Contractor Information. LCD Information. Local Coverage Determination (LCD): Magnetic Resonance Imaging of the Orbit, Face, and/or Neck (L34425)

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1 Local Coverage Determination (LCD): Magnetic Resonance Imaging of the Orbit, Face, and/or Neck (L34425) Links in PDF documents are not guaranteed to work. To follow a web link, please use the MCD Website. Contractor Information Contractor Name Contract Type Contract Number Jurisdiction State(s) Palmetto GBA A and B and HHH MAC MAC A J - M South Carolina Palmetto GBA A and B and HHH MAC MAC A J - M Virginia Palmetto GBA A and B and HHH MAC MAC A J - M West Virginia Palmetto GBA A and B and HHH MAC MAC A J - M North Carolina Back to Top LCD Information Document Information LCD ID L34425 Original ICD-9 LCD ID L31605 LCD Title Magnetic Resonance Imaging of the Orbit, Face, and/or Neck Proposed LCD in Comment Period N/A Source Proposed LCD N/A AMA CPT / ADA CDT / AHA NUBC Copyright Statement CPT only copyright American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. Original Effective Date For services performed on or after 10/01/2015 Revision Effective Date For services performed on or after 09/21/2017 Revision Ending Date N/A Retirement Date N/A Notice Period Start Date N/A Notice Period End Date N/A The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright American Dental Association. All rights reserved. CDT and CDT-2016 are trademarks of the American Dental Association. Printed on 9/21/2017. Page 1 of 22

2 UB-04 Manual. OFFICIAL UB-04 DATA SPECIFICATIONS MANUAL, 2014, is copyrighted by American Hospital Association ( AHA ), Chicago, Illinois. No portion of OFFICIAL UB-04 MANUAL may be reproduced, sorted in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior express, written consent of AHA. Health Forum reserves the right to change the copyright notice from time to time upon written notice to Company. CMS National Coverage Policy Title XVIII of the Social Security Act 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim. Title XVIII of the Social Security Act 1862(a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Title XVIII of the Social Security Act 1833(E) related to outpatient hospital radiology services. CMS Internet-Only Manual, Pub , Medicare National Coverage Determinations Manual, Chapter 1, Part 4, CMS Internet-Only Manual, Pub , Medicare Claims Processing Manual, Chapter 13, 40 Coverage Guidance Coverage Indications, Limitations, and/or Medical Necessity Magnetic Resonance Imaging (MRI) is a noninvasive diagnostic imaging modality used to diagnose a variety of central nervous system disorders. MRI provides superior tissue contrast when compared to a Computerized Tomography (CT) scan, is able to image in multiple planes, is not affected by bone artifact, provides vascular imaging capability, and makes use of safer contrast media (gadolinium chelate agents). Its major disadvantage over a CT scan is the longer scanning time required for study, making it less useful for emergency evaluations. Contraindications include patients with implanted neurostimulators or cochlear implants. Potential contraindications may include patients with cardiac pacemakers (refer to the CMS Internet-Only Manual, Pub , Medicare National Coverage Determinations Manual, Chapter 1, Part 4, 220.2), metal fragments in the eye, magnetic ocular implants or patients with older ferromagnetic intracranial aneurysm clips. All of these objects may be potentially displaced when exposed to the powerful magnetic fields used in MRI. MRI of the Orbit, Face, and/or Neck may be considered medically reasonable and necessary when used to diagnose and characterize pathology of the eye, nasopharynx, oropharynx, and neck including tumors, infection, soft tissue pathologies, and congenital abnormalities. In cases involving trauma to the orbit, face and/or neck, a CT scan is frequently superior to MRI for assessing injury. Magnetic Resonance Imaging is considered investigational when medical records document the service was performed only for one of the following: measurement of blood flow and spectroscopy, imaging of cortical bone and calcifications, and procedures involving spatial resolution of bone or calcifications. In some instances, ordering a MRI of the brain in addition to a MRI of the orbit, face, and/or neck may be Printed on 9/21/2017. Page 2 of 22

3 medically necessary on the same day. The medical record should document the medical necessity for these two procedures being performed on the same day. Initial imaging of the thyroid should be done with ultrasound or nuclear medicine, unless there is a known carcinoma present. Summary of Evidence N/A Analysis of Evidence (Rationale for Determination) N/A Back to Top Coding Information Bill Type : Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims. N/A Revenue : Contractors may specify Revenue to help providers identify those Revenue typically used to report this service. In most instances Revenue are purely advisory. Unless specified in the policy, services reported under other Revenue are equally subject to this coverage determination. Complete absence of all Revenue indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue. N/A CPT/HCPCS Group 1 Paragraph: N/A Group 1 : MAGNETIC RESONANCE (EG, PROTON) IMAGING, ORBIT, FACE, AND/OR NECK; WITHOUT CONTRAST MATERIAL(S) MAGNETIC RESONANCE (EG, PROTON) IMAGING, ORBIT, FACE, AND/OR NECK; WITH CONTRAST MATERIAL(S) MAGNETIC RESONANCE (EG, PROTON) IMAGING, ORBIT, FACE, AND/OR NECK; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES ICD-10 that Support Medical Necessity Group 1 Paragraph: N/A Group 1 : Printed on 9/21/2017. Page 3 of 22

4 A18.50 Tuberculosis of eye, unspecified A18.51 Tuberculous episcleritis A18.52 Tuberculous keratitis A18.53 Tuberculous chorioretinitis A18.54 Tuberculous iridocyclitis A18.59 Other tuberculosis of eye A18.6 Tuberculosis of (inner) (middle) ear A18.81 Tuberculosis of thyroid gland A39.82 Meningococcal retrobulbar neuritis C00.0 Malignant neoplasm of external upper lip C00.1 Malignant neoplasm of external lower lip C00.3 Malignant neoplasm of upper lip, inner aspect C00.4 Malignant neoplasm of lower lip, inner aspect C00.6 Malignant neoplasm of commissure of lip, unspecified C00.8 Malignant neoplasm of overlapping sites of lip C01 Malignant neoplasm of base of tongue C02.0 Malignant neoplasm of dorsal surface of tongue C02.1 Malignant neoplasm of border of tongue C02.2 Malignant neoplasm of ventral surface of tongue C02.3 Malignant neoplasm of anterior two-thirds of tongue, part unspecified C02.4 Malignant neoplasm of lingual tonsil C02.8 Malignant neoplasm of overlapping sites of tongue C02.9 Malignant neoplasm of tongue, unspecified C03.0 Malignant neoplasm of upper gum C03.1 Malignant neoplasm of lower gum C04.0 Malignant neoplasm of anterior floor of mouth C04.1 Malignant neoplasm of lateral floor of mouth C04.8 Malignant neoplasm of overlapping sites of floor of mouth C04.9 Malignant neoplasm of floor of mouth, unspecified C05.0 Malignant neoplasm of hard palate C05.1 Malignant neoplasm of soft palate C05.2 Malignant neoplasm of uvula C05.8 Malignant neoplasm of overlapping sites of palate C05.9 Malignant neoplasm of palate, unspecified C06.0 Malignant neoplasm of cheek mucosa C06.1 Malignant neoplasm of vestibule of mouth C06.2 Malignant neoplasm of retromolar area C06.80 Malignant neoplasm of overlapping sites of unspecified parts of mouth C06.89 Malignant neoplasm of overlapping sites of other parts of mouth C06.9 Malignant neoplasm of mouth, unspecified C07 Malignant neoplasm of parotid gland C08.0 Malignant neoplasm of submandibular gland C08.1 Malignant neoplasm of sublingual gland C08.9 Malignant neoplasm of major salivary gland, unspecified C09.0 Malignant neoplasm of tonsillar fossa C09.1 Malignant neoplasm of tonsillar pillar (anterior) (posterior) C09.8 Malignant neoplasm of overlapping sites of tonsil C09.9 Malignant neoplasm of tonsil, unspecified C10.0 Malignant neoplasm of vallecula C10.1 Malignant neoplasm of anterior surface of epiglottis C10.2 Malignant neoplasm of lateral wall of oropharynx C10.3 Malignant neoplasm of posterior wall of oropharynx C10.4 Malignant neoplasm of branchial cleft C10.8 Malignant neoplasm of overlapping sites of oropharynx C10.9 Malignant neoplasm of oropharynx, unspecified C11.0 Malignant neoplasm of superior wall of nasopharynx C11.1 Malignant neoplasm of posterior wall of nasopharynx C11.2 Malignant neoplasm of lateral wall of nasopharynx Printed on 9/21/2017. Page 4 of 22

5 C11.3 Malignant neoplasm of anterior wall of nasopharynx C11.8 Malignant neoplasm of overlapping sites of nasopharynx C11.9 Malignant neoplasm of nasopharynx, unspecified C12 Malignant neoplasm of pyriform sinus C13.0 Malignant neoplasm of postcricoid region C13.1 Malignant neoplasm of aryepiglottic fold, hypopharyngeal aspect C13.2 Malignant neoplasm of posterior wall of hypopharynx C13.8 Malignant neoplasm of overlapping sites of hypopharynx C13.9 Malignant neoplasm of hypopharynx, unspecified C14.0 Malignant neoplasm of pharynx, unspecified C14.2 Malignant neoplasm of Waldeyer's ring C14.8 Malignant neoplasm of overlapping sites of lip, oral cavity and pharynx C30.0 Malignant neoplasm of nasal cavity C30.1 Malignant neoplasm of middle ear C31.0 Malignant neoplasm of maxillary sinus C31.1 Malignant neoplasm of ethmoidal sinus C31.2 Malignant neoplasm of frontal sinus C31.3 Malignant neoplasm of sphenoid sinus C31.8 Malignant neoplasm of overlapping sites of accessory sinuses C31.9 Malignant neoplasm of accessory sinus, unspecified C32.0 Malignant neoplasm of glottis C32.1 Malignant neoplasm of supraglottis C32.2 Malignant neoplasm of subglottis C32.3 Malignant neoplasm of laryngeal cartilage C32.8 Malignant neoplasm of overlapping sites of larynx C32.9 Malignant neoplasm of larynx, unspecified C41.0 Malignant neoplasm of bones of skull and face C41.1 Malignant neoplasm of mandible C43.0 Malignant melanoma of lip C43.11 Malignant melanoma of right eyelid, including canthus C43.12 Malignant melanoma of left eyelid, including canthus C43.21 Malignant melanoma of right ear and external auricular canal C43.22 Malignant melanoma of left ear and external auricular canal C43.30 Malignant melanoma of unspecified part of face C43.31 Malignant melanoma of nose C43.39 Malignant melanoma of other parts of face C43.4 Malignant melanoma of scalp and neck C44.00 Unspecified malignant neoplasm of skin of lip C44.01 Basal cell carcinoma of skin of lip C44.02 Squamous cell carcinoma of skin of lip C44.09 Other specified malignant neoplasm of skin of lip C Unspecified malignant neoplasm of skin of right eyelid, including canthus C Unspecified malignant neoplasm of skin of left eyelid, including canthus C Basal cell carcinoma of skin of right eyelid, including canthus C Basal cell carcinoma of skin of left eyelid, including canthus C Squamous cell carcinoma of skin of right eyelid, including canthus C Squamous cell carcinoma of skin of left eyelid, including canthus C Other specified malignant neoplasm of skin of right eyelid, including canthus C Other specified malignant neoplasm of skin of left eyelid, including canthus C Unspecified malignant neoplasm of skin of right ear and external auricular canal C Unspecified malignant neoplasm of skin of left ear and external auricular canal C Basal cell carcinoma of skin of right ear and external auricular canal C Basal cell carcinoma of skin of left ear and external auricular canal C Squamous cell carcinoma of skin of right ear and external auricular canal C Squamous cell carcinoma of skin of left ear and external auricular canal C Other specified malignant neoplasm of skin of right ear and external auricular canal C Other specified malignant neoplasm of skin of left ear and external auricular canal Printed on 9/21/2017. Page 5 of 22

6 C Unspecified malignant neoplasm of skin of nose C Unspecified malignant neoplasm of skin of other parts of face C Basal cell carcinoma of skin of unspecified parts of face C Basal cell carcinoma of skin of nose C Basal cell carcinoma of skin of other parts of face C Squamous cell carcinoma of skin of unspecified parts of face C Squamous cell carcinoma of skin of nose C Squamous cell carcinoma of skin of other parts of face C Other specified malignant neoplasm of skin of unspecified parts of face C Other specified malignant neoplasm of skin of nose C Other specified malignant neoplasm of skin of other parts of face C44.40 Unspecified malignant neoplasm of skin of scalp and neck C44.41 Basal cell carcinoma of skin of scalp and neck C44.42 Squamous cell carcinoma of skin of scalp and neck C44.49 Other specified malignant neoplasm of skin of scalp and neck C44.80 Unspecified malignant neoplasm of overlapping sites of skin C44.81 Basal cell carcinoma of overlapping sites of skin C44.82 Squamous cell carcinoma of overlapping sites of skin C44.89 Other specified malignant neoplasm of overlapping sites of skin C44.90 Unspecified malignant neoplasm of skin, unspecified C44.91 Basal cell carcinoma of skin, unspecified C44.92 Squamous cell carcinoma of skin, unspecified C44.99 Other specified malignant neoplasm of skin, unspecified C46.2 Kaposi's sarcoma of palate C46.7 Kaposi's sarcoma of other sites C47.0 Malignant neoplasm of peripheral nerves of head, face and neck C47.8 Malignant neoplasm of overlapping sites of peripheral nerves and autonomic nervous system C49.0 Malignant neoplasm of connective and soft tissue of head, face and neck C49.8 Malignant neoplasm of overlapping sites of connective and soft tissue C69.01 Malignant neoplasm of right conjunctiva C69.02 Malignant neoplasm of left conjunctiva C69.11 Malignant neoplasm of right cornea C69.12 Malignant neoplasm of left cornea C69.21 Malignant neoplasm of right retina C69.22 Malignant neoplasm of left retina C69.31 Malignant neoplasm of right choroid C69.32 Malignant neoplasm of left choroid C69.41 Malignant neoplasm of right ciliary body C69.42 Malignant neoplasm of left ciliary body C69.51 Malignant neoplasm of right lacrimal gland and duct C69.52 Malignant neoplasm of left lacrimal gland and duct C69.61 Malignant neoplasm of right orbit C69.62 Malignant neoplasm of left orbit C69.81 Malignant neoplasm of overlapping sites of right eye and adnexa C69.82 Malignant neoplasm of overlapping sites of left eye and adnexa C69.91 Malignant neoplasm of unspecified site of right eye C69.92 Malignant neoplasm of unspecified site of left eye C73 Malignant neoplasm of thyroid gland C75.0 Malignant neoplasm of parathyroid gland C76.0 Malignant neoplasm of head, face and neck C77.0 Secondary and unspecified malignant neoplasm of lymph nodes of head, face and neck C77.8 Secondary and unspecified malignant neoplasm of lymph nodes of multiple regions C79.51 Secondary malignant neoplasm of bone C79.52 Secondary malignant neoplasm of bone marrow C79.89 Secondary malignant neoplasm of other specified sites C81.01 Nodular lymphocyte predominant Hodgkin lymphoma, lymph nodes of head, face, and neck C81.11 Nodular sclerosis Hodgkin lymphoma, lymph nodes of head, face, and neck C81.21 Mixed cellularity Hodgkin lymphoma, lymph nodes of head, face, and neck Printed on 9/21/2017. Page 6 of 22

7 C81.31 Lymphocyte depleted Hodgkin lymphoma, lymph nodes of head, face, and neck C81.41 Lymphocyte-rich Hodgkin lymphoma, lymph nodes of head, face, and neck C81.71 Other Hodgkin lymphoma, lymph nodes of head, face, and neck C82.01 Follicular lymphoma grade I, lymph nodes of head, face, and neck C82.11 Follicular lymphoma grade II, lymph nodes of head, face, and neck C82.21 Follicular lymphoma grade III, unspecified, lymph nodes of head, face, and neck C82.31 Follicular lymphoma grade IIIa, lymph nodes of head, face, and neck C82.41 Follicular lymphoma grade IIIb, lymph nodes of head, face, and neck C82.51 Diffuse follicle center lymphoma, lymph nodes of head, face, and neck C82.61 Cutaneous follicle center lymphoma, lymph nodes of head, face, and neck C82.81 Other types of follicular lymphoma, lymph nodes of head, face, and neck C82.91 Follicular lymphoma, unspecified, lymph nodes of head, face, and neck C83.01 Small cell B-cell lymphoma, lymph nodes of head, face, and neck C83.11 Mantle cell lymphoma, lymph nodes of head, face, and neck C83.31 Diffuse large B-cell lymphoma, lymph nodes of head, face, and neck C83.51 Lymphoblastic (diffuse) lymphoma, lymph nodes of head, face, and neck C83.71 Burkitt lymphoma, lymph nodes of head, face, and neck C83.81 Other non-follicular lymphoma, lymph nodes of head, face, and neck C83.91 Non-follicular (diffuse) lymphoma, unspecified, lymph nodes of head, face, and neck C84.41 Peripheral T-cell lymphoma, not classified, lymph nodes of head, face, and neck C84.61 Anaplastic large cell lymphoma, ALK-positive, lymph nodes of head, face, and neck C84.71 Anaplastic large cell lymphoma, ALK-negative, lymph nodes of head, face, and neck C84.A1 Cutaneous T-cell lymphoma, unspecified lymph nodes of head, face, and neck C84.Z1 Other mature T/NK-cell lymphomas, lymph nodes of head, face, and neck C84.91 Mature T/NK-cell lymphomas, unspecified, lymph nodes of head, face, and neck C85.11 Unspecified B-cell lymphoma, lymph nodes of head, face, and neck C85.21 Mediastinal (thymic) large B-cell lymphoma, lymph nodes of head, face, and neck C85.81 Other specified types of non-hodgkin lymphoma, lymph nodes of head, face, and neck C85.91 Non-Hodgkin lymphoma, unspecified, lymph nodes of head, face, and neck C86.0 Extranodal NK/T-cell lymphoma, nasal type D00.00 Carcinoma in situ of oral cavity, unspecified site D00.01 Carcinoma in situ of labial mucosa and vermilion border D00.02 Carcinoma in situ of buccal mucosa D00.03 Carcinoma in situ of gingiva and edentulous alveolar ridge D00.04 Carcinoma in situ of soft palate D00.05 Carcinoma in situ of hard palate D00.06 Carcinoma in situ of floor of mouth D00.07 Carcinoma in situ of tongue D00.08 Carcinoma in situ of pharynx D02.0 Carcinoma in situ of larynx D03.0 Melanoma in situ of lip D03.11 Melanoma in situ of right eyelid, including canthus D03.12 Melanoma in situ of left eyelid, including canthus D03.21 Melanoma in situ of right ear and external auricular canal D03.22 Melanoma in situ of left ear and external auricular canal D03.30 Melanoma in situ of unspecified part of face D03.39 Melanoma in situ of other parts of face D03.4 Melanoma in situ of scalp and neck D09.21 Carcinoma in situ of right eye D09.22 Carcinoma in situ of left eye D10.2 Benign neoplasm of floor of mouth D10.30 Benign neoplasm of unspecified part of mouth D10.39 Benign neoplasm of other parts of mouth D10.4 Benign neoplasm of tonsil D10.5 Benign neoplasm of other parts of oropharynx D10.6 Benign neoplasm of nasopharynx D10.7 Benign neoplasm of hypopharynx Printed on 9/21/2017. Page 7 of 22

8 D10.9 Benign neoplasm of pharynx, unspecified D11.0 Benign neoplasm of parotid gland D11.7 Benign neoplasm of other major salivary glands D11.9 Benign neoplasm of major salivary gland, unspecified D14.0 Benign neoplasm of middle ear, nasal cavity and accessory sinuses D14.1 Benign neoplasm of larynx D16.4 Benign neoplasm of bones of skull and face D16.5 Benign neoplasm of lower jaw bone D21.0 Benign neoplasm of connective and other soft tissue of head, face and neck D31.01 Benign neoplasm of right conjunctiva D31.02 Benign neoplasm of left conjunctiva D31.11 Benign neoplasm of right cornea D31.12 Benign neoplasm of left cornea D31.21 Benign neoplasm of right retina D31.22 Benign neoplasm of left retina D31.31 Benign neoplasm of right choroid D31.32 Benign neoplasm of left choroid D31.41 Benign neoplasm of right ciliary body D31.42 Benign neoplasm of left ciliary body D31.51 Benign neoplasm of right lacrimal gland and duct D31.52 Benign neoplasm of left lacrimal gland and duct D31.61 Benign neoplasm of unspecified site of right orbit D31.62 Benign neoplasm of unspecified site of left orbit D31.91 Benign neoplasm of unspecified part of right eye D31.92 Benign neoplasm of unspecified part of left eye D34 Benign neoplasm of thyroid gland D35.1 Benign neoplasm of parathyroid gland D37.01 Neoplasm of uncertain behavior of lip D37.02 Neoplasm of uncertain behavior of tongue D Neoplasm of uncertain behavior of the parotid salivary glands D Neoplasm of uncertain behavior of the sublingual salivary glands D Neoplasm of uncertain behavior of the submandibular salivary glands D Neoplasm of uncertain behavior of the major salivary glands, unspecified D37.04 Neoplasm of uncertain behavior of the minor salivary glands D37.05 Neoplasm of uncertain behavior of pharynx D37.09 Neoplasm of uncertain behavior of other specified sites of the oral cavity D38.0 Neoplasm of uncertain behavior of larynx D48.1 Neoplasm of uncertain behavior of connective and other soft tissue D48.2 Neoplasm of uncertain behavior of peripheral nerves and autonomic nervous system D48.7 Neoplasm of uncertain behavior of other specified sites D49.2 Neoplasm of unspecified behavior of bone, soft tissue, and skin D49.81 Neoplasm of unspecified behavior of retina and choroid D49.89 Neoplasm of unspecified behavior of other specified sites E01.0 Iodine-deficiency related diffuse (endemic) goiter E01.2 Iodine-deficiency related (endemic) goiter, unspecified E03.4 Atrophy of thyroid (acquired) E04.1 Nontoxic single thyroid nodule E06.0 Acute thyroiditis E07.89 Other specified disorders of thyroid E21.4 Other specified disorders of parathyroid gland E35 Disorders of endocrine glands in diseases classified elsewhere G44.1 Vascular headache, not elsewhere classified H05.00 Unspecified acute inflammation of orbit H Cellulitis of right orbit H Cellulitis of left orbit H Cellulitis of bilateral orbits H Osteomyelitis of right orbit H Osteomyelitis of left orbit Printed on 9/21/2017. Page 8 of 22

9 H Osteomyelitis of bilateral orbits H Periostitis of right orbit H Periostitis of left orbit H Periostitis of bilateral orbits H Tenonitis of right orbit H Tenonitis of left orbit H Tenonitis of bilateral orbits H05.10 Unspecified chronic inflammatory disorders of orbit H Granuloma of right orbit H Granuloma of left orbit H Granuloma of bilateral orbits H Orbital myositis, right orbit H Orbital myositis, left orbit H Orbital myositis, bilateral H05.20 Unspecified exophthalmos H Displacement (lateral) of globe, right eye H Displacement (lateral) of globe, left eye H Displacement (lateral) of globe, bilateral H Edema of right orbit H Edema of left orbit H Edema of bilateral orbit H Hemorrhage of right orbit H Hemorrhage of left orbit H Hemorrhage of bilateral orbit H Constant exophthalmos, right eye H Constant exophthalmos, left eye H Constant exophthalmos, bilateral H Intermittent exophthalmos, right eye H Intermittent exophthalmos, left eye H Intermittent exophthalmos, bilateral H Pulsating exophthalmos, right eye H Pulsating exophthalmos, left eye H Pulsating exophthalmos, bilateral H05.30 Unspecified deformity of orbit H Atrophy of right orbit H Atrophy of left orbit H Atrophy of bilateral orbit H Deformity of right orbit due to bone disease H Deformity of left orbit due to bone disease H Deformity of bilateral orbits due to bone disease H Deformity of right orbit due to trauma or surgery H Deformity of left orbit due to trauma or surgery H Deformity of bilateral orbits due to trauma or surgery H Enlargement of right orbit H Enlargement of left orbit H Enlargement of bilateral orbits H Exostosis of right orbit H Exostosis of left orbit H Exostosis of bilateral orbits H Unspecified enophthalmos, right eye H Unspecified enophthalmos, left eye H Unspecified enophthalmos, bilateral H Enophthalmos due to atrophy of orbital tissue, right eye H Enophthalmos due to atrophy of orbital tissue, left eye H Enophthalmos due to atrophy of orbital tissue, bilateral H Enophthalmos due to trauma or surgery, right eye H Enophthalmos due to trauma or surgery, left eye Printed on 9/21/2017. Page 9 of 22

10 H Enophthalmos due to trauma or surgery, bilateral H05.51 Retained (old) foreign body following penetrating wound of right orbit H05.52 Retained (old) foreign body following penetrating wound of left orbit H05.53 Retained (old) foreign body following penetrating wound of bilateral orbits H Cyst of right orbit H Cyst of left orbit H Cyst of bilateral orbits H Myopathy of extraocular muscles, right orbit H Myopathy of extraocular muscles, left orbit H Myopathy of extraocular muscles, bilateral H05.89 Other disorders of orbit H05.9 Unspecified disorder of orbit H Ophthalmia nodosa, right eye H Ophthalmia nodosa, left eye H Ophthalmia nodosa, bilateral H Parasitic cyst of iris, ciliary body or anterior chamber, right eye H Parasitic cyst of iris, ciliary body or anterior chamber, left eye H Parasitic cyst of iris, ciliary body or anterior chamber, bilateral H Parasitic cyst of retina, right eye H Parasitic cyst of retina, left eye H Parasitic cyst of retina, bilateral H Unspecified purulent endophthalmitis, right eye H Unspecified purulent endophthalmitis, left eye H Unspecified purulent endophthalmitis, bilateral H Panophthalmitis (acute), right eye H Panophthalmitis (acute), left eye H Panophthalmitis (acute), bilateral H Vitreous abscess (chronic), right eye H Vitreous abscess (chronic), left eye H Vitreous abscess (chronic), bilateral H Panuveitis, right eye H Panuveitis, left eye H Panuveitis, bilateral H Parasitic endophthalmitis, unspecified, right eye H Parasitic endophthalmitis, unspecified, left eye H Parasitic endophthalmitis, unspecified, bilateral H Sympathetic uveitis, right eye H Sympathetic uveitis, left eye H Sympathetic uveitis, bilateral H44.19 Other endophthalmitis H46.00 Optic papillitis, unspecified eye H46.01 Optic papillitis, right eye H46.02 Optic papillitis, left eye H46.03 Optic papillitis, bilateral H46.11 Retrobulbar neuritis, right eye H46.12 Retrobulbar neuritis, left eye H46.13 Retrobulbar neuritis, bilateral H46.2 Nutritional optic neuropathy H46.3 Toxic optic neuropathy H46.8 Other optic neuritis H46.9 Unspecified optic neuritis H Ischemic optic neuropathy, right eye H Ischemic optic neuropathy, left eye H Ischemic optic neuropathy, bilateral H Hemorrhage in optic nerve sheath, right eye H Hemorrhage in optic nerve sheath, left eye H Hemorrhage in optic nerve sheath, bilateral H Optic nerve hypoplasia, right eye Printed on 9/21/2017. Page 10 of 22

11 H Optic nerve hypoplasia, left eye H Optic nerve hypoplasia, bilateral H Other disorders of optic nerve, not elsewhere classified, right eye H Other disorders of optic nerve, not elsewhere classified, left eye H Other disorders of optic nerve, not elsewhere classified, bilateral H47.10 Unspecified papilledema H47.11 Papilledema associated with increased intracranial pressure H47.12 Papilledema associated with decreased ocular pressure H47.13 Papilledema associated with retinal disorder H Foster-Kennedy syndrome, right eye H Foster-Kennedy syndrome, left eye H Foster-Kennedy syndrome, bilateral H47.20 Unspecified optic atrophy H Primary optic atrophy, right eye H Primary optic atrophy, left eye H Primary optic atrophy, bilateral H47.22 Hereditary optic atrophy H Glaucomatous optic atrophy, right eye H Glaucomatous optic atrophy, left eye H Glaucomatous optic atrophy, bilateral H Other optic atrophy, right eye H Other optic atrophy, left eye H Other optic atrophy, bilateral H Coloboma of optic disc, right eye H Coloboma of optic disc, left eye H Coloboma of optic disc, bilateral H Drusen of optic disc, right eye H Drusen of optic disc, left eye H Drusen of optic disc, bilateral H Pseudopapilledema of optic disc, right eye H Pseudopapilledema of optic disc, left eye H Pseudopapilledema of optic disc, bilateral H Other disorders of optic disc, right eye H Other disorders of optic disc, left eye H Other disorders of optic disc, bilateral H47.41 Disorders of optic chiasm in (due to) inflammatory disorders H47.42 Disorders of optic chiasm in (due to) neoplasm H47.43 Disorders of optic chiasm in (due to) vascular disorders H47.49 Disorders of optic chiasm in (due to) other disorders H Disorders of visual pathways in (due to) inflammatory disorders, right side H Disorders of visual pathways in (due to) inflammatory disorders, left side H Disorders of visual pathways in (due to) neoplasm, right side H Disorders of visual pathways in (due to) neoplasm, left side H Disorders of visual pathways in (due to) vascular disorders, right side H Disorders of visual pathways in (due to) vascular disorders, left side H Cortical blindness, right side of brain H Cortical blindness, left side of brain H Disorders of visual cortex in (due to) inflammatory disorders, right side of brain H Disorders of visual cortex in (due to) inflammatory disorders, left side of brain H Disorders of visual cortex in (due to) neoplasm, right side of brain H Disorders of visual cortex in (due to) neoplasm, left side of brain H Disorders of visual cortex in (due to) vascular disorders, right side of brain H Disorders of visual cortex in (due to) vascular disorders, left side of brain H47.9 Unspecified disorder of visual pathways H49.01 Third [oculomotor] nerve palsy, right eye H49.02 Third [oculomotor] nerve palsy, left eye H49.03 Third [oculomotor] nerve palsy, bilateral Printed on 9/21/2017. Page 11 of 22

12 H49.11 Fourth [trochlear] nerve palsy, right eye H49.12 Fourth [trochlear] nerve palsy, left eye H49.13 Fourth [trochlear] nerve palsy, bilateral H49.21 Sixth [abducent] nerve palsy, right eye H49.22 Sixth [abducent] nerve palsy, left eye H49.23 Sixth [abducent] nerve palsy, bilateral H49.31 Total (external) ophthalmoplegia, right eye H49.32 Total (external) ophthalmoplegia, left eye H49.33 Total (external) ophthalmoplegia, bilateral H49.41 Progressive external ophthalmoplegia, right eye H49.42 Progressive external ophthalmoplegia, left eye H49.43 Progressive external ophthalmoplegia, bilateral H Other paralytic strabismus, right eye H Other paralytic strabismus, left eye H Other paralytic strabismus, bilateral H49.9 Unspecified paralytic strabismus H50.60 Mechanical strabismus, unspecified H Brown's sheath syndrome, right eye H Brown's sheath syndrome, left eye H50.69 Other mechanical strabismus H Duane's syndrome, right eye H Duane's syndrome, left eye H50.89 Other specified strabismus H51.0 Palsy (spasm) of conjugate gaze H51.11 Convergence insufficiency H51.12 Convergence excess H51.21 Internuclear ophthalmoplegia, right eye H51.22 Internuclear ophthalmoplegia, left eye H51.23 Internuclear ophthalmoplegia, bilateral H51.8 Other specified disorders of binocular movement H53.10 Unspecified subjective visual disturbances H53.11 Day blindness H Transient visual loss, right eye H Transient visual loss, left eye H Transient visual loss, bilateral H Sudden visual loss, right eye H Sudden visual loss, left eye H Sudden visual loss, bilateral H Visual discomfort, right eye H Visual discomfort, left eye H Visual discomfort, bilateral H53.15 Visual distortions of shape and size H53.19 Other subjective visual disturbances H53.2 Diplopia H53.30 Unspecified disorder of binocular vision H53.40 Unspecified visual field defects H Scotoma involving central area, right eye H Scotoma involving central area, left eye H Scotoma involving central area, bilateral H Scotoma of blind spot area, right eye H Scotoma of blind spot area, left eye H Scotoma of blind spot area, bilateral H Sector or arcuate defects, right eye H Sector or arcuate defects, left eye H Sector or arcuate defects, bilateral H Other localized visual field defect, right eye H Other localized visual field defect, left eye H Other localized visual field defect, bilateral Printed on 9/21/2017. Page 12 of 22

13 H Homonymous bilateral field defects, right side H Homonymous bilateral field defects, left side H53.47 Heteronymous bilateral field defects H Generalized contraction of visual field, right eye H Generalized contraction of visual field, left eye H Generalized contraction of visual field, bilateral H55.00 Unspecified nystagmus H55.01 Congenital nystagmus H55.02 Latent nystagmus H55.03 Visual deprivation nystagmus H55.04 Dissociated nystagmus H55.09 Other forms of nystagmus H55.81 Saccadic eye movements H55.89 Other irregular eye movements H57.00 Unspecified anomaly of pupillary function H57.01 Argyll Robertson pupil, atypical H57.02 Anisocoria H57.03 Miosis H57.04 Mydriasis H Tonic pupil, right eye H Tonic pupil, left eye H Tonic pupil, bilateral H57.09 Other anomalies of pupillary function H57.11 Ocular pain, right eye H57.12 Ocular pain, left eye H57.13 Ocular pain, bilateral H57.8 Other specified disorders of eye and adnexa H Postprocedural hematoma of right eye and adnexa following an ophthalmic procedure H Postprocedural hematoma of left eye and adnexa following an ophthalmic procedure H Postprocedural hematoma of eye and adnexa following an ophthalmic procedure, bilateral H Postprocedural hematoma of right eye and adnexa following other procedure H Postprocedural hematoma of left eye and adnexa following other procedure H Postprocedural hematoma of eye and adnexa following other procedure, bilateral H Postprocedural seroma of right eye and adnexa following an ophthalmic procedure H Postprocedural seroma of left eye and adnexa following an ophthalmic procedure H Postprocedural seroma of eye and adnexa following an ophthalmic procedure, bilateral H Postprocedural seroma of right eye and adnexa following other procedure H Postprocedural seroma of left eye and adnexa following other procedure H Postprocedural seroma of eye and adnexa following other procedure, bilateral H59.40 Inflammation (infection) of postprocedural bleb, unspecified H59.41 Inflammation (infection) of postprocedural bleb, stage 1 H59.42 Inflammation (infection) of postprocedural bleb, stage 2 H59.43 Inflammation (infection) of postprocedural bleb, stage 3 J33.0 Polyp of nasal cavity J33.1 Polypoid sinus degeneration J33.8 Other polyp of sinus J33.9 Nasal polyp, unspecified J34.0 Abscess, furuncle and carbuncle of nose J34.1 Cyst and mucocele of nose and nasal sinus J34.81 Nasal mucositis (ulcerative) J34.89 Other specified disorders of nose and nasal sinuses J38.5 Laryngeal spasm J38.6 Stenosis of larynx J38.7 Other diseases of larynx J39.0 Retropharyngeal and parapharyngeal abscess J39.1 Other abscess of pharynx J39.2 Other diseases of pharynx Printed on 9/21/2017. Page 13 of 22

14 K12.2 Cellulitis and abscess of mouth L02.01 Cutaneous abscess of face L02.11 Cutaneous abscess of neck L Cellulitis of face L Acute lymphangitis of face L Periorbital cellulitis L Cellulitis of neck L Acute lymphangitis of neck R04.0 Epistaxis R04.1 Hemorrhage from throat R07.0 Pain in throat R09.81 Nasal congestion R22.0 Localized swelling, mass and lump, head R22.1 Localized swelling, mass and lump, neck R47.01 Aphasia R47.02 Dysphasia R47.1 Dysarthria and anarthria R47.81 Slurred speech R47.82 Fluency disorder in conditions classified elsewhere R47.89 Other speech disturbances R47.9 Unspecified speech disturbances R49.0 Dysphonia R49.1 Aphonia R49.21 Hypernasality R49.22 Hyponasality R49.8 Other voice and resonance disorders R49.9 Unspecified voice and resonance disorder R51 Headache R68.84 Jaw pain R90.0 Intracranial space-occupying lesion found on diagnostic imaging of central nervous system R90.82 White matter disease, unspecified R93.0 Abnormal findings on diagnostic imaging of skull and head, not elsewhere classified S02.30XA Fracture of orbital floor, unspecified side, initial encounter for closed fracture S02.30XB Fracture of orbital floor, unspecified side, initial encounter for open fracture S02.30XD Fracture of orbital floor, unspecified side, subsequent encounter for fracture with routine S02.30XG Fracture of orbital floor, unspecified side, subsequent encounter for fracture with delayed S02.30XK Fracture of orbital floor, unspecified side, subsequent encounter for fracture with nonunion S02.30XS Fracture of orbital floor, unspecified side, sequela S02.31XA Fracture of orbital floor, right side, initial encounter for closed fracture S02.31XB Fracture of orbital floor, right side, initial encounter for open fracture S02.31XD Fracture of orbital floor, right side, subsequent encounter for fracture with routine S02.31XG Fracture of orbital floor, right side, subsequent encounter for fracture with delayed S02.31XK Fracture of orbital floor, right side, subsequent encounter for fracture with nonunion S02.31XS Fracture of orbital floor, right side, sequela S02.32XA Fracture of orbital floor, left side, initial encounter for closed fracture S02.32XB Fracture of orbital floor, left side, initial encounter for open fracture S02.32XD Fracture of orbital floor, left side, subsequent encounter for fracture with routine S02.32XG Fracture of orbital floor, left side, subsequent encounter for fracture with delayed S02.32XK Fracture of orbital floor, left side, subsequent encounter for fracture with nonunion S02.32XS Fracture of orbital floor, left side, sequela S02.40AA Malar fracture, right side, initial encounter for closed fracture S02.40AB Malar fracture, right side, initial encounter for open fracture S02.40AD Malar fracture, right side, subsequent encounter for fracture with routine S02.40AG Malar fracture, right side, subsequent encounter for fracture with delayed S02.40AK Malar fracture, right side, subsequent encounter for fracture with nonunion S02.40AS Malar fracture, right side, sequela S02.40BA Malar fracture, left side, initial encounter for closed fracture S02.40BB Malar fracture, left side, initial encounter for open fracture Printed on 9/21/2017. Page 14 of 22

15 S02.40BD Malar fracture, left side, subsequent encounter for fracture with routine S02.40BG Malar fracture, left side, subsequent encounter for fracture with delayed S02.40BK Malar fracture, left side, subsequent encounter for fracture with nonunion S02.40BS Malar fracture, left side, sequela S02.40CA Maxillary fracture, right side, initial encounter for closed fracture S02.40CB Maxillary fracture, right side, initial encounter for open fracture S02.40CD Maxillary fracture, right side, subsequent encounter for fracture with routine S02.40CG Maxillary fracture, right side, subsequent encounter for fracture with delayed S02.40CK Maxillary fracture, right side, subsequent encounter for fracture with nonunion S02.40CS Maxillary fracture, right side, sequela S02.40DA Maxillary fracture, left side, initial encounter for closed fracture S02.40DB Maxillary fracture, left side, initial encounter for open fracture S02.40DD Maxillary fracture, left side, subsequent encounter for fracture with routine S02.40DG Maxillary fracture, left side, subsequent encounter for fracture with delayed S02.40DK Maxillary fracture, left side, subsequent encounter for fracture with nonunion S02.40DS Maxillary fracture, left side, sequela S02.40EA Zygomatic fracture, right side, initial encounter for closed fracture S02.40EB Zygomatic fracture, right side, initial encounter for open fracture S02.40ED Zygomatic fracture, right side, subsequent encounter for fracture with routine S02.40EG Zygomatic fracture, right side, subsequent encounter for fracture with delayed S02.40EK Zygomatic fracture, right side, subsequent encounter for fracture with nonunion S02.40ES Zygomatic fracture, right side, sequela S02.40FA Zygomatic fracture, left side, initial encounter for closed fracture S02.40FB Zygomatic fracture, left side, initial encounter for open fracture S02.40FD Zygomatic fracture, left side, subsequent encounter for fracture with routine S02.40FG Zygomatic fracture, left side, subsequent encounter for fracture with delayed S02.40FK Zygomatic fracture, left side, subsequent encounter for fracture with nonunion S02.40FS Zygomatic fracture, left side, sequela S02.601A Fracture of unspecified part of body of right mandible, initial encounter for closed fracture S02.601B Fracture of unspecified part of body of right mandible, initial encounter for open fracture S02.601D Fracture of unspecified part of body of right mandible, subsequent encounter for fracture with routine S02.601G Fracture of unspecified part of body of right mandible, subsequent encounter for fracture with delayed S02.601K Fracture of unspecified part of body of right mandible, subsequent encounter for fracture with nonunion S02.601S Fracture of unspecified part of body of right mandible, sequela S02.602A Fracture of unspecified part of body of left mandible, initial encounter for closed fracture S02.602B Fracture of unspecified part of body of left mandible, initial encounter for open fracture S02.602D Fracture of unspecified part of body of left mandible, subsequent encounter for fracture with routine S02.602G Fracture of unspecified part of body of left mandible, subsequent encounter for fracture with delayed S02.602K Fracture of unspecified part of body of left mandible, subsequent encounter for fracture with nonunion S02.602S Fracture of unspecified part of body of left mandible, sequela S02.610A Fracture of condylar process of mandible, unspecified side, initial encounter for closed fracture S02.610B Fracture of condylar process of mandible, unspecified side, initial encounter for open fracture S02.610D Fracture of condylar process of mandible, unspecified side, subsequent encounter for fracture with routine S02.610G Fracture of condylar process of mandible, unspecified side, subsequent encounter for fracture with delayed S02.610K Fracture of condylar process of mandible, unspecified side, subsequent encounter for fracture with nonunion S02.610S Fracture of condylar process of mandible, unspecified side, sequela S02.611A Fracture of condylar process of right mandible, initial encounter for closed fracture S02.611B Fracture of condylar process of right mandible, initial encounter for open fracture S02.611D Fracture of condylar process of right mandible, subsequent encounter for fracture with routine Printed on 9/21/2017. Page 15 of 22

16 S02.611G S02.611K S02.611S S02.612A S02.612B S02.612D S02.612G S02.612K S02.612S S02.620A S02.620B S02.620D S02.620G S02.620K S02.620S S02.621A S02.621B S02.621D S02.621G S02.621K S02.621S S02.622A S02.622B S02.622D S02.622G S02.622K S02.622S S02.630A S02.630B S02.630D S02.630G S02.630K S02.630S S02.631A S02.631B S02.631D S02.631G S02.631K S02.631S S02.632A S02.632B S02.632D Fracture of condylar process of right mandible, subsequent encounter for fracture with delayed Fracture of condylar process of right mandible, subsequent encounter for fracture with nonunion Fracture of condylar process of right mandible, sequela Fracture of condylar process of left mandible, initial encounter for closed fracture Fracture of condylar process of left mandible, initial encounter for open fracture Fracture of condylar process of left mandible, subsequent encounter for fracture with routine Fracture of condylar process of left mandible, subsequent encounter for fracture with delayed Fracture of condylar process of left mandible, subsequent encounter for fracture with nonunion Fracture of condylar process of left mandible, sequela Fracture of subcondylar process of mandible, unspecified side, initial encounter for closed fracture Fracture of subcondylar process of mandible, unspecified side, initial encounter for open fracture Fracture of subcondylar process of mandible, unspecified side, subsequent encounter for fracture with routine Fracture of subcondylar process of mandible, unspecified side, subsequent encounter for fracture with delayed Fracture of subcondylar process of mandible, unspecified side, subsequent encounter for fracture with nonunion Fracture of subcondylar process of mandible, unspecified side, sequela Fracture of subcondylar process of right mandible, initial encounter for closed fracture Fracture of subcondylar process of right mandible, initial encounter for open fracture Fracture of subcondylar process of right mandible, subsequent encounter for fracture with routine Fracture of subcondylar process of right mandible, subsequent encounter for fracture with delayed Fracture of subcondylar process of right mandible, subsequent encounter for fracture with nonunion Fracture of subcondylar process of right mandible, sequela Fracture of subcondylar process of left mandible, initial encounter for closed fracture Fracture of subcondylar process of left mandible, initial encounter for open fracture Fracture of subcondylar process of left mandible, subsequent encounter for fracture with routine Fracture of subcondylar process of left mandible, subsequent encounter for fracture with delayed Fracture of subcondylar process of left mandible, subsequent encounter for fracture with nonunion Fracture of subcondylar process of left mandible, sequela Fracture of coronoid process of mandible, unspecified side, initial encounter for closed fracture Fracture of coronoid process of mandible, unspecified side, initial encounter for open fracture Fracture of coronoid process of mandible, unspecified side, subsequent encounter for fracture with routine Fracture of coronoid process of mandible, unspecified side, subsequent encounter for fracture with delayed Fracture of coronoid process of mandible, unspecified side, subsequent encounter for fracture with nonunion Fracture of coronoid process of mandible, unspecified side, sequela Fracture of coronoid process of right mandible, initial encounter for closed fracture Fracture of coronoid process of right mandible, initial encounter for open fracture Fracture of coronoid process of right mandible, subsequent encounter for fracture with routine Fracture of coronoid process of right mandible, subsequent encounter for fracture with delayed Fracture of coronoid process of right mandible, subsequent encounter for fracture with nonunion Fracture of coronoid process of right mandible, sequela Fracture of coronoid process of left mandible, initial encounter for closed fracture Fracture of coronoid process of left mandible, initial encounter for open fracture Fracture of coronoid process of left mandible, subsequent encounter for fracture with routine Printed on 9/21/2017. Page 16 of 22

17 S02.632G S02.632K S02.632S S02.640A S02.640B S02.640D S02.640G S02.640K S02.640S S02.641A S02.641B S02.641D S02.641G S02.641K S02.641S S02.642A S02.642B S02.642D S02.642G S02.642K S02.642S S02.650A S02.650B S02.650D S02.650G S02.650K S02.650S S02.651A S02.651B S02.651D S02.651G S02.651K S02.651S S02.652A S02.652B S02.652D S02.652G S02.652K S02.652S S02.670A S02.670B S02.670D S02.670G S02.670K S02.670S S02.671A S02.671B S02.671D S02.671G S02.671K Fracture of coronoid process of left mandible, subsequent encounter for fracture with delayed Fracture of coronoid process of left mandible, subsequent encounter for fracture with nonunion Fracture of coronoid process of left mandible, sequela Fracture of ramus of mandible, unspecified side, initial encounter for closed fracture Fracture of ramus of mandible, unspecified side, initial encounter for open fracture Fracture of ramus of mandible, unspecified side, subsequent encounter for fracture with routine Fracture of ramus of mandible, unspecified side, subsequent encounter for fracture with delayed Fracture of ramus of mandible, unspecified side, subsequent encounter for fracture with nonunion Fracture of ramus of mandible, unspecified side, sequela Fracture of ramus of right mandible, initial encounter for closed fracture Fracture of ramus of right mandible, initial encounter for open fracture Fracture of ramus of right mandible, subsequent encounter for fracture with routine Fracture of ramus of right mandible, subsequent encounter for fracture with delayed Fracture of ramus of right mandible, subsequent encounter for fracture with nonunion Fracture of ramus of right mandible, sequela Fracture of ramus of left mandible, initial encounter for closed fracture Fracture of ramus of left mandible, initial encounter for open fracture Fracture of ramus of left mandible, subsequent encounter for fracture with routine Fracture of ramus of left mandible, subsequent encounter for fracture with delayed Fracture of ramus of left mandible, subsequent encounter for fracture with nonunion Fracture of ramus of left mandible, sequela Fracture of angle of mandible, unspecified side, initial encounter for closed fracture Fracture of angle of mandible, unspecified side, initial encounter for open fracture Fracture of angle of mandible, unspecified side, subsequent encounter for fracture with routine Fracture of angle of mandible, unspecified side, subsequent encounter for fracture with delayed Fracture of angle of mandible, unspecified side, subsequent encounter for fracture with nonunion Fracture of angle of mandible, unspecified side, sequela Fracture of angle of right mandible, initial encounter for closed fracture Fracture of angle of right mandible, initial encounter for open fracture Fracture of angle of right mandible, subsequent encounter for fracture with routine Fracture of angle of right mandible, subsequent encounter for fracture with delayed Fracture of angle of right mandible, subsequent encounter for fracture with nonunion Fracture of angle of right mandible, sequela Fracture of angle of left mandible, initial encounter for closed fracture Fracture of angle of left mandible, initial encounter for open fracture Fracture of angle of left mandible, subsequent encounter for fracture with routine Fracture of angle of left mandible, subsequent encounter for fracture with delayed Fracture of angle of left mandible, subsequent encounter for fracture with nonunion Fracture of angle of left mandible, sequela Fracture of alveolus of mandible, unspecified side, initial encounter for closed fracture Fracture of alveolus of mandible, unspecified side, initial encounter for open fracture Fracture of alveolus of mandible, unspecified side, subsequent encounter for fracture with routine Fracture of alveolus of mandible, unspecified side, subsequent encounter for fracture with delayed Fracture of alveolus of mandible, unspecified side, subsequent encounter for fracture with nonunion Fracture of alveolus of mandible, unspecified side, sequela Fracture of alveolus of right mandible, initial encounter for closed fracture Fracture of alveolus of right mandible, initial encounter for open fracture Fracture of alveolus of right mandible, subsequent encounter for fracture with routine Fracture of alveolus of right mandible, subsequent encounter for fracture with delayed Fracture of alveolus of right mandible, subsequent encounter for fracture with nonunion Printed on 9/21/2017. Page 17 of 22