CPT Codes Requiring Prior Authorization

Transcription

1 NOTE: To validate coverage by site of service, please reference the appropriate Appendices below. Services not designated as a covered service in the applicable Appendix, based on the location and type of service, are not reimbursable in accordance with the Ohio Administrative Code rules, unless prior authorization is obtained. Prior authorization is always required for non-covered or non-grouper surgical codes (codes not listed in the Appendices designated for the site of service). Site of Service Appendix Ohio Administrative Code (OAC) Physician Services Appendix DD 5101: Ambulatory Surgical Centers Appendix DD 5101: (These codes are noted in the Current ASC Group column of the Medicaid Fee Schedule, Appendix DD. Please reference ASC Facility Payment Rates for the ASC grouper assigned in Appendix DD.) Outpatient Hospital Surgical Services Appendix C 5101: Outpatient Hospital Clinic Services Appendix D 5101: Hospital Emergency Room Visits Appendix E 5101: Outpatient Hospital Ancillary Services Appendix F 5101: Outpatient Hospital Radiology Services Appendix G 5101: Outpatient Hospital Laboratory Services Appendix H 5101: The appropriate Medicaid Supply List and Orthotic and Prosthetic List should be referenced for prior authorization requirements regarding medical/surgical supplies, durable medical equipment, and orthotic and prosthetic services. 5101: Appendix A, Medicaid Supply List 5101: Appendix A, List of Orthotic and Prosthetic Procedures Date of Coverage Change, if Applicable Drainage of skin abscess Hospital setting only or if performed by a podiatrist Cleansing of skin/tissue All Cleansing of tissue/muscle All Cleansing tissue/muscle/bone All Biopsy of skin lesion Hospital setting only or if performed by a podiatrist Biopsy, each added lesion Hospital setting only or if performed by a podiatrist Removal of skin tags Hospital setting only or if performed by a podiatrist Removal of added skin tags Hospital setting only or if performed by a podiatrist Shave skin lesion Hospital setting only or if performed by a podiatrist Shave skin lesion Hospital setting only or if performed by a podiatrist

2 11302 Shave skin lesion Hospital setting only or if performed by a podiatrist Shave skin lesion Hospital setting only or if performed by a podiatrist Shave skin lesion Hospital setting only or if performed by a podiatrist Shave skin lesion Hospital setting only or if performed by a podiatrist Shave skin lesion Hospital setting only or if performed by a podiatrist Shave skin lesion Hospital setting only or if performed by a podiatrist Shave skin lesion Hospital setting only or if performed by a podiatrist Shave skin lesion Hospital setting only or if performed by a podiatrist Removal of skin lesion Hospital setting only or if performed by a podiatrist Removal of skin lesion Hospital setting only or if performed by a podiatrist Removal of skin lesion Hospital setting only or if performed by a podiatrist Removal of skin lesion Hospital setting only or if performed by a podiatrist Removal of skin lesion Hospital setting only or if performed by a podiatrist Removal of skin lesion Hospital setting only or if performed by a podiatrist Removal of skin lesion Hospital setting only or if performed by a podiatrist Removal of skin lesion Hospital setting only or if performed by a podiatrist Removal of skin lesion All Injection into skin lesions Hospital setting only or if performed by a podiatrist Added skin lesion injections Hospital setting only or if performed by a podiatrist Subcutaneous inj. of filling material, 1cc or less All Subcutaneous inj. of filling material, 1.1 to 5.0 All cc Subcutaneous inj. of filling material, 5.1 to All 10.0 cc Subcutaneous inj. of filling material, over 10.0 All cc Insert tissue expander(s) All Remove tissue expander(s) All Insert drug delivery implant device All Remove rein drug deliv implant device All Skin tissue rearrangement All Skin tissue rearrangement All Skin tissue rearrangement All Skin tissue rearrangement All Skin tissue rearrangement All Skin tissue rearrangement All Skin tissue rearrangement All Skin tissue rearrangement All

3 14301 Skin tissue rearrangement All Skin tissue rearrange add-on All Skin tissue rearrangement All Wnd prep, ch/inf, trk/arm/lg All Wnd prep, ch/inf addl 100 cm All Wnd prep ch/inf, f/n/hf/g All Wnd prep, f/n/hf/g, addl cm All Skin pinch graft procedure All Skin split graft procedure All Skin split graft procedure All Skin split graft procedure All Skin split graft procedure All Skin full graft procedure All Skin full graft procedure All Skin full graft procedure All Skin full graft procedure All Skin full graft procedure All Skin full graft procedure All Skin full graft procedure All Skin full graft procedure All Skin sub graft trnk/arm/leg All Skin sub graft t/a/l add-on All Skin sub grft t/arm/lg child All Skn sub grft t/a/l child add All Skin sub graft face/nk/hf/g All Skin sub graft f/n/hf/g addl All Skn sub grft f/n/hf/g child All Skn sub grft f/n/hf/g ch add All Form skin pedicle flap All Form skin pedicle flap All Form skin pedicle flap All Form skin pedicle flap All Skin graft procedure All Skin graft procedure All Skin graft procedure All Skin graft procedure All Transfer skin pedicle flap All Forehead flap w/vasc pedicle All

4 15732 Muscle-skin graft, head/neck All Muscle-skin graft, trunk All Muscle-skin graft, arm All Muscle-skin graft, leg All Island pedicle flap graft All Neurovascular pedicle graft All Free muscle flap All Free skin flap All Free fascial flap All Composite skin graft All Derma-fat-fascia graft All Acellular derm matrix implt All Abrasion treatment of lesion All Abrasion, added skin lesions All Graft for face nerve palsy All Graft for face nerve palsy All Graft for face nerve palsy All Skin and muscle repair, face All Removal of sutures Hospital setting only or if performed by a podiatrist Removal of tail bone ulcer All Removal of tail bone ulcer All Remove sacrum pressure sore All Remove sacrum pressure sore All Remove sacrum pressure sore All Remove sacrum pressure sore All Remove sacrum pressure sore All Remove sacrum pressure sore All Removal of pressure sore All Removal of pressure sore All Removal of pressure sore All Removal of pressure sore All Removal of pressure sore All Remove thigh pressure sore All Remove thigh pressure sore All Remove thigh pressure sore All Remove thigh pressure sore All Remove thigh pressure sore All Remove thigh pressure sore All

5 15999 Removal of pressure sore All Treatment of burn(s) Hospital setting only or if performed by a podiatrist Treatment of burn(s) All Treatment of burn(s) All Destruction of benign lesions; 15 or more Hospital setting only or if performed by a podiatrist Destruction of skin lesions Hospital setting only or if performed by a podiatrist Destruction of skin lesions Hospital setting only or if performed by a podiatrist Destruction of skin lesions Hospital setting only or if performed by a podiatrist Destruction of skin lesions Hospital setting only or if performed by a podiatrist Destruction of skin lesions Hospital setting only or if performed by a podiatrist Chemical cautery, tissue Hospital setting only or if performed by a podiatrist Destruction of skin lesions Hospital setting only or if performed by a podiatrist Destruction of skin lesions Hospital setting only or if performed by a podiatrist Destruction of skin lesions Hospital setting only or if performed by a podiatrist Destruction of skin lesions Hospital setting only or if performed by a podiatrist Destruction of skin lesions Hospital setting only or if performed by a podiatrist Destruction of skin lesions Hospital setting only or if performed by a podiatrist Cryotherapy of skin All Skin peel therapy All Skin tissue procedure All Cryosurg ablate fa, each All Removal of chest wall lesion All Revision of chest wall All Extensive chest wall surgery All Place po breast cath for rad All Removal of breast tissue All Partical mastectomy All P-mastectomy w/ln removal All Mast, simple, complete All Mast, subq All Mast, radical All Mast, rad, urban type All Mast, mod rad All Reduction of large breast All Removal of breast implant All Removal of implant material All Immediate breast prosthesis All Delayed breast prosthesis All

6 19350 Breast reconstruction All Breast reconstruction All Breast reconstruction All Breast reconstruction All Breast reconstruction All Breast reconstruction All Breast reconstruction All Breast Reconstruction All Surgery of breast capsule All Removal of breast capsule All Breast surgery procedure All Injection, enzyme (eg, collagenase), palmar All fascial cord (ie, Dupuytren s contracture) Place ndl musc/tis for rt All Comp multiplane ext fixation All Comp ext fixate strut change All Replantation, arm, complete All Replant forearm, complete All Replantation, hand, complete All Replantation digit, complete All Replantation digit, complete All Replantation thumb, complete All Replantation thumb, complete All Replantation, foot, complete All Removal of bone for graft All Removal of bone for graft All Remove cartilage for graft All Remove cartilage for graft All Removal of fascia for graft All Removal of fascia for graft All Removal of tendon for graft All Removal of tissue for graft All Spinal bone allograft All Spinal bone autograft All Spinal bone autograft All Record fluid pressure,muscle All Microvascular fibula graft All Microvascular bone graft, iliac crest All

7 20957 Microvascular bone graft, metatarsal All Microvascular bone graft All Bone-skin graft All Bone-skin graft, pelvis All Bone-skin graft, metatarsal All Bone-skin graft, great toe All Electrical bone stimulation All Electrical bone stimulation All Low intensity ultrasound stimulation Hospital setting only or if performed by a podiatrist Ablate, Bone Tumor(s) Perq All Cptr-asst dir ms px All Musculoskeletal surgery All Incision of jaw joint All Exc face les sc < 2 cm All Exc face les sc = 2 cm All Exc face tum deep < 2 cm All Exc face tum deep = 2 cm All Resect facial tumor <2 cm All Resect face tum = 2 cm All Excision of bone, lower jaw All Excision of facial bone(s) All Contour of face bone lesion All Removal of face bone lesion All Remove exostosis, mandible All Remove exostosis, maxilla All Removal of face bone lesion All Removal of jaw bone lesion All Removal of jaw bone lesion All Extensive jaw surgery All Remove mandible cyst complex All Excise lwr jaw cyst w/repair All Remove maxilla cyst complex All Excis uppr jaw cyst w/repair All Removal of jaw joint All Remove jaw joint cartilage All Remove coronoid process All Surgical obturator prosthesis All Orbital prosthesis All

8 21079 Interim obturator prosthesis All Definitive obturator prosthesis All Mandibular resection prosthesis All Palatal augmentation prosthesis All Palatal left prosthesis All Speech aid prosthesis All Oral surgical splint All Auricular prosthesis All Nasal prosthesis All Facial prosthesis All Unlisted maxillofacial prosthesis All Maxillofacial fixation All Injection, jaw joint x-ray All Reconstruction of chin All Reconstruction of chin All Reconstruction of chin All Reconstruction of chin All Augmentation lower jaw bone All Augmentation lower jaw bone All Reduction of forehead All Reduction of forehead All Reduction of forehead All Reconstruct midface, LeFort All Reconstruct midface, LeFort All Reconstruct midface, LeFort All Reconstruct midface, lefort All Reconstruct midface, lefort All Reconstruct midface, lefort All Reconstruct midface, lefort All Reconstruct midface, lefort All Reconstruct midface, lefort All Reconstruct midface, lefort All Reconstruct midface, lefort All Reconstruct midface, lefort All Reconstruct orbit/forehead All Reconstruct orbit/forehead All Reconstruct entire forehead All Reconstruct entire forehead All

9 21181 Contour cranial bone lesion All Reconstruct cranial bone All Reconstruct cranial bone All Reconstruct cranial bone All Reconstruction of midface All Reconstruct lower jaw bone All Reconstruct lower jaw bone All Reconstruct lower jaw bone All Reconstruct lower jaw bone All Reconstruct lower jaw bone All Reconstr lwr jaw w/advance All Reconstruct upper jaw bone All Augmentation of facial bones All Reduction of facial bones All Face bone graft All Lower jaw bone graft All Rib cartilage graft All Ear cartilage graft All Reconstruction of jaw joint All Reconstruction of jaw joint All Reconstruction of jaw joint All Reconstruction of lower jaw All Reconstruction of jaw All Reconstruction of jaw All Reconstruct lower jaw bone All Reconstruction of jaw All Reconstruction of jaw All Reconstruct lower jaw bone All Reconstruction of orbit All Revise eye sockets All Revise eye sockets All Revise eye sockets All Revise eye sockets All Revise eye sockets All Augmentation cheek bone All Revision orbitofacial bones All Revision of eyelid All Revision of eyelid All

10 21295 Revision of jaw muscle/bone All Revision of jaw muscle/bone All Cranio/maxillofacial surgery All Head surgery procedure All Exc back less sc = 3 cm All Exc neck tum deep = 5 cm All Resect neck tum <5cm All Resect neck tum = 5 cm All Partial removal of rib All Partial removal of rib All Removal of rib All Removal of rib and nerves All Partial removal of sternum All Sternal debridement All Extensive sternum surgery All Extensive sternum surgery All Hyoid Myotomy & Suspension All Revision of neck muscle All Revision of neck muscle/rib All Revision of neck muscle All Revision of neck muscle All Reconstruction of sternum All Repair stern/nuss w/o scope All Repair sternum/nuss w/scope All Neck/chest surgery procedure All Exc back les sc = 3 cm All Exc back tum deep < 5 cm All Exc back tum deep = 5 cm All Resect back tum <5 cm All Resect back tum = 5 cm All Remove part of neck vertebra All Remove part, thorax vertebra All Remove part, lumbar vertebra All Remove extra spine segment All Remove part of neck vertebra All Remove part, thorax vertebra All Remove part, lumbar vertebra All Remove extra spine segment All

11 22206 Cut spine 3 col, thor All Cut spine 3 col, lumb All Cut spine 3 col, addl seg All Revision of neck spine All Revision of thorax spine All Revision of lumbar spine All Revision of extra spine segment All Revision of neck spine All Revision of thorax spine All Revision of lumbar spine All Revision of extra spine segment All Manipulation of spine All Percut vertebroplasty thor All Percut vertebroplasty lumb All Percut vertebroplasty addl All Percut kyphoplasty, thor All Percut kyphoplasty, lumbar All Percut kyphoplasty, add-on All Idet, single level All Idet, 1 or more levels All Lat Thorax Spine Fusion All Lat Lumbar Spine Fusion All Lat Thor/Lumb, Addæl Seg All Neck spine fusion All Arthrd ant interbody decompress cervical All belw c Arthrd ant interdy cervcl belw c2 ea addl All ntrspc Neck spine fusion All Thorax spine fusion All Lumbar spine fusion All Additional spinal fusion All Prescrl fuse w/ instr l5/s1 All New Spine & skull spinal fusion All Neck spinal fusion All Neck spine fusion All Thorax spine fusion All Lumbar spine fusion All

12 22614 Spine fusion, extra segment All Lumbar spine fusion All Spine fusion, extra segment All Arthdsis post/posterlatrl/postintrbdyadl spc/ All seg Arthdsis post/posterlatrl/postintrbdyadl spc/ All each additional seg Fusion of spine All Fusion of spine All Fusion of spine All Fusion of spine All Fusion of spine All Fusion of spine All Kyphectomy All Kyphectomy All Exploration of spinal fusion All Insert spine fixation device All Insert spine fixation device All Insert spine fixation device All Insert spine fixation device All Insert spine fixation device All Insert spine fixation device All Insert spine fixation device All Insert spine fixation device All Insert pelvic fixation device All Reinsert spinal fixation All Remove spine fixation device All Apply prosthetic spine device All Remove spine fixation device All Remove spine fixation device All Cerv artific diskectomy All Revise cerv artific disc All Remove cerv artif disc All Spine surgery procedure All Exc Back Tumor Deep <5cm All Exc back tum deep = 5 cm All Exc abd les sc < 3 cm All Exc abd les sc > 3 cm All Resect abd tum < 5 cm All

13 22905 Resect abd tum > 5 cm All Abdomen surgery procedure All Release shoulder joint All Drain shoulder bone lesion All Exploratory shoulder surgery All Exploratory shoulder surgery All Exc shoulder les sc > 3 cm All Exc shoulder tum deep > 5 cm All Resect shoulder tumor < 5 cm All Resect shoulder tum > 5 cm All Biopsy of shoulder joint All Shoulder joint surgery All Remove shoulder joint lining All Incision of collarbone joint All Explore,treat shoulder joint All Partial removal, collarbone All Removal of collarbone All Partial removal,shoulderbone All Removal of bone lesion All Removal of bone lesion All Removal of bone lesion All Removal of humerus lesion All Removal of humerus lesion All Removal of humerus lesion All Remove collarbone lesion All Remove shoulder blade lesion All Remove humerus lesion All Remove collarbone lesion All Remove shoulderblade lesion All Remove humerus lesion All Partial removal of scapula All Removal of head of humerus All Resect clavicle tumor All Resect scapula tumor All Resect prox humerus tumor All Remove shoulder foreign body All Injection for shoulder x-ray All Muscle transfer,shoulder/arm All

14 23397 Muscle transfers All Fixation of shoulderblade All Incision of tendon & muscle All Incise tendon(s) & muscle(s) All Repair of tendon(s) All Repair of tendon(s) All Release of shoulder ligament All Repair of shoulder All Repair biceps tendon rupture All Removal/transplant tendon All Repair shoulder capsule All Repair shoulder capsule All Repair shoulder capsule All Repair shoulder capsule All Repair shoulder capsule All Repair shoulder capsule All Reconstruct shoulder joint All Reconstruct shoulder joint All Revis reconst shoulder joint All New Revis reconst shoulder joint All New Revision of collarbone All Revision of collarbone All Reinforce clavicle All Reinforce shoulder bones All Fusion of shoulder joint All Fusion of shoulder joint All Amputation of arm & girdle All Amputation at shoulder joint All Amputation follow-up surgery All Shoulder surgery procedure All Exploratory elbow surgery All Exc arm/elbow les sc = 3 cm All Ex arm/elbow tum deep > 5 cm All Resect arm/elbow tum > 5 cm All Biopsy elbow joint lining All Explore/treat elbow joint All Remove elbow joint lining All Removal of elbow bursa All

15 24110 Remove humerus lesion All Remove/graft bone lesion All Remove/graft bone lesion All Remove elbow lesion All Remove/graft bone lesion All Remove/graft bone lesion All Removal of head of radius All Removal of arm bone lesion All Remove radius bone lesion All Remove elbow bone lesion All Partial removal of arm bone All Partial removal of radius All Partial removal of elbow All Radical resection, elbow All Resect distal humerus tumor All Resect radius tumor All Removal of elbow joint All Remove elbow joint implant All Remove radius head implant All Removal of arm foreign body All Removal of arm foreign body All Injection for elbow x-ray All Manipulate elbow, under anesthesia All Muscle/tendon transfer All Arm tendon lengthening All Revision of arm tendon All Repair of arm tendon All Revision of arm muscles All Revision of arm muscles All Tenolysis of triceps All Repair of ruptured tendon All Repair tendon/muscle, upper arm or elbow All Repair of ruptured tendon All Repair, elbow ligament, w. local tissue All Repair, elbow ligament, w tendon graft All Repair, medial ligament, w local tissue All Reconstruct elbow ligament All Repair elbow, perc All Repair elbow w/deb, open All

16 24359 Repair elbow deb/attch open All Reconstruct elbow joint All Reconstruct elbow joint All Reconstruct elbow joint All Replace elbow joint All Reconstruct head of radius All Reconstruct head of radius All Revise reconst elbow joint All New Revise reconst elbow joint All New Revision of humerus All Revision of humerus All Revision of humerus All Repair of humerus All Repair humerus with graft All Revision of elbow joint All Decompression of forearm All Reinforce humerus All Fusion of elbow joint All Fusion/graft of elbow joint All Amputation of upper arm All Amputation of upper arm All Amputation follow-up surgery All Amputation follow-up surgery All Amputate upper arm & implant All Revision of amputation All Revision of upper arm All Upper arm/elbow surgery All Incision of tendon sheath All Incision flexor tendon sheath, wrist All Decompression of forearm All Decompression of forearm All Decompress fasciotomy, forea/wrist, All Decompress fasciotomy, forea/wrist, w debr All Drainage of forearm lesion All Drainage of forearm bursa All Treat forearm bone lesion All Exc forearm les sc > 3cm All Exc forearm tum deep = 3 cm All Exc forearm les sc < 3 cm All

17 25076 Exc forearm tum deep < 3 cm All Resect forearm/wrist tum < 3cm All Resect forearm/wrist tum = 3 cm All Incision of wrist capsule All Biopsy of wrist joint All Explore/treat wrist joint All Remove wrist joint lining All Remove wrist joint cartilage All Excise tendon forearm/wrist All Remove wrist tendon lesion All Remove wrist tendon lesion All Reremove wrist tendon lesion All Remove wrist/forearm lesion All Remove wrist/forearm lesion All Excise wrist tendon sheath All Partial removal of ulna All Removal of forearm lesion All Remove/graft forearm lesion All Remove/graft forearm lesion All Removal of wrist lesion All Remove & graft wrist lesion All Remove & graft wrist lesion All Remove forearm bone lesion All Partial removal of ulna All Partial removal of radius All Resect radius/ulnar tumor All Removal of wrist bone All Removal of wrist bones All Partial removal of radius All Partial removal of ulna All Injection for wrist x-ray All Remove forearm foreign body All Removal of wrist prosthesis All Removal of wrist prosthesis All Repair forearm tendon/muscle All Repair forearm tendon/muscle All Repair forearm tendon/muscle All Repair forearm tendon/muscle All Repair forearm tendon/muscle All

18 25274 Repair forearm tendon/muscle All Repair tendon sheath, forearm/wrist All Revise wrist/forearm tendon All Incise wrist/forearm tendon All Release wrist/forearm tendon All Fusion of tendons at wrist All Fusion of tendons at wrist All Transplant forearm tendon All Transplant forearm tendon All Revise palsy hand tendon(s) All Revise palsy hand tendon(s) All Repair/revise wrist joint All Revise wrist joint All Realignment of hand All Reconstruct ulna/radioulnar All Revision of radius All Revision of radius All Revision of ulna All Revise radius & ulna All Revise radius or ulna All Revise radius & ulna All Shorten radius/ulna All Lengthen radius/ulna All Shorten radius & ulna All Lengthen radius & ulna All Osteoplasty of carpal bone All Repair radius or ulna All Repair/graft radius or ulna All Repair radius & ulna All Repair/graft radius & ulna All Repair/graft radius or ulna All Repair/graft radius & ulna All Vascular pedicle graft for carpal bone All Repair nonunion carpal bone All Repair/graft wrist bone All Reconstruct wrist joint All Reconstruct wrist joint All Reconstruct wrist joint All Reconstruct wrist joint All

19 25445 Reconstruct wrist joint All Wrist replacement All Repair wrist joint(s) All Remove wrist joint implant All Revision of wrist joint All Revision of wrist joint All Reinforce radius All Reinforce ulna All Reinforce radius and ulna All Fusion of wrist joint All Fusion/graft of wrist joint All Fusion/graft of wrist joint All Fusion of hand bones All Fusion hand bones with graft All Fusion radioulnar joint/ulna All Amputation of forearm All Amputation of forearm All Amputation follow-up surgery All Amputation follow-up surgery All Amputation of forearm All Amputate hand at wrist All Amputate hand at wrist All Amputation follow-up surgery All Amputation of hand All Amputation follow-up surgery All Amputation follow-up surgery All Forearm or wrist surgery All Release palm contracture All Release palm contracture All Incise finger tendon sheath All Incision of finger tendon All Biopsy hand joint lining All Biopsy finger joint lining All Biopsy finger joint lining All Exc hand les sc > 1.5 cm All Exc hand tum deep > 5 cm All Exc hand les sc < 1.5 cm All Exc hand tum deep < 1.5 cm All

20 26117 Exc hand tum ra < 3 cm All Exc hand tum ra > 3cm All Release palm contracture All Release palm contracture All Release palm contracture All Remove wrist joint lining All Revise finger joint, each All Revise finger joint, each All Tendon excision, palm/finger All Remove tendon sheath lesion All Removal of palm tendon, each All Removal of finger tendon All Sesamoidectomy, thumb or finger All Remove hand bone lesion All Remove/graft bone lesion All Removal of finger lesion All Remove/graft finger lesion All Partial removal of hand bone All Partial removal, finger bone All Partial removal, finger bone All Extensive hand surgery All Resect prox finger tumor All Resect distal finger tumor All Manipulation, palmar fascial cord (ie, Dupuytren s All cord), post enzyme injection (eg, collagenase), single cord Repair finger/hand tendon All Repair/graft hand tendon All Repair finger/hand tendon All Repair finger/hand tendon All Repair/graft hand tendon All Repair finger/hand tendon All Repair/graft hand tendon All Repair finger/hand tendon All Revise hand/finger tendon All Repair/graft hand tendon All Repair hand tendon All Repair/graft hand tendon All

21 26415 Excision, hand/finger tendon All Graft hand or finger tendon All Repair finger tendon All Repair/graft finger tendon All Repair finger/hand tendon All Repair/graft finger tendon All Repair finger tendon All Repair finger tendon All Repair/graft finger tendon All Realignment of tendons All Release palm/finger tendon All Release palm & finger tendon All Release hand/finger tendon All Release forearm/hand tendon All Incision of palm tendon All Incision of finger tendon All Incise hand/finger tendon All Fusion of finger tendons All Fusion of finger tendons All Tendon lengthening All Tendon shortening All Lengthening of hand tendon All Shortening of hand tendon All Transplant hand tendon All Transplant/graft hand tendon All Transplant palm tendon All Transplant/graft palm tendon All Revise thumb tendon All Tendon transfer with graft All Hand tendon/muscle transfer All Revise thumb tendon All Finger tendon transfer All Finger tendon transfer All Revision of finger All Hand tendon reconstruction All Hand tendon reconstruction All Release thumb contracture All Thumb tendon transfer All

22 26516 Fusion of knuckle joint All Fusion of knuckle joints All Fusion of knuckle joints All Release knuckle contracture All Release finger contracture All Revise knuckle joint All Revise knuckle with implant All Revise finger joint All Revise/implant finger joint All Repair hand joint All Repair hand joint with graft All Repair hand joint with graft All Reconstruct finger joint All Repair non-union metacarpal or phalanx All Reconstruct finger joint All Construct thumb replacement All Microvascular toe-to-hand transfer All Microvascular toe-to-hand transfer All Microvascular toe-to-hand transfer All Positional change of finger All Microvascular free toe joint transfer All Repair of web finger All Repair of web finger All Repair of web finger All Correct metacarpal flaw All Correct finger deformity All Lengthen metacarpal/finger All Repair hand deformity All Reconstruct extra finger All Repair finger deformity All Repair muscles of hand All Release muscles of hand All Excision constricting tissue All Thumb fusion with graft All Fusion of thumb All Thumb fusion with graft All Fusion of hand joint All Fusion/graft of hand joint All

23 26850 Fusion of knuckle All Fusion of knuckle with graft All Fusion of finger joint All Fusion of finger joint,added All Fusion/graft of finger joint All Fuse/graft added joint All Amputate metacarpal bone All Amputation of finger/thumb All Amputation of finger/thumb All Hand/finger surgery All Drainage of pelvis lesion All Drainage of pelvis bursa All Drainage of bone lesion All Incision of hip tendon All Incision of hip tendon All Incision of hip tendon All Incision of hip tendon All Incision of hip tendons All Incision of hip/thigh fascia All Buttock fasciotomy All Drainage of hip joint All Exploration of hip joint All Denervation of hip joint All Capsulectomy or capsulotomy of hip All Exc hip pelvis les sc > 3 cm All Exc hip/pelv tum deep > 5cm All Exc hip/pelvis les sc < 3 cm All Exc hip/pelvis les sc < 5 cm All Resect hip/pelvis tum < 5 cm All Biopsy of sacroiliac joint All Biopsy of hip joint All Removal of hip joint lining All Buttock fasciotomy w/dbrdmt All Resect hip/pelv tum > 5 cm All Removal of ischial bursa All Remove femur lesion/bursa All Removal of hip bone lesion All Removal of hip bone lesion All

24 27067 Remove/graft hip bone lesion All Partial removal of hip bone All Partial removal of hip bone All Resect hip tumor All Resect hip tum incl acetabul All Resect hip tum w/innom bone All Rsect hip tum incl femur All Removal of tail bone All Removal of hip prosthesis All Removal of hip prosthesis All Injection for hip x-ray All Injection for hip x-ray All Injection procedure for sacroiliac joint All Revision of hip tendon All Transfer tendon to pelvis All Transfer of abdominal muscle All Transfer of spinal muscle All Transfer of iliopsoas muscle All Transfer of iliopsoas muscle All Reconstruction of hip socket All Reconstruction of hip socket All Partial hip replacement All Total hip replacement All Total hip replacement All Revise hip joint replacement All Revise hip joint replacement All Revise hip joint replacement All Transplant of femur ridge All Incision of hip bone All Revision of hip bone All Incision of hip bones All Revision of hip bones All Revision of pelvis All Incision of neck of femur All Incision/fixation of femur All Repair/graft femur head/neck All Treat slipped epiphysis All Treat slipped epiphysis All

25 27177 Repair slipped epiphysis All Repair slipped epiphysis All Revise head/neck of femur All Repair slipped epiphysis All Revision of femur epiphysis All Reinforce hip bones All Fusion of sacroiliac joint All Fusion of pubic bones All Fusion of hip joint All Fusion of hip joint All Amputation of leg at hip All Amputation of leg at hip All Pelvis/hip joint surgery All Incise thigh tendon & fascia All Incision of thigh tendon All Incision of thigh tendons All Exploration of knee joint All Neurectomy, hamstring All Neurectomy, popliteal All Exc thigh/knee les sc < 3 cm All Exc thigh/knee tum deep < 5 cm All Resect thigh/knee tum < 5 cm All Biopsy knee joint lining All Explore/treat knee joint All Removal of knee cartilage All Removal of knee cartilage All Remove knee joint lining All Remove knee joint lining All Exc thigh/knee les sc > 3 cm All Exc thigh/knee tum > 5 cm All Removal of kneecap bursa All Removal of knee cyst All Knee lesion excision All Removal of kneecap All Remove femur lesion All Remove femur lesion/graft All Remove femur lesion/graft All Remove femur lesion/fixation All

26 27360 Partial removal leg bone(s) All Resect thigh/knee tum > 5cm All Resect femur/knee tumor All Injection for knee x-ray All Repair of kneecap tendon All Repair/graft kneecap tendon All Repair of thigh muscle All Repair/graft of thigh muscle All Incision of thigh tendon All Incision of thigh tendons All Incision of thigh tendons All Lengthening of thigh tendon All Lengthening of thigh tendons All Lengthening of thigh tendons All Transplant of thigh tendon All Transplants of thigh tendons All Revise thigh muscles/tendons All Repair of knee cartilage All Repair of knee ligament All Repair of knee ligament All Repair of knee ligaments All Autochondrocyte implant knee All Osteochondral knee allograft All Osteochondral knee autograft All Repair degenerated kneecap All Revision of unstable kneecap All Revision of unstable kneecap All Revision/removal of kneecap All Lateral retinacular release All Reconstruction, knee All Reconstruction, knee All Reconstruction, knee All Revision of thigh muscles All Incision of knee joint All Revise kneecap All Revise kneecap with implant All Revision of knee joint All Revision of knee joint All

27 27442 Revision of knee joint All Revision of knee joint All Revision of knee joint All Revision of knee joint All Total knee replacement All Incision of thigh All Incision of thigh All Realignment of thigh bone All Realignment of knee All Realignment of knee All Shortening of thigh bone All Lengthening of thigh bone All Shorten/lengthen thighs All Repair of thigh All Repair/graft of thigh All Surgery to stop leg growth All Surgery to stop leg growth All Surgery to stop leg growth All Surgery to stop leg growth All Revise knee joint replace All Revise knee joint replace All Removal of knee prosthesis All Reinforce thigh All Decompression of thigh/knee All Decompression of thigh/knee All Decompression of thigh/knee All Decompression of thigh/knee All Fusion of knee All Amputate leg at thigh All Amputate leg at thigh All Amputate leg at thigh All Amputation follow-up surgery All Amputation follow-up surgery All Amputate lower leg at knee All Leg surgery procedure All Decompression of lower leg All Decompression of lower leg All Decompression of lower leg All

28 27605 Incision of achilles tendon All Incision of achilles tendon All Treat lower leg bone lesion All Explore/treat ankle joint All Exploration of ankle joint All Resect leg/ankle tum < 5 cm All Resect leg/ankle tum > 5 cm All Exc leg/ankle tum < 3 cm All Exc leg/ankle tum deep < 5 cm All Explore, treat ankle joint All Remove ankle joint lining All Remove ankle joint lining All Exc leg/ankle les sc > 3cm All Exc leg/ankle tum deep > 5cm All Remove lower leg bone lesion All Remove/graft leg bone lesion All Remove/graft leg bone lesion All Partial removal of tibia All Partial removal of fibula All Resect tibia tumor All Resect fibula tumor All Resect talus/calcaneus tumor All Repair achilles tendon All Repair/graft achilles tendon All Repair of achilles tendon All Repair leg fascia defect All Repair of leg tendon, each All Repair of leg tendon, each All Repair of leg tendon, each All Repair of leg tendon, each All Repair lower leg tendons All Repair lower leg tendons All Release of lower leg tendon All Release of lower leg tendons All Revision of lower leg tendon All Revise lower leg tendons All Revision of calf tendon All Revise lower leg tendon All

29 27691 Revise lower leg tendon All Revise additional leg tendon All Repair of ankle ligament All Repair of ankle ligaments All Repair of ankle ligament All Revision of ankle joint All Reconstruct ankle joint All Reconstruction, ankle joint All Removal of ankle implant All Incision of tibia All Incision of fibula All Incision of tibia & fibula All Realignment of lower leg All Revision of lower leg All Repair of tibia All Repair/graft of tibia All Repair/graft of tibia All Repair of lower leg All Repair fibula nonunion All Repair of lower leg All Repair of tibia epiphysis All Repair of fibula epiphysis All Repair lower leg epiphyses All Repair of leg epiphyses All Repair of leg epiphyses All Reinforce tibia All Fusion of ankle joint All Fusion of tibiofibular joint All Amputation of lower leg All Amputation of lower leg All Amputation of lower leg All Amputation follow-up surgery All Amputation follow-up surgery All Amputation of foot at ankle All Amputation of foot at ankle All Decompression of leg All Decompression of leg All Decompression of leg All

30 27899 Leg/ankle surgery procedure All Treat foot bone lesion All Incision of foot fascia All Incision of toe tendon All Incision of toe tendons All Exploration of a foot joint All Exploration of a foot joint All Exploration of a toe joint All Decompression of tibia nerve All Exc foot/toe tum sc > 1.5 cm All Exc foot/toe tum deep > 1.5 cm All Exc foot/toe tum sc < 1.5 cm All Exc foot/toe tum deep <1.5 cm All Resect foot/toe tumo r< 3 cm All Resect foot/toe tumor > 3 cm All Biopsy of foot joint lining All Biopsy of foot joint lining All Biopsy of toe joint lining All Neurectomy, foot All Partial removal foot fascia All Removal of foot fascia All Removal of foot joint lining All Removal of foot joint lining All Removal of foot lesion All Excise foot tendon sheath All Excise foot tendon sheath All Removal of foot lesion All Removal of toe lesions All Removal of ankle/heel lesion All Remove/graft foot lesion All Remove/graft foot lesion All Removal of foot lesion All Remove/graft foot lesion All Remove/graft foot lesion All Removal of toe lesions All Part removal of metatarsal All Part removal of metatarsal All Part removal of metatarsal All

31 28113 Part removal of metatarsal All Removal of metatarsal heads All Revision of foot All Removal of heel bone All Removal of heel spur All Part removal of ankle/heel All Partial removal of foot bone All Partial removal of toe Hospital setting only or if performed by a podiatrist Partial removal of toe All Removal of ankle bone All Removal of metatarsal All Removal of toe All Partial removal of toe All Partial removal of toe All Resect tarsal tumor All Resect metatarsal tumor All Resect phalanx of toe tumor All Repair of foot tendon All Repair/graft of foot tendon All Repair of foot tendon All Repair/graft of foot tendon All Release of foot tendon Hospital setting only or if performed by a podiatrist Release of foot tendons All Release of foot tendon All Release of foot tendons All Incision of foot tendon(s) Hospital setting only or if performed by a podiatrist Incision of toe tendon Hospital setting only or if performed by a podiatrist Incision of foot tendon All Revision of foot tendon All Release of big toe All Revision of foot fascia All Release of midfoot joint All Revision of foot tendon All Revision of foot and ankle All Release of midfoot joint All Release of foot contracture All Release of toe joint, each Hospital setting only or if performed by a podiatrist Fusion of toes All

32 28285 Repair of hammertoe All Repair of hammertoe All Partial removal of foot bone All Hallux rigidus correction All Correction of bunion All Correction of bunion All Correction of bunion All Correction of bunion All Correction of bunion All Correction of bunion All Correction of bunion All Correction of bunion All Incision of heel bone All Incision of ankle bone All Incision of midfoot bones All Incise/graft midfoot bones All Incision of metatarsal All Incision of metatarsal All Incision of metatarsal All Incision of metatarsals All Revision of big toe All Revision of toe All Repair deformity of toe All Removal of sesamoid bone All Repair of foot bones All Repair of metatarsals All Resect enlarged toe tissue All Resect enlarged toe All Repair extra toe(s) All Repair webbed toe(s) All Reconstruct cleft foot All Fusion of foot bones All Fusion of foot bones All Fusion of foot bones All Fusion of foot bones All Fusion of foot bones All Revision of foot bones All Fusion of foot bones All

33 28750 Fusion of big toe joint All Fusion of big toe joint All Fusion of big toe joint All Amputation of midfoot All Amputation thru metatarsal All Amputation toe & metatarsal All Amputation of toe All Partial amputation of toe All High energy eswt, plantar f Hospital setting only or if performed by a podiatrist Foot/toes surgery procedure All Application of multi-layer compression system; All thigh and leg, including ankle and foot, when performed Application of multi-layer compression system; All upper arm and forearm Application of multi-layer compression system; All upper arm, forearm, hand, and fingers Casting/strapping procedure All Jaw arthroscopy/surgery All Jaw arthroscopy/surgery All Shouder arthroscopy, w/w/o synov biopsy All Shoulder arthroscopy, capsulorrhaphy All Repair of slap lesion All Shoulder arthroscopy/surgery All Shoulder arthroscopy/surgery All Shoulder arthroscopy/surgery All Shoulder arthroscopy/surgery All Shoulder arthroscopy/surgery All Shoulder arthroscopy, dist claviculect All Shoulder arthroscopy/surgery All Shoulder arthroscopy/surgery All Arthroscop rotator cuff repr All Arthroscopy biceps tenodesis All Elbow arthroscopy All Elbow arthroscopy/surgery All Elbow arthroscopy/surgery All Elbow arthroscopy/surgery All Elbow arthroscopy/surgery All Elbow arthroscopy/surgery All

34 29840 Wrist arthroscopy All Wrist arthroscopy/surgery All Wrist arthroscopy/surgery All Wrist arthroscopy/surgery All Wrist arthroscopy/surgery All Wrist arthroscopy/surgery All Wrist arthroscopy/surgery All Knee arthroscopy/surgery All Knee arthroscopy/surgery All Tibial arthroscopy/surgery All Tibial arthroscopy/surgery All Hip arthroscopy, diagnostic All Hip arthroscopy/surgery All Hip arthroscopy/surgery All Hip arthroscopy/surgery All Autgrft implnt, knee w/scope All Allgrft implnt, knee w/scope All Meniscal trnspl, knee w/scpe All Knee arthroscopy, diagnostic All Knee arthroscopy/drainage All Knee arthroscopy/surgery All Knee arthroscopy/surgery All Knee arthroscopy/surgery All Knee arthroscopy/surgery All Knee arthroscopy/surgery All Knee arthroscopy/surgery All Knee arthroscopy/surgery All Knee arthroscopy/surgery All Knee arthroscopy/surgery All Knee arthroscopy/surgery All Knee arthroscopy/surgery All Knee arthroscopy/surgery All Knee arthroscopy/surgery All Knee arthroscopy/surgery All Knee arthroscopy/surgery All Knee arthroscopy/surgery All Ankle arthroscopy/surgery All Ankle arthroscopy/surgery All

35 29893 Endoscopic plantar fasciotomy All Ankle arthroscopy/surgery All Ankle arthroscopy/surgery All Ankle arthroscopy/surgery All Ankle arthroscopy/surgery All Ankle arthroscopy/surgery All Metacarp jt arthroscopy,w synov biop All Metacarp joint arthroscopy w debride All Metacarp jt arthroscopy, w reduc ligam All Subtalar arthro w/fb rmvl All Subtalar arthro w/exc All Subtalar arthro w/deb All Subtalar arthro w/fusion All Arthroscopy hip w/femoroplasty All Arthroscopy hip w/acetabuloplasty All Arthroscopy hip w/labral repair All Unlisted arthroscopy procedure All Reconstruction of nose All Reconstruction of nose All Reconstruction of nose All Revision of nose All Revision of nose All Revision of nose All Revision of nose All Revision of nose All Repair nasal stenosis All Repair of nasal septum All Repair nasal defect All Repair nasal defect All Release of nasal adhesions All Repair upper jaw fistula All Repair mouth/nose fistula All Intranasal reconstruction All Repair nasal septum defect All Ligation nasal sinus artery All Ligation upper jaw artery All Nasal surgery procedure All Irrigation sphenoid sinus All