prior authorization list

Prior Authorization List

DISCLAIMER: This list represents our standard codes for pre-service review requirements. Please note that a request may require a letter of intent and photo. Please call (800) 274-7767 or (866) 470-6244 to verify the specific requirements of the patient’s plan as requirements may vary. For details on Specialty Pharmacy Pre-certification Requirements, please visit our Specialty Pharmacy website at https://www11.anthem.com/ca/provider/f1/s0/t0/pw_a120298.pdf?refer=provider.

* Applicable to Individual Plans only for Cervical Fusion (CG-SURG-42), Elective Total Hip Arthroplasty (CG-SURG-53), and Elective Total Knee Arthroplasty (CG-SURG-54)

Medical necessity review of all genetic testing services (Medical Policies GENE.00001 through GENE.00047) for local fully insured members is managed by AIM Specialty Health®.

ABA - Not all plans include benefits for Applied Behavioral Analysis/ Adaptive Behavioral Treatment; contact Customer Service to determine if this is included as a benefit under the member’s plan and to confirm precertification requirements.

REV codes for Behavioral Health – see page 63

Code Description

Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. ® ANTHEM is a registered trademark. ® The Blue Cross name and symbol are registered marks of the Blue Cross Association. Rev 1/17/19 of 63

00731 Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum; not otherwise specified 00732 Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum; endoscopic retrograde

cholangiopancreatography (ERCP) 00811 Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; not otherwise specified 00812 Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; screening colonoscopy 00813 Anesthesia for combined upper and lower gastrointestinal endoscopic procedures, endoscope introduced both proximal to and

distal to the duodenum 11920 Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.0

sq. cm or less (when specified for nipple/areola reconstruction) 11921 Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation 11922 Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation 11950 Injection of collagen or other filling material 11951 Injection of collagen or other filling material 11952 Injection of collagen or other filling material 11954 Injection of collagen or other filling material 15775 Hair transplant (hairplasty), punch graft, 1 to 15 punch grafts 15776 Hair transplant (hairplasty), punch graft, more than 15 punch grafts 15780 Facial dermabrasion or acid peel/Scar revision (of any kind) 15781 Dermabrasion; segmental, face 15782 Dermabrasion; regional, other than face







Code Description


15783 Dermabrasion; superficial, any site (eg. tattoo removal) 15786 Abrasion; single lesion (eg. keratosis, scar) 15787 Abrasion, each additional four lesions or less 15788 Chemical peel, facial; epidermal

15792 Chemical peel, non-facial; epidermal 15793 Chemical peel, non-facial; dermal 15819 Cervicoplasty 15820 Blepharoplasty - lower eyelid 15821 Blepharoplasty - lower eyelid with extensive herniated fat pad 15822 Blepharoplasty - upper eyelid 15823 Blepharoplasty - upper eyelid; with excessive skin weighing down lid 15824 Rhytidectomy - brow or face lift 15825 Rhytidectomy; neck with platysmal tightening (platysmal flap, P-flap) 15826 Rhytidectomy; glabellar frown lines 15828 Malar (cheek) implants 15829 Rhytidectomy; superficial musculoaponeurotic system (SMAS) flap 15830 Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy 15832 Lipectomy/Liposuction procedures - Excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh







Code Description


15833 Lipectomy/Liposuction procedures - Excision, excessive skin and subcutaneous tissue (includes lipectomy); leg 15834 Lipectomy/Liposuction procedures - Excision, excessive skin and subcutaneous tissue (includes lipectomy); hip 15835 Lipectomy/Liposuction procedures - Excision, excessive skin and subcutaneous tissue (includes lipectomy); buttock 15836 Lipectomy/Liposuction procedures - Excision, excessive skin and subcutaneous tissue (includes lipectomy); arm 15837 Lipectomy/Liposuction procedures - Excision, excessive skin and subcutaneous tissue (includes lipectomy); forearm or hand 15838 Lipectomy/Liposuction procedures - Excision, excessive skin and subcutaneous tissue (including lipectomy); submental fat pad 15839 Lipectomy/Liposuction procedures - Excision, excessive skin and subcutaneous tissue (includes lipectomy), other area 15840 Graft for facial nerve paralysis; free fascia graft (including obtaining fascia) 15841 Graft for facial nerve paralysis; free muscle graft (including obtaining graft) 15842 Graft for facial nerve paralysis; free muscle flap by microsurgical technique 15845 Graft for facial nerve paralysis; regional muscle transfer 15847 Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen (eg, abdominoplasty) 15876 Lipectomy/Liposuction procedures - Suction assisted lipectomy; head and neck

15877 Lipectomy/Liposuction procedures - Suction assisted lipectomy; trunk 15878 Lipectomy/Liposuction procedures - Suction assisted lipectomy; upper extremity 15879 Lipectomy/Liposuction procedures - Suction assisted lipectomy; lower extremity 17106 Rosacea treatment - destruction of cutaneous vascular proliferative lesions by laser 17107 Rosacea treatment - destruction of cutaneous vascular proliferative lesions by laser







Code Description


17108 Rosacea treatment - destruction of cutaneous vascular proliferative lesions by laser 17380 Electrolysis epilation 19105 Ablation, cryosurgical, of fibroadenoma, including ultrasound guidance, each fibroadenoma 19300 Gynecomastia repair 19316 Mastopexy 19318 Breast Reduction (mammoplasty) 19324 Augmentation of breast - mammoplasty 19325 Augmentation of breast - mammoplasty 19328 Removal of breast implant/material (periprosthetic capsulectomy 19330 Removal of breast implant/material (periprosthetic capsulectomy 19340 Breast procedure - Immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction 19342 Breast procedure - Delayed insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction 19350 Breast procedure - Nipple/areola reconstruction 19355 Breast procedure - Correction of inverted nipples 19357 Breast procedure - Breast reconstruction, immediate or delayed, with tissue expander, including subsequent expansion 19361 Breast procedure - Breast reconstruction with latissimus dorsi flap, with or without prosthetic implant 19364 Breast procedure - Breast reconstruction with free flap 19366 Breast procedure - Breast reconstruction with other technique







Code Description


19367 Breast procedure - Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), single pedicle, including closure of donor site

19368 Breast procedure - Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), single pedicle, including closure of donor site, with microvascular anastomosis (supercharging)

19369 Breast procedure - Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), double pedicle, including closure of site

19380 Breast procedure - Revision of reconstructed breast

19396 Breast procedure - Preparation of moulage for custom breast implant 20605 Temporomandibular Disorders: Arthodesis, aspiration and/or injection; intermediate joint or bursa 20606 Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or

ankle, olecranon bursa); with ultrasound guidance, with permanent recording and reporting 20930 Allograft, morselized, or placement of osteopromotive material, for spine surgery only. 20931 Allograft, morselized, or placement of osteopromotive material, for spine surgery only. 20936 Autograft for spine surgery only (includes harvesting the graft); local (e.g., ribs, spinous process, or laminar fragments) obtained

from same incision (List separately in addition to code for primary procedure). 20937 Autograft for spine surgery only (includes harvesting the graft); morselized (through separate skin or fascial incision). 20938 Autograft for spine surgery only (includes harvesting the graft); structural, bicortical or tricortical (through separate skin or fascial

incision). 20974 Bone Growth Stimulator - electrical stimulation to aid bone healing 20979 Bone Growth Stimulators - Low intensity ultrasound stimulation to aid bone healing, noninvasive (non-operative) 20982 Ablation, bone tumor(s) (e.g. osteoid osteoma, metastasis) radiofrequency, percutaneous, including CT guidance







Code Description


20985 Computer-assisted surgical navigational procedure 20999 Extracorpeal shock wave therapy (Orthotripsy)/Orthotripsy (heel) Ossatron 21010 Temporomandibular Disorders: Arthrotomy, temporomandibular joint 21050 Temporomandibular Disorders: Condylectomy, temporomandibular joint (separate procedure) 21060 Temporomandibular Disorders: Meniscectomy, partial or complete, temporomandibular joint (separate procedure) 21073 Temporomandibular Disorders: Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia service (i.e.,

general or monitored anesthesia care) 21083 Nasal (dorsal-external) implants 21087 Nasal (dorsal-external) implants 21116 Temporomandibular Disorders: Injection procedure for temporomandibular joint arthrography 21120 Mandibular/Maxillary (Orthognathic) Surgery - Anterior horizontal mandibular osteotomy (chin)-genioplasty 21121 Mandibular/Maxillary (Orthognathic) Surgery - Anterior horizontal mandibular osteotomy (chin)-genioplasty 21122 Mandibular/Maxillary (Orthognathic) Surgery - Anterior horizontal mandibular osteotomy (chin)-genioplasty 21123 Mandibular/Maxillary (Orthognathic) Surgery - Anterior horizontal mandibular osteotomy (chin)-genioplasty 21125 Mandibular/Maxillary (Orthognathic) Surgery - Augmentation, mandibular body or angle; prosthetic material 21127 Mandibular/Maxillary (Orthognathic) Surgery - Augmentation, lower jaw bone

21137 Forehead Reduction 21138 Forehead Reduction 21139 Forehead Reduction







Code Description


21141 Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction Midface (LeFort) 21142 Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction Midface (LeFort) 21143 Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction Midface (LeFort) 21145 Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction Midface (LeFort) 21146 Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction Midface (LeFort) 21147 Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction Midface (LeFort) 21150 Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction Midface (LeFort II) 21151 Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction Midface (LeFort II) 21154 Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction Midface (LeFort III) 21155 Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction Midface (LeFort III) 21159 Mandibular Osteotomies, Reconstruction Midface (LeFort) 21160 Mandibular Osteotomies, Reconstruction Midface (LeFort) 21172 Mandibular Osteotomies, Reconstruction superior-lateral orbital rim and lower forehead 21175 Mandibular Osteotomies, Reconstruction bifrontal, superior-lateral orbital rims and lower forehead 21179 Mandibular Osteotomies, Reconstruction entire or majority of forehead and/or supraorbital rims 21180 Mandibular Osteotomies, Reconstruction entire or majority of forehead and/or supraorbital rims 21188 Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction Midface (other than LeFort type) 21193 Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; without

bone graft







Code Description


21194 Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction of mandibular rami, horizontal, vertical, C or L osteotomy; with bone graft

21195 Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction of mandibular rami and/or body, sagittal split; without internal rigid fixation

21196 Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction of mandibular rami and/or body, sagittal split; with internal rigid fixation

21198 Mandibular/Maxillary (Orthognathic) Surgery - Osteotomy, mandible, segmental

21199 Mandibular Osteotomies, segmental with genioglossus advancement 21206 Mandibular/Maxillary (Orthognathic) Surgery - Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard) 21208 Mandibular/Maxillary (Orthognathic) Surgery - Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant) 21209 Mandibular/Maxillary (Orthognathic) Surgery - Osteoplasty, facial bones; reduction 21210 Mandibular/Maxillary (Orthognathic) Surgery - Graft, bone; nasal, maxillary or malar areas (includes obtaining graft) 21215 Mandibular/Maxillary (Orthognathic) Surgery - Graft, bone; mandible (includes obtaining graft) 21230 Graft; rib cartilage, autogenous, to face, chin, nose or ear (includes obtaining graft) 21235 Graft; ear cartilage, autogenous, to nose or ear (includes obtaining graft) 21240 Temporomandibular Disorders: Arthroplasty, temporomandibular joint, with or without autograft (includes obtaining graft) 21242 Temporomandibular Disorders: Arthroplasty, temporomandibular joint, with allograft 21243 Temporomandibular Disorders: Arthroplasty, temporomandibular joint, with prosthetic joint replacement 21244 Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction of mandible extraoral, with transosteal bone plate (eg, mandibular

staple bone plate)







Code Description


21245 Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction of mandible or maxilla, subperiosteal implant 21246 Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction mandible or maxilla, subperiosteal implant; complete 21247 Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction of mandibular condyle with bone and cartilage autografts (includes

obtaining grafts)(e.g., for hemifacial microsomia) 21255 Reconstruction zygomatic arch and glenoid fossa with bone and cartilage (includes obtaining autografts) 21256 Mandibular Osteotomies, Reconstruction of orbit (includes obtaining autografts) 21270 Malar (cheek) implants 21685 Hyoid myotomy and suspension 21740 Reconstructive repair of pectus excavatum or carinatum; open 21742 Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), without thoracoscopy 21743 Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), with thoracoscopy 22214 Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; lumbar 22216 Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; each additional vertebral segment. 22224 Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; lumbar 22505 Manipulation of spine under anesthesia 22510 Kyphoplasty - Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral

injection, inclusive of all imaging guidance; cervicothoracic 22511 Kyphoplasty - Percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; lumbar 22512 Kyphoplasty - Percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; each additional thoracic or lumbar

body







Code Description


22513 Kyphoplasty - Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; thoracic

22514 Kyphoplasty - Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; lumbar

22515 Kyphoplasty - Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; each additional thoracic or lumbar vertebral body

22533 Spinal fusion - Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar

22534 Spinal fusion - Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic or lumbar, each additional vertebral segment

22548 * Arthrodesis, anterior transoral or extraoral technique, clivus-C1-C2 (atlas-axis), with or without excision of odontoid process 22551 *

Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2

22552 * Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2, each additional interspace

22554 * Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); cervical below C2

22558 Spinal fusion - Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar







Code Description


22585 * Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each additional interspace.

22590 * Arthrodesis, posterior technique, craniocervical (occiput-C2) 22595 * Arthrodesis, posterior technique, atlas-axis (C1-C2) 22600 * Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment 22612 Spinal fusion - Arthrodesis, posterior or posterolateral technique, single level; lumbar (with or without lateral transverse technique) 22614 * Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment. 22630 Spinal fusion - Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other

than for decompression), single interspace; lumbar

22632 Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; each additional interspace. .

22633 Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; lumbar

22634 Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; each additional interspace and segment (List separately in addition to code for primary procedure)

22800 Surgical Interventions for Scoliosis and Spinal Deformity - Arthrodesis, posterior, for spinal deformity, with or without cast; up to 6 vertebral segments

22802 Surgical Interventions for Scoliosis and Spinal Deformity - Arthrodesis, posterior, for spinal deformity, with or without cast; 7 to 12 vertebral segments

22804 Surgical Interventions for Scoliosis and Spinal Deformity - Arthrodesis, posterior, for spinal deformity, with or without cast; 13 or more vertebral segments







Code Description


22808 Surgical Interventions for Scoliosis and Spinal Deformity - Arthrodesis, anterior, for spinal deformity, with or without cast; 2 to 3 vertebral segments

22810 Surgical Interventions for Scoliosis and Spinal Deformity - Arthrodesis, anterior, for spinal deformity, with or without cast; 4 to 7 vertebral segments

22812 Surgical Interventions for Scoliosis and Spinal Deformity - Arthrodesis, anterior, for spinal deformity, with or without cast; 8 or more vertebral segments

22818 Surgical Interventions for Scoliosis and Spinal Deformity - Kyphectomy, circumferential exposure of spine and resection of vertebral segment(s) (including body and posterior elements); single or 2 segments

22819 Surgical Interventions for Scoliosis and Spinal Deformity - Kyphectomy, circumferential exposure of spine and resection of vertebral segment(s) (including body and posterior elements); 3 or more segments

22830 Exploration of spinal fusion 22840 Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial

transarticular screw fixation, sublaminar wiring at C1, facet screw fixation) 22841 Internal spinal fixation by wiring of spinous processes. 22842 Surgical Interventions for Scoliosis and Spinal Deformity - Posterior segmental instrumentation (eg, pedicle fixation, dual rods with

multiple hooks and sublaminar wires); 3 to 6 vertebral segments. 22843 Surgical Interventions for Scoliosis and Spinal Deformity - Posterior segmental instrumentation (eg, pedicle fixation, dual rods with

multiple hooks and sublaminar wires); 7 to 12 vertebral segments. 22844 Surgical Interventions for Scoliosis and Spinal Deformity - Posterior segmental instrumentation (eg, pedicle fixation, dual rods with

multiple hooks and sublaminar wires); 13 or more vertebral segments. 22845 Surgical Interventions for Scoliosis and Spinal Deformity - Anterior instrumentation; 2 to 3 vertebral segments 22846 Surgical Interventions for Scoliosis and Spinal Deformity - Anterior instrumentation; 4 to 7 vertebral segments.







Code Description


22847 Surgical Interventions for Scoliosis and Spinal Deformity - Anterior instrumentation; 8 or more vertebral segments. 22849 Surgical Interventions for Scoliosis and Spinal Deformity - Reinsertion of spinal fixation device 22851 Application of intervertebral biomechanical device(s) (e.g., synthetic cage(s), methylmethacrylate) to vertebral defect or interspace. 22852 Removal of posterior segmental instrumentation 22855 Removal of anterior instrumentation 22856 Artificial Intervertebral Discs - total disc arthroplasty, anterior approach, including diskectomy with end plate preparation (includes

osteophytectomy for nerve root or spinal cord decompression and microdissection), single interspace, cervical 22857 Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for

decompression), single interspace, lumbar 22858 Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy

for nerve root or spinal cord decompression and microdissection); second level, cervical 22862 Artificial Intervertebral Discs - revision including replacement of total disc arthroplasty, lumbar, single interspace 22865 Artificial Intervertebral Discs - removal of total disc arthroplasty, anterior approach, lumbar, single interspace 22899 Kyphoplasty - unlisted procedure; spine

22999 Unlisted procedure, abdomen, musculoskeletal system 27130 * Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft

27132 * Conversion of previous hip surgery to total hip arthroplasty, with or without autograft or allograft 27134 * Revision of total hip arthroplasty; both components, with or without autograft or allograft

27137 * Revision of total hip arthroplasty; acetabular component only, with or without autograft or allograft







Code Description


27138 * Revision of total hip arthroplasty; femoral component only, with or without autograft or allograft

27279 Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixing device

27280 Arthrodesis, sacroiliac joint (including obtaining graft) 27412 Autologous chondroctye transplantation - knee

27415 Autologous/Osteochondral allograft, knee, open 27416 Osteochondral autograft(s), knee, open 27445 * Arthroplasty, knee, hinge prosthesis (eg, Walldius type) 27447 * Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total knee

arthroplasty) 27486 * Revision of total knee arthroplasty, with or without allograft, 1 component 27487 * Revision of total knee arthroplasty, with or without allograft, femoral and entire tibial component 27702 Ankle Replacement 28446 Open osteochondral autograft-talus 28890 Extracorpeal shock wave therapy (Orthotripsy)/Orthotripsy (heel) Ossatron 28899 Subtalar Arthroereisis - Unlisted procedure, foot or toes (Orthotripsy) 29800 Temporomandibular Disorders: Arthroscopy, temporomandibular joint, diagnostic, with or without synovial biopsy 29804 Temporomandibular Disorders: Arthroscopy, temporomandibular joint, surgical







Code Description


29866 Autologous chondrocyte transplantation/Arthroscopy knee, surgical; osteochondral autograft(s) (eg. Mosaicplasty) (includes harvesting of the autograft)

29867 Autologous chondrocyte transplantation/Arthroscopy knee, surgical; osteochondral autograft(s) (eg. Mosaicplasty) 29868 Meniscal Transplantation 29892 Ankle arthroscopy/surgery 29999 Electrothermal capsular shrinkage (i.e. thermal capsulorrhaphy, electrothermal capsulorrhaphy, thermal capsular shrinkage,

electrothermal arthroscopy) as a technique for use in arthroscopic or open surgery for tightening the capsular or ligamentous structures of ankles, hips, knees, or wrists.

30110 Excision, nasal polyp(s), simple 30115 Excision, nasal polyp(s), extensive 30120 Rosacea treatment - excision or surgical planing of skin of nose for rhinophyma 30130 Excision inferior turbinate, partial or complete, any method - Note: Authorization is required only when the diagnosis is associated

with obstructive sleep apnea or snoring 30140 Submucous resection inferior turbinate, partial or complete, any method - Note: Authorization is required only when the diagnosis is

associated with obstructive sleep apnea or snoring 30400 Rhinoplasty 30410 Rhinoplasty 30420 Rhinoplasty 30430 Rhinoplasty 30435 Rhinoplasty







Code Description


30450 Rhinoplasty 30465 Repair of nasal vestibular stenosis (eg, spreader grafting, lateral nasal wall reconstruction) - Note: Authorization is required only

when the diagnosis is associated with obstructive sleep apnea or snoring 30520 Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft 30620 Septal or other intranasal dermatoplasty (does not include obtaining graft) 30801 Ablation, soft tissue of inferior turbinates, unilateral or bilateral, any method (eg, electrocautery, radiofrequency ablation, or tissue

volume reduction); superficial - Note: Authorization is required only when the diagnosis is associated with obstructive sleep apnea or snoring

30802 Ablation, soft tissue of inferior turbinates, unilateral or bilateral, any method (eg, electrocautery, radiofrequency ablation, or tissue volume reduction); intramural (i.e., submucosal) - Note: Authorization is required only when the diagnosis is associated with obstructive sleep apnea or snoring

30999 Unlisted procedure, nose [when specified as nasal endoscopy with balloon dilation of eustachian tube] 31200 Ethmoidectomy; intranasal, anterior - Note: Authorization is required only when the diagnosis is associated with chronic headaches 31201 Ethmoidectomy; intranasal, total - Note: Authorization is required only when the diagnosis is associated with chronic headaches 31205 Ethmoidectomy, extranasal, total - Note: Authorization is required only when the diagnosis is associated with chronic headaches 31237 Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement 31253 Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including frontal sinus exploration, with removal

of tissue from frontal sinus, when performed 31254 Nasal/sinus endoscopy, surgical with ethmoidectomy; partial (anterior) 31255 Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior) 31256 Nasal/sinus endoscopy, surgical, with maxillary antrostomy







Code Description


31257 Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotom 31259 Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotomy, with removal of tissue

from the sphenoid sinus 31267 Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus 31276 Nasal/sinus endoscopy, surgical, with frontal sinus exploration, including removal of tissue from frontal sinus, when performed 31287 Nasal/sinus endoscopy, surgical, with sphenoidotomy 31288 Nasal/sinus endoscopy, surgical, with sphenoidotomy; with removal of tissue from the sphenoid sinus 31295 Nasal/sinus endoscopy, surgical; with dilation of maxillary sinus ostium (eg, balloon dilation), transnasal or via canine fossa 31296 Nasal/sinus endoscopy, surgical; with dilation of frontal sinus ostium (eg, balloon dilation) 31297 Nasal/sinus endoscopy, surgical; with dilation of sphenoid sinus ostium (eg, balloon dilation) 31298 Nasal/sinus endoscopy, surgical; with dilation of frontal and sphenoid sinus ostia (eg, balloon dilation) 31299 Unlisted procedure, accessory sinuses [when specified as insertion of a drug-eluting sinus stent] 32491 Removal of lung, other than pneumonectomy; with resection-plication of emphysematous lung(s) (bullous or non-bullous) for lung

volume reduction, sternal split or transthoracic approach, includes any pleural procedure, when performed 32664 Thorascopy, surgical: with thoracic sympathectomy 32701 Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of

treatment 32994 Ablation therapy for reduction or eradication of 1 or more pulmonary tumor(s) including pleura or chest wall when involved by tumor

extension, percutaneous, including imaging guidance when performed, unilateral; cryoablation 32998 Ablation therapy for reduction or eradication of 1 or more pulmonary tumor(s) including pleura or chest wall when involved by tumor

extension, percutaneous, radiofrequency, unilateral







Code Description


33202 Insertion of epicardial electrode(s); open incision (e.g., thoracotomy, median sternotomy, subxiphoid approach) 33203 Insertion of epicardial electrode(s); endoscopic approach (eg, thoracoscopy, pericardioscopy) 33207 Cardiac Resynchronization Therapy - Insertion or replacement of permanent pacemaker with transvenous electrode(s); ventricular 33208 Cardiac Resynchronization Therapy - Insertion or replacement of permanent pacemaker with transvenous electrode(s); atrial and

ventricular 33211 Cardiac Resynchronization Therapy - Insertion or replacement of temporary transvenous dual chamber pacing electrodes 33213 Cardiac Resynchronization Therapy -Insertion or replacement of pacemaker pulse generator only; dual chamber 33214 Cardiac Resynchronization Therapy - Upgrade of implanted pacemaker system, conversion of single chamber system to dual

chamber 33216 Insertion of a single transvenous electrode, permanent pacemaker or cardioverter-defibrillator 33217 Insertion of 2 transvenous electrodes, permanent pacemaker or cardioverter-defibrillator 33224 Cardiac Resynchronization Therapy - Insertion of pacing electrode, cardiac venous system, for left ventricular pacing; with

attachment to previously placed pacemaker or pacing cardioverter-defibrillator pulse generator 33225 Cardiac Resynchronization Therapy - Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of

insertion of pacing cardioverter defibrillator or pacemaker pulse generator 33226 Cardiac Resynchronization Therapy - Repositioning of previously implanted cardiac venous system (left ventricular) electrode

(including removal, insertion and/or replacement of generator) 33240 Cardiac Resynchronization Therapy - Insertion of single or dual chamber pacing cardioverter-defibrillator pulse generator 33249 Cardiac Resynchronization Therapy - Insertion or repositioning of electrode lead(s) for single or dual chamber pacing cardioverter-

defibrillator and insertion of pulse generator 33254 Maze Procedure - Operative tissue ablation and reconstruction of atria, limited (eg, modified maze procedure)







Code Description


33255 Maze Procedure - Operative tissue ablation and reconstruction of atria, extensive (eg, maze procedure); without cardiopulmonary bypass

33256 Maze Procedure - Operative tissue ablation and reconstruction of atria, extensive (eg, maze procedure); with cardiopulmonary bypass

33257 Maze Procedure - Operative tissue ablation and reconstruction of atria, performed at the time of other cardiac procedure(s), limited (eg, modified maze procedure) (List separately in addition to code for primary procedure)

33258 Maze Procedure - Operative tissue ablation and reconstruction of atria, performed at the time of other cardiac procedure(s), extensive (eg, maze procedure), without cardiopulmonary bypass (List separately in addition to code for primary procedure)

33259 Maze Procedure - Operative tissue ablation and reconstruction of atria, performed at the time of other cardiac procedure(s), extensive (eg, maze procedure), with cardiopulmonary bypass (List separately in addition to code for primary procedure)

33265 Maze Procedure - Endoscopy, surgical; operative tissue ablation and reconstruction of atria, limited (eg, modified maze procedure), without cardiopulmonary bypass

33266 Maze Procedure - Endoscopy, surgical; operative tissue ablation and reconstruction of atria, extensive (eg, maze procedure), without cardiopulmonary bypass

33270 Insertion or replacement of permanent subcutaneous implantable defibrillator system, with subcutaneous electrode, including defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters, when performed

33271 Insertion of subcutaneous implantable defibrillator electrode 33340 Percutaneous transcatheter closure of the left atrial appendage with implant, including fluoroscopy, transseptal puncture, catheter

placement(s), left atrial angiography, left atrial appendage angiography, radiological supervision and interpretation 33548 Surgical ventricular restoration procedure, includes prosthetic patch, when performed (e.g., ventricular remodeling, SVR, SAVER,

DOR procedures)







Code Description


36260 Implantable Infusion Pumps - Insertion of implantable intra-arterial infusion pump (e.g., for chemotherapy of liver)

36465 Injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; single incompetent extremity truncal vein (eg, great saphenous vein, accessory saphenous vein)

36466 Injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; multiple incompetent truncal veins (eg, great saphenous vein, accessory saphenous vein), same leg

36468 Injections of sclerosant for spider veins (telangiectasia); limb or trunk 36470 Injection of sclerosant; single incompetent vein (other than telangiectasia) 36471 Injection of sclerosant; multiple incompetent veins (other than telangiectasia), same leg 36473 Mechanochemical ablation 36475 Radiofrequency ablation of varicose veins 36478 Radiofrequency ablation of varicose veins 36482 Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (eg, cyanoacrylate)

remote from the access site, inclusive of all imaging guidance and monitoring, percutaneous; first vein treated 36483 Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (eg, cyanoacrylate)

remote from the access site, inclusive of all imaging guidance and monitoring, percutaneous; subsequent vein(s) treated in a single extremity, each through separate access sites

36511 Therapeutic apheresis; for white blood cells 36512 Therapeutic apheresis; for red blood cells 36513 Therapeutic apheresis; for platelets







Code Description


36514 Therapeutic apheresis; for plasma pheresis 36515 Therapeutic apheresis; with extracorporeal immunoadsorption and plasma reinfusion 36516 Therapeutic apheresis; with extracorporeal selective adsorption or selective filtration and plasma reinfusion 36563 Implantable Infusion Pumps - Insertion of tunneled centrally inserted central venous access device with subcutaneous pump 37215 Carotid, Vertebral and Intracranial Artery Angioplasty - Transcatheter placement of stent, cervical cartoid artery with distal embolic

protection 37216 Carotid, Vertebral and Intracranial Artery Angioplasty - Transcatheter placement of stent, cervical cartoid artery without distal

embolic protection 37220 Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal angioplasty 37221 Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal stent placement(s),

includes angioplasty within the same vessel, when performed 37222 Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with transluminal

angioplasty 37223 Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with transluminal stent

placement(s), includes angioplasty within the same vessel, when performed 37224 Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal angioplasty 37225 Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with atherectomy, includes

angioplasty within the same vessel, when performed 37226 Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s),

includes angioplasty within the same vessel, when performed 37227 Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s)

and atherectomy, includes angioplasty within the same vessel, when performed







Code Description


37228 Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal angioplasty

37229 Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with atherectomy, includes angioplasty within the same vessel, when performed

37230 Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed

37231 Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed

37232 Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with transluminal angioplasty

37233 Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with atherectomy, includes angioplasty within the same vessel, when performed (List separately in addition to code for primary procedure)

37234 Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed (List separately in addition to code for primary procedure)

37235 Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed

37241 Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; venous, other than hemorrhage (eg, congenital or acquired venous malformations, venous and capillary hemangiomas, varices, varicoceles) [when specified as coil embolization for varicose vein diagnoses]

37243 Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural road mapping, and imaging guidance necessary to complete the intervention; for tumors, organ ischemia, or infarction







Code Description


37244 Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural road mapping, and imaging guidance necessary to complete the intervention; for arterial or venous hemorrhage or lymphatic extravasation

37246 Carotid, Vertebral and Intracranial Artery Angioplasty - Transluminal balloon angioplasty (except lower extremity artery[ies]) for occlusive disease, intracranial, coronary, pulmonary, or dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty within the same artery; initial artery

41512 Tongue base suspension, permanent suture technique 41530 Tongue - Submucosal ablation of the tongue base, radiofrequency, one or more sites per session 41870 Periodontal Mucosal Grafting 42145 Palatopharynoplasty - UPPP, LAUP's, and somnoplasty 42299 Somnoplasty for snoring 42820 Tonsillectomy and adenoidectomy - review is required only for children under the age of 18 42821 Tonsillectomy and adenoidectomy - review is required only for children under the age of 18 42825 Tonsillectomy, primary or secondary - review is required only for children under the age of 18 42826 Tonsillectomy, primary or secondary - review is required only for children under the age of 18 43192 Transendoscopic Therapy for Gastroesophageal Reflux Disease and Dysphagia 43201 Transendoscopic Therapy for Gastroesophageal Reflux Disease and Dysphagia 43210 Transendoscopic Therapy for Gastroesophageal Reflux Disease and Dysphagia 43228 Ablative Techniques as a Treatment for Barrett's Esophagus - Esophagoscopy, rigid or flexible; with ablation of tumor(s), polyp(s),

or other lesion(s), not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique [when specified as radiofrequency ablation]

43236 Transendoscopic Therapy for Gastroesophageal Reflux Disease and Dysphagia







Code Description


43257 Transendoscopic Therapy for Gastroesophageal Reflux Disease and Dysphagia 43258 Ablative Techniques as a Treatment for Barrett's Esophagus - Upper gastrointestinal endoscopy including esophagus, stomach,

and either the duodenum and/or jejunum as appropriate; with ablation of tumor(s), polyp(s) or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique [when specified as radiofrequency ablation]

43632 Gastrectomy, partial distal; with gastrojejunostomy 43633 Gastrectomy, partial, distal; with Roux-en-y recontruction 43644 Gastric Bypass - Need BMI, psychiatric evaluation, and nutritional consult 43645 Gastric Bypass - gastroplasty - Need BMI, psychiatric evaluation, and nutritional consult 43647 Gastric Pacemaker 43648 Gastric Pacemaker 43659 Gastric Bypass - Need BMI, psychiatric evaluation, and nutritional consult 43770 Gastric Bypass - Need BMI, psychiatric evaluation, and nutritional consult 43771 Gastric Bypass - revision of adjustable gastric restrictive device component only. 43772 Gastric Bypass - removal of adjustable gastric restrictive device component only. 43773 Gastric Bypass - removal and replacement of adjustable gastric restrictive device component only. 43774 Gastric Bypass - removal of adjustable gastric restrictive device and subcutaneous port components. 43775 Gastric restrictive procedure - Laparoscopy, surgical; longitudinal gastrectomy (i.e., sleeve gastrectomy) 43842 Gastric Bypass - gastroplasty - Need BMI, psychiatric evaluation, and nutritional consult 43843 Gastric Bypass - gastroplasty - Need BMI, psychiatric evaluation, and nutritional consult







Code Description


43845 Gastric Bypass - Need BMI, psychiatric evaluation, and nutritional consult 43846 Gastric Bypass - Need BMI, psychiatric evaluation, and nutritional consult 43847 Gastric Bypass - Need BMI, psychiatric evaluation, and nutritional consult 43848 Gastric Bypass - revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric restrictive device

(separate procedure). 43881 Gastric Pacemaker 43882 Gastric Pacemaker 43886 Gastric restrictive procedure open; revision of subcutaneous port component only 43887 Gastric restrictive procedure open; removal of subcutaneous port component only 43888 Gastric restrictive procedure open; removal and replacement of subcutaneous port component only 46505 Chemodenervation of internal anal sphincter 47370 Ablative Techniques for Treating Primary and Metastatic Liver Malignancies - Laparoscopy, surgical, ablation of 1 or more liver

tumor(s); radiofrequency 47371 Ablative Techniques for Treating Primary and Metastatic Liver Malignancies - Laparoscopy, surgical, ablation of 1 or more liver

tumor(s); cryosurgical 47380 Ablative Techniques for Treating Primary and Metastatic Liver Malignancies - Ablation, open, of 1 or more liver tumor(s);

radiofrequency 47381 Ablative Techniques for Treating Primary and Metastatic Liver Malignancies - Ablation, open, of 1 or more liver tumor(s);

cryosurgical 47382 Ablative Techniques for Treating Primary and Metastatic Liver Malignancies - Ablation, 1 or more liver tumor(s), percutaneous,

radiofrequency







Code Description


50250 Ablation, open, 1 or more renal mass lesion(s), cryosurgical, including intraoperative ultrasound, if performed

50542 Ablation of renal mass lesion(s), including intraoperative ultrasound guidance and monitoring, when performed - Laparoscopy, surgical

50592 Ablation, 1 or more renal tumor(s), percutaneous, unilateral, radiofrequency

50593 Ablation, renal tumor(s), unilateral, percutaneous, cryotherapy 52441 Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; single implant 52442 Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; each additional permanent adjustable

transprostatic implant 52647 Laser surgery of prostate 52648 Contact laser vaporization of prostate 52649 Laser enucleation of the prostate with morcellation, including control of postoperative bleeding, complete (vasectomy, meatotomy,

cystourethroscopy, urethral calibration and/or dilation 53850 Transurethral destruction of prostate tissue; by microwave thermotherapy 53852 Transurethral destruction of prostate tissue; by radiofrequency thermotherapy 53854 Transurethral destruction of prostate tissue; by radiofrequency generated water vapor thermotherapy (effective 1/1/19) 54125 Gender Reassignment Surgery - Amputation of penis; complete 54360 Penis plastic surgery 54400 Penile Prosthesis Implantation - Insertion of penile prosthesis; non-inflatable (semi-rigid) 54401 Penile Prosthesis Implantation - Insertion of penile prosthesis; inflatable (self-contained)







Code Description


54405 Penile Prosthesis Implantation - Insertion of multi-component, inflatable penile prosthesis, including placement of pump, cylinders, and reservoir

54410 Penile Prosthesis Implantation - Removal and replacement of all component(s) of a multi-component, inflatable penile prosthesis at the same operative session

54411 Penile Prosthesis Implantation - Removal and replacement of all components of a multi-component inflatable penile prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue

54416 Penile Prosthesis Implantation - Removal and replacement of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis at the same operative session

54417 Penile Prosthesis Implantation - Removal and replacement of a non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue

54440 Plastic operation on penis for injury 54520 Gender Reassignment Surgery - Orchiectomy, simple (including subcapsular), with or without testicular prosthesis, scrotal or

inguinal approach 54660 Gender Reassignment Surgery - Insertion of testicular prosthesis 54690 Gender Reassignment Surgery - Laparoscopy, surgical; orchiectomy 55180 Gender Reassignment Surgery - Scrotoplasty; complicated 55873 Cryosurgical ablation of the prostate (includes ultrasonic guidance and monitoring) 56625 Gender Reassignment Surgery - Vulvectomy, simple; complete 56800 Gender Reassignment Surgery - Plastic repair of introitus 56805 Gender Reassignment Surgery - Clitoroplasty for intersex state 56810 Perineoplasty, repair of perineum, nonobstetrical (separate procedure)







Code Description


57110 Gender Reassignment Surgery - Vaginectomy, complete removal of vaginal wall 57291 Gender Reassignment Surgery - Construction of artificial vagina; without graft 57292 Gender Reassignment Surgery - Construction of artificial vagina; with graft 57295 Gender Reassignment Surgery - Revision (including removal) of prosthetic vaginal graft; vaginal approach 57296 Gender Reassignment Surgery - Revision (including removal) of prosthetic vaginal graft; open abdominal approach 57335 Vaginoplasty for intersex state 58150 Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s) 58152 Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s) 58180 Supracervical Abdominal hysterectomy (subtotal hysterectomy), with or without removal of tube(s), with or without removal of

ovary(s) 58200 Total abdominal hysterectomy, including partial vaginectomy, with para-aortic and pelvic lymph node biopsy(s) 58210 Radical abdominal hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymphadenectomy 58240 Pelvic exenteration for gynecologic malignancy, with total abdominal hysterectomy or cervicectomy 58260 Vaginal hysterectomy 58262 Vaginal hysterectomy; with removal of tube(s), and or ovary(s) 58263 Vaginal hysterectomy; with removal of tube(s), and or ovary(s) with repair of enterocele 58267 Vaginal hysterectomy, for uterus 250 grams or less; with colpo- urethrocystopexy 58270 Vaginal hysterectomy, with or without removal of tubes(s), with or without removal of ovary(s) with repair of enterocele 58275 Vaginal hysterectomy¸ with total or partial colpectomy







Code Description


58280 Vaginal hysterectomy, with total or partial vaginectomy; with repair of enterocele 58285 Vaginal hysterectomy, radical (Schauta type operation) 58290 Vaginal hysterectomy, for uterus greater than 250 grams: 58291 Vaginal hysterectomy, for uterus greater than 250 grams; with removal of tube(s) and/or ovaries 58292 Vaginal hysterectomy, for uterus greater than 250 grams; with removal of tube(s) and/or ovaries 58293 Vaginal hysterectomy, for uterus greater than 250 grams; with colpo-urethrocystopexy 58294 Vaginal hysterectomy, for uterus greater than 250 grams; with repair of enterocele 58541 Laparoscopy, surgical, supracervical hystgerectomy, for uterus 250 grams or less 58542 Laparoscopy, surgical, supracervical hystgerectomy, for uterus 250 grams or less; with removal of tubes(s) and/or ovary(s)

58543 Laparoscopy, surgical, supracervical hystgerectomy, for uterus greater than 250 grams

58544 Laparoscopy, surgical, supracervical hystgerectomy, for uterus greater than 250 grams; with removal of tubes(s) and/or ovary(s)

58548 Laparoscopy surgical, with radical hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy), with removal of tube(s) and/or ovary(s)

58550 Laparoscopy, surgical with vaginal hysterectomy with or without removal of tube(s) and/or ovary(s) (laparoscopic assisted vaginal hysterectomy)

58552 Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 grams or less; with removal of tube(s) and/or ovary(s) 58553 Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 grams 58554 Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 grams; with removal of tube(s) and/or ovary(s)







Code Description


58570 Laparoscopy, surgical, with total hysterectomy, for uterus 250 grams or less 58571 Laparoscopy, surgical, with total hysterectomy, for uterus 250 grams or less, with removal of tube(s) and/or ovary(s) 58572 Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 grams 58573 Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250, with removal of tube(s) and/or ovary(s) 58953 Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical dissection 58954 Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical dissection 58956 Bilateral salpingo-oophorectomy with total omentectomy, total abdominal hysterectomy for malignancy 59525 Subtotal or total hysterectomy after cesarean delivery (List separately in addition to code for primary procedure) 58578 HALT procedure (Unlisted laparoscopy procedure, uterus) 61215 Implantable Infusion Pumps - Insertion of subcutaneous reservoir, pump or continuous infusion system for connection to ventricular

catheter 61630 Carotid, Vertebral and Intracranial Artery Angioplasty - Balloon angioplasty, intracranial (eg, atherosclerotic stenosis), percutaneous 61635 Carotid, Vertebral and Intracranial Artery Angioplasty - Transcatheter placement of intravascular stent(s), intracranial (e.g.,

atherosclerotic stenosis), including balloon angioplasty, if performed 61640 Carotid, Vertebral and Intracranial Artery Angioplasty - Balloon dilatation of intracranial vasospasm, percutaneous; initial vessel 61641 Carotid, Vertebral and Intracranial Artery Angioplasty - Balloon dilatation of intracranial vasospasm, percutaneous; each additional

vessel in same vascular family (list separately in addition to code for primary procedure) 61642 Carotid, Vertebral and Intracranial Artery Angioplasty - Balloon dilatation of intracranial vasospasm, percutaneous; each additional

vessel in different vascular family (list separately in addition to code for primary procedure) 61796 Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 simple cranial lesion







Code Description


61797 Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional cranial lesion, simple 61798 Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 complex cranial lesion 61799 Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional cranial lesion, complex 61800 Application of stereotactic headframe for stereotactic radiosurgery 61863 Deep Brain Stimulation - Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode

array in subcortical site (eg, thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperat

61864 Deep Brain Stimulation - Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (eg, thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; each additional array

61867 Deep Brain Stimulation - Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (eg, thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array

61868 Deep Brain Stimulation - Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (eg, thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; each additional array

61870 Craniectomy for implantation of neurostimulator electrodes, cerebellar; cortical 61875 Craniectomy for implantation of neurostimulator electrodes, cerebellar; subcortical 61885 Deep Brain Stimulation - Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive

coupling; with connection to a single electrode array 61886 Deep Brain Stimulation - Incision and subcutaneous placement of cranial neurostimulator pulse generator or receiver, direct or

inductive coupling; with connection to two or more electrode arrays







Code Description


62263 Percutaneous Lysis of Epidural Adhesions using Solution Injection or Mechanical means including Radiologic Localization, Multiple Adhesiolysis Sessions, 2 or more days

62264 Percutaneous Lysis of Epidural Adhesions using Solution Injection or Mechanical means including Radiologic Localization, Multiple Adhesiolysis Sessions, 1 day

62287 Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, any method, single or multiple levels, lumbar 62350 Implantable Infusion Pumps - Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term

medication administration via an external pump or implantable reservoir/infusion pump; without laminectomy 62351 Implantable Infusion Pumps - Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term

medication administration via an external pump or implantable reservoir/infusion pump; with laminectomy 62360 Implantable Infusion Pumps - Implantation or replacement of device for intrathecal or epidural drug infusion; subcutaneous reservoir

62361 Implantable Infusion Pumps - Implantation or replacement of device for intrathecal or epidural drug infusion; non-programmable pump

62362 Implantable Infusion Pumps - Implantation or replacement of device for intrathecal or epidural drug infusion; programmable pump, including preparation of pump, with or without programming

63005 Spinal surgery - Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; lumbar, except for spondylolisthesis

63011 Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (e.g., spinal stenosis), 1 or 2 vertebral segments; sacral

63012 Spinal surgery - Laminectomy with removal of abnormal facets and/or pars inter-articularis with decompression of cauda equina and nerve roots for spondylolisthesis, lumbar (Gill type procedure)







Code Description


63017 Spinal surgery - Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral segments; lumbar

63030 Spinal surgery - Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, including open and endoscopically-assisted approaches; 1 interspace, lumbar

63035 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; each additional interspace, lumbar. Note: A clinical review is required for this secondary procedure code only when requested with a lumbar or thoracic spinal surgery. Prior authorization is not required for cervical spinal surgeries related to this procedure code unless the request is for an inpatient stay.

63042 Spinal surgery - Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; lumbar

63044 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; each additional lumbar interspace. Note: A clinical review is required for this secondary procedure code only when requested with a lumbar or thoracic spinal surgery. Prior authorization is not required for cervical spinal surgeries related to this procedure code unless the request is for an inpatient stay.

63047 Spinal surgery - Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar

63048 Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [e.g., spinal or lateral recess stenosis]), single vertebral segment; each additional segment, cervical, thoracic, or lumbar. Note: A clinical review is required for this secondary procedure code only when requested with a lumbar or thoracic spinal surgery. Prior authorization is not required for cervical spinal surgeries related to this procedure code unless the request is for an inpatient stay.







Code Description


63056 Spinal surgery - Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; lumbar (including transfacet, or lateral extraforaminal approach) (eg, far lateral herniated intervertebral disc)

63057 Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (e.g., herniated intervertebral disc), single segment; each additional segment, thoracic or lumbar. Note: A clinical review is required for this secondary procedure code only when requested with a lumbar or thoracic spinal surgery. Prior authorization is not required for cervical spinal surgeries related to this procedure code unless the request is for an inpatient stay.

63081 Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, single segment

63082 Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, each additional segment (List separately in addition to code for primary procedure)

63085 Vertebral corpectomy (vertebral body resection), partial or complete, transthoracic approach with decompression of spinal cord and/or nerve root(s); thoracic, single segment

63087 Vertebral corpectomy (vertebral body resection), partial or complete, combined thoracolumbar approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic or lumbar; single segment

63090 Vertebral corpectomy (vertebral body resection), partial or complete; transperitoneal or retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic, lumbar, or sacral; single segment

63091 Vertebral corpectomy (vertebral body resection), partial or complete; transperitoneal or retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic, lumbar, or sacral; each additional segment

63267 Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; lumbar 63620 Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator), 1 spinal lesion 63621 Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator), each additional spinal lesion







Code Description


63650 Neurostimulator Implantation - Percutaneous implantation of neurostimulator electrode array, epidural 63655 Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural 63685 Neurostimulator Implantation - Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive

coupling 64553 Neurostimulator Implantation - Percutaneous implantation of neurostimulator electrodes; cranial nerve 64555 Neurostimulator Implantation - Percutaneous implantation of neurostimulator electrodes; peripheral nerve (excludes sacral nerve) 64568 Incision for implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator [when specified as

implantation of hypoglossal nerve stimulator] 64569 Revision or replacement of cranial nerve (eg, vagus nerve) neurostimulator electrode array, including connection to existing pulse

generator 64595 Gastric Pacemaker 64633 Destruction by neurolytic agent paravertebral facet joint nerve; lumbar or sacral, single level

64634 Destruction by neurolytic agent, paravertebral facet joint nerve; lumbar or sacral, each additional level [when specified as radiofrequency facet neurolysis]

64635 Destruction by neurolytic agent; cervical or thoracic, single level 64636 Destruction by neurolytic agent; cervical or thoracic, each additional level 64640 Destruction by neurolytic agent; other peripheral nerve or branch 64999 Unlisted procedure, nervous system [when specified as percutaneous decompression or laser procedures of cervical or thoracic

spine] 64716 Neuroplasty and/or transposition; cranial nerve







Code Description


64732 Transection or avulsion of; supraorbital nerve 64734 Transection or avulsion of; infraorbital nerve 64736 Transection or avulsion of; mental nerve 64738 Transection or avulsion of; inferior alveolar nerve by osteotomy 64740 Transection or avulsion of; lingual nerve 64742 Transection or avulsion of; facial nerve, differential or complete 64864 Suture of facial nerve; extracranial 64865 Suture of facial nerve; infratemporal, with or without grafting 64866 Anastomosis; facial-spinal accessory 64868 Anastomosis; facial-hypoglossal 64870 Anastomosis; facial-phrenic 64999 Unlisted procedure, nervous system [when specified as percutaneous decompression or laser procedures of cervical or thoracic

spine] 66174 Canaloplasty - Transluminal dilation of aqueous outflow canal; without retention of device or stent 66175 Canaloplasty - Transluminal dilation of aqueous outflow canal; with retention of device or stent 66183 Insertion of anterior segment aqueous drainage device, without extraocular reservoir, external approach 67220 Treatment of choroid lesion 67900 Blepharoplasty - repair of brow ptosis ( supraciliary, mid-forehead or cornal approach) 67901 Blepharoplasty - repair of blepharoptosis; frontalis muscle technique with suture or other material (eg, banked fascia)







Code Description


67902 Blepharoplasty - repair of blepharoptosis; frontalis muscle technique with autolgous facial sling (includes obtaining fascia) 67903 Blepharoplasty - repair of blepharoptosis; (tarso) levator resection or advancement, internal approach 67904 Blepharoplasty - repair of blepharoptosis; (tarso) levator resection or advancement, external approach 67906 Blepharoplasty - repair of blepharoptosis; superior rectus technique with facial sling (includes obtaining fascia) 67908 Blepharoplasty - repair of blepharoptosis; conjunctivo-tarso-Muller's muscle-levator resection (eg, Fasanella-Servat type) 67999 Unlisted procedure, middle ear [when specified as balloon dilation of eustachian tube, any approach] 69090 Ear piercing 69300 Otoplasty, protruding ear, with or without size reduction 69710 Implant/replace hearing aid 69714 Implantable hearing aids 69715 Implantation, osseointegrated implant, temporal bone 69717 Bone-Anchored Hearing Aids -Replacement (including removal of existing device), osseointegrated implant, temporal bone 69718 Bone-Anchored Hearing Aids - Replacement (including removal of existing device), osseointegrated implant, temporal bone 69930 Cochlear device implantation, with or without mastoidectomy 69955 Total facial nerve decompression and/or repair (may include graft) 77301 Intensity modulated radiotherapy plan, including dose-volume histograms for target and critical structure partial tolerance

specifications [when specified as treatment planning for PBRT] 74261 Virtual Colonoscopy - Computed tomographic (CT) colonography, diagnostic, including image post processing; without contrast

material







Code Description


74262 Virtual Colonoscopy - Computed tomographic (CT) colonography, diagnostic, including image post processing; with contrast material(s) including non-contrast images, if performed

74263 Virtual Colonoscopy - Computed tomographic (CT) colonography, screening, including image post processing 75571 Ultra-fast CT - Computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium 76376 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound or other

tomographic modality; not requiring image post processing on an independent workstation. 76377 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound or other

tomographic modality; requiring image post processing on an independent workstation. 76390 Magnetic Resonance Spectroscopy 76499 Unlisted Diagnostic Radiographic Procedure 77046 Magnetic resonance imaging, breast, without contrast material; unilateral 77047 Magnetic resonance imaging, breast, without contrast material; bilateral 77048 Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time

lesion detection, characterization and pharmacokinetic analysis) when performed; unilateral 77049 Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time

lesion detection, characterization and pharmacokinetic analysis) when performed; bilateral 77338 Multi-leaf collimator (MLC) device(s) for intensity modulated radiation therapy (IMRT), design and construction per IMRT plan [when

specified as devices for SRS or SBRT] 77371 Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1

session; multi-source Cobalt 60 based 77372 Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1

session; linear accelerator based







Code Description


77373 Stereotactic body radiation therapy, treatment delivery per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions

77385 Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed; simple 77386 Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed; complex 77432 Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session) 77435 Stereotactic body radiation therapy, treatment management, per treatment course, to one or more lesions, including image

guidance, entire course not to exceed 5 fractions G0339 Image-guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session or first session

of fractionated treatment G0340 Image-guided robotic linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging,

fractionated treatment, all lesions, per session, second through fifth sessions; maximum five sessions per course of treatment 77520 Proton Beam Therapy 77522 Proton Beam Therapy 77523 Proton Beam Therapy 77525 Proton Beam Therapy 81162 Genetic testing for cancer susceptibility - BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg,

hereditary breast and ovarian cancer) gene analysis; full sequence analysis and full duplication/deletion analysis (ie, detection of large gene rearrangements)

81212 Genetic testing for cancer susceptibility - BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; 185delAG, 5385insC, 6174delT variants

81215 Genetic testing for cancer susceptibility - BRCA1 (BRCA1, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; known familial variant







Code Description


81216 Genetic testing for cancer susceptibility - BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis

81217 Genetic testing for cancer susceptibility - BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; known familial variant

81292 Genetic testing for cancer susceptibility - MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis

81293 Genetic testing for cancer susceptibility - MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; known familial variants

81294 Genetic testing for cancer susceptibility - MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion variants

81295 Genetic testing for cancer susceptibility - MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis

81296 Genetic testing for cancer susceptibility - MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; known familial variants

81297 Genetic testing for cancer susceptibility - MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion variants

81298 Genetic testing for cancer susceptibility - MSH6 (mutS homolog 6 [E. coli]) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis

81299 Genetic testing for cancer susceptibility - MSH6 (mutS homolog 6 [E. coli]) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; known familial variants

81300 Genetic testing for cancer susceptibility - MSH6 (mutS homolog 6 [E. coli]) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; known familial variants







Code Description


81317 Genetic testing for cancer susceptibility - PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis

81318 Genetic testing for cancer susceptibility - PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; known familial variants

81319 Genetic testing for cancer susceptibility - PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion variants

81321 Genetic Testing for PTEN Hamartoma Tumor Syndrome - PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; full sequence analysis

81322 Genetic Testing for PTEN Hamartoma Tumor Syndrome - PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; known familial variant

81323 Genetic Testing for PTEN Hamartoma Tumor Syndrome - PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; duplication/deletion variant]

81324 Genetic Testing for Inherited Peripheral Neuropathies - PMP22 (peripheral myelin protein 22) (eg, Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; duplication/deletion analysis

81325 Genetic Testing for Inherited Peripheral Neuropathies - PMP22 (peripheral myelin protein 22) (eg, Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; full sequence analysis

81326 Genetic Testing for Inherited Peripheral Neuropathies - PMP22 (peripheral myelin protein 22) (eg, Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; known familial variant

81402 Genetic Testing for Inherited Peripheral Neuropathies - Molecular pathology procedure, Level 3









Code Description




81448 Hereditary peripheral neuropathies (eg, Charcot-Marie-Tooth, spastic paraplegia), genomic sequence analysis panel, must include sequencing of at least 5 peripheral neuropathy-related genes (eg, BSCL2, GJB1, MFN2, MPZ, REEP1, SPAST, SPG11, SPTLC1)

81479 Unlisted molecular pathology procedure

81518 Oncology (breast), mRNA, gene expression profiling by real-time RT-PCR of 11 genes (7 content and 4 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithms reported as percentage risk for metastatic recurrence and likelihood of benefit from extended endocrine therapy

81519 Oncology (breast), mRNA, gene expression profiling by real-time RT-PCR of 21 genes, utilizing formalin-fixed paraffin embedded tissue, algorithm reported as recurrence score

81520 Oncology (breast), mRNA gene expression profiling by hybrid capture of 58 genes (50 content and 8 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a recurrence risk score

81521 Oncology (breast), mRNA, microarray gene expression profiling of 70 content genes and 465 housekeeping genes, utilizing fresh frozen or formalin-fixed paraffin-embedded tissue, algorithm reported as index related to risk of distant metastasis

81599 Unlisted multianalyte assay with algorithmic analysis [when specified as testing for thyroid molecular markers]

89344 Cryopreservation of Oocytes or Ovarian Tissue - Storage, (per year); reproductive tissue, testicular/ovarian [specified as ovarian tissue]

89354 Cryopreservation of Oocytes or Ovarian Tissue - Thawing of cryopreserved; reproductive tissue, testicular/ovarian [specified as ovarian tissue]

91110 Capsule Endoscopy - Gastrointestinal tract imaging, intraluminal, esophagus through ileum, with physician interpretation and report







Code Description


91111 Capsule Endoscopy - Gastrointestinal tract imaging, intraluminal, esophagus, with physician interpretation and report 93228 External mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and

greater than 24 hours of accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events transmitted to a remote attended surveillance center for up to 30 days; physician review and interpretation with report

93229 External mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events transmitted to a remote attended surveillance center for up to 30 days; technical support for connection and patient instructions for use, attended surveillance, analysis and physician prescribed transmission of daily and emergent data reports

93580 Transcatheter closure of a patent foramen ovale - Percutaneous transcatheter closure of congenital interatrial communication (i.e., fontan fenestration, atrial septal defect) with implant

93600 Bundle of His recording 93602 Intra-artrial recording 93603 Right ventricular recording 93609 Intraventricular and/or intra-arterial mapping of tachycardia site(s) with catheter manipulation to record from multiple sites to identify

origin of tachycardia 93613 Intracardiac electrophysiologic 3-dimensional mapping (add-on to 93620, 93653, 93656) 93619 Comprehensive electrophysiologic evaluation with right atrial pacing and recording, right ventricular pacing and recording, His

bundle recording, including insertion and repositioning of multiple electrode catheters, without induction or attempted induction of arrhythmia

93620 Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with right atrial pacing and recording, right ventricular pacing and recording, His bundle recording







Code Description


93621 Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with left atrial pacing and recording from coronary sinus or left atrium (add-on to 93620, 93653, 93654)

93622 Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with left ventricular pacing and recording (add-on to 93620, 93653, 93654)

93624 Electrophysiologic follow-up study with pacing and recording to test effectiveness of therapy, including induction or attempted induction of arrhythmia

93650 Intracardiac catheter ablation of atrioventricular node function, atrioventricular conduction for creation of complete heart block, with or without temporary pacemaker placement

93653 Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of an arrhythmia with right atrial pacing and recording, right ventricular pacing and recording (when necessary), and His bundle recording (when necessary) with intracardiac catheter ablation of arrhythmogenic focus; with treatment of supraventricular tachycardia by ablation of fast or slow atrioventricular pathway, accessory atrioventricular connection, cavo-tricuspid isthmus or other single atrial focus or source of atrial re-entry

93654 Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of an arrhythmia with right atrial pacing and recording, right ventricular pacing and recording (when necessary), and His bundle recording (when necessary) with intracardiac catheter ablation of arrhythmogenic focus; with treatment of ventricular tachycardia or focus of ventricular ectopy including intracardiac electrophysiologic 3D mapping, when performed, and left ventricular pacing and recording, when performed

93655 Intracardiac catheter ablation of a discrete mechanism of arrhythmia which is distinct from the primary ablated mechanism, including repeat diagnostic maneuvers, to treat a spontaneous or induced arrhythmia (List separately in addition to code for primary procedure)

95803 Sleep study/Actigraphy testing, recording, analysis, interpretation, and report (minimum of 72 hours to 14 consecutive days of recording)







Code Description


95965 Magnetoencephalography (MEG) 95966 Magnetoencephalography (MEG) 95967 Magnetoencephalography (MEG) 95976 Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact group(s), interleaving, amplitude, pulse

width, frequency [Hz], on/of cycling, burst, magnet mode, dose lockout, patient selectable algorithms, closed loop parameters, and passive parameters) by physician or other qualified health care professional; with simple cranial nerve neurostimulator pulse generator/transmitter programming by physician or other qualified health care professional) (replacing 95974 effective 1/1/19)

95977 Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact group(s), interleaving, amplitude, pulse width, frequency [Hz], on/of cycling, burst, magnet mode, dose lockout, patient selectable algorithms, closed loop parameters, and passive parameters) by physician or other qualified health care professional; with complex cranial nerve neurostimulator pulse generator/transmitter programming by physician or other qualified health care professional) (replacing 95975 effective 1/1/19)

99183 Physician attendance and supervision of hyperbaric oxygen therapy, per session 0054T Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on fluoroscopic images 0055T Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on CT/MRI images 0071T Focused ultrasound ablation of uterine leiomyomata 0072T Focused ultrasound ablation of uterine leiomyomata 0075T Carotid, Vertebral and Intracranial Artery Angioplasty - Transcatheter placement of extracranial vertebral or intrathoracic carotid

artery stent(s); initial vessel 0076T Carotid, Vertebral and Intracranial Artery Angioplasty - Transcatheter placement of extracranial vertebral or intrathoracic carotid

artery stent(s); each additional vessel 0095T Artificial Intervertebral Discs - Removal of total disc arthroplasty, anterior approach cervical; each additional interspace







Code Description


0098T Artificial Intervertebral Discs - Revision of total disc anthroplasty, anterior approach cervical; each additional interspace 0101T Extracorpeal shock wave therapy (Orthotripsy) 0102T Extracorpeal shock wave therapy (Orthotripsy) 0163T Artificial Intervertebral Discs - total disc arthroplasty, anterior approach, including diskectomy to prepare interspace (other than for

decompression); lumbar, each additional interspace 0164T Artificial Intervertebral Discs - Removal of total disc arthroplasty, anterior approach, lumbar, each additional interspace

0165T Artificial Intervertebral Discs - Revision of total disc arthroplasty, anterior approach, lumbar, each additional interspace 0171T Insertion of posterior spinous process distraction device , lumbar; single level 0172T Insertion of posterior spinous process distraction device, lumbar; each additional level 0200T Kyphoplasty - Percutaneous sacral augmentation (sacroplasty), unilateral injection(s), including the use of a balloon or mechanical

device, when used, 1 or more needles, includes imaging guidance and bone biopsy, when performed 0201T Kyphoplasty - Percutaneous sacral augmentation (sacroplasty), bilateral injections, including the use of a balloon or mechanical

device, when used, 2 or more needles, includes imaging guidance and bone biopsy, when performed 0202T Implanted Devices for Spinal Stenosis - Posterior vertebral joint(s) arthroplasty (e.g., facet joint[s] replacement) including

facetectomy, laminectomy, foraminotomy and vertebral column fixation, with or without injection of bone cement, including fluoroscopy, single level, lumbar spine

0219T Spinal surgery - Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; cervical

0220T Spinal surgery - Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; thoracic

0221T Spinal surgery - Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; lumbar







Code Description


0222T Spinal surgery - Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; each additional vertebral segment

0312T Vagus nerve blocking therapy (morbid obesity); laparoscopic implantation of neurostimulator electrode array, anterior and posterior vagal trunks adjacent to esophagogastric junction (EGJ), with implantation of pulse generator, includes programming

0313T Vagus nerve blocking therapy (morbid obesity); laparoscopic revision or replacement of vagal trunk neurostimulator electrode array, including connection to existing pulse generator

0314T Vagus nerve blocking therapy (morbid obesity); laparoscopic removal of vagal trunk neurostimulator electrode array and pulse generator

0315T Vagus nerve blocking therapy (morbid obesity); removal of pulse generator 0316T Vagus nerve blocking therapy (morbid obesity); replacement of pulse generator 0317T Vagus nerve blocking therapy (morbid obesity); neurostimulator pulse generator electronic analysis, includes reprogramming when

performed 0326T, 0363T Exposure behavioral follow-up assessment 0331T Myocardial sympathetic innervation imaging, planar qualitative and quantitative Y assessment 0332T Myocardial sympathetic innervation imaging, planar qualitative and quantitative assessment; with tomographic SPECT 0335T Insertion of sinus tarsi implant 0342T Therapeutic apheresis with selective HDL delipidation and plasma reinfusion 0360T, 0361T Observational behavioral follow-up assessment 0364T, 0365T Adaptive Behavior Tx by Protocol 0366T, 0367T Group Adaptive Behavior Tx Protocol 0368T, 0369T Adaptive behavior treatment with protocol modification







Code Description


0370T Family adaptive behavior treatment guidance 0371T Multiple-family group adaptive behavior treatment guidance 0372T Adaptive behavior treatment social skills group 0373T, 0374T Exposure Adaptive Behavior Treatment With Protocol Modification 0375T Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy

for nerve root or spinal cord decompression and microdissection), cervical, three or more levels 0376T Insertion of anterior segment aqueous drainage device, without extraocular reservoir; internal approach, into the trabecular

meshwork; each additional device insertion 0398T Magnetic resonance image guided high intensity focused ultrasound (MRgFUS), stereotactic ablation lesion, intracranial for

movement disorder including stereotactic navigation and frame placement when performed 0465T Suprachoroidal delivery of pharmacologic agent (does not include supply of medication) 0505T Endovenous femoral-popliteal arterial revascularization, with transcatheter placement of intravascular stent graft(s) and closure by

any method, including percutaneous or open vascular access, ultrasound guidance for vascular access when performed, all catheterization(s) and intraprocedural roadmapping and imaging guidance necessary to complete the intervention, all associated radiological supervision and interpretation, when performed, with crossing of the occlusive lesion in an extraluminal fashion

0510T Removal of sinus tarsi implant (effective 1/1/19) 0511T Removal and reinsertion of sinus tarsi implant (effective 1/1/19) A0380 BLS mileage (per mile) – non-emergency transport A0390 ALS mileage (per mile) – non-emergency transport A0425 Ground ambulance mileage, per statute mile – non-emergency transport A0426 Ambulance service, advanced life support, non-emergency transport, Level 1 (ALS1)







Code Description


A0428 Ambulance service, basic life support, non-emergency transport (BLS) A0430 Ambulance service, conventional air services, non-emergency transport, one way (fixed wing) A0431 Ambulance service, conventional air services, non-emergency transport, one way (rotary wing) A0435 Ambulance service - Fixed wing air mileage, per statute mile - non-emergency transport A0436 Ambulance service - Rotary wing air mileage, per statute mile - non-emergency transport A0999 Ambulance service - Unlisted [when specified as ambulance service, water transport] - non-emergency transport A7025 High frequency chest wall oscillation system vest, replacement for use with patient owned equipment A9274 External ambulatory insulin delivery system, disposable, each, includes all supplies and accessories A9582 Myocardial sympathetic innervations imaging with or without SPECT - Iodine I-123 iobenguane, diagnostic, per study dose, up to 15

millicuries [AdreView; when specified for use in myocardial imaging] C1300 Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval C1721 Cardioverter-defibrillator, dual chamber (implantable) C1722 Cardioverter-defibrillator, single chamber (implantable) C1767 Generator, neurostimulator (implantable), nonrechargeable C1777 Cardiac Resynchronization Therapy - Lead, cardioverter-defibrillator, endocardial single coil (implantable) C1882 Cardioverter-defibrillator, other than single or dual chamber (implantable) C1895 Cardiac Resynchronization Therapy - Lead, cardioverter-defibrillator, endocardial dual coil (implantable) C1896 Cardiac Resynchronization Therapy - Lead, cardioverter-defibrillator, other than endocardial single or dual coil (implantable) C2625 Stent, noncoronary, temporary, with delivery system (SURG.00132 Drug-Eluting Devices for Maintaining Sinus Ostial Patency C8903 MRI - Breast







Code Description


C8905 MRI - Breast C8906 MRI - Breast C8908 MRI - Breast C9727 Insertion of implants into the soft palate; minimum of three implants C9734 Focused ultrasound ablation/therapeutic intervention, other than uterine leiomyomata, with magnetic resonance (MR) guidance C9745 Nasal endoscopy, surgical; balloon dilation of eustachian tube C9748 Transurethral destruction of prostate tissue; by radiofrequency water vapor (steam) thermal therapy D7810 Temporomandibular Disorders: Open reduction of dislocation D7820 Temporomandibular Disorders: Closed reduction of dislocation D7830 Temporomandibular Disorders: Manipulation under anesthesia D7840 Temporomandibular Disorders: Condylectomy D7850 Temporomandibular Disorders: Surgical discectomy with/without implant-excision of the intra-articular disc of a joint D7852 Temporomandibular Disorders: Disc repair D7854 Temporomandibular Disorders: Synovectomy D7856 Temporomandibular Disorders: Myotomy D7858 Temporomandibular Disorders: Joint reconstruction D7860 Temporomandibular Disorders: Arthrotomy D7865 Temporomandibular Disorders: Arthroplasty D7870 Temporomandibular Disorders: Arthrocentesis







Code Description


D7871 Temporomandibular Disorders: Nonarthroscopic lysis and lavage D7873 Temporomandibular Disorders: Arthroscopy-surgical: lavage and lysis of adhesions D7874 Temporomandibular Disorders: Arthroscopy - surgical: debridement D7875 Temporomandibular Disorders: Arthroscopy - surgical: synovectomy D7876 Temporomandibular Disorders: Arthroscopy - surgical: discectomy D7877 Temporomandibular Disorders: Arthroscopy - surgical: debridement D7880 Temporomandibular Disorders: Occlusal orthotic appliance D7940 Mandibular/Maxillary (Orthognathic) Surgery - Osteoplasty - for orthognathic deformities D7941 Mandibular/Maxillary (Orthognathic) Surgery - Osteotomy; mandibular rami D7943 Mandibular/Maxillary (Orthognathic) Surgery - Osteotomy; mandibular rami with bone graft; includes obtaining the graft D7944 Mandibular/Maxillary (Orthognathic) Surgery - Osteotomy-segmented or subapical-per sextant or quadrant D7945 Mandibular/Maxillary (Orthognathic) Surgery -Osteotomy-body of mandible D7946 Mandibular/Maxillary (Orthognathic) Surgery - LeFort I (maxilla, total) D7947 Mandibular/Maxillary (Orthognathic) Surgery - LeFort I (maxilla - segmented) D7948 Mandibular/Maxillary (Orthognathic) Surgery - LeFort II or LeFort III (osteoplasty of facial bones for midface hypoplasia or

retrusion); without bone graft D7949 Mandibular/Maxillary (Orthognathic) Surgery - LeFort II or LeFort III; with bone graft D7950 Mandibular/Maxillary (Orthognathic) Surgery - Osseous graft to mandible D7995 Mandibular/Maxillary (Orthognathic) Surgery - Synthetic graft, mandible or facial bones, by report







Code Description


D7996 Mandibular/Maxillary (Orthognathic) Surgery - Implant-mandible or augmentation purposes (excluding alveolar ridge) D9940 Temporomandibular Disorders: Occlusal guard, by report D9950 Temporomandibular Disorders: Occlusion analysis- mounted case D9951 Temporomandibular Disorders: Occlusal adjustment- limited D9952 Temporomandibular Disorders: Occlusal adjustment- complete E0481 Intrapulmonary percussive ventilation system and related accessories E0483 High frequency chest wall oscillation system, includes all accessories and supplies, each E0638 Standing frame system, one position (e.g. upright, E0641 Standing frame system, multi-position (e.g. three- E0642 Standing frame system, mobile (dynamic stander), any size including pediatric E0652 Pneumatic Compression Devices for Lymphedema - segmental home model with calibrated gradient pressure E0656 Pneumatic Compression Devices for Lymphedema - Segmental pneumatic appliance for use with pneumatic compressor, trunk E0657 Pneumatic Compression Devices for Lymphedema -Segmental pneumatic appliance for use with pneumatic compressor, full leg E0670 Pneumatic Compression Devices for Lymphedema - Segmental pneumatic appliance for use with pneumatic compressor,

integrated, 2 full legs and trunk E0671 Pneumatic Compression Devices for Lymphedema - Segmental gradient pressure pneumatic appliance, full leg E0672 Pneumatic Compression Devices for Lymphedema - Segmental gradient pressure pneumatic appliance, full arm E0673 Pneumatic Compression Devices for Lymphedema - Segmental gradient pressure pneumatic appliance, half leg E0745 Neuromuscular stimulator, electronic shock unit







Code Description


E0747 Bone Growth Stimulators - Osteogenesis stimulator; electrical, noninvasive, other than spinal applications E0760 Bone Growth Stimulators - Low intensity ultrasound stimulation to aid bone healing, noninvasive (non-operative) E0764 Functional neuromuscular stimulator, transcutaneous stimulation of sequential muscle groups of ambulation with computer control,

used for walking by spinal cord injured, entire system, after completion of training program E0770 Functional electrical stimulator, transcutaneous stimulation of nerve and/or muscle groups, any type, complete system, not

otherwise specified E0784 Insulin Pump E1002 Wheelchair accessory, power seating system E1003 Wheelchair accessory, power seating system E1004 Wheelchair accessory, power seating system E1005 Wheelchair accessory, power seating system E1006 Wheelchair accessory, power seating system E1007 Wheelchair accessory, power seating system E1008 Wheelchair accessory, power seating system E1009 Wheelchair accessory, addition to power seating system, mechanically linked leg elevation system including pushrod and leg rest,

each E1010 Wheelchair accessory, addition to power seating system, power leg elevation system, including leg rest, pair E1012 Wheelchair accessory, power seating system E1230 Wheelchair - Power operated vehicle (three- or four-wheel non highway) E1239 Wheelchair - Power wheelchair, pediatric size, not otherwise specified







Code Description


E1399 Misc/Unlisted DME code E1902 Speech Generating Devices - Communication board, non-electronic augmentative or alternative communication device E2120 Pulse generator system for tympanic treatment of inner ear endolymphatic fluid E2300 Power wheelchair accessory, power seat elevation system E2301 Power wheelchair accessory, power standing system E2351 Power wheelchair accessory, electronic interface to operate speech generating device using E2500 Speech generating device, digitized speech, using prerecorded messages, less than or equal to 8 minutes recording time E2502 Speech generating device, digitized speech, using prerecorded messages, greater than 8 minutes but less than or equal to 20

minutes recording time E2504 Speech generating device, digitized speech, using prerecorded messages, greater than 20 minutes but less than or equal to 40

minutes recording time E2506 Speech generating device, digitized speech, using prerecorded messages, greater than 40 minutes recording time E2508 Speech generating device, synthesized speech, requiring message formulation by spelling and access by physical contact with the

device E2510 Speech generating device, synthesized speech, permitting multiple methods of message formulation and multiple methods of

device access G6015 Intensity modulated treatment delivery, single or multiple fields/arcs, via narrow spatially and temporally modulated beams, binary,

dynamic MLC, per treatment session G6016 Compensator-based beam modulation treatment delivery of inverse planned treatment using 3 or more high resolution (milled or

cast) compensator, convergent beam modulated fields, per treatment session J7330 Autologous cultured chondrocytes knee, implant







Code Description


J3490 Unclassified drugs [when specified as SINUVA sinus implant] K0005 Wheelchair - Ultra lightweight K0010 Wheelchair - Motorized/power K0011 Wheelchair - Motorized/power K0012 Wheelchair - Motorized/power K0013 Wheelchair - Motorized/power K0014 Wheelchair - Motorized/power K0606 Automatic external defibrillator, with integrated electrocardiogram analysis, garment type K0800 Wheelchair - Power operated vehicle, group 1 K0801 Wheelchair - Power operated vehicle, group 1 K0802 Wheelchair - Power operated vehicle, group 1 K0806 Wheelchair - Power operated vehicle, group 2 K0807 Wheelchair - Power operated vehicle, group 2 K0808 Wheelchair - Power operated vehicle, group 2 K0812 Wheelchair - Power operated vehicle, not otherwise classified [scooter] K0813 Wheelchair - Power wheelchair, group 1 standard K0814 Wheelchair - Power wheelchair, group 1 standard K0815 Wheelchair - Power wheelchair, group 1 standard







Code Description


K0816 Wheelchair - Power wheelchair, group 1 standard K0820 Wheelchair - Power wheelchair, group 2 standard/heavy duty K0821 Wheelchair - Power wheelchair, group 2 standard/heavy duty K0822 Wheelchair - Power wheelchair, group 2 standard/heavy duty K0823 Wheelchair - Power wheelchair, group 2 standard/heavy duty K0824 Wheelchair - Power wheelchair, group 2 standard/heavy duty K0825 Wheelchair - Power wheelchair, group 2 standard/heavy duty K0826 Wheelchair - Power wheelchair, group 2 standard/heavy duty K0827 Wheelchair - Power wheelchair, group 2 standard/heavy duty K0828 Wheelchair - Power wheelchair, group 2 standard/heavy duty K0829 Wheelchair - Power wheelchair, group 2 standard/heavy duty K0830 Wheelchair - Power wheelchair, group 2 standard/heavy duty K0831 Wheelchair - Power wheelchair, group 2 standard/heavy duty K0835 Wheelchair - Power wheelchair, group 2 standard/heavy duty K0836 Wheelchair - Power wheelchair, group 2 standard/heavy duty K0837 Wheelchair - Power wheelchair, group 2 standard/heavy duty K0838 Wheelchair - Power wheelchair, group 2 standard/heavy duty K0839 Wheelchair - Power wheelchair, group 2 standard/heavy duty







Code Description


K0840 Wheelchair - Power wheelchair, group 2 standard/heavy duty K0841 Wheelchair - Power wheelchair, group 2 standard/heavy duty K0842 Wheelchair - Power wheelchair, group 2 standard/heavy duty K0843 Wheelchair - Power wheelchair, group 2 standard/heavy duty K0848 Wheelchair - Power wheelchair, group 3 standard/heavy duty K0849 Wheelchair - Power wheelchair, group 3 standard/heavy duty K0850 Wheelchair - Power wheelchair, group 3 standard/heavy duty K0851 Wheelchair - Power wheelchair, group 3 standard/heavy duty K0852 Wheelchair - Power wheelchair, group 3 standard/heavy duty K0853 Wheelchair - Power wheelchair, group 3 standard/heavy duty K0854 Wheelchair - Power wheelchair, group 3 standard/heavy duty K0855 Wheelchair - Power wheelchair, group 3 standard/heavy duty K0856 Wheelchair - Power wheelchair, group 3 standard/heavy duty K0857 Wheelchair - Power wheelchair, group 3 standard/heavy duty K0858 Wheelchair - Power wheelchair, group 3 standard/heavy duty K0859 Wheelchair - Power wheelchair, group 3 standard/heavy duty K0860 Wheelchair - Power wheelchair, group 3 standard/heavy duty K0861 Wheelchair - Power wheelchair, group 3 standard/heavy duty







Code Description


K0862 Wheelchair - Power wheelchair, group 3 standard/heavy duty K0863 Wheelchair - Power wheelchair, group 3 standard/heavy duty K0864 Wheelchair - Power wheelchair, group 3 standard/heavy duty K0868 Wheelchair - Power wheelchair, group 4 standard/heavy duty K0869 Wheelchair - Power wheelchair, group 4 standard/heavy duty K0870 Wheelchair - Power wheelchair, group 4 standard/heavy duty K0871 Wheelchair - Power wheelchair, group 4 standard/heavy duty K0877 Wheelchair - Power wheelchair, group 4 standard/heavy duty K0878 Wheelchair - Power wheelchair, group 4 standard/heavy duty K0879 Wheelchair - Power wheelchair, group 4 standard/heavy duty K0880 Wheelchair - Power wheelchair, group 4 standard/heavy duty K0884 Wheelchair - Power wheelchair, group 4 standard/heavy duty K0885 Wheelchair - Power wheelchair, group 4 standard/heavy duty K0886 Wheelchair - Power wheelchair, group 4 standard/heavy duty K0890 Wheelchair - Power wheelchair, group 5 pediatric K0891 Wheelchair - Power wheelchair, group 5 pediatric K0898 Wheelchair - Power wheelchair, not otherwise classified K0899 Wheelchair - Power mobility device, not coded by DME PDAC or does not meet criteria







Code Description


L5856 Custom prosthesis - Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase

L5857 Custom prosthesis - Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing phase only

L5858 Custom prosthesis - Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, stance phase only

L5859 Custom prosthesis - Addition to lower extremity prosthesis, endoskeletal knee-shin system, powered and programmable flexion/extension assist control, includes any type motor(s)

L6025 Custom prosthesis - Partial hand disarticulation prosthesis, external power, self-suspended, inner socket with removable forearm section, electrodes and cables, two batteries, charger, myoelectric control of terminal device

L6611 Custom prosthesis - Addition to upper extremity prosthesis, external powered, additional switch, any type L6677 Custom prosthesis - Upper extremity addition, harness, triple control, simultaneous operation of terminal device and elbow L6881 Custom Prosthesis - Automatic grasp feature, addition to upper limb prosthetic terminal device L6925 Custom prosthesis - Wrist disarticulation, external power, self-suspended inner socket, removable forearm shell L6935 Custom prosthesis - Below elbow, external power, self-suspended inner socket, removable forearm shell L6945 Custom prosthesis - Elbow disarticulation, external power, molded inner socket, removable humeral shell, outside locking hinges,

forearm, Otto Bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device L6955 Custom prosthesis - Above elbow, external power, molded inner socket, removable humeral shell, internal locking elbow, forearm L6965 Custom prosthesis - Shoulder disarticulation, external power, molded inner socket, removable shoulder shell, shoulder bulkhead,

humeral section, mechanical elbow, forearm L6975 Custom prosthesis - Interscapular-thoracic, external power, molded inner socket, removable shoulder shell, shoulder bulkhead,

humeral section, mechanical elbow, forearm







Code Description


L7007 Custom Prosthesis - Adult electric hand L7008 Custom prosthesis - Electric hand, switch or myoelectric controlled, pediatric L7009 Custom prosthesis - Electric hook, switch or myoelectric controlled, adult L7045 Custom prosthesis - Electronic hook, child, Michigan or equal, switch controlled L7180 Custom prosthesis - Electronic elbow, Boston, Utah or equal, myoelectronically controlled L7181 Custom prosthesis - Electronic elbow, microprocessor simultaneous control of elbow and terminal device L7190 Custom prosthesis - Electronic elbow, adolescent, Variety Village or equal, myoelectronically controlled L7191 Custom prosthesis - Electronic elbow, child, variety village or equal, myoelectronically controlled L8614 Cochlear device, includes all internal and external components L8619 Cochlear Implant - external speech processor and controller, integrated system, replacement L8627 Cochlear Implant - external speech processor, component, replacement L8628 Cochlear Implant - external controller component, replacement L8679 Implantable neurostimulator, pulse generator, any type L8680 Implantable Neurostimulator Electrode L8682 Neurostimulator Implantation - Implantable Neurostimulator Radiofrequency Receiver L8683 Neurostimulator Implantation - Radiofrequency Transmitter (external) For Use With Implantable Neurostimulator Radiofrequency

Receiver L8684 Neurostimulator Implantation - Radiofrequency transmitter (external) for use with implantable sacral root neurostimulator receiver

for bowel and bladder management, replacement L8685 Neurostimulator Implantation - Implantable Neurostimulator Pulse Generator, single array, rechargeable, includes extension







Code Description


L8686 Neurostimulator Implantation - Implantable Neurostimulator Pulse Generator, single array, non-rechargeable, includes extension L8687 Neurostimulator Implantation - Implantable Neurostimulator Pulse Generator, dual array, rechargeable, includes extension L8688 Neurostimulator Implantation - Implantable Neurostimulator Pulse Generator, dual array, non-rechargeable, includes extension L8690 Bone-Anchored Hearing Aids - Auditory osseointegrated device, includes all internal and external components L8691 Auditory osseointegrated device, external sound processor, excludes transducer/actuator, replacement only, each L8694 Auditory osseointegrated device, transducer/actuator, replacement only, each L8699 Prothetic implant, not otherwise specified [when specified as drug-eluting sinus stent implant] S1034 Artificial pancreas device system (e.g., low glucose suspend [LGS] feature) including continuous glucose monitor, blood glucose

device, insulin pump and computer algorithm that communicates with all of the devices S1090 Mometasone furoate sinus implant, 370 micrograms [Propel sinus implant] S2066 Breast procedure - Breast reconstruction with gluteal artery perforator (GAP) flap, including harvesting of the flap, microvascular

transfer, closure of donor site and shaping the flap into a breast, unilateral S2067 Breast procedure - Breast reconstruction of a single breast with "stacked" deep inferior epigastric perforator (DIEP) flap(s) and/or

gluteal artery perforator S2068 Breast procedure - Breast reconstruction with deep inferior epigastric perforator flap or superficial inferior epigastric artery flap,

including harvesting of the flap, microvascular transfer, closure of donor site and shaping the flap into a breast, unilateral S2080 Laser-assisted uvulopalatoplasty S2112 Autologous chondrocyte transplantation/Arthroscopy knee, surgical harvesting of cartilage (chondrocyte cells) S2117 Subtalar Arthroereisis - Arthroereisis, subtalar S2120 Therapeutic Apheresis - Low density lipoprotein (LDL) apheresis using heparin-induced extracorporeal LDL precipitation







Code Description


S2202 Sclerotherapy S2230 Implantation of magnetic component of semi-implantable hearing device on ossicles in middle ear S2235 Cochlear Implant - implantation of auditory brain stem implant S2300 Electrothermal capsular shrinkage - Arthroscopy, shoulder, surgical; with thermally-induced capsulorrhaphy S2342 Nasal endoscopy for post-operative debridement following functional endoscopic sinus surgery, nasal and/or sinus cavity(s),

unilateral or bilateral S2350 Diskectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; lumbar, single interspace S2351 Diskectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; lumbar, each additional

interspace S8030 Proton Beam Therapy S8092 Ultra-fast CT - Electron beam computed tomography V2788 Presbyopia correcting function of intraocular lens







Code Description


REV codes for Behavioral Health as follows:

0114 Psychiatric Inpatient 0124 Psychiatric Inpatient 0134 Psychiatric Inpatient 0144 Psychiatric Inpatient 0154 Psychiatric Inpatient 0116 Inpatient Detox 0126 Inpatient Detox 0136 Inpatient Detox 0146 Inpatient Detox 0156 Inpatient Detox 0118 Inpatient Rehabilitation 0128 Inpatient Rehabilitation 0138 Inpatient Rehabilitation 0148 Inpatient Rehabilitation 0158 Inpatient Rehabilitation 0204 Psychiatric ICU 1001 Psychiatric RTC 1002 Substance Abuse RTC 0905 Psychiatric IOP 0906 Substance Abuse IOP 0912 Partial Hospitalization - Full Day (Psychiatric or Substance Abuse) 0913 Partial Hospitalization - Full Day (Psychiatric or Substance Abuse)

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