11313 Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter over 2.

Transcription

1 Code This list may not include new procedural, experimental/investigational or cosmetic codes. Providers must submit a PA request for services that are potentially cosmetic or experimental/investigational or if they are unsure of coverage. Authorization does not guarantee payment; and claim payment is subject to benefit exclusions and limitations. * Please refer to note in description Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum (including MAC) Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum (including MAC) Anesthesia for intraoral procedures, including biopsy; not otherwise specified Paring or cuting of benign hyperkeratotic lesion (eg, corn or callus); single lesion Paring or cuting of benign hyperkeratotic lesion (eg, corn or callus); 2 to 4 lesions Paring or cuting of benign hyperkeratotic lesion (eg, corn or callus); more than 4 lesions Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.5 cm or less Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.6 to 1.0 cm Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 1.1 to 2.0 cm Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter over 2.0 cm Shaving of epidermal or dermal lesion, single lesion, scalp, neck,hands, feet, genitalia; lesion diameter 0.5 cm or less Shaving of epidermal or dermal lesion, single lesion, scalp, neck,hands, feet, genitalia; lesion diameter 0.6 to 1.0 cm Shaving of epidermal or dermal lesion, single lesion, scalp, neck,hands, feet, genitalia; lesion diameter 1.1 to 2.0 cm Shaving of epidermal or dermal lesion, single lesion, scalp, neck,hands, feet, genitalia; lesion diameter over 2.0 cm Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.5 cm or less Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.6 to 1.0 cm Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 01.1 to 2.0 cm Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter over 2.0 cm Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.5 cm or less Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.6 to 1.0 cm Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 1.1 to 2.0 cm Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 2.1 to 3.0 cm Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 3.1 to 4.0 cm Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter over 4.0 cm Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 0.5 cm or less Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 0.6 to 1.0 cm Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 1.1 to 2.0 cm Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 2.1 to 3.0 cm

2 11424 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 3.1 to 4.0 cm Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter over 4.0 cm Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face ears, eyelids, nose, lips, mucous membrane; excised diameter 0.5 cm or less Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face ears, eyelids, nose, lips, mucous membrane; excised diameter 0.6 to 1.0 cm Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face ears, eyelids, nose, lips, mucous membrane; excised diameter 1.1 to 2.0 cm Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face ears, eyelids, nose, lips, mucous membrane; excised diameter 2.1 to Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face ears, eyelids, nose, lips, mucous membrane; excised diameter 3.1 to 4.0 cm Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face ears, eyelids, nose, lips, mucous membrane; excised diameter over 4.0 cm Injection, intralesional; up to and including 7 lesions Injection, intralesional; more than 7 lesions 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) Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation Injection of collagen or other filling material Injection of collagen or other filling material Injection of collagen or other filling material Injection of collagen or other filling material Cervicoplasty Blepharoplasty lower eyelid Blepharoplasty lower eyelid with extensive herniated fat pad Blepharoplasty upper eyelid Blepharoplasty upper eyelid; with excessive skin weighing down lid Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy Lipectomy/Liposuction procedures Excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh Lipectomy/Liposuction procedures Excision, excessive skin and subcutaneous tissue (includes lipectomy); leg Lipectomy/Liposuction procedures Excision, excessive skin and subcutaneous tissue (includes lipectomy); hip Lipectomy/Liposuction procedures Excision, excessive skin and subcutaneous tissue (includes lipectomy); buttock

3 15836 Lipectomy/Liposuction procedures Excision, excessive skin and subcutaneous tissue (includes lipectomy); arm Lipectomy/Liposuction procedures Excision, excessive skin and subcutaneous tissue (includes lipectomy); forearm or hand Lipectomy/Liposuction procedures Excision, excessive skin and subcutaneous tissue (including lipectomy); submental fat pad Lipectomy/Liposuction procedures Excision, excessive skin and subcutaneous tissue (includes lipectomy), other area Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen (eg, abdominoplasty) Lipectomy/Liposuction procedures Suction assisted lipectomy; head and neck Lipectomy/Liposuction procedures Suction assisted lipectomy; trunk Lipectomy/Liposuction procedures Suction assisted lipectomy; upper extremity Lipectomy/Liposuction procedures Suction assisted lipectomy; lower extremity Gynecomastia repair Mastopexy Breast Reduction (mammoplasty) Augmentation of breast mammoplasty Augmentation of breast mammoplasty Removal of breast implant/material (periprosthetic capsulectomy) Removal of breast implant/material (periprosthetic capsulectomy) Breast procedure Immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction Breast procedure Delayed insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction Breast procedure Nipple/areola reconstruction Breast procedure Correction of inverted nipples Breast procedure Breast reconstruction, immediate or delayed, with tissue expander, including subsequent expansion Breast procedure Breast reconstruction with latissimus dorsi flap, with or without prosthetic implant Breast procedure Breast reconstruction with free flap Breast procedure Breast reconstruction with other technique Breast procedure Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), single pedicle, including closure of donor site Breast procedure Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), single pedicle, including closure of donor site, with microvascular anastomosis (supercharging) Breast procedure Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), double pedicle, including closure of site Breast procedure Open periprosthetic capsulotomy, breast Breast procdure Periprosthetic capsulectomy, breast Breast procedure Revision of reconstructed breast Breast procedure Preparation of moulage for custom breast implant Allograft, morselized, or placement of osteopromotive material, for spine surgery only

4 *20931 Allograft, morselized, or placement of osteopromotive material, for spine surgery only. Note: A clinical review is required for this secondary procedure code only when requested with a lumbar spinal surgery. Prior authorization is not required for cervical or thoracic spinal surgeries related to this procedure code. *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). Note: A clinical review is required for this secondary procedure code only when requested with a lumbar spinal surgery. Prior authorization is not required for cervical or thoracic spinal surgeries related to this procedure code *20937 Autograft for spine surgery only (includes harvesting the graft); morselized (through seperate skin or fascial incision). Note: A clinical review is required for this secondary procedure code only when requested with a lumbar spinal surgery. Prior authorization is not required for cervical or thoracic spinal surgeries related to this procedure code. *20938 Autograft for spine surgery only (includes harvesting the graft); structural, bicortical or tricortical (through separate skin or fascial incision). Note: A clinical review is required for this secondary procedure code only when requested with a lumbar spinal surgery. Prior authorization is not required for cervical or thoracic spinal surgeries related to this procedure code Bone Growth Stimulator electrical stimulation to aid bone healing Bone Growth Stimulator low intensity ultrasound stimulation to aid bone healing Bone Growth Stimulators Low intensity ultrasound stimulation to aid bone healing, noninvasive (non operative) Nasal (dorsal external) implants Forehead Reduction; conturing only Forehead Reduction; conturing and application of prosthetic material or bone graft (includes obtaining autograft) Forehead Reduction; conturing and setback of anterior frontal sinus wall Mandibular Osteotomies, Reconstruction superior lateral orbital rim and lower forehead Mandibular Osteotomies, Reconstruction bifrontal, superior lateral orbital rims and lower forehead Mandibular Osteotomies, Reconstruction entire or majority of forehead and/or supraorbital rims Mandibular Osteotomies, Reconstruction entire or majority of forehead and/or supraorbital rims Reconstruction zygomatic arch and glenoid fossa with bone and cartilage (includes obtaining autografts) Mandibular Osteotomies, Reconstruction of orbit (includes obtaining autografts) Malar (cheek) implants Unlisted craniofacial and maxillofacial procedure Hyoid myotomy and suspension Reconstructive repair of pectus excavatum or carinatum; open Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), without thoracoscopy Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), with thoracoscopy Osteotomy of spine, posterior or posterlateral approach, 3 columns, 1 veterbral segment; thoracic Osteotomy of spine, posterior or posterlateral approach, 3 columns, 1 veterbral segment; lumbar Osteotomy of spine, posterior or posterlateral approach, 3 columns, 1 veterbral segment; each additional veterbral segment Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; cervical

5 22212 Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; thoracic Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; lumbar Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; each additional vertebral segment Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; cervical Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; thoracic Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; lumbar Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; each additional vertebral segment Manipulation of spine under anesthesia Kyphoplasty Percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; cervicothoracic Kyphoplasty Percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; lumbosacral Kyphoplasty Percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; each additional thoracic or lumbar body Percutaneous vertebral augmentation, including cavity creation using mechanical device, 1 vertebral body, unilateral or bilateral cannulation, thoracic Percutaneous vertebral augmentation, including cavity creation using mechanical device, 1 vertebral body, unilateral or bilateral cannulation, lumbar Percutaneous vertebral augmentation, including cavity creation using mechanical device, 1 vertebral body, unilateral or bilateral cannulation, each additional thoracic or lumbar vertebral body Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral; single level Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral; one or more additional levels Spinal fusion Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic Spinal fusion Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar Spinal fusion Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic or lumbar, each additional vertebral segment Arthrodesis, anterior transoral or extraoral technique, clivus C1 C2, with or without excision of odontoid process Arthrodesis, anterial interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C Arthrodesis, anterial interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2, each additional interspace Arthrodesis, anterial interbody technique, including minimal discectomy to prepare interspace; cervical below C Arthrodesis, anterial interbody technique, including minimal discectomy to prepare interspace; thoracic Spinal fusion Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each additional interspace

6 22586 Arthrodesis, presacral interbody technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft when performed, L5 S1 interspace Arthrodesis, posterior technique, craniocervical (occiput C2) Arthrodesis, posterior technique, atlas axis (C1 C2) Arthrodesis, posterior or posteriolateral technique, single level;cervical below C2 segment Spinal fusion Arthrodesis, posterior or posterolateral technique, single level; thoracic (with or without lateral transverse technique) Spinal fusion Arthrodesis, posterior or posterolateral technique, single level; lumbar (with or without lateral transverse technique) Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment Spinal fusion Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; each additional interspace 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 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) Arthrodesis, posterior, for spinal deformity, with or without cast; up to 6 vertebral segments Arthrodesis, posterior, for spinal deformity, with or without cast; 7 12 vertebral segments Arthrodesis, posterior, for spinal deformity, with or without cast; 13 or more vertebral segments Arthrodesis, anterior, for spinal deformity, with or without cast; 2 3 vertebral segments Arthrodesis, anterior, for spinal deformity, with or without cast; 4 7 vertebral segments Arthrodesis,anterior, for spinal deformity, with or without cast; 8 or more vertebral segments Kyphectomy, circumferential exposure of spine and resection of vertebral segment(s); single or two segments Kyphectomy, circumferential exposure of spine and resection of vertebral segment(s); 3 or more segments Exploration of spinal fusion Posterior non segmental instrumentation (eg, Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation) Internal spinal fixation by wiring of spinous processes Posterior segmental instrumentation (e.g., pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segments Posterior segmental instrumentation (e.g., pedicle fixation, dual rods with multiple hooks and sublaminar wires); 7 to 12 vertebral segments Posterior segmental instrumentation (e.g., pedicle fixation, dual rods with multiple hooks and sublaminar wires); 13 or more vertebral segments.

7 22845 Anterior instrumentation; 2 to 3 vertebral segments Anterior instrumentation; 4 to 7 vertebral segments Anterior instrumentation; 8 or more vertebral segments Pelvic fixation other than sacrum Reinsertion of spinal fixation device Removal of posterior nonsegmental instrumentation Application of intervertebral biomechanical device(s) (e.g., synthetic cage(s), methylmethacrylate) to vertebral defect or interspace Removal of posterior segmental instrumentation Removal of anterior instrumentation 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 Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), single interspace, lumbar 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), second level cervical Artificial Intervertebral Discs revision including replacement of total disc arthroplasty, cervical, single interspace Artificial Intervertebral Discs revision including replacement of total disc arthroplasty, lumbar, single interspace Artificial Intervertebral Discs removal of total disc arthroplasty, anterior approach,cervical, single interspace Artificial Intervertebral Discs removal of total disc arthroplasty, anterior approach, lumbar, single interspace Unlisted procedure; spine Unlisted procedure, abdomen, musculoskeletal system Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (including obtaining graft), and placement of transfixing device Arthrodesis, sacroiliac joint, open (including obtaining graft) *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 Rhinoplasty primary; lateral and alar cartilages and/or elevation of nasal tip Rhinoplasty complete, external parts includingbony pyramid, lateral and alar cartilages, and/or elevation of nasal tip Rhinoplasty including major septal repair Rhinoplasty secondary; minor revision (small amount of nasal tip work) Rhinoplasty intermediate revision (bony work with osteotomies) Rhinoplasty major revision (nasal tip work and osteotomies) *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 Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft

8 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 Donor pneumonectomy from cadaver donor Lung transplant, single; without cardiopulmonary bypass Lung transplant, single; with cardiopulmonary bypass Lung transplant, double; without cardiopulmonary bypass Lung transplant, double; with cardiopulmonary bypass Backbench standard prepartion of cadaver donor lung allograft prior to transplantation; unilateral Backbench standard prepartion of cadaver donor lung allograft prior to transplantation; bilateral Donor cardiectomy pneumonectomy Backbench standard prepartion of cadaver donor heart/ lung allograft prior to transplantation Heart/lung transplant with recipient cardiectomy pneumonectomy Donor cardiectomy Backbench standard prepartion of cadaver donor heart allograft prior to transplantation Heart transplant, with or without recipient cardiectomy Sclerotherapy injection of sclerosing solution, single vein Sclerotherapy injection of sclerosing solution, multiple vein Radiofrequency ablation of varicose veins, first vein treated Radiofrequency ablation of varicose veins, second and subsequent Laser ablation of varicose veins, first vein Laser ablation of varicose veins, second or subsequent Therapeutic apheresis; for white blood cells Therapeutic apheresis; for red blood cells Therapeutic apheresis; for platelets Therapeutic apheresis; for plasma pheresis Therapeutic apheresis; with extracorporeal immunoadsorption and plasma reinfusion Therapeutic apheresis; with extracorporeal selective adsorption or selective filtration and plasma reinfusion Tongue base suspension, permanent suture technique Tongue Submucosal ablation of the tongue base, radiofrequency, one or more sites per session Palatopharynoplasty UPPP, LAUP's, and somnoplasty Unlisted procedure, palate/uvula Esophagogstroduodenoscopy, flexible, transoral; including collection of specimen

9 43236 Esophagogstroduodenoscopy, flexible, transoral; with directed submucosal injection(s), any substance Esophagogstroduodenoscopy, flexible, transoral; with endoscopic ultrasound limited to esophagus, stomach or duodenum, and adjacent structures Esophagogstroduodenoscopy, flexible, transoral, with transendoscopic ultrasound guided intramual or transmural fine needle aspiration/biopsy Esophagogstroduodenoscopy, flexible, transoral; with biopsy, single or multiple Esophagogstroduodenoscopy, flexible, transoral; with tranmural drainage of pseudocyst Esophagogstroduodenoscopy, flexible, transoral; with insertion of intraluminal tube or catheter Esophagogstroduodenoscopy, flexible, transoral; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy Esophagogstroduodenoscopy, flexible, transoral; with injection sclerosis of esophageal/gastric varices Esophagogstroduodenoscopy, flexible, transoral,with band ligation of esophageal/gastric varices Esophagogstroduodenoscopy, flexible, transoral; with dilation of gastric/duodenal stricture(s) Esophagogstroduodenoscopy, flexible, transoral; with directed placement of percutaneous gastrostomy tube Esophagogstroduodenoscopy, flexible, transoral; with removal of foreign bodies Esophagogstroduodenoscopy, flexible, transoral; with insertion of guide wire followed by passage of dilator through esophagus over guide wire Esophagogstroduodenoscopy, flexible, transoral; with tranendoscopic balloon dilation of espphagud (less than 30 mm) Esophagogstroduodenoscopy, flexible, transoral; with dilation of esophagus with balloon ( 30mm diameter or larger) Esophagogstroduodenoscopy, flexible, transoral; with removal of tumor, polyps or other lesions by hot biopsy forceps Esophagogstroduodenoscopy, flexible, transoral; with removal of tumor, polyps or other lesions by snare technique Esophagogstroduodenoscopy, flexible, transoral; with optical endomicroscopy Esophagogstroduodenoscopy, flexible, transoral; with transedoscopic ultrasound guided transmural injection of diagnostic or therapeutic substance Esophagogstroduodenoscopy, flexible, transoral; with endoscopic mucosal resection Esophagogstroduodenoscopy, flexible, transoral; with control of bleeding, any method Esophagogstroduodenoscopy, flexible, transoral; with delivery of thermal energy to the muscle of the lower esophageal sphincter and/or gastric cardia, for treatment of gastroesophageal reflux disease Esophagogstroduodenoscopy, flexible, transoral; with endoscopic ultrasound examination Endoscopic retrograde cholangiopancreatography (ERCP); diagnostic, including collection of specimens(s) by brushing or washing, when performed (separate procedure) Endoscopic retrograde cholangiopancreatography (ERCP); with biopsy, single or multiple Endoscopic retrograde cholangiopancreatography (ERCP); with sphincterotomy/papillotomy Endoscopic retrograde cholangiopancreatography (ERCP); with pressure measurement sphincter of Oddi Endoscopic retrograde cholangiopancreatography (ERCP); with removal of calculi/debris from biliary/pancreatic duct(s) Endoscopic retrograde cholangiopancreatography (ERCP); with destruction of calculi, any method

10 43266 Code is out of numerical sequence, See Code is out of numerical sequence, See Endocopic cannulation of papilla with direct visualization of pancreatic/common bile duct(s) Stretta or Endocinch procedure, Endoscopic treatment of GERD Gastrectomy, partial distal; with gastrojejunostomy Gastrectomy, partial distal; with Roux En Y, reconstruction Gastrectomy, partial distal, with formation of intestinal pouch Gastric Bypass Need BMI, psychiatric evaluation, and nutritional consult Gastric Bypass gastroplasty Need BMI, psychiatric evaluation, and nutritional consult Gastric Pacemaker Gastric Pacemaker Unlisted laproscopic procedure, stomach *43770 Gastric Bypass Laparacscopy, surgical, gastric restrictive procedure (e.g. Gastric band) Note: Need BMI, psychiatric evaluation, and nutritional consult Gastric Bypass revision of adjustable gastric restrictive device component only Gastric Bypass removal of adjustable gastric restrictive device component only Gastric Bypass removal and replacement of adjustable gastric restrictive device component only Gastric Bypass removal of adjustable gastric restrictive device and subcutaneous port component Gastric restrictive procedure Laparoscopy, surgical; longitudinal gastrectomy (i.e., sleeve gastrectomy) *43842 Gastric Restrictive procedure, without gastric bypass, for morbid obesity; vertical banded gastroplasty Note: Need BMI, psychiatric evaluation, and nutritional consult *43843 Gastric Restrictive procedure, without gastric bypass, for morbid obesity; other than vertical banded gastroplasty Note: Need BMI, psychiatric evaluation, and nutritional consult *43845 Gastric restriction procedure with partial gatrectomy, pylorus preserving duodenoileostomy and ileoileostomy (biliopancreatic diversion with duodenal switch Note: Need BMI, psychiatric evaluation, and nutritional consult *43846 Gastric restriction procedure with gastric bypass for morbid obesity; with short limb Rous En Y gastroenterostomy Note: Need BMI, psychiatric evaluation, and nutritional consult *43847 Gastric restriction procedure with gastric bypass for morbid obesity;with short limb Rous En Y gastroenterostomy with small intestine reconstruction Note: 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). Note: Need BMI, psychiatric evaluation, and nutritional consult *43881 Gastric Pacemaker,implantation or replacement of gastric neurostimulator, electodes, antrum, open Note: Need BMI, psychiatric evaluation, and nutritional consult Gastric Pacemaker,revision or removal of gastric neurostimulator, electodes, antrum, open Gastric restrictive procedure open; revision of subcutaneous port component only Gastric restrictive procedure open; removal of subcutaneous port component only

11 43888 Gastric restrictive procedure open; removal and replacement of subcutaneous port component only *43999 Unlisted procedure of stomach Note: Need BMI, psychiatric evaluation, and nutritional consult Endoscopy, Small Intestine enteroscopy beyond second portion of duodenum, not including ileum; diagnostic, including collection of specifmen(s) by brushing or washing, when performed (separate procedure) Endoscopy, Small Intestine enteroscopy beyond second portion of duodenum, not including ileum; diagnostic, including collection of specifmen(s) by brushing or washing, when performed (separate procedure) with biopsy, single or multiple Endoscopy, Small Intestine enteroscopy beyond second portion of duodenum, not including ileum; diagnostic, including collection of specifmen(s) by brushing or washing, when performed (separate procedure) with removal of foreign body(s) Endoscopy, Small Intestine enteroscopy beyond second portion of duodenum, not including ileum; diagnostic, including collection of specifmen(s) by brushing or washing, when performed (separate procedure) with removal of tumor(s), polyp(s), or other lesion(s) by snare technique Endoscopy, Small Intestine enteroscopy beyond second portion of duodenum, not including ileum; diagnostic, including collection of specifmen(s) by brushing or washing, when performed (separate procedure) with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery Endoscopy, Small Intestine enteroscopy beyond second portion of duodenum, not including ileum; diagnostic, including collection of specifmen(s) by brushing or washing, when performed (separate procedure) with control of bleeding (eg. Injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator) Endoscopy, Small Intestine enteroscopy beyond second portion of duodenum, not including ileum; diagnostic, including collection of specifmen(s) by brushing or washing, when performed (separate procedure) with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique Endoscopy, Small Intestine enteroscopy beyond second portion of duodenum, not including ileum; diagnostic, including collection of specifmen(s) by brushing or washing, when performed (separate procedure) with transendoscopic stent placement (includes predilation) Endoscopy, Small Intestine enteroscopy beyond second portion of duodenum, not including ileum; diagnostic, including collection of specifmen(s) by brushing or washing, when performed (separate procedure) with placement of percutaneous jejunostomy tube Endoscopy, Small Intestine enteroscopy beyond second portion of duodenum, not including ileum; diagnostic, including collection of specifmen(s) by brushing or washing, when performed (separate procedure) with conversion of percutaneous gastrostomy tube to percutaneous jejunostomy tube Endoscopy, Small Intestine enteroscopy beyond second portion of duodenum, including ileum; diagnostic, with or without collection of specifmen(s) by brushing or washing, (separate procedure) Endoscopy, Small Intestine enteroscopy beyond second portion of duodenum, including ileum; diagnostic, with or without collection of specifmen(s) by brushing or washing, (separate procedure) with biopsy, single or multiple Endoscopy, Small Intestine enteroscopy beyond second portion of duodenum, including ileum; diagnostic, with or without collection of specifmen(s) by brushing or washing, (separate procedure) with control of bleeding (eg, injection, biploar cautery, unipolar cautery, laser, heater probe, stapler, plasmac coagulator) Endoscopy, Small Intestine enteroscopy beyond second portion of duodenum, including ileum; diagnostic, with or without collection of specifmen(s) by brushing or washing, (separate procedure) with transendoscopic stent placement (incudes predilation)

12 47370 Ablative Techniques for Treating Primary and Metastatic Liver Malignancies Laparoscopy, surgical, ablation of 1 or more liver tumor(s); radiofrequency Ablative Techniques for Treating Primary and Metastatic Liver Malignancies Laparoscopy, surgical, ablation of 1 or more liver tumor(s); cryosurgical Unlisted laparoscopic procedure/liver Ablative Techniques for Treating Primary and Metastatic Liver Malignancies Ablation, open, of 1 or more liver tumor(s); radiofrequency Ablative Techniques for Treating Primary and Metastatic Liver Malignancies Ablation, open, of 1 or more liver tumor(s); cryosurgical Ablative Techniques for Treating Primary and Metastatic Liver Malignancies Ablation, 1 or more liver tumor(s), percutaneous, radiofrequency Ablation, 1 or more liver tumors, percutaneous, cryoablation Ablation, open, 1 or more renal mass lesion(s), cryosurgical, including intraoperative ultrasound, if performed Ablation, 1 or more renal tumor(s), percutaneous, unilateral, radiofrequency Ablation, renal tumor(s), unilateral, percutaneous, cryotherapy Laser surgery of prostate Contact laser vaporization of prostate Laser enucleation of the prostate with morcellation, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation) Transurethral destruction of prostate tissue; by microwave thermotherapy Transurethral destruction of prostate tissue; by radiofrequency thermotherapy Transuretheral readiofrequency micro remodeling of the female bladder neck and proximal urethra for stress urinary incontinence Penile Prosthesis Implantation Insertion of penile prosthesis; non inflatable (semi rigid) Penile Prosthesis Implantation Insertion of penile prosthesis; inflatable (self contained) Penile Prosthesis Implantation Insertion of multi component, inflatable penile prosthesis, including placement of pump, cylinders, and reservoir Removal of all components of a multi component, inflatable penile prosthesis without replacement of prosthesis Repair of components of a multi component, inflatable penile prosthesis Penile Prosthesis Implantation Removal and replacement of all component(s) of a multi component, inflatable penile prosthesis at the same operative session 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 Penile Prosthesis Implantation Removal of non inflatable (semi rigid) or inflatable (self contained) penile prosthesis, wihtout replacement of prosthesis Penile Prosthesis Implantation Removal and replacement of non inflatable (semi rigid) or inflatable (self contained) penile prosthesis at the same operative session

13 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 Orchiectomy, simple (including subcapsular), with or without testicular prosthesis, scrotal or inguinal approach Insertion of testicular prosthesis Laparoscopy, surgical; orchiectomy Scrotoplasty; complicated Cryosurgical ablation of the prostate (includes ultrasonic guidance and monitoring) Intersex surgery; male to female Intersex surgery; female to male Vulvectomy, simple; complete Clitoroplasty for intersex state Vaginectomy, complete removal of vaginal wall Construction of artificial vagina; without graft Construction of artificial vagina; with graft Revision (including removal) of prosthetic vaginal graft; vaginal approach Revision (including removal) of prosthetic vaginal graft; open abdominal approach Vaginoplasty for intersex state Implantable Infusion Pumps Insertion of subcutaneous reservoir, pump or continuous infusion system for connection to ventricular catheter Stereotactic Radiosurgery (Particle beam, Gamma Ray or Linear Accelerator); Cyberknife; 1 simple cranial lesion Stereotactic Radiosurgery (Particle beam, Gamma Ray or Linear Accelerator); Cyberknife; each additional cranial lesion, simple Stereotactic Radiosurgery (Particle beam, Gamma Ray or Linear Accelerator); Cyberknife; 1 complex cranial lesion Stereotactic Radiosurgery (Particle beam, Gamma Ray or Linear Accelerator); Cyberknife; each additional cranial lesion, complex Stereotactic Radiosurgery Application of stereotactic head frame 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 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 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

14 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 Craniectomy for implantation of neurostimulator electrodes, cerebellar; cortical Deep Brain Stimulation Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array 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 Percutaneous Lysis of Epidural Adhesions using Solution Injection or Mechanical means including Radiologic Localization, Multiple Adhesiolysis Sessions, 2 or more days Percutaneous Lysis of Epidural Adhesions using Solution Injection or Mechanical means including Radiologic Localization, Multiple Adhesiolysis Sessions, 1 day Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, any method, single or multiple levels, lumbar 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 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 Removal of previously implanted intrathecal or epidural catheter Endoscopic decompression of the spinal cord, nerve root(s), including laminotomy, partial facetectomy, foraminotomy, discectomy and/or excision of herniated intervertebral disc, 1 interspace, lumbar Implantable Infusion Pumps Implantation or replacement of device for intrathecal or epidural drug infusion; subcutaneous reservoir Implantable Infusion Pumps Implantation or replacement of device for intrathecal or epidural drug infusion; non programmable pump Implantable Infusion Pumps Implantation or replacement of device for intrathecal or epidural drug infusion; programmable pump, including preparation of pump, with or without programming Removal of subcutaneous reservoir or pump, previously implanted for intrathecal or epidural infusion 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; cervical 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; thoracic 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 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

15 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) 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; cervical 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; thoracic 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 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, cervical 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 spinal surgery. Prior authorization is not required for cervical or thoracic spinal surgeries related to this procedure code Spinal surgery Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; cervical 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 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, cervicalreexploration, single interspace; each additional cervical interspace 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 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; cervical 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;thoracic 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 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 Laminoplasty, cervical, with decompression of the spinal cord, two or more veterbral segments Laminoplasty, cervical, with decompression of the spinal cord, two or more veterbral segments; with reconstruction of the posterior bony elements

16 63055 Spinal surgery Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; thoracic 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) 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 Costovertebral approach with decompression of spinal cord or nerve roots (e.g. herniated vertebral disc), thoracic; single segment Costovertebral approach with decompression of spinal cord or nerve roots (e.g. herniated vertebral disc), thoracic; each additional segment Discectomy, anterior, with decompression of spinal cord and/or nerve root, including osteophytectomy; cervical, single interspace Discectomy, anterior, with decompression of spinal cord and/or nerve root, including osteophytectomy; cervical, each additional interspace Discectomy, anterior, with decompression of spinal cord and/or nerve root, including osteophytectomy; thoracic, single interspace Discectomy, anterior, with decompression of spinal cord and/or nerve root, including osteophytectomy; thoracic, each additional interspace Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, single segment 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) Vertebral corpectomy (vertebral body resection), partial or complete, transthoracic approach with decompression of spinal cord and/or nerve root(s); thoracic, single segment Vertebral corpectomy (vertebral body resection), partial or complete, transthoracic approach with decompression of spinal cord and/or nerve root(s); thoracic, each additional segment 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 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; each additonal segment 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 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 Vertebral corpectomy (vertebral body resection), partial or complete, lateral extracavitary approach with decompression of spinal cord and/or nerve roots (e.g. for tumor or retropulsed bone fragments); thoracic, single segment Vertebral corpectomy (vertebral body resection), partial or complete, lateral extracavitary approach with decompression of spinal cord and/or nerve roots (e.g. for tumor or retropulsed bone fragments);lumbar, single segment Vertebral corpectomy (vertebral body resection), partial or complete, lateral extracavitary approach with decompression of spinal cord and/or nerve roots (e.g. for tumor or retropulsed bone fragments);thoracic or lumbar, each additional segment Laminectomy with myelotomy (eg, Bischof or DREZ type), cervical, thoracic, or thoracolumbar