PhilHealth Circular No. 0035, s.2013 Annex 2 List Of Procedure Case Rates

ANNEX 2.LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 10060 10080 10120 10140 10160 10180 11000 11010 DESCRIPTION Incision and drainage of abscess (e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia) Incision and drainage of pilonidal cyst Incision and removal of foreign body, subcutaneous tissues Incision and drainage of hematoma, seroma, or fluid collection Puncture aspiration of abscess, hematoma, bulla, or cyst Incision and drainage, complex, postoperative wound infection Debridement of extensive eczematous or infected skin Debridement including removal of foreign material associated w/ open fracture(s) and/or dislocation(s); skin and subcutaneous tissues Debridement including removal of foreign material associated w/ open fracture(s) and/or dislocation(s); skin, subcutaneous tissue, muscle fascia, and muscle Debridement including removal of foreign material associated w/ open fracture(s) and/or dislocation(s); skin, subcutaneous tissue, muscle fascia, muscle, and bone Debridement; skin, partial thickness Debridement; skin, full thickness Debridement; skin, and subcutaneous tissue Debridement; skin, subcutaneous tissue, and muscle Debridement; skin, subcutaneous tissue, muscle, and bone Paring or curettement of benign hyperkeratotic skin lesion w/ or w/o chemical cauterization (such as verrucae or clavi) not extending through the stratum corneum (e.g., callus or wart) w/ or w/o local anesthesia; single lesion Paring or curettement of benign hyperkeratotic skin lesion w/ or w/o chemical cauterization (such as verrucae or clavi) not extending through the stratum corneum (e.g., callus or wart) w/ or w/o local anesthesia; two to four lesions Paring or curettement of benign hyperkeratotic skin lesion w/ or w/o chemical cauterization (such as verrucae or clavi) not extending through the stratum corneum (e.g., callus or wart) w/ or w/o local anesthesia; more than four lesions Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed; single or multiple lesion Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.5 cm or less Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.6 to 1.0 cm Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 1.1 to 2.0 cm Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter over 2.0 cm Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 0.5 cm or less Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 0.6 to 1.0 cm Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 1.1 to 2.0 cm Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter over 2.0 cm Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose ,lips, mucous membrane; lesion diameter 0.5 cm or less Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose ,lips, mucous membrane; lesion diameter 0.6 to 1.0 cm Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose ,lips, mucous membrane; lesion diameter 1.1 to 2.0 cm Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose ,lips, mucous membrane; lesion diameter over 2.0 cm Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms or legs; lesion diameter 0.5 cm or less Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms or legs; lesion diameter 0.6 to 1.0 cm Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms or legs; lesion diameter 1.1 to 2.0 cm Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms or legs; lesion diameter 2.1 to 3.0 cm Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms or legs; lesion diameter 3.1 to 4.0 cm Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms or legs; lesion diameter over 4.0 cm Excision, benign lesion, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; lesion diameter 0.5 cm or less Case Rate 3,640 3,640 3,640 3,640 3,640 5,560 10,540 10,540 Professional Fee 840 840 840 840 840 1,260 5,040 5,040 Health Care Institution Fee 2,800 2,800 2,800 2,800 2,800 4,300 5,500 5,500 11011 11,980 5,880 6,100 11012 11040 11041 11042 11043 11044 11050 12,120 3,640 3,640 5,680 8,020 8,020 3,640 6,720 840 840 1,680 2,520 2,520 840 5,400 2,800 2,800 4,000 5,500 5,500 2,800 11051 5,560 1,260 4,300 11052 5,680 1,680 4,000 11100 11300 11301 11302 11303 11305 11306 11307 11308 11310 11311 11312 11313 11400 11401 11402 11403 11404 11406 11420 3,640 5,560 3,700 8,020 8,440 5,560 3,700 8,020 8,440 3,700 8,020 8,440 8,260 3,640 3,640 3,640 3,640 3,640 3,640 3,640 840 1,260 1,344 2,520 2,940 1,260 1,344 2,520 2,940 1,344 2,520 2,940 3,360 840 840 840 840 840 840 840 2,800 4,300 2,356 5,500 5,500 4,300 2,356 5,500 5,500 2,356 5,500 5,500 4,900 2,800 2,800 2,800 2,800 2,800 2,800 2,800 Page 1 of 98 ANNEX 2. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 11421 11422 11423 11424 11426 11440 11441 11442 11443 11444 11446 11450 11462 11470 11600 11601 11602 11603 11604 11606 11620 11621 11622 11623 11624 11626 11640 11641 11642 11643 11644 11646 11720 11721 11730 11740 11750 11752 11755 11760 11762 11765 DESCRIPTION Excision, benign lesion, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; lesion diameter 0.6 to 1.0 cm Excision, benign lesion, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; lesion diameter 1.1 to 2.0 cm Excision, benign lesion, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; lesion diameter 2.1 to 3.0 cm Excision, benign lesion, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; lesion diameter 3.1 to 4.0 cm Excision, benign lesion, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; lesion diameter over 4.0 cm Excision, other benign lesion (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.5 cm or less Excision, other benign lesion (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.6 to 1.0 cm Excision, other benign lesion (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 1.1 to 2.0 cm Excision, other benign lesion (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 2.1 to 3.0 cm Excision, other benign lesion (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 3.1 to 4.0 cm Excision, other benign lesion (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter over 4.0 cm Excision of skin and subcutaneous tissue for hidradenitis, axillary Excision of skin and subcutaneous tissue for hidradenitis, inguinal Excision of skin and subcutaneous tissue for hidradenitis, perianal, perineal or umbilical Excision, malignant lesion, trunk, arms, or legs; lesion diameter 0.5 cm or less Excision, malignant lesion, trunk, arms, or legs; lesion diameter 0.6 to 1.0 cm Excision, malignant lesion, trunk, arms, or legs; lesion diameter 1.1 to 2.0 cm Excision, malignant lesion, trunk, arms, or legs; lesion diameter 2.1 to 3.0 cm Excision, malignant lesion, trunk, arms, or legs; lesion diameter 3.1 to 4.0 cm Excision, malignant lesion, trunk, arms, or legs; lesion diameter over 4.0 cm Excision, malignant lesion, scalp, neck, hands, feet, genitalia; lesion diameter 0.5 cm or less Excision, malignant lesion, scalp, neck, hands, feet, genitalia; lesion diameter 0.6 to 1.0 cm Excision, malignant lesion, scalp, neck, hands, feet, genitalia; lesion diameter 1.1 to 2.0 cm Excision, malignant lesion, scalp, neck, hands, feet, genitalia; lesion diameter 2.1 to 3.0 cm Excision, malignant lesion, scalp, neck, hands, feet, genitalia; lesion diameter 3.1 to 4.0 cm Excision, malignant lesion, scalp, neck, hands, feet, genitalia; lesion diameter over 4.0 cm Excision, malignant lesion, face, ears, eyelids, nose, lips; lesion diameter 0.5 cm or less Excision, malignant lesion, face, ears, eyelids, nose, lips; lesion diameter 0.6 to 1.0 cm Excision, malignant lesion, face, ears, eyelids, nose, lips; lesion diameter 1.1 to 2.0 cm Excision, malignant lesion, face, ears, eyelids, nose, lips; lesion diameter 2.1 to 3.0 cm Excision, malignant lesion, face, ears, eyelids, nose, lips; lesion diameter 3.1 to 4.0 cm Excision, malignant lesion, face, ears, eyelids, nose, lips; lesion diameter over 4.0 cm Debridement of nail(s) by any method(s); one to five Debridement of nail(s) by any method(s); six or more Avulsion of nail plate, partial or complete Evacuation of subungual hematoma Excision of nail and nail matrix, partial or complete (e.g., ingrown or deformed nail) for permanent removal Excision of nail and nail matrix, partial or complete (e.g., ingrown or deformed nail) for permanent removal w/ amputation of tuft of distal phalanx Biopsy of nail unit, any method (e.g., plate, bed, matrix, hyponychium, proximal and lateral nail folds) Repair of nail bed Reconstruction of nail bed w/ graft Wedge excision of skin of nail fold (e.g., for ingrown toenail) Case Rate 3,640 3,640 3,640 3,640 3,640 4,108 4,108 4,108 4,108 4,108 4,108 8,020 8,020 8,020 5,560 5,560 5,560 5,560 5,560 5,560 5,680 5,680 5,680 5,680 5,680 5,680 5,680 5,680 5,680 5,680 5,680 5,680 3,640 5,560 3,640 3,640 3,640 9,300 3,640 5,560 9,300 3,640 Professional Fee 840 840 840 840 840 1,008 1,008 1,008 1,008 1,008 1,008 2,520 2,520 2,520 1,260 1,260 1,260 1,260 1,260 1,260 1,680 1,680 1,680 1,680 1,680 1,680 1,680 1,680 1,680 1,680 1,680 1,680 840 1,260 840 840 840 2,100 840 1,260 2,100 840 Health Care Institution Fee 2,800 2,800 2,800 2,800 2,800 3,100 3,100 3,100 3,100 3,100 3,100 5,500 5,500 5,500 4,300 4,300 4,300 4,300 4,300 4,300 4,000 4,000 4,000 4,000 4,000 4,000 4,000 4,000 4,000 4,000 4,000 4,000 2,800 4,300 2,800 2,800 2,800 7,200 2,800 4,300 7,200 2,800 Page 2 of 98 ANNEX 2. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 11770 12001 DESCRIPTION Excision of pilonidal cyst or sinus Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.6 cm to 7.5 cm Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 7.6 cm to 12.5 cm Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 12.6 cm to 20.0 cm Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 20.1 cm to 30.0 cm Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); over 30.0 cm Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 5.1 cm to 7.5 cm Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 7.6 cm to 12.5 cm Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 12.6 cm to 20.0 cm Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 20.1 cm to 30.0 cm Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; over 30.0 cm Layer closure of wounds of scalp, axillae, trunk, and/or extremities (excluding hands and feet); 2.5 cm or less Layer closure of wounds of scalp, axillae, trunk, and/or extremities (excluding hands and feet); 2.6 cm to 7.5 cm Layer closure of wounds of scalp, axillae, trunk, and/or extremities (excluding hands and feet); 7.6 cm to 12.5 cm Layer closure of wounds of scalp, axillae, trunk, and/or extremities (excluding hands and feet); 12.6 cm to 20.0 cm Layer closure of wounds of scalp, axillae, trunk, and/or extremities (excluding hands and feet); 20.1 cm to 30.0 cm Layer closure of wounds of scalp, axillae, trunk, and/or extremities (excluding hands and feet); over 30.0 cm Layer closure of wounds of neck, hands, feet and/or external genitalia; 2.5 cm or less Layer closure of wounds of neck, hands, feet and/or external genitalia; 2.6 cm to 7.5 cm Layer closure of wounds of neck, hands, feet and/or external genitalia; 7.6 cm to 12.5 cm Layer closure of wounds of neck, hands, feet and/or external genitalia; 12.6 cm to 20.0 cm Layer closure of wounds of neck, hands, feet and/or external genitalia; 20.1 cm to 30.0 cm Layer closure of wounds of neck, hands, feet and/or external genitalia; over 30.0 cm Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membrances; 2.5 cm or less Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membrances; 2.6 cm to 5.0 cm Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membrances; 5.1 cm to 7.5 cm Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membrances; 7.6 cm to 12.5 cm Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membrances; 12.6 cm to 20.0 cm Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membrances; 20.1 cm to 30.0 cm Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membrances; over 30.0 cm Adjacent tissue transfer or rearrangement, trunk; defect 10 sq cm or less Adjacent tissue transfer or rearrangement, trunk; defect 10.1 sq cm to 30.0 sq cm Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10 sq cm or less Case Rate 5,680 3,640 Professional Fee 1,680 840 Health Care Institution Fee 4,000 2,800 12002 5,560 1,260 4,300 12004 5,680 1,680 4,000 12005 5,680 1,680 4,000 12006 5,680 1,680 4,000 12007 12011 12013 12014 12015 12016 12017 12018 12031 12032 12034 12035 12036 12037 12041 12042 12044 12045 12046 12047 12051 12052 12053 12054 12055 12056 12057 14000 14001 14020 5,680 5,680 9,300 9,552 8,020 8,020 8,020 8,020 3,640 5,560 5,680 5,680 5,680 5,680 5,680 9,300 8,020 8,440 8,260 10,880 5,680 5,680 8,020 8,020 8,260 8,260 9,700 12,120 12,120 10,540 1,680 1,680 2,100 2,352 2,520 2,520 2,520 2,520 840 1,260 1,680 1,680 1,680 1,680 1,680 2,100 2,520 2,940 3,360 3,780 1,680 1,680 2,520 2,520 3,360 3,360 4,200 6,720 6,720 5,040 4,000 4,000 7,200 7,200 5,500 5,500 5,500 5,500 2,800 4,300 4,000 4,000 4,000 4,000 4,000 7,200 5,500 5,500 4,900 7,100 4,000 4,000 5,500 5,500 4,900 4,900 5,500 5,400 5,400 5,500 Page 3 of 98 260 3.620 4.240 13.000 18. trunk Formation of direct or tubed pedicle.100 5. free. w/ or w/o transfer. including direct closure of donor site.500 18. forehead. w/ ostectomy Excision. sacral pressure ulcer. or each one percent of body area of infants and children (except 15050) Split graft. donor area Graft. w/ primary suture Excision.440 6. w/ coccygectomy.360 9.700 12. genitalia.740 12.800 13. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 14021 14040 DESCRIPTION Adjacent tissue transfer or rearrangement. face.600 9. head and neck (e.300 38. defect 10 sq cm or less Adjacent tissue transfer or rearrangement. including preparation of recipient site Pinch graft. myocutaneous.440 16.400 13. w/ muscle or myocutaneous flap closure. nose. arms. hands. or fasciocutaneous flap.000 27. Excision. ears. trunk Muscle.400 13. trunk. legs. w/ primary suture.640 38. neurovascular pedicle Free muscle flap w/ or w/o skin graft w/ microvascular anastomosis Free skin flap w/ microvascular anastomosis Free fascial flap w/ microvascular anastomosis Graft.300 21. free muscle graft (including obtaining graft) Graft for facial nerve paralysis.500 9. with excessive skin weighting down lid Graft for facial nerve paralysis.700 5. genitalia.840 21. including primary closure.880 16.640 38.940 21. up to defect size 2 cm diameter Split graft. eyelids.000 18. tip or digit.740 30.040 21.800 8.240 13. eyelids. levator scapulae) Muscle. unusual or complicated.840 9. including direct closure of donor site. and/or feet (except multiple digits). or legs Formation of direct or tubed pedicle.700 17. neck. Case Rate 11. upper eyelid.740 30.120 30. or fasciocutaneous flap. intermediate. genitalia. free. coccygeal pressure ulcer.700 12. full thickness of external ear or nasal ala). defect 10.500 16. neck. hands or feet Formation of direct or tubed pedicle.260 8.500 12. arms.800 12.800 16. mouth. forehead. any area Filleted finger or toe flap. including free graft to donor site Transfer.120 10. more than 30 sq cm.940 10.720 Health Care Institution Fee 6. free fascia graft (including obtaining fascia) Graft for facial nerve paralysis.000 4. including direct closure of donor site.940 30.0 sq cm Adjacent tissue transfer or rearrangement.740 12. Blepharoplasty. of any pedicle flap (e.340 38.300 5.300 21.240 9. neck. and/or lips.740 30.640 38.1 sq cm to 30.040 26. chin. 100 sq cm or less.600 9. axillae.300 21.300 30. 20 sq cm or less Full thickness graft. defect 10 sq cm or less Adjacent tissue transfer or rearrangement. and/or feet. cheeks.800 16.800 16. free. trunk.000 30. derma-fat-fascia Blepharoplasty.500 13. including direct closure of donor site. myocutaneous. or fasciocutaneous flap.300 17. to cover small ulcer.840 21.300 30.640 38. defect 10.840 16.300 30.240 9.g. eyelids. w/ skin flap closure. scalp. and/or multiple digits. arms.400 8.720 16. sacral pressure ulcer. single or multiple.300 13. abdomen to wrist. mouth.940 30. axillae.1 sq cm to 30.800 16. sacral pressure ulcer. w/ flap closure Excision. coccygeal pressure ulcer.440 16.300 21.440 16. chin. w/ or w/o transfer.500 5.340 47.800 16.000 18. scalp. nose.040 26.240 9. nose. w/ or w/o transfer.440 13. cheeks. ears.640 21.120 8.300 13. skin Formation of direct or tubed pedicle. forehead.880 6.340 47. free muscle graft by microsurgical technique Graft for facial nerve paralysis.800 21. neck.400 8. 100 sq cm or less. island pedicle Flap.500 17. sternocleidomastoid. hands.800 9.700 Page 4 of 98 . or each one percent of body area of infants and children (except 15050) Full thickness graft.340 47. axillae. 20 sq cm or less Full thickness graft. genitalia. neck.980 12.900 15120 15200 15220 15240 15260 15350 15400 15570 15572 15574 15576 15580 15650 15732 15734 15736 15738 15740 15750 15756 15757 15758 15760 15770 15820 15822 15823 15840 15841 15842 15845 15920 15922 15931 15933 15934 15935 15936 21.620 5.0 sq cm Adjacent tissue transfer or rearrangement. lower eyelid Blepharoplasty. any location Muscle.. ears.700 12.120 3. upper eyelid. w/ primary suture.800 19. arms and/or legs. forehead. skin Application of xenograft. mouth.800 16. defect 10.840 21.400 15.800 16.400 14041 14060 14061 14300 14350 15050 18. 20 sq cm or less Application of allograft. regional muscle transfer Excision. Excision.500 13. free.840 21.. mouth. upper extremity Muscle. sacral pressure ulcer.500 12.300 21. ears and/or lips.1 sq cm to 30. myocutaneous.800 9.440 9.300 30.. 20 sq cm or less Full thickness graft.120 Professional Fee 5.600 17.600 9. eyelids. composite (e. ears and/or lips. hands and/or feet. sacral pressure ulcer.300 38.120 11. chin. "Walking" tube).400 8.500 6.ANNEX 2. temporalis.g.300 13.900 15100 8. chin. w/ or w/o transfer.940 21. and/or legs. w/ coccygectomy. myocutaneous.500 13. eyelids. axillae. w/ skin flap closure. genitalia. or other minimal open area (except on face). cheeks. scalp.800 13.980 30.360 4. nose. masseter. orbits. w/ ostectomy Excision.240 9.040 26.g.940 21.300 16.940 21.600 12.640 30. hands and/or feet.0 sq cm Adjacent tissue transfer or rearrangement.240 26.100 13.300 18. mouth. scalp.700 21.940 47.700 17.740 30. or fasciocutaneous flap. lower extremity Flap. cheeks.700 12.240 4. lips or intraoral Cross finger flap. arms or legs.680 1. lesion diameter 3. mucous membrane. w/ muscle or myocutaneous flap closure Excision. malignant lesion.680 1. w/ ostectomy.300 9.0 cm Case Rate 37.300 38. ischial pressure ulcer.680 1. trunk. hands. w/ ostectomy Excision. sinus or fistula) Destruction.. hands. any method. any method. ears.740 3.000 4. malignant lesion.1 to 4. Excision. w/ skin flap closure. lesion diameter 3. eyelids. including local anesthesia. any method. laser technique) Destruction by any method of flat warts or molluscum contagiosum.1 to 2. nose. genitalia.940 21. w/ primary suture.240 13.000 4. hands.0 cm Destruction.500 18. ears. neck.240 13. malignant lesion. lesion diameter 1. malignant lesion.500 4.400 12.1 to 2.0 cm Destruction. trochanteric pressure ulcer.440 17.680 1. all benign facial lesions or premalignant lesions in any location. all lesions Electosurgical destruction of multiple fibrocutaneous tags.000 4. lesion diameter 0.680 1.. hands. genitalia. ischial pressure ulcer. malignant lesion. mucous membrane.0 cm Destruction.440 16.000 4.680 5. lesion diameter over 4.0 cm Destruction.100 2. ears. mucous membrane. face.200 7. any number of lesions Destruction of cutaneous vascular proliferative lesions (e.100 2. trunk.680 5. w/ ostectomy Excision.0 cm Destruction. nose. malignant lesion.740 9.360 13. synthetic mesh). any method.1 to 2. any method.0 cm Destruction. w/ primary suture. mucous membrane.000 5.300 13. feet. malignant lesion.700 Professional Fee 21. any method.680 5. malignant lesion.1 to 4. eyelids. scalp. trunk.300 5. lips. sacral pressure ulcer.740 5. genitalia. lesion diameter 0. eyelids. ischial pressure ulcer. arms or legs.680 1.ANNEX 2. neck.680 1. any method. w/ muscle or myocutaneous flap closure.800 5.120 21. eyelids.000 6.200 7.g. neck.6 to 1. scalp. trochanteric pressure ulcer.0 cm Destruction. any method. lesion diameter 3.300 9.020 2. Excision. trunk.5 cm or less Destruction. arms or legs. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 15937 15940 15941 15944 15945 15946 15950 15951 15952 15953 15956 15958 16010 16035 16040 DESCRIPTION Excision.240 9. w/ ostectomy (ischiectomy) Excision. w/ primary suture. of benign skin lesions other than cutaneous vascular proliferative lesions on any area other than the face. neck. including local anesthesia. trochanteric pressure ulcer.680 1.6 to 1. Excision.700 6.500 18. any method. malignant lesion. face. ears.980 21. hands.740 30. w/ skin flap closure. lips.520 5.0 cm Destruction.940 30.200 7. malignant lesion.520 5. trochanteric pressure ulcer. malignant lesion.0 cm Destruction.680 5.000 4.680 2. all lesions Chemical cauterization of granulation tissue (proud flesh. neck. or benign lesions other than cutaneous vascular proliferative lesions.1 to 4.200 Page 5 of 98 .440 11. feet. nose. w/ ostectomy Dressings and/or debridement. neck. arms or legs.5 cm or less Destruction.1 to 3. lips.680 2. ears. malignant lesion. malignant lesion.100 2.680 5. lesion diameter 0.000 4. face.100 9. ears.100 2. employing alloplastic dressing (e. any method.300 13. initial or subsequent Escharotomy Excision burn wound. mucous membrane. arms or legs.680 5.740 31.200 7.680 5.520 1. face. scalp.200 Health Care Institution Fee 16.940 30.400 1. lesion diameter 0. lesion diameter 0.680 5.800 19.680 1.680 5.300 9.0 cm Destruction.1 to 3. w/ or w/o surgical curettement.700 4. any method.000 7.200 7. face. any method. Excision. eyelids. lesion diameter over 4. eyelids. trochanteric pressure ulcer. lips.680 5.0 cm Destruction. mucous membrane. feet. feet.000 4. ischial pressure ulcer. feet. any method.020 5. w/ ostectomy Excision. genitalia. genitalia. any method. lesion diameter 1. any method.900 17. lesion diameter 0. any method. lesion diameter 2. nose.5 cm or less Destruction. w/ skin flap closure. feet.000 4. including laser. w/ primary suture.g. lips.500 17106 17110 17200 17250 17260 17261 17262 17263 17264 17266 17270 17271 17272 17273 17274 17276 17280 17281 17282 17283 17284 17286 18.680 1.300 8.680 5.000 4. genitalia. lesion diameter 1. malignant lesion. including laser. hands.300 9. lesion diameter over 4.000 4. malignant lesion. lesion diameter 2.800 12. w/o skin grafting. w/ ostectomy Excision.000 4. any number of Destruction by any method.700 12. milia. Excision.140 38.720 9. nose. face.680 1.700 17. any method. scalp.680 5. scalp.100 12. w/ muscle or myocutaneous flap closure.1 to 3.600 4. nose. w/ muscle or myocutaneous flap closure. w/ skin flap closure.020 2. ischial pressure ulcer. any method.440 8. trunk.0 cm Destruction.0 cm Destruction.100 2.680 8.000 4.000 5. trunk.0 cm Destruction. lips.300 9. malignant lesion. malignant lesion.680 1. lesion diameter 2.640 19.700 17.440 4.260 30. trochanteric pressure ulcer. arms or legs. scalp.500 17100 8.880 9. any anatomic site Destruction by any method.680 9.6 to 1. malignant lesion.500 17000 8. ANNEX 2. femur) Biopsy.600 16.800 55.640 5.360 2.560 9.780 8.000 22. temporomandibular. ischium.000 9. with or without prosthetic implant Breast reconstruction with free flap Breast reconstruction with other technique Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM). including removal Application of halo. major joint or bursa (e. pelvic Case Rate Professional Fee Health Care Institution Fee 17304 8.800 21.200 4. or needle. ribs) Biopsy.020 5.g.560 8.020 8.300 37.260 8.300 7.400 21.g. axillary lymph nodes Mastectomy.000 55. w/ or w/o pectoralis minor muscle. ilium.260 2.008 504 3. aspiration and/or injection. breast Periprosthetic capsulectomy.200 13.800 8. open. single pedicle.000 33. wrist.. fresh tissue technique. lumbar or cervical Removal of foreign body in muscle or tendon sheath Arthrocentesis.000 7.000 55.600 37.700 Page 6 of 98 . breast Biopsy.800 8. open.800 8.500 16. including closure of donor site Open periprosthetic capsulotomy.540 23.000 840 4.800 8.200 33. partial.300 5. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE DESCRIPTION Chemosurgery (Mohs micrographic technique). Mastotomy w/ exploration or drainage of abscess. including subsequent expansion Breast reconstruction with latissimus dorsi flap. bone. immediate or delayed. and complete histopathologic preparation.600 13. simple.000 16.. up to 5 specimens Puncture aspiration of cyst of breast.700 17.300 33.g.200 7. spinous process.940 3.200 13.g. complete Mastectomy. trocar. deep (vertebral body. single lesion Mastectomy for gynecomastia Mastectomy. including removal. sternum.400 19369 19370 19371 20200 20206 20220 20225 20240 20245 20250 20251 20520 20600 20605 20610 20615 20650 20660 20661 20662 55. surgical excision of tissue specimens. double pedicle. subacromial bursa) Aspiration and injection for treatment of bone cyst Insertion of wire or pin w/ application of skeletal traction.400 4.000 22.800 8.000 22.500 5. thoracic Biopsy. w/ mediastinal lymphadenectomy Immediate insertion of breast prosthesis following mastopexy.108 3. with tissue expander. excisional. axillary and internal mammary lymph nodes (Urban type operation) Mastectomy. olecranon bursa) Arthrocentesis.108 12.740 8.000 22.100 3.800 25.500 2. trochanter of femur) Biopsy. muscle Biopsy.020 9.880 18. w/ plastic reconstruction. including removal Application of cranial tongs. deep Biopsy of breast.520 8. including axillary lymph nodes.800 4. elbow or ankle.300 37.g. vertebral body.500 4.520 5.020 22.100 9.600 5.100 2.500 19000 19020 19100 19101 19110 19112 19120 19125 19140 19160 19162 19180 19182 19200 19220 19240 19260 19271 19272 19340 19342 19350 19357 19361 19364 19366 19367 3.000 58. duct lesion or nipple lesion (except 19140).500 55.500 13. muscle.200 13. icnluding pectoral muscles.000 22. excisional.200 13. partial. mastectomy or in reconstruction Nipple/areola reconstruction Breast reconstruction. first stage. cranial Application of halo.000 21. shoulder.440 8. needle core Biopsy of breast.520 4.300 8.100 3. trocar.900 5. aspiration and/or injection.800 21.500 4. spinous process.400 10..200 7. including pectoral muscles. incisional Nipple exploration. sternum. Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM).500 5.000 22. humerus.360 2. bursa or ganglion cyst (e.868 8.400 13.400 21. color coding of specimens.520 2. toes) Arthrocentesis.504 10.600 33. or needle.800 8.000 22. acromioclavicular.600 33.300 30. hip.800 37. caliper.300 9.800 21. mastectomy or in reconstruction Delayed insertion of breast prosthesis following mastopexy.800 16.200 13.440 2. or other benign or malignant tumor aberrant breast tissue. ilium. including removal. but excluding pectoralis major muscle Excision of chest wall tumor including ribs Excision of chest wall tumor involving ribs. modified radical. male or female. or stereotactic frame. aspiration and/or injection. radical. including closure of donor site.500 10. femur) Biopsy.800 8.300 21. bursa or ganglion cyst (e. w/ or w/o excision of a solitary lactiferous duct or a papilloma lactiferous duct Excision of lactiferous duct fistula Excision of cyst. w/ plastic reconstruction.600 2..800 3.520 1.500 5.368 3.500 16.200 13. bone.g.800 5.. small joint.608 23. fibroadenoma.000 55. one or more lesions Excision of breast lesion identified by preoperative placement of radiological marker. vertebral body.800 21.400 21. fingers. deep (e.200 21.640 9. ribs.600 33. including removal of all gross tumor.700 12.200 840 1.300 5. mapping. Mastectomy..000 46.500 5.140 12.900 5.700 3. superficial (e. superficial (e. microscopic examination of specimens by the surgeon.800 13.800 30. subcutaneous Mastectomy. intermediate joint.000 16.260 8. w/o mediastinal lymphadenectomy Excision of chest wall tumor involving ribs.000 30. percutaneous needle Biopsy.800 37.800 4. knee joint.600 21.020 2.260 2. with axillary lymphadenectomy Mastectomy.200 13.400 21.000 1. radical. 300 30.040 8.120 9.000 12.700 13. mandible Excision of bone (e.080 15.000 18.g.g.520 12. structural.700 9.300 30. pin or rod) Removal of implant. deep (e.400 5.. complete amputation Replantation. spinous process. other than fibula.600 21. morselized Allograft for spine surgery only.400 8. fibula Bone graft w/ microvascular anastomosis. any donor area. metal band. or laminar fragments) obtained from same incision Autograft for spine surgery only (includes harvesting the graft).g.040 5. thumb (includes distal tip to MP joint).900 12.100 5.300 30.700 12.700 23. any donor area.600 16.540 18.800 10. percutaneous..200 12. Excision of malignant tumor of mandible. excluding thumb (includes distal tip to sublimis tendon insertion)..120 18.700 10. Monticelli type) Replantation. foot.540 11.g.800 13.800 16.800 10.800 37. screw. or metatarsal Free osteocutaneous flap w/ microvascular anastomosis.700 5. complete amputation Replantation. complex or sheet Tendon graft. by stripper Fascia lata graft.500 10. iliac crest Bone graft w/ microvascular anastomosis.500 9. pin.540 18.500 9. costochondral Cartilage graft..000 18.000 5.200 4.940 23.200 Health Care Institution Fee 12.240 5.120 10. rod or plate) Application of a uniplane (pins or wires in one plane). llizarov..000 46.800 16.460 4.400 5. plantaris) Tissue grafts.600 9. iliac crest. toe extensor.400 5.580 2. metastasis) radiofrequency. allograft. external fixation system (e. unilateral.600 12.940 10.500 13. single piece Case Rate 21.700 16.500 5.700 12.300 23.800 8..000 21.200 6.500 6.300 18. bone tumor(s) (e. simple Excision of benign cyst or tumor of mandible.600 8.320 40.000 16.500 10.500 5. complete amputation Replantation. paratenon.980 12.120 39.300 40.120 9. radical resection Condylectomy.300 23.700 12. buried wire. thumb (includes carpometacarpal joint to MP joint). metatarsal Bone graft w/ microvascular anastomosis. excluding thumb (includes metacarpophalangeal joint to insertion of flexor sublimis tendon).600 8. arm (includes surgical neck of humerus through elbow joint). dowel or button) Bone graft.300 18.600 10.500 13..720 4.800 5.120 4.000 18. soft tissue of face or scalp Excision of bone (e. structural Autograft for spine surgery only (includes harvesting the graft)..420 10.600 16. nasal septum Fascia lata graft.. osteoid osteoma. partial or complete.g.120 21.040 5.720 5.g.800 12. including computed tomographic guidance Arthrotomy. sliding osteotomy.700 7. prosthetic material) Genioplasty. unilateral.500 5. temporomandibular joint Radical resection of tumor (e. dermis) Allograft for spine surgery only.600 5.120 37.720 20.300 27.000 21.320 23. complete amputation Replantation.400 8.700 9.600 15. for osteomyelitis or bone abscess). digit.400 12.600 16. complete amputation Replantation.600 9.500 Professional Fee 9. major or large Cartilage graft.500 5. superficial (e. metatarsal. including removal.960 9.600 9.400 18.400 8.800 12. form a distance (e. external fixation system Application of multiplane (pins or wires in more than one plane). femoral Removal of implant. complex Excision of malignant tumor of mandible.300 23.600 9.400 9. fat.000 18. or great toe Free osteocutaneous flap w/ microvascular anastomosis.600 9..700 13.200 16.000 18. other than iliac crest.720 8. augmentation (autograft.300 18. metatarsal Free osteocutaneous flap w/ microvascular anastomosis.280 9.700 10.800 16. by incision and area exposure.g. iliac crest Free osteocutaneous flap w/ microvascular anastomosis.800 10.980 27. great toe w/ web space Ablation.720 6.g.600 12.240 12.520 23. forearm (includes radius and ulna to radial carpal joint).400 9.000 23.g. facial bone(s) Removal by contouring of benign tumor of facial bone (e.000 5.120 12.g.540 10. digit. complete amputation Replantation.800 16. local (e.. minor or small (e.800 16. malignant neoplasm)..040 8.800 20.000 10.600 5.100 23.400 8.300 30.820 5. ribs.800 30. temporomandibular joint Meniscectomy.500 9. for osteomyelitis or bone abscess).300 37. complete amputation Replantation.600 21.500 5.000 16. fibrous dysplasia) Excision of benign tumor or cyst of facial bone other than mandible Excision of torus mandibularis Excision of maxillary torus palatinus Excision of malignant tumor of facial bone other than mandible Excision of benign cyst or tumor of mandible. temporomandibular joint Coronoidectomy Genioplasty. palmaris.400 21. buried wire.400 6.300 30. other (e.400 25.g.200 6. nail. bicortical or tricortial (through separate skin or fascial incision) Bone graft w/ microvascular anastomosis.400 8.500 10. hand (includes hand through metacarpophalangeal joint(s). morselized (thorugh separate skin or fascial incision) Autograft for spine surgery only (includes harvesting the graft).g. complete amputation Bone graft.500 13.300 Page 7 of 98 .ANNEX 2.000 37.700 9. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 20663 20670 20680 20690 20692 20802 20805 20808 20816 20822 20824 20827 20838 20900 20902 20910 20912 20920 20922 20924 20926 20930 20931 20936 20937 20938 20955 20956 20957 20962 20969 20970 20972 20973 20982 21010 21015 21025 21026 21029 21030 21031 21032 21034 21040 21041 21044 21045 21050 21060 21070 21120 21121 DESCRIPTION Application of halo.880 6. 600 21. two or more osteotomies (e.g. Treacher-Collins Syndrome) Reconstruction midface.000 21184 55.000 21182 46.600 21.400 21. w/ LeFort I Reconstruction midface. vertical. LeFort I. requiring bone grafts (includes obtaining autografts) (e.800 25.400 21150 21151 21154 21155 21159 55. LeFort III (extra and intracranial) w/ forehead advancement (e. LeFort III (extracranial). segment movement in any direction. forehead. horizontal. brachycephaly).g. mono bloc).000 46. contouring only Reduction forehead..400 21.300 21.ANNEX 2.000 46.400 21179 21180 21181 55. LeFort I.300 21. w/ or w/o grafts (includes obtaining autografts) Reconstruction. prosthetic material Augmentation.200 25. advancement or alteration.. w/ autograft (includes obtaining grafts) Reconstruction by contouring of benign tumor of cranial bones (e.500 55. LeFort I. vertical.400 25. forehead.500 18..500 33.600 33. segment movement in any direction.g.600 25. augmentation w/ interpositional bone grafts (includes obtaining autografts) Augmentation.400 21.600 37. w/ LeFort I Reconstruction superior-lateral orbital rim and lower forehead.g.300 Page 8 of 98 . three or more pieces.g. three or more pieces.300 21.000 33. superior-lateral orbital rims and lower forehead. w/ grafts (allograft or prosthetic material) Reconstruction.500 46.000 33.500 24.300 13. w/o bone graft Reconstruction midface. w/o bone graft Reconstruction midface.400 21.200 16.500 46. fibrous dysplasia). contouring and application of prosthetic material or bone graft (includes obtaining autograft) Reduction forehead. contouring and setback of anterior frontal sinus wall Reconstruction midface.400 24. any type.800 33.000 33.400 33.300 9.. fibrous dysplasia). osteotomies (other than LeFort type) and bone grafts (includes obtaining autografts) Reconstruction of mandibular rami.600 25.400 21.400 21175 55. w/ multiple autografts (includes obtaining grafts). w/ bone graft (includes obtaining graft) Reconstruction of mandibular rami and/or body. sliding osteotomies. w/o LeFort I Reconstruction midface.g. fibrous dysplasia).200 21.300 30. w/o bone graft Reconstruction midface.. nasoethmoid complex following intra-and extracranial excision of benign tumor of cranial bone (e. requiring bone grafts (includes obtaining autografts). rims. mandibular body or angle.500 25.200 21.400 21. LeFort II.600 21. segment movement in any direction..800 29. segment movement in any direction (e.500 30.000 55. sliding.600 33. wedge excision or bone wedge reversal for asymmetrical chin) Genioplasty.500 21. requiring bone grafts (includes obtaining autografts)...000 46.. LeFort II. w/ or w/o grafts (includes obtaining autografts) Reconstruction.200 Health Care Institution Fee 13. nasoethmoid complex following intra-and extracranial excision of benign tumor of cranial bone (e. any type. mono bloc).g. single piece.200 25. two pieces.300 53. requiring bone grafts (includes obtaining autografts) (e.g. sagittal split. w/ multiple autografts (includes obtaining grafts). two pieces. for Long Face Syndrome). "C".400 25. w/ multiple autografts (includes obtaining grafts).600 33.500 13.400 21. single piece.600 21.800 16. requiring bone grafts (includes obtaining autografts) Reconstruction midface.g.. rims.000 58. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 21122 21123 21125 21127 21137 21138 21139 21141 21142 21143 21145 21146 DESCRIPTION Genioplasty. horizontal. total area of bone grafting greater than 80 cm2 Reconstruction midface. extracranial Reconstruction of orbital walls. trigonocephaly.. requiring bone grafts (includes obtaining autografts). LeFort I.400 21188 21193 21194 21195 55. ungrafted unilateral alveolar cleft) Reconstruction midface. w/o bone graft Reconstruction of mandibular rami. anterior intrusion (e.200 8.000 33.200 21. or "L" osteotomy.400 24. entire or majority of forehead and/or supraorbital rims.500 46.000 55.. segment movement in any direction.300 21147 55. onlay or interpositional (includes obtaining autograft) Reduction forehead.300 21183 53. any direction.800 55. w/ bone graft. total area of bone grafting less Reconstruction of orbital walls.400 29.300 30.600 21.200 25.300 21172 55.400 21160 46. LeFort III (extracranial). fibrous dysplasia).000 55. bifrontal. mandibular body or angle.500 25.g.g. forehead.000 53. w/o LeFort I Reconstruction midface.600 29.000 21. total area of bone grafting greater than 40 cm2 but less than 80 cm2 Reconstruction of orbital walls. ungrafted bilateral alveolar cleft or multiple osteotomies) Reconstruction midface. requiring bone grafts (includes obtaining autografts) Reconstruction midface.500 Professional Fee 16. plagiocephaly. nasoethmoid complex following intra-and extracranial excision of benign tumor of cranial bone (e. rims.g. requiring bone grafts (includes obtaining autografts).000 21.500 13.300 46.800 16. or "L" osteotomy. advancement or alteration (e. LeFort I. "C".300 21.200 33. entire or majority of forehead and/or supraorbital rims.400 46.000 33. w/o internal rigid fixation Case Rate 30. LeFort III (extra and intracranial) w/ forehead advancement (e.600 21. segment movement in any direction. LeFort I. complete Reconstruction of zygomatic arch and glenoid fossa w/ bone and cartilage (includes obtaining autografts) Reconstruction of orbit w/ osteotomies (extracranial) and w/ bone grafts (includes obtaining autografts) (e. uncomplicated Open treatment of nasal fracture.000 55. bone. subperiosteal implant.240 12.500 21.500 21365 37.g. w/ or w/o stabilization Closed treatment of nasal septal fracture Open treatment of nasoethmoid fracture.500 55. w/ splint.720 6.000 21.000 55.660 23.600 42.000 9.600 25.400 5.300 21.500 46.800 21366 46.500 5.040 6.200 33.000 21.400 33. rib cartilage.300 21.700 10. w/ bone grafts Orbital repositioning..040 6.000 55. mandible (includes obtaining graft) Graft.500 16. temporomandibular joint.g.200 21.. segmental (e.g. w/ concomitant open treatment of fractured septum Open treatment of nasal septal fracture. blade. wire or headcap fixation. w/ or w/o autograft (includes obtaining graft) Arthroplasty. w/ internal and/or external skeletal fixation Open treatment of nasal fracture.300 21. micro-ophthalmia) Periorbital osteotomies for orbital hypertelorism.. via coronal or multiple approaches Closed treatment of nasomaxillary complex fracture (LeFort II type).400 5. w/ bone grafting (includes obtaining graft) Case Rate 55. w/ transosteal bone plate (e.400 21. periorbital osteotomies.040 5. w/ allograft Arthroplasty. Gilles approach) Open treatment of depressed malar fracture.500 21. w/ wiring and/or local fixation Open treatment of nasomaxillary complex fracture (LeFort II type). including zygomatic arch and malar tripod..700 13.500 30.000 30.700 10. w/ bone grafts. cylinder). complicated.000 46.600 33.600 16.940 21. Wassmund or Schuchard) Graft.300 24.400 21. w/ internal rigid fixation Osteotomy. complete Reconstruction of mandibular condyle w/ bone and cartilage autografts (includes obtaining grafts) (e.g. including zygomatic arch and malar tripod Open treatment of complicated (e.400 55.700 10.600 12.000 16. mandible.800 21.400 5.400 21.ANNEX 2.400 5.540 12.300 30.200 29. ear cartilage. temporomandibular joint. requiring multiple open approaches Open treatment of nasomaxillary complex fracture (LeFort II type).g..700 13.300 Page 9 of 98 . autogenous. temporomandibular joint.600 33.g. endosteal implant (e.720 5.700 12.600 5. w/ prosthetic joint replacement Reconstruction of mandible.000 55.120 12.400 21. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 21196 21198 21206 21210 21215 21230 21235 21240 21242 21243 21244 21245 21246 21247 21248 21249 21255 21256 21260 21267 21300 21315 21325 21330 21335 21336 21337 21338 21339 21340 21343 21344 21345 21346 21347 21348 21355 21356 21360 DESCRIPTION Reconstruction of mandibular rami and/or body.000 33. comminuted or involving posterior wall) frontal sinus fracture.300 30.500 5. maxilla.600 11.800 25.200 25.720 6..400 5.300 46. extraoral.300 22. to face.400 21.600 16.800 21.300 37.800 Health Care Institution Fee 21. including repair of canthal ligaments and/or the nasolacrimal apparatus Open treatment of depressed frontal sinus fracture Open treatment of complicated (e.500 46. unilateral.120 18. including zygomatic arch and malar tripod.240 9. partial Reconstruction of mandible or maxilla.300 Professional Fee 33.300 46.940 23.600 33. partial Reconstruction of mandible or maxilla.400 21.800 12. to nose or ear (includes obtaining graft) Arthroplasty. cylinder).500 53.800 25.200 16.g.600 33.540 12.760 12.120 10. w/ manipulation Open treatment of depressed zygomatic arch fracture (e. mandibular staple bone plate) Reconstruction of mandible or maxilla. nose or ear (includes obtaining graft) Graft. w/ interdental wire fixation or fixation of denture or splint Open treatment of nasomaxillary complex fracture (LeFort II type). sagittal split.g..240 12. maxillary or malar areas (includes obtaining graft) Graft.720 8. w/ external fixation Percutaneous treatment of nasoethmoid complex fracture. subperiosteal implant. extracranial approach Closed treatment of skull fracture w/o operation Closed treatment of nasal bone fracture Open treatment of nasal fracture.000 46. for hemifacial microsomia) Reconstruction of mandible or maxilla.540 10. comminuted or involving cranial nerve foramina) fracture(s) of malar area.g.940 23.400 21.500 5.g.000 55.000 21. segmental Osteotomy. w/ bone grafting (includes obtaining graft) Percutaneous treatment of fracture of malar area.120 12.600 33. endosteal implant (e.500 55.600 16.800 21.200 33.200 25.400 21. nasal..500 25. autogenous.900 10.400 9.400 13. blade.600 25. comminuted or involving cranial nerve foramina) fracture(s) of malar area.300 21. chin.000 63. w/o external fixation Open treatment of nasoethmoid fracture. bone.720 6.300 13.000 55. w/ internal fixation and multiple surgical approaches Open treatment of complicated (e.120 12.000 10.400 9. including zygomatic arch and malar tripod. 600 21435 23.g.580 31.700 5.100 4. complicated (e. multiple approaches Closed treatment of craniofacial separation (LeFort III type) using interdental wire fixation of denture or splint Open treatment of craniofacial separation (LeFort III type).600 10. soft tissues of neck or thorax.980 30. and/or wiring of dentures or splints Closed treatment of temporomandibular dislocation.580 18.680 2.720 8. multiple surgical approaches.600 10.300 17. for condition other than fracture Incision and drainage. and/or intermaxillary fixation) Open treatment of craniofacial separation (LeFort III type). w/ external fixation Closed treatment of mandibular fracture.300 9.500 16.580 12.200 10.000 25...180 37.980 31. complicated (comminuted or involving cranial nerve foramina).280 14.500 5.280 6.700 30.500 10.700 9.700 20. partial Costotransversectomy Excision first and/or cervical rib.200 6.600 8. w/o interdental fixation Open treatment of mandibular fracture.700 7. soft tissue of neck or thorax Excision tumor. periorbital approach Open treatment of orbital floor "blowout" fracture.300 12. malignant neoplasm).120 6.020 4. w/ implant Open treatment of fracture of orbit.120 20. soft tissue of neck or thorax Excision of rib.900 10.300 5.400 12. w/ interdental wire fixation or fixation of denture or splint Open treatment of palatal or maxillary fracture (LeFort I type). open operation Case Rate 20.600 10. transantral approach (Caldwell-Luc type operation) Open treatment of orbital floor "blowout" fracture.700 5. w/ partial rib ostectomy Incision. except "blowout".300 18.080 16.300 18.400 16. complicated.000 4.800 8. deep abscess or hematoma. Open treatment of palatal or maxillary fracture (LeFort I type).680 2.980 23. utilizing internal and/or external fixation techniques (e. complicated.000 23. intramuscular Radical resection of tumor (e.300 17.400 9.800 5. w/ bone grafting (includes obtaining graft) Closed treatment of palatal or maxillary fracture (LeFort I type)..600 16.700 13. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 21385 21386 21387 21390 21395 21400 21406 21407 21408 21421 21422 21423 21431 21432 21433 DESCRIPTION Open treatment of orbital floor "blowout" fracture.800 17.540 20.500 10. w/ wiring and/or internal fixation Open treatment of craniofacial separation (LeFort III type).000 20. periorbital approach..900 10.600 6.300 12.800 9. recurrent requiring intermaxillary fixation or splinting). except "blowout" Open treatment of fracture of orbit.720 1. initial or subsequent Closed treatment of temporomandibular dislocation.800 21.080 8. except "blowout". w/o implant Open treatment of fracture of orbit.300 5.400 12.080 18.960 22.000 5.900 18. subcutaneous Excision tumor.400 10.300 18.888 21. for osteomyelitis or bone abscess).980 37. w/ interdental fixation Open treatment of mandibular condylar fracture Open treatment of complicated mandibular fracture by multiple surgical approaches including internal fixation.120 18.400 8. w/ alloplastic or other implant Open treatment of orbital floor "blowout" fracture.000 Professional Fee 10.580 31.480 21.288 37.400 21. head cap.800 18. Incision and drainage.500 13.280 14. except "blowout". halo device.120 5.300 30.000 23.280 8.800 27. initial or subsequent Open treatment of temporomandibular dislocation Closed treatment of hyoid fracture Open treatment of hyoid fracture Interdental wiring.600 10.600 8.080 12. deep.720 10.600 9. Excision first and/or cervical rib.080 14.400 10. w/ interdental fixation Open treatment of mandibular fracture.760 11.900 10.760 12.200 16.900 17.600 10. subfascial.660 23.108 5.800 9.400 Health Care Institution Fee 10.g.500 5.660 22.400 10..800 12.000 5. internal fixation.980 18. thorax Biopsy.680 8. interdental fixation. w/ sympathectomy Ostectomy of sternum.000 5.400 12.000 23. periorbital approach w/ bone graft (includes obtaining graft) Closed treatment of fracture of orbit.800 31. w/ bone grafting (includes obtaining graft) Closed treatment of mandibular or maxillary alveolar ridge fracture Open treatment of mandibular or maxillary alveolar ridge fracture Closed treatment of mandibular fracture Percutaneous treatment of mandibular fractue.040 10.020 9. deep abscess or hematoma.g.900 13. w/o resection of cervical rib Division of scalenus anticus.400 21. multiple surgical approaches Open treatment of craniofacial separation (LeFort III type).560 11.008 1.ANNEX 2.700 16.000 18.500 12.900 9.000 14.600 6.600 Page 10 of 98 . complicated (e. deep.520 4.600 16. w/ opening of bone cortex (e.000 37. combined approach Open treatment of orbital floor "blowout" fracture.680 8.600 7.120 23.720 12. comminuted or involving cranial nerve foramina).g.520 1.300 14.400 10. soft tissue of neck or thorax.120 12.g. w/ resection of cervical rib Division of sternocleidomastoid for torticollis. w/ external fixation Open treatment of mandibular fracture.300 10. soft tissues of neck or thorax.800 5. Division of scalenus anticus.700 21436 21440 21445 21450 21452 21453 21454 21461 21462 21465 21470 21480 21485 21490 21493 21495 21497 21501 21502 21510 21550 21555 21556 21557 21600 21610 21615 21616 21620 21627 21630 21700 21705 21720 46.300 37.500 9.000 8.400 4.700 9.500 3.300 12.000 15. partial Sternal debridement Radical resection of sternum. soft tissue of neck or thorax. 740 38. single level.868 21.800 25.400 12.400 53.400 21. atlas-axis (C1-C2) Arthrodesis.640 21. single vertebral segment.000 22101 27.120 12.500 16.000 22556 46.400 29.500 22114 22210 22212 22214 22220 22222 22224 22305 22310 22325 30. anterior interbody technique. w/ or w/o excision of odontoid process Arthrodesis. including diskectomy.600 13. spinous process.940 3.400 53.520 29. including diskectomy. single interspace. single vertebral segment. posterior or posterolateral approach. posterior approach. cervical below C2 segment.. lumbar Osteotomy of spine. thoracic Partial excision of vertebral body. single level. including diskectomy.000 10.200 25. posterior or posterolateral approach. single vertebral segment.300 25.g. including minimal diskectomy to prepare interspace (other than for decompression). lumbar Partial excision of vertebral body.500 10. one vertebral segment.300 24.160 13.300 8. requiring and including casting or bracing Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s). one vertebral segment.800 16. lumbar Osteotomy of spine.000 23.800 13. including minimal diskectomy to prepare interspace (other than for decompression). tumor. single vertebral segment.300 24. spinous process. lumbar (w/ or w/o lateral transverse technique) Arthrodesis.120 12.300 16.000 22102 27.800 21. for intrinsic bony lesion. posterior technique. posterior or posterolateral technique.000 24.000 10.400 29. lumbar Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s).800 22327 22548 22554 37. one fractured vertebrae or dislocated segment.800 40.500 25. anterior approach. lamina or facet) for intrinsic bony lesion. cervical Partial excision of vertebral body. posterior or posterolateral technique. posterior or posterolateral technique.300 22558 22590 22595 22600 22610 46.500 21. lumbar Arthrodesis. soft tissue of back or flank Excision.240 504 1. lumbar Closed treatment of vertebral process fracture(s) Closed treatment of vertebral body fracture(s).500 53.000 10.960 20. single level. cervical Osteotomy of spine.400 53.700 17.300 30.860 16.120 23. posterior technique.000 24.120 15.320 53. Arthrodesis. cervical below C2 segment. clivus-C1-C2 (atlasaxis).. single vertebral segment.500 12.320 16.000 13. thoracic Arthrodesis. cervical Osteotomy of spine. cervical below C2 Arthrodesis.500 25.400 29.400 16. single vertebral segment. one vertebral segment. for intrinsic bony lesion.400 53. soft tissue of back or flank Partial excision of posterior vertebral component (e.600 15.200 29.700 22326 38.120 15. thoracic Osteotomy of spine.ANNEX 2. spinous process. anterior interbody technique. cervical Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s).200 29.900 5. one fractured vertebrae or dislocated segment.800 23. one fractured vertebrae or dislocated segment.g.500 46.460 10.440 20.600 2. lamina or facet) for intrinsic bony lesion.500 53. w/o decompression of spinal cord or nerve root(s). single vertebral segment. posterior approach.080 4.200 21.680 12.800 Page 11 of 98 .800 24.840 16.300 21.700 12.200 21.980 9. thoracic Osteotomy of spine.700 3.500 46.500 22612 22630 30.300 46. for intrinsic bony lesion.520 13. posterior approach..700 5.120 Health Care Institution Fee 12.680 23..400 30. posterior or posterolateral approach.400 16.g. cervical Partial excision of posterior vertebral component (e.500 5. thoracic (w/ or w/o lateral transverse technique) Arthrodesis. single vertebral segment. posterior interbody technique.520 5.000 24. including minimal diskectomy to prepare interspace (other than for decompression).300 40. malignant neoplasm). cervical below C2 segment. anterior approach. anterior transoral or extraoral technique.000 4.120 12.g.368 9. lumbar Case Rate 27. craniocervical (occiput-C2) Arthrodesis. w/o decompression of spinal cord or nerve root(s). lamina or facet) for intrinsic bony lesion. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 21740 21750 21800 21805 21810 21820 21825 21920 21930 21935 22100 DESCRIPTION Reconstructive repair of pectus excavatum or carinatum Closure of sternotomy separation w/ or w/o debridement Closed treatment of rib fracture Open treatment of rib fracture w/o fixation Treatment of rib fracture requiring external fixation ("flail chest") Closed treatment of sternum fracture Open treatment of sternum fracture w/ or w/o skeletal fixation Biopsy. thoracic Partial excision of posterior vertebral component (e. soft tissue of back or flank Radical resection of tumor (e. thoracic Arthrodesis.300 27.400 29. single vertebral segment.504 5.200 25. anterior approach. anterior interbody technique.000 24.000 22110 46.300 21.300 18.300 22112 30. w/o decompression of spinal cord or nerve root(s).120 Professional Fee 15.400 23.020 10. 000 10.560 10.680 2.400 54. 8 or more vertebral segments Posterior non-segmental instrumentation (e. soft tissue of shoulder area Arthrotomy w/ biopsy.680 8.g.980 21. sternoclavicular joint Arthrotomy w/ synovectomy.g.900 17..340 11. for spinal deformity. posterior.000 12.600 15.000 46. soft tissue of shoulder area Excision.300 17.920 21. dual rods w/ multiple hooks and sublaminal wires)..g.800 21. deep.504 5. acromioclavicular. shoulder area.000 21. Excision or curettage of bone cyst or benign tumor of clavicle or scapula.800 27. dual rods w/ multiple hooks and sublaminal wires).000 21. 2 to 3 vertebral segments Arthrodesis. drainage..240 30.g. 7 to 12 vertebral segments Posterior segmental instrumentation (e. w/ exploration. glenohumeral joint.g.980 23.000 5. 2 to 3 vertebral segments Anterior instrumentation. w/ or w/o cast.660 Health Care Institution Fee 21.920 13.g. 7 to 12 vertebral segments Arthrodesis. tumor. w/ exploration.440 14.120 18.000 21.820 46. w/ or w/o cast.120 27. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 22800 22802 22804 22808 22810 22812 22840 22841 22842 DESCRIPTION Arthrodesis.120 16. glenohumeral joint.800 67.940 58.000 58.400 9. w/ allograft Sequestrectomy (e. w/ or w/o cast. w/ autograft (includes obtaining graft) Excision or curettage of bone cyst or benign tumor of proximal humerus.900 10. metal cages.540 10.280 10.200 55. subfascial (e. shoulder area Arthrotomy.280 14.120 10.400 10. partial Excision or curettage of bone cyst or benign tumor of clavicle or scapula. anterior.080 15.120 21.700 10. abdominal wall tumor.200 55.800 42.600 15.g.120 8.000 10.000 21.800 63.000 53.300 10.700 12. for osteomyelitis or bone abscess). infected bursa Incision.300 27.660 Professional Fee 37. for osteomyelitis or bone abscess). tumor. Excision or curettage of bone cyst or benign tumor of proximal humerus. for infection. scapula Case Rate 58.400 21.980 22.700 12. for spinal deformity. desmoid) Removal of subdeltoid (or intratendinous) calcareous deposits.080 10.000 21. for osteomyelitis or bone abscess).800 46.580 20.000 24... dual rods w/ multiple hooks and sublaminal wires).900 10.800 46.000 21.300 27.000 9.200 33. 13 or more vertebral segments Arthrodesis. up to 6 vertebral segments Arthrodesis. Harrington rod) Application of prosthetic device (e.600 37. or removal of foreign body Biopsy.600 10.740 23. shoulder area. for spinal deformity.000 4.200 55. total Acromioplasty or acromionectomy.g. anterior.020 37.960 15.120 30. anterior.900 3. acromioclavicular.000 53. single Harrington rod technique) Internal spinal fixation by wiring of spinous processes Posterior segmental instrumentation (e.800 15.900 10. for infection. sternoclavicular joint.000 22844 22845 22846 22847 22848 22849 22850 22851 22852 22855 22900 23000 23020 23030 23031 23035 23040 23044 23065 23075 23076 23077 23100 23101 23105 23106 23107 23120 23125 23130 23140 23145 23146 23150 23155 23156 23170 23172 67. or removal of foreign body Arthrotomy. 4 to 7 vertebral segments Arthrodesis.g.400 24.000 21.800 23.800 10.g. open method Capsular contracture release (Sever type procedure) Incision and drainage. subcutaneous Excision.ANNEX 2.540 20. w/ opening of cortex (e. posterior. pedicle fixation. shoulder area.980 27.000 12. glenohumeral joint Arthrotomy w/ biopsy.000 21.400 7. w/ autograft (includes obtaining graft) Excision or curettage of bone cyst or benign tumor of clavicle or scapula.520 21.440 12. w/ allograft Excision or curettage of bone cyst or benign tumor of proximal humerus.200 33.820 30.240 22. clavicle Sequestrectomy (e.080 12. for spinal deformity.080 11. w/ or w/o cast.500 10. for spinal deformity.900 17.300 17.. 8 or more vertebral segments Pelvic fixation (attachment of caudal end of instrumentation to pelvic bony structures) other than sacrum Reinsertion of spinal fixation device Removal of posterior nonsegmental instrumentation (e.600 29.900 10...200 33. glenohumeral joint Arthrotomy w/ synovectomy. or w/ excision of torn cartilage. drainage..300 20. pedicle fixation.500 16.300 10. w/ or w/o removal of loose or foreign body Claviculectomy.000 67. w/ or w/o cast.. w/ or w/o cast.000 12.080 504 1.000 13.200 55. or intramuscular Radical resection of tumor (e. partial Claviculectomy.000 22843 58. deep.800 37.700 10.740 31.000 12.980 3.200 33. shoulder area.600 7. posterior..400 24.340 13.g. pedicle fixation. 13 or more vertebral segments Anterior instrumentation.240 37. for spinal deformity. 3 to 6 vertebral segments Posterior segmental instrumentation (e. w/ joint exploration.600 10.300 20. malignant neoplasm).900 Page 12 of 98 .120 15.600 29.960 27.580 31.600 37.700 21.800 67.800 12.300 23.000 58.960 20. sternoclavicular joint Arthrotomy. subfascial.000 12.400 21.000 14. deep abscess or hematoma Incision and drainage. methylmethacrylate) to vertebral defect or interspace Removal of posterior segmental instrumentation Removal of anterior instrumentation Excision.900 12. 4 to 7 vertebral segments Anterior instrumentation.400 30.400 21. 520 7.400 15.900 5.080 15.800 21. any type.980 8. acute or chronic.120 9. plating or wiring) w/ or w/o methylmethacrylate.180 53.g. any type..040 12.300 5. w/ bone graft for nonunion or malunion (includes obtaining graft and/or necessary fixation) Prophylactic treatment (nailing.900 10. Osteotomy. for osteomyelitis).520 26. for osteomyelitis).700 18.300 27. proximal humerus and humeral head Closed treatment of clavicular fracture Open treatment of clavicular fracture. complicated . proximal humerus. rotator cuff). proximal humerus. humeral head to surgical neck Partial excision (craterization.260 6..800 18.or diaphysectomy) of bone (e.200 21.180 40.480 21. shoulder. Putti-Platt procedure or Magnuson type operation Capsulorrhaphy.120 15.560 11.900 12. total shoulder) Osteotomy.g.160 18.g. w/ coracoid process transfer Capsulorrhaphy for recurrent dislocation.120 27.000 12. Bankart type operation w/ or w/o stapling Capsulorrhaphy.120 21.500 12. single Tenomyotomy.700 18. saucerization.652 21.. Open treatment of proximal humeral (surgical or anatomical neck) fracture. single Muscle transfer. acute Repair of ruptured musculotendinous cuff (e.800 16.120 2.940 23. Open treatment of sternoclavicular disloction.180 10..g.800 40.960 22.120 2.520 29. for osteomyelitis).160 20. shoulder or upper arm. clavicle Radical resection for tumor. anterior. deep (e. acute or chronic.300 21.400 21.700 12.700 10. shoulder area. Sprengels deformity or for paralysis) Tenomyotomy. suacerization.700 16. anterior. chronic Coracoacromial ligament release. for osteomyelitis or bone abscess).000 18.400 27.100 10. acute or chronic.920 10. rotator cuff).880 20. anterior.980 37.900 16.000 12.820 21. scapula Radical resection for tumor.380 15.520 9.820 27. clavicle Prophylactic treatment (nailing..240 10.300 7.120 8. partial (e.980 22.500 10. shoulder area.080 11.340 9.240 12.g. subcutaneous Removal of foreign body.340 10. shoulder.500 10.000 12. plating or wiring) w/ or w/o methylmethacrylate.056 3. scapula Partial excision (craterization.520 10.980 27..320 53.900 14.000 5.340 12. w/ or w/o repair of tuberosity(-ies).700 10.240 21.600 15..040 4.020 12.. proximal humerus Ostectomy of scapula. pinning.700 12.g. posterior.148 23. w/ prosthetic replacement Removal of foreign body. w/ or w/o repair of tuberosity(-ies).240 23.020 21.600 7. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 23174 23180 23182 23184 23190 23195 23200 23210 23220 23221 23222 23330 23331 23332 23395 23397 23400 23405 23406 23410 23412 23415 23420 23430 23440 23450 23455 23460 23462 23465 23466 23470 23472 23480 23485 23490 23491 23500 23515 23520 23530 23532 23540 23550 23552 23570 23585 23600 23615 DESCRIPTION Sequestrectomy (e.g.500 10.900 5.700 10. multiple Scapulopexy (e.700 16.320 48. w/ or w/o internal or external fixation.700 26. w/ proximal humeral prosthetic replacement Closed treatment of greater tuberosity fracture Case Rate 23.900 10.120 8.920 15.300 21.900 10..480 23.900 10.080 5.900 10.g. any type.980 10.700 23616 23620 47.880 29. w/ or w/o bone block Capsulorrhaphy w/ any type multi-directional instability Arthroplasty w/ proximal humeral implant (e.000 5.940 20.400 1. pinning.400 10. multiple through same incision Repair of ruptured musculotendinous cuff (e.456 10.120 27. saucerization. w/ bone block Capsulorrhaphy. chronic (includes acromioplasty) Tenodesis of long tendon of biceps Resection or transplantation of long tendon of biceps Capsulorrhaphy. Open treatment of acromioclavicular dislocation.540 18. glenoid or acromion) w/ or w/o internal fixation Closed treatment of proximal humeral (surgical or anatomical neck) fracture Open treatment of proximal humeral (surgical or anatomical neck) fracture.g.000 12. anterior. w/ or w/o internal or external fixation.500 5.540 37. superior medial angle) Resection humeral head Radical resection for tumor.540 23. w/ or w/o internal fixation.700 10.020 20.000 12. Neer prosthesis removal) Removal of foreign body.000 12. w/ fascial graft (includes obtaining graft) Closed treatment of scapular fracture Open treatment of scapular fracture (body.300 Professional Fee 12.800 24. w/ or w/o internal or external fixation Closed treatment of sternoclavicular dislocation Open treatment of sternoclavicular disloction. any type.560 12.120 15.900 10.080 21.. w/ autograft (includes obtaining graft) Radical resection for tumor. proximal humerus. shoulder or upper arm.ANNEX 2.780 10.or diaphysectomy) of bone (e. clavicle.400 5.860 38.300 6.248 12. shoulder. or diaphysectomy) of bone (e. Neer type operation) Arthroplasty w/ glenoid and proximal humeral replacement (e.600 10.800 38. Radical resection for tumor.380 27. w/ fascial graft (includes obtaining graft) Closed treatment of acromioclavicular dislocation Open treatment of acromioclavicular dislocation.240 10.120 28. clavicle Partial excision (craterization. w/ or w/o acromioplasty Repair of complete shoulder (rotator) cuff avulsion.g.900 10.080 2.860 37.600 Health Care Institution Fee 10.000 4.120 15.080 20.000 20.900 10.500 Page 13 of 98 .400 7.600 9.300 24. clavicle.752 10.000 23. including "total shoulder" Muscle transfer.120 16. w/ or w/o internal fixation.g.940 20.180 37.000 12.120 27.900 12. 980 20.820 20.180 30.980 23.700 13.600 10.700 4. humerus..g.700 12.480 16.. for osteomyelitis or bone abscess). humerus or elbow Arthrotomy.108 5. infected bursa Incision. w/ opening of bone cortex (e.120 11.772 12.980 20.820 21.000 5.900 10.300 10.120 9. w/ wedge resection of lung.008 1.900 10.900 10. w/ or w/o local bone graft Arthrodesis. Excision or curettage of bone cyst or benign tumor. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 23630 23650 23657 23660 23665 23670 23675 23680 23700 23800 23802 23900 23920 23930 23931 23935 24000 24006 24065 24075 24076 24077 24100 24101 24102 24105 24110 24115 24116 24120 24125 24126 24130 24134 24136 24138 24140 24145 24147 24149 24150 24151 24152 24153 24155 24160 24164 24200 24301 DESCRIPTION Open treatment of greater tuberosity fracture.456 37.504 5. subcutaneous Excision.180 12.400 23.600 3. w/ exploration.300 20.080 10. w/ joint exploration. radial head Removal of foreign body. Radical resection for tumor. w/ or w/o internal or external fixation Closed treatment of shoulder dislocation. including application of fixation apparatus (dislocation excluded) Arthrodesis. elbow joint Implant removal.920 10.248 10.700 10.120 6. for osteomyelitis or bone abscess).900 13. radial head or neck.120 15. upper arm or elbow area.. elbow. for infection.360 8.980 21. w/ autograft (includes obtaining graft) Excision or curettage of bone cyst or benign tumor.000 3.980 3. deep.ANNEX 2.400 12. or diaphysectomy) of bone (e. shoulder joint.660 10.600 15. w/ surgical or anatomical neck fracture.080 12. elbow.720 15.500 5.180 16.700 12. saucerization. tumor.560 21.800 15.080 23. humerus.700 Page 14 of 98 .120 21.900 10.680 2.080 10.g. deep.300 27.. shaft or distal humerus.g. drainage or removal of foreign body Arthrotomy of the elbow. or diaphysectomy) of bone (e.g.272 23. elbow. radial head or neck.080 10. radial head Sequestrectomy (e.800 12. upper arm or elbow area.900 10.500 10. soft tissue.980 21. shoulder joint.000 5.900 10. single Case Rate 23.980 20. deep abscess or hematoma Incision and drainage.700 5. radial head or neck Partial excision (craterization.900 10. single or mutiple Open treatment of acute shoulder dislocation Closed treatment of shoulder dislocation.g. shaft or distal humerus.360 10. and heterotopic bone.120 27. olecranon process Partial excision (craterization. w/ capsular excision for capsular release Biopsy.300 Professional Fee 12. w/ autograft (includes obtaining graft) Excision or curettage of bone cyst or benign tumor of head or neck of radius or olecranon process.900 10.900 10. soft tissue of upper arm or elbow area Arthrotomy.148 21.500 12.980 20.360 20. w/ surgical or anatomical neck fracture Open treatment of shoulder dislocation.100 4. Excision or curettage of bone cyst or benign tumor of head or neck of radius or olecranon process.120 5.400 18. soft tissue of upper arm or elbow area Excision. Incision and drainage.680 8.600 5. olecranon process Radical resection of capsule. w/ or w/o removal of loose or foreign body Arthrotomy.300 23.g.120 1.900 10. for osteomyelitis or bone abscess).200 7. humerus Partial excision (craterization. any type. w/ autograft (includes obtaining graft) Radical resection for tumor..900 10. elbow.500 16.000 4. w/ or w/o internal or external fixation Manipulation under anesthesia.980 27.g. Radical resection for tumor.080 21.. w/ autograft (includes obtaining graft) Resection of elbow joint (arthrectomy) Implant removal.260 20. w/ synovial biopsy only Arthrotomy.900 10.080 10.100 12.240 9.700 10.020 23. elbow.900 10.056 18.800 12.900 10.000 12.040 24. for osteomyelitis of bone abscess). w/ allograft Excision. w/ synovectomy Excision. saucerization.700 5.080 30.980 20.900 10.160 27.880 15.180 10.000 5./ fracture of greater tuberosity Open treatment of shoulder dislocation.980 20. upper arm or elbow.000 12.240 9.g. radial head or neck Sequestrectomy (e.520 12.940 22.000 6.920 10. upper arm or elbow area. olecranon bursa Excision or curettage of bone cyst or benign tumor.940 22. subfascial or intramuscular Radical resection of tumor (e. saucerization. for osteomyelitis). upper arm or elbow area Muscle or tendon transfer. humerus.700 12. w/ fracture of greater tuberosity.120 12.300 27.540 41..080 504 1.600 Health Care Institution Fee 10. for osteomyelitis).360 15.500 10.900 10. w/ or w/o biopsy. shaft or distal humerus Sequestrectomy (e. upper arm or elbow area.300 8.120 4.080 10.700 12. w/ allograft Excision or curettage of bone cyst or benign tumor of head or neck of radius or olecranon process.900 3. w/ primary autogenous graft (includes obtaining graft) Interthoracoscapular amputation (forequarter) Disarticulation of shoulder.660 2.500 10.080 10.900 10. malignant neoplasm)..920 12.500 12.120 4.080 10.120 9. shoulder joint.120 27. surgical.260 9. w/ or w/o internal or external fixation Closed treatment of shoulder dislocation Thoracoscopy.820 23. for osteomyelitis). tumor. or diaphysectomy) of bone (e. w/ contracture release Radical resection for tumor.300 12.080 10. 300 17.120 11.120 12.800 10. w/ manipulation Open treatment of humeral epicondylar fracture. Steindler type advancement).400 12. w/ iliac or other autograft (includes obtaining graft) Hemiepiphyseal arrest (e. medial or lateral.880 27. humerus (e.120 8.740 10.000 16.120 22. medial or lateral Open treatment of humeral condylar fracture.120 9.980 23.000 5.900 5. "tennis elbow" or epicondylitis). w/ intercondylar extension Closed treatment of humeral epicondylar fracture.500 10.040 12. lateral or medial (e. shortening or lengthening) Repair of non-union or malunion. w/ manipulation Open treatment of periarticular fracture and/or dislocation of the elbow (fracture distal humerus and proximal ulna and/or proximal radius). forearm.720 6. upper arm or elbow.120 8.720 5. w/ extensor advancement Tenodesis of biceps tendon at elbow Repair. compression technique).700 12.000 12.440 13. w/ or w/o internal or external fixation Percutaneous skeletal fixation of humeral condylar fracture.400 5.900 10.080 12.900 10.480 15.120 7.400 5.900 5.760 17.300 12.000 17.600 7. w/ or w/o free graft.740 30.300 21. single. elbow to shoulder.940 27.600 16. each tendon or muscle.360 10.080 4.740 27. Open treatment of periarticular fracture and/or dislocation of the elbow (fracture distal humerus and proximal ulna and/or proximal radius).980 21.120 10.g. w/ or w/o intercondylar extension Percutaneous skeletal fixation of supracondylar or transcondylar humeral fracture.980 10.700 12.640 21. medial or lateral. elbow.ANNEX 2.000 9. humeral shaft (Sofield type procedure) Osteoplasty.120 30. Arthroplasty. radial head. w/ membrane. w/ stripping Fasciotomy. compression technique).000 4. w/ or w/o cerclage Open treatment of humeral shaft fracture.. humerus.700 10. w/ distal humerus and proximal ulnar prosthetic replacement ("total elbow") Arthroplasty. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 24305 24310 24320 24330 24331 24340 24341 24342 24350 24351 24352 24354 24356 24360 24361 24362 24363 24365 24366 24400 24410 24420 24430 24435 24470 24495 24498 24500 24515 24516 24530 24538 24545 DESCRIPTION Tendon lengthening. single.g.700 12.g.120 20.120 27.720 6.120 12.400 3. lateral or medial (e. distal.980 12. w/ extensor origin detachment Fasciotomy. "tennis elbow" or epicondylitis). w/ or w/o tendon graft Fasciotomy. w/o graft (e. single (Seddon-Brookes type procedure) Flexor-plasty.900 24587 24600 24615 37.600 12..780 8.g. elbow.600 12.500 17.400 5.620 15. humerus. open.240 15.000 5. distal humerus) Decompression fasciotomy.120 10. w/ brachial artery exploration Prophylactic treatment (nailing. w/ implant Osteotomy.300 5.660 15. humerus Closed treatment of humeral shaft fracture Open treatment of humeral shaft fracture w/ plate/screws.500 12.700 Page 15 of 98 .120 37.720 6. Percutaneous skeletal fixation of humeral epicondylar fracture.300 7..240 15. w/ or w/o internal fixation Multiple osteotomies w/ realignment on intramedullary rod. "tennis elbow" or epicondylitis). w/ implant arthroplasty Treatment of closed elbow dislocation Open treatment of acute or chronic elbow dislocation Case Rate 20.120 22.800 12. w/ membrane.700 3. plating or wiring). w/ or w/o cerclage and/or locking screws Closed treatment of supracondylar or transcondylar humeral fracture.000 10. lateral or medial (e. elbow.900 10.000 18.540 23. Flexor-plasty. w/ implant and fascia lata ligament reconstruction Arthroplasty.120 18.900 12.180 27.980 20.456 Professional Fee 10.900 12.400 24546 24560 24566 24575 24576 24579 24582 24586 32.840 9. w/ distal humeral prosthetic replacement Arthroplasty.080 9. medial or lateral.g.120 21.g.880 18. w/o graft (e.080 6.120 20. w/ or w/o internal or external fixation..940 27.120 38. w/ membrane. each Tenoplasty.120 10.080 10. w/ or w/o methylmethacrylate. w/ muscle transfer. radial head.440 15. elbow (e.700 12. tendon or muscle.120 30. Fasciotomy.g.360 27. w/o intercondylar extension Open treatment of humeral supracondylar or transcondylar fracture.660 14.080 27.540 12..120 18.000 10.000 27.720 15. w/ annular ligament resection Fasciotomy.260 20.120 27.440 4.100 12.300 23.000 10.056 Health Care Institution Fee 10.. lateral or medial (e. w/ or w/o internal or external fixation Closed treatment of humeral condylar fracture. w/ partial ostectomy Arthroplasty. w/ or w/o intercondylar extension Open treatment of humeral supracondylar or transcondylar fracture.120 12. "tennis elbow" or epicondylitis). elbow (e.500 5. medial or lateral.. Arthroplasty. each Tenotomy. pinning.000 10. primary or secondary (excludes rotator cuff) Reinsertion of ruptured biceps or triceps tendon. for cubitus varus or valgus.g. w/ or w/o internal or external fixation. medial or lateral. Steindler type advancement).400 15. elbow. lateral or medial (e.120 13..120 3.620 13.400 5.. upper arm or elbow.. w/ insertion of intramedullary implant.g..040 6.120 12.100 9. Repair of non-union or malunion.800 5.g. elbow to shoulder.000 10. "tennis elbow" or epicondylitis).180 15. w/ membrane.780 15. humerus.g. w/ or w/o local autograft or allograft Arthrodesis. forearm and/or wrist.900 25126 25130 25135 21. forearm and/or wrist area. forearm and/or wrist area.300 15.300 10. deep. Synovectomy. tenosynovitis. w/ autograft (includes obtaining graft) Case Rate 10.400 12.080 2.880 10.g.400 5.920 9.780 9.920 Health Care Institution Fee 7. fungus.500 5.920 4.000 14.000 12.240 15. w/ or w/o internal or external fixation Arthrodesis. elbow joint.080 10. tumor.900 10. for deQuervains disease) Decompression fasciotomy. rheumatoid arthritis).000 5. w/ or w/o internal or external fixation Closed treatment of radial head subluxation in child...000 9.120 5.780 4.400 10.700 7.820 8.680 8. secondary closure or scar revision Amputation. wrist.620 504 1.720 4.980 8.620 6. w/ resection of distal ulna Excision or curettage of bone cyst or benign tumor of radius or ulna (excluding head or neck of radius and olecranon process). extensor tendon sheath. upper extremity Cineplasty. single compartment. elbow joint. arm through humerus. for osteomyelitis or bone abscess). tumor. upper extremity. arm through humerus.g.544 7. w/ biopsy Arthrotomy. subcutaneous Excision.900 12.700 10. arm through humerus.680 3.520 3.600 5. or forearm tendon sheaths (e.960 14. arm through humerus. w/ debridement of nonviable muscle and/or nerve Incision and drainage. or removal of foreign body Biopsy.500 5.400 7.100 10.g.120 16.400 7.600 7. distal radioulnar joint for repair of triangle cartilage complex Excision. subfascial or intramuscular Radical resection of tumor (e.420 9..500 9.100 12. complete procedure Tendon sheath incision.500 10.ANNEX 2. wrist (dorsal or volar) Radical excision of bursa.020 23.680 10. rheumatoid arthritis). open.900 5. w/ primary closure Amputation.880 21.980 20.940 27. w/ joint exploration. infected bursa Incision. w/ exploration. flexor or extensor compartment Decompression fasciotomy.980 27.120 27. w/ or w/o transposition of dorsal retinaculum Synovectomy. "nursemaid elbow" Closed treatment of radial head or neck fracture Open treatment of radial head or neck fracture.g.500 4. w/ allograft Excision or curettage of bone cyst or benign tumor of carpal bones.940 5.452 9.900 10.260 21.400 5.680 2.600 5. deep abscess or hematoma Incision and drainage. forearm and/or wrist.400 5.880 21.120 10.080 10. single compartment. or other granulomas.540 18.504 5.500 6.600 Page 16 of 98 . arm through humerus.400 7.960 14.. w/ autograft (includes obtaining graft) Excision or curettage of bone cyst or benign tumor of radius or ulna (excluding head or neck of radius and olecranon process).080 15.120 10. w/ autograft (includes obtaining graft other than locally obtained) Amputation.240 10.780 10. Open treatment of periarticular fracture and/or dislocation of the elbow (fracture distal humerus and proximal ulna and/or proximal radius). flexors Radical excision of bursa.700 4.980 5. soft tissue of forearm and/or wrist area Capsulotomy.940 20. wrist.400 5.020 8.000 5.000 4.600 7.952 21. forearm and/or wrist.120 28.500 3.120 12.900 10.460 7.380 18. forearm and/or wrist Excision of ganglion.720 5. Tbc. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 24620 24635 24640 24650 24665 24666 24670 24685 24800 24802 24900 24920 24925 24930 24931 24935 24940 25000 25020 25023 25028 25031 25035 25040 25065 25075 25076 25077 25085 25100 25101 25105 25107 25110 25111 25115 DESCRIPTION Closed treatment of Monteggia type of fracture dislocation at elbow (fracture proximal end of ulna w/ dislocation of radial head) Open treatment of Monteggia type of fracture dislocation at elbow (fracture proximal end of ulna w/ dislocation of radial head).500 7. proximal end (olecranon process) Open treatment of ulnar fracture proximal end (olecranon process). drainage.040 8. forearm and/or wrist Arthrotomy.880 20. w/ radial head prosthetic replacement Closed treatment of ulnar fracture. circular (guillotine) Amputation.140 10. synovia of wrist. Excision or curettage of bone cyst or benign tumor of radius or ulna (excluding head or neck of radius and olecranon process).560 6.100 12.540 20.120 10. Tbc.500 12.. w/ or w/o removal of loose or foreign body Arthrotomy.820 Professional Fee 3. lesion of tendon sheath. or other granulomas.380 8.400 6.380 11.820 9.000 7.240 1. Excision or curettage of bone cyst or benign tumor of carpal bones. wrist joint.900 25116 25118 25119 25120 25125 18.900 10. w/ or w/o internal fixation or radial head excision. w/ synovectomy Arthrotomy. wrist joint.000 7.452 6. w/ opening of bone cortex (e.960 12. extensors.520 12. deep.120 10.900 5.100 5.720 15.952 12. tenosynovitis. synovia of wrist.044 12. or forearm tendon sheaths (e. w/ or w/o biopsy.980 21. at radial styloid (e. wrist (e.g. w/ implant Stump elongation. wrist joint.960 10.120 3.560 3.560 7.000 12. re-amputation Amputation.120 3.g. extensor tendon sheath. malignant neoplasm).700 12.820 4. fungus.780 9. soft tissue of forearm and/or wrist Excision. for contracture) Arthrotomy.360 10. radiocarpal or midcarpal joint.. forearm and/or wrist. 800 17.040 5. or diaphysectomy) of bone (e.500 4.960 20.500 4.460 5. flexor. flexor or extensor. single.240 13.900 13. single. forearm and/or wrist.000 12. lengthening w/ autograft Repair of nonunion or malunion. secondary by soft tissue stabilization (e. tendon transfer. single. one bone Carpectomy. single. capsulotomy and open reduction) for carpal instability Arthroplasty.900 10.120 15.700 17.480 Health Care Institution Fee 6.g.040 3.300 30. forearm and/or wrist.932 22.360 9.940 21. middle or proximal third Osteotomy. forearm and/or wrist. for osteomyelitis).920 16. ulna Osteotomy.500 10.. capsulodesis. flexor.800 18. complicated.540 8.600 12.000 12.440 5.820 12.880 8.540 8. radius or ulna.g.120 27.240 15.400 9. tendon or muscle.240 9. for cerebral palsy.040 10. radius and ulna. forearm and/or wrist. primary. secondary.120 10.000 4. tendon or muslce.900 21.960 10. radius Radical resection for tumor. forearm and/or wrist. single. for osteomyelitis). flexor. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 25136 25145 25150 25151 25170 25210 25215 25230 25240 25248 25250 25251 25260 25263 25265 25270 25272 25274 25280 25290 25295 25300 25301 25310 25312 25315 25316 DESCRIPTION Excision or curettage of bone cyst or benign tumor of carpal bones.360 4. for cerebral palsy. single each tendon Tenodesis at wrist.440 15. w/ or w/o interposition.700 12..540 8.120 27.932 9. wrist. radius and ulna Osteoplasty.500 7.000 12.980 23.240 8. radius and ulna. single. w/ or w/o external or internal fixation Centralization of wrist on ulna (e.640 15.600 10. each tendon or muscle Repair. forearm and/or wrist.700 12. w/o graft (compression technique) Repair of nonunion or malunion.700 25320 27. Removal of wrist prosthesis.360 5.500 13. flexor or extensor tendon. each tendon Tendon transplantation or transfer.000 10.080 10.600 13.500 5.040 3.940 30.900 5. w/ free graft (includes obtaining graft).300 31. tendon or muscle.700 12. tendon or muslce. including "total wrist" Repair.300 5.900 10. radius. forearm and/or wrist..040 3. each tendon or muscle Repair. forearm and/or wrist.080 12. Darrach type or matched resection) Exploration w/ removal of deep foreign body. flexor or extensor tendon.. radius and ulna. tendon or muscle. each tendon or muscle Repair.g. each tendon Tenotomy.900 12. tendon graft or weave. or diaphysectomy) of bone (e.120 5. radial club hand) Reconstruction for stabilization of unstable distal ulna or distal radioulnar joint.300 37. distal third Osteotomy.600 12. any method (e.500 18. open.960 15. flexor or extensor. shortening Osteoplasty.000 9. radius or ulna.500 5.000 12. primary. radius or ulna Carpectomy.980 21.260 10. each tendon or muscle Repair.300 30. lengthening w/ autograft Osteoplasty.g. radius.700 9.000 21. single.360 10.960 8.g.620 5. radius or ulna Multiple osteotomies.g. forearm and/or wrist. forearm and/or wrist.900 5.960 27.260 10.500 12. each tendon Tenolysis.420 23.540 20. forearm and/or wrist Partial excision (craterization. tendon or muscle. tendon transfer or graft) (includes synovectomy. extensor.. secondary.960 15.360 5.440 13.120 1..960 18. forearm and/or wrist. extensor. w/ tendon graft (includes obtaining graft). radius or ulna.100 4. w/ allograft Sequestrectomy (e.240 9.100 7..300 9.780 3.780 3.120 15. Volkmann contracture).940 27.900 5. forearm and/or wrist. radius or ulna. single. extensors of fingers Tendon transplantation or transfer. each tendon Flexor origin slide (e. w/ realignment on intramedullary rod (Sofield type procedure).940 21.g. each tendon or muscle Lengthening or shortening of flexor or extensor tendon.820 30. secondary.960 10.120 12.120 15. ligament repair.740 27. wrist.g.740 10.000 25332 25335 25337 25350 25355 25360 25365 25370 25375 25390 25391 25392 25393 25400 25405 25415 30.960 27. or tenodesis) w/ or w/o open reduction of distal radioulnar joint Osteotomy. flexors of fingers Tenodesis at wrist. Flexor origin slide (e..700 5.500 5. compression technique) Case Rate 12.500 4. saucerization.040 3. w/ tendon(s) transfer Capsulorrhaphy or reconstruction. all bones of proximal row Radial styloidectomy Excision distal ulna partial or complete (e.260 10. w/ iliac or other autograft (includes obtaining graft) Repair of nonunion or malunion.300 12.660 5. saucerization.880 10.700 17.180 Professional Fee 6.300 Page 17 of 98 .540 10. for osteomyelitis or bone abscess)..740 16.ANNEX 2.600 13. each tendon or muscle Repair. forearm and/or wrist.000 12.540 10. w/ realignment on intramedullary rod (Sofield type procedure). ulna Partial excision (craterization. w/ tendon graft(s) (includes obtaining graft).700 17. secondary.940 18. shortening Osteoplasty. radius and ulna Multiple osteotomies. extensor. Volkmann contracture).140 27. forearm or wrist Removal of wrist prosthesis.g. w/o graft (e.g.260 21. 800 27.260 21. w/ or w/o internal or external fixation Closed treatment of carpal scaphoid (navicular) fracture Open treatment of carpal scaphoid (navicular) fracture.960 23.980 8. w/o bone graft Case Rate 27.660 8. wrist joint (including radiocarpal and/or ulnocarpal fusion).120 15.400 3.904 8. of radius and ulna Closed treatment of distal radial fracture (e.360 10.940 21. distal radius and partial or entire carpus ("total wrist") Arthroplasty w/ prosthetic replacement.900 10.700 Professional Fee 15.g.120 3.000 8. including removal of implant.400 4. of radius or ulna Open treatment of radial and ulnar shaft fractures.940 9.800 15. scaphoid (navicular) bone.900 4.360 8. acute or chronic Closed treatment of trans-scaphoperilunar type of fracture dislocation Open treatment of trans-scaphoperilunar type of fracture dislocation Closed treatment of lunate dislocation Open treatment of lunate dislocation Arthrodesis.700 17.700 25620 25622 25628 25630 25645 25650 25660 25670 25675 25676 25680 25685 25690 25695 25800 23.260 23. trapezium Arthroplasty w/ prosthetic replacement.700 18. radius or ulna Repair of defect w/ autograft. w/ or w/o internal or external fixation of distal radioulnar joint (Galleazi fracture/dislocation).960 21.900 5.360 12.360 10.580 37.080 10.g.800 12. Colles or Smith type) or epiphyseal separation.260 21.120 27.000 9.300 8.900 4.600 10.500 12.200 Health Care Institution Fee 12.900 10.700 27.900 10.300 10.120 14. w/ or w/o fracture of ulnar styloid . distal radius Arthroplasty w/ prosthetic replacement.000 12.960 27.320 20.440 8.700 5. w/ or w/o radial styloidectomy (includes obtaining graft and necessary fixation) Arthroplasty w/ prosthetic replacement. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 25420 25425 25426 25440 25441 25442 25443 25444 25445 25446 25447 25449 25450 25455 25490 25491 25492 25500 25515 25520 DESCRIPTION Repair of nonunion or malunion.240 8.500 12. w/ or w/o internal or external fixation Closed treatment of radial shaft fracture.900 4.800 10. lunate Arthroplasty w/ prosthetic replacement.300 11.240 18.700 5.900 10. w/ or w/o external fixation Open treatment of distal radial fracture (e. pinning.400 10.000 17.900 10. plating or wiring) w/ or w/o methylmethacrylate.240 13. w/ or w/o internal or external fixation Closed treatment of carpal bone fracture (excluding carpal scaphoid (navicular)) Open treatment of carpal bone fracture (excluding carpal scaphoid (navicular)).000 16.600 5.260 20. wrist joint Epiphyseal arrest by epiphysiodesis or stapling. scaphoid (navicular) Arthroplasty w/ prosthetic replacement. w/ internal and/or external fixation and open treatment.120 15.920 3.940 30.740 23.120 27.000 12.000 15. requiring manipulation.900 9..300 12.360 11.740 21.280 21.720 30.ANNEX 2. radius Prophylactic treatment (nailing. pinning.. radius and ulna.004 2.300 16.440 13.940 3. w/ internal or external fixation. ulna Prophylactic treatment (nailing. w/ or w/o fracture of ulnar styloid.960 15.820 8.g. one or more bones Closed treatment of distal radioulnar dislocation Open treatment of distal radioulnar dislocation. distal ulna Arthroplasty w/ prosthetic replacement.500 4. Colles or Smith type) or epiphyseal separation.240 9.520 10.180 9.900 12. includes repair of triangular cartilage Closed treatment of ulnar shaft fracture Open treatment of ulnar shaft fracture.940 37.700 21. each bone Closed treatment of ulnar styloid fracture Closed treatment of radiocarpal or intercarpal dislocation. w/ or w/o fracture of ulnar styloid Percutaneous skeletal fixation of distal radial fracture (e.480 4.960 40. Interposition arthroplasty. w/ iliac or other autograft (includes obtaining graft) Repair of defect w/ autograft.. one or more bones Open treatment of radiocarpal or intercarpal dislocation. plating or wiring) w/ or w/o methylmethacrylate.020 16.260 18. distal radius or ulna Epiphyseal arrest by epiphysiodesis or stapling.700 9.240 4.000 12.500 12.900 9.600 Page 18 of 98 .080 3. Colles or Smith type) or epiphyseal separation.360 9.600 3.440 9. distal radius and ulna Prophylactic treatment (nailing. w/ internal and/or external fixation and closed treatment of dislocation of distal radio-ulnar joint (Galeazzi fracture/dislocation).920 3.700 4. pinning.260 21. w/ dislocation of distal radio-ulnar joint (Galeazzi fracture/dislocation) Open treatment of radial shaft fracture.000 12.200 9.260 21.960 9.900 4.080 13.300 27.500 25525 20. plating or wiring) w/ or w/o methylmethacrylate.120 8.980 30.200 15. w/ internal or external fixation.000 12.900 17. w/ or w/o percutaneous skeletal fixation Open treatment of radial shaft fracture.700 12.360 10. radius and ulna Repair of nonunion.760 3.000 4.940 18.120 31.900 25526 25530 25545 25560 25574 25575 25600 25611 22. intercarpal or carpometacarpal joints Revision of arthroplasty.820 8.360 8.260 18. w/ or w/o internal or external fixation Closed treatment of radial and ulnar shaft fractures Open treatment of radial and ulnar shaft fractures. radius and ulna Closed treatment of radial shaft fracture Open treatment of radial shaft fracture.600 4.980 10.700 13. 980 20.120 15.720 6. w/ opening of bone cortex (e.360 7.040 9.120 22. single.440 14. interphalangeal joint.900 9. through. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 25805 25810 25820 25825 25830 25900 25905 25907 25909 25915 25920 25922 25924 25927 25929 25931 26010 26011 26020 26025 26030 26034 26035 26037 26040 26045 26055 26060 26070 26075 26080 26100 26105 26110 26115 26116 26117 26121 26123 DESCRIPTION Arthrodesis. w/ or w/o Z-plasty. simple Drainage of finger abscess.500 7.960 8.984 12. percutaneous.400 5. palm.120 27. forearm.504 4. re-amputation Drainage of finger abscess.500 7. through.920 6.400 10.240 6.880 8.200 3. Case Rate 21.600 15..600 5.460 7.260 15.. wrist joint (including radiocarpal and/or ulnocarpal fusion).600 7.000 7.960 8.980 23.900 5.900 6. through.100 4.g. for Dupuytrens contracture. single. w/ or w/o Z-plasty.600 6.900 11.940 7.400 7. felon) Drainage of tendon sheath. hand or finger.500 5. metacarpophalangeal joint Arthrotomy.300 5.900 10.940 12. w/ exploration.100 5..800 7. palmar.000 3. Fasciectomy.384 7.400 Page 19 of 98 .880 10.400 5. w/ iliac or other autograft (includes obtaining graft) Intercarpal fusion.000 12. for Dupuytrens contracture.900 10. or distal phalanx of finger.400 12.120 12. each digit Excision of lesion of tendon sheath or capsule (e.940 12.120 11.400 6.120 12.940 14.240 6. mucous cyst..700 5. each Arthrotomy w/ synovial biopsy. tumor or vascular malformation. or ganglion). wrist joint (including radiocarpal and/or ulnocarpal fusion).260 3. partial palmar w/ release of single digit including proximal interphalangeal joint. injection injury (e.100 7. through.600 6. malignant neoplasm).500 7. other local tissue rearrangement.560 21.960 14. radical (tenosynovectomy).560 7.720 6.080 12. single. each Excision. Excision or curettage of bone cyst or benign tumor of metacarpal. complicated (e.500 4.224 9. drainage. each digit Synovectomy.300 7.600 7.440 14.540 9. ulnar or radial Drainage of palmar bursa. drainage. grease gun) Decompressive fasciotomy.900 6. w/ or w/o Z-plasty. including extensor reconstruction. or skin grafting (includes obtaining graft). interphalangeal joint.984 15.400 6.520 3. open.980 7.500 7. for osteomyelitis or bone abscess). re-amputation Transmetacarpal amputation.980 5.720 5.960 21.920 10.260 12.384 6. subfascial. intramuscular Radical resection of tumor (e. carpometacarpal joint Arthrotomy. Transmetacarpal amputation.g.920 8.380 12. Amputation.660 Professional Fee 10.720 10. other local tissue rearrangement. hand or finger Decompression fingers and/or hand. Sauve-Kapandji procedure).g.400 5. each digit Arthrotomy.400 6.980 8. tumor or vascular malformation.960 14. circular (guillotine) Amputation.400 5. or removal of foreign body.400 3. percutaneous Fasciotomy.100 5.900 14. or removal of foreign body.100 10. thumb or finger Excision or curettage of bone cyst or benign tumor of metacarpal.880 2.760 6.560 9. middle. flexor Sesamoidectomy.360 4.120 11.940 7.440 8.400 12. w/ or w/o bone graft Amputation. flexor. finger.ANNEX 2.560 2.040 4. drainage.560 504 1.120 10.500 12. palm or finger.120 10.008 2.000 10. w/ exploration.400 5. secondary closure or scar revision Transmetacarpal amputation. multiple or complicated Inicision. one digit and/or palm Drainage of palmar bursa. w/ exploration.g. hand or finger.360 6.960 21. flexor. deep. open. palmar.720 5. capometacarpal joint Synovectomy.g.880 10.560 2.780 3. secondary closure or scar revision Amputation..500 7.820 21. soft tissue of hand or finger Fasciectomy. other local tissue rearrangement. single .540 21.300 27.900 7. metacarpophalangeal joint Arthrotomy w/ synovial biopsy. single.780 3.960 37. carpometacarpal joint Arthrotomy w/ synovial biopsy. Disarticulation through wrist.700 12.380 11. metacarpophalangeal joint including intrinsic release and extensor hood reconstruction.020 10.. forearm.108 8.940 3.g. proximal interphalangeal joint. palm only. partial Tendon sheath incision (e.624 21.880 10.820 12.560 10.700 5.000 12. each interphalangeal joint Synovectomy tendon sheath.900 26125 8. forearm. each additional digit (List separately in addition to code for primary procedure Synovectomy.800 14.700 10.660 12.780 5. each Excision of tendon.960 3.240 7. cyst.400 16. w/o bone graft Intercarpal fusion. subcutaneous Excision. deep. re-amputation Krukenberg procedure Disarticulation through wrist. forearm. hand (excludes 26035) Fasciotomy. or skin grafting (includes obtaining graft).g.820 18.700 7.100 5. partial palmar w/ release of single digit including proximal interphalangeal joint. hand or finger Excision of tendon. w/ sliding graft Arthrodesis.900 26130 26135 26140 26145 26160 26170 26180 26185 26200 26205 26210 22.760 Health Care Institution Fee 10. w/ autograft (includes obtaining graft) Distal radioulnar joint arthrodesis and segmental resection of ulna (e. or skin grafting (includes obtaining graft) Fasciectomy. or removal of foreign body.400 5. radius and ulna. for trigger finger) Tenotomy. secondary closure or scar revision Disarticulation through wrist. w/ autograft (includes obtaining graft) Excision or curettage of bone cyst or benign tumor of proximal. Radical resection (ostectomy) for tumor. w/ autograft (includes obtaining graft) Radical resection (ostectomy) for tumor. w/ free graft (includes obtaining graft) Extensor tendon repair.380 21. dorsum of hand or finger. for osteomyelitis). primary or secondary repair. each tendon Profundus tendon repair or advancement. primary or secondary.400 5.440 8. each Case Rate 15. distal insertion ("mallet finger"). open.500 5. palm. or diaphysectomy) of bone (e. single. in "no mans land".360 3.940 2. single. proximal or middle phalanx of finger Partial excision (craterization.100 7. not in "no mans land". simple. Radical resection (ostectomy) for tumor. w/ free graft (includes obtaining graft). single.040 2. open.880 10. flexor.g.500 5.360 3.520 2. metacarpal Partial excision (craterization.000 30. complex. extensor.500 5. finger. flexor tendon.900 7. single. primary or secondary.100 7. central slip repair. w/ intact sublimis.780 2.400 10.100 5. each Tendon lengthening.440 8. for osteomyelitis). palm and finger.700 17. in "no mans land".936 14.100 7.700 13.520 2.500 7. extensor tendon.ANNEX 2. distal insertion ("mallet finger"). carpometacarpal area or dorsum of hand. secondary (boutonniere deformity). hand or finger Extensor tendon repair.260 10.g.020 8. secondary w/ free graft (includes obtaining graft) Profundus tendon repair or advancement.440 14.900 4. single. distal insertion ("mallet finger").780 5. primary or secondary repair. single.280 12.900 5. each tendon Flexor tendon repair or advancement. single.440 Professional Fee 7.240 7. for osteomyelitis).880 8.260 8. w/ autograft (includes obtaining graft) Radical resection (ostectomy) for tumor.360 3.360 3. single.. or diaphysectomy) of bone (e. each tendon Tenolysis.500 5.120 10.500 7. w/o graft Extensor tendon repair.260 10.300 17. primary Profundus tendon repair or advancement.040 4.100 5. implantation of plastic tube or rod for delayed extensor tendon graft.360 3. w/ intact sublimis.880 10. w/o free graft. in "no mans land". each Tendon shortening. w/o free graft.940 Health Care Institution Fee 7.100 5. single.880 10.500 5.940 2. or distal phalanx of finger.780 5.260 10. hand or finger Removal of tube or rod and insertion of flexor tendon graft (includes obtaining graft).260 8. palm or finger. dorsum of finger. single.740 31.500 4.540 10.940 3. metacarpal.300 10. w/ free graft (includes obtaining graft). central slip repair. w/ intact sublimis. secondary w/o free graft Flexor tendon excision. middle.300 17. secondary w/ free graft (includes obtaining graft). each tendon Extensor tendon repair. single.440 8. single.120 23.780 3.500 5.700 7. primary or secondary w/o free graft.260 8. hand or finger. extensor.636 32. single. single. primary. each Tenodesis. dorsum of finger. each tendon Tenolysis.900 4.032 3. each tendon Flexor tendon repair or advancement. proximal or middle phalanx of finger..500 5. saucerization.780 3.940 2. for proximal interphalangeal joint stabilization Tenodesis. dorsum of hand. dorsum of hand. extensor tendon. simple.360 3. flexor. single.940 2. hand or finger Removal of tube or rod and insertion of extensor tendon graft (includes obtaining graft). for distal joint stabilizaton Tendon lengthening.500 4.440 8. each tendon Flexor tendon repair or advancement.g.500 5. hand or finger. w/o free graft.780 3. secondary w/ free graft (includes obtaining graft). open. single.380 12. each tendon Flexor tendon repair or advancement. primary or secondary.260 8. distal phalanx of finger Radical resection (ostectomy) for tumor. each tendon Extensor tendon repair. secondary (boutonniere deformity).720 5.440 8. saucerization.260 8. flexor tendon. saucerization.940 2. hand Tenolysis.192 3. secondary.020 8.880 8.500 Page 20 of 98 . each Tendon shortening. each tendon Extensor tendon repair. or diaphysectomy) of bone (e. each Tendon transfer or transplant.440 8.780 3. hand or finger.900 4.360 3. single.780 3. each Tenotomy.400 12. open. closed splinting w/ or w/o percutaneous pinning Extensor tendon repair.900 4.440 8.580 23.900 7.880 10.132 10.100 7. single.900 4.692 8.980 9.500 5.260 8.980 6.940 2. including hand and forearm Tenotomy. flexor.900 7.540 8..360 3.540 11. extensor. implantation of plastic tube or rod for delayed tendon graft.780 3.940 15. distal phalanx of finger Flexor tendon repair or advancement.500 5.440 8.400 5. w/ free graft (includes obtaining graft) Extensor tendon realignment.940 2.040 3.940 2.360 3. metacarpal. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 26215 26230 26235 26236 26250 26255 26260 26261 26262 26350 26352 26356 26357 26358 26370 26372 26373 26390 26392 26410 26412 26415 26416 26418 26420 26426 26428 26432 26433 26434 26437 26440 26442 26445 26449 26450 26455 26460 26471 26474 26476 26477 26478 26479 26480 DESCRIPTION Excision or curettage of bone cyst or benign tumor of proximal. each Tenotomy. w/ autograft (includes obtaining graft) Partial excision (craterization. open. proximal or middle phalanx of finger.500 5. hand or finger. hand or finger Extensor tendon repair.080 12. not in "no mans land".880 10. hand or finger.100 7. using local tissues Extensor tendon repair. dorsum of hand or finger.100 4.720 12.440 8. flexor.900 4.880 8. each tendon Tenolysis. primary or secondary. each tendon Extensor tendon excision.180 6.880 10.100 5. 876 1.080 12. flexor or extensor. each Arthroplasty interphalangeal joint.900 10.900 5. metacarpophalangeal joint.120 18.192 2.300 30. single. single.120 8. metacarpophalangeal joint.980 23.820 10.080 13.820 21.720 8. metacarpophalangeal joint.900 4.120 18.428 10.500 6.800 13.980 30.120 7. interphalangeal joint.000 20.620 6.500 Page 21 of 98 .400 12. (includes obtaining bone graft w/ or w/o external or internal fixation) Repair and reconstruction. w/ multiple Z-plasties Release of scar contracture.628 4.500 5.900 4. single.600 4.440 13.428 18.300 30.100 1.260 8. collateral ligament.500 17. or Z-plasties.528 3. sublimis tendon transfer type Opponensplasty.040 5.120 12.740 30.920 10.900 4.000 9.600 10. w/ free tendon graft (includes obtaining graft).900 10. each bone Closed treatment of carpometacarpal dislocation.300 20.300 12. collateral ligament.528 8. w/ tendon prosthesis Thenar muscle release for thumb contracture Cross intrinsic transfer Capsulodesis for M-P joint stabilization.040 3. palmar.080 10.980 8. each Repair of collateral ligament. each Arthroplasty interphalangeal joint.940 10.. each tendon. interphalangeal joint. metacarpal Osteotomy for correction of deformity. single. carpometacarpal area or dorsum of hand. metacarpophalangeal joint.900 8. soft tissue and bone Repair macrodactylia Repair. interphalangeal joint Pollicization of a digit Toe-to-hand transfer w/ microvascular anastmosis.460 5.400 3.040 3.428 8.880 10. hypothenar muscle transfer Opponensplasty.300 17.600 7. w/ tendon or fascial graft (includes obtaining graft) Tendon pulley reconstruction.500 4. adductor advancement) Reconstruction.080 16.400 5.980 30. finger. w/o free tendon graft Tendon transfer or transplant.700 10.000 21.520 8.300 10. single.752 3. three or four digits Capsulectomy or capsulotomy for contracture.400 9. each tendon. w/ skin grafts. each tendon Opponensplasty. other than great toe.240 3. w/ local tissues Tendon pulley reconstruction. phalanx of finger Osteoplasty for lengthening of metacarpal or phalanx Repair cleft hand Repair bifid digit Reconstruction of supernumerary digit. volar plate.000 7.600 5.740 20. each joint Repair non-union.440 12.600 12.428 8.300 23.540 8.040 Health Care Institution Fee 7.500 4.780 5.900 17.600 12.880 8.600 10. each Arthroplasty.460 5.260 10.360 3.400 10.900 5.440 15.428 20.400 10. metacarpophalangeal joint.400 9.900 10.780 3.700 10. each tendon Tendon transfer or transplant.960 10.900 10.g. w/ prosthetic implant. rearrangement flaps.540 12.540 10.600 10.120 10.120 14.980 20.100 5.540 Professional Fee 3. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 26483 26485 26489 26490 26492 26494 26496 26497 26498 26499 26500 26502 26504 26508 26510 26516 26517 26518 26520 26525 26530 26531 26535 26536 26540 26541 26542 26545 26546 26548 26550 26551 26553 26554 26555 26556 26560 26561 26562 26565 26567 26568 26580 26585 26587 26590 26591 26593 26596 26597 26600 26607 26608 26615 26641 DESCRIPTION Tendon transfer or transplant. each bone Open treatment of metacarpal fracture.880 10. single. each Capsulectomy or capsulotomy for contracture. involving bone.528 3. complex (e.528 10.300 6.300 3.080 3. single Closed treatment of metacarpal fracture.600 12. intrinsic muscles of hand (specify) Excision of constricting ring of finger.900 13.980 21. single. including graft. single.500 5. other methods Tendon trasfer to restore intrinsic function.740 27.360 5. single. great toe "wraparound" w/ bone graft Toe-to-hand transfer w/ microvascular anastmosis. single digit Capsulodesis for M-P joint stabilization.700 17.560 15. palmar.300 10. intrinsic muscles of hand (specify) Release. collateral ligament.720 5.900 7.540 8.500 5.528 5. w/ internal or external fixation Percutaneous skeletal fixation of metacarpal fracture.500 6. w/ prosthetic implant.960 10. single.920 4. ring and small finger Tendon trasfer to restore intrinsic function.788 8.620 6. tendon transfer w/ graft (includes obtaining graft) Opponensplasty.596 5. w/ local tissue (e.700 7.880 5.. other than great toe.500 5.080 10. single.528 3.500 9. hand and/or finger Closed treatment of metacarpal fracture.400 5. w/ skin flaps Repair of syndactyly (web finger) each web space.000 10. two digits Capsulodesis for M-P joint stabilization. w/ skin flaps and grafts Repair of syndactyly (web finger) each web space.780 4.900 4.900 5.900 9. metacarpophalangeal or interphalangeal joint Reconstruction.900 10.040 6.g. each Arthroplasty.780 3.740 23.000 20.700 10.440 10. w/ tendon or fascial graft (includes obtainig graft) Reconstruction. nails) Osteotomy for correction of deformity.500 5.720 6.300 23. single.ANNEX 2.100 5.100 4. w/ free tendon graft (includes obtaining graft). metacarpal or phalanx.120 12. double Positional change of other finger Free toe joint transfer w/ microvascular anastomosis Repair of syndactyly (web finger) each web space.540 10.900 12. single. thumb Case Rate 10. w/ or w/o internal or external fixation.120 12. single Toe-to-hand transfer w/ microvascular anastmosis.020 18.040 5.other methods Tendon pulley reconstruction.600 13.960 27. all four fingers Correction claw finger.428 10. 720 7.700 5.400 5. abductors of hip.720 7. involving metacarpophalangeal or interphalangeal joint Open treatment of articular fracture. other than thumb (Bennett fracture). finger or thumb.980 21.140 4. each Closed treatment of interphalangeal joint dislocation. each Closed treatment of articular fracture. including neurectomies. closed Tenotomy. single.900 10.560 7.400 10. thumb (Bennett fracture).120 10. deep abscess or hematoma Incision and drainage. single Fusion in opposition. hood) Incision and drainage.960 12. proximal or middle phalanx. thumb (Bennett fracture) Percutaneous skeletal fixation of carpometacarpal fracture dislocation. infected bursa Incision.400 5.700 10.600 7.560 4.120 11.540 10. subcutaneous.500 7.100 12.540 5.820 12. digits.620 7.740 23.620 7.500 26686 26700 26706 26715 26720 26727 11.500 7. each Open treatment of distal phalangeal fracture. w/ manipulation Open treatment of metacarpophalangeal dislocation.700 10. digits.140 7. finger or thumb Percutaneous skeletal fixation of unstable phalangeal shaft fracture. multiple or delayed reduction Closed treatment of metacarpophalangeal dislocation. w/ manipulation Open treatment of carpometacarpal dislocation. w/ manipulation. iliopsoas.080 10.240 6.300 10. single Percutaneous skeletal fixation of carpometacarpal dislocation. carpometacarpal joint. proximal or middle phalanx.980 21. single.100 5. Arthrodesis. single Percutaneous skeletal fixation of metacarpophalangeal dislocation.560 6.400 26685 10.400 6. w/ or w/o internal fixation.400 5. subcutaneous. other than thumb (Bennett fracture).920 6. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 26645 26650 26665 26670 26676 DESCRIPTION Closed tratment of carpometacarpal fracture dislocation. w/ obturator neurectomy Tenotomy.300 12. pelvis or hip joint area. carpometacarpal joint.960 10.080 10. other than thumb.400 7.900 10. w/ autograft (includes obtaining graft) Amputation.940 12. finger or thumb.400 26735 26740 26746 26750 26756 26765 26770 26776 26785 26820 26841 26842 26843 26844 26850 26852 26860 26862 26910 26951 26952 26990 26991 26992 27000 27001 27003 27005 27006 14.400 5.400 7.140 10. w/ or w/o internal fixation.040 5. single. carpometacarpal joint. carpometacarpal joint. w/ autogenous graft (includes obtaining graft) Arthrodesis. adductor. deep.820 20. single.980 21.920 10.400 5.980 20. w/ local advancement flaps (V-Y. w/ or w/o internal or external fixation.780 7. w/ autograft (includes obtaining graft) Arthrodesis. w/ manipulation. w/ finger or thumb (ray amputation).040 7.960 10.560 7.720 3. finger or thumb.600 6.960 Professional Fee 6. other than thumb (Bennett fracture). w/ or w/o internal or external fixation. internal or external fixation Open treatment of carpometacarpal dislocation. w/ or w/o internal fixation. pelvis and/or hip joint Tenotomy. single. single. w/ or w/o Open treatment of carpometacarpal dislocation.560 Health Care Institution Fee 5. including neurectomies.820 20.960 12. pelvis or hip joint area.900 10.900 5.g.400 10.940 20.960 14.080 10. metacarpal.600 12.540 14. subcutaneous. w/ manipulation Open treatment of interphalangeal joint dislocation. proximal or middle phalanx. w/ direct closure Amputation. any joint or phalanx. w/ or w/o internal fixation.720 6.120 14. primary or secondary. finger or thumb.720 5.880 12.960 5.920 10. involving metacarpophalangeal or interphalangeal joint. each Closed treatment of distal phalangeal fracture.900 12. w/ or w/o internal or external fixation.. thumb (Bennett fracture). thumb.500 7. Arthrodesis.100 5.140 4.560 6.700 Page 22 of 98 . w/ or w/o interosseous transfer Amputation. metacarpophalangeal joint. each Open treatment of phalangeal shaft fracture. finger or thumb.400 5. other than thumb (Bennett fracture).980 20.880 9.720 12.500 7. single.400 5.900 10.440 12. interphalangeal joint.620 7.400 7.980 21.700 5.540 10.540 14.500 5. finger or thumb. open Tenotomy. open Tenotomy.120 14.120 23. w/ or w/o internal or external fixation. w/ autograft (includes obtaining graft) Arthrodesis. w/ or w/o external fixation Open treatment of carpometacarpal fracture dislocation.400 7.900 10. single.560 13. adductor of hip. complex.080 10. w/ autograft (includes obtaining graft) Arthrodesis. Arthrodesis. w/ or w/o internal or external fixation Closed treatment of carpometacarpal dislocation. adductor of hip.ANNEX 2. for osteomyelitis or bone abscess). other than thumb (Bennett fracture).560 5. w/ or w/o internal fixation.040 7.300 7. primary or secondary.120 12. single.900 10. any joint or phalanx. other than thumb. Arthrodesis.240 10.980 10.120 12. w/ or w/o internal or external fixation Closed treatment of phalangeal shaft fracture.400 17. open.080 9. open Case Rate 12.880 5. metacarpophalangeal joint.400 5. single Percutaneous skeletal fixation of interphalangeal joint dislocation.300 23.120 14. thumb. single. w/ opening of bone cortex (e.540 21.540 12. finger or thumb Percutaneous skeletal fixation of distal phalangeal fracture. w/ or w/o internal fixation. interphalangeal joint.960 30. thumb.120 14. 300 17. gluteus medius.300 17. superficial (wing of ilium. hip joint Excision.960 37.920 13.120 15. for osteomyelitis).400 31.500 27036 27040 27047 27048 27049 27050 27052 27054 27060 27062 27065 27066 27067 27070 27071 27075 27076 27077 27078 27079 27080 27086 27090 27091 27097 27098 27100 27105 27110 27111 27120 27122 27125 27130 27132 27134 27137 27138 27140 27146 27147 27151 27156 27158 27161 37. femoral stem prosthesis. w/ or w/o autograft Excision of bone cyst or benign tumor. including "total hip" and methlmethacrylate. iliac. w/ or w/o allograft Osteotomy and transfer of greater trochanter Osteotomy . w/ open reduction of hip Osteotomy .300 38.640 25.440 13.480 17.000 12.640 27.820 30. femoral.700 10. sartorius.500 13. for congenital malformation) Osteotomy.600 13.700 13. w/ biopsy.300 21. to greater trochanter Transfer iliopsoas.740 37. iliac.640 18.180 38.300 31. tumor. proximal Adductor transfer to ischium Transfer external oblique muscle to greater trochanter including fascial or tendon extension (graft) Transfer paraspinal muscle to hip (includes fascial or tendon extension graft) Transfer iliopsoas. both pubic rami.800 3. hip.g. sacroiliac joint Arthrotomy.g.480 17.000 13. pelvis. w/ or w/o autograft or allograft Revision of total hip arthroplasty. femoral neck Case Rate 21.500 38. for infection.g.860 38. gluteus minimus. malignant neoplasm).700 18.960 16.160 18. Removal of hip prosthesis. or greater trochanter of femur) w/ or w/o autograft Excision of bone cyst or benign tumor.000 15. acetabular or innominate bone.740 30. w/ or w/o autograft or allograft Revision of total hip arthroplasty.160 20.300 31.640 18. or ischium and acetabulum Radical resection of tumor or infection. soft tissue of pelvis and hip area Arthrotomy. acetabular and proximal femoral prosthetic replacement (total hip replacement). subfascial.120 27.800 12.500 13. pelvis and hip area.740 30.140 37.960 16.260 37.. hip or thigh. soft tissue of pelvis and hip area Excision.300 17. Whitman.120 15.200 25.060 7.440 13. when applicable Hamstring recession.. wing of ilium. primary Removal of foreign body.000 17.000 24.000 18.360 21. w/ exploration or removal of loose or foreign body Hip joint denervation.480 29.380 14.000 13. resection femoral head (Girdlestone procedure) Partial hip replacement.500 18. complicated. trochanteric bursa or calcification Excision of bone cyst or benign tumor. w/ autograft requiring separate incision Partial excision (craterization.140 31. femoral component only.000 4.440 16. saucerization) (e. intramuscular Radical resection of tumor (e.180 31.900 10. iliac. acetabular or innominate bone.700 17.680 8.140 27.960 18. (e.800 12.800 13.140 46. w/ biopsy.000 504 1. ischial tuberosity and greater trochanter of femur.500 7.660 23. Osteotomy . superficial (e.700 18. acetabular component only.960 30.000 21.300 30. wing of ilium.400 16.480 18.980 7. innominate bone.700 13.400 13. w/ skin flaps Coccygectomy.300 17.840 21.700 18.960 30. Haygroves.680 3.g. deep.800 31. bilateral (e. both components.960 30. for osteomyelitis).480 18.860 37.500 13. hip..440 13.180 53.g. deep.700 24. acetabular or innominate bone.020 37. one pubic or ischial ramus or symphysis pubis Radical resection of tumor or infection.640 15. hip joint Arthrotomy w/ synovectomy.400 7.500 46.440 18. symphysis pubis or greater trochanter of femur) Partial excision (craterization. w/ drainage Arthrotomy. symphysis pubis. bipolar arthroplasty) Arthroplasty.800 3.300 18. tensor fascia latae.740 30.900 16. or cup type) Acetabuloplasty. w/ femoral osteotomy Osteotomy .300 Professional Fee 10.000 38.800 Health Care Institution Fee 10. tumor.200 20. subcutaneous Excision.700 16.ANNEX 2.800 19.640 38.320 11. intrapelvic or extrapelvic intra-articular branches of sciatic. ilium. w/ or w/o autograft or allograft Conversion of previous hip surgery to total hip replacement.g. to femoral neck Acetabuloplasty.120 27.300 18. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 27025 27030 27033 27035 DESCRIPTION Fasciotomy.020 22. w/ or w/o excision of heterotopic bone.500 21.320 21.000 4. ischial tuberosity and greater trochanter of femur Radical resection of tumor or infection.700 18. w/ or w/o autograft or allograft Revision of total hip arthroplasty.800 16. deep Radical resection of tumor or infection.500 18.500 Page 23 of 98 . saucerization) (e. Colonna.080 33.180 37.600 21.080 55. rectus femoris. w/ femoral osteotomy and w/ open reduction of hip Osteotomy. total Radical resection of tumor or infection.560 16.800 17. pelvis or hip Removal of hip prosthesis.840 15.000 12. including acetabulum.800 27.740 30... any type Arthrotomy.740 30. w/ release of hip flexor muscles (ie.700 18..400 55.760 12.140 21.640 16.504 5. iliopsoas) Biopsy.480 19.300 13. prosthesis (e.. or obturator nerves Capsulectomy or capsulotomy of hip. ischial bursa Excision.900 17. pelvis and hip area.800 17.560 15.180 31. acetabular or innominate bone. iliac.440 13.500 12.g.180 37. 300 31.660 37. thigh or knee region Case Rate 37. Open treatment of spontaneous hip dislocation (developmental. includes T-fracture and both column fracture w/ complete articular detachment.000 23. proximal end.600 18.800 40.520 25.500 13.700 18.140 23.500 13. w/ internal fixation Open treatment of acetabular fracture(s) involving anterior or posterior (one) column. pertrochanteric. in situ Open treatment of slipped femoral epiphysis. w/ or w/o internal or external fixation Closed treatment of hip dislocation.960 21.200 16. infected bursa.300 16.400 10.640 15.300 17.500 30.500 46. neck Percutaneous skeletal fixation of femoral fracture. neck. dislocation. proximal end.480 8. greater trochanter Prophylactic treatment (nailing.300 27. w/ subtrochanteric osteotomy Interpelviabdominal amputation (hindquarter amputation) Disarticulation of hip Incision and drainage of deep abscess.500 4.g. w/ internal fixation Open treatment of acetabular fracture(s) involving anterior and posterior (two) columns.320 46. osteoplasty of femoral neck (Heyman type procedure) Open treatment of slipped femoral epiphysis.480 15. traumatic Open treatment of hip dislocation. tuberosity avulsion. including congenital or pathological).140 37. hip joint (includes obtaining graft).800 13.640 12. pelvic fracture(s) w/c do not disrupt the pelvic ring). plating. or subtrochanteric femoral fracture.200 12.640 17.500 18. w/o internal fixation Open treatment of hip dislocation.500 10.500 46.180 27. or subtrochanteric femoral fracture Open treatment of intertrochanteric.200 25.320 Professional Fee 18.960 14.140 31.800 40.640 18. pertrochanteric.800 16.520 25.140 31.300 27245 27246 27248 27250 27253 27254 27258 31.300 21.300 17. single of multiple pinning or bone graft (includes obtaining graft) Open treatment of slipped femoral epiphysis. by single or multiple pinning.700 21. w/ internal fixation Percutaneous skeletal fixation of posterior pelvic ring fracture and/or dislocation (includes ilium. sacroiliac joint (including obtaining graft) Arthrodesis. diastasis or subluxation Closed treatment of coccygeal fracture Open treatment of coccygeal fracture Open treatment of iliac spine(s).700 12.200 13.700 12.120 12.300 46.520 16. intertrochanteric or subtrochanteric area (includes obtaining bone graft) Treatment of slipped femoral epiphysis.800 12. w/ or w/o interlocking screws and/or cerclage Closed treatment of greater trochanteric fracture Open treatment of greater trochanteric fracture.800 16. or impacted fracture Open treatment of femoral fracture. or single column or transverse fracture w/ associated acetabular wall fracture. replacement of femoral head in acetabulum (including tenotomy.400 21.180 40. or wiring) w/ or w/o methylmethacrylate.300 21.300 10.000 16.120 23.000 13.440 21.600 25.300 30.900 16. w/ plate/screw type implant.700 21.180 18. traumatic. etc). hip joint (includes obtaining graft).960 7.140 27.740 38.000 10.. w/ femoral shaft shortening Closed treatment of post hip arthroplasty dislocation Arthrodesis. etc).360 18.ANNEX 2.900 Page 24 of 98 .800 13.500 12. osteotomy and internal fixation Epiphyseal arrest by epiphysiodesis or stapling.500 10.800 27.640 40.800 3. Arthrodesis.320 30.480 23.000 23.800 21.640 12.960 17. w/ inte Closed treatment of femoral fracture.640 17.300 46.500 30.600 15. femoral neck and proximal femur Closed treatment of pelvic ring fracture.300 10.000 7. or subtrochanteric femoral fracture.300 8.960 22.320 46.500 25.200 21.520 Health Care Institution Fee 18. neck. or iliac wing fracture(s) (e.960 31. proximal end. w/o reduction Treatment of slipped femoral epiphysis.960 37.560 11.500 23. w/ or w/o internal or external fixation Open treatment of spontaneous hip dislocation (developmental.700 16.140 23.700 9.500 27259 27265 27280 27282 27284 27286 27290 27295 27301 37.600 16. neck. mildly displaced.200 25.000 37. sacroiliac joint and/or sacrum) Closed treatment of acetabulum (hip socket) fracture(s) Open treatment of posterior or anterior acetabular wall fracture. or a fracture running transversely across the acetabulum.000 15. symphysis pubis (including obtaining graft) Arthrodesis. femoral head. undisplaced.600 25.500 23.800 27228 27230 27235 27236 27238 27244 46. replacement of femoral head in acetabulum (including tenotomy.800 17.300 37.200 12.840 23. intertrochanteric or subtrochanteric including internal or external fixation and/or cast Bone graft.260 18. w/ intramedullary implant.600 16. internal fixation or prosthetic replacement (direct fracture exposure) Closed treatment of intertrochanteric. closed manipulation w/ single or multiple pinning Open treatment of slipped femoral epiphysis.300 13.800 21.700 13. by traction. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 27165 27170 27175 27176 27177 27178 27179 27181 27185 27187 27193 27200 27202 27215 27216 27217 27218 27220 27226 27227 DESCRIPTION Osteotomy.800 16. pinning. sacroiliac joint and/or sacrum) Open treatment of anterior ring fracture and/or dislocation w/ internal fixation (includes pubic symphysis and/or rami) Open treatment of posterior ring fracture and/or dislocation w/ internal fixation (includes ilium.480 17. including congenital or pathological). traumatic w/ acetabular wall and femoral head fracture.180 31. or hematoma.760 21.500 13. pertrochanteric.700 13. w/ or w/o cerclage Open treatment of intertrochanteric. intra-articular (open) Ligamentous reconstruction (augmentation). secondary reconstruction.020 15.440 17. drainage or removal of foreign body Neurectomy.000 21. tumor. open.080 13. intra-articular (open) and extra-articular Quadricepsplasty (Bennett or Thompson type) Capsulotomy. knee to hip.120 30.300 3.280 15.600 9.000 9.120 30. w/ exploration.000 12.500 12. hamstring muscle Neurectomy.140 37.120 13. hamstring.980 23.240 10. multiple Arthrotomy.000 18.500 Page 25 of 98 . hamstring.120 16.000 10.900 12.600 12.500 16. primary. w/ synovectomy.080 12. patella..020 13.080 30.560 10.120 8. open.720 27.. knee.800 17. thigh or knee area.300 27.120 8. hamstring. Excision or curettage of bone cyst or benign tumor of femur.g.900 17.gers type procedure) Arthrotomy w/ open meniscus repair Repair.700 7. multiple.600 9. primary Suture of quadriceps or hamstring muscle rupture. w/ or w/o biopsy. deep.. one leg Tenotomy.000 5.600 8. primary Suture of infrapatellar tendon.720 27.300 14.700 10.520 15.300 17. knee.700 12.120 14. femur.080 12.700 12.g.700 12.152 23. w/ synovial biopsy only Arthrotomy.120 18.700 17.300 21. w/ excision of semilunar cartilage (meniscectomy).120 18.940 20. single Tenotomy.300 23.000 10.700 10. bone. Goldwaite type procedure) Reconstruction for recurrent dislocating patella.600 9. including fascial or tendon graft Suture of quadriceps or hamstring muscle rupture.920 16.600 15.000 21. hamstring tendon to patella. anterior or posterior Arthrotomy.120 13. w/ joint exploration. tumor.900 10. open. primary.000 10. collateral and cruciate ligaments Anterior tibial tubercleplasty (e.920 15.400 10.740 30. subcutaneous Excision.300 37.680 2. w/ patellectomy Lateral retinacular release (any method) Ligamentous reconstruction (augmentation).600 10.680 8.120 23. thigh region or knee area Suture of infrapatellar tendon. deep. multiple.800 10.300 12. knee.300 10.g.340 13. knee to hip.120 32.700 3. for osteomyelitis).. open Tenotomy. single Transplant. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 27303 27305 27306 27307 27310 27315 27320 27323 27327 27328 27329 27330 27331 27332 27333 27334 27335 27340 27345 27350 27355 27356 27357 27358 27360 27365 27372 27380 27381 27385 27386 27390 27391 27392 27393 27394 27395 27396 27397 27400 27403 27405 27407 27409 27418 27420 27422 27424 27425 27427 27428 27429 27430 27435 27437 27438 DESCRIPTION Incision. closed. or intramuscular Radical resection of tumor (e.g. w/ or w/o removal of loose or foreign bodies Arthrotomy.000 9.360 23.900 13. or diaphysectomy) of bone (e. subcutaneous. subcutaneous.600 10. bilateral Lengthening of hamstring tendon. one leg Lengthening of hamstring tendon.300 13. multiple.700 9. knee.700 12. knee.120 10. extra-articular Ligamentous reconstruction (augmentation). for osteomyelitis or bone abscess).440 13.400 8.740 31. torn ligament and/or capsule.120 20.960 13.960 6.900 10. w/ synovectomy. deep.600 7.700 10.600 12.300 17.400 9. torn ligament and/or capsule.980 23. knee.000 17.400 12.180 13.820 27.120 12.504 5.600 10. primary.000 13. knee. hamstring tendon to patella.000 11.000 23.140 Professional Fee 12.740 30.900 17.300 31. w/ excision of semilunar cartilage (meniscectomy). single Lengthening of hamstring tendon.660 23.000 27. torn ligament and/or capsule. anterior and posterior including popliteal area Excision. for chondromalacia patellae) Reconstruction for recurrent dislocating patella. knee. multiple.900 10.552 12.020 15.980 30.700 12.000 4.580 27.640 Health Care Institution Fee 10. adductor or hamstring. medial and lateral Arthrotomy. knee.480 15. knee. w/ autograft (includes obtaining graft) Excision or curettage of bone cyst or benign tumor of femur.080 12.440 10.240 23.640 18. femur or knee Removal of foreign body. collateral Repair.300 18.020 27. for infection.800 22.700 15. posterior capsular release Arthroplasty.500 18.820 30.980 23. soft tissue of thigh or knee area Arthrotomy.740 21. knee.400 10.700 12. w/ allograft Excision or curettage of bone cyst or benign tumor of femur. popliteal (gastrocnemius) Biopsy. w/ extensor realignment and/or muscle advancement or release (Campbell.600 14.g. including fascial or tendon graft Tenotomy. patella.900 10.000 17.700 12.600 504 1.440 13. single Tenotomy.760 12.120 23.660 12. knee. cruciate Repair.500 13.960 27. thigh or knee area. medial or lateral Arthrotomy. bilateral Transplant. w/ prosthesis Case Rate 23.000 6. subfascial.300 31.300 12.240 10.180 27.440 11. hamstrings to femur (e.300 22.700 10.ANNEX 2.300 27. knee. adductor or hamstring. w/ internal fixation Partial excision (craterization.600 15. proximal tibia and/or fibula Radical resection of tumor. knee.960 20. prepatellar bursa Excision of synovial cyst of popliteal space (Bakers cyst) Patellectomy or hemipatellectomy Excision or curettage of bone cyst or benign tumor of femur. multiple Tendon or muscle transfer. saucerization.700 10.900 10. closed. soft tissue of thigh or knee area Excision. (Hauser type procedure) Reconstruction for recurrent dislocating patella.940 20. secondary reconstruction.960 15.740 22. femur or knee Fasciotomy. w/o prosthesis Arthroplasty.300 10. malignant neoplasm). w/ opening of bone cortex (e.800 21. iliotibial (tenotomy). knee to hip.720 23. Decompression fasciotomy. w/ or w/o cerclage and/or locking screws Open treatment of femoral shaft fracture w/ plate/screws.120 15.180 37. shortening (excluding 64876) Osteoplasty. w/ or w/o intercondylar extension. distal to head and neck.000 12.120 15.000 21. medial or lateral condyle Open treatment of femoral supracondylar or transcondylar fracture w/o intercondylar extension.520 8. shaft or supracondylar.820 23. w/ debridement of nonviable muscle and/or nerve Decompression fasciotomy.500 39. including fibular excision or osteotomy (includes correction of genu varus (bowleg) or genu valgus (knock-knee)).600 15. nonunion or malunion. femoral condyles or tibial plateaus. femur. all components Removal of knee prosthesis.820 21. distal femur Epiphyseal arrest by epiphysiodesis or stapling.800 16.820 12. compression technique) Repair. after epiphyseal closure Osteoplasty. nonunion or malunion. constrained prosthesis (e.300 16. thigh and/or knee.. distal end.000 21.000 12. knee.180 30.480 40.000 37.600 15.800 8. w/ realignment on intramedullary rod (Sofield type procedure) Osteotomy.440 29. thigh and/or knee.920 10.480 14.420 23.480 21. Decompression fasciotomy.080 10. when applicable Prophylactic treatment (nailing.120 18. w/ fixation Osteotomy.800 16. w/ or w/o internal or external fixation Case Rate 37. one compartment (flexor or extensor or adductor). w/ or w/o skin or skeletal traction Open treatment of femoral shaft fracture.700 17. thigh and/or knee.640 39.300 24. femur.200 22. or distal femoral epiphyseal separation Closed treatment of femoral fracture.740 23.920 12.900 10. proximal tibia. knee.300 17.600 10.g.120 37. w/ or w/o external fixation. combined distal femur.g.560 8. plating or writing) w/ or w/o methylmethacrylate.700 7.440 13. w/ iliac or other autogenous bone graft (includes obtaining graft) Epiphyseal arrest by epiphysiodesis or stapling. femur.120 27.800 16.840 21. distal end. knee. knee.300 10.820 12.120 30. w/ or w/o skin or skeletal traction Closed treatment of supracondylar or transcondylar femoral fracture w/ or w/o intercondylar extension.480 46. for genu varus or valgus) Revision of total knee arthroplasty. shaft or supracondylar. femoral shaft.700 12.800 38.820 8.120 Health Care Institution Fee 16.680 23.900 10. thigh and/or knee. w/ debridement of nonviable muscle and/or nerve Closed treatment of supracondylar or transcondylar femoral fracture w/ or w/o intercondylar extension Closed treatment of femoral shaft fracture. condyle and plateau.600 9.820 18.ANNEX 2. condyle and plateau. one compartment (flexor or extensor or adductor). femur.960 13.440 10.480 13.320 18. w/o fixation Osteotomy.980 21.700 12.840 22. Arthroplasty. lengthening and shortening w/ femoral segment transfer Repair.960 18. w/ or w/o allograft.300 10. w/ or w/o cerclage Percutaneous skeletal fixation of femoral fracture.800 21. or supracondylar or transcondylar.680 25.g.600 7. w/ or w/o internal or external fixation Open treatment of femoral supracondylar or transcondylar fracture w/ intercondylar extension.740 53. Walldius type) Arthroplasty. including "total knee" methylmethacrylate and insertion of spacer. multiple compartments.700 16. tibial plateau.400 18. multiple.420 18.120 15..600 18. femur Decompression fasciotomy.000 18.400 55.800 9. lengthening Osteoplasty.480 18.900 10. medial or lateral compartment Arthroplasty. tibia and fibula.180 31. w/ or w/o allograft.700 27510 27511 27513 18. femoral condyles or tibial plateaus.640 38.000 17. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 27440 27441 27442 27443 27445 27446 27447 27448 27450 27454 27455 DESCRIPTION Arthroplasty.420 37.420 15.960 30. tibial plateau.600 27506 27507 30. distal to head and neck. hemiepiphyseal.300 12.000 17.000 9.300 27.740 20. w/ insertion of intramedullary implant. proximal Epiphyseal arrest by epiphysiodesis or stapling. medial or lateral condyle. w/ debridement and partial synovectomy Arthroplasty.600 18.440 17. combined. proximal tibia and fibula Arrest.000 12. pinning. knee. w/ debridement and partial synovectomy Arthroplasty. knee. medial and lateral compartments w/ or w/o patella resurfacing ("total knee replacement") Osteotomy.120 13.740 13. knee.000 27457 27465 27466 27468 27470 27472 27475 27477 27479 27485 27486 27487 27488 27495 27496 27497 27498 27499 27501 27502 27503 27. proximal tibia. one component Revision of total knee arthroplasty.800 16. femur.120 27. including fibular excision or osteotomy (includes correction of genu varus (bowleg) or genu valgus (knock-knee)). femur. Arthroplasty.280 15. before epiphyseal closure Osteotomy.300 27. femur. w/o graft (e.120 27. multiple compartments..300 14. distal femur or proximal leg (e.400 33.440 12.180 18.700 17.300 27509 37.580 27.740 30.120 Professional Fee 21.800 Page 26 of 98 .400 9. deep.120 27.300 12. subcutaneous .000 17. w/ primary ligamentous repair. and posterior compartment(s) Incision and drainage.940 22.260 4. Achilles tendon.700 10. general anesthesia Incision. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 27514 27516 27519 27520 27524 27530 27535 27536 27538 27540 27550 27556 27557 27558 27560 27566 27580 27590 27591 27592 27594 27596 27598 27600 27601 27602 27603 27604 27605 27606 27607 27610 27612 27613 27615 27618 27619 27620 27625 27626 27630 27635 27637 27638 27640 27641 27645 27646 DESCRIPTION Open treatment of femoral fracture. ankle. leg.020 12.800 10.540 18. subcutaneous Excision. Arthrotomy.300 10.440 12. w/ or w/o Achilles tendon lengthening Biopsy.080 8.740 30. leg or ankle area. ankle.680 12. w/ or w/o internal or external fixation Open treatment of tibial fracture.140 8.900 10.240 1. subfascial or intramuscular Arthrotomy.940 21..108 5.500 5. including tenosynovectomy Excision of lesion of tendon sheath or capsule (e. through femur.700 12. leg.700 10.680 8.600 11. w/ exploration.120 30.504 20.240 8.g.008 1.300 23.500 12. any level.240 11.120 8.120 10.400 12.120 5. leg and/or ankle Excision or curettage of bone cyst or benign tumor.880 11.300 22. tumor.600 12.420 21. leg or ankle. leg or ankle area.960 21.900 3.960 37.660 27. ankle.820 9.940 5.420 18.900 10.700 10. w/ or w/o removal of loose or foreign body Arthrotomy.900 5.300 23.600 17. through femur.300 11.440 15.500 6.000 10.000 5. w/ primary ligamentous repair Open treatment of knee dislocation.g. Excision or curettage of bone cyst or benign tumor.500 10.900 12.g. for osteomyelitis or bone abscess). ankle. proximal (plateau). leg or ankle Arthrotomy. deep abscess or hematoma Incision and drainage.760 10. w/ or w/o internal or external fixation.680 14. bone. ankle. w/ internal fixation and/or partial or complete patellectomy and soft tissue repair Closed treatment of tibial fracture.520 3. w/ or w/o internal fixation Closed treatment of intercondylar spine(s) and/or tuberosity fracture(s) of knee Open treatment of intercondylar spine(s) and/or tuberosity fracture(s) of the knee.760 Health Care Institution Fee 17. local anesthesia.000 7.120 2.940 18. tibia Partial excision (craterization.400 9.740 23.040 10. w/o primary ligamentous repair or augmentation/reconstruction Open treatment of knee dislocation. Tenotomy. through femur.700 6. or diaphysectomy) of bone (e. thigh.540 21.520 2.600 10.600 11. unicondylar. distal end. Amputation. through femur. deep.820 8.820 10.120 13. any level.660 Professional Fee 13. w/ or w/o internal or external fixation Closed treatment of knee dislocation Open treatment of knee dislocation. w/ joint exploration.920 5.600 5.660 3. bicondylar. cyst or ganglion). thigh.440 16.600 9.600 12.980 18.980 5. any level.000 5.000 12. w/ augmentation/reconstruction Closed treatment of patellar dislocation Open treatment of patellar dislocation. tumor. drainage. for infection.g. w/ opening of bone cortex (e. soft tissue of leg or ankle area Excision. circular (guillotine) Amputation. saucerization.680 7. w/ or w/o partial or total patellectomy Fusion of knee.080 10. medial or lateral condyle.500 4. leg.000 5.820 10.040 15..900 Page 27 of 98 . local anesthesia. any level.600 9. fibula Radical resection of tumor.680 7. through femur. tibia or fibula. for osteomyelitis or exostosis).100 10.000 23. re-amputaion Disarticulation at knee Decompression fasciotomy. w/ synovectomy.020 8.900 12. or removal of foreign body Arthrotomy..400 12.540 27. w/ or w/o internal or external fixation Closed treatment of distal femoral epiphyseal separation Open treatment of distal femoral epiphyseal separation.700 9. saucerization.820 13.660 20.980 22.300 13. leg or ankle.120 15.300 22.. anterior and/or lateral compartments only Decompression fasciotomy. fibula Case Rate 30.000 10.020 8.900 3. any level..100 4. posterior compartments(s) only Decompression fasciotomy.300 8.900 9.900 18.980 20. w/ allograft Partial excision (craterization. any technique Amputation. thigh. anterior and/or lateral.000 16.ANNEX 2.360 1. proximal (plateau).080 9. for osteomyelitis or exostosis).760 504 10. or diaphysectomy) of bone (e.080 1.g.420 30. thigh. immediate fitting technique including first cast Amputation. soft tissue of leg or ankle area Radical resection of tumor (e.980 21. tibia or fibula.900 4.600 10. w/ or w/o internal or external fixation.080 15. w/ or w/o biopsy. tibia Radical resection of tumor.240 9.700 10.800 12.560 9.500 10.520 6.980 27.960 21.760 15. secondary closure or scar revision Amputation.700 4. infected bursa Tenotomy. open. subcutaneous . posterior capsular release. thigh.420 20.680 2. w/ or w/o internal or external fixation.900 12. w/ autograft(includes obtaining graft) Excision or curettage of bone cyst or benign tumor. tibia or fibula. proximal (plateau) Open treatment of tibial fracture. w/ or w/o internal or external fixation Closed treatment of patellar fracture Open treatment of patellar fracture. bone.740 27. Achilles tendon. w/ synovectomy. malignant neoplasm).800 20.000 5. 600 7.080 10. anterior tibial extensors into midfoot) Transfer or transplant of single tendon (w/ muscle redirection or rerouting).g. tibia Epiphyseal arrest by epiphysiodesis or stapling. fascial defect of leg Repair or suture of flexor tendon of leg. primary.000 18.360 18.980 8. w/o graft.600 10.900 10.920 11.120 21.760 15. tibia and fibula. primary.960 8.700 12.700 9.g.380 18.000 18.400 9.660 10.900 10. Arthroplasty. collateral (Watson-Jones procedure) Arthroplasty. plating or wiring) w/ or w/o methylmethacrylate.920 1. superficial (e.120 5. multiple. each additional tendon Suture. each Repair or suture of extensor tendon of leg. multiple (through same incision).040 Health Care Institution Fee 10.600 12. ruptured Achilles tendon.600 12.820 22.g. ankle.900 12.600 11.940 23.120 31.760 13.380 18.600 9.960 18. collateral Suture.400 7.700 10.120 12.600 10.720 5. pins or screws) Open treatment of tibial shaft fracture (w/ or w/o fibular fracture) w/ plate/screws.460 6.820 7. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 27647 27650 27652 27654 27656 27658 27659 27664 27665 27675 27676 27680 27681 27685 27686 27687 27690 27692 27695 27696 27698 27700 27702 27703 27704 27705 27707 27709 27712 27715 27720 27722 27724 27725 27727 27730 27732 27734 27740 27742 27745 27750 27752 27756 27758 27759 27760 27766 27780 27784 27786 DESCRIPTION Radical resection of tumor.720 10.980 8. combined.600 12. talus or calcaneus Repair.300 21.000 9.180 21.300 22.940 18.900 10. each Repair or suture of flexor tendon of leg. fibula. including tibia.400 10.700 10.660 23.760 12. w/o graft. including tibia.000 14. w/ realignment on intramedullary rod (Sofield type procedure) Osteoplasty. w/o graft. with or without skeletal traction Percutaneous skeletal fixation of tibial shaft fracture (w/ or w/o fibular fracture) (e. with manipulation. and ankle flexor.. ankle.400 5. ruptured or severed ligament.000 23.400 7. each Lengthening or shortening of tendon.240 8.960 22. (e.480 10.300 18..900 10. primary. w/ or w/o internal or external fixation Closed treatment of distal fibular fracture (lateral malleolus) Case Rate 23.080 12.400 10.420 15.560 8.940 18.160 12.300 5.400 8. and distal femur Prophylactic treatment (nailing.600 7. w/ graft (includes obtaining graft) Repair.920 9. ruptured or severed ligament. w/ fibula. secondary repair.300 21.960 18.700 9. Strayer procedure) Transfer or transplant of single tendon (w/ muscle redirection or rerouting). distal tibia and fibula Epiphyseal arrest by epiphysiodesis or stapling.980 21. tibia.820 20.000 27.300 21. lengthening Repair of nonunion or malunion.. primary. single.000 15.000 5. multiple (through same incision).900 17.000 22. secondary w/ or w/o graft. tibia Osteotomy.900 4. w/ implant ("total ankle") Arthroplasty. both collateral ligaments Suture. distal fibula Epiphyseal arrest by epiphysiodesis or stapling.400 9.900 5.600 9.240 8. ankle. and ankle flexor.600 7.600 10.400 12. Repair.400 9.980 8.600 10. w/ iliac or other autograft (includes obtaining graft) Repair of nonunion or malunion. torn.700 10. Epiphyseal arrest by epiphysiodesis or stapling.900 12.700 10.500 18. distal tibia Epiphyseal arrest by epiphysiodesis or stapling. single tendon. proximal and distal tibia and fibula. tibia. open or percutaneous. fibula Osteotomy.020 15.720 6. ankle. leg or ankle.920 11.400 9.640 18. tibia.g. each Repair or suture of extensor tendon of leg.920 10.400 5.860 6.460 11.400 8. tibia.120 10. single tendon.300 23.000 7. single Lengthening or shortening of tendon.820 21.240 12.380 18.820 22. ruptured Achilles tendon.140 37. pinning. tibia Closed treatment of tibial shaft fracture (w/ or w/o fibular fracture) Closed treatment of tibial shaft fracture (with or without fibular fracture). secondary w/ or w/o graft. any method Repair of congenital pseudarthrosis. w/ or w/o cerclage Open treatment of tibial shaft fracture (w/ or w/o fibular fracture) by intramedullary implant. secondary. leg or ankle.660 31.600 10. torn.700 9.000 13. tibia and fibula Osteotomy. primary.760 13..500 Page 28 of 98 . proximal and distal tibia and fibula.000 21. fibula.400 9. w/ sliding graft Repair of nonunion or malunion. ruptured Achilles tendon.400 11.120 17.600 8.540 Professional Fee 12.900 10. primary.900 10.ANNEX 2.700 9.000 20.900 10. each Repair for dislocating peroneal tendons.700 10.760 5. ankle.680 7. combined. compression technique) Repair of nonunion or malunion. by synostosis. single Tenolysis.660 27. torn.600 9. w/ or w/o graft Repair.600 12.820 5.660 8. ruptured or severed ligament. secondary reconstruction.120 10. w/ or w/o interlocking screws and/or cerclage Closed treatment of medial malleolus fracture Open treatment of medial malleolus fracture. each Gastrocnemius recession (e.680 15. open or percutaneous. ankle. w/ fibular osteotomy Tenolysis.720 27.700 10. w/ or w/o internal or external fixation Closed treatment of proximal fibula or shaft fracture Open treatment of proximal fibula or shaft fracture.960 12. single.660 23.400 9. w/o fibular osteotomy Repair for dislocating peroneal tendons.000 22. total ankle Removal of ankle implant Osteotomy. bone.700 12.500 10.500 5.400 15.980 23. 400 1.000 4. of tibia only Open treatment of fracture of weight bearing articular surface/portion of distal tibia (e.g..600 12.. medial and/or lateral malleolus. or removal of loose or foreign body. soft tissue of foot Arthrotomy for synovial biopsy. w/ or w/o tendon sheath involvement.080 10.900 10. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 27792 27808 27814 27816 27822 DESCRIPTION Open treatment of distal fibular fracture (lateral malleolus).260 9.300 23.600 5. drainage. foot and/or toe Tenotomy.820 1. through tibia and fibula. pilon or tibial plafond) Open treatment of fracture of weight bearing articular surface/portion of distal tibia (e.700 10. w/ internal or external fixation. (including Potts) Open treatment of bimalleolar ankle fracture. w/ repair or internal or external fixation Arthrodesis.520 21.960 11.g.040 10.600 4.700 27823 27824 27826 23. w/ debridement of nonviable muscle and/or nerve Decompression fasciotomy. w/ debridement of nonviable muscle and/or nerve Incision and drainage.040 6.300 9. Deep dissection below fascia.400 10. ankle.700 10. of fibula only Open treatment of fracture of weight bearing articular surface/portion of distal tibia (e.540 20. through tibia and fibula.900 8.240 12.400 6.900 6.300 10.740 18. Pirogoff type procedures).000 18. drainage. w/ internal or external fixation. subcutaneous Excision.900 7.600 5. leg. any method Arthrodesis.400 8. secondary closure or scar revision Amputation.700 12.080 5. w/ internal or external fixation.360 4. w/ or w/o internal or external fixation Closed treatment of proximal tibiofibular joint dislocation Open treatment of proximal tibiofibular joint dislocation.600 9. intertarsal or tarsometatarsal joint Arthrotomy.620 10. w/ debridement of nonviable muscle and/or nerve Decompression fasciotomy. w/ or w/o internal or external fixation w/o manipulation Closed treatment of bimalleolar ankle fracture.500 Page 29 of 98 .800 10.420 5.500 10. foot. medial and/or lateral malleolus. anterior and/or lateral compartments only. w/ or w/o internal or external fixation.300 Professional Fee 10.900 5.300 21.900 4. malignant neoplasm). tumor. w/ fixation of posterior lip Closed treatment of fracture of weight bearing articular portion of distal tibia (e.040 6. w/ opening of bone cortex (e.600 4. or removal of loose or foreign body.000 5.980 10. w/ or w/o internal or external fixation. re-amputation Amputation. leg.400 8. foot.120 8. circular (guillotine) Amputation.700 9.980 12.500 5.300 30.000 21..680 8.700 5.400 4. tumor.440 8.460 5.680 2. w/o fixation of posterior lip Open treatment of trimalleolar ankle fracture. through malleoli of tibia and fibula (Syme. foot Fasciotomy.900 23. subcutaneous.000 5. w/ immediate fitting technique including application of first cast Amputation.720 3.880 5. leg.. leg.000 4.760 13.020 8.360 3.600 12. for osteomyelitis or bone abscess). metatarsophalangeal joint Arthrotomy.540 12.980 10.300 23. through tibia and fibula.500 10.900 5. of both tibia and fibula Open treatment of distal tibiofibular joint (syndesmosis) disruption.920 10.600 10. infected bursa. and posterior compartment(s). w/ exploration. w/ plastic closure and resection of nerves Ankle disarticulation Decompression fasciotomy. drainage. deep. through tibia and fibula. pilon or tibial plafond). deep.600 10.400 10.132 18. intramuscular Radical resection of tumor (e.900 13.g.. leg. anterior and/or lateral. subfascial.200 5.300 23. intertarsal or tarsometatarsal joint Case Rate 20.720 12. toe. w/ exploration.500 17.g.600 12.800 5.540 12. specify.260 11.100 5.100 9.700 9. w/ or w/o internal or external fixation Closed treatment of trimalleolar ankle fracture Open treatment of trimalleolar ankle fracture.800 13. single Tenotomy. multiple areas Incision. ankle. for deep infection of foot. open. w/ or w/o percutaneous skeletal fixation. or w/ excision of proximal fibula Closed treatment of ankle dislocation Open treatment of ankle dislocation. or removal of loose or foreign body.000 12. tibiofibular joint. interphalangeal joint Neurectomy of intrinsic musculature of foot Tarsal tunnel release (posterior tibial nerve decompression) Excision.700 10. multiple Arthrotomy. leg.940 18.500 16.020 37.960 22.080 6.900 10.300 12.300 3.600 9.260 8. w/ exploration.600 9. for deep infection of foot.600 4.500 6.500 6. w/ or w/o tendon sheath involvement.500 16.g.460 11.820 20.680 3. specify.980 12. proximal or distal Amputation.500 5.g.680 8. pilon or tibial plafond).120 23.360 5.240 8.260 10.660 23. w/o repair or internal fixation Open treatment of ankle dislocation. posterior compartment(s) only.360 4.700 10. w/ or w/o percutaneous skeletal fixation. w/ or w/o internal or external fixation.400 30. pilon or tibial plafond).720 18. through tibia and fibula.120 10.940 9. single bursal space.000 18.900 27827 21.900 5.ANNEX 2. Amputation. toe. single bursal space. foot Deep dissection below fascia.600 Health Care Institution Fee 10. leg.032 8. subcutaneous.700 27828 27829 27830 27832 27840 27846 27848 27870 27871 27880 27881 27882 27884 27886 27888 27889 27892 27893 27894 28001 28002 28003 28005 28008 28010 28011 28020 28022 28024 28030 28035 28043 28045 28046 28050 21. leg. 440 8.900 7. foot. or diaphysectomy) of bone (e. toe.380 15.100 7. open.420 18.140 7.960 10.500 5. each tendon (includes obtaining graft) Repair or suture of tendon.400 6. bone.200 5. each Excision of interdigital (Morton) neuroma.500 5.000 18.400 5. single toe. Tenotomy.420 12. open.000 20.600 9.240 9. secondary w/ free graft.820 8.400 7.132 18.700 9. for osteomyelitis or tarsal bossing).980 9. w/ allograft Excision or curettage of bone cyst or benign tumor. metatarsal Radical resection of tumor. midfoot. foot.500 5.380 21.g.040 13. complete excision.400 9.400 8.540 12. head of phalanx. w/ allograft Excision or curettage of bone cyst or benign tumor.960 10. Excision or curettage of bone cyst or benign tumor.500 5.600 9.600 5. extensor. partial or complete.032 8. medial release only Capsulotomy.940 21.540 22.240 8. primary or secondary.100 5. foot.400 12. talus or metatarsal bones.300 10.780 5.400 12. saucerization. metatarsophalangeal joint.540 10.. bone. interphalangeal joint Fasciectomy.500 5. talus or metatarsal bones.400 12. complete excision.760 8.120 9.100 9. foot.780 5. calcaneus.400 7.440 11.540 18.000 18. single Tenotomy. or diaphysectomy) of bone (e. extensor.680 10. except tarsal or calcaneus. flexor Synovectomy. flexor. fifth metatarsal head (bunionette) Ostectomy. tendon sheath.240 8.600 9.200 4. except talus or calcaneus Partial excision (craterization.100 5.880 10.400 7. other metatarsal head (second. phalangeal base.700 28122 28124 28126 28130 28140 28150 28153 28160 28171 28173 28175 28200 28202 28208 28210 28220 28222 28225 28226 28230 28232 28234 28238 28240 28250 28260 28261 18.960 8. foot.240 9.820 8.400 10. saucerization.240 Health Care Institution Fee 5. excision of tarsal coalition Ostectomy. foot. single Tenolysis. or release.g.140 7. multiple (through same incision) Tenolysis. midfoot. each tendon Repair or suture of tendon.600 10. intertarsal or tarsometatarsal joint. talus or calcaneus.400 12.700 7. tarsal or metatarsal bone. sequestrectomy. complete excision. toe. flexor.400 9.400 5. extensor Excision of lesion of tendon or fibrous sheath or capsule (including synovectomy) (cyst or ganglion). bone. excision of plantar fascia.460 1.880 5. saucerization. phalanx of toe Repair or suture of tendon.240 7..720 6. for osteomyelitis or talar bossing)..960 5.760 9. single.460 2. single.000 12.600 9.g.600 Page 30 of 98 .460 5. each tendon (includes obtaining graft) Tenolysis. except tarsal or calcaneus. each Synovectomy.500 7.620 4. foot.400 5.360 7.120 10.460 3. secondary w/ free graft.560 9.400 7. excision of plantar fascia.400 5.120 12. foot.940 21.700 10.080 7. flexor. radical Synovectomy. toes Excision or curettage of bone cyst or benign tumor. foot.500 6.700 9.820 7.740 22. single or multiple. third or fourth) Ostectomy. excluding first metatarsal (Clayton type procedure) Ostectomy.140 11.500 17.700 12. first metatarsal head Ostectomy.900 12. w/ tendon lengthening Case Rate 10.700 12. phalanx of toe Resection. for spur. lengthening.600 5. single. each tendon Repair or suture of tendon. single.500 5. multiple (through same incision) Tenotomy.400 8.000 8.680 5.980 9. all metatarsal heads. each Resection.240 7. abductor hallucis muscle Division of plantar fascia and muscle ("Steindler stripping") Capsulotomy.940 18.560 9. foot or toe Advancement of posterior tibial tendon w/ excision of accessory navicular bone (Kidner type procedure) Tenotomy.500 4. talus or calcaneus.540 30.700 9. single.540 12.960 21.540 12.940 18.460 5. except tarsal or calcaneus.380 21.960 10.660 18. each Radical resection of tumor.140 3. Ostectomy.980 7. talus or calcaneus.660 21. calcaneus. tarsal (except talus or calcaneus) Radical resection of tumor.600 5. Excision or curettage of bone cyst or benign tumor. extensor.ANNEX 2. talus or metatarsal bones.880 11.900 9. extensor.940 15.940 Professional Fee 4. w/ iliac or other autograft (includes obtaining graft) Excision or curettage of bone cyst or benign tumor. metatarsophalangeal joint Arthrotomy for synovial biopsy. partial excision. for osteomyelitis or dorsal bossing). w/ partial proximal phalangectomy. w/ iliac or other autograft (includes obtaining graft) Excision or curettage of bone cyst or benign tumor.460 3.260 15.780 4.000 5.140 7.940 14. foot.000 12. phalanges of foot Ostectomy. foot.100 5.380 14.400 10.960 11.700 7. or diaphysectomy) of bone (e. flexor. single Tenolysis.500 7. single or multiple.980 10.600 5. tendon sheath. w/ or w/o plantar fascial release Partial excision (craterization.500 4. primary or secondary. foot Excision of lesion of tendon or fibrous sheath or capsule (including synovectomy) (cyst or ganglion). each Talectomy (astragalectomy) Metatarsectomy Phalangectomy of toe.400 7. each Synovectomy. foot. open.980 7.940 3.720 5. single.900 7.140 8.420 18. w/o free graft. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 28052 28054 28060 28062 28070 28072 28080 28086 28088 28090 28092 28100 28102 28103 28104 28106 28107 28108 28110 28111 28112 28113 28114 28116 28118 28119 28120 DESCRIPTION Arthrotomy for synovial biopsy.000 12. partial Fasciectomy. flexor.400 5. fifth metatarsal head Ostectomy.980 15. single. extensor.960 10.460 5. complete excision.960 21. toe Hemiphalangectomy or interphalangeal joint excision. flexor. talus or calcaneus Partial excision (craterization.880 10. w/ or w/o internal or external fixation Treatment of tarsal bone fracture (except talus and calcaneus) Percutaneous skeletal fixation of tarsal bone fracture (except talus and calcaneus).080 6.980 4. partial.120 12.980 9.400 5. first metatarsal w/ autograft Osteotomy.120 12.200 7.300 10. exostectomy or condylectomy.240 7. single.900 20.420 14.100 6. first toe Repair of nonunion or malunion. single.880 8. w/ or w/o sesamoidectomy. single. midfoot. angular or rotational correction.420 22. one toe (e..400 7.760 12. multiple.140 9.900 5.960 9.820 7.940 15.660 9.400 12. metatarsal. w/ primary iliac or other autogenous bone graft (includes obtaining graft) Closed treatment of talus fracture Percutaneous skeletal fixation of talus fracture.080 7.600 12.720 6.080 7.720 7.660 23.180 10.032 5.980 15. metatarsal. w/ autograft (includes obtaining graft)(Fowler type) Osteotomy.600 12. Chevron. phalangectomy) Cock-up fifth toe operation w/ plastic skin closure (Ruiz-Mora type procedure) Ostectomy.400 5.g.400 12. by other methods (e.900 10. midtarsal (Heyman type procedure) Capsulotomy. toe(s).700 12. first metatarsal Osteotomy. w/ or w/o sesamoidectomy.760 11. tarsal bones (e.360 10. metatarsal head.120 12.660 22.700 7. filleting. toe(s).100 Page 31 of 98 .940 22. cleft foot Closed treatment of calcaneal fracture Percutaneous skeletal fixation of calcaneal fracture. other than calcaneus or talus.460 4.380 10. metatarsophalangeal joint.980 15.820 9. angular deformity of toe (overlapping second toe. Keller. w/ or w/o sesamoidectomy. w/ or w/o internal or external fixation.g.980 21. single.400 5.380 21.700 12.760 11. calcaneus (Dwyer or Chambers type procedure). talus) Repair of nonunion or malunion. each joint Capsulotomy. macrodactyly.900 10. Mitchell.500 7.240 9.360 22.700 5.180 12. toe.900 10. soft tissue resection Reconstruction.900 10. w/ or w/o sesamoidectomy. or concentric type procedures) Hallux valgus (bunion) correction.460 5.140 9.900 7. proximal phalanx. Lapidus type procedure Hallux valgus (bunion) correction.660 9. metatarsal. w/ or w/o lenghtening.360 12.900 10.080 21.980 8.g.. including posterior talotibial capsulotomy and tendon(s) lengthening as for resistant clubfoot deformity Capsulotomy.400 12.000 22.700 15.900 10.900 10.980 12. w/ manipulation Case Rate 20. extensive.660 9.960 22. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 28262 28264 28270 28272 28280 28285 28286 28288 28290 28292 28293 28294 28296 28297 28298 28299 28300 28302 28304 28305 28306 28307 28308 28309 28310 28312 28313 28315 28320 28322 28340 28341 28344 28345 28360 28400 28406 28415 28420 28430 28436 28445 28450 28456 DESCRIPTION Capsulotomy.ANNEX 2.400 9. w/ or w/o sesamoidectomy. each metatarsal head Hallux valgus (bunion) correction.980 5. soft tissue procedures only Sesamoidectomy. w/ or w/o internal or external fixation.900 7. base or shaft.980 Professional Fee 10.132 11. by phalanx osteotomy Hallux valgus (bunion) correction.380 20.360 15. polydactyly Reconstruction. syndactyly.980 10. for cavus foot (Swanson type procedure) Osteotomy for shortening. or Mayo type procedure Hallux valgus (bunion) correction. w/ manipulation Open treatment of talus fracture.560 6.820 21.540 21.400 5. requiring bone resection Reconstruction. w/ tendon transplants (Joplin type procedure) Hallux valgus (bunion) correction. for shortening or angular correction.240 7. metatarsals. w/ or w/o lenghtening.700 12.500 5.820 22. w/ or w/o lenghtening. w/ or w/o sesamoidectomy. other than first metatarsal Osteotomy. Open treatment of calcaneal fracture. single each joint Webbing operation (create syndactylism of toes) (Kelikian type procedure) Hammertoe operation. w/ or w/o sesamoidectomy. curly toes). simple exostectomy (Silver type procedure) Hallux valgus (bunion) correction.980 18. fifth toe.400 9. any toe Reconstruction. w/ or w/o internal fixation Osteotomy. other than calcaneus or talus.400 10. base or shaft. Osteotomy. w/ or w/o sesamoidectomy. first through fifth. other phalanges.600 7.700 12. talus Osteotomy.400 12.g.540 21. first toe Osteotomy for shortening. calcaneus. double osteotomy) Osteotomy. w/ or w/o bone graft (includes obtaining graft) Reconstruction.100 9. resection of joint w/ implant Hallux valgus (bunion) correction.380 18.660 7.960 11.400 6.880 Health Care Institution Fee 10. angular or rotational correction. single.. for shortening or angular correction.360 21.700 7.700 5.360 22. for shortening or angular correction.700 9.660 22. base or shaft. midtarsal bones.400 20. metatarsal.660 5. w/ or w/o tenorrhaphy.080 10. w/ or w/o skin graft(s) Reconstruction.080 23.940 18. interphalangeal joint. interphalangeal fusion. toe.600 10.660 7.560 9.500 6.500 10.700 7.720 6.940 14.960 12. w/ metatarsal osteotomy (e.380 11.900 10. McBride. midtarsal bones.. macrodactyly. w/ manipulation Open treatment of calcaneal fracture.240 8.900 10.920 11.920 10. w/ manipulation Open treatment of fracture great toe.120 10.400 5.260 Health Care Institution Fee 5.000 12. localizer.400 5. w/ manipulation Open treatment of interphalangeal joint dislocation.240 23.540 10. metatarsal.900 5.780 4.540 10.600 7.100 5. phalanx or phalanges Percutaneous skeletal fixation of fracture great toe. Application of body cast.120 10. Arthrodesis.040 5. w/ or w/o internal or external fixation Closed treatment of sesamoid fracture Open treatment of sesamoid fracture.780 3.260 10.300 Page 32 of 98 .720 5. only Application of Risser jacket.260 12. midtarsal or tarsometatarsal.400 10.040 5.100 5. phalanx or phalanges.040 5.120 12.540 10.460 7. including one thigh Application of body cast.040 5.700 9.780 7.880 8.120 12. w/ or w/o internal or external fixation Closed treatment of interphalangeal joint dislocation Percutaneous skeletal fixation of interphalangeal joint dislocation.420 15. for deep infection of foot. localizer.140 8. w/ or w/o internal or external fixation Closed treatment of tarsometatarsal joint dislocation Percutaneous skeletal fixation of tarsometatarsal joint dislocation.720 6.880 12.000 12.120 9.260 21.400 9.400 5.140 7.360 7. shoulder spica Application of body cast.120 12. w/ or w/o internal fixation Closed treatment of tarsal bone dislocation. midtarsal or tarsometatarsal. toe. including head.360 10.400 7. only Application of turnbuckle jacket.500 5.140 3.500 5.720 3.400 5. plaster Velpeau Case Rate 10. interphalangeal joint Application of halo type body cast (see 20661-20663 for insertion) Application of Risser jacket.820 7. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 28465 28470 28476 28485 28490 28496 28505 28510 28525 28530 28531 28540 28546 28555 28570 28576 28585 28600 28606 28615 28630 28636 28645 28660 28666 28675 28705 28715 28725 28730 28735 28737 28740 28750 28755 28760 28800 28802 28805 28810 28820 28825 29000 29010 29015 29020 29025 29035 29040 29044 29046 29055 29058 DESCRIPTION Open treatment of tarsal bone fracture (except talus and calcaneus).540 18.540 12. w/ or w/o tendon shealth involvement. phalanx or phalanges.400 9.000 27. w/ manipulation Open treatment of talotarsal joint dislocation.400 7.540 18.620 6. shoulder to hips. other than talotarsal Percutaneous skeletal fixation of tarsal bone dislocation. w/ manipulation Open treatment of metatarsal fracture.400 3.500 5. interphalangeal joint Arthrodesis.000 10.180 9.600 7. including head Application of body cast. shoulder to hips.120 8.500 5.400 6. single bursal space specify Deep disection below fascia.940 18. w/ tendon lengthening and advancement (Miller type procedure) Arthrodesis.880 12.100 5.960 12.900 10.500 5.500 5.040 5.400 9. w/ or w/o tendon shealth involvement. great toe.360 3.900 5. w/ extensor hallucis longus transfer to first metatarsal neck (Jones type procedure) Amputation. body. metatarsophalangeal joint Arthrodesis.900 12. great toe.340 12.900 10.960 15.040 6.700 10.500 5.100 1. w/ or w/o internal or external fixation Closed treatment of metatarsal fracture Percutaneous skeletal fixation of metatarsal fracture. body.900 5.120 10.200 4. w/ or w/o internal or external fixation Closed treatment of metatarsophalangeal joint dislocation Percutaneous skeletal fixation of metatarsophalangeal joint dislocation. single joint Arthrodesis.540 18. other than talotarsal .920 6.900 5. w/ manipulation Open treatment of metatarsophalangeal joint dislocation.140 8. single Amputation.600 3.700 4.720 8.620 3.300 8.380 22. midtarsal navicular-cuneiform. multiple or transverse.500 5. foot.040 5.540 12.540 10.120 23.500 5.600 12.300 5.880 10.500 5.040 6.120 15. midtarsal or tarsometatarsal. shoulder to hips. other than great toe Open treatment of fracture. phalanx or phalanges.400 5. including head Application of turnbuckle jacket.w/ manipulation Open treatment of tarsal bone dislocation. midtarsal (Chopart type procedure) Deep disection below fascia.400 9. w/ or w/o internal or external fixation Closed treatment of fracture.140 8.400 15. Minerva type Application of body cast. w/ or w/o internal or external fixation Closed treatment of fracture great toe.100 4.500 5.820 8.ANNEX 2. transmetatarsal Amputation. body.540 12.400 4. w/ toe. metatarsophalangeal joint Amputation.240 8.300 23.360 7.960 27.720 2.420 18. w/ manipulation Open treatment of tarsometatarsal joint dislocation.560 Professional Fee 4.600 5. including both thighs Application of body cast.120 8.600 5.000 8.400 9.000 12.600 4.820 12. other than great toe. shoulder to hips.540 10.360 4.400 3. phalanx or phalanges. w/ osteotomy as for flatfoot correction Arthrodesis. w/ or w/o internal or external fixation Pantalar arthrodesis Triple arthrodesis Subtalar arthrodesis Arthrodesis.120 18.500 4. for deep infection of foot.780 7.900 7.540 10.000 10. body.000 10. shoulder to hips.600 12.600 9.260 10.120 10.980 11. shoulder to hips.540 10.540 18.720 4.080 21. great toe.120 27.500 7. interphalangeal joint.620 5.140 8. toe. multiple or transverse. w/ or w/o internal or external fixation Closed treatment of talotarsal joint dislocation Percutaneous skeletal fixation of talotarsal joint dislocation.620 3.260 12. 600 13. elbow.820 20.000 21. surgical. osteochondritis dissecans fragmentation. shoulder.940 2. complete Arthroscopy. diagnostic.940 20.700 10. synovectomy.300 12. shoulder.300 4. debridement.120 Health Care Institution Fee 4. wrist. shoulder.940 20. elbow.400 10.000 29851 27.980 21.900 10. excision and/or repair of triangular fibrocartilage and/or joint debridement Arthroscopy. medial or lateral) Arthroscopy.680 1.600 15.020 8.000 20.080 9. surgical.500 5.520 2. synovectomy. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 29065 29075 29085 29305 29325 29345 29355 29358 29365 29405 29425 29435 29445 29450 29800 29804 29815 29819 29820 29821 29822 29823 29825 29826 29830 29834 29835 29836 29837 29838 29840 29843 29844 29845 29846 29847 29848 29850 DESCRIPTION Application of body cast.940 30.400 9. w/ or w/o coracoacromial release Arthroscopy.900 10.980 18.120 8.520 1.000 29856 29870 29871 29874 29875 29876 29877 29879 27. wrist.300 5.700 12.300 23.440 15.300 12.520 2. proximal (plateau). w/ internal or external fixation (includes arthroscopy) Arthroscopically aided treatment of tibial fracture. debridement. complete Arthroscopy. surgical.000 9.000 9.900 12.740 31.120 15.980 21. surgical. synovectomy.120 12.980 21. shoulder to hips. shoulder. w/ or w/o synovial biopsy Arthroscopy.020 8.300 23.020 8. w/ or w/o synovial biopsy Arthroscopy. Application of long leg cast (thigh to toes). wrist. synovectomy. limited (e. partial Arthroscopy.580 23. wrist. knee.520 2. limited Arthroscopy.700 Page 33 of 98 . partial Arthroscopy.700 5. surgical. elbow.680 5.680 5.300 10.600 12.920 10. elbow to finger (short arm) Application of body cast. synovectomy.560 5.520 2.000 9. temporomandibular joint. shoulder to hips. chondral fragmentation) Arthroscopy. unicondylar. wrist. surgical Arthroscopy. shoulder to hips. debridement.820 23.500 5.300 27.740 27. decompression of subacromial space w/ partial acromioplasty. w/ lysis and resection of adhesions.020 8.020 8.500 5. w/ or w/o synovial biopsy Arthroscopy.000 4.g. walker or ambulatory type Application of long leg cast brace Application of cylinder cast (thigh to ankle) Application of short leg cast (below knee to toes).240 10. temporomandibular joint.920 10. lavage and drainage Arthroscopy. internal fixation for fracture or instability Arthroscopy. major.440 14.980 21.080 10.900 9. w/ or w/o synovial biopsy Arthroscopy. diagnostic.120 Professional Fee 1. elbow.500 4.300 30.500 5. diagnostic. for removal of loose body or foreign body (e. wrist. partial Arthroscopy. surgical.300 17. proximal (plateau).600 6.000 20. w/o internal or external fixation (includes arthroscopy) Arthroscopically aided treatment of intercondylar spine(s) and/or tuberosity fracture(s) of the knee.560 8. surgical.940 2. elbow..980 23.440 8. w/ release of transverse carpal ligament Arthroscopically aided treatment of intercondylar spine(s) and/or tuberosity fracture(s) of the knee.900 10. one and one-half spica or both legs Application of long leg cast (thigh to toes). surgical. surgical. w/ or w/o manipulation.700 10.120 21.720 9.400 12.700 10. knee.700 17. w/ or w/o manipulation Arthroscopy. surgical.680 8.080 10.900 10.600 10.440 8. shoulder.960 18. diagnostic.000 29855 27. synovectomy. w/ removal of loose body or foreign body Arthroscopy.080 12.020 5.080 12.900 10.700 10. elbow.300 15. surgical. bicondylar. synovectomy. walking or ambulatory type Application of patellar tendon bearing (PTB) cast Application of rigid total contact leg cast Application of clubfoot cast w/ molding or manipulation.400 10.ANNEX 2.680 1. Application of short leg cast (below knee to toes). knee.080 10. shoulder.680 18. shoulder.500 5. long or short leg Arthroscopy. knee. surgical.900 10.240 10.920 12.280 12. plica or shelf resection) Arthroscopy.700 17.940 20.400 9.520 2. w/ or w/o manipulation. shoulder to hand (long arm) Application of body cast.960 8. surgical... surgical. synovectomy.700 10.120 12. surgical.120 15. knee. two or more compartments (e.080 8.000 21.500 5.500 5. surgical. surgical. surgical. surgical.900 10.820 20.600 12. complete Arthroscopy. w/ or w/o synovial biopsy Arthroscopy. surgical. surgical. lavage and drainage Arthroscopy.300 23.g. dianostic.260 1.980 23.600 12.240 10.600 10.240 13.900 10. for infection.600 12. one leg Application of hip spica cast.120 18. knee. w/ removal of loose body or foreign body Arthroscopy. debridement. knee. extensive Arthroscopy. surgical.260 2. for infection. abrasion arthroplasty (includes chondroplasty where necessary) or multiple drilling Case Rate 5.600 12. surgical. limited Arthroscopy. shoulder. debridement/shaving of articular cartilage (chondroplasty) Arthroscopy. hand and lower forearm (gauntlet) Application of hip spica cast.g.440 8.500 5. w/ or w/o internal or external fixation (includes arthroscopy) Arthroscopy.940 2. surgical.600 12. extensive Arthroscopy.700 10.000 4. w/ or w/o internal or external fixation (includes arthroscopy) Arthroscopically aided treatment of tibial fracture. wrist. intranasal lesion. radical (Caldwell-Luc) w/o removal of antrochoanal polyps Sinusotomy. .000 6.600 18. surgical. maxillary (antrotomy).400 10.520 6.900 12.520 16. internal approach Drainage abscess or hematoma. knee. tip only Rhinoplasty for nasal deformity secondary to congenital cleft tip and/or palate.120 30.900 10.300 8. w/ or w/o cartilage scoring.820 5. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 29880 29881 29882 29883 29884 29885 29886 29887 29888 29889 29894 29895 29897 29898 30000 30020 30100 30110 30115 30117 30118 30130 30140 30310 30320 30460 30462 30465 30520 30540 30545 30560 30580 30600 30630 30801 30802 30905 30915 30920 30930 31000 31002 31020 31030 31032 31040 31050 31051 31070 DESCRIPTION Arthroscopy.120 12.720 6.200 6.900 4.300 37. surgical. knee.720 6.500 16.120 12.260 1. surgical.300 12.500 13.500 5. superficial Cauterization and/or ablation.700 8. ankle (tibiotalar and fibulotalar joints). nasal polyp(s).400 5. limited Arthroscopy.400 5.740 30.600 15. partial or complete Removal foreign body. w/ meniscectomy (medial or lateral.200 2.100 2.600 6. ankle (tibiotalar and fibulotalar joints). mucosa of turbinates.400 5.120 Professional Fee 13. internal maxillary artery. w/ or w/o biopsy. drilling for osteochondritis dissecans w/ bone grafting. nasal polyp(s). maxillary (antrotomy).120 9.500 5. nasal.520 4.680 2.600 6. unilateral or bilateral. including columellar lengthening. knee.300 23. drilling for intact osteochondritis dissecans lesion Arthroscopy.940 20.160 9.700 9.300 6.800 16. intranasal lesion.240 10.200 4. surgical.700 10.600 5.900 10.500 5.600 12. ankle (tibiotalar and fibulotalar joints).120 12.260 12. sphenoid.020 9. surgical.020 30.700 10.500 10.120 9. knee. intranasal.700 12.200 4.800 6. including any meniscal shaving) Arthroscopy.500 13.980 21.680 8. by lateral rhinotomy Rhinoplasty for nasal deformity secondary to congenital cleft tip and/or palate.300 17. synovectomy.980 20.120 23. radical (Caldwell-Luc) w/ removal of antrochoanal polyps Pterygomaxillary fossa surgery.720 12.000 8. oronasal Repair nasal septal perforations Cauterization and/or ablation.600 4. extensive Drainage abscess or hematoma.200 5.500 5. intranasal Sinusotomy.900 18.440 13.920 1. mucosa of turbinates.520 4. osteotomies Rhinoplasty for nasal vestibular stenosis Septoplasty or submucous resection.300 27.400 5.700 5.360 6. partial Arthroscopy.300 23.560 5.020 12. any method. any method.740 27. nasal septum Biopsy.300 37.000 10. simple Excision.700 18. surgical.ANNEX 2.700 12.720 4.300 4.300 23. partial or complete Submucous resection turbinate.700 9.800 12.260 1.900 5.600 12. maxillary (antrotomy).800 12. w/ meniscus repair (medial or lateral) Arthroscopy. any method (including laser).200 4.180 38. debridement. surgical. surgical.000 5. transantral Fracture nasal turbinate(s). any method.300 6.400 3.800 21. Sinusotomy. debridement.700 18.120 12. surgical.700 10. w/ removal of loose body or foreign body Arthroscopy. sphenoid. knee.400 Page 34 of 98 .900 12. sphenoid sinus Sinusotomy. surgical.300 30.400 5.600 12.720 4.900 8. including columellar lengthening. w/ posterior nasal packs and/or cauterization.120 12. w/ meniscus repair (medial and lateral) Arthroscopy. ankle (tibiotalar and fibulotalar joints). drilling for intact osteochondritis dissecans lesion w/ internal fixation Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction Arthroscopically aided posterior cruciate ligament repair/augmentation or reconstruction Arthroscopy. external. initial Ligation arteries. external approach (lateral rhinotomy) Excision turbinate.700 9. requiring general anesthesia Removal foreign body. surgical.500 5. knee. including any meniscal shaving) Arthroscopy. w/ meniscectomy (medial and lateral. simple (trephine operation) Case Rate 30.500 5. w/ or w/o internal fixation (including debridement of base of lesion) Arthroscopy. w/ or w/o biopsy. posterior. intranasal Excision. intranasal.020 8. oromaxillary (combine w/ 31030 if antrotomy is included) Repair fistula.500 5.300 8. septum.440 15.020 9. intramural Control nasal hemorrhage.600 9.500 5.500 5.700 12. knee. any approach Sinusotomy.700 12. .720 6. w/ or w/o manipulation Arthroscopy.300 2. tip.500 7.600 6. knee. ethmoidal Ligation arteries.500 6. unilateral or bilateral.300 4. w/ lysis of adhesions. therapeutic Lavage by cannulation. maxillary sinus (antrum puncture or natural ostium) Lavage by cannulation.300 23.560 5. w/ mucosal stripping or removal of polyp(s) Sinusotomy frontal. extensive Excision or destruction.080 10. intranasal Repair choanal atresia. contouring or replacement w/ graft Repair choanal atresia. internal approach Excision or destruction. surgical.400 5.120 16.720 Health Care Institution Fee 17. transpalatine Lysis intranasal synechia Repair fistula.200 2.120 23.480 20.860 21.200 6.700 10.700 9.520 2.080 10.300 12. any method (including laser).000 13.720 6. surgical. w/ or w/o tracheoscopy. surgical. surgical.700 10. w/ or w/o tracheoscopy. w/ or w/o tracheoscopy.500 5. w/ radical neck dissection. w/ or w/o tracheoscopy. w/ medial orbital wall and inferior orbital wall decompression Nasal/sinus endoscopy. external approach Epiglottidectomy Intubation. w/ removal of tissue from maxillary sinus Nasal/sinus endoscopy.600 9.720 8. total Maxillectomy. w/o osteoplastic flap. laterovertical Partial laryngectomy (hemilaryngectomy). anterior Ethmoidectomy.500 5.600 9.300 23.700 9.600 9.500 5. intranasal.400 8. surgical.700 5.300 23.120 12.200 29.300 23.600 8.500 5. w/ dilatation. w/ osteoplastic flap. w/ osteoplastic flap.140 31.000 18.400 17.700 10. polypectomy or debridement Nasal/sinus endoscopy.720 6.500 Page 35 of 98 .400 12.600 9. diagnostic w/ sphenoid sinusoscopy (via puncture of sphenoidal face or cannulation of ostium) Nasal/sinus endoscopy.700 0 5.600 9. coronal incision Sinusotomy frontal.500 53. obliterative.400 21. partial (anterior) Nasal/sinus endoscopy. endotracheal.600 9. surgical. w/ osteoplastic flap.000 31.040 6. w/ operating microscope Laryngoscopy direct.500 13.720 12. surgical. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 31075 31080 31081 31084 31085 31086 31087 31090 31200 31201 31205 31225 31230 31231 31233 31235 31237 31238 31239 31240 31254 31255 31256 31267 31276 31287 31288 31290 31291 31292 31293 31294 31300 31360 31365 31367 31368 31370 31375 31380 31382 31390 31395 31400 31420 31500 31515 31520 31525 31526 31527 31528 31529 DESCRIPTION Sinusotomy frontal. horizontal Partial laryngectomy (hemilaryngectomy). total. total Ethmoidectomy.720 25.000 18.400 8. w/ biopsy.400 5.000 23.600 0 2.400 8. surgical.400 8. sphenoid region Nasal/sinus endoscopy. obliterative w/o osteoplastic flap.500 16.400 8.400 5.600 9. unilateral or bilateral Nasal/sinus endoscopy. w/ or w/o tracheoscopy.640 21.000 5.020 8.020 Professional Fee 6.300 12.520 4. surgical. diagnostic. w/ or w/o removal of tissue from frontal sinus Nasal/sinus endoscopy.700 10. transorbital.000 25.140 31.500 5.400 8.640 17.700 13. surgical.500 5.400 5.700 8.500 30. w/ radical neck dissection.000 18. surgical.540 10. brow incision Sinusotomy frontal. surgical.300 18. surgical.520 2.400 5. nonobliterative. nonobliterative.120 12.720 6.000 18. emergency emergency procedure Laryngoscopy direct.600 12. cordectomy Laryngectomy. three or more sinuses Ethmoidectomy.700 18.120 23.200 2.520 4. initial Laryngoscopy direct.200 16.300 24.860 31.120 12.120 18.000 18.140 37. extranasal.800 21. w/ removal of tumor or laryngocele.160 17.540 12.200 2.600 12.640 17.800 37.300 13. surgical. ethmoid region Nasal/sinus endoscopy.500 10.000 18.600 9. Lynch type) Sinusotomy frontal. w/ orbital exenteration (en bloc) Nasal endoscopy. antero-latero-vertical Pharyngolaryngectomy.500 5. w/ optic nerve decompression Laryngotomy (thyrotomy. w/o radical neck dissection Laryngectomy. w/ concha bullosa resection Nasal/sinus endoscopy.180 38. w/o reconstruction Pharyngolaryngectomy.400 5. brow incision Sinusotomy frontal.000 18. w/ insertion of obturator Laryngoscopy direct. unilateral (for mucocele or osteoma. obliterative.720 6.400 5.000 18. w/ or w/o tracheoscopy.720 6.400 5.300 23.140 37. w/ radical neck dissection Laryngectomy.540 10. subtotal supraglottic.120 12.400 5. w/ ethmoidectomy.000 18. subsequent Case Rate 12.120 12. w/ reconstruction Arytenoidectomy or arytenoidopexy. w/ dacrylocystorhinostomy Nasal/sinus endoscopy. w/ repair of cerebrospinal fluid leak.520 Health Care Institution Fee 5. w/ ethmoidectomy. w/ dilatation. newborn Laryngoscopy direct.500 13. for aspiration Laryngoscopy direct.520 2.400 8.720 6. w/ radical neck dissection Partial laryngectomy (hemilaryngectomy). diagnostic.120 46.300 0 8. w/ medial or inferior orbital wall decompression Nasal/sinus endoscopy. w/ or w/o tracheoscopy. coronal incision Sinusotomy combined. obliterative. surgical w/ frontal sinus exploration.700 8.020 8.000 18. except newborn Laryngoscopy direct.020 9.400 8. surgical.800 46.400 8.500 13.120 12.400 8.040 5. diagnostic w/ maxillary sinusoscopy (via inferior meatus or canine fossa puncture) Nasal/sinus endoscopy.400 10. coronal inicision (includes ablation) Sinusotomy frontal.400 8.000 18.ANNEX 2. subtotal supraglottic. brow incision (includes ablation) Sinusotomy frontal.120 12.480 20.400 10.640 17.720 6.040 5. surgical. w/ sphenoidotomy Nasal/sinus endoscopy.800 18.600 9.600 9. w/o radical neck dissection Laryngectomy. anterovertical Partial laryngectomy (hemilaryngectomy).600 13.600 10.140 31.640 21.400 9.500 5. total. intranasal. w/ osteoplastic flap.500 5. w/ removal of tissure from the sphenoid sinus Nasal/sinus endoscopy.800 12. laryngofissure). diagnostic.600 9.600 6.000 18. w/ maxillary antrostomy Nasal/sinus endoscopy. w/ control of epistaxis Nasal/sinus endoscopy.500 16. total (anterior and posterior) Nasal/sinus endoscopy. diagnostic.600 12. w/o orbital exenteration Maxillectomy.720 6.020 9. 400 33. w/ placement of catheters for intracavitary radioelement application Bronchoscopy. direct.300 12. intrathoracic Carinal reconstruction Bronchoplasty.120 12. w/ graft or core mold.500 13. therapeutic. operative.800 16. w/ arytenoidectomy.400 5. operative.140 12.500 13.960 10.700 5.000 55. w/ closed manipulative reduction Laryngoplasty.600 13.120 30. w/ tracheal or bronchial dilation or closed reduction of fracture Bronchoscopy.400 8.120 12.g. for burns. for laryngeal web.400 5.300 30. tracheopharyngeal fistulization. w/ biopsy.400 13.120 12. diagnostic.120 12.460 5. transtracheal Tracheostomy.400 2. w/ foreign body removal.120 10. cervical Case Rate 12.400 12. complex. cricoid split Laryngoplasty.500 13.000 55.720 6. voice button. (e.700 Page 36 of 98 .500 9.600 25. cervical Excision of tracheal tumor or carcinoma.400 5..120 12. w/ biopsy Laryngoscopy. Blom-Singer prosthesis) Tracheal puncture.800 21. flexible or rigid fiberoptic.720 6.720 16.000 46.720 6.800 53.600 6.720 6.460 5. w/ or w/o fluoroscopic guidance Bronchoscopy. operative.400 5.300 6.800 6.300 30. w/ operating microscope Laryngoscopy.w/ placement of bronchial stents Bronchoscopy.300 30.800 16.300 30.800 16. w/o flap rotation Tracheostoma revision.000 18.400 21. laser) Bronchoscopy.500 5.560 6.600 33.g. simple.700 4.g. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 31530 31531 31535 31536 31540 31541 31560 31561 31570 31571 31575 31576 31577 31578 31579 31580 31582 31584 31586 31587 31588 31590 31595 31600 31601 31603 31605 31610 31611 31612 31613 31614 31615 31622 31625 31628 31629 31630 31631 31635 31636 31640 31641 31643 31645 31710 31717 31750 31755 31760 31766 31770 31775 31780 31781 31785 31786 31800 DESCRIPTION Laryngoscopy. w/ destruction of tumor or relief of stenosis by any method other than excision (e.720 7.800 55. flexible fiberoptic. cervical Excision tracheal stenosis and anastomosis.120 12.460 8.300 Professional Fee 6.400 5.000 29.500 13.400 21.120 12.720 6.720 6.960 10.720 7.600 9.760 7.800 37.000 18. w/ excision of tumor and/or stripping of vocal cords or epiglottis. w/ flap rotation Tracheobronchoscopy through established tracheostomy incision Bronchoscopy. Laryngoscopy.500 53. flexible fiberoptic. direct. diagnostic Laryngoscopy. therapeutic.400 5.400 8.400 5.000 23.400 37.300 30.540 7. w/ or w/o instillation of contrast material Catheterization w/ bronchial brush biopsy Tracheoplasty. Laryngoscopy.800 16.540 14. under two years Tracheostomy.540 12.600 9. w/ biopsy Bronchoscopy.120 14.720 5.960 12.500 13.560 23.400 16.800 12.900 12. graft repair Bronchoplasty.300 23.720 6.800 16.500 13.120 30. w/ transbronchial needle aspiration biopsy Bronchoscopy.500 5.ANNEX 2.720 6.300 24. operative.960 10. w/ excision of tumor and/or stripping of vocal cords or epiglottis. w/ tracheal dilation and placement of tracheal stent Bronchoscopy.000 23. operative.400 7.960 12. emergency procedure.. w/ operating microscope Laryngoscopy. planned .400 5. flexible fiberoptic. w/ transbronchial lung biopsy. cricothyroid membrane Tracheostomy.400 21. fenestration procedure with skin flaps Construction of tracheoesophageal fistula and subsequent insertion of an alaryngeal speech prosthesis (e. operative.000 30. w/ removal of lesion Laryngoscopy. direct.720 6.700 16. operative.400 55. w/ open reduction of fracture Laryngoplasty.500 9. w/ therapeutic aspiration of tracheobronchial tree.120 12. Tracheostomy. (flexible or rigid).000 16.500 13.400 10..720 6.300 5.120 12.400 8.400 5. w/ excision of tumor Bronchoscopy. thoracic Suture of tracheal wound or injury.560 6. not otherwise specified (e. w/ biopsy. w/ foreign body removal.800 16. for laryngeal stenosis.140 7.720 16. planned .300 30.600 12. w/ injection into vocal cord(s).500 10.120 12. direct.300 10.800 16. w/ stroboscopy Laryngoplasty.000 21.600 Health Care Institution Fee 5. therapeutic .600 5. emergency procedure.800 8. Laryngoscopy.720 6.400 5.460 5.. cervicothoracic Excision of tracheal tumor or carcinoma.300 30.400 7.400 6.140 4.120 12. (flexible or rigid). w/ keel insertion and removal Laryngoplasty. w/ operating microscope Laryngoscopy.600 9. two stage.300 37.300 12. w/ removal of foreign body Bronchoscopy. direct.600 10.600 21.380 5.400 21.300 30.400 5.120 12.800 16. reconstruction after partial laryngectomy) Laryngeal reinnervation by neuromuscular pedicle Section recurrent laryngeal nerve. direct.500 13.260 12. cervical Tracheoplasty.000 18.300 18.400 13. diagnostic. including tracheotomy Laryngoplasty. w/ operating microscope Laryngoscopy.140 7. Laryngoscopy. w/ operating microscope Laryngoscopy. drainage of lung abscess) Catheterization for bronchography.800 16.600 33.500 5.000 33.000 21.400 5. excision stenosis and anastomosis Excision tracheal stenosis and anastomosis. w/ arytenoidectomy. direct. w/ injection into vocal cord(s). w/ or w/o cell washing or brushing Bronchoscopy.500 5. flexible fiberoptic. each stage Tracheoplasty.400 5. unilateral Tracheostomy. percutaneous w/ transtracheal aspiration and/or injection Tracheostoma revision.600 1.800 24. direct. direct. Laryngoscopy. operative.960 18.400 5.g. direct.400 5. w/ removal of foreign body Laryngoscopy.200 29. 000 24. w/o biopsy Thoracoscopy. extrapleural Removal of lung. for pneumothorax) Chemical pleurodesis (e.940 4.740 16.700 5.800 21.720 6. w/o biopsy Thoracoscopy.980 12.720 6.480 2.980 12.500 16.360 16. surgical.800 5.720 6.g. w/ rib resection for empyema Thoracostomy. w/ open intrapleural pneumonolysis Thoracotomy. percutaneous needle Biopsy.840 19. for recurrent or persistent pneumothorax) Tube thoracostomy w/ or w/o water seal (e.. pericardial sac. single lobe (lobectomy) Removal of lung.500 5. mediastinal space.700 6.440 5. major. limited.400 19. major. diagnostic .400 5. major.620 21.500 4.160 38.300 37.800 21.300 21.120 12.740 19.200 31.000 21.400 29. all remaining lung following previous removal of a portion of lung (completion pneumonectomy) Removal of lung.000 18.440 38.260 18.000 21. w/ cardiac massage Pneumonostomy.800 16.400 24.600 13.200 840 5.800 32500 32520 32522 32525 32540 32601 32602 32603 32604 32605 32606 32650 32651 32652 32653 40. w/ removal of intrapleural foreign body or firbin deposit Case Rate 37. major.800 18.. total Decortication.120 12. w/ open drainage of abscess or cyst Pleural scarification for repeat pneumothorax Decortication. surgical.400 38.400 53. w/ biopsy Thoracoscopy.000 21.120 18. intrathoracic Surgical closure tracheostomy or fistula w/o plastic repair Surgical closure tracheostomy or fistula with plastic repair Thoracentesis.080 Professional Fee 21.740 4. pulmonary .080 31.800 16. any method Thoracoscopy. pleura. pulmonary . open Biopsy.400 5.440 38.800 4.200 25. w/ resection of chest wall Resection of lung. w/ total pulmonary decortication.700 18.420 31. other than total pneumonectomy. surgical. w/ exploration and biopsy Thoracotomy.140 37.000 24.700 13.120 12.560 37.120 12.720 8.360 25.500 5. puncture of lung for aspiration Removal of lung.540 7.000 1. hemothorax. single segment (segmentectomy) Removal of lung.560 46. excision-plication of emphysematous lung(s) (bullous or non-bullous) for lung volumeRemoval of lung. w/ or w/o a pleural procedure Thoracotomy.400 5.300 21. w/o biopsy Thoracoscopy. reduction. other than total pneumonectomy. w/ biopsy Thoracoscopy.120 38. two lobes (bilobectomy) Removal of lung.000 32491 41.300 24. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 31805 31820 31825 32000 32002 32005 32020 32035 32036 32095 32100 32110 32120 32124 32140 32141 32150 32151 32160 32200 32215 32220 32225 32310 32320 32400 32402 32405 32420 32440 32442 32445 32480 32482 32484 32486 DESCRIPTION Suture of tracheal wound or injury.400 Page 37 of 98 . other than total pneumonectomy.400 53. w/ prosthesis Extrapleural enucleation of empyema (empyemectomy) Thoracoscopy.900 12.400 5. puncture of pleural cavity for aspiration. mediastinal space.ANNEX 2.400 9.720 6. w/ excision-plication of bullae.400 5. major. MAJOR. initial or subsequent Thoracentesis w/ insertion of tube w/ or w/o water seal (e. w/ major reconstruction of chest wall. w/ or w/o a pleural procedure Thoracotomy.g.200 31.800 8. w/ pleurodesis. diagnostic .720 16. partial Pleurectomy. pleura.800 16.320 6. w/ removal of intrapulmonary foreign body THORACOTOMY.120 12. w/ partial pulmonary decortication Thoracoscopy. for abscess.000 16.700 1. other than total pneumonectomy.800 16.700 5.500 2.320 53.120 23.080 41.400 5.000 32488 53.040 5.800 5.500 420 5.800 41.080 Health Care Institution Fee 16. w/ resection of segment of trachea followed by bronchotracheal anastomosis (sleeve pneumonectomy) Removal of lung.g.000 21. for postoperative complications Thoracotomy. diagnostic .800 18.440 11.000 21. major.880 6.120 12.400 5.800 37.820 17.300 24. other than total pneumonectomy. w/ reconstruction of chest wall. including intrapleural pneumonolysis Thoracoscopy.300 18.800 37.500 55. major.400 29.400 29.000 24. diagnostic .720 6.000 2.740 5.000 24. w/o prothesis Resection of lung. w/ biopsy Thoracoscopy. parietal Decortication and parietal pleurectomy Biopsy. lungs and pleural space.800 37. pericardial sac. w/ removal of intrapleural foreign body or fibrin deposit Thoracotomy.500 55.360 19.080 24.500 16. major. other than total pneumonectomy.540 10.160 46.260 25.440 30. percutaneous needle Pneumonocentesis. diagnostic . for biopsy of lung or pleura Thoracotomy. diagnostic .720 6.640 21.080 55.. single or multiple Resection of lung.260 10.440 9.100 6. w/ control of traumatic hemorrhage and/or repair of lung tear Thoracotomy. other than total pneumonectomy. w/ open flap drainage for empyema Thoracotomy.180 8. w/ cyst(s) removal. lungs and pleural space. empyema) Thoracostomy.040 5.520 29.800 24.800 37.300 6.700 18.740 19. lung or mediastinum.800 16. surgical.500 46.440 10.660 5.160 24.720 6. w/ circumferential resection of segment of bronchus followed by broncho-bronchial anastomosis (sleeve lobectomy) Removal of lung.500 16. other than total pneumonectomy. total pneumonectomy Removal of lung.120 12. w/ or w/o any pleural procedure Removal of lung.800 37. sternal split or transthoracic approach.940 1.800 16. wedge resection.600 5.640 38. insertion of new lead.200 37.800 24.400 21.900 5. extraperiosteal.400 9. w/ control of traumatic hemorrhage Thoracoscopy.900 Professional Fee 16.300 Health Care Institution Fee 13.700 10.500 41. w/ esophagomyotomy (Heller type) Repair lung hernia through chest wall Closure of chest wall following open flap drainage for empyema (Clagett type procedure) Open closure of major bronchial fistula Major reconstruction.600 Page 38 of 98 . w/o cardiopulmonary bypass Lung transplant. w/ excision of pericardial cyst. Schede type or extrapleural (all stages). tumor.700 9.800 21. Schede type or extrapleural (all stages).520 44.800 21. double (bilateral sequential or en bloc).800 21.700 25. atrial and ventricular Insertion or placement of temporary transvenous single chamber cardiac electrodes Insertion or replacement of temporary transvenous dual chamber cardiac electrodes Insertion or replacement of pacemaker pulse generator only.360 24. including any pleural procedure Thoracoscopy.500 6.700 9.160 46.200 4.800 10.900 23.840 21. single.300 6.000 43. total or segmental Thoracoscopy.600 12. w/ excision of mediastinal cyst.560 8.300 21.400 10.600 17.300 5.900 39.800 37. Thoracoplasty.160 41. single.200 4. subtotal or complete. resection w/ cardiopulmonary bypass Resection of external cardiac tumor Insertion of permanent pacemaker w/ epicardial electrode(s). surgical. surgical.800 10. w/ removal of clot or foreign body from pericardial sac Thoracoscopy.400 18.520 46. atrial or ventricular Insertion. surgical.300 21.400 9. surgical.360 21.500 16.000 16. replacement or repositioning of permanent transvenous electrode(s) only (15 days or more after initial insertion).200 25. subtotal or complete.680 65. extrapleural.800 16.000 46.000 21.160 41.700 18.840 21.200 25.300 16. tumor.000 8.200 33.100 10.200 24.300 21.400 14.000 21.500 30.900 6. atrial Insertion or replacement of permanent pacemaker w/ transvenous electrode(s).500 4.500 9. w/ excision-plication of bullae.640 38. surgical.300 33216 12.800 16.800 60.000 32. surgical.500 46.000 64.900 9. w/ thoracic sympathectomy Thoracoscopy.600 25.000 14.000 39.520 25. w/o cardiopulmonary bypass Pericardiectomy.600 10.300 41. ventricular Insertion or replacement of permanent pacemaker w/ transvenous electrode(s).300 23.520 65.200 16.600 33217 18.800 16.300 13. all stages Thoracoplasty.160 38. surgical. including filling or packing procedures Pneumothorax.300 21.700 21.500 58.800 1.700 17.520 4. conversion of single chamber system to dual chamber system (includes removal of previously placed pulse generator.840 24.500 5. w/ closure of bronchial fistula Pneumonolysis.800 16.300 46.700 12.500 46.300 21.800 16. surgical.160 41.160 23.500 5.400 8. w/ cardiopulmonary bypass Excision of pericardial cyst or tumor Excision of intracardiac tumor. intrapleural injection of air Pericardiocentesis Tube pericardiostomy Pericardiotomy for removal of clot or foreign body (primary procedure) Creation of pericardial window or partial resection for drainage Pericardiectomy.000 21.000 18.200 25. replacement or repositioning of permanent transvenous electrode(s) only (15 days or more after initial insertion).200 6. testing of existing lead. w/ total pericardiectomy Thoracoscopy. w/ creation of percardial window or partial resection of pericardial sac for drainage Thoracoscopy.360 25. or mass Thoracoscopy.300 21.500 55.800 16.000 21. w/ lobectomy.800 16. w/ cardiopulmonary bypass Resection of ribs.500 10. by xiphoid approach Insertion or replacement of permanent pacemaker w/ transvenous electrode(s). single chamber Insertion or replacement of pacemaker pulse generator only. or mass Thoracoscopy.900 21.200 8.500 46. surgical.600 42.000 16.000 21.640 38.360 24. w/ cardiopulmonary bypass Lung transplant.ANNEX 2.640 41.000 63.600 9.500 8.260 2. double (bilateral sequential or en bloc). dual chamber Upgrade of implanted pacemaker system. w/ parietal pleurectomy Thoracoscopy. insertion of new pulse generator) Insertion.360 12. w/o cardiopulmonary bypass Lung transplant.500 4.500 5. surgical. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 32654 32655 32656 32658 32659 32660 32661 32662 32663 32664 32665 32800 32810 32815 32820 32850 32851 32852 32853 32854 32900 32905 32906 32940 32960 33010 33015 33020 33025 33030 33031 33050 33120 33130 33200 33201 33206 33207 33208 33210 33211 33212 33213 DESCRIPTION Thoracoscopy.020 9. by thoracotomy Insertion of permanent pacemaker w/ epicardial electrode(s).400 21. single chamber. surgical.360 24.600 33214 32. dual chamber Case Rate 30.300 5.900 10.680 44. therapeutic. chest wall (posttraumatic) Donor pneumonectomy(ies) w/ preparation and maintenance of allograft (cadaver) Lung transplant. 000 21. aortic valve.000 63. single lead system.000 13.000 30.600 18.400 16. A-V node reentry). open.900 21.800 6.300 58. w/ insertion of cardio-defibrillator pulse generator Operative ablation of supraventicular arrhythmogenic focus or pathway (e.400 25. w/ aortic annulus enlargement. atrial or ventricular Removal of permanent of transvenous pacemaker electrode(s).200 37.000 24. Wolff-Parkinson-White.600 6. dual lead chamber Removal of permanent transvenous electrode(s) by thoracotomy Insertion or replacement of implantable cardioverter-defibrillator pulse generator Removal of implantable cardioverter-defibrillator pulse generator Removal of implantable cardioverter-defibrillator pulse generator and/or lead system.600 13.800 16.800 37.400 9. w/o shunt or cardiopulmonary bypass Suture repair of aorta or great vessels.800 58.700 10.000 21. aorta or great vessels.800 37. aortic valve. w/ prosthetic valve other than homograft Replacement. aortic valve.800 55.300 12.400 8.600 8.. Wolff-Parkinson-White.800 25. w/o shunt.000 53. or cardiopulmonary bypass Insertion of graft. w/ cardiopulmonary bypass Valvuloplasty.600 14. open. tract(s) and/or focus (foci). exploratory (includes removal of foreign body). by transvenous extraction Implantation or replacement of implantable cardioverter-defibrillator pads by thoracotomy.400 33.800 33.400 58. exploratory (includes removal of foreign body).200 24. w/ cardiopulmonary bypass Operative incisions and reconstruction of atria for treatment of atrial fibrillation or atrial flutter (e.700 16.900 23. w/ insertion of implantable cardioverter-defibrillator pulse generator Implantation or replacement of implantable cardioverter-defibrillator pads by thoracotomy.600 10.600 37.500 58.400 Professional Fee 12.000 21.000 30.400 53. w/o bypass Cardiotomy.800 46.. maze procedure) Operative ablation of ventricular arrhythmogenic focus w/ cardiopulmonary bypass Repair of cardiac wound.300 18.000 58. permanent pacemaker or dual chamber pacing cardioverter-defibrillator Revision or relocation of skin pocket for pacemaker Revision or relocation of skin pocket for single or dual chamber pacing cardioverter-defibrillator Removal of transvenous pacemaker pulse generator Removal of permanent of transvenous pacemaker electrode(s). w/ translocation of autologous pulmonary valve w/ hemograft repacement of pulmonary valve (Ross procedure) Repair of left ventricular outflow tract obtruction by patch enlargement of the outflow tract Case Rate 23. single lead system.500 13.800 25. aortic valve. aorta or great vessels. dual lead chamber Removal of permanent epicardial pacemaker and electrodes by thoracotomy. using transventricular dilation.000 42.800 46.300 12.000 21.000 29.300 10. by thoracotomy Removal of implantable cardioverter-defibrillator pulse generator and/or lead system.000 18.300 23. w/ homograft valve (freehand) Replacement.800 25.000 58.700 33251 33253 33261 33300 33305 33310 33315 33320 33321 33322 33330 33332 33335 33400 33401 33403 33404 33405 33406 33411 33412 33413 33414 53. aortic valve.700 9. A-V node reentry).400 29.700 13.800 46.500 21.600 33250 37. w/ cardiopulmonary bypass Suture repair of aorta or great vessels.400 55.700 17.900 33249 18.800 8.300 13.400 37.000 21. aortic valve. permanent pacemaker or single chamber pacing cardioverter-defibrillator Repair of two transvenous electrode for a dual chamber.800 53. aortic valve.800 30.000 8.600 37.000 21.500 29.g.000 21.ANNEX 2.800 71.500 58.400 21.400 8. atrial or ventricular Removal of permanent epicardial pacemaker and electrodes by thoracotomy.000 12.200 42. w/ cardiopulmonary bypass Insertion of graft. noncoronary cusp Replacement.300 32.000 21.000 24.300 Page 39 of 98 .000 21.600 10.g.400 21.000 21.000 21.900 16.800 18. w/ transventricular aortic annulus enlargement (Konno procedure) Replacement.600 30.000 21. w/o bypass Repair of cardiac wound.000 18..800 16. w/ cardiopulmonary bypass Cardiotomy.500 Health Care Institution Fee 10.300 30.400 37.200 37.400 58. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 33218 33220 33222 33223 33233 33234 33235 33236 33237 33238 33240 33241 33243 33244 33245 33246 DESCRIPTION Repair of single transvenous electrode for a single chamber.400 46. w/ cardiopulmonary bypass. aortic valve.300 21.300 21. w/ cardiopulmonary bypass Valvuloplasty.600 9.500 63. w/ inflow occlusion Valvuloplasty.300 37. Implantation or replacement of implantable cardioverter-defibrillator pads by thoracotomy.g.500 6.300 18.800 37.500 9.000 24.600 9.600 12. w/ cardiopulmonary bypass Construction of apica-aortic conduit Replacement. tract(s) and/or focus (foci).800 58. w/ shunt bypass Insertion of graft.800 29.300 21.800 50. w/ or w/o sensing electrodes.500 18. w/ shunt bypass Suture repair of aorta or great vessels. w/ cardiopulmonary bypass. w/o cardiopulmonary bypass Operative ablation of supraventicular arrhythmogenic focus or pathway (e.400 6. aorta or great vessels.900 18. 800 42. mitral valve. using arterial graft(s). five venous grafts (list separately in addition to code for arterial graft) Coronary artery bypass.400 55.800 53.800 37. using arterial graft(s). w/ cardiopulmonary bypass Valvuloplasty.500 53. vein only.300 21.200 25.800 46. tricuspid valve. mitral valve.000 58.300 24.400 58.800 25.500 10.500 46.600 37.400 Professional Fee 25. two coronary arterial grafts Coronary artery bypass. closed heart.800 21.600 25. by translocation from pulmonary artery to aorta Coronary artery bypass.800 21.400 46.000 21. mitral valve. vein only.800 24.400 24. Valvuloplasty. asymmetric septal hypertrophy) Aortoplasty (gusset) for supravalvular stenosis Valvotomy. five coronary venous grafts Coronary artery bypass.200 33. w/ cardiopulmonary bypass.000 21. asymmetric septal hypertrophy) Ventriculomyotomy (-myectomy) for idiopathic hypertrophic subaortic stenosis (e.300 24.400 53.800 16.000 24. w/ cardiopulmonary bypass Valvuloplasty.400 53.600 21.400 21. w/o cardiopulmonary bypass Repair of anomalous coronary artery.g.000 Page 40 of 98 .000 29.400 33.400 55. mitral valve.000 58. three coronary venous grafts Coronary artery bypass.000 21.000 24.500 13.ANNEX 2.400 46. pulmonary valve. w/ cardiopulmonary bypass Replacement. closed heart Valvotomy.200 29.800 58. w/ or w/o commissurotomy or infundibular resection Repair of coronary arteriovenous or arteriocardiac chamber fistula. coronary artery bypass procedure or valve procedure. with or without commisurotomy Outflow tract augmentation (gusset).800 30. single arterial graft Coronary artery bypass.400 21. using venous graft(s) and arterial graft(s). w/o ring insertion Valvuloplasty..800 37. using venous graft(s) and arterial graft(s).400 29.400 55.000 21.500 46.400 33521 58.800 53. six or more venous grafts (list separately in addition to code for arterial graft) Reoperation.000 33.200 16.000 24. four or more coronary arterial grafts Myocardial resection (e.400 53.700 37.400 Health Care Institution Fee 21.g.000 57.400 55. four venous grafts (list separately in addition to code for arterial graft) Coronary artery bypass.. tricuspid valve. pulmonary valve.300 24. six or more coronary venous grafts Coronary artery bypass. tricuspid valve. via pulmonary artery Valvotomy. vein only.600 25.000 42.400 25.000 33523 58. by graft.000 21.000 13.000 24.500 55. using arterial graft(s). by ligation Repair of anomalous coronary artery. transventricular Valvotomy.400 29.g.000 24.400 33. w/ cardiopulmonary bypass Repair of anomalous coronary artery. vein only. single vein graft (list separately in addition to code for arterial graft) Coronary artery bypass.200 29.400 21.300 21.000 33522 58.400 33.800 63. two venous grafts (list separately in addition to code for arterial graft) Coronary artery bypass. three venous grafts (list separately in addition to code for arterial graft) Coronary artery bypass.400 29. open heart.300 13. using venous graft(s) and arterial graft(s). w/ ring insertion Replacement.400 33.500 30.400 29. more than one month after original operation (list separately in addition to code for primary procedure) Coronary artery bypass.100 58. tricuspid valve.800 12.000 33530 33533 33534 33535 33536 33542 63.000 29. three coronary arterial grafts Coronary artery bypass. single coronary venous graft Coronary artery bypass.500 21. mitral valve.700 21.000 21.800 37.400 29.000 33518 53. mitral valve.300 16.800 37. radical reconstruction.800 58.200 29. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 33415 33416 33417 33420 33422 33425 33426 33427 33430 33460 33463 33464 33465 33468 33470 33471 33472 33474 33475 33476 33478 33500 33501 33502 33503 33504 33505 33506 33510 33511 33512 33513 33514 33516 33517 DESCRIPTION Resection or incision of subvalvular tissue for discrete subaortic stenosis (e.500 53.500 53. pulmonary valve.000 53.000 24.000 21.000 24.300 23. using arterial graft(s).300 46. four coronary venous grafts Coronary artery bypass. using venous graft(s) and arterial graft(s).600 37.000 21.000 21. w/ inflow occlusion Valvotomy.400 21.. using venous graft(s) and arterial graft(s). pulmonary valve.400 29. w/ prosthetic ring Valvuloplasty.400 37. w/ cardiopulmonary bypass Repair of coronary arteriovenous or arteriocardiac chamber fistula.000 33519 55. closed heart.300 21.800 16. vein only. vein only.200 29. open heart.200 25. w/o cardiopulmonary bypass Repair of anomalous coronary artery. open heart.800 29. ventricular aneurysmectomy) Case Rate 46.400 21. pulmonary valve Right ventricular resection for infundibular stenosis. w/ cardiopulmonary bypass. using venous graft(s) and arterial graft(s).000 46.000 53. two coronary venous grafts Coronary artery bypass.600 29.400 24. by graft.400 53.600 35. w/ cardiopulmonary bypass Valvectomy.300 24.300 46.000 21.800 25. with construction of intrapulmonary artery tunnel (Takeuchi procedure) Repair of anomalous coronary artery.500 53.000 21.000 21.800 37.400 25. w/ or w/o ring Replacement.500 37.300 30.800 21. w/ cardiopulmonary bypass Tricuspid valve repositioning and plication for Ebstein anomaly Valvotomy.400 53. w/ cardiopulmonary bypass.200 21. 600 33.000 55.200 5.600 33. w/ or w/o patch Direct or patch closure.400 29. of left anterior descending.400 21.ANNEX 2.000 Professional Fee 42.600 33. w/ or w/o atrioventricular valve repair Repair of complete atrioventricular canal. with cardiopulmonary bypass Closure of aortico-left ventricular tunnel Complete repair of anomalous venous return (supracardiac.000 55.400 10.200 33.600 33.300 21. w/ or w/o anomalous pulmonary venous drainage Repair of atrial septal defect and ventricular septal defect.700 13.400 33.g. circumflex.400 33. w/ or w/o gusset Banding of pulmonary artery Complete repair of tetralogy of Fallot w/o pulmonary atresia.200 37.400 55.600 33.000 63.000 55. single ventricle) by modified Fontan procedure Repair of single ventricle w/ aortic outflow obstruction and aortic arch hypoplasia (hypoplastic left heart syndrome) (e.500 33.200 25.600 33.400 33.600 25.600 33. open heart w/ inflow occlusion Shunt. w/o surgical enlargement of ventricular septal defect Case Rate 63.200 29.400 21.000 24.400 33610 33611 33612 33615 33617 33619 33641 33645 33647 33660 33665 33670 33681 33684 33688 33690 33692 33694 33697 33702 33710 33720 33722 33730 33732 33735 33736 33737 33750 33764 33766 33767 33770 55.000 55.. open heart w/ cardiopulmonary bypass Atrial septectomy or septostomy.000 21..200 29.g.400 46. w/ or w/o myocardial resection Coronary endarterectomy.300 21. secundum.000 Health Care Institution Fee 21.400 21.600 33.400 21.400 55.000 33572 9.500 30.000 21.500 55.600 33. w/ direct or patch closure Repair of incomplete or partial atrioventricular canal (ostium primum atrial septal defect). intracardiac.500 25. w/ prosthetic graft Shunt.400 21.800 21.400 10.000 55.000 55.300 30.000 46. with transannular patch Complete repair of tetralogy of Fallot w/ pulmonary atresia including construction of conduit right ventricle to pulmonary artery and closure of ventricular septal defect Repair sinus of Valsalva fistula.000 21. single ventricle with subaortic obstruction) by surgical enlargement of interventricular septal defect Repair of double outlet right ventricle with intraventricular tunnel repair Repair of double outlet right ventricle with intraventricular tunnel repair with repair of right ventricular outflow tract obstruction Repair of complex cardiac anomalies (e.200 16.000 46.400 21.300 13.700 4.400 55.400 21.800 25. or infracardiac types) Repair of cor triatum or supravalvular mitra ring by resection of left atrial membrane Atrial septectomy or septostomy. superior vena cava to pulmonary artery for flow to both lungs (bidirectional Glenn procedure) Repair of transposition of great arteries w/ ventricular septal defect and subpulmonary stenosis.300 24.000 58.900 21.300 21.500 58. sinus venosus. with pulmonary valvotomy or infundibular resection (acyanotic) Closure of ventricular septal defect.600 29. w/ or w/o atrioventricular valve repair Repair of intermediate or transitional atrioventricular canal.g.800 12.800 25.000 55.500 33600 33602 33606 33608 46. Norwood procedure) Repair atrial septal defect.000 21.400 21.600 37.500 55.000 25. w/ cardiopulmonary bypass.000 55.500 46.600 16.500 21.400 21.600 33. open. w/ or w/o patch. subclavian to pulmonary artery (Blalock. superior vena cava to pulmonary artery for flow to one lung (classical Glenn procedure) Shunt. any method.g. w/ or w/o prosthetic valve Closure of ventricular septal defect.200 33. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 33545 DESCRIPTION Repair of postinfarction ventricular septal defect. or right coronary artery performed in conjuction w/ coronary artery bypass graft procedure.400 55. tricuspid atresia) by closure of atrial septal defect and anastomosis of atria or vena cava to pulmonary artery (simple Fontan procedure) Repair of complex cardiac anomalies (e.600 10. w/ or w/o patch.Taussig type operation) Shunt.200 25.400 53.400 24.400 21.000 53.600 21.500 10.500 53.600 10.900 21.000 25.000 55. central...000 Page 41 of 98 . Complete repair of tetralogy of Fallot w/o pulmonary atresia.500 53. with repair of ventricular septal defect Repair sinus of Valsalva aneurysm.300 24.400 21.400 21. with removal of pulmonary artery band.300 23. closed heart (Blalock-Hanlon type operation) Atrial septectomy or septostomy.000 21.800 33.000 21. each vessel (list separately in addition to primary procedure) Closure of atrioventricular valve (mitral or tricuspid) by suture or patch Closure of semilunar valve (aortic or pulmonary) by suture or patch Anastomosis of pulmonary artery to aorta (Damus-Kaye-Stansel procedure) Repair of complex cardiac anomaly other than pulmonary atresia with ventricular septal defect by construction or replacemnet of conduit from right or left ventricle to pulmonary artery Repair of complex cardiac anomalies (e.000 21.300 21. w/ cardiopulmonary bypass Repair sinus of Valsalva fistula. w/ or w/o patch.400 21.800 46. Closure of ventricular septal defect.600 42.000 55.300 46.500 46.300 21. 400 30.600 46.000 50.000 21. aortic pulmonary artery reconstruction (e. w/ cardiopulmonary bypass Repair of pulmonary artery stenosis by reconstruction w/ patch or graft Repair of pulmonary atresia w/ ventricular septal defect. w/ or w/o associated patent ductus arteriosus.600 21. aortic pulmonary artery reconstruction (e. truncus arteriosus (Rastelli type operation) Reimplantation of an anomalous pulmonary artery Aortic suspension (aortopexy) for tracheal decompression (e.300 9.300 46.900 60.400 10.400 71. w/ cardiopulmonary bypass.400 29.300 17. for tracheomalacia) Division of aberrant vessel (vascular ring) Division of aberrant vessel (vascular ring) w/ reanastomosis Division of aberrant vessel (vascular ring) w/ cardiopulmonary bypass Repair of patent ductus arteriosus.400 21.800 33..900 60..900 39.400 53.000 21. w/ cardiopulmonary bypass Pulmonary artery embolectomy. w/ direct anastomosis Excision of coarctation of aorta.300 13.000 21. by construction or replacement of conduit from right or left ventricle to pulmonary artery Transection of pulmonary artery w/ cardiopulmonary bypass Ligation and takedown of a systemic-to-pulmonary artery shunt.300 30.g.800 60.800 58.g. with surgical enlagement of ventricular septal defect Repair of transposition of the great arteries.100 71.600 25.400 16.500 24. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 33771 33774 33775 33776 33777 33778 33779 33780 DESCRIPTION Repair of transposition of great arteries w/ ventricular septal defect and subpulmonary stenosis.400 21.000 21. by unifocalization of pulmonary arteries. Jatene type) w/ removal of pulmonary band Repair of transposition of the great arteries.500 32.600 50.700 21.800 29. by division.000 Page 42 of 98 . w/ preparation and maintenance of allograft Heart transplant.000 21.400 37.500 13.000 46.500 21.g.400 46.400 58.900 10.400 50.300 46.900 39. Ascending aorta graft. Mustard or Senning type) w/ cardiopulmonary bypass Repair of transposition of the great arteries.500 10.800 50. w/ cardiopulmonary bypass Repair of pulmonary atresia w/ ventricular septal defect.800 25.300 53. aortic pulmonary artery reconstruction (e.g.300 30.500 13. Mustard or Senning type) w/ removal of pulmonary band Repair of transposition of the great arteries.000 21. w/ or w/o recipient cardiectomy Case Rate 58.300 21.400 23..000 65.000 71.900 63.500 75. w/ or w/o bypass Repair of thoracoabdominal aortic aneurysm w/ graft.400 63.400 42.000 58.000 21.200 14.500 58.200 33.200 37.000 21.000 21. w/ cardiopulmonary bypass Descending thoracic aorta graft.000 33781 33786 33788 33800 33802 33803 33814 33820 33822 33824 33840 33845 33851 33852 33853 33860 33861 33863 33870 33875 33877 33910 33915 33916 33917 33918 33919 33920 33922 33924 33930 33935 33940 33945 71.g. w/ or w/o cardiopulmonary bypass Pulmonary artery embolectomy. w/ preparation and maintenance of allograft Heart-lung transplant w/ recipient cardiectomy-pneumonectomy Donor cardiectomy.. Jatene type) w/ closure of ventricular septal defect Repair of transposition of the great arteries. performed in conjuction w/ a congenital heart procedure (List separately in addition to code for primary procedure) Donor cardiectomy-pneumonectomy.800 25.800 16. w/ or w/o associated patent ductus arteriosus.300 21. under 18 years Repair of patent ductus arteriosus. 18 years and older Excision of coarctation of aorta.400 Health Care Institution Fee 21.200 16.200 54.000 30.000 44.g. w/ cardiopulmonary bypass. by unifocalization of pulmonary arteries. Mustard or Senning type) w/ repair of subpulmonic obstruction Repair of transposition of the great arteries.600 10.000 21.500 30.500 12.300 30..500 18.000 21. by ligation Repair of patent ductus arteriosus.300 13.000 21.800 71. w/ coronary reconstruction Ascending aorta graft. Jatene type) Repair of transposition of the great arteries.000 21. atrial baffle procedure (e.400 Professional Fee 37.800 16.300 30.600 37..000 21.300 21.000 21.800 16. w/ cardiopulmonary bypass Ascending aorta graft.300 21.g.000 21.800 25. w/ or w/o valve suspension.800 46. atrial baffle procedure (e.g. w/o cardiopulmonary bypass Repair of hypoplastic or interrupted aortic arch using autogenous or prosthetic material. Mustard or Senning type) w/ closure of ventricular septal defect Repair of transposition of the great arteries.200 54. w/ or w/o embolectomy..500 13..500 13. w/ aortic root replacement using composite prosthesis and coronary reconstruction Transverse arch graft.400 25.400 25.000 21. w/ cardiopulmonary bypass.900 42.800 55..800 37. w/ or w/o valve suspension. w/ or w/o valve suspension.700 16.g.500 55.300 30. by division.500 75. repair using either left subclavian artery or prosthetic material as gusset for enlargement Repair of hypoplastic or interrupted aortic arch using autogenous or prosthetic material. w/o cardiopulmonary bypass Pulmonary endarterectomy. w/o cardiopulmonary bypass Repair of pulmonary atresia w/ ventricular septal defect.300 46.800 39. atrial baffle procedure (e. aortic pulmonary artery reconstruction (e.200 8.100 50.500 13. Jatene type) w/ repair of subpulmonic obstruction Total repair. atrial baffle procedure (e.000 24. w/ or w/o associated patent ductus arteriosus.600 25.800 16.ANNEX 2.600 21.800 16. with graft Excision of coarctation of aorta.500 21.000 13.900 10. by abdominal and leg incision Thrombectomy.300 35082 53. iliac. by arm incision Direct repair of aneurysm.500 35011 18. false aneurysm. for aneurysm and associated occlusive disease.500 10. w/ or w/o catheter. femoropopliteal. false aneurysm.800 14. false aneurysm. any vein donor Cross-over vein graft to venous sytem Saphenopopliteal vein anastomosis Direct repair of aneurysm. w/ or w/o graft Implantation of ventricular assist device.600 5. aortoiliac artery. or excision (partial or total) and graft insertion. by leg incision Embolectomy or thrombectomy. biventricular support Embolectomy or thrombectomy.800 12. w/ or w/o catheter. w/ or w/o catheter.300 30.500 55.700 35002 30. single ventricle support Implantation of ventricular assist device.000 25. direct or w/ catheter.500 13.300 17. for ruptured aneurysm. w/ or w/o patch graft. or excision (partial or total) and graft insertion. or excision (partial or total) and graft insertion.300 30.000 23.300 12. single ventricle support Removal of ventricular assist device.600 16. including repair of the ascending aorta.000 32.300 30. w/ or w/o catheter.700 13.600 32. open approach Removal of intra-aortic balloon assist device including repair of femoral artery w/ or w/o graft Insertion of intra-aortic balloon assist device through the ascending aorta Removal of intra-aortic balloon assist device from the ascending aorta.700 10.500 13.300 21. vena cava.300 Professional Fee 6. false aneurysm. for aneurysm.400 9. axillary and subclavian vein. subclavian or innominate artery.800 16.400 24.500 17. by neck incision Direct repair of aneurysm. by neck incision Direct repair of aneurysm. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 33970 33971 33973 33974 33975 33976 33977 33978 34001 34051 34101 34111 34151 34201 34203 34401 34421 34451 34471 34490 34501 34502 34510 34520 34530 35001 DESCRIPTION Insertion of intra-aortic balloon assist device through the femoral artery.300 46. w/ or w/o patch graft.300 30.600 16. femoral vein Reconstruction of vena cava.200 14. false aneurysm.700 10. mesentery.300 4.800 16. subclavian artery.300 30. w/ or w/o patch graft.600 12. w/ or w/o catheter. subclavian vein. by thoracic incision Embolectomy or thrombectomy.300 32.300 10. false aneurysm. by arm incision Embolectomy or thrombectomy.800 21. and associated occlusive disease.300 23. by leg incision Thrombectomy. w/ or w/o patch graft.900 13. or excision (partial or total) and graft insertion. and associated occlusive disease. for ruptured aneurysm.300 16. for ruptured aneurysm. radial or ulnar artery. w/ or w/o patch graft.000 37. w/ or w/o patch graft. radial or ulnar artery Direct repair of aneurysm.000 23.800 13.200 10.400 16.600 10. false aneurysm. w/ or w/o catheter.600 16.000 Page 43 of 98 . false aneurysm. innominate.800 12. false aneurysm.300 23.600 12. carotid. w/ or w/o patch graft. abdominal aorta Direct repair of aneurysm. or excision (partial or total) and graft insertion. vena cava.800 16. any method Venous valve transposition.700 18.800 46.700 13. biventricular support Removal of ventricular assist device. direct or w/ catheter. and associated occlusive disease. false aneurysm. false aneurysm. innominate. for ruptured aneurysm. or excision (partial or total) and graft insertion.300 10. false aneurysm. false aneurysm. w/ or w/o catheter.200 33. or excision (partial or total) and graft insertion. innominate. brachial. for aneurysm. subclavian artery.300 18. iliac vein. subclavian artery.700 21.800 16. by abdominal incision Embolectomy or thrombectomy. axillary. vena cava. direct or w/ catheter.500 32. for aneurysm and associated occlusive disease. by neck incision Thrombectomy. axillarybrachial artery.700 13.700 12.500 10. by neck incision Embolectomy or thrombectomy.600 35081 46. by thoracic incision Direct repair of aneurysm. by arm incision Valvuloplasty.600 10. axillary-brachial artery. direct or w/ catheter.500 13. w/ or w/o patch graft.700 35022 30.500 25.700 17. femoropopliteal vein. popliteal-tibioperoneal artery.ANNEX 2.300 30.200 21.500 35005 30. or excision (partial or total) and graft insertion. subclavian artery.300 30. by arm incision Embolectomy or thrombectomy. subclavian artery. or excision (partial or total) and graft insertion.700 35021 23. abdominal aorta Case Rate 12.700 14.500 21. false aneurysm. and associated occlusive disease.600 35013 23.800 25.000 37. iliac. w/ or w/o patch graft. subclavian artery.500 13.300 16. for aneurysm. by abdominal incision Thrombectomy.000 8. carotid.500 35045 18.300 23.300 16.800 13. carotid.400 30. aortoiliac artery. renal. vertebral artery Direct repair of aneurysm. by leg incision Thrombectomy.500 16.600 21.300 12. or excision (partial or total) and graft insertion.600 Health Care Institution Fee 6. for aneurysm. by arm incision Direct repair of aneurysm.400 29.000 8.700 12.900 9. innominate.900 14.500 10. femoropopliteal vein. celiac. direct or w/ catheter. w/ or w/o patch graft. by thoracic insertion Direct repair of aneurysm.300 17.800 13.400 9.300 23. celiac. renal) Direct repair of aneurysm. w/ or w/o patch graft. neck Repair blood vessel w/ vein graft.700 35142 30. celiac. head and neck Repair. false aneurysm.300 30. intrathoracic. false aneurysm. w/ or w/o patch graft.400 29.300 16.300 35112 53. intra-abdominal Repair blood vessel.500 9. and associated occlusive disease. or excision (partial or total) and graft insertion. w/ or w/o patch graft. false aneurysm. popliteal artery Direct repair of aneurysm. extremities Repair. superficial femoral) Direct repair of aneurysm. celiac. w/ or w/o patch graft. for ruptured aneurysm.600 8.600 16.600 10. other arteries Direct repair of aneurysm. false aneurysm. head and neck Repair. direct. false aneurysm. for aneurysm. w/ or w/o patch graft.000 23. false aneurysm. hypogastric.300 18.400 8.300 18. intra-abdominal Repair blood vessel w/ vein graft.300 23. false aneurysm. abdominal aorta involving iliac vessels (common.600 10. or excision (partial or total) and graft insertion. false aneurysm.400 25. false aneurysm.400 35102 46. lower extremity Repair blood vessel w/ graft other than vein. and associated occlusive disease.700 9.700 10.600 9. intrathoracic.200 21. upper extremity Repair blood vessel.800 21. direct.000 12.800 12. false aneurysm.300 35122 53.300 16.700 35132 30. neck Repair blood vessel. false aneurysm. upper extremity Repair blood vessel w/ vein graft.600 21. false aneurysm.500 30.800 13.400 35092 55. common femoral artery (profunda femoris. iliac artery (common.600 8.700 13. and associated occlusive disease.400 24.000 35111 46. w/ or w/o patch graft.600 9. w/ or w/o patch graft. false aneurysm.500 10.700 9.400 29. w/ bypass Repair blood vessel. hypogastric.500 35162 35180 35182 35184 35188 35189 35190 35201 35206 35207 35211 35216 35221 35226 35231 35236 35241 35246 35251 35256 35261 37. direct. w/ or w/o patch graft. and associated occlusive disease.400 29. or excision (partial or total) and graft insertion. direct. direct. false aneurysm. false aneurysm.000 18.000 46.800 13.600 10.800 10. for aneurysm.800 13.600 21. external) Direct repair of aneurysm. for aneurysm.800 13.000 46. hand.300 18.300 18.300 21.ANNEX 2. false aneurysm.600 9. for aneurysm. splenic artery Direct repair of aneurysm.200 21. false aneurysm. w/ or w/o patch graft. or excision (partial or total) and graft insertion. false aneurysm. and associated occlusive disease.300 35103 53.000 33.500 35151 30. or excision (partial or total) and graft insertion.800 23.600 16.800 12. for aneurysm. other arteries Repair.500 25.300 30. direct. false aneurysm. for ruptured aneurysm. for ruptured aneurysm. or excision (partial or total) and graft insertion.500 30. hypogastric.300 12.300 12. hepatic. or excision (partial or total) and graft insertion. external) Direct repair of aneurysm. false aneurysm. thorax and abdomen Repair. congenital arteriovenous fistula. for ruptured aneurysm. extremities Repair blood vessel.200 21.000 35121 46.400 24. and associated occlusive disease. external) Direct repair of aneurysm. neck Case Rate Professional Fee Health Care Institution Fee 24.600 10. w/ or w/o patch graft. w/o bypass Repair blood vessel.600 12. popliteal artery Direct repair of aneurysm. renal.300 13.300 23. finger Repair blood vessel.700 Page 44 of 98 . w/ or w/o patch graft. for ruptured aneurysm. acquired or traumatic arteriovenous fistula.600 16.500 25. w/ or w/o patch graft. false aneurysm. false aneurysm. or excision (partial or total) and graft insertion. thorax and abdomen Repair. and associated occlusive disease. direct. for aneurysm. for ruptured aneurysm. for aneurysm.500 35152 37. abdominal aorta involving iliac vessels (common. or excision (partial or total) and graft insertion. w/ or w/o patch graft. for ruptured aneurysm. congenital arteriovenous fistula. abdominal aorta involving visceral vessels (mesenteric. hypogastric.300 16.500 10. or excision (partial or total) and graft insertion.400 12.300 23. w/ or w/o patch graft.200 16. hepatic. congenital arteriovenous fistula. false aneurysm. w/o bypass Repair blood vessel w/ vein graft. external) Direct repair of aneurysm. or excision (partial or total) and graft insertion.400 8.800 8. or excision (partial or total) and graft insertion.500 25.400 25.400 29.400 12. common femoral artery (profunda femoris. or excision (partial or total) and graft insertion. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE DESCRIPTION Direct repair of aneurysm. and associated occlusive disease. superficial femoral) Direct repair of aneurysm. abdominal aorta involving visceral vessels (mesenteric.400 8. lower extremity Repair blood vessel w/ vein graft.800 35161 30.300 13.000 16.600 21.600 8. intrathoracic.000 18. for ruptured aneurysm. renal. or excision (partial or total) and graft insertion.000 35091 53. or excision (partial or total) and graft insertion.300 23.400 24. acquired or traumatic arteriovenous fistula. w/ or w/o patch graft.500 10.700 9.700 13.500 35141 23. celiac.200 16.300 16. iliac artery (common.000 23. false aneurysm. splenic artery Direct repair of aneurysm.800 12.000 35131 23. or excision (partial or total) and graft insertion. or mesenteric artery Direct repair of aneurysm. or mesenteric artery Direct repair of aneurysm. w/ or w/o patch graft. renal) Direct repair of aneurysm. w/ bypass Repair blood vessel w/ vein graft. acquired or traumatic arteriovenous fistula.000 18. for aneurysm. intrathoracic. aortic Transluminal balloon angioplasty. subclavian.700 18. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 35266 35271 35276 35281 35286 35301 35311 35321 35331 35341 35351 35355 35361 35363 35371 35372 35381 35450 35452 35454 35456 35458 35459 35460 35470 35471 35472 35473 35474 35475 35476 35480 35481 35482 35483 35484 35485 35490 35491 35492 35493 35494 35495 35501 35506 35507 35508 35509 35511 35515 35516 35518 35521 35526 35531 35533 DESCRIPTION Repair blood vessel w/ graft other than vein. iliac Transluminal peripheral atherectomy.800 25. open.600 8. w/ vein.900 12. renal or other visceral artery Transluminal peripheral atherectomy. each vessel Transluminal peripheral atherectomy. w/ vein. by neck incision Thromboendarterectomy. renal or other visceral artery Transluminal peripheral atherectomy.600 37. iliac Thromboendarterectomy.700 10.ANNEX 2.300 21. brachiocephalic trunk or branches.300 10. w/ vein.300 21. w/ or w/o patch graft.700 9.900 18. w/ vein. axillary-femoral Bypass graft. w/ or w/o patch graft.500 10. w/ or w/o patch graft.000 46.400 21.900 6.600 6. each vessel Transluminal balloon angioplasty.900 16.600 37.600 37.600 12.500 46.600 37. common femoral Thromboendarterectomy.900 18.500 10.500 10. venous Transluminal balloon angioplasty. each vessel Transluminal balloon angioplasty.500 10. subclavian-axillary Bypass graft.900 18.400 12. open. w/ or w/o patch graft. carotid.300 23. w/ or w/o patch graft.700 10.300 13.500 10. w/ bypass Repair blood vessel w/ graft other than vein.900 18.500 10.400 21. w/ vein. percutaneous.700 18.300 6.600 12. aortic Transluminal peripheral atherectomy. w/ vein.600 12.600 16.900 10. vertebral.600 37.900 18.300 23.700 18. percutaneous.500 23. abdominal aorta Thromboendarterectomy. celiac. open. w/ vein.600 37. by thoracic incision Thromboendarterectomy.800 10.700 13. or renal Thromboendarterectomy.900 12.600 12.500 10.900 18. w/ or w/o patch graft. iliac Transluminal balloon angioplasty.600 12. percutaneous.500 10. renal or visceral artery Transluminal balloon angioplasty.300 30.600 37.300 6.600 46.900 18.300 30.700 18.900 10. subclavian.600 12.200 Health Care Institution Fee 9.700 18.800 12. open. each vessel Transluminal peripheral atherectomy. intra-abdominal Repair blood vessel w/ graft other than vein.900 12.800 16. renal or other visceral artery Transluminal balloon angioplasty.700 18.200 25. combined aortoiliac Thromboendarterectomy. w/o bypass Repair blood vessel w/ graft other than vein.300 6. axillary-brachial Thromboendarterectomy.400 18. w/ vein. deep (profunda) femoral Thromboendarterectomy.400 21.200 16.500 18.900 10. aortic Transluminal balloon angioplasty.500 10. iliac Transluminal balloon angioplasty.400 25.900 12.900 10.700 18. tibioperoneal trunk and branches Transluminal balloon angioplasty. w/ vein. percutaneous.900 10. aortosubclavian or carotid Bypass graft. open. mesenteric.900 10.400 21.700 10. lower extremity Thromboendarterectomy.300 23.600 10.300 Page 45 of 98 .600 37.700 18.900 18. percutaneous.700 18.600 37. combined aortoiliofemoral Thromboendarterectomy.600 6. tibioperoneal trunk and branches Bypass graft. open. innominate. open. w/ or w/o patch graft.600 18.300 6.400 21. intrathoracic.300 21. w/ or w/o patch graft.500 6.900 12. percutaneous.500 10.400 21. upper extremity Repair blood vessel w/ graft other than vein.300 6.900 10. w/ or w/o patch graft. femoral and/or popliteal. iliofemoral Thromboendarterectomy.300 23. axillary-axillary Bypass graft.900 18.900 18. venous Transluminal peripheral atherectomy.600 6.600 37. carotid-vertebral Bypass graft.600 21.600 6.400 21.700 18.700 13.900 10. tibioperoneal trunk and branches Transluminal peripheral atherectomy.900 18.600 37. w/ or w/o patch graft. percutaneous.900 10.300 23. femoral-popliteal Transluminal balloon angioplasty.900 10.300 21. tibioperoneal trunk or branches. w/ or w/o patch graft.900 18. open. axillary-femoral-femoral Case Rate 18.600 37. percutaneous.700 10.700 10.900 18.400 37. femoral-popliteal Transluminal peripheral atherectomy.700 18.400 21. carotid Bypass graft. open.500 21.600 37. percutaneous.700 10.700 10.900 25.200 25. w/ vein. aortic Transluminal peripheral atherectomy. open.900 23.700 10.300 18.300 23.500 10. percutaneous.400 21.900 10. carotid-carotid Bypass graft.900 18.300 6.600 6.600 6.300 46.500 13.500 30. femoral-popliteal Transluminal balloon angioplasty. subclavian-carotid Bypass graft.500 10. w/ vein.200 12. brachiocephalic trunk or branches. branchiocephalic trunk or branches.500 Professional Fee 8.300 23. femoral-popliteal Transluminal peripheral atherectomy. w/ vein.700 18.700 21.000 37.400 21.900 12.300 12. each vessel Transluminal balloon angioplasty. and/or tibioperoneal Transluminal balloon angioplasty. subclavian-vertebral Bypass graft.600 30. carotid-subclavian Bypass graft.300 23. subclavian-subclavian Bypass graft. open. branchiocephalic trunk or branches.600 10. percutaneous. intrathoracic. percutaneous. percutaneous.500 46. open.700 18.600 12.500 10. open. w/ vein. aortoceliac or aortomesenteric Bypass graft.400 21. iliac Transluminal peripheral atherectomy. w/ or w/o patch graft. ANNEX 2. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 35536 35541 35546 35548 35549 35551 35556 35558 35560 35563 35565 35566 35571 35582 35583 35585 35587 35601 35606 35612 35616 35621 35623 35626 35631 35636 35641 35642 35645 35646 35650 35651 35654 35656 35661 35663 35665 35666 35671 35681 35691 35693 35694 35695 35700 DESCRIPTION Bypass graft, w/ vein; splenorenal Bypass graft, w/ vein; aortoiliac or bi-iliac Bypass graft, w/ vein; aortofemoral or bifemoral Bypass graft, w/ vein; aortoilliofemoral, unilateral Bypass graft, w/ vein; aortoilliofemoral, bilateral Bypass graft, w/ vein; aortofemoral - popliteal Bypass graft, w/ vein; femoral - popliteal Bypass graft, w/ vein; femoral-femoral Bypass graft, w/ vein; aortorenal Bypass graft, w/ vein; ilioiliac Bypass graft, w/ vein; iliofemoral Bypass graft, w/ vein; femoral - anterior tibial, posterior tibial, peroneal artery or other distal vessels Bypass graft, w/ vein; popliteal-tibial, peroneal artery or other distal vessels In-situ vein bypass; aortofemoral-popliteal (only femoral-popliteal portion insitu) In-situ vein bypass;femoral-popliteal In-situ vein bypass; femoral-anterior tibial, posterior tibial, or peroneal artery In-situ vein bypass; popliteal -tibial, peroneal Bypass graft, with other than vein; carotid Bypass graft, with other than vein; carotid-subclavian Bypass graft, with other than vein; subclavian-subclavian Bypass graft, with other than vein; subclavian-axillary Bypass graft, with other than vein; axillary-femoral Bypass graft, with other than vein; axillary-popliteal or -tibial Bypass graft, with other than vein; aortosubclavian or carotid Bypass graft, with other than vein; aortoceliac, aortomesenteric, aortorenal Bypass graft, with other than vein; splenorenal (splenic to renal arterial anastomosis) Bypass graft, with other than vein; aortoiliac or bi-iliac Bypass graft, with other than vein; carotid-vertebral Bypass graft, with other than vein; subclavian-vertebral Bypass graft, with other than vein; aortofemoral or bifemoral Bypass graft, with other than vein; axillary-axillary Bypass graft, with other than vein; aortofemoral-popliteal Bypass graft, with other than vein; axillary-femoral-femoral Bypass graft, with other than vein; femoral-popliteal Bypass graft, with other than vein; femoral-femoral Bypass graft, with other than vein; ilioiliac Bypass graft, with other than vein; iliofemoral Bypass graft, with other than vein; femoral-anterior tibial, posterior tibial, or peroneal artery Bypass graft, with other than vein; popliteal-tibial or -peroneal artery Bypass graft, composite Transposition and/or reimplantation; vertebral to carotid artery Transposition and/or reimplantation; vertebral to subclavian artery Transposition and/or reimplantation; subclavian to carotid artery Transposition and/or reimplantation; carotid to subclavian artery Reoperation, femoral-popliteal or femoral (popliteal) -anterior tibial,posterior tibial, peroneal artery or other distal vessels, more than one month after original operation (List separately in addition to code for primary procedure) Exploration (not followed by surgical repair), w/ or w/o lysis of artery; carotid artery Exploration (not followed by surgical repair), w/ or w/o lysis of artery; femoral artery Exploration (not followed by surgical repair), w/ or w/o lysis of artery; popliteal artery Exploration (not followed by surgical repair), w/ or w/o lysis of artery; other vessels Exploration for postoperative hemorrhage, thrombosis or infection; neck Exploration for postoperative hemorrhage, thrombosis or infection; chest Exploration for postoperative hemorrhage, thrombosis or infection; abdomen Exploration for postoperative hemorrhage, thrombosis or infection; extremity Repair of graft-enteric fistula Thrombectomy of arterial or venous graft; Thrombectomy of arterial or venous graft; w/ revision of arterial or venous graft Excision of infected graft; neck Case Rate 46,500 46,500 46,500 46,500 46,500 46,500 30,300 23,300 37,800 30,300 30,300 30,300 23,300 46,500 37,800 37,800 37,800 37,600 37,600 37,600 37,600 37,600 37,600 46,500 46,500 46,500 46,500 37,600 37,600 46,500 37,600 46,500 37,600 30,300 23,300 30,300 30,300 30,300 23,300 46,500 37,600 37,600 37,600 37,600 18,000 Professional Fee 25,200 25,200 25,200 25,200 25,200 25,200 16,800 12,600 21,000 16,800 16,800 16,800 12,600 25,200 21,000 21,000 21,000 18,900 18,900 18,900 18,900 18,900 18,900 25,200 25,200 25,200 25,200 18,900 18,900 25,200 18,900 25,200 18,900 16,800 12,600 16,800 16,800 16,800 12,600 25,200 18,900 18,900 18,900 18,900 8,400 Health Care Institution Fee 21,300 21,300 21,300 21,300 21,300 21,300 13,500 10,700 16,800 13,500 13,500 13,500 10,700 21,300 16,800 16,800 16,800 18,700 18,700 18,700 18,700 18,700 18,700 21,300 21,300 21,300 21,300 18,700 18,700 21,300 18,700 21,300 18,700 13,500 10,700 13,500 13,500 13,500 10,700 21,300 18,700 18,700 18,700 18,700 9,600 35701 35721 35741 35761 35800 35820 35840 35860 35870 35875 35876 35901 18,000 18,000 18,000 18,000 9,700 18,000 18,000 9,700 23,300 23,300 23,300 30,300 8,400 8,400 8,400 8,400 4,200 8,400 8,400 4,200 12,600 12,600 12,600 16,800 9,600 9,600 9,600 9,600 5,500 9,600 9,600 5,500 10,700 10,700 10,700 13,500 Page 46 of 98 ANNEX 2. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 35903 35905 35907 36010 36011 36012 36013 36014 36015 36100 36120 36140 36145 36200 36215 36216 36217 DESCRIPTION Excision of infected graft; extremity Excision of infected graft; thorax Excision of infected graft; abdomen Introduction of catheter, superior or inferior vena cava Selective catheter placement, venous system; first order branch (e.g., renal vein, jugular vein) Selective catheter placement, venous system; second order, or more selective, branch (e.g., left adrenal vein, petrosal sinus) Introduction of catheter, right heart or main pulmonary artery Selective catheter placement, left or right pulmonary artery Selective catheter placement, segmental or subsegmental pulmonary artery Introduction of needle or intracatheter, carotid or vertebral artery Introduction of needle or intracatheter; retrograde brachial artery Introduction of needle or intracatheter; extremity artery Introduction of needle or intracatheter; arteriovenous shunt created for dialysis (cannula, fistula, or graft) Introduction of catheter, aorta Selective catheter placement, arterial system; each first order thoracic or brachiocephalic branch, w/in a vascular family Selective catheter placement, arterial system; initial second order thoracic or brachiocephalic branch, w/in a vascular family Selective catheter placement, arterial system; initial third order or more selective thoracic or brachiocephalic branch, w/in a vascular family Selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery branch, w/in a vascular family Selective catheter placement, arterial system; initial second order abdominal, pelvic or lower extremity artery branch, w/in a vascular family Selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic or lower extremity artery branch, w/in a vascular family Insertion of implantable intra-arterial infusion pump (e.g., for chemotherapy of liver) Revision of implanted intra-arterial infusion pump Removal of implanted intra-arterial infusion pump Outpatient Transfusion of Blood or Blood Products; one or more units Exchange transfusion, blood Percutaneous portal vein catheterization by any method Placement of central venous catheter (subclavian, jugular, or other vein) (e.g., for central venous pressure, hyperalimentation, hemodialysis, or chemotherapy); percutaneous or cutdown Catheterization of umbilical vein for diagnosis or therapy, newborn Therapeutic apheresis Insertion of peripherally inserted central venous catheter (PICC) Arterial catheterization for prolonged infusion therapy (chemotherapy), cutdown Catheterization, umbilical artery, newborn, for diagnosis or therapy Percutaneousportal vein catheterization by any method Insertion of cannula for hemodialysis, other purpose ; vein to vein Insertion of cannula for hemodialysis, other purpose ; arteriovenous, external (Scribner type) Insertion of cannula for hemodialysis, other purpose ; arteriovenous, external revision, or closure Arteriovenous anastomosis, direct, any site (e.g., Cimino type) Insertion of cannula(s) for prolonged extracorporeal circulation for cardiopulmonary insufficiency (ECMO) Creation of arteriovenous fistula by other than direct arteriovenous anastomosis ; autogenous graft Creation of arteriovenous fistula by other than direct arteriovenous anastomosis ; nonautogenous graft Revision of an arteriovenous fistula, w/ or w/o thrombectomy, autogenous or nonautogenous graft Plastic repair of arteriovenous aneurysm Insertion of Thomas shunt Venous anastomosis; portocaval Venous anastomosis; renoportal Venous anastomosis; caval-mesenteric Venous anastomosis; splenorenal, proximal Venous anastomosis; splenorenal, distal (selective decompression of esophagogastric varices, any technique) Case Rate 30,300 37,800 30,300 3,640 9,300 8,020 8,020 8,020 8,440 8,440 9,300 9,300 8,260 9,300 9,300 9,300 8,020 Professional Fee 16,800 21,000 16,800 840 2,100 2,520 2,520 2,520 2,940 2,940 2,100 2,100 3,360 2,100 2,100 2,100 2,520 Health Care Institution Fee 13,500 16,800 13,500 2,800 7,200 5,500 5,500 5,500 5,500 5,500 7,200 7,200 4,900 7,200 7,200 7,200 5,500 36245 9,300 2,100 7,200 36246 9,300 2,100 7,200 36247 36260 36261 36262 36430 36450 36481 36488 36510 36511 36568 36640 36660 36781 36800 36810 36815 36821 36822 36825 36830 36832 36834 36835 37140 37145 37160 37180 37181 8,020 23,300 9,700 9,700 3,640 5,680 9,300 9,700 3,640 3,640 9,700 3,640 5,680 9,300 9,300 9,700 9,700 9,700 18,000 12,900 12,900 9,700 8,260 9,300 30,300 37,800 30,300 37,600 37,800 2,520 12,600 4,200 4,200 840 1,680 2,100 4,200 840 840 4,200 840 1,680 2,100 2,100 4,200 4,200 4,200 8,400 6,300 6,300 4,200 3,360 2,100 16,800 21,000 16,800 18,900 21,000 5,500 10,700 5,500 5,500 2,800 4,000 7,200 5,500 2,800 2,800 5,500 2,800 4,000 7,200 7,200 5,500 5,500 5,500 9,600 6,600 6,600 5,500 4,900 7,200 13,500 16,800 13,500 18,700 16,800 Page 47 of 98 ANNEX 2. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE DESCRIPTION Insertion of transvenous intrahepatic portosystemic shunt(s) (TIPS) includes venous access, hepatic and portal vein catheterization, portography, hemodynamic evaluation, intrahepatic tract formation/dilatation, stent placement and all associated imaging g Primary percutaneous transluminal mechanical thrombectomy, noncoronary, arterial or arterial bypass graft including fluoroscopic guidance and intraprocedural pharmacological thrombolytic injections; one or more vessels Percutaneous transluminal mechanical thrombectomy, veins, including intraprocedural pharmacological thrombolytic injections and fluoroscopic guidance; one or more vessels Transcatheter biopsy Transcatheter therapy, infusion for thrombolysis other than coronary Transchatheter therapy, infusion other than for thrombolysis, any type (e.g., spasmolytic, vasoconstrictive) Transcatheter retrieval, percutaneous, of intravascular foreign body (e.g., fractured venous or arterial catheter) Transcatheter occlusion or embolization (e.g., for tumor destruction, to achieve hemostasis, to occlude a vascular malformation), percutaneous, any method, non-central nervous system, non-head or neck Transcatheter placement of an intravascular stent(s), (non-coronary vessel), percutaneous; initial vessel Transcatheter placement of an intravascular stent(s), (non-coronary vessel), open; initial vessel Ligation, internal jugular vein Ligation; external carotid artery Ligation; internal or common carotid artery Ligation; internal or common carotid artery, w/ gradual occlusion, as w/ Selverstone or Crutchfield camp Ligation or banding of angioaccess arteriovenous fistula Ligation or biopsy, temporal artery Ligation, major artery (e.g., post-traumatic, rupture); neck Ligation, major artery (e.g., post-traumatic, rupture); chest Ligation, major artery (e.g., post-traumatic, rupture); abdomen Ligation, major artery (e.g., post-traumatic, rupture); extremity Interruption, partial or complete, of inferior vena cava by suture, ligation, plication, clip, extravascular, intravascular (umbrella device) Ligation of femoral vein Ligation of common iliac vein Ligation and division of long saphenous vein at saphenofemoral junction, or distal interruptions Ligation and division and complete stripping of long or short saphenous veins Ligation and division and complete stripping of long and short saphenous veins Ligation and division and complete stripping of long or short saphenous veins w/ radical excision of ulcer and skin graft and/or interruption of communicating veins of lower leg, w/ excision of deep fascia Ligation of perforators, subfascial, radical (Linton type), w/ or w/o skin graft Ligation and division of short saphenous vein at saphenopopliteal junction Penile revascularization, artery, w/ or w/o vein graft Penile venous occlusive procedure Splenectomy; total Splenectomy; partial Splenectomy; total, en bloc for extensive disease, in conjuction w/ other procedure Repair of ruptured spleen (splenorrhaphy) w/ or w/o partial splenectomy Laparoscopy, surgical; splenectomy Blood-derived hematopoietic progenitor cell harvesting for transplantation Bone marrow aspiration or biopsy Bone marrow harvesting for transplantation Bone marrow or peripheral blood derived peripheral stem cell transplantation Drainage of lymph node abscess or lymphadenitis Suture and/or ligation of thoracic duct; cervical approach Suture and/or ligation of thoracic duct; thoracic approach Suture and/or ligation of thoracic duct; abdominal approach Biopsy or excision or lymph node(s); superficial Case Rate Professional Fee Health Care Institution Fee 24,000 37182 53,400 29,400 37184 46,500 25,200 21,300 37187 37200 37201 37202 37203 46,500 8,260 8,020 8,020 9,700 25,200 3,360 2,520 2,520 4,200 21,300 4,900 5,500 5,500 5,500 37204 46,500 25,200 21,300 37205 37207 37565 37600 37605 37606 37607 37609 37615 37616 37617 37618 37620 37650 37660 37700 37720 37730 46,500 23,300 5,680 5,680 18,000 21,940 9,300 9,300 18,000 21,400 18,000 12,900 23,300 9,300 12,900 9,300 12,900 18,000 25,200 12,600 1,680 1,680 8,400 9,240 2,100 2,100 8,400 10,500 8,400 6,300 12,600 2,100 6,300 2,100 6,300 8,400 21,300 10,700 4,000 4,000 9,600 12,700 7,200 7,200 9,600 10,900 9,600 6,600 10,700 7,200 6,600 7,200 6,600 9,600 37735 21,400 10,500 10,900 37760 37780 37788 37790 38100 38101 38102 38115 38120 38205 38220 38230 38240 38300 38380 38381 38382 38500 21,400 9,700 46,500 23,300 30,740 23,300 32,000 30,300 30,740 10,880 10,880 18,000 37,800 8,260 30,300 30,300 30,300 5,680 10,500 4,200 25,200 12,600 13,440 12,600 14,700 16,800 13,440 3,780 3,780 8,400 21,000 3,360 16,800 16,800 16,800 1,680 10,900 5,500 21,300 10,700 17,300 10,700 17,300 13,500 17,300 7,100 7,100 9,600 16,800 4,900 13,500 13,500 13,500 4,000 Page 48 of 98 inguinal. by needle.520 23.700 17.500 16.100 9.000 23. Estlander or fan) V-excision w/ primary defect linear closure.320 40.520 2.000 13.300 21.700 9.160 14.800 15. diaphragmatic hernia (esophageal hiatal). including Cloquets node Inguinofemoral lymphadenectomy.300 23.000 25. chronic Imbrication of diaphragm for eventration.500 10.300 30.800 4.800 21.600 12.800 10.120 16.600 16.800 16.500 21. with or without biopsy Repair. deep cervical node(s) Biopsy or excision or lymph node(s). deep jugular node(s) Excision of cystic hygroma. w/ mucosal advancement Excision of lip.300 9. over one-half vertical height.500 16.800 Page 49 of 98 . acute Repair. combined. unilateral Plastic repair of cleft lip/nasal deformity. superficial Axillary lymphadenectomy.560 21.740 8.940 37.520 23. diaphragmatic hernia (esophageal hiatal).200 4.600 13. except neonatal Repair.800 16.100 2.520 1. with or without chest tube insertion and with or without creation of ventral hernia Repair.440 3.700 37. paralytic or nonparalytic Biopsy of lip Vermilionectomy (lip shave). full thickness.800 16. including either transthoracic or median sternotomy Excision of mediastinal cyst Excision of mediastinal tumor Mediastinoscopy. full thickness.000 8.360 7.300 37.100 2.500 13. transthoracic Repair.000 21.500 27.200 15. in continuity w/ pelvic lymphadenectomy.500 10.400 12.800 7.200 7. diaphragmatic hernia (other than neonatal). with retroperitoneal lymph node sampling (biopsy).800 23. superficial.000 4.600 21.520 2. neonatal diaphragmatic hernia.000 12. vagotomy.200 21. and/or pyloroplasty. including external iliac.800 16.800 40.700 9.000 23.500 5.700 16. with bilateral total pelvic lymphadenectomy and periaortic lymph node sampling (biopsy). with or without fundoplasty. superficial.800 9. hypogastric.800 16.800 16. deep axillary node(s) Biopsy or excision or lymph node(s).320 5.300 9.520 23.000 24. transverse wedge excision w/ primary closure V-excision w/ primary defect linear closure. laceration of diaphragm.. combined. reconstruction w/ cross lip flap (Abbe-Estlander) Resection of lip. full thickness. axillary or cervical.320 46. hypogastric.000 21.500 5. including external iliac.800 37. single or multiple Suprahyoid lymphadenectomy Cervical lymphadenectomy (complete) Cervical lymphadenectomy (modified radical neck dissection) Axillary lymphadenectomy. axillary or cervical.260 9. traumatic.320 40. w/ deep neurovascular dissection Laparoscopy.500 5.800 21.200 12.400 16. cervical.300 12. single or multiple Laparoscopy. including celiac. full thickness.300 16.800 18. removal of foreign body. thoracoabdominal.960 37.560 8.g.000 13. including mediastinal and peritracheal nodes Abdominal lymphadenectomy. and obturator nodes Retroperitoneal transabdominal lymphadenectomy. traumatic.900 7.260 9.300 23. diaphragmatic hernia (esophageal hiatal). regional.300 37.320 40. transthoracic or transabdominal.ANNEX 2. any approach Repair. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 38505 38510 38520 38525 38530 38542 38550 38555 38570 38571 38572 38700 38720 38724 38740 38745 38746 38747 38760 38765 38770 38780 39000 39010 39200 39220 39400 39501 39502 39503 39520 39530 39531 39540 39541 39545 40490 40500 40510 40520 40525 40527 40530 40650 40652 40654 40700 40701 DESCRIPTION Biopsy or excision or lymph node(s).300 37. up to half vertical height Repair lip.680 3.020 8. primary bilateral. including pelvic. regional.520 12.800 46.800 16. and obturator nodes Pelvic lymphadenectomy.020 23.260 2.240 21. vermilion only Repair lip.800 41.800 27. cervical approach Transthoracic approach.800 16.300 5.020 8. surgical..680 8. or biopsy. transabdominal.120 30.200 23. superficial (e.120 16.500 40.200 7.800 37. with bilateral total pelvic lymphadenectomy Laparoscopy.700 10. one stage procedure Case Rate 5. primary. para-aortic and venal caval nodes Inguinofemoral lymphadenectomy. drainage.800 37. deep cervical node(s) w/ excision scalene fat pad Biopsy or excision or lymph node(s).300 58.800 Professional Fee 1.600 12. reconstruction w/ local flap (e. diaphragmatic hernia (other than neonatal).300 30.800 12.800 21.600 10.320 40.900 5.800 16.520 23. axillary) Biopsy or excision or lymph node(s).320 40.700 16.360 2. more than one-fourth. extensive. full thickness.700 13.300 4. surgical. complete Thoracic lymphadenectomy.120 30.600 21.000 12.700 10.360 4. thoracoabdominal Repair.800 16.200 4.520 23. paraesophageal hiatus hernia. with dilation of stricture (with or without gastroplasty) Repair. w/o deep neurovascular dissection Excision of cystic hygroma.300 23. and renal nodes Mediastinotomy with exploration.300 30. aortic. w/o reconstruction Repair lip.500 5.g.000 Health Care Institution Fee 4. surgical.700 16. or complex Plastic repair of cleft lip/nasal deformity.520 25. internal mammary node(s) Dissection. V-excision w/ primary defect linear closure. partial or complete. or hematoma of tongue or floor of mouth.400 5. soft tissues Removal of embedded foreign body from dentoalveolar structures.800 16.500 5. or hematoma of tongue or floor of mouth.200 29. vestibule of mouth Biopsy.6 cm or complex Frenoplasty (surgical revision of frenum. w/o radical neck dissection Glossectomy.680 1.800 37.000 4.680 5. bone Gingivectomy.500 5. hemiglossectomy Glossectomy.000 1.680 1.680 1.320 46.880 37.or hematoma of floor of mouth.or hematoma of floor of mouth.680 1.or hematoma of floor of mouth.260 1. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 40702 40720 40761 40800 40808 40810 40818 40819 40830 40831 40840 40842 40843 40844 40845 41000 41005 41006 41007 41008 41009 41015 41016 41017 41018 41100 41105 41108 41110 41112 41113 41114 41115 41116 41120 41130 41135 41140 41145 41150 41153 41155 41250 41251 41252 41500 41510 41520 41800 41805 41806 41820 41821 DESCRIPTION Plastic repair of cleft lip/nasal deformity. sublingual Extraoral incision and drainage of abscess. and radical neck dissection (Commando type) Repair of laceration 2. posterior. deep.000 5.400 8.800 5.520 2.500 4.560 5. cyst. mandibular resection. floor of mouth.680 1.560 9. eg. over 2.680 5. submental space Intraoral incision and drainage of abscess.120 12.680 1.200 4.680 1.300 8.800 2.300 4.100 3.000 4.600 9.440 9.680 5.680 5.680 6. composite procedure w/ resection floor of mouth.900 7.5 cm or complex Vestibuloplasty. muscle repositioning) Intraoral incision and drainage of abscess.500 53.800 21. anterior two-thirds Biopsy of tongue.500 5. cyst. frenectomy) Closure of laceration.360 3.000 4.680 5.200 7.300 9.800 16. one of two stages Plastic repair of cleft lip/nasal deformity. posterior one-third of tongue Repair of laceration of tongue.260 1. lingual Intraoral incision and drainage of abscess. lesion of floor of mouth Glossectomy. cyst.680 5.680 2.560 5.680 840 840 2. sublingual. w/ Z-plasty) Suture of tongue to lip for micrognathia (Douglas type procedure) Frenoplasty (surgical revision of frenum.800 16.680 5. complex (including ridge extension. submandibular Extraoral incision and drainage of abscess.700 5.680 5.200 4.640 3.680 8.020 8.500 Page 50 of 98 . or hematoma of tongue or floor of mouth.400 1.cyst.680 1. eg.720 6.680 1.200 4. sublingual. complete or total.000 5.100 2. by recreation of defect and reclosure Plastic repair of cleft lip/nasal deformity. posterior one-third Biopsy of floor of mouth Excision of lesion of tongue w/o closure Excision of lesion of tongue w/ closure.5 cm or less.780 21. primary bilateral.000 4. w/ cross lip pedicle flap (AbbeEstlander type).100 16.000 21.680 5. cyst.000 4. anterior two-thirds Excision of lesion of tongue w/ closure. unilateral Vestibuloplasty. hematoma.300 7. or hematoma of tongue or floor of mouth.100 2. w/ or w/o tracheostomy.400 9.200 4.500 5.640 8.720 6.680 1.700 9.200 7.600 4.or hematoma of floor of mouth.000 4. floor of mouth and/or anterior twothirds of tongue Repair of laceration 2.120 18. bilateral Vestibuloplasty.300 9. w/ suprahyoid neck dissection Glossectomy.cyst. w/ unilateral radical neck dissection Glossectomy. masticator space Extraoral incision and drainage of abscess.200 4.680 5. w/o radical neck dissection Glossectomy.200 7. vestibule of mouth.000 5.000 4.200 1. excision gingiva Operculectomy.5 cm or less. vestibule of mouth Excision of mucosa of vestibule of mouth as donor graft Excision of frenum. hematoma from dentoalveolar structures Removal of embedded foreign body from dentoalveolar structures.500 7. w/ unilateral radical neck dissection Glossectomy. composite procedure w/ resection floor of mouth.000 5.260 2.500 16.000 4. posterior one-third Excision of lesion of tongue w/ closure.100 2. supramylohyoid Intraoral incision and drainage of abscess.520 Health Care Institution Fee 13.720 8.200 4.000 21. posterior. frenulectomy. w/ or w/o tracheostomy.500 13.100 1.000 4.800 4. entire arch Vestibuloplasty.000 4. secondary.680 12. masticator space Biopsy of tongue.680 1.400 4. w/ Z-plasty) Drainage of abscess. composite procedure w/ resection floor of mouth and mandibular resection.000 4. cyst. vestibule of mouth Excision of lesion of mucosa and submucosa.300 5.200 4. less than one-half tongue Glossectomy.680 5. submandibular space Intraoral incision and drainage of abscess.800 37.120 12.cyst. excision pericoronal tissues Case Rate 30.680 5. partial.300 9.800 16. cyst.300 9.800 5.5 cm or less Closure of laceration.300 4. superficial Intraoral incision and drainage of abscess.680 1.800 40. cyst. including sectioning and inserting of pedicle Drainage of abscess.700 9.300 30.000 2. over 2.680 1.700 9. cyst.700 9. labial or buccal (frenumectomy.300 9.680 3.940 2.400 5.100 2.700 9. w/ local tongue flap Excision of lingual frenum (frenectomy) Excision.300 24.300 37.020 Professional Fee 16.520 25.200 7.cyst. 2.800 21.500 5. submental Extraoral incision and drainage of abscess.100 2.400 9.500 5. complete or total.000 4. anterior Vestibuloplasty. or hematoma of tongue or floor of mouth.000 23.000 4.000 18.680 5. vestibule of mouth.260 10.ANNEX 2.200 7. or hematoma of tongue or floor of mouth. 300 37.740 23.260 1. retropharyngeal or parapharyngeal.600 4. including curettage of osteitis or sequestrectomy Destruction of lesion (except excision).520 2.600 12.400 8. submaxillary or sublingual. w/ ligation of both submandibular (Whartons) ducts Closure salivary fistula Ligation salivary duct. submaxillary.200 7.120 5.360 2. bilateral (Wilke type procedure).300 4.260 8. intraoral Biopsy of salivary gland. w/ dissection and preservation of facial nerve Excision of parotid tumor or parotid gland.600 9.400 10.720 1. intraoral Incision and drainage abscess.400 8.260 8. bilateral (Wilke type procedure).000 8.300 7.600 9. w/ local flap closure Resection of palate or extensive resection of lesion Uvulectomy.400 10.520 2. oropharynx Biopsy..560 5. dentoalveolar structures Excision of lesion or or tumor (except listed above).360 3.700 13.520 2. excision of uvula Palatopharyngoplasty (e.500 13.360 3. sublingual or parotid.800 16. secondary or complicated Parotid duct diversion.500 4.300 10.080 6.000 7.300 9. simple Case Rate 8.680 9. w/ closure of alveolar ridge.900 4.800 9. laceration of palate.020 8.520 Health Care Institution Fee 5. uvula.360 8. uvula. submandibular (submaxillary).600 13.600 12.680 5. lesion of palate . w/ island flap Repair of anterior palate. uvula.300 30.100 2.600 10. sialodochoplasty.400 3.700 5.260 8.520 2.000 18.760 12.000 18. primary or simple Plastic repair of salivary duct.540 12.300 30.ANNEX 2.g.600 5. parotid Drainage of abscess.000 20. secondary lengthening procedure Palatoplasty for cleft palate.600 5.560 5. dentoalveolar structures Excision of hyperplastic alveolar mucosa Alveolectomy.360 3.100 2.300 30. uvula Excision.500 Page 51 of 98 .900 4.900 10. w/ excision of one submandibular gland Parotid duct diversion. intraoral Drainage of abscess.100 1. w/ dissection and preservation of facial nerve Excision of parotid tumor or parotid gland.260 8.400 9.000 18.500 13.900 10.400 8.800 18. retropharyngeal or parapharyngeal.100 10. w/ closure of alveolar ridge.520 1.360 3.120 23.500 5. lesion of palate . Fistulization of sublingual salivary cyst (ranula).300 23. attachment pharyngeal flap Lengthening of palate. w/ excision of both submandibular glands Parotid duct diversion. external approach Biopsy. soft tissue only Palatoplasty for cleft palate.980 12.520 3.500 5.300 4. uvula Biopsy of palate.400 8. palate or uvula (thermal.800 16.680 1.200 4.300 5. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 41822 41823 41825 41828 41830 41850 41870 41872 41874 42000 42100 42104 42106 42107 42120 42140 42145 42160 42180 42182 42200 42205 42210 42215 42220 42225 42226 42227 42235 42260 42300 42310 42320 42325 42326 42330 42400 42405 42408 42409 42410 42415 42420 42425 42426 42440 42450 42500 42505 42507 42508 42509 42510 42600 42665 42700 42720 42725 42800 42802 42804 DESCRIPTION Excision of fibrous tuberosities.020 8.200 10. en bloc removal w/ sacrifice of facial nerve Excision of parotid tumor or parotid gland.000 8.700 5.020 5.700 10.500 4.020 8. sialodochoplasty.500 16.400 4. soft and/or hard palate only Palatoplasty for cleft palate.680 1.600 9.900 4.680 5.980 21.360 3.520 2.400 8. bilateral (Wilke type procedure).400 8.600 9.920 11.300 10.300 12. cryo or chemical) Repair.680 2.000 18. including vomer flap Repair of nasolabial fistula Drainage of abscess.700 10.500 5. uvulopharyngoplasty) Destruction of lesion.200 7.900 9.000 4.000 18.300 20.600 16.100 2.680 2.200 7.360 3. major revision Palatoplasty for cleft palate. w/o closure Excision.000 18.600 9. w/ bone graft to alveolar ridge (includes obtaining graft) Palatoplasty for cleft palate.020 Professional Fee 2.020 8. and pharyngeal flap Lengthening of palate.300 23.400 8.260 8. dentoalveolar structures Periodontal mucosal grafting Gingivoplasty Alveoloplasty Drainage of abscess of palate.680 9.000 18.300 30.900 4.600 9.720 8. lateral lobe. hypopharynx Biopsy.000 4.020 8. peritonsillar Incision and drainage abscess.200 10. w/ unilateral radical neck dissection Excision of submandibular (submaxillary) gland Excision of sublingual gland Plastic repair of salivary duct. nasopharynx.440 12.100 12. visible lesion.900 4.080 10.700 10.820 22.300 23. total. up to 2 cm Repair.500 5.500 5.500 5. lateral lobe. w/ simple primary closure Excision.720 12.660 23.900 5.260 18. laceration of palate. lesion of palate .600 12.020 8.400 2.120 18.000 18. needle Biopsy of salivary gland.900 10.000 7. intraoral approach Incision and drainage abscess. bilateral (Wilke type procedure). total. w/ prosthesis Sialolithotomy.900 5.260 8. Parotid duct diversion. incisional Excision of sublingual salivary cyst (ranula) Marsupialization of sublingual salivary cyst (ranula) Excision of parotid tumor or parotid gland.800 21.300 9.400 8.000 8.000 4.600 6.900 4. over 2 cm or complex Palatoplasty for cleft palate.560 9.260 8.600 9.600 9. w/o nerve dissection Excision of parotid tumor or parotid gland. uvulopalatopharyngoplasty.700 17.300 23. external Fistulization of sublingual salivary cyst (ranula).300 9.680 1.680 5. total. dentoalveolar structures Excision of osseous tuberosities.260 2.260 1.040 6. or esophagus. obtaining the graft and intestinal reconstruction Partial esophagectomy. including bowel mobilization.300 10. w/ or w/o pyloroplasty (transhiatal) Total or near esophagectomy. and/or retromolar trigone.000 33. thoracic or abdominal approach Total or near esophagectomy.020 8.400 43118 58. w/ thoracotomy and separate abdominal incision.800 37.800 55.900 10. w/ thoracotomy and separate abdominal incision. or esophagus.600 16. including microvascular anastomosis. distal two-thirds.000 12.400 8.700 16. w/ colon interposition or small bowel reconstruction. thoracic approach Esophagoscopy. vestige.000 33. w/ colon interposition or small bowel reconstruction.400 5. rigid or flexible. w/ removal of foreign body Excision of lesion.700 5.520 2. nasopharynx.720 6. w/ colon interposition or small bowel reconstruction. and anastomosis(ses) Total or partial esophagectomy. direct closure by advancement of lateral and posterior pharyngeal walls Resection of pharyngeal wall requiring closure w/ myocutaneous flap Suture pharynx for wound or injury Pharyngoplasty (plastic or reconstructive operation on pharynx) Pharyngoesophageal repair Pharyngostomy (fistulization of pharynx. w/o thoracotomy.800 46.000 37. w/ free intestinal graft.000 5.600 21. w/ pharyngogastrostomy. w/ thoracotomy.520 2.400 5.400 8. w/ biopsy.400 43117 55.400 43122 55.600 21.600 9. buccal) Radical resection of tonsil.600 Health Care Institution Fee 5.800 5.000 18. and anastomosis(ses) Partial esophagectomy. any method Limited pharyngectomy Resection of lateral pharyngeal wall or pyriform sinus.500 5. w/ or w/o pyloroplasty Partial esophagectomy.400 43123 58. and/or retromolar trigone.600 9.600 21.720 8.200 12.520 8.720 2.800 21.080 10. or fistula.000 43112 59.400 9.120 8.000 43113 63. w/ or w/o proximal gastrectomy. esophagus.980 23.600 5.000 Professional Fee 2. w/ thoracotomy only. w/ cervical esophagostomy Diverticulectomy of hypopharynx.980 20.800 21. and/or retromolar trigone. secondary Radical resection of tonsil.400 8. cervical approach.540 10. cervical approach Diverticulectomy of hypopharynx.600 9. w/ or w/o pyloroplasty (Ivor Lewis) Partial esophagectomy.300 37. confined to skin and subcutaneous tissues Excision branchial cleft cyst.300 37.600 21. distal two-thirds.000 10.g. extending beneath subcutaneous tissues and/or into pharynx Tonsillectomy and adenoidectomy Tonsillectomy.000 43124 43130 43135 43200 43202 43204 46.000 43121 55. w/ or w/o myotomy. thoracoabdominal or abdominal approach.000 25.640 21.960 25. w/ primary repair. tonsillar pillars. w/ or w/o proximal gastrectomy.000 18.020 37. w/ or w/o myotomy.000 21. or cervical esophagogastrostomy.000 18. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 42806 42808 42809 42810 42815 42820 42825 42830 42835 42842 42844 42845 42860 42870 42890 42892 42894 42900 42950 42953 42955 43020 43030 43045 43100 43101 43107 DESCRIPTION Biopsy. external for feeding) Esophagotomy.120 12.300 8.500 5.000 33.800 37. including bowel mobilization. rigid or flexible.400 Page 52 of 98 .800 37.500 23. w/ or w/o pyloroplasty Partial esophagectomy.400 43108 58.000 18.800 21. thoracoabdominal or abdominal approach.640 38.000 33.020 18.400 8. primary or secondary Adenoidectomy.020 12.600 2. w/ thoracic esophagogastrostomy. esophagus. w/ primary repair. including bowel mobilization. w/ or w/o proximal gastrectomy.000 18. w/ injection sclerosis of esophageal varices Case Rate 8. thoracic approach.000 42. diagnostic.500 53. w/ or w/o pyloroplasty Total or near total esophagectomy. w/ or w/o proximal gastrectomy. w/ thoracotomy.400 5. any method Removal of foreign body from pharynx Excision branchial cleft cyst or vestige. single or multiple Esophagoscopy. w/ removal of foreign body Cricopharyngeal myotomy Esophagotomy. w/ thoracic esophagogastrotomy. distal two-thirds.000 10.500 5. w/o thoracotomy.560 21.200 29.500 5. survey for unknown primary lesion Excision or destruction of lesion of pharynx.300 24.400 10.600 21. including bowel mobilization. w/o reconstruction (any approach).500 7.400 21.540 12. preparation and anastomosis(es) Total or near total esophagectomy.000 43116 55.000 33. w/ pharyngogastrostomy or cervical esophagogastrostomy. primary Adenoidectomy.ANNEX 2.400 20.700 16.600 21.020 8.500 16.540 14.500 5.080 12.800 23. w/ or w/o collection of specimen(s) by brushing or washing Esophagoscopy. cervical approach Excision of lesion. cervical. tongue.120 18.020 8.800 21.800 21. preparation.040 5.600 9.800 10. closure w/ local flap (e. tonsillar pillars.520 2. preparation.040 7.800 10. w/ colon interposition or small bowel reconstruction. w/ or w/o proximal gastrectomy.040 6. preparation and anastomosis(es) Partial esophagectomy..600 9. tonsillar pillars.400 8. closure w/ other flap Excision of tonsil tags Excision or destruction lingual tonsil.520 21. w/ esophagogastrotomy.500 5.900 10.500 9. rigid or flexible. w/o closure Radical resection of tonsil.520 6. w/ removal or foreign body Upper gastrointestinal endoscopy including esophagus.600 43247 14.400 43245 18.400 9.040 5.900 Page 53 of 98 . w/ removal of tumor(s). and either the duodenum and/or jejunum as appropriate.400 8. and either the duodenum and/or jejunum as appropriate. and either the duodenum and/or jejunum as appropriate. w/ sphincterotomy/papillotomy Endoscopic retrograde cholangiopancreatography (ERCP).720 5.960 7. or other lesion(s).600 7. and either the duodenum and/or jejunum as appropriate.000 8. stomach. w/ or w/o collection of specimen(s) by brushing or washing Endoscopic retrograde cholangiopancreatography (ERCP).560 7.000 8. stomach. polyp(s). and either the duodenum and/or jejunum as appropriate. w/ directed placement of percutaneous gastrostomy tube Upper gastrointestinal endoscopy including esophagus.600 9. stomach.560 5.820 21.600 43249 18. and either the duodenum and/or jejunum as appropriate.080 10. rigid or flexible.960 7. rigid or flexible.960 7.000 8.120 6.600 5.560 7.400 5.720 8.400 9. w/ transendoscopic tube or catheter placement Upper gastrointestinal endoscopy including esophagus. and either the duodenum and/or jejunum as appropriate. stomach. and either the duodenum and/or jejunum as appropriate.900 10.ANNEX 2. w/ balloon dilation (less than 30 mm diameter) Esophagoscopy.000 8.400 9. w/ pressure measurement of sphincter of Oddi (pancreatic duct or common bile duct) Case Rate 14.000 14. and either the duodenum and/or jejunum as appropriate. and either the duodenum and/or jejunum as appropriate. and either the duodenum and/or jejunum as appropriate.000 8. single or multiple Upper gastrointestinal endoscopy including esophagus.500 43235 10. w/ injection sclerosis of esophageal and/or gastric varices Upper gastrointestinal endoscopy including esophagus.400 7.980 12. stomach. or other lesion(s) by snare technique Esophagoscopy. w/ ablation of tumor(s). polyp(s). and either the duodenum and/or jejunum as appropriate.120 18.000 18.400 9.960 18. stomach. w/ ballon dilation of esophagus (less than 30 mm diameter) Upper gastrointestinal endoscopy including esophagus. w/ or w/o collection of specimen(s) by brushing or washing Upper gastrointestinal endoscopy including esophagus.560 7. stomach. single or multiple Endoscopic retrograde cholangiopancreatography (ERCP). not amenable to removal by hot biopsy forceps. bipolar cautery or snare technique Upper gastrointestinal endoscopy.000 18.960 14. w/ dilation of gastric outlet for obstruction. rigid or flexible.400 43255 14.080 10.880 6. w/ insertion of plastic tube or stent Esophagoscopy. stomach.040 5.820 10.560 7. rigid or flexible. stomach.960 7. polyp(s).900 10. rigid or flexible. or other lesion(s) not amenable to removal by hot biopsy forceps.400 9.400 43244 14.540 Professional Fee 7. w/ band ligation of esophageal and/or gastric varices Upper gastrointestinal endoscopy including esophagus. rigid or flexible.400 9. w/ removal of tumor(s). rigid or flexible.600 43250 11. w/ insertion of guide wire followed by dilation of esophagus over guide wire Upper gastrointestinal endoscopy including esophagus. w/ insertion of guide wire followed by dilation over guide wire Esophagoscopy.100 5.920 10.980 20. w/ band ligation of esophageal varices Esophagoscopy.600 43259 14.600 43246 18.540 5. simple primary examination ( e. stomach. any method Esophagoscopy. w/ biopsy.560 8.600 9. stomach. w/ small diameter flexible endoscope) Upper gastrointestinal endoscopy including esophagus.400 43243 14. stomach. bipolar cautery or snare technique Upper gastrointestinal endoscopy including esophagus. or other lesion(s) by hot biopsy forceps or bipolar cautery Upper gastrointestinal endoscopy including esophagus. w/ removal of tumor(s).400 6. or other lesion(s) by hot biopsy forceps or bipolar cautery Esophagoscopy.500 43241 12. and either the duodenum and/or jejunum as appropriate.560 7.960 7. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 43205 43215 43216 43217 43219 43220 43226 43227 43228 43234 DESCRIPTION Esophagoscopy.540 5. w/ ablation of tumor(s) polyp(s). polyp(s). diagnostic. w/ removal of foreign body Esophagoscopy.400 43248 18.120 6. stomach.000 10.400 43260 43261 43262 43263 20. any method Upper gastrointestinal endoscopy including esophagus. w/ removal of tumor(s).720 5.900 10.400 8. w/ endoscopic ultrasound examination Endoscopic retrograde cholangiopancreatography (ERCP).960 11. or other lesion(s) by snare technique Upper gastrointestinal endoscopy including esophagus.980 5. any method Upper gastrointestinal endoscopy including esophagus.400 43258 18. and either the duodenum and/or jejunum as appropriate. diagnostic.040 Health Care Institution Fee 7. w/ control of bleeding. stomach. w/ control of bleeding. rigid or flexible.920 10.880 6.400 7.g.500 43239 10. and either the duodenum and/or jejunum as appropriate.560 7.100 43251 12. w/ biopsy.980 21. stomach. rigid or flexible.400 9. polyp(s). 260 8. w/ endoscopic retrograde insertion of tube or stent into bile or pancreatic duct Endoscopic retrograde cholangiopancreatography (ERCP).800 16. esophageal varices Transection of esophagus w/ repair.500 37.000 25. transthoracic or transabdominal approach Closure of esophagostomy or fistula..800 5.400 46.500 46.800 37.660 11.760 10.200 25.500 5.720 21. (plastic repair or reconstruction).. abdominal approach Esophagostomy.660 11. and anastomosis(es) Ligation.500 48.200 37.800 21.000 21.600 25.400 25.800 16. for esophageal varices Ligation or stapling at gastroesophageal junction for pre-existing esophageal perforation Suture of esophageal wound or injury. external.300 Professional Fee 12. for obstructing esophageal lesion or fistula. Collis) Esophagomyotomy (Heller type).800 46.500 21. preparation. w/ suture repair of bleeding ulcer Gastrotomy.300 16.760 10.700 21.360 3.200 16.500 13.900 43268 22. Nissen.300 21.500 23.700 Page 54 of 98 .020 42. over guide wire Dilation of esophagus. w/ endoscopic retrograde removal of foreign body and/or change of tube or stent Endoscopic retrograde cholangiopancreatography (ERCP).700 43272 43280 43300 43305 43310 43312 43320 43324 43325 43326 43330 43331 43340 43341 43350 43351 43352 43360 23. w/ endoscopic retrograde balloon dilation of ampulla. thoracic approach Esophagostomy. cervical approach Gastrointestinal reconstruction for previous esophagectomy.300 24. surgical.000 3. cervical approach.700 18. w/ ablation of tumor(s).120 58.360 4.600 37. retrograde Dilation of esophagus w/ balloon (30 mm diameter or larger) for achalasia Esophagogastric tamponade. w/ suture repair of pre-existing esophagogastric laceration (e.700 43265 30. w/ or w/o vagotomy and pyloroplasty. w/ balloon (Sengstaaken type) Free jejunum transfer w/ microvascular anastomosis Gastrotomy.800 5.ANNEX 2.320 21. thoracic approach.720 37.800 10. direct. w/ stomach.360 3.300 38.200 25.120 37. or other lesion(s) not amenable to removal by hot biopsy forceps.120 37.300 21.g. thoracic approach Esophagojejunostomy (w/o total gastrectomy). biliary and/or pancreatic duct(s) Endoscopic retrograde cholangiopancreatography (ERCP).800 8.760 10.400 21. Nissen. lithotripsy of stone(s).300 46. cervical approach Suture of esophageal wound or injury. bipolar cautery or snare technique Laparoscopy. or for previous esophageal exclusion.600 10. transabdominal or transthoracic approach Esophagogastric fundoplasty (e.200 27.800 19.800 12. esophagogastic fundoplasty (e.300 43267 22.800 37. w/ or w/o pyloroplasty Gastrointestinal reconstruction for previous esophagectomy.500 18. including bowel mobilization.g.360 3. w/ fundic patch (Thal-Nissen procedure) Esophagogastric fundoplasty. abdominal approach Esophagomyotomy (Heller type). external.800 21.320 19.300 12.500 46. w/ exploration or foreign body removal Gastrotomy.g.740 13. w/ colon interposition or small bowel reconstruction.g.300 30.800 30.500 53.660 11.200 29. Hill procedures) Esophagogastric fundoplasty.800 16. any method Endoscopic retrograde cholangiopancreatography (ERCP). thoracic approach..300 10. abdominal approach Esophagojejunostomy (w/o total gastrectomy).000 6. fistulization of esophagus. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 43264 DESCRIPTION Endoscopic retrograde cholangiopancreatography (ERCP). Mallory-Weiss) Case Rate 23.900 43269 22.600 Health Care Institution Fee 10.800 6. Belsey IV. w/ endoscopic retrograde removal of stone(s) from biliary and/or pancreatic ducts Endoscopic retrograde cholangiopancreatography (ERCP).900 43271 23.800 16.500 21.800 12.300 21. (plastic repair or reconstruction)..400 16.800 4.300 30.900 5.300 21. cervical approach Closure of esophagostomy or fistula.000 43361 43400 43401 43405 43410 43415 43420 43425 43450 43453 43456 43458 43460 43496 43500 43501 43502 63.300 12.900 4.800 46. polyp(s).900 4.440 17.000 13. cervical approach. fistulization of esophagus.000 21.260 8.400 16. external. w/o repair of tracheoesophageal fistula Esophagoplasty. or for previous esophageal exclusion.000 6. (plastic repair or reconstruction).600 16. by unguided sound or bougie.720 21.260 9.300 16. w/o repair of tracheoesophageal fistula Esophagoplasty. by balloon or dilator.300 13. w/ endoscopic retrograde insertion of nasobiliary or nasopancreatic drainage tube Endoscopic retrograde cholangiopancreatography (ERCP).260 8. fistulization of esophagus. transthoracic or transabdominal approach Dilation of esophagus. (plastic repair or reconstruction). w/ gastroplasty (e. w/ repair of tracheoesophageal fistula Esophagoplasty. thoracic approach Esophagostomy.200 21.000 25. single or multiple passes Dilation of esophagus.800 12.000 37.800 25.300 46.020 38.700 13.000 16.000 21. for obstructing esophageal lesion or fistula. w/ repair of tracheoesophageal fistula Esophagogastrostomy (cardioplasty).700 58.200 12.000 21. Toupet procedures) Esophagoplasty.500 30.900 4. w/ endoscopic retrograde destruction. 800 16. intussusception. truncal or selective Vagotomy including pyloroplasty. local. w/o gastric bypass.800 58.800 29. cutting of pyloric muscle (Fredet-Ramstedt type operation) Biopsy of stomach.000 25.520 1. wound.320 42.600 37. distal. temporary (tube. without construction of gastric tube (e.000 21.g.320 3.020 38.300 21. by laparotomy Excision.200 33. w/o gastric bypass. w/ esophagoenterostomy Gastrectomy.800 24.940 18. any type Gastrostomy.400 21. internal hernia.200 55.800 21.500 55. w/ short limb (less than 100 cm) Roux-en-Y gastroenterostomy Gastric restrictive procedure.500 53.700 9. total. w/ construction of gastric tube Gastrorrhaphy. w/ small bowel reconstruction to limit absorption Revision of gastric restrictive procedure for morbid obesity Revision of gastroduodenal anastomosis (gastroduodenostomy) w/ reconstruction.300 24. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 43510 43520 43600 43605 43610 43611 43620 43621 43622 43631 43632 43633 43634 43638 43639 43640 43641 43651 43652 43653 43750 43760 43800 43810 43820 43825 43830 43831 43832 43840 43842 43843 43846 43847 43848 43850 43855 43860 DESCRIPTION Gastrotomy.000 67.260 21.200 46.300 9. suture of perforated duodenal or gastric ulcer.000 21.300 21.800 16.000 63. w/ or w/o partial gastrectomy or bowel resection. proximal. for feeding Gastrostomy.200 29. partial. ulcer or benign tumor of stomach Excision.000 58. total.600 5.g.000 21.000 42.800 63.000 21. Baker tube) Colotomy.600 33. w/ Roux-en-Y reconstruction Gastrectomy.000 21. biopsy(s). for exploration.400 21.400 33. w/ or w/o partial gastrectomy or bowel resection. other than duodenum.500 4. Celestin or Mousseaux-Barbin) Pyloromyotomy.000 58.000 55.600 8.000 21. biopsy(s).800 37. w/o vagotomy Revision of gastrojejunal anastomosis (gastrojejunostomy) w/ reconstruction.800 37.000 25.200 67. Gastrostomy.000 21. surgical Closure of gastrocolic fistula Enterolysis (freeing of intestinal adhesion) Duodenotomy.400 37.320 19.800 21.400 21.800 58.000 46.200 33.000 25. rubber or plastic) .400 21.000 21. neonatal. by capsule.000 46. permanent. tube.400 2. parietal cell (highly selective) Laparoscopy.000 21.. for morbid obesity.000 21. small bowel.800 58. thoracic or abdominal approach including esophagogastrostomy.800 37. other than duodenum.800 53.800 16. for exploration..500 18. distal.000 16. small bowel.800 37.800 37.900 13. or foreign body removal.240 8.700 18. w/o vagotomy Revision of gastroduodenal anastomosis (gastroduodenostomy) w/ reconstruction. Stamm Procedure) Percutaneous placement of gastrostomy tube Change of gastrostomy tube Pyloroplasty Gastroduodenostomy Gastrojejunostomy.300 38.700 4.800 42. thoracic or abdominal approach including esophagogastrostomy. for exploration.400 21. partial.800 63.000 24. partial. transection of vagus nerve.020 8. w/ formation of intestinal pouch Gastrectomy. total.020 38. w/ vagotomy..800 53. Enterotomy.400 37.400 21.000 21.000 21.700 18. tube.000 46.800 16.000 21. or foreign body removal Enterotomy.000 46.000 37.800 21.300 16.000 21. vertical-banded gastroplasty Gastric restrictive procedure. w/o vagotomy Gastrojejunostomy.800 58.800 46.g.600 Page 55 of 98 . rubber or plastic) . or foreign body removal.000 21.020 5. surgical.000 42. w/ or w/o gastrostomy. w/ or w/o gastrostomy.800 37.000 18.800 58.500 58. for decompression (e. w/ formation of intestinal pouch. any type Gastrectomy.800 19. w/ vagotomy Revision of gastrojejunal anastomosis (gastrojejunostomy) w/ reconstruction.600 12.800 37. partial.800 37.000 21.200 37. Gastrectomy.000 16. or injury Gastric restrictive procedure.260 30.800 Professional Fee 19. malignant tumor of stomach Gastrectomy.320 19. Ladd procedure) Biopsy of intestine by capsule.000 63. w/ vagotomy.400 9.000 43865 43870 43880 44005 44010 44020 44021 44025 44050 44055 44100 63. partial.. temporary (tube. for morbid obesity.400 55.000 29. truncal Laparoscopy. other than vertical-banded gastroplasty Gastric restrictive procedure.g.360 16. local. w/ gastroduodenostomy Gastrectomy. for exploration. surgical. w/ vagotomy.800 37. distal.800 Health Care Institution Fee 18. selective or highly selective Laparoscopy. proximal. w/ gastric bypass for morbid obesity.000 63.200 8.800 46. by laparotomy Correction of malrotation by lysis of duodenal bands and/or reduction of midgut volvulus (e.200 37. w/ Roux-en-Y reconstruction Gastrectomy. peroral (one or more specimens) Case Rate 38.700 21.000 21.500 18. transection of vagus nerves.000 67. w/ gastrojejunostomy Gastrectomy.000 21. surgical. partial. or foreign body removal Reduction of volvulus.ANNEX 2.000 21.000 42. w/ vagotomy Closure of gastrostomy. distal.000 16. w/ esophageal dilation and insertion of permanent intraluminal tube (e.560 37.400 9.000 42.020 63.000 8. w/ pyloroplasty or pyloromyotomy Vagotomy including pyloroplasty. biopsy(s). peroral (one or more specimens) Biopsy of stomach.200 21.000 21. gastrostomy. biopsy(s).600 42.000 21. w/ gastric bypass for morbid obesity.000 25. or fistulization. large or small intestine.000 58.300 30.600 37. complicated (reconstruction in .800 12.820 23. surgical.600 37. w/ coloproctostomy (low pelvic anastomosis) Colectomy. w/ multiple biopsies (e.800 55.800 58. colectomy.. w/ coloproctostomy (low pelvic anastomosis).800 33.800 56.. with resection and anastomosis Enterostomy or cecostomy. total. partial. w/o proctectomy.800 58. jejunostomy (e. w/ proctectomy. abdominal. anastomosis of intestine.300 23.300 24. total. creation of ileal reservoir (S or J). surgical.800 16. not including ileum.600 21.000 63. with anastomosis.500 10.000 21. Colostomy or skin level cecostomy.400 10. w/ or w/o cutaneous enterostomy Colectomy. with end colostomy and closure of distal segment (Hartmann type procedure) Laparoscopy.000 21. simple (release of superficial scar) Revision of colostomy.800 7.120 12.680 58. w/ rectal mucosectomy. with ileostomy Laparoscopy. enterectomy. non. surgical.800 42. colectomy. closure of enterostomy. abdominal.400 10.ANNEX 2.200 46.300 21. diagnostic. ileoanal anastomosis.000 46. abdominal.900 10. w/ ileostomy Colectomy.400 Page 56 of 98 .200 25. complicated (reconstruction in-depth) Continent ileostomy (Koch procedure) Colostomy or skin level cecostomy.500 53.700 16. colectomy.000 21.200 29. abdominal and transanal approach Colectomy.800 37. partial.600 16.g.tube Revision of ileostomy. partial.600 5. with anastomosis.500 7. total.600 10. w/ colostomy or ileostomy and creation of mucofistula Colectomy.800 Professional Fee 21. w/ or w/o loop ileostomy Colectomy. w/ ileostomy or ileoproctostomy Colectomy. with coloproctostomy (low pelvic anastomosis) Laparoscopy.300 21. enterolysis (freeing of intestinal adhesion) Laparoscopy.600 16.920 12. for decompression or feeding).000 21.000 21. single resection and anastomosis Laparoscopy. w/ enterostomy Enteroenterostomy.200 8. beyond second portion of duodenum.800 58. resection of small intestine. w/ skin level cecostomy or colostomy Colectomy. with protectomy.500 10.depth ) Revision of colostomy. with protectomy.800 55.000 21.280 37. single resection and anastomosis Enterectomy. surgical.800 12. abdominal. abdominal.000 58.700 13. enteroscopy.300 14. surgical.960 14. with or without rectal mucosectomy Laparoscopy.900 13. single enterotomy Excision of one or more lessions of small or large bowel not requiring anastomosis. partial.000 21.000 23..200 67.300 37.000 12. not including ileum.560 7.400 12. w/o proctectomy. colostomy or skin level cecostomy Laparoscopy.800 37. w/ or w/o collection of specimen(s) by brushing or washing Small intestinal endoscopy.000 Health Care Institution Fee 16.000 16. creation of ileal reservior (S or J).000 67.500 13.300 23. with coloproctostomy (low pelvic anastomosis) with colostomy Laparoscopy.800 58.200 46.200 25. with ileo-anal anastomosis. partial.. Laparoscopy. w/ rectal mucosectomy.960 25.000 42. surgical.400 7. beyond second portion of duodenum.300 18. for Hirschsprung disease) Revision of colostomy. partial.000 63. surgical. tube (e.200 67.400 9. exteriorization.000 21. abdominal. or fistulization.700 10.800 21. exteriorization. w/ resection. resection of small intestine.800 33. surgical.700 9.000 42.200 46.g.000 21.800 55. partial.300 21.400 21.700 13.400 5. single or multiple Case Rate 37.820 30.400 21.800 63.600 8.200 46. with loop ileostomy.000 21.400 37. multiple enterotomies Enterectomy.000 21. w/ proctectomy.000 33. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 44110 DESCRIPTION Excision of one or more lessions of small or large bowel not requiring anastomosis. abdominal. surgical.g. total.g. w/o proctectomy.000 21.300 30. abdominal.720 8. surgical. colectomy.600 12.200 18. without protectomy. ileostomy or jejunostomy.300 30.800 37. w/ or w/o loop ileostomy Colectomy. total. simple (release of superficial scar) Revision of ileostomy. surgical. w/ biopsy. w/ end colostomy and closure of distal segment (Hartmann type procedure) Colectomy. surgical.000 9. total. partial. colectomy. w/ continent ileostomy Colectomy w/ removal of terminal ileum and ileocolostomy Laparoscopy. with anastomosis Laparoscopy.400 21.800 37. w/o proctectomy.000 21. total. non-tube Laparoscopy. abdominal.000 21.200 67.500 46.000 37. total.600 10. w/ colostomy Colectomy. w/ continent ileostomy Colectomy.500 46. surgical. ileoanal anastomosis.000 21.800 35.920 16.560 21. for decompression or feeding) Ileostomy or jejunostomy.000 21. partial. w/ anastomosis Colectomy. w/ repair of paracolostomy hernia Small intestinal endoscopy. jejunostomy (e. with ileostomy or ileoproctostomy Laparoscopy.000 23.800 21. colectomy. colectomy. total. with removal of terminal ileum with ileocolostomy Laparoscopy. colectomy. partial. partial.200 67. surgical. for decompression or feeding.800 21. partial.400 6.600 10.720 6. resection of small intestine.120 18.400 58. enteroscopy.800 44111 44120 44125 44130 44140 44141 44143 44144 44145 44146 44147 44150 44151 44152 44153 44155 44156 44160 44180 44186 44187 44188 44202 44204 44205 44206 44207 44208 44210 44211 44212 44227 44300 44310 44312 44314 44316 44320 44322 44340 44345 44346 44360 44361 46. 400 Health Care Institution Fee 9. injury or rupture.800 37. surgical. not including ileum.700 5.500 13. not including ileum.600 9. not including ileum.600 44369 21.000 8. Closure of enterostomy. single or multiple Endoscopic evaluation of small intestinal (abdominal or pelvic) pouch. or other lesion(s) by snare technique Introduction of long gastrointestinal tube (e.300 21.000 18.400 8.g.700 44376 44377 44378 44380 44382 44385 44386 44388 44389 44390 44391 44392 44393 44394 44500 44602 44603 44604 18.400 13. polyp(s).560 7. wound.400 9.600 9. not including ileum.400 7.000 8. injury or rupture.000 18.540 24.600 12.600 44365 44366 18. beyond second portion of duodenum. bipolar caurtery or snare technique Colonoscopy through stoma.800 16.000 21.000 21.400 8.240 12.800 44605 44615 44620 44625 44640 44650 44660 44661 44800 44820 44850 44900 44950 44960 44970 45000 37. diagnostic. for intestinal obstruction Closure of enterostomy.800 21. enteroscopy. w/ biopsy. w/ or w/o collection of specimen(s) by brushing or washing Ileoscopy. w/ removal of tumor(s). for ruptured appendix w/ abscess or generalized peritonitis Laparoscopy.600 5. including ileum.020 37.000 21.000 9. through stoma.600 9. w/o intestinal or bladder resection Closure of enterovesical fistula.400 8.800 16.800 18. w/ control of bleeding.400 9. through stoma. single perforation Suture of small intestine (enterorrhaphy) for perforated ulcer.500 16.500 13.300 37.800 37. w/ removal of tumor(s).400 14.400 7. beyond second portion of duodenum. enteroscopy.600 12.940 9. any method Colonoscopy through stoma.000 18.560 7.000 Professional Fee 8. diverticulum.400 7. single or multiple Colonoscopy through stoma. beyond second portion of duodenum.560 8. w/ removal of tumor(s).520 21.800 37.940 8. injury or rupture (single or multiple perforations). diverticulum.600 9. transabdominal Appendectomy. diverticulum.800 30.940 9. single or multiple Small intestinal endoscopy. polyp(s). large or small intestine.ANNEX 2.400 7. polyp(s). or other lesion(s) by hot biopsy forceps or bipolar cautery Small intestinal endoscopy. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 44363 44364 DESCRIPTION Small intestinal endoscopy.000 18. or other lesions(s) by snare technique Small intestinal endoscopy.720 5.000 21.600 16.000 18.000 24.940 21. w/ or w/o collection of specimen(s) by brushing or washing Colonoscopy through stoma.800 16. enteroscopy. diverticulum. wound. not including ileum. w/ colostomy Intestinal stricturoplasty (enterotomy and enterorrhaphy) w/ or w/o dilation.800 16.240 2. w/ bowel and/or bladder resection Excision of Meckels diverticulum (diverticulectomy) or omphalomesenteric duct Excision of lesion of mesentery Suture of mesentery Incision and drainage of appendiceal abscess.040 9.600 9.800 16.800 37.500 13. enteroscopy beyond second portion of duodenum.560 7. any method Ileoscopy. enteroscopy. single or multiple Colonoscopy through stoma.800 13. including ileum.120 10.800 16. beyond second portion of duodenum.600 9.240 9. polyp(s). not including ileum. Miller-Abbott) Suture of small intestine (enterorrhaphy) for perforated ulcer.800 8. w/ removal of foreign body Small intestinal endoscopy.240 7.000 21.400 14.700 7.400 6. diagnostic.300 30. appendectomy Transrectal drainage of pelvic abscess Case Rate 18. enteroscopy.w/ biopsy.960 14.w/ control of bleeding.500 16.000 21. beyond second portion of duodenum.560 7. injury or rupture (single or multiple perforations).960 18.240 12.960 14.560 7.400 5. enteroscopy. beyond second portion of duodenum. w/ conversion of percutaneous gastrostomy tube to percutaneous jejunostomy tube Small intestinal endoscopy. wound.960 14.600 9. polyp(s).400 9. w/ or w/o collection of specimen(s) by brushing or washing Small intestinal endoscopy. w/ removal of tumor(s).700 44372 21. w/ placement of percutaneous jejunostomy tube Small intestinal endoscopy.600 9. enteroscopy beyond second portion of duodenum. multiple perforation Suture of large intestine (colorrhaphy) for perforated ulcer.300 30.000 24.400 8.000 18. w/ control of bleeding. w/ resection and anastomosis Closure of intestinal cutaneous fistula Closure of enteroenteric or enterocolic fistula Closure of enterovesical fistula. bipolar cautery or snare tenchnique Small intestinal endoscopy.000 16. w/ ablation of tumor(s). diagnostic. not including ileum. w/ or w/o collection of specimen(s) by brushing or washing Endoscopic evaluation of small intestinal (abdominal or pelvic) pouch.940 14.800 16.400 7.700 44373 21.300 30.960 14.400 8.800 9. w/ biopsy. or other lesion(s) by hot biopsy forceps or bipolar cautery Colonoscopy through stoma.500 14.000 12. enteroscopy beyond second portion of duodenum..700 12. w/o colostomy Suture of large intestine (colorrhaphy) for perforated ulcer. w/ removal of foreign body Colonoscopy through stoma.240 12. w/ ablation of tumor(s).960 14. w/ biopsy. or other lesion(s) not amenable to removal by hot biopsy forceps. including ileum. wound.400 9. Appendectomy. beyond second portion of duodenum. enteroscopy. any method Small intestinal endoscopy. or other lesion(s) not amenable to removal by hot biopsy forceps.500 Page 57 of 98 .800 16. polyp(s). diagnostic.400 8.000 30. large or small intestine.940 9. 120 12.000 21. polyp(s). transanal approach Destruction of rectal tumor. partial. w/ or w/o collection of specimen(s) by brushing or washing Sigmoidoscopy.500 5.720 8. polyp. w/ or w/o colon decompression Colonoscopy. creation of ileal reservoir (S or J).000 30.800 37. abdominal and perineal approach Division of stricture of rectum Excision of rectal tumor by proctotomy. proximal to splenic flexure. any method (e.360 3. any method Sigmoidoscopy.540 10.600 5. or other lesion(s) not amenable to removal by hot biopsy forceps.400 2. or other lesion by hot biopsy forceps or bipolar cautery Proctosigmoidoscopy. flexible.g.560 21.000 14.200 2.540 11.800 33. flexible. rigid. w/ removal of multiple tumors. diagnostic. perineal approach Excision of rectal procidentia. or other lesion(s) by snare technique Sigmoidoscopy.500 5. w/ subtotal or total colectomy. w/ anatomosis. rigid.540 12. transsacral or transcoccygeal approach Excision of rectal tumor. w/ removal of single tumor. Duhamel. proximal to splenic flexure. rigid. laser) Proctosigmoidoscopy.800 33. single or multiple Colonoscopy. flexible.500 5. flexible. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 45005 45020 45100 45108 45110 45111 45112 45113 45114 45116 45120 DESCRIPTION Incision and drainage of submucosal abscess. or other lesion(s) not amenable to removal by hot biopsy forceps. polyp(s). abdominal and perineal approach.700 8.400 9. perineal approach Excision of rectal procidentia.700 9. w/ ablation of tumor(s). flexible. w/ removal of foreign body Proctosigmoidoscopy. pelvirectal.700 9. w/ biopsy.880 5.200 4. w/ dilation.800 12. any method Colonoscopy. w/ removal of foreign body Colonoscopy.260 9.600 9.260 9.400 Page 58 of 98 .400 33. bipolar cautery or snare technique (e.500 21.800 Professional Fee 8.400 21.500 5.500 5.ANNEX 2.600 16.720 5. rigid. or other lesion(s) not amenable to removal by hot biopsy forceps.600 37.600 33..980 10.040 6..400 16.600 29. flexible. w/ decompression of volvulus Sigmoidoscopy.500 5.400 5. any method Proctosigmoidoscopy. partial. w/ control of bleeding.. complete (for congenital megacolon). flexible.360 4. rigid. w/o anastomosis.400 21. transsacral approach only (Kraske type) Proctectomy. rectum Incision and drainage of deep supralevator.260 8.500 6. w/ ablation of tumor(s). flexible. diagnostic. partial. or other lesion(s) by hot biopsy forceps or bipolar cautery Sigmoidoscopy.400 7.700 10.960 37. rigid. polyp(s). ileoanal anastomosis. w/ multiple biopsies Proctectomy.400 8. w/ biopsy. bipolar cautery or snare technique Case Rate 18. w/ colostomy Proctectomy.g. w/ removal of tumor(s). anal approach (e.720 6.120 10.040 5. transabdominal approach Proctectomy.800 55. partial.540 10. polyp(s).720 6. abdominal and transsacral approach Proctectomy.120 12.200 5.g. bipolar cautery or snare technique Proctosigmoidoscopy. colo-anal anastomosis) Proctectomy. proximal to splenic flexure. w/ or w/o collection of specimen(s) by brushing or washing.600 7. w/ pull-through procedure and anastomosis (e.720 33.120 18. w/ control of bleeding.300 30. or retrorectal abscess Biopsy of anorectal wall.540 12. rigid or flexible.040 3.000 18.000 58.500 5. abdominal and perineal approach.000 18.000 55.800 33.700 13. congenital megacolon) Anorectal myomectomy Proctectomy.500 5.200 5.400 21.100 5.020 8.520 4. or Soave type operation) Proctectomy.500 4. w/ biopsy.400 21. any method Sigmoidoscopy.000 21.120 55. polyp.000 21. transabdominal via colotomy.000 53.000 55.360 4.000 21..600 37.900 5. w/ decompression of volvulus. w/ control of bleeding. polyp(s). pull-through procedure (e.000 8. electrodesiccation) transanal approach Proctosigmoidoscopy. proximal to splenic flexure. w/ anastomosis. w/ removal of single tumor. flexible. or other lesion by snare technique Proctosigmoidoscopy..800 55.400 5. w/ anastomosis.600 33.600 6. rigid. polyps or other lesions by hot biopsy forceps. rigid. w/ rectal mucosectomy.400 24.400 9.000 12. flexible. w/ removal of foreign body Sigmoidoscopy.040 5. combined abdominoperineal.040 6. bipolar cautery or snare technique Colonoscopy.020 9. proximal to splenic flexure.500 5.500 5. rigid.500 4.400 55.400 5.g.300 55. complete.400 21. single or multiple Colonoscopy.540 10. flexible. single or multiple Proctosigmoidoscopy.400 5. complete (for congenital megacolon).900 4. partial resection of rectum. diagnostic. flexible.540 8.600 13.000 58.800 Health Care Institution Fee 9. w/ removal of tumor(s).600 8. any method Proctosigmoidoscopy.500 5.800 58. w/ or w/o collection of specimen(s) by brushing or washing Proctosigmoidoscopy.300 23.g. w/ or w/o loop ileostomy Proctectomy. Swenson. w/ anatomosis.700 10. w/ ablation of tumor(s).500 10. combined abdominoperineal.900 5.520 3. rigid. flexible. single or multiple Sigmoidoscopy.040 5.200 4.040 5.000 45121 45123 45130 45135 45150 45160 45170 45190 45300 45303 45305 45307 45308 45309 45315 45317 45320 45321 45330 45331 45332 45333 45334 45337 45338 45339 45355 45378 45379 45380 45382 45383 58. 400 5. simple. complex or extensive. proximal to splenic flexure. proctectomy. Hemorrhoidectomy.600 15.120 15. w/ or w/o placement of seton Surgical treatment of anal fistula (fistulectomy/fistulotomy).400 6.120 16. surgical.520 3. external.560 8. diagnostic. w/ removal of foreign body Anoscopy. colo-anal anastomosis).260 9.300 27.020 8.400 12.000 16. submuscular Surgical treatment of anal fistula (fistulectomy/fistulotomy). w/ fissurectomy Hemorrhoidectomy. by simple ligature (e. transanal. surgical. anus Hemorrhoidectomy. internal and external. under anesthesia Incision and drainage. simple.400 33.720 6..900 4. w/ or w/o fissurectomy Hemorrhoidectomy.720 8. polyp(s).000 3.400 5. proctopexy (for prolapse) Laparoscopy.900 5.300 37. with diverting enterostomy.120 30. complex or extensive.600 21. bipolar cautery or snare technique Case Rate 14. or other lesion(s) by snare technique Laparoscopy.400 5.900 4. combined abdominoperineal pull through procedure (e. anal.400 5. any method Anoscopy.120 16.200 3.400 9.400 5. superficial Incision and drainage of ischiorectal or intramural abscess.400 9.400 45397 45400 45402 45500 45505 45540 45541 45550 45560 45562 45563 45800 45805 45820 45825 45905 45910 45915 46040 46045 46050 46060 46070 46080 46083 46200 46210 46211 46220 46221 46230 46250 46255 46257 46258 46260 46261 46262 46270 46275 46280 46285 46288 46320 46600 46604 46606 46608 46610 46611 46612 55.000 4.900 Page 59 of 98 ..120 12.120 12. Closure of rectourethral fistula. w/ fissurectomy Hemorrhoidectomy.260 8.500 4. for prolapse of mucous membrane Proctopexy for prolapse.200 4.360 3.000 13.500 5.g.720 1. flexible.800 13. flexible. or submucosal abscess.600 Health Care Institution Fee 7. internal and external.360 4.680 8.800 21.900 5. complete Hemorrhoidectomy. w/ colostomy Closure of rectourethral fistula.400 5.360 4. w/ removal of single tumor.000 Professional Fee 7.400 8. or other lesion by hot biopsy forceps or bipolar cautery Anoscopy.960 18.500 5.700 9.400 5. w/ fistulectomy or fistulotomy. or other lesion(s) by hot biopsy forceps or bipolar cautery Colonoscopy.200 3.520 3.g. polyps. proximal to splenic flexure.260 9.680 5.900 4. single Cryptectomy. w/ colostomy Dilation of anal sphincter under anesthesia other than local Dilation of rectal stricture under anesthesia other than local Removal of fecal impaction or foreign body under anesthesia Incision and drainage of ischiorectal and/or perirectal abscess Incision and drainage of intramural. w/ dilation.360 6.400 5.720 6. w/ colostomy Closure of rectovesical fistula.720 6.120 12.680 5.700 9.260 8.g.260 12.720 6. with colostomy Laparoscopy.900 5.120 30.400 15.500 9.800 8. complex or multiple. surgical.700 12.400 5. proctopexy (for prolapse).400 5. w/ or w/o fissurectomy Surgical treatment of anal fistula (fistulectomy/fistulotomy).500 16.120 30. w/ biopsy.360 21. J-pouch).600 9.120 12.360 3.120 12. complete combined abdominoperineal.500 16.600 12.600 5. polyp(s).900 4.700 8.260 8.300 18.680 1. with sigmoid resection Proctoplasty. or other lesions by hot biopsy forceps. division of sphincter Incision of thrombosed hemorrhoid. subcutaneous Surgical treatment of anal fistula (fistulectomy/fistulotomy).360 3. polyp.000 5.000 18. repair and presacral drainage for rectal injury.020 8.400 5.120 12.400 5.120 16..000 13. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 45384 45385 45395 DESCRIPTION Colonoscopy.000 12.260 8.500 4. second stage Closure of anal fistula w/ rectal advancement flap Enucleation or excision of external thrombotic hemorrhoid Anoscopy. anal septum (infant) Sphincterotomy.680 5.000 13.200 4. when performed Laparoscopy.120 12.300 37. complex or extensive.120 12.120 18. abdominal approach Repair of rectocele Exploration.260 8.600 15.900 5. single or multiple Anoscopy.200 2. repair and presacral drainage for rectal injury. submuscular. w/ or w/o placement of seton Incision.720 6.ANNEX 2. w/ or w/o sphincterotomy Cryptectomy.680 1.720 6. simple. with creation of colonic reservoir (e.120 12. internal and external. for stenosis Proctoplasty. intramuscular. polyp or other lesion by snare technique Anoscopy.120 27.000 55. internal and external. w/ removal of multiple tumor.000 4.500 4. multiple Papillectomy or excision of single tag.500 4.800 30.000 27.800 4.360 3. w/ or w/o collection of specimen(s) by brushing or washing Anoscopy.900 4.360 3.800 8. surgical. perineal approach Proctopexy combined w/ sigmoid resection.720 6.500 5.260 33.360 4.120 5.120 12. protectomy.680 1. Hemorrhoidectomy. perianal abscess. internal and external. Exploration.720 6.720 6.720 6.800 21. w/ removal of tumor(s). w/ removal of single tumor. Closure of rectovesical fistula.500 9. w/ removal of tumor(s).400 12.700 8.120 12.000 12.300 18.120 12.720 6.400 4.600 10.000 23.000 27. w/ fistulectomy.800 8. rubber band) Excision of external hemorrhoid tags and/or multiple papillae Hemorrhoidectomy. external Fissurectomy. w/ fistulectomy.000 4. abdominal approach Proctopexy for prolapse. internal and external.720 6.260 9.700 8.680 2. needle.700 8.000 7. anal. simple.600 8. condyloma.520 8.200 3.000 21.000 18.360 2. combined abdominal and sacroperineal approach. anal canal Sphincteroplasty. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 46614 46615 46700 46705 46715 46716 46730 46735 46740 46742 46744 46746 46748 46750 46751 46753 46754 46760 46761 46762 46900 46910 46916 46917 46922 46924 46934 46935 46936 46937 46938 46940 46945 47000 47010 47015 47100 47120 47122 47125 47130 47134 47135 47136 47300 47350 47360 DESCRIPTION Anoscopy. molluscum contagiosum..400 58.000 21. any age Marsupialization of cyst or abscess of liver Management of liver hemorrhage. anal. heterotopic.300 13.200 29. adult Sphincteroplasty.g. total left lobectomy Hepatectomy.700 9.800 42.300 9. malignant Curettage or cauterization of anal fissure. papilloma. partial or whole. surgical excision Destruction of lesion(s).080 23.500 9.400 9.300 21.900 4.300 53. anus (e.700 21.500 53. electrodesiccation Destruction of lesion(s).600 25.400 46.800 46.700 5. from living donor Liver allotransplantation. simple. simple. herpetic vesicle). w/ or w/o hepatic artery ligation Case Rate 8. condyloma. any method. w/ preparation and maintenance of allograft. resection of liver. any method.500 4. including dilation of anal sphincter Ligation of internal hemorrhoids Biopsy of liver.020 9.g.600 21. levator muscle imbrication (Park posterior anal repair) Sphincteroplasty. chemical Destruction of lesion(s).900 16.360 3.500 24. combined transabdominal and sacroperineal approaches Repair of cloacal anomaly by anorectovaginoplasty and urethroplasty.g.400 12. bipolar cautery or snare technique Anoplasty.500 4.500 5.320 8.800 21.260 8.800 10. molluscum contagiosum. simple suture of liver wound or injury Management of liver hemorrhage. anus (e.200 4. perineal or sacroperineal approach Repair of high imperforate anus w/o fistula.600 10.800 37.000 42.520 3. resection of liver.260 8.300 46.500 55.800 16. molluscum contagiosum. adult.g. for incontinence.900 16.300 23.360 3. plastic operation for stricture.260 9.360 4. condyloma.200 Health Care Institution Fee 5.. papilloma. any method Anoscopy.000 55. extensive. implantation artificial sphincter Destruction of lesion(s). papilloma.800 63.300 37.500 5.300 24. trisegmentectomy Hepatectomy.600 12. benign Cryosurgery of rectal tumor.900 23. herpetic vesicle). cryosurgery Destruction of lesion(s). amoebic or echinococcal) cyst(s) or abscess(es) Biopsy of liver. internal and external Cryosurgery of rectal tumor.700 9.200 4. anus (e.000 46.500 5.700 9. for incontinence or prolapse.600 33.. Repair of cloacal anomaly by anorectovaginoplasty and urethroplasty. infant Repair of low imperforate anus.700 9.700 9.400 8.500 5. total right lobectomy Donor hepatectomy. anus (e.900 5.260 40.200 4. simple. molluscum contagiosum.300 12.360 3.400 21.400 8.320 20. for incontinence or prolapse. muscle transplant Sphincteroplasty.g.200 6.020 18. partial or whole. w/ vaginal lengthening by intestinal graft or pedicle flaps Sphincteroplasty.900 4. papilloma.900 5.400 55. condyloma. for incontinence.700 12.200 4. anus (e. simple.000 63. papilloma.400 33.520 10. w/ ablation of tumor(s).400 10.g. sacroperineal approach Repair of cloacal anomaly by anorectovaginoplasty and urethroplasty.980 40.400 29. child Graft (Thiersch operation) for rectal incontinence and/or prolapse Removal of Thiersch wire or suture.500 5.200 33.g.000 7. anal.. herpetic vesicle). any age Liver allotransplantation.500 30. laser surgery Destruction of lesion(s).900 4.700 8. for incontinence.260 8. partial.200 4.500 Professional Fee 2. external Destruction of hemorrhoids.700 10.400 25. anal. perineal or sacroperineal approach Repair of high imperforate anus w/ rectourethral or rectovaginal fistula. one or two stages Laparotomy. herpetic vesicle). orthotopic. anal. adult Anoplasty.000 23..200 3.520 4. resection of liver. from cadaver or living donor. complex suture of liver wound or injury.400 21. percutaneous Hepatotomy for drainage of abscess or cyst.ANNEX 2.600 4. from cadaver or living donor.600 9.600 10. herpetic vesicle).200 16.360 23. resection of liver.960 23. molluscum contagiosum. w/ aspiration and/or injection of hepatic parasitic (e.. molluscum contagiosum. w/ transportation of anoperineal or anovestibular fistula Repair of high imperforate anus w/o fistula.800 4. w/ control of bleeding. or other lesion(s) not amenable to removal by hot biopsy forceps. any method. partial lobectomy Hepatectomy. combined abdominal and sacroperineal approach. herpetic vesicle). anus (e.700 16.000 21.000 21.500 5.600 9.000 18. condyloma. combined transabdominal and sacroperineal approaches Repair of high imperforate anus w/ rectourethral or rectovaginal fistula.800 29. adult.360 3. wedge Hepatectomy.200 4.500 6.300 Page 60 of 98 . w/ anoperineal fistula ("cut-back" procedure) Repair of low imperforate anus.560 12.700 9.000 18.260 8.500 5. plastic operation for stricture.260 8.400 37.000 53. any method Destruction of hemorrhoids..000 25.600 25.000 21. condyloma. adult.600 24. papilloma.000 14. polyp(s).900 4. internal Destruction of hemorrhoids.000 21. open.400 8.600 12.600 12.360 12.500 30.600 12. cryosurgical Ablation. cholecystoenterostomy Cholecystectomy. ablation of one or more liver tumor(s).300 16.500 24.000 58.800 33.700 9. with biopsy Laparoscopy.800 37. basket.000 21.900 10.500 23.700 53.800 16. w/o excision Cholecystoenterostomy.tube or other tract.700 18. of or more liver tumor(s).300 23.000 31.300 53.300 21.000 31. percutaneous via T-tube tract. diagnostic.000 16.800 16. with guided transhepatic cholangiography. Roux-en-Y.260 23. w/ gastroenterostomy Roux-en-Y Roux-en-Y w/ gastroenterostomy Anastomosis.700 24. Cholecystectomy. w/ or w/o primary repair of bile duct.500 13..800 47425 47460 47480 47490 47510 47511 47525 47530 47552 47553 47554 47555 47556 47560 47561 47562 47563 47564 47570 47600 47605 47610 47612 47620 47630 47700 47701 47711 47712 47715 47716 47720 47721 47740 47741 47760 47765 47780 46. w/ or w/o transduodenal extraction of calculus Cholecystotomy or cholecystostomy w/ exploration.400 25.000 55. or removal of calculus.ANNEX 2.700 10.600 37. of extrahepatic biliary ducts and gastrointestinal tract Case Rate 37. of or more liver tumor(s).600 18.200 12.300 30. drainage.300 Page 61 of 98 .000 21.300 23.tube or other tract.000 25.000 46.400 29.400 25.700 9. percutaneous via T. w/ or w/o cholecystotomy. percutaneous via T. w/ cholangiography Cholecystectomy w/ exploration of common duct.800 2.500 46.600 25.400 46.400 46. surgical.600 9. w/ or w/o collection of specimen(s) by brushing and/or washing Biliary endoscopy. w/ dilation of biliary duct stricture(s) w/o stent Biliary endoscopy.400 12.600 21. percutaneous via T.000 21. drainage.400 21.200 4.200 4.000 Health Care Institution Fee 16.600 18.400 33.000 46.020 8. w/ or w/o primary repair of bile duct. percutaneous via T.400 25.500 25.. ablation of one or more liver tumor(s). re-exploration of hepatic wound for removal of packing Laparoscopy. open.700 10. w/o repair. extensive debridement.200 25.000 21. surgical.800 9.400 46. of extrahepatic biliary ducts and gastrointestinal tract Anastomosis.000 46. percutaneous via T.400 25. w/ or w/o cholangiography Portoenterostomy (e.000 24. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 47361 47362 47370 47371 47380 47381 47382 47400 47420 DESCRIPTION Management of liver hemorrhage.500 13.800 16.300 18.200 29. surgical. direct Cholecystoenterostomy. cholecystectomy (any method) Laparoscopy. Kasai procedure) Excision of bile duct tumor. surgical.400 21.400 12. w/ transduodenal sphincterotomy or sphincteroplasty. radiofrequency Ablation.300 31.400 25.800 Professional Fee 21. with guided transhepatic cholangiography.500 31. or removal of calculus Choledochotomy or choledochostomy w/ exploration.tube or other tract.600 21.500 53.500 13. w/ or w/o cholecystotomy.800 55. w/ or w/o cholangiography Biliary duct stone extraction. choledochal cyst.000 18.300 10.600 18.g. w/ biopsy. extrahepatic Excision of bile duct tumor.300 24.600 18. w/ or w/o packing of liver Management of liver hemorrhage. drainage.300 23.800 18. without biopsy Laparoscopy.600 29.400 4.200 16.800 16.800 46.300 13.200 12. w/ removal of stone(s) Biliary endoscopy.tube or other tract.500 53. or snare (e.000 31.800 21.400 53.200 29. cholecystectomy with exploration of common duct Laparoscopy.200 29. w/o transduodenal sphincterotomy or sphincteroplasty Choledochotomy or choledochostomy w/ exploration. coagulation and/or suture.500 5. radiofrequency Laparoscopy.600 18. surgical. Cholecystectomy w/ exploration of common duct.500 5. w/ or w/o liver biopsy. w/ choledochoenterostomy Cholecystectomy w/ exploration of common duct.600 5.300 23. cryosurgical Ablation. w/ dilation of biliary duct stricture(s) w/ stent Laparoscopy. surgical.500 4.600 33.400 55. percutaneous radiofrequency Hepaticotomy or hepaticostomy w/ exploration.300 30.000 31.tube or other tract. surgical. intrahepatic Excision of choledochal cyst Anastomosis.400 21.300 24.500 53.400 12. one or more liver tumor(s). Burhenne technique) Exploration for congenital atresia of bile ducts. or removal of calculus.200 29.400 12.000 21.500 5.200 21. drainage.600 12.520 3.300 24. single or multiple Biliary endoscopy.400 37.000 9.500 37. cholecystectomy with cholangiography Laparoscopy. surgical. exploration of hepatic wound.000 31.000 21.g.700 10. or removal of calculus Percutaneous cholecystostomy Introduction of percutaneous transhepatic catheter for biliary drainage Introduction of percutaneous transhepatic stent for internal and external biliary drainage Change of percutaneous biliary drainage catheter Revision and/or reinsertion of transhepatic tube Biliary endoscopy.600 12. w/ transduodenal sphincterotomy or sphincteroplasty Transduodenal sphincterotomy or sphincteroplasty.200 21. of intrahepatic ducts and gastrointestinal tract Anastomosis.700 10.300 30.300 8.000 8.400 21.400 12. 200 12.300 21. partial gastrectomy.300 21.000 24.300 46.700 10.000 21.500 21.360 21. cyst.300 9. and jejunostomy Resection or debridement of pancreas and peripancreatic tissue for acute necrotizing pancreatitis Removal of pancreatic calculus Biopsy of pancreas. of intrahepatic biliary ducts and gastrointestinal tract Reconstruction. peripancreatic. partial gastrectomy.300 23.720 4.200 37.300 23.300 24. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 47785 47800 47801 47802 47900 48000 48001 48005 48020 48100 48102 48120 48140 48145 48146 48148 48150 DESCRIPTION Anastomosis.500 13.300 23. open. resection of omentum Case Rate 53.260 23.700 10.360 12.800 42.500 46.800 12.000 48154 48155 48160 48180 48500 48510 48520 48540 48545 48547 48550 48554 48556 49000 49010 49020 49021 49040 49060 49080 49085 49180 49200 49201 49215 49220 49250 49255 58.200 25. of extrahepatic biliary ducts w/ end-to-end anastomosis Placement of choledochal stent U-tube hepaticoenterostomy Suture of extrahepatic biliary duct for pre-existing injury Placement of drains. w/ pancreatojejunostomy Pancreatectomy.200 29.260 37.600 12.700 30.400 29..300 8.800 63.400 46. excision of umbilicus Omentectomy.800 46.000 42.200 4.800 25.500 13.000 48152 55.200 29.700 37.400 53.700 5.000 29.600 2.800 16. proximal subtotal w/ total duodenectomy. exclusive of appendiceal abscess.300 10. plastic.200 21. w/o pancreaticojejunostomy Pancreatectomy.000 13. Placement of drains.500 Page 62 of 98 .700 10.600 12.000 21.500 10.500 5.700 4.500 53.500 58.300 10.000 21.500 53.g. Excision or destruction by any method of intra-abdominal or retroperitoneal tumors or cysts or endometriomas.000 33.300 8.600 21.500 46. exclusive of appendiceal abscess. distal subtotal.000 63.600 12. retroperitoneal area w/ or w/o biopsy(s) Drainage of peritoneal abscess or localized peritonitis.400 25.600 3..800 21.400 30.700 21.900 10.400 53.600 3. w/ cholecystostomy.300 8.300 16. epiploectomy.800 Health Care Institution Fee 24.500 23.000 21. for acute pancreatitis.g. choledochoenterostomy and gastrojejunostomy (Whippletype procedure). percutaneous Drainage of subdiaphargmatic or subphrenic abscess Drainage of retroperitoneal abscess Peritoneocentesis.800 12. Whipple-type procedure).300 30.800 Professional Fee 29. total Pancreatectomy.400 29. proximal subtotal w/ near total duodenectomy. psuedocyst of pancreas Internal anastomosis of pacreatic cyst to gastrointestinal tract.300 23. open Drainage of peritoneal abscess or localized peritonitis.200 21.400 25.120 9.300 46.500 37. possibly also removal of abdominal nodes.700 10.000 21.500 23. total or subtotal. Roux-en-Y.000 42.900 16. extensive Excision of presacral or sacrococcygeal tumor Staging celiotomy (laparotomy) for Hodgkins disease or lymphoma (includes splenectomy.000 21.520 12.600 25.800 5.400 5.200 21. percutaneous needle Excision of lesion of pancreas (e. fine needle aspiration. w/ pancreaticojejunostomy Pancreatectomy. abdominal paracentesis.300 46.800 53. proximal subtotal w/ near total duodenectomy. Roux-en-Y Pancreatorrhaphy for trauma Duodenal exclusion w/ gastrojejunostomy for pancreatic trauma Donor pancreatectomy.300 21. abdominal node and/or bone marrow biopsies.500 10. gastrostomy. any method (e. choledochoenterostomy and gastrojejunostomy (Whippletype procedure).700 4.600 12.300 16.400 46. w/ or w/o duodenal segment for transplantation Transplantation of pancreatic allograft Removal of transplanted pancreatic allograft Exploratory laparotomy. needle or open biopsies of both liver lobes. near-total w/ preservation of duodenum (Child-type procedure) Excision of ampulla of Vater Pancreatectomy.600 25. adenoma) Pancreatectomy. peripancreatic. w/ autologous transplantation of pancreas or pancreatic islets Pancreaticojejunostomy.400 16. omphalectomy.000 24.500 37.000 6.300 24.000 30. percutaneous needle Excision or destruction by any method of intra-abdominal or retroperitoneal tumors or cysts or endometriomas.700 9.200 12. w/o pancreatojejunostomy Pancreatectomy.000 25. side-to-side anastomosis (Puestow-type operation) Marsupialization of cyst of pancreas External drainage.400 13. w/ or w/o splenectomy. w/ pancreatojejunostomy Pancreatectomy.400 46. choledochoenterostomy and duodenojejunostomy (pylorus-sparing.800 12. for acute pancreatitis. ovarian repositioning) Umbilectomy. or peritoneal lavage (diagnostic or therapeutic) Removal of peritoneal foreign body from peritoneal cavity Biopsy.500 10.200 16.000 21. Whipple-type procedure).200 25. exploratory celiotomy w/ or w/o biopsy(s) Exploration.800 37. choledochoenterostomy and duodenojejunostomy (pylorus-sparing.000 21.ANNEX 2.700 5.020 23. abdominal or retroperitoneal mass.700 21.400 48153 63.300 23. w/o pancreatojejunostomy Pancreatectomy. w/ or w/o splenectomy.800 16. proximal subtotal w/ total duodenectomy. wedge biopsy) Biopsy of pancreas. needle core biopsy. distal. distal subtotal.800 24.000 55.000 33. direct Internal anastomosis of pacreatic cyst to gastrointestinal tract.400 25.300 23.600 4.600 16. w/ preparation and maintenance of allograft from cadaver donor. 600 12. reducible Repair recurrent incisional hernia.000 21.120 30. any age Repair lumbar hernia Repair initial femoral hernia.000 23.400 8.000 21. endoscopy.500 10.000 21.000 21. strangulated Repair umbilical hernia.600 12.600 12. lithotripsy.400 8.000 21.600 12.000 21.360 8. age 6 months to under 5 years.300 30.600 12. w/ or w/o hydrocelectomy. under age 6 months.600 12.400 8.600 12. removal of calculus Nephrolithotomy. secondary surgical operation for calculus Nephrolithotomy.600 9.400 8.600 12.300 20.. w/ exploration Nephrolithotomy. age 5 years or over.800 10. incarcerated Repair recurrent femoral hernia. age 6 months to under 5 years. repair of recurrent inguinal hernia Suture.000 16.000 21.680 9.400 8. incarcerated Repair initial inguinal hernia.700 13. reducible Repair umbilical hernia.400 8. final reduction and closure. strangulated Repair umbilical hernia.400 8.600 12. reducible Repair initial inguinal hernia. up to 2 cm Case Rate 5.400 8.400 8.400 8. any age.120 37. w/ or w/o prosthesis Repair large omphalocele or gastroschisis.400 8. surgical.400 12. any age.000 16.000 21.600 12.500 12. not necessitating other specific procedures Drainage of perirenal or renal abscess Nephrostomy. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 49320 49321 49322 49323 49420 49425 49495 49496 49497 49500 49501 49502 49505 49507 49509 49520 49521 49522 49525 49540 49550 49553 49554 49555 49557 49558 49560 49561 49562 49565 49566 49567 49570 49572 49573 49580 49582 49583 49585 49587 49588 49590 49600 49605 49606 49610 49611 49650 49651 49900 49905 49906 50010 50020 50040 50045 50060 50065 50070 50075 50080 DESCRIPTION Laparoscopy. reducible Repair initial inguinal hernia. w/ or w/o dilation.300 23.400 8. abdomen. surgical.600 12.600 12.000 21. with or without collection of specimen(s) by brushing or washing Laparoscopy. w/ or w/o hydrocelectomy.720 3.000 21.600 12.600 12.000 27. surgical.800 30.300 30. age 5 years or over. incarcerated Repair initial inguinal hernia.980 18. repair of initial inguinal hernia Laparoscopy.260 8.300 Professional Fee 1.000 21.800 15. reducible Repair epigastric hernia (e.400 8.400 8.. w/ or w/o hydrocelectomy.400 8.600 12.000 21.400 8.400 8.600 12. reducible Repair umbilical hernia.g.600 12. preperitoneal fat).000 21.000 18.800 8. first stage Repair of omphalocele (Gross type operation).000 21.600 12.500 5.260 18. strangulated Repair inguinal hernia. strangulated Repair recurrent femoral hernia.000 23.900 4. under age 5 years.500 Page 63 of 98 .000 21.000 21. sliding.000 18.400 8. peritoneum. strangulated Repair recurrent inguinal hernia.000 21. stenting. incarcerated Repair initial femoral hernia. age 6 months to under 5 years.800 12.400 8.800 13.g. strangulated Repair initial inguinal hernia.000 21.200 6.600 21.600 12.000 21.000 21.600 12. of abdominal wall for evisceration or dehiscence Omental flap (e.700 12. incarcerated Repair recurrent incisional hernia. age 5 years or over. under age 6 months.120 21.700 13. any age.000 21.500 12.400 8.600 12. w/ removal of prosthesis.360 3.600 16.300 21.680 4.g.400 8. under age 6 months.800 Health Care Institution Fee 4.120 8.000 21.600 12.400 8. w/ or w/o hydrocelectomy. strangulated Repair recurrent incisional hernia.700 16.120 16. strangulated Repair spigelian hernia Repair of small omphalocele. incarcerated Repair epigastric hernia (e..400 8.600 12.400 8. and omentum.600 12.400 8. incarcerated Repair umbilical hernia. under age 5 years. any age.000 13.400 8.800 13.000 21. reducible Repair recurrent femoral hernia. surgical. age 5 years or over. in operating room Repair of omphalocele (Gross type operation).600 12. removal of large staghorn calculus filling renal pelvis and calyces (including anatrophic pyelolithotomy) Percutaneous nephrostolithotomy or pyelostolithotomy.000 5.600 12. strangulated Repair epigastric hernia (e.600 12. w/ or w/o hydrocelectomy. reducible Repair initial femoral hernia. with drainage of lymphocele to peritoneal cavity Insertion of intraperitoneal cannula or catheter for drainage or dialysis Insertion of peritoneal-venous shunt Repair initial inguinal hernia.ANNEX 2.600 16. age 5 years or over. reducible Repair initial inguinal hernia.500 10. second stage Laparoscopy. incarcerated Repair umbilical hernia.400 8. incarcerated Repair initial incisional hernia.400 8. incarcerated Repair recurrent inguinal hernia.000 21.400 12.400 4.600 12. surgical.000 21.400 8.400 8. age 5 years or over.400 8.400 8.400 15.900 9.600 12. diagnostic.400 8. with aspiration of cavity or cyst (single or multiple) Laparoscopy. with biopsy (single or multiple) Laparoscopy.000 16. for reconstruction of sternal and chest wall defects) (list separately in addition to code for primary procedure) Free omental flap w/ microvascular anastomosis Renal exploration. preperitoneal fat). w/ or w/o hydrocelectomy. or basket extraction.000 21.000 21.. nephrotomy w/ drainage Nephrotomy.600 9.g. any age.400 8. incarcerated Repair initial inguinal hernia. secondary.000 21.000 21.000 18.600 9.400 8.300 27.600 12.400 8. preperitoneal fat). any age.600 12.300 37.400 8.600 10.400 8.600 12.000 21.600 12.000 21.000 21.600 12.600 12.000 21.000 21. strangulated Repair initial inguinal hernia. strangulated Repair initial incisional hernia.600 12.600 10.600 12.400 8. reducible Repair initial incisional hernia.800 30.400 8. under age 5 years.000 21.600 12.900 9.080 8.000 21.000 21. complicated by congenital kidney abnormality Nephrolithotomy. w/ primary closure Repair large omphalocele or gastroschisis. reducible Repair recurrent inguinal hernia. 300 30. exclusive of radiologic service.300 46.120 12.700 20. congenital kidney abnormality) Renal biopsy. ablation of renal cysts Laparoscopy.700 21.300 18.120 9.400 8.000 13. by surgical exposure of kidney Nephrectomy.500 5.300 30. any approach including rib resection. including coagulum pyelolithotomy) Pyelotomy.680 4.600 12. pyelostomy. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 50081 50100 50120 50125 50130 50135 50200 50205 50220 50225 DESCRIPTION Percutaneous nephrostolithotomy or pyelostolithotomy.000 10.700 8..800 15.692 18. thoracic approach Symphysiotomy for horseshoe kidney w/ or w/o pyeloplasty and/or other plastic procedure. removal of regional lymph nodes and adrenalectomy) Laparoscopy..500 Page 64 of 98 . from living donor Laparoscopy.120 27. including partial ureterectomy.500 13. surgical.000 10. pyelostomy Pyelotomy.500 12. any approach including rib resection.800 15.500 13.300 10.200 10. partial nephrectomy Laparoscopy. w/ preparation and maintenance of allograft. one or more renal mass lesion(s).300 5.080 10.600 8.300 53. endoscopy.080 15. solitary kidney. any approach including rib resection. secondary operation.g.000 5.540 9.g.120 4.200 40.700 17. stenting. surgical.300 8.800 5.ANNEX 2. nephrectomy with total ureterectomy Renal endoscopy through established nephrostomy or pyelostomy.600 25. plastic operation on renal pelvis.300 30.300 30. surgical.500 50230 50234 50236 50240 50250 50280 50290 50320 50340 50360 50365 50370 50380 50390 50391 50392 50393 50395 50400 30. including partial ureterectomy Laparoscopy. radical nephrectomy (includes removal of Gerotas fascia and surrounding fatty tissue.600 9.500 5.120 23.500 9.320 30.g.300 16.280 2.300 21. surgical. suture of kidney wound or injury Closure of nephrocutaneous or pyelocutaneous fistula Closure of nephrovisceral fistula (e.500 9. reimplantation of kidney Aspiration and/or injection of renal cyst or pelvis by needle.800 8. including partial ureterectomy. percutaneous Introduction of ureteral catheter or stent into ureter through renal pelvis for drainage and/or injection. surgical.800 13.260 30.300 30. unilateral or bilateral (one operation) Laparoscopy. Case Rate 30. complicated (congenital kidney abnormality. through separate incision Nephrectomy. percutaneous. complicated because of previous surgery on same kidney Nephrectomy.580 8. w/ regional lymphadenectomy and/or vena caval thrombectomy Nephrectomy w/ total ureterectomy and bladder cuff. w/ or w/o plastic operation on ureter.120 12. complicated (e.600 16.900 12.400 5.800 Health Care Institution Fee 13. donor nephrectomy (including cold preservation).192 18. partial Ablation.200 16. pyeloplasty Laparoscopy.520 8.120 23. over 2 cm Transection or repositioning of aberrant renal vessels Pyelotomy. or basket extraction.700 13. from living donor Recipient nephrectomy Renal allotransplantation.040 4.200 4.500 24.500 50405 50500 50520 50525 50526 50540 50541 50542 50543 50544 50545 50546 50547 50548 50551 37. percutaneous Pyeloplasty (Foley Y-pyeloplasty). w/ recipient nephrectomy Removal of transplanted renal allograft Renal autotransplantation.500 5.200 4.980 27. instillation.200 3.500 13.500 4. simple Pyeloplasty (Foley Y-pyeloplasty). nephropexy. secondary pyeloplasty.320 16. renocolic).600 14.700 9. percutaneous Instillation of therapeutic agent into renal pelvis and/or ureter through established nephrostomy. w/ exploration Pyelotomy.600 10. w/ or w/o dilation.300 23. calycoplasty) Nephrorrhaphy. including visceral repair. w/ or w/o plastic operation on ureter.600 10. w/ or w/o irrigation. radical.000 13.400 12.000 18.120 16.680 9. by trocar or needle Renal biopsy. cryosurgical. percutaneous Introduction of guide into renal pelvis and/or ureter w/ dilation to establish nephrostomy tract.000 4.700 13.300 18.800 16.180 23. w/ drainage. abdominal approach Closure of nephrovisceral fistula (e.800 16. or ureteropyelography. w/ removal of calculus (pyelolithotomy. nephrectomy. including visceral repair.120 15.800 29.500 12.980 20.600 12.600 16.500 13.400 12. pyelostomy.700 10.300 31.000 5.480 12.500 61. or ureteral splinting. lithotripsy.700 9.120 30.500 13. nephrostomy.900 13.360 16.000 23.300 27.500 5. excluding donor and recipient nephrectomy Renal allotransplantation.300 27. nephrostomy.500 10.700 30..020 18. surgical.000 23. pelviolithotomy.300 30. through same incision Nephrectomy w/ total ureterectomy and bladder cuff. Nephrectomy. renocolic). implantation of graft. surgical. implantation of graft.000 27. including intraoperative ultrasound. surgical. ablation of renal mass lesion(s) Laparoscopy. or ureteral splinting.400 1.900 10.800 3. nephropexy. if performed Excision or unroofing of cyst(s) of kidney Excision of perinephric cyst Donor nephrectomy.700 9.300 Professional Fee 16. open. including partial ureterectomy.700 10.000 12. pyelostomy or ureterostomy tube Introduction of intracatheter or catheter into renal pelvis for drainage and/or injection.500 5.400 15. plastic operation on renal pelvis.800 16.800 16. 200 5.800 13.080 10. or ureteropyelography.856 5. or ureteropyelography.700 4. w/ biopsy Renal endoscopy through nephrotomy or pyelotomy. one or more renal tumor(s).780 7.360 4.920 10. instillation. w/ or w/o biopsy Renal endoscopy through nephrotomy or pyelotomy. w/ fulguration and/or incision.920 10. ectopic ureter.900 50575 9. w/ or w/o repositioning of ureter for retroperitoneal fibrosis Ureterolysis for ovarian vein syndrome Ureterolysis for retrocaval ureter. exclusive of radiologic service.920 10.300 30.700 18. w/ or w/o irrigation. instillation.900 10. exclusive of radiologic service.600 11.500 50570 8.500 16. or ureteropyelography. w/ ureteral catheterization.720 6. instillation. or ureteropyelography. w/ removal of foreign body or calculus Lithotripsy. w/ or w/o dilation of ureter Renal endoscopy through nephrotomy or pyelotomy.300 16. instillation.820 20. lower one-third of ureter Ureterectomy.920 10. instillation.760 11.800 Page 65 of 98 . anastomosis of ureter to contralateral ureter Ureteroneocystostomy.980 21.700 10. all types Ureterolithotomy. w/ or w/o irrigation. w/ vesico-psoas hitch or bladder flap Ureteroenterostomy.900 50553 8.700 4.660 23.120 27.760 12.980 21.900 10.800 21. w/ fulguration and/or incision.080 10.100 50557 8.120 16. w/ biopsy Renal endoscopy through established nephrostomy or pyelostomy.500 50576 9.200 5. w/ extensive ureteral tailoring Ureteroneocystostomy. exclusive of radiologic service.800 4.900 12. w/ or w/o irrigation. ureteroscopy. or ureteropyelography.500 50561 9. w/ or w/o dilation of ureter Renal endoscopy through established nephrostomy or pyelostomy.920 15.700 4.300 22.000 16.900 10. instillation.440 21.700 12.500 50578 9.820 20.604 5. anastomosis of ureter to renal calyx Ureteroureterostomy Transureteroureterostomy. instillation.356 2. instillation. w/ or w/o biopsy Renal endoscopy through established nephrostomy or pyelostomy. w/ creation of sigmoid bladder and establishment of abdominal or perineal colostomy. exclusive of radiologic service.300 37.660 22. w/ bladder cuff Ureterectomy. extracorporeal shock wave Ablation.900 10. vaginal and/or perineal approach Ureteroplasty. exclusive of radiologic service. w/ or w/o irrigation.500 9.ANNEX 2.360 50555 10.120 15.200 8.800 30.900 10. exclusive of radiologic service.700 12. exclusive of radiologic service. or ureteropyelography. w/ insertion of radioactive substance w/ or w/out biopsy and/or fulguration Renal endoscopy through established nephrostomy or pyelostomy. w/ or w/o irrigation.360 4. percutaneous.900 10.120 21. w/ or w/o irrigation. anastomosis of single ureter to bladder Ureteroneocystostomy. anastomosis of duplicated ureter to bladder Ureteroneocystostomy.000 5. w/ insertion of radioactive substance. w/ or w/o biopsy and/or fulguration Renal endoscopy through nephrotomy or pyelotomy. exclusive of radiologic service. instillation.820 21.080 12.200 5.000 9.720 10. w/ reanastomosis of upper urinary tract or vena cava Revision of urinary-cutaneous anastomosis (any type urostomy). upper one-third of ureter Ureterolithotomy.740 37. anastomosis of ureter and renal pelvis Ureterocalycostomy.260 3. w/ or w/o irrigation.500 50580 50590 50592 50600 50605 50610 50620 50630 50650 50660 50700 50715 50722 50725 50727 50728 50740 50750 50760 50770 50780 50782 50783 50785 50800 50810 9. dilation of ureter and ureteral pelvic junction.120 12. or ureteropyelography.980 23. or ureteropyelography.120 21. unilateral frequency Ureterotomy w/ exploration or drainage Ureterotomy for insertion of indwelling stent. or ureteropyelography. w/ repair of fascial defect and hernia Ureteropyelostomy.820 27.400 4. Renal endoscopy through nephrotomy or pyelotomy.000 12. w/ or w/o irrigation.820 21. middle one-third of ureter Ureterolithotomy.000 13.900 50572 8. instillation. exclusive of radiologic service.900 10.820 20.700 4.300 27.900 10. incision of ureteral pelvic junction and insertion of endopyelotomy stent) Renal endoscopy through nephrotomy or pyelotomy.120 30.600 15.360 4. total. w/ or w/o irrigation. stricture) Ureterolysis. w/ or w/o irrigation.920 10.000 10. instillation. exclusive of radiologic service. instillation.120 10. w/ or w/o irrigation.260 3.400 5.900 50574 8. including bowel anastomosis Case Rate Professional Fee Health Care Institution Fee 4.880 3.200 6.260 3.800 13.900 10. Revision of urinary-cutaneous anastomosis (any type urostomy).500 5.g. or ureteropyelography. plastic operation on ureter (e. direct anastomosis of ureter to intestine Ureterosigmoidostomy.400 10.900 10. w/ ureteral catheterization. exclusive of radiologic service. exclusive of radiologic service. w/ removal of foreign body or calculus Renal endoscopy through nephrotomy or pyelotomy.200 5. combination abdominal.600 5. w/ endopyelotomy (includes cystoscopy.260 3.. or ureteropyelography. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE DESCRIPTION Renal endoscopy through established nephrostomy or pyelostomy.500 17. or ureteropyelography.500 50559 8. w/ or w/o irrigation.104 2. 260 3.100 50978 9.500 10.200 4. cystotomy w/ drainage Cystotomy.900 5.260 5. including bowel anastomosis (Bricker operation) Continent diversion.800 21.200 5.900 50953 8.880 3.300 8.900 10. or ureteropyelography.000 16.600 3.900 50976 10. exclusive of radiologic service.980 23. w/ or w/o irrigation. ureterosigmoidostomy or ureteroenterostomy w/ ureteroureterostomy or ureteroneocystostomy) Replacement of all or part of ureter by bowel segment. w/ or w/o irrigation.880 3. w/ or w/o dilation of ureter Ureteral endoscopy through established ureterostomy. w/ or w/o irrigation. ureterolithotomy Laparoscopy. w/ or w/o irrigation.980 8. ureteroneocystostomy with cystoscopy and ureteral stent placement Laparoscopy.500 13. Ureteral endoscopy through established ureterostomy. ureteroneocystostomy without cystoscopy and ureteral stent placement Ureteral endoscopy through established ureterostomy. w/ fulguration and/or insertion of radioactive material Cystotomy or cystostomy.100 50959 9. w/ stone basket extraction and/or ultrasonic or electrohydraulic fragmentation of ureteral calculus Drainage of perivesical or prevesical space abscess Excision of urachal cyst or sinus.700 4.600 10. surgical.140 10.980 5.700 4.800 16.g. exclusive of radiologic service. w/ ureteral catheterization.500 5. exclusive of radiologic service. exclusive of radiologic service.980 18.780 7. or ureteropyelography.800 37.260 3.800 10.ANNEX 2.500 50980 51010 51020 51030 51040 51045 51050 51060 51065 51080 51500 51520 11. w/ cryosurgical destruction of intravesical lesion Cystostomy.360 4.900 Page 66 of 98 .260 3. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 50815 50820 50825 DESCRIPTION Ureterocolon conduit. or ureteropyelography. w/ or w/o irrigation. w/ fulguration and/or incision.800 13.500 5.500 5. cystotomy w/ removal of calculus. instillation.820 10. Ureteral endoscopy through established ureterostomy.680 9. transplantation of ureter to skin Ureterorrhaphy. by trocar or intracatheter w/ insertion of suprapubic catheter Cystotomy or cystostomy.500 Professional Fee 21.300 20.100 4.520 25. w/ or w/o irrigation. taking down of ureteroileal conduit.900 50974 8.360 4.300 20.400 10.800 10. w/ or w/o irrigation. exclusive of radiologic service. exclusive of radiologic service. exclusive of radiologic service. or ureteropyelography.040 7. including bowel anastomosis Ureteroileal conduit (ileal bladder).000 23.100 4. w/ or w/o biopsy and/or fulguration (not including provision of material) Ureteral endoscopy through established ureterostomy. or ureteropyelography.360 6. w/ or w/o biopsy Ureteral endoscopy through established ureterostomy.500 50961 50970 11. w/ insertion of radioactive substance. w/ insertion of ureteral catheter or stent Cystolithotomy.500 5.320 46. surgical.900 10. w/ insertion of radioactive substance.540 12.300 21.900 9. or ureteropyelography. instillation. w/ or w/o irrigation.920 5.780 7. exclusive of radiologic service. instillation. w/ or w/o biopsy Ureteral endoscopy through established ureterostomy.200 5. w/ ureteral catheterization.400 10.080 6. instillation..980 5. instillation. or ureteropyelography. w/ or w/o irrigation. for simple excision of vesical neck Case Rate 37.700 10. instillation.360 4.540 30.920 10.880 3. surgical. w/ or w/o umbilical hernia repair Cystotomy. w/ or w/o irrigation. exclusive of radiologic service.360 4.540 21. or ureteropyelography.200 5. instillation.200 4.200 Health Care Institution Fee 16. w/ biopsy Ureteral endoscopy through established ureterostomy.000 20. or ureteropyelography.000 5. including bowel anastomosis using any segment of small and/or large bowel (Kock pouch or Camey enterocystoplasty Urinary undiversion (e. or ureteropyelography.300 23. exclusive of radiologic service.600 10. including bowel anastomosis Cutaneous appendico-vesicostomy Ureterostomy. w/ removal of foreign body or calculus Ureteral endoscopy through ureterotomy.880 1. instillation.800 30.700 4.700 10. or ureteropyelography.040 16.800 40.500 10.700 9.700 10.700 9.900 50957 10.000 21. w/ or w/o biopsy and/or fulguration (not including provision of material) Ureteral endoscopy through established ureterostomy.260 3.800 16. w/ or w/o irrigation.820 21. w/ fulguration and/or incision. instillation. w/ biopsy Ureteral endoscopy through established ureterostomy. instillation. w/ removal of foreign body or calculus Aspiration of bladder. instillation.260 21.080 8.680 4.360 16. instillation. w/ or w/o dilation of ureter Ureteral endoscopy through established ureterostomy. exclusive of radiologic service.300 50830 50840 50845 50860 50900 50920 50930 50940 50945 50947 50948 50951 37.920 9. suture of ureter Closure of ureterocutaneous fistula Closure of ureterovisceral fistula (including visceral repair) Deligation of ureter Laparoscopy.940 23.240 12. w/ or w/o irrigation.700 10. exclusive of radiologic service. or ureteropyelography.080 12.900 12.820 21.600 12. w/o vesical neck resection Transvesical ureterolithotomy Cystotomy.900 50955 8.900 50972 8. w/ fulguration (including cryosurgery or laser surgery) of trigone.400 21.120 27. w/ ureteroileal conduit or sigmoid bladder.880 23.000 25. Stamey.800 30. w/ dilation of bladder for insterstitial cystitis.300 16. and obturator nodes Cystectomy. and obturator nodes Cystectomy.400 13.300 6. w/ ureteroileal conduit or sigmoid bladder. surgical. or any combination thereof Injection procedure for cystography or voiding urethrocystography Bladder instillation of anticarcinogenic agent Cystoplasty or cystourethroplasty.500 5.g.. w/ or w/o biopsy or fulguration Cystourethroscopy. sling operation for stress incontinence (e. injury or rupture Closure of cystostomy Closure of vesicovaginal fistula.900 5.g.080 6. w/ or w/o wedge resection of posterior vesical neck Cystourethroplasty w/ unilateral or bilateral ureteroneocystostomy Anterior vesicourethropexy.440 6.300 8. or ureteropyelography.600 16.840 58. any procedure. for excision of bladder diverticulum.800 21.700 13. hypogastric.400 8.000 16. complete.800 16. previous surgery.240 23. complete. Cystectomy. surgical.000 21.900 17.500 40. w/ hysterectomy Closure of bladder exstrophy Enterocystoplasty.720 3. SMALL bladder tumor(s) (0.500 13.040 5.980 5.360 21.000 5. Raz. hypogastric.800 16. including external iliac.900 10. w/ bilateral pelvic lymphadenectomy.500 4. w/ reimplantation of ureter(s) into bladder (ureteroneocystostomy) Cystectomy. Cystectomy.600 12.ANNEX 2.800 31.440 10. bladder neck.500 17.900 52010 52204 52214 8.700 8.120 10. w/ bilateral pelvic lymphadenectomy.440 5.260 50. w/ biopsy Cystourethroscopy. incision. fascia or synthetic) Cystourethroscopy Cystourethroscopy. w/ or w/o irrigation. complete. including bowel anastomosis Cutaneous vesicostomy Laparoscopy.800 13.360 5.520 10. any technique. prostatic or urethral malignancy. or ureteropyelography.0 cm) Cystourethroscopy. w/ or w/o irrigation.880 4.900 52235 52240 52250 52260 22. or duct radiography.980 12.000 10.g.340 12.100 10. single or multiple Cystotomy..260 9. or periurethral glands Cystourethroscopy.300 16. w/ fulguration (including cryosurgery or laser surgery) and/or resection of.200 3.600 13.880 6.700 10.980 10. partial Cystectomy. or urethropexy (Marshall-Marchetti-Krantz type) complicated (e.120 10.900 5.000 12. w/ continent diversion. complete.320 Professional Fee 15.300 30.540 11. prostatic fossa. partial.500 13. including external iliac.120 23.300 5. w/ brush biopsy of ureter and/or renal pelvis Cystourethroscopy.0 cm) LARGE bladder tumor(s) Cystourethroscopy w/ insertionof radioactive substance. exclusive of radiologic service.920 55.800 24.100 52224 11.400 2.300 30.000 51590 51595 51596 55. and obturator nodes Cystectomy.120 15. abdominal approach Closure of vesicouterine fistula. w/ removal of bladder and ureteral transplantations. complete.740 11. vesical fundus resection).520 Health Care Institution Fee 12.800 3.000 10. for excision of bladder tumor Cystotomy for excision. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 51525 51530 51535 51550 51555 51565 51570 51575 51580 DESCRIPTION Cystotomy.0 to 5. complicated (e. hypogastric.g. Cystourethroscopy. w/ ureterosigmoidostomy or ureterocutaneous transplantations.980 3.400 24. suture of bladder wound.980 27. plastic operation on bladder and/or vesical neck (anterior Y-plasty.200 23. urethra.360 4.520 2.980 11.260 10. w/ fulguration (including cryosurgery or laser surgery) and/or resection of MEDIUM bladder tumor(s) (2. using any segment of small and/or large bowel to construct neobladder Pelvic exenteration.500 16.800 21. exclusive of radiologic service.440 21.700 17. w/ or w/o endoscopic control (e.740 37.300 30. including external iliac. w/ ureteral catheterization.. instillation.500 4. instillation. for vesical.5 cm) lesion(s) w/ or w/o biopsy Cystourethroscopy.300 37.080 15.300 30.300 10.100 Page 67 of 98 .700 17.920 34. w/ fulguration (including cryosurgery or laser surgery) or treatment of MINOR (less than 0. w/ ureterosigmoidostomy or ureterocutaneous transplantations.740 12.100 52234 20. Cystectomy.880 10.5 cm to 2.020 20.900 12. difficult location) Cystectomy.. complete. urethral suspension for stress incontinence Laparoscopy.500 10.080 10. complete. modified Pereyra) Cystorrhaphy.400 7.080 13.440 37. including bowel anastomosis. or repair of ureterocele Cystectomy. including bowel anastomosis.300 23. w/ or w/o irrigation.300 30. w/ or w/o hysterectomy and/or abdominoperineal resection of rectum and colon and colostomy.800 13.300 30.720 16.800 51585 53.900 5.740 20.020 8.120 12.600 13. w/ ejaculatory duct catheterization. secondary repair) Abdomino-vaginal vesical neck suspension.120 30.800 46.980 30.400 29.780 12. w/ ureteral catheterization. complete. Closure of vesicouterine fistula. exclusive of radiologic service Cystourethroscopy.500 6.000 51597 51600 51720 51800 51820 51840 51841 51845 51860 51880 51900 51920 51925 51940 51960 51980 51990 51992 52000 52005 52007 71. instillation.120 20. postradiation. w/ bilateral pelvic lymphadenectomy. general or conduction (spinal) anesthesia Case Rate 27. 940 9.940 23.500 5.120 10.300 23. or congenital obstructive hypertrophic mucosal folds Transurethral incision of prostate Transurethral resection of bladder neck Transurethral balloon dilation of the prostatic urethra.400 9.020 8. w/ fragmentation of ureteral calculus (e. unilateral or bilateral Cystourethroscopy.900 12.500 6.900 12.500 52290 52300 52301 52305 52310 52317 11.100 12. w/ removal of ureteral calculus Cystourethroscopy (including ureteral catheterization).400 52336 12.240 9. retrograde Cystourethroscopy.000 5.700 10. w/ biopsy and/or fulguration of lesion Cystourethroscopy.g. w/ incision or resection of orifice of bladder diverticulum. any method Transurethral electrosurgical resection of prostate.720 21. and internal urethrotomy are included) Transurethral fulguration for postoperative bleeding occuring after the usual follow-up time Transurethral resection of prostate. including control of postoperative bleeding. urethral dilation.000 9. lateral incisions of the bladder neck.240 12.120 6.940 9.900 Page 68 of 98 .500 9. male or female Cystourethroscopy.940 21.000 21. single or multiple Cystourethroscopy.600 6. meatomy.940 20. or resection of congenital posterior urethral valves. w/ resection of tumor Cystourethroscopy w/ incision.700 52338 21.040 8.880 8.700 10.940 11.040 5.. w/ internal urethrotomy.500 5.700 12. bladder neck. simple or small (less than 2. w/ ureteroscopy and/or pyeloscopy (includes dilation of the ureter and/or pyeloureteral junction by any method).700 5.140 6. first stage of two-stage resection (partial resection) Transurethral resection of prostate.720 5.540 12.700 6.5 cm) Litholapaxy: crushing or fragmentation of calculus by any means in bladder and removal of fragments. for treatment of the female urethral syndrome w/ any or all of the following: urethral meatotomy.080 9. w/ calibration and/or dilation of urethral stricture or stenosis. fulguration.120 37. w/ internal urethrotomy. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 52265 52270 52275 52276 52277 52281 52283 DESCRIPTION local anesthesia Cystourethroscopy.600 52318 52320 52325 52327 52330 52332 52334 52335 21. unilateral or bilateral Cystourethroscopy. w/ ureteroscopy and/or pyeloscopy (includes dilation of the ureter and/or pyeloureteral junction by any method). female Cystourethroscopy.040 4. ultrasonic or electro-hydraulic technique) Cystourethroscopy (including ureteral catheterization). unilateral or bilateral Cystourethroscopy.600 5.300 6.940 12.200 5.980 8.600 5. lysis of urethrovaginal septal fibrosis.600 6.240 5.400 5.400 5.880 9.400 6.300 12.700 5.600 12.5 cm) Cystourethroscopy (including ureteral catheterization). complete (vasectomy.520 2. w/ removal or manipulation of calculus (ureteral catheterization is included) Cystourethroscopy.300 7.500 5. w/ ureteroscopy and/or pyeloscopy (includes dilation of the ureter and/or pyeloureteral junction by any method). w/ manipulation.020 12.g. urethral calibration and/or dilation.240 6.540 5. internal urethrotomy. male Cystourethroscopy w/ direct vision internal urethrotomy Cystourethroscopy.240 12.980 18.540 18.600 12.. w/ ureteroscopy and/or pyeloscopy (includes dilation of the ureter and/or pyeloureteral junction by any method).500 5.240 9. w/ ureteroscopy and/or pyeloscopy (includes dilation of the ureter and/or pyeloureteral junction by any method).980 21.800 52606 52612 52614 52620 18.200 6.540 10.040 5.240 10. of residual obstructive tissue after 90 days postoperative Case Rate 8.720 2. second stage of two-stage resection (resection completed) Transurethral resection.800 9. w/ subureteric injection of implant material Cystourethroscopy (including ureteral catheterization). Cystourethroscopy.720 5.120 9. w/ resection of external sphincter (sphincterotomy) Cystourethroscopy.100 9. or ureteral stent from urethra or bladder Litholapaxy: crushing or fragmentation of calculus by any means in bladder and removal of fragments.700 10. w/ or w/o meatotomy and injection procedure for cystography. w/ resection or fulguration of orthotopic ureterocele(s).940 21.ANNEX 2.700 12.720 12. and/or trigone Cystourethroscopy. cystourethroscopy.500 5. Gibbons or double-J type) Cystourethroscopy w/ insertion of ureteral guide wire through kidney to establish a percutaneous nephrostomy. and fulguration of polyp(s) of urethra.500 52285 10.400 52337 21.520 Health Care Institution Fee 5.700 52339 12.120 8. w/ lithotripsy (ureteral catheterization is included) Cystourethroscopy. w/ steroid injection into stricture Cystourethroscopy.400 4.700 12. w/ removal of foreign body.400 5.540 9.240 12. complicated or large (over 2.720 5.020 Professional Fee 2.400 16. calculus. w/ resection or fulguration of ectopic ureterocele(s). w/o removal of ureteral calculus Cystourethroscopy. w/ ureteral meatotomy.120 6.700 10.000 12.400 52340 52450 52500 52510 52601 21. w/ insertion of indwelling ureteral stent (e.520 6. second stage Urethroplasty.400 17.400 4. diverticulum.000 9. Johannsen type) Urethroplasty. suture of urethral wound or injury.000 18.560 2.400 8.e. meatotomy.g.600 9.100 16.120 Professional Fee 21.900 5.000 16.120 8.400 16.260 3.960 40.000 16.260 1.120 15.600 9. male Dilation of urethral stricture or vesical neck.500 12.520 1.200 13.020 5. perineal urethra.000 8.700 10. general or conduction (spinal) anesthesia Transurethral destruction of prostate tissue. total.800 9.260 9. cystourethroscopy.900 4.020 5.300 12. including cystostomy. male or female Excision of bulbourethral gland (Cowpers gland) Excision or fulguration. two-stage reconstruction or repair of prostatic or membranous urethra.560 9. suture of urethral wound or injury.000 4. repair.100 6. perineal Urethrorrhaphy.520 8.260 8.800 16.560 23. infant Drainage of deep periurethral abscess Drainage of Skenes gland abscess or cyst Drainage of perineal urinary extravasation Biopsy of urethra Urethrectomy.900 12.000 21. complete (vasectomy.800 27. total. meatotomy. female Urethrorrhaphy. Tenago.360 4.800 15.700 16.720 1.320 37. w/ mucosal advancement Urethromeatoplasty. including placement of pump and/or reservoir Removal.360 2.000 52648 27. complete (vasectomy. and internal urethrotomy are included) Contact laser vaporization w/ or w/o transurethral resection of prostate. external Meatotomy.500 4.240 10.260 2. general or conduction (spinal) anesthesia Dilation of female urethra.820 9.800 16.600 4.680 1. urethral calibration and/or dilation.e.000 7.120 12. transurethral laser incision of the prostate (TULIP) Case Rate 37. including urinary diversion Urethroplasty. for fistula.000 4.260 5.800 18. reconstruction of female urethra Operation for correction of male urinary incontinence.500 4.360 1.100 1. urethral polyp(s).600 13.900 5.540 10.600 4.700 18.300 30.260 1.800 21. by microwave thermotherapy i. female Urethrectomy.640 18.680 5.480 23. and internal urethrotomy are included) High intensity focused ultrasound (HIFU) of the prostate including transurethral resection of the prostate (TURP) Transurethral drainage of prostatic abscess Urethrotomy or urethrostomy.500 5.500 9.560 5.120 7.300 5.000 31.260 9.320 18. one stage.360 3.600 7.680 8.120 5.800 20.200 8..400 8.040 2.260 9.800 Page 69 of 98 .680 21.000 15.040 5.500 18. urethral caruncle Skenes glands Skenes glands urethral prolapse Urethroplasty. urethral calibration and/or dilation. w/ partial excision of distal urethral segment (Richardson type procedure) Urethrorrhaphy.920 4. distal urethra Excision or fulguration.. Transurethral Needle Ablation (TUNA). Leadbetter procedure) Operation for correction of urinary incontinence w/ placement of inflatable urethral or bladder neck sphincter.300 4.680 37.000 10.520 1. male Excision of fulguration of carcinoma of urethra Excision of urethral diverticulum .500 5.680 1.300 7.700 9.300 4. for reconstruction or repair of prostatic or membranous urethra Urethroplasty. pendulous urethra Urethrotomy or urethrostomy. cystourethroscopy. by radiofrequncy ablation i.260 2.120 18.900 4.900 7. of postoperative bladder neck contracture Non-contact laser coagulation of prostate. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 52630 52640 52647 DESCRIPTION Transurethral resection.680 3.200 5. external .000 14.120 Health Care Institution Fee 16. including control of postoperative bleeding. prostatomembranous Closure of urethrostomy or urethrocutaneous fistula.560 8.300 27.300 4.400 1. cutting of meatus .700 10.560 8. Transurethral Microwave Thermotherapy (TUMT) Transurethral destruction of prostate tissue.500 5. first stage Urethroplasty.960 9. female Excision of urethral diverticulum .000 4.200 5.520 21.ANNEX 2.540 8. first stage. male Dilation of urethral stricture by passage of sound or urethral dilator.940 21. external .800 37. of regrowth of obstructive tissue longer than one year postoperative Transurethral resection.180 40. second stage (formation of urethra).200 4.800 10.400 7.560 21. including cystostomy.g.500 5. w/ or w/o introduction of prosthesis Removal of perineal prosthesis introduced for continence Urethroplasty w/ tubularization of posterior urethra and/or lower bladder for incontinence (e.200 4.120 14. cutting of meatus . one-stage reconstruction of male anterior urethra Urethroplasty.300 12. or replacement of inflatable sphincter including pump and/or reservoir and/or cuff Surgical correction of hydraulic abnormality of inflatable sphincter device Urethromeatoplasty. male.000 8. suture of urethral wound or injury. two-stage reconstruction or repair of prostatic or membranous urethra. male Marsupialization of urethral diverticulum. suture of urethral wound or injury.300 5.000 18.800 12. transpubic or perineal.400 3.080 15. penile Urethrorrhaphy.680 5.400 7..000 52649 52700 53000 53010 53020 53025 53040 53060 53080 53200 53210 53215 53220 53230 53235 53240 53250 53260 53265 53270 53275 53400 53405 53410 53415 53420 53425 53430 53440 53442 53443 53445 53447 53449 53450 53460 53502 53505 53510 53515 53520 53600 53605 53665 53850 53852 37.980 27.140 37. except infant Meatotomy.000 5. or stricture (e. including control of postoperative bleeding.560 5.800 9. penis (e.000 18.800 18.700 14.g.504 9.480 18. condyloma.080 10.100 4.000 16. newborn Circumcision.700 10.600 54348 20.180 16.000 25.000 5. diverticula). in continuity w/ bilateral pelvic lymphadenectomy. molluscum contagiosum.980 8.g. less than 3 cm Urethroplasty for second stage hypospadias repair (including urinary diversion). w/ bilateral inguinofemoral lymphadenectomy Amputation of penis.400 12.400 18. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 54015 54050 54100 54110 54111 54112 54115 54120 54125 54130 54135 54150 54152 54160 54161 54200 54205 54220 54300 54304 54308 54312 54316 54318 54322 54324 DESCRIPTION Incision and drainage of penis Destruction of lesion(s).540 11.. radical. including external iliac.560 5. diverticula).900 5. hypogastric and obturator nodes Circumcision. any method Biopsy of penis Excision of penile plaque (Peyronie disease).180 37. by closure.300 37.200 5. fistula.500 54332 37. w/ or w/o mobilization of urethra Plastic operation on penis for correction of chordee or for first stage hypospadias repair w/ or w/o transplantation of prepuce and/or skin flaps Urethroplasty for second stage hypospadias repair (including urinary diversion).500 18.260 1.500 21.200 7. skin graft patch. simple Repair of hypospadias complications (ie.700 Page 70 of 98 .260 1.120 27. w/ urethroplasty by local skin flaps and mobilization of urethra One stage distal hypospadias repair (w/ or w/o chordee or circumcision). diverticula). flip-flap. surgical excision other than clamp.. surgical excision other than clamp.500 5.260 1.260 5.120 15.700 5.000 12.300 4.700 18.040 5. incision. newborn Circumcision.180 18.700 9.800 21.800 54380 54385 30. fistula.400 37. herpetic vesicle). third stage Cecil repair) One stage distal hypospadias repair (w/ or w/o chordee or circumcision).400 10.560 12. and/or island flap One stage proximal penile or penoscrotal hypospadias repair requiring extensive dissection to correct chordee and urethroplasty by use of skin graft tube and/or island flap One stage perineal hypospadias repair requiring extensive dissection to correct chordee and urethroplasty by use of skin graft tube and/or island flap Repair of hypospadias complications (ie.500 7.040 10.100 5.360 5. Plastic operation on penis for epispadias distal to external sphincter.g. or excision. plastic implant) Amputation of penis. w/ graft to 5 cm in length Excision of penile plaque (Peyronie disease). stricture.600 6.000 54328 30. using clamp or other device.g.000 54326 27.120 12.180 18.300 16.540 21.200 840 840 840 840 1.700 10.300 23.g. w/ urethroplasty by local skin flaps (e.800 21.680 8.ANNEX 2.300 23.480 13.640 3. w/ extensive dissection to correct chordee and urethroplasty w/ local skin flaps. Magpi.120 15. stricture.g.700 54336 54340 54344 37.980 10.500 6.720 15. stricture.800 2..120 27. using clamp or other device.680 2. device or dorsal slit. requiring extensive dissection and urethroplasty w/ flap. papilloma. except newborn Circumcision. hypospadias).900 54352 37. device or dorsal slit. requiring mobilization of skin flaps and urethroplasty w/ flap or patch graft Repair of hypospadias complications (ie.120 Professional Fee 840 840 504 2.300 10.480 8.800 13.800 3. patch or tubed graft (includes urinary diversion) Repair of hypospadias cripple requiring extensive dissection and excision of previously constructed structures including re-release of chordee and reconstruction of urethra and penis by use of local skin as grafts and island flaps and skin brought in as flaps or grafts Plastic operation on penis for epispadias distal to external sphincter.520 4.600 12.w/ surgical exposure of plaque Irrigation of corpora cavernosa for priapism Plastic operation of penis for straightening of chordee (e.120 Health Care Institution Fee 2.960 23.260 1.800 46.020 9. prepucial flap) One stage distal hypospadias repair (w/ or w/o chordee or circumcision). w/ graft greater than 5 cm in length Removal of foreign body from deep penile tissue (e. radical. except newborn Injection procedure for Peyronie disease..900 16. partial Amputation of penis.640 3.480 18.000 7. w/ simple meatal advancement (e.300 420 420 420 420 4.300 12. Excision of penile plaque (Peyronie disease). V-flap) One stage distal hypospadias repair (w/ or w/o chordee or circumcision).880 3.600 12. greater than 3 cm Urethroplasty for second stage hypospadias repair (including urinary diversion) w/ free skin graft obtained from site other than genitalia Urethroplasty for third stage hypospadias repair to release penis from scrotum (e. fistula.w/ incontinence Case Rate 3.260 10. complete Amputation of penis. Injection procedure for Peyronie disease..500 1..500 10. 960 14. external drainage of prostatic abscess.300 8.008 504 2. orchiectomy Laparoscopy. Excision of varicocele or ligation of spermatic veins for varicocele.500 7. for tumor.680 5. perineal radical.500 7.120 3.040 8.040 4.200 5. meatotomy.300 5. unilateral Epididymovasostomy. needle Exploration of epididymis.700 11.120 12.200 5..100 2.500 4.540 10.680 1.900 14.940 5.400 5. needle Biopsy of testis.960 14.100 5.260 12. unilateral Excision of hydrocele.860 46.000 10.500 3. prostate. perineal radical.400 7.200 5.700 18.200 4.000 5.700 8.400 4. inguinal approach.540 10..400 5.680 5.900 5.880 Health Care Institution Fee 16. surgical.680 5.400 4. unilateral Epididymectomy. w/ or w/o epididymectomy Epididymectomy.ANNEX 2.680 1.200 7.500 9.200 3.800 12. w/ hernia repair Laparoscopy.440 10. for tumor. w/ or w/o hernia repair Orchiopexy. vasectomy. surgical. for intra-abdominal testis (e. Prostatectomy.360 6. with ligation of spermatic veins for varicocele Vesiculotomy.500 48. bilateral Repair of tunica vaginalis hydrocele (Bottle type) Drainage of scrotal wall abscess Drainage and debridement of Fourniers gangrene of the scrotum Scrotal exploration Removal of foreign body in scrotum Resection of scrotum Scrotoplasty Vasotomy. abdominal approach.000 7.300 21.680 8. w/ or w/o biopsy Excision of local lesion of epidydimis Excision of spermatocele.800 5. single or multiple.140 5.260 9.020 9.000 4. unilateral or bilateral Corpora cavernosa-corpus spongiosum shunt (priapism operation)..300 7. or punch) for priapism Plastic operation of penis for injury Biopsy of testis.960 9.300 5. surgical.w/ exstrophy of bladder Corpora cavernosa-saphenous vein shunt (priapism operation).980 4. abdominal approach Excision of varicocele or ligation of spermatic veins for varicocele.000 3.680 38. Vesiculectomy.108 3.600 7. w/ or w/o testicular prosthesis. surgical. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 54390 54420 54430 54435 54440 54500 54505 54510 54520 54530 54535 54550 54560 54600 54620 54640 54650 54670 54680 54690 54692 54700 54800 54820 54830 54840 54860 54861 54900 54901 55000 55040 55041 55060 55100 55101 55110 55120 55150 55175 55200 55250 55400 55500 55520 55530 55535 55540 55550 55600 55650 55680 55700 55720 55801 55810 55812 DESCRIPTION Plastic operation on penis for epispadias distal to external sphincter. unilateral or bilateral Vasovasostomy.140 5.500 5. rongeur.720 504 1.600 7.500 5.120 18. any approach Prostatotomy.000 9.540 18.500 5.680 1.120 8.100 1.000 9. biopsy needle.300 Page 71 of 98 .460 7.680 20.500 5.008 1.000 7. scrotal or inguinal approach Orchiectomy.000 5.040 7. perineal.040 7.200 4.400 5.400 504 4.400 5.000 4.100 1.000 6.680 10.540 9.960 10.500 9. radical.700 21.540 9. unilateral Excision of lesion of spermatic cord Excision of varicocele or ligation of spermatic veins for varicocele.500 5.360 4. any approach Excision of Mullerian duct cyst Biopsy.400 2.600 5.g. vasovasorrhaphy Excision of hydrocele of spermatic cord. incisional Excision of local lesion of testis Orchiectomy. tunica vaginalis.g.200 504 2.000 3.600 3.560 7.540 12.600 9.g. urethral calibration and/or dilation.180 Professional Fee 21.040 5.700 3.560 7. subtotal (including control of postoperative bleeding.000 5. needle or punch. unilateral or bilateral Vasectomy.960 12. radical. cannulization w/ or w/o incision of vas.400 5. w/ abdominal exploration Exploration for undescended testis (inguinal or scrotal area) Exploration for undescended testis w/ abdominal exploration Reduction of torsion of testis. testis and/or scrotal space (e.520 2. anastomosis of epididymis to vas deferens.504 5.880 1.900 6. bilateral Epididymovasostomy. any approach Prostatectomy. Winter procedure.100 3. and internal urethrotomy) Prostatectomy.500 4.560 5.100 2.500 5.108 5.400 3.200 8.200 3. FowlerStephens) Suture or repair of testicular injury Transplantation of testis(es) to thigh (because of scrotal destruction) Laparoscopy.900 5. unilateral or bilateral Corpora cavernosa-glans penis fistulization (e.300 9. abscess or hematoma) Biopsy of epididymis.400 7.160 25. orchiopexy for intra-abdominal testis Incision and drainage of epididymis.200 26.500 6.100 3. anastomosis of epididymis to vas deferens.300 4.000 5. inguinal approach Orchiectomy.700 8.200 3.540 12.300 4.680 4.260 12. w/ lymph node biopsy(s) (limited pelvic lymphadenectomy) Case Rate 37.504 9.000 5.260 1.680 2.140 4.100 4.360 6.720 6.560 4.620 8. w/ or w/o fixation of contralateral testis Fixation of contralateral testis Orchiopexy.000 18. w/ or w/o injection of medication Excision of hydrocele.000 4.400 8.300 10.000 18.100 1.540 10.720 3. bilateral Puncture aspiration of hydrocele.504 9.460 2.500 9.504 9. simple (including subcapsular). 000 Page 72 of 98 .800 21.200 7.300 23. w/ bilateral inguinofemoral lymphadenectomy Vulvectomy.880 13. complete. vulva. w/ bilateral inguinofemoral lymphadenectomy Vulvectomy.980 20.120 20. surgical prostatectomy.300 37.800 9.500 55. hypogastric and obturator nodes Laparoscopy.080 12.700 12. partial. urethral calibration and/or dilation. Vulvectomy.700 12.200 26. obliteration of vagina.700 9. simple incision Excision of Bartholins gland or cyst Colpotomy.600 16.600 15. including external iliac.500 5.500 16.720 12. partial Vulvectomy simple. any approach.120 23. subtotal.300 21.300 46. any approach.120 12.500 5.500 10. vaginal approach (e.680 5.600 16. suture of injury of vagina and/or perineum (nonobstetrical) Plastic operation on urethral sphincter.860 20. retropubic.400 10.500 5.800 4. retropubic radical.200 7.680 5.300 27.200 29.400 4.400 10.000 58.200 8. w/ inguinofemoral.300 12. including external iliac. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 55815 DESCRIPTION Prostatectomy.300 9. w/ lymph node biopsy(s) (limited pelvic lymphadenectomy) Prostatectomy.800 25. Exposure of prostate. w/ exploration Colpocentesis Destruction of vaginal lesion(s) Biopsy of vaginal mucosa Colpectomy.300 21. and obturator nodes Transperineal placement of needles.680 1.200 5. w/ enterocele repair Repair of enterocele.700 8.600 37. with or without cystoscopy.300 9.400 9.500 48.120 2.700 9. urethral calibration and/or dilation.680 1.600 1.400 21.040 6. Kelly urethral plication) Plastic repair of urethrocele Anterior colporrhaphy.680 12. one or two stages Prostatectomy (including control of postoperative bleeding.500 5.600 55865 55866 55873 56405 56420 56440 56441 56501 56605 56620 56625 56630 56631 56632 56633 56634 56637 56640 56700 56720 56740 57000 57020 57061 57100 57108 57110 57120 57130 57135 57155 57200 57210 57220 57230 57240 57250 57260 57265 57268 57270 23.000 21.700 55831 55840 55842 55845 30.700 18. radical.560 9.500 5. Vulvectomy. partial. w/ or w/o nerve sparing.100 2. subtotal Prostatectomy.ANNEX 2.800 12.120 5.600 15.200 6. complete Vulvectomy.400 55. w/ lymph node biopsy(s) (limited pelvic lymphadenectomy) Exposure of prostate.300 24. abdominal approach Case Rate 48. complete. vasectomy.160 18.000 7.100 4. for insertion of radioactive substance. complete Colpocleisis (Le Fort type) Excision of vaginal septum Excision of vaginal cyst or tumor Insertion of uterine tandems and/or vaginal ovoids for clinical brachytherapy Colporrhaphy. w/ bilateral pelvic lymphadenectomy.000 10.400 4.120 30.100 6. for insertion of radioactive substance.300 27. hypogastric and obturator nodes Prostatectomy (including control of postoperative bleeding.900 10.600 25.880 26.500 12.720 6. perineal radical.180 48.900 10. Combined anteroposterior colporrhaphy.000 5.120 10.200 2. radical. including external iliac.000 13.000 5.180 Professional Fee 26.800 46.400 4.100 4.400 33. w/ or w/o nerve sparing. retropubic radical.300 21.700 12. any approach.700 13.300 30.500 9.700 9. retropubic radical. partial Colpectomy. vasectomy. including nerve sparing Cryosurgical ablation of the prostate (cryotherapy of the prostate) Incision and drainage of vulva or perineal abscess Incision and drainage of Bartholins gland abscess Marsupialization of Bartholins gland cyst Lysis of labial adhesions Destruction of lesion(s). vaginal approach Repair of enterocele.300 9. iliac. Prostatectomy. radical.540 12.880 Health Care Institution Fee 21.. catheters or pellets into prostate for interstitial radioelement application.120 9.300 46.080 10.100 4. w/ bilateral pelvic lymphadenectomy.000 9. retropubic radical. radical.g.500 7. w/ unilateral inguinofemoral lymphadenectomy Vulvectomy.200 5.980 23.300 9. radical.200 4. for insertion of radioactive substance. and internal urethrotomy).680 23.700 21.120 12.500 53.300 27.720 1. any method Biopsy of vulva or perineum . meatotomy.020 10. radical. and pelvic lymphadenectomy Partial hymenectomy or revision of hymenal ring Hymenotomy. complete.200 2.200 2. w/ unilateral inguinofemoral lymphadenectomy Vulvectomy. one lesion Vulvectomy simple.700 13. obliteration of vagina.260 2. partial.300 7. ultrasound or CT scan guidance Exposure of prostate.120 16.100 2.400 5.200 5. suture of injury of vagina (nonobsterical) Colpoperineorrhaphy.000 8.800 21. suprapubic. hypogastric.000 25. meatotomy. repair of cystocele w/ or w/o repair of urethrocele Posterior colporrhaphy.300 55821 38. repair of rectocele w/ or w/o perineorrhaphy Combined anteroposterior colporrhaphy.200 5. and internal urethrotomy).300 30.180 16.800 15.500 7.000 4. radical.720 10.300 55859 55860 55862 18.200 33.300 9.000 4.600 5. w/ bilateral pelvic lymphadenectomy.500 21. w/ or w/o nerve sparing.520 5. complete. 600 9. single or multiple . w/ or w/o dilation and curettage.800 21. nonobstetrical Trachelorrhaphy. w/ or w/o fulguration. any method Dilation and curettage Myomectomy.700 5. loop electrode excision Trachelectomy (cervicectomy).700 9.800 3. abdominal approach.000 23. abdominal approach Sacrospinous ligament fixation for prolapse of vagina Paravaginal defect repair (including repair of cystocele.300 20.600 6. w/ repair of enterocele Vaginal hysterectomy.600 16.800 21.800 10. vaginal approach Total abdominal hysterectomy (corpus and cervix).000 30.800 12. w/ total or partial colpectomy.900 9.800 10. plastic repair of uterine cervix. single or multiple .200 25. vaginal approach Endometrial sampling (biopsy) w/ or w/o endocervical sampling (biopsy).700 18.800 10.800 23.600 6. w/ loop electrode excision procedure of the cervix Biopsy.300 21. abdominal approach Myomectomy.g.300 30.700 13.300 8.400 12.120 15.800 46.500 10. w/ anterior and/or posterior repair Excision of cervical stump.260 9.000 30. vaginal or transanal approach Closure of rectovaginal fistula.000 30.120 15.300 30.900 5. w/ or w/o repair.400 12. transvesical and vaginal approach Removal of impacted vaginal foreign body under anesthesia Laparoscopy. w/ bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy). w/ repair of enterocele Vaginal hysterectomy.400 4. w/ removal of tube(s).200 25.120 30.700 12. w/ or w/o removal of ovary(s) Total abdominal hysterectomy.500 2. w/ biopsy(s) of the cervix and/or endocervical curettage Colposcopy.900 13.980 23. including partial vaginectomy. and/or incomplete vaginal prolapse) Sling operation for stress incontinence (e.ANNEX 2.300 8.000 11.000 12. w/ or w/o removal of tube(s). Vaginal hysterectomy.500 13. cold knife or laser Conization of cervix.500 10.800 46.500 4.000 58260 58262 58263 58267 58270 58275 58280 58285 58300 58345 30.000 12.080 16.000 18.400 16.600 13. w/ or w/o removal of ovary(s). w/ or w/o removal of ovary(s).800 16. w/ removal of tube(s).680 1.600 21.000 18. vaginal approach Closure of vesicovaginal fistula.000 16.300 16.000 5.000 13.800 21.300 37.000 18.400 13.500 46. w/ or w/o removal of tube(s). colpopexy (suspension of vaginal apex) Colposcopy (Vaginoscopy) Colposcopy.300 30. abdominal approach.120 2.900 10. amputation of cervix Excision of cervical stump.800 39. w/ or w/o repair.800 5.000 12. Total abdominal hysterectomy (corpus and cervix).500 16.400 50. Excision of cervical stump.360 4.300 1. radical (Schauta type operation) Insertion of intrauterine device (IUD) Transcervical introduction of fallopian tube catheter for diagnosis and/or reestablishing patency (any method). w/ or w/o hysterosalpingography Case Rate 27. stress urinary incontinence. w/ or w/o removal of tube(s). w/ or w/o fulguration. w/o cervical dilation. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 57280 57282 57284 57288 57289 57300 57305 57307 57310 57311 57320 57330 57415 57425 57452 57454 57460 57500 57510 57520 57522 57530 57540 57545 57550 57555 57556 57700 57720 58100 58120 58140 58145 58150 58152 58180 58200 DESCRIPTION Colpopexy. w/ pelvic floor repair Excision of cervical stump. w/ or w/o removal of tube(s).200 1.360 15. surgical. w/ or w/o removal of ovary(s).200 8.120 16. w/ or w/o dilation and curettage.800 16. w/ repair of enterocele Cerclage of uterine cervix. w/ or w/o removal of ovary(s) Radical abdominal hysterectomy. w/ concomitant colostomy Closure of urethrovaginal fistula. w/ or w/o endoscopic control) Vaginal hysterectomy.500 10.000 12.500 4.500 16. Pereyra type.500 4. Vaginal hysterectomy. w/ or w/o fulguration Cauterization of cervix.000 12.700 16.900 18. and/or ovary(s) Vaginal hysterectomy.000 30.000 11.300 37.200 6. or any combination thereof Vaginal hysterectomy.200 21.800 16.300 37.000 33..000 23.680 5. or local excision of lesion. excision of fibroid tumor of uterus. and/or ovary(s). Closure of urethrovaginal fistula.000 18.000 Health Care Institution Fee 12. w/ colpo-urethrocystopexy (Marshall-MarchettiKrantz type.500 13.520 3.200 800 8.000 5.000 12.980 30. w/ bulbocavernosus transplant Closure of vesicovaginal fistula.400 21.120 27.000 58210 55.700 13. w/ total abdominal hysterectomy or cervicectomy. vaginal approach.000 4.000 25.300 18.300 30. fascia or synthetic) Pereyra procedure. including anterior colporrhaphy Closure of rectovaginal fistula. vaginal approach.600 21.900 12.100 4.120 27. Excision of cervical stump. single or multiple. any method Conization of cervix. w/ paraaortic and pelvic lymph node sampling.080 12. abdominal approach.200 9. vaginal approach.600 10.260 27.300 23. excision of fibroid tumor of uterus.000 25.020 8. w/ or w/o removal of ovary(s) Pelvic exenteration for gynecologic malignancy.500 6.500 9.300 21. abdominal approach Closure of rectovaginal fistula.680 9. w/ removal of bladder and ureteral transplantations.500 46.400 58240 71.600 18. and/or abdominoperineal resection of rectum and colon and colostomy. w/ total or partial colpectomy. w/ repair of enterocele Vaginal hysterectomy.500 37.600 Page 73 of 98 .400 4.300 20.800 21.000 30.000 Professional Fee 15. w/ or w/o removal of tube(s). w/ or w/o removal of tube(s). w/ colpo-urethrocystopexy (MarshallMarchetti-Krantz type) Supracervical abdominal hysterectomy (subtotal hysterectomy).600 8.600 16.680 4.120 8. ovariolysis) Tubotubal anastomosis Fimbrioplasty Salpingostomy (salpingoneostomy) Drainage of ovarian cyst(s).900 21.000 23. surgical.400 12.120 12.800 10.400 12. w/ radical dissection for debulking Laparotomy.900 10.. with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy) Laparoscopy.800 Health Care Institution Fee 5.400 7.g. w/ or w/o shortening of sacrouterine ligaments.900 10.960 12.800 16. with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants Ligation or transection of fallopian tube(s). pelvic viscera. surgical.900 10.000 10.300 18. surgical.500 10.560 6. surgical. intramural myomas and/or removal of surface myomas Laparoscopy surgical.500 58950 58951 53. surgical. unilateral or bilateral Salpingo-oophorectomy. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 58346 58400 58410 58520 58540 58545 58550 58552 58555 58558 58559 58560 58561 58562 58563 58565 58600 58660 58661 58662 58670 58671 58672 58673 58700 58720 58740 58750 58760 58770 58800 58805 58820 58822 58825 58900 58920 58925 58940 58943 DESCRIPTION Insertion of heyman capsules for brachytherapy Uterine suspension.080 10.120 23. repair of ruptured uterus (nonobstetrical) Hysteroplasty.000 29.500 5.600 21. with removal of leiomyomata Hysteroscopy. surgical.700 9.000 Page 74 of 98 . unilateral or bilateral. with fulguration of oviducts (with or without transection) Laparoscopy.680 1.300 20. vaginal approach Drainage of ovarian abscess.400 58952 58. w/ or w/o salpingectomy(s). with fimbrioplasty Laparoscopy.700 12.980 23.800 21. or peritoneal surface by any method Laparoscopy.700 10. with salphingostomy (salpingoneostomy) Salpingectomy. unilateral or bilateral . for staging or restaging of ovarian malignancy ("second look").980 20.600 9.600 10. vaginal approach Drainage of ovarian cyst(s).600 9.300 37.300 23..300 8.300 23. unilateral or bilateral. unilateral or bilateral Lysis of adhesions (salpingolysis.g.700 23. with or without D&C Hysteroscopy. unilateral or bilateral .600 24. with endometrial ablation (e.000 18. abdominal (e.000 7. partial or total.080 8.ANNEX 2.400 7.900 12.000 10.g.700 10.600 5.400 53. clip. surgical. w/ or w/o shortening of sacrouterine ligaments.300 30.000 10. with sampling (biopsy) of endometrium and/or polypectomy.960 14.400 16.200 12.980 18.700 16.300 9.300 27.700 10. myomectomy.600 8.800 23. peritoneal washing. abortion) Surgical treatment of ectopic pregnancy. with vaginal hysterectomy. with removal of tube(s) and/or ovary(s) Hysteroscopy.300 30.300 6. unilateral or bilateral Wedge resection or bisection of ovary. abdominal or vaginal approach. unilateral or bilateral Laparoscopy.720 1.600 13. electrosurgical ablation thermoablation) Hysteroscopy.600 10.120 12. with division or resection of intrauterine septum (any method) Hysteroscopy. Resection of ovarian malignancy w/ bilateral salpingo-oophorectomy and omentectomy.400 12.000 58960 59100 59120 27.900 10.700 12.300 12.400 4.560 7.120 5. w/ total abdominal hysterectomy.600 12. w/ or w/o shortening of round ligaments.600 12. surgical. with vaginal hysterectomy. w/ para-aortic and pelvic lymph node biopsies. with lysis of adhesions (salphingolysis.700 13. unilateral or bilateral Ovarian cystectomy. unilateral or bilateral Oophorectomy. w/ or w/o shortening of round ligaments. Laparoscopy surgical. surgical.300 10. w/ or w/o omentectomy. ovary(s) Biopsy of ovary.000 18.120 23.400 8.900 24.600 10.500 12.600 8.980 20. band.600 6. abdominal or vaginal approach Case Rate 9.400 8. Oophorectomy.000 23.080 10.680 4.400 33. abdominal approach Drainage of ovarian abscess. with removal of impacted foreign body Hysteroscopy.500 29. complete or partial. with lysis of intrauterine adhesions (any method) Hysteroscopy.800 4. surgical. for ovarian malignancy.600 10.500 6.600 9.300 Professional Fee 4. excision. surgical. w/ or w/o omentectomy Resection of ovarian malignancy w/ bilateral salpingo-oophorectomy and omentectomy.700 6.000 30.600 10.000 12. peritoneal biopsies. for hydatidiform mole. surgical.000 21. partial or total. ovariolysis) Laparoscopy. abdominal approach Transposition.400 6.000 10.600 16.000 3. or Falope ring) Laparoscopy.080 12.700 12.120 15.700 9.500 13. repair of uterine anomaly (Strassman type) Laparoscopy.400 14. complete or partial.800 37.600 10. surgical.. Uterine suspension.080 10.600 15.900 10. with fulguration or excision of lesions of the ovary. endometrial resection.080 10.300 20. w/ presacral sympathectomy Hysterorrhaphy.900 10. tubal or ovarian.400 23. with occlusion of oviducts by device (e.900 18. diagnostic Hysteroscopy. surgical. surgical.300 18.300 27.000 23.200 6.700 10. diaphragmatic assessment w/ pelvic and limited paraaortic lymphadenectomy Hysterotomy.600 15.980 20.000 21.120 12. peritoneal washings.400 55. requiring salpingectomy and/or oophorectomy. diaphragmatic assessments. pelvic and limited paraaortic lymphadenectomy Resection of ovarian malignancy w/ bilateral salpingo-oophorectomy and omentectomy.980 20. biopsy of abdominal and pelvic peritoneum.900 9. 800 16. recurrent Parathyroidectomy or exploration of parathyroid(s). partial or complete.900 30. including substernal thyroid gland. total or subtotal for malignancy.120 39.000 31.300 18. vaginal delivery and/or postpartum care for hospitals.600 12. re-exploration Parathyroidectomy or exploration of parathyroid(s).600 9.500 20.440 15. w/o salpingectomy and/or oophorectomy Laparoscopic treatment of ectopic pregnancy. during pregnancy.360 3.000 11.080 12.000 12.000 31.700 13.500 3.400 12. partial or total.000 46.720 7.500 37. tubal or ovarian.000 18. w/ radical neck dissection Thyroidectomy.120 19.300 16.ANNEX 2.900 18. sternal split or transthoracic approach.000 6.800 15. partial or total.600 6.600 7.400 6.000 18. Adrenalectomy.000 5. total or subtotal for malignancy.980 23.000 46.300 21.800 37. w/ excision of carotid artery Case Rate 27.400 12.400 12. partial or complete.500 16.900 4.600 4. interstitial.000 4. w/ evacuation Laparoscopic treatment of ectopic pregnancy.980 31.600 13. w/ or w/o isthmusectomy Total thyroid lobectomy.900 10.120 25.200 25. w/ excision of adjacent retroperitoneal tumor Excision of carotid body tumor.500 18.100 23. primary Cesarian delivery Subtotal or total hysterectomy after cesarean delivery Vaginal delivery only.360 10.800 2.800 13. abdominal Hysterorrhaphy of ruptured uterus Routine obstetric care including antepartum care.600 18.600 21.120 27.900 16.400 5.900 39. lumbar or dorsal. completed surgically Manual vacuum aspiration for spontaneous abortion Uterine evacuation and curettage for hydatidiform mole Incision and drainage of thyroglossal cyst. uterine pregnancy w/ partial resection of uterus Surgical treatment of ectopic pregnancy. infected Aspiration and/or injection.260 8. w/ limited neck dissection Thyroidectomy.700 12. cervical. transabdominal.000 31.100 16.600 3. delivery and newborn services of non-hospital facilities (Maternity Care Package).400 16.000 19. with bilateral tubal ligation Vaginal delivery only (w/ episiotomy) Breech extraction Caesarian section. abdominal pregnancy Surgical treatment of ectopic pregnancy.000 10. Treatment of incomplete abortion.720 7. removal of all remaining thyroid tissue following previous removal of a portion of thyroid Thyroidectomy.600 5. sternal split or transthoracic approach.900 5.200 21.600 4.080 12.600 18.800 18.200 10.120 8.504 8.000 16.120 46. including isthmusectomy Total thyroid lobectomy. transabdominal.900 39. unilateral.600 13. percutaneous core needle Excision of cyst or adenoma of thyroid . interstitial. unilateral.600 30. during pregnancy. or exploration of adrenal gland w/ or w/o biopsy.720 504 3. vaginal delivery and/or postpartum care (Normal Spontaneous Delivery Package) for hospitals Routine Obstetric care including prenatal.800 Page 75 of 98 .100 16.600 30.200 12. w/ radical mediastinal dissection Adrenalectomy.300 6.400 25. w/o radical mediastinal dissection Thymectomy. w/ mediastinal exploration.800 2.800 21.000 12.000 12.300 39. transcervical approach Thymectomy. including substernal thyroid gland.500 16.400 11. partial or total.800 18.300 37.000 31.300 10.300 37.600 18.400 8. or transection of isthmus Partial thyroid lobectomy.300 30.120 23.700 17.900 16. sternal split or transthoracic approach Parathyroid autotransplantation Thymectomy.120 19.000 30.600 21. w/ salpingectomy and/or oophorectomy Cerclage of cervix.400 12.600 18.900 30.000 Health Care Institution Fee 12.120 3. thyroid cyst Biopsy thyroid.300 12.500 9.000 9.400 3. Excision of thyroglossal duct cyst or sinus. after previous cesarean delivery (w/ or w/o episiotomy) Cesarean delivery only.400 4. sternal split or transhoracic approach Thyroidectomy. Parathyroidectomy or exploration of parathyroid(s).000 31.900 10.260 20.100 23.400 11.120 18.500 12.800 23. w/ or w/o isthmusectomy Partial thyroid lobectomy. following attempted vaginal delivery after previous cesarean delivery. w/ contralateral subtotal lobectomy. lumbar or dorsal. vaginal Cerclage of cervix. unilateral. 1st claim Routine obstetric care including antepartum care. any trimester.000 30.000 11. unilateral.400 6.000 3.300 27. w/ contralateral subtotal lobectomy.800 13.700 13. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 59121 59130 59135 59136 59140 59150 59151 59320 59325 59350 59400 DESCRIPTION Surgical treatment of ectopic pregnancy.000 59401 59402 59409 59411 59513 59514 59525 59612 59620 59812 59814 59870 60000 60001 60100 60200 60210 60212 60220 60225 60240 60252 60254 60260 60270 60271 60280 60281 60500 60502 60505 60512 60520 60521 60522 60540 60545 60600 60605 8.200 6.400 18. w/o salpingectomy and/or oophorectomy Surgical treatment of ectopic pregnancy. uterine pregnancy requiring total hysterectomy Surgical treatment of ectopic pregnancy. cervical approach Excision of thyroglossal duct cyst or sinus.000 21.740 27.120 15.400 25.500 Professional Fee 15. including isthmusectomy Thyroidectomy.400 11. total or complete Thyroidectomy. or exploration of adrenal gland w/ or w/o biopsy.500 5.500 46.800 16.600 18. w/o excision of carotid artery Excision of carotid body tumor.400 12.500 31. suture.400 29. for evacuation and/or drainage of subdural hematoma Burr hole(s) for ventricular puncture (including injection of gas. extradural or subdural Craniectomy or craniotomy for evacuation of hematoma.600 25. for excision of meningioma.800 10. for exploration or decompression of cranial nerves Craniectomy.600 33. subtemporal). supratentorial Burr hole(s) or trephine. bone flap craniotomy. bone flap craniotomy.300 30.600 13. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 60650 61000 61020 61050 61105 61106 61107 61108 61120 DESCRIPTION Laparoscopy.800 21.000 33.800 21. bone flap craniotomy. subtemporal. for mesencephalic tractotomy or pedunculotomy Craniotomy for lobotomy. or radioactive material).000 53. surgical. bone flap craniotomy.300 21. w/ drainage of brain abscess or cyst Burr hole(s) w/ evacuation and/or drainage of hematoma. Arnold-Chiari malformation) Other cranial decompression. except meningioma.000 5. for section of one or more cranial nerves Craniectomy. drainage of intracranial abscess.400 21. trephination.300 24.000 16.300 24. posterior fossa Craniotomy for section of tentorium cerebelli Craniectomy.400 46.400 29. w/ biopsy of brain or intracranial lesion Burr hole(s) or trephine. except meningioma Craniectomy.400 21.ANNEX 2.400 25. infratentorial. drainage of intracranial abscess.000 21. infratentorial Decompression of orbit only. with adrenalectomy.000 24.600 42.800 1.820 16.500 16.000 21.500 4.400 53.200 29. infratentorial (posterior fossa) Craniectomy or craniotomy for evacuation of hematoma. w/ excision of tumor or other bone lesion of skull Craniectomy.400 16. dye..400 25.500 53. or radioactive material).680 5. supratentorial Craniectomy.800 16. cerebellopontine angle tumor. or implanted ventricular catheter/reservoir Cisternal or lateral cervical (C1-C2) puncture Twist drill hole for subdural or ventricular puncture.200 25.000 4.000 Page 76 of 98 . followed by other surgery Burr hole(s) or trephine.500 53.000 21.800 23.200 29.400 33. infratentorial.600 33. supratentorial. not followed by other surgery Twist drill hole for subdural or ventricular puncture. dye.800 46. followed by other surgery Twist drill hole for subdural or ventricular puncture. or midline tumor at base of skull Case Rate 30. for excision or fenestration of cyst.200 25.400 53.000 12.000 63. suboccipital. partial or complete.800 37.000 29. w/ aspiration of hematoma or cyst.400 53. for excision of brain abscess. exploratory. supratentorial Craniectomy for excision of brain tumor.600 16.g.040 8. supratentorial Craniectomy.300 24. suboccipital. trephination. supratentorial Craniectomy.500 9. w/ biopsy Exploration of orbit (transcranial approach).g.300 21. or suture.300 21.400 37.800 21. suboccipital w/ cervical laminectomy for decompression of medulla and spinal cord.500 46.800 16..000 55. compression.200 29. w/ removal of lesion Exploration of orbit (transcranial approach).000 21. for excision of brain tumor.800 24. intracerebral Craniectomy or craniotomy for evacuation of hematoma. infratentorial or posterior fossa. supratentorial Craniectomy or craniotomy. for medullary tractotomy Craniectomy.400 65. unilateral or bilateral Craniectomy or craniotomy.400 21.400 55.300 37. contrast media. including cingulotomy Craniectomy.400 29.000 18.500 53.300 24.800 55.500 55.200 25. supratentorial.500 46.000 21. exploratory. intracerebellar Craniectomy or craniotomy.900 16. or decompression of sensory root of gasserian ganglion Craniectomy.420 30. transabdominal. w/ or w/o dural graft (e.000 24.500 46. fontanelle. w/ removal of foreign body Other cranial decompression (e.400 8.800 23.000 46.400 46.300 21. transcranial approach Exploration of orbit (transcranial approach).800 21.600 9.500 16. suboccipital.100 10. extradural or subdural Burr hole(s).000 25.000 21.000 37.000 12.800 53.800 10.800 37. suboccipital. extradural or subdural Craniectomy or craniotomy for evacuation of hematoma. unilateral or bilateral Ventricular puncture through previous burr hole.000 24.600 Health Care Institution Fee 13.000 29.400 21.200 33.680 1. for section. lumbar or dorsal Subdural tap through fontanelle.400 46.000 24.680 5.100 11.000 21.400 21.400 25. for osteomyelitis Craniectomy. for implanting venticular catheter or pressure recording device Twist drill hole for subdural or ventricular puncture. infant.540 18.680 10. not followed by other surgery Burr hole(s) for ventricular puncture (including injection of gas. infratentorial.000 24.000 55.400 44.300 Professional Fee 16. intracerebral Burr hole(s) or trephine.400 53.000 24.200 29.800 37.500 53.240 37.600 21.700 61130 61140 61150 61154 61156 61250 61253 61304 61305 61312 61313 61314 61315 61320 61321 61330 61332 61333 61334 61340 61343 61345 61440 61450 61458 61460 61470 61480 61490 61500 61501 61510 61512 61514 61516 61518 22. contrast media. supratentorial.800 16. supratentorial Craniectomy or craniotomy.400 29. or exploration of adrenal gland with or without biopsy.000 21.340 21.400 29.400 53. trephination.300 5.300 37. trephination.700 13. 600 29.000 61563 61564 61570 61571 61575 61576 58. for subdural implantation of an electrode array. w/ treatment of penetrating wound of brain Transoral approach to skull base. combined w/ middle/posterior fossa craniotomy/ craniectomy Subdural implantation of strip electrodes through one or more burr or trephine hole(s) for long term seizure monitoring Craniotomy w/ elevation of bone flap. decompression or excision of lesion.400 29. recontouring w/ multiple osteotomies and bone autografts (e.000 24.400 55. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 61519 61520 61521 61522 61524 61526 61530 61531 61533 61534 61535 61536 61538 61539 61541 61542 61543 61544 61545 61546 61548 61550 61552 61556 61557 61558 DESCRIPTION Craniectomy for excision of brain tumor. meningioma Craniectomy for excision of brain tumor. including unilateral or bifrontal craniotomy. transtemporal (mastoid) for excision of cerebellopontine angle tumor.g.200 25.000 42.000 63.000 21.200 50.800 21.500 58.000 24. cloverleaf skull). elevation of frontal lobe(s).000 21.400 33.000 24. for lobectomy w/ electrocorticography during surgery.000 21. transtemporal (mastoid) for excision of cerebellopontine angle tumor.000 21. intracranial approach Hypophysectomy or excision of pituitary tumor. Craniectomy.000 21.000 21.800 Health Care Institution Fee 21.000 21.400 55.000 21.300 21. extradural.000 24.000 61559 58.000 24.800 29.000 21. transnasal or transseptal approach.800 53.600 29. midline tumor at base of skull Craniectomy. for excision of brain abscess Craniectomy. Craniectomy..000 21.000 61581 63. intra and extracranial. nonstereotactic Craniectomy for craniosynostosis. infratentorial or posterior fossa. for excision of cerebral epileptogenic focus.600 54.000 24.000 61580 63.000 55.400 71. for removal of epidural or subdural electrode array.400 53.000 21. for transection of corpus callosum Craniotomy w/ elevation of bone flap. multiple cranial sutures Craniotomy for craniosynostosis. orbital exenteration.000 75. infratentorial or posterior fossa.g. barrel-stave procedure) (includes obtaining grafts) Excision. including lateral rhinotomy. not requiring bone grafts Extensive craniectomy for multiple cranial suture craniosynostosis (e. for excision of epileptogenic focus w/o electrocorticography during surgery Craniotomy w/ elevation of bone flap. for partial or subtotal hemispherectomy Craniotomy w/ elevation of bone flap. infratentorial or posterior fossa. for excision or fenestration of cyst.600 54. frontal or parietal bone flap Craniotomy for craniosynostosis.400 21.400 21.600 37. brain stem or upper spinal cord for biopsy.400 67.000 53.500 54.800 Professional Fee 46. intra and extracranial..000 37. benign tumor of cranial bone (e.000 53.200 25.800 21. infratentorial or posterior fossa. w/o maxillectomy or orbital exenteration Craniofacial approach to anterior cranial fossa.400 55.600 75. including lateral rhinotomy.000 63. for excision of coagulation of choroid plexus Craniotomy w/ elevation of bone flap.200 71. osteotomy of base of anterior cranial fossa Case Rate 67. fibrous dysplasia).600 75.200 42.400 53.400 50. for long term seizure monitoring Craniotomy w/ elevation of bone flap.400 53.500 75. infratentorial or posterior fossa. requiring splitting of tongue and/or mandible (including tracheostomy) Craniofacial approach to anterior cranial fossa. for total hemispherectomy Craniotomy w/ elevation of bone flap. w/ optic nerve decompression Craniectomy or craniotomy. sphenoidectomy.000 16.g.400 53.000 61582 63.. sphenoidectomy and/or maxillectomy Craniofacial approach to anterior cranial fossa.400 63.000 42. benign tumor of cranial bone (e.g.g. w/ excision of foreign body from brain Craniectomy or craniotomy. w/ electrocorticography during surgery (includes removal of electrode array) Craniotomy w/ elevation of bone flap.000 42.500 46.600 54.400 29. partial or total Craniotomy w/ elevation of bone flap.300 21. for lobectomy w/ electrocorticography during surgery. w/o optic nerve decompression Excision.ANNEX 2. temporal lobe Craniotomy w/ elevation of bone flap.000 21.000 21.800 37. extradural.000 25.000 21.400 31.200 63. single cranial suture Craniectomy for craniosynostosis..000 21.400 42.800 58.000 21. brain stem or upper spinal cord for biopsy.400 33.500 46. Transoral approach to skull base. cloverleaf skull).600 33.000 24.600 21. w/o excision of cerebral tissue Craniotomy w/ elevation of bone flap. extradural.400 46. fibrous dysplasia). ethmoidectomy.000 24.000 Page 77 of 98 . ethmoidectomy.000 42. cerebellopontine angle tumor Craniectomy for excision of brain tumor.000 42.000 21.000 24.000 29.300 21. bone flap craniotomy.200 37.. decompression or excision of lesion.400 29.400 29.400 24.400 53.400 29.800 46. bifrontal bone flap Extensive craniectomy for multiple cranial suture craniosynostosis (e. other than temporal lobe. for excision of craniopharyngioma Craniotomy for hypophysectomy or excision of pituitary tumor. bone flap craniotomy.800 37.600 53. craniotomy.400 21. clivus or midline skull base. decompression of sigmoid sinus and/or facial nerve.000 61598 61600 61601 71. parasellar area.400 50. mastoidectomy. intradural. vascular or infectious lesion of parasellar area.400 50. cavernous sinus. carotid artery in petrous canal.400 50.400 50.400 46.000 21.200 21. including occiptal condylectomy. extradural Resection or excision of neoplastic.000 61618 67.000 Professional Fee 42.400 50. adipose tissue. vascular or infectious lesion of infratemporal fossa. including supraorbital ridge osteotomy and elevation of frontal and/or temporal lobe(s).400 63.g. including dural repair.000 21. carotid artery in cavernous sinus.400 67.400 21. clivus or midline skull base. including supraorbital ridge osteotomy and elevation of frontal and/or temporal lobe(s). including ligation of superior petrosal sinus and/or sigmoid sinus Resection or excision of neoplastic.000 21. w/ or w/o decompression and/or mo Orbitocranial zygomatic approach to middle cranial fossa (cavernous sinus and carotid artery.or intradural elevation of temporal lobe Transtemporal approach to posterior cranial fossa. tensor fascia lata.000 61592 67.200 50. foramen magnum.200 46.400 50.200 46. petrous apex. elevation or resection of frontal lobe. w/ or w/o mobilization of facial nerve and/or petrous carotid artery Transcondylar (far lateral) approach to posterior cranial fossa.200 67. decompression and/or mobilization of th Infratemporal post-auricular approach to middle cranial fossa (internal auditory meatus.000 61605 71. extradural Resection or excision of neoplastic.400 21. or CI-C3 vertebral bodies. cavernous sinus. including dural repair.000 61607 71. homologous or synthetic grafts) Case Rate 63. craniotomy. decompression.000 21. vascular or infectious lesion of base of anterior cranial fossa. or CI-C3 vertebral bodies. w/o orbital exenteration Orbitocranial approach to anterior cranial fossa. jugular foramen.w/ or w/o graft Resection or excision of neoplastic. w/ or w/o mobilization Transcochlear approach to posterior cranial fossa. clivus.000 50. fascia. vascular or infectious lesion of base of posterior cranial fossa. intradural.000 21. transzygomatic and/or LeFort I osteotomy approach to anterior cranial fossa w/ or w/o internal fixation.400 42. anterior. cavernous sinus.400 21.400 71. vascular or infectious lesion of parasellar area.000 21.000 61597 71.000 61590 71. including dural repair. arteriovenous malformation. w/ or w/o graft Secondary repair of dura for CSF leak.000 61595 71. osteotomy of base of anterior cranial fossa Orbitocranial approach to anterior cranial fossa. resection of C1-C3 vertebral body(s). including labyrinthectomy.000 61608 61609 61610 61611 61612 61613 61615 71.000 61596 71. intradural.000 21. jugular foramen or midline skull base. infratemporal and midline skull base. including dural repair. vascular or infectious lesion of infratemporal fossa. carotid artery in cavernous sinus. extradural.400 50.400 71. jugular foramen.400 21. middle or posterior cranial fossa following surgery of the skull base. petrous apex.400 50. pericranium. petrous apex. jugular foramen or midline skull base.400 50. nasopharynx).400 21.400 21. intradural.400 50.000 61584 63. w/ repair by anastomosis or graft Transection or ligation . w/o repair Transection or ligation. extradural Resection or excision of neoplastic.000 61616 71. w/ repair by anastomosis or graft Obliteration of carotid aneurysm. parapharyngeal space.000 61591 71. w/ or w/o graft Transection or ligation. w/ orbital exenteration Bicoronal.000 Page 78 of 98 .000 21. w/o repair Transection or ligation .000 42.000 71. vascular or infectious lesion of base of anterior cranial fossa.400 50. w/ or w/o graft Resection or excision of neoplastic. extradural.400 71.000 21. w/ or w/o disarticulation of the mandible.400 21. decompression of vertebral artery.000 21.000 61606 71.200 46.000 63.000 61585 61586 63.ANNEX 2.. basilar artery or petrous apex) including osteotomy of zygoma.000 Health Care Institution Fee 21. including mastoidectomy.000 42. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 61583 DESCRIPTION Craniofacial approach to anterior cranial fossa. jugular foramen or midline skull base. including unilateral or bifrontal craniotomy.000 21. by free tissue graft (e.400 50. clivus or framen magnum. w/o bone graft Infratemporal pre-auricular approach to middle cranial fossa (parapharyngeal space. parapharyngeal space.400 50. extra. w/ or w/o mobilization Transpetrosal approach to posterior cranial fossa. vascular or infectious lesion of base of posterior cranial fossa.200 21. infratemporal fossa) inlcuding mastoidectomy. extradural Resection or excision of neoplastic. including parotidectomy. intradural. resection of sigmoid sinus. carotid artery in petrous canal. tentorium. foramen magnum.400 50.400 21.000 42.400 21. or carotidcavernous fistula by dissection w/in cavernous sinus Resection or excision of neoplastic.400 71.200 21. trigeminal medullary tract Stereotactic radiosurgery (particle beam.000 16. percutaneous.000 21. to achieve hemostasis. percutaneous.000 61624 71. middle or posterior cranial fossa following surgery of the skull base. infratentorial.400 33.000 42. supratentorial. central nervous system (intracranial.200 46. extracranial-intracranial (e. dural. subcortical structure(s) other than globus pallidus or thalamus Stereotactic biopsy.000 21.400 55.000 42.000 21.200 21.800 46. w/ insertion of catheter(s) for brachytherapy Creation of lesion by stereotactic method. thermal.200 58. middle cerebral/cortical) arteries Microdissection.000 16.600 12.000 13.000 21. by intra-arterial embolization.600 23. subcortical Craniectomy for implantation of neurostimulator electrodes.000 71. supratentorial. arterial.200 42.000 53.800 42.000 42.. to achieve hemostasis. globus pallidus or thalamus Creation of lesion by stereotactic method. single or multiple stages.800 63. vertebral-basilar circulation Surgery of intracranial aneurysm.800 25.including burr hole(s). aspiration.800 Page 79 of 98 . or excision.000 21.000 42.gamma ray or linear accelerator) Stereotactic computer assisted volumetric intracranial procedure Twist drill or burr hole(s) for implantation of neurostimulator electrodes.200 46.000 63. infratentorial..400 75. any method. intracranial approach.800 21.300 71.000 21. direct or inductive coupling Case Rate Professional Fee Health Care Institution Fee 21.200 37.800 67.000 29.000 63. w/ computerized axial tomography Stereotactic implantation of depth electrodes into the cerebrum for long term seizure monitoring Stereotactic localization . gasserian ganglion Creation of lesion by stereotactic method. including burr hole(s) and localizing and recording techniques. electrical.000 30.200 37..200 21. cerebellar.000 21.000 21. subcortical Craniectomy or craniotomy for implantation of neurostimulator electrodes.000 63.000 21.000 16.300 21. Stereotactic biopsy.000 50.000 67.000 42.000 50. percutaneous. cortical Craniectomy for implantation of neurostimulator electrodes.000 61619 63.000 10.000 50.400 46. for intracranial lesion..400 61680 61682 61684 61686 61690 61692 61700 61702 61703 61705 61708 61710 61711 61712 61720 63.000 63.400 21. brachiocephalic branch) Surgery of intracranial arteriovenous malformation.000 71.800 21.400 63. radiofrequency). by neurolytic agent (e.000 21. by intracranial electrothrombosis Surgery of aneurysm.000 21. vascular malformation or carotid-cavernous fistula.800 63. any method. for intracranial lesion.400 50.000 33.800 21. anterior. for tumor destruction.000 21. cervical approach by application of occluding clamp to cervical carotid artery (Selverstone-Crutchfield type) Surgery of aneurysm.600 42. cortical Twist drill or burr hole(s) for implantation of neurostimulator electrodes. including burr hole(s). simple Surgery of intracranial arteriovenous malformation.g. percutaneous. injection procedure or balloon catheter Anastomosis.400 21.000 71. any method. spinal cord) Transcatheter oclussion or embolization (e.000 21. carotid circulation Surgery of intracranial aneurysm.temporalis.g.800 46.200 67.g.700 21.000 61735 61750 61751 61760 61770 61790 63. alcohol.000 42. simple Surgery of intracranial arteriovenous malformation.g.including burr hole(s).800 21. non-central nervous system. intracranial approach.000 21.300 37.000 63. by local or regionalized vascularized pedicle flap or myocutaneous flap (including galea. complex Surgery of intracranial aneurysm. thermal.200 67. simple Surgery of intracranial arteriovenous malformation. vascular malformation or carotid-cavernous fistula. subcortical Incision and subcutaneous placement of cranial neurostimulator pulse generator or receiver. head or neck (extracranial. electrical.400 37.200 37. by neurolytic agent (e.ANNEX 2.g.400 21. cortical Craniectomy or craniotomy for implantation of neurostimulator electrodes.000 16.500 16. for tumor destruction.000 21. including burr hole(s) and localizing and recording techniques. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE DESCRIPTION Secondary repair of dura for CSF leak.600 21.400 67. to occlude a vascular malformation). intracranial or spinal procedure (list separately in addition to code for primary procedure) Creation of lesion by stereotactic method. frontalis or occipitalis muscle) Transcatheter oclussion or embolization (e.000 24.000 21. complex Surgery of intracranial arteriovenous malformation. or excision.600 50.000 21.400 54. cerebral.000 61626 55.400 42. cerebral. by intracranial and cervical occlusion of carotid artery Surgery of aneurysm. single or multiple stages.000 42. dural. vascular malformation or carotid-cavernous fistula.000 21. alcohol.500 58. cerebellar. complex Surgery of intracranial arteriovenous malformation.000 46.800 61791 61793 61795 61850 61855 61860 61865 61870 61875 61885 37.. aspiration. radiofrequency). to occlude a vascular malformation). obstructed valve. with excision of pituitary tumor.300 21. up to 5 cm diameter Cranioplasty for skull defect.200 21.200 25.800 12.300 21.500 13. including surgery for rhinorrhea/otorrhea Reduction of craniomegalic skull (e. one or two vertebral segments.800 16.000 25. -jugular.400 37. other terminus Ventriculocisternostomy.700 6. up to 5 cm diameter Cranioplasty w/ autograft (includes obtaining bone grafts).000 Health Care Institution Fee 13.300 16. w/ or w/o programming Implantation or replacement of device for intrathecal or epidural drug infusion.800 62161 46. intracranial.400 37.000 25.300 12. fenestration of septum pellucidum or intraventricular cyst (including placement.800 16.000 16..300 37. intracranial.400 55.300 18. for placement or replacement of ventricular catheter and attachment to shunt system or external drainage Neuroendoscopy.400 58.300 30.300 63001 55.000 25. with dissection of adhesions.800 21.g. not requiring bone grafts or cranioplasty Reduction of craniomegalic skull (e.300 30.000 4.900 5.800 16. any method. larger than 5 cm diameter Removal of bone flap or prosthetic plate of skull Replacement of bone flap or prosthetic plate of skull Cranioplasty for skull defect w/ reparative brain surgery Cranioplasty w/ autograft (includes obtaining bone grafts). for implantable reservoir or implantable infusion pump.200 21.000 23. including preparation of pump. including placement of external ventricular catheter for drainage Laminectomy w/ exploration and/or decompression of spinal cord and/or cauda equina.300 30. third ventricle.560 23.800 46.500 46. for drainage of spinal fluid (by needle or catheter) Aspiration procedure.800 21.600 8.500 25. extradural Elevation of depressed skull fracture.500 71. requiring craniotomy and reconstruction w/ or w/o bone graft (includes obtaining grafts) Repair of encephalocele.600 4. third ventricle.g.700 9.500 16. with fenestration or excision of colloid cyst. lumbar Implantation.260 12. w/ laminectomy Implantation or replacement of device for intrathecal or epidural drug infusion.600 10.300 1.400 29.600 16. with retrieval of foreign body Neuroendoscopy.800 46. compound or comminuted. skull vault.000 12.700 16.800 29.000 25. percutaneous needle Spinal puncture.g.400 21. spinal cord cyst or syrinx Biopsy of spinal cord.300 53.300 10. w/o facetectomy. treated hydrocephalus). -jugular.000 21. simple. spinal stenosis). ventriculo-peritonial.500 13.800 10. treated hydrocephalus). foraminotomy or diskectomy.300 21..200 8.-pleural. skull base Cranioplasty for skull defect. w/ simple cranioplasty Reduction of craniomegalic skull (e.400 16. single or multiple levels.600 62351 62360 62361 62362 37. w/o laminectomy Implantation.800 16. subcutaneous reservoir Implantation or replacement of device for intrathecal or epidural drug infusion. larger than 5 cm diameter Neuroendoscopy.300 13.000 24. -auricular Creation of shunt. percutaneous.300 62162 62163 62165 62180 62190 62192 62200 62201 62220 62223 62230 62268 62269 62270 62272 62287 62350 46.200 21.g.680 5.-auricular Creation of shunt.800 23.500 9.300 6.500 13.600 6.400 33. therapeutic..300 23. lumbar. stereotactic method Creation of shunt.400 13.800 33.500 37.800 9. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 62000 62005 62010 62100 62115 62116 62117 62120 62121 62140 62141 62142 62143 62145 62146 62147 62160 DESCRIPTION Elevation of depressed skull fracture.600 21.300 23. diagnostic Spinal puncture .500 30.900 12.400 53.ANNEX 2.800 5. revision or repositioning of intrathecal or epidural catheter. intracranial.200 25.000 21.500 25.500 53.800 55. including placement of external ventricular catheter for drainage Neuroendoscopy. non-programmable pump Implantation or replacement of device for intrathecal or epidural drug infusion. or distal catheter in shunt system Percutaneous aspiration. extradural Elevation of depressed skull fracture.000 33.000 30. treated hydrocephalus).700 10.500 10.800 Professional Fee 16..700 62464 46.600 21.400 21.000 37.600 6.300 24. replacement or removal of ventricular catheter) Neuroendoscopy. with excision of brain tumor. (e.200 50.000 4.400 Page 80 of 98 . ventriculo-atrial.700 18. other terminus Replacement or revision of CSF (VP) shunt. revision or repositioning of intrathecal or epidural catheter.200 16.300 21.500 46. cervical Case Rate 30.800 21. subarachnoid/subdural-atrial.300 30.500 13.600 21.500 24. -pleural.400 12. w/ repair of dura and /or debridement of brain Craniotomy for repair of dural /CSF leak.600 12. transnasal or transphenoidal approach Ventriculocisternostomy (Torkildsen type operation) Creation of shunt.800 21. including cranioplasty Craniotomy for repair of encephalocele . of nucleus pulposus of intervertebral disk. subarachnoid/subdural-peritonial.000 21. intracranial.800 46. for implantable reservoir or implantable infusion pump. intracranial.300 37. programmable pump.200 29.600 16. Ventriculocisternostomy.680 1. g. foraminotomy and/or excision of herniated intervertebral disk.400 29. herniated intervetebral disk). re-exploration. thoracic Laminectomy w/ exploration and/or decompression of spinal cord and/or cauda equina. foraminotomy or diskectomy.000 63056 63064 63075 63077 63081 46. more than 2 vertebral segments.500 25.400 63016 53.200 29. single vertebral segment. more than 2 vertebral segments. cauda equina and/or nerve root(s). including partial facetectomy . cervical Laminotomy (hemilaminectomy).000 16.000 63042 46.400 16.400 29.g.000 33.400 63085 53.lumbar Laminotomy (hemilaminectomy). partial or complete.000 21.500 25. foraminotomy and/or excision or herniated intervertebral disk. anterior approach w/ decompression of spinal cord and/ or nerve root(s). thoracic Transpedicular approach w/ decompression of spinal cord. one or two vertebral segments. w/ decompression of nerve root (s). cervical Laminectomy w/ exploration and/or decompression of spinal cord and/or cauda equina.000 63047 46.500 25.000 33.400 29. one interspace. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE DESCRIPTION Laminectomy w/ exploration and/or decompression of spinal cord and/or cauda equina. w/o facetectomy.g. lumbar Costovertebral approach w/ decompression of spinal cord or nerve root(s).600 21. single interspace Vertebral corpectomy (vertebral body resection).000 33.400 63030 46. partial or complete. single segment Case Rate Professional Fee Health Care Institution Fee 24. foraminotomy or diskectomy.g.400 24.800 21.400 24. transperitoneal or retroperitoneal approach w/ decompression of spinal cord.800 21.200 21.400 24. equina and/ or nerve root(s) (e. w/ decompression of spinal cord and/ or nerve root(s).400 29.800 21.800 63012 53. spinal or lateral recess stenosis).400 29..400 24.400 24.. thoracic Laminectomy w/ exploration and/or decompression of spinal cord and/or cauda equina.200 21. facetectomy and foraminotomy (unilateral or bilateral w/ decompression of spinal cord.g. w/ decompression of spinal cord and/ or nerve root(s). w/o facetectomy. combined thoracolumbar approach w/ decompression of spinal cord. anterior.400 33.300 63020 55.400 29.000 63017 46. thoracic. lower thoracic. (e. ( eg.200 21. w/o facetectomy. (e. cauda equina or nerve root(s). (e.200 21. cervical. single segment.300 63090 53.. (e. w/o facetectomy.400 29.g. spinal stenosis). thoracic. ( eg.400 63046 53.000 63087 46. thoracic Laminectomy.000 16. foraminotomy or diskectomy.300 63055 53. single interspace Diskectomy. single segment Vertebral corpectomy (vertebral body resection).except for spondylolisthesis Laminectomy w/ exploration and/or decompression of spinal cord and/or cauda equina. cauda equina and/or nerve root(s).600 21. including partial facetectomy . sacral Laminectomy w/ removal of abnormal facets and/or pars inter-articularis w/ decompression of cauda equina and nerve roots for spondylolisthesis. including partial facetectomy .. spinal stenosis) .000 Page 81 of 98 . cervical Laminotomy (hemilaminectomy). herniated intervertebral disk). cervical Laminectomy.300 63040 53.. herniated intervetebral disk). including osteophytectomy.g. re-exploration. spinal or lateral recess stenosis). facetectomy and foraminotomy (unilateral or bilateral w/ decompression of spinal cord. spinal stenosis). equina and/ or nerve root(s) (e. one or two vertebral segments.400 29.g. cauda equina or nerve root(s).200 21. single segment Vertebral corpectomy (vertebral body resection).. lower thoracic or lumbar.600 21.500 25. lumbar.800 63011 37. lumbar. anterior. lumbar Transpedicular approach w/ decompression of spinal cord.500 53. including osteophytectomy.ANNEX 2. (e.500 25. w/ decompression of nerve root (s).000 33.400 63005 37.600 21... w/o facetectomy. cauda equina and/or nerve root(s). spinal or lateral recess stenosis). single vertebral segment.000 63003 53.400 55. single segment Diskectomy. or sacral. lumbar Laminectomy.300 24. thoracic. partial or complete. (e. single segment Vertebral corpectomy (vertebral body resection).400 24. ( eg.800 55. more than 2 vertebral segments. w/ decompression of nerve root (s). including partial facetectomy . foraminotomy or diskectomy. w/ decompression of nerve root (s). foraminotomy or diskectomy.000 63015 55.400 24. foraminotomy and/or excision of herniated intervertebral disk. lumbar (Gill type procedure) Laminectomy w/ exploration and/or decompression of spinal cord and/or cauda equina. one or two vertebral segments.300 63045 55. spinal stenosis) .000 25. w/o facetectomy. facetectomy and foraminotomy (unilateral or bilateral w/ decompression of spinal cord. one interspace.600 21. spinal stenosis). single segment. cervical. (e. transthoracic approach w/ decompression of spinal cord and/ or nerve root(s).. partial or complete. foraminotomy and/or excision or herniated intervertebral disk. single vertebral segment. spinal stenosis) .g.000 37. foraminotomy or diskectomy. lumbar Laminotomy (hemilaminectomy). thoracolumbar Laminectomy for biopsy/ excision of intraspinal neoplasm.500 58. Bischof or DREZ type). more than two segments Laminectomy w/ rhizotomy. intramedullary.000 53. one or two segments Laminectomy w/ rhizotomy. single segment.000 37. extradural.000 21.500 37. cervical Laminectomy w/ cordotomy w/ section of both spinothalamic tracts.400 46.300 21.400 24.400 53.800 33. lumbar Laminectomy for excision of intraspinal lesion other than neoplasm.500 37.400 36. to subarachnoid space Laminectomy w/ drainage of intramedullary cyst/ syrinx. extradural.400 24.000 24.400 24. thoracic Laminectomy w/ cordotomy w/ section of both spinothalamic tracts.600 29. intradural.400 49. extradural. w/ release of tethered spinal cord.000 33. intradural.400 24. cervical Laminectomy for biopsy/ excision of intraspinal neoplasm. extradural. partial or complete. thoracic Laminectomy w/ cordotomy w/ section of both spinothalamic tracts. cervical Laminectomy for excision or occlusion of arteriovenous malformation of spinal cord.400 33. w/ section of one spinothalamic tract.400 46. intradural. extradural. sacral Laminectomy for biopsy/ excision of intraspinal neoplasm. cervical Laminectomy w/ cordotomy.000 53.800 58. sacral Laminectomy for biopsy/ excision of intraspinal neoplasm. or thoracolumbar Laminectomy w/ drainage of intramedullary cyst/ syrinx.200 37.600 29. extradural.400 27.400 21.000 53.600 Health Care Institution Fee 21. cervical Case Rate 58.800 21.400 55. intradural. w/ or w/o dural graft.400 25. thoracic Laminectomy for excision of intraspinal lesion other than neoplasm.720 33.000 33. intradural.300 16. w/ section of one spinothalamic tract.400 57.400 24.400 29. cervical Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm.200 21. extradural.000 24.000 21.400 25. cervical.500 55.800 21. cervical Laminectomy for excision of intraspinal lesion other than neoplasm.600 29. thoracolumbar Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm.000 21. combined extradural-intradural lesion.000 21.400 24.400 Page 82 of 98 . extradural.500 55. for excision of intraspinal lesion.000 21.000 53. lumbar Laminectomy for excision or occlusion of arteriovenous malformation of spinal cord.g. thoracic Laminectomy for biopsy/ excision of intraspinal neoplasm. thoracic Laminectomy for biopsy/ excision of intraspinal neoplasm.400 55. one stage.800 55.000 53. cervical Laminectomy for biopsy/ excision of intraspinal neoplasm.000 55. extradural. cervical. extradural.600 33. lumbar Laminectomy for biopsy/ excision of intraspinal neoplasm.600 29. w/ or w/o dural graft.400 55.400 46.000 55.300 21.000 21.500 37. intradural.000 53.400 25.000 21. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 63170 63172 63173 63180 63182 63185 63190 63191 63194 63195 63196 63197 63198 63199 63200 63250 63251 63252 63265 63266 63267 63268 63270 63271 63272 63273 63275 63276 63277 63278 63280 63281 63282 63283 63285 63286 63287 63290 63300 DESCRIPTION Laminectomy w/ myelotomy (e.300 21. intradural.000 Professional Fee 37. cervical Laminectomy for biopsy/ excision of intraspinal neoplasm.400 46.000 21.200 33. cervical thoracic.400 33. extramedullarry.400 25. two stages w/in 14 days. extramedullary.600 29.400 21.600 29.800 55.400 24. thoracic Laminectomy for biopsy/ excision of intraspinal neoplasm.800 21.600 33. cervical Laminectomy w/ cordotomy w/ section of both spinothalamic tracts.800 33. extradural.400 46. one of two segments Laminectomy and section of dentate ligaments.800 55. extradural.ANNEX 2.400 24.300 16.400 24.400 21.000 21. one stage.400 33.800 53.400 46. lumbar Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm. more than two segments Laminectomy w/ section of spinal accessory nerve Laminectomy w/ cordotomy. intradural. extradural.020 55. extradural.200 21. any level Vertebral corpectomy (vertebral body resection). sacral Laminectomy for excision of intraspinal lesion other than neoplasm.000 21.000 21.000 53.800 29. extradural. intramedullary.000 53.120 33.600 29.000 21. intradural. extradural. extradural.600 29. extramedullary.200 33.300 16. extradural. lumbar Laminectomy for biopsy/ excision of intraspinal neoplasm.800 55. to peritoneal space Laminectomy and section of dentate ligaments.600 29.400 25.000 53.. thoracic Laminectomy for excision or occlusion of arteriovenous malformation of spinal cord. thoracic Laminectomy.000 53. extradural. extradural. two stages w/in 14 days.400 24. intradural. intramedullary. intradural. sacral Laminectomy for biopsy/ excision of intraspinal neoplasm.400 25.300 21.600 29.000 21.520 55.200 21. thoracic Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm. one stage. one stage. any modality (including stimulation and/ or recording) Stereotactic stimulation of spinal cord. transthoracic Transection or avulsion of.200 16. partial or complete.300 46.800 18. vagi limited to proximal stomach (selective proximal vagotomy.300 37.400 5.940 21. spinal cord Percutaneous implantation of neurostimulator electrodes.600 9.000 18.000 25.900 13.720 6.700 9. single segment.200 4.080 10. or other.000 30.600 Page 83 of 98 .120 18. lumbar or sacral by transperitoneal or retroperitoneal approach Creation of lesion of spinal cord by stereotactic method.000 20.000 63306 53.400 29. intradural.500 5.600 9. proximal gastric vagotomy.400 24. -pleural. requiring use of operating microscope (list separately in addition to code for neuroplasty) (Neuroplasty inlcudes external neurolysis) Transection or avulsion of.400 8.800 46. major peripheral nerve.300 13.200 25.600 8.020 46. not requiring laminectomy Repair of dural/ CSF leak or pseudomeningocele. single segment.000 18. nerve of hand or foot Neuroplasty. for excision of intraspinal lesion. facial nerve.ANNEX 2.520 25.000 33.700 9.400 10. direct or inductive coupling Repair of meningocele. for excision of intraspinal lesion.900 10.920 16.800 9.300 21.120 21. separate procedure not followed by other surgery Stereotactic biopsy. larger than 5 diameter Repair of myelomeningocele. thoracic by transthoracic approach Vertebral corpectomy (vertebral body resection). for excision of intraspinal lesion. arm or leg. percutaneous.820 30.500 18.720 9.120 12. brachial plexus Neuroplasty. single segment.500 46.940 18. sciatic nerve Neuroplasty. lumbar plexus Neuroplasty and/or transposition. median nerve at carpal tunnel Decompression.200 8. vagus nerve (vagotomy).400 8. single segment.700 5. supra.200 4. phrenic nerve Transection or avulsion of. infraorbital nerve Transection or avulsion of.500 21.000 63304 55.400 29. extradural. arm or leg.700 16.240 8.600 9.500 13. partial or complete. percutaneous.980 20. ulnar nerve at elbow Neuroplasty and/or transposition.300 30. partial or complete.480 21.500 9.500 30. one or both.980 37.000 63600 63610 63615 63650 63655 63685 63700 63702 63704 63706 63707 63709 63710 63740 63741 64702 64704 64708 64712 64713 64714 64716 64718 64719 64721 64722 64726 64727 64732 64734 64736 64738 64740 64742 64744 64746 64752 64755 64760 64761 64763 30. lumbar. intradural. unspecified nerve(s) (specify) Decompression. same digit Neuroplasty. lumbar.400 24. other than specified Neuroplasty. inferior alveolar nerve by osteotomy Transection or avulsion of. partial or complete.080 10.500 5. supraorbital nerve Transection or avulsion of.600 6. ulnar nerve at wrist Neuroplasty and/or transposition.400 8.200 6.300 10. extrapelvic.700 12.500 5.120 9.600 9. major peripheral nerve. thoracic by thoracolumbar approach Vertebral corpectomy (vertebral body resection).700 12. thoracic by thoracolumbar approach Vertebral corpectomy (vertebral body resection). cranial nerve (specify) Neuroplasty and/or transposition.800 4.300 23.000 63307 53. single segment. lumbar or sacral by transperitoneal or retroperitoneal approach Vertebral corpectomy (vertebral body resection).500 30.300 37.600 10.000 16.800 18. epidural Incision and subscutaneous placement of spinal neurostimulator pulse generator or receiver.500 5. subarachnoid-peritoneal. mental nerve Transection or avulsion of.400 Professional Fee 29. greater occipital nerve Transection or avulsion of. larger than 5 diameter Repair of dural/ CSF leak.400 24.240 9. less than 5 cm diameter Repair of myelomeningocele. w/ or w/o adductor tenotomy Case Rate 53.400 63305 53.400 24. plantar digital nerve Internal neurolysis. abdominal Transection or avulsion of. extradural.800 16.000 8.400 5.500 5.400 29.400 9. cervical Vertebral corpectomy (vertebral body resection).000 9. percutaneous.000 18. differential or complete Transection or avulsion of. less than 5 cm diameter Repair of meningocele.400 24.300 13.700 18. major peripheral nerve. subarachnoid-peritoneal. vagus nerve (vagotomy). partial or complete. digital.300 12.000 63303 53.600 5.400 4.980 20.700 9. single segment.720 4. extradural. single segment.200 4.700 9.500 21.400 Health Care Institution Fee 24.500 18.200 10.080 21.400 16.500 5. spinal Creation of shunt.000 63302 53. parietal cell vagotomy.300 9. arm or leg. partial or complete.900 16.800 12. intradural.400 13. or excision of lesion.400 12. aspiration.500 10. or other.400 29. for excision of intraspinal lesion.600 21.200 6.720 8.or highly selective vagotomy) Transection or avulsion of.700 12.200 16. thoracic by transthoracic approach Vertebral corpectomy (vertebral body resection).500 5. for excision of intraspinal lesion. including laminectomy Creation of shunt.180 37. major peripheral nerve.400 8. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 63301 DESCRIPTION Vertebral corpectomy (vertebral body resection). for excision of intraspinal lesion. not requiring laminectomy Neuroplasty. w/ laminectomy Dural graft.800 21. lingual nerve Transection or avulsion of. pudendal nerve Transection or avulsion of obturator nerve.500 21.800 25.400 29.000 18.700 9.200 4. epidural Laminectomy for implantation of neurostimulator electrodes.700 5.900 10. partial or complete. for excision of intraspinal lesion.900 2.600 13.800 18. intradural. arm or leg. -pleural. 000 16.500 5. w/ or w/o adductor tenotomy Transection or avulsion of other cranial nerve.ANNEX 2.520 4. facial-hypoglossal Anastomosis.600 12.080 10.900 10.020 8.600 9. up to 4 cm length Nerve graft (includes obtaining graft).020 18.900 9.800 16.900 5.020 8. w/ implant.500 5.400 21. muscles not attached to implant Enucleation of eye.000 18. hand or foot.000 18. hand or foot. arm or leg.400 8. hand or foot. hand or foot.500 Page 84 of 98 . hand or foot.520 10.000 8.700 8. arm or leg.900 10.400 8.000 12. ulnar motor Suture of each additional nerve.900 9.000 18.400 8.080 6.800 38.280 15.400 16.500 5.120 12. after evisceration. each digit Microdissection and/or microrepair of nerve (list separately in addition to code for nerve repair) Suture of digital nerve.580 30. brachial plexus Suture of.000 8.400 5. surgically identifiable Excision of neuroma.080 8. more than 4 cm length Nerve graft. hand or foot.580 8.600 9.900 10.500 5. extensive (including malignant type) Biopsy of nerve Sympathectomy. infratemporal.580 27. up to 4 cm length Nerve graft (includes obtaining graft).200 2.300 23. w/ therapeutic removal of bone Exenteration of orbit without skin graft. hand or foot.980 18.500 13.080 12.520 4.020 18.400 5.960 Professional Fee 8.600 5.000 37.520 8.500 10.520 2. first stage Nerve pedicle transfer.600 10.120 12.800 12.800 2. multiple strands (cable). more than 4 cm length Nerve graft (includes obtaining graft). except digital nerve Excision of neuroma.500 5.400 10.980 23.520 8.500 9.300 8.400 2.300 31. cervicothoracic Sympathectomy.600 9. w/o implant Enucleation of eye.600 12.980 20.120 37.500 5.800 12.600 14.520 10. multiple strands (cable).000 18.900 10.300 31.300 23.520 2.120 16.300 13.680 5.020 8. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 64766 64771 64772 64774 64776 64782 64784 64786 64788 64790 64792 64795 64802 64804 64809 64818 64820 64830 64831 64832 64834 64835 64836 64837 64840 64856 64857 64858 64859 64861 64862 64864 64865 64866 64868 64870 64885 64886 64890 64891 64892 64893 64895 64896 64897 64898 64901 64902 64905 64907 65091 65093 65101 65103 65105 65110 65112 65114 65130 DESCRIPTION Transection or avulsion of obturator nerve.120 12.520 2.000 20.600 14.720 21.300 23.300 5.700 10.200 2.500 5. single strand.800 5.400 2.700 17. w/o implant Evisceration of ocular contents.400 6.020 8.400 8.500 10.000 21.000 18. hand or foot. digital nerve.280 2. extracranial Suture of facial nerve.700 8. only Exenteration of orbit without skin graft.500 9. w/ implant.700 17. muscles attached to implant Exenteration of orbit without skin graft.400 10.800 30.700 17. second stage Evisceration of ocular contents. arm or leg. up to 4 cm length Nerve graft (includes obtaining graft).700 10.700 10. removal of orbital contents. single strand.080 8.500 9.020 9.800 16. thoracolumbar Sympathectomy. multiple strands (cable). same digit Excision of neuroma. facial-spinal accessory Anastomosis. extradural Excision of neuroma. in scleral shell Case Rate 18.640 39. including transposition Suture of major peripheral nerve. hand or foot.120 20.980 12.000 18.400 5.020 18.400 8.120 12.080 10.400 2. common sensory nerve Suture of one nerve. cervical Sympathectomy.840 22.600 9. head or neck.720 6. facial-phrenic Nerve graft (includes obtaining graft).300 31. arm or leg.520 2. hand or foot Suture of posterior tibial nerve Suture of major peripheral nerve.720 6.300 12. multiple strands (cable) Nerve pedicle transfer.980 20. w/ magnification. lumbar plexus Suture of facial nerve. more than 4 cm length Nerve graft (includes obtaining graft).720 6.600 9. removal of orbital contents.600 5.600 9.300 30.300 23.720 6. each additional nerve. major peripheral nerve.800 16. major peripheral nerve Excision of neurofibroma or neurolemmoma.800 13.520 8. w/ muscle or myocutaneous flap Insertion of ocular implant. except sciatic. arm or leg.280 16. hand or foot. more than 4 cm length Nerve graft (includes obtaining graft).500 5.900 10. intradural Transection or avulsion of other spinal nerve. one or both. multiple strands (cable).520 2.080 10.500 5. w/o transposition Suture of sciatic nerve Suture of each additional major peripheral nerve Suture of. one nerve Suture of digital nerve. head or neck.400 5. except sciatic Excision of neuroma. single strand. cutaneous nerve. more than 4 cm length Nerve graft (includes obtaining graft).020 8.600 5. except sciatic.400 8.000 8.020 20.480 10.600 14. sciatic nerve Excision of neurofibroma or neurolemmoma.020 20. single strand.980 18. up to 4cm in length Nerve graft (includes obtaining graft).460 Health Care Institution Fee 9. removal of orbital contents. median motor thenar Suture of one nerve.020 9.000 13. intrapelvic. each additional nerve.500 10.600 5.980 20.720 10. w/ or w/o grafting Anastomosis. arm or leg. cutaneous nerve Excision of neurofibroma or neurolemmoma.080 10.600 12. w/ implant Enucleation of eye. lumbar Sympathectomy. digital arteries.300 23.500 10. up to 4 cm length Nerve graft (includes obtaining graft).980 20.120 30. single strand Nerve graft.500 5.600 16. each additional digital nerve Suture of one nerve. with or without conjunctival graft Reinsertion of ocular implant.700 20.200 840 2.000 30.200 4.700 23.540 18.300 30. not involving uveal tissue Repair of laceration. w/ or w/o removal foreign body Repair of laceration.800 2.700 3.700 5.800 7.520 2. conjunctiva. nonperforating.200 12.040 5. from posterior segment.500 5. without graft Excision or transposition of pterygium.700 10.040 8. w/ or w/o air injection Paracentesis of anterior chamber of eye.000 8.200 4. cornea (keratectomy.880 4. incisional technique (w/ or w/o injection of air or liquid). external eye.700 9.100 6.520 16.100 6.960 14.600 6.540 Professional Fee 5.800 16.600 2. corneovitreal adhesions Case Rate 10.700 8.500 4.800 5.500 6.500 13.800 16.260 8.800 16.020 8.700 8. with slit lamp Removal of foreign body.900 10.300 18.560 7.980 23.640 8. cornea and/or sclera.040 5.300 30.560 16. partial).500 5.400 16.100 5.400 29. posterior synechiae Severing adhesions of anterior segment of eye. laser technique Severing adhesions of anterior segment of eye. application of tissue glue. except pterygium Biopsy of cornea Excision or transposition of pterygium. external eye.800 16.300 9. perforating.500 5. conjunctiva.500 13.560 7.500 5. nonmagnetic extraction Repair of laceration.400 55.600 12. w/ removal of blood. muscles not attached to implant Insertion of ocular implant.260 9.400 7.960 30.700 5.500 13.020 9. limbal stem cell allograft (eg.800 8. cornea.540 10.400 5. intraocular. direct closure Repair of laceration.540 10. anterior or posterior route Removal of foreign body.600 5. lamellar Keratoplasty (corneal transplant).200 2. goniosynechiae Severing adhesions of anterior segment of eye. anterior synechiae.400 5.600 24.500 10.500 5.040 5. w/ or w/o irrigation and/or air injection Goniotomy Trabeculotomy ab externo Trabeculoplasty by laser surgery. penetrating (in pseudophakia) Keratomileusis Keratophakia Epikeratoplasty Keratoprosthesis Radial keratotomy Corneal relaxing incision for correction of surgically induced astigmatism Corneal wedge resection for correction of surgically induced astigmatism Ocular surface reconstruction. external eye.500 4.720 5. extraocular muscle.120 10.960 11. cornea. photocoagulation or thermocauterization Keratoplasty (corneal transplant). subconjunctival or scleral. w/ removal of vitreous and/or discission of anterior hyaloid membrane.080 12.540 10.500 7.360 4.520 4.900 5. amniotic membrane transplantation Ocular surface reconstruction.980 11. after enucleation.540 10.000 53.360 2.300 8.500 5. w/ therapeutic release of aqueous Paracentesis of anterior chamber of eye.400 5.600 4. limbal conjunctival autograft (includes obtaining graft) Paracentesis of anterior chamber of eye. with slit lamp Removal of foreign body.980 11.300 12. penetrating (except in aphakia) Keratoplasty (corneal transplant).000 10. except goniosynechiae Severing adhesions of anterior segment of eye. intraocular.880 5.400 7. intraocular.300 23.520 8. incisional technique (w/ or w/o injection of air or liquid).400 33.020 18.520 3. muscles attached to implant Reinsertion of ocular implant. conjunctival.300 30.300 14.020 8. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 65135 65140 65150 65155 65175 65205 65210 65222 65235 65260 65265 65270 65273 65275 65280 65285 65286 65290 65400 65410 65420 65426 65450 65710 65730 65750 65755 65760 65765 65767 65770 65771 65772 65775 65780 65781 65782 65805 65810 65815 65820 65850 65855 65860 65865 65870 65875 65880 DESCRIPTION Insertion of ocular implant.300 30.600 13.960 14. cornea and/or sclera. w/ or w/o nonperforating laceration sclera.520 4.500 9.520 2. cadaveric or living donor) Ocular surface reconstruction. wounds of cornea and/or sclera Repair of wound.500 2.500 5.200 10. superficial Removal of foreign body. from posterior segment. lamellar.300 30. perforating. incisional technique (w/ or w/o injection of air or liquid). w/ reposition or resection of uveal tissue Repair of laceration.020 8.ANNEX 2. incisional technique (w/ or w/o injection of air or liquid).460 5.500 Page 85 of 98 .880 5.500 5.500 10.400 13.200 3. after enucleation. one or more sessions (defined treatment series) Severing adhesions of anterior segment. with graft Destruction of lesion of cornea by cryotherapy. penetrating (in aphakia) Keratoplasty (corneal transplant).500 13.500 5. from anterior chamber or lens Removal of foreign body. magnetic extraction.040 Health Care Institution Fee 5.020 9.000 21.500 9.500 5.500 13.040 5.700 9.500 5.500 13. tendon and/ or Tenons capsule Excision of lesion.500 5.980 9.800 16. by mobilization and rearrangement Repair of laceration. with use of foreign material for reinforcement and/or attachment of muscles to implant Removal of ocular implant Removal of foreign body.020 30.900 5.500 9. 120 12. diathermy Ciliary body destruction. with excision of bleb cyst Case Rate 10. complex. phacoemulsification). requiring an incision Removal of secondary membranous cataract (opacified posterior lens capsule and/or anterior hyaloid) w/ corneo-scleral section..120 8. w/ corneoscleral or corneal section.600 5.600 9.120 16.600 9.600 9. McCannel suture) Ciliary body destruction.400 6.000 16. stab incision technique (Ziegler or Wheeler knife) Discission of secondary membranous cataract (opacified posterior lens capsule and/or anterior hyaloid).. trabeculectomy ab externo in absence of previous surgery Fistulization of scalera for glaucoma. sclera Fistulization of scalera for glaucoma. w/ or w/o iridectomy (iridocapsulotomy.400 21. for glaucoma) ( one or more sessions) Iridoplasty by photocoagulation (one or more sessions) (e.720 12.260 18.800 37.980 11. any type.040 6. anterior segment eye Excision of lesion. irrigation and aspiration or phacoemulsification).500 5.700 7. iridencleisis or iridotasis Fistulization of scalera for glaucoma.. one or more stages Removal of lens material. aspiration technique.600 5. anterior segment eye Removal of blood clot.900 9.000 16.ANNEX 2.120 30.400 6. intracapsular Removal of lens material.500 5.400 8. major or minor procedure Iridotomy by stab incision.g.720 6.880 5. except transfixion Iridotomy by stab incision.800 16.500 13. w/ corneoscleral or corneal section. phacofragmentation technique (mechanical or ultrasonic) (e.600 9. extracapsular Extracapsular cataract removal with insertion of intraocular lens prosthesis (one stage procedure). iridocapsulectomy) Removal of lens material.100 6.000 18. DenverKrupin) Revision of aqueous shunt to extraocular reservoir Repair of scleral staphyloma.400 5.600 7.720 2.260 18.400 66821 66825 66830 66840 66850 66852 66920 66930 66940 66982 8.120 18. Schocket. intracapsular. irrigation and aspiration) Insertion of intraocular lens prosthesis.000 27.880 5. manual or mechanical technique (eg.540 10.000 16.400 8.000 16.100 6.600 9. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 65900 65920 65930 66130 66150 66155 66160 66165 66170 66172 66180 66185 66220 66225 66250 66500 66505 66600 66605 66625 66630 66680 66682 66700 66710 66720 66740 66761 66762 66770 66820 DESCRIPTION Removal of epithelial material.800 6.000 18.400 6..540 12. with or without explantation/exchange of shunt Revision of failed filter. early or late. w/ cyclectomy Iridectomy.g.120 18.g.040 6.400 6.000 16.000 16. ciliary body w/ retrieval of suture through small incision (e.600 9.000 18.600 9. w/ transfixion as for iris bombe Iridectomy.040 5.040 6.300 12. trephination w/ iridectomy Fistulization of scalera for glaucoma.800 Page 86 of 98 .800 16.800 6.600 7.880 5.000 21. (e.000 37.520 3.600 9.400 6. for widening of anterior chamber angle) Destruction of cyst or lesion iris or ciliary body (nonexcisional procedure) Discission of secondary membranous cataract (opacified posterior lens capsule and/or anterior hyaloid).900 9.400 15.400 6.400 6. laser surgery (e.g.400 7.980 11.000 12.g.120 16.400 8.100 6. requiring devices or techniques not generally used in rout Intracapsular cataract extraction w/ insertion of intraocular lens prosthesis (one stage procedure) Extracapsular cataract removal w/ insertion of intraocular lens prosthesis (one stage procedure).720 8..500 4. cryotherapy Ciliary body destruction.400 9. anterior segment eye Removal of implanted material. sector for glaucoma Repair of iris.000 18. for removal of lesion Iridectomy.040 6.540 12.120 10.400 6.400 5.600 9. (e.400 6.g. w/ corneoscleral or corneal section.980 10.960 10..000 12.500 5.540 12.400 6.720 8..000 16. pars plana approach.720 5.100 5.960 11. w/ corneoscleral or corneal section. cyclodialysis Iridotomy/iridectomy by laser surgery (e.400 9.600 12.600 66983 66984 66985 66986 66987 66991 66992 16.400 6.400 6.600 9.560 5. sclerectomy w/ punch or scissors.600 9.020 8. w/ aspiration Removal of lens material. for improvement of vision. phacoemulsification) Revision of failed filter. trabeculectomy ab externo w/ scarring from previous ocular surgery or trauma (includes injection of antifibrotic agents) Aquenous shunt to extraocular reservoir (e.g. ciliary body (as for iridodialysis) Suture of iris. w/o graft Repair of scleral staphyloma. with or without vitrectomy Removal of lens material.000 16.880 5.500 5.400 5. thermocauterization w/ iridectomy Fistulization of scalera for glaucoma.600 16.400 9.720 Health Care Institution Fee 5. Molteno.000 9.600 9. not associated with cataract removal Exchange of intraocular lens Extracapsular cataract removal w/ insertion of intraocular lens prosthesis (one stage procedure). for dislocated lens Removal of lens material.000 16.400 5.360 8.400 6. peripheral for glaucoma Iridectomy. w/ graft Revision or repair of operative wound of anterior segment.540 12.600 9.720 6.000 13.980 11.000 14. w/ iridectomy Fistulization of scalera for glaucoma.g.500 5.400 8. cyclophotocoagulation Ciliary body destruction.300 14.400 4.500 5.600 9.000 3.. YAG laser) (one or more stages) Repositioning of intraocular lens prosthesis.300 30.360 8.560 5.120 Professional Fee 5.000 16.120 23.400 10. silicone oil. pars plana approach.300 16. subretinal or choroidal fluid.g. pars plana approach. needling technique. pars plana approach. partial removal Removal of vitreous.300 21. w/ vitrectomy. perfluorocarbon liquid Vitrectomy.300 21. cryotherapy. with endodrainage of subretinal hemorrhage (with or without tPA injection) Vitrectomy. Vitrectomy. pars plana approach.300 21.400 5. choroidopathy. with removal of subretinal membranes Vitrectomy.200 25. by injection of air or other gas (e.200 6.600 5. one or more sessions. with anterior chamber reformation Revision of filtering bleb.120 16.300 18. vitreous face adhesions. pars plana approach. scleral buckling (such as lamellar scleral dissection. pars plana or limbal approach.300 6.. cryotherapy or diathermy.120 18.120 31.040 25.200 6.000 25.400 17.720 14.400 9. with internal limiting membrane (ILM) peeling Vitrectomy. with macular translocation (total) Vitrectomy.500 46.500 46. (fluid-gas exchange). cryotherapy.200 21. with or without anterior vitrectomy Repair of retinal detachment.400 4. focal endolaser photocoagulation.300 67108 46. anterior approach (open sky technique or limbal incision).500 46. mattress sutures.200 8. pars plana approach. pars plana approach.500 46.500 12.900 10.500 13. with removal of choroidal neovascular membrane Vitrectomy.700 18. mechanical.300 21. laser surgery (one or more stages) Vitrectomy.500 37.080 6.g. with phacofragmentation for dropped lens material Vitrectomy.400 21. pars plana approach (posterior sclerotomy) Injection of vitreous substitute.800 24. maculopathy. with injection of antimetabolite Release of scleral flap suture by laser suture lysis (new code) Revision of overfiltering bleb (includes autologous blood injection.300 67110 67112 67115 67120 67121 67208 30.580 12. sheets. with posterior sclerotomy Revision of failed filter. on patient having previous ipsilateral retinal detachment repair(s) using scleral buckling or vitrectomy techniques Release of encircling material (posterior segment) Removal of implanted material.500 46.500 46.200 25. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 66993 66994 66995 66996 66997 66998 66999 67005 67010 67015 67025 67027 67030 67031 67036 67038 67039 67040 67041 67042 67043 67044 67045 67046 67047 67048 67049 67050 67051 67052 67101 67105 DESCRIPTION Revision of failed filter. extraocular Removal of implanted material. w/ or w/o implant. pars plana approach. mechanical. mechanical. without injection of antimetabolite Revision of filtering bleb.200 18.200 25.500 9. diathermy Case Rate 30.000 37.500 5.200 25.200 25. with choroidal tap Revision of failed filter.200 25.800 46. mechanical.300 46.800 53.ANNEX 2. by scleral buckling or vitrectomy. cryotherapy.800 25.800 16. mechanical. one or more sessions.120 20.400 10. needling technique. posterior segment. with sheathotomy for branch retinal vein occlusion Vitrectomy.000 5.500 46. w/ or w/o cryotherapy.500 46.280 6. w/ or w/o aspiration Implantation of intravitreal drug delivery system (eg.400 9.180 Professional Fee 16.720 13. with removal of dropped IOL Vitrectomy. pars plana approach. photocoagulation.500 21. with insertion of scleral fixated intraocular lens.. mechanical.300 21. includes concomitant removal of vitreous Discission of vitreous strands (w/o removal). w/ epiretinal membrane stripping Vitrectomy. mechanical.300 12. w/ or w/o drainage of subretinal fluid Repair of retinal detachment. pars plana approach.120 12. anterior approach (open sky technique or limbal incision). gas. and drainage of subretinal fluid Repair of retinal detachment.300 21.200 25. imbrication or encircling procedure). mechanical.300 21.600 16. small tumors).300 21.200 25.000 9.300 5. membranes or opacities. pars plana approach. with radial optic nerve neurotomy (RON) Vitrectomy.480 Health Care Institution Fee 13. pars plana approach.700 67107 46.000 29. mechanical.500 46.720 10.200 21.600 5. mechanical. mechanical. w/ endolaser panretinal photocoagulation Vitrectomy.800 21.500 46.500 46. photocoagulation. mechanical.540 46. with macular translocation (limited by retinotomy and/or scleral imbrication) Vitrectomy.500 21. and/or removal of lens by same technique Repair of retinal detachment. pars plana approach.300 30.500 25.500 46. with internal tamponade with air.300 21. ganciclovir implant).300 21.300 21. posterior segment.200 21.400 4.500 25.980 12.200 25.720 8.) Removal of vitreous.300 5.200 25.500 37.800 6. any method. pars plana approach. subtotal removal w/ mechanical vitrectomy Aspiration or release of vitreous.900 5. pars plana approach.300 30. w/ or w/o air or gas tamponade.500 13.800 16. pars plana approach Severing of vitreous strands.500 5.300 21. drainage of subretinal fluid.500 46.200 25. mechanical. w/ or w/o drainage of subretinal fluid Repair of retinal detachment.200 25. scleral buckling.200 25.500 46. one or more sessions.300 21. mechanical.700 12. pars plana approach. mechanical. w/ focal endolaser photocoagulation Vitrectomy. intraocular Destruction of localized lesion of retina (e. etc.300 21.200 25. mechanical.400 Page 87 of 98 .720 6. pneumatic retinopexy) Repair of retinal detachment. 200 25. w/ drainage Orbitotomy w/ bone flap or window.080 10. photodynamic therapy (includes intravenous infusions Destruction of localized lesion of choroid (e.120 12.960 53.100 10.200 25.980 20.g.200 25. insertion Orbital implant (implant outside muscle cone).400 4.900 9.g.ANNEX 2.300 21.720 6. w/ removal of lesion Orbitotomy w/o bone flap (frontal or transconjunctival approach).300 21.g. with exchange or orbital implant Repair of anophthalmic socket.980 20.000 18.. diathermy Destruction of extensive or progressive retinopathy (e. laser).500 46.400 9.600 9.760 8.. one horizontal muscle Strabismus surgery.600 9. strabismus or retinal detachment surgery) or restrictive myopathy (e.980 22.120 6.g. choroidal neovascularization).980 8.720 6. recession or resection procedure (patient not previously operated on).400 8.g.g. photocoagulation (laser or xenon arc) Scleral reinforcement Strabismus surgery. prior ocular injury.500 5. Kroenlein).080 10.500 46.. lateral approach (e.400 5.200 25. diabetic retinopathy). maculopathy.000 5. Kroenlein).900 10. incision or fenestration of optic nerve sheath) Repair of anophthalmic socket.500 46. any extraocular muscle (specify) Strabismus surgery on patient w/ previous eye surgery or injury that did not involve the extraocular muscles Strabismus surgery on patient w/ scaring of extraocular muscles (e.400 5. one or more sessions.720 5.300 21. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 67210 DESCRIPTION Destruction of localized lesion of retina (e.720 6. any procedure (patient not previously operated on).720 4.120 20.000 18.700 6.g.200 4.g. w/ removal of bone for decompression Fine needle aspiration of orbital contents Orbitotomy w/ bone flap or window.120 6.120 12.120 Professional Fee 6.720 5.g. superior oblique muscle Transposition procedure (e.300 21. w/ removal of bone for decompression Orbital implant (implant outside muscle cone). with exchange of orbital implant and reattachment of muscles Repair of anophthalmic socket..200 25. w/ removal of foreign body Orbitotomy w/ bone flap or window. Kroenlein).400 8.400 10.500 46.940 11. w/ removal of lesion Orbitotomy w/ bone flap or window. one or more sessions.120 12.960 10. cryotherapy..200 25.600 9.500 46.120 6.400 67220 12.300 21.720 Health Care Institution Fee 5.300 21.500 46.400 5.g. two or more vertical muscles (excluding superior oblique) Strabismus surgery. transpupillary thermotherapy Destruction of extensive or progressive retinopathy (e.200 5.900 Page 88 of 98 .120 12.120 12. photocoagulation (laser or xenon arc) Destruction of localized lesion of retina (e. lateral approach (e.g.g.600 5.500 46.400 8. photocoagulation (e.500 10. radiation by implantation of source (includes removal of source) Destruction of localized lesion of choroid (e.300 5.720 6. w/ or w/o biopsy Orbitotomy w/o bone flap (frontal or transconjunctival approach).300 21. for exploration.500 5.660 18.g..g... dysthyroid ophthalmopathy) Strabismus surgery by posterior fixation suture technique.880 11.200 25. maculopathy.200 25.. w/ or w/o muscle recession Strabismus surgery involving exploration and/or repair of detached extraocular muscle(s) Release of extensive scar tissue w/o detaching extraocular muscle Chemodenervation of extraocular muscle Biopsy of extraocular muscle Orbitotomy w/o bone flap (frontal or transconjunctival approach). Kroenlein). small tumors).400 5.g.000 18. with insertion or removal of orbital implant within muscle cone Repair of anophthalmic socket. removal or revision Optic nerve decompression (e.700 9.500 24. w/ drainage only Orbitotomy w/o bone flap (frontal or transconjunctival approach).500 46.600 12.300 21. recession or resection procedure (patient not previously operated on). lateral approach (e.720 10.400 5.620 6.300 21...120 12. one or more sessions. w/ removal of foreign body Orbitotomy w/o bone flap (frontal or transconjunctival approach)..g.720 5.. one or more sessions.. lateral approach (e. two horizontal muscles Strabismus surgery.400 12.400 67218 12.400 67221 67222 67227 67228 67250 67311 67312 67314 12. choroidal neovascularization). choroidopathy.500 21..460 29. recession or resection procedure (patient not previously operated on).120 10.240 5.460 5. small tumors).. diabetic retinopathy).080 9. recession or resection procedure (patient not previously operated on).720 6.200 25.000 9. choroidopathy.900 10. one or more sessions Destruction of localized lesion of choroid (e.500 46.700 46. for paretic extraocular muscle).500 5.200 25. with fornix reconstruction using sutures Case Rate 12.400 67316 67318 67320 67331 67332 67334 67340 67343 67345 67350 67400 67405 67412 67413 67414 67415 67420 67430 67440 67445 67550 67560 67570 67580 67581 67582 67583 18.400 6.000 21. one vertical muscle (excluding superior oblique) Strabismus surgery.400 5. choroidal neovascularization). 200 6. lower. full thickness Canthoplasty (reconstruction of canthus) Excision and repair of eyelid.900 9. or full thickness. frontalis muscle technique with fascial sling (includes obtaining fascia) Repair of blepharoptosis.680 1. one stage or first stage Reconstruction of eyelid. by electroepilation. frontalis muscle technique with suture or other material Repair of blepharoptosis. incision of lid margin. up to two-thirds of eyelid.500 Page 89 of 98 .520 4.700 2.000 16. tarsus.500 5.000 4.520 2. excision tarsal wedge Blepharoplasty.120 12. second stage Biopsy of conjunctiva Excision of lesion.000 16.200 6. total eyelid.g. and/ or palpebral conjunctiva direct closure. conjunctivo-tarso-Mullers muscle-levator resection (Fasanella-Servat type) Repair of lid retraction (eyelid recession).900 5.680 3.500 14. involving lid margin.720 6.520 2. superior rectus technique with fascial sling (includes obtaining fascia) Repair of blepharoptosis. extensive (e.680 1. or full thickness.800 1. involving lid margin. full thickness by transfer of tarsoconjunctival flap from opposing eyelid.400 8.020 8. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 67584 67585 67586 67700 67710 67715 67800 67810 67825 67830 67835 67840 67875 67880 67882 67900 67901 67902 67903 67904 67906 67908 67911 67912 67914 67915 67916 67917 67921 67922 67923 67924 67930 67935 67950 67961 DESCRIPTION Repair of anophthalmic socket. extensive (e.000 5.000 20.640 9.600 9. may include preparation for skin graft or pedicle flap with adjacent tissue transfer or rearrangement.120 30. conjunctiva.980 20.980 18.900 10. up to one-fourth of lid margin Excision and repair of eyelid.000 5.680 4. one stage or first stage Reconstruction of eyelid.600 9.700 12.080 8. Construction of intermargin adhesions.500 6. canthus.560 5. eyelid.680 840 2.400 10.000 4. and/ or palpebral conjunctiva direct closure. (tarso) levator resection or advancement. with fornix reconstruction using buccal mucosal graft or amnion graft.300 5.520 2.740 Professional Fee 10.680 5.200 6.680 5.000 4.000 21. or canthorrhaphy.400 5.400 17.500 5. with revision of implant and fornix reconstruction using sutures Repair of anophthalmic socket. with adjacent sclera Case Rate 20.260 1.020 8.000 2.120 15.800 7. may include preparation for skin graft or pedicle flap with adjacent tissue transfer or rearrangement.g.720 13. excision tarsal wedge Blepharoplasty. canthus.600 5.600 10.200 4.000 18.500 4. without spacer Correction of lagophthalmos. up to 1 cm Excision of lesion. with free mucous membrane graft Excision of lesion of eyelid (except chalazion) without closure or with simple direct closure Temporary closure of eyelids suture (e.100 1. frost suture) Construction of intermargin adhesions. eyelid Severing of tarsorrhaphy Canthotomy Excision of chalazion Biopsy of eyelid Repair of trichiasis.680 1.800 13. involving lid margin..500 5.g.500 9. or amnion graft (including harvesting of graft) Blepharotomy.700 12.680 5. thermocauterization Blepharoplasty.000 18.500 5.600 4.680 1. conjunctiva.680 8.300 16. full thickness by transfer of tarsoconjunctival flap from opposing eyelid. eyelid.680 9. internal approach Repair of blepharoptosis.440 Health Care Institution Fee 10.020 21.800 13.020 9. over 1 cm Excision of lesion.680 1.900 9.400 10.980 5.ANNEX 2. incision of lid margin Repair of trichiasis..600 9. upper. with transportation of tarsal plate Repair of brow ptosis (supraciliary. Wheeler operation) Suture of recent wound. cryotherapy or laser surgery Repair of trichiasis.680 2. partial thickness Suture of recent wound.980 20. full thickness by transfer of tarsoconjunctival flap from opposing eyelid.300 1.520 16.400 32. suture Repair of ectropion.120 12. conjunctiva.680 5.300 5.680 5.000 4. one stage or first stage Reconstruction of eyelid..300 4.680 1.900 10. tarsus. involving lid margin. thermocauterization Blepharoplasty.400 8.000 8.080 10.000 18.900 17.680 2.680 5.000 5. median tarsorrhaphy. electrosurgery. suture Repair of entropion. external approach Repair of blepharoptosis. total eyelid.020 18. drainage of abscess.000 4.000 18. tarsus.800 67974 67975 68100 68110 68115 68130 37. full thickness by transfer of tarsoconjunctival flap from opposing eyelid. over one-fourth of lid margin Reconstruction of eyelid.680 8.600 10.800 30. including harvesting of graft Repair of anophthalmic socket. with revision of implant and fornix reconstruction using buccal mucosal graft.400 8.500 6. conjunctiva. midforehead or coronal approach) Repair of blepharoptosis.080 10.300 67966 27.520 8. tarsus. (tarso) levator resection or advancement.080 1.800 21.400 8.500 67973 37.500 5.000 4. median tarsorrhaphy.000 4. with implantation of upper eyelid load Repair of ectropion. or canthorrhaphy.600 9. conjunctiva.680 5.000 67971 30.700 12.300 4. Kuhnt-Szymanowski or tarsal strip operations) Repair of entropion.300 5.020 8.680 1.900 4. 400 5. by thermocauterization. with insertion of tube or stent Drainage external ear.300 4.900 10.680 5. transnasal.560 9.540 12.000 18.020 9.800 2.700 10. transtympanic Myringotomy including aspiration and/or eustachian tube inflation Myringotomy including aspiration and/or eustachian tube inflation requiring general anesthesia Tympanostomy (requiring insertion of ventilating tube).240 8.000 20.600 12..880 10. partial.080 1. local or topical anesthesia Tympanostomy (requiring insertion of ventilating tube). division of symblepharon. abscess Biopsy external ear Biopsy external auditory canal Excision external ear.200 2.500 7.520 Health Care Institution Fee 5. drainage of lacrimal sac (dacryocystostomy) Snip incision of lacrimal punctum Excision of lacrimal gland (dacryoadenectomy).g.300 9.680 8.672 3. except for tumor Biopsy of lacrimal gland Excision of lacrimal sac (dacryocystectomy) Biopsy of lacrimal sac Removal of foreign body or dacryolith.700 9.980 11. for stenosis due to trauma.980 20.720 7.000 3.500 3.400 4.400 7.500 10. complete Mastoidectomy.400 4.680 18.ANNEX 2.700 10.500 10.680 1.200 840 8.040 6.900 4. simple (e.680 12.100 2.700 10.900 9.680 2.960 21. mastoidectomy cavity.640 18.000 4.000 5.000 18.600 25.980 5.400 9.020 10.700 3.680 3. with buccal mucous membrane graft (includes obtaining graft) Repair of symblepharon. bridge or partial Conjunctival flap. with or without insertion of conformer or contact lens Conjunctival flap.520 4.700 23. external approach Excision aural polyp Case Rate 10.000 4.200 5.000 11.500 7. or laser surgery Closure of lacrimal fistula Probing of nasolacrimal duct.472 5.680 1.980 23.940 18.720 1.980 8.500 5.020 9.700 21.680 1.300 8. conjunctivoplasty.600 12.500 5.000 9. with conjunctival graft or extensive rearrangement Conjunctivoplasty reconstruction cul-de-sac.000 4. cautery Dacryocystorhinostomy (fistulization of lacrimal sac to nasal cavity) Conjunctivorhinostomy (fistulization of conjunctiva to nasal cavity).400 4. w/ catheterization Eustachian tube catheterization.600 9.680 5.500 2.700 13.200 10. mastoidectomy cavity.800 9.000 4. radical Petrous apicectomy including radical mastoidectomy Resection temporal bone.500 Page 90 of 98 .520 3.500 4. lacrimal passages Excision of lacrimal gland tumor. drainage of lacrimal gland Incision.560 8. w/o neck dissection Radical excision external auditory canal lesion. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 68320 68325 68326 68328 68330 68335 68340 68360 68362 68371 68400 68420 68440 68500 68510 68520 68525 68530 68540 68550 68700 68705 68720 68745 68750 68760 68770 68811 68815 69000 69020 69100 69105 69110 69120 69140 69145 69150 69155 69200 69220 69222 69310 69320 69400 69405 69420 69421 69433 69436 69440 69450 69501 69502 69505 69511 69530 69535 69540 DESCRIPTION Conjunctivoplasty.700 4.000 9.900 5.300 30.120 5..600 6.360 3. external auditory canal Excision soft tissue lesion.020 8. infection) Reconstruction external auditory canal for congenital atresia.400 8.812 5. frontal approach Excision of lacrimal gland tumor.600 5.200 12.600 16.000 4.700 20. w/ general anesthesia Debridement.680 6.680 5. with insertion of tube or stent Closure of the lacrimal punctum.080 2. with conjunctival graft or extensive rearrangement Conjunctivoplasty. simple repair Excision external ear. single stage Eustachian tube inflation. with buccal mucous membrane graft (includes obtaining graft) Conjunctivoplasty reconstruction cul-de-sac.300 46.400 8. total (such as Gunderson thin flap or purse string flap) Harvesting conjunctival allograft.700 10.680 5.000 9.300 23.020 Professional Fee 5.880 5.500 5.000 5.300 23.880 8.680 12.400 7. with free graft conjunctiva or buccal mucous membrane (includes obtaining graft) Repair of symblepharon.900 4.500 10.500 5.120 14.680 1.720 1.512 1.300 23.360 6.720 4.680 1.200 672 252 1. complex (e.000 4. w/ neck dissection Removal foreign body from external auditory canal.680 5.600 12. w/ anesthesia or more than routine cleaning) Reconstruction of external auditory canal (meatoplasty) (e. w/ general anesthesia Middle ear exploration through postauricular or ear canal incision Tympanolysis.400 10.900 5.600 1.600 5.260 12.500 8.g.300 5.200 12. requiring general anesthesia Probing of nasolacrimal duct.600 9.520 4.080 12. modified radical Mastoidectomy.520 3.200 4.000 5.700 3.100 6.300 23.300 5.960 18.600 10. transcanal Transmastoid antrotomy ("simple" mastoidectomy) Mastoidectomy.600 7. abscess or hematoma Drainage external auditory canal. involving osteotomy Plastic repair of canaliculi Correction of everted punctum.400 5. routine cleaning) Debridement.220 4.780 2.120 9. ligation. complete amputation Excision exostosis(es). living donor Incision.360 8.600 12.260 18. external auditory canal Radical excision external auditory canal lesion.400 12.700 23.100 10.260 8.100 5. without graft Repair of symblepharon.g. without tube Conjunctivorhinostomy (fistulization of conjunctiva to nasal cavity).680 8.000 14.400 4.680 8.700 9.680 6..120 5. intratemporal. w/ or w/o graft or decompression.300 69646 69650 69660 69661 69662 69666 69667 69670 69676 69700 69720 69725 69740 69745 69801 46. resulting in complete mastoidectomy Revision mastoidectomy.800 Page 91 of 98 .300 37. w/ ossicular chain reconstruction and synthetic prosthesis (e. transcanal Labyrinthotomy.980 30.440 Health Care Institution Fee 13. middle ear surgery.840 21. tympanic membrane repair). middle ear surgery. middle ear surgery. Stapedectomy or stapedotomy w/ reestablishment of ossicular continuity. lateral to geniculate ganglion Suture facial nerve. w/ ossicular chain reconstruction Stapes mobilization Stapedectomy or stapedotomy w/ reestablishment of ossicular continuity.800 38. initial or revision.540 30.800 21.200 21.040 21. atticotomy. and/ or tympanic membrane repair).840 21.640 38.800 16.300 30.800 16. atticotomy. w/ ossicular chain reconstruction and synthetic prosthesis (e. and/ or tympanic membrane repair).720 21. w/ ossicular chain reconstruction Tympanoplasty w/ mastoidectomy (including canalplasty.040 21.300 69636 47.800 16.300 69637 47.800 16. tympanic membrane repair). (PORP).680 16.480 22. middle ear surgery.300 69633 30.440 17.600 14. resulting in modified radical mastoidectomy Revision mastoidectomy. intratemporal. intratemporal. tympanic membrane repair). w/ ossicular chain reconstruction (e. initial or revision. atticotomy and/ or middle ear surgery).180 26.g.300 69644 49.200 21.840 21.720 10.300 31.800 17.080 13.500 13.500 13.340 26.280 12.300 23..040 21. w/o ossicular chain reconstruction Tympanoplasty w/ mastoidectomy (including canalplasty.300 69642 47.040 16. w/ mastoidectomy Case Rate 30.500 13.640 38. w/ or w/o cryosurgery including other nonexcisional destructive procedures or perfusion of vestbuloactive drugs (single or multiple perfusions).500 25. w/ or w/o use of foreign material..g. radical or complete.640 38.000 21.600 12.300 69632 30.800 16. w/ footplate drill out Revision of stapedectomy or stapedotomy Repair oval window fistula Repair round window fistula Mastoid obliteration Tympanic neurectomy Closure postauricular fistula. w/ or w/o patch Myringoplasty (surgery confined to drumhead and donor area) Tympanoplasty w/o mastoidectomy (including canalplasty.800 16. including medial to geniculate ganglion Suture facial nerve. middle ear surgery.300 23. w/ or w/o site preparation or perforation for closure. w/o ossicular chain reconstruction Tympanoplasty w/ antrotomy or mastoidotomy (including canalplasty.700 17.200 21.800 16.000 21.300 16.740 13.800 16.020 27.340 26.740 Professional Fee 16.300 69645 46. atticotomy and/ or middle ear surgery). partial ossicular replacement prosthesis. w/ or w/o cryosurgery including other nonexcisional destructive procedures or perfusion of vestbuloactive drugs (single or multiple perfusions).900 17.840 14. w/ intact or reconstructed wall.800 5.300 13. w/o ossicular chain reconstruction Tympanoplasty w/ mastoidectomy (including canalplasty. intratemporal.500 16.500 25.300 10. tympanic membrane repair).340 26. resulting in radical mastoidectomy Revision mastoidectomy.120 20. extended (extratemporal) Revision mastoidectomy.500 37.300 69635 46. middle ear surgery. mastoid Decompression facial nerve.500 25. radical or complete.300 10.300 30.840 21.800 37.580 30.300 23.640 38. middle ear surgery. atticotomy and/ or middle ear surgery).880 21.800 38.300 30. w/ or w/o graft or decompression. total ossicular replacement prosthesis (TORP) Tympanoplasty w/ mastoidectomy (including canalplasty. middle ear surgery.700 10.800 12. initial or revision. partial ossicular replacement prosthesis.800 69802 39.840 21. transcanal Excision aural glomus tumor. w/ or w/o use of foreign material.500 10. atticotomy. lateral to geniculate ganglion Decompression facial nerve.740 13. w/ intact or reconstructed canal wall.g.640 25.800 16. w/ ossicular chain reconstruction Tympanoplasty w/ mastoidectomy (including canalplasty. transmastoid Excision aural glomus tumor.300 69643 48. tympanic membrane repair).580 23. and/ or tympanic membrane repair). total ossicular replacement prosthesis (TORP) Tympanoplasty w/ antrotomy or mastoidotomy (including canalplasty. middle ear surgery.280 16.300 69641 46. w/o ossicular chain reconstruction Tympanoplasty w/ mastoidectomy (including canalplasty.800 16. resulting in tympanoplasty Revision mastoidectomy.700 10.000 21.700 5.600 12.300 12.200 21. (PORP). postfenestration) Tympanoplasty w/o mastoidectomy (including canalplasty.640 31. w/ ossicular chain reconstruction Tympanoplasty w/ antrotomy or mastoidotomy (including canalplasty. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 69550 69552 69554 69601 69602 69603 69604 69605 69610 69620 69631 DESCRIPTION Excision aural glomus tumor. w/ apicectomy Tympanic membrane repair.ANNEX 2. tympanic membrane repair).440 17.600 6. w/o ossicular chain reconstruction Tympanoplasty w/o mastoidectomy (including canalplasty. including medial to geniculate ganglion Labyrinthotomy.500 13.500 5.400 10. unilateral.700 9. radiological supervision and interpretation Angiography. bilateral.700 9. fluoroscopy and radiography.200 4.020 8.200 4. radiological supervision and interpretation Angiography. unilateral.700 9.500 5. spinal.400 2. radiological supervision and interpretation Introduction of ureteral catheter or stent into ureter through renal pelvis for drainage and/or injection. selective. radiological supervision and interpretation Angiography.200 29.500 5.500 5.ANNEX 2. percutaneous. radiological supervision and interpretation Percutaneous transhepatic dilation of sbiliary duct stricture.200 4. cerebral.020 9. radiological supervision and interpretation Introduction of long gastrointestinal tube (e.400 21.200 4.200 4. carotid. radiological supervision and interpretation Case Rate 46.500 8.200 29. spine. w/ shunt Fenestration semicircular canal Revision fenestration operation Labyrinthectomy. radiological supervision and interpretation Angiography.020 8.200 4.520 2.520 2. radiological supervision and interpretation Computed tomographic angiography. radiological supervision and interpretation Angiography. radiological supervision and interpretation Angiography.500 5.400 53.500 5. external carotid.200 4.500 5. cervical and/or intracranial.200 4.500 5.600 33. vertebral. radiological supervision and interpretation Angiography.400 25.000 55.400 25.500 5. bilateral. radiological supervision and interpretation Percutaneous placement of enteroclysis tube.020 8.400 24.700 9.200 4. selective. brachial retrograde. extremity. carotid.500 53.500 5.700 18.000 21. brain.g.200 9.200 4.000 24.000 21.020 9.520 2.020 8.600 33.000 18. radiological supervision and interpretation Combined endoscopic catheterization of the biliary and pancreatic ductal system.000 55.000 Professional Fee 25. abdominal aorta and bilateral iliofemoral lower extremity. external carotid. radiological supervision and interpretation Angiography.300 24.500 53.700 9. transcanal Labyrinthectomy. radiological supervision and interpretation Aortography. cervical. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 69805 69806 69820 69840 69905 69910 69915 69930 69950 69955 69960 69970 70010 70390 71090 72240 74300 74328 74329 74330 74340 74350 74355 74360 74363 74475 DESCRIPTION Endolymphatic sac operation. radiological supervision and interpretation Angiography.200 4.020 8.500 5.700 9.200 4. cervical.700 9.500 5.300 24.200 4. temporal bone Myelography. including duct catheterization and radiological supervision and interpretation Insertion pacemaker.500 5.400 21. radiological supervision and interpretation Angiography.400 Health Care Institution Fee 21.000 8. extremity.200 4.600 5. intraoperative.700 9.400 25.020 8. thoracic.400 8.400 46.500 5.600 74480 74742 75600 75625 75630 75635 75650 75658 75660 75662 75665 75671 75676 75680 75685 75705 75710 75716 18.500 5.500 5.600 29. radiological supervision and interpretation Aortography.300 5.500 5.020 8.500 5.700 9. radiological supervision and interpretation Introduction of intracatheter or catheter into renal pelvis for drainage and/or injection.400 55. radiological supervision and interpretation Myelography.500 5.200 8.500 5. radiological supervision and interpretation Aortography.400 46.700 9.500 5.700 9. percutaneous.500 5.500 53. radiological supervision and interpretation Percutaneous placement of gastrostomy tube.700 9.500 5. abdominal. transcranial approach Total facial nerve decompression and/or repair (may include graft) Decompression internal auditory canal Removal of tumor. w/o shunt Endolymphatic sac operation.200 4.400 29.400 33..500 5. radiological supervision and interpretation Endoscopic catheterization of the pancreatic ductal system. Miller-Abbott ). radiological supervision and interpretation Endoscopic catheterization of the biliary ductal system. radiological supervision and interpretation Intraluminal dilation of strictures and/or obstructions.700 9.200 4. radiological supervision and interpretation Angiography.500 5. w/ or w/o mastoidectomy Vestibular nerve section.520 4.700 9.000 53. bilateral.300 24. carotid.700 9. bilateral.000 21.700 9.700 9.200 4.500 Page 92 of 98 .700 8.500 5.520 2. translabyrinthine approach Cochlear device implantation.500 5.200 2.520 2. radiological supervision and interpretation Angiography.000 21.520 2. unilateral. radiological supervision and interpretation Transcervical catheterization of fallopian tube.400 46.500 9.700 9.520 2.520 4. cervicocerebral. w/ mastoidectomy Vestibular nerve section.200 4.600 9.500 5.200 29. cerebral. including spinal puncture and radiological supervision and interpretation Cholangiography and/or pancreatography. including spinal puncture and radiological supervision and interpretation Sialography. abdominal plus bilateral iliofemoral lower extremity. 200 4. pulmonary. radiological supervision and interpretation Lymphangiography. radiological supervision and interpretation Case Rate 9. radiological supervision and interpretation Angiography. radiological supervision and interpretation Venography.200 4.700 9.500 5. inferior.200 4.700 9.500 5.500 5. caval.200 4.600 4. radiological supervision and interpretation Venography.700 12.700 9.300 6.500 5..300 16. radiological supervision and interpretation Mechanical removal of pericatheter obstructive material (e. radiological supervision and interpretation Angiography. radiological supervision and interpretation Angiography.900 12. extremity. bilateral.500 75902 75940 75945 75952 9. orbital.200 4. caval.400 29. radiological supervision and interpretation Percutaneous transhepatic portography.000 Page 93 of 98 .500 5. radiological supervision and interpretation Venography.700 9.700 9.400 4. radiological supervision and interpretation Lymphangiography.200 4. or dissection. radiological supervision and interpretation Angiography. superior sagittal sinus. radiological supervision and interpretation Venography. renal.200 29.500 5. radiologic supervision and interpretation Intravascular ultrasound (non-coronary-vessel).800 Health Care Institution Fee 5. pelvis.200 4.600 13.700 53.500 24.500 5.500 5.700 9.700 9. extremity. unilateral.600 6.500 5.700 23.500 5.700 9. dialysis patient).500 5.200 4.. radiological supervision and interpretation Exchanged of a previously placed intravascular catheter during thrombolytic therapy with contrast monitoring.700 9.400 24.500 5.400 5. fluorescein (eye) Angiography. nonselective.500 5. fibrin sheath) from central venous device via separate venous access. pulmonary. bilateral. radiological supervision and interpretation Splenoportography.700 9.500 5. adrenal.500 5.200 4. internal mammary. pelvic/abdominal.200 4. visceral.500 5. radiological supervision and interpretation Venography. radiological supervision and interpretation Hepatic venography. radiological supervision and interpretation Angiography.200 4. unilateral. unilateral. radiological supervision and interpretation Angiography. adrenal.200 4.500 10.200 5. bilateral. unilateral.g.g.200 4.500 5.700 9.300 Professional Fee 4.ANNEX 2. radiological supervision and interpretation Angiography.700 9. pseudoaneurysm.700 9. bilateral.500 5.200 6.700 9. petrosal and inferior sagittal) or jugular. renal. radiological supervision and interpretation Venography.600 21.500 5.700 9.700 9.200 4.500 5. unilateral .500 5.700 9.500 5.700 9. radiological supervision and interpretation Venography. adrenal.200 4.700 9. unilateral or bilateral.700 4. epidural.500 5.700 9.700 9.700 9. renal. radiological supervision and interpretation Angiography. radiological supervision and interpretation. bilateral.200 4.200 4.200 12. unilateral.200 4.700 9.000 75953 55.500 6. unilateral.500 75901 9.500 5. pulmonary. adrenal.500 5..700 5.700 9.200 4. radiologic supervision and interpretation Mechanical removal of intraluminal (intracatheter) obstructive material from central venous device through device lumen. radiologic supervision and interpretation Percutaneous placement of IVC filter. arteriovenous malformation. radiological supervision and interpretation Lymphangiography. initial vessel Endovascular repair of infrarenal abdominal aortic aneurysm or dissection.200 4.200 4.200 4. radiological supervision and interpretation Angiography. venous sinus(e.200 4. extremity. or trauma.g. radiological supervision and interpretation Venography.400 75954 53.700 9. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 75722 75724 75726 75731 75733 75736 75741 75743 75746 75756 75757 75790 75801 75803 75805 75807 75810 75820 75825 75827 75831 75833 75840 75842 75860 75870 75872 75880 75885 75889 75900 DESCRIPTION Angiography. arteriovenous shunt (e. pseudoanuerysm. radiological supervision and interpretation Endovascular repair of iliac artery aneurysm.900 30. radiological supervision and interpretation Lymphangiography. pelvic/abdominal.200 4. radiological supervision and interpretation Placement of proximal or distal extension prosthesis for endovascular repair of infrarenal aortic or iliac artery aneurysm. radiological supervision and interpretation Venography.700 9. radiological supervision and interpretation Angiography. radiological supervision and interpretation Venography. bilateral.200 4.700 9.300 9.500 5. renal.200 4. radiological supervision and interpretation Venography.200 4. bilateral.000 33.500 5. superior. ANNEX 2. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE DESCRIPTION Endovascular repair of descending thoracic aorta (e.g., aneurysm, psuedoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption); involving coverage of left subclavian artery origin, initial endoprosthesis plus descending thoracic aortic extension(s), if required, to level of celiac artery origin, radiologic supervision and interpretation Endovascular repair of descending thoracic aorta (e.g., aneurysm, psuedoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption); not involving coverage of left subclavian artery origin, initial endoprosthesis plus descending thoracic aortic extension(s), if required, to level of celiac artery origin, radiologic supervision and interpretation Placement of proximal extension prosthesis for endovascular repair of descending thoracic aorta (e.g., aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption), radiologic supervision and interpretation Placement of distal extension prosthesis(s) (delayed) after endovascular repair of descending thoracic aorta, as needed, to level of celiac origin, radiological supervision and interpretation Transcatheter induction of intravascular stent(s), (except coronary, carotid, and vertebral vessel), percutaneous and/ or open, radiological supervision and interpretation Transcatheter retrieval, percutaneous, of intravascular foreign body (e.g., fractured venous or arterial catheter), radiological supervision and interpretation Transluminal balloon angioplasty, peripheral artery, radiological supervision and interpretation Transluminal balloon angioplasty, renal or other visceral artery, radiological supervision and interpretation Transcatheter biopsy, radiological supervision and interpretation Transluminal balloon angioplasty, venous (e.g., subclavian stenosis) radiological supervision and interpretation Percutaneous transhepatic biliary drainage with contrast monitoring, radiological supervision and interpretation Percutaneous placement of drainagecatheter combined internal and external billiary drainage or of a drainage stent for internal billiary drainage in patients with an inoperable mechanical billiary obstruction, radiologic supervision and interpretation. Change of percutaneous tube or drainage catheter with contrast monitoring (e.g., gastrointestinal system, genitourinary system, abscess), radiologic supervision and interpretation Radiological guidance for percutaneous drainage (abscess, cyst, fluid collection), with placement of catheter and radiological supervision and interpretation Transluminal atherectomy, peripheral artery, radiological supervision and interpretation Transluminal atherectomy, renal, radiological supervision and interpretation Transluminal atherectomy, visceral, radiological supervision and interpretation Fluoroscopic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device) Radiological supervision and interpretation, percutaneous vertebroplasty or vertebral augmentation including cavity creation; under fluoroscopic guidance Radiological supervision and interpretation, percutaneous vertebroplasty or vertebral augmentation including cavity creation; under CT guidance Radiologic examination, abscess, fistula or sinus tract study, including catheterization of lesion and radiological supervision and interpretation Mammary ductogram or galactogram, 1 or multiple duct, injection and radiological supervision and interpretation Stereotactic localization guidance for breast biopsy or needle placement (e.g., for wire localization or for injection), one or more lesion, radiological supervision and interpretation Mammographic guidance for needle placement, breast (e.g., for wire localization or for injection), each lesion, radiological supervision and interpretation Computed tomography guidance for stereotactic localization Computed tomography guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), radiological supervision and interpretation Computed tomography guidance for visceral tissue ablation Magnetic resonance guidance for needle placement (e.g., for biopsy, needle aspiration, injection, or placement of localization device) radiological supervision and interpretation Case Rate Professional Fee Health Care Institution Fee 75956 55,000 33,600 21,400 75957 53,400 29,400 24,000 75958 55,000 33,600 21,400 75959 55,000 33,600 21,400 75960 46,500 25,200 21,300 75961 75962 75966 75970 75978 75980 46,500 23,300 23,300 23,300 23,300 37,800 25,200 12,600 12,600 12,600 12,600 21,000 21,300 10,700 10,700 10,700 10,700 16,800 75982 46,500 25,200 21,300 75984 8,020 2,520 5,500 75989 75992 75994 75995 76003 76012 8,020 23,300 23,300 23,300 8,020 30,300 2,520 12,600 12,600 12,600 2,520 16,800 5,500 10,700 10,700 10,700 5,500 13,500 76013 30,300 16,800 13,500 76080 76086 76095 8,020 8,020 8,020 2,520 2,520 2,520 5,500 5,500 5,500 76096 76355 76360 76362 76393 8,020 8,020 8,020 8,020 8,020 2,520 2,520 2,520 2,520 2,520 5,500 5,500 5,500 5,500 5,500 Page 94 of 98 ANNEX 2. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 76394 76930 76932 76936 76940 76942 76965 76986 77261 77401 77401 77418 77421 77432 77600 77750 77761 DESCRIPTION Magnetic resonance guidance for visceral tissue ablation Ultrasonic guidance for pericardiocentesis, imaging supervision and interpretation Ultrasonic guidance for endomyocardial biopsy, imaging supervision and interpretation Ultrasound guided compression repair of arterial pseudoaneurysm or arteriovenous fistulae (includes diagnostic ultrasound evaluation, compression of lesion and imaging) Ultrasonic guidance for visceral tissue ablation Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation Ultrasonic guidance for interstitial radioelement application Ultrasonic guidance, intraoperative Therapeutic radiology treatment planning; simple, intermediate or complex, (Only one may be reported for a given course of therapy) Radiation treatment delivery (Linear Accelerator) Radiation treatment delivery (Cobalt) Intensity modulated treatment delivery, single or multiple fields/arcs, via narrow spatially and temporally modulated beams, binary, dynamic MLC per session Stereoscopic X-ray guidance for localization of target volume for the delivery of radiation therapy Stereotactic radiation treatment management of cerebral lesion(s) Hyperthermia for treatment of malignancy, one or more sessions during the course of therapy including follow-up care for 90 days after procedure Infusion or instillation of radioelement solution Intracavitary radiation source application, 1 or more sources/ribbons (Brachytherapy), one or more sessions during the course of therapy including follow-up care for 90 days after procedure Interstitial radiation source application, 1 or more sources/ribbons (Brachytherapy), one or more sessions during the course of therapy including follow-up care for 90 days after procedure Remote after loading high intensity brachytherapy (RAHIB); 1 or more source position or catheters per session Surface application of radiation source (Brachytherapy), one or more sessions during the course of therapy including follow-up care for 90 days after procedure Radiopharmaceutical (radioactive iodine) therapy Radiopharmaceutical ablation of gland for thyroid carcinoma or metastases of thyroid carcinoma Radiopharmaceutical therapy, by intracavitary administration Radiopharmaceutical therapy, by interstitial radioactive colloid administration Radiopharmaceutical therapy, by radiolabeled monoclonal antibody by intravenous infusion Radiopharmaceutical therapy, by intra-articular administration Radiopharmaceutical therapy, by intra-arterial particulate administration Outpatient Malaria Package Evaluation of aspirate (CT-guided biopsy) with or without preparation of smears; immediate cytologic study to determine adequacy of specimen(s), interpretation and report Pathology consultation during surgery; with frozen section(s), single block Pathology consultation during surgery; with frozen section(s), two (2) or more blocks Directly Observed Treatment Short-course; intensive phase Directly Observed Treatment Short-course; maintenance phase Animal bite Hemodialysis procedure Dialysis procedure other than hemodialysis (e.g. peritoneal, hemofiltration) Esophagus, gastroesophageal reflux test; with nasal catheter pH electrode(s) placement, recording, analysis and interpretation Esophageal function test, gastroesophageal reflux test with nasal catheter intraluminal impedance electrode(s) placement, recording, analysis and interpretation; Intestinal bleeding tube, passage, positioning and monitoring Gastric intubation, and aspiration or lavage for treatment (e.g., for ingested poisons) Percutaneous transluminal coronary thrombectomy Thrombolysis, coronary; by intracoronary infusion, including coronary angiography Case Rate 8,020 8,020 8,020 8,020 8,020 8,020 8,020 8,020 18,000 3,000 2,000 5,680 30,300 30,300 12,120 5,680 18,000 Professional Fee 2,520 2,520 2,520 2,520 2,520 2,520 2,520 2,520 8,400 800 800 1,680 16,800 16,800 6,720 1,680 8,400 Health Care Institution Fee 5,500 5,500 5,500 5,500 5,500 5,500 5,500 5,500 9,600 2,200 1,200 4,000 13,500 13,500 5,400 4,000 9,600 77776 77781 77789 79000 79005 79200 79300 79403 79440 79445 87207 88174 88331 88332 89221 89222 90375 90935 90945 91034 91037 91100 91105 92973 92975 18,000 5,680 9,700 3,640 8,020 9,700 9,700 8,020 8,020 8,020 600 5,680 5,680 9,700 2,500 1,500 3,000 4,000 4,000 8,260 8,260 8,260 8,260 30,300 23,300 8,400 1,680 4,200 840 2,520 4,200 4,200 2,520 2,520 2,520 9,600 4,000 5,500 2,800 5,500 5,500 5,500 5,500 5,500 5,500 600 1,680 1,680 4,200 4,000 4,000 5,500 2,500 1,500 3,000 3,500 3,500 4,900 4,900 4,900 4,900 13,500 10,700 500 500 3,360 3,360 3,360 3,360 16,800 12,600 Page 95 of 98 ANNEX 2. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE 92980 DESCRIPTION Transcatheter placement of an intracoronary stent(s), percutaneous, with or without other therapeutic interventions, any method; single vessel Transcatheter placement of an intracoronary stent(s), percutaneous, with or without other therapeutic interventions, any method; each additional vessel Percutaneous transluminal coronary balloon angioplasty, one or more vessel Percutaneous balloon valvuloplasty; aortic Percutaneous balloon valvuloplasty; mitral Percutaneous balloon valvuloplasty; pulmonary valve Atrial septectomy or septostomy; transvenous method, balloon (e.g., Rashkind type) (includes cardiac catheterization) Atrial septectomy or septostomy; blade method (Park septostomy) (includes cardiac catheterization) Percutaneous transluminal coronary atherectomy, by mechanical or other method, with or without balloon angioplasty, one or more vessel Percutaneous transluminal pulmonary balloon angioplasty, one or more vessel Right heart catheterization Insertion and placement of flow directed catheter (e.g., Swan-Ganz) for monitoring purposes Endomyocardial biopsy Catheter placement in coronary artery(s), arterial coronary conduits and/or venous coronary bypass grafts for coronary angiography without concomitant left heart catheterization Left heart catheterization, retrograde, from the brachial artery, axillary artery or femoral artery; percutaneous Left heart catheterization, retrograde, from the brachial artery, axillary artery or femoral artery; by cutdown Left heart catheterization by left ventricular puncture Combined transseptal and retrograde left heart catheterization Combined right heart catheterization and retrograde left heart catheterization Combined right heart catheterization and transseptal left heart catheterization through intact septum (with or without retrograde left heart catheterization) Combined right heart catheterization with left ventricular puncture (with or without retrograde left heart catheterization) Combined right heart catheterization and left heart catheterization through existing septal opening (with or without retrograde left heart catheterization) Right heart catheterization, for congenital cardiac anomalies Combined right heart catheterization and retrograde left heart catheterization, for congenital cardiac anomalies Combined right heart catheterization and transseptal left heart catheterization through intact septum with or without retrograde left heart catheterization, for congenital cardiac anomalies Combined right heart catheterization and transseptal left heart catheterization through existing septal opening, with or without retrograde left heart catheterization, for congenital cardiac anomalies Injection procedure during cardiac catheterization; for selective opacification of arterial conduits (e.g., internal mammary), whether native or used bypass Injection procedure during cardiac catheterization; for selective opacification of aortocoronary venous bypass grafts, one or more coronary arteries Injection procedure during cardiac catheterization; for pulmonary angiography Injection procedure during cardiac catheterization; for selective right ventricular or right atrial angiography Injection procedure during cardiac catheterization; for selective coronary angiography (injection of radiopaque material may be by hand) Injection procedure during cardiac catheterization; for aortography Injection procedure during cardiac catheterization; for selective coronary angiography (injection of radiopaque material may be by hand) Imaging supervision, interpretation and report for injection procedure(s) during cardiac catheterization; ventricular and/or atrial angiography Case Rate 30,300 Professional Fee 16,800 Health Care Institution Fee 13,500 92981 92982 92986 92987 92990 92992 92993 92995 92997 93501 93503 93505 93508 93510 93511 93514 93524 93526 93527 93528 93529 93530 93531 93532 30,300 30,300 53,400 53,400 53,400 21,400 21,400 30,300 12,900 18,000 9,700 23,300 9,700 18,000 18,000 18,000 23,300 23,300 23,300 23,300 23,300 18,000 23,300 9,700 16,800 16,800 29,400 29,400 29,400 10,500 10,500 16,800 6,300 8,400 4,200 12,600 4,200 8,400 8,400 8,400 12,600 12,600 12,600 12,600 12,600 8,400 12,600 4,200 13,500 13,500 24,000 24,000 24,000 10,900 10,900 13,500 6,600 9,600 5,500 10,700 5,500 9,600 9,600 9,600 10,700 10,700 10,700 10,700 10,700 9,600 10,700 5,500 93533 9,700 4,200 5,500 93539 9,700 4,200 5,500 93540 93541 93542 93543 93544 93545 9,700 9,700 9,700 9,700 23,300 9,700 4,200 4,200 4,200 4,200 12,600 4,200 5,500 5,500 5,500 5,500 10,700 5,500 93555 9,700 4,200 5,500 Page 96 of 98 Esophageal recording of atrial electrogram with or without ventricular electrogram(s).500 5.700 4. His bundle recording. with continuous ECG monitoring and intermittent blood pressure monitoring. atrial septal defect) with implant Percutaneous transcatheter closure of congenital ventricular septal defect with implant Bundle of His recording Intra-atrial recording Right ventricular recording Intra-atrial pacing Intraventricular pacing Esophageal recording of atrial electrogram with or without ventricular electrogram(s).500 93640 9.200 5.700 4. aortography..700 4.300 5.000 55.500 96408 Chemotherapy administration 7. with pacing Induction of arrhythmia by electrical pacing Comprehensive electrophysiologic evaluation with right atrial pacing and recording. interpretation and report for injection procedure(s) during cardiac catheterization.200 4.500 93651 9.500 93652 93660 9.200 4.520 1. for treatment of supraventricular tachycardia by ablation of fast or slow atrioventricular pathways. requiring and including thoracentesis Chemotherapy administration into peritoneal cavity.260 2.280 1.700 33. with testing of single or dual chamber pacing cardioverter-defribrillator pulse generator Electrophysiologic evaluation of single or dual chamber pacing cardioverterdefibrillator (includes defibrillation threshold evaluation.500 5.200 5.560 3. without induction of arrhythmia Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia.800 Page 97 of 98 .ANNEX 2.700 4.700 9. with or without temporary pacemaker placement Intracardiac catheter ablation of arrhythmogenic focus. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE DESCRIPTION Imaging supervision. evaluation of sensing and pacing for arrhythmia termination.300 2.680 5.560 8.500 93624 9.500 93641 9. with or without pharmacological intervention Case Rate Professional Fee Health Care Institution Fee 93556 9. and programming or reprogramming Intracardiac catheter ablation of atrioventricular node function.400 21. singly or in combination Intracardiac catheter ablation of arrhythmogenic focus. evaluation of sensing and pacing for arrhythmia termination) at time of initial implantation or replacement. requiring and including peritoneocentesis Chemotherapy administration into CNS. with right atrial pacing and recording. requiring and including spinal puncture Chemotherapy injection.200 5.600 4.700 4.700 9. induction of arrhythmia.200 21.700 4.500 93642 9. subarachnoid or interventricular via subcutaneous reservoir 5.700 4.200 5.700 4.500 5.000 9.200 5.200 4.640 1.200 4.500 4. Fontan fenestration.500 5.e.700 9.200 4. for treatment of ventricular tachycardia Evaluation of cardiovascular function with tilt table evaluation.700 9.020 5.700 9.200 5. and/or selective coronary angiography including venous bypass grafts and arterial conduits (whether native or used in bypass) Percutaneous transcatheter closure of congenital interatrial communications (i.600 33.500 5. including insertion and repositioning of multiple electrode catheters. pulmonary angiography. atrioventricular conduction for creation of complete heart block.700 9.400 5.200 5.260 840 4.700 4.500 93580 93581 93600 93602 93603 93610 93612 93615 93616 93618 93619 55.200 5.200 4. including induction or attempted induction of arrhythmia Intra-operative epicardial and endocardial pacing and mapping to localize the site tachycardia or zone of slow conduction for surgical correction Electrophysiologic evaluation of single or dual chamber pacing cardioverterdefibrillator leads including defibrillation threshold evaluation (induction of arrhythmia.500 93631 9.500 5. evaluation of sensing and pacing for arrhythmia termination) at time of initial implantation or replacement.500 5. accessory atrioventricular connections or other atrial foci.500 93620 9.200 4.500 93650 9.500 5. His bundle recording Electrophysiologic follow-up study with pacing and recording to test effectiveness of therapy.700 9.200 5. right ventricular pacing and recording.500 5.700 4. Electrophysiologic evaluation of single or dual chamber pacing cardioverterdefibrillator leads including defibrillation threshold evaluation (induction of arrhythmia.700 9.600 96440 96445 96450 96542 Chemotherapy administration into pleural cavity.200 4.200 4.200 5.700 9. 000 96567 99246 8. operative standby).ANNEX 2.200 0 1. requiring physician attendance (e. examination and medical decision making..520 99256 0 0 0 99360 99432 P00001 0 1.000 0 500 1.800 Page 98 of 98 .750 4. 1 or more phototherapy exposure session Outpatient HIV / AIDS Packages Preoperative inpatient consultation for a new or established patient which requires: an expanded problem focused history.g.250 2.g.000 2. including preoperative inpatient consultation for high-risk patients or those with severe systemic disease including follow-up care for 90 days after procedure Normal newborn care package Referral package Case Rate Professional Fee Health Care Institution Fee 5. the consultant advices the requesting physician about the management of specific problem including follow-up care for 90 days after procedure (CP Clearance) Physician standby service.500 30. lip) by activation of photosensitive drug(s). LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE DESCRIPTION Photodynamic therapy by external application of light to destroy premalignant and/or malignant lesions of the skin and adjacent mucosa (e.020 30.. This service is requested by another physician or an appropriate source.