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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

ANNEX 2. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE
14021 14040

DESCRIPTION
Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10.1 sq cm to 30.0 sq cm Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10.1 sq cm to 30.0 sq cm Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq cm or less Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10.1 sq cm to 30.0 sq cm Adjacent tissue transfer or rearrangement, more than 30 sq cm, unusual or complicated, any area Filleted finger or toe flap, including preparation of recipient site Pinch graft, single or multiple, to cover small ulcer, tip or digit, or other minimal open area (except on face), up to defect size 2 cm diameter Split graft, trunk, scalp, arms, legs, hands, and/or feet (except multiple digits); 100 sq cm or less, or each one percent of body area of infants and children (except 15050) Split graft, face, eyelids, mouth, neck, ears, orbits, genitalia, and/or multiple digits; 100 sq cm or less, or each one percent of body area of infants and children (except 15050) Full thickness graft, free, including direct closure of donor site, trunk; 20 sq cm or less Full thickness graft, free, including direct closure of donor site, scalp, arms, and/or legs; 20 sq cm or less Full thickness graft, free, including direct closure of donor site, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, and/or feet; 20 sq cm or less Full thickness graft, free, including direct closure of donor site, nose, ears, eyelids, and/or lips; 20 sq cm or less Application of allograft, skin Application of xenograft, skin Formation of direct or tubed pedicle, w/ or w/o transfer; trunk Formation of direct or tubed pedicle, w/ or w/o transfer; scalp, arms, or legs Formation of direct or tubed pedicle, w/ or w/o transfer; forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands or feet Formation of direct or tubed pedicle, w/ or w/o transfer; eyelids, nose, ears, lips or intraoral Cross finger flap, including free graft to donor site Transfer, intermediate, of any pedicle flap (e.g., abdomen to wrist, "Walking" tube), any location Muscle, myocutaneous, or fasciocutaneous flap; head and neck (e.g., temporalis, masseter, sternocleidomastoid, levator scapulae) Muscle, myocutaneous, or fasciocutaneous flap; trunk Muscle, myocutaneous, or fasciocutaneous flap; upper extremity Muscle, myocutaneous, or fasciocutaneous flap; lower extremity Flap; island pedicle Flap; 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; composite (e.g., full thickness of external ear or nasal ala), including primary closure, donor area Graft; derma-fat-fascia Blepharoplasty, lower eyelid Blepharoplasty, upper eyelid; Blepharoplasty, upper eyelid; with excessive skin weighting down lid Graft for facial nerve paralysis; free fascia graft (including obtaining fascia) Graft for facial nerve paralysis; free muscle graft (including obtaining graft) Graft for facial nerve paralysis; free muscle graft by microsurgical technique Graft for facial nerve paralysis; regional muscle transfer Excision, coccygeal pressure ulcer, w/ coccygectomy; w/ primary suture Excision, coccygeal pressure ulcer, w/ coccygectomy; w/ flap closure Excision, sacral pressure ulcer, w/ primary suture; Excision, sacral pressure ulcer, w/ primary suture; w/ ostectomy Excision, sacral pressure ulcer, w/ skin flap closure; Excision, sacral pressure ulcer, w/ skin flap closure; w/ ostectomy Excision, sacral pressure ulcer, w/ muscle or myocutaneous flap closure;

Case Rate 11,980 12,120

Professional Fee 5,880 6,720

Health Care Institution Fee 6,100 5,400

14041 14060 14061 14300 14350 15050

18,000 18,000 18,000 18,000 27,120 8,260

8,400 8,400 8,400 8,400 15,120 3,360

9,600 9,600 9,600 9,600 12,000 4,900

15100

8,260

3,360

4,900

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

21,940 21,940 21,940 30,740 30,300 30,300 30,300 18,000 30,740 30,740 30,300 21,940 21,940 47,340 47,340 47,340 47,340 38,640 38,640 38,640 38,640 38,640 21,940 21,940 10,120 10,120 11,980 30,300 30,300 38,640 30,300 30,740 30,300 21,940 30,740 12,120 30,300 38,440

9,240 9,240 9,240 13,440 16,800 16,800 16,800 8,400 13,440 13,440 16,800 9,240 9,240 26,040 26,040 26,040 26,040 21,840 21,840 21,840 21,840 21,840 9,240 9,240 4,620 4,620 5,880 16,800 16,800 21,840 16,800 13,440 16,800 9,240 13,440 6,720 16,800 19,740

12,700 12,700 12,700 17,300 13,500 13,500 13,500 9,600 17,300 17,300 13,500 12,700 12,700 21,300 21,300 21,300 21,300 16,800 16,800 16,800 16,800 16,800 12,700 12,700 5,500 5,500 6,100 13,500 13,500 16,800 13,500 17,300 13,500 12,700 17,300 5,400 13,500 18,700

Page 4 of 98

ANNEX 2. 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, sacral pressure ulcer, w/ muscle or myocutaneous flap closure; w/ ostectomy Excision, ischial pressure ulcer, w/ primary suture; Excision, ischial pressure ulcer, w/ primary suture; w/ ostectomy (ischiectomy) Excision, ischial pressure ulcer, w/ skin flap closure; Excision, ischial pressure ulcer, w/ skin flap closure; w/ ostectomy Excision, ischial pressure ulcer, w/ ostectomy, w/ muscle or myocutaneous flap closure Excision, trochanteric pressure ulcer, w/ primary suture; Excision, trochanteric pressure ulcer, w/ primary suture; w/ ostectomy Excision, trochanteric pressure ulcer, w/ skin flap closure; Excision, trochanteric pressure ulcer, w/ skin flap closure; w/ ostectomy Excision, trochanteric pressure ulcer, w/ muscle or myocutaneous flap closure; Excision, trochanteric pressure ulcer, w/ muscle or myocutaneous flap closure; w/ ostectomy Dressings and/or debridement, initial or subsequent Escharotomy Excision burn wound, w/o skin grafting, employing alloplastic dressing (e.g., synthetic mesh), any anatomic site Destruction by any method, including laser, w/ or w/o surgical curettement, all benign facial lesions or premalignant lesions in any location, or benign lesions other than cutaneous vascular proliferative lesions, including local anesthesia; any number of Destruction by any method, including laser, of benign skin lesions other than cutaneous vascular proliferative lesions on any area other than the face, including local anesthesia; any number of lesions Destruction of cutaneous vascular proliferative lesions (e.g., laser technique) Destruction by any method of flat warts or molluscum contagiosum, milia, all lesions Electosurgical destruction of multiple fibrocutaneous tags; all lesions Chemical cauterization of granulation tissue (proud flesh, sinus or fistula) Destruction, malignant lesion, any method, trunk, arms or legs; lesion diameter 0.5 cm or less Destruction, malignant lesion, any method, trunk, arms or legs; lesion diameter 0.6 to 1.0 cm Destruction, malignant lesion, any method, trunk, arms or legs; lesion diameter 1.1 to 2.0 cm Destruction, malignant lesion, any method, trunk, arms or legs; lesion diameter 2.1 to 3.0 cm Destruction, malignant lesion, any method, trunk, arms or legs; lesion diameter 3.1 to 4.0 cm Destruction, malignant lesion, any method, trunk, arms or legs; lesion diameter over 4.0 cm Destruction, malignant lesion, any method, scalp, neck, hands, feet, genitalia; lesion diameter 0.5 cm or less Destruction, malignant lesion, any method, scalp, neck, hands, feet, genitalia; lesion diameter 0.6 to 1.0 cm Destruction, malignant lesion, any method, scalp, neck, hands, feet, genitalia; lesion diameter 1.1 to 2.0 cm Destruction, malignant lesion, any method, scalp, neck, hands, feet, genitalia; lesion diameter 2.1 to 3.0 cm Destruction, malignant lesion, any method, scalp, neck, hands, feet, genitalia; lesion diameter 3.1 to 4.0 cm Destruction, malignant lesion, any method, scalp, neck, hands, feet, genitalia; lesion diameter over 4.0 cm Destruction, malignant lesion, any method, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.5 cm or less Destruction, malignant lesion, any method, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.6 to 1.0 cm Destruction, malignant lesion, any method, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 1.1 to 2.0 cm Destruction, malignant lesion, any method, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 2.1 to 3.0 cm Destruction, malignant lesion, any method, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 3.1 to 4.0 cm Destruction, malignant lesion, any method, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter over 4.0 cm

Case Rate 37,800 12,120 21,940 30,740 30,300 38,440 11,980 21,940 21,940 30,740 31,140 38,440 8,260 30,740 9,700

Professional Fee 21,000 6,720 9,240 13,440 16,800 19,740 5,880 9,240 9,240 13,440 17,640 19,740 3,360 13,440 4,200

Health Care Institution Fee 16,800 5,400 12,700 17,300 13,500 18,700 6,100 12,700 12,700 17,300 13,500 18,700 4,900 17,300 5,500

17000

8,020

2,520

5,500

17100

8,020

2,520

5,500

17106 17110 17200 17250 17260 17261 17262 17263 17264 17266 17270 17271 17272 17273 17274 17276 17280 17281 17282 17283 17284 17286

18,000 5,680 8,020 5,680 5,680 5,680 5,680 5,680 5,680 5,680 5,680 5,680 5,680 5,680 5,680 5,680 9,300 9,300 9,300 9,300 9,300 9,300

8,400 1,680 2,520 1,680 1,680 1,680 1,680 1,680 1,680 1,680 1,680 1,680 1,680 1,680 1,680 1,680 2,100 2,100 2,100 2,100 2,100 2,100

9,600 4,000 5,500 4,000 4,000 4,000 4,000 4,000 4,000 4,000 4,000 4,000 4,000 4,000 4,000 4,000 7,200 7,200 7,200 7,200 7,200 7,200

Page 5 of 98

ANNEX 2. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE DESCRIPTION
Chemosurgery (Mohs micrographic technique), including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and complete histopathologic preparation; first stage, fresh tissue technique, up to 5 specimens Puncture aspiration of cyst of breast; Mastotomy w/ exploration or drainage of abscess, deep Biopsy of breast; needle core Biopsy of breast; incisional Nipple exploration, w/ or w/o excision of a solitary lactiferous duct or a papilloma lactiferous duct Excision of lactiferous duct fistula Excision of cyst, fibroadenoma, or other benign or malignant tumor aberrant breast tissue, duct lesion or nipple lesion (except 19140), male or female, one or more lesions Excision of breast lesion identified by preoperative placement of radiological marker; single lesion Mastectomy for gynecomastia Mastectomy, partial; Mastectomy, partial; with axillary lymphadenectomy Mastectomy, simple, complete Mastectomy, subcutaneous Mastectomy, radical, icnluding pectoral muscles, axillary lymph nodes Mastectomy, radical, including pectoral muscles, axillary and internal mammary lymph nodes (Urban type operation) Mastectomy, modified radical, including axillary lymph nodes, w/ or w/o pectoralis minor muscle, but excluding pectoralis major muscle Excision of chest wall tumor including ribs Excision of chest wall tumor involving ribs, w/ plastic reconstruction; w/o mediastinal lymphadenectomy Excision of chest wall tumor involving ribs, w/ plastic reconstruction; w/ mediastinal lymphadenectomy Immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction Delayed insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction Nipple/areola reconstruction Breast reconstruction, immediate or delayed, with tissue expander, including subsequent expansion Breast reconstruction with latissimus dorsi flap, with or without prosthetic implant Breast reconstruction with free flap Breast reconstruction with other technique Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), single pedicle, including closure of donor site; Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), double pedicle, including closure of donor site Open periprosthetic capsulotomy, breast Periprosthetic capsulectomy, breast Biopsy, muscle Biopsy, muscle, percutaneous needle Biopsy, bone, trocar, or needle; superficial (e.g., ilium, sternum, spinous process, ribs) Biopsy, bone, trocar, or needle; deep (vertebral body, femur) Biopsy, excisional; superficial (e.g., ilium, sternum, spinous process, ribs, trochanter of femur) Biopsy, excisional; deep (e.g., humerus, ischium, femur) Biopsy, vertebral body, open; thoracic Biopsy, vertebral body, open; lumbar or cervical Removal of foreign body in muscle or tendon sheath Arthrocentesis, aspiration and/or injection; small joint, bursa or ganglion cyst (e.g., fingers, toes) Arthrocentesis, aspiration and/or injection; intermediate joint, bursa or ganglion cyst (e.g., temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa) Arthrocentesis, aspiration and/or injection; major joint or bursa (e.g., shoulder, hip, knee joint, subacromial bursa) Aspiration and injection for treatment of bone cyst Insertion of wire or pin w/ application of skeletal traction, including removal Application of cranial tongs, caliper, or stereotactic frame, including removal Application of halo, including removal; cranial Application of halo, including removal; pelvic Case Rate Professional Fee Health Care Institution Fee

17304

8,020

2,520

5,500

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

3,640 9,700 3,640 5,560 8,440 8,260 8,020 8,020 22,000 22,000 22,000 22,000 22,000 22,000 22,000 22,000 46,500 55,000 58,800 37,800 37,800 30,300 37,800 55,000 55,000 55,000 55,000

840 4,200 840 1,260 2,940 3,360 2,520 2,520 8,800 8,800 8,800 8,800 8,800 8,800 8,800 8,800 25,200 33,600 37,800 21,000 21,000 16,800 21,000 33,600 33,600 33,600 33,600

2,800 5,500 2,800 4,300 5,500 4,900 5,500 5,500 13,200 13,200 13,200 13,200 13,200 13,200 13,200 13,200 21,300 21,400 21,000 16,800 16,800 13,500 16,800 21,400 21,400 21,400 21,400

19369 19370 19371 20200 20206 20220 20225 20240 20245 20250 20251 20520 20600 20605 20610 20615 20650 20660 20661 20662

55,000 30,300 37,800 4,108 3,504 10,880 18,000 9,700 12,540 23,300 30,740 8,020 5,560 9,300 9,300 8,260 8,020 9,868 8,608 23,300

33,600 16,800 21,000 1,008 504 3,780 8,400 4,200 7,140 12,600 13,440 2,520 1,260 2,100 2,100 3,360 2,520 4,368 3,108 12,600

21,400 13,500 16,800 3,100 3,000 7,100 9,600 5,500 5,400 10,700 17,300 5,500 4,300 7,200 7,200 4,900 5,500 5,500 5,500 10,700

Page 6 of 98

ANNEX 2. 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, including removal; femoral Removal of implant; superficial (e.g., buried wire, pin or rod) Removal of implant; deep (e.g., buried wire, pin, screw, metal band, nail, rod or plate) Application of a uniplane (pins or wires in one plane), unilateral, external fixation system Application of multiplane (pins or wires in more than one plane), unilateral, external fixation system (e.g., llizarov, Monticelli type) Replantation, arm (includes surgical neck of humerus through elbow joint), complete amputation Replantation, forearm (includes radius and ulna to radial carpal joint), complete amputation Replantation, hand (includes hand through metacarpophalangeal joint(s), complete amputation Replantation, digit, excluding thumb (includes metacarpophalangeal joint to insertion of flexor sublimis tendon), complete amputation Replantation, digit, excluding thumb (includes distal tip to sublimis tendon insertion), complete amputation Replantation, thumb (includes carpometacarpal joint to MP joint), complete amputation Replantation, thumb (includes distal tip to MP joint), complete amputation Replantation, foot, complete amputation Bone graft, any donor area; minor or small (e.g., dowel or button) Bone graft, any donor area; major or large Cartilage graft; costochondral Cartilage graft; nasal septum Fascia lata graft; by stripper Fascia lata graft; by incision and area exposure, complex or sheet Tendon graft, form a distance (e.g., palmaris, toe extensor, plantaris) Tissue grafts, other (e.g., paratenon, fat, dermis) Allograft for spine surgery only; morselized Allograft for spine surgery only; structural Autograft for spine surgery only (includes harvesting the graft); local (e.g., ribs, spinous process, or laminar fragments) obtained from same incision Autograft for spine surgery only (includes harvesting the graft); morselized (thorugh separate skin or fascial incision) Autograft for spine surgery only (includes harvesting the graft); structural, bicortical or tricortial (through separate skin or fascial incision) Bone graft w/ microvascular anastomosis; fibula Bone graft w/ microvascular anastomosis; iliac crest Bone graft w/ microvascular anastomosis; metatarsal Bone graft w/ microvascular anastomosis; other than fibula, iliac crest, or metatarsal Free osteocutaneous flap w/ microvascular anastomosis; other than iliac crest, metatarsal, or great toe Free osteocutaneous flap w/ microvascular anastomosis; iliac crest Free osteocutaneous flap w/ microvascular anastomosis; metatarsal Free osteocutaneous flap w/ microvascular anastomosis; great toe w/ web space Ablation, bone tumor(s) (e.g., osteoid osteoma, metastasis) radiofrequency, percutaneous, including computed tomographic guidance Arthrotomy, temporomandibular joint Radical resection of tumor (e.g., malignant neoplasm), soft tissue of face or scalp Excision of bone (e.g., for osteomyelitis or bone abscess); mandible Excision of bone (e.g., for osteomyelitis or bone abscess); facial bone(s) Removal by contouring of benign tumor of facial bone (e.g., 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; simple Excision of benign cyst or tumor of mandible; complex Excision of malignant tumor of mandible; Excision of malignant tumor of mandible; radical resection Condylectomy, temporomandibular joint Meniscectomy, partial or complete, temporomandibular joint Coronoidectomy Genioplasty; augmentation (autograft, allograft, prosthetic material) Genioplasty; sliding osteotomy, single piece

Case Rate 21,940 10,540 11,980 12,120 39,280 9,300 40,320 40,320 23,300 23,300 30,300 23,300 37,800 10,540 18,000 12,120 12,120 9,700 12,120 10,960 9,700 12,120 18,420 10,540 10,540 18,000 37,800 37,800 20,980 27,120 37,800 30,300 23,300 27,120 9,700 9,700 23,300 18,000 18,000 18,000 18,000 18,000 18,000 23,300 18,000 21,940 23,300 30,300 30,300 30,300 30,300 18,000 46,500

Professional Fee 9,240 5,040 5,880 6,720 20,580 2,100 23,520 23,520 12,600 12,600 16,800 12,600 21,000 5,040 8,400 6,720 6,720 4,200 6,720 5,460 4,200 6,720 8,820 5,040 5,040 8,400 21,000 21,000 10,080 15,120 21,000 16,800 12,600 15,120 4,200 4,200 12,600 8,400 8,400 8,400 8,400 8,400 8,400 12,600 8,400 9,240 12,600 16,800 16,800 16,800 16,800 8,400 25,200

Health Care Institution Fee 12,700 5,500 6,100 5,400 18,700 7,200 16,800 16,800 10,700 10,700 13,500 10,700 16,800 5,500 9,600 5,400 5,400 5,500 5,400 5,500 5,500 5,400 9,600 5,500 5,500 9,600 16,800 16,800 10,900 12,000 16,800 13,500 10,700 12,000 5,500 5,500 10,700 9,600 9,600 9,600 9,600 9,600 9,600 10,700 9,600 12,700 10,700 13,500 13,500 13,500 13,500 9,600 21,300

Page 7 of 98

ANNEX 2. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE
21122 21123 21125 21127 21137 21138 21139 21141 21142 21143 21145 21146

DESCRIPTION
Genioplasty; sliding osteotomies, two or more osteotomies (e.g., wedge excision or bone wedge reversal for asymmetrical chin) Genioplasty; sliding, augmentation w/ interpositional bone grafts (includes obtaining autografts) Augmentation, mandibular body or angle; prosthetic material Augmentation, mandibular body or angle; w/ bone graft, onlay or interpositional (includes obtaining autograft) Reduction forehead; contouring only Reduction forehead; contouring and application of prosthetic material or bone graft (includes obtaining autograft) Reduction forehead; contouring and setback of anterior frontal sinus wall Reconstruction midface, LeFort I; single piece, segment movement in any direction (e.g., for Long Face Syndrome), w/o bone graft Reconstruction midface, LeFort I; two pieces, segment movement in any direction, w/o bone graft Reconstruction midface, LeFort I; three or more pieces, segment movement in any direction, w/o bone graft Reconstruction midface, LeFort I; single piece, segment movement in any direction, requiring bone grafts (includes obtaining autografts) Reconstruction midface, LeFort I; two pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (e.g., ungrafted unilateral alveolar cleft) Reconstruction midface, LeFort I; three or more pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (e.g., ungrafted bilateral alveolar cleft or multiple osteotomies) Reconstruction midface, LeFort II; anterior intrusion (e.g., Treacher-Collins Syndrome) Reconstruction midface, LeFort II; any direction, requiring bone grafts (includes obtaining autografts) Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining autografts); w/o LeFort I Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining autografts); w/ LeFort I Reconstruction midface, LeFort III (extra and intracranial) w/ forehead advancement (e.g., mono bloc), requiring bone grafts (includes obtaining autografts); w/o LeFort I Reconstruction midface, LeFort III (extra and intracranial) w/ forehead advancement (e.g., mono bloc), requiring bone grafts (includes obtaining autografts); w/ LeFort I Reconstruction superior-lateral orbital rim and lower forehead, advancement or alteration, w/ or w/o grafts (includes obtaining autografts) Reconstruction, bifrontal, superior-lateral orbital rims and lower forehead, advancement or alteration (e.g., plagiocephaly, trigonocephaly, brachycephaly), w/ or w/o grafts (includes obtaining autografts) Reconstruction, entire or majority of forehead and/or supraorbital rims; w/ grafts (allograft or prosthetic material) Reconstruction, entire or majority of forehead and/or supraorbital rims; w/ autograft (includes obtaining grafts) Reconstruction by contouring of benign tumor of cranial bones (e.g., fibrous dysplasia), extracranial Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra-and extracranial excision of benign tumor of cranial bone (e.g., fibrous dysplasia), w/ multiple autografts (includes obtaining grafts); total area of bone grafting less Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra-and extracranial excision of benign tumor of cranial bone (e.g., fibrous dysplasia), w/ multiple autografts (includes obtaining grafts); total area of bone grafting greater than 40 cm2 but less than 80 cm2 Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra-and extracranial excision of benign tumor of cranial bone (e.g., fibrous dysplasia), w/ multiple autografts (includes obtaining grafts); total area of bone grafting greater than 80 cm2 Reconstruction midface, osteotomies (other than LeFort type) and bone grafts (includes obtaining autografts) Reconstruction of mandibular rami, horizontal, vertical, "C", or "L" osteotomy; w/o bone graft Reconstruction of mandibular rami, horizontal, vertical, "C", or "L" osteotomy; w/ bone graft (includes obtaining graft) Reconstruction of mandibular rami and/or body, sagittal split; w/o internal rigid fixation

Case Rate 30,300 30,300 30,300 46,500 18,000 46,500 30,300 53,400 46,500 46,500 46,500 46,500

Professional Fee 16,800 16,800 16,800 25,200 8,400 25,200 16,800 29,400 25,200 25,200 25,200 25,200

Health Care Institution Fee 13,500 13,500 13,500 21,300 9,600 21,300 13,500 24,000 21,300 21,300 21,300 21,300

21147

55,000

33,600

21,400

21150 21151 21154 21155 21159

55,000 55,000 58,800 55,000 55,000

33,600 33,600 37,800 33,600 33,600

21,400 21,400 21,000 21,400 21,400

21160

46,500

25,200

21,300

21172

55,000

33,600

21,400

21175

55,000

33,600

21,400

21179 21180 21181

55,000 55,000 53,400

33,600 33,600 29,400

21,400 21,400 24,000

21182

46,500

25,200

21,300

21183

53,400

29,400

24,000

21184

55,000

33,600

21,400

21188 21193 21194 21195

55,000 46,500 55,000 46,500

33,600 25,200 33,600 25,200

21,400 21,300 21,400 21,300

Page 8 of 98

ANNEX 2. 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, sagittal split; w/ internal rigid fixation Osteotomy, mandible, segmental Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard) Graft, bone; nasal, maxillary or malar areas (includes obtaining graft) Graft, bone; mandible (includes obtaining graft) Graft; rib cartilage, autogenous, to face, chin, nose or ear (includes obtaining graft) Graft; ear cartilage, autogenous, to nose or ear (includes obtaining graft) Arthroplasty, temporomandibular joint, w/ or w/o autograft (includes obtaining graft) Arthroplasty, temporomandibular joint, w/ allograft Arthroplasty, temporomandibular joint, w/ prosthetic joint replacement Reconstruction of mandible, extraoral, w/ transosteal bone plate (e.g., mandibular staple bone plate) Reconstruction of mandible or maxilla, subperiosteal implant; partial Reconstruction of mandible or maxilla, subperiosteal implant; complete Reconstruction of mandibular condyle w/ bone and cartilage autografts (includes obtaining grafts) (e.g., for hemifacial microsomia) Reconstruction of mandible or maxilla, endosteal implant (e.g. blade, cylinder); partial Reconstruction of mandible or maxilla, endosteal implant (e.g. blade, cylinder); 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.g., micro-ophthalmia) Periorbital osteotomies for orbital hypertelorism, w/ bone grafts Orbital repositioning, periorbital osteotomies, unilateral, w/ bone grafts; extracranial approach Closed treatment of skull fracture w/o operation Closed treatment of nasal bone fracture Open treatment of nasal fracture; uncomplicated Open treatment of nasal fracture; complicated, w/ internal and/or external skeletal fixation Open treatment of nasal fracture; w/ concomitant open treatment of fractured septum Open treatment of nasal septal fracture, w/ or w/o stabilization Closed treatment of nasal septal fracture Open treatment of nasoethmoid fracture; w/o external fixation Open treatment of nasoethmoid fracture; w/ external fixation Percutaneous treatment of nasoethmoid complex fracture, w/ splint, wire or headcap fixation, including repair of canthal ligaments and/or the nasolacrimal apparatus Open treatment of depressed frontal sinus fracture Open treatment of complicated (e.g., comminuted or involving posterior wall) frontal sinus fracture, via coronal or multiple approaches Closed treatment of nasomaxillary complex fracture (LeFort II type), w/ interdental wire fixation or fixation of denture or splint Open treatment of nasomaxillary complex fracture (LeFort II type); w/ wiring and/or local fixation Open treatment of nasomaxillary complex fracture (LeFort II type); requiring multiple open approaches Open treatment of nasomaxillary complex fracture (LeFort II type); w/ bone grafting (includes obtaining graft) Percutaneous treatment of fracture of malar area, including zygomatic arch and malar tripod, w/ manipulation Open treatment of depressed zygomatic arch fracture (e.g., Gilles approach) Open treatment of depressed malar fracture, including zygomatic arch and malar tripod Open treatment of complicated (e.g., comminuted or involving cranial nerve foramina) fracture(s) of malar area, including zygomatic arch and malar tripod; w/ internal fixation and multiple surgical approaches Open treatment of complicated (e.g., comminuted or involving cranial nerve foramina) fracture(s) of malar area, including zygomatic arch and malar tripod; w/ bone grafting (includes obtaining graft)

Case Rate 55,000 30,300 46,500 46,500 55,000 46,500 30,300 46,500 46,500 55,000 46,500 53,400 55,000 55,000 55,000 63,000 55,000 55,000 55,000 55,000 10,540 10,540 12,120 12,120 12,120 12,120 10,540 12,120 18,000 21,940 21,940 23,300 22,660 23,300 30,300 37,800 21,940 23,300 30,300

Professional Fee 33,600 16,800 25,200 25,200 33,600 25,200 16,800 25,200 25,200 33,600 25,200 29,400 33,600 33,600 33,600 42,000 33,600 33,600 33,600 33,600 5,040 5,040 6,720 6,720 6,720 6,720 5,040 6,720 8,400 9,240 9,240 12,600 11,760 12,600 16,800 21,000 9,240 12,600 16,800

Health Care Institution Fee 21,400 13,500 21,300 21,300 21,400 21,300 13,500 21,300 21,300 21,400 21,300 24,000 21,400 21,400 21,400 21,000 21,400 21,400 21,400 21,400 5,500 5,500 5,400 5,400 5,400 5,400 5,500 5,400 9,600 12,700 12,700 10,700 10,900 10,700 13,500 16,800 12,700 10,700 13,500

21365

37,800

21,000

16,800

21366

46,500

25,200

21,300

Page 9 of 98

ANNEX 2. 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; transantral approach (Caldwell-Luc type operation) Open treatment of orbital floor "blowout" fracture; periorbital approach Open treatment of orbital floor "blowout" fracture; combined approach Open treatment of orbital floor "blowout" fracture; periorbital approach, w/ alloplastic or other implant Open treatment of orbital floor "blowout" fracture; periorbital approach w/ bone graft (includes obtaining graft) Closed treatment of fracture of orbit, except "blowout" Open treatment of fracture of orbit, except "blowout"; w/o implant Open treatment of fracture of orbit, except "blowout"; w/ implant Open treatment of fracture of orbit, except "blowout"; w/ bone grafting (includes obtaining graft) Closed treatment of palatal or maxillary fracture (LeFort I type), w/ interdental wire fixation or fixation of denture or splint Open treatment of palatal or maxillary fracture (LeFort I type); Open treatment of palatal or maxillary fracture (LeFort I type); complicated (comminuted or involving cranial nerve foramina), 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); w/ wiring and/or internal fixation Open treatment of craniofacial separation (LeFort III type); complicated (e.g., comminuted or involving cranial nerve foramina); multiple surgical approaches Open treatment of craniofacial separation (LeFort III type); complicated, utilizing internal and/or external fixation techniques (e.g., head cap, halo device, and/or intermaxillary fixation) Open treatment of craniofacial separation (LeFort III type); complicated, multiple surgical approaches, internal fixation, 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, w/ external fixation Closed treatment of mandibular fracture; w/ interdental fixation Open treatment of mandibular fracture; w/ external fixation Open treatment of mandibular fracture; w/o interdental fixation Open treatment of mandibular fracture; w/ interdental fixation Open treatment of mandibular condylar fracture Open treatment of complicated mandibular fracture by multiple surgical approaches including internal fixation, interdental fixation, and/or wiring of dentures or splints Closed treatment of temporomandibular dislocation; initial or subsequent Closed treatment of temporomandibular dislocation; complicated (e.g., recurrent requiring intermaxillary fixation or splinting), initial or subsequent Open treatment of temporomandibular dislocation Closed treatment of hyoid fracture Open treatment of hyoid fracture Interdental wiring, for condition other than fracture Incision and drainage, deep abscess or hematoma, soft tissues of neck or thorax; Incision and drainage, deep abscess or hematoma, soft tissues of neck or thorax; w/ partial rib ostectomy Incision, deep, w/ opening of bone cortex (e.g., for osteomyelitis or bone abscess), thorax Biopsy, soft tissue of neck or thorax Excision tumor, soft tissue of neck or thorax; subcutaneous Excision tumor, soft tissue of neck or thorax; deep, subfascial, intramuscular Radical resection of tumor (e.g., malignant neoplasm), soft tissue of neck or thorax Excision of rib, partial Costotransversectomy Excision first and/or cervical rib; Excision first and/or cervical rib; w/ sympathectomy Ostectomy of sternum, partial Sternal debridement Radical resection of sternum; Division of scalenus anticus; w/o resection of cervical rib Division of scalenus anticus; w/ resection of cervical rib Division of sternocleidomastoid for torticollis, open operation

Case Rate 20,980 18,000 37,800 31,580 31,580 18,000 20,980 31,580 31,580 12,120 20,980 23,300 12,120 23,300 18,000

Professional Fee 10,080 8,400 21,000 14,280 14,280 8,400 10,080 14,280 14,280 6,720 10,080 12,600 6,720 12,600 8,400

Health Care Institution Fee 10,900 9,600 16,800 17,300 17,300 9,600 10,900 17,300 17,300 5,400 10,900 10,700 5,400 10,700 9,600

21435

23,300

12,600

10,700

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

46,500 12,120 18,000 18,000 23,300 14,960 22,660 22,660 23,300 30,300 37,800 9,700 20,980 30,300 18,000 23,300 12,120 5,680 8,020 4,108 5,680 8,020 9,700 30,300 10,540 20,980 37,180 37,800 27,120 12,288 37,800 18,000 23,300 18,000

25,200 6,720 8,400 8,400 12,600 7,560 11,760 11,760 12,600 16,800 21,000 4,200 10,080 16,800 8,400 12,600 6,720 1,680 2,520 1,008 1,680 2,520 4,200 16,800 5,040 10,080 18,480 21,000 15,120 6,888 21,000 8,400 12,600 8,400

21,300 5,400 9,600 9,600 10,700 7,400 10,900 10,900 10,700 13,500 16,800 5,500 10,900 13,500 9,600 10,700 5,400 4,000 5,500 3,100 4,000 5,500 5,500 13,500 5,500 10,900 18,700 16,800 12,000 5,400 16,800 9,600 10,700 9,600

Page 10 of 98

ANNEX 2. 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, soft tissue of back or flank Excision, tumor, soft tissue of back or flank Radical resection of tumor (e.g., malignant neoplasm), soft tissue of back or flank Partial excision of posterior vertebral component (e.g., spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; cervical Partial excision of posterior vertebral component (e.g., spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; thoracic Partial excision of posterior vertebral component (e.g., spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; lumbar Partial excision of vertebral body, for intrinsic bony lesion, w/o decompression of spinal cord or nerve root(s), single vertebral segment; cervical Partial excision of vertebral body, for intrinsic bony lesion, w/o decompression of spinal cord or nerve root(s), single vertebral segment; thoracic Partial excision of vertebral body, for intrinsic bony lesion, w/o decompression of spinal cord or nerve root(s), single vertebral segment; lumbar Osteotomy of spine, posterior or posterolateral approach, one vertebral segment; cervical Osteotomy of spine, posterior or posterolateral approach, one vertebral segment; thoracic Osteotomy of spine, posterior or posterolateral approach, one vertebral segment; lumbar Osteotomy of spine, including diskectomy, anterior approach, single vertebral segment; cervical Osteotomy of spine, including diskectomy, anterior approach, single vertebral segment; thoracic Osteotomy of spine, including diskectomy, anterior approach, single vertebral segment; lumbar Closed treatment of vertebral process fracture(s) Closed treatment of vertebral body fracture(s), requiring and including casting or bracing Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, one fractured vertebrae or dislocated segment; lumbar Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, one fractured vertebrae or dislocated segment; cervical Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, one fractured vertebrae or dislocated segment; thoracic Arthrodesis, anterior transoral or extraoral technique, clivus-C1-C2 (atlasaxis), w/ or w/o excision of odontoid process Arthrodesis, anterior interbody technique, including minimal diskectomy to prepare interspace (other than for decompression); cervical below C2 Arthrodesis, anterior interbody technique, including minimal diskectomy to prepare interspace (other than for decompression); thoracic Arthrodesis, anterior interbody technique, including minimal diskectomy to prepare interspace (other than for decompression); lumbar Arthrodesis; posterior technique, craniocervical (occiput-C2) Arthrodesis, posterior technique, atlas-axis (C1-C2) Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment; Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment; thoracic (w/ or w/o lateral transverse technique) Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment; lumbar (w/ or w/o lateral transverse technique) Arthrodesis, posterior interbody technique, single interspace; lumbar

Case Rate 27,120 23,300 8,020 10,960 20,980 9,868 21,940 3,504 5,680 23,300 27,120

Professional Fee 15,120 12,600 2,520 5,460 10,080 4,368 9,240 504 1,680 12,600 15,120

Health Care Institution Fee 12,000 10,700 5,500 5,500 10,900 5,500 12,700 3,000 4,000 10,700 12,000

22101

27,120

15,120

12,000

22102

27,120

15,120

12,000

22110

46,500

25,200

21,300

22112

30,300

16,800

13,500

22114 22210 22212 22214 22220 22222 22224 22305 22310 22325

30,300 46,500 46,500 46,500 53,400 53,400 53,400 23,300 30,740 38,860

16,800 25,200 25,200 25,200 29,400 29,400 29,400 12,600 13,440 20,160

13,500 21,300 21,300 21,300 24,000 24,000 24,000 10,700 17,300 18,700

22326

38,640

21,840

16,800

22327 22548 22554

37,800 40,320 53,400

21,000 23,520 29,400

16,800 16,800 24,000

22556

46,500

25,200

21,300

22558 22590 22595 22600 22610

46,500 53,400 53,400 53,400 30,300

25,200 29,400 29,400 29,400 16,800

21,300 24,000 24,000 24,000 13,500

22612 22630

30,300 40,320

16,800 23,520

13,500 16,800

Page 11 of 98

ANNEX 2. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE
22800 22802 22804 22808 22810 22812 22840 22841 22842

DESCRIPTION
Arthrodesis, posterior, for spinal deformity, w/ or w/o cast; up to 6 vertebral segments Arthrodesis, posterior, for spinal deformity, w/ or w/o cast; 7 to 12 vertebral segments Arthrodesis, posterior, for spinal deformity, w/ or w/o cast; 13 or more vertebral segments Arthrodesis, anterior, for spinal deformity, w/ or w/o cast; 2 to 3 vertebral segments Arthrodesis, anterior, for spinal deformity, w/ or w/o cast; 4 to 7 vertebral segments Arthrodesis, anterior, for spinal deformity, w/ or w/o cast; 8 or more vertebral segments Posterior non-segmental instrumentation (e.g., single Harrington rod technique) Internal spinal fixation by wiring of spinous processes Posterior segmental instrumentation (e.g., pedicle fixation, dual rods w/ multiple hooks and sublaminal wires); 3 to 6 vertebral segments Posterior segmental instrumentation (e.g., pedicle fixation, dual rods w/ multiple hooks and sublaminal wires); 7 to 12 vertebral segments Posterior segmental instrumentation (e.g., pedicle fixation, dual rods w/ multiple hooks and sublaminal wires); 13 or more vertebral segments Anterior instrumentation; 2 to 3 vertebral segments Anterior instrumentation; 4 to 7 vertebral segments Anterior instrumentation; 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.g., Harrington rod) Application of prosthetic device (e.g., metal cages, methylmethacrylate) to vertebral defect or interspace Removal of posterior segmental instrumentation Removal of anterior instrumentation Excision, abdominal wall tumor, subfascial (e.g., desmoid) Removal of subdeltoid (or intratendinous) calcareous deposits, open method Capsular contracture release (Sever type procedure) Incision and drainage, shoulder area; deep abscess or hematoma Incision and drainage, shoulder area; infected bursa Incision, deep, w/ opening of cortex (e.g., for osteomyelitis or bone abscess), shoulder area Arthrotomy, glenohumeral joint, for infection, w/ exploration, drainage, or removal of foreign body Arthrotomy, acromioclavicular, sternoclavicular joint, for infection, w/ exploration, drainage, or removal of foreign body Biopsy, soft tissue of shoulder area Excision, tumor, shoulder area; subcutaneous Excision, tumor, shoulder area; deep, subfascial, or intramuscular Radical resection of tumor (e.g., malignant neoplasm), soft tissue of shoulder area Arthrotomy w/ biopsy, glenohumeral joint Arthrotomy w/ biopsy, or w/ excision of torn cartilage, acromioclavicular, sternoclavicular joint Arthrotomy w/ synovectomy; glenohumeral joint Arthrotomy w/ synovectomy; sternoclavicular joint Arthrotomy, glenohumeral joint, w/ joint exploration, w/ or w/o removal of loose or foreign body Claviculectomy; partial Claviculectomy; total Acromioplasty or acromionectomy, partial Excision or curettage of bone cyst or benign tumor of clavicle or scapula; Excision or curettage of bone cyst or benign tumor of clavicle or scapula; w/ autograft (includes obtaining graft) Excision or curettage of bone cyst or benign tumor of clavicle or scapula; w/ allograft Excision or curettage of bone cyst or benign tumor of proximal humerus; Excision or curettage of bone cyst or benign tumor of proximal humerus; w/ autograft (includes obtaining graft) Excision or curettage of bone cyst or benign tumor of proximal humerus; w/ allograft Sequestrectomy (e.g., for osteomyelitis or bone abscess), clavicle Sequestrectomy (e.g., for osteomyelitis or bone abscess), scapula

Case Rate 58,800 63,000 67,200 55,000 58,800 67,200 55,000 53,400 54,660

Professional Fee 37,800 42,000 46,200 33,600 37,800 46,200 33,600 29,400 30,660

Health Care Institution Fee 21,000 21,000 21,000 21,400 21,000 21,000 21,400 24,000 24,000

22843

58,800

37,800

21,000

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

67,200 55,000 58,800 67,200 55,000 53,400 21,940 58,800 27,120 30,300 23,300 20,980 27,120 18,000 14,960 20,980 23,300 20,980 3,504 5,680 8,020 37,800 23,300 27,120 27,120 21,820 30,740 23,300 27,960 27,540 20,980 22,240 22,240 30,740 31,580 31,580 20,980 21,820

46,200 33,600 37,800 46,200 33,600 29,400 9,240 37,800 15,120 16,800 12,600 10,080 15,120 8,400 7,560 10,080 12,600 10,080 504 1,680 2,520 21,000 12,600 15,120 15,120 10,920 13,440 12,600 15,960 15,540 10,080 11,340 11,340 13,440 14,280 14,280 10,080 10,920

21,000 21,400 21,000 21,000 21,400 24,000 12,700 21,000 12,000 13,500 10,700 10,900 12,000 9,600 7,400 10,900 10,700 10,900 3,000 4,000 5,500 16,800 10,700 12,000 12,000 10,900 17,300 10,700 12,000 12,000 10,900 10,900 10,900 17,300 17,300 17,300 10,900 10,900

Page 12 of 98

ANNEX 2. 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., for osteomyelitis or bone abscess), humeral head to surgical neck Partial excision (craterization, saucerization,or diaphysectomy) of bone (e.g., for osteomyelitis), clavicle Partial excision (craterization, saucerization,or diaphysectomy) of bone (e.g., for osteomyelitis), scapula Partial excision (craterization, suacerization, or diaphysectomy) of bone (e.g., for osteomyelitis), proximal humerus Ostectomy of scapula, partial (e.g., superior medial angle) Resection humeral head Radical resection for tumor; clavicle Radical resection for tumor; scapula Radical resection for tumor; proximal humerus; Radical resection for tumor; proximal humerus; w/ autograft (includes obtaining graft) Radical resection for tumor; proximal humerus; w/ prosthetic replacement Removal of foreign body, shoulder; subcutaneous Removal of foreign body, shoulder; deep (e.g., Neer prosthesis removal) Removal of foreign body, shoulder; complicated , including "total shoulder" Muscle transfer, any type, shoulder or upper arm; single Muscle transfer, any type, shoulder or upper arm; multiple Scapulopexy (e.g., Sprengels deformity or for paralysis) Tenomyotomy, shoulder area; single Tenomyotomy, shoulder area; multiple through same incision Repair of ruptured musculotendinous cuff (e.g., rotator cuff); acute Repair of ruptured musculotendinous cuff (e.g., rotator cuff); chronic Coracoacromial ligament release, w/ or w/o acromioplasty Repair of complete shoulder (rotator) cuff avulsion, chronic (includes acromioplasty) Tenodesis of long tendon of biceps Resection or transplantation of long tendon of biceps Capsulorrhaphy, anterior; Putti-Platt procedure or Magnuson type operation Capsulorrhaphy, anterior; Bankart type operation w/ or w/o stapling Capsulorrhaphy, anterior, any type; w/ bone block Capsulorrhaphy, anterior, any type; w/ coracoid process transfer Capsulorrhaphy for recurrent dislocation, posterior, w/ or w/o bone block Capsulorrhaphy w/ any type multi-directional instability Arthroplasty w/ proximal humeral implant (e.g., Neer type operation) Arthroplasty w/ glenoid and proximal humeral replacement (e.g. total shoulder) Osteotomy, clavicle, w/ or w/o internal fixation; Osteotomy, clavicle, w/ or w/o internal fixation; w/ bone graft for nonunion or malunion (includes obtaining graft and/or necessary fixation) Prophylactic treatment (nailing, pinning, plating or wiring) w/ or w/o methylmethacrylate; clavicle Prophylactic treatment (nailing, pinning, plating or wiring) w/ or w/o methylmethacrylate; proximal humerus and humeral head Closed treatment of clavicular fracture Open treatment of clavicular fracture, w/ or w/o internal or external fixation Closed treatment of sternoclavicular dislocation Open treatment of sternoclavicular disloction, acute or chronic; Open treatment of sternoclavicular disloction, w/ fascial graft (includes obtaining graft) Closed treatment of acromioclavicular dislocation Open treatment of acromioclavicular dislocation, acute or chronic; Open treatment of acromioclavicular dislocation, acute or chronic; w/ fascial graft (includes obtaining graft) Closed treatment of scapular fracture Open treatment of scapular fracture (body, 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, w/ or w/o internal or external fixation, w/ or w/o repair of tuberosity(-ies); Open treatment of proximal humeral (surgical or anatomical neck) fracture, w/ or w/o internal or external fixation, w/ or w/o repair of tuberosity(-ies); w/ proximal humeral prosthetic replacement Closed treatment of greater tuberosity fracture

Case Rate 23,300 21,400 21,652 21,820 21,820 27,120 27,120 27,540 37,180 40,320 53,400 5,560 12,900 14,960 22,240 23,300 27,120 21,940 23,080 20,980 22,240 21,148 23,300 21,940 20,980 37,800 38,860 38,860 37,180 37,800 40,320 48,180 53,400 27,120 28,380 27,120 27,120 8,020 12,456 10,880 20,980 27,120 8,020 21,940 20,980 8,020 20,980 10,540 23,300

Professional Fee 12,600 10,500 10,752 10,920 10,920 15,120 15,120 15,540 18,480 23,520 29,400 1,260 6,300 7,560 11,340 12,600 15,120 9,240 12,180 10,080 11,340 10,248 12,600 9,240 10,080 21,000 20,160 20,160 18,480 21,000 23,520 26,880 29,400 15,120 16,380 15,120 15,120 2,520 7,056 3,780 10,080 15,120 2,520 9,240 10,080 2,520 10,080 5,040 12,600

Health Care Institution Fee 10,700 10,900 10,900 10,900 10,900 12,000 12,000 12,000 18,700 16,800 24,000 4,300 6,600 7,400 10,900 10,700 12,000 12,700 10,900 10,900 10,900 10,900 10,700 12,700 10,900 16,800 18,700 18,700 18,700 16,800 16,800 21,300 24,000 12,000 12,000 12,000 12,000 5,500 5,400 7,100 10,900 12,000 5,500 12,700 10,900 5,500 10,900 5,500 10,700

23616 23620

47,340 9,700

26,040 4,200

21,300 5,500

Page 13 of 98

ANNEX 2. 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, w/ or w/o internal or external fixation Closed treatment of shoulder dislocation Thoracoscopy, surgical; w/ wedge resection of lung, single or mutiple Open treatment of acute shoulder dislocation Closed treatment of shoulder dislocation,/ fracture of greater tuberosity Open treatment of shoulder dislocation, w/ fracture of greater tuberosity, w/ or w/o internal or external fixation Closed treatment of shoulder dislocation, w/ surgical or anatomical neck fracture Open treatment of shoulder dislocation, w/ surgical or anatomical neck fracture, w/ or w/o internal or external fixation Manipulation under anesthesia, shoulder joint, including application of fixation apparatus (dislocation excluded) Arthrodesis, shoulder joint; w/ or w/o local bone graft Arthrodesis, shoulder joint; w/ primary autogenous graft (includes obtaining graft) Interthoracoscapular amputation (forequarter) Disarticulation of shoulder; Incision and drainage, upper arm or elbow area; deep abscess or hematoma Incision and drainage, upper arm or elbow area; infected bursa Incision, deep, w/ opening of bone cortex (e.g., for osteomyelitis of bone abscess), humerus or elbow Arthrotomy, elbow, for infection, w/ exploration, drainage or removal of foreign body Arthrotomy of the elbow, w/ capsular excision for capsular release Biopsy, soft tissue of upper arm or elbow area Excision, tumor, upper arm or elbow area; subcutaneous Excision, tumor, upper arm or elbow area; deep, subfascial or intramuscular Radical resection of tumor (e.g., malignant neoplasm), soft tissue of upper arm or elbow area Arthrotomy, elbow; w/ synovial biopsy only Arthrotomy, elbow; w/ joint exploration, w/ or w/o biopsy, w/ or w/o removal of loose or foreign body Arthrotomy, elbow; w/ synovectomy Excision, olecranon bursa Excision or curettage of bone cyst or benign tumor, humerus; Excision or curettage of bone cyst or benign tumor, humerus; w/ autograft (includes obtaining graft) Excision or curettage of bone cyst or benign tumor, humerus; w/ allograft Excision or curettage of bone cyst or benign tumor of head or neck of radius or olecranon process; Excision or curettage of bone cyst or benign tumor of head or neck of radius or olecranon process; w/ autograft (includes obtaining graft) Excision or curettage of bone cyst or benign tumor of head or neck of radius or olecranon process; w/ allograft Excision, radial head Sequestrectomy (e.g., for osteomyelitis or bone abscess), shaft or distal humerus Sequestrectomy (e.g., for osteomyelitis or bone abscess), radial head or neck Sequestrectomy (e.g., for osteomyelitis or bone abscess), olecranon process Partial excision (craterization, saucerization, or diaphysectomy) of bone (e.g., for osteomyelitis), humerus Partial excision (craterization, saucerization, or diaphysectomy) of bone (e.g., for osteomyelitis), radial head or neck Partial excision (craterization, saucerization, or diaphysectomy) of bone (e.g., for osteomyelitis), olecranon process Radical resection of capsule, soft tissue, and heterotopic bone, elbow, w/ contracture release Radical resection for tumor, shaft or distal humerus; Radical resection for tumor, shaft or distal humerus; w/ autograft (includes obtaining graft) Radical resection for tumor, radial head or neck; Radical resection for tumor, radial head or neck; w/ autograft (includes obtaining graft) Resection of elbow joint (arthrectomy) Implant removal; elbow joint Implant removal; radial head Removal of foreign body, upper arm or elbow area Muscle or tendon transfer, any type, upper arm or elbow, single

Case Rate 23,300 10,540 41,160 27,120 11,980 27,120 12,120 27,120 9,700 12,456 37,180 30,300 27,120 4,108 5,560 21,940 22,360 20,980 3,504 5,680 8,020 23,300 20,980 21,820 23,300 8,260 20,980 23,080 23,080 21,148 21,820 21,820 20,980 20,980 20,980 20,980 20,980 20,980 20,980 21,400 23,080 30,300 23,300 27,120 27,120 21,940 22,360 8,272 23,300

Professional Fee 12,600 5,040 24,360 15,120 5,880 15,120 6,720 15,120 4,200 7,056 18,480 16,800 15,120 1,008 1,260 9,240 9,660 10,080 504 1,680 2,520 12,600 10,080 10,920 12,600 3,360 10,080 12,180 12,180 10,248 10,920 10,920 10,080 10,080 10,080 10,080 10,080 10,080 10,080 10,500 12,180 16,800 12,600 15,120 15,120 9,240 9,660 2,772 12,600

Health Care Institution Fee 10,700 5,500 16,800 12,000 6,100 12,000 5,400 12,000 5,500 5,400 18,700 13,500 12,000 3,100 4,300 12,700 12,700 10,900 3,000 4,000 5,500 10,700 10,900 10,900 10,700 4,900 10,900 10,900 10,900 10,900 10,900 10,900 10,900 10,900 10,900 10,900 10,900 10,900 10,900 10,900 10,900 13,500 10,700 12,000 12,000 12,700 12,700 5,500 10,700

Page 14 of 98

ANNEX 2. 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, upper arm or elbow, single, each Tenotomy, open, elbow to shoulder, single, each Tenoplasty, w/ muscle transfer, w/ or w/o free graft, elbow to shoulder, single (Seddon-Brookes type procedure) Flexor-plasty, elbow (e.g., Steindler type advancement); Flexor-plasty, elbow (e.g., Steindler type advancement); w/ extensor advancement Tenodesis of biceps tendon at elbow Repair, tendon or muscle, upper arm or elbow, each tendon or muscle, primary or secondary (excludes rotator cuff) Reinsertion of ruptured biceps or triceps tendon, distal, w/ or w/o tendon graft Fasciotomy, lateral or medial (e.g., "tennis elbow" or epicondylitis); Fasciotomy, lateral or medial (e.g., "tennis elbow" or epicondylitis); w/ extensor origin detachment Fasciotomy, lateral or medial (e.g., "tennis elbow" or epicondylitis); w/ annular ligament resection Fasciotomy, lateral or medial (e.g., "tennis elbow" or epicondylitis); w/ stripping Fasciotomy, lateral or medial (e.g., "tennis elbow" or epicondylitis); w/ partial ostectomy Arthroplasty, elbow; w/ membrane; Arthroplasty, elbow; w/ membrane; w/ distal humeral prosthetic replacement Arthroplasty, elbow; w/ membrane; w/ implant and fascia lata ligament reconstruction Arthroplasty, elbow; w/ membrane; w/ distal humerus and proximal ulnar prosthetic replacement ("total elbow") Arthroplasty, radial head; Arthroplasty, radial head; w/ implant Osteotomy, humerus, w/ or w/o internal fixation Multiple osteotomies w/ realignment on intramedullary rod, humeral shaft (Sofield type procedure) Osteoplasty, humerus (e.g., shortening or lengthening) Repair of non-union or malunion, humerus; w/o graft (e.g., compression technique); Repair of non-union or malunion, humerus; w/o graft (e.g., compression technique); w/ iliac or other autograft (includes obtaining graft) Hemiepiphyseal arrest (e.g., for cubitus varus or valgus, distal humerus) Decompression fasciotomy, forearm, w/ brachial artery exploration Prophylactic treatment (nailing, pinning, plating or wiring), w/ or w/o methylmethacrylate, humerus Closed treatment of humeral shaft fracture Open treatment of humeral shaft fracture w/ plate/screws, w/ or w/o cerclage Open treatment of humeral shaft fracture, w/ insertion of intramedullary implant, w/ or w/o cerclage and/or locking screws Closed treatment of supracondylar or transcondylar humeral fracture, w/ or w/o intercondylar extension Percutaneous skeletal fixation of supracondylar or transcondylar humeral fracture, w/ or w/o intercondylar extension Open treatment of humeral supracondylar or transcondylar fracture, w/ or w/o internal or external fixation; w/o intercondylar extension Open treatment of humeral supracondylar or transcondylar fracture, w/ or w/o internal or external fixation; w/ intercondylar extension Closed treatment of humeral epicondylar fracture, medial or lateral; Percutaneous skeletal fixation of humeral epicondylar fracture, medial or lateral, w/ manipulation Open treatment of humeral epicondylar fracture, medial or lateral, w/ or w/o internal or external fixation Closed treatment of humeral condylar fracture, medial or lateral Open treatment of humeral condylar fracture, medial or lateral, w/ or w/o internal or external fixation Percutaneous skeletal fixation of humeral condylar fracture, medial or lateral, w/ manipulation Open treatment of periarticular fracture and/or dislocation of the elbow (fracture distal humerus and proximal ulna and/or proximal radius); Open treatment of periarticular fracture and/or dislocation of the elbow (fracture distal humerus and proximal ulna and/or proximal radius); w/ implant arthroplasty Treatment of closed elbow dislocation Open treatment of acute or chronic elbow dislocation

Case Rate 20,980 21,940 27,120 30,740 27,120 8,260 20,980 12,120 10,540 12,120 12,120 12,120 12,120 27,120 37,180 27,120 38,640 21,940 27,120 20,980 20,980 23,300 23,080 27,120 22,360 27,120 20,980 10,120 30,740 30,740 10,120 27,120 12,456

Professional Fee 10,080 9,240 15,120 13,440 15,120 3,360 10,080 6,720 5,040 6,720 6,720 6,720 6,720 15,120 18,480 15,120 21,840 9,240 15,120 10,080 10,080 12,600 12,180 15,120 9,660 15,120 10,080 4,620 13,440 13,440 4,620 15,120 7,056

Health Care Institution Fee 10,900 12,700 12,000 17,300 12,000 4,900 10,900 5,400 5,500 5,400 5,400 5,400 5,400 12,000 18,700 12,000 16,800 12,700 12,000 10,900 10,900 10,700 10,900 12,000 12,700 12,000 10,900 5,500 17,300 17,300 5,500 12,000 5,400

24546 24560 24566 24575 24576 24579 24582 24586

32,000 10,880 27,120 18,000 10,880 18,000 27,120 22,660

14,700 3,780 15,120 8,400 3,780 8,400 15,120 11,760

17,300 7,100 12,000 9,600 7,100 9,600 12,000 10,900

24587 24600 24615

37,800 10,540 23,300

21,000 5,040 12,600

16,800 5,500 10,700

Page 15 of 98

ANNEX 2. 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), w/ or w/o internal or external fixation Closed treatment of radial head subluxation in child, "nursemaid elbow" Closed treatment of radial head or neck fracture Open treatment of radial head or neck fracture, w/ or w/o internal fixation or radial head excision; Open treatment of periarticular fracture and/or dislocation of the elbow (fracture distal humerus and proximal ulna and/or proximal radius); w/ radial head prosthetic replacement Closed treatment of ulnar fracture, proximal end (olecranon process) Open treatment of ulnar fracture proximal end (olecranon process), w/ or w/o internal or external fixation Arthrodesis, elbow joint; w/ or w/o local autograft or allograft Arthrodesis, elbow joint; w/ autograft (includes obtaining graft other than locally obtained) Amputation, arm through humerus; w/ primary closure Amputation, arm through humerus; open, circular (guillotine) Amputation, arm through humerus; secondary closure or scar revision Amputation, arm through humerus; re-amputation Amputation, arm through humerus; w/ implant Stump elongation, upper extremity Cineplasty, upper extremity, complete procedure Tendon sheath incision; at radial styloid (e.g., for deQuervains disease) Decompression fasciotomy, forearm and/or wrist; flexor or extensor compartment Decompression fasciotomy, forearm and/or wrist; w/ debridement of nonviable muscle and/or nerve Incision and drainage, forearm and/or wrist; deep abscess or hematoma Incision and drainage, forearm and/or wrist; infected bursa Incision, deep, w/ opening of bone cortex (e.g., for osteomyelitis or bone abscess), forearm and/or wrist Arthrotomy, radiocarpal or midcarpal joint, w/ exploration, drainage, or removal of foreign body Biopsy, soft tissue of forearm and/or wrist Excision, tumor, forearm and/or wrist area; subcutaneous Excision, tumor, forearm and/or wrist area; deep, subfascial or intramuscular Radical resection of tumor (e.g., malignant neoplasm), soft tissue of forearm and/or wrist area Capsulotomy, wrist (e.g., for contracture) Arthrotomy, wrist joint; w/ biopsy Arthrotomy, wrist joint; w/ joint exploration, w/ or w/o biopsy, w/ or w/o removal of loose or foreign body Arthrotomy, wrist joint; w/ synovectomy Arthrotomy, distal radioulnar joint for repair of triangle cartilage complex Excision, lesion of tendon sheath, forearm and/or wrist Excision of ganglion, wrist (dorsal or volar) Radical excision of bursa, synovia of wrist, or forearm tendon sheaths (e.g., tenosynovitis, fungus, Tbc, or other granulomas, rheumatoid arthritis); flexors Radical excision of bursa, synovia of wrist, or forearm tendon sheaths (e.g., tenosynovitis, fungus, Tbc, or other granulomas, rheumatoid arthritis); extensors, w/ or w/o transposition of dorsal retinaculum Synovectomy, extensor tendon sheath, wrist, single compartment; Synovectomy, extensor tendon sheath, wrist, single compartment; 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); Excision or curettage of bone cyst or benign tumor of radius or ulna (excluding head or neck of radius and olecranon process); 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); w/ allograft Excision or curettage of bone cyst or benign tumor of carpal bones; Excision or curettage of bone cyst or benign tumor of carpal bones; w/ autograft (includes obtaining graft)

Case Rate 10,880 21,940 5,680 10,880 20,980 27,120 10,880 21,940 27,120 28,380 18,000 12,120 10,960 14,960 14,960 12,120 27,120 10,540 18,000 14,960 10,880 10,120 12,120 10,120 3,504 5,680 8,020 23,300 15,380 11,044 12,540 20,980 20,980 8,020 8,260 21,820

Professional Fee 3,780 9,240 1,680 3,780 10,080 15,120 3,780 9,240 15,120 16,380 8,400 6,720 5,460 7,560 7,560 6,720 15,120 5,040 8,400 7,560 3,780 4,620 6,720 4,620 504 1,680 2,520 12,600 7,980 5,544 7,140 10,080 10,080 2,520 3,360 10,920

Health Care Institution Fee 7,100 12,700 4,000 7,100 10,900 12,000 7,100 12,700 12,000 12,000 9,600 5,400 5,500 7,400 7,400 5,400 12,000 5,500 9,600 7,400 7,100 5,500 5,400 5,500 3,000 4,000 5,500 10,700 7,400 5,500 5,400 10,900 10,900 5,500 4,900 10,900

25116 25118 25119 25120 25125

18,420 9,952 21,940 20,980 21,820

8,820 4,452 9,240 10,080 10,920

9,600 5,500 12,700 10,900 10,900

25126 25130 25135

21,820 9,952 12,900

10,920 4,452 6,300

10,900 5,500 6,600

Page 16 of 98

ANNEX 2. 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; w/ allograft Sequestrectomy (e.g., for osteomyelitis or bone abscess), forearm and/or wrist Partial excision (craterization, saucerization, or diaphysectomy) of bone (e.g., for osteomyelitis); ulna Partial excision (craterization, saucerization, or diaphysectomy) of bone (e.g., for osteomyelitis); radius Radical resection for tumor, radius or ulna Carpectomy; one bone Carpectomy; all bones of proximal row Radial styloidectomy Excision distal ulna partial or complete (e.g., Darrach type or matched resection) Exploration w/ removal of deep foreign body, forearm or wrist Removal of wrist prosthesis; Removal of wrist prosthesis; complicated, including "total wrist" Repair, tendon or muscle, flexor, forearm and/or wrist; primary, single, each tendon or muscle Repair, tendon or muscle, flexor, forearm and/or wrist; secondary, single, each tendon or muscle Repair, tendon or muscle, flexor, forearm and/or wrist; secondary, w/ free graft (includes obtaining graft), each tendon or muscle Repair, tendon or muslce, extensor, forearm and/or wrist; primary, single, each tendon or muscle Repair, tendon or muslce, extensor, forearm and/or wrist; secondary, single, each tendon or muscle Repair, tendon or muscle, extensor, secondary, w/ tendon graft (includes obtaining graft), forearm and/or wrist, each tendon or muscle Lengthening or shortening of flexor or extensor tendon, forearm and/or wrist, single, each tendon Tenotomy, open, flexor or extensor tendon, forearm and/or wrist, single, each tendon Tenolysis, flexor or extensor tendon, forearm and/or wrist, single each tendon Tenodesis at wrist; flexors of fingers Tenodesis at wrist; extensors of fingers Tendon transplantation or transfer, flexor or extensor, forearm and/or wrist, single; each tendon Tendon transplantation or transfer, flexor or extensor, forearm and/or wrist, single; w/ tendon graft(s) (includes obtaining graft), each tendon Flexor origin slide (e.g., for cerebral palsy, Volkmann contracture), forearm and/or wrist; Flexor origin slide (e.g., for cerebral palsy, Volkmann contracture), forearm and/or wrist; w/ tendon(s) transfer Capsulorrhaphy or reconstruction, wrist, any method (e.g., capsulodesis, ligament repair, tendon transfer or graft) (includes synovectomy, capsulotomy and open reduction) for carpal instability Arthroplasty, wrist, w/ or w/o interposition, w/ or w/o external or internal fixation Centralization of wrist on ulna (e.g., radial club hand) Reconstruction for stabilization of unstable distal ulna or distal radioulnar joint, secondary by soft tissue stabilization (e.g., tendon transfer, tendon graft or weave, or tenodesis) w/ or w/o open reduction of distal radioulnar joint Osteotomy, radius; distal third Osteotomy, radius; middle or proximal third Osteotomy; ulna Osteotomy; radius and ulna Multiple osteotomies, w/ realignment on intramedullary rod (Sofield type procedure); radius or ulna Multiple osteotomies, w/ realignment on intramedullary rod (Sofield type procedure); radius and ulna Osteoplasty, radius or ulna; shortening Osteoplasty, radius or ulna; lengthening w/ autograft Osteoplasty, radius and ulna; shortening Osteoplasty, radius and ulna; lengthening w/ autograft Repair of nonunion or malunion, radius or ulna; w/o graft (compression technique) Repair of nonunion or malunion, radius or ulna; w/ iliac or other autograft (includes obtaining graft) Repair of nonunion or malunion, radius and ulna; w/o graft (e.g. compression technique)

Case Rate 12,900 21,940 21,940 21,940 27,120 5,932 22,360 10,540 10,540 8,260 21,940 30,740 10,540 8,260 10,120 10,540 8,260 10,540 10,880 10,880 8,260 10,960 10,540 20,980 21,820 30,300 37,180

Professional Fee 6,300 9,240 9,240 9,240 15,120 1,932 9,660 5,040 5,040 3,360 9,240 13,440 5,040 3,360 4,620 5,040 3,360 5,040 3,780 3,780 3,360 5,460 5,040 10,080 10,920 16,800 18,480

Health Care Institution Fee 6,600 12,700 12,700 12,700 12,000 4,000 12,700 5,500 5,500 4,900 12,700 17,300 5,500 4,900 5,500 5,500 4,900 5,500 7,100 7,100 4,900 5,500 5,500 10,900 10,900 13,500 18,700

25320

27,120

15,120

12,000

25332 25335 25337 25350 25355 25360 25365 25370 25375 25390 25391 25392 25393 25400 25405 25415

30,300 31,140 27,960 18,000 21,940 18,420 23,300 30,740 27,960 27,120 27,960 27,120 27,960 20,980 23,300 30,740

16,800 17,640 15,960 8,400 9,240 8,820 12,600 13,440 15,960 15,120 15,960 15,120 15,960 10,080 12,600 13,440

13,500 13,500 12,000 9,600 12,700 9,600 10,700 17,300 12,000 12,000 12,000 12,000 12,000 10,900 10,700 17,300

Page 17 of 98

ANNEX 2. 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, radius and ulna; w/ iliac or other autograft (includes obtaining graft) Repair of defect w/ autograft; radius or ulna Repair of defect w/ autograft; radius and ulna Repair of nonunion, scaphoid (navicular) bone, w/ or w/o radial styloidectomy (includes obtaining graft and necessary fixation) Arthroplasty w/ prosthetic replacement; distal radius Arthroplasty w/ prosthetic replacement; distal ulna Arthroplasty w/ prosthetic replacement; scaphoid (navicular) Arthroplasty w/ prosthetic replacement; lunate Arthroplasty w/ prosthetic replacement; trapezium Arthroplasty w/ prosthetic replacement; distal radius and partial or entire carpus ("total wrist") Arthroplasty w/ prosthetic replacement; Interposition arthroplasty, intercarpal or carpometacarpal joints Revision of arthroplasty, including removal of implant, wrist joint Epiphyseal arrest by epiphysiodesis or stapling; distal radius or ulna Epiphyseal arrest by epiphysiodesis or stapling; distal radius and ulna Prophylactic treatment (nailing, pinning, plating or wiring) w/ or w/o methylmethacrylate; radius Prophylactic treatment (nailing, pinning, plating or wiring) w/ or w/o methylmethacrylate; ulna Prophylactic treatment (nailing, pinning, plating or wiring) w/ or w/o methylmethacrylate; radius and ulna Closed treatment of radial shaft fracture Open treatment of radial shaft fracture, w/ or w/o internal or external fixation Closed treatment of radial shaft fracture, w/ dislocation of distal radio-ulnar joint (Galeazzi fracture/dislocation) Open treatment of radial shaft fracture, w/ internal and/or external fixation and closed treatment of dislocation of distal radio-ulnar joint (Galeazzi fracture/dislocation), w/ or w/o percutaneous skeletal fixation Open treatment of radial shaft fracture, w/ internal and/or external fixation and open treatment, w/ or w/o internal or external fixation of distal radioulnar joint (Galleazi fracture/dislocation), includes repair of triangular cartilage Closed treatment of ulnar shaft fracture Open treatment of ulnar shaft fracture, w/ or w/o internal or external fixation Closed treatment of radial and ulnar shaft fractures Open treatment of radial and ulnar shaft fractures, w/ internal or external fixation; of radius or ulna Open treatment of radial and ulnar shaft fractures, w/ internal or external fixation; of radius and ulna Closed treatment of distal radial fracture (e.g., Colles or Smith type) or epiphyseal separation, w/ or w/o fracture of ulnar styloid Percutaneous skeletal fixation of distal radial fracture (e.g., Colles or Smith type) or epiphyseal separation, w/ or w/o fracture of ulnar styloid , requiring manipulation, w/ or w/o external fixation Open treatment of distal radial fracture (e.g., Colles or Smith type) or epiphyseal separation, w/ or w/o fracture of ulnar styloid, w/ or w/o internal or external fixation Closed treatment of carpal scaphoid (navicular) fracture Open treatment of carpal scaphoid (navicular) fracture, 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)), each bone Closed treatment of ulnar styloid fracture Closed treatment of radiocarpal or intercarpal dislocation, one or more bones Open treatment of radiocarpal or intercarpal dislocation, one or more bones Closed treatment of distal radioulnar dislocation Open treatment of distal radioulnar dislocation, 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, wrist joint (including radiocarpal and/or ulnocarpal fusion); w/o bone graft

Case Rate 27,960 21,940 30,740 23,720 30,300 27,120 27,120 27,120 31,580 37,800 27,960 40,320 20,980 30,740 21,940 21,940 37,180 9,700 21,940 9,700

Professional Fee 15,960 9,240 13,440 13,020 16,800 15,120 15,120 15,120 14,280 21,000 15,960 23,520 10,080 13,440 9,240 9,240 18,480 4,200 9,240 4,200

Health Care Institution Fee 12,000 12,700 17,300 10,700 13,500 12,000 12,000 12,000 17,300 16,800 12,000 16,800 10,900 17,300 12,700 12,700 18,700 5,500 12,700 5,500

25525

20,980

10,080

10,900

25526 25530 25545 25560 25574 25575 25600 25611

22,660 8,260 18,000 9,700 27,960 27,120 8,260 23,300

11,760 3,360 8,400 4,200 15,960 15,120 3,360 12,600

10,900 4,900 9,600 5,500 12,000 12,000 4,900 10,700

25620 25622 25628 25630 25645 25650 25660 25670 25675 25676 25680 25685 25690 25695 25800

23,300 8,260 21,820 8,260 21,904 8,440 8,260 18,000 8,260 21,820 8,260 20,980 8,260 21,940 18,000

12,600 3,360 10,920 3,360 11,004 2,940 3,360 8,400 3,360 10,920 3,360 10,080 3,360 9,240 8,400

10,700 4,900 10,900 4,900 10,900 5,500 4,900 9,600 4,900 10,900 4,900 10,900 4,900 12,700 9,600

Page 18 of 98

ANNEX 2. 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, wrist joint (including radiocarpal and/or ulnocarpal fusion); w/ sliding graft Arthrodesis, wrist joint (including radiocarpal and/or ulnocarpal fusion); w/ iliac or other autograft (includes obtaining graft) Intercarpal fusion; w/o bone graft Intercarpal fusion; w/ autograft (includes obtaining graft) Distal radioulnar joint arthrodesis and segmental resection of ulna (e.g. Sauve-Kapandji procedure), w/ or w/o bone graft Amputation, forearm, through, radius and ulna; Amputation, forearm, through, open, circular (guillotine) Amputation, forearm, through, secondary closure or scar revision Amputation, forearm, through, re-amputation Krukenberg procedure Disarticulation through wrist; Disarticulation through wrist; secondary closure or scar revision Disarticulation through wrist; re-amputation Transmetacarpal amputation; Transmetacarpal amputation; secondary closure or scar revision Transmetacarpal amputation; re-amputation Drainage of finger abscess; simple Drainage of finger abscess; complicated (e.g., felon) Drainage of tendon sheath, one digit and/or palm Drainage of palmar bursa; single, ulnar or radial Drainage of palmar bursa; single, multiple or complicated Inicision, deep, w/ opening of bone cortex (e.g., for osteomyelitis or bone abscess), hand or finger Decompression fingers and/or hand, injection injury (e.g., grease gun) Decompressive fasciotomy, hand (excludes 26035) Fasciotomy, palmar, for Dupuytrens contracture; percutaneous Fasciotomy, palmar, for Dupuytrens contracture; open, partial Tendon sheath incision (e.g., for trigger finger) Tenotomy, percutaneous, single, each digit Arthrotomy, w/ exploration, drainage, or removal of foreign body; carpometacarpal joint Arthrotomy, w/ exploration, drainage, or removal of foreign body; metacarpophalangeal joint Arthrotomy, w/ exploration, drainage, or removal of foreign body; interphalangeal joint, each Arthrotomy w/ synovial biopsy, carpometacarpal joint Arthrotomy w/ synovial biopsy, metacarpophalangeal joint Arthrotomy w/ synovial biopsy, interphalangeal joint, each Excision, tumor or vascular malformation, hand or finger; subcutaneous Excision, tumor or vascular malformation, hand or finger; deep, subfascial, intramuscular Radical resection of tumor (e.g., malignant neoplasm), soft tissue of hand or finger Fasciectomy, palm only, w/ or w/o Z-plasty, other local tissue rearrangement, or skin grafting (includes obtaining graft) Fasciectomy, partial palmar w/ release of single digit including proximal interphalangeal joint, w/ or w/o Z-plasty, other local tissue rearrangement, or skin grafting (includes obtaining graft); Fasciectomy, partial palmar w/ release of single digit including proximal interphalangeal joint, w/ or w/o Z-plasty, other local tissue rearrangement, or skin grafting (includes obtaining graft); each additional digit (List separately in addition to code for primary procedure Synovectomy, capometacarpal joint Synovectomy, metacarpophalangeal joint including intrinsic release and extensor hood reconstruction, each digit Synovectomy, proximal interphalangeal joint, including extensor reconstruction, each interphalangeal joint Synovectomy tendon sheath, radical (tenosynovectomy), flexor, palm or finger, single, each digit Excision of lesion of tendon sheath or capsule (e.g., cyst, mucous cyst, or ganglion), hand or finger Excision of tendon, palm, flexor, single , each Excision of tendon, finger, flexor Sesamoidectomy, thumb or finger Excision or curettage of bone cyst or benign tumor of metacarpal; Excision or curettage of bone cyst or benign tumor of metacarpal; w/ autograft (includes obtaining graft) Excision or curettage of bone cyst or benign tumor of proximal, middle; or distal phalanx of finger;

Case Rate 21,820 21,820 12,900 14,960 21,820 18,000 12,120 10,960 14,960 37,800 14,960 8,440 14,960 14,960 8,440 14,960 3,504 4,108 8,020 10,880 10,540 21,940 14,960 21,940 12,120 12,120 10,540 9,700 10,880 10,880 8,260 12,120 12,900 11,980 20,980 23,300 27,120 27,120 22,660

Professional Fee 10,920 10,920 6,300 7,560 10,920 8,400 6,720 5,460 7,560 21,000 7,560 2,940 7,560 7,560 2,940 7,560 504 1,008 2,520 3,780 5,040 9,240 7,560 9,240 6,720 6,720 5,040 4,200 3,780 3,780 3,360 6,720 6,300 5,880 10,080 12,600 15,120 15,120 11,760

Health Care Institution Fee 10,900 10,900 6,600 7,400 10,900 9,600 5,400 5,500 7,400 16,800 7,400 5,500 7,400 7,400 5,500 7,400 3,000 3,100 5,500 7,100 5,500 12,700 7,400 12,700 5,400 5,400 5,500 5,500 7,100 7,100 4,900 5,400 6,600 6,100 10,900 10,700 12,000 12,000 10,900

26125

8,260

3,360

4,900

26130 26135 26140 26145 26160 26170 26180 26185 26200 26205 26210

22,660 12,984 12,984 15,380 11,980 8,440 8,260 15,380 12,624 21,940 12,120

11,760 6,384 6,384 7,980 5,880 2,940 3,360 7,980 7,224 9,240 6,720

10,900 6,600 6,600 7,400 6,100 5,500 4,900 7,400 5,400 12,700 5,400

Page 19 of 98

ANNEX 2. 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, middle; or distal phalanx of finger; w/ autograft (includes obtaining graft) Partial excision (craterization, saucerization, or diaphysectomy) of bone (e.g., for osteomyelitis); metacarpal Partial excision (craterization, saucerization, or diaphysectomy) of bone (e.g., for osteomyelitis); proximal or middle phalanx of finger Partial excision (craterization, saucerization, or diaphysectomy) of bone (e.g., for osteomyelitis); distal phalanx of finger Radical resection (ostectomy) for tumor, metacarpal; Radical resection (ostectomy) for tumor, metacarpal; w/ autograft (includes obtaining graft) Radical resection (ostectomy) for tumor, proximal or middle phalanx of finger; Radical resection (ostectomy) for tumor, proximal or middle phalanx of finger; w/ autograft (includes obtaining graft) Radical resection (ostectomy) for tumor, distal phalanx of finger Flexor tendon repair or advancement, single, not in "no mans land", primary or secondary w/o free graft, each tendon Flexor tendon repair or advancement, single, not in "no mans land", secondary w/ free graft (includes obtaining graft), each tendon Flexor tendon repair or advancement, single, in "no mans land"; primary, each tendon Flexor tendon repair or advancement, single, in "no mans land"; secondary, each tendon Flexor tendon repair or advancement, single, in "no mans land"; secondary w/ free graft (includes obtaining graft), each tendon Profundus tendon repair or advancement, w/ intact sublimis; primary Profundus tendon repair or advancement, w/ intact sublimis; secondary w/ free graft (includes obtaining graft) Profundus tendon repair or advancement, w/ intact sublimis; secondary w/o free graft Flexor tendon excision, implantation of plastic tube or rod for delayed tendon graft, hand or finger Removal of tube or rod and insertion of flexor tendon graft (includes obtaining graft), hand or finger Extensor tendon repair, dorsum of hand, single, primary or secondary; w/o free graft, each tendon Extensor tendon repair, dorsum of hand, single, primary or secondary; w/ free graft (includes obtaining graft), each tendon Extensor tendon excision, implantation of plastic tube or rod for delayed extensor tendon graft, hand or finger Removal of tube or rod and insertion of extensor tendon graft (includes obtaining graft), hand or finger Extensor tendon repair, dorsum of finger, single, primary or secondary; w/o free graft, each tendon Extensor tendon repair, dorsum of finger, single, primary or secondary; w/ free graft (includes obtaining graft), each tendon Extensor tendon repair, central slip repair, secondary (boutonniere deformity); using local tissues Extensor tendon repair, central slip repair, secondary (boutonniere deformity); w/ free graft (includes obtaining graft) Extensor tendon repair, distal insertion ("mallet finger"), closed splinting w/ or w/o percutaneous pinning Extensor tendon repair, distal insertion ("mallet finger"), open, primary or secondary repair; w/o graft Extensor tendon repair, distal insertion ("mallet finger"), open, primary or secondary repair; w/ free graft (includes obtaining graft) Extensor tendon realignment, hand Tenolysis, simple, flexor tendon; palm or finger, single, each tendon Tenolysis, simple, flexor tendon; palm and finger, each tendon Tenolysis, extensor tendon, dorsum of hand or finger; each tendon Tenolysis, complex, extensor tendon, dorsum of hand or finger, including hand and forearm Tenotomy, flexor, single, palm, open, each Tenotomy, flexor, single, finger, open, each Tenotomy, extensor, hand or finger, single, open, each Tenodesis; for proximal interphalangeal joint stabilization Tenodesis; for distal joint stabilizaton Tendon lengthening, extensor, hand or finger, single, each Tendon shortening, extensor, hand or finger, single, each Tendon lengthening, flexor, hand or finger, single, each Tendon shortening, flexor, hand or finger, single, each Tendon transfer or transplant, carpometacarpal area or dorsum of hand, single; w/o free graft, each

Case Rate 15,380 21,940 15,380 12,120 23,636 32,000 30,740 31,580 23,080 12,120 10,540 10,880 10,880 10,880 10,880 10,540 11,132 10,880 10,880 8,260 8,260 10,880 8,692 8,260 8,260 8,260 8,260 8,260 8,260 10,880 10,540 8,020 8,440 8,020 8,440 8,440 8,440 8,440 8,260 10,880 8,440 8,440 8,440 8,440 8,440

Professional Fee 7,980 9,240 7,980 6,720 12,936 14,700 13,440 14,280 12,180 6,720 5,040 3,780 3,780 3,780 3,780 5,040 4,032 3,780 3,780 3,360 3,360 3,780 3,192 3,360 3,360 3,360 3,360 3,360 3,360 3,780 5,040 2,520 2,940 2,520 2,940 2,940 2,940 2,940 3,360 3,780 2,940 2,940 2,940 2,940 2,940

Health Care Institution Fee 7,400 12,700 7,400 5,400 10,700 17,300 17,300 17,300 10,900 5,400 5,500 7,100 7,100 7,100 7,100 5,500 7,100 7,100 7,100 4,900 4,900 7,100 5,500 4,900 4,900 4,900 4,900 4,900 4,900 7,100 5,500 5,500 5,500 5,500 5,500 5,500 5,500 5,500 4,900 7,100 5,500 5,500 5,500 5,500 5,500

Page 20 of 98

ANNEX 2. 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, carpometacarpal area or dorsum of hand, single; w/ free tendon graft (includes obtaining graft), each tendon Tendon transfer or transplant, palmar, single, each tendon; w/o free tendon graft Tendon transfer or transplant, palmar, single, each tendon; w/ free tendon graft (includes obtaining graft), each tendon Opponensplasty; sublimis tendon transfer type Opponensplasty; tendon transfer w/ graft (includes obtaining graft) Opponensplasty; hypothenar muscle transfer Opponensplasty; other methods Tendon trasfer to restore intrinsic function; ring and small finger Tendon trasfer to restore intrinsic function; all four fingers Correction claw finger,other methods Tendon pulley reconstruction; w/ local tissues Tendon pulley reconstruction; w/ tendon or fascial graft (includes obtaining graft) Tendon pulley reconstruction; w/ tendon prosthesis Thenar muscle release for thumb contracture Cross intrinsic transfer Capsulodesis for M-P joint stabilization; single digit Capsulodesis for M-P joint stabilization; two digits Capsulodesis for M-P joint stabilization; three or four digits Capsulectomy or capsulotomy for contracture; metacarpophalangeal joint, single, each Capsulectomy or capsulotomy for contracture; interphalangeal joint, single, each Arthroplasty, metacarpophalangeal joint; single, each Arthroplasty, metacarpophalangeal joint; w/ prosthetic implant, single, each Arthroplasty interphalangeal joint, single, each Arthroplasty interphalangeal joint, w/ prosthetic implant, single, each Repair of collateral ligament, metacarpophalangeal or interphalangeal joint Reconstruction, collateral ligament, metacarpophalangeal joint, single, w/ tendon or fascial graft (includes obtainig graft) Reconstruction, collateral ligament, metacarpophalangeal joint, single, w/ local tissue (e.g., adductor advancement) Reconstruction, collateral ligament, interphalangeal joint, single, including graft, each joint Repair non-union, metacarpal or phalanx, (includes obtaining bone graft w/ or w/o external or internal fixation) Repair and reconstruction, finger, volar plate, interphalangeal joint Pollicization of a digit Toe-to-hand transfer w/ microvascular anastmosis; great toe "wraparound" w/ bone graft Toe-to-hand transfer w/ microvascular anastmosis; other than great toe, single Toe-to-hand transfer w/ microvascular anastmosis; other than great toe, double Positional change of other finger Free toe joint transfer w/ microvascular anastomosis Repair of syndactyly (web finger) each web space; w/ skin flaps Repair of syndactyly (web finger) each web space; w/ skin flaps and grafts Repair of syndactyly (web finger) each web space; complex (e.g., involving bone, nails) Osteotomy for correction of deformity; metacarpal Osteotomy for correction of deformity; phalanx of finger Osteoplasty for lengthening of metacarpal or phalanx Repair cleft hand Repair bifid digit Reconstruction of supernumerary digit, soft tissue and bone Repair macrodactylia Repair, intrinsic muscles of hand (specify) Release, intrinsic muscles of hand (specify) Excision of constricting ring of finger, w/ multiple Z-plasties Release of scar contracture, flexor or extensor, w/ skin grafts, rearrangement flaps, or Z-plasties, hand and/or finger Closed treatment of metacarpal fracture, single Closed treatment of metacarpal fracture, w/ internal or external fixation Percutaneous skeletal fixation of metacarpal fracture, each bone Open treatment of metacarpal fracture, single, w/ or w/o internal or external fixation, each bone Closed treatment of carpometacarpal dislocation, thumb

Case Rate 10,880 8,260 8,260 10,540 10,960 10,540 10,540 8,428 18,000 21,940 10,880 10,120 12,900 8,428 10,960 10,540 12,120 18,000 10,880 5,628 4,788 8,020 18,000 20,980 8,428 8,428 8,428 10,880 10,540 8,428 20,980 30,300 30,740 27,120 14,960 27,120 18,000 20,980 30,740 23,300 23,300 23,300 20,980 20,980 23,300 30,740 30,740 20,980 21,820 21,820 10,120 12,900 12,120 12,120 10,540

Professional Fee 3,780 3,360 3,360 5,040 5,460 5,040 5,040 3,528 8,400 9,240 3,780 4,620 6,300 3,528 5,460 5,040 6,720 8,400 3,780 3,752 3,192 2,520 8,400 10,080 3,528 3,528 3,528 3,780 5,040 3,528 10,080 16,800 13,440 15,120 7,560 15,120 8,400 10,080 13,440 12,600 12,600 12,600 10,080 10,080 12,600 13,440 13,440 10,080 10,920 10,920 4,620 6,300 6,720 6,720 5,040

Health Care Institution Fee 7,100 4,900 4,900 5,500 5,500 5,500 5,500 4,900 9,600 12,700 7,100 5,500 6,600 4,900 5,500 5,500 5,400 9,600 7,100 1,876 1,596 5,500 9,600 10,900 4,900 4,900 4,900 7,100 5,500 4,900 10,900 13,500 17,300 12,000 7,400 12,000 9,600 10,900 17,300 10,700 10,700 10,700 10,900 10,900 10,700 17,300 17,300 10,900 10,900 10,900 5,500 6,600 5,400 5,400 5,500

Page 21 of 98

ANNEX 2. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE
26645 26650 26665 26670 26676

DESCRIPTION
Closed tratment of carpometacarpal fracture dislocation, thumb (Bennett fracture) Percutaneous skeletal fixation of carpometacarpal fracture dislocation, thumb (Bennett fracture), w/ manipulation, w/ or w/o external fixation Open treatment of carpometacarpal fracture dislocation, thumb (Bennett fracture), w/ or w/o internal or external fixation Closed treatment of carpometacarpal dislocation, other than thumb (Bennett fracture); single Percutaneous skeletal fixation of carpometacarpal dislocation, other than thumb (Bennett fracture), single, w/ manipulation Open treatment of carpometacarpal dislocation, other than thumb (Bennett fracture); single, w/ or w/o Open treatment of carpometacarpal dislocation, other than thumb (Bennett fracture); single, internal or external fixation Open treatment of carpometacarpal dislocation, other than thumb (Bennett fracture); single, complex, multiple or delayed reduction Closed treatment of metacarpophalangeal dislocation, single Percutaneous skeletal fixation of metacarpophalangeal dislocation, single, w/ manipulation Open treatment of metacarpophalangeal dislocation, single, w/ or w/o internal or external fixation Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb Percutaneous skeletal fixation of unstable phalangeal shaft fracture, proximal or middle phalanx, finger or thumb, w/ manipulation, each Open treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb, w/ or w/o internal or external fixation, each Closed treatment of articular fracture, involving metacarpophalangeal or interphalangeal joint Open treatment of articular fracture, involving metacarpophalangeal or interphalangeal joint, w/ or w/o internal or external fixation, each Closed treatment of distal phalangeal fracture, finger or thumb Percutaneous skeletal fixation of distal phalangeal fracture, finger or thumb, each Open treatment of distal phalangeal fracture, finger or thumb, w/ or w/o internal or external fixation, each Closed treatment of interphalangeal joint dislocation, single Percutaneous skeletal fixation of interphalangeal joint dislocation, single, w/ manipulation Open treatment of interphalangeal joint dislocation, w/ or w/o internal or external fixation, single Fusion in opposition, thumb, w/ autogenous graft (includes obtaining graft) Arthrodesis, carpometacarpal joint, thumb, w/ or w/o internal fixation; Arthrodesis, carpometacarpal joint, thumb, w/ or w/o internal fixation; w/ autograft (includes obtaining graft) Arthrodesis, carpometacarpal joint, digits, other than thumb; Arthrodesis, carpometacarpal joint, digits, other than thumb; w/ autograft (includes obtaining graft) Arthrodesis, metacarpophalangeal joint, w/ or w/o internal fixation; Arthrodesis, metacarpophalangeal joint, w/ or w/o internal fixation; w/ autograft (includes obtaining graft) Arthrodesis, interphalangeal joint, w/ or w/o internal fixation; Arthrodesis, interphalangeal joint, w/ or w/o internal fixation; w/ autograft (includes obtaining graft) Amputation, metacarpal, w/ finger or thumb (ray amputation), single, w/ or w/o interosseous transfer Amputation, finger or thumb, primary or secondary, any joint or phalanx, single, including neurectomies; w/ direct closure Amputation, finger or thumb, primary or secondary, any joint or phalanx, single, including neurectomies; w/ local advancement flaps (V-Y, hood) Incision and drainage, pelvis or hip joint area; deep abscess or hematoma Incision and drainage, pelvis or hip joint area; infected bursa Incision, deep, w/ opening of bone cortex (e.g., for osteomyelitis or bone abscess), pelvis and/or hip joint Tenotomy, adductor of hip, subcutaneous, closed Tenotomy, adductor of hip, subcutaneous, open Tenotomy, adductor, subcutaneous, open, w/ obturator neurectomy Tenotomy, iliopsoas, open Tenotomy, abductors of hip, open

Case Rate 12,120 14,960 14,960 10,540 14,960

Professional Fee 6,720 7,560 7,560 5,040 7,560

Health Care Institution Fee 5,400 7,400 7,400 5,500 7,400

26685

10,540

5,040

5,500

26686 26700 26706 26715 26720 26727

11,980 10,540 14,960 12,540 10,120 14,960

5,880 5,040 7,560 7,140 4,620 7,560

6,100 5,500 7,400 5,400 5,500 7,400

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

14,960 10,120 12,540 10,120 14,960 12,120 10,880 12,540 12,540 21,820 20,980 20,980 21,940 20,980 20,980 21,820 20,980 21,820 12,120 11,980 21,940 12,120 12,120 23,300 12,120 14,960 30,740 23,300 23,300

7,560 4,620 7,140 4,620 7,560 6,720 3,780 7,140 7,140 10,920 10,080 10,080 9,240 10,080 10,080 10,920 10,080 10,920 6,720 5,880 9,240 6,720 6,720 12,600 6,720 7,560 13,440 12,600 12,600

7,400 5,500 5,400 5,500 7,400 5,400 7,100 5,400 5,400 10,900 10,900 10,900 12,700 10,900 10,900 10,900 10,900 10,900 5,400 6,100 12,700 5,400 5,400 10,700 5,400 7,400 17,300 10,700 10,700

Page 22 of 98

ANNEX 2. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE
27025 27030 27033 27035

DESCRIPTION
Fasciotomy, hip or thigh, any type Arthrotomy, hip, for infection, w/ drainage Arthrotomy, hip, w/ exploration or removal of loose or foreign body Hip joint denervation, intrapelvic or extrapelvic intra-articular branches of sciatic, femoral, or obturator nerves Capsulectomy or capsulotomy of hip, w/ or w/o excision of heterotopic bone, w/ release of hip flexor muscles (ie, gluteus medius, gluteus minimus, tensor fascia latae, rectus femoris, sartorius, iliopsoas) Biopsy, soft tissue of pelvis and hip area Excision, tumor, pelvis and hip area; subcutaneous Excision, tumor, pelvis and hip area; deep, subfascial, intramuscular Radical resection of tumor (e.g., malignant neoplasm), soft tissue of pelvis and hip area Arthrotomy, w/ biopsy; sacroiliac joint Arthrotomy, w/ biopsy; hip joint Arthrotomy w/ synovectomy, hip joint Excision; ischial bursa Excision; trochanteric bursa or calcification Excision of bone cyst or benign tumor; superficial (wing of ilium, symphysis pubis, or greater trochanter of femur) w/ or w/o autograft Excision of bone cyst or benign tumor; deep, w/ or w/o autograft Excision of bone cyst or benign tumor; w/ autograft requiring separate incision Partial excision (craterization, saucerization) (e.g., for osteomyelitis); superficial (e.g., wing of ilium, symphysis pubis or greater trochanter of femur) Partial excision (craterization, saucerization) (e.g., for osteomyelitis); deep Radical resection of tumor or infection; wing of ilium, one pubic or ischial ramus or symphysis pubis Radical resection of tumor or infection; ilium, including acetabulum, both pubic rami, or ischium and acetabulum Radical resection of tumor or infection; innominate bone, total Radical resection of tumor or infection; ischial tuberosity and greater trochanter of femur Radical resection of tumor or infection; ischial tuberosity and greater trochanter of femur, w/ skin flaps Coccygectomy, primary Removal of foreign body, pelvis or hip Removal of hip prosthesis; Removal of hip prosthesis; complicated, including "total hip" and methlmethacrylate, when applicable Hamstring recession, 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; to greater trochanter Transfer iliopsoas; to femoral neck Acetabuloplasty; (e.g., Whitman, Colonna, Haygroves, or cup type) Acetabuloplasty; resection femoral head (Girdlestone procedure) Partial hip replacement, prosthesis (e.g., femoral stem prosthesis, bipolar arthroplasty) Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip replacement), w/ or w/o autograft or allograft Conversion of previous hip surgery to total hip replacement, w/ or w/o autograft or allograft Revision of total hip arthroplasty; both components, w/ or w/o autograft or allograft Revision of total hip arthroplasty; acetabular component only, w/ or w/o autograft or allograft Revision of total hip arthroplasty; femoral component only, w/ or w/o allograft Osteotomy and transfer of greater trochanter Osteotomy , iliac, acetabular or innominate bone; Osteotomy , iliac, acetabular or innominate bone; w/ open reduction of hip Osteotomy , iliac, acetabular or innominate bone; w/ femoral osteotomy Osteotomy , iliac, acetabular or innominate bone; w/ femoral osteotomy and w/ open reduction of hip Osteotomy, pelvis, bilateral (e.g., for congenital malformation) Osteotomy, femoral neck

Case Rate 21,820 30,740 30,740 30,300

Professional Fee 10,920 13,440 13,440 16,800

Health Care Institution Fee 10,900 17,300 17,300 13,500

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

37,800 3,504 5,680 8,260 37,800 27,960 37,180 31,140 27,120 27,120 27,960 30,300 31,140 46,500 46,500 38,860 38,860 37,180 31,140 31,560 15,380 14,960 30,300 38,020 22,660 23,300 30,740 30,740 30,740 30,740 37,180 37,180 37,180 53,400 55,080 55,000 38,640 38,640 27,960 30,300 31,140 37,180 38,020 37,800 31,140

21,000 504 1,680 3,360 21,000 15,960 18,480 17,640 15,120 15,120 15,960 16,800 17,640 25,200 25,200 20,160 20,160 18,480 17,640 18,060 7,980 7,560 16,800 19,320 11,760 12,600 13,440 13,440 13,440 13,440 18,480 18,480 18,480 29,400 31,080 33,600 21,840 21,840 15,960 16,800 17,640 18,480 19,320 21,000 17,640

16,800 3,000 4,000 4,900 16,800 12,000 18,700 13,500 12,000 12,000 12,000 13,500 13,500 21,300 21,300 18,700 18,700 18,700 13,500 13,500 7,400 7,400 13,500 18,700 10,900 10,700 17,300 17,300 17,300 17,300 18,700 18,700 18,700 24,000 24,000 21,400 16,800 16,800 12,000 13,500 13,500 18,700 18,700 16,800 13,500

Page 23 of 98

ANNEX 2. 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, intertrochanteric or subtrochanteric including internal or external fixation and/or cast Bone graft, femoral head, neck, intertrochanteric or subtrochanteric area (includes obtaining bone graft) Treatment of slipped femoral epiphysis; by traction, w/o reduction Treatment of slipped femoral epiphysis; by single or multiple pinning, in situ Open treatment of slipped femoral epiphysis; single of multiple pinning or bone graft (includes obtaining graft) Open treatment of slipped femoral epiphysis; closed manipulation w/ single or multiple pinning Open treatment of slipped femoral epiphysis; osteoplasty of femoral neck (Heyman type procedure) Open treatment of slipped femoral epiphysis; osteotomy and internal fixation Epiphyseal arrest by epiphysiodesis or stapling, greater trochanter Prophylactic treatment (nailing, pinning, plating, or wiring) w/ or w/o methylmethacrylate, femoral neck and proximal femur Closed treatment of pelvic ring fracture, dislocation, diastasis or subluxation Closed treatment of coccygeal fracture Open treatment of coccygeal fracture Open treatment of iliac spine(s), tuberosity avulsion, or iliac wing fracture(s) (e.g., pelvic fracture(s) w/c do not disrupt the pelvic ring), w/ internal fixation Percutaneous skeletal fixation of posterior pelvic ring fracture and/or dislocation (includes ilium, 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, sacroiliac joint and/or sacrum) Closed treatment of acetabulum (hip socket) fracture(s) Open treatment of posterior or anterior acetabular wall fracture, w/ internal fixation Open treatment of acetabular fracture(s) involving anterior or posterior (one) column, or a fracture running transversely across the acetabulum, w/ internal fixation Open treatment of acetabular fracture(s) involving anterior and posterior (two) columns, includes T-fracture and both column fracture w/ complete articular detachment, or single column or transverse fracture w/ associated acetabular wall fracture, w/ inte Closed treatment of femoral fracture, proximal end, neck Percutaneous skeletal fixation of femoral fracture, proximal end, neck, undisplaced, mildly displaced, or impacted fracture Open treatment of femoral fracture, proximal end, neck, internal fixation or prosthetic replacement (direct fracture exposure) Closed treatment of intertrochanteric, pertrochanteric, or subtrochanteric femoral fracture Open treatment of intertrochanteric, pertrochanteric, or subtrochanteric femoral fracture; w/ plate/screw type implant, w/ or w/o cerclage Open treatment of intertrochanteric, pertrochanteric, or subtrochanteric femoral fracture; w/ intramedullary implant, w/ or w/o interlocking screws and/or cerclage Closed treatment of greater trochanteric fracture Open treatment of greater trochanteric fracture, w/ or w/o internal or external fixation Closed treatment of hip dislocation, traumatic Open treatment of hip dislocation, traumatic, w/o internal fixation Open treatment of hip dislocation, traumatic w/ acetabular wall and femoral head fracture, w/ or w/o internal or external fixation Open treatment of spontaneous hip dislocation (developmental, including congenital or pathological), replacement of femoral head in acetabulum (including tenotomy, etc); Open treatment of spontaneous hip dislocation (developmental, including congenital or pathological), replacement of femoral head in acetabulum (including tenotomy, etc); w/ femoral shaft shortening Closed treatment of post hip arthroplasty dislocation Arthrodesis, sacroiliac joint (including obtaining graft) Arthrodesis, symphysis pubis (including obtaining graft) Arthrodesis, hip joint (includes obtaining graft); Arthrodesis, hip joint (includes obtaining graft); w/ subtrochanteric osteotomy Interpelviabdominal amputation (hindquarter amputation) Disarticulation of hip Incision and drainage of deep abscess, infected bursa, or hematoma, thigh or knee region

Case Rate 37,180 31,140 23,300 30,300 31,140 31,140 31,140 37,180 27,960 31,140 27,960 14,960 22,660 37,800 40,320 46,500 46,500 30,740 38,640 40,320

Professional Fee 18,480 17,640 12,600 16,800 17,640 17,640 17,640 18,480 15,960 17,640 15,960 7,560 11,760 21,000 23,520 25,200 25,200 13,440 21,840 23,520

Health Care Institution Fee 18,700 13,500 10,700 13,500 13,500 13,500 13,500 18,700 12,000 13,500 12,000 7,400 10,900 16,800 16,800 21,300 21,300 17,300 16,800 16,800

27228 27230 27235 27236 27238 27244

46,500 23,300 46,500 46,500 23,300 46,500

25,200 12,600 25,200 25,200 12,600 25,200

21,300 10,700 21,300 21,300 10,700 21,300

27245 27246 27248 27250 27253 27254 27258

31,140 23,300 27,120 23,300 37,180 40,320 30,300

17,640 12,600 15,120 12,600 18,480 23,520 16,800

13,500 10,700 12,000 10,700 18,700 16,800 13,500

27259 27265 27280 27282 27284 27286 27290 27295 27301

37,180 18,000 37,800 27,960 37,800 40,320 46,500 30,300 8,260

18,480 8,400 21,000 15,960 21,000 23,520 25,200 16,800 3,360

18,700 9,600 16,800 12,000 16,800 16,800 21,300 13,500 4,900

Page 24 of 98

ANNEX 2. 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, deep, w/ opening of bone cortex (e.g., for osteomyelitis or bone abscess), femur or knee Fasciotomy, iliotibial (tenotomy), open Tenotomy, subcutaneous, closed, adductor or hamstring; single Tenotomy, subcutaneous, closed, adductor or hamstring; multiple Arthrotomy, knee, for infection, w/ exploration, drainage or removal of foreign body Neurectomy, hamstring muscle Neurectomy, popliteal (gastrocnemius) Biopsy, soft tissue of thigh or knee area Excision, tumor, thigh or knee area; subcutaneous Excision, tumor, thigh or knee area; deep, subfascial, or intramuscular Radical resection of tumor (e.g., malignant neoplasm), soft tissue of thigh or knee area Arthrotomy, knee; w/ synovial biopsy only Arthrotomy, knee; w/ joint exploration, w/ or w/o biopsy, w/ or w/o removal of loose or foreign bodies Arthrotomy, knee, w/ excision of semilunar cartilage (meniscectomy); medial or lateral Arthrotomy, knee, w/ excision of semilunar cartilage (meniscectomy); medial and lateral Arthrotomy, knee, w/ synovectomy; anterior or posterior Arthrotomy, knee, w/ synovectomy; anterior and posterior including popliteal area Excision, 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; Excision or curettage of bone cyst or benign tumor of femur; w/ allograft Excision or curettage of bone cyst or benign tumor of femur; w/ autograft (includes obtaining graft) Excision or curettage of bone cyst or benign tumor of femur; w/ internal fixation Partial excision (craterization, saucerization, or diaphysectomy) of bone (e.g., for osteomyelitis), femur, proximal tibia and/or fibula Radical resection of tumor, bone, femur or knee Removal of foreign body, deep, thigh region or knee area Suture of infrapatellar tendon; primary Suture of infrapatellar tendon; secondary reconstruction, including fascial or tendon graft Suture of quadriceps or hamstring muscle rupture; primary Suture of quadriceps or hamstring muscle rupture; secondary reconstruction, including fascial or tendon graft Tenotomy, open, hamstring, knee to hip; single Tenotomy, open, hamstring, knee to hip; multiple, one leg Tenotomy, open, hamstring, knee to hip; multiple, bilateral Lengthening of hamstring tendon; single Lengthening of hamstring tendon; multiple, one leg Lengthening of hamstring tendon; multiple, bilateral Transplant, hamstring tendon to patella; single Transplant, hamstring tendon to patella; multiple Tendon or muscle transfer, hamstrings to femur (e.g.gers type procedure) Arthrotomy w/ open meniscus repair Repair, primary, torn ligament and/or capsule, knee; collateral Repair, primary, torn ligament and/or capsule, knee; cruciate Repair, primary, torn ligament and/or capsule, knee; collateral and cruciate ligaments Anterior tibial tubercleplasty (e.g., for chondromalacia patellae) Reconstruction for recurrent dislocating patella; (Hauser type procedure) Reconstruction for recurrent dislocating patella; w/ extensor realignment and/or muscle advancement or release (Campbell, Goldwaite type procedure) Reconstruction for recurrent dislocating patella; w/ patellectomy Lateral retinacular release (any method) Ligamentous reconstruction (augmentation), knee; extra-articular Ligamentous reconstruction (augmentation), knee; intra-articular (open) Ligamentous reconstruction (augmentation), knee; intra-articular (open) and extra-articular Quadricepsplasty (Bennett or Thompson type) Capsulotomy, knee, posterior capsular release Arthroplasty, patella; w/o prosthesis Arthroplasty, patella; w/ prosthesis

Case Rate 23,300 18,000 18,000 21,820 27,120 23,300 23,300 3,504 5,680 8,020 27,120 20,980 23,300 31,580 27,960 13,152 23,300 14,960 20,980 30,740 22,240 23,720 23,720 27,120 23,720 27,120 18,000 23,300 27,120 32,000 27,120 18,000 21,940 20,980 23,300 21,940 20,980 23,300 22,360 23,300 27,960 27,120 30,300 37,800 22,660 23,080 30,740 30,740 21,820 30,300 31,140 37,180 27,120 30,740 30,740 31,140

Professional Fee 12,600 8,400 8,400 10,920 15,120 12,600 12,600 504 1,680 2,520 15,120 10,080 12,600 14,280 15,960 6,552 12,600 7,560 10,080 13,440 11,340 13,020 13,020 15,120 13,020 15,120 8,400 12,600 15,120 14,700 15,120 8,400 9,240 10,080 12,600 9,240 10,080 12,600 9,660 12,600 15,960 15,120 16,800 21,000 11,760 12,180 13,440 13,440 10,920 16,800 17,640 18,480 15,120 13,440 13,440 17,640

Health Care Institution Fee 10,700 9,600 9,600 10,900 12,000 10,700 10,700 3,000 4,000 5,500 12,000 10,900 10,700 17,300 12,000 6,600 10,700 7,400 10,900 17,300 10,900 10,700 10,700 12,000 10,700 12,000 9,600 10,700 12,000 17,300 12,000 9,600 12,700 10,900 10,700 12,700 10,900 10,700 12,700 10,700 12,000 12,000 13,500 16,800 10,900 10,900 17,300 17,300 10,900 13,500 13,500 18,700 12,000 17,300 17,300 13,500

Page 25 of 98

ANNEX 2. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE
27440 27441 27442 27443 27445 27446 27447 27448 27450 27454 27455

DESCRIPTION
Arthroplasty, knee, tibial plateau; Arthroplasty, knee, tibial plateau; w/ debridement and partial synovectomy Arthroplasty, knee, femoral condyles or tibial plateaus; Arthroplasty, knee, femoral condyles or tibial plateaus; w/ debridement and partial synovectomy Arthroplasty, knee, constrained prosthesis (e.g., Walldius type) Arthroplasty, knee, condyle and plateau; medial or lateral compartment Arthroplasty, knee, condyle and plateau; medial and lateral compartments w/ or w/o patella resurfacing ("total knee replacement") Osteotomy, femur, shaft or supracondylar; w/o fixation Osteotomy, femur, shaft or supracondylar; w/ fixation Osteotomy, multiple, femoral shaft, w/ realignment on intramedullary rod (Sofield type procedure) Osteotomy, proximal tibia, including fibular excision or osteotomy (includes correction of genu varus (bowleg) or genu valgus (knock-knee)); before epiphyseal closure Osteotomy, proximal tibia, including fibular excision or osteotomy (includes correction of genu varus (bowleg) or genu valgus (knock-knee)); after epiphyseal closure Osteoplasty, femur; shortening (excluding 64876) Osteoplasty, femur; lengthening Osteoplasty, femur; combined, lengthening and shortening w/ femoral segment transfer Repair, nonunion or malunion, femur, distal to head and neck; w/o graft (e.g., compression technique) Repair, nonunion or malunion, femur, distal to head and neck; w/ iliac or other autogenous bone graft (includes obtaining graft) Epiphyseal arrest by epiphysiodesis or stapling; distal femur Epiphyseal arrest by epiphysiodesis or stapling; tibia and fibula, proximal Epiphyseal arrest by epiphysiodesis or stapling; combined distal femur, proximal tibia and fibula Arrest, hemiepiphyseal, distal femur or proximal leg (e.g., for genu varus or valgus) Revision of total knee arthroplasty, w/ or w/o allograft; one component Revision of total knee arthroplasty, w/ or w/o allograft; all components Removal of knee prosthesis, including "total knee" methylmethacrylate and insertion of spacer, when applicable Prophylactic treatment (nailing, pinning, plating or writing) w/ or w/o methylmethacrylate, femur Decompression fasciotomy, thigh and/or knee, one compartment (flexor or extensor or adductor); Decompression fasciotomy, thigh and/or knee, one compartment (flexor or extensor or adductor); w/ debridement of nonviable muscle and/or nerve Decompression fasciotomy, thigh and/or knee, multiple compartments; Decompression fasciotomy, thigh and/or knee, multiple compartments; 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, w/ or w/o skin or skeletal traction Closed treatment of supracondylar or transcondylar femoral fracture w/ or w/o intercondylar extension, w/ or w/o skin or skeletal traction Open treatment of femoral shaft fracture, w/ or w/o external fixation, w/ insertion of intramedullary implant, w/ or w/o cerclage and/or locking screws Open treatment of femoral shaft fracture w/ plate/screws, w/ or w/o cerclage Percutaneous skeletal fixation of femoral fracture, distal end, medial or lateral condyle, or supracondylar or transcondylar, w/ or w/o intercondylar extension, or distal femoral epiphyseal separation Closed treatment of femoral fracture, distal end, medial or lateral condyle Open treatment of femoral supracondylar or transcondylar fracture w/o intercondylar extension, w/ or w/o internal or external fixation Open treatment of femoral supracondylar or transcondylar fracture w/ intercondylar extension, w/ or w/o internal or external fixation

Case Rate 37,800 38,640 38,640 39,480 46,500 39,480 40,320 18,420 23,300 27,120 27,120

Professional Fee 21,000 21,840 21,840 22,680 25,200 22,680 23,520 8,820 12,600 15,120 15,120

Health Care Institution Fee 16,800 16,800 16,800 16,800 21,300 16,800 16,800 9,600 10,700 12,000 12,000

27457 27465 27466 27468 27470 27472 27475 27477 27479 27485 27486 27487 27488 27495 27496 27497 27498 27499 27501 27502 27503

27,120 27,120 27,120 37,180 31,580 27,960 30,740 23,300 27,120 30,740 53,400 55,000 37,180 30,740 20,980 21,820 21,820 23,300 14,960 18,420 18,420

15,120 15,120 15,120 18,480 14,280 15,960 13,440 12,600 15,120 13,440 29,400 33,600 18,480 13,440 10,080 10,920 10,920 12,600 7,560 8,820 8,820

12,000 12,000 12,000 18,700 17,300 12,000 17,300 10,700 12,000 17,300 24,000 21,400 18,700 17,300 10,900 10,900 10,900 10,700 7,400 9,600 9,600

27506 27507

30,740 30,740

13,440 13,440

17,300 17,300

27509

37,180

18,480

18,700

27510 27511 27513

18,420 37,180 37,800

8,820 18,480 21,000

9,600 18,700 16,800

Page 26 of 98

ANNEX 2. 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, distal end, medial or lateral condyle, w/ or w/o internal or external fixation Closed treatment of distal femoral epiphyseal separation Open treatment of distal femoral epiphyseal separation, w/ or w/o internal or external fixation Closed treatment of patellar fracture Open treatment of patellar fracture, w/ internal fixation and/or partial or complete patellectomy and soft tissue repair Closed treatment of tibial fracture, proximal (plateau) Open treatment of tibial fracture, proximal (plateau); unicondylar, w/ or w/o internal or external fixation Open treatment of tibial fracture, proximal (plateau); bicondylar, 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, w/ or w/o internal or external fixation Closed treatment of knee dislocation Open treatment of knee dislocation, w/ or w/o internal or external fixation; w/o primary ligamentous repair or augmentation/reconstruction Open treatment of knee dislocation, w/ or w/o internal or external fixation; w/ primary ligamentous repair Open treatment of knee dislocation, w/ or w/o internal or external fixation; w/ primary ligamentous repair, w/ augmentation/reconstruction Closed treatment of patellar dislocation Open treatment of patellar dislocation, w/ or w/o partial or total patellectomy Fusion of knee, any technique Amputation, thigh, through femur, any level; Amputation, thigh, through femur, any level; immediate fitting technique including first cast Amputation, thigh, through femur, any level; open, circular (guillotine) Amputation, thigh, through femur, any level; secondary closure or scar revision Amputation, thigh, through femur, any level; re-amputaion Disarticulation at knee Decompression fasciotomy, leg; anterior and/or lateral compartments only Decompression fasciotomy, leg; posterior compartments(s) only Decompression fasciotomy, leg; anterior and/or lateral, and posterior compartment(s) Incision and drainage, leg or ankle; deep abscess or hematoma Incision and drainage, leg or ankle; infected bursa Tenotomy, Achilles tendon, subcutaneous ; local anesthesia; Tenotomy, Achilles tendon, subcutaneous ; local anesthesia; general anesthesia Incision, deep, w/ opening of bone cortex (e.g., for osteomyelitis or bone abscess), leg or ankle Arthrotomy, ankle, for infection, w/ exploration, drainage, or removal of foreign body Arthrotomy, ankle, posterior capsular release, w/ or w/o Achilles tendon lengthening Biopsy, soft tissue of leg or ankle area Radical resection of tumor (e.g., malignant neoplasm), soft tissue of leg or ankle area Excision, tumor, leg or ankle area; subcutaneous Excision, tumor, leg or ankle area; deep, subfascial or intramuscular Arthrotomy, ankle, w/ joint exploration, w/ or w/o biopsy, w/ or w/o removal of loose or foreign body Arthrotomy, ankle, w/ synovectomy; Arthrotomy, ankle, w/ synovectomy; including tenosynovectomy Excision of lesion of tendon sheath or capsule (e.g., cyst or ganglion), leg and/or ankle Excision or curettage of bone cyst or benign tumor, tibia or fibula; Excision or curettage of bone cyst or benign tumor, tibia or fibula; w/ autograft(includes obtaining graft) Excision or curettage of bone cyst or benign tumor, tibia or fibula; w/ allograft Partial excision (craterization, saucerization, or diaphysectomy) of bone (e.g., for osteomyelitis or exostosis); tibia Partial excision (craterization, saucerization, or diaphysectomy) of bone (e.g., for osteomyelitis or exostosis); fibula Radical resection of tumor, bone; tibia Radical resection of tumor, bone; fibula

Case Rate 30,740 23,300 22,660 20,980 20,980 18,420 30,740 27,120 10,540 21,820 10,540 27,120 27,960 37,800 20,980 27,120 30,740 30,300 23,300 23,300 11,980 22,660 27,120 8,020 8,020 8,260 4,108 5,680 12,540 18,420 20,980 21,940 22,660 3,504 20,980 5,680 8,020 12,900 18,420 21,940 5,680 14,960 21,940 21,940 18,420 18,000 23,300 22,660

Professional Fee 13,440 12,600 11,760 10,080 10,080 8,820 13,440 15,120 5,040 10,920 5,040 15,120 15,960 21,000 10,080 15,120 13,440 16,800 12,600 12,600 5,880 11,760 15,120 2,520 2,520 3,360 1,008 1,680 7,140 8,820 10,080 9,240 11,760 504 10,080 1,680 2,520 6,300 8,820 9,240 1,680 7,560 9,240 9,240 8,820 8,400 12,600 11,760

Health Care Institution Fee 17,300 10,700 10,900 10,900 10,900 9,600 17,300 12,000 5,500 10,900 5,500 12,000 12,000 16,800 10,900 12,000 17,300 13,500 10,700 10,700 6,100 10,900 12,000 5,500 5,500 4,900 3,100 4,000 5,400 9,600 10,900 12,700 10,900 3,000 10,900 4,000 5,500 6,600 9,600 12,700 4,000 7,400 12,700 12,700 9,600 9,600 10,700 10,900

Page 27 of 98

ANNEX 2. 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, bone; talus or calcaneus Repair, primary, open or percutaneous, ruptured Achilles tendon; Repair, primary, open or percutaneous, ruptured Achilles tendon; w/ graft (includes obtaining graft) Repair, secondary, ruptured Achilles tendon, w/ or w/o graft Repair, fascial defect of leg Repair or suture of flexor tendon of leg; primary, w/o graft, single, each Repair or suture of flexor tendon of leg; secondary w/ or w/o graft, single tendon, each Repair or suture of extensor tendon of leg; primary, w/o graft, single, each Repair or suture of extensor tendon of leg; secondary w/ or w/o graft, single tendon, each Repair for dislocating peroneal tendons; w/o fibular osteotomy Repair for dislocating peroneal tendons; w/ fibular osteotomy Tenolysis, including tibia, fibula, and ankle flexor; single Tenolysis, including tibia, fibula, and ankle flexor; multiple (through same incision), each Lengthening or shortening of tendon, leg or ankle; single Lengthening or shortening of tendon, leg or ankle; multiple (through same incision), each Gastrocnemius recession (e.g., Strayer procedure) Transfer or transplant of single tendon (w/ muscle redirection or rerouting); superficial (e.g., anterior tibial extensors into midfoot) Transfer or transplant of single tendon (w/ muscle redirection or rerouting); each additional tendon Suture, primary, torn, ruptured or severed ligament, ankle; collateral Suture, primary, torn, ruptured or severed ligament, ankle; both collateral ligaments Suture, secondary repair, torn, ruptured or severed ligament, ankle, collateral (Watson-Jones procedure) Arthroplasty, ankle; Arthroplasty, ankle; w/ implant ("total ankle") Arthroplasty, ankle; secondary reconstruction, total ankle Removal of ankle implant Osteotomy; tibia Osteotomy; fibula Osteotomy; tibia and fibula Osteotomy; multiple, w/ realignment on intramedullary rod (Sofield type procedure) Osteoplasty, tibia and fibula, lengthening Repair of nonunion or malunion, tibia; w/o graft, (e.g., compression technique) Repair of nonunion or malunion, tibia; w/ sliding graft Repair of nonunion or malunion, tibia; w/ iliac or other autograft (includes obtaining graft) Repair of nonunion or malunion, tibia; by synostosis, w/ fibula, any method Repair of congenital pseudarthrosis, tibia Epiphyseal arrest by epiphysiodesis or stapling; distal tibia Epiphyseal arrest by epiphysiodesis or stapling; distal fibula Epiphyseal arrest by epiphysiodesis or stapling; distal tibia and fibula Epiphyseal arrest by epiphysiodesis or stapling, combined, proximal and distal tibia and fibula; Epiphyseal arrest by epiphysiodesis or stapling, combined, proximal and distal tibia and fibula; and distal femur Prophylactic treatment (nailing, pinning, plating or wiring) w/ or w/o methylmethacrylate, tibia Closed treatment of tibial shaft fracture (w/ or w/o fibular fracture) Closed treatment of tibial shaft fracture (with or without fibular fracture); with manipulation, with or without skeletal traction Percutaneous skeletal fixation of tibial shaft fracture (w/ or w/o fibular fracture) (e.g., pins or screws) Open treatment of tibial shaft fracture (w/ or w/o fibular fracture) w/ plate/screws, w/ or w/o cerclage Open treatment of tibial shaft fracture (w/ or w/o fibular fracture) by intramedullary implant, w/ or w/o interlocking screws and/or cerclage Closed treatment of medial malleolus fracture Open treatment of medial malleolus fracture, w/ or w/o internal or external fixation Closed treatment of proximal fibula or shaft fracture Open treatment of proximal fibula or shaft fracture, w/ or w/o internal or external fixation Closed treatment of distal fibular fracture (lateral malleolus)

Case Rate 23,300 21,940 23,300 21,820 5,680 15,380 18,000 15,380 18,000 18,000 22,360 18,000 21,940 18,000 18,000 14,960 18,420 15,380 18,000 23,300 18,000 27,120 31,140 37,180 21,820 21,940 18,000 22,660 23,720 27,960 18,000 20,980 21,820 22,660 23,300 21,820 20,980 23,300 23,300 22,660 31,160 12,120 12,120 21,820 22,660 27,120 10,960 12,120 10,960 22,660 10,540

Professional Fee 12,600 9,240 12,600 10,920 1,680 7,980 8,400 7,980 8,400 8,400 9,660 8,400 9,240 8,400 8,400 7,560 8,820 7,980 8,400 12,600 8,400 15,120 17,640 18,480 10,920 9,240 8,400 11,760 13,020 15,960 8,400 10,080 10,920 11,760 12,600 10,920 10,080 12,600 12,600 11,760 13,860 6,720 6,720 10,920 11,760 15,120 5,460 6,720 5,460 11,760 5,040

Health Care Institution Fee 10,700 12,700 10,700 10,900 4,000 7,400 9,600 7,400 9,600 9,600 12,700 9,600 12,700 9,600 9,600 7,400 9,600 7,400 9,600 10,700 9,600 12,000 13,500 18,700 10,900 12,700 9,600 10,900 10,700 12,000 9,600 10,900 10,900 10,900 10,700 10,900 10,900 10,700 10,700 10,900 17,300 5,400 5,400 10,900 10,900 12,000 5,500 5,400 5,500 10,900 5,500

Page 28 of 98

ANNEX 2. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE
27792 27808 27814 27816 27822

DESCRIPTION
Open treatment of distal fibular fracture (lateral malleolus), w/ or w/o internal or external fixation w/o manipulation Closed treatment of bimalleolar ankle fracture, (including Potts) Open treatment of bimalleolar ankle fracture, w/ or w/o internal or external fixation Closed treatment of trimalleolar ankle fracture Open treatment of trimalleolar ankle fracture, w/ or w/o internal or external fixation, medial and/or lateral malleolus; w/o fixation of posterior lip Open treatment of trimalleolar ankle fracture, w/ or w/o internal or external fixation, medial and/or lateral malleolus; w/ fixation of posterior lip Closed treatment of fracture of weight bearing articular portion of distal tibia (e.g., pilon or tibial plafond) Open treatment of fracture of weight bearing articular surface/portion of distal tibia (e.g., pilon or tibial plafond), w/ internal or external fixation; of fibula only Open treatment of fracture of weight bearing articular surface/portion of distal tibia (e.g., pilon or tibial plafond), w/ internal or external fixation; of tibia only Open treatment of fracture of weight bearing articular surface/portion of distal tibia (e.g., pilon or tibial plafond), w/ internal or external fixation; of both tibia and fibula Open treatment of distal tibiofibular joint (syndesmosis) disruption, w/ or w/o internal or external fixation Closed treatment of proximal tibiofibular joint dislocation Open treatment of proximal tibiofibular joint dislocation, w/ or w/o internal or external fixation, or w/ excision of proximal fibula Closed treatment of ankle dislocation Open treatment of ankle dislocation, w/ or w/o percutaneous skeletal fixation; w/o repair or internal fixation Open treatment of ankle dislocation, w/ or w/o percutaneous skeletal fixation; w/ repair or internal or external fixation Arthrodesis, ankle, any method Arthrodesis, tibiofibular joint, proximal or distal Amputation, leg, through tibia and fibula; Amputation, leg, through tibia and fibula; w/ immediate fitting technique including application of first cast Amputation, leg, through tibia and fibula; open, circular (guillotine) Amputation, leg, through tibia and fibula; secondary closure or scar revision Amputation, leg, through tibia and fibula; re-amputation Amputation, ankle, through malleoli of tibia and fibula (Syme, Pirogoff type procedures), w/ plastic closure and resection of nerves Ankle disarticulation Decompression fasciotomy, leg; anterior and/or lateral compartments only, w/ debridement of nonviable muscle and/or nerve Decompression fasciotomy, leg; posterior compartment(s) only, w/ debridement of nonviable muscle and/or nerve Decompression fasciotomy, leg; anterior and/or lateral, and posterior compartment(s), w/ debridement of nonviable muscle and/or nerve Incision and drainage, infected bursa, foot Deep dissection below fascia, for deep infection of foot, w/ or w/o tendon sheath involvement; single bursal space, specify; Deep dissection below fascia, for deep infection of foot, w/ or w/o tendon sheath involvement; single bursal space, specify; multiple areas Incision, deep, w/ opening of bone cortex (e.g. for osteomyelitis or bone abscess), foot Fasciotomy, foot and/or toe Tenotomy, subcutaneous, toe; single Tenotomy, subcutaneous, toe; multiple Arthrotomy, w/ exploration, drainage, or removal of loose or foreign body; intertarsal or tarsometatarsal joint Arthrotomy, w/ exploration, drainage, or removal of loose or foreign body; metatarsophalangeal joint Arthrotomy, w/ exploration, drainage, or removal of loose or foreign body; interphalangeal joint Neurectomy of intrinsic musculature of foot Tarsal tunnel release (posterior tibial nerve decompression) Excision, tumor, foot; subcutaneous Excision, tumor, foot; deep, subfascial, intramuscular Radical resection of tumor (e.g., malignant neoplasm), soft tissue of foot Arthrotomy for synovial biopsy; intertarsal or tarsometatarsal joint

Case Rate 20,980 12,900 23,300 23,300 23,300

Professional Fee 10,080 6,300 12,600 12,600 12,600

Health Care Institution Fee 10,900 6,600 10,700 10,700 10,700

27823 27824 27826

23,300 10,540 20,980

12,600 5,040 10,080

10,700 5,500 10,900

27827

21,940

9,240

12,700

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

21,820 20,980 10,960 11,980 10,960 22,660 23,720 18,000 21,400 30,300 30,740 18,000 12,120 23,300 23,300 21,940 18,000 18,000 18,420 5,680 8,260 9,700 10,540 12,120 8,260 10,540 12,900 8,260 8,260 11,132 18,000 5,680 8,020 37,800 10,120

10,920 10,080 5,460 5,880 5,460 11,760 13,020 8,400 10,500 16,800 13,440 8,400 6,720 12,600 12,600 9,240 8,400 8,400 8,820 1,680 3,360 4,200 5,040 6,720 3,360 5,040 6,300 3,360 3,360 4,032 8,400 1,680 2,520 21,000 4,620

10,900 10,900 5,500 6,100 5,500 10,900 10,700 9,600 10,900 13,500 17,300 9,600 5,400 10,700 10,700 12,700 9,600 9,600 9,600 4,000 4,900 5,500 5,500 5,400 4,900 5,500 6,600 4,900 4,900 7,100 9,600 4,000 5,500 16,800 5,500

Page 29 of 98

ANNEX 2. 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; metatarsophalangeal joint Arthrotomy for synovial biopsy; interphalangeal joint Fasciectomy, excision of plantar fascia; partial Fasciectomy, excision of plantar fascia; radical Synovectomy; intertarsal or tarsometatarsal joint, each Synovectomy; metatarsophalangeal joint, each Excision of interdigital (Morton) neuroma, single, each Synovectomy, tendon sheath, foot; flexor Synovectomy, tendon sheath, foot; extensor Excision of lesion of tendon or fibrous sheath or capsule (including synovectomy) (cyst or ganglion); foot Excision of lesion of tendon or fibrous sheath or capsule (including synovectomy) (cyst or ganglion); toes Excision or curettage of bone cyst or benign tumor, talus or calcaneus; Excision or curettage of bone cyst or benign tumor, talus or calcaneus; w/ iliac or other autograft (includes obtaining graft) Excision or curettage of bone cyst or benign tumor, talus or calcaneus; w/ allograft Excision or curettage of bone cyst or benign tumor, talus or metatarsal bones, except tarsal or calcaneus; Excision or curettage of bone cyst or benign tumor, talus or metatarsal bones, except tarsal or calcaneus; w/ iliac or other autograft (includes obtaining graft) Excision or curettage of bone cyst or benign tumor, talus or metatarsal bones, except tarsal or calcaneus; w/ allograft Excision or curettage of bone cyst or benign tumor, phalanges of foot Ostectomy, partial excision, fifth metatarsal head (bunionette) Ostectomy, complete excision; first metatarsal head Ostectomy, complete excision; other metatarsal head (second, third or fourth) Ostectomy, complete excision; fifth metatarsal head Ostectomy, complete excision; all metatarsal heads, w/ partial proximal phalangectomy, excluding first metatarsal (Clayton type procedure) Ostectomy, excision of tarsal coalition Ostectomy, calcaneus; Ostectomy, calcaneus; for spur, w/ or w/o plantar fascial release Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) of bone (e.g., for osteomyelitis or talar bossing); talus or calcaneus Partial excision (craterization, saucerization, or diaphysectomy) of bone (e.g., for osteomyelitis or tarsal bossing), tarsal or metatarsal bone, except talus or calcaneus Partial excision (craterization, saucerization, or diaphysectomy) of bone (e.g., for osteomyelitis or dorsal bossing), phalanx of toe Resection, partial or complete, phalangeal base, single toe, each Talectomy (astragalectomy) Metatarsectomy Phalangectomy of toe, single, each Resection, head of phalanx, toe Hemiphalangectomy or interphalangeal joint excision, toe, single, each Radical resection of tumor, bone; tarsal (except talus or calcaneus) Radical resection of tumor, bone; metatarsal Radical resection of tumor, bone; phalanx of toe Repair or suture of tendon, foot, flexor, single; primary or secondary, w/o free graft, each tendon Repair or suture of tendon, foot, flexor, single; secondary w/ free graft, each tendon (includes obtaining graft) Repair or suture of tendon, foot, extensor, single; primary or secondary, each tendon Repair or suture of tendon, foot, extensor, single; secondary w/ free graft, each tendon (includes obtaining graft) Tenolysis, flexor, foot; single Tenolysis, flexor, foot; multiple (through same incision) Tenolysis, extensor, foot; single Tenolysis, extensor, foot; multiple (through same incision) Tenotomy, open, flexor; foot, single or multiple; Tenotomy, open, flexor; foot, single or multiple; toe, single Tenotomy, open, extensor, foot or toe Advancement of posterior tibial tendon w/ excision of accessory navicular bone (Kidner type procedure) Tenotomy, lengthening, or release, abductor hallucis muscle Division of plantar fascia and muscle ("Steindler stripping") Capsulotomy, midfoot; medial release only Capsulotomy, midfoot; w/ tendon lengthening

Case Rate 10,120 9,700 9,700 10,960 11,980 10,960 5,680 10,960 10,960 8,440 8,260 15,380 21,940 21,940 15,380 21,940 21,940 14,960 21,940 18,420 18,420 18,000 20,980 15,380 15,380 14,960 21,940

Professional Fee 4,620 4,200 4,200 5,460 5,880 5,460 1,680 5,460 5,460 2,940 3,360 7,980 9,240 9,240 7,980 9,240 9,240 7,560 9,240 8,820 8,820 8,400 10,080 7,980 7,980 7,560 9,240

Health Care Institution Fee 5,500 5,500 5,500 5,500 6,100 5,500 4,000 5,500 5,500 5,500 4,900 7,400 12,700 12,700 7,400 12,700 12,700 7,400 12,700 9,600 9,600 9,600 10,900 7,400 7,400 7,400 12,700

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

18,000 18,000 12,540 22,660 18,000 12,120 12,120 10,540 30,740 22,660 21,940 18,000 18,000 12,540 12,540 10,880 10,960 10,880 10,960 10,960 10,880 11,132 18,420 12,540 12,540 12,540 18,000

8,400 8,400 7,140 11,760 8,400 6,720 6,720 5,040 13,440 11,760 9,240 8,400 8,400 7,140 7,140 3,780 5,460 3,780 5,460 5,460 3,780 4,032 8,820 7,140 7,140 7,140 8,400

9,600 9,600 5,400 10,900 9,600 5,400 5,400 5,500 17,300 10,900 12,700 9,600 9,600 5,400 5,400 7,100 5,500 7,100 5,500 5,500 7,100 7,100 9,600 5,400 5,400 5,400 9,600

Page 30 of 98

ANNEX 2. 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, midfoot; extensive, including posterior talotibial capsulotomy and tendon(s) lengthening as for resistant clubfoot deformity Capsulotomy, midtarsal (Heyman type procedure) Capsulotomy; metatarsophalangeal joint, w/ or w/o tenorrhaphy, single, each joint Capsulotomy; interphalangeal joint, single each joint Webbing operation (create syndactylism of toes) (Kelikian type procedure) Hammertoe operation, one toe (e.g., interphalangeal fusion, filleting, phalangectomy) Cock-up fifth toe operation w/ plastic skin closure (Ruiz-Mora type procedure) Ostectomy, partial, exostectomy or condylectomy, single, metatarsal head, first through fifth, each metatarsal head Hallux valgus (bunion) correction, w/ or w/o sesamoidectomy; simple exostectomy (Silver type procedure) Hallux valgus (bunion) correction, w/ or w/o sesamoidectomy; Keller, McBride, or Mayo type procedure Hallux valgus (bunion) correction, w/ or w/o sesamoidectomy; resection of joint w/ implant Hallux valgus (bunion) correction, w/ or w/o sesamoidectomy; w/ tendon transplants (Joplin type procedure) Hallux valgus (bunion) correction, w/ or w/o sesamoidectomy; w/ metatarsal osteotomy (e.g., Mitchell, Chevron, or concentric type procedures) Hallux valgus (bunion) correction, w/ or w/o sesamoidectomy; Lapidus type procedure Hallux valgus (bunion) correction, w/ or w/o sesamoidectomy; by phalanx osteotomy Hallux valgus (bunion) correction, w/ or w/o sesamoidectomy; by other methods (e.g., double osteotomy) Osteotomy; calcaneus (Dwyer or Chambers type procedure), w/ or w/o internal fixation Osteotomy; talus Osteotomy, midtarsal bones, other than calcaneus or talus; Osteotomy, midtarsal bones, other than calcaneus or talus; w/ autograft (includes obtaining graft)(Fowler type) Osteotomy, metatarsal, base or shaft, single, w/ or w/o lenghtening, for shortening or angular correction; first metatarsal Osteotomy, metatarsal, base or shaft, single, w/ or w/o lenghtening, for shortening or angular correction; first metatarsal w/ autograft Osteotomy, metatarsal, base or shaft, single, w/ or w/o lenghtening, for shortening or angular correction; other than first metatarsal Osteotomy, metatarsals, multiple, for cavus foot (Swanson type procedure) Osteotomy for shortening, angular or rotational correction; proximal phalanx, first toe Osteotomy for shortening, angular or rotational correction; other phalanges, any toe Reconstruction, angular deformity of toe (overlapping second toe, fifth toe, curly toes), soft tissue procedures only Sesamoidectomy, first toe Repair of nonunion or malunion; tarsal bones (e.g., calcaneus, talus) Repair of nonunion or malunion; metatarsal, w/ or w/o bone graft (includes obtaining graft) Reconstruction, toe, macrodactyly; soft tissue resection Reconstruction, toe, macrodactyly; requiring bone resection Reconstruction, toe(s); polydactyly Reconstruction, toe(s); syndactyly, w/ or w/o skin graft(s) Reconstruction, cleft foot Closed treatment of calcaneal fracture Percutaneous skeletal fixation of calcaneal fracture, w/ manipulation Open treatment of calcaneal fracture, w/ or w/o internal or external fixation; Open treatment of calcaneal fracture, w/ or w/o internal or external fixation; w/ primary iliac or other autogenous bone graft (includes obtaining graft) Closed treatment of talus fracture Percutaneous skeletal fixation of talus fracture, w/ manipulation Open treatment of talus fracture, 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), w/ manipulation

Case Rate 20,980 12,120 12,120 12,900 20,980 15,380 21,940 15,380 20,980 21,820 21,820 22,660 22,660 22,660 23,080 23,080 21,400 20,980 15,380 18,420 22,360 22,360 22,360 21,940 18,420 14,960 22,360 12,540 21,940 14,960 12,120 12,540 21,940 22,360 15,380 10,960 11,980 18,000 22,360 10,960 9,700 15,380 11,132 11,980

Professional Fee 10,080 6,720 6,720 6,300 10,080 7,980 9,240 7,980 10,080 10,920 10,920 11,760 11,760 11,760 12,180 12,180 10,500 10,080 7,980 8,820 9,660 9,660 9,660 9,240 8,820 7,560 9,660 7,140 9,240 7,560 6,720 7,140 9,240 9,660 7,980 5,460 5,880 8,400 9,660 5,460 4,200 7,980 4,032 5,880

Health Care Institution Fee 10,900 5,400 5,400 6,600 10,900 7,400 12,700 7,400 10,900 10,900 10,900 10,900 10,900 10,900 10,900 10,900 10,900 10,900 7,400 9,600 12,700 12,700 12,700 12,700 9,600 7,400 12,700 5,400 12,700 7,400 5,400 5,400 12,700 12,700 7,400 5,500 6,100 9,600 12,700 5,500 5,500 7,400 7,100 6,100

Page 31 of 98

ANNEX 2. 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), w/ or w/o internal or external fixation Closed treatment of metatarsal fracture Percutaneous skeletal fixation of metatarsal fracture, w/ manipulation Open treatment of metatarsal fracture, w/ or w/o internal or external fixation Closed treatment of fracture great toe, phalanx or phalanges Percutaneous skeletal fixation of fracture great toe, phalanx or phalanges, w/ manipulation Open treatment of fracture great toe, phalanx or phalanges, w/ or w/o internal or external fixation Closed treatment of fracture, phalanx or phalanges, other than great toe Open treatment of fracture, phalanx or phalanges, other than great toe, w/ or w/o internal or external fixation Closed treatment of sesamoid fracture Open treatment of sesamoid fracture, w/ or w/o internal fixation Closed treatment of tarsal bone dislocation, other than talotarsal Percutaneous skeletal fixation of tarsal bone dislocation, other than talotarsal ,w/ manipulation Open treatment of tarsal bone dislocation, w/ or w/o internal or external fixation Closed treatment of talotarsal joint dislocation Percutaneous skeletal fixation of talotarsal joint dislocation, w/ manipulation Open treatment of talotarsal joint dislocation, w/ or w/o internal or external fixation Closed treatment of tarsometatarsal joint dislocation Percutaneous skeletal fixation of tarsometatarsal joint dislocation, w/ manipulation Open treatment of tarsometatarsal joint dislocation, w/ or w/o internal or external fixation Closed treatment of metatarsophalangeal joint dislocation Percutaneous skeletal fixation of metatarsophalangeal joint dislocation, w/ manipulation Open treatment of metatarsophalangeal joint dislocation, w/ or w/o internal or external fixation Closed treatment of interphalangeal joint dislocation Percutaneous skeletal fixation of interphalangeal joint dislocation, w/ manipulation Open treatment of interphalangeal joint dislocation, w/ or w/o internal or external fixation Pantalar arthrodesis Triple arthrodesis Subtalar arthrodesis Arthrodesis, midtarsal or tarsometatarsal, multiple or transverse; Arthrodesis, midtarsal or tarsometatarsal, multiple or transverse; w/ osteotomy as for flatfoot correction Arthrodesis, midtarsal navicular-cuneiform, w/ tendon lengthening and advancement (Miller type procedure) Arthrodesis, midtarsal or tarsometatarsal, single joint Arthrodesis, great toe; metatarsophalangeal joint Arthrodesis, great toe; interphalangeal joint Arthrodesis, great toe, interphalangeal joint, w/ extensor hallucis longus transfer to first metatarsal neck (Jones type procedure) Amputation, foot; midtarsal (Chopart type procedure) Deep disection below fascia, for deep infection of foot, w/ or w/o tendon shealth involvement; single bursal space specify Deep disection below fascia, for deep infection of foot, w/ or w/o tendon shealth involvement; transmetatarsal Amputation, metatarsal, w/ toe, single Amputation, toe; metatarsophalangeal joint Amputation, toe; interphalangeal joint Application of halo type body cast (see 20661-20663 for insertion) Application of Risser jacket, localizer, body; only Application of Risser jacket, localizer, body; including head Application of turnbuckle jacket, body; only Application of turnbuckle jacket, body; including head Application of body cast, shoulder to hips; Application of body cast, shoulder to hips; including head, Minerva type Application of body cast, shoulder to hips; including one thigh Application of body cast, shoulder to hips; including both thighs Application of body cast, shoulder to hips; shoulder spica Application of body cast, shoulder to hips; plaster Velpeau

Case Rate 10,120 10,880 8,260 10,880 10,120 10,540 12,120 10,120 12,120 8,260 10,120 8,260 12,540 12,540 10,880 12,540 18,000 10,960 12,540 18,000 8,260 12,540 18,000 10,880 12,540 18,000 27,120 27,960 27,120 23,300 23,080 21,940 18,420 18,420 15,380 22,240 23,300 8,260 21,820 12,120 18,000 12,120 10,540 10,540 10,540 10,540 10,540 10,540 10,540 12,120 12,120 9,300 5,560

Professional Fee 4,620 3,780 3,360 3,780 4,620 5,040 6,720 4,620 6,720 3,360 4,620 3,360 7,140 7,140 3,780 7,140 8,400 5,460 7,140 8,400 3,360 7,140 8,400 3,780 7,140 8,400 15,120 15,960 15,120 12,600 12,180 9,240 8,820 8,820 7,980 11,340 12,600 3,360 10,920 6,720 8,400 6,720 5,040 5,040 5,040 5,040 5,040 5,040 5,040 6,720 6,720 2,100 1,260

Health Care Institution Fee 5,500 7,100 4,900 7,100 5,500 5,500 5,400 5,500 5,400 4,900 5,500 4,900 5,400 5,400 7,100 5,400 9,600 5,500 5,400 9,600 4,900 5,400 9,600 7,100 5,400 9,600 12,000 12,000 12,000 10,700 10,900 12,700 9,600 9,600 7,400 10,900 10,700 4,900 10,900 5,400 9,600 5,400 5,500 5,500 5,500 5,500 5,500 5,500 5,500 5,400 5,400 7,200 4,300

Page 32 of 98

ANNEX 2. 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, shoulder to hips; shoulder to hand (long arm) Application of body cast, shoulder to hips; elbow to finger (short arm) Application of body cast, shoulder to hips; hand and lower forearm (gauntlet) Application of hip spica cast; one leg Application of hip spica cast; one and one-half spica or both legs Application of long leg cast (thigh to toes); Application of long leg cast (thigh to toes); 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); Application of short leg cast (below knee to toes); 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, long or short leg Arthroscopy, temporomandibular joint, diagnostic, w/ or w/o synovial biopsy Arthroscopy, temporomandibular joint, surgical Arthroscopy, shoulder, diagnostic, w/ or w/o synovial biopsy Arthroscopy, shoulder, surgical; w/ removal of loose body or foreign body Arthroscopy, shoulder, surgical; synovectomy, partial Arthroscopy, shoulder, surgical; synovectomy, complete Arthroscopy, shoulder, surgical; debridement, limited Arthroscopy, shoulder, surgical; debridement, extensive Arthroscopy, shoulder, surgical; w/ lysis and resection of adhesions, w/ or w/o manipulation Arthroscopy, shoulder, surgical; decompression of subacromial space w/ partial acromioplasty, w/ or w/o coracoacromial release Arthroscopy, elbow, dianostic, w/ or w/o synovial biopsy Arthroscopy, elbow, surgical; w/ removal of loose body or foreign body Arthroscopy, elbow, surgical; synovectomy, partial Arthroscopy, elbow, surgical; synovectomy, complete Arthroscopy, elbow, surgical; debridement, limited Arthroscopy, elbow, surgical; debridement, extensive Arthroscopy, wrist, diagnostic, w/ or w/o synovial biopsy Arthroscopy, wrist, surgical; for infection, lavage and drainage Arthroscopy, wrist, surgical; synovectomy, partial Arthroscopy, wrist, surgical; synovectomy, complete Arthroscopy, wrist, surgical; excision and/or repair of triangular fibrocartilage and/or joint debridement Arthroscopy, wrist, surgical; internal fixation for fracture or instability Arthroscopy, wrist, surgical; w/ release of transverse carpal ligament Arthroscopically aided treatment of intercondylar spine(s) and/or tuberosity fracture(s) of the knee, w/ or w/o manipulation; w/o internal or external fixation (includes arthroscopy) Arthroscopically aided treatment of intercondylar spine(s) and/or tuberosity fracture(s) of the knee, w/ or w/o manipulation; w/ internal or external fixation (includes arthroscopy) Arthroscopically aided treatment of tibial fracture, proximal (plateau); unicondylar, w/ or w/o internal or external fixation (includes arthroscopy) Arthroscopically aided treatment of tibial fracture, proximal (plateau); bicondylar, w/ or w/o internal or external fixation (includes arthroscopy) Arthroscopy, knee, diagnostic, w/ or w/o synovial biopsy Arthroscopy, knee, surgical; for infection, lavage and drainage Arthroscopy, knee, surgical; for removal of loose body or foreign body (e.g., osteochondritis dissecans fragmentation, chondral fragmentation) Arthroscopy, knee, surgical; synovectomy, limited (e.g., plica or shelf resection) Arthroscopy, knee, surgical; synovectomy, major, two or more compartments (e.g., medial or lateral) Arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty) Arthroscopy, knee, surgical; abrasion arthroplasty (includes chondroplasty where necessary) or multiple drilling

Case Rate 5,680 5,560 5,560 8,020 8,440 8,020 8,440 8,440 8,020 8,020 8,020 8,020 5,680 5,680 18,000 20,980 18,000 21,940 20,980 21,820 20,980 23,300 30,740 27,120 18,000 21,940 20,980 21,820 20,980 23,300 12,120 21,940 20,980 21,820 23,300 23,300 23,300 27,120

Professional Fee 1,680 1,260 1,260 2,520 2,940 2,520 2,940 2,940 2,520 2,520 2,520 2,520 1,680 1,680 8,400 10,080 8,400 9,240 10,080 10,920 10,080 12,600 13,440 15,120 8,400 9,240 10,080 10,920 10,080 12,600 6,720 9,240 10,080 10,920 12,600 12,600 12,600 15,120

Health Care Institution Fee 4,000 4,300 4,300 5,500 5,500 5,500 5,500 5,500 5,500 5,500 5,500 5,500 4,000 4,000 9,600 10,900 9,600 12,700 10,900 10,900 10,900 10,700 17,300 12,000 9,600 12,700 10,900 10,900 10,900 10,700 5,400 12,700 10,900 10,900 10,700 10,700 10,700 12,000

29851

27,120

15,120

12,000

29855

27,120

15,120

12,000

29856 29870 29871 29874 29875 29876 29877 29879

27,960 18,000 20,980 21,940 30,740 31,580 23,300 23,300

15,960 8,400 10,080 9,240 13,440 14,280 12,600 12,600

12,000 9,600 10,900 12,700 17,300 17,300 10,700 10,700

Page 33 of 98

ANNEX 2. 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, knee, surgical; w/ meniscectomy (medial and lateral, including any meniscal shaving) Arthroscopy, knee, surgical; w/ meniscectomy (medial or lateral, including any meniscal shaving) Arthroscopy, knee, surgical; w/ meniscus repair (medial or lateral) Arthroscopy, knee, surgical; w/ meniscus repair (medial and lateral) Arthroscopy, knee, surgical; w/ lysis of adhesions, w/ or w/o manipulation Arthroscopy, knee, surgical; drilling for osteochondritis dissecans w/ bone grafting, w/ or w/o internal fixation (including debridement of base of lesion) Arthroscopy, knee, surgical; drilling for intact osteochondritis dissecans lesion Arthroscopy, knee, surgical; 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, ankle (tibiotalar and fibulotalar joints), surgical; w/ removal of loose body or foreign body Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; synovectomy, partial Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; debridement, limited Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; debridement, extensive Drainage abscess or hematoma, nasal, internal approach Drainage abscess or hematoma, nasal septum Biopsy, intranasal Excision, nasal polyp(s), simple Excision, nasal polyp(s), extensive Excision or destruction, any method (including laser), intranasal lesion; internal approach Excision or destruction, any method (including laser), intranasal lesion; external approach (lateral rhinotomy) Excision turbinate, partial or complete Submucous resection turbinate, partial or complete Removal foreign body, intranasal; requiring general anesthesia Removal foreign body, intranasal; by lateral rhinotomy Rhinoplasty for nasal deformity secondary to congenital cleft tip and/or palate, including columellar lengthening; tip only Rhinoplasty for nasal deformity secondary to congenital cleft tip and/or palate, including columellar lengthening; tip, septum, osteotomies Rhinoplasty for nasal vestibular stenosis Septoplasty or submucous resection, w/ or w/o cartilage scoring, contouring or replacement w/ graft Repair choanal atresia; intranasal Repair choanal atresia; transpalatine Lysis intranasal synechia Repair fistula; oromaxillary (combine w/ 31030 if antrotomy is included) Repair fistula; oronasal Repair nasal septal perforations Cauterization and/or ablation, mucosa of turbinates, unilateral or bilateral, any method, ; superficial Cauterization and/or ablation, mucosa of turbinates, unilateral or bilateral, any method, ; intramural Control nasal hemorrhage, posterior, w/ posterior nasal packs and/or cauterization, any method; initial Ligation arteries; ethmoidal Ligation arteries; internal maxillary artery, transantral Fracture nasal turbinate(s), therapeutic Lavage by cannulation; maxillary sinus (antrum puncture or natural ostium) Lavage by cannulation; sphenoid sinus Sinusotomy, maxillary (antrotomy); intranasal Sinusotomy, maxillary (antrotomy); radical (Caldwell-Luc) w/o removal of antrochoanal polyps Sinusotomy, maxillary (antrotomy); radical (Caldwell-Luc) w/ removal of antrochoanal polyps Pterygomaxillary fossa surgery, any approach Sinusotomy, sphenoid, w/ or w/o biopsy; Sinusotomy, sphenoid, w/ or w/o biopsy; w/ mucosal stripping or removal of polyp(s) Sinusotomy frontal; external, simple (trephine operation)

Case Rate 30,740 30,740 27,120 30,300 23,300 23,300 27,120 23,300 37,180 38,860 21,940 20,980 20,980 21,820 5,560 5,560 5,680 8,020 9,700 9,700 9,700 12,900 12,900 8,020 8,020 30,300 30,300 37,800 12,900 12,900 18,000 8,260 12,120 12,120 12,120 9,700 9,700 8,020 12,120 12,120 9,700 9,300 8,020 9,700 12,120 12,120 23,300 23,300 23,300 12,120

Professional Fee 13,440 13,440 15,120 16,800 12,600 12,600 15,120 12,600 18,480 20,160 9,240 10,080 10,080 10,920 1,260 1,260 1,680 2,520 4,200 4,200 4,200 6,300 6,300 2,520 2,520 16,800 16,800 21,000 6,300 6,300 8,400 3,360 6,720 6,720 6,720 4,200 4,200 2,520 6,720 6,720 4,200 2,100 2,520 4,200 6,720 6,720 12,600 12,600 12,600 6,720

Health Care Institution Fee 17,300 17,300 12,000 13,500 10,700 10,700 12,000 10,700 18,700 18,700 12,700 10,900 10,900 10,900 4,300 4,300 4,000 5,500 5,500 5,500 5,500 6,600 6,600 5,500 5,500 13,500 13,500 16,800 6,600 6,600 9,600 4,900 5,400 5,400 5,400 5,500 5,500 5,500 5,400 5,400 5,500 7,200 5,500 5,500 5,400 5,400 10,700 10,700 10,700 5,400

Page 34 of 98

ANNEX 2. 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; transorbital, unilateral (for mucocele or osteoma, Lynch type) Sinusotomy frontal; obliterative w/o osteoplastic flap, brow incision (includes ablation) Sinusotomy frontal; obliterative, w/o osteoplastic flap, coronal inicision (includes ablation) Sinusotomy frontal; obliterative, w/ osteoplastic flap, brow incision Sinusotomy frontal; obliterative, w/ osteoplastic flap, coronal incision Sinusotomy frontal; nonobliterative, w/ osteoplastic flap, brow incision Sinusotomy frontal; nonobliterative, w/ osteoplastic flap, coronal incision Sinusotomy combined, three or more sinuses Ethmoidectomy; intranasal, anterior Ethmoidectomy; intranasal, total Ethmoidectomy; extranasal, total Maxillectomy; w/o orbital exenteration Maxillectomy; w/ orbital exenteration (en bloc) Nasal endoscopy, diagnostic, unilateral or bilateral Nasal/sinus endoscopy, diagnostic w/ maxillary sinusoscopy (via inferior meatus or canine fossa puncture) Nasal/sinus endoscopy, diagnostic w/ sphenoid sinusoscopy (via puncture of sphenoidal face or cannulation of ostium) Nasal/sinus endoscopy, surgical; w/ biopsy, polypectomy or debridement Nasal/sinus endoscopy, surgical; w/ control of epistaxis Nasal/sinus endoscopy, surgical; w/ dacrylocystorhinostomy Nasal/sinus endoscopy, surgical; w/ concha bullosa resection Nasal/sinus endoscopy, surgical; w/ ethmoidectomy, partial (anterior) Nasal/sinus endoscopy, surgical; w/ ethmoidectomy, total (anterior and posterior) Nasal/sinus endoscopy, surgical, w/ maxillary antrostomy Nasal/sinus endoscopy, surgical, w/ removal of tissue from maxillary sinus Nasal/sinus endoscopy, surgical w/ frontal sinus exploration, w/ or w/o removal of tissue from frontal sinus Nasal/sinus endoscopy, surgical, w/ sphenoidotomy Nasal/sinus endoscopy, surgical, w/ removal of tissure from the sphenoid sinus Nasal/sinus endoscopy, surgical, w/ repair of cerebrospinal fluid leak; ethmoid region Nasal/sinus endoscopy, surgical, sphenoid region Nasal/sinus endoscopy, surgical; w/ medial or inferior orbital wall decompression Nasal/sinus endoscopy, surgical; w/ medial orbital wall and inferior orbital wall decompression Nasal/sinus endoscopy, surgical; w/ optic nerve decompression Laryngotomy (thyrotomy, laryngofissure); w/ removal of tumor or laryngocele, cordectomy Laryngectomy; total, w/o radical neck dissection Laryngectomy; total, w/ radical neck dissection Laryngectomy; subtotal supraglottic, w/o radical neck dissection Laryngectomy; subtotal supraglottic, w/ radical neck dissection Partial laryngectomy (hemilaryngectomy); horizontal Partial laryngectomy (hemilaryngectomy); laterovertical Partial laryngectomy (hemilaryngectomy); anterovertical Partial laryngectomy (hemilaryngectomy); antero-latero-vertical Pharyngolaryngectomy, w/ radical neck dissection; w/o reconstruction Pharyngolaryngectomy, w/ radical neck dissection; w/ reconstruction Arytenoidectomy or arytenoidopexy, external approach Epiglottidectomy Intubation, endotracheal, emergency emergency procedure Laryngoscopy direct, w/ or w/o tracheoscopy; for aspiration Laryngoscopy direct, w/ or w/o tracheoscopy; diagnostic, newborn Laryngoscopy direct, w/ or w/o tracheoscopy; diagnostic, except newborn Laryngoscopy direct, w/ or w/o tracheoscopy; diagnostic, w/ operating microscope Laryngoscopy direct, w/ or w/o tracheoscopy; w/ insertion of obturator Laryngoscopy direct, w/ or w/o tracheoscopy; w/ dilatation, initial Laryngoscopy direct, w/ or w/o tracheoscopy; w/ dilatation, subsequent

Case Rate 12,120 12,120 12,120 12,120 23,300 23,300 23,300 23,300 12,120 12,120 12,120 46,500 53,400 10,540 10,540 10,540 12,120 12,120 12,120 18,000 18,000 18,000 18,000 18,000 18,000 18,000 18,000 18,000 18,000 18,000 18,000 23,300 18,000 31,140 37,800 37,180 38,860 31,140 31,140 31,140 31,140 37,800 46,500 30,300 23,300 0 8,020 9,700 8,020 9,700 8,020 8,020 8,020

Professional Fee 6,720 6,720 6,720 6,720 12,600 12,600 12,600 12,600 6,720 6,720 6,720 25,200 29,400 5,040 5,040 5,040 6,720 6,720 6,720 8,400 8,400 8,400 8,400 8,400 8,400 8,400 8,400 8,400 8,400 8,400 8,400 12,600 8,400 17,640 21,000 18,480 20,160 17,640 17,640 17,640 17,640 21,000 25,200 16,800 12,600 0 2,520 4,200 2,520 4,200 2,520 2,520 2,520

Health Care Institution Fee 5,400 5,400 5,400 5,400 10,700 10,700 10,700 10,700 5,400 5,400 5,400 21,300 24,000 5,500 5,500 5,500 5,400 5,400 5,400 9,600 9,600 9,600 9,600 9,600 9,600 9,600 9,600 9,600 9,600 9,600 9,600 10,700 9,600 13,500 16,800 18,700 18,700 13,500 13,500 13,500 13,500 16,800 21,300 13,500 10,700 0 5,500 5,500 5,500 5,500 5,500 5,500 5,500

Page 35 of 98

ANNEX 2. 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, direct, operative, w/ foreign body removal; Laryngoscopy, direct, operative, w/ foreign body removal; w/ operating microscope Laryngoscopy, direct, operative, w/ biopsy; Laryngoscopy, direct, operative, w/ biopsy; w/ operating microscope Laryngoscopy, direct, operative, w/ excision of tumor and/or stripping of vocal cords or epiglottis; Laryngoscopy, direct, operative, w/ excision of tumor and/or stripping of vocal cords or epiglottis; w/ operating microscope Laryngoscopy, direct, operative, w/ arytenoidectomy; Laryngoscopy, direct, operative, w/ arytenoidectomy; w/ operating microscope Laryngoscopy, direct, w/ injection into vocal cord(s), therapeutic; Laryngoscopy, direct, w/ injection into vocal cord(s), therapeutic; w/ operating microscope Laryngoscopy, flexible fiberoptic; diagnostic Laryngoscopy, flexible fiberoptic; w/ biopsy Laryngoscopy, flexible fiberoptic; w/ removal of foreign body Laryngoscopy, flexible fiberoptic; w/ removal of lesion Laryngoscopy, flexible or rigid fiberoptic, w/ stroboscopy Laryngoplasty; for laryngeal web, two stage, w/ keel insertion and removal Laryngoplasty; for laryngeal stenosis, w/ graft or core mold, including tracheotomy Laryngoplasty; w/ open reduction of fracture Laryngoplasty; w/ closed manipulative reduction Laryngoplasty, cricoid split Laryngoplasty, not otherwise specified (e.g., for burns, reconstruction after partial laryngectomy) Laryngeal reinnervation by neuromuscular pedicle Section recurrent laryngeal nerve, therapeutic , unilateral Tracheostomy, planned ; Tracheostomy, planned ; under two years Tracheostomy, emergency procedure; transtracheal Tracheostomy, emergency procedure; cricothyroid membrane Tracheostomy, fenestration procedure with skin flaps Construction of tracheoesophageal fistula and subsequent insertion of an alaryngeal speech prosthesis (e.g., voice button, Blom-Singer prosthesis) Tracheal puncture, percutaneous w/ transtracheal aspiration and/or injection Tracheostoma revision; simple, w/o flap rotation Tracheostoma revision; complex, w/ flap rotation Tracheobronchoscopy through established tracheostomy incision Bronchoscopy; diagnostic, (flexible or rigid), w/ or w/o cell washing or brushing Bronchoscopy; w/ biopsy Bronchoscopy; w/ transbronchial lung biopsy, w/ or w/o fluoroscopic guidance Bronchoscopy; w/ transbronchial needle aspiration biopsy Bronchoscopy; w/ tracheal or bronchial dilation or closed reduction of fracture Bronchoscopy; w/ tracheal dilation and placement of tracheal stent Bronchoscopy; w/ removal of foreign body Bronchoscopy; diagnostic, (flexible or rigid),w/ placement of bronchial stents Bronchoscopy; w/ excision of tumor Bronchoscopy; w/ destruction of tumor or relief of stenosis by any method other than excision (e.g., laser) Bronchoscopy; w/ placement of catheters for intracavitary radioelement application Bronchoscopy; w/ therapeutic aspiration of tracheobronchial tree, (e.g., drainage of lung abscess) Catheterization for bronchography, w/ or w/o instillation of contrast material Catheterization w/ bronchial brush biopsy Tracheoplasty; cervical Tracheoplasty; tracheopharyngeal fistulization, each stage Tracheoplasty; intrathoracic Carinal reconstruction Bronchoplasty; graft repair Bronchoplasty; excision stenosis and anastomosis Excision tracheal stenosis and anastomosis; cervical Excision tracheal stenosis and anastomosis; cervicothoracic Excision of tracheal tumor or carcinoma; cervical Excision of tracheal tumor or carcinoma; thoracic Suture of tracheal wound or injury; cervical

Case Rate 12,120 12,120 12,120 12,120 12,120 12,120 30,300 30,300 12,120 12,120 12,120 12,120 12,120 12,120 12,120 30,300 30,300 30,300 30,300 30,300 30,300 30,300 23,300 12,120 12,540 7,140 12,540 12,540 14,960 12,900 12,120 14,960 12,120 10,960 10,960 10,960 10,960 18,000 18,000 18,000 18,000 30,300 30,300 18,000 23,300 5,560 23,300 37,800 37,800 53,400 55,000 55,000 55,000 46,500 53,400 37,800 55,000 23,300

Professional Fee 6,720 6,720 6,720 6,720 6,720 6,720 16,800 16,800 6,720 6,720 6,720 6,720 6,720 6,720 6,720 16,800 16,800 16,800 16,800 16,800 16,800 16,800 12,600 6,720 7,140 4,760 7,140 7,140 7,560 6,300 6,720 7,560 6,720 5,460 5,460 5,460 5,460 8,400 8,400 8,400 8,400 16,800 16,800 8,400 12,600 1,260 12,600 21,000 21,000 29,400 33,600 33,600 33,600 25,200 29,400 21,000 33,600 12,600

Health Care Institution Fee 5,400 5,400 5,400 5,400 5,400 5,400 13,500 13,500 5,400 5,400 5,400 5,400 5,400 5,400 5,400 13,500 13,500 13,500 13,500 13,500 13,500 13,500 10,700 5,400 5,400 2,380 5,400 5,400 7,400 6,600 5,400 7,400 5,400 5,500 5,500 5,500 5,500 9,600 9,600 9,600 9,600 13,500 13,500 9,600 10,700 4,300 10,700 16,800 16,800 24,000 21,400 21,400 21,400 21,300 24,000 16,800 21,400 10,700

Page 36 of 98

ANNEX 2. 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; intrathoracic Surgical closure tracheostomy or fistula w/o plastic repair Surgical closure tracheostomy or fistula with plastic repair Thoracentesis, puncture of pleural cavity for aspiration, initial or subsequent Thoracentesis w/ insertion of tube w/ or w/o water seal (e.g., for pneumothorax) Chemical pleurodesis (e.g., for recurrent or persistent pneumothorax) Tube thoracostomy w/ or w/o water seal (e.g., for abscess, hemothorax, empyema) Thoracostomy; w/ rib resection for empyema Thoracostomy; w/ open flap drainage for empyema Thoracotomy, limited, for biopsy of lung or pleura Thoracotomy, major; w/ exploration and biopsy Thoracotomy, major; w/ control of traumatic hemorrhage and/or repair of lung tear Thoracotomy, major; for postoperative complications Thoracotomy, major; w/ open intrapleural pneumonolysis Thoracotomy, major; w/ cyst(s) removal, w/ or w/o a pleural procedure Thoracotomy, major; w/ excision-plication of bullae, w/ or w/o a pleural procedure Thoracotomy, major; w/ removal of intrapleural foreign body or fibrin deposit Thoracotomy, major; w/ removal of intrapulmonary foreign body THORACOTOMY, MAJOR; w/ cardiac massage Pneumonostomy, w/ open drainage of abscess or cyst Pleural scarification for repeat pneumothorax Decortication, pulmonary ; total Decortication, pulmonary ; partial Pleurectomy, parietal Decortication and parietal pleurectomy Biopsy, pleura; percutaneous needle Biopsy, pleura; open Biopsy, lung or mediastinum, percutaneous needle Pneumonocentesis, puncture of lung for aspiration Removal of lung, total pneumonectomy Removal of lung, w/ resection of segment of trachea followed by bronchotracheal anastomosis (sleeve pneumonectomy) Removal of lung, extrapleural Removal of lung, other than total pneumonectomy; single lobe (lobectomy) Removal of lung, other than total pneumonectomy; two lobes (bilobectomy) Removal of lung, other than total pneumonectomy; single segment (segmentectomy) Removal of lung, other than total pneumonectomy; w/ circumferential resection of segment of bronchus followed by broncho-bronchial anastomosis (sleeve lobectomy) Removal of lung, other than total pneumonectomy; all remaining lung following previous removal of a portion of lung (completion pneumonectomy) Removal of lung, other than total pneumonectomy; excision-plication of emphysematous lung(s) (bullous or non-bullous) for lung volumeRemoval of lung, other than total pneumonectomy; reduction, sternal split or transthoracic approach, w/ or w/o any pleural procedure Removal of lung, other than total pneumonectomy; wedge resection, single or multiple Resection of lung; w/ resection of chest wall Resection of lung; w/ reconstruction of chest wall, w/o prothesis Resection of lung; w/ major reconstruction of chest wall, w/ prosthesis Extrapleural enucleation of empyema (empyemectomy) Thoracoscopy, diagnostic ; lungs and pleural space, w/o biopsy Thoracoscopy, diagnostic ; lungs and pleural space, w/ biopsy Thoracoscopy, diagnostic ; pericardial sac, w/o biopsy Thoracoscopy, diagnostic ; pericardial sac, w/ biopsy Thoracoscopy, diagnostic ; mediastinal space, w/o biopsy Thoracoscopy, diagnostic ; mediastinal space, w/ biopsy Thoracoscopy, surgical; w/ pleurodesis, any method Thoracoscopy, surgical; w/ partial pulmonary decortication Thoracoscopy, surgical; w/ total pulmonary decortication, including intrapleural pneumonolysis Thoracoscopy, surgical; w/ removal of intrapleural foreign body or firbin deposit

Case Rate 37,800 8,440 9,700 1,260 10,540 10,540 7,980 12,120 18,420 31,140 37,800 37,800 37,800 37,800 37,800 41,160 38,440 38,440 38,440 10,120 38,640 38,440 30,300 37,800 37,800 5,560 37,180 8,440 5,560 46,500 55,080 55,080 41,160 46,500 46,500 55,080

Professional Fee 21,000 2,940 4,200 840 5,040 5,040 5,320 6,720 8,820 17,640 21,000 21,000 21,000 21,000 21,000 24,360 19,740 19,740 19,740 4,620 21,840 19,740 16,800 21,000 21,000 1,260 18,480 2,940 1,260 25,200 31,080 31,080 24,360 25,200 25,200 31,080

Health Care Institution Fee 16,800 5,500 5,500 420 5,500 5,500 2,660 5,400 9,600 13,500 16,800 16,800 16,800 16,800 16,800 16,800 18,700 18,700 18,700 5,500 16,800 18,700 13,500 16,800 16,800 4,300 18,700 5,500 4,300 21,300 24,000 24,000 16,800 21,300 21,300 24,000

32488

53,400

29,400

24,000

32491

41,160

24,360

16,800

32500 32520 32522 32525 32540 32601 32602 32603 32604 32605 32606 32650 32651 32652 32653

40,320 53,400 53,400 53,400 38,440 11,980 12,900 12,120 12,120 12,120 12,120 12,120 12,120 12,120 12,120

23,520 29,400 29,400 29,400 19,740 5,880 6,300 6,720 6,720 6,720 6,720 6,720 6,720 6,720 6,720

16,800 24,000 24,000 24,000 18,700 6,100 6,600 5,400 5,400 5,400 5,400 5,400 5,400 5,400 5,400

Page 37 of 98

ANNEX 2. 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, surgical; w/ control of traumatic hemorrhage Thoracoscopy, surgical; w/ excision-plication of bullae, including any pleural procedure Thoracoscopy, surgical; w/ parietal pleurectomy Thoracoscopy, surgical; w/ removal of clot or foreign body from pericardial sac Thoracoscopy, surgical; w/ creation of percardial window or partial resection of pericardial sac for drainage Thoracoscopy, surgical; w/ total pericardiectomy Thoracoscopy, surgical; w/ excision of pericardial cyst, tumor, or mass Thoracoscopy, surgical; w/ excision of mediastinal cyst, tumor, or mass Thoracoscopy, surgical; w/ lobectomy, total or segmental Thoracoscopy, surgical; w/ thoracic sympathectomy Thoracoscopy, surgical; 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, chest wall (posttraumatic) Donor pneumonectomy(ies) w/ preparation and maintenance of allograft (cadaver) Lung transplant, single; w/o cardiopulmonary bypass Lung transplant, single; w/ cardiopulmonary bypass Lung transplant, double (bilateral sequential or en bloc); w/o cardiopulmonary bypass Lung transplant, double (bilateral sequential or en bloc); w/ cardiopulmonary bypass Resection of ribs, extrapleural, all stages Thoracoplasty, Schede type or extrapleural (all stages); Thoracoplasty, Schede type or extrapleural (all stages); w/ closure of bronchial fistula Pneumonolysis, extraperiosteal, including filling or packing procedures Pneumothorax, therapeutic, 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, subtotal or complete; w/o cardiopulmonary bypass Pericardiectomy, subtotal or complete; w/ cardiopulmonary bypass Excision of pericardial cyst or tumor Excision of intracardiac tumor, resection w/ cardiopulmonary bypass Resection of external cardiac tumor Insertion of permanent pacemaker w/ epicardial electrode(s); by thoracotomy Insertion of permanent pacemaker w/ epicardial electrode(s); by xiphoid approach Insertion or replacement of permanent pacemaker w/ transvenous electrode(s); atrial Insertion or replacement of permanent pacemaker w/ transvenous electrode(s); ventricular Insertion or replacement of permanent pacemaker w/ transvenous electrode(s); 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; single chamber Insertion or replacement of pacemaker pulse generator only; dual chamber Upgrade of implanted pacemaker system, conversion of single chamber system to dual chamber system (includes removal of previously placed pulse generator, testing of existing lead, insertion of new lead, insertion of new pulse generator) Insertion, replacement or repositioning of permanent transvenous electrode(s) only (15 days or more after initial insertion); single chamber, atrial or ventricular Insertion, replacement or repositioning of permanent transvenous electrode(s) only (15 days or more after initial insertion); dual chamber

Case Rate 30,300 41,160 38,640 38,640 38,640 41,160 41,160 41,160 46,500 41,160 41,160 23,300 23,300 46,500 46,500 55,000 63,000 64,680 65,520 65,520 46,500 46,500 46,500 30,300 5,560 8,020 9,700 18,000 32,000 46,500 58,800 37,800 60,900 39,900 21,400 21,400 18,000 18,000 21,400 9,700 9,700 9,700 12,900

Professional Fee 16,800 24,360 21,840 21,840 21,840 24,360 24,360 24,360 25,200 24,360 24,360 12,600 12,600 25,200 25,200 33,600 42,000 43,680 44,520 44,520 25,200 25,200 25,200 16,800 1,260 2,520 4,200 8,400 14,700 25,200 37,800 21,000 39,900 23,100 10,500 10,500 8,400 8,400 10,500 4,200 4,200 4,200 6,300

Health Care Institution Fee 13,500 16,800 16,800 16,800 16,800 16,800 16,800 16,800 21,300 16,800 16,800 10,700 10,700 21,300 21,300 21,400 21,000 21,000 21,000 21,000 21,300 21,300 21,300 13,500 4,300 5,500 5,500 9,600 17,300 21,300 21,000 16,800 21,000 16,800 10,900 10,900 9,600 9,600 10,900 5,500 5,500 5,500 6,600

33214

32,000

14,700

17,300

33216

12,900

6,300

6,600

33217

18,000

8,400

9,600

Page 38 of 98

ANNEX 2. 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, permanent pacemaker or single chamber pacing cardioverter-defibrillator Repair of two transvenous electrode for a dual chamber, 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); single lead system, atrial or ventricular Removal of permanent of transvenous pacemaker electrode(s); dual lead chamber Removal of permanent epicardial pacemaker and electrodes by thoracotomy; single lead system, atrial or ventricular Removal of permanent epicardial pacemaker and electrodes by thoracotomy; 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; by thoracotomy Removal of implantable cardioverter-defibrillator pulse generator and/or lead system; by transvenous extraction Implantation or replacement of implantable cardioverter-defibrillator pads by thoracotomy, w/ or w/o sensing electrodes; Implantation or replacement of implantable cardioverter-defibrillator pads by thoracotomy, w/ insertion of implantable cardioverter-defibrillator pulse generator Implantation or replacement of implantable cardioverter-defibrillator pads by thoracotomy, w/ insertion of cardio-defibrillator pulse generator Operative ablation of supraventicular arrhythmogenic focus or pathway (e.g., Wolff-Parkinson-White, A-V node reentry), tract(s) and/or focus (foci); w/o cardiopulmonary bypass Operative ablation of supraventicular arrhythmogenic focus or pathway (e.g., Wolff-Parkinson-White, A-V node reentry), tract(s) and/or focus (foci); w/ cardiopulmonary bypass Operative incisions and reconstruction of atria for treatment of atrial fibrillation or atrial flutter (e.g., maze procedure) Operative ablation of ventricular arrhythmogenic focus w/ cardiopulmonary bypass Repair of cardiac wound; w/o bypass Repair of cardiac wound; w/ cardiopulmonary bypass Cardiotomy, exploratory (includes removal of foreign body); w/o bypass Cardiotomy, exploratory (includes removal of foreign body); w/ cardiopulmonary bypass Suture repair of aorta or great vessels; w/o shunt or cardiopulmonary bypass Suture repair of aorta or great vessels; w/ shunt bypass Suture repair of aorta or great vessels; w/ cardiopulmonary bypass Insertion of graft, aorta or great vessels; w/o shunt, or cardiopulmonary bypass Insertion of graft, aorta or great vessels; w/ shunt bypass Insertion of graft, aorta or great vessels; w/ cardiopulmonary bypass Valvuloplasty, aortic valve; open, w/ cardiopulmonary bypass Valvuloplasty, aortic valve; open, w/ inflow occlusion Valvuloplasty, aortic valve; using transventricular dilation, w/ cardiopulmonary bypass Construction of apica-aortic conduit Replacement, aortic valve, w/ cardiopulmonary bypass; w/ prosthetic valve other than homograft Replacement, aortic valve, w/ cardiopulmonary bypass; w/ homograft valve (freehand) Replacement, aortic valve; w/ aortic annulus enlargement, noncoronary cusp Replacement, aortic valve; w/ transventricular aortic annulus enlargement (Konno procedure) Replacement, aortic valve; 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 23,300 23,300 18,000 18,000 12,900 23,300 32,000 30,300 37,600 30,300 18,000 18,000 30,300 30,300 12,900 21,400

Professional Fee 12,600 12,600 8,400 8,400 6,300 12,600 14,700 16,800 18,900 16,800 8,400 8,400 16,800 16,800 6,300 10,500

Health Care Institution Fee 10,700 10,700 9,600 9,600 6,600 10,700 17,300 13,500 18,700 13,500 9,600 9,600 13,500 13,500 6,600 10,900

33249

18,000

8,400

9,600

33250

37,600

18,900

18,700

33251 33253 33261 33300 33305 33310 33315 33320 33321 33322 33330 33332 33335 33400 33401 33403 33404 33405 33406 33411 33412 33413 33414

53,400 58,800 58,800 46,500 58,800 46,500 58,800 30,300 58,800 58,800 46,500 63,000 63,000 53,400 53,400 55,000 58,800 53,400 58,800 55,000 58,800 71,400 46,500

29,400 37,800 37,800 25,200 37,800 25,200 37,800 16,800 37,800 37,800 25,200 42,000 42,000 29,400 29,400 33,600 37,800 29,400 37,800 33,600 37,800 50,400 25,200

24,000 21,000 21,000 21,300 21,000 21,300 21,000 13,500 21,000 21,000 21,300 21,000 21,000 24,000 24,000 21,400 21,000 24,000 21,000 21,400 21,000 21,000 21,300

Page 39 of 98

ANNEX 2. 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.g., asymmetric septal hypertrophy) Ventriculomyotomy (-myectomy) for idiopathic hypertrophic subaortic stenosis (e.g., asymmetric septal hypertrophy) Aortoplasty (gusset) for supravalvular stenosis Valvotomy, mitral valve; closed heart Valvotomy, mitral valve; open heart, w/ cardiopulmonary bypass Valvuloplasty, mitral valve, w/ cardiopulmonary bypass; Valvuloplasty, mitral valve, w/ cardiopulmonary bypass; w/ prosthetic ring Valvuloplasty, mitral valve, w/ cardiopulmonary bypass; radical reconstruction, w/ or w/o ring Replacement, mitral valve, w/ cardiopulmonary bypass Valvectomy, tricuspid valve, w/ cardiopulmonary bypass Valvuloplasty, tricuspid valve; w/o ring insertion Valvuloplasty, tricuspid valve; w/ ring insertion Replacement, tricuspid valve, w/ cardiopulmonary bypass Tricuspid valve repositioning and plication for Ebstein anomaly Valvotomy, pulmonary valve, closed heart; transventricular Valvotomy, pulmonary valve, closed heart; via pulmonary artery Valvotomy, pulmonary valve, open heart; w/ inflow occlusion Valvotomy, pulmonary valve, open heart; w/ cardiopulmonary bypass Replacement, pulmonary valve Right ventricular resection for infundibular stenosis, with or without commisurotomy Outflow tract augmentation (gusset), w/ or w/o commissurotomy or infundibular resection Repair of coronary arteriovenous or arteriocardiac chamber fistula; w/ cardiopulmonary bypass Repair of coronary arteriovenous or arteriocardiac chamber fistula; w/o cardiopulmonary bypass Repair of anomalous coronary artery; by ligation Repair of anomalous coronary artery; by graft, w/o cardiopulmonary bypass Repair of anomalous coronary artery; by graft, w/ cardiopulmonary bypass Repair of anomalous coronary artery; with construction of intrapulmonary artery tunnel (Takeuchi procedure) Repair of anomalous coronary artery; by translocation from pulmonary artery to aorta Coronary artery bypass, vein only; single coronary venous graft Coronary artery bypass, vein only; two coronary venous grafts Coronary artery bypass, vein only; three coronary venous grafts Coronary artery bypass, vein only; four coronary venous grafts Coronary artery bypass, vein only; five coronary venous grafts Coronary artery bypass, vein only; six or more coronary venous grafts Coronary artery bypass, using venous graft(s) and arterial graft(s); single vein graft (list separately in addition to code for arterial graft) Coronary artery bypass, using venous graft(s) and arterial graft(s); two venous grafts (list separately in addition to code for arterial graft) Coronary artery bypass, using venous graft(s) and arterial graft(s); three venous grafts (list separately in addition to code for arterial graft) Coronary artery bypass, using venous graft(s) and arterial graft(s); four venous grafts (list separately in addition to code for arterial graft) Coronary artery bypass, using venous graft(s) and arterial graft(s); five venous grafts (list separately in addition to code for arterial graft) Coronary artery bypass, using venous graft(s) and arterial graft(s); six or more venous grafts (list separately in addition to code for arterial graft) Reoperation, coronary artery bypass procedure or valve procedure, more than one month after original operation (list separately in addition to code for primary procedure) Coronary artery bypass, using arterial graft(s); single arterial graft Coronary artery bypass, using arterial graft(s); two coronary arterial grafts Coronary artery bypass, using arterial graft(s); three coronary arterial grafts Coronary artery bypass, using arterial graft(s); four or more coronary arterial grafts Myocardial resection (e.g., ventricular aneurysmectomy)

Case Rate 46,500 55,000 46,500 37,800 53,400 55,000 57,100 58,800 46,500 46,500 53,400 55,000 53,400 58,800 30,300 23,300 46,500 46,500 53,400 46,500 53,400 46,500 30,300 30,300 46,500 53,400 53,400 53,400 53,400 53,400 55,000 58,800 58,800 58,800 53,400

Professional Fee 25,200 33,600 25,200 21,000 29,400 33,600 35,700 37,800 25,200 25,200 29,400 33,600 29,400 37,800 16,800 12,600 25,200 25,200 29,400 25,200 29,400 25,200 16,800 16,800 25,200 29,400 29,400 29,400 29,400 29,400 33,600 37,800 37,800 37,800 29,400

Health Care Institution Fee 21,300 21,400 21,300 16,800 24,000 21,400 21,400 21,000 21,300 21,300 24,000 21,400 24,000 21,000 13,500 10,700 21,300 21,300 24,000 21,300 24,000 21,300 13,500 13,500 21,300 24,000 24,000 24,000 24,000 24,000 21,400 21,000 21,000 21,000 24,000

33518

53,400

29,400

24,000

33519

55,000

33,600

21,400

33521

58,800

37,800

21,000

33522

58,800

37,800

21,000

33523

58,800

37,800

21,000

33530 33533 33534 33535 33536 33542

63,000 53,400 53,400 55,000 58,800 63,000

42,000 29,400 29,400 33,600 37,800 42,000

21,000 24,000 24,000 21,400 21,000 21,000

Page 40 of 98

ANNEX 2. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE
33545

DESCRIPTION
Repair of postinfarction ventricular septal defect, w/ or w/o myocardial resection Coronary endarterectomy, open, any method, of left anterior descending, circumflex, or right coronary artery performed in conjuction w/ coronary artery bypass graft procedure, 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.g., 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.g., 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.g., single ventricle) by modified Fontan procedure Repair of single ventricle w/ aortic outflow obstruction and aortic arch hypoplasia (hypoplastic left heart syndrome) (e.g., Norwood procedure) Repair atrial septal defect, secundum, w/ cardiopulmonary bypass, w/ or w/o patch Direct or patch closure, sinus venosus, w/ or w/o anomalous pulmonary venous drainage Repair of atrial septal defect and ventricular septal defect, w/ direct or patch closure Repair of incomplete or partial atrioventricular canal (ostium primum atrial septal defect), w/ or w/o atrioventricular valve repair Repair of intermediate or transitional atrioventricular canal, w/ or w/o atrioventricular valve repair Repair of complete atrioventricular canal, w/ or w/o prosthetic valve Closure of ventricular septal defect, w/ or w/o patch; Closure of ventricular septal defect, w/ or w/o patch; with pulmonary valvotomy or infundibular resection (acyanotic) Closure of ventricular septal defect, w/ or w/o patch; with removal of pulmonary artery band, w/ or w/o gusset Banding of pulmonary artery Complete repair of tetralogy of Fallot w/o pulmonary atresia; Complete repair of tetralogy of Fallot w/o pulmonary atresia; 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, w/ cardiopulmonary bypass Repair sinus of Valsalva fistula, with repair of ventricular septal defect Repair sinus of Valsalva aneurysm, with cardiopulmonary bypass Closure of aortico-left ventricular tunnel Complete repair of anomalous venous return (supracardiac, intracardiac, or infracardiac types) Repair of cor triatum or supravalvular mitra ring by resection of left atrial membrane Atrial septectomy or septostomy; closed heart (Blalock-Hanlon type operation) Atrial septectomy or septostomy; open heart w/ cardiopulmonary bypass Atrial septectomy or septostomy; open heart w/ inflow occlusion Shunt; subclavian to pulmonary artery (Blalock- Taussig type operation) Shunt; central, w/ prosthetic graft Shunt; superior vena cava to pulmonary artery for flow to one lung (classical Glenn procedure) Shunt; 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; w/o surgical enlargement of ventricular septal defect

Case Rate 63,000

Professional Fee 42,000

Health Care Institution Fee 21,000

33572

9,700

4,200

5,500

33600 33602 33606 33608

46,500 46,500 53,400 55,000

25,200 25,200 29,400 33,600

21,300 21,300 24,000 21,400

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 55,000 55,000 55,000 55,000 63,000 46,500 53,400 55,000 55,000 55,000 58,800 46,500 55,000 55,000 21,400 55,000 55,000 55,000 46,500 55,000 53,400 53,400 55,000 55,000 21,400 46,500 46,500 30,300 23,300 30,300 46,500 58,800

33,600 33,600 33,600 33,600 33,600 42,000 25,200 29,400 33,600 33,600 33,600 37,800 25,200 33,600 33,600 10,500 33,600 33,600 33,600 25,200 33,600 29,400 29,400 33,600 33,600 10,500 25,200 25,200 16,800 12,600 16,800 25,200 37,800

21,400 21,400 21,400 21,400 21,400 21,000 21,300 24,000 21,400 21,400 21,400 21,000 21,300 21,400 21,400 10,900 21,400 21,400 21,400 21,300 21,400 24,000 24,000 21,400 21,400 10,900 21,300 21,300 13,500 10,700 13,500 21,300 21,000

Page 41 of 98

ANNEX 2. 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; with surgical enlagement of ventricular septal defect Repair of transposition of the great arteries, atrial baffle procedure (e.g., Mustard or Senning type) w/ cardiopulmonary bypass Repair of transposition of the great arteries, atrial baffle procedure (e.g., Mustard or Senning type) w/ removal of pulmonary band Repair of transposition of the great arteries, atrial baffle procedure (e.g., Mustard or Senning type) w/ closure of ventricular septal defect Repair of transposition of the great arteries, atrial baffle procedure (e.g., Mustard or Senning type) w/ repair of subpulmonic obstruction Repair of transposition of the great arteries, aortic pulmonary artery reconstruction (e.g., Jatene type) Repair of transposition of the great arteries, aortic pulmonary artery reconstruction (e.g., Jatene type) w/ removal of pulmonary band Repair of transposition of the great arteries, aortic pulmonary artery reconstruction (e.g., Jatene type) w/ closure of ventricular septal defect Repair of transposition of the great arteries, aortic pulmonary artery reconstruction (e.g., Jatene type) w/ repair of subpulmonic obstruction Total repair, truncus arteriosus (Rastelli type operation) Reimplantation of an anomalous pulmonary artery Aortic suspension (aortopexy) for tracheal decompression (e.g., 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; by ligation Repair of patent ductus arteriosus; by division, under 18 years Repair of patent ductus arteriosus; by division, 18 years and older Excision of coarctation of aorta, w/ or w/o associated patent ductus arteriosus; w/ direct anastomosis Excision of coarctation of aorta, w/ or w/o associated patent ductus arteriosus; with graft Excision of coarctation of aorta, w/ or w/o associated patent ductus arteriosus; 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 Repair of hypoplastic or interrupted aortic arch using autogenous or prosthetic material; w/ cardiopulmonary bypass Ascending aorta graft, w/ cardiopulmonary bypass, w/ or w/o valve suspension; Ascending aorta graft, w/ cardiopulmonary bypass, w/ or w/o valve suspension; w/ coronary reconstruction Ascending aorta graft, w/ cardiopulmonary bypass, w/ or w/o valve suspension; w/ aortic root replacement using composite prosthesis and coronary reconstruction Transverse arch graft, w/ cardiopulmonary bypass Descending thoracic aorta graft, w/ or w/o bypass Repair of thoracoabdominal aortic aneurysm w/ graft, w/ or w/o cardiopulmonary bypass Pulmonary artery embolectomy; w/ cardiopulmonary bypass Pulmonary artery embolectomy; w/o cardiopulmonary bypass Pulmonary endarterectomy, w/ or w/o embolectomy, w/ cardiopulmonary bypass Repair of pulmonary artery stenosis by reconstruction w/ patch or graft Repair of pulmonary atresia w/ ventricular septal defect, by unifocalization of pulmonary arteries; w/o cardiopulmonary bypass Repair of pulmonary atresia w/ ventricular septal defect, by unifocalization of pulmonary arteries; w/ cardiopulmonary bypass Repair of pulmonary atresia w/ ventricular septal defect, 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, performed in conjuction w/ a congenital heart procedure (List separately in addition to code for primary procedure) Donor cardiectomy-pneumonectomy, w/ preparation and maintenance of allograft Heart-lung transplant w/ recipient cardiectomy-pneumonectomy Donor cardiectomy, w/ preparation and maintenance of allograft Heart transplant, w/ or w/o recipient cardiectomy

Case Rate 58,800 58,800 60,900 60,900 60,900 63,000 65,100 71,400

Professional Fee 37,800 37,800 39,900 39,900 39,900 42,000 44,100 50,400

Health Care Institution Fee 21,000 21,000 21,000 21,000 21,000 21,000 21,000 21,000

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

71,400 58,800 55,000 21,400 21,400 23,300 46,500 32,000 30,300 30,300 30,300 30,300 30,300 30,300 46,500 55,000 58,800 71,400 71,400 63,000 71,400 46,500 30,300 53,400 53,400 30,300 46,500 58,800 46,500 18,000 46,500 75,600 46,500 75,600

50,400 37,800 33,600 10,500 10,500 12,600 25,200 14,700 16,800 16,800 16,800 16,800 16,800 16,800 25,200 33,600 37,800 50,400 50,400 42,000 50,400 25,200 16,800 29,400 29,400 16,800 25,200 37,800 25,200 8,400 25,200 54,600 25,200 54,600

21,000 21,000 21,400 10,900 10,900 10,700 21,300 17,300 13,500 13,500 13,500 13,500 13,500 13,500 21,300 21,400 21,000 21,000 21,000 21,000 21,000 21,300 13,500 24,000 24,000 13,500 21,300 21,000 21,300 9,600 21,300 21,000 21,300 21,000

Page 42 of 98

ANNEX 2. 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, 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, including repair of the ascending aorta, w/ or w/o graft Implantation of ventricular assist device; single ventricle support Implantation of ventricular assist device; biventricular support Removal of ventricular assist device; single ventricle support Removal of ventricular assist device; biventricular support Embolectomy or thrombectomy, w/ or w/o catheter; carotid, subclavian or innominate artery, by neck incision Embolectomy or thrombectomy, w/ or w/o catheter; innominate, subclavian artery, by thoracic incision Embolectomy or thrombectomy, w/ or w/o catheter; axillary, brachial, innominate, subclavian artery, by arm incision Embolectomy or thrombectomy, w/ or w/o catheter; radial or ulnar artery, by arm incision Embolectomy or thrombectomy, w/ or w/o catheter; renal, celiac, mesentery, aortoiliac artery, by abdominal incision Embolectomy or thrombectomy, w/ or w/o catheter; femoropopliteal, aortoiliac artery, by leg incision Embolectomy or thrombectomy, w/ or w/o catheter; popliteal-tibioperoneal artery, by leg incision Thrombectomy, direct or w/ catheter; vena cava, iliac vein, by abdominal incision Thrombectomy, direct or w/ catheter; vena cava, iliac, femoropopliteal vein, by leg incision Thrombectomy, direct or w/ catheter; vena cava, iliac, femoropopliteal vein, by abdominal and leg incision Thrombectomy, direct or w/ catheter; subclavian vein, by neck incision Thrombectomy, direct or w/ catheter; axillary and subclavian vein, by arm incision Valvuloplasty, femoral vein Reconstruction of vena cava, any method Venous valve transposition, any vein donor Cross-over vein graft to venous sytem Saphenopopliteal vein anastomosis Direct repair of aneurysm, false aneurysm, or excision (partial or total) and graft insertion, w/ or w/o patch graft; for aneurysm and associated occlusive disease, carotid, subclavian artery, by neck incision Direct repair of aneurysm, false aneurysm, or excision (partial or total) and graft insertion, w/ or w/o patch graft; for ruptured aneurysm, carotid, subclavian artery, by neck incision Direct repair of aneurysm, false aneurysm, or excision (partial or total) and graft insertion, w/ or w/o patch graft; for aneurysm, false aneurysm, and associated occlusive disease, vertebral artery Direct repair of aneurysm, false aneurysm, or excision (partial or total) and graft insertion, w/ or w/o patch graft; for aneurysm and associated occlusive disease, axillary-brachial artery, by arm incision Direct repair of aneurysm, false aneurysm, or excision (partial or total) and graft insertion, w/ or w/o patch graft; for ruptured aneurysm, axillarybrachial artery, by arm incision Direct repair of aneurysm, false aneurysm, or excision (partial or total) and graft insertion, w/ or w/o patch graft; for aneurysm, false aneurysm, and associated occlusive disease, innominate, subclavian artery, by thoracic incision Direct repair of aneurysm, false aneurysm, or excision (partial or total) and graft insertion, w/ or w/o patch graft; for ruptured aneurysm, innominate, subclavian artery, by thoracic insertion Direct repair of aneurysm, false aneurysm, or excision (partial or total) and graft insertion, w/ or w/o patch graft; for aneurysm, false aneurysm, and associated occlusive disease, radial or ulnar artery Direct repair of aneurysm, false aneurysm, or excision (partial or total) and graft insertion, w/ or w/o patch graft; for aneurysm, false aneurysm, and associated occlusive disease, abdominal aorta Direct repair of aneurysm, false aneurysm, or excision (partial or total) and graft insertion, w/ or w/o patch graft; for ruptured aneurysm, abdominal aorta

Case Rate 12,900 9,700 21,400 30,300 46,500 55,000 37,800 46,500 32,000 32,000 23,300 23,300 30,300 23,300 23,300 30,300 32,000 37,600 32,000 23,300 30,300 30,300 30,300 30,300 30,300 23,300

Professional Fee 6,300 4,200 10,500 16,800 25,200 33,600 21,000 25,200 14,700 14,700 12,600 12,600 16,800 12,600 12,600 16,800 14,700 18,900 14,700 12,600 16,800 16,800 16,800 16,800 16,800 12,600

Health Care Institution Fee 6,600 5,500 10,900 13,500 21,300 21,400 16,800 21,300 17,300 17,300 10,700 10,700 13,500 10,700 10,700 13,500 17,300 18,700 17,300 10,700 13,500 13,500 13,500 13,500 13,500 10,700

35002

30,300

16,800

13,500

35005

30,300

16,800

13,500

35011

18,000

8,400

9,600

35013

23,300

12,600

10,700

35021

23,300

12,600

10,700

35022

30,300

16,800

13,500

35045

18,000

8,400

9,600

35081

46,500

25,200

21,300

35082

53,400

29,400

24,000

Page 43 of 98

ANNEX 2. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE DESCRIPTION
Direct repair of aneurysm, false aneurysm, or excision (partial or total) and graft insertion, w/ or w/o patch graft; for aneurysm, false aneurysm, and associated occlusive disease, abdominal aorta involving visceral vessels (mesenteric, celiac, renal) Direct repair of aneurysm, false aneurysm, or excision (partial or total) and graft insertion, w/ or w/o patch graft; for ruptured aneurysm, abdominal aorta involving visceral vessels (mesenteric, celiac, renal) Direct repair of aneurysm, false aneurysm, or excision (partial or total) and graft insertion, w/ or w/o patch graft; for aneurysm, false aneurysm, and associated occlusive disease, abdominal aorta involving iliac vessels (common, hypogastric, external) Direct repair of aneurysm, false aneurysm, or excision (partial or total) and graft insertion, w/ or w/o patch graft; for ruptured aneurysm, abdominal aorta involving iliac vessels (common, hypogastric, external) Direct repair of aneurysm, false aneurysm, or excision (partial or total) and graft insertion, w/ or w/o patch graft; for aneurysm, false aneurysm, and associated occlusive disease, splenic artery Direct repair of aneurysm, false aneurysm, or excision (partial or total) and graft insertion, w/ or w/o patch graft; for ruptured aneurysm, splenic artery Direct repair of aneurysm, false aneurysm, or excision (partial or total) and graft insertion, w/ or w/o patch graft; for aneurysm, false aneurysm, and associated occlusive disease, hepatic, celiac, renal, or mesenteric artery Direct repair of aneurysm, false aneurysm, or excision (partial or total) and graft insertion, w/ or w/o patch graft; for ruptured aneurysm, hepatic, celiac, renal, or mesenteric artery Direct repair of aneurysm, false aneurysm, or excision (partial or total) and graft insertion, w/ or w/o patch graft; for aneurysm, false aneurysm, and associated occlusive disease, iliac artery (common, hypogastric, external) Direct repair of aneurysm, false aneurysm, or excision (partial or total) and graft insertion, w/ or w/o patch graft; for ruptured aneurysm, iliac artery (common, hypogastric, external) Direct repair of aneurysm, false aneurysm, or excision (partial or total) and graft insertion, w/ or w/o patch graft; for aneurysm, false aneurysm, and associated occlusive disease, common femoral artery (profunda femoris, superficial femoral) Direct repair of aneurysm, false aneurysm, or excision (partial or total) and graft insertion, w/ or w/o patch graft; for ruptured aneurysm, common femoral artery (profunda femoris, superficial femoral) Direct repair of aneurysm, false aneurysm, or excision (partial or total) and graft insertion, w/ or w/o patch graft; for aneurysm, false aneurysm, and associated occlusive disease, popliteal artery Direct repair of aneurysm, false aneurysm, or excision (partial or total) and graft insertion, w/ or w/o patch graft; for ruptured aneurysm, popliteal artery Direct repair of aneurysm, false aneurysm, or excision (partial or total) and graft insertion, w/ or w/o patch graft; for aneurysm, false aneurysm, and associated occlusive disease, other arteries Direct repair of aneurysm, false aneurysm, or excision (partial or total) and graft insertion, w/ or w/o patch graft; for ruptured aneurysm, other arteries Repair, congenital arteriovenous fistula; head and neck Repair, congenital arteriovenous fistula; thorax and abdomen Repair, congenital arteriovenous fistula; extremities Repair, acquired or traumatic arteriovenous fistula; head and neck Repair, acquired or traumatic arteriovenous fistula; thorax and abdomen Repair, acquired or traumatic arteriovenous fistula; extremities Repair blood vessel, direct; neck Repair blood vessel, direct; upper extremity Repair blood vessel, direct; hand, finger Repair blood vessel, direct; intrathoracic, w/ bypass Repair blood vessel, direct; intrathoracic, w/o bypass Repair blood vessel, direct; intra-abdominal Repair blood vessel, direct; lower extremity Repair blood vessel w/ vein graft; neck Repair blood vessel w/ vein graft; upper extremity Repair blood vessel w/ vein graft; intrathoracic, w/ bypass Repair blood vessel w/ vein graft; intrathoracic, w/o bypass Repair blood vessel w/ vein graft; intra-abdominal Repair blood vessel w/ vein graft; lower extremity Repair blood vessel w/ graft other than vein; neck Case Rate Professional Fee Health Care Institution Fee 24,000

35091

53,400

29,400

35092

55,000

33,600

21,400

35102

46,500

25,200

21,300

35103

53,400

29,400

24,000

35111

46,500

25,200

21,300

35112

53,400

29,400

24,000

35121

46,500

25,200

21,300

35122

53,400

29,400

24,000

35131

23,300

12,600

10,700

35132

30,300

16,800

13,500

35141

23,300

12,600

10,700

35142

30,300

16,800

13,500

35151

30,300

16,800

13,500

35152

37,800

21,000

16,800

35161

30,300

16,800

13,500

35162 35180 35182 35184 35188 35189 35190 35201 35206 35207 35211 35216 35221 35226 35231 35236 35241 35246 35251 35256 35261

37,800 23,300 30,300 23,300 23,300 30,300 23,300 18,000 18,000 18,000 46,500 30,300 18,000 18,000 23,300 18,000 46,500 30,300 23,300 18,000 23,300

21,000 12,600 16,800 12,600 12,600 16,800 12,600 8,400 8,400 8,400 25,200 16,800 8,400 8,400 12,600 8,400 25,200 16,800 12,600 8,400 12,600

16,800 10,700 13,500 10,700 10,700 13,500 10,700 9,600 9,600 9,600 21,300 13,500 9,600 9,600 10,700 9,600 21,300 13,500 10,700 9,600 10,700

Page 44 of 98

ANNEX 2. 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; upper extremity Repair blood vessel w/ graft other than vein; intrathoracic, w/ bypass Repair blood vessel w/ graft other than vein; intrathoracic, w/o bypass Repair blood vessel w/ graft other than vein; intra-abdominal Repair blood vessel w/ graft other than vein; lower extremity Thromboendarterectomy, w/ or w/o patch graft; carotid, vertebral, subclavian, by neck incision Thromboendarterectomy, w/ or w/o patch graft; subclavian, innominate, by thoracic incision Thromboendarterectomy, w/ or w/o patch graft; axillary-brachial Thromboendarterectomy, w/ or w/o patch graft; abdominal aorta Thromboendarterectomy, w/ or w/o patch graft; mesenteric, celiac, or renal Thromboendarterectomy, w/ or w/o patch graft; iliac Thromboendarterectomy, w/ or w/o patch graft; iliofemoral Thromboendarterectomy, w/ or w/o patch graft; combined aortoiliac Thromboendarterectomy, w/ or w/o patch graft; combined aortoiliofemoral Thromboendarterectomy, w/ or w/o patch graft; common femoral Thromboendarterectomy, w/ or w/o patch graft; deep (profunda) femoral Thromboendarterectomy, w/ or w/o patch graft; femoral and/or popliteal, and/or tibioperoneal Transluminal balloon angioplasty, open; renal or other visceral artery Transluminal balloon angioplasty, open; aortic Transluminal balloon angioplasty, open; iliac Transluminal balloon angioplasty, open; femoral-popliteal Transluminal balloon angioplasty, open; brachiocephalic trunk or branches, each vessel Transluminal balloon angioplasty, open; tibioperoneal trunk and branches Transluminal balloon angioplasty, open; venous Transluminal balloon angioplasty, percutaneous; tibioperoneal trunk or branches, each vessel Transluminal balloon angioplasty, percutaneous; renal or visceral artery Transluminal balloon angioplasty, percutaneous; aortic Transluminal balloon angioplasty, percutaneous; iliac Transluminal balloon angioplasty, percutaneous; femoral-popliteal Transluminal balloon angioplasty, percutaneous; branchiocephalic trunk or branches, each vessel Transluminal balloon angioplasty, percutaneous; venous Transluminal peripheral atherectomy, open; renal or other visceral artery Transluminal peripheral atherectomy, open; aortic Transluminal peripheral atherectomy, open; iliac Transluminal peripheral atherectomy, open; femoral-popliteal Transluminal peripheral atherectomy, open; brachiocephalic trunk or branches, each vessel Transluminal peripheral atherectomy, open; tibioperoneal trunk and branches Transluminal peripheral atherectomy, percutaneous; renal or other visceral artery Transluminal peripheral atherectomy, percutaneous; aortic Transluminal peripheral atherectomy, percutaneous; iliac Transluminal peripheral atherectomy, percutaneous; femoral-popliteal Transluminal peripheral atherectomy, percutaneous; branchiocephalic trunk or branches, each vessel Transluminal peripheral atherectomy, percutaneous; tibioperoneal trunk and branches Bypass graft, w/ vein; carotid Bypass graft, w/ vein; carotid-subclavian Bypass graft, w/ vein; subclavian-carotid Bypass graft, w/ vein; carotid-vertebral Bypass graft, w/ vein; carotid-carotid Bypass graft, w/ vein; subclavian-subclavian Bypass graft, w/ vein; subclavian-vertebral Bypass graft, w/ vein; subclavian-axillary Bypass graft, w/ vein; axillary-axillary Bypass graft, w/ vein; axillary-femoral Bypass graft, w/ vein; aortosubclavian or carotid Bypass graft, w/ vein; aortoceliac or aortomesenteric Bypass graft, w/ vein; axillary-femoral-femoral

Case Rate 18,000 46,500 30,300 23,300 18,000 37,600 37,600 37,600 37,600 37,600 30,300 30,300 46,500 23,300 23,300 23,300 30,300 21,400 21,400 21,400 21,400 21,400 21,400 21,400 12,900 12,900 12,900 12,900 12,900 12,900 12,900 23,300 23,300 23,300 23,300 23,300 23,300 21,400 21,400 21,400 21,400 21,400 21,400 37,600 37,600 37,600 37,600 37,600 37,600 37,600 37,600 37,600 37,600 46,500 46,500 46,500

Professional Fee 8,400 25,200 16,800 12,600 8,400 18,900 18,900 18,900 18,900 18,900 16,800 16,800 25,200 12,600 12,600 12,600 16,800 10,500 10,500 10,500 10,500 10,500 10,500 10,500 6,300 6,300 6,300 6,300 6,300 6,300 6,300 12,600 12,600 12,600 12,600 12,600 12,600 10,500 10,500 10,500 10,500 10,500 10,500 18,900 18,900 18,900 18,900 18,900 18,900 18,900 18,900 18,900 18,900 25,200 25,200 25,200

Health Care Institution Fee 9,600 21,300 13,500 10,700 9,600 18,700 18,700 18,700 18,700 18,700 13,500 13,500 21,300 10,700 10,700 10,700 13,500 10,900 10,900 10,900 10,900 10,900 10,900 10,900 6,600 6,600 6,600 6,600 6,600 6,600 6,600 10,700 10,700 10,700 10,700 10,700 10,700 10,900 10,900 10,900 10,900 10,900 10,900 18,700 18,700 18,700 18,700 18,700 18,700 18,700 18,700 18,700 18,700 21,300 21,300 21,300

Page 45 of 98

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

ANNEX 2. 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); by needle, superficial (e.g., cervical, inguinal, axillary) Biopsy or excision or lymph node(s); deep cervical node(s) Biopsy or excision or lymph node(s); deep cervical node(s) w/ excision scalene fat pad Biopsy or excision or lymph node(s); deep axillary node(s) Biopsy or excision or lymph node(s); internal mammary node(s) Dissection, deep jugular node(s) Excision of cystic hygroma, axillary or cervical; w/o deep neurovascular dissection Excision of cystic hygroma, axillary or cervical; w/ deep neurovascular dissection Laparoscopy, surgical; with retroperitoneal lymph node sampling (biopsy), single or multiple Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy and periaortic lymph node sampling (biopsy), single or multiple Suprahyoid lymphadenectomy Cervical lymphadenectomy (complete) Cervical lymphadenectomy (modified radical neck dissection) Axillary lymphadenectomy; superficial Axillary lymphadenectomy; complete Thoracic lymphadenectomy, regional, including mediastinal and peritracheal nodes Abdominal lymphadenectomy, regional, including celiac, para-aortic and venal caval nodes Inguinofemoral lymphadenectomy, superficial, including Cloquets node Inguinofemoral lymphadenectomy, superficial, in continuity w/ pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes Pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes Retroperitoneal transabdominal lymphadenectomy, extensive, including pelvic, aortic, and renal nodes Mediastinotomy with exploration, drainage, removal of foreign body, or biopsy; cervical approach Transthoracic approach, including either transthoracic or median sternotomy Excision of mediastinal cyst Excision of mediastinal tumor Mediastinoscopy, with or without biopsy Repair, laceration of diaphragm, any approach Repair, paraesophageal hiatus hernia, transabdominal, with or without fundoplasty, vagotomy, and/or pyloroplasty, except neonatal Repair, neonatal diaphragmatic hernia, with or without chest tube insertion and with or without creation of ventral hernia Repair, diaphragmatic hernia (esophageal hiatal); transthoracic Repair, diaphragmatic hernia (esophageal hiatal); combined, thoracoabdominal Repair, diaphragmatic hernia (esophageal hiatal); combined, thoracoabdominal, with dilation of stricture (with or without gastroplasty) Repair, diaphragmatic hernia (other than neonatal), traumatic; acute Repair, diaphragmatic hernia (other than neonatal), traumatic; chronic Imbrication of diaphragm for eventration, transthoracic or transabdominal, paralytic or nonparalytic Biopsy of lip Vermilionectomy (lip shave), w/ mucosal advancement Excision of lip; transverse wedge excision w/ primary closure V-excision w/ primary defect linear closure; V-excision w/ primary defect linear closure; full thickness, reconstruction w/ local flap (e.g., Estlander or fan) V-excision w/ primary defect linear closure; full thickness, reconstruction w/ cross lip flap (Abbe-Estlander) Resection of lip, more than one-fourth, w/o reconstruction Repair lip, full thickness; vermilion only Repair lip, full thickness; up to half vertical height Repair lip, full thickness; over one-half vertical height, or complex Plastic repair of cleft lip/nasal deformity; primary, partial or complete, unilateral Plastic repair of cleft lip/nasal deformity; primary bilateral, one stage procedure

Case Rate 5,680 8,260 9,300 9,300 9,300 21,940 37,800 46,500 27,120 30,300 58,800 27,120 30,300 30,300 23,300 30,300 37,800 23,300 23,300 23,300 37,800 37,800 18,000 23,300 37,800 41,160 14,960 37,800 40,320 40,320 40,320 40,320 40,320 40,320 46,500 40,320 5,560 8,020 8,020 8,020 23,300 30,740 8,260 9,700 9,700 9,700 37,800 37,800

Professional Fee 1,680 3,360 2,100 2,100 2,100 9,240 21,000 25,200 15,120 16,800 37,800 15,120 16,800 16,800 12,600 16,800 21,000 12,600 12,600 12,600 21,000 21,000 8,400 12,600 21,000 24,360 7,560 21,000 23,520 23,520 23,520 23,520 23,520 23,520 25,200 23,520 1,260 2,520 2,520 2,520 12,600 13,440 3,360 4,200 4,200 4,200 21,000 21,000

Health Care Institution Fee 4,000 4,900 7,200 7,200 7,200 12,700 16,800 21,300 12,000 13,500 21,000 12,000 13,500 13,500 10,700 13,500 16,800 10,700 10,700 10,700 16,800 16,800 9,600 10,700 16,800 16,800 7,400 16,800 16,800 16,800 16,800 16,800 16,800 16,800 21,300 16,800 4,300 5,500 5,500 5,500 10,700 17,300 4,900 5,500 5,500 5,500 16,800 16,800

Page 49 of 98

ANNEX 2. 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; primary bilateral, one of two stages Plastic repair of cleft lip/nasal deformity; secondary, by recreation of defect and reclosure Plastic repair of cleft lip/nasal deformity; w/ cross lip pedicle flap (AbbeEstlander type), including sectioning and inserting of pedicle Drainage of abscess, cyst, hematoma, vestibule of mouth Biopsy, vestibule of mouth Excision of lesion of mucosa and submucosa, vestibule of mouth Excision of mucosa of vestibule of mouth as donor graft Excision of frenum, labial or buccal (frenumectomy, frenulectomy, frenectomy) Closure of laceration, vestibule of mouth; 2.5 cm or less Closure of laceration, vestibule of mouth; over 2.5 cm or complex Vestibuloplasty; anterior Vestibuloplasty; posterior, unilateral Vestibuloplasty; posterior, bilateral Vestibuloplasty; entire arch Vestibuloplasty; complex (including ridge extension, muscle repositioning) Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; lingual Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; sublingual, superficial Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; sublingual, deep, supramylohyoid Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; submental space Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; submandibular space Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; masticator space Extraoral incision and drainage of abscess,cyst,or hematoma of floor of mouth; sublingual Extraoral incision and drainage of abscess,cyst,or hematoma of floor of mouth; submental Extraoral incision and drainage of abscess,cyst,or hematoma of floor of mouth; submandibular Extraoral incision and drainage of abscess,cyst,or hematoma of floor of mouth; masticator space Biopsy of tongue; anterior two-thirds Biopsy of tongue; posterior one-third Biopsy of floor of mouth Excision of lesion of tongue w/o closure Excision of lesion of tongue w/ closure; anterior two-thirds Excision of lesion of tongue w/ closure; posterior one-third Excision of lesion of tongue w/ closure; w/ local tongue flap Excision of lingual frenum (frenectomy) Excision, lesion of floor of mouth Glossectomy; less than one-half tongue Glossectomy; hemiglossectomy Glossectomy; partial, w/ unilateral radical neck dissection Glossectomy; complete or total, w/ or w/o tracheostomy, w/o radical neck dissection Glossectomy; complete or total, w/ or w/o tracheostomy, w/ unilateral radical neck dissection Glossectomy; composite procedure w/ resection floor of mouth and mandibular resection, w/o radical neck dissection Glossectomy; composite procedure w/ resection floor of mouth, w/ suprahyoid neck dissection Glossectomy; composite procedure w/ resection floor of mouth, mandibular resection, and radical neck dissection (Commando type) Repair of laceration 2.5 cm or less; floor of mouth and/or anterior twothirds of tongue Repair of laceration 2.5 cm or less; posterior one-third of tongue Repair of laceration of tongue, floor of mouth, over 2.6 cm or complex Frenoplasty (surgical revision of frenum, eg, w/ Z-plasty) Suture of tongue to lip for micrognathia (Douglas type procedure) Frenoplasty (surgical revision of frenum, eg, w/ Z-plasty) Drainage of abscess, cyst, hematoma from dentoalveolar structures Removal of embedded foreign body from dentoalveolar structures; soft tissues Removal of embedded foreign body from dentoalveolar structures; bone Gingivectomy, excision gingiva Operculectomy, excision pericoronal tissues

Case Rate 30,300 30,300 37,800 5,680 5,680 5,680 8,440 9,300 5,680 5,680 12,120 12,120 12,120 18,000 18,000 5,680 5,680 5,680 5,680 5,680 5,680 5,680 5,680 5,680 5,680 5,560 5,560 5,560 9,300 9,300 9,300 9,300 9,300 9,300 8,260 10,880 37,800 37,800 37,800 40,320 46,500 53,400 9,700 9,700 9,700 9,700 9,700 9,700 5,680 3,640 3,640 8,020 8,020

Professional Fee 16,800 16,800 21,000 1,680 1,680 1,680 2,940 2,100 1,680 1,680 6,720 6,720 6,720 8,400 8,400 1,680 1,680 1,680 1,680 1,680 1,680 1,680 1,680 1,680 1,680 1,260 1,260 1,260 2,100 2,100 2,100 2,100 2,100 2,100 3,360 3,780 21,000 21,000 21,000 23,520 25,200 29,400 4,200 4,200 4,200 4,200 4,200 4,200 1,680 840 840 2,520 2,520

Health Care Institution Fee 13,500 13,500 16,800 4,000 4,000 4,000 5,500 7,200 4,000 4,000 5,400 5,400 5,400 9,600 9,600 4,000 4,000 4,000 4,000 4,000 4,000 4,000 4,000 4,000 4,000 4,300 4,300 4,300 7,200 7,200 7,200 7,200 7,200 7,200 4,900 7,100 16,800 16,800 16,800 16,800 21,300 24,000 5,500 5,500 5,500 5,500 5,500 5,500 4,000 2,800 2,800 5,500 5,500

Page 50 of 98

ANNEX 2. 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, dentoalveolar structures Excision of osseous tuberosities, dentoalveolar structures Excision of lesion or or tumor (except listed above), dentoalveolar structures Excision of hyperplastic alveolar mucosa Alveolectomy, including curettage of osteitis or sequestrectomy Destruction of lesion (except excision), dentoalveolar structures Periodontal mucosal grafting Gingivoplasty Alveoloplasty Drainage of abscess of palate, uvula Biopsy of palate, uvula Excision, lesion of palate , uvula; w/o closure Excision, lesion of palate , uvula; w/ simple primary closure Excision, lesion of palate , uvula; w/ local flap closure Resection of palate or extensive resection of lesion Uvulectomy, excision of uvula Palatopharyngoplasty (e.g., uvulopalatopharyngoplasty, uvulopharyngoplasty) Destruction of lesion, palate or uvula (thermal, cryo or chemical) Repair, laceration of palate; up to 2 cm Repair, laceration of palate; over 2 cm or complex Palatoplasty for cleft palate, soft and/or hard palate only Palatoplasty for cleft palate, w/ closure of alveolar ridge; soft tissue only Palatoplasty for cleft palate, w/ closure of alveolar ridge; w/ bone graft to alveolar ridge (includes obtaining graft) Palatoplasty for cleft palate; major revision Palatoplasty for cleft palate; secondary lengthening procedure Palatoplasty for cleft palate; attachment pharyngeal flap Lengthening of palate, and pharyngeal flap Lengthening of palate, w/ island flap Repair of anterior palate, including vomer flap Repair of nasolabial fistula Drainage of abscess; parotid Drainage of abscess; submaxillary or sublingual, intraoral Drainage of abscess; submaxillary, external Fistulization of sublingual salivary cyst (ranula); Fistulization of sublingual salivary cyst (ranula); w/ prosthesis Sialolithotomy; submandibular (submaxillary), sublingual or parotid, intraoral Biopsy of salivary gland; needle Biopsy of salivary gland; incisional Excision of sublingual salivary cyst (ranula) Marsupialization of sublingual salivary cyst (ranula) Excision of parotid tumor or parotid gland; lateral lobe, w/o nerve dissection Excision of parotid tumor or parotid gland; lateral lobe, w/ dissection and preservation of facial nerve Excision of parotid tumor or parotid gland; total, w/ dissection and preservation of facial nerve Excision of parotid tumor or parotid gland; total, en bloc removal w/ sacrifice of facial nerve Excision of parotid tumor or parotid gland; total, w/ unilateral radical neck dissection Excision of submandibular (submaxillary) gland Excision of sublingual gland Plastic repair of salivary duct, sialodochoplasty; primary or simple Plastic repair of salivary duct, sialodochoplasty; secondary or complicated Parotid duct diversion, bilateral (Wilke type procedure); Parotid duct diversion, bilateral (Wilke type procedure); w/ excision of one submandibular gland Parotid duct diversion, bilateral (Wilke type procedure); w/ excision of both submandibular glands Parotid duct diversion, bilateral (Wilke type procedure); w/ ligation of both submandibular (Whartons) ducts Closure salivary fistula Ligation salivary duct, intraoral Incision and drainage abscess; peritonsillar Incision and drainage abscess; retropharyngeal or parapharyngeal, intraoral approach Incision and drainage abscess; retropharyngeal or parapharyngeal, external approach Biopsy; oropharynx Biopsy; hypopharynx Biopsy; nasopharynx, visible lesion, simple

Case Rate 8,020 8,020 8,020 8,020 8,260 8,260 8,260 18,000 18,000 8,020 5,560 5,680 9,300 9,300 20,980 12,120 23,300 10,540 12,120 18,000 20,980 21,820 22,660 23,300 23,300 30,740 23,300 23,300 23,300 12,120 5,680 5,680 5,680 5,680 9,300 9,300 5,560 5,560 9,300 9,300 23,300 30,300 30,300 30,300 37,800 18,000 18,000 18,000 18,000 18,000 18,000 18,000 18,000 8,260 8,260 8,260 8,260 8,260 8,020 8,020 8,020

Professional Fee 2,520 2,520 2,520 2,520 3,360 3,360 3,360 8,400 8,400 2,520 1,260 1,680 2,100 2,100 10,080 6,720 12,600 5,040 6,720 8,400 10,080 10,920 11,760 12,600 12,600 13,440 12,600 12,600 12,600 6,720 1,680 1,680 1,680 1,680 2,100 2,100 1,260 1,260 2,100 2,100 12,600 16,800 16,800 16,800 21,000 8,400 8,400 8,400 8,400 8,400 8,400 8,400 8,400 3,360 3,360 3,360 3,360 3,360 2,520 2,520 2,520

Health Care Institution Fee 5,500 5,500 5,500 5,500 4,900 4,900 4,900 9,600 9,600 5,500 4,300 4,000 7,200 7,200 10,900 5,400 10,700 5,500 5,400 9,600 10,900 10,900 10,900 10,700 10,700 17,300 10,700 10,700 10,700 5,400 4,000 4,000 4,000 4,000 7,200 7,200 4,300 4,300 7,200 7,200 10,700 13,500 13,500 13,500 16,800 9,600 9,600 9,600 9,600 9,600 9,600 9,600 9,600 4,900 4,900 4,900 4,900 4,900 5,500 5,500 5,500

Page 51 of 98

ANNEX 2. 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; nasopharynx, survey for unknown primary lesion Excision or destruction of lesion of pharynx, any method Removal of foreign body from pharynx Excision branchial cleft cyst or vestige, confined to skin and subcutaneous tissues Excision branchial cleft cyst, vestige, or fistula, extending beneath subcutaneous tissues and/or into pharynx Tonsillectomy and adenoidectomy Tonsillectomy, primary or secondary Adenoidectomy, primary Adenoidectomy, secondary Radical resection of tonsil, tonsillar pillars, and/or retromolar trigone; w/o closure Radical resection of tonsil, tonsillar pillars, and/or retromolar trigone; closure w/ local flap (e.g., tongue, buccal) Radical resection of tonsil, tonsillar pillars, and/or retromolar trigone; closure w/ other flap Excision of tonsil tags Excision or destruction lingual tonsil, any method Limited pharyngectomy Resection of lateral pharyngeal wall or pyriform sinus, 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, external for feeding) Esophagotomy, cervical approach, w/ removal of foreign body Cricopharyngeal myotomy Esophagotomy, thoracic approach, w/ removal of foreign body Excision of lesion, esophagus, w/ primary repair; cervical approach Excision of lesion, esophagus, w/ primary repair; thoracic or abdominal approach Total or near esophagectomy, w/o thoracotomy; w/ pharyngogastrostomy or cervical esophagogastrostomy, w/ or w/o pyloroplasty (transhiatal) Total or near esophagectomy, w/o thoracotomy; w/ colon interposition or small bowel reconstruction, including bowel mobilization, preparation and anastomosis(es) Total or near total esophagectomy, w/ thoracotomy; w/ pharyngogastrostomy, or cervical esophagogastrostomy, w/ or w/o pyloroplasty Total or near total esophagectomy, w/ thoracotomy; w/ colon interposition or small bowel reconstruction, including bowel mobilization, preparation and anastomosis(es) Partial esophagectomy, cervical, w/ free intestinal graft, including microvascular anastomosis, obtaining the graft and intestinal reconstruction Partial esophagectomy, distal two-thirds, w/ thoracotomy and separate abdominal incision, w/ or w/o proximal gastrectomy; w/ thoracic esophagogastrotomy, w/ or w/o pyloroplasty (Ivor Lewis) Partial esophagectomy, distal two-thirds, w/ thoracotomy and separate abdominal incision, w/ or w/o proximal gastrectomy; w/ colon interposition or small bowel reconstruction, including bowel mobilization, preparation, and anastomosis(ses) Partial esophagectomy, distal two-thirds, w/ thoracotomy only, w/ or w/o proximal gastrectomy, w/ thoracic esophagogastrostomy, w/ or w/o pyloroplasty Partial esophagectomy, thoracoabdominal or abdominal approach, w/ or w/o proximal gastrectomy; w/ esophagogastrotomy, w/ or w/o pyloroplasty Partial esophagectomy, thoracoabdominal or abdominal approach, w/ or w/o proximal gastrectomy; w/ colon interposition or small bowel reconstruction, including bowel mobilization, preparation, and anastomosis(ses) Total or partial esophagectomy, w/o reconstruction (any approach), w/ cervical esophagostomy Diverticulectomy of hypopharynx, or esophagus, w/ or w/o myotomy; cervical approach Diverticulectomy of hypopharynx, or esophagus, w/ or w/o myotomy; thoracic approach Esophagoscopy, rigid or flexible; diagnostic, w/ or w/o collection of specimen(s) by brushing or washing Esophagoscopy, rigid or flexible; w/ biopsy, single or multiple Esophagoscopy, rigid or flexible; w/ injection sclerosis of esophageal varices

Case Rate 8,020 8,020 8,020 18,000 18,000 18,000 18,000 18,000 18,000 10,540 12,120 12,120 8,020 8,020 37,800 46,500 53,400 20,980 20,980 23,300 8,020 12,120 18,000 37,800 23,300 37,800 55,000

Professional Fee 2,520 2,520 2,520 8,400 8,400 8,400 8,400 8,400 8,400 5,040 6,720 6,720 2,520 2,520 21,000 25,200 29,400 10,080 10,080 12,600 2,520 6,720 8,400 21,000 12,600 21,000 33,600

Health Care Institution Fee 5,500 5,500 5,500 9,600 9,600 9,600 9,600 9,600 9,600 5,500 5,400 5,400 5,500 5,500 16,800 21,300 24,000 10,900 10,900 10,700 5,500 5,400 9,600 16,800 10,700 16,800 21,400

43108

58,800

37,800

21,000

43112

59,640

38,640

21,000

43113

63,000

42,000

21,000

43116

55,000

33,600

21,400

43117

55,000

33,600

21,400

43118

58,800

37,800

21,000

43121

55,000

33,600

21,400

43122

55,000

33,600

21,400

43123

58,800

37,800

21,000

43124 43130 43135 43200 43202 43204

46,500 23,300 37,800 10,540 10,540 14,960

25,200 12,600 21,000 5,040 5,040 7,560

21,300 10,700 16,800 5,500 5,500 7,400

Page 52 of 98

ANNEX 2. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE
43205 43215 43216 43217 43219 43220 43226 43227 43228 43234

DESCRIPTION
Esophagoscopy, rigid or flexible; w/ band ligation of esophageal varices Esophagoscopy, rigid or flexible; w/ removal of foreign body Esophagoscopy, rigid or flexible; w/ removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery Esophagoscopy, rigid or flexible; w/ removal of tumor(s), polyp(s), or other lesion(s) by snare technique Esophagoscopy, rigid or flexible; w/ insertion of plastic tube or stent Esophagoscopy, rigid or flexible; w/ balloon dilation (less than 30 mm diameter) Esophagoscopy, rigid or flexible; w/ insertion of guide wire followed by dilation over guide wire Esophagoscopy, rigid or flexible; w/ control of bleeding, any method Esophagoscopy, rigid or flexible; w/ ablation of tumor(s) polyp(s), or other lesion(s), not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique Upper gastrointestinal endoscopy, simple primary examination ( e.g. w/ small diameter flexible endoscope) Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, w/ or w/o collection of specimen(s) by brushing or washing Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; w/ biopsy, single or multiple Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; w/ transendoscopic tube or catheter placement Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; w/ injection sclerosis of esophageal and/or gastric varices Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; w/ band ligation of esophageal and/or gastric varices Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; w/ dilation of gastric outlet for obstruction, any method Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; w/ directed placement of percutaneous gastrostomy tube Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; w/ removal or foreign body Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; w/ insertion of guide wire followed by dilation of esophagus over guide wire Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; w/ ballon dilation of esophagus (less than 30 mm diameter) Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; w/ removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; w/ removal of tumor(s), polyp(s), or other lesion(s) by snare technique Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; w/ control of bleeding, any method Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; w/ ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; w/ endoscopic ultrasound examination Endoscopic retrograde cholangiopancreatography (ERCP); diagnostic, w/ or w/o collection of specimen(s) by brushing or washing Endoscopic retrograde cholangiopancreatography (ERCP); w/ biopsy, single or multiple Endoscopic retrograde cholangiopancreatography (ERCP); w/ sphincterotomy/papillotomy Endoscopic retrograde cholangiopancreatography (ERCP); w/ pressure measurement of sphincter of Oddi (pancreatic duct or common bile duct)

Case Rate 14,960 14,960 11,980 12,120 18,000 18,000 18,000 14,960 18,000 10,540

Professional Fee 7,560 7,560 5,880 6,720 8,400 8,400 8,400 7,560 8,400 5,040

Health Care Institution Fee 7,400 7,400 6,100 5,400 9,600 9,600 9,600 7,400 9,600 5,500

43235

10,540

5,040

5,500

43239

10,540

5,040

5,500

43241

12,120

6,720

5,400

43243

14,960

7,560

7,400

43244

14,960

7,560

7,400

43245

18,000

8,400

9,600

43246

18,000

8,400

9,600

43247

14,960

7,560

7,400

43248

18,000

8,400

9,600

43249

18,000

8,400

9,600

43250

11,980

5,880

6,100

43251

12,120

6,720

5,400

43255

14,960

7,560

7,400

43258

18,000

8,400

9,600

43259

14,960

7,560

7,400

43260 43261 43262 43263

20,980 20,980 21,820 21,820

10,080 10,080 10,920 10,920

10,900 10,900 10,900 10,900

Page 53 of 98

ANNEX 2. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE
43264

DESCRIPTION
Endoscopic retrograde cholangiopancreatography (ERCP); w/ endoscopic retrograde removal of stone(s) from biliary and/or pancreatic ducts Endoscopic retrograde cholangiopancreatography (ERCP); w/ endoscopic retrograde destruction, lithotripsy of stone(s), any method Endoscopic retrograde cholangiopancreatography (ERCP); w/ endoscopic retrograde insertion of nasobiliary or nasopancreatic drainage tube Endoscopic retrograde cholangiopancreatography (ERCP); w/ endoscopic retrograde insertion of tube or stent into bile or pancreatic duct Endoscopic retrograde cholangiopancreatography (ERCP); w/ endoscopic retrograde removal of foreign body and/or change of tube or stent Endoscopic retrograde cholangiopancreatography (ERCP); w/ endoscopic retrograde balloon dilation of ampulla, biliary and/or pancreatic duct(s) Endoscopic retrograde cholangiopancreatography (ERCP); w/ ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique Laparoscopy, surgical, esophagogastic fundoplasty (e.g., Nissen, Toupet procedures) Esophagoplasty, (plastic repair or reconstruction), cervical approach; w/o repair of tracheoesophageal fistula Esophagoplasty, (plastic repair or reconstruction), cervical approach; w/ repair of tracheoesophageal fistula Esophagoplasty, (plastic repair or reconstruction), thoracic approach; w/o repair of tracheoesophageal fistula Esophagoplasty, (plastic repair or reconstruction), thoracic approach; w/ repair of tracheoesophageal fistula Esophagogastrostomy (cardioplasty), w/ or w/o vagotomy and pyloroplasty, transabdominal or transthoracic approach Esophagogastric fundoplasty (e.g., Nissen, Belsey IV, Hill procedures) Esophagogastric fundoplasty; w/ fundic patch (Thal-Nissen procedure) Esophagogastric fundoplasty; w/ gastroplasty (e.g., Collis) Esophagomyotomy (Heller type); abdominal approach Esophagomyotomy (Heller type); thoracic approach Esophagojejunostomy (w/o total gastrectomy); abdominal approach Esophagojejunostomy (w/o total gastrectomy); thoracic approach Esophagostomy, fistulization of esophagus, external; abdominal approach Esophagostomy, fistulization of esophagus, external; thoracic approach Esophagostomy, fistulization of esophagus, external; cervical approach Gastrointestinal reconstruction for previous esophagectomy, for obstructing esophageal lesion or fistula, or for previous esophageal exclusion; w/ stomach, w/ or w/o pyloroplasty Gastrointestinal reconstruction for previous esophagectomy, for obstructing esophageal lesion or fistula, or for previous esophageal exclusion; w/ colon interposition or small bowel reconstruction, including bowel mobilization, preparation, and anastomosis(es) Ligation, direct, esophageal varices Transection of esophagus w/ repair, for esophageal varices Ligation or stapling at gastroesophageal junction for pre-existing esophageal perforation Suture of esophageal wound or injury; cervical approach Suture of esophageal wound or injury; transthoracic or transabdominal approach Closure of esophagostomy or fistula; cervical approach Closure of esophagostomy or fistula; transthoracic or transabdominal approach Dilation of esophagus, by unguided sound or bougie, single or multiple passes Dilation of esophagus, over guide wire Dilation of esophagus, by balloon or dilator, retrograde Dilation of esophagus w/ balloon (30 mm diameter or larger) for achalasia Esophagogastric tamponade, w/ balloon (Sengstaaken type) Free jejunum transfer w/ microvascular anastomosis Gastrotomy; w/ exploration or foreign body removal Gastrotomy; w/ suture repair of bleeding ulcer Gastrotomy; w/ suture repair of pre-existing esophagogastric laceration (e.g., Mallory-Weiss)

Case Rate 23,300

Professional Fee 12,600

Health Care Institution Fee 10,700

43265

30,740

13,440

17,300

43267

22,660

11,760

10,900

43268

22,660

11,760

10,900

43269

22,660

11,760

10,900

43271

23,300

12,600

10,700

43272 43280 43300 43305 43310 43312 43320 43324 43325 43326 43330 43331 43340 43341 43350 43351 43352 43360

23,300 46,500 30,300 30,300 46,500 53,400 46,500 46,500 46,500 48,600 37,800 46,500 37,800 46,500 23,300 30,300 12,120 58,800

12,600 25,200 16,800 16,800 25,200 29,400 25,200 25,200 25,200 27,300 21,000 25,200 21,000 25,200 12,600 16,800 6,720 37,800

10,700 21,300 13,500 13,500 21,300 24,000 21,300 21,300 21,300 21,300 16,800 21,300 16,800 21,300 10,700 13,500 5,400 21,000

43361 43400 43401 43405 43410 43415 43420 43425 43450 43453 43456 43458 43460 43496 43500 43501 43502

63,000 37,800 37,800 37,800 12,120 37,800 12,120 37,800 8,260 8,260 8,260 8,260 9,700 58,800 30,300 38,020 38,020

42,000 21,000 21,000 21,000 6,720 21,000 6,720 21,000 3,360 3,360 3,360 3,360 4,200 37,800 16,800 19,320 19,320

21,000 16,800 16,800 16,800 5,400 16,800 5,400 16,800 4,900 4,900 4,900 4,900 5,500 21,000 13,500 18,700 18,700

Page 54 of 98

ANNEX 2. 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; w/ esophageal dilation and insertion of permanent intraluminal tube (e.g., Celestin or Mousseaux-Barbin) Pyloromyotomy, cutting of pyloric muscle (Fredet-Ramstedt type operation) Biopsy of stomach; by capsule, tube, peroral (one or more specimens) Biopsy of stomach; by laparotomy Excision, local; ulcer or benign tumor of stomach Excision, local; malignant tumor of stomach Gastrectomy, total; w/ esophagoenterostomy Gastrectomy, total; w/ Roux-en-Y reconstruction Gastrectomy, total; w/ formation of intestinal pouch, any type Gastrectomy, partial, distal; w/ gastroduodenostomy Gastrectomy, partial, distal; w/ gastrojejunostomy Gastrectomy, partial, distal; w/ Roux-en-Y reconstruction Gastrectomy, partial, distal; w/ formation of intestinal pouch Gastrectomy, partial, proximal, thoracic or abdominal approach including esophagogastrostomy, w/ vagotomy; Gastrectomy, partial, proximal, thoracic or abdominal approach including esophagogastrostomy, w/ vagotomy; w/ pyloroplasty or pyloromyotomy Vagotomy including pyloroplasty, w/ or w/o gastrostomy; truncal or selective Vagotomy including pyloroplasty, w/ or w/o gastrostomy; parietal cell (highly selective) Laparoscopy, surgical; transection of vagus nerves, truncal Laparoscopy, surgical; transection of vagus nerve, selective or highly selective Laparoscopy, surgical; gastrostomy, without construction of gastric tube (e.g., Stamm Procedure) Percutaneous placement of gastrostomy tube Change of gastrostomy tube Pyloroplasty Gastroduodenostomy Gastrojejunostomy; w/o vagotomy Gastrojejunostomy; w/ vagotomy, any type Gastrostomy, temporary (tube, rubber or plastic) ; Gastrostomy, temporary (tube, rubber or plastic) ; neonatal, for feeding Gastrostomy, permanent, w/ construction of gastric tube Gastrorrhaphy, suture of perforated duodenal or gastric ulcer, wound, or injury Gastric restrictive procedure, w/o gastric bypass, for morbid obesity; vertical-banded gastroplasty Gastric restrictive procedure, w/o gastric bypass, for morbid obesity; other than vertical-banded gastroplasty Gastric restrictive procedure, w/ gastric bypass for morbid obesity; w/ short limb (less than 100 cm) Roux-en-Y gastroenterostomy Gastric restrictive procedure, w/ gastric bypass for morbid obesity; w/ small bowel reconstruction to limit absorption Revision of gastric restrictive procedure for morbid obesity Revision of gastroduodenal anastomosis (gastroduodenostomy) w/ reconstruction; w/o vagotomy Revision of gastroduodenal anastomosis (gastroduodenostomy) w/ reconstruction; w/ vagotomy Revision of gastrojejunal anastomosis (gastrojejunostomy) w/ reconstruction, w/ or w/o partial gastrectomy or bowel resection; w/o vagotomy Revision of gastrojejunal anastomosis (gastrojejunostomy) w/ reconstruction, w/ or w/o partial gastrectomy or bowel resection; w/ vagotomy Closure of gastrostomy, surgical Closure of gastrocolic fistula Enterolysis (freeing of intestinal adhesion) Duodenotomy, for exploration, biopsy(s), or foreign body removal Enterotomy, small bowel, other than duodenum; for exploration, biopsy(s), or foreign body removal; Enterotomy, small bowel, other than duodenum; for exploration, biopsy(s), or foreign body removal; for decompression (e.g., Baker tube) Colotomy, for exploration, biopsy(s), or foreign body removal Reduction of volvulus, intussusception, internal hernia, by laparotomy Correction of malrotation by lysis of duodenal bands and/or reduction of midgut volvulus (e.g., Ladd procedure) Biopsy of intestine by capsule, tube, peroral (one or more specimens)

Case Rate 38,020 38,020 8,260 30,300 38,020 38,020 63,000 67,200 67,200 55,000 55,000 63,000 63,000 63,000 67,200 37,800 46,500 18,000 21,940 18,000 8,020 5,560 37,800 63,000 46,500 53,400 37,800 37,800 37,800 46,500 55,000 58,800 58,800 58,800 58,800 58,800 63,000 58,800

Professional Fee 19,320 19,320 3,360 16,800 19,320 19,320 42,000 46,200 46,200 33,600 33,600 42,000 42,000 42,000 46,200 21,000 25,200 8,400 9,240 8,400 2,520 1,260 21,000 42,000 25,200 29,400 21,000 21,000 21,000 25,200 33,600 37,800 37,800 37,800 37,800 37,800 42,000 37,800

Health Care Institution Fee 18,700 18,700 4,900 13,500 18,700 18,700 21,000 21,000 21,000 21,400 21,400 21,000 21,000 21,000 21,000 16,800 21,300 9,600 12,700 9,600 5,500 4,300 16,800 21,000 21,300 24,000 16,800 16,800 16,800 21,300 21,400 21,000 21,000 21,000 21,000 21,000 21,000 21,000

43865 43870 43880 44005 44010 44020 44021 44025 44050 44055 44100

63,000 46,500 58,800 58,800 53,400 37,800 37,800 37,800 53,400 55,000 18,000

42,000 25,200 37,800 37,800 29,400 21,000 21,000 21,000 29,400 33,600 8,400

21,000 21,300 21,000 21,000 24,000 16,800 16,800 16,800 24,000 21,400 9,600

Page 55 of 98

ANNEX 2. 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, exteriorization, or fistulization; single enterotomy Excision of one or more lessions of small or large bowel not requiring anastomosis, exteriorization, or fistulization; multiple enterotomies Enterectomy, resection of small intestine; single resection and anastomosis Enterectomy, resection of small intestine; w/ enterostomy Enteroenterostomy, anastomosis of intestine, w/ or w/o cutaneous enterostomy Colectomy, partial; w/ anastomosis Colectomy, partial; w/ skin level cecostomy or colostomy Colectomy, partial; w/ end colostomy and closure of distal segment (Hartmann type procedure) Colectomy, partial; w/ resection, w/ colostomy or ileostomy and creation of mucofistula Colectomy, partial; w/ coloproctostomy (low pelvic anastomosis) Colectomy, partial; w/ coloproctostomy (low pelvic anastomosis), w/ colostomy Colectomy, partial; abdominal and transanal approach Colectomy, total, abdominal, w/o proctectomy; w/ ileostomy or ileoproctostomy Colectomy, total, abdominal, w/o proctectomy; w/ continent ileostomy Colectomy, total, abdominal, w/o proctectomy; w/ rectal mucosectomy, ileoanal anastomosis, w/ or w/o loop ileostomy Colectomy, total, abdominal, w/o proctectomy; w/ rectal mucosectomy, ileoanal anastomosis, creation of ileal reservior (S or J), w/ or w/o loop ileostomy Colectomy, total, abdominal, w/ proctectomy; w/ ileostomy Colectomy, total, abdominal, w/ proctectomy; w/ continent ileostomy Colectomy w/ removal of terminal ileum and ileocolostomy Laparoscopy, surgical, enterolysis (freeing of intestinal adhesion) Laparoscopy, surgical; jejunostomy (e.g., for decompression or feeding; Laparoscopy, surgical; jejunostomy (e.g., for decompression or feeding); ileostomy or jejunostomy, non-tube Laparoscopy, surgical, colostomy or skin level cecostomy Laparoscopy, surgical; enterectomy, resection of small intestine, single resection and anastomosis Laparoscopy, surgical; colectomy, partial, with anastomosis Laparoscopy, surgical; colectomy, partial, with removal of terminal ileum with ileocolostomy Laparoscopy, surgical; colectomy, partial, with end colostomy and closure of distal segment (Hartmann type procedure) Laparoscopy, surgical; colectomy, partial, with anastomosis, with coloproctostomy (low pelvic anastomosis) Laparoscopy, surgical; colectomy, partial, with anastomosis, with coloproctostomy (low pelvic anastomosis) with colostomy Laparoscopy, surgical; colectomy, total, abdominal, without protectomy, with ileostomy or ileoproctostomy Laparoscopy, surgical; colectomy, total, abdominal, with protectomy, with ileo-anal anastomosis, creation of ileal reservoir (S or J), with loop ileostomy, with or without rectal mucosectomy Laparoscopy, surgical; colectomy, total, abdominal, with protectomy, with ileostomy Laparoscopy, surgical; closure of enterostomy, large or small intestine, with resection and anastomosis Enterostomy or cecostomy, tube (e.g., for decompression or feeding) Ileostomy or jejunostomy, non- tube Revision of ileostomy; simple (release of superficial scar) Revision of ileostomy; complicated (reconstruction in-depth) Continent ileostomy (Koch procedure) Colostomy or skin level cecostomy; Colostomy or skin level cecostomy; w/ multiple biopsies (e.g., for Hirschsprung disease) Revision of colostomy; simple (release of superficial scar) Revision of colostomy; complicated (reconstruction in - depth ) Revision of colostomy; w/ repair of paracolostomy hernia Small intestinal endoscopy, enteroscopy, beyond second portion of duodenum, not including ileum; diagnostic, w/ or w/o collection of specimen(s) by brushing or washing Small intestinal endoscopy, enteroscopy, beyond second portion of duodenum, not including ileum; w/ biopsy, single or multiple

Case Rate 37,800

Professional Fee 21,000

Health Care Institution Fee 16,800

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

46,500 46,500 46,500 53,400 58,800 58,800 58,800 58,800 56,680 58,800 63,000 63,000 63,000 67,200 67,200 67,200 67,200 67,200 18,000 12,120 12,120 18,000 23,300 37,800 58,800 37,800 55,000 58,800 55,000 58,800 55,000 23,300 18,000 21,820 23,300 21,820 30,300 23,300 30,300 23,300 30,300 30,300 14,960 14,960

25,200 25,200 25,200 29,400 37,800 37,800 37,800 37,800 35,280 37,800 42,000 42,000 42,000 46,200 46,200 46,200 46,200 46,200 8,400 6,720 6,720 8,400 12,600 21,000 37,800 21,000 33,600 37,800 33,600 37,800 33,600 12,600 8,400 10,920 12,600 10,920 16,800 12,600 16,800 12,600 16,800 16,800 7,560 7,560

21,300 21,300 21,300 24,000 21,000 21,000 21,000 21,000 21,400 21,000 21,000 21,000 21,000 21,000 21,000 21,000 21,000 21,000 9,600 5,400 5,400 9,600 10,700 16,800 21,000 16,800 21,400 21,000 21,400 21,000 21,400 10,700 9,600 10,900 10,700 10,900 13,500 10,700 13,500 10,700 13,500 13,500 7,400 7,400

Page 56 of 98

ANNEX 2. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE
44363 44364

DESCRIPTION
Small intestinal endoscopy, enteroscopy, beyond second portion of duodenum, not including ileum; w/ removal of foreign body Small intestinal endoscopy, enteroscopy, beyond second portion of duodenum, not including ileum; w/ removal of tumor(s), polyp(s), or other lesions(s) by snare technique Small intestinal endoscopy, enteroscopy, beyond second portion of duodenum, not including ileum; w/ removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery Small intestinal endoscopy, enteroscopy, beyond second portion of duodenum, not including ileum; w/ control of bleeding, any method Small intestinal endoscopy, enteroscopy, beyond second portion of duodenum, not including ileum; w/ ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare tenchnique Small intestinal endoscopy, enteroscopy, beyond second portion of duodenum, not including ileum; w/ placement of percutaneous jejunostomy tube Small intestinal endoscopy, enteroscopy, beyond second portion of duodenum, not including ileum; w/ conversion of percutaneous gastrostomy tube to percutaneous jejunostomy tube Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; diagnostic, w/ or w/o collection of specimen(s) by brushing or washing Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum;w/ biopsy, single or multiple Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum;w/ control of bleeding, any method Ileoscopy, through stoma; diagnostic, w/ or w/o collection of specimen(s) by brushing or washing Ileoscopy, through stoma; w/ biopsy, single or multiple Endoscopic evaluation of small intestinal (abdominal or pelvic) pouch; diagnostic, w/ or w/o collection of specimen(s) by brushing or washing Endoscopic evaluation of small intestinal (abdominal or pelvic) pouch; w/ biopsy, single or multiple Colonoscopy through stoma; diagnostic, w/ or w/o collection of specimen(s) by brushing or washing Colonoscopy through stoma; w/ biopsy, single or multiple Colonoscopy through stoma; w/ removal of foreign body Colonoscopy through stoma; w/ control of bleeding, any method Colonoscopy through stoma; w/ removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery Colonoscopy through stoma; w/ ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar caurtery or snare technique Colonoscopy through stoma; w/ removal of tumor(s), polyp(s), or other lesion(s) by snare technique Introduction of long gastrointestinal tube (e.g., Miller-Abbott) Suture of small intestine (enterorrhaphy) for perforated ulcer, diverticulum, wound, injury or rupture; single perforation Suture of small intestine (enterorrhaphy) for perforated ulcer, diverticulum, wound, injury or rupture; multiple perforation Suture of large intestine (colorrhaphy) for perforated ulcer, diverticulum, wound, injury or rupture (single or multiple perforations); w/o colostomy Suture of large intestine (colorrhaphy) for perforated ulcer, diverticulum, wound, injury or rupture (single or multiple perforations); w/ colostomy Intestinal stricturoplasty (enterotomy and enterorrhaphy) w/ or w/o dilation, for intestinal obstruction Closure of enterostomy, large or small intestine; Closure of enterostomy, large or small intestine; w/ resection and anastomosis Closure of intestinal cutaneous fistula Closure of enteroenteric or enterocolic fistula Closure of enterovesical fistula; w/o intestinal or bladder resection Closure of enterovesical fistula; 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, transabdominal Appendectomy; Appendectomy; for ruptured appendix w/ abscess or generalized peritonitis Laparoscopy, surgical; appendectomy Transrectal drainage of pelvic abscess

Case Rate 18,000 18,000

Professional Fee 8,400 8,400

Health Care Institution Fee 9,600 9,600

44365 44366

18,000 18,000

8,400 8,400

9,600 9,600

44369

21,940

9,240

12,700

44372

21,940

9,240

12,700

44373

21,940

9,240

12,700

44376 44377 44378 44380 44382 44385 44386 44388 44389 44390 44391 44392 44393 44394 44500 44602 44603 44604

18,000 18,000 21,940 14,960 14,960 14,960 14,960 14,960 14,960 18,000 18,000 18,000 21,940 21,940 8,020 37,800 37,800 37,800

8,400 8,400 9,240 7,560 7,560 7,560 7,560 7,560 7,560 8,400 8,400 8,400 9,240 9,240 2,520 21,000 21,000 21,000

9,600 9,600 12,700 7,400 7,400 7,400 7,400 7,400 7,400 9,600 9,600 9,600 12,700 12,700 5,500 16,800 16,800 16,800

44605 44615 44620 44625 44640 44650 44660 44661 44800 44820 44850 44900 44950 44960 44970 45000

37,800 37,800 30,300 30,300 30,300 30,300 37,800 37,800 18,000 18,000 12,120 10,540 24,000 24,000 24,000 30,300

21,000 21,000 16,800 16,800 16,800 16,800 21,000 21,000 8,400 8,400 6,720 5,040 9,600 9,600 9,600 16,800

16,800 16,800 13,500 13,500 13,500 13,500 16,800 16,800 9,600 9,600 5,400 5,500 14,400 14,400 14,400 13,500

Page 57 of 98

ANNEX 2. 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, rectum Incision and drainage of deep supralevator, pelvirectal, or retrorectal abscess Biopsy of anorectal wall, anal approach (e.g., congenital megacolon) Anorectal myomectomy Proctectomy; complete, combined abdominoperineal, w/ colostomy Proctectomy; partial resection of rectum, transabdominal approach Proctectomy, combined abdominoperineal, pull-through procedure (e.g., colo-anal anastomosis) Proctectomy, partial, w/ rectal mucosectomy, ileoanal anastomosis, creation of ileal reservoir (S or J), w/ or w/o loop ileostomy Proctectomy, partial, w/ anastomosis; abdominal and transsacral approach Proctectomy, partial, w/ anastomosis; transsacral approach only (Kraske type) Proctectomy, complete (for congenital megacolon), abdominal and perineal approach; w/ pull-through procedure and anastomosis (e.g., Swenson, Duhamel, or Soave type operation) Proctectomy, complete (for congenital megacolon), abdominal and perineal approach; w/ subtotal or total colectomy, w/ multiple biopsies Proctectomy, partial, w/o anastomosis, perineal approach Excision of rectal procidentia, w/ anatomosis; perineal approach Excision of rectal procidentia, w/ anatomosis; abdominal and perineal approach Division of stricture of rectum Excision of rectal tumor by proctotomy, transsacral or transcoccygeal approach Excision of rectal tumor, transanal approach Destruction of rectal tumor, any method (e.g., electrodesiccation) transanal approach Proctosigmoidoscopy, rigid; diagnostic, w/ or w/o collection of specimen(s) by brushing or washing Proctosigmoidoscopy, rigid; w/ dilation, any method Proctosigmoidoscopy, rigid; w/ biopsy, single or multiple Proctosigmoidoscopy, rigid; w/ removal of foreign body Proctosigmoidoscopy, rigid; w/ removal of single tumor, polyp, or other lesion by hot biopsy forceps or bipolar cautery Proctosigmoidoscopy, rigid; w/ removal of single tumor, polyp, or other lesion by snare technique Proctosigmoidoscopy, rigid; w/ removal of multiple tumors, polyps or other lesions by hot biopsy forceps, bipolar cautery or snare technique Proctosigmoidoscopy, rigid; w/ control of bleeding, any method Proctosigmoidoscopy, rigid; w/ ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique (e.g., laser) Proctosigmoidoscopy, rigid; w/ decompression of volvulus Sigmoidoscopy, flexible; diagnostic, w/ or w/o collection of specimen(s) by brushing or washing Sigmoidoscopy, flexible; w/ biopsy, single or multiple Sigmoidoscopy, flexible; w/ removal of foreign body Sigmoidoscopy, flexible; w/ removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery Sigmoidoscopy, flexible; w/ control of bleeding, any method Sigmoidoscopy, flexible; w/ decompression of volvulus, any method Sigmoidoscopy, flexible; w/ removal of tumor(s), polyp(s), or other lesion(s) by snare technique Sigmoidoscopy, flexible; w/ ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique Colonoscopy, rigid or flexible, transabdominal via colotomy, single or multiple Colonoscopy, flexible, proximal to splenic flexure; diagnostic, w/ or w/o collection of specimen(s) by brushing or washing, w/ or w/o colon decompression Colonoscopy, flexible, proximal to splenic flexure; w/ removal of foreign body Colonoscopy, flexible, proximal to splenic flexure; w/ biopsy, single or multiple Colonoscopy, flexible, proximal to splenic flexure; w/ control of bleeding, any method Colonoscopy, flexible, proximal to splenic flexure; w/ ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique

Case Rate 18,000 30,300 23,300 30,300 55,000 55,000 55,000 58,800 58,800 55,000 58,800

Professional Fee 8,400 16,800 12,600 16,800 33,600 33,600 33,600 37,800 37,800 33,600 37,800

Health Care Institution Fee 9,600 13,500 10,700 13,500 21,400 21,400 21,400 21,000 21,000 21,400 21,000

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

58,800 55,000 53,400 55,000 12,120 55,000 18,000 18,000 8,020 9,700 8,020 8,260 9,700 9,700 10,540 10,540 10,540 10,540 8,260 8,260 9,700 9,700 10,540 12,120 10,540 11,980 10,540 12,120 12,120 12,120 18,000 14,960

37,800 33,600 29,400 33,600 6,720 33,600 8,400 8,400 2,520 4,200 2,520 3,360 4,200 4,200 5,040 5,040 5,040 5,040 3,360 3,360 4,200 4,200 5,040 6,720 5,040 5,880 5,040 6,720 6,720 6,720 8,400 7,560

21,000 21,400 24,000 21,400 5,400 21,400 9,600 9,600 5,500 5,500 5,500 4,900 5,500 5,500 5,500 5,500 5,500 5,500 4,900 4,900 5,500 5,500 5,500 5,400 5,500 6,100 5,500 5,400 5,400 5,400 9,600 7,400

Page 58 of 98

ANNEX 2. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE
45384 45385 45395

DESCRIPTION
Colonoscopy, flexible, proximal to splenic flexure; w/ removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery Colonoscopy, flexible, proximal to splenic flexure; w/ removal of tumor(s), polyp(s), or other lesion(s) by snare technique Laparoscopy, surgical; proctectomy, complete combined abdominoperineal, with colostomy Laparoscopy, surgical; protectomy, combined abdominoperineal pull through procedure (e.g., colo-anal anastomosis), with creation of colonic reservoir (e.g., J-pouch), with diverting enterostomy, when performed Laparoscopy, surgical; proctopexy (for prolapse) Laparoscopy, surgical; proctopexy (for prolapse), with sigmoid resection Proctoplasty; for stenosis Proctoplasty; for prolapse of mucous membrane Proctopexy for prolapse; abdominal approach Proctopexy for prolapse; perineal approach Proctopexy combined w/ sigmoid resection, abdominal approach Repair of rectocele Exploration, repair and presacral drainage for rectal injury; Exploration, repair and presacral drainage for rectal injury; w/ colostomy Closure of rectovesical fistula; Closure of rectovesical fistula; w/ colostomy Closure of rectourethral fistula; Closure of rectourethral fistula; 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, intramuscular, or submucosal abscess, transanal, under anesthesia Incision and drainage, perianal abscess, superficial Incision and drainage of ischiorectal or intramural abscess, w/ fistulectomy or fistulotomy, submuscular, w/ or w/o placement of seton Incision, anal septum (infant) Sphincterotomy, anal, division of sphincter Incision of thrombosed hemorrhoid, external Fissurectomy, w/ or w/o sphincterotomy Cryptectomy; single Cryptectomy; multiple Papillectomy or excision of single tag, anus Hemorrhoidectomy, by simple ligature (e.g., rubber band) Excision of external hemorrhoid tags and/or multiple papillae Hemorrhoidectomy, external, complete Hemorrhoidectomy, internal and external, simple; Hemorrhoidectomy, internal and external, simple; w/ fissurectomy Hemorrhoidectomy, internal and external, simple; w/ fistulectomy, w/ or w/o fissurectomy Hemorrhoidectomy, internal and external, complex or extensive; Hemorrhoidectomy, internal and external, complex or extensive; w/ fissurectomy Hemorrhoidectomy, internal and external, complex or extensive; w/ fistulectomy, w/ or w/o fissurectomy Surgical treatment of anal fistula (fistulectomy/fistulotomy); subcutaneous Surgical treatment of anal fistula (fistulectomy/fistulotomy); submuscular Surgical treatment of anal fistula (fistulectomy/fistulotomy); complex or multiple, w/ or w/o placement of seton Surgical treatment of anal fistula (fistulectomy/fistulotomy); second stage Closure of anal fistula w/ rectal advancement flap Enucleation or excision of external thrombotic hemorrhoid Anoscopy; diagnostic, w/ or w/o collection of specimen(s) by brushing or washing Anoscopy; w/ dilation, any method Anoscopy; w/ biopsy, single or multiple Anoscopy; w/ removal of foreign body Anoscopy; w/ removal of single tumor, polyp, or other lesion by hot biopsy forceps or bipolar cautery Anoscopy; w/ removal of single tumor, polyp or other lesion by snare technique Anoscopy; w/ removal of multiple tumor, polyps, or other lesions by hot biopsy forceps, bipolar cautery or snare technique

Case Rate 14,960 18,000 55,000

Professional Fee 7,560 8,400 33,600

Health Care Institution Fee 7,400 9,600 21,400

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 27,120 30,300 18,000 18,000 27,120 27,120 30,300 18,000 23,300 27,120 30,300 37,800 30,300 37,800 8,260 8,260 8,260 8,260 9,700 8,260 9,700 9,700 9,700 8,020 8,260 8,260 9,700 8,260 12,120 12,120 12,120 12,120 12,120 12,120 12,120 12,120 12,120 12,120 12,120 12,120 12,120 18,000 12,120 5,680 5,680 5,680 5,680 8,020 8,260 8,260

33,600 15,120 16,800 8,400 8,400 15,120 15,120 16,800 8,400 12,600 15,120 16,800 21,000 16,800 21,000 3,360 3,360 3,360 3,360 4,200 3,360 4,200 4,200 4,200 2,520 3,360 3,360 4,200 3,360 6,720 6,720 6,720 6,720 6,720 6,720 6,720 6,720 6,720 6,720 6,720 6,720 6,720 8,400 6,720 1,680 1,680 1,680 1,680 2,520 3,360 3,360

21,400 12,000 13,500 9,600 9,600 12,000 12,000 13,500 9,600 10,700 12,000 13,500 16,800 13,500 16,800 4,900 4,900 4,900 4,900 5,500 4,900 5,500 5,500 5,500 5,500 4,900 4,900 5,500 4,900 5,400 5,400 5,400 5,400 5,400 5,400 5,400 5,400 5,400 5,400 5,400 5,400 5,400 9,600 5,400 4,000 4,000 4,000 4,000 5,500 4,900 4,900

Page 59 of 98

ANNEX 2. 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; w/ control of bleeding, any method Anoscopy; w/ ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique Anoplasty, plastic operation for stricture; adult Anoplasty, plastic operation for stricture; infant Repair of low imperforate anus; w/ anoperineal fistula ("cut-back" procedure) Repair of low imperforate anus; w/ transportation of anoperineal or anovestibular fistula Repair of high imperforate anus w/o fistula; perineal or sacroperineal approach Repair of high imperforate anus w/o fistula; combined transabdominal and sacroperineal approaches Repair of high imperforate anus w/ rectourethral or rectovaginal fistula; perineal or sacroperineal approach Repair of high imperforate anus w/ rectourethral or rectovaginal fistula; combined transabdominal and sacroperineal approaches Repair of cloacal anomaly by anorectovaginoplasty and urethroplasty, sacroperineal approach Repair of cloacal anomaly by anorectovaginoplasty and urethroplasty, combined abdominal and sacroperineal approach; Repair of cloacal anomaly by anorectovaginoplasty and urethroplasty, combined abdominal and sacroperineal approach; w/ vaginal lengthening by intestinal graft or pedicle flaps Sphincteroplasty, anal, for incontinence or prolapse; adult Sphincteroplasty, anal, for incontinence or prolapse; child Graft (Thiersch operation) for rectal incontinence and/or prolapse Removal of Thiersch wire or suture, anal canal Sphincteroplasty, anal, for incontinence, adult; muscle transplant Sphincteroplasty, anal, for incontinence, adult; levator muscle imbrication (Park posterior anal repair) Sphincteroplasty, anal, for incontinence, adult; implantation artificial sphincter Destruction of lesion(s), anus (e.g., condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; chemical Destruction of lesion(s), anus (e.g., condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; electrodesiccation Destruction of lesion(s), anus (e.g., condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; cryosurgery Destruction of lesion(s), anus (e.g., condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; laser surgery Destruction of lesion(s), anus (e.g., condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; surgical excision Destruction of lesion(s), anus (e.g., condyloma, papilloma, molluscum contagiosum, herpetic vesicle), extensive, any method Destruction of hemorrhoids, any method; internal Destruction of hemorrhoids, any method; external Destruction of hemorrhoids, any method; internal and external Cryosurgery of rectal tumor; benign Cryosurgery of rectal tumor; malignant Curettage or cauterization of anal fissure, including dilation of anal sphincter Ligation of internal hemorrhoids Biopsy of liver, needle; percutaneous Hepatotomy for drainage of abscess or cyst, one or two stages Laparotomy, w/ aspiration and/or injection of hepatic parasitic (e.g., amoebic or echinococcal) cyst(s) or abscess(es) Biopsy of liver, wedge Hepatectomy, resection of liver; partial lobectomy Hepatectomy, resection of liver; trisegmentectomy Hepatectomy, resection of liver; total left lobectomy Hepatectomy, resection of liver; total right lobectomy Donor hepatectomy, w/ preparation and maintenance of allograft; partial, from living donor Liver allotransplantation; orthotopic, partial or whole, from cadaver or living donor, any age Liver allotransplantation; heterotopic, partial or whole, from cadaver or living donor, any age Marsupialization of cyst or abscess of liver Management of liver hemorrhage; simple suture of liver wound or injury Management of liver hemorrhage; complex suture of liver wound or injury, w/ or w/o hepatic artery ligation

Case Rate 8,020 9,700 12,900 23,300 23,300 37,800 37,800 46,500 30,300 53,400 58,800 63,000 63,000 14,960 23,300 9,700 8,260 40,320 20,980 40,320 8,260 8,260 8,260 8,260 8,260 9,700 9,700 9,700 9,700 9,700 9,700 9,700 8,260 8,020 18,000 18,000 18,000 53,400 55,000 46,500 53,400 46,500 55,000 55,000 18,000 23,300 46,500

Professional Fee 2,520 4,200 6,300 12,600 12,600 21,000 21,000 25,200 16,800 29,400 37,800 42,000 42,000 7,560 12,600 4,200 3,360 23,520 10,080 23,520 3,360 3,360 3,360 3,360 3,360 4,200 4,200 4,200 4,200 4,200 4,200 4,200 3,360 2,520 8,400 8,400 8,400 29,400 33,600 25,200 29,400 25,200 33,600 33,600 8,400 12,600 25,200

Health Care Institution Fee 5,500 5,500 6,600 10,700 10,700 16,800 16,800 21,300 13,500 24,000 21,000 21,000 21,000 7,400 10,700 5,500 4,900 16,800 10,900 16,800 4,900 4,900 4,900 4,900 4,900 5,500 5,500 5,500 5,500 5,500 5,500 5,500 4,900 5,500 9,600 9,600 9,600 24,000 21,400 21,300 24,000 21,300 21,400 21,400 9,600 10,700 21,300

Page 60 of 98

ANNEX 2. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE
47361 47362 47370 47371 47380 47381 47382 47400 47420

DESCRIPTION
Management of liver hemorrhage; exploration of hepatic wound, extensive debridement, coagulation and/or suture, w/ or w/o packing of liver Management of liver hemorrhage; re-exploration of hepatic wound for removal of packing Laparoscopy, surgical, ablation of one or more liver tumor(s); radiofrequency Laparoscopy, surgical, ablation of one or more liver tumor(s); cryosurgical Ablation, open, of or more liver tumor(s); radiofrequency Ablation, open, of or more liver tumor(s); cryosurgical Ablation, one or more liver tumor(s), percutaneous radiofrequency Hepaticotomy or hepaticostomy w/ exploration, drainage, or removal of calculus Choledochotomy or choledochostomy w/ exploration, drainage, or removal of calculus, w/ or w/o cholecystotomy; w/o transduodenal sphincterotomy or sphincteroplasty Choledochotomy or choledochostomy w/ exploration, drainage, or removal of calculus, w/ or w/o cholecystotomy; w/ transduodenal sphincterotomy or sphincteroplasty Transduodenal sphincterotomy or sphincteroplasty, w/ or w/o transduodenal extraction of calculus Cholecystotomy or cholecystostomy w/ exploration, drainage, 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, percutaneous via T- tube or other tract; diagnostic, w/ or w/o collection of specimen(s) by brushing and/or washing Biliary endoscopy, percutaneous via T- tube or other tract; w/ biopsy, single or multiple Biliary endoscopy, percutaneous via T- tube or other tract; w/ removal of stone(s) Biliary endoscopy, percutaneous via T- tube or other tract; w/ dilation of biliary duct stricture(s) w/o stent Biliary endoscopy, percutaneous via T- tube or other tract; w/ dilation of biliary duct stricture(s) w/ stent Laparoscopy, surgical; with guided transhepatic cholangiography, without biopsy Laparoscopy, surgical; with guided transhepatic cholangiography, with biopsy Laparoscopy, surgical; cholecystectomy (any method) Laparoscopy, surgical; cholecystectomy with cholangiography Laparoscopy, surgical; cholecystectomy with exploration of common duct Laparoscopy, surgical; cholecystoenterostomy Cholecystectomy; Cholecystectomy; w/ cholangiography Cholecystectomy w/ exploration of common duct; Cholecystectomy w/ exploration of common duct; w/ choledochoenterostomy Cholecystectomy w/ exploration of common duct; w/ transduodenal sphincterotomy or sphincteroplasty, w/ or w/o cholangiography Biliary duct stone extraction, percutaneous via T-tube tract, basket, or snare (e.g., Burhenne technique) Exploration for congenital atresia of bile ducts, w/o repair, w/ or w/o liver biopsy, w/ or w/o cholangiography Portoenterostomy (e.g., Kasai procedure) Excision of bile duct tumor, w/ or w/o primary repair of bile duct; extrahepatic Excision of bile duct tumor, w/ or w/o primary repair of bile duct; intrahepatic Excision of choledochal cyst Anastomosis, choledochal cyst, w/o excision Cholecystoenterostomy; direct Cholecystoenterostomy; w/ gastroenterostomy Roux-en-Y Roux-en-Y w/ gastroenterostomy Anastomosis, of extrahepatic biliary ducts and gastrointestinal tract Anastomosis, of intrahepatic ducts and gastrointestinal tract Anastomosis, Roux-en-Y, of extrahepatic biliary ducts and gastrointestinal tract

Case Rate 37,800 37,800 18,000 18,000 9,700 9,700 9,700 53,400 37,800

Professional Fee 21,000 21,000 8,400 8,400 4,200 4,200 4,200 29,400 21,000

Health Care Institution Fee 16,800 16,800 9,600 9,600 5,500 5,500 5,500 24,000 16,800

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

46,500 46,500 30,300 30,300 30,300 30,300 8,020 8,260 23,300 23,300 23,300 23,300 23,300 31,000 31,000 31,000 31,000 46,500 31,000 31,000 31,000 46,500 53,400 46,500 23,300 53,400 55,000 55,000 58,800 55,000 46,500 37,800 46,500 53,400 53,400 46,500 53,400 46,500

25,200 25,200 16,800 16,800 16,800 16,800 2,520 3,360 12,600 12,600 12,600 12,600 12,600 12,400 12,400 12,400 12,400 25,200 12,400 12,400 12,400 25,200 29,400 25,200 12,600 29,400 33,600 33,600 37,800 33,600 25,200 21,000 25,200 29,400 29,400 25,200 29,400 25,200

21,300 21,300 13,500 13,500 13,500 13,500 5,500 4,900 10,700 10,700 10,700 10,700 10,700 18,600 18,600 18,600 18,600 21,300 18,600 18,600 18,600 21,300 24,000 21,300 10,700 24,000 21,400 21,400 21,000 21,400 21,300 16,800 21,300 24,000 24,000 21,300 24,000 21,300

Page 61 of 98

ANNEX 2. 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, Roux-en-Y, of intrahepatic biliary ducts and gastrointestinal tract Reconstruction, plastic, 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, peripancreatic, for acute pancreatitis; Placement of drains, peripancreatic, for acute pancreatitis; w/ cholecystostomy, gastrostomy, and jejunostomy Resection or debridement of pancreas and peripancreatic tissue for acute necrotizing pancreatitis Removal of pancreatic calculus Biopsy of pancreas, open, any method (e.g., fine needle aspiration, needle core biopsy, wedge biopsy) Biopsy of pancreas, percutaneous needle Excision of lesion of pancreas (e.g., cyst, adenoma) Pancreatectomy, distal subtotal, w/ or w/o splenectomy; w/o pancreaticojejunostomy Pancreatectomy, distal subtotal, w/ or w/o splenectomy; w/ pancreaticojejunostomy Pancreatectomy, distal, near-total w/ preservation of duodenum (Child-type procedure) Excision of ampulla of Vater Pancreatectomy, proximal subtotal w/ total duodenectomy, partial gastrectomy, choledochoenterostomy and gastrojejunostomy (Whippletype procedure); w/ pancreatojejunostomy Pancreatectomy, proximal subtotal w/ total duodenectomy, partial gastrectomy, choledochoenterostomy and gastrojejunostomy (Whippletype procedure); w/o pancreatojejunostomy Pancreatectomy, proximal subtotal w/ near total duodenectomy, choledochoenterostomy and duodenojejunostomy (pylorus-sparing, Whipple-type procedure); w/ pancreatojejunostomy Pancreatectomy, proximal subtotal w/ near total duodenectomy, choledochoenterostomy and duodenojejunostomy (pylorus-sparing, Whipple-type procedure); w/o pancreatojejunostomy Pancreatectomy, total Pancreatectomy, total or subtotal, w/ autologous transplantation of pancreas or pancreatic islets Pancreaticojejunostomy, side-to-side anastomosis (Puestow-type operation) Marsupialization of cyst of pancreas External drainage, psuedocyst of pancreas Internal anastomosis of pacreatic cyst to gastrointestinal tract; direct Internal anastomosis of pacreatic cyst to gastrointestinal tract; Roux-en-Y Pancreatorrhaphy for trauma Duodenal exclusion w/ gastrojejunostomy for pancreatic trauma Donor pancreatectomy, w/ preparation and maintenance of allograft from cadaver donor, w/ or w/o duodenal segment for transplantation Transplantation of pancreatic allograft Removal of transplanted pancreatic allograft Exploratory laparotomy, exploratory celiotomy w/ or w/o biopsy(s) Exploration, retroperitoneal area w/ or w/o biopsy(s) Drainage of peritoneal abscess or localized peritonitis, exclusive of appendiceal abscess; open Drainage of peritoneal abscess or localized peritonitis, exclusive of appendiceal abscess; percutaneous Drainage of subdiaphargmatic or subphrenic abscess Drainage of retroperitoneal abscess Peritoneocentesis, abdominal paracentesis, or peritoneal lavage (diagnostic or therapeutic) Removal of peritoneal foreign body from peritoneal cavity Biopsy, abdominal or retroperitoneal mass, percutaneous needle Excision or destruction by any method of intra-abdominal or retroperitoneal tumors or cysts or endometriomas; Excision or destruction by any method of intra-abdominal or retroperitoneal tumors or cysts or endometriomas; extensive Excision of presacral or sacrococcygeal tumor Staging celiotomy (laparotomy) for Hodgkins disease or lymphoma (includes splenectomy, needle or open biopsies of both liver lobes, possibly also removal of abdominal nodes, abdominal node and/or bone marrow biopsies, ovarian repositioning) Umbilectomy, omphalectomy, excision of umbilicus Omentectomy, epiploectomy, resection of omentum

Case Rate 53,400 46,500 37,800 37,800 46,500 23,300 46,500 46,500 37,800 12,120 9,700 30,300 46,500 53,400 53,400 46,500 58,800

Professional Fee 29,400 25,200 21,000 21,000 25,200 12,600 25,200 25,200 21,000 6,720 4,200 16,800 25,200 29,400 29,400 25,200 37,800

Health Care Institution Fee 24,000 21,300 16,800 16,800 21,300 10,700 21,300 21,300 16,800 5,400 5,500 13,500 21,300 24,000 24,000 21,300 21,000

48152

55,000

33,600

21,400

48153

63,000

42,000

21,000

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

58,800 63,000 63,000 55,000 30,300 23,300 46,500 46,500 53,400 53,400 30,300 30,300 23,300 23,300 23,300 23,300 8,260 23,300 23,300 8,020 23,300 8,260 37,800 53,400 46,500 23,300 9,700 9,700

37,800 42,000 42,000 33,600 16,800 12,600 25,200 25,200 29,400 29,400 16,800 16,800 12,600 12,600 12,600 12,600 3,360 12,600 12,600 2,520 12,600 3,360 21,000 29,400 25,200 12,600 4,200 4,200

21,000 21,000 21,000 21,400 13,500 10,700 21,300 21,300 24,000 24,000 13,500 13,500 10,700 10,700 10,700 10,700 4,900 10,700 10,700 5,500 10,700 4,900 16,800 24,000 21,300 10,700 5,500 5,500

Page 62 of 98

ANNEX 2. 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, abdomen, peritoneum, and omentum, diagnostic, with or without collection of specimen(s) by brushing or washing Laparoscopy, surgical; with biopsy (single or multiple) Laparoscopy, surgical; with aspiration of cavity or cyst (single or multiple) Laparoscopy, surgical; 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, under age 6 months, w/ or w/o hydrocelectomy; reducible Repair initial inguinal hernia, under age 6 months, w/ or w/o hydrocelectomy; incarcerated Repair initial inguinal hernia, under age 6 months, w/ or w/o hydrocelectomy; strangulated Repair initial inguinal hernia, age 6 months to under 5 years, w/ or w/o hydrocelectomy; reducible Repair initial inguinal hernia, age 6 months to under 5 years, w/ or w/o hydrocelectomy; incarcerated Repair initial inguinal hernia, age 6 months to under 5 years, w/ or w/o hydrocelectomy; strangulated Repair initial inguinal hernia, age 5 years or over; reducible Repair initial inguinal hernia, age 5 years or over; incarcerated Repair initial inguinal hernia, age 5 years or over; strangulated Repair recurrent inguinal hernia, any age; reducible Repair recurrent inguinal hernia, any age; incarcerated Repair recurrent inguinal hernia, any age; strangulated Repair inguinal hernia, sliding, any age Repair lumbar hernia Repair initial femoral hernia, any age; reducible Repair initial femoral hernia, any age; incarcerated Repair initial femoral hernia, any age; strangulated Repair recurrent femoral hernia; reducible Repair recurrent femoral hernia; incarcerated Repair recurrent femoral hernia; strangulated Repair initial incisional hernia; reducible Repair initial incisional hernia; incarcerated Repair initial incisional hernia; strangulated Repair recurrent incisional hernia; reducible Repair recurrent incisional hernia; incarcerated Repair recurrent incisional hernia; strangulated Repair epigastric hernia (e.g., preperitoneal fat); reducible Repair epigastric hernia (e.g., preperitoneal fat); incarcerated Repair epigastric hernia (e.g., preperitoneal fat); strangulated Repair umbilical hernia, under age 5 years; reducible Repair umbilical hernia, under age 5 years; incarcerated Repair umbilical hernia, under age 5 years; strangulated Repair umbilical hernia, age 5 years or over; reducible Repair umbilical hernia, age 5 years or over; incarcerated Repair umbilical hernia, age 5 years or over; strangulated Repair spigelian hernia Repair of small omphalocele, w/ primary closure Repair large omphalocele or gastroschisis; w/ or w/o prosthesis Repair large omphalocele or gastroschisis; w/ removal of prosthesis, final reduction and closure, in operating room Repair of omphalocele (Gross type operation); first stage Repair of omphalocele (Gross type operation); second stage Laparoscopy, surgical; repair of initial inguinal hernia Laparoscopy, surgical; repair of recurrent inguinal hernia Suture, secondary, of abdominal wall for evisceration or dehiscence Omental flap (e.g., 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, not necessitating other specific procedures Drainage of perirenal or renal abscess Nephrostomy, nephrotomy w/ drainage Nephrotomy, w/ exploration Nephrolithotomy; removal of calculus Nephrolithotomy; secondary surgical operation for calculus Nephrolithotomy; complicated by congenital kidney abnormality Nephrolithotomy; removal of large staghorn calculus filling renal pelvis and calyces (including anatrophic pyelolithotomy) Percutaneous nephrostolithotomy or pyelostolithotomy, w/ or w/o dilation, endoscopy, lithotripsy, stenting, or basket extraction; up to 2 cm

Case Rate 5,680 9,700 12,120 8,260 8,260 18,000 21,000 21,000 21,000 21,000 21,000 21,000 21,000 21,000 21,000 21,000 21,000 21,000 21,000 21,000 21,000 21,000 21,000 21,000 21,000 21,000 21,000 21,000 21,000 21,000 21,000 21,000 21,000 21,000 21,000 21,000 21,000 21,000 21,000 21,000 21,000 21,000 23,300 37,800 30,300 23,300 30,300 21,000 21,000 18,000 23,300 30,300 20,980 18,000 18,000 18,000 27,120 30,300 27,120 37,800 30,300

Professional Fee 1,680 4,200 6,720 3,360 3,360 8,400 8,400 8,400 8,400 8,400 8,400 8,400 8,400 8,400 8,400 8,400 8,400 8,400 8,400 8,400 8,400 8,400 8,400 8,400 8,400 8,400 8,400 8,400 8,400 8,400 8,400 8,400 8,400 8,400 8,400 8,400 8,400 8,400 8,400 8,400 8,400 8,400 12,600 21,000 16,800 12,600 16,800 8,400 8,400 8,400 12,600 16,800 10,080 8,400 8,400 8,400 15,120 16,800 15,120 21,000 16,800

Health Care Institution Fee 4,000 5,500 5,400 4,900 4,900 9,600 12,600 12,600 12,600 12,600 12,600 12,600 12,600 12,600 12,600 12,600 12,600 12,600 12,600 12,600 12,600 12,600 12,600 12,600 12,600 12,600 12,600 12,600 12,600 12,600 12,600 12,600 12,600 12,600 12,600 12,600 12,600 12,600 12,600 12,600 12,600 12,600 10,700 16,800 13,500 10,700 13,500 12,600 12,600 9,600 10,700 13,500 10,900 9,600 9,600 9,600 12,000 13,500 12,000 16,800 13,500

Page 63 of 98

ANNEX 2. 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, w/ or w/o dilation, endoscopy, lithotripsy, stenting, or basket extraction; over 2 cm Transection or repositioning of aberrant renal vessels Pyelotomy; w/ exploration Pyelotomy; w/ drainage, pyelostomy Pyelotomy; w/ removal of calculus (pyelolithotomy, pelviolithotomy, including coagulum pyelolithotomy) Pyelotomy; complicated (e.g., secondary operation, congenital kidney abnormality) Renal biopsy; percutaneous, by trocar or needle Renal biopsy; by surgical exposure of kidney Nephrectomy, including partial ureterectomy, any approach including rib resection; Nephrectomy, including partial ureterectomy, any approach including rib resection; complicated because of previous surgery on same kidney Nephrectomy, including partial ureterectomy, any approach including rib resection; radical, w/ regional lymphadenectomy and/or vena caval thrombectomy Nephrectomy w/ total ureterectomy and bladder cuff; through same incision Nephrectomy w/ total ureterectomy and bladder cuff; through separate incision Nephrectomy, partial Ablation, open, one or more renal mass lesion(s), cryosurgical, including intraoperative ultrasound, if performed Excision or unroofing of cyst(s) of kidney Excision of perinephric cyst Donor nephrectomy, w/ preparation and maintenance of allograft; from living donor Recipient nephrectomy Renal allotransplantation, implantation of graft; excluding donor and recipient nephrectomy Renal allotransplantation, implantation of graft; w/ recipient nephrectomy Removal of transplanted renal allograft Renal autotransplantation, reimplantation of kidney Aspiration and/or injection of renal cyst or pelvis by needle, percutaneous Instillation of therapeutic agent into renal pelvis and/or ureter through established nephrostomy, pyelostomy or ureterostomy tube Introduction of intracatheter or catheter into renal pelvis for drainage and/or injection, percutaneous Introduction of ureteral catheter or stent into ureter through renal pelvis for drainage and/or injection, percutaneous Introduction of guide into renal pelvis and/or ureter w/ dilation to establish nephrostomy tract, percutaneous Pyeloplasty (Foley Y-pyeloplasty), plastic operation on renal pelvis, w/ or w/o plastic operation on ureter, nephropexy, nephrostomy, pyelostomy, or ureteral splinting; simple Pyeloplasty (Foley Y-pyeloplasty), plastic operation on renal pelvis, w/ or w/o plastic operation on ureter, nephropexy, nephrostomy, pyelostomy, or ureteral splinting; complicated (congenital kidney abnormality, secondary pyeloplasty, solitary kidney, calycoplasty) Nephrorrhaphy, suture of kidney wound or injury Closure of nephrocutaneous or pyelocutaneous fistula Closure of nephrovisceral fistula (e.g., renocolic), including visceral repair; abdominal approach Closure of nephrovisceral fistula (e.g., renocolic), including visceral repair; thoracic approach Symphysiotomy for horseshoe kidney w/ or w/o pyeloplasty and/or other plastic procedure, unilateral or bilateral (one operation) Laparoscopy, surgical; ablation of renal cysts Laparoscopy, surgical; ablation of renal mass lesion(s) Laparoscopy, surgical; partial nephrectomy Laparoscopy, surgical; pyeloplasty Laparoscopy, surgical; radical nephrectomy (includes removal of Gerotas fascia and surrounding fatty tissue, removal of regional lymph nodes and adrenalectomy) Laparoscopy, surgical; nephrectomy, including partial ureterectomy Laparoscopy, surgical; donor nephrectomy (including cold preservation), from living donor Laparoscopy, surgical; nephrectomy with total ureterectomy Renal endoscopy through established nephrostomy or pyelostomy, w/ or w/o irrigation, instillation, or ureteropyelography, exclusive of radiologic service;

Case Rate 30,300 30,300 18,000 18,000 23,300 31,580 8,020 18,000 27,120 30,300

Professional Fee 16,800 16,800 8,400 8,400 12,600 14,280 2,520 8,400 15,120 16,800

Health Care Institution Fee 13,500 13,500 9,600 9,600 10,700 17,300 5,500 9,600 12,000 13,500

50230 50234 50236 50240 50250 50280 50290 50320 50340 50360 50365 50370 50380 50390 50391 50392 50393 50395 50400

30,300 30,300 30,300 27,120 9,700 20,980 20,980 27,120 23,300 46,500 61,320 30,300 53,400 5,680 9,700 9,700 9,700 8,260 30,300

16,800 16,800 16,800 15,120 4,200 10,080 10,080 15,120 12,600 25,200 40,320 16,800 29,400 1,680 4,200 4,200 4,200 3,360 16,800

13,500 13,500 13,500 12,000 5,500 10,900 10,900 12,000 10,700 21,300 21,000 13,500 24,000 4,000 5,500 5,500 5,500 4,900 13,500

50405 50500 50520 50525 50526 50540 50541 50542 50543 50544 50545 50546 50547 50548 50551

37,180 23,300 18,000 23,300 30,300 30,300 10,540 9,700 30,300 27,120 27,120 23,300 23,300 30,300 8,692

18,480 12,600 8,400 12,600 16,800 16,800 5,040 4,200 16,800 15,120 15,120 12,600 12,600 16,800 3,192

18,700 10,700 9,600 10,700 13,500 13,500 5,500 5,500 13,500 12,000 12,000 10,700 10,700 13,500 5,500

Page 64 of 98

ANNEX 2. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE DESCRIPTION
Renal endoscopy through established nephrostomy or pyelostomy, w/ or w/o irrigation, instillation, or ureteropyelography, exclusive of radiologic service; w/ ureteral catheterization, w/ or w/o dilation of ureter Renal endoscopy through established nephrostomy or pyelostomy, w/ or w/o irrigation, instillation, or ureteropyelography, exclusive of radiologic service; w/ biopsy Renal endoscopy through established nephrostomy or pyelostomy, w/ or w/o irrigation, instillation, or ureteropyelography, exclusive of radiologic service; w/ fulguration and/or incision, w/ or w/o biopsy Renal endoscopy through established nephrostomy or pyelostomy, w/ or w/o irrigation, instillation, or ureteropyelography, exclusive of radiologic service; 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, instillation, or ureteropyelography, exclusive of radiologic service; w/ removal of foreign body or calculus Renal endoscopy through nephrotomy or pyelotomy, w/ or w/o irrigation, instillation, or ureteropyelography, exclusive of radiologic service; Renal endoscopy through nephrotomy or pyelotomy, w/ or w/o irrigation, instillation, or ureteropyelography, exclusive of radiologic service; w/ ureteral catheterization, w/ or w/o dilation of ureter Renal endoscopy through nephrotomy or pyelotomy, w/ or w/o irrigation, instillation, or ureteropyelography, exclusive of radiologic service; w/ biopsy Renal endoscopy through nephrotomy or pyelotomy, w/ or w/o irrigation, instillation, or ureteropyelography, exclusive of radiologic service; w/ endopyelotomy (includes cystoscopy, ureteroscopy, dilation of ureter and ureteral pelvic junction, incision of ureteral pelvic junction and insertion of endopyelotomy stent) Renal endoscopy through nephrotomy or pyelotomy, w/ or w/o irrigation, instillation, or ureteropyelography, exclusive of radiologic service; w/ fulguration and/or incision, w/ or w/o biopsy Renal endoscopy through nephrotomy or pyelotomy, w/ or w/o irrigation, instillation, or ureteropyelography, exclusive of radiologic service; w/ insertion of radioactive substance, w/ or w/o biopsy and/or fulguration Renal endoscopy through nephrotomy or pyelotomy, w/ or w/o irrigation, instillation, or ureteropyelography, exclusive of radiologic service; w/ removal of foreign body or calculus Lithotripsy, extracorporeal shock wave Ablation, one or more renal tumor(s), percutaneous, unilateral frequency Ureterotomy w/ exploration or drainage Ureterotomy for insertion of indwelling stent, all types Ureterolithotomy; upper one-third of ureter Ureterolithotomy; middle one-third of ureter Ureterolithotomy; lower one-third of ureter Ureterectomy, w/ bladder cuff Ureterectomy, total, ectopic ureter, combination abdominal, vaginal and/or perineal approach Ureteroplasty, plastic operation on ureter (e.g., stricture) Ureterolysis, w/ or w/o repositioning of ureter for retroperitoneal fibrosis Ureterolysis for ovarian vein syndrome Ureterolysis for retrocaval ureter, w/ reanastomosis of upper urinary tract or vena cava Revision of urinary-cutaneous anastomosis (any type urostomy); Revision of urinary-cutaneous anastomosis (any type urostomy); w/ repair of fascial defect and hernia Ureteropyelostomy, anastomosis of ureter and renal pelvis Ureterocalycostomy, anastomosis of ureter to renal calyx Ureteroureterostomy Transureteroureterostomy, anastomosis of ureter to contralateral ureter Ureteroneocystostomy; anastomosis of single ureter to bladder Ureteroneocystostomy; anastomosis of duplicated ureter to bladder Ureteroneocystostomy; w/ extensive ureteral tailoring Ureteroneocystostomy; w/ vesico-psoas hitch or bladder flap Ureteroenterostomy, direct anastomosis of ureter to intestine Ureterosigmoidostomy, w/ creation of sigmoid bladder and establishment of abdominal or perineal colostomy, including bowel anastomosis Case Rate Professional Fee Health Care Institution Fee 4,900

50553

8,260

3,360

50555

10,880

3,780

7,100

50557

8,104

2,604

5,500

50559

8,356

2,856

5,500

50561

9,700

4,200

5,500

50570

8,260

3,360

4,900

50572

8,260

3,360

4,900

50574

8,260

3,360

4,900

50575

9,700

4,200

5,500

50576

9,700

4,200

5,500

50578

9,700

4,200

5,500

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

9,700 18,000 9,700 12,120 12,120 21,820 20,980 21,820 21,820 20,980 21,820 21,820 20,980 23,300 22,660 22,660 23,300 27,120 21,820 27,120 27,120 30,300 37,800 30,300 30,740 37,800

4,200 8,400 4,200 6,720 6,720 10,920 10,080 10,920 10,920 10,080 10,920 10,920 10,080 12,600 11,760 11,760 12,600 15,120 10,920 15,120 15,120 16,800 21,000 16,800 13,440 21,000

5,500 9,600 5,500 5,400 5,400 10,900 10,900 10,900 10,900 10,900 10,900 10,900 10,900 10,700 10,900 10,900 10,700 12,000 10,900 12,000 12,000 13,500 16,800 13,500 17,300 16,800

Page 65 of 98

ANNEX 2. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE
50815 50820 50825

DESCRIPTION
Ureterocolon conduit, including bowel anastomosis Ureteroileal conduit (ileal bladder), including bowel anastomosis (Bricker operation) Continent diversion, including bowel anastomosis using any segment of small and/or large bowel (Kock pouch or Camey enterocystoplasty Urinary undiversion (e.g., taking down of ureteroileal conduit, ureterosigmoidostomy or ureteroenterostomy w/ ureteroureterostomy or ureteroneocystostomy) Replacement of all or part of ureter by bowel segment, including bowel anastomosis Cutaneous appendico-vesicostomy Ureterostomy, transplantation of ureter to skin Ureterorrhaphy, suture of ureter Closure of ureterocutaneous fistula Closure of ureterovisceral fistula (including visceral repair) Deligation of ureter Laparoscopy, surgical; ureterolithotomy Laparoscopy, surgical; ureteroneocystostomy with cystoscopy and ureteral stent placement Laparoscopy, surgical; ureteroneocystostomy without cystoscopy and ureteral stent placement Ureteral endoscopy through established ureterostomy, w/ or w/o irrigation, instillation, or ureteropyelography, exclusive of radiologic service; Ureteral endoscopy through established ureterostomy, w/ or w/o irrigation, instillation, or ureteropyelography, exclusive of radiologic service; w/ ureteral catheterization, w/ or w/o dilation of ureter Ureteral endoscopy through established ureterostomy, w/ or w/o irrigation, instillation, or ureteropyelography, exclusive of radiologic service; w/ biopsy Ureteral endoscopy through established ureterostomy, w/ or w/o irrigation, instillation, or ureteropyelography, exclusive of radiologic service; w/ fulguration and/or incision, w/ or w/o biopsy Ureteral endoscopy through established ureterostomy, w/ or w/o irrigation, instillation, or ureteropyelography, exclusive of radiologic service; w/ insertion of radioactive substance, w/ or w/o biopsy and/or fulguration (not including provision of material) Ureteral endoscopy through established ureterostomy, w/ or w/o irrigation, instillation, or ureteropyelography, exclusive of radiologic service; w/ removal of foreign body or calculus Ureteral endoscopy through ureterotomy, w/ or w/o irrigation, instillation, or ureteropyelography, exclusive of radiologic service; Ureteral endoscopy through established ureterostomy, w/ or w/o irrigation, instillation, or ureteropyelography, exclusive of radiologic service; w/ ureteral catheterization, w/ or w/o dilation of ureter Ureteral endoscopy through established ureterostomy, w/ or w/o irrigation, instillation, or ureteropyelography, exclusive of radiologic service; w/ biopsy Ureteral endoscopy through established ureterostomy, w/ or w/o irrigation, instillation, or ureteropyelography, exclusive of radiologic service; w/ fulguration and/or incision, w/ or w/o biopsy Ureteral endoscopy through established ureterostomy, w/ or w/o irrigation, instillation, or ureteropyelography, exclusive of radiologic service; w/ insertion of radioactive substance, w/ or w/o biopsy and/or fulguration (not including provision of material) Ureteral endoscopy through established ureterostomy, w/ or w/o irrigation, instillation, or ureteropyelography, exclusive of radiologic service; w/ removal of foreign body or calculus Aspiration of bladder; by trocar or intracatheter w/ insertion of suprapubic catheter Cystotomy or cystostomy; w/ fulguration and/or insertion of radioactive material Cystotomy or cystostomy; w/ cryosurgical destruction of intravesical lesion Cystostomy, cystotomy w/ drainage Cystotomy, w/ insertion of ureteral catheter or stent Cystolithotomy, cystotomy w/ removal of calculus, w/o vesical neck resection Transvesical ureterolithotomy Cystotomy, 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, w/ or w/o umbilical hernia repair Cystotomy; for simple excision of vesical neck

Case Rate 37,800 40,320 46,500

Professional Fee 21,000 23,520 25,200

Health Care Institution Fee 16,800 16,800 21,300

50830 50840 50845 50860 50900 50920 50930 50940 50945 50947 50948 50951

37,800 37,800 30,300 20,980 18,000 20,980 23,300 21,820 21,940 23,300 23,300 8,260

21,000 21,000 16,800 10,080 8,400 10,080 12,600 10,920 9,240 12,600 12,600 3,360

16,800 16,800 13,500 10,900 9,600 10,900 10,700 10,900 12,700 10,700 10,700 4,900

50953

8,260

3,360

4,900

50955

8,260

3,360

4,900

50957

10,880

3,780

7,100

50959

9,700

4,200

5,500

50961 50970

11,980 8,260

5,880 3,360

6,100 4,900

50972

8,260

3,360

4,900

50974

8,260

3,360

4,900

50976

10,880

3,780

7,100

50978

9,700

4,200

5,500

50980 51010 51020 51030 51040 51045 51050 51060 51065 51080 51500 51520

11,980 5,680 9,700 9,700 9,700 10,540 12,540 21,820 21,820 10,540 30,300 20,980

5,880 1,680 4,200 4,200 4,200 5,040 7,140 10,920 10,920 5,040 16,800 10,080

6,100 4,000 5,500 5,500 5,500 5,500 5,400 10,900 10,900 5,500 13,500 10,900

Page 66 of 98

ANNEX 2. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE
51525 51530 51535 51550 51555 51565 51570 51575 51580

DESCRIPTION
Cystotomy; for excision of bladder diverticulum, single or multiple Cystotomy; for excision of bladder tumor Cystotomy for excision, incision, or repair of ureterocele Cystectomy, partial Cystectomy, complicated (e.g., postradiation, previous surgery, difficult location) Cystectomy, partial, w/ reimplantation of ureter(s) into bladder (ureteroneocystostomy) Cystectomy, complete; Cystectomy, complete; w/ bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes Cystectomy, complete, w/ ureterosigmoidostomy or ureterocutaneous transplantations; Cystectomy, complete, w/ ureterosigmoidostomy or ureterocutaneous transplantations; w/ bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes Cystectomy, complete, w/ ureteroileal conduit or sigmoid bladder, including bowel anastomosis; Cystectomy, complete, w/ ureteroileal conduit or sigmoid bladder, including bowel anastomosis; w/ bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes Cystectomy, complete, w/ continent diversion, any technique, using any segment of small and/or large bowel to construct neobladder Pelvic exenteration, complete, for vesical, prostatic or urethral malignancy, w/ removal of bladder and ureteral transplantations, w/ or w/o hysterectomy and/or abdominoperineal resection of rectum and colon and colostomy, or any combination thereof Injection procedure for cystography or voiding urethrocystography Bladder instillation of anticarcinogenic agent Cystoplasty or cystourethroplasty, plastic operation on bladder and/or vesical neck (anterior Y-plasty, vesical fundus resection), any procedure, w/ or w/o wedge resection of posterior vesical neck Cystourethroplasty w/ unilateral or bilateral ureteroneocystostomy Anterior vesicourethropexy, or urethropexy (Marshall-Marchetti-Krantz type) complicated (e.g., secondary repair) Abdomino-vaginal vesical neck suspension, w/ or w/o endoscopic control (e.g., Stamey, Raz, modified Pereyra) Cystorrhaphy, suture of bladder wound, injury or rupture Closure of cystostomy Closure of vesicovaginal fistula, abdominal approach Closure of vesicouterine fistula; Closure of vesicouterine fistula; w/ hysterectomy Closure of bladder exstrophy Enterocystoplasty, including bowel anastomosis Cutaneous vesicostomy Laparoscopy, surgical; urethral suspension for stress incontinence Laparoscopy, surgical; sling operation for stress incontinence (e.g., fascia or synthetic) Cystourethroscopy Cystourethroscopy, w/ ureteral catheterization, w/ or w/o irrigation, instillation, or ureteropyelography, exclusive of radiologic service; Cystourethroscopy, w/ ureteral catheterization, w/ or w/o irrigation, instillation, or ureteropyelography, exclusive of radiologic service; w/ brush biopsy of ureter and/or renal pelvis Cystourethroscopy, w/ ejaculatory duct catheterization, w/ or w/o irrigation, instillation, or duct radiography, exclusive of radiologic service Cystourethroscopy, w/ biopsy Cystourethroscopy, w/ fulguration (including cryosurgery or laser surgery) of trigone, bladder neck, prostatic fossa, urethra, or periurethral glands Cystourethroscopy, w/ fulguration (including cryosurgery or laser surgery) or treatment of MINOR (less than 0.5 cm) lesion(s) w/ or w/o biopsy Cystourethroscopy, w/ fulguration (including cryosurgery or laser surgery) and/or resection of; SMALL bladder tumor(s) (0.5 cm to 2.0 cm) Cystourethroscopy, w/ fulguration (including cryosurgery or laser surgery) and/or resection of MEDIUM bladder tumor(s) (2.0 to 5.0 cm) LARGE bladder tumor(s) Cystourethroscopy w/ insertionof radioactive substance, w/ or w/o biopsy or fulguration Cystourethroscopy, w/ dilation of bladder for insterstitial cystitis; general or conduction (spinal) anesthesia

Case Rate 27,120 27,120 23,300 30,740 37,800 30,300 37,800 46,500 40,320

Professional Fee 15,120 15,120 12,600 13,440 21,000 16,800 21,000 25,200 23,520

Health Care Institution Fee 12,000 12,000 10,700 17,300 16,800 13,500 16,800 21,300 16,800

51585

53,400

29,400

24,000

51590 51595 51596

55,920 55,840 58,800

31,920 34,440 37,800

24,000 21,400 21,000

51597 51600 51720 51800 51820 51840 51841 51845 51860 51880 51900 51920 51925 51940 51960 51980 51990 51992 52000 52005 52007

71,400 8,020 8,020 20,980 27,120 20,980 30,740 20,980 12,120 10,880 23,300 23,300 30,300 30,300 30,740 12,120 30,300 30,300 8,260 9,700 8,260

50,400 2,520 2,520 10,080 15,120 10,080 13,440 10,080 6,720 3,780 12,600 12,600 16,800 16,800 13,440 6,720 16,800 16,800 3,360 4,200 3,360

21,000 5,500 5,500 10,900 12,000 10,900 17,300 10,900 5,400 7,100 10,700 10,700 13,500 13,500 17,300 5,400 13,500 13,500 4,900 5,500 4,900

52010 52204 52214

8,260 10,540 11,980

3,360 5,040 5,880

4,900 5,500 6,100

52224

11,980

5,880

6,100

52234

20,980

10,080

10,900

52235 52240 52250 52260

22,240 23,300 30,740 11,980

11,340 12,600 13,440 5,880

10,900 10,700 17,300 6,100

Page 67 of 98

ANNEX 2. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE
52265 52270 52275 52276 52277 52281 52283

DESCRIPTION
local anesthesia Cystourethroscopy, w/ internal urethrotomy; female Cystourethroscopy, w/ internal urethrotomy; male Cystourethroscopy w/ direct vision internal urethrotomy Cystourethroscopy, w/ resection of external sphincter (sphincterotomy) Cystourethroscopy, w/ calibration and/or dilation of urethral stricture or stenosis, w/ or w/o meatotomy and injection procedure for cystography, male or female Cystourethroscopy, w/ steroid injection into stricture Cystourethroscopy, for treatment of the female urethral syndrome w/ any or all of the following: urethral meatotomy, urethral dilation, internal urethrotomy, lysis of urethrovaginal septal fibrosis, lateral incisions of the bladder neck, and fulguration of polyp(s) of urethra, bladder neck, and/or trigone Cystourethroscopy; w/ ureteral meatotomy, unilateral or bilateral Cystourethroscopy; w/ resection or fulguration of orthotopic ureterocele(s), unilateral or bilateral Cystourethroscopy; w/ resection or fulguration of ectopic ureterocele(s), unilateral or bilateral Cystourethroscopy; w/ incision or resection of orifice of bladder diverticulum, single or multiple Cystourethroscopy, w/ removal of foreign body, calculus, or ureteral stent from urethra or bladder Litholapaxy: crushing or fragmentation of calculus by any means in bladder and removal of fragments; simple or small (less than 2.5 cm) Litholapaxy: crushing or fragmentation of calculus by any means in bladder and removal of fragments; complicated or large (over 2.5 cm) Cystourethroscopy (including ureteral catheterization); w/ removal of ureteral calculus Cystourethroscopy (including ureteral catheterization); w/ fragmentation of ureteral calculus (e.g., ultrasonic or electro-hydraulic technique) Cystourethroscopy (including ureteral catheterization); w/ subureteric injection of implant material Cystourethroscopy (including ureteral catheterization); w/ manipulation, w/o removal of ureteral calculus Cystourethroscopy, w/ insertion of indwelling ureteral stent (e.g., Gibbons or double-J type) Cystourethroscopy w/ insertion of ureteral guide wire through kidney to establish a percutaneous nephrostomy, retrograde Cystourethroscopy, w/ ureteroscopy and/or pyeloscopy (includes dilation of the ureter and/or pyeloureteral junction by any method); Cystourethroscopy, w/ ureteroscopy and/or pyeloscopy (includes dilation of the ureter and/or pyeloureteral junction by any method); w/ removal or manipulation of calculus (ureteral catheterization is included) Cystourethroscopy, w/ ureteroscopy and/or pyeloscopy (includes dilation of the ureter and/or pyeloureteral junction by any method); w/ lithotripsy (ureteral catheterization is included) Cystourethroscopy, w/ ureteroscopy and/or pyeloscopy (includes dilation of the ureter and/or pyeloureteral junction by any method); w/ biopsy and/or fulguration of lesion Cystourethroscopy, w/ ureteroscopy and/or pyeloscopy (includes dilation of the ureter and/or pyeloureteral junction by any method); w/ resection of tumor Cystourethroscopy w/ incision, fulguration, or resection of congenital posterior urethral valves, or congenital obstructive hypertrophic mucosal folds Transurethral incision of prostate Transurethral resection of bladder neck Transurethral balloon dilation of the prostatic urethra, any method Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete (vasectomy, meatomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included) Transurethral fulguration for postoperative bleeding occuring after the usual follow-up time Transurethral resection of prostate; first stage of two-stage resection (partial resection) Transurethral resection of prostate; second stage of two-stage resection (resection completed) Transurethral resection; of residual obstructive tissue after 90 days postoperative

Case Rate 8,020 12,900 12,900 12,540 12,120 8,020 8,020

Professional Fee 2,520 6,300 6,300 7,140 6,720 2,520 2,520

Health Care Institution Fee 5,500 6,600 6,600 5,400 5,400 5,500 5,500

52285

10,540

5,040

5,500

52290 52300 52301 52305 52310 52317

11,980 21,940 21,940 12,120 10,540 18,000

5,880 9,240 9,240 6,720 5,040 8,400

6,100 12,700 12,700 5,400 5,500 9,600

52318 52320 52325 52327 52330 52332 52334 52335

21,940 11,980 18,000 9,700 10,540 10,540 9,700 12,120

9,240 5,880 8,400 4,200 5,040 5,040 4,200 6,720

12,700 6,100 9,600 5,500 5,500 5,500 5,500 5,400

52336

12,120

6,720

5,400

52337

21,940

9,240

12,700

52338

21,940

9,240

12,700

52339

12,120

6,720

5,400

52340 52450 52500 52510 52601

21,940 23,300 23,300 12,120 37,800

9,240 12,600 12,600 6,720 21,000

12,700 10,700 10,700 5,400 16,800

52606 52612 52614 52620

18,000 21,940 21,940 20,980

8,400 9,240 9,240 10,080

9,600 12,700 12,700 10,900

Page 68 of 98

ANNEX 2. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE
52630 52640 52647

DESCRIPTION
Transurethral resection; of regrowth of obstructive tissue longer than one year postoperative Transurethral resection; of postoperative bladder neck contracture Non-contact laser coagulation of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included) Contact laser vaporization w/ or w/o transurethral resection of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, 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, external ; pendulous urethra Urethrotomy or urethrostomy, external ; perineal urethra, external Meatotomy, cutting of meatus ; except infant Meatotomy, cutting of meatus ; infant Drainage of deep periurethral abscess Drainage of Skenes gland abscess or cyst Drainage of perineal urinary extravasation Biopsy of urethra Urethrectomy, total, including cystostomy; female Urethrectomy, total, including cystostomy; male Excision of fulguration of carcinoma of urethra Excision of urethral diverticulum ; female Excision of urethral diverticulum ; male Marsupialization of urethral diverticulum, male or female Excision of bulbourethral gland (Cowpers gland) Excision or fulguration; urethral polyp(s), distal urethra Excision or fulguration; urethral caruncle Skenes glands Skenes glands urethral prolapse Urethroplasty; first stage, for fistula, diverticulum, or stricture (e.g., Johannsen type) Urethroplasty; second stage (formation of urethra), including urinary diversion Urethroplasty, one-stage reconstruction of male anterior urethra Urethroplasty, transpubic or perineal, one stage, for reconstruction or repair of prostatic or membranous urethra Urethroplasty, two-stage reconstruction or repair of prostatic or membranous urethra; first stage Urethroplasty, two-stage reconstruction or repair of prostatic or membranous urethra; second stage Urethroplasty, reconstruction of female urethra Operation for correction of male urinary incontinence, 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.g., Tenago, Leadbetter procedure) Operation for correction of urinary incontinence w/ placement of inflatable urethral or bladder neck sphincter, including placement of pump and/or reservoir Removal, repair, or replacement of inflatable sphincter including pump and/or reservoir and/or cuff Surgical correction of hydraulic abnormality of inflatable sphincter device Urethromeatoplasty, w/ mucosal advancement Urethromeatoplasty, w/ partial excision of distal urethral segment (Richardson type procedure) Urethrorrhaphy, suture of urethral wound or injury, female Urethrorrhaphy, suture of urethral wound or injury; penile Urethrorrhaphy, suture of urethral wound or injury; perineal Urethrorrhaphy, suture of urethral wound or injury; prostatomembranous Closure of urethrostomy or urethrocutaneous fistula, male Dilation of urethral stricture by passage of sound or urethral dilator, male Dilation of urethral stricture or vesical neck, male, general or conduction (spinal) anesthesia Dilation of female urethra, general or conduction (spinal) anesthesia Transurethral destruction of prostate tissue; by microwave thermotherapy i.e. Transurethral Microwave Thermotherapy (TUMT) Transurethral destruction of prostate tissue; by radiofrequncy ablation i.e., Transurethral Needle Ablation (TUNA), transurethral laser incision of the prostate (TULIP)

Case Rate 37,800 20,980 27,120

Professional Fee 21,000 10,080 15,120

Health Care Institution Fee 16,800 10,900 12,000

52648

27,120

15,120

12,000

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

37,800 18,000 5,680 8,260 5,560 8,260 9,300 5,560 8,020 5,560 21,940 21,820 9,700 18,000 14,960 9,300 12,120 5,560 5,560 5,560 9,300 30,300 27,120 14,960 40,320 37,800 27,120 18,000 18,000 18,000 31,140 37,180 40,320 18,000 8,260 8,260 9,700 9,700 10,540 10,540 8,020 5,680 5,680 5,680 37,800 37,800

21,000 8,400 1,680 3,360 1,260 3,360 2,100 1,260 2,520 1,260 9,240 10,920 4,200 8,400 7,560 2,100 6,720 1,260 1,260 1,260 2,100 16,800 15,120 7,560 23,520 21,000 15,120 8,400 8,400 8,400 17,640 18,480 23,520 8,400 3,360 3,360 4,200 4,200 5,040 5,040 2,520 1,680 1,680 1,680 21,000 21,000

16,800 9,600 4,000 4,900 4,300 4,900 7,200 4,300 5,500 4,300 12,700 10,900 5,500 9,600 7,400 7,200 5,400 4,300 4,300 4,300 7,200 13,500 12,000 7,400 16,800 16,800 12,000 9,600 9,600 9,600 13,500 18,700 16,800 9,600 4,900 4,900 5,500 5,500 5,500 5,500 5,500 4,000 4,000 4,000 16,800 16,800

Page 69 of 98

ANNEX 2. 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), penis (e.g., condyloma, papilloma, molluscum contagiosum, herpetic vesicle), any method Biopsy of penis Excision of penile plaque (Peyronie disease); Excision of penile plaque (Peyronie disease); w/ graft to 5 cm in length Excision of penile plaque (Peyronie disease); w/ graft greater than 5 cm in length Removal of foreign body from deep penile tissue (e.g., plastic implant) Amputation of penis; partial Amputation of penis; complete Amputation of penis, radical; w/ bilateral inguinofemoral lymphadenectomy Amputation of penis, radical; in continuity w/ bilateral pelvic lymphadenectomy, including external iliac, hypogastric and obturator nodes Circumcision, using clamp or other device; newborn Circumcision, using clamp or other device; except newborn Circumcision, surgical excision other than clamp, device or dorsal slit; newborn Circumcision, surgical excision other than clamp, device or dorsal slit; except newborn Injection procedure for Peyronie disease; Injection procedure for Peyronie disease;w/ surgical exposure of plaque Irrigation of corpora cavernosa for priapism Plastic operation of penis for straightening of chordee (e.g., hypospadias), 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); less than 3 cm Urethroplasty for second stage hypospadias repair (including urinary diversion); 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.g., third stage Cecil repair) One stage distal hypospadias repair (w/ or w/o chordee or circumcision); w/ simple meatal advancement (e.g., Magpi, V-flap) One stage distal hypospadias repair (w/ or w/o chordee or circumcision); w/ urethroplasty by local skin flaps (e.g., flip-flap, prepucial flap) One stage distal hypospadias repair (w/ or w/o chordee or circumcision); w/ urethroplasty by local skin flaps and mobilization of urethra One stage distal hypospadias repair (w/ or w/o chordee or circumcision); w/ extensive dissection to correct chordee and urethroplasty w/ local skin flaps, skin graft patch, 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, fistula, stricture, diverticula); by closure, incision, or excision, simple Repair of hypospadias complications (ie, fistula, stricture, diverticula); requiring mobilization of skin flaps and urethroplasty w/ flap or patch graft Repair of hypospadias complications (ie, fistula, stricture, diverticula); requiring extensive dissection and urethroplasty w/ flap, 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; Plastic operation on penis for epispadias distal to external sphincter;w/ incontinence

Case Rate 3,640 3,640 3,504 9,300 10,540 11,980 8,260 10,540 21,400 37,800 46,500 1,260 1,260 1,260 1,260 5,560 5,680 8,020 9,700 14,960 23,300 23,300 23,300 12,120 27,120 27,120

Professional Fee 840 840 504 2,100 5,040 5,880 3,360 5,040 10,500 21,000 25,200 840 840 840 840 1,260 1,680 2,520 4,200 7,560 12,600 12,600 12,600 6,720 15,120 15,120

Health Care Institution Fee 2,800 2,800 3,000 7,200 5,500 6,100 4,900 5,500 10,900 16,800 21,300 420 420 420 420 4,300 4,000 5,500 5,500 7,400 10,700 10,700 10,700 5,400 12,000 12,000

54326

27,120

15,120

12,000

54328

30,300

16,800

13,500

54332

37,180

18,480

18,700

54336 54340 54344

37,180 37,180 18,000

18,480 18,480 8,400

18,700 18,700 9,600

54348

20,980

10,080

10,900

54352

37,800

21,000

16,800

54380 54385

30,300 37,180

16,800 18,480

13,500 18,700

Page 70 of 98

ANNEX 2. 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;w/ exstrophy of bladder Corpora cavernosa-saphenous vein shunt (priapism operation), unilateral or bilateral Corpora cavernosa-corpus spongiosum shunt (priapism operation), unilateral or bilateral Corpora cavernosa-glans penis fistulization (e.g., biopsy needle, Winter procedure, rongeur, or punch) for priapism Plastic operation of penis for injury Biopsy of testis, needle Biopsy of testis, incisional Excision of local lesion of testis Orchiectomy, simple (including subcapsular), w/ or w/o testicular prosthesis, scrotal or inguinal approach Orchiectomy, radical, for tumor; inguinal approach Orchiectomy, radical, for tumor; w/ abdominal exploration Exploration for undescended testis (inguinal or scrotal area) Exploration for undescended testis w/ abdominal exploration Reduction of torsion of testis, surgical, w/ or w/o fixation of contralateral testis Fixation of contralateral testis Orchiopexy, inguinal approach, w/ or w/o hernia repair Orchiopexy, abdominal approach, for intra-abdominal testis (e.g., FowlerStephens) Suture or repair of testicular injury Transplantation of testis(es) to thigh (because of scrotal destruction) Laparoscopy, surgical; orchiectomy Laparoscopy, surgical; orchiopexy for intra-abdominal testis Incision and drainage of epididymis, testis and/or scrotal space (e.g., abscess or hematoma) Biopsy of epididymis, needle Exploration of epididymis, w/ or w/o biopsy Excision of local lesion of epidydimis Excision of spermatocele, w/ or w/o epididymectomy Epididymectomy; unilateral Epididymectomy; bilateral Epididymovasostomy, anastomosis of epididymis to vas deferens; unilateral Epididymovasostomy, anastomosis of epididymis to vas deferens; bilateral Puncture aspiration of hydrocele, tunica vaginalis, w/ or w/o injection of medication Excision of hydrocele; unilateral Excision of hydrocele; 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, cannulization w/ or w/o incision of vas, unilateral or bilateral Vasectomy, unilateral or bilateral Vasovasostomy, vasovasorrhaphy Excision of hydrocele of spermatic cord, unilateral Excision of lesion of spermatic cord Excision of varicocele or ligation of spermatic veins for varicocele; Excision of varicocele or ligation of spermatic veins for varicocele; abdominal approach Excision of varicocele or ligation of spermatic veins for varicocele; w/ hernia repair Laparoscopy, surgical; with ligation of spermatic veins for varicocele Vesiculotomy; Vesiculectomy, any approach Excision of Mullerian duct cyst Biopsy, prostate; needle or punch, single or multiple, any approach Prostatotomy, external drainage of prostatic abscess, any approach Prostatectomy, perineal, subtotal (including control of postoperative bleeding, vasectomy, meatotomy, urethral calibration and/or dilation, and internal urethrotomy) Prostatectomy, perineal radical; Prostatectomy, perineal radical; w/ lymph node biopsy(s) (limited pelvic lymphadenectomy)

Case Rate 37,800 12,120 12,120 8,260 12,120 3,504 5,680 5,680 10,540 10,960 12,540 10,540 12,540 10,960 9,300 10,540 12,540 9,700 8,260 9,700 11,980 4,108 3,504 9,300 5,680 8,020 9,300 8,440 10,540 18,000 3,504 9,700 18,000 9,700 3,504 9,300 9,300 4,108 5,560 5,680 5,680 4,000 10,540 9,700 8,260 12,900 14,960 14,960 14,960 10,120 18,000 18,000 9,300 5,680 38,860 46,500 48,180

Professional Fee 21,000 6,720 6,720 3,360 6,720 504 1,680 1,680 5,040 5,460 7,140 5,040 7,140 5,460 2,100 5,040 7,140 4,200 3,360 4,200 5,880 1,008 504 2,100 1,680 2,520 2,100 2,940 5,040 8,400 504 4,200 8,400 4,200 504 2,100 2,100 1,008 1,260 1,680 1,680 1,000 5,040 4,200 3,360 6,300 7,560 7,560 7,560 4,620 8,400 8,400 2,100 1,680 20,160 25,200 26,880

Health Care Institution Fee 16,800 5,400 5,400 4,900 5,400 3,000 4,000 4,000 5,500 5,500 5,400 5,500 5,400 5,500 7,200 5,500 5,400 5,500 4,900 5,500 6,100 3,100 3,000 7,200 4,000 5,500 7,200 5,500 5,500 9,600 3,000 5,500 9,600 5,500 3,000 7,200 7,200 3,100 4,300 4,000 4,000 3,000 5,500 5,500 4,900 6,600 7,400 7,400 7,400 5,500 9,600 9,600 7,200 4,000 18,700 21,300 21,300

Page 71 of 98

ANNEX 2. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE
55815

DESCRIPTION
Prostatectomy, perineal radical; w/ bilateral pelvic lymphadenectomy, including external iliac, hypogastric and obturator nodes Prostatectomy (including control of postoperative bleeding, vasectomy, meatotomy, urethral calibration and/or dilation, and internal urethrotomy); suprapubic, subtotal, one or two stages Prostatectomy (including control of postoperative bleeding, vasectomy, meatotomy, urethral calibration and/or dilation, and internal urethrotomy); retropubic, subtotal Prostatectomy, retropubic radical, w/ or w/o nerve sparing; Prostatectomy, retropubic radical, w/ or w/o nerve sparing; w/ lymph node biopsy(s) (limited pelvic lymphadenectomy) Prostatectomy, retropubic radical, w/ or w/o nerve sparing; w/ bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes Transperineal placement of needles, catheters or pellets into prostate for interstitial radioelement application, with or without cystoscopy, ultrasound or CT scan guidance Exposure of prostate, any approach, for insertion of radioactive substance; Exposure of prostate, any approach, for insertion of radioactive substance; w/ lymph node biopsy(s) (limited pelvic lymphadenectomy) Exposure of prostate, any approach, for insertion of radioactive substance; w/ bilateral pelvic lymphadenectomy, including external iliac, hypogastric and obturator nodes Laparoscopy, surgical prostatectomy, retropubic radical, 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), vulva; any method Biopsy of vulva or perineum ; one lesion Vulvectomy simple; partial Vulvectomy simple; complete Vulvectomy, radical, partial; Vulvectomy, radical, partial; w/ unilateral inguinofemoral lymphadenectomy Vulvectomy, radical, partial; w/ bilateral inguinofemoral lymphadenectomy Vulvectomy, radical, complete; Vulvectomy, radical, complete; w/ unilateral inguinofemoral lymphadenectomy Vulvectomy, radical, complete; w/ bilateral inguinofemoral lymphadenectomy Vulvectomy, radical, complete, w/ inguinofemoral, iliac, and pelvic lymphadenectomy Partial hymenectomy or revision of hymenal ring Hymenotomy, simple incision Excision of Bartholins gland or cyst Colpotomy; w/ exploration Colpocentesis Destruction of vaginal lesion(s) Biopsy of vaginal mucosa Colpectomy, obliteration of vagina; partial Colpectomy, obliteration of vagina; 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, suture of injury of vagina (nonobsterical) Colpoperineorrhaphy, suture of injury of vagina and/or perineum (nonobstetrical) Plastic operation on urethral sphincter, vaginal approach (e.g., Kelly urethral plication) Plastic repair of urethrocele Anterior colporrhaphy, repair of cystocele w/ or w/o repair of urethrocele Posterior colporrhaphy, repair of rectocele w/ or w/o perineorrhaphy Combined anteroposterior colporrhaphy; Combined anteroposterior colporrhaphy; w/ enterocele repair Repair of enterocele, vaginal approach Repair of enterocele, abdominal approach

Case Rate 48,180

Professional Fee 26,880

Health Care Institution Fee 21,300

55821

38,860

20,160

18,700

55831 55840 55842 55845

30,300 46,500 48,180 48,180

16,800 25,200 26,880 26,880

13,500 21,300 21,300 21,300

55859 55860 55862

18,000 9,700 18,000

8,400 4,200 8,400

9,600 5,500 9,600

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

23,300 46,500 55,000 5,560 9,300 9,700 9,300 9,300 9,300 12,120 23,300 27,120 30,300 37,800 46,500 53,400 55,000 58,800 9,700 9,300 9,700 12,120 5,680 5,680 5,680 23,300 30,300 27,120 9,300 9,700 9,700 8,020 10,540 12,120 12,120 20,980 20,980 23,300 30,300 23,300 27,120

12,600 25,200 33,600 1,260 2,100 4,200 2,100 2,100 2,100 6,720 12,600 15,120 16,800 21,000 25,200 29,400 33,600 37,800 4,200 2,100 4,200 6,720 1,680 1,680 1,680 12,600 16,800 15,120 2,100 4,200 4,200 2,520 5,040 6,720 6,720 10,080 10,080 12,600 16,800 12,600 15,120

10,700 21,300 21,400 4,300 7,200 5,500 7,200 7,200 7,200 5,400 10,700 12,000 13,500 16,800 21,300 24,000 21,400 21,000 5,500 7,200 5,500 5,400 4,000 4,000 4,000 10,700 13,500 12,000 7,200 5,500 5,500 5,500 5,500 5,400 5,400 10,900 10,900 10,700 13,500 10,700 12,000

Page 72 of 98

ANNEX 2. 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, abdominal approach Sacrospinous ligament fixation for prolapse of vagina Paravaginal defect repair (including repair of cystocele, stress urinary incontinence, and/or incomplete vaginal prolapse) Sling operation for stress incontinence (e.g., fascia or synthetic) Pereyra procedure, including anterior colporrhaphy Closure of rectovaginal fistula; vaginal or transanal approach Closure of rectovaginal fistula; abdominal approach Closure of rectovaginal fistula; abdominal approach, w/ concomitant colostomy Closure of urethrovaginal fistula; Closure of urethrovaginal fistula; w/ bulbocavernosus transplant Closure of vesicovaginal fistula; vaginal approach Closure of vesicovaginal fistula; transvesical and vaginal approach Removal of impacted vaginal foreign body under anesthesia Laparoscopy, surgical, colpopexy (suspension of vaginal apex) Colposcopy (Vaginoscopy) Colposcopy; w/ biopsy(s) of the cervix and/or endocervical curettage Colposcopy; w/ loop electrode excision procedure of the cervix Biopsy, single or multiple, or local excision of lesion, w/ or w/o fulguration Cauterization of cervix; any method Conization of cervix, w/ or w/o fulguration, w/ or w/o dilation and curettage, w/ or w/o repair; cold knife or laser Conization of cervix, w/ or w/o fulguration, w/ or w/o dilation and curettage, w/ or w/o repair; loop electrode excision Trachelectomy (cervicectomy), amputation of cervix Excision of cervical stump, abdominal approach; Excision of cervical stump, abdominal approach; w/ pelvic floor repair Excision of cervical stump, vaginal approach; Excision of cervical stump, vaginal approach; w/ anterior and/or posterior repair Excision of cervical stump, vaginal approach; w/ repair of enterocele Cerclage of uterine cervix, nonobstetrical Trachelorrhaphy, plastic repair of uterine cervix, vaginal approach Endometrial sampling (biopsy) w/ or w/o endocervical sampling (biopsy), w/o cervical dilation, any method Dilation and curettage Myomectomy, excision of fibroid tumor of uterus, single or multiple ; abdominal approach Myomectomy, excision of fibroid tumor of uterus, single or multiple ; vaginal approach Total abdominal hysterectomy (corpus and cervix), w/ or w/o removal of tube(s), w/ or w/o removal of ovary(s); Total abdominal hysterectomy (corpus and cervix), w/ or w/o removal of tube(s), w/ or w/o removal of ovary(s); w/ colpo-urethrocystopexy (MarshallMarchetti-Krantz type) Supracervical abdominal hysterectomy (subtotal hysterectomy), w/ or w/o removal of tube(s), w/ or w/o removal of ovary(s) Total abdominal hysterectomy, including partial vaginectomy, w/ paraaortic and pelvic lymph node sampling, w/ or w/o removal of tube(s), w/ or w/o removal of ovary(s) Radical abdominal hysterectomy, w/ bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy), w/ or w/o removal of tube(s), w/ or w/o removal of ovary(s) Pelvic exenteration for gynecologic malignancy, w/ total abdominal hysterectomy or cervicectomy, w/ or w/o removal of tube(s), w/ or w/o removal of ovary(s), w/ removal of bladder and ureteral transplantations, and/or abdominoperineal resection of rectum and colon and colostomy, or any combination thereof Vaginal hysterectomy; Vaginal hysterectomy; w/ removal of tube(s), and/or ovary(s) Vaginal hysterectomy; w/ removal of tube(s), and/or ovary(s), w/ repair of enterocele Vaginal hysterectomy; w/ colpo-urethrocystopexy (Marshall-MarchettiKrantz type, Pereyra type, w/ or w/o endoscopic control) Vaginal hysterectomy; w/ repair of enterocele Vaginal hysterectomy, w/ total or partial colpectomy; Vaginal hysterectomy, w/ total or partial colpectomy; w/ repair of enterocele Vaginal hysterectomy, 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 27,120 27,120 27,120 30,300 30,300 20,980 23,300 30,300 20,980 30,300 23,300 30,300 8,260 27,120 8,020 8,260 9,700 5,680 5,680 9,700 12,900 18,000 30,300 37,800 23,300 37,800 39,900 9,700 18,000 11,000 11,000 23,300 18,000 30,000 30,000 30,000 30,000

Professional Fee 15,120 15,120 15,120 16,800 16,800 10,080 12,600 16,800 10,080 16,800 12,600 16,800 3,360 15,120 2,520 3,360 4,200 1,680 1,680 4,200 6,300 8,400 16,800 21,000 12,600 21,000 23,100 4,200 8,400 4,400 4,400 12,600 8,400 12,000 12,000 12,000 12,000

Health Care Institution Fee 12,000 12,000 12,000 13,500 13,500 10,900 10,700 13,500 10,900 13,500 10,700 13,500 4,900 12,000 5,500 4,900 5,500 4,000 4,000 5,500 6,600 9,600 13,500 16,800 10,700 16,800 16,800 5,500 9,600 6,600 6,600 10,700 9,600 18,000 18,000 18,000 18,000

58210

55,000

33,600

21,400

58240

71,400

50,400

21,000

58260 58262 58263 58267 58270 58275 58280 58285 58300 58345

30,300 30,300 37,800 46,500 46,500 37,800 46,500 46,500 2,000 18,000

16,800 16,800 21,000 25,200 25,200 21,000 25,200 25,200 800 8,400

13,500 13,500 16,800 21,300 21,300 16,800 21,300 21,300 1,200 9,600

Page 73 of 98

ANNEX 2. 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, w/ or w/o shortening of round ligaments, w/ or w/o shortening of sacrouterine ligaments; Uterine suspension, w/ or w/o shortening of round ligaments, w/ or w/o shortening of sacrouterine ligaments; w/ presacral sympathectomy Hysterorrhaphy, repair of ruptured uterus (nonobstetrical) Hysteroplasty, repair of uterine anomaly (Strassman type) Laparoscopy, surgical, myomectomy, excision; intramural myomas and/or removal of surface myomas Laparoscopy surgical, with vaginal hysterectomy; Laparoscopy surgical, with vaginal hysterectomy; with removal of tube(s) and/or ovary(s) Hysteroscopy, diagnostic Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D&C Hysteroscopy, surgical; with lysis of intrauterine adhesions (any method) Hysteroscopy, surgical; with division or resection of intrauterine septum (any method) Hysteroscopy, surgical; with removal of leiomyomata Hysteroscopy, surgical; with removal of impacted foreign body Hysteroscopy, surgical; with endometrial ablation (e.g., endometrial resection, electrosurgical ablation thermoablation) Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants Ligation or transection of fallopian tube(s), abdominal or vaginal approach, unilateral or bilateral Laparoscopy, surgical; with lysis of adhesions (salphingolysis, ovariolysis) Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy) Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method Laparoscopy, surgical; with fulguration of oviducts (with or without transection) Laparoscopy, surgical; with occlusion of oviducts by device (e.g., band, clip, or Falope ring) Laparoscopy, surgical; with fimbrioplasty Laparoscopy, surgical; with salphingostomy (salpingoneostomy) Salpingectomy, complete or partial, unilateral or bilateral Salpingo-oophorectomy, complete or partial, unilateral or bilateral Lysis of adhesions (salpingolysis, ovariolysis) Tubotubal anastomosis Fimbrioplasty Salpingostomy (salpingoneostomy) Drainage of ovarian cyst(s), unilateral or bilateral ; vaginal approach Drainage of ovarian cyst(s), unilateral or bilateral ; abdominal approach Drainage of ovarian abscess; vaginal approach Drainage of ovarian abscess; abdominal approach Transposition, ovary(s) Biopsy of ovary, unilateral or bilateral Wedge resection or bisection of ovary, unilateral or bilateral Ovarian cystectomy, unilateral or bilateral Oophorectomy, partial or total, unilateral or bilateral; Oophorectomy, partial or total, unilateral or bilateral; for ovarian malignancy, w/ para-aortic and pelvic lymph node biopsies, peritoneal washings, peritoneal biopsies, diaphragmatic assessments, w/ or w/o salpingectomy(s), w/ or w/o omentectomy Resection of ovarian malignancy w/ bilateral salpingo-oophorectomy and omentectomy; Resection of ovarian malignancy w/ bilateral salpingo-oophorectomy and omentectomy; w/ total abdominal hysterectomy, pelvic and limited paraaortic lymphadenectomy Resection of ovarian malignancy w/ bilateral salpingo-oophorectomy and omentectomy; w/ radical dissection for debulking Laparotomy, for staging or restaging of ovarian malignancy ("second look"), w/ or w/o omentectomy, peritoneal washing, biopsy of abdominal and pelvic peritoneum, diaphragmatic assessment w/ pelvic and limited paraaortic lymphadenectomy Hysterotomy, abdominal (e.g., for hydatidiform mole, abortion) Surgical treatment of ectopic pregnancy; tubal or ovarian, requiring salpingectomy and/or oophorectomy, abdominal or vaginal approach

Case Rate 9,700 23,300 27,120 23,300 37,800 23,300 30,300 30,300 9,700 12,900 18,000 18,000 23,300 12,900 12,120 5,680 4,000 21,400 53,400 14,960 14,960 12,900 21,400 23,300 20,980 23,300 23,300 18,000 23,300 23,300 20,980 20,980 20,980 20,980 20,980 18,000 18,000 23,300 18,000 30,300

Professional Fee 4,200 12,600 15,120 12,600 21,000 12,600 16,800 16,800 4,200 6,300 8,400 8,400 12,600 6,300 6,720 1,680 1,000 10,500 29,400 7,560 7,560 6,300 10,500 12,600 10,080 12,600 12,600 8,400 12,600 12,600 10,080 10,080 10,080 10,080 10,080 8,400 8,400 12,600 8,400 16,800

Health Care Institution Fee 5,500 10,700 12,000 10,700 16,800 10,700 13,500 13,500 5,500 6,600 9,600 9,600 10,700 6,600 5,400 4,000 3,000 10,900 24,000 7,400 7,400 6,600 10,900 10,700 10,900 10,700 10,700 9,600 10,700 10,700 10,900 10,900 10,900 10,900 10,900 9,600 9,600 10,700 9,600 13,500

58950 58951

53,400 55,000

29,400 33,600

24,000 21,400

58952

58,800

37,800

21,000

58960 59100 59120

27,120 23,300 27,120

15,120 12,600 15,120

12,000 10,700 12,000

Page 74 of 98

ANNEX 2. 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; tubal or ovarian, w/o salpingectomy and/or oophorectomy Surgical treatment of ectopic pregnancy; abdominal pregnancy Surgical treatment of ectopic pregnancy; interstitial, uterine pregnancy requiring total hysterectomy Surgical treatment of ectopic pregnancy; interstitial, uterine pregnancy w/ partial resection of uterus Surgical treatment of ectopic pregnancy; cervical, w/ evacuation Laparoscopic treatment of ectopic pregnancy; w/o salpingectomy and/or oophorectomy Laparoscopic treatment of ectopic pregnancy; w/ salpingectomy and/or oophorectomy Cerclage of cervix, during pregnancy; vaginal Cerclage of cervix, during pregnancy; abdominal Hysterorrhaphy of ruptured uterus Routine obstetric care including antepartum care, vaginal delivery and/or postpartum care (Normal Spontaneous Delivery Package) for hospitals Routine Obstetric care including prenatal, delivery and newborn services of non-hospital facilities (Maternity Care Package), 1st claim Routine obstetric care including antepartum care, vaginal delivery and/or postpartum care for hospitals; with bilateral tubal ligation Vaginal delivery only (w/ episiotomy) Breech extraction Caesarian section, primary Cesarian delivery Subtotal or total hysterectomy after cesarean delivery Vaginal delivery only, after previous cesarean delivery (w/ or w/o episiotomy) Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery; Treatment of incomplete abortion, any trimester, completed surgically Manual vacuum aspiration for spontaneous abortion Uterine evacuation and curettage for hydatidiform mole Incision and drainage of thyroglossal cyst, infected Aspiration and/or injection, thyroid cyst Biopsy thyroid, percutaneous core needle Excision of cyst or adenoma of thyroid , or transection of isthmus Partial thyroid lobectomy, unilateral; w/ or w/o isthmusectomy Partial thyroid lobectomy, unilateral; w/ contralateral subtotal lobectomy, including isthmusectomy Total thyroid lobectomy, unilateral; w/ or w/o isthmusectomy Total thyroid lobectomy, unilateral; w/ contralateral subtotal lobectomy, including isthmusectomy Thyroidectomy, total or complete Thyroidectomy, total or subtotal for malignancy; w/ limited neck dissection Thyroidectomy, total or subtotal for malignancy; w/ radical neck dissection Thyroidectomy, removal of all remaining thyroid tissue following previous removal of a portion of thyroid Thyroidectomy, including substernal thyroid gland; sternal split or transhoracic approach Thyroidectomy, including substernal thyroid gland; cervical approach Excision of thyroglossal duct cyst or sinus; Excision of thyroglossal duct cyst or sinus; recurrent Parathyroidectomy or exploration of parathyroid(s); Parathyroidectomy or exploration of parathyroid(s); re-exploration Parathyroidectomy or exploration of parathyroid(s); w/ mediastinal exploration, sternal split or transthoracic approach Parathyroid autotransplantation Thymectomy, partial or total; transcervical approach Thymectomy, partial or total; sternal split or transthoracic approach, w/o radical mediastinal dissection Thymectomy, partial or total; sternal split or transthoracic approach, w/ radical mediastinal dissection Adrenalectomy, partial or complete, or exploration of adrenal gland w/ or w/o biopsy, transabdominal, lumbar or dorsal; Adrenalectomy, partial or complete, or exploration of adrenal gland w/ or w/o biopsy, transabdominal, lumbar or dorsal; w/ excision of adjacent retroperitoneal tumor Excision of carotid body tumor; w/o excision of carotid artery Excision of carotid body tumor; w/ excision of carotid artery

Case Rate 27,120 46,500 37,800 37,600 30,300 27,120 27,120 18,000 18,000 30,300 6,500

Professional Fee 15,120 25,200 21,000 18,900 16,800 15,120 15,120 8,400 8,400 16,800 2,000

Health Care Institution Fee 12,000 21,300 16,800 18,700 13,500 12,000 12,000 9,600 9,600 13,500 3,000

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

8,000 10,500 9,700 12,120 19,000 19,000 30,000 12,120 19,000 11,000 11,000 12,120 3,504 8,260 8,260 20,980 31,000 31,000 31,000 31,000 31,000 31,000 46,500 31,000 46,500 46,500 20,980 23,300 30,740 27,120 39,900 30,300 39,900 39,900 39,900 30,300 37,600 30,300 37,800

2,600 3,600 4,200 6,720 7,600 7,600 12,000 6,720 7,600 4,400 4,400 6,720 504 3,360 3,360 10,080 12,400 12,400 12,400 12,400 12,400 12,400 25,200 12,400 25,200 25,200 10,080 12,600 13,440 15,120 23,100 16,800 23,100 23,100 23,100 16,800 18,900 16,800 21,000

3,900 5,400 5,500 5,400 11,400 11,400 18,000 5,400 11,400 6,600 6,600 5,400 3,000 4,900 4,900 10,900 18,600 18,600 18,600 18,600 18,600 18,600 21,300 18,600 21,300 21,300 10,900 10,700 17,300 12,000 16,800 13,500 16,800 16,800 16,800 13,500 18,700 13,500 16,800

Page 75 of 98

ANNEX 2. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE
60650 61000 61020 61050 61105 61106 61107 61108 61120

DESCRIPTION
Laparoscopy, surgical, with adrenalectomy, partial or complete, or exploration of adrenal gland with or without biopsy, transabdominal, lumbar or dorsal Subdural tap through fontanelle, or suture, infant, unilateral or bilateral Ventricular puncture through previous burr hole, fontanelle, suture, or implanted ventricular catheter/reservoir Cisternal or lateral cervical (C1-C2) puncture Twist drill hole for subdural or ventricular puncture; not followed by other surgery Twist drill hole for subdural or ventricular puncture; followed by other surgery Twist drill hole for subdural or ventricular puncture; for implanting venticular catheter or pressure recording device Twist drill hole for subdural or ventricular puncture; for evacuation and/or drainage of subdural hematoma Burr hole(s) for ventricular puncture (including injection of gas, contrast media, dye, or radioactive material); not followed by other surgery Burr hole(s) for ventricular puncture (including injection of gas, contrast media, dye, or radioactive material); followed by other surgery Burr hole(s) or trephine; w/ biopsy of brain or intracranial lesion Burr hole(s) or trephine; w/ drainage of brain abscess or cyst Burr hole(s) w/ evacuation and/or drainage of hematoma, extradural or subdural Burr hole(s); w/ aspiration of hematoma or cyst, intracerebral Burr hole(s) or trephine, supratentorial Burr hole(s) or trephine, infratentorial, unilateral or bilateral Craniectomy or craniotomy, exploratory; supratentorial Craniectomy or craniotomy, exploratory; infratentorial (posterior fossa) Craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural Craniectomy or craniotomy for evacuation of hematoma, supratentorial; intracerebral Craniectomy or craniotomy for evacuation of hematoma, infratentorial; extradural or subdural Craniectomy or craniotomy for evacuation of hematoma, infratentorial; intracerebellar Craniectomy or craniotomy, drainage of intracranial abscess; supratentorial Craniectomy or craniotomy, drainage of intracranial abscess; infratentorial Decompression of orbit only, transcranial approach Exploration of orbit (transcranial approach); w/ biopsy Exploration of orbit (transcranial approach); w/ removal of lesion Exploration of orbit (transcranial approach); w/ removal of foreign body Other cranial decompression (e.g., subtemporal), supratentorial Craniectomy, suboccipital w/ cervical laminectomy for decompression of medulla and spinal cord, w/ or w/o dural graft (e.g., Arnold-Chiari malformation) Other cranial decompression, posterior fossa Craniotomy for section of tentorium cerebelli Craniectomy, subtemporal, for section, compression, or decompression of sensory root of gasserian ganglion Craniectomy, suboccipital; for exploration or decompression of cranial nerves Craniectomy, suboccipital; for section of one or more cranial nerves Craniectomy, suboccipital; for medullary tractotomy Craniectomy, suboccipital; for mesencephalic tractotomy or pedunculotomy Craniotomy for lobotomy, including cingulotomy Craniectomy; w/ excision of tumor or other bone lesion of skull Craniectomy; for osteomyelitis Craniectomy, trephination, bone flap craniotomy; for excision of brain tumor, supratentorial, except meningioma Craniectomy, trephination, bone flap craniotomy; for excision of meningioma, supratentorial Craniectomy, trephination, bone flap craniotomy; for excision of brain abscess, supratentorial Craniectomy, trephination, bone flap craniotomy; for excision or fenestration of cyst, supratentorial Craniectomy for excision of brain tumor, infratentorial or posterior fossa; except meningioma, cerebellopontine angle tumor, or midline tumor at base of skull

Case Rate 30,300 5,680 5,680 10,540 18,000 18,420 30,300 37,800 23,300

Professional Fee 16,800 1,680 1,680 5,040 8,400 8,820 16,800 21,000 12,600

Health Care Institution Fee 13,500 4,000 4,000 5,500 9,600 9,600 13,500 16,800 10,700

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

22,240 37,800 37,800 37,800 37,800 23,300 30,300 37,800 46,500 46,500 46,500 53,400 53,400 46,500 53,400 46,500 53,400 53,400 53,400 37,800 53,400 46,500 46,500 53,400 53,400 55,000 55,000 55,000 46,500 55,000 37,800 55,000 63,000 53,400 53,400 65,100

11,340 21,000 21,000 21,000 21,000 12,600 16,800 21,000 25,200 25,200 25,200 29,400 29,400 25,200 29,400 25,200 29,400 29,400 29,400 21,000 29,400 25,200 25,200 29,400 29,400 33,600 33,600 33,600 25,200 33,600 21,000 33,600 42,000 29,400 29,400 44,100

10,900 16,800 16,800 16,800 16,800 10,700 13,500 16,800 21,300 21,300 21,300 24,000 24,000 21,300 24,000 21,300 24,000 24,000 24,000 16,800 24,000 21,300 21,300 24,000 24,000 21,400 21,400 21,400 21,300 21,400 16,800 21,400 21,000 24,000 24,000 21,000

Page 76 of 98

ANNEX 2. 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, infratentorial or posterior fossa; meningioma Craniectomy for excision of brain tumor, infratentorial or posterior fossa; cerebellopontine angle tumor Craniectomy for excision of brain tumor, infratentorial or posterior fossa; midline tumor at base of skull Craniectomy, infratentorial or posterior fossa; for excision of brain abscess Craniectomy, infratentorial or posterior fossa; for excision or fenestration of cyst, Craniectomy, bone flap craniotomy, transtemporal (mastoid) for excision of cerebellopontine angle tumor; Craniectomy, bone flap craniotomy, transtemporal (mastoid) for excision of cerebellopontine angle tumor; 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; for subdural implantation of an electrode array, for long term seizure monitoring Craniotomy w/ elevation of bone flap; for excision of epileptogenic focus w/o electrocorticography during surgery Craniotomy w/ elevation of bone flap; for removal of epidural or subdural electrode array, w/o excision of cerebral tissue Craniotomy w/ elevation of bone flap; for excision of cerebral epileptogenic focus, w/ electrocorticography during surgery (includes removal of electrode array) Craniotomy w/ elevation of bone flap; for lobectomy w/ electrocorticography during surgery, temporal lobe Craniotomy w/ elevation of bone flap; for lobectomy w/ electrocorticography during surgery, other than temporal lobe, partial or total Craniotomy w/ elevation of bone flap; for transection of corpus callosum Craniotomy w/ elevation of bone flap; for total hemispherectomy Craniotomy w/ elevation of bone flap; for partial or subtotal hemispherectomy Craniotomy w/ elevation of bone flap; for excision of coagulation of choroid plexus Craniotomy w/ elevation of bone flap; for excision of craniopharyngioma Craniotomy for hypophysectomy or excision of pituitary tumor, intracranial approach Hypophysectomy or excision of pituitary tumor, transnasal or transseptal approach, nonstereotactic Craniectomy for craniosynostosis; single cranial suture Craniectomy for craniosynostosis; multiple cranial sutures Craniotomy for craniosynostosis; frontal or parietal bone flap Craniotomy for craniosynostosis; bifrontal bone flap Extensive craniectomy for multiple cranial suture craniosynostosis (e.g., cloverleaf skull); not requiring bone grafts Extensive craniectomy for multiple cranial suture craniosynostosis (e.g., cloverleaf skull); recontouring w/ multiple osteotomies and bone autografts (e.g., barrel-stave procedure) (includes obtaining grafts) Excision, intra and extracranial, benign tumor of cranial bone (e.g., fibrous dysplasia); w/o optic nerve decompression Excision, intra and extracranial, benign tumor of cranial bone (e.g., fibrous dysplasia); w/ optic nerve decompression Craniectomy or craniotomy; w/ excision of foreign body from brain Craniectomy or craniotomy; w/ treatment of penetrating wound of brain Transoral approach to skull base, brain stem or upper spinal cord for biopsy, decompression or excision of lesion; Transoral approach to skull base, brain stem or upper spinal cord for biopsy, decompression or excision of lesion; requiring splitting of tongue and/or mandible (including tracheostomy) Craniofacial approach to anterior cranial fossa; extradural, including lateral rhinotomy, ethmoidectomy, sphenoidectomy, w/o maxillectomy or orbital exenteration Craniofacial approach to anterior cranial fossa; extradural, including lateral rhinotomy, orbital exenteration, ethmoidectomy, sphenoidectomy and/or maxillectomy Craniofacial approach to anterior cranial fossa; extradural, including unilateral or bifrontal craniotomy, elevation of frontal lobe(s), osteotomy of base of anterior cranial fossa

Case Rate 67,200 71,400 71,400 55,000 55,000 75,600 75,600 53,400 53,400 53,400 53,400 55,000 53,400 53,400 53,400 67,200 63,000 53,400 63,000 63,000 63,000 37,800 46,500 46,500 46,500 58,800

Professional Fee 46,200 50,400 50,400 33,600 33,600 54,600 54,600 29,400 29,400 29,400 29,400 33,600 29,400 29,400 29,400 46,200 42,000 29,400 42,000 42,000 42,000 21,000 25,200 25,200 25,200 37,800

Health Care Institution Fee 21,000 21,000 21,000 21,400 21,400 21,000 21,000 24,000 24,000 24,000 24,000 21,400 24,000 24,000 24,000 21,000 21,000 24,000 21,000 21,000 21,000 16,800 21,300 21,300 21,300 21,000

61559

58,800

37,800

21,000

61563 61564 61570 61571 61575 61576

58,800 58,800 53,400 55,500 75,600 75,600

37,800 37,800 29,400 31,500 54,600 54,600

21,000 21,000 24,000 24,000 21,000 21,000

61580

63,000

42,000

21,000

61581

63,000

42,000

21,000

61582

63,000

42,000

21,000

Page 77 of 98

ANNEX 2. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE
61583

DESCRIPTION
Craniofacial approach to anterior cranial fossa; intradural, including unilateral or bifrontal craniotomy, elevation or resection of frontal lobe, osteotomy of base of anterior cranial fossa Orbitocranial approach to anterior cranial fossa, extradural, including supraorbital ridge osteotomy and elevation of frontal and/or temporal lobe(s); w/o orbital exenteration Orbitocranial approach to anterior cranial fossa, extradural, including supraorbital ridge osteotomy and elevation of frontal and/or temporal lobe(s); w/ orbital exenteration Bicoronal, transzygomatic and/or LeFort I osteotomy approach to anterior cranial fossa w/ or w/o internal fixation, w/o bone graft Infratemporal pre-auricular approach to middle cranial fossa (parapharyngeal space, infratemporal and midline skull base, nasopharynx), w/ or w/o disarticulation of the mandible, including parotidectomy, craniotomy, decompression and/or mobilization of th Infratemporal post-auricular approach to middle cranial fossa (internal auditory meatus, petrous apex, tentorium, cavernous sinus, parasellar area, infratemporal fossa) inlcuding mastoidectomy, resection of sigmoid sinus, w/ or w/o decompression and/or mo Orbitocranial zygomatic approach to middle cranial fossa (cavernous sinus and carotid artery, clivus, basilar artery or petrous apex) including osteotomy of zygoma, craniotomy, extra- or intradural elevation of temporal lobe Transtemporal approach to posterior cranial fossa, jugular foramen or midline skull base, including mastoidectomy, decompression of sigmoid sinus and/or facial nerve, w/ or w/o mobilization Transcochlear approach to posterior cranial fossa, jugular foramen or midline skull base, including labyrinthectomy, decompression, w/ or w/o mobilization of facial nerve and/or petrous carotid artery Transcondylar (far lateral) approach to posterior cranial fossa, jugular foramen or midline skull base, including occiptal condylectomy, mastoidectomy, resection of C1-C3 vertebral body(s), decompression of vertebral artery, w/ or w/o mobilization Transpetrosal approach to posterior cranial fossa, clivus or framen magnum, including ligation of superior petrosal sinus and/or sigmoid sinus Resection or excision of neoplastic, vascular or infectious lesion of base of anterior cranial fossa; extradural Resection or excision of neoplastic, vascular or infectious lesion of base of anterior cranial fossa; intradural, including dural repair,w/ or w/o graft Resection or excision of neoplastic, vascular or infectious lesion of infratemporal fossa, parapharyngeal space, petrous apex; extradural Resection or excision of neoplastic, vascular or infectious lesion of infratemporal fossa, parapharyngeal space, petrous apex; intradural, including dural repair, w/ or w/o graft Resection or excision of neoplastic, vascular or infectious lesion of parasellar area, cavernous sinus, clivus or midline skull base; extradural Resection or excision of neoplastic, vascular or infectious lesion of parasellar area, cavernous sinus, clivus or midline skull base; intradural, including dural repair, w/ or w/o graft Transection or ligation, carotid artery in cavernous sinus; w/o repair Transection or ligation, carotid artery in cavernous sinus; w/ repair by anastomosis or graft Transection or ligation , carotid artery in petrous canal; w/o repair Transection or ligation , carotid artery in petrous canal; w/ repair by anastomosis or graft Obliteration of carotid aneurysm, arteriovenous malformation, or carotidcavernous fistula by dissection w/in cavernous sinus Resection or excision of neoplastic, vascular or infectious lesion of base of posterior cranial fossa, jugular foramen, foramen magnum, or CI-C3 vertebral bodies; extradural Resection or excision of neoplastic, vascular or infectious lesion of base of posterior cranial fossa, jugular foramen, foramen magnum, or CI-C3 vertebral bodies; intradural, including dural repair, w/ or w/o graft Secondary repair of dura for CSF leak, anterior, middle or posterior cranial fossa following surgery of the skull base; by free tissue graft (e.g., pericranium, fascia, tensor fascia lata, adipose tissue, homologous or synthetic grafts)

Case Rate 63,000

Professional Fee 42,000

Health Care Institution Fee 21,000

61584

63,000

42,000

21,000

61585 61586

63,000 63,000

42,000 42,000

21,000 21,000

61590

71,400

50,400

21,000

61591

71,400

50,400

21,000

61592

67,200

46,200

21,000

61595

71,400

50,400

21,000

61596

71,400

50,400

21,000

61597

71,400

50,400

21,000

61598 61600 61601

71,400 67,200 67,200

50,400 46,200 46,200

21,000 21,000 21,000

61605

71,400

50,400

21,000

61606

71,400

50,400

21,000

61607

71,400

50,400

21,000

61608 61609 61610 61611 61612 61613 61615

71,400 71,400 71,400 63,000 71,400 71,400 71,400

50,400 50,400 50,400 42,000 50,400 50,400 50,400

21,000 21,000 21,000 21,000 21,000 21,000 21,000

61616

71,400

50,400

21,000

61618

67,200

46,200

21,000

Page 78 of 98

ANNEX 2. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE DESCRIPTION
Secondary repair of dura for CSF leak, anterior, middle or posterior cranial fossa following surgery of the skull base; by local or regionalized vascularized pedicle flap or myocutaneous flap (including galea,temporalis, frontalis or occipitalis muscle) Transcatheter oclussion or embolization (e.g., for tumor destruction, to achieve hemostasis, to occlude a vascular malformation), percutaneous, any method; central nervous system (intracranial, spinal cord) Transcatheter oclussion or embolization (e.g., for tumor destruction, to achieve hemostasis, to occlude a vascular malformation), percutaneous, any method; non-central nervous system, head or neck (extracranial, brachiocephalic branch) Surgery of intracranial arteriovenous malformation; supratentorial, simple Surgery of intracranial arteriovenous malformation; supratentorial, complex Surgery of intracranial arteriovenous malformation; infratentorial, simple Surgery of intracranial arteriovenous malformation; infratentorial, complex Surgery of intracranial arteriovenous malformation; dural, simple Surgery of intracranial arteriovenous malformation; dural, complex Surgery of intracranial aneurysm, intracranial approach; carotid circulation Surgery of intracranial aneurysm, intracranial approach; vertebral-basilar circulation Surgery of intracranial aneurysm, cervical approach by application of occluding clamp to cervical carotid artery (Selverstone-Crutchfield type) Surgery of aneurysm, vascular malformation or carotid-cavernous fistula; by intracranial and cervical occlusion of carotid artery Surgery of aneurysm, vascular malformation or carotid-cavernous fistula; by intracranial electrothrombosis Surgery of aneurysm, vascular malformation or carotid-cavernous fistula; by intra-arterial embolization, injection procedure or balloon catheter Anastomosis, arterial, extracranial-intracranial (e.g., middle cerebral/cortical) arteries Microdissection, intracranial or spinal procedure (list separately in addition to code for primary procedure) Creation of lesion by stereotactic method, including burr hole(s) and localizing and recording techniques, single or multiple stages; globus pallidus or thalamus Creation of lesion by stereotactic method, including burr hole(s) and localizing and recording techniques, single or multiple stages; subcortical structure(s) other than globus pallidus or thalamus Stereotactic biopsy, aspiration, or excision,including burr hole(s), for intracranial lesion; Stereotactic biopsy, aspiration, or excision,including burr hole(s), for intracranial lesion; w/ computerized axial tomography Stereotactic implantation of depth electrodes into the cerebrum for long term seizure monitoring Stereotactic localization , any method, including burr hole(s), w/ insertion of catheter(s) for brachytherapy Creation of lesion by stereotactic method, percutaneous, by neurolytic agent (e.g., alcohol, thermal, electrical, radiofrequency); gasserian ganglion Creation of lesion by stereotactic method, percutaneous, by neurolytic agent (e.g., alcohol, thermal, electrical, radiofrequency); trigeminal medullary tract Stereotactic radiosurgery (particle beam,gamma ray or linear accelerator) Stereotactic computer assisted volumetric intracranial procedure Twist drill or burr hole(s) for implantation of neurostimulator electrodes; cortical Twist drill or burr hole(s) for implantation of neurostimulator electrodes; subcortical Craniectomy or craniotomy for implantation of neurostimulator electrodes, cerebral; cortical Craniectomy or craniotomy for implantation of neurostimulator electrodes, cerebral; subcortical Craniectomy for implantation of neurostimulator electrodes, cerebellar; cortical Craniectomy for implantation of neurostimulator electrodes, cerebellar; subcortical Incision and subcutaneous placement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling Case Rate Professional Fee Health Care Institution Fee 21,000

61619

63,000

42,000

61624

71,400

50,400

21,000

61626

55,000

33,600

21,400

61680 61682 61684 61686 61690 61692 61700 61702 61703 61705 61708 61710 61711 61712 61720

63,000 71,400 63,000 71,400 55,000 63,000 71,400 75,600 23,300 71,400 37,800 63,000 67,200 67,200 67,200

42,000 50,400 42,000 50,400 33,600 42,000 50,400 54,600 12,600 50,400 21,000 42,000 46,200 46,200 46,200

21,000 21,000 21,000 21,000 21,400 21,000 21,000 21,000 10,700 21,000 16,800 21,000 21,000 21,000 21,000

61735 61750 61751 61760 61770 61790

63,000 63,000 63,000 63,000 30,300 37,800

42,000 42,000 42,000 42,000 16,800 21,000

21,000 21,000 21,000 21,000 13,500 16,800

61791 61793 61795 61850 61855 61860 61865 61870 61875 61885

37,800 63,000 63,000 53,400 67,200 58,800 46,500 58,800 67,200 37,800

21,000 42,000 42,000 29,400 46,200 37,800 25,200 37,800 46,200 21,000

16,800 21,000 21,000 24,000 21,000 21,000 21,300 21,000 21,000 16,800

Page 79 of 98

ANNEX 2. 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; simple, extradural Elevation of depressed skull fracture; compound or comminuted, extradural Elevation of depressed skull fracture; w/ repair of dura and /or debridement of brain Craniotomy for repair of dural /CSF leak, including surgery for rhinorrhea/otorrhea Reduction of craniomegalic skull (e.g., treated hydrocephalus); not requiring bone grafts or cranioplasty Reduction of craniomegalic skull (e.g., treated hydrocephalus); w/ simple cranioplasty Reduction of craniomegalic skull (e.g., treated hydrocephalus); requiring craniotomy and reconstruction w/ or w/o bone graft (includes obtaining grafts) Repair of encephalocele, skull vault, including cranioplasty Craniotomy for repair of encephalocele , skull base Cranioplasty for skull defect; up to 5 cm diameter Cranioplasty for skull defect; 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); up to 5 cm diameter Cranioplasty w/ autograft (includes obtaining bone grafts); larger than 5 cm diameter Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage Neuroendoscopy, intracranial; with dissection of adhesions, fenestration of septum pellucidum or intraventricular cyst (including placement, replacement or removal of ventricular catheter) Neuroendoscopy, intracranial; with fenestration or excision of colloid cyst, including placement of external ventricular catheter for drainage Neuroendoscopy, intracranial; with retrieval of foreign body Neuroendoscopy, intracranial; with excision of pituitary tumor, transnasal or transphenoidal approach Ventriculocisternostomy (Torkildsen type operation) Creation of shunt; subarachnoid/subdural-atrial, -jugular, -auricular Creation of shunt; subarachnoid/subdural-peritonial, -pleural, other terminus Ventriculocisternostomy, third ventricle; Ventriculocisternostomy, third ventricle; stereotactic method Creation of shunt; ventriculo-atrial, -jugular,-auricular Creation of shunt; ventriculo-peritonial,-pleural, other terminus Replacement or revision of CSF (VP) shunt, obstructed valve, or distal catheter in shunt system Percutaneous aspiration, spinal cord cyst or syrinx Biopsy of spinal cord, percutaneous needle Spinal puncture, lumbar, diagnostic Spinal puncture , therapeutic, for drainage of spinal fluid (by needle or catheter) Aspiration procedure, percutaneous, of nucleus pulposus of intervertebral disk, any method, single or multiple levels, lumbar Implantation, revision or repositioning of intrathecal or epidural catheter, for implantable reservoir or implantable infusion pump; w/o laminectomy Implantation, revision or repositioning of intrathecal or epidural catheter, for implantable reservoir or implantable infusion pump; w/ laminectomy Implantation or replacement of device for intrathecal or epidural drug infusion; subcutaneous reservoir Implantation or replacement of device for intrathecal or epidural drug infusion; non-programmable pump Implantation or replacement of device for intrathecal or epidural drug infusion; programmable pump, including preparation of pump, w/ or w/o programming Implantation or replacement of device for intrathecal or epidural drug infusion; with excision of brain tumor, including placement of external ventricular catheter for drainage Laminectomy w/ exploration and/or decompression of spinal cord and/or cauda equina, w/o facetectomy, foraminotomy or diskectomy, (e.g., spinal stenosis), one or two vertebral segments; cervical

Case Rate 30,300 37,800 46,500 71,400 37,800 46,500 53,400 58,800 55,000 30,300 30,300 30,300 30,300 53,400 53,400 55,000 37,800

Professional Fee 16,800 21,000 25,200 50,400 21,000 25,200 29,400 37,800 33,600 16,800 16,800 16,800 16,800 29,400 29,400 33,600 21,000

Health Care Institution Fee 13,500 16,800 21,300 21,000 16,800 21,300 24,000 21,000 21,400 13,500 13,500 13,500 13,500 24,000 24,000 21,400 16,800

62161

46,500

25,200

21,300

62162 62163 62165 62180 62190 62192 62200 62201 62220 62223 62230 62268 62269 62270 62272 62287 62350

46,500 46,500 46,500 37,800 23,300 23,300 37,800 46,500 30,300 30,300 23,300 12,900 12,900 5,680 5,560 23,300 18,000

25,200 25,200 25,200 21,000 12,600 12,600 21,000 25,200 16,800 16,800 12,600 6,300 6,300 1,680 1,260 12,600 8,400

21,300 21,300 21,300 16,800 10,700 10,700 16,800 21,300 13,500 13,500 10,700 6,600 6,600 4,000 4,300 10,700 9,600

62351 62360 62361 62362

37,800 9,700 18,000 23,300

21,000 4,200 8,400 12,600

16,800 5,500 9,600 10,700

62464

46,500

25,200

21,300

63001

55,000

33,600

21,400

Page 80 of 98

ANNEX 2. 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, foraminotomy or diskectomy, (e.g., spinal stenosis), one or two vertebral segments; thoracic Laminectomy w/ exploration and/or decompression of spinal cord and/or cauda equina, w/o facetectomy, foraminotomy or diskectomy, (e.g., spinal stenosis), one or two vertebral segments; lumbar,except for spondylolisthesis Laminectomy w/ exploration and/or decompression of spinal cord and/or cauda equina, w/o facetectomy, foraminotomy or diskectomy, (e.g., spinal stenosis), one or two vertebral segments; sacral Laminectomy w/ removal of abnormal facets and/or pars inter-articularis w/ decompression of cauda equina and nerve roots for spondylolisthesis, lumbar (Gill type procedure) Laminectomy w/ exploration and/or decompression of spinal cord and/or cauda equina, w/o facetectomy, foraminotomy or diskectomy, (e.g., spinal stenosis) , more than 2 vertebral segments; cervical Laminectomy w/ exploration and/or decompression of spinal cord and/or cauda equina, w/o facetectomy, foraminotomy or diskectomy, (e.g., spinal stenosis) , more than 2 vertebral segments; thoracic Laminectomy w/ exploration and/or decompression of spinal cord and/or cauda equina, w/o facetectomy, foraminotomy or diskectomy, (e.g., spinal stenosis) , more than 2 vertebral segments; lumbar Laminotomy (hemilaminectomy), w/ decompression of nerve root (s), including partial facetectomy , foraminotomy and/or excision of herniated intervertebral disk; one interspace, cervical Laminotomy (hemilaminectomy), w/ decompression of nerve root (s), including partial facetectomy , foraminotomy and/or excision of herniated intervertebral disk; one interspace,lumbar Laminotomy (hemilaminectomy), w/ decompression of nerve root (s), including partial facetectomy , foraminotomy and/or excision or herniated intervertebral disk; re-exploration; cervical Laminotomy (hemilaminectomy), w/ decompression of nerve root (s), including partial facetectomy , foraminotomy and/or excision or herniated intervertebral disk; re-exploration; lumbar Laminectomy, facetectomy and foraminotomy (unilateral or bilateral w/ decompression of spinal cord, cauda equina and/or nerve root(s), ( eg, spinal or lateral recess stenosis), single vertebral segment; cervical Laminectomy, facetectomy and foraminotomy (unilateral or bilateral w/ decompression of spinal cord, cauda equina and/or nerve root(s), ( eg, spinal or lateral recess stenosis), single vertebral segment; thoracic Laminectomy, facetectomy and foraminotomy (unilateral or bilateral w/ decompression of spinal cord, cauda equina and/or nerve root(s), ( eg, spinal or lateral recess stenosis), single vertebral segment; lumbar Transpedicular approach w/ decompression of spinal cord, equina and/ or nerve root(s) (e.g., herniated intervetebral disk), single segment; thoracic Transpedicular approach w/ decompression of spinal cord, equina and/ or nerve root(s) (e.g., herniated intervetebral disk), single segment; lumbar Costovertebral approach w/ decompression of spinal cord or nerve root(s), (e.g., herniated intervertebral disk), thoracic; single segment Diskectomy, anterior, w/ decompression of spinal cord and/ or nerve root(s), including osteophytectomy; cervical, single interspace Diskectomy, anterior, w/ decompression of spinal cord and/ or nerve root(s), including osteophytectomy; thoracic, single interspace Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach w/ decompression of spinal cord and/ or nerve root(s); cervical, single segment Vertebral corpectomy (vertebral body resection), partial or complete, transthoracic approach w/ decompression of spinal cord and/ or nerve root(s); thoracic, single segment Vertebral corpectomy (vertebral body resection), partial or complete, combined thoracolumbar approach w/ decompression of spinal cord, cauda equina or nerve root(s), lower thoracic or lumbar; single segment Vertebral corpectomy (vertebral body resection), partial or complete, transperitoneal or retroperitoneal approach w/ decompression of spinal cord, cauda equina or nerve root(s), lower thoracic, lumbar, or sacral; single segment Case Rate Professional Fee Health Care Institution Fee 24,000

63003

53,400

29,400

63005

37,800

21,000

16,800

63011

37,800

21,000

16,800

63012

53,400

29,400

24,000

63015

55,000

33,600

21,400

63016

53,400

29,400

24,000

63017

46,500

25,200

21,300

63020

55,000

33,600

21,400

63030

46,500

25,200

21,300

63040

53,400

29,400

24,000

63042

46,500

25,200

21,300

63045

55,000

33,600

21,400

63046

53,400

29,400

24,000

63047

46,500

25,200

21,300

63055

53,400

29,400

24,000

63056 63064 63075 63077 63081

46,500 53,400 55,000 37,800 55,000

25,200 29,400 33,600 21,000 33,600

21,300 24,000 21,400 16,800 21,400

63085

53,400

29,400

24,000

63087

46,500

25,200

21,300

63090

53,400

29,400

24,000

Page 81 of 98

ANNEX 2. 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.g., Bischof or DREZ type), cervical thoracic, or thoracolumbar Laminectomy w/ drainage of intramedullary cyst/ syrinx; to subarachnoid space Laminectomy w/ drainage of intramedullary cyst/ syrinx; to peritoneal space Laminectomy and section of dentate ligaments, w/ or w/o dural graft, cervical; one of two segments Laminectomy and section of dentate ligaments, w/ or w/o dural graft, cervical; more than two segments Laminectomy w/ rhizotomy; one or two segments Laminectomy w/ rhizotomy; more than two segments Laminectomy w/ section of spinal accessory nerve Laminectomy w/ cordotomy, w/ section of one spinothalamic tract, one stage; cervical Laminectomy w/ cordotomy, w/ section of one spinothalamic tract, one stage; thoracic Laminectomy w/ cordotomy w/ section of both spinothalamic tracts, one stage; cervical Laminectomy w/ cordotomy w/ section of both spinothalamic tracts, one stage; thoracic Laminectomy w/ cordotomy w/ section of both spinothalamic tracts, two stages w/in 14 days; cervical Laminectomy w/ cordotomy w/ section of both spinothalamic tracts, two stages w/in 14 days; thoracic Laminectomy, w/ release of tethered spinal cord, lumbar Laminectomy for excision or occlusion of arteriovenous malformation of spinal cord; cervical Laminectomy for excision or occlusion of arteriovenous malformation of spinal cord; thoracic Laminectomy for excision or occlusion of arteriovenous malformation of spinal cord; thoracolumbar Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm; extradural; cervical Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm; extradural; thoracic Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm; extradural; lumbar Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm; extradural; sacral Laminectomy for excision of intraspinal lesion other than neoplasm; intradural; cervical Laminectomy for excision of intraspinal lesion other than neoplasm; intradural; thoracic Laminectomy for excision of intraspinal lesion other than neoplasm; intradural; lumbar Laminectomy for excision of intraspinal lesion other than neoplasm; intradural; sacral Laminectomy for biopsy/ excision of intraspinal neoplasm; extradural, cervical Laminectomy for biopsy/ excision of intraspinal neoplasm; extradural, extradural, thoracic Laminectomy for biopsy/ excision of intraspinal neoplasm; extradural, extradural, lumbar Laminectomy for biopsy/ excision of intraspinal neoplasm; extradural, extradural, sacral Laminectomy for biopsy/ excision of intraspinal neoplasm; extradural, intradural, extramedullary, cervical Laminectomy for biopsy/ excision of intraspinal neoplasm; extradural, intradural, extramedullarry, thoracic Laminectomy for biopsy/ excision of intraspinal neoplasm; extradural, intradural, extramedullary, lumbar Laminectomy for biopsy/ excision of intraspinal neoplasm; extradural, intradural, sacral Laminectomy for biopsy/ excision of intraspinal neoplasm; extradural, intradural, intramedullary, cervical Laminectomy for biopsy/ excision of intraspinal neoplasm; extradural, intradural, intramedullary, thoracic Laminectomy for biopsy/ excision of intraspinal neoplasm; extradural, intradural, intramedullary, thoracolumbar Laminectomy for biopsy/ excision of intraspinal neoplasm; extradural, combined extradural-intradural lesion, any level Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; extradural, cervical

Case Rate 58,800 53,400 55,000 55,000 55,000 53,400 53,400 57,520 55,000 53,400 55,000 53,400 55,000 53,400 49,020 55,000 53,400 46,500 55,000 53,400 46,500 37,800 55,000 53,400 46,500 37,800 55,000 53,400 46,500 37,800 58,800 55,000 53,400 46,500 58,800 55,000 53,400 46,500 55,000

Professional Fee 37,800 29,400 33,600 33,600 33,600 29,400 29,400 36,120 33,600 29,400 33,600 29,400 33,600 29,400 27,720 33,600 29,400 25,200 33,600 29,400 25,200 21,000 33,600 29,400 25,200 21,000 33,600 29,400 25,200 21,000 37,800 33,600 29,400 25,200 37,800 33,600 29,400 25,200 33,600

Health Care Institution Fee 21,000 24,000 21,400 21,400 21,400 24,000 24,000 21,400 21,400 24,000 21,400 24,000 21,400 24,000 21,300 21,400 24,000 21,300 21,400 24,000 21,300 16,800 21,400 24,000 21,300 16,800 21,400 24,000 21,300 16,800 21,000 21,400 24,000 21,300 21,000 21,400 24,000 21,300 21,400

Page 82 of 98

ANNEX 2. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE
63301

DESCRIPTION
Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; extradural, thoracic by transthoracic approach Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; extradural, thoracic by thoracolumbar approach Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; extradural, lumbar or sacral by transperitoneal or retroperitoneal approach Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; intradural, cervical Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; intradural, thoracic by transthoracic approach Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; intradural, thoracic by thoracolumbar approach Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; intradural, lumbar or sacral by transperitoneal or retroperitoneal approach Creation of lesion of spinal cord by stereotactic method, percutaneous, any modality (including stimulation and/ or recording) Stereotactic stimulation of spinal cord, percutaneous, separate procedure not followed by other surgery Stereotactic biopsy, aspiration, or excision of lesion, spinal cord Percutaneous implantation of neurostimulator electrodes; epidural Laminectomy for implantation of neurostimulator electrodes; epidural Incision and subscutaneous placement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling Repair of meningocele; less than 5 cm diameter Repair of meningocele; larger than 5 diameter Repair of myelomeningocele; less than 5 cm diameter Repair of myelomeningocele; larger than 5 diameter Repair of dural/ CSF leak, not requiring laminectomy Repair of dural/ CSF leak or pseudomeningocele, w/ laminectomy Dural graft, spinal Creation of shunt, lumbar, subarachnoid-peritoneal, -pleural, or other; including laminectomy Creation of shunt, lumbar, subarachnoid-peritoneal, -pleural, or other; percutaneous, not requiring laminectomy Neuroplasty; digital, one or both, same digit Neuroplasty; nerve of hand or foot Neuroplasty, major peripheral nerve, arm or leg; other than specified Neuroplasty, major peripheral nerve, arm or leg; sciatic nerve Neuroplasty, major peripheral nerve, arm or leg; brachial plexus Neuroplasty, major peripheral nerve, arm or leg; lumbar plexus Neuroplasty and/or transposition; cranial nerve (specify) Neuroplasty and/or transposition; ulnar nerve at elbow Neuroplasty and/or transposition; ulnar nerve at wrist Neuroplasty and/or transposition; median nerve at carpal tunnel Decompression; unspecified nerve(s) (specify) Decompression; plantar digital nerve Internal neurolysis, requiring use of operating microscope (list separately in addition to code for neuroplasty) (Neuroplasty inlcudes external neurolysis) Transection or avulsion of; supraorbital nerve Transection or avulsion of; infraorbital nerve Transection or avulsion of; mental nerve Transection or avulsion of; inferior alveolar nerve by osteotomy Transection or avulsion of; lingual nerve Transection or avulsion of; facial nerve, differential or complete Transection or avulsion of; greater occipital nerve Transection or avulsion of; phrenic nerve Transection or avulsion of; vagus nerve (vagotomy), transthoracic Transection or avulsion of; vagi limited to proximal stomach (selective proximal vagotomy, proximal gastric vagotomy, parietal cell vagotomy, supra- or highly selective vagotomy) Transection or avulsion of; vagus nerve (vagotomy), abdominal Transection or avulsion of; pudendal nerve Transection or avulsion of obturator nerve, extrapelvic, w/ or w/o adductor tenotomy

Case Rate 53,400

Professional Fee 29,400

Health Care Institution Fee 24,000

63302

53,400

29,400

24,000

63303

53,400

29,400

24,000

63304

55,000

33,600

21,400

63305

53,400

29,400

24,000

63306

53,400

29,400

24,000

63307

53,400

29,400

24,000

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

30,300 30,300 37,600 8,020 46,500 21,820 30,300 37,180 37,800 46,500 30,300 46,500 46,500 30,300 23,300 12,120 12,120 18,000 20,980 20,980 20,980 37,800 18,000 18,000 18,000 18,000 18,000 30,300 9,700 9,700 9,700 9,700 9,700 12,120 9,700 12,120 21,940 21,940 18,000 9,700 18,000

16,800 16,800 18,900 2,520 25,200 10,920 16,800 18,480 21,000 25,200 16,800 25,200 25,200 16,800 12,600 6,720 6,720 8,400 10,080 10,080 10,080 21,000 8,400 8,400 8,400 8,400 8,400 16,800 4,200 4,200 4,200 4,200 4,200 6,720 4,200 6,720 9,240 9,240 8,400 4,200 8,400

13,500 13,500 18,700 5,500 21,300 10,900 13,500 18,700 16,800 21,300 13,500 21,300 21,300 13,500 10,700 5,400 5,400 9,600 10,900 10,900 10,900 16,800 9,600 9,600 9,600 9,600 9,600 13,500 5,500 5,500 5,500 5,500 5,500 5,400 5,500 5,400 12,700 12,700 9,600 5,500 9,600

Page 83 of 98

ANNEX 2. 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, intrapelvic, w/ or w/o adductor tenotomy Transection or avulsion of other cranial nerve, intradural Transection or avulsion of other spinal nerve, extradural Excision of neuroma; cutaneous nerve, surgically identifiable Excision of neuroma; digital nerve, one or both, same digit Excision of neuroma; hand or foot, except digital nerve Excision of neuroma; major peripheral nerve, except sciatic Excision of neuroma; sciatic nerve Excision of neurofibroma or neurolemmoma; cutaneous nerve Excision of neurofibroma or neurolemmoma; major peripheral nerve Excision of neurofibroma or neurolemmoma; extensive (including malignant type) Biopsy of nerve Sympathectomy, cervical Sympathectomy, cervicothoracic Sympathectomy, thoracolumbar Sympathectomy, lumbar Sympathectomy, digital arteries, w/ magnification, each digit Microdissection and/or microrepair of nerve (list separately in addition to code for nerve repair) Suture of digital nerve, hand or foot; one nerve Suture of digital nerve, hand or foot; each additional digital nerve Suture of one nerve, hand or foot; common sensory nerve Suture of one nerve, hand or foot; median motor thenar Suture of one nerve, hand or foot; ulnar motor Suture of each additional nerve, hand or foot Suture of posterior tibial nerve Suture of major peripheral nerve, arm or leg, except sciatic; including transposition Suture of major peripheral nerve, arm or leg, except sciatic; w/o transposition Suture of sciatic nerve Suture of each additional major peripheral nerve Suture of; brachial plexus Suture of; lumbar plexus Suture of facial nerve; extracranial Suture of facial nerve; infratemporal, w/ or w/o grafting Anastomosis; facial-spinal accessory Anastomosis; facial-hypoglossal Anastomosis; facial-phrenic Nerve graft (includes obtaining graft), head or neck; up to 4cm in length Nerve graft (includes obtaining graft), head or neck; more than 4 cm length Nerve graft (includes obtaining graft), single strand, hand or foot; up to 4 cm length Nerve graft (includes obtaining graft), single strand, hand or foot; more than 4 cm length Nerve graft (includes obtaining graft), single strand, arm or leg; up to 4 cm length Nerve graft (includes obtaining graft), single strand, arm or leg; more than 4 cm length Nerve graft (includes obtaining graft), multiple strands (cable), hand or foot; up to 4 cm length Nerve graft (includes obtaining graft), multiple strands (cable), hand or foot; more than 4 cm length Nerve graft (includes obtaining graft), multiple strands (cable), arm or leg; up to 4 cm length Nerve graft (includes obtaining graft), multiple strands (cable), arm or leg; more than 4 cm length Nerve graft, each additional nerve; single strand Nerve graft, each additional nerve; multiple strands (cable) Nerve pedicle transfer; first stage Nerve pedicle transfer; second stage Evisceration of ocular contents; w/o implant Evisceration of ocular contents; w/ implant Enucleation of eye; w/o implant Enucleation of eye; w/ implant, muscles not attached to implant Enucleation of eye; w/ implant, muscles attached to implant Exenteration of orbit without skin graft, removal of orbital contents; only Exenteration of orbit without skin graft, removal of orbital contents; w/ therapeutic removal of bone Exenteration of orbit without skin graft, removal of orbital contents; w/ muscle or myocutaneous flap Insertion of ocular implant; after evisceration, in scleral shell

Case Rate 18,000 37,800 30,300 8,020 8,020 8,020 8,020 9,700 8,020 8,020 9,700 8,020 18,000 18,000 18,000 18,000 12,120 20,980 18,000 8,020 18,000 18,000 18,000 8,020 18,000 20,980 18,000 18,000 8,020 20,980 20,980 20,980 20,980 23,300 23,300 23,300 23,300 31,580 30,300 30,300 23,300 31,580 27,120 30,300 23,300 31,580 8,020 8,020 20,980 20,980 12,120 12,120 12,120 12,120 12,120 37,800 38,640 39,480 10,960

Professional Fee 8,400 21,000 16,800 2,520 2,520 2,520 2,520 4,200 2,520 2,520 4,200 2,520 8,400 8,400 8,400 8,400 6,720 10,080 8,400 2,520 8,400 8,400 8,400 2,520 8,400 10,080 8,400 8,400 2,520 10,080 10,080 10,080 10,080 12,600 12,600 12,600 12,600 14,280 16,800 16,800 12,600 14,280 15,120 16,800 12,600 14,280 2,520 2,520 10,080 10,080 6,720 6,720 6,720 6,720 6,720 21,000 21,840 22,680 5,460

Health Care Institution Fee 9,600 16,800 13,500 5,500 5,500 5,500 5,500 5,500 5,500 5,500 5,500 5,500 9,600 9,600 9,600 9,600 5,400 10,900 9,600 5,500 9,600 9,600 9,600 5,500 9,600 10,900 9,600 9,600 5,500 10,900 10,900 10,900 10,900 10,700 10,700 10,700 10,700 17,300 13,500 13,500 10,700 17,300 12,000 13,500 10,700 17,300 5,500 5,500 10,900 10,900 5,400 5,400 5,400 5,400 5,400 16,800 16,800 16,800 5,500

Page 84 of 98

ANNEX 2. 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; after enucleation, muscles not attached to implant Insertion of ocular implant; after enucleation, muscles attached to implant Reinsertion of ocular implant; with or without conjunctival graft Reinsertion of ocular implant; with use of foreign material for reinforcement and/or attachment of muscles to implant Removal of ocular implant Removal of foreign body, external eye; conjunctival, superficial Removal of foreign body, external eye; subconjunctival or scleral, with slit lamp Removal of foreign body, external eye; cornea, with slit lamp Removal of foreign body, intraocular; from anterior chamber or lens Removal of foreign body, intraocular; from posterior segment, magnetic extraction, anterior or posterior route Removal of foreign body, intraocular; from posterior segment, nonmagnetic extraction Repair of laceration; conjunctiva, w/ or w/o nonperforating laceration sclera, direct closure Repair of laceration; conjunctiva, by mobilization and rearrangement Repair of laceration; cornea, nonperforating, w/ or w/o removal foreign body Repair of laceration; cornea and/or sclera, perforating, not involving uveal tissue Repair of laceration; cornea and/or sclera, perforating, w/ reposition or resection of uveal tissue Repair of laceration; application of tissue glue, wounds of cornea and/or sclera Repair of wound, extraocular muscle, tendon and/ or Tenons capsule Excision of lesion, cornea (keratectomy, lamellar, partial), except pterygium Biopsy of cornea Excision or transposition of pterygium; without graft Excision or transposition of pterygium; with graft Destruction of lesion of cornea by cryotherapy, photocoagulation or thermocauterization Keratoplasty (corneal transplant); lamellar Keratoplasty (corneal transplant); penetrating (except in aphakia) Keratoplasty (corneal transplant); penetrating (in aphakia) Keratoplasty (corneal transplant); 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; amniotic membrane transplantation Ocular surface reconstruction; limbal stem cell allograft (eg, cadaveric or living donor) Ocular surface reconstruction; limbal conjunctival autograft (includes obtaining graft) Paracentesis of anterior chamber of eye; w/ therapeutic release of aqueous Paracentesis of anterior chamber of eye; w/ removal of vitreous and/or discission of anterior hyaloid membrane, w/ or w/o air injection Paracentesis of anterior chamber of eye; w/ removal of blood, w/ or w/o irrigation and/or air injection Goniotomy Trabeculotomy ab externo Trabeculoplasty by laser surgery, one or more sessions (defined treatment series) Severing adhesions of anterior segment, laser technique Severing adhesions of anterior segment of eye, incisional technique (w/ or w/o injection of air or liquid); goniosynechiae Severing adhesions of anterior segment of eye, incisional technique (w/ or w/o injection of air or liquid); anterior synechiae, except goniosynechiae Severing adhesions of anterior segment of eye, incisional technique (w/ or w/o injection of air or liquid); posterior synechiae Severing adhesions of anterior segment of eye, incisional technique (w/ or w/o injection of air or liquid); corneovitreal adhesions

Case Rate 10,960 11,980 11,980 11,980 9,700 3,640 8,020 8,020 18,000 53,400 55,000 8,020 8,020 9,700 20,980 23,300 9,700 9,700 8,260 8,020 8,260 9,700 8,020 30,300 30,300 30,300 30,300 18,000 10,540 18,000 30,300 14,960 14,960 14,960 30,300 30,300 30,300 8,020 9,700 9,700 23,300 23,300 12,120 10,540 10,540 10,540 10,540 10,540

Professional Fee 5,460 5,880 5,880 5,880 4,200 840 2,520 2,520 8,400 29,400 33,600 2,520 2,520 4,200 10,080 12,600 4,200 4,200 3,360 2,520 3,360 4,200 2,520 16,800 16,800 16,800 16,800 8,400 5,040 8,400 16,800 7,560 7,560 7,560 16,800 16,800 16,800 2,520 4,200 4,200 12,600 12,600 6,720 5,040 5,040 5,040 5,040 5,040

Health Care Institution Fee 5,500 6,100 6,100 6,100 5,500 2,800 5,500 5,500 9,600 24,000 21,400 5,500 5,500 5,500 10,900 10,700 5,500 5,500 4,900 5,500 4,900 5,500 5,500 13,500 13,500 13,500 13,500 9,600 5,500 9,600 13,500 7,400 7,400 7,400 13,500 13,500 13,500 5,500 5,500 5,500 10,700 10,700 5,400 5,500 5,500 5,500 5,500 5,500

Page 85 of 98

ANNEX 2. 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, anterior segment eye Removal of implanted material, anterior segment eye Removal of blood clot, anterior segment eye Excision of lesion, sclera Fistulization of scalera for glaucoma; trephination w/ iridectomy Fistulization of scalera for glaucoma; thermocauterization w/ iridectomy Fistulization of scalera for glaucoma; sclerectomy w/ punch or scissors, w/ iridectomy Fistulization of scalera for glaucoma; iridencleisis or iridotasis Fistulization of scalera for glaucoma; trabeculectomy ab externo in absence of previous surgery Fistulization of scalera for glaucoma; trabeculectomy ab externo w/ scarring from previous ocular surgery or trauma (includes injection of antifibrotic agents) Aquenous shunt to extraocular reservoir (e.g., Molteno, Schocket, DenverKrupin) Revision of aqueous shunt to extraocular reservoir Repair of scleral staphyloma; w/o graft Repair of scleral staphyloma; w/ graft Revision or repair of operative wound of anterior segment, any type, early or late, major or minor procedure Iridotomy by stab incision; except transfixion Iridotomy by stab incision; w/ transfixion as for iris bombe Iridectomy, w/ corneoscleral or corneal section; for removal of lesion Iridectomy, w/ corneoscleral or corneal section; w/ cyclectomy Iridectomy, w/ corneoscleral or corneal section; peripheral for glaucoma Iridectomy, w/ corneoscleral or corneal section; sector for glaucoma Repair of iris, ciliary body (as for iridodialysis) Suture of iris, ciliary body w/ retrieval of suture through small incision (e.g., McCannel suture) Ciliary body destruction; diathermy Ciliary body destruction; cyclophotocoagulation Ciliary body destruction; cryotherapy Ciliary body destruction; cyclodialysis Iridotomy/iridectomy by laser surgery (e.g., for glaucoma) ( one or more sessions) Iridoplasty by photocoagulation (one or more sessions) (e.g., for improvement of vision, 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); stab incision technique (Ziegler or Wheeler knife) Discission of secondary membranous cataract (opacified posterior lens capsule and/or anterior hyaloid); laser surgery (e.g., YAG laser) (one or more stages) Repositioning of intraocular lens prosthesis, requiring an incision Removal of secondary membranous cataract (opacified posterior lens capsule and/or anterior hyaloid) w/ corneo-scleral section, w/ or w/o iridectomy (iridocapsulotomy, iridocapsulectomy) Removal of lens material; aspiration technique, one or more stages Removal of lens material; phacofragmentation technique (mechanical or ultrasonic) (e.g., phacoemulsification), w/ aspiration Removal of lens material; pars plana approach, with or without vitrectomy Removal of lens material; intracapsular Removal of lens material; intracapsular, for dislocated lens Removal of lens material; extracapsular Extracapsular cataract removal with insertion of intraocular lens prosthesis (one stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification), complex, 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), (e.g., irrigation and aspiration) Insertion of intraocular lens prosthesis, not associated with cataract removal Exchange of intraocular lens Extracapsular cataract removal w/ insertion of intraocular lens prosthesis (one stage procedure), (e.g., phacoemulsification) Revision of failed filter; with or without explantation/exchange of shunt Revision of failed filter; with excision of bleb cyst

Case Rate 10,540 12,120 8,020 8,260 18,000 18,000 18,000 18,000 18,000 27,120 30,300 30,300 12,120 23,300 14,960 10,540 10,540 12,120 18,000 12,120 12,120 18,000 14,960 11,980 11,980 11,980 11,980 10,540 12,120 10,540 12,120

Professional Fee 5,040 6,720 2,520 3,360 8,400 8,400 8,400 8,400 8,400 15,120 16,800 16,800 6,720 12,600 7,560 5,040 5,040 6,720 8,400 6,720 6,720 8,400 7,560 5,880 5,880 5,880 5,880 5,040 6,720 5,040 6,720

Health Care Institution Fee 5,500 5,400 5,500 4,900 9,600 9,600 9,600 9,600 9,600 12,000 13,500 13,500 5,400 10,700 7,400 5,500 5,500 5,400 9,600 5,400 5,400 9,600 7,400 6,100 6,100 6,100 6,100 5,500 5,400 5,500 5,400

66821 66825 66830 66840 66850 66852 66920 66930 66940 66982

8,260 18,000 12,120 16,000 16,000 16,000 16,000 16,000 16,000 16,000

3,360 8,400 6,720 6,400 6,400 6,400 6,400 6,400 6,400 6,400

4,900 9,600 5,400 9,600 9,600 9,600 9,600 9,600 9,600 9,600

66983 66984 66985 66986 66987 66991 66992

16,000 16,000 16,000 16,000 16,000 37,800 37,800

6,400 6,400 6,400 6,400 6,400 21,000 21,000

9,600 9,600 9,600 9,600 9,600 16,800 16,800

Page 86 of 98

ANNEX 2. 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; with choroidal tap Revision of failed filter; with posterior sclerotomy Revision of failed filter; with anterior chamber reformation Revision of filtering bleb, needling technique; without injection of antimetabolite Revision of filtering bleb, needling technique; with injection of antimetabolite Release of scleral flap suture by laser suture lysis (new code) Revision of overfiltering bleb (includes autologous blood injection, cryotherapy, mattress sutures, etc.) Removal of vitreous, anterior approach (open sky technique or limbal incision); partial removal Removal of vitreous, anterior approach (open sky technique or limbal incision); subtotal removal w/ mechanical vitrectomy Aspiration or release of vitreous, subretinal or choroidal fluid, pars plana approach (posterior sclerotomy) Injection of vitreous substitute, pars plana or limbal approach, (fluid-gas exchange), w/ or w/o aspiration Implantation of intravitreal drug delivery system (eg, ganciclovir implant), includes concomitant removal of vitreous Discission of vitreous strands (w/o removal), pars plana approach Severing of vitreous strands, vitreous face adhesions, sheets, membranes or opacities, laser surgery (one or more stages) Vitrectomy, mechanical, pars plana approach; Vitrectomy, mechanical, pars plana approach; w/ epiretinal membrane stripping Vitrectomy, mechanical, pars plana approach; w/ focal endolaser photocoagulation Vitrectomy, mechanical, pars plana approach; w/ endolaser panretinal photocoagulation Vitrectomy, mechanical, pars plana approach; with internal limiting membrane (ILM) peeling Vitrectomy, mechanical, pars plana approach; with radial optic nerve neurotomy (RON) Vitrectomy, mechanical, pars plana approach; with sheathotomy for branch retinal vein occlusion Vitrectomy, mechanical, pars plana approach; with macular translocation (limited by retinotomy and/or scleral imbrication) Vitrectomy, mechanical, pars plana approach; with macular translocation (total) Vitrectomy, mechanical, pars plana approach; with removal of subretinal membranes Vitrectomy, mechanical, pars plana approach; with removal of choroidal neovascular membrane Vitrectomy, mechanical, pars plana approach; with endodrainage of subretinal hemorrhage (with or without tPA injection) Vitrectomy, mechanical, pars plana approach; with removal of dropped IOL Vitrectomy, mechanical, pars plana approach; with phacofragmentation for dropped lens material Vitrectomy, mechanical, pars plana approach; with internal tamponade with air, gas, silicone oil, perfluorocarbon liquid Vitrectomy, mechanical, pars plana approach; with insertion of scleral fixated intraocular lens, with or without anterior vitrectomy Repair of retinal detachment, one or more sessions; cryotherapy or diathermy, w/ or w/o drainage of subretinal fluid Repair of retinal detachment, one or more sessions; photocoagulation, w/ or w/o drainage of subretinal fluid Repair of retinal detachment; scleral buckling (such as lamellar scleral dissection, imbrication or encircling procedure), w/ or w/o implant, w/ or w/o cryotherapy, photocoagulation, and drainage of subretinal fluid Repair of retinal detachment; w/ vitrectomy, any method, w/ or w/o air or gas tamponade, focal endolaser photocoagulation, cryotherapy, drainage of subretinal fluid, scleral buckling, and/or removal of lens by same technique Repair of retinal detachment; by injection of air or other gas (e.g., pneumatic retinopexy) Repair of retinal detachment; by scleral buckling or vitrectomy, 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, posterior segment; extraocular Removal of implanted material, posterior segment; intraocular Destruction of localized lesion of retina (e.g., maculopathy, choroidopathy, small tumors), one or more sessions; cryotherapy, diathermy

Case Rate 30,300 30,300 30,300 12,120 18,000 9,700 18,000 37,800 53,400 9,700 12,120 31,580 12,900 10,540 46,500 46,500 46,500 46,500 46,500 46,500 46,500 46,500 46,500 46,500 46,500 46,500 46,500 46,500 46,500 37,800 46,500 37,180

Professional Fee 16,800 16,800 16,800 6,720 8,400 4,200 8,400 21,000 29,400 4,200 6,720 14,280 6,300 5,040 25,200 25,200 25,200 25,200 25,200 25,200 25,200 25,200 25,200 25,200 25,200 25,200 25,200 25,200 25,200 21,000 25,200 18,480

Health Care Institution Fee 13,500 13,500 13,500 5,400 9,600 5,500 9,600 16,800 24,000 5,500 5,400 17,300 6,600 5,500 21,300 21,300 21,300 21,300 21,300 21,300 21,300 21,300 21,300 21,300 21,300 21,300 21,300 21,300 21,300 16,800 21,300 18,700

67107

46,500

25,200

21,300

67108

46,500

25,200

21,300

67110 67112 67115 67120 67121 67208

30,300 46,500 12,120 12,120 20,980 12,120

16,800 25,200 6,720 6,720 10,080 6,720

13,500 21,300 5,400 5,400 10,900 5,400

Page 87 of 98

ANNEX 2. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE
67210

DESCRIPTION
Destruction of localized lesion of retina (e.g., maculopathy, choroidopathy, small tumors), one or more sessions; photocoagulation (laser or xenon arc) Destruction of localized lesion of retina (e.g., maculopathy, choroidopathy, small tumors), one or more sessions; radiation by implantation of source (includes removal of source) Destruction of localized lesion of choroid (e.g., choroidal neovascularization); photocoagulation (e.g., laser), one or more sessions Destruction of localized lesion of choroid (e.g., choroidal neovascularization); photodynamic therapy (includes intravenous infusions Destruction of localized lesion of choroid (e.g., choroidal neovascularization); transpupillary thermotherapy Destruction of extensive or progressive retinopathy (e.g., diabetic retinopathy), one or more sessions; cryotherapy, diathermy Destruction of extensive or progressive retinopathy (e.g., diabetic retinopathy), one or more sessions; photocoagulation (laser or xenon arc) Scleral reinforcement Strabismus surgery, recession or resection procedure (patient not previously operated on); one horizontal muscle Strabismus surgery, recession or resection procedure (patient not previously operated on); two horizontal muscles Strabismus surgery, recession or resection procedure (patient not previously operated on); one vertical muscle (excluding superior oblique) Strabismus surgery, recession or resection procedure (patient not previously operated on); two or more vertical muscles (excluding superior oblique) Strabismus surgery, any procedure (patient not previously operated on), superior oblique muscle Transposition procedure (e.g., for paretic extraocular muscle), 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.g., prior ocular injury, strabismus or retinal detachment surgery) or restrictive myopathy (e.g., dysthyroid ophthalmopathy) Strabismus surgery by posterior fixation suture technique, 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); for exploration, w/ or w/o biopsy Orbitotomy w/o bone flap (frontal or transconjunctival approach); w/ drainage only Orbitotomy w/o bone flap (frontal or transconjunctival approach); w/ removal of lesion Orbitotomy w/o bone flap (frontal or transconjunctival approach); w/ removal of foreign body Orbitotomy w/o bone flap (frontal or transconjunctival approach); w/ removal of bone for decompression Fine needle aspiration of orbital contents Orbitotomy w/ bone flap or window, lateral approach (e.g., Kroenlein); w/ removal of lesion Orbitotomy w/ bone flap or window, lateral approach (e.g., Kroenlein); w/ removal of foreign body Orbitotomy w/ bone flap or window, lateral approach (e.g., Kroenlein); w/ drainage Orbitotomy w/ bone flap or window, lateral approach (e.g., Kroenlein); w/ removal of bone for decompression Orbital implant (implant outside muscle cone); insertion Orbital implant (implant outside muscle cone); removal or revision Optic nerve decompression (e.g., incision or fenestration of optic nerve sheath) Repair of anophthalmic socket; with insertion or removal of orbital implant within muscle cone Repair of anophthalmic socket; with exchange or orbital implant Repair of anophthalmic socket; with exchange of orbital implant and reattachment of muscles Repair of anophthalmic socket; with fornix reconstruction using sutures

Case Rate 12,120

Professional Fee 6,720

Health Care Institution Fee 5,400

67218

12,120

6,720

5,400

67220

12,120

6,720

5,400

67221 67222 67227 67228 67250 67311 67312 67314

12,120 12,120 12,120 12,120 12,120 10,120 12,120 12,120

6,720 6,720 6,720 6,720 6,720 4,620 6,720 6,720

5,400 5,400 5,400 5,400 5,400 5,500 5,400 5,400

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

18,000 18,000 18,000 18,000 21,940 11,980 22,660 18,000 9,700 9,700 46,500 46,500 46,500 46,500 46,500 46,500 46,500 46,500 46,500 46,500 10,960 10,960 53,400 12,120 20,980 20,980 20,980

8,400 8,400 8,400 8,400 9,240 5,880 11,760 8,400 4,200 4,200 25,200 25,200 25,200 25,200 25,200 25,200 25,200 25,200 25,200 25,200 5,460 5,460 29,400 6,720 10,080 10,080 10,080

9,600 9,600 9,600 9,600 12,700 6,100 10,900 9,600 5,500 5,500 21,300 21,300 21,300 21,300 21,300 21,300 21,300 21,300 21,300 21,300 5,500 5,500 24,000 5,400 10,900 10,900 10,900

Page 88 of 98

ANNEX 2. 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; with fornix reconstruction using buccal mucosal graft or amnion graft, including harvesting of graft Repair of anophthalmic socket; with revision of implant and fornix reconstruction using sutures Repair of anophthalmic socket; with revision of implant and fornix reconstruction using buccal mucosal graft, or amnion graft (including harvesting of graft) Blepharotomy, drainage of abscess, eyelid Severing of tarsorrhaphy Canthotomy Excision of chalazion Biopsy of eyelid Repair of trichiasis; by electroepilation, electrosurgery, cryotherapy or laser surgery Repair of trichiasis; incision of lid margin Repair of trichiasis; incision of lid margin, 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.g., frost suture) Construction of intermargin adhesions, median tarsorrhaphy, or canthorrhaphy; Construction of intermargin adhesions, median tarsorrhaphy, or canthorrhaphy; with transportation of tarsal plate Repair of brow ptosis (supraciliary, midforehead or coronal approach) Repair of blepharoptosis; frontalis muscle technique with suture or other material Repair of blepharoptosis; frontalis muscle technique with fascial sling (includes obtaining fascia) Repair of blepharoptosis; (tarso) levator resection or advancement, internal approach Repair of blepharoptosis; (tarso) levator resection or advancement, external approach Repair of blepharoptosis; superior rectus technique with fascial sling (includes obtaining fascia) Repair of blepharoptosis; conjunctivo-tarso-Mullers muscle-levator resection (Fasanella-Servat type) Repair of lid retraction (eyelid recession); without spacer Correction of lagophthalmos, with implantation of upper eyelid load Repair of ectropion; suture Repair of ectropion; thermocauterization Blepharoplasty, excision tarsal wedge Blepharoplasty, extensive (e.g., Kuhnt-Szymanowski or tarsal strip operations) Repair of entropion; suture Repair of entropion; thermocauterization Blepharoplasty, excision tarsal wedge Blepharoplasty, extensive (e.g., Wheeler operation) Suture of recent wound, eyelid, involving lid margin, tarsus, and/ or palpebral conjunctiva direct closure; partial thickness Suture of recent wound, eyelid, involving lid margin, tarsus, and/ or palpebral conjunctiva direct closure; full thickness Canthoplasty (reconstruction of canthus) Excision and repair of eyelid, involving lid margin, tarsus, conjunctiva, canthus, or full thickness, may include preparation for skin graft or pedicle flap with adjacent tissue transfer or rearrangement; up to one-fourth of lid margin Excision and repair of eyelid, involving lid margin, tarsus, conjunctiva, canthus, or full thickness, may include preparation for skin graft or pedicle flap with adjacent tissue transfer or rearrangement; over one-fourth of lid margin Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap from opposing eyelid; up to two-thirds of eyelid, one stage or first stage Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap from opposing eyelid; total eyelid, lower, one stage or first stage Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap from opposing eyelid; total eyelid, upper, one stage or first stage Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap from opposing eyelid; second stage Biopsy of conjunctiva Excision of lesion, conjunctiva; up to 1 cm Excision of lesion, conjunctiva; over 1 cm Excision of lesion, conjunctiva; with adjacent sclera

Case Rate 20,980 20,980 20,980 5,680 5,680 5,680 5,680 5,680 5,680 3,640 9,300 5,560 5,680 5,680 8,020 18,000 18,000 20,980 18,000 18,000 18,000 18,000 21,400 32,000 8,020 8,020 9,700 12,900 5,680 5,680 9,700 12,900 9,700 12,120 12,120 30,740

Professional Fee 10,080 10,080 10,080 1,680 1,680 1,680 1,680 1,680 1,680 840 2,100 1,260 1,680 1,680 2,520 8,400 8,400 10,080 8,400 8,400 8,400 8,400 10,500 14,700 2,520 2,520 4,200 6,300 1,680 1,680 4,200 6,300 4,200 6,720 6,720 13,440

Health Care Institution Fee 10,900 10,900 10,900 4,000 4,000 4,000 4,000 4,000 4,000 2,800 7,200 4,300 4,000 4,000 5,500 9,600 9,600 10,900 9,600 9,600 9,600 9,600 10,900 17,300 5,500 5,500 5,500 6,600 4,000 4,000 5,500 6,600 5,500 5,400 5,400 17,300

67966

27,120

15,120

12,000

67971

30,300

16,800

13,500

67973

37,800

21,000

16,800

67974 67975 68100 68110 68115 68130

37,800 30,300 5,680 8,020 8,020 8,020

21,000 16,800 1,680 2,520 2,520 2,520

16,800 13,500 4,000 5,500 5,500 5,500

Page 89 of 98

ANNEX 2. 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; with conjunctival graft or extensive rearrangement Conjunctivoplasty; with buccal mucous membrane graft (includes obtaining graft) Conjunctivoplasty reconstruction cul-de-sac; with conjunctival graft or extensive rearrangement Conjunctivoplasty reconstruction cul-de-sac; with buccal mucous membrane graft (includes obtaining graft) Repair of symblepharon; conjunctivoplasty, without graft Repair of symblepharon; with free graft conjunctiva or buccal mucous membrane (includes obtaining graft) Repair of symblepharon; division of symblepharon, with or without insertion of conformer or contact lens Conjunctival flap; bridge or partial Conjunctival flap; total (such as Gunderson thin flap or purse string flap) Harvesting conjunctival allograft, living donor Incision, drainage of lacrimal gland Incision, drainage of lacrimal sac (dacryocystostomy) Snip incision of lacrimal punctum Excision of lacrimal gland (dacryoadenectomy), except for tumor Biopsy of lacrimal gland Excision of lacrimal sac (dacryocystectomy) Biopsy of lacrimal sac Removal of foreign body or dacryolith, lacrimal passages Excision of lacrimal gland tumor; frontal approach Excision of lacrimal gland tumor; involving osteotomy Plastic repair of canaliculi Correction of everted punctum, cautery Dacryocystorhinostomy (fistulization of lacrimal sac to nasal cavity) Conjunctivorhinostomy (fistulization of conjunctiva to nasal cavity); without tube Conjunctivorhinostomy (fistulization of conjunctiva to nasal cavity); with insertion of tube or stent Closure of the lacrimal punctum; by thermocauterization, ligation, or laser surgery Closure of lacrimal fistula Probing of nasolacrimal duct; requiring general anesthesia Probing of nasolacrimal duct; with insertion of tube or stent Drainage external ear, abscess or hematoma Drainage external auditory canal, abscess Biopsy external ear Biopsy external auditory canal Excision external ear; partial, simple repair Excision external ear; complete amputation Excision exostosis(es), external auditory canal Excision soft tissue lesion, external auditory canal Radical excision external auditory canal lesion; w/o neck dissection Radical excision external auditory canal lesion; w/ neck dissection Removal foreign body from external auditory canal; w/ general anesthesia Debridement, mastoidectomy cavity, simple (e.g., routine cleaning) Debridement, mastoidectomy cavity, complex (e.g., w/ anesthesia or more than routine cleaning) Reconstruction of external auditory canal (meatoplasty) (e.g., for stenosis due to trauma, infection) Reconstruction external auditory canal for congenital atresia, single stage Eustachian tube inflation, transnasal; w/ catheterization Eustachian tube catheterization, 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), local or topical anesthesia Tympanostomy (requiring insertion of ventilating tube), w/ general anesthesia Middle ear exploration through postauricular or ear canal incision Tympanolysis, transcanal Transmastoid antrotomy ("simple" mastoidectomy) Mastoidectomy; complete Mastoidectomy; modified radical Mastoidectomy; radical Petrous apicectomy including radical mastoidectomy Resection temporal bone, external approach Excision aural polyp

Case Rate 10,540 12,120 14,960 18,000 14,960 21,940 18,000 11,980 11,980 20,980 5,680 5,680 5,680 12,120 5,680 12,120 5,680 5,680 18,000 18,000 9,700 3,640 18,000 18,000 20,980 8,020 10,880 8,020 9,700 3,672 3,472 5,680 5,680 8,260 12,120 9,700 9,700 23,300 30,300 9,300 8,020 9,700 23,300 23,300 5,812 5,680 5,680 8,020 8,260 8,260 18,000 9,700 20,980 23,300 23,300 23,300 23,300 46,500 8,020

Professional Fee 5,040 6,720 7,560 8,400 7,560 9,240 8,400 5,880 5,880 10,080 1,680 1,680 1,680 6,720 1,680 6,720 1,680 1,680 8,400 8,400 4,200 840 8,400 8,400 10,080 2,520 3,780 2,520 4,200 672 252 1,680 1,680 3,360 6,720 4,200 4,200 12,600 16,800 2,100 2,520 4,200 12,600 12,600 1,512 1,680 1,680 2,520 3,360 3,360 8,400 4,200 10,080 12,600 12,600 12,600 12,600 25,200 2,520

Health Care Institution Fee 5,500 5,400 7,400 9,600 7,400 12,700 9,600 6,100 6,100 10,900 4,000 4,000 4,000 5,400 4,000 5,400 4,000 4,000 9,600 9,600 5,500 2,800 9,600 9,600 10,900 5,500 7,100 5,500 5,500 3,000 3,220 4,000 4,000 4,900 5,400 5,500 5,500 10,700 13,500 7,200 5,500 5,500 10,700 10,700 4,300 4,000 4,000 5,500 4,900 4,900 9,600 5,500 10,900 10,700 10,700 10,700 10,700 21,300 5,500

Page 90 of 98

ANNEX 2. 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; transcanal Excision aural glomus tumor; transmastoid Excision aural glomus tumor; extended (extratemporal) Revision mastoidectomy; resulting in complete mastoidectomy Revision mastoidectomy; resulting in modified radical mastoidectomy Revision mastoidectomy; resulting in radical mastoidectomy Revision mastoidectomy; resulting in tympanoplasty Revision mastoidectomy; w/ apicectomy Tympanic membrane repair, w/ or w/o site preparation or perforation for closure, w/ or w/o patch Myringoplasty (surgery confined to drumhead and donor area) Tympanoplasty w/o mastoidectomy (including canalplasty, atticotomy and/ or middle ear surgery), initial or revision; w/o ossicular chain reconstruction Tympanoplasty w/o mastoidectomy (including canalplasty, atticotomy and/ or middle ear surgery), initial or revision; w/ ossicular chain reconstruction (e.g., postfenestration) Tympanoplasty w/o mastoidectomy (including canalplasty, atticotomy and/ or middle ear surgery), initial or revision; w/ ossicular chain reconstruction and synthetic prosthesis (e.g., partial ossicular replacement prosthesis, (PORP), total ossicular replacement prosthesis (TORP) Tympanoplasty w/ antrotomy or mastoidotomy (including canalplasty, atticotomy, middle ear surgery, and/ or tympanic membrane repair); w/o ossicular chain reconstruction Tympanoplasty w/ antrotomy or mastoidotomy (including canalplasty, atticotomy, middle ear surgery, and/ or tympanic membrane repair); w/ ossicular chain reconstruction Tympanoplasty w/ antrotomy or mastoidotomy (including canalplasty, atticotomy, middle ear surgery, and/ or tympanic membrane repair); w/ ossicular chain reconstruction and synthetic prosthesis (e.g. partial ossicular replacement prosthesis, (PORP), total ossicular replacement prosthesis (TORP) Tympanoplasty w/ mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repair); w/o ossicular chain reconstruction Tympanoplasty w/ mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repair); w/ ossicular chain reconstruction Tympanoplasty w/ mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repair); w/ intact or reconstructed wall, w/o ossicular chain reconstruction Tympanoplasty w/ mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repair); w/ intact or reconstructed canal wall, w/ ossicular chain reconstruction Tympanoplasty w/ mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repair); radical or complete, w/o ossicular chain reconstruction Tympanoplasty w/ mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repair); radical or complete, w/ ossicular chain reconstruction Stapes mobilization Stapedectomy or stapedotomy w/ reestablishment of ossicular continuity, w/ or w/o use of foreign material; Stapedectomy or stapedotomy w/ reestablishment of ossicular continuity, w/ or w/o use of foreign material; w/ footplate drill out Revision of stapedectomy or stapedotomy Repair oval window fistula Repair round window fistula Mastoid obliteration Tympanic neurectomy Closure postauricular fistula, mastoid Decompression facial nerve, intratemporal; lateral to geniculate ganglion Decompression facial nerve, intratemporal; including medial to geniculate ganglion Suture facial nerve, intratemporal, w/ or w/o graft or decompression; lateral to geniculate ganglion Suture facial nerve, intratemporal, w/ or w/o graft or decompression; including medial to geniculate ganglion Labyrinthotomy, w/ or w/o cryosurgery including other nonexcisional destructive procedures or perfusion of vestbuloactive drugs (single or multiple perfusions); transcanal Labyrinthotomy, w/ or w/o cryosurgery including other nonexcisional destructive procedures or perfusion of vestbuloactive drugs (single or multiple perfusions); w/ mastoidectomy

Case Rate 30,300 30,300 30,300 23,300 31,580 23,300 23,300 23,300 12,120 20,980 30,740

Professional Fee 16,800 16,800 16,800 12,600 14,280 12,600 12,600 12,600 6,720 10,080 13,440

Health Care Institution Fee 13,500 13,500 13,500 10,700 17,300 10,700 10,700 10,700 5,400 10,900 17,300

69632

30,740

13,440

17,300

69633

30,740

13,440

17,300

69635

46,500

25,200

21,300

69636

47,340

26,040

21,300

69637

47,340

26,040

21,300

69641

46,500

25,200

21,300

69642

47,340

26,040

21,300

69643

48,180

26,880

21,300

69644

49,020

27,720

21,300

69645

46,500

25,200

21,300

69646 69650 69660 69661 69662 69666 69667 69670 69676 69700 69720 69725 69740 69745 69801

46,500 37,800 38,640 38,640 38,640 38,640 38,640 31,580 30,300 10,540 30,300 30,300 37,800 37,800 38,640

25,200 21,000 21,840 21,840 21,840 21,840 21,840 14,280 16,800 5,040 16,800 16,800 21,000 21,000 21,840

21,300 16,800 16,800 16,800 16,800 16,800 16,800 17,300 13,500 5,500 13,500 13,500 16,800 16,800 16,800

69802

39,480

22,680

16,800

Page 91 of 98

ANNEX 2. 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; w/o shunt Endolymphatic sac operation; w/ shunt Fenestration semicircular canal Revision fenestration operation Labyrinthectomy; transcanal Labyrinthectomy; w/ mastoidectomy Vestibular nerve section, translabyrinthine approach Cochlear device implantation, w/ or w/o mastoidectomy Vestibular nerve section, transcranial approach Total facial nerve decompression and/or repair (may include graft) Decompression internal auditory canal Removal of tumor, temporal bone Myelography, brain, including spinal puncture and radiological supervision and interpretation Sialography; including duct catheterization and radiological supervision and interpretation Insertion pacemaker, fluoroscopy and radiography, radiological supervision and interpretation Myelography, spine, including spinal puncture and radiological supervision and interpretation Cholangiography and/or pancreatography, intraoperative, radiological supervision and interpretation Endoscopic catheterization of the biliary ductal system, radiological supervision and interpretation Endoscopic catheterization of the pancreatic ductal system, radiological supervision and interpretation Combined endoscopic catheterization of the biliary and pancreatic ductal system, radiological supervision and interpretation Introduction of long gastrointestinal tube (e.g., Miller-Abbott ), radiological supervision and interpretation Percutaneous placement of gastrostomy tube, radiological supervision and interpretation Percutaneous placement of enteroclysis tube, radiological supervision and interpretation Intraluminal dilation of strictures and/or obstructions, radiological supervision and interpretation Percutaneous transhepatic dilation of sbiliary duct stricture, radiological supervision and interpretation Introduction of intracatheter or catheter into renal pelvis for drainage and/or injection, percutaneous, radiological supervision and interpretation Introduction of ureteral catheter or stent into ureter through renal pelvis for drainage and/or injection, percutaneous, radiological supervision and interpretation Transcervical catheterization of fallopian tube, radiological supervision and interpretation Aortography, thoracic, radiological supervision and interpretation Aortography, abdominal, radiological supervision and interpretation Aortography, abdominal plus bilateral iliofemoral lower extremity, radiological supervision and interpretation Computed tomographic angiography, abdominal aorta and bilateral iliofemoral lower extremity, radiological supervision and interpretation Angiography, cervicocerebral, radiological supervision and interpretation Angiography, brachial retrograde, radiological supervision and interpretation Angiography, external carotid, unilateral, selective, radiological supervision and interpretation Angiography, external carotid, bilateral, selective, radiological supervision and interpretation Angiography, cerebral, radiological supervision and interpretation Angiography, carotid, cerebral, bilateral, radiological supervision and interpretation Angiography, carotid, cervical, unilateral, radiological supervision and interpretation Angiography, carotid, cervical, bilateral, radiological supervision and interpretation Angiography, vertebral, cervical and/or intracranial, radiological supervision and interpretation Angiography, spinal, radiological supervision and interpretation Angiography, extremity, unilateral, radiological supervision and interpretation Angiography, extremity, bilateral, radiological supervision and interpretation

Case Rate 46,500 53,400 46,500 53,400 46,500 53,400 53,400 55,000 55,000 55,000 53,400 46,500 8,020 8,020 8,020 8,020 8,020 8,020 8,020 8,020 9,700 9,700 9,700 9,700 18,000 18,000

Professional Fee 25,200 29,400 25,200 29,400 25,200 29,400 29,400 33,600 33,600 33,600 29,400 25,200 2,520 2,520 2,520 2,520 2,520 2,520 2,520 2,520 4,200 4,200 4,200 4,200 8,400 8,400

Health Care Institution Fee 21,300 24,000 21,300 24,000 21,300 24,000 24,000 21,400 21,400 21,400 24,000 21,300 5,500 5,500 5,500 5,500 5,500 5,500 5,500 5,500 5,500 5,500 5,500 5,500 9,600 9,600

74480 74742 75600 75625 75630 75635 75650 75658 75660 75662 75665 75671 75676 75680 75685 75705 75710 75716

18,000 8,020 9,700 9,700 9,700 9,700 9,700 9,700 9,700 9,700 9,700 9,700 9,700 9,700 9,700 9,700 9,700 9,700

8,400 2,520 4,200 4,200 4,200 4,200 4,200 4,200 4,200 4,200 4,200 4,200 4,200 4,200 4,200 4,200 4,200 4,200

9,600 5,500 5,500 5,500 5,500 5,500 5,500 5,500 5,500 5,500 5,500 5,500 5,500 5,500 5,500 5,500 5,500 5,500

Page 92 of 98

ANNEX 2. 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, renal, unilateral, radiological supervision and interpretation Angiography, renal, bilateral, radiological supervision and interpretation Angiography, visceral, radiological supervision and interpretation Angiography, adrenal, unilateral, radiological supervision and interpretation Angiography, adrenal, bilateral, radiological supervision and interpretation Angiography, pelvis, radiological supervision and interpretation Angiography, pulmonary, unilateral, radiological supervision and interpretation Angiography, pulmonary, bilateral, radiological supervision and interpretation Angiography, pulmonary, nonselective, radiological supervision and interpretation Angiography, internal mammary, radiological supervision and interpretation Angiography, fluorescein (eye) Angiography, arteriovenous shunt (e.g., dialysis patient), radiological supervision and interpretation Lymphangiography, extremity, unilateral, radiological supervision and interpretation Lymphangiography, extremity, bilateral, radiological supervision and interpretation Lymphangiography, pelvic/abdominal, unilateral , radiological supervision and interpretation Lymphangiography, pelvic/abdominal, bilateral, radiological supervision and interpretation Splenoportography, radiological supervision and interpretation Venography, extremity, unilateral or bilateral, radiological supervision and interpretation Venography, caval, inferior, radiological supervision and interpretation Venography, caval, superior, radiological supervision and interpretation Venography, renal, unilateral, radiological supervision and interpretation Venography, renal, bilateral, radiological supervision and interpretation Venography, adrenal, unilateral, radiological supervision and interpretation Venography, adrenal, bilateral, radiological supervision and interpretation Venography, venous sinus(e.g., petrosal and inferior sagittal) or jugular, radiological supervision and interpretation Venography, superior sagittal sinus, radiological supervision and interpretation Venography, epidural, radiological supervision and interpretation Venography, orbital, radiological supervision and interpretation Percutaneous transhepatic portography, radiological supervision and interpretation Hepatic venography, radiological supervision and interpretation Exchanged of a previously placed intravascular catheter during thrombolytic therapy with contrast monitoring, radiological supervision and interpretation Mechanical removal of pericatheter obstructive material (e.g., fibrin sheath) from central venous device via separate venous access, 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, radiologic supervision and interpretation Intravascular ultrasound (non-coronary-vessel), radiological supervision and interpretation; initial vessel Endovascular repair of infrarenal abdominal aortic aneurysm or dissection, radiological supervision and interpretation Placement of proximal or distal extension prosthesis for endovascular repair of infrarenal aortic or iliac artery aneurysm, pseudoanuerysm, or dissection, radiological supervision and interpretation Endovascular repair of iliac artery aneurysm, pseudoaneurysm, arteriovenous malformation, or trauma, radiological supervision and interpretation

Case Rate 9,700 9,700 9,700 9,700 9,700 9,700 9,700 9,700 9,700 9,700 9,700 9,700 9,700 9,700 9,700 9,700 9,700 9,700 9,700 9,700 9,700 9,700 9,700 9,700 9,700 9,700 9,700 9,700 12,900 12,900 30,300

Professional Fee 4,200 4,200 4,200 4,200 4,200 4,200 4,200 4,200 4,200 4,200 4,200 4,200 4,200 4,200 4,200 4,200 4,200 4,200 4,200 4,200 4,200 4,200 4,200 4,200 4,200 4,200 4,200 4,200 6,300 6,300 16,800

Health Care Institution Fee 5,500 5,500 5,500 5,500 5,500 5,500 5,500 5,500 5,500 5,500 5,500 5,500 5,500 5,500 5,500 5,500 5,500 5,500 5,500 5,500 5,500 5,500 5,500 5,500 5,500 5,500 5,500 5,500 6,600 6,600 13,500

75901

9,700

4,200

5,500

75902 75940 75945 75952

9,700 23,300 9,700 53,400

4,200 12,600 4,200 29,400

5,500 10,700 5,500 24,000

75953

55,000

33,600

21,400

75954

53,400

29,400

24,000

Page 93 of 98

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

ANNEX 2. LIST OF PROCEDURE CASE RATES FIRST CASE RATE RVS CODE DESCRIPTION
Imaging supervision, interpretation and report for injection procedure(s) during cardiac catheterization; pulmonary angiography, aortography, 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.e., Fontan fenestration, 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); Esophageal recording of atrial electrogram with or without ventricular electrogram(s); with pacing Induction of arrhythmia by electrical pacing Comprehensive electrophysiologic evaluation with right atrial pacing and recording, right ventricular pacing and recording, His bundle recording, including insertion and repositioning of multiple electrode catheters, without induction of arrhythmia Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with right atrial pacing and recording, His bundle recording Electrophysiologic follow-up study with pacing and recording to test effectiveness of therapy, 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, evaluation of sensing and pacing for arrhythmia termination) at time of initial implantation or replacement; Electrophysiologic evaluation of single or dual chamber pacing cardioverterdefibrillator leads including defibrillation threshold evaluation (induction of arrhythmia, evaluation of sensing and pacing for arrhythmia termination) at time of initial implantation or replacement; 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, induction of arrhythmia, evaluation of sensing and pacing for arrhythmia termination, and programming or reprogramming Intracardiac catheter ablation of atrioventricular node function, atrioventricular conduction for creation of complete heart block, with or without temporary pacemaker placement Intracardiac catheter ablation of arrhythmogenic focus; for treatment of supraventricular tachycardia by ablation of fast or slow atrioventricular pathways, accessory atrioventricular connections or other atrial foci, singly or in combination Intracardiac catheter ablation of arrhythmogenic focus; for treatment of ventricular tachycardia Evaluation of cardiovascular function with tilt table evaluation, with continuous ECG monitoring and intermittent blood pressure monitoring, with or without pharmacological intervention Case Rate Professional Fee Health Care Institution Fee

93556

9,700

4,200

5,500

93580 93581 93600 93602 93603 93610 93612 93615 93616 93618 93619

55,000 55,000 9,700 9,700 9,700 9,700 9,700 9,700 9,700 9,700 9,700

33,600 33,600 4,200 4,200 4,200 4,200 4,200 4,200 4,200 4,200 4,200

21,400 21,400 5,500 5,500 5,500 5,500 5,500 5,500 5,500 5,500 5,500

93620

9,700

4,200

5,500

93624

9,700

4,200

5,500

93631

9,700

4,200

5,500

93640

9,700

4,200

5,500

93641

9,700

4,200

5,500

93642

9,700

4,200

5,500

93650

9,700

4,200

5,500

93651

9,700

4,200

5,500

93652 93660

9,700 9,700

4,200 4,200

5,500 5,500

96408

Chemotherapy administration

7,280

1,680

5,600

96440 96445 96450 96542

Chemotherapy administration into pleural cavity, requiring and including thoracentesis Chemotherapy administration into peritoneal cavity, requiring and including peritoneocentesis Chemotherapy administration into CNS, requiring and including spinal puncture Chemotherapy injection, subarachnoid or interventricular via subcutaneous reservoir

5,560 8,020 5,560 3,640

1,260 2,520 1,260 840

4,300 5,500 4,300 2,800

Page 97 of 98

ANNEX 2. 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.g., lip) by activation of photosensitive drug(s), 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, examination and medical decision making. This service is requested by another physician or an appropriate source; 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, requiring physician attendance (e.g., operative standby), 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 5,500 30,000

96567 99246

8,020 30,000

2,520

99256

99360 99432 P00001

0 1,750 4,000

0 500 1,200

0 1,250 2,800

Page 98 of 98

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