Maine Workers' Compensation Board Medical Fee Schedule

Transcription

1 001 SURG HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W MCC $243, $257, SURG SYSTEM W/O MCC $123, $131, SURG MOUTH & NECK W MAJ O.R $168, $178, SURG NECK W/O MAJ O.R $105, $111, SURG TRANSPLANT $94, $100, SURG LIVER TRANSPLANT W/O MCC $44, $47, SURG LUNG TRANSPLANT $98, $103, SURG SIMULTANEOUS PANCREAS/KIDNEY TRANSPLANT $48, $51, SURG PANCREAS TRANSPLANT $41, $44, SURG DIAGNOSES OR LARYNGECTOMY W MCC $45, $47, SURG DIAGNOSES OR LARYNGECTOMY W CC $35, $37, SURG DIAGNOSES OR LARYNGECTOMY W/O CC/MCC $21, $22, SURG ALLOGENEIC BONE MARROW TRANSPLANT $110, $116, SURG CC/MCC OR T-CELL IMMUNOTHERAPY $60, $63, SURG CC/MCC $40, $42, SURG HEMORRHAGE W MCC $96, $101, SURG HEMORRHAGE W CC $72, $77, SURG HEMORRHAGE W/O CC/MCC $47, $50, SURG COMPLEX CNS PDX W MCC OR CHEMOTHERAPY $50, $53, SURG PDX W/O MCC $36, $38, SURG PROCEDURES W MCC $39, $41, SURG PROCEDURES W CC $27, $29, SURG PROCEDURES W/O CC/MCC $22, $23, SURG SPINAL PROCEDURES W MCC $49, $52, SURG NEUROSTIMULATORS $29, $30, SURG SPINAL PROCEDURES W/O CC/MCC $20, $21, SURG VENTRICULAR SHUNT PROCEDURES W MCC $38, $40, SURG VENTRICULAR SHUNT PROCEDURES W CC $21, $22, SURG VENTRICULAR SHUNT PROCEDURES W/O CC/MCC $15, $16, SURG CAROTID ARTERY STENT PROCEDURE W MCC $33, $35, SURG CAROTID ARTERY STENT PROCEDURE W CC $20, $21, SURG CAROTID ARTERY STENT PROCEDURE W/O CC/MCC $15, $16, SURG EXTRACRANIAL PROCEDURES W MCC $29, $31, SURG EXTRACRANIAL PROCEDURES W CC $15, $16, SURG EXTRACRANIAL PROCEDURES W/O CC/MCC $10, $11, SURG W MCC $36, $38, SURG W CC OR PERIPH NEUROSTIM $21, $23, SURG W/O CC/MCC $17, $18, MED SPINAL DISORDERS & INJURIES W CC/MCC $15, $16, MED SPINAL DISORDERS & INJURIES W/O CC/MCC $8, $8, MED NERVOUS SYSTEM NEOPLASMS W MCC $12, $12, MED NERVOUS SYSTEM NEOPLASMS W/O MCC $9, $10, MED MCC $19, $20, MED MCC $11, $11, MED MULTIPLE SCLEROSIS & CEREBELLAR ATAXIA W MCC $16, $17, MED MULTIPLE SCLEROSIS & CEREBELLAR ATAXIA W CC $10, $10, MED CC/MCC $7, $8, MED TRANSIENT ISCHEMIA W THROMBOLYTIC AGENT W $26, $27, MED TRANSIENT ISCHEMIA W THROMBOLYTIC AGENT W CC $17, $18, MED TRANSIENT ISCHEMIA W THROMBOLYTIC AGENT W/O $15, $15, MED INFARCTION W MCC $17, $18, MED INFARCTION W CC OR TPA IN 24 HRS $9, $10, MED INFARCTION W/O CC/MCC $6, $7, MED INFARCT W MCC $13, $14, MED INFARCT W/O MCC $8, $8, MED TRANSIENT ISCHEMIA W/O THROMBOLYTIC $7, $7,

2 070 MED MCC $15, $16, MED NONSPECIFIC CEREBROVASCULAR DISORDERS W CC $9, $9, MED CC/MCC $6, $7, MED CRANIAL & PERIPHERAL NERVE DISORDERS W MCC $13, $13, MED CRANIAL & PERIPHERAL NERVE DISORDERS W/O MCC $8, $9, MED VIRAL MENINGITIS W CC/MCC $13, $14, MED VIRAL MENINGITIS W/O CC/MCC $7, $8, MED HYPERTENSIVE ENCEPHALOPATHY W MCC $14, $15, MED HYPERTENSIVE ENCEPHALOPATHY W CC $8, $9, MED HYPERTENSIVE ENCEPHALOPATHY W/O CC/MCC $6, $7, MED NONTRAUMATIC STUPOR & COMA W MCC $17, $18, MED NONTRAUMATIC STUPOR & COMA W/O MCC $7, $8, MED TRAUMATIC STUPOR & COMA, COMA >1 HR W MCC $19, $21, MED TRAUMATIC STUPOR & COMA, COMA >1 HR W CC $11, $12, MED CC/MCC $8, $9, MED TRAUMATIC STUPOR & COMA, COMA <1 HR W MCC $20, $21, MED TRAUMATIC STUPOR & COMA, COMA <1 HR W CC $11, $12, MED CC/MCC $7, $8, MED CONCUSSION W MCC $13, $14, MED CONCUSSION W CC $9, $10, MED CONCUSSION W/O CC/MCC $7, $7, MED OTHER DISORDERS OF NERVOUS SYSTEM W MCC $14, $15, MED OTHER DISORDERS OF NERVOUS SYSTEM W CC $8, $9, MED CC/MCC $6, $7, MED NERVOUS SYSTEM W MCC $33, $35, MED NERVOUS SYSTEM W CC $21, $23, MED NERVOUS SYSTEM W/O CC/MCC $19, $20, MED MENINGITIS W MCC $32, $34, MED MENINGITIS W CC $17, $18, MED MENINGITIS W/O CC/MCC $11, $12, MED SEIZURES W MCC $16, $17, MED SEIZURES W/O MCC $8, $8, MED HEADACHES W MCC $9, $10, MED HEADACHES W/O MCC $7, $7, SURG ORBITAL PROCEDURES W CC/MCC $21, $22, SURG ORBITAL PROCEDURES W/O CC/MCC $11, $12, SURG EXTRAOCULAR PROCEDURES EXCEPT ORBIT $12, $13, SURG INTRAOCULAR PROCEDURES W CC/MCC $15, $16, SURG INTRAOCULAR PROCEDURES W/O CC/MCC $9, $9, MED ACUTE MAJOR EYE INFECTIONS W CC/MCC $9, $10, MED ACUTE MAJOR EYE INFECTIONS W/O CC/MCC $6, $6, MED NEUROLOGICAL EYE DISORDERS $6, $7, MED OTHER DISORDERS OF THE EYE W MCC $12, $12, MED OTHER DISORDERS OF THE EYE W/O MCC $7, $7, SURG MAJOR DEVICE $22, $23, SURG MAJOR HEAD & NECK PROCEDURES W/O CC/MCC $13, $14, SURG CRANIAL/FACIAL PROCEDURES W CC/MCC $24, $25, SURG CRANIAL/FACIAL PROCEDURES W/O CC/MCC $14, $14, SURG PROCEDURES W CC/MCC $19, $20, SURG PROCEDURES W/O CC/MCC $11, $11, SURG SINUS & MASTOID PROCEDURES W CC/MCC $21, $22, SURG SINUS & MASTOID PROCEDURES W/O CC/MCC $11, $11, SURG MOUTH PROCEDURES W CC/MCC $12, $13, SURG MOUTH PROCEDURES W/O CC/MCC $7, $8, SURG SALIVARY GLAND PROCEDURES $10, $11, MED EAR, NOSE, MOUTH & THROAT MALIGNANCY W MCC $17, $18,

3 147 MED EAR, NOSE, MOUTH & THROAT MALIGNANCY W CC $11, $12, MED CC/MCC $6, $7, MED DYSEQUILIBRIUM $6, $6, MED EPISTAXIS W MCC $12, $12, MED EPISTAXIS W/O MCC $6, $6, MED OTITIS MEDIA & URI W MCC $9, $10, MED OTITIS MEDIA & URI W/O MCC $6, $6, MED MCC $13, $14, MED CC $8, $8, MED W/O CC/MCC $6, $6, MED DENTAL & ORAL DISEASES W MCC $15, $16, MED DENTAL & ORAL DISEASES W CC $8, $8, MED DENTAL & ORAL DISEASES W/O CC/MCC $6, $6, SURG MAJOR CHEST PROCEDURES W MCC $45, $48, SURG MAJOR CHEST PROCEDURES W CC $23, $25, SURG MAJOR CHEST PROCEDURES W/O CC/MCC $17, $18, SURG OTHER RESP SYSTEM O.R. PROCEDURES W MCC $32, $34, SURG OTHER RESP SYSTEM O.R. PROCEDURES W CC $17, $18, SURG CC/MCC $12, $13, MED PULMONARY EMBOLISM W MCC $13, $14, MED PULMONARY EMBOLISM W/O MCC $8, $8, MED RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC $16, $17, MED RESPIRATORY INFECTIONS & INFLAMMATIONS W CC $11, $12, MED CC/MCC $8, $8, MED RESPIRATORY NEOPLASMS W MCC $15, $16, MED RESPIRATORY NEOPLASMS W CC $10, $11, MED RESPIRATORY NEOPLASMS W/O CC/MCC $7, $7, MED MAJOR CHEST TRAUMA W MCC $13, $14, MED MAJOR CHEST TRAUMA W CC $9, $9, MED MAJOR CHEST TRAUMA W/O CC/MCC $6, $7, MED PLEURAL EFFUSION W MCC $14, $15, MED PLEURAL EFFUSION W CC $9, $10, MED PLEURAL EFFUSION W/O CC/MCC $7, $7, MED PULMONARY EDEMA & RESPIRATORY FAILURE $11, $12, MED CHRONIC OBSTRUCTIVE PULMONARY DISEASE W MCC $10, $11, MED CHRONIC OBSTRUCTIVE PULMONARY DISEASE W CC $8, $8, MED CC/MCC $6, $7, MED SIMPLE PNEUMONIA & PLEURISY W MCC $12, $12, MED SIMPLE PNEUMONIA & PLEURISY W CC $8, $8, MED SIMPLE PNEUMONIA & PLEURISY W/O CC/MCC $6, $6, MED INTERSTITIAL LUNG DISEASE W MCC $15, $15, MED INTERSTITIAL LUNG DISEASE W CC $9, $9, MED INTERSTITIAL LUNG DISEASE W/O CC/MCC $6, $7, MED PNEUMOTHORAX W MCC $16, $17, MED PNEUMOTHORAX W CC $9, $10, MED PNEUMOTHORAX W/O CC/MCC $6, $6, MED BRONCHITIS & ASTHMA W CC/MCC $8, $9, MED BRONCHITIS & ASTHMA W/O CC/MCC $6, $6, MED RESPIRATORY SIGNS & SYMPTOMS $7, $7, MED OTHER RESPIRATORY SYSTEM DIAGNOSES W MCC $13, $14, MED OTHER RESPIRATORY SYSTEM DIAGNOSES W/O MCC $7, $8, MED SUPPORT >96 HOURS OR PERIPHERAL $51, $54, MED SUPPORT <=96 HOURS $22, $23, SURG OTHER HEART ASSIST SYSTEM IMPLANT $118, $125, SURG W CARD CATH W MCC $90, $95, SURG W CARD CATH W CC $58, $62,

4 218 SURG W CARD CATH W/O CC/MCC $54, $57, SURG W/O CARD CATH W MCC $70, $75, SURG W/O CARD CATH W CC $47, $50, SURG W/O CARD CATH W/O CC/MCC $42, $44, SURG AMI/HF/SHOCK W MCC $75, $79, SURG AMI/HF/SHOCK W/O MCC $58, $62, SURG AMI/HF/SHOCK W MCC $68, $72, SURG AMI/HF/SHOCK W/O MCC $52, $55, SURG CATH W MCC $62, $66, SURG CATH W/O MCC $49, $51, SURG OTHER CARDIOTHORACIC PROCEDURES W MCC $60, $64, SURG OTHER CARDIOTHORACIC PROCEDURES W/O MCC $42, $45, SURG CORONARY BYPASS W PTCA W MCC $77, $82, SURG CORONARY BYPASS W PTCA W/O MCC $56, $60, SURG CORONARY BYPASS W CARDIAC CATH W MCC $70, $74, SURG CORONARY BYPASS W CARDIAC CATH W/O MCC $47, $50, SURG CORONARY BYPASS W/O CARDIAC CATH W MCC $53, $56, SURG CORONARY BYPASS W/O CARDIAC CATH W/O MCC $36, $38, SURG LIMB & TOE W MCC $43, $45, SURG LIMB & TOE W CC $25, $26, SURG LIMB & TOE W/O CC/MCC $14, $15, SURG PERMANENT CARDIAC PACEMAKER IMPLANT W MCC $34, $36, SURG PERMANENT CARDIAC PACEMAKER IMPLANT W CC $23, $24, SURG CC/MCC $19, $20, SURG AICD GENERATOR PROCEDURES $46, $48, SURG DRUG-ELUTING STENT W MCC OR 4+ ARTERIES OR $29, $31, SURG W/O MCC $19, $20, SURG NON-DRUG-ELUTING STENT W MCC OR 4+ ARTERIES $29, $30, SURG STENT W/O MCC $18, $19, SURG STENT W MCC $23, $25, SURG STENT W/O MCC $15, $16, SURG OTHER VASCULAR PROCEDURES W MCC $30, $31, SURG OTHER VASCULAR PROCEDURES W CC $23, $25, SURG OTHER VASCULAR PROCEDURES W/O CC/MCC $16, $17, SURG DISORDERS W MCC $23, $24, SURG DISORDERS W CC $16, $17, SURG DISORDERS W/O CC/MCC $10, $10, SURG CARDIAC PACEMAKER DEVICE REPLACEMENT W MCC $27, $29, SURG MCC $19, $20, SURG REPLACEMENT W MCC $33, $35, SURG REPLACEMENT W CC $18, $19, SURG REPLACEMENT W/O CC/MCC $15, $15, SURG VEIN LIGATION & STRIPPING $22, $23, SURG OTHER CIRCULATORY SYSTEM O.R. PROCEDURES $29, $30, SURG AICD LEAD PROCEDURES $28, $30, SURG MCC $66, $70, SURG MCC $53, $57, SURG PULSATION BALLOON W MCC $61, $65, SURG PULSATION BALLOON W/O MCC $38, $40, SURG MCC $46, $49, SURG OTHER MAJOR CARDIOVASCULAR PROCEDURES W CC $32, $34, SURG CC/MCC $24, $25, SURG MCC $33, $35, SURG MCC $27, $29, MED W MCC $15, $16, MED W CC $9, $9,

5 282 MED W/O CC/MCC $6, $7, MED ACUTE MYOCARDIAL INFARCTION, EXPIRED W MCC $16, $17, MED ACUTE MYOCARDIAL INFARCTION, EXPIRED W CC $7, $7, MED CC/MCC $5, $5, MED CATH W MCC $20, $21, MED CATH W/O MCC $10, $11, MED ACUTE & SUBACUTE ENDOCARDITIS W MCC $24, $26, MED ACUTE & SUBACUTE ENDOCARDITIS W CC $15, $16, MED ACUTE & SUBACUTE ENDOCARDITIS W/O CC/MCC $9, $9, MED EXTRACORPOREAL MEMBRANE OXYGENATION $12, $13, MED HEART FAILURE & SHOCK W CC $8, $8, MED HEART FAILURE & SHOCK W/O CC/MCC $6, $6, MED DEEP VEIN THROMBOPHLEBITIS W CC/MCC $10, $11, MED DEEP VEIN THROMBOPHLEBITIS W/O CC/MCC $5, $5, MED PERIPHERAL EXTRACORPOREAL MEMBRANE $14, $14, MED CARDIAC ARREST, UNEXPLAINED W CC $6, $6, MED CARDIAC ARREST, UNEXPLAINED W/O CC/MCC $4, $4, MED PERIPHERAL VASCULAR DISORDERS W MCC $13, $14, MED PERIPHERAL VASCULAR DISORDERS W CC $9, $9, MED PERIPHERAL VASCULAR DISORDERS W/O CC/MCC $6, $7, MED ATHEROSCLEROSIS W MCC $9, $10, MED ATHEROSCLEROSIS W/O MCC $6, $6, MED HYPERTENSION W MCC $9, $10, MED HYPERTENSION W/O MCC $6, $7, MED MCC $12, $13, MED MCC $7, $8, MED MCC $11, $11, MED CC $7, $7, MED W/O CC/MCC $5, $5, MED ANGINA PECTORIS $6, $6, MED SYNCOPE & COLLAPSE $7, $7, MED CHEST PAIN $6, $6, MED OTHER CIRCULATORY SYSTEM DIAGNOSES W MCC $18, $19, MED OTHER CIRCULATORY SYSTEM DIAGNOSES W CC $8, $9, MED CC/MCC $6, $7, SURG STOMACH, ESOPHAGEAL & DUODENAL PROC W MCC $48, $51, SURG STOMACH, ESOPHAGEAL & DUODENAL PROC W CC $22, $24, SURG CC/MCC $14, $15, SURG MAJOR SMALL & LARGE BOWEL PROCEDURES W MCC $46, $48, SURG MAJOR SMALL & LARGE BOWEL PROCEDURES W CC $23, $24, SURG CC/MCC $15, $16, SURG RECTAL RESECTION W MCC $31, $33, SURG RECTAL RESECTION W CC $17, $18, SURG RECTAL RESECTION W/O CC/MCC $12, $12, SURG PERITONEAL ADHESIOLYSIS W MCC $37, $39, SURG PERITONEAL ADHESIOLYSIS W CC $21, $22, SURG PERITONEAL ADHESIOLYSIS W/O CC/MCC $14, $15, SURG MCC $26, $27, SURG CC $16, $16, SURG W/O CC/MCC $10, $11, SURG W MCC $21, $22, SURG W CC $13, $13, SURG W/O CC/MCC $10, $10, SURG MINOR SMALL & LARGE BOWEL PROCEDURES W MCC $27, $29, SURG MINOR SMALL & LARGE BOWEL PROCEDURES W CC $15, $15, SURG CC/MCC $11, $12,

6 347 SURG ANAL & STOMAL PROCEDURES W MCC $22, $23, SURG ANAL & STOMAL PROCEDURES W CC $12, $13, SURG ANAL & STOMAL PROCEDURES W/O CC/MCC $8, $9, SURG INGUINAL & FEMORAL HERNIA PROCEDURES W MCC $22, $23, SURG INGUINAL & FEMORAL HERNIA PROCEDURES W CC $13, $14, SURG CC/MCC $9, $10, SURG W MCC $27, $28, SURG W CC $15, $16, SURG W/O CC/MCC $12, $13, SURG OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W MCC $36, $38, SURG OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W CC $19, $20, SURG CC/MCC $12, $13, MED MAJOR ESOPHAGEAL DISORDERS W MCC $17, $18, MED MAJOR ESOPHAGEAL DISORDERS W CC $10, $10, MED MAJOR ESOPHAGEAL DISORDERS W/O CC/MCC $6, $7, MED PERITONEAL INFECTIONS W MCC $16, $16, MED PERITONEAL INFECTIONS W CC $9, $10, MED PERITONEAL INFECTIONS W/O CC/MCC $6, $7, MED DIGESTIVE MALIGNANCY W MCC $19, $20, MED DIGESTIVE MALIGNANCY W CC $11, $11, MED DIGESTIVE MALIGNANCY W/O CC/MCC $8, $8, MED G.I. HEMORRHAGE W MCC $16, $17, MED G.I. HEMORRHAGE W CC $9, $9, MED G.I. HEMORRHAGE W/O CC/MCC $6, $6, MED COMPLICATED PEPTIC ULCER W MCC $17, $19, MED COMPLICATED PEPTIC ULCER W CC $10, $10, MED COMPLICATED PEPTIC ULCER W/O CC/MCC $7, $7, MED UNCOMPLICATED PEPTIC ULCER W MCC $12, $13, MED UNCOMPLICATED PEPTIC ULCER W/O MCC $7, $8, MED INFLAMMATORY BOWEL DISEASE W MCC $15, $16, MED INFLAMMATORY BOWEL DISEASE W CC $9, $9, MED INFLAMMATORY BOWEL DISEASE W/O CC/MCC $6, $6, MED G.I. OBSTRUCTION W MCC $14, $14, MED G.I. OBSTRUCTION W CC $7, $8, MED G.I. OBSTRUCTION W/O CC/MCC $5, $5, MED DISORDERS W MCC $11, $11, MED DISORDERS W/O MCC $6, $7, MED OTHER DIGESTIVE SYSTEM DIAGNOSES W MCC $15, $15, MED OTHER DIGESTIVE SYSTEM DIAGNOSES W CC $8, $9, MED OTHER DIGESTIVE SYSTEM DIAGNOSES W/O CC/MCC $6, $6, SURG PANCREAS, LIVER & SHUNT PROCEDURES W MCC $49, $52, SURG PANCREAS, LIVER & SHUNT PROCEDURES W CC $26, $27, SURG CC/MCC $18, $19, SURG OR W/O C.D.E. W MCC $37, $39, SURG OR W/O C.D.E. W CC $21, $22, SURG OR W/O C.D.E. W/O CC/MCC $15, $16, SURG CHOLECYSTECTOMY W C.D.E. W MCC $36, $39, SURG CHOLECYSTECTOMY W C.D.E. W CC $21, $23, SURG CHOLECYSTECTOMY W C.D.E. W/O CC/MCC $15, $16, SURG C.D.E. W MCC $32, $34, SURG C.D.E. W CC $18, $19, SURG C.D.E. W/O CC/MCC $12, $13, SURG MCC $22, $23, SURG LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W CC $15, $16, SURG CC/MCC $12, $12, SURG HEPATOBILIARY DIAGNOSTIC PROCEDURES W MCC $32, $34,

7 421 SURG HEPATOBILIARY DIAGNOSTIC PROCEDURES W CC $16, $17, SURG CC/MCC $13, $14, SURG PROCEDURES W MCC $36, $38, SURG PROCEDURES W CC $20, $21, SURG PROCEDURES W/O CC/MCC $13, $14, MED CIRRHOSIS & ALCOHOLIC HEPATITIS W MCC $16, $17, MED CIRRHOSIS & ALCOHOLIC HEPATITIS W CC $9, $10, MED CIRRHOSIS & ALCOHOLIC HEPATITIS W/O CC/MCC $6, $6, MED PANCREAS W MCC $15, $16, MED PANCREAS W CC $10, $11, MED PANCREAS W/O CC/MCC $7, $8, MED MCC $15, $15, MED CC $7, $8, MED CC/MCC $5, $6, MED W MCC $17, $18, MED W CC $8, $9, MED W/O CC/MCC $6, $6, MED DISORDERS OF THE BILIARY TRACT W MCC $14, $15, MED DISORDERS OF THE BILIARY TRACT W CC $9, $10, MED DISORDERS OF THE BILIARY TRACT W/O CC/MCC $7, $7, SURG MCC $87, $92, SURG CC $58, $61, SURG W/O CC/MCC $46, $48, SURG OR EXT FUS W MCC $84, $89, SURG OR EXT FUS W CC $60, $63, SURG OR EXT FUS W/O CC/MCC $47, $50, SURG SPINAL FUSION EXCEPT CERVICAL W MCC $58, $62, SURG SPINAL FUSION EXCEPT CERVICAL W/O MCC $37, $39, SURG LOWER EXTREMITY W MCC $41, $43, SURG LOWER EXTREMITY W/O MCC $29, $31, SURG CONN TISS DIS W MCC $47, $50, SURG CONN TISS DIS W CC $27, $28, SURG CONN TISS DIS W/O CC/MCC $16, $17, SURG REVISION OF HIP OR KNEE REPLACEMENT W MCC $47, $49, SURG REVISION OF HIP OR KNEE REPLACEMENT W CC $31, $33, SURG CC/MCC $25, $27, SURG REATTACHMENT OF LOWER EXTREMITY W MCC OR $29, $30, SURG REATTACHMENT OF LOWER EXTREMITY W/O MCC $18, $19, SURG CERVICAL SPINAL FUSION W MCC $46, $48, SURG CERVICAL SPINAL FUSION W CC $27, $28, SURG CERVICAL SPINAL FUSION W/O CC/MCC $21, $23, SURG TISSUE DIS W MCC $34, $37, SURG TISSUE DIS W CC $19, $20, SURG TISSUE DIS W/O CC/MCC $10, $11, SURG CONNECTIVE TISSUE W MCC $28, $30, SURG CONNECTIVE TISSUE W CC $21, $22, SURG CONNECTIVE TISSUE W/O CC/MCC $16, $17, SURG MCC $27, $29, SURG CC $19, $20, SURG W/O CC/MCC $15, $16, SURG UPPER EXTREMITIES $21, $23, SURG KNEE PROCEDURES W PDX OF INFECTION W MCC $30, $32, SURG KNEE PROCEDURES W PDX OF INFECTION W CC $20, $21, SURG CC/MCC $15, $16, SURG CC/MCC $19, $20, SURG CC/MCC $11, $12,

8 492 SURG HIP,FOOT,FEMUR W MCC $31, $33, SURG HIP,FOOT,FEMUR W CC $20, $21, SURG HIP,FOOT,FEMUR W/O CC/MCC $16, $17, SURG & FEMUR W MCC $31, $33, SURG & FEMUR W CC $18, $19, SURG & FEMUR W/O CC/MCC $13, $14, SURG & FEMUR W CC/MCC $20, $22, SURG & FEMUR W/O CC/MCC $10, $10, SURG SOFT TISSUE PROCEDURES W MCC $28, $29, SURG SOFT TISSUE PROCEDURES W CC $15, $16, SURG SOFT TISSUE PROCEDURES W/O CC/MCC $11, $12, SURG FOOT PROCEDURES W MCC $23, $25, SURG FOOT PROCEDURES W CC $15, $16, SURG FOOT PROCEDURES W/O CC/MCC $14, $15, SURG MAJOR THUMB OR JOINT PROCEDURES $12, $13, SURG CC/MCC $17, $18, SURG W/O CC/MCC $13, $14, SURG ARTHROSCOPY $15, $16, SURG JOINT PROC W MCC $25, $26, SURG JOINT PROC W CC $17, $18, SURG JOINT PROC W/O CC/MCC $14, $14, SURG JOINT PROC W CC/MCC $15, $16, SURG JOINT PROC W/O CC/MCC $9, $9, SURG W MCC $28, $30, SURG W CC $17, $18, SURG W/O CC/MCC $12, $13, SURG DISC DEVICE/NEUROSTIM $28, $30, SURG BACK & NECK PROC EXC SPINAL FUSION W CC $17, $18, SURG BACK & NECK PROC EXC SPINAL FUSION W/O CC/MCC $12, $12, MED FRACTURES OF FEMUR W MCC $14, $14, MED FRACTURES OF FEMUR W/O MCC $7, $7, MED FRACTURES OF HIP & PELVIS W MCC $11, $12, MED FRACTURES OF HIP & PELVIS W/O MCC $6, $7, MED THIGH W CC/MCC $8, $8, MED THIGH W/O CC/MCC $6, $7, MED OSTEOMYELITIS W MCC $18, $19, MED OSTEOMYELITIS W CC $11, $12, MED OSTEOMYELITIS W/O CC/MCC $8, $8, MED CONN TISS MALIG W MCC $16, $17, MED CONN TISS MALIG W CC $9, $10, MED CONN TISS MALIG W/O CC/MCC $7, $7, MED CONNECTIVE TISSUE DISORDERS W MCC $22, $24, MED CONNECTIVE TISSUE DISORDERS W CC $11, $11, MED CONNECTIVE TISSUE DISORDERS W/O CC/MCC $7, $8, MED SEPTIC ARTHRITIS W MCC $19, $20, MED SEPTIC ARTHRITIS W CC $11, $12, MED SEPTIC ARTHRITIS W/O CC/MCC $8, $9, MED MEDICAL BACK PROBLEMS W MCC $14, $15, MED MEDICAL BACK PROBLEMS W/O MCC $8, $8, MED BONE DISEASES & ARTHROPATHIES W MCC $11, $12, MED BONE DISEASES & ARTHROPATHIES W/O MCC $6, $7, MED & CONN TISSUE W MCC $11, $12, MED & CONN TISSUE W/O MCC $7, $7, MED TENDONITIS, MYOSITIS & BURSITIS W MCC $13, $13, MED TENDONITIS, MYOSITIS & BURSITIS W/O MCC $7, $8, MED CONNECTIVE TISSUE W MCC $16, $17,

9 560 MED CONNECTIVE TISSUE W CC $9, $9, MED CONNECTIVE TISSUE W/O CC/MCC $6, $7, MED THIGH W MCC $12, $13, MED THIGH W/O MCC $7, $8, MED TISSUE DIAGNOSES W MCC $14, $15, MED TISSUE DIAGNOSES W CC $8, $9, MED TISSUE DIAGNOSES W/O CC/MCC $7, $7, SURG SKIN DEBRIDEMENT W MCC $27, $29, SURG SKIN DEBRIDEMENT W CC $15, $16, SURG SKIN DEBRIDEMENT W/O CC/MCC $10, $11, SURG SKIN GRAFT FOR SKIN ULCER OR CELLULITIS W MCC $48, $51, SURG SKIN GRAFT FOR SKIN ULCER OR CELLULITIS W CC $28, $29, SURG CC/MCC $16, $17, SURG MCC $44, $47, SURG CC $23, $24, SURG CC/MCC $14, $14, SURG OTHER SKIN, SUBCUT TISS & BREAST PROC W MCC $25, $27, SURG OTHER SKIN, SUBCUT TISS & BREAST PROC W CC $14, $15, SURG CC/MCC $11, $12, SURG MASTECTOMY FOR MALIGNANCY W CC/MCC $14, $15, SURG MASTECTOMY FOR MALIGNANCY W/O CC/MCC $12, $13, SURG PROCEDURES W CC/MCC $17, $18, SURG PROCEDURES W/O CC/MCC $14, $15, MED SKIN ULCERS W MCC $15, $16, MED SKIN ULCERS W CC $10, $11, MED SKIN ULCERS W/O CC/MCC $7, $7, MED MAJOR SKIN DISORDERS W MCC $18, $19, MED MAJOR SKIN DISORDERS W/O MCC $9, $9, MED MALIGNANT BREAST DISORDERS W MCC $15, $16, MED MALIGNANT BREAST DISORDERS W CC $10, $11, MED MALIGNANT BREAST DISORDERS W/O CC/MCC $6, $6, MED NON-MALIGNANT BREAST DISORDERS W CC/MCC $8, $9, MED NON-MALIGNANT BREAST DISORDERS W/O CC/MCC $5, $6, MED CELLULITIS W MCC $13, $14, MED CELLULITIS W/O MCC $7, $8, MED TRAUMA TO THE SKIN, SUBCUT TISS & BREAST W MCC $13, $13, MED MCC $7, $8, MED MINOR SKIN DISORDERS W MCC $12, $13, MED MINOR SKIN DISORDERS W/O MCC $7, $7, SURG ADRENAL & PITUITARY PROCEDURES W CC/MCC $21, $23, SURG ADRENAL & PITUITARY PROCEDURES W/O CC/MCC $13, $14, SURG METABOL DIS W MCC $38, $40, SURG METABOL DIS W CC $19, $20, SURG METABOL DIS W/O CC/MCC $10, $11, SURG O.R. PROCEDURES FOR OBESITY W MCC $26, $28, SURG O.R. PROCEDURES FOR OBESITY W CC $16, $17, SURG O.R. PROCEDURES FOR OBESITY W/O CC/MCC $14, $15, SURG & METAB DIS W MCC $35, $37, SURG & METAB DIS W CC $17, $18, SURG & METAB DIS W/O CC/MCC $11, $12, SURG PROCEDURES W MCC $25, $27, SURG PROCEDURES W CC $14, $15, SURG PROCEDURES W/O CC/MCC $10, $10, SURG MCC $33, $35, SURG CC $21, $22, SURG CC/MCC $14, $14,

10 637 MED DIABETES W MCC $12, $13, MED DIABETES W CC $8, $8, MED DIABETES W/O CC/MCC $5, $6, MED NUTRITION,METABOLISM,FLUIDS/ELECTROLYTES W $10, $11, MED NUTRITION,METABOLISM,FLUIDS/ELECTROLYTES W/O $6, $7, MED INBORN AND OTHER DISORDERS OF METABOLISM $11, $12, MED ENDOCRINE DISORDERS W MCC $15, $15, MED ENDOCRINE DISORDERS W CC $9, $9, MED ENDOCRINE DISORDERS W/O CC/MCC $6, $7, SURG KIDNEY TRANSPLANT $30, $32, SURG MAJOR BLADDER PROCEDURES W MCC $50, $53, SURG MAJOR BLADDER PROCEDURES W CC $26, $28, SURG MAJOR BLADDER PROCEDURES W/O CC/MCC $19, $20, SURG MCC $30, $32, SURG CC $17, $19, SURG CC/MCC $14, $15, SURG NEOPLASM W MCC $25, $26, SURG NEOPLASM W CC $13, $14, SURG NEOPLASM W/O CC/MCC $9, $10, SURG MINOR BLADDER PROCEDURES W MCC $29, $31, SURG MINOR BLADDER PROCEDURES W CC $15, $16, SURG MINOR BLADDER PROCEDURES W/O CC/MCC $10, $11, SURG PROSTATECTOMY W MCC $29, $31, SURG PROSTATECTOMY W CC $16, $17, SURG PROSTATECTOMY W/O CC/MCC $9, $10, SURG TRANSURETHRAL PROCEDURES W MCC $25, $27, SURG TRANSURETHRAL PROCEDURES W CC $14, $15, SURG TRANSURETHRAL PROCEDURES W/O CC/MCC $8, $9, SURG URETHRAL PROCEDURES W CC/MCC $15, $16, SURG URETHRAL PROCEDURES W/O CC/MCC $9, $10, SURG MCC $32, $34, SURG CC $21, $22, SURG CC/MCC $14, $15, MED RENAL FAILURE W MCC $14, $14, MED RENAL FAILURE W CC $8, $8, MED RENAL FAILURE W/O CC/MCC $5, $6, MED KIDNEY & URINARY TRACT NEOPLASMS W MCC $15, $16, MED KIDNEY & URINARY TRACT NEOPLASMS W CC $9, $10, MED KIDNEY & URINARY TRACT NEOPLASMS W/O CC/MCC $7, $7, MED KIDNEY & URINARY TRACT INFECTIONS W MCC $10, $10, MED KIDNEY & URINARY TRACT INFECTIONS W/O MCC $7, $7, MED URINARY STONES W ESW LITHOTRIPSY W CC/MCC $14, $15, MED URINARY STONES W ESW LITHOTRIPSY W/O CC/MCC $10, $11, MED URINARY STONES W/O ESW LITHOTRIPSY W MCC $12, $12, MED URINARY STONES W/O ESW LITHOTRIPSY W/O MCC $6, $6, MED MCC $10, $11, MED MCC $6, $6, MED URETHRAL STRICTURE $8, $9, MED OTHER KIDNEY & URINARY TRACT DIAGNOSES W MCC $14, $15, MED OTHER KIDNEY & URINARY TRACT DIAGNOSES W CC $9, $10, MED CC/MCC $7, $7, SURG MAJOR MALE PELVIC PROCEDURES W CC/MCC $16, $17, SURG MAJOR MALE PELVIC PROCEDURES W/O CC/MCC $12, $13, SURG PENIS PROCEDURES W CC/MCC $18, $19, SURG PENIS PROCEDURES W/O CC/MCC $15, $16, SURG TESTES PROCEDURES W CC/MCC $19, $20,

11 712 SURG TESTES PROCEDURES W/O CC/MCC $9, $10, SURG TRANSURETHRAL PROSTATECTOMY W CC/MCC $13, $14, SURG TRANSURETHRAL PROSTATECTOMY W/O CC/MCC $8, $8, SURG MALIGNANCY W CC/MCC $20, $21, SURG MALIGNANCY W/O CC/MCC $13, $14, SURG MALIGNANCY W CC/MCC $18, $19, SURG MALIGNANCY W/O CC/MCC $11, $12, MED MALIGNANCY, MALE REPRODUCTIVE SYSTEM W MCC $15, $16, MED MALIGNANCY, MALE REPRODUCTIVE SYSTEM W CC $10, $10, MED CC/MCC $6, $6, MED BENIGN PROSTATIC HYPERTROPHY W MCC $11, $11, MED BENIGN PROSTATIC HYPERTROPHY W/O MCC $7, $7, MED W MCC $13, $14, MED W/O MCC $7, $7, MED CC/MCC $9, $10, MED W/O CC/MCC $5, $5, SURG VULVECTOMY W CC/MCC $21, $22, SURG VULVECTOMY W/O CC/MCC $12, $13, SURG MALIGNANCY W MCC $37, $39, SURG MALIGNANCY W CC $18, $19, SURG MALIGNANCY W/O CC/MCC $12, $13, SURG MALIG W MCC $33, $35, SURG MALIG W CC $16, $17, SURG MALIG W/O CC/MCC $12, $12, SURG CC/MCC $15, $16, SURG CC/MCC $10, $10, SURG INTERRUPTION W CC/MCC $15, $16, SURG INTERRUPTION W/O CC/MCC $9, $10, SURG VAGINA, CERVIX & VULVA PROCEDURES W CC/MCC $15, $16, SURG VAGINA, CERVIX & VULVA PROCEDURES W/O CC/MCC $8, $9, SURG PROCEDURES $11, $12, SURG PROCEDURES W CC/MCC $23, $25, SURG PROCEDURES W/O CC/MCC $11, $11, MED MCC $16, $17, MED MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM W CC $9, $10, MED CC/MCC $7, $7, MED INFECTIONS, FEMALE REPRODUCTIVE SYSTEM W MCC $13, $14, MED INFECTIONS, FEMALE REPRODUCTIVE SYSTEM W CC $9, $9, MED CC/MCC $6, $6, MED SYSTEM DISORDERS W CC/MCC $8, $8, MED SYSTEM DISORDERS W/O CC/MCC $5, $5, SURG &/OR D&C $10, $11, SURG PROCEDURE $13, $14, SURG HYSTEROTOMY $9, $10, MED O.R. PROCEDURE $6, $6, MED ABORTION W/O D&C $6, $7, SURG CESAREAN SECTION W STERILIZATION W MCC $16, $17, SURG CESAREAN SECTION W STERILIZATION W CC $10, $10, SURG CESAREAN SECTION W STERILIZATION W/O CC/MCC $7, $8, SURG CESAREAN SECTION W/O STERILIZATION W MCC $14, $15, SURG CESAREAN SECTION W/O STERILIZATION W CC $9, $10, SURG CESAREAN SECTION W/O STERILIZATION W/O CC/MCC $8, $8, MED ACUTE CARE FACILITY $15, $16, MED SYNDROME, NEONATE $50, $53, MED PREMATURITY W MAJOR PROBLEMS $34, $36, MED PREMATURITY W/O MAJOR PROBLEMS $20, $22,

12 793 MED FULL TERM NEONATE W MAJOR PROBLEMS $35, $37, MED NEONATE W OTHER SIGNIFICANT PROBLEMS $12, $13, MED NORMAL NEWBORN $1, $1, SURG VAGINAL DELIVERY W STERILIZATION/D&C W MCC $13, $14, SURG VAGINAL DELIVERY W STERILIZATION/D&C W CC $7, $8, SURG CC/MCC $7, $8, SURG SPLENECTOMY W MCC $43, $45, SURG SPLENECTOMY W CC $24, $25, SURG SPLENECTOMY W/O CC/MCC $14, $15, SURG ORGANS W MCC $30, $32, SURG ORGANS W CC $15, $16, SURG ORGANS W/O CC/MCC $11, $12, MED VAGINAL DELIVERY W/O STERILIZATION/D&C W MCC $9, $9, MED VAGINAL DELIVERY W/O STERILIZATION/D&C W CC $6, $6, MED CC/MCC $5, $5, MED CRISIS & COAGUL W MCC $19, $20, MED CRISIS & COAGUL W CC $11, $11, MED CRISIS & COAGUL W/O CC/MCC $8, $9, MED RED BLOOD CELL DISORDERS W MCC $12, $13, MED RED BLOOD CELL DISORDERS W/O MCC $8, $8, MED COAGULATION DISORDERS $14, $15, MED MCC $15, $16, MED CC $9, $9, MED CC/MCC $6, $7, SURG PROCEDURE W MCC $23, $24, SURG PROCEDURE W CC $12, $13, SURG PROCEDURE W/O CC/MCC $7, $8, SURG W MCC $50, $53, SURG W CC $22, $23, SURG W/O CC/MCC $11, $11, SURG W MCC $41, $44, SURG W CC $20, $21, SURG W/O CC/MCC $12, $13, SURG MAJ O.R. PROC W MCC $45, $48, SURG MAJ O.R. PROC W CC $20, $21, SURG MAJ O.R. PROC W/O CC/MCC $15, $15, SURG DIFFERENTIATED NEOPLASMS W OTHER PROCEDURE $28, $30, SURG DIFFERENTIATED NEOPLASMS W OTHER PROCEDURE $13, $13, MED PROCEDURE W MCC $9, $10, MED PROCEDURE W CC $6, $7, MED PROCEDURE W/O CC/MCC $4, $4, MED MCC $50, $53, MED ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W CC $19, $20, MED CC/MCC $11, $11, MED CHEMO AGENT W MCC $49, $52, MED DOSE CHEMO AGENT $21, $22, MED CHEMO W ACUTE LEUKEMIA AS SDX W/O CC/MCC $11, $12, MED LYMPHOMA & NON-ACUTE LEUKEMIA W MCC $30, $32, MED LYMPHOMA & NON-ACUTE LEUKEMIA W CC $15, $15, MED LYMPHOMA & NON-ACUTE LEUKEMIA W/O CC/MCC $10, $10, MED DIAG W MCC $17, $18, MED DIAG W CC $10, $11, MED DIAG W/O CC/MCC $7, $8, MED SECONDARY DIAGNOSIS W MCC $25, $27, MED SECONDARY DIAGNOSIS W CC $12, $12, MED SECONDARY DIAGNOSIS W/O CC/MCC $8, $9,

13 849 MED RADIOTHERAPY $18, $19, SURG PROCEDURE W MCC $46, $49, SURG PROCEDURE W CC $20, $21, SURG PROCEDURE W/O CC/MCC $14, $15, SURG O.R. PROC W MCC $41, $43, SURG O.R. PROC W CC $18, $20, SURG O.R. PROC W/O CC/MCC $12, $13, MED MCC $16, $17, MED W/O MCC $9, $9, MED FEVER AND INFLAMMATORY CONDITIONS $7, $8, MED VIRAL ILLNESS W MCC $12, $13, MED VIRAL ILLNESS W/O MCC $7, $8, MED DIAGNOSES W MCC $19, $20, MED DIAGNOSES W CC $9, $10, MED DIAGNOSES W/O CC/MCC $7, $7, MED PERIPHERAL EXTRACORPOREAL MEMBRANE $58, $61, MED W MCC $17, $18, MED W/O MCC $9, $10, SURG MENTAL ILLNESS $30, $32, MED DYSFUNCTION $7, $7, MED DEPRESSIVE NEUROSES $6, $7, MED NEUROSES EXCEPT DEPRESSIVE $7, $7, MED DISORDERS OF PERSONALITY & IMPULSE CONTROL $12, $12, MED ORGANIC DISTURBANCES & INTELLECTUAL DISABILITY $12, $13, MED PSYCHOSES $11, $11, MED BEHAVIORAL & DEVELOPMENTAL DISORDERS $9, $9, MED OTHER MENTAL DISORDER DIAGNOSES $9, $10, MED ALCOHOL/DRUG ABUSE OR DEPENDENCE, LEFT AMA $4, $5, MED REHABILITATION THERAPY $13, $13, MED REHABILITATION THERAPY W MCC $16, $17, MED REHABILITATION THERAPY W/O MCC $7, $8, SURG WOUND DEBRIDEMENTS FOR INJURIES W MCC $41, $43, SURG WOUND DEBRIDEMENTS FOR INJURIES W CC $17, $18, SURG WOUND DEBRIDEMENTS FOR INJURIES W/O CC/MCC $10, $11, SURG SKIN GRAFTS FOR INJURIES W CC/MCC $29, $31, SURG SKIN GRAFTS FOR INJURIES W/O CC/MCC $16, $17, SURG HAND PROCEDURES FOR INJURIES $16, $17, SURG OTHER O.R. PROCEDURES FOR INJURIES W MCC $38, $41, SURG OTHER O.R. PROCEDURES FOR INJURIES W CC $18, $19, SURG OTHER O.R. PROCEDURES FOR INJURIES W/O CC/MCC $12, $12, MED TRAUMATIC INJURY W MCC $13, $14, MED TRAUMATIC INJURY W/O MCC $7, $8, MED ALLERGIC REACTIONS W MCC $15, $16, MED ALLERGIC REACTIONS W/O MCC $5, $6, MED POISONING & TOXIC EFFECTS OF DRUGS W MCC $13, $14, MED POISONING & TOXIC EFFECTS OF DRUGS W/O MCC $7, $7, MED COMPLICATIONS OF TREATMENT W MCC $16, $17, MED COMPLICATIONS OF TREATMENT W CC $9, $9, MED COMPLICATIONS OF TREATMENT W/O CC/MCC $6, $6, MED MCC $14, $15, MED MCC $8, $8, SURG >96 HRS W SKIN GRAFT $169, $179, SURG W CC/MCC $54, $57, SURG W/O CC/MCC $27, $29, MED >96 HRS W/O SKIN GRAFT $26, $27, MED FULL THICKNESS BURN W/O SKIN GRAFT OR INHAL INJ $16, $17,

14 935 MED NON-EXTENSIVE BURNS $16, $17, SURG HEALTH SERVICES W MCC $30, $32, SURG HEALTH SERVICES W CC $20, $21, SURG HEALTH SERVICES W/O CC/MCC $17, $18, MED REHABILITATION W CC/MCC $12, $13, MED REHABILITATION W/O CC/MCC $9, $10, MED SIGNS & SYMPTOMS W MCC $11, $11, MED SIGNS & SYMPTOMS W/O MCC $7, $7, MED AFTERCARE W CC/MCC $10, $11, MED AFTERCARE W/O CC/MCC $6, $7, MED OTHER FACTORS INFLUENCING HEALTH STATUS $7, $7, SURG CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA $56, $59, SURG MULTIPLE SIGNIFICANT TRAUMA $34, $36, SURG SIGNIFICANT TRAUMA W MCC $70, $74, SURG SIGNIFICANT TRAUMA W CC $38, $40, SURG SIGNIFICANT TRAUMA W/O CC/MCC $22, $23, MED OTHER MULTIPLE SIGNIFICANT TRAUMA W MCC $25, $27, MED OTHER MULTIPLE SIGNIFICANT TRAUMA W CC $13, $14, MED OTHER MULTIPLE SIGNIFICANT TRAUMA W/O CC/MCC $8, $9, SURG HIV W EXTENSIVE O.R. PROCEDURE W MCC $51, $54, SURG HIV W EXTENSIVE O.R. PROCEDURE W/O MCC $25, $27, MED HIV W MAJOR RELATED CONDITION W MCC $25, $26, MED HIV W MAJOR RELATED CONDITION W CC $11, $12, MED HIV W MAJOR RELATED CONDITION W/O CC/MCC $8, $9, MED HIV W OR W/O OTHER RELATED CONDITION $10, $11, SURG PRINCIPAL DIAGNOSIS W MCC $40, $42, SURG PRINCIPAL DIAGNOSIS W CC $22, $23, SURG PRINCIPAL DIAGNOSIS W/O CC/MCC $14, $15, NON-EXTENSIVE O.R. PROC UNRELATED TO SURG PRINCIPAL DIAGNOSIS W MCC NON-EXTENSIVE O.R. PROC UNRELATED TO SURG PRINCIPAL DIAGNOSIS W CC NON-EXTENSIVE O.R. PROC UNRELATED TO SURG PRINCIPAL DIAGNOSIS W/O CC/MCC