Part 533 - STATE REIMBURSEMENT FOR PAYMENT TO PHYSICIANS

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Statutory Authority: 
Social Services Law, Sections 20, 34, 363-a, 364, 365-a, 365-b, 368-a

Section 533.1 - Payment for physician's services to hospitalized

Section 533.1 Payment for physician's services to hospitalized patients. (a) expenditures by social services districts for their payments to a physician for services rendered to a hospitalized patient shall be subject to State reimbursement as follows:

(1) when the physician has the responsibility for the care of the patient, or

(2) when the physician's services were rendered as a consultant, surgical assistant, or for a special service at the request of the physician responsible for the care of the patient.

(b) State reimbursement shall not be available: (1) for compensation paid to a physician for the care of hospitalized patients when such compensation has been included as an element of costs reflected in a hospital rate approved by the State Director of the Budget pursuant to section 2807 of the Public Health Law;

(2) for services provided by a physician or physician's associate or a registered specialist's assistant employed by the physician to patients other than those determined in accordance with Part 505 of this Subchapter by the Commissioner of Health or his designee.

(c) Maximum reimbursable fee schedule for physician providing inpatient care at hospitals with approved training programs.

(1) Conditions for payment: (i) Individual private practitioner. Qualified physicians may be paid on a fee-for-service basis for direct care of hospital inpatients when their hospital salary is not paid for purposes of providing direct patient care; i.e., when the salary is paid exclusively for hospital activities such as teaching, various administrative duties (department heads, etc.) or for research.

(ii) Group practice. Payments for physicians' services on a group care basis may begin September 1, 1968, provided that the State Department of Health has approved a plan submitted in accordance with section 405.22 of 10 NYCRR, by the hospital describing how the group care will function, or is already functioning, how the requirements of such section are being met, and to which services it will apply.

(2) Conditions barring payment. Payment on a fee-for-service basis to a salaried hospital physician may not be made when:

(i) any portion of the salary paid by the hospital to such salaried physicians is for direct care of hospital inpatients or outpatients; or

(ii) there is any prohibition for such payment in law, in the rules of the particular hospital or in the contractual arrangement with the salaried physician or group.

(3) Medicine (effective April 1, 1974). 9020 First visit, history, examination and treatment ............ $ 6.50 9021 Subsequent visit, including treatment ........................ 5.00

During the first week of care, payments for no more than one visit daily shall be subject to reimbursement. Thereafter, payment for no more than three visits weekly shall be subject to reimbursement.

(4) Surgery. Reimbursement for inpatient surgical care shall be limited to 80 percent of the maximum reimbursable allowances as set out in section 533.5 of this Part when after-care is provided in the outpatient department. Payment for such after-care shall be made on a per visit basis to the hospital and the outpatient physician in accordance with prescribed procedures.

(d) State reimbursement for payment to physicians providing emergency services under contract with certain hospitals. Maximum reimbursable fees for payments made to physicians providing emergency services under contract with a hospital, effective April 1, 1974, shall be as follows:

(1) Reimbursement for inpatient emergency care shall be limited to 70 percent of the maximum reimbursable allowances set out in section 533.4 of this Part.

(2) Reimbursement for outpatient emergency care shall be limited to 70 percent of the maximum reimbursable allowances set out in section 533.4 of this Part.

(3) If the contract with physicians either individually, or as a group includes the provision that the hospital will pay to such physicians or physician group an amount equal to the difference between the billings for physicians' services and an established guaranteed amount, the hospitals may include, as an allowable hospital cost for outpatient rate determination purposes, either the amount paid under the guarantee or 15 percent of the guaranteed amount, whichever is less. Such amount shall not be included in determination of the inpatient rate.

(4) Salaries of physicians employed by a hospital to provide patient care are included as hospital costs in determining inpatient and outpatient reimbursement rates and therefore, no separate payments shall be made to such salaried physicians.

 

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Section 533.2 - Definitions.

533.2 Definitions. When used in this Part, unless otherwise expressly stated or unless the context or subject matter requires a different interpretation, the terms hereinafter set forth shall be interpreted in accordance with the definitions herein provided.

(a) Reimbursement shall mean State reimbursement.

(b) Maximum reimbursable allowance shall mean that portion of the expenditures for any service or procedure which is subject to reimbursement.

(c) By report shall mean the maximum reimbursable allowance determined on an individual basis, in consideration of the nature, extent, and need for the procedure or service, the time, skill and equipment necessary therefor, and such other factors as may be pertinent.

(d) Clinic fees shall mean fees for services provided in organized clinics of hospitals possessing valid operating certificates issued by the New York State Department of Health and for services of physicians in providing prior arranged group care, outside a hospital clinic setting in the physically handicapped children's program and in the New York State vocational rehabilitation program.

(e) Consultation shall mean advice and counsel, from an accredited specialist called in by the responsible physician, necessary to further treatment of the case by the responsible physician.

(f) Conversion factor shall mean the dollar amount by which the value of a procedure or service is multiplied to determine the maximum reimbursable allowance.

(g) Value shall mean the relative factor assigned to a procedure or service by which the conversion factor is multiplied to determine the maximum reimbursable allowance.

(h) Home call shall mean services rendered to a patient in a private household or in a boarding home, nursing home, convalescent home, proprietary home for adults, private home for the aged, institution for the blind, or child caring institution.

(i) New illness shall mean an illness or condition for which the patient has not received continuous or intermittent care from the physician providing the service.

(j) Referral shall mean the transfer of a patient from one physician to another for definitive treatment.

(k) The notation T shall mean one time unit for each 15 minutes of anesthesia time.

(l) Services or procedures shall mean the services or procedures provided by a physician or an osteopathic physician.

(m) Intensive care shall mean extraordinary care by the responsible physician in personal attendance in the care of a medical emergency, both directing and personally administering specific corrective measures after initial examination has determined the nature of the ailment.

 

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Section 533.3 - State reimbursement.

533.3 State reimbursement. (a) Basis for reimbursement. Reimbursement for physicians' services for which a maximum reimbursable allowance has been established in this Part shall be based upon payments actually made. However, reimbursement shall not be available for amounts paid in excess of the maximum reimbursable allowance prescribed nor for services not included in Part 505 of this Subchapter.

(1) If a physicians' service or procedure for which no maximum reimbursable allowance has been established in this Part is necessarily rendered, reimbursement shall be based upon the expenditures actually made therefor, in accordance with applicable regulations of the department.

(2) If, in accordance with the accepted practice, a physician's service or a procedure hereinafter listed in this Part is commonly carried out as an integral part of the total service, only the value of the principal service or procedure shall be the basis for reimbursement. When such a procedure is carried out as a separate entity not immediately related to other services, reimbursement shall be based upon the fee for the particular service or procedure.

(i) When a special procedure is performed during a medical emergency when the physician is rendering intensive care, items 9072 and 9073, for which there would be a separate allowance, reimbursement shall be available for the higher of the two allowances, i.e., the allowance for service or allowance for time.

(3) If immunization is administered at the time of an office visit, reimbursement will be based upon the immunization fee in addition to the fee appropriate for the level of services provided during an office visit.

(4) Charges for special diagnostic procedures which are not considered to be a routine part of a physician's or consultant's examination (e.g.) complete blood count, diagnostic X-ray, lumbar puncture) are reimbursable in addition to the physician's usual office or home visit fee.

(b) Intensive or unusual services. (1) For intensive or unusual medical treatment rendered to a patient who has an illness of such serious, critical or unusual nature as to require time and study far beyond normal limits, a fee in excess of that listed in the fee schedule may be approved by the appropriate authority. Decision shall be based on the facts of the case supplied by the attending physician.

(2) When a special procedure is performed during a medical emergency for which there would be a separate fee, the physician shall receive the higher of the two fees (fee for special service or fee for time).

(c) Services by more than one physician. When warranted by the necessity of supplemental skills, reimbursement shall be available for expenditures for services rendered to a patient by two or more physicians.

(d) Multiple visits. If an Individual patient is necessarily seen on more than one occasion during a single day, expenditures for each such visit shall be subject to reimbursement.

(e) Drugs and supplies. Expenditures made by a social services district for necessary drugs, materials and supplies provided by a physician, where separate payment therefore is made in accordance with the local medical plan, shall be subject to reimbursement in accordance with applicable regulations of the department.

(f) Consultation fees. (1) Reimbursement for consultation fee expenditures shall be available only when an examination is made by an accredited specialist, within the scope of his specialty, upon request of the responsible physician who is treating the medical problem for which consultation is required. The responsible physician shall certify that he requested such consultation and that it was incident to and necessary for his further treatment of the patient.

(2) When the consultant physician assumes the continuing care of the patient, any subsequent services rendered by him shall not be considered as consultation, and the established visit fees shall apply.

(g) Specialists' fees. Reimbursement for a specialist's fee shall be available only where the services rendered are within the field of his specialty. Services performed by a specialist outside his field of specialization shall be charged in accordance with the general practitioner's fee schedule.

(h) Complete physical examination. Reimbursement for expenditures for a complete physical examination shall be available only when such examination has prior approval by the appropriate authority except when such examination is required in an emergency.

(i) Telephone calls. The services rendered by a physician directly to a patient over the telephone are not reimbursable. Long distance calls by a physician to another physician who has previously attended the patient or to a hospital or other medical facility to obtain additional medical information are reimbursable.

 

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Section 533.4 - Medicine.

EXPLANATION--matter in braces { } is superscript material

533.4 Medicine. (a) Conversion factor. The conversion factor for the services and procedures listed in subdivision (g) of this section shall be $5.

(b) Services and values. For the numbered and described items of services or procedures set forth in subdivision (g) of this section, the maximum reimbursable fee shall be computed on the basis of the respective assigned value multiplied by the conversion factor of $5.

(c) Clinic services. (1) Maximum reimbursable allowances established for payment to a physician for clinic services (items 9023, 9024, 9032, 9033, 9026, 9027, 9030, 9031) shall not apply when the physician receives any form of compensation from the facility for providing such services.

(2) Clinic fees (items 9023, 9024, 9032, 9033, 9026, 9027, 9030, 9031) shall be prorated according to the number of medical assistance patients treated as a percentage of the total number of patients seen during a clinic session.

(d) Hospital visits. (1) Hospital visit fees shall not apply to preoperative consultations or follow-up visits as designated in accordance with the surgical fees listed in section 533.5 of this Part.

(2) Reimbursement for hospital visits shall only be made for care provided in accordance with the provisions of Part 505 of this Subchapter.

(e) Newborn care. Newborn care (fee codes 9035 and 9038) is in addition to any appropriate fee for maternity care.

(f) Psychiatric services by a private practicing physician require prior approval of the local professional director when more than 15 visits within a continuous six-month period are required to complete the course of treatment.

(g) Maximum reimbursable medical fee schedule.

GENERAL PRACTITIONER

(or Specialist Providing Service in Nonspecialist Area)

OFFICE VISITS

Unit or Dollar

Value 9000 First visit, new patient or new illness, history,

examination and treatment $ 7.80 9001 Subsequent visit, including treatment $ 6.00 9002 Complete physical examination with special report $12.00

HOME VISITS 9010 First visit, new patient or new illness, history,

examination and treatment 1.6 9011 Subsequent visit, including treatment 1.4 9012 Complete physical examination with special report 2.25 9018 Home visit each additional member of same

household 1.0

HOSPITAL VISITS 9020 First visit, new patient or new illness, history,

examination and treatment 1.3 9021 Subsequent visit, including treatment 1.0 9022 Complete physical examination with special report 2.0

NURSING HOME VISITS 9003 First visit, new patient or new illness, history,

examination and treatment 1.6 9005 Subsequent visit, including treatment 1.4 9014 Complete physical examination with special report 2.25 9019 Visit, each additional patient, same nursing home,

same session 1.0

CLINIC VISITS, NONSPECIALIST 9023 One-hour session 3.0 9024 Two-hour session 5.0 9032 Three-hour session 7.0 9033 Each additional hour (per hour) 1.4

OSTEOPATHIC PHYSICIAN 9041 Osteopathic manipulation, where indicated,

additional .2

SPECIALIST PROCEDURES

CONSULTATION BY SPECIALIST 9028G Initial consultation (office) $24.00 9029G Subsequent consultation when required to complete

diagnosis (office) $18.00 9028J Initial consultation (other than office) 4.0 9029J Subsequent consultation when required to complete

diagnosis (other than office) 3.0

INTERNIST

Office Visits

Comprehensive diagnostic history, physical examination and treatment, including screening test for anemia and urinary glucose and albumin, taking of blood specimens, and furnishing of reports when requested. 9002B Up to 45 minutes $15.00 9002M 46 minutes to one hour $20.00 9002E More than one hour $25.00 9004 Follow-up visit, routine $7.50 9006 Follow-up visit, prolonged (over 20 minutes) $10.00

Home Visits 9012B Initial home visit, routine, new patient or new

illness, history and examination 3.0 9012M Initial home visit, complete diagnostic history

and physical examination, established patient or minor chronic illness, including initiation of diagnostic and treatment programs 4.0 9021E Initial home visit, complete diagnostic history

and physical examination, new patient or major illness, including initiation of diagnostic and treatment programs 5.0 9015 Examination or evaluation, routine 2.0

Hospital Visits 9020B Initial hospital visit, brief history and physical

examination, including initiation of diagnostic and treatment programs and preparation of hospital records 3.0 9021M Initial hospital visit, complete diagnostic history

and physical examination, established patient or minor chronic illness, including initiation of diagnostic and treatment programs and preparation of hospital records 4.0 9022E Initial hospital visit, complete diagnostic history

and physical examination, new patient or major illness, including initiation of diagnostic and treatment programs and preparation of hospital records 5.0 9025 Examination or evaluation, routine follow-up 1.5

PEDIATRICIAN

Office, Home and Hospital Visits 9007F Comprehensive diagnostic history and physical

examination, new patient or new illness, office $12.00 9007R Comprehensive diagnostic history and physical

examination, new patient or new illness, home 2.0 9007H Comprehensive diagnostic history and physical

examination, new patient or new illness, hospital 2.0 9009F Routine office visit, including treatment $7.20 9009H Routine hospital visit, including treatment 1.2 9013 Routine home visit, including treatment 1.8 9018P Each additional child at home 1.0 9037 Pediatrician in attendance at problem

deliveries 5.0 9038 Total newborn care in hospital, including

physical examinations of the baby and discussion with the mother during the hospital stay (total fee for minimum 3-day stay) 4.0
OTOLARYNGOLOGIST

Office Visits 9042 Complete diagnosis, history, physical

examination, new patient or new illness $12.00 9043 Routine visit and treatment $7.20

Hospital Visits 9044 Initial visit 2.0 9045 Follow-up visit, including treatment 1.2

UROLOGIST

Office Visits 9078 Complete diagnosis, history, physical

examination, new patient or new illness $12.00 9079 Routine visit, including treatment $7.20

Hospital Visits 9080 Initial visit 2.0 9081 Follow-up visit, including treatment 1.2

DERMATOLOGIST Office Visits 9065 Comprehensive diagnosis, history, physical

examination, new patient or new illness $12.00 9066 Routine visit, including treatment $7.30

Hospital Visits 9067 Initial visit 2.0 9068 Follow-up visit, including treatment 1.2

SURGEON (excluding neurosurgeon)

Office Visits 9074 Complete diagnosis, history, physical

examination, new patient or new illness $12.00 9075 Routine visit, including treatment $7.20

Hospital Visits 9076 Initial visit 2.0 9077 Follow-up visit, including treatment 1.2

PSYCHIATRIST 9082 Complete diagnosis, history, physical

examination, new patient or new illness, office $12.00 9083 Routine visit, including treatment, office $7.20 9084 Initial visit, hospital 2.0 9085 Follow-up visit, including treatment,

hospital 1.2

FAMILY PRACTITIONER

Office Visits

Comprehensive diagnostic history and physical

examination--new patient or new illness 9660 Child up to and including 16 years $12.00 9661 Persons over 16 years $12.50

Routine Office Visit, including treatment 9662 Child up to and including 16 years $7.20 9663 Persons over 16 years $7.50

Home Visits

Comprehensive diagnostic history and physical

examination--new patient or new illness 9666 Child up to and including 16 years 2.0 9667 Persons over 16 years 2.5

Routine home visit including treatment 9668 Child up to and including 16 years 1.8 9669 Persons over 16 years 2.0 9670 Each additional person at home 1.0

Hospital Visits

Initial Visit 9671 Child up to and including 16 years 2.0 9672 Persons over 16 years 2.5

Follow-up visit, including treatment 9673 Child up to and including 16 years 1.2 9674 Persons over 16 years 1.5

ORTHOPEDIST

Office Visits 9086 Complete diagnosis, physical examination,

history, new patient or new illness $12.00 9087 Routine visit, including treatment $7.20

Home Visits 9088 Home visit, including treatment 1.8

Hospital Visits 9089 Initial visit 2.0 9090 Follow-up visit, including treatment 1.2

OBSTETRICIAN-GYNECOLOGIST

Office Visits 9091 Pelvic examination, breast examination, Pap smear

exclusive of laboratory charge, or new illness $12.00 9092 Follow-up visit $7.20

Hospital Visits 9093 Initial visit 2.0 9094 Follow-up visit, including treatment 1.2

NEUROLOGIST AND NEUROSURGEON

Office Visits

Comprehensive diagnostic history, physical examination and treatment 9500 Up to 45 minutes $15.00 9501 46 minutes to one hour $20.00 9502 More than one hour $25.00 9503 Follow-up visit, routine $7.50 9504 Follow-up visit, prolonged (over

20 minutes) $10.00

Home Visits 9505 Initial home visit, routine, new patient

or new illness, history and examination 3.0 9506 Initial home visit, complete diagnostic

history and physical examination, established patient, including initiation of diagnostic and treatment programs 4.0 9507 Initial home visit, complete diagnostic history

and physical examination, new patient, including initiation of diagnostic and treatment programs 5.0 9508 Examination or evaluation, routine follow-up 2.0

Hospital Visits 9509 Initial hospital visit, brief history

and physical examination, including initiation of diagnostic and treatment programs and preparation of hospital records 3.0 9510 Initial hospital visit, complete diagnostic

history and physical examination, established patient, including initiation of diagnostic and treatment programs and preparation of hospital records 4.0 9511 Initial hospital visit, complete diagnostic

history and physical examination, new patient, including initiation of diagnostic and treatment programs and preparation of hospital records 5.0 9512 Examination or evaluation, routine follow-up 1.5

CLINIC VISITS, SPECIALISTS 9026 One-hour session 4.0 9027 Two-hour session 7.0 9030 Three-hour session 10.0 9031 Each additional hour (per hour) 2.0

CHAP (Child Health Assurance Program)

The following composite fee codes for use in the Medicaid program, effective April 1, 1974, include: office visit, 9040; immunization, 9998; average cost of materials, L112; hemoglobin or hematocrit; and L557 urinalysis for CHAP when performed by a pediatrician, internist, obstetrician-gynecologist, general practitioner or other specialist. 9008P Pediatrician $21.20 9008B Internist $21.20 9008Y Obstetrician-Gynecologist $21.20 9008G General Practitioner or other specialist $21.20

No provider shall be paid such a composite fee more than once annually per patient.

{1} In addition to the above composite fee codes, optional tests, when indicated and when performed in accordance with criteria outlined in Item 44 of the State Medical Handbook, are eligible for additional payment on a fee-for-service basis at fees established in applicable fee schedules; e.g., 9340--audiometric hearing screening, etc.

For completion of the Child Health Care Status Report, effective Sept. 27, 1974: 9008R Child Health Care Status Report (once per patient

per period of eligibility) $5.00

PSYCHIATRIC TREATMENT 9050G Psychotherapy, office, verbal, drug augmented

or other methods, one hour (office) $30.00 9051G Comprehensive psychiatric examination with written

report (office) $30.00 9053G Group (maximum eight persons per group) one and

one half hours, per person (office) $9.00 9050J Psychotherapy, hospital or home, verbal, drug

augmented or other methods, one hour 5.0 9051J Comprehensive psychiatric examination with written

report (other than office) 5.0 9053J Group (maximum eight persons per group) one

and one half hours, per person (other than office) 1.5 9055 Electroshock, (per treatment), subconvulsive 4.0 9056 convulsive 5.0

for anesthetist 3.0+T 9057 Insulin shock (per treatment), subcoma 4.0 9058 coma 6.0 9059 Metrazol convulsive shock (per treatment) 5.0 9060 Psychometric testing (one hour) with written report 5.0 9061G Initial routine office visit to include general

history, physical and treatment $12.00 9062G Routine follow-up visit $7.20 9061J Initial routine visit to include general history,

physical and treatment (other than office) 2.0 9062J Routine follow-up visit (other than office) 1.2 9064 Inpatient care, prolonged (chronic case) by report

FAMILY PLANNING VISITS

Office Visits 9160 Family planning visit, specialist in

obstetrics-gynecology, initial visit $12.00 9161 Follow-up visit $7.20 9165 Family planning visit, nonspecialist,

initial visit $7.80 9166 Follow-up visit $6.00

OTHER SERVICES

In calculating fees please refer to general instructions, rules 10, 11, 12 9035 Total newborn care in hospital provided

by a physician other than a pediatrician, including physical examinations of the baby and discussions with the mother during the hospital stay (total fee for minimum 3-day stay) 3.0 9040 Immunization(s), per visit (plus cost of

materials) 0.4 9049 Theraputic injectable material used for each

injection may be charged at acquisition cost rounded to the nearest one-dollar amount, (effective 3/15/78). 9070 Mileage, per mile, one way, beyond 10 mile radius

of point of origin (office or home) 0.1 9071 Night emergency: additional fee for service

rendered between hours of 10 p.m. and 8 a.m. 1.0 9072 Intensive care, minimum of one hour 5.0 9073 each additional half hour 2.5 9998 cost of materials by report

SPECIFIC DIAGNOSTIC AND THERAPEUTIC PROCEDURES

Listed values may be added to other significant services rendered at the same visit. Values for items 9101 to 9227 include laboratory procedure(s), interpretation and physicians' services (except surgical and anesthesia services as listed in the section on Surgery), unless otherwise stated. For other similar services, see appropriate sections. 9101 Electrocardiogram with interpretation and

report 3.0 9102 tracing only, without interpretation and

report 1.5 9103 interpretation and report only 1.5 9104 with exercise test 5.0 9105 tracing only without interpretation and report 2.5 9106 interpretation and report only 2.5 9107 single lead (for rhythm) with interpretation 1.0

Continuous EKG Monitoring

(e.g., Holter Monitor) 9109 Up to 12 hours 9.0 9110 Over 12 to 16 hours 10.0 9111 Over 16 hours 12.0 9112 Phonocardiogram with interpretation

and report 4.0 9113 with indirect carotid artery tracing or

similar study 5.0 9115 Vectorcardiogram (VCG), with or without EKG,

interpretation and report 5.0 9116 when part of other diagnostic studies 4.0 9120 Venous pressure determination 1.0 9121 Circulation time, per test (not

to exceed 2.0 units) 1.0

(For radioisotope tests, see 7836.) 9123 Recording of direct arterial pressure tracings

(independent procedure) 4.0

(Recording of intracardiac pressures with evaluation and interpretation included as part of items 2330-2335.) 9126 Cardiac output (Fick) (independent procedure) (excluding

cardiac catheterization--see 2330-2335) 5.0

(For radioisotope methods, see 7835.) 9127 Dye dilution studies, indicator dye curves 1.0 9128 cardiac output, initial (independent procedure) 5.0 9129 subsequent, same study period, each (independent

procedure) 2.5

(When dye dilution studies are part of right heart catheterization, maximum units allowed will be 18; when part of combined right and left heart catheterization, maximum units allowed will be 22.) 9140 Screening throat culture 0.75 9190 Peripheral vascular disease studies by report 9192 Plethysmography by report 9193 Temperature gradient studies by report 9194 Thermogram by report

NONSURGICAL OPERATING ROOM SERVICES 9195 Operation of pump with oxygenator or heart exchanger,

per hour pump time 6.0 9196 Monitoring E.K.G., pressures, etc., in intrathoracic or

other critical surgery, per hour 5.0

PULMONARY 9201 Spirometry, complete (respirometer) including graphic

record, total and timed vital capacity and maximal breathing capacity, with written report 3.0 9203 Branchospirometry; expired gas analysis, (independent

procedure) (for insertion of tube see 2126) 5.0 9206 Bronchospasm evaluation; spirometry as in 9201 before

and after bronchodilator (aerosol or parenteral) 5.0 9215 Vital capacity, total 0.6 9216 total and timed 1.0 9220 Maximal breathing capacity 2.0 9221 Maximal expiratory flow rate measurement or equivalent

(independent procedure) 1.0 9224 Residual air (helium method) including equilibration

time, initial 3.0 9225 subsequent 2.0 9228 Residual air (open circuit method) including alveolar

nitrogen, initial 6.0 9229 subsequent 4.0 9235 Nitrogen washout curve (continuous) by report 9268 Oxygen uptake, expired gas analysis rest and

exercise (direct) 5.0 9269 rest (indirect) 1.5 9272 Carbon monoxide diffusing capacity by report 9275 Pulmonary compliance by report 9277 Carbon dioxide, expired gas determination by

infrared analyzer by report

ALLERGY TESTING AND TREATMENT

The following values are based on the type and number of tests performed, and must include observation and interpretation of the tests by a physician. In routine office practice, the following items may be added to fee code items 9004 or 9009F. 9300 Scratch or puncture tests, up to 60 tests,

per 10 tests (minimum-1.0 unit) 1.0 9301 in excess of first 60 tests, per 20 tests 1.0 9302 Intradermal tests, up to total of 60 tests,

per 10 tests (minimum-1.0 unit) 1.5 9303 in excess of first 60 tests, per 20 tests 1.5 9304 Patch tests, each (minimum-1.0 unit) 0.2 9305 Direct opththalmic tests, each (minimum-1.0 unit) 0.4 9306 Direct nasal tests, each (minimum-1.0 unit) 0.4 9307 Passive transfer tests (including cost of recipient)

per 10 tests (minimum-10.0 units) 3.0 9308 Maximum allowable for allergy testing; reserved for

allergic conditions necessitating unusually extensive testing 22.0 9550 Antigens-treatment sets prepared by allergist for

administration by or under the supervision of another physician; solutions of increasing concentration, e.g., ragweed, dust, feathers, four vials 4.0 9551 five vials 5.0 9552 one vial or one refill 2.0 9553 Injection(s) of antigens prepared by allergists

for own patients allow maximum of 0.5 unit plus immunization fee (code 9040) 0.5

MISCELLANEOUS 9320 Skin test with bacterial, viral or fungal extracts

(includes reading test), e.g., brucella, tuberculln, histoplasma, coccidioidin, Frel, etc. each 1.0 9321 Tine test, includes injection and reading 0.375 9323 Exclusion test for pheochromocytoma, e.g.,

regitine, benzodiozane, histamine, each 2.0 9330 Electroencephalogram, awake, asleep (natural or

induced) and activation 7.0 9331 at surgery by report 9332 Electroencephalogram, interpretation

and report only 1.5 9333 Electroencephalogram, tracing only,

without interpretation and report 5.0 9340 Audiometric hearing screening, pure tone

(air only) 1.0 9341 air and bone, with or without masking 2.0 9342 Air, bone and speech audiometry (includes reception

and discrimination tests) 3.0 9343 Vestibular function test 3.0 9350 Muscle testing, manual or electrical, with

report, one extremity 1.5 9351 four extremities and trunk 4.0 9354 Range of motion measurements and report, two

extremities 1.0 9358 Electromyography, one extremity and related

areas of the back 7.0 9362 Nerve velocity determination, each nerve

(independent procedure) 3.0

(For vision testing see 5400-5411.) 9400 Phlebotomy, therapeutic (independent

procedure) 2.0 9404 Intermittent positive pressure treatment, initial

or subsequent 0.6 9412 Chemotherapy for malignant disease by report 9413 Perfusion for malignant disease by report 9415 Desensitization, e.g., horse serum by report 9417 Gastric lavage, treatment, e.g., ingested

poisons, etc. 8v. 9420 Cardioversion 10.0 9420a Cardioversion, anesthesia fee 3.0+T

Professional Dialysis Fees for Physician in Personal

Attendance* 9405 Peritoneal dialysis (hospital) 15.0 9407 Patient's first hemodialysis 20.0 9408 See item 9405 above 9410 Home hemodialysis 3.0

(This fee is applicable when physician participates in a training session in the home. In all other instances, the regular home visit fee will apply.) ---------------

FOOTNOTE: *For corresponding surgical procedures see codes 2590-2592.

 

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Section 533.5 - Anesthesia and surgery.

533.5 Anesthesia and surgery. All fees billed must be in accordance with the provisions of Part 505 of this Subchapter.

(a) Anesthesia. (1) The conversion factor for the anesthesia services and procedures listed in this section shall be $5.

(2) Anesthesia values. (i) The total values for anesthesia services include pre- and post-operative visits, the administration of fluids and/or blood incident to the anesthesia or surgery.

(ii) Calculated values for anesthesia services shall be used only when the anesthesia is personally administered by a licensed physician who remains in constant attendance during the procedure for the sole purpose of rendering such anesthesia services.

(iii) For anesthesia procedures, the same item number as the related surgical procedure shall be used with the suffix "a" added.

(iv) When hypothermia and/or pump oxygenator are employed in conjunction with an anesthesia, the anesthesia "basic" value shall be 20 units instead of the "basic" value presently listed and the suffix "y" shall be substituted for "a".

(v) If the general or regional anesthetic is administered by the attending surgeon, the value shall be 50 percent of the calculated value and the suffix "p" shall be substituted for "a".

(vi) In procedures where no value is listed, the basic portion of the calculated value shall be the same as listed for a comparable procedure.

(vii) Necessary drugs and materials provided by the physician anesthetist may be charged for separately.

(viii) Where unusual detention with the patient is essential for the safety and welfare of such patient, the necessary time shall be valued on the same basis as indicated below for anesthesia time.

(ix) No fee shall be allowed for local Ultration or digital block anesthesia administered by the operating surgeon.

(3) Calculation of total anesthesia values. Calculation of total anesthesia value shall be determined by adding the listed basic value and time units. The time units shall be computed by allowing one unit for each 15 minutes of anesthesia time. Anesthesia time shall start with the beginning of the administration of the anesthetic agents and shall end when the physician anesthetist is no longer in personal attendance.

(b) Surgery. (1) The conversion factor for the surgical services and procedures listed in this section shall be $4.

(2) The values hereinafter listed for surgical procedures include the surgery and follow-up care for the period indicated. In cases in which follow-up care beyond the required period is necessary, reimbursement shall be available for additional payments made by the social services district to the physician on a fee-for-service basis.

(3) Where an asterisk (*) precedes a procedure number and its listed value, reimbursement shall be determined on the basis of the following factors:

(i) the listed value is for the surgical procedure only;

(ii) reimbursement for all post-operative care shall be available for payments made to the physician on a fee-for-service basis;

(iii) when such procedure requires admission to a hospital, an additional two units shall be added to its listed value in lieu of any hospital visit fee;

(iv) when such procedure is carried out at the time of the initial visit, one additional unit shall be added to the value of the procedure in lieu of any office visit fee.

(4) When the notation "Sv" follows a listed surgical procedure, the maximum reimbursable allowance therefor shall be the sum of the values of the various respective services rendered, such as for a hospital visit, application of cast or splint, detention with the patient, or office visit, multiplied by the respective appropriate conversion factor.

(5) In the event of complications or other circumstances requiring additional and unusual services concurrent with the procedure or during the established period of follow-up care, reimbursement shall be available for payment to a physician on a fee-for-service basis in addition to the reimbursement for the procedure.

(6) (i) When multiple or bilateral surgical procedures are performed at the same operative session, the total value shall be the value of the major procedure plus 50 percent of the value of the lesser procedure(s) after the conversion factor ($4) has been applied to all fee items, unless otherwise specified.

(ii) When an incidental procedure, such as an incidental appendectomy, lysis of adhesions, excision of a previous scar, or puncture of an ovary cyst, is performed through the same incision, the value of such procedure shall be that of the major procedure only, unless otherwise specified.

(7) When the skills of two surgeons are required in the management of a specific surgical procedure, by prior agreement, the total value may be apportioned in relation to the responsibility and work done, provided the patient is made aware of the fee distribution according to medical ethics. The value of such procedure may be increased by 25 percent.

(8) When an additional surgical procedure is carried out within the established period of follow-up care for a previous surgery, the follow-up periods for each shall be deemed to run concurrently.

(9) When the value of a surgical procedure is to be determined "by report" the social services district shall require the physician to submit the following information:

(i) postoperative diagnosis;

(ii) size, location and number of lesions on procedures where appropriate;

(iii) major surgical procedure and supplementary procedures;

(iv) where possible, a list of similar procedures, by item number, as set forth in this section;

(v) an estimate of the follow-up period;

(vi) operative time;

(vii) such other information as may be required.

(10) In the case of a kidney transplant, procedure item 3850, if the recipient of a kidney transplant is eligible for medical assistance, all costs attributable to medical services provided to a live donor of a kidney shall be reimbursable. If, however, the recipient of a kidney transplant is not eligible for medical assistance, payments for neither the transplant nor the costs incured for the live donor shall be reimbursable even though the live donor may be eligible for medical assistance.

(11) Surgical fees. The maximum reimbursable allowance for the numbered and described items of surgical procedures listed in this section shall be computed on the basis of the respective listed value multiplied by the conversion factor of $4.

(12) The maximum reimbursable allowance to an individual physician for a single operation shall be $800.

(c) Maximum reimbursable anesthesia and surgery fee schedules:

SURGICAL ASSISTANTS 6993 Assist at surgery, 20% of listed unit

value(s) of surgical procedure(s)--...........

Integumitary System

Skin, Mucous Membrane, Subcutaneous and Areolar Tissues

Unit or FollowDollar up Value Days Anes.Section

Incision *0101 Incision and drainage of infected

or non-infected sebaceous cyst *2.0 0 3.0+T

(2nd lesion 50%; each additional lesion 25%) *0102 Incision and drainage of furuncle *2.0 0 3.0+T *0103 Acne surgery; marsupialization,

opening, or removal of multiple milia, comedones, cysts, pustules, etc. *1.5 0 3.0+T *0108 Incision and drainage of carbuncle,

suppurative hidradenitis and other cutaneous or subcutaneous abscesses, simple *2.0 0 3.0+T 0109 extensive by report 3.0+T *0115 Drainage of pilonidal cyst *2.0 0 3.0+T *0125 Drainage of onychia or
paronychia *2.0 0 3.0+T 0126 multiple or complicated by report 3.0+T *0130 Incision and removal of foreign

body, subcutaneous tissues, simple *2.0 0 3.0+T 0131 complicated by report 0 3.0+T *0140 Drainage of hematoma, simple *2.0 0 3.0+T 0141 complicated by report 0 3.0+T *0145 Puncture aspiration of abscess or

hematoma *1.0 0 3.0+T Excision Debridement (for abrasions and burns see 0164, 0330-0334, 0351-0356.) *0160 Debridement of extensively

eczematized or infected skin up to 10% of the body surface *2.0 0 3.0+T *0161 for each additional 10% of body

surface, add *1.0 0 3.0+T *0162 Debridement of nails, any method,

five or less *2.0 0 3.0+T *0163 for each additional five or major

portion thereof *1.0 0 3.0+T 0164 Debridement of abrasions by report

Excision and Simple Closure--(Not reconstructive surgery; for reconstructive surgery see "Repair-Complex.")

(For electro-surgical methods see 0401, et seq.) 0171 Biopsy; excision of skin,

subcutaneous tissue or mucous membrane for biopsy (including simple closure)

(independent procedure) 3.0 15 3.0+T Excision (including simple closure) of BENIGN cicatricial, fibrous, inflammatory, congenital, cystic, etc., lesions of skin, subcutaneous tissue or mucous membrane; one (see appropriate size below.)

(For multiple lesions see Surgical Rule 9.) 0175 lesion diameter up to 1/4 inch 4.0 3 3.0+T 0176 lesion diameter 1/4 to 1/2 inch 5.0 30 3.0+T 0177 lesion diameter 1/2 to 3/4 inch 6.0 30 3.0+T 0178 lesion diameter more than 3/4 inch or

complicated by report 3.0+T Excision (including simple closure) or treatment by any other method (except radiation) of MALIGNANT lesions of skin or mucous membrane

(except melanoma) to include local anesthesia. Trunk, arms or legs: 0188 lesion diameter up to 1/4 inch 6.0 90 3.0+T 0189 lesion diameter 1/4 to 1/2 inch 8.0 90 3.0+T 0190 lesion diameter 1/2 to 3/4 inch 10.0 90 3.0+T

Face, scalp, ears, neck, hands, feet, genitalia: 0191 lesion diameter up to 1/4 inch 10.0 90 3.0+T 0192 lesion diameter up to 1/2 inch 15.0 90 3.0+T 0193 lesion diameter 1/2 to 3/4 inch 20.0 90 3.0+T

Eyelids, nose, lips, mucous membrane: 0194 lesion diameter up to 1/4 inch 15.0 90 3.0+T 0195 lesion diameter 1/4 to 1/2 inch 20.0 90 3.0+T 0196 lesion diameter 1/2 to 3/4 inch 25.0 90 3.0+T 0197 Lesions over 3/4 inch, complicated or unusually located by report 3.0+T 0225 Avulsion, nail, partial, or

complete, simple *2.0 0 3.0+T 0228 Excision of nail or nail matrix,

partial or complete, e.g., ingrown or deformed nail for permanent removal 10.0 30 3.0+T 0238 Excision of pilonidal cyst or

sinus 30.0 60 3.0+T Miscellaneous lesions (use appropriate procedure number and state diagnosis.) Hermangioma (see 0175-0178, 0260-0324.) Hidradenitis (see 0106, 0175-0178, 0260-0324.) Lipoma (see 0175-0178, 0260-0324.) Lymph node dissection (see 2651-2672.) Melanoma (see 0188-0197, 0260-0324.) Ulcer-vascular or inflammatory (see 0175-0178, 0260-0324.) Introduction *0242 Injection, intralesional (up

to and including seven lesions) *2.0 0 3.0+T *0243 more than seven *3.0 0 3.0+T

Repair--Simple *0251 Wounds, recent, up to 2-1/2

inches *2.0 0 3.0+T *0252 for each additional inch add *1.0 0 3.0+T

(For multiple wounds, see Surgical Rule 9.) REPAIR--COMPLEX (e.g., reconstructive surgery, complicated wound closure, skin grafts, etc.). The following values (0260-0324) are to be applied in situations requiring unusual and time-consuming techniques of repair to obtain the maximum functional and cosmetic result. Unless otherwise noted, the stated values include the creation of the defect and necessary preparation for repair, or the debridement and repair of complicated lacerations (excluding 0251, 0252.) Excision and/or repair by direct closure of lesion or laceration resulting in a LINEAR REPAIR: 0260 up to 1/2 inch, forehead,

cheeks, chin, mouth, neck, axilla, genitalia, hands and feet 8.0 30 3.0+T 0261 eyelids, nose, ears and lips

(See also 0290-0294, 2737-2746.) 10.0 30 3.0+T

(For other areas see 0175-0178, 0188-0197, 0251-0252.) 0262 1/2 inch to 1 inch, trunk 7.0 30 3.0+T 0263 scalp, arms and legs 10.0 30 3.0+T 0264 forehead, cheeks, chin, mouth,

neck, axilla, genitalia, hands and feet 14.0 30 3.0+T 0265 eyelids, nose, ears and lips 17.0 30 3.0+T

(See also 0290-0294, 2737-2746.) 0266 1 inch to 3 inches, trunk 15.0 30 3.0+T 0267 scalp, arms and legs 22.0 30 3.0+T 0268 forehead, cheeks, chin, mouth,

neck, axilla, genitalia, hands and feet 30.0 30 3.0+T 0269 eyelids, nose, ears and lips

(See also 0290-0294, 2737-2746.) 40.0 30 3.0+T 0270 Unusual, complicated or over 3

inch linear repair by report 3.0+T Excision and/or repair by adjacent tissue transfer or rearrangement (e.g., Z-plasty, rotation flap, advanced flap, double pedicle flap, etc.): 0275 for defect up to 1 square inch,

trunk 20.0 60 3.0+T 0276 scalp, arms and legs 30.0 60 3.0+T 0277 forehead, cheeks, chin, mouth,

neck, axilla, genitalia, hands and feet 40.0 60 3.0+T 0278 eyelids, nose, ears and lips 50.0 60 3.0+T 0279 defect size between 1 square

inch and 3 square inches, trunk 30.0 60 3.0+T 0280 scalp, arms and legs 40.0 60 3.0+T 0281 forehead, cheeks, chin, mouth, neck,

axilla, genitalia, hands and feet 50.0 60 3.0+T 0282 eyelids, nose, ears and lips 60.0 60 3.0+T 0283 more than 3 square inches, unusual

or complicated by report 3.0+T Eyelid, full thickness, excision and repair: 0290 by advancement flaps, up to 1/4

eyelid margin 37.0 60 3.0+T 0291 over 1/4 of eyelid margin 50.0 60 3.0+T 0292 by transfer flaps of tarsoconjunctivea

from opposing eyelid, up to 2/3 of eyelid 50.0 60 3.0+T 0293 total eyelid, one or more stages,

lower lid 75.0 60 3.0+T 0294 upper lid 85.0 60 3.0+T

SKIN GRAFTS--The value is to be determined on the basis of size and location of defect

(recipient area) and type of graft. Unless otherwise noted, these values include creation and/or surgical preparation of the defect, obtaining and placing of the graft, and the care of the donor site. For repair of the donor site requiring skin graft or local flaps, see section 533.5 (b) (6) (i). *0300 Pinch, split or full thickness skin

to cover small ulcer, tip of digit or other minimal open area (except on face, use 0301-0304) up to defect size 3/4 inch diameter *5.0 0

(Values for items 0301-0304 include simple debridement of granulations or recent evulsions. When the recipient area for grafting is created by surgical excision of essentially intact skin, scar or other lesion (including subcutaneous tissue) add 50% to the calculated value for the graft. This includes primary or delayed application of the graft.) 0301 Split skin graft, up to 16 square

inches (except 0300), trunk, scalp, arms, legs, hands and feet (except multiple digits) 25.0 45 0302 each additional 16 square inches

or part thereof 5.0 45 0303 face, neck, ears, genitalia or

multiple digits 38.0 45 0304 each additional 16 square inches

or part thereof 7.0 45 0308 Full thickness, free, up to 3

square inches, including direct closure of donor site, trunk 20.0 45 0309 scalp, arms and legs 30.0 45 0310 forehead, cheeks, chin, mouth,

neck, axilla, genitalia, hands and feet 40.0 45 0311 eyelids, nose, ears and lips 50.0 45

(For each additional 3 square inches in the above procedures, add 50% of area value.)

(For repair of donor site requiring skin graft or local flaps. see section 533.5 (b) (6) (i)). Values for following items (0312-0323) do NOT include extensive immobilizing; for plaster casts see 1851-1890 for values for these services. 0312 Pedicle flap, direct or tubed,

(including direct closure of donor site) trunk 20.0 45 0313 scalp, arms and legs 30.0 45 0314 forehead, cheeks, chin, mouth,

neck, axilla, genitalia, hands and feet 40.0 45 0315 eyelids, nose, ears and lips 50.0 45

(For repair of donor site requiring skin graft or local flaps, see section 533.5 (b) (6) (i)). 0316 delay, intermediate transfer or

sectioning of pedicle of tubed or direct flap, trunk 15.0 45 0317 scalp, arms and legs 22.0 45 0318 forehead, cheeks, chin, mouth,

neck, axilla, genitalia, hands and feet 30.0 45 0319 eyelids, nose, ears and lips 37.0 45 0320 excision of lesion and/or preparation

of recipient site and attachment of direct or tubed pedicle flap, trunk 30.0 45 0321 scalp, arms and legs 45.0 45 0322 forehead, cheeks, chin, mouth,

neck, axilla, genitalia, hands and feet 60.0 45 0323 eyelids, nose, ears and lips 75.0 45

(Revision, defatting or rearranging of transferred pedicle or flap skin graft, see 0260-0283 inclusive.) 0324 Composite graft (full thickness of

external ear or nasal ala) 25.0 45 3.0+T 0325 Derma-fat-fascia-graft (except

to breast--0484) 45.0 60 3.0+T 0330 Abrasion of skin, total face,

for removal of scars, tattoos, etc., primary 60.0 90 3.0+T 0331 secondary, total face 30.0 45 3.0+T 0333 regional (1/4 face, cheeks, chin,

forehead or elsewhere) primary 15.0 60 3.0+T 0334 secondary, regional 7.5 30 3.0+T 0335 Rhytidectomy, lower eyelids 60.0 30 3.0+T 0336 upper eyelids 40.0 30 3.0+T 0337 forehead 50.0 30 3.0+T 0338 glabellar frown 40.0 30 3.0+T 0339 cheeks, chin and neck 150.0 45 4.0+T 0340 Facial nerve paralysis, free

fascia grafts 100.0 100 4.0+T 0341 reanimation-muscle transfers 120.0 120 4.0+T

(For nerve transfers, decompression or suture, see 5350, 6002, 6003.) BURNS--List percentage of body surface involved and depth of burn. Does not include skin grafts. *0351 Initial treatment, first degree,

where no more than local treatment necessary *1.5 0 *0352 Dressings, initial or subsequent

under anesthesia, small *4.0 0 3.0+T *0353 under anesthesia, large or with

major debridement, per hour *10.0 0 3.0+T *0354 without anesthesia, small, office

or hospital *2.0 0 *0355 without anesthesia, medium (whole

face or whole extremity, etc.) *3.0 0 *0356 without anesthesia, large (more

than one extremity, etc.) *4.0 0 Destruction *0401 Electro-surgicai destruction with

or without surgical curettement of facial nevi, leukoplakia, actinic or senile keratoses, or keratoacanthomas, to include local anesthesia, one lesion *3.0 0 3.0+T

(50% for each additional lesion up to a total of three; over three, each additional lesion 25%.) 0402 complicated lesion(s) by report *0403 Electro-surgical destruction

(except 0401 and 0402) or chemocautery

(Mono-, Bi-, Trichloracetic acid, phenol, etc.) or cryocautery (liquid N(2), CO(2), etc.) of benign or pre-malignant lesions of skin or mucous membrane (except 0405 and 0406) with or without curettement, one lesion *2.0 0

(50% for second lesion; over two, each additional lesion 25%.) 0404 complicated lesion(s) by report *0405 flat (plane, juvenile) warts, up

to fifteen *2.0 0

(Retreatment same as routine office visit,) *0406 Electro-surgical destruction of

multiple fibro-cutaneous tags, up to fifteen *2.0 0 0408 Chemosurgery, (Mohs type technique),

malignancies of skin, includes removal of growth and microscopic delineation of margins and base, first stage--fulguration and application of chemicals 20.0 30 0409 each subsequent treatment, up to

five sections 5.0 30 0410 each additional section over

five 1.0 30 *0411 Cryotherapy--(CO(2), slush,

liquid N(2)) *1.5 0 *0412 Electrolysis epilation, and each

1/2 hour *3.0 0

(For actinotherapy and galvanic iontophoresis, see 9425-9427.) Breast Incision *0430 Puncture aspiration of cyst *2.0 0 0431 Mastotomy with exploration or

drainage of abscess, deep 10.0 14 3.0+T Excision 0441 Biopsy of breast 15.0 30 3.0+T 0444 Excision of cyst, fibro-adenoma or

other benign tumor, aberrant breast tissue, duct lesion (including gynecomastia) or nipple lesion (including any other partial mastectomy) male or female, unilateral 15.0 30 3.0+T 0445 bilateral 25.0 30 3.0+T 0446 Excision of chest wall tumor

involving ribs 70.0 60 9.0+T 0447 Excision of chest wall tumor

involving ribs plus plastic reconstruction 100.0 60 9.0+T 0457 Complete (simple) mastectomy 30.0 45 3.0+T 0470 Radical mastectomy, including

breast, pectoral muscles and axillary lymph nodes 70.0 60 3.0+T 0481 Mammoplasty, plastic operation on

breasts, reduction or repositioning, bilateral, one stage 150.0 90 3.0+T 0482 two stage by report 3.0+T 0483 augmentation, prosthetic,

unilateral 75.0 90 3.0+T 0484 bilateral 100.0 90 3.0+T 0485 derma-fat fascia, unilateral 100.0 90 3.0+T

MUSCULOSKELETAL SYSTEM Listed value include the application of first cast or traction device only. Values for major replacement casts and traction devices necessarily applied during listed period of aftercare to be added. Incision 0501 Aspiration or curette biopsy of

bone marrow 3.0 7 3.0+T

(For sternal or iliac puncture, see L116) 0502 Needle (Trocar) biopsy, vertebra 10.0 7 4.0+T *0506 Incision of superficial soft tissue

abscess secondary to osteomyelitis *2.0 0 3.0+T 0507 deep or complicated by report 3.0+T 0513 Sequestrectomy for osteomyelitis or

bone abscess by report 30 3.0+T 0516 Removal of metal band, plate, screw

or nail (independent procedure) 15.0 15 3.0+T

(For pins, etc., see 0596, 0599.) OSTEOTOMY--Cutting, division or transection of bone, with or without internal fixation. 0526 Clavicle 40.0 90 3.0+T 0527 Humerus 50.0 150 3.0+T 0529 Radius 40.0 120 3.0+T 0530 Ulna 40.0 120 3.0+T 0531 Femur, neck, under age 8 80.0 180 3.0+T 0532 over age 8 100.0 180 3.0+T 0533 subtrochanteric 80.0 180 3.0+T 0534 supracondylar 70.0 180 3.0+T 0536 Tibia 55.0 150 3.0+T 0537 Smaller bones (fibula, metacarpals,

metatarsals, etc.) 30.0 120 3.0+T 0538 Correction of bowlegs or

knock-knees, unilateral 50.0 150 3.0+T 0539 bilateral 75.0 150 3.0+T

(For iliac osteotomy, see 1341, 1342.) 0540 Multiple osteotomies, single bones

for realignment on intramedullary rod, Scofield type procedure, humerous 50.0 150 3.0+T 0541 radius or ulna 50.0 120 3.0+T 0542 femur 100.0 180 3.0+T 0543 tibia 75.0 150 3.0+T

Excision 0549 Biopsy bone, radius, ulna, fibula,

skull, sternum 10.0 15 3.0+T 0550 humerus, pelvis, femur, tibia 20.0 15 3.0+T 0551 vertebra 40.0 45 3.0+T

(For needle biopsy, see 0502.)

(Value of biopsy done preceding definitive surgery is 50 percent of listed value.) 0552 Claviculectomy, partial 35.0 60 3.0+T 0553 total 65.0 60 3.0+T 0554 Astragalectomy 55.0 120 3.0+T 0556 Excision of head of radius 35.0 90 3.0+T 0557 Carpectomy 30.0 90 3.0+T 0560 Coccygectomy 30.0 90 4.0+T 0561 Patelectomy or hemipatellectomy 50.0 120 3.0+T 0563 Metatarsectomy 25.0 60 3.0+T 0566 Excision of chondroma, osteochondroma, or exostosis; humerus, pelvis, femur, tibia, radius, fibula, ulna 40.0 150 3.0+T 0567 small bones 25.00 90 3.0+T 0568 Excision of bone cyst, simple,

large bones 40.0 120 3.0+T 0569 small bones 25.00 90 3.0+T

(With autogenous bone graft, add 10.0 units to 0568, 0569.) 0576 Partial ostectomy; partial excision

of bone, craterization, guttering or saucerization of bone; diaphysectomy; humerus, pelvis, femur, tibia, fibula, radius, ulna 50.0 150 3.0+T 0577 small bones 25.0 90 3.0+T 0578 Excision of tumor of mandible

without replacement 75.00 90 6.0+T

(For replacement see 0619.) 0580 Radical resection of bones for

tumor with bone graft; scapula, humerous, pelvis, femur, tibia 100.0 120 5.0+T 0581 other bones 65.0 90 3.0+T

Introduction

(For associated procedures, see Fractures.)

(For injection procedure for intraosseus venography, see radiology.) *0591 Insertion of wire, pin, caliper

or tongs (independent procedure) *5.0 0 3.0+T *0598 Removal buried wire or pin (independent procedure) *2.0 0 3.0+T *0599 Removal of caliper or tongs

(independent procedure) *1.0 0 3.0+T Repair 0611 Osteoplasty; shortening of bone,

femur, tibia, humerus 100.0 180 3.0+T 0612 radius, ulna 65.0 120 3.0+T 0613 other bones 45.0 90 3.0+T 0614 lengthening of bone 100.0 365 3.0+T 0616 mandible for prognathism or micrognathism, one or two stages 100.0 90 5.0+T BONE OR CARTILAGE GRAFT--Osteoperiosteal graft, periosteal graft, or cartilage graft. Includes obtaining and placing of graft. Unless otherwise indicated, values are for autogenous graft. When non-autogenous material is used, reduce value by 5.0 units. 0617 Bone graft; femur, tibia, humerus 100.0 180 3.0+T 0618 radius, ulna 65.0 150 3.0+T 0619 skull or significant portion of

mandible 100.0 180 7.0+T 0620 other bones, including chin, nose,

malar prominences 45.0 120 3.0+T 0621 Cartilage graft, autogenous, to

face, nose, ear or skull 70.0 120 7.0+T Spinal Fusion (For fusion of childhood scoliosis, see 0643, 0644, 0645.)

(Items 0634-0642 refer to spinal procedures at one interspace; for each additional interspace, add 10%.) (If two surgeons are involved, see sections 533.3(c) and 533.5

(b) (7).) 0634 Spinal fusion, cervical region,

posterior technique 90.0 180 7.0+T 0635 anterior technique 80.0 180 7.0+T 0636 thoracic region, posterior or

posterior -lateral technique 90.0 180 7.0+T 0637 interbody technique, anterior,

lateral or posterior 100.0 270 7.0+T 0638 lumbar region, posterior or

posterior -lateral technique 90.0 270 7.0+T

(For interbody technique, anterior see 0642.) 0639 Spinal fusion with removal of

intervertebral disc, cervical region, posterior, technique 120.0 180 7.0+T 0640 anterior interbody technique 80.00 180 7.0+T 0641 lumbar or thoracic region, posterior,

posterior-lateral, or posterior interbody technique 120.0 270 7.0+T 0642 anterior interbody technique 100.0 270 7.0+T 0643 Spinal fusion for scoliosis, child or

young adult (less than 18 years of age), up to and including five interspaces 120.0 270 7.0+T 0644 Harrington rod technique 150.0 270 7.0+T 0645 Halo technique 150.0 270 9.0+T

(For adult scoliotic fusion see 0634-0642.) 0647 Scapulopexy 65.0 90 6.0+T 0648 Patellapexy 50.0 90 3.0+T 0649 Pectus excavatum, infants, plastic repair 25.0 60 3.0+T 0650 Pectus excavatum (major) plastic repair 90.0 90 9.0+T 0654 Epiphyseal-diaphyseal fusion; epiphyseal

arrest; epiphysiodesis or stapling; femur 55.0 90 3.0+T 0655 tibia and fibula, proximal or distal 55.0 90 3.0+T 0656 combined distal femur and proximal tibia

and fibula (knee) 75.0 90 3.0+T 0657 combined proximal and distal, tibia and

fibula 75.0 90 3.0+T 0658 combined distal femur and proximal and

distal tibia and fibula 100.0 120 3.0+T 0660 Hemi-epiphyseal arrest (e.g. for genu

varus or genu valgus) distal femur 45.0 180 3.0+T

(For removal and re-insertion of staples at same operation, use values listed above.)

(For removal of staples only, 50% of listed values.) (Freeing of bone adhesions, callus or synostosis, independent procedure, see Ostectomy.) FRACTURES Skull 0681 Skull, non-operative Sv.ô

(Depressed with operation, see 5018, 5020.) Facial Bones 0685 Nasal, simple or compound, no reduction Sv.ô *0686 uncomplicated (digital) closed reduction *5.0 0 0687 complicated (instrumental) closed

reduction 10.0 30 4.0+T 0688 open reduction, uncomplicated 25.0 30 4.0+T 0689 complicated with either internal and/or

external skeletal fixation 40.0 45 4.0+T 0690 with concomitant open reduction of

fractured septum 60.0 45 4.0+T 0691 Malar, simple or compound, no reduction Sv.ô *0692 closed reduction (including towel clip

technique) *5.0 0 4.0+T 0693 depressed, open reduction 30.0 60 4.0+T 0694 complicated, depressed, open reduction

with internal skeletal fixation and multiple surgical approaches 65.0 90 5.0+T 0698 Maxilla, simple or compound, no reduction Sv.ô 0699 closed reduction, with

wiring of teeth 30.0 90 4.0+T 0701 open reduction, with wiring of teeth

and/or local fixation 50.0 90 4.0+T 0702 complicated, open reduction, fixation

by head cap, multiple surgical approaches, internal fixation, wiring teeth, etc by report 90 6.0+T

(For antral approach, see 1988.) 0703 Mandible, simple or compound, no reduction Sv.ô 0704 closed reduction and wiring of teeth 30.0 90 4.0+T 0705 open reduction with or without wiring

of teeth 50.0 90 4.0+T 0706 skeletal pinning with external fixation 40.0 90 4.0+T

Spine and Trunk 0720 Vertebral process, one or more Sv.ô 0721 Vertebral body, one or more not requiring

reduction Sv.ô 0722 requiring reduction 30.0 180 3.0+T 0732 Sacrum, simple, not requiring reduction Sv.ô 0733 compound or complex by report 0735 Coccyx, simple, not requiring reduction Sv.ô 0736 compound or complicated by report 0740 Clavicle, simple, no reduction Sv.ô 0741 simple, closed reduction 15.0 90 3.0+T 0742 compound, including uncomplicated soft

tissue closure 20.0 90 3.0+T 0743 simple or compound, open reduction 40.0 120 3.0+T 0747 Scapula, simple, no reduction Sv.ô 0748 simple or compound, open reduction 55.0 90 3.0+T 0756 Sternum, simple Sv.ô 5757 compound or complicated by report 3.0+T 0761 Ribs, simple Sv.ô 0762 compound or complicated by report 3.0+T

Pelvis (Ilium, Ischium, Pubis) 0767 Fracture, simple, no reduction Sv.ô 0768 complicated, closed reduction by report 3.0+T 0771 compound, open reduction 75.0 120 3.0+T 0772 Acetabulum, with or without other

fractures of pelvis, simple, no reduction Sv.ô 0773 central, with displacement, requiring

closed reduction 55.0 180 3.0+T 0775 simple or compound, open reduction 75.0 180 3.0+T

Upper Extremity 0778 Humerus, surgical neck, simple, not

requiring reduction Sv.ô 0780 requiring manipulative reduction 30.0 120 3.0+T 0781 compound, with uncomplicated soft

tissue closure 35.0 120 3.0+T 0782 simple or compound, open reduction 50.0 120 3.0+T 0783 shaft, simple, not requiring

reduction Sv.ô 0784 simple, closed reduction 25.0 120 3.0+T 0785 compound with uncomplicated soft tissue

closure 30.0 120 3.0+T 0786 simple or compound, open reduction 45.0 120 3.0+T 0787 simple or compound, open reduction,

skeletal pinning with external fixation 40.0 120 3.0+T 0788 supracondylar or dicondylar, nor requiring

reduction Sv.ô 0789 closed reduction 25.0 120 3.0+T 0790 compound with uncomplicated soft tissue

closure 30.0 120 3.0+T 0791 simple or compound, open reduction 50.0 120 3.0+T 0792 medial or lateral condyle, simple not

requiring reduction Sv.ô 0793 closed reduction 20.0 120 3.0+T 0794 compound with uncomplicated soft tissue

closure 25.0 120 3.0+T 0795 simple or compound, open reduction 40.0 120 3.0+T 0796 Elbow, proximal end of ulna with dislocation

dislocation of radial head, simple,

(Monteggia fracture) closed reduction 20.0 90 3.0+T 0797 simple or compound, open reduction 55.0 120 3.0+T

(see also 1292.) 0798 Radius, head, simple, no reduction Sv.ô 0799 closed reduction 15.0 60 3.0+T 0800 compound with uncomplicated soft

tissue closure 20.0 60 3.0+T 0801 simple or compound, open reduction

or excision

(See also 0556.) 35.0 90 3.0+T 0802 shaft, simple, no reduction Sv.ô 0803 simple, closed reduction 20.0 120 3.0+T 0804 compound, with uncomplicated soft

tissue closure 25.0 120 3.0+T 0805 simple or compound, open reduction 40.0 150 3.0+T 0806 distal end (e.g. Colle's type),

simple, no reduction Sv.ô 0807 closed reduction 15.0 120 3.0+T 0808 with severe comminution and

impaction, closed reduction 20.0 120 3.0+T 0809 simple or compound, open reduction 40.0 120 3.0+T 0810 skeletal pinning, with external fixation 30.0 120 3.0+T 0811 Ulna, proximal end, olecranon process,

simple, no reduction Sv.ô 0812 compound with uncomplicated soft

tissue closure 25.0 120 3.0+T 0813 simple or compound, open reduction and/or

resection 40.0 120 3.0+T 0814 shaft, simple, no reduction Sv.ô 0815 closed reduction 20.0 120 3.0+T 0816 compound, with uncomplicated soft

tissue closure 25.0 120 3.0+T 0817 simple or compound, open reduction 40.0 120 3.0+T 0818 skeletal pinning with external fixation 30.0 120 3.0+T 0820 Radius and ulna shaft, simple,

no reduction Sv.ô 0821 simple, closed reduction 25.0 120 3.0+T 0822 compound, with uncomplicated soft

tissue closure 30.0 120 3.0+T 0823 simple or compound, open reduction 50.0 150 3.0+T 0824 skeletal pinning with external fixation 40.0 150 3.0+T

(For Colle's fracture see 0806-0810.) 0827 Carpal bones, one or more, simple

reduction Sv.ô 0830 simple or compound, open reduction 35.0 120 3.0+T 0840 Metacarpal, simple, no reduction Sv.ô 0842 one, simple or compound, closed reduction

with uncomplicated soft tissue closure 10.0 45 3.0+T 0843 more than one, simple or compound,

closed reduction, with uncomplicated soft tissue closure 12.5 60 3.0+T 0844 one or more, simple or compound, open

reduction 30.0 90 3.0+T 0848 skeletal pinning with external fixation 25.0 90 3.0+T 0852 Phalanx or phalanges, finger, proximal,

middle or thumb, simple, no reduction Sv.ô 0853 closed reduction 7.5 45 3.0+T 0854 compound, with uncomplicated soft tissue

closure 10.0 45 3.0+T 0855 simple or compound, open reduction 20.0 60 3.0+T 0856 Phalanx or phalanges, distal, simple,

no reduction Sv.ô 0857 simple or compound, closed reduction with

uncomplicated soft tissue closure 5.0 30 3.0+T 0858 simple or compound, open reduction 12.5 45 3.0+T

LOWER EXTREMITY 0865 Femur, neck, simple, no reduction Sv.ô 0866 with fixation or traction 50.0 180 3.0+T 0867 simple or compound, open reduction 80.0 180 5.0+T 0868 multiple pinning, with or without

external fixation 80.0 180 5.0+T 0869 treatment with replacement prosthesis 80.0 180 6.0+T 0872 intertrochanteric, simple, no reduction Sv.ô 0873 with fixation or traction 45.0 180 3.0+T 0874 simple or compound, open reduction 80.0 180 5.0+T 0877 slipped epiphysis, no reduction, treatment

by traction, bed rest or cast application Sv.ô 0878 open reduction, single or multiple pinning

or bone graft 80.0 180 5.0+T 0879 reconstruction 100.0 180 5.0+T 0880 shaft, including supracondylar, simple,

no reduction Sv.ô 0881 simple, closed reduction 40.0 180 3.0+T 0882 compound, with uncomplicated soft tissue

closure 45.0 180 3.0+T 0883 simple or compound, open reduction 80.0 180 3.0+T 0884 skeletal pinning with external fixation 60.0 180 3.0+T 0885 distal end, medial or lateral condyle,

simple, no reduction Sv.ô 0886 condyle or condyles, simple, closed

reduction 35.0 120 3.0+T 0887 simple or compound, open reduction 60.0 150 3.0+T 0889 Patella, simple, no reduction Sv.ô 0890 compound, with uncomplicated soft tissue

closure 25.0 120 3.0+T 0891 simple or compound, open reduction 50.0 120 3.0+T 0893 Tibia, proximal end, tibial plateaus,

condyle, condyles or intercondylar spines, simple, no reduction Sv.ô 8894 close reduction 25.0 120 3.0+T 0895 compound with uncomplicated soft tissue

closure 30.0 120 3.0+T 0896 simple or compound, open reduction 55.0 150 3.0+T 0901 shaft, simple, no reduction Sv.ô 0902 closed reduction 25.0 180 3.0+T 0903 compound with uncomplicated soft tissue

closure 30.0 180 3.0+T 0904 simple or compound, open reduction 50.0 180 3.0+T 0905 simple or compound, open or "blind"

insertion of intramedullary rod (e.g. Lottes nail) 50.0 180 3.0+T 0907 distal end, malleolus, simple, no

reduction Sv.ô 0908 simple, closed reduction 15.0 120 3.0+T 0909 compound with uncomplicated soft tissue

closure 20.0 120 3.0+T 0910 simple or compound, open reduction 40.0 120 3.0+T 0914 Fibula, shaft, simple, no reduction Sv.ô 0915 compound, with uncomplicated soft tissue

closure 20.0 60 3.0+T 0916 simple or compound, open reduction 30.0 60 3.0+T 0920 distal end, malleolus, simple,

no reduction Sv.ô 0921 closed reduction 15.0 75 3.0+T 0922 compound with uncomplicated soft tissue

closure 20.0 120 3.0+T 0923 simple or compound, open reduction 40.0 120 3.0+T 0925 Tibia and fibula, shafts, simple,

no reduction Sv.ô 0926 closed reduction 30.0 180 3.0+T 0927 compound with uncomplicated soft tissue

closure 35.0 180 3.0+T 0928 simple or compound, open reduction 60.0 180 3.0+T 0930 skeletal pinning with external fixation 40.0 180 3.0+T 0932 Ankle, bimalleolar (including Potts)

simple, no reduction Sv.ô 0933 simple, closed reduction 25.0 150 3.0+T 0934 compound with uncomplicated soft tissue

closure 30.0 150 3.0+T 0935 simple or compound, open reduction 50.0 150 3.0+T 0937 trimalleolar, simple, no reduction Sv.ô 0938 closed reduction 30.0 150 3.0+T 0940 compound with uncomplicated soft tissue

closure 35.0 150 3.0+T 0941 simple or compound, open reduction 60.0 150 3.0+T 0943 Tarsal (except astragalus and os calcis)

one or more, simple, no reduction Sv.ô 0944 closed reduction 10.0 90 3.0+T 0945 compound with uncomplicated soft tissue

closure 15.0 90 3.0+T 0946 simple or compound, open reduction 30.0 90 3.0+T 0954 Astragalus, simple, no reduction Sv.ô 0955 simple, closed reduction 20.0 120 3.0+T 0956 compound with uncomplicated soft tissue

closure 25.0 120 3.0+T 0957 simple or compound, open reduction 55.0 120 3.0+T 0960 Os calcis, simple, no reduction Sv.ô 0961 closed reduction 20.0 120 3.0+T 0962 compound, with uncomplicated soft tissue

closure 25.0 270 3.0+T 0963 simple or compound, open reduction 50.0 270 3.0+T 0964 skeletal pinning with external fixation 40.0 270 3.0+T 0966 Metatarsal, simple, no reduction Sv.ô 0967 closed reduction 10.0 90 3.0+T 0968 compound with uncomplicated soft tissue

closure 15.0 90 3.0+T 0970 simple or compound, open reduction 25.0 90 3.0+T 0975 Phalanx or phalanges, great toe, simple,

no reduction Sv.ô 0976 simple, closed reduction 5.0 60 3.0+T 0977 simple or compound, open reduction 15.0 60 3.0+T 0979 other than great toe, simple, no reduction Sv.ô 0981 closed reduction 5.0 60 3.0+T 0982 simple or compound, open reduction 12.5 60 3.0+T

Joints Incision ARTHROTOMY or capsulotomy with exploration, drainage, or removal of loose body, e.g., osteochondritis or foreign body. 1001 Shoulder 50.0 90 3.0+T 1002 Elbow 50.0 60 3.0+T 1003 Wrist 40.0 60 3.0+T 1005 Other joints of upper extremity 30.0 60 3.0+T 1006 Finger, one 15.0 60 3.0+T 1007 Hip 70.0 90 3.0+T 1008 Knee 50.0 90 3.0+T

(For meniscectomy, see 1082.) 1010 Ankle 50.0 90 3.0+T 1013 Other joints of lower extremity 30.0 90 3.0+T 1020 Toe great toe 15.0 60 3.0+T 1026 other 10.0 60 3.0+T *1044 Arthrocentesis; puncture for aspiration of

hemarthrosis, initial *3.0 0 3.0+T *1045 subsequent *2.0 0 3.0+T *1046 puncture for aspiration of joint effusion

(not traumatic), or injection of medication, initial or subsequent *2.0 0 3.0+T 1050 Sesamoid bone, excision, one or more,

unilateral 15.0 60 3.0+T Excision ARTHRECTOMY--Excision of joint (See also Arthrodesis.) 1065 Temporomandibular joint, unilateral 75.0 90 5.0+T 1074 Excision of intervertebral disc 90.0 90 7.0+T

(See also 5208-5211.)

(With spinal fusion, see 0639-0642.)

(For laminectomy for spondylolisthesis, see 5225.) 1082 Menisectomy: excision of semilunar

cartilage of knee joint 50.0 90 3.0+T 1085 temporomandibular joint 75.0 90 5.0+T 1093 Synovectomy elbow 70.0 120 3.0+T 1101 hip 80.0 120 4.0+T 1102 knee 70.0 120 3.0+T 1103 ankle 50.0 120 3.0+T

Introduction *1131 injection procedure for arthrography 3.0 0 3.0+T

Repair ARTHROPLASTY--plastic or reconstructive operation on joint, any type unless otherwise specified. 1141 Shoulder (See also 1200, 1201) 80.0 120 3.0+T 1142 Elbow 80.0 120 3.0+T 1143 Wrist 80.0 120 3.0+T 1144 Finger, one joint 30.0 90 3.0+T 1148 Hip, cup 100.0 270 5.0+T 1149 replacement prosthesis, primary for

fracture 80.0 270 5.0+T 1150 secondary reconstruction 100.0 270 5.0+T

(For acetabuloplasty, either 1148 or 1150, add 25% to listed values.) 1151 Knee 100.0 270 3.0+T 1152 Ankle 75.0 180 3.0+T 1154 Toe, one joint 20.0 60 3.0+T 1159 Metatarsal--phalangeal joint; bunion

operation, Silver type 20.0 60 3.0+T 1160 Keller, McBride, etc., types 30.0 120 3.0+T 1162 Joplin type 35.0 150 3.0+T 1163 Club foot corrective procedure, medial

release, Brockman type 30.0 120 3.0+T ARTHRODESIS--Fusion of joint (For spine see 0634-0645.) 1166 Shoulder 90.0 150 3.0+T 1167 Elbow 70.0 150 3.0+T 1168 Wrist 60.0 120 3.0+T 1170 Finger, thumb, one joint 20.0 120 3.0+T 1175 Hip 100.0 365 5.0+T 1176 Knee 80.0 180 3.0+T 1177 Ankle 70.0 180 3.0+T 1178 Toe, one or more joints 15.0 120 3.0+T 1179 Hammer toe operation, one toe (e.g.,

interphalangeal fusion, filleting, phalangectomy) 20.0 120 3.0+T

(More than one toe, see section 533.5(b) (6) (i).) 1183 Tarsal joints, one or more (e.g. Grice

procedure) 50.0 120 3.0+T 1184 Other joints, lower extremity 40.0 120 3.0+T 1185 Foot, triple arthrodesis, unilateral under

age 14 years 50.0 180 3.0+T 1186 over age 14 years 60.0 180 3.0+T

(With tendon transplantation see 1585, 1586, and see section 533.5(b) (6) (i).) Suture CAPSULORRAPHY OR RECONSTRUCTION 1200 Shoulder, suture or repair of joint capsule

for recurrent dislocation (independent procedure), Putti-Platt, Magnusen types 70.0 90 3.0+T 1201 Bankart type 80.0 90 3.0+T 1206 Patella, (See also 0561, 1352, 1632) 60.0 120 3.0+T 1211 Knee, suture of a torn, ruptured or severed

collateral ligament 55.0 120 3.0+T 1212 suture of a torn, ruptured, or severed

cruciate ligament 55.0 120 3.0+T 1213 suture of torn, ruptured or severed

collateral and cruciate ligaments 75.0 180 3.0+T 1214 reconstruction of a collateral or cruciate

ligament 65.0 180 3.0+T 1215 both collateral or cruciate ligaments 85.0 180 3.0+T 1216 Ankle, reconstruction of a collateral

ligament, ankle 45.0 180 3.0+T 1217 both ligaments 60.0 180 3.0+T 1218 Hand, reconstruction, metacarpophalangeal

or interphalangeal ligaments 35.0 90 3.0+T Manipulation Manipulation of joint under general anesthesia, including application of fixation apparatus

(dislocation excluded).

(For club feet and turnbuckle casts, see section on casts.) *1221 Shoulder *5.0 0 3.0+T *1222 Elbow *4.0 0 3.0+T *1223 Wrist *4.0 0 3.0+T *1224 Digits, one or more, under anesthesia,

where no other surgical procedure is performed *2.5 0 3.0+T *1226 Hip *6.0 0 3.0+T *1227 Knee *5.0 0 3.0+T *1228 Ankle *4.0 0 3.0+T *1232 Spine *6.0 0 3.0+T

Dislocations *1251 Temporomandibular, simple, closed

reduction, initial *5.0 0 3.0+T *1252 subsequent *1.0 0 1255 Vertebra, cervical, simple, closed

reduction, using traction Sv.ô 1256 closed reduction with anesthesia 55.0 180 3.0+T 1262 thoracic, simple, closed reduction with

anesthesia 55.0 180 3.0+T 1264 simple or compound, open reduction 100.0 180 6.0+T 1267 lumbar, simple, closed reduction with

anesthesia 55.0 180 3.0+T 1270 simple or compound, open reduction 100.0 180 6.0+T 1273 Clavicle, sternoclavicular, simple, no

reduction Sv.ô 1274 closed reduction with anesthesia 10.0 45 3.0+T 1275 simple or compound, open reduction 40.0 120 3.0+T 1278 acromioclavicular, simple, no reduction Sv.ô 1279 closed reduction with anesthesia 10.0 45 3.0+T 1281 simple or compound, open reduction 40.0 120 3.0+T 1284 Shoulder (humerus), simple, closed

reduction, without anesthesia Sv.ô *1285 with anesthesia *5.0 0 3.0+T 1286 simple or compound, open reduction 55.0 120 3.0+T *1290 Elbow, simple, closed reduction *5.0 0 3.0+T 1291 compound with uncomplicated soft tissue

closure 25.0 120 3.0+T 1292 simple or compound, open reduction 55.0 120 3.0+T *1295 Wrist, carpal, one bone, simple, closed

reduction *5.0 0 3.0+T 1296 compound, with uncomplicated soft tissue

closure 25.0 120 3.0+T 1297 simple or compound, open reduction 45.0 120 3.0+T *1298 more than one bone, simple, closed

reduction *7.0 0 3.0+T 1300 compound, with uncomplicated soft tissue

closure 25.0 120 3.0+T 1301 simple or compound, open reduction 45.0 120 3.0+T *1304 Metacarpal, one bone, simple, closed

reduction *3.0 0 3.0+T 1305 compound with uncomplicated soft tissue

closure 10.0 90 3.0+T 1306 simple or compound, open reduction 20.0 90 3.0+T *1315 Finger, one, one or more joints, simple,

closed reduction *3.0 0 3.0+T 1316 compound, with uncomplicated soft tissue

closure 7.5 75 3.0+T 1317 simple or compound, open reduction 15.0 75 3.0+T *1326 Thumb, simple, closed reduction *4.0 0 3.0+T 1327 compound with uncomplicated soft tissue

closure 10.0 75 3.0+T 1328 simple or compound, open reduction 20.0 75 3.0+T 1332 Hip (femur), simple, closed reduction 20.0 180 3.0+T 1334 simple or compound, open reduction 60.0 180 5.0+T 1338 congenital, abduction splinting or

traction in any form Sv.ô 1339 congenital, closed reduction with

anesthesia 20.0 45 3.0+T 1340 congenital, open reduction and replacement

of femoral head in acetabulum 60.0 180 4.0+T 1341 iliac or acetabular osteotomy, (e.g.,

Pemberton or Salter type), under age 8 80.0 180 4.0+T 1342 over age 8 100.0 180 5.0+T

(For dislocated or slipped femoral head epiphyses, see (0877-0879.) 1344 Knee (femoral-tibial joint), simple,

closed reduction 20.0 90 3.0+T 1345 compound with uncomplicated soft tissue

closure 25.0 120 3.0+T 1346 simple or compound, open reduction 60.0 120 3.0+T *1350 Patella, simple, closed reduction *3.0 0 1351 compound with uncomplicated soft tissue

closure 15.0 120 3.0+T 1352 simple or compound, open reduction

(with or without partial or total patellectomy) 50.0 120 3.0+T

(See also 0561, 1206 and 1632.) 1354 Distal tibial-fibular joint (ankle

mortise), open reduction and fixation 45.0 90 3.0+T 1355 Ankle, simple, closed reduction 10.0 90 3.0+T 1356 compound, with uncomplicated soft tissue

closure 25.0 90 3.0+T 1357 simple or compound, open reduction 50.0 90 3.0+T 1361 Tarsal, simple, closed reduction 10.0 90 3.0+T 1362 compound, with uncomplicated soft tissue

closure 17.5 90 3.0+T 1363 simple or compound, open reduction 45.0 120 3.0+T 1371 Astragalo-tarsal, simple, closed reduction 10.0 90 3.0+T 1372 compound with uncomplicated soft tissue

closure 17.5 180 3.0+T 1373 simple or compound, open reduction 45.0 180 3.0+T 1376 Metatarsal, one bone, simple, closed

reduction 7.0 45 3.0+T 1377 compound with uncomplicated soft tissue

closure 12.0 60 3.0+T 1378 simple or compound, open reduction 25.0 60 3.0+T *1385 Toe, one, simple, closed reduction *2.0 0 1386 compound with uncomplicated soft tissue

closure 7.0 15 3.0+T 1387 simple or compound, open reduction 15.0 45 3.0+T 1391 multiple joints and/or toes, simple,

closed reduction 7.0 30 3.0+T 1392 compound with uncomplicated soft tissue

closure 12.0 45 3.0+T 1393 simple or compound, open reduction 20.0 45 3.0+T

Bursae Incision *1401 Drainage of infected bursa *3.00 3.0+T 1406 Removal of subdeltoid calcium deposits 25.0 60 3.0+T 1410 Removal of subtrochanteric calcium

deposits 30.0 60 3.0+T *1413 Needle puncture of bursa, with or without

aspiration, injection or irrigation, initial or subsequent *2.0 0 Excision 1430 Radical excision of bursa, hand, wrist or

forearm, (i.e., tenosynovitis fungosa, Tbc., and other granulomas) 50.0 60 3.0+T 1431 Excision of bursa, olecranon 20.0 60 3.0+T 1433 prepatellar 20.0 60 3.0+T 1435 subacromial (subdeltoid) 25.0 90 3.0+T 1436 peritrochanteric, femur 30.0 90 3.0+T

(For popliteal see 1562.) Muscles Incision 1450 Removal of foreign body in muscle, with

anesthesia by report 1454 Division of scalenus anticus, without

resection of cervical rib 35.0 60 3.0+T 1456 with resection of cervical rib 50.0 60 5.0+T 1458 Division of sternocleidomastoid for

torticollis, open operation 35.0 60 3.0+T 1460 Muscle biopsy, superficial 5.0 15 3.0+T 1462 deep 10.0 15 3.0+T

Suture 1495 Suture of ruptured diaphragm, chronic,

transabdominal 70.0 60 5.0+T 1496 transthoracic or combined 80.0 60 11.0+T 1497 acute, traumatic by report 60 13.0+T

(For other specific muscles, see 1633, 1640, 1654.) Tendons, Tendon Sheaths and Fascia Incision *1511 Drainage of tendon sheath, acute

suppurative tenosynovitis, one digit *3.0 0 3.0+T 1514 single palmar and/or ulnar or radial bursa 30.0 60 3.0+T 1515 multiple or complicated by report 60 3.0+T *1517 Injection of medication, tendon sheath *2.0 0 1519 Incision of fibrous sheath of tendon for

stenosing tenosynovitis, including freeing of tendons or removal of foreign body 20.0 30 3.0+T 1531 Division of iliotibial band, open

operation 30.0 45 3.0+T 1534 Stripping of ilium (Soutter operation) 40.0 90 3.0+T

Tenotomy *1535 Tenotomy, subcutaneous, corrective, single

digit *5.0 0 3.0+T *1536 multiple digits *7.5 0 3.0+T 1537 adductor, hip 10.0 15 3.0+T 1538 open, elbow to shoulder, single 20.0 30 3.0+T 1539 multiple 25.0 30 3.0+T 1540 elbow to wrist, single 15.0 30 3.0+T 1541 multiple 25.0 30 3.0+T 1542 knee to hip, single 30.0 45 3.0+T 1543 multiple 40.0 45 3.0+T 1544 knee to thigh, single 15.0 45 3.0+T 1545 multiple 30.0 45 3.0+T

Exclusion 1550 Excision of lesion of tendon or fibrous

sheath, or ganglion, digits only 10.0 30 3.0+T 1553 in other locations 15.0 30 3.0+T

(For radical excision of bursa, forearm, i.e., tenosynovitis fungosa, Tbc., and other granulomas, see 1430.) 1562 Excision of synovial cyst of popliteal

space (Baker's cyst) 30.0 60 5.0+T 1570 Fasciotomy, palmar or plantar,

subcutaneous 10.0 60 3.0+T 1573 Fasciectomy, for Dupuytren's contracture

partial 30.0 60 3.0+T 1574 radical, including finger extensions and

vertical bands 50.0 90 3.0+T Repair Includes necessary initial dressing

(including cast and/or splint application).

(For multiple structures unless otherwise specified see 1593 or section 533.5(a)

(6) (i).) 1580 Repair or suture of an extensor tendon,

primary or late, hand or foot, distal to wrist or ankle 12.0 60 3.0+T 1582 forearm or leg 18.0 60 3.0+T 1583 Repair or suture of a flexor tendon,

primary or late, finger, hand or forearm, foot or leg 30.0 120 3.0+T 1585 Transfer, transplant or free tendon graft,

distal to elbow, or distal to knee, single 40.0 120 3.0+T 1586 multiple 50.0 120 3.0+T 1587 elbow to shoulder or knee to hip, single 50.0 120 3.0+T 1588 multiple 60.0 120 3.0+T 1589 Tenolysis, single 25.0 60 3.0+T 1590 multiple (any number through same

incision) 30.0 60 3.0+T 1591 Lengthening or shortening of tendon, (e.g.

Achilles' tendon) 30.0 60 3.0+T

(Retrieve or reroute tendon through separate incision, add 25 percent of appropriate fee.) 1593 Multiple tendons and/or other structures

through same incision or wound by report 3.0+T 1612 Free fascial graft for reconstruction of

tendon pulley or gliding surface, etc. 15.0 90 3.0+T 1616 Abdominal fascial transplants, bilateral

(Lowman type procedure) 75.0 90 3.0+T

(For free fascial graft to face see 0340.) 1618 Fascia lata transplants, other by report 3.0+T 1632 Patellar (extensor mechanism) advancement,

with or without patellectomy 80.0 90 3.0+T 1633 Ruptured quadriceps insertion 45.0 90 3.0+T 1635 Ruptured Achilles tendon from insertion

at heel 45.0 120 3.0+T 1639 Ruptured long head of biceps, proximal 35.0 90 3.0+T 1640 Ruptured biceps tendon from insertion at

elbow 45.0 90 3.0+T 1641 Flexor-plasty, elbow (e.g. Steindler type

advancement or extensor release) 30.0 90 3.0+T 1664 Repair ruptured supraspinatus tendon or

musculotendinous cuff shoulder, acute 50.0 120 3.0+T 1655 Repair of complete shoulder cuff avulsion,

chronic 70.0 150 3.0+T

EXTREMITIES

Incision *1681 Drainage of felon, superficial *2.0 0 3.0+T *1682 in hospital *5.0 0 3.0+T

(For drainage of single or multiple infected spaces of hand, lumbrical, hypothenar, thenar, middle palmar, etc. with or without tendon sheath involvement, see 1514, 1515.) Amputation UPPER EXTREMITY: 1701 Interthoracoscapular 100.0 90 11.0+T 1703 Disarticulation of shoulder 75.0 90 5.0+T 1705 Arm through humerus 40.0 90 3.0+T 1708 Forearm, through radius and ulna 40.0 90 3.0+T 1709 Open (Guillotine) arm 35.0 90 3.0+T *1710 secondary closure or minor scar revision *5.0 0 3.0+T 1711 re-amputation 40.0 90 3.0+T 1713 Cineplasty, complete procedure 75.0 150 3.0+T 1718 Disarticulation through wrist or amputation

of hand through metacarpal bones 40.0 90 3.0+T 1725 Metacarpal, with finger or thumb, one,

with or without split or Wolff graft, or skin-plasty and/or tenodesis, with or without resection of digital nerves 30.0 60 3.0+T 1737 Digit (finger or thumb), any joint or

phalanx, one, with or without split or Wolff graft, or skin-plasty and/or tenodesis, with or without resection of digital nerves 15.0 45 3.0+T LOWER EXTREMITY: 1745 Interpelviabdominal by report 11.0+T 1748 Disarticulation of hip 80.0 180 8.0+T 1750 Disarticulation of knee 40.0 120 3.0+T 1752 Thigh, through femur, including

supracondylar 60.0 120 3.0+T 1760 open (Guillotine) 50.0 180 3.0+T *1761 secondary closure or minor revision *5.0 0 3.0+T 1763 reamputation 60.0 120 3.0+T 1767 Leg, through tibia and fibula 50.0 90 3.0+T 1771 open (Guillotine) 40.0 120 3.0+T *1772 secondary closure or minor revision *5.0 0 3.0+T 1774 reamputation 50.0 90 3.0+T 1778 Ankle (Syme, Pirogoff types), with skinplasty and resection of nerves 50.0 90 3.0+T 1782 Midtarsal 35.0 90 3.0+T 1785 Foot, transmetatarsal 35.0 90 3.0+T 1788 Metatarsal with toe, with or without split

or Wolff graft, or skin-plasty and/or tenodesis, with or without resection of digital nerves 25.0 90 3.0+T 1802 Toe, one, with or without split or Wolff

graft, or skin-plasty and/or tenodesis, with or without resection of digital nerves10.0 45 3.0+T 1803 more than one 15.0 60 3.0+T

Repair 1811 Freeing of web fingers, with flaps 35.0 60 3.0+T 1815 with skin graft 45.0 60 3.0+T 1816 complex by report

Plaster Casts (Independent Procedure Only)

(Excluding Cost of Materials) 1840 Club-foot cast with molding or

manipulation, long or short leg, under age of 24 months, single 2.0 2 3.0+T 1841 bilateral 3.5 2 3.0+T

(if over age 24 months, see casts, general.) 1842 Wedgling club-foot cast single 1.0 2 3.0+T 1843 bilateral 1.5 2 3.0+T

(For children 10 years of age or under, reduce listed values 1851-1890 by 30%.) 1851 Molded plaster to forearm (splint) 2.0 2 3.0+T 1854 Elbow to fingers (short arm) 2.0 2 3.0+T 1856 Hand and wrist (gauntlet) 2.0 2 3.0+T 1860 Shoulder to hand (full arm) 3.0 2 3.0+T 1862 Shoulder spica 6.0 2 3.0+T 1863 Thigh-foot, molded splint 3.0 2 3.0+T 1864 Leg-foot, molded splint 2.0 2 3.0+T 1865 Ankle (foot to midleg) (short leg) 3.0 2 3.0+T 1867 Knee (foot to thigh) (long leg) 4.0 2 3.0+T 1871 Ambulatory leg cast (walking boot cast) 3.5 2 3.0+T 1878 Hip spica, unilateral 7.0 2 3.0+T 1882 bilateral 8.0 2 3.0+T 1884 Body, shoulder to hips 8.0 2 3.0+T 1885 including head 10.0 2 3.0+T 1886 Risser jacket, localizer, body only 12.5 2 3.0+T 1887 including head 15.02 3.0+T 1888 Turnbuckle jacket, body only, for

scoliosis 12.5 2 3.0+T 1889 including head 15.0 2 3.0+T 1890 "Halo" type fixation and cast 20.0 2 3.0+T 1891 Unna boot 2.0 2 1892 Wedging cast, any age (except 1842-1843) 1.0 3.0+T 1894 Windowing a cast 1.0 3.0+T 1895 Removal or bivalving of cast applied by

another physician, small, (e.g., gauntlet, boot, body, full arm) 1.5 1896 large, (e.g., long leg, shoulder or hip

spica, Minerva, Calot jacket, turnbuckle, etc.) 2.0 1897 Repair of spica, body cast or jacket 3.0

(For change of cast, unit value will be that of application only.)

RESPIRATORY SYSTEM

Nose

Incision *1901 Drainage of nasal abscess or hematoma *2.0 0 3.0+T *1905 Drainage of septal abscess or hematoma *2.5 0 3.0+T

Excision 1911 Biopsy, soft tissue, nose 3.0 7 3.0+T 1916 Excision of nasal polyp(s) one or more,

unilateral or bilateral, one or more stages, office 7.0 15 3.0+T 1917 complicated, requiring hospitalization 20.0 30 3.0+T

(For excision of nasopharyngeal fibroma, see 3005.) 1924 Excision or surgical planing of skin of

nose for rhinophyina 35.0 60 3.0+T 1928 Submucous resection, classic, nasal septum 30.0 90 3.0+T

(For septoplasty, see 1952.) 1935 Resection of inferior turbinate

(submucous), complete or partial, unilateral or bilateral (independent procedure) 15.0 90 3.0+T Endoscopy *1941 Removal of intranasal foreign body by

rhinoscopy *2.0 0 3.0+T 1942 bylateral rhinotomy by report 3.0+T

Repair

(See also Repair-Complex 0260-0324, and 0620, 0621.) 1950 Rhinoplasty, lateral and alar cartilages

and/or elevation of nasal tip 40.0 180 3.0+T 1951 complete, external parts including bony

pyramid, lateral and alar cartilages, and/or elevation of nasal tip 80.0 180 3.0+T 1952 including major septal repair 90.0 180 3.0+T 1953 secondary minor revision 15.0 45 3.0+T

(For total or major partial reconstruction, see 0260-0324, 0620, 0621.)

(For nasal bridge collapse, bone or cartilage graft, see 0620, 0621.) 1954 Septoplasty, (not 1928) independent

procedure 40.0 90 3.0+T 1959 Repair, choanal atresia, intranasal 10.0 60 3.0+T 1960 transpalatine 60.0 365 3.0+T *1961 Lysis of synechia *2.0 0 3.0+T 1962 Repair of oromaxillary fistula by report 3.0+T 1963 with radical antrotomy 50.0 90 3.0+T 1964 Repair oronasal fistula 20.0 30 3.0+T 1965 Reconstruction, functional, of the

internal nose 40.0 90 3.0+T Destruction *1966 Cauterization of turbinates, unilateral

or bilateral (independent procedure) *2.0 0 Manipulation

(For reduction of fracture, see 0685-0690.) *1971 Nasal hemorrhage, anterior, control of,

unilateral or bilateral, with or without cauterization or anterior packs *2.0 0 *1973 posterior, with cauterization or

posterior nasal packs, with or without anterior pack, initial *10.0 0 3.0+T *1974 subsequent *2.0 0 3.0+T 1978 by ligation of anterior ethmoidal artery 30.0 30 3.0+T

ACCESSORY SINUSES Incision *1981 Antrum lavage, puncture or natural ostium,

unilateral *2.0 0 3.0+T *1982 bilateral *3.0 0 3.0+T *1983 Antroscopy *4.0 0 3.0+T 1985 Antrotomy, intranasal, unilateral 15.0 90 3.0+T 1986 bilateral 25.0 90 3.0+T 1988 Radical (Caldwell-Luc), unilateral 50.0 90 3.0+T 1989 bilateral 65.0 90 3.0+T 1991 Sphenoid sinusotomy 30.0 90 3.0+T 1992 Frontal sinusotomy, external, simple

(trephine operation) 20.0 30 3.0+T 1993 transorbital, unilateral 40.0 180 3.0+T 1994 radical, obliterative 60.0 180 3.0+T 1995 Combined external frontal, ethmoidal and

sphenoidal sinusotomy, unilateral 80.0 180 3.0+T Excision 2006 Ethmoidectomy, intranasal or external,

unilateral 30.0 90 3.0+T 2017 Maxillectomy, unilateral, with or without

orbital exenteration and/or lateral rhinotomy 100.0 365 3.0+T 2019 Hypophysectomy, transeptal 70.0 90 4.0+T

(See also 5130.)

LARYNX

Incision 2041 Laryngofissure with removal of tumor or

laryngocele 60.0 365 6.0+T 2042 Thyrotomy, diagnostic 35.0 60 6.0+T 2043 for laryngeal web, two stage, with

Keel insertion, (McNaught type) 90.0 365 6.0+T 2044 for laryngeal stenosis with graft

or core mold, including tracheotomy by report 6.0+T Excision 2051 Laryngectomy, without neck dissection 100.0 365 6.0+T 2054 with neck dissection 140.0 365 6.0+T 2055 Hemilaryngectomy 60.00 365 6.0+T 2056 Arytenoidectomy, external

approach (See also 2084.) 70.00 180 6.0+T 2057 Epiglottidectomy,

external approach 60.0 365 6.0+T 2058 endoral approach 25.0 90 4.0+T

Introduction *2060 Injection procedure for

bronchography, indirect method *3.0 0 4.0+T *2061 with insertion of catheter,

(independent procedure) *4.0 0 4.0+T *2062 Endotracheal intubation,

emergency procedure *5.0 0

Endoscopy 2070 Laryngoscopy, indirect

with biopsy 4.0 7 2071 direct, diagnostic

(independent procedure) 10.0 30 4.0+T 2072 operative, including foreign

body removal 30.0 30 4.0+T 2073 with biopsy 15.0 30 4.0+T 2074 including excision of tumor 25.0 180 4.0+T 2075 with Lynch suspension 30.0 180 4.0+T 2084 Endoscopic arytenoidectomy 50.0 180 4.0+T

TRACHEA AND BRONCHI

Incision 2101 Tracheotomy (independent

procedure) 20.0 15 4.0+T 2102 Tracheal fenestration 50.0 180 4.0+T

Endoscopy 2111 Bronchoscopy, diagnostic 15.0 30 4.0+T 2113 with biopsy 20.0 30 4.0+T 2117 with removal of foreign body 25.0 30 4.0+T 2120 with excision of tumor 25.0 30 4.0+T 2121 with therapeutic aspiration of bronchus 15.0 30 4.0+T 2122 with drainage of lung abscess or

cavity,initial 15.0 30 4.0+T 2123 with injection of contrast media 15.0 30 4.0+T 2124 subsequent 10.0 30 4.0+T 2126 Catheterization for bronchospirometry

(independent procedure) (exclusive of gasanalysis)

(See also 9201-9206.) 10.0 30 4.0+T 2127 Tracheal aspiration (independent

procedure) under direct vision 10.0 30 4.0+T *2128 indirect *1.0 0

Repair 2131 Tracheoplasty; plastic operation on

trachea, cervical by report 6.0+T 2132 intrathoracic by report 11.0+T 2133 Bronchoplasty, graft repair by report 11.0+T 2134 excision of stenosis and anastomosis by report 11.0+T 2135 with lobectomy and anastomosis by report 11.0+T

Suture 2141 Tracheorrhaphy: suture of external

tracheal wound or injury, depending on structure and extent of injury, cervical by report 5.0+T 2142 intrathoracic by report 11.0+T 2144 Closure of tracheostomy or tracheal

fistula 25.0 30 4.0+T 2147 Closure of tracheo-esophageal fistula 90.0 90 11.0+T 2148 complicated by report 90 11.0+T

Incision 2151 Thoracotomy, exploratory, including biopsy 50.0 90 11.0+T 2152 including control of hemorrhage and/or

repair of lung fistula 75.0 90 11.0+T 2153 for post-operative complications 75.0 90 11.0+T 2154 with open drainage of empyema cavity by

rib resection (independent procedure) 40.0 90 11.0+T 2155 with cyst removal 75.0 90 11.0+T *2157 with closed drainage of empyema cavity;

tube drainage with negative pressure

(independent procedure), in hospital *5.0 0 3.0+T 2160 with removal of intra-pleural foreign body

or fibrin body 70.0 90 11.0+T 2161 with cardiac massage by report 12.0+T 2163 with open intra-pleural pneumonolysis

(See also 2207.) 75.0 90 11.0+T 2170 Pneumonotomy, with open drainage of

pulmonary abscess or cyst 60.0 120 11.0+T 2173 with removal of foreign body from lung 75.0 90 11.0+T 2177 Decortication, pulmonary, total 100.0 90 11.0+T *2180 Pneumonocentesis: puncture of lung for

aspiration biopsy *5.0 0 *2183 Thoracentesis: puncture of pleural cavity

for aspiration, initial or subsequent *3.0 0 Excision 2191 Pneumonectomy, total 100.0 90 11.0+T 2193 Lobectomy, total, subtotal or segmental 100.0 90 11.0+T 2194 with concomitant decortication 125.0 90 11.0+T 2195 Wedge resection, single or multiple 80.0 90 11.0+T 2196 Pulmonary resection with concomitant

thoracoplasty 150.0 180 11.0+T 2197 Pleurectomy, any type (independent

procedure) 50.0 90 11.0+T Endoscopy 2201 Thoracoscopy, exploratory (independent

procedure) 20.0 30 4.0+T 2204 with biopsy 20.0 30 4.0+T 2207 Closed intrapleural pneumonolysis 30.0 30 4.0+T

Surgical Collapse Therapy Thoracoplasty 2211 Extrapleural resection of ribs, any type,

first stage 60.0 90 6.0+T 2212 second stage 30.0 90 5.0+T 2213 third stage 30.0 90 5.0+T 2217 Extrapleural pneumonolysis, including

associated filling or packing procedures 60.0 90 6.0+T 2218 Extraperiosteal pneumonolysis, including

associated filling or packing procedures 70.0 90 6.0+T *2221 Pneumothorax: intrapleural injection of

air, initial *5.0 0 *2222 subsequent *2.0 0

CARDIOVASCULAR SYSTEM Heart and Pericardium Values for principal surgeon only. For monitoring, operation of pump and other non-surgical services, see 9195, 9196, etc. Incision 2301 Cardiotomy, exploratory (includes removal

of foreign body) 100.0 90 15.0+T 2305 Pericardiotomy with exploration, drainage

or removal of foreign body 100.0 90 3.0+T *2309 Pericardiocentesis, initial *5.0 0 *2310 subsequent *4.0 0 2311 Blalock-Hanlon procedure (creation of

atrial-septal defect) (closed) 150.0 90 15.0+T Excision 2316 Pericardiectomy, extensive 120.0 90 15.0+T 2317 Excision intracardiac tumor 200.0 90 15.0+T 2319 Infundibular stenosis by report 15.0+T

Introduction Listed values include usual preassessment of clinical problem and recording of intracardiac pressures. (For consultation services, see 9028-9031.) 2330 Catheterization of heart, including

recording of intracardiac pressures where indicated (independent procedure) right 35.0 7 2331 left, percutaneous 15.0 7 2332 trans-septal 20.0 7 2333 retrograde 20.0 7 2334 combined left and right 45.0 7 2335 final evaluation and report only 5.0

(For injection procedures see radiology.) Suture 2337 Cardiorrhaphy: suture of heart wound

or injury 100.0 90 15.0+T Repair 2340 Aortic valve, valvotomy (commissurotomy)

(closed) 150.0 90 15.0+T 2341 valvuloplasty for stenosis or

insufficiency (open) 200.0 90 15.0+T 2342 replacement (open) 200.0 90 15.0+T 2343 Pulmonic valve, valvotomy (commissurotomy)

(closed) 150.0 90 15.0+T 2344 valvotomy; infundibular stenosis (open) 200.0 90 15.0+T 2345 Mitral valve, valvotomy (commissurotomy)

(closed) 140.0 90 15.0+T 2346 valvuloplasty for stenosis or

insufficiency (open) 200.0 90 15.0+T 2347 replacement (open) 200.0 90 15.0+T 2348 Tricuspid valve by report 90 15.0+T 2349 Coronary endarterectomy, myocardial

revascularization by implantation or anastomosis 100.0 90 15.0+T 2350 Myocardial aneurysm 200.0 90 15.0+T 2351 Atrial septal defect (secundum type;

endocardial cushion defect) (open) 180.0 90 15.0+T 2352 Ventricular septal defect (open) 180.0 90 15.0+T 2353 Tetralogy of Fallot (with or without

previous shunt) (open) 200.0 90 15.0+T 2354 Aortic sinus of Valsalva fistula (open) 200.0 90 15.0+T 2355 Repair anomalous pulmonary venous

connection, total (open) 200.0 90 15.0+T 2356 Insert internal pacemaker with myocardial

electrodes, initial 100.0 90 15.0+T 2357 replacement or repair 30.0 30 3.0+T 2358 Pervenous or transvenous insertion of

a pacemaker and subcutaneous implantation of a battery 50.0 30 3.0+T 2359 Subcutaneous implantation of a battery

(used with code 2330, right heart catheterization, currently in fee schedule) 18.75 7 3.0+T Arteries and Veins Incision ARTERIOTOMY--With removal of embolus: 2373 Trunk 80.0 60 6.0+T 2374 Neck 60.0 60 6.0+T 2375 Extremity 60.0 60 5.0+T

PHLEBOTOMY--With removal of thrombus: 2380 Trunk 70.0 60 5.0+T 2381 Extremity 45.0 60 4.0+T

Excision 2390 Thromboendarterectomy, abdominal aorta and

iliac arteries and/or femoral arteries 150.0 90 13.0+T 2392 femoral and/or popliteal arteries 120.0 90 5.0+T 2394 carotid artery 120.0 90 6.0+T 2400 Excision and graft or by-pass graft of

arch of aorta by report 90 15.0+T 2404 Excision and graft, thoracic aorta 150.0 90 15.0+T 2408 abdominal aorta 150.0 90 3.0+T 2412 extremity 120.0 90 5.0+T 2420 Excision of arteriovenous fistula

(See also 2474) by report Introduction

(For injection procedures see radiology.) 2441 Venopuncture, withdrawal of venous blood,

intravenous injection (femoral, internal or external juglar or sagittal sinus) for diagnostic study or introduction of intravenous therapy, up to three years of age 2.0 2442 scalp vein, for fluid therapy or indirect

transfusion, up to three year of age 3.0 2443 Exposure of and incision into vein

("cutdown") for fluid therapy or indirect transfusion, under one year of age 4.0 2444 over one year of age 3.0 2445 Blood transfusion, indirect method 2.0 0 2446 replacement type, infant, initial or

subsequent 30.0 15 2448 direct method 5.0 7 2450 "push" transfusion, given under two years

of age 5.0 0 *2454 Injection of sclerosing solution into

vein of leg, one *1.0 0 *2455 two or more injections, same leg *2.0 0

Repair 2460 Repair aneurysm of aorta, lateral repair 150.0 90 13.0+T 2464 dissecting ("window" operation) 150.0 90 13.0+T 2466 Banding of pulmonary artery 100.0 90 13.0+T 2472 Repair of aortic arch anomalies

(vascular ring) 120.0 90 15.0+T 2473 Repair of atrial septal defect 200.0 90 15.0+T 2474 Repair arterio-venous fistula, plastic

procedure by report 2475 Excision of corarctation of aorta with

primary anastomosis (See also 2400-2408.) 150.0 90 15.0+T

(For aortic anastomosis, see also 24002408, 2472.) 2478 Pulmonary--subclavian anastomosis,

Potts 150.0 90 15.0+T 2482 Blalock 120.0 90 15.0+T 2486 Pulmonary--superiorcaval anastomosis,

Glenn 150.0 90 15.0+T 2487 Baffes procedure: inferior cava to left

atrium-right pulmonary vein to right antrium 150.0 90 15.0+T 2490 Portocaval anastomosis 100.0 90 9.0+T 2496 Splenorenal anastomosis 100.0 90 9.0+T

Suture 2511 Arteriorrhaphy: suture of wound or injury Abdominal

of artery 6.0+T

(independent procedure), trunk or Thoracic

60.0 60 12.0+T 2512 extremity 60.0 60 4.0+T

Abdominal 2515 Phleborrhaphy: suture of wound or injury 4.0+T

of vein (independent procedure), trunk

or Thoracic

60.0 60 12.0+T 2516 extremity 60.0 60 4.0+T 2520 Ligation and division of ductus arteriosus 100.0 90 13.0+T 2522 Ligation of carotid artery 40.00 30 4.0+T 2525 Ligation and division of inferior vena

cava 60.0 90 5.0+T 2526 Ligation of femoral vein 25.0 30 3.0+T 2530 Ligation and division of common iliac

vein 50.0 90 3.0+T 2558 Ligation and division of long saphenous

vein at saphenofemoral junction, with or without retrograde injection or distal interruptions 20.0 30 3.0+T 2561 Ligation and division and complete stripping

of long or short saphenous veins, unilateral 30.0 30 3.0+T 2562 bilateral 50.0 30 3.0+T 2563 long and short saphenous veins, unilateral 40.0 30 3.0+T 2565 bilateral 60.0 30 3.0+T 2576 Ligation and division of short saphenous

vein at saphenopopliteal junction

(independent procedure) 12.5 30 3.0+T 2581 minor varicose vein of leg, initial 5.0 15 2585 subsequent 3.0 15

HEMODIALYSIS-RELATED SURGICAL PROCEDURES 2590 Insertion of initial arteriovenous shunt

(including revisions during 21 follow-up days) 50.0 21 by

report 2591 Revision of either arterial or

venous cannula 31.25 21 by

report 2592 Construction of arterio-venous fistula 50.0 21 by

report

HEMIC AND LYMPHATIC SYSTEMS Spleen Excision 2601 Splenectomy 60.0 45 6.0+T

Introduction 2610 Injection procedure for splenoportography 10.0 7 3.0+T

Lymph Nodes and Lymphatic Channels Incision *2631 Drainage of lymph node abscess or

lymphadenitis, simple *3.0 0 2632 extensive by report 3.0+T

Excision 2641 Biopsy or excision of lymph node

(independent procedure) (except 2642) 5.0 30 3.0+T 2642 anterior scalene 15.0 30 3.0+T

RADICAL LYMPHADENECTOMY

(Radical resection of lymph nodes): 2651 Supra-hyoid, unilateral 50.0 60 4.0+T 2652 bilateral 60.0 60 4.0+T 2655 Cervical (complete), unilateral 80.0 60 4.0+T 2658 Axilla 50.0 60 3.0+T 2671 Groin, superficial 50.0 60 3.0+T 2672 deep, with common iliac dissection 80.0 60 3.0+T 2673 Retroperitoneal, extensive, including

pelvic, aortic and renal dissection 100.0 90 5.0+T Introduction 2676 Injection procedure for lymphangiography,

unilateral 10.0 14 2677 bilateral 15.0 14

MEDIASTINUM Incision 2680 Mediastinotomy with exploration or

drainage, cervical approach 40.0 90 12.0+T 2681 transthoracic 80.0 90 12.0+T 2683 Foreign body removal, cervical approach 70.0 90 12.0+T 2684 transthoracic 80.0 90 12.0+T

Excision 2691 Excision of mediastinal cyst 80.0 90 12.0+T 2693 Excision of mediastinal tumor 100.0 90 12.0+T 2696 Ligation or repair, thoracic duct 75.0 90 12.0+T

DIGESTIVE SYSTEM Mouth Incision *2701 Drainage of sublingual abscess* 2.0 0 3.0+T 2705 Drainage of Ludwig's angina 8.0 7 4.0+T

LIPS Excision

(For excision of mucocele see 0175-0178 or 0260-0269.)

(For excision of small lesion of lip see 0175-0178 or 0260-0269.) 2737 Vermilionectomy ("lip peel") 40.0 120 3.0+T 2739 Transverse wedge excision, lip 25.0 120 3.0+T 2743 V-excision of large lesion of lip up

to one-half lip 25.0 120 3.0+T 2746 Resection of more than one-half lip

without plastic closure 25.0 120 3.0+T

(With plastic closure, primary or secondary see 0260-0324.) Repair (Cheiloplasty) 2754 Plastic repair of cleft lip, primary,

unilateral 70.0 90 6.0+T 2758 bilateral, one stage 90.0 90 6.0+T 2759 bilateral, two stages, per stage 60.0 90 6.0+T

(For secondary, local revision, unilateral or bilateral see 0260-0324.) 2762 Plastic repair (secondary) of unilateral

cleft lip by recreation of defect and reclosure 70.0 90 6.0+T 2765 Plastic repair (secondary) of bilateral

harelip by recreation of defect and reclosureper major stage 60.0 90 6.0+T

(For plastic or reconstruction operation on lip see also 0260-0324.) TONGUE Incision (Glossotomy) *2771 Drainage of lingual abscess *2.0 0 3.0+T

Excision (Glossectomy) 2781 Biopsy of tongue, anterior third 3.0 30 3.0+T 2782 posterior two-thirds 5.0 30 3.0+T 2785 Partial glossectomy or hemiglossectomy 40.0 120 6.0+T 2787 Complete or total glossectomy 70.0 120 6.0+T

Repair (Glossoplasty)

(For plastic repair of tongue see 0260-0324.) Suture (Glossorrhaphy)

(For suture of injury see 0251, 0260-0270.) TEETH AND GUMS Incision *2815 Drainage of alveolar abscess, acute with

cellulltis, intra-oral *2.0 0 3.0+T 2820a General anesthesia for multiple extractions

in hospital 3.0+T PALATE AND UVULA Incision *2871 Incision and drainage of abscess of palate *2.0 0 3.0+T

Excision 2881 Biopsy of palate 3.0 30 3.0+T

(For excision of local lesion of palate see 0175-0196, 0260-0270.)

(For graft or flap closure see 0275-0283, 0300-0304.) 2885 Resection of palate or extensive excision

of lesion of palate 40.0 90 6.0+T

(For resection of palate with reconstruction see 0277-0283, 0312-0323.) 2887 Uvulectomy: excision of uvula 3.0 30 3.0+T

Repair 2890 Palatoplasty: plastic operation for cleft

palate, partial 60.0 90 6.0+T 2892 complete, including alveolar ridge 80.0 90 6.0+T 2895 major revision 60.0 90 6.0+T 2897 secondary lengthening procedure 70.0 90 6.0+T 2898 attachment pharyngeal flap 60.0 90 6.0+T 2899 alveolar ridge, anterior palate defect 30.0 90 6.0+T

(For secondary minor revision see 0260-0270, 0277-0283.) Suture

(For suture of palate injury see 0260-0270, 0277-0283.) Salivary Glands and Ducts Incision *2911 Drainage of parotid abscess *5.0 0 3.0+T *2912 Drainage of submaxillary abscess *5.0 0 3.0+T *2914 Sialolithotomy, submaxillary or parotid,

uncomplicated *3.0 0 3.0+T 2915 Sialolithotomy, submaxillary, complicated 10.0 30 3.0+T 2916 Sialolithotomy, parotid, extraoral 25.0 30 3.0+T

Excision 2921 Biopsy of salivary gland 5.0 30 3.0+T 2927 Excision of parotid tumor or gland,

superficial, without nerve dissection 20.0 60 3.0+T 2928 with nerve dissection 60.0 60 3.0+T 2934 Excision of parotid gland, total, with

dissection of facial nerve 70.0 60 3.0+T 2937 with sacrifice of facial nerve 60.0 60 3.0+T 2938 Excision of submaxillary tumor

and/or gland 40.0 60 3.0+T Repair (Slalodochoplasty) 2941 Plastic repair of salivary duct, simple 35.0 60 3.0+T 2942 complicated by report 3.0+T

Introduction *2945 Injection procedure for sialography *1.0 0 3.0+T

Suture 2951 Closure of salivary fistula 40.0 60 3.0+T

Manipulation *2961 Dilation of salivary duct; ptyalectasis *1.0 0

Pharynx, Adenoids and Tonsils Incision *2970 Drainage of peritonsillar abscess *3.0 0 4.0+T 2971 Drainage of retropharyngeal or parapharyngeal

abscess, intraoral 10.0 15 4.0+T 2973 external approach by report 4.0+T

Excision 2981 Biopsy of oropharynx 3.0 15 3.0+T 2982 hypopharynx 5.0 15 3.0+T 2983 nasopharynx 5.0 15 3.0+T

(For larynx, see 2070 or 2073.) 2984 Excision of pharyngoesophageal

diverticulum, single stage 50.0 60 3.0+T 2985 multiple stages 60.0 60 4.0+T 2989 Excision branchial cleft cyst or vestige,

confined to skin and subcutaneous tissues 15.0 30 3.0+T 2990 extending beneath subcutaneous tissues 50.0 30 3.0+T 2992 Tonsillectomy, with or without

adenoidectomy, under age 18 years 15.0 30 3.0+T 2993 18 years or over 20.0 30 4.0+T 2994 Adenoidectomy (independent procedure),

primary or secondary 10.0 30 3.0+T 3000 Excision of tonsil tag(s), hospital 10.0 30 3.0+T 3002 office 6.0 30 3.0+T 3004 Excision of lingual tonsil (independent

procedure) 10.0 30 3.0+T 3005 Excision of nasopharyngeal fibroma by report 3.0+T

Suture 3006 Suture of wound or injury of pharynx by report 3.0+T

Repair 3011 Pharyngoplasty: plastic or reconstructive

operation on pharynx by report 4.0+T

(For pharyngeal flap, see 2898.) Esophagus Incision 3031 Esophagotomy, cervical 60.0 90 6.0+T 3032 for removal of foreign body, cervical 60.0 90 6.0+T 3033 thoracic 80.0 90 12.0+T

Excision 3043 Esophagectomy: resection of esophagus,

transpleural or extrapleural (upper two thirds) 120.0 90 12.0+T 3045 Esophagogastrectomy, combined thoracoabdominal 120.0 90 12.0+T 3046 Local excision, end-to-end anastomosis 90.0 90 12.0+T

Endoscopy 3051 Esophagoscopy, diagnostic 15.0 15 4.0+T 3053 with insertion of radioactive substance 20.0 30 4.0+T 3055 with biopsy 20.0 15 4.0+T 3057 with foreign body removal 25.0 15 4.0+T 3061 with dilation, direct 20.0 15 4.0+T 3063 subsequent dilation 15.0 15 4.0+T

(See also 3092, 3095.) Repair 3071 Esophagoplasty: plastic repair or

reconstruction of esophagus by report 12.0+T 3072 Esophagogastrostomy (cardioplasty) 80.0 90 12.0+T 3073 Esophagomyotomy (Heller type) 80.0 90 12.0+T 3074 Esophagoduodenostomy (including total

gastrectomy) 100.0 90 11.0+T 3075 Esophagojejunostomy, including total

gastrectomy 100.0 90 11.0+T 3076 Esophagostomy; fistulization of esophagus,

external 60.0 90 6.0+T Suture 3077 Direct ligation of esophageal varices 80.0 90 12.0+T 3081 Suture of esophageal wound, injury or

rupture, cervical approach by report 7.0+T 3083 transthoracic 70.0 90 12.0+T 3086 Closure of esophagostomy or other external

esophageal fistula, cervical 45.0 90 7.0+T 3087 thoracic 70.0 90 12.0+T

Manipulation *3092 Dilation of esophagus by sound, bougie

or bag, indirect, initial *5.0 0 *3095 subsequent *3.0 0

(For direct see 3061 and 3063.) STOMACH Incision 3101 Gastrotomy with exploration or foreign

body removal 50.0 45 5.0+T 3105 Pyloromyotomy: cutting of pyloric muscle

(Fredet-Ramstedt type operation) 50.0 45 6.0+T Excision 3111 Biopsy by laparotomy 50.0 45 5.0+T 3112 Local excision of ulcer or tumor 60.0 45 5.0+T 3114 Total gastrectomy 100.0 90 6.0+T 3115 Subtotal or hemi-gastrectomy, without

vagotomy 80.0 60 6.0+T 3116 with vagotomy 90.0 60 6.0+T 3117 Vagotomy and pyloroplasty 70.0 60 6.0+T

(See also 3131.) Endoscopy (independent procedure) 3121 Gastroscopy, diagnostic 15.0 7 4.0+T 3123 with biopsy 15.0 7 4.0+T

Suture 3131 Pyloroplasty 50.0 45 5.0+T 3133 Gastroduodenostomy 60.0 45 5.0+T 3135 Gastrojejunostomy 60.0 45 5.0+T 3136 with vagotomy 75.0 45 6.0+T 3137 Gastrostomy 40.0 45 5.0+T 3141 Gastrorrhaphy: suture of perforated

duodeal or gastric ulcer, wound or injury 50.0 45 6.0+T 3144 Revision of gastroduodenal anastomosis

(gastroduodenostomy) with reconstruction, without vagotomy 90.0 60 6.0+T 3145 with vagotomy 100.0 60 6.0+T 3146 Revision of gastrojejunal anastomosis

(gastrojejunostomy) with reconstruction, without vagotomy 90.0 60 6.0+T 3147 with vagotomy 100.0 60 6.0+T 3153 Closure of gastrostomy, surgical 40.0 45 5.0+T

INTESTINES (EXCEPT RECTUM) Incision 3161 Enterotomy with exploration or foreign

body removal, small bowel 60.0 60 4.0+T 3162 large bowel 65.0 60 4.0+T 3166 Exteriorizatlon of intestine

(Mikulicz resection of colon, with or without crushing of spur) 70.0 60 4.0+T Excision 3171 Excision of one or more lesions of

small or large bowel not requiring anastomosis, exteriorination or fistulization, single enterotomy 60.0 60 4.0+T 3172 multiple enterotomies 70.0 60 4.0+T 3174 Enterectomy: resection of small intestine

with anastomosis 70.0 60 4.0+T 3176 with enterostomy 70.0 60 4.0+T 3178 Colectomy, partial resection of large

intestine in two stages, including first stage colostomy or cecostomy 100.0 90 5.0+T 3179 Colectomy, partial, with anastomosis,

with or without concomitant proximal colostomy 80.0 90 5.0+T 3180 total, with ileostomy or ilioproctostomy 110.0 90 6.0+T 3181 with proctectomy and ileostomy 120.0 90 6.0+T 3191 Enteroenterostomy; anastomosis of

intestine 60.0 90 5.0+T ENTEROSTOMY-External fistulization of intestines

(independent procedure): 3193 small bowel (ileostomy or jejunostomy) 50.0 90 4.0+T 3195 large bowel, (colostomy or cecostomy) 50.0 90 4.0+T 3197 small or large bowel, for

ulcerative colitis 75.0 90 6.0+T 3200 Reduction of volvulus, intussusception,

internal hernia, by laparotomy 60.0 90 4.0+T 3203 Revision of colostomy, simple, (release

of superficial scar) 5.0 90 3204 complicated (reconstruction in depth) 25.0 60 4.0+T

Destruction 3211 Enterolysis (freeing of intestinal

adhesion) 40.0 45 4.0+T 3212 with acute bowel obstruction 60.0 45 4.0+T 3213 Intestinal plication (Noble type) 60.0 90 4.0+T

Suture 3220 Suture of intestine (enterorrhaphy),

large or small, for perforated ulcer, wound, injury or rupture, single 60.0 45 4.0+T 3221 multiple by report 6.0+T 3222 Suture of intestine with colostomy 70.0 90 4.0+T 3225 Closure of enterostomy, large or small

intestine 40.0 90 4.0+T 3227 Closure of fecal fistula by report 4.0+T

Meckel's Diverticulum and the Mesentery

Excision 3231 Excision of Meckel's diverticulum

(diverticulectomy) 50.0 45 4.0+T 3235 Excision of lesion of mesentery 50.0 45 4.0+T

(With bowel resection, see 3174.) Suture 3241 Suture of mesentery 40.0 45 4.0+T

Appendix

Incision 3251 Incision and drainage of appendicular

abscess, transabdominal 30.0 45 4.0+T Excision 3261 Appendectomy 40.0 45 4.0+T

Rectum

Incision 3282 Transrectal drainage of pelvic abscess 15.0 15 3.0+T 3283 Incision and drainage of deep

supralevator, pelvirectal or retrorectal abscess 20.0 30 3.0+T

(See also 3357, 3358.) Excision 3291 Complete proctectomy, combined abdominoperineal, one or two stages 100.0 90 6.0+T 3292 Complete proctectomy for congenital

megacolon (Swenson type procedure) 100.0 90 7.0+T 3294 Excision of rectal procidentia, with

anastomosis, perineal approach 60.0 90 4.0+T 3295 abdominal and perineal approach 100.0 90 6.0+T 3296 Division of stricture in rectum 20.0 90 4.0+T 3298 Perineal excision of primary or

recurrent malignant tumor (Kraske type) 80.0 90 4.0+T 3299 Local excision of extensive villous

papilloma of rectum 40.0 90 4.0+T Endoscopy (Independent procedure) 3310 proctosigmoidoscopy, diagnostic, initial 3.0 15 3.0+T 3311 subsequent 2.0 15 3.0+T 3312 with biopsy, initial 5.0 15 3.0+T 3313 subsequent for same lesion 3.0 15 3.0+T 3314 with removal of papilloma or polyp,

initial 7.0 15 3.0+T 3315 subsequent for same lesion 5.0 15 3.0+T 3316 with removal of multiple papillomas or

polyps 9.0 15 3.0+T 3317 complicated by report 3.0+T 3318 Endoscopic control of hemorrhage by report 3.0+T 3319 Endoscopic removal of foreign body,

anus or rectum by report 3.0+T Repair 3320 Proctoplasty, for stenosis 40.0 90 3.0+T 3321 for prolapse of mucous membrane 40.0 90 3.0+T 3322 Perirectal injection of sclerosing

solution for prolapse, in hospital 10.0 30 3323 Proctopexy for prolapse, abdominal

approach 60.0 90 4.0+T 3325 Proctopexy combined with sigmoid

resection, abdominal approach 90.0 90 4.0+T Suture 3331 Closure of rectovesical fistula 60.0 90 5.0+T

(See also 3965.) 3333 Closure of rectourethral fistula 70.0 90 5.0+T

(See also 4026.) 3335 Closure of rectovaginal fistula 60.0 90 5.0+T

(When a colostomy is part of the above procedures, add 10 units.) Manipulation *3341 Reduction of procidentia (independent

procedure) *2.0 0

Anus

Incision 3351 Fistulotomy or fistulectomy, subcutaneous 10.0 30 3.0+T 3352 submuscular 40.0 90 3.0+T 3353 complex or multiple by report 3.0+T 3354 second stage 10.0 60 3.0+T 3355 Remove seton, office 2.0 15 3356 Incision and drainage of ischiorectal

abscess (independent procedure) 10.0 15 3.0+T *3357 Incision and drainage, perianal

abscess (See also 3283.) *2.0 0 3.0+T 3358 Incision and drainage of ischiorectal

abscess with fistulotomy or fistulectomy, submuscular (See also 3283.) 40.0 90 3.0+T *3364 Sphincterotomy, anal: division of anal

sphincter (independent procedure) *5.0 0 3.0+T Excision 3371 Fissurectomy, with or without

sphincterotomy 20.0 90 3.0+T 3372 Cryptectomy, single, office 5.0 30 3373 multiple, hospital procedure 30.0 90 3.0+T 3374 Papillectomy or excision of single tab

(independent procedure), office 3.0 15 3375 Excision of external hemorrhoidal tags

and/or multiple papillae, office 5.0 15 3377 Hemorrhoidectomy, external, complete 20.0 90 3.0+T 3380 internal and external 30.0 90 3.0+T 3381 radical (Bule or amputative type) 40.0 90 3.0+T 3382 Fistulotomy or fistulectomy, submuscular,

and hemorrhoidectomy 40.0 90 3.0+T 3386 Fissurectomy and hemorrhoidectomy 30.0 90 3.0+T *3392 Enucleatlon or excision of external

thrombotic hemorrhoid *3.0 0 3.0+T Introduction *3401 Hemorrhoids, injection of sclerosing

solution *2.0 0 3.0+T Endoscopy (independent procedure) *3411 Anoscopy, diagnostic with or

without biopsy *1.0 0

(For with removal of foreign body, see 3319.)

(For control of hemorrhage, endoscopIc, see 3318.) Repair 3420 Anoplasty: plastic operation for stricture 40.0 90 5.0+T 3421 infant, minor thin septum 5.0 30 3.0+T 3422 Construction of anus for congenital

absence, perineal approach 50.0 90 5.0+T 3423 combined abdominal and perineal approach 80.0 90 7.0+T 3425 Sphincteroplasty, anal, for incontinence 40.0 90 4.0+T 3426 muscle transplant by report 4.0+T 3427 Theiersch procedure for incontinence

and/or prolapse 25.0 30 4.0+T Destruction 3433 Condyloma, single or multiple, internal

and external, in hospital 20.0 30 3.0+T *3434 external, electrodesiccation, initial *3.0 0 *3435 subsequent *2.0 0

LIVER

Incision *3456 Aspiration biopsy of liver *5.0 0 3.0+T

Excision 3464 Hepatectomy, partial: resection of liver 80.0 45 9.0+T

Repair 3471 Marsupialization of cyst or abscess of

liver 70.0 80 8.0+T Suture 3481 Hepatorrhaphy: suture of liver wound

or injury 60.0 45 9.0+T

BILIARY TRACT

Incision 3491 Hepaticotomy or hepaticostomy with

exploration, drainage or removal of calculus 70.0 45 8.0+T 3495 Choledochotomy or choledochostomy with

exploration, drainage or removal of calculus, with or without cholecystotomy 70.0 45 6.0+T 3500 Duodenocholedochotomy: transduodenal

choledochollthomy 80.0 60 6.0+T 3501 Transduodenal spincterotomy 80.0 60 6.0+T 3504 Cholecystotomy or cholecystostomy with

exploration, drainage or removal of calculus 50.0 45 5.0+T Introduction 3509 Injection procedure for percutaneous

trans-hepatic cholangiography

(independent procedure) 10.0 7 3.0+T Excision 3515 Cholecystectomy 60.0 45 5.0+T 3517 with open exploration of common duct 70.0 45 5.0+T

Repair 3518 Exploration for congenital

atresia of bile ducts 50.0 60 7.0+T 3519 Direct anastomosis of gallbladder and

gastrointestinal tract 60.0 60 5.0+T 3520 Roux-en-y anastomosis of gallbladder and

gastrointestinal tract 65.0 60 5.0+T 3521 Direct anastomosis of extrahepatic

biliary ducts and gastrointestinal tract 75.0 90 5.0+T 3522 Roux-en-y anastomosis of extrahepatic

biliary ducts and gastrointestinal tract 85.0 90 5.0+T 3523 Plastic reconstruction of extrahepatic

billary ducts with end-to-end anastomosis 80.0 90 5.0+T

PANCREAS

Incision 3541 Abdominal drainage of pancreatitis 50.0 60 6.0+T 3544 Removal of calculus 70.0 60 6.0+T

Excision 3550 Pancreatectomy, subtotal 80.0 90 6.0+T 3551 subtotal (Whipple type) 140.0 90 6.0+T 3552 total 140.0 90 6.0+T 3553 Pancreatico-jejunostomy 80.0 90 6.0+T

Repair 3565 Marsupialization of cyst of pancreas 60.0 60 6.0+T 3566 Internal direct anastomosis of cyst to

gastrointestinal tract 70.0 60 6.0+T 3567 Roux-en-y internal anastomosis, cyst

to gastrointestinal tract 80.0 60 6.0+T

ABDOMEN, PERITONEUM AND OMENTUM

Incision 3571 Exploratory laparotomy: exploratory

celiotomy 40.0 45 4.0+T 3573 Drainage of peritoneal abscess or localized

peritonitis exclusive of appendicular abscess 40.0 45 4.0+T 3575 Subdiaphragmatic or subphrenic abscess 50.0 45 5.0+T 3578 Retroperitoneal abscess 40.0 45 5.0+T *3588 Peritoneocentesis: abdominal

paracentesis, initial *4.0 0 *3590 subsequent *3.0 0

Excision 3591 Trans-peritoneal excision of intra-abdominal

or retroperitoneal tumors or cysts 70.0 60 5.0+T Endoscopy 3595 Peritoneoscopy 15.0 15

Introduction *3611 Pneumoperitoneum: intraperitoneal injection

of air, initial *4.0 0 *3612 subsequent *1.0 0 *3614 Injection procedure for retroperitoneal

pneumography, unilateral or bilateral

(independent procedure) *5.0 *3615 Injection procedure for pelvic pneumography

(independent procedure) *4.0

(See also 4462.) Repair Hernioplasty, Herniorrhaphy, Herniotomy:

(For bilateral herniorrhaphy see Rule 11.) 3631 Inguinal, unilateral 35.0 45 3.0+T 3633 with orchiectomy 40.0 45 3.0+T 3634 with excision of hydrocele 40.0 45 3.0+T 3635 recurrent 40.0 45 3.0+T 3646 Femoral, unilateral 35.0 45 3.0+T 3651 recurrent 45.0 45 3.0+T 3661 Ventral, incisional 45.0 45 3.0+T 3662 recurrent 50.0 45 3.0+T 3663 Epigastric 35.0 45 3.0+T 3664 recurrent 45.0 45 3.0+T 3665 Umbilical, under age five years 30.0 45 3.0+T 3666 over age five years 35.0 45 3.0+T 3667 Omphalocele, in newborn, one stage 40.0 60 6.0+T 3668 Gross type procedure, first stage 50.0 80 6.0+T 3669 second stage 50.0 80 6.0+T

(For diaphragmatic hernia, see 1495, 1496.) Suture 3734 Secondary suture of abdominal wall for

evisceration or disruption 20.0 30 4.0+T

(For suture of ruptured diaphragm, see 1495, 1496.)

URINARY SYSTEM

Kidney Incision 3802 Drainage of perirenal abscess

(independent procedure) 50.0 90 5.0+T 3808 Nephrotomy with drainage; nephrostomy 80.0 90 5.0+T 3811 Nephrolithotomy, removal of calculus 80.0 90 5.0+T 3812 large (staghorn) calculus 90.0 90 5.0+T 3813 Division or transection of aberrant

renal vessels (independent procedure) 70.0 90 5.0+T 3815 Pyelotomy with exploration 70.0 90 5.0+T 3816 Pyelotomy with drainage, pyelostomy 70.0 90 5.0+T 3817 Pyelotomy with removal of calculus;

pyelolithotomy; pelviolithotomy 70.0 90 5.0+T Excision *3820 Renal biopsy, trochar or needle *5.0 0 3821 Nephrectomy, including partial

ureterectomy 80.0 90 4.0+T 3822 with total ureterectomy through same or

separate incision 100.0 90 4.0+T 3824 Heminephrectomy 100.0 90 4.0+T 3827 Excision of cyst of kidney 70.0 90 4.0+T *3829 Aspiration or injection of renal cyst

or renal pelvis *5.0 0 Introduction

(For perirenal insufflation, unilateral or bilateral, see 3614.) Repair 3831 Pycloplasty: plastic operation on renal

pelvis with or without plastic operation on ureter or nephropexy 80.0 90 4.0+T 3835 Nephropexy: fixation or suspension of

kidney (independent procedure) 70.0 90 4.0+T Suture 3841 Nephrorrhaphy: suture of kidney wound

or injury 80.0 90 8.0+T 3845 Closure of nephrostomy, pyelostomy or

other renal fistula (e.g., renocolic fistula) 80.0 90 4.0+T 3846 Symphysiotomy for horseshoe kidney 100.0 90 6.0+T

Transplant 3850 Kidney transplant 125.0 90 4.0+T

URETER

Incision 3851 Urteterotomy with exploration or

drainage (independent procedure) 70.0 90 4.0+T 3857 Ureterolithotomy, upper three quarters

of ureter 70.0 90 4.0+T 3858 lower one quarter 80.0 90 4.0+T

Excision 3861 Ureterectomy, with bladder cuff

(independent procedure) 80.0 90 4.0+T Repair 3871 Ureteroplasty: plastic operation on

ureter (stricture) 80.0 90 5.0+T 3872 Ureterolysis, with or without repositioning

of ureter, unilateral 70.0 90 5.0+T 3873 bilateral 90.0 90 5.0+T 3874 Ureteropyclostomy: anastomosis of ureter

and renal pelvis 80.0 90 5.0+T 3875 Ureteroureterostomy 80.0 90 5.0+T 3876 Ureteroneocystostomy: anastomosis of

ureter to bladder, unilateral 80.0 90 5.0+T 3877 bilateral 100.0 90 5.0+T 3880 Ureteroenterostomy: anastomosis of ureter

to intestine, unilateral 80.0 90 5.0+T 3881 bilateral 100.0 90 5.0+T 3884 Ureterostomy: transplantation of ureter

to skin, unilateral 70.0 90 5.0+T 3885 bilateral 90.0 90 5.0+T

Suture 3891 Ureterorrhaphy: suture of ureter

(independent procedure) 80.0 90 5.0+T 3895 Closure of fistula of ureter by report 5.0+T

BLADDER

Incision *3900 Aspiration of bladder by needle or

trochar *5.0 0 3902 with insertion of suprapubic catheter 10.0 30 3904 Cystotomy or cystostomy with fulguration 60.0 90 5.0+T 3906 Cystotomy with drainage; cystostomy 50.0 90 5.0+T 3907 Cystotomy with removal of calculus

(cystolithotomy) without vesical neck resection 50.0 90 5.0+T 3908 Drainage of perivesical or prevesical

space abscess 50.0 90 5.0+T Excision 3911 Cystectomy, partial 70.0 90 6.0+T 3912 with re-implantation of ureter into

bladder (ureteroneocystostomy) 80.0 90 6.0+T 3913 complete 100.0 90 6.0+T 3914 radical with ureteral transplants 120.0 180 7.0+T 3915 with ureteral-ileo conduit 140.0 180 7.0+T 3918 Transurethral resection, vesical neck,

female or child (See also 4321) 50.0 90 4.0+T 3919 Cystotomy for excision of vesical neck

(independent procedure) 60.0 90 5.0+T 3920 Excision of bladder diverticulum

(independent procedure) 70.0 90 5.0+T 3922 Excision of bladder tumor

(See also 3904.) 60.0 90 5.0+T 3924 Transurethral resection of bladder tumors,

large (For small tumors, see 3936, 3937.) 60.0 90 5.0+T Introduction *3926 Bladder irrigation, simple, lavage

and/or instillation *1.0 0 *3927 Injection procedure for cystography or

urethro-cystography *1.0 0 CYSTOSCOPY (independent procedure): 3930 Diagnostic, office, initial 5.0 7 3931 subsequent within 30 days 3.0 7 3932 with ureteral catheterization 8.0 7 3933 hospital 8.0 7 3.0+T 3834 with ureteral catheterizatlon 15.0 7 3.0+T

(For Howard or Stamey type renal function test see 3948.) 3935 With biopsy 10.0 7 3936 With fulguration or treatment of minor

(less than 0.5 cm.) lesion, with or without biopsy 10.0 7 3937 With fulguration of small bladder tumors

(0.5 cm. to 2 cm.) (For larger tumors, see 3924.) 25.0 30 3.0+T 3938 With subsequent fulguration of bladder

tumor 10.0 7 3.0+T 3939 With insertion of radioactive substance,

with or without biopsy or fulguration 30.0 30 3.0+T 3940 With dilatation of bladder, for interstitial

cystitis, general anesthesia 15.0 30 3.0+T 3942 With ureteral meatotomy 20.0 30 3.0+T 3943 With resection or fulguration of

ureterocele 20.0 30 3.0+T 3944 With removal of foreign body from urethra

or bladder 20.0 30 3.0+T 3945 With removal of calculus from ureter 30.0 30 3.0+T 3946 With manipulation of ureteral calculus,

primary 20.0 7 3.0+T 3947 subsequent 10.0 7 3.0+T 3948 Differential quantitative and chemical

renal function test (e.g., Howard or Stamey type), see 3932 or 3934, and add detention time beyond that required for usual catheterization, see 9071. Destruction 3951 Litholapaxy: crushing of calculus in

bladder and removal of fragments 50.0 90 3.0+T Repair 3952 Cystoplasty; plastic operation on bladder

(anterior Y-plasty, vesical fundus resection, etc.) any procedure 80.0 90 5.0+T Suture 3961 Cystorrhaphy: suture of bladder wound,
injury or rupture 60.0 90 6.0+T 3963 Closure of cystostomy (independent

procedure) 30.0 90 3.0+T 3965 Closure of vesicovaginal, vesicouterine, or

vesicoenteric fistula (See also 3331.) 60.0 90 5.0+T

Urethra

Incision 3971 Urethotomy, external (independent

procedure) anterior 10.0 15 3.0+T 3973 perineal, external 25.0 15 3.0+T 3977 Meatotomy: cutting of meatus (independent

procedure) 3.0 7 3.0+T 3978 Drainage of deep periurethral abscess,

hospital 10.0 30 3.0+T 3979 Drainage of simple perineal urinary

extravasation (independent procedure), uncomplicated 15.0 15 3.0+T 3980 complicated, with or without diversion of

urinary stream 50.0 60 5.0+T

(See also 3908.) Excision

(For excision or fulguration of urethral caruncle, see 4437.) 3987 Excision or fulguration of carcinoma

of urethra by report 3.0+T 3991 Excision of diverticulum of urethra

(independent procedure) 50.0 80 3.0+T 3994 Excision or fulguration of urethral

polyps, distal 3/4 inch of urethra 5.0 15 3.0+T

(For posterior urethra, see 4006.) Endoscopy 4000 Urethroscopy, diagnostic 5.0 15 3.0+T 4001 with removal of calculus or foreign

body 20.0 45 3.0+T 4004 with internal urethrotomy 20.0 45 3.0+T 4006 with fulguration of posterior urethra 10.0 15 3.0+T 4008 subsequent, within 30 days 5.0 15 3.0+T

Repair 4011 Urethroplasty: plastic operation on

urethra (except 4132 and 4135) by report 3.0+T Suture 4021 Urethrorrhaphy: suture of urethral wound

or injury by report 4.0+T 4023 Closure of urethrostomy or fistual of

urethra (independent procedure) 30.0 60 4.0+T 4025 Closure of urethrovaginal fistula 50.0 60 4.0+T 4026 Closure of urethrorectal fistula

(See also 3333.) 70.0 90 4.0+T Manipulation *4031 Dilation of urethral stricture by passage

of sound, initial, male *3.0 0 *4032 subsequent within 30 days *1.5 0 *4033 Dilation of urethral stricture by passage

of fillform and follower, male *5.0 0 *4034 subsequent within 30 days *2.5 0 *4035 Passage of filiform and follower for

acute vesical retention, male *5.0 0 *4036 Dilation of female urethra including

suppository and/or installation *2.0 0 *4037 subsequeni within 30 days *1.0 0

MALE GENITAL SYSTEM

PENIS

Incision *4101 Dorsal or lateral "slit" of prepuce

(independent procedure) *3.0 0 Excision 4111 Biopsy of penis (independent procedure) 3.0 15 4114 Amputation of penis, partial 40.0 60 3.0+T 4115 complete 60.0 60 3.0+T 4116 radical 100.0 90 4.0+T

(For local excision of lesion of penis, see Integumentary System.) 4122 Circumcision, clamp procedure, newborn 3.0 15 4123 except newborn 5.0 15 3.0+T 4124 surgical excision other than clamp or

dorsal slit, any age (except newborn) 10.0 30 3.0+T

(For excision or fulguration of warts, see 0403, 0405.) Repair 4131 Plastic operation on penis for

hypospadias, straightening of chordee 30.0 30 3.0+T

(For urethroplasty for hypospadias, see 0260 to 0324.) 4134 Plastic operation on penis for injury by report 4.0+T 4135 Plastic operation on penis for

epispadias with extrophy of bladder by report 4.0+T 4136 Plastic operation for penis epispadias

distal to external sphincter 50.0 30 4.0+T

TESTIS

Excision 4140 Biopsy, needle (independent procedure) 2.0 15 4141 incisional (independent procedure) 10.0 15 3.0+T 4143 Orchiectomy, simple unilateral 20.0 30 3.0+T 4144 bilateral 30.0 30 3.0+T 4145 with superficial inguinal node

dissection, unilateral 50.0 90 3.0+T

(For radical retroperitoneal node dissection, see 2673.) Repair 4152 Reduction of torsion of testis by

surgical means 30.0 30 3.0+T 4153 with fixation of contralateral testis 45.0 30 3.0+T 4154 Fixation of contralateral testis

(independent procedure) 20.0 30 3.0+T 4156 Orchiopexy, any type, with or without

hernia repair 50.0 60 3.0+T 4157 second stage (Torek type) 10.0 30 3.0+T

(For orchiectomy with repair of hernia, see 3633.)

EPIDIDYMIS

Incision *4161 Drainage of abscess of epididymis *3.0 0 3.0+T

Excision 4171 Biopsy of epididymis, needle 2.0 15 3.0+T 4172 Exploration of epidedymis with or

without biopsy 10.0 30 3.0+T 4174 Excision of spermatocele with or

without epididymectomy 30.0 90 3.0+T 4176 Epididymectomy, unilateral 30.0 90 3.0+T

Repair 4181 Epididymovasostomy (anastomosis of

epididymis to vas deferens), unilateral 40.0 90 3.0+T 4182 bilateral 50.0 90 3.0+T

TUNICA VAGINALIS

Incision *4191 Puncture aspiration of hydrocele with

or without injection of medication *2.0 0 4200 Repair to hydrocele (Bottle type) 20.0 90 3.0+T 4201 Excision of hydrocele, unilateral 30.0 90 3.0+T 4202 with hernia repair 40.0 45 3.0+T

SCROTUM

Incision *4211 Drainage of scrotal abscess *2.0 0 3.0+T 4215 Removal of foreign body in scrotum by report 3.0+T

Excision

(For local excision of lesion of skin of scrotum, see 0175-0197, 0260-0270.) 4224 Resection of scrotum by report 3.0+T 4227 Serotoplasty; plastic operation on scrotum

by report 3.0+T

Vas Deferens

Incision 4231 Vasotomy: incision or transection of vas,

unilateral or bilateral (independent procedure) 15.0 30 3.0+T Excision 4241 Vasectomy, unilateral or bilateral

(independent procedure) 15.0 30 3.0+T Repair 4251 Vasovasostomy, unilateral 30.0 30 3.0+T 4252 bilateral 40.0 30 3.0+T

Suture 4261 Ligation (percutaneous) of vas

deferens (independent procedure) 5.0 30 3.0+T

Spermatic Cord

Excision 4271 Excision of hydrocele of spermatic

cord (independent procedure), unilateral 30.0 90 3.0+T 4275 Excision of varicocele (independent

procedure), unilateral 30.0 45 3.0+T 4278 with hernia repair 40.0 45 3.0+T

Seminal Vesicles

Incision 4281 Vesiculotomy, unilateral by report

Excision 4291 Vesiculectomy 80.0 90 3.0+T

Prostate

Incision 4300 Biopsy, prostate, needle, single or

multiple 5.0 15 4301 incisional, perineal approach 30.0 30 4.0+T 4302 transrectal 20.0 30 3.0+T 4303 Prostatotomy: external drainage of

prostatic abscess 30.0 60 4.0+T 4304 Prostatolithotomy: removal of prostatic

calculus (independent procedure) 70.0 60 4.0+T Excision 4311 Prostatectomy, perineal, subtotal 80.0 90 6.0+T 4313 radical 100.0 90 6.0+T 4316 suprapubic, one or two stages 80.0 90 4.0+T 4318 retropubic 80.0 90 4.0+T 4319 radical 100.0 90 6.0+T

Endoscopy 4321 Transurethral resection of prostate,

including control of post-operative bleeding, complete (See also 3918.) 80.0 90 4.0+T

FEMALE GENITAL SYSTEM

Vulva and Introitus

Incision 4403 Incision and drainage, abscess of

vulva 5.0 15 3.0+T 4405 Incision and drainage of Bartholin's

gland abscess, unilateral 5.0 15 3.0+T Excision 4421 Biopsy of vulva (independent

procedure) 3.0 15 3.0+T

(For local excision or fulgration of lesion(s) of external genitalia, see 01750197, 0260-0324, 0401-0406.) 4423 Vulvectomy, complete, bilateral 55.0 60 3.0+T 4424 partial, less than 80% of vulvar

area 40.0 60 3.0+T 4425 radical, including unilateral regional

lymph nodes 100.0 90 4.0+T 4426 including bilateral regional lymph

nodes 150.0 90 4.0+T 4428 Clitoridectomy: circumcision, female 7.5 30 3.0+T 4429 Clitoridectomy 10.0 30 3.0+T 4431 Hymenectomy, partial excision of hymen 10.0 30 3.0+T 4433 Excision of Bartholin's gland or cyst 20.0 30 3.0+T 4434 Marsupialization or cautery destruction

of Bartholin's gland or cyst 15.0 30 3.0+T 4436 Excision or fulguration of Skene's glands 7.0 30 3.0+T 4437 Excision or fulguration of unrethral

caruncle 7.0 30 3.0+T

(For excision of unrethral diverticulum see 3991.)

(For excision or fulguration of unrethal carcinoma see 3987.) Repair 4441 Episioplasty: plastic repair of vulva

(non obstetrical) 20.0 30 3.0+T 4443 Plastic operation on unrethral sphincter,

vaginal approach 30.0 60 3.0+T 4445 Plastic repair of urethra for mucosal

prolapse (independent procedure) by report 60 3.0+T 4447 Plastic repair of unrethocele

(independent procedure) 30.0 60 3.0+T Suture

(For episiorrhaphy or episioperineorrhaphy: for recent injury of vulva and/or perineum

(non-obstetrical), see 4480.)

Vagina

Incision 4461 Colpotomy with exploration or drainage

of pelvic abscess 15.0 30 3.0+T *4462 Colpocentesis (independent

procedure) *4.0 0 3.0+T *4463 Puncture and aspiration of cul

de sac *3.0 0 3.0+T 4471 Biopsy of vaginal mucosa (independent

procedure) 3.0 15 3.0+T

(For excision and/or fulguration of local lesion(s) see 0175-0197, 0401-0406.) 4473 Colpocleisis, complete obliteration

of vagina 50.0 60 3.0+T 4475 Le Fort type 35.0 60 3.0+T 4477 Excision of vaginal septum by report 30 3.0+T

Introduction *4478 Irrigation and/or application of any

medicament for treatment of bacterial, parasitic or fungoid disease *1.0 0 Repair 4479 Colporrhaphy: suture of injury of

vagina (non-obsterical) by report 60 3.0+T 4480 Colpoperineorrhaphy: suture of injury

of vagina and/or perineum (non-obstetrical)

by report 80 3.0+T 4481 Anterior colporrhaphy, repair of cystocele

with or without repair of urethocele

(independent procedure) 35.0 60 3.0+T 4484 Posterior colporrhaphy, repair of

rectocele (independent procedure) 30.0 60 3.0+T 4485 with perineoplasty or perineorrhaphy 35.0 60 3.0+T 4488 Combined anterior-posterior

colporrhaphy 50.0 60 3.0+T 4492 Urethral suspension, abdominal approach

(Marshall-Marchetti type) 40.0 45 4.0+T 4493 Repair of enterocele (independent

procedure) abdominal approach 45.0 60 4.0+T 4494 vaginal approach 45.0 60 4.0+T 4495 Colpopexy, abdominal approach 45.0 60 4.0+T 4497 Construction of artificial vagina

(vaginal atresia or absence) with or without graft by report 60 3.0+T

(For closure of vaginal fistulae, see 3335, 3965, 4025.) Manipulation *4511 Dilation of vagina under anesthesia *2.0 0 3.0+T *4512 Pelvic examination under anesthesia *2.0 0 3.0+T

Endoscopy 4521 Culdoscopy (independent procedure) 15.0 15 3.0+T

Oviduct

Incision 4531 Transection of Fallopian tube,

unilateral or bilateral, abdominal or vaginal approach 40.0 45 4.0+T 4532 post-partum, during same hospitalization 30.0 45 4.0+T

Excision 4541 Salpingectomy, complete or partial,

unilateral or bilateral (independent procedure) 45.0 45 4.0+T 4545 Salpingo-oophorectomy, complete or
partial, unilateral or bilateral

(independent procedure) 45.0 45 4.0+T 4551 Salpingoplasty, unilateral or bilateral

(independent procedure) 50.0 45 4.0+T

Ovary

Incision 4561 Drainage of ovarian cyst, vaginal

approach, unilateral or bilateral 25.0 60 4.0+T 4562 abdominal approach, unilateral or

bilateral 40.0 60 4.0+T 4564 Drainage of ovarian abscess, vaginal

approach 20.0 60 4.0+T 4565 abdominal approach 40.0 60 4.0+T

Excision 4566 Biopsy of ovary, unilateral or

bilateral (independent procedure) 45.0 60 4.0+T 4568 Partial oophorectomy, bilateral or

unilateral 45.0 60 4.0+T

Cervix Uteri

Excision

(For radical surgical procedures, see 4620, 4626.) 4571 Biopsy or local excision of lesion,

with or without fuloration, quadrant biopsy

(independent procedure) 3.0 15 3.0+T *4572 Cauterization of cervix, office *3.0 0 4573 Biopsy of cervix, circumferential

(cone) with or without dilation and curettage, with or without Sturmdorff type repair 20.0 45 3.0+T 4574 Cryocautery of the cervix 5.0 0 4575 Trachelectomy: cervicectomy: amputation

of cervix (independent procedure) 20.0 45 3.0+T 4577 total excision of cervical stump, with

or without pelvic floor repair, abdominal approach 50.0 45 4.0+T 4578 vaginal approach 60.0 45 3.0+T

Introduction *4581 Insertion of any hemostatic agent for

control of hemorrhage (independent procedure) *3.0 0 3.0+T

(For insertion of any radioactive materials, see 7615.) *4583 Insertion of intracervical or

intrauterine device *3.0 0 3.0+T Repair *4585 Tracheloplasty: surgical repair of

incompetent cervix, loop type *8.0 0 3.0+T 4586 Shirodkar type 20.0 45 3.0+T 4587 Trachelorrhaphy, plastic repair of

uterine cervix, vaginal approach by report 60 3.0+T Manipulation *4588 Dilation of cervical canal,

instrumental (independent procedure) *3.0 0 3.0+T 4589 Dilation and curettement of cervical

canal 15.0 15 3.0+T

Corpus Uteri

Excision 4610 Endometrial biopsy (independent

procedure) 3.0 15 3.0+T 4612 Dilation and curettage, diagnostic

and/or therapeutic (nonobstetrical) 15.0 15 3.0+T 4613 Myomectomy: excision of fibroid tumor

of uterus (independent procedure, nonobstetrical) 50.0 45 4.0+T 4614 Total hysterectomy (corpus and cervix)

with or without tubes, and/or ovaries, one or both 60.0 45 4.0+T 4618 Supracervical hysterectomy: subtotal

hysterectomy, with or without tubes, and/or ovaries, one or both 55.0 45 4.0+T 4620 Radical hysterectomy for cancer

including regional lymph nodes 100.0 90 6.0+T 4626 plus removal of bladder and ureteral

transplantations and/or abdomino-perineal resection of rectum and colon and colostomy or any combination thereof by report 90 7.0+T 4631 Vaginal hysterectomy 60.0 45 4.0+T 4632 with plastic repair of vagina, anterior

and/or posterior coloporrhaphy 70.0 45 4.0+T 4634 with repair of enterocele 75.0 45 4.0+T

Introduction

(For insertion of radioactive substance into corpus with or without dilation and curettage, see 7615.) *4675 Insufflation of uterus and tubes

with air or CO(2) *3.0 0 3.0+T *4676 Injection procedure for hystero

salpingography *3.0 0 3.0+T Repair 4683 Uterine suspension with or without

shortening of round ligaments

(independent procedure) 40.0 45 4.0+T 4684 with presacral sympathectomy 45.0 45 4.0+T 4685 with interposition operation, with

or without pelvic floor repair 50.0 45 4.0+T 4690 with shortening of endopelvic fascia:

parametrial fixation with or without pelvic floor repair (Manchester type) 50.0 45 4.0+T 4692 with shortening of sacro-uterine

ligaments 50.0 45 4.0+T 4694 Hysterosalpingostomy: anastomosic of

tubes of uterus 50.0 45 4.0+T 4695 Hysterorrhaphy: repair of ruptured

uterus (non-obstetrical) 40.0 45 4.0+T

Perineum

Excision 4710 Biopsy of perineum

(independent procedure) 3.0 15 3.0+T

(For excision of local lesion, see 0175-0178, 0260-0324.) Incision *4720 Incision and drainage of perineal

abscess (non-obsterical) *3.0 0 3.0+T Repair 4731 Perineoplasty: repair of perineum

(independent procedure) 15.0 45 3.0+T 4735 third degree laceration, old

(independent procedure) 40.0 45 3.0+T

(Also see 4441, 4480.) 4742 Perineorrhaphy, post-partum, by

other than delivering physician 20.0 45 3.0+T 4745 Repair of perineal fistula 25.0 45 3.0+T

(For repair of recent injury of perineum, non-obstetrical, see 4480.)

MATERNITY

Nonspecialist in Obstetrics

(For medical or surgical complications during maternity care, see section 533.5(a)(2)(vii). Fees for all maternity procedures include prenatal and postpartum care unless otherwise specified.) Incision 4801 Classic cesarean section 50.0 45 4.0+T 4802 Low cervical (lower uterine segment)

cesarean section. 50.0 45 4.0+T 4803 Cesarean section and hysterectomy,

total or subtotal 60.0 45 4.0+T 4804 Extraperitoneal cesarean section 60.0 45 4.0+T

Excision 4809 Hysterotomy induced abortion 50.0 45 4.0+T 4811 Ectopic pregnancy, tubal, requiring

salpingectomy and/or oophorectomy, abdominal or vaginal approach 50.0 60 4.0+T 4812 ovarian, requiring oophorectomy by report 60 4.0+T 4815 Hysterotomy, abdominal, for removal

of hydatidiform mole 45.0 90 4.0+T Manipulation

(For value of anesthesia service rendered by attending physician, see Anesthesia sections 533.5(a)(2)(v) and 533.5(a) (2) (ix)) 4821 Total obstetrical care including antepartum

care, obstetrical delivery and postpartum care (with or without low forceps, and/or episiotomy) 35.0 45 3.0+T 4822 Obstetrical delivery (with or without low

forceps, and/or episiotomy) and including hospital postpartum care 20.0 45 3.0+T 4823 Antepartum care only (independent

procedure) Sv.ô 4824 Postpartum care only (independent

procedure) Sv.ô 4843 Dilation and curettage, and/or suction,

induced abortion 20.0 45 3.0+T 4850 Abortion, first trimester, completed

medically Sv.ô 4851 (incomplete) completed surgically,

(dilatation and curettage) 15.0 45 3.0+T 4853 second trimester, completed medically Sv.ô 4854 (incomplete) completed surgically,

(dilatation and curettage) 15.0 45 3.0+T 4856 missed, first or second trimester,

completed medically or surgically by report 45 3.0+T 4858 Incomplete, septic, requiring dilatation

and curettage and additional care by report 45 3.0+T 4870 Dilatation and curettage of uterus

for postpartum bleeding 15.0 45 3.0+T

MATERNITY

Specialist in Obstetrics

(For medical or surgical complications during maternity care, see Surgery Rule 6. Fees for all maternity procedures include prenatal and postpartum care unless otherwise specified.) Incision (Obstetrician) 4805 Classic caesarean section 68.75 45 5.0+T 4806 Low cervical (lower uterine segment)

caesarean section 68.75 45 5.0+T 4807 Caesarean section & hysterectomy,

total or subtotal 81.25 45 5.0+T 4808 Extraperitoneal caesarean section 75.0 45 5.0+T

Excision (Obstetrician) 4810 Hysterotomy, induced abortion 68.75 45 5.0+T 4811 Ectopic pregnancy, tubal, requiring

salpingectomy and/or oophorectomy, abdominal or vaginal approach 50.0 60 5.0+T 4812 ovarian, requiring oophorectomy by report 60 5.0+T 4815 Hysterotomy, abdominal, for removal

of hydatidiform mole 45.0 90 5.0+T Manipulation (Obstetrician) 4825 Total obstetrical care (with or without

low forceps, and/or episiotomy) 50.0 45 3.0+T 4826 Obstetrical delivery (with or without

low forcepts, and/or episiotomy) & including hospital postpartum care

(excludes prenatal care) 27.5 45 3.0+T 4827 Antepartum care only (independent

procedure) Sv.ô 4828 Postpartum care only (independent

procedure) Sv.ô 4830 Abortion, first trimester, completed

medically Sv.ô 4831 (incomplete) completed surgically,

(dilatation and curettage) 18.75 45 3.0+T 4833 second trimester, completed medically Sv.ô 4834 (Incomplete) completed surgically,

(dilatation and curettage) 18.75 45 3.0+T 4836 missed, first or second trimester,

completed medically or surgically by report 45 3.0+T 4838 incomplete, septic, requiring dilatation

and curettage and additional care by report 45 3.0+T 4841 Amniocentesis, diagnostic 5.0 7 3.0+T 4842 Amniocentesis with hypertonic solution

including terminal curettage, induced abortion 40.0 45 4.0+T 4844 Dilatation and curettage, and/or suction,

induced abortion 25.0 45 3.0+T 4845 Dilatation and curettage of uterus for

postpartum bleeding 18.75 45 3.0+T

(For medical complications of pregnancies, e.g. toxemia, cardiac, neurological, etc., or problems requiring additional and unusual services, see Medicine or other appropriate sections of these studies.)

ENDOCRINE SYSTEM

Thyroid Gland

Incision *4904 Incision and drainage of

thyroglossal cyst (infected) *3.0 0 3.0+T Excision 4911 Local excision of small cyst or

adenoma of thyroid 40.0 45 5.0+T 4912 Total thyroid lobectomy, unilateral 50.00 45 5.0+T 4914 Thyroidectomy, total or complete 70.0 45 5.0+T 4917 subtotal or partial 60.0 45 5.0+T 4924 total or subtotal for malignancy with

radical neck dissection 100.0 45 6.0+T 4925 total or subtotal for malignancy with

limited neck dissection 80.0 45 5.0+T 4937 secondary, unilateral 60.0 45 5.0+T 4938 bilateral 70.0 45 5.0+T 4941 Excision of thyroglossal duct, cyst or

sinus 45.0 45 4.0+T Paratyroid, Thymus, Pituitary, Pineal Adrenal Glands and Carotid Body

(For hypophysectomy, see 2019 and 5130.) Excision 4971 Parathyroidectomy or exploration of

parathyroid 70.0 45 4.0+T 4972 with mediastinal exploration with or

without splitting of sternum 90.0 60 12.0+T 4985 Adrenalectomy, transabdominal, lumbar

or dorsal, unilateral 80.0 90 9.0+T 4986 bilateral, one stage 100.0 90 8.0+T 4987 two stages 120.0 90 9.0+T 4989 Biopsy adrenal, unilateral 60.0 45 9.0+T 4990 bilateral 70.0 45 9.0+T 4993 Excision of carotid body tumor, with

excision of carotid artery 100.0 60 8.0+T 4994 without excision of carotid artery 70.0 60 8.0+T

NERVOUS SYSTEM

Skull, Meninges and Brain

CRANIOTOMY FOLLOWING TRAUMA: Incision 5001 Burr holes, unilateral, exploratory for

subdural puncture, not followed by surgery 30.0 60 8.0+T 5002 multiple, bilateral, not followed by

surgery 50.0 60 8.0+T 5003 Evacuation of hematoma, subdural,

extradural, or introcerebral by burr holes only 90.0 60 9.0+T 5004 requiring craniotomy 100.0 60 9.0+T 5012 Removal of foreign body from brain 100.0 60 9.0+T

Excision 5015 Removal of brain scar by report 9.0+T

Repair 5018 Elevation of depressed skull fracture,

simple 75.0 60 9.0+T 5020 with debridement of brain and repair

of dura 100.0 60 9.0+T 5022 Cranioplasty for skull defect, bone,

metal or plastic 100.0 60 9.0+T 5024 Repair of dura by graft, including

repair for cerebrosipnal rhinorrhea 100.0 60 9.0+T CRANIOTOMY FOR NON-TRAUMATIC CAUSES: Incision 5101 Burr holes, exploratory or ventricular

puncture, not followed by surgery 30.0 30 7.0+T 5102 Ventricular puncture through previous

burr holes or fontanelle 5.0 7 5106 Craniotomy for drainage of brain

abscess 75.0 90 11.0+T 5108 Subsequent tapping (aspiration) abscess

in operating room 10.0 7 4.0+T 5110 at bedside 5.0 7 5112 Sub-occipital craniectomy for tractotomy

or section of 5th, 8th, 9th or other cranial nerves 125.0 90 9.0+T 5113 Intratemporal (mastoid) craniectomy for

decompression, neurolysis or excision of acoustic nerve tumor 100.0 90 9.0+T 5114 Craniotomy for surgery of sensory root

of gasserian ganglion 100.0 90 9.0+T 5116 Craniotomy for lobotomy, unilateral 40.0 90 9.0+T 5117 bilateral 60.0 90 9.0+T 5119 Craniotomy for orbital decompression,

unilateral 100.0 90 9.0+T *5121 Cisternal puncture (independent procedure) *3.0 0 *5122 Subdural tap through fontanelle (infant) *3.0 0

Excision

(For trans-septal hypophysectomy see 2019.) 5130 Osteoplastic craniotomy for excision of

brain tumor, abscess, or cyst, supratentorial 125.0 90 9.0+T 5132 Suboccipital craniectomy for brain

tumor 150.0 90 11.0+T 5134 Osteoplastic craniotomy for arteriovenous

malformation by report 11.0+T 5136 Osteoplastic craniotomy for obliteration

of aneurysm 150.0 90 11.0+T 5140 Craniotomy for pallidectomy, any method,

including localizing techniques, single or multiple stages 100.0 90 9.0+T 5144 for topectomy 100.0 90 11.0+T 5146 for excision of choroid plexus 50.0 90 11.0+T 5148 Craniectomy for osteomyelitis of skull by report 8.0+T

Introduction

(For cerebral angiography, see radiology.) 5152 Burr holes with ventriculography, not

followed by surgery 30.0 30 7.0+T 5153 followed by surgery 20.0 30 5154 Ventriculography through fontanelle

or previous burr holes 10.0 7 7.0+T 5155 Ventricular puncture with introduction

of dye and recovery by spinal puncture 12.0 7 7.0+T 5159 Injection procedure for pneumo

-encephalography 10.0 7 5.0+T Repair 5160 Ventriculocisternostomy 100.0 90 11.0+T 5162 Repair of encephalocele by report 9.0+T 5166 Ventriculoauricular shunt 100.0 90 11.0+T 5167 replacement or irrigation of

obstructed valve 90.0 90 11.0+T 5168 replacement or irrigation of

ventricular catheter 30.0 30 5.0+T 5169 removal of shunt in toto

without replacement 30.0 30 11.0+T 5170 Ventriculo-auricularperitoneal-pleural-ureteral shunt 100.0 90 11.0+T 5171 co-surgeon 80.0 90 5174 Craniectomy for crantostenosis,

single suture 75.0 90 9.0+T 5175 multiple sutures 100.0 90 9.0+T

Spine and Spinal Cord

Incision 5190 Laminectomy for decompression

of the spinal cord and nerve roots

(See also 5208-5210, 5225.) 100.0 90 7.0+T 5192 Cordotomy, cervico-dorsal 100.0 90 8.0+T 5194 Rhizotomy 75.0 60 8.0+T *5198 Spinal puncture, lumbar, simple

(independent procedure) *2.0 0 *5199 diagnostic, initial, with study

of hydrodynamics *4.0 0

(Add one unit to value assigned to 5198 and 5199 if patient is under 4 years.) Excision 5206 Laminectomy for lesion of spinal cord or

meninges 100.0 90 7.0+T 5208 Laminotomy for removal of intervertebral

discs, cervical 90.0 90 8.0+T 5209 thoracic 90.0 90 7.0+T 5210 lumbar 90.0 90 7.0+T 5211 Excision of intervertebral discs,

anterior approach, cervical 80.0 90 7.0+T

(Also see 0634-0642.) Introduction 5214 Injection procedure for myelography 10.0 7 3.0+T 5216 for discography 10.0 7 3.0+T

Repair 5225 Laminectomy for spondylolisthesis

(See also 5190) 100.0 90 7.0+T 5227 Repair of meningocele 75.0 90 9.0+T 5229 Repair of meningomyelocele 90.0 90 9.0+T 5231 Lumbar subarachnoid-peritoneal-ureteral

shunt 80.0 90 9.0+T 5232 co-surgeon 75.0 90 *5233 Application crutchfield tongs or other

skeletal traction device *5.0 0 Peripheral Nerves, Other Extracranial nerves, and Ganglia Incision

(For transection of trigeminal or glossopharyngeal nerves, see 5112, 5114.) 5252 Phrenic nerve transection or avulsion 15.0 30 3.0+T 5255 Transection, spinal nerve 40.0 60 3.0+T 5257 Transection occipital nerve 40.0 60 4.0+T

Excision

(For excision of tender scar, skin and subcutaneous tissues with or without tiny neuroma, see 0175, 0178, 0265, 0266.) 5273 Excision of surgical identifiable neuroma

of cutaneous nerve 8.0 60 3.0+T 5274 digital nerve, one or both, same digit 10.0 60 3.0+T 5275 hand or foot, one (add 10 percent each

additional) 15.0 60 3.0+T 5276 arm or leg 25.0 60 3.0+T 5277 Avulsion infraorbital nerve 20.0 60 3.0+T 5280 Stoefel's neurectomy 40.0 60 3.0+T 5282 Obturator neurectomy 40.0 60 3.0+T

Introduction *5290 Alcohol injection, subarachnoid *5.0 0 5294 2nd or 3rd branch of trigeminal nerve 7.5 30 5295 under x-ray control (excluding x-ray

charge) 10.0 30 Nerve Block: 5298 Paravertebral block, lumbar or thoracic 5.0 7 5300 Sympathetic block (cervical) 5.0 7 5302 Stellate ganglion 5.0 7 5311 Brachial plexus block 5.0 7 5312 Intercostal nerves 3.0 7 5313 Lumbar, sacral and coccygeal nerves 5.0 7 5314 Pudendal nerve 5.0 7 5315 Splanchnic nerves 5.0 7 5316 Ilioinguinal and iliohypogastric nerves 5.0 7 5317 Sciatic nerve 3.0 7 5318 Phrenic nerve 3.0 7 5319 Other peripheral nerves 3.0 7

Repair NEURORRHAPHY--Suture of nerve. Primary 5320 Digital, one (add 25% each additional

nerve) 15.0 90 3.0+T 5322 Hand or foot (except motor thenar or

ulnar motor) 20.0 90 3.0+T 5323 Motor thenar or ulnar motor 30.0 90 3.0+T 5325 Arm or leg (except sciatic) 40.0 90 3.0+T 5326 Sciatic by report 3.0+T 5328 Brachial or lumbar plexus by report 3.0+T 5330 Cranial, extra-cranial 75.0 90 5.0+T

(For facial nerve, see 6002, 6003.) Secondary or delayed anastomosis or reanastomosis including local advancement to overcome gap. (Add 25 percent to primary repair.) Secondary or delayed anastomosis involving additional procedures such as nerve graft and/or rerouting of nerve to overcome gap by report

(See 6003 for facial nerve.) NEUROPLASTIES; plastic procedure on intact nerve 5335 Freeing nerve from scar, including internal

and external lysis and transposition away from scarred area, digital, one or both 15.0 90 3.0+T 5337 hand or foot 20.0 90 3.0+T 5339 arm or leg (except sciatic) 40.0 90 3.0+T 5340 sciatic by report 5341 brachial or lumbar plexus by report 5343 cranial, extra-cranial 75.0 90 5.0+T

(For facial nerve, see 6002, 6003.) 5345 Transplantation ulnar nerve, elbow

(independent procedure)

(includes neurolysls) 25.0 90 3.0+T 5347 Median nerve decompression at carpal

tunnel, simple 30.0 45 3.0+T

(If complex, see also 1550, 1553.) NEURO-ANASTOMOSIS to establish other than normal anatomical continuity. 5350 Spinal accessory-facial, hypoglossal-facial,

spinal accessory-hypoglossal, etc. 75.0 90 6.0+T

Vegetative Nervous System

Excision Sympathectomies: 5371 Cervical, unilateral 60.0 60 6.0+T 5372 bilateral 80.0 60 6.0+T 5375 Cervico-thoracic (Smithwicke type, supraand infra- diaphragmatic), unilateral 70.0 60 6.0+T 5376 bilateral, concomitant or delayed 100.0 60 8.0+T 5381 Lumbar, unilateral 55.0 60 4.0+T 5382 bilateral 75.0 60 6.0+T 5385 Splanchnicectomy (Peet type) unilateral 65.0 60 5.0+T 5386 bilateral 80.0 60 8.0+T 5390 Presacral neurectomy, hypogastric

plexus 50.0 60 4.0+T

EYE

Diagnostic and Manipulative Procedures 5400 Eye examination to include refraction,

ophthalmoscopy, tonometry, gross visual field and muscle balance examination and medical diagnosis $20.00 5401 with complete visual fields included $28.00 *5402 Gonioscopy, diagnostic, adult *2.0 0 3.0+T 5403 infant 4.0 7 3.0+T *5404 Refraction without cycloplegic or

mydriatic *$12.00 0 *5405 with cycloplegic or mydriatic, including

post-cycloplegic visit *$16.00 0 5406 Orthoptic evaluation 2.0 0 5407 training, each 30 minutes 1.0 0 *5408 Visual fields, complete *2.0 0 *5409 Tonography (recording tonometer method

or perilimbal suction device) *2.0 0 *5410 Provocative test(s) for glaucoma

including water drinking and/or mydriatic *2.0 5411 Funduscopic, under anesthesia 4.0 7 3.0+T 5412 Fitting contact lenses Sv.ô

Ophthalmologist

Office Visits 5414 **External eye examination (medical

treatment of minor external eye diseases, e.g., conjunctivitis, chalazion, hordeolum, blepharitis) $10.00 5416 Follow-up visit to external eye

examination $7.20 **Not to be added to codes 5400 or 5401. Hospital Visits 5417 Initial visit 2.5 5418 Follow-up visit, including treatment 1.5

Eyeball

Incision 5420 Goniotomy 50.0 30 4.0+T

Excision 5421 Enucleation of eyeball with or without

sphere implant 40.0 30 4.0+T 5422 with integrated implant 50.0 30 4.0+T 5424 Secondary implantation of integrated

implant 60.0 30 4.0+T 5427 Evisceration of eyeball 40.0 30 4.0+T 5428 with implantation in scleral shell 50.0 30 4.0+T 5431 Suture of eyeball for

wound or injury by report 4.0+T

Cornea

Incision 5441 Keratotomy, any type 10.0 14 4.0+T 5443 Paracentesis of cornea 10.0 14 4.0+T *5445 Removal of foreign body from surface

of cornea *2.0 0 *5448 under slit lamp *3.0 0

Excision 5451 Keratectomy, partial 30.0 30 6.0+T 5452 complete 40.0 30 6.0+T 5457 Pterygium 25.0 30 4.0+T

Introduction 5461 Tattoo of cornea, mechanical or chemical 30.0 30 4.0+T *5465 Curettage and cauterization of corneal

ulcer *5.0 0 *5466 Iontophoresis of corneal ulcer *5.0 0

Repair 5471 Keratoplasty, (corneal transplant)

lamellar 100.0 90 8.0+T 5472 partial or complete, penetrating 110.0 90 8.0+T

Suture 5481 Suture of perforated cornea by report 6.0+T

Sclera

Incision 5491 Sclarotomy, operative incision, with

removal of intraocular foreign body

(with or without magnet) 50.0 45 6.0+T 5492 with removal of foreign body from

anterior chamber (with or without magnet) 50.0 45 6.0+T 5495 Sclerotomy, posterior 30.0 15 4.0+T *5496 Aspiration of anterior chamber,

diagnostic *4.0 0 Excision 5501 Sclerectomy for glaucoma, with scissors,

punch or trephination 60.0 45 6.0+T 5503 Scleral resection 100.0 90 6.0+T

Introduction 5511 Irrigation and/or air injection into

anterior chamber 15.0 15 4.0+T Suture 5521 Suture of sclera for wound

or injury by report 8.0+T

Iris and Ciliary Body

Incision 5531 Iridotomy 20.0 30 4.0+T 5532 with transfixion of iris; iris bombe 20.0 30 4.0+T 5534 Iridotomy - performed with photocoagulator 10.0 30 4.0+T

Excision 5541 Excision of lesion of iris 60.0 45 4.0+T 5542 and/or ciliary body (iridocyclectomy) 80.0 45 4.0+T 5544 Iridectomy; basal, optical or preliminary 50.0 45 4.0+T 5546 peripheral 50.0 45 4.0+T

Repair 5552 Iridodialysis 40.0 45 4.0+T 5561 Repair of prolapsed iris with suture of

perforated sclera or cornea by report 8.0+T Manipulation 5571 Iridencleisis or comparable procedure 50.0 45 4.0+T

Destruction 5580 Diathermy of the ciliary body;

cyclodiathermy 30.0 30 4.0+T 5582 Cyclodialysis 50.0 45 4.0+T

Crystalline Lens

Incision 5601 Discission (needling of lens), initial 20.0 45 4.0+T 5602 subsequent 10.0 45 4.0+T 5603 Aspiration of lens material for congenital

cataract, one or more stages 60.0 30 4.0+T Excision 5611 Extraction of lens, intracapsular,

extracapsular or linear, unilateral 80.0 90 8.0+T 5616 Removal of dislocated lens 80.0 90 8.0+T

Vitreous

Introduction 5622 Transplantation of vitreous 50.0 60 8.0+T

Retina

Repair 5630 Reattachment of retina, electrocoagulation, scleral resection, buckling or partial tubing 100.0 90 7.0+T 5631 encircling tube, initial 100.0 90 7.0+T 5632 subsequent by report 30 7.0+T 5633 Removal of encircling tube 40.0 30 4.0+T 5634 Reattachment of retina, light coagulation

of retinal break(s), one or more stages during same period of hospitalization 40.0 30 7.0+T 5635 with drainage of subretinal fluid 50.0 60 7.0+T 5636 Light coagulation of retina for tumor,

Eales disease, etc., initial 40.0 30 4.0+T 5637 subsequent 20.0 30 4.0+T

Examination 5638 Comprehensive retinal examination prior

to or in anticipation of surgery, to include the following: 10.0 0 1. Code 5400 - Eye examination to include refraction, opthalmoscopy, tonometry, gross visual field and muscle balance examination and medical diagnosis. 2. Complete visual fields and records. 3. Study of the vitreous cavities and the fundi of both eyes including contact lens examination and binocular indirect ophthalmoscopy. 4. Gonioscopy. 5. Complete retinal drawings of both eyes.

Ocular Muscles

Incision, Excision and Repair 5641 Any type of muscle operation involving

one or more muscles in one or both eyes done in one stage 60.0 30 4.0+T 5647 Muscle transplant (Hummelscheim type,

etc.) 70.0 30 4.0+T

Orbit

Incision 5651 Orbitotomy with exploration 60.0 30 7.0+T 5652 with drainage of intraorbital abscess 60.0 30 7.0+T 5653 with removal of intraorbital foreign body 60.0 30 7.0+T 5662 Excision of benign lesion of orbit,

requiring bone flap 90.0 30 7.0+T 5664 Exenteration or evisceration of orbital

contents with or without graft 60.0 60 7.0+T 5665 including orbital bone by report

Introduction 5671 Orbital injection of alcohol for

hemorrhagic glaucoma or intractable pain 10.0 15 Repair

(For plastic repair of orbit, see 0260-0324, 0619-0621.)

Eyelids

Incision *5691 Blepharotomy with drainage of abscess

of eyelid *2.0 0 *5692 with drainage of Meibomian glands;

hordeolum (stye) *2.0 0 Excision

(For blepharectomy, see 0175-0197, 0260 0324.) 5702 Excision or incision of Meibomian

gland (chalazion), single 5.0 15 3.0+T 5703 multiple, same lid 6.0 15 3.0+T 5704 multiple, different lids 7.0 15 3.0+T

(For excision of lesion of eyelid, maglignant, see 0194-0197, 0260-0324.) 5712 Epilation, electrolysis 4.0 15 3.0+T

(For excision of xantholasma, 0175-0178, 0260-0324.) Repair

(Blepharoplasty: plastic repair of eyelid with or without graft, any type, see 0251, 0252, 0260-0324.)

(Canthoplasty: plastic repair of canthus, see 0251, 0252, 0260-0324.)

(Plastic restoration of eyebrow, by graft, see 0308-0324.)

(Tarsoplasty: plastic repair of tarsal cartilage, see 0261-0275.)

(Reposition of ciliary base, see 0260-0324.) 5727 Blepharoptosis repair, superior rectus,

levator, or frontalis methods, unilateral 60.0 60 4.0+T 5728 fascia sling method 40.0 60 4.0+T 5729 lid suture method 25.0 60 3.0+T 5730 Cautery puncture for entropion or

ectropion 5.0 15 5731 Ectropion repair (e.g., Kuhnt-Szymanowski

type) 40.0 30 4.0+T 5732 Entropion repair (e.g., Wheeler type) 40.0 30 4.0+T

Suture

(Blepharorrhaphy: suture of eyelid, see 0251, 0261-0269.)

(Tarsorrhaphy: suture of tarsal cartilage see 0251, 0261-0269.)

(Canthorrhaphy: suture of palpebral fissure of canthus, see 0251, 0261-0269.)

Conjunctiva

Incision *5741 Removal of foreign body from surface

of conjunctiva *1.0 0 *5742 embedded in conjunctiva *2.0 0 5743 Suture of conjunctiva 5.0 15 4.0+T

Excision 5751 Biopsy of conjunctiva 5.0 15 4.0+T 5753 Excision of lesion of conjunctiva, e.g.,

cyst 5.0 15 4.0+T

(For epithelioma, see 0175-0196, 0261-0269.)

(For nevus, see 0175-0196, 0261-0269.) Repair 5760 Conjunctivoplasty, free graft using

conjunctiva 50.0 30 5.0+T 5762 using buccal mucous membrane 60.0 30 5.0+T 5774 Flap operation of corneal ulcer 20.0 30 4.0+T 5775 Flap operation: "flapping" of conjunctiva

for perforating injuries or operative wound 20.0 30 5.0+T

(For repair of symblepharon without graft, see 0175-0178, 0260-0276.)

Lacrimal Tract

Incision 5801 Drainage of lacrimal gland (abscess) 10.0 15 4.0+T 5803 Drainage of lacrimal sac, dacryocystotomy

or dacryocystostomy) 7.5 15 4.0+T Excision 5811 Excision of lacrimal gland

(dacryoadenectomy) 50.0 45 4.0+T 5813 Excision of lacrimal sac

(dacryocystectomy) 50.0 45 4.0+T 5815 Excision of lacrimal gland tumor 60.0 45 4.0+T

Introduction 5821 Catheterization of nasolacrimal duct

with implantation of tube or stent 10.0 15 3.0+T *5823 Injection procedure for dacryocystography *3.0 0

Repair 5831 Plastic operation on canaliculi by report 4.0+T 5833 Dacryocystorrhinostomy; fistulization

of lacrimal sac into nasal cavity, with or without anterior ethmoliidectomy 70.0 60 5.0+T 5835 Closure of punctum by cautery 4.0 15 3.0+T

Manipulation *5841 Dilation of punctum *2.0 0 3.0+T *5843 Probing of nasolacrimal duct *3.0 0 3.0+T *5846 Probing and/or irrigation of canaliculus *2.0 0 3.0+T

EAR

External Ear

(For audiometric, vestibular and speech tests, see 9340-9342.) Incision *5901 Drainage of abscess or hematoma of

auricle, simple *2.0 0 3.0+T 5902 complicated, including suppurative

chondritis by report 3.0+T *5905 drainage of abscess of external

auditory canal *2.0 0 3.0+T Excision 5911 Biopsy of ear 3.0 15

(For local destruction or excision of lesion of ear, see 0175-0197.)

(For plastic closure, see 0260-0324.) 5916 Excision ear, partial, simple repair 10.0 30 3.0+T 5917 Complete amputation, auricle 20.0 90 3.0+T *5920 Excision osteoma, external canal, simple *5.0 0 5923 Excision of exostois of external auditory

canal, end-aural or post-aural approach, complicated 50.0 90 3.0+T 5924 Radical excision of malignant lesion of

external auditory canal by report 4.0+T 5926 with neck dissection by report 6.0+T

Endoscopy *5931 Otoscopy with removal foreign body in

external auditory canal *2.0 0 3.0+T Repair

(Otoplasty: plastic operation on ear, see 0260-0324.)

(Reconstruction of ear with graft of skin plus cartilage, bone or other implant, see 0260-0324, 0620, 0621.) 5947 Otoplasty, of cartilage ("lop-ear"), with

or without reduction in size, unilateral 50.0 180 3.0+T 5948 bilateral 70.0 180 3.0+T 5949 Reconstruct external auditory canal for

congenital atresia, single stage 100.0 180 3.0+T Suture

(For suture of wound or injury of ear, see 0251, 0252, 0260-0270.)

Middle Ear

Introduction 5955 Eustachian tube catheterization and

insufflation, unilateral or bilateral 1.5 0 Incision *5961 Myringotomy; tympanotomy; plicotomy,

with or without Eustachian inflation and/or aspiration *3.0 0 3.0+T 5962 Tympanotomy, diagnostic, exploratory for

middle ear exposure 50.0 30 3.0+T 5963 with insertion of tube for serous otitis

media, unilateral 5.0 7 3.0+T 5964 with insertion of collar-button tube for

muco-serous otitis media, unilateral or bilateral 25.0 45 3.0+T 5968 Tympanolysis, transtympanic 80.0 180 3.0+T

Excision 5971 Mastoidectomy, simple 50.0 180 4.0+T 5972 Mastoidectomy, modified radical or radical,

without skin graft 80.0 180 4.0+T 5975 with skin graft 90.0 180 4.0+T 5980 Petrous apicectomy, including radical

mastoidectomy by report 4.0+T 5982 Removal of middle ear polyp 10.0 30 3.0+T

Repair 5990 Revision of radical mastoidectomy, with

or without skin graft 90.0 180 4.0+T *5991 Patching tympanic membrane, with or without

cauterization *2.0 0 5992 Myringoplasty, uncomplicated 80.0 180 4.0+T 5993 Tympanoplasty without mastoidectomy

(may include change in contours of external auditory canal and be combined with middle ear, including ossicular chain construction and/or attic surgery), post-auricular or endaural approach 100.0 180 4.0+T 5994 Tympanoplasty with mastoidectomy 120.0 180 4.0+T 5996 Incudo-stapedial arthrodesis, with or

without graft 70.0 90 4.0+T 5997 Stapes mobiliation, primary or secondary 70.0 90 4.0+T 5998 Stapedectomy with insertion of prosthetic

stapes with fenestration of the oval window 100.0 90 4.0+T 5999 Mastoid obliteration 80.0 90 4.0+T

Suture 6001 Closure of fistula, mastoid

(independent procedure) 25.0 60 4.0+T 6002 Decompression, intratemporal, facial nerve,

with or without neurolysis 100.0 180 9.0+T

(see also 5330) 6003 Suture and/or graft, facial nerve,

intratemporal 120.0 180 9.0+T

Internal Ear

Incision 6011 Labyrinthotomy, any type 100.0 180 6.0+T 6012 Fenestration of semicircular canal 100.0 180 6.0+T 6014 Revision of fenestration operation 60.0 180 6.0+T

Excision 6021 Labyrinthectomy 100.0 180 6.0+T

 

Doc Status: 
Complete

Section 533.6 - Radiology.

533.6 Radiology. (a) Maximum payment for radiology services. The department will pay providers of radiology services according to the radiology fees listed in the Radiology Fee Schedule in subdivision (f) of this section. Unless otherwise indicated, these fees are full payment for the radiology service provided.

(b) Radiology fee components. The fees listed in the Radiology Fee Schedule include payment for the professional component and for the technical and administrative component of radiology services.

(1) Professional component. (i) The professional component of radiology services refers to the various professional services performed by physicians, including:

(a) determining the patient's problem, including interviewing the patient, obtaining the patient's medical history, and physically examining the patient to decide how to perform radiology procedures;

(b) studying the results of diagnostic or therapeutic procedures, interpreting X-rays or radioisotope data and estimating treatment results;

(c) dictating examination or treatment reports; and

(d) consulting with and furnishing written reports to referring physicians regarding the results of diagnostic or therapeutic procedures.

(ii) Physicians who render these services in hospitals are paid 40 percent of the appropriate fee listed in the Radiology Fee Schedule. The remaining 60 percent is applied to the technical and administrative component described in paragraph (2) of this subdivision.

(iii) Payments may be made only to physicians meeting the requirements of section 505.17 of this Title. Only physicians who are not paid by a hospital for patient care and who bill separately from a hospital may be paid under this section.

(2) Technical and administrative component of radiology services. (i) The technical and administrative component of radiology services refers to the various services provided to the physician by the hospital, including the following:

(a) use of hospital personnel, such as technologists and clerical staff;

(b) use of hospital supplies such as film, opaques, radioactive substances, chemicals and drugs; and

(c) purchase, rental or maintenance of space, equipment, telephones or other facilities or supplies.

(ii) Sixty percent of the fee listed in the Radiology Fee Schedule is applicable to these technical and administrative services provided by the hospital.

(3) Procedures not separable into professional and technical and administrative components. Injections of radiopaque media, fluoroscopy and consultations must be performed by the physician. Consequently, these procedures are not separated for billing into professional and technical and administrative components, and the total fee listed in the Radiology Fee Schedule for such services is paid to the physician.

(c) General rules. These rules apply to all procedure codes found in the Radiology Fee Schedule.

(1) What is included in radiology fees. Fees listed in the Radiology Fee Schedule include the following:

(i) the usual contrast media, equipment and materials. When the physician supplies special surgical trays or materials, an additional charge may be claimed from the department;

(ii) consultation with and written reports provided to the referring physician; and

(iii) payment for injection procedures, such as local anesthesia, needle or catheter placement or injection of contrast media as provided in the Radiology Fee Schedule, except for injection procedures which are identified by an asterisk before the MMIS code in the Radiology Fee Schedule.

(2) Payment for multiple or repeat radiology procedures. (i) When more than one radiology procedure is performed on different parts of the body during the same visit, the total payment is the sum of the fee for the more costly procedure plus 60 percent of the fee for the less costly procedure.

(ii) When a single radiology procedure is performed which shows more than one part of the body, payment will be made for only one procedure.

(iii) When repeat radiology procedures are performed on the same part of the body and for the same illness, payment for the repeat procedures will be made according to the fee listed in the Radiology Fee Schedule. However, no payment will be made for repeat procedures on the same part of the body and for the same illness when the reason for the repeat procedure is technical or professional error in the original procedure.

(d) Outpatient and clinic services. No additional payment will be made for outpatient emergency and clinic services if the cost of providing radiology or radiotherapy services is included in the maximum reimbursement rate promulgated for the hospital by the Director of the Budget pursuant to section 2807 of the Public Health Law. When physicians refer patients for outpatient radiology or radiotherapy services, payment will be made according to the Radiology Fee Schedule except when radiology or radiotherapy services are provided in a facility that includes the cost of these services in its clinic rate calculation. In these cases, the recipient shall be registered as a clinic patient and the clinic rate shall be billed.

(e) Medicaid management information system (MMIS) modifiers. Each radiology procedure listed in the Radiology Fee Schedule is preceded by a five-digit number identifying the specific procedure for which payment is claimed. Known as the MMIS procedure code, this number sometimes must be expanded by two additional digits, or modifiers, to describe more completely the particular procedure involved. The modifiers used in radiology are described below:

(1) '-60' Professional component. When physicians provide radiology services in hospitals but are not paid for these services by the hospitals, the physicians' services are identified for billing purposes by adding the modifier '-60' to the MMIS procedure code.

(2) '-61' Technical and administrative component. When physicians provide radiology services in hospitals but are not paid for these services by the hospitals, the services, facilities and supplies furnished to the physicians by the hospitals are identified for billing purposes by adding the modifier '-61' to the MMIS procedure code.

(3) '-62' Multiple radiology procedures. When more than one radiology procedure is performed on different parts of the body during the same visit, the more costly procedure is identified for billing purposes by its MMIS procedure code and the less costly procedure is identified by adding the modifier '-62' to its MMIS procedure code.

(4) '-65' Multiple vascular radiology procedures. Wnen more than one vascular radiology procedure is performed at the same time, the more costly procedure is identified for billing purposes by its MMIS procedure code and the less costly procedure is identified by adding the modifier '-65' to its MMIS procedure code.

(5) '-66' Repeal radiology procedures. When radiology procedures are repeated for reasons other than technical or professional error in the original procedure, the repeat procedure is identified for billing purposes by adding the modifier, '-66' to the MMIS procedure code.

(6) '-19' Multiple modifiers. More than one modifier often may be needed to identify radiology procedures for which payment is sought. Add the modifier '-19' to the MMIS procedure code and list the applicable modifiers in the procedure description.

(f) Radiology Fee Schedule. Listed below are the maximum medical assistance reimbursement fees for radiology procedures. A fee includes payment for injection procedures only if the MMIS code is not preceded by an asterisk. To be reimbursed for a procedure whose fee is to be determined "By Report" (BR), providers must submit information to MMIS on the nature and extent of the radiology procedure performed, the need for the procedure, and the time, skill and equipment necessary to perform the procedure. Reports, procedure descriptions or itemized invoices should accompany "BR" claims for reimbursement. Interim MMIS procedure codes are denoted by parentheses enclosing the fees. These procedure codes may be used pending final approval and promulgation by the Director of the Budget.

(1) X-ray, diagnostic. MMIS Code Maximum

Fee 70001 Unlisted radiology procedure BR

HEAD AND NECK *70002 Pneumoencephalography or positive contrast

encephalography $ 75.00* 70003 including injection procedure 110.00 *70020 Ventriculography 50.00* 70030 Eye, for foreign body 20.00 70040 for localization of foreign body (70030 not included) 30.00 70050 Combined 70030 and 70040 40.00 70100 Mandible, partial, less than four views 15.00 70110 complete, minimum of four views 25.00 70120 Mastoids, less than three views per side 15.00 70130 complete study, minimum three views per side 25.00 70140 Facial bones, less than three views 15.00 70150 complete, minimum three views 25.00 70160 Nasal bones 15.00 *70172 Nasolacrimal duct (dacryocystography) 20.00* 70171 including injection procedure 30.00 70190 Optic foramina 15.00 70200 Orbits, complete, minimum four views 25.00 70210 Paranasal sinuses, less than three views 12.50 70231 complete study, minimum of three views 20.00 70240 Sella turcica 12.50 70250 Skull, less than four views with or without stereo 15.00 70260 complete study, minimum of four views, with or without

stereo 25.00 70300 Teeth, single view 5.00 70310 partial examination, less than full mouth 10.00 70320 complete examination, full mouth 15.00 70328 Temporomandibular joint, open and closed, unilateral 12.50 70330 bilateral 20.00 70350 Cephalogram (orthodontic) 7.50 70360 Neck for soft tissues 10.00 70370 Pharynx or larynx, including fluoroscopy 25.00 70380 Salivary gland for calculus 15.00 *70390 Sialography 20.00* 70391 including injection procedure 25.00 70374 Laryngogram 25.00 70134 Internal auditory meati (25.00)

CHEST 71000 Chest,"minifilm" $ 4.00 71010 Chest, single view 10.00 71020 two views 15.00 71023 three views (17.50) 71034 complete, minimum of four views, including

fluoroscopy where indicated 20.00 76001 Fluoroscopy, (independent procedure) 10.00 *71040 Bronchography, unilateral 35.00* 71041 including injection procedure 50.00 *71060 bilateral 40.00* 71061 including injection procedure 55.00 71100 Ribs, unilateral 15.00 71110 bilateral 25.00 71120 Sternum 15.00 71130 Sternoclavicular joints, minimum of three views 20.00

SPINE AND PELVIS 72010 Spine, entire, survey study (A-P and lateral) 40.00 72040 cervical, A-P and lateral 15.00 72050 cervical, minimum of four views 20.00 72052 cervical, complete, including flexion

and extension studies 30.00 72070 thoracic, minimum of two views 15.00 72080 thoraco-lumbar, A-P and lateral 15.00 72100 lumbo-sacral, A-P and lateral 15.00 72110 complete lumbo-sacral, minimum five views 30.00 72120 lumbo-sacral, bending views 20.00 72170 Pelvis, A-P only 12.50 72180 stereo 15.00 72190 complete, minimum of three views 20.00

(for Pelvimetry, see 74710) 72200 sacroiliac studies, A-P only 12.50

(For complete, see 72190) 72220 sacrume and coccyx 15.00 *72265 Myelography, lumbar or any other single level 40.00* 72266 including injection procedure 80.00 *72270 Myelography, complete spinal canal 60.00* 72271 including injection procedure 100.00 *72295 Discography, lumbar or cervical 50.00* 72296 including injection procedure 90.00

UPPER EXTREMITIES 73000 Clavicle 10.00 73010 Scapula 15.00 73020 Shoulder, one projection 10.00 73030 complete study 15.00 73050 Acromio-clavicular joints, bilateral, with or without

weighted distraction 17.50 73060 Humerus, including one joint 10.00 73070 Elbow, A-P and lateral 10.00 73080 complete, minimum three views 12.50 73090 Forearm, including one joint 10.00 73100 Wrist, A-P and lateral 10.00 73110 complete study, minimum three views 12.50 73120 Hand 10.00 73140 Fingers 7.50

LOWER EXTREMITIES 73500 Hip, one view 12.50 73510 complete study 20.00 73530 during operative procedure, up to four studies 30.00 73531 each additional study over four 7.50 73540 Hips and pelvis, infant and child, two views 15.00 73550 Femur, (thigh) including one joint 15.00 73560 Knee, two views 10.00 73570 complete study, minimum three views 15.00 73590 Tibia and fibula (leg) including one joint 10.00 73600 Ankle, two views 10.00 73610 complete study, minimum three views 12.50 73620 Foot, two views 10.00 73640 complete routine study, minimum three views 12.50 73631 complete including special os calcis views 20.00 73650 Os calcis (heel), minimum two views 10.00 73660 Toes 7.50

ABDOMEN 74000 Abdomen, single A-P 10.00 74020 complete study, minimum of three views 20.00

GASTRO-INTESTINAL TRACT

All X-ray studies included in fee codes 74220 to 74280 that include examinations of upper or lower gastrointestinal tract shall include fluoroscopic examination as an integral part of the study. All gallbladder series require erect and/or decubitus views necessary to determine the presence or absence of pathology. MMIS Code Maximum

Fee 74220 Esophagus, must include fluoroscopy $20.00 74240 Upper gastro-intestinal tract, with or without delayed

films, must include fluoroscopy 30.00 74241 with K.U.B., must include fluoroscopy 35.00 74245 with small bowel, includes multiple serial films,

must include fluoroscopy 40.00 74250 Small bowel, includes multiple serial films, with or

without K.U.B., must include fluoroscopy 30.00 74270 Colon, barium enema, must include fluoroscopy 25.00 74275 barium enema and air contrast, must include fluoroscopy 40.00 74280 air contrast only, minimum six views, must include

fluoroscopy 30.00 74290 Cholecystography, oral dye 20.00 74300 Cholangiography, operative 30.00 74305 Post-operative 22.50 74310 intravenous 37.50 74315 oral dye 30.00 *74320 percutaneous, transhepatic 25.00* 74321 including injection procedure 70.00 74322 Transduodenal cholangiography 30.00

UROLOGICAL 74401 Kidney, ureter and bladder (K.U.B.) single view 10.00 74402 multiple views 15.00 74400 Urography, intravenous, including K.U.B. 35.00 74405 including special hypertensive dye concentration

and clearance studies ("renal washout") 50.00 *74420 retrograde, including K.U.B. 25.00* *74430 Cystography, minimum three views 20.00* 74431 including injection procedure 25.00 74451 Urethrocystography, retrograde 20.00 74456 voiding 35.00 74415 Aorto-nephrotomography,intravenous 75.00 *74460 Retroperitoneal pneumography 25.00* 74461 including injection procedure 45.00 *74470 Translumbar renal cyst study (contrast visualization)

or antegrade urography 20.00* 74471 including injection procedure 40.00 74425 Loopagram, minimum three views 20.00 74426 Loopagram, including injection procedure 25.00

GYNECOLOGICAL AND OBSTETRICAL

For abdomen and pelvis, see 72170-72190, 74000, 74020) 74710 Pelvimetry, with or without cephalometry or placental

localization 25.00 74720 Placental localization 20.00 *74740 Hysterosal pingography 25.00* 74741 including injection procedure 35.00 *74760 Pelvic pneumography 25.00* 74761 including injection procedure 40.00

MISCELLANEOUS STUDIES 76000 Fluoroscopy (independent procedure) 10.00 76125 Cline Radiology, as part of other radiological

procedures except when otherwise included 20.00 74427 Pyelogram intravenous drip infusion (includes injection) 45.00 76020 Bone age studies 15.00 76040 Bone length studies (orthoroentgenogram) 25.00 76061 one survey (long bone or for metastasis) 35.00 *73527 Arthrography, contrast, three views or less 15.00* 73524 including injection procedure by same physician 25.00 *73528 minimum of four views 25.00* 73529 including injection procedure by same physician 35.00 76350 Kymography 25.00 76080 Fistula or sinus tract study 15.00* 76081 including injection procedure 20.00 76090 Mammography, unilateral 20.00 76091 bilateral 30.00 76100 Body section radiography (tomography, planigraphy, etc.)

(For more complex studies, an additional value may be warranted.) 30.00 75525 Cardiacoesophagogram 25.00 76300 Thermography (Breast), unilateral 20.00 76351 Thermography (Breast), bilateral 30.00 76140 Consultation on X-ray examination made elsewhere

(This value does not necessarily include consultation involving litigation.) 15.00 76141 Examination in home, additional charge (20.00)

VASCULAR SYSTEM *75505 Angiocardiography, single projection 100.00* *75507 additional projection 25.00* 75510 by CO(2) injection for auricular wall measurement 50.00 *75600 Aortography, thoracic or lumbar 50.00* *75610 including lower extremities 75.00* *75660 Angiography, cerebral, unilateral 90.00* *75662 bilateral 125.00* 75656 Angiography, 4 Vessel Cerebral (carotid and vertebral) 200.00 *75710 extremity, unilateral 35.00* *75729 arch, renal or splanchnic vessels 50.00* *75752 coronary (Sonne's or comparable technique) 100.00* *75746 pulmonary (intravenous) 50.00* *75809 Lymphangiography, unilateral or bilateral 50.00* *75810 Splenoportography 40.00* 74331 Pancreatography 40.00 *75824 Venography, extremity or caval 40.00* *75850 intraosseus 40.00*

(2) Radiotherapy. Radiotherapy fees include one year follow-up care for treatment of malignancies and 60-day follow-up care for treatment of nonmalignancies. Fees also include office visits during which radiotherapy is provided. However, radiotherapy fees do not include payment for surgical, radiology or laboratory procedures performed with the radiotherapy service.

CONSULTATIONS MMIS Maximum Code Fee 90611 Initial consultation, Office 24.00 90601 Subsequent consultation (when required to complete

diagnosis), office 18.00 90612 Initial consultation, other than office 20.00 90602 Subsequent consultation (when required to complete

diagnosis), other than office 15.00

PER TREATMENT SCHEDULE

SUPERFICIAL GRENZ OR LOW VOLTAGE

X-RAY THERAPY: 74401 Dermatoses (3 fields or less), per treatment 7.50 77402 more than 3 fields 10.00 77403 Benign tumors, per treatment 10.00 77404 Malignant lesions, per treatment 15.00 ORTHOVOLTAGE (150-500 KVP): 77466 Benign lesions, per treatment 10.00 77467 Malignant lesions, per treatment 15.00 SUPERVOLTAGES, 1 MILLION VOLTS AND HIGHER: (BETATRON, LINEAR ACCELERATOR, COBALT, ETC.) 77411 Per treatment 20.00

(3) Radium and radioisotopes (Nuclear medicine). (For consultation, dosage calculation and preparation, see 90611, 90601, 90612.) MMIS Code Maxium

Fee 77276 Basic value for placement of radioactive material
(add cost of radioactive material - see 99070) 75.00 77770 Interstitial application of radium or radioisotope BR 77760 Application of radium or radioisotope plaque or mold

for malignant lesion BR 77786 Application of Thorium X or similar liquid radioactive

material, includes office visit (add cost of radioactive material - see 99070) 7.50 77787 Surface application of sealed radioactive sources to

benign lesions, including radioactive source, single application 15.00

THERAPEUTIC

(Radioactive drugs not included, preliminary and follow-up diagnostic tests not included.) 79000 Hyperthyroidism, initial 100.00 79001 subsequent, each 50.00 79025 Thyroid suppression, initial 100.00 79026 subsequent, each 50.00 78030 Thyroid carcinoma BR 79100 Polycythemia vera, chronic leukemia, etc., per treatment 30.00 79400 Metastatic bone or other carcinoma, per treatment 30.00 79200 Inter-cavitary radioactive colloid therapy 45.00 79300 Interstitial radioactive colloid therapy 150.00 90792 Perfusion for malignant disease 3.00

DIAGNOSTIC

(Radioactive drugs not included) 78000 Radio-iodine uptake, single determination 15.00 78001 multiple determination (as 6 and 24 hours etc.) 20.00 78006 with scan 40.00 78010 Thyroid scanning only 25.00 78003 Thyroid stimulation or suppression test (including 2

uptakes) (THS or other drugs not included) 25.00 78005 Radioactive study, thyroid washout (thiocyanate,

perchlorate or other drugs not included) (20.00) 78072 Thyroid carcinoma metastases, imaging, neck

and chest only (45.00) 76360 Protein bound radio-iodine plasma, or conversion ratio 15.00 76370 Protein bound radlo-iodine plasma, or conversion ratio

(with uptake) 25.00 76352 Radio-tri-iodo-thyronine (in vitro) uptake 10.00

CIRCULATION AND BLOOD STUDIES 78271 Vitamin B-12 absorption study (e.g., Schilling Test); with

intrinsic factor 30.00 78270 without intrinsic factor 25.00 78272 combined, with and without intrinsic factor 50.00 78110 Blood or plasma volume (e.g., radio-iodinated HSA) 20.00 78120 Red cell mass determination 30.00 78130 Red cell survival (e.g., radio-chromate) 50.00 78135 Red cell survival plus splenic (and/or hepatic)

function study 75.00 78280 Gastrointestinal blood loss study 40.00 78160 Plasma radio-iron turnover rate 30.00 78170 Radio-iron red cell utilization and body distribution 50.00 78470 Cardiac output (e.g., radio-iodinated HSA) 30.00 78408 Circulation time (e.g., radio-iodinated HSA) 30.00 78034 Cardiac dynamic flow study (30.00) 78490 Tissue clearance studies 25.00 78491 Carotid/cerebral flow study (40.00)

MISCELLANEOUS 78222 Liver function (e.g., radio-iodinated rose bengal) 30.00 78226 Cholescintingraphy (60.00) 78724 Renal function (e.g., radio-iodinated hippurate sodium) 30.00 78721 Renogram (Isotope Study/Renal Image Flow) 85.00 78288 Gastrointestinal absorption study with radioactive

fat, first phase 30.00 78289 second phase 20.00 78282 Gastrointestinal protein loss (e.g., I-131, P.V.P.) 30.00 78081 Xenon washout (80.00) 78195 Lymphatics and lymph glands imaging (40.00) 78405 Myocardium, imaging (60.00)

LOCALIZATION AND SCANNING 78080 Bone marrow scan (45.00) 78803 Bone tumor 60.00 78804 positron method or complex instrumentation BR 78054 Joint scan (40.00) 78620 Brain tumor 60.00 78606 positron method or complex instrumentation BR 78201 Liver scintiscan 40.00 78223 Liver function with scanning 60.00 78850 Total body or multiple area scanning for metastatic

carcinoma 60.00 78655 Ocular tumor 35.00 78079 Lacrimal scan (20.00) 78404 Cardiac scan 60.00 78240 Pancreas (e.g., Selenium-75) 40.00 78070 Parathyroid scan 60.00 78775 Placental (e.g., RISA) 25.00 78185 Spleen scan 60.00 78707 Renal uptake and scintiscan (e.g., Mercury 203 or 197) 40.00 78582 Lung scan 60.00 78607 Brain scan 60.00 70017 Gamma Cisternogram 75.00 78805 Gallium scan 60.00 78290 Intestinal scan 40.00 78230 Salivary gland(s) scan 35.00 78403 MUGA Scan, cardiac blood pool imaging, with

determination of regional ventricular function including ejection fraction and wall motion

(e.g., gated blood pool images) 150.00 78407 Cardiac blood pool scan 40.00 76155 Scrotal scan (40.00)

(4) Diagnostic ultrasound. Note: A-Mode: Implies a one-dimensional ultrasonic measurement procedure.

M-Mode: Implies a one-dimensional ultrasonic measurement procedure with movements of the trace to record amplitude and velocity of moving echo producing structures.

B-Scan: Implies a two-dimensional ultrasonic scanning procedure with a two-dimensional display.

HEAD AND NECK MMIS Code Maximum

Fee 76500 Echoencephalography, Diencephalic Midine (A-Mode) 20.00 76505 Echoencephalography, Complete (Diencephalic Midline

and Ventricular Size) (A-Mode) 30.00 76516 Ophthalmic Echography(A-Mode) 40.00 76517 Ophthalmic Sonography (contact B-Scan) 60.00 76529 Parotid gland Sonography (B-Mode) (20.00) 76531 Soft tissue/neck mass Sonography (B-Scan) (30.00) 76530 Thyroid Echography (B-Scan) 20.00 76536 Thyroid Sonography (B-Scan) 30.00 76550 Non-invasive studies carotid artery, B-scan, Doppler (67.50)

HEART 76630 Echocardiagraphy, Pericardial Effusion (M-Mode) 25.00 76635 Echocardiography, Cardiac Valve(s) (M-Mode) 30.00 76620 Echocardiography, Complete (76630 and 76635 combined

and chamber dimensions) (M-Mode) 40.00 76628 Echocardiography, limited (e.g., follow-up or
limited study) (M-mode) 20.00 76621 Echocardiography, Two-dimensional (60.00) 76622 Echocardiography, Two-dimensional and M-Mode (90.00) 76931 Pericardiocentesis, by Ultrasonic Guidance (B-Mode,

real time) (BR) 76636 Doppler Echocardiography, Including 2-D

Echocardiography (87.00)

THORAX 76935 Thoracentesis, by Ultrasonic Guidance (BR) 76631 Pleural Effusion Echography (B-scan or real time) 25.00 76633 Diaphragm Sonography (B-Scan) (20.00) 76640 Breast Echography (B-Scan, real time) 25.00 76645 Breast Sonography (B-Scan) 50.00 76632 Mediastinum Mass Sonography (B-Scan, real time) (30.00)

ABDOMEN AND RETROPERITONEUM 76700 Abdominal Sonography, Complete Survey Study (B-Scan) 60.00 76705 Abdominal Sonography, Limited (e.g., follow-up or

limited study) (B-Scan) 40.00 76706 Hepatic Sonography (B-Scan) 60.00 76707 Gallbladder Sonography (B-Scan) 60.00 76775 Adrenal Gland Sonography (B-Scan) (70.00) 76776 Renal Sonography (B-Scan) 60.00 76940 Renal cyst aspiration, by Ultrasonic Guidance

(B-Scan, real time) (BR) 76944 Renal biopsy, by Ultrasonic Guidance (B-Scan real time) (BR) 76710 Pancreas Sonography (B-Scan) 60.00 76720 Spleen Sonography (B-Scan) 60.00 76730 Abdominal Aorta Echography (B-Mode, real time) 25.00 76735 Abdominal Aorta Sonography (B-Scan) 55.00 76780 Retroperitoneal Sonography (B-Scan) 60.00 76801 Urinary bladder Sonography (B-Scan) 40.00 76803 Prostate Sonography (B-Scan) (30.00) 76150 Scrotal Sonography (B-Scan) (30.00)

OBSTETRICS, GYNECOLOGY AND PELVIS 76816 Pregnancy Diagnosis Sonography (B Scan) 30.00 76817 Fetal Age Determination (Biparietal Diameter) Sonography

(B-Scan) and/or femur length, total intrauterine volume-TIUV and abdominal measurements 35.00 76815 Fetal Growth Rate (series of 76817) Sonography (B-Scan) 25.00 76818 Placental Localization Sonography (B-Scan) 40.00 76820 Pregnancy Sonography, Complete (76816; 76817; 76818

combined) (B-Scan) 55.00 76830 Molar Pregnancy Diagnosis Sonography (B-Scan) 40.00 76840 Ectopic Pregnancy Diagnosis Sonography (B-Scan) 60.00 76947 Amniocentesis, by Ultrasonic guidance (B-Scan, real time) (BR) 76841 Intrauterine Contraceptive Device Sonography (B-Scan) 40.00 76856 Pelvic Mass Diagnosis Sonography (B-Scan) 55.00

PERIPHERAL VASCULAR SYSTEM 76900 Arterial Flow Study, peripheral (Doppler) 45.00 76922 Venous Flow Study, peripheral (Doppler) (45.00)

MISCELLANEOUS 76901 Knee Sonography (B-Scan) (30.00) 76499 Ultrasonic planning of radiation field (B-Scan) (35.00)

(5) Computerized tomography scans. The fees for CT Scans with enhancement include the cost of all tomograph scans of the same anatomical site performed at the same session prior to the administration of contrast material.

CT SCANS HEAD MMIS Code Maximum

Fee 76101 CT Scan, head only, multiple views, without

enhancement; professional, administrative and technical components (120.00) 76102 CT Scan, head only, multiple views, with

enhancement; professional, administrative and technical components (145.00) 76103 CT Scan, head only, multiple views, without

enhancement; administrative and technical components (90.00) 76104 CT Scan, head only, multiple views, without

enhancement; professional component (30.00) 76105 CT Scan, head only, multiple views, with

enhancement; administrative and technical components (110.00) 76106 CT Scan, head only, multiple views, with

enhancement; professional component (35.00)

CT SCANS BODY 76107 Body CT Scan, multiple views performed to

investigate a specific anatomical region at the direction of an approved prescriber, without enhancement; includes administrative, technical and professional components (140.00) 76108 Body CT Scan, multiple views performed to

investigate a specific anatomical region at the direction of an approved prescriber, without enhancement; includes administrative and technical components (105.00) 76109 Body CT Scan, multiple views performed to

investigate a specific anatomical region at the direction of an approved prescriber, without enhancement; professional component (35.00) 76110 Body CT Scan, multiple views performed to

investigate a specific anatomical region at the direction of an approved prescriber, with enhancement; professional, administrative and technical components (170.00) 76111 Body CT Scan, multiple views performed to investigate

a specific anatomical region at the direction of an approved prescriber, with enhancement; includes administrative and technical components (130.00) 76112 Body CT Scan, multiple views performed to investigate

a specific anatomical region at the direction of an approved prescriber, with enhancement; professional component (40.00)

 

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Section 533.7 - Preferred Physicians and Children Program.

533.7 Preferred Physicians and Children Program. (a) Scope. The Preferred Physicians and Children Program (PPAC) is a program under which a written agreement is entered into by a provider and the department pursuant to which the department pays enhanced fees for certain medical services provided to children under the age of 21 who are eligible for Medical Assistance (MA). Only qualified primary care and specialist physicians meeting the requirements of this section are eligible to participate in PPAC. Physicians who wish to participate in PPAC must apply in writing on forms provided by the department. Applications for participation will be reviewed by and must receive approval of the department and the Department of Health. Participating physicians may obtain payment at the enhanced fees for medical services by using special PPAC procedure codes on their MA claim.

(b) Purpose. The purpose of PPAC is to improve access to quality medical care for MA-eligible children by paying enhanced MA fees to physicians meeting the minimum criteria for program participation.

(c) Definitions. (1) Medical care coordination, for purposes of this section, means providing or arranging for the provision of:

(i) scheduling of elective hospital admissions;

(ii) assistance with emergency admissions;

(iii) management of and/or participation in hospital care and discharge planning;

(iv) scheduling of referral appointments with written referrals as necessary and with requests for follow-up reports;

(v) scheduling of necessary ancillary services;

(vi) telephone notification to the social services district responsible for furnishing MA to the recipient when transportation services are essential to ensure the MA recipient's access to medically necessary care and services provided under the MA program; and

(vii) maintenance of complete medical records in compliance with the requirements of section 540.7 of this Title, including notation of referrals and hospitalizations, and copies of test results and reports.

(2) Qualified primary care physician, for purposes of this section, means a physician who:

(i) has current admitting privileges at a hospital which has a valid operating certificate issued in accordance with article 28 of the Public Health Law and is accredited by the Joint Commission on Accreditation of Hospitals (JCAH). The Department of Health may waive this requirement for a physician who qualifies for hospital admitting privileges but does not have such privileges for one of the reasons listed in clauses (a) through (d) of this subparagraph and who complies with the requirements of subdivision (e) of this section; however, the Department of Health will not waive the requirement for a physician who has been denied, or who has lost, hospital admitting privileges based on findings that the physician provided poor quality care or was guilty of misconduct:

(a) admitting privileges are not available at area hospitals; or

(b) the physician's specialty is not accepted for admitting privileges at area hospitals; or

(c) the nearest hospital at which admitting privileges could be granted if so removed by time or distance from the physician's office that access to such hospital is impractical; or

(d) the physician's hours of practice are not sufficient to warrant hospital admitting privileges and the physician has an agreement for provision of hospital care for his or her patients with a physician who does have admitting privileges;

(ii) is either:

(a) board-certified in family practice, internal medicine, obstetrics and gynecology, or pediatrics; or

(b) board-admissible in one of the specialties specified in clause (a) of this subparagraph and no more than five years has elapsed since the physician's completion of a residency program accredited by the American Medical Association Council for Graduate Medical Education or the American Osteopathic Association Committee on Postdoctoral Training in that specialty; or

(c) a primary care physician continuously enrolled as a Child/Teen-Health Plan (C/THP) provider on or before August 1, 1990; or

(d) holds an active staff appointment with specialty privileges in a hospital accredited for residency training by the Accreditation Council for Graduate Medical Education or the American Osteopathic Association Committee on Postdoctoral Training in the specialty in which the physician has privileges; or

(e) certified by the Royal College of Physicians and Surgeons of Canada or La Corporation Professelle des Medicins du Quebec;

(iii) provides 24-hour telephone coverage of his or her practice and ensures timely access to a practitioner qualified to respond to patients' health care needs. This requirement cannot be met by a recording which refers patients to emergency rooms;

(iv) provides medical care coordination;

(v) provides periodic health assessment examinations in accordance with the standards of C/THP;

(vi) complies with all applicable statutory and regulatory requirements of the MA program; and

(vii) is enrolled in the MA program and accepted for participation in PPAC by the department and the Department of Health.

(3) Qualified specialist physician, for purposes of this section, means a physician who:

(i) has current admitting privileges at a hospital which has a valid operating certificate issued in accordance with article 28 of the Public Health Law and is accredited by the JCAH. The Department of Health may waive this requirement for physicians whose specialty does not require the use of admitting privileges and who comply with the requirements of subdivision (e) of this section; however, the Department of Health will not waive the requirement for a physician who has been denied, or who has lost, hospital admitting privileges based on findings that the physician provided poor quality care or was guilty of misconduct;

(ii) is either:

(a) board-certified in a specialty recognized by the Department of Health; or

(b) board-admissible in a specialty recognized by the Department of Health and no more than five years have elapsed since the physician's completion of a residency program accredited by the American Medical Association Council for Graduate Medical Education or the American Osteopathic Association Committee on Postdoctoral Training; or

(c) holds an active staff appointment with specialty privileges in a hospital accredited for residency training by the Accreditation Council for Graduate Medical Education or the American Osteopathic Association Committee on Postdoctoral Training in the specialty in which the physician has privileges; or

(d) certified by the Royal College of Physicians and Surgeons of Canada or La Corporation Professelle des Medicins du Quebec;

(iii) provides consultation summaries or appropriate periodic progress notes to a qualified primary care physician on a timely basis following a referral or routinely scheduled consultant visit;

(iv) notifies the qualified primary care physician when scheduling a hospital admission;

(v) maintains complete medical records in compliance with the requirements of section 540.7 of this Title, including but not limited to notation of referrals and hospitalizations, and copies of test results and reports;

(vi) complies with all applicable statutory and regulatory requirements of the MA program; and

(vii) is enrolled in the MA program and accepted for participation in PPAC by the department and the Department of Health.

(d) Written agreement required. (1) As a condition of participation in PPAC, each qualified primary care and specialist physician must sign an agreement with the department to meet the minimum standards for participation set forth in either paragraph (2) or (3) or subdivision (c) of this section.

(2) Each qualified primary care and specialist physician must agree in writing that:

(i) informational material provided by the department concerning MA eligibility and services for person under 21 years of age and pregnant women will be conspicuously displayed on the physician's premises and that the physician will request additional informational material from the department as necessary;

(ii) the physician will notify the department within 30 days of circumstances resulting in his or her ineligibility to participate in PPAC and/or the inability to perform the activities and services required under the agreement;

(iii) the Department of Health has the authority to establish a new reimbursement methodology which supersedes that in effect at the time the physician first entered into an agreement to participate in PPAC and which may be applied prospectively to services furnished under the program by the physician;

(iv) the physician will comply with all policies, procedures and instruction provided by the department and the Department of Health to implement PPAC and make claims for payment under the MA program in accordance with the claiming procedures and the payment methodology which the department and the Department of Health establish;

(v) the department may cancel the physician's participation in PPAC at any time by providing at least 30 days' written notice; and

(vi) the physician will provided the department with at least 30 days written notice of his or her intent to cancel the PPAC agreement, which notice must include a description of the basis for the cancellation. The physician must agree to continue to provided and/or arrange for the provision of medical services for patients up to the date of termination of the PPAC agreement, to assist patients to maintain continuity of care, to provided patients with information to assist them in transferring their care to another provider and to make timely transfer of appropriate information in the patients' records upon request.

(e) Waiver of admitting privileges. The Department of Health may waive the admitting privileges requirements of this section in individual cases. A physician requesting waiver of the requirement must submit the following documentation demonstrating the physician's ability to guarantee coordinated care in the inpatient setting and to meet the standards required for admitting privileges:

(1) a description of the circumstance that merits consideration of a waiver of the requirement; and

(2) evidence of an agreement between the applicant and a primary care physician who is licensed to practice in New York State and who has active hospital admitting privileges at a hospital certified under article 28 of the Public Health Law and accredited by the JCAH for monitoring and providing continuity of care to the applicant's patients who are hospitalized; and

(3) a curriculum vitae; and

(4) proof of medical malpractice insurance; and

(5) two letters of reference, each of which must be from a physician who has direct knowledge of and attests to the applicant's qualifications as a practicing physician.

(f) Payment. (1) Qualified primary care and specialist physicians will be paid for their services at fees established by the Department of Health and approved by the Director of the Budget.

(2) Qualified primary care and specialist physicians who provide services in free-standing or hospital-based clinics licensed under article 28 of the Public Health Law may not submit claims for their services using the PPAC procedure codes if the clinic submits a claim to the MA program and is paid for these services. When the physician's services are not included in the clinic's MA rate, the physician may submit a claim using the regular (non-PPAC) MA procedure codes.

(3) Qualified primary care and specialist physicians who, either individually or as members of a group practice, provide services in the emergency room of a facility licensed under article 28 of the Public Health Law, pursuant to a contract with that facility, may not submit MA claims for their services using the PPAC procedure codes. When the emergency room physician's services are not included in the article 28 facility's MA rate, the physician may submit a claim using the regular

(non-PPAC) MA procedure codes.

 

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Section 533.8 - Human immunodeficiency virus enhanced fees for physicians

533.8 Human immunodeficiency virus enhanced fees for physicians program (HIV-EFP). (a) Scope. The HIV-EFP is a program under which a written agreement is entered into by a provider and the department pursuant to which the department agrees to pay enhanced fees for certain medical services provided to HIV-infected Medical Assistance (MA) recipients. Only qualified primary care and specialist physicians meeting the requirements of this section are eligible to participate in the HIV-EFP. Physicians who wish to participate in the HIV-EFP must apply in writing on forms provided by the department. Applications will be reviewed by and must receive approval of the department and the Department of Health. Participating physicians may obtain payment at the enhanced fees for medical services provided to HIV-infected MA recipients by using special HIV-EFP procedure codes on their MA claims.

(b) Purpose. The purpose of the HIV-EFP is to improve access to quality medical care for HIV-infected MA recipients by paying enhanced fees to physicians meeting the minimum criteria for program participation.

(c) Definitions. (l) Medical care coordination, for purposes of this section, means providing or arranging for the provision of:

(i) scheduling of elective hospital admissions;

(ii) assistance with emergency admissions;

(iii) management of and/or participation in hospital care and discharge planning;

(iv) scheduling of referral appointments with written referrals as necessary and with requests for follow-up reports;

(v) scheduling of necessary ancillary services such as laboratory, radiology, aerosolized pentamidine, physical therapy and infusion therapy;

(vi) telephone notification to the social services district responsible for furnishing MA to the recipient when transportation services are essential to ensure the MA recipient's access to medically necessary care and services provided under the MA program; and

(vii) maintenance of complete medical records in compliance with the requirements of section 540.7 of this Title including, but not limited to, notation of referrals and hospitalizations, and copies of test results and reports.

(2) Qualified primary care physician, for purposes of this section, means a physician who:

(i) has current admitting privileges at a hospital which has a valid operating certificate issued in accordance with Article 28 of the Public Health Law and accredited by the Joint Commission on Accreditation of Hospitals (JCAH). The Department of Health may waive this requirement for a physician who qualifies for hospital admitting privileges but does not have such privileges for one of the reasons listed in paragraph

(e)(1) of this section and who complies with the requirements of subdivision (e) of this section; however, the Department of Health will not waive this requirement for a physician who has been denied or who has lost hospital admitting privileges based on findings that the physician provided poor quality care or was guilty of misconduct;

(ii) is:

(a) board-certified in family practice, internal medicine, obstetrics and gynecology, or pediatrics; or

(b) board-admissible in one of the specialties specified in clause (a) of this subparagraph and no more than five years have elapsed since the physician's completion of a residency program accredited by the American Medical Association Council for graduate Medical Education or the American Osteopathic Association Committee on Postdoctoral Training in that specialty; or

(c) certified by the Royal College of Physicians and Surgeons of Canada or La Corporation Professelle des Medicins du Quebec;

(iii) provides 24-hour telephone coverage of his or her practice and ensures timely access to a practitioner qualified to respond to patient health needs; this requirement cannot be met by a recording referring patients to emergency rooms;

(iv) provides medical care coordination;

(v) maintains referral linkages with drug treatment programs and local acquired immune deficiency syndrome (AIDS) community-based organizations;

(vi) participates in training recommended by the AIDS Institute of the Department of Health;

(vii) complies with all applicable statutory and regulatory requirements of the MA program; and

(viii) is enrolled in the MA program and accepted for participation in the HIV-EFP by the department and the Department of Health.

(3) Qualified specialist physician, for purposes of this section, means a physician who:

(i) has current admitting privileges at a hospital which has a valid operating certificate issued in accordance with Article 28 of the Public Health Law and is accredited by the JCAH;

(ii) is:

(a) board-certified in a specialty recognized by the Department of Health; or

(b) board-admissible in a specialty recognized by the Department of Health and no more than five years have elapsed since the physician's completion of a residency program accredited by the American Medical Association Council for Graduate Medical Education or the American Osteopathic Association Committee on Postdoctoral Training; or

(c) certified by the Royal College of Physicians and Surgeons of Canada or La Corporation Professelle des Medicins du Quebec;

(iii) provides consultation summaries or appropriate periodic progress notes to a qualified primary care physician on a timely basis following a referral or routinely scheduled consultant visit;

(iv) notifies the primary care physician when scheduling a hospital admission;

(v) maintains complete medical records in compliance with the requirements of section 540.7 of this Title including, but not limited to, notation of referrals and hospitalizations, and copies of test results and reports;

(vi) complies with all applicable statutory and regulatory requirements of the MA program; and

(vii) is enrolled in the MA program and accepted for participation in the HIV-EFP by the department and the Department of Health.

(4) HIV-infected MA recipient, for purposes of this section, means a recipient:

(i) who has tested positive for HIV; or

(ii) who is seeking testing for HIV infection, pre-test counseling or post-test counseling.

(d) Written agreement required. (l) As a condition of participation in the HIV-EFP, each qualified primary care and specialist physician must sign an agreement with the department to meet the minimum standards for participation set forth in either paragraph (2) or paragraph (3) of subdivision (c) of this section.

(2) Each qualified primary care and specialist physician must agree in writing that:

(i) the physician will notify the department within 30 days of any circumstances resulting in his or her ineligibility to participate in the HIV-EFP and/or inability to perform the activities and services required under the agreement;

(ii) the Department of Health has the authority to establish a new payment methodology which supersedes that in effect at the time the physician first entered into an agreement to participate in the HIV-EFP and which may be applied prospectively to services furnished under the program by the physician;

(iii) the physician will comply with all policies, procedures and instructions provided by the department and the Department of Health to implement the HIV-EFP and make claims for payment under the MA program in accordance with the claiming procedures and the payment methodology which the department and the Department of Health establish;

(iv) the department may cancel the physician's participation in the HIV-EFP at any time by providing at least 30 days' written notice; and

(v) the physician will provide the department at least 30 days' written notice of his or her intent to cancel the HIV-EFP agreement, which notice must include a description of the basis for the cancellation. The physician must agree to continue to provide and/or arrange for the provision of medical services for patients up to the date of termination of the HIV-EFP agreement, to assist patients to maintain continuity of care, to provide patients with information to assist them in transferring their care to another provider and to make timely transfer of appropriate information in the patients' records upon request.

(e) Waiver of admitting privileges. (l) The Department of Health may waive the hospital admitting privileges requirement of subparagraph

(c)(2)(i) of this section in individual cases only for a physician who does not have such privileges for one of the following reasons:

(i) admitting privileges are not available at area hospitals; or

(ii) the physician's specialty is not accepted for admitting privileges at area hospitals; or

(iii) the nearest hospital at which admitting privileges could be granted is so far from the physician's office that use of admitting privileges would be impractical; or

(iv) the physician's hours of practice are not sufficient to warrant hospital admitting privileges and the physician has an agreement for provision of hospital care for his other patients with a physician who does have admitting privileges.

(2) A physician requesting a waiver of the requirement must submit the following documentation demonstrating the physician's ability to guarantee coordinated care in the in-patient setting and to meet the standards required for admitting privileges with the application for participation in the HIV-EFP:

(i) a description of the circumstance that merits consideration of a waiver of the requirement; and

(ii) evidence of an agreement between the applicant and a primary care physician who is licensed to practice in New York State and who has active hospital admitting privileges at a hospital certified under Article 28 of the Public Health Law and accredited by the JCAH for monitoring and providing continuity of care to the applicant's patients who are hospitalized;

(iii) a curriculum vitae;

(iv) proof of medical malpractice insurance; and

(v) two letters of reference, each of which must be from a physician who has direct knowledge of and attests to the applicant's qualifications as a practicing physician.

(f) Waiver of board-certification or board admissibility requirements.

(1) The Department of Health may waive the requirements of subparagraph

(c)(2)(ii) of this section based on a finding that the physician is a general practitioner currently serving MA recipients in a geographic area where enrollment of primary care physicians in the MA program is low.

(2) Physicians seeking a waiver under this subdivision must submit the following with the application for participation in the HIV-EFP:

(i) a description of the physician's clinical experience treating persons who are HIV-infected, including the physician's training, the population which the physician serves and referral arrangements; and

(ii) a listing of the primary zip code areas that the physician serves.

(g) Payment. (l) Qualified primary care and specialist physicians will be paid for their services at fees established by the Department of Health and approved by the Director of the Budget.

(2) Qualified primary care physicians may submit claims for HIV counseling performed by persons employed by the qualified primary care physicians who have completed an HIV counseling training program approved by the Department of Health.

(3) Qualified primary care and specialist physicians who provide services in freestanding or hospital-based clinics licensed under Article 28 of the Public Health Law may not submit claims for their services using the HIV-EFP procedure codes if the clinic submits a claim to the MA program and is paid for these services by the program. When the physician's services are not included in the clinic's MA rate, the physician may submit a claim using the regular (non-HIV-EFP) MA procedure codes.

(4) Qualified primary care and specialist physicians who, either individually or as members of a group practice, provide services in the emergency room of a facility licensed under Article 28 of the Public Health Law, pursuant to a contract with that facility, may not submit MA claims for their services using the HIV-EFP procedure codes. When the emergency room physician's services are not included in the Article 28 facility's MA rate, the physician may submit a claim using the regular

(non- HIV-EFP) MA procedure codes.

 

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