPATECTOMY LIVING DONOR;
TOT LT LOBECTOMY
DONOR HEPATECTOMY LIVING DONOR;
TOT RT LOBECTOMY
BCKBNCH STD PREP CD WHOLE LG;NO
TRISEG/LOBE SPLT
BCKBNCH STD PREP CD WHOLE LIVR GFT;
TRISEG SPLIT
BCKBNCH STD PREP CD WHOLE LIVR GFT;
W/LOBE SPLIT
BACKBENCH RECONSTR CD/LD LG; VENUS
ANASTOM EA
BACKBENCH RECONSTR CD/LD LIVR
GFT;ART ANASTOM EA
47300
Yes
MARSUPIALIZATION CYST/ABSCESS LIVER
No
47350
47360
No
No
MGMT LIVER HEMORR; SIMPL SUT WOUND
MGMT LIVER HEMORR; COMPLX
No
No
47361
No
MGMT LIVER HEMORR; EXTEN DEBRID/SUT
No
47362
47370
47371
47379
47380
47381
47382
47399
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
MGMT LIVER HEMORR; RE-EXPLOR WOUND
LAP ABLAT 1/> LIVR TUMR; RADIOFREQ
LAP ABLAT 1/> LIVR TUMR; CRYOSURG
UNLISTED LAPAROSCOPIC PROC, LIVER
ABLAT OPN 1/> LIVR TUMR; RADIOFREQ
ABLAT OPN 1/> LIVR TUMR; CRYOSURG
ABLAT 1/> LIVR TUMR PERQ RADIOFREQ
UNLISTED PROC LIVER
No
No
No
Yes
No
No
No
Yes
47400
Yes
No
47420
Yes
47425
Yes
47460
Yes
HEPATICOTOMY W/EXPLOR/REMOV CALCU
CHOLEDOCH W/EXPLR/DRAIN; WO
SPHINCT
CHOLEDOCHOTOMY; W/SPHINC
TEROTOMY
TRANSDUODEN SPHINCTEROTOM (SEP
PRO)
No
No
Yes
Yes
Yes
No
No
No
No
No
CPT Code
July 2011
47480
47490
Yes
Yes
47500
Code Description
No
No
No
CHOLECYSTOTOMY W/EXPLOR (SEP PRO)
PERCUT CHOLECYSTOSTOMY
INJ PROC TRANSHEPATIC
CHOLANGIOGRAP
47505
47510
47511
47525
47530
47550
47552
47553
No
Yes
Yes
Yes
Yes
No
No
No
INJ PROC CHOLANGIOGRAPHY THRU CATH
INTRO TRANSHEPATIC CATH BILI DRAIN
INTRO TRANSHEPATIC STENT BILI DRAIN
CHANGE PERCUT BILI DRAINAGE CATH
REVIS/REINSERT TRANSHEPATIC TUBE
BILI ENDO INTRAOPERATIVE
BILI ENDO VIA T-TUBE; DX (SEP PROC)
BILI ENDO VIA T-TUBE; W/BX 1/MX
No
No
No
No
No
No
No
No
47554
47555
47556
No
No
No
No
No
No
47560
Yes
47561
47562
Yes
Yes
47563
Yes
47564
Yes
BILI ENDO VIA T-TUBE; W/REMOV STONE
BILI ENDO; W/DILAT DUCT WO STENT
BILI ENDO; W/DILAT DUCT W/STENT
LAP SURG; W/TRNSHEP CHOLANGIO WO
BX
LAP SURG; W/TRNSHEP CHOLANGIOG
W/BX
LAP SURG; CHOLECYSTECTOMY
LAP SURG; CHOLECYSTECTOMY
W/CHOLANG
LAP SURG; CHOLE W/EXPLR COMMON
DUCT
47570
47579
47600
47605
47610
Yes
Yes
Yes
Yes
Yes
No
Yes
No
No
No
47612
Yes
47620
47630
47700
Yes
Yes
Yes
LAP SURG; CHOLECYSTOENTEROSTOMY
UNLISTED LAP PROC-BILIARY TRACT
CHOLEY
CHOLEY; W/CHOLANGIOGRAPHY
CHOLEY W/EXPLOR COMMON DUCT
CHOLEY W/EXPLOR DUCT;
CHOLEDOCHEONT
CHOLEY; W/TRANSDUODEN
SPHINCTEROTMY
BILI DUCT STONE EXTRACT VIA T-TUBE
EXPLOR ATRESIA BILE DUCTS WO REPR
No
No
No
No
No
No
No
No
No
No
CPT Code
47701
47711
47712
47715
47720
July 2011
Yes
Yes
Yes
Yes
Yes
47721
Yes
47740
Yes
47741
47760
Yes
Yes
47765
Yes
47780
47785
47800
47801
47802
Yes
Yes
Yes
Yes
Yes
47900
47999
48000
Yes
Yes
Yes
48001
48020
48100
48102
48105
48120
Yes
Yes
Yes
No
Yes
Yes
48140
Yes
48145
Yes
48146
48148
Yes
Yes
Code Description
PORTOENTEROSTOMY
EXC BILE DUCT TUMOR; EXTRAHEPATIC
EXC BILE DUCT TUMOR; INTRAHEPATIC
EXC CHOLEDOCHAL CYST
CHOLECYSTOENTEROSTOMY; DIRECT
CHOLECYSTOENTEROS;
W/GASTROENTEROST
No
No
No
No
No
No
CHOLECYSTOENTEROSTOMY; ROUX-EN-Y
CHOLECYSTOENTEROS; ROUX-EN-Y
W/GAST
ANAS EXTRAHEP BIL DUCTS & GI TRACT
No
ANASTOM INTRAHEPAT DUCTS & GI TRACT
ANASTOM ROUX-EN-Y EXTRAHEPATIC
DUCT
ANAS ROUX-EN-Y INTRAHEP DUCTS & GI
RECON PLASTIC EXTRAHEPATIC BILI
PLCMT CHOLEDOCHAL STENT
U-TUBE HEPATICOENTEROSTOMY
No
SUTURE EXTRAHEP BIL DUCT (SEP PROC)
UNLISTED PROC BILI TRACT
PLCMT DRAINS PERIPANCREATIC
PLCMT DRAINS; W/CHOLECYSTOS
GASTROS
REMOV PANCREATIC CALCU
BX PANCREAS OPEN ANY METHD
BX PANCREAS PERCUT NEEDLE
RESECT/DEBRIDE PANCREAS
EXC LES PANCREAS
PANCREATECTMY; WO
PANCREATICOJEJUNO
PANCREATECTOMY;
W/PANCREATICOJEJUNO
PANCREATECTMY DIST NEAR-TOT
PRESERV
EXC AMPULLA VATER
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
48150
Yes
48152
Yes
48153
Yes
48154
48155
Yes
Yes
Code Description
PANCREATECTMY
W/PANCREATICODUODENEC
PANCREATEC TOT DUODEN; WO
PANCREATO
PANCREATEC W/NEAR-TOT;
W/PANCREATOJ
PANCREATEC W/NEAR-TOT; WO
PANCREATJ
PANCREATECTOMY TOT
48160
Yes
PANCREATECT TOT/SUBTOT W/TRANSPL
Yes
48400
48500
Yes
Yes
No
No
48510
Yes
48511
48520
48540
48545
Yes
Yes
Yes
Yes
INJ PROC INTRAOPERAT PANCREATOGRPH
MARSUPIALIZATION CYST PANCREAS
EXT DRAIN PSEUDOCYST PANCREAS;
OPEN
EXT DRAIN PSEUDOCYST PANCREAS;
PERC
INT ANAST PANCREATIC CYST-GI; DIREC
INT ANAST PANCREAT CYST; ROUX-EN-Y
PANCREATORRHAPHY TRAUMA
48547
48548
Yes
Yes
No
No
48550
Yes
48551
48554
Yes
Yes
DUODENAL EXCLUS W/GASTROJEJUNOS
FUSE PANCREAS AND BOWEL
DONOR PANCREATECTOMY W/WO
DUODENAL SEGMENT TPLNT
BACKBENCH STD PREP CADVR DONR PANC
ALLOGFT
TRANSPC PANCREATIC ALLOGFT
48556
48999
Yes
Yes
49000
49002
49010
49020
49021
Yes
Yes
Yes
Yes
No
REMOV TRANSPL PANCREATIC ALLOGFT
UNLISTED PROC PANCREAS
EXPLOR LAPAROTOMY W/WO BX (SEP
PRO)
REOPENING RECENT LAPAROTOMY
EXPLOR RETROPERITONEAL (SEP PRO)
DRAIN PERITONEAL ABSC; OPEN
DRAIN PERITONEAL ABSC; PERCUT
No
No
No
No
No
No
No
No
No
No
Yes
Yes
No
No
Yes
No
No
No
No
No
CPT Code
July 2011
49040
Yes
DRAIN SUBDIAPHRAGMATIC ABSC; OPEN
No
49041
49060
No
Yes
DRAIN SUBDIAPHRAGMATIC ABSC; PERCUT
DRAIN RETROPERITONEAL ABSC; OPEN
No
No
49061
No
No
49062
49080
49081
Yes
No
No
DRAIN RETROPERITONEAL ABSC; PERCUT
DRAIN EXTRAPERITON LYMPHOCELE,
OPEN
PERITONEOCENTESIS; INIT
PERITONEOCENTESIS; SUBSQT
49180
49203
49204
49205
Yes
Yes
Yes
Yes
No
No
No
No
49215
Yes
BX ABD/RETROPERITONEAL MASS PERCUT
EXC ABD TUM 5 CM OR LESS
EXC ABD TUM OVER 5 CM
EXC ABD TUM OVER 10 CM
EXC PRESACRAL/SACROCOCCYGEAL
TUMOR
49220
Yes
STAGING CELIOTOMY-HODGKIN'S DISEASE
No
49250
Yes
UMBILECTOMY/OMPHALECTOMY (SEP PRO)
No
49255
49320
Yes
Yes
OMENTECTOMY/EPIPLOECTOMY (SEP PRO)
LAP SURG-ABD; DX-W/WO SPECMN (SP)
No
No
49321
49322
49323
49324
49325
49326
49327
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
49329
49400
49402
49411
49412
Yes
No
Yes
No
No
LAP SURG-ABD PERITNM & OMENTM; W/BX
LAP SURG-ABD PERITNM; W/ASPIR
LAP SURG-ABD; W/DRAIN LYMPHOCELE
LAP INSERTION PERM IP CATH
LAP REVISION PERM IP CATH
LAP W/OMENTOPEXY ADD-ON
LAP INS DEVICE FOR RT
UNLIST LAP PROCABD/PERITONM/OMENTM
INJ AIR/CONTRAST-PERITONEAL CAVITY
REMOVE FOREIGN BODY, ADBOMEN
INS MARK ABD/PEL FOR RT PERQ
INS DEVICE FOR RT GUIDE OPEN
Code Description
No
No
No
No
Yes
No
Yes
No
Mp
CPT Code
49418
July 2011
No
49419
No
Code Description
INSERT TUN IP CATH PERC
INSRT INTRAPER CANNULA/CATH W/SUBQ
RESRVOR PERM
49421
Yes
INSRT INTRAPERITONEAL CANNULA; PERM
No
49422
No
REMOV PERM INTRAPERITONEAL CANNULA
No
49423
49424
49425
49426
No
No
Yes
Yes
EXCHG ABSC/CYST CATH-RAD GUIDE (SP)
CONTRST INJ-ABSC/CYST VIA CATH (SP)
INSRT PERITONEAL-VENOUS SHUNT
REVIS PERITONEAL-VENOUS SHUNT
No
No
No
No
49427
49428
49429
49435
49436
49440
49441
49442
49446
49450
49451
49452
49460
49465
49491
49492
49495
49496
49500
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
INJ PROC-EVAL PERITON-VENOUS SHUNT
LIG PERITONEAL-VENOUS SHUNT
REMOV PERITONEAL-VENOUS SHUNT
INSERT SUBQ EXTEN TO IP CATH
EMBEDDED IP CATH EXIT-SITE
PLACE GASTROSTOMY TUBE PERC
PLACE DUOD/JEJ TUBE PERC
PLACE CECOSTOMY TUBE PERC
CHANGE G-TUBE TO G-J PERC
REPLACE G/C TUBE PERC
REPLACE DUOD/JEJ TUBE PERC
REPLACE G-J TUBE PERC
FIX G/COLON TUBE W/DEVICE
FLUORO EXAM OF G/COLON TUBE
REP ING HERN PRTERM INFNT; REDUC
REP ING HERN PRTERM INFNT; INCAR
REPR INIT ING HERNIA <6 MO; REDUCIB
REPR INIT ING HERNIA <6MO; INCARCER
REPR INIT ING HERNIA 6MO-<5YR; REDU
No
No
No
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
49501
49505
49507
49520
No
No
No
No
REPR ING HERNIA 6MO-<5YR;INCAR/STRN
REPR INIT ING HERNIA 5YR/MORE; REDU
REPR INIT ING HERNIA > 5YR; INCARC
REPR RECUR ING HERNIA; REDUCIBLE
No
No
No
No
49521
No
REPR RECUR ING HERNIA; INCARC/STRAN
No
No
No
CPT Code
49525
49540
July 2011
No
No
49550
No
REPR INIT FEM HERNIA ANY AGE; REDUC
No
49553
49555
No
No
REPR INIT FEM HERNIA; INCARC/STRANG
REPR RECUR FEM HERNIA; REDUCIBLE
No
No
49557
49560
49561
No
No
No
REPR RECUR FEM HERNIA; INCARC/STRAN
REPR INIT INCS/VENT HERNIA; REDUCIB
REPR INIT INCS/VENT HERN; INCARCER
No
No
No
49565
No
REPR RECUR INCS/VENT HERNIA; REDUCI
No
49566
No
REPR RECUR INCS/VENT HERNIA; INCARC
No
49568
49570
No
No
IMPLNT MESH/OTH-INCS/VENT HERN REPR
REPR EPIGASTRIC HERNIA; REDUCIBLE
No
No
49572
No
REPR EPIGAST HERNIA; INCARC/STRANG
No
49580
49582
No
No
REPR UMBILIC HERNIA <5YR; REDUCIBLE
REPR UMBILIC HERNIA <5YR; INCAR/STR
No
No
49585
No
REPR UMBIL HERNIA 5YR/OVER; REDUCIB
No
49587
49590
49600
No
No
No
REPR UMBIL HERNIA 5YR/OVER; INCARCR
REPR SPIGELIAN HERNIA
REPR SM OMPHALOCELE W/PRIM CLO
No
No
No
49605
No
No
49606
49610
49611
49650
No
No
No
No
REPR LG OMPHALOCELE; W/WO PROSTH
REPR LG OMPHALOCELE; W/REMOV
PROSTH
REPR OMPHALOCELE; FIRST STAGE
REPR OMPHALOCELE; SECOND STAGE
LAP SURG; REPR INIT INGUINAL HERNIA
49651
49652
No
No
LAP SURG; REPR RECUR INGUIN HERNIA
LAP VENT/ABD HERNIA REPAIR
No
No
Code Description
REPR ING HERNIA SLIDING ANY AGE
REPR LUMBAR HERNIA
No
No
No
No
No
No
CPT Code
49653
49654
49655
49656
49657
July 2011
No
No
No
No
No
49659
49900
49904
49905
Yes
Yes
Yes
Yes
49906
Yes
Code Description
LAP VENT/ABD HERN PROC COMP
LAP INC HERNIA REPAIR
LAP INC HERN REPAIR COMP
LAP INC HERNIA REPAIR RECUR
LAP INC HERN RECUR COMP
UNLISTED LAP PROCHERNIOPLSTY/OTOMY
SUTURE 2ND ABD WALL EVISCERATION
OMENTL FLAP EXTRA-ABDOMINAL
OMENTAL FLAP
FREE OMENTAL FLAP W/MICROVASC
ANAST
49999
Yes
UNLIST PROC ABD PERITONEUM/OMENTUM
Yes
50010
50020
Yes
Yes
RENAL EXPLOR WO OTHER SPECIFIC PROC
DRAIN PERIRENAL/RENAL ABSC; OPEN
No
No
50021
No
No
50040
50045
50060
Yes
Yes
Yes
50065
Yes
DRAIN PERIRENAL/RENAL ABSC; PERCUT
NEPHROSTOMY NEPHROTOMY
W/DRAINAGE
NEPHROTOMY W/EXPLOR
NEPHROLITHOTOMY; REMOV CALCU
NEPHROLITHOTOMY; 2ND SURG FOR
CALCU
50070
50075
Yes
Yes
No
No
50080
Yes
NEPHROLITHOTOMY; CONGEN KIDNEY ABN
NEPHROLITHOTOMY; REMOV LG CALCU
PERQ NEPHROSTOLITHOTOMY; UP TO 2
CM
50081
Yes
PERQ NEPHROSTOLITHOTOMY; OVER 2 CM
No
50100
50120
Yes
Yes
TRANSEC ABERRNT RENAL VESS (SEP PRO
PYELOTOMY; W/EXPLOR
No
No
50125
50130
50135
Yes
Yes
Yes
PYELOTOMY; W/DRAINAGE PYELOSTOMY
PYELOTOMY; W/REMOV CALCU
PYELOTOMY; COMPLIC
No
No
No
No
No
No
No
No
Yes
No
No
No
Yes
No
No
No
No
No
CPT Code
50200
50205
July 2011
No
Yes
50220
50225
Yes
Yes
NEPHRECTOMY W/PART URETERECTOMY
NEPHRECT; PREV SURG SAME KIDNEY
No
No
50230
Yes
NEPHREC; RAD W/REGION LYMPHADENECT
No
50234
Yes
NEPHRECT W/TOT URETERECT; SAME INCS
No
50236
50240
Yes
Yes
No
No
50250
50280
50290
Not Reimbursable
Yes
Yes
50300
Yes
50320
Yes
50323
Yes
50325
Yes
50327
Yes
50328
Yes
50329
Yes
NEPHRECT W/URETERECT; SEPART INCS
NEPHRECTOMY PART
ABLTJ OPN 1+ RNL LES CRYOSURG
W/INTRAOP US
EXC/UNROOFING CYST KIDNEY
EXC PERINEPHRIC CYST
DONOR NEPHRECTOMY CADAVER DONOR
UNI/BIL
DONOR NEPRECTOMY; OPEN LIVING
DONOR
RENL ALLOGFT
BACKBENCH STD PREP L/D RENAL
ALLOGFT OPEN/LAP
BCKBNCH RECONSTR CD/LD RENL
ALLOGFT;VEN ANAST EA
BCKBNCH RECONSTR CD/LD RENL
ALLOGFT;ART ANAST EA
BCKBNCH RECNSTR CD/LD RENL
ALLOGFT;URET ANAST EA
50340
Yes
50360
Code Description
RENAL BX; PERCUT-TROCAR/NEEDLE
RENAL BX; BY SURG EXPOSURE KIDNEY
No
No
Not Reimbursable
No
No
Yes
No
Yes
Yes
No
No
No
No
Yes
RECIPIENT NEPHRECTOMY (SEPART PROC)
RENAL ALLOTPLNT IMPLNT GRAFT; W/O
RECIP NEPHRECT
50365
50370
Yes
Yes
RENAL ALLOTRANSPL; W/RECIP NEPHRECT
REMOV TRANSPL RENAL ALLOGFT
No
No
50380
Yes
RENAL AUTOTRANSPL; REIMPLNT KIDNEY
No
No
CPT Code
July 2011
50382
50384
50385
50386
No
No
No
No
50387
50389
50390
Yes
Yes
No
50391
50392
No
No
Code Description
RMVL&RPLCMT INTLY DWELLING URTRL
STENT
RMVL INTLY DWELLING URTRL STENT
CHANGE STENT VIA TRANSURETH
REMOVE STENT VIA TRANSURETH
RMVL&RPLCMT XTRNLLY ACCESSIBLE
URTRL STENT
RMVL NFROS TUBE REQ FLUOR GID
ASPIRAT &/OR INJ RENAL CYST-NEEDLE
INSTL TX AGT RENL PELV&/URETR THRU
EST NEPHROST
INTRO INTRACATH-RENAL PELVIS-DRAIN
50393
No
INTRO URETERAL CATH THRU RENAL PELV
No
50394
50395
No
No
No
No
50396
No
50398
50400
50405
No
Yes
Yes
50500
50520
50525
50526
50540
50541
Yes
Yes
Yes
Yes
Yes
Yes
50542
Yes
50543
50544
50545
50546
Yes
Yes
Yes
Yes
50547
Yes
INJ PROC PYELOGRAPHY-NEPHROST TUBE
INTRO-GUIDE-RENAL PELVIS W/DILAT
MANOMETRIC STUDIES-NEPHROSTOMY
TUBE
CHANGE NEPHROSTOMY/PYELOSTOMY
TUBE
PYELOPLASTY; SIMPL
PYELOPLASTY; COMPLIC
NEPHRORRHAPHY SUTURE KIDNEY
WOUND
CLO NEPHROCUT/PYELOCUT FISTULA
CLO NEPHROVISCERAL FISTULA; ABD
CLO NEPHROVISCERAL FIST; THORACIC
SYMPHYSIOTOMY UNILAT/BILAT
LAP SURG; ABLATION RENAL CYSTS
LAPAROSCOPY SURGICAL; ABLAT RENAL
MASS LESION
LAPAROSCOPY SURGICAL; PARTIAL
NEPHRECTOMY
LAP SURG; PYELOPLASTY
LAP SURG; RADICAL NEPHRECTOMY
LAP SURG; NEPHRECTOMY
LAPARSCPY SURG; DONOR NEPHRECT
FROM LIVING DONOR
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
50548
50549
50551
50553
Yes
Yes
Yes
Yes
LAP ASSISTED NEPHROURETERECTOMY
UNLISTED LAP PROC-RENAL
RENAL ENDO-ESTAB NEPHROSTOMY
RENAL ENDO; W/URETHERAL CATH
No
Yes
No
No
50555
Yes
RENAL ENDO-ESTAB NEPHROSTOMY; W/BX
No
50557
50561
Yes
Yes
No
No
50562
Yes
RENAL ENDO-ESTAB NEPHROST; W/FULG
RENAL ENDO; W/REMOV FB/CALCU
RENL ENDO THRU EST
NEPHROST/PYELOST; W/RES TUMR
50570
Yes
No
50572
50574
Yes
Yes
50575
50576
50580
50590
50592
50593
Yes
Yes
Yes
Yes
Not Reimbursable
Yes
RENAL ENDO-NEPHROTOMY; W/WO IRRIGA
RENAL ENDO-NEPHROTMY; W/URETER
CATH
RENAL ENDO-NEPHROTOMY; W/BX
RENAL ENDO-NEPHROT;
W/ENDOPYELOTOMY
RENAL ENDO-NEPHROTOMY; W/FULG
RENAL ENDO-NEPHROTOMY; REMOV FB
LITH EXTRACORPOREAL SHOCK WAVE
ABLTJ 1+ RNL TUM PRQ UNI RF
PERC CRYO ABLATE RENAL TUM
No
No
No
No
Not Reimbursable
No
50600
Yes
URETEROTOMY W/EXPLOR (SEPART PROC)
No
50605
Yes
URETEROTOMY INSRT STENT ALL TYPES
No
50610
50620
Yes
Yes
URETEROLITHOTOMY; UPPER 1/3 URETER
URETEROLITHOTOMY; MID 1/3 URETER
No
No
50630
Yes
No
50650
50660
50684
Yes
Yes
No
50686
No
URETEROLITHOTOMY; LOWER 1/3 URETER
URETERECTMY W/BLADDER CUFF(SEP
PRO)
URETERECTOMY TOT-COMBO ABD/VAG
INJ PROC-URETEROGRAPHY THRU CATH
MANOMETRIC STUDIES THRU
URETEROSTMY
Code Description
No
No
No
No
No
No
No
CPT Code
50688
50690
50700
July 2011
No
No
Yes
50715
Yes
URETEROLYSIS W/WO REPOSIT URETER
No
50722
Yes
No
50725
50727
Yes
Yes
URETEROLYSIS OVARIAN VEIN SYNDROME
URETEROLYSIS W/REANASTOM URIN
TRACT
REVIS URIN-CUT ANASTOM
50728
50740
50750
50760
50770
Yes
Yes
Yes
Yes
Yes
50780
Yes
50782
Yes
50783
50785
Yes
Yes
50800
Yes
50810
Yes
50815
50820
Yes
Yes
50825
50830
Yes
Yes
50840
50845
Yes
Yes
50860
50900
Yes
Yes
Code Description
CHANGE URETEROSTOMY TUBE
INJ PROC-VISUALIZ ILEAL CONDUIT
URETEROPLASTY PLASTIC OR URETER
No
No
No
No
No
REVIS URIN-CUT ANASTOM; REPR DEFECT
URETEROPYELOSTOMY ANASTOM
URETEROCALYCOSTOMY ANASTOM
URETEROURETEROSTOMY
TRANSURETEROURETEROSTOMY
URETERONEOCYSTOSTOMY; SNGL
URETER
URETERONEOCYSTOSTOMY; DUPLIC
URETER
No
No
No
No
No
URETERONEOCYSTOSTOMY; W/TAILORING
URETERONEOCYSTOSTOMY; W/HITCH
URETEROENTEROSTOMY DIRECT
ANASTOM
URETEROSIGMOIDOSTOMY W/CREAT
BLADDR
No
No
URETEROCOLON CONDUIT INCL ANASTOM
URETEROILEAL CONDUIT INCL ANASTOM
CONTINENT DIVERSION W/BOWEL
ANASTOM
URIN UNDIVERSION
No
No
REPL ALL/PART URETER BY BOWEL SEGMT
CUT APPENDICO-VESICOSTOMY
URETEROSTOMY TRANSPL URETER TO
SKIN
URETERORRHAPHY (SEPART PROC)
No
No
No
No
No
No
No
No
No
No
CPT Code
50920
50930
50940
50945
July 2011
Yes
Yes
Yes
Yes
50947
Yes
50948
Yes
50949
50951
Yes
No
50953
No
50955
No
50957
No
50961
50970
Code Description
CLO URETEROCUTANEOUS FISTULA
CLO URETEROVISCERAL FISTULA
DELIGATION URETER
LAP SURG-URETEROLITHOTOMY
LAP SURG; URETERONEOCYSTOSTOMY
W/CYSTOSCOPY
LAP SURG; URETERONEOCYSTOSTOMY
W/OUT CYSTOSCOPY
LAP SURG; UNLISTED LAPAROSCOPY
PROC, URETER
URETERAL ENDO-URETEROSTOMY
URETERAL ENDO-URETEROSTOMY;
W/CATH
No
No
No
No
No
No
Yes
No
No
No
No
No
URETERAL ENDO-URETEROSTOMY; W/BX
URETERAL ENDO-URETEROSTOMY;
W/FULG
URETERAL ENDO-URETEROSTMY; REMOV
FB
URETERAL ENDO-URETEROTOMY
50972
50974
No
No
URETERAL ENDO-URETEROTOMY; W/CATH
URETERAL ENDO-URETEROTOMY; W/BX
No
No
50976
No
No
50980
No
URETERAL ENDO-URETEROTOMY; W/FULG
URETERAL ENDO-URETEROTOMY; REMOV
FB
51020
Yes
CYSTOTOMY; W/FULG &/OR INSRT RADIOA
No
51030
Yes
CYSTOTOMY; W/CRYOSURG DESTRCT LES
No
51040
51045
Yes
Yes
No
No
51050
51060
Yes
Yes
51065
Yes
CYSTOSTOMY CYSTOTOMY W/DRAINAGE
CYSTOTOMY W/INSRT CATH (SEP PRO)
CYSTOLITHOTMY WO VESICL NECK
RESECT
TRANSVESICAL URETEROLITHOTOMY
CYSTOTOMY W/STONE BSKT EXTRACT
CALC
No
No
No
No
No
No
No
CPT Code
July 2011
51080
51100
51101
51102
Yes
No
No
No
DRAINAGE PERIVESICAL SPACE ABSCESS
DRAIN BLADDER BY NEEDLE
DRAIN BLADDER BY TROCAR/CATH
DRAIN BL W/CATH INSERTION
No
No
No
No
51500
Yes
EXC URACHAL CYST W/WO HERNIA REPR
No
51520
51525
51530
Yes
Yes
Yes
No
No
No
51535
51550
51555
Yes
Yes
Yes
CYSTOTOMY; EXC VESIC NECK (SEP PRO)
CYSTOTOMY; EXC DIVERTIC (SEP PRO)
CYSTOTOMY; EXC BLADDER TUMOR
CYSTOTOMY EXC INCS/REPR
URETEROCELE
CYSTECTOMY PART; SIMPL
CYSTECTOMY PART; COMPLIC
51565
51570
Yes
Yes
No
No
51575
Yes
51580
Yes
51585
Yes
CYSTECTOMY PART W/REIMPLNT URETER
CYSTECTOMY COMPLT; (SEPART PROC)
CYSTECTOMY COMPLT; W/BILAT
LUMPHADN
CYSTECTMY COMPLT
W/URETEROSIGMOIDOS
CYSTECTOMY W/URETERSIGMOID;
W/LYMPH
51590
Yes
CYSTECTOMY COMPLT W/URETEROILEAL
No
51595
Yes
No
51596
Yes
CYSTECTOMY W/SIGMOID BLAD; W/LYMPH
CYSTECTOMY COMPLT W/CONTINENT
DIVER
51597
51600
Yes
No
51605
No
51610
51700
No
No
Code Description
PELVIC EXENTERATION-URETHRAL MALIG
INJ PROC-CYSTOGRAPHY
INJ PROC-CONTRAST
URETHROCYSTOGRAPY
INJ PRO RETROGRD
URETHROCYSTOGRAPHY
BLADDER IRRIGA SIMPL LAVAGE
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
51701
No
51702
No
51703
51705
51710
No
No
No
Code Description
INSERT OF NON-INDWELLING BLADDER
CATHETER
INSERT OF TEMP INDWELLING BLADDER
CATHETER
INSERT OF NON-INDWELLING BLADDER
CATHETER COMPL
CHANGE CYSTOSTOMY TUBE; SIMPL
CHANGE CYSTOSTOMY TUBE; COMPLIC
51715
No
ENDO INJ IMPLNT MAT-URETH/BLAD NECK
No
51720
51725
51726
51727
51728
51729
51736
51741
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
51784
No
BLADDER INSTILL ANTICARCOGENIC AGNT
SIMPL CYSTOMETROGRAM
COMPLX CYSTOMETROGRAM
CYSTOMETROGRAM W/UP
CYSTOMETROGRAM W/VP
CYSTOMETROGRAM W/VP&UP
SIMPL UROFLOWMETRY
COMPLX UROFLOWMETRY
EMG ANAL/URETH SPHINCTER-NOT
NEEDLE
51785
51792
51797
No
No
No
No
No
No
51798
51800
No
Yes
51820
51840
51841
Yes
Yes
Yes
NEEDLE EMG STDY ANAL/URETHRAL SPHIN
STIMULUS EVOKED RESPONSE
VOIDING PRESS STUDIES; INTRA-ABD
MEASUREMENT PVR URIN&/BLADD
CAPACTY US NON-IMAG
CYSTOPLASTY/CYSTOURETHROPLASTY
CYSTOURETHROPLASTY
W/URETERONEOCYST
ANT VESICOURETHROPEXY; SIMPL
ANT VESICOURETHROPEXY; COMPLIC
51845
51860
Yes
Yes
ABD-VAG VESICAL NECK SUSP W/WO ENDO
CYSTORRHAPHY WOUND/RUPT; SIMPL
No
No
51865
51880
Yes
Yes
CYSTORRHAPHY WOUND/RUPT; COMPLIC
CLO CYSTOSTOMY (SEPART PROC)
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
51900
51920
51925
51940
Yes
Yes
Yes
Yes
51960
51980
51990
Code Description
No
No
No
No
Yes
Yes
Yes
CLO VESICOVAG FISTULA ABD APPROACH
CLO VESICOUTERINE FISTULA
CLO VESICOUTERINE FISTULA; W/HYST
CLO BLADDER EXSTROPHY
ENTEROCYSTOPLASTY INCL BOWEL
ANASTO
CUT VESICOSTOMY
LAP SURG; URETHRAL SUSPENSION
51992
51999
52000
Yes
Yes
No
LAP SURG; SLING OPER-STRESS INCONTI
UNLIS LAPS PX BLDR
CYSTOURETHROSCOPY (SEPART PROC)
No
Yes
No
52001
No
No
52005
52007
No
No
52010
52204
No
No
CYSTURETHRSCPY W/IRRIG&EVAC CLOTS
CYSTOURETHROSCOPY W/URETERAL
CATH
CYSTOURETHROSCOPY; W/BRUSH BX
CYSTOURETHROSCOPY W/EJACULAT
DUCT
CYSTOURETHROSCOPY W/BX
52214
No
CYSTOURETHROSCOPY W/FULG TRIGONE
No
52224
No
No
52234
No
52235
No
52240
No
52250
No
CYSTOURETHROSCOPY W/TX MINOR LES
CYSTOURETHROSCOPY W/FULG &/ RES;
SM BLADDER TUMR
CYSTOURETHROSCOPY W/FULG; MED
TUMOR
CYSTOURETHROSCOPY W/FULG; LG
TUMOR
CYSTOURETHROSCOPY W/INSRT
RADIOACT
52260
No
52265
No
52270
No
CYSTOURETHROSCPY W/DILAT; GEN ANES
CYSTOURETHROSCOPY W/DIL; LOCAL
ANES
CYSTOURETHROSCOPY
W/URETHROTOMY; FE
No
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
52275
No
52276
No
52277
52281
No
No
52282
52283
No
No
52285
No
52290
No
52300
No
52301
Code Description
CYSTOURETHROSCPY W/URETHROTMY;
MALE
CYSTOURETHROSCOPY W/INT
URETHROTOMY
CYSTOURETHROSCOPY W/RESECT
SPHINCT
CYSTOURETHROSCOPY W/CALIBRAT
No
No
No
No
No
No
No
CYSTOURETHSCPY W/INSRT URETH STENT
CYSTOURETHROSCOPY W/STEROID INJ
CYSTOURETHROSCPY TX FE URETHRL
SYND
CYSTOURETHROSCOPY; W/URETERL
MEATOT
CYSTURETHROSCPY; W/RESECT
URETERCEL
CYSTURETHSCPY; RESEC ECTOP
URETOCEL
52305
No
CYSTOURETHROSCOPY; W/INCS DIVERTIC
No
52310
No
No
52315
No
CYSTOURETHROSCOPY (SEP PRO); SIMPL
CYSTOURETHROSCPY (SEP PRO);
COMPLIC
52317
52318
No
No
LITH: CRUSH CALCU-BLADDER; SIMPL/SM
LITH: CRUSH CALCU-BLADDER; LG
No
No
52320
No
No
52325
No
52327
No
52330
52332
No
No
52334
No
CYSTOURETHROSCOPY; W/REMOV CALCU
CYSTOURETHROSCOPY; W/FRAGMNT
CALCU
CYSTOURETHROSCOPY; W/INJ IMPLNT
MAT
CYSTOURETHROSCOPY; W/MANIP WO
REMOV
CYSTOURETHROSCOPY W/INSRT STENT
CYSTOURETHROSCPY W/INSRT GUIDE
WIRE
No
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
52341
No
52342
No
52343
No
52344
No
52345
No
52346
No
52351
No
52352
No
52353
No
52354
No
52355
No
52400
No
52402
52450
52500
No
No
No
52601
No
52630
No
52640
No
52647
No
Code Description
CYSTOURETHROSCOPY; W/TREATMNT OF
URETERAL STRICTURE
CYSTOURETHROSCOPY; W/URETERPELVIC
JUNCT STRICT TRTMNT
CYSTOURETHROSCOPY; W/INTRA-RENAL
STRICT TRTMNT
CYSTOURETHROSCOPY
W/URETEROSCOPY
CYSTOURETHROSCOPY W TRTMNT OF
INTRA RENAL STRICTURE
CYSTOURETHROSCOPY W/INTRA RENAL
STRICT TRTMNT
CYSTOURETHROSCOPY,
W/URETEROSCOPY AND/OR PYELOSCOPY
CYSTOURETHROSCOPY W/REMOVE OR
MANIPUL OF CALCULUS
No
No
No
No
No
No
No
No
CYSTOURETHROSCOPY; W/LITHOTRIPSY
CYSTOURETHROSCOPY; W/BX AND/OR
FULGURTION OF LESION
CYSTOURETHROSCOPY; W/RESECTION OF
TUMOR
CYSTOURETHROSCOPY W/INCISION, FULG,
RESECT
CYSTURETHRSCPY TRNSURETH RES/INCI
EJACULAT DUCTS
TRANSURETHRAL INCS PROSTATE
T U R BLADDER NECK (SEPART PROC)
No
T U R P INCL CONTRL POSTOP BLEEDING
T U R; REGROWTH OBSTRUC >1YR
POSTOP
No
T U R; POSTOP BLADDR NECK CONTRACTU
NON-CONTACT LASER COAGULA
PROSTATE
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
52648
52649
No
Yes
CONTACT LASER VAPORIZA W/WO TURP
PROSTATE LASER ENUCLEATION
No
No
52700
53000
53010
No
Yes
Yes
TRANSURETH DRAIN PROSTATIC ABSCESS
URETHROT EXT (SEP PRO); PENDULOUS
URETHROT EXT (SEP PRO); PERINEAL
No
No
No
53020
Yes
MEATOTOMY (SEPART PROC); EX INFANT
No
53025
Yes
MEATOTOMY CUTTING MEATUS (SEP PRO)
No
53040
No
DRAINAGE DEEP PERIURETHRAL ABSCESS
No
53060
No
DRAINAGE SKENE'S GLAND ABSCESS/CYST
No
53080
No
DRAIN EXTRAVASAT; UNCOMP (SEP PRO)
No
53085
53200
No
No
No
No
53210
Yes
53215
53220
53230
53235
Yes
Yes
Yes
Yes
DRAIN PERINEAL EXTRAVASAT; COMPLIC
BX URETHRA
URETHRECTMY TOT INCL CYSTOSTOMY;
FE
URETHRECTOMY TOT W/CYSTOSTOMY;
MALE
EXC/FULG CARCINOMA URETHRA
EXC URETHRAL DIVERTIC (SEP PRO); FE
EXC URETH DIVERTIC (SEP PRO); MALE
53240
53250
Yes
Yes
MARSUPIALIZ URETH DIVERTIC; MALE/FE
EXC BULBOURETHRAL GLAND
No
No
53260
53265
53270
53275
53400
Yes
Yes
Yes
Yes
Yes
EXC; URETHRAL POLYP/DISTAL URETHRA
EXC/FULG; URETHRAL CARUNCLE
EXC/FULG; SKENE'S GLANDS
EXC/FULG; URETHRAL PROLAPSE
URETHROPLASTY; 1ST STAGE-FISTULA
No
No
No
No
No
53405
53410
Yes
Yes
URETHROPLASTY; 2ND STAGE W/DIVERS
URETHROPLSTY 1-STAGE RECON MALE
No
No
Code Description
No
No
No
No
No
CPT Code
July 2011
53415
Yes
Code Description
URETHROPLASTY 1 STAGE RECON
URETHRA
53420
Yes
URETHROPLSTY 2-STAGE RECON; 1ST STG
No
53425
53430
Yes
Yes
No
No
53431
Yes
53440
Yes
53442
53444
Yes
Yes
URETHROPLSTY 2-STAGE RECON; 2ND STG
URETHROPLASTY RECON FE URETHRA
URETHRPLSTY W/TUBULARIZ PST
URETHRA
OR CORRECT MALE INCONT W/WO
PROSTH
REMOV PERINEAL PROSTH FOR
CONTINENC
INSERTION OF TANDEM CUFF
53445
53446
Yes
No
OR-CORRECT URIN INCONT W/SPHINCTER
REMV INFLATABLE SPHNCTR W/PUMP
No
No
53447
53448
Yes
Yes
REMOV/REPR/REPLAC INFLATBL SPHINCTR
REMV&REPL INFLAT SPHNCTR INF FLD
No
No
53449
Yes
No
53450
Yes
53460
Yes
53500
Yes
SURG CORRECT ABNL INFLATBL SPHINCTR
URETHROMEATOPLASTY W/MUCOS
ADVANCMT
URETHROMEATOPLSTY W/EXC URETHRL
SEG
URETHROLYSIS TRANSVAG SEC OPN
W/CYSTOURETHROSCPY
53502
Yes
No
53505
53510
Yes
Yes
53515
Yes
URETHRORRHAPHY SUTURE WOUND; FE
URETHRORRHAPHY SUTURE WOUND;
PENILE
URETHRORRHAPHY WOUND; PERINEAL
URETHRORRHAPHY;
PROSTATOMEMBRANOUS
53520
53600
53601
Yes
No
No
CLO URETHROSTMY FIST MALE (SEP PRO)
DILAT URETHRAL STRICT-MALE; INIT
DILAT URETHRAL STRICT-MALE; SUBSQT
No
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
53605
53620
No
No
DILAT URETHRAL STRICT-MALE-GEN ANES
DILAT URETHRAL-FILLIFORM-MALE; INIT
No
No
53621
53660
No
No
DILAT URETHRAL FILLIFRM-MALE; SUBSQ
DILAT FE URETHRA W/SUPPOSIT; INIT
No
No
53661
No
DILAT FE URETHRA W/SUPPOSIT; SUBSQT
No
53665
Yes
No
53850
Yes
53852
53855
53860
53899
54000
Yes
Yes
Not Reimbursable
Yes
No
DILAT FE URETHRA GEN/CONDUCT ANES
TRNSURETH DESTRUC PROSTATE;
MICWAVE
TRNSURETH DESTRUC PROSTAT;
RADIOFRQ
INSERT PROST URETHRAL STENT
TRANSURETHRAL RF TREATMENT
UNLISTED PROC URIN SYST
SLIT PREPUCE DORSAL (SEP PRO); NB
No
No
Not Reimbursable
Yes
No
54001
54015
54050
No
No
No
SLIT PREPUCE DORSL (SEP PRO); EX NB
I&D PENIS DEEP
DESTRCT LES PENIS SIMPL; CHEM
No
No
No
54055
54056
No
No
DESTRCT LES PENIS SIMPL; ELECTRODES
DESTRCT LES PENIS SIMPL; CRYOSURG
No
No
54057
54060
54065
54100
54105
54110
54111
54112
54115
54120
54125
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
DESTRCT LES PENIS SIMPL; LASER SURG
DESTRCT LES PENIS SIMPL; SURG EXC
DESTRCT LES PENIS EXTEN ANY METHD
BX PENIS; (SEP PROC)
BX PENIS; DEEP STRUCT
EXC PENILE PLAQUE
EXC PENILE PLAQUE; W/GFT TO 5 CM
EXC PENILE PLAQUE; W/GFT > 5 CM
REMOV FB FROM DEEP PENILE TISS
AMPUTA PENIS; PART
AMPUTA PENIS; COMPLT
No
No
No
No
No
No
No
No
No
No
No
54130
Yes
AMPUTA PENIS RAD; W/INGUINOFEM LYMP
No
Code Description
No
CPT Code
July 2011
54135
54150
Yes
Yes
AMPUTA PENIS RAD; W/PELVIC LYMPHADN
CIRCUMCISION USING CLAMP; NB
No
Yes
54160
54161
54162
54163
54164
54200
Yes
Yes
Yes
Yes
No
No
CIRCUMCISION SURG EXC NOT CLAMP; NB
CIRCUMCISION SURG EXC; EX NB
LYSIS/EXC PENILE POST-CIRC ADHES
REPAIR INCOMPLETE CIRCUMCISION
FRENULOTOMY OF PENIS
INJ PROC PEYRONIE DISEASE
Yes
Yes
Yes
Yes
No
No
54205
Yes
INJ PROC PEYRONIE DISEAS; W/EXPOSUR
No
54220
No
IRRIGA CORPORA CAVERNOSA PRIAPISM
No
54230
No
No
54231
No
54235
54240
No
No
INJ PROC CORPORA CAVERNOSOGRAPHY
DYNAMIC CAVERNOSOMETRY W/INJ
DRUGS
INJ CORPORA CAVERNOSA W/PHARM
AGENT
PENILE PLETHYSMOGRAPHY
54250
54300
Not Reimbursable
Yes
NOCTURNAL PENILE TUMESCENCE TEST
PLASTIC OPERAT PENIS-CHORDEE
Not Reimbursable
No
54304
Yes
PLASTIC OPERAT PENIS W/WO TRANSPL
No
54308
Yes
URETHROPLSTY 2ND STAGE REPR; < 3 CM
No
54312
Yes
URETHROPLSTY 2ND STAGE REPR; > 3 CM
No
54316
Yes
No
54318
Yes
URETHROPLSTY 2ND STAGE REPR; W/GFT
URETHROPLSTY RELEAS PENIS FRM
SCROT
54322
Yes
1 STAGE DISTAL REPR; W/SIMPL ADVANC
No
54324
54326
Yes
Yes
1 STAGE DISTAL REPR; W/URETHROPLSTY
1 STAGE DISTAL REPR; MOBILIZ URETHR
No
No
Code Description
No
No
No
No
CPT Code
July 2011
54328
Yes
1 STAGE DISTAL REPR; W/EXTEN DISSEC
No
54332
Yes
1 STAGE PENILE REPR W/EXTEN DISSECT
No
54336
Yes
1 STAGE PERINEAL HYPOSPADIAS REPR
No
54340
Yes
REPR HYPOSPADIAS COMPLIC; CLO SIMPL
No
54344
Yes
REPR HYPOSPADIAS COMPLIC; REQ FLAPS
No
54348
Yes
REPR HYPOSPADIAS COMPLIC; W/DISSECT
No
54352
Yes
REPR HYPOSPADIAS CRIPPLE W/DISSECT
No
54360
54380
54385
Yes
Yes
Yes
PLASTIC OR PENIS CORRECT ANGULATION
PLASTIC OR PENIS EPISPADIAS
PLASTIC-PENIS EPISPADIAS; W/INCONT
No
No
No
54390
Yes
PLASTIC-PENIS EPISPAD; W/EXSTROPHY
No
54400
54401
54405
Yes
Not Reimbursable
Not Reimbursable
INSRT PENILE PROSTH; NON-INFLATABLE
INSRT PENILE PROSTH; INFLATABLE
INSRT PENILE PROSTH W/PLCMT PUMP
No
Not Reimbursable
Not Reimbursable
54406
Yes
REMV INFLATABL PENIL PROSTH NO REPL
No
54408
54410
Not Reimbursable
Not Reimbursable
REP CMPNT INFLATABLE PENILE PROSTH
REMV&REPL INFLAT PENIL PRSTH-ID OP
Not Reimbursable
Not Reimbursable
54411
Not Reimbursable
REMV&REPL INFLAT PNIL PRSTH-INF FLD
Not Reimbursable
54415
54416
54417
Yes
Yes
Yes
No
No
No
54420
Yes
54430
Yes
REMV PENILE PROSTH NO REPLACEMENT
REMV&REPL PENILE PROSTH-SAME OP
REMV&REPL PENILE PROSTH-INF FIELD
CORPORA CAVERNOSA-SAPHENOUS
SHUNT
CORPORA CAVERNOSA-CORPUS
SPONGIOSUM
Code Description
No
No
CPT Code
July 2011
54435
54440
Yes
Yes
CORPORA CAVERNOSA-GLANS PENIS FIST
PLASTIC OR PENIS INJURY
No
Yes
54450
54500
54505
No
No
No
FORESKIN MANIP INCL LYSIS ADHESIONS
BX TESTIS NEEDLE (SEPART PROC)
BX TESTIS INCS (SEPART PROC)
No
No
No
54512
54520
54522
54530
Yes
Yes
Yes
Yes
EXC OF EXTRAPARENCHYMAL LES TESTIS
ORCHIECTOMY SIMPL W/WO PROSTH
ORCHIECTOMY, PARTIAL
ORCHIECTOMY RADICAL-TUMOR; ING
No
No
No
No
54535
54550
Yes
Yes
No
No
54560
54600
Yes
Yes
ORCHIECTOMY RADICAL; W/ABD EXPLOR
EXPLOR UNDESCENDED TESTIS
EXPLOR UNDESCEND TESTIS W/ABD
EXPLO
REDUCTION TORSION TESTIS-SURG
54620
54640
54650
54660
54670
54680
54690
54692
54699
54700
54800
54830
Yes
Yes
Yes
Not Reimbursable
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
Not Reimbursable
No
No
No
No
Yes
No
No
No
54840
54860
54861
54865
54900
54901
No
No
No
No
Yes
Yes
FIXA CONTRALAT TESTIS (SEPART PROC)
ORCHIOPEXY-ING-W/WO HERNIA REPR
ORCHIOPEXY ABD APPROACH
INSRT TESTICULAR PROSTH (SEP PRO)
SUTURE/REPR TESTICULAR INJURY
TRANSPL TESTIS TO THIGH
LAP SURG; ORCHIECTOMY
LAP SURG; ORCHIOPEXY ABD TESTIS
UNLISTED LAP PROC-TESTIS
I&D EPIDIDYMIS/TESTIS &/OR SCROTAL
BX EPIDIDYMIS NEEDLE
EXC LOCAL LES EPIDIDYMIS
EXC SPERMATOCELE W/WO
EPIDIDYMECTMY
EPIDIDYMECTOMY; UNILAT
EPIDIDYMECTOMY; BILAT
EXPLORE EPIDIDYMIS
EPIDIDYMOVASOSTOMY; UNILAT
EPIDIDYMOVASOSTOMY; BILAT
Code Description
No
No
No
No
No
No
No
No
CPT Code
July 2011
55000
55040
55041
55060
55100
55110
55120
55150
55175
55180
55200
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
PUNCT ASPIRAT HYDROCELE W/WO MEDS
EXC HYDROCELE; UNILAT
EXC HYDROCELE; BILAT
REPR TUNICA VAG HYDROCELE
DRAINAGE SCROTAL WALL ABSCESS
SCROTAL EXPLOR
REMOV FB SCROTUM
RESECT SCROTUM
SCROTOPLASTY; SIMPL
SCROTOPLASTY; COMPLIC
VASOTOMY CANNULIZ (SEPART PROC)
No
No
No
No
No
No
No
No
No
No
No
55250
55300
No
No
VASECTOMY (SEP PRO) W/POSTOP SEMEN
VASOTOMY-VASOGMS UNI/BILAT
No
No
55400
55450
Not Reimbursable
No
55500
55520
55530
55535
55540
55550
55559
55600
55605
55650
55680
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
EXC HYDROCELE SPERM CORD (SEP PRO)
EXC LES SPERMATIC CORD (SEP PRO)
EXC VARICOCELE; (SEPART PROC)
EXC VARICOCELE; ABD APPROACH
EXC VARICOCELE; W/HERNIA REPR
LAP SURG-W/LIG SPERMATIC VEINS
UNLISTED LAP PROC-SPERMATIC CORD
VESICULOTOMY
VESICULOTOMY; COMPLIC
VESICULECTOMY ANY APPROACH
EXC MULLERIAN DUCT CYST
No
No
No
No
No
No
Yes
No
No
No
No
55700
55705
55706
No
No
No
BX PROSTATE; NEEDLE/PUNCH SNGL/MX
BX PROSTATE; INCS ANY APPROACH
PROSTATE SATURATION SAMPLING
No
No
No
55720
No
PROSTATOMY EXT DRAIN ABSCESS; SIMPL
No
55725
55801
No
Yes
PROSTATOMY DRAIN ABSCESS; COMPLIC
PROSTATECTOMY PERINEAL SUBTL
No
No
Code Description
VASOVASOSTOMY VASOVASORRHAPHY
LIG VAS DEFER UNI/BILAT (SEP PRO)
Not Reimbursable
No
CPT Code
55810
55812
July 2011
Yes
Yes
55815
Yes
PROSTATECT PERINEAL; W/BILAT LYMPH
No
55821
55831
Yes
Yes
PROSTATECTOMY; SUPRAPUBIC SUBTOT
PROSTATECTOMY; RETROPUBIC SUBTL
No
No
55840
Yes
No
55842
Yes
PROSTATECT RETROPUB RAD W/WO NERV
PROSTATECTOMY RETROPUBIC; W/NODE
BX
55845
Yes
No
55860
Yes
PROSTATECT RETROPUBIC; W/BILAT LYMP
EXPOSURE PROSTATE-INSRT
RADIOACTIVE
55862
Yes
No
55865
Yes
55866
55870
55873
55875
55876
55899
55920
55970
55980
56405
56420
Yes
Not Reimbursable
Yes
Yes
Yes
Yes
No
Not Reimbursable
Not Reimbursable
No
No
EXPOS PROSTATE-INSRT RADIOACT; W/BX
EXPOSURE PROSTATE-RADIOACT;
W/LYMPH
LAP SURG PROSCTOMY RETROPUB RADL
INCL NERVE SPAR
ELECTROEJACULATION
CRYOSURGICAL ABLATION PROSTATE
TRANSPERI NEEDLE PLACE, PROS
PLACE RT DEVICE/MARKER, PROS
UNLISTED PROC MALE GENIT SYST
PLACE NEEDLES PELVIC FOR RT
INTERSEX SURG; MALE TO FE
INTERSEX SURG; FE TO MALE
I&D VULVA/PERINEAL ABSCESS
I&D BARTHOLIN'S GLAND ABSCESS
56440
56441
56442
No
No
No
MARSUPIALIZ BARTHOLIN'S GLAND CYST
LYSIS LABIAL ADHESIONS
HYMENOTOMY
No
No
No
56501
No
DESTRCT LES VULVA; SIMPL ANY METHD
No
56515
No
DESTRCT LES VULVA; EXTEN ANY METHD
No
Code Description
PROSTATECTOMY PERINEAL RADICAL
PROSTATECT PERINEAL; W/NODE BX
No
No
No
No
No
No
Not Reimbursable
No
Yes
Yes
Yes
No
Not Reimbursable
Not Reimbursable
No
No
CPT Code
56605
56606
56620
56625
56630
July 2011
No
No
Yes
Yes
Yes
56631
Yes
Code Description
BX VULVA/PERINEUM (SEP PRO); 1 LES
BX VULVA (SEP PRO); EA SEP ADD LES
VULVECTOMY SIMPL; PART
VULVECTOMY SIMPL; COMPLT
VULVECTOMY RADICAL PART
VULVECTOMY PART; W/INGUINOFEM
LYMPH
56632
56633
Yes
Yes
VULVECT RAD PART; W/INGUINOFEM LYMP
VULVECTOMY RADICAL COMPLT
No
No
56634
Yes
VULVECT COMPLT; W/INGUINOFEM LYMPH
No
56637
56640
Yes
Yes
No
No
56700
56740
56800
56805
No
No
Yes
Yes
VULVECT COMPLT; W/BILAT INGUINOFEM
VULVECT COMPLT W/INGUINOFEM/ILIAC
PART HYMENECTOMY/REVIS HYMENAL
RING
EXC BARTHOLIN'S GLAND/CYST
PLASTIC REPR INTROITUS
CLITOROPLASTY INTERSEX STATE
56810
56820
Yes
No
No
No
56821
57000
No
No
PERINEOPLASTY NON-OB (SEPART PROC)
COLPOSCOPY OF THE VULVA;
COLPOSCOPY OF THE VULVA; WITH
BIOPSY
COLPOTOMY; W/EXPLOR
57010
57020
No
No
No
No
57022
No
57023
57061
57065
57100
57105
No
No
No
No
No
COLPOTOMY; W/DRAIN PELVIC ABSCESS
COLPOCENTESIS (SEPART PROC)
INCISION DRAINAGE VAG HEMATOMA;
POST O/B
INCISION DRAINAGE VAG HEMATOMA; NON
O/B
DESTRCT VAG LES; SIMPL ANY METHD
DESTRCT VAG LES; EXTEN ANY METHD
BX VAG MUCOS; SIMPL (SEPART PROC)
BX VAG MUCOS; EXTEN REQ SUTURE
57106
Yes
VAGINECTOMY PART REMOV VAG WALL;
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
57107
Yes
57109
57110
Yes
Yes
57111
Code Description
No
Yes
VAGINECT REMOV WALL; REMOV PARAVAG
VAGINECT REMOV WALL;
W/LYMPHADENECT
VAGINECT COMPLT REMOV VAG WALL;
VAGINECT COMPLT REMOV WALL;
PARAVAG
57112
57120
57130
57135
57150
57155
57156
Yes
Yes
No
No
No
Yes
Yes
VAGINECT COMPLT REMOV; W/LYMPHADEN
COLPOCLEISIS
EXC VAG SEPTUM
EXC VAG CYST/TUMOR
IRRIGA VAG &/OR APPLIC MEDICAMENT
INSRT UTERN TANDEMS &/ VAG OVOIDS
INS VAG BRACHYTX DEVICE
No
No
No
No
No
No
No
57160
57170
No
No
FIT/INSRT PESSARY-OTH SUPPORT DEVIC
DIAPHRAGM/CERVICAL CAP FITTING
No
No
57180
57200
No
No
INTRO HEMOSTATC AGENT VAG (SEP PRO)
COLPORRHAPHY SUTURE INJURY VAG
No
No
57210
No
COLPOPERINEORRHAPHY SUTURE INJURY
No
57220
57230
No
Yes
PLASTIC OR URETHRAL SPHINCT-VAGINAL
PLASTIC REPR URETHROCELE
No
No
57240
Yes
ANT COLPORRHAPHY REPR CYSTOCELE
No
57250
Yes
No
57260
Yes
57265
Yes
57267
No
POST COLPORRHAPHY REPR RECTOCELE
COMBO ANTEROPOSTERIOR
COLPORRHAPHY
COMBO A-P COLPORRHAPHY;
W/ENTEROCEL
INSRT MESH/OTH REPR PELV FLR EA SITE
VAG APPRCH
57268
Yes
REPR ENTEROCELE-VAGINAL (SEP PRO)
No
No
No
No
No
No
No
CPT Code
July 2011
57270
57280
Yes
Yes
57282
Yes
57283
57284
57285
57287
57288
Code Description
No
No
Yes
Yes
Yes
Yes
Yes
REPR ENTEROCELE-ABD (SEPART PROC)
COLPOPEXY ABD APPROACH
COLPOPEXY VAGNIAL; EXTRA-PERITONEAL
APPROACH
COLPOPEXY VAGNIAL; INTRA-PERITONEAL
APPROACH
PARAVAGINAL DEFEC REPR
REPAIR PARAVAG DEFECT, VAG
REMOV & REVIS SLING STRESS INCONT
SLING OPERATION FOR STRESS INCONT
57289
Yes
PEREYRA PROC INCL ANT COLPORRHAPHY
No
57291
57292
Not Reimbursable
Not Reimbursable
CONSTRUCTION ARTIFICIAL VAG; WO GFT
CONSTRUCTION ARTIFICIAL VAG; W/GFT
Not Reimbursable
Not Reimbursable
57295
57296
Yes
Yes
REVJ RMVL PROSTC VAG GRF VAG APPR
REVISE VAG GRAFT, OPEN ABD
No
Yes
57300
Yes
CLO RECTOVAG FISTULA; VAG/TRANSANAL
No
57305
Yes
CLO RECTOVAG FISTULA; ABD APPROACH
No
57307
57308
57310
Yes
Yes
No
CLO RECTOVAG FIST; ABD W/COLOSTOMY
CLO RECTOVAG FIST; TRNSPERITONEAL
CLO URETHROVAGINAL FISTULA
No
No
No
57311
57320
57330
57335
57400
57410
No
No
Yes
Yes
No
No
CLO URETHROVAG FIST; W/BULBOCAVERN
CLO VESICOVAG FIST; VAG APPROACH
CLO VESICOVAG FIST; TRANSVESICAL
VAGINOPLASTY INTERSEX STATE
DILAT VAG UNDER ANES
PELVIC EXAM UNDER ANES
No
No
No
No
No
No
57415
No
No
57420
No
REMOV VAG FB (SEP PRO) UNDER ANES
COLPOSCOPY ENTIRE VAGINA W/CERVIX IF
PRESENT;
No
No
No
No
No
No
No
CPT Code
July 2011
57421
57423
57425
57426
57452
No
No
Yes
Yes
No
57454
No
57455
No
57456
No
57460
No
57461
No
Code Description
COLPOSCOPY ENTIRE VAG W/CERV IF
PRESENT; W/BX
REPAIR PARAVAG DEFECT, LAP
LAPAROSCOPY SURGICAL COLPOPEXY
REVISE PROSTH VAG GRAFT LAP
COLPOSCOPY; (SEPART PROC)
COLPOSCOPY; W/BX-CERV &/OR
ENDOCERV
COLPOSCOPY CERV INCL UP/ADJ VAGINA;
W/BX CERVIX
COLPSCPY CERV INCL UP/ADJ VAG;
W/ENDOCERV CURET
COLPOSCOPY; W/LOOP ELECTRD EXCCERV
COLPSCPY CERV W/UP VAG; W/LOOP ELEC
CONIZAT CERV
57500
57505
57510
No
No
No
BX 1/MX LOCAL EXC LES (SEPART PROC)
ENDOCERVICAL CURET
CAUT CERV; ELEC/THERMAL
No
No
No
57511
57513
No
No
CAUT CERV; CRYOCAUTERY INIT/REPEAT
CAUT CERV; LASER ABLATION
No
No
57520
No
CONIZATION CERV W/WO D&C; KNIF/LASR
No
57522
No
No
57530
Yes
57531
57540
Yes
Yes
CONIZA CERV W/WO D&C; LOOP ELEC EXC
TRACHELECTOMY AMPUTA CERV (SEP
PRO)
RAD TRACHELECTMY W/PELV
LYMPHADENEC
EXC CERV STUMP ABD APPROACH
57545
57550
57555
Yes
Yes
Yes
No
No
No
57556
57558
Yes
Yes
EXC CERV STUMP ABD; W/PELVIC FLOOR
EXC CERV STUMP VAG APPROACH
EXC CERV STUMP VAG; W/ANT REPR
EXC CERV STUMP VAG; W/REPR
ENTEROCE
D&C OF CERVICAL STUMP
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
CPT Code
57700
July 2011
Yes
57720
57800
Yes
Yes
58100
No
58110
58120
No
No
Code Description
CERCLAGE UTERINE CERV NON-OB
TRACHELORRHAPHY REPR CERV-VAG
APPRO
DILAT CERV CANAL INSTRUM (SEP PRO)
ENDOMET BX W/WO ENDOCERV BX
(SEPAR)
ENDOMETRIAL BX CONJUNCT
W/COLPOSCOPY
D&C DX &/OR THERAP (NON OB)
58140
Yes
MYOMECTOMY SNGL/MX (SEP PRO); ABD
No
58145
Yes
No
58146
58150
Yes
Yes
58152
Yes
58180
58200
Yes
Yes
MYOMECTOMY SNGL/MX (SEP PRO); VAG
MYOMECT 5/>MYOMAS&/MYOMAS W/TOT
WT>250 GMS ABD
TAH W/WO REMOV TUBE(S) - OVARY(S)
TOT HYST; W/COLPOURETHROCYSTOPEXY
SUPRACERV ABD HYST W/WO REMOV
TUBE
TAH W/PART VAGINECT W/LYMPH NODE
58210
Yes
RAD ABD HYST W/TOT PELVIC LYMPHADEN
No
58240
58260
Yes
Yes
PELVIC EXENTERATION-GYN MALIG W/TAH
VAG HYST
No
No
58262
Yes
VAG HYST; W/REMOV TUBE &/OR OVARY
No
58263
Yes
No
58267
58270
58275
Yes
Yes
Yes
58280
58285
Yes
Yes
58290
Yes
VAG HYST; TUBE/OVARY W/REPR ENTEROC
VAG HYST; W/COLPOURETHROCYSTOPEXY
VAG HYST; W/REPR ENTEROCELE
VAG HYST W/TOT/PART COLPECTOMY
VAG HYST W/COLPECT; W/REPR
ENTEROCE
VAG HYST RADICAL
VAG HYST FOR UTERUS GREATER THAN
250 GRAMS;
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
58291
Yes
58292
Yes
58293
Yes
58294
58300
58301
58321
58322
58323
Yes
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
58340
No
Code Description
VAG HYST UTRUS >250 GMS; W/REMV TUBE
&/ OVARY
VAG HYST UTRUS>250 GMS; REMV T&/O
REP ENTEROCL
VAG HYST UTRUS > 250 GMS; W/COLPOURETHROCYSTPXY
VAG HYST UTERUS > 250 GRAMS;
W/REPAIR ENTEROCELE
INSRT INTRAUTERINE DEVICE
REMOV INTRAUTERINE DEVICE
ARTIFICIAL INSEMINATION; INTRA-CERV
ARTIFICIAL INSEMINAT; INTRA-UTERINE
SPERM WASH-ARTIFICIAL INSEMINATION
CATH & INTRO SALINE/CONTRAST MATL
SIS/HSG
58345
Not Reimbursable
TRANSCERV INTRO FALLOPIAN TUBE CATH
Not Reimbursable
58346
58350
Yes
Not Reimbursable
No
Not Reimbursable
58353
Yes
58356
58400
Yes
Yes
58410
Yes
58520
Yes
INSERTION HEYMAN CAPS CLIN BRACHYTX
CHROMOTUBATION OVIDUCT INCL MAT
ENDOMETR ABLATION, THERM, W/OUT
HYSTEROSCOPIC
ENDOMET CRYOABLAT W/US GUID INCL
ENDOMETRL CURET
UTERINE SUSPEN; (SEP PRO)
UTERINE SUSPEN; W/PRESACRAL
SYMPATH
HYSTERORRHAPHY REPR UTERUS (NONOB)
58540
58541
58542
58543
58544
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
58545
Yes
HYSTEROPLASTY REPR UTERINE ANOMALY
LSH, UTERUS 250 G OR LESS
LSH W/T/O UT 250 G OR LESS
LSH UTERUS ABOVE 250 G
LSH W/T/O UTERUS ABOVE 250 G
LAP MYOMECT; 1-4 MYOM TOT 250
GMS/<&/SURFCE MYOM
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
No
No
No
No
No
CPT Code
July 2011
58546
58548
Yes
Yes
58550
Yes
58552
Yes
58553
Yes
58554
58555
Yes
No
LAP MYOMECT EXC;5/>MYOMAS&/MYOMAS
TOT WT>250 GMS
LAP RADICAL HYST
LAP SURG; W/VAG HYST W/WO REMOV
OVA
LAP VAG HYST UTRUS 250 GMS/<; W/REMV
TUBE&/OVRY
LAPARSCPY SURGICAL W/VAG HYST
UTERUS > 250 GMS;
LAP W/VAG HYST UTRUS >250 GMS;
W/REMV TUBE&/OVRY
HYSTEROSCOPY DX (SEPART PROC)
58558
No
HYSTEROSCPY SURG; W/SAMP/POLYPECT
No
58559
No
HYSTEROSCOPY SURG; W/LYSIS ADHES
No
58560
Yes
No
58561
58562
Yes
No
HYSTEROSCPY SURG; W/RESECT SEPTUM
HYSTEROSCOPY SURG; W/REMOV
LEIOMYOM
HYSTEROSCOPY SURG; W/REMOV FB
58563
Yes
No
58565
58570
58571
58572
58573
58578
Yes
Yes
Yes
Yes
Yes
Yes
HYSTEROSCOPY SURG; W/ENDO ABLATION
HYSTEROSC;BIL FALLP TUBE CANNULAT
PLCMT PRM IMPL
TLH, UTERUS 250 G OR LESS
TLH W/T/O 250 G OR LESS
TLH, UTERUS OVER 250 G
TLH W/T/O UTERUS OVER 250 G
UNLISTED LAP PROC-UTERUS
YES
No
No
No
No
Yes
58579
Yes
UNLISTED HYSTEROSCOPY PROC-UTERUS
Yes
58600
58605
58611
58615
58660
No
No
No
No
Yes
LIG/TRANSECT FALLOPIAN TUBE ABD/VAG
LIG FALLOPIAN-SAME HOSP (SEP PRO)
LIG FALLOPIAN-W/C-SECT/INTRA-ABD
OCCLUD FALLOPIAN TUBE-DEVICE VAG
LAP SURG; W/LYSIS ADHES (SEP PROC)
No
No
No
No
No
Code Description
No
No
No
No
No
No
No
No
No
CPT Code
58661
58662
58670
July 2011
Yes
Yes
No
58671
58672
58673
58679
No
Not Reimbursable
Yes
Yes
58700
Yes
58720
58740
58750
58752
58760
58770
58800
58805
Code Description
LAP SURG; W/REMOV ADNEXAL STRUCT
LAP SURG; W/FULG/EXCIS LES-OVARY
LAP SURG; W/FULG OVIDUCTS
LAP SURG; W/OCCLUS OVIDUCTS-DEVICE
LAP SURG; W/FIMBRIOPLASTY
LAP SURG; W/SALPINGOSTOMY
UNLISTED LAP PROC-OVIDUCT/OVARY
No
No
No
No
Not Reimbursable
No
Yes
Yes
Yes
Not Reimbursable
Not Reimbursable
Not Reimbursable
Yes
Yes
Yes
SALPINGECTOMY COMPLT/PART (SEP PRO)
SALPINGO-OOPHORECTOMY (SEPART
PROC)
LYSIS ADHESIONS
TUBOTUBAL ANASTOM
TUBOUTERINE IMPLNT
FIMBRIOPLASTY
SALPINGOSTOMY
DRAIN OVARIAN CYST (SEP PRO); VAG
DRAIN OVARIAN CYST (SEP PRO); ABD
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
No
58820
Yes
DRAIN OVARIAN ABSC; VAG APPRCH OPEN
No
58822
Yes
DRAIN OVARIAN ABSCESS; ABD APPROACH
No
58823
58825
Yes
Yes
DRAIN PELV ABSC TRNSVAG/RECT-PERCUT
TRANSPOSITION OVARY
No
No
58900
58920
58925
Yes
Yes
Yes
BX OVARY UNILAT/BILAT (SEPART PROC)
WEDGE RESECT OVARY UNILAT/BILAT
OVARIAN CYSTECTOMY UNILAT/BILAT
No
No
No
58940
Yes
OOPHORECTOMY PART/TOT UNILAT/BILAT
No
58943
Yes
OOPHORECTOMY; OVARIAN MALIG W/BX
No
58950
Yes
RESECT OVARIAN MALIG W/SALPINGO-OOP
No
58951
Yes
RESECT OVARIAN MALIG; W/TAH-LYMPHAD
No
No
CPT Code
July 2011
58952
Yes
RESECT OVARIAN MALIG; W/RAD DISSECT
No
58953
Yes
BIL S-O W/OMENTECT TAH&RADL DEBULK;
No
58954
Yes
No
58956
58957
58958
58960
58970
58974
Yes
Yes
Yes
Yes
Not Reimbursable
Not Reimbursable
58976
58999
59000
Not Reimbursable
Yes
No
BIL S-O OMENTECT TAH; PELV LYMPHECT
BIL SALPINGOOOPHORECT W/TOT
OMENTECT TAH MALIG
RESECT RECURRENT GYN MAL
RESECT RECUR GYN MAL W/LYM
LAPAROTOMY STAGING OVARIAN MALIG
FOLLICLE PUNCT OOCYTE RETRIEVAL
EMBRYO TRANSF, INTRAUTERINE
GAMETE/ZYGOTE/EMBRYO INFALLOP
TRNSF
UNLISTED PROC FE GENIT SYST
AMNIOCENTESIS ANY METHD
59001
59012
59015
59020
59025
59030
59050
No
No
No
No
No
No
No
AMNIO; THERAPEUTIC AMNIOTIC FL RDUC
CORDOCENTESIS ANY METHD
CHORIONIC VILLUS SAMPL ANY METHD
FETAL CONTRACTION STRESS TEST
FETAL NON-STRESS TEST
FETAL SCLP BLD SAMPL
FETAL MONITOR-LABOR-CONS MD; S&I
No
No
No
No
No
No
No
59051
No
No
59070
Yes
59072
Yes
59074
Yes
59076
59100
Yes
Yes
FETAL MONITOR-LABOR-CONS MD; INTERP
TRANSABD AMNIOINFUS INCLUDING
ULTRASOUND GUID
FETAL UMBILICAL CORD OCCLUSION INCL
US GUID
FETAL FLUID DRAIN INCLUDING
ULTRASOUND GUIDANCE
FETAL SHUNT PLACEMENT INCLUDING
ULTRASOUND GUID
HYSTEROTOMY ABD
59120
59121
No
No
SURG TX ECTOPIC PG; REQ SALPINGECT
SURG TX ECTOPIC PG; WO SALPINGECT
No
No
Code Description
No
No
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Yes
No
No
No
No
No
No
CPT Code
59130
59135
59136
July 2011
No
No
No
59140
59150
59151
59160
59200
No
No
No
No
No
SURG TX ECTOPIC PG; CERV W/EVACUAT
LAP TX ECTOPIC PG; WO SALPINGECT
LAP TX ECTOPIC PG; W/SALPINGECT
CURET PP
INSRT CERV DILAT (SEPART PROC)
No
No
No
No
No
59300
59320
No
No
EPISIOTOMY-BY OTHER THAN ATTEND MD
CERCLAGE CERV DURING PG; VAG
No
No
Code Description
SURG TX ECTOPIC PG; ABD PG
SURG TX ECTOPIC PG; REQ TOT HYST
SURG TX ECTOPIC PG; RESEC UTERUS
No
No
No
59325
Prior Authorization for Basic Health Plan only CERCLAGE CERV DURING PG; ABD
No
59350
HYSTERORRHAPHY RUPT UTERUS
No
ROUTINE OB CARE INCL VAG DEL
No
VAG DELIV ONLY
No
59410
Prior Authorization for Basic Health Plan only
Hosp Notification Required at time of
admission; Prior Authorzation required for
Basic Health Plan only
VAG DELIV ONLY; INCL PP CARE
No
59412
59414
59425
No
No
No
EXT CEPHALIC VERSION W/WO TOCOLYSIS
DELIV PLACENTA (SEPART PROC)
ANTEPARTUM CARE ONLY; 4-6 VISITS
No
No
No
59426
59430
No
No
ANTEPARTUM CARE ONLY; 7/MORE VISITS
PP CARE ONLY (SEPART PROC)
No
No
ROUTINE OB CARE INCL C SECT
No
C DELIV ONLY;
No
59400
59409
59510
59514
59622
July 2011
59812
No
TX INCOMPL AB ANY TRIMES COMPL SURG
No
59820
No
TX MISSED AB COMPL SURG; 1ST TRIMES
No
59821
59830
59840
59841
59850
59851
59852
59855
No
No
Yes
Yes
Yes
Yes
Yes
Yes
TX MISSED AB COMPL SURG; 2ND TRIMES
TX SEPTIC AB COMPLT SURGICALLY
INDUCED AB BY DILAT & CURET
INDUCED AB BY DILAT & EVACUATION
INDUCED AB BY INTRA-AMNIOTIC INJ
INDUCED AB-INTRA-AMNIOT INJ; W/D&C
INDUCED AB BY INJ; W/HYSTEROTOMY
INDUCED AB BY VAG SUPPOS;
No
No
No
No
No
No
No
No
59856
Yes
INDUCED AB-VAG SUPPOS; W/D&C/EVAC
No
CPT Code
59515
59525
59610
59612
59614
59618
59620
Code Description
C DELIV ONLY; INCL PP CARE
No
SUBTL/TOT HYST AFTER CESAREAN DELIV
No
ROUT OB CARE-VAG DELIV-PREV C DELIV
No
VAG DELIV ONLY AFTER PREV C DELIV;
No
VAG DELIV AFT PREV C DELIV; INCL PP
No
ROUT OB CARE-C DELIV-VAG TRY-PREV C
No
C DELIV ONLY AFT VAG TRY-PREV C;
No
C DELIV AFT VAG TRY-PREV C; INCL PP
No
CPT Code
July 2011
59857
59866
Yes
Not Reimbursable
59870
59871
No
No
59897
Code Description
INDUCED AB-VAG SUPPOS;
W/HYSTEROTMY
MULTIFETAL PG REDUCTION(S) (MPR)
No
Not Reimbursable
Yes
UTERINE EVACU & CURET HYDATIDIFORM
REMOV CERCLAGE SUT UNDER ANES
UNLISTED FETAL INVASV PROC INCL
ULTRASOUND GUID
Yes
59898
59899
60000
60100
60200
Yes
Yes
No
No
Yes
UNLISTED LAP PROC-MATERNITY & DELIV
UNLISTED PROC MATERN CARE & DELIV
I&D THYROGLOSSAL CYST INFEC
BX THYROID PERCUT CORE NEEDLE
EXC CYST/ADENOMA THYROID
Yes
Yes
No
No
No
60210
Yes
PART THYRO LOBEC UNI; W/WO ISTHMSCT
No
60212
Yes
PART THYRO LOBEC UNI; W/CNTRLAT LOB
No
60220
Yes
TOT THYR LOBEC UNI; W/WO ISTHMUSEC
No
60225
60240
Yes
Yes
TOT THYROID LOBEC; W/CONTRALAT LOBE
THYROIDECTOMY TOT/COMPLT
No
No
60252
Yes
THYROIDECT-MALIG; W/LTD NECK DISSEC
No
60254
60260
Yes
Yes
No
No
60270
Yes
THYROIDECT-MALIG; W/RAD NECK DISSEC
THYROIDECTOMY-REMOV REMAIN TISS
THYROIDECTOMY INCL SUBSTERNL
GLAND;
60271
60280
Yes
Yes
THYROIDECT INCL SUBSTERN GLND; CERV
EXC THYROGLOSSAL DUCT CYST/SINUS
No
No
60281
60300
Yes
No
No
No
60500
60502
Yes
Yes
EXC THYROGLOSSAL DUCT CYST; RECURR
ASPIR/INJ THYROID CYST
PARATHYROIDECTMY/EXPLOR
PARATHYROID
PARATHYROIDECTOMY; RE-EXPLOR
No
No
No
No
No
CPT Code
July 2011
60505
60512
Yes
Yes
PARATHYROIDECT; W/MEDIASTINAL EXPLO
PARATHYROID AUTOTRANSPL
No
No
60520
60521
60522
60540
60545
Yes
Yes
Yes
Yes
Yes
THYMECT PART/TOT; TRNCERV (SEP PRO)
THYMECT PART/TOT; STERN SPLIT (SP)
THYMECT; W/RAD MEDIAST DISSEC (SP)
ADRENALECTOMY (SEPART PROC)
ADRENALECT (SEP PRO); W/EXC TUMOR
No
No
No
No
No
60600
60605
Yes
Yes
EXC CAROTID BODY TUMOR; WO EXC ART
EXC CAROTID BODY TUMOR; W/EXC ART
No
No
60650
Yes
LAP SURG W/ADRENALECT PART/COMPLT
No
60659
60699
61000
Yes
Yes
No
UNLISTED LAP PROC-ENDOCRINE SYSTEM
UNLISTED PROC ENDOCRINE SYST
SUBDURAL TAP-FONTANEL INFANT; INIT
Yes
Yes
No
61001
61020
No
No
SUBDURAL TAP-FONTANEL; SUBSQT TAPS
VENTRICULAR PUNCT-SUTURE; WO INJ
No
No
61026
61050
61055
No
No
No
VENTRICULAR PUNCT; W/INJ DRUG-DX/TX
CISTERNAL PUNCT; WO INJ (SEP PRO)
CISTERNAL PUNCT; W/INJ DRUG-DX/TX
No
No
No
61070
No
PUNCT SHUNT TUBE/RESERVOIR-ASPIRAT
No
61105
61107
No
No
TWIST DRILL HOLE SUBDUR/VENT PUNCT;
TWIST DRILL HOLE; IMPLNT VENT CATH
No
No
61108
61120
61140
61150
No
No
No
No
TWIST DRILL HOLE; EVACUAT HEMATOMA
BURR HOLE VENT PUNCT
BURR HOLE/TREPHINE; W/BX-BRAIN/LES
BURR HOLE; W/DRAIN BRAIN ABSCESS
No
No
No
No
61151
No
BURR HOLE; W/SUBSQT TAPPING ABSCESS
No
61154
No
BURR HOLE W/EVACUATION HEMATOMA
No
Code Description
CPT Code
July 2011
61156
61210
61215
No
No
No
61250
61253
Code Description
No
No
No
No
No
BURR HOLE; W/ASPIRAT-INTRACEREBRAL
BURR HOLE; IMPLNT CATH (SEP PRO)
INSRT SUBQ RESERVOIR/PUMP
BURR HOLE SUPRATENTOR-NO OTHER
SURG
BURR HOLE-INFRATENTORIAL-UNI/BILAT
61304
Yes
CRANIECTOMY/-OTOMY; SUPRATENTORIAL
No
61305
Yes
No
61312
Yes
CRANIECTOMY/-OTOMY; INFRATENTORIAL
CRANIECTMY-SUPRATEN;
EXTRA/SUBDURAL
61313
Yes
CRANIECTMY-SUPRATEN; INTRACEREBRAL
No
61314
Yes
CRANIECTMY-INFRATEN; EXTRA/SUBDURAL
No
61315
Yes
No
61316
No
CRANIECT-INFRATENT; INTRACEREBELLAR
INCISION & SUBQ PLACEMENT CRANIAL
BONE GRAFT
61320
61321
Yes
Yes
No
No
61322
Yes
61323
Yes
61330
61332
61333
61334
Yes
Yes
Yes
Yes
61340
61343
61345
Yes
Yes
Yes
CRANIECT DRAIN ABSCESS; SUPRATENT
CRANIECT DRAIN ABSCESS; INFRATENT
CRANI/CRANIOT DECOMP W/O EVAC
HEMAT; W/O LOBECT
CRANI/CRANIOT DECOMP W/O EVAC
HEMAT; W/LOBECT
DECOMP ORBIT ONLY TRANSCRAN
APPROCH
EXPLOR ORBIT; W/BX
EXPLOR ORBIT; W/REMOV LES
EXPLOR ORBIT; W/REMOV FB
OTHER CRANIAL DECOMP
SUPRATENTORIAL
CRANIECTOMY-SUBOCCIPIT W/LAMINEC
OTHER CRANIAL DECOMP POST FOSSA
61440
Yes
CRANIOT SECT TENT CEREBELI (SEP PRO
No
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
61450
Yes
Code Description
CRANIECT-SUBTEMP-SECT GASSERIAN
GAN
61458
Yes
CRANIECT SUBOCCIPITAL; EXPLOR NERV
No
61460
Yes
No
61470
Yes
CRANIECT SUBOCCIPIT; SECT CRAN NERV
CRANIEC SUBOCCIP; MEDULLARY
TRACTOT
61480
Yes
No
61490
Yes
CRANIECT SUBOCCIPIT; PEDUNCULOTOMY
CRANIOTOMY LOBOTOMY INCL
CINGULOTMY
61500
61501
61510
Yes
Yes
Yes
No
No
No
61512
Yes
CRANIECTOMY; W/EXC TUMOR/OTHER LES
CRANIECTOMY; OSTEOMYELITIS
CRANIECTOMY; EXC BRAIN TUMOR
CRANIECTMY; EXC MENINGOMASUPRATENT
61514
61516
Yes
Yes
No
No
61517
Yes
CRANIECTOMY; EXC ABSCESS-SUPRATENT
CRANIECTOMY; EXC CYST-SUPRATENT
IMPLANT BRAIN INTRACAVITARY
CHEMOTHERAPY AGENT
61518
61519
Yes
Yes
CRANIECT-POST FOSSA; EX MENINGIOMA
CRANIECT-POST FOSSA; MENINGIOMA
No
No
61520
Yes
CRANIECT-POST FOSA; CEREBELLOPONTIN
No
61521
Yes
CRANIECT; MIDLINE TUMOR @ BASE SKUL
No
61522
61524
Yes
Yes
No
No
61526
Yes
61530
61531
Yes
Yes
CRANIECTOMY INFRATENT; EXC ABSCESS
CRANIECTOMY INFRATENT; EXC CYST
CRANIECT-TRANSTEMP; EXC
CEREBELLOPO
CRANIEC; COMBO W/POST FOSSA
CRANIOT
SUBDURAL IMPLNT STRIP ELECTRODES
No
No
No
No
No
No
No
No
CPT Code
July 2011
61533
Yes
CRANIOTOMY W/FLAP; IMPLNT ELECTRODE
No
61534
Yes
CRANIOT W/FLAP; EXC EPILEPTOG FOCUS
No
61535
Yes
CRANIOT W/FLP; REMOV ELECT (SEP PRO
No
61536
Yes
No
61537
Yes
61538
Yes
61539
Yes
61540
Yes
61541
61542
Yes
Yes
61543
Yes
61544
61545
Yes
Yes
61546
Yes
61548
Yes
CRANIOT W/FLAP; EXC CEREBRAL EPILEP
CRANIOT; LOBECT TEMPORL LOBE W/O
ELECCORTICGRPH
CRANIOTOMY W/FLAP; LOBECTOMY
TEMPORAL LOBE
CRANIOTOMY W/FLAP; LOBECTOMY NOT
TEMPORAL LOBE
CRANIOT; LOBECT NO TEMPORL LOBE
PART/TOT NO ECOG
CRANIOTMY; TRANSECT CORPUS
CALLOSUM
CRANIOTOMY; TOT HEMISPHERECTOMY
CRANIOT W/ELEV BN FLP; PART/SUBTOTAL
HEMISPHERCT
CRANIOT; COAGULATION CHOROID
PLEXUS
CRANIOTOMY; CRANIOPHARYNGIOMA
CRANIOTOMY-HYPOPHYSECTOMYINTRACRAN
HYPOPHYSECTOMY-TRANSNASAL
NONSTEREO
61550
Yes
No
61552
Yes
CRANIEC-CRANIOSYNOSTOSIS; 1 SUTURE
CRANIEC-CRANIOSYNOSTOSIS; MX
SUTURE
61556
Yes
CRANIOT-CRANIOSYNOSTOSIS; FRONTAL
No
61557
61558
Yes
Yes
No
No
61559
Yes
CRANIOT CRANIOSYNOSTOSIS; BIFRONTAL
EXTEN CRANIEC-CRANIOSYNOS; NO GFT
EXTEN CRANIEC; RECONTOUR
W/OSTEOTOM
Code Description
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
61563
61564
July 2011
Yes
Yes
61566
Yes
61567
61570
Yes
Yes
Code Description
EXC BEN TUMOR; WO OPTIC NERV
EXC BEN TUMOR; W/OPTIC NERV
CRANIOT ELEV BN FLP; SELCTV
AMYGDALOHIPPOCAMPECT
CRANIOT ELEV BN FLP; MX SUBPIAL
TRANSECT W/ECOG
CRANIEC/CRANIOT; W/EXC FB BRAIN
61571
Yes
CRANIECT; W/TX PENETRAT WOUND BRAIN
No
61575
Yes
TRANSORAL APPROACH SKULL BASE-BX
No
61576
Yes
TRANSORAL-SKULL BASE; W/SPLIT TONGU
No
61580
61581
Yes
Yes
CRANIOFAC-ANT CRAN; WO MAXILLECTMY
CRANIOFAC-ANT CRAN; INCL MAXILLECT
No
No
61582
Yes
No
61583
Yes
61584
Yes
CRANIOFAC APPROACH; ELEV FRONT LOBE
CRANIOFAC APPROACH; RESEC FRONT
LOB
ORBITOCRAN APPROACH; WO ORBIT
EXENT
61585
Yes
No
61586
Yes
ORBITOCRAN APPROACH; W/ORBIT EXENT
BICORON/TRANSZYGO APPRCH-ANT
CRANIA
61590
Yes
INFRATEMP APPROACH INCL PAROTIDECT
No
61591
Yes
No
61592
Yes
INFRATEMP APPROACH INCL MASTOIDECT
ORBITOCRAN ZYGOMAT APPROACH
OSTEOT
61595
Yes
No
61596
Yes
TRANSTEMP APPROACH INCL MASTOIDECT
TRANSCOCHLR APPROACH INCL
LABYRINTH
61597
Yes
TRNSCONDYL APPRO INCL RESECT C1-C3
No
No
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
61598
Yes
TRNSPETROS APPROACH INCL LIG SINUS
No
61600
Yes
RESECT/EXC LES ANT FOSSA; EXTRADURL
No
61601
Yes
RESECT/EXC LES ANT FOSSA; INTRADURL
No
61605
Yes
RESECT/EXC LES INFRATEMP; XTRADURAL
No
61606
Yes
RESECT/EXC LES INFRATEMP; INTRADURL
No
61607
Yes
RESECT/EXC LES PARASELLAR; EXTRDURL
No
61608
61609
61610
Yes
Yes
Yes
RESECT/EXC LES PARASELLAR; INTRDURL
TRANSECT/LIG CAROTID ART; WO REPR
TRANSECT/LIG CAROTID ART; W/REPR
No
No
No
61611
Yes
No
61612
61613
Yes
Yes
TRANSECT CAROTID-PETROUS; WO REPR
TRANSEC CAROTID-PETROUS; W/REPRGFT
OBLIT CAROTID ANEURY/FIST-DISSECT
61615
Yes
RESECT/EXC LES POST FOSSA; XTRADURL
No
61616
61618
Yes
Yes
RESECT/EXC LES POST FOSSA; NTRADURL
SECNDRY REPR DURA; FREE TISS GFT
No
No
61619
Yes
No
61623
61624
61626
61630
Yes
Yes
Yes
Not Reimbursable
61635
61640
Not Reimbursable
Yes
61641
Yes
SECNDRY REPR DURA; LOCAL/REGION FLP
ENDOVASC TEMP BALLOON ARTERIAL
OCCL HEAD/NECK
TRANSCATH OCCLUD PERCUT; CNS
TRANSCATH OCCLUD PERCUT; NON-CNS
BALO ANGIOP ICRA PRQ
TCAT PLMT IV STENT ICRA W/BALO ANGIOP
IF PFRMD
BALO DILAT ICRA PRQ 1ST VSL
BALO DILAT ICRA PRQ EA VSL SM VASC
FAM
Code Description
No
No
No
No
No
Not Reimbursable
Not Reimbursable
No
No
CPT Code
July 2011
61642
61680
Yes
Yes
Code Description
BALO DILAT ICRA PRQ EA VSL DIFF VASC
FAM
SURG AV MALFORM; SUPRATENT-SIMPL
61682
61684
Yes
Yes
SURG AV MALFORM; SUPRATENT COMPLX
SURG AV MALFORM; INFRATENT SIMPL
No
No
61686
61690
61692
61697
61698
Yes
Yes
Yes
Yes
Yes
SURG AV MALFORM; INFRATENT COMPLX
SURG AV MALFORM; DURAL SIMPL
SURG AV MALFORM; DURAL COMPLX
SURG COMPLEX INTRACRA ANEURY
SURG VERTEBROBASILAR CIRCULATION
No
No
No
No
No
61700
Yes
SURG ANEURY INTRACRAN; CAROTID CIRC
No
61702
Yes
No
61703
Yes
61705
Yes
61708
Yes
SURG ANEURY INTRACRAN; VERTEB-BASIL
SURG ANEURY-CERV-APPLIC CLAMPCAROT
SURG ANEURY; INTRACRAN OCCLUD
CAROT
SURG ANEURY; INTRACRAN
ELECTROTHROM
61710
61711
Yes
Yes
SURG ANEURY; INTRA-ART EMBOLIZATION
ANASTOM ART EXTRA-INTRACRAN ART
No
No
61720
Yes
CREAT LES-STEREOTAC; GLOBUS PALLIDS
No
61735
61750
61751
Yes
Yes
Yes
No
No
No
61760
Yes
CREAT LES-STEREOTACTIC; SUBCORTICAL
STEREOTACTIC BX/EXC INTRACRAN LES
STEREOTAC BX INTRACRAN LES; CT/MRI
STEREOTAC IMPLNT-ELECTRODECEREBRUM
61770
61781
61782
61783
Yes
Not Reimbursable
Not Reimbursable
Not Reimbursable
STEREOTAC LOCALIZ W/CATH BRACHYTHR
SCAN PROC CRANIAL INTRA
SCAN PROC CRANIAL EXTRA
SCAN PROC SPINAL
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
No
No
No
No
CPT Code
July 2011
61790
Yes
61791
61796
61797
61798
61799
61800
Yes
Yes
Yes
Yes
Yes
Yes
61850
Yes
61860
Yes
61863
Yes
61864
Yes
61867
Yes
61868
Yes
61870
Yes
61875
Yes
61880
Yes
61885
Yes
61886
Yes
61888
62000
Yes
Yes
62005
62010
Yes
Yes
62100
Yes
Code Description
CREAT LES-STEREOTAC; GASSERIAN
GANG
CREAT LES-STEREOTAC; TRIGEM
MEDULRY
SRS, CRANIAL LESION SIMPLE
SRS, CRAN LES SIMPLE, ADDL
SRS, CRANIAL LESION COMPLEX
SRS, CRAN LES COMPLEX, ADDL
APPLY SRS HEADFRAME ADD-ON
IMPLNT NEUROSTIM ELECTRODESCORTICL
CRANIEC-IMPLNT NEUROSTIM-CEREBCORT
TWIST DRILL BURR HOLE CRANIOT/ECT NO
REC;1 ARRAY
TWIST DRILL BURR HOLE CRANIOT/ECT NO
REC; EA ADD
TWIST DRILL BURR HOLE CRANIOT/ECT
W/REC; 1 ARRAY
TWIST DRILL BURR HOLE CRANIOT/ECT
W/REC; EA ADD
No
No
No
No
No
No
No
No
No
No
No
No
No
CRANIECT-ELECTROD CEREBELLAR; CORTI
CRANIECT-ELECTROD CEREBELLAR;
SUBCO
No
REVIS/REMOV INTRACRAN ELECTRODES
INSRT/REPL CRANIAL NEUROSTIM
GEN/RECV; W/1 ARRAY
INSRT/REPL CRANIAL NEUROSTIM GEN; W/
2/> ARRAY
No
REVIS/REMOV CRANIAL NEUROSTIM GEN
ELEVAT SKULL FX; SIMPL EXTRADURAL
ELEVAT SKULL FX; COMPOUND
EXTRADURL
ELEVAT SKULL FX; W/REPR DURA
CRANIOT-REPR CSF LEAK W/SURGOTORRH
No
No
No
No
No
No
No
No
CPT Code
July 2011
62115
Yes
REDUCT CRANIOMEGALIC SKULL; WO GFT
No
62116
62117
Yes
Yes
No
No
62120
Yes
62121
Yes
REDUCT CRANIOMEGALIC SKULL; W/PLSTY
REDUCT CRANIOMEGALIC; W/CRANIOT
REPR ENCEPHALOCELE INCL
CRANIOPLSTY
CRANIOT-REPR ENCEPHALOCE SKULL
BASE
62140
62141
Yes
Yes
CRANIOPLASTY SKULL DEFECT; TO 5 CM
CRANIOPLASTY SKULL DEFECT; > 5 CM
No
No
62142
Yes
REMOV BONE FLAP/PROSTH PLATE-SKULL
No
62143
Yes
No
62145
62146
62147
Yes
Yes
Yes
62148
Yes
62160
Yes
62161
Yes
62162
Yes
62163
Yes
62164
Yes
62165
62180
Yes
Yes
REPLAC BONE FLAP/PROSTH PLATE-SKULL
CRANIOPLSTY-DEFEC W/REPR BRAIN
SURG
CRANIOPLASTY W/AUTOGFT; TO 5 CM
CRANIOPLASTY W/AUTOGFT; > 5 CM
INCI&RETRIEVAL SUBQ CRANIL BONE
GRAFT CRANIPLSTY
NEUROENDO IC PLCMT/REPLAC VENT
CATH SHNT SYS/EXT
NEUROENDO IC;DISSCT ADHS FENSTRAT
SEPTUM/IV CYST
NEUROENDO IC; EXC COLLOID CYST
PLCMT VENT CATH
NEUROENDO INTRACRANIAL; W/RETRIEVAL
FOREIGN BODY
NEUROENDO IC; EXC BRAIN TUMR PLCMT
EXT VENT CATH
NEUROENDO IC; W/EXC PITUIT TUMR
TRANSNASL APPRCH
VENTRICULOCISTERNOSTOMY
62190
62192
62194
Yes
Yes
Yes
CREAT SHUNT; SUBARACHNOID/SUBDURAL
CREAT SHUNT; SUBDURAL-PERITONEAL
REPLAC/IRRIGA SUBARACHNOID CATH
No
No
No
Code Description
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
62200
Yes
62201
62220
Yes
Yes
Code Description
VENTRICULOCISTERNOSTMY 3RD
VENTRICL
VENTRICULOCISTERNOST-3RD;
STEREOTAC
CREAT SHUNT; VENTRICULO-ATRIAL
62223
62225
Yes
Yes
CREAT SHUNT; VENTRICULO-PERITONEAL
REPLAC/IRRIGA VENTRICULAR CATH
No
No
62230
Yes
No
62252
Yes
REPLAC/REVIS CSF SHUNT/OBSTRUC VALV
REPROGRAMMING OF PROGRAMMABLE
CSF SHUNT
No
62256
Yes
REMOV COMPLT CSF SHUNT; WO REPLAC
No
62258
62263
Yes
Yes
No
No
62264
62267
62268
62269
62270
62272
62273
Yes
Yes
Yes
Yes
No
No
No
REMOV COMPLT CSF SHUNT; W/REPLAC
PERC LYSIS EPIDUR ADHES-INCL RAD
PERQ LYSIS EPIDURL ADHES RAD LOC MX
SESS; 1 DAY
INTERDISCAL PERQ ASPIR, DX
PERCUT ASPIRAT SPINAL CORD CYST
BX SPINAL CORD PERCUT NEEDLE
SPINAL PUNCT LUMBAR DX
SPINAL PUNCT THERAP-DRAIN FLUID
INJ EPIDURAL-BLOOD/CLOT PATCH
62280
No
INJ NEUROLY W/WO OTH SUB; SUBARACH
No
62281
No
INJ NEUROLY W/WO OTH SUBST; EPI C/T
No
62282
No
INJ NEUROLY W/WO OTH SUBST; EPI L/S
No
62284
Yes
INJ PROC-MYELOGRPHY &/OR CAT-SPINAL
No
62287
Yes
ASPIR/DECOMPRESS-NUC PULPOS-LUMB
No
62290
Non Reimbursible
INJ PROC DISKOGRPHY EA LEVEL; LUMB
No
62291
Non Reimbursible
INJ PROC-DISKGRPHY EA LEV; CRV/THOR
No
No
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
62292
Yes
INJ PROC-CHEMONUCLEOLYSIS; 1/MX LUM
No
62294
62310
62311
62318
62319
62350
62351
Yes
No
No
Yes
Yes
Yes
Yes
INJ PROC ART-OCCLUD AV MALFM SPINAL
INJ NOT LYTIC-EPIDUR; CERV/THOR
INJ NOT LYTIC-EPIDUR; LUMB/SAC
INJ NOT LYTIC-EPIDUR; CERV/THOR
INJ NOT LYTIC-EPIDUR; LUMB/SAC
IMPLNT EPIDUR CATH; WO LAMINECT
IMPLNT EPIDUR CATH; W/LAMINECT
No
No
No
No
No
No
No
62355
Yes
REMOV PREV IMPLNT INTHEC/EPDUR CATH
No
62360
Yes
IMPLNT/REPLAC DEVIC-EPIDUR; RESVOIR
No
62361
Yes
IMPLNT/REPLC DEVIC-EPIDUR; NONPROGM
No
62362
Yes
No
62365
Yes
62367
No
62368
No
IMPLNT/REPLAC DEVIC-EPIDUR; PROGMBL
REMOV PREV IMPLNT SUBQ
RESVOIR/PUMP
ELEC ANALY PROGRM PUMP; WO
REPROGRM
ELEC ANALYS PROGRM PUMP;
W/REPROGRM
63001
Yes
LAMINECT W/EXPLOR 1-2 VERTEB; CERV
No
63003
Yes
LAMINECT W/EXPLOR 1-2 VERTEB; THORA
No
63005
Yes
LAMINECT W/EXPLOR; LUMBAR EX SPONDY
No
63011
Yes
No
63012
63015
Yes
Yes
LAMINECT W/EXPLOR 1-2 SEGMT; SACRAL
LAMINECT W/REMOV ABNL FACETSLUMBAR
LAMINECT W/EXPLOR > 2 SEGMT; CERV
63016
Yes
LAMINECT W/EXPLOR > 2 SEGMT; THORAC
No
63017
Yes
LAMINECT W/EXPLOR > 2 SEGMT; LUMBAR
No
Code Description
No
No
No
No
No
CPT Code
July 2011
63020
Yes
LAMINOT W/DECOMP; 1 INTERSPACE CERV
No
63030
Yes
LAMINOT W/ DECOMP; 1 INTERSPACE LUM
No
63035
63040
63042
Yes
Yes
Yes
LAMINOT; EA ADD INTERSPAC CERV/LUMB
LAMINOTOMY RE-EXPLOR; CERV
LAMINOTOMY RE-EXPLOR; LUMBAR
No
No
No
63043
Yes
No
63044
63045
63046
63047
63048
Yes
Yes
Yes
Yes
Yes
63050
Yes
63051
Yes
63055
Yes
LAMINOTOMY EA ADD CERV INTERSPACE
LAMINOTOMY EA ADD LUMBAR
INTERSPACE
LAMINECT 1 VERT SEGMT-UNI/BIL; CERV
LAMINECT 1 VERT SEGMT-UNI/BIL; THOR
LAMINECT 1 VERT SEGMT-UNI/BIL; LUMB
LAMINECT 1 SEGMT-UNI/BIL; EA ADD
LAMINOPLASTY CERV W/DECOMP SP CRD
2/> VERT SEG;
LAMINOPLASTY CERV 2/> SEG; RECON
POST BONY ELEM
TRANSPEDICULAR SNGL SEGMT;
THORACIC
63056
Yes
TRANSPEDIC APPRCH W/DECOM 1 SEG; L
No
63057
Yes
No
63064
Yes
TRANSPEDICULAR SNGL SEGMT; EA ADD
COSTOVERTEBRAL THORACIC; SNGL
SEGMT
63066
63075
Yes
Yes
COSTOVERTEB THORACIC; EA ADD SEGMT
DISKECT ANT; CERV SNGL INTERSPACE
No
No
63076
63077
Yes
Yes
DISKECT ANT; CERV EA ADD INTERSPACE
DISKECT ANT; THORACIC 1 INTERSPACE
No
No
63078
Yes
DISKECT; THORACIC EA ADD INTERSPACE
No
63081
Yes
VERTEBRAL CORPECTOMY; CERV 1 SEGMT
No
Code Description
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
63082
Yes
63085
Code Description
No
Yes
VERTEBRAL CORPECT; CERV EA AD SEGMT
VERTEBRAL CORPECT; THORACIC 1
SEGMT
63086
Yes
VERTEBRAL CORPECT; THORAC EA AD SEG
No
63087
Yes
VERTEB CORPECT LOW THORACIC/LUMB; 1
No
63088
Yes
No
63090
Yes
VERTEB CORPECT THORAC/LUMB; EA ADD
VERTEBRAL CORPECTOMY LUMB/SACRAL;
1
63091
Yes
No
63101
Yes
63102
Yes
63103
Yes
VERTEB CORPECT LUMB/SACRAL; EA ADD
VERT CORPECT W/DECOMPRS SC&/NRV
ROOT; THOR 1 SEG
VERT CORPECT W/DECOMPRS SC&/NRV
ROOT; LUMB 1 SEG
VERT CORPECT DECOMPRS SC&/NRV
ROOT; T/L EA ADD
63170
Yes
LAMINECT W/MYELOTOMY CERV/THORACIC
No
63172
Yes
No
63173
63180
63182
Yes
Yes
Yes
LAMINECT W/DRAIN CYST; SUBARACHNOID
LAMINECT W/DRAIN CYST;
PERITONEAL/PLEURAL SPACE
LAMINECT & SECT LIGAMNT CERV; 1-2
LAMINECT & SECT LIGAMNT CERV; >2
63185
Yes
LAMINECTOMY W/RHIZOTOMY; 1 OR 2 SEG
No
63190
Yes
LAMINECTOMY W/RHIZOTOMY; > 2 SEGMT
No
63191
Yes
LAMINECT W/SECT SPINAL ACCES NERV
No
63194
Yes
LAMINECTOMY W/1 SPINOTHALAMIC; CERV
No
63195
Yes
LAMINECT W/1 SPINOTHALAM; THORACIC
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
63196
Yes
63197
63198
63199
Code Description
No
Yes
Yes
Yes
LAMINECT W/BOTH SPINOTHALAMIC; CERV
LAMINECT W/BOTH SPINOTHALAM;
THORAC
LAMINECT-2 STAGES W/IN 14 DA; CERV
LAMINECT-2 STAGE W/IN 14 DA; THORAC
63200
Yes
LAMINECTOMY W/RELEASE CORD LUMBAR
No
63250
63251
Yes
Yes
No
No
63252
63265
Yes
Yes
LAMINECTOMY-EXC AV MALFORM; CERV
LAMINECT-EXC AV MALFORM; THORACIC
LAMINECT-EXC AV MALFORM;
THORACOLUM
LAMINECT-EXC LES-EXTRADURAL; CERV
63266
Yes
LAMINECT-EXC LES-EXTRADURAL; THORAC
No
63267
Yes
LAMINECT EXC LES-EXTRADURAL; LUMBAR
No
63268
63270
Yes
Yes
LAMINECT-EXC LES-EXTRADURAL; SACRAL
LAMINECT-EXC LES-INTRADURAL; CERV
No
No
63271
Yes
LAMINECT-EXC LES-INTRADURAL; THORAC
No
63272
Yes
LAMINECT-EXC LES-INTRADURAL; LUMBAR
No
63273
Yes
LAMINECT-EXC LES-INTRADURAL; SACRAL
No
63275
Yes
No
63276
Yes
LAMINECT BX NEOPLSM; EXTRADURL-CERV
LAMINECT BX NEOPLSM; EXTRADURLTHOR
63277
Yes
LAMINECT BX NEOPLSM; EXTRADURL-LUMB
No
63278
Yes
LAMINECT BX NEOPLSM; EXTRADUR-SACRL
No
63280
Yes
LAMINECT; INTRADUR EXTRAMEDUL CERV
No
63281
Yes
LAMINECT; INTRADUR EXTRAMED THORAC
No
No
No
No
No
No
No
CPT Code
July 2011
63282
Yes
LAMINECT; INTRADUR EXTRAMEDUL LUMB
No
63283
Yes
LAMINECT-BX NEOPLSM; INTRADUR SACRL
No
63285
Yes
LAMINECT; INTRADUR INTRAMEDUL CERV
No
63286
Yes
No
63287
Yes
LAMINECT; INTRADUR INTRAMEDUL THORA
LAMINECT; INTRAMEDULLARY
THORACULUM
63290
Yes
No
63295
Yes
LAMINECTOMY; COMBO EXTRA-INTRADURL
OSTEOPLASTIC RECON DORS SP FLW PRIM
INTRASP PROC
63300
63301
63302
63303
Yes
Yes
Yes
Yes
VERTEBRAL CORPECT; EXTRADURAL CERV
VERTEB CORPECT; TRANSTHORACIC
VERTEB CORPECT; THORACOLUMBAR
VERTEB CORPECT; TRANSPERITONEAL
No
No
No
No
63304
Yes
No
63305
Yes
63306
Yes
63307
63308
Yes
Yes
VERTEBRAL CORPECT; INTRADURAL CERV
VERTEB CORPECT; INTRADURTRANSTHORA
VERTEB CORPEC; INTRADURTHORACOLUMB
VERTEB CORPECT; INTRADURTRANSPERIT
VERTEBRAL CORPECT; EA ADD SEGMT
63600
Yes
No
63610
Yes
CREAT LES-CORD-STEREOTACTIC PERCUT
STEREOTACTIC STIM-CORD-PERQ SEP
PRO
63615
63620
63621
Yes
Yes
Yes
STEREOTACTIC BX/EXC LES SPINAL CORD
SRS, SPINAL LESION
SRS, SPINAL LESION, ADDL
No
No
No
63650
Yes
PERCUT IMPLNT ELECT ARRAY EPIDURAL
No
Code Description
No
No
No
No
No
No
No
CPT Code
July 2011
63655
63661
63662
63663
63664
Yes
Yes
Yes
Yes
Yes
63685
63688
63700
63702
Code Description
No
No
No
No
No
Yes
Yes
Yes
Yes
LAMINECT IMPLNT ELECTRODE EPIDURAL
REMOVE SPINE ELTRD PERQ ARAY
REMOVE SPINE ELTRD PLATE
REVISE SPINE ELTRD PERQ ARAY
REVISE SPINE ELTRD PLATE
INSRT/REPL SPINAL NEUROSTIM PULSE
GEN/RECV
REVIS IMPLNT SPINAL NEUROSTIM GEN
REPR MENINGOCELE; < 5 CM DIAMETER
REPR MENINGOCELE; > 5 CM DIAMETER
63704
Yes
REPR MYELOMENINGOCELE; < 5 CM DIAM
No
63706
Yes
REPR MYELOMENINGOCELE; > 5 CM DIAM
No
63707
63709
63710
63740
Yes
Yes
Yes
Yes
REPR DURAL/CSF LEAK WO LAMINECTOMY
REPR DURAL/CSF LEAK W/LAMINECT
DURAL GFT SPINAL
CREAT SHUNT LUMBAR; W/LAMINECT
No
No
No
No
63741
63744
63746
64400
64402
Yes
Yes
Yes
No
No
CREAT SHUNT LUMB; PERQ WO LAMINECT
REPLAC LUMBOSUBARACHNOID SHUNT
REMOV LUMBOSUBARACH SHUNT SYST
INJ ANES AGENT; TRIGEMINAL NERV
INJ ANES AGENT; FACIAL NERV
No
No
No
No
No
64405
64408
64410
64412
64413
64415
No
No
No
No
No
No
No
No
No
No
No
No
64416
64417
No
No
INJ ANES AGENT; GREATER OCCIPT NERV
INJ ANES AGENT; VAGUS NERV
INJ ANES AGENT; PHRENIC NERV
INJ ANES AGENT; SPINAL ACCES NERV
INJ ANES AGENT; CERV PLEXUS
INJ ANES AGENT; BRACHIAL PLEXUS
INJ ANES AGT; BRACH PLEXUS CONT CATH
DAILY MGMT
INJ ANES AGENT; AXILRY NERV
64418
64420
No
No
INJ ANES AGENT; SUPRASCAPULAR NERV
INJ ANES AGENT; INTERCOSTAL NERV 1
No
No
No
No
No
No
No
No
CPT Code
July 2011
64421
64425
64430
64435
64445
No
No
No
No
No
64446
No
64447
No
64448
No
64449
64450
64455
64479
64480
64483
64484
64490
64491
64492
64493
64494
64495
No
No
No
No
No
No
No
No
No
No
No
No
No
64505
64508
64510
No
No
No
64517
64520
64530
64550
Code Description
INJ ANES AGENT; INTERCOSTAL NERV-MX
INJ ANES AGENT; ILIOINGUINAL NERV
INJ ANES AGENT; PUDENDAL NERV
INJ ANES AGENT; PARACERVICAL NERV
INJ ANES AGENT; SCIATIC NERV
INJ ANES AGT; SCIATIC NRV CONT CATH
DAILY MGMT
INJECTION ANESTHETIC AGENT; FEMORAL
NERVE SINGLE
INJ ANES AGT; FEM NRV CONT INFUS CATH
DAILY MGMT
INJ ANES; LUMB PLEXUS POST CONT INFUS
DAILY MGMT
INJ ANES AGENT; OTHER PERIPHERAL
N BLOCK INJ, PLANTAR DIGIT
INJ ANES EPIDUR; CERV/THOR 1 LEVEL
INJ ANES EPIDUR; CERV/THOR-EA ADD
INJ ANES EPIDUR; LUMB/SAC 1 LEVEL
INJ ANES EPIDUR; LUMB/SAC-EA ADD
INJ PARAVERT F JNT C/T 1 LEV
INJ PARAVERT F JNT L/S 1 LEV
No
No
No
No
No
No
No
No
No
No
No
Yes
INJ ANES AGENT; SPHENOPALATINE GANG
INJ ANES AGENT; CAROTID SINUS (SEP)
INJ ANES AGENT; STELLATE GANGLION
INJECTION ANESTHETIC AGT; SUP
HYPOGASTRIC PLEXUS
INJ ANES AGENT; LUMBAR/THORACIC
INJ ANES AGENT; CELIAC PLEXUS
APPLIC SURFACE NEUROSTIMULATOR
64553
Yes
PERQ IMPLNT ELECTRODE; CRANIAL NERV
No
64555
Yes
PERQ IMPLNT ELECTRODES; PERIPHERAL
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
64560
Yes
PERQ IMPLNT ELECTRODES; AUTONOMIC
No
64561
Yes
No
64565
64566
64568
64569
64570
Yes
Not Reimbursable
Yes
Yes
Yes
PERQ IMPL NEUROSTIM ELEC; SAC NERV
PERQ IMPLNT ELECTRODES;
NEUROMUSCUL
NEUROELTRD STIM POST TIBIAL
INC FOR VAGUS N ELECT IMPL
REVISE/REPL VAGUS N ELTRD
REMOVE VAGUS N ELTRD
64575
64577
Yes
Yes
64580
Code Description
No
Not Reimbursable
No
No
No
No
No
Yes
INCS IMPLNT ELECTRODES; PERIPHERAL
INCS IMPLNT ELECTRODES; AUTONOMIC
INCS IMPLNT ELECTRODES;
NEUROMUSCUL
64581
Yes
INCI IMPL NEUROSTIM ELEC; SAC NERVE
No
64585
Yes
No
64590
64595
64600
64605
64610
64611
64612
Yes
Yes
Yes
Yes
Yes
Yes
Yes
REVIS/REMOV PERIPHERAL ELECTRODE
INSRT/REPL PERIPHERAL NEUROSTIM
PULSE GEN/RECV
REVIS/REMOV PERIPHERAL PULSE GEN
DESTRCT TRIGEMINAL; SUPRAORBITAL
DESTRCT TRIGEMOMAL; 2ND & 3RD DIV
DESTRCT TRIGEMINAL; W/RADIOLOGIC
CHEMODENERV SALIV GLANDS
DESTRUC; MUSC INNERV-FACIAL NRV
64613
64614
64620
64622
64623
Yes
Yes
Yes
Yes
Yes
DESTRCT NEUROLYT; CERV SPINAL MUSCL
DESTRUC; EXTRMTY &/OR TRUNK MUSC
DESTRUC-NEUROLYTIC INTERCOST NRV
DESTRUC FACET JT NRV; L/S-1 LEVEL
DESTRUC FACET JT NRV; L/S-EA AD LEV
No
No
No
No
No
64626
Yes
DESTRUC FACET NRV; CERV/THOR 1 LEV
No
64627
Yes
DESTRUC FACET NRV; CRV/THOR-EA ADD
No
64630
Yes
DESTRCT NEUROLYTIC; PUDENDAL NERV
No
No
No
No
No
No
No
No
No
CPT Code
64632
64640
64650
July 2011
Yes
Yes
Yes
64653
Yes
64680
Yes
64681
64702
64704
Yes
Yes
Yes
Code Description
N BLOCK INJ, COMMON DIGIT
DESTRCT; OTHER PERIPHERAL NERV
CHEMODNRVTJ ECCRINE GLNDS BTH AX
CHEMODNRVTJ ECCRINE GLNDS OTH
AREA PR D
DESTRUC NEURLYT AGT W/WO RAD MON;
CELIAC PLEXUS
DESTRUC NEURLYT AGT; SUPERIOR
HYPOGASTRIC PLEXUS
NEUROPLASTY; DIGITAL 1/BOTH SAME
NEUROPLASTY; NERV HAND/FT
64708
Yes
NEUROPLSTY PERIPHRL NERV; NOT SPECI
No
64712
Yes
NEUROPLSTY PERIPHERAL NERV; SCIATIC
No
64713
Yes
No
64714
Yes
NEUROPLSTY PERIPHRL; BRACHIAL PLEXS
NEUROPLSTY PERIPHERL; LUMBAR
PLEXUS
64716
64718
64719
Yes
Yes
Yes
No
No
No
64721
Yes
NEUROPLSTY/TRANSPOSIT; CRANIAL NERV
NEUROPLASTY; ULNAR NERV @ ELBOW
NEUROPLASTY; ULNAR NERV @ WRIST
NEUROPLASTY; MEDIAN @ CARPAL
TUNNEL
64722
64726
64727
Yes
Yes
Yes
No
No
No
64732
Yes
DECOMP; UNSPECIFIED NERV (SPECIFY)
DECOMP; PLANTAR DIGITAL NERV
INT NEUROLYSIS W/USE OR MICRO
TRANSECT/AVULSION SUPRAORBITAL
NERV
64734
64736
64738
64740
64742
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
64744
Yes
TRANSECT/AVULSION INFRAORBITAL NERV
TRANSECTION/AVULSION MENTAL NERV
TRANSECT INFERIOR ALVEOLAR NERV
TRANSECT/AVULSION LINGUAL NERV
TRANSECT FACIAL NERV DIFF/COMPLT
TRANSECT/AVULSION GREATR OCCIP
NERV
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
64746
July 2011
Yes
64752
Yes
TRANSECT VAGUS NERV TRANSTHORACIC
No
64755
Yes
TRANSECT/VAGI LTD TO PROX STOMACH
No
64760
64761
Yes
Yes
No
No
64763
Yes
64766
Yes
64771
Yes
64772
64774
Yes
Yes
TRANSECT/AVULSION VAGUS NERV ABD
TRANSECT/AVULSION PUDENDAL NERV
TRANSECT OBTURATOR NERV
EXTRAPELVIC
TRANSECT OBTURATOR NERV
INTRAPELVIC
TRANSECT OTHR CRANIAL NERV
EXTRADUR
TRANSECT OTHER SPINAL NERV
EXTRADUR
EXC NEUROMA; CUT NERV SURG IDENT
64776
Yes
EXC NEUROMA; DIGIT NERV 1/BOTH SAME
No
64778
64782
64783
Yes
Yes
Yes
EXC NEUROMA; DIGIT NERV EA ADD DIGT
EXC NEUROMA; HAND/FT EX DIGIT NERV
EXC NEUROMA; HAND/FT EA ADD NERV
No
No
No
64784
64786
64787
64788
64790
64792
64795
64802
64804
64809
64818
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
Yes
EXC NEUROMA; MAJOR NERV EX SCIATIC
EXC NEUROMA; SCIATIC NERV
IMPLNT NERV END INTO BONE/MUSCL
EXC NEUROFIBROMA; CUT NERV
EXC NEUROFIBROMA; MAJ PERIPHERAL
EXC NEUROFIBROMA; EXTEN
BX NERV
SYMPATHECTOMY CERV
SYMPATHECTOMY CERVICOTHORACIC
SYMPATHECTOMY THORACOLUMBAR
SYMPATHECTOMY LUMBAR
No
No
No
No
No
No
No
No
No
No
No
64820
64821
64822
Yes
Yes
Yes
SYMPATHECTOMY DIG ARTS W/MAGNIFI-EA
SYMPATHECTOMY; RADIAL ARTERY
SYMPATHECTOMY; ULNAR ARTERY
No
No
No
Code Description
TRANSECT/AVULSION PHRENIC NERV
No
No
No
No
No
No
CPT Code
64823
July 2011
Yes
64831
Yes
SUTURE DIGITAL NERV HAND/FT; 1 NERV
No
64832
Yes
No
64834
64835
Yes
Yes
SUTURE DIGITAL NERV HAND/FT; EA ADD
SUTURE 1 NERV HAND/FT; COMMON
SENSO
SUTURE 1 NERV HAND/FT; MED MOTOR
64836
64837
64840
Yes
Yes
Yes
SUTURE 1 NERV HAND/FT; ULNAR MOTOR
SUTURE EA ADD NERV HAND/FT
SUTURE POST TIBIAL NERV
No
No
No
64856
Yes
No
64857
64858
Yes
Yes
SUTURE MAJ NERV ARM/LEG; W/TRANSPOS
SUTURE MAJ NERV ARM/LEG; WO
TRANSPO
SUTURE SCIATIC NERV
No
No
64859
64861
64862
64864
Yes
Yes
Yes
Yes
SUTURE EA ADD MAJOR PERIPHERAL NERV
SUTURE BRACHIAL PLEXUS
SUTURE LUMBAR PLEXUS
SUTURE FACIAL NERV; EXTRACRANIAL
No
No
No
No
64865
64866
64868
64870
Yes
Yes
Yes
Yes
No
No
No
No
64872
64874
Yes
Yes
SUTURE FACIAL NERV; INFRATEMPORAL
ANASTOM; FACIAL-SPINAL ACCES
ANASTOM; FACIAL-HYPOGLOSSAL
ANASTOM; FACIAL-PHRENIC
SUTURE NERV; W/SECNDRY/DELAY
SUTURE
SUTURE NERV; REQ EXTEN MOBILIZAT
64876
Yes
SUTURE NERV; W/SHORTEN BONE EXTREM
No
64885
64886
64890
64891
64892
64893
Yes
Yes
Yes
Yes
Yes
Yes
NERV GFT HEAD/NECK; TO 4 CM LENGTH
NERV GFT HEAD/NECK; > 4 CM LENGTH
NERV GFT 1 STRAND HAND/FT; TO 4 CM
NERV GFT 1 STRAND HAND/FT; > 4 CM
NERV GFT 1 STRAND ARM/LEG; TO 4 CM
NERV GFT 1 STRAND ARM/LEG; > 4 CM
No
No
No
No
No
No
Code Description
SYMPATHECTOMY; SUP PALMAR ARCH
No
No
No
No
No
CPT Code
July 2011
64895
64896
Yes
Yes
NERV GFT MX STRAND HAND/FT; TO 4 CM
NERV GFT MX STRAND HAND/FT; > 4 CM
No
No
64897
64898
64901
64902
64905
Yes
Yes
Yes
Yes
Yes
NERV GFT MX STRAND ARM/LEG; TO 4 CM
NERV GFT MX STRAND ARM/LEG; > 4 CM
NERV GFT EA ADD NERV; SNGL STRAND
NERV GFT EA ADD NERV; MX STRANDS
NERV PEDICLE TRANSF; FIRST STAGE
No
No
No
No
No
64907
64910
64911
64999
Yes
Yes
Prof Not Reim/OPPS Reimb w PA
Yes
NERV PEDICLE TRANSF; SECOND STAGE
NERVE REPAIR W/ALLOGRAFT
NEURORRAPHY W/VEIN AUTOGRAFT
UNLISTED PROC NERV SYST
No
Yes
Not Reimbursable
Yes
65091
Yes
EVISCERAT OCULAR CONTENT; WO IMPLNT
No
65093
65101
Yes
Yes
EVISCERAT OCULAR CONTENTS; W/IMPLNT
ENUCLEATION EYE; WO IMPLNT
No
No
65103
Yes
ENUCLEAT EYE; MUSCL NO ATTACH-IMPLT
No
65105
Yes
ENUCLEAT EYE; MUSCL ATTACHED-IMPLNT
No
65110
Yes
EXENTERATION ORBITAL CONTENTS; ONLY
No
65112
Yes
EXENTERAT ORBITAL CONTENTS; W/BONE
No
65114
Yes
EXENTERAT ORBITAL CONTENTS; W/FLAP
No
65125
65130
Yes
Yes
MODIF OCULAR IMPLNT W/PLC PEGS (SP)
INSRT OCULAR IMPLNT 2ND; AFTR EVISC
No
No
65135
65140
65150
Yes
Yes
Yes
INSRT OCULAR IMPLNT 2ND; AFTR ENUCL
INSRT OCULAR IMPLNT; MUSCL ATTACH
REINSRT OCULAR IMPLNT; W/WO GFT
No
No
No
65155
65175
Yes
Yes
REINSRT OCULAR IMPLNT; W/REINFORCE
REMOV OCULAR IMPLNT
No
No
Code Description
CPT Code
65205
July 2011
No
65210
No
REMOV FB EXT EYE; CONJUNC EMBEDDED
No
65220
65222
65235
65260
No
No
No
No
REMOV FB EXT EYE; CORNEAL WO LAMP
REMOV FB EXT EYE; CORNEAL W/LAMP
REMOV FB IO; ANT CHAMBER/LENS
REMOV FB IO; POST SEGMT MAGNETIC
No
No
No
No
65265
No
REMOV FB IO; POST SEGMT NONMAGNETC
No
65270
65272
65273
No
No
No
REPR LACERAT; CONJUNC W/WO SCLERA
REPR LACERAT; CONJUNC WO HOSP
REPR LACERAT; CONJUNC W/HOSP
No
No
No
65275
No
REPR LACERAT; CORNEA NONPERFORAT
No
65280
No
REPR LACERAT; CORNEA PERFORATING
No
65285
65286
No
No
No
No
65290
65400
65410
No
No
No
REPR LACERAT; CORNEA W/REPOSIT TISS
REPR LACERAT; APPLIC TISS GLUE
REPR WOUND EXTRAOCULAR
MUSCL/TENDON
EXC LES CORNEA EX PTERYGIUM
BX CORNEA
65420
No
EXC/TRANSPOSITION PTERYGIUM; WO GFT
No
65426
No
EXC/TRANSPOSITION PTERYGIUM; W/GFT
No
65430
No
No
65435
No
SCRAPING CORNEA DX SMEAR &/OR CULT
REMOV CORNEAL EPITHEL; W/WO
CHEMOCA
65436
65450
65600
65710
No
No
No
Yes
REMOV CORNEAL EPITHELIUM; W/CHELAT
DESTRCT LES CORNEA-CRYOTHERAPY
MX PUNCTURES ANT CORNEA
KERATOPLASTY; LAMELLAR
No
No
No
No
Code Description
REMOV FB EXT EYE; CONJUNC SUPERF
No
No
No
No
No
CPT Code
July 2011
65730
Yes
KERATOPLASTY; PENETRAT (EX APHAKIA)
No
65750
Yes
No
65755
65756
65757
65760
65765
65767
65770
65771
65772
Yes
Yes
Yes
Not Reimbursable
Not Reimbursable
Not Reimbursable
Yes
Not Reimbursable
Yes
KERATOPLASTY; PENETRATING (APHAKIA)
KERATOPLSTY; PENETRAT
(PSEUDOAPHAK)
CORNEAL TRNSPL, ENDOTHELIAL
PREP CORNEAL ENDO ALLOGRAFT
KERATOMILEUSIS
KERATOPHAKIA
EPIKERATOPLASTY
KERATOPROSTHESIS
RADIAL KERATOTOMY
CORNEAL RELAXING INCS-ASTIGMATISM
65775
65778
65779
Yes
Yes
Yes
65780
Yes
65781
Yes
65782
Yes
65800
No
65805
65810
No
No
65815
65820
65850
No
No
No
65855
65860
65865
Code Description
No
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
Not Reimbursable
No
CORNEAL WEDGE RESECT-ASTIGMATISM
COVER EYE W/MEMBRANE
COVER EYE W/MEMBRANE STENT
OCULR SURFCE RECNSTR; AMNIOTIC
MEMBRANE TPLNT
OCULR SURFCE RECNSTR; LIMBAL STEM
CELL ALLOGFT
OCULR SURFCE RECNSTR; LIMBAL
CONJUNCT AUTOGFT
No
No
No
PARACENTESIS ANT CHAMBR; W/DX ASPIR
PARACENTESIS ANT CHAMB; RELS
AQUEOS
PARACENTESIS; W/REMOV VITREOUS
No
No
No
No
No
No
PARACENTESIS (SEP PRO); W/REMOV BLD
GONIOTOMY
TRABECULOTOMY AB EXT
TRABECULOPLSTY-LASER-1/MORE
SESSION
SEVERING ADHESIONS (SEPART PROC)
No
SEVERING ADHESIONS; GONIOSYNECHIAE
No
No
No
No
No
No
No
No
CPT Code
July 2011
65870
No
SEVERING ADHESIONS; ANT SYNECHIAE
No
65875
No
SEVERING ADHESIONS; POST SYNECHIAE
No
65880
No
No
65900
65920
65930
66020
66030
66130
66150
No
No
No
No
No
No
No
SEVERING ADHESIONS; CORNEOVITREAL
REMOV EPITHEL DNGROWTH ANT
CHAMBER
REMOV IMPLNT MAT ANT SEGMT EYE
REMOV BLD CLOT ANT SEGMT EYE
INJ ANT CHAMBER (SEP PRO); AIR/LIQ
INJ ANT CHAMBER (SEP PRO); MEDS
EXC LES SCLERA
FISTULIZ SCLERA; TREPHINAT W/IRIDEC
66155
No
FISTULIZAT SCLERA; THERMOCAUTERIZAT
No
66160
66165
66170
66172
66174
66175
No
No
No
No
Not Reimbursable
Not Reimbursable
No
No
No
No
Not Reimbursable
Not Reimbursable
66180
Yes
66185
66220
66225
66250
66500
66505
Yes
Yes
Yes
Yes
Yes
Yes
FISTULIZAT SCLERA; SCLERECT W/PUNCH
FISTULIZAT SCLERA; IRIDENCLEISIS
FISTULIZ SCLER; TRABECULECT AB EXT
FISTULIZAT SCLERA; TRABECULECT
TRANSLUM DIL EYE CANAL
TRNSLUM DIL EYE CANAL W/STNT
AQUEOUS SHUNT-EXTRAOCULAR
RESERVOIR
REVIS AQUEOUS SHUNT-EXTOCULAR
RESER
REPR SCLERAL STAPHYLOMA; WO GFT
REPR SCLERAL STAPHYLOMA; W/GFT
REVIS OPERATIVE WOUND ANT SEGMT
IRIDOTOMY (SEP PRO); EX TRANSFIXION
IRIDOTOMY (SEP PRO); W/TRANSFIXION
66600
Yes
66605
66625
66630
66635
Yes
Yes
Yes
Yes
Code Description
IRIDECTOMY W/CORNEO SECT; REMOV LES
IRIDECTOMY W/CORNEO SECT;
W/CYCLECT
IRIDECT; PERIPHERAL GLAU (SEP PRO)
IRIDECTOMY; SECTOR GLAU (SEP PRO)
IRIDECTOMY; "OPTICAL" (SEPART PROC)
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
66680
66682
66700
July 2011
Yes
Yes
Yes
66710
Yes
66711
Yes
Code Description
REPR IRIS CILIARY BODY
SUTURE IRIS CILIARY BODY (SEP PRO)
CILIARY BODY DESTRCT; DIATHERMY
CILIARY BDY DESTRUC;
CYCLOPHOTOCOAG TRANSSCLERAL
CILIARY BODY DESTRCTION;
CYCLOPHOTOCOAGULAT ENDO
66720
Yes
CILIARY BODY DESTRCT; CRYOTHERAPY
No
66740
Yes
CILIARY BODY DESTRCT; CYCLODIALYSIS
No
66761
66762
66770
66820
Yes
Yes
Yes
Yes
IRIDOTOMY/IRIDECTOMY BY LASER SURG
IRIDOPLASTY BY PHOTOCOAGULATION
DESTRCT CYST/LES IRIS/CILIARY BODY
DISCISSION 2ND CATARACT; STAB INCS
No
No
No
No
66821
66825
Yes
Yes
No
No
66830
Yes
DISCISSION 2ND CATARACT; LASER SURG
REPOSIT IO LENS REQ INCS (SEP PRO)
REMOV 2ND CATARACT W/CORNEOSCLERAL
66840
Yes
REMOV LENS MAT; ASPIRT TECH 1/MORE
No
66850
Yes
No
66852
66920
Yes
Yes
REMOV LENS MAT; PHACOFRAGMENTAT
REMOV LENS MAT; PARS PLANA
APPROACH
REMOV LENS MAT; INTRACAPSULAR
66930
66940
Yes
Yes
No
No
66982
Yes
66983
Yes
REMOV LENS MAT;INTRACAP-DISLOC LENS
REMOV LENS MAT; EXTRACAPSULAR
REMOV EXTR CATARACT W/INSERT OF
INTRAOCU LENS
INTRACAPSULAR CATARACT EXTRAC
W/IOL
66984
66985
66986
Yes
Yes
Yes
EXTRACAPSULAR CATARACT REMOV IOL
INSRT IOL PROSTH (SECNDRY IMPLNT)
EXCHG IO LENS
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
66990
66999
July 2011
No
Yes
67005
67010
67015
67025
No
No
No
No
REMOV VITREOUS ANT APPROACH; PART
REMOV VITREOUS ANT; SUBTL REMOV
ASPIRAT/VITREOUS/SUBRETINAL FLUID
INJ VITREOUS SUBSTITUTE (SEP PRO)
No
No
No
No
67027
67028
67030
67031
Yes
No
No
No
No
No
No
No
67036
No
IMPLNT INTRAVITREAL DRUG DELIV SYST
INTRAVITREAL INJ-AGENT (SEP PRO)
DISCISSION VITREOUS STRANDS
SEVERING VITREOUS STRANDS-LASER
VITRECTOMY MECH PARS PLANA
APPROACH
67039
No
No
67040
67041
67042
67043
67101
Yes
No
No
No
Yes
VITRECTOMY MECH; W/FOCAL ENDOLASER
VITRECTOMY MECH; W/PANRETINAL
PHOTO
VIT FOR MACULAR PUCKER
VIT FOR MACULAR HOLE
VIT FOR MEMBRANE DISSECT
REPR RETINAL DETACH; CRYOTHERAPY
67105
Yes
REPR RETINAL DETACH; PHOTOCOAGULAT
No
67107
67108
67110
Yes
Yes
Yes
REPR RETINAL DETACH; SCLERAL BUCKL
REPR RETINAL DETACH; W/VITRECTOMY
REPR RETINAL DETACH; INJ AIR/GAS
No
No
No
67112
67113
67115
67120
67121
Yes
Yes
Yes
Yes
Yes
REPR RETINAL DETACH; PREV OPERAT ON
REPAIR RETINAL DETACH, CPLX
RELEASE ENCIRCLING MAT
REMOV IMPLNT MAT; EXTRAOCULAR
REMOV IMPLNT MAT POST SEGMT; IO
No
No
No
No
No
67141
Yes
No
67145
67208
Yes
Yes
PROPHYLAXIS RETINAL DETACH; CRYOTHE
PROPHYLAXIS RETINAL DETACH;
PHOTOCO
DESTRCT LES RETINA; CRYOTHERAPY
Code Description
USE OF OPHTHALMIC ENDOSCOPE
UNLISTED PROC ANT SEGMT EYE
No
Yes
No
No
No
No
No
No
No
No
CPT Code
July 2011
67210
67218
67220
67221
Yes
Yes
Yes
Yes
DESTRCT LES RETINA; PHOTOCOAGULAT
DESTRCT LES RETINA; RADIATION-IMPLT
DESTRUC LES CHOROID-1/> SESSION
DESTRUC; PHOTODYNAMIC THPY
No
No
No
No
67225
Yes
DSTRUC LES CHROID;PHOTODYN TX 2 EYE
No
67227
Yes
No
67228
67229
Yes
Yes
DESTRCT RETINOPATHY; CRYOTHERAPY
DESTRCT RETINOPATHY;
PHOTOCOAGULAT
TR RETINAL LES PRETERM INF
67250
Yes
SCLERAL REINFORCE (SEP PRO); WO GFT
No
67255
67299
Yes
Yes
SCLERAL REINFORCE (SEP PRO); W/GFT
UNLISTED PROC POST SEGMT
No
Yes
67311
Yes
STRABISMUS SURG; 1 HORIZONTAL MUSCL
No
67312
67314
67316
67318
67320
Yes
Yes
Yes
Yes
Yes
STRABISMUS SURG; 2 HORIZONTAL MUSCL
STRABISMUS SURG; 1 VERTICAL MUSCL
STRABISMUS SURG; 2/MORE VERTICAL
STRABISMUS SURG SUPER OBLIQUE
TRANSPOSITION EXTRAOCULAR MUSCL
No
No
No
No
No
67331
Yes
No
67332
67334
Yes
Yes
STRABISMUS SURG-PT W/PREV EYE SURG
STRABISMUS SURG-PT W/SCARRING
MUSCL
STRABISMUS SURG-POST FIXA SUTURE
67335
67340
67343
Yes
Yes
Yes
No
No
No
67345
67346
67399
Yes
Prof Not Reim/OPPS Reimb w PA
Yes
PLCMT ADJUSTABLE SUTURE-STRABISMUS
STRABISMUS SURG EXPLOR &/OR REPR
RELEASE EXTEN SCAR TISS (SEP PRO)
CHEMODENERVATION EXTRAOCULAR
MUSCL
BIOPSY, EYE MUSCLE
UNLISTED PROC OCULAR MUSCL
Code Description
No
No
No
No
No
Not Reimbursable
Yes
CPT Code
July 2011
67400
67405
Yes
Yes
67412
Code Description
No
No
Yes
ORBITOTOMY WO BONE FLAP; W/WO BX
ORBITOTOMY WO BONE FLAP; W/DRAIN
ORBITOTOMY WO BONE FLP; W/REMOV
LES
67413
Yes
ORBITOTOMY WO BONE FLP; W/REMOV FB
No
67414
Yes
ORBITOTOMY WO FLAP; W/REMOV BONE
No
67415
No
FINE NEEDLE ASPIRAT ORBIT CONTENTS
No
67420
Yes
ORBITOTOMY W/BONE FLAP; W/REMOV LES
No
67430
67440
Yes
Yes
No
No
67445
67450
67500
67505
67515
67550
67560
67570
67599
Yes
Yes
No
No
No
Yes
Yes
Yes
Yes
ORBITOTOMY W/BONE FLAP; W/REMOV FB
ORBITOTOMY W/BONE FLAP; W/DRAIN
ORBITOTOMY W/BONE FLP; W/REMOV
BONE
ORBITOTOMY W/BONE FLAP; EXPLOR
RETROBULBAR INJ; MEDS
RETROBULBAR INJ; ALCOHOL
INJ THERAP AGENT TENON'S CAPSULE
ORBITAL IMPLNT; INSRT
ORBITAL IMPLNT; REMOV/REVIS
OPTIC NERV DECOMP
UNLISTED PROC ORBIT
No
No
No
No
No
No
No
No
Yes
67700
67710
67715
67800
67801
67805
67808
67810
67820
No
No
No
No
No
No
No
No
No
BLEPHAROTOMY DRAIN ABSCESS EYELID
SEVERING TARSORRHAPHY
CANTHOTOMY (SEPART PROC)
EXC CHALAZION; SNGL
EXC CHALAZION; MX SAME LID
EXC CHALAZION; MX DIFF LIDS
EXC CHALAZION; GEN ANES &/OR HOSP
BX EYELID
CORRECT TRICHIASIS; EPILAT-FORCEPS
No
No
No
No
No
No
No
No
No
67825
67830
No
No
CORREC TRICHIASIS; EPILA NOT FORCPS
CORRECT TRICHIASIS; INCS LID MARGIN
No
No
No
CPT Code
67835
July 2011
No
67840
67850
67875
No
No
No
EXC LES LID WO CLO/W SMPL DIREC CLO
DESTRCT LES LID MARGIN
TEMPORARY CLO EYELIDS BY SUTURE
No
No
No
67880
67882
67900
No
No
Yes
No
No
No
67901
Yes
CONSTRUCT INTERMARGINAL ADHESIONS
CONSTRCT ADHESIONS; W/TRANSPOSIT
REPR BROW PTOSIS
REPR BLEPHAROPTOSIS;
W/SUTURE/OTHER
67902
67903
67904
Yes
Yes
Yes
REPR BLEPHAROPTOSIS; W/FASCIAL SLNG
REPR BLEPHAROPTOSIS; RESECT-INT
REPR BLEPHAROPTOSIS; RESECT-EXT
No
No
No
67906
Yes
REPR BLEPHAROPTOSIS; SUPER RECTUS
No
67908
67909
67911
Yes
Yes
Yes
No
No
No
67912
67914
Yes
Yes
67915
Yes
67916
67917
67921
Yes
Yes
Yes
67922
Yes
67923
67924
Yes
Yes
REPR BLEPHAROPTOSIS; CONJUNC-TARSO
REDUCTION OVERCORRECTION PTOSIS
CORRECT LID RETRACTION
CORR LAGOPHTHALMOS W/IMPL UPPER
EYELID LID LOAD
REPR ECTROPION; SUTURE
REPR ECTROPION;
THERMOCAUTERIZATION
REPAIR ECTROPION; EXCISION TARSAL
WEDGE
REPAIR OF ECTROPION; EXTENSIVE
REPR ENTROPION; SUTURE
REPR ENTROPION;
THERMOCAUTERIZATION
REPAIR ENTROPION; EXCISION TARSAL
WEDGE
REPAIR OF ENTROPION; EXTENSIVE
67930
No
SUTURE RECENT WOUND LID; PART THICK
No
67935
No
SUTURE RECENT WOUND LID; FULL THICK
No
Code Description
CORRECT TRICHIASIS; INCS LID W/GFT
No
No
No
No
No
No
No
No
No
No
No
CPT Code
67938
67950
67961
67966
67971
67973
67974
67975
67999
68020
68040
68100
68110
68115
July 2011
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
68130
68135
68200
68320
68325
No
No
No
Yes
Yes
EXC LES CONJUNC; W/ADJACENT SCLERA
DESTRCT LES CONJUNC
SUBCONJUNCTIVAL INJ
CONJUNCTIVOPLASTY; W/CONJUNC GFT
CONJUNCTIVOPLASTY; W/BUCCAL GFT
No
No
No
No
No
68326
Yes
CONJUNCTIVOPLASTY CUL-DE-SAC; W/GFT
No
68328
Yes
No
68330
68335
Yes
Yes
68340
Yes
CONJUNCTIVOPL CUL-DE-SAC; BUCCL GFT
REPR SYMBLEPHARON;
CONJUNCTIVOPLSTY
REPR SYMBLEPHARON; W/FREE GFT
REPR SYMBLEPHARON; DIVIS
SYMBLEPHAR
68360
68362
Yes
Yes
No
No
68371
68399
68400
68420
68440
68500
Yes
Yes
No
No
No
No
CONJUNC FLAP; BRIDGE/PART (SEP PRO)
CONJUNC FLAP; TOT
HARVESTING CONJUNCTIVAL ALLOGRAFT
LIVING DONOR
UNLISTED PROC CONJUNC
INCS DRAINAGE LACRIMAL GLAND
INCS DRAINAGE LACRIMAL SAC
SNIP INCS LACRIMAL PUNCTUM
EXC LACRIMAL GLAND EX TUMOR; TOT
Code Description
REMOV EMBEDDED FB EYELID
CANTHOPLASTY
EXC & REPR LID; TO 1/4 LID MARGIN
EXC & REPR EYELID > 1/4 LID MARGIN
RECON LID; UP TO 2/3 LID 1 STAGE
RECON LID; TOT LID LOWER 1 STAGE
RECON LID; TOT LID UPPER 1 STAGE
RECON LID-TRANSF FLAP; 2ND STAGE
UNLISTED PROC EYELIDS
INCS CONJUNC DRAINAGE CYST
EXPRESSION CONJUNC FOLLICLES
BX CONJUNC
EXC LES CONJUNC; UP TO 1 CM
EXC LES CONJUNC; OVER 1 CM
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
CPT Code
68505
68510
68520
68525
July 2011
No
No
No
No
68530
No
REMOV FB/DACRYOLITH LACRIMAL PASSG
No
68540
No
No
68550
68700
68705
68720
68745
No
Yes
No
No
No
68750
No
EXC LACRIMAL GLAND TUMOR; FRONTAL
EXC LACRIMAL GLAND TUMOR;
OSTEOTOMY
PLASTIC REPR CANALICULI
CORRECT EVERTED PUNCTUM CAUT
DACRYOCYSTORHINOSTOMY
CONJUNCTIVORHINOSTOMY; WO TUBE
CONJUNCTIVORHINOSTOMY; W/INSRT
TUBE
68760
68761
68770
No
No
No
CLO LACRIMAL PUNCTUM; THERMOCAUT
CLO LACRIMAL PUNCTUM; BY PLUG EA
CLO LACRIMAL FISTULA (SEPART PROC)
No
No
No
68801
No
DILAT LACRIMAL PUNCTUM W/WO IRRIGA
No
68810
No
No
68811
No
PROBE NASOLACRIM DUCT W/WO IRRIG;
PROBE NASOLACRIM DUCT; REQ GEN
ANES
68815
68816
68840
No
No
No
No
No
No
68850
68899
69000
69005
69020
69090
69100
69105
No
Yes
No
No
No
Not Reimbursable
No
No
PROBE NASOLAC DUCT; W/INSERT TUBE
PROBE NL DUCT W/BALLOON
PROBING LACRIMAL CANALICULI
INJ CONTRAST MEDIUM
DACRYOCYSTOGPHY
UNLISTED PROC LACRIMAL SYST
DRAIN EXT EAR ABSCESS; SIMPL
DRAIN EXT EAR ABSCESS; COMPLIC
DRAIN EXT AUDITORY CANAL ABSCESS
EAR PIERCING
BX EXT EAR
BX EXT AUDITORY CANAL
Code Description
EXC LACRIMAL GLAND EX TUMOR; PART
BX LACRIMAL GLAND
EXC LACRIMAL SAC
BX LACRIMAL SAC
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
Not Reimbursable
No
No
CPT Code
69110
69120
69140
69145
July 2011
Yes
Yes
Yes
Yes
Code Description
EXC EXT EAR; PART SIMPL REPR
EXC EXT EAR; COMPLT AMPUTA
EXC EXOSTOSIS EXT AUDITORY CANAL
EXC SOFT TISS LES EXT AUDITRY CANAL
No
No
No
No
69150
Yes
RAD EXC AUDITRY CANAL LES; WO DISSC
No
69155
69200
69205
Yes
No
No
RAD EXC AUDITRY CANAL LES; W/DISSEC
REMOV FB-EXT AUDIT CANAL; WO ANES
REMOV FB-EXT AUDIT CANAL; W/ANES
No
No
No
69210
69220
69222
No
No
No
REMOV IMPACTED CERUMEN (SEP PRO)
DEBRID MASTOIDEC CAVITY SIMPL
DEBRID MASTOIDEC CAVITY COMPLX
No
No
No
69300
Not Reimbursable
69310
69320
69399
Yes
Yes
Yes
RECON EXT AUDITORY CANAL (SEP PRO)
RECON EXT AUDITORY CANAL; 1 STAGE
UNLISTED PROC EXT EAR
No
No
Yes
69400
No
EUSTACHIAN INFLAT TRNSNASAL; W/CATH
No
69401
No
EUSTACHIAN INFLAT TRNSNASL; WO CATH
No
69405
69420
No
No
EUSTACHIAN TUBE CATH TRANSTYMPANIC
MYRINGOTOMY INCL ASPIRAT
No
No
69421
No
MYRINGOTOMY W/ASPIRAT REQ GEN ANES
No
69424
69433
69436
69440
69450
69501
69502
69505
69511
No
No
No
No
No
Yes
Yes
Yes
Yes
VENTILAT TUBE REMOV-INSRT BY ANOTHR
TYMPANOSTOMY LOCAL/TOPICAL ANES
TYMPANOSTOMY GEN ANES
MID EAR EXPLOR-POSTAURICULAR INCS
TYMPANOLYSIS TRANSCANAL
TRANSMASTOID ANTROTOMY
MASTOIDEC; COMPLT
MASTOIDEC; MODIF RADICAL
MASTOIDEC; RADICAL
No
No
No
No
No
No
No
No
No
OTOPLASTY PROTRUD EAR W/WO REDUCT
Not Reimbursable
CPT Code
July 2011
69530
Yes
Code Description
PETROUS APICECTOMY W/RAD
MASTOIDEC
69535
69540
Yes
No
RESECT TEMPORAL BONE EXT APPROACH
EXC AURAL POLYP
No
No
69550
Yes
No
69552
69554
69601
69602
Yes
Yes
Yes
Yes
EXC AURAL GLOMUS TUMOR; TRANSCANAL
EXC AURAL GLOMUS TUMR;
TRANSMASTOID
EXC AURAL GLOMUS TUMOR; EXTEN
REVIS MASTOIDEC; RESULT-COMPLT
REVIS MASTOIDEC; RESULT-MODIF RAD
69603
Yes
REVIS MASTOIDEC; RESULT-RAD MASTOID
No
69604
69605
Yes
Yes
No
No
69610
69620
No
No
REVIS MASTOIDEC; RESULT-TYMPANOPLST
REVIS MASTOIDEC; W/APICECTOMY
TYMPANIC MEMB REPR W/WO SITE PREP
W/WO PATCH
MYRINGOPLASTY
69631
Yes
TYMP WO MASTOIDEC; WO OSSICUL CHAIN
No
69632
Yes
TYMP WO MASTOIDEC; W/OSSICUL CHAIN
No
69633
Yes
No
69635
Yes
69636
Yes
TYMP WO MASTOIDEC; W/CHAIN & PROSTH
TYMP W/ANTROTMY; WO OSSICULAR
CHAIN
TYMP W/ANTROTOMY; W/OSSICULAR
CHAIN
69637
Yes
TYMP W/ANTROTOMY; W/CHAIN & PROSTH
No
69641
Yes
TYMP W/MASTOIDEC; WO OSSICULR CHAIN
No
69642
69643
Yes
Yes
TYMP W/MASTOIDEC; W/OSSICULAR CHAIN
TYMP W/MASTOIDEC; W/RECON WALL
No
No
69644
Yes
TYMP W/MASTOIDEC; RECON CANAL WALL
No
No
No
No
No
No
No
No
No
No
CPT Code
69645
July 2011
Yes
69646
69650
69660
Yes
Yes
Yes
69661
69662
69666
69667
69670
69676
Code Description
TYMP W/MASTOIDEC; RADICAL/COMPLT
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
TYMP W/MASTOIDEC; RAD W/CHAIN RECON
STAPES MOBILIZATION
STAPEDECTOMY/STAPEDOTOMY
STAPEDECTOMY; W/FOOTPLATE DRILL
OUT
REVIS STAPEDECTOMY/STAPEDOTOMY
REPR OVAL WINDOW FISTULA
REPR ROUND WINDOW FISTULA
MASTOID OBLIT (SEPART PROC)
TYMPANIC NEURECTOMY
69700
Yes
CLO POSTAURICULAR FISTULA (SEP PRO)
No
69710
Not Reimbursable
Not Reimbursable
69711
Not Reimbursable
69714
69715
69717
69718
Yes
Yes
Yes
Yes
IMPLNT ELECTROMAGNET BONE HEARING
REMOV ELECTROMAGNETIC BONE
HEARING
IMPLANT; OSSEOINTEGRATED, TEMPORAL
BONE
IMPLANT; W/MASTOIDECTOMY
REPLAC; OSSEOINTEGRATED IMPLANT
REPLAC; W/MASTOIDECTOMY
69720
Yes
DECOMP FACIAL NERV; LAT-GENICULATE
No
69725
69740
Yes
Yes
DECOMP FACIAL NERV; MED-GENICULATE
SUTURE FACIAL NERV; LAT-GENICULATE
No
No
69745
69799
69801
69802
69805
69806
69820
69840
69905
69910
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
SUTURE FACIAL NERV; MED-GENICULATE
UNLISTED PROC MID EAR
LABYRINTHOTOMY; TRANSCANAL
LABYRINTHOTOMY; W/MASTOIDEC
ENDOLYMPHATIC SAC OR; WO SHUNT
ENDOLYMPHATIC SAC OR; W/SHUNT
FENESTRATION SEMICIRCULAR CANAL
REVIS FENESTRATION OR
LABYRINTHECTOMY; TRANSCANAL
LABYRINTHECTOMY; W/MASTOIDEC
No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Not Reimbursable
No
No
No
No
CPT Code
July 2011
69915
Yes
69930
69949
Code Description
Yes
Yes
VESTIB NERV SECT TRANSLABYRINTHINE
COCHLEAR DEVICE IMPLNT W/WO
MASTOID
UNLISTED PROC INNER EAR
No
Yes
69950
69955
69960
69970
69979
69990
70010
Yes
Yes
Yes
Yes
Yes
No
No
VESTIBULAR NERV SECT-TRANSCRANIAL
TOT FACIAL NERV DECOMP &/OR REPR
DECOMP INT AUDITORY CANAL
REMOV TUMOR TEMPORAL BONE
UNLISTED-TEMPORAL BONE-MID FOSSA
USE OPER MICROSCOPE
MYELOGRAPHY POST FOSSA-RAD S & I
No
No
No
No
Yes
No
No
70015
70030
70100
No
No
No
CISTERNOGRAPHY + CONTRAST-RAD S & I
RAD EXAM EYE DETECTION FB
RAD EXAM MANDIB; PART < 4 VIEWS
No
No
No
70110
70120
70130
No
No
No
RAD EXAM MANDIB; COMPLT MINI 4 VIEW
RAD EXAM MASTOIDS; < 3 VIEWS-SIDE
RAD EXAM MASTOIDS; COMPLT MINI 3
No
No
No
70134
70140
No
No
RAD EXAM INT AUDITORY MEATI COMPLT
RAD EXAM FACIAL BONES; < 3 VIEWS
No
No
70150
No
RAD EXAM FACIAL BONES; COMPLT MIN 3
No
70160
70170
70190
No
No
No
RAD EXAM NASAL BONES COMPLT MINI 3
DACRYOCYSTOGRAPHY-RAD S & I
RAD EXAM; OPTIC FORAMINA
No
No
No
70200
No
RAD EXAM; ORBITS COMPLT MINI 4 VIEW
No
70210
No
RAD EXAM SINUSES PARANASAL <3 VIEWS
No
70220
70240
No
No
No
No
70250
No
RAD EXAM SINUSES PARANASAL COMPLT-3
RAD EXAM SELLA TURCICA
RADIOLOGIC EXAMINATION SKULL; LESS
THAN 4 VIEWS
No
No
CPT Code
July 2011
70260
70300
70310
No
No
No
Code Description
RADIOLOGIC EXAM SKULL; COMPLETE
MINIMUM 4 VIEWS
RAD EXAM TEETH; SNGL VIEW
RAD EXAM TEETH; PART < FULL MOUTH
70320
No
RAD EXAM TEETH; COMPLT FULL MOUTH
No
70328
70330
70332
70336
70350
70355
70360
70370
No
No
No
Yes
No
No
No
No
RAD EXAM TMJ OPEN & CLO MOUTH; UNI
RAD EXAM TMJ OPEN & CLO MOUTH; BIL
TMJ ARTHROGRAPHY-RAD S & I
MRI TEMPOROMANDIBULAR JT
CEPHALOGRAM ORTHODONTIC
ORTHOPANTOGRAM
RAD EXAM; NECK SOFT TISS
RAD EXAM; PHARYNX INCL FLUORO
No
No
No
Yes
No
No
No
No
70371
70373
70380
70390
70450
70460
No
No
No
No
Yes
Yes
No
No
No
No
Yes
Yes
70470
70480
70481
Yes
Yes
Yes
70482
Yes
COMPLX DYNAMIC PHARYNGEAL & SPEECH
LARYNGOGRAPHY CONTRAST-RAD S & I
RAD EXAM SALIVARY GLAND CALCU
SIALOGRAPHY-RAD S & I
CAT HEAD/BRAIN; WO CONTRAST MAT
CAT HEAD/BRAIN; W/CONTRAST MAT
CAT HEAD; WO CONTRAST THEN
CONTRAST
CAT ORBIT/SELLA/EAR; WO CONTRAST
CAT ORBIT/SELLA/EAR; W/CONTRAST
CAT ORBIT; WO CONTRAST THEN
CONTRST
70486
Yes
CAT MAXILLOFACIAL AREA; WO CONTRAST
Yes
70487
Yes
CAT MAXILLOFACIAL AREA; W/CONTRAST
Yes
70488
70490
70491
70492
70496
70498
Yes
Yes
Yes
Yes
Yes
Yes
CAT MAXILLOFAC; WO THEN W/CONTRAST
CAT SOFT TISS NECK; WO CONTRAST
CAT SOFT TISS NECK; W/CONTRAST
CAT TISS NECK; WO THEN W/CONTRAST
CT ANGIO HEAD W/OUT CONTRAST
CT ANGIO NECK W/OUT CONTRAST
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
Yes
CPT Code
70540
70542
July 2011
Yes
Yes
70543
70544
70545
70546
70547
70548
70549
70551
70552
70553
70554
70555
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Not Reimbursable
Not Reimbursable
70557
Yes
70558
Yes
70559
Yes
MRI ORBIT FACE/NECK W/OUT CONTRAST
MRI ANGIO HEAD W/O CONTRAST
MRI ANGIO HEAD W/ CONTRAST
MRI ANGIO HEAD W/W/O CONTRAST
MRI ANGIO NECK W/O CONTRAST
MRI ANGIO NECK W/CONTRAST
MRI ANGIO NECK W/WO CONTRAST
MRI BRAIN; WO CONTRAST
MRI BRAIN; W/CONTRAST
MRI BRAIN; WO THEN W/CONTRAST
FMRI BRAIN BY TECH
FMRI BRAIN BY PHYS/PSYCH
MRI BRAIN DUR OPN INTRACRAN PROC;
W/O CONTRST
MRI BRAIN DUR OPN INTRACRAN PROC;
W/CONTRST
MRI BRAIN DUR INTRACRAN;NO CONTRST
FLWED CONTRST
71010
71015
No
No
RAD EXAM CHEST; SNGL VIEW FRONTAL
RAD EXAM CHEST; STEREO FRONTAL
No
No
71020
No
RAD EXAM CHEST 2 VIEWS FRONT & LAT
No
71021
71022
No
No
RAD EXAM CHEST-FRONT & LAT; W/APICL
RAD EXAM CHEST; WO OBLIQ PROJ
No
No
71023
No
RAD EXAM CHEST FRONT & LAT; W/FLUOR
No
71030
No
No
71034
71035
71040
71060
No
No
No
No
RAD EXAM CHEST COMPLT MINI 4 VIEWS
RAD EXAM CHEST COMPLT;
W/FLOUROSCPY
RAD EXAM CHEST SPECIAL VIEWS
BRONCHOGRAPHY UNILAT-RAD S & I
BRONCHOGRAPHY BILAT-RAD S & I
Code Description
MRI ORBIT FACE/NECK
MRI ORBIT FACE/NECK W/CONTRAST
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Not Reimbursable
Not Reimbursable
Yes
Yes
Yes
No
No
No
No
CPT Code
July 2011
71090
71100
71101
71110
71111
71120
71130
71250
71260
71270
71275
71550
71551
71552
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
INSRT PACEMAKER FLUORO & -RAD S & I
RAD EXAM RIBS UNILAT; 2 VIEWS
RAD EXAM RIBS UNILAT; W/PA CHEST
RAD EXAM RIBS BILAT; 3 VIEWS
RAD EXAM RIBS BILAT; W/PA CHEST
RAD EXAM; STERNUM MINI 2 VIEWS
RAD EXAM; STERNOCLAVICULAR JT/JTS
CAT THORAX; WO CONTRAST MAT
CAT THORAX; W/CONTRAST MAT
CAT THORAX; WO THEN W/CONTRAST
CT SCAN ANGIO CHEST W/O CONTRAST
MRI CHEST
MRI CHEST W/CONTRAST
MRI CHEST W/WO CONTRAST
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
71555
72010
Yes
No
MRI ANGIO CHEST W/WO CONTRAST MAT
RAD EXAM SPINE-ENTIRE-AP & LAT
Yes
No
72020
72040
72050
No
No
No
RAD EXAM SPINE SNGL VIEW SPEC LEVEL
RAD EXAM SPINE CERV; AP & LAT
RAD EXAM SPINE CERV; MINI 4 VIEWS
No
No
No
72052
No
No
72069
72070
No
No
RAD EXAM SPINE CERV; COMPLT W/OBLIQ
RAD EXAM SPINE THORACOLUMBAR
STAND
RAD EXAM SPINE; THORACIC AP & LAT
72072
72074
No
No
RAD EXAM SPINE; THORAC W/SWIM VIEW
RAD EXAM SPINE; THORACIC COMPLT
No
No
72080
72090
No
No
RAD EXAM SPINE; THORACOLUM AP & LAT
RAD EXAM SPINE; SCOLIOSIS STUDY
No
No
72100
No
RAD EXAM SPINE LUMBOSACR; AP & LAT
No
72110
No
RAD EXAM SPINE LUMBOSACRAL; W/OBLIQ
No
72114
No
RAD EXAM SPINE LUMBOSACRAL; W/BEND
No
Code Description
No
No
CPT Code
72120
72125
72126
July 2011
No
Yes
Yes
72127
72128
72129
Yes
Yes
Yes
CAT CERV SPINE; WO THEN W/CONTRAST
CAT THORACIC SPINE; WO CONTRAST
CAT THORACIC SPINE; W/CONTRAST
Yes
Yes
Yes
72130
72131
72132
Yes
Yes
Yes
CAT THORACIC SPINE; WO THEN W/CONTR
CAT LUMBAR SPINE; WO CONTRAST
CAT LUMBAR SPINE; W/CONTRAST
Yes
Yes
Yes
72133
Yes
CAT LUMBAR SPINE; WO THEN W/CONTRST
Yes
72141
72142
Yes
Yes
MRI SPINAL CANAL CERV; WO CONTRAST
MRI SPINAL CANAL CERV; W/CONTRAST
Yes
Yes
72146
Yes
MRI SPINAL CANAL THORAC; WO CONTRST
Yes
72147
Yes
MRI SPINAL CANAL THORAC; W/CONTRAST
Yes
72148
Yes
MRI SPINAL CANAL LUMB; WO CONTRAST
Yes
72149
Yes
MRI SPINAL CANAL LUMBAR; W/CONTRAST
Yes
72156
Yes
MRI SPINAL WO THEN W/CONTRAST; CERV
Yes
72157
Yes
MRI SPINAL WO THEN W/CONTRST; THORA
Yes
72158
Yes
MRI SPINAL WO THEN W/CONTRAST; LUMB
Yes
72159
72170
72190
72191
72192
72193
72194
72195
Not Reimbursable
No
No
Yes
Yes
Yes
Yes
Yes
MRI ANGIO SPINAL CANAL W/WO CONTRST
RAD EXAM PELVIS; AP ONLY
RAD EXAM PELVIS; COMPLT MINI 3 VIEW
CT ANGIO PELVIS W/O CONTRAST
CAT PELVIS; WO CONTRAST
CAT PELVIS; W/CONTRAST
CAT PELVIS; WO THEN W/CONTRAST
MRI PELVIS W/O CONTRAST
Not Reimbursable
No
No
Yes
Yes
Yes
Yes
Yes
Code Description
RAD EXAM SPINE LUMBOSACRAL MINI 4
CAT CERV SPINE; WO CONTRAST
CAT CERV SPINE; W/CONTRAST
No
Yes
Yes
CPT Code
72196
72197
July 2011
Yes
Yes
72198
72200
Yes
No
MRI ANGIO PELVIS W/WO CONTRAST MAT
RAD EXAM SACROILIAC JT; < 3 VIEWS
Yes
No
72202
No
RAD EXAM SACROILIAC JT; 3/MORE VIEW
No
72220
72240
72255
No
No
No
RAD EXAM SACRUM & COCCYX MIN 2 VIEW
MYELOGRAPHY CERV-RAD S & I
MYELOGRAPHY THORACIC-RAD S & I
No
No
No
72265
No
No
72270
72275
72285
72291
72292
72295
73000
73010
73020
73030
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
No
No
MYELOGRAPHY LUMBOSACRAL-RAD S & I
MYELOGRAPHY TWO/MORE REGIONS
RADIOLOGIC S&I
EPIDUROGRAPHY RAD S&I
DISKOGRAPHY CERV/THOR RAD S&I
PERQ VERTEBROPLASTY, FLUOR
PERQ VERTEBROPLASTY, CT
DISKOGRAPHY LUMBAR-RAD S & I
RAD EXAM; CLAV COMPLT
RAD EXAM; SCAPULA COMPLT
RAD EXAM SHOULDER; 1 VIEW
RAD EXAM SHOULDER; COMPLT MINI 2
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
No
No
73040
No
RAD EXAM SHLDER ARTHROGRAPHY-S & I
No
73050
73060
73070
No
No
No
RAD EXAM; AC JT BILAT W/WO DISTRACT
RAD EXAM; HUMERUS MINI 2 VIEWS
RAD EXAM ELBOW; AP & LAT VIEWS
No
No
No
73080
No
RAD EXAM ELBOW; COMPLT MINI 3 VIEWS
No
73085
73090
No
No
RAD EXAM ELBOW ARTHROGRAPHY-S & I
RAD EXAM; FOREARM AP & LAT VIEWS
No
No
73092
73100
No
No
RAD EXAM; UPPER EXTREM INFANT MIN 2
RAD EXAM WRIST; AP & LAT VIEWS
No
No
Code Description
MRI PELVIS
MRI PELVIS W/O CONTRAST
Yes
Yes
CPT Code
July 2011
73110
73115
73120
73130
73140
73200
73201
No
No
No
No
No
Yes
Yes
73202
73206
73218
73219
73220
73221
73222
73223
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
73225
73500
73510
Code Description
Not Reimbursable
No
No
RAD EXAM WRIST; COMPLT MINI 3 VIEWS
RAD EXAM WRIST ARTHROGRAPHY-S & I
RAD EXAM HAND; 2 VIEWS
RAD EXAM HAND; MINI 3 VIEWS
RAD EXAM FINGER(S) MINI 2 VIEWS
CAT UPPER EXTREM; WO CONTRAST
CAT UPPER EXTREM; W/CONTRAST
CAT UPPER EXTREM; WO THEN
W/CONTRST
CT ANGIO UPPER EXTR W/O CONTRAST
MRI UPPER EXTR W/O CONTRAST
MRI UPPER EXTR W/CONTRAST
MRI UPPER EXTREM OTHER THAN JT
MRI ANY JT UPPER EXTREM
MRI UPPER EXTR W/ CONTRAST
MRI UPPER EXTR W/O CONTRAST
MRI ANGIO UPPER EXTREM W/WO
CONTRST
RAD EXAM HIP; UNILAT 1 VIEW
RAD EXAM HIP; COMPLT MINI 2 VIEWS
Not Reimbursable
No
No
73520
No
RAD EXAM HIPS BILAT W/AP VIEW PELVS
No
73525
73530
73540
No
No
No
RAD EXAM HIP ARTHROGRAPHY-RAD S & I
RAD EXAM HIP DURING OR PROC
RAD EXAM PELVIS & HIPS INFANT/CHILD
No
No
No
73542
73550
73560
73562
No
No
No
No
RAD EXAM S I JT ARTHROGRPHY RAD S&I
RAD EXAM FEMUR AP & LAT VIEWS
RAD EXAM KNEE; ONE/TWO VIEWS
RAD EXAM KNEE; THREE VIEWS
No
No
No
No
73564
73565
73580
73590
No
No
No
No
RAD EXAM KNEE; COMPLT 4/MORE VIEWS
RAD EXAM KNEE; BOTH STANDING AP
RAD EXAM KNEE ARTHROGRAPHY-S & I
RAD EXAM; TIB & FIB AP & LAT VIEWS
No
No
No
No
73592
No
RAD EXAM; LOWER EXTREM INFANT MIN 2
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
CPT Code
73600
73610
July 2011
No
No
73615
73620
73630
73650
73660
73700
73701
No
No
No
No
No
Yes
Yes
73702
73706
73718
73719
73720
73721
73722
Yes
Yes
Yes
Yes
Yes
Yes
Yes
73723
Yes
73725
74000
Code Description
RAD EXAM ANK; AP & LAT VIEWS
RAD EXAM ANK; COMPLT MINI 3 VIEWS
No
No
No
No
No
No
No
Yes
Yes
Yes
No
RAD EXAM ANK ARTHROGRAPHY-RAD S & I
RAD EXAM FT; AP & LAT VIEWS
RAD EXAM FT; COMPLT MINI 3 VIEWS
RAD EXAM; CALCAN MINI 2 VIEWS
RAD EXAM; TOE(S) MINI 2 VIEWS
CAT LOWER EXTREM; WO CONTRAST
CAT LOWER EXTREM; W/CONTRAST
CAT LOWER EXTREM; WO THEN
W/CONTRST
CT ANGIO LOWER EXTR W/O CONTRAST
MRI LOWER EXTR W/O CONTRAST
MRI LOWER EXTR W/ CONTRAST
MRI LOWER EXTREM OTHER THAN JT
MRI ANY JT LOWER EXTREM
MRI LOWER EXTR W/ CONTRAST
MRI LOWER EXTR W/O CONTRAST & W/
CONTRAST
MRI ANGIO LOWER EXTREM W/WO
CONTRST
RAD EXAM ABD; SNGL AP VIEW
74010
No
RAD EXAM ABD; AP & ADD OBLIQ & CONE
No
74020
74022
74150
74160
74170
74175
74176
74177
74178
74181
74182
74183
74185
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
RAD EXAM ABD; COMPLT INCL DECUBITUS
RAD EXAM ABD; COMPLT ACUTE ABD
CAT ABD; WO CONTRAST
CAT ABD; W/CONTRAST
CAT ABD; WO THEN W/CONTRAST
CT ANGIO ABD W/WO CONTRAST
CT ABD & PELVIS W/O CONTRAST
CT ABDOMEN&PELVIS W/CONTRAST
CT ABD&PELV 1+ SECTION/REGNS
MRI ABD
MRI ABD W/CONTRAST
MRI ABD W/WO CONTRAST
MRI ANGIO ABD W/WO CONTRAST MAT
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
CPT Code
74190
July 2011
No
74210
74220
No
No
74230
74235
74240
74241
Code Description
PERITONEOGRAM-RAD S & I
No
No
No
No
No
No
No
RAD EXAM; PHARYNX &/OR CERV ESOPH
RAD EXAM; ESOPH
SWALLOWING FUNCT PHARYNX &/OR
ESOPH
REMOV FB ESOPH W/CATH-RAD S & I
RAD EXAM GI TRACT UPPER; WO KUB
RAD EXAM GI TRACT UPPER; W/KUB
74245
No
RAD EXAM GI TRACT UPPER; W/SM BOWEL
No
74246
74247
No
No
RAD EXAM GI UP-AIR CONTRAST; WO KUB
RAD EXAM GI UP-AIR CONTRAST; W/KUB
No
No
74249
74250
No
No
RAD EXAM GI-AIR CONTRST; W/SM BOWEL
RAD EXAM SM BOWEL INCL MX SERIAL
No
No
74251
74260
74261
74262
74263
74270
No
No
Non Reimbursible
Non Reimbursible
Non Reimbursible
No
RAD EXAM SM BOWEL; VIA ENTEROCLYSIS
DUODENOGRAPHY HYPOTONIC
CT COLONOGRAPHY, W/O DYE
CT COLONOGRAPHY, W/DYE
CT COLONOGRAPHY, SCREEN
RAD EXAM COLON; B E W/WO KUB
No
No
Non Reimbursible
Non Reimbursible
Non Reimbursible
No
74280
No
No
74283
74290
No
No
74291
No
RAD EXAM COLON; AIR CONTRAST-BARIUM
THERAP ENEMA-CM/AIR REDUC
OBSTRUCTN
CHOLECYSTOGRAPHY ORAL CONTRAST
CHOLECYSTOGRPY ORAL CONTRST;
REPEAT
74300
No
CHOLANGIOGRAPHY; INTRAOP-RAD S & I
No
74301
74305
No
No
CHOLANGIOGRPHY; ADD SET-INTRAOP-S&I
CHOLANGIOGRAPHY; POSTOP-RAD S & I
No
No
74320
74327
No
No
CHOLANGIOG PERQ TRANSHEPATIC-S & I
POSTOP BILI DUCT STONE REMOV-S & I
No
No
No
No
No
No
No
No
No
CPT Code
74328
July 2011
No
74329
No
ENDO CATH-PANCREAT DUCT SYST-S & I
No
74330
74340
No
No
COMBO ENDO CATH-BILI/PANCREAT-S & I
INTRO LONG GI TUBE W/MX FILMS-S & I
No
No
74355
74360
74363
No
No
No
No
No
No
74400
No
PERQ PLCMT ENTEROCLYSIS TUBE-S & I
INTRALUMINAL DILAT STRICT-RAD S & I
PERQ TRANSHEPAT DILAT STRICT-S & I
UROGRAPHY IV W/WO KUB W/WO
TOMOGPHY
74410
No
UROGRAPHY INFUSION DRIP &/OR BOLUS
No
74415
74420
74425
74430
No
No
No
No
UROGRAPHY DRIP/BOLUS; W/NEPHROTOM
UROGRAPHY RETROGRADE W/WO KUB
UROGRAPHY ANTEGRADE-RAD S & I
CYSTOGRAPHY MINI 3 VIEWS-RAD S & I
No
No
No
No
74440
No
VASOGRPHY/VESICULOGRPHY-RAD S & I
No
74445
No
No
74450
No
CORPORA CAVERNOSOGRAPHY-RAD S & I
URETHROCYSTOGRAPHY RETROGRADE-S
&I
74455
No
URETHROCYSTOGRPHY VOIDING-RAD S & I
No
74470
74475
No
No
RAD EXAM-RENAL CYST-TRNSLUMB-S & I
INTRO INTRACATH-RENAL PELVIS-S & I
No
No
74480
No
INTRO URETERAL CATH-RENAL PELV-S&I
No
74485
No
DILAT NEPHROST/URETERS/URETHRA-S&I
No
74710
74740
No
YES
PELVIMETRY W/WO PLACENTAL LOCALIZ
HYSTEROSALPINGOGRAPHY-RAD S & I
No
No
74742
YES
TRANSCERV CATH FALLOPIAN TUBE-S & I
No
Code Description
ENDO CATH-BILI DUCT SYST-RAD S & I
No
No
No
CPT Code
74775
75557
75559
75561
75563
75565
75571
75572
75573
75574
July 2011
No
Yes
Yes
Yes
Yes
YES
YES
Yes
Yes
Yes
75600
No
Code Description
PERINEOGRAM
CARDIAC MRI FOR MORPH
CARDIAC MRI W/STRESS IMG
CARDIAC MRI FOR MORPH W/DYE
CARD MRI W/STRESS IMG & DYE
CARD MRI VEL FLW MAP ADD-ON
CT HRT W/O DYE W/CA TEST
CT HRT W/3D IMAGE
CT HRT W/3D IMAGE, CONGEN
CT ANGIO HRT W/3D IMAGE
AORTOGRPHY THORACIC WO SERIALOGS&I
75605
No
AORTOGRAPHY THORACIC-SERIALOG-S & I
No
75625
No
AORTOGRAPHY ABD-SERIALOG-RAD S & I
No
75630
No
No
75635
75650
Yes
No
AORTOGRAPHY ABD+BILAT ILIOFEM-S & I
CT ANGIO ABD AORTA BILAT ILIOFEMORAL
L/E
ANGIO CERVICOCEREBRAL CATH-S&I
Yes
No
75658
75660
75662
75665
75671
75676
75680
No
No
No
No
No
No
No
ANGIO BRACHIAL RETROGRADE-RAD S & I
ANGIO EXT CAROTID UNILAT SELECT-S&I
ANGIO EXT CAROTID BILAT SELECT-S&I
ANGIO CAROTID CEREBRAL UNILAT-S & I
ANGIO CAROTID CEREBRAL BILAT-S & I
ANGIO CAROTID CERV UNILAT-RAD S & I
ANGIO CAROTID CERV BILAT-RAD S & I
No
No
No
No
No
No
No
75685
75705
75710
75716
75722
75724
No
No
No
No
No
No
ANGIO VERTEBRAL CERV/INTRACRAN-S&I
ANGIO SPINAL SELECT-RAD S & I
ANGIO EXTREM UNILAT-RAD S & I
ANGIO EXTREM BILAT-RAD S & I
ANGIO RENAL UNILAT SELECT-RAD S & I
ANGIO RENAL BILAT SELECT-RAD S & I
No
No
No
No
No
No
75726
No
ANGIO VISCERAL SELEC/SUPRASELEC-S&I
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
No
CPT Code
July 2011
75731
75733
No
No
ANGIO ADRENAL UNILAT SELECT-RAD S&I
ANGIO ADRENAL BILAT SELEC-RAD S & I
No
No
75736
75741
75743
No
No
No
ANGIO PELVIC SELEC/SUPRASELEC-S & I
ANGIO PULM UNILAT SELECT-RAD S & I
ANGIO PULM BILAT SELECT-RAD S & I
No
No
No
75746
75756
75774
75791
No
No
No
No
ANGIO PULM-NONSELECT CATH-RAD S & I
ANGIO INT MAMMARY-RAD S & I
ANGIO SELECT EA ADD VESSEL-S&I
AV DIALYSIS SHUNT IMAGING
No
No
No
No
75801
No
LYMPHANGIOG EXTREM ONLY UNILAT-S&I
No
75803
75805
75807
No
No
No
LYMPHANGIOG EXTREM ONLY BILAT-S & I
LYMPHANGIO PELVIC/ABD UNILAT-S & I
LYMPHANGIOG PELVIC/ABD BILAT-S & I
No
No
No
75809
75810
No
No
SHUNTOGM INVESTIGAT PREV PLACED-S&I
SPLENOPORTOGRAPHY-RAD S & I
No
No
75820
75822
No
No
VENOGRAPHY EXTREM UNILAT-RAD S & I
VENOGRAPHY EXTREM BILAT-RAD S & I
No
No
75825
75827
No
No
VENOGRAPHY CAVAL INFERIOR-RAD S & I
VENOGRAPHY CAVAL SUPER-RAD S & I
No
No
75831
No
VENOGRPHY RENAL UNILAT SELECT-S & I
No
75833
No
VENOGRAPHY RENAL BILAT SELECT-S & I
No
75840
No
VENOGRPHY ADRENAL UNILAT SELECT-S&I
No
75842
No
No
75860
No
VENOGRAPHY ADRENAL BILAT SELECT-S&I
VENOGRAPHY VENOUS SINUS/JUGULAR
CATHETER RAD S&I
No
75870
No
VENOGRPHY SUPER SAGIT SINUS-RAD S&I
No
Code Description
CPT Code
75872
75880
July 2011
No
No
75885
No
PERQ TRANSHEPAT PORTOG W/EVAL-S & I
No
75887
No
PERQ TRANSHEPAT PORTOG WO EVAL-S&I
No
75889
No
No
75891
No
HEPAT VENOG WEDGED/FREE W/EVAL-S&I
HEPAT VENOG WEDGED/FREE WO EVALS&I
75893
No
VENOUS SAMPL-CATH W/WO ANGIO-S & I
No
75894
No
TRANSCATH THERAP EMBOLIZAT-RAD S&I
No
75896
75898
75900
No
No
No
No
No
No
75901
No
75902
75940
75945
75946
No
No
No
No
75952
Yes
75953
Yes
75954
Yes
75956
Yes
75957
Yes
75958
Yes
75959
Yes
TRANSCATH THERAP INFUSION-RAD S & I
ANGIO-EXIST CATH F/U STUDY-THERAP
EXCHG PREV PLCD ART CATH-RAD S & I
MECH REMV PERICATH OBST CV DEV SEP
ACSS RAD S&I
MECH REMV INTRALUM OBST CV DEV THRU
LUMN RAD S&I
PERCUT PLCMT IVC FILTER-RAD S & I
INTRAVASC US RAD S/I; INITIAL VESSL
INTRAVASC US S/I; EA ADD NON-CORN
TRANSCATHETER REPR INFRARENAL ABD
AORTIC ANEURY
TRANSCATHETER PLACEMNT PROX/DIST
EXTEN PROSTETH
ENDVSC REP ILIAC ART ANEUR AV
MAL/TRAUMA RAD S&I
EVASC RPR DTA COVERAGE L SUBCLA
ORIGIN RS&I
EVASC RPR DTA X COVERAGE L SUBCLA
ORIGIN RS&I
RS&I
PLMT DSTL XTN PROSTH AFTER EVASC
RPR DTA RS&I
Code Description
VENOGRAPHY EPIDURAL-RAD S & I
VENOGRAPHY ORBITAL-RAD S & I
No
No
No
No
No
No
No
No
Yes
Yes
Yes
No
No
No
No
CPT Code
July 2011
75960
75961
No
No
Code Description
TRANSCATH INTRO INTRAVASC STENT RAD
S&I EA VES
TRANSCATH RETRIEVAL PERQ IV FB-S&I
75962
No
TRANSLUM BALLOON ANGIOPL PERIPH-S&I
No
75964
No
TRANSLUM BALLOON ANGIOPL EA ADD-S&I
No
75966
No
TRANSLUM BALOON ANGIOPL RENAL-S & I
No
75968
75970
No
No
No
No
75978
75980
No
No
TRNSLUM BALN ANGIOPL EA ADD VISCER
TRANSCATH BX-RAD S & I
TRANSLUM BALLOON ANGIOPL VENOUSS&I
PERQ TRANSHEP BILI DRAIN-RAD S&I
75982
No
PERQ PLCMT CATH-INOPER OBSTRCT-S&I
No
75984
No
CHANGE PERQ DRAIN CATH W/MONIT-S&I
No
75989
76000
No
No
RAD GUID PERC DRAIN ABSC W/CATH-S&I
FLUORO (SEP) TO 1HR-NOT 71023/71034
No
No
76001
No
FLUORO-TIME > 1HR-ASSIST NON-RAD MD
No
76010
No
RAD EXAM NOSE-RECTUM FB-SNGL-CHILD
No
76080
76098
No
No
RAD EXAM ABSC/FISTUL/SINUS TRAC-S&I
RAD EXAM SURG SPECMN
No
No
76100
No
RAD EXAM 1 PLNE BOD SECT-NOT W/UROG
No
76101
No
RAD EXAM COMPLX MOTION BODY; UNILA
No
76102
No
RAD EXAM COMPLX MOTION BODY; BILAT
No
76120
No
No
76125
No
CINERADIOGRAPHY EX WHERE SPEC INCL
CINERADIOGRAPHY-COMPLEMENT
ROUTINE
No
No
No
No
No
CPT Code
July 2011
76140
Not Reimbursable
76376
No
76377
76380
No
No
76390
76496
Yes
Yes
76497
Yes
76498
76499
76506
Yes
Yes
No
76510
No
76511
No
76512
No
76513
No
76514
No
76516
Code Description
CONS X-RAY EXAM MADE ELSEWHERE
WRIT
3D RNDR I&R CT MRI US/OTH X REQ
POSTPCX
3D RNDR I&R CT MRI US/OTH REQ
POSTPCX
CT LTD/LOCALIZ F/U STUDY
Not Reimbursable
No
No
No
Yes
Yes
No
MAGNETIC RESONANCE SPECTROSCOPY
UNLISTED FLUOROSCOPIC PROCEDURE
UNLISTED COMPUTED TOMOGRAPHY
PROCEDURE
UNLISTED MAGNETIC RESONANCE
PROCEDURE
UNLISTED DX RAD PROC
ECHO B-SCAN/REAL TIME W/A-MODE
OPHTHALMIC US DX; B-SCAN&QUAN ASCAN SAME ENCNTR
OPHTHALMIC US DX; QUANTITATIVE ASCAN ONLY
OPHTHALMIC US DX; B-SCAN W/WO NONQUAN A-SCAN
OPHTHALMIC US DX; ANT SEG US BSCAN/BIOMICROSCPY
OPHTHALMIC US DX; CORNEAL
PACHYMETRY UNI/BIL
OPHTH BIOMETRY-ULTRASND ECHO ASCAN
76519
76529
No
No
OPHTH BIOMET A-SCAN; W/IO LENS POWR
OPHTH ULTRASONIC FB LOCALIZ
No
No
76536
No
ECHO-SOFT TISS HEAD B-SCAN W/IMAGE
No
76604
No
ECHO CHEST B-SCAN W/IMAGE DOCUMEN
No
76645
No
ECHO BREAST(S) B-SCAN W/IMAGE DOCUM
No
76700
No
ECHO ABD B-SCAN W/IMAGE DOC; COMPLT
No
Yes
Yes
Yes
No
No
No
No
No
No
No
CPT Code
76705
76770
76775
76776
76800
July 2011
No
No
No
No
No
76801
No
76802
76805
76810
No
No
No
76811
No
76812
76813
76814
No
No
No
76815
No
76816
No
76817
76818
No
No
76819
No
76820
No
76821
Code Description
ECHO ABD B-SCAN W/IMAGE DOC; LTD
ECHO RETROPERITON B-SCAN; COMPLT
ECHO RETROPERITON B-SCAN; LTD
US EXAM K TRANSPL W/DOPPLER
ECHO SPINAL CANAL & CONTENTS
RTU PG UTRUS 1 TRI TRANSABD APPRCH;
1/1ST GEST
RTU PG UTRUS 1 TRI TRANSABD APPRCH;
EA ADD GEST
ECHO PG UTERUS B-SCAN; COMPLT
ECHO PG UTERUS; COMPLT MX GEST
RTU PG UTRUS DTL FETL ANAT EX
TRANSABD; 1/1 GEST
RTU PG UTRUS DTL FETL ANAT EX
TRANSABD; EA GEST
OB US NUCHAL MEAS, 1 GEST
OB US NUCHAL MEAS, ADD-ON
ECHO PG UTERUS B-SCAN W/DOCUMN;
LTD
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
ECHO PG UTERUS B-SCAN W/DOC; REPEAT
US PG UTERUS REAL TIME W/IMAGE DOC
TRANSVAGINAL
FETAL BIOPHYSICAL PROFILE
PROFILE FETAL BIOPHYSICAL W/NONSTRESS TEST
DOPPLER VELOCIMETRY FETAL; UMBILICAL
ARTERY
DOPPLER VELOCIMETRY FETAL; MIDDLE
CEREBRAL ART
76825
No
ECHO FETAL-CV SYST-REAL TIME W/DOC
No
76826
No
No
76827
No
76828
76830
No
No
ECHO FETAL-CV SYST-REAL TIME; REPET
DOPPLER ECHO FETAL PULSED WAVE
&/CONT WAVE; CMPL
DOPPLER ECHO FETAL PULSE
WAVE&/CONT WAVE; REPEAT
ECHO TRANSVAGINAL
No
No
No
No
No
No
No
No
CPT Code
July 2011
76831
No
Code Description
SIS INCLUDING COLOR FLOW DOPPLER
WHEN PERFORMED
76856
No
ECHO PELVIC B-SCAN W/DOCUMN; COMPLT
No
76857
76870
76872
No
No
No
No
No
No
76873
76881
76882
76885
76886
No
No
No
No
No
ECHO PELVIC B-SCAN W/DOCUMEN; LTD
ECHO SCROTUM & CONTENTS
ULTRASOUND TRANSRECTAL;
US TRNSRECTL; PROSTATE BRACHYTX
PLAN-SEP PROC
US XTR NON-VASC COMPLETE
US XTR NON-VASC LMTD
U/S INFANT HIPS; DYNAMIC
U/S INFANT HIPS; LTD, STATIC
76930
No
ULTRASON GUIDAN PERICARDIOCENTESIS
No
76932
No
No
76936
No
76937
No
76940
76941
No
No
ULTRASON GUIDAN ENDOMYOCARD BX-S&I
US GUID COMPRESS REPR PSEUDOANEURY
US GUID VASC ACSS PTNTL ACSS SITE
W/PERM REC&RPT
ULTRASOUND GUID&MONITORING
VISCERAL TISSUE ABLAT
US GUID IN UTERO FETAL TRNSFUS-S&I
76942
76945
No
No
ULTRASON GUIDAN NEEDLE BX-RAD S & I
US GUID CHORIONIC VILLUS SAMPL-S&I
No
No
76946
76948
No
No
ULTRASON GUIDAN AMNIOCENTESIS-S & I
ULTRASON GUIDAN ASPIRAT OVA-S & I
No
No
76950
No
ECHO PLCMT-RAD THERAP FIELDS B-SCAN
No
76965
76970
76975
76977
76998
No
No
No
No
No
US GUID INTERST RADIOELEMENT APPLIC
ULTRASOUND STUDY F/U
GI ENDO ULTRASND-RAD S & I
US BONE DENSITY MEASUR & INTERP
US GUIDE, INTRAOP
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
76999
77001
77002
77003
77011
77012
77013
77014
77021
77022
77031
77032
77051
77052
77053
77054
77055
77056
77057
77058
77059
77071
77072
77073
77074
77075
77076
77077
77078
77079
77080
77081
77082
77083
77084
77261
77262
77263
77280
July 2011
Yes
No
No
No
No
No
No
No
Yes
Yes
No
No
No
No
No
No
No
No
No
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
Code Description
UNLISTED ULTRASOUND PROC
FLUOROGUIDE FOR VEIN DEVICE
NEEDLE LOCALIZATION BY XRAY
FLUOROGUIDE FOR SPINE INJECT
CT SCAN FOR LOCALIZATION
CT SCAN FOR NEEDLE BIOPSY
CT GUIDE FOR TISSUE ABLATION
CT SCAN FOR THERAPY GUIDE
MR GUIDANCE FOR NEEDLE PLACE
MRI FOR TISSUE ABLATION
STEREOTACT GUIDE FOR BRST BX
GUIDANCE FOR NEEDLE, BREAST
COMPUTER DX MAMMOGRAM ADD-ON
COMP SCREEN MAMMOGRAM ADD-ON
X-RAY OF MAMMARY DUCT
X-RAY OF MAMMARY DUCTS
MAMMOGRAM, ONE BREAST
MAMMOGRAM, BOTH BREASTS
MAMMOGRAM, SCREENING
MRI, ONE BREAST
MRI, BOTH BREASTS
X-RAY STRESS VIEW
X-RAYS FOR BONE AGE
X-RAYS, BONE LENGTH STUDIES
X-RAYS, BONE SURVEY, LIMITED
X-RAYS, BONE SURVEY COMPLETE
X-RAYS, BONE SURVEY, INFANT
JOINT SURVEY, SINGLE VIEW
CT BONE DENSITY, AXIAL
CT BONE DENSITY, PERIPHERAL
DXA BONE DENSITY, AXIAL
DXA BONE DENSITY/PERIPHERAL
DXA BONE DENSITY, VERT FX
RADIOGRAPHIC ABSORPTIOMETRY
MAGNETIC IMAGE, BONE MARROW
THERAP RAD TX PLANNING; SIMPL
THERAP RAD TX PLANNING; INTERMED
THERAP RAD TX PLANNING; COMPLX
THERAP RAD SIMULAT-AIDED FIELD; SIM
Yes
No
No
No
No
No
No
No
Yes
Yes
No
No
No
No
No
No
No
No
No
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
CPT Code
July 2011
77285
77290
77295
No
No
No
THERAP RAD SIMULAT-AID FLD; INTERMD
THERAP RAD SIMULAT-AID FLD; COMPLX
TX RAD SIM-AIDED FIELD SETTING; 3-D
No
No
No
77299
Yes
UNLIST PROC THERAP RAD TX PLANNING
Yes
77300
No
BASIC RAD DOSIMETRY CALCULAT-BY MD
No
77301
77305
No
No
INTENS MOD RADIOTX DOSE-VOL HSTOGM
TELETHERAPY ISODOSE PLAN; SIMPL
No
No
77310
77315
No
No
TELETHERAPY ISODOSE PLAN; INTERMED
TELETHERAPY ISODOSE PLAN; COMPLX
No
No
77321
No
SPEC TELETHERAP PORT PLAN PARTICLES
No
77326
No
No
77327
No
77328
No
BRACHYTHERAP ISODOSE CALCUL; SIMPL
BRACHYTHERAP ISODOS CALCUL;
INMTERM
BRACHYTHERAP ISODOSE CALCUL;
COMPLX
77331
No
SPEC DOSIMETRY-PRESCRIB BY TX PHYS
No
77332
No
TX DEVICES DESIGN & CONSTRUCT; SMPL
No
77333
No
TX DEVIC DESIGN & CONSTRUCT; INTERM
No
77334
No
TX DEVIC DESIGN & CONSTRUCT; COMPLX
No
77336
77338
No
Yes
CONT MED PHYSICS CONS PER WK THER
DESIGN MLC DEVICE FOR IMRT
No
No
77370
77371
77372
77373
No
No
No
No
SPECIAL MED RADIATION PHYSICS CONS
SRS, MULTISOURCE
SRS, LINEAR BASED
SBRT DELIVERY
No
No
No
No
Code Description
No
No
CPT Code
July 2011
77399
77401
77402
77403
77404
77406
77407
77408
77409
77411
Yes
No
No
No
No
No
No
No
No
No
UNLIST PROC MED RAD PHYSICS DOSIMET
RAD TX DELIV SUPERF/ORTHO VOLTAGE
RAD TX DELIV-1 TX AREA; TO 5 MEV
RAD TX DELIV-1 TX AREA; 6-10 MEV
RAD TX DELIV-1 TX AREA; 11-19 MEV
RAD TX DELIV-1 TX AREA; 20MEV/GRTER
RAD TX DELIV-2 TX AREAS; TO 5 MEV
RAD TX DELIV-2 TX AREAS; 6-10 MEV
RAD TX DELIV-2 TX AREAS; 11-19 MEV
RAD TX DELIV-2 TX AREAS; 20 MEV/GRT
Yes
No
No
No
No
No
No
No
No
No
77412
77413
No
No
RAD TX DELIV-3/MORE AREAS; TO 5 MEV
RAD TX DELIV-3/MORE AREAS; 6-10 MEV
No
No
77414
77416
77417
No
No
No
No
No
No
77418
77427
No
No
77431
No
77432
77435
77470
77499
No
No
No
Yes
RAD TX DELIV-3/MORE AREAS; 11-19MEV
RAD TX DELIV-3/MORE AREAS; 20 MEV
THERAP RAD PORT FILM
INTENS MOD TX DEL VIA TEMPORLLY MOD
BEAM-TX SESS
RADIATION TX MGMT-FIVE TREATMENTS
RADIAT THERAP MGMT W/COMPLT
COURSE
STEREOTACT RAD TX MGMT CEREBRAL
LES
SBRT MANAGEMENT
SPECIAL TX PROC
UNLISTED PROC THERAP RAD TX MGMT
No
No
No
Yes
77520
77522
Yes
Yes
PROTON BEAM DELIV-1 TX AREA-W/SETUP
PROTON BEAN DELIV; SIMPLE W/COMP
Yes
Yes
77523
77525
77600
77605
Yes
Yes
No
No
PROTON BEAM DELIV 1-2 AREAS-W/SETUP
PROTON BEAN DELIV; COMPLEX
HYPERTHERMIA EXT GEN; SUPERF
HYPERTHERMIA EXT GEN; DEEP
Yes
Yes
No
No
77610
No
HYPERTHERM-INTERSTIT PROBE; 5/LESS
No
Code Description
No
No
No
CPT Code
July 2011
77615
No
HYPERTHERM-INTERSTIT PROBE; > 5 APP
No
77620
No
No
77750
77761
No
No
HYPERTHERMIA GEN-INTRACAVIT PROBE
INFUS/INSTILL RADIOELEMENT SOL INCL 3
MO FLW UP
INTRACAVIT RADIOELEM APPLIC; SIMPL
77762
No
INTRACAVIT RADIOELEM APPLIC; INTERM
No
77763
77776
No
No
INTRACAVIT RADIOELEM APPLIC; COMPLX
INTERSTITIAL RADIOELEM APPLIC; SMPL
No
No
77777
77778
77785
77786
77787
77789
No
No
No
No
No
No
INTERSTIT RADIOELEM APPLIC; INTERMD
INTERSTIT RADIOELEM APPLIC; COMPLX
HDR BRACHYTX, 1 CHANNEL
HDR BRACHYTX, 2-12 CHANNEL
HDR BRACHYTX OVER 12 CHAN
SURFACE APPLIC RADIOELEMENT
No
No
No
No
No
No
77790
77799
78000
78001
No
Yes
No
No
SUPERVS HANDLING LOAD-RADIOELEMENT
UNLIST PROC CLINICAL BRACHYTHERAP
THYROID UPTAKE; SNGL DETERM
THYROID UPTAKE; MX DETERM
No
Yes
No
No
78003
No
THYROID UPTAKE; STIM SUPRESS/DISCHG
No
78006
No
THYROID IMAGING W/UPTAKE; 1 DETERM
No
78007
78010
78011
No
No
No
THYROID IMAGING W/UPTAKE; MX DETERM
THYROID IMAGING; ONLY
THYROID IMAGING; W/VASCULAR FLOW
No
No
No
78015
No
THYROID CA METASTAS IMAG; LTD AREA
No
78016
No
THYROID CA METASTASES IMAG; W/ADD
No
78018
78020
No
No
THYROID CA METASTAS IMAG; WHOLE BOD
THYROID CA METS UPTAKE
No
No
Code Description
No
No
CPT Code
78070
July 2011
No
78075
No
ADRENAL IMAGING CORTEX &/OR MEDULLA
No
78099
78102
78103
Yes
No
No
UNLIST ENDOCRIN PROC DX NUCLEAR MED
BONE MARROW IMAGING; LTD AREA
BONE MARROW IMAGING; MX AREAS
Yes
No
No
78104
No
BONE MARROW IMAGING; WHOLE BODY
No
78110
No
PLASMA VOLU RADIOPHARM (SEP PRO); 1
No
78111
78120
No
No
PLASMA VOL RADIOPHARM (SEP PRO); MX
RED CELL VOLUM DETERM (SEP PRO); 1
No
No
78121
No
RED CELL VOLUM DETERM (SEP PRO); MX
No
78122
78130
No
No
WHOLE BLD VOL DETER W/SEP PLASM/RBC
RED CELL SURVIVAL STUDY
No
No
78135
No
RED CELL SURVIVAL STUDY; DIFF ORGAN
No
78140
No
LABELED RED CELL SEQUESTRATION DIFF
No
78185
78190
78191
No
No
No
SPLEEN IMAGING ONLY W/WO VASCUL FLO
KINETICS STUDY PLATELET SURVIVAL
PLATELET SURVIVAL STUDY
No
No
No
78195
No
LYMPHATICS & LYMPH GLANDS IMAGING
No
78199
78201
78202
78205
78206
78215
Yes
No
No
No
No
No
UNLIST HEMATOPOIETIC PROC-DX NUCLER
LIVER IMAGING; STATIC ONLY
LIVER IMAGING; W/VASCULAR FLOW
LIVER IMAGING (SPECT);
LIVER IMAG (SPECT); W/VASC FLOW
LIVER & SPLEEN IMAGING; STATIC ONLY
Yes
No
No
No
No
No
78216
No
LIVER & SPLEEN IMAG; W/VASCULAR FLO
No
Code Description
PARATHYROID IMAGING
No
CPT Code
July 2011
78220
78223
78230
78231
78232
78258
78261
78262
78264
No
No
No
No
No
No
No
No
No
78267
No
78268
78270
78271
No
No
No
78272
78278
78282
78290
No
No
No
No
78291
78299
78300
78305
78306
Code Description
LIVER FUNCT STUDY W/HEPATOBILI AGEN
HEPATOBILI DUCT SYST IMAG INCL GB
SALIVARY GLAND IMAGING
SALIVARY GLAND IMAG; W/SERIAL IMAG
SALIVARY GLAND FUNCT STUDY
ESOPH MOTILITY
GASTRIC MUCOS IMAGING
GASTROESOPHAGEAL REFLUX STUDY
GASTRIC EMPTYING STUDY
UREA BREATH TEST C14 ISOTOPIC; ACQN
ANALYSIS
UREA BREATH TEST C14 ISOTOPIC;
ANALYSIS
VIT B-12 ABSORP STUDY; WO INTRINSIC
VIT B-12 ABSORP STUDY; W/INTRINSIC
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
Yes
No
No
No
VIT B-12 ABSORP COMBO W/WO INTRINSC
ACUTE GI BLD LOSS IMAGING
GI PROT LOSS
BOWEL IMAGING
PERITONEAL-VENOUS SHNT PATENCY
TEST
UNLISTED GI PROC DX NUCLEAR MEDS
BONE &/OR JT IMAGING; LTD AREA
BONE &/OR JT IMAGING; MX AREAS
BONE &/OR JT IMAGING; WHOLE BODY
No
Yes
No
No
No
78315
78320
No
No
BONE &/OR JT IMAGING; 3 PHASE STUDY
BONE &/OR JT IMAGING; TOMO (SPECT)
No
No
78350
78351
78399
No
No
Yes
No
No
Yes
78414
78428
No
No
BONE DENSITY-1/> SITES; SNGL PHOTON
BONE DENSITY-1/>SITES; DUAL PHOTON
UNLISTED MS PROC DX NUCLEAR MEDS
DETERM CENTRAL C-V HEMODYNAMIC
1/MX
CARDIAC SHUNT DETECTION
78445
No
NON-CARDIAC VASCULAR FLOW IMAGING
No
No
No
No
No
No
No
CPT Code
78451
78452
78453
78454
July 2011
No
No
No
No
78456
No
78457
No
78458
Code Description
HT MUSCLE IMAGE SPECT, SING
HT MUSCLE IMAGE SPECT, MULT
HT MUSCLE IMAGE,PLANAR,SING
HT MUSC IMAGE, PLANAR, MULT
No
No
No
No
No
No
ACUTE VEN THROMBOSIS IMAG-PEPTIDE
VENOUS THROMBOSIS IMAG-VENOGRM;
UNI
VENOUS THROMBOSIS IMAG-VENOGRM;
BIL
78459
PA
MYOCARDIAL IMAG-PET-METABOLIC EVAL
PA
78466
78468
78469
78472
78473
78481
78483
No
No
No
No
No
No
No
MYOCARDIAL IMAG PLANAR; QUAL/QUAN
MYOCARDIAL IMAG; W/EJECT FRACT
MYOCARDIAL IMAG; TOMOGRPH SPECT
CARDIAC BLD POOL IMAG; SNGL STUDY
CARDIAC BLD POOL IMAG; MX STUDIES
CARDIAC BLD POOL 1ST PASS; SNGL
CARDIAC BLD POOL IMAG 1ST PASS; MX
No
No
No
No
No
No
No
78491
Not Reimbursable
MYOCARD IMAG-PET-PERFUS; SNGL STUDY
Not Reimbursable
78492
Not Reimbursable
MYOCARD IMAG-PET-PERFUS; MX STUDIES
Not Reimbursable
78494
78496
No
No
No
No
78499
Yes
CARD BLD POOL IMAG-GATED SPECT-REST
CARD BLD POOL IMAG-GATED-1 STUDY
UNLISTED CARDIOVASC PROC DX
NUCLEAR
Yes
78580
78584
No
No
PULM PERFUSION IMAGING PARTICULATE
PULM PERFUS PARTICULATE; 1 BREATH
No
No
78585
78586
No
No
PULM PERFUS PARTICULATE; REBREATH
PULM VENTILAT IMAG AEROSOL; 1 PROJ
No
No
78587
No
PULM VENTILAT IMAG AEROSOL; MX PROJ
No
78588
No
PULM PERF IMAG-PARTIC W/VENT-AEROSL
No
No
No
CPT Code
July 2011
78591
No
PULM VENTILAT IMAG GASEOUS 1 BREATH
No
78593
No
PULM VENTILAT GASEOUS W/REBREATH; 1
No
78594
78596
No
No
PULM VENTILAT GASEOUS W/REBRTH; MX
PULM QUAN DIFF FUNCT STUDY
No
No
78599
78600
Yes
No
UNLIST RESPIR PROC DX NUCLEAR MEDS
BRAIN IMAGING LTD PROC; STATIC
Yes
No
78601
78605
No
No
BRAIN IMAG LTD PROC; W/VASCULAR FLO
BRAIN IMAGING COMPLT STUDY; STATIC
No
No
78606
No
BRAIN IMAG COMPLT STUDY; W/VASC FLO
No
78607
No
BRAIN IMAGING COMPLT STUDY; (SPECT)
No
78608
PA
PA
78609
78610
Not Reimbursable
No
BRAIN IMAG POSITRON TOMOG; METABOLC
BRAIN IMAG POSITRON TOMOG;
PERFUSON
BRAIN IMAGING VASCULAR FLOW ONLY
Not Reimbursable
No
78630
No
CEREBROSPINAL FLUID IMAG; CISTERNOG
No
78635
No
CEREBROSPINAL FLUID; VENTRICULOGRPY
No
78645
78647
78650
78660
No
No
No
No
CEREBROSPINAL FLUID IMAG; SHUNT EVL
CSF FLOW IMAG; TOMO (SPECT)
CSF LEAKAGE DETECTION & LOCALIZ
RADIOPHARM DACRYOCYSTOGRAPHY
No
No
No
No
78699
78700
78701
Yes
No
No
UNLISTED NERV SYST PROC DX NUCLEAR
KIDNEY IMAGING; STATIC ONLY
KIDNEY IMAGING; W/VASCULAR FLOW
Yes
No
No
78707
No
KIDNEY IMAG W/FLO-FUNC; 1 W/O PHARM
No
78708
No
KIDNEY IMAG W/FLO & FUNC; 1 W/PHARM
No
Code Description
CPT Code
July 2011
78709
No
KIDNEY IMAG FLO-FUNC; MX W&WO PHARM
No
78710
No
KIDNEY IMAGING, TOMOGRAPHIC (SPECT)
No
78725
78730
78740
No
No
No
KIDNEY FUNT NON-IMAGE RADIOISOTOPIC
URIN BLADDER RESIDUAL STUDY
URETERAL REFLUX STUDY
No
No
No
78761
78799
No
Yes
No
Yes
78800
No
78801
No
78802
No
78803
No
78804
78805
No
No
78806
No
TESTICULAR IMAGING; W/VASCULAR FLOW
UNLISTED G U PROC DX NUCLEAR MEDS
RADOPHARM LOC TUMR/DSTRB
RADOPHARM AGT; LTD AREA
RADOPHARM LOC TUMR/DSTRB
RADOPHARM AGT; MX AREAS
RADPHARM LOC TUMR/DSTRB AGT; WHOLE
BDY 1 DA IMAG
RADPHARM LOC TUMR/DSTRB AGT;
TOMOGRAPHIC
RADPHRM LOC TUMR/DSTRB AGT;WHOLE
BDY 2/> DA IMAG
RADIOPHARM LOCALIZ ABSCESS; LTD
RADIOPHARM LOCALIZ ABSC; WHOLE
BODY
78807
78808
No
No
No
No
78811
Yes
78812
78813
Yes
Yes
78814
Yes
78815
Yes
78816
Yes
RADIOPHARM LOCALIZ ABSCESS; (SPECT)
IV INJ RA DRUG DX STUDY
TUMOR IMAGING PET; LTD AREA EG CHEST
HEAD/NECK
TUMOR IMAGING PET; SKULL BASE TO MID
THIGH
TUMOR IMAGING PET; WHOLE BODY
TUMOR IMAG PET W/CONCURRNT CT; LTD
AREA
TUMOR IMAG PET W/CONCURRNT CT; SKUL
BASE MID THI
TUMOR IMAG PET W/CONCURRNT CT;
WHOLE BDY
Code Description
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
CPT Code
July 2011
78999
Yes
79005
No
79101
No
79200
No
79300
No
79403
No
79440
No
79445
No
79999
80047
80048
80050
80051
80053
80055
80061
80069
80074
80076
80100
Yes
No
No
No
No
No
No
No
No
No
No
No
80101
80102
80103
80104
80150
80152
80154
80156
80157
Effec 1/1/2011 Non Reimbursible; prior Reimb
No
No
Not Reimbursable
No
No
No
No
No
Code Description
UNLISTED MISC PROC DX NUCLEAR MEDS
RADIOPHARMACEUTICAL THERAPY ORAL
ADMNISTRATION
RADIOPHARMACEUTICAL THERAPY IV
ADMNISTRATION
RADIOPHARMACEUTICAL THERAPY
INTRACAVITARY ADMIN
RADIOPHARM TX INTERSTITIAL RAD
COLLOID ADMIN
RADOPHRM TX MONOCLONAL ANTIBODY IV
INFUSION
RADIOPHARMACEUTICAL THERAPY INTRAARTICULR ADMIN
RADIOPHARM TX INTRA-ARTERIAL
PARTICULATE ADMIN
RADIOPHARMACEUTICAL THERAPY
UNLISTED PROCEDURE
METABOLIC PANEL IONIZED CA
BASIC METABOLIC PANEL
GENERAL HEALTH PANEL
ELECTROLYTE PANEL
COMP METABOLIC PANEL
OBSTETRIC PANEL
LIPID PANEL
RENAL FUNCTION PANEL
ACUTE HEPATITIS PANEL
HEPATIC FUNCTION PANEL
DRUG SCREEN; MX DRUG CLASSES EA
DRUG SCREEN; SNGL DRUG CLASS EA
DRUG CONFIRM EA PROC
TISS PREP DRUG ANALY
DRUG SCRN 1+ CLASS NONCHROMO
AMIKACIN
AMITRIPTYLINE
BENZODIAZEPINES
CARBAMAZEPINE
CARBAMAZEPINE; FREE
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Not Reimbursable
No
No
No
No
No
CPT Code
80158
80160
80162
80164
80166
80168
80170
80172
80173
80174
80176
80178
80182
80184
80185
80186
80188
80190
80192
80194
80195
80196
80197
80198
80200
80201
80202
80299
80400
July 2011
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
80402
No
ACTH STIM PANEL; 21 HYDROXYLASE DEF
No
80406
No
ACTH STIM PANEL; 3 BETA-HYDROXYDEHY
No
80408
80410
No
No
ALDOSTERONE SUPPRESSION EVAL PANEL
CALCITONIN STIM PANEL
No
No
80412
No
CORTICOTROPIC RELEAS HORMONE STIM
No
Code Description
CYCLOSPORINE
DESIPRAMINE
DIGOXIN
DIPROPYLACETIC ACID
DOXEPIN
ETHOSUXIMIDE
GENTAMICIN
GOLD
HALOPERIDOL
IMIPRAMINE
LIDOCAINE
LITHIUM
NORTRIPTYLINE
PHENOBARBITAL
PHENYTOIN; TOT
PHENYTOIN; FREE
PRIMIDONE
PROCAINAMIDE
PROCAINAMIDE; W/METABOLITES
QUINIDINE
SIROLIMUS
SALICYLATE
TACROLIMUS
THEOPHYLLINE
TOBRAMYCIN
TOPIRAMATE
VANCOMYCIN
QUAN DRUG NES
ACTH STIM PANEL; ADRENAL INSUFF
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
80414
No
Code Description
CHORION GONADOTRO STIM;
TESTOSTERON
80415
80416
80417
80418
No
No
No
No
CHORION GONADOT STIM; ESTRADIOL RES
RENAL VEIN RENIN STIM PANEL
PERIPHERAL VEIN RENIN STIM PANEL
COMBO RAPID PITUITARY EVAL PANEL
No
No
No
No
80420
80422
No
No
No
No
80424
No
80426
80428
No
No
DEXAMETHASONE SUPPRESS PANEL 48 HR
GLUCAGON TOLERANCE; INSULINOMA
GLUCAGON TOLERANC;
PHEOCHROMOCYTOMA
GONADOTROPN RELEAS HORMONE STIM
PAN
GROWTH HORMONE STIM PANEL
80430
No
GROWTH HORMONE SUPPRESSION PANEL
No
80432
No
INSULIN-INDUCED C-PEPTIDE SUPPRESS
No
80434
No
No
80435
80436
No
No
80438
No
80439
No
80440
80500
80502
No
No
No
INSULIN TOLERANC PANEL; ACTH INSUFF
INSULIN TOLERANC; GROWTH HORMON
DEF
METYRAPONE PANEL
THYROTROPIN RELEAS HORMON STIM;
1HR
THYROTROPIN RELEAS HORMON STIM;
2HR
THYROTROP RELEAS HORMON;
HYPERPROLA
CLINIC PATH CONS; LTD WO REVIEW
CLINIC PATH CONS; COMP W/REVIEW
81000
81001
No
No
UA DIPSTIK/TABLET; NON-AUTO W/MICRO
UA DIP STICK/TABLET; AUTO W/MICRO
No
No
81002
81003
No
No
UA DIP STIK/TABLT;WO MICRO NON-AUTO
UA DIP STIK/TABLET; WO MICRO AUTO
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
81005
81007
81015
81020
81025
81050
81099
82000
82003
82009
No
No
No
No
No
No
No
No
No
No
UA; QUAL/SEMIQUAN EX IMMUNOASSAYS
UA; BACTERURIA SCRN NON-CULT KIT
UA; MICRO ONLY
UA; 2 OR 3 GLASS TEST
URIN PG TEST VISUAL COLOR COMPAR
VOLUM MEASUR TIMED COLLEC EA
UNLISTED UA PROC
ACETALDEHYDE BLD
ACETAMINOPHEN
ACETONE/OTHER BODIES SERUM; QUAL
No
No
No
No
No
No
No
No
No
No
82010
82013
82016
82017
82024
No
No
No
No
No
ACETONE/OTHER BODIES SERUM; QUAN
ACETYLCHOLINESTERASE
ACYLCARNITINES; QUAL EA SPEC
ACYLCARNITINES; QUAN EA SPEC
ADRENOCORTICOTROPIC HORMONE
No
No
No
No
No
82030
82040
82042
82043
No
No
No
No
ADENOSINE 5'-MONOPHOSPHATE CYCLIC
ALBUMIN; SERUM
ALBUMIN; URIN QUAN
ALBUMIN; URIN MICROALBUMIN QUAN
No
No
No
No
82044
82055
82075
82085
82088
82101
82103
82104
82105
82106
82107
82108
82120
82127
82128
82131
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
ALBUMIN; URIN MICROALBUMIN SEMIQUAN
ALCOHOL; ANY SPECMN EX BREATH
ALCOHOL; BREATH
ALDOLASE
ALDOSTERONE
ALKALOIDS URIN QUAN
ALPHA-1-ANTITRYPSIN; TOT
ALPHA-1-ANTITRYPSIN; PHENOTYPE
ALPHA-FETOPROTEIN; SERUM
ALPHA-FETOPROTEIN; AMNIOTIC FLUID
ALPHA-FETOPROTEIN L3
ALUMINUM
AMINES VAG FLUID-QUAL
AMINO ACIDS; 1-QUAL EA SPEC
AMINO ACIDS; MX QUAL EA SPEC
AMINO ACIDS; SINGL QUAN EA SPEC
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Code Description
CPT Code
82135
82136
82139
82140
82143
82145
82150
82154
82157
82160
82163
82164
82172
82175
82180
July 2011
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
82190
82205
82232
82239
82240
82247
82248
82252
82261
No
No
No
No
No
No
No
No
No
82270
No
82271
No
82272
82274
82286
82300
82306
82308
82310
82331
Code Description
AMINOLEVULINIC ACID DELTA
AMINO ACIDS 2 TO 5-QUAN-EA SPEC
AMINO ACIDS 6/>-QUAN-EA SPEC
AMMONIA
AMNIOTIC FLUID SCAN
AMPHETAMINE/METHAMPHETAMINE
AMYLASE
ANDROSTANEDIOL GLUCURONIDE
ANDROSTENEDIONE
ANDROSTERONE
ANGIOTENSIN II
ANGIOTENSIN I- CONVERTING ENZYME
APOLIPOPROTEIN EA
ARSENIC
ASCORBIC ACID BLD
ATOMIC ABSORP SPECTROSCPY EA
ANALYT
BARBITURATES NES
BETA-2 MICROGLOBULIN
BILE ACIDS; TOT
BILE ACIDS; CHOLYLGLYCINE
BILIRUBIN; TOT
BILIRUBIN; DIRECT
BILI; FECES QUAL
BIOTINIDASE EA SPEC
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
BLD OCCULT; FECES 1-3 SIMULT DETERM
BLD OCLT PROXIDASE ACTV QUAL OTH
SRCS
BLD OCLT PROXIDASE ACTV QUAL FECES 1
SPEC
No
No
No
No
No
No
No
BLD OCCLT FECL HGB IMMUOAS QUAL FEC
BRADYKININ
CADMIUM
CALCIFEDIOL
CALCITONIN
CALCIUM; TOT
CALCIUM; AFTER CALCIUM INFUSN TEST
No
No
No
No
No
No
No
No
No
CPT Code
82340
82355
82360
82365
82370
July 2011
No
No
No
No
No
82373
82374
82375
82376
82378
No
No
No
No
No
CARBOHYDRATE DEFICIENT TRANSFERRIN
CARBON DIOXIDE
CARBON MONOXIDE; QUAN
CARBON MONOXIDE; QUAL
CARCINOEMBRYONIC ANTIG
No
No
No
No
No
82379
82380
82382
82383
82384
82387
82390
82397
82415
82435
82436
82438
No
No
No
No
No
No
No
No
No
No
No
No
CARNITINE (TOT & FREE) QUAN EA SPEC
CAROTENE
CATECHOLAMINES; TOT URIN
CATECHOLAMINES; BLD
CATECHOLAMINES; FRACTIONATED
CATHEPSIN-D
CERULOPLASMIN
CHEMILUMINESCENT ASSAY
CHLORAMPHENICOL
CHLORIDE; BLD
CHLORIDE; URIN
CHLORIDE; OTHER SOURCE
No
No
No
No
No
No
No
No
No
No
No
No
82441
82465
82480
82482
82485
No
No
No
No
No
No
No
No
No
No
82486
No
CHLORINATED HYDROCARBONS SCREEN
CHOL SERUM TOT
CHOLINESTERASE; SERUM
CHOLINESTERASE; RBC
CHONDROITIN B SULFATE QUAN
CHRMATOGRPHY QUAL; COLUMN ANLYT
NES
82487
No
CHRMATGRPHY QUAL; PAPR 1-DIM ANALYT
No
82488
No
CHRMATGRPHY QUAL; PAPR 2-DIM ANALYT
No
82489
No
CHRMATGRPHY QUAL; THIN LAYER ANALYT
No
Code Description
CALCIUM; URIN QUAN TIMED SPECMN
CALCU; QUAL ANALY
CALCU; QUAN ANALY CHEM
CALCU; INFRARED SPECTROSCOPY
CALCU; X-RAY DIFFRACTION
No
No
No
No
No
No
CPT Code
July 2011
82491
No
82492
82495
82507
82520
82523
82525
82528
82530
82533
82540
No
No
No
No
No
No
No
No
No
No
82541
No
82542
Code Description
CHROMATOG QUAN COLMN; 1 ANALYTE
NES
No
No
No
No
No
No
No
No
No
No
No
No
CHROMATOGRAPHY QUAN COLUMN; MULT
CHROMIUM
CITRATE
COCAINE/METABOLITE
COLLAGEN CROSS LINKS-ANY METHD
COPPER
CORTICOSTERONE
CORTISOL; FREE
CORTISOL; TOT
CREATINE
CHROMATOG/SPECTROM-ANALYT NES;
QUAL
CHROMATOG/SPECTROM-ANALYT NES;
QUAN
82543
No
CHROMATOG ANALYT NES; ISOTOPE DIL-1
No
82544
82550
82552
82553
82554
82565
82570
82575
82585
82595
82600
82607
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
82608
82610
82615
82626
82627
82633
No
No
No
No
No
No
CHROMATOG ANALYT NES; ISOTOP DIL-MX
CREATINE KINASE; TOT
CREATINE KINASE; ISOENZYMES
CREATINE KINASE; MB FRACTION ONLY
CREATINE KINASE; ISOFORMS
CREATININE; BLD
CREATININE; OTHER SOURCE
CREATININE; CLEARANCE
CRYOFIBRINOGEN
CRYOGLOBULIN
CYANIDE
CYANOCOBALAMIN
CYANOCOBALAMIN; UNSATURATED
BINDING
CYSTATIN C
CYSTINE & HOMOCYSTINE URIN QUAL
DEHYDROEPIANDROSTERONE
DEHYDROEPIANDROSTERONE-SULFATE
DESOXYCORTICOSTERONE 11-
No
No
No
No
No
No
No
No
CPT Code
82634
82638
82646
82649
82651
82652
82654
July 2011
No
No
No
No
No
No
No
82656
82657
82658
82664
82666
82668
82670
82671
82672
82677
82679
82690
82693
82696
82705
82710
82715
82725
82726
82728
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Code Description
DEOXYCORTISOL 11DIBUCAINE NUMBER
DIHYDROCODEINONE
DIHYDROMORPHINONE
DIHYDROTESTOSTERONE
DIHYDROXYVITAMIN D 1 25DIMETHADIONE
ELASTASE PANCREATIC FECAL
QUALITATIVE/SEMIQUAN
ENZYM ACTIV-CELLS/TISS NES; NONRAD
ENZYM ACTIV-CELLS/TISS NES; RAD-EA
ELEC-PHORE TECH NES
EPIANDROSTERONE
ERYTHROPOIETIN
ESTRADIOL
ESTROGENS; FRACTIONATED
ESTROGENS; TOT
ESTRIOL
ESTRONE
ETHCHLORVYNOL
ETHYLENE GLYCOL
ETIOCHOLANOLONE
FAT/LIPIDS FECES; QUAL
FAT/LIPIDS FECES; QUAN
FAT DIFF FECES QUAN
FATTY ACIDS NONESTERIFIED
VERY LONG CHAIN FATTY ACIDS
FERRITIN
82731
82735
82742
82746
82747
82757
82759
82760
No
No
No
No
No
No
No
No
FETAL FIBRONECTIN-CERV/VAG SECRETNS
FLUORIDE
FLURAZEPAM
FOLIC ACID; SERUM
FOLIC ACID; RBC
FRUCTOSE SEMEN
GALACTOKINASE RBC
GALACTOSE
No
No
No
No
No
No
No
No
82775
No
GALACTOSE-1-PHOSP URIDYL TRNS; QUAN
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
82776
82784
82785
82787
82800
82803
No
No
No
No
No
No
GALACTOSE-1-PHOSP URIDYL TRNS; SCRN
GG; IGA, IGD, IGG, IGM, EA
GG; IGE
GG; IMMUNOGLOBULIN SUBCLASSES
GASES BLD PH ONLY
GASES BLD ANY COMBO
No
No
No
No
No
No
82805
82810
82820
82930
82938
82941
82943
82945
82946
82947
82948
82950
82951
No
No
No
No
No
No
No
No
No
No
No
No
No
GASES BLD COMBO; W/O2 SAT EX OXIMTR
GAS BLD O2 SAT ONLY EX OXIMETRY
HGB-O2 AFFINITY
GASTRIC ANALY W/PH EA SPEC
GASTRIN AFTER SECRETIN STIM
GASTRIN
GLUCAGON
GLUCOSE, BODY FLUID
GLUCAGON TOLERANCE TEST
GLU; QUAN
GLU; BLD REAGENT STRIP
GLU; POST GLU DOSE
GLU; TOLERANCE TEST 3 SPECMN
No
No
No
No
No
No
No
No
No
No
No
No
No
82952
82953
No
No
No
No
82955
No
82960
No
GLU; TOLERANCE EA ADD BEYOND 3 SPEC
GLU; TOLBUTAMIDE TOLERANCE TEST
GLU-6-PHOSPHATE DEHYDROGENASE;
QUAN
GLU-6-PHOSPHATE DEHYDROGENASE;
SCRN
82962
82963
82965
82975
82977
82978
82979
82980
82985
No
No
No
No
No
No
No
No
No
GLU BLD MONITR CLEARED-FDA-HOME USE
GLUCOSIDASE BETA
GLUTAMATE DEHYDROGENASE
GLUTAMINE
GLUTAMYLTRANSFERASE GAMMA
GLUTATHIONE
GLUTATHIONE REDUCTASE RBC
GLUTETHIMIDE
GLYCATED PROT
No
No
No
No
No
No
No
No
No
Code Description
No
No
CPT Code
July 2011
83001
No
83002
83003
83008
No
No
No
83009
83010
83012
No
No
No
83013
No
83014
83015
83018
Code Description
GONADOTROPIN; FOLLICLE STIM
HORMONE
No
No
No
No
No
No
No
GONADOTROPIN; LUTEINIZING HORMONE
GROWTH HORMONE HUMAN
GUANOSINE MONOPHOSPHATE CYCLIC
H PYLORI BLOOD TEST UREASE NONRADIOACTV ISOTOPE
HAPTOGLOBIN; QUAN
HAPTOGLOBIN; PHENOTYPES
H PYLORI; BREATH TEST UREASE NONRADACTV ISOTOPE
HELICOBACTER PYLORI; DRUG
ADMINISTRATION
HEAVY METAL; SCREEN
HEAVY METAL; QUAN EA
83020
No
HGB FRACTION-QUANTITAT: ELEC-PHORE
No
83021
No
HEMOGLOB FRACT & QUAN; CHROMATOGR
No
83026
83030
83033
83036
No
No
No
No
No
No
No
No
83037
No
83037
83045
83050
83051
83055
83060
83065
83068
83069
83070
83071
No
No
No
No
No
No
No
No
No
No
No
HGB; COPPER SULFATE METHD NON-AUTO
HGB; F CHEM
HGB; F QUAL TEST FECAL
HGB; GLYCATED
HGB GLYCOSYLATED DEV CLEARED FDA
HOME USE
HGB GLYCOSYLATED DEV CLEARED FDA
HOME USE
HGB; METHEMOGLOBIN QUAL
HGB; METHEMOGLOBIN QUAN
HGB; PLASMA
HGB; SULFHEMOGLOBIN QUAL
HGB; SULFHEMOGLOBIN QUAN
HGB; THERMOLABILE
HGB; UNSTABLE SCREEN
HGB; URIN
HEMOSIDERIN; QUAL
HEMOSIDERIN; QUAN
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
83080
83088
83090
83150
83491
83497
83498
83499
83500
83505
July 2011
No
No
No
No
No
No
No
No
No
No
83516
No
IMMNASSY ANALYT NOT AB/INFEC AG; MX
No
83518
No
IMMUNOASSY ANALYT NOT AB/INFECT; 1
No
83519
83520
83525
83527
83528
83540
83550
83550
83570
83582
83586
83593
83605
83615
83625
83630
83631
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
83632
83633
83634
83655
83661
83662
No
No
No
No
No
No
IMMNASSY ANALYTE QUAN; RADIOPHARM
IMMUNOASSAY ANALYTE QUAN; NOS
INSULIN; TOT
INSULIN; FREE
INTRINSIC FACTOR
IRON
CALCIUM; IONIZED
IRON BINDING CAPACITY
ISOCITRIC DEHYDROGENASE
KETOGENIC STEROIDS FRACTIONATION
KETOSTEROIDS 17-; TOT
KETOSTEROIDS 17-; FRACTIONATION
LACTATE
LACTATE DEHYDROGENASE
LDH; ISOENZYMES SEPART & QUAN
LACTOFERRIN FECAL QUALITATIVE
LACTOFERRIN FECAL QUAN
LACTOGN HUMN PLACENT HUMN C
SOMATOM
LACTOSE URIN; QUAL
LACTOSE URIN; QUAN
LEAD
LECITHIN-SPHINGOMYELIN RATIO; QUAN
L/S RATIO; FOAM STABILITY TEST
Code Description
B-HEXOSAMINIDASE EA ASSAY
HISTAMINE
HOMOCYSTINE
HOMOVANILLIC ACID
HYDROXYCORTICOSTEROIDS 17HYDROXYINDOLACETIC ACID 5HYDROXYPROGESTERONE 17-D
HYDROXYPROGESTERONE 20HYDROXYPROLINE; FREE
HYDROXYPROLINE; TOT
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
83663
83664
83670
83690
83695
83698
No
No
No
No
No
No
L/S RATIO; FLUORESCENCE POLARIZATION
L/S RATIO; LAMELLAR BODY DENSITY
LEUCINE AMINOPEPTIDASE
LIPASE
LIPOPROTEIN A
ASSAY LIPOPROTEIN PLA2
No
No
No
No
No
No
83700
83701
No
No
No
No
83704
No
LIPOPROTEIN BLD ELECTROP SEP&QUAN
LIPOPROTEIN BLD HR SUBCLASSES
LIPOPROTEIN BLD QUAN
NUMBERS&SUBCLASSES
83718
83719
No
No
LIPOPROTEIN DIRECT MEASUR; HDL CHOL
LIPOPROT DIRECT MEASUR; VLDL CHOL
No
No
83721
83727
83735
83775
83785
No
No
No
No
No
LIPOPROTEIN DIRECT MEASUR; LDL CHOL
LUTEINIZING RELEASING FACTOR
MAGNESIUM
MALATE DEHYDROGENASE
MANGANESE
No
No
No
No
No
83788
No
MASS & TANDEM SPECTR ANAL NES; QUAL
No
83789
83805
83825
83835
83840
83857
83858
83861
83864
No
No
No
No
No
No
No
Not Reimbursable
No
MASS & TANDEM SPECTR ANAL NES; QUAN
MEPROBAMATE
MERCURY QUAN
METANEPHRINES
METHADONE
METHEMALBUMIN
METHSUXIMIDE
MORPHINE; QUANTITATIVE
MUCOPOLYSACCHARIDES ACID; QUAN
No
No
No
No
No
No
No
Not Reimbursable
No
83866
83872
83873
83874
83876
No
No
No
No
Non Reimbursible
MUCOPOLYSACCHARIDES ACID; SCREEN
MUCIN SYNOVIAL FLUID
MYELIN BASIC PROT CSF
MYOGLOBIN
ASSAY, MYELOPEROXIDASE
No
No
No
No
Non Reimbursible
Code Description
No
CPT Code
83880
83883
83885
83887
83890
83891
83892
83893
83894
83896
83897
83898
83900
83901
83902
83903
83904
83905
83906
83907
83908
July 2011
No
No
No
No
PA for all Basic Health. For Medicaid, PA
unless pregnancy related.
Code Description
NALORPHINE
NEPHELOMETRY EA ANALYTE NES
NICKEL
NICOTINE
MOLECULAR DX; MOLEC ISOLAT/EXTRACT
No
No
No
No
PA for all Basic Health. For Medicaid, PA unless
pregnancy related.
pregnancy related.
pregnancy related.
pregnancy related.
pregnancy related.
pregnancy related.
pregnancy related.
pregnancy related.
pregnancy related.
pregnancy related.
pregnancy related.
pregnancy related.
pregnancy related.
pregnancy related.
pregnancy related.
pregnancy related.
pregnancy related.
CPT Code
83909
83912
83913
83914
83915
83916
83918
83919
83921
83925
83930
83935
83937
83945
83950
83951
83970
83986
83987
83992
83993
84022
84030
84035
84060
84061
84066
84075
July 2011
No
No
No
No
No
No
No
No
No
No
Non Reimbursible
No
No
No
No
No
No
No
No
No
No
No
No
84078
84080
84081
No
No
No
84085
No
Code Description
OLIGOCLONAL IMMUNOGLOBULIN
ORGANIC ACIDS QUAN EA SPEC
ORGANIC ACIDS; QUAL EA SPEC
ORGANIC ACID, SINGLE, QUANTITATIVE
OPIATES
OSMOLALITY; BLD
OSMOLALITY; URIN
OSTEOCALCIN
OXALATE
ONCOPROTEIN HER-2/NEU
ONCOPROTEIN, DCP
PARATHORMONE
PH BODY FLUID EX BLD
EXHALED BREATH CONDENSATE
PHENCYCLIDINE
ASSAY FOR CALPROTECTIN FECAL
PHENOTHIAZINE
PHENYLALANINE BLD
PHENYLKETONES QUAL
PHOSPHATASE ACID; TOT
PHOSPHATASE ACID; FORENSIC EXAM
PHOSPHATASE ACID; PROSTATIC
PHOSPHATASE ALKALINE
PHOSPHATASE ALKALINE; HEAT STABLE
PHOSPHATASE ALKALINE; ISOENZYMES
PHOSPHATIDYLGLYCEROL
PHOSPHOGLUCONATE 6- DEHYDROGENA
RBC
pregnancy related.
pregnancy related.
pregnancy related.
pregnancy related.
pregnancy related.
No
No
No
No
No
No
No
No
No
No
Non Reimbursible
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
84087
84100
84105
84106
84110
84112
84119
84120
84126
84127
84132
84133
84134
84135
84138
84140
84143
84144
84145
84146
84150
84152
84153
84154
July 2011
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
84155
No
84156
No
84157
No
84160
No
84163
No
84165
No
84166
No
Code Description
PHOSPHOHEXOSE ISOMERASE
PHOSPHORUS INORGANIC
PHOSPHORUS INORGANIC; URIN
PORPHOBILINOGEN URIN; QUAL
PORPHOBILINOGEN URIN; QUAN
PLACENTA ALPHA MICRO IG C/V
PORPHYRINS URIN; QUAL
PORPHYRINS URIN; QUAN & FRACT
PORPHYRINS FECES; QUAN
PORPHYRINS FECES; QUAL
POTASSIUM; SERUM
POTASSIUM; URIN
PREALBUMIN
PREGNANEDIOL
PREGNANETRIOL
PREGNENOLONE
17-HYDROXYPREGNENOLONE
PROGESTERONE
PROCALCITONIN (PCT)
PROLACTIN
PROSTAGLANDIN EA
PSA; COMPLEX
PROSTATE SPEC ANTIG; TOT
PROSTATE SPEC ANTIG; FREE
PROTEIN TOTAL EXCEPT
REFRACTOMETRY; SERUM
PROTEIN TOTAL EXCEPT BY
REFRACTOMETRY; URINE
PROTEIN TOTAL EXCEPT
REFRACTOMETRY; OTHER SOURCE
PROTEIN TOTAL BY REFRACTOMETRY ANY
SOURCE
PREGNANCY-ASSOCIATED PLASMA
PROTEIN-A PAPP-A
PROTEIN; ELECTROPHORETIC
FRACTIONATN&QUAN SERUM
PROTEIN; ELECTROPHORETIC
FRACTIONATN&QUAN OTH FL
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
84181
No
84182
84202
84203
84206
84207
84210
84220
84228
84233
84234
No
No
No
No
No
No
No
No
No
No
84235
84238
84244
84252
84255
84260
84270
84275
84285
84295
84300
84302
84305
84307
84311
84315
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
84375
84376
No
No
84377
84378
84379
84392
84402
No
No
No
No
No
Code Description
PROTEIN; WESTERN BLOT W/I&R
BLOOD/OTH BODY FLUID
PROT; WESTERN BLOT IMMUNOL PROBEBAND ID EA
PROTOPORPHYRIN RBC; QUAN
PROTOPORPHYRIN RBC; SCREEN
PROINSULIN
PYRIDOXAL PHOSPHATE
PYRUVATE
PYRUVATE KINASE
QUININE
RECEPTOR ASSAY; ESTROGEN
RECEPTOR ASSAY; PROGESTERONE
RECPTR ASSAY; ENDOCRN NOT
ESTR/PROG
RECEPTOR ASSAY; NON-ENDOCRINE
RENIN
RIBOFLAVIN
SELENIUM
SEROTONIN
SEX HORMONE BINDING GLOB
SIALIC ACID
SILICA
SODIUM; SERUM
SODIUM; URIN
SODIUM; OTHER SOURCE
SOMATOMEDIN
SOMATOSTATIN
SPECTROPHOTOMETRY ANALYTE NES
SPEC GRAVITY
SUGARS CHROMAT TLC/PAPER
CHROMATOG
SUGARS; 1 QUAL EA SPECMN
SUGARS; MULTIPLE QUALITATIVE EACH
SPECIMEN
SUGARS; 1 QUAN EA SPECMN
SUGARS; MX QUAN EA SPECMN
SULFATE URIN
TESTOSTERONE; FREE
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
84403
84425
84430
84431
84432
84436
84437
84439
84442
84443
84445
84446
84449
84450
84460
84466
84478
July 2011
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
84479
84480
84481
84482
84484
84485
84488
84490
84510
84512
84520
84525
84540
84545
84550
84560
84577
84578
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Code Description
TESTOSTERONE; TOT
THIAMINE
THIOCYANATE
THROMBOXANE, URINE
THYROGLOBULIN
THYROXINE; TOT
THYROXINE; REQUIRING ELUTION
THYROXINE; FREE
THYROXINE BINDING GLOB
THYROID STIM HORMONE
THYROID STIM IMMUNOGLOBULINS
TOCOPHEROL ALPHA
TRANSCORTIN
TRANSFERASE; ASPARTATE AMINO
TRANSFERASE; ALANINE AMINO
TRANSFERRIN
TRIGLYCERIDES
THYROID HORMONE UPTAKE/BINDNG
RATIO
TRIIODOTHYRONINE T3; TOT (TT3)
TRIIODOTHYRONINE T3; FREE
TRIIODOTHYRONINE T3; REVERSE
TROPONIN, QUAN
TRYPSIN; DUODENAL FLUID
TRYPSIN; FECES QUAL
TRYPSIN; FECES QUAN 24-HR COLLEC
TYROSINE
TROPONIN, QUAL
UREA NITRO; QUAN
UREA NITRO; SEMIQUANTITATIVE
UREA NITRO URIN
UREA NITRO CLEARANCE
URIC ACID; BLD
URIC ACID; OTHER SOURCE
UROBILINOGEN FECES QUAN
UROBILINOGEN URIN; QUAL
84580
84583
No
No
UROBILINOGEN URIN; QUAN TIMED SPECM
UROBILINOGEN URIN; SEMIQUAN
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
84585
84586
84588
84590
84591
84597
84600
84620
84630
84681
84702
84703
84704
July 2011
No
No
No
No
No
No
No
No
No
No
No
No
No
84830
84999
85002
No
Yes, if over $200
No
85004
85007
Code Description
VANILLYLMANDELIC ACID URIN
VASOACTIVE INTESTINAL PEPTIDE
VASOPRESSIN
VITAMIN A
VITAMIN, NOT OTHERWISE SPECIFIED
VITAMIN K
VOLATILES
XYLOSE ABSORPT TEST BLD &/OR URIN
ZINC
C-PEPTIDE
GONADOTROPIN CHORIONIC; QUAN
GONADOTROPIN CHORIONIC; QUAL
HCG, FREE BETACHAIN TEST
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes, if over $200
No
No
No
OVULATION TEST VISUAL COLOR COMPAR
UNLISTED CHEM PROC
BLEEDING TIME
BLOOD COUNT; AUTOMATED
DIFFERENTIAL WBC COUNT
BLD CT; MANUAL DIFF WBC CT
85008
85009
85013
No
No
No
BLD CT; MANUAL SMEAR WO DIFF PARAME
BLD CT; DIFF WBC CT BUFFY COAT
BLD CT; SPUN MICROHEMATOCRIT
No
No
No
85014
85018
No
No
BLD CT; OTHER THAN SPUN HEMATOCRIT
BLD CT; HGB
No
No
85025
85027
85032
85041
85044
No
No
No
No
No
BLD CT; HG/PLTLT CT AUTO/COMPLT WBC
BLD CT; HG & PLATELET CT AUTOMATED
MANUAL CELL COUNT EACH
BLD CT; RED BLD CELL ONLY
BLD CT; RETICULOCYTE CT MANUAL
No
No
No
No
No
85045
No
No
85046
85048
85049
No
No
No
BLD CT; RETICULOCYTE CT FLO CYTOMET
BLD COUNT;RETICS AUTO 1/>CELLULR
PARAMTR DIR MSR
BLD CT; WHITE BLD CELL
PLATELET, AUTOMATED
No
No
No
No
No
CPT Code
85055
July 2011
No
85060
85097
85130
85170
85175
85210
85220
85230
85240
85244
85245
85246
85247
85250
85260
85270
85280
85290
85291
85292
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
BLD SMEAR PERIPHRL INTRPT W/REPORT
BONE MARROW; SMEAR INTERPT ONLY
CHROMOGENIC SUBSTRATE ASSAY
CLOT RETRACTION
CLOT LYSIS TIME WHOLE BLD DILUT
CLOTTING; FACT II PROTHROMBIN SPEC
CLOTTING; FACTOR V LABILE FACTOR
CLOTTING; FACTOR VII
CLOTTING; FACTOR VIII 1 STAGE
CLOTTING; FACTOR VIII RELATED ANTIG
CLOT; VIII VW RISTOCETIN COFACTOR
CLOTTING; FACT VIII VW FACTOR ANTIG
CLOT; VIII VON WILLEBRAND MX-METRIC
CLOTTING; FACTOR IX
CLOTTING; FACTOR X
CLOTTING; FACTOR XI
CLOTTING; FACTOR XII
CLOTTING; FACTOR XIII
CLOTTING; FACT XIII SCRN SOLUBILITY
CLOTTING; PREKALLIKREIN ASSAY
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
85293
85300
85301
85302
85303
85305
85306
85307
85335
85337
85345
85347
85348
85360
No
No
No
No
No
No
No
No
No
No
No
No
No
No
CLOTTING; HI MOLECULAR WT KININOGEN
CLOT INHIB/ANTICOAG; ANTITHRMBN III
CLOT INHIB/ANTCG;ANTTHRMB III ANTIG
CLOT INHIB/ANTICOAG; PROT C ANTIG
CLOT INHIB/ANTICOAG;PROT C ACTIVITY
CLOT INHIB/ANTICOAG; PROT S TOT
CLOT INHIB/ANTICOAG; PROT S FREE
ACTIVATED PROTEIN C
FACTOR INHIBIT TEST
THROMBOMODULIN
COAGULATION TIME; LEE & WHITE
COAGULATION TIME; ACTIVATED
COAGULATION TIME; OTHER METHD
EUGLOBULIN LYSIS
No
No
No
No
No
No
No
No
No
No
No
No
No
No
85362
No
FIBRN DEGRAD PROD; AGGLUT-SEMIQUAN
No
Code Description
RETICULATED PLATELET ASSAY
No
CPT Code
July 2011
85366
No
FIBRIN DEGRADAT PRODUCTS; PARACOAG
No
85370
No
FIBRIN DEGRADATION PRODUCTS; QUAN
No
85378
No
FIBRN DEGRAD PROD D-DIMER; SEMIQUAN
No
85379
No
No
85380
85384
85385
85390
85396
85397
85400
85410
No
No
No
No
No
Non Reimbursible
No
No
FIBRIN DEGRADAT PROD D-DIMER; QUAN
FDP D-DIMER; ULTRASENSITIVE
QUAL/SEMIQUAN
FIBRINOGEN; ACTIVITY
FIBRINOGEN; ANTIG
FIBRINOLYSN/COAGULOPATHY SCREEN
FIBRINOLYSINS;
CLOTTING FUNCT ACTIVITY
FIBRINOLYTIC FACT & INHIB; PLASMIN
FIBRNOLYTC FACT/INHIB;ALPHA-2ANTIPL
No
No
No
No
No
Non Reimbursible
No
No
85415
No
FIBRNOLYTC FACT/INHIB;PLSMNGN ACTIV
No
85420
85421
85441
No
No
No
FBRNLYTC FACT/INHIB;PLSMNGN NO ANTI
FBRNLYTC FACT/INHIB;PLSMNGN ANTIG
HEINZ BODIES; DIRECT
No
No
No
85445
85460
85461
85475
85520
85525
85530
85536
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
85540
85547
85549
No
No
No
HEINZ BOD; INDUCED ACETYL PHENYLHYD
HGB/RBC FETAL-HEMORR; DIFF LYSIS
HGB/RBC FETAL-HEMORR; ROSETTE
HEMOLYSIN; ACID
HEPARIN ASSAY
HEPARIN NEUTRALIZATION
HEPARIN-PROTAMINE TOLERANCE TEST
IRON STAIN, PERIPHERAL BLOOD
LEUKOCYTE ALKALINE PHOSPHATASE
W/CT
MECH FRAGILITY RBC
MURAMIDASE
85555
85557
No
No
OSMOTIC FRAGILITY RBC; UNINCUBATED
OSMOTIC FRAGILITY RBC; INCUBATED
No
No
Code Description
No
No
No
CPT Code
85576
85597
85598
85610
July 2011
No
No
Not Reimbursable
No
85611
No
PROTHRMBN TIME; SUB PLASMA FRACT EA
No
85612
85613
85635
No
No
No
No
No
No
85651
85652
85660
85670
85675
85705
85730
85732
85810
No
No
No
No
No
No
No
No
No
85999
86000
No
No
86001
No
RUSSELL VIPER VENOM TIME; UNDILUTED
RUSSELL VIPER VENOM TIME; DILUTED
REPTILASE TEST
SED RATE ERYTHROCYTE NONAUTOMATED
SED RATE, ERYTHROCYTE; AUTO
SICKLING RBC REDUCTION
THROMBIN TIME; PLASMA
THROMBIN TIME; TITER
THROMBOPLASTIN INHIBIT; TISS
P T T; PLASMA/WHOLE BLD
P T T; SUBSTIT PLASMA FRACT EA
VISCOSITY
UNLIST HEMATOLOGY & COAGULATION
PRO
AGGLUTININS FEBRILE EA ANTIG
ALLERGEN SPEC; IgG QUANTITATIVE OR
SEMI
86003
No
ALLERG SPEC IGE; QUAN/SEMI-QUAN, EA
No
86005
86021
86022
No
No
No
ALLERG SPEC IGE; QUAL MXALLERG SCRN
ANTIB IDENT; LEUKOCYTE ANTIB
ANTIB IDENT; PLATELET ANTIB
No
No
No
86023
86038
86039
86060
86063
No
No
No
No
No
ANTIB ID; PLATELET ASSOC IMMUNOGLOB
ANTINUCLEAR ANTIB
ANTINUCLEAR ANTIB; TITER
ANTISTREPTOLYSIN 0; TITER
ANTISTREPTOLYSIN 0; SCREEN
No
No
No
No
No
86077
No
BLD BNK PHYS SERV; DIF X-MATCH/EVAL
No
Code Description
PLATELET; AGGREGATION EA AGENT
PLATELET NEUTRALIZATION
HEXAGNAL PHOSPH PLTLT NEUTRL
PROTHROMBIN TIME
No
No
Not Reimbursable
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
86078
No
BLD BNK PHYS SERV; INVESTIGAT REACT
No
86079
86140
86141
No
No
No
BLD BNK PHYS SERV;AUTH DEVIAT STAND
C-REACTIVE PROT
C-REACTV PROTEIN; HIGH SENSITIVITY
No
No
No
86146
86147
86148
86155
86156
86157
86160
No
No
No
No
No
No
No
BETA 2 GLYCOPROTEIN I ANTIBODY, EACH
CARDIOLIPIN ANTIB
ANTI-PHOSPHATIDYLSERINE ANTIBODY
CHEMOTAXIS ASSAY SPEC METHD
COLD AGGLUTININ; SCREEN
COLD AGGLUTININ; TITER
COMPLEMENT; ANTIG EA COMPONENT
No
No
No
No
No
No
No
86161
86162
86171
No
No
No
COMPLEMENT; FUNCT ACTIVIT EA COMPON
COMPLEMENT; TOT HEMOLYTIC
COMPLEMENT FIXA TESTS EA ANTIG
No
No
No
86185
86200
86215
86225
86226
No
No
No
No
No
COUNTERIMMUNOELECTROPHORESIS EA
CYCLIC CITRULLINATED PEPTIDE ANTB
DEOXYRIBONUCLEASE ANTIB
DNA ANTIB; NATIVE/DOUBLE STRANDED
DNA ANTIB; SNGL STRANDED
No
No
No
No
No
86235
86243
86255
86256
86277
86280
No
No
No
No
No
No
No
No
No
No
No
No
86294
No
86300
No
86301
No
86304
No
EXTRACT NUCLR ANTIG ANTIB ANY METHD
FC RECEPTOR
FLUORES NONINFECT AGENT ANTIB; EA
FLUORESCENT ANTIB; TITER EA ANTIB
GROWTH HORMONE HUMAN ANTIB
HEMAGGLUTINATION INHIBIT TEST
IMMUNOASSAY FOR TUMOR ANTIGEN,
QUANTATIVE OR SEMI
IMMUNOASSAY TUMOR ANTIGEN, QUANT
CA 15-3
IMMUNOASSAY TUMOR ANTIGEN, QUANT,
CA 19-98
IMMUNOASSAY TUMOR ANTIGEN, QUANT,
CA 125
Code Description
No
No
No
No
CPT Code
86305
86308
86309
July 2011
No
No
No
86310
86316
No
No
86317
No
86318
86320
No
No
86325
86327
86329
No
No
No
86331
86332
No
No
86334
No
86335
86336
86337
86340
86341
86343
86344
86352
No
No
No
No
No
No
No
No
86353
86355
86356
86357
86359
86360
86361
86367
Code Description
HUMAN EPIDIDYMIS PROTEIN 4
HETEROPHILE ANTIB; SCREENING
HETEROPHILE ANTIB; TITER
No
No
No
HETEROPHILE ANTIB; TITER AFTR ABSRP
IMMUNOASSAY TUMOR ANTIG EA
IMMUNOASSAY INFEC AGENT AB QUAN
NOS
No
No
IMMNASSY INFEC AGNT ANTIB SNGL STEP
IMMUNOELECTROPHORESIS; SERUM
IMMUNOELEC-PHORE; OTHER FLDS
CONCEN
IMMUNOELECTROPHORESIS; CROSSED
IMMUNODIFFUSION; NES
No
No
No
No
No
No
No
No
No
IMMUNODIFFUSION; GEL DIFFUS QUAL EA
IMMUNE COMPLX ASSAY
IMMUNOFIXATION ELECTROPHORESIS;
SERUM
IMMUNOFIXATION ELECTROPHORESIS;
OTH FL W/CONC
INHIBIN A
INSULIN ANTIB
INTRINSIC FACTOR ANTIB
ISLET CELL ANTIBODY
LEUKOCYTE HISTAMINE RELEASE TEST
LEUKOCYTE PHAGOCYTOSIS
CELL FUNCTION ASSAY W/STIM
LYMPHOCYTE TRANSFORM
MITOGEN/ANTIG
B CELLS TOT CNT
MONONUCLEAR CELL ANTIGEN
NATURAL KILLER CELLS TOT CNT
T CELLS; TOT CT
No
No
No
T CELLS; ABSOLUTE CD4-CD8 CNT-RATIO
T CELLS; ABSOLUTE CD4 COUNT
STEM CELLS TOT CNT
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
86376
86378
86382
86384
July 2011
No
No
No
No
86403
86406
86430
86431
No
No
No
No
86480
86481
86485
86486
86490
86510
Code Description
MICROSOMAL ANTIB EA
MIGRATION INHIBIT FACTOR TEST
NEUTRALIZATION TEST VIRAL
NITROBLUE TETRAZOLIUM DYE TEST
No
No
No
No
No
Not Reimbursable
No
No
No
No
PARTICLE AGGLUTINATN; SCRN-EA ANTIB
PARTICLE AGGLUTINATION; TITER EA AB
RHEUMATOID FACTOR; QUAL
RHEUMATOID FACTOR; QUAN
TUBERCULOSIS TST CELL MEDIATED
IMMUNITY
TB AG RESPONSE T-CELL SUSP
SKIN TEST; CANDIDA
SKIN TEST, NOS ANTIGEN
SKIN TEST; COCCIDIOIDOMYCOSIS
SKIN TEST; HISTOPLASMOSIS
No
Not Reimbursable
No
No
No
No
86580
86590
86592
86593
86602
86603
86606
86609
86611
86612
86615
No
No
No
No
No
No
No
No
No
No
No
SKIN TEST; TUBERCULOSIS INTRADERMAL
STREPTOKINASE ANTIB
SYPHILIS TEST; QUAL
SYPHILIS TEST; QUAN
ANTIB; ACTINOMYCES
ANTIB; ADENOVIRUS
ANTIB; ASPERGILLUS
ANTIB; BACTERIUM NES
ANTIB; BATONELLA
ANTIB; BLASTOMYCES
ANTIB; BORDETELLA
No
No
No
No
No
No
No
No
No
No
No
86617
86618
86619
86622
86625
86628
86631
86632
86635
86638
No
No
No
No
No
No
No
No
No
No
BORRELIA BURGDORFERI CONFIRM TEST
ANTIB; BORRELIA BURGDORFERI
ANTIB; BORRELIA
ANTIB; BRUCELLA
ANTIB; CAMPYLOBACTER
ANTIB; CANDIDA
ANTIB; CHLAMYDIA
ANTIB; CHLAMYDIA IGM
ANTIB; COCCIDIOIDES
ANTIB; COXIELLA BRUNETII
No
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
86641
86644
86645
86648
86651
86652
86653
July 2011
No
No
No
No
No
No
No
Code Description
ANTIB; CRYPTOCOCCUS
ANTIB; CYTOMEGALOVIRUS
ANTIB; CYTOMEGALOVIRUS IGM
ANTIB; DIPHTHERIA
ANTIB; ENCEPHALITIS CALIFORNIA
ANTIB; ENCEPHALITIS EASTERN EQUINE
ANTIB; ENCEPHALITIS ST. LOUIS
No
No
No
No
No
No
No
86654
86658
86663
86664
86665
86666
86668
86671
86674
86677
86682
86684
86687
86688
86689
86692
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
ANTIB; ENCEPHALITIS WESTERN EQUINE
ANTIB; ENTEROVIRUS
ANTIB; EPSTEIN-BARR EARLY ANTIG
ANTIB; EPSTEIN-BARR NUCLEAR ANTIG
ANTIB; EPSTEIN-BARR VIRAL CAPSID
ANTIB; EHRLICHIA
ANTIB; FRANCISELLA TULARENSIS
ANTIB; FUNGUS NES
ANTIB; GIARDIA LAMBLIA
ANTIB; HELICOBACTER PYLORI
ANTIB; HELMINTH NES
ANTIBODY; HAEMOPHILUS INFLUENZA
ANTIB; HTLV I
ANTIB; HTLV-II
ANTIB; HTLV/HIV ANTIB CONFIRM TEST
ANTIB; HEPATITIS DELTA AGENT
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
86694
86695
86696
86698
86701
86702
86703
86704
86705
86706
86707
86708
86709
86710
No
No
No
No
No
No
No
No
No
No
No
No
No
No
ANTIB; HERPES SIMPLEX NON-SPEC TYPE
ANTIB; HERPES SIMPLEX TYPE I
ANTIB; HERPES SIMPLEX, TYPE 2
ANTIB; HISTOPLASMA
ANTIB; HIV-1
ANTIB; HIV-2
ANTIB; HIV-1 & HIV-2 SNGL ASSAY
HEPATITIS B CORE ANTIB; IGG & IGM
HEPATITIS B CORE ANTIBODY; IGM AB
HEPATITIS B SURFACE ANTIBODY
HEPATITIS BE ANTIBODY
HEPATITIS A ANTIBODY; IGG & IGM
HEPATITIS A ANTIBODY; IGM ANTIBODY
ANTIB; INFLUENZA VIRUS
No
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
86713
86717
86720
86723
July 2011
No
No
No
No
86727
No
ANTIB; LYMPHOCYTIC CHORIOMENINGITIS
No
86729
86732
86735
86738
86741
86744
86747
86750
86753
86756
86757
86759
86762
86765
86768
86771
86774
86777
86778
86780
86784
86787
86788
86789
86790
86793
86800
86803
86804
86805
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
ANTIB; LYMPHOGRANULOMA VENEREUM
ANTIB; MUCORMYCOSIS
ANTIB; MUMPS
ANTIB; MYCOPLASMA
ANTIB; NEISSERIA MENINGITIDIS
ANTIB; NOCARDIA
ANTIB; PARVOVIRUS
ANTIB; PLASMODIUM
ANTIB; PROTOZOA NES
ANTIB; RESPIRATORY SYNCYTIAL VIRUS
ANTIB; RICKETTSIA
ANTIB; ROTAVIRUS
ANTIB; RUBELLA
ANTIB; RUBEOLA
ANTIB; SALMONELLA
ANTIB; SHIGELLA
ANTIB; TETANUS
ANTIB; TOXOPLASMA
ANTIB; TOXOPLASMA IGM
TREPONEMA PALLIDUM
ANTIB; TRICHINELLA
ANTIB; VARICELLA-ZOSTER
WEST NILE VIRUS AB, IGM
WEST NILE VIRUS ANTIBODY
ANTIB; VIRUS NES
ANTIB; YERSINIA
THYROGLOBULIN ANTIB
HEPATITIS C ANTIBODY;
HEPATITIS C ANTIBODY; CONFIRM TEST
LYMPHOCYTOTOXIC X-MATCH; W/TITRAT
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
86806
No
LYMPHOCYTOTOXIC X-MATCH;WO TITRAT
No
Code Description
ANTIB; LEGIONELLA
ANTIB; LEISHMANIA
ANTIB; LEPTOSPIRA
ANTIB; LISTERIA MONOCYTOGENES
No
No
No
No
CPT Code
July 2011
86807
No
Code Description
SERUM SCREN CYTOTOXIC % REACT
ANTIB
86808
86812
86813
86816
86817
No
No
No
No
No
SRM SCRN CYTOTOX % REACT ANTIB;QUIK
HLA TYPING; A B/C SNGL ANTIG
HLA TYPING; A B/C MX ANTIG
HLA TYPING; DR/DQ SNGL ANTIG
HLA TYPING; DR/DQ MX ANTIG
No
No
No
No
No
86821
No
HLA TYPING; LYMPHOCYTE CULTURE MIX
No
86822
86825
86826
86849
86850
86860
No
Non Reimbursible
Non Reimbursible
No
No
No
HLA TYPING; LYMPHOCYTE CULT PRIMED
HLA X-MATCH, NON-CYTOTOXIC
HLA X-MATCH, NON-CYT ADD-ON
UNLISTED IMMUNOLOGY PROC
ANTIB SCREEN RBC EA SERUM TECH
ANTIB ELUTION EA ELUTION
No
Non Reimbursible
Non Reimbursible
No
No
No
86870
No
ANTIB ID RBC ANTIB EA PANEL EA SERM
No
86880
No
ANTIHUMAN GLOB TEST; DIREC EA ANTIS
No
86885
86886
86890
No
No
No
No
No
No
86891
86900
86901
86902
86904
No
No
No
No
No
ANTIHUMAN GLOB TST; INDIREC QUAL EA
ANTIHUMAN GLOB; INDIRECT TITER EA
AUTOLGUS BLD/COMP; PREDEPOSIT
AUTOLOGOUS BLD; INTRA/POSTOP
SALVAG
BLD TYPING; ABO
BLD TYPING; RH
BLOOD TYPE ANTIGEN DONOR EA
BLD TYP; ANTIG SCRN PT SERM EA UNIT
86905
86906
86910
86911
86920
86921
86922
No
No
Not Reimbursable
Not Reimbursable
No
No
No
BLD TYPING; RBC ANTIG NOT ABO/RH EA
BLD TYPING; RH PHENOTYPING COMPLT
BLD TYP PATERNITY-INDIV; ABO/RH/MN
BLD TYP PATERN/INDIVI; EA ADD ANTIG
COMPAT TEST EA UNIT; IMMED SPIN
COMPAT TEST EA UNIT; INCUBATION
COMPAT TEST EA UNIT; ANTIGLOBULIN
No
No
Not Reimbursable
Not Reimbursable
No
No
No
No
No
No
No
No
No
CPT Code
86923
86923
July 2011
No
No
86927
86930
No
No
FRESH FROZEN PLASMA THAWING EA UNIT
FROZEN BLD PREP FREEZING EA UNIT
No
No
86931
No
FROZEN BLD PREP FREEZE EA; W/THAW
No
86932
No
FROZN BLD PREP FREZ EA;W/FREEZ/THAW
No
86940
86941
86945
86950
86960
86960
No
No
No
No
No
No
No
No
No
No
No
No
86965
No
HEMOLYSINS & AGGLUTNS; AUTO SCRN EA
HEMOLYSINS & AGGLUTINS; INCUBATED
IRRADIATION BLD PRODUCT EA UNIT
LEUKOCYTE TRANSFUSION
VOL RDCTJ BLD/BLD PRODUX EA UNIT
VOL RDCTJ BLD/BLD PRODUX EA UNIT
POOLING PLATELETS/OTHER BLD
PRODUCT
86970
86971
No
No
PRETX RBC; INCUBATE W/AGENTS/DRG EA
PRETX RBC; INCUBATE W/ENZYMES EA
No
No
86972
86975
86976
No
No
No
PRETX RBC; DENSITY GRADIENT SEPART
PRETX SERUM-ANTIB ID; INCUBATION EA
PRETX SERUM-RBC ANTIB ID; DILUTION
No
No
No
86977
86978
86985
86999
87001
87003
No
No
No
No
No
No
PRETX SERM-RBC ANTIB; W/INHBITOR EA
PRETX SERM-ANTIB; DIFF RED CELL EA
SPLITTING BLD/BLD PRODUCTS EA UNIT
UNLISTED TRANSFUSION MEDS PROC
ANIMAL INOCUL SM ANIMAL; W/OBSRV
ANIMAL INOCUL SM; W/OBSRV/DISSECT
No
No
No
No
No
No
87015
No
No
87040
No
87045
No
CONCNTR PARASITES OVA/TUBERCLE BACI
CULT BACT;BLD AEROBIC
ISOLAT&PRESUMP ID ISOLATES
CULT BACT;STOOL AEROBIC
SALMONELLA&SHIGELLA SPEC
Code Description
COMPATIBILITY EA UNIT ELEC
COMPATIBILITY EA UNIT ELEC
No
No
No
No
No
CPT Code
July 2011
87046
No
87070
No
87071
No
87073
No
87075
87076
87077
87081
No
No
No
No
Code Description
CULT BACT;STOOL AEROBIC ADD PATH
ISOLAT EA PLATE
CULT BACT; NO URINE/BLD/STOOL
AEROBIC W/ISOLAT
CULT BACTERIAL QUANTITATIVE, AEROBIC
W/ISOLATION
CULT BACTERIAL QUANTITATIVE
ANAEROBIC W/ISOLATION
CULT BACT; ANY SRC NO BLOOD ANAEROB
ISOLAT & ID
CULT BACT ANY; DEFIN ID EA ANAEROB
CULT BACT AEROBIC ISOLATE
CULT BACT SCREEN ONLY SNGL ORGAN
87084
No
CULT PRSMPT SCRN ONLY KIT;COLNY EST
No
87086
87088
87101
No
No
No
CULT BACTERIAL URIN; QUAN COLONY CT
CULT BACT URIN; ID ADD QUAN/KIT
CULTURE FUNGI ISOLATION; SKIN
No
No
No
87102
87103
87106
87107
87109
87110
No
No
No
No
No
No
CULTURE FUNGI ISOLAT; OTHER SOURCE
CULTURE FUNGI ISOLATION; BLD
CULTURE FUNGI DEFINITIVE ID EA FUNG
CULTURE, MOLD
CULTURE MYCOPLASMA ANY SOURCE
CULTURE CHLAMYDIA
No
No
No
No
No
No
87116
No
CULT TB/AFB/MYCOBACT;ANY ISOLAT ONL
No
87118
No
CULT MYCOBACTERIA DEFFIN ID EA ORGA
No
87140
No
No
87143
No
CULTURE TYPING; FLUORESC EA ANTISER
CULTURE TYPING; GAS LIQ
CHROMATOGRA
87147
No
No
87149
87150
No
Non Reimbursible
CULT TYP; SEROLOG AGGLUT/ANTISERUM
CULTURE IDENTIFICATION BY NUCLEIC
ACID PROBE
DNA/RNA, AMPLIFIED PROBE
No
No
No
No
No
No
No
No
No
No
Non Reimbursible
CPT Code
July 2011
87152
87153
87158
No
Non Reimbursible
No
87164
87166
87168
87169
87172
No
No
No
No
No
DARK FIELD ANY SOURCE; W/SPEC COLL
DARK FIELD ANY SOURCE; WO COLLEC
MACROSCOPIC EXAM; ANTHROPOD
MACROSCOPIC EXAM; PARASITE
PINWORM EXAM
No
No
No
No
No
87176
No
ENDOTOX BACT; HOMOGENIZAT TISS CULT
No
87177
87181
87184
No
No
No
No
No
No
87185
87186
87187
No
No
No
OVA/PARASITS DIRECT SMEAR CONCNT&ID
SENSIT ANTIBIOT; AGAR DIFF/ANTIBIOT
SENSIT ANTIBIOT; DISK METHOD/PLATE
SENSIT ANTIBIOT; ENZYME DETECTION,
PER ENZYME
SENSIT ANTIBIOT; MICRTITR MIC ANY #
SENSIT ANTIBIOT; MINI BACTRCDL CONC
87188
87190
87197
No
No
No
SENSIT ANTIBIOT; MACROTUBE DILUT EA
SENSIT ANTIBIOTIC; TB/AFB EA DRUG
SERUM BACTERICIDAL TITER
No
No
No
87205
No
SMEAR PRIM W/INTERPT; ROUTINE STAIN
No
87206
No
SMEAR PRIM W/INTRPT; FLUOR/ACID AFB
No
87207
No
No
87209
No
SMEAR PRIM W/INTERPT; SPECIAL STAIN
SMR PRIM SRC CPLX SPEC STAIN
OVA&PARASITS
87210
87220
87230
87250
87252
87253
No
No
No
No
No
No
SMEAR PRIM W/INTRPT; WET MNT W/SIMP
TISS EXAM FUNGI
TOXIN/ANTITOXIN ASSAY TISS CULTURE
VIRUS ID; W/OBSRV & DISSECT
VIRUS ID; TISS CULT INOCULAT & OBSV
VIRUS ID; TISS CULT ADD STUDIES EA
No
No
No
No
No
No
Code Description
CULTURE IDENTIFICATION BY PULSE FIELD
GEL TYPE
DNA/RNA SEQUENCING
CULTURE TYPING; OTHER METHD
No
Non Reimbursible
No
No
No
No
No
CPT Code
July 2011
87254
No
87255
87260
No
No
87265
No
87267
No
87269
No
87270
No
87271
No
87272
No
87273
Code Description
VIRUS ID; SHELL VIAL, INCLUDES ID
W/IMMUNOFLURESCENCE STAIN
VIRUS ISOLAT; W/ID NON-IMMUOLOGIC NOT
CYTOPATHIC
AG-DIR FLUORES AB; ADENOVIRUS
No
No
No
AG-FLUORES AB; BORDATELLA PERTUSSIS
INF AGT ANTIG DET IMMUOFLUORS TECH;
ENTRVRUS DFA
INF AGT ANTIG DETECT IMMUNOFLUORES
TECH; GIARDIA
No
No
No
AG-FLUORES AB; CHLAMYDIA TRCHOMATIS
INF AGT ANTIG DET IMMUOFLUORES
TECH;CYTOMEGA DFA
INF AGT IMMUNOFLUORRSCENT TECH;
CRYPTOSPORIDIUM
AG-FLOURES AB; HERPES SIMPLEX VIRUS
TYPE 2
87274
87275
87276
No
No
No
AG-FLUORES AB; HERPES SIMPLEX VIRUS
AG-FLOURES AB; INFLUENZA B VIRUS
AG-FLUORES AB; INFLUENZA A VIRUS
No
No
No
87277
No
AG-FLOURES AB; LEGIONELLA MICDADEL
No
87278
No
No
87279
No
AG-FLUORES AB; LEGIONELLA PNEUMOPHL
AG-FLOURES AB; PARAINFLUENZA VIRUS,
EACH TYPE
No
87280
No
AG-FLUORES AB; RESP SYNCYTIAL VIRUS
No
87281
87283
No
No
AG-FLUORES AB; PNEUMOCYSTIS CARINI
AG-FLOURES AB; RUBEOLA
No
No
87285
No
AG-DIR FLUORES AB; TREPONEMA PALLID
No
87290
87299
No
No
AG-DIR FLUORES AB; VARICELLA ZOSTER
INFEC AG-DIR FLUORES AB; NOS
No
No
No
No
No
No
No
CPT Code
July 2011
87300
No
87301
87305
No
No
87320
No
87324
No
87327
No
87328
No
87329
Code Description
INFEC AG-ANTIGEN DETECT BY
IMMUNOFLUORESCENT
No
AG-IMMUNOASSAY; ADENOVIRUS ENTERIC
ASPERGILLUS AG, EIA
AG-IMMUNOASSAY; CHLAMYDIA
TRCHOMATS
No
No
No
No
AG-IMMUNOASSAY; CLOSTRIDIUM-TOXIN A
AG-IMMUNOASSAY; CRYPTOCOCCUS
NEOFORMANS
INF AGT ENZYME IMMUNOASSAY TECH;
CRYPTOSPORIDUM
INF AGT ANTIG EIA MX STEP METH;
GIARDIA
87332
No
AG-IMMUNOASSAY; CYTOMEGALOVIRUS
No
87335
No
No
87336
No
87337
87338
No
No
AG-IMMUNOASSAY; ESCHERICH COLI 0157
AG-IMMUNOASSAY; ENTAMOEBA
HISTOLYTICA DISPAR GRP
AG-IMMUNOASSAY; ENTAMOEBA
HISTOLYTICA GRP
INFEC AG-MX STEP; H PYLORI-STOOL
87339
No
AG-IMMUNOASSAY; HELICOBACTER PYLORI
No
87340
No
No
87341
87350
87380
No
No
No
87385
87390
87391
No
No
No
87400
No
AG-IMMUNOASSAY; HEP B SURFACE ANTIG
AG-IMMUNOASSAY; HEPATITUS B SURFACE
ANTIGEN HBsAg
AG-IMMUNOASSAY; HEP BE ANTIG
AG-IMMUNOASSAY; HEP DELTA AGENT
AG-IMMUNOASSAY; HISTOPLASMA
CAPSULA
AG-IMMUNOASSAY; HIV-1
AG-IMMUNOASSAY; HIV-2
AG-IMMUNOASSAY; INFLUENZA A OR B,
EACH
No
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
87420
87425
87427
87430
No
No
No
No
AG-IMMUNOASSAY; RESP SYNCYTIAL VIR
AG-IMMUNOASSAY; ROTAVIRUS
AG-IMMUNOASSAY; SHIGA-LIKE TOXIN
AG-IMMUNOASSAY; STREP GROUP A
No
No
No
No
87449
No
No
87450
87451
87470
No
No
No
AG-IMMUNOASSAY; MX STEP METHD-NOS
AG-IMMUNOASSAY; SNGL STEP METHDNOS
AG-IMMUNOASSAY; MULTI STEP METH
AGT-DNA/RNA; BARTONELLA-DIR PROBE
No
No
No
87471
No
AGT-DNA/RNA; BARTONELLA-AMPLI PROBE
No
87472
No
AGT-DNA/RNA; BARTONELLA H & Q-QUAN
No
87475
No
AGT-DNA/RNA; BORRELIA BURGDORF-DIR
No
87476
No
No
87477
No
AGT-DNA/RNA; BORRELIA BURGDOR-AMPLI
AGT-DNA/RNA; BORRELIA BURGDORFQUAN
87480
87481
87482
No
No
No
AGT-DNA/RNA; CANDIDA SPECIES-DIRECT
AGT-DNA/RNA; CANDIDA SPECIES-AMPLI
AGT-DNA/RNA; CANDIDA SPECIES-QUAN
No
No
No
87485
No
AGT-DNA/RNA; CHLAMYDIA PNEUMON-DIR
No
87486
No
No
87487
No
AGT-DNA/RNA; CHLAMYDIA PNEUMO-AMPLI
AGT-DNA/RNA; CHLAMYDIA PNEUMONQUAN
87490
No
AGT-DNA/RNA; CHLAMYDIA TRACH-DIRECT
No
87491
No
AGT-DNA/RNA; CHLAMYDIA TRACH-AMPLI
No
87492
87493
No
No
AGT-DNA/RNA; CHLAMYDIA TRACH-QUAN
C DIFF AMPLIFIED PROBE
No
No
Code Description
No
No
CPT Code
July 2011
87495
No
Code Description
AGT-DNA/RNA; CYTOMEGALOVIRUSDIRECT
87496
No
AGT-DNA/RNA; CYTOMEGALOVIRUS-AMPLI
No
87497
87498
87500
87501
87502
87503
No
No
No
No
No
No
AGT-DNA/RNA; CYTOMEGALOVIRUS-QUAN
ENTEROVIRUS, DNA, AMP PROBE
VANOMYCIN, DNA, AMP PROBE
INFLUENZA DNA AMP PROB 1+
INFLUENZA DNA AMP PROBE
INFLUENZA DNA AMP PROB ADDL
No
No
No
No
No
No
87510
No
AGT-DNA/RNA; GARDNERELLA VAG-DIRECT
No
87511
No
AGT-DNA/RNA; GARDNERELLA VAG-AMPLI
No
87512
87515
No
No
AGT-DNA/RNA; GARDNERELLA VAG-QUAN
AGT-DNA/RNA; HEP B VIRUS-DIR PROBE
No
No
87516
87517
87520
87521
87522
87525
87526
87527
No
No
No
No
No
No
No
No
AGT-DNA/RNA; HEP B VIRUS-AMPLI PROB
AGT-DNA/RNA; HEP B VIRUS-QUAN
AGT-DNA/RNA; HEP C-DIRECT PROBE
AGT-DNA/RNA; HEP C-AMPLI PROBE
AGT-DNA/RNA; HEP C-QUAN
AGT-DNA/RNA; HEP G-DIRECT PROBE
AGT-DNA/RNA; HEP G-AMPLI PROBE
AGT-DNA/RNA; HEP G-QUAN
No
No
No
No
No
No
No
No
87528
87529
87530
87531
87532
87533
87534
87535
87536
87537
87538
No
No
No
No
No
No
No
No
No
No
No
AGT-DNA/RNA; HERPES SIMPLEX-DIRECT
AGT-DNA/RNA; HERPES SIMPLEX-AMPLI
AGT-DNA/RNA; HERPES SIMPLEX-QUAN
AGT-DNA/RNA; HERPES VIRUS-6-DIRECT
AGT-DNA/RNA; HERPES VIRUS-6-AMPLI
AGT-DNA/RNA; HERPES VIRUS-6-QUAN
AGT-DNA/RNA; HIV-1-DIRECT PROBE
AGT-DNA/RNA; HIV-1-AMPLI PROBE
AGT-DNA/RNA; HIV-1-QUAN
AGT-DNA/RNA; HIV-2-DIRECT PROBE
AGT-DNA/RNA; HIV-2-AMPLI PROBE
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
87539
July 2011
No
87540
No
AGT-DNA/RNA; LEGIONELLA PNEUMO-DIR
No
87541
No
AGT-DNA/RNA; LEGIONELLA PNEUMO-AMPL
No
87542
No
AGT-DNA/RNA; LEGIONELLA PNEUMO-QUAN
No
87550
No
No
87551
87552
No
No
AGT-DNA/RNA; MYCOBACTERIA-DIR PROBE
AGT-DNA/RNA; MYCOBACTERIA-AMPL
PROB
AGT-DNA/RNA; MYCOBACTERIA-QUAN
87555
No
AGT-DNA/RNA; MYCOBACTERIA TB-DIRECT
No
87556
No
AGT-DNA/RNA; MYCOBACTERIA TB-AMPLI
No
87557
No
AGT-DNA/RNA; MYCOBACTERIA TB-QUAN
No
87560
No
AGT-DNA/RNA; MYCOBACTERIA AVIUM-DIR
No
87561
No
AGT-DNA/RNA; MYCOBACTERIA AVIUM-AMP
No
87562
No
No
87580
No
87581
No
87582
No
AGT-DNA/RNA; MYCOBACTER AVIUM-QUAN
AGT-DNA/RNA; MYCOPLASMA PNEUMONDIR
AGT-DNA/RNA; MYCOPLASMA PNEUMOAMPL
AGT-DNA/RNA; MYCOPLASMA PNEUMOQUAN
87590
No
No
87591
No
87592
No
AGT-DNA/RNA; NEISSER GONORRHEA-DIR
AGT-DNA/RNA; NEISSER GONORRHEAAMPL
AGT-DNA/RNA; NEISSER GONORRHEAQUAN
87620
87621
No
No
AGT-DNA/RNA; PAPILLOMAVIRUS-DIRECT
AGT-DNA/RNA; PAPILLOMAVIRUS-AMPLI
No
No
Code Description
AGT-DNA/RNA; HIV-2-QUAN
No
No
No
No
No
No
No
No
CPT Code
87622
87640
87641
87650
87651
87652
87653
July 2011
No
No
No
No
No
No
No
87660
No
87797
87798
87799
87800
No
No
No
No
87801
87802
87803
87804
No
No
No
No
87807
87808
87809
Code Description
AGT-DNA/RNA; PAPILLOMAVIRUS-QUAN
STAPH A, DNA, AMP PROBE
MR-STAPH, DNA, AMP PROBE
AGT-DNA/RNA; STREP GROUP A-DIRECT
AGT-DNA/RNA; STREP GROUP A-AMPLI
AGT-DNA/RNA; STREP GROUP A-QUAN
STREP B, DNA, AMP PROBE
INF AGT DETECT NUCLEIC ACID; TRICH
VAG DIR PROBE
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
AGT-DNA/RNA; NOS-DIRECT PROBE TECH
AGT-DNA/RNA; NOS-AMPLIFIED PROBE
AGT-DNA/RNA; NOS-QUAN
AGT-DNA/RNA; MULTI ORGANISMS
AGT-DNA/RNA; AMPLIFIED PROBE
TECHNIQUE
INF AGT ANTIG IMMUOAS; STREP GRP B
INF AGT ANTIG IMMUNOAS;C-DIFF TOX A
INF AGT ANTIG DETECT IMMUNOAS; FLU
INF AGT ANTIG DETCT IMMUOASSY DIR
OPTICL OBS;RSV
TRICHOMONAS ASSAY W/OPTIC
ADENOVIRUS ASSAY W/OPTIC
87810
No
AGT-IMMUNASSAY DIR OBSER; CHLAMYDIA
No
87850
No
AGT-IMMUNOASSAY DIR OBS; GONORRHEA
No
87880
No
AGT-IMMUNASSAY DIR OBS; STREP GRP A
No
87899
87900
No
No
No
No
87901
87902
No
No
87903
No
AGT-IMMUNOASSAY W/DIR OBSERV; NOS
NFCT AGT DRUG SC PHEXYP PREDICT
AGT-DNA/RNA; GENOTYPE ANALYSIS BY
NUCLEIC ACID
INF AGT GENOTYPE DNA/RNA; HCV
AGT-DNA/RNA; PHENOTYPE ANALYSIS BY
NUCLEIC ACID
87904
No
AGT-DNA/RNA; ADD DRUG UP TO 5 DRUGS
No
No
No
No
No
No
No
No
No
No
No
CPT Code
87905
87906
87999
July 2011
Non Reimbursible
No
No
88000
Not Reimbursable
NECROPSY GROSS EXAM ONLY; WO CNS
Not Reimbursable
88005
Not Reimbursable
NECROPSY GROSS EXAM ONLY; W/BRAIN
Not Reimbursable
88007
Not Reimbursable
NECROPSY GROSS ONLY; W/BRAIN-CORD
Not Reimbursable
88012
Not Reimbursable
NECROPSY GROSS ONLY; INFANT W/BRAIN
Not Reimbursable
88014
Not Reimbursable
NECRPSY GRSS ONLY;STILB/NB W/BRAIN
Not Reimbursable
88016
88020
88025
Not Reimbursable
Not Reimbursable
Not Reimbursable
NECROPSY GROSS ONLY; MACERAT STILLB
NECROPSY GROSS & MICRO; WO CNS
NECROPSY GROSS & MICRO; W/BRAIN
Not Reimbursable
Not Reimbursable
Not Reimbursable
88027
Not Reimbursable
NECROPSY GROSS/MICRO; W/BRAIN/CORD
Not Reimbursable
88028
Not Reimbursable
NECRPSY GROSS/MICRO; INFANT W/BRAIN
Not Reimbursable
88029
Not Reimbursable
NECRPSY GRSS/MICRO;STILB/NB W/BRAIN
Not Reimbursable
88036
Not Reimbursable
NECROPSY LTD GROSS/MICRO; REGIONAL
Not Reimbursable
88037
88040
88045
88099
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
NECROPSY LTD GROSS/MICRO; 1 ORGAN
NECROPSY; FORENSIC EXAM
NECROPSY; CORONER'S CALL
UNLISTED NECROPSY PROC
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
88104
No
CYTOPATH NO CERV/VAG; SMEARS W/INTE
No
88106
No
CYTPTH NO CERV/VAG;FLTR ONLY W/INTE
No
88107
No
CYTOPATH NO CERV/VAG; PREP W/INTRPT
No
88108
No
CYTOPATH CONCENTRA-SMEARS & INTERP
No
Code Description
SIALIDASE ENZYME ASSAY
GENOTYPE DNA HIV REVERSE T
UNLISTED MICROBIOLOGY PROC
Non Reimbursible
No
No
CPT Code
July 2011
88112
88120
88121
88125
88130
No
Not Reimbursable
Not Reimbursable
No
No
88140
No
SEX CHROMAT ID; PERIPHERL BLD SMEAR
No
88141
No
CYTOPATH CERV/VAG; REQ INTERPT PHYS
No
88142
No
No
88143
No
88147
No
CYTPTH CERV/VAG; THIN PREP; MAN SCR
CYTOPATH CERV/VAG; W/MAN SCRNRESCR
CYTOPATH CERV/VAG; AUTO SCRNSUPRVS
88148
No
CYTOPATH CERV; SCR-RESCRN-MD SUPR
No
88150
No
No
88152
No
CYTPTH SLIDE CERV/VAG; MANUAL-SUPRV
CYTPTH SLDE CERV/VAG; MANUALCMPUTR
88153
No
No
88154
No
88155
88160
No
No
CYTOPATH CERV/VAG; MAN SCRN-RESCRN
CYTOPATH CERV/VAG; SCRN-RESCRNCELL
CYTPTH SLIDES CERV/VAG DEF
HORMONAL
CYTPATH SMEARS; SCREEN & INTRPT
88161
No
CYTOPATH SMEAR; PREP/SCREEN/INTERPT
No
88162
No
CYTOPATH SMEARS; EXTEN STDY >5 SLDS
No
88164
No
CYTOPATH SLIDES-CERV/VAG; MAN SCRN
No
88165
No
No
88166
No
CYTOPATH SLIDES-CERV; MAN SCRN & RE
CYTOPATH SLIDES-CERV; MAN-COMPU
SCR
Code Description
CYTOPATH SELCTV CELLR ENHANCE
INTEPR NO CERV/VAG
CYTP URNE 3-5 PROBES EA SPEC
CYTP URINE 3-5 PROBES CMPTR
CYTOPATHOLOGY FORENSIC
SEX CHROMATIN IDENT; BARR BODIES
No
Not Reimbursable
Not Reimbursable
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
88167
No
CYTOPATH SLIDES-CERV/VAG; SCRN CELL
No
88172
No
EVAL FINE NEEDL ASPIRAT; IMMED STDY
No
88173
88174
88175
88177
No
No
No
Not Reimbursable
EVAL FINE NEEDL ASPIRAT;INTRPT/REPR
CYTOPATH, C/V AUTO, IN FLUID
CYPTOPATH, C/V AUTO FLUID REDO
CYTP C/V AUTO THIN LYR ADDL
No
No
No
Not Reimbursable
88182
No
88184
No
88185
No
88187
No
88188
No
88189
88199
Code Description
No
No
No
FLO CYTOMETRY; CELL CYCLE/DNA ANALY
FLOW CYTOMETRY CELL SURF/NUCLR TC
ONLY; 1 MARKER
FLOW CYTOMETRY CELL SURF/NUCLR TC
ONLY; EA ADD
FLOW CYTOMETRY INTERPRETATION; 2 TO
8 MARKERS
FLOW CYTOMETRY INTERPRETATION; 9 TO
15 MARKERS
FLOW CYTOMETRY INTERPRETATION;
16/MORE MARKERS
UNLISTED CYTOPATHOLOGY PROC
88230
88233
No
No
TISS CULT NON-NEOPLASM; LYMPHOCYTE
TISS CULT NON-NEOPLASM; SKIN
No
No
88235
No
TISS CULT NON-NEOPLAS; AMNIOT FLUID
No
88237
No
TISS CULT NEOPLASM; MARROW/BLD CELL
No
88239
88240
No
Not Reimbursable
TISS CULTURE NEOPLASM; SOLID TUMOR
CRYOPRESERV CELLS-EA CELL LINE
No
Not Reimbursable
88241
Not Reimbursable
THAW & EXPANS FROZ CELLS EA ALIQUOT
Not Reimbursable
88245
No
No
88248
No
CHROMOS ANALY BREAK SYNDROM; 20-25
CHROMOSOME ANALY; BASELINE
BREAKAGE
No
No
No
No
No
No
No
CPT Code
July 2011
88249
88261
No
No
Code Description
CHROMOSOME ANALY; CLASTOGEN
STRESS
CHROMO ANALY; CT 5 CEL 1 KAROTYPE
88262
88263
No
No
CHROMO ANALY; CT 15-20 CELL 2 KARYO
CHROMO ANALY; CT 45 CEL MOSAICISM
No
No
88264
No
CHROMOSOME ANALY; ANALY 20-25 CELLS
No
88267
No
CHROMO ANALY AMNIO FLUID CT 15 CELL
No
88269
88271
No
No
No
No
88272
No
88273
88274
88275
No
No
No
88280
No
CHROMO ANAL AMNIO FLD CT 6-12 COLNY
MOLEC CYTOGEN; DNA PROBE EA
MOLEC CYTOGEN; CHROMOSOM HYBRID 35
CYTOGEN; CHROMOSOM HYBRID 10-3O
CEL
CYTOGEN; INTERPHASE HYBRID 25-99
CYTOGEN; INTERPHASE HYBRID 100-300
CHROMOSOME ANALY; ADD KARYOTYPES
EA
88283
No
CHROMO ANALY; ADD SPECIALIZED BAND
No
88285
No
CHROMO ANALY; ADD CELLS COUNTED EA
No
88289
No
CHROMO ANALY; ADD HIGH RESOLUTION
No
88291
88299
No
No
CYTOGEN & MOLEC CYTOGEN INTER & RPT
UNLISTED CYTOGENETIC STUDY
No
No
88300
No
LEVEL I- SURG PATH GROSS EXAM ONLY
No
88302
No
LEVEL II-SURG PATH GROSS/MICRO EXAM
No
88304
No
LEVEL III-SURG PATH GROS/MICRO EXAM
No
88305
No
LEVEL IV-SURG PATH GROSS/MICRO EXAM
No
No
No
No
No
No
No
No
CPT Code
July 2011
88307
No
LEVEL V-SURG PATH GROSS/MICRO EXAM
No
88309
88311
No
No
No
No
88312
No
88313
No
88314
No
88318
No
88319
No
LEVEL VI-SURG PATH GROSS/MICRO EXAM
DECALCIFICATION PROC
SPECIAL STAINS; GROUP I FOR
MICROORGANISMS EACH
SPCL STAINS; GRP II ALL BUT
ICYTOCHEM/IPEROX EA
SPCL STAINS; HISTOCHEM STAINING
W/FRZN SECTION
DETERM HISTOCHEM TO ID CHEM
COMPONT
DETERM HSTOCHEM/CYTCHEM ID ENZYM
EA
88321
No
CONS & REPRT REF SLIDES PREP ELSEWH
No
88323
No
No
88325
88329
No
No
CONS & REPRT REF MAT REQ PREP SLIDE
CONS COMP W/REVW
RECORD/SPECMN/REPT
PATH CONS DURING SURG
88331
No
PATH CONS DURNG SURG; FROZEN 1 SPEC
No
88332
No
No
88333
No
88334
No
PATH CONS DURING SURG; EA ADD BLOCK
PATH CONSLTJ SURG CYTOLOGIC XM 1ST
SIT
PATH CONSLTJ SURG CYTOLOGIC XM EA
SIT
88342
No
IMMUNOHISTOCHEMISTRY EACH ANTIBODY
No
88346
No
IMMUNOFLUOR STUDY EA ANTIB; DIRECT
No
88347
88348
88349
No
No
No
IMMUNOFLUOR STUDY EA ANTIB; INDIREC
ELECTRON MICRO; DX
ELECTRON MICRO; SCANNING
No
No
No
Code Description
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
88355
88356
88358
No
No
No
88360
No
88361
88362
88363
88365
No
No
Not Reimbursable
No
88367
No
88368
No
MORPHOMETRIC ANALY; SKELETAL MUSCL
MORPHOMETRIC ANALY; NERV
MORPHOMETRIC ANALYSIS; TUMOR
MORPHOMTRIC ANALYSIS TUMR IHC EA
ANTIBDY; MANUAL
MORPHOMTRIC ANALY TUMR IHC EA
ANTIBDY; CMPT ASST
NERV TEASING PREP
XM ARCHIVE TISSUE MOLEC ANAL
IN SITU HYBRIDIZATION EA PROBE
MORPHOMTRIC ANALY IN SITU HYBRID EA;
CMPT ASST
MORPHOMTRIC ANALY IN SITU HYBRID EA
PROBE; MNL
88371
No
PROT ANALY TISS W BLOT W/INTRPT/REP
No
88372
88380
88381
No
No
No
No
No
No
88384
No
88385
No
88386
88387
88388
88399
88720
88738
88740
88741
88749
89049
89050
89051
No
No
No
No
No
No
No
No
Not Reimbursable
No
No
No
PROT ANALY W BLOT W/I & R; IMMUN EA
MICRODISSECTION
MICRODISSECTION, MANUAL
RA-BASED EVAL MLT MOLEC PRBS 11 THRU
50 PRBS
RA-BASED EVAL MLT MOLEC PRBS 51 THRU
250 PRBS
RA-BASED EVAL MLT MOLEC PRBS 251
THRU 500 PRBS
TISS EXAM MOLECULAR STUDY
TISS EX MOLECUL STUDY ADD-ON
UNLISTED SURG PATH PROC
BILIRUBIN TOTAL TRANSCUT
HGB QUANT TRANSCUTANEOUS
TRANSCUTANEOUS CARBOXYHB
TRANSCUTANEOUS METHB
IN VIVO LAB SERVICE
CAFFEINE HALOTHANE CONTRCURE
CELL CT MISC BODY FLUIDS EX BLD
CELL CT MISC FLUIDS EX BLD; W/DIFF
Code Description
No
No
No
No
No
No
Not Reimbursable
No
No
No
No
No
No
No
No
No
No
No
No
No
Not Reimbursable
No
No
No
CPT Code
July 2011
89055
89060
89125
89160
89190
No
No
No
No
No
89220
No
89230
No
89240
Not Reimbursable
89250
Not Reimbursable
89251
Not Reimbursable
SWEAT COLLECTION BY IONTOPHORESIS
UNLISTED MISCELLANEOUS PATHOLOGY
TEST
CULTURE OOCYTE/EMBRYO LESS THAN 4
DAYS;
CULT OOCYTE/EMBRYO <4 DAY; CO-CULT
OOCYTE/EMBRYO
89253
89254
89255
Not Reimbursable
Not Reimbursable
Not Reimbursable
ASSISTED EMBRYO HATCHING-MICROTECH
OOCYTE ID FROM FOLLICULAR FLUID
PREP EMBRYO FOR TRANSFER
Not Reimbursable
Not Reimbursable
Not Reimbursable
89257
89258
89259
Not Reimbursable
Not Reimbursable
Not Reimbursable
SPERM ID FROM ASPIR (NOT SEM FLUID)
CRYOPRESERVATION; EMBRYO
CRYOPRESERVATION; SPERM
Not Reimbursable
Not Reimbursable
Not Reimbursable
89260
Not Reimbursable
SPERM ISOLA; SIMPL PREP W/SEMN ANAL
Not Reimbursable
89261
Not Reimbursable
SPERM ISOLA; CMPLX PREP W/SEMN ANAL
Not Reimbursable
89264
89268
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
89272
Not Reimbursable
89280
Not Reimbursable
89281
Not Reimbursable
89290
Not Reimbursable
SPERM ID TESTIS TISS-FRESH/CRYOPRES
INSEMINATION OF OOCYTES
EXTENDED CULTURE OF OOCYTE/EMBRYO
4-7 DAYS
ASSTD OOCYTE FERTILIZ MICROTECH; </=
10 OOCYTES
ASSTD OOCYTE FERTILIZ MICROTECH; > 10
OOCYTES
BX OOCYTE POLAR BDY/EMBRYO
BLASTOMERE;</= 5 EMB
Code Description
LEUKOCYTE ASSESSMENT FECAL
QUALITATIVE/SEMIQUAN
CRYSTAL ID LITE MICRO ANY FLUID
FAT STAIN FECES URIN/SPUTUM
MEAT FIBERS FECES
NASAL SMEAR EOSINOPHILS
SPUTUM OBTAINING SPECIMEN AROSL
INDUCD TECHNIQUE
No
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
CPT Code
July 2011
89291
Not Reimbursable
89300
89310
89320
Not Reimbursable
Not Reimbursable
Not Reimbursable
89321
89322
89325
89329
89330
89331
Bundled
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
89335
89342
89343
Not Reimbursable
Not Reimbursable
Not Reimbursable
89344
89346
Not Reimbursable
Not Reimbursable
89352
Not Reimbursable
89353
Not Reimbursable
89354
Not Reimbursable
89356
89398
90281
90283
90284
Code Description
BX OOCYTE POLAR BDY/EMBRYO
BLASTOMERE; > 5 EMB
Not Reimbursable
SEMEN; PRESENCE/MOTILITY INC HUHNER
SEMEN ANALY; MOTILITY & CT
SEMEN ANALY; COMPLT
SEMEN ANALY; PRESENCE &/OR MOTILITY
OF SPERM
SEMEN ANAL, STRICT CRITERIA
SPERM ANTIB
SPERM EVAL; HAMSTER PENETRATION
SPERM; CERV MUCOS PENETRAT
RETROGRADE EJACULATION ANAL
CRYOPRESERVATION REPRODUCTIVE
TISSUE TESTICULAR
STORAGE; EMBRYO
STORAGE; SPERM/SEMEN
STORAGE; REPRODUCTIVE TISSUE
TESTICULAR/OVARIAN
STORAGE PER YEAR; OOCYTES
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Non Reimbursible
Not Reimbursable
Not Reimbursable
Not Reimbursable
THAWING OF CRYOPRESERVED; EMBRYO
THAWING CRYOPRESERVED;
SPERM/SEMEN EACH ALIQUOT
THAWING CRYOPRES; TISS
TESTICULAR/OVARIAN
THAWING OF CRYOPRESERVED; OOCYTES
EACH ALIQUOT
UNLISTED REPROD MED LAB PROC
IMMUNE GLOBULIN HUMAN-IM USE
IMMUNE GLOBULIN HUMAN-IV USE
HUMAN IG, SC
90287
90288
Not Reimbursable
Not Reimbursable
BOTULINUM ANTITOX-EQUINE-ANY ROUTE
BOTULISM IMMUNE GLOBULIN HUMAN-IV
Not Reimbursable
Not Reimbursable
90291
Not Reimbursable
CYTOMEGALOVIRUS IMMUNE GLOBULIN-IV
Not Reimbursable
90296
Not Reimbursable
DIPHTHERIA ANTITOX EQUINE ANY ROUTE
Not Reimbursable
Bundled
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Non Reimbursible
Not Reimbursable
Not Reimbursable
Not Reimbursable
CPT Code
90371
July 2011
Yes >19
Code Description
HEPATITIS B IMMUNE GLOBULIN-IM USE
Yes >19
90375
90376
No
No
RABIES IMMUNE GLOBULIN-IM &/SUBCUT
RABIES IG HEAT-TREATED IM &/SUBCUT
No
No
90378
90384
90385
90386
90389
90393
Yes
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
RESP SYNCYTIAL VIRUS IMMUN GLOBULIN
RHO IMMUNE GLOBULIN FULL DOSE-IM
RHO IMMUNE GLOBULIN MINI DOSE-IM
RHO IMMUNE GLOBULIN HUMAN-IV USE
TETANUS IMMUNE GLOBULIN HUMAN-IM
VACCINIA IMMUNE GLOBULIN HUMAN-IM
Yes
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
90396
90399
1/1/2011 Non Reimb; prior reimb
Not Reimbursable
1/1/2011 Non Reimb; prior reimb
Not Reimbursable
90460
90461
90470
Not Reimbursable
Not Reimbursable
Non Reimbursible
90471
No
90472
90473
No
Not Reimbursable
VARICELLA-ZOSTER IMMUNE GLOBULIN IM
UNLISTED IMMUNE GLOBULIN
REST HOME (EG, BOARDING HOME),
DOMICILIARY, OR CUSTODIAL CAR
INADM ANY ROUTE ADDL VAC/TOX
IMMUNE ADMIN H1N1 IM/NASAL
IMMUNIZATION ADMINISTRATION ; ONE
VACCINE
IMMUNIZATION ADMINISTRATION; EA ADD
VACCINE
IMMU ADMN INTRANASAL/ORAL; 1 VAC
90474
Not Reimbursable
IMMU ADMN INTRANASAL/ORAL; ADD VAC
Not Reimbursable
90476
Not Reimbursable
ADENOVIRUS VACCINE TYPE 4 LIVE-ORAL
Not Reimbursable
90477
90581
Not Reimbursable
Not Reimbursable
ADENOVIRUS VACCINE TYPE 7 LIVE-ORAL
ANTHRAX VACCINE-SUBCUT USE
Not Reimbursable
Not Reimbursable
90585
90586
90632
Yes
Yes
Yes
BCG VACCINE FOR TB LIVE-PERCUT USE
BCG VACC BLADDER CA LIVE-INTRAVES
HEPATITIS A VACCINE ADULT DOSE-IM
Yes
Yes
Yes
90633
Yes for >19; <19 free from DOH
HEP A VACCINE PED/ADOLES DOSE-2-IM
Yes for >19; <19 free from DOH
90634
90636
Not Reimbursable
Yes
HEP A VACCINE PED/ADOLES DOSE-3-IM
HEP A-HEP B VACCINE ADULT DOSE-IM
Not Reimbursable
Yes
Not Reimbursable
Not Reimbursable
Non Reimbursible
No
No
Not Reimbursable
CPT Code
July 2011
90645
90646
No
No
HEMOPHILUS FLU B VACC HBOC CONJU-IM
HEMOPHIL FLU B VACC PRPD-D BOOST IM
No
No
90647
No
HEMOPHIL FLU B VACC PRP-OMP CONJ-IM
No
90648
90655
No
90656
No
90657
Eff 7/1/2010 Not Reimbursable
90658
90660
90661
90662
90663
90664
No
Yes
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
HEMOPHIL FLU B VACC PRP-T CONJUG-IM
HPV TYP 6 11 16 18 QUADRIV 3 DOSE
SCHED IM
HPV TYP BIVAL 3 DOSE IM
FLU VIRUS VAC SPLIT PRES FREE 6-35 MO
AGE IM
FLU VIRUS VAC SPLIT PRES FREE IND 3 YR
AGE&> IM
INFLUENZA VIRUS VACC-SPLIT VIRUS 6-35
MO IM USE
INFLUENZA VIRUS VACC-SPLIT VIRUS 3 YR
AGE & > IM
FLU VIRUS VACC-LIVE-INTRANASAL USE
FLU VACC CELL CULT PRSV FREE
FLU VACC PRSV FREE INC ANTIG
FLU VACC PANDEMIC
FLU VACC PANDEMIC LIVE NASAL
No
90649
90650
No
Yes for Ages 19 to 20, BHP nc for 19, 20; nc
>20
Not Reimbursable
90665
90666
90667
90668
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
90669
90675
90676
Code Description
Yes for Ages 19 to 20, BHP nc for 19, 20; nc >20
Not Reimbursable
No
No
Eff 7/1/2010 Not Reimbursable
No
Yes
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
No
LYME DISEASE VACC-ADULT DOSE-IM USE
FLU VACC PANDEMIC NO PRSV IM
FLU VACC PANDEMIC ADJ IM
FLU VACC PANDEMIC SPLT V IM
PNEUMOCOCCAL VACC-POLYVALENT-IM
USE
RABIES VACCINE-IM USE
RABIES VACCINE-INTRADERMAL USE
90680
90681
90690
90691
Covered for infants
Not Reimbursable
Not Reimbursable
Yes
ROTAVIRUS VACC TETRAVLNT-LIVE-ORAL
ROTAVIRUS VACC 2 DOSE ORAL
TYPHOID VACCINE-LIVE-ORAL
TYPHOID VACCINE-VICPS-IM USE
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
90692
Not Reimbursable
TYPHOID VACC-HEAT INACTIV-SUBQ/DERM
Not Reimbursable
No
No
No
CPT Code
July 2011
90693
90696
Not Reimbursable
Not Reimbursable
90698
Covered for children 0-18 years of age
90700
No
90701
90702
No
No
90703
No
90704
No
90705
No
90706
No
90707
No
90708
No
90710
90712
90713
90714
No
No
No
90715
90716
90717
No
No
No
90718
90719
No
Not Reimbursable
90720
90721
No
Not Reimbursable
90723
Code Description
TYPHOID VACCINE ACETONE-KILLED DRIED
SUBQ USE
DTAP-IPV VACC 4-6 YR IM
Not Reimbursable
Not Reimbursable
DTAP-HIB-IPV FOR INTRAMUSCULAR USE
DTAP INDIVIDUAL YOUNGER THAN 7 YRS IM
USE
DIPH/TET/WHOLE CELL PERTUSS VAC-IM
DIPHTH & TET TOX -PED USE-IM USE
TETANUS TOXOID ADSORBED FOR
INTRAMUSCULAR USE
MUMPS VIRUS VACCINE LIVE FOR
SUBCUTANEOUS USE
MEASLES VIRUS VACCINE LIVE
SUBCUTANEOUS USE
RUBELLA VIRUS VACCINE LIVE
SUBCUTANEOUS USE
MEASLES MUMPS & RUBELLA VIRUS VACC
LIVE-SUBQ USE
MEASLES & RUBELLA VIRUS VACCINE LIVE
SUBQ USE
MEASLES/MUMPS/RUBELLA/VARCELLASUBQ
POLIOVIRUS VACCINE LIVE-ORAL USE
POLIOVIRUS VAC INACTIVATED-SUBQ
TD ADSORBED PRSRV FR 7 YR/> IM
TDAP VACCINE INDIVIDUAL 7 YEARS/OLDER
IM USE
VARICELLA VIRUS VAC LIVE-SUBQ USE
YELLOW FEVER VAC LIVE-SUBQ USE
TD ADSORBED USE INDIVIDUALS 7
YRS/OLDER-IM USE
DIPHTHERIA TOXOID-IM USE
No
No
DIPTH/TET/WHLE CELL PERTUSS/INFLU B
DIPTH/TET/ACELL PERTUSSIS/INFLU B V
DIPHTHERIA, TETANUS TOXOIDS,
ACELLULAR PERTUSSIS VACCINE, HE
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Not Reimbursable
No
Not Reimbursable
CPT Code
90725
July 2011
No
90727
Not Reimbursable
90732
No
90733
Yes
90734
Yes, if No SL Modifier
90735
90736
No
Non Reimbursible
90740
No
90743
Code Description
CHOLERA VACCINE-INJ USE
PLAGUE VACCINE INTRAMUSCULAR USE
PNEUMOCOCCAL POLYSACCH VAC-ADULT
MENINGOCOCCAL POLYSACCHARIDE VACC
SUBQ USE
MNINGOCOCCL CONJUGATE VAC
SEROGRP A C Y&W-135 IM
No
Not Reimbursable
No
YES
Yes, if No SL Modifier
No
Non Reimbursible
Yes
JAPANESE ENCEPHALITIS VAC-SUBQ USE
ZOSTER VACC LIVE SUBQ NJX
HEPATITIS B VACCINE, DIALYSIS OR
IMMUNOSUPPRESSED PATIENT DO
HEPATITIS B VACCINE, ADOLESCENT (2
DOSAGE SCHEDULE) IM USE
90744
90746
Yes, if no SL modfier
Yes
HEP B VACCINE-PED/ADOLES DOS-IM USE
HEPATITIS B VAC ADULT DOSE-IM USE
Yes, if No SL modifier
Yes
90747
No
HEP B VAC DIALYSIS/IMMUNOSUPPRES-IM
No
90748
90749
90801
No
Not Reimbursable
No
90802
Yes
INTERACT PSYCH DX INTERVIEW W/EQUIP
Yes
90804
Yes
PSYCHOTHER OV/OP-BEHV MOD 20-30 MN;
Yes
90805
Yes
PSYCHOTHER OP 20-30 MIN; W/MED E&M
Yes
90806
No
No
90807
No
No
90808
Yes
Yes
90809
Yes
Yes
HEP B/HEMOPHILUS INFLU B VAC-IM USE
UNLIST VACCINE/TOXOID
PSYCH DX INTERVIEW EXAM
No
No
No
Not Reimbursable
No
CPT Code
July 2011
90810
Yes
PSYCHOTHER OV/OP-INTERACT 20-30 MN;
Yes
90811
Yes
PSYCHOTHER OP-INTRAC 20-30 MIN; E&M
Yes
90812
No
No
90813
Yes
Yes
90814
Yes
Yes
90815
Yes
Yes
90816
Yes
PSYCHOTHER IP/PH/RCS-BEHV 20-30 MN;
Yes
90817
Yes
PSYCHOTHER IP-BEHV 20-30 MIN; W/E&M
Yes
90818
Yes
Yes
90819
Yes
Yes
90821
Yes
Yes
90822
90823
90824
90826
90827
90828
90829
90845
90846
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Not Reimbursable
PSYCHOTHER IP/RCS-INTRAC 20-30 MIN;
PSYCHOTHER IP-INTRAC 20-30 MIN; E&M
PSYCHOANALYSIS
FAMILY PSYCHOTHERAPY (WO PT)
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Not Reimbursable
90847
90849
No
Not Reimbursable
No
Not Reimbursable
90853
90857
90862
Yes
Yes
No
FAMILY PSYCHOTHER (CONJOINT) (W/PT)
MX-FAMILY GROUP PSYCHOTHERAPY
GROUP PSYCHOTHERAPY (NOT MXFAMILY)
INTERACTIVE GROUP PSYCHOTHERAPY
PHARM MGMT W/SCRIPT USE & REVIEW
Code Description
Yes
Yes
No
CPT Code
July 2011
90865
90867
90868
Yes
Not Reimbursable
Not Reimbursable
NARCOSYNTHESIS FOR PSYCH DX & THER
TCRANIAL MAGN STIM TX PLAN
TCRANIAL MAGN STIM TX DELI
Yes
Not Reimbursable
Not Reimbursable
90870
90875
90876
90880
Yes
Not Reimbursable
Not Reimbursable
Not Reimbursable
ELEC-CONVULS THERAP; SNGL SEIZURE
INDIV PSYCHPHYSIOL THER; 20-30 MIN
INDIV PSYCHOPHYSIOL THER; 45-50 MIN
HYPNOTHERAPY
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
90882
Not Reimbursable
Not Reimbursable
90885
90887
Bundled
Bundled
ENVIRONM INTERVEN-W/AGENCIES/INSTIT
PSYCH EVAL HOSP RECRD-MED DX
PURPOS
INTERPT/EXPLAN RESULTS EXAM/DATA
90889
90899
90901
Bundled
Yes
Not Reimbursable
PREP REPORT PT STATUS/TX FOR OTHER
UNLISTED PSYCH SERV/PROC
BIOFEEDBACK TRAINING-ANY MODALITY
Bundled
Yes
Not Reimbursable
90911
Yes
BIOFEEDBACK TRAIN-ANORECTAL W/EMG
Yes
90935
90937
90940
90945
90947
90951
90952
90953
90954
90955
90956
90957
90958
90959
90960
90961
90962
90963
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
HEMODIALYSIS PROC W/SNGL PHYS EVAL
HEMODIALYSIS PROC W/REPEAT EVAL
HEMODIALYSIS ACCESS FLOW STUDY
DIALYSIS OTHER THAN HEMO W/1 EVAL
DIALYSIS NOT HEMO W/REPEAT EVAL
ESRD SERV, 4 VISITS P MO, <2
ESRD SERV, 2-3 VSTS P MO, <2
ESRD SERV, 1 VISIT P MO, <2
ESRD SERV, 4 VSTS P MO, 2-11
ESRD SRV 2-3 VSTS P MO, 2-11
ESRD SRV, 1 VISIT P MO, 2-11
ESRD SRV, 4 VSTS P MO, 12-19
ESRD SRV 2-3 VSTS P MO 12-19
ESRD SERV, 1 VST P MO, 12-19
ESRD SRV, 4 VISITS P MO, 20+
ESRD SRV, 2-3 VSTS P MO, 20+
ESRD SERV, 1 VISIT P MO, 20+
ESRD HOME PT, SERV P MO, <2
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Code Description
Bundled
Bundled
CPT Code
90964
90965
90966
90967
90968
90969
90970
90989
90993
90997
90999
91010
91013
91020
91022
91030
July 2011
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
91034
No
91035
No
91037
No
91038
No
91040
91065
No
No
91110
91111
91117
Not Reimbursable
Not Reimbursable
No
91120
91122
No
No
91132
No
91133
No
Code Description
ESRD HOME PT SERV P MO, 2-11
ESRD HOME PT SERV P MO 12-19
ESRD HOME PT, SERV P MO, 20+
ESRD HOME PT SERV P DAY, <2
ESRD HOME PT SRV P DAY, 2-11
ESRD HOME PT SRV P DAY 12-19
ESRD HOME PT SERV P DAY, 20+
DIALYSIS TRAIN-PT-INCL HELPR-COMPLT
DIALYSIS TRAIN-PT-PER SESSION
HEMOPERFUSION
UNLIST DIALYSIS PROC INPT/OUTPT
ESOPH MOTILITY STUDY;
ESOPHGL MOTIL W/STIM/PERFUS
GASTRIC MOTILITY STUDIES
DUOL MOTILITY STD
ESOPH ACID PERFUSION-ESOPHAGITIS
ESOPH GER TEST; W/NASAL CATH PH ELEC
PLCMT REC
ESOPH GER TEST; W/MUCOSL ATTCH PH
ELEC PLCMT REC
ESOPH FUNCT TST GER W/NASL CATH
ELEC PLCMT REC;
ESOPH FUNCT TST GER NASL CATH ELEC
PLCMT; PROLNG
ESOPHAGEAL BALLOON DISTENSION
PROVOCATION STUDY
BREATH HYDROGEN TEST
GI TRACT IMAG INTRALUM ESOPH THRU
ILEUM PHYS I&R
ESOPHAGEAL CAPSULE ENDOSCOPY
COLON MOTILITY 6 HR STUDY
RECTAL SENSATION TONE AND
COMPLIANCE TEST
ANORECTAL MANOMETRY
ELECTROGASTROGRAPHY, DIAGNOSTIC,
TRANSCUTANEOUS
ELECTROGASTROGRAPHY,
W/PROVOCATIVE TESTING
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
No
No
No
No
No
CPT Code
July 2011
91299
No
UNLISTED DX GASTROENTEROLOGY PROC
No
92002
No
OPHTH SERV: EXAM-EVAL; INTERMED NEW
No
92004
No
OPHTH SERV: MED EXAM; COMP NEW PT
No
92012
No
OPHTH SERV: MED EXAM; INTERM ESTAB
No
92014
92015
No
No
OPHTH SERV: MED EXAM; COMP ESTAB PT
DETERM REFRACTIVE STATE
No
No
92018
92019
92020
92025
Yes
Yes
No
No
Yes
Yes
No
No
92060
92065
92070
92081
92082
92083
92100
No
Yes
Yes
No
No
No
No
92120
92130
92132
92133
92134
No
No
No
No
No
92136
No
92140
92225
No
No
OPHTH EXAM & EVAL-GEN ANES; COMPLT
OPHTH EXAM & EVAL-GEN ANES; LTD
GONIOSCOPY (SEPART PROC)
CORNEAL TOPOGRAPHY
SENSORIMOTOR EXAM W/MEAS (SEP
PROC)
ORTHOPTIC &/OR PLEOPTIC TRAIN
FIT CONTACT LENS-TX INCL LENS
VISL FIELD EXAM UNI/BIL W/I&R; LTD
VISUAL FIELD EXAM W/I&R; INTERMED
VISUAL FIELD EXAM W/I&R; EXTEN
SERIAL TONOMETRY (SEP PRO) W/I&R
TONOGRAPHY W/I&R-RECORD INDEN
TONOM
TONOGRAPHY W/WATER PROVOCATION
CMPTR OPHTH DX IMG ANT SEGMT
CMPTR OPHTH IMG OPTIC NERVE
CPTR OPHTH DX IMG POST SEGMT
OPHTH BIOMET PART COHERNC
INTRFROMT
PROVOC TESTS-GLAU W/I&R WO
TONOGRPH
OPHTH EXTEN W/RET DRAW W/I&R; INIT
92226
92227
92228
No
Not Reimbursable
Not Reimbursable
Code Description
OPHTH EXTEN W/RET DRAW W/I&R; SUBSQ
REMOTE DX RETINAL IMAGING
REMOTE RETINAL IMAGING MGMT
No
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
CPT Code
92230
92235
92240
92250
92260
July 2011
No
No
No
No
No
92265
92270
92275
92283
92284
No
No
No
No
No
92285
No
92286
No
92287
92310
92311
92312
Code Description
FLUORESCEIN ANGIOSCOPY W/I&R
FLUORESCEIN ANGIOGRAPHY W/I&R
INDOCYANINE-GREEN ANGIO W/I & R
FUNDUS PHOTOGRAPHY W/I&R
OPHTHALMODYNAMOMETRY
NEEDLE OCULOELECTROMYO 1/MORE
W/I&R
ELEC-OCULOGRAPHY W/I&R
ELECTRORETINOGRAPHY W/I&R
COLOR VISION EXAM EXTEN
DARK ADAPTATION EXAM W/I&R
EXT OCULAR PHOTO W/I&R DOCUMNT
PROG
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
SPEC ANT SEGMT PHOTO; W/MICRO/CNT
SPECIAL ANT SEGMT PHOTO
W/FLUOROESC
SCRIPT & FIT CONTACT; EX APHAKIA
SCRIPT & FIT CONTACT; APHAKIA-1 EYE
SCRIPT CONTACT LENS; APHAKIA-BOTH
No
Yes
Yes
Yes
92313
92314
92315
92316
Yes
Yes
Yes
Yes
SCRIPT CONTACT LENS; CORNEOSCLERAL
SCRIPT W/FIT BY TECH; LENS-EX APHAK
SCRIPT W/FIT BY TECH; APHAKIA-1 EYE
SCRIPT W/FIT BY TECH; APHAKIA-BOTH
Yes
Yes
Yes
Yes
92317
Yes
SCRIPT W/FIT BY TECH; CORNEOSCLERAL
Yes
92325
92326
Not Reimbursable
Not Reimbursable
92340
92341
No
No
FIT SPECTACLES EX APHAKIA; MONOFOCL
FIT SPECTACLES EX APHAKIA; BIFOCAL
No
No
92342
No
No
92352
No
FIT SPECTACLE EX APHAKIA; MULTIFOCL
FIT SPECTACL PROSTH-APHAK;
MONOFOCL
92353
No
FIT SPECTACL PROSTH-APHAK; MULTIFOC
No
MODIFICAT LENS (SEP PRO) W/SUPERVS
REPLAC CONTACT LENS
No
Not Reimbursable
Not Reimbursable
No
CPT Code
92354
92355
92358
July 2011
Yes
Yes
Not Reimbursable
92370
No
REPR & REFIT SPECTACLES; EX APHAKIA
No
92371
92499
No
Yes
No
Yes
92502
92504
No
No
92506
92507
eff 1/1/2009 -No - unless over 24 visits
REPR & REFIT; SPECTACL PROSTH-APHAK
UNLISTED OPHTH SERV/PROC
OTOLARYNGOLOGIC EXAM UNDER GEN
ANES
BINOCULAR MICRO (SEPART DX PROC)
EVAL SPEECH/LANG/COMMUN/AUD
PROCESS
TX SPEECH/LANG/AUD DISORDER; INDIV
92508
92511
92512
92516
92520
No
No
No
No
92526
92531
92532
92533
92540
92540
92540
No
No
No
No
92541
Code Description
FIT LO VISION AID; 1 ELEMNT SYST
FIT LO VISION AID; TELESCOP/OTHER
PROSTH SERV APHAKIA TEMPORARY
No
Yes
Not Reimbursable
No
No
TX SPEECH/LANG/AUD DISORDER; 2/MORE eff 1/1/2009 -No - unless over 24 visits
NASOPHARYNGOSCOPY W/ENDO (SEP
PRO)
No
NASAL FUNCT STUDIES
No
FACIAL NERV FUNCT STUDIES
No
LARYNGEAL FUNCT STUDIES
No
No
Bundled
Bundled
Bundled
No
No
No
No
TX SWALLOW DYSFUNC &/OR ORAL FUNCT
SPONTANEOUS NYSTAGMUS INCL GAZE
POSIT NYSTAGMUS
CALORIC VESTIBULAR TEST EA IRRIGA
BASIC VESTIBULAR EVALUATION
SPONTANEOUS NYSTAGMUS TEST
W/RECORD
92542
92543
No
No
POSIT NYSTAGMS MIN 4 POSIT W/RECORD
CALORIC VESTIB EA IRRIG W/RECORD
No
No
92544
No
OPTOKINETIC NYSTAGMS BIDIREC/FOVEAL
No
92545
No
OSCILLATING TRACKING TEST W/RECORD
No
No
CPT Code
July 2011
92546
92547
No
No
92548
92550
92551
92552
92553
92555
No
No
No
No
No
No
92556
92557
92559
92560
92561
Code Description
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
SINUSOIDAL VERTCL AXIS ROTATNL TEST
USE VERTICAL ELECTRODES
COMPUTERIZED DYNAMIC
POSTUROGRAPHY
TYMPANOMETRY & REFLEX THRESH
SCREENING TEST PURE TONE AIR ONLY
PURE TONE AUDIOMETRY; AIR ONLY
PURE TONE AUDIOMETRY; AIR & BONE
SPEECH AUDIOMETRY THRESHOLD;
SPEECH AUDIOM THRESHLD;
W/RECOGNITN
COMP AUDIOMETRY THRESHOLD EVAL
AUDIOMETRIC TESTING GRP
BEKESY AUDIOMETRY; SCREENING
BEKESY AUDIOMETRY; DX
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
92562
92563
92564
92565
92567
92568
92570
92571
92572
92575
92576
92577
92579
92582
92583
92584
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
Not Reimbursable
No
LOUD BALANC TEST ALTERN BI/MONAURAL
TONE DECAY TEST
SHORT INCREMENT SENSITIVITY INDX
STENGER TEST PURE TONE
TYMPANOMETRY
ACOUSTIC REFLEX TESTING
ACOUSTIC IMMITTANCE TESTING
FILTERED SPEECH TEST
STAGGERED SPONDAIC WORD TEST
SENSORINEURAL ACUITY LEVEL TEST
SYNTHETIC SENTENCE IDENT TEST
STENGER TEST SPEECH
VISUAL REINFORCEMENT AUDIOMETRY
CONDITIONING PLAY AUDIOMETRY
SELECT PICTURE AUDIOMETRY
ELECTROCOCHLEOGRAPHY
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
Not Reimbursable
No
92585
92586
No
No
AUD EVOKED POTENTIALS &/OR TEST-CNS
AUD EVOKED POTENTIAL, LIMITED
No
No
92587
No
EVOKED OTOACOUSTIC EMISSIONS; LTD
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
92588
No
92590
Not Reimbursable
HEARING AID EXAM & SELECT; MONAURAL
Not Reimbursable
92591
92592
92593
Not Reimbursable
Not Reimbursable
Not Reimbursable
HEARING AID EXAM & SELECT; BINAURAL
HEARING AID CHECK; MONAURAL
HEARING AID CHECK; BINAURAL
Not Reimbursable
Not Reimbursable
Not Reimbursable
92594
Not Reimbursable
ELECTROACOUST EVAL H-AID; MONAURAL
Not Reimbursable
92595
Not Reimbursable
ELECTROACOUST EVAL H-AID; BINAURAL
Not Reimbursable
92596
92597
Not Reimbursable
No
Not Reimbursable
No
92601
No
92602
No
EAR PROTECTOR ATTENUATION MEASUR
EVAL VOICE PROSTH/COMMUN DEVICE
DX ANALY COCHLEAR IMPL PT UND 7 YR
AGE; W/PROG
DX ANALY COCHLEAR IMPL PT >7 YR;
SUBSQT REPROG
92603
No
92604
No
92605
Bundled
92606
Bundled
92607
No
92608
No
92609
No
92610
No
92611
No
92612
No
Code Description
EVOKED OTOACOUSTIC EMISSNS;
COMP/DX
DX ANALY COCHLEAR IMPL 7 YR/>; W/PROG
DX ANALY COCHLEAR IMPL 7 YR/>; SUBSQT
REPROG
EVAL PRSC NON-SPCH-GEN AUG&ALT
CMNCT DEVICE
TX SRVC NON-SPCH-GEN DEVC INCL
PROGMMING&MOD
EVAL PRSC SPCH-GEN AUG&ALT DEVC F/F
W/PT; 1 HR
EVAL PRSC SPCH-GEN AUG&ALT DEVC F/F
PT;30 MIN
TX SRVC USE SPCH-GEN DEVICE INCL
PROGMMING&MOD
EVALUATION ORAL&PHARYNGEAL
SWALLOWING FUNCTION
MOT FLUORO EVAL SWALLWING FUNCT
CINE/VIDEO
FLX FIBEROPTIC ENDO EVAL SWALLWING
CINE/VIDEO;
No
No
No
No
No
Bundled
Bundled
No
No
No
No
No
No
CPT Code
July 2011
92613
Bundled
92614
No
92615
Bundled
92616
No
92617
Bundled
92620
No
92621
92625
92626
92627
92630
92630
92633
92640
No
No
No
No
Yes
Yes
Yes
Yes
92700
92950
Yes
No
Code Description
FLX FO ENDO EVAL SWALLW CINE/VIDEO;
PHYS I&R
FLX FO ENDO EVAL LARYNG SENSY TST
CINE/VIDEO;
FLX ENDO LARYNG SENSY TST CINE/VIDEO;
PHYS I&R
FLX FO ENDO SWALLW&LARYNG SENSY
TST CINE/VIDEO;
FLX ENDO SWALLW&LARYNG SENSY
CINE/VIDEO;PHYS I&R
EVAL CNTRL AUDITORY FUNCTION W/RPT;
INIT 60 MIN
EVAL CNTRL AUDITORY FUNCTION
W/RPT;EA ADD 15 MIN
ASSESSMENT OF TINNITUS
EVAL AUD RHAB STATUS 1ST HR
EVAL AUD RHAB STATUS EA 15 MIN
AUD RHAB PRELNG HEARING LOSS
AUD RHAB PRELNG HEARING LOSS
AUD RHAB POST-LNGL HEARING LOSS
AUD BRAINSTEM IMPLT PROGRAMG
UNLISTED OTORHINOLARYNGOLOGICAL
SERVICE/PROC
CARDIOPULMONARY RESUSCITATION
92953
Yes
TEMPORARY TRANSCUTANEOUS PACING
No
92960
Yes
CARDIOVERS ELEC-CONVER ARRHY; EXT
No
92961
92970
No
Yes
CARDIOVERSION ELECT; INT (SEP PROC)
CARDIOASSIST-METHD CIRC ASSIST; INT
No
No
92971
92973
92974
Yes
Yes
Yes
CARDIOASSIST-METHD CIRC ASSIST; EXT
PERQ TRANSLUMINAL COR THROMBECT
TRNSCATH PLCMT RAD DEL DEVC
No
No
No
92975
Yes
THROMBOLYSIS CORON; INTRACOR INFUS
No
92977
Yes
THROMBOLYSIS CORONARY; IV INFUSION
No
Bundled
No
Bundled
No
Bundled
No
No
No
No
No
No
No
No
Yes
Yes
No
CPT Code
92978
92979
July 2011
Yes
Yes
92980
Yes
92981
92982
92984
Code Description
VASC US (CORN) DX/TX-S/I&R; INIT
INVASC US (CORN/GFT)-S/I&R; EA ADD
NA
NA
No
Yes
Yes
Yes
TRNSCATH PLCMT INCORONARY STENT; 1
TRNSCATH PLC CORONARY STENT; EA
ADD
PTCA; 1 VESSEL
PTCA; EA ADD VESSEL
92986
Yes
PERCUT BALLOON VALVULOPLSTY; AORTIC
No
92987
Yes
PERC BALLOON VALVULOPLASTY; MITRAL
No
92990
92992
Yes
Yes
PERCUT BALLOON VALVULOPLASTY; PULM
ATRIAL SEPTECT/SEPTOST; TRANSVEN
No
NA
92993
Yes
NA
92995
Yes
ATRIAL SEPTECT/SEPTOST; BLADE METHD
PERQ TRNSLUM CORON ATHEREC; 1
VESSL
92996
Yes
PERQ TRNSLUM CORON ATHEREC; EA ADD
No
92997
92998
93000
93005
93010
Yes
Yes
No
No
No
PERC TRNSLUM PULM ART ANGIOPLSTY; 1
PERC PULM ART ANGIOPLSTY; EA ADD
ECG-ROUTINE 12 LEAD; W/INTRPT & RPT
ECG-ROUTINE 12 LEAD; TRACING ONLY
ECG-ROUTINE 12 LEAD; INTRPT & REPRT
No
No
No
No
No
93015
93016
93017
93018
93024
No
No
No
No
No
No
No
No
No
No
93025
Not Reimbursable
CV STRESS TST W/PHARM; INTRPT & RPT
CV STRESS; PHYS SUPERVS ONLY
CV STRESS TEST; TRACING ONLY
CV STRESS; INTERPT & REPRT ONLY
ERGONOVINE PROVOCATION TEST
MICROVLT T-WAVE ALTRNANS VENT
ARRHY
Not Reimbursable
93040
No
RHYTHM ECG 1-3 LEAD; W/INTRPT-REPRT
No
93041
No
RHYTHM ECG 1-3 LEADS; TRACING ONLY
No
No
No
No
No
CPT Code
93042
July 2011
No
93224
93225
93226
93227
93228
93229
No
No
No
No
No
Yes
ECG-24 HR W/SCAN; REPRT-REVW-INTRPT
ECG-24 HR W/SCAN; RECORDING
ECG-24 HR W/SCAN; ANALY W/REPORT
ECG-24 HR W/SCAN; MD REVW & REPRT
REMOTE 30 DAY ECG REV/REPORT
REMOTE 30 DAY ECG TECH SUPP
No
No
No
No
No
No
93268
No
PT DEMND RECRD/30 DA; TRNSMIS/INTRP
No
93270
No
PT DEMND RECRD/30 DA; HOOK-UP/RECRD
No
93271
No
PT DEMND RECRD/30 DA; MONITOR/ANALY
No
93272
93278
93279
93280
93281
93282
93283
93284
93285
93286
93287
93288
93289
93290
93291
93292
93293
93294
93295
93296
93297
93298
93299
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
PT DEMND RECRD/30 DA; REVIEW/INTERP
SIGNAL-AVG ELECTROCARDIOGRAPHY
PM DEVICE PROGR EVAL, SNGL
PM DEVICE PROGR EVAL, DUAL
PM DEVICE PROGR EVAL, MULTI
ICD DEVICE PROG EVAL, 1 SNGL
ICD DEVICE PROGR EVAL, DUAL
ICD DEVICE PROGR EVAL, MULT
ILR DEVICE EVAL PROGR
PRE-OP PM DEVICE EVAL
PRE-OP ICD DEVICE EVAL
PM DEVICE EVAL IN PERSON
ICD DEVICE INTERROGATE
ICM DEVICE EVAL
ILR DEVICE INTERROGATE
WCD DEVICE INTERROGATE
PM PHONE R-STRIP DEVICE EVAL
PM DEVICE INTERROGATE REMOTE
ICD DEVICE INTERROGAT REMOTE
PM/ICD REMOTE TECH SERV
ICM DEVICE INTERROGAT REMOTE
ILR DEVICE INTERROGAT REMOTE
ICM/ILR REMOTE TECH SERV
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Code Description
RHYTHM ECG; INTERPT & REPORT ONLY
No
CPT Code
July 2011
93303
No
93304
93306
No
No
93307
93308
No
No
93312
Code Description
TRANSTHOR ECHO-CONG CARD ANOM;
COMP
TRANSTHOR ECHO-CONG CARD ANOM;
LTD
TTE W/DOPPLER, COMPLETE
No
No
No
No
No
No
ECHO TRNSTHORAC REAL-TIME; COMPLT
ECHO TRNSTHORAC REAL-TIME; F/U-LTD
ECHO TRNSESOPH; W/PROBE PLCMTREPRT
93313
No
ECHO TRANSESOPH; PLCMT PROBE ONLY
No
93314
No
No
93315
No
93316
No
93317
No
ECHO TRANSESOPH; INTERPT & REPORT
TRANSESOPH ECHO-CONG CARD ANOM;
TOT
TRANSESOPH ECHO-CONG CARD; PLC
PROB
TRNSESOPH ECHO-CONG CARD; IMAGEI&R
93318
93320
93321
No
No
No
No
No
No
93325
No
ECHO TEE FOR MONITORING PURPOSES
DOPPLER ECHO CONT WAVE; COMPLT
DOPPLER ECHO CONT WAVE; F/U-LTD
DOPPLR ECHO COLOR FLOW VELOCITY
MAP
93350
93351
93352
93451
93452
93453
93454
93455
93456
93457
93458
93459
No
No
No
No
No
No
No
No
No
No
No
No
ECHO W/REST & STRESS-INTERP & REPRT
STRESS TTE COMPLETE
ADMIN ECG CONTRAST AGENT
RIGHT HEART CATH
LEFT HRT CATH W/VENTRCLGRPHY
R&L HRT CATH W/VENTRICLGRPHY
CORONARY ARTERY ANGIO S&I
CORONARY ART/GRFT ANGIO S&I
R HRT CORONARY ARTERY ANGIO
R HRT ART/GRFT ANGIO
L HRT ARTERY/VENTRICLE ANGIO
L HRT ART/GRFT ANGIO
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
93460
93461
93462
93463
93464
93464
July 2011
No
No
No
Not Reimbursable
No
No
93503
93505
No
No
93530
Code Description
R&L HRT ART/VENTRICLE ANGIO
R&L HRT ART/VENTRICLE ANGIO
L HRT CATH TRNSPTL PUNCTURE
DRUG ADMIN & HEMODYNMIC MEAS
EXERCISE W/HEMODYNAMIC MEAS
EXERCISE W/HEMODYNAMIC MEAS
No
No
No
Not Reimbursable
No
No
No
No
No
INSRT & PLCMT FLO DIREC CATH-MONITR
ENDOMYOCARDIAL BX
RT HEART CATH-CONGEN CARD
ANOMALIES
93531
No
RT & RETRO LT HRT CATH-CONGEN ANOM
No
93532
No
RT-LT TRNSSEPT-INTACT-HRT CATH-CONG
No
93533
93561
93562
93563
93564
93565
93566
93567
93568
93571
No
No
No
No
No
No
No
No
No
No
RT-LT TRNSSEP-EXIST OP-HRT CTH-CONG
INDICA DIL STDY; W/CARD OUTPUT (SP)
INDICAT DILUT; SUBSQT CARD OUTPUT
INJECT CONGENITAL CARD CATH
INJECT HRT CONGNTL ART/GRFT
INJECT L VENTR/ATRIAL ANGIO
INJECT R VENTR/ATRIAL ANGIO
INJECT SUPRVLV AORTOGRAPHY
INJECT PULM ART HRT CATH
INTRAVASC DOPPLER DURING SCA; INIT
No
No
No
No
No
No
No
No
No
No
93572
No
No
93580
Yes
93581
93600
93602
93603
93609
93610
93612
93613
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
INTRAVASC DOPPLER DUR SCA; EA ADD
PERQ TRNSCATH CLO CONGN
INTERATRIAL CMNCT W/IMPL
PERQ TRNSCATH CLO CONGN VENT
SEPTAL DEFEC W/IMPL
BUNDLE HIS RECORDING
INTRA-ATRIAL RECORDING
RT VENTRICULAR RECORDING
INTRAVENT/-ATRIAL MAP TACHY SITE
INTRA-ATRIAL PACING
INTRAVENTRICULAR PACING
INTRACARD EP 3-D MAPPING
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
CPT Code
93615
July 2011
Yes
93616
93618
Yes
Yes
93619
Yes
Code Description
ESOPH RECORD ATRIAL ELECTROGM
ESOPH RECORD ATRIAL ELECGM;
W/PACNG
INDUCTION ARRHY BY ELEC PACING
COMP ELECTROPHYS EVAL; WO INDUC
ARR
93620
Yes
COMP ELECTROPHYS EVAL; W/INDUCT ARR
Yes
93621
Yes
COMP ELECTROPHYS; LT ATRIAL RECORD
Yes
93622
93623
93624
93631
Yes
Yes
Yes
Yes
COMP ELECTROPHYS; LT VENT RECORD
PROGRAM STIM & PACE AFTER IV DRUG
ELECTROPHYSIOL F/U W/INDUCT ARRHY
INTRA-OP PACING/MAP-SITE OF TACHY
Yes
Yes
Yes
Yes
93640
93641
Yes
Yes
EVAL CARDIOVERTER-DEFIB LEADS-INIT;
EVAL DEFIB LEADS-INIT; W/GEN TEST
Yes
Yes
93642
Yes
EVAL 1/2 CHAMBER CARDIOVERTER-DEFIB
Yes
93650
Yes
INTRACARD CATH ABLAT-AV NODE FUNCT
Yes
93651
Yes
INTRACARD CATH ABLAT ARRHY; TX TACH
Yes
93652
Yes
INTRACARD CATH ABLAT; TX VENT TACHY
Yes
93660
No
No
93662
Yes
EVAL CARDIOVASC FUNCT W/TILT TABLE
INTRACARDIAC ECHO DURING
THERAPEUTIC/DIAGNOST INTERVENTION
Yes
93668
93701
Not Reimbursable
Not Reimbursable
PERIPHERAL ARTERIAL DISEASE REHAB
BIOIMPEDANCE THORACIC ELECTRICAL
Not Reimbursable
Not Reimbursable
93720
No
PLETHYSMOG BODY; W/INTERPT & REPORT
No
93721
No
PLETHYSMOGRAPHY TOT BODY; TRACING
No
93722
No
PLETHYSMOG BODY; INTRPT & REPT ONLY
No
Yes
Yes
Yes
Yes
CPT Code
July 2011
93724
93740
No
93745
93750
93770
Code Description
No
Bundled
No
No
ELECT ANALY ANTITACHY PACEMAKR SYST
TEMP GRADIENT STUDIES
INIT SETUP&PROG BY PHYS WEARBLE
CARDIOVERT-DEFIB
INTERROGATION VAD, IN PERSON
DETERM VENOUS PRESS
93784
93786
No
No
AMB BP MONIT; RECORD-INTERPT-REPORT
AMB BP MONITOR; RECORDING ONLY
No
No
93788
No
AMB BP MONITOR; SCAN ANALY W/REPRT
No
93790
No
AMB BP MONITOR; REVW-INTERPT-REPRT
No
93797
Not Reimbursable
PHYS SERV-OUTPT CARD REHAB; WO ECG
Not Reimbursable
93798
No/Not covered for Basic Health Plan
PHYS SERV-OUTPT CARD REHAB; W/MONIT
NA
93799
Yes
UNLISTED CARDIOVASCULAR SERV/PROC
Yes
93875
93880
93882
No
No
No
NONINVASIV STDIES EXTRACRAN ART BIL
DUPLEX SCAN EXTRACRAN ART; BILAT
DUPLEX SCAN EXTRACRAN ART; UNI/LTD
No
No
No
93886
93888
No
No
No
No
93890
No
93892
No
93893
No
TRANSCRAN DOPPLER STDY ART; COMPLT
TRANSCRAN DOPPLER STDY ART; LTD
TRANSCRANIL DOPPLR INTRACRAN
ART;VASOREACTV STDY
TRANSCRANIL DOPPLR; EMBOLI NO IV
MICROBUBBLE INJ
TRANSCRANIL DOPPLR; EMBOLI W/IV
MICROBUBBLE INJ
93922
No
NONINVASV STDY-UP/LO EXTM ART 1 LEV
No
93923
No
NONINVAS STDY-UP/LO EXTM ART MX LEV
No
93924
No
NONINVASIV PHYSIOL STDY-LO EXTM ART
No
No
No
Bundled
No
No
No
CPT Code
July 2011
93925
93926
No
No
93930
93931
93965
93970
93971
No
No
No
No
No
Code Description
DUPLEX SCAN LOWR EXTREM ART;
COMPLT
DUPLEX SCAN LOWR EXT ART; UNI/LTD
DUPLEX SCAN UPPR EXTREM ART;
COMPLT
DUPLEX SCAN UPPR EXT ART; UNI/LTD
NON-INVAS STDY EXTREM VEIN; BILAT
DUPLEX SCAN-EXTREM VEINS; COMPLT
DUPLEX SCAN-EXTREM VEINS; UNI/LTD
93975
No
DUPLEX SCAN FLO ABD ORGANS; COMPLT
No
93976
93978
93979
No
No
No
DUPLEX SCAN FLO ABD/PEL ORGANS; LTD
DUPLEX SCAN AORTA/GFTS; COMPLT
DUPLEX SCAN AORTA/IVC/GFTS; UNI/LTD
No
No
No
93980
No
DUPLEX SCAN PENILE VESSELS; COMPLT
No
93981
93982
93990
94002
94003
94004
94005
No
No
No
No
No
No
Not Reimbursable
DUPLEX SCAN PENILE VESSELS; F/U-LTD
ANEURYSM PRESSURE SENS STUDY
DUPLEX SCAN HEMODIALYSIS ACCESS
VENT MGMT INPAT, INIT DAY
VENT MGMT INPAT, SUBQ DAY
VENT MGMT NF PER DAY
HOME VENT MGMT SUPERVISION
No
No
No
No
No
No
Not Reimbursable
94010
94011
94012
94013
94014
No
No
No
No
No
SPIROMTRY W/RECRD-VC-EXPIR FLO RATE
UP TO 2 YRS OLD, SPIROMETRY
= 2 YRS, SPIROMTRY W/DILATOR
= 2 YRS, LUNG VOLUMES
PT INIT SPIROM/30 DA; INCL ANAL-1&R
No
No
No
No
No
94015
94016
No
No
No
No
94060
No
94070
94150
No
PT INIT SPIROM RECRD/30 DA; RECRDNG
PT INIT SPIROM RECRD/30 DA; 1&R
BRONCHODILAT RESPN PRE&POST
BRONCHODILAT ADMIN
BRONCHOSPASM EVAL MX SPIROMETRC
DETRM W/AGTS
VITAL CAPACITY TOT (SEPART PROC)
No
No
No
No
No
No
No
No
No
Bundled
CPT Code
July 2011
94200
94240
No
No
MAX BREATH CAPACITY MAX VOLUN VENT
FUNCT RESIDUAL CAPACITY/VOLUM
No
No
94250
94260
No
No
EXPIRED GAS COLLEC QUAN 1 (SEP PRO)
THORACIC GAS VOLUM
No
No
94350
94360
94370
94375
94400
94450
No
No
No
No
No
No
No
No
No
No
No
No
94452
Not Reimbursable
94453
94610
94620
94621
Not Reimbursable
Prof Not Reim/OPPS Paid w NO PA
No
No
DETERM MALDISTRIBUTION INSPIRED GAS
DETERM RESIST AIRFLO-OSCILLATORY
DETERM AIRWAY CLO VOLUM 1 BREATH
RESPIRATORY FLOW VOLUM LOOP
BREATHING RESPONSE TO CO2
BREATHING RESPONSE TO HYPOXIA
HAST WITH PHYSICIAN
INTERPRETATION&REPORT;
HAST W/PHYS INTERP&RPT; W/SUPLMNTL
O2 TITRATION
SURFACTANT ADMIN THRU TUBE
PULM STRESS TESTING; SIMPL
PULM STRESS TEST; COMPLEX
94640
No
NONPRESS INHALA TX ACUTE AIRWAY OBS
No
94642
94644
94645
94660
94662
No
No
No
AEROSOL INHALA PENTAMIDINE PC PNEUM
CBT, 1ST HOUR
CBT, EACH ADDL HOUR
CPAP VENTILAT INIT & MGMT
CNP VENTILAT INIT & MGMT
No
Not Reimbursable
Not Reimbursable
No
No
94664
94667
94668
94680
No
No
No
No
AEROSOL/VAPOR INHALA; 1ST DEMO/EVAL
MANIP CHEST WALL; 1ST DEMO/EVAL
MANIP CHEST WALL; SUBSQT
O2 UPTAKE EXPIRED GAS; DIREC SIMPL
No
No
No
No
94681
94690
No
No
No
No
94720
94725
No
No
O2 UPTAKE EXPIRED GAS; W/CO2 OUTPUT
O2 UPTAKE EXPIRED GAS; REST (SEP)
CO MONOXD DIFFUS CAPACITY ANY
METHD
MEMBRN DIFFUS CAPACITY
Code Description
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
No
No
CPT Code
94750
July 2011
No
94760
NONINVAS OXIMETRY-O2 SAT; 1 DETERM
Bundled
94761
94762
94770
No
No
NONINVAS OXIMETRY-O2 SAT; MX DETERM
NONINVAS OXIMETRY; OVERNITE (SEP)
CO2 EXPIRED GAS DETERM-INFRARED
Bundled
No
No
94772
94774
94775
94776
94777
94799
95004
95010
95012
No
No
No
No
No
Yes
No
No
Not Reimbursable
95015
No
INTRACUT SEQUENT/INCREM-SPEC # TEST
No
95024
95027
95028
95044
95052
95056
95060
95065
No
No
No
No
No
No
No
No
INTRACUT W/ALLERG EXTRCT-SPEC # TES
SKIN END POINT TITRATION
INTRACUT W/ALLERG DELAYED-# TESTS
PATCH/APPLIC TEST(S)
PHOTO PATCH TEST(S)
PHOTO TESTS
OPHTH MUCOS MEMBRN TESTS
DIRECT NASAL MUCOS MEMBRN TEST
No
No
No
No
No
No
No
No
95070
No
INHALA BRONCH CHALLENG; W/HISTAMINE
No
95071
95075
95115
95117
95120
95125
95130
95131
No
No
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
INHALA BRONCHIAL CHALLENGE; W/ANTIG
INGESTION CHALLENGE TEST
PROF IMMUNOTX WO EXTRCT; 1 INJ
PROF IMMUNOTX WO EXTRACT; 2/> INJ
PROF IMMUNOTX INCL EXTRACT; 1 INJ
PROF IMMUNOTX INCL EXTRACT; 2/> INJ
PROF IMMUNOTX W/EXTRACT; 1 INSECT
PROF IMMUNOTX W/EXTRACT; 2 INSECT
No
No
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Code Description
PULM COMPLIANCE STUDY ANY METHD
CIRCADN RESP PATTRN 12-24 HR-INFANT
PED HOME APNEA REC, COMPL
PED HOME APNEA REC, HK-UP
PED HOME APNEA REC, DOWNLD
PED HOME APNEA REC, REPORT
UNLISTED PULM SERV/PROC
PERQ W/ALLERG EXTRACT-SPEC # TEST
PERQ SEQUENT/INCREM-SPEC # TEST
EXHALED NITRIC OXIDE MEAS
No
No
No
No
No
No
Yes
No
No
Not Reimbursable
CPT Code
95132
95133
95134
95144
95145
95146
95147
95148
95149
95165
July 2011
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
No
No
No
No
No
95170
95180
95199
No
No
Yes
95250
Not Reimbursable
95251
95800
95801
95803
No
Not Reimbursable
Not Reimbursable
Non Reimbursible
95805
Yes
95806
Not Reimbursable
95807
Yes
95808
Yes
95810
95811
95812
95813
95816
95819
95822
95824
Code Description
PROF IMMUNOTX W/EXTRCT; 3 INSECT
PRO SERV-IMMUNTX; 1/MX ANTIG 1 VIAL
PRO-SUPERVS/PROVIS; 1 VENOM
PRO-SUPERVS/PROVIS; 2 VENOMS
PRO SERV-IMMUNOTX; 1/MX ANTIG
PRO-IMMUNOTX;WHOLE BOD EXTRCTINSEC
RAPID DESENZT PROC EA HR
UNLIST ALLERG/CLINIC IMMUNOL SERV
GLU MON TO 72 HR CONT RECORD&STOR
GLUC MNTR CONT REC FROM NTRSTL TISS
FLU PHYS I&R
SLP STDY UNATTENDED
SLP STDY UNATND W/ANAL
ACTIGRAPHY TESTING
MX SLEEP LATENCY-MX TRIAL-SLEEPINES
SLEEP STUDY RESP-ECG-02 UNATTENDED
TECH
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
No
No
No
No
No
No
No
Yes
Not Reimbursable
No
Not Reimbursable
Not Reimbursable
Non Reimbursible
Yes
Not Reimbursable
Yes
Yes
SLEEP STUDY RESP-ECG-O2-ATTEND TECH
POLYSOMNOGRAPHY; W/1-3 ADD
PARAMETR
POLYSOMNOGRAPHY; W/4-MORE ADD
PARAM
Yes
No
No
No
No
No
No
POLYSOMNOG; W/4/> ADD PARAM W/CPAP
EEG EXTEND MONITOR; UP TO 1 HR
EEG EXTEND MONITOR; >1 HR
EEG AWAKE & DROWSY
EEG AWAKE & ASLEEP
EEG; SLEEP ONLY
EEG; CEREBRAL DEATH EVAL ONLY
Yes
No
No
No
No
No
Yes
Yes
Yes
CPT Code
95827
July 2011
No
95829
No
ELECTROCORTICOGM AT SURG (SEP PRO)
No
95830
95831
No
No
INSRT-PHYS SPHENOIDAL ELECTROD-EEG
MUSC TEST (SEP PROC); EXTREM/TRNK
No
No
95832
No
MUSC TEST MAN (SEP PRO) W/RPT; HAND
No
95833
No
MUSC TEST (SEP PROC) W/RPT; TOT BOD
No
95834
No
MUSC TEST (SEP PRO); TOT BOD W/HAND
No
95851
No
ROM REPRT (SP);EA EXTREM/TRUNK SEC
No
95852
95857
No
No
ROM-REPORT (SP); HAND W/WO COMPAR
TENSILON TEST MYASTHENIA GRAVIS
No
No
95860
No
NEEDLE EMG; 1 EXTREM W/WO PARASPIN
No
95861
No
No
95863
No
No
95864
95865
95866
No
No
No
NEEDLE EMG; 4 EXTREME W/WO PARASPIN
NDL EMG LARX
NDL EMG HEMIDPHRM
No
No
No
95867
No
NEEDLE EMG CRAN NERV-MUSCL; UNILAT
No
95868
No
NEEDLE EMG CRAN NERV-MUSCL; BILAT
No
95869
No
NEEDLE EMG; THORACIC PARASPIN MUSC
No
95870
No
No
95872
95873
No
No
NEEDL EMG; LTD-1 MUS EXTREM/NON-LIM
NEEDLE EMG W/QUAN MEAS EA MUSC
STDY
ESTIM GDN CONJUNCT CHEMODNRVTJ
Code Description
EEG; ALL NIGHT SLEEP ONLY
No
No
No
CPT Code
July 2011
95874
No
NDL EMG GDN CONJUNCT CHEMODNRVTJ
No
95875
No
ISCHEM LIMB EXER W/NEEDLE EMG-LACTC
No
95900
No
NRV CONDUC STDY EA ; MOTOR WO F-WAV
No
95903
No
NRV CONDUC STDY EA ; MOTOR W/F-WAVE
No
95904
95905
No
Non Reimbursible
NERVE CONDUC STUDY EA NRV; SENSORY
MOTOR/SENS NRVE CONDUCT TEST
No
Non Reimbursible
95920
No
INTRAOPER NEUROPHYSIOL TEST PER HR
No
95921
No
AUTO NERV SYS FUNC TEST; CARDIOVAGL
No
95922
No
AUTO NERV SYS FUNC TEST; VASOMOTOR
No
95923
No
AUTO NERV SYS FUNC TEST; SUDOMOTOR
No
95925
No
SOMATOSENS STUDY 1/ > NERV; UP LIMB
No
95926
No
SOMATOSEN STUDY 1/> NERV; LOW LIMBS
No
95927
No
No
95928
No
95929
No
SOMATOSEN STUDY 1/> NERV; TRNK/HEAD
CENTRAL MOTOR EVOKED POTENTIAL
STUDY; UPR LIMBS
CENTRAL MOTOR EVOKED POTENTIAL
STUDY; LWER LIMBS
95930
No
VEP TESTING CNS-CHECKERBOARD/FLASH
No
95933
No
ORBICULARIS OCULI REFLEX BY ELEC-DX
No
95934
No
H-REFLEX AMP STUDY; GASTNEM/SOLEUS
No
95936
No
H-REFLEX STUDY; NOT GASTNEM/SOLEUS
No
95937
No
NEUROMUSCL JUNCT TST EA NERV 1 METH
No
Code Description
No
No
CPT Code
July 2011
95950
95951
Yes
Yes
MONITOR-CEREBRAL SEIZ-EEG EA 24 HR
MONITOR CEREBRAL SEIZ-CABLE/RADIO
No
No
95953
Yes
No
95954
95955
95956
95957
Yes
Yes
Yes
Yes
MONITOR SEIZ FOC-PORT EEG; EA 24 HR
PHARM/PHYS ACTIV-MD ATTND-EEG
RECRD
EEG DURING NONINTRACRANIAL SURG
MONIT CEREB SEIZ-TELEMET EEG-24 HR
DIGITAL ANALY EEG
95958
95961
Yes
Yes
WADA ACTIVAT HEMISPHER FUNCT W/EEG
FUNCT CORTIC MAP; INIT HR MD ATTEND
No
No
95962
Yes
FUNC CORTIC MAP; EA AD HR MD ATTEND
No
95965
95966
95967
95970
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
95971
No
95972
No
95973
No
MEG REC&ANALY;BRAIN MAGNETIC ACTV
MEG REC&ANALY; EVOKED 1 MODALITY
MEG REC&ANALY; EA ADD MODALITY
ANALY NEUROSTIM; WO REPROGRM
ELEC ANALY NEUROSTIM; SMPL SP
CRD/PERIPH W/PROG
ELEC ANALY NEUROSTIM; CMPLX
SC/PERIPH PROG 1 HR
ELEC ANALY NEUROSTIM;CMPLX SC PROG
EA ADD 30 MIN
95974
Yes
ANAL NEUROSTIM; CRAN NERV W/PROG-1
No
95975
Yes
No
95978
No
95979
95980
95981
95982
No
No
No
No
95990
Yes
ANALY NEUROSTIM; CRAN NRV W/PROG-RX
ELEC ANALY NEUROSTIM CMPLX BRAIN
W/PROG; 1 HR
ELEC ANALY NEUROSTIM CMPLX BRAIN;EA
ADD 30 MIN
IO ANAL GAST N-STIM INIT
IO ANAL GAST N-STIM SUBSQ
IO GA N-STIM SUBSQ W/REPROG
REFIL&MNT IMPL PUMP/RESRVR DRUG DEL
SP/BRAIN;
Code Description
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
95991
95992
Yes
No
95999
Yes
96000
Not Reimbursable
COMP CMPT-BASD MOT ANALY VIDEO-TAP;
Not Reimbursable
96001
Not Reimbursable
COMP CMPT-BSD MOT ANALY; PLNTR PRSS
Not Reimbursable
96002
96003
Not Reimbursable
Not Reimbursable
DYN SURF EMG WLK/OTH ACTV 1-12 MUSC
DYN FINE WIRE EMG WALK/OTH 1 MUSC
Not Reimbursable
Not Reimbursable
96004
96020
96040
96101
Not Reimbursable
Not Reimbursable
Yes
Yes
PHYS REV COMP CMPT BASD MOT ANALY
FUNCTIONAL BRAIN MAPPING
GENETIC COUNSELING, 30 MIN
PSYCL TSTG PR HR F2F TIME W/PT
Not Reimbursable
Not Reimbursable
Yes
Yes
96102
Not Reimbursable
Not Reimbursable
96103
96105
96110
Not Reimbursable
Not Reimbursable
Reimbursable for Psychologist
96111
Reimbursable for Psychologist
96116
Yes
96118
Yes
96119
Yes
96120
96125
96150
96151
96152
Not Reimbursable
YES
Prof Not Reim/OPPS Paid w PA
PSYCL TSTG PR HR ADMN BY TECH PR HR
PSYCL TSTG PR HR ADMN BY CPTR
W/PROF I&R
ASSESS APHASIA W/I&R PER HR
DEVELOPMENTAL TESTING; LTD W/I&R
DEVELOPMENTAL TESTING; EXTENDED
W/INTERP&REPORT
NUBHVL STATUS XM PR HR F2F W/PT
INTERPJ&PREPJ
NUROPSYC TSTG PR HR F2F W/PT +
INTERPJ TIME
NUROPSYC TSTG WPROF I&R ADMN BY
TECH PR HR
NUROPSYC TSTG ADMN BY CPTR W/PROF
I&R
COGNITIVE TEST BY HC PRO
HLTH&BHV ASSESS 15 MIN W/PT; INIT
HLTH&BHV ASSESS 15 MIN; RE-ASSESS
HLTH&BHV INTRVN EA 15 MIN; IND
96153
HEALTH&BHV INTRVN EA 15 MIN; GROUP
Not Reimbursable
Code Description
REFIL&MNT IMPL PUMP/RESRVR RX DEL
SP/BRAIN;BY MD
CANALITH REPOSITIONING PROC
UNLIST NEUROLOGIC/NEUROMUSCL DX
PRO
No
No
Yes
Not Reimbursable
Not Reimbursable
Yes
Yes
Yes
Yes
Yes
Not Reimbursable
Yes
Not Reimbursable
Not Reimbursable
Not Reimbursable
CPT Code
96154
96155
96360
96361
96365
96366
96367
96368
96369
96370
96371
96372
96373
96374
96375
96376
96379
July 2011
Not Reimbursable
No
No
No
No
No
No
No
No
No
No
No
No
No
Non Reimbursible
No
96401
No
96402
96405
96406
No
No
No
96409
No
96411
No
96413
No
96415
No
96416
No
96417
96420
96422
96423
Code Description
HEALTH&BHV INTRVN EA 15 MIN; FAM
HEALTH&BHV INTRVN EA 15 MIN; FAM
HYDRATION IV INFUSION, INIT
HYDRATE IV INFUSION, ADD-ON
THER/PROPH/DIAG IV INF, INIT
THER/PROPH/DIAG IV INF ADDON
TX/PROPH/DG ADDL SEQ IV INF
THER/DIAG CONCURRENT INF
SC THER INFUSION, UP TO 1 HR
SC THER INFUSION, ADDL HR
SC THER INFUSION, RESET PUMP
THER/PROPH/DIAG INJ, SC/IM
THER/PROPH/DIAG INJ, IA
THER/PROPH/DIAG INJ, IV PUSH
TX/PRO/DX INJ NEW DRUG ADDON
TX/PRO/DX INJ NEW DRUG ADON
THER/PROP/DIAG INJ/INF PROC
CHEMOTX ADMN SUBQ/IM NON-HORMONAL
ANTI-NEO
CHEMOTX ADMN SUBQ/IM HORMONAL ANTINEO
CHEMOTX ADMIN INTRALES; TO & INCL 7
CHEMOTX ADMIN INTRALES; > 7 LES
CHEMOTX ADMN IV PUSH TQ 1/1ST
SBST/DRUG
CHEMOTX ADMN IV PUSH TQ EA
SBST/DRUG
CHEMOTX ADMN IV NFS TQ UP 1 HR 1/1ST
SBST/DRUG
Not Reimbursable
Not Reimbursable
No
No
No
No
No
No
No
No
No
No
No
No
No
Non Reimbursible
No
No
No
No
No
No
No
No
No
No
CHEMOTX ADMN IV NFS TQ EA HR 1 8 HR
CHEMOTX ADMN TQ INIT PROLNG
CHEMOTX NFUS PMP
CHEMOTX ADMN IV NFS TQ EA SEQL NFS
TO 1 HR
No
No
No
CHEMOTX ADMIN INTRA-ART; PUSH TECH
CHEMOTX INTRA-ART; INFUSION TO 1 HR
CHEMOTX INTRA-ART; 1-8 HR EA ADD HR
No
No
No
No
No
CPT Code
July 2011
96425
No
96440
96446
No
No
96450
96521
No
No
96522
No
96523
96542
96549
No
No
No
96567
96570
96571
96900
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
96902
96904
Not Reimbursable
96910
96912
96913
No
No
No
96920
Yes
96921
Yes
96922
96999
97001
97002
97003
97004
97005
97006
Yes
Yes
No - unless over 24 visits
Not Reimbursable
Not Reimbursable
Code Description
CHEMOTX INTRA-ART; PROLONGED
W/PUMP
CHEMOTX-PLEURAL CAVITYW/THORACENTE
CHEMOTX ADMN PRTL CAVITY
CHEMOTX-CNS-REQ & INCL LUMBAR
PUNCT
RFL/MAIN PORTABLE PMP
RFL/MAIN IMPLTABLE PMP/RSVR F/DRUG
DLVR SYSIC
IRRIGATION IMPLTED VAD F/DRUG DLVR
SYSS
CHEMOTX INJ SUBARACH-1/MX AGENTS
UNLISTED CHEMOTX PROC
PHOTODYN TX EXT APPL LGHT EA EXPOS
PHOTODYNAM THER-LIGHT; 1ST 30 MIN
PHOTODYNAM TX-LIGHT; EA ADD 15 MIN
ACTINOTHERAPY
MICRO EXAM HAIRS-TELOGEN-ANAGEN
CNT
WHOLE BODY PHOTOGRAPHY
PHOTOCHEMOTX; TAR-UV B/PETROL-UV B
PHOTOCHEMOTX; PSORALENS & UV A
PHOTOCHEMOTX 4-8 HR CARE BY PHYS
LASER TX INFLAM SKIN DZ; TOT AREA < 250
SQ CM
LASER TX INFLAMMATORY SKIN DZ; 250-500
SQ CM
LASER TX INFLAMMATORY SKIN DZ; OVER
500 SQ CM
UNLISTED SPECIAL DERM SERV/PROC
PHYS THERAP EVAL
PHYS THERAP RE-EVAL
OCCUPATIONAL THERAP EVAL
OCCUPATIONAL THERAP RE-EVAL
ATHLETIC TRAINING EVALUATION
ATHLETIC TRAINING RE-EVALUATION
No
No
No
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
Bundled
Not Reimbursable
No
No
No
No
No
No
Yes
Not Reimbursable
Not Reimbursable
CPT Code
July 2011
97010
Bundled
97012
97014
APPLIC MODAL 1/> AREAS; TRACTN-MECH
APPLIC MODAL 1/> AREAS; ELEC STIM
97016
APPLIC MODAL 1/> AREAS; VASPNEU DEV
97018
97022
97024
97026
APPLIC MODAL 1/> AREAS; PARAFN BATH
APPLIC MODAL 1/> AREAS; WHIRLPOOL
APPLIC MODAL 1/> AREAS; DIATHERMY
APPLIC MODAL 1/> AREAS; INFRARED
97028
97032
APPLIC MODAL 1/> AREAS; ULTRAVIOLET
APPLIC MODAL 1/> AREAS; ELEC STIM
97033
APPLIC MODAL 1/> AREAS; IONTOPHORES
97034
APPLIC MODAL 1/> AREAS; CNTRST BATH
97035
APPLIC MODAL 1/> AREAS; ULTRASOUND
97036
APPLIC MODAL 1/> AREAS; HUBBRD TANK
97039
97110
UNLIST MODAL (SPEC TYP/TIME-ATTEND)
THERAP 1/> AREAS/15 MIN; EXERCISES
97112
97113
97116
97124
97139
THERAP 1/> AREA/15 MIN; BALNC/COORD
THERAP 1/> AREAS/15 MIN; AQUATIC
THERAP 1/> AREAS/15 MIN; GAIT TRAIN
THERAP 1/> AREAS/15 MIN; MASSAGE
THERAP 1/> AREAS/15 MIN; UNLISTED
97140
97150
97530
97532
97533
97535
MAN THER TECH-1/> REGIONS-EA 15 MIN
THERAP PROC(S)-GROUP
THERAP ACTIVITIES 1-ON-1 EA 15 MIN
DEVELOPMENT OF COGNITIVE SKILLS
SENSORY INTEGRATIVE TECHNIQUES
SELF CARE TRAIN-1 ON 1-EA 15 MIN
Code Description
APPLIC MODAL 1/> AREAS; HOT/CLD PKS
Bundled
CPT Code
July 2011
97537
97542
97545
Not Reimbursable
97546
Not Reimbursable
97597
No
97598
No
97602
No
97605
Bundled Prof/OPPS Paid with No PA
97606
Bundled Prof/OPPS Paid with No PA
97750
97755
97760
97761
97762
97799
Yes
97802
97803
No
No
97804
No
97810
Code Description
COMMUNITY/WORK REINTEGRAT TRAIN-1
ON 1-EA 15 MIN
WHEELCHAIR MGMT TRAIN-EA 15 MIN
WORK HARDENING/CONDITION; INIT 2 HR
WORK HARDENING/CONDITION; EA ADD HR
REMV DEVITLZ TISS SELCTV DEBRID; </= 20
SQ CM
REMV DEVITLZ TISS SELCTV DEBRID; >20
SQ CM
REMV DEVITLZ TISS NONSELCTV DEBRID
W/O ANES SESS
NEG PRESS WND TX PER SESS; TOT SURF
</= 50 SQ CM
NEG PRESS WND TX PER SESS; TOT SURF
> 50 SQ CM
PHYS PERFMNCE TEST/MEASUR
W/REPORT
ASSTIV TECH ASSESS DIR 1:1 CNTC W/RPT
EA 15 MIN
ORTHOTIC MGMT&TRAINJ UXTR
LXTR&/TRNK EA 15 MIN
PROSTC TRAINJ UPR&/LXTR EA 15 MIN
CHECKOUT F/ORTHOTIC/PROSTC USE EST
PT EA 15 MIN
Not Reimbursable
Not Reimbursable
No
No
No
Bundled
Bundled
Yes
UNLISTED PHYS MEDS/REHAB SERV/PROC
MED NUTRI THERAPY, INITIAL
ASSESSMENT
MED NUTRI THERAPY, RE-ASSESSMENT
MED NUTRI THERAPY, GRP (2 OR MORE
INDIVID) 30 MIN EA
ACUPUNCT 1/> NDLES W/O E-STIM; INIT 15
MIN 1-1
Yes
97811
Yes
ACUP 1/> NDLS W/O ELEC STIMJ EA 15 MIN
Yes
97813
Yes
ACUP 1/> NDLS W/ELEC STIMJ 1ST 15 MIN
Yes
Yes
No
No
No
CPT Code
July 2011
97814
Yes
Code Description
ACUPUNCT 1/> NDLES WITH E-STIM;EA ADD
15 MIN 1-1
98925
No
OSTEOPATH MANIP TX; 1-2 BOD REGIONS
No
98926
No
No
98927
No
No
98928
No
No
98929
98940
98941
98942
98943
No
Yes
Yes
Yes
Not Reimbursable
No
Yes
Yes
Yes
Not Reimbursable
98960
Not Reimbursable
98961
Not Reimbursable
98962
98966
98967
98968
98969
99000
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Bundled
OSTEOPATH MANIP TX; 9-10 BOD REGION
CHIRO MANIP TX; SPINAL 1-2 REGIONS
CHIRO MANIP TX; SPINAL 3-4 REGIONS
CHIRO MANIP TX; SPINAL 5 REGIONS
CHIRO MANIP TX; EXTRASPIN 1/> AREAS
EDUCAJ&TRAINJ F/PT SELF-MGMT BY
NONPHYS 1 PT
NONPHYS 2-4 PT
NONPHYS 5-8 PTS
HC PRO PHONE CALL 5-10 MIN
ONLINE SERVICE BY HC PRO
HANDL/CONVEY SPECMN-OFFIC TO LAB
99001
Bundled
HANDL/CONVEY SPECMN-FRON PT TO LAB
Bundled
99002
Bundled
Bundled
99024
Bundled
99026
Not Reimbursable
99027
Not Reimbursable
99050
No
HANDL/CONVEY/OTHER SERV W/DEVICES
POSTOP F/U VST E&M DUR POSTOP PRD
REL ORIG PROC
HOSP MANDATED CALL SERVICE; IN-HOSP
EA HOUR
HOSP MANDATED CALL SERVICE; OUT-OFHOSP EA HOUR
SRVC REQUEST AFTER POSTED OFFICE HR
ADD BASIC
Yes
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Bundled
Bundled
Not Reimbursable
Not Reimbursable
No
CPT Code
July 2011
99051
Bundled
99053
No
SVC PRV BTW 10 PM&8 AM AT 24-HR FAC
No
99056
99058
Bundled
Bundled
Bundled
Bundled
99060
99070
99071
99075
99078
Bundled
Bundled
Bundled
No
No
SERV @ REQ OF PT @ LOCAT NOT OFFIC
OFFIC SERV PROVID-EMER BASIS
SVC PRV EMER OUT OFFICE DISRUPTS
OFFICE SVC
SUPPL/MAT PROVID-PHYS NOT W/VISIT
EDUCAT SUPPL @ COST TO PHYS
MED TESTIMONY
PHYS EDUCAT SERV RENDERED IN GRP
99080
99082
Bundled
No
Bundled
No
99090
Bundled
SPEC REPORT >INFO IN USUAL MED FORM
UNUSUAL TRAVEL
ANALYS INFORM DATA STOREDCOMPUTERS
99091
99100
Bundled
Bundled
CLCT&INTEPR PHYSIOLOGIC DATA 30 MIN
ANES PT EXTREM AGE <1 YR & OVER 70
Bundled
Bundled
99116
99135
99140
Bundled
Bundled
Bundled
Bundled
Bundled
Bundled
99143
Bundled
ANES COMPLIC BY UTILIZ BODY HYPOTHE
ANES COMPLIC BY UTILIZ HYPOTENSION
ANES COMPLIC BY EMER CONDITIONS
M-SEDATJ BY SM PHYS PERFRMG SVC <5
YR
99144
Bundled
Bundled
99145
Bundled
99148
Bundled
99149
Bundled
99150
Bundled
M-SEDAJ BY SM PHYS PERFRMG SVC 5+ YR
M-SEDAJ BY SM PHYS PERFRMG SVC EA 15
MIN
M-SEDAJ BY PHYS OTH/THN HC PROF
PERFRMG <5 YR
M-SEDAJ BY PHYS OTH/THN HC PROF
PERFRMG 5+ YRS
M-SEDAJ PHYS OTH/THN HC PROF
PERFRMG EA 15 MIN
99170
No
ANOGENITAL EXAM W/COLPOSCOP-CHILD
No
Code Description
SVC PRV OFFICE REG SCHEDD EVN
WKEND/HOLIDAY HRS
Bundled
Bundled
Bundled
Bundled
No
No
Bundled
Bundled
Bundled
Bundled
Bundled
Bundled
CPT Code
July 2011
99172
99173
99174
99175
Not Reimbursable
Bundled
Yes
No
Code Description
VISUAL FUNCT SCREENING,
AUTOMAT/SEMI BILAT QUANITATIVE
SCREEN TEST VISUAL ACUITY-QUAN-BIL
OCULAR PHOTOSCREENING
IPECAC ADMIN FOR EMESIS & OBSRV
99183
99190
99191
Yes
No
No
PHYS ATTEND/SUPERVS HYPERBARIC O2
ASSEMBLY & OPERAT-PUMP; EA HR
ASSEMBLY & OPERAT-PUMP; 3/4 HR
No
No
No
99192
99195
99199
99201
No
No
Not Reimbursable
No
ASSEMBLY &/OR PUMP W/OXYGENATOR
PHLEBOTOMY THERAP (SEPART PROC)
UNLISTED SPECIAL SERV/PROC/RPT
OFFIC/OUTPT E&M NEW MINOR 10MIN
No
No
Not Reimbursable
No
99202
No
OFFIC/OUTPT E&M NEW LOW-MOD 20MIN
No
99203
99204
99205
99211
99212
No
No
No
No
No
OFFIC/OUTPT E&M NEW MOD SEVER 30MIN
OFFIC/OUTPT E&M NEW MOD-HI 45 MIN
OFFIC/OUTPT E&M NEW MOD-HI 60 MIN
OFFIC/OUTPT E&M ESTAB 5 MIN
OFFIC/OUTPT E&M ESTAB MINOR 10MIN
No
No
No
No
No
99213
No
OFFIC/OUTPT E&M ESTAB LOW-MOD 15MIN
No
99214
No
OFFIC/OUTPT E&M ESTAB MOD-HI 25 MIN
No
99215
99217
No
No
OFFIC/OUTPT E&M ESTAB MOD-HI 40 MIN
OBSRV CARE D/C DA MGMT
No
No
99218
No
INIT OBSRV CARE-DA E&M LOW SEVERITY
No
99219
99220
No
No
INIT OBSRV CARE-DA E&M MOD SEVERITY
INIT OBSRV CARE-DA E&M HI SEVERITY
No
No
99221
No
INIT HOSP-DA E&M LOW SEVERITY 30MIN
No
99222
99223
No
No
INIT HOSP-DA E&M MOD SEVERITY 50MIN
INIT HOSP-DA E&M HI SEVERITY 70 MIN
No
No
Not Reimbursable
Bundled
Yes
No
CPT Code
99224
99225
99226
99231
July 2011
No
No
No
No
99232
No
SUBSQT HOSP-DA E&M MINR COMPL 25MIN
No
99233
No
SUBSQT HOSP-DA E&M SIG COMPL 35 MIN
No
99234
No
OBSRV/INPT HOSP CARE E&M LOW SEVER
No
99235
No
OBSRV/INPT HOSP CARE E&M MOD SEVER
No
99236
99238
No
No
OBSRV/INPT HOSP CARE E&M HIGH SEVER
HOSP D/C DA MGMT; 30 MIN/LESS
No
No
99239
99241
No
No
HOSP D/C DA MGMT; MORE THAN 30 MIN
OFFIC CONS NEW/ESTAB MINOR 15 MIN
No
No
99242
99243
99244
99245
99251
99252
99253
99254
99255
99281
No
No
No
No
No
No
No
No
No
No
OFFICE CONS NEW/EST LO SEVER 30 MIN
OFFIC CONS NEW/ESTAB MOD 40 MIN
OFFIC CONS NEW/ESTAB MOD-HI 60 MIN
OFFIC CONS NEW/ESTAB MOD-HI 80 MIN
INIT INPT CONS NEW/ESTAB MINR 20MIN
INIT INPT CONS NEW/ESTAB LOW 40MIN
INIT INPT CONS NEW/ESTAB MOD 55MIN
INIT INPT CONS NEW/EST MOD-HI 80MIN
INIT INPT CONS N/E MOD-HI 110MIN
EMER VISIT E&M SELF LIMITED/MINOR
No
No
No
No
No
No
No
No
No
No
99282
No
EMER VISIT E&M LOW-MODERAT SEVERITY
No
99283
No
EMER DEPT VISIT E&M MODERATE SEVER
No
99284
99285
99288
99291
99292
No
No
Not Reimbursable
No
No
EMER VISIT E&M HI SEVER URGENT EVAL
ER E&M-HIGH SEVERITY SIGNIF THREAT
PHYS DIRECT EMS/EMER CARE/ALS
CRITICAL CARE E&M; 1ST 30-74 MIN
CRITICAL CARE E&M; EA ADD 30 MIN
No
No
Not Reimbursable
No
No
Code Description
SUBSEQUENT OBSERVATION CARE
SUBSQT HOSP-DA E&M STABLE 15 MIN
No
No
No
No
CPT Code
99304
99305
99306
99307
July 2011
No
No
No
No
99308
No
SBSQ NF CARE PR D E/M MINOR COMPLCTJ
No
99309
No
No
99310
99315
99316
99324
No
No
No
No
SBSQ NF CARE PR D E/M NEW PROBLEM
SBSQ NF CARE PR D E/M UNSTABLE/NEW
PROBLEM
NURS FACIL D/C DA MGMT; 30 MIN/LESS
NURS FACIL D/C DA MGMT; > 30 MIN
DOM/R-HOME LW SEVERITY
99325
No
No
99326
99327
No
No
99328
No
99334
No
99335
No
99336
No
99337
No
99339
No
99340
No
DOM/R-HOME E/M NEW PT MOD SEVERITY
DOM/R-HOME E/M NEW PT MOD HI
SEVERITY
DOM/R-HOME E/M NEW PT HI SEVERITY
DOM/R-HOME E/M NEW PT SIGNIFICANT
NEW PROBLEM
DOM/R-HOME E/M EST PT SELFLMTD/MINOR
DOM/R-HOME E/M EST PT LW MOD
SEVERITY
DOM/R-HOME E/M EST PT MOD HI
SEVERITY
DOM/R-HOME E/M EST PT SIGNIFICANT
NEW PROBLEM
INDIV PHYS SUPVJ HOME/DOM/R-HOME MO
15-29 MIN
INDIV PHYS SUPVJ HOME/DOM/R-HOME MO
30 MIN/>
99341
No
HOME VISIT E&M NEW PT LO SEV-20 MIN
No
99342
99343
99344
No
No
No
HOME VISIT E&M NEW PT MOD SEV-30 MN
HOME VISIT E&M NEW PT MOD-HI-45 MIN
HOME VISIT E&M NEW PT HI SEV-60 MIN
No
No
No
Code Description
1ST NF CARE PR D E/M LW SEVERITY
1ST NF CARE PR D E/M MOD SEVERITY
1ST NF CARE PR D E/M HI SEVERITY
SBSQ NF CARE PR D E/M STABLE
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
99345
99347
No
No
HOME VISIT E&M NEW PT UNSTBL-75 MIN
HOME VISIT E&M ESTAB MINOR-15 MIN
No
No
99348
99349
99350
No
No
No
HOME VISIT E&M ESTAB LOW-MOD 25 MIN
HOME VISIT E&M ESTAB MOD-HI 40 MIN
HOME VISIT E&M ESTAB MOD-HI 60 MIN
No
No
No
99354
No
PROLONG MD SERV OUTPT W/PT; 1ST HR
No
99355
No
PROLONG MD SERV OUTPT W/PT; EA 30MN
No
99356
No
PROLONG PHYS SERV INPT W/PT; 1ST HR
No
99357
99358
No
No - Reimbursed FOR WMIP ONLY
PROLONG MD SERV INPT W/PT; ADD 30MN
PROLONG E/M WO PT CONTACT; 1ST HR
No
99359
PROLONG E/M WO PT CONTCT; ADD 30MIN
99360
99363
99364
99366
99367
99368
No
No
No
Not Reim Prof/Bundled OPPS
No
Not Reim Prof/Bundled OPPS
PHYS STANDBY W/PROLONG ATTEND EA 30
ANTICOAG MGMT, INIT
ANTICOAG MGMT, SUBSEQ
TEAM CONF W/PAT BY HC PRO
TEAM CONF W/O PAT BY PHYS
TEAM CONF W/O PAT BY HC PRO
No
No
No
Not Reimbursable
No
Not Reimbursable
99374
Bundled
PHYS SUPERVS PT-HOME HLTH; 15-29 MN
Bundled
99375
99377
99378
No
Bundled
No
PHYS SUPERVS PT-HOME HLTH; 30/> MIN
PHYS SUPERVS HOSPICE PT; 15-29 MIN
PHYS SUPERVS HOSPICE PT; 30 MIN/>
No
Bundled
No
99379
99380
Bundled
No
PHYS SUPERVS NURS FAC PT; 15-29 MIN
PHYS SUPERVS NURS FAC PT; 30 MIN/>
Bundled
No
99381
No
INIT PREVEN MEDS E&M NEW PT; INFANT
No
99382
99383
No
No
INIT PREVEN MEDS E&M NEW PT; 1-4 YR
INIT PREVEN MEDS E&M NEW PT; 5-11
No
No
Code Description
CPT Code
99384
99385
99386
99387
July 2011
No
No
No
No
99391
99392
99393
No
No
No
PREVEN MEDS E&M ESTAB PT; INFANT <1
PREVEN MEDS E&M ESTAB PT; 1-4 YR
No
No
No
99394
No
No
99395
No
No
99396
99397
No
No
PREVEN MEDS E&M ESTAB PT; 65/> YR
No
No
99401
No
PREVEN MED COUNSL (SEP PRO); 15 MIN
No
99402
Not Reimbursable
Not Reimbursable
99403
Not Reimbursable
Not Reimbursable
99404
99406
99407
99408
99409
Not Reimbursable
No
No
Not Reimbursable
Not Reimbursable
BEHAV CHNG SMOKING 3-10 MIN
BEHAV CHNG SMOKING < 10 MIN
AUDIT/DAST, 15-30 MIN
AUDIT/DAST, OVER 30 MIN
Not Reimbursable
No
No
Not Reimbursable
Not Reimbursable
99411
Not Reimbursable
PREVEN MED COUNSL GRP (SEP PRO); 30
Not Reimbursable
99412
99420
99429
99441
99442
99443
99444
99450
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
No
Not Reimbursable
Not Reimbursable
PREVEN MED COUNSL GRP (SEP PRO); 60
ADMIN/INTRPT HEALTH RISK ASSESS
UNLISTED PREVEN MEDS SERV
PHONE E/M BY PHYS 5-10 MIN
ONLINE E/M BY PHYS
BASIC LIFE &/OR DISABILITY EXAM
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
No
Not Reimbursable
Not Reimbursable
Code Description
INIT PREVEN MEDS E&M NEW
PT; 12-17
PT; 18-39
PT; 40-64
PT; 65/>
No
No
No
No
CPT Code
July 2011
99455
Not Reimbursable
99456
99460
99461
99462
99463
99464
99465
99466
99467
99468
99469
99471
99472
99475
99476
99477
99478
99479
99480
99499
Not Reimbursable
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
99499-HE is No PA, otherwise Yes
99500
Not Reimbursable
99501
Not Reimbursable
99502
Code Description
WORK RELAT/DISABL EXAM-TREATING MD
WORK RELAT/DISABL EXAM-NOT TRTNG
MD
INIT NB EM PER DAY, HOSP
INIT NB EM PER DAY, NON-FAC
SBSQ NB EM PER DAY, HOSP
SAME DAY NB DISCHARGE
ATTENDANCE AT DELIVERY
NB RESUSCITATION
PED CRIT CARE TRANSPORT
PED CRIT CARE TRANSPORT ADDL
NEONATE CRIT CARE, INITIAL
NEONATE CRIT CARE, SUBSQ
PED CRITICAL CARE, INITIAL
PED CRITICAL CARE, SUBSQ
PED CRIT CARE AGE 2-5, INIT
PED CRIT CARE AGE 2-5, SUBSQ
INIT DAY HOSP NEONATE CARE
IC, LBW INF < 1500 GM SUBSQ
IC LBW INF 1500-2500 G SUBSQ
IC INF PBW 2501-5000 G SUBSQ
UNLISTED EVAL & MGMT SERV
ER 15-20 MIN EG MED REFILLS LACERATION
NO SUTURES
Not Reimbursable
Not Reimbursable
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
99499-HE is No PA, otherwise Yes
Not Reimbursable
Not Reimbursable
Not Reimbursable
HOME VISIT POSTNATL ASSESS&F/U CARE
HOME VISIT NEWBORN
CARE&ASSESSMENT
99503
99504
Not Reimbursable
Not Reimbursable
HOME VISIT RESPIRATORY THERAPY CARE
HOME VISIT PTS RECEIVING MECH VENT
Not Reimbursable
Not Reimbursable
99505
Not Reimbursable
HOME VISIT STOMA CARE&MAINTENANCE
Not Reimbursable
99506
99507
Not Reimbursable
Not Reimbursable
HOME VISIT INTRAMUSCULAR INJECTIONS
HOME VISIT CARE&MAINT CATHETER
Not Reimbursable
Not Reimbursable
99509
Not Reimbursable
HOME VST ASST W/DAILY LIV&PERS CARE
Not Reimbursable
Not Reimbursable
CPT Code
July 2011
99510
Not Reimbursable
99511
99512
Not Reimbursable
Not Reimbursable
99600
Not Reimbursable
99601
Not Reimbursable
99602
99605
99606
99607
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
0019T
Not Reimbursable
0030T
Not Reimbursable
0042T
Not Reimbursable
0048T
Not Reimbursable
0050T
Not Reimbursable
0051T
Yes
0052T
Not Reimbursable
0053T
0054T
Yes
Non Reimbursible
0054T
0055T
Not Reimbursable
Non Reimbursible
0055T
0058T
0059T
Not Reimbursable
Not Reimbursable
Not Reimbursable
Code Description
HOME VISIT FOR INDIVIDUAL, FAMILY OR
MARRIAGE COUNSELING
HOME VISIT FOR FECAL IMPACTION
MANAGEMENT AND ENEMA ADMIN
HOME VISIT FOR HEMODIALYSIS
UNLISTED HOME VISIT SERVICE OR
PROCEDURE
HOME INFUSION/SPECIALTY DRUG ADMIN
PER VISIT
HOME INFUS/SPEC DRUG ADMIN PER VISIT;
EA ADD HR
MTMS BY PHARM, NP, 15 MIN
MTMS BY PHARM, EST, 15 MIN
MTMS BY PHARM, ADDL 15 MIN
XTRACORP SHOCK WAVE TX; INVLV
MUSCU
ANTIPROTHROMBIN ANTIBODY EACH IG
CLASS
CERBRL PERFUS ANALY CT W/CONTRST
W/PARAMETRC MAP
IMPL VAD XTRACORP PERQ TRANSSEPTAL
1/2 CANNULAT
REMV VAD XTRACORP PERQ TRNSSEPTL
ACSS 1/2 CANNUL
IMPL TOTAL REPL HEART SYS W/RECIPIENT
CARDIECT
REPL/REPR THORACIC UNIT TOTAL REPL
HEART SYSTEM
REPL/REPR IMPL CMPNT TOT REPL HEART
SYS NOT THOR
BONE SURGERY USING COMPUTER
CMPT ASST MS SURG NAVIGATNL ORTHO
PROC W/FLUORO
BONE SURGERY USING COMPUTER
CMPT-ASST MS SURG NAVIGATNL ORTHO
PROC W/CT&MRI
CRYOPRESERVATION, OVARY TISS
CRYOPRESERVATION, OOCYTE
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Yes
Not Reimbursable
Yes
Non Reimbursible
Not Reimbursable
Non Reimbursible
Not Reimbursable
Not Reimbursable
Not Reimbursable
CPT Code
July 2011
0071T
Not Reimbursable
0072T
Not Reimbursable
0073T
Not Reimbursable
0075T
Yes
0076T
Yes
0078T
Yes
0079T
Yes
0080T
Yes
0081T
0123T
Yes
Yes
0124T
Yes
Code Description
FOC US ABLAT UTERN LEIOMYOMA;TOT
VOL<200 CC TISS
FOC US ABLAT UTRN LEIOMYOMATA;
TOT>/=200 CC TISS
COMP-BASD BEAM MODULATD TX DEL TX
3/> FIELDS-TX
TRNSCATH PLCMT VERT/CAROTID ART
STENT PREQ;1 VES
TRNSCATH PLCMT VERT/CAROTID ART
STNT PREQ;EA ADD
ENDOVASC REPR AAA FENESTRATED
PROS 2 DOCK LIMBS
PLCMT VISCERAL EXTENSION PROSTH EA
VISCERAL BR
ENDOVSC REP AAA FNSTRATD PROS 2
DOCK LMB RAD S&I
PLCMT VISCERAL EXT PROS EA VISCERAL
BR RAD S&I
FSTLJ SCL GLC THRU CILIARY BDY
CJNCL INC W/PST JUXTASCLL PLMT RX
AGT
0126T
0141T
0142T
0143T
0163T
0164T
0165T
0166T
0167T
0168T
0169T
0171T
0172T
0173T
0174T
0175T
0183T
Yes
Yes
Yes
Yes
Not Reimbursable
Not Reimbursable
Not Reimbursable
Yes
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Bundled
Not Reimbursable
Not Reimbursable
Not Reimbursable
COMMON CRTD IMT RISK FACTOR ASSMT
PERQ ISLET TRANSPLANT
OPEN ISLET TRANSPLANT
LAPAROSCOPIC ISLET TRANSPLNT
LUMB ARTIF DISKECTOMY ADDL
REMOVE LUMB ARTIF DISC ADDL
REVISE LUMB ARTIF DISC ADDL
TCATH VSD CLOSE W/O BYPASS
TCATH VSD CLOSE W BYPASS
RHINOPHOTOTX LIGHT APP BILAT
PLACE STEREO CATH BRAIN
LUMBAR SPINE PROCES DISTRACT
LUMBAR SPINE PROCES ADDL
IOP MONIT IO PRESSURE
CAD CXR WITH INTERP
CAD CXR REMOTE
WOUND ULTRASOUND
Not Reimbursable
Not Reimbursable
Not Reimbursable
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Not Reimbursable
Not Reimbursable
Not Reimbursable
Yes
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Bundled
Not Reimbursable
Not Reimbursable
Not Reimbursable
CPT Code
0184T
0185T
0186T
0195T
0196T
0197T
0198T
0199T
0200T
0201T
0202T
0205T
0206T
0207T
0208T
0209T
0210T
0211T
0212T
0213T
0214T
0215T
0216T
0217T
0218T
0219T
0220T
0221T
0222T
0223T
0223T
0224T
0224T
0225T
0225T
0226T
0226T
0227T
0227T
July 2011
Not Reimbursable
Not Reimbursable
Not Reimbursable
Non Reimbursible
Non Reimbursible
Non Reimbursible
Non Reimbursible
Non Reimbursible
Non Reimbursible
Non Reimbursible
Non Reimbursible
Non Reimbursible
Non Reimbursible
Non Reimbursible
Non Reimbursible
Non Reimbursible
Non Reimbursible
Non Reimbursible
Non Reimbursible
Non Reimbursible
Non Reimbursible
Non Reimbursible
Non Reimbursible
Non Reimbursible
Non Reimbursible
Non Reimbursible
Non Reimbursible
Non Reimbursible
Non Reimbursible
Non Reimbursible
Not Reimbursable
Non Reimbursible
Not Reimbursable
Non Reimbursible
Not Reimbursable
Non Reimbursible
Not Reimbursable
Non Reimbursible
Not Reimbursable
Code Description
EXC RECTAL TUMOR ENDOSCOPIC
COMPTR PROBABILITY ANALYSIS
SUPRACHOROIDAL DRUG DELIVERY
ARTHROD PRESAC INTERBODY
ARTHROD PRESAC INTERBODY EAC
INTRAFRACTION TRACK MOTION
OCULAR BLOOD FLOW MEASURE
PHYSIOLOGIC TREMOR RECORD
PERQ SACRAL AUGMT UNILAT INJ
PERQ SACRAL AUGMT BILAT INJ
POST VERT ARTHRPLST 1 LUMBAR
INIRS EACH VESSEL ADD-ON
REMOTE ALGORITHM ANALYS ECG
CLEAR EYELID GLAND W/HEAT
AUTOMATED AUDIOMETRY AIR
AUTO AUDIOMETRY AIR/BONE
AUTO AUDIOMETRY SP THRESH
AUTO AUDIOMETRY SP RECOG
COMPREHEN AUTO AUDIOMETRY
US FACET JT INJ CERV/T 1 LEV
US FACET JT INJ LS 1 LEVEL
FUSE SPINE FACET JT CERV
FUSE SPINE FACET JT THOR
FUSE SPINE FACET JT LUMBAR
FUSE SPINE FACET JT ADD SEG
ACOUSTIC/ELECTR CARDGRPHY
ACOUSTIC/ELECTR CARDGRPHY
ACSTIC/ELEC CARDGRPHY AV/VV
ACSTIC/ELEC CARDGRPHY AV/VV
ACSTIC/ELEC CARDGRPHY AV+VV
ACSTIC/ELEC CARDGRPHY AV+VV
ANOSC HIGH RESOL DX +-COLL
ANOSC HIGH RESOL DX +-COLL
ANOSC HIGH RESOL DX W/BX
ANOSC HIGH RESOL DX W/BX
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Non Reimbursible
Not Reimbursable
Non Reimbursible
Non Reimbursible
Non Reimbursible
Non Reimbursible
Non Reimbursible
Non Reimbursible
Non Reimbursible
Non Reimbursible
Non Reimbursible
Non Reimbursible
Non Reimbursible
Non Reimbursible
Non Reimbursible
Non Reimbursible
Non Reimbursible
Non Reimbursible
Non Reimbursible
Non Reimbursible
Non Reimbursible
Non Reimbursible
Non Reimbursible
Non Reimbursible
Non Reimbursible
Not Reimbursable
Non Reimbursible
Not Reimbursable
Non Reimbursible
Not Reimbursable
Non Reimbursible
Not Reimbursable
Non Reimbursible
Not Reimbursable
CPT Code
0228T
0228T
0229T
0229T
0230T
0230T
0231T
0231T
0232T
0232T
0233T
0233T
0234T
0235T
0236T
0237T
0238T
0239T
0240T
0241T
0242T
0243T
0244T
0245T
0246T
0247T
0248T
0249T
0250T
0251T
0252T
0253T
0254T
0255T
0256T
0257T
0258T
0259T
0260T
July 2011
Non Reimbursible
Not Reimbursable
Non Reimbursible
Not Reimbursable
Non Reimbursible
Not Reimbursable
Non Reimbursible
Not Reimbursable
Non Reimbursible
Not Reimbursable
Non Reimbursible
Not Reimbursable
YES
YES
YES
YES
YES
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Code Description
US TFRML EDRL INJ CRV/T 1LVL
US TFRML EDRL INJ CRV/T 1LVL
US TFRML EDRL INJ CRV/T +LVL
US TFRML EDRL INJ CRV/T +LVL
US TFRML EDRL INJ L/S 1LVL
US TFRML EDRL INJ L/S 1LVL
US TFRML EDRL INJ L/S +LVL
US TFRML EDRL INJ L/S +LVL
INJ PLSM IMG GUID HRVSTG&PREP
INJ PLSM IMG GUID HRVSTG&PREP
SKN AGE MEAS SPCTRSCPY
SKN AGE MEAS SPCTRSCPY
TRLUML PERIP ATHRC RENAL ART
TRLUML PERIP ATHRC VISCERAL
TRLUML PERIP ATHRC ABD AORTA
TRLUML PERIP ATHRC BRCHIOCPH
TRLUML PERIP ATHRC ILIAC ART
BIOIMPEDANCE SPECTROSCOPY
ESOPH MOTILITY 3D TOPOGRAPHY
ESOPH MOTILITY W/STIM/PERF
GI TRACT TRANSIT & PRES MEAS
INTM MSR BRONCHODIL WHEEZE
CONT MSR BRONCHODIL WHEEZE
OPN TX RIB FX 1-2 RIBS
OPN TX RIB FX 7+ RIBS
LIGATION HEMORRHOID W/US
INSERT BRONCHIAL VALVE
REMOV BRONCHIAL VALVE ADDL
BRONCHSCPC RMVL BRONCH VALVE
INSERT AQUEOUS DRAIN DEVICE
EVASC RPR ILIAC ART BIFUR
EVASC RPR ILIAC ART BIFR S&I
EVASC AORTIC HRT VALVE
OPN TTHRC AORTIC HRT VALVE
AORTIC HRT VALV W/O CARD BYP
AORTIC HRT VALVE W/CARD BYP
HYPTHRM BDY NEONATE 28D/<
Non Reimbursible
Not Reimbursable
Non Reimbursible
Not Reimbursable
Non Reimbursible
Not Reimbursable
Non Reimbursible
Not Reimbursable
Non Reimbursible
Not Reimbursable
Non Reimbursible
Not Reimbursable
NA
NA
NA
NA
NA
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
CPT Code
0261T
A4230
A4231
A4232
A4250
A4261
A4262
July 2011
Not Reimbursable
PA for All POS for $0 and up
No
No
No
A4264
A4267
A4268
A4269
A4561
A4562
A4565
A4570
???
No
No
No
No
No
No
No
A4601
A4614
Code Description
HYPTHRM HEAD NEONATE 28D/<
INFUS SET EXT INSULIN PUMP NONNDLE
INFUS SET EXT INSULIN PUMP NEEDLE
SYRINGE NDLE EXT INSULIN PUMP STERL
URIN TEST REAG STR/TAB (100)
CERV CAP CONTRACEPTIVE USE
HCPCS - No Auth
Not Reimbursable
No under $50
No, under $200
No, under $200
No
No, under $200
No, under $200
No, under $200
No under $50
No under $50
No, under $200
No, under $200
No
No
PERM IMPL CONTRCPTV TUBAL OCCL DEV
HCPCS - No Auth
HCPCS - No Auth
HCPCS - No Auth
PESSARY RUBBER ANY TYPE
PESSARY NON RUBBER ANY TYPE
SLINGS
SPLINTS
LITHIUM ION BATTERY NONPROSTHETIC
USE REPLACMENT
PEAK EXPIR FLOW METER HAND HELD
A4627
No
SPAC/BG/RESVR W/WO MASK USE W/INHAL
No, under $200
A4641
No
SUPP RADIOPHARM DX IMAG AGENT NOS
No under $50
A4642
A5507
A9500
Yes
No
No
SUPP SATUMOMAB PENDETIDE PER DOSE
HCPCS - No Auth
TECHNETIUM TC 99M SESTAMIBI/DOSE
No
No
No
A9502
No
TECHNETIUM TC 99M TETROFOSMIN EA UD
No
A9503
A9504
A9505
No
No
No
TECHNETIUM TC 99/MEDRONATE <= 30MCI
TECHNETIUM TC 99M APCITIDE
THALLOUS CHLORIDE TL 201/MCI
No
No
No
A9507
Yes
No
A9508
Yes
A9510
No
RP DX INDIUM IN 111 CAPROMABPENDET
SUPP RADIOPHARMACEUTICAL DIAG
IMAGING AGENT-IOBENGUANE SULFA
SUPP RADIOPHARMACEUTICAL DIAG
IMAGING AGENT-TECHNETIUM TC99M
No under $50
No, under $200
No
No
CPT Code
A9512
A9516
A9517
A9521
A9524
July 2011
No
No
No
No
No
A9526
No
A9527
No
A9528
No
A9529
No
A9530
No
A9531
No
A9532
No
A9568
No
A9580
Non Reimbursible
A9600
Yes
A9699
Not Reimbursable
A9700
A9900
No
No
C8900
Yes
C8901
Yes
SUPP THERAP STRONTIUM-89 CL PER MCI
SUPPLY RADOPHRM THERAPEUTIC
IMAGING AGT NOC
SUPP INJECT CONTRAST MATERIALECHOCARDIOGRAPHY
MISC SUPP/ACCES/SERV
MR ANGIOGRAPHY W/CONTRAST
ABDOMEN
MR ANGIOGRAPHY WITHOUT CONTRST
ABD
C8902
C8903
C8904
Yes
Yes
Yes
MR ANGIO W/O CONTRST W/CONTRST ABD
MR IMAGING W/CONTRAST BREAST; UNI
MR IMAG W/O CONTRST BREAST; UNI
Code Description
TECHNETIUM TC 99M PER TECHNETATE
I-123 SODIUM IODIDE CAPSULE
I-131 SODIUM IODIDE CAPSULE
TECHNETIUM TC 99M EXAMETAZINE
IODINATED I-131 SERUM ALBUMIN
SUPPLY RADOPHRM DX IMAG AGT
AMMONIA N-13-DOSE
IODINE I-125 SODIUM IODIDE SOL TX PER
MCI
SPL RADOPHRM DX AGT I-131 SODIM
IODIDE CAP-MCI
IODIDE SOL-MCI
SPL RADOPHRM TX AGT I-131 SODIM
IODIDE SOL-MCI
IODIDE-MICROCURI
SPL RADOPHRM TX AGT IODINATED I-125
SERUM ALBUMI
TECHTM TC-99M ARCITUMOMAB DX STDY
DOSE TO 45 MCI
SODIUM FLUORIDE F-18 DX PER STUDY
DOSE TO 30 MCI
No
No
No under $50
No
No
No under $50
No under $50
No under $50
No under $50
No under $50
No under $50
No under $50
No
Not Reimbursable
No
Not Reimbursable
No under $50
No under $50
Yes
Yes
Yes
Yes
Yes
CPT Code
July 2011
C8905
C8906
C8907
Yes
Yes
Yes
MR NO CONTRST FLW W/CNTRST BRST;UNI
MR IMAGING W/CONTRST BREAST; BIL
MR IMAG W/O CONTRST BREAST; BIL
Yes
Yes
Yes
C8908
Yes
Yes
C8909
C8910
Yes
Yes
C8911
Yes
MR NO CONTRST FLW CNTRST BRST; BIL
MR ANGIOGRAPHY WITH CONTRAST
CHEST
MR ANGIO WITHOUT CONTRST CHEST
MR ANGIO NO CONTRST FLW CNTRST
CHST
C8912
Yes
Yes
C8913
Yes
C8914
Yes
C8918
C8919
Yes
Yes
C8920
Yes
C8931
Yes
MR ANGIO W/CONTRST LOWER EXTREMITY
MR ANGIO WITHOUT CONTRST LOW
EXTREM
MR ANGIO NO CNTRST FLW CON LW
EXTRM
MR ANGIOGRAPHY WITH CONTRAST
PELVIS
MRA WITHOUT CONTRAST PELVIS
MRA NO CONTRST FLWED W/CONTRST
PELV
MRA W/CONTRST SPINAL CANAL
CONTENTS
C8932
Yes
Yes
C8933
Yes
MRA W/O CONTRST SP CANAL CONTENTS
MRA NO CONTRST CONTRST SP CANAL
CNT
C8934
Yes
Yes
C8935
Yes
C8936
C9270
C9272
Yes
No
No
MRA WITH CONTRAST UPPER EXTREMITY
MRA WITHOUT CONTRST UPPER
EXTREMITY
MRA NO CONTRST FLW W/CONTRST UP
EXT
INJ IG IV NONLYOPHILIZED 500 MG
INJECTION DENOSUMAB 1 MG
C9273
No
SIPULEUCEL-T LEUKAPHERES PER INFUS
No
Code Description
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
CPT Code
July 2011
C9367
C9728
No
No
Code Description
SKN SUBST ENDOFRM DERM TEMPLT-SQ
CM
Place device/marker, non pro
C9800
No
DERM INJ FACL LDS RADIESSE/SCULPTRA
No
D1203
No
TOP FLUORIDE (PROPHYL NOT INCL) CHD
No
G0008
Bundled
G0009
G0010
Bundled
ADMIN FLU VIRUS VAC-NO PHYS SRV/DAY
ADMIN PNEUMOCOC VAC-NO PHYS
SRV/DAY
ADMIN HEPAT B VAC-NO PHYS SRV/DAY
G0027
G0101
G0102
G0103
G0104
G0105
G0106
Not Reimbursable
No
Bundled
No
No
No
No
SEMEN ANALY; PRES/MOT EXCLD HUHNER
CERV/VAG CA SCREEN PELVIC/BREAST
PROSTATE CA SCRN DIG RECTAL EXAM
PROSTATE CA SCRN (PSA) TOTAL
COLORECTAL CA SCREEN FLEX SCOPE
COLORECTAL CA SCREEN HI RISK IND
COLON CA SCREEN BARIUM ENEMA
Not Reimbursable
No
Bundled
No
No
No
No
G0108
G0109
No
No
DIAB OUTPT SELF-MGMT INDIV /SESSION
DIAB SELF-MGMT GRP TRAIN PER INDIV
No
No
G0117
G0118
GLAUC SCR HI RISK BY OPT/OPHTHLGIST
GLAUC SCR HI RISK UND DIR SUP DR
Bundled
Bundled
G0120
G0121
No
No
COLORECT CA SCRN ALT G0105 SCOPE BE
COLORECTAL CA SCRN NOT HI RISK
No
No
G0122
No
COLORECTAL CA SCREEN BARIUM ENEMA
No
G0123
G0124
G0127
G0128
G0129
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
Bundled
Bundled
SCRN CERV/VAG THIN LAY W/MD SUPER
Not Reimbursable
SCREEN CERV/VAG THIN LAY PHYS INTRP
TRIM DYSTROPHIC NAILS ANY NUMBER
DIR SKILL NSG RN OUTPT REHAB EA 10
SKILLS OCCUP THERAP PT HOSP TX QD
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
CPT Code
July 2011
G0130
No
G0141
Code Description
Not Reimbursable
SEXA BONE DENS STUD APPEND >=1 SITE
SCR CERV/VAG CYTO/AUTOSYS MAN
RESCR
Not Reimbursable
G0143
SCR CERV/VAG THIN-SCRN/RESCR-TECH
Not Reimbursable
G0144
G0145
G0147
SCR CYTO CERV/VAG SCRN-COMP RESCRN
SCR CERV/VAG THIN MAN SCR COMP
SCR SMEARS CERV/VAG AUTO-MD
Not Reimbursable
Not Reimbursable
Not Reimbursable
G0148
SCR SMEAR CERV/VAG AUTO MAN RESCR
Not Reimbursable
G0151
Not Reimbursable
SERV PHYS THERAP/HOME HEALTH/15 MIN
Not Reimbursable
G0152
Not Reimbursable
SERV OCCUP THERAP/HOME HLTH/15 MIN
Not Reimbursable
G0153
Not Reimbursable
SERV SPEECH/LANG PATH/HOME/15 MIN
Not Reimbursable
G0154
Not Reimbursable
SERV SKL NURS/HOME HLTH SET/15 MIN
Not Reimbursable
G0155
Not Reimbursable
SERV CSW/HOME HEALTH SET/EA 15 MIN
Not Reimbursable
G0156
G0166
G0168
Not Reimbursable
No
Not Reimbursable
Not Reimbursable
No
G0173
No
SERV HOME HLTH AIDE/HOME/EA 15 MIN
EXT COUNTERPULSATION PER TX SES
WOUND CLO UTILIZ TISS ADHES ONLY
LINR ACCELERATOR STEREOTAC
RADIOSURG CMPL 1 SESS
G0179
G0180
No
No
INTENSITY MODULATED RAD THERAP PLAN
PHY SERV-MC-HHA PROV/CERT PERIOD
No
No
G0181
No
PHYS SUPVSN HAA PT-CMPLX/MO-30/>MIN
No
G0182
G0186
No
No
No
No
G0202
No
PHYS SUPV HOSPIC PT-CMPLX/MO-30/>MI
PHOTOCOAG FDR VES TECH->=1SES
SCR MAMMOGRAPHY PRODUCING DIRECT
DIGITAL IMAGE
No
No
No
CPT Code
July 2011
G0204
No
G0206
No
G0219
G0237
G0238
Not Reimbursable
Not Reimbursable
Not Reimbursable
G0239
Not Reimbursable
G0245
G0246
G0247
G0248
G0249
G0250
G0251
G0252
G0255
G0257
G0259
G0260
G0268
G0269
G0270
Code Description
DIAG MAMMOGRAPHY, DIRECT DIGITAL
IMAGE, BILAT, ALL VIEWS
DIAG MAMMOGRAPHY, DIRECT DIGITAL
IMAGE, UNILAT, ALL VIEWS
PET IMAGING WHOLE BODY; MELANOMA
FOR NON-COVERED INIDICATION
MUSCLES FACE FACE 1 ON 1 EA 15 MIN
TX PROC IMPRV RESP NOT G0237 15 MIN
TX PROC IMPRV RESP NOT G0237 2/MORE
INITIAL PHYS E&M DIABETIC NEUROPATHY
W/LOPS
Not Reimbursable
FOLLOWUP EVAL DIABETIC PT
Not Reimbursable
NEUROPATHY W/LOPS
ROUTINE FOOT CARE BY PHYS OF
DIABETIC PT W/LOPS
Not Reimbursable
DEM USE HOME INR MON PT W/MECH
Not Reimbursable
HEART VALVE
PRVS TEST MATL & EQUIP HOME INR MON;
Not Reimbursable
PER 8 TESTS
PHYS REV INTEPR & PT MGMT HOME INR
MON; 8 TESTS
Not Reimbursable
Yes
LINR RADIOSRG TX ALL LES MAX 5 SESS
Not Reimbursable
PET IMAGING, FULL & PARTIAL-RING
CURRNT PERCEPT THRESHOLD/SNCT PER
LIMB ANY NERVE
Not Reimbursable
UNSCHD/EMERG DIALYSIS TX ESRD PT
Non Reimb Prof/OPPS Paid w PA
HOS OP NOT CERT
INJECTION PROCEDURE FOR SI JNT;
ARTHROGRAPY
Prof Not Reim/OPPS Packaged
NO PA in ASC ASC POS 24 Grouper 1; No PA INJ PROC SI JNT;ANES STEROID&/TX
OP Hospital
AGT&ARTHROGRPH
REMV IMP CERUMEN PHYS SAME DATE
AUDIO FUNCT TST
PLCMT OCCL DEVC VENUS/ART POST
SURG/INTRVNL PROC
Bundled
MED NUT TX; REASSESS FLW 2 REF YR
Not Reimbursable
W/PT EA 15 MIN
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Yes
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Bundled
Not Reimbursable
CPT Code
July 2011
G0271
Not Reimbursable
G0275
G0278
G0281
Not Reimbursable
G0282
Not Reimbursable
G0283
Not Reimbursable
G0288
G0289
G0290
Yes
G0291
Yes
G0293
Not Reimbursable
G0294
Not Reimbursable
G0295
Not Reimbursable
G0302
No
G0303
No
G0304
No
G0305
No
Code Description
MED NUT TX REASSESS FLW 2 REF YR GRP
EA 30 MIN
RENL ART ANGIO PRFRM AT CARD CATH
RAD SUP&INTEPR
ILIAC ART ANGIO PRFRM W/CARD CATH
RAD SUP&INTEPR
E-STIM 1/> AREAS CHRONIC STAGE III&IV
ULCERS
E-STIM 1/MORE AREAS WND CARE OTH
THAN DESC G0281
E-STIM 1/> AREAS OTH THAN WND CARE
PART TX PLAN
RECON CT ANGIO AORTA SURG PLANNING
VASC SURG
SCOPE KNEE REMV FB/SHAV TM OTH SURG
DIFF CMPRTMT
TRNSCATH PLCMT RX ELUTING INTRACOR
STNT; 1 VES
TRNSCATH PLCMT RX ELUTING INTRACOR
STNT; EA ADD
NONCOVR SURG CONSC SEDAT ANES-MCR
QUAL TRIAL-DAY
NONCOVR PROC NO ANES/LOC ANES-MCR
QUAL TRIAL-DAY
ELECMAGNET TX 1/>AREA WND CARE NOT
G0329/OTH USE
PRE-OP PULM SURG SRVC PREP LVRS
CMPL COURSE SRVC
PRE-OP PULM SURG SRVC PREP LVRS 10
15 DA SRVC
PRE-OP PULM SURG SRVC PREP LVRS 1 9
DA SRVC
POST-DISCHRG PULM SURG SRVC AFTER
LVRS MINI 6 DA
G0306
G0307
No
No
COMPLETE CBC AUTOMATED&AUTOMATED
WBC DIFF COUNT
COMPLETE AUTOMATED
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
NA
NA
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
No
No
No
No
CPT Code
July 2011
G0328
No
G0329
Not Reimbursable
G0337
Not Reimbursable
G0339
Not Reimbursable
G0340
Not Reimbursable
G0341
Not Reimbursable
G0342
Not Reimbursable
G0343
Not Reimbursable
G0364
Not Reimbursable
G0365
Not Reimbursable
G0389
No
G0390
Bundled
G0398
Non Reimbursible
G0399
Non Reimbursible
G0400
Non Reimbursible
G0402
Non Reimbursible
G0403
Non Reimbursible
G0404
Non Reimbursible
G0405
Non Reimbursible
Code Description
COLOREC CA SCR; FOB TST IMMUNO 1-3
SIMULTANEOUS
ELECMAGNET TX ULCERS NOT HEALING 30
DAYS CARE
HOSPICE EVALUATION & CNSL SERVICES
PREELECTION
IMAG GUID ROBOT SRS CMPL TX 1
SESS/1ST FRACT TX
IMAG GUID ROBOT SRS FRACT TX 2-5 SESS
MAX 5 SESS
PERQ ISLET CELL TPLNT INCL PORTL VEIN
CATH&INFUS
LAP ISLET CELL TPLNT INCL PORTAL VEIN
CATH&INFUS
LAPAROT ISLET CELL TPLNT W/PORTL VEIN
CATH&INFUS
BN MARROW ASPIR PRFRM W/BX SAME
INCI SAME DOS
VESSEL MAPPING OF VESSELS FOR
HEMODIALYSIS ACESS
US B-SCAN &/OR REAL TIME W/IMAG DOC;
AAA SCREEN
TRAUMA RESPONSE TEAM ASSOC W/HOSP
CC SERVICE
HST W/TYPE II PRTBLE MON UNATTENDED
MIN 7 CH
HST W/TYPE III PRTBLE MON UNATTENDED
MIN 4 CH
HST W/TYPE IV PRTBLE MON UNATTENDED
MIN 3 CH
INIT PREV PE LTD NEW BENEF DUR 1ST 12
MOS MCR
ECG RTN ECG W/12 LEADS SCR INIT
PREVNTV PE W/I&R
ECG RTN ECG W/12 LEADS TRACING ONLY
W/O I&R
ECG RTN ECG W/12 LEADS INTERPR &
REPORT ONLY
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
Bundled
Non Reimbursible
Non Reimbursible
Non Reimbursible
Non Reimbursible
Non Reimbursible
Non Reimbursible
Non Reimbursible
CPT Code
July 2011
G0406
Non Reimbursible
G0407
Non Reimbursible
G0408
Non Reimbursible
G0409
Non Reimbursible
G0410
Non Reimbursible
G0411
Non Reimbursible
G0412
Non Reimbursible
G0413
No
G0414
No
G0415
No
G0416
G0417
G0418
G0419
G0422
Yes
INTENS CARD REHAB; W/WO ECG W/EXER
No
G0423
Non Reimbursible
INTENS CARD REHAB; W/WO ECG W/O EX
Non Reimbursible
G0424
G0425
G0426
G0427
Non Reimbursible
No
No
No
PULM REHAB EXER 1 HR SESS 2 PER DAY
INIT IP TELEHEALTH CONSULT 30 MIN
INIT IP TELEHEALTH CONSULT 50 MIN
INIT IP TELEHEALTH CONSULT 70 MIN/>
Non Reimbursible
No
No
No
G0428
Not Reimbursable
COLL MENISC IMPL FIL MENISCAL DEFEC
Not Reimbursable
Code Description
F/U IP CNSLT LTD PHYS 15 MIN W/PT VIA
TELEHEALTH
F/U IP CNSLT INTRMED PHYS 25 MIN PT VIA
TELEHLTH
F/U IP CNSLT CMPLX PHYS 35 MIN/>PT VIA
TELEHLTH
SOCL WRK & PSYCH SRVC EA 15 MIN FACETO-FACE IND
GRP PSYCHOTX NOT MX FAM GRP PART
HOS 45-50 MIN
INTERACTV GRP PSYCHOTX PART HOS 45
TO 50 MIN
OPN TX ILIAC SPINE TUBEROSITY
AVUL/ILIAC WING FX
PERQ SKEL FIX POST PELV BONE
FX&/DISLOC UNI/BIL
OPN TX ANT PELV BONE FX &/ DISLOC
UNI/BIL
OPN TX POST PELV BONE FX &/ DISLOC
UNI/BIL
SURG PATH PROSTATE NEEDLE SAT
BIOPSY 1-20 SPEC
BIOPSY 21-40 SPEC
BIOPSY 41-60 SPEC
BIOPSY > 60 SPEC
Non Reimbursible
Non Reimbursible
Non Reimbursible
Non Reimbursible
Non Reimbursible
Non Reimbursible
Non Reimbursible
No
No
No
Non Reimbursible
Non Reimbursible
Non Reimbursible
Non Reimbursible
CPT Code
G0429
July 2011
Not Reimbursable
G0431
G0432
G0433
No
No
No
DRUG SCR QUAL; SINGLE CLASS METH EA
INF AB EIA TECH HIV-1 &/OR HIV-2
INF AB ELISA TECH HIV-1 &/OR HIV-2
No
No
No
G0434
G0435
G0440
G0441
No
No
Not Reimbursable
Not Reimbursable
No
No
Not Reimbursable
Not Reimbursable
G3001
G9001
G9002
G9003
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
DRUG SCR NOT CGC: ANY NUMBER PT ENC
INF AB RAPID TEST HIV-1 &/OR HIV-2
APPL TISS; LOW LIMB; 1ST 25 SQ CM/<
APPL TISS; LW LIMB; EA ADD 25 SQ CM
ADMINISTRATION AND SUPPLY OF
TOSITUMOMAB 450MG
COORDINATED CARE FEE INIT RATE
COORDINATED CARE FEE MAINT RATE
COORD CARE FEE RISK ADJUST-HI-INIT
G9004
G9005
G9006
Not Reimbursable
Not Reimbursable
Not Reimbursable
COORD CARE FEE RISK ADJUST-LOW-INIT
COORD CARE FEE RISK ADJST MAINT
COORD CARE FEE-HOME MONITOR
Not Reimbursable
Not Reimbursable
Not Reimbursable
G9007
Not Reimbursable
COORD CARE FEE-SCHED TEAM CONFER
Not Reimbursable
G9008
Not Reimbursable
COORD CARE FEE-PHYS OVRSIGHT SERV
Not Reimbursable
G9009
Not Reimbursable
COORD CARE FEE RSK ADJST MNT LEVL 3
Not Reimbursable
G9010
Not Reimbursable
Not Reimbursable
G9011
Not Reimbursable
Not Reimbursable
G9012
Not Reimbursable
Not Reimbursable
G9016
Not Reimbursable
SMOKNG CESS CNSLG-W/WO OTH
E&M/SESS
G9141
INFLUENZA A H1N1 IMMUNIZATION ADMIN
Non Reimbursible
G9142
Not Reimbursable
INFLUENZA A H1N1 IMMUNIZATION ADMIN
Non Reimbursible
G9142
No
INFLUENZA A H1N1 VACCINE ANY ROUTE
No
Code Description
DERMAL FILLER INJ TREATMENT LDS
Not Reimbursable
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
CPT Code
July 2011
Code Description
Not Reimbursable
INFLUENZA A H1N1 VACCINE ANY ROUTE
G9142
Yes
WARFARIN RSPN TEST GEN TECH ANY #
G9143
OIVIT MSR: RQ; &/UUN; &/GLU; &/K+
G9147
No
Genetic Testing Comment: PA for all Basic Health. For Medicaid, PA unless pregnancy related.
No
AL &/OR DRG SRV;ACUTE DETOX-IP
H0009
No
INJ TETRACYCLINE TO 250 MG
J0120
No
INJ ABCIXIMAB 10 MG
J0130
No
INJECTION ACETYLCYSTEINE 100 MG
J0132
No
INJECTION ACYCLOVIR 5 MG
J0133
INJECTION ADENOSINE THERAPEUTIC USE
6 MG
No
J0150
INJECTION ADENOSINE DIAGNOSTIC USE
No
30 MG
J0152
No
INJ ADRENALIN EPINEPHRINE 0.1 MG
J0171
No
INJECTION AGALSIDASE BETA 1 MG
J0180
No
INJ BIPERIDEN LACTATE, PER 5 MG
J0190
Not Reimbursable
Yes
No
No
No
No
No
No
No
No
No
No
No
J0200
J0205
J0207
J0210
J0215
J0220
J0256
J0270
No
No
No
No
No
Yes
No
No
INJ ALATROFLOXACIN MESYLATE 100 MG
INJ ALGLUCERASE/10 U (CEREDASE)
INJ AMIFOSTINE 500 MG
INJ METHYLDOPATE HCL TO 250 MG
INJECTION ALEFACEPT 0.5 MG
INJ ALGLUCOSIDASE ALFA 10 MG
INJ ALPHA 1 PROTEINASE INHIB/10 MG
INJ ALPROSTADIL 1.25 MCG DIR PHYS
No
No
No
No
No
Yes
No
No
J0275
J0278
J0280
No
No
No
ALPROSTADIL URETHRAL SUPP ADMIN MD
INJECTION AMIKACIN SULFATE 100 MG
INJ AMINOPHYLLIN TO 250 MG
No
No
No
J0282
J0285
No
No
No
No
J0287
No
J0288
No
J0289
No
INJ AMIODARONE HYDROCHLORIDE 30 MG
INJ AMPHOTERICIN B 50 MG
INJECTION AMPHOTERICIN B LIPID
COMPLEX 10 MG
INJ AMPHOTERICIN B CHOLESTRYL SULFAT
CMPLX 10 MG
INJECTION AMPHOTERICIN B LIPOSOME 10
MG
No
No
No
CPT Code
J0290
J0295
J0300
J0330
J0350
J0360
J0365
J0380
J0390
J0395
J0400
J0456
J0470
J0475
J0476
J0480
J0500
J0515
J0520
J0558
J0561
J0583
J0585
J0587
July 2011
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
Yes
Yes
J0592
No
Code Description
INJ AMPICILLIN SODIUM 500 MG
INJ AMPICILLIN SODIUM 1.5 GM
INJ AMOBARBITAL TO 125 MG
SUCCINYLCHOLINE CHLORIDE TO 20 MG
INJ ANISTREPLASE PER 30 UNITS
INJ HYDRALAZINE HCL TO 20 MG
INJECTION APROTONIN 10000 KIU
INJ METARAMINOL BITARTRATE/10 MG
INJ CHLOROQUINE HCL TO 250 MG
INJ ARBUTAMINE HCL 1 MG
INJ ARIPIPRAZOLE IM 0.25 MG
INJ AZITHROMYCIN 500 MG
INJ DIMECAPROL PER 100 MG
INJ BACLOFEN 10 MG
INJ BACLOFEN 50 MCG IT TRIAL
INJECTION BASILIXIMAB 20 MG
INJ DICYCLOMINE HCL UP TO 20 MG
INJ BENZTROPINE MESYLATE, PER 1 MG
INJ BETHANECHOL CHLORIDE, <= 5 MG
INJ PCN G BENZ & PROCAINE 100000 U
INJECTION PCN G BENZ 100000 UNITS
INJECTION BIVALIRUDIN 1 MG
BOTULINUM TOXIN TYPE A /PER UNIT
BOTULINUM TOXIN TYPE B-100 UNITS
INJECTION BUPRENORPHINE
HYDROCHLORIDE 0.1 MG
J0595
J0597
No
No
INJECTION BUTORPHANOL TARTRATE 1 MG
INJ C1 ESTERASE INHIB BERINERT 10 U
No
No
J0600
J0610
No
No
EDETATE CALCIUM DISODIUM TO 1000 MG
INJ CALCIUM GLUCONATE PER 10 ML
No
No
J0620
J0630
J0636
J0637
J0638
J0640
No
No
No
No
No
No
CA GLYCEROPHOSPHATE/LACTATE/10 ML
INJ CALCITONIN SALMON TO 400 UNITS
INJECTION CALCITRIOL 0.1 MCG
CASPOFUNGIN ACETATE
INJECTION CANAKINUMAB 1 MG
INJ LEUCOVORIN CALCIUM PER 50 MG
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
No
CPT Code
July 2011
J0641
J0670
J0690
J0692
J0694
J0696
J0697
J0698
No
No
No
No
No
No
No
No
Code Description
INJECTION LEVOLEUCOVORIN CALCIUM 0.5
MG
INJ MEPIVACAINE HCL, PER 10 ML
INJ CEFAZOLIN SODIUM 500 MG
INJ CEFEPIME HYDROCHLORID 500 MG
INJ CEFOXITIN SODIUM 1 GM
INJ CEFTRIAXONE SODIUM PER 250 MG
INJ STER CEFUROXIME SODIUM/750 MG
CEFOTAXIME SODIUM PER GM
J0702
J0706
J0710
J0713
J0715
No
No
No
No
No
BETAMETHASONE ACETATE-NA PHOS/3 MG
INJECTION, CAFFEINE CITRATE, 5MG
INJ CEPHAPIRIN SODIUM TO 1 GM
INJECTION, CEFTAZIDIME, PER 500 MG
INJ CEFTIZOXIME SODIUM PER 500 MG
No
No
No
No
No
J0720
J0725
J0735
J0740
J0743
J0744
J0745
J0760
J0770
J0775
J0780
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
J0795
J0800
J0850
No
No
Yes
J0881
No
J0882
No
J0885
No
J0886
No
CHLORAMPHENICOL NA SUCCINATE-1 GM
CHORIONIC GONADOTROPIN/1000 USP U
INS CLONIDINE HYDROCHLORIDE 1 MG
INJ CIDOFOVIR 375 MG
IMIPENEM-CILASTATIN SODIUM/250MG
INJ CIPROFLOXACIN IV INFUS 200 MG
INJ CODEINE PHOSPHATE PER 30 MG
INJ COLCHICINE PER 1 MG
INJ COLISTIMETHATE SODIUM TO 150 MG
INJ COLLAGENASE CHC 0.01 MG
INJ PROCHLORPERAZINE TO 10 MG
INJ CORTICORELIN OVINE TRIFLUTATE 1
MICROGM
INJ CORTICOTROPIN TO 40 UNITS
INJ CMV IMMUNE GLOBULIN IV/VIAL
INJECTION DARBEPOETIN ALFA 1 MCG NONESRD USE
INJ DARBEPOETIN ALFA 1 MCG FOR ESRD
DIALYSIS
INJECTION EPOETIN ALFA FOR NON-ESRD
1000 UNITS
INJ EPOETIN ALFA 1000 UNITS FOR ESRD
DIALYSIS
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
J0895
J0900
No
No
DEFEROXAMINE MESYLATE 500 MG/5 CC
TESTOS ENANTH/ESTRA VALERATE-1CC
No
No
J0945
J1000
No
No
INJ BROMPHENIRAMINE MALEATE/10 MG
DEPO-ESTRADIOL CYPIONATE TO 5 MG
No
No
J1020
No
METHYLPREDNISOLONE ACETATE-20 MG
No
J1030
No
No
J1040
No
No
J1051
No
INJECTION MEDROXYPROGESTERONE
ACETATE 50 MG
J1055
No
MEDROXYPRO ACETATE-CONTRA-150 MG
No
J1056
J1060
J1070
No
No
No
INJ MDRXYPRGESTRON/ESTRDIOL 5/25MG
TESTOS/ESTRADIOL CYPIONATE-1 ML
TESTOSTERONE CYPIONATE TO 100 MG
No
No
No
J1080
No
No
J1094
No
TESTOSTERONE CYPIONATE-1 CC-200 MG
INJECTION DEXAMETHASONE ACETATE 1
MG
J1100
No
DEXAMETHASONE NA PHOSPATE-4 MG/ML
No
J1110
J1120
J1160
No
No
No
No
No
No
J1162
J1165
J1170
J1180
J1190
J1200
J1205
J1212
No
No
No
No
No
No
No
No
INJ DIHYDROERGOTAMINE MESYLATE/1 MG
INJ ACETAZOLAMIDE SODIUM TO 500 MG
INJ DIGOXIN TO 0.5 MG
INJECTION DIGOXIN IMMUNE FAB OVINE
PER VIAL
INJ PHENYTOIN SODIUM, PER 50 MG
INJ HYDROMORPHONE TO 4 MG
INJ DYPHYLLINE TO 500 MG
INJ DEXRAZOXANE HCL PER 250 MG
INJ DIPHENHYDRAMINE HCL TO 50 MG
CHLOROTHIAZIDE SODIUM, PER 500 MG
DMSO DIMETHYL SULFOXIDE 50%-50 ML
Code Description
No
No
No
No
No
No
No
No
No
No
July 2011
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
J1320
J1325
J1327
J1330
J1335
J1364
J1380
Yes
No
Yes
No
No
No
No
No
Code Description
INJ METHADONE HCL UP TO 10 MG
INJ DIMENHYDRINATE TO 50 MG
INJ DIPYRIDAMOLE PER 10MG
INJ, DOBUTAMINE HCL, PER 250 MG
INJ DOLASETRON MESYLATE 10 MG
INJECTION DOPAMINE HCL 40 MG
INJECTION DORIPENEM 10 MG
INJECTION, DUOVAL 2X-P.A., UP TO 1 ML
INJECTION, DURACILLIN AS, UP TO 600,000
UNITS
INJ AMITRIPTYLINE HCL TO 20 MG
INJ EPOPROSTENOL 0.5 MG
INJ EPTIFIBATIDE 5 MG
INJ ERGONOVINE MALEATE TO 0.2 MG
INJECTION ERTAPENEM SODIUM 500 MG
ERYTHROMYCIN LACTOBIONATE/500 MG
INJ ESTRADIOL VALERATE TO 10 MG
J1410
No
INJ ESTROGEN CONJUGATED PER 25 MG
No
J1430
J1435
J1436
No
No
No
INJECTION ETHANOLAMINE OLEATE 100 MG
INJ ESTRONE PER 1 MG
INJ ETIDRONATE DISODIUM TO 300 MG
No
No
No
J1438
J1440
J1441
J1450
J1451
J1452
J1453
J1455
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
J1459
J1460
J1559
J1560
J1561
J1562
No
No
Yes
No
No
No
INJ ETANERCEPT 25 MG-NOT SELF ADMIN
INJ FILGRASTIM 300 MCG
INJ FILGRASTIM 480 MCG
INJ FLUCONAZOLE 200 MG
INJECTION FOMEPIZOLE 15 MG
INJ FOMIVIRSEN SODIUM IO 1.65MG
INJECTION FOSAPREPITANT 1 MG
INJ FOSCARNET SODIUM PER 1000MG
INJ IMMUNE GLOBULIN IV NONLYOPHILIZED
500 MG
INJ GAMMA GLOBULIN IM 1 CC
INJECTION IG HIZENTRA 100 MG
INJ GAMMA GLOBULIN IM OVER 10 CC
INJ IG GAMUNEX IV NONLYO 500 MG
INJECTION IG VIVAGLOBIN 100 MG
CPT Code
J1230
J1240
J1245
J1250
J1260
J1265
J1267
J1270
J1290
Yes
No
Yes
No
No
No
No
No
No
No
Yes
No
No
No
CPT Code
July 2011
J1566
J1570
J1580
J1590
No
No
No
No
J1595
J1599
J1600
No
Not Reimbursable
No
J1610
No
INJECTION GLATIRAMER ACETATE 20 MG
INJ IG IV NONLYOPHILIZED NOS 500 MG
GOLD SODIUM THIOMALATE-50 MG
INJ GLUCAGON HYDROCHLORIDE PER 1
MG
J1620
J1626
J1630
No
No
No
GONADORELIN HYDROCHLORIDE/100 MCG
INJ GRANISETRON HCL 100 MCG
INJ HALOPERIDOL TO 5 MG
No
No
No
J1631
J1640
No
No
INJ HALOPERIDOL DECANOATE PER 50 MG
INJECTION HEMIN 1 MG
No
No
J1642
J1644
J1645
J1650
No
No
No
No
HEPARIN SODIUM-HEP LOCK FLUSH-10 U
INJ HEPARIN SODIUM PER 1000 UNITS
INJ DALTEPARIN SODIUM PER 2500 IU
INJECTION ENOXAPARIN SODIUM 10 MG
No
No
No
No
J1652
J1655
No
No
INJECTION FONDAPARINUX SODIUM 0.5 MG
INJECTION TINZAPARIN SODIUM 1000 IU
No
No
J1670
No
No
J1675
No
TETANUS IMMUNE GLOBULIN HUMAN-250 U
INJECTION HISTRELIN ACETATE 10
MICROGRAMS
J1700
No
INJ HYDROCORTISONE ACETATE TO 25 MG
No
J1710
No
HYDROCORTISONE NA PHOSPHATE-50 MG
No
J1720
J1730
J1742
J1745
No
No
No
No
HYDROCORTISONE NA SUCCINATE-100 MG
INJ DIAZOXIDE TO 300 MG
INJ IBUTILIDE FUMARATE 1 MG
INJ INFLIXIMAB 10 MG
No
No
No
No
Code Description
INJECTION IG IV LYOPHILIZED POWDER 500
MG
INJ GANCICLOVIR SODIUM 500 MG
INJ GARAMYCIN GENTAMICIN TO 80 MG
INJECTION, GLUKOR, UP TO 1 ML
No
No
No
No
No
Not Reimbursable
No
No
No
CPT Code
J1750
J1750
J1756
J1786
J1790
J1800
J1810
J1815
July 2011
No
No
No
Yes
No
No
Not Reimbursable
No
J1817
No
Code Description
INJECTION IRON DEXTRAN 50 MG
INJECTION IRON DEXTRAN 50 MG
IRON SUCROSE INJECTION
INJECTION IMIGLUCERASE 10 UNITS
INJ DROPERIDOL TO 5 MG
INJ PROPRANOLOL HCL TO 1 MG
DROPERIDOL-FENTANYL CITRATE-2 ML
INJECTION INSULIN PER 5 UNITS
INSULIN ADMINISTRATION THROUGH DME
PER 50 UNITS
Yes
INJECTION INTERFERON BETA-1A 30 MCG
Yes
J1830
J1835
J1840
J1850
No
No
No
No
No
No
No
No
J1885
J1890
J1930
J1930
J1940
J1945
J1950
J1953
J1955
J1956
J1960
J1980
J1990
No
No
No
No
No
No
No
No
No
No
No
No
No
J2001
J2010
J2020
J2060
J2150
J2175
No
No
No
No
No
No
INTERFERON BETA-1B PER 0.25 MG/PHYS
INJECTION, ITRACONAZOLE, 50 MG
INJ KANAMYCIN SULFATE TO 500 MG
INJ KANAMYCIN SULFATE UP TO 500 MG
INJ KETOROLAC TROMETHAMINE PER
15MG
INJ CEPHALOTHIN SODIUM TO 1 GM
INJECTION LANREOTIDE 1 MG
INJECTION LANREOTIDE 1 MG
INJ FUROSEMIDE TO 20 MG
INJECTION LEPIRUDIN 50 MG
INJ LEUPROLIDE ACETATE PER 3.75 MG
INJECTION LEVETIRACETAM 10 MG
INJ LEVOCARNITINE PER 1 GM
INJ LEVOFLOXACIN 250 MG
INJ LEVORPHANOL TARTRATE TO 2 MG
INJ HYOSCYAMINE SULFATE TO .25 MG
INJ CHLORDIAZEPOXIDE HCL TO 100 MG
INJECTION LIDOCAINE HCL INTRAVENOUS
INFUS 10 MG
INJ LINCOMYCIN HCL TO 300 MG
INJECTION, LIPO-HEPIN
INJ LORAZEPAM 2MG
INJ MANNITOL 25% IN 50 ML
MEPERIDINE HYDROCHLORIDE/100 MG
J1826
No
No
No
Yes
No
No
Not Reimbursable
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
J2180
J2185
No
No
MEPERIDINE & PROMETHAZINE HCL-50 MG
INJECTION MEROPENEM 100 MG
No
No
J2210
J2250
J2260
J2270
J2271
J2275
J2278
J2280
J2300
J2310
No
No
No
No
No
No
No
No
No
No
METHYLERGONOVINE MALEATE TO 0.2 MG
INJ, MIDAZOLAM HCL, PER 1 MG
MILRINONE LACTATE PER 5 ML
INJ MORPHINE SULFATE TO 10 MG
INJ MORPHINE SULFATE 100MG
INJ MORPHINE SULFATE UP TO 10MG
INJECTION ZICONOTIDE 1 MICROGRAM
INJECTION, MYCHEL-S, UP TO 250MG
INJ, NALBUPHINE HCL, PER 10 MG
INJ, NALOXONE HCL, PER 1 MG
No
No
No
No
No
No
No
No
No
No
J2320
J2325
No
No
INJ NANDROLONE DECANOATE TO 50 MG
INJECTION NESIRITIDE 0.1 MG
No
No
J2353
No
No
J2354
J2355
J2357
J2358
No
No
Yes
Yes
INJ OCTREOTIDE DEPOT FORM IM INJ 1 MG
INJ OCTREOTIDE NON-DEPOT FORM
SUBQ/IV INJ 25 MCG
INJ OPRELVEKIN 5 MG
INJ OMALIZUMAB 5 MG
INJ OLANZAPINE LONG-ACTING 1 MG
No
No
Yes
Yes
J2360
J2370
J2400
J2405
J2410
No
No
No
No
No
INJ ORPHENADRINE CITRATE UP TO 60MG
INJ PHENYLEPHRINE HCL TO 1 ML
INJ CHLOROPROCAINE HCL, PER 30 ML
INJ ONDANSETRON HCL PER 1 MG
INJ OXYMORPHONE HCL TO 1 MG
No
No
No
No
No
J2425
No
INJECTION PALIFERMIN 50 MICROGRAMS
No
Yes
No
No
No
No
Yes
INJ PALIPERIDONE PALM EXT RLSE 1 MG
INJ PAMIDRONATE DISODIUM PER 30 MG
INJ PAPAVERINE HCL TO 60 MG
INJ OXYTETRACYCLINE HCL TO 50 MG
PARICALCITOL
INJECTION PEGAPTANIB SODIUM 0.3 MG
Yes
No
No
No
No
No
J2426
J2430
J2440
J2460
J2501
J2503
Code Description
CPT Code
J2504
J2505
J2510
July 2011
No
No
No
J2513
J2515
J2540
J2543
No
No
No
No
Code Description
INJECTION PEGADEMASE BOVINE 25 IU
INJECTION PEGFILGRASTIM 6 MG
PEN G PROCAINE AQUEOUS-600,000 U
INJECTION PENTASTARCH 10% SOLUTION
100 ML
INJ PENTOBARBITAL SODIUM PER 50 MG
PEN G POTASSIUM-600,000 U
INJ PIPERACILLIN NA/TAZOBACTAM NA
J2545
J2550
J2560
J2590
J2597
J2650
J2670
J2675
No
No
No
No
No
No
No
No
PENTAM ISETH INHAL SOLN/300 MG(DME)
INJ PROMETHAZINE HCL TO 50 MG
INJ PHENOBARBITAL SODIUM TO 120 MG
INJ OXYTOCIN TO 10 UNITS
INJ, DESMOPRESSIN ACETATE/1 MCG
INJ PREDNISOLONE ACETATE TO 1 ML
INJ TOLAZOLINE HCL TO 25 MG
INJ PROGESTERONE PER 50 MG
No
No
No
No
No
No
No
No
J2680
J2690
J2700
J2710
J2720
J2725
J2730
J2760
J2765
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
J2770
J2780
J2783
J2785
No
No
No
No
J2788
J2790
J2792
No
No
No
INJ FLUPHENAZINE DECANOATE TO 25 MG
INJ PROCAINAMIDE HCL TO 1 GM
INJ OXACILLIN SODIUM TO 250 MG
NEOSTIGMINE METHYLSULFATE-0.5 MG
INJ PROTAMINE SULFATE PER 10 MG
INJ PROTIRELIN PER 250 MCG
INJ PRALIDOXIME CHLORIDE TO 1 GM
INJ PHENTOLAMINE MESYLATE TO 5 MG
INJ METOCLOPRAMIDE HCL TO 10 MG
INJECTION QUINUPRISTIN/DALFOPRISTIN
500 MG
INJ RANITIDINE HYDROCHLORIDE 25 MG
INJECTION RASBURICASE 0.5 MG
INJECTION REGADENOSON 0.1 MG
INJECTION RHO D IG HUMAN MINIDOSE 50
MCG
RHO D IG HUMAN 1 DOSE PKG
INJ RHO D IMMUNE GLOBULIN IV 100 IU
J2795
J2800
No
No
INJ ROPIVACAINE HYDROCHLORIDE 1 MG
INJ METHOCARBAMOL TO 10 ML
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
J2805
J2810
J2820
July 2011
No
No
No
J2850
J2910
J2916
J2920
J2930
J2940
J2941
J2950
J2993
J2995
J2997
J3000
J3010
No
No
No
No
No
No
No
No
No
No
No
No
No
J3030
J3070
J3095
J3101
J3105
J3120
No
No
Not Reimbursable
No
No
No
INJ SUMATRIPTAN SUCCINATE 6 MG/PHYS
INJ PENTAZOCINE HCL TO 30 MG
INJECTION TELAVANCIN 10 MG
INJECTION TENECTEPLASE 1 MG
INJ TERBUTALINE SULFATE TO 1 MG
TESTOSTERONE ENANTHATE TO 100 MG
No
No
Not Reimbursable
No
No
No
J3130
J3140
No
No
TESTOSTERONE ENANTHATE TO 20O MG
TESTOSTERONE SUSPENSION TO 50 MG
No
No
J3150
J3230
J3240
No
No
Yes
TESTOSTERONE PROPIONATE TO 100 MG
INJ CHLORPROMAZINE HCL TO 50 MG
INJ THYROTROPIN ALFA 0.9MG
No
No
No
J3250
J3260
J3262
J3265
J3280
J3285
No
No
Yes
No
No
Yes
INJ TRIMETHOBENZAMIDE HCL TO 200 MG
INJ TOBRAMYCIN SULFATE TO 80 MG
INJECTION TOCILIZUMAB 1 MG
INJECTION, TORSEMIDE, 10 MG/ML
THIETHYLPERAZINE MALEATE TO 10 MG
INJECTION TREPROSTINIL 1 MG
No
No
Yes
No
No
Yes
Code Description
INJECTION SINCALIDE 5 MICROGRAMS
INJ THEOPHYLLINE PER 40 MG
INJ SARGRAMOSTIN (GM-CSF)/50MCG
INJECTION SECRETIN SYNTHETIC HUMAN 1
MICROGRAM
INJ AUROTHIOGLUCOSE TO 50 MG
NA FERRIC GLUCONATE COMPLEX
METHYLPRED NA SUCCINATE-40 MG
METHYLPRED NA SUCCINATE TO 125MG
INJECTION, SPANESTRIN P, UP TO 1 ML
INJECTION, SOMATROPIN, 1 MG
INJ PROMAZINE HCL TO 25 MG
INJ RETEPLASE 18.8 MG
INJ STREPTOKINASE PER 250,000 IU
INJ ALTEPLASE RECOMBINANT 1 MG
INJ STREPTOMYCIN TO 1 GM
INJ FENTANYL CITRATE TO 2 ML
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
J3300
J3301
J3302
J3303
No
No
No
No
Code Description
INJ TRIAMCINOLONE ACETONIDE PRES
FREE 1 MG
TRIAMCINOLONE ACETONIDE/10 MG
TRIAMCINOLONE DIACETATE/5 MG
TRIAMCINOLONE HEXACETONIDE/5 MG
J3305
J3310
No
No
INJ, TRIMETREXATE GLUCORONATE/25 MG
INJ PERPHENAZINE TO 5 MG
No
No
J3315
J3320
J3350
J3355
J3357
J3360
J3364
J3364
J3365
J3370
J3385
J3400
J3410
J3411
J3415
J3420
J3430
J3465
J3470
No
No
No
No
Yes
No
No
No
No
No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No
Yes
No
No
No
No
No
No
No
No
J3471
No
J3472
J3475
J3480
J3485
No
No
No
No
INJECTION TRIPTORELIN PAMOATE 3.75 MG
SPECTINOMYCIN HCL, 2GM
INJ UREA TO 40 GM
INJECTION UROFOLLITROPIN 75 IU
INJECTION USTEKINUMAB 1 MG
INJ DIAZEPAM TO 5 MG
INJECTION UROKINASE 5000 IU VIAL
INJ UROKINASE 5000 IU VIAL
INJ IV UROKINASE 250,000 IU VIAL
INJ VANCOMYCIN HCL 500MG
INJ VELAGLUCERASE ALFA 100 UNITS
INJ TRIFLUPROMAZINE HCL TO 20 MG
INJ HYDROXYZINE HCL TO 25 MG
INJECTION THIAMINE HCL 100 MG
INJECTION PYRIDOXINE HCL 100 MG
VIT B-12 CYANOCOBALAMIN-1000 MCG
INJ PHYTONADIONE (VIT K) PER 1 MG
INJECTION VORICONAZOLE 10 MG
INJ HYALURONIDASE TO 150 UNITS
INE HYALURONIDASE OVINE PRES FREE 1
USP UNIT
INJ HYALURONIDASE OVINE PRES FREE1000 USP UNITS
INJ, MAGNESIUM SULFATE/500 MG
INJ, POTASSUIM CHLORIDE/2 MEQ
INJ ZIDOVUDINE 10 MG
J3486
J3487
J3490
No
No
No
INJECTION ZIPRASIDONE MESYLATE 10 MG
ZOLEDRONIC ACID
UNCLASSIFIED DRUGS
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
J3520
J3530
July 2011
Not Reimbursable
No
J3535
J3570
J3590
J7030
J7040
J7042
J7050
J7060
J7070
J7100
J7110
No
Not Reimbursable
No
No
No
No
No
No
No
No
No
J7120
No
RINGERS LACTATE INFUSION TO 1000 CC
No
J7130
No
HYPERTON SAL SOLN 50-100 MEQ, 20 CC
No
J7184
Yes
J7185
Yes
INJ VWF CMPLX WILATE 100 IU VWF:RCO
INJECTION FACTOR VIII PER IU
Yes
Yes
J7186
Yes
Yes
J7187
J7189
J7190
J7191
J7192
J7193
J7194
J7195
J7196
J7197
J7198
J7199
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Not Reimbursable
INJ AHF/ VWF CMPLX PER FACTOR VIIII IU
INJ VONWILLEBRND FACTOR CMPLX HUMN
RISTOCETIN IU
FACTOR VIIA 1 MICROGRAM
FACT VIII(ANTI-HEMOPHI HUMAN)PER IU
FACT VIII/ANTIHEMOPH/PORCINE PER IU
FACTOR VIII (ANTIHEMO RECOMB)PER IU
FACTOR IX PER I.U.
FACTOR IX COMPLX PER IU
FACTOR IX PER I.U.
OTH HEMOPHILIA CLOTTING FACT_IU
ANTITHROMBIN III (HUMAN) PER IU
ANTI-INHIBITOR PER I.U.
HEMOPHILIA CLOT FACT NOC
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Not Reimbursable
J7300
No
INTRAUTERINE COPPER CONTRACEPTIVE
No
Code Description
EDETATE DISODIUM PER 150 MG
NASAL VACCINE INHALATION
DRUG ADMIN THRU METERED DOSE INHAL
LAETRILE AMYGDALIN VITAMIN B17
UNCLASSIFIED BIOLOGICS
INFUS NORMAL SALINE SOLN 1000 CC
INFUS NS SOLN STER 500 ML
D5NS 500 ML = 1 UNIT
INFUS NORMAL SALINE SOLN 250 CC
5% DEXTROSE/WATER 500 ML = 1 UNIT
INFUSION D5W 1000 CC
INFUSION DEXTRAN 40, 500 ML
INFUSION DEXTRAN 75, 500 ML
Not Reimbursable
No
No
Not Reimbursable
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
J7302
No
J7303
No
J7306
Yes
J7308
Not Reimbursable
Code Description
LEVONORGESTREL INTRAUTERN
CNTRACPT
CONTRACEPT SUPPLY HORMONE
CONTAINING VAG RING EA
LEVONORGESTREL CNTRACPTV IMPL SYS
INCL IMPL&SPL
AMINOLEVULINIC ACID HCL TOP ADMN 20%
1 U DOSE
No
METHYL AMINOLEVULINATE TOP 16.8% 1G
No
J7310
J7312
Yes
No
Yes
No
J7330
Not Reimbursable
GANCICLOVIR 4.5 MG LONG-ACT IMPLANT
INJ DEXAMETH INTRAVIT IMPL 0.1 MG
AUTOLOGOUS CULTURED
CHONDROCYTES, IMPLANT
Not Reimbursable
J7500
J7501
J7502
Not Reimbursable
Not Reimbursable
No
Not Reimbursable
CAPSAICIN 8% PATCH PER 10 SQUARE CM
AZATHIOPRINE ORAL 50 MG
AZATHIOPRINE PARENTERAL 100 MG
CYCLOSPORINE ORAL 100 MG
Not Reimbursable
Not Reimbursable
No
Not Reimbursable
J7504
J7505
J7506
J7507
J7509
J7510
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
No
LYMPH IG/ANTITHYMOCYTE GLOB 250 MG
MONOCLONAL ANTIBODIES PAR/5MG
PREDNISONE/ORAL/PER 5 MG
TACROLIMUS ORAL PER 1 MG
METHYLPREDNISOLONE PO/4 MG
PREDNISOLONE ORAL, PER 5 MG
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
No
J7511
J7513
J7515
J7516
No
No
No
No
LYMPHCYT GLOB RABBIT PARNTRAL 25MG
DACLIZUMAB PARENTERAL 25 MG
CYCLOSPORINE ORAL 25 MG
CYCLOSPORIN PARENTERAL 250 MG
No
No
No
No
J7517
J7520
J7525
J7599
No
No
No
No
No
No
No
No
J7606
Non Reimbursible
MYCOPHENOLATE MOFETIL ORAL 250 MG
SIROLIMUS ORAL 1 MG
TACROLIMUS PARENTERAL 5 MG
IMMUNOSUPPRESSIVE DRUG, NOC
FORMOTEROL FUMARATE INHAL SOL U
DOSE FORM 20 MCG
J7309
J7335
No
No
No
Not Reimbursable
No
CPT Code
July 2011
J7608
No
ACETYLCYSTEINE INHAL SOL UD PER GM
No
J7610
J7615
No
No
No
No
J7620
No
ALBUTEROL INHAL ADMIN THRU DME 1MG
LEVALBUTEROL INHAL DME UNIT 0.5 MG
ALBUTEROL TO 2.5 MG & IPRATROPIUM BR
TO 0.5 MG
J7622
No
BETHAMETHASONE INHAL SOL DME U MG
No
J7624
J7626
No
No
No
No
J7627
J7628
J7629
No
No
No
BETHAMETHASONE INHAL SOL DME U MG
BUDESONIDE INHAL SOL DME .25 MG
BUDESONIDE PWDR CMPND INHAL SOL U
DOSE TO 0.5 MG
BITOLTEROL MESYLATE INHAL SOL CON
BITOLTEROL MESYLATE INHAL SOL/MG
J7631
No
No
J7633
J7635
J7636
No
No
No
CROMOLYN NA INHAL SOL UD PER 10 MGS
BUDESONIDE INHAL SOL ADMND THRU
DME CONC-0.25 MG
ATROPINE INHAL SOL/CONCEN PER MG
ATROPINE INHAL SOL UD PER MG
J7637
No
DEXAMETHASONE INHAL SOL/CON PER MG
No
J7638
No
DEXAMETHASONE INHAL SOL UD PER MG
No
J7639
No
No
J7640
No
DORNASE ALPHA INHAL SOL UD PER MG
FORMOTEROL INHAL SOL UNIT DOSE 12
MICROGRAMS
J7641
No
No
J7642
No
FLUNISOLIDE INHAL SOL ADMNED DME-MG
GLYCOPYRROLATE INHAL SOL CON PER
MG
J7643
No
GLYCOPYRROLATE INHAL SOL UD PER MG
No
J7644
No
IPRATROPIUM BROMIDE INHAL SOL UD/MG
No
Code Description
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
J7645
J7648
No
No
IPRATROPIUM BROMIDE INHAL U PER MG
ISOETHARINE HCL INHAL SOL CON/MG
No
No
J7649
No
ISOETHARINE HCL INHAL SOL UD PER MG
No
J7650
No
ISOETHARINE HCI INHAL U DOSE PER MG
No
J7658
No
ISOPROTERENOL HCL INHAL SOL CON/MG
No
J7659
No
ISOPROTERENOL HCL INHAL SOL UD/ MG
No
J7660
No
No
J7668
No
ISOPROTERENOL HCI INHAL UNIT PER MG
METAPROTERENOL INHAL SOL CON/10
MGS
No
J7669
No
METAPROTERENOL INHAL SOL UD/10 MGS
No
J7670
J7680
No
No
METAPROTERENOL SULFATE INHAL 10 MG
TERBUTALINE SO4 INHAL SOL CON/MG
No
No
J7681
J7682
No
No
TERBUTALINE SO4 INHAL SOL UD/PER MG
TOBRAMYCIN UD 300 MG INHAL SOL
No
No
J7683
No
TRIAMCINOLONE INHAL SOL CONC/PER MG
No
J7684
J7686
J7699
J7799
No
Not Reimbursable
No
No
No
Not Reimbursable
No
No
J8498
J8499
J8510
J8515
J8520
J8521
J8530
J8540
No
Not Reimbursable
No
No
No
No
No
No
TRIAMCINOLONE INHAL SOL CON PER MG
TREPROSTINIL INHAL UNIT DOS 1.74 MG
NOC DRUGS, INHAL SOLN ADMIN-DME
NOC DRUGS, OTH THAN INHAL
ANTIEMETIC DRUG RECTAL/SUPPOSITORY
NOS
RX DRUG/ORAL/NON-CHEMO/NOS
BUSULFAN ORAL 2 MG
CABERGOLINE ORAL 0.25 MG
TRIAMCINOLONE INHAL SOL/DME UD/MG
CAPECITABINE ORAL 500 MG
CYCLOPHOSPHAMIDE ORAL 25 MG
DEXAMETHASONE ORAL 0.25 MG
Code Description
No
Not Reimbursable
No
No
No
No
No
No
CPT Code
J8560
J8562
July 2011
No
No
J8597
J8600
J8610
J8700
J8705
J8999
J9000
J9001
J9010
J9015
J9017
J9020
J9025
J9027
J9031
J9033
J9040
J9045
J9050
J9060
J9065
J9070
J9098
J9100
J9120
J9130
J9150
No
No
No
No
No
Not Reimbursable
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Code Description
ETOPOSIDE ORAL 50 MG
FLUDARABINE PHOSPHATE ORAL 10 MG
ANTIEMETIC DRUG ORAL NOT OTHERWISE
SPECIFIED
MELPHALEN ORAL 2 MG
METHOTREXATE ORAL 2.5 MG
TEMOZOLOmIDE ORAL 5 MG
TOPOTECAN ORAL 0.25 MG
RX DRUGORALCHEMONOS
DOXORUBICIN HCL 10 MG
DOXORUBICIN HCL/ALL LIPID/10 MG
ALEMTUZUMAB 10 MG
ALDESLEUKIN, PER SINGLE USE VIAL
ARSENIC TRIOXIDE, 1MG
ASPARAGINASE 10,000 UNITS
INJECTION AZACITIDINE 1 MG
INJECTION CLOFARABINE 1 MG
BCG (INTRAVESICAL) PER INSTALLATION
INJECTION BENDAMUSTINE HCL 1 MG
BLEOMYCIN SULFATE 15 UNITS
CARBOPLATIN, 50 MG
CARMUSTINE, 100MG
CISPLATIN, POW/SOLN/10 MG
INJ CLADRIBINE PER 1 MG
CYCLOPHOSPHAMIDE 100MG
CYTARABINE LIPOSOME 10 MG
CYTARABINE 100 MG
DACTINOMYCIN 0.5 MG
DACARBAZINE 100 MG
DAUNORUBICIN HCL 10 MG
J9151
J9160
J9165
J9175
J9178
J9181
J9185
J9190
No
No
No
No
No
No
No
No
DAUNORUBICN CITRATE LIPOSOML 10 MG
DENILEUKIN DIFTITOX 300 MCG
DIETHYLSTILBESTROL DIPHOS/250 MG
INJECTION ELLIOTTS B SOLUTION 1 ML
INJECTION EPIRUBICIN HCL 2 MG
ETOPOSIDE, 10 MG
FLUDARABINE PHOSPHATE 50 MG
FLUOROURACIL 500 MG
No
No
No
No
No
No
No
Not Reimbursable
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
CPT Code
J9200
J9201
J9202
J9206
J9207
J9208
J9209
J9211
J9212
J9213
J9214
J9215
J9216
J9217
J9218
J9219
J9225
J9226
J9230
July 2011
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
No
J9245
J9250
J9260
J9263
No
No
No
No
J9264
J9265
J9266
J9268
J9270
J9280
J9293
J9300
J9302
J9307
J9310
J9315
J9320
Code Description
FLOXURIDINE 500 MG
GEMCITABINE HCL 200 MG
GOSERELIN ACETATE IMPLANT/3.6 MG
IRINOTECAN 20 MG
INJECTION IXABEPILONE 1 MG
IFOSFAMIDE PER 1 GM
MESNA, 200 MG
IDARUBICIN HYDROCHLORIDE, 5MG
INJ INTERFERN ALFAC-1 RECOMB 1 MCG
INTERFERON,ALFA-2A,RECOMB/3 MIL U
INTERFERON,ALFA-2B,RECOMB,1 MIL U
INTERFERON, ALFA-N3, 250,000 IU
INTERFERON, GAMMA-1B, 3 MIL U
LEUPROLIDE ACET/DEPOT SUSP 7.5 MG
LEUPROLIDE ACETATE PER 1 MG
LEUPROLIDE ACETATE IMPLANT 65 MG
HISTRELIN IMPLANT 50 MG
HISTRELIN IMPLANT 50 MG
MECHLORETHAMINE HCL/10 MG
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
No
No
No
No
No
No
No
INJ MELPHALAN HYDROCHLORIDE 50 MG
METHOTREXATE SODIUM 5 MG
METHOTREXATE SODIUM 50 MG
INJECTION OXALIPLATIN 0.5 MG
INJECTION PACLITAXEL PROTEINBOUND
PARTICLES 1 MG
PACLITAXEL 30 MG
No
No
No
No
No
No
No
Yes
No
No
No
PEGASPARGASE, PER SINGLE DOSE VIAL
PENTOSTATIN PER 10 MG
PLICAMYCIN 2500 MCG
MITOMYCIN 5 MG
MITOXANTRONE HCL/5 MG
Gemtuzumab ozogamicin, 5 mg
INJECTION OFATUMUMAB 10 MG
INJECTION PRALATREXATE 1 MG
RITUXIMAB 100 MG
INJECTION ROMIDEPSIN 1 MG
STREPTOZOCIN 1 GM
No
No
No
No
No
No
No
Yes
No
No
No
No
No
CPT Code
J9330
J9340
J9351
J9355
J9357
J9360
J9370
J9390
J9395
J9600
J9999
L0113
L0120
July 2011
No
No
No
No
No
No
No
No
No
No
No
No
No
L0220
L1810
Yes
No
L1820
Code Description
INJECTION TEMSIROLIMUS 1 MG
THIOTEPA 15 MG
INJECTION TOPOTECAN 0.1 MG
TRASTUZUMAB 10 MG
VALRUBICIN INTRAVESICAL 200 MG
VINBLASTINE SULFATE 1 MG
VINCRISTINE SULFATE 1 MG
VINORELBINE TARTRATE, PER 10 MG
INJECTION FULVESTRANT 25 MG
PORFIMER SODIUM 75 MG
NOC ANTINEOPLASTIC DRUGS
CRANIL CERV ORTHOT TORTICOLLI PRFB
CERV FLEX NON ADJUS (FOAM COLLAR)
No
No
No
No
No
No
No
No
No
No
No
No, under $200
No, under $200
No, under $200
No, under $200
Yes
THORACIC RIB BELT CUSTOM FABRICATED
KO ELASTIC W/JOINTS
KO ELAST W/CONDYLR PADS&JNT PRFAB
INCL FIT&ADJ
L1830
L1902
No
No
KO IMMOBILIZER CANVAS LONGITUDINAL
AFO ANKLE GAUNTLET
No, under $200
No, under $200
L1906
L3000
L3030
No
Yes
No
AFO MULTILIGAMENTUS ANKLE SUPPORT
FT INSRT MOLD UCB, BERKELEY SHELL
FT INSERT FORMED TO PT FT EA
No, under $200
No, under $200
No, under $200
L3100
L3140
L3150
L3170
No
Yes
No
No
HALLUS-VALGUS NIGHT DYNAMIC SPLINT
FT/ABDUCT ROTATION BAR INCL SHOES
FT/ABDUCT ROTATION BAR/WO SHOES
FT PLASTIC HEEL STABILIZER
No, under $200
No, under $200
No, under $200
No under $50
L3215
Yes
ORTHO FOOTWEAR LADIES SHOE OXFORD
Yes
L3219
Yes
ORTHO FOOTWEAR LADIES SHOE OXFORD
Yes
L3230
L3310
L3320
L3334
Yes
No
No
No
ORTHO FTWEAR CUST SHOES DPTH INLAY
LIFT ELEV HEEL/SOLE NEOPRENE/IN
LIFT ELEV HEEL/SOLE CORK/IN
LIFT ELEVATE HEEL PER IN
No, under $200
No, under $200
No, under $200
No, under $200
No, under $200
CPT Code
L3340
L3350
L3360
L3400
July 2011
No
No
No
No
L3410
No
METATARSAL BAR WEDGE BETWEEN SOLE
No, under $200
L3420
L3650
No
No
FULL SOLE & HEEL WEDGE BETWEEN SOLE
SO FIG 8 DESIGN ABDUCT RESTRAIN
No, under $200
No, under $200
L3807
L3908
Yes
No
No, under $200
No, under $200
L4350
No
L4360
L4380
Yes
Yes
WHFO/AIR SUPPRT W/WO THUMB EXTEN
WHO WRIST EXTEN COCK-UP NONMOLD
ANKLE CNTRL ORTHOSIS STIRRUP RIGID
PRFAB FIT&ADJ
WALKING BOOT PNEUMATC W/WO JNTS
PREFAB W/FIT&ADJ
PNEUMATIC KNEE SPLINT
WALKING BOOT NON-PNEUMATC PREFAB
W/FIT&ADJ
BREAST PROSTH MASTECTOMY BRA
L4386
L8000
L8001
L8002
L8010
L8015
L8600
Yes
No PA - No $200 auth limit
Yes
L8603
Yes
L8604
L8606
L8614
L8619
Yes
No
Yes
Yes
L8623
Yes
L8624
Yes
L8690
Yes
Code Description
HEEL WEDGE SACH
HEEL WEDGE
SOLE WEDGE OUTSIDE SOLE
METATARSAL BAR WEDGE ROCKER
BREAST PROSTHESIS MASTECTOMY
SLEEVE
IMPLNT BREAST PROSTH SLCN/EQUAL
COLLAGEN IMPLNT/URIN/2.5CC SYR/SUPP
INJECTABLE BULKING AGENT URINARY
TRACT 1 ML
INJ SYN IMP URIN TRACT 1 ML SYRNG
Cochlear device/system
Replace cochlear processor
LITHIUM ION BATTERY OTH THAN EAR
LEVEL REPL EA
LITHIUM ION BATTERY EAR LEVEL REPL EA
AUDITORY OSSEOINTEGRATED DEVC
INT/EXT COMPONENTS
No, under $200
No, under $200
No, under $200
No, under $200
No, under $200
No, under $200
No, under $200
No, under $200
No, under $200
No, under $200
No under $50
No, under $200
NA
NA
No under $50
No under $50
No under $50
CPT Code
July 2011
L8691
Yes
L8695
L8699
Yes
No
Code Description
AUDITORY OSSEOINTEGRATD DEVC EXT
SOUND PROC REPL
EXT RECHARGING SYSTEM BATTERY
W/IMPL NEUROSTIM
Prosthetic Implant
L9900
Yes
ORTHO/PROSTH SUPP ACCES &/OR SERV
No under $50
P3000
No
SCREEN PAP <=3 SMEARS TECH/PHYS DIR
No
P3001
P9010
P9011
P9012
P9016
No
No
No
No
No
No
No
No
No
No
P9017
P9019
P9020
P9021
P9022
No
No
No
No
No
SCREEN PAP <=3 SMEARS INTERPT/PHYS
BLOOD (WHOLE)/TRANSFUSION/UNIT
BLOOD (SPLIT UNIT) SPECIFY AMOUNT
CRYOPRECIPITATE EACH UNIT
LEUKOCYTE POOR BLOOD EACH UNIT
FRESH FRZN PLASMA FRZN WITHIN 8 HRS
CLCT EA UNIT
PLATELET CONCENTRATE EACH UNIT
PLATELET RICH PLASMA EACH UNIT
RED BLOOD CELLS EACH UNIT
WASHED RED BLOOD CELLS EACH UNIT
P9023
No
PLASMA POOL SOL/DTRGNT FROZ EA UNIT
No
P9031
P9032
P9033
P9034
No
No
No
No
PLATELETS LEUKOCYTES REDUC EA UNT
PLATELETS IRRADIATED EA UNT
PLATELETS LEUKOCYTES REDUC IRRAD
PLATELETS PHERESIS EA UNT
No
No
No
No
P9035
P9036
No
No
PLATELETS PHERESIS LEUKOCYTES RED
PLATELETS PHERESIS IRRADIATED EA
No
No
P9037
P9038
P9039
P9040
P9041
No
No
No
No
No
PLTLTS PHERESIS LEUKOCYTS RED IRRAD
RED BLD CELLS IRRADIATED EA UNT
RB CELLS DEGLYCEROLIZED EA UNT
RED BLD CELLS LYTES RED IRRADIATED
INFUS ALBUMIN (HUMAN) 5% 50 ML
No
No
No
No
No
P9043
No
INFUS PLASMA PROT FRACTION 5% 50 ML
No
No under $50
No under $50
NA
No
No
No
No
No
CPT Code
P9044
P9045
P9046
P9047
July 2011
No
No
No
No
P9048
P9050
P9612
P9615
Q0081
Q0083
Q0084
Q0085
No
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
INFUS PLASMA PROT FRACTION 5% 250ML
GRANULOCYTES PHERESIS EACH UNIT
CATH COLLECT SPECMN 1 PT ALL POS
CATH COLLECT SPEC MULT PTS
INFUS THERAP NOT CHEMO/VISIT
CHEMO ADMIN NOT INFUS TECH/VISIT
CHEMO ADMIN INFUS TECH ONLY/VISIT
CHEMO ADMIN INFUS & OTH TECH/VISIT
No
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Q0091
Q0092
Q0111
Q0112
Q0113
Q0114
Q0115
Q0144
Q0163
Not Reimbursable
Bundled
No
No
No
No
No
No
No
SCREEN PAP OBTAIN PREP CONVEY LAB
SET-UP PORTABLE X-RAY EQUIPMENT
WET MOUNTS/PREP VAG/CERV/SKIN
ALL POTASSIUM HYDROXIDE PREP
PINWORM EXAM
FERN TEST
POST-COITAL DIR QUAL EXAM
AZITHROMYCIN DIHYDRATE ORAL-1GM
DIPHENHYDRAMINE HCL 50 MG ORAL
Not Reimbursable
Bundled
No
No
No
No
No
No
No
Q0164
No
Q0165
Q0166
Q0167
Q0168
Q0169
Q0170
No
No
No
No
No
No
Q0171
No
Q0172
Q0173
Code Description
PLASMA CRYOPRECIPITATE REDUC EA
INFUSION ALBUMIN 5% 250 ML
No
No
No
No
No
No
PROCHLORPERAZINE MALEATE 5 MG ORAL
PROCHLORPERAZINE MALEATE 10 MG
ORAL
GRANISETRON HCL 1 MG ORAL
DRONABINOL 2.5 MG ORAL ANTI-EMETIC
DRONABINOL 5 MG ORAL ANTI-EMETIC
PROMETHAZINE HCL 12.5 MG ORAL
PROMETHAZINE HCL 25 MG ORAL
CHLORPROMAZINE HCL 10 MG ORAL
CHEMO
CHLORPROMAZINE HCL 25 MG ORAL
CHEMO
No
TRIMETHOBENZAMIDE HCL 250 MG ORAL
No
No
No
No
No
No
No
No
No
CPT Code
July 2011
Q0174
No
THIETHYLPERAZINE MALEATE 10 MG ORAL
No
Q0175
No
PERPHENZAINE 4 MG ORAL ANTI-EMETIC
No
Q0176
Q0177
Q0178
Q0179
Q0180
No
No
No
No
No
PERPHENZAINE 8 MG ORAL ANTI-EMETIC
HYDROXYZINE PAMOATE 25 MG ORAL
HYDROXYZINE PAMOATE 50 MG ORAL
ODANSETRON HCL 8 MG ORAL
DOLASETRON MESYLATE 100 MG ORAL
No
No
No
No
No
Q0181
No
No
Q0515
No
Q1003
Not Reimbursable
Q1004
Not Reimbursable
Q1005
Q2004
Q2009
Q2017
Q2026
Q2026
Q2027
Q2027
Q2035
Q2036
Q2037
Q2038
Q2039
Q2041
Q2043
Q2044
Q3001
Q3014
Q3025
Q3026
Not Reimbursable
No
No
No
No
Not Reimbursable
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Yes
Yes
Yes
Not Reimbursable
No
No
No
UNSPEC ORAL DOSE FORM ANTI-EMETIC
INJECTION SERMORELIN ACETATE 1
MICROGRAM
NEW TECH INTRAOCULAR LENS
CATEGORY
CATEGORY
CATEGORY
IRRIG SOLN TX OF BLDR CALCULI 500ML
INJ FOSPHENYTOIN 50 MG
INJ TENIPOSIDE 50 MG
INJECTION RADIESSE 0.1ML
INJECTION RADIESSE 0.1ML
INJECTION SCULPTRA 0.1ML
INJECTION SCULPTRA 0.1ML
FLU VACC SPLIT 3 YRS & > IM AFLURIA
FLU VACC SPLIT 3 YR & > IM FLULAVAL
FLU VACC SPLIT 3 YR & > IM FLUVIRIN
FLU VACC SPLIT 3 YRS & > IM FLUZONE
FLU VACC SPLIT VIRUS 3 YRS > IM NOS
Code Description
RADIOELEMENTS FOR BRACHYTHERAP
TELEHEALTH ORIG SITE FACILITY FEE
IM INJ INTERFERON BETA 1-A
SUB INJ INTERFERON BETA 1-A
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
No
No
Not Reimbursable
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Yes
Yes
Yes
No
No
No
No
CPT Code
Q3031
July 2011
Bundled
Q4001
No
CAST BDY CAST ADLT W/WO HEAD PLAST
No
Q4002
Q4003
Q4004
No
No
No
CAST BDY CAST ADLT W/WO HEAD F-GLSS
CAST SPL SHLDR CAST ADULT PLASTR
CAST SPL SHLDR CAST ADULT FIBRGLS
No
No
No
Q4005
No
CAST SPL LONG ARM CAST ADULT PLASTR
No
Q4006
Q4007
Q4008
No
No
No
CAST SPL LONG ARM CAST ADLT FIBRGLS
CAST SPL LNG ARM CAST PED PLASTR
CAST SPL LNG ARM CAST PED FIBRGLS
No
No
No
Q4009
No
CAST SPL SHORT ARM CAST ADLT PLASTR
No
Q4010
No
CAST SPL SHRT ARM CAST ADLT FIBRGLS
No
Q4011
No
CAST SPL SHORT ARM CAST PED PLASTR
No
Q4012
No
CAST SPL SHORT ARM CAST PED FIBRGLS
No
Q4013
No
CAST SPL GAUNTLT CAST ADULT PLASTR
No
Q4014
Q4015
No
No
CAST SPL GAUNTLET CAST ADLT F-GLASS
CAST SPL GAUNTLT CAST PED PLASTR
No
No
Q4016
No
CAST SPL GAUNTLET CAST PED F-GLASS
No
Q4017
No
CAST SPL LNG ARM SPLINT ADLT PLASTR
No
Q4018
No
CAST SPL LNG ARM SPLNT ADLT FIBRGLS
No
Q4019
No
CAST SPL LNG ARM SPLINT PED PLASTR
No
Q4020
No
CAST SPL LNG ARM SPLINT PED FIBRGLS
No
Q4021
No
CAST SPL SHRT ARM SPLINT ADLT PLAST
No
Code Description
COLLAGEN SKIN TEST
Bundled
CPT Code
July 2011
Q4022
No
CAST SPL SHRT ARM SPLNT ADLT F-GLSS
No
Q4023
No
CAST SPL SHORT ARM SPLINT PED PLAST
No
Q4024
Q4025
Q4026
Q4027
Q4028
No
No
No
No
No
CAST SPL SHRT ARM SPLNT PED FIBRGLS
CAST SPL HIP SPICA ADULT PLASTR
CAST SPL HIP SPICA ADULT FIBRGLS
CAST SPL HIP SPICA PEDIATRIC PLASTR
CAST SPL HIP SPICA PED FIBRGLS
No
No
No
No
No
Q4029
No
CAST SPL LONG LEG CAST ADULT PLASTR
No
Q4030
Q4031
Q4032
No
No
No
CAST SPL LONG LEG CAST ADLT FIBRGLS
CAST SPL LNG LEG CAST PED PLASTR
CAST SPL LNG LEG CAST PED FIBRGLS
No
No
No
Q4033
No
CAST LNG LEG CYCLE CAST ADLT PLAST
No
Q4034
Q4035
No
No
CAST LNG LEG CYCLE CAST ADLT F-GLSS
CAST LNG LEG CYCLE CAST PED PLAST
No
No
Q4036
No
CAST LNG LEG CYCLE CAST PED F-GLSS
No
Q4037
No
CAST SPL SHORT LEG CAST ADLT PLASTR
No
Q4038
No
CAST SPL SHRT LEG CAST ADLT FIBRGLS
No
Q4039
No
CAST SPL SHORT LEG CAST PED PLASTR
No
Q4040
No
CAST SPL SHORT LEG CAST PED FIBRGLS
No
Q4041
No
CAST SPL LNG LEG SPLINT ADLT PLASTR
No
Q4042
Q4043
No
No
CAST SPL LNG LEG SPLNT ADLT FIBRGLS
CAST SPL LNG LEG SPLINT PED PLASTR
No
No
Q4044
No
CAST SPL LNG LEG SPLINT PED FIBRGLS
No
Code Description
CPT Code
July 2011
Q4045
No
CAST SPL SHRT LEG SPLINT ADLT PLAST
No
Q4046
No
CAST SPL SHRT LEG SPLNT ADLT F-GLSS
No
Q4047
No
CAST SPL SHORT LEG SPLINT PED PLAST
No
Q4048
Q4049
Q4050
Q4051
No
No
No
No
No
No
No
No
Q4100
Non Reimbursible
CAST SPL SHRT LEG SPLNT PED FIBRGLS
FINGER SPLINT STATIC
CAST SPL UNLIST TYPES&MATL CASTS
SPLINT SUPPLIES MISCELLANEOUS
SKIN SUBSTITUTE NOT OTHERWISE
SPECIFIED
Q4101
No
Q4102
No
Q4103
No
Q4104
No
Q4105
No
Q4106
No
Q4107
No
Q4108
No
Q4110
No
Q4111
Q4112
No
Non Reimbursible
Q4113
Non Reimbursible
Q4114
Q4121
Non Reimbursible
Not Reimbursable
Code Description
Non Reimbursible
SKIN SUBSTITUTE APLIGRAF PER SQ CM
SKIN SUBSTITUTE OASIS WOUND MATRIX
PER SQ CM
SKIN SUBSTITUTE OASIS BURN MATRIX
PER SQ CM
SKIN SUBSTITUTE INTEGRA BMWD PER SQ
CM
SKIN SUBSTITUTE INTEGRA DRT PER SQ
CM
SKIN SUBSTITUTE DERMAGRAFT PER SQ
CM
SKIN SUBSTITUTE GRAFTJACKET PER SQ
CM
SKIN SUBSTITUTE INTEGRA MATRIX PER
SQ CM
No under $50
SKIN SUBSTITUTE PRIMATRIX PER SQ CM
SKIN SUBSTITUTE GAMMAGRAFT PER SQ
CM
ALLOGRAFT CYMETRA INJECTABLE 1 CC
ALLOGRAFT GRAFTJACKET EXPRESS
INJECTABLE 1CC
INTEGRA FLOWABLE WOUND MATRIX
INJECTABLE 1 CC
THERASKIN PER SQ CM
No under $50
No under $50
No under $50
No under $50
No under $50
No under $50
No under $50
No under $50
No under $50
Non Reimbursible
Non Reimbursible
Non Reimbursible
Not Reimbursable
CPT Code
July 2011
Q5010
Q9951
Not Reimbursable
No
Q9968
No
INJ NONRA NONCNTRST VIZ ADJNCT 1 MG
No
R0070
R0075
R0076
No
No
Bundled
No
No
Bundled
S0012
S0014
S0017
Not Reimbursable
Not Reimbursable
Not Reimbursable
TRANSP PORT X-RAY/PERS/TRIP SNGL PT
TRANSP PORT X-RAY/PERS MX PT EA
TRANSP PORT EKG/FACIL/LOCATION/PT
BUTORPHANOL TARTRATE NAS SPRAY
25MG
TACRINE HYDROCHLORIDE 10 MG
INJ AMINOCAPROIC ACID 5 GMS
Not Reimbursable
Not Reimbursable
Not Reimbursable
S0020
S0021
Not Reimbursable
Not Reimbursable
INJ BUPIVICAINE HYDROCHLORIDE 30 ML
INJ CEFTOPERAZONE NA 1 GM
Not Reimbursable
Not Reimbursable
S0023
S0028
S0030
S0032
S0034
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
INJ CIMETIDINE HYDROCHLORIDE 300 MG
INJ FAMOTIDINE 20 MG
INJ METRONIDAZOLE 500 MG
INJ NAFCILLIN NA 2 GMS
INJ OFLOXACIN 400 MG
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
S0039
S0040
S0073
S0074
S0077
S0078
S0080
S0081
S0088
S0090
S0091
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
Not Reimbursable
No
INJ SULFAMETHOXAZOLE/TRIMETHOPRIM
INJ TICARCILLIN/CLAVULANATE 3.1 GM
INJ AZTREONAM 500 MG
INJ CEFOTETAN DINA 500 MG
INJ CLINDAMYCIN PHOSPHATE 300 MG
INJ FOSPHENYTOIN NA 750 MG
INJ PENTAMIDINE ISETHIONATE 300 MG
INJ PIPERACILLIN NA 500 MG
IMATINIB 100 MG
SILDENAFIL CITRATE 25 MG
GRANISETRON HYDROCHLORIDE 1 MG
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
Not Reimbursable
No
S0092
S0093
S0104
No
No
No
INJECTION HYDROMORPHONE HCL 250 MG
INJECTION MORPHINE SULFATE 500 MG
ZIDOVUDINE, ORAL, 100 MG
No
No
No
Code Description
HOSPICE HOME CARE PROV HOSPICE FACL
LOCM 400/> MG/ML IODINE CONC ML
Not Reimbursable
No
CPT Code
July 2011
S0106
S0108
S0122
S0126
S0128
S0132
S0136
S0137
S0138
S0139
S0140
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
Code Description
BUPROPION HCI SUSTAINED RLSE TAB 150
MG 60 TABS
MERCAPTOPURINE ORAL 50 MG
INJECTION MENOTROPINS 75 IU
INJECTION FOLLITROPIN ALFA 75 IU
INJECTION FOLLITROPIN BETA 75 IU
INJECTION GANIRELIX ACETATE 250 MCG
CLOZAPINE 25 MG
DIDANOSINE 25 MG
FINASTERIDE 5 MG
MINOXIDIL 10 MG
SAQUINAVIR 200 MG
S0148
Not Reimbursable
INJ PEGYLATD INTRFER ALFA-2B 10 MCG
Not Reimbursable
Not Reimbursable
INJ PEGYLATD INTRFER ALFA-2B 10 MCG
Not Reimbursable
S0148
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
S0155
S0156
S0157
S0160
No
No
No
No
STERILE DILUTANT EPOPROSTENOL 50 ML
EXEMESTANE 25 MG
BECAPLERMIN GEL 0.01% 0.5 GM
DEXTROAMPHETAMINE SULFATE 5 MG
No
No
No
No
S0164
S0169
S0169
S0170
S0171
S0172
S0174
S0175
S0176
No
Not Reimbursable
Not Reimbursable
No
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
No
No
No
No
No
No
S0177
S0178
S0179
No
No
No
S0181
No
S0182
No
INJECTION PANTOPRAZOLE SODIUM 40 MG
CALCITROL 0.25 MICROGRAM
CALCITROL 0.25 MICROGRAM
ANASTROZOLE ORAL 1 MG
INJECTION BUMETANIDE 0.5 MG
CHLORAMBUCIL ORAL 2 MG
DOLASETRON MESYLATE ORAL 50 MG
FLUTAMIDE ORAL 125 MG
HYDROXYUREA ORAL 500 MG
LEVAMISOLE HYDROCHLORIDE ORAL 50
MG
LOMUSTINE ORAL 10 MG
MEGESTROL ACETATE ORAL 20 MG
ONDANSETRON HYDROCHLORIDE ORAL 4
MG
PROCARBAZINE HYDROCHLORD ORAL 50
MG
No
No
No
No
No
CPT Code
July 2011
S0183
S0187
S0189
S0190
S0191
No
No
No
No
No
S0194
Not Reimbursable
S0195
Not Reimbursable
S0201
Not Reimbursable
S0207
Not Reimbursable
S0265
Non Reimbursible
S0315
S0316
Not Reimbursable
Not Reimbursable
S0317
Not Reimbursable
S0320
S0390
Not Reimbursable
Not Reimbursable
S1040
S2068
Not Reimbursable
Yes
PROCHLORPERAZINE MALEATE ORAL 5 MG
TAMOXIFEN CITRATE ORAL 10 MG
TESTOSTERONE PELLET 75 MG
MITEPRISTONE, ORAL, 200 MG
MISOPROSTOL, ORAL 200 MCG
DIALYSIS/STRESS VITAMIN SUPL ORAL 100
CAPSULES
PNEUMCOCCL CONJUGAT VAC IM 5-9 YR
NOT PREV RECVD
PARTIAL HOSITALIZTION SERVICES < 24 HR
PER DIEM
PARAMEDIC INTERCPT NON-HOSP ALS
SRVC NON-TRNSPRT
GENETIC COUNSELING PHYS SUPERVISION
EA 15 MINS
DISEASE MANAGEMENT PROGM; INIT
ASSESS&INIT PROGM
FOLLOW-UP/REASSESSMENT
DISEASE MANAGEMENT PROGRAM; PER
DIEM
TEL CALL BY RN TO DZ MGMT PROG
MEMBER MON;-MONTH
ROUTINE FOOT CARE; PER VISIT
CRANIL REMOLD ORTHOS RIGD
W/INTERFCE MATL CSTM
BREAST RECON DIEP/SIEA FLAP UNI
S2070
Not Reimbursable
CYSTO W/URETERSCPY&/PYELSCPY;LASR
TX URETRL CALC
S2079
Non Reimbursible
S2083
Not Reimbursable
S2095
Not Reimbursable
S2107
Not Reimbursable
Code Description
LAP ESOPHAGOMYOTOMY HELLER TYPE
ADJ GASTRIC BAND DIAM SUBQ PORT
INJ/ASPIR SALINE
TRNSCATH OCCL/EMBOLIZ TUMR DESTRUC
PERQ METH USI
ADOPTIVE IMMUNOTHERAPY PER COURSE
OF TREATMENT
No
No
No
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
CPT Code
July 2011
S2118
Yes
S2152
S2225
Not Reimbursable
Not Reimbursable
S2230
Not Reimbursable
S2235
Not Reimbursable
S2265
Not Reimbursable
S2266
Not Reimbursable
S2267
Not Reimbursable
S2270
S2325
Non Reimbursible
Yes
S2344
Not Reimbursable
S2405
Not Reimbursable
S2900
No
S3000
Not Reimbursable
S3625
Yes
S3626
No
S3628
S3655
S3711
S3713
Non Reimbursible
Not Reimbursable
Non Reimbursible
Non Reimbursible
S3820
Not Reimbursable
S3822
Not Reimbursable
Code Description
METL-ON-METL TOT HIP RESRFC
ACETAB&FEM CMPNT
SOLID ORGAN; TRANSPLANTATION &
RELATED COMP
MYRINGOTOMY LASER-ASSISTED
IMPL MAGNET CMPNT SEMI-IMPL HEARING
DEVC MID EAR
IMPLANTATION OF AUDITORY BRAIN STEM
IMPLANT
ABORTION FOR FETAL INDICATION 25-28
WEEKS
ABORTION FOR FETAL INDICATION 29-31
WEEKS
ABORTION FETAL INDICATION 32 WEEKS
OR GREATER
INSRT VAG CYL APPLIC RAD SOURCE/CLIN
BRACHYTX
HIP CORE DECOMPRESSION
NASAL/SINUS ENDO; ENLARGE OSTIUM
INFLAT DEVICE
REPR SACROCOC TERATOMA FETUS IN
UTERO
SURG TECHNIQUES REQUIRING USE
ROBOTIC SURG SYS
DIABETIC INDICATOR; RETINAL EYE EXAM
DILAT BILAT
MATERNL SERUM TRIPLE MARKR SCR
W/AFP ESTRIOL&HCG
MATERNAL SERUM SCR W/AFP ESTRIOL
HCG INHIBIN A
PLACNTL ALPHA MICROGLOBULN-1 RAPID
IA DETECT ROM
ANTISPERM ANTIBODIES TEST
CIRCULATING TUMOR CELL TEST
KRAS MUTATION ANALYSIS TESTING
COMPL BRCA1&BRCA2 GENE SEQ ANALY
BRST&OVARN CA
SINGLE-MUTAT ANALY SUSCEPT
BREAST&OVARIAN CANCER
NA
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Non Reimbursible
Yes
Not Reimbursable
Not Reimbursable
No
Not Reimbursable
Yes
No
Non Reimbursible
Not Reimbursable
Non Reimbursible
Non Reimbursible
Not Reimbursable
Not Reimbursable
CPT Code
July 2011
S3823
Not Reimbursable
S3828
Not Reimbursable
S3829
Not Reimbursable
S3833
Not Reimbursable
S3834
Not Reimbursable
S3840
Not Reimbursable
S3841
Not Reimbursable
S3842
Not Reimbursable
S3843
Not Reimbursable
S3844
Not Reimbursable
S3845
Not Reimbursable
S3846
Not Reimbursable
S3847
Not Reimbursable
S3848
Not Reimbursable
S3849
Not Reimbursable
S3850
Not Reimbursable
S3851
Not Reimbursable
S3852
Not Reimbursable
S3853
Not Reimbursable
Code Description
3-MUTATION BRCA1&BRCA2 ANALYSIS
ASHKENAZI IND
COMPLETE GENE SEQUENCE ANALYSIS;
MLH1 GENE
COMPLETE GENE SEQUENCE ANALYSIS;
MLH2 GENE
CMPL APC GENE SEQ ANALY SUSCPT
FAP&ATTENUATD FAP
SINGLE-MUTAT ANALY SUSCEPT
FAP&ATTENUATED FAP
DNA ANALYSIS GERMLINE MUTATS RET
PROTO-ONCOGENE
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
GENETIC TESTING FOR RETINOBLASTOMA
GENETIC TESTING FOR VON HIPPELLINDAU DISEASE
DNA ANALYSIS F5 GENE FCT V LEIDEN
THROMBOPHILIA
DNA ANALY CONNEXIN 26 GENE CONGN
PFND DEAFNESS
GENETIC TESTING FOR ALPHATHALASSEMIA
GENETIC TESTING HEMOGLOBIN E BETATHALASSEMIA
GENETIC TESTING FOR TAY-SACHS
DISEASE
Not Reimbursable
GENETIC TESTING FOR GAUCHER DISEASE
GENETIC TESTING FOR NIEMANN-PICK
DISEASES
GENETIC TESTING FOR SICKLE CELL
ANEMIA
Not Reimbursable
GENETIC TESTING FOR CANAVAN DISEASE
DNA ANALY APOE EPSILON 4 ALLELE
SUSECPT ALZS DZ
GENETIC TESTING FOR MYOTONIC
MUSCULAR DYSTROPHY
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
CPT Code
July 2011
S3854
Not Reimbursable
S3855
Not Reimbursable
S3860
Non Reimbursible
S3861
Non Reimbursible
S3862
Non Reimbursible
Code Description
GENE EXPRSSGENE EXPRSSION
PROFILING PANL MGMT BR
GENETIC TEST DETECT MUTATIONS
PRESENILIN 1 GENE
GENETIC TESTING COMP CARDIAC ION
CHANNEL ANALY
GENETIC TESTING SCN5A & VARIANTS FOR
SUSPCTED BS
GENETIC TEST FAMILY-SPECIFIC ION
CHANNEL ANALY
S3865
S3866
Non Reimbursible
Non Reimbursible
COMP GENE SEQUENCE ANALYSIS HCM
GENETIC ANALYSIS GENE MUTAT HCM
Non Reimbursible
Non Reimbursible
S3870
Non Reimbursible
Non Reimbursible
S3890
Not Reimbursable
S4013
Not Reimbursable
S4014
Not Reimbursable
S4017
Not Reimbursable
S4023
Not Reimbursable
S4035
Not Reimbursable
S4037
Not Reimbursable
S4040
S4995
S5000
S5001
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
CGH MICROARRAY TEST DD ASD AND/ MR
DNA ANALYSIS FECAL COLORECTAL
CANCER SCREENING
CMPL CYCLE GAMETE INTRAFALLOPIAN
TRNSF CASE RATE
CMPL CYCLE ZYGOTE INTRAFALLOPIAN
TRNSF CASE RATE
INCPL CYCLE TX CANCELED PRIOR TO
STIM CASE RATE
DONOR EGG CYCLE INCOMPLETE CASE
RATE
STIM INTRAUTERINE INSEMINATION CASE
RATE
CRYOPRESERVED EMBRYO TRANSFER
CASE RATE
MON & STORAGE CRYOPRESERVED
EMBRYOS PER 30 DAYS
SMOKING CESSATION GUM
SCRIPT DRUG GENERIC
SCRIPT DRUG BRAND NAME
S5010
No
S5011
No
5% DEXTROSE AND 45% NORM SAL 1000ML
5% DEXTROSE-LACTATD RINGERS
1000ML
Not Reimbursable
Not Reimbursable
Non Reimbursible
Non Reimbursible
Non Reimbursible
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
CPT Code
July 2011
S5012
No
5% DEXTROSE W/POT CHLORIDE 1000 ML
No
S5013
No
5% DEXTROSE/45% NORM SALINE/1000ML
No
S5014
No
No
S5100
Not Reimbursable
S5101
S5102
Not Reimbursable
Not Reimbursable
S5105
Not Reimbursable
S5108
Not Reimbursable
S5109
Not Reimbursable
S5110
Not Reimbursable
S5111
Not Reimbursable
S5115
Not Reimbursable
S5116
S5120
S5121
S5126
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
S5130
S5131
Not Reimbursable
Not Reimbursable
S5135
S5136
S5140
S5141
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
S5145
Not Reimbursable
5% DEXTROSE/45% NORM SALINE/1500ML
DAY CARE SERVICES ADULT; PER 15
MINUTES
DAY CARE SERVICES ADULT; PER HALF
DAY
DAY CARE SERVICES, ADULT; PER DIEM
DAY CARE SRVC CENTER-BASED; NOT
W/PROG FEE-DIEM
HOME CARE TRAINING HOME CARE CLIENT
PER 15 MIN
HOME CARE TRAINING HOME CARE CLIENT
PER SESSION
HOME CARE TRAINING FAMILY; PER 15
MINUTES
HOME CARE TRAINING FAMILY; PER
SESSION
HOME CARE TRAINING NON-FAMILY; PER 15
MINUTES
HOME CARE TRAINING NON-FAMILY; PER
SESSION
CHORE SERVICES; PER 15 MINUTES
CHORE SERVICES; PER DIEM
ATTENDANT CARE SERVICES; PER DIEM
HOMEMAKER SERVICE NOS; PER 15
MINUTES
HOMEMAKER SERVICE, NOS; PER DIEM
COMPANION CARE ADULT ; PER 15
MINUTES
COMPANION CARE, ADULT ; PER DIEM
FOSTER CARE, ADULT; PER DIEM
FOSTER CARE, ADULT; PER MONTH
FOSTER CARE THERAPEUTIC CHILD; PER
DIEM
Code Description
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
CPT Code
July 2011
S5146
Not Reimbursable
S5150
Not Reimbursable
S5151
Not Reimbursable
S5160
Not Reimbursable
S5161
Not Reimbursable
S5162
S5165
Not Reimbursable
Not Reimbursable
S5170
Not Reimbursable
S5175
Not Reimbursable
S5180
Not Reimbursable
S5181
Not Reimbursable
S5185
Not Reimbursable
S5190
S5199
S5550
S5551
S5552
S5553
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
S5560
Not Reimbursable
S5561
Not Reimbursable
S5565
Not Reimbursable
S5566
Not Reimbursable
Code Description
FOSTER CARE THERAPEUTIC CHILD; PER
MONTH
UNSKILLED RESPITE CARE NOT HOSPICE;
PER 15 MIN
UNSKILLED RESPITE CARE NOT HOSPICE;
PER DIEM
EMERGENCY RESPONSE SYSTEM;
INSTALLATION&TESTING
EMERGENCY RESPONSE SYSTEM; SERVICE
FEE PER MONTH
EMERGENCY RESPONSE SYSTEM;
PURCHASE ONLY
HOME MODIFICATIONS; PER SERVICE
HOME DELIV MEALS INCLUDING
PREPARATION; PER MEAL
LAUNDRY SERVICE EXTERNAL
PROFESSIONAL; PER ORDER
HOME HEALTH RESPIRATORY THERAPY
INIT EVALUATION
HOME HEALTH RESPIRATORY THERAPY
NOS PER DIEM
MEDREMINDER SERVICE NON-FCE-TO-FCE;MONTH
WELLNESS ASSESSMENT PERFORMED BY
NON-PHYSICIAN
PERSONAL CARE ITEM, NOS, EACH
INSULIN RAPID ONSET; 5 UNITS
INSULIN MOST RAPID ONSET; 5 UNITS
INSULIN INTERMEDIATE ACTING; 5 UNITS
INSULIN LONG ACTING; 5 UNITS
INSULIN DELIVERY DEVICE REUSABLE PEN;
1.5 ML SZ
INSULIN DELIVERY DEVICE REUSABLE PEN;
3 ML SIZE
INSULIN CARTRIDGE INSULIN DEVC NOT
PUMP; 150 U
INSULIN CARTRIDGE INSULIN DEVC NOT
PUMP; 300 U
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
CPT Code
July 2011
S5570
Not Reimbursable
S5571
Not Reimbursable
S8042
Not Reimbursable
S8101
Not Reimbursable
S8120
Not Reimbursable
S8121
Not Reimbursable
S8262
S8301
S8460
Not Reimbursable
Not Reimbursable
Not Reimbursable
S8948
Not Reimbursable
S8990
Not Reimbursable
S9034
Not Reimbursable
S9145
S9150
Not Reimbursable
Not Reimbursable
S9335
Not Reimbursable
S9401
Not Reimbursable
S9430
Not Reimbursable
S9434
Not Reimbursable
S9437
Not Reimbursable
S9438
Not Reimbursable
S9439
Not Reimbursable
Code Description
INSULIN DELIV DEVICE DISPOSABLE PEN;
1.5 ML SIZE
INSULIN DELIV DEVICE DISPOSABLE PEN; 3
ML SIZE
MAGNETIC RESONANCE IMAGING LOWFIELD
HOLD CHAMB W/INHAL/NEBULIZR; W/MASK
O2 CONTENTS GASEOUS 1 UNIT EQULS 1
CUBIC FOOT
OXYGEN CONTENTS LIQUID 1 UNIT EQUALS
1 POUND
MANDIBULAR ORTHOPEDIC
REPOSITIONING DEVICE EACH
INFECTION CONTROL SUPPLIES NOS
CAMISOLE POST-MASTECTOMY
APPLIC MODAL 1/MORE AREAS; LW-LEVL
LASR; EA 15 M
PHYSICAL/MANIP TX MAINT RATHER THAN
RESTORATION
EXTRACORPOREAL SHOCKWAVE
LITHOTRIPSY GALL STONES
INSULIN PUMP INITIATION INSTRUCTION
USE OF PUMP
EVALUATION BY OCCULARIST
HOM TX HD; ADMIN PROF PHRM SRVC
SPL&EQP PER DIEM
ANTICOAGULAT CLIN INCL ALL SERV NO
LAB PER SESS
PHARMACY COMPOUNDING AND
DISPENSING SERVICES
MOD SOLID FOOD SUPPLEMENTS INBORN
ERRORS METAB
CHILDBRTH REFRESH CLASSES NONPHYSICIAN PER SESS
CESAREAN BIRTH CLASSES NONPHYSICIAN PER SESSION
VBAC CLASSES NON-PHYSICIAN PER
SESSION
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
CPT Code
July 2011
S9444
Not Reimbursable
S9447
Not Reimbursable
S9449
Not Reimbursable
S9451
Not Reimbursable
S9452
Not Reimbursable
S9453
Not Reimbursable
S9454
Not Reimbursable
S9476
Not Reimbursable
S9484
Not Reimbursable
S9490
Not Reimbursable
S9590
Not Reimbursable
S9900
S9970
Not Reimbursable
Not Reimbursable
S9975
Not Reimbursable
S9976
Not Reimbursable
S9977
Not Reimbursable
Code Description
PARENTING CLASSES NON-PHYSICIAN PER
SESS
INFANT SAFETY CLASSES NON-PHYSICIAN
PER SESSION
WEIGHT MANAGEMENT CLASSES NONPHYS PER SESSION
EXERCISE CLASSES NON-PHYSICIAN PER
SESSION
NUTRITION CLASSES NON-PHYSICIAN PER
SESSION
SMOKING CESSATION CLASSES NONPHYSICIAN PER SESS
STRESS MGMT CLASSES NON-PHYSICIAN
PER SESSION
VESTIBULAR REHAB PROGM NONPHYSICIAN PROV-DIEM
CRISIS INTERVEN MENTAL HEALTH
SERVICES PER HOUR
HOME INFUSION TX CORTICOSTEROID
INFUS; PER DIEM
HOM TX IRRIG TX; W/ADMN PHRM SRVC
CARE-PER DIEM
SRVC AUTH CHRISTIAN SCI PRACTITIONER;
NO IP SRVC
HEALTH CLUB MEMBERSHIP ANNUAL
TRANSPLANT REL LODG MEALS &
TRNSPRT PER DIEM
LODGING PER DIEM NOT OTHERWISE
SPECIFIED
MEALS PER DIEM NOT OTHERWISE
SPECIFIED
T1000
T1003
T1004
Not Reimbursable
Not Reimbursable
Not Reimbursable
PRIV DUTY/INDEPENDENT NRS TO 15 MIN
LPN/LVN SERVICES UP TO 15 MINUTES
SRVC QUALIFIED NRS AIDE TO 15 MIN
Not Reimbursable
Not Reimbursable
Not Reimbursable
T1005
Not Reimbursable
SRVC QUAL NURSING AIDE UP TO 15 MIN
Not Reimbursable
T1006
Not Reimbursable
ALCOHL&/SBSTNC ABS FAM/COUPLE CNSL
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
CPT Code
July 2011
T1007
Not Reimbursable
ALCOHOL&/SUBSTANCE ABUSE SERVICES
Not Reimbursable
T1009
Not Reimbursable
CHILD SIT IND ALC&/SUBSTNC ABS SRVC
Not Reimbursable
T1010
Not Reimbursable
MEALS REC ALCOHL&/SUBSTNC ABS SRVC
Not Reimbursable
T1012
Not Reimbursable
Not Reimbursable
T1013
T1014
T1020
Not Reimbursable
Not Reimbursable
No
T1021
Not Reimbursable
T1022
Not Reimbursable
T1025
Not Reimbursable
T1026
Not Reimbursable
T1027
Not Reimbursable
T1028
Not Reimbursable
T1029
Not Reimbursable
T1030
Not Reimbursable
T1031
Not Reimbursable
T1502
Not Reimbursable
T1999
Not Reimbursable
T2001
Not Reimbursable
T2002
Not Reimbursable
ALCOHOL&/SBSTNC ABS SRVC SKL DVLP
SIGN LANGUAGE/ORAL INTERPRETER
SRVC
TELEHEALTH TRANS MIN PROF SRVC
PERSONAL CARE SERVICES PER DIEM
HOME HEALTH AIDE/CERTIFIED NURSE
ASST PER VISIT
CONTRACT HOME HEALTH SRVC UNDER
CONTRACT DAY
INTEN MXDISCPLIN SRVC CHILD W/CMPLX
IMPAIR DIEM
INTEN MXDISCPLIN SRVC CHILD W/CMPLX
IMPAIR HR
FAMILY TRAIN & COUNSEL CHILD
DEVELOPMENT 15 MINS
ASSESSMENT HOME PHYSICAL & FAMILY
ENVIRONMENT
COMP ENVIR LEAD INVESTIGAT NOT W/LAB
ANALY-DWELL
NURSING CARE THE HOME REGISTERED
NURSE PER DIEM
NURSING CARE IN THE HOME BY LPN PER
DIEM
ADMIN ORL IM&/SUBQ MED HLTH CARE
AGCY/PROF-VISIT
MISC TX ITEMS & SUPPLIES RETAIL
PURCHASES NOC
NON-EMERG TRANSPORTATION; PT
ATTENDANT/ESCORT
NON-EMERGENCY TRANSPORTATION; PER
DIEM
Code Description
Not Reimbursable
Not Reimbursable
Yes for home type settings
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
CPT Code
July 2011
T2003
Not Reimbursable
T2004
Not Reimbursable
T2005
Not Reimbursable
T2007
Not Reimbursable
T2010
Not Reimbursable
T2011
Not Reimbursable
T2012
Not Reimbursable
T2013
Not Reimbursable
T2014
Not Reimbursable
T2015
Not Reimbursable
T2016
Not Reimbursable
T2017
Not Reimbursable
T2018
Not Reimbursable
T2019
T2020
Not Reimbursable
Not Reimbursable
T2021
T2022
Not Reimbursable
Not Reimbursable
T2023
Not Reimbursable
T2024
Not Reimbursable
T2025
Not Reimbursable
Code Description
NON-EMERGENCY TRANSPORTATION;
ENCOUNTER/TRIP
NON-EMERG TRNSPRT; COMMERCIAL
CARRIER MULTI-PASS
NONEMERGENCY TRANSPORTATION;
STRETCHER VAN
TRNSPRT WAIT TIME AIR AMB&NON-EMERG
VEH 1/2 HR
PASRR LEVL I IDENTIFICATION SCREEN
PER SCREEN
PASRR LEVEL II EVALUATION PER
EVALUATION
HABILITATION EDUCATIONAL WAIVER; PER
DIEM
HABILITATION EDUCATIONAL WAIVER; PER
HOUR
HABILITATION PREVOCATIONAL WAIVER;
PER DIEM
HABILITATION PREVOCATIONAL WAIVER;
PER HOUR
HABILITATION RESIDENTIAL WAIVER; PER
DIEM
HABILITATION RESIDENTIAL WAIVER; PER
15 MINUTES
HABILITATION SUPP EMPLOYMENT
WAIVER; PER DIEM
HABILITATION SUPP EMPLOYMENT
WAIVER; PER 15 MIN
DAY HABILITATION WAIVER; PER DIEM
DAY HABILITATION WAIVER; PER 15
MINUTES
CASE MANAGEMENT; PER MONTH
TARGETED CASE MANAGEMENT; PER
MONTH
SERVICE ASSESSMENT/PLAN CARE
DEVELOPMENT WAIVER
WAIVER SERVICES; NOT OTHERWISE
SPECIFIED
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
CPT Code
July 2011
T2026
Not Reimbursable
T2027
Not Reimbursable
T2028
Not Reimbursable
T2029
T2030
T2031
Not Reimbursable
Not Reimbursable
Not Reimbursable
T2032
Not Reimbursable
T2033
Not Reimbursable
T2034
Not Reimbursable
T2035
Not Reimbursable
T2036
Not Reimbursable
T2037
Not Reimbursable
T2038
Not Reimbursable
T2039
Not Reimbursable
T2040
Not Reimbursable
T2041
Not Reimbursable
T2042
Not Reimbursable
T2043
Not Reimbursable
T2044
Not Reimbursable
T2045
Not Reimbursable
Code Description
SPECIALIZED CHILDCARE WAIVER; PER
DIEM
SPECIALIZED CHILDCARE WAIVER; PER 15
MINUTES
SPECIALIZED SUPPLY NOT OTH SPECIFIED
WAIVER
SPECIALIZED MEDICAL EQUIPMENT NOS
WAIVER
ASSISTED LIVING WAIVER; PER MONTH
ASSISTED LIVING WAIVER; PER DIEM
RESIDENTIAL CARE NOS WAIVER; PER
MONTH
RESIDENTIAL CARE NOS WAIVER; PER
DIEM
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
CRISIS INTERVENTION WAIVER; PER DIEM
UTIL SRVC SUPP MED EQP&ASSTIV
TECH/DEVC WAIVER
THERAPEUTIC CAMPING OVERNIGHT
WAIVER; EA SESSION
THERAPEUTIC CAMPING DAY WAIVER;
EACH SESSION
COMMUNITY TRANSITION WAIVER; PER
SERVICE
VEHICLE MODIFICATIONS WAIVER; PER
SERVICE
FINANCIAL MGMT SELF-DIRECTED WAIVER;
PER 15 MIN
SUPPORTS BROKERAGE SELF-DIRECTED
WAIVER; 15 MIN
Not Reimbursable
HOSPICE ROUTINE HOME CARE; PER DIEM
HOSPICE CONTINUOUS HOME CARE; PER
HOUR
HOSPICE INPATIENT RESPITE CARE; PER
DIEM
HOSPICE GENERAL INPATIENT CARE; PER
DIEM
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
CPT Code
July 2011
T2046
Not Reimbursable
T2048
Not Reimbursable
T2049
Not Reimbursable
T2101
Not Reimbursable
T5001
T5999
V2623
V2624
No
No
Yes
Yes
Code Description
HOSPICE LONG TERM CARE RM AND BD
ONLY PER DIEM
BHVAL HEALTH; LONG-TERM CARE RES
W/ROOM&BD-DIEM
NON-EMERG TRNSPRT; STRETCHER VAN
MILEAGE; MILE
HUMAN BREAST MILK PROCESSING
STORAGE&DSTRB ONLY
PSTN SEAT PERSONS W/SPCL ORTHOPED
NEEDS USE VEHS
SUPPLY NOT OTHERWISE SPECIFIED
PROSTHETIC EYE PLASTIC CUSTOM
POLISH/RESURF/OCULAR PROSTH
V2625
V2626
V2627
Yes
Yes
Yes
ENLARGEMENT OF OCULAR PROSTHESIS
REDUCTION OF OCULAR PROSTHESIS
SCLERAL COVER SHELL
NA
NA
NA
V2628
Yes
FABRICATION & FIT OCULAR CONFORMER
NA
V2630
V2631
Yes
Yes
ANTERIOR CHAMBER INTRAOCULAR LENS
IRIS SUPPORTED INTRAOCULAR LENS
NA
NA
V2632
Yes
NA
V2788
V2799
Yes
Not Reimbursable
POSTERIOR CHAMBER INTRAOCULAR LENS
PRESBYOPIA CORRECTION FUNCTION
INTRAOCULAR LENS
VISION SERVICE MISCELLANEOUS
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
NA
NA
NA
Not Reimbursable

This prior authorization guide applies to the following lines of business

Transcription

Similar documents

Direct Deposit Authorization

Farmers State Bank Switch Kit

ACH Loan Payment Authorization

help family and friends save on a new gm vehicle

bluecrossca formulary

YEAR-END FINANCIAL CLOSING PROCEDURES Encl: (I) FYI 5 Ye

© 2009 Lucasfi lm Ltd. and TM. All Rights Reserved. Used Under

Biosimilares y nuevas regulaciones en Perú

Colonial Co-operative Bank

help your family and friends save big on a new gm