Your Map of the ICD-9 to ICD-10 PCS Conversion

Your Map of the ICD-9 to ICD-10 PCS Conversion

Table of Contents Disclaimer 3 Endoscopy 4 Interventional Cardiology 11 Neuromodulation 14 Peripheral Interventions 15 Rhythm Management and Electrophysiology 55 Urology 62 Pelvic Health 65 2

Disclaimers Health economic and reimbursement information provided by Boston Scientific Corporation is gathered from third party sources and is subject to change without notice as a result of complex and frequently changing laws, regulations, rules and policies. This information is presented for illustrative purposes only and does not constitute reimbursement or legal advice. Boston Scientific encourages providers to submit accurate and appropriate claims for services. It is always the provider s responsibility to determine medical necessity, the proper site for delivery of any services and to submit appropriate codes, charges, and modifiers for services that are rendered. Boston Scientific recommends that you consult with your payers, reimbursement specialists and/or legal counsel regarding coding, coverage and reimbursement matters. Boston Scientific does not promote the use of its products outside their FDA approved label. CPT copyright 2013 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors, and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. Advantage, Advantage Fit, Capio, Capio SLIM, Lynx, Obtryx, Obtryx II, Polyform, Solyx, Uphold and Xenform are registered trademarks of Boston Scientific Corporation or its affiliates. All other trademarks are property of their respective owners. Accordingly for medical devices: CAUTION: Federal Law (USA) restricts these devices to sale by or on the order of a physician. Accordingly for mesh for stress urinary incontinence: CAUTION: Federal Law (USA) restricts this device to sale by or on the order of a physician trained in use of mesh for the repair of stress urinary incontinence. Accordingly for mesh for transvaginal repair of pelvic organ prolapse: CAUTION: Federal Law (USA) restricts this device to sale by or on the order of a physician trained in use of surgical mesh for transvaginal repair of pelvic organ prolapse. Repliform Tissue Regeneration Matrix complies with U.S. Regulations in 21 CFR part 1270 and 1271 Human Tissue Intended for Transplantation. Coaptite is manufactured by Merz Aesthetics, Inc. and distributed by Boston Scientific. Caution: Federal Law (USA) restricts the Coaptite Implant device to sale by or on the order of a physician trained in diagnostic and therapeutic cystoscopy. Please refer to package insert provided with the product for complete Indications for Use, Contraindications, Warnings, Precautions, Adverse Events and Instructions prior to using this product. This document is not a reflection of the Center for Medicare and Medicaid Services (CMS) official General Equivalence Mapping (GEM) for ICD-9-CM procedure classification to ICD-10-PCS. There is not a simple crosswalk from I-9- to PCS in the GEM files. The GEM file is an official CMS reference mapping that attempts to include all valid relationships between the codes in the ICD-9-CM procedure classification and the ICD-10 Procedure System (ICD- 10-PCS). Although helpful for review, the GEM translation should not replace coding from the official medical record and assigning the appropriate ICD-10 code based on the individual case record. The translations provided in this document were derived from coding directly using ICD-10-PCS coding resources making use of the increased specificity in PCS. Therefore, the translations provided are not an exact match to the CMS GEM files and are not based on any official CMS resource. The most accurate coding for ICD-10-PCS should be based on access to the individual medical record to see the specific nature of the procedure and assign the correct PCS code(s) to the record. See page 3 for important information about the uses and limitations of this document. CORP-224204-AB SEPT2015 3

Endoscopy BF110ZZ Fluoroscopy of Biliary and Pancreatic Ducts using High Osmolar Contrast 51.10 Endoscopic retrograde cholangiopancreatography [ERCP] BF111ZZ BF11YZZ 0FJB8ZZ Fluoroscopy of Biliary and Pancreatic Ducts using Low Osmolar Contrast Fluoroscopy of Biliary and Pancreatic Ducts using Contrast Inspection of Hepatobiliary Duct, Via Natural or Artificial Opening Endoscopic 0FJD8ZZ Inspection of Pancreatic Duct, Via Natural or Artificial Opening Endoscopic BF100ZZ Fluoroscopy of Bile Ducts using High Osmolar Contrast BF101ZZ Fluoroscopy of Bile Ducts using Low Osmolar Contrast 51.11 Endoscopic retrograde cholangiography (ERC) BF10YZZ BF000ZZ Fluoroscopy of Bile Ducts using Contrast Plain Radiography of Bile Ducts using High Osmolar Contrast BF001ZZ Plain Radiography of Bile Ducts using Low Osmolar Contrast BF00YZZ Plain Radiography of Bile Ducts using Contrast 0F954ZX Drainage of Right Hepatic Duct, Percutaneous Endoscopic, Diagnostic 0F957ZX Drainage of Right Hepatic Duct, Via Natural or Artificial Opening, Diagnostic 0F958ZX Drainage of Right Hepatic Duct, Via Natural or Artificial Opening Endoscopic, Diagnostic 0F964ZX Drainage of Left Hepatic Duct, Percutaneous Endoscopic, Diagnostic 0F967ZX Drainage of Left Hepatic Duct, Via Natural or Artificial Opening, Diagnostic 0F968ZX Drainage of Left Hepatic Duct, Via Natural or Artificial Opening Endoscopic, Diagnostic 0F984ZX Drainage of Cystic Duct, Percutaneous Endoscopic, Diagnostic 0F987ZX Drainage of Cystic Duct, Via Natural or Artificial Opening, Diagnostic 0F988ZX Drainage of Cystic Duct, Via Natural or Artificial Opening Endoscopic, Diagnostic 0F994ZX Drainage of Common Bile Duct, Percutaneous Endoscopic, Diagnostic 0F997ZX Drainage of Common Bile Duct, Via Natural or Artificial Opening, Diagnostic 0F998ZX Drainage of Common Bile Duct, Via Natural or Artificial Opening Endoscopic, Diagnostic 0F9C4ZX Drainage of Ampulla of Vater, Percutaneous Endoscopic, Diagnostic 0F9C7ZX Drainage of Ampulla of Vater, Via Natural or Artificial Opening, Diagnostic 51.14 closed (endoscopic) biopsy of biliary duct or sphincter of Oddi 0F9C8ZX 0FB44ZX 0FB54ZX Drainage of Ampulla of Vater, Via Natural or Artificial Opening Endoscopic, Diagnostic Excision of Gallbladder, Percutaneous Endoscopic, Diagnostic Excision of Right Hepatic Duct, Percutaneous Endoscopic, Diagnostic 0FB57ZX Excision of Right Hepatic Duct, Via Natural or Artificial Opening, Diagnostic 0FB58ZX Excision of Right Hepatic Duct, Via Natural or Artificial Opening Endoscopic, Diagnostic 0FB64ZX Excision of Left Hepatic Duct, Percutaneous Endoscopic, Diagnostic 0FB67ZX Excision of Left Hepatic Duct, Via Natural or Artificial Opening, Diagnostic 0FB68ZX Excision of Left Hepatic Duct, Via Natural or Artificial Opening Endoscopic, Diagnostic 0FB84ZX Excision of Cystic Duct, Percutaneous Endoscopic, Diagnostic 0FB87ZX Excision of Cystic Duct, Via Natural or Artificial Opening, Diagnostic 0FB88ZX Excision of Cystic Duct, Via Natural or Artificial Opening Endoscopic, Diagnostic 0FB94ZX Excision of Common Bile Duct, Percutaneous Endoscopic, Diagnostic 0FB97ZX Excision of Common Bile Duct, Via Natural or Artificial Opening, Diagnostic 0FB98ZX Excision of Common Bile Duct, Via Natural or Artificial Opening Endoscopic, Diagnostic 0FBC4ZX Excision of Ampulla of Vater, Percutaneous Endoscopic, Diagnostic 0FBC7ZX Excision of Ampulla of Vater, Via Natural or Artificial Opening, Diagnostic 0FBC8ZX Excision of Ampulla of Vater, Via Natural or Artificial Opening Endoscopic, Diagnostic See page 3 for important information about the uses and limitations of this document. CORP-224204-AB SEPT2015 4

Endoscopy 0F753DZ Dilation of Right Hepatic Duct with Intraluminal Device, Percutaneous 0F753ZZ Dilation of Right Hepatic Duct, Percutaneous 0F763DZ Dilation of Left Hepatic Duct with Intraluminal Device, Percutaneous 0F763ZZ Dilation of Left Hepatic Duct, Percutaneous 0F783DZ Dilation of Cystic Duct with Intraluminal Device, Percutaneous 0F783ZZ Dilation of Cystic Duct, Percutaneous 0F793DZ Dilation of Common Bile Duct with Intraluminal Device, Percutaneous 0F793ZZ Dilation of Common Bile Duct, Percutaneous 0F754ZZ Dilation of Right Hepatic Duct, Percutaneous Endoscopic 0F764ZZ Dilation of Left Hepatic Duct, Percutaneous Endoscopic 51.98 percutaneous biliary tract 0F784ZZ 0F794ZZ Dilation of Cystic Duct, Percutaneous Endoscopic Dilation of Common Bile Duct, Percutaneous Endoscopic 0FJB3ZZ Inspection of Hepatobiliary Duct, Percutaneous 0FJB4ZZ Inspection of Hepatobiliary Duct, Percutaneous Endoscopic 0F993ZZ Drainage of Common Bile Duct, Percutaneous 0F994ZZ Drainage of Common Bile Duct, Percutaneous Endoscopic 0FC53ZZ Extirpation of Matter from Right Hepatic Duct, Percutaneous 0FC54ZZ Extirpation of Matter from Right Hepatic Duct, Percutaneous Endoscopic 0FC63ZZ Extirpation of Matter from Left Hepatic Duct, Percutaneous 0FC64ZZ Extirpation of Matter from Left Hepatic Duct, Percutaneous Endoscopic 0FC83ZZ Extirpation of Matter from Cystic Duct, Percutaneous 0FC84ZZ Extirpation of Matter from Cystic Duct, Percutaneous Endoscopic See page 3 for important information about the uses and limitations of this document. CORP-224204-AB SEPT2015 5

Endoscopy 0B538ZZ Destruction of Right Main Bronchus, Via Natural or Artificial Opening Endoscopic 0B548ZZ Destruction of Right Upper Lobe Bronchus, Via Natural or Artificial Opening Endoscopic 32.27 Bronchoscopic bronchial thermoplasty, ablation of airway smooth muscle 0B568ZZ 0B578ZZ 0B588ZZ Destruction of Right Lower Lobe Bronchus, Via Natural or Artificial Opening Endoscopic Destruction of Left Main Bronchus, Via Natural or Artificial Opening Endoscopic Destruction of Left Upper Lobe Bronchus, Via Natural or Artificial Opening Endoscopic 0B598ZZ Destruction of Lingula Bronchus, Via Natural or Artificial Opening Endoscopic 0B5B8ZZ Destruction of Left Lower Lobe Bronchus, Via Natural or Artificial Opening Endoscopic 0B534ZZ Destruction of Right Main Bronchus, Percutaneous Endoscopic 0B538ZZ Destruction of Right Main Bronchus, Via Natural or Artificial Opening Endoscopic 0B544ZZ Destruction of Right Upper Lobe Bronchus, Percutaneous Endoscopic 0B548ZZ Destruction of Right Upper Lobe Bronchus, Via Natural or Artificial Opening Endoscopic 0B554ZZ Destruction of Right Middle Lobe Bronchus, Percutaneous Endoscopic 0B558ZZ Destruction of Right Middle Lobe Bronchus, Via Natural or Artificial Opening Endoscopic 0B564ZZ Destruction of Right Lower Lobe Bronchus, Percutaneous Endoscopic 0B568ZZ Destruction of Right Lower Lobe Bronchus, Via Natural or Artificial Opening Endoscopic 0B574ZZ Destruction of Left Main Bronchus, Percutaneous Endoscopic 0B578ZZ Destruction of Left Main Bronchus, Via Natural or Artificial Opening Endoscopic 0B584ZZ Destruction of Left Upper Lobe Bronchus, Percutaneous Endoscopic 0B588ZZ Destruction of Left Upper Lobe Bronchus, Via Natural or Artificial Opening Endoscopic 0B594ZZ Destruction of Lingula Bronchus, Percutaneous Endoscopic 0B598ZZ Destruction of Lingula Bronchus, Via Natural or Artificial Opening Endoscopic 32.01 Endoscopic excision or destruction of lesion or tissue of bronchus 0B5B4ZZ 0B5B8ZZ 0BB34ZZ 0BB38ZZ Destruction of Left Lower Lobe Bronchus, Percutaneous Endoscopic Destruction of Left Lower Lobe Bronchus, Via Natural or Artificial Opening Endoscopic Excision of Right Main Bronchus, Percutaneous Endoscopic Excision of Right Main Bronchus, Via Natural or Artificial Opening Endoscopic 0BB44ZZ Excision of Right Upper Lobe Bronchus, Percutaneous Endoscopic 0BB48ZZ Excision of Right Upper Lobe Bronchus, Via Natural or Artificial Opening Endoscopic 0BB54ZZ Excision of Right Middle Lobe Bronchus, Percutaneous Endoscopic 0BB58ZZ Excision of Right Middle Lobe Bronchus, Via Natural or Artificial Opening Endoscopic 0BB64ZZ Excision of Right Lower Lobe Bronchus, Percutaneous Endoscopic 0BB68ZZ Excision of Right Lower Lobe Bronchus, Via Natural or Artificial Opening Endoscopic 0BB74ZZ Excision of Left Main Bronchus, Percutaneous Endoscopic 0BB78ZZ Excision of Left Main Bronchus, Via Natural or Artificial Opening Endoscopic 0BB84ZZ Excision of Left Upper Lobe Bronchus, Percutaneous Endoscopic 0BB88ZZ Excision of Left Upper Lobe Bronchus, Via Natural or Artificial Opening Endoscopic 0BB94ZZ Excision of Lingula Bronchus, Percutaneous Endoscopic 0BB98ZZ Excision of Lingula Bronchus, Via Natural or Artificial Opening Endoscopic 0BBB4ZZ Excision of Left Lower Lobe Bronchus, Percutaneous Endoscopic 0BBB8ZZ Excision of Left Lower Lobe Bronchus, Via Natural or Artificial Opening Endoscopic See page 3 for important information about the uses and limitations of this document. CORP-224204-AB SEPT2015 6

Endoscopy 33.23 bronchoscopy 33.24 Closed [endoscopic] biopsy of bronchus 0BJ08ZZ 0BJK8ZZ 0BJL8ZZ 0B933ZX 0B934ZX 0B937ZX 0B938ZX 0B943ZX 0B944ZX 0B947ZX 0B948ZX 0B953ZX 0B954ZX 0B957ZX 0B958ZX 0B963ZX 0B964ZX 0B967ZX 0B968ZX 0B973ZX 0B974ZX 0B977ZX 0B978ZX 0B983ZX 0B984ZX 0B987ZX 0B988ZX 0B993ZX 0B994ZX 0B997ZX 0B998ZX 0B9B3ZX 0B9B4ZX 0B9B7ZX 0B9B8ZX 0BB33ZX 0BB34ZX 0BB37ZX 0BB38ZX 0BB43ZX 0BB44ZX 0BB47ZX 0BB48ZX 0BB53ZX Inspection of Tracheobronchial Tree, Via Natural or Artificial Opening Endoscopic Inspection of Right Lung, Via Natural or Artificial Opening Endoscopic Inspection of Left Lung, Via Natural or Artificial Opening Endoscopic Drainage of Right Main Bronchus, Percutaneous, Diagnostic Drainage of Right Main Bronchus, Percutaneous Endoscopic, Diagnostic Drainage of Right Main Bronchus, Via Natural or Artificial Opening, Diagnostic Drainage of Right Main Bronchus, Via Natural or Artificial Opening Endoscopic, Diagnostic Drainage of Right Upper Lobe Bronchus, Percutaneous, Diagnostic Drainage of Right Upper Lobe Bronchus, Percutaneous Endoscopic, Diagnostic Drainage of Right Upper Lobe Bronchus, Via Natural or Artificial Opening, Diagnostic Drainage of Right Upper Lobe Bronchus, Via Natural or Artificial Opening Endoscopic, Diagnostic Drainage of Right Middle Lobe Bronchus, Percutaneous, Diagnostic Drainage of Right Middle Lobe Bronchus, Percutaneous Endoscopic, Diagnostic Drainage of Right Middle Lobe Bronchus, Via Natural or Artificial Opening, Diagnostic Drainage of Right Middle Lobe Bronchus, Via Natural or Artificial Opening Endoscopic, Diagnostic Drainage of Right Lower Lobe Bronchus, Percutaneous, Diagnostic Drainage of Right Lower Lobe Bronchus, Percutaneous Endoscopic, Diagnostic Drainage of Right Lower Lobe Bronchus, Via Natural or Artificial Opening, Diagnostic Drainage of Right Lower Lobe Bronchus, Via Natural or Artificial Opening Endoscopic, Diagnostic Drainage of Left Main Bronchus, Percutaneous, Diagnostic Drainage of Left Main Bronchus, Percutaneous Endoscopic, Diagnostic Drainage of Left Main Bronchus, Via Natural or Artificial Opening, Diagnostic Drainage of Left Main Bronchus, Via Natural or Artificial Opening Endoscopic, Diagnostic Drainage of Left Upper Lobe Bronchus, Percutaneous, Diagnostic Drainage of Left Upper Lobe Bronchus, Percutaneous Endoscopic, Diagnostic Drainage of Left Upper Lobe Bronchus, Via Natural or Artificial Opening, Diagnostic Drainage of Left Upper Lobe Bronchus, Via Natural or Artificial Opening Endoscopic, Diagnostic Drainage of Lingula Bronchus, Percutaneous, Diagnostic Drainage of Lingula Bronchus, Percutaneous Endoscopic, Diagnostic Drainage of Lingula Bronchus, Via Natural or Artificial Opening, Diagnostic Drainage of Lingula Bronchus, Via Natural or Artificial Opening Endoscopic, Diagnostic Drainage of Left Lower Lobe Bronchus, Percutaneous, Diagnostic Drainage of Left Lower Lobe Bronchus, Percutaneous Endoscopic, Diagnostic Drainage of Left Lower Lobe Bronchus, Via Natural or Artificial Opening, Diagnostic Drainage of Left Lower Lobe Bronchus, Via Natural or Artificial Opening Endoscopic, Diagnostic Excision of Right Main Bronchus, Percutaneous, Diagnostic Excision of Right Main Bronchus, Percutaneous Endoscopic, Diagnostic Excision of Right Main Bronchus, Via Natural or Artificial Opening, Diagnostic Excision of Right Main Bronchus, Via Natural or Artificial Opening Endoscopic, Diagnostic Excision of Right Upper Lobe Bronchus, Percutaneous, Diagnostic Excision of Right Upper Lobe Bronchus, Percutaneous Endoscopic, Diagnostic Excision of Right Upper Lobe Bronchus, Via Natural or Artificial Opening, Diagnostic Excision of Right Upper Lobe Bronchus, Via Natural or Artificial Opening Endoscopic, Diagnostic Excision of Right Middle Lobe Bronchus, Percutaneous, Diagnostic See page 3 for important information about the uses and limitations of this document. CORP-224204-AB SEPT2015 7

Endoscopy 0BB54ZX Excision of Right Middle Lobe Bronchus, Percutaneous Endoscopic, Diagnostic 0BB57ZX Excision of Right Middle Lobe Bronchus, Via Natural or Artificial Opening, Diagnostic 0BB58ZX Excision of Right Middle Lobe Bronchus, Via Natural or Artificial Opening Endoscopic, Diagnostic 0BB63ZX Excision of Right Lower Lobe Bronchus, Percutaneous, Diagnostic 0BB64ZX Excision of Right Lower Lobe Bronchus, Percutaneous Endoscopic, Diagnostic 0BB67ZX Excision of Right Lower Lobe Bronchus, Via Natural or Artificial Opening, Diagnostic 0BB68ZX Excision of Right Lower Lobe Bronchus, Via Natural or Artificial Opening Endoscopic, Diagnostic 0BB73ZX Excision of Left Main Bronchus, Percutaneous, Diagnostic 0BB74ZX Excision of Left Main Bronchus, Percutaneous Endoscopic, Diagnostic 0BB77ZX Excision of Left Main Bronchus, Via Natural or Artificial Opening, Diagnostic 33.24 Closed [endoscopic] biopsy of bronchus (Continued) 0BB78ZX 0BB83ZX 0BB84ZX Excision of Left Main Bronchus, Via Natural or Artificial Opening Endoscopic, Diagnostic Excision of Left Upper Lobe Bronchus, Percutaneous, Diagnostic Excision of Left Upper Lobe Bronchus, Percutaneous Endoscopic, Diagnostic 0BB87ZX Excision of Left Upper Lobe Bronchus, Via Natural or Artificial Opening, Diagnostic 0BB88ZX Excision of Left Upper Lobe Bronchus, Via Natural or Artificial Opening Endoscopic, Diagnostic 0BB93ZX Excision of Lingula Bronchus, Percutaneous, Diagnostic 0BB94ZX Excision of Lingula Bronchus, Percutaneous Endoscopic, Diagnostic 0BB97ZX Excision of Lingula Bronchus, Via Natural or Artificial Opening, Diagnostic 0BB98ZX Excision of Lingula Bronchus, Via Natural or Artificial Opening Endoscopic, Diagnostic 0BBB3ZX Excision of Left Lower Lobe Bronchus, Percutaneous, Diagnostic 0BBB4ZX Excision of Left Lower Lobe Bronchus, Percutaneous Endoscopic, Diagnostic 0BBB7ZX Excision of Left Lower Lobe Bronchus, Via Natural or Artificial Opening, Diagnostic 0BBB8ZX Excision of Left Lower Lobe Bronchus, Via Natural or Artificial Opening Endoscopic, Diagnostic 0B9K8ZX Drainage of Right Lung, Via Natural or Artificial Opening Endoscopic, Diagnostic 0B9L8ZX Drainage of Left Lung, Via Natural or Artificial Opening Endoscopic, Diagnostic 0B9M8ZX Drainage of Bilateral Lungs, Via Natural or Artificial Opening Endoscopic, Diagnostic 0BBK7ZX Excision of Right Lung, Via Natural or Artificial Opening, Diagnostic 33.27 Closed endoscopic biopsy of lung 0BBK8ZX 0BBL7ZX Excision of Right Lung, Via Natural or Artificial Opening Endoscopic, Diagnostic Excision of Left Lung, Via Natural or Artificial Opening, Diagnostic 0BBL8ZX Excision of Left Lung, Via Natural or Artificial Opening Endoscopic, Diagnostic 0BBM4ZX Excision of Bilateral Lungs, Percutaneous Endoscopic, Diagnostic 0BBM7ZX Excision of Bilateral Lungs, Via Natural or Artificial Opening, Diagnostic 0BBM8ZX Excision of Bilateral Lungs, Via Natural or Artificial Opening Endoscopic, Diagnostic 0C7S0DZ Dilation of Larynx with Intraluminal Device, Open 0C7S3DZ Dilation of Larynx with Intraluminal Device, Percutaneous 0C7S4DZ Dilation of Larynx with Intraluminal Device, Percutaneous Endoscopic 31.93 Replacement of laryngeal or tracheal stent 0C7S7DZ 0C7S8DZ 0CPS0DZ Dilation of Larynx with Intraluminal Device, Via Natural or Artificial Opening Dilation of Larynx with Intraluminal Device, Via Natural or Artificial Opening Endoscopic Removal of Intraluminal Device from Larynx, Open 0CPS3DZ Removal of Intraluminal Device from Larynx, Percutaneous 0CPS7DZ Removal of Intraluminal Device from Larynx, Via Natural or Artificial Opening 0CPS8DZ Removal of Intraluminal Device from Larynx, Via Natural or Artificial Opening Endoscopic See page 3 for important information about the uses and limitations of this document. CORP-224204-AB SEPT2015 8

Endoscopy 31.99 operations on trachea 98.15 42.81 Removal of intraluminal foreign body from trachea and bronchus without incision Insertion of permanent tube into esophagus 0B710DZ 0B710ZZ 0B713DZ 0B713ZZ 0B714DZ 0B714ZZ 0B717DZ 0B717ZZ 0B718DZ 0B718ZZ 0B720DZ 0B720ZZ 0B723DZ 0B723ZZ 0B724DZ 0B724ZZ 0B727DZ 0B727ZZ 0B728DZ 0B728ZZ 0BC17ZZ 0BC18ZZ 0BC37ZZ 0BC38ZZ 0BC77ZZ 0BC78ZZ 0DH50DZ 0DH50UZ 0DH53DZ 0DH53UZ 0DH54DZ 0DH54UZ 0DH57DZ 0DH57UZ 0DH58DZ 0DH58UZ Dilation of Trachea with Intraluminal Device, Open Dilation of Trachea, Open Dilation of Trachea with Intraluminal Device, Percutaneous Dilation of Trachea, Percutaneous Dilation of Trachea with Intraluminal Device, Percutaneous Endoscopic Dilation of Trachea, Percutaneous Endoscopic Dilation of Trachea with Intraluminal Device, Via Natural or Artificial Opening Dilation of Trachea, Via Natural or Artificial Opening Dilation of Trachea with Intraluminal Device, Via Natural or Artificial Opening Endoscopic Dilation of Trachea, Via Natural or Artificial Opening Endoscopic Dilation of Carina with Intraluminal Device, Open Dilation of Carina, Open Dilation of Carina with Intraluminal Device, Percutaneous Dilation of Carina, Percutaneous Dilation of Carina with Intraluminal Device, Percutaneous Endoscopic Dilation of Carina, Percutaneous Endoscopic Dilation of Carina with Intraluminal Device, Via Natural or Artificial Opening Dilation of Carina, Via Natural or Artificial Opening Dilation of Carina with Intraluminal Device, Via Natural or Artificial Opening Endoscopic Dilation of Carina, Via Natural or Artificial Opening Endoscopic Extirpation of Matter from Trachea, Via Natural or Artificial Opening Extirpation of Matter from Trachea, Via Natural or Artificial Opening Endoscopic Extirpation of Matter from Right Main Bronchus, Via Natural or Artificial Opening Extirpation of Matter from Right Main Bronchus, Via Natural or Artificial Opening Endoscopic Extirpation of Matter from Left Main Bronchus, Via Natural or Artificial Opening Extirpation of Matter from Left Main Bronchus, Via Natural or Artificial Opening Endoscopic Insertion of Intraluminal Device into Esophagus, Open Insertion of Feeding Device into Esophagus, Open Insertion of Intraluminal Device into Esophagus, Percutaneous Insertion of Feeding Device into Esophagus, Percutaneous Insertion of Intraluminal Device into Esophagus, Percutaneous Endoscopic Insertion of Feeding Device into Esophagus, Percutaneous Endoscopic Insertion of Intraluminal Device into Esophagus, Via Natural or Artificial Opening Insertion of Feeding Device into Esophagus, Via Natural or Artificial Opening Insertion of Intraluminal Device into Esophagus, Via Natural or Artificial Opening Endoscopic Insertion of Feeding Device into Esophagus, Via Natural or Artificial Opening Endoscopic See page 3 for important information about the uses and limitations of this document. CORP-224204-AB SEPT2015 9

Endoscopy 46.86 51.87 97.05 Endoscopic insertion of colonic stent(s) Endoscopic insertion of stent (tube) into bile duct Replacement of stent (tube) in biliary or pancreatic duct 52.99 pancreatic procedures 0D788DZ 0D798DZ 0D7A8DZ 0D7B8DZ 0D7E8DZ 0DH88DZ 0DH98DZ 0DHA8DZ 0DHB8DZ 0DHE8DZ 0DHP8DZ 0D7K8DZ 0D7L8DZ 0D7M8DZ 0D7N8DZ 0F758DZ 0F768DZ 0F788DZ 0F798DZ 0FHB4DZ 0FHB8DZ 0F757DZ 0F758DZ 0F767DZ 0F768DZ 0F787DZ 0F788DZ 0F797DZ 0F798DZ 0F7D7DZ 0F7D8DZ 0FHB7DZ 0FHB8DZ 0FPB7DZ 0FPB8DZ 0FPBXDZ 0FPD7DZ 0FPD8DZ 0FPDXDZ OF9G4ZZ OF9G40Z Dilation of Small Intestine with Intraluminal Device, Via Natural or Artificial Opening Endoscopic Dilation of Duodenum with Intraluminal Device, Via Natural or Artificial Opening Endoscopic Dilation of Jejunum with Intraluminal Device, Via Natural or Artificial Opening Endoscopic Dilation of Ileum with Intraluminal Device, Via Natural or Artificial Opening Endoscopic Dilation of Large Intestine with Intraluminal Device, Via Natural or Artificial Opening Endoscopic Insertion of Intraluminal Device into Small Intestine, Via Natural or Artificial Opening Endoscopic Insertion of Intraluminal Device into Duodenum, Via Natural or Artificial Opening Endoscopic Insertion of Intraluminal Device into Jejunum, Via Natural or Artificial Opening Endoscopic Insertion of Intraluminal Device into Ileum, Via Natural or Artificial Opening Endoscopic Insertion of Intraluminal Device into Large Intestine, Via Natural or Artificial Opening Endoscopic Insertion of Intraluminal Device into Rectum, Via Natural or Artificial Opening Endoscopic Dilation of Ascending Colon with Intraluminal Device, Via Natural or Artificial Opening Endoscopic Dilation of Transverse Colon with Intraluminal Device, Via Natural or Artificial Opening Endoscopic Dilation of Descending Colon with Intraluminal Device, Via Natural or Artificial Opening Endoscopic Dilation of Sigmoid Colon with Intraluminal Device, Via Natural or Artificial Opening Endoscopic Dilation of Right Hepatic Duct with Intraluminal Device, Via Natural or Artificial Opening Endoscopic Dilation of Left Hepatic Duct with Intraluminal Device, Via Natural or Artificial Opening Endoscopic Dilation of Cystic Duct with Intraluminal Device, Via Natural or Artificial Opening Endoscopic Dilation of Common Bile Duct with Intraluminal Device, Via Natural or Artificial Opening Endoscopic Insertion of Intraluminal Device into Hepatobiliary Duct, Percutaneous Endoscopic Insertion of Intraluminal Device into Hepatobiliary Duct, Via Natural or Artificial Opening Endoscopic Dilation of Right Hepatic Duct with Intraluminal Device, Via Natural or Artificial Opening Dilation of Right Hepatic Duct with Intraluminal Device, Via Natural or Artificial Opening Endoscopic Dilation of Left Hepatic Duct with Intraluminal Device, Via Natural or Artificial Opening Dilation of Left Hepatic Duct with Intraluminal Device, Via Natural or Artificial Opening Endoscopic Dilation of Cystic Duct with Intraluminal Device, Via Natural or Artificial Opening Dilation of Cystic Duct with Intraluminal Device, Via Natural or Artificial Opening Endoscopic Dilation of Common Bile Duct with Intraluminal Device, Via Natural or Artificial Opening Dilation of Common Bile Duct with Intraluminal Device, Via Natural or Artificial Opening Endoscopic Dilation of Pancreatic Duct with Intraluminal Device, Via Natural or Artificial Opening Dilation of Pancreatic Duct with Intraluminal Device, Via Natural or Artificial Opening Endoscopic Insertion of Intraluminal Device into Hepatobiliary Duct, Via Natural or Artificial Opening Insertion of Intraluminal Device into Hepatobiliary Duct, Via Natural or Artificial Opening Endoscopic Removal of Intraluminal Device from Hepatobiliary Duct, Via Natural or Artificial Opening Removal of Intraluminal Device from Hepatobiliary Duct, Via Natural or Artificial Opening Endoscopic Removal of Intraluminal Device from Hepatobiliary Duct, External Removal of Intraluminal Device from Pancreatic Duct, Via Natural or Artificial Opening Removal of Intraluminal Device from Pancreatic Duct, Via Natural or Artificial Opening Endoscopic Removal of Intraluminal Device from Pancreatic Duct, External Drainage of Pancreas, Percutaneous Endoscopic Drainage of Pancreas with Drainage Device, Percutaneous Endoscopic See page 3 for important information about the uses and limitations of this document. CORP-224204-AB SEPT2015 10

Interventional Cardiology 37.21 37.22 37.23 17.55 36.06 36.07 35.05 35.06 35.07 35.08 Right heart cardiac catheterization Left heart cardiac catheterization Combined right and left heart cardiac catheterization Transluminal coronary atherectomy Insertion of non-drug-eluting coronary artery stent(s) Insertion of drugeluting coronary artery stent(s) Endovascular replacement of aortic valve Transapical replacement of aortic valve Endovascular replacement of pulmonary valve Transapical replacement of pulmonary valve 4A023N6 4A023N7 4A023N8 02C03ZZ 02C13ZZ 02C23ZZ 02C33ZZ 02703DZ 02703D6 02713D6 02713DZ 02723D6 02723DZ 02733D6 02733DZ 027034Z Measurement of Cardiac Sampling and Pressure, Right Heart, Percutaneous Measurement of Cardiac Sampling and Pressure, Left Heart, Percutaneous Measurement of Cardiac Sampling and Pressure, Bilateral, Percutaneous Extirpation of Matter from Coronary Artery, One Site, Percutaneous Extirpation of Matter from Coronary Artery, Two Sites, Percutaneous Extirpation of Matter from Coronary Artery, Three Sites, Percutaneous Extirpation of Matter from Coronary Artery, Four or More Sites, Percutaneous Dilation of Coronary Artery, One Site with Intraluminal Device, Percutaneous Dilation of Coronary Artery, One Site, Bifurcation, with Intraluminal Device, Percutaneous Dilation of Coronary Artery, Two Sites, Bifurcation, with Intraluminal Device, Percutaneous Dilation of Coronary Artery, Two Sites with Intraluminal Device, Percutaneous Dilation of Coronary Artery, Three Sites, Bifurcation, with Intraluminal Device, Percutaneous Dilation of Coronary Artery, Three Sites with Intraluminal Device, Percutaneous Dilation of Coronary Artery, Four or More Sites, Bifurcation, with Intraluminal Device, Percutaneous Dilation of Coronary Artery, Four or More Sites with Intraluminal Device, Percutaneous Dilation of Coronary Artery, One Site with Drug-eluting Intraluminal Device, Percutaneous 0270346 Dilation of Coronary Artery, One Site, Bifurcation, with Drug-eluting Intraluminal Device, Percutaneous 027034Z Dilation of Coronary Artery, One Site with Drug-eluting Intraluminal Device, Percutaneous 0271346 Dilation of Coronary Artery, Two Sites, Bifurcation, with Drug-eluting Intraluminal Device, Percutaneous 027134Z 0272346 027234Z 0273346 027334Z 02RF37Z 02RF38Z 02RF3JZ 02RF3KZ 02RF37H 02RF38H 02RF3JH 02RF3KH 02RH37Z 02RH38Z 02RH3JZ 02RH3KZ 02RH37H 02RH38H 02RH3JH 02RH3KH Dilation of Coronary Artery, Two Sites with Drug-eluting Intraluminal Device, Percutaneous Dilation of Coronary Artery, Three Sites, Bifurcation, with Drug-eluting Intraluminal Device, Percutaneous Dilation of Coronary Artery, Three Sites with Drug-eluting Intraluminal Device, Percutaneous Dilation of Coronary Artery, Four or More Sites, Bifurcation, with Drug-eluting Intraluminal Device, Percutaneous Dilation of Coronary Artery, Four or More Sites with Drug-eluting Intraluminal Device, Percutaneous Replacement of Aortic Valve with Autologous Tissue Substitute, Percutaneous Replacement of Aortic Valve with Zooplastic Tissue, Percutaneous Replacement of Aortic Valve with Synthetic Substitute, Percutaneous Replacement of Aortic Valve with Nonautologous Tissue Substitute, Percutaneous Replacement of Aortic Valve with Autologous Tissue Substitute, Transapical, Percutaneous Replacement of Aortic Valve with Zooplastic Tissue, Transapical, Percutaneous Replacement of Aortic Valve with Synthetic Substitute, Transapical, Percutaneous Replacement of Aortic Valve with Nonautologous Tissue Substitute, Transapical, Percutaneous Replacement of Pulmonary Valve with Autologous Tissue Substitute, Percutaneous Replacement of Pulmonary Valve with Zooplastic Tissue, Percutaneous Replacement of Pulmonary Valve with Synthetic Substitute, Percutaneous Replacement of Pulmonary Valve with Nonautologous Tissue Substitute, Percutaneous Replacement of Pulmonary Valve with Autologous Tissue Substitute, Transapical, Percutaneous Replacement of Pulmonary Valve with Zooplastic Tissue, Transapical, Percutaneous Replacement of Pulmonary Valve with Synthetic Substitute, Transapical, Percutaneous Replacement of Pulmonary Valve with Nonautologous Tissue Substitute, Transapical, Percutaneous See page 3 for important information about the uses and limitations of this document. CORP-224204-AB SEPT2015 11

Interventional Cardiology 027F3ZZ Dilation of Aortic Valve, Percutaneous 027F4ZZ Dilation of Aortic Valve, Percutaneous Endoscopic 35.96 Percutaneous balloon valvuloplasty 027G3ZZ 027G4ZZ 027H3ZZ 027H4ZZ Dilation of Mitral Valve, Percutaneous Dilation of Mitral Valve, Percutaneous Endoscopic Dilation of Pulmonary Valve, Percutaneous Dilation of Pulmonary Valve, Percutaneous Endoscopic 027J3ZZ Dilation of Tricuspid Valve, Percutaneous 35.97 00.59 Percutaneous mitral valve repair with implant Intravascular pressure measurement of coronary arteries 027J4ZZ 02UG3JZ 4A033BC 02703ZZ Dilation of Tricuspid Valve, Percutaneous Endoscopic Supplement Mitral Valve with Synthetic Substitute, Percutaneous Measurement of Arterial Pressure, Coronary, Percutaneous Dilation of Coronary Artery, One Site, Percutaneous 02704ZZ Dilation of Coronary Artery, One Site, Percutaneous Endoscopic 02713ZZ Dilation of Coronary Artery, Two Sites, Percutaneous 02714ZZ Dilation of Coronary Artery, Two Sites, Percutaneous Endoscopic 00.66 Percutaneous transluminal coronary angioplasty [PTCA] 02723ZZ 02724ZZ 02733ZZ 02734ZZ Dilation of Coronary Artery, Three Sites, Percutaneous Dilation of Coronary Artery, Three Sites, Percutaneous Endoscopic Dilation of Coronary Artery, Four or More Sites, Percutaneous Dilation of Coronary Artery, Four or More Sites, Percutaneous Endoscopic 02703Z6 Dilation of Coronary Artery, One Site, Bifurcation, Percutaneous 02713Z6 Dilation of Coronary Artery, Two Sites, Bifurcation, Percutaneous 02723Z6 Dilation of Coronary Artery, Three Sites, Bifurcation, Percutaneous 02733Z6 Dilation of Coronary Artery, Four or More Sites, Bifurcation, Percutaneous 39.61 Extracorporeal circulation auxiliary to open heart surgery 5A1221Z Performance of Cardiac Output, Continuous B240ZZ3 Ultrasonography of Single Coronary Artery, Intravascular B241ZZ3 Ultrasonography of Multiple Coronary Arteries, Intravascular 00.24 Intravascular imaging of coronary vessels B244ZZ3 B245ZZ3 B246ZZ3 Ultrasonography of Right Heart, Intravascular Ultrasonography of Left Heart, Intravascular Ultrasonography of Right and Left Heart, Intravascular B24DZZ3 Ultrasonography of Pediatric Heart, Intravascular B244ZZ3 Ultrasonography of Right Heart, Intravascular See page 3 for important information about the uses and limitations of this document. CORP-224204-AB SEPT2015 12

Interventional Cardiology B2000ZZ Plain Radiography of Single Coronary Artery using High Osmolar Contrast B2001ZZ Plain Radiography of Single Coronary Artery using Low Osmolar Contrast B200YZZ Plain Radiography of Single Coronary Artery using Contrast B2010ZZ Plain Radiography of Multiple Coronary Arteries using High Osmolar Contrast B2011ZZ Plain Radiography of Multiple Coronary Arteries using Low Osmolar Contrast B201YZZ Plain Radiography of Multiple Coronary Arteries using Contrast B2020ZZ Plain Radiography of Single Coronary Artery Bypass Graft using High Osmolar Contrast B2021ZZ Plain Radiography of Single Coronary Artery Bypass Graft using Low Osmolar Contrast B202YZZ Plain Radiography of Single Coronary Artery Bypass Graft using Contrast B2030ZZ Plain Radiography of Multiple Coronary Artery Bypass Grafts using High Osmolar Contrast B2031ZZ Plain Radiography of Multiple Coronary Artery Bypass Grafts using Low Osmolar Contrast B203YZZ Plain Radiography of Multiple Coronary Artery Bypass Grafts using Contrast B2070ZZ Plain Radiography of Right Internal Mammary Bypass Graft using High Osmolar Contrast B2071ZZ Plain Radiography of Right Internal Mammary Bypass Graft using Low Osmolar Contrast B207YZZ Plain Radiography of Right Internal Mammary Bypass Graft using Contrast B2080ZZ Plain Radiography of Left Internal Mammary Bypass Graft using High Osmolar Contrast B2081ZZ Plain Radiography of Left Internal Mammary Bypass Graft using Low Osmolar Contrast B208YZZ Plain Radiography of Left Internal Mammary Bypass Graft using Contrast B20F0ZZ Plain Radiography of Bypass Graft using High Osmolar Contrast 88.50 Angio, not otherwise specified B20F1ZZ B20FYZZ B2100ZZ B2101ZZ Plain Radiography of Bypass Graft using Low Osmolar Contrast Plain Radiography of Bypass Graft using Contrast Fluoroscopy of Single Coronary Artery using High Osmolar Contrast Fluoroscopy of Single Coronary Artery using Low Osmolar Contrast B210YZZ Fluoroscopy of Single Coronary Artery using Contrast B2110ZZ Fluoroscopy of Multiple Coronary Arteries using High Osmolar Contrast B2111ZZ Fluoroscopy of Multiple Coronary Arteries using Low Osmolar Contrast B211YZZ Fluoroscopy of Multiple Coronary Arteries using Contrast B2120ZZ Fluoroscopy of Single Coronary Artery Bypass Graft using High Osmolar Contrast B2121ZZ Fluoroscopy of Single Coronary Artery Bypass Graft using Low Osmolar Contrast B212YZZ Fluoroscopy of Single Coronary Artery Bypass Graft using Contrast B2130ZZ Fluoroscopy of Multiple Coronary Artery Bypass Grafts using High Osmolar Contrast B2131ZZ Fluoroscopy of Multiple Coronary Artery Bypass Grafts using Low Osmolar Contrast B213YZZ Fluoroscopy of Multiple Coronary Artery Bypass Grafts using Contrast B2170ZZ Fluoroscopy of Right Internal Mammary Bypass Graft using High Osmolar Contrast B2171ZZ Fluoroscopy of Right Internal Mammary Bypass Graft using Low Osmolar Contrast B217YZZ Fluoroscopy of Right Internal Mammary Bypass Graft using Contrast B2180ZZ Fluoroscopy of Left Internal Mammary Bypass Graft using High Osmolar Contrast B2181ZZ Fluoroscopy of Left Internal Mammary Bypass Graft using Low Osmolar Contrast B218YZZ Fluoroscopy of Left Internal Mammary Bypass Graft using Contrast B21F0ZZ Fluoroscopy of Bypass Graft using High Osmolar Contrast B21F1ZZ Fluoroscopy of Bypass Graft using Low Osmolar Contrast B21FYZZ Fluoroscopy of Bypass Graft using Contrast B2050ZZ Plain Radiography of Left Heart using High Osmolar Contrast B2051ZZ Plain Radiography of Left Heart using Low Osmolar Contrast 88.53 Angio of left heart structures B205YZZ B2150ZZ Plain Radiography of Left Heart using Contrast Fluoroscopy of Left Heart using High Osmolar Contrast B2151ZZ Fluoroscopy of Left Heart using Low Osmolar Contrast B215YZZ Fluoroscopy of Left Heart using Contrast See page 3 for important information about the uses and limitations of this document. CORP-224204-AB SEPT2015 13

Neuromodulation 03.93 86.98 Implantation or Replacement of Spinal Neurostimulator Lead(s) Insertion or Replacement of Multiple Array (two or more) Rechargeable Neurostimulator Pulse Generator Insertion/Spinal Canal 00HU0MZ 00HU3MZ 00HU4MZ Insertion of Neurostimulator Lead into Spinal Canal, Open Insertion of Neurostimulator Lead into Spinal Canal, Percutaneous Insertion of Neurostimulator Lead into Spinal Canal, Percutaneous Endoscopic Insertion/Subcutaneous Tissue and Fascia, Back 0JH70EZ 0JH73EZ Insertion of Multiple Array Rechargeable Stimulator Generator into Back Subcutaneous Tissue and Fascia, Open Insertion of Multiple Array Rechargeable Stimulator Generator into Back Subcutaneous Tissue and Fascia, Percutaneous See page 3 for important information about the uses and limitations of this document. CORP-224204-AB SEPT2015 14

02LS3DZ Occlusion of Right Pulmonary Vein with Intraluminal Device, Percutaneous 02LS3ZZ Occlusion of Right Pulmonary Vein, Percutaneous 02LT3DZ Occlusion of Left Pulmonary Vein with Intraluminal Device, Percutaneous 02LT3ZZ Occlusion of Left Pulmonary Vein, Percutaneous 02VP3DZ Restriction of Pulmonary Trunk with Intraluminal Device, Percutaneous 02VP3ZZ Restriction of Pulmonary Trunk, Percutaneous 02VQ3DZ Restriction of Right Pulmonary Artery with Intraluminal Device, Percutaneous 02VQ3ZZ Restriction of Right Pulmonary Artery, Percutaneous 02VR3DT Restriction of Ductus Arteriosus with Intraluminal Device, Percutaneous 02VR3DZ Restriction of Left Pulmonary Artery with Intraluminal Device, Percutaneous 02VR3ZT Restriction of Ductus Arteriosus, Percutaneous 02VR3ZZ Restriction of Left Pulmonary Artery, Percutaneous 02VS3DZ Restriction of Right Pulmonary Vein with Intraluminal Device, Percutaneous 02VS3ZZ Restriction of Right Pulmonary Vein, Percutaneous 02VT3DZ Restriction of Left Pulmonary Vein with Intraluminal Device, Percutaneous 02VT3ZZ Restriction of Left Pulmonary Vein, Percutaneous 02VW3DZ Restriction of Thoracic Aorta with Intraluminal Device, Percutaneous 02VW3ZZ Restriction of Thoracic Aorta, Percutaneous 03L03ZZ Occlusion of Right Internal Mammary Artery, Percutaneous 03L13ZZ Occlusion of Left Internal Mammary Artery, Percutaneous 03L23ZZ 03L33ZZ 03L43ZZ 03L50DZ Occlusion of Innominate Artery, Percutaneous Occlusion of Right Subclavian Artery, Percutaneous Occlusion of Left Subclavian Artery, Percutaneous Occlusion of Right Axillary Artery with Intraluminal Device, Open 03L53DZ Occlusion of Right Axillary Artery with Intraluminal Device, Percutaneous 03L53ZZ Occlusion of Right Axillary Artery, Percutaneous 03L54DZ Occlusion of Right Axillary Artery with Intraluminal Device, Percutaneous Endoscopic 03L60DZ Occlusion of Left Axillary Artery with Intraluminal Device, Open 03L63DZ Occlusion of Left Axillary Artery with Intraluminal Device, Percutaneous 03L63ZZ Occlusion of Left Axillary Artery, Percutaneous 03L64DZ Occlusion of Left Axillary Artery with Intraluminal Device, Percutaneous Endoscopic 03L70DZ Occlusion of Right Brachial Artery with Intraluminal Device, Open 03L73DZ Occlusion of Right Brachial Artery with Intraluminal Device, Percutaneous 03L73ZZ Occlusion of Right Brachial Artery, Percutaneous 03L74DZ Occlusion of Right Brachial Artery with Intraluminal Device, Percutaneous Endoscopic 03L80DZ Occlusion of Left Brachial Artery with Intraluminal Device, Open 03L83DZ Occlusion of Left Brachial Artery with Intraluminal Device, Percutaneous 03L83ZZ Occlusion of Left Brachial Artery, Percutaneous 03L84DZ Occlusion of Left Brachial Artery with Intraluminal Device, Percutaneous Endoscopic 03L90DZ Occlusion of Right Ulnar Artery with Intraluminal Device, Open 03L93DZ Occlusion of Right Ulnar Artery with Intraluminal Device, Percutaneous 03L93ZZ Occlusion of Right Ulnar Artery, Percutaneous 03L94DZ Occlusion of Right Ulnar Artery with Intraluminal Device, Percutaneous Endoscopic 03LA0DZ Occlusion of Left Ulnar Artery with Intraluminal Device, Open See page 3 for important information about the uses and limitations of this document. CORP-224204-AB SEPT2015 15

03LA3DZ Occlusion of Left Ulnar Artery with Intraluminal Device, Percutaneous 03LA3ZZ Occlusion of Left Ulnar Artery, Percutaneous 03LA4DZ Occlusion of Left Ulnar Artery with Intraluminal Device, Percutaneous Endoscopic 03LB0DZ Occlusion of Right Radial Artery with Intraluminal Device, Open 03LB3DZ Occlusion of Right Radial Artery with Intraluminal Device, Percutaneous 03LB3ZZ Occlusion of Right Radial Artery, Percutaneous 03LB4DZ Occlusion of Right Radial Artery with Intraluminal Device, Percutaneous Endoscopic 03LC0DZ Occlusion of Left Radial Artery with Intraluminal Device, Open 03LC3DZ Occlusion of Left Radial Artery with Intraluminal Device, Percutaneous 03LC3ZZ Occlusion of Left Radial Artery, Percutaneous 03LC4DZ Occlusion of Left Radial Artery with Intraluminal Device, Percutaneous Endoscopic 03LD0DZ Occlusion of Right Hand Artery with Intraluminal Device, Open 03LD3DZ Occlusion of Right Hand Artery with Intraluminal Device, Percutaneous 03LD3ZZ Occlusion of Right Hand Artery, Percutaneous 03LD4DZ Occlusion of Right Hand Artery with Intraluminal Device, Percutaneous Endoscopic 03LF0DZ Occlusion of Left Hand Artery with Intraluminal Device, Open 03LF3DZ Occlusion of Left Hand Artery with Intraluminal Device, Percutaneous 03LF3ZZ Occlusion of Left Hand Artery, Percutaneous 03LF4DZ Occlusion of Left Hand Artery with Intraluminal Device, Percutaneous Endoscopic 03LG3ZZ Occlusion of Intracranial Artery, Percutaneous 03LH3ZZ 03LJ3ZZ 03LK3ZZ 03LL3ZZ Occlusion of Right Common Carotid Artery, Percutaneous Occlusion of Left Common Carotid Artery, Percutaneous Occlusion of Right Internal Carotid Artery, Percutaneous Occlusion of Left Internal Carotid Artery, Percutaneous 03LM3ZZ Occlusion of Right External Carotid Artery, Percutaneous 03LN3ZZ Occlusion of Left External Carotid Artery, Percutaneous 03LP3ZZ Occlusion of Right Vertebral Artery, Percutaneous 03LQ3ZZ Occlusion of Left Vertebral Artery, Percutaneous 03LR3ZZ Occlusion of Face Artery, Percutaneous 03LS3ZZ Occlusion of Right Temporal Artery, Percutaneous 03LT3ZZ Occlusion of Left Temporal Artery, Percutaneous 03LU3ZZ Occlusion of Right Thyroid Artery, Percutaneous 03LV3ZZ Occlusion of Left Thyroid Artery, Percutaneous 03LY0DZ Occlusion of Upper Artery with Intraluminal Device, Open 03LY3DZ Occlusion of Upper Artery with Intraluminal Device, Percutaneous 03LY3ZZ Occlusion of Upper Artery, Percutaneous 03LY4DZ Occlusion of Upper Artery with Intraluminal Device, Percutaneous Endoscopic 03V00DZ Restriction of Right Internal Mammary Artery with Intraluminal Device, Open 03V03DZ Restriction of Right Internal Mammary Artery with Intraluminal Device, Percutaneous 03V03ZZ Restriction of Right Internal Mammary Artery, Percutaneous 03V04DZ Restriction of Right Internal Mammary Artery with Intraluminal Device, Percutaneous Endoscopic 03V10DZ Restriction of Left Internal Mammary Artery with Intraluminal Device, Open 03V13DZ Restriction of Left Internal Mammary Artery with Intraluminal Device, Percutaneous 03V13ZZ Restriction of Left Internal Mammary Artery, Percutaneous See page 3 for important information about the uses and limitations of this document. CORP-224204-AB SEPT2015 16

03V14DZ Restriction of Left Internal Mammary Artery with Intraluminal Device, Percutaneous Endoscopic 03V20DZ Restriction of Innominate Artery with Intraluminal Device, Open 03V23DZ Restriction of Innominate Artery with Intraluminal Device, Percutaneous 03V23ZZ Restriction of Innominate Artery, Percutaneous 03V24DZ Restriction of Innominate Artery with Intraluminal Device, Percutaneous Endoscopic 03V30DZ Restriction of Right Subclavian Artery with Intraluminal Device, Open 03V33DZ Restriction of Right Subclavian Artery with Intraluminal Device, Percutaneous 03V33ZZ Restriction of Right Subclavian Artery, Percutaneous 03V34DZ Restriction of Right Subclavian Artery with Intraluminal Device, Percutaneous Endoscopic 03V40DZ Restriction of Left Subclavian Artery with Intraluminal Device, Open 03V43DZ Restriction of Left Subclavian Artery with Intraluminal Device, Percutaneous 03V43ZZ Restriction of Left Subclavian Artery, Percutaneous 03V44DZ Restriction of Left Subclavian Artery with Intraluminal Device, Percutaneous Endoscopic 03V50DZ Restriction of Right Axillary Artery with Intraluminal Device, Open 03V53DZ Restriction of Right Axillary Artery with Intraluminal Device, Percutaneous 03V53ZZ Restriction of Right Axillary Artery, Percutaneous 03V54DZ Restriction of Right Axillary Artery with Intraluminal Device, Percutaneous Endoscopic 03V60DZ Restriction of Left Axillary Artery with Intraluminal Device, Open 03V63DZ Restriction of Left Axillary Artery with Intraluminal Device, Percutaneous 03V63ZZ Restriction of Left Axillary Artery, Percutaneous 03V64DZ 03V70DZ 03V73DZ 03V73ZZ Restriction of Left Axillary Artery with Intraluminal Device, Percutaneous Endoscopic Restriction of Right Brachial Artery with Intraluminal Device, Open Restriction of Right Brachial Artery with Intraluminal Device, Percutaneous Restriction of Right Brachial Artery, Percutaneous 03V74DZ Restriction of Right Brachial Artery with Intraluminal Device, Percutaneous Endoscopic 03V80DZ Restriction of Left Brachial Artery with Intraluminal Device, Open 03V83DZ Restriction of Left Brachial Artery with Intraluminal Device, Percutaneous 03V83ZZ Restriction of Left Brachial Artery, Percutaneous 03V84DZ Restriction of Left Brachial Artery with Intraluminal Device, Percutaneous Endoscopic 03V90DZ Restriction of Right Ulnar Artery with Intraluminal Device, Open 03V93DZ Restriction of Right Ulnar Artery with Intraluminal Device, Percutaneous 03V93ZZ Restriction of Right Ulnar Artery, Percutaneous 03V94DZ Restriction of Right Ulnar Artery with Intraluminal Device, Percutaneous Endoscopic 03VA0DZ Restriction of Left Ulnar Artery with Intraluminal Device, Open 03VA3DZ Restriction of Left Ulnar Artery with Intraluminal Device, Percutaneous 03VA3ZZ Restriction of Left Ulnar Artery, Percutaneous 03VA4DZ Restriction of Left Ulnar Artery with Intraluminal Device, Percutaneous Endoscopic 03VB0DZ Restriction of Right Radial Artery with Intraluminal Device, Open 03VB3DZ Restriction of Right Radial Artery with Intraluminal Device, Percutaneous 03VB3ZZ Restriction of Right Radial Artery, Percutaneous 03VB4DZ Restriction of Right Radial Artery with Intraluminal Device, Percutaneous Endoscopic 03VC0DZ Restriction of Left Radial Artery with Intraluminal Device, Open 03VC3DZ Restriction of Left Radial Artery with Intraluminal Device, Percutaneous 03VC3ZZ Restriction of Left Radial Artery, Percutaneous See page 3 for important information about the uses and limitations of this document. CORP-224204-AB SEPT2015 17

03VC4DZ Restriction of Left Radial Artery with Intraluminal Device, Percutaneous Endoscopic 03VD0DZ Restriction of Right Hand Artery with Intraluminal Device, Open 03VD3DZ Restriction of Right Hand Artery with Intraluminal Device, Percutaneous 03VD3ZZ Restriction of Right Hand Artery, Percutaneous 03VD4DZ Restriction of Right Hand Artery with Intraluminal Device, Percutaneous Endoscopic 03VF0DZ Restriction of Left Hand Artery with Intraluminal Device, Open 03VF3DZ Restriction of Left Hand Artery with Intraluminal Device, Percutaneous 03VF3ZZ Restriction of Left Hand Artery, Percutaneous 03VF4DZ Restriction of Left Hand Artery with Intraluminal Device, Percutaneous Endoscopic 03VG3ZZ Restriction of Intracranial Artery, Percutaneous 03VH3ZZ Restriction of Right Common Carotid Artery, Percutaneous 03VJ3ZZ Restriction of Left Common Carotid Artery, Percutaneous 03VK3ZZ Restriction of Right Internal Carotid Artery, Percutaneous 03VL3ZZ Restriction of Left Internal Carotid Artery, Percutaneous 03VM3ZZ Restriction of Right External Carotid Artery, Percutaneous 03VN3ZZ Restriction of Left External Carotid Artery, Percutaneous 03VP3ZZ Restriction of Right Vertebral Artery, Percutaneous 03VQ3ZZ Restriction of Left Vertebral Artery, Percutaneous 03VR3ZZ Restriction of Face Artery, Percutaneous 03VS3ZZ Restriction of Right Temporal Artery, Percutaneous 03VT3ZZ 03VU3ZZ 03VV3ZZ 03VY0DZ Restriction of Left Temporal Artery, Percutaneous Restriction of Right Thyroid Artery, Percutaneous Restriction of Left Thyroid Artery, Percutaneous Restriction of Upper Artery with Intraluminal Device, Open 03VY3DZ Restriction of Upper Artery with Intraluminal Device, Percutaneous 03VY3ZZ Restriction of Upper Artery, Percutaneous 03VY4DZ Restriction of Upper Artery with Intraluminal Device, Percutaneous Endoscopic 04L03ZZ Occlusion of Abdominal Aorta, Percutaneous 04L13ZZ Occlusion of Celiac Artery, Percutaneous 04L23ZZ Occlusion of Gastric Artery, Percutaneous 04L33ZZ Occlusion of Hepatic Artery, Percutaneous 04L43ZZ Occlusion of Splenic Artery, Percutaneous 04L53ZZ Occlusion of Superior Mesenteric Artery, Percutaneous 04L63ZZ Occlusion of Right Colic Artery, Percutaneous 04L73ZZ Occlusion of Left Colic Artery, Percutaneous 04L83ZZ Occlusion of Middle Colic Artery, Percutaneous 04L93ZZ Occlusion of Right Renal Artery, Percutaneous 04LA3ZZ Occlusion of Left Renal Artery, Percutaneous 04LB3ZZ Occlusion of Inferior Mesenteric Artery, Percutaneous 04LC0DZ Occlusion of Right Common Iliac Artery with Intraluminal Device, Open 04LC3DZ Occlusion of Right Common Iliac Artery with Intraluminal Device, Percutaneous 04LC3ZZ Occlusion of Right Common Iliac Artery, Percutaneous 04LC4DZ Occlusion of Right Common Iliac Artery with Intraluminal Device, Percutaneous Endoscopic 04LD0DZ Occlusion of Left Common Iliac Artery with Intraluminal Device, Open See page 3 for important information about the uses and limitations of this document. CORP-224204-AB SEPT2015 18