Multispecialty Physician Services
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1 Code Description 1999 Unlisted Anesthesia Procedure Dermabrasion, Chemical Peel Blepharoplasty and Brow Pitosis repair Blepharoplasty Excision, Excessive Skin Subcutaneous Abdomen Excision, Excessive Skin Thigh Excision, Excessive Skin Hip Excision, Excessive Skin Buttock Abdominoplasty Suction Assisted Lipectomy Removal of Pressure Sore Skin Tissue Procedure Mastectomy Gynecosmatia Suspension of Breast Breast Reduction Surgery Breast Repair Reconstruction Mammoplasty, Augmentation Removal of Breast implant Removal of Implant Material Immediate Breast Prosthesis Delayed Insertion of Breast Prosthesis Breast Reconstruction Breast Reconstruction With Lat Flap Revised Oct 2017 Page 1 of 12 Physician Services
2 19364 Breast Reconstruction With Free Flap Blepheroplasty, upper eyelid Breast Reconstruction With Other Technique Breast Reconstruction With TRAM Flap, Single Pedicle Breast Reconstruction With Microvascular Anastomosis Breast Reconstruction With TRAM Flap, Double Pedicle Surgery of Breast Capsule Removal of Breast Capsule Revised Breast Reconstruction Breast Surgery Procedure Other Bone Graf Microvasc Musculoskeletal Surgery Speech Aid Prosthesis Facial Prosthesis Unlisted Maxillofacial Prosthetic Procedure Reconstruction of Chin Reduction Forehead Contouring Only Unlisted Cranio/Maxillofacial Procedure Unlisted Musculoskeletal Procedure, Head Unlisted Procedure of the Head or Neck Kyphectomy, 1-2 segments Kyphectomy, 3 or more segments Unlisted Procedure, Spine Unlisted Procedure, Abdomen, Musculoskeletal System Revised Oct 2017 Page 2 of 12 Physician Services
3 23929 Unlisted Procedure, Shoulder Unlisted Procedure, Humorous or Elbow Injection Procedure, Wrist Arthroscopy Unlisted Procedure, Forearm or Wrist Unlisted Procedure, Hand/Finger Unlisted Procedure, Pelvis/Hip Joint Unlisted Procedure, Femur or Knee Unlisted Procedure, Leg/Ankle Foot/Toes Surgery Procedure Casting/Strapping Procedure Arthroscopy of Joint Rhinoplasty Revision of Nose - Medical Necessity Only Repair of Nasal Stenosis Repair of Nasal Septum Nasal Surgery Procedure Sinus Surgery Procedure Larynx Surgery Procedure Endobronchial US Add On Airways Surgical Procedure Chest Surgery Procedure Transplantation Heart/Lung Cardiac Surgery Procedure Vessel Injection Procedure Revised Oct 2017 Page 3 of 12 Physician Services
4 36468 Single or Multiple Injections of Sclerosing Solutions Transfusion service, fetal Sclerotherapy Injection, Single Vein Insert Hepatic Shunt Remove Hepatic Shunt Vascular Endoscopy Procedure Vascular Surgery Procedure Laparoscopic Procedure Spleen Bone Marrow Harvest Allogen Bone Marrow/Stem Transplant Auto Laparoscope Procedure Lymphatic Blood/Lymph System Procedure Chest Procedure Diaphragm Surgery Procedure Lip Surgery Procedure Mouth Surgery Procedure Tongue and Mouth Surgery Dental Surgery, Procedure Palate/Uvula Surgery Salivary Surgery, Procedure Throat Surgery, Procedure Laparoscope Procedure, Esophagus Esophagus Surgery Procedure Laparoscopy Procedure, Stomach Revised Oct 2017 Page 4 of 12 Physician Services
5 43770 Laparoscopy, Gastric Restrictive Procedure Laparoscopy, Surgical, Gastric Restrictive Procedure; Revision of Adjustable Gastric Restrictive Device Component Only Laparoscopy, Surgical, Gastric Restrictive Procedure; Removal of Adjustable Gastric Restrictive Device Component Only Laparoscopy, Surgical, Gastric Restrictive Procedure; Removal and Replacement of Adjustable Gastric Restrictive Device Component Only Laparoscopy, Surgical, Gastric Restrictive Procedure; Removal of Adjustable Gastric Restrictive Device and Subcutaneous Port Components Laparoscopy, Surgical, Gastric Restrictive Procedure; Longitudinal Gastrectomy Gastric Restrictive Procedure, Without Gastric Bypass, for Morbid Obesity; Vertical-banded Gastroplasty Gastric Restrictive Procedure, Without Gastric Bypass, for Morbid Obesity; other than Vertical-banded Gastroplasty Gastric Restrictive Procedure, With Gastric Bypass for Morbid Obesity; With short limb (150 cm or less) Rouxen-Y Gastroenterostomy Gastric Restrictive Procedure, With Gastric Bypass for Morbid Obesity; With Small Intestine Reconstruction to Limit Absorption Gastric Restrictive Procedure, Open; Removal and Replacement of Subcutaneous Port Component Only Unlisted Stomach Procedure Unlisted Laparoscopy Procedure, Intestine Revised Oct 2017 Page 5 of 12 Physician Services
6 44799 Unlisted Procedure, Small Intestine Unlisted Procedure, Meckel's Diverticulum and Mesentery Unlisted Laparoscopy Procedure, Appendix Pelvic Exenteration for Colorectal Cancer Unlisted Procedure, Colon Laparoscope Procedure Rectum Rectum Surgery Procedure Anus Surgery Procedure Laparoscope Procedure Liver Liver Surgery Procedure Laparoscope Procedure Biliary Bile Tract Surgery Procedure Pancreas Removal/Transplant Pancreas Surgery Procedure Laparoscopic Procedure Abdominal/Per/Oment Laparoscopic Procedure Hernia Repair Extra Abdominal Omental Flap Suture Procedures of the abdomen, Peritoneum, and Omentum Abdomen Surgery Procedure Laparoscope Procedure Renal Laparoscope Procedure Ureter Endoscopic Injection / Implant Laparoscope Proc Bladder Urology Surgery Procedure Revised Oct 2017 Page 6 of 12 Physician Services
7 54150 Circumcision, Using Clamp Circumcision, Surgical Excision Circumcision, Older Than 28 Days of Age Unlisted Laparoscopic Procedure, Testis Unlisted laparoscopic Procedure, Spermatic Cord Unlisted Procedure, Male Genital System Plastic Repair, Introitus Clitoroplasty for Intersex State Construction of Artificial Vagina, Without Graft Construct Vagina With Graft Endometrial Ablation, Thermal, Without Hysteroscopic Guidance Unlisted Laparoscopy Procedure, Uterus Unlisted Hysteroscopy Procedure, Uterus Unlisted Laparoscopy Procedure, Oviduct, Ovary Transposition Ovary Unlisted Procedure, Female Genital System Vaginal, Delivery Only Vaginal, Delivery Including Postpartum Care Multifetal Pregnancy Reduction(s) (MPR) Unlisted Fetal Invasive Procedure, Including Ultrasound Unlisted Laparoscopic Procedure, Maternity Care & Delivery Unlisted Procedure, Maternity Care & Delivery Unlisted Laparoscopic Procedure, Endocrine Unlisted Procedure, Endocrine Revised Oct 2017 Page 7 of 12 Physician Services
8 64999 Unlisted Procedure, Nervous System Unlisted Procedure, Anterior Segment of Eye Unlisted Procedure, Posterior Segment of Eye Unlisted Procedure, Extraocular Muscles Unlisted Procedure, Orbit Eye Repair Of Blepharoptosis; Frontalis Muscle Technique With Suture Or Other Material Repair Of Blepharoptosis; Frontalis Muscle Technique With Autologous Fascial Sling Repair Of Blepharoptosis; (Tarso) Levator Resection Or Advancement, Internal Approach Repair Of Blepharoptosis; (Tarso) Levator Resection Or Advancement, External Approach Repair Of Blepharoptosis; Superior Rectus Technique With Fascial Sling Repair Of Blepharoptosis; Conjunctivo-Tarso-Muller's Muscle-Levator Resection Reduction of Overcorrection of Ptosis Correction of Lid Retraction Unlisted Procedure, Eyelids Unlisted Procedure, Conjunctivia Unlisted Procedure, Lacrimal System Otoplasty, Protruding Ears Unlisted Procedure, External Ear Implantation or Replacement of Electromagnetic Bone Conduction Revised Oct 2017 Page 8 of 12 Physician Services
9 Hearing Device Remove/Repair of Electromagnetic Bone Conduction Hearing Device Implantation, Osseointegrated Implant, Temporal Bone, With Percutaneous Attachment to External Speech Processor/Cochlear Without Mastoidectomy Implantation, Osseointegrated Implant, Temporal Bone, With Percutaneous Attachment To External Speech Processor/Cochlear With Mastoidectomy Replacement (Including Removal of Existing Device), Osseointegrated Implant, Temporal Bone, With Percutaneous Attachment to External Speech Processor/Cochlear Stimulator; Without Mastoidectomy Unlisted Procedure, Temporal Bone, Middle Fossa Cochlear Device Implantation With or Without Masteoidectomy Unlisted Procedure, Inner Ear Temporal Bone Surgery Unlisted Fluoroscopic Procedure Unlisted Computed Tomography Procedure Unlisted Magnetic Resonance Procedure Unlisted Diagnostic Radiographic Procedure Unlisted Procedure, Therapeutic Treatment Planning External Radiation Dosimetry Radiation Therapy Management Radium/Radioisotope Therapy Endocrine Nuclear Procedure Revised Oct 2017 Page 9 of 12 Physician Services
10 78199 Blood/ Lymph Nuclear Exam GI Nuclear Procedure Musculoskeletal Nuclear Exam Cardiovascular Nuclear Exam Respiratory Nuclear Exam PET Brain Metabolic Evaluation PET Brain Perfusion Evaluation Nervous System Nuclear Exam Genitourinary Nuclear Exam Nuclear Diagnostic Exam Nuclear Medicine Therapy Microbiology Procedure Immune Globulin Vaccine/Toxoid Psychiatric Service/Therapy Unlisted Dialysis Procedure GI Tract Capsule Endoscopy Gastroenterology Procedure Eye Service or Procedure ENT Procedure Service Transesophageal Echocardiography (TEE) Unlisted Cardiovascular Service or Procedure Non Invasive Vascular Diagnostic Studies Procedure Pediatric Home Apnea Monitoring Event Revised Oct 2017 Page 10 of 12 Physician Services
11 94799 Unlisted Pulmonary Service or Procedure Allergy Immunology Services Visual Evoked Potential Test Neurological Procedure Therapeutic, Prophylactic, and Diagnostic Injections and Infusions Unlisted Chemotherapy Procedure Dermatological Procedure Unlisted Modality Unlisted Therapeutic Procedure Unlisted Physical Medicine/Rehabilitation Service or Procedure Other Medicine Services and Procedures Office or Other Outpatient Visit, New Patient Office or Other Outpatient Visit, New Patient, Expanded Problems Office or Other Outpatient Visit, New Patient, Moderate Severity Problems Unlisted Preventive Medicine Service A4641 Radiopharmaceutical, Diagnostic, Not Otherwise Classified A9600 Strontium sr-89 Chloride, Therapeutic A9699 Radiopharmaceutical, Therapeutic, Not Otherwise Classified J0585 Injection, Onabotulinumtoxina, 1 Unit L8603 Injectable Bulking Agent, Collagen Implant, Urinary Tract, 2.5 Ml Syringe L8606 Injectable Bulking Agent, Synthetic Implant, Urinary Tract, 1 Ml Syringe Q4112 Cymetra injectable, 1cc Revised Oct 2017 Page 11 of 12 Physician Services
12 Q4051 S2411 Splint Supplies Miscellaneous Fetoscopic Laser Therapy for Treatment of Twin To Twin Transfusion Syndrome Ultrasound, Pregnant Uterus Ultrasound, Pregnant Uterus, Re-Evaluation Ultrasound, Pregnant Uterus, Transvaginal Fetal Biophysical Profile, Non Stress Test Fetal Biophysical Profile, Without Stress Test Ultrasound, Transvaginal Saline Infusion Sonohysterography Ultrasound, Pelvic, Non Obsteric, Complete Ultrasound, Pelvic, Non Obsteric, Limited or Follow Up Unlisted Ultrasound Procedure Revised Oct 2017 Page 12 of 12 Physician Services
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