HAAD JAWDA Quality Performance monthly KPI Profile (specialized and general hospitals)

Transcription

1 HAAD JAWDA Quality Performance monthly KPI Profile (specialized and general hospitals) June 2017 Page 1 of 159

2 Executive Summary The Health Authority Abu Dhabi (HAAD) is the regulative body of the Healthcare Sector in the Emirate of Abu Dhabi and ensures excellence in Healthcare for the community by monitoring the health status of its population. The Emirate of Abu Dhabi is experiencing a substantial growth in the number of hospitals, centers and clinics. This is ranging from school clinics and mobile units to internationally renowned specialist and tertiary Academic centers. Although, access and quality of care has improved dramatically over the last couple of decades, mirroring the economic upturn and population boom of the Abu Dhabi Emirate, challenges remain in addressing further improvements. The main challenges that are presented with increasingly dynamic population include an aging population with increased expectation for treatment, utilization of technology and diverse workforce leading to increased complexity of healthcare provision in Abu Dhabi. All of this results in an increased and inherent risk to quality and patient safety. HAAD has developed dynamic and comprehensive quality framework in order to bring about improvements across the health sector. This guidance relates to the quality indicators that HAAD is mandating the monthly reporting against by the operating general and specialist hospitals in Abu Dhabi. The guidance sets out the full definition and method of calculation for patient safety and clinical effectiveness indicators. For enquiries about this guidance, please contact jawda@haad.ae This document is subject for review and therefore it is advisable to utilize online versions available on the HAAD website at all times. Published: June 2017, Version 3 Page 2 of 159

3 1. Contents Page No. Executive Summary 2 1. Contents 3 2. Introduction 4 3. Patient Safety and Clinical Effectiveness 5 4. Planning for data collection and submission 6 5. About this Guidance 7 6. Quality Indicators 8-60 Appendix Appendix A 1 CPT Operating Room Procedure Codes for for KPI Number QI Appendix A 2 ICD-10 Pneumonia Codes for KPI Number QI009 Table 4: Specific sites of an organ/ space SSI Appendix A 3 Excluded ICD10 CM Codes for QI 019 and QI020 Emergency and Elective primary Caesarian Section rate Appendix A 4; ICD 10 CM Codes for Present on Admission (POA); Page 3 of 159

4 2. Introduction 2.1 The Health Authority Abu Dhabi (HAAD) is the regulative body of the Healthcare Sector in the Emirate of Abu Dhabi and ensures excellence in Healthcare for the community by monitoring the health status of the population. HAAD is mandated: To achieve the highest standards in health curative, preventative and medical services and health insurance in the Emirate. To lay down the strategies, policies and plans, including future projects and extensions for the health sector in the Emirate, and to follow-up their implementation To apply the laws, rules, regulations and policies which are issued as they are related to its purposes and responsibilities, in addition to what is issued by the respective international and regional organizations in line with the development of the health sector. To follow up and monitor the operation of the health sectors, to achieve and exemplary Standard in the provision of health, curative, preventive and medicinal services and health insurance 2.2 HAAD defines the strategy for the health system, monitors and analyses the health status of the population and performance of the system. In addition, HAAD shapes the regulatory framework for the health system, inspects against regulations, enforce standards, and encourages adoption of world class best practices and performance targets by all healthcare service providers in the Emirate of Abu Dhabi. 2.3 HAAD also drives programs to increase awareness and adoption of healthy living standards among the residents of the Emirate of Abu Dhabi in addition to regulating scope of services, premiums and reimbursement rates of the health system in the Emirate of Abu Dhabi. 2.4 The Health System of the Emirate of Abu Dhabi is comprehensive, encompassing the full spectrum of health services and is accessible to all residents of Abu Dhabi. The system is driven towards excellence through continuous outcome Improvement culture and monitoring achievement of specified indicators. Providers of health services are independent, Predominately private and follow highest international quality standards. The system is financed through mandatory health insurance. In doing so HAAD will: Page 4 of 159

5 Drive structure, process and outcome improvements across health sector Put people first and champion their rights Focus on quality and act swiftly to eliminate poor quality of care Work with Stakeholders and apply fair processes. Gather information and utilize knowledge and expertise to improve care. Link the care to payment in a way that results in a continuous improvement and maximize the value of the care provided in Abu Dhabi. 3. Patient Safety and Clinical Effectiveness Patient safety is the discipline in the health care sector that applies safety science methods toward the goal of achieving a trustworthy system of health care delivery. Patient safety is also an attribute of health care systems; it minimizes the incidence and impact of, and maximizes recovery from, adverse events. Clinical effectiveness is the application of the best knowledge, derived from research, clinical experience and patient preferences to achieve optimum processes and outcomes of care for patients. The process involves a framework of informing, changing and monitoring practice Clinical effectiveness is about doing the right thing at the right time for the right patient and is concerned with demonstrating improvements in quality and performance. The right thing (evidence-based practice requires that decisions about health care are based on the best available, current, valid and reliable evidence) In the right way (developing a workforce that is skilled and competent to deliver the care required) At the right time (accessible services providing treatment when the patient needs them) In the right place (location of treatment/services). With the right outcome (clinical effectiveness/maximising health gain) Patient safety, clinical effectiveness and patient experience are recognized as the main pillars of quality in healthcare. In Abu Dhabi, the measurement of Patient safety, clinical effectiveness and patient experience data is intended to identify strengths and weaknesses of healthcare delivery, drive-quality improvement, inform regulation and promote patient choice. In addition to data on harm avoidance or success rates for Page 5 of 159

6 treatments, providers will be assessed on aspects of care such as dignity and respect, compassion and involvement in care decisions through patient satisfaction surveys. The inclusion of patient safety, clinical effectiveness and patient experience for quality performance is often justified on grounds of its intrinsic value. For example, clear information, empathic, two-way communication and respect for patients beliefs and concerns could lead to patients being more informed and involved in decision-making and create an environment where patients are more willing to disclose information. 4. Planning for data collection and submission In planning for data collection and submission Healthcare must adhere to reporting, definition and calculation requirements as set out in section 6 and the attached appendices. Healthcare providers must also consider the following: Nominate responsible data collection and quality leads(s). Ensure data collection leads are adequately skilled and resourced. Understand and identify what data is required, how it will be collected (sources) and when it will be collected. Create a data collection plan. Ensure adequate data collection systems and tools are in place. Maintain accurate and reliable data collection methodology. Data collation, cleansing and analysis for reliability and accuracy. Back up and protect data integrity. Have in place a data checklist before submission. Submit data on time and ensure validity. Review and feedback data findings to the respective teams in order to promote performance improvement. Failing to submit valid data will be in breach of the licensing condition and could result in fines being applied, penalties associated with performance or revoke of license. Page 6 of 159

7 When needed, documentation and tracks will be provided instantly to HAAD, or their representative, to assure HAAD that all dues processes are being followed in collecting, analyzing, validating and submitting your performance 5. About this Guidance 3.1 This guidance sets out the Patient Safety and Clinical Effectiveness reporting requirements so as to ensure High quality and safety of healthcare services offered to patients in the Emirate of Abu Dhabi. The guidance sets out the definitions, parameters and frequency by which JAWDA Quality indicators will be measured and submitted to HAAD and will ensure Healthcare Providers provide safe, effective and high quality services. Q. Who is this guidance for? All HAAD Licensed Healthcare general and specialist Hospital Providers in the Emirate of Abu Dhabi Q. How do I follow this guidance? Each Hospital will nominate one member of staff to coordinate, collect, quality control, monitor and report relevant Inpatient data as per communicated dates. The nominated healthcare facility lead must in the first instance their contact details (if different from previous submission) to JAWDA@haad.ae and submit the required monthly quality performance indicators through Online Portal. Q. What are the Regulation related to this guidance? Legislation establishing the Health Sector As per Circular CEO 38/12 issued August 5th 2012 this guidance applies to all HAAD Licensed Hospital Healthcare Facilities in the Emirate of Abu Dhabi in accordance with the requirements set out in this Standard. Page 7 of 159

8 Type: Quality Indicator Indicator Number: QI001 KPI Description (title): Domain Count of procedures involving wrong patient or wrong body parts Patient Safety Sub-Domain Adverse Events (AE) and Sentinel events Definition: Count of sentinel events involving wrong patient or wrong body part in a set period Count of sentinel events due to wrong patient or wrong body part in a set period For the purpose of calculating this indicator, we are using the following abstract from HAAD standards on reporting sentinel events: Calculation: Sentinel Event: Any unanticipated adverse event in a healthcare setting resulting in death or serious physical or psychological injury to a patient or patients, not arising from the natural course of the patient's illness, including as defined by already published HAAD standards as: 1. A patient fall that results in death or major permanent loss of function as a direct result of the injuries sustained in the fall. 2. Any intra-partum (related to the birth process) maternal death. 3. Any peri-natal death unrelated to a congenital condition in an infant having a birth weight greater than 2,000 grams. 4. Discharge of an infant to the wrong family. 5. Haemolytic transfusion reaction involving administration of blood or blood products having major blood group incompatibilities. 6. Prolonged fluoroscopy with cumulative dose >1500 rads to a single field or any delivery of radiotherapy to the wrong body region or >25% above the planned radiotherapy dose. 7. Severe neonatal hyperbilirubinemia (bilirubin >30 milligrams/decil. 8. Suicide of any patient or within 72 hours of inpatient discharge. 9. Surgery on the wrong patient or wrong body part (all events of surgery on the wrong patient or wrong body part are Page 8 of 159

9 reviewable under the policy, regardless of the magnitude of the procedure or the outcome.). 10. Unanticipated death of a full-term infant. 11. Unintended retention of a foreign object in a patient after surgery or other procedure. 12. Rape or physical assault of a patient Reporting Frequency: Monthly Unit of Measure: International comparison if available Desired direction: Count OECD Healthcare quality Indicators, AHRQ quality indicators, CQC intelligent reporting tool of UK Lower is better Notes for all providers Data sources and guidance: - Hospital internal adverse event and incident reporting system - See provided guidance on reporting and categorization Page 9 of 159

10 Type: Quality Indicator Indicator Number: QI002 KPI Description (title): Domain Count of incidents where Haemolytic blood transfusion reactions have occurred due to ABO incompatibility Patient Safety Sub-Domain Adverse Events (AE) and Sentinel events Definition: Count of Haemolytic blood transfusion reactions that resulted from ABO incompatibility in a set period Count of number of sentinel events where Haemolytic blood transfusion reaction happened due to ABO incompatibility in a set period. Haemolytic blood transfusion reactions ICD-10 CM Codes; T80.30XA,T80.30XD,T80.30XS,T80.310A,T80.310D,T80.310S, T80.311A,T80.311D,T80.311S,T80.319A,T80.319D, T80.319S,T80.39XA,T80.39XD,T80.39XS For the purpose of calculating this indicator, we are using the following abstract from HAAD standards on reporting sentinel events: Calculation: Sentinel Event: Any unanticipated adverse event in a healthcare setting resulting in death or serious physical or psychological injury to a patient or patients, not arising from the natural course of the patient's illness, including as defined by already published HAAD standards as: 1. A patient fall that results in death or major permanent loss of function as a direct result of the injuries sustained in the fall. 2. Any intra-partum (related to the birth process) maternal death. 3. Any peri-natal death unrelated to a congenital condition in an infant having a birth weight greater than 2,000 grams. 4. Discharge of an infant to the wrong family. 5. Haemolytic transfusion reaction involving administration of blood or blood products having major blood group incompatibilities. 6. Prolonged fluoroscopy with cumulative dose >1500 rads to a single field or any delivery of radiotherapy to the wrong body region or >25% above the planned radiotherapy dose. Page 10 of 159

11 7. Severe neonatal hyperbilirubinemia (bilirubin >30 milligrams/decil. 8. Suicide of any patient or within 72 hours of inpatient discharge. 9. Surgery on the wrong patient or wrong body part (all events of surgery on the wrong patient or wrong body part are reviewable under the policy, regardless of the magnitude of the procedure or the outcome.). 10. Unanticipated death of a full-term infant. 11. Unintended retention of a foreign object in a patient after surgery or other procedure. 12. Rape or physical assault of a patient Reporting Frequency: Monthly Unit of Measure: International comparison if available Count OECD Healthcare quality Indicators, AHRQ quality indicators, CQC intelligent reporting tool of UK Desired direction: Data sources and guidance: Lower is better Notes for all providers - Hospital internal adverse event and incident reporting system - See provided guidance on reporting and categorization - Please refer to section 5 for further guidance Page 11 of 159

12 Type: Quality Indicator Indicator Number: QI003 KPI Description (title): Domain Rate of selected reported Adverse Incidents (level 1-3 as in the attached guidance) out of all persons bed days/1000 Patient Safety Sub-Domain Adverse Events (AE) and Sentinel events Definition: Rate of low rank reported Adverse Incidents (Level 1-3) per all persons bed days in a set period/1000 Numerator: number of all reported medical or nonmedical Adverse Incidents (level 1-3) in a set period An adverse event as an injury related to medical or nonmedical management, in contrast to complications of disease. Medical management includes all aspects of care, including diagnosis and treatment, failure to diagnose or treat, and the systems and equipment used to deliver care. Some definition to be used in reporting on this standard are: Calculation: Adverse Incidents: An incident can be at the following four levels: 1. Level One: A reportable circumstance is a situation in which there was significant potential for harm, but no incident occurred (i.e. a busy intensive care unit remaining grossly understaffed for an entire shift, or taking a defibrillator to an emergency and discovery it does not work although it was not needed, lacking roof). 2. Level Two: A near miss is an incident that did not reach the patient (e.g., a unit of blood being connected to the wrong patient s intravenous line, but the error was detected before the infusion started). 3. Level Three: A no harm incident is one in which an event reached a patient but no discernable harm resulted (e.g., if the unit of blood was infused, but was not incompatible. 4. Level Four: A harmful incident (adverse event) is an incident that results in harm to a patient (e.g., the wrong unit of blood was infused and the patient died from a Haemolytic reaction). Harm implies impairment of structure or function of the body and/or any deleterious effect arising there from, including disease, injury, suffering, disability and death, and may be physical, social or psychological. Page 12 of 159

13 Denominator: number of all (Inpatient and Day Procedure) Patients (only DRG Patients) in that set period Calculation: Formula is calculated as rate per 1000 bed-days. Denominator should calculated using only inpatient & day surgery Reporting Frequency: Monthly Unit of Measure: International comparison if available Desired direction: Rate per 1,000 bed days CQC of UK with modification following discussion with local experts and taking local culture into consideration Higher is better Notes for all providers Data sources and guidance: - Hospital internal adverse event and incident reporting system - See provided guidance on reporting and categorization Page 13 of 159

14 Type: Quality Indicator Indicator Number: QI004 KPI Description (title): Domain Sub-Domain Definition: Rate of Surgical Site Infection (SSI) for selected procedures Patient Safety Complication Rate of number of patients having SSI within 30 days of Abdominal Hysterectomy and within 90 days of Hip or Knee Prosthesis per 100 operative procedures to be counted as part of the readmission month. Numerator: Number of all SSI identified within 30 days for all patients undergoing Abdominal Hysterectomy (HYST) AND within 90 days for all patients undergoing Hip (HPRO) and Knee Prosthesis (KPRO) procedures confirmed in the reporting month period. Note: days is calculated following original intervention (day 1 is day of procedure) SSI included in the numerator is based on the date of procedure, not the date of event Calculation: Numerator Inclusions and Exclusions: SSI identified during active surveillance for all patients (inpatients and outpatients) undergoing selected surgical for: o Abdominal Hysterectomy within 30 days and o Hip and Knee Prosthesis within 90 days Includes SSIs identified on admission, readmission & via post-discharge surveillance within days of the original intervention (day 1 is day of procedure) (Note: Date of event (infection date) must be within 30 days or 90 days of the date of procedure, depending on the operative procedure category) Infections reported for procedures done at the hospital by the external physicians. SSI could be presented as: o Superficial incisional SSI, affecting the skin and subcutaneous tissue. Infections in this case may be indicated by localized (Celsian) signs such as redness, pain, heat or swelling at the site of the incision or by the drainage of pus. Must meet the following criteria: Page 14 of 159

15 a) Infection occurs within 30 days after any NHSN operative procedure (where day 1 = the procedure date), including those coded as OTH b) And involves only skin and subcutaneous tissue of the incision c) And patient has at least one of the following: a) Purulent drainage from the superficial incision. b) Organisms isolated from an asepticallyobtained culture of fluid or tissue from the superficial incision or subcutaneous tissue. c) Superficial incision that is deliberately opened by a surgeon, attending physician or other designee and is culture positive or not cultured and patient has at least one of the following signs or symptoms: pain or tenderness; localized swelling; redness; or heat. A culture negative finding does not meet this criterion. d) Diagnosis of a superficial incisional SSI by the surgeon or attending physician** or other designee. Comments : There are two specific types of superficial incisional SSIs: a) Superficial Incisional Primary (SIP) a superficial incisional SSI that is identified in the primary incision in a patient that has had an operation with one or more incisions (e.g., C-section incision or chest incision for CBGB). b) Superficial Incisional Secondary (SIS) a superficial incisional SSI that is identified in the secondary incision in a patient that has had an operation with more than one incision (e.g., donor site incision for CBGB). REPORTING INSTRUCTIONS for Superficial SSI The following do not qualify as criteria for meeting the definition of superficial SSI: a) A stitch abscess alone (minimal inflammation and discharge confined to the points of suture penetration) b) A localized stab wound or pin site infection. While it would be considered either a skin (SKIN) or soft tissue (ST) infection, depending on its depth, it is not reportable under Page 15 of 159

16 this guidance. Note: a laparoscopic trocar site for an NHSN operative procedure is not considered a stab wound. c) Diagnosis/treatment of cellulitis (redness/warmth/swelling), by itself, does not meet criterion for superficial incisional SSI. An incision that is draining or culture (+) is not considered a cellulitis. d) Circumcision is not an NHSN operative procedure. An infected circumcision site in newborns is classified as CIRC and is not reportable under this module. e) An infected burn wound is classified as BURN and is not reportable under this module. o Deep incisional SSI: Must meet the following criteria: a) Infection occurs within 30 or 90 days after the operative procedure (where day 1 = the procedure date). b) And involves deep soft tissues of the incision (e.g., fascial and muscle layers) c) And patient has at least one of the following: a) Purulent drainage from the deep incision. b) A deep incision that spontaneously dehisces or is deliberately opened or aspirated by a surgeon, attending physician or other designee and is culturepositive or not cultured and patient has at least one of the following signs or symptoms: fever (>38 C); localized pain or tenderness. A culture-negative finding does not meet this criterion. c) An abscess or other evidence of infection involving the deep incision that is detected on gross anatomical, or by histopathological examination or imaging test. Comments: There are two specific types of deep incisional SSIs: a) Deep Incisional Primary (DIP) a deep incisional SSI that is identified in a primary incision in a patient that has had an operation with one or more incisions (e.g., C- section incision or chest incision for CBGB) b) Deep Incisional Secondary (DIS) a deep incisional SSI that is identified in the Page 16 of 159

17 secondary incision in a patient that has had an operation with more than one incision (e.g., donor site incision for CBGB) o Organ/Spaces SSI (for the purposes of first phase quality monitoring by HAAD; Currently, this type of infection is not included) Must meet the following criteria: a) Infection occurs within 30 or 90 days after the operative procedure (where day 1 = the procedure date). b) And infection involves any part of the body fascial/muscle layers, excluding the skin incision deeper than the fascia, or muscle layers, that is opened or manipulated during the operative procedure c) And patient has at least one of the following: - Purulent drainage from a drain that is placed into the organ/space (e.g., closed suction drainage system, open drain, T- tube drain, CT guided drainage) - Organisms isolated from an asepticallyobtained culture of fluid or tissue in the organ/space - An abscess or other evidence of infection involving the organ/space that is detected on gross anatomical, during invasive procedure, or by histopathological examination or imaging test d) And meets at least one criterion for a specific organ/space infection site as defined by CDC in their guidance from January 2015 Available on: page 9-17 Denominator: Total number of all patients undergoing Abdominal Hysterectomy for the previous month (e.g. Had infection in June for the admission of May ) Hip Prosthesis and Knee Prosthesis in that facility for the previous three months (e.g. Had infection in June for the admission of March, April and May ). Denominator Inclusions: All surgical patients (inpatients and outpatients) for whom operative procedure was performed including following ICD-10-CM Codes and/or CPT codes:(primary and Secondary Diagnosis Codes); Page 17 of 159

18 o Abdominal Hysterectomy CPT Codes (58150, 58152, 58180, 58200, 58210, 58541, 58542, 58543, , 58570, 58571, 58572, 58573, 58951, , 58956)) o Knee Prosthesis CPT Codes (27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447, 27486, 27487) o Hip Prosthesis CPT Codes (27125, 27130, 27132, 27134, 27137, 27138, 27236, 27299) Definition of an operative procedure: An operative procedure is a procedure o o o That is stated below Takes place during an operation where at least one incision (including laparoscopic approach) is made through the skin or mucous membrane, or reoperation via an incision that was left open during a prior operative procedure and Takes place in an operating room which may include an operating room, C-section room, interventional radiology room, or a cardiac catheterization lab. Settings: Reporting of surgical patients will occur in any inpatient and/or outpatient setting where the selected operative procedure(s) are performed. An SSI will be associated with a particular operative procedure and the facility in which that procedure was performed. Denominator Exclusions: Procedures during which the patient expired in the OR Patients with an ASA score of 6 Exclude stitch abscess, cellulitis (redness/warmth/swelling), localized stab wound, circumcision, episiotomy or infected burn wounds Reporting Frequency: Unit of Measure: International comparison if available Desired direction: Data sources and guidance: Calculation: [Numerator] / [Denominator] x 100 Monthly Rate per 100 surgical procedures OECD, AHRQ and HAAD standards Lower is better Notes for all providers - Captured by infection control team/ nursing as part of regular surveillance activities and infection control documentation. - Patient medical record. Page 18 of 159

19 Type: Quality Indicator Indicator Number: QI005 KPI Description (title): Domain Rate of Perioperative Pulmonary Embolism or Deep Vein Thrombosis Patient Safety Sub-Domain Definition: Complication Perioperative pulmonary embolism or deep vein thrombosis (secondary diagnosis) per 1,000 surgical discharges for patients ages 16 years and older, post-operative period to be calculated limited to 30 days after surgery Numerator: All adults (16 years of age and older) patients (among cases meeting the inclusion and exclusion rules for the denominator) with a secondary ICD-10-CM Diagnosis Codes for Deep Vein Thrombosis or Pulmonary Embolism. Calculation: Codes: :(Primary and Secondary Diagnosis Codes) Secondary ICD-10-CM Diagnosis Codes, as follows: Deep Vein Thrombosis: ICD 10 CM Codes: I80.10, I80.11, I80.12, I80.13, I80.201, I80.202, I80.203, I80.209, I80.3, I80.211, I80.212, I80.213, I80.219, I80.221, I80.222, I80.223, I80.229, I80.231, I80.232, I80.233, I80.239, I80.291, I80.292, I80.293, I80.299, I82.401, I82.402, I82.403, I82.409, I82.411, I82.412, I82.413, I82.419, I82.421, I82.422, I82.423, I82.429, I82.431, I82.432, I82.433, I82.439, I82.441, I82.442, I82.443, I82.449, I82.491, I82.492, I82.493, I82.499, I82.4Y1, I82.4Y2, I82.4Y3, I82.4Y9, I82.4Z1, I82.4Z2, I82.4Z3, I82.4Z9, I82.601, I82.602, I82.603, I82.609, I82.621, I82.622, I82.623, I82.629, I80.3, I80.8, I80.9 Pulmonary Embolism: ICD 10 CM Codes: T80.0XXA, T80.0XXD, T80.0XXS, T81.72XA, T81.72XD, T81.72XS, T82.817A, T82.817D, T82.817S, T82.818A, T82.818D, T82.818S,, I26.02, I26.09, I26.90, I26.92, I26.99 CPT for the DVT and pulmonary cath. procedures; 01522, 34001, 34051, 34101, 34111, 34151, 34201, 34203, 34401, 34421, 34451, 34471, 34490, 78457, 78458, 37184, 37185, 37186, 37187, 37188, 37201, Denominator: all adult patients undergoing surgical intervention in that set period. Total Number of discharged surgical patients ages Page 19 of 159

20 16 years and older, with any listed CPT procedures codes for and operating room procedure specified in Appendix A - CPT Operating Room Procedure Codes Codes: Denominator Inclusions: - Patients ages 16 years and older - Discharged Patients with surgical procedures listed in Appendix A 1 CPT Operating Room Procedure Codes Denominator Exclusions: - Patients with a principal ICD-10-CM Diagnosis Code (or secondary diagnosis present on admission) for: o Deep Vein Thrombosis (please see above) o Pulmonary Embolism (please see above) Patients where s procedure for interruption of vena cava occurs before or on the same date as the first operating room procedure (CPT Procedure Code: Interruption of Vena Cava) Reporting Frequency: Monthly Unit of Measure: International comparison if available Rate per 1,000 surgical discharges Mainly using source of AHRQ QI Version 4.5, Patient Safety Indicators #12, Technical Specifications, Perioperative Pulmonary Embolism or Deep Vein Thrombosis Rate Also using OECD, CQC of UK with modification following discussion with local experts and taking local culture into consideration. Desired direction: Data sources and guidance: Lower is better Notes for all providers - Hospital internal adverse event system and complication log - Based on list of discharged patients with specific ICD10 Diagnosis and Procedure codes - Patient medical record. Page 20 of 159

21 Type: Quality Indicator Indicator Number: QI006 KPI Description (title): Domain Count of healthcare acquired MDRO infection/colonization in adult in all inpatients Patient Safety Sub-Domain Complication Definition: Count of hospital-acquired MDRO cases in all patients in a set period (Defined by HAAD policy on infection control HAAD/HSED/ST/0017/HS_EHSMS and included in the attached guidance) within set period ( monthly basis) Indicator: Count of MDRO acquired while in the hospital. To include in the reporting patients/cases, colonized or infected with MDRO (Multi Drug Resistant Organisms), which include: Calculation: MDRO ICD-10 Codes Z16.24,Z16.35 KPI MDRO-01 Methicillin-resistant Staphylococcus aureus (MRSA): Number of patients colonized or infected with MRSA, MRSA ICD-10 Codes; A41.02,A49.02,B95.62,J15.212,Z KPI MDRO-02 Clostridium difficile (CDIFF): Number of patients colonized or infected with Clostridium difficile CDIFF ICD-10 Codes A04.7,A41.4,A48.0, B96.89, P36.5 KPI MDRO-03 Vancomycin-resistant Enterococci (VRE): Number of patients colonized or infected with VRE VRE ICD-10 Codes B95.2,Z16.21 KPI MDRO-04 Extended spectrum beta-lactamase producing Escherichia coli and Klebsiella spp. (ESBL): Number of patients colonized or infected with ESBL E. coli and/or Klebsiella oxytoca and Klebsiella pneumonia. (ESBL) ICD-10 Codes B96.1,B96.20,B96.21,B96.22,B96.23, B96.29, Z16.12, KPI MDRO-05 Multi-drug/Extensively-drug resistant Mycobacterium tuberculosis (MDR-Tb/XDR-Tb): Number of patients with active MDR-Tb/XDRTb. (MDR-Tb/XDRTb.) ICD-10 Codes ;A15.0,A15.4,A15.5, A15.6 A15.7, A15.8, A15.9, A17.0, A17.1, A17.81, A17.82, A17.83, A17.89, A17.9, A18.01, A18.02, A18.03, A18.09, A18.10, A18.11, A18.12, A18.13, A18.14, A18.15, A18.16, A18.17, A18.18, A18.2, A18.31, A18.32, A18.39, A18.4, A18.50, A18.51, A18.52, A18.53, A18.54, A18.59, A18.6, A18.7, A18.81, A18.82, A18.83, A18.84, A18.85, A18.89, A19.0, A19.1, A19.2, A19.8, A19.9 Page 21 of 159

22 Inclusions: All patients Patient admitted in hospital (Inpatients) All Inpatient Wards (Excluding Inpatient Rehabilitation Facilities and Inpatient Psychiatric Facilities) Healthcare facility-onset (HO): Positive Laboratory results collected >3 days after admission Positive Laboratory results collected for Clinical Purpose (Diagnosis and Treatments) All Specimen types All non-duplicated Positive Lab test results: o First positive lab test result that occurred during this admission (encounter) AND o Same patient and location, following laboratory result of a previous C. difficile toxin-positive or MDRO isolate from blood within the past two weeks [14 days]. Exclusion: Community-Onset (CO): Positive Lab Tests results for collected specimens on an inpatient location 3 days after admission to the facility (i.e., days 1, 2 or 3 of admission) Positive Lab Tests results for collected specimens in an outpatient location Positive Lab Tests results for collected specimens in an Inpatient Rehabilitation Facility and Inpatient Psychiatric Facility Duplicated Positive Lab Test results (Positive Lab Tests results for same patient with the same MDRO in 2 weeks) Active Surveillance Testing (AST) Duplicate MDRO isolate from any specimen (except C. difficile toxinpositive or MDRO isolate from blood within the past two weeks [14 days]) per patient and location. Reporting Frequency: Unit of Measure: International comparison if available Desired direction: Monthly Count Indicators are based on US CDC NHSN MDRO/CDI Module: modified (per bed days removed initially) OECD Quality indicators, AHRQ, CQC Lower is better Notes for all providers Page 22 of 159

23 Data sources and guidance: - Lab test results of all specimen - Captured by infection control team/ nursing as part of regular surveillance activities and infection control documentation. - Patient medical record. Page 23 of 159

24 Type: Quality Indicator Indicator Number: QI007 KPI Description (title): Domain Sub-Domain Definition: Rate of unplanned readmission for planned Hernia Repair Effectiveness Readmission Rate of unplanned emergency readmission for adult patients (16 years and over) undergoing a planned Hernia Repair of all types using all surgical methods within 30 days of discharge from the indexed (the planned hernia repair admission) hospitalization. All related and Unrelated readmissions to be included. Numerator: number of adult patients (more than or equal to 16 years of age) with unplanned readmission to any facility within 30 days of being discharge from hospital for having a planned Hernia Repair (all types) Denominator: number of finished adult planned Hernia Repair episodes for the previous month done by a specific providers Calculation: Reporting Frequency: Unit of Measure: International comparison if available Desired direction: Data sources and guidance: Codes: (Primary and Secondary Diagnosis Codes) Numerator: Number of cases from denominator 16+ admitted as in emergency within 30 days of discharge date of the indexed hospitalization Denominator: Hernia Repair CPT Code; (49505,49520,49525,49540,49550,49555,49560,49565,49568,49570,49580, 49585,49650,49651,49652,49656,49659) Exclusions; 49507, 49521, 49553, 49557, 49561, 49566, 49572, 49582, 49587, 49653, 49654, Monthly Rate per 100 Hernia Repair admissions Developed locally by modifying similar indicators used by AHRQ, OECD and CQC Lower is better Notes for all providers - Mortality and Morbidity record - Hospital internal adverse event and incident report system - Hospital patient data source Page 24 of 159

25 Type: Quality Indicator Indicator Number: QI008 KPI Description (title): Domain Rate of unplanned readmission for planned primary Knee Replacement Effectiveness Sub-Domain Readmission Definition: Calculation: Reporting Frequency: Rate of unplanned emergency readmission for adult patients (16 years and over) undergoing a planned Knee Replacement of all types using all surgical methods within 30 days of discharge from the indexed (the planned Knee Replacement admission) hospitalization. All related and Unrelated readmissions to be included. Numerator: number of adult patients with unplanned readmission to any facilities within 30 days following discharge from hospital for having Knee Replacement (all types) Denominator: number of adult patients with planned primary Knee Replacements episodes for the previous month. Codes:(Primary and Secondary Diagnosis Codes) Numerator: Number of cases from denominator admitted as in emergency within 30 days of discharge date Denominator: : Knee replacement CPT Code (27437, 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447, 27486, 27486, 27488) Monthly Unit of Measure: International comparison if available Desired direction: Data sources and guidance: Rate per 100 Knee Replacement admissions AHRQ Lower is better Notes for all providers - Hospital internal adverse event and incident reporting system - Mortality and morbidity record - Hospital patient data and record Page 25 of 159

26 Type: Quality Indicator Indicator Number: QI009 KPI Description (title): Rate of unplanned readmission for unplanned Pneumonia Domain Effectiveness Sub-Domain Readmission Definition: Rate of unplanned emergency readmission for adult patients (16 years and over) with Pneumonia within 30 days of discharge from the indexed hospitalization for having emergency Pneumonia. All related and Unrelated cases to be included Numerator: Number of unplanned (related and Unrelated) admission of all adult patients to any facilities who were discharged from hospital (with unplanned admission with pneumonia) in the previous 30 days (mapped against primary facility) Denominator: Number of adult patients unplanned admissions with finished episodes of Pneumonia episodes for the previous month Calculation: Reporting Frequency: Unit of Measure: International comparison if available Desired direction: Codes: :(Primary and Secondary Diagnosis Codes) Numerator: Number of adult patients from denominator admitted as emergency within 30 days of discharge date Denominator: Adult patients discharged with Pneumonia ICD-10-CM (Primary and Secondary diagnosis ) Codes specified in Appendix A (labelled Appendix A- 2); ICD-10-CM Codes; A15.0, A37.91, A48.1, J09.X1, J10.00, J10.08, J11.00, J11.08, J12.0, J12.1, J12.2, J12.81, J12.89, J12.9, J13, J14, J15.0, J15.1, J15.3,J15.4, J15.20, J15.211, J15.212, J15.29, J15.3, J15.4, J15.5, J15.6, J15.7, J15.8, J15.9, J16.0, J16.8, J17, J18.0, J18.1, J18.2, J18.8, J18.9, J84.111, J84.113, J84.116, J84.117, J84.2, J85.1, J95.851, J95.4 Monthly Rate per 100 Pneumonia admissions Developed locally by modifying similar indicators used by AHRQ, OECD and CQC Lower is better Page 26 of 159

27 Notes for all providers Data sources and guidance: -Hospital internal adverse event and incident reporting system. -Mortality and morbidity record -Hospital patient data source Page 27 of 159

28 Type: Quality Indicator Indicator Number: QI010 KPI Description (title): Domain Rate of unplanned readmission for unplanned Urinary Tract Infection (UTI) Effectiveness Sub-Domain Definition: Readmission Rate of unplanned emergency readmission for adult patients (16 years and over) with unplanned UTI within 30 days of discharge from the indexed hospitalization for having emergency UTI. All related and Unrelated readmissions to be included. Numerator: number of unplanned admissions of all adult patients to any facilities who were discharged from hospital (with unplanned admission with UTI) in the previous 30 days (mapped against primary facility) Denominator: number of all adult admissions with finished episodes of UTI for the previous month. Calculation: Codes: :(Primary and Secondary Diagnosis Codes) Numerator: Number of cases from denominator admitted as in emergency within 30 days of discharge date Denominator: ICD 10 CM Code : N39.0, N30.00, N30.01, N30.30, N30.31, N30.40, N30.41,N30.80,N30.81,N30.90,N30.91,N13.6,N28.85,N28.86,A18.13,N33,N34.0, N34.1,N34.2,A18.10,A18.11,A18.12,A18.13,A54.00,A54.01, A54.1, A54.21, A56.00, A56.01,A59.03,A52.75,A52.76,B37.41, B37.49, N34.0,N34.1,N34.2, T83.51XA, T83.51XD, T83.51XS, T83.59XA, T83.59XD, T83.59XS, N15.1, N15.8, N15.9, N99.511, N99.521, N99.81 Exclusions; - Chronic UTI - Recurrent Pregnancy related UTI - ICD-10-CM Excluded codes; N11.0, N11.1, N11.8, N13.70, N13.71, N13.721, N13.722, N13.729, N13.731,N13.732, N13.739, N13.9, N30.10, N30.11, N30.20, N30.21,P37.5,P39.3,O03.38,O07.38,O03.88,O04.88,O08.83, O23.00,O23.01,O23.02, O23.03, O23.10, O23.11, O23.12, O23.13, O23.20,O23.21, O23.22, O23.23, O23.30, O23.31, O23.32, O23.33, O23.40, O23.41, O23.42, O23.43, O75.3, O86.20, O86.21, O86.22, O86.29 Reporting Frequency: Unit of Measure: Monthly Rate per 100 UTI admissions Page 28 of 159

29 International comparison if available Desired direction: Data sources and guidance: Developed locally by modifying similar indicators used by AHRQ, OECD and CQC Lower is better Notes for all providers - Hospital internal adverse event and incident reporting system. - Mortality and morbidity record - Hospital patient data source Page 29 of 159

30 Type: Quality Indicator KPI Description (title): Domain Sub-Domain Indicator Number: QI011 Count of Cardiopulmonary arrests outside critical care area in a given period Effectiveness Recovery Definition: Count of all patients cardiopulmonary arrest incidents that occurred outside critical care area within the specified period. Number of all cardiac arrests occurring outside critical care irrespective of outcome in the specific facility for the previous month Indicator: Number In-hospital inpatient cardiac/pulmonary arrests that occurred outside the critical care wards Cardiac arrests occurring ICD-10 CM Codes; R57.0,O03.36,O07.36, O03.86,O04.86,O08.81,O29.111,O29.112,O29.113, O29.119,O74.2,O89.1,I46.2,I46.8,I46.9,P Cardiac arrests occurring CPT Codes; Calculation: Reporting Frequency: Unit of Measure: International comparison if available Inclusions: Cardiac or respiratory arrests outside of critical care wards All inpatients: neonate, pediatric and adult Exclusions: Cardiac or respiratory arrests occurred in OR, ICU (critical care wards) and ED Cardiac or respiratory arrests occurred in outpatients or visitors Still births Patients that are prone to cardiac arrest but kept out of critical care due to clinical or palliative reasons.(e.g. ; patient with end stage cancer). Excluded ICD-10 CM Codes;; O36.4XX0,O36.4XX1, O36.4XX2,O36.4XX3,O36.4XX4,O36.4XX5,O36.4XX9, Z37.1,Z37.3,Z37.4,Z37.60,Z37.61,Z37.62,Z37.63, Z37.64, Z37.69, Z37.7,P95,I97.710,I97.711,I97.120,I Monthly Count Definition based on IHI literature available on: Page 30 of 159

31 /Pages/RapidResponseSystems.aspx modified to suit local culture and setting Desired direction: Data sources and guidance: Lower is better Notes for all providers - Data from telephone operator regarding activated code blue and code pink calls and CPR Record or a similar system. - Mortality and Morbidity Record Page 31 of 159

32 Type: Quality Indicator KPI Description (title): Domain Sub-Domain Definition: Indicator Number: QI012 Rate of Falls resulting in any injury per 1000 person bed days (patient days) Patient Safety Adverse Events (AE) and Sentinel events Falls resulting in any injury per 1000 all person bed days (Patient Days) (adverse event level 4) Numerator: Total number of patient falls resulting in injury (minor, moderate, major, or death) to the patient Inclusions: Inpatients falls with injury: minor, moderate, major, or death Exclusions: Inpatient falls, but no harm was evident Calculation: Denominator: Total number of all person bed day (patient days) the previous month Inclusions: Patients with finished episodes Exclusions: N/A Calculation: [numerator / denominator] x 1000 Reporting Frequency: Unit of Measure: International comparison if available Monthly Rate per 1,000 bed days (patient days) Developed locally by modifying similar indicators used by AHRQ, OECD and CQC following local discussion and taking local culture and setting into consideration Definition is based on NDNQI Glossary & Reference Guide to Clinical Indicators, 2014 Desired direction: Data sources and guidance: Lower is better Notes for all providers -Hospital internal adverse event and incident reporting system Page 32 of 159

33 Type: Quality Indicator Indicator Number: QI013 KPI Description (title): Domain Sub-Domain Definition: Calculation: Rate of hospital acquired or worsening Pressure Ulcers (Stage II and above) per 1000 person bed days (inpatient patient days) Patient Safety Adverse Events (AE) and Sentinel events Hospital Acquired or worsening Pressure Ulcers (Stage II and above) Rate per 1000 all person bed days (Inpatient patient-days) Numerator: Number of patients with hospital acquired pressure ulcer Stage II, III, IV, Unstageable or Deep Tissue Injury (DTI) hospital acquired or worsening Pressure Ulcers (Stage II and above) ICD- 1O CM Codes; L89.000, L89.002,L89.003,L89.004, L89.010,L89.012,L89.013,L89.014,L89.020, L89.022,L89.023,L89.024,L89.100,L89.102, L89.103,L89.104,L89.110,L89.112,L89.113, L89.114,L89.120,L89.122,L89.123,L89.124, L89.130,L89.132,L89.133,L89.134,L89.140, L89.142,L89.143,L89.144,L89.150,L89.152, L89.153,L89.154,L89.200,L89.202,L89.203, L89.204,L89.210,L89.212,L89.213,L89.214, L89.220,L89.222,L89.223,L89.224,L89.300, L89.302,L89.303,L89.304,L89.310,L89.312, L89.313,L89.314,L89.320,L89.322,L89.323, L89.324,L89.42,L89.43,L89.44,L89.45, L89.500, L89.502,L89.503,L89.504,L89.510,L89.512, L89.513,L89.514,L89.520,L89.522,L89.523, L89.524,L89.600,L89.602,L89.603,L89.604,L89.610,L89.612, L89.613,L89.614,L89.620,L89.622,L89.623,L89.624,L89.810, L89.812,L89.813,L89.814,L89.890,L89.892,L89.893, L89.894,L89.92,L89.93,L89.94,L89.95 Guide on stage is defined below; Category/Stage II: Partial thickness Partial thickness loss of dermis presenting as a shallow open ulcer withy a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising*. This Category/Stage should not be used to describe skin tears, tape burns, incontinence associated with dermatitits, maceration or excoriation. Page 33 of 159

34 *Bruising indicates deep tissue injury. Category/Stage III: Full thickness skin loss Full thickness skin loss. Subcutaneous fat may be visible but bone, tendon or muscle are not explosed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant Quick Reference Guide Prevention 8 adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage IV: Full thickness tissue loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often included undermining and tunneling. The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Category/Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis or osteitis likely to occur. Exposed bone/muscle is visible or directly papable. Inclusions: All Inpatients (Adult, Pediatric and Neonatal) Hospital Acquired Pressure Ulcers (not present or present but with lower a lower stage on admission to hospital). Exclusions: Patients with pressure ulcers present on admission, that stayed the same stage or improved following hospital stay Hospital Acquired Pressure Stage I (ICD- 10 CM Codes; L89.001, L89.011,L89.021,L89.101,L89.111, L89.121,L89.131,L89.141,L89.151, L89.201,L89.211,L89.221,L89.301,L89.311,L89.321, L89.41, L89.501,L89.511,L89.521,L89.601,L89.611, L89.621,L89.811,L89.891,L Day care patients Medical Management ( ICD-10 CM Code; Day care patients Procedures ( ICD-10 CM Code; Denominator: The total number of all person bed days (inpatient patient- days) in the previous month Calculation: [Numerator] / [Denominator] x 1000 Page 34 of 159

35 Reporting Frequency: Monthly Unit of Measure: International comparison if available Desired direction: Rate per 1000 bed days (patient days) CQC of UK with modification following discussion with local experts and taking local culture into consideration Lower is better Notes for all providers Data sources and guidance: - Manual Data Collection - Patient record or EMR (Medical Chart Review): Skin and Wound Assessment Chart- - Hospital internal adverse event system Page 35 of 159

36 Type: Quality Indicator KPI Description (title): Domain Sub-Domain Definition: Indicator Number: QI014 Rate of unplanned readmissions for unplanned Heart Failure Effectiveness Readmission Rate of all unplanned emergency (related and non-related) readmissions for adult patients (16 years and over) to any acute care hospital within 30-days of the date of discharge from the index heart failure (HF) emergency admission. Numerator: number of any unplanned adult admissions (regardless of admitting diagnosis) to any acute care hospital within a 30-day period from the date of discharge from the index heart failure (HF) admission. Denominator: number of unplanned adult patients admissions with primary and secondary diagnosis of heart failure episodes for the previous month Codes (Primary and Secondary Diagnosis Codes): Calculation: Reporting Frequency: Unit of Measure: International comparison if available Desired direction: Data sources and guidance: Denominator: Heart failure ICD-10-CM Codes; I50.1, I50.20, I50.21, I50.22, I50.23,I50.30, I50.31, I50.32, I50.33, I50.40, I50.41, I50.42, I50.43, I50.9,I02.0, I01.8,I09.81,I13.0,I13.2,I11.0,I97.130,I Inclusion Unplanned readmissions to any general or specialist hospital within a 30-day period from the date of discharge of the index heart failure (HF) admission. exclusion Admissions for patients who are discharged against medical advice (AMA) Admissions for patients having a principal diagnosis of HF during the index hospitalization and subsequently transferred to another acute care facility. Planned Readmissions Neonatal cardiac failure (ICD-10-CM Codes P29.0) Monthly Rate Per 100 patients HF admissions AHRQ readmission Lower is better Notes for all providers - Mortality and morbidity record - Hospital patient data source Page 36 of 159

37 Type: Quality Indicator KPI Description (title): Domain Sub-Domain Definition: Indicator Number: QI015 Rate of unplanned readmission for unplanned Appendectomy Effectiveness Readmission Rate of all unplanned emergency (related or non-related) readmission to any inpatient facility for adult patients (16 years and over) within 30 days of the date of discharge from hospital after undergoing an appendectomy of all types using all surgical methods. Numerator: number of adult patients (more than or equal to 16 years of age) with unplanned readmission to any facility within 30 days of being discharged from general or specialist hospital post emergency appendectomy (all types and all approaches) Denominator: number of finished adult emergency appendectomy over all approaches for the previous month Codes (Primary and Secondary Diagnosis Codes): Calculation: Reporting Frequency: Unit of Measure: International comparison if available Desired direction: Appendectomy CPT Codes; 44950, 44955, 44960, ICD-10CM Codes; K35.2,K35.3,K35.80,K35.89,K36,K37 Inclusion Unplanned readmissions to any acute care hospital within a 30-day period from the date of discharge from the appendectomy exclusion Planned Readmissions. Appendectomy for cancer cases. Pheochromocytome. Operation where appendectomy is part of a larger procedure e.g., Meckel s diverticulum, right hemicolectomy etc. Excluded ICD-10CM Codes C18.1,C74.00,C74.01, C74.02, C74.10, C74.11, C74.12, C74.90, C74.91, C74.92, C79.70, C79.71, C79.72, D09.3,D35.00,D35.01,D35.02 Monthly Rate Per 100 appendectomy admissions Developed locally by modifying similar indicators used by AHRQ, OECD and CQC Lower is better Notes for all providers Page 37 of 159

38 Data sources and guidance: - Hospital internal mortality and morbidity. - Hospital patient data source. Page 38 of 159

39 Type: Quality Indicator KPI Description (title): Domain Sub-Domain CAUTI rate per 1000 device days (all inpatients) Patient Safety Adverse Events (AE) and Sentinel events Indicator Number: QI016 Catheter-associated UTI (CAUTI): A UTI where an indwelling urinary catheter was in place for >2 calendar days on the date of event, with day of device placement being Day 1, AND An indwelling urinary catheter was in place on the date of event or the day before. If an indwelling urinary catheter was in place for > 2 calendar days and then removed, the date of event for the UTI must be the day of discontinuation or the next day for the UTI to be catheter-associated. Indwelling catheter: A drainage tube that is inserted into the urinary bladder through the urethra, is left in place, and is connected to a drainage bag (including leg bags). These devices are also called Foley catheters. Condom or straight inand-out catheters are not included nor are nephrostomy tubes, ileoconduits, or suprapubic catheters unless a Foley catheter is also present. Indwelling urethral catheters that are used for intermittent or continuous irrigation are included in CAUTI surveillance. Definition: Location of Attribution: The inpatient location where the patient was assigned on the date of event is the location of attribution ( Exception to Location of Attribution: Transfer Rule: If the date of event is on the date of transfer or discharge, or the next day, the infection is attributed to the transferring/discharging location) Date of Event (Event Date): The Date of Event is the date the first element used to meet site-specific infection criterion occurs for the first time within the seven-day infection window period. Infection Window Period: Infection Window Period is defined as the 7-days during which all site-specific infection criteria must be met. It includes the day the first positive diagnostic test that is an element of the site-specific infection criterion, was obtained, the 3 calendar days before and the 3 calendar days after. Indwelling catheter days: Indwelling urinary catheter days, which are the number of patients with an indwelling urinary catheter device, are collected daily, at the same time each day. Page 39 of 159

40 Numerator: number of patient with CAUTI that is identified during the period selected for surveillance. ICD-10CM Code; T83.51XA Denominator: Total number of catheter device days Criteria used to define CAUTI in Adult Patients: Criteria 1a. Patient must meet 1, 2, and 3 below: 1. Patient had an indwelling urinary catheter that had been in place for > 2days on the date of event (day of device placement = Day 1) AND was either: Still present on the date of event, OR Removed the day before the date of event Calculation and Criteria to define CAUTI: 2. Patient has at least one of the following signs or symptoms: fever (>38.0 C) suprapubic tenderness costovertebral angle pain or tenderness urinary urgency urinary frequency dysuria 3. Patient has a urine culture with no more than two species of organisms, at least one of which is a bacteria of 105 CFU/ml. All elements of the UTI criterion must occur during the Infection Window Period Criteria used to define CAUTI for Patients 1 year: Patient must meet 1, 2, and 3 below: 1. Patient is 1 year of age (an indwelling urinary catheter in place for >2 calendar days)) 2. Patient has at least one of the following signs or symptoms: fever (>38.0 C) hypothermia (<36.0 C) apnea bradycardia lethargy vomiting suprapubic tenderness 3. Patient has a urine culture with no more than two species of organisms, at least one of which is a bacteria of 105 CFU/ml. All elements of the SUTI criterion must occur during the Infection Window Period Page 40 of 159

41 Comment; Mixed flora cannot be reported as a pathogen to meet the CAUTI criteria. Additionally, mixed flora represent at least two species of organisms. Therefore an additional organism recovered from the same culture, would represent >2 species of microorganisms. Such a specimen also cannot be used to meet the UTI criteria. Exclusion: Reporting Frequency: Unit of Measure: International comparison if available Desired direction: Data sources and guidance: - Outpatients - ICD-10CM Codes T83.51XD Monthly rate per 1000 urinary catheter days AHRQ and HAAD standards Lower is better Notes for all providers - Captured by infection control team - Patient s records - Lab reports - Hospital internal mortality and morbidity Page 41 of 159

42 Type: Quality Indicator KPI Description (title): Domain Sub-Domain Definition: Indicator Number: QI017 CLABSI Rate per 1000 Central Line-Days ( all inpatients) Patient Safety Adverse Events (AE) and Sentinel events Central line-associated BSI (CLABSI): A laboratory-confirmed bloodstream infection (LCBI) where central line (CL) or umbilical catheter (UC) was in place for >2 calendar days on the date of event, with day of device placement being Day 1, AND a CL or UC was in place on the date of event or the day before. If a CL or UC was in place for >2 calendar days and then removed, the date of event of the LCBI must be the day of discontinuation or the next day. If the patient is admitted or transferred into a facility with an implanted central line (port) in place, and that is the patient s only central line, day of first access in an inpatient location is considered Day1. Access is defined as line placement, infusion or withdrawal through the line. Such lines continue to be eligible for CLABSI once they are accessed until they are either discontinued or the day after patient discharged (as per the Transfer Rule). Note that the de-access of a port does not result in the patient s removal from CLABSI surveillance. Central line: An intravascular catheter that terminates at, close to the heart, or in one of the great vessels that used for infusion, withdrawal of blood, or hemodynamic monitoring. The following are considered great vessels for the purpose of reporting central-line BSI and counting central-line days in the NHSN system: Aorta Pulmonary artery Superior vena cava Inferior vena cava Brachiocephalic veins Internal jugular veins Subclavian veins External iliac veins Common iliac veins Femoral veins In neonates, the umbilical artery/vein. Umbilical catheter: A central vascular device inserted through the umbilical artery or vein in a neonate. Infusion: The introduction of a solution through a blood vessel via a catheter lumen. This may include continuous infusions such as nutritional fluids or Page 42 of 159

43 medications, or it may include intermittent infusions such as flushes, IV antimicrobial administration, or blood transfusion or hemodialysis. Temporary central line: A non-tunneled, non- implanted catheter. Permanent central line: Includes Tunneled catheters, including certain dialysis catheters Implanted catheters (including ports) Location of Attribution: The inpatient location where the patient was assigned on the date of event is the location of attribution ( Exception to Location of Attribution: Transfer Rule: If the date of event is on the date of transfer or discharge, or the next day, the infection is attributed to the transferring/discharging location) Date of Event (Event Date): The Date of Event is the date the first element used to meet site-specific infection criterion occurs for the first time within the seven-day infection window period. Infection Window Period: Infection Window Period is defined as the 7-days during which all site-specific infection criteria must be met. It includes the day the first positive diagnostic test that is an element of the site-specific infection criterion, was obtained, the 3 calendar days before and the 3 calendar days after. Central Line days: Central Line days are the number of patients with an indwelling central lines, are collected daily, at the same time each day. Page 43 of 159

44 Numerator: Each CLABSI that is identified during the period selected for surveillance in all inpatient setting patients ICD-10CM Codes T80.211A Denominator: Number of all central line days for all patients in the specified period Exclusion: ICD 10 CM Codes; T80.211D,T80.212S,T80.218S,T80.219S Laboratory-Confirmed Bloodstream Infection (LCBI) Criteria to define BSI: LCBI 1. (in Adult Patients) Patient has a recognized pathogen cultured from one or more blood cultures AND organism cultured from blood is not related to an infection at another site Calculation and Criteria to define CLABSI: LCBI 2 (in Adult Patients) Patient has at least one of the following signs or symptoms: fever (>38.0oC), chills, or hypotension AND organism cultured from blood is not related to an infection at another site AND the same common commensal (i.e., diphtheroids [Corynebacterium spp. not C. diphtheriae], Bacillus spp. [not B. anthracis], Propionibacterium spp., coagulasenegative staphylococci [including S. epidermidis], viridans group streptococci, Aerococcus spp., and Micrococcus spp.) is cultured from two or more blood cultures drawn on separate occasions. LCBI 3 (In Patients 1 year) Patient 1 year of age has at least one of the following signs or symptoms: fever (>38.0oC), hypothermia (<36.0oC), apnea, or bradycardia AND organism cultured from blood is not related to an infection at another site. AND the same common commensal (i.e., diphtheroids [Corynebacterium spp. not C. diphtheriae], Bacillus spp. [not B. anthracis], Propionibacterium spp., coagulasenegative staphylococci [including S. epidermidis], viridans group streptococci, Aerococcus spp., and Micrococcus spp.) is cultured from two or more blood cultures drawn on separate occasions Reporting Frequency: Unit of Measure: Monthly Rate per 1000 central line days Page 44 of 159

45 International comparison if available Desired direction: Data sources and guidance: AHRQ and HAAD standards Lower is better Notes for all providers - Captured by infection control team - Patient s records - Lab reports - Hospital internal mortality and morbidity Page 45 of 159

46 Type: Quality Indicator KPI Description (title): Domain Sub-Domain Definition: Indicator Number: QI018 Surgical Site Infection (SSI) per 100 Appendectomy procedures Patient Safety Complication SSI following appendectomy: Percentage rate of all patients developing an SSI within 30 days post emergency appendectomy Infection present at time of surgery (PATOS): PATOS denotes that there is evidence of an infection or abscess at the start of or during the index surgical procedure (in other words, it is present preoperatively). PATOS does not apply if there is a period of wellness between the time of a preoperative condition and surgery. The evidence of infection or abscess must be noted/documented preoperatively or found intraoperatively in a pre-operative or intraoperative note. Numerator: Number of all SSI identified within 30 days post emergency appendectomy within the specified period Denominator: Total number of all patients undergoing emergency appendectomy in the specific facility within the specified related set period. Calculation and Criteria to define SSI in appendectomy: Criteria to define SSI following appendectomy (Organ/Space SSI) Patients must meet the following criteria: Infection occurs within 30 days after the NHSN operative procedure (where day 1 = the procedure date) AND infection involves any part of the body deeper than the fascial/muscle layers, that is opened or manipulated during the operative procedure AND patient has at least one of the following: a. purulent drainage from a drain that is placed into the organ/space (e.g., closed suction drainage system, open drain, T-tube drain, CT guided drainage) b. organisms isolated from an aseptically-obtained culture of fluid or tissue in the organ/space c. an abscess or other evidence of infection involving the organ/space that is detected on gross anatomical or histopathologic exam, or imaging test Codes: CPT: 44950, 44955, 44960, Reporting Frequency: Monthly Page 46 of 159

47 Unit of Measure: International comparison if available Desired direction: Data sources and guidance: Rate Per 100 appendectomy Procedures Developed locally by modifying similar indicators used by CDC/ NHSN Lower is better Notes for all providers - Captured by infection control team/ nursing as part of regular surveillance activities and infection control documentation. - Patient s records - Hospital internal mortality and morbidity Page 47 of 159

48 Type: Quality Indicator KPI Description (title): Domain Sub-Domain Definition: Emergency primary Caesarian Section rate Patient safety Evidence Based Medicine Indicator Number: QI019 Percentage rate of unplanned ( all those that do not fall into delivery timed to suit the woman, or staff / Operating Room availability in the absence of maternal or fetal compromise ).Cesarean deliveries in adult (over or equal to 16 years old) woman without a prior history of cesarean out of all deliveries Numerator: Number of first time unplanned Cesarean section deliveries, Codes: CPT Codes; 59510, 59514, 59515, 59618, 59620, Denominator: All deliveries. Exclude cases: Calculation: Reporting Frequency: Unit of Measure: International comparison if available Desired direction: Monthly Any diagnosis of abnormal presentation, preterm(<37 weeks),fetal death, multiple gestation Previous Cesarean delivery diagnosis in any diagnosis field Placenta preavia or acreta Any caesarian section delivery timed to suit the woman, or staff / Operating Room availability in the absence of maternal or fetal compromise. ICD 10 CM Excluded codes in Appendix A 3 Rate per 100 deliveries AHRQ Lower is better Notes for all providers Data sources and guidance: Patient s records Page 48 of 159

49 Type: Quality Indicator KPI Description (title): Domain Sub-Domain Definition: Elective primary Caesarian Section rate Patient safety Evidence Based Medicine Indicator Number: QI020 Percentage rate of planned (delivery timed to suit the woman, or staff / Operating Room availability in the absence of maternal or fetal compromise) Cesarean deliveries for adult woman (over or equal to 16 years old) without a prior history of cesarean out of all deliveries Numerator: Number of planned first time planned Cesarean section deliveries, Codes: CPT Codes; 59510, 59514, 59515, 59618, 59620, Calculation: Denominator: All deliveries Exclude cases: Any diagnosis of abnormal presentation, preterm (<37weeks), fetal death, multiple gestation diagnosis codes, placenta preavia or acreta Previous Cesarean delivery diagnosis in any diagnosis field ICD 10 CM Excluded codes in Appendix A 3 Reporting Frequency: Unit of Measure: International comparison if available Desired direction: Monthly Rate per 100 deliveries AHRQ Lower is better Notes for all providers Data sources and guidance: Patient s records Page 49 of 159

50 Type: Quality Indicator KPI Description (title): Domain Sub-Domain Indicator Number: QI021 Surgical Site Infection (SSI) per 100 emergency Caesarian Section Patient safety Complication Definition: Percentage rate of patients having Infection within 30 days after the unplanned Cesarean Section per all unplanned C/S procedures Numerator: Number of all SSI identified within 30 days for all patients who underwent an unplanned Caesarean Section Denominator: Total number of all patients undergoing unplanned Caesarean Section in that facility in the specified related set period Inclusion: All inpatients Cesarean section CPT codes; 59510, 59514, 59515, 59618, 59620, Exclusion;- Conditions Present On Admission (POA) ( see below Appendix A 4) Calculation and criteria to define SSI following Emergency C- Section: Reporting Frequency: Criteria to define SSI following Emergency C-Section (Organ/Space SSI) Patients must meet the following criteria: Infection occurs within 30 days after the NHSN operative procedure (where day 1 = the procedure date) AND infection involves any part of the body deeper than the fascial/muscle layers, that is opened or manipulated during the operative procedure AND patient has at least one of the following: a. purulent drainage from a drain that is placed into the organ/space (e.g., closed suction drainage system, open drain, T-tube drain, CT guided drainage) b. organisms isolated from an aseptically-obtained culture of fluid or tissue in the organ/space c. an abscess or other evidence of infection involving the organ/space that is detected on gross anatomical or histopathologic exam, or imaging test AND Meets at least one criterion for a specific organ / space infection site listed in Table 4. These criteria are in the surveillance definitions for specific types of infection chapter. Monthly Page 50 of 159

51 Unit of Measure: International comparison if available Desired direction: Data sources and guidance: Rate Per 100 Emergency C/S CDC/ NHSN chapter 9, Procedure-associated Module SSI: Surgical Site Infection (SSI) Event Lower is better Notes for all providers - Captured by infection control team/ nursing as part of regular surveillance activities and infection control documentation - Patient s records Page 51 of 159

52 Type: Quality Indicator KPI Description (title): Domain Sub-Domain Definition: Indicator Number: QI022 Surgical Site Infection (SSI) Per 100 elective Caesarian Section Patient safety Complication Rate of adult (16 years and over) patients contracting Infection occurring within 30 days after the planned Cesarean Section per all planned caesarian sections performed within the set period Numerator: Number of all SSI identified within 30 days for all patients who underwent a planned Caesarean Section (primary or otherwise) (ICD 10 CM Code; O86.0 (Infection of obstetric surgical wound ) Denominator: Total number of all patients that underwent a planned Caesarean Section in that facility in the specified related set period Inclusion: All inpatients Cesarean section CPT codes; 59510, 59514, 59515, 59618, 59620, Exclusion;- Conditions Present On Admission (POA) ( see below Appendix A 4) Calculation and criteria to define SSI following Elective C-Section: Reporting Frequency: Criteria to define SSI following Elective C-Section (Organ/Space SSI) Patients must meet the following criteria: Infection occurs within 30 days after the NHSN operative procedure (where day 1 = the procedure date) AND infection involves any part of the body deeper than the fascial/muscle layers, that is opened or manipulated during the operative procedure AND patient has at least one of the following: a. purulent drainage from a drain that is placed into the organ/space (e.g., closed suction drainage system, open drain, T-tube drain, CT guided drainage) b. organisms isolated from an aseptically-obtained culture of fluid or tissue in the organ/space c. an abscess or other evidence of infection involving the organ/space that is detected on gross anatomical or histopathologic exam, or imaging test AND Meets at least one criterion for a specific organ / space infection site listed in Table 4. These criteria are in the surveillance definitions for specific types of infection chapter. Monthly Page 52 of 159

53 Unit of Measure: International comparison if available Desired direction: Data sources and guidance: Rate Per 100 Elective C/S CDC/ NHSN chapter 9, Procedure-associated Module SSI: Surgical Site Infection (SSI) Event Lower is better Notes for all providers - Captured by infection control team/ nursing as part of regular surveillance activities and infection control documentation - Patient s records - Hospital internal mortality and morbidity Page 53 of 159

54 Type: Quality Indicator KPI Description (title): Domain Sub-Domain Indicator Number: QI023 Perinatal Mortality rate per 1000 births Outcome Perinatal Mortality rate per 1000 births Perinatal Mortality: Rate of all still births and early neonatal death out of all births in the specified period. To monitor perinatal mortality Definition: Perinatal: Describes the period surrounding birth, and traditionally includes the time from fetal viability from about 24 weeks of pregnancy up to either 7 or 28 days Perinatal mortality: Fetal deaths (stillbirths) after 24 completed weeks of gestation and neonatal death before 7 completed days. Numerator: Number of : a) fetal deaths (stillbirths from 24 weeks of gestation and/or 500g birth weight)) and b) early neonatal deaths (birth to age 7 days of life) Include: ICD 10 CM Code: Z38.00, Z38.01, Z38.30, Z38.31, Z38.61, Z38.62, Z38.63, Z38.64, Z38.65, Z38.66, Z38.68, with discharge disposition Death for neonate, patients age up to 7 days of life Calculation: Denominator: (ICD 10 CM Code: Z38.00, Z38.01, Z38.30, Z38.31, Z38.61, Z38.62, Z38.63, Z38.64, Z38.65, Z38.66, Z38.68,) Inclusion: All babies born in the facility and/ or being care for in the specified facility Exclusion: Reporting Frequency: Unit of Measure: International comparison if available Desired direction: Monthly - Major congenital anomalies - <24 weeks gestation and/or <500g birth weight Rate per 1000 births Lower is better Page 54 of 159

55 Notes for all providers Data sources and guidance: - Manual Data Collection - Patient s Records Page 55 of 159

56 Type: Quality Indicator KPI Description (title): Domain Sub-Domain Definition: Indicator Number: QI024 Perinatal Mortality - corrected rate per 1000 births Outcome Perinatal Mortality - corrected rate per 1000 births Perinatal Mortality: Rate of all stillbirths and early neonatal death out of all births in the specified period. To monitor perinatal mortality Perinatal: Describes the period surrounding birth, and traditionally includes the time from fetal viability from about 24 weeks of pregnancy up to either 7 or 28 days Perinatal mortality: Fetal deaths (stillbirths) after 24 completed weeks of gestation and neonatal death before 7 completed days. Corrected Perinatal Mortality = excluding major congenital anomalies, <24 weeks gestation and/or <500g birth weight Numerator: Number of : a) fetal deaths (stillbirths from 24 weeks of gestation and/or 500g birth weight)) and b) early neonatal deaths (birth to age 7 days of life) Include: ICD 10 CM Code: Z38.00, Z38.01, Z38.30, Z38.31, Z38.61, Z38.62, Z38.63, Z38.64, Z38.65, Z38.66, Z38.68, with discharge disposition Death for neonate, patients age up to 7 days of life Calculation: Denominator: Total number of births Total number of births (ICD 10 CM Code: Z38.00, Z38.01, Z38.30, Z38.31, Z38.61, Z38.62, Z38.63, Z38.64, Z38.65, Z38.66, Z38.68,) Inclusion: All babies born in the facility and/ or being care for in the specified facility Exclusion: Reporting Frequency: Unit of Measure: Monthly - Major congenital anomalies - <24 weeks gestation and/or <500g birth weight Rate per 1000 births Page 56 of 159

57 International comparison if available Desired direction: Lower is better Notes for all providers Data sources and guidance: - Manual Data Collection - Patient s Records Page 57 of 159

58 Type: Quality Indicator KPI Description (title): Domain Sub-Domain Definition: Neonatal Mortality rate per 1000 births Outcome Neonatal Mortality rate per 1000 births To monitor neonatal mortality Indicator Number: QI025 Neonatal mortality: Death before the age of 28 completed days following live birth. Numerator: Number of neonatal death during first 28 days of life during hospital stay Include: All patients age up to 28 days of life Calculation: Denominator: Total number of live births (ICD 10 CM Code: Z38.00, Z38.01, Z38.30, Z38.31, Z38.61, Z38.62, Z38.63, Z38.64, Z38.65, Z38.66, Z38.68) Inclusion: All babies born in the facility Exclusion: Reporting Frequency: Unit of Measure: International comparison if available Desired direction: Data sources and guidance: Monthly - Deaths on or after 28 days of life - Stillbirths Rate per 1000 births Lower is better Notes for all providers - Manual Data Collection - Patient s Records - Mortality and Morbidity - Patient s follow up Page 58 of 159

59 Type: Quality Indicator KPI Description (title): Domain Sub-Domain Definition: Indicator Number: QI026 Neonatal Mortality - corrected rate per 1000 births Outcome Neonatal Mortality - corrected rate per 1000 births To monitor neonatal mortality Neonatal mortality: Death before the age of 28 completed days following live birth. Corrected Neonatal Mortality = excluding major congenital anomalies irrespective of gestation; also < 24weeks gestation and those <500g Numerator: Number of neonatal death during first 28 days of life during hospital stay Include: All patients age up to 28 days of life Calculation: Denominator: Total number of live births (ICD 10 CM Code: Z38.00, Z38.01, Z38.30, Z38.31, Z38.61, Z38.62, Z38.63, Z38.64, Z38.65, Z38.66, Z38.68) Inclusion: All babies born in the facility Exclusion: Reporting Frequency: Unit of Measure: International comparison if available Desired direction: Monthly - Major congenital anomalies irrespective of gestation - Deaths on or after 28 days of life - Born at < 24weeks gestation and those <=500g in weight - Stillbirths Rate per 1000 births Lower is better Notes for all providers Page 59 of 159

60 Data sources and guidance: - Manual Data Collection - Patient s Records - Mortality and Morbidity - Patient s follow up Page 60 of 159

61 10 Appendix Appendix A 1 CPT Operating Room Procedure Codes for for KPI Number QI005 CPT CODE CPT DESCRIPTION 0192T INSERTION OF ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE 0249T LIGATION, HEMORRHOIDAL VASCULAR BUNDLE(S), INCLUDING ULTRASOUND GUIDANCE FINE NEEDLE ASPIRATION, WITH IMAGING GUIDANCE IMAGE-GUIDED FLUID COLLECTION DRAINAGE BY CATHETER (EG, ABSCESS, HEMATOMA, SEROMA, LYMPHOCELE, CYST), SOFT TISSUE (EG, EXTREMITY, ABDOMINAL WALL, NECK), PERCUTANEOUS INCISION AND DRAINAGE OF PILONIDAL CYST; COMPLICATED INCISION AND DRAINAGE, COMPLEX, POSTOPERATIVE WOUND INFECTION DEBRIDEMENT OF SKIN, SUBCUTANEOUS TISSUE, MUSCLE AND FASCIA FOR NECROTIZING SOFT TISSUE INFECTION; ABDOMINAL WALL, WITH OR WITHOUT FASCIAL CLOSURE DEBRIDEMENT INC REMOVAL FOREIGN MATERIAL ASSOCIATED W/ OPEN FRACTURE(S) &/OR DEBRIDEMENT INC REMOVAL FOREIGN MATERIAL ASSOCIATED W/ OPEN FRACTURE(S) &/OR DEBRIDEMENT INC REMOVAL FOREIGN MATERIAL ASSOCIATED W/ OPEN FRACTURE(S) &/OR DEBRIDEMENT, SKIN, SUBCUTANEOUS TISSUE, AND MUSCLE DEBRIDEMENT; SKIN, PARTIAL THICKNESS EXCISION, BENIGN LESION, EXCEPT SKIN TAG, TRUNK, ARMS OR LEGS; LESION DIAMETER OV EXCISION, BENIGN LESION, EXCEPT SKIN TAG, SCALP, NECK, HANDS, FEET, GENITA; LESION EXCISION, OTHER BENIGN LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, AXILLARY; WITH EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, AXILLARY; W/ COMPLEX EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, AXILLARY; WITH EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, INGUINAL; W/ COMPLEX EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, PERIANAL, PERINEAL, EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, PERIANAL, PERINEAL, SPLIT GRAFT, TRUNK. ARMS LEGS; EACH ADDITIONAL 100 SQCM OR EACH ADDITIONAL ONE PERCENT OF BODY AREA OF INFANTS & CHILDRENDS EXCISION, MALIGNANT LESION, TRUNK, ARMS, OR LEGS; LESION DIAMETER 3.1 TO 4.0 CM EXCISION, MALIGNANT LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER OVER EXCISION, MALIGNANT LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION 2.1 TO 3.0 CM EXCISION, MALIGNANT LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION 3.1 TO 4.0 CM EXCISION, MALIGNANT LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION EXCISION, MALIGNANT LESION, FACE, EARS, EYELIDS, NOSE, LIPS; LESION 3.1 TO 4.0 CM. Page 61 of 159

62 11646 EXCISION, MALIGNANT LESION, FACE, EARS, EYELIDS, NOSE, LIPS; LESION OVER 4.0 CM REPAIR OF NAIL BED RECONSTRUCTION OF NAIL BED WITH GRAFT EXCISION OF PILONIDAL CYST OR SINUS; SIMPLE EXCISION OF PILONIDAL CYST OR SINUS; EXTENSIVE EXCISION OF PILONIDAL CYST OR SINUS; COMPLICATED TATTOOING, INTRADERMAL INTRODUCTION OF INSOLUBLE OPAQUE PIGMENTS TO CORRECT SUBCUTANEOUS INJECTION OF "FILLING" MATERIAL (EG, COLLAGEN); OVER 10.0 CC INSERTION OF TISSUE EXPANDER FOR OTHER THAN BREAST, INCLUDING SUBSEQUE REPLACEMENT OF TISSUE EXPANDER WITH PERMANENT PROSTHESIS REMOVAL OF TISSUE EXPANDER(S) WITHOUT INSERTION OF PROSTHESIS REMOVAL IMPLANTABLE CONTRACEPTIVE CAPSULES SECONDARY CLOSURE OF SURGICAL WOUND DEHISCENCE, EXTENSIVE OR COMPLICATED ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK; DEFECT 10 SQ CM OR LESS ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK; DEFECT 10.1 SQ CM TO ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP, ARMS AND/OR LEGS; DEFECT 10.0 SQ CM OR LESS ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP, ARMS AND/OR LEGS; DEFECT 10.1 SQ CM TO 30.0 SQ CM ADJACENT TISSUE TRANSFER OR REARRANGEMENT, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; DEFECT 10 SQ CM OR LESS ADJACENT TISSUE TRANSFER OR REARRANGEMENT, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; DEFECT 10.1 SQ CM TO 30.0 SQ CM ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, NOSE, EARS AND/OR LIPS; DEFECT 10.1 SQ CM TO 30 SQ CM ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, NOSE, EARS AND/OR LIPS; DEFECT 10 SQ CM OR LESS ADJACENT TISSUE TRANSFER OR REARRANGEMENT, ANY AREA,; DEFECT 30.1 SQ CM TO MORE THAN 60.0 SQ CM FILLETED FINGER OR TOE FLAP, INCLUDING PREPARATION OF RECIPIENT SITE SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR, ORINCISIONAL RELEASE IF A SCAR CONTRACTURE, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR 1% OF BODY AREA OF INFANTS AND CHILDREN SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION; OR INCISIONAL RELEASE OF SCAR CONTRACTURE, FACE, SCALP, EYELIDS, MOUTH, NECK EARS, ORBITS, GENITALIA, HANDS, FEET AND /OR MULTIPLE DIGITS; FIRST 100 SQ CM OR 1% IF BODY AREA OF INFANTS AND CH SPLIT GRAFT, TRUNK. ARMS LEGS; EACH ADDITIONAL 100 SQCM OR EACH ADDITIONAL ONE PERCENT OF BODY AREA OF INFANTS & CHILDRENS Page 62 of 159

63 15120 SPLIT GRAFT, FACE, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA AND/OR MULTIPLE DI DERMAL AUTOGRAFT, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR LESS, OR 1% OF BODY AREA OF INFANTS OR CHILDREN FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, TRUNK; 20 SQ CM OR LESS FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, SCALP, ARMS FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS, AND/OR FEET; 20 SQ CM OR LESS FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, NOSE, EARS, EYELIDS, AND/OR LIPS; 20 SQ CM OR LESS APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; FIRST 100 SQ CM WOUND SURFACE AREA, OR 1% OF BODY AREA OF INFANTS AND CHILDREN APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA FORMATION OF DIRECT OR TUBED PEDICLE, WITH OR WITHOUT TRANSFER; SCALP, ARMS, OR LEGS FORMATION OF DIRECT OR TUBED PEDICLE, WITH OR WITHOUT TRANSFER; FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS OR FEET FORMATION OF DIRECT OR TUBED PEDICLE, WITH OR WITHOUT TRANSFER; EYELIDS, NOSE, EARS, LIPS OR INTRORAL DELAY OF FLAP OR SECTIONING OF FLAP (DIVISION AND INSET); AT TRUNK DELAY OF FLAP OR SECTIONING OF FLAP (DIVISION AND INSET); AT SCALP, ARMS, LEGS DELAY OF FLAP OR SECTIONING OF FLAP (DIVISION AND INSET); AT FOREHEAD, CHEEKS, CHIN, NECK, ACILLAE, GENITALIA, HANDS, OR FEET DELAY OF FLAP OR SECTIONING OF FLAP (DIVISION AND INSET); AT EYELIDS, NOSE, EARS OR LIPS MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; HEAD AND NECK (EG, TEMPORALIS, MASSETER MUSCLE, STERNOCLEIDOMASTOID, LEVATOR SCAPULAE) FLAP; ISLAND PEDICLE FLAP FREE FASCIAL FLAP WITH MIRCROVASCULAR ANASTOMOSIS GRAFT; COMPOSITE, INCLUDING PRIMARY CLOSURE, DONOR AREA GRAFT; DERMA-FAT-FASCIA DERMABRASION; TOTAL FACE (EG, FOR ACNE SCARRING, FINE WRINKLING, RHYTIDS, GENERAL KERATOSIS) DERMABRASION; SEGMENTAL, FACE BLEPHAROPLASTY, LOWER EYELID BLEPHAROPLASTY, WITH EXTENSIVE HERNIATED FAT PAD BLEPHEROPLASTY, UPPER EYELID; Page 63 of 159

64 15823 BLEPHEROPLASTY, UPPER EYELID; WITH WEIGHTING DOWN LID RHYTIDECTOMY; FOREHEAD EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); ABDOMEN, INFRAUMBILICAL PANNICULECTOMY EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDING LIPECTOMY); THIGH EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); LEG EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDING LIPECTOMY); ARM EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE; FOREARM OR HAND EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INC LIPECTOMY); OTHER AREA GRAFT FOR FACIAL NERVE PARALYSIS; FREE FASCIA GRAFT (INCLUDING OBTAINING FASCIA) GRAFT FOR FACIAL NERVE PARALYSIS; REGIONAL MUSCLE TRANSFER REMOVAL OF SUTURES UNDER ANESTHESIA (OTHER THAN LOCAL), SAME SURGEON REMOVAL OF SUTURES UNDER ANESTHESIA (OTHER THAN LOCAL), OTHER SURGEON SUCTION ASSISTED LIPECTOMY; TRUNK EXCISION, SACRAL PRESSURE ULCER, WITH SKIN FLAP CLOSURE; WITH OSTECTOMY EXCISION, ISCHIAL PRESSURE ULCER, WITH PRIMARY SUTURE EXCISION, ISCHIAL PRESSURE ULCER, W/ OSTECTOMY, IN PREP FOR MUSCLE OR MYOCUTANEOUS OR SKIN GRAFT CLOSURE DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN FIVE PERCENT TOTAL BODY SURFACT AREA) DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; MEDIUM (E.G., WHOLE FACE OR WHOLE EXTREMITY, OR FIVE TO TEN PERCENT TOTAL BODY SURFACE AREA) DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; LARGE (E.G., MORE THAN ONE EXTREMITY, OR GREATER THAN 10 PERCENT TOTAL BODY AREA) ESCHAROTOMY; INITIAL INCISION DESTRUCTION OF CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; OVER 50.0 SQ CM DESTRUCTION, MALIGNANT LESION, ANY METHOD, TRUNK, ARMS OR LEGS; LESION DIAMETER OVER 4.0 CM DESTRUCTION, MALIGNANT LESION, ANY METHOD, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 2 CM TO 3.0 CM DESTRUCTION, MALIGNANT LESION, ANY METHOD, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 3.1 CM TO 4.0 CM DESTRUCTION, MALIGNANT LESION, ANY METHOD, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER OVER 4.0 CM DESTRUCTION, MALIGNANT LESION, ANY METHOD, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 1.1 to 2.0 CM CM OR LESS DESTRUCTION, MALIGNANT LESION, ANY METHOD, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER OVER 4.0 CM Page 64 of 159

65 17286 DESTRUCTION, MALIGNANT LESION, ANY METHOD, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 2.1 to 3.0 CM CM OR LESS MASTOTOMY WITH EXPLORATION OR DRAINAGE OF ABSCESS, DEEP BX BREAST 1ST LESION STRUCTURE BIOPSY BREAST, WITH PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET), WHEN PERFORMED, AND IMAGING OF BIOPSY SPECIMEN, WHEN PERFORMED, PERCUTANEOUS; FIRST LESION, INCLUDING ULTRASOUND GUIDANCE BIOPSY OF BREAST: PERCUTANEOUS, NEEDLE CORE. USING IMAGING GUIDANCE BREAST BIOPSY VACCUM ASSISTED/ROTATING DEVICE NIPPLE EXPLORATION, WITH OR WITHOUT EXCISION OF A SOLITARY LACTIFEROUS DUCT EXCISION OF LACTIFEROUS DUCT FISTULA. EXCISION OF CYST, FIBROADENOMA OR OTHER BENIGN OR MALIGNANT TUMOR, ABERRANT BREAST TISSUE, DUCT LESION, NIPPLE OR AREOLAR LESION, OPEN, MALE OR FEMALE, 1 OR MORE LESIONS EXCISION OF BREAST LESION IDENTIFIED BY PREOPERATIVE PLACEMENT OF RADIOLOGICAL MARKER, OPEM, SINGLE LESION EXCISION OF CHEST WALL TUMOR INCLUDING RIBS PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET, WIRE/NEEDLE, RADIOACTIVE SEEDS), PERCUTANEOUS; FIRST LESION, INCLUDING ULTRASOUND GUIDANCE PREOPERATIVE PLACEMENT OF NEEDLE LOCALIZATION WIRE, BREAST PLACEMENT OF RADIOTHERAPY AFTERLOADING BALLOON CATHETER INTO THE BREAST FOR INTERSTITIAL RADIOELEMENT APPLICTION FOLLIWNG PARTIAL MASTECTOMY, INCLUDES IMAGING GUIDANCE; ON DATE SEPARATE FROM PARTIAL MASTECTOMY MASTECTOMY FOR GYNECOMASTIA THROUGH MASTECTOMY, PARTIAL MASTECTOMY, PARTIAL WITH AXILLARY LYMPHADENECTOMY MASTECTOMY, SIMPLE, COMPLETE MASTECTOMY, SUBCUTANEOUS MASTECTOMY, RADICAL, INCLUDING PECTORAL MUSCLES, AXILLARY LYMPH NOTES MASTECTOMY, MODIFIED RADICAL, INCLUDING AXILLARY LYMPH NODES, WITH OR WITHOUT PECTORIALS MINOR MUSCLE, BUT EXCLUDING PECTORALIS MAJOR MUSCLE MASTOPEXY REDUCTION MAMMOPLASTY MAMMAPLASTY, AUGMENTATION; W/O PROSTHETIC IMPLANT MAMMAPLASTY, AUGMENTATION; WITH PROSTHETIC IMPLANT REMOVAL OF INTACT MAMMARY IMPLANT REMOVAL OF MAMMARY IMPLANT MATERIAL IMMEDIATE INSERTION OF BREAST PROTHESIS FOLLOWING MASTOPEXY, MASTECTOMY OR IN RECONSTRUCTION Page 65 of 159

66 19342 DELAYED INSERTION OF BREAST PROSTHESIS FOLLOWING MASTOPEXY, MASTECTOMY OR IN RECONSTRUCTION NIPPLE/AREOLA RECONSTRUCTION CORRECTION OF INVERTED NIPPLES BREAST RECONSTRUCTION, IMMEDIATE OR DELAYED, WITH TISSUE EXPANDER, INCLUDING SUBSEQUENT EXPANSION BREAST RECONSTRUCTION WITH OTHER TECHNIQUE OPEN PERIPROSTHETIC CAPSULOTOMY, BREAST PERIPROSTHETIC CAPSULECTOMY, BREAST REVISION OF RECONSTRUCTED BREAST PREPARATION OF MOULAGE FOR CUSTOM BREAST IMPLANT INCISION OF SOFT TISSUE ABSCESS; SUBFASCIAL EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE);NECK EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE);CHEST EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE);ABDOMEN/FLANK/BACK EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE);EXTREMITY BIOPSY, MUSCLE; SUPERFICIAL BIOPSY, MUSCLE; DEEP BIOPSY, MUSCLE, PERCUTANEOUS NEEDLE BIOPSY, BONE, TROCAR OR NEEDLE; SUPERFICIAL BIOPSY, BONE, TROCAR OR NEEDLE; DEEP BIOPSY, BONE, OPEN; SUPERFICIAL BIOPSY, BONE, OPEN; DEEP BIOPSY, VERTEBRAL BODY, OPEN; THORACIC REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH; SIMPLE REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH; DEEP OR COMPLICATED INJECTION, ENZYME (EG, COLLAGENASE), PALMAR FASCIAL CORD (IE, DUPUYTREN'S CONTRACTURE) PLACEMENT OF NEEDLES OR CATHETERS INTO MUSCLE AND/OR SOFT TISSUE FOR SUBSEQUENT INTERSTITIAL RADIOELEMENT APPLICATION (AT TIME OF OR SUBSEQUENT TO THE PROCEDURE) ARTHROCENTESIS, ASPIRATION &/OR INJECTION; MAJOR JOINT OR BURSA ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING INSERTION OF WIRE OR PIN WITH APPLICATION OF SKELETAL TRACTION, INCLUDING REMOVAL APPLICATION OF CRANIAL TONGS, CALIPER, OR STEREOTACTIC FRAME, INCLUDING REMOVAL APPLICATION OF HALO, INCLUDING REMOVAL; CRANIAL REMOVAL OF TONGS OR HALO APPLIED BY ANOTHER PHYSICIAN REMOVAL OF IMPLANT; SUPERFICIAL, (EG, BURIED WIRE, PIN OR ROD) (SEPARATE PROCEDURE) REMOVAL OF IMPLANT; DEEP, (EG, BURIED WIRE, PIN, SCREW, METAL BAND, NAIL, ROD OR Page 66 of 159

67 20690 APPLICATION OF A UNIPLANE (PINS OR WIRES IN ONE PLANE), UNILAT, EXTER FIXATION SYSTEM APPLICATION OF A MULTIPLANE (PINS OR WIRES IN MORE THAN ONE PLANE), UNILATERAL, EXTERNAL FIXATION SYSTEM ADJUSTMENT OR REVISION OF EXTERNAL FIXATION SYSTEM REQUIRING ANESTHESIA REMOVAL, UNDER ANESTHESIA, OF EXTERNAL FIXATION SYSTEM REPLANTATION, THUMB (INCLUDES DISTAL TIP TO MP JOINT); COMPLETE AMPUTATION BONE GRAFT, ANY DONOR AREA; MINOR OR SMALL (EG, DOWEL OR BUTTON) BONE GRAFT, ANY DONOR AREA; MAJOR OR LARGE FASCIA LATA GRAFT; BY STRIPPER TENDON GRAFT, FROM A DISTANCE (EG, PALMARIS, TOE EXTENSOR, PLANTARIS) TISSUE GRAFTS, OTHER (EG, PARATENON, FAT, DERMIS) ELECTRICAL STIMULATION TO AID BONE HEALING; NONINVASIVE (NONOPERATIVE) ELECTRICAL STIMULATION TO AID BONE HEALING; INVASIVE (OPERATIVE) ABLATION, BONE TUMOR(S) (EG, OSTEOID OSTEOMA, METASTASIS) RADIOFREQUENCY, PERCUTANEOUS, INCLUDING COMPUTED TOMOGRAPHIC GUIDANCE EXCISION, TUMOR, SOFT TISSUE OF FACE OR SCALP, SUBCUTANEOUS; 2CM OR GREATER EXCISION, TUMOR, SOFT TISSUE OF FACE AND SCALP, SUBFASCIAL (EG. SUBJALEAL, INTRAMUSCULAR); 2CM OR GREATER RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM) SOFT TISSUE OR FACE EXCISION OF BONE (EG, FOR OSTEOMYELITIS OR BONE ABSCESS); MANDIBLE REMOVAL BY CONTOURING OF BENIGN TUMOR OF FACIAL BONE (EG, FIBROUS DYSPLASIA) EXCISION OF TORUS MANDIBULARIS EXCISION OF MAXILLARY TORUS PALATINUS EXCISION OF BENIGN TUMOR OR CYST OF MANDIBLE; REQUIRING INTRA-ORAL OSTECTOMY (EG, LOCALLY AGGRESSIVE EXCISION OF BENIGN TUMOR OR CYST OF MANDIBLE; REQUIRING EXTRA-ORAL OSTECTOMY AND PARTIAL MANDIBULECT EXCISION OF BENIGN TUMOR OR CYST OF MAXILLA; REQUIRING INTRA-ORAL OSTECTOMY EXCISION OF BENIGN TUMOR OR CYST OF MAXILLA; REQUIRING EXTRA-ORAL OSTECTOMY AND PARTIAL MAXILLECTOMY CONDYLECTOMY, TEMPOROMANDIBULAR JOINT (SEPARATE PROCEDURE) MANIPULATION OF TEMPOROMANDIBULAR JOINT(S) (TMJ), THERAPEUTIC, REQUIRING AN ANESTHESIA SERVICES (IE, GENERAL OR MONITORED ANESTHESIA CARE) IMPRESSION AND CUSTOM PREPARATION; INTERIM OBTURATOR PROSTHESIS IMPRESSION AND CUSTOM PREPARATION; ORAL SURGICAL SPLINT IMPRESSION AND CUSTOM PREPARATION; AURICULAR PROSTHESIS GENIOPLASTY; AUGMENTATION (AUTOGRAFT, ALLOGRAFT, PROSTHETIC MATERIAL) GENIOPLASTY; SLIDING OSTEOTOMY, SINGLE PIECE RECONSTRUCTION MIDFACE, LEFORT I; 3 OR MORE PIECES, SEGMENT MOVEMENT IN ANY DIRECTION, WITHOUT BONE GRAFT Page 67 of 159

68 21179 RECONSTRUCTION, ENTIRE OR MAJORITY OF FOREHEAD AND/OR SUPRAORBITAL RIMS, W/O RECONSTRUCTION OF ORBITAL WALLS, RIMS, FOREHEAD, NASOETHMOID COMPLEX FOLLOW RECONSTRUCTION OF MANDIBULAR RAMI, H ORIZONTAL, VERTICAL, C, OR L OSTEOTOMY, WITHOUT BONE GRAFT RECONSTRUCTION OF MANDIBULAR RAMI AND/OR BODY, SAGITTAL SPLIT; WITH INTERNAL RIGID FIXATION OSTEOTOMY, MANDIBLE, SEGMENTAL OSTEOTOMY, MAXILLA, SEGMENTAL (EG. WASSMUND OR SCHUCHARD) GRAFT, BONE; NASAL, MAXILLARY OR MALAR AREAS (INCLUDES OBTAINING GRAFT) GRAFT, BONE; MANDIBLE (INCLUDES OBTAINING GRAFT) GRAFT; RIB CARTILAGE, AUTOGENOUS, TO FACE, CHIN, NOSE OR EAR (INCLUDES OBTAIN GRAFT; EAR CARTILAGE, AUTOGRAFT, TO NOSE OR EAR (INCLUDES OBTAINING GRAFT) ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH PROSTHETIC JOINT REPLACEMENT MALAR AUGMENTATION, PROSTHETIC MATERIAL MEDIAL CANTHOPEXY (SEPARATE PROCEDURE) LATERAL CANTHOPEXY CLOSED TREATMENT OF NASAL BONE FRACTURE; WITH STABILIZATION OPEN TREATMENT OF NASAL FRACTURE; UNCOMPLICATED OPEN TREATMENT OF NASAL FRACTURE; COMPLICATED, WITH INTERNAL AND/OR EXTERNAL OPEN TREATMENT NASAL FRACTURE; W/ CONCOMITANT OPEN TREATMENT FRACTURED SEP OPEN TREATMENT OF NASAL SEPTAL FRACTURE, WITH OR WITHOUT STABILIZATION CLOSED TREATMENT OF NASAL SEPTAL FRACTURE, WITH OR WITHOUT STABILIZATION OPEN TREATMENT OF NASOETHMOID FRACTURE; WITHOUT EXTERNAL FIXATION OPEN TREATMENT OF NASOETHMOID FRACTURE; WITH EXTERNAL FIXATION OPEN TREATMENT OF DEPRESSED FRONTAL SINUS FRACTURE OPEN TREATMENT OF COMPLICATED FRONTAL SINUS FRACTURE, VIA CORONAL OR MULTIP OPEN TREATMENT OF DEPRESSED ZYGOMATIC ARCH FRACTURE (EG, GILLES APPROACH) OPEN TREATMENT OF DEPRESSED MALAR FRACTURE, INCLUDING ZYGOMATIC ARCH AND MALAR TRIPOD OPEN TREATMENT OF COMPLICATED FRACTURE(S) OF MALAR AREA, INCLUDING ZYGOMATIC ARCH AND MALAR TRIPOD; WITH INTERNAL FIXATION AND MULTIPLE SURGICAL APPROACHES OPEN TREATMENT OF ORBITAL FLOOR BLOWOUT FRACTURE; TRANSANTRAL APPROACH OPEN TREATMENT OF ORBITAL FLOOR BLOWOUT FRACTURE; PERIORBITAL APPROACH OPEN TREATMENT OF ORBITAL FLOOR BLOWOUT FRACTURE; COMBINED APPROACH OPEN TREATMENT OF ORBITAL FLOOR BLOWOUT FRACTURE; PERIORBITAL APPROACH, WITH ALLOPLASTIC OR OTHER IMPLANT OPEN TREATMENT OF ORBITAL FLOOR "BLOWOUT" FRACTURE; PERIORBITAL APPROACH W/ BONE GRAFT CLOSED TREATMENT OF FRACTURE OF ORBIT, EXCEPT BLOWOUT; WITHOUT MANIPULATION CLOSED TREATMENT OF FRACTURE OF ORBIT, EXCEPT BLOWOUT; WITH MANIPULATION Page 68 of 159

69 21406 OPEN TREATMENT OF FRACTURE OF ORBIT, EXCEPT BLOWOUT; WITHOUT IMPLANT OPEN TREATMENT OF FRACTURE OF ORBIT, EXCEPT "BLOWOUT"; WITH IMPLANT CLOSED TREATMENT OF PALATAL OR MAXILLARY FRACTURE ; W/ INTERDENTAL WIRE FIXATION OR FIXATION OF DENTURE OR SPLINT CLOSED TREATMENT OF MANDIBULAR OR MAXILLARY ALVEOLAR RIDGE FRACTURE OPEN TREATMENT OF MANDIBULAR OR MAXILLARY ALVEOLAR RIDGE FRACTURE CLOSED TREATMENT OF MANDIBULAR FRACTURE; WITHOUT MANIPULATION CLOSED TREATMENT OF MANDIBULAR FRACTURE; WITH MANIPULATION CLOSED TREATMENT OF MANIBULAR FRACTURE WITH INTERDENTAL FIXATION OPEN TREATMENT OF MANDIBULAR FRACTURE WITH EXTERNAL FIXATION OPEN TREATMENT OF MANDIBULAR FRACTURE; WITHOUT INTERDENTAL FIXATION OPEN TREATMENT OF MANDIBULAR FRACTURE; WITH INTERDENTAL FIXATION OPEN TREATMENT OF MANDIBULAR CONDYLAR FRACTURE OPEN TREATMENT OF COMPLICATED MANDIBULAR FRACTURE BY MULTIPLE SURGICAL APPR CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION, INITIAL OR SUBSEQUENT OPEN TREATMENT OF TEMPOROMANDIBULAR DISLOCATION OPEN TREATMENT OF HYOID FRACTURE INCISION AND DRAINAGE, DEEP ABSCESS OR HEMATOMA, SOFT TISSUES OF NECK EXCISION OF TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBQ, 3 CM OR GREATER BIOPSY, SOFT TISSUE OF NECK OR THORAX; 5CM OR GREATER EXCISION TUMOR, SOFT TISSUE OF NECK OR THORAX; SUBCUTANEOUS EXCISION BENIGN TUMOR; DEEP, SUBFASCIAL, INTRAMUSCULAR EXCISION OF RIB, PARTIAL COSTOTRANSVERSECTOMY (SEPARATE PROCEDURE) EXCISION FIRST AND/OR CERVICAL RIB OSTECTOMY OF STERNUM, PARTIAL HYOID MYOTOMY AND SUSPENSION DIVISION OF SCALENUS ANTICUS; WITHOUT RESECTION OF CERVICAL RIB DIVISION OF SCALENUS ANTICUS; WITH RESECTION OF CERVICAL RIB DIVISION OF STERNOCLEIDOMASTOID FOR TORTICOLLIS, OPEN OPERATION; W/O CAST APPL RECONSTRUCTIVE REPAIR OF EXCAVATUM OR CARINATUM; MINIMALLY INVASIVE APPROACH (NUSS PROCEDURE), WITHOUT THORACOSCOPY RECONSTRUCTIVE REPAIR OF EXCAVATUM OR CARINATUM; MINIMALLY INVASIVE APPROACH (NUSS PROCEDURE), WITH THORACOSPCOPY CLOSED TREATMENT OF RIB FRACTURE; UNCOMPLICATED, EACH BIOPSY, SOFT TISSUE OF BACK OR FLANK; DEEP EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK EXCISION OF TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBQ, 3 CM OR GREATER EXCISION OF TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBFASCIAL (EG INTRAMUSCULAR); LESS THAN 5 CM Page 69 of 159

70 21933 EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBFASCIAL (EG. INTRAMUSCULAR); 5CM OR GREATER RADICAL RESECTION OF TUMOR, SOFT TISSUE OF BACK OR FLANK INCISION AND DRAINAGE, OPEN, OF DEEP ABSCESSI (SUPERFICIAL), POSTERIOR SPINE; CERVICAL, THROACIC, OR CERVICOTHORACIC INCISION AND DRAINAGE, OPEN, OF DEEP ABSCESS (SUBFASCIAL), POSTERIOR SPINE; LUMBAR, SACRAL, OR LUMBOSACRAL PARTIAL RESECTION OF VERTEBRAL COMPONENT, SPINOUS PROCESSES; CERVICAL OSTEOTOMY OF SPINE, POSTERIOR OR POSTEROLATERAL APPROACH, THREE COLUMNS, ONE VERTEBRAL SEGMENT (EG, PEDICLE/VERTEBRAL BODY SUBTRACTION); THORACIC OSTEOTOMY OF SPINE, POSTERIOR OR POSTEROLATERAL APPROACH, THREE COLUMNS, ONE VERTEBRAL SEGMENT (EG, PEDICLE/VERTEBRAL BODY SUBTRACTION); LUMBAR CLOSED TREATMENT OF VERTEBRAL PROCESS FRACTURE(S) CLOSED TREATMENT OF VERTEBRAL BODY FRACTURE(S), WITHOUT MANIPULATION CLOSED TREATMENT OF VERTEBRAL FRACTURE &/OR DISLOCATION REQ CASTING OR BRAC PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; THORACIC PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; LUMBAR PERCUTANEOUS VERTEBROPLASTY, 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION; LUMBAR PERCUTANEOUS VETEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE, ONE VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION (E.G., KYPHOPLASTY; THORACIC PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE, ONE VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION (E.G., KYPHOPLASTY; LUMBAR ARTHRODESIS, ANTERIOR INTERBODY, INCLUDING DISC SPACE PREPARATION, DISCECTOMY, OSTEOPHYTECTOMY AND DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOTS; CERVICAL BELOW C ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE ARTHRODESIS, POSTERIOR OR POSTEROLATERAL, SINGLE LEVEL; LUMBAR ARTHRODESIS, POST INTERBODY WITH LAMINEC AND/OR DISKECTOMY; LUMBAR Page 70 of 159

71 ARTHRODESIS, COMBINED POSTERIOR OR POSTEROLATERAL TECHNIQUE WITH POSTERIOR INTERBODY TECHNIQUE INCLUDING LAMINECTOMY AND/OR DISCECTOMY SUFFICIENT TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE AND SEGMENT; LUMBAR POSTERIOR NON-SEGMENTAL INSTRUMENTATION REMOVAL OF POSTERIOR SEGMENTAL INSTRUMENTATION TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, INCLUDING DISCECTOMY WITH END PLATE PREPARATION (INLCUDES OSTEOPHYTECTOMY FOR NERVE ROOT ORSPINAL CORD DECOMPRESSION AND MICRODISSECTION), SINGLE INTERSPACE, CERVICAL EXCISION, ABDOMINAL WALL TUMOR, SUBFASCIAL (EG, DESMOID) EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBFASCIAL (EG. INTRAMUSCULAR); 5CM OR GREATER EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBCUTANEOUS; LESS THAN 3 CM EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBCUTANEOUS; 3 CM OR GREATER REMOVAL OF SUBDELTOID CALCAREOUS DEPOSITS, OPEN CAPSULAR CONTRACTURE RELEASE (EG, SEVER TYPE PROCEDURE) INCISION AND DRAINAGE, SHOULDER AREA; DEEP ABSCESS OR HEMATOMA INCISION AND DRAINAGE, SHOULDER AREA; INFECTED BURSA INCISION, BONE CORTEX (EG, OSTEOMYELITIS OR BONE ABSCESS), SHOULDER AREA ARTHROTOMY, GLENOHUMERAL JNT, INC EXPLORATION, DRAINAGE OR REMOVAL OF FB ARTHROTOMY, ACROMIOCLAVICULAR, STERNOCLAVICULAR JNT, INC EXPLORATION, DRAINAG BIOPSY, SOFT TISSUE OF SHOULDER AREA; DEEP BIOPSY, SOFT TISSUE OF SHOULDER AREA; 3CM OR GREATER BIOPSY, SOFT TISSUE OF SHOULDER AREA; 5CM OR GREATER EXCISION, TUMOR, SHOULDER AREA; DEEP, SUBFACIAL OR INTRAMUSCULAR RADICAL RESECTION OF TUMOR (EG, MALIG NEOPLASM), SOFT TISSUE OF SHOULDER AREA ARTHROTOMY, ACROMICLAVICULAR JOINT OR STERNOCLAVICULAR JOINT, INCLUDING BIOPSY AND/OR EXCISION OF TORN CARTILAGE ARTHROTOMY; STERNOCLAVICULAR JOINT, WITH SYNOVECTOMY, WITH OR WITHOUT BIOPSY ARTHROTOMY, GLENOHUMERAL JOINT, W/ JOINT EXPLORATION, W/ OR W/O REMOVAL LOOSE CLAVICULECTOMY; PARTIAL CLAVICULECTOMY; TOTAL ACROMIOPLASTY, OR ACROMIONECTOMY, PARTIAL EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF PROXIMAL HUMER EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF PROXIMAL HUMERUS EXC OF CURETTAGE OF BONE CYST OF BENIGN TUMOR OF PROXIMAL HUMERUS; W/ AUTOGR PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE, CLAVICLE PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE, SCAPULA Page 71 of 159

72 23331 REMOVAL OF FOREIGN BODY, SHOULDER; DEEP (NEER HEMIARTHROPLASTY REMOVAL) INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT/MRI SHOULDER TENOTOMY, SHOULDER AREA; SINGLE TENDON REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG, ROTATOR CUFF); ACUTE REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG, ROTATOR CUFF); CHRONIC CORACOACROMIAL LIGAMENT RELEASE, WITH OR WITHOUT ACROMINOPLASTY REPAIR OF COMPLETE SHOULDER (ROTATOR) CUFF AVULSION, CHRONIC TENODESIS OF LONG TENDON OF BICEPS RESECTION OR TRANSPLANTATION OF LONG TENDON OF BICEPS CAPSULORRHAPHY, ANTERIOR; PUTTI-PLATT PROCEDURE OR MAGNUSON TYPE OP CAPSULORRHAPHY, ANTERIOR; BANKART TYPE OPERATION WITH OR WITHOUT STAP CAPSULORRHAPHY, ANTERIOR, ANY TYPE; WITH BONE BLOCK CAPSULORRHAPHY, ANTERIOR, ANY TYPE; WITH BONE BLOCK CAPSULORRHAPHY FOR RECURRENT DISLOCATION, POSTERIOR, WITH OR WITHOUT CAPSULORRHAPHY WITH ANY TYPE MULTIDIRECTIONAL INSTABILITY ARTHROPLASTY, GLENOHUMERAL JOINT; HEMIARTHROPLASTY ARTHROPLASTY, GLENOHUMERAL JOINT; TOTAL SHOULDER (GLENOID AND PROXIMAL HUMERAL REPLACEMENT (EG, TOTAL SHOULDER)) OSTEOTOMY, CLAVICLE, WITH OR WITHOUT INTERNAL FIXATION OSTEOTOMY, CLAVICLE, W/ OR W/O INTERNAL FIXATION; W/ BONE GRAFT FOR NONUNION OR CLOSED TREATMENT OF CLAVICULAR FRACTURE; WITH MANIPULATION OPEN TREATMENT OF CLAVICULAR FRACTURE, WITH OR WITHOUT INTERNAL OR EXTERNAL SKELETAL FIXATION CLOSED TREATMENT OF ACROMIOCLAVICULAR DISLOCATION; WITH MANIPULATION OPEN TREATMENT OF ACROMIOCLAVICULAR DISLOCATION, ACUTE OR CHRONIC OPEN TREATMENT OF ACROMIOCLAVICULAR DISLOCATION, ACUTE OR CHRONIC; WITH FASCIAL GRAFT (INCLUDES OBTAINING GRAFT) CLOSED TREATMENT OF SCAPULAR FRACTURE; WITHOUT MANIPULATION CLOSED TREATMENT SCAPULAR FRACTURE;W/ MANIPULATION,W/ OR W/O SKELETAL TRACTI CLOSED TREATMENT PROXIMAL HUMERAL FRACTURE; WITHOUT MANIPULATION CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL NECK) FR OPEN TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL NECK) FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, INCLUDES REPAIR OF TUBEROSITY(S), WHEN PERFORMED OPEN TREATMENT PROXIMAL HUMERAL FRACTURE,W/ OR W/O INTERNAL OR EXTERNAL FIX CLOSED TREATMENT OF GREATER HUMERAL TUBEROSITY FRACTURE; W/O MANIPUATION OPEN TREATMENT OF GREATER HUMERAL TUBEROSITY FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHE OPEN TREATMENT OF ACUTE SHOULDER DISLOCATION Page 72 of 159

73 CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH FRACTURE OF GREATER HUMERAL TUBEROSITY, WITH MANIPULATION OPEN TREATMENT OF SHOULDER DISLOCATION, WITH FRACTURE OF GREATER HUMERAL TUBEROSITY, INCLUDING INTERNAL FIXATION, WHEN PERFORMED CLOSED TREATMENT OF SHOULDER DISLOCATION, W/ SURG OR ANATOMICAL NECK FRAC OPEN TREATMENT OF SHOULDER DISLOCATION, W/ SURG OR ANATOMICAL NECK FRACTURE MANIPULATION UNDER ANESTHESIA, SHOULDER JOINT, INCLUDING APPLICATION OF FIXATIO ARTHRODESIS, GLENOHUMERAL JOINT INCISION AND DRAINAGE, UPPER ARM OR ELBOW AREA; DEEP ABSCESS OR HEMAT INCISION AND DRAINAGE, UPPER ARM OR ELBOW AREA; BURSA INCISION, DEEP, W/ OPENING OF BONE CORTEX HUMERUS OR ELBOW ARTHROTOMY, ELBOW, FOR INFECTION, INC EXPLORATION, DRAINAGE OR REMOVAL OF FB ARTHROTOMY OF THE ELBOW, WITH CAPSULAR EXCISION FOR CAPSULAR RELEASE BIOPSY, SOFT TISSUE OF UPPER ARM OR ELBOW AREA; DEEP EXCISION, TUMOR, SOFT TISSUE UPPER ARM OR ELBOW AREA, SUBQ,; LESS THAN 3 CM EXCISION, TUMOR, SOFT TISSUE UPPER ARM OR ELBOW AREA, SUBFASCIAL; LESS THAN 5 CM EXCISION, TUMOR, UPPER ARM OR ELBOW AREA; SUBCUTANEOUS EXCISION, TUMOR, UPPER ARM OR ELBOW AREA; DEEP, SUBFASCIAL OR INTRAMUSCULAR RADICAL RESECTION OF TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA ARTHROTOMY, ELBOW; WITH JOINT EXPLORATION, WITH OR WITHOUT BIOPSY, WITH ARTHROTOMY, ELBOW; WITH SYNOVECTOM EXCISION, OLECRANON BURSA EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, HUMERUS EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR,HUMERUS;W/ AUTOGRAFT EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF HEAD OR NECK OF RADIUS EXCISION, RADIAL HEAD PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) OF BONE RADICAL RESECTION OF CAPSULE, SOFT TISSUE & HETEROTOPIC BONE, ELBOW, W/ CONTR IMPLANT, REMOVAL; RADIAL HEAD REMOVAL OF FB, UPPER ARM OR ELBOW AREA; DEEP(SUBFASCIAL OR INTRASMUSCULAR) TENDON LENGHENING, UPPER ARM OR ELBOW, EACH TENDON TENOTOMY, OPEN, ELBOW TO SHOULDER, SINGLE, EACH TENDON TENOPLASTY, W/ MUSCLE TRANSFER, W/ OR W/O FREE GRAFT, ELBOW TO SHOULDER, SING TENODESIS OF BICEPS TENDO AT ELBOW (SEPARATE PROCEDURE) REPAIR, TENDON OR MUSCLE, UPPER ARM OR ELBOWS,EA TENDON OR MUSCLE, PRIMARY REINSERTION OF RUPTURED BICEPS OR TRICEPS TENDON, DISTAL, WITH OR W/O REPAIR LATERAL COLLATERAL LIGAMENT, ELBOW, WITH LOCAL TISSUE RECONSTRUCTION LATERAL COLLATERAL LIGAMENT, ELBOW, WITH TENDON GRAFT (INCLUDES HARVESTING OF GRAFT) REPAIR MEDICAL COLLATERAL LIGAMENT, ELBOW, WITH LOCAL TISSUE Page 73 of 159

74 24346 RECONSTRUCTION MEDIAL COLLATERAL LIGAMENT, ELBOW, WITH TENDON GRAFT (INCLUDES HARVESTING OF GRAFT) FASCIOTOMY, LATERAL OR MEDIAL (EG, "TENNIS ELBOW" OR EPICONDYLITIS); FASCIOTOMY, LATERAL OR MEDIAL (EG, "TENNIS ELBOW" OR EPICONDYLITIS); WITH FASCIOTOMY, LATERAL OR MEDIAL (EG, "TENNIS ELBOW" OR EPICONDYLITIS) W/ ANNULAR FASCIOTOMY, LATERAL OR MEDIAL (EG, "TENNIS ELBOW" OR EPICONDYLITIS); WITH TENOTOMY, ELBOW, LATERAL OR MEDIAL (EG, EPICONDYLITIS, TENNIS ELBOW, GOLFER'S ELBOW); PERCUTANEOUS TENOTOMY, ELBOW, LATERAL OR MEDIAL (EG, EPICONDYLITIS, TENNIS ELBOW, GOLFER'S ELBOW); DEBRIDEMENT, SOFT TISSUE AND/OR BONE, OPEN TENOTOMY, ELBOW, LATERAL OR MEDIAL (EG, EPICONDYLITIS, TENNIS ELBOW, GOLFER'S ELBOW); DEBRIDEMENT, SOFT TISSUE AND/OR BONE, OPEN WITH TENDON REPAIR OR REATTACHMENT ARTHROPLASTY, RADIAL HEAD; WITH IMPLANT OSTEOTOMY, HUMERUS, WITH OR WITHOUT INTERNAL FIXATION REPAIR OF NONUNION OR MALUNION, HUMERUS; WITHOUT GRAFT REPAIR OF NONUNION OR MALUNION, HUMERUS; WITH ILIAC OR OTHER AUTOGRAFT PROPHYLACTIC TREATMENT, WITH OR WITHOUT METHYLMETHACRYLAT, HUMERUS SHAFT CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE; WITHOUT MANIPULATION CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE; WITH MANIPULATION OPEN TREATMENT OF HUMERAL SHAFT FRACTURE WITH PLATE/SCREWS, WITH OR WITHOUT CERCLAGE TREATMENT OF HUMERAL SHAFT FRACTURE, WITH INSERTION OF INTRAMEDULLARY IMPLANT, WITH OR WITHOUT CERCLAGE AND/OR LOCKING SCREWS CLOSED TREATMENT OF SUPRACONDYLAR OR TRANSCONDYLAR HUMERAL FRACTURE WITH PERCUTANEOUS SKELETAL FIXATION SUPRACONDYLAR OR TRANSCONDYLAR FRACTURE OPEN TREATMENT OF HUMERAL SUPRACONDYLAR OR TRANSCONDYLAR FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED; WITHOUT INTERCONDYLAR EXTENSION CLOSED TREATMENT OF HUMERAL EPICONDYLAR FRACTURE, MEDIAL OR LATERAL; W/O MAN CLOSED TREATMENT OF HUMERAL EPICONDYLAR FRACTURE, MEDIAL OR LATERAL; W/ MANIP PERCUTANEOUS SKELETAL FIXATION OF HUMERAL EPICONDYLAR FRACTURE, MEDIAL OR LA OPEN TREATMENT OF HUMERAL EPICONDYLAR FRACTURE, MEDIAL OR LATERAL, W/ OR W/O CLOSED TREATMENT OF HUMERAL CONDYLAR FRACTURE, MEDIAL OR LATERAL;W/O MANIPU OPEN TREATMENT OF HUMERAL CONDYLAR FRACTURE, MEDIAL OR LATERAL, WITH OR W/O PERCUTANEOUS SKELETAL FIXATION OF HUMERAL CONDYLAR FRACTURE, MEDIAL OPEN TREATMENT OF PERIARTICULAR FRACTURE &/OR DISLOCATION OF THE ELBOW TREATMENT OF CLOSED ELBOW DISLOCATION; WITHOUT ANESTHESIA TREATMENT OF CLOSED ELBOW DISLOCATION; REQUIRING ANESTHESIA OPEN TREATMENT OF ACUTE OR CHRONIC ELBOW DISLOCATION CLOSED TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION AT ELBOW,W/ MANI Page 74 of 159

75 24635 OPEN TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION AT ELBOW, WI CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, "NURSEMAID ELBOW", W/ MA CLOSED TREATMENT OF RADIAL HEAD OR NECK FRACTURE; WITHOUT MANIPULATION CLOSED TREATMENT OF RADIAL HEAD OR NECK FRACTURE; WITH MANIPULATION OPEN TREATMENT OF RADIAL HEAD OR NECK FRACTURE, WITH OR WITHOUT INTERN PERCUTANEOUS SKELETAL FIXATION OF HUMERAL EPICONDYLAR FRACTURE, MEDIAL OR LATERAL WITH MANIPULATION CLOSED TREATMENT OF ULNAR FRACTURE, PROXIMAL END; WITHOUT MANIPULATION CLOSED TREATMENT OF ULNAR FRACTURE, PROXIMAL END; WITH MANIPULATION OPEN TREATMENT OF ULNAR FRACTURE PROXIMAL END (OLECRANON PROCESS), WITH OR AMPUTATION, ARM THROUGH HUMERUS; WITH PRIMARY CLOSURE TENDON SHEATH INCISION; AT RADIAL STYLOID INCISION, FLEXOR TENDON SHEATH, WRIST (EG FLEXOR CARPI RADIALIS) DECOMPRESSION FASCIOTOMY, FOREARM AND/OR WRIST; FLEXOR EXTENSOR COMPART INCISION AND DRAINAGE, FOREARM AND/OR WRIST; DEEP ABSCESS OR HEMATOMA INCISION AND DRAINAGE, FOREARM AND/OR WRIST; BURSA INCISION, DEEP, BONE CORTEX, FOREARM AND/OR WRIST ARTHROTOMY,RADIOCARPAL OR MIDCARPAL JNT,W/ EXPLORATION, DRAINAGE, OR REM FB BIOPSY, SOFT TISSUE OF FOREARM AND/OR WRIST; SUPERFICIAL BIOPSY, SOFT TISSUE OF FOREARM AND/OR WRIST; DEEP EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA, SUBCUTANEOUS; 3 CM OR GREATER EXCISION TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA, SUBQ, 3 CM OR GREATER EXCISION, TUMOR, FOREARM AND/OR WRIST AREA; SUBCUTANEOUS EXCISION, TUMOR, FOREARM AND/OR WRIST AREA; DEEP, SUBFASCIAL OR INTRAMUSCULAR RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM), SOFT TISSUE OF FOREARM ARTHROTOMY, WRIST JOINT; WITH JOINT EXPLORATION, WITH OR WITHOUT BIOPSY, WITH OR ARTHROTOMY, WRIST JOINT; WITH SYNOVECTOM ARTHROTOMY, DISTAL RADIOULNAR JOINT INCLUDING REPAIR OF TRIANGULAR CARTILAGE, COMPLEX EXCISION OF TENDON, FOREARM AND / OR WRIST, FLEXOR OR EXTENSOR EXCISION, LESION OF TENDON SHEATH, FOREARM AND/OR WRIST EXCISION OF GANGLION, WRIST (DORSAL OR VOLAR); PRIMARY EXCISION OF GANGLION, WRIST (DORSAL OR VOLAR); RECURRENT RADICAL EXCISION OF BURSA, SYNOVIA OF WRIST, OR FOREARM TENDON SHEATHS; FLEXOR RADICAL EXCISION OF BURSA, SYNOVIA OF WRIST, OR FOREARM TENDON SHEATHS SYNOVECTOMY, ETENSOR TENDON SHEATH, WRIST; SINGLE COMPARTMENT SYNOVECTOMY, EXTENSOR TENDON SHEATH, WRIST, SINGLE COMPARTMENT; W/ RESECT EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF RADIUS OR ULNA EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF CARPAL BO Page 75 of 159

76 25170 RADICAL RESECTION FOR TUMOR, RADIUS OR ULNA CARPECTOMY; ONE BONE CARPECTOMY; ALL BONES OF PROXIMAL ROW EXCISION DISTAL ULNA PARTIAL OR COMPLETE INJECTION PROCEDURE FOR WRIST ARTHOGRAPHY EXPLORATION WITH REMOVAL OF DEEP FOREIGN BODY, FOREARM OR WRIST REPAIR, TENDON OR MUSCLE, FLEXOR, FOREARM AND/OR WRIST; PRIMARY, SINGLE, EACH REPAIR, TENDON OR MUSCLE, FLEXOR, FOREARM &/OR WRIST;SECONDARY, SINGLE, EA TEN REPAIR, TENDON OR MUSCLE, FLEXOR, FOREARM &/OR WRIST;SECONDARY,W/ FREE GRAFT REPAIR, TENDON OR MUSCLE, EXTENSOR, FOREARM AND/OR WRIST; PRIMARY, SINGLE, EA REPAIR, TENDON OR MUSCLE, EXTENSOR, SECONDARY, W/ TENDON GRAFT,FOREARM &/OR REPAIR, TENDON SHEATH, EXTENSOR, FOREARM AND/OR WRIST WITH FREE GRAFT (INCLUDES OBTAINING GRAFT)( EG, FOR EXTENSOR CARPI ULNARIS SUBLUXATION) TENOTOMY, OPEN, FLEXOR OR EXTENSOR TENDON, FOREARM AND/OR WRIST, SINGLE, EA TENOLYSIS, FLEXOR OR EXTENSOR TENDON, FOREARM AND/OR WRIST, SINGLE, EACH TEND TENOLYSIS AT WRIST; EXTENSORS OF FINGERS TENDON TRANSPLANTATION OR TRANSFER, FLEXOR OR EXTENSOR, FOREARM AND/OR WRIS TENDON TRANSPLANTATION OR TRANSFER, FLEXOR OR EXTENSOR, FOREARM &/OR WRIST CAPSULORRHAPHY OR RECONSTRUCTION, WRIST, ANY METHOD (INC SYNOVECTOMY, CAP ARTHROPLASTY, WRIST, WITH OR WITHOUT INTERPOSITION, WITH OR WITHOUT EXTERNAL OR INTERNAL FIXATION RECONSTRUCTION FOR STABILIZATION OF UNSTABLE DISTAL ULNA OR DISTAL RADIOULNAR OSTEOTOMY, RADIUS; DISTAL THIRD OSTEOPLASTY, RADIUS OR ULNA; SHORTENING OSTEOPLASTY, RADIUS OR ULNA; LENGTHENING WITH AUTOGRAFT REPAIR OF NONUNION OR MALUNION, RADIUS OR ULNA; WITHOUT GRAFT (EG. COMPRESSION REPAIR OF NONUNION OR MALUNION, RADIUS OR ULNA; WITH ILIAC OR OTHER AUTOGRAFT REPAIR OF NONUNION OR MALUNION, RADIUS AND ULNA; WITH ILIAC OR OTHER AUTOGRAFT REPAIR OF NONUNION OF CARPAL BONE (EXCLUSING CARPAL SCAPHOID (NAVICULAR)) (INCLUDES OBTAINING GRAFT AND NECESSARY FIXATION), EACH BONE REPAIR OF NONUNION, SCAPHOID (NAVICULAR) BONE, WITH OR WITHOUT RADIAL STYLOIDEC ARTHROPLASTY WITH PROSTHETIC REPLACEMENT; TRAPEZIUM INTERPOSITION ARTHROPLASTY, INTERCARPAL OR CARPOMETACARPAL JOINTS CLOSED TREATMENT OF RADIAL SHAFT FRACTURE; WITHOUT MANIPULATION OPEN TREATMENT OF RADIAL SHAFT FACTURE, WITH OR WITHOUT INTERNAL OR EXTERNAL CLOSED TREATMENT OF RADIAL SHAFT FRACTURE,W/ DISLOCATION OF DISTAL RADIOULNAR OPEN TREATMENT OF RADIAL SHAFT FRACTURE,W/ INTERNAL &/OR EXTERNAL FIXATION & CL OPEN TREATMENT OF RADIAL SHAFT FRACTURE, W/ INTERNAL &/ OR EXTERNAL FIXATION & CLOSED TREATMENT OF ULNAR SHAFT FRACTURE; WITHOUT MANIPULATION CLOSED TREATMENT OF ULNAR SHAFT FRACTURE, WITH MANIPULATION Page 76 of 159

77 25545 OPEN TREATMENT OF ULNAR SHAFT FRACTURE, WITH OR WITHOUT INTERNAL OR EXTERNAL CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES; WITHOUT MANIPULATION CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES; WITH MANIPULATION OPEN TREATMENT OF RADIAL & ULNAR SHAFT FRACTURES,W/ INTERNAL OR EXTERNAL FIX OPEN TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES, WITH INTERNAL OR EXTERNA CLOSED TREATMENT OF DISTAL RADIAL FRACTURE OR EPIPHYSEAL SEPARATION, WITH OR PERCUTANEOUS SKELETAL FIXATION OF DISTAL RADIAL FRACTURE OR EPIPHYSEAL SEPARA OPEN TREATMENT OF DISTAL RADIAL EXTRA-ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION, WITH INTERNAL FIXATION OPEN TREATMENT OF DISTAL RADIAL INTRA-ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION, WITH INTERNAL FIXATION OF 2 FRAGMENTS OPEN TREATMENT OF DISTAL RADIAL INTRA-ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION, WITH INTERNAL FIXATION OF 3 OR MORE FRAGMENTS OPEN TREATMENT OF CARPAL SCAPHOID (NAVICULAR) FRACTURE, WITH OR WITHOUT INTER OPEN TREATMENT OF CARPAL BONE FRACTURE (EXC CARPAL SCAPHOID), EACH BONE CLOSED TREATMENT OF ULNAR STYLOID FRACTURE CLOSED TREATMENT OF READIOCARPAL OR INTERCARPAL DISLOCATION, 1 OR MORE BONES, WITH MANIPULATION OPEN TREATMENT OF RADIOCARPAL OR INTERCARPAL DISLOCATION, ONE OR MORE BONES CLOSED TREATMENT OF DISTAL RADIOULNAR DISLOCATION WITH MANIPULATION OPEN TREATMENT OF DISTAL RADIOULNAR DISLOCATION, ACUTE OR CHRONIC CLOSED TREATMENT OF TRANS-SCAPHOPERILUNAR TYPE OF FRACTURE DISLOCATION WITH OOPEN TREATMENT OF TRANS-SCAPHOPERILUNAR TYPE OF FRACTURE DISLOCATION CLOSED TREATMENT OF LUNATE DISLOCATION, WITH MANIPULATION OPEN TREATMENT OF LUNATE DISLOCATION ARTHRODESIS, WRIST JOINT (INCLUDING RADIOCARPAL AND/OR ULNOCARPAL FUSION); W/O ARTHRODESIS, WRIST; LIMITED, WITHOUT BONE GRAFT (EG, INTERCARPAL OR RADIOCARPAL) INTERCARPAL FUSION; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT) ARTHRODESIS, DISTAL RADIOULNAR JOINT WITH SEGMENTAL RESECTION OF ULNA, WITH OR WITHOUT BONE GRAFT (EG, SAUVE-KAPANDJI PROCEDURE) AMPUTATION, FOREARM, THROUGH RADIUS AND ULNA; RE-AMPUTATION DRAINAGE OF TENDON SHEATH, ONE DIGIT AND/OR PALM DRAINAGE OF PALMAR BURSA; SINGLE, BURSA DRAINAGE OF PALMAR BURSA; MULTIPLE BURSA INCISION, BONE, CORTEX, HAND OR FINGER (EG, OSTEOMYELITIS OR BONE ABSCESS) DECOMPRESSION FINGERS AND/OR HAND, INJECTION INJURY (EG, GREASE GUN) DECOMPRESSIVE FASCIOTOMY, HAND (EXCLUDES 26035) FASCIOTOMY, PALMAR, FOR DUPUYTREN'S CONTRACTURE; PERCUTANEOUS FASCIOTOMY, PALMAR, FOR DUPUYTREN'S CONTRACTURE; OPEN, PARTIAL TENDON SHEATH INCISION (EG, FOR TRIGGER FINGER) Page 77 of 159

78 26060 TENOTOMY, SUBCUTANEOUS, SINGLE, EACH DIGIT ARTHROTOMY, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY; CARPOMETA ARTHROTOMY, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY; METACARP ARTHROTOMY, WITH EXPLORATION, DRAINAGE OR REMOVAL OF FOREIGN BODY; INTERPHALA ARTHROTOMY WITH BIOPSY; CARPOMETACARPAL JOINT, EACH ARTHROTOMY WITH BIOPSY; METACARPOPHALANGEAL JOINT, EACH ARTHROTOMY WITH SYNOVIAL BIOPSY; INTERPHALANGEAL JOINT, EACH EXCISION TUMOR OR VASCULAR MALFORMATION, SOFT TISSUE OF HAND OR FINGER, SUBQ; 1.5 CM OR GREATER EXCISION, TUMOR, SOF TISSUE, OR VASCULAR MALFORMATION, OF HAND OR FINGER; 1.5 CM OR GREATER EXCISION OF TUMOR OR VASCULAR MALFORMATION, HAND OR FINGER; SUBCUTANEOUS EXCISION OF TUMOR OR VASCULAR MALFORMATION, HAND OR FINGER; DEEP, SUBFASCIAL, RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM), SOFT TISSUE OF HAND OR FIN FASCIECTOMY, PALM ONLY, WITH OR WITHOUT Z-PLASTY, OTHER LOCAL TISSUE REARRANGE FASCIECTOMY, PARTIAL PALMAR WITH RELEASE OF SINGLE DIGIT INCLUDING PROXIMAL SYNOVECTOMY, CARPOMETACARPAL JOINT SYNOVECTOMY, METACARPOPHALANGEAL JOINT INCLUDING INTRINSIC RELEASE AND EXTER SYNOVECTOMY, PROXIMAL INTERPHALANGEAL JOINT, INCLUDING EXTENSOR RECONSTRUC SYNOVECTOMY TENDON SHEATH, RADICAL (TENOSYNOVECTOMY), FLEXOR, PALM OR FINGER, EXCISION OF LESION OF TENDON SHEATH OR CAPSULE (EG, CYST, MUCOUS CYST OR GANG EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF METACARPAL EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF METACARPAL; WITH AUTOG EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF PROXIMAL, MIDDLE OR DIS EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF PROXIMAL, MIDDLE OR DIS PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE;METACARP PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE;PROXIMAL PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE;DISTAL PH RADICAL RESECTION (OSTECTOMY) FOR TUMOR, PROXIMAL OR MIDDLE PHALANX FINGER;W/ RADICAL RESECTION, DISTAL PHALANX OF FINGER (EG, TUMOR) REMOVAL OF IMPLANT FROM FINGER OR HAND MANIPULATION, FINGER JOINT, UNDER ANESTHESIA, EACH JOINT FLEXOR TENDON REPAIR OR ADVANCEMENT, SINGLE, NOT IN "NO MAN'S LAND"; PRIMARY OR REPAIR OF ADVANCEMENT, FLEXOR TENDON, NOT IN ZONE 2 DIGITAL FLEXOR TENDON SHEATH (EG. NO MAN'S LAND); SECONDARY WITH FREE GRAFT (INCLUDES OBTAINING GRAFT) EACH TENDON FLEXOR TENDON REPAIR OR ADVANCEMENT, SINGLE, IN "NO MAN'S LAND"; PRIMARY, EACH FLEXOR TENDON REPAIR OR ADVANCEMENT, SINGLE, IN "NO MAN'S LAND"; SECONDARY, EA FLEXOR TENDON REPAIR OR ADVANCEMENT, SINGLE, IN "NO MAN'S LAND"; SECONDARY W/ PROFUNDUS TENDON REPAIR OR ADVANCEMENT, WITH INTACT SUBLIMIS; PRIMARY Page 78 of 159

79 26373 PROFUNDUS TENDON REPAIR OR ADVANCEMENT, WITH INTACT SUBLIMIS; SECONDARY W/O FLEXOR TENDON EXCISION, IMPLANTATION OF PLASTIC TUBE OR ROD FOR DELAYED TENDON REMOVAL OF TUBE OR ROD AND INSERTION OF TENDON GRAFT, HAND OR FINGER EXTENSOR TENDON REPAIR, DORSUM OF HAND, SINGLE, PRIMARY OR SECONDARY, WITHOU EXCISION OF EXTENSOR TENDON,IMPLANTATION OF PROSTHETIC ROD FOR DELAYED TEND EXTENSOR TENDON REPAIR, DORSUM OF FINGER, SINGLE, PRIMARY OR SECONDARY; W/O EXTENSOR TENDON REPAIR, CENTRAL SLIP REPAIR, SECONDARY; USING LOCAL TISSUES REPAIR OF EXTENSOR TENDON, CENTRAL SLIP, SECONDARY (EG. BOUTONNIER DEFORMITY); WITH FREE GRAFT (INCLUDES OBTAINING GRAFT), EACH FINGER CLOSED TREATMENT OF DISTAL EXTENSOR TENDON INSERTION W/ OR W/O PERCUTANEOUS REPAIR OF EXTENSOR TENDON, DISTAL INSERTION, PRIMARY OR SECONDARY; W/O GRAFT REALIGNMENT OF EXTENSOR TENDON, HAND, EACH TENDON TENOLYSIS, SIMPLE, FLEXOR TENDON; PALM OR FINGER, SINGLE, EACH TENDON TENOLYSIS, SIMPLE, FLEXOR TENDON; PALM AND FINGER, EACH TENDON TENOLYSIS, EXTENSOR TENDON, HAND OR FINGER; EACH TENDON TENOLYSIS, COMPLEX, EXTENSOR TENDON, FINGER, INCLUDING FOREARM, EACH TENDON TENOTOMY, FLEXOR, SINGLE, FINGER, OPEN; EACH TENODESIS; OF PROXIMAL INTERPHALANGEAL JOINT, EACH JOINT LENGTHENING OF TENDON, EXTENSOR, HAND OR FINGER, EACH TENDON TENDON TRANSFER OR TRANSPLANT, CARPOMETACARPAL AREA OR DORSUM OF HAND, SIN TRANSFER OR TRANSPLANT OF TENDON, PALMAR; W/O FREE TENDON GRAFT, EACH TENDON OPPONENSPLASTY; SUPERFICIALIS TENDON TRANSFER TYPE, EACH TENDON OPPONENSPLASTY; OTHER METHODS TRANSFER OF TENDON TO RESTORE INTRINSIC FUNCTION; RINGAND SMALL FINGER TENDON TRANSFER TO RESTORE INTRINSIC FUNCTION; ALL FOUR FINGERS CORRECTION CLAW FINGER, OTHER METHODS RELEASE OF THENAR MUSCLE(S) (EG, THUMB CONTRACTURE) CROSS INTRINSIC TRANSFER CAPSULODESIS, METACARPOPHALANGEAL JOINT; SINGLE DIGIT CAPSULECTOMY OR CAPSULOTOMY; METACARPOPHALANGEAL JOINT, EACH JOINT CAPSULTECTOMY OR CAPSULOTOMY; INTERPHALANGEAL JOINT, EACH JOINT ARTHROPLASTY, METACARPOPHALANGEAL JOINT; SINGLE, EACH ARTHROPLASTY, METACARPOPHALANGEAL JOINT; WITH PROSTHETIC IMPLANT, EACH JOINT ARTHROPLASTY INTERPHALANGEAL JOINT; SINGLE, EACH ARTHROPLASTY INTERPHALANGEAL JOINT; WITH PROSTHETIC IMPLANT, SINGLE, EACH REPAIR OF COLLATERAL LIGAMENT, METACARPOPHALANGEAL OR INTERPHALANGEAL JOINT RECONSTRUCTION, COLLATERAL LIGAMENT, METACARPOPHALANGEAL JOINT, SINGLE, WITH RECONSTRUCTION, COLLATERAL LIGAMENT, METACARPOPHALANGEAL JOINT, SINGLE, WITH RECONSTRUCTION, COLLATERAL LIGAMENT, INTERPHALANGEAL JOINT, SINGLE, INC GRAFT, REPAIR NON-UNION, METACARPAL OR PHALANX, (INC OBTAINING BONE GRAFT W/ OR W/O EX Page 79 of 159

80 26548 REPAIR AND RECONSTRUCTION, FINGER, VOLAR PLATE, INTERPHALANGEAL JOINT REPAIR OF SYNDACTYLY (WEB FINGER) EACH WEB SPACE; WITH SKIN FLAPS REPAIR OF SYNDACTYLY (WEB FINGER) EACH WEB SPACE; WITH SKIN FLAPS AND GRAFTS REPAIR OF SYNDACTYLY (WEB FINGER) EACH WEB OSTEOTOMY; METACARPAL, EACH OSTEOTOMY FOR CORRECTION OF DEFORMITY; PHALANX OSTEOPLASTY, LENGTHENING, METACARPAL OR PHALANX RECONSTRUCTION OF POLYDACTYLOUS DIGIT, SOFT TISSUE AND BONE REPAIR, INTRINSIC MUSCLES OF HAND, EACH MUSCLE RELEASE, INTRINSIC MUSCLES OF HAND (SPECIFY) CLOSED TREATMENT OF METACARPAL FRACTURE, WITH MANIPULATION, WITH INTERNAL OR PERCUTANEOUS SKELETAL FIXATION OF METACARPAL EACH BONE OPEN TREATMENT OF METACARPAL FRACTURE, SINGLE, WITH OR WITHOUT INTERNAL OR CLOSED TREATMENT OF CARPOMETACARPAL DISLOCATION, THUMB, WITH MANIPULATION CLOSED TREATMENT OF CARPOMETACARPAL FRACTURE DISLOCATION, THUMB,W/ MANIPUL PERCUTANEOUS SKELETAL FIXATION OF CARPOMETACARPAL FRACTURE DISLOCATION, TH OPEN TREATMENT OF CARPOMETACARPAL FRACTURE DISLOCATION, THUMB, WITH OR W/O CLOSED TREATMENT OF CARPOMETACARPAL DISLOCATION, OTHER THAN THUMB, SINGLE,W/ PRECUTANEOUS SKELETAL FIXATION OF CARPOMETACARPAL DISLOCATION, OTHER THAN OPEN TREATMENT OF CARPOMETACARPAL DISLOCATION,OTHER THAN THUMB,W/ OR W/O INT OPEN TREATMENT OF CARPOMETACARPAL DISLOCATION,OTHER THAN THUMB;COMPLEX, MU CLOSED TREATMENT OF METACARPOPHALANGEAL DISLOCATION, SINGLE, W/ MANIPULATION; CLOSED TREATMENT OF METACARPOPHALANGEAL DISLOCATION, SINGLE, W/ MANIPULATION; PERCUTANEOUS SKELETAL FIXATION OF METACARPOPHALANGEAL DISLOCATION, SINGLE,W/ OPEN TREATMENT OF METACARPOPHALANGEAL DISLOCATION,SINGLE,W/ OR W/O INTERNAL PERCUTANEOUS SKELETAL FIXATION OF UNSTABLE PHALANGEAL SHAFT FRACTURE, PROX OPEN TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FIN OPEN TREATMENT OF ARTICULAR FRACTURE, INVOLVING METACARPOPHALANGEAL OR INTE PERCUTANEOUS SKELETAL FIXATION OF DISTAL PHALANGEAL FRAC, FINGER OPEN TREATMENT OF DISTAL PHALANGEAL FRACTURE, FINGER OR THUMB, WITH OR W/O CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, SINGLE, W/ MANIPULATION OPEN TREATMENT OF CLOSED OR OPEN INTERPHALANGEAL JOINT DISLOCATION, WITH OR FUSION IN OPPOSITION, THUMB, WITH AUTOGENOUS GRAFT (INCLUDES OBTAINING GRAFT) ARTHRODESIS, CARPOMETACARPAL JOINT, THUMB, WITH OR WITHOUT INTERNAL FIXATION ARTHRODESIS, CARPOMETACARPAL JOINT, THUMB, W/ OR W/O INTERNAL FIXATION; W/ AUTO ARTHRODESIS, METACARPOPHALANGEAL JOINT, WITH OR WITHOUT INTERNAL FIXATION; ARTHRODESIS, METACARPOPHALANGEAL JOINT, W/ OR W/O INTERNAL FIXATION; W/ AUTOGR ARTHRODESIS, INTERPHALANGEAL JOINT, WITH OR WITHOUT INTERNAL FIXATION; ARTHRODESIS, INTERPHALANGEAL JOINT, WITH OR WITHOUT INTERNAL FIXATION; WITH AUTO AMPUTATION,METACARPAL,W/ FINGER OR THUMB,SINGLE, W/ OR W/O INTEROSSEOUS TRANS Page 80 of 159

81 26951 AMPUTATION, FINGER OR THUMB, PRIMARY OR SECONDARY, ANY JOINT OR PHALANX, SINGLE AMPUTATION, FINGER OR THUMB, PRIMARY OR SECONDARY, ANY JOINT OR PHALANX, SINGLE INCISION AND DRAINAGE, PELVIS OR HIP JOINT AREA; DEEP ABSCESS OR HEMATOMA TENOTOMY, ADDUCTOR OF HIP, OPEN ARTHROTOMY, HIP, WITH EXPLORATION OR REMOVAL OF LOOSE OR FOREIGN BODY BIOPSY, SOFT TISSUES OF PELVIS AND HIP AREA; DEEP EXCISION TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA, SUBQ; 3 CM OR GREATER EXCISION, TUMOR, PELVIS AND HIP AREA; SUBCUTANEOUS TISSUE EXCISION, TUMOR, PELVIS AND HIP AREA; DEEP, SUBFASCIAL, INTRAMUSCULAR RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM), SOFT TISSUE OF PELVIS AND ARTHROTOMY, WITH BIOPSY; SACROILIAC JOINT ARTHROTOMY, WITH BIOPSY; HIP JOINT EXCISION; ISCHIAL BURSA EXCISION OF BONE CYST OR BENIGN TUMOR; DEEP, WITH OR WITHOUT AUTOGRAFT REMOVAL OF FOREIGN BODY, PELVIS OR HIP; DEEP (SUBFASCIAL OR INTRAMUSCULAR) INJECTION PROCEDURE FOR HIP ARTHOGRAPHY; WITH OR WITHOUT ANESTHESIA INJECTION PROCEDURE FOR SACROILIAC JOINT, ARTHROGRAPHY AND/OR ANESTHETIC/STEROID ARTHROPLASTY, ACETABULAR AND PROXIMAL FEMORAL PROSTHETIC REPLACEMENT (TOTAL HIP ARTHROPLASTY), WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT BONE GRAFT, FEMORAL HEAD, NECK, INTERTROCHANTERIC OR SUBTROCHANTERIC AREA (INCLUDES OBTAINING BONE GRAFT) TREATMENT OF SLIPPED FEMORAL EPIPHYSIS; BY SINGLE OR MULTIPLE PINNING, IN SITU OPEN TREATMENT OF SLIPPED FEMORAL EPIPHYSIS; SINGLE OR MULTIPLE PINNING OR BONE GRAT (INCLUDES OBTAINING GRAFT) CLOSED TREATMENT OF PELVIC RING FRACTURE, DISLOCATION, DIASTASIS OR SUBLUXATI CLOSED TREATMENT OF PELVIC RING FRACTURE, DISLOCATION, DIASTASIS OR SUBLUXATIO CLOSED TREATMENT OF COCCYGEAL FRACTURE CLOSED TREATMENT OF ACETABULUM (HIP SOCKET) FRACTURE(S); WITHOUT MANIPULATION CLOSED TREATMENT OF FEMORAL FRACTURE, PROXIMAL END, NECK; W/O MANIPULATION PERCUTANEOUS SKELETAL FIXATION OF FEMORAL FRACTURE, PROXIMAL END, NECK OPEN TREATMENT OF FEMORAL FRACTURE. PROXIMAL END, NECK, INTERNAL FIXATION OR PROSTHETIC REPLACEMENT (DIRECT FRACTURE) CLOSED TREATMENT OF GREATER TROCHANTERIC FRACTURE, WITHOUT MANIPULATION CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; WITHOUT ANESTHESIA CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING ANESTHESIA CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION; WITHOUT ANESTHESIA CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION; REQUIRING REGIONAL OR CLOSED TREATMENT OF FEMORAL FRACTURE, PROXIMAL END, HEAD; WITHOUT MANIPULATION CLOSED TREATMENT OF FEMORAL FRACTURE, PROXIMAL END, HEAD; WITH MANIPULATION Page 81 of 159

82 27269 OPEN TREATMENT OF FEMORAL FRACTURE, PROXIMAL END, HEAD, INCLUDES INTERNAL FIXATION, WHEN PERFORMED INCISION AND DRAINAGE DEEP ABCESS, BURSA, OR HEMATOMA, THIGH OR KNEE REGION FASCIOTOMY, ILIOTIBIAL (TENOTOMY), OPEN ARTHROTOMY, KNEE, FOR INFECTION, WITH EXPLORATION, DRAINAGE OR REMOVAL OF FORE BIOPSY, SOFT TISSUES, OF THIGH OR KNEE AREA; DEEP NEURECTOMY, HAMSTRING MUSCLE NEURECTOMY, POPLITEAL (GASTROCNEMIUS) EXCISION, TUMOR, THIGH OR KNEE AREA; SUBCUTANEOUS EXCISION, TUMOR, THIGH OR KNEE AREA; DEEP, SUBFASCIAL OR INTRAMUSCULAR RADICAL RESECTION OF TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA ARTHROTOMY, KNEE; WITH SYNOVIAL BIOPSY ONLY ARTHROTOMY, KNEE; WITH JOINT EXPLORATION, WITH OR WITHOUT BIOPSY, WITH OR W/O ARTHROTOMY, KNEE, WITH EXCISION OF SEMILUNAR CARTILAGE (MENISCECTOMY); MEDIAL ARTHROTOMY, KNEE WITH EXCISION OF SEMILUNAR CARTILAAGE; MEDIAL AND LATERAL ARTHROTOMY, WITH SYNOVECTOMY KNEE; ANTERIOR OR POSTERIOR ARTHROTOMY, KNEE, W/ SYNOVECTOMY; ANTERIOR & POSTERIOR INC POPLITEAL AREA EXCISION TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBQ; 3 CM OR GREATER EXCISION, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBFASCIAL (EG. INTRAMUSCULAR); 5CM OR GREATER EXCISION, PREPATELLAR BURSA EXCISION OF SYNOVIAL CYST OF POPLITEAL SPACE (BAKER'S CYST) EXCISION OF LESION OF MENISCUS OR CAPSULE(EG, CYST, GANGLION), KNEE PATELLECTOMY OR HEMIPATELLECTOMY EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF FEMUR; WITH ALLOGRAFT EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF FEMUR; WITH ALLOGRAFT EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF FEMUR; WITH AUTOGRAFT PARTIAL EXC(CRATERIZATION,SAUCERIZATION OR DIAPHYSECTOMY) BONE,FEMUR,PROXIMA RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM), SOFT TISSUE OF THIGH OR KNEE AREA; 5CM OR GREATER INJECTION PROCEDURE FOR KNEE ARTHROGRAPHY REMOVAL FOREIGN BODY, DEEP, THIGH REGION OR KNEE AREA SUTURE OF INFRAPATELLAR TENDON; PRIMARY SUTURE OF INFRAPATELLAR TENDON; SECONDARY RECONSTRUCTION, INCLUDING FASCIAL SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE; PRIMARY LENGTHENING OF HAMSTRING TENDON; MULTIPLE TENDONS, BILATERAL ARTHROTOMY WITH OPEN MENISCUS REPAIR REPAIR, PRIMARY, TORN LIGAMENT AND/OR CAPSULE, KNEE; COLLATERAL REPAIR, PRIMARY, TORN LIGAMENT AND/OR CAPSULE, KNEE; CRUCIATE REPAIR, PRIMARY, TORN LIGAMENT &/OR CAPSULE, KNEE; COLLATERAL & CRUCIATE LIGAME Page 82 of 159

83 27412 AUTOLOGOUS CHONDROCYTE IMPLANTATION, KNEE OSTEOCHONDRAL AUTOGRAFT(S), KNEE, OPEN (EG, MOSAICPLASTY) (INCLUDES HARVESTING OF AUTOGRAFT(S)) ANTERIOR TIBIAL TUBERCLEPLASTY (EG, MAQUET TYPE PROCEDURE) RECONSTRUCTION OF DISLOCATING PATELLA; (EG, HAUSER TYPE PROCEDURE) RECONSTRUCTION OF DISLOCATING PATELLA;W/ EXTENSOR REALIGNMENT OR RELEASE RECONSTRUCTION OF DISLOCATING PATELLA, (EG, HAUSERE TYPE PROCEDURE); WITH PATELLECTOMY LATERAL RETINACULAR RELEASE (ANY METHOD) LIGAMENTOUS RECONSTRUCTION (AUGMENTATION), KNEE; EXTRA-ARTICULAR LIGAMENTOUS RECONSTRUCTION (AUGMENTATION), KNEE; INTRA-ARTICULAR (OPEN) LIGAMENTOUS RECONSTRUCTION (AUGMENTATION), KNEE; INTRA-ARTICULAR (OPEN) & EXT QUADRICEPSPLASTY (EG, BENNETT OR THOMPSON TYPE) CAPSULOTOMY, POSTERIOR CAPSULAR RELEASE, KNEE ARTHROPLASTY, PATELLA; WITHOUT PROSTHESIS ARTHROPLASTY, FEMORAL CONDYLES OR TIBIAL PLATEAU(S), KNEE; ARTHROPLASTY, FEMORAL CONDYLES OR TIBIAL PLATEAU(S), KNEE; WITH DEBRIDEMENT AND PARTIAL SYNOVECTOMY ARTHROPLASTY, KNEE, CONDYLE AND PLATEAU; MEDIAL OR LATERAL COMPARTMENT ARTHROPLASTY, KNEE, CONDYLE AND PLATEAU; MEDIAL AND LATERAL COMPARTMENTS WITH OR WITHOUT PATELLA RESURFACING (TOTAL KNEE ARTHROPLASTY) ARREST, EPIPHYSEAL, ANY METHOD (EG, EPIPHYSIODESIS); DISTAL FEMUR ARREST, HEMIPIPHYSEAL, DISTAL FEMUR OR PROXIMAL TIBIA OR FIBULA (EG, GENU VARUS OR VALGUS) PROPHYLACTIC TREATMENT WITH OR WITHOUT METHYLMETHACRYLATE, FEMUR DECOMPRESSION FASCIOTOMY,THIGH &/OR KNEE, MULTIPLE COMPARTMENTS;W/ DEBRIDE CLOSED TREATMENT OF FEMORAL SHAFT FRACTURE WITHOUT MANIPULATION CLOSED TREATMENT OF SUPRACONDYLAR OR TRANSCONDYLAR FEMORAL FRAC W/ OR W/O CLOSED TREATMENT OF FEMORAL SHAFT FRACTURE W/ MANIPULATION,W/ OR W/O SKIN OR CLOSED TREATMENT OF FEMORAL FRAC,DISTAL END,MEDIAL OR LATERAL CONDYLE, W/O MA PERCUTANEOUS SKELETAL FIXATION OF FEMORAL FRAC,DISTAL END,MEDIAL OR LATERAL OPEN TREATMENT OF FEMORAL FRACTURE, DISTAL FEMORAL EPIPHYSEAL SEPARATION, INCLUDES INTERNAL FIXATION WHEN PERFORMED CLOSED TREATMENT OF PATELLAR FRACTURE, WITHOUT MANIPULATION OPEN TREATEMENT OF PATELLAR FRACTURE, W/INTERNAL FIZATION AND/OR PARTIAL/COMPLETE PATELLECTOMY AND SOFT TISSUE REPAIR CLOSED TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); WITHOUT MANIPULATION CLOSED TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); W/ OR W/O MANIPULATION OPEN TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); UNICONDYLAR, INCLUDES INTERNAL FIXATION, WHEN PERFORMED Page 83 of 159

84 27538 CLOSED TREATMENT OF INTERCONDYLAR SPINE(S) &/OR TUBEROSITY FRACTURE(S) KNEE, OPEN TREATMENT OF INTERCONDYLAR SPINE(S) AND/OR TUBEROSITY FRACTURE(S) OF KNEE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED CLOSED TREATMENT OF KNEE DISLOCATION; WITHOUT ANESTHESIA CLOSED TREATMENT OF KNEE DISLOCATION; REQUIRING ANESTHESIA CLOSED TREATMENT OF PATELLAR DISLOCATION; WITHOUT ANESTHESIA CLOSED TREATMENT OF PATELLAR DISLOCATION; REQUIRING ANESTHESIA OPEN TREATMENT OF PATELLAR DISLOCATION, WITH OR WITHOUT PARTIAL OR TOTAL PATELLECTOMY MANIPULATION OF KNEE JOINT UNDER GENERAL ANESTHESIA (INCLUDES APPLICATION OF DECOMPRESSION FASCIOTOMY, LEG; ANTERIOR AND/OR LATERAL COMPARTMENT(S) ONLY DECOMPRESSION FASCIOTOMY, LEG; ANTERIOR &/OR LATERAL, & POSTERIOR COMPARTMEN INCISION AND DRAINAGE, LEG OR ANKLE; DEEP ABSCESS OR HEMATOMA INCISION AND DRAINAGE, LEG OR ANKLE; INFECTED BURSA TENOTOMY, PERCUTANEOUS, ACHILLES TENDON (SEP PROCEDURE); LOCAL ANESTHESIA TENOTOMY, ACHILLES TENDON, SUBCUTANEOUS (SEP PROC); GENERAL ANESTHESIA INCISION,DEEP, WITH OPENING OF BONE CORTEX, LEG OR ANKLE ARTHROTOMY, ANKLE, FOR INFECTION, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF FB ARTHROTOMY, ANKLE, POSTERIOR CAPSULAR RELEASE, WITH OR WITHOU ACHILLES TENDO BIOPSY, SOFT TISSUES OF LEG OR ANKLE AREA; DEEP RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM), SOFT TISSUE OF LEG OR ANKL EXCISION, TUMOR, LEG OR ANKLE AREA; SUBCUTANEOUS TISSUE EXCISION, TUMOR, LEG OR ANKLE AREA; DEEP, SUBFASCIAL OR INTRAMUSCULAR ARTHROTOMY, ANKLE, WITH JOINT EXPLORATION, WITH OR WITHOUT BIOPSY, WITH OR W/O ARTHROTOMY, WITH SYNOVECTOMY; ANKLE; INCLUDING TENOSYNOVECTOMY EXCISION OF LESION OF TENDON SHEATH OR CAPSULE, LEG AND/OR ANKLE EXCISION TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBQ, 3 CM OR GREATER EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBCUTANEOUS; 3 CM OR GREATER EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TIBIA OR FIBULA EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TIBIA OR FIBULA; W/ AUTOGRA EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TIBIA OR FIBULA; W/ ALLOGRA PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) OF BONE; TIBIA PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE; FIBULA RADICAL RESECTION OF TUMOR, BONE; TALUS OR CALCANEUS REPAIR, PRIMARY, OPEN OR PERCUTANEOUS, RUPTURED ACHILLES TENDON REPAIR, PRIMARY, OPEN OR PERCUTANEOUS, RUPTURED ACHILLES TENDON, WITH GRAFT SUTURE, SECONDARY, RUPTURED ACHILLES TENDON, WITH OR WITHOUT GRAFT REPAIR, FASCIAL DEFECT OF LEG REPAIR, FLEXOR TENDON, LEG; PRIMARY, WITHOUT GRAFT, EACH TENDON REPAIR, FLEXOR TENDON, LEG; SECONDARY WITH OR WITHOUT GRAFT, EACH TENDON Page 84 of 159

85 27664 REPAIR, EXTENSOR TENDON, LEG; PRIMARY, WITHOUT GRAFT, EACH TENDON REPAIR, EXTENSOR TENDON, LEG; SECONDARY WITH OR WITHOUT GRAFT, EACH TENDON REPAIR FOR DISLOCATING PERONEAL TENDONS; WITHOUT FIBULAR OSTEOTOMY REPAIR FOR DISLOCATING PERONEAL TENDONS; WITH FIBULAR OSTEOTOMY TENOLYSIS, FLEXOR OR EXTENSOR TENDON, LEG AND/OR ANKLE; SINGLE, EACH TENDON TENOLYSIS, FLEXOR OR EXTENSOR TENDON, LEG AND/OR ANKLE; MULTIPLE TENDONS LENGTHENING OR SHORTENING OF TENDON, LEG OR ANKLE; SINGLE (SEPARATE PROCEDU GASTROCNEMIUS RECESSION (EG, STRAYER PROCEDURE) TRANSFER OR TRANSPLANT OF SINGLE TENDON; SUPERFICIAL (EG, ANTERIOR TIBIAL EXTEN TRANSFER OR TRANSPLANT OF SINGLE TENDON (WITH MUSCLE REDIRECTION OR REROUT REPAIR, PRIMARY, DISRUPTED LIGAMENT, ANKLE; COLLATERAL SUTURE, SECONDARY REPAIR, TORN, RUPTURED OR SEVERED LIGAMANT, ANKLE, C ARTHROPLASTY, ANKLE; ARTHROPLASTY, ANKLE; WITH IMPLANT (TOTAL ANKLE) REMOVAL OF ANKLE IMPLANT OSTEOTOMY; TIBIA OSTEOTOMY; FIBULA OSTEOTOMY; TIBIA AND FIBULA REPAIR OF NONUNION OR MALUNION, TIBIA; WITHOUT GRAFT, (EG, COMPRESSION TECHNIQUE) REPAIR OF FIBULA NONUNION AND/OR MALUNION WITH INTERNAL FIXATION ARREST, EPIPHYSEAL (EPIPHYSIODESIS), OPEN; DISTAL TIBIA AND FIBULA CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (W/ OR W/O FIBULAR FRACTURE);W/O MANI CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE; WITH MANIPULATION, WITH OR WITHOUT PERCUTANEOUS SKELETAL FIXATION OF TIBIAL SHAFT FRACTURE (W/ OR W/O FIBULAR FRAC CLOSED TREATMENT OF MEDIAL MALLEOLUS FRACTURE; WITH MANIPULATION, WITH OR W/O OPEN TREATMENT OF MEDIAL MALLEOLUS FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED CLOSED TREATMENT OF POSTERIOR MALLEOLUS FRACTUREL WITHOUT MANIPULATION CLOSED TREATMENT OF POSTERIOR MALLEOLUS FRACTURE; WITH MANIPULATION OPEN TREATMENT OF POSTERIOR MALLEOUS FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE; WITHOUT MANIPULATION CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE; WITH MANIPULATION OPEN TREATMENT OF MEDIAL MALLEOLUS FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED CLOSED TREATMENT OF DISTAL FIBULAR FRAC (LATERAL MALLEOLUS); W/O MANIPULATION CLOSED TREATMENT OF DISTAL FIBULULAR FRACTURE (LATERAL MALLEOLUS); WITHOUT MA OPEN TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOLUS), WITH OR WITHOUT INTERNAL OR EXTERNAL FIXATION Page 85 of 159

86 27810 CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE, (INCLUDING POTTS); WITHOUT MA OPEN TREATMENT OF BIMALLEOLAR ANKLE FRACTURE, (INCLUDING POTTS); WITHOUT MANIPULATION CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE; WITHOUT MANIPULATION CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE; WITH MANIPULATION OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE W/OR W/O INTERNAL OR EXTERNAL FIXATION, MEDIAL AND/OR LATERAL MALLEOLUS; WITHOUT FIXATION OF POSTERIOR LIP CLOSED TREATMENT OF FRAC OF WEIGHT BEARING ARTICULAR PORTION DISTAL TIBIA, W/OR CLOSED TREATMENT OF FRAC OF WEIGHT BEARING ARTICULAR PORTION DISTAL TIBIA, W/OR OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFACE/PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), WITH INTERNAL FIXATION, WHEN PERFORMED; OF FIBULA ONLY OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFACE/PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), WITH INTERNAL FIXATION, WHEN PERFORMED; OF FIBULA ONLY OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFACE/PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), WITH INTERNAL FIXATION, WHEN PERFORMED; OF BOTH TIBIA AND FIBULA OPEN TREATMENT OF DISTAL TIBIOFIBULAR JOINT (SYNDESMOSIS) DISRUPTION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED CLOSED TREATMENT OF ANKLE DISLOCATION; WITHOUT ANESTHESIA CLOSED TREATMENT OF ANKLE DISLOCATION; REQ ANESTHESIA, W/ OR W/O PERCUTANEOU OPEN TREATMENT OF ANKLE DISLOCATION, W/ OR W/O PERCUTANEOUS SKELETAL FIXATION; OPEN TREATMENT OF ANKLE DISLOCATION, W/ OR W/O PERCUTANEOUS SKELETAL FIXATION; ARTHRODESIS, ANKLE, ANY METHOD ARTHRODESIS, TIBIOFIBULAR JOINT, PROXIMAL OR DISTAL AMPUTATION LEG, THROUGH TIBIA AND FIBULA; SECONDARY CLOSURE OR SCAR REVISION DECOMPRESSION FASCIOTOMY, LEG; ANTERIOR AND/OR LATERAL COMPARTMENTS ONLY, WI DECOMPRESSION FASCIOTOMY, LEG; ANTERIOR &/OR LATERAL, & POSTERIOR COMPARTMEN INCISION AND DRAINAGE, BURSA, FOOT I & DRAINAGE BELOW FASCIA, W/ OR W/O TENDON SHEATH INVOLVEMENT, FOOT; SINGLE BUR DEEP DISSECTION BELOW FASCIA, FOR DEEP INFECTION OF FOOT, W/ OR W/O TENDON SHE INCISION, BONE CORTEX (EG, OSTEOMYELITIS OR BONE ABSCESS), FOO FASCIOTOMY, FOOT AND/OR TOE TENOTOMY, PERCUTANEOUS, TOE; SINGLE TENDON TENOTOMY, PERCUTANEOUS, TOE; MULTIPLE TENDONS ARTHROTOMY,INC EXPLORATION,DRAINAGE OR REMOVAL LOOSE OR FB;INTERTARSAL OR TA ARTHROTOMY, WITH EXPLORATION, DRAINAGE OR REMOVAL OF LOOSE OR FOREIGN BODY; ARTHROTOMY,W/ EXPLORATION,DRAINAGE OR REMOVAL OF LOOSE OR FB;INTERPHALANGEA TARSAL TUNNEL RELEASE (POSTERIOR TIBIAL NERVE DECOMPRESSION) Page 86 of 159

87 28039 EXCISION, TUMOR, SOFT TISSUE OF FOOT OR TOE. SUBCUTANEOUS; 1.5 CM OR GREATER EXCISION, TUMOR, SOFT TISSUE OF FOOT OR TOE, SUBFASCIAL INTRAMUSCULAR; 1.5 CM OR GREATER EXCISION, TUMOR, FOOT; SUBCUTANEOUS TISSUE EXCISION, TUMOR, FOOT; DEEP, SUBFASCIAL, INTRAMUSCULAR RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM), SOFT TISSUE OF FOOT ARTHROTOMY FOR SYNOVIAL BIOPSY; METATARSOPHALANGEAL JOINT ARTHROTOMY FOR SYNOVIAL BIOPSY; INTERPHALANGEAL JOINT NEURECTOMY, INTRINSIC MUSCULATURE OF FOOT FASCIECTOMY, EXCISION OF PLANTAR FASCIA; PARTIAL (SEPARATE PROCEDURE) FASCIECTOMY, EXCISION OF PLANTAR FASCIA; RADICAL (SEPARATE PROCEDURE) SYNOVECTOMY; METATARSOPHALANGEAL JOINT, EACH EXCISION OF INTERDIGITAL (MORTON) NEUROMA, SINGLE, EACH SYNOVECTOMY, TENDON SHEATH, FOOT; FLEXOR SYNOVECTOMY, TENDON SHEATH, FOOT; EXTENSOR EXCISION OF LESION OF TENDON OR FIBROUS SHEATH OR CAPSULE; FOOT EXCISION OF LESION OF TENDON OR FIBROUS SHEATH OR CAPSULE; TOES EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TALUS OR CALCANEUS; EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR,TALUS OR CALCANEUS; W/ ILIA EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TARSAL OR METATARSAL BON EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, PHALANGES OF FOOT OSTECTOMY, PARTIAL EXCISION, FIFTH METATARSAL HEAD (BUNIONETTE) (SEPARATE PROC OSTECTOMY, COMPLETE EXCISION; FIRST METATARSAL HEAD OSTECTOMY,COMPLETE EXCISION;OTHER METATARSAL HEAD (SECOND, THIRD OR FOURTH) OSTECTOMY, COMPLETE EXCISION; FIFTH METATARSAL HEAD OSTECTOMY; ALL METATARSAL HEADS WITH PARTIAL PROXIMAL PHALANGECTOMY, EXCLUD OSTECTOMY, EXCISION OF TARSAL COALITION OSTECTOMY, CALCANEUS OSTECTOMY, CALCANEUS; FOR SPUR, WITH OR WITHOUT PLANTAR FASCIAL RELEASE PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, SEQUESTRECTOMY OR DIAPHYSECTO PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR SEQUESTRECTOMY OR DIAPHYSEC PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR SEQUESTRECTOMY OR DIAPHYSEC RESECTION, PARTIAL OR COMPLETE, PHALANGEAL BASE, EACH TOE TALECTOMY (ASTRAGALECTOMY) METATARSECTOMY PHLANGECTOMY OF TOE, EACH TOE RESECTION, CONDYLE(S), DISTAL END OF PHALANX, EACH TOE HEMIPHALANGECTOMY OR INTERPHALANGEAL JOINT EXC,TOE,PROXIMAL END OF PHALANX, RADICAL RESECTION OF TUMOR, BONE; METATARSAL RADICAL RESECTION OF TUMOR, BONE; PHALANX OF TOE Page 87 of 159

88 28192 REMOVAL OF FOREIGN BODY, FOOT; DEEP REMOVAL OF FOREIGN BODY, FOOT; COMPLICATED REPAIR OR SUTURE OF TENDON, FOOT, FLEXOR, SINGLE; PRIMARY OR SECONDARY, WITHOU REPAIR,TENDON,FLEXOR,FOOT;SECONDARY W/ FREE GRAFT,EACH TENDON REPAIR OR SUTURE OF TENDON, FOOT, EXTENSOR, SINGLE; PRIMARY OR SECONDARY, EACH TENOLYSIS, FLEXOR, FOOT; SINGLE TENDON TENOLYSIS, FLEXOR, FOOT; MULTIPLE TENDONS TENOLYSIS, EXTENSOR, FOOT; SINGLE TENDON TENOLYSIS, EXTENSOR, FOOT; MULTIPLE TENDONS TENOTOMY, OPEN, TENDON FLEXOR; FOOT, SINGLE OR MULTIPLE TENDON(S) (SEP PROC) TENOTOMY, OPEN, TENDON FLEXOR; TOE, SINGLE TENDON (SEPARATE PROCEDURE) TENOTOMY, OPEN, EXTENSOR, FOOT OR TOE, EACH TENDON ADVANCEMENT OF POSTERIOR TIBIAL TENDON WITH EXCISION OF ACCESSORY NAVICULAR TENOTOMY, LENGTHENING, OR RELEASE, ABDUCTOR HALLUCIS MUSCLE DIVISION OF PLANTAR FASCIA AND MUSCLE CAPSULOTOMY, MIDFOOT; WITH TENDON LENGTHENING CAPSULOTOMY, MIDFOOT; EXTENSIVE, INC POSTERIOR TALOTIBIAL CAPSULOTOMY & TENDON CAPSULOTOMY; METATARSOPHALANGEAL JOINT, W/ OR W/O TENORRHAPHY, EA JOINT (SEP CAPSULOTOMY FOR CONTRACTURE; INTERPHALANGEAL JOINT, SINGLE, EACH JOINT (SEPAR SYNDACTYLIZATION, TOES (EG, WEBBING OR KELIKIAN TYPE PROCEDURE) HAMMERTOE OPERATION; ONE TOE (EG, INTERPHALANGEAL FUSION, FILLETING, PHALANGEC OSTECTOMY, PARTIAL, EXOSTECTOMY OR CONDYLECTOMY, SINGLE, METATARSAL HEAD, FIRS HALLUX VALGUS (BUNION) CORRECTION, W/ OR W/O SESAMOIDECTOMY; SIMPLE EXO HALLUX VALGUS (BUNION) CORRECTION, WITH OR WITHOUT SESAMOIDECTOMY; SIMPLE EXO HALLUX VALGUS (BUNION) CORRECTION, WITH OR WITHOUT SESAMOIDECTOMY; KELLER, M HALLUX VALGUS (BUNION) CORRECTION, WITH OR WITHOUT SESAMOIDECTOMY; RESECTION CORRECTION, HALLUX VALGUS (BUNION),W/ OR W/O SESAMOIDECTOMY;W/ TENDON TRANSP HALLUX VALGUS (BUNION) CORRECTION, WITH OR WITHOUT SESAMOIDECTOMY; WITH META HALLUX VALGUS (BUNION) CORRECTION, WITH OR WITHOUT SESAMOIDECTOMY; LAPIDUS TY HALLUX VALGUS (BUNION) CORRECTION, W/ OR W/O SESAMOIDECTOMY;BY PHALANX OSTEO HALLUX VALGUS (BUNION) CORRECTION; BY OTHER METHODS (EG, DOUBLE OSTEOTOMY) OSTEOTOMY;CALCANEUS (EG, DWYER OR CHAMBERS TYPE PROC) W/ OR W/O INTERNAL FIXA OSTEOTOMY; TALUS OSTEOTOMY, TARSAL BONES, OTHER THAN CALCANEUS OR TALUS OSTEOTOMY, METATARSAL, BASE OR SHAFT, SINGLE, WITH OR WITHOUT LENGTHENING, FOR OSTEOTOMY,W/ OR W/O LENGTHENING,SHORTENING OR ANGULAR CORRECTION,METATARS OSTEOTOMY, METATARSAL, BASE OR SHAFT, SINGLE, WITH OR WITHOUT LENGTHENING, FOR OSTEOTOMY, METATARSALS, MULTIPLE, FOR CAVUS FOOD (SWANSON TYPE PROCEDURE) OSTEOTOMY,SHORTENING,ANGULAR OR ROTATIONAL CORRECTION;PROXIMAL PHALANX, FIR OSTEOTOMYSHORTENING, ANGULAR OR ROTATIONAL CORRECTION;OTHER PHALANGES, AN Page 88 of 159

89 28313 RECONSTRUCTION, ANGULAR DEFORMITY OF TOE (OVERLAPPING SECOND TOE, FIFTH TOE, SESAMOIDECTOMY, FIRST TOE (SEPARATE PROCEDURE) REPAIR OF NONUNION OR MALUNION; METATARSAL, W/ OR W/O BONE GRAFT (INC OBTAINING RECONSTRUCTION, TOE, MACRODACTYLY; SOFT TISSUE RESECTION REQUIRING BONE RES RECONSTRUCTION, TOE(S); POLYDACTYLY RECONSTRUCTION, TOE(S); SYNDACTYLY, WITH OR WITHOUT SKIN GRAFT(S), EACH WEB CLOSED TREATMENT OF CALCANEAL FRACTURE; WITH MANIPULATION PERCUTANEOUS SKELETAL FIXATION OF CALCANEAL FRACTURE; WITH MANIPULATION OPEN TREATMENT OF CALCANEAL FRACTURE, WITH OR WITHOUT INTERNAL OR EXTERNAL OPEN TREATMENT OF CALCANEAL FRACTURE, W/ OR W/O INTERNAL OR EXTERNAL FIXATION; OPEN TREATMENT OF TALUS FRACTURE, W/ OR W/O INTERNAL OR EXTERNAL FIXATION OPEN OSTEOCHONDRAL AUTOGRAFT, TALUS (INCLUDES OBTAINING GRAFT(S)) TREATMENT TARSAL BONE FRACTURE (EXCEPT TALUS & CALCANEUS);W/O ANIPULATION, EA OPEN TREATMENT TARSAL BONE FRAC (EXCEPT TALUS & CALCANEUS), W/ OR W/O INTERNAL PERCUTANEOUS SKELETAL FIXATION OF METATARSAL FRACTURE, WITH MANIPULATION, EAC OPEN TREATMENT OF METATARSAL FRACTURE, WITH OR WITHOUT INTERNAL OR EXTERNAL PERCUTANEOUS SKELETAL FIXATION OF FRAC GREAT TOE,PHALANX OR PHALANGES;W/ MANI OPEN TREATMENT OF FRACTURE GREAT TOE, PHALANX OR PHALANGES, WITH OR WITHOUT OPEN TREATMENT OF FRACTURE, PHALANX OR PHALANGES, OTHER THAN GREAT TOE, WITH OPEN TREATMENT OF TARSAL BONE DISLOCATION, W/ OR W/ INTERNAL OR EXTERNAL FIXAT CLOSED TREATMENT OF TALOTARSAL JOINT DISLOCATION; REQUIRING ANESTHESIA PERCUTANEOUS SKELETAL FIXATION OF TALOTARSAL JOINT DISLOCATION,W/ MANIPULATION OPEN TREATMENT OF TALOTARSAL JOINT DISLOCATION, WITH MANIPULATION CLOSED TREATMENT OF TARSOMETATARSAL JOINT DISLOCATION; REQUIRING ANESTHESIA PERCUTANEOUS SKELETAL FIXATION OF TARSOMETATARSAL JOINT DISLOCATION, W/ MANIPU OPEN TREATMENT OF TARSOMETATARSAL JOINT DISLOCATION, W/ OR W/O INTERNAL OR EXT CLOSED TREATMENT OF METATARSOPHALANGEAL JOINT DISLOCATION; REQ ANESTHESIA PERCUTANEOUS SKELETAL FIXATION OF METATARSOPHALANGEAL JOINT DISLOCATION,W/ MA OPEN TREATMENT OF METATARSOPHALANGEAL JOINT DISLOCATION,W/ OR W/O INTERNAL OR CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION; REQUIRING ANESTHESIA PERCUTANEOUS SKELETAL FIXATION OF INTERPHALANGEAL JOINT DISLOCATION, WITH MANIPULATION OPEN TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, WITH OR WITHOUT INTERNAL ARTHRODESIS; PANTALA ARTHRODESIS; TRIPLE ARTHRODESIS; SUBTALAR ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, MULTIPLE OR TRANSVERSE ARTHRODESIS,MIDTARSAL OR TARSOMETATARSAL, MULTIPLE ORTRANSVERSE;W/ OSTEOTO Page 89 of 159

90 28737 ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, MULTIPLE OR TRANSVER ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, SINGLE JOINT ARTHRODESIS, GREAT TOE; METATARSOPHALANGEAL JOINT ARTHRODESIS, GREAT TOE; INTERPHALANGEAL JOINT AMPUTATION, FOOT; TRANSMETATARSAL AMPUTATION, METATARSAL, WITH TOE, SINGLE AMPUTATION, TOE; METATARSOPHALANGEAL JOINT AMPUTATION, TOE; INTERPHALANGEAL JOINT APPLICATION OF HALO TYPE BODY CAST APPLICATION OF RISSER JACKET, LOCALIZER, BODY, HEAD ONLY ARTHROSCOPY, SHOULDER, DIAGNOSTIC, WITH OR WITHOUT SYNOVIAL BIOPSY (SEPARATE PROCEDURE) ARTHROSCOPY, SHOULDER, SURGICAL; CAPSULORRHAPHY ARTHROSCOPY, SHOULDER, SURGICAL; REPAIR OF SLAP LESION ARTHROSCOPY, SHOULDER, SURGICAL; WITH REMOVAL OF LOOSE BODY OR FOREIGN BODY ARTHROSCOPY, SHOULDER, SURGICAL; SYNOVECTOMY, PARTIAL ARTHROSCOPY, SHOULDER, SURGICAL; SYNOVECTOMY, COMPLETE ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDEMENT, LIMITED ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDEMENT, EXTENSIVE ARTHROSCOPY, SHOULDER, SURGICAL; DISTAL CLAVICULECTOMY INCLUDING DISTAL ARTICULAR SURFACE (MUMFORD P ARTHROSCOPY, SHOULDER, SURGICAL; WITH LYSIS AND RESECTION OF ADHESIONS, WITH ARTHROSCOPY, SHOULDER, SURGICAL; WITH ROTATOR CUFF REPAIR ARTHROSCOPY, SHOULDER, SURGICAL; BICEPS TENODESIS ARTHROSCOPY, ELBOW, DIAGNOSTIC, W/ OR W/O SYNOVIAL BIOPSY (SEPARATE PROC ARTHROSCOPY, ELBOW, SURGICAL; WITH REMOVAL OF LOOSE BODY OR FOREIGN BODY ARTHROSCOPY, ELBOW, SURGICAL; SYNOVECTOMY, PARTIAL ARTHROSCOPY, ELBOW, SURGICAL; SYNOVECTOMY, COMPLETE ARTHROSCOPY, ELBOW, SURGICAL; DEBRIDEMENT, LIMITED ARTHROSCOPY, ELBOW, SURGICAL; DEBRIDEMENT, EXTENSIVE ARTHROSCOPY, WRIST, DIAGNOSTIC, W/ OR W/O SYNOVIAL BIOPSY (SEP PRO ARTHROSCOPY, WRIST, SURGICAL; FOR INFECTION, LAVAGE AND DRAINAGE ARTHROSCOPY, WRIST, SURGICAL; SYNOVECTOMY, PARTIAL ARTHROSCOPY, WRIST, SURGICAL; SYNOVECTOMY, COMPLETE ARTHROSCOPY, WRIST, SURGICAL; EXCISION AND/OR REPAIR OF TRIANGULAR FIBROCARTILA ARTHROSCOPY, WRIST, SURGICAL; INTERNAL FIXATION FOR FRACTURE OR INSTABILITY ARTHROSCOPY, WRIST, SURGICAL; WITH RELEASE OF TRANSVERSE CARPAL LIGAMENT ARTHROSCOPICALLY AIDED TREATMENT OF INTERCONDYLAR SPINE(S) &/OR TUBEROSITY F ARTHROSCOPICALLY AIDED TREATMENT OF TIBIAL FRACTURE, PROXIMAL; UNICONDYLAR,W/ ARTHROSCOPICALLY AIDED TREATMENT OF TIBIAL FRACTURE, PROXIMAL; BICONDYLAR, W/ Page 90 of 159

91 29862 ARTHROSCOPICALLY AIDED TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU) ARTHROSCOPY, HIP, SURGICAL WITH SYNOVECTOMY ARTHROSCOPY, KNEE, DIAGNOSTIC, WITH OR WITHOUT SYNOVIAL BIOPSY (SEPARATE PROC ARTHROSCOPY, KNEE, SURGICAL; FOR INFECTION, LAVAGE AND DRAINAGE ARTHROSCOPY, KNEE, SURGICAL; WITH LATERAL RELEASE ARTHROSCOPY, KNEE, SURGICAL; FOR REMOVAL OF LOOSE BODY OR FOREIGN BODY ARTHROSCOPY, KNEE, SURGICAL; SYNOVECTOMY, LIMITED ARTHROSCOPY, KNEE, SURGICAL; SYNOVECTOMY, MAJOR, TWO OR MORE COMPARTMENTS ARTHROSCOPY, KNEE, SURGICAL; DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE ARTHROSCOPY, KNEE, SURGICAL; ABRASION ARTHROPLASTY OR MULTIPLE DRILLING ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL AND LATERAL, INCLUDING ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL OR LATERAL, INCLUDING ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCUS REPAIR (MEDIAL OR LATERAL) ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCUS REPAIR (MEDIAL AND LATERAL) ARTHROSCOPY, KNEE, SURGICAL; WITH LYSIS OF ADHESIONS, WITH OR WITHOUT MANIPULA ARTHROSCOPY, KNEE, SURGICAL; DRILLING FOR OSTEOCHONDRITIS DISSECANS W/ BONE ARTHROSCOPY, KNEE, SURGICAL; DRILLING FOR INTACT OSTEOCHONDRITIS DISSECANS ARTHROSCOPY, KNEE, SURGICAL; DRILLING FOR INTACT OSTEOCHONDRITIS DISSECANS LE ARTHROSCOPY AIDED ANTERIOR CRUCIATE LIGAMENT REPAIR/AUGMENTATION OR RECONS ARTHROSCOPICALLY AIDED POSTERIOR CRUCIATE LIGAMENT REPAIR/AUGMENTATION OR RE ARTHROSCOPY, ANKLE, SURGICAL; EXC OF OSTEOCHONDRAL DEFECT OF TALUS &/OR TIBIA; ARTHROSCOPIALLY AIDED REPAIR OF LARGE OSTEOCHONDRITIS DISSECANS LESION, TALAR DOME FRACTURE, OR TIBIAL PLAFOND FRACTURE, WITH OR WITHOUT INTERNAL FIXATION (INCLUDES ARTHROSCOPY) ENDOSCOPIC PLANTAR FASCIOTOM ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS), SURGICAL; WITH REMOVAL ARTHROSCOPY, ANKLE, SURGICAL; SYNOVECTOMY, PARTIAL ARTHROSCOPY, ANKLE, SURGICAL; DEBRIDEMENT, LIMITED ARTHROSCOPY, ANKLE, SURGICAL; DEBRIDEMENT, EXTENSIVE ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS), SURGICAL; WITH ANKLE ARTHRODESIS ARTHROSCOPY, SUBTALAR JOINT, SURGICAL; WITH REMOVAL OF LOOSE BODY OR FOREIGN BODY ARTHROSCOPY, SUBTALAR JOINT, SURGICAL; WITH SYNOVECTOMY ARTHROSCOPY, SUBTALAR JOINT, SURGICAL; WITH DEBRIDEMENT ARTHROSCOPY, SUBTALAR JOINT, SURGICAL; WITH SUBTALAR ARTHRODESIS ARTHROSCOPY, HIP, SURGICAL; WITH REMOVAL OFLOOSE BODY OR FOREIGN BODY WITH FEMOROPLASTY (IE, TREAMENT OF CAM LESION) ARTHROSCOPY, HIP, SURGICAL; WITH REMOVAL OFLOOSE BODY OR FOREIGN BODY WITH ACETABULOPLASTY (IE, TREATMENT OF PINCER LESION) Page 91 of 159

92 29916 ARTHROSCOPY HIP W/LABRAL REPAIR EXCISION, NASAL POLYP(S), EXTENSIVE EXCISION OR DESTRUCTION, ANY METHOD, INTRANASAL LESION; INTERNAL APPROACH EXCISION OR DESTRUCTION, ANY METHOD (INC LASER), INTRANASAL LESION; EXTERNAL APP EXCISION OR SURGICAL PLANING OF SKIN OR NOSE FOR RHINOPHYMA EXCISION DERMOID CYST, NOSE; COMPLEX, UNDER BONE OR CARTILAGE EXCISION INFERIOR TURBINATE, PARTIAL OR COMPLETE, ANY METHOD SUBMUCOUS RESECTION INFERIOR TURBINATE, PARTIAL OR COMPLETE, ANY METHOD RHINECTOMY; PARTIAL REMOVAL FOREIGN BODY, INTRANASAL; REQUIRING GENERAL ANESTHESIA RHINOPLASTY, PRIMARY; LATERAL AND ALAR CARTILAGES AND/OR ELEVATION OF NASAL TIP RHINOPLASTY, PRIMARY; COMPLETE, EXTERNAL PARTS INCLUDING BONY PYRAMID, LATERAL RHINOPLASTY, PRIMARY; INCLUDING MAJOR SEPTAL RHINOPLASTY, SECONDARY; MINOR REVISION RHINOPLASTY, SECONDARY; INTERMEDIATE REVISION RHINOPLASTY FOR NASAL DEFORMITY SECONDARY TO CONGENITAL CLEFT LIP AND/OR PALA RHINOPLASTY FOR NASAL DEFORMITY SECONDARY TO CONGENITAL CLEFT LIP &/OR PALATE, REPAIR OF NASAL VESTIBULAR STENOSIS (e.g., SPREADER GRAFTING, LATERAL NASAL WALL RECONSTRUCTION) SEPTOPLASTY OR SUBMUCOUS RESECTION WITH OR WITHOUT CARTILAGE SCORING, CON REPAIR CHOANAL ATRESIA; INTRANASAL REPAIR CHOANAL ATRESIA; TRANSPALATINE REPAIR FISTULA; OROMAXILLARY (COMBINE WITH IF ANTROTOMY IS INCLUDED) REPAIR FISTULA; ORONASAL SEPTAL OR OTHER INTRANASAL DERMATOPLASTY (DOES NOT INCLUDE OBTAINING GRAFT) REPAIR NASAL SEPTAL PERFORATIONS CAUTERIZATION AND/OR ABLATION,MUCOSA OF INFERIOR TURBINATES, UNILATERAL OR BILATERAL, ANY METHOD, INTRAMURAL CONTROL NASAL HEMORRHAGE, POSTERIOR, W/ POSTERIOR NASAL PACKS &/OR CAUTERIZA CONTROL NASAL HEMORRHAGE, POSTERIOR, W/ POSTERIOR NASAL PACKS &/OR CAUTERIZA LIGATION ARTERIES; ETHMOIDAL LIGATION ARTERIES; INTERNAL MAXILLARY ARTERY, TRANSANTRAL FRACTURE NASAL INFERIOR TURBINATE(S), THERAPEUTIC SINUSOTOMY, MAXILLARY (ANTROTOMY); INTRANASAL SINUSOTOMY, MAXILLARY (ANTROTOMY); RADICAL (CALDWELL-LUC) WITHOUT REMOVAL OF SINUSOTOMY, MAXILLARY (ANTROTOMY); RADICAL (CALDWELL-LUC) WITH REMOVAL OF ANTR PTERYGOMAXILLARY FOSSA SURGERY, ANY APPROACH SINUSOTOMY, SPHENOID, WITH OR WITHOUT BIOPSY SINUSOTOMY, SPHENOID, WITH OR WITHOUT BIOPSY; WITH MUCOSAL STRIPPING OR REMOVA SINUSOTOMY FRONTAL; EXTERNAL, SIMPLE (TREPHINE OPERATION) Page 92 of 159

93 31075 SINUSOTOMY FRONTAL; TRANSORBITAL, UNILATERAL (FOR MUCOCELE OR OSTEOMA, LYNCH SINUSOTOMY FRONTAL;OBLITERATIVE, W/O OSTEOPLASTIC FLAP,BROW INCISION (INC ABLAT SINUSOTOMY FRONTAL; OBLITERATIVE, WITH OSTEOPLASTIC FLAP, CORONAL INCISION SINUSOTOMY FRONTAL; NONOBLITERATIVE, WITH OSTEOPLASTIC FLAP, BROW INCISION SINUSOTOMY COMBINED, THREE OR MORE SINUSES ETHMOIDECTOMY; INTRANASAL, ANTERIOR ETHMOIDECTOMY; INTRANASAL, TOTAL ETHMOIDECTOMY; EXTRANASAL, TOTAL MAXILLECTOMY; WITHOUT ORBITAL EXENTERATION NASAL/SINUS ENDOSCOPY, DIAG W/ MAXILLARY SINUSOSCOPY (VIA INFERIOR MEATUS OR CA NASAL/SINUS ENDOSCOPY, DIAG W/ SPHENOID SINUSOSCOPY (VIA PUNCTURE OF SPHENOID NASAL/SINUS ENDOSCOPY, SURGICAL; WITH BIOPSY, POLYPECTOMY OR DEBRIDEMENT (SEP NASAL/SINUS ENDOSCOPY, SURGICAL; WITH CONTROL OF EPISTAXIS NASAL/SINUS ENDOSCOPY, SURGICAL; WITH DACRYOCYSTORHINOSTOMY NASAL/SINUS ENDOSCOPY, SURGICAL; WITH CONCHA BULLOSA RESECTION NASAL/SINUS ENDOSCOPY, SURGICAL; WITH ETHMOIDECTOMY, PARTIAL (ANTERIOR) NASAL/SINUS ENDOSCOPY, SURGICAL; WITH ETHMOIDECTOMY, TOTAL (ANTERIOR AND POSTI NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY; NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY SINUS NASAL/SINUS ENDOSCOPY, SURGICAL WITH FRONTAL SINUS EXPLORATION, WITH OR WITHO NASAL/SINUS ENDOSCOPY, SURGICAL, WITH SPHENOIDOTOMY; NASAL/SINUS ENDOSCOPY, SURGICAL, WITH REMOVAL OF TISSUE FROM THE SPHENOID SINU NASAL/SINUS ENDOSCOPY,SURG,W/ REPAIR OF CEREBROSPINAL FLUID LEAK;SPHENOID RE NASAL/SINUS ENDOSCOPY, SURGICAL; WITH DILATION OF MAXILLARY SINUS OSTIUM 9E.G., BALLOON DILATION), TRANSNASAL OR VIA CANINE FOSSA NASAL/SINUS ENDOSCOPY, SURGICAL; WITH DILATION OF FRONTAL SINUS OSTIUM 9E.G., BALLOON DILATION) NASAL/SINUS ENDOSCOPY, SURGICAL; WITH DILATION OF SPHENOID SINUS OSTIUM 9E.G., BALLOON DILATION) LARYNGOTOMY (THYROTOMY, LARYNGOFISSURE);W/ REMOVAL OF TUMOR OR LARYNGOCELE INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE TRACHEOTOMY TUBE CHANGE PRIOR TO ESTABLISHMENT OF FISTULA TRACT LARYNGOSCOPY, INDIRECT (SEPARATE PROCEDURE); WITH BIOPSY LARYNGOSCOPY, INDIRECT (SEPARATE PROCEDURE); WITH REMOVAL OF FOREIGN BODY LARYNGOSCOPY, INDIRECT (SEPARATE PROCEDURE); WITH REMOVAL OF LESION LARYNGOSCOPY, INDIRECT (SEPARATE PROCEDURE); WITH VOCAL CORD INJECTION LARYNGOSCOPY, DIRECT, WITH OR WITHOUT TRACHEOSCOPY; FOR ASPIRATION LARYNGOSCOPY DIRECT, WITH OR WITHOUT TRACHEOSCOPY; WITH DILATATION, INITIAL LARYNGOSCOPY DIRECT, WITH OR WITHOUT TRACHEOSCOPY; WITH DILATION, SUBSEQUENT LARYNGOSCOPY, DIRECT, OPERATIVE, WITH FOREIGN BODY REMOVAL; Page 93 of 159

94 31531 LARYNGOSCOPY, DIRECT, OPERATIVE, WITH FOREIGN BODY REMOVAL; WITH OPERATING MICROSCOPE OR TELESCOPE LARYNGOSCOPY, DIRECT, OPERATIVE, WITH BIOPSY; LARYNGOSCOPY DIRECT, OPERATIVE, WITH BIOPSY; WITH OPERATING MICROSCOPE OR TELESCOPE LARYNGOSCOPY, DIRECT, OPERATIVE, WITH EXCISION OF TUMOR AND/OR STRIPPING OF VOC LARYNGOSCOPY, DIRECT, OPERATIVE, WITH EXCISION OF TUMOR AND/OR STRIPPING OF VOCAL CORDS OR EPIGLOTIS; WITH OPERATING MICROSCOPE OR TELESCOPE LARYNGOSCOPY, DIRECT, OPERATIVE, WITH OPERATING MICROSCOPE OR TELESCOPE, WITH SUBMUCOSAL REMOVAL OF NON-NEOPLASTIC LESION(S) OF VOCAL CORD; RECONSTRUCTION WITH LOCAL TISSUE FLAP(S) LARYNGOSCOPY,DIRECT,OPERATIVE, WITH ARYTENOIDECTOMY; OPERATING MICROSCOPE OR TELESCOPE LARYNGOSCOPY, DIRECT, WITH INJECTION INTO VOCAL CORD, THERAPEUTIC; LARYNGOSCOPY, DIRECT, WITH INJECTION INTO VOCAL CORD(S),THERAPEUTIC; WITH OPERATING MICROSCOPE OR TELESCOPE LARYNGOSCOPY, FLEXIBLE FIBERSCOPIC; WITH BIOPSY LARYNGOSCOPY, FLEXIBLE FIBERSCOPIC; WITH REMOVAL OF FOREIGN BODY LARYNGOSCOPY, FLEXIBLE FIBERSCOPIC; WITH REMOVAL OF LESION LARYNGOSCOPY, FLEXIBLE FIBEROPTIC; WITH STROBOSCOPY LARYNGOPLASTY,NOT OTHERWISE SPECIFIED (EG, FOR BURNS, RECONSTRUCTION AFTER TRACHEOSTOMY, PLANNED (SEPARATE PROCEDURE) TRACHEOSTOMY, PLANNED (SEPARATE PROCEDURE); UNDER TWO YEARS TRACHEOSTOMY, EMERGENCY PROCEDURE; TRANSTRACHEAL TRACHEOSTOMY, EMERGENCY PROCEDURE; CRICOTHYROID MEMBRANE TRACHEOSTOMA REVISION; SIMPLE, WITHOUT FLAP ROTATION TRACHEOBRONCHOSCOPY THROUGH ESTABLISHED TRACHEOSTOMY INCISION BRONCHOSCOPY; DIAGNOSTIC, (FLEXIBLE OR RIGID), WITH OR WITHOUT CELL WASHING OR BROCHOSOCPY; DIAGNOSTIC; W/ BRUSHING OR PROTECTED BRUSHINGS BRONCHOSCOPY; WITH BRONCHIAL ALVEOLAR LAVAGE BRONCHOSCOPY; WITH BIOPSY BRONCHOSCOPY; WITH TRANSBRONCHIAL LUNG BIOPSY, WITH OR WITHOUT FLUOROSCOPI BRONCHOSCOPY; WITH TRANSBRONCHIAL NEEDLE ASPIRATION BIOPSY BRONCHOSCOPY;W/ TRACHEAL OR BRONCHIAL DILATION OR CLOSED REDUCTION OF FRAC BRONCHOSCOPY; WITH REMOVAL OF FOREIGN BODY BRONCHOSCOPY; WITH EXCISION OF TUMOR BRONCHOSCOPY; WITH DESTRUCTION OF TUMOR OR RELIEF OF STENOSIS BY ANY METHOD BRONCHOSCOPY; WITH PLACEMENT OF CATHETER(S) FOR INTRACAVITY RADIOELEMENT APPLICATION BRONCHOSCOPY;W/ THERAPEUTIC ASPIRATION OF TRACHEOBRONCHIAL TREE,INITIAL Page 94 of 159

95 31646 BRONCHOSCOPY;W/ THERAPEUTIC ASPIRATION OF TRACHEOBRONCHIAL TREE,SUBSEQUE BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH ENDOBRONCHIAL ULTRASOUND (EBUS) GUIDED TRANSTRACHEAL AND/OR TRANSBRONCHIAL SAMPLING (EG, ASPIRATION[S]/BIOPSY[IES]), ONE OR TWO MEDIASTINAL AND/OR HILAR LYMPH NODE STATIONS OR STRUCTURES BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL THERMOPLASTY, 1 LOBE BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL THERMOPLASTY, 2 OR MORE LOBES CATHETER ASPIRATION (SEPARATE PROCEDURE); NASOTRACHEAL CATHETER ASPIRATION (SEP PROC); TRACHEOBRONCHIAL WITH FIBERSCOPE, BEDSIDE TRANSTRACHEAL INTRO OF NEEDLE WIRE DILATOR/STENT OR INDWELLING TUBE FOR OXYG SURGICAL CLOSURE TRACHEOSTOMY OR FISTULA; WITHOUT PLASTIC REPAIR REVISION OF TRACHEOSTOMY SCAR THORACENTESIS, PUNCTURE OF PLEURAL CAVITY FOR ASPIRAATION, INITIAL OR SUBSEQUE THORACENTESIS W/ INSERTION OF TUBE W/ OR W/O WATER SEAL (SEPARATE PROCEDURE) CHEMICAL PLEURODESIS (EG, FOR RECURRENT OR PERSISTENT PNEUMOTHORAX) TUBE THORACOSTOMY WITH OR WITHOUT WATER SEAL (EG, FOR ABSCESS, HEMOTHORAX, THORACOTOMY, WITH DIAGNOSTIC BIOPSY(IES) OF LUNG INFILTRATE(S) (EG, WEDGE, INCISIONAL), UNILATERAL THORACOTOMY, WITH DIAGNOSTIC BIOPSY(IES) OF LUNG NODULE(S) OR MASS(ES) (EG, WEDGE, INCISIONAL), UNILATERAL THORACOTOMY, WITH BIOPSY(IES) OF PLEURA PLEURAL SCARIFICATION FOR REPEAT PNEUMOTHORAX BIOPSY, PLEURA; PERCUTANEOUS NEEDLE BIOPSY, LUNG OR MEDIASTINUM, PERCUTANEOUS NEEDLE PNEUMONOCENTESIS, PUNCTURE OF LUNG FOR ASPIRATION THORACENTESIS WITH INSERTION OF TUBE, INCLUDES WATER SEAL (EG, PNEUMOTHORAX), WHEN PERFORMED, SEPARATE PROCEDURE THORACENTESIS WITH INSERTION OF TUBE, INCLUDES WATER SEAL ( PNEUMOTHORAX), WHEN PERFORMED (SEPARATE PROCEDURE) THORACOTOMY; WITH THERAPEUTIC WEDGE RESECTION (EG, MASS, NODULE), INITIAL INSERTION OF INDWELLING TUNNELED PLEURAL CATHETER WITH CUFF TUBE THORACOSTOMY, INCLUDES WATER SEAL (EG, FOR ABSCESS, HEMOTHORAX, EMPYEMA), WHEN PERFORMED (SEPARATE PROCEDURE); REMOVAL OF INDWELLING TUNNELED PLEURAL CATHETER WITH CUFF THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITH IMAGING GUIDANCE Page 95 of 159

96 32557 PLEURAL DRAINAGE, PERCUTANEOUS, WITH INSERTION OF INDWELLING CATHETER; WITH IMAGING GUIDANCE THORACOSCOPY, DIAGNOSTIC (SEPARATE PROC);LUNGS & PEURAL SPACE, W/O BIOPSY THORACOSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE); MEDIASTINAL SPACE, WITH BIOPSY THORACOSCOPY; WITH DIAGNOSTIC BIOPSY(IES) OF LUNG INFILTRATE(S) (EG, WEDGE, INCISIONAL), UNILATERAL THORACOSCOPY; WITH DIAGNOSTIC BIOPSY(IES) OF LUNG NODULE(S) OR MASS(ES) (EG, WEDGE, INCISIONAL), UNILATERAL THORACOSCOPY; WITH BIOPSY(IES) OF PLEURA THORACOSCOPY, SURGICAL; WITH PLEURODESIS, ANY METHOD THORACOSCOPY PY, SURGICAL; WITH THORACIC SYMPATHECTOMY THORACOSCOPY, SURGICAL; WITH THERAPEUTIC WEDGE RESECTION (EG, MASS, NODULE), INITIAL UNILATERAL THORACOSCOPY, SURGICAL; WITH REMOVAL OF A SINGLE LUNG SEGMENT (SEGMENTECTOMY) THORACOSCOPY, SURGICAL; WITH REMOVAL OF TWO LOBES (BILOBECTOMY) THORACOSCOPY, SURGICAL; WITH REMOVAL OF LUNG (PNEUMONECTOMY) THORACOSCOPY, SURGICAL; WITH RESECTION-PLICATION FOR EMPHYSEMATOUS LUNG (BULLOUS OR NON-BULLOUS) FOR LUNG VOLUME REDUCTION (LVRS), UNILATERAL INCLUDES ANY PLEURAL PROCEDURE, WHEN PERFORMED THORACOSCOPY, SURGICAL; WITH RESECTION OF THYMUS, UNILATERAL OR BILATERAL ABLATION THERAPY FOR REDUCTION OR ERADICATION OF 1 OR MORE PULMONARY TUMOR(S) INCLUDING PLEURA OR CHEST WALL WHEN INVOLVED BY TUMOR EXXTENSION, PERCUTANEOUS,RADIOFREQUENCY, UNILATERAL PERICARDIOCENTESIS; INITIAL PERICARDIOCENTESIS; SUBSEQUENT TUBE PERICARDIOSTOMY CREATION OF PERICARDIAL WINDOW OR PARTIAL RESECTION FOR DRAINAGE INSERTION OR REPLACEMENT OF PERMANENT PACEMAKER W/ TRANSVENOUS ELECTRODE INSERTION OF PERMANENT PACEMAKER WITH TRANSVENOUS ELECTRODE(S); VENTRICULAR INSERTION OR REPLACEMENT OF PERMANENT PACEMAKER W/ TRANSVENOUS ELECTRODE INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHAMBER CARDIAC E INSERTION OR REPLACEMENT OF TEMPORARY TRANSVERNOUS DUAL CHAMBER PACING EL INSERTION OR REPLACEMENT OF PULSE GENERATOR ONL; SINGLE CHAMBER, ATRIAL OR VE INSERTION OR REPLACEMENT OF PACEMAKER PULSE GENERATOR ONLY DUAL CHAMBER UPGRADE OF IMPLANTED PACEMAKER SYS,CONVERSION SINGLE CHAMBER SYSTEM TO DUA REPOSITIONING OF PREVIOUSLY IMPLANTED TRANSVENOUS PACEMAKER OR PACING CARDIOVERTER-DEFIBRILLATOR (RI INSERTION OR REPOSITIONING OF A TRANSVENUS ELECTRODE (15 DAYS OR MORE AFTER INSERTION OR REPOSITIONING OF A TRANSVENOUS ELECTRODE (15 DAYS OR MORE AFTER REPAIR OF A SINGLE TRANSVENOUS ELECTRODE FOR A SINGLE CHAMBER, PERMANENT PAC Page 96 of 159

97 33220 REPAIR OF 2 TRANSVENOUS ELECTRODES FOR A DUAL CHAMBER PERMANENT PACEMAKER OR DUAL CHAMBER PACING CARDIOVERTER-DEFIBRILLATOR INSERTION OF PACEMAKER PULSE GENERATOR ONLY; WITH EXISTING MULTIPLE LEADS REVISION OR RELOCATION OF SKIN POCKET FOR PACEMAKER REVISION OR RELOCATION OF SKIN POCKET FOR IMPLANTABLE CARDIOVERTER-DEFIBRILLA INSERTION OF PACING ELECTRODE,CARDIAC VENOUS SYSTEM,FOR LEFT VENTRICULAR PACING,W/ATTACHMENT TO PREV REPOSITIONING OF PREVIOUSLY IMPLANTED CARDIAC VENOUS SYSTEM (LEFT VENTRICULAR) ELECTRODE (INCLUDING REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEMENT OF PACEMAKER PULSE GENERATOR; SINGLE LEAD SYSTEM REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEMENT OF PACEMAKER PULSE GENERATOR; DUAL LEAD SYSTEM REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEMENT OF PACEMAKER PULSE GENERATOR; MULTIPLE LEAD SYSTEM INSERTION OF PACING CARDIOVERTER-DEFIBRILLATOR PULSE GENERATOR ONLY; WITH EXISTING DUAL LEADS INSERTION OF PACING CARDIOVERTER-DEFIBRILLATOR PULSE GENERATOR ONLY; WITH EXISTING MULTIPLE LEADS REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR REMOVAL OF TRANSVENOUS PACEMAKER ELECTRODE(S); SINGLE LEAD SYSTEM, ATRIAL OR VENTRICULAR REMOVAL OF TRANSVENOUS PACEMAKER ELECTRODE(S); DUAL LEAD SYSTEM INSERTION OF SINGLE OR DUAL CHAMBER PACING CARDIOVERTER-DEFIBRILLATOR PULSE SUBCUTANEOUS REMOVAL OF SINGLE OR DUAL CHAMBER PACING CARDIODEFIBRILLATOR PULSE GENERATOR REMOVAL OF SINGLE OR DUAL CHAMBER PACING CARDIOVERTER-DEFIBRILLATOR ELECTRODE(S); BY TRANSVENOUS EXTRACTION INSERTION OR REPLACEMENT OF IMPLANTABLE CARDIOVERTER-DEFIBRILLATOR LEAD(S), BY REMOVAL OF PACING CARDIOVERTER-DEFIBRILLATOR PULSE GENERATOR WITH REPLACEMENT OF PACING CARDIOVERTER-DEFIBRILLATOR PULSE GENERATOR; SINGLE LEAD SYSTEM REMOVAL OF PACING CARDIOVERTER-DEFIBRILLATOR PULSE GENERATOR WITH REPLACEMENT OF PACING CARDIOVERTER-DEFIBRILLATOR PULSE GENERATOR; DUAL LEAD SYSTEM REMOVAL OF PACING CARDIOVERTER-DEFIBRILLATOR PULSE GENERATOR WITH REPLACEMENT OF PACING CARDIOVERTER-DEFIBRILLATOR PULSE GENERATOR; MULTIPLE LEAD SYSTEM IMPLANTATION OF PATIENT-ACTIVATED CARDIAC EVENT RECORDER REMOVAL OF AN IMPLANTABLE, PATIENT-ACTIVATED CARDIAC EVENT RECORDER EMBOLECTOMY OR THROMBECTOMY, WITH OR WITHOUT CATHETER; RADIAL OR ULNAR ARTERY, BY ARM INCISION DIRECT REPAIR ANEURYSM,FALSE ANEURYSM OR EXCISION & GRAFT INSERTION,W/ OR W/O Page 97 of 159

98 35045 DIRECT REPAIR OF ANEURYSM, FALSE ANEURYSM, OR EXCISION AND GRAFT INSERTION, WIT DIRECT REPAIR ANEURYSM,FALSE ANEURYSM OR EXCISION & GRAFT INSERTION W/ OR W/O REPAIR, CONGENITAL ARTERIOVENOUS FISTULA; EXTREMITIES REPAIR, ACQUIRED OR TRAUMATIC ARTERIOVENOUS FISTULA; HEAD AND NECK REPAIR, ACQUIRED OR TRAUMATIC ARTERIOVENOUS FISTULA; EXTREMITIES REPAIR BLOOD VESSEL, DIRECT; NECK REPAIR BLOOD VESSEL, DIRECT; UPPER EXTREMITY REPAIR BLOOD VESSEL, DIRECT; HAND, FINGER REPAIR BLOOD VESSEL, DIRECT; LOWER EXTREMITY THROMBOENDARTERECTOMY, INCLUDING PATCH GRAFT, IF PERFORMED; AXILLARY-BRACHIAL TRANSLUMINAL BALLOON ANGIOPLASTY, OPEN; ILIAC TRANSLUMINAL BALLOON ANGIOPLASTY, OPEN; FEMORAL-POPLITEAL TRANSLUMINAL BALLOON ANGIOPLASTY,OPEN;BRACHIOCEPHALIC TRUNK OR BRANCHES,EA TRANSLUMINAL BALLOON ANGIOPLASTY, OPEN; VENOUS TRANSLUMINAL BALLOON ANGIOPLASTY, PERCUTANEOUS; TIBIOPERONEAL TRUNK OR BRAN TRANSLUMINAL BALLOON ANGIOPLASTY, PERCUTANEOUS; RENAL OR VISCERAL ARTERY TRANSLUMINAL ANGIOPLASTY, PERCUTANEOUS; ILIAC TRANSLUMINAL ANGIOPLASTY, PERCUTANEOUS; FEMORAL-POPLITEAL TRANSLUMINAL BALLOON ANGIOPLASTY,PERCUTANEOUS;BRACHIOCEPHALIC TRUNK OR BR TRANSLUMINAL ANGIOPLASTY, PERCUTANEOUS; VENOUS TRANSLUMINAL PERIPHERAL ATHERECTOMY, OPEN; RENAL OR OTHER VISCERAL ARTERY TRANSLUMINAL PERIPHERAL ATHERECTOMY,OPEN;BRACHIOCEPHALIC TRUNK OR BRANCH TRANSLUMINAL PERIPHERAL ATHERECTOMY, PERCUTANEOUS; FEMORAL-POPLITEAL TRANSLUMINAL PERIPHERAL ATHERECTOMY,PERCUTANEOUS;BRACHIOCEPHALIC TRUNK BYPASS GRAFT, WITH VEIN; BRACHIAL-ULNAR OR -RADIAL THROMBECTOMY OF ARTERIAL OR VENOUS GRAFT (OTH THAN HEMODIALYSIS GRAFT OR FIST THROMBECTOMY OF ARTERIAL OR VENOUS GRAFT;W/ REVOF ARTERIAL OR VENOUS GRAFT EXCISION OF INFECTED GRAFT; EXTREMITY INTRODUCTION OF CATHETER, IN SUPERIOR OR INFERIOR VENA CAVA SELECTIVE CATHETER PLACEMENT, VENOUS SYSTEM; FIRST ORDER BRANCH (EG, RENAL VE SELECTIVE CATHETER PLACEMENT, VENOUS SYSTEM; SECOND ORDER, OR MORE SELECTIV INTRODUCTION OF CATHETER, RIGHT HEART OR MAIN PULMONARY ARTERY SELECTIVE CATHETER PLACEMENT, LEFT OR RIGHT PULMONARY ARTERY SELECTIVE CATHETER PLACEMENT, SEGMENTAL OR SUBSEGMENTAL PULMONARY ARTERY INTRODUCTION OF NEEDLE OR INTRACATHETER; EXTREMITY ARTERY ARTERIOVENOUS SHUNT CREATED FOR DIALYSIS (CANNULA, FISTULA, OR GRAFT) INTRODUCTION OF NEEDLE AND/OR CATHETER, ARETERIOVENOUS SHUNT CREATED FOR DIALYSIS (GRAFT/FISTULA); INITIAL ACCESS WITH COMPLETE RADIOLOGICAL EVALUATION OF DIALYSIS ACCESS, INCLUDING FLUOROSCOPY, IMAGE DOCUMENTATION AND REPORT (INLCUDES ACCESS OF SHUNT, IN Page 98 of 159

99 36200 INTRODUCTION OF CATHETER; AORTA SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; EACH FIRST ORDER THORACIC OR SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL SECOND ORDER THORACIC SELECTIVE CATHETER PLACEMENT,ARTERIAL SYSTEM;INITIAL THIRD ORDER OR MORE SELE SELECTIVE CATHETER PLACEMENT, INTERNAL CAROTID ARTERY. UNILATERAL, WITH ANGIOGRAPHY OF THE IPSILATERAL INTRACRANIAL CAROTID CIRCULATION AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION, INCLUDES ANGIOGRAPHY OF THE EXTRACRANIAL CAROTID AND CE SELECTIVE CATHETER PLACEMENT, VERTEVBRAL ARTERY, UNILATERAL, WITH ANGIOGRAPHY OF THE IPSILATERAL VERTEBRAL CIRCULATION AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION, INCLUDES ANGIOGRAPHY OF THE CERVICOCEREBRAL ARCH, WHEN PERFORMED SELECTIVE CATHETER PLACMENT, ARTERIAL SYSTEM; EACH FIRST ORDER ABDOMINAL, PELV SELECTIVE CATHETER PLACEMENT, ARTIERIAL SYSTEM; INTIAL SECOND ORDER ABD SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL THIRD ORDER OR MORE SEL SELECTIVE CATHETER PLACEMENT (FIRST-ORDER), MAIN RENAL ARTERY AND ANY ACCESSORY RENAL ARTERY(S) FOR RENAL ANGIOGRAPHY, INCLUDING ARTERIAL PUNCTURE AND CATHETER PLACEMENT(S), FLUOROSCOPY, CONTRAST INJECTION(S), IMAGE POSTPROCESSING, PERMANENT RECORDING OF SELECTIVE CATHETER PLACEMENT (FIRST-ORDER), MAIN RENAL ARTERY AND ANY ACCESSORY RENAL ARTERY(S) FOR RENAL ANGIOGRAPHY, INCLUDING ARTERIAL PUNCTURE AND CATHETER PLACEMENT(S), FLUOROSCOPY, CONTRAST INJECTION(S), IMAGE POSTPROCESSING, PERMANENT RECORDING OF SUPERSELECTIVE CATHETER PLACEMENT (ONE OR MORE SECOND ORDER OR HIGHER RENAL ARTERY BRANCHES) RENAL ARTERY AND ANY ACCESSORY RENAL ARTERY(S) FOR RENAL ANGIOGRAPHY, INCLUDING ARTERIAL PUNCTURE, CATHETERIZATION, FLUOROSCOPY, CONTRAST INJECTION(S), IMAGE POST SUPERSELECTIVE CATHETER PLACEMENT (ONE OR MORE SECOND ORDER OR HIGHER RENAL ARTERY BRANCHES) RENAL ARTERY AND ANY ACCESSORY RENAL ARTERY(S) FOR RENAL ANGIOGRAPHY, INCLUDING ARTERIAL PUNCTURE, CATHETERIZATION, FLUOROSCOPY, CONTRAST INJECTION(S), IMAGE POST INSERTION OF IMPLANTABLE INTRA-ARTERIAL INFUSION PUMP (EG, FOR CHEMOTHERAPY OF REMOVAL OF IMPLANTED INTRA-ARTERIAL INFUSION PUMP SINGLE OR MULTIPLE INJECTIONS SCLEROSING SOLUTIONS,SPIDER VEINS; LIMB OR TRUNK INJECTION OF SCLEROSING SOLUTION; SINGLE VEIN INJECTION OF SCLEROSING SOLUTION; MULTIPLE VEINS, SAME LEG ENDOVENOUS ABLATION ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, LASER; FIRST VEIN TREATED PERCUTANEOUS PORTAL VEIN CATHETERIZATION BY ANY METHOD DECLOTTING BY THROMBOLYTIC AGENT OF IMPLANTED VASCULAR ACCESS DEVICE OR CATHETER Page 99 of 159

100 INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; YOUNGER THAN 5 YEARS OF AGE INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; WITHOUT SUBCUTENEOUS PORT OR PUMP; YOUNGER THAN 5 YEARS OF AGE INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; WITHOUT SUBCUTENEOUS PORT OR PUMP; AGE 5 YEARS OR OLDER INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; YOUNGER THAN 5 YEARS OF AGE INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; AGE 5 YEARS OR OLDER INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, REQUIRING TWO CATHETERS VIA TWO SEPARATE VENOUS ACCESS SITES; WITHOUT SUBCUTANEOUS PRT OR PUMP INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, REQUIRING TWO CATHETERS VIA TWO SEPARATE VENOUS ACCESS SITES; WITH SUBCUTANEOUS PORT(S) INSERTION OF PERIPHERALLY INSERTED CENTRAL VENOUS CATHETER (PICC), WITHOUT SUBCUTANEOUS PORT OR PUMP; YOUNGER THAN 5 YEARS OF AGE INSERTION OF PERIPHERALLY INSERTED CENTRAL VENUS CATHETER (PICC), WITHOUT SUBCUTANEOUS PORT OF PUMP, AGE FIVE YEARS OR OLDER INSERTION OF PERIPHERALLY INSERTED CENTRAL VENUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT, YOUNGER THAN FIVE YEARS OF AGE INSERTION OF PERIPHERALLY INSERTED CENTRAL VENUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT, FIVE YEARS OR OLDER REPLACEMENT, COMPLETE, OF A TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER, WITHOUT SUBCUTENEOUS PRT OR PUMP, THROUGH SAME VENOUS ACCESS REPLACEMENT, COMPLETE, OF A TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT, THROUGH SAME VENOUS ACCESS REPLACEMENT, COMPLETE, OF A PERIPHERALLY INSERTED CENTRAL VENOUS CATHETER (PICC), WITHOUT SUBCUTANEOUS PORT OR PUMP, THROUGH SAME VENOUS ACCESS REMOVAL OR TUNNELED CENTRAL VENOUS CATHETER, WITHOUT SUBCUTENEOUS PORT OR PUMP REMOVAL OR TUNNELED CENTRAL VENOUS CATHETER, WITH SUBCUTANEOUS PORT OR PUMP, CENTRAL OR PERIPHERAL INSERTION DECLOTTING BY THROMBOLYTIC AGENT OR IMPLANTED VASCLAR ACCESS DEVICE OR CATHETER MECHANICAL REMOVAL OF PERICATHETER OBSTRUCTIVE MATERIAL (E.G., FIBRIN SHEATH) FORM CENTRAL VENOUS DEVICE VIA SEPARATE VENOUS ACCESS REPOSITIONING OF PREVIOUSLY PLACED CENTRAL VENOUS CATHETER UNDER FLUOROSCOPIC GUIDANCE ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING,MONITORING OR TRANSFUSI ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING, MONITORING OR TRANSFUSI ARTERIAL CATHETERIZATION FOR PROLONGED INFUSION THERAPY(CHEMOTHERAPY),CUTD Page 100 of 159

101 36660 CATHETERIZATION, UMBILICAL ARTERY, NEWBORN, FOR DIAGNOSIS OR THERAPY PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION INSERTION OF CANNULA FOR HEMODIALYSIS, OTHER PURPOSE (SEPARATE PROCEDURE); INSERTION OF CANNULA FOR HEMODIALYSIS, OTHER PURPOSE (SEPARATE PROCEDURE); ARTERIOVENOUS, EXTERNAL (SCRIBNER TYPE) INSERTION OF CANNULA FOR HEMODIALYSIS, OTHER PURPOSE (SEPARATE PROCEDURE); ARTERIOVENOUS ANASTOMOSIS, OPEN; BY UPPER ARM CEPHALIC VEIN TRANSPOSITION ARTERIOVENOUS ANASTOMOSIS, OPEN; BY UPPER ARM BASILIC VEIN TRANSPOSITION ARTERIOVENOUS ANASTOMOSIS, OPEN; BY FOREARM VEIN TRANSPOSITION ARTERIOVENOUS ANASTOMOSIS, DIRECT, ANY SITE (EG, CIMINO TYPE) (SEPARATE PROCEDU CREATION OF ARTERIOVENOUS FISTULA; BY OTHER THAN DIRECT ARTERIOVENOUS ANASTO CREATION OF ARTERIOVENOUS FISTULA; BY OTHER THAN DIRECT ARTERIOVENOUS ANASTO THROMBECTOMY, ARTERIOVENOUS FISTULA W/O REVISON, AUTOGENOUS OR NONA REVISION OF AN ARTERIOVENOUS FISTULA, WITH OR WITHOUT THROMBECTOMY, AUTOGENO REVISON, ARTERIOVENOUS FISTULA; W/ THROMBECTOMY, AUTOGENOUS OR NONAU PLASTIC REPAIR OF ARTERIOVENOUS ANEURYSM (SEPARATE PROCEDURE) DISTAL REVASCULARIZATION AND INTERVAL LIGATION (DRILL), UPPER EXTREMITY HEMODIALYSIS ACCESS (STEAL SYNDROME) CANNULA DECLOTTING (SEPARATE PROCEDURE); WITHOUT BALLOON CATHETER CANNULA DECLOTTING (SEPARATE PROCEDURE); WITH BALLOON CATHETER THROMBECTOMY, PERCUTANEOUS, ARTERIOVENOUS FISTULA, AUTO GENOUS OR NONAUTOGENOUS GRAFT (INCLUDES MECHANICAL THROMBUS EXTRACTION AND INTRAGRAFT THROMBOLYSIS) INSERTION OF TRANSVENOUS INTRAHEPATIC PORTOSYSTEMIC SHUNT(S) (TIPS) INCLUDES VENOUS ACCESS PRIMARY PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY, NONCORONARY, ARTERIAL BYPASS GRAFT, INCLUDING FLUOROSCOPIC GUIDANCE AND INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTION(S); INITIAL VESSEL PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY, VEIN(S), INCLUDING INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTIONS AND FLUOROSCOPIC GUIDANCE. INSERTION OF INTRAVASCULAR VENA CAVA FILTER, ENDOVASCULAR APPROACH INCLUDING VASCULAR ACCESS, VESSEL SELECTION, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE (ULTRASOUND AND FLUOROSCOPY), WHEN PERFORMED REPOSITIONING OF INTRAVASCULAR VENA CAVA FILTER, ENDOVASCULAR APPROACH INCLUDING VASCULAR ACCESS, VESSEL SELECTION, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE (ULTRASOUND AND FLUOROSCOPY), WHEN PERFO Page 101 of 159

102 37193 RETRIEVAL (REMOVAL) OF INTRAVASCULAR VENA CAVA FILTER, ENDOVASCULAR APPROACH INCLUDING VASCULAR ACCESS, VESSEL SELECTION, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE (ULTRASOUND AND FLUOROSCOPY), WHEN TRANSCATHETER BIOPSY TRANSCATHETER THERAPY, INFUSION FOR THROMBOLYSIS OTHER THAN CORONARY TRANSCATHETER RETRIEVAL,PERCUTANEOUS,OF INTRAVASCULAR FB (EG, FRAC VENOUS TRANSCATHETER OCCLUSION OR EMBOLIZATION,PERCUTANEOUS,ANY METHOD,EA LOCATIO TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S),PERCUTANEOUS; INITIAL VE TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S), OPEN; INITIAL VESSEL EXCHANGE OF A PREVIOUSLY PLACED ARTERIAL CATHETER DURING THROMBOLYTIC THER 0201 UTERINE FIBROID EMBOLIZATION (UFE, EMBOLIZATION OF THE UTERINE FIBROIDS, LEIOMYOMATA), PERCUTANEOUS APPROACH INCLUSIVE OF VASCULAR ACCESS, VESSEL SELECTION, EMBOLIZATION, AND ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCED REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, ILIAC ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL ANGIOPLASTY REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, ILIAC ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL ANGIOPLASTY REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH ATHERECTOMY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL STENT PLACEMENT(S) AND ATHERECTOMY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, TIBIAL, PERONEAL ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL ANGIOPLASTY REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, TIBIAL, PERONEAL ARTERY, UNILATERAL, INITIAL VESSEL; WITH ATHERECTOMY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, TIBIAL, PERONEAL ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED Page 102 of 159

103 REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, TIBIAL, PERONEAL ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL STENT PLACEMENT(S) AND ATHERECTOMY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S) (EXCEPT LOWER EXTREMITY ARTERY(S) FOR OCCLUSIVE DISEASE, CERVICAL CAROTID, EXTRACRANIAL VERTEBRAL OR INTRATHORACIC CAROTID, INTRACRANIAL, OR CORONARY), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ALL ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; INITIAL ARTERY TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; INITIAL VEIN VASCULAR EMBOLIZATION OR OCCLUSION, INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; ARTERIAL, OTHER THAN HEMORRHAGE OR TUMOR (EG, CONGENITAL OR ACQUIRED ARTERIAL MALFORMATIONS, ARTERIOVENOUS MALFORMATIONS, ARTERIOVENOUS FISTULAS, ANEURYSMS, PSEUDOANEURYSMS) VASCULAR EMBOLIZATION OR OCCLUSION, INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; FOR TUMORS, ORGAN ISCHEMIA, OR INFARCTION LIGATION, INTERNAL JUGULAR VEIN LIGATION; EXTERNAL CAROTID ARTERY LIGATION; INTERNAL OR COMMON CAROTID ARTERY LIGATION OR BANDING OF ANGIOACCESS ARTERIOVENOUS FISTULA LIGATION OR BIOPSY, TEMPORAL ARTERY LIGATION, MAJOR ARTERY (EG, POST-TRAUMATIC, RUPTURE); EXTREMITY LIGATION OF INFERIOR VENA CAVA INTERRUPTION,PART OR COMP,OF INFERIOR VENA CAVA BY SUTURE,LIGATION,PLICATION, CL LIGATION OF FEMORAL VEIN LIGATION OF COMMON ILIAC VEIN LIGATION AND DIVISION OF LONG SPHENOUS VEIN AT SAPHENOFEMORAL JUNCTION, OR DIS LIGATION, DIVISION, AND STRIPPING, SHORT SAPHENOUS VEIN LIGATION, DIVISION, AND STRIPPING, LONG (GREATER) SAPHENOUS VEIN FROM SAPHENOFEMORAL JUNCTION TO KNEE BELOW LIGATION AND DIVISION AND COMPLETE STRIPPING OF LONG OR SHORT SAPHENOUS VEINS LIGATION OF PERFORATORS, SUBFASCIAL, RADICAL (LINTON TYPE), WITH OR WITHOUT SKIN STAB PHLEBECTOMY OF VAICOSE VEINS, ONE EXTREMITY; STAB INCISIONS STAB PHLEBECTOMY OF VAICOSE VEINS, ONE EXTREMITY; MORE THAN 20 INCISIONS LIGATION AND DIVISION OF SHORT SAPHENOUS VEIN AT SAPHENOPOPLITEAL JUNCTION (SEP LIGATION, DIVISION &/OR EXCISION OF RECURRENT OR SECONDARY VARICOSE VEINS Page 103 of 159

104 BLOOD-DERIVED HEMATOPOIETIC PROGENITOR CELL HARVESTING FOR TRANSPLANTATION, PER COLLECTION; ALLOGENIC BLOOD-DERIVED HEMOPOIETIC PROGENITOR CELL HARVESTING, FOR TRANSPLANTATION, PER COLLECTION, AUTOLOGOUS BONE MARROW ASPIRATION ONLY BONE MARROW BIOPSY NEEDLE BONE MARROW HARVESTING FOR TRANSPLANTATION BONE MARROW HARVESTING FOR TRANSPLANTATION; AUTOLOGOUS BONE MARROW OR BLOOD-DERIVED PERIPHERAL STEM CELL TRANSPLANTATION; ALLOGEN BONE MARROW OR BLOOD-DERIVED PERIPHERAL STEM CELL TRANSPLANTATION; AUTOLOGOUS DRAINAGE OF LYMPH NODE ABSCESS OR LYMPHADENITIS; EXTENSIVE LYMPHANGIOTOMY OR OTHER OPERATIONS ON LYMPHATIC CHANNELS SUTURE AND/OR LIGATION OF THORACIC DUCT; CERVICAL APPROACH BIOPSY OR EXCISION OF LYMPH NODE(S); SUPERFICIAL (SEPARATE PROCEDURE) BIOPSY OR EXCISION OF LYMPH NODE(S); DEEP CERVICAL NODE(S) BIOPSY OR EXCISION OF LYMPH NODE(S); DEEP CERVICAL NODE(S) WITH EXCISION SCALENE BIOPSY OR EXCISION OF LYMPH NODE(S); DEEP AXILLARY NODE(S) DISSECTION; DEEP JUGULAR NODE(S) EXCISION OF CYSTIC HYGROMA, AXILLARY OR CERVICAL; WITHOUT DEEP NEUROVASCULAR EXCISION OF CYSTIC HYGROMA,AXILLARY OR CERVICAL;W/ DEEP NEUROVASCULAR DISSECT SUPRAHYOID LYMPHADENECTOMY CERVICAL LYMPHADENECTOMY (COMPLETE) CERVICAL LYMPHADENECTOMY (MODIFIED RADICAL NECK DISSECTION) AXILLARY LYMPHADENECTOMY; SUPERFICIAL AXILLARY LYMPHADENECTOMY; COMPLETE INGUINOFEMORAL LYMPHADENECTOMY, SUPERFICIAL, INCLUDING CLOQUET'S NODE (SEPARATE PROCEDURE) PELVIC LYMPHADENECTOMY, INCLUDING EXTERNAL ILIAC, HYPOGASTRIC, AND OBTURATION NODES 9SEPARATE PROCEDURE) INJECTION PROCEDURE FOR IDENTIFICATION OF SENTINEL NODE MEDIASTINOTOMY W/ EXPLORATION,DRAINAGE,REMOVAL OF FB OR BIOPSY;TRANSTHORACIC EXCISION OF MEDIASTINAL CYST EXCISION OF MEDIASTINAL TUMOR MEDIASTINOSCOPY, WITH OR WITHOUT BIOPSY VERMILIONECTOMY (LIP SHAVE), WITH MUCOSAL ADVANCEMENT EXCISION OF LIP; FULL THICKNESS, RECONSTRUCTION WITH LOCAL FLAP (EG, ESTLANDER RESECTION OF LIP, MORE THAN ONE-FOURTH, WITHOUT RECONSTRUCTION REPAIR LIP, FULL THICKNESS; UP TO HALF VERTICAL HEIGHT REPAIR LIP, FULL THICKNESS; OVER ONE-HALF VERTICAL HEIGHT, OR COMPLEX Page 104 of 159

105 40700 PLASTIC REPAIR OF CLEFT LIP/NASAL DEFORMITY;PRIMARY,PARTIAL OR COMPLETE,UNILATE PLASTIC REPAIR OF CLEFT LIP; SECONDARY, BY RECREATION OF DEFECT AND RECLOSURE PLASTIC REPAIR OF CLEFT LIP/NASAL DEFORMITY;W/ CROSS LIP PEDICLE FLAP,INC SECTION DRAINAGE OF ABSCESS, CYST, HEMATOMA, VESTIBULE OF MOUTH; COMPLICATED REMOVAL OF EMBEDDED FOREIGN BODY, VESTIBULE OF MOUTH, COMPLICATED INCISION OF LABIAL FRENUM (FRENOTOMY) BIOPSY, VESTIBULE OF MOUTH EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBLE OF MOUTH; WITHOUT REPAIR EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH;W/ COMPLEX REP EXCISION OF LESION OF MUCOSA & SUBMUCOSA,VESTIBULE OF MOUTH;COMPLEX,W/ EXC UN EXCISION OF MUCOSA OF VESTIBULE OF MOUTH AS DONOR GRAFT EXCISION OF FRENUM, LABIAL OR BUCCAL (FRENUMECTOMY, FRENULECTOMY, FRENECTOM DESTRUCTION OF LESION OR SCAR OF VESTIBULE OF MOUTH BY PHYSICAL METHODS CLOSURE OF LACERATION, VESTIBULE OF MOUTH; 2.5 CM OR LESS CLOSURE OF LACERATION, VESTIBULE OF MOUTH; OVER 2.5 CM OR COMPLEX VESTIBULOPLASTY; ANTERIOR INTRAORAL INCISION & DRAINAGE OF ABSCESS,CYST OR HEMATOMA OF TONGUE OR FLOOR INTRAORAL INCISION & DRAINAGE OF ABSCESS, CYST, OR HEMATOMA OF TONGUE OR FLOOR INCISION OF LINGUAL FRENUM (FRENOTOMY) BIOPSY OF TONGUE; ANTERIOR TWO-THIRDS BIOPSY OF FLOOR OF MOUTH EXCISION OF LESION OF TONGUE WITH CLOSURE; POSTERIOR ONE-THIRDS EXCISION OF LESION OF TONGUE WITH CLOSURE; WITH LOCAL TONGUE FLAP EXCISION OF LINGUAL FRENUM (FRENECTOMY) EXCISION, LESION OF FLOOR OF MOUTH GLOSSECTOMY; LESS THAN ONE-HALF TONGUE GLOSSECTOMY; HEMIGLOSSECTOMY REPAIR OF LACERATION 2.5 CM OR LESS; FLOOR OF MOUTH AND/OR ANTERIOR TWO-THIRDS REPAIR OF LACERATION OF TONGUE, FLOOR OF MOUTH, FRENOPLASTY (SURGICAL REVISION OF FRENUM, EG, WITH Z-PLASTY) DRAINAGE OF ABSCESS, CYST, HEMATOMA FROM DENTOALVEOLAR STRUCTURES REMOVAL OF EMBEDDED FB FROM DENTOALVEOLAR STRUCTURES; SOFT TISSUES REMOVAL OF EMBEDDED FB FROM DENTOALVEOLAR STRUCTURES; BONE EXCISION OF FIBROUS TUBEROSITIES, DENTOALVEOLAR STRUCTURES EXCISION OF OSSEOUS TUBEROSITIES, DENTOALVEOLAR STRUCTURES EXCISION OF LESION OR TUMOR, DENTOALVEOLAR STRUCTURES; WITHOUT REPAIR EXCISION OF LESION OR TUMOR, DENTOALVEOLAR STRUCTURES; WITH SIMPLE REPAIR EXCISION OF LESION OR TUMOR,DENTOALVEOLAR STRUCTURES; WITH COMPLEX REPAIR EXCISION OF HYPERPLASTIC ALVEOLAR MUCOSA, EACH QUADRANT (SPECIFY) DESTRUCTION OF LESION (EXCEPT EXCISION), DENTOALVEOLAR STRUCTURES Page 105 of 159

106 41870 PERIODONTAL MUCOSAL GRAFTING ALVEOLOPLASTY, EACH QUADRANT (SPECIFY) DRAINAGE OF ABSCESS OF PALATE, UVULA EXCISION, LESION OF PALATE, UVULA; WITHOUT CLOSURE EXCISION, LESION OF PALATE, UVULA; WITH SIMPLE PRIMARY CLOSURE RESECTION OF PALATE OR EXTENSIVE RESECTION OF LESION UVULECTOMY, EXCISION OF UVULA PALATOPHARYNGOPLASTY (EG, UVULOPALATOPHARYNGOPLASTY, UVULOPHARYNGOPLASTY) DESTRUCTION OF LESION, PALATE OR UVULA (THERMAL, CRYO OR CHEMICAL) REPAIR, LACERATION OF PALATE; UP TO 2 CM REPAIR, LACERATION OF PALATE; OVER 2 CM OR COMPLEX PALATOPLASTY FOR CLEFT PALATE, SOFT AND/OR HARD PALATE ONLY PALATOPLASTY FOR CLEFT PALATE, W/ CLOSURE OF ALVEOLAR RIDGE; SOFT TISSUE ONLY PALATOPLASTY FOR CLEFT PALATE,W/ CLOSURE OF ALVEOLAR RIDGE;W/ BONE GRAFT TO AL PALATOPLASTY FOR CLEFT PALATE; MAJOR REVISION PALATOPLASTY FOR CLEFT PALATE; ATTACHMENT PHARYNGEAL FLAP LENGTHENING OF PALATE, AND PHARYNGEAL FLAP REPAIR OF NASOLABIAL FISTULA DRAINAGE OF ABSCESS; PAROTID, COMPLICATED DRAINAGE OF ABSCESS; SUBMAXILLARY OR SUBLINGUAL, INTRAORAL DRAINAGE OF ABSCESS; SUBMAXILLARY, EXTERNAL SIALOLITHOTOMY; SUBMANDIBULAR (SUBMAXILLARY), SUBLINGUAL OR PAROTID, UNCOMPLIC SIALOLITHOTOMY; SUBMANDIBULAR (SUBMAXILLARY), COMPLICATED, INTRAORAL BIOPSY OF SALIVARY GLAND; NEEDLE BIOPSY OF SALIVARY GLAND; INCISIONAL EXCISION OF SUBLINGUAL SALIVARY CYST (RANULA) MARSUPIALIZATION OF SUBLINGUAL SALIVARY CYST (RANULA) EXCISION OF PAROTID TUMOR OR PAROTID GLAND; LATERAL LOBE, WITHOUT NERVE DISSEC EXCISION OF PAROTID TUMOR OR PAROTID GLAND; LATERAL LOBE, WITH DISSECTION AND EXCISION OF PAROTID TUMOR OR PAROTID GLAND;TOTAL,W/ DISSECTION & PRESERVATION EXCISION OF PAROTID TUMOR OR PAROTID GLAND;TOTAL, EN BLOC REMOVAL W/ SACRIFICE EXCISION OF SUBMANDIBULAR (SUBMAXILLARY) GLAND EXCISION OF SUBLINGUAL GLAND PLASTIC REPAIR OF SALIVARY DUCT, SIALODOCHOPLASTY; PRIMARY OR SIMPLE PLASTIC REPAIR OF SALIVARY DUCT, SIALODOCHOPLASTY; SECONDARY OR COMPLICATED PAROTID DUCT DIVERSION, BILATERAL ; WITH EXCISION OF ONE SUBMANDIBULAR GLAND DILATION AND CATHETERIZATION OF SALIVARY DUCT, WITH OR WITHOUT INJECTION INCISION AND DRAINAGE ABSCESS; PERITONSILLAR INCISION & DRAINAGE ABSCESS; RETROPHARYNGEAL OR PARAPHARYNGEAL,INTRAORAL APP BIOPSY; HYPOPHARYNX Page 106 of 159

107 42806 BIOPSY; NASOPHARYNX, SURVEY FOR UNKNOWN PRIMARY LESION REMOVAL OF FOREIGN BODY FROM PHARYNX EXCISION BRANCHIAL CLEFT CYST OR VESTIGE, CONFINED TO SKIN AND SUBCUTANEOUS TIS EXCISION BRANCHIAL CLEFT CYST, OR VESTIGE, OR FISTULA, EXTENDING BENEATH SUBCUT TONSILLECTOMY AND ADENOIDECTOMY; UNDER AGE TONSILLECTOMY AND ADENOIDECTOMY; AGE 12 OR OVER TONSILLECTOMY, PRIMARY OR SECONDARY; UNDER AGE TONSILLECTOMY, PRIMARY OR SECONDARY; AGE 12 OR OVER ADENOIDECTOMY, PRIMARY; UNDER AGE ADENOIDECTOMY, PRIMARY; AGE 12 OR OVER ADENOIDECTOMY, SECONDARY; UNDER AGE ADENOIDECTOMY, AGE 12 OR OVER RADICAL RESECTION OF TONSIL,TONSILLAR PILLARS &/OR RETROMOLAR TRIGONE;CLOSUR EXCISION OF TONSIL TAGS EXCISION OR DESTRUCTION LINGUAL TONSIL, ANY METHOD (SEPARATE PROCEDURE) LIMITED PHARYNGECTOMY CONTROL OROPHARYNGEAL HEMORRHAGE,PRIMARY OR SECONDARY; SIMPLE CONTROL OROPHARYNGEAL HEMORRHAGE,PRIMARY OR SECONDARY;COMPLICATED,REQ CONTROL OROPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY; WITH SECONDARY CONTROL OF NASOPHARYNGEAL HEMORRHAGE,PRIMARY OR SECONDARY;SIMPLE,W/ POSTE CRICOPHARYNGEAL MYOTOMY DIVERTICULECTOMY OF HYPOPHARYNX OR ESOPHAGUS,W/ OR W/O MYOTOMY; CERVICAL APP DIVERTICULECTOMY OF HYPOPHARYNX OR ESOPHAGUS,W/ OR W/O MYOTOMY;THORACIC APP ESOPHAGOSCOPY, RIGID, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING WHEN PERFORMED (SEPARATE PROCEDURE) ESOPHAGOSCOPY, RIGID, TRANSORAL; WITH REMOVAL OF FOREIGN BODY ESOPHAGOSCOPY, RIGID OR FLEXIBLE; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPE ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH INJECTION SCLEROSIS OF ESOPHAGEAL VARIC ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH BAND LIGATION OF ESOPHAGEAL VARICES ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH REMOVAL OF FOREIGN BODY ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYSP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH INSERTION OF PLASTIC TUBE OR STENT ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH BALLOON DILATION (LESS THAN 30 MM DIAMETE ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH INSERTION OF GUIDE WIRE FOLLOWED BY DILA ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH ABLATION OF TUMOR(S),POLYP(S),OTHER LESIO Page 107 of 159

108 43229 ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED) ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S) ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DILATION OF ESOPHAGUS WITH BALLOON (30 MM DIAMETER OR LARGER) (INCLUDES FLUOROSCOPIC GUIDANCE, WHEN PERFORMED) UPPER GANTROINTESTINAL ENDOSCOPY, SIMPLE PRIMARY EXAMINATION UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH AND EITHER UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH AND EITHER THE DUODENUM AND/OR JEJUNUM ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE ESOPHAGUS, STOMACH OR DUODENUM, AND ADJACENT STRUCTURES ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S), (INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE ESOPHAGUS, STOMACH OR DUODENUM, AND ADJACENT STRUCTURES) UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH AND EITHER UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH TRANSMURAL DRAINAGE OF PSEUDOCYST UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS,STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE ; WITH TRANSENDOSCOPIC ULTRASOUND GUIDED INTRAMURALOR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S)..SEE CPT FOR FULL TEXT UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH AND EITHER UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH AND EITHER UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH AND EITHER UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH AND EITHER UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH AND EITHER UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH AND EITHER UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH AND EITHER UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH AND EITHER UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH AND EITHER Page 108 of 159

109 43253 ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED TRANSMURAL INJECTION OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, NEUROLYTIC AGENT) OR FIDUCIAL MARKER(S) (INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION OF THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM OR A SURGICALLY ALTERED STOMACH WHERE THE JEJUNUM IS EXAMINED DISTAL TO THE ANASTOMOSIS) ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC MUCOSAL RESECTION UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH AND EITHER UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH TRANSENDOSCOPIC STENT PLACEMENT UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH AND EITHER UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER ENDOSCOPIC RETROGRADE CHOLANGIOPANGREATOGRAPHY; DIAGNOSTIC, WITH OR WITHO ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY; DIAGNOSTIC, WITH BIO ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY; WITH SPHINCTEROTOMY/PAP ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY;W/ PRESSURE MEASUREMEN ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY;W/ ENDOSCOPIC RETROGRAD ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY,W/ OR W/O BIOPSY &/OR COLL ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH PLACEMENT OF ENDOSCOPIC STENT (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED) ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY;W/ ENDOSCOPIC RETROGRAD ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY; WITH ENDOSCOPIC RETROGR ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY; WITH ENDOSCOPIC RETROGR ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED) ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY; WITH ENDOSCOPIC RETROGR WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) NOT AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH PLACEMENT OF ENDOSCOPIC STENT INTO BILIARY OR PANCREATIC DUCT, INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH STENT ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL OF FOREIGN BODY(S) OR STENT(S) FROM BILIARY/PANCREATIC DUCT(S) Page 109 of 159

110 43276 ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL AND EXCHANGE OF STENT(S), BILIARY OR PANCREATIC DUCT, INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH STENT EXCHANGED ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH TRANS-ENDOSCOPIC BALLOON DILATION OF BILIARY/PANCREATIC DUCT(S) OR OF AMPULLA (SPHINCTEROPLASTY), INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH DUCT LAPAROSCOPY SURGICAL, ESOPHAGOGASTRIC FUNDOPLASTY LAPAROSCOPY, SURGICAL, REPAIR OF PARAESOPHAGEAL HERNIA, INCLUDES FUNDOPLASTY, WHEN PERFORMED; WITHOUT IMPLATATION OF MESH ESOPHAGOPLASTY,CERVICAL APPROACH;W/O REPAIR OF TRACHEOESOPHAGEAL FISTULA REPAIR, PARAESOPHAGEAL HIATAL HERNIA (INCLUDING FUNDOPLICATION), VIA LAPAROTOMY, EXCEPT NEONATAL; WITHOUT IMPLANTATION OF MESH OR OTHER PROSTHESIS DILATION OF ESOPHAGUS, BY UNGUIDED SOUND OR BOUGIE, SINGLE OR MULTIPLE PASSES DILATION OF ESOPHAGUS, OVER GUIDE WIRE DILATION OF ESOPHAGUS, BY BALLOON OR DILATOR, RETROGRADE DILATION OF ESOPHAGUS WITH BALLOON (30 MM DIAMETER OR LARGER) FOR ACHALASIA BIOPSY OF STOMACH; BY LAPAROTOMY LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; WITH GASTRIC BYPASS AND ROUX- EN-Y GASTROENTEROSTOMY (ROUX LIMB 150 CM OR LESS) PERCUTANEOUS PLACEMENT OF GASTROSTOMY TUBE REPOSITIONING OF GASTRIC FEEDING TUBE THRU DUODENUM FOR ENTERIC NUTRITION LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; PLACEMENT OF ADJUSTABLE GASTRIC BAND (GASTRIC BAND AND SUBCUTANEOUS PORT COMPONENTS) LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; REVISION OF ADJUSTABLE GASTRIC BAND COMPONENT ONLY LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; REMOVAL OF ADJUSTABLE GASTRIC BAND COMPONENT ONLY LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; REMOVAL OF ADJUSTABLE GASTRIC BAND AND SUBCUTANEOUS PORT COMPONENTS CLOSURE OF GASTROSTOMY, SURGICAL CLOSURE OF GASTROCOLIC FISTULA GASTRIC RESTRICTIVE PROCEDURE, OPEN; REVISION OF SUBCUTANEOUS PORT GASTRIC RESTRICTIVE PROCEDURE, OPEN; REMOVAL OF SUBCUTANEOUS PORT ONLY GASTRIC RESTRICTIVE PROCEDURE, OPEN; REMOVAL AND REPLACEMENT OF SUBCUTANEOUS PORT ONLY LAPAROSCOPY, SURGICAL; ELECTROLYSIS (FREEING OF INTESTINAL ADHESION (SEPARATE PROCEDURE) LAPAROSCOPY, SURGICAL; JEJUNOSTOMY (E.G., FOR DECOMPRESSION OR FEEDING) Page 110 of 159

111 44187 LAPAROSCOPY, SURGICAL; ILEOSTOMY OR JEJUNOSTOMY, NON-TUBE LAPAROSCOPY, SURGICAL; COLOSTOMY OR SKIN LEVEL CECOSTOMY LAPAROSCOPY, SURGICAL; COLECTOMY, PARTIAL, WITH ANASTOMOSIS LAPAROSCOPY, SURGICAL; CLOSURE OF ENTEROSTOMY, LARGE OR SMALL INTESTINE, WITH RESCECTION AND ANASTOMOSIS PLACEMENT, ENTEROSTOMY OR CECOSTOMY, TUBE OPEN (EG, FOR FEEDING OR DECOMPRESSION) (SEPARATE PROCEDURE) REVISION OF COLOSTOMY; SIMPLE (RELEASE OF SUPERFICIAL SCAR) (SEPARATE PROC) REVISION OF COLOSTOMY; WITH REPAIR OF PARACOLOSTOMY HERNIA (SEPARATE PROC) SMALL INTESTINAL ENDOSCOPY,ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM; SMALL INTESTIONAL ENDOSCOPOY, ENTEROSCOPY BEYOND SECOND PORTION OF SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM ILEOSCOPY, THROUGH STOMA; DIAGNOSTIC,W/ OR W/O COLLECTION OF SPECIMEN(S) BY BR ILEOSCOPY, THROUGH STOMA; WITH TRANSENDOSCOPIC BALLOON DILATION FIBEROPTIC ILEOSCOPY THROUGH STOMA; DIAGNOSTIC, WITH BIOPSY, SINGLE OR MULTIPLE ILEOSCOPY, THROUGH STOMA; WITH PLACEMENT OF ENDOSCOPIC STENT (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED) ENDOSCOPIC EVALUATION OF SMALL INTESTINAL POUCH; DIAGNOSTIC,W/ OR W/O COLLECT ENDOSCOPIC EVALUATION OF SMALL INTESTINAL (ABDOMINAL OR PELVIC) POUCH; COLONSCOPY THROUGH STOMA; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIME COLONSCOPY THROUGH STOMA; WITH BIOPSY, SINGLE OR MULTIPLE COLONOSCOPY THROUGH STOMA; WITH CONTROL OF BLEEDING, ANY METHOD COLONSCOPY THROUGH STOMA; WITH REMOVAL OF FOREIGN BODY COLONOSCOPY WITH ABLATION OF TUMOR(S) COLONOSCOPY THROUGH STOMA; WITH REMOVAL OFTUMOR, POLY OR OTHER LESION BY SN COLONOSCOPY THROUGH STOMA; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) (INCLUDES PRE-AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED) COLONOSCOPY THROUGH STOMA; WITH ENDOSCOPIC STENT PLACEMENT (INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED) COLONOSCOPY THROUGH STOMA; WITH ENDOSCOPIC MUCOSAL RESECTION COLONOSCOPY THROUGH STOMA; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE COLONOSCOPY THROUGH STOMA; WITH TRANSENDOSCOPIC BALLOON DILATION Page 111 of 159

112 COLONOSCOPY THROUGH STOMA; WITH ENDOSCOPIC ULTRASOUND EXAMINATION, LIMITED TO THE SIGMOID, DESCENDING, TRANSVERSE, OR ASCENDING COLON AND CECUM AND ADJACENT STRUCTURES COLONOSCOPY THROUGH STOMA; WITH TRANSENDOSCOPIC ULTRASOUND GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S), INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE SIGMOID, DESCENDING, TRANSVERSE, OR ASCENDING COLON AND CECUM AND ADJACENT STRUCTURES COLONOSCOPY THROUGH STOMA; WITH DECOMPRESSION (FOR PATHOLOGIC DISTENTION) (EG, VOLVULUS, MEGACOLON), INCLUDING PLACEMENT OF DECOMPRESSION TUBE, WHEN PERFORMED INTRODUCTION OF LONG GASTROINTESTINAL TUBE (EG, MILLER-ABBOTT) (SEPARATE PROC) CLOSURE OF ENTEROSTOMY, LARGE OR SMALL INTESTINE INCISION AND DRAINAGE OF ABSCESS; PERCUTANEOUS APPENDECTOMY LAPARSCOPY; SURGICAL, APPENDECTOMY TRANSRECTAL DRAINAGE OF PELVIC ABSCESS INCISION AND DRAINAGE OF SUBMUCOSAL ABSESS, RECTUM INCISION & DRAINAGE OF DEEP SUPRALEVATOR, PELVIRECTAL, OR RETRORECTAL ABSCESS BIOPSY OF ANORECTAL WALL AND APPROACH (EG, CONGENITAL MEGACOLON) ANORECTAL MYOMECTOMY EXCISION OF RECTAL TUMOR BY PROCTOTOMY, TRANSACRAL OR TRANSCOCCYGEAL APPRO EXCISION OF RECTAL TUMOR, TRANSANAL APPROACH EXCISION OF RECTAL TUMOR, TRANSANAL APPROACH; NOT INCLUDING MUSCULARIS PROPRIA (IE, PARTIAL THICKNESS) EXCISION OF RECTAL TUMOR, TRANSANAL APPROACH; INCLUDING MUSCULARIS PROPRIA (IE, FULL THICKNESS) DESTRUCTION OF RECTAL TUMOR, (EG, ELECTRODESICCATION, ELECTORSURGERY, LASER ABLATION, LASER RESECTION, CRYOSURGERY) TRANSANAL APPROACH PROCTOSIGMOIDOSCOPY, RIGID; WITH REMOVAL OF FOREIGN BODY PROCTOSIGMOIDOSCOPY, RIGID; WITH REMOVAL OF SINGLE TUMOR, POLYP OR OTHER LESI PROCTOSIGMOIDOSCOPY, RIGID; WITH REMOVAL OF SINGLE TUMOR, POLYP OR OTHER LESI PROCTOSIGMOIDOSCOPY, RIGID; WITH REMOVAL OF MULTIPLE TUMORS, POLYPS OR OTHER PROCTOSIGMOIDOSCOPY, RIGID; WITH CONTROL OF BLEEDING, ANY METHOD PROCTOSIGMOIDOSCOPY; RIGID; WITH ABLATION OF TUMOR, POLYP OR OTHER LESIONS NOT SIGMOIDOSCOPY, FLEXIBLE FIBEROPTIC; WITH REMOVAL OF FOREIGN BODY SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR, POLYP OR OTHER LESTIONS BY HOT SIGMOIDOSCOPY, FLEXIBLE; WITH CONTROL OF BLEEDING, ANY METHOD SIGMOIDOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE SIGMOIDOSCOPY, FLEXIBLE; WITH DECOMPRESSION OF VOLVULUS, ANY METHOD SIGMOIDOSCOPY,FLEXIBLE;W/ REMOVAL OF TUMOR(S),POLYP(S) OR OTHER LESION(S) BY SN Page 112 of 159

113 45339 SIGMOIDOSCOPY, FLEXIBLE; WITH ABLATION OF TUMOR, POLYP OR OTHER LESION NOT AMEN SIGMOIDOSCOPY, FLEXIBLE; WITH DILATION BY BALLOON, 1 OR MORE STRICTURES SIGMOIDOSCOPY, FLEXIBLE; WITH ENDOSCOPIC ULTRASOUND EXAMINATIONS SIGMOIDOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC ULTRASOUND GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(IES) SIGMOIDOSCOPY, FLEXIBLE; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED) SIGMOIDOSCOPY, FLEXIBLE; WITH PLACEMENT OF ENDOSCOPIC STENT (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED) SIGMOIDOSCOPY, FLEXIBLE; WITH ENDOSCOPIC MUCOSAL RESECTION SIGMOIDOSCOPY, FLEXIBLE; WITH BAND LIGATION(S) (EG, HEMORRHOIDS) COLONOSCOPY, RIGID OR FLEXIBLE, TRANSABDOMINAL VIA COLOTOMY, SINGLE OR MULTIPLE COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; DIAGNOSTIC, WITH OR WITHOUT COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH REMOVAL OF FOREIGN BO COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH BIOPSY, SINGLE OR MULT COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBST COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH CONTROL OF BLEEDING COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH ABLATION OF TUMOR, POL COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH REMOVAL OF TUMOR, POL COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH REMOVAL OF TUMOR, POL COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH DILATION BY BALLOON, 1 OR MORE STRICTURES COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH TRANSENDOSCOPIC STENT PLACEMENT (INCLUDES PREDILATION) COLONOSCOPY, FLEXIBLE; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED) COLONOSCOPY, FLEXIBLE; WITH ENDOSCOPIC STENT PLACEMENT (INCLUDES PRE- AND POST- DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED) COLONOSCOPY, FLEXIBLE; WITH ENDOSCOPIC MUCOSAL RESECTION COLONOSCOPY, FLEXIBLE; WITH ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE RECTUM, SIGMOID, DESCENDING, TRANSVERSE, OR ASCENDING COLON AND CECUM, AND ADJACENT STRUCTURES COLONOSCOPY, FLEXIBLE; WITH DECOMPRESSION (FOR PATHOLOGIC DISTENTION) (EG, VOLVULUS, MEGACOLON), INCLUDING PLACEMENT OF DECOMPRESSION TUBE, WHEN PERFORMED COLONOSCOPY, FLEXIBLE; WITH BAND LIGATION(S) (EG, HEMORRHOIDS) LAPAROSCOPY, SURGICAL; PROCTOPEXY (FOR PROLAPSE) PROCTOPLASTY; FOR STENOSIS PROCTOPLASTY; FOR PROLAPSE OF MUCOUS MEMBRANE Page 113 of 159

114 45541 PROCTOPLASTY; PERINEAL APPROACH PROCTOPEXY COMBINED WITH SIGMOID RESECTION, ABDOMINAL APPROACH REPAIR OF RECTOCELE (SEPARATE PROCEDURE) DILATION OF ANAL SPHINCTER (SEPARATE PROCEDURE) UNDER ANESTHESIA OTHER THAN DILATION OF RECTAL STRICTURE (SEP PROC) UNDER ANESTHESIA OTHER THAN LOCAL REMOVAL OF FECAL IMPACTION OR FOREIGN BODY (SEP PROC) UNDER ANESTHESIA ANORECTAL EXAM, SURGICAL, REQUIRING ANESTHESIA (GENERAL, SPINAL, OR EPIDURAL), DIAGNOSTIC INCISION; PLACEMENT OF SETON REMOVAL OF ANAL SETON, OTHER MARKER INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSCESS (SEPARATE PRO INCISION AND DRAINAGE OF INTRAMURAL, INTRAMUSCULAR OR SUBMUCOL ABSCESS, TRAN INCISION AND DRAINAGE OF ISCHIORECTAL OR INTRAMURAL ABSCESS, WITH FISTULECTOMY SPHINCTEROTOMY, ANAL, DIVISION OF SPHINCTER (SEPARATE PROCEDURE) INCISION OF THROMBOSED HEMORRHOID, EXTERNAL FISSURECTOMY, WITH OR WITHOUT SPHINCTEROTOMY CRYPTECTOMY; SINGLE CRYPTECTOMY; MULTIPLE (SEPARATE PROCEDURE) HEMORRHOIDECTOMY, EXTERNAL, COMPLETE HEMORRHOIDECTOMY INTERNAL AND EXTERNAL, SIMPLE; HEMORRHOIDECTOMY INTERNAL AND EXTERNAL, WITH FISSURECTOMY HEMORRHOIDECTOMY INTERNAL AND EXTERNAL, WITH FISTULECTOMY, WITH OR WITHOUT HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, COMPLEX OR EXTENSIVE HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, WITH FISSURECTOMY HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, WITH FISTULECTOMY, WITH OR WITHOUT SUGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); SUBCUTANEOUS FISTULECTOMY; SUBMUSCULAR FISTULECTOMY; COMPLEX OR MULTIPLE, WITH OR WITHOUT PLACEMENT OF SETON SUGICAL TREATMENT OF ANAL FISTULA SECOND STAGE CLOSURE OF ANAL FISTULA WITH RECTAL ADVANCEMENT FLAP INJECTION OF SCLEROSING SOLUTION, HEMORRHOIDS CHEMODENERVATION OF INTERNAL ANAL SPHINCTER ANOSCOPY; DIAGNOSTIC, WITH HIGH-RESOLUTION MAGNIFICATION (HRA) (EG, COLPOSCOPE, OPERATING MICROSCOPE) AND CHEMICAL AGENT ENHANCEMENT, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED ANOSCOPY; WITH HIGH-RESOLUTION MAGNIFICATION (HRA) (EG, COLPOSCOPE, OPERATING MICROSCOPE) AND CHEMICAL AGENT ENHANCEMENT, WITH BIOPSY, SINGLE OR MULTIPLE ANOSCOPY; WITH REMOVAL OF FOREIGN BODY ANOSCOPY; WITH REMOVAL OF SINGLE TUMOR, POLYP, OR OTHER LESION BY SNARE TECH ANOSCOPY; WITH REMOVAL OF MULTIPLE TUMORS, POLYPS OR OTHER LESIONS BY HOT BIOP Page 114 of 159

115 46614 ANOSCOPY; WITH CONTROL OF BLEEDING, ANY METHOD ANOSCOPY;W/ ABLATION OF TUMOR(S),POLYP(S) OR OTHER LESION(S) NOT AMENDABLE TO ANOPLASTY, PLASTIC OPERATION FOR STRICTURE; ADULT REPAIR OF ANAL FISTULA WITH FIBRIN GLUE REPAIR OF ILEOANAL POUCH FISTULA/SINUS (E.G., PERINEAL OR VAGINAL), POUCH ADVANCEMENT; TRANSPERINEAL APPROACH SPHINCTEROPLASTY, ANAL, FOR INCONTINENCE OR PROLAPSE; ADULT SPHINCTEROPLASTY, ANAL, FOR INCONTINENCE OR PROLAPSE; CHILD SPHINCTEROPLASTY, ANAL, FOR INCONTINENCE, ADULT; MUSCLE TRANSPLANT DESTRUCTION OF LESION(S), ANUS, SIMPLE; CHEMICAL DESTRUCTION OF LESION, ANUS, EXTENSIVE, ANY METHOD DESTRUCTION OF INTERNAL HEMORRHOID(S) BY THERMAL ENERGY (EG, INFRARED COAGULATION, CAUTERY, RADIOFREQUENCY) DESTRUCTION OF HEMORRHOIDS, ANY METHOD; INTERNAL DESTRUCTION OF HEMORRHOIDS, ANY METHOD; EXTERNAL DESTRUCTION OF HEMORRHOIDS ANY METHOD; INTERNAL AND EXTERNAL CURETTAGE OR CAUTERIZATION OF ANAL FISSURE, INCLUDING DILATION OF ANAL SPHINC CURETTAGE OR CAUTERIZATION OF ANAL FISSURE, INCLUDING DILATION OF ANAL SPHINC HEMORRHOIDOPEXY BIOPSY OF LIVER HEPATOTOMY; FOR PERCUTANEOUS DRAINAGE OF ABSCESS OR CYST, ONE OR TWO STAGES ABLATION, OPEN, OF ONE OR MORE LIVE TUMOR(S); PERCUTANEOUS PERCUTANEOUS CHOLECYSTOSTOMY INJECTION PROCEDURE FOR CHOLANGIOGRAPHY THROUGH AN EXISTING CATHETER (EG, PERCUTANEOUS TRANSHEPATIC OR T-TUBE) INTRODUCTION OF PERCUTANEOUS TRANSHEPATIC CATHETER FOR BILIARY DRAINAGE INTRODUCTION OF PERCUTANEOUS TRANSHEPATIC STENT FOR INTERNAL AND EXTERNAL CHANGE OF PERCUTANEOUS BILIARY DRAINAGE CATHETER EXCHANGE OF BILIARY DRAINAGE CATHETER (EG, EXTERNAL, INTERNAL-EXTERNAL, OR CONVERSION OF INTERNAL-EXTERNAL TO EXTERNAL ONLY), PERCUTANEOUS, INCLUDING DIAGNOSTIC CHOLANGIOGRAPHY WHEN PERFORMED, IMAGING GUIDANCE (EG, FLUOROSCOPY), AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION BILIARY ENDOSCOPY, PERCUTANEOUS VIA T-TUBE OR OTHER TRACT; DIAGNOSTIC, WITH OR BILIARY,ENDOSCOPY,PERCUTANEOUS VIA T-TUBE OR OTH TRACT;W/ REMOVAL OF STONE(S) BILIARY ENDOSCOPY, PERCUTANEOUS VIA T-TUBE OR OTHER TRACT; WITH REMOVAL OF STO BILIARY ENDOSCOPY,PERCUTANEOUS VIA T-TUBE OR OTHER TRACT;W/ DILATION OF BILIARY LAPAROSCOPY, SURGICAL; WITH GUIDED TRANSHEPATIC CHOLANGIOGRAPHY, WITHOUT BIOPSY LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY LAPAROSCOPY, SUGICAL; CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY CHOLECYSTECTOMY Page 115 of 159

116 47630 BILIARY DUCT STONE EXTRACTION, PERCUTANEOUS VIA T-TUE TRACT, BASKET OR SNARE PLACEMENT OF CHOLEDOCHAL STENT BIOPSY OF PANCREAS,OPEN,ANY METHOD (EG, FINE NEEDLE ASPIRATION, NEEDLE CORE BIO BIOPSY OF PANCREAS, PERCUTANEOUS NEEDLE REOPENING OF RECENT LAPAROTOMY EXPLORATION, RETROPERITONEAL AREAS WITH OR WITHOUT BIOPSY(IES) (SPEARATE PROCEDURE) DRAINAGE OF PERITONEAL ABSCESS OR LOCALIZED PERITONITIS,EXCLUSIVE OF APPENDIC DRAINAGE OF SUBDIAPHRAGMATIC OR SUBPHRENIC ABSCESS; PERCUTANEOUS DRAINAGE OF RETROPERITONEAL ABSCESS; PERCUTANEOUS ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC); WITHOUT IMAGING GUIDANCE ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC); WITH IMAGING GUIDANCE PERITONEAL LAVAGE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED BIOPSY, ABDOMINAL OR RETROPERITONEAL MASS, PERCUTANEOUS NEEDLE EXCISION OR DESTRUCTION BY ANY METHOD OF INTRA-ABDOMINAL OR RETROPERITONEAL EXCISION OR DESTRUCTION, OPEN, INTRA-ABDOMINAL TUMORS, CYSTS OR ENDOMETRIOMAS, OR MORE PERITONEAL, MESENTERIC, OR RETROPERITONEAL PRIMARY OR SECONDARY TUMORS; LARGEST TUMOR 5 CM DIAMETER OR LESS EXCISION OR DESTRUCTION, OPEN, INTRA-ABDOMINAL TUMORS, CYSTS OR ENDOMETRIOMAS, 1 OR MORE PERITONEAL, MESENTERIC, OR RETROPERITONEAL PRIMARY OR SECONDARY TUMORS; LARGEST TUMOR CM DIAMETER EXCISION OR DESTRUCTION, OPEN, INTRA-ABDOMINAL TUMORS, CYSTS OR ENDOMETRIOMAS, 1 OR MORE PERITONEAL, MESENTERIC, OR RETROPERITONEAL PRIMARY OR SECONDARY TUMORS; LARGEST TUMOR GREATER THAN 10.0 CM DIAMETER EXCISION OF PRESACRAL OR SACROCOCCYGEAL TUMOR UMBILECTOMY, OMPHALECTOMY, EXCISION OF UMBILICUS (SEPARATE PROCEDURE) OMENTECTOMY, EPIPLOECTOMY, RESECTION OF OMENTUM (SEPARATE PROCEDURE) LAPAROSCOPY, ABDOMEN, PERITONEUM & OMENTUM, DIAGNOSTIC, W/ OR W/O COLLECTION LAPAROSCOPY, SURGICAL; WITH BIOPSY (SINGLE OR MULTIPLE) LAPAROSCOPY, ABDOMEN, PERITONEUM & OMENTUM, DIAGNOSTIC,W/ ASPIRATION OF CAVITY OR LAPAROSCOPY WITH INSERTION OF INTRAPERITONEAL CANNULA LAPAROSCOPY WITH REVISION OF PREVIOUSLY PLACED INTRAPERITONEAL CANNULA INJECTION OF AIR OR CONTRAST INTO PERITONEAL CAVITY (SEPARATE PROCEDURE) REMOVAL OF PERITONEAL FOREIGN BODY FROM PERITONEAL CAVITY IMAGE-GUIDED FLUID COLLECTION DRAINAGE BY CATHETER (EG, ABSCESS, HEMATOMA, SEROMA, LYMPHOCELE, CYST); VISCERAL (EG, KIDNEY, LIVER, SPLEEN, LUNG/MEDIASTINUM), PERCUTANEOUS IMAGE-GUIDED FLUID COLLECTION DRAINAGE BY CATHETER (EG, ABSCESS, HEMATOMA, SEROMA, LYMPHOCELE, CYST); PERITONEAL OR RETROPERITONEAL, PERCUTANEOUS Page 116 of 159

117 49418 INSERTION OF TUNNELED INTRAPERITONEAL CATHETER (EG, DIALYSIS, INTRAPERITONEAL CHEMOTHERAPY INSTILLATION, MANAGEMENT OF ASCITES), COMPLETE PROCEDURE, INCLUDING IMAGING GUIDANCE, CATHETER PLACEMENT, CONTRAST INJECTION WHEN PERFORMED, AND RADIOLOGICAL SUPERV INSERTION OF INTRAPERITONEAL CANNULA OR CATHETER, WITH SUBCUTANEOUS RESERVIOR, PERMANENT (IE, TOTALL INSERTION OF INTRAPERITONEAL CANNULA OR CATHETER DRAINAGE OR DIALYSIS; PERMAN REMOVAL OF PERMANENT INTRAPERITONEAL CANNULA OR CATHETER EXCHANGE OF PREVIOUSLY PLACED ABSCESS OR CYST DRAINAGE CATHETER UNDER RADI REVISION OF PERITONEAL-VENOUS SHUNT REMOVAL OF PERITONEAL-VENOUS SHUNT DELAYED CREATION OF EXIT SITE FROM EMBEDDED SUBCUTANEOUS SEGMENT OF INTRAPERITONEAL CANNULA OR CATHETER INSERTION OF GASTROSTOMY TUBE, PERCUTANEOUS, UNDER FLUOROSCOPIC GUIDANCE INCLUDING CONTRAST INJECTION(S), IMAGE DOCUMENTATION AND REPORT INSERTION OF DUODENOSTOMY OR JEJUNOSTOMY TUBE, PERCUTANEOUS, UNDER FLUOROSCOPIC GUIDANCE INCLUDING CONTRAST INJECTION(S), IMAGE DOCUMENTATION AND REPORT. INSERTION OF CECOSTOMY OR OTHER COLONIC TUBE, PERCUTANEOUS, UNDER FLUOROSCOPIC GUIDANCE INCLUDING CONTRAST INJECTION(S), IMAGE DOCUMENTATION AND REPORT. CONVERSION OF GASTROSTOMY TUBE TO GASTRO-JEJUNOSTOMY TUBE, PERCUTANEOUS, UNDER FLUOROSCOPIC GUIDANCE INCLUDING CONTRAST INJECTION(S), IMAGE DOCUMENTATION AND REPORT. REPLACEMENT OF GASTROSTOMY OR CECOSTOMY (OR OTHER COLONIC) TUBE, PERCUTANEOUS, UNDER FLUOROSCOPIC GUIDANCE INCLUDING CONTRAST INJECTION(S), IMAGE DOCUMENTATION AND REPORT. REPLACEMENT OF DUODENOSTOMY OR JEJUNOSTOMY TUBE, PERCUTANEOUS, UNDER FLUOROSCOPIC GUIDANCE INCLUDING CONTRAST INJECTION(S), IMAGE DOCUMENTATION AND REPORT. REPLACEMENT OF GASTRO-JEJUNOSTOMY TUBE, PERCUTANEOUS, UNDER FLUOROSCOPIC GUIDANCE INCLUDING CONTRAST INJECTION(S), IMAGE DOCUMENTATION AND REPORT. MECHANICAL REMOVAL OF OBSTRUCTIVE MATERIAL FROM GASTROSTOMY, DUODENOSTOMY, JEJUNOSTOMY, GASTRO-JEJUNOSOTOMY, OR CECOSTOMY (OR OTHER COLONIC) TUBE, ANY METHOD, UNDER FLUOROSCOPIC GUIDANCE INCLUDING CONTRAST INJECTION(S), IF PERFORMED, IMAGE DOCUMENTATION A REPAIR, INITIAL INGUINAL HERNIA REPAIR INITIAL INGUINAL HERNIA, UNDER AGE 6 MONTHS, WITH OR WITHOUT HYDOCELECTO REPAIR INITIAL INGUINAL HERNIA, UNDER AGE 6 MONTHS, WITH OR WITHOUT HYDOCELECTO REPAIR INITIAL INGUINAL HERNIA, UNDER AGE 5 YEARS, WITH OR WITHOUT HYDOCELECTOM REPAIR INITIAL INGUINAL HERNIA, UNDER AGE 5 YEARS, WITH OR WITHOUT HYDOCELECTOM Page 117 of 159

118 49505 REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS OR OVER; REDUCIBLE REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS OR OVER; INCARCERATED OR STRANGULATE REPAIR INGUINAL HERNIA, ANY AGE; REDUCIBLE REPAIR RECURRENT INGUINAL HERNIA, ANY AGE; REPAIR INGUINAL HERNIA, ANY AGE; SLIDING, ANY AGE REPAIR LUMBAR HERNIA REPAIR INITIAL FEMORAL HERNIA, ANY AGE; REDUCIBLE REPAIR INITIAL FEMORAL HERNIA, ANY AGE; INCARCERATED OR STRANGULATED REPAIR INITIAL INCISIONAL HERNIA; REDUCIBLE REPAIR INITIAL INCISIONAL HERNIA; INCARCERATED OR STRANGULATED REPAIR RECURRENT INCISIONAL HERNIA; REDUCIBLE REPAIR RECURRENT INCISIONAL OR VENTRAL HERNIA; INCARCERATED OR STRANGULATED REPAIR EPIGASTRIC HERNIA (EG, PROPERITONEAL FAT); REDUCIBLE (SEPARATE PROCEDU REPAIR EPIGASTRIC HERNIA (EG, PREPERITONEAL FAT); INCARCERATED OR STRANGULATED REPAIR UMBILICAL HERNIA; UNDER AGE 5 YEARS; REDUCIBLE REPAIR UMBILICAL HERNIA, UNDER AGE 5 YEARS; INCARCERATED OR STRANGULATED REPAIR UMBILICAL HERNIA, AGE 5 YEARS OR OVER; REDUCIBLE REPAIR UMBILICAL HERNIA, AGE 5 YEARS OR OVER; INCARCERATED OR STRANGULATED REPAIR SPIGELIAN HERNIA LAPARSCOPY,SURGICAL; REPAIR INITIAL INGUINAL HERNIA LAPARSCOPY,SURGICAL; REPAIR RECURRENT INGUINAL HERNIA LAPAROSCOPY, SURGICAL, REPAIR, VENTRAL, UMBILICAL, SPIGELIAN OR EPIGASTRIC HERNIA (INCLUDES MESH INSERTION, WHEN PERFORMED); REDUCIBLE LAPAROSCOPY, SURGICAL, REPAIR, VENTRAL, UMBILICAL, SPIGELIAN OR EPIGASTRIC HERNIA (INCLUDES MESH INSERTION, WHEN PERFORMED; INCARCERATED OR STRANGULATED LAPAROSCOPY, SURGICAL, REPAIR, INCISIONAL HERNIA (INCLUDES MESH INSERTION, WHEN PERFORMED); REDUCIBLE LAPAROSCOPY, SURGICAL, REPAIR, INCISIONAL HERNIA (INCLUDES MESH INSERTION, WHEN PERFORMED; INCARCERATED OR STRANGULATED LAPAROSCOPY, SURGICAL, REPAIR, RECURRENT INCISIONAL HERNIA (INCLUDES MESH INSERTION, WHEN PERFORMED; REDUCIBLE LAPAROSCOPY, SURGICAL, REPAIR, RECURRENT INCISIONAL HERNIA (INCLUDES MESH INSERTION, WHEN PERFORMED); INCARCERATED OR STRANGULATED DRAINAGE OF PERIRENAL OR RENAL ABSCESS; OPEN DRAINAGE OF PERIRENAL ABSCESS; PERCUTANEOUS NEPHROSTOMY, NEPHROTOMY WITH DRAINAGE NEPHROLITHOTOMY;REMOVAL OF LGE STAGHORN CALCULUS FILLING RENAL PELVIS & CALY PERCUTANEOUS NEPHROSTOLITHOTOMY OR PYELOSTOLITHOTOMY, WITH OR WITHOUT DILA PERCUTANEOUS NEPHROSTOLITHOTOMY OR PYELOSTOLITHOTOMY,W/ OR W/O DILATION,EN PYELOTOMY; WITH EXPLORATION Page 118 of 159

119 50130 PYELOTOMY;W/ REMOVAL OF CALCULUS (PYELOLITHOTOMY,PELVIOLITHOTOMY,INC COAGUL RENAL BIOPSY; PERCUTANEOUS, BY TROCAR OR NEEDLE RENAL BIOPSY; BY SURGICAL EXPOSURE OF KIDNEY EXCISION OR UNROOFING OF CYST(S) OF KIDNEY REMOVAL (VIA SNARE/CAPTURE) AND REPLACEMENT OF INTERNALLY DWELLING URETERAL STENT VIA TRANSURETHRAL APPROACH, WITHOUT USE OF CYSTOSCOPY, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION REMOVAL (VIA SNARE/CAPTURE) OF INTERNALLY DWELLING URETERAL STENT VIA TRANSURETHRAL APPROACH, WITHOUT USE OF CYSTOSCOPY, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION REMOVAL AND REPLACEMENT OF EXTERNALLY ACCESSIBLE TRANSNEPHRIC URETERAL STENT REQUIRING FLUOROSCOPIC GUIDANCE, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION REMOVAL OF NEPHROSTOMY TUBE REQUIRING FLUOROSCOPIC GUIDANCE ASPIRATION AND/OR INJECTION OF RENAL CYST OR PELVIS BY NEEDLE, PERCUTANEOUS INTRODUCTION OF INTRACATHETER OR CATHETER INTO RENAL PELVIS FOR DRAINAGE &/OR INTRODUCTION OF URETERAL CATHETER OR CATHETER INTO RENAL PELVIS FOR DRAINAGE INTRODUCTION OF GUIDE INTO RENAL PELVIS &/OR URETER W/ DILATION TO ESTABLISH NEP CHANGE OF NEPHROSTOMY OR PYELOSTOMY TUBE LAPAROSCOPY, SURGICAL; ABLATION OF RENAL MASS LESION(S) LAPAROSCOPY, SURGICAL; PARTIAL NEPHRECTOMY RENAL ENDOSCOPY THRU ESTABLISHED NEPHROSTOMY OR PYELOSTOMY,W/ OR W/O IRRIG RENAL ENDOSCOPY THRU ESTABLISHED NEPHROSTOMY OR PYELOSTOMY,W/ OR W/O IRRIG RENAL ENDOSCOPY THRU ESTABLISHED NEPHROSTOMY OR PYELOSTOMY,W/ OR W/O IRRIG RENAL ENDOSCOPE THROUGH ESTABLISHED NEPHROSTOMY OR PYELOSTOMY, WITH OR WITHOUT IRRIGATION, INSTILLAT RENAL ENDOSCOPY THRU ESTABLISHED NEPHROSTOMY OR PYELOSTOMY,W/ OR W/O IRRIG RENAL ENDOSCOPY;W/ ENDOPYELOTOMY (INC CYSTOSCOPY, URETEROSCOPY, DILATION OF RENAL ENDOSCOPY THRU NEPHROTOMY OR PYELOTOMY,W/ OR W/O IRRIGATION,INSTILLATI LITHOTRIPSY, EXTRACORPOREAL SHOCK WAVE URETEROTOMY FOR INSERTION OF INDWELLING STENT, ALL TYPES URETEROLITHOTOMY; LOWER ONE-THIRD OF URETER CHANGE OF URETEROSTOMY TUBE URETERAL ENDOSCOPY THROUGH ESTABLISHED URETEROSTOMY, WITH OR WITHOUT IRRI URETERAL ENDOSCOPY THROUGH ESTABLISHED URETEROSTOMY, WITH INSERTION OF RA ASPIRATION OF BLADDER BY NEEDLE ASPIRATION OF BLADDER; WITH INSERTION OF SUPRAPUBIC CATHETER CYSTOTOMY OR CYSTOSTOMY; W/ FULGURATION &/OR INSERTION OF RADIOACTIVE MATERIAL CYSTOSTOMY, CYSTOTOMY WITH DRAINAGE CYSTOTOMY, WITH INSERTION OF URETERAL CATHETER OR STENT (SEPARATE PROCEDURE) Page 119 of 159

120 51050 CYSTOLITHOTOMY, CYSTOTOMY W/ REMOVAL OF CALCULUS, W/O VESICAL NECK RESECTION DRAINAGE OF PERIVESICAL OR PREVESICAL SPACE ABSCESS EXCISION OF URACHAL CYST OR SINUS, WITH OR WITHOUT UMBILICAL HERNIA REPAIR CYSTOTOMY; FOR EXCISION OF BLADDER TUMOR BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; COMPLICATED (EG, ALTERED ANATOMY, FRACTURED CATH CHANGE OF CYSTOSTOMY TUBE; SIMPLE CHANGE OF CYSTOSTOMY TUBE; COMPLICATED ENDOSCOPIC INJECTION OF IMPLANT MATERIAL INTO THE SUBMUCOSAL TISSUES OF THE UR BLADDER INSTILLATION OF ANTICARCINOGENIC AGENT (INCLUDING DETENTION TIME) COMPLEX CYSTOMETROGRAM (EG, CALIBRATED ELECTRONIC EQUIPMENT) COMPLEX CYSTOGRAM (IE, CALIBRATED ELECTRONIC EQUIPMENT); WITH VOIDING PRESSURE STUDIES (IE, BLADDER GVOIDING PRESSURE) ANY TECHNIQUE COMPLEX UROFLOWMETRY (EG, CALIBRATED ELECTRONIC EQUIPMENT) URETHRAL PRESSURE PROFILE STUDIES (UPP) (URETHRAL CLOSURE PRESSURE PROFILE), ANY TECHNIQUE ELECTROMYOGRAPHY STUDIES (EMG) OF ANAL OR URETHRAL SPHINCTER, OTHER THAN NEEDLE, ANY TECHNIQUE STIMULUS EVOKED REPONSE (EG, MEASUREMENT OF BULBOCAVERNOSUS RELFEX LATENCY TIME) MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING ANTERIOR VESICOURETHROPEXY, OR URETHROPEXY; SIMPLE ABDOMINO-VAGINAL VESICAL NECK SUSPENSION, W/ OR W/O ENDOSCOPIC CONTROL CLOSURE OF CYSTOSTOMY (SEPARATE PROCEDURE) CUTANEOUS VESICOSTOMY LAPAROSCOPY, SURGICAL; URETHRAL SUSPENSION FOR STRESS INCONTI CYSTOURETHROSCOPY (SEPARATE PROCEDURE) CYSTOURETHROSCOPY WITH IRRIGATION AND EVACUATION OF MULTIPLE OBSTRUCTING CLOTS CYSTOURETHROSCOPY WITH URETERAL CATHETERIZATION, WITH OR WITHOUT IRRIGATION, CYSTOURETHROSCOPY, W/ URETERAL CATHETERIZATION,W/ OR W/O IRRIGATION, INSTILLAT CYSTOURETHROSCOPY; WITH BIOPSY CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGER OR LASER SURGER CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGER OR LASER SURGER CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGER OR LASER SURGER CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGER OR LASER SURGER CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGER OR LASER SURGER CYSTOURETHROSCOPY WITH INSERTION OF OF RADIOACTIVE SUBSTANCE, WITH OR WITHOU CYSTOURETHROSCOPY, WITH DILATION OF BLADDER FOR INTERSTITIAL CYSTITIS; GENERAL CYSTOURETHROSCOPY, WITH DILATION OF BLADDER FOR INTERSTITIAL CYSTITIS; GENERAL Page 120 of 159

121 52270 CYSTOURETHROSCOPY, WITH INTERNAL URETHROTOMY; FEMALE CYSTOURETHROSCOPY, WITH INTERNAL URETHROTOMY; MALE CYSTOURETHROSCOPY, WITH DIRECT VISION INTERNAL URETHROTOMY CYSTOURETHROSCOPY, WITH CALIBRATION AND/OR DILATION OR URETHRAL STRICTURE OR CYSTOURETHROSCOPY, WITH INSERTION OF PERMANENT URETHRAL STENT CYSTOURETHROSCOPY, WITH STEROID INJECTION INTO STRICTURE CYSTOURETHROSCOPY FOR TREATMENT OF THE FEMALE URETHRAL SLYNDROME WITH ANY CYSTOURETHROSCOPY; WITH URETERAL MEATOTOMY, UNILATERAL OR BILATERAL CYSTOURETHROSCOPY; WITH RESECTION OR FULGURATION OF ORTHOTOPIC URETEROCE CYSTOURETHROSCOPY; WITH RESECTION OR FULGURATION OF ECTOPIC URETEROCELE(S), UNILATERAL OR BILATERAL CYSTOURETHROSCOPY, WITH REMOVAL OF FOREIGN BODY, CALCULUS OR URETERAL STEN CYSTOURETHROSCOPY, WITH REMOVAL OF FOREIGN BODY, CALCULUS OR URETERAL STEN LITHOLAPAXY: CRUSHING OR FRAGMENTATION OF CALCULUS BY ANY MEANS IN BLADDER AN LITHOLAPAXY: CRUSHING OR FRAGMENTATION OF CALCULUS BY ANY MEANS IN BLADDER AN CYSTOURETHROSCOPY (INCLUDING URETERAL CATHERIZATION); WITH REMOVAL OF URETE CYSTOURETHROSCOPY (INCLUDING URETERAL CATHERIZATION); WITH FRAGMENTATION OF CYSTOURETHROSCOPY WITH SUBURETERIC INJECTION CYSTOURETHROSCOPY (INCLUDING URETERAL CATHERIZATION); WITH MANIPULATION, WITH CYSTOURETHROSCOPY; WITH INSERTION OF INDWELLING CYSTOURETHROSCOPY WITH INSERTION OF URETERAL GUIDE WIRE THROUGH KIDNE CYSTOURETHROSCOPY WITH URETEROSCOPY; WITH TREATMENT OF URETEROPELVIC JUNCTION STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION) CYSTOURETHROSCOPY WITH URETEROSCOPY AND/OR PYELOSCOPY; DIAGNOSTIC CYSTOURETHROSCOPY WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH REMOVAL OR MANIPULATION OF CALCULUS (URE CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH LITHOTRIPSY (URETERAL CATHERIZATION IS CYSTOURETHROSCOPY WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH BIOPSY AND/OR FULGURATION OF LESION. CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; DIAGNOSTIC WITH LITHOTRIPSY INCLUDING INSERTION OF INDWELLING UTERAL STENT (EG, GIBBONS OR DOUBLE-J TYPE) CYSTOURETHROSCOPY WITH TRANSURETHRAL RESECTION OR INCISION OF EJACULATORY DUCTS TRANSURETHRAL INCISION OF PROSTATE TRANSURETHRAL RESECTION OF BLADDER NECK (SEPARATE PROCEDURE) TRANSURETHRAL ELECTROSURGICAL RESECTION OF PROSTATE,INC CONTROL OF POSTOP TRANSURETHRAL RESECTION OF PROSTATE; FIRST STAGE OR TWO-STAGE RESECTION (PAR TRANSURETHRAL RESECTION OF PROSTATE;SECOND STAGE OF TWO-STAGE RESECTION TRANSURETHRAL RESECTION; OF RESIDUAL OBSTRUCTIVE TISSUE AFTER 90 DAYS POSTOP Page 121 of 159

122 52630 TRANSURETHRAL RESECTION;OF REGROWTH OF OBSTRUCTIVE TISSUE LONGER THAN ONE TRANSURETHRAL RESECTION; OF POSTOPERATIVE BLADDER NECK CONTRACTURE NON-CONTACT LASER COAGULATION OF PROSTATE, INCLUDING CONTROL OF POSTOPERA CONTACT LASER VAPORIZATION WITH OR WITHOUT TRANSURETHRAL RESECTION OF PROST LASER ENUCLEATION OF THE PROSTATE WITH MORCELLATION, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, INTERNAL URETHROTOMY AND TRANSURETHRAL RESECTION OF PROSTATE ARE INC URETHROTOMY OR URETHROSTOMY,EXTERNAL (SEP PROC);PERINEAL URETHRA, EXTERNAL MEATOTOMY, CUTTING OF MEATUS (SEPARATE PROCEDURE); EXCEPT INFANT DRAINAGE OF DEEP PERIURETHRAL ABSCESS DRAINAGE OF SKENE'S GLAND ABSCESS OR CYST BIOPSY OF URETHRA URETHRECTOMY, TOTAL, INCLUDING CYSTOSTOMY; MALE EXCISION OF URETHRAL DIVERTICULUM (SEPARATE PROCEDURE); FEMALE EXCISION OR FULGURATION; URETHRAL POLYP(S), DISTAL URETHRA EXCISION OR FULGURATION; URETHRAL CARUNCLE EXCISION OR FULGURATION; SKENE'S GLANDS EXCISION OR FULGURATION; URETHRAL PROLAPSE URETHROPLASTY; FIRST STAGE, FOR FISTULA, DIVERTICULUM, OR STRICTURE (EG, JOHANNE URETHROPLASTY; SECOND STAGE (FORMATION OF URETHRA), INCLUDING URINA URETHROPLASTY, ONE-STAGE RECONSTRUCTION OF MALE ANTERIOR URETHRA URETHROPLASTY, RECONSTRUCTION OF FEMALE URETHRA SLING OPERATION FOR CORRECTION OF MALE URINARY INCONTINENCE (EG, FASICA OR SYNTHETIC) INSERTION OF TANDEM CUFF (DUAL CUFF) OPERATION FOR CORRECTION OF URINARY INCONTINENCE WITH PLACEMENT OF INFLATABL REMOVAL,REPAIR OR REPLACEMENT OF INFLATABLE SPHINCTER INC PUMP &/OR RESERVO URETHRAL MEATOPLASTY, WITH MUCOSAL ADVANCEMENT CLOSURE OF URETHROSTOMY OR URETHROCUTANEOUS FISTULA,MALE (SEPARATE PROCEDURE) TRANSURETHRAL DESTRUCTION OF PROSTATE TISSUE: BY MICROWAVE THERMOTHERAPY TRANSURETHRAL DESTRUCTION OF PROSTATE TISSUE;BY RADIOFREQUENCY THERMOTHE SLITTING OF PREPUCE, DORSAL OR LATERAL (SEPARATE PROCEDURE); EXCEPT NEWBORN INCISION AND DRAINAGE OF PENIS, DEEP DESTRUCTION OF LESION(S), PENIS, SIMPLE; LASER SURGERY DESTRUCTION OF LESION(S), PENIS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOS BIOPSY OF PENIS; DEEP STRUCTURES EXCISION OF PENILE PLAQUE (PEYRONIE DISEASE) REMOVAL FOREIGN BODY FROM DEEP PENILE TISSUE (EG, PLASTIC IMPLANT) Page 122 of 159

123 54150 CIRCUMCISION, USING CLAMP OR OTHER DEVICE; NEWBORN CIRCUMCISION, SURGICAL EXCISION OTHER THAN CLALMP, DEVICE OR DIRSAL SLIT, NEWBO CIRCUMCISION, SURGICAL EXCISION OTHER THAN CLALMP, DEVICE OR DIRSAL SLIT, EXCEPT LYSIS OR EXCISION OF PENILE POST-CIRCUMCISION ADHESIONS CIRCUMCISION; REPAIR INCOMPLETE INJECTION PROCEDURE FOR PEYRONIE DISEASE; WITH SURGICAL EXPOSURE OF PLAQUE IRRIGATION OF CORPORA CAVERNOSA FOR PRIAPISM INJECTION OF CORPORA CAVERNOSA WITH PHARMACOLOGIC AGENT(S) (EG, PAPAVERINE, PENILE PLETHYSMOGRAPHY PLASTIC OPERATION OF PENIS FOR STREIGHTENING OF CHORDEE (EG, HYPOSPADIAS), WITH PLASTIC OPERATION ON PENIS FOR CORRECTION OF CHORDEE OR FOR FIRST STAGE HYPO URETHROPLASTY FOR SECOND STAGE HYPOSPADIAS REPAIR (INCLUDING URINARY DIVERSION); GREATER THAN 3 CM URETHROPLASTY FOR THIRD STAGE HYPOSPADIAS REPAIR TO RELEASE PENIS FROM SCROT ONE STAGE DISTAL HYPOSPADIAS REPAIR (WITH OR WITHOUT CHORDEE OR CIRCUMCISION) ONE STAGE DISTAL HYPOSPADIAS REPAIR (WITH OR WITHOUT CHORDEE OR CIRCUMCISION) ONE STAGE DISTAL HYPOSPADIAS REPAIR;W/ URETHROPLASTY BY LOCAL SKIN FLAPS & MOBI ONE STAGE DISTAL HYPOSPADIAS REPAIR;W/ EXTENSIVE DISSECTION TO CORRECT CHORDE ONE STAGE PROXIMAL PENILE OR PENOSCROTAL HYPOSPADIAS REPAIR REQUIRING EXTENS ONE STAGE PERINEAL HYPOSPADIAS REP REQ EXTENSIVE DISSECTION TO CORRECT CHORD REPAIR OF HYPOSPADIAS COMPLICATIONS;BY CLOSURE, INCISION, OR EXCISION, SIMPLE REPAIR OF HYPOSPADIAS COMPLICATIONS; REQ MOBILIZATION OF SKIN FLAPS & URETHROP REPAIR OF HYPOSPADIAS COMPLICATIONS (IE, FISTULA;REQ EXTENSIVE DISSECTION & URET REPAIR OF HYPOSPADIAS CRIPPLE REQUIRING EXTENSIVE DISSECTION AND EXCISION OF PR PLASTIC OPERATION ON PENIS TO CORRECT ANGULATION PLASTIC OPERATION ON PENIS FOR EPISPADIAS DISTAL TO EXTERNA SPHINCTER PLASTIC OPERATION ON PENIS FOR EPISPADIAS DISTAL TO EXTERNAL SPHINTER;W/ EXSTRO INSERTION OF PENILE PROSTHESIS; NON-INFLATABLE (SEMI-RIGID) INSERTION OF INFLATABLE PENILE PROSTHESIS, INC PLACEMENT OF PUMP,CYLINDERS &/OR REMOVAL AND REPLACEMENT OF ALL COMPONENTS OF A MULTICOMPONENT INFLATABLE PENILE PROSTHESIS THROUGH AN INFECTED FIELD AT THE SAME OPERATIVE SESSION, INCLUDING DEBRIDEMENT AND IRRIGATION OF INFECTED TISSUE CORPORA CAVERNOSA-CORPUS SPONGIOSUM SHUNT, UNILATERAL OR BILATERAL PLASTIC OPERATION OF PENIS FOR INJURY FORESKIN MANIPULATION INCLUDING LYSIS OF PREPUTIAL ADHESIONS AND STRETCHING BIOPSY OF TESTIS, NEEDLE (SEPARATE PROCEDURE) BIOPSY OF TESTIS, INCISIONAL (SEPARATE PROCEDURE) EXCISION OF EXTRAPARENCHYMAL LESION OF TESTIS ORCHIECTOMY, SIMPLE (INCLUDING SUBCAPSULAR), WITH OR WITHOUT TESTICULAR PROS ORCHIECTOMY, PARTIAL Page 123 of 159

124 54530 ORCHIECTOMY, RADICAL, FOR TUMOR; INGUINAL APPROACH EXPLORATION FOR UNDESCENDED TESTIS (INGUINAL OR SCROTAL AREA) REDUCTION OF TORSION OF TESTIS, SURGICAL; WITH OR TESTIS, SURGICAL WITH OR WITHO ORCHIOPEXY, ANY TYPE, WITH OR WITHOUT HERNIA REPAIR ORCHIOPEXY, ABDOMINAL APPROACH, FOR INTRA-ABDOMINAL TESTIS (EG, FOWLER-STEPHENS) INSERTION OF TESTICULAR PROSTHESIS (SEPARATE PROCEDURE) SUTURE OR REPAIR OF TESTICULAR INJURY LAPAROSCOPY, SURGICAL; ORCHIECTOMY LAPAROSCOPY, SURGICAL; ORCHIOPEXY FOR INTRA-ABDOMINAL TESTIS INCISION AND DRAINAGE OF EPIDIDYMIS, TESTIS AND/OR EPIDIDYMIS, TESTIS AND/OR SCROT EXCISION OF LOCAL LESION OF EPIDIDYMIS EXCISION OF SPERMATOCELE, WITH OR WITHOUT EPIDIDYMECTOMY EPIDIDYMECTOMY; UNILATERAL EXPLORATION OF EPIDIDYMIS PUNCTURE ASPIRATION OF HYDROCELE,TUNICA VAGINALIS,W/ OR W/O INJ OF MEDICATION EXCISION OF HYDROCELE; UNILATERAL EXCISION OF HYDROCELE; BILATERAL REPAIR OF TUNICA VAGINALIS HYDROCELE (BOTTLE TYPE) SCROTAL EXPLORATION REMOVAL OF FOREIGN BODY IN SCROTUM RESECTION OF SCROTUM SCROTOPLASTY; SIMPLE SCROTOPLASTY; COMPLICATED VASOTOMY, CANNULIZATION W/ OR W/O INCISION OF VAS, UNI OR BILATERAL (SEP PROC) VASOTOMY FOR VASOGRAMS,SEMINAL VESICULOGRAMS,OR EPIDIDYMOGRAMS,UNI OR BILATE EXCISION OF HYDROCELE OF SPERMATIC CORD, UNILATERAL (SEPARATE PROCEDURE) EXCISION OF LESION OF SPERMATIC CORD (SEPARATE PROCEDURE) EXCISION OF VARICOCELE OR LIGATION OF SPERMATIC VEINS FOR VARICOCELE; (SEPARATE EXCISION OF VARICOCELE OR LIGATION OF SPERMATIC VEINS FOR VARICOCELE; ABDOMINAL EXCISION OF VARICOCELE OR LIGATION OF SPERMATIC VEINS FOR VARICOCELE; WITH HERN LAPAROSCOPY, SURGICAL, WITH LIGATION OF SPERMATIC VEINS FOR VARICOCELE BIOPSY, PROSTATE; NEEDLE OR PUNCH, SINGLE OR MULTLIPLE, ANY APPROACH BIOPSY, PROSTATE; INCISIONAL, ANY APPROACH BIOPSIES, PROSTATE, NEEDLE, TRANSPERINEAL, STEREOTACTIC TEMPLATE GUIDED SATURATION SAMPLING, INCLUDING IMAGING GUIDANCE CRYOSURGICAL ABLATION OF THE PROSTATE PLACEMENT OF NEEDLES OR CATHETERS INTO PELVIC ORGANS AND/OR GENITALIA (EXCEPT PROSTATE) FOR SUBSEQUENT INTERSTITIAL RADIOELEMENT APPLICATION Page 124 of 159

125 56440 MARSUPIALIZATION OF BARTHOLIN'S GLAND CYST LYSIS OF LABIAL ADHESIONS HYMENOTOMY DESTRUCTION OF LESION(S), VULVA; EXTENSIVE, ANY METHOD VULVECTOMY SIMPLE; PARTIAL VULVECTOMY SIMPLE; COMPLETE VULVECTOMY, RADICAL;PARTIAL PARTIAL HYMENECTOMY OR REVISION OF HYMENAL RING EXCISION OF BARTHOLIN'S GLAND OR CYST PLASTIC REPAIR OF INTROITUS CLITOROPLASTY FOR INTERSEX STATE -- ANEST BY TECHNICIAN PERINEOPLASTY, REPAIR OF PERINEUM, NON-OBSTETRICAL (SEPARATE PROCEDURE) COLPOSCOPY OF THE VULVA COLPOSCOPY OF THE VULVA; WITH BIOPSY(S) COLPOTOMY; WITH EXPLORATION COLPOTOMY; WITH DRAINAGE OF PELVIC ABSCESS COLPOCENTESIS (SEPARATE PROCEDURE) DESTRUCTION OF VAGINAL LESION(S); SIMPLE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY) DESTRUCTION OF VAGINAL LESION(S); EXTENSIVE, ANY METHOD BIOPSY OF VAGINAL MUCOSA; EXTENSIVE, REQUIRING SUTURE (INCLUDING CYSTS) VAGINECTOMY, PARTIAL REMOVAL OF VAGINAL WALL COLPOCLEISIS (LE FORT TYPE) EXCISION OF VAGINAL SEPTUM EXCISION OF VAGINAL CYST OR TUMOR INSERTION OF UTERINE TANDEMS INSERTION OF A VAGINAL RADIATION AFTERLOADING APPARATUS FOR CLINICAL BRACHYTHERAPY COLPORRHAPHY, SUTURE OF INJURY OF VAGINA (NONOBSTETRICAL) COLPOPERINEORRHAPHY, SUTURE OF INJURY OF VAGINA AND/OR PERINEUM (NONOBSTET PLASTIC OPERATIN ON URETHARAL SPHINCTER, VAGINAL APPROACH (EG, KELLY URETHROC ANTERIOR COLPORRHAPHY,REPAIR OF CYSTOCELE W/ OR W/O REPAIR OF URETHROCELE POSTERIOR COLPORRHAPHY, REPAIR OF RECTOCELE WITH OR WITHOUT PERINEORRHAPH COMBINED ANTEROPOSTERIOR COLPORRHAPHY COMBINED ANTEROPOSTERIOR COLPORRHAPHY; WITH ENTEROCELE REPAIR REPAIR OF ENTEROCELE, VAGINAL APPROACH (SEPARATE PROCEDURE) COLPOPEXY, VAGINAL; ESTRA-PERITONEAL APPROACH (SACROSPINOUS, ILIOCCYGEUS) PARAVAGINAL DEFECT REPAIR (INC REP OF CYSTOCELE, STRESS URINARY INCONTINENCE, PARAVAGINAL DEFECT REPAIR (INCLUDING REPAIR OF CYSTOCELE, IF PERFORMED; VAGINAL APPROACH Page 125 of 159

126 57287 REMOVAL OR REVISION OF SLING FOR STRESS INCONTINENCE (EG, FASCIA OR SYNTHETIC) SLING OPERATION FOR STRESS INCONTINENCE (EG, FASCIA OR SYNTHETIC) PEREYRA PROCEDURE, INCLUDING ANTERIOR COLPORRHAPHY CONSTRUCTION OF ARTIFICIAL VAGINA; WITHOUT GRAFT REVISION (INCLUDING REMOVAL) OF PROSTHETIC VAGINAL GRAFT, VAGINAL APPROACH CLOSURE OF RECTOVAGINAL FISTULA; VAGINAL OR TRANSANAL APPROACH CLOSURE OF URETHROVAGINAL FISTULA CLOSURE OF URETHROVAGINAL FISTULA; WITH BULBOCAVERNOSUS TRANSPLANT PELVIC EXAMINATION UNDER ANESTHESIA REMOVAL OF IMPACTED VAGINAL FB (SEPARATE PROCEDURE) UNDER ANESTHESIA COLPOSCOPY OF THE ENTIRE VAGINA, WITH CERVIX PRESENT COLPOSCOPY OF THE ENTIRE VAGINA, WITH CERVIX PRESENT; WITH BIOPSY(S) PARAVAGINAL DEFECT REPAIR (INCLUDING REPAIR OF CYSTOCELE, IF PERFORMED), LAPAROSCOPIC APPROACH COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH BIOPSY(S) OF THE CERVIX COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH ENDOCERVICAL CURETTAGE COLPOSCOPY (VAGINOSCOPY); WITH LOOP ELECTRODE EXCISION PROCEDURE OF THE CER COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH LOOP ELECTRODE CONIZATION OF THE CERV ENDOCERVICAL CURETTAGE (NOT DONE AS PART OF A DILATION AND CURETTAGE) CAUTERIZATION OF CERVIX; LASER ABLATION CONIZATION OF CERVIX, WITH OR WITHOUT FULGURATION, WITH OR WITHOUT DILATION AND CONIZATION OF CERVIX, WITH OR WITHOUT FULGURATION, WITH OR WITHOUT DILATION AND TRACHELECTOMY (CERVICECTOMY), AMPUTATION OF CERVIX (SEPARATE PROCEDURE) EXCISION OF CERVICAL STUMP, VAGINAL APPROACH DILATION AND CURETTAGE CERCLAGE OF UTERINE CERVIX, NONOBSTETRICAL TRACHELORRHAPHY, PLASTIC REPAIR OF UTERINE CERVIX, VAGINAL APPROACH DILATION AND CURETTAGE, DIAGNOSTIC AND/OR THERAPEUTIC (NONOBSTETRICAL) MYOMECTOMY, EXCISION OF LEIOMYOMATA OF UTERUS, SINGLE OR MULTIPLE (SEPARATE PROCEDURE); ABDOMINAL APPROACH MYOMECTOMY, EXCISION OF FIBROID TUMOR OF UTERUS, SINGLE OR MULTIPLE (SEPARATE MYOMECTOMY, EXCISION OF FIBROID TUMOR(S) OF UTERUS, 5 OR MORE INTRAMURAL MYOMAS AND / OR INTRAMURAL MYOMAS WITH TOTAL WEIGHT OF 250 GRAMS; ABDOMINAL APPROACH VAGINAL HYSTERECTOMY VAGINAL HYSTERECTOMY; WITH REMOVAL OF TUBE(S), AND/OR OVARY(S) VAGINAL HYSTERECTOMY, WITH TOTAL OR PARTIAL VAGINECTOMY Page 126 of 159

127 58285 VAGINAL HYSTERECTOMY, RADICAL (SCHAUTA TYPE OPERATION) VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(IES) ARTIFICIAL INSEMINATION; INTRA-CERVICAL ARTIFICIAL INSEMINATION; INTRA-UTERINE CATHETERIZATION AND INTRODUCTION OF SALINE OR CONTRAST MATERIAL FOR SALINE INFUSION SONOHYSTEROGRAPHY (SIS) OR HYSTEROSALPINGOGRAPHY TRANSCERVICAL INTRODUCTION OF FALLOPIAN TUBE CATHETER FOR DIAGNOSIS AND/OR CHROMOTUBATION OF OVIDUCT, INCLUDING MATERIALS ENDOMETRIAL ABLATION, THERMAL, WITHOUT HYTEROSCOPIC GUIDANCE LAPAROSCOPY, SURGICAL SUPRACERVICAL HYSTERECTOMY LAPAROSCOPY, SURGICAL SUPRACERVICAL HYSTERECTOMY WITH REMOVAL OF TUBES LAPAROSCOPY, SURGICAL SUPRACERVICAL HYSTERECTOMY FOR UTERUS GREATER THAN 250G LAPAROSCOPY, SURGICAL SUPRACERVICAL HYSTERECTOMY FOR UTERUS GREATER THAN 250G WITH REMOVAL OF TUBE(S) LAPAROSCOPY, SURGICAL, MYOMECTOMY, EXCISION; 1 TO 4 INTRAMURAL MYOMAS WITH TOTAL WEIGHT OF 250 GRAMS LAPAROSCOPY, SURGICAL, MYOMECTOMY, EXCISION; 5 OR MORE INTRAMURAL MYOMAS AND/OR INTRAMURAL MYOMAS WI LAPAROSCOPY, SURGICAL, WITH RADICAL HYSTERECTOMY, WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY AND PARA-AORTIC LYMP NODE SAMPLING (BIOPSY), WITH REMOVAL OF TUBE(S) AND OVARY(IES), IF PERFORMED LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS 250 G. OR LESS LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS 250 GRAMS OR LESS; WITH REMOVAL OF TUBE LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 GRAMS LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 GRAMS; WITH REMOVAL OF HYSTEROSCOPY, DIAGNOSTIC (SEPARATE PROCDURE) HYSTEROSCOPY, SURGICAL; W/ SAMPLING (BIOPSY) OF ENDOMETRIUM &/OR POLYPECTOMY, HYSTEROSCOY,SURGICAL; W/ SAMPLING OF ENDOMETRIUM &/OR POLYPECTOMY, W/ LYSIS HYSTEROSCOPY, SURGICAL; W/ DIVISON OR RESECTION OF INTRAUTERINE HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF LEIOMYOMATA HYSTEROSCOPY, SURGICAL; W/ REMOVAL OF IMPACTED FOREIGN BODY HYSTEROSCOY,SURGICAL; W/ SAMPLING OF ENDOMETRIUM &/OR POLYPECTOMY, W/ ENDOME HYSTEROSCOPY, SURGICAL W/BILATERAL FALLOPIAN TUBE CANNULATION TO INDUCE OCCLUSION BY PLACEMENT OF PERMANENT IMPLANTS LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS Page 127 of 159

128 58571 LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S) LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S) LIGATION OR TRANSECTION OF FALLOPIAN TUBE(S), ABDOMINAL OR VAGINAL APPROACH, UNI LIGATION OR TRANSECTION OF FALLOPIAN TUBE(S), ABDOMINAL OR VAGINAL APPROACH, PO OCCLUSION OF FALLOPIAN TUBE(S) BY DEVICE (EG, BAND, CLIP, FALOPE RING) VAGINAL OR LAPARSCOPY,SURGICAL; W/ LYSIS OF ADHESIONS (SALPINGOLYSIS,OVAIOLYSIS)(SEP PROC) LAPAROSCOPY, SURGICAL W/ REMOVAL OF ADNEXAL STRUCTURES LAPAROSCOPY, SURGICAL; W/ FULGURATION OR EXCISION OF LESIONS OF THE OVARY PEL LAPAROSCOPY, SURGICAL; W/ FULGURATION OF OVIDUCTS (W/ OR W/O TRANSECTION) LAPAROSCOPY,SURGICAL; W/ OCCLUSION OF OVIDUCTS BY DEVICE (EG,BAND, CLIP OR FALO LAPAROSCOPY,SURGICAL; WITH FIMBRIOPLASTY LAPAROSCOPY,SURGICAL; W/ SALPINGOSTOMY (SALPINGONEOSTOMY) SALPINGECTOMY, COMPLETE OR PARTIAL, UNILATERAL OR BILATERAL (SEPARATE PROCEDU SALPINGO-OOPHORECTOMY, COMPLETE OR PARTIAL, UNILATERAL OR BILATERAL (SEPARATE DRAINAGE OF OVARIAN CYST(S), UNILATERAL OR BILATERAL, (SEPARATE PROCEDURE); VAGI DRAINAGE OF OVARIAN CYST(S),UNILATERAL OR BILATERAL, (SEP PROC);ABDOMINAL APPRO BIOPSY OF OVARY, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE) WEDGE RESECTION OR BISECTION OF OVARY, UNILATERAL OR BILATERAL OVARIAN CYSTECTOMY, UNILATERAL OR BILATERAL OOPHORECTOMY,PARTIAL OR TOTAL,UNILATERAL OR BILATERAL;FOR OVARIAN MALIGNANCY FOLLICLE PUNCTURE FOR OOCYTE RETRIEVAL, ANY METHOD AMNIOCENTESIS, DIAGNOSTIC Amniocentesis; therapeutic amniotic fluid reduction (includes ultrasound guidance) CORDOCENTESIS (INTRAUTERINE), ANY METHOD CHORIONIC VILLUS SAMPLING, ANY METHOD HYSTEROTOMY, ABDOMINAL ( HYDATIDIFORM MOLE ABORTION) SURGICAL TREATMENT OF ECTOPIC PREGNANCY; TUBAL OR OVARIAN, REQUIRING SALPINGE SURGICAL TREATMENT OF ECTOPIC PREGNANCY; TUBAL OR OVARIAN, W/O SALPINGECTOMY SURGICAL TREATMENT OF ECTOPIC PREGNANCY; CERVICAL, WITH EVACUATION LAPAROSCOPIC TREATMENT OF ECTOPIC PREGNANCY; WITHOUT SALPINGECTOMY AND/OR LAPAROSCOPIC TREATMENT OF ECTOPIC PREGNANCY; WITH SALPINGECTOMY AND/OR OOPH CURETTAGE, POSTPARTUM (SEPARATE PROCEDURE) EPISIOTOMY OR VAGINAL REPAIR, BY OTHER THAN ATTENDING CERCLAGE OF CERVIX, DURING PREGNANCY; VAGINAL TREATMENT OF INCOMPLETE ABORTION, ANY TRIMESTER, COMPLETE SURGICALLY TREATMENT OF MISSED ABORTION, COMPLETED SURGICALLY; FIRST TRIMESTER TREATMENT OF MISSED ABORTION, COMPLETED SURGICALLY; SECOND TRIMESTER Page 128 of 159

129 59830 TREATMENT OF SEPTIC ABORTION, COMPLETED SURGICALLY INDUCED ABORTION, BY DILATION AND CURETTAGE INDUCED ABORTION, BY DILATION AND EVACUATION INDUCED ABORTION, BY ONE OR MORE INTRA-AMNIOTIC INJECTIONS (AMNIOCENTESIS-INJEC INDUCED ABORTION, BY ONE OR MORE INTRA-AMNIOTIC INJECTIONS (AMNIOCENTESIS-INJEC INDUCED ABORTION, BY ONE OR MORE VAGINAL SUPPOSITORIES WITH DILATION AND UTERINE EVACUATION AND CURETTAGE FOR HYDATIDIFORM MOLE REMOVAL OF CERCLAGE SUTURE UNDER ANESTHESIA (OTHER THAN LOCAL) INCISION AND DRAINAGE OF THYROGLOSSAL CYST, INFECTED ASPIRATION AND/OR INJECTION, THYROID CYST BIOPSY THYROID, PERCUTANEOUS CORE NEEDLE EXCISION OF CYST OR ADENOMA OF THYROID, OR TRANSECTION ISTHMUS PARTIAL THYROID LOBECTOMY, UNILATERAL; WITH OR WITHOUT ISTHMUSECTOMY PARTIAL THYROID LOBECTOMY, UNILATERAL; WITH CONTRALATERAL SUBTOTAL LOBECTOMY, TOTAL THYROID LOBECTOMY, UNILATERAL; WITH OR WITHOUT ISTHMUSECTOMY TOTAL THYROID LOBECTOMY,UNILATERAL;W/ CONTRALATERAL SUBTOTAL LOBECTOMY,INC THROIDECTOMY, TOTAL OR COMPLETE THYROIDECTOMY, TOTAL OR SUBTOTAL FOR MALIGNANCY; WITH LIMITED NECK DISSECTION THROIDECTOMY,REMOVAL OF ALL REMAINING THYROID TISSUE FOLLOWING PREVIOUS REMO THYROIDECTOMY, INCLUDING SUBSTERNAL THYROID GLAND; CERVICAL APPROACH EXCISION OF THYROGLOSSAL DUCT CYST OR SINUS; EXCISION OF THYROGLOSSAL DUCT CYST OR SINUS; RECURRENT PARATHYROIDECTOMY OR EXPLORATION OF PARATHYROID(S) PARATHYROIDECTOMY RE-EXPLORATION THYMECTOMY, PARTIAL OR TOTAL; TRANSCERVICAL APPROACH (SEPARATE PROCEDURE) SUBDURAL TAP THRU FONTANELLE OR SUTURE,INFANT,UNILATERAL OR BILATERAL; INITIAL VENTRICULAR PUNCTURE THRU PREVIOUS BURR HOLE,FONTANELLE,SUTURE OR IMPLANT VENTRICULAR PUNCTURE THRU PREVIOUS BURR HOLE,FONTANELLE,SUTURE OR IMPLANT CISTERNAL OR LATERAL CERVICAL PUNCTURE; WITH INJECTION OF DRUG OR OTHER SUBS BURR HOLE(S); FOR IMPLANTING VENTRICULAR CATHETER, RESERVOIT, EEG ELECTRODE(S), PRESURE RECORDING DEVICE, OR OTHER CEREBRAL MONITORING DEVICE (SEPARATE PROCEDURE) INSERTION OF SUBCUTANEOUS RESERVOIR, PUMP OR CONTINUOUS INFUSION SYSTEM FOR CRANIECTOMY OR CRANIOTOMY, DRAINAGE OF INTRACRANIAL ABSCESS; SUPRATENTORIAL CRANIECTOMY; WITH EXCISION OF TUMOR OR OTHER BONE LESION OF SKULL SUBDURAL IMPLANTATION OF STRIP ELECTRODES THRU ONE OR MORE BURR OR TREPHINE TRANSTEMPORAL APPROACH TO POSTERIOR CRANIAL FOSSA, JUGULAR FORAMEN OR MIDLINE SKULL BASE, INCLUDING MASTOIDECTOMY, DECOMPRESSION OF SIGMOID SINUS AND/OR FACIAL NERVE, WITH OR WITHOUT MOBILIZATION Page 129 of 159

130 61623 ENDOVASCULAR TEMPORARY BALLOON ARTERIAL OCCLUSION, HEAD OR NECK (EXTRACRANIAL/INTRACRANIAL) INCLUDIN TRANSCATHETER OCCLUSION OR EMBOLIZATION (EG, FOR TUMOR DESTRUCTION, TO ACHIE TRANSCATHETER OCCLUSION OR EMBOLIZATION (EG, FOR TUMOR DESTRUCTION, TO ACHIE STEREOTACTIC BIOPSY, ASPIRATION, OR EXCISION, INCLUDING BURR HOLE(S), FOR INTRACRANIAL LESION; CREATION OF LESION BY STERETACTIC METHOD, PERCUTANEOUS, BY NEUROLYTIC AGENT STEREOTACTIC RADIOSURGERY (PARTICLE BEAM, GAMMA RAY OR LINEAR ACCELERATOR), STEREOTATIC COMPUTER ASSISTED VOLUMETRIC PROC, INTRACRANIAL, EXTRACRANIAL, REVISION OR REMOVAL OF INTRACRANIAL NEUROSTIMULATOR ELECTRODES INCISION & SUBCUTANEOUS PLACEMENT OF CRANIAL NEUROSTIMULATOR PULSE GENERAT INSERTION OR REPLACEMENT OF CRANIAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, DIRECT OR INDUCTIVE COUPLING; WITH CONNECTION TO 2 OR MORE ELECTRODE ARRAYS CRANIOPLASTY FOR SKULL DEFECT; LARGER THAN 5 CM DIAMETER REPLACEMENT OF BONE FLAP OR PROSTHETIC PLATE OF SKULL NEUROENDOSCOPY, INTRACRANIAL; WITH FENESTRATION OR EXCISION OF COLLOID CYST, INCLUDING PLACEMENT OF EXTERNAL VENTRICULAR CATHETER FOR DRAINAGE REPLACEMENT OR IRRIGATION, SUBARACHNOID/SUBDURAL CATHETER VENTRICULOCISTERNOSTOMY, THIRD VENTRICLE; STEROTACTIC, NEUROENDOSCOPIC METHOD REPLACEMENT OR IRRIGATION, VENTRICULAR CATHETER REPLACEMENT OR REVISION OF CSF SHUNT, OBSTRUCTED VALVE, OR DISTAL CATHETER IN REMOVAL OF COMPLETE CSF SHUNT SYSTEM; WITHOUT REPLACEMENT REMOVAL OF COMPLETE CSF SHUNT SYSTEM;W/ REPLACEMENT BY SIMILAR OR OTHER SHU PERCUTANEOUS LYSIS OF EPIDURAL ADHESIONS USING SOLUTION INJECTION (EG, HYPERTONIC SALINE, ENZYME) OR PERCUTANEOUS ASPIRATION, SPINAL CORD CYST OR SYRINX SPINAL PUNCTURE, LUMBAR, DIAGNOSTIC SPINAL PUNCTURE, THERAPEUTIC, FOR DRAINAGE OF SPINAL FLUID (BY NEEDLE OR CATHET INJECTION, LUMBAR EPIDURAL, OF BLOOD OR CLOT PATCH INJECTION OF NEUROLYTIC SUBSTANCE (EG, ALCOHOL, PHENOL, ICED SALINE SOLUTIONS); INJECTION OF NEUROLYTIC SUBSTANCE (EG, ALCOHOL, PHENOL, ICED SALINE SOLUTIONS); ASPIRATION OR DECOMPRESSION PROC,PERCUTANEOUS,OF NUCLEUS PULPOSUS OF INTE INJECTION PROCEDURE FOR DISKOGRAPHY, EACH LEVEL; LUMBAR INJECTION PROCEDURE FOR DISKOGRAPHY, EACH LEVEL; CERVICAL OR THORACIC INJECTION PROCEDURE FOR CHEMONUCLEOLYSIS, INCLUDING DISKOGRAPHY, INTERVERTEBRAL DISK, SINGLE OR MULTIPLE LEVELS, LUMBAR MYELOGRAPHY VIA LUMBAR INJECTION, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION; CERVICAL Page 130 of 159

131 62310 INJECTION,SINGLE(NOT VIS INDWELLING CATHETER),NOT INCLUDING NEUROLYTIC SUBSTANCES,W/ORW/O CONTRAST INJECTION, SINGLE, NOT INC NEUROLYTIC SUBSTANCES W/ OR W/O CONTRAST OF DIAGNOSIS INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITHOUT IMAGING GUIDANCE INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT) INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, LUMBAR OR SACRAL (CAUDAL); WITHOUT IMAGING GUIDANCE INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, LUMBAR OR SACRAL (CAUDAL); WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT) IMPLANTATON,REVISION OR REPOSITIONING OF TUNNELED INTRATHECAL OR EPIDURAL CAT IMPLANTATION,REVISION OR REPOSITIONING OF INTRATHECAL OR EPIDURAL CATHETER,FO IMPLANTATION OR REPLACEMENT OF DEVICE FOR INTRATHECAL OR EPIDURAL DRUG INFUS IMPLANTATION OR REPLACEMENT OF DEVICE FOR INTRATHECAL OR EPIDURAL DRUG INFUS REMOVAL OF SUBCUTANEOUS RESERVOIR OR PUMP,PREVIOUSLY IMPLANTED FOR INTRATH ELECTRONIC ANALYSIS OF PROGRAMMABLE, IMPLANTED PUMP FOR INTRATHECAL OR EPIDU ELECTRONIC ANALYSIS OF PROGRAMMABLE, IMPLANTED PUMP FOR INTRATHECAL OR EPIDU ELECTRONIC ANALYSIS OF PROGRAMMABLE, IMPLANTED PUMP FOR INTRATHECAL OR EPIDURAL DRUG INFUSION (INCLUDES EVALUATION OF RESERVOIR STATUS, ALARM STATUS, DRUG PRESCRIPTION STATUS); WITH REPROGRAMMING AND REFILL ELECTRONIC ANALYSIS OF PROGRAMMABLE, IMPLANTED PUMP FOR INTRATHECAL OR EPIDURAL DRUG INFUSION (INCLUDES EVALUATION OF RESERVOIR STATUS, ALARM STATUS, DRUG PRESCRIPTION STATUS); WITH REPROGRAMMING AND REFILL (REQUIRING PHYSICIAN'S SKILL) LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; LUMBAR, EXCEPT FOR SPONDYLOLISTHESIS LAMINECTOMY W/ REMOVAL OF FACETS W/ DECOMP NERVE ROOTS FOR SPONDYLO (GILL TYPE) Page 131 of 159

132 63015 LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), MORE THAN 2 VERTEBRAL SEGMENTS; CERVICAL CERVICAL LAMINOTOMY W/ NRD &/OR EXCISION DISK LAMINOTOMY (HEMILAMINECTOMY),W/ DECOMPRESSION OF NERVE ROOT(S),INC PARTIAL FAC RE-EXPLORATION CERVICAL LAMINOTOMY W/ NRD &/OR EXCISION DISK LUMBAR CERVICAL LAMINECTOMY (COMPLETE) WITH FACETECTOMY, FORAMINOTOMY & NRD LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILAT OR BILAT W/ DECOMP); THORACIC LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA ETC LUMBAR LAMINECTOMY FOR LATERAL HNP DISKECTOMY, ANTERIOR W/ DECOMP SPINAL CORD/NERVE ROOT(S); CERVICAL SINGLE SPACE DISKTECTOMY, ANTERIOR W/ DECOMP SPINAL CORD/NERVE ROOT(S); THORACIC SINGLE SPACE VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), ANTERIOR W/ DECOMP CERVICAL LAMINECTOMY FOR EXCISE/EVACUATION INTRASPINAL LESION NOT NEOPLASM, EXTRADURAL; LUMBAR PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY, EPIDURAL REVISION OR REMOVAL OF SPINAL NEUROSTIMULATOR ELECTRODE PERCUTANEOUS ARRAY REVISION INCLUDING REPLACEMENT, WHEN PERFORMED, OF SPINAL NEUROSTIMULATOR ELECTRODE PERCUTANEOUS ARRAY(S), INCLUDING FLUOROSCOPY, WHEN PERFORMED REVISION INCLUDING REPLACEMENT, WHEN PERFORMED, OF SPINAL NEUROSTIMULATOR ELECTRODE PLATE/PADDLE(S) PLACED VIA LAMINOTOMY OR LAMINECTOMY, INCLUDING FLUOROSCOPY, WHEN PERFORMED INCISION & SUBCUTANEOUS PLACEMENT OF SPINAL NEUROSTIMULATOR PULSE GENERATO REVISION OR REMOVAL OF IMPLANTED SPINAL NEUROSTIMULATOR PULSE GENERATOR OR CREATION OF SHUNT,LUMBAR,SUBARACHNOID-PERITONEAL,-PLEURAL,OR OTHER;PERCUTA INJECTION, ANESTHETIC AGENT; TRIGEMINAL NERVE, ANY DIVISION OR BRANCH GREATER OCCIPITAL NERVE BLOCK (ONB) INJECTION, ANESTHETIC AGENT; PHRENIC NERVE INJECTION, ANESTHETIC AGENT; SPINAL ACCESSORY NERVE INJECTION, ANESTHETIC AGENT; CERVICAL PLEXUS INJECTION, ANESTHETIC AGENT; BRACHIAL PLEXUS INJECTION, ANESTHETIC AGENT; BRACHIAL PLEXUS, CONTINOUS INFUSION BY CATHETER (INCLUDING CATHETER PLAMENT) INJECTION, ANESTHETIC AGENT; AXILLARY NERVE INJECTION, ANESTHETIC AGENT; INTERCOSTAL NERVE, SINGLE INJECTION, ANESTHETIC AGENT; PUDENTAL NERVE Page 132 of 159

133 64446 INJECTION, ANESTHETIC AGENT; SCIATIC NERVE, CONTINUOUS INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT) INJECTION, ANESTHETIC AGENT; FEMORAL NERVE, SINGLE INJECTION, ANESTHETIC AGENT; FEMORAL NERVE, CONTINUOUS INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT) INJECTION, ANESTHETIC AGENT AND/OR STEROID, PARAVERTEBRAL FACET JOINT OR FACET JOINT NERVE; CERVICAL OR THORACIC, SINGLE LEVEL INJECTION, ANESTHETIC AGENT &/OR STEROID, LUMBAR OR SACRAL, SINGLE INJECTION(S), ANESTHETIC AGENT AND/OR STEROID, TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE LEVEL INJECTION, ANESTHETIC AGENT &/OR STEROID, TRANFORAMINAL EPIDURAL; LUMBAR OR SAC INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL INJECTION, ANESTHETIC AGENT; SPHENOPALATINE GANGLION INJECTION, ANESTHETIC AGENT; STELLATE GANGLION (SERVICAL SYMPATHETIC) INJECTION, ANESTHETIC AGENT; SUPERIOR HYPOGASTRIC PLEXUS INJECTION, ANESTHETIC AGENT; CELIAC PLEXUS, WITH OR WITOUT RADIOLOGIC MONITORIN APPLICATION OF SURFACE (TRANSCUTANEOUS) NEUROSTIMULATOR PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODES; PERIPHERAL NERVE PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODES; SACRAL NERVE (TRANSFORAMINAL PLACEMENT) REMOVAL OF CRANIAL NERVE (VAGUS NERVE) NEUROSTIMULATOR ELECTRODE ARRAY AND PULSE GENERATOR INCISION FOR IMPLANTATION OF NEUROSTIMULATOR ELECTRODES; PERIPHERAL NERVE INCISION FOR IMPLANTATION OF NEUROSTIMULATOR ELECTRODES SACRAL NERVE (TRANSFORAMINAL PLACEMENT) REVISION OR REMOVAL OF PERIPHERAL NEUROSTIMULATOR ELECTRODE ARRAY INCISION & SUBCUTANEOUS PLACEMENT OF PERIPHERAL NEUROSTIMULATOR PULSE GENE REVISION OR REMOVAL OF PERIPHERAL OR GASTRIC NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER DESTRUCTION BY NEUROLYTIC AGENT, TRIGEMINAL NERVE; SUPRAORBITAL, INFRAORBITAL, MENTAL, OR INFERIOR ALVEOLAR BRANCH DESTRUCTION BY NEUROLYTIC AGENT,TRIGEMINAL NERVE;SECOND & THIRD DIVISION BRAN DESTRUCTION BY NEUROLYTIC AGENT;CERVICAL SPINAL MUSCLES (EG, FOR SPASMODIC TO DESTRUCTION BY NEUROLYTIC AGENT; INTERCOSTAL NERVE DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT Page 133 of 159

134 64640 DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH CHEMODENERVATION OF ONE EXTREMITY; 1-4 MUSCLE(S) CHEMODENERVATION OF ONE EXTREMITY; 5 OR MORE MUSCLES DESTRUCTION BY NEUROLYTIC AGENT, CELIAC PLEXUS, WITH OR WITHOUT RADIOLOGIC MON NEUROPLASTY; DIGITAL, ONE OR BOTH, SAME DIGIT NEUROPLASTY; NERVE OF HAND OR FOOT NEUROPLASTY; MAJOR PERIPHERAL NERVE, ARM OR LEG, OTHER THAN SPECIFIED NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG; SCIATIC NERVE NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG; BRACHIAL PLEXUS NEUROPLASTY AND/OR TRANSPOSITION; ULNAR NERVE AT ELBOW NEUROPLASTY AND/OR TRANSPOSITION; ULNAR NERVE AT WRIST NEUROPLASTY AND/OR TRANSPOSITION; MEDIAN NERVCE AT CARPAL TUNNET DECOMPRESSION; UNSPECIFIED NERVE(S) (SPECIFY) DECOMPRESSION; PLANTAR DIGITAL NERVE TRANSECTION OR AVULSION OF OTHER SPINAL NERVE, EXTRADURAL EXCISION OF NEUROMA; CUTANEOUS NERVE, SURGICALLY IDENTIFIABLE EXCISION OF NEUROMA; DIGITAL NERVE, ONE OR BOTH, SAME DIGIT EXCISION OF NEUROMA; HAND OR FOOT, EXCEPT DIGITAL NERVE EXCISION OF NEUROMA; MAJOR PERIPHERAL NERVE, EXCEPT SCIATIC EXCISION OF NEUROFIBROMA OR NEUROLEMMOMA; CUTANEOUS NERVE EXCISION OF NEUROFIBROMA OR NEUROLEMMOMA; MAJOR PERIPHERAL NERVE EXCISION OF NEUROFIBROMA OR NEUROLEMMOMA; EXTENSIVE (INC MALIGNANT TYPE) BIOPSY OF NERVE SYMPATHECTOMY, DIGITAL ARTERIES, WITH MAGNIFICATION, EACH DIGIT SYMPATHECTOMY; ULNAR ARTERY SUTURE OF DIGITAL NERVE, HAND OR FOOT; ONE NERVE SUTURE OF ONE NERVE, HAND OR FOOT; COMMON SENSORY NERVE SUTURE OF ONE NERVE, HAND OR FOOT; MEDIAN MOTOR THENAR SUTURE OF 1 NERVE; ULNAR MOTOR SUTURE OF POSTERIOR TIBIAL NERVE SUTURE OF MAJOR PERIPHERAL NERVE,ARM OR LEG,EXCEPT SCIATIC;INC TRANSPOSITION SUTURE OF MAJOR PERIPHERAL NERVE, ARM OR LEG, EXCEPT SCIATIC, WITHOUT TRANSPOS SUTURE OF; BRACHIAL PLEXUS SUTURE OF FACIAL NERVE; EXTRACRANIAL NERVE GRAFT (INCLUDES OBTAINING GRAFT), HEAD OR NECK; UP TO 4 CM IN LENGTH NERVE GRAFT (INC OBTAINING GRAFT), SINGLE STRAND,HAND OR FOOT;UP TO 4 CM LENGTH NERVE GRAFT (INCLUDES OBTAINING GRAFT), SINGLE STRAND, HAND OR FOOT; MORE THAN 4 CM LENGTH ENUCLEATION OF EYE; WITHOUT IMPLANT ENUCLEATION EYE; WITH IMPLANT, MUSCLES NOT ATTACHED TO IMPLANT Page 134 of 159

135 65105 ENUCLEATION EYE; WITH IMPLANT, MUSCLES ATTACHED TO IMPLANT EXENTERATION OF ORBIT (DOES NOT INCLUDE SKIN GRAFT), REMOVAL OF ORBITAL CONTENTS; ONLY MODIFICATION OF OCULAR IMPLANT WITH PLACEMENT OR REPALCEMENT OF PEGS (EG, DRIL INSERTION OCULAR IMPLANT SECONDARY; AFTER ENUCLEATION, MUSCLES ATTACHED TO REINSERTION OF OCULAR IMPLANT; WITH OR WITHOUT CONJUNCTIVAL GRAFT REINSERTION OCULAR IMPLANT; WITH USE OF FOREIGN MATERIAL FOR REINFORCEMENT AN REMOVAL OF OCULAR IMPLANT REMOVAL OF FOREIGN BODY,EXTERNAL EYE;CONJUNCTIVAL EMBEDDED,SUBCONJUNCTIVAL REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITH SLIT LAMP REMOVAL OF FOREIGN BODY, INTRAOCULAR; FROM ANTERIOR CHAMBER OR LENS REMOVAL OF FOREIGN BODY,INTRAOCULAR;FR POSTERIOR SEGMENT,MAGNETIC EXTRACTI REMOVAL OF FOREIGN BODY,INTRAOCULAR;FR POSTERIOR SEGMENT,NONMAGNETIC EXTRA REPAIR OF LACERATION;CONJUNCTIVA,W/ OR W/O NONPERFORATING LACERATION SCLERA, REPAIR LACERATION; CONJUNCTIVA, BY MOBILIZATION AND REARRANGEMENT, WITH HOSPIT REPAIR OF LACERATION; CORNEA, NONPERFORATING,W/ OR W/O REMOVAL FOREIGN BODY REPAIR OF LACERATION;CORNEA &/OR SCLERA,PERFORATING,NOT INVOLVING UVEAL TISSU REPAIR OF LACERATION;CORNEA &/OR SCLERA,PERFORATING,W/ REPOSITION OR RESECTI REPAIR OF LACERATION;APPLICATION OF TISSUE GLUE,WOUNDS OF CORNEA &/OR SCLERA REPAIR WOUND EXTRAOCULAR MUSCLE, TENDON AND/OR TENON'S CAPSULE EXCISION LESION CORNEA (KERATECTOMY, LAMELLAR, PARTIAL), EXCEPT PTERYGIUM EXCISION OR TRANSPOSITION PTERYGIUM; WITHOUT GRAFT EXCISION OR TRANSPOSITION PTERYGIUM; WITH GRAFT REMOVAL OF CORNEAL EPITHELIUM;W/ OR W/O CHEMOCAUTRIZATION (ABRASION, CURETTA REMOVAL OF CORNEAL EPITHELIUM; WITH APPLICATION OF CHELATING AGENT (EG, EDTA) DESTRUCTION OF LESION OF CORNEA BY CRYOTHERAPY,PHOTOCOAGULATION OR TERMOC MULTIPLE PUNCTURES OF ANTERIOR CORNEA (EG, FOR CORNEAL EROSION, TATTOO) KERATOPLASTY (CORNEAL TRANSPLANT); LAMELLAR KERATOPLASTY (CORNEAL TRANSPLANT) PENETRATING (EXCEPT IN APHAKIA) KERATOPLASTY (CORNEAL TRANSPLANT); PENETRATING (IN APHAKIA) KERATOPLASTY (CORNEAL TRANSPLANT); PENETRATING (IN PSEUDOPHAKIA) KERATOPLASTY (CORNEAL TRANSPLANT); ENDOTHELIAL KERATOMILEUSIS KERATOPROSTHESIS RADIAL KERATOTOMY CORNEAL RELAXING INCISION FOR CORRECTION OF SURGICALLY INDUCED ASTIGMATISM PLACEMENT OF AMNIOTIC MEMBRANE ON THE OCULAR SURFACE FOR WOUND HEALING; SINGLE LAYER, SUTURED OCULAR SURFACE RECONSTRUCTION; AMNIOTIC MEMBRANE TRANSPLANTATION PARACENTESIS OF ANTERIOR CHAMBER OF EYE (SEP PROC);W/ THERAPEUTIC RELEASE OF Page 135 of 159

136 65815 PARACENTESIS OF ANTERIOR CHAMBER OF EYE (SEPARATE PROCEDURE), WITH REMOVAL GONIOTOMY; WITHOUT GONIOPUNCTURE TRABECULOTOMY AB EXTERNO TRABECULOPLASTY BY LASER SURGERY, ONE OR MORE SESSIONS (DEFINED TREATMENT SEVERING ADHESIONS OF ANTERIOR SEGMENT, LASER TECHNIQUE (SEPARATE PROC) SEVERING ADHESIONS OF ANTERIOR SEGMENT OF EYE, INCISIONAL TECHNIQUE (WITH OR REMOVAL OF EPITHELIAL DOWNGROWTH ANTERIOR CHAMBER EYE REMOVAL OF IMPLANTED MATERIAL, ANTERIOR SEGMENT EYE INJECTION, ANTERIOR CHAMBER OF EYE (SEPARATE PROCEDURE); AIR OR LIQUID EXCISION OF LESION, SCLERA FISTULIZATION OF SCLERA FOR GLAUCOMA; SCLERECTOMY WITH PUNCH OR SCISSORS, WITH IRIDECTOMY FISTULIZATION OF SCLERA FOR GLAUCOMA; TRABECULECTOMY AB EXTERNO IN ABSCENCE FISTULIZATION OF SCLERA FOR GLAUCOMA; TRABECULECTOMY AB EXTERNO WITH SCARRIN TRANSLUMINAL DILATION OF AQUEOUS OUTFLOW CANAL; WITH RETENTION OF DEVICE OR STENT AQUEOUS SHUNT TO EXTRAOCULAR RESERVOIR, (EG, MOLTENO, SCHOCKET, DENVER-KRUP INSERTION OF ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, EXTERNAL APPROACH REVISION OF AQUEOUS SHUNT TO EXTRAOCULAR RESERVOIR REVISION OR REPAIR OF OPERATIVE WOUND OF ANTERIOR SEGMENT, ANY TYPE, EARLY OR LATE, MAJOR OR MINOR PROCEDURE IRIDOTOMY BY STAB INCISION (SEPARATE PROCEDURE); EXCEPT TRANSFIXION IRIDECTOMY, WITH CORNEOSCLERAL OR CORNEAL SECTION; FOR REMOVAL OF LESION IRIDECTOMY,W/ CORNEOSCLERAL OR CORNEAL SECTION;PERIPHERAL FOR GLAUCOMA (SEP REPAIR OF IRIS, CILIARY BODY (AS FOR IRIDODIALYSIS) SUTURE OF IRIS, CILIARY BODY (SEP PROC) W/ RETRIEVAL OF SUTURE THRU SM INCISION CILIARY BODY DESTRUCTION; CYCLOPHOTOCOAGULATION CILIARY BODY DESTRUCTION; CYCLOPHOTOCOAGULATION, ENDOSCOPIC CILIARY BODY DESTRUCTION; CRYOTHERAPHY CILIARY BODY DESTRUCTION; CYCLODIALYSIS IRIDOTOMY/IRIDECTOMY BY LASER SURGERY (EG, FOR GLAUCOMA) (ONE OR MORE SESSION IRIDOPLASTY BY PHOTOCOAGULATLION (ONE OR MORE SESSIONS) (EG, FOR IMPROVEMENT DISCISSION OF SECONDARY MEMBRANEOUS CATARACT (OPACIFIED POSTERIOR LENS CAPS DISCISSION OF SECONDARY MEMBRANEOUS CATARACT (OPACIFIED POSTERIOR LENS CAPS REPOSITIONING OF INTRAOCULAR LENS PROSTHESIS, REQUIRING AN INCISION (SEPARATE REMOVAL OF SECONDARY MEMBRANOUS CATARACT (OPACIFIED POSTERIOR LENS CAPSULE REMOVAL OF LENS MATERIAL; ASPIRATION TECHNIQUE, ONE OR MORE STAGES REMOVAL OF LENS MATERIAL; PHACOFRAGMENTATION TECHNIQUE (MECHANICAL OR ULTRA REMOVAL OF LENS MATERIAL; PARS PLANA APPROACH, WITH OR WITHOUT VITRECTOMY Page 136 of 159

137 66920 REMOVAL OF LENS MATERIAL; INTRACAPSULAR REMOVAL OF LENS MATERIAL; EXTRACAPSULAR EXTRACAPSULAR CATARCT REMOVAL W/ INSERTION OF INTRAOCULAR LENS PROSTHESIS INTRACAPSULAR CATARACT EXTRACTION W/ INSERT OF INTRAOCULAR LENS PROSTHESIS EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROTHESIS INSERTION OF INTRAOCULAR LENS PROSTHESIS (SECONDARY IMPLANT), NOT ASSOCIATED EXCHANGE OF INTRAOCULAR LENS REMOVAL OF VITREOUS, ANTERIOR APPROACH (OPEN SKY TECHNIQUE OR LIMBAL INCISION) REMOVAL OF VITREOUS, ANTERIOR APPROACH (OPEN SKY TECHNIQUE OR LIMBAL INCISION) ASPIRATION OR RELEASE OF VITREOUS,SUBRETINAL OR CHOROIDAL FLUID,PARS PLANA APP INJECTION OF VITREOUS SUBSTITUTE, PARS PLANA OR LIMBAL APPROACH, (FLUID-GAS EXCH IMPLANTATION OF INTRAVITREAL DRUG DELIVERY SYSTEM,INC CONCOMITANT REMOVAL OF DISCSSION OF VITREOUS STRANDS (W/O REMOVAL), PARS PLANA APPROACH SEVERING OF VITREOUS STRANDS, VITREOUS FACE ADHESIONS, SHEETS, MEMBRANES OR VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH EPIRETINAL MEMBRANCE STRIPPI VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH FOCAL ENDOLASER PHOTOCOAG VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH ENDOLASER PANRETINAL PHOTO VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH REMOVAL OF PERITONEAL CELLULAR MEMBRANE (EG, MACULAR PUCKER) VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH REMOVAL OF INTERNAL LIMITING MEMBRANE OF RETINA (EG, FOR REPAIR OF MACULAR HOLE, DIABETIC MACULAR EDEMA), INCLUDES, IF PERFORMED, INTRAOCULAR TAMPONADE (IE, AIR, GAS OR SILICONE OIL) VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH REMOVAL OF SUBRETINAL MEMBRANE (EG, CHOROIDAL NEOVASCULARIZATION), INCLUDES, IF PERFORMED, INTRAOCULAR TAMPONADE (IE, AIR, GAS OR SILICONE OIL) AND LASER PHOTOCOAGULATION REPAIR OF RETINAL DETACHMENT, ONE OR MORE SESSIONS; CRYOTHERAPHY OR DIATHERM REPAIR OF RETINAL DETACHMENT, ONE OR MORE SESSIONS; CRYOTHERAPHY OR DIATHERM REPAIR OF RETINAL DETACHMENT; SCLERAL BUCKLING (SUCH AS LAMELLAR SCLERAL DISS REPAIR OF RETINAL DETACHMENT; WITH VITRECTOMY, ANY METHOD, WITH OR WITHOUT AIR REPAIR OF RETINAL DETACHMENT; BY INJECTION OF AIR OR OTHER GAS (EG, PNEUMATIC RE REPAIR OF RETINAL DETACHMENT; BY SCLERAL BUCKLING OR VITRECTOMY, ON PATIENT HA REPAIR OF RETINAL DETACHMENT; BY SCLERAL BUCKLING OR VITRECTOMY, ON PATIENT HA REPAIR OF COMPLEX RETINAL DETACHMENT (EG, PROLIFERATIVE VITREORETINOPATHY, STAGE C- 1 OR GREATER, DIABETIC TRACTION RETINAL DETACHMENT, RETINOPATHY OR PREMATURITY, RETINAL TEAR OF GREATER THAN 90 DEGREES), WITH VITRECTOMY AND MEMBRANE PEELING, MAY INCLUDE REMOVAL IMPLANTED MATERIAL, POSTERIOR SEGMENT; EXTRAOCULAR REMOVAL OF IMPLANTED MATERIAL, POSTERIOR SEGMENT; INTRAOCULAR PROPHYLAXIS OF RETINAL DETACHMENT (EG, RETINAL BREAK, LATTICE DEGENERATION) WIT Page 137 of 159

138 67145 PROPHYLAXIS OF RETINAL DETACHMENT (EG, RETINAL BREAK, LATTICE DEGENERATION) WIT DESTRUCTION OF LOCALIZED LESION OF RETINA (EG, MACULOPATHY, CHOROIDOPATHY, SM DESTRUCTION OF LOCALIZED LESION OF RETINA (EG, MACULOPATHY, CHOROIDOPATHY, SM DESTRUCTION OF LOCALIZED LESION OF RETINA,ONE OR MORE SESSIONS; RADIATION BY IM DESTRUCTION OF LOCALIZED LESION OF CHOROID,ONE OR MORE SESSIONS, PHOTOCOAGU DESTRUCTION OF LOCALIZED LESION OF CHOROID (EG, CHROIDAL NEOVASCULARIZATION); PHOTODYNAMIC THERAPY DESTRUCTION OF EXTENSIVE OR PROGRESSIVE RETINOPATHY (EG, DIABETIC RETINOPATHY DESTRUCTION OF EXTENSIVE OR PROGRESSIVE RETINOPATHY (EG, DIABETIC RETINOPATHY TREATMENT OF EXTENSIVE OR PROGRESSIVE RETINOPATHY, ONE OR MORE SESSION; PRETERM INFANT (LESS THAN 37 WEEKS GESTATION AT BIRTH), PERFORMED FROM BIRTH UP TO 1 YEAR OF AGE (EG, RETINOPATHY OF PREMATURITY), PHOTOCOAGULATION OR CRYOTHERAPY SCLERAL REINFORCEMENT (SEPARATE PROCEDURE); WITHOUT GRAFT SCLERAL REINFORCEMENT (SEPARATE PROCEDURE); WITH GRAFT STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE (PATIENT NOT PREVIOUSL STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE (PATIENT NOT PREVIOUSL STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE (PATIENT NOT PREVIOUSL STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE (PATIENT NOT PREVIOUSL STRABISMUS SURGERY, ANY PROCEDURE (PATIENT NOT PREVIOUSLY OPERATED ON), SUPE RELEASE OF EXTENSIVE SCAR TISSUE W/O DETACHING EXTRAOCULAR MUSCLE (SEP PROC) CHEMODENERVATION OF EXTRAOCULAR MUSCLE BIOPSY OF EXTRAOCULAR MUSCLE ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); FOR EX ORBITOTOMY W/O BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH);W/ DRAINAGE ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); WITH R ORBITOTOMY W/O BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH);W/ REMOVAL ORBITOTOMY W/O BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH);W/ REMOVAL FINE NEEDLE ASPIRATION OF ORBITAL CONTENTS ORBITOTOMY WITH BONE FLAP OR WINDOW, LATERAL APPROACH (EG, KROENLEIN); WITH RE ORBITOTOMY W/ BONE FLAP OR WINDOW,LATERAL APPROACH;W/ REMOVAL OF BONE FOR DE ORBITOTOMY WITH BONE FLAP OR WINDOW, LATERAL APPROACH (EG, KROENLEIN); WITH DR RETROBULBAR INJECTION; ALCOHOL INJECTION OF THERAPEUTIC AGENT INTO TENON'S CAPSULE ORBITAL IMPLANT (IMPLANT OUTSIDE MUSCLE CONE); INSERTION ORBITAL IMPLANT (IMPLANT OUTSIDE MUSCLE CONE); REMOVAL OR REVISION SEVERING OF TARSORRHAPHY CANTHOTOMY (SEPARATE PROCEDURE) EXCISION CHALAZION; UNDER GENERAL ANESTHESIA AND/OR REQUIRING HOSPITALIZATION CORRECTION OF TRICHIASIS; INCISION OF LID MARGIN CORRECTION OF TRICHIASIS; INCISION OF LID MARGIN,W/ FREE MUCOUS MEMBRANE GRAFT Page 138 of 159

139 67850 DESTRUCTION OF LESION OF LID MARGIN (UP TO 1 CM) TEMPORARY CLOSURE OF EYELIDS BY SUTURE (EG, FROST SUTURE) CONSTRUCTION OF INTERMARGINAL ADHESIONS,MEDIAN TARSORRHAPHY OR CANTHORRH CONSTRUCTION OF INTERMARGINAL ADHESIONS,MEDIAN TARSORRHAPHY OR CANTHORRH REPAIR OF BROW PTOSIS (SUPRACILIARY, MID-FOREHEAD OR CORONAL APPROACH) REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSCLE TECHNIQUE WITH SUTURE OR OTHER MA REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSCLE TECHNIQUE WITH FACIAL SLING (INCLUD REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR RESECTION OR ADVANCEMENT, INTERNAL REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR RESECTION OR ADVANCEMENT, EXTERNAL REPAIR OF BLEPHAROPTOSIS;CONJUNCTIVO-TARSO-MULLER'S MUSCLE-LEVATOR RESECTI CORRECTION OF LID RETRACTION CORRECTION OF LAGOPHTHALMOS, WITH IMPLANTATION OF UPPER EYELID LOAD (E.G., GOLD WEIGHT) REPAIR OF ECTROPION; SUTURE REPAIR OF ECTROPION; BLEPHAROPLASTY, EXCISION TARSAL WEDGE REPAIR OF ENTROPION; BLEPHAROPLASTY, EXTENSIVE (EG, KUHNT-SZYMANOWSKI OR TARS REPAIR OF ENTROPION; SUTURE REPAIR OF ENTROPION; BLEPHAROPLASTY, EXCISION TARSAL WEDGE REPAIR OF ENTROPION; BLEPHAROPLASTY, EXTENSIVE (EG, WHEELER OPERATION) SUTURE OF RECENT WOUND, EYELID,INVOLVING LID MARGIN,TARSUS &/OR PALPEBRAL CON SUTURE RECENT WOUND, EYELID, INVOLVING LID MARGIN, TARSUS AND/OR PALPEBRAL CON REMOVAL OF EMBEDDED FOREIGN BODY, EYELID CANTHOPLASTY (RECONSTRUCTION OF CANTHUS) EXCISION AND REPAIR OF EYELID, INVOLVING LID MARGIN, TARSUS, CONJUNCTIVA, CANTHUS EXCISION AND REPAIR OF EYELID, INVOLVING LID MARGIN, TARSUS, CONJUNCTIVA, CANTHUS RECONSTRUCTION OF EYELID FULL THICKNESS BY TRANSFER OF TARSOCONJUNCTIVAL FL RECONSTRUCTION OF EYELID,FULL THICKNESS BY TRANSFER OF TARSONCONJUNCTIVAL BIOPSY OF CONJUNCTIVA EXCISION OF LESION CONJUNCTIVA; UP TO 1 CM EXCISION OF LESION CONJUNCTIVA; OVER 1 CM EXCISION OF LESION, CONJUNCTIVA; WITH ADJACENT SCLERA DESTRUCTION OF LESION, CONJUNCTIVA SUBCONJUNCTIVAL INJECTION CONJUNCTIVOPLASTY; WITH CONJUNCTIVAL GRAFT OR EXTENSIVE REARRANGEMENT CONJUNCTIVOPLASTY, RECONSTRUCTION CUL-DE-SAC; WITH CONJUNCTIVAL GRAFT OR EX REPAIR OF SYMBLEPHARON; CONJUNCTIVOPLASTY, WITHOUT GRAFT REPAIR OF SYMBLEPHARON;DIVISION OF SYMBLEPHARON W/ OR W/O INSERTION OF CONFOR CONJUNCTIVAL FLAP; BRIDGE OR PARTIAL (SEPARATE PROCEDURE) CONJUNCTIVAL FLAP; TOTAL (SUCH AS GUNDERSON THIN FLAP OR PURSE STRING FLAP) INCISION, DRAINAGE OF LACRIMAL GLAND Page 139 of 159

140 68420 INCISION, DRAINAGE OF LACRIMAL SAC (DACRYOCYSTOTOMY OR DACRYOCYSTOSTOMY) BIOPSY OF LACRIMAL GLAND EXCISION OF LACRIMAL SAC (DACRYOCYSTECTOMY) REMOVAL OF FOREIGN BODY OR DACRYOLITH, LACRIMAL PASSAGES EXCITION OF LACRIMAL GLAND TUMOR; FRONTAL APPORACH PLASTIC REPAIR OF CANALICULI DACRYOCYSTORHINOSTOMY (FISTULIZATION OF LACRIMAL SAC TO NASAL CAVITY) CONJUNCTIVORHINOSTOMY (FISTULIZATION OF CONJUNCTIVA TO NASAL CAVITY);W/ INSERT CLOSURE OF LACRIMAL PUNCTUM; BY THERMOCAUTERIZATION, LIGATION, OR LASER SURG CLOSURE OF THE LACRIMAL PUNCTUM; BY PLUG, EACH CLOSURE OF LACRAL FISTULA (SEPARATE PROCEDURE) DILATION OF LACRIMAL PUNCTUM, WITH OR WITHOUT IRRIGATION PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION PROBING OF NASOLACRIMAL DUCT, REQUIRING GENERAL ANESTHESIA PROBING OF NASOLACRIMAL DUCT, WITH INSERTION OF TUBE OR STENT PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION; WITH TRANSLUMINAL BALLOON CATHETER DILATION EXCISION EXOSTOSIS(ES), EXTERNAL AUDITORY CANAL RADICAL EXCISION EXTERNAL AUDITORY CANAL LESION; WITHOUT NECK DISSECTION REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITH GENERAL ANESTHESIA DEBRIDEMENT,MASTOIDECTOMY CAVITY,COMPLEX (EG,W/ ANESTHESIA OR MORE THAN ROU OTOPLASTY PROTRUDING EAR, WITH OR WITHOUT SIZE REDUCTION RECONSTRUCTION OF EXTERNAL AUDITORY CANAL (MEATOPLASTY) (EG, FOR STENOSIS DUE RECONSTRUCTION EXTERNAL AUDITORY CANAL FOR CONGENITAL ATRESIA, SINGLE STAGE EUSTACHIAN TUBE INFLATION, TRANSNASAL; WITH CATHETERIZATION EUSTACHIAN TUBE INFLATION, TRANSNASAL; WITHOUT CATHETERIZATION MYRINGOTOMY INCLUDING ASPIRATION AND/OR EUSTACHIAN TUBE INFLATION REQUIRING VENTILATING TUBE REMOVAL WHEN ORIGINALLY INSERTED BY ANOTHER PHYSICIAN TYMPANOSTOMY (REQUIRING INSERTION OF VENTILATING TUBE), GENERAL ANESTHESIA MIDDLE EAR EXPLORATION THROUGH POSTAURICU LAR OR EAR CANAL INCISION TYMPANOLYSIS, TRANSCANAL TRANSMASTOID ANTROTOMY ("SIMPLE" MASTOIDECTOMY) MASTOIDECTOMY; COMPLETE MASTOIDECTOMY; MODIFIED RADICAL MASTOIDECTOMY; RADICAL RESECTION TEMPORAL BONE, EXTERNAL APPROACH EXCISION AURAL POLYP EXCISION AURAL GLOMUS TUMOR; TRANSCANAL REVISION MASTOIDECTOMY; RESULTING IN COMPLETE MASTOIDECTOMY Page 140 of 159

141 69602 REVISION MASTOIDECTOMY; RESULTING IN MODIFIED RADICAL MASTOIDECTOMY REVISION MASTOIDECTOMY; RESULTING IN TYMPANOPLASTY TYMPANIC MEMBRANE REPAIR, WITH OR WITHOUT SITE PREPARATION OR PERFORATION FOR MYRINGOPLASTY (SURGERY CONFINED TO DRUMHEAD AND DONAR AREA) TYMPANOPLASTY WITHOUT MASTOIDECTOMY (INCLUDING CANALPLASTY, ATTICOTOMY AND/OR MIDDLE EAR SURGERY), INITIAL OR REVISION; WITHOUT OSSICULAR CHAIN RECONSTRUCTION TYMPANOPLASTY WITHOUT MASTOIDECTOMY (INCLUDING CANALPLASTY, ATTICOTOMY AND/OR MIDDLE EAR SURGERY), INITIAL OR REVISION; WITH OSSICULAR CHAIN RECONSTRUCTION (EG, POSTFENESTRATION) TYMPANOPLASTY WITHOUT MASTOIDECTOMY (INCLUDING CANALPLASTY, ATTICOTOMY AND/OR MIDDLE EAR SURGERY), INITIAL OR REVISION; WITH OSSICULAR CHAIN RECONSTRUCTION AND SYNTHETIC PROSTHESIS (EG, PARTIAL OSSICULAR REPLACEMENT PROSTHESIS [PORP], TOTAL OSSICULAR REPL TYMPANOPLASTY WITH ANTROTOMY OR MASTOIDOTOMY (INCLUDING CANALPLASTY, ATTICOTOMY, MIDDLE EAR SURGERY, AND/OR TYMPANIC MEMBRANE REPAIR); WITHOUT OSSICULAR CHAIN RECONSTRUCTION TYMPANOPLASTY WITH ANTROTOMY OR MASTOIDOTOMY (INCLUDING CANALPLASTY, ATTICOTOMY, MIDDLE EAR SURGERY, AND/OR TYMPANIC MEMBRANE REPAIR); WITH OSSICULAR CHAIN RECONSTRUCTION TYMPANOPLASTY WITH ANTROTOMY OR MASTOIDOTOMY (INCLUDING CANALPLASTY, ATTICOTOMY, MIDDLE EAR SURGERY, AND/OR TYMPANIC MEMBRANE REPAIR); WITH OSSICULAR CHAIN RECONSTRUCTION AND SYNTHETIC PROSTHESIS (EG, PARTIAL OSSICULAR REPLACEMENT PROSTHESIS [PORP], TOTAL TYMPANOPLASTY WITH MASTOIDECTOMY (INCLUDING CANALPLASTY, MIDDLE EAR SURGERY, TYMPANIC MEMBRANE REPAIR); WITHOUT OSSICULAR CHAIN RECONSTRUCTION TYMPANOPLASTY WITH MASTOIDECTOMY (INCLUDING CANALPLASTY, MIDDLE EAR SURGERY, TYMPANIC MEMBRANE REPAIR); WITH INTACT OR RECONSTRUCTED WALL, WITHOUT OSSICULAR CHAIN RECONSTRUCTION TYMPANOPLASTY WITH MASTOIDECTOMY (INCLUDING CANALPLASTY, MIDDLE EAR SURGERY TYMPANOPLASTY WITH MASTOIDECTOMY (INCLUDING CANALPLASTY, MIDDLE EAR SURGERY, TYMPANIC MEMBRANE REPAIR); WITH INTACT OR RECONSTRUCTED CANAL WALL, WITH OSSICULAR CHAIN RECONSTRUCTION TYMPANOPLASTY WITH MASTOIDECTOMY (INCLUDING CANALPLASTY, MIDDLE EAR SURGERY, TYMPANIC MEMBRANE REPAIR); RADICAL OR COMPLETE, WITHOUT OSSICULAR CHAIN RECONSTRUCTION TYMPANOPLASTY WITH MASTOIDECTOMY (INCLUDING CANALPLASTY, MIDDLE EAR SURGERY, TYMPANIC MEMBRANE REPAIR); RADICAL OR COMPLETE, WITH OSSICULAR CHAIN RECONSTRUCTION STAPES MOBILIZATION STAPEDECTOMY OR STAPEDOTOMY WITH REESTABLISHMENT OF OSSICULAR CONTINUITY, WI Page 141 of 159

142 69661 STAPEDECTOMY OR STAPEDOTOMY WITH REESTABLISHMENT OF OSSICULAR CONTINUITY, WI REVISION OF STAPEDECTOMY OR STAPEDOTOMY REPAIR OVAL WINDOW FISTULA REPAIR ROUND WINDOW FISTULA MASTOID OBLITERATION (SEPARATE PROCEDURE) CLOSURE POSTAURICULAR FISTULA, MASTOID (SEPARATE PROCEDURE) IMPLANTATION OR REPLACEMENT OF ELECTROMAGNETIC BONE CONDUCTION HEARING DEVICE IN TEMPORAL BONE IMPLANTATION, OSSEOINTEGRATED IMPLANT, TEMPORAL BONE, WITH PERCUTANEOUS ATTACHMENT TO EXTERNAL SPEECH PROCESSOR/COCHLEAR STIMULATOR; WITHOUT MASTOIDECTOMY IMPLANTATION, OSSEOINTEGRATED IMPLANT, TEMPORAL BONE, WITH PERCUTANEOUS ATTACHMENT TO EXTERNAL SPEECH PROCESSOR/COCHLEAR STIMULATOR; WITH MASTOIDECTOMY REPLACEMENT (INCLUDING REMOVAL OF EXISTING DEVICE), OSSEOINTEGRATED IMPLANT, TEMPORAL BONE, WITH PERCUTANEOUS ATTACHMENT TO EXTERNAL SPEECH PROCERSSOR/COCHLEAR STIMULATOR; WITH MASTOIDECTOMY LABRYINTHOTOMY,W/ OR W/O CRYOSURGERY INC OTH NONEXCISIONAL DESTRUCTIVE PROC ENDOLYMPHATIC SAC OPERATION; WITHOUT SHUNT ENDOLYMPHATIC SAC OPERATION; WITH SHUNT FENESTRATION SEMICIRULAR CANAL COCHLEAR DEVICE IMPLANTATION, WITH OR WITHOUT MASTOIDECTOMY TOTAL FACIAL NERVE DECOMPRESSION AND/OR REPAIR (MAY INCLUDE GRAFT) MYELOGRAPHY,LUMBOSACRAL,RADIOLOGICAL SUPERVISION & INTERPRETATION MAGNETIC RESONANCE (EG, PROTON) IMAGIN, ANY JOINT OF LOWER EXTREMITY; WITH CONTRAST MATERIAL(S) UROGRAPHY (PYELOGRAPHY), INTRAVENOUS, W/ OR W/O DUB, W/ OR W/O TOMOGRAPHY; AORTOGRAPHY,THORACIC, BY SERIALOGRAPHY,SUPERVISION & INTERPRETATION ONLY AORTOGRAPHY,ABDOMINAL PLUS BILATERAL ILIOFEMORAL LOW EXTERMITY,CATHETER,BYSE ANGIOGRAPHY,CERVICOCERBRAL,CATHETER,INC VESSEL ORIGIN,RADIOLOGICAL SUPERVISI ANGIOGRAPHY,EXTERNAL CAROTID,CEREBRAL,UNILATERAL,SELECTIVE;SUPERVISION & INT ANTIOGRAPHY,CAROTID,CEREBRAL,BILATERAL,RADIOLOGICAL SUPERVISION & INTERPRETA ANGIOGRAPHY,EXTREMITY,UNILATERAL;SUPERISION & INTERPRETATION ONLY ANGIOGRAPHY,VISCERAL,SELECT OR SUPRASELECTIVE (W/ OR W/O FLUSH AORTOGRAM), RA FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE) MAMMOGRAPHIC GUIDANCE FOR NEEDLE PLACEMENT, BREAST (EG, FOR WIRE LOCALIZATION OR FOR INJECTION), EACH LESION THERAPEUTIC REPETITIVE TRANSCRANIAL MAGNETIC STIMULATION (TMS) TREATMENT; SUBSEQUENT MOTOR THRESHOLD RE-DETERMINATION WITH DELIVERY AND MANAGEMENT Page 142 of 159

143 91010 ESOPHAGEAL MOTILITY (MANOMETRIC STUDY OF THE ESOPHAGUS &/OR GRASTROE ESOPHAGUS, GASTROESOPHAGEAL REFLUX TEST; WITH NASAL CATHETER PH ELECTRODE(S) PLACEMENT, RECORDING, ANALYSIS ESOPHAGUS, GASTROESOPHAGEAL REFLUX TEST; WITH MUCOSAL ATTACHED TELEMETRY PH ELECTRODE PLACEMENT, RECORDING GASTROINTESTINAL TRACT IMAGING OPTHALMOLOGICAL EXAM & EVALUATION, UNDER GENERAL ANESTHESIA, W/ OR W/O OPHTHALMOLOGICAL EXAMINATION AND EVALUATION, UNDER GENERAL ANESTHESIA, WITH OR WITHOUT MANIPULATION OF GLOBE FOR PASSIVE RANGE OF MOTION OR OTHER MANIPULATION TO FACILITATE DIAGNOSTIC EXAM; LIMITED PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY; SINGLE MAJOR CORONARY ARTERY OR BRANCH PERCUTANEOUS TRANSCATHETER PLACEMENT OF INTRACORONARY STENT(S), WITH CORONARY ANGIOPLASTY WHEN PERFORMED; SINGLE MAJOR CORONARY ARTERY OR BRANCH PERCUTANEOUS TRANSLUMINAL REVASCULARIZATION OF CHRONIC TOTAL OCCLUSION, CORONARY ARTERY, CORONARY ARTERY BRANCH, OR CORONARY ARTERY BYPASS GRAFT, ANY COMBINATION OF INTRACORONARY STENT, ATHERECTOMY AND ANGIOPLASTY; SINGLE VESSEL CARDIOPULMONARY RESUSCITATION (EG, IN CARDIAC ARREST) CARDIOVERSION, ELECTIVE, ELECTRICAL CONBERSION OR ARRHYTHMIA, EXTERNAL THROMBOLYSIS, CORONARY; BY INTRAVENOUS INFUSION TRANSCATHETER PLACEMENT OF AN INTRCORONARY STENT(S), PERCUTANEOUS, WITH OR WITHOUT OTHER THERAPEUTIC INTERVENTION, ANY METHOD; SINGLE VESSEL PERCUTANEOUS TRANSLUMINAL CORONARY BALLOON ANGIOPLASTY; SINGLE VESSEL PERCUTANEOUS TRANSLUMINAL CORONARY ARTHRECTOMY, BY MECHANICAL OR OTHER METHOD WITH OR WITHOUT ANGIOPLASTY; SINGLE VESSEL ECHOCARDIOGRAPHY, REAL TIME WITH IMG DOC (W/ OR W/O M-MODE RECT),TRANSESOPHAG ECHOCARDIOGRAPHY, TRANSE OPHAGEAL (TEE) FOR MONITORING PURPOSES, INCLUDING PROBE PLACEMENT, REAL TIME2-DIMENTIONAL IMAGE ACQUISITION AND INTERPRETATION LEADING TO ONGOING (CONTINUOUS) ASSESSMENT OF (DYNAMICALLY CHANGING( CARDIAC PUMPING FUNCTION AN TO THE RIGHT HEART CATHETERIZATION INCLUDING MEASUREMENT(S) OF OXYGEN SATURATION AND CARDIAC OUTPUT, WHEN PERFORMED LEFT HEART CATHETERIZATION INCLUDING INTRAPROCEDURAL INJECTIONS(S) FOR LEFT VENTRICULOGRAPHY, IMAGING SUPERVISION AND INTERPRETATION, WHEN PERFORMED COMBINED RIGHT AND LEFT HEART CATHETERIZATION INCLUDING INTRAPROCEDURAL INJECTION(S) FOR LEFT VENTRICULOGRAPHY, IMAGING SUPERVISION AND INTERPRETATION, WHEN PERFORMED CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING SUPERVISION AND INTERPRETATION; Page 143 of 159

144 93455 CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING SUPERVISION AND INTERPRETATION; WITH CATHETER PLACEMENT(S) IN BYPASS GRAFT(S) (INTERNAL MAMMARY, FREE ARTERIAL VENO CATHETER PLACEMENT IN CORORNARY ARTERY(IES) FOR CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEUDRAL INJECTIONS(S) FOR CORONARY ANGIOGRAPHY, IMAGING SUPERVISION AND INTERPRETATION; WITH RIGHT HEART CATHETERIZATION CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING SUPERVISION AND INTERPRETATION; WITH CATHETER PLACEMENT(S) IN BYPASS GRAFT(S) (INTERNAL MAMMARY, FREE ARTERIAL, VEN CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING SUPERVISION AND INTERPRETATION; WITH LEFT HEART CATHETERIZATION INCLUDING INTRAPROCEDURAL INJECTION(S) FOR LEFT VEN CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING SUPERVISION AND INTERPRETATION; WITH LEFT HEART CATHETERIZATION INCLUDING INTRAPROCEDURAL INJECTION(S) FOR LEFT VEN CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING SUPERVISION AND INTERPRETATION; WITH RIGHT AND LEFT HEART CATHETERIZATION INCLUDING INTRAPROCEDURAL INJECTION(S) FO CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING SUPERVISION AND INTERPRETATION; WITH RIGHT AND LEFT HEART CATHETERIZATION INCLUDING INTRAPROCEDURAL INJECTION(S) FO ENDOMYOCARDIAL BIOPSY RIGHT HEART CATHETERIZATION, FOR CONGENITAL CARDIAC ANOMALIES COMBINED RIGHT HEART CATHETERIZATION AND RETROGRADE LEFT HEART CATHETERIZATION, FOR CONGENITAL CARDIAC ANOMALIES COMBINED RIGHT HEART CATHETERIZATION AND TRANSSEPTAL LEFT HEART CATHETERIZATION THROUGH EXISTING SEPTAL OPENING, WITH OR WITHOUT RETROGRADE LEFT HEART CATHETERIZATION, FOR CONGENITAL CARDIAC ANOMALIES PERCUTANEOUS TRANSCATHETER CLOSURE OF CONGENITAL INTERATRIAL COMMUNICATION (IE, FONTAN FENESTRATION, ATRIAL SEPTAL DEFECT) WITH IMPLANT PERCUTANEOUS TRANSCATHETER CLOSURE OF A CONGENITAL VENTRICULAR SEPTAL DEFECT WITH IMPLANT PERCUTANEOUS TRANSCATHETER CLOSURE OF PATENT DUCTUS ARTERIOSUS Page 144 of 159

145 93619 COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH RIGHT ATRIAL PACING AND RECORDING, RIGHT VENTRICULAR PACING AND RECORDING, HIS BUNDLE RECORDING, INCLUDING INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, WITHOUT INDUCTION OR ATTEMPTED INDUCTI COMP ELECTROPHYS EVAL W/ RIGHT ATRIAL & VENT PACE & REC, HIS BUNDLE REC,INC INSE ELECTROPHYSIOLOGIC FOLLOW-UP STUDY WITH PACING AND RECORDING TO TEST EFFECTIVENESS OF THERAPY, INCLUDING INDUCTION OR ATTEMPTED INDUCTION OF ARRHYTHMIA ELECTROPHYSIOLOGIC EVALUATION OF SINGLE OR DUAL CHAMBER PACING CARDIOVERTER- DEFIBRILLATOR LEADS INCLUDING DEFIBRILLATION THRESHOLD EVALUATION (INDUCTION OF ARRHYTHMIA, EVALUATION OF SENSING AND PACING FOR ARRHYTHMIA TERMINATION) AT TIME OF INITIAL IMPLANT INTRACARDIAC CATHETER ABLATION INTRACARDIAC CATHETER ABLATION ARRYTHMOGENIC FOCUS INTRACARDIAC CATH ABLATION ARRHYTHMOGENIC FOCUS,FOR TREATMENT OF VENTRICUL COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION INCLUDING INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS WITH INDUCTION OR ATTEMPTED INDUCTION OF AN ARRHYTHMIA WITH RIGHT ATRIAL PACING AND RECORDING, RIGHT VENTRICULAR PACING AND RECORDING, HIS RE AUTONOMIC NERVOUS SYSTEM EVALUATION OF CARIOVASCULAR FUNCTION W/ TILT TABLE E G0105 G0121 G0260 G0269 G0289 G0290 PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION OR FOR SPUTUM INDUCTION FOR DIAGNOSTIC PURPOSES (EG, WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) DEVICE). THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); INTRA-ARTERIAL COLORECTAL CANCER SCREENING, COLONOSCOPY ON INDIVIDUAL AT HIGH RISK COLORECTAL CANCER SCREENING, COLONOSCOPY ON INDIVIDUAL NOT MEETING CRITERIA FOR HIGH RISK INJECTION PROCEDURE FOR SACROILIAC JOINT; PROVISION OF ANESTHETIC, STEROID AND/OR OTHER THERAPEUTIC AGENT, WITH OR WITHOUT ARTHROGRAPHY PLACEMENT OF OCCLUSIVE DEVICE INTO EITHER A VENOUS OR ARTERIAL ACCESS ISTE, POST SURGICAL OR INTERVENTIONAL PROCEDURE (E.G., ANGIOSEAL PLUG, VASCULAR PLUG) ARTHROSCOPY, KNEE, SURGICAL, FOR REMOVAL OF LOOSE BODY, FOREIGN BODY, DEBRIDEMENT / SHAVING OF ARTICULARE CARTILAGE TRANSCATHETER PLACEMENT OF A DRUG ELUTING INTRACORONARY STENT(S). PERCUTANEOUS, WITH OR WITHOUT OTHER THERAPEUTIC Page 145 of 159

146 G0291 G0364 G0378 PLACEMENT OF OCCLUSIVE DEVICE INTO EITHER A VENOUS OR ARTERIAL ACCESS SITE, POST SURGICAL OR INTERVENTIONAL PROCEDURE (E.G., ANGIOSEAL PLUG, VASCULAR PLUG). BONE MARROW ASPIRATION PERFORMED WITH BONE MARROW BIOPSY THROUGH THE SAME INCISION ON THE SAME DATE OF SERVICE. HOSPITAL OBSERVATION SERVICE, PER HOUR Appendix A 2 ICD-10 Pneumonia Codes for KPI Number QI009 ICD 10 CM ICD 10 CM Description Set 1: A37.91 Whooping cough, unspecified species with pneumonia A48.1 Legionnaires' disease J09.X1 Influenza due to ident novel influenza A virus w pneumonia J10.00 Flu due to oth ident flu virus w unsp type of pneumonia J10.08 Influenza due to oth ident influenza virus w oth pneumonia J11.00 Flu due to unidentified flu virus w unsp type of pneumonia J11.08 Flu due to unidentified flu virus w specified pneumonia J12.0 Adenoviral pneumonia J12.1 Respiratory syncytial virus pneumonia J12.2 Parainfluenza virus pneumonia J12.81 Pneumonia due to SARS-associated coronavirus J12.89 Other viral pneumonia J12.9 Viral pneumonia, unspecified J13 Pneumonia due to Streptococcus pneumoniae J14 Pneumonia due to Hemophilus influenzae J15.0 Pneumonia due to Klebsiella pneumoniae J15.1 Pneumonia due to Pseudomonas J15.20 Pneumonia due to staphylococcus, unspecified J Pneumonia due to methicillin suscep staph J Pneumonia due to Methicillin resistant Staphylococcus aureus J15.29 Pneumonia due to other staphylococcus J15.3 Pneumonia due to streptococcus, group B J15.4 Pneumonia due to other streptococci J15.5 Pneumonia due to Escherichia coli J15.6 Pneumonia due to other aerobic Gram-negative bacteria J15.7 Pneumonia due to Mycoplasma pneumoniae J15.8 Pneumonia due to other specified bacteria Page 146 of 159

147 J15.9 Unspecified bacterial pneumonia J16.0 Chlamydial pneumonia J16.8 Pneumonia due to other specified infectious organisms J17 Pneumonia in diseases classified elsewhere J18.0 Bronchopneumonia, unspecified organism J18.1 Lobar pneumonia, unspecified organism J18.2 Hypostatic pneumonia, unspecified organism J18.8 Other pneumonia, unspecified organism J18.9 Pneumonia, unspecified organism J20.0 Acute bronchitis due to Mycoplasma pneumoniae Set 2: A15.0 Tuberculosis of lung Set 3: J Idiopathic interstitial pneumonia, not otherwise specified J Idiopathic non-specific interstitial pneumonitis J Cryptogenic organizing pneumonia J Desquamative interstitial pneumonia J84.2 Lymphoid interstitial pneumonia J85.1 Abscess of lung with pneumonia Set 4: J Ventilator associated pneumonia J95.4 Chemical pneumonitis due to anesthesia Page 147 of 159