HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

0099T* Implant corneal ring Y R2 23.6808 $1,002.38

0100T Prosth retina receive&gen Y G2 38.7337 $1,639.56

0101T Extracorp shockwv tx hi enrg Y G2 30.378 $1,285.87

0102T Extracorp shockwv tx anesth Y G2 30.378 $1,285.87

0123T Scleral fistulization Y G2 23.6808 $1,002.38

0124T* Conjunctival drug placement Y R2 2.7589 $116.78

0186T Suprachoroidal drug delivery Y G2 21.3578 $904.05

0190T Place intraoc radiation src Y G2 21.3578 $904.05

0191T Insert ant segment drain int Y G2 39.1634 $1,657.75

0192T Insert ant segment drain ext Y G2 39.1634 $1,657.75

0200T Perq sacral augmt unilat inj Y G2 30.378 $1,285.87

0201T Perq sacral augmt bilat inj Y G2 30.378 $1,285.87

0213T Njx paravert w/us cer/thor Y CH R2 7.0747 $299.46

0214T Njx paravert w/us cer/thor Y CH R2 2.5957 $109.87

0215T Njx paravert w/us cer/thor Y CH R2 2.5957 $109.87

0216T Njx paravert w/us lumb/sac Y CH R2 7.0747 $299.46

0217T Njx paravert w/us lumb/sac Y CH R2 2.5957 $109.87

0218T Njx paravert w/us lumb/sac Y CH R2 2.5957 $109.87

0226T* Anoscopy hra w/spec collect N R2 0.6316 $26.73

0227T* Anoscopy hra w/biopsy Y R2 5.9086 $250.11

0228T Njx tfrml eprl w/us cer/thor Y G2 7.0747 $299.46

0229T Njx tfrml eprl w/us cer/thor Y G2 3.6902 $156.20

0230T Njx tfrml eprl w/us lumb/sac Y G2 7.0747 $299.46

0231T Njx tfrml eprl w/us lumb/sac Y G2 3.6902 $156.20

0232T* Njx platelet plasma N R2 0.6316 $26.73

0238T Trluml perip athrc iliac art Y G2 98.3094 $4,161.34

0249T Ligation hemorrhoid w/us Y G2 15.0188 $635.73

0250T Insert bronchial valve Y G2 27.2989 $1,155.54

0251T Remov bronchial valve Y G2 9.7594 $413.11

0252T Remov bronch valve addl Y G2 9.7594 $413.11

0253T Insert aqueous drain device Y G2 23.6808 $1,002.38

0260T Hypthrm bdy neonate 28d/< N N1

0261T Hypthrm head neonate 28d/< N N1

10021 Fna w/o image Y CH P3 $66.62

10022 Fna w/image Y G2 4.3075 $182.33

10040 Acne surgery Y CH P3 $38.34

10060 Drainage of skin abscess Y CH P3 $46.97

10061 Drainage of skin abscess Y P2 1.3573 $57.45

10080 Drainage of pilonidal cyst Y P2 1.3573 $57.45

10081 Drainage of pilonidal cyst Y P3 $116.70

10120 Remove foreign body Y P3 $63.74

10121 Remove foreign body Y A2 16.113 $682.05

10140 Drainage of hematoma/fluid Y P3 $69.01

10160 Puncture drainage of lesion Y CH P3 $55.83

10180 Complex drainage wound Y A2 19.2522 $814.93

11000 Debride infected skin Y P3 $21.81

11001 Debride infected skin add-on Y P3 $6.95

11010 Debride skin at fx site Y A2 4.5706 $193.47

11011 Debride skin musc at fx site Y A2 4.5706 $193.47

11012 Deb skin bone at fx site Y A2 4.5706 $193.47

11042 Deb subq tissue 20 sq cm/< Y A2 2.6477 $112.07

11043 Deb musc/fascia 20 sq cm/< Y A2 2.6477 $112.07

11044 Deb bone 20 sq cm/< Y A2 8.0762 $341.86

11045 Deb subq tissue add-on Y G2 2.6477 $112.07

11046 Deb musc/fascia add-on Y G2 2.6477 $112.07

11047 Deb bone add-on Y G2 8.0762 $341.86

11055 Trim skin lesion Y P3 $23.72

11056 Trim skin lesions 2 to 4 Y CH P3 $25.88

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

Date Printed: 3/14/2013 @ 8:00 PM Page 1 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

11057 Trim skin lesions over 4 Y CH P3 $28.76

11100 Biopsy skin lesion Y CH P3 $50.56

11101 Biopsy skin add-on Y P3 $11.98

11200 Removal of skin tags Y CH P3 $38.10

11201 Remove skin tags add-on Y P3 $5.27

11300 Shave skin lesion Y CH P3 $34.99

11301 Shave skin lesion Y P2 0.9172 $38.82

11302 Shave skin lesion Y P2 0.9172 $38.82

11303 Shave skin lesion Y CH P3 $57.99

11305 Shave skin lesion Y CH P3 $31.39

11306 Shave skin lesion Y P2 0.9172 $38.82

11307 Shave skin lesion Y P2 0.9172 $38.82

11308 Shave skin lesion Y P2 0.9172 $38.82

11310 Shave skin lesion Y P2 0.9172 $38.82

11311 Shave skin lesion Y P2 0.9172 $38.82

11312 Shave skin lesion Y P2 0.9172 $38.82

11313 Shave skin lesion Y P2 0.9172 $38.82

11400 Exc tr-ext b9+marg 0.5 < cm Y P3 $60.39

11401 Exc tr-ext b9+marg 0.6-1 cm Y P3 $67.82

11402 Exc tr-ext b9+marg 1.1-2 cm Y P3 $74.53

11403 Exc tr-ext b9+marg 2.1-3 cm Y P3 $81.00

11404 Exc tr-ext b9+marg 3.1-4 cm Y A2 16.113 $682.05

11406 Exc tr-ext b9+marg > 4.0 cm Y A2 16.113 $682.05

11420 Exc h-f-nk-sp b9+marg 0.5 < Y P3 $57.03

11421 Exc h-f-nk-sp b9+marg 0.6-1 Y P3 $68.78

11422 Exc h-f-nk-sp b9+marg 1.1-2 Y P3 $75.01

11423 Exc h-f-nk-sp b9+marg 2.1-3 Y P3 $83.39

11424 Exc h-f-nk-sp b9+marg 3.1-4 Y A2 16.113 $682.05

11426 Exc h-f-nk-sp b9+marg > 4 cm Y A2 21.9487 $929.07

11440 Exc face-mm b9+marg 0.5 < cm Y P3 $63.98

11441 Exc face-mm b9+marg 0.6-1 cm Y P3 $74.29

11442 Exc face-mm b9+marg 1.1-2 cm Y P3 $81.96

11443 Exc face-mm b9+marg 2.1-3 cm Y P3 $91.30

11444 Exc face-mm b9+marg 3.1-4 cm Y A2 8.0762 $341.86

11446 Exc face-mm b9+marg > 4 cm Y A2 21.9487 $929.07

11450 Removal sweat gland lesion Y A2 21.9487 $929.07

11451 Removal sweat gland lesion Y A2 21.9487 $929.07

11462 Removal sweat gland lesion Y A2 21.9487 $929.07

11463 Removal sweat gland lesion Y A2 21.9487 $929.07

11470 Removal sweat gland lesion Y A2 21.9487 $929.07

11471 Removal sweat gland lesion Y A2 21.9487 $929.07

11600 Exc tr-ext mlg+marg 0.5 < cm Y P3 $86.99

11601 Exc tr-ext mlg+marg 0.6-1 cm Y P3 $102.08

11602 Exc tr-ext mlg+marg 1.1-2 cm Y P3 $110.71

11603 Exc tr-ext mlg+marg 2.1-3 cm Y P3 $119.34

11604 Exc tr-ext mlg+marg 3.1-4 cm Y A2 8.0762 $341.86

11606 Exc tr-ext mlg+marg > 4 cm Y A2 16.113 $682.05

11620 Exc h-f-nk-sp mlg+marg 0.5 < Y P3 $88.66

11621 Exc h-f-nk-sp mlg+marg 0.6-1 Y P3 $103.04

11622 Exc h-f-nk-sp mlg+marg 1.1-2 Y P3 $112.87

11623 Exc h-f-nk-sp mlg+marg 2.1-3 Y P3 $123.65

11624 Exc h-f-nk-sp mlg+marg 3.1-4 Y A2 16.113 $682.05

11626 Exc h-f-nk-sp mlg+mar > 4 cm Y A2 21.9487 $929.07

11640 Exc face-mm malig+marg 0.5 < Y P3 $92.98

11641 Exc face-mm malig+marg 0.6-1 Y P3 $106.64

11642 Exc face-mm malig+marg 1.1-2 Y P3 $118.38

11643 Exc face-mm malig+marg 2.1-3 Y P3 $129.64

11644 Exc face-mm malig+marg 3.1-4 Y A2 16.113 $682.05

Date Printed: 3/14/2013 @ 8:00 PM Page 2 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

11646 Exc face-mm mlg+marg > 4 cm Y A2 21.9487 $929.07

11719 Trim nail(s) Y P3 $11.02

11720 Debride nail 1-5 Y P3 $13.66

11721 Debride nail 6 or more Y P3 $15.82

11730 Removal of nail plate Y P2 0.9172 $38.82

11732 Remove nail plate add-on Y P3 $13.66

11740 Drain blood from under nail Y P2 0.3793 $16.06

11750 Removal of nail bed Y P3 $87.71

11752 Remove nail bed/finger tip Y P3 $124.37

11755 Biopsy nail unit Y P3 $59.19

11760 Repair of nail bed Y G2 1.1378 $48.16

11762 Reconstruction of nail bed Y P3 $115.02

11765 Excision of nail fold toe Y P2 0.9172 $38.82

11770 Removal of pilonidal lesion Y A2 21.9487 $929.07

11771 Removal of pilonidal lesion Y A2 21.9487 $929.07

11772 Removal of pilonidal lesion Y A2 21.9487 $929.07

11900 Injection into skin lesions Y CH P3 $24.92

11901 Added skin lesions injection Y CH P3 $27.56

11920 Correct skin color defects Y P3 $78.12

11921 Correct skin color defects Y P3 $87.47

11922 Correct skin color defects Y P3 $29.71

11950 Therapy for contour defects Y P3 $27.32

11951 Therapy for contour defects Y P3 $40.50

11952 Therapy for contour defects Y CH P3 $53.92

11954 Therapy for contour defects Y P2 1.1378 $48.16

11960 Insert tissue expander(s) Y A2 20.437 $865.08

11970 Replace tissue expander Y A2 44.2257 $1,872.03

11971 Remove tissue expander(s) Y A2 21.9487 $929.07

11976 Removal of contraceptive cap Y P3 $52.24

11980 Implant hormone pellet(s) N P2 0.6316 $26.73

11981 Insert drug implant device N P2 0.6316 $26.73

11982 Remove drug implant device N P2 0.6316 $26.73

11983 Remove/insert drug implant N P2 0.6316 $26.73

12001 Repair superficial wound(s) Y CH P3 $41.94

12002 Repair superficial wound(s) Y CH P3 $46.25

12004 Repair superficial wound(s) Y P2 1.1378 $48.16

12005 Repair superficial wound(s) Y A2 1.1378 $48.16

12006 Repair superficial wound(s) Y A2 1.1378 $48.16

12007 Repair superficial wound(s) Y A2 1.1378 $48.16

12011 Repair superficial wound(s) Y P2 1.1378 $48.16

12013 Repair superficial wound(s) Y P2 1.1378 $48.16

12014 Repair superficial wound(s) Y P2 1.1378 $48.16

12015 Repair superficial wound(s) Y G2 1.1378 $48.16

12016 Repair superficial wound(s) Y A2 1.1378 $48.16

12017 Repair superficial wound(s) Y A2 1.1378 $48.16

12018 Repair superficial wound(s) Y A2 3.0787 $130.32

12020 Closure of split wound Y A2 4.8714 $206.20

12021 Closure of split wound Y A2 3.0787 $130.32

12031 Intmd wnd repair s/tr/ext Y CH P3 $109.03

12032 Intmd wnd repair s/tr/ext Y P2 3.0787 $130.32

12034 Intmd wnd repair s/tr/ext Y A2 3.0787 $130.32

12035 Intmd wnd repair s/tr/ext Y A2 3.0787 $130.32

12036 Intmd wnd repair s/tr/ext Y A2 3.0787 $130.32

12037 Intmd wnd repair s/tr/ext Y A2 3.0787 $130.32

12041 Intmd wnd repair n-hf/genit Y P2 1.1378 $48.16

12042 Intmd wnd repair n-hg/genit Y CH P3 $125.81

12044 Intmd wnd repair n-hg/genit Y A2 3.0787 $130.32

12045 Intmd wnd repair n-hg/genit Y A2 3.0787 $130.32

Date Printed: 3/14/2013 @ 8:00 PM Page 3 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

12046 Intmd wnd repair n-hg/genit Y A2 3.0787 $130.32

12047 Intmd wnd repair n-hg/genit Y A2 3.0787 $130.32

12051 Intmd wnd repair face/mm Y CH P3 $117.18

12052 Intmd wnd repair face/mm Y CH P3 $129.16

12053 Intmd wnd repair face/mm Y P2 3.0787 $130.32

12054 Intmd wnd repair face/mm Y A2 1.1378 $48.16

12055 Intmd wnd repair face/mm Y A2 3.0787 $130.32

12056 Intmd wnd repair face/mm Y A2 3.0787 $130.32

12057 Intmd wnd repair face/mm Y A2 3.0787 $130.32

13100 Repair of wound or lesion Y A2 4.8714 $206.20

13101 Repair of wound or lesion Y A2 4.8714 $206.20

13102 Repair wound/lesion add-on Y A2 3.0787 $130.32

13120 Repair of wound or lesion Y A2 3.0787 $130.32

13121 Repair of wound or lesion Y A2 3.0787 $130.32

13122 Repair wound/lesion add-on Y A2 1.1378 $48.16

13131 Repair of wound or lesion Y A2 3.0787 $130.32

13132 Repair of wound or lesion Y A2 4.8714 $206.20

13133 Repair wound/lesion add-on Y A2 3.0787 $130.32

13150 Repair of wound or lesion Y A2 4.8714 $206.20

13151 Repair of wound or lesion Y A2 4.8714 $206.20

13152 Repair of wound or lesion Y A2 4.8714 $206.20

13153 Repair wound/lesion add-on Y A2 3.0787 $130.32

13160 Late closure of wound Y A2 20.437 $865.08

14000 Skin tissue rearrangement Y A2 16.1914 $685.37

14001 Skin tissue rearrangement Y A2 16.1914 $685.37

14020 Skin tissue rearrangement Y A2 16.1914 $685.37

14021 Skin tissue rearrangement Y A2 16.1914 $685.37

14040 Skin tissue rearrangement Y A2 16.1914 $685.37

14041 Skin tissue rearrangement Y A2 16.1914 $685.37

14060 Skin tissue rearrangement Y A2 16.1914 $685.37

14061 Skin tissue rearrangement Y A2 16.1914 $685.37

14301 Skin tissue rearrangement Y G2 20.437 $865.08

14302 Skin tissue rearrange add-on Y G2 20.437 $865.08

14350 Skin tissue rearrangement Y A2 20.437 $865.08

15002 Wound prep trk/arm/leg Y A2 4.8714 $206.20

15003 Wound prep addl 100 cm Y A2 4.8714 $206.20

15004 Wound prep f/n/hf/g Y A2 3.0787 $130.32

15005 Wnd prep f/n/hf/g addl cm Y A2 4.8714 $206.20

15040 Harvest cultured skin graft Y A2 3.0787 $130.32

15050 Skin pinch graft Y A2 3.0787 $130.32

15100 Skin splt grft trnk/arm/leg Y A2 20.437 $865.08

15101 Skin splt grft t/a/l add-on Y A2 20.437 $865.08

15110 Epidrm autogrft trnk/arm/leg Y A2 4.8714 $206.20

15111 Epidrm autogrft t/a/l add-on Y A2 4.8714 $206.20

15115 Epidrm a-grft face/nck/hf/g Y A2 4.8714 $206.20

15116 Epidrm a-grft f/n/hf/g addl Y A2 3.0787 $130.32

15120 Skn splt a-grft fac/nck/hf/g Y A2 20.437 $865.08

15121 Skn splt a-grft f/n/hf/g add Y A2 20.437 $865.08

15130 Derm autograft trnk/arm/leg Y A2 16.1914 $685.37

15131 Derm autograft t/a/l add-on Y A2 16.1914 $685.37

15135 Derm autograft face/nck/hf/g Y A2 16.1914 $685.37

15136 Derm autograft f/n/hf/g add Y A2 16.1914 $685.37

15150 Cult epiderm grft t/arm/leg Y A2 4.8714 $206.20

15151 Cult epiderm grft t/a/l addl Y A2 4.8714 $206.20

15152 Cult epiderm graft t/a/l +% Y A2 4.8714 $206.20

15155 Cult epiderm graft f/n/hf/g Y A2 4.8714 $206.20

15156 Cult epidrm grft f/n/hfg add Y A2 4.8714 $206.20

15157 Cult epiderm grft f/n/hfg +% Y A2 4.8714 $206.20

Date Printed: 3/14/2013 @ 8:00 PM Page 4 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

15170 Acell graft trunk/arms/legs Y G2 4.8714 $206.20

15171 Acell graft t/arm/leg add-on Y G2 3.0787 $130.32

15175 Acellular graft f/n/hf/g Y G2 4.8714 $206.20

15176 Acell graft f/n/hf/g add-on Y G2 4.8714 $206.20

15200 Skin full graft trunk Y A2 16.1914 $685.37

15201 Skin full graft trunk add-on Y A2 16.1914 $685.37

15220 Skin full graft sclp/arm/leg Y A2 16.1914 $685.37

15221 Skin full graft add-on Y A2 4.8714 $206.20

15240 Skin full grft face/genit/hf Y A2 16.1914 $685.37

15241 Skin full graft add-on Y A2 3.0787 $130.32

15260 Skin full graft een & lips Y A2 16.1914 $685.37

15261 Skin full graft add-on Y A2 16.1914 $685.37

15300 Apply skinallogrft t/arm/lg Y A2 4.8714 $206.20

15301 Apply sknallogrft t/a/l addl Y A2 4.8714 $206.20

15320 Apply skin allogrft f/n/hf/g Y A2 4.8714 $206.20

15321 Aply sknallogrft f/n/hfg add Y A2 4.8714 $206.20

15330 Aply acell alogrft t/arm/leg Y A2 4.8714 $206.20

15331 Aply acell grft t/a/l add-on Y A2 4.8714 $206.20

15335 Apply acell graft f/n/hf/g Y A2 4.8714 $206.20

15336 Aply acell grft f/n/hf/g add Y A2 4.8714 $206.20

15340 Apply cult skin substitute Y G2 3.0787 $130.32

15341 Apply cult skin sub add-on Y G2 3.0787 $130.32

15360 Apply cult derm sub t/a/l Y G2 3.0787 $130.32

15361 Aply cult derm sub t/a/l add Y G2 3.0787 $130.32

15365 Apply cult derm sub f/n/hf/g Y G2 3.0787 $130.32

15366 Apply cult derm f/hf/g add Y G2 3.0787 $130.32

15400 Apply skin xenograft t/a/l Y A2 4.8714 $206.20

15401 Apply skn xenogrft t/a/l add Y A2 4.8714 $206.20

15420 Apply skin xgraft f/n/hf/g Y A2 4.8714 $206.20

15421 Apply skn xgrft f/n/hf/g add Y A2 4.8714 $206.20

15430 Apply acellular xenograft Y A2 3.0787 $130.32

15431 Apply acellular xgraft add Y A2 4.8714 $206.20

15570 Form skin pedicle flap Y A2 20.437 $865.08

15572 Form skin pedicle flap Y A2 20.437 $865.08

15574 Form skin pedicle flap Y A2 20.437 $865.08

15576 Form skin pedicle flap Y A2 20.437 $865.08

15600 Skin graft Y A2 20.437 $865.08

15610 Skin graft Y A2 20.437 $865.08

15620 Skin graft Y A2 20.437 $865.08

15630 Skin graft Y A2 20.437 $865.08

15650 Transfer skin pedicle flap Y A2 20.437 $865.08

15731 Forehead flap w/vasc pedicle Y A2 20.437 $865.08

15732 Muscle-skin graft head/neck Y A2 20.437 $865.08

15734 Muscle-skin graft trunk Y A2 20.437 $865.08

15736 Muscle-skin graft arm Y A2 20.437 $865.08

15738 Muscle-skin graft leg Y A2 20.437 $865.08

15740 Island pedicle flap graft Y A2 16.1914 $685.37

15750 Neurovascular pedicle graft Y A2 20.437 $865.08

15760 Composite skin graft Y A2 20.437 $865.08

15770 Derma-fat-fascia graft Y A2 20.437 $865.08

15775 Hair transplant punch grafts Y A2 1.1378 $48.16

15776 Hair transplant punch grafts Y A2 1.1378 $48.16

15780 Abrasion treatment of skin Y P3 $345.79

15781 Abrasion treatment of skin Y P2 4.5706 $193.47

15782 Abrasion treatment of skin Y P2 4.5706 $193.47

15783 Abrasion treatment of skin Y P2 2.6477 $112.07

15786 Abrasion lesion single Y P2 0.9172 $38.82

15787 Abrasion lesions add-on Y P3 $25.40

Date Printed: 3/14/2013 @ 8:00 PM Page 5 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

15788 Chemical peel face epiderm Y P2 0.9172 $38.82

15789 Chemical peel face dermal Y P2 1.4 $59.26

15792 Chemical peel nonfacial Y P2 1.4 $59.26

15793 Chemical peel nonfacial Y P2 0.9172 $38.82

15819 Plastic surgery neck Y G2 3.0787 $130.32

15820 Revision of lower eyelid Y A2 20.437 $865.08

15821 Revision of lower eyelid Y A2 20.437 $865.08

15822 Revision of upper eyelid Y A2 20.437 $865.08

15823 Revision of upper eyelid Y A2 20.437 $865.08

15824 Removal of forehead wrinkles Y A2 20.437 $865.08

15825 Removal of neck wrinkles Y A2 20.437 $865.08

15826 Removal of brow wrinkles Y A2 20.437 $865.08

15828 Removal of face wrinkles Y A2 20.437 $865.08

15829 Removal of skin wrinkles Y A2 20.437 $865.08

15830 Exc skin abd Y A2 21.9487 $929.07

15832 Excise excessive skin tissue Y A2 21.9487 $929.07

15833 Excise excessive skin tissue Y A2 21.9487 $929.07

15834 Excise excessive skin tissue Y A2 21.9487 $929.07

15835 Excise excessive skin tissue Y A2 21.9487 $929.07

15836 Excise excessive skin tissue Y A2 16.113 $682.05

15837 Excise excessive skin tissue Y G2 16.113 $682.05

15838 Excise excessive skin tissue Y G2 16.113 $682.05

15839 Excise excessive skin tissue Y A2 16.113 $682.05

15840 Graft for face nerve palsy Y A2 20.437 $865.08

15841 Graft for face nerve palsy Y A2 20.437 $865.08

15842 Flap for face nerve palsy Y G2 20.437 $865.08

15845 Skin and muscle repair face Y A2 20.437 $865.08

15847 Exc skin abd add-on Y A2 21.9487 $929.07

15850 Removal of sutures Y G2 2.6477 $112.07

15851 Removal of sutures Y P3 $44.57

15852 Dressing change not for burn N R2 0.6316 $26.73

15860 Test for blood flow in graft N G2 0.6316 $26.73

15876 Suction assisted lipectomy Y A2 20.437 $865.08

15877 Suction assisted lipectomy Y A2 20.437 $865.08

15878 Suction assisted lipectomy Y A2 20.437 $865.08

15879 Suction assisted lipectomy Y A2 20.437 $865.08

15920 Removal of tail bone ulcer Y A2 4.5706 $193.47

15922 Removal of tail bone ulcer Y A2 20.437 $865.08

15931 Remove sacrum pressure sore Y A2 21.9487 $929.07

15933 Remove sacrum pressure sore Y A2 21.9487 $929.07

15934 Remove sacrum pressure sore Y A2 20.437 $865.08

15935 Remove sacrum pressure sore Y A2 20.437 $865.08

15936 Remove sacrum pressure sore Y A2 16.1914 $685.37

15937 Remove sacrum pressure sore Y A2 20.437 $865.08

15940 Remove hip pressure sore Y A2 21.9487 $929.07

15941 Remove hip pressure sore Y A2 21.9487 $929.07

15944 Remove hip pressure sore Y A2 20.437 $865.08

15945 Remove hip pressure sore Y A2 20.437 $865.08

15946 Remove hip pressure sore Y A2 20.437 $865.08

15950 Remove thigh pressure sore Y A2 21.9487 $929.07

15951 Remove thigh pressure sore Y A2 21.9487 $929.07

15952 Remove thigh pressure sore Y A2 16.1914 $685.37

15953 Remove thigh pressure sore Y A2 16.1914 $685.37

15956 Remove thigh pressure sore Y A2 16.1914 $685.37

15958 Remove thigh pressure sore Y A2 16.1914 $685.37

16000 Initial treatment of burn(s) Y P3 $23.96

16020 Dress/debrid p-thick burn s Y P3 $37.62

16025 Dress/debrid p-thick burn m Y A2 1.4 $59.26

Date Printed: 3/14/2013 @ 8:00 PM Page 6 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

16030 Dress/debrid p-thick burn l Y A2 1.4 $59.26

16035 Incision of burn scab initi Y G2 1.4 $59.26

17000 Destruct premalg lesion Y P2 0.9172 $38.82

17003 Destruct premalg les 2-14 Y P3 $2.88

17004 Destroy premlg lesions 15+ Y P3 $69.73

17106 Destruction of skin lesions Y P2 2.6477 $112.07

17107 Destruction of skin lesions Y P2 2.6477 $112.07

17108 Destruction of skin lesions Y P2 2.6477 $112.07

17110 Destruct b9 lesion 1-14 Y P2 0.9172 $38.82

17111 Destruct lesion 15 or more Y P2 1.4 $59.26

17250 Chemical cautery tissue Y P3 $40.74

17260 Destruction of skin lesions Y P3 $40.50

17261 Destruction of skin lesions Y P2 1.4 $59.26

17262 Destruction of skin lesions Y P2 1.4 $59.26

17263 Destruction of skin lesions Y P2 1.4 $59.26

17264 Destruction of skin lesions Y P2 1.4 $59.26

17266 Destruction of skin lesions Y CH P3 $97.53

17270 Destruction of skin lesions Y P2 1.4 $59.26

17271 Destruction of skin lesions Y P2 1.4 $59.26

17272 Destruction of skin lesions Y P2 1.4 $59.26

17273 Destruction of skin lesions Y CH P3 $88.66

17274 Destruction of skin lesions Y CH P3 $100.41

17276 Destruction of skin lesions Y CH P3 $110.95

17280 Destruction of skin lesions Y P2 1.4 $59.26

17281 Destruction of skin lesions Y CH P3 $76.44

17282 Destruction of skin lesions Y CH P3 $86.51

17283 Destruction of skin lesions Y CH P3 $98.97

17284 Destruction of skin lesions Y CH P3 $109.27

17286 Destruction of skin lesions Y P2 2.6477 $112.07

17311 Mohs 1 stage h/n/hf/g Y P2 5.0323 $213.01

17312 Mohs addl stage Y CH P3 $187.87

17313 Mohs 1 stage t/a/l Y P2 5.0323 $213.01

17314 Mohs addl stage t/a/l Y CH P3 $174.21

17315 Mohs surg addl block Y P3 $32.35

17340 Cryotherapy of skin Y P3 $14.62

17360 Skin peel therapy Y P2 0.9172 $38.82

17380 Hair removal by electrolysis Y R2 0.9172 $38.82

19000 Drainage of breast lesion Y P3 $53.92

19001 Drain breast lesion add-on Y P3 $7.19

19020 Incision of breast lesion Y A2 19.2522 $814.93

19030 Injection for breast x-ray N N1

19100 Bx breast percut w/o image Y A2 4.3075 $182.33

19101 Biopsy of breast open Y A2 24.2182 $1,025.13

19102 Bx breast percut w/image Y A2 7.631 $323.01

19103 Bx breast percut w/device Y A2 14.3964 $609.39

19105 Cryosurg ablate fa each Y P2 31.7198 $1,342.67

19110 Nipple exploration Y A2 24.2182 $1,025.13

19112 Excise breast duct fistula Y A2 24.2182 $1,025.13

19120 Removal of breast lesion Y A2 24.2182 $1,025.13

19125 Excision breast lesion Y A2 24.2182 $1,025.13

19126 Excision addl breast lesion Y A2 24.2182 $1,025.13

19290 Place needle wire breast N N1

19291 Place needle wire breast N N1

19295 Place breast clip percut N N1

19296 Place po breast cath for rad Y A2 57.8024 $2,446.72

19297 Place breast cath for rad Y A2 57.8024 $2,446.72

19298 Place breast rad tube/caths Y A2 57.8024 $2,446.72

19300 Removal of breast tissue Y A2 24.2182 $1,025.13

Date Printed: 3/14/2013 @ 8:00 PM Page 7 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

19301 Partical mastectomy Y A2 24.2182 $1,025.13

19302 P-mastectomy w/ln removal Y A2 42.2696 $1,789.23

19303 Mast simple complete Y A2 31.7198 $1,342.67

19304 Mast subq Y A2 31.7198 $1,342.67

19316 Suspension of breast Y A2 31.7198 $1,342.67

19318 Reduction of large breast Y A2 42.2696 $1,789.23

19324 Enlarge breast Y A2 42.2696 $1,789.23

19325 Enlarge breast with implant Y A2 57.8024 $2,446.72

19328 Removal of breast implant Y A2 31.7198 $1,342.67

19330 Removal of implant material Y A2 31.7198 $1,342.67

19340 Immediate breast prosthesis Y A2 42.2696 $1,789.23

19342 Delayed breast prosthesis Y A2 57.8024 $2,446.72

19350 Breast reconstruction Y A2 24.2182 $1,025.13

19355 Correct inverted nipple(s) Y A2 31.7198 $1,342.67

19357 Breast reconstruction Y A2 57.8024 $2,446.72

19366 Breast reconstruction Y A2 31.7198 $1,342.67

19370 Surgery of breast capsule Y A2 31.7198 $1,342.67

19371 Removal of breast capsule Y A2 31.7198 $1,342.67

19380 Revise breast reconstruction Y A2 42.2696 $1,789.23

19396 Design custom breast implant Y G2 31.7198 $1,342.67

20005 I&d abscess subfascial Y G2 8.0762 $341.86

20103 Explore wound extremity Y G2 12.6328 $534.73

20150 Excise epiphyseal bar Y G2 44.2257 $1,872.03

20200 Muscle biopsy Y A2 16.113 $682.05

20205 Deep muscle biopsy Y A2 16.113 $682.05

20206 Needle biopsy muscle Y A2 7.631 $323.01

20220 Bone biopsy trocar/needle Y A2 8.0762 $341.86

20225 Bone biopsy trocar/needle Y A2 16.113 $682.05

20240 Bone biopsy excisional Y A2 21.9487 $929.07

20245 Bone biopsy excisional Y A2 21.9487 $929.07

20250 Open bone biopsy Y A2 30.378 $1,285.87

20251 Open bone biopsy Y A2 30.378 $1,285.87

20500 Injection of sinus tract Y P3 $42.18

20501 Inject sinus tract for x-ray N N1

20520 Removal of foreign body Y P3 $87.47

20525 Removal of foreign body Y A2 21.9487 $929.07

20526 Ther injection carp tunnel Y P3 $26.84

20550 Inj tendon sheath/ligament Y P3 $20.13

20551 Inj tendon origin/insertion Y P3 $21.09

20552 Inj trigger point 1/2 muscl Y P3 $20.13

20553 Inject trigger points =/> 3 Y P3 $23.48

20555 Place ndl musc/tis for rt Y R2 30.378 $1,285.87

20600 Drain/inject joint/bursa Y P3 $20.37

20605 Drain/inject joint/bursa Y P3 $23.24

20610 Drain/inject joint/bursa Y P3 $34.03

20612 Aspirate/inj ganglion cyst Y P3 $22.77

20615 Treatment of bone cyst Y P3 $99.45

20650 Insert and remove bone pin Y A2 30.378 $1,285.87

20662 Application of pelvis brace Y R2 20.7775 $879.49

20663 Application of thigh brace Y R2 30.378 $1,285.87

20665 Removal of fixation device N G2 0.6316 $26.73

20670 Removal of support implant Y A2 16.113 $682.05

20680 Removal of support implant Y A2 21.9487 $929.07

20690 Apply bone fixation device Y A2 30.378 $1,285.87

20692 Apply bone fixation device Y A2 30.378 $1,285.87

20693 Adjust bone fixation device Y A2 30.378 $1,285.87

20694 Remove bone fixation device Y A2 20.7775 $879.49

20696 Comp multiplane ext fixation Y G2 30.378 $1,285.87

Date Printed: 3/14/2013 @ 8:00 PM Page 8 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

20697 Comp ext fixate strut change Y P2 17.5202 $741.61

20822 Replantation digit complete Y G2 27.1987 $1,151.29

20900 Removal of bone for graft Y A2 30.378 $1,285.87

20902 Removal of bone for graft Y A2 30.378 $1,285.87

20910 Remove cartilage for graft Y A2 20.437 $865.08

20912 Remove cartilage for graft Y A2 20.437 $865.08

20920 Removal of fascia for graft Y A2 16.1914 $685.37

20922 Removal of fascia for graft Y A2 16.1914 $685.37

20924 Removal of tendon for graft Y A2 30.378 $1,285.87

20926 Removal of tissue for graft Y A2 4.8714 $206.20

20950 Fluid pressure muscle Y G2 1.3573 $57.45

20972 Bone/skin graft metatarsal Y G2 53.6228 $2,269.80

20973 Bone/skin graft great toe Y R2 53.6228 $2,269.80

20975 Electrical bone stimulation N N1

20979 Us bone stimulation N CH P3 $20.37

20982 Ablate bone tumor(s) perq Y G2 44.2257 $1,872.03

20985 Cptr-asst dir ms px N N1

21010 Incision of jaw joint Y A2 23.5618 $997.35

21011 Exc face les sc < 2 cm Y P3 $165.11

21012 Exc face les sbq 2+ cm Y R2 8.0762 $341.86

21013 Exc face tum deep < 2 cm Y P3 $222.62

21014 Exc face tum deep 2+ cm Y R2 8.0762 $341.86

21015 Resect face tum < 2 cm Y CH G2 16.113 $682.05

21016 Resect face tum + cm Y G2 21.9487 $929.07

21025 Excision of bone lower jaw Y A2 42.299 $1,790.47

21026 Excision of facial bone(s) Y A2 42.299 $1,790.47

21029 Contour of face bone lesion Y A2 42.299 $1,790.47

21030 Excise max/zygoma b9 tumor Y P3 $225.02

21031 Remove exostosis mandible Y P3 $182.12

21032 Remove exostosis maxilla Y P3 $185.24

21034 Excise max/zygoma mlg tumor Y A2 42.299 $1,790.47

21040 Excise mandible lesion Y A2 23.5618 $997.35

21044 Removal of jaw bone lesion Y A2 42.299 $1,790.47

21046 Remove mandible cyst complex Y A2 42.299 $1,790.47

21047 Excise lwr jaw cyst w/repair Y A2 42.299 $1,790.47

21048 Remove maxilla cyst complex Y R2 42.299 $1,790.47

21050 Removal of jaw joint Y A2 42.299 $1,790.47

21060 Remove jaw joint cartilage Y A2 42.299 $1,790.47

21070 Remove coronoid process Y A2 42.299 $1,790.47

21073 Mnpj of tmj w/anesth Y P3 $172.54

21076 Prepare face/oral prosthesis Y P3 $326.38

21077 Prepare face/oral prosthesis Y P3 $805.65

21079 Prepare face/oral prosthesis Y P3 $560.75

21080 Prepare face/oral prosthesis Y P3 $632.40

21081 Prepare face/oral prosthesis Y P3 $586.87

21082 Prepare face/oral prosthesis Y P3 $572.97

21083 Prepare face/oral prosthesis Y P3 $561.94

21084 Prepare face/oral prosthesis Y P3 $632.40

21085 Prepare face/oral prosthesis Y P3 $273.66

21086 Prepare face/oral prosthesis Y P3 $597.89

21087 Prepare face/oral prosthesis Y P3 $594.29

21088 Prepare face/oral prosthesis Y R2 42.299 $1,790.47

21100 Maxillofacial fixation Y A2 42.299 $1,790.47

21110 Interdental fixation Y P2 7.5315 $318.80

21116 Injection jaw joint x-ray N N1

21120 Reconstruction of chin Y A2 23.5618 $997.35

21121 Reconstruction of chin Y A2 23.5618 $997.35

21122 Reconstruction of chin Y A2 23.5618 $997.35

Date Printed: 3/14/2013 @ 8:00 PM Page 9 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

21123 Reconstruction of chin Y A2 23.5618 $997.35

21125 Augmentation lower jaw bone Y A2 23.5618 $997.35

21127 Augmentation lower jaw bone Y A2 42.299 $1,790.47

21137 Reduction of forehead Y G2 23.5618 $997.35

21138 Reduction of forehead Y G2 42.299 $1,790.47

21139 Reduction of forehead Y G2 42.299 $1,790.47

21150 Reconstruct midface lefort Y G2 42.299 $1,790.47

21181 Contour cranial bone lesion Y A2 23.5618 $997.35

21198 Reconstr lwr jaw segment Y G2 42.299 $1,790.47

21199 Reconstr lwr jaw w/advance Y G2 42.299 $1,790.47

21206 Reconstruct upper jaw bone Y A2 42.299 $1,790.47

21208 Augmentation of facial bones Y A2 42.299 $1,790.47

21209 Reduction of facial bones Y A2 42.299 $1,790.47

21210 Face bone graft Y A2 42.299 $1,790.47

21215 Lower jaw bone graft Y A2 42.299 $1,790.47

21230 Rib cartilage graft Y A2 42.299 $1,790.47

21235 Ear cartilage graft Y A2 23.5618 $997.35

21240 Reconstruction of jaw joint Y A2 42.299 $1,790.47

21242 Reconstruction of jaw joint Y A2 42.299 $1,790.47

21243 Reconstruction of jaw joint Y A2 42.299 $1,790.47

21244 Reconstruction of lower jaw Y A2 42.299 $1,790.47

21245 Reconstruction of jaw Y A2 42.299 $1,790.47

21246 Reconstruction of jaw Y A2 42.299 $1,790.47

21248 Reconstruction of jaw Y A2 42.299 $1,790.47

21249 Reconstruction of jaw Y A2 42.299 $1,790.47

21260 Revise eye sockets Y G2 42.299 $1,790.47

21267 Revise eye sockets Y A2 42.299 $1,790.47

21270 Augmentation cheek bone Y A2 42.299 $1,790.47

21275 Revision orbitofacial bones Y A2 42.299 $1,790.47

21280 Revision of eyelid Y A2 42.299 $1,790.47

21282 Revision of eyelid Y A2 15.8572 $671.22

21295 Revision of jaw muscle/bone Y A2 7.5315 $318.80

21296 Revision of jaw muscle/bone Y A2 23.5618 $997.35

21310 Treatment of nose fracture Y A2 1.0193 $43.15

21315 Treatment of nose fracture Y A2 15.8572 $671.22

21320 Treatment of nose fracture Y A2 15.8572 $671.22

21325 Treatment of nose fracture Y A2 23.5618 $997.35

21330 Treatment of nose fracture Y A2 23.5618 $997.35

21335 Treatment of nose fracture Y A2 23.5618 $997.35

21336 Treat nasal septal fracture Y A2 24.5925 $1,040.98

21337 Treat nasal septal fracture Y A2 15.8572 $671.22

21338 Treat nasoethmoid fracture Y A2 23.5618 $997.35

21339 Treat nasoethmoid fracture Y A2 23.5618 $997.35

21340 Treatment of nose fracture Y A2 42.299 $1,790.47

21345 Treat nose/jaw fracture Y A2 23.5618 $997.35

21355 Treat cheek bone fracture Y A2 42.299 $1,790.47

21356 Treat cheek bone fracture Y A2 23.5618 $997.35

21360 Treat cheek bone fracture Y G2 23.5618 $997.35

21390 Treat eye socket fracture Y G2 42.299 $1,790.47

21400 Treat eye socket fracture Y A2 7.5315 $318.80

21401 Treat eye socket fracture Y A2 15.8572 $671.22

21406 Treat eye socket fracture Y G2 42.299 $1,790.47

21407 Treat eye socket fracture Y G2 42.299 $1,790.47

21421 Treat mouth roof fracture Y A2 23.5618 $997.35

21440 Treat dental ridge fracture Y P3 $302.18

21445 Treat dental ridge fracture Y A2 23.5618 $997.35

21450 Treat lower jaw fracture Y A2 3.1429 $133.04

21451 Treat lower jaw fracture Y A2 7.5315 $318.80

Date Printed: 3/14/2013 @ 8:00 PM Page 10 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

21452 Treat lower jaw fracture Y A2 15.8572 $671.22

21453 Treat lower jaw fracture Y A2 42.299 $1,790.47

21454 Treat lower jaw fracture Y A2 23.5618 $997.35

21461 Treat lower jaw fracture Y A2 42.299 $1,790.47

21462 Treat lower jaw fracture Y A2 42.299 $1,790.47

21465 Treat lower jaw fracture Y A2 42.299 $1,790.47

21480 Reset dislocated jaw Y A2 1.0193 $43.15

21485 Reset dislocated jaw Y A2 15.8572 $671.22

21490 Repair dislocated jaw Y A2 42.299 $1,790.47

21495 Treat hyoid bone fracture Y G2 15.8572 $671.22

21497 Interdental wiring Y A2 15.8572 $671.22

21501 Drain neck/chest lesion Y A2 19.2522 $814.93

21502 Drain chest lesion Y A2 20.7775 $879.49

21550 Biopsy of neck/chest Y G2 16.113 $682.05

21552 Exc neck les sc 3+ cm Y G2 21.9487 $929.07

21554 Exc neck tum deep 5+ cm Y G2 21.9487 $929.07

21555 Exc neck les sc < 3 cm Y CH G2 16.113 $682.05

21556 Exc neck tum deep < 5 cm Y G2 21.9487 $929.07

21557 Resect neck tum < 5 cm Y G2 16.113 $682.05

21558 Resect neck tum 5+ cm Y G2 21.9487 $929.07

21600 Partial removal of rib Y A2 30.378 $1,285.87

21610 Partial removal of rib Y A2 30.378 $1,285.87

21685 Hyoid myotomy & suspension Y G2 7.5315 $318.80

21700 Revision of neck muscle Y A2 20.7775 $879.49

21720 Revision of neck muscle Y A2 20.7775 $879.49

21725 Revision of neck muscle Y A2 1.3573 $57.45

21800 Treatment of rib fracture Y A2 1.5056 $63.73

21805 Treatment of rib fracture Y A2 24.5925 $1,040.98

21820 Treat sternum fracture Y A2 1.5056 $63.73

21920 Biopsy soft tissue of back Y P3 $124.13

21925 Biopsy soft tissue of back Y A2 21.9487 $929.07

21930 Exc back les sc < 3 cm Y CH G2 16.113 $682.05

21931 Exc back les sc 3+ cm Y G2 21.9487 $929.07

21932 Exc back tum deep < 5 cm Y G2 16.113 $682.05

21933 Exc back tum deep 5+ cm Y G2 21.9487 $929.07

21935 Resect back tum < 5 cm Y G2 16.113 $682.05

21936 Resect back tum 5+ cm Y G2 21.9487 $929.07

22102 Remove part lumbar vertebra Y G2 47.9122 $2,028.08

22103 Remove extra spine segment Y G2 47.9122 $2,028.08

22305 Treat spine process fracture Y A2 1.5056 $63.73

22310 Treat spine fracture Y A2 4.6747 $197.88

22315 Treat spine fracture Y A2 17.5202 $741.61

22505 Manipulation of spine Y A2 14.5437 $615.62

22520 Percut vertebroplasty thor Y A2 30.378 $1,285.87

22521 Percut vertebroplasty lumb Y A2 30.378 $1,285.87

22522 Percut vertebroplasty addl Y A2 30.378 $1,285.87

22523 Percut kyphoplasty thor Y G2 82.0766 $3,474.22

22524 Percut kyphoplasty lumbar Y G2 82.0766 $3,474.22

22525 Percut kyphoplasty add-on Y G2 82.0766 $3,474.22

22900 Exc abdl tum deep < 5 cm Y G2 21.9487 $929.07

22901 Exc abdl tum deep > 5 cm Y G2 21.9487 $929.07

22902 Exc abd les sc < 3 cm Y G2 16.113 $682.05

22903 Exc abd les sc > 3 cm Y G2 21.9487 $929.07

22904 Resect abd tum < 5 cm Y G2 16.113 $682.05

22905 Resect abd tum > 5 cm Y G2 21.9487 $929.07

23000 Removal of calcium deposits Y A2 16.113 $682.05

23020 Release shoulder joint Y A2 30.378 $1,285.87

23030 Drain shoulder lesion Y A2 19.2522 $814.93

Date Printed: 3/14/2013 @ 8:00 PM Page 11 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

23031 Drain shoulder bursa Y A2 19.2522 $814.93

23035 Drain shoulder bone lesion Y A2 20.7775 $879.49

23040 Exploratory shoulder surgery Y A2 30.378 $1,285.87

23044 Exploratory shoulder surgery Y A2 30.378 $1,285.87

23065 Biopsy shoulder tissues Y P3 $89.86

23066 Biopsy shoulder tissues Y A2 21.9487 $929.07

23071 Exc shoulder les sc > 3 cm Y G2 21.9487 $929.07

23073 Exc shoulder tum deep > 5 cm Y G2 21.9487 $929.07

23075 Exc shoulder les sc < 3 cm Y CH G2 16.113 $682.05

23076 Exc shoulder tum deep < 5 cm Y G2 16.113 $682.05

23077 Resect shoulder tum < 5 cm Y G2 16.113 $682.05

23078 Resect shoulder tum > 5 cm Y G2 21.9487 $929.07

23100 Biopsy of shoulder joint Y A2 20.7775 $879.49

23101 Shoulder joint surgery Y A2 30.378 $1,285.87

23105 Remove shoulder joint lining Y A2 30.378 $1,285.87

23106 Incision of collarbone joint Y A2 30.378 $1,285.87

23107 Explore treat shoulder joint Y A2 30.378 $1,285.87

23120 Partial removal collar bone Y A2 30.378 $1,285.87

23125 Removal of collar bone Y A2 30.378 $1,285.87

23130 Remove shoulder bone part Y A2 44.2257 $1,872.03

23140 Removal of bone lesion Y A2 20.7775 $879.49

23145 Removal of bone lesion Y A2 30.378 $1,285.87

23146 Removal of bone lesion Y A2 30.378 $1,285.87

23150 Removal of humerus lesion Y A2 30.378 $1,285.87

23155 Removal of humerus lesion Y A2 30.378 $1,285.87

23156 Removal of humerus lesion Y A2 30.378 $1,285.87

23170 Remove collar bone lesion Y A2 30.378 $1,285.87

23172 Remove shoulder blade lesion Y A2 30.378 $1,285.87

23174 Remove humerus lesion Y A2 30.378 $1,285.87

23180 Remove collar bone lesion Y A2 30.378 $1,285.87

23182 Remove shoulder blade lesion Y A2 30.378 $1,285.87

23184 Remove humerus lesion Y A2 30.378 $1,285.87

23190 Partial removal of scapula Y A2 30.378 $1,285.87

23195 Removal of head of humerus Y A2 30.378 $1,285.87

23330 Remove shoulder foreign body Y A2 8.0762 $341.86

23331 Remove shoulder foreign body Y A2 21.9487 $929.07

23350 Injection for shoulder x-ray N N1

23395 Muscle transfer shoulder/arm Y A2 44.2257 $1,872.03

23397 Muscle transfers Y A2 82.0766 $3,474.22

23400 Fixation of shoulder blade Y A2 30.378 $1,285.87

23405 Incision of tendon & muscle Y A2 30.378 $1,285.87

23406 Incise tendon(s) & muscle(s) Y A2 30.378 $1,285.87

23410 Repair rotator cuff acute Y A2 44.2257 $1,872.03

23412 Repair rotator cuff chronic Y A2 44.2257 $1,872.03

23415 Release of shoulder ligament Y A2 44.2257 $1,872.03

23420 Repair of shoulder Y A2 44.2257 $1,872.03

23430 Repair biceps tendon Y A2 44.2257 $1,872.03

23440 Remove/transplant tendon Y A2 30.378 $1,285.87

23450 Repair shoulder capsule Y A2 82.0766 $3,474.22

23455 Repair shoulder capsule Y A2 82.0766 $3,474.22

23460 Repair shoulder capsule Y A2 82.0766 $3,474.22

23462 Repair shoulder capsule Y A2 44.2257 $1,872.03

23465 Repair shoulder capsule Y A2 82.0766 $3,474.22

23466 Repair shoulder capsule Y A2 44.2257 $1,872.03

23480 Revision of collar bone Y A2 44.2257 $1,872.03

23485 Revision of collar bone Y A2 82.0766 $3,474.22

23490 Reinforce clavicle Y A2 82.0766 $3,474.22

23491 Reinforce shoulder bones Y A2 82.0766 $3,474.22

Date Printed: 3/14/2013 @ 8:00 PM Page 12 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

23500 Treat clavicle fracture Y A2 1.5056 $63.73

23505 Treat clavicle fracture Y A2 17.5202 $741.61

23515 Treat clavicle fracture Y A2 62.8575 $2,660.70

23520 Treat clavicle dislocation Y A2 4.6747 $197.88

23525 Treat clavicle dislocation Y A2 4.6747 $197.88

23530 Treat clavicle dislocation Y A2 46.3836 $1,963.37

23532 Treat clavicle dislocation Y A2 24.5925 $1,040.98

23540 Treat clavicle dislocation Y A2 1.5056 $63.73

23545 Treat clavicle dislocation Y A2 4.6747 $197.88

23550 Treat clavicle dislocation Y A2 46.3836 $1,963.37

23552 Treat clavicle dislocation Y A2 46.3836 $1,963.37

23570 Treat shoulder blade fx Y A2 1.5056 $63.73

23575 Treat shoulder blade fx Y A2 4.6747 $197.88

23585 Treat scapula fracture Y A2 62.8575 $2,660.70

23600 Treat humerus fracture Y P2 1.5056 $63.73

23605 Treat humerus fracture Y A2 17.5202 $741.61

23615 Treat humerus fracture Y A2 62.8575 $2,660.70

23616 Treat humerus fracture Y A2 62.8575 $2,660.70

23620 Treat humerus fracture Y P2 1.5056 $63.73

23625 Treat humerus fracture Y A2 17.5202 $741.61

23630 Treat humerus fracture Y A2 62.8575 $2,660.70

23650 Treat shoulder dislocation Y A2 1.5056 $63.73

23655 Treat shoulder dislocation Y A2 14.5437 $615.62

23660 Treat shoulder dislocation Y A2 46.3836 $1,963.37

23665 Treat dislocation/fracture Y A2 4.6747 $197.88

23670 Treat dislocation/fracture Y A2 62.8575 $2,660.70

23675 Treat dislocation/fracture Y A2 1.5056 $63.73

23680 Treat dislocation/fracture Y A2 46.3836 $1,963.37

23700 Fixation of shoulder Y A2 14.5437 $615.62

23800 Fusion of shoulder joint Y A2 82.0766 $3,474.22

23802 Fusion of shoulder joint Y A2 82.0766 $3,474.22

23921 Amputation follow-up surgery Y A2 16.1914 $685.37

23930 Drainage of arm lesion Y A2 19.2522 $814.93

23931 Drainage of arm bursa Y A2 19.2522 $814.93

23935 Drain arm/elbow bone lesion Y A2 20.7775 $879.49

24000 Exploratory elbow surgery Y A2 30.378 $1,285.87

24006 Release elbow joint Y A2 30.378 $1,285.87

24065 Biopsy arm/elbow soft tissue Y P3 $121.26

24066 Biopsy arm/elbow soft tissue Y A2 16.113 $682.05

24071 Exc arm/elbow les sc 3+ cm Y G2 21.9487 $929.07

24073 Ex arm/elbow tum deep > 5 cm Y G2 21.9487 $929.07

24075 Exc arm/elbow les sc < 3 cm Y CH G2 16.113 $682.05

24076 Ex arm/elbow tum deep < 5 cm Y G2 16.113 $682.05

24077 Resect arm/elbow tum < 5 cm Y G2 16.113 $682.05

24079 Resect arm/elbow tum > 5 cm Y G2 21.9487 $929.07

24100 Biopsy elbow joint lining Y A2 20.7775 $879.49

24101 Explore/treat elbow joint Y A2 30.378 $1,285.87

24102 Remove elbow joint lining Y A2 30.378 $1,285.87

24105 Removal of elbow bursa Y A2 20.7775 $879.49

24110 Remove humerus lesion Y A2 20.7775 $879.49

24115 Remove/graft bone lesion Y A2 30.378 $1,285.87

24116 Remove/graft bone lesion Y A2 30.378 $1,285.87

24120 Remove elbow lesion Y A2 20.7775 $879.49

24125 Remove/graft bone lesion Y A2 30.378 $1,285.87

24126 Remove/graft bone lesion Y A2 30.378 $1,285.87

24130 Removal of head of radius Y A2 30.378 $1,285.87

24134 Removal of arm bone lesion Y A2 30.378 $1,285.87

24136 Remove radius bone lesion Y A2 30.378 $1,285.87

Date Printed: 3/14/2013 @ 8:00 PM Page 13 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

24138 Remove elbow bone lesion Y A2 30.378 $1,285.87

24140 Partial removal of arm bone Y A2 30.378 $1,285.87

24145 Partial removal of radius Y A2 30.378 $1,285.87

24147 Partial removal of elbow Y A2 30.378 $1,285.87

24149 Radical resection of elbow Y G2 30.378 $1,285.87

24152 Resect radius tumor Y G2 44.2257 $1,872.03

24155 Removal of elbow joint Y A2 30.378 $1,285.87

24160 Remove elbow joint implant Y A2 30.378 $1,285.87

24164 Remove radius head implant Y A2 30.378 $1,285.87

24200 Removal of arm foreign body Y P3 $91.54

24201 Removal of arm foreign body Y A2 16.113 $682.05

24220 Injection for elbow x-ray N N1

24300 Manipulate elbow w/anesth Y G2 14.5437 $615.62

24301 Muscle/tendon transfer Y A2 30.378 $1,285.87

24305 Arm tendon lengthening Y A2 30.378 $1,285.87

24310 Revision of arm tendon Y A2 20.7775 $879.49

24320 Repair of arm tendon Y A2 30.378 $1,285.87

24330 Revision of arm muscles Y A2 82.0766 $3,474.22

24331 Revision of arm muscles Y A2 44.2257 $1,872.03

24332 Tenolysis triceps Y G2 30.378 $1,285.87

24340 Repair of biceps tendon Y A2 44.2257 $1,872.03

24341 Repair arm tendon/muscle Y A2 44.2257 $1,872.03

24342 Repair of ruptured tendon Y A2 44.2257 $1,872.03

24343 Repr elbow lat ligmnt w/tiss Y G2 30.378 $1,285.87

24344 Reconstruct elbow lat ligmnt Y G2 82.0766 $3,474.22

24345 Repr elbw med ligmnt w/tissu Y A2 30.378 $1,285.87

24346 Reconstruct elbow med ligmnt Y G2 82.0766 $3,474.22

24357 Repair elbow perc Y G2 30.378 $1,285.87

24358 Repair elbow w/deb open Y G2 30.378 $1,285.87

24359 Repair elbow deb/attch open Y G2 30.378 $1,285.87

24360 Reconstruct elbow joint Y A2 38.7078 $1,638.46

24361 Reconstruct elbow joint Y CH J8 177.1433 $7,498.30

24362 Reconstruct elbow joint Y A2 56.2694 $2,381.83

24363 Replace elbow joint Y CH J8 177.1433 $7,498.30

24365 Reconstruct head of radius Y A2 38.7078 $1,638.46

24366 Reconstruct head of radius Y CH J8 177.1433 $7,498.30

24400 Revision of humerus Y A2 82.0766 $3,474.22

24410 Revision of humerus Y A2 44.2257 $1,872.03

24420 Revision of humerus Y A2 44.2257 $1,872.03

24430 Repair of humerus Y A2 82.0766 $3,474.22

24435 Repair humerus with graft Y A2 82.0766 $3,474.22

24470 Revision of elbow joint Y A2 44.2257 $1,872.03

24495 Decompression of forearm Y A2 30.378 $1,285.87

24498 Reinforce humerus Y A2 82.0766 $3,474.22

24500 Treat humerus fracture Y A2 1.5056 $63.73

24505 Treat humerus fracture Y A2 1.5056 $63.73

24515 Treat humerus fracture Y A2 62.8575 $2,660.70

24516 Treat humerus fracture Y A2 62.8575 $2,660.70

24530 Treat humerus fracture Y A2 1.5056 $63.73

24535 Treat humerus fracture Y A2 4.6747 $197.88

24538 Treat humerus fracture Y A2 24.5925 $1,040.98

24545 Treat humerus fracture Y A2 62.8575 $2,660.70

24546 Treat humerus fracture Y A2 62.8575 $2,660.70

24560 Treat humerus fracture Y A2 1.5056 $63.73

24565 Treat humerus fracture Y A2 1.5056 $63.73

24566 Treat humerus fracture Y A2 24.5925 $1,040.98

24575 Treat humerus fracture Y A2 62.8575 $2,660.70

24576 Treat humerus fracture Y A2 1.5056 $63.73

Date Printed: 3/14/2013 @ 8:00 PM Page 14 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

24577 Treat humerus fracture Y A2 1.5056 $63.73

24579 Treat humerus fracture Y A2 62.8575 $2,660.70

24582 Treat humerus fracture Y A2 24.5925 $1,040.98

24586 Treat elbow fracture Y A2 62.8575 $2,660.70

24587 Treat elbow fracture Y A2 62.8575 $2,660.70

24600 Treat elbow dislocation Y A2 1.5056 $63.73

24605 Treat elbow dislocation Y A2 14.5437 $615.62

24615 Treat elbow dislocation Y A2 62.8575 $2,660.70

24620 Treat elbow fracture Y A2 17.5202 $741.61

24635 Treat elbow fracture Y A2 62.8575 $2,660.70

24640 Treat elbow dislocation Y CH P3 $58.23

24650 Treat radius fracture Y P2 1.5056 $63.73

24655 Treat radius fracture Y A2 4.6747 $197.88

24665 Treat radius fracture Y A2 46.3836 $1,963.37

24666 Treat radius fracture Y A2 62.8575 $2,660.70

24670 Treat ulnar fracture Y A2 1.5056 $63.73

24675 Treat ulnar fracture Y A2 1.5056 $63.73

24685 Treat ulnar fracture Y A2 46.3836 $1,963.37

24800 Fusion of elbow joint Y A2 44.2257 $1,872.03

24802 Fusion/graft of elbow joint Y A2 82.0766 $3,474.22

24925 Amputation follow-up surgery Y A2 20.7775 $879.49

25000 Incision of tendon sheath Y A2 20.7775 $879.49

25001 Incise flexor carpi radialis Y G2 20.7775 $879.49

25020 Decompress forearm 1 space Y A2 30.378 $1,285.87

25023 Decompress forearm 1 space Y A2 30.378 $1,285.87

25024 Decompress forearm 2 spaces Y A2 30.378 $1,285.87

25025 Decompress forearm 2 spaces Y A2 30.378 $1,285.87

25028 Drainage of forearm lesion Y A2 20.7775 $879.49

25031 Drainage of forearm bursa Y A2 20.7775 $879.49

25035 Treat forearm bone lesion Y A2 20.7775 $879.49

25040 Explore/treat wrist joint Y A2 30.378 $1,285.87

25065 Biopsy forearm soft tissues Y P3 $122.21

25066 Biopsy forearm soft tissues Y A2 21.9487 $929.07

25071 Exc forearm les sc > 3 cm Y G2 21.9487 $929.07

25073 Exc forearm tum deep 3+ cm Y G2 21.9487 $929.07

25075 Exc forearm les sc < 3 cm Y CH G2 16.113 $682.05

25076 Exc forearm tum deep < 3 cm Y G2 16.113 $682.05

25077 Resect forearm/wrist tum<3cm Y G2 16.113 $682.05

25078 Resect forearm/wrist tum3+cm Y G2 21.9487 $929.07

25085 Incision of wrist capsule Y A2 20.7775 $879.49

25100 Biopsy of wrist joint Y A2 20.7775 $879.49

25101 Explore/treat wrist joint Y A2 30.378 $1,285.87

25105 Remove wrist joint lining Y A2 30.378 $1,285.87

25107 Remove wrist joint cartilage Y A2 30.378 $1,285.87

25109 Excise tendon forearm/wrist Y G2 20.7775 $879.49

25110 Remove wrist tendon lesion Y A2 20.7775 $879.49

25111 Remove wrist tendon lesion Y A2 20.7775 $879.49

25112 Reremove wrist tendon lesion Y A2 20.7775 $879.49

25115 Remove wrist/forearm lesion Y A2 20.7775 $879.49

25116 Remove wrist/forearm lesion Y A2 20.7775 $879.49

25118 Excise wrist tendon sheath Y A2 30.378 $1,285.87

25119 Partial removal of ulna Y A2 30.378 $1,285.87

25120 Removal of forearm lesion Y A2 30.378 $1,285.87

25125 Remove/graft forearm lesion Y A2 30.378 $1,285.87

25126 Remove/graft forearm lesion Y A2 30.378 $1,285.87

25130 Removal of wrist lesion Y A2 30.378 $1,285.87

25135 Remove & graft wrist lesion Y A2 30.378 $1,285.87

25136 Remove & graft wrist lesion Y A2 30.378 $1,285.87

Date Printed: 3/14/2013 @ 8:00 PM Page 15 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

25145 Remove forearm bone lesion Y A2 30.378 $1,285.87

25150 Partial removal of ulna Y A2 30.378 $1,285.87

25151 Partial removal of radius Y A2 30.378 $1,285.87

25210 Removal of wrist bone Y A2 30.378 $1,285.87

25215 Removal of wrist bones Y A2 30.378 $1,285.87

25230 Partial removal of radius Y A2 30.378 $1,285.87

25240 Partial removal of ulna Y A2 30.378 $1,285.87

25246 Injection for wrist x-ray N N1

25248 Remove forearm foreign body Y A2 20.7775 $879.49

25250 Removal of wrist prosthesis Y A2 30.378 $1,285.87

25251 Removal of wrist prosthesis Y A2 30.378 $1,285.87

25259 Manipulate wrist w/anesthes Y G2 17.5202 $741.61

25260 Repair forearm tendon/muscle Y A2 30.378 $1,285.87

25263 Repair forearm tendon/muscle Y A2 30.378 $1,285.87

25265 Repair forearm tendon/muscle Y A2 30.378 $1,285.87

25270 Repair forearm tendon/muscle Y A2 30.378 $1,285.87

25272 Repair forearm tendon/muscle Y A2 30.378 $1,285.87

25274 Repair forearm tendon/muscle Y A2 30.378 $1,285.87

25275 Repair forearm tendon sheath Y A2 30.378 $1,285.87

25280 Revise wrist/forearm tendon Y A2 30.378 $1,285.87

25290 Incise wrist/forearm tendon Y A2 30.378 $1,285.87

25295 Release wrist/forearm tendon Y A2 20.7775 $879.49

25300 Fusion of tendons at wrist Y A2 30.378 $1,285.87

25301 Fusion of tendons at wrist Y A2 30.378 $1,285.87

25310 Transplant forearm tendon Y A2 30.378 $1,285.87

25312 Transplant forearm tendon Y A2 44.2257 $1,872.03

25315 Revise palsy hand tendon(s) Y A2 30.378 $1,285.87

25316 Revise palsy hand tendon(s) Y A2 82.0766 $3,474.22

25320 Repair/revise wrist joint Y A2 44.2257 $1,872.03

25332 Revise wrist joint Y A2 38.7078 $1,638.46

25335 Realignment of hand Y A2 44.2257 $1,872.03

25337 Reconstruct ulna/radioulnar Y A2 44.2257 $1,872.03

25350 Revision of radius Y A2 44.2257 $1,872.03

25355 Revision of radius Y A2 44.2257 $1,872.03

25360 Revision of ulna Y A2 44.2257 $1,872.03

25365 Revise radius & ulna Y A2 82.0766 $3,474.22

25370 Revise radius or ulna Y A2 44.2257 $1,872.03

25375 Revise radius & ulna Y A2 44.2257 $1,872.03

25390 Shorten radius or ulna Y A2 44.2257 $1,872.03

25391 Lengthen radius or ulna Y A2 82.0766 $3,474.22

25392 Shorten radius & ulna Y A2 30.378 $1,285.87

25393 Lengthen radius & ulna Y A2 44.2257 $1,872.03

25394 Repair carpal bone shorten Y G2 44.2257 $1,872.03

25400 Repair radius or ulna Y A2 82.0766 $3,474.22

25405 Repair/graft radius or ulna Y A2 82.0766 $3,474.22

25415 Repair radius & ulna Y A2 82.0766 $3,474.22

25420 Repair/graft radius & ulna Y A2 82.0766 $3,474.22

25425 Repair/graft radius or ulna Y A2 82.0766 $3,474.22

25426 Repair/graft radius & ulna Y A2 44.2257 $1,872.03

25430 Vasc graft into carpal bone Y G2 44.2257 $1,872.03

25431 Repair nonunion carpal bone Y G2 44.2257 $1,872.03

25440 Repair/graft wrist bone Y A2 82.0766 $3,474.22

25441 Reconstruct wrist joint Y CH J8 177.1433 $7,498.30

25442 Reconstruct wrist joint Y CH J8 177.1433 $7,498.30

25443 Reconstruct wrist joint Y A2 56.2694 $2,381.83

25444 Reconstruct wrist joint Y A2 56.2694 $2,381.83

25445 Reconstruct wrist joint Y A2 56.2694 $2,381.83

25446 Wrist replacement Y CH J8 177.1433 $7,498.30

Date Printed: 3/14/2013 @ 8:00 PM Page 16 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

25447 Repair wrist joint(s) Y A2 38.7078 $1,638.46

25449 Remove wrist joint implant Y A2 38.7078 $1,638.46

25450 Revision of wrist joint Y A2 44.2257 $1,872.03

25455 Revision of wrist joint Y A2 44.2257 $1,872.03

25490 Reinforce radius Y A2 44.2257 $1,872.03

25491 Reinforce ulna Y A2 44.2257 $1,872.03

25492 Reinforce radius and ulna Y A2 44.2257 $1,872.03

25500 Treat fracture of radius Y P2 1.5056 $63.73

25505 Treat fracture of radius Y A2 4.6747 $197.88

25515 Treat fracture of radius Y A2 46.3836 $1,963.37

25520 Treat fracture of radius Y A2 4.6747 $197.88

25525 Treat fracture of radius Y A2 46.3836 $1,963.37

25526 Treat fracture of radius Y A2 46.3836 $1,963.37

25530 Treat fracture of ulna Y P2 1.5056 $63.73

25535 Treat fracture of ulna Y A2 1.5056 $63.73

25545 Treat fracture of ulna Y A2 46.3836 $1,963.37

25560 Treat fracture radius & ulna Y P2 1.5056 $63.73

25565 Treat fracture radius & ulna Y A2 4.6747 $197.88

25574 Treat fracture radius & ulna Y A2 62.8575 $2,660.70

25575 Treat fracture radius/ulna Y A2 62.8575 $2,660.70

25600 Treat fracture radius/ulna Y P2 1.5056 $63.73

25605 Treat fracture radius/ulna Y A2 4.6747 $197.88

25606 Treat fx distal radial Y A2 24.5925 $1,040.98

25607 Treat fx rad extra-articul Y A2 62.8575 $2,660.70

25608 Treat fx rad intra-articul Y A2 62.8575 $2,660.70

25609 Treat fx radial 3+ frag Y A2 62.8575 $2,660.70

25622 Treat wrist bone fracture Y P2 1.5056 $63.73

25624 Treat wrist bone fracture Y A2 4.6747 $197.88

25628 Treat wrist bone fracture Y A2 46.3836 $1,963.37

25630 Treat wrist bone fracture Y P2 1.5056 $63.73

25635 Treat wrist bone fracture Y A2 1.5056 $63.73

25645 Treat wrist bone fracture Y A2 46.3836 $1,963.37

25650 Treat wrist bone fracture Y P2 1.5056 $63.73

25651 Pin ulnar styloid fracture Y G2 24.5925 $1,040.98

25652 Treat fracture ulnar styloid Y G2 46.3836 $1,963.37

25660 Treat wrist dislocation Y A2 1.5056 $63.73

25670 Treat wrist dislocation Y A2 24.5925 $1,040.98

25671 Pin radioulnar dislocation Y A2 24.5925 $1,040.98

25675 Treat wrist dislocation Y A2 1.5056 $63.73

25676 Treat wrist dislocation Y A2 24.5925 $1,040.98

25680 Treat wrist fracture Y A2 1.5056 $63.73

25685 Treat wrist fracture Y A2 24.5925 $1,040.98

25690 Treat wrist dislocation Y A2 17.5202 $741.61

25695 Treat wrist dislocation Y A2 24.5925 $1,040.98

25800 Fusion of wrist joint Y A2 82.0766 $3,474.22

25805 Fusion/graft of wrist joint Y A2 82.0766 $3,474.22

25810 Fusion/graft of wrist joint Y A2 82.0766 $3,474.22

25820 Fusion of hand bones Y A2 44.2257 $1,872.03

25825 Fuse hand bones with graft Y A2 82.0766 $3,474.22

25830 Fusion radioulnar jnt/ulna Y A2 82.0766 $3,474.22

25907 Amputation follow-up surgery Y A2 20.7775 $879.49

25922 Amputate hand at wrist Y A2 20.7775 $879.49

25929 Amputation follow-up surgery Y A2 16.1914 $685.37

25931 Amputation follow-up surgery Y G2 20.7775 $879.49

26010 Drainage of finger abscess Y P2 1.3573 $57.45

26011 Drainage of finger abscess Y A2 12.6328 $534.73

26020 Drain hand tendon sheath Y A2 16.318 $690.72

26025 Drainage of palm bursa Y A2 16.318 $690.72

Date Printed: 3/14/2013 @ 8:00 PM Page 17 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

26030 Drainage of palm bursa(s) Y A2 16.318 $690.72

26034 Treat hand bone lesion Y A2 16.318 $690.72

26035 Decompress fingers/hand Y G2 16.318 $690.72

26037 Decompress fingers/hand Y G2 16.318 $690.72

26040 Release palm contracture Y A2 16.318 $690.72

26045 Release palm contracture Y A2 27.1987 $1,151.29

26055 Incise finger tendon sheath Y A2 16.318 $690.72

26060 Incision of finger tendon Y A2 16.318 $690.72

26070 Explore/treat hand joint Y A2 16.318 $690.72

26075 Explore/treat finger joint Y A2 16.318 $690.72

26080 Explore/treat finger joint Y A2 16.318 $690.72

26100 Biopsy hand joint lining Y A2 16.318 $690.72

26105 Biopsy finger joint lining Y A2 16.318 $690.72

26110 Biopsy finger joint lining Y A2 16.318 $690.72

26111 Exc hand les sc > 1.5 cm Y G2 21.9487 $929.07

26113 Exc hand tum deep > 1.5 cm Y G2 21.9487 $929.07

26115 Exc hand les sc < 1.5 cm Y CH G2 16.113 $682.05

26116 Exc hand tum deep < 1.5 cm Y G2 16.113 $682.05

26117 Exc hand tum ra < 3 cm Y G2 16.113 $682.05

26118 Exc hand tum ra > 3 cm Y G2 21.9487 $929.07

26121 Release palm contracture Y A2 27.1987 $1,151.29

26123 Release palm contracture Y A2 27.1987 $1,151.29

26125 Release palm contracture Y A2 16.318 $690.72

26130 Remove wrist joint lining Y A2 16.318 $690.72

26135 Revise finger joint each Y A2 27.1987 $1,151.29

26140 Revise finger joint each Y A2 16.318 $690.72

26145 Tendon excision palm/finger Y A2 16.318 $690.72

26160 Remove tendon sheath lesion Y A2 16.318 $690.72

26170 Removal of palm tendon each Y A2 16.318 $690.72

26180 Removal of finger tendon Y A2 16.318 $690.72

26185 Remove finger bone Y A2 16.318 $690.72

26200 Remove hand bone lesion Y A2 16.318 $690.72

26205 Remove/graft bone lesion Y A2 27.1987 $1,151.29

26210 Removal of finger lesion Y A2 16.318 $690.72

26215 Remove/graft finger lesion Y A2 16.318 $690.72

26230 Partial removal of hand bone Y A2 16.318 $690.72

26235 Partial removal finger bone Y A2 16.318 $690.72

26236 Partial removal finger bone Y A2 16.318 $690.72

26250 Extensive hand surgery Y A2 16.318 $690.72

26260 Resect prox finger tumor Y A2 16.318 $690.72

26262 Resect distal finger tumor Y A2 16.318 $690.72

26320 Removal of implant from hand Y A2 16.113 $682.05

26340 Manipulate finger w/anesth Y G2 4.6747 $197.88

26350 Repair finger/hand tendon Y A2 27.1987 $1,151.29

26352 Repair/graft hand tendon Y A2 27.1987 $1,151.29

26356 Repair finger/hand tendon Y A2 27.1987 $1,151.29

26357 Repair finger/hand tendon Y A2 27.1987 $1,151.29

26358 Repair/graft hand tendon Y A2 27.1987 $1,151.29

26370 Repair finger/hand tendon Y A2 27.1987 $1,151.29

26372 Repair/graft hand tendon Y A2 27.1987 $1,151.29

26373 Repair finger/hand tendon Y A2 27.1987 $1,151.29

26390 Revise hand/finger tendon Y A2 27.1987 $1,151.29

26392 Repair/graft hand tendon Y A2 27.1987 $1,151.29

26410 Repair hand tendon Y A2 16.318 $690.72

26412 Repair/graft hand tendon Y A2 27.1987 $1,151.29

26415 Excision hand/finger tendon Y A2 27.1987 $1,151.29

26416 Graft hand or finger tendon Y A2 27.1987 $1,151.29

26418 Repair finger tendon Y A2 16.318 $690.72

Date Printed: 3/14/2013 @ 8:00 PM Page 18 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

26420 Repair/graft finger tendon Y A2 27.1987 $1,151.29

26426 Repair finger/hand tendon Y A2 27.1987 $1,151.29

26428 Repair/graft finger tendon Y A2 27.1987 $1,151.29

26432 Repair finger tendon Y A2 16.318 $690.72

26433 Repair finger tendon Y A2 16.318 $690.72

26434 Repair/graft finger tendon Y A2 27.1987 $1,151.29

26437 Realignment of tendons Y A2 16.318 $690.72

26440 Release palm/finger tendon Y A2 16.318 $690.72

26442 Release palm & finger tendon Y A2 27.1987 $1,151.29

26445 Release hand/finger tendon Y A2 16.318 $690.72

26449 Release forearm/hand tendon Y A2 27.1987 $1,151.29

26450 Incision of palm tendon Y A2 16.318 $690.72

26455 Incision of finger tendon Y A2 16.318 $690.72

26460 Incise hand/finger tendon Y A2 16.318 $690.72

26471 Fusion of finger tendons Y A2 16.318 $690.72

26474 Fusion of finger tendons Y A2 16.318 $690.72

26476 Tendon lengthening Y A2 16.318 $690.72

26477 Tendon shortening Y A2 16.318 $690.72

26478 Lengthening of hand tendon Y A2 16.318 $690.72

26479 Shortening of hand tendon Y A2 16.318 $690.72

26480 Transplant hand tendon Y A2 27.1987 $1,151.29

26483 Transplant/graft hand tendon Y A2 27.1987 $1,151.29

26485 Transplant palm tendon Y A2 27.1987 $1,151.29

26489 Transplant/graft palm tendon Y A2 27.1987 $1,151.29

26490 Revise thumb tendon Y A2 27.1987 $1,151.29

26492 Tendon transfer with graft Y A2 27.1987 $1,151.29

26494 Hand tendon/muscle transfer Y A2 27.1987 $1,151.29

26496 Revise thumb tendon Y A2 27.1987 $1,151.29

26497 Finger tendon transfer Y A2 27.1987 $1,151.29

26498 Finger tendon transfer Y A2 27.1987 $1,151.29

26499 Revision of finger Y A2 27.1987 $1,151.29

26500 Hand tendon reconstruction Y A2 16.318 $690.72

26502 Hand tendon reconstruction Y A2 27.1987 $1,151.29

26508 Release thumb contracture Y A2 16.318 $690.72

26510 Thumb tendon transfer Y A2 27.1987 $1,151.29

26516 Fusion of knuckle joint Y A2 27.1987 $1,151.29

26517 Fusion of knuckle joints Y A2 27.1987 $1,151.29

26518 Fusion of knuckle joints Y A2 27.1987 $1,151.29

26520 Release knuckle contracture Y A2 16.318 $690.72

26525 Release finger contracture Y A2 16.318 $690.72

26530 Revise knuckle joint Y A2 38.7078 $1,638.46

26531 Revise knuckle with implant Y A2 56.2694 $2,381.83

26535 Revise finger joint Y A2 38.7078 $1,638.46

26536 Revise/implant finger joint Y A2 56.2694 $2,381.83

26540 Repair hand joint Y A2 16.318 $690.72

26541 Repair hand joint with graft Y A2 27.1987 $1,151.29

26542 Repair hand joint with graft Y A2 16.318 $690.72

26545 Reconstruct finger joint Y A2 27.1987 $1,151.29

26546 Repair nonunion hand Y A2 27.1987 $1,151.29

26548 Reconstruct finger joint Y A2 27.1987 $1,151.29

26550 Construct thumb replacement Y A2 27.1987 $1,151.29

26555 Positional change of finger Y A2 27.1987 $1,151.29

26560 Repair of web finger Y A2 16.318 $690.72

26561 Repair of web finger Y A2 27.1987 $1,151.29

26562 Repair of web finger Y A2 27.1987 $1,151.29

26565 Correct metacarpal flaw Y A2 27.1987 $1,151.29

26567 Correct finger deformity Y A2 27.1987 $1,151.29

26568 Lengthen metacarpal/finger Y A2 27.1987 $1,151.29

Date Printed: 3/14/2013 @ 8:00 PM Page 19 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

26580 Repair hand deformity Y A2 16.318 $690.72

26587 Reconstruct extra finger Y A2 16.318 $690.72

26590 Repair finger deformity Y A2 16.318 $690.72

26591 Repair muscles of hand Y A2 27.1987 $1,151.29

26593 Release muscles of hand Y A2 16.318 $690.72

26596 Excision constricting tissue Y A2 16.318 $690.72

26600 Treat metacarpal fracture Y P2 1.5056 $63.73

26605 Treat metacarpal fracture Y A2 1.5056 $63.73

26607 Treat metacarpal fracture Y A2 17.5202 $741.61

26608 Treat metacarpal fracture Y A2 24.5925 $1,040.98

26615 Treat metacarpal fracture Y A2 46.3836 $1,963.37

26641 Treat thumb dislocation Y P2 1.5056 $63.73

26645 Treat thumb fracture Y A2 4.6747 $197.88

26650 Treat thumb fracture Y A2 24.5925 $1,040.98

26665 Treat thumb fracture Y A2 46.3836 $1,963.37

26670 Treat hand dislocation Y P2 1.5056 $63.73

26675 Treat hand dislocation Y A2 1.5056 $63.73

26676 Pin hand dislocation Y A2 24.5925 $1,040.98

26685 Treat hand dislocation Y A2 24.5925 $1,040.98

26686 Treat hand dislocation Y A2 62.8575 $2,660.70

26700 Treat knuckle dislocation Y P2 1.5056 $63.73

26705 Treat knuckle dislocation Y A2 1.5056 $63.73

26706 Pin knuckle dislocation Y A2 17.5202 $741.61

26715 Treat knuckle dislocation Y A2 24.5925 $1,040.98

26720 Treat finger fracture each Y P2 1.5056 $63.73

26725 Treat finger fracture each Y P2 1.5056 $63.73

26727 Treat finger fracture each Y A2 24.5925 $1,040.98

26735 Treat finger fracture each Y A2 24.5925 $1,040.98

26740 Treat finger fracture each Y P2 1.5056 $63.73

26742 Treat finger fracture each Y A2 1.5056 $63.73

26746 Treat finger fracture each Y A2 24.5925 $1,040.98

26750 Treat finger fracture each Y P2 1.5056 $63.73

26755 Treat finger fracture each Y G2 1.5056 $63.73

26756 Pin finger fracture each Y A2 24.5925 $1,040.98

26765 Treat finger fracture each Y A2 24.5925 $1,040.98

26770 Treat finger dislocation Y G2 1.5056 $63.73

26775 Treat finger dislocation Y P3 $156.24

26776 Pin finger dislocation Y A2 24.5925 $1,040.98

26785 Treat finger dislocation Y A2 24.5925 $1,040.98

26820 Thumb fusion with graft Y A2 27.1987 $1,151.29

26841 Fusion of thumb Y A2 27.1987 $1,151.29

26842 Thumb fusion with graft Y A2 27.1987 $1,151.29

26843 Fusion of hand joint Y A2 27.1987 $1,151.29

26844 Fusion/graft of hand joint Y A2 27.1987 $1,151.29

26850 Fusion of knuckle Y A2 27.1987 $1,151.29

26852 Fusion of knuckle with graft Y A2 27.1987 $1,151.29

26860 Fusion of finger joint Y A2 27.1987 $1,151.29

26861 Fusion of finger jnt add-on Y A2 27.1987 $1,151.29

26862 Fusion/graft of finger joint Y A2 27.1987 $1,151.29

26863 Fuse/graft added joint Y A2 27.1987 $1,151.29

26910 Amputate metacarpal bone Y A2 27.1987 $1,151.29

26951 Amputation of finger/thumb Y A2 16.318 $690.72

26952 Amputation of finger/thumb Y A2 16.318 $690.72

26990 Drainage of pelvis lesion Y A2 20.7775 $879.49

26991 Drainage of pelvis bursa Y A2 20.7775 $879.49

27000 Incision of hip tendon Y A2 20.7775 $879.49

27001 Incision of hip tendon Y A2 30.378 $1,285.87

27003 Incision of hip tendon Y A2 30.378 $1,285.87

Date Printed: 3/14/2013 @ 8:00 PM Page 20 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

27033 Exploration of hip joint Y A2 44.2257 $1,872.03

27035 Denervation of hip joint Y A2 30.378 $1,285.87

27040 Biopsy of soft tissues Y A2 8.0762 $341.86

27041 Biopsy of soft tissues Y A2 8.0762 $341.86

27043 Exc hip pelvis les sc > 3 cm Y G2 21.9487 $929.07

27045 Exc hip/pelv tum deep > 5 cm Y G2 21.9487 $929.07

27047 Exc hip/pelvis les sc < 3 cm Y CH G2 16.113 $682.05

27048 Exc hip/pelv tum deep < 5 cm Y G2 16.113 $682.05

27049 Resect hip/pelv tum < 5 cm Y G2 16.113 $682.05

27050 Biopsy of sacroiliac joint Y A2 20.7775 $879.49

27052 Biopsy of hip joint Y A2 20.7775 $879.49

27059 Resect hip/pelv tum > 5 cm Y G2 21.9487 $929.07

27060 Removal of ischial bursa Y A2 20.7775 $879.49

27062 Remove femur lesion/bursa Y A2 20.7775 $879.49

27065 Remove hip bone les super Y A2 20.7775 $879.49

27066 Remove hip bone les deep Y A2 30.378 $1,285.87

27067 Remove/graft hip bone lesion Y A2 30.378 $1,285.87

27080 Removal of tail bone Y A2 30.378 $1,285.87

27086 Remove hip foreign body Y A2 8.0762 $341.86

27087 Remove hip foreign body Y A2 20.7775 $879.49

27093 Injection for hip x-ray N N1

27095 Injection for hip x-ray N N1

27097 Revision of hip tendon Y A2 30.378 $1,285.87

27098 Transfer tendon to pelvis Y A2 30.378 $1,285.87

27100 Transfer of abdominal muscle Y A2 44.2257 $1,872.03

27105 Transfer of spinal muscle Y A2 44.2257 $1,872.03

27110 Transfer of iliopsoas muscle Y A2 44.2257 $1,872.03

27111 Transfer of iliopsoas muscle Y A2 44.2257 $1,872.03

27193 Treat pelvic ring fracture Y A2 1.5056 $63.73

27194 Treat pelvic ring fracture Y A2 14.5437 $615.62

27200 Treat tail bone fracture Y P2 1.5056 $63.73

27202 Treat tail bone fracture Y A2 46.3836 $1,963.37

27220 Treat hip socket fracture Y G2 1.5056 $63.73

27230 Treat thigh fracture Y A2 1.5056 $63.73

27238 Treat thigh fracture Y A2 4.6747 $197.88

27246 Treat thigh fracture Y A2 4.6747 $197.88

27250 Treat hip dislocation Y A2 1.5056 $63.73

27252 Treat hip dislocation Y A2 14.5437 $615.62

27256 Treat hip dislocation Y G2 1.5056 $63.73

27257 Treat hip dislocation Y A2 14.5437 $615.62

27265 Treat hip dislocation Y A2 1.5056 $63.73

27266 Treat hip dislocation Y A2 14.5437 $615.62

27267 Cltx thigh fx Y G2 1.5056 $63.73

27275 Manipulation of hip joint Y A2 14.5437 $615.62

27301 Drain thigh/knee lesion Y A2 19.2522 $814.93

27305 Incise thigh tendon & fascia Y A2 20.7775 $879.49

27306 Incision of thigh tendon Y A2 20.7775 $879.49

27307 Incision of thigh tendons Y A2 30.378 $1,285.87

27310 Exploration of knee joint Y A2 30.378 $1,285.87

27323 Biopsy thigh soft tissues Y A2 8.0762 $341.86

27324 Biopsy thigh soft tissues Y A2 21.9487 $929.07

27325 Neurectomy hamstring Y A2 17.8674 $756.31

27326 Neurectomy popliteal Y A2 17.8674 $756.31

27327 Exc thigh/knee les sc < 3 cm Y CH G2 21.9487 $929.07

27328 Exc thigh/knee tum deep <5cm Y G2 16.113 $682.05

27329 Resect thigh/knee tum < 5 cm Y G2 16.113 $682.05

27330 Biopsy knee joint lining Y A2 30.378 $1,285.87

27331 Explore/treat knee joint Y A2 30.378 $1,285.87

Date Printed: 3/14/2013 @ 8:00 PM Page 21 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

27332 Removal of knee cartilage Y A2 30.378 $1,285.87

27333 Removal of knee cartilage Y A2 30.378 $1,285.87

27334 Remove knee joint lining Y A2 30.378 $1,285.87

27335 Remove knee joint lining Y A2 30.378 $1,285.87

27337 Exc thigh/knee les sc 3+ cm Y G2 21.9487 $929.07

27339 Exc thigh/knee tum deep 5+cm Y G2 21.9487 $929.07

27340 Removal of kneecap bursa Y A2 20.7775 $879.49

27345 Removal of knee cyst Y A2 20.7775 $879.49

27347 Remove knee cyst Y A2 20.7775 $879.49

27350 Removal of kneecap Y A2 30.378 $1,285.87

27355 Remove femur lesion Y A2 30.378 $1,285.87

27356 Remove femur lesion/graft Y A2 30.378 $1,285.87

27357 Remove femur lesion/graft Y A2 30.378 $1,285.87

27358 Remove femur lesion/fixation Y A2 30.378 $1,285.87

27360 Partial removal leg bone(s) Y A2 30.378 $1,285.87

27364 Resect thigh/knee tum 5+ cm Y G2 21.9487 $929.07

27370 Injection for knee x-ray N N1

27372 Removal of foreign body Y A2 21.9487 $929.07

27380 Repair of kneecap tendon Y A2 30.378 $1,285.87

27381 Repair/graft kneecap tendon Y A2 30.378 $1,285.87

27385 Repair of thigh muscle Y A2 30.378 $1,285.87

27386 Repair/graft of thigh muscle Y A2 30.378 $1,285.87

27390 Incision of thigh tendon Y A2 20.7775 $879.49

27391 Incision of thigh tendons Y A2 20.7775 $879.49

27392 Incision of thigh tendons Y A2 30.378 $1,285.87

27393 Lengthening of thigh tendon Y A2 30.378 $1,285.87

27394 Lengthening of thigh tendons Y A2 30.378 $1,285.87

27395 Lengthening of thigh tendons Y A2 44.2257 $1,872.03

27396 Transplant of thigh tendon Y A2 30.378 $1,285.87

27397 Transplants of thigh tendons Y A2 44.2257 $1,872.03

27400 Revise thigh muscles/tendons Y A2 44.2257 $1,872.03

27403 Repair of knee cartilage Y A2 30.378 $1,285.87

27405 Repair of knee ligament Y A2 44.2257 $1,872.03

27407 Repair of knee ligament Y A2 82.0766 $3,474.22

27409 Repair of knee ligaments Y A2 82.0766 $3,474.22

27416 Osteochondral knee autograft Y G2 44.2257 $1,872.03

27418 Repair degenerated kneecap Y A2 44.2257 $1,872.03

27420 Revision of unstable kneecap Y A2 44.2257 $1,872.03

27422 Revision of unstable kneecap Y A2 44.2257 $1,872.03

27424 Revision/removal of kneecap Y A2 44.2257 $1,872.03

27425 Lat retinacular release open Y A2 30.378 $1,285.87

27427 Reconstruction knee Y A2 82.0766 $3,474.22

27428 Reconstruction knee Y A2 82.0766 $3,474.22

27429 Reconstruction knee Y A2 82.0766 $3,474.22

27430 Revision of thigh muscles Y A2 44.2257 $1,872.03

27435 Incision of knee joint Y A2 30.378 $1,285.87

27437 Revise kneecap Y A2 38.7078 $1,638.46

27438 Revise kneecap with implant Y A2 56.2694 $2,381.83

27440 Revision of knee joint Y G2 38.7078 $1,638.46

27441 Revision of knee joint Y A2 38.7078 $1,638.46

27442 Revision of knee joint Y A2 38.7078 $1,638.46

27443 Revision of knee joint Y A2 38.7078 $1,638.46

27446 Revision of knee joint Y J8 177.1433 $7,498.30

27475 Surgery to stop leg growth Y G2 30.378 $1,285.87

27479 Surgery to stop leg growth Y G2 30.378 $1,285.87

27496 Decompression of thigh/knee Y A2 30.378 $1,285.87

27497 Decompression of thigh/knee Y A2 20.7775 $879.49

27498 Decompression of thigh/knee Y A2 30.378 $1,285.87

Date Printed: 3/14/2013 @ 8:00 PM Page 22 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

27499 Decompression of thigh/knee Y A2 30.378 $1,285.87

27500 Treatment of thigh fracture Y A2 4.6747 $197.88

27501 Treatment of thigh fracture Y A2 1.5056 $63.73

27502 Treatment of thigh fracture Y A2 17.5202 $741.61

27503 Treatment of thigh fracture Y A2 1.5056 $63.73

27508 Treatment of thigh fracture Y A2 1.5056 $63.73

27509 Treatment of thigh fracture Y A2 24.5925 $1,040.98

27510 Treatment of thigh fracture Y A2 4.6747 $197.88

27516 Treat thigh fx growth plate Y A2 1.5056 $63.73

27517 Treat thigh fx growth plate Y A2 1.5056 $63.73

27520 Treat kneecap fracture Y A2 1.5056 $63.73

27530 Treat knee fracture Y A2 1.5056 $63.73

27532 Treat knee fracture Y A2 17.5202 $741.61

27538 Treat knee fracture(s) Y A2 1.5056 $63.73

27550 Treat knee dislocation Y A2 1.5056 $63.73

27552 Treat knee dislocation Y A2 14.5437 $615.62

27560 Treat kneecap dislocation Y A2 1.5056 $63.73

27562 Treat kneecap dislocation Y A2 14.5437 $615.62

27566 Treat kneecap dislocation Y A2 46.3836 $1,963.37

27570 Fixation of knee joint Y A2 14.5437 $615.62

27594 Amputation follow-up surgery Y A2 20.7775 $879.49

27600 Decompression of lower leg Y A2 20.7775 $879.49

27601 Decompression of lower leg Y A2 20.7775 $879.49

27602 Decompression of lower leg Y A2 30.378 $1,285.87

27603 Drain lower leg lesion Y A2 19.2522 $814.93

27604 Drain lower leg bursa Y A2 30.378 $1,285.87

27605 Incision of achilles tendon Y A2 20.7836 $879.75

27606 Incision of achilles tendon Y A2 20.7775 $879.49

27607 Treat lower leg bone lesion Y A2 20.7775 $879.49

27610 Explore/treat ankle joint Y A2 30.378 $1,285.87

27612 Exploration of ankle joint Y A2 30.378 $1,285.87

27613 Biopsy lower leg soft tissue Y P3 $117.90

27614 Biopsy lower leg soft tissue Y A2 21.9487 $929.07

27615 Resect leg/ankle tum < 5 cm Y G2 16.113 $682.05

27616 Resect leg/ankle tum 5+ cm Y G2 21.9487 $929.07

27618 Exc leg/ankle tum < 3 cm Y CH G2 16.113 $682.05

27619 Exc leg/ankle tum deep <5 cm Y G2 16.113 $682.05

27620 Explore/treat ankle joint Y A2 30.378 $1,285.87

27625 Remove ankle joint lining Y A2 30.378 $1,285.87

27626 Remove ankle joint lining Y A2 30.378 $1,285.87

27630 Removal of tendon lesion Y A2 20.7775 $879.49

27632 Exc leg/ankle les sc 3+ cm Y G2 21.9487 $929.07

27634 Exc leg/ankle tum deep 5+ cm Y G2 21.9487 $929.07

27635 Remove lower leg bone lesion Y A2 30.378 $1,285.87

27637 Remove/graft leg bone lesion Y A2 30.378 $1,285.87

27638 Remove/graft leg bone lesion Y A2 30.378 $1,285.87

27640 Partial removal of tibia Y A2 30.378 $1,285.87

27641 Partial removal of fibula Y A2 30.378 $1,285.87

27647 Resect talus/calcaneus tum Y A2 30.378 $1,285.87

27648 Injection for ankle x-ray N N1

27650 Repair achilles tendon Y A2 44.2257 $1,872.03

27652 Repair/graft achilles tendon Y A2 82.0766 $3,474.22

27654 Repair of achilles tendon Y A2 44.2257 $1,872.03

27656 Repair leg fascia defect Y A2 20.7775 $879.49

27658 Repair of leg tendon each Y A2 20.7775 $879.49

27659 Repair of leg tendon each Y A2 20.7775 $879.49

27664 Repair of leg tendon each Y A2 30.378 $1,285.87

27665 Repair of leg tendon each Y A2 30.378 $1,285.87

Date Printed: 3/14/2013 @ 8:00 PM Page 23 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

27675 Repair lower leg tendons Y A2 20.7775 $879.49

27676 Repair lower leg tendons Y A2 30.378 $1,285.87

27680 Release of lower leg tendon Y A2 30.378 $1,285.87

27681 Release of lower leg tendons Y A2 30.378 $1,285.87

27685 Revision of lower leg tendon Y A2 30.378 $1,285.87

27686 Revise lower leg tendons Y A2 30.378 $1,285.87

27687 Revision of calf tendon Y A2 30.378 $1,285.87

27690 Revise lower leg tendon Y A2 44.2257 $1,872.03

27691 Revise lower leg tendon Y A2 44.2257 $1,872.03

27692 Revise additional leg tendon Y A2 44.2257 $1,872.03

27695 Repair of ankle ligament Y A2 30.378 $1,285.87

27696 Repair of ankle ligaments Y A2 30.378 $1,285.87

27698 Repair of ankle ligament Y A2 30.378 $1,285.87

27700 Revision of ankle joint Y A2 38.7078 $1,638.46

27704 Removal of ankle implant Y A2 20.7775 $879.49

27705 Incision of tibia Y A2 44.2257 $1,872.03

27707 Incision of fibula Y A2 30.378 $1,285.87

27709 Incision of tibia & fibula Y A2 30.378 $1,285.87

27720 Repair of tibia Y G2 46.3836 $1,963.37

27726 Repair fibula nonunion Y G2 46.3836 $1,963.37

27730 Repair of tibia epiphysis Y A2 30.378 $1,285.87

27732 Repair of fibula epiphysis Y A2 30.378 $1,285.87

27734 Repair lower leg epiphyses Y A2 30.378 $1,285.87

27740 Repair of leg epiphyses Y A2 30.378 $1,285.87

27742 Repair of leg epiphyses Y A2 44.2257 $1,872.03

27745 Reinforce tibia Y A2 82.0766 $3,474.22

27750 Treatment of tibia fracture Y A2 1.5056 $63.73

27752 Treatment of tibia fracture Y A2 17.5202 $741.61

27756 Treatment of tibia fracture Y A2 24.5925 $1,040.98

27758 Treatment of tibia fracture Y A2 46.3836 $1,963.37

27759 Treatment of tibia fracture Y A2 62.8575 $2,660.70

27760 Cltx medial ankle fx Y A2 1.5056 $63.73

27762 Cltx med ankle fx w/mnpj Y A2 17.5202 $741.61

27766 Optx medial ankle fx Y A2 46.3836 $1,963.37

27767 Cltx post ankle fx Y P2 1.5056 $63.73

27768 Cltx post ankle fx w/mnpj Y G2 1.5056 $63.73

27769 Optx post ankle fx Y G2 46.3836 $1,963.37

27780 Treatment of fibula fracture Y A2 1.5056 $63.73

27781 Treatment of fibula fracture Y A2 17.5202 $741.61

27784 Treatment of fibula fracture Y A2 46.3836 $1,963.37

27786 Treatment of ankle fracture Y A2 1.5056 $63.73

27788 Treatment of ankle fracture Y A2 1.5056 $63.73

27792 Treatment of ankle fracture Y A2 46.3836 $1,963.37

27808 Treatment of ankle fracture Y A2 1.5056 $63.73

27810 Treatment of ankle fracture Y A2 1.5056 $63.73

27814 Treatment of ankle fracture Y A2 46.3836 $1,963.37

27816 Treatment of ankle fracture Y A2 1.5056 $63.73

27818 Treatment of ankle fracture Y A2 4.6747 $197.88

27822 Treatment of ankle fracture Y A2 46.3836 $1,963.37

27823 Treatment of ankle fracture Y A2 62.8575 $2,660.70

27824 Treat lower leg fracture Y A2 1.5056 $63.73

27825 Treat lower leg fracture Y A2 17.5202 $741.61

27826 Treat lower leg fracture Y A2 46.3836 $1,963.37

27827 Treat lower leg fracture Y A2 62.8575 $2,660.70

27828 Treat lower leg fracture Y A2 62.8575 $2,660.70

27829 Treat lower leg joint Y A2 46.3836 $1,963.37

27830 Treat lower leg dislocation Y A2 1.5056 $63.73

27831 Treat lower leg dislocation Y A2 17.5202 $741.61

Date Printed: 3/14/2013 @ 8:00 PM Page 24 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

27832 Treat lower leg dislocation Y A2 46.3836 $1,963.37

27840 Treat ankle dislocation Y A2 1.5056 $63.73

27842 Treat ankle dislocation Y A2 14.5437 $615.62

27846 Treat ankle dislocation Y A2 46.3836 $1,963.37

27848 Treat ankle dislocation Y A2 46.3836 $1,963.37

27860 Fixation of ankle joint Y A2 14.5437 $615.62

27870 Fusion of ankle joint open Y A2 82.0766 $3,474.22

27871 Fusion of tibiofibular joint Y A2 82.0766 $3,474.22

27884 Amputation follow-up surgery Y A2 20.7775 $879.49

27889 Amputation of foot at ankle Y A2 30.378 $1,285.87

27892 Decompression of leg Y A2 30.378 $1,285.87

27893 Decompression of leg Y A2 30.378 $1,285.87

27894 Decompression of leg Y A2 30.378 $1,285.87

28001 Drainage of bursa of foot Y P3 $118.14

28002 Treatment of foot infection Y A2 20.7775 $879.49

28003 Treatment of foot infection Y A2 20.7775 $879.49

28005 Treat foot bone lesion Y A2 20.7836 $879.75

28008 Incision of foot fascia Y A2 20.7836 $879.75

28010 Incision of toe tendon Y P3 $85.07

28011 Incision of toe tendons Y A2 20.7836 $879.75

28020 Exploration of foot joint Y A2 20.7836 $879.75

28022 Exploration of foot joint Y A2 20.7836 $879.75

28024 Exploration of toe joint Y A2 20.7836 $879.75

28035 Decompression of tibia nerve Y A2 17.8674 $756.31

28039 Exc foot/toe tum sc > 1.5 cm Y CH G2 21.9487 $929.07

28041 Exc foot/toe tum deep 1.5cm+ Y CH G2 21.9487 $929.07

28043 Exc foot/toe tum sc < 1.5 cm Y CH G2 16.113 $682.05

28045 Exc foot/toe tum deep <1.5cm Y CH G2 16.113 $682.05

28046 Resect foot/toe tumor < 3 cm Y CH G2 16.113 $682.05

28047 Resect foot/toe tumor > 3 cm Y G2 21.9487 $929.07

28050 Biopsy of foot joint lining Y A2 20.7836 $879.75

28052 Biopsy of foot joint lining Y A2 20.7836 $879.75

28054 Biopsy of toe joint lining Y A2 20.7836 $879.75

28055 Neurectomy foot Y A2 17.8674 $756.31

28060 Partial removal foot fascia Y A2 20.7836 $879.75

28062 Removal of foot fascia Y A2 20.7836 $879.75

28070 Removal of foot joint lining Y A2 20.7836 $879.75

28072 Removal of foot joint lining Y A2 20.7836 $879.75

28080 Removal of foot lesion Y A2 20.7836 $879.75

28086 Excise foot tendon sheath Y A2 20.7836 $879.75

28088 Excise foot tendon sheath Y A2 20.7836 $879.75

28090 Removal of foot lesion Y A2 20.7836 $879.75

28092 Removal of toe lesions Y A2 20.7836 $879.75

28100 Removal of ankle/heel lesion Y A2 20.7836 $879.75

28102 Remove/graft foot lesion Y A2 53.6228 $2,269.80

28103 Remove/graft foot lesion Y A2 53.6228 $2,269.80

28104 Removal of foot lesion Y A2 20.7836 $879.75

28106 Remove/graft foot lesion Y A2 53.6228 $2,269.80

28107 Remove/graft foot lesion Y A2 53.6228 $2,269.80

28108 Removal of toe lesions Y A2 20.7836 $879.75

28110 Part removal of metatarsal Y A2 20.7836 $879.75

28111 Part removal of metatarsal Y A2 20.7836 $879.75

28112 Part removal of metatarsal Y A2 20.7836 $879.75

28113 Part removal of metatarsal Y A2 20.7836 $879.75

28114 Removal of metatarsal heads Y A2 20.7836 $879.75

28116 Revision of foot Y A2 20.7836 $879.75

28118 Removal of heel bone Y A2 20.7836 $879.75

28119 Removal of heel spur Y A2 20.7836 $879.75

Date Printed: 3/14/2013 @ 8:00 PM Page 25 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

28120 Part removal of ankle/heel Y A2 20.7836 $879.75

28122 Partial removal of foot bone Y A2 20.7836 $879.75

28124 Partial removal of toe Y P3 $201.05

28126 Partial removal of toe Y A2 20.7836 $879.75

28130 Removal of ankle bone Y A2 20.7836 $879.75

28140 Removal of metatarsal Y A2 20.7836 $879.75

28150 Removal of toe Y A2 20.7836 $879.75

28153 Partial removal of toe Y A2 20.7836 $879.75

28160 Partial removal of toe Y A2 20.7836 $879.75

28171 Resect tarsal tumor Y A2 20.7836 $879.75

28173 Resect metatarsal tumor Y A2 20.7836 $879.75

28175 Resect phalanx of toe tumor Y A2 20.7836 $879.75

28190 Removal of foot foreign body Y P3 $124.13

28192 Removal of foot foreign body Y A2 16.113 $682.05

28193 Removal of foot foreign body Y A2 8.0762 $341.86

28200 Repair of foot tendon Y A2 20.7836 $879.75

28202 Repair/graft of foot tendon Y A2 20.7836 $879.75

28208 Repair of foot tendon Y A2 20.7836 $879.75

28210 Repair/graft of foot tendon Y A2 53.6228 $2,269.80

28220 Release of foot tendon Y P3 $190.27

28222 Release of foot tendons Y A2 20.7836 $879.75

28225 Release of foot tendon Y A2 20.7836 $879.75

28226 Release of foot tendons Y A2 20.7836 $879.75

28230 Incision of foot tendon(s) Y P3 $186.44

28232 Incision of toe tendon Y P3 $180.68

28234 Incision of foot tendon Y A2 20.7836 $879.75

28238 Revision of foot tendon Y A2 53.6228 $2,269.80

28240 Release of big toe Y A2 20.7836 $879.75

28250 Revision of foot fascia Y A2 20.7836 $879.75

28260 Release of midfoot joint Y A2 20.7836 $879.75

28261 Revision of foot tendon Y A2 20.7836 $879.75

28262 Revision of foot and ankle Y A2 20.7836 $879.75

28264 Release of midfoot joint Y A2 53.6228 $2,269.80

28270 Release of foot contracture Y A2 20.7836 $879.75

28272 Release of toe joint each Y P3 $171.82

28280 Fusion of toes Y A2 20.7836 $879.75

28285 Repair of hammertoe Y A2 20.7836 $879.75

28286 Repair of hammertoe Y A2 20.7836 $879.75

28288 Partial removal of foot bone Y A2 20.7836 $879.75

28289 Repair hallux rigidus Y A2 20.7836 $879.75

28290 Correction of bunion Y A2 30.505 $1,291.25

28292 Correction of bunion Y A2 30.505 $1,291.25

28293 Correction of bunion Y A2 30.505 $1,291.25

28294 Correction of bunion Y A2 30.505 $1,291.25

28296 Correction of bunion Y A2 30.505 $1,291.25

28297 Correction of bunion Y A2 30.505 $1,291.25

28298 Correction of bunion Y A2 30.505 $1,291.25

28299 Correction of bunion Y A2 30.505 $1,291.25

28300 Incision of heel bone Y A2 53.6228 $2,269.80

28302 Incision of ankle bone Y A2 20.7836 $879.75

28304 Incision of midfoot bones Y A2 53.6228 $2,269.80

28305 Incise/graft midfoot bones Y A2 53.6228 $2,269.80

28306 Incision of metatarsal Y A2 20.7836 $879.75

28307 Incision of metatarsal Y A2 20.7836 $879.75

28308 Incision of metatarsal Y A2 20.7836 $879.75

28309 Incision of metatarsals Y A2 53.6228 $2,269.80

28310 Revision of big toe Y A2 20.7836 $879.75

28312 Revision of toe Y A2 20.7836 $879.75

Date Printed: 3/14/2013 @ 8:00 PM Page 26 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

28313 Repair deformity of toe Y A2 20.7836 $879.75

28315 Removal of sesamoid bone Y A2 20.7836 $879.75

28320 Repair of foot bones Y A2 53.6228 $2,269.80

28322 Repair of metatarsals Y A2 53.6228 $2,269.80

28340 Resect enlarged toe tissue Y A2 20.7836 $879.75

28341 Resect enlarged toe Y A2 20.7836 $879.75

28344 Repair extra toe(s) Y A2 20.7836 $879.75

28345 Repair webbed toe(s) Y A2 20.7836 $879.75

28400 Treatment of heel fracture Y A2 1.5056 $63.73

28405 Treatment of heel fracture Y A2 17.5202 $741.61

28406 Treatment of heel fracture Y A2 24.5925 $1,040.98

28415 Treat heel fracture Y A2 62.8575 $2,660.70

28420 Treat/graft heel fracture Y A2 46.3836 $1,963.37

28430 Treatment of ankle fracture Y P2 1.5056 $63.73

28435 Treatment of ankle fracture Y A2 1.5056 $63.73

28436 Treatment of ankle fracture Y A2 24.5925 $1,040.98

28445 Treat ankle fracture Y A2 46.3836 $1,963.37

28446 Osteochondral talus autogrft Y G2 53.6228 $2,269.80

28450 Treat midfoot fracture each Y P2 1.5056 $63.73

28455 Treat midfoot fracture each Y P2 1.5056 $63.73

28456 Treat midfoot fracture Y A2 24.5925 $1,040.98

28465 Treat midfoot fracture each Y A2 46.3836 $1,963.37

28470 Treat metatarsal fracture Y P2 1.5056 $63.73

28475 Treat metatarsal fracture Y P2 1.5056 $63.73

28476 Treat metatarsal fracture Y A2 24.5925 $1,040.98

28485 Treat metatarsal fracture Y A2 46.3836 $1,963.37

28490 Treat big toe fracture Y P2 1.5056 $63.73

28495 Treat big toe fracture Y P2 1.5056 $63.73

28496 Treat big toe fracture Y A2 24.5925 $1,040.98

28505 Treat big toe fracture Y A2 24.5925 $1,040.98

28510 Treatment of toe fracture Y CH P3 $53.44

28515 Treatment of toe fracture Y P2 1.5056 $63.73

28525 Treat toe fracture Y A2 24.5925 $1,040.98

28530 Treat sesamoid bone fracture Y CH P3 $50.32

28531 Treat sesamoid bone fracture Y A2 24.5925 $1,040.98

28540 Treat foot dislocation Y P2 1.5056 $63.73

28545 Treat foot dislocation Y A2 24.5925 $1,040.98

28546 Treat foot dislocation Y A2 24.5925 $1,040.98

28555 Repair foot dislocation Y A2 46.3836 $1,963.37

28570 Treat foot dislocation Y P2 1.5056 $63.73

28575 Treat foot dislocation Y A2 17.5202 $741.61

28576 Treat foot dislocation Y A2 24.5925 $1,040.98

28585 Repair foot dislocation Y A2 24.5925 $1,040.98

28600 Treat foot dislocation Y P2 1.5056 $63.73

28605 Treat foot dislocation Y A2 1.5056 $63.73

28606 Treat foot dislocation Y A2 24.5925 $1,040.98

28615 Repair foot dislocation Y A2 46.3836 $1,963.37

28630 Treat toe dislocation Y CH P3 $59.91

28635 Treat toe dislocation Y A2 14.5437 $615.62

28636 Treat toe dislocation Y A2 24.5925 $1,040.98

28645 Repair toe dislocation Y A2 24.5925 $1,040.98

28660 Treat toe dislocation Y P3 $44.33

28665 Treat toe dislocation Y A2 14.5437 $615.62

28666 Treat toe dislocation Y A2 24.5925 $1,040.98

28675 Repair of toe dislocation Y A2 24.5925 $1,040.98

28705 Fusion of foot bones Y A2 53.6228 $2,269.80

28715 Fusion of foot bones Y A2 82.0766 $3,474.22

28725 Fusion of foot bones Y A2 53.6228 $2,269.80

Date Printed: 3/14/2013 @ 8:00 PM Page 27 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

28730 Fusion of foot bones Y A2 53.6228 $2,269.80

28735 Fusion of foot bones Y A2 53.6228 $2,269.80

28737 Revision of foot bones Y A2 53.6228 $2,269.80

28740 Fusion of foot bones Y A2 53.6228 $2,269.80

28750 Fusion of big toe joint Y A2 53.6228 $2,269.80

28755 Fusion of big toe joint Y A2 20.7836 $879.75

28760 Fusion of big toe joint Y A2 53.6228 $2,269.80

28810 Amputation toe & metatarsal Y A2 20.7836 $879.75

28820 Amputation of toe Y A2 20.7836 $879.75

28825 Partial amputation of toe Y A2 20.7836 $879.75

28890 High energy eswt plantar f Y P3 $144.98

29000 Application of body cast N G2 1.0665 $45.14

29010 Application of body cast N CH P3 $93.22

29015 Application of body cast N P2 2.5362 $107.35

29020 Application of body cast N G2 1.0665 $45.14

29025 Application of body cast N P2 1.0665 $45.14

29035 Application of body cast N P2 2.5362 $107.35

29040 Application of body cast N G2 1.0665 $45.14

29044 Application of body cast N P2 2.5362 $107.35

29046 Application of body cast N G2 2.5362 $107.35

29049 Application of figure eight N CH P3 $41.46

29055 Application of shoulder cast N CH P3 $101.61

29058 Application of shoulder cast N CH P3 $31.39

29065 Application of long arm cast N P3 $42.18

29075 Application of forearm cast N P3 $40.74

29085 Apply hand/wrist cast N CH P3 $41.70

29086 Apply finger cast N CH P3 $36.90

29105 Apply long arm splint N CH P3 $36.66

29125 Apply forearm splint N P3 $30.67

29126 Apply forearm splint N CH P3 $34.51

29130 Application of finger splint N P3 $14.62

29131 Application of finger splint N P3 $21.09

29200 Strapping of chest N P3 $19.65

29240 Strapping of shoulder N P3 $21.33

29260 Strapping of elbow or wrist N P3 $21.57

29280 Strapping of hand or finger N P3 $21.81

29305 Application of hip cast N P2 2.5362 $107.35

29325 Application of hip casts N P2 2.5362 $107.35

29345 Application of long leg cast N P3 $55.12

29355 Application of long leg cast N P3 $55.12

29358 Apply long leg cast brace N P3 $69.49

29365 Application of long leg cast N P3 $51.52

29405 Apply short leg cast N P3 $35.71

29425 Apply short leg cast N P3 $34.27

29435 Apply short leg cast N P3 $49.84

29440 Addition of walker to cast N P3 $23.96

29445 Apply rigid leg cast N P3 $47.93

29450 Application of leg cast N P2 1.0665 $45.14

29505 Application long leg splint N CH P3 $36.66

29515 Application lower leg splint N P3 $29.48

29520 Strapping of hip N P3 $20.37

29530 Strapping of knee N P3 $21.09

29540 Strapping of ankle and/or ft N P3 $15.10

29550 Strapping of toes N P3 $15.34

29580 Application of paste boot N P3 $21.81

29581 Apply multlay comprs lwr leg N P2 1.0665 $45.14

29590 Application of foot splint N P3 $17.49

29700 Removal/revision of cast N P3 $29.71

Date Printed: 3/14/2013 @ 8:00 PM Page 28 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

29705 Removal/revision of cast N P3 $25.16

29710 Removal/revision of cast N P3 $37.62

29715 Removal/revision of cast N CH P3 $35.47

29720 Repair of body cast N CH P3 $38.58

29730 Windowing of cast N P3 $24.68

29740 Wedging of cast N CH P3 $32.59

29750 Wedging of clubfoot cast N CH P3 $35.71

29800 Jaw arthroscopy/surgery Y A2 27.5786 $1,167.37

29804 Jaw arthroscopy/surgery Y A2 27.5786 $1,167.37

29805 Shoulder arthroscopy dx Y A2 27.5786 $1,167.37

29806 Shoulder arthroscopy/surgery Y A2 45.4164 $1,922.43

29807 Shoulder arthroscopy/surgery Y A2 45.4164 $1,922.43

29819 Shoulder arthroscopy/surgery Y A2 45.4164 $1,922.43

29820 Shoulder arthroscopy/surgery Y A2 45.4164 $1,922.43

29821 Shoulder arthroscopy/surgery Y A2 45.4164 $1,922.43

29822 Shoulder arthroscopy/surgery Y A2 27.5786 $1,167.37

29823 Shoulder arthroscopy/surgery Y A2 45.4164 $1,922.43

29824 Shoulder arthroscopy/surgery Y A2 27.5786 $1,167.37

29825 Shoulder arthroscopy/surgery Y A2 45.4164 $1,922.43

29826 Shoulder arthroscopy/surgery Y A2 45.4164 $1,922.43

29827 Arthroscop rotator cuff repr Y A2 45.4164 $1,922.43

29828 Arthroscopy biceps tenodesis Y G2 45.4164 $1,922.43

29830 Elbow arthroscopy Y A2 27.5786 $1,167.37

29834 Elbow arthroscopy/surgery Y A2 27.5786 $1,167.37

29835 Elbow arthroscopy/surgery Y A2 27.5786 $1,167.37

29836 Elbow arthroscopy/surgery Y A2 27.5786 $1,167.37

29837 Elbow arthroscopy/surgery Y A2 27.5786 $1,167.37

29838 Elbow arthroscopy/surgery Y A2 27.5786 $1,167.37

29840 Wrist arthroscopy Y A2 27.5786 $1,167.37

29843 Wrist arthroscopy/surgery Y A2 27.5786 $1,167.37

29844 Wrist arthroscopy/surgery Y A2 27.5786 $1,167.37

29845 Wrist arthroscopy/surgery Y A2 27.5786 $1,167.37

29846 Wrist arthroscopy/surgery Y A2 27.5786 $1,167.37

29847 Wrist arthroscopy/surgery Y A2 45.4164 $1,922.43

29848 Wrist endoscopy/surgery Y A2 27.5786 $1,167.37

29850 Knee arthroscopy/surgery Y A2 27.5786 $1,167.37

29851 Knee arthroscopy/surgery Y A2 45.4164 $1,922.43

29855 Tibial arthroscopy/surgery Y A2 45.4164 $1,922.43

29856 Tibial arthroscopy/surgery Y A2 45.4164 $1,922.43

29860 Hip arthroscopy dx Y A2 45.4164 $1,922.43

29861 Hip arthro w/fb removal Y A2 45.4164 $1,922.43

29862 Hip arthr0 w/debridement Y A2 45.4164 $1,922.43

29863 Hip arthr0 w/synovectomy Y A2 45.4164 $1,922.43

29866 Autgrft implnt knee w/scope Y G2 45.4164 $1,922.43

29870 Knee arthroscopy dx Y A2 27.5786 $1,167.37

29871 Knee arthroscopy/drainage Y A2 27.5786 $1,167.37

29873 Knee arthroscopy/surgery Y A2 27.5786 $1,167.37

29874 Knee arthroscopy/surgery Y A2 27.5786 $1,167.37

29875 Knee arthroscopy/surgery Y A2 27.5786 $1,167.37

29876 Knee arthroscopy/surgery Y A2 27.5786 $1,167.37

29877 Knee arthroscopy/surgery Y A2 27.5786 $1,167.37

29879 Knee arthroscopy/surgery Y A2 27.5786 $1,167.37

29880 Knee arthroscopy/surgery Y A2 27.5786 $1,167.37

29881 Knee arthroscopy/surgery Y A2 27.5786 $1,167.37

29882 Knee arthroscopy/surgery Y A2 27.5786 $1,167.37

29883 Knee arthroscopy/surgery Y A2 27.5786 $1,167.37

29884 Knee arthroscopy/surgery Y A2 27.5786 $1,167.37

29885 Knee arthroscopy/surgery Y A2 45.4164 $1,922.43

Date Printed: 3/14/2013 @ 8:00 PM Page 29 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

29886 Knee arthroscopy/surgery Y A2 27.5786 $1,167.37

29887 Knee arthroscopy/surgery Y A2 27.5786 $1,167.37

29888 Knee arthroscopy/surgery Y A2 82.0766 $3,474.22

29889 Knee arthroscopy/surgery Y A2 82.0766 $3,474.22

29891 Ankle arthroscopy/surgery Y A2 45.4164 $1,922.43

29892 Ankle arthroscopy/surgery Y A2 82.0766 $3,474.22

29893 Scope plantar fasciotomy Y A2 20.7836 $879.75

29894 Ankle arthroscopy/surgery Y A2 27.5786 $1,167.37

29895 Ankle arthroscopy/surgery Y A2 27.5786 $1,167.37

29897 Ankle arthroscopy/surgery Y A2 27.5786 $1,167.37

29898 Ankle arthroscopy/surgery Y A2 27.5786 $1,167.37

29899 Ankle arthroscopy/surgery Y A2 45.4164 $1,922.43

29900 Mcp joint arthroscopy dx Y A2 27.5786 $1,167.37

29901 Mcp joint arthroscopy surg Y A2 27.5786 $1,167.37

29902 Mcp joint arthroscopy surg Y A2 27.5786 $1,167.37

29904 Subtalar arthro w/fb rmvl Y G2 27.5786 $1,167.37

29905 Subtalar arthro w/exc Y G2 27.5786 $1,167.37

29906 Subtalar arthro w/deb Y G2 27.5786 $1,167.37

29907 Subtalar arthro w/fusion Y G2 45.4164 $1,922.43

29914 Hip arthro w/femoroplasty Y G2 45.4164 $1,922.43

29915 Hip arthro acetabuloplasty Y G2 45.4164 $1,922.43

29916 Hip arthro w/labral repair Y G2 45.4164 $1,922.43

30000 Drainage of nose lesion Y CH P3 $124.61

30020 Drainage of nose lesion Y CH P3 $125.09

30100 Intranasal biopsy Y P3 $76.20

30110 Removal of nose polyp(s) Y P3 $118.38

30115 Removal of nose polyp(s) Y A2 15.8572 $671.22

30117 Removal of intranasal lesion Y A2 15.8572 $671.22

30118 Removal of intranasal lesion Y A2 23.5618 $997.35

30120 Revision of nose Y A2 23.5618 $997.35

30124 Removal of nose lesion Y R2 7.5315 $318.80

30125 Removal of nose lesion Y A2 42.299 $1,790.47

30130 Excise inferior turbinate Y A2 15.8572 $671.22

30140 Resect inferior turbinate Y A2 23.5618 $997.35

30150 Partial removal of nose Y A2 42.299 $1,790.47

30160 Removal of nose Y A2 42.299 $1,790.47

30200 Injection treatment of nose Y P3 $60.39

30210 Nasal sinus therapy Y P3 $76.44

30220 Insert nasal septal button Y A2 7.5315 $318.80

30300 Remove nasal foreign body N P2 0.6316 $26.73

30310 Remove nasal foreign body Y A2 15.8572 $671.22

30320 Remove nasal foreign body Y A2 15.8572 $671.22

30400 Reconstruction of nose Y A2 42.299 $1,790.47

30410 Reconstruction of nose Y A2 42.299 $1,790.47

30420 Reconstruction of nose Y A2 42.299 $1,790.47

30430 Revision of nose Y A2 23.5618 $997.35

30435 Revision of nose Y A2 42.299 $1,790.47

30450 Revision of nose Y A2 42.299 $1,790.47

30460 Revision of nose Y A2 42.299 $1,790.47

30462 Revision of nose Y A2 42.299 $1,790.47

30465 Repair nasal stenosis Y A2 42.299 $1,790.47

30520 Repair of nasal septum Y A2 23.5618 $997.35

30540 Repair nasal defect Y A2 42.299 $1,790.47

30545 Repair nasal defect Y A2 42.299 $1,790.47

30560 Release of nasal adhesions Y A2 3.1429 $133.04

30580 Repair upper jaw fistula Y A2 42.299 $1,790.47

30600 Repair mouth/nose fistula Y A2 42.299 $1,790.47

30620 Intranasal reconstruction Y A2 42.299 $1,790.47

Date Printed: 3/14/2013 @ 8:00 PM Page 30 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

30630 Repair nasal septum defect Y A2 23.5618 $997.35

30801 Ablate inf turbinate superf Y A2 7.5315 $318.80

30802 Ablate inf turbinate submuc Y A2 15.8572 $671.22

30901 Control of nosebleed Y CH P3 $37.86

30903 Control of nosebleed Y A2 1.0193 $43.15

30905 Control of nosebleed Y A2 1.0193 $43.15

30906 Repeat control of nosebleed Y A2 1.0193 $43.15

30915 Ligation nasal sinus artery Y A2 25.2303 $1,067.97

30920 Ligation upper jaw artery Y A2 25.2303 $1,067.97

30930 Ther fx nasal inf turbinate Y A2 15.8572 $671.22

31000 Irrigation maxillary sinus Y P3 $96.33

31002 Irrigation sphenoid sinus Y R2 7.5315 $318.80

31020 Exploration maxillary sinus Y A2 23.5618 $997.35

31030 Exploration maxillary sinus Y A2 42.299 $1,790.47

31032 Explore sinus remove polyps Y A2 42.299 $1,790.47

31040 Exploration behind upper jaw Y R2 23.5618 $997.35

31050 Exploration sphenoid sinus Y A2 42.299 $1,790.47

31051 Sphenoid sinus surgery Y A2 42.299 $1,790.47

31070 Exploration of frontal sinus Y A2 23.5618 $997.35

31075 Exploration of frontal sinus Y A2 42.299 $1,790.47

31080 Removal of frontal sinus Y A2 42.299 $1,790.47

31081 Removal of frontal sinus Y A2 42.299 $1,790.47

31084 Removal of frontal sinus Y A2 42.299 $1,790.47

31085 Removal of frontal sinus Y A2 42.299 $1,790.47

31086 Removal of frontal sinus Y A2 42.299 $1,790.47

31087 Removal of frontal sinus Y A2 42.299 $1,790.47

31090 Exploration of sinuses Y A2 42.299 $1,790.47

31200 Removal of ethmoid sinus Y A2 42.299 $1,790.47

31201 Removal of ethmoid sinus Y A2 42.299 $1,790.47

31205 Removal of ethmoid sinus Y A2 42.299 $1,790.47

31231 Nasal endoscopy dx Y P2 1.8254 $77.27

31233 Nasal/sinus endoscopy dx Y A2 1.8254 $77.27

31235 Nasal/sinus endoscopy dx Y A2 20.0293 $847.82

31237 Nasal/sinus endoscopy surg Y A2 20.0293 $847.82

31238 Nasal/sinus endoscopy surg Y A2 20.0293 $847.82

31239 Nasal/sinus endoscopy surg Y A2 28.3273 $1,199.07

31240 Nasal/sinus endoscopy surg Y A2 20.0293 $847.82

31254 Revision of ethmoid sinus Y A2 28.3273 $1,199.07

31255 Removal of ethmoid sinus Y A2 28.3273 $1,199.07

31256 Exploration maxillary sinus Y A2 28.3273 $1,199.07

31267 Endoscopy maxillary sinus Y A2 28.3273 $1,199.07

31276 Sinus endoscopy surgical Y A2 28.3273 $1,199.07

31287 Nasal/sinus endoscopy surg Y A2 28.3273 $1,199.07

31288 Nasal/sinus endoscopy surg Y A2 28.3273 $1,199.07

31295 Sinus endo w/balloon dil Y G2 28.3273 $1,199.07

31296 Sinus endo w/balloon dil Y G2 28.3273 $1,199.07

31297 Sinus endo w/balloon dil Y G2 28.3273 $1,199.07

31300 Removal of larynx lesion Y A2 23.5618 $997.35

31320 Diagnostic incision larynx Y A2 42.299 $1,790.47

31400 Revision of larynx Y A2 42.299 $1,790.47

31420 Removal of epiglottis Y A2 42.299 $1,790.47

31500 Insert emergency airway N G2 2.1345 $90.35

31502 Change of windpipe airway N G2 1.313 $55.58

31505 Diagnostic laryngoscopy Y P2 0.9861 $41.74

31510 Laryngoscopy with biopsy Y A2 20.0293 $847.82

31511 Remove foreign body larynx Y A2 1.8254 $77.27

31512 Removal of larynx lesion Y A2 20.0293 $847.82

31513 Injection into vocal cord Y A2 1.8254 $77.27

Date Printed: 3/14/2013 @ 8:00 PM Page 31 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

31515 Laryngoscopy for aspiration Y A2 20.0293 $847.82

31520 Dx laryngoscopy newborn Y G2 1.8254 $77.27

31525 Dx laryngoscopy excl nb Y A2 20.0293 $847.82

31526 Dx laryngoscopy w/oper scope Y A2 20.0293 $847.82

31527 Laryngoscopy for treatment Y A2 28.3273 $1,199.07

31528 Laryngoscopy and dilation Y A2 20.0293 $847.82

31529 Laryngoscopy and dilation Y A2 20.0293 $847.82

31530 Laryngoscopy w/fb removal Y A2 20.0293 $847.82

31531 Laryngoscopy w/fb & op scope Y A2 20.0293 $847.82

31535 Laryngoscopy w/biopsy Y A2 20.0293 $847.82

31536 Laryngoscopy w/bx & op scope Y A2 20.0293 $847.82

31540 Laryngoscopy w/exc of tumor Y A2 20.0293 $847.82

31541 Larynscop w/tumr exc + scope Y A2 20.0293 $847.82

31545 Remove vc lesion w/scope Y A2 28.3273 $1,199.07

31546 Remove vc lesion scope/graft Y A2 28.3273 $1,199.07

31560 Laryngoscop w/arytenoidectom Y A2 28.3273 $1,199.07

31561 Larynscop remve cart + scop Y A2 28.3273 $1,199.07

31570 Laryngoscope w/vc inj Y A2 20.0293 $847.82

31571 Laryngoscop w/vc inj + scope Y A2 28.3273 $1,199.07

31575 Diagnostic laryngoscopy Y P3 $52.72

31576 Laryngoscopy with biopsy Y A2 20.0293 $847.82

31577 Remove foreign body larynx Y A2 4.2293 $179.02

31578 Removal of larynx lesion Y A2 28.3273 $1,199.07

31579 Diagnostic laryngoscopy Y P3 $91.30

31580 Revision of larynx Y A2 42.299 $1,790.47

31582 Revision of larynx Y A2 42.299 $1,790.47

31588 Revision of larynx Y A2 42.299 $1,790.47

31590 Reinnervate larynx Y A2 42.299 $1,790.47

31595 Larynx nerve surgery Y A2 42.299 $1,790.47

31603 Incision of windpipe Y A2 7.5315 $318.80

31605 Incision of windpipe Y G2 7.5315 $318.80

31611 Surgery/speech prosthesis Y A2 23.5618 $997.35

31612 Puncture/clear windpipe Y A2 23.5618 $997.35

31613 Repair windpipe opening Y A2 23.5618 $997.35

31614 Repair windpipe opening Y A2 42.299 $1,790.47

31615 Visualization of windpipe Y A2 7.5315 $318.80

31620 Endobronchial us add-on N N1

31622 Dx bronchoscope/wash Y A2 9.7594 $413.11

31623 Dx bronchoscope/brush Y A2 9.7594 $413.11

31624 Dx bronchoscope/lavage Y A2 9.7594 $413.11

31625 Bronchoscopy w/biopsy(s) Y A2 9.7594 $413.11

31626 Bronchoscopy w/markers Y G2 27.2989 $1,155.54

31627 Navigational bronchoscopy N N1

31628 Bronchoscopy/lung bx each Y A2 9.7594 $413.11

31629 Bronchoscopy/needle bx each Y A2 9.7594 $413.11

31630 Bronchoscopy dilate/fx repr Y A2 27.2989 $1,155.54

31631 Bronchoscopy dilate w/stent Y A2 27.2989 $1,155.54

31632 Bronchoscopy/lung bx addl Y G2 9.7594 $413.11

31633 Bronchoscopy/needle bx addl Y G2 9.7594 $413.11

31634 Bronch w/balloon occlusion Y G2 9.7594 $413.11

31635 Bronchoscopy w/fb removal Y A2 9.7594 $413.11

31636 Bronchoscopy bronch stents Y A2 27.2989 $1,155.54

31637 Bronchoscopy stent add-on Y A2 9.7594 $413.11

31638 Bronchoscopy revise stent Y A2 27.2989 $1,155.54

31640 Bronchoscopy w/tumor excise Y A2 27.2989 $1,155.54

31641 Bronchoscopy treat blockage Y A2 27.2989 $1,155.54

31643 Diag bronchoscope/catheter Y A2 9.7594 $413.11

31645 Bronchoscopy clear airways Y A2 9.7594 $413.11

Date Printed: 3/14/2013 @ 8:00 PM Page 32 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

31646 Bronchoscopy reclear airway Y A2 9.7594 $413.11

31656 Bronchoscopy inj for x-ray Y A2 9.7594 $413.11

31715 Injection for bronchus x-ray N N1

31717 Bronchial brush biopsy Y A2 4.2293 $179.02

31720 Clearance of airways N A2 0.3959 $16.76

31730 Intro windpipe wire/tube Y A2 4.2293 $179.02

31750 Repair of windpipe Y A2 42.299 $1,790.47

31755 Repair of windpipe Y A2 42.299 $1,790.47

31820 Closure of windpipe lesion Y A2 23.5618 $997.35

31825 Repair of windpipe defect Y A2 23.5618 $997.35

31830 Revise windpipe scar Y A2 23.5618 $997.35

32400 Needle biopsy chest lining Y A2 9.1181 $385.96

32405 Biopsy lung or mediastinum Y A2 9.1181 $385.96

32420 Puncture/clear lung Y A2 5.2088 $220.48

32421 Thoracentesis for aspiration Y A2 5.2088 $220.48

32422 Thoracentesis w/tube insert Y G2 5.2088 $220.48

32550 Insert pleural cath Y G2 28.7055 $1,215.08

32552 Remove lung catheter N G2 1.313 $55.58

32553 Ins mark thor for rt perq N G2 12.4155 $525.54

32960 Therapeutic pneumothorax Y G2 5.2088 $220.48

32998 Perq rf ablate tx pul tumor Y G2 53.5857 $2,268.23

33010 Drainage of heart sac Y A2 5.2088 $220.48

33011 Repeat drainage of heart sac Y A2 5.2088 $220.48

33206 Insertion of heart pacemaker Y J8 159.1438 $6,736.40

33207 Insertion of heart pacemaker Y J8 159.1438 $6,736.40

33208 Insertion of heart pacemaker Y J8 197.4745 $8,358.90

33210 Insertion of heart electrode Y G2 45.5308 $1,927.27

33211 Insertion of heart electrode Y G2 45.5308 $1,927.27

33212 Insertion of pulse generator Y CH J8 135.5021 $5,735.67

33213 Insertion of pulse generator Y CH J8 145.9713 $6,178.82

33214 Upgrade of pacemaker system Y J8 197.4745 $8,358.90

33215 Reposition pacing-defib lead Y G2 21.7851 $922.14

33216 Insert 1 electrode pm-defib Y G2 45.5308 $1,927.27

33217 Insert 2 electrode pm-defib Y G2 45.5308 $1,927.27

33218 Repair lead pace-defib one Y G2 21.7851 $922.14

33220 Repair lead pace-defib dual Y G2 21.7851 $922.14

33222 Revise pocket pacemaker Y A2 16.1914 $685.37

33223 Revise pocket for defib Y A2 16.1914 $685.37

33224 Insert pacing lead & connect Y J8 197.4745 $8,358.90

33225 L ventric pacing lead add-on Y J8 586.7483 $24,836.47

33226 Reposition l ventric lead Y G2 21.7851 $922.14

33233 Removal of pacemaker system Y A2 21.7851 $922.14

33234 Removal of pacemaker system Y G2 21.7851 $922.14

33235 Removal pacemaker electrode Y G2 21.7851 $922.14

33240 Insert pulse generator Y J8 512.0414 $21,674.20

33241 Remove pulse generator Y G2 21.7851 $922.14

33249 Eltrd/insert pace-defib Y J8 586.7483 $24,836.47

33282 Implant pat-active ht record N J8 112.9401 $4,780.64

33284 Remove pat-active ht record Y G2 8.0762 $341.86

33508 Endoscopic vein harvest N N1

34490 Removal of vein clot Y G2 38.6411 $1,635.64

35188 Repair blood vessel lesion Y A2 38.6411 $1,635.64

35207 Repair blood vessel lesion Y A2 38.6411 $1,635.64

35460 Repair venous blockage Y G2 61.0293 $2,583.31

35475 Repair arterial blockage Y CH P3 $1,375.27

35476 Repair venous blockage Y CH P3 $1,075.24

35572 Harvest femoropopliteal vein N N1

35761 Exploration of artery/vein Y G2 28.847 $1,221.06

Date Printed: 3/14/2013 @ 8:00 PM Page 33 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

35875 Removal of clot in graft Y A2 38.6411 $1,635.64

35876 Removal of clot in graft Y A2 38.6411 $1,635.64

36000 Place needle in vein N N1

36002 Pseudoaneurysm injection trt N G2 2.0509 $86.81

36005 Injection ext venography N N1

36010 Place catheter in vein N N1

36011 Place catheter in vein N N1

36012 Place catheter in vein N N1

36013 Place catheter in artery N N1

36014 Place catheter in artery N N1

36015 Place catheter in artery N N1

36100 Establish access to artery N N1

36120 Establish access to artery N N1

36140 Establish access to artery N N1

36147 Access av dial grft for eval Y P2 8.8399 $374.18

36148 Access av dial grft for proc N N1

36160 Establish access to aorta N N1

36200 Place catheter in aorta N N1

36215 Place catheter in artery N N1

36216 Place catheter in artery N N1

36217 Place catheter in artery N N1

36218 Place catheter in artery N N1

36245 Place catheter in artery N N1

36246 Place catheter in artery N N1

36247 Place catheter in artery N N1

36248 Place catheter in artery N N1

36260 Insertion of infusion pump Y A2 28.3971 $1,202.02

36261 Revision of infusion pump Y A2 21.7851 $922.14

36262 Removal of infusion pump Y A2 21.7851 $922.14

36400 Bl draw < 3 yrs fem/jugular N N1

36405 Bl draw < 3 yrs scalp vein N N1

36406 Bl draw < 3 yrs other vein N N1

36410 Non-routine bl draw > 3 yrs N N1

36416 Capillary blood draw N N1

36420 Vein access cutdown < 1 yr N R2 0.2547 $10.78

36425 Vein access cutdown > 1 yr N R2 0.2547 $10.78

36430 Blood transfusion service N P3 $23.72

36440 Bl push transfuse 2 yr or < N R2 3.156 $133.59

36450 Bl exchange/transfuse nb N R2 3.156 $133.59

36455 Bl exchange/transfuse non-nb N G2 3.156 $133.59

36468 Injection(s) spider veins Y R2 0.9172 $38.82

36469 Injection(s) spider veins Y R2 0.9172 $38.82

36470 Injection therapy of vein Y P2 0.9172 $38.82

36471 Injection therapy of veins Y P2 0.9172 $38.82

36475 Endovenous rf 1st vein Y A2 40.9473 $1,733.26

36476 Endovenous rf vein add-on Y A2 25.2303 $1,067.97

36478 Endovenous laser 1st vein Y A2 25.2303 $1,067.97

36479 Endovenous laser vein addon Y A2 25.2303 $1,067.97

36481 Insertion of catheter vein N N1

36500 Insertion of catheter vein N N1

36510 Insertion of catheter vein N N1

36511 Apheresis wbc N G2 11.0009 $465.66

36512 Apheresis rbc N G2 11.0009 $465.66

36513 Apheresis platelets N G2 11.0009 $465.66

36514 Apheresis plasma N G2 11.0009 $465.66

36515 Apheresis adsorp/reinfuse N P2 30.5575 $1,293.47

36516 Apheresis selective N P2 30.5575 $1,293.47

36522 Photopheresis N G2 30.5575 $1,293.47

Date Printed: 3/14/2013 @ 8:00 PM Page 34 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

36555 Insert non-tunnel cv cath Y A2 10.4623 $442.86

36556 Insert non-tunnel cv cath Y A2 10.4623 $442.86

36557 Insert tunneled cv cath Y A2 23.5534 $996.99

36558 Insert tunneled cv cath Y A2 23.5534 $996.99

36560 Insert tunneled cv cath Y A2 28.3971 $1,202.02

36561 Insert tunneled cv cath Y A2 28.3971 $1,202.02

36563 Insert tunneled cv cath Y A2 28.3971 $1,202.02

36565 Insert tunneled cv cath Y A2 28.3971 $1,202.02

36566 Insert tunneled cv cath Y A2 28.3971 $1,202.02

36568 Insert picc cath Y A2 10.4623 $442.86

36569 Insert picc cath Y A2 10.4623 $442.86

36570 Insert picvad cath Y A2 23.5534 $996.99

36571 Insert picvad cath Y A2 23.5534 $996.99

36575 Repair tunneled cv cath Y A2 5.9217 $250.66

36576 Repair tunneled cv cath Y A2 10.4623 $442.86

36578 Replace tunneled cv cath Y A2 23.5534 $996.99

36580 Replace cvad cath Y A2 10.4623 $442.86

36581 Replace tunneled cv cath Y A2 23.5534 $996.99

36582 Replace tunneled cv cath Y A2 28.3971 $1,202.02

36583 Replace tunneled cv cath Y A2 28.3971 $1,202.02

36584 Replace picc cath Y A2 10.4623 $442.86

36585 Replace picvad cath Y A2 23.5534 $996.99

36589 Removal tunneled cv cath Y A2 5.9217 $250.66

36590 Removal tunneled cv cath Y A2 10.4623 $442.86

36591 Draw blood off venous device N N1

36592 Collect blood from picc N N1

36593 Declot vascular device Y P3 $20.37

36595 Mech remov tunneled cv cath Y G2 23.5534 $996.99

36596 Mech remov tunneled cv cath Y G2 10.4623 $442.86

36597 Reposition venous catheter Y G2 10.4623 $442.86

36598 Inj w/fluor eval cv device Y P3 $59.67

36600 Withdrawal of arterial blood N N1

36620 Insertion catheter artery N N1

36625 Insertion catheter artery N N1

36640 Insertion catheter artery Y A2 28.3971 $1,202.02

36680 Insert needle bone cavity Y G2 1.6367 $69.28

36800 Insertion of cannula Y A2 34.5668 $1,463.18

36810 Insertion of cannula Y A2 34.5668 $1,463.18

36815 Insertion of cannula Y A2 34.5668 $1,463.18

36818 Av fuse uppr arm cephalic Y A2 38.6411 $1,635.64

36819 Av fuse uppr arm basilic Y A2 38.6411 $1,635.64

36820 Av fusion/forearm vein Y A2 38.6411 $1,635.64

36821 Av fusion direct any site Y A2 38.6411 $1,635.64

36825 Artery-vein autograft Y A2 38.6411 $1,635.64

36830 Artery-vein nonautograft Y A2 38.6411 $1,635.64

36831 Open thrombect av fistula Y A2 38.6411 $1,635.64

36832 Av fistula revision open Y A2 38.6411 $1,635.64

36833 Av fistula revision Y A2 38.6411 $1,635.64

36835 Artery to vein shunt Y A2 34.5668 $1,463.18

36860 External cannula declotting Y A2 2.1942 $92.88

36861 Cannula declotting Y A2 34.5668 $1,463.18

36870 Percut thrombect av fistula Y A2 40.4355 $1,711.59

37184 Prim art mech thrombectomy Y G2 38.6411 $1,635.64

37185 Prim art m-thrombect add-on Y G2 38.6411 $1,635.64

37186 Sec art m-thrombect add-on Y G2 38.6411 $1,635.64

37187 Venous mech thrombectomy Y G2 38.6411 $1,635.64

37188 Venous m-thrombectomy add-on Y G2 38.6411 $1,635.64

37200 Transcatheter biopsy Y G2 28.3971 $1,202.02

Date Printed: 3/14/2013 @ 8:00 PM Page 35 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

37203 Transcatheter retrieval Y G2 28.3971 $1,202.02

37204 Transcatheter occlusion Y G2 98.3094 $4,161.34

37210 Embolization uterine fibroid Y G2 107.0983 $4,533.36

37220 Iliac revasc Y G2 61.0293 $2,583.31

37221 Iliac revasc w/stent Y G2 107.0983 $4,533.36

37222 Iliac revasc add-on Y G2 61.0293 $2,583.31

37223 Iliac revasc w/stent add-on Y G2 61.0293 $2,583.31

37250 Iv us first vessel add-on N N1

37251 Iv us each add vessel add-on N N1

37500 Endoscopy ligate perf veins Y A2 40.9473 $1,733.26

37607 Ligation of a-v fistula Y A2 25.2303 $1,067.97

37609 Temporal artery procedure Y A2 16.113 $682.05

37650 Revision of major vein Y A2 25.2303 $1,067.97

37700 Revise leg vein Y A2 25.2303 $1,067.97

37718 Ligate/strip short leg vein Y A2 25.2303 $1,067.97

37722 Ligate/strip long leg vein Y A2 40.9473 $1,733.26

37735 Removal of leg veins/lesion Y A2 40.9473 $1,733.26

37760 Ligate leg veins radical Y A2 25.2303 $1,067.97

37761* Ligate leg veins open Y R2 25.2303 $1,067.97

37765 Stab phleb veins xtr 10-20 Y P3 $258.09

37766 Phleb veins - extrem 20+ Y P3 $288.76

37780 Revision of leg vein Y A2 25.2303 $1,067.97

37785 Ligate/divide/excise vein Y A2 25.2303 $1,067.97

37790 Penile venous occlusion Y A2 32.2247 $1,364.04

38200 Injection for spleen x-ray N N1

38204 Bl donor search management N N1

38206 Harvest auto stem cells N G2 11.0009 $465.66

38220 Bone marrow aspiration Y P3 $82.67

38221 Bone marrow biopsy Y P3 $81.00

38230 Bone marrow collection N G2 30.5575 $1,293.47

38241 Bone marrow/stem transplant N G2 30.5575 $1,293.47

38242 Lymphocyte infuse transplant N R2 11.0009 $465.66

38300 Drainage lymph node lesion Y A2 12.6328 $534.73

38305 Drainage lymph node lesion Y A2 19.2522 $814.93

38308 Incision of lymph channels Y A2 23.8893 $1,011.21

38500 Biopsy/removal lymph nodes Y A2 23.8893 $1,011.21

38505 Needle biopsy lymph nodes Y A2 7.631 $323.01

38510 Biopsy/removal lymph nodes Y A2 23.8893 $1,011.21

38520 Biopsy/removal lymph nodes Y A2 23.8893 $1,011.21

38525 Biopsy/removal lymph nodes Y A2 23.8893 $1,011.21

38530 Biopsy/removal lymph nodes Y A2 23.8893 $1,011.21

38542 Explore deep node(s) neck Y A2 48.0198 $2,032.63

38550 Removal neck/armpit lesion Y A2 23.8893 $1,011.21

38555 Removal neck/armpit lesion Y A2 23.8893 $1,011.21

38570 Laparoscopy lymph node biop Y A2 44.7246 $1,893.15

38571 Laparoscopy lymphadenectomy Y A2 66.5906 $2,818.71

38572 Laparoscopy lymphadenectomy Y A2 44.7246 $1,893.15

38700 Removal of lymph nodes neck Y G2 23.8893 $1,011.21

38740 Remove armpit lymph nodes Y A2 48.0198 $2,032.63

38745 Remove armpit lymph nodes Y A2 48.0198 $2,032.63

38760 Remove groin lymph nodes Y A2 23.8893 $1,011.21

38790 Inject for lymphatic x-ray N N1

38792 Identify sentinel node N N1

38794 Access thoracic lymph duct N N1

38900 Io map of sent lymph node N N1

40490 Biopsy of lip Y P3 $57.51

40500 Partial excision of lip Y A2 15.8572 $671.22

40510 Partial excision of lip Y A2 23.5618 $997.35

Date Printed: 3/14/2013 @ 8:00 PM Page 36 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

40520 Partial excision of lip Y A2 15.8572 $671.22

40525 Reconstruct lip with flap Y A2 23.5618 $997.35

40527 Reconstruct lip with flap Y A2 23.5618 $997.35

40530 Partial removal of lip Y A2 23.5618 $997.35

40650 Repair lip Y A2 7.5315 $318.80

40652 Repair lip Y A2 7.5315 $318.80

40654 Repair lip Y A2 7.5315 $318.80

40700 Repair cleft lip/nasal Y A2 42.299 $1,790.47

40701 Repair cleft lip/nasal Y A2 42.299 $1,790.47

40702 Repair cleft lip/nasal Y R2 42.299 $1,790.47

40720 Repair cleft lip/nasal Y A2 42.299 $1,790.47

40761 Repair cleft lip/nasal Y A2 42.299 $1,790.47

40800 Drainage of mouth lesion Y P2 1.3573 $57.45

40801 Drainage of mouth lesion Y A2 7.5315 $318.80

40804 Removal foreign body mouth N P2 0.6316 $26.73

40805 Removal foreign body mouth Y P3 $177.33

40806 Incision of lip fold Y P3 $98.25

40808 Biopsy of mouth lesion Y CH P3 $104.96

40810 Excision of mouth lesion Y P3 $109.75

40812 Excise/repair mouth lesion Y P3 $138.51

40814 Excise/repair mouth lesion Y A2 15.8572 $671.22

40816 Excision of mouth lesion Y A2 23.5618 $997.35

40818 Excise oral mucosa for graft Y A2 3.1429 $133.04

40819 Excise lip or cheek fold Y A2 7.5315 $318.80

40820 Treatment of mouth lesion Y P3 $153.61

40830 Repair mouth laceration Y G2 3.1429 $133.04

40831 Repair mouth laceration Y A2 7.5315 $318.80

40840 Reconstruction of mouth Y A2 23.5618 $997.35

40842 Reconstruction of mouth Y A2 23.5618 $997.35

40843 Reconstruction of mouth Y A2 23.5618 $997.35

40844 Reconstruction of mouth Y A2 42.299 $1,790.47

40845 Reconstruction of mouth Y A2 42.299 $1,790.47

41000 Drainage of mouth lesion Y P3 $78.36

41005 Drainage of mouth lesion Y A2 3.1429 $133.04

41006 Drainage of mouth lesion Y A2 23.5618 $997.35

41007 Drainage of mouth lesion Y A2 15.8572 $671.22

41008 Drainage of mouth lesion Y A2 15.8572 $671.22

41009 Drainage of mouth lesion Y A2 3.1429 $133.04

41010 Incision of tongue fold Y A2 7.5315 $318.80

41015 Drainage of mouth lesion Y A2 3.1429 $133.04

41016 Drainage of mouth lesion Y A2 7.5315 $318.80

41017 Drainage of mouth lesion Y A2 7.5315 $318.80

41018 Drainage of mouth lesion Y A2 7.5315 $318.80

41019 Place needles h&n for rt Y G2 23.5618 $997.35

41100 Biopsy of tongue Y P3 $81.72

41105 Biopsy of tongue Y P3 $81.96

41108 Biopsy of floor of mouth Y P3 $75.96

41110 Excision of tongue lesion Y P3 $110.47

41112 Excision of tongue lesion Y A2 15.8572 $671.22

41113 Excision of tongue lesion Y A2 15.8572 $671.22

41114 Excision of tongue lesion Y A2 23.5618 $997.35

41115 Excision of tongue fold Y P3 $130.60

41116 Excision of mouth lesion Y A2 15.8572 $671.22

41120 Partial removal of tongue Y A2 23.5618 $997.35

41250 Repair tongue laceration Y A2 1.0193 $43.15

41251 Repair tongue laceration Y A2 3.1429 $133.04

41252 Repair tongue laceration Y A2 7.5315 $318.80

41500 Fixation of tongue Y A2 23.5618 $997.35

Date Printed: 3/14/2013 @ 8:00 PM Page 37 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

41510 Tongue to lip surgery Y A2 15.8572 $671.22

41512 Tongue suspension Y G2 7.5315 $318.80

41520 Reconstruction tongue fold Y A2 7.5315 $318.80

41530 Tongue base vol reduction Y CH P2 23.5618 $997.35

41800 Drainage of gum lesion Y A2 1.3573 $57.45

41805 Removal foreign body gum Y P3 $136.11

41806 Removal foreign body jawbone Y P3 $174.93

41820 Excision gum each quadrant Y R2 7.5315 $318.80

41821 Excision of gum flap Y G2 7.5315 $318.80

41822 Excision of gum lesion Y P3 $138.51

41823 Excision of gum lesion Y P3 $198.90

41825 Excision of gum lesion Y P3 $110.23

41826 Excision of gum lesion Y P3 $152.17

41827 Excision of gum lesion Y A2 23.5618 $997.35

41828 Excision of gum lesion Y P3 $129.16

41830 Removal of gum tissue Y P3 $181.40

41850 Treatment of gum lesion Y R2 15.8572 $671.22

41870 Gum graft Y G2 23.5618 $997.35

41872 Repair gum Y P3 $208.24

41874 Repair tooth socket Y P3 $174.69

42000 Drainage mouth roof lesion Y A2 3.1429 $133.04

42100 Biopsy roof of mouth Y P3 $70.21

42104 Excision lesion mouth roof Y P3 $107.60

42106 Excision lesion mouth roof Y P3 $133.96

42107 Excision lesion mouth roof Y A2 23.5618 $997.35

42120 Remove palate/lesion Y A2 42.299 $1,790.47

42140 Excision of uvula Y A2 7.5315 $318.80

42145 Repair palate pharynx/uvula Y A2 23.5618 $997.35

42160 Treatment mouth roof lesion Y P3 $118.38

42180 Repair palate Y A2 3.1429 $133.04

42182 Repair palate Y A2 42.299 $1,790.47

42200 Reconstruct cleft palate Y A2 42.299 $1,790.47

42205 Reconstruct cleft palate Y A2 42.299 $1,790.47

42210 Reconstruct cleft palate Y A2 42.299 $1,790.47

42215 Reconstruct cleft palate Y A2 42.299 $1,790.47

42220 Reconstruct cleft palate Y A2 42.299 $1,790.47

42225 Reconstruct cleft palate Y G2 42.299 $1,790.47

42226 Lengthening of palate Y A2 42.299 $1,790.47

42227 Lengthening of palate Y G2 42.299 $1,790.47

42235 Repair palate Y A2 15.8572 $671.22

42260 Repair nose to lip fistula Y A2 23.5618 $997.35

42280 Preparation palate mold Y P3 $70.69

42281 Insertion palate prosthesis Y G2 15.8572 $671.22

42300 Drainage of salivary gland Y A2 15.8572 $671.22

42305 Drainage of salivary gland Y A2 15.8572 $671.22

42310 Drainage of salivary gland Y A2 3.1429 $133.04

42320 Drainage of salivary gland Y A2 3.1429 $133.04

42330 Removal of salivary stone Y P3 $105.92

42335 Removal of salivary stone Y P3 $177.33

42340 Removal of salivary stone Y A2 15.8572 $671.22

42400 Biopsy of salivary gland Y P3 $56.07

42405 Biopsy of salivary gland Y A2 23.5618 $997.35

42408 Excision of salivary cyst Y A2 15.8572 $671.22

42409 Drainage of salivary cyst Y A2 15.8572 $671.22

42410 Excise parotid gland/lesion Y A2 42.299 $1,790.47

42415 Excise parotid gland/lesion Y A2 42.299 $1,790.47

42420 Excise parotid gland/lesion Y A2 42.299 $1,790.47

42425 Excise parotid gland/lesion Y A2 42.299 $1,790.47

Date Printed: 3/14/2013 @ 8:00 PM Page 38 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

42440 Excise submaxillary gland Y A2 42.299 $1,790.47

42450 Excise sublingual gland Y A2 23.5618 $997.35

42500 Repair salivary duct Y A2 23.5618 $997.35

42505 Repair salivary duct Y A2 42.299 $1,790.47

42507 Parotid duct diversion Y A2 42.299 $1,790.47

42508 Parotid duct diversion Y A2 42.299 $1,790.47

42509 Parotid duct diversion Y A2 42.299 $1,790.47

42510 Parotid duct diversion Y A2 42.299 $1,790.47

42550 Injection for salivary x-ray N N1

42600 Closure of salivary fistula Y A2 15.8572 $671.22

42650 Dilation of salivary duct Y P3 $39.30

42660 Dilation of salivary duct Y P3 $45.29

42665 Ligation of salivary duct Y A2 23.5618 $997.35

42700 Drainage of tonsil abscess Y A2 3.1429 $133.04

42720 Drainage of throat abscess Y A2 15.8572 $671.22

42725 Drainage of throat abscess Y A2 42.299 $1,790.47

42800 Biopsy of throat Y P3 $75.72

42802 Biopsy of throat Y A2 15.8572 $671.22

42804 Biopsy of upper nose/throat Y A2 15.8572 $671.22

42806 Biopsy of upper nose/throat Y A2 23.5618 $997.35

42808 Excise pharynx lesion Y A2 23.5618 $997.35

42809 Remove pharynx foreign body N G2 0.6316 $26.73

42810 Excision of neck cyst Y A2 23.5618 $997.35

42815 Excision of neck cyst Y A2 42.299 $1,790.47

42820 Remove tonsils and adenoids Y A2 23.5618 $997.35

42821 Remove tonsils and adenoids Y A2 23.5618 $997.35

42825 Removal of tonsils Y A2 23.5618 $997.35

42826 Removal of tonsils Y A2 23.5618 $997.35

42830 Removal of adenoids Y A2 23.5618 $997.35

42831 Removal of adenoids Y A2 23.5618 $997.35

42835 Removal of adenoids Y A2 23.5618 $997.35

42836 Removal of adenoids Y A2 23.5618 $997.35

42860 Excision of tonsil tags Y A2 23.5618 $997.35

42870 Excision of lingual tonsil Y A2 23.5618 $997.35

42890 Partial removal of pharynx Y A2 42.299 $1,790.47

42892 Revision of pharyngeal walls Y A2 42.299 $1,790.47

42900 Repair throat wound Y A2 7.5315 $318.80

42950 Reconstruction of throat Y A2 23.5618 $997.35

42955 Surgical opening of throat Y A2 23.5618 $997.35

42960 Control throat bleeding Y A2 1.0193 $43.15

42962 Control throat bleeding Y A2 42.299 $1,790.47

42970 Control nose/throat bleeding Y R2 1.0193 $43.15

42972 Control nose/throat bleeding Y A2 15.8572 $671.22

43030 Throat muscle surgery Y G2 15.8572 $671.22

43130 Removal of esophagus pouch Y G2 42.299 $1,790.47

43200 Esophagus endoscopy Y A2 7.8534 $332.43

43201 Esoph scope w/submucous inj Y A2 11.7812 $498.69

43202 Esophagus endoscopy biopsy Y A2 7.8534 $332.43

43204 Esoph scope w/sclerosis inj Y A2 7.8534 $332.43

43205 Esophagus endoscopy/ligation Y A2 11.7812 $498.69

43215 Esophagus endoscopy Y A2 11.7812 $498.69

43216 Esophagus endoscopy/lesion Y A2 23.8908 $1,011.27

43217 Esophagus endoscopy Y A2 11.7812 $498.69

43219 Esophagus endoscopy Y A2 27.2035 $1,151.50

43220 Esoph endoscopy dilation Y A2 11.7812 $498.69

43226 Esoph endoscopy dilation Y A2 11.7812 $498.69

43227 Esoph endoscopy repair Y A2 11.7812 $498.69

43228 Esoph endoscopy ablation Y A2 23.8908 $1,011.27

Date Printed: 3/14/2013 @ 8:00 PM Page 39 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

43231 Esoph endoscopy w/us exam Y A2 11.7812 $498.69

43232 Esoph endoscopy w/us fn bx Y A2 11.7812 $498.69

43234 Upper gi endoscopy exam Y A2 7.8534 $332.43

43235 Uppr gi endoscopy diagnosis Y A2 7.8534 $332.43

43236 Uppr gi scope w/submuc inj Y A2 7.8534 $332.43

43237 Endoscopic us exam esoph Y A2 11.7812 $498.69

43238 Uppr gi endoscopy w/us fn bx Y A2 11.7812 $498.69

43239 Upper gi endoscopy biopsy Y A2 7.8534 $332.43

43240 Esoph endoscope w/drain cyst Y A2 11.7812 $498.69

43241 Upper GI endoscopy with tube Y A2 7.8534 $332.43

43242 Uppr gi endoscopy w/us fn bx Y A2 11.7812 $498.69

43243 Upper gi endoscopy & inject Y A2 7.8534 $332.43

43244 Upper GI endoscopy/ligation Y A2 11.7812 $498.69

43245 Uppr gi scope dilate strictr Y A2 11.7812 $498.69

43246 Place gastrostomy tube Y A2 11.7812 $498.69

43247 Operative upper GI endoscopy Y A2 7.8534 $332.43

43248 Uppr gi endoscopy/guide wire Y A2 7.8534 $332.43

43249 Esoph endoscopy dilation Y A2 11.7812 $498.69

43250 Upper GI endoscopy/tumor Y A2 11.7812 $498.69

43251 Operative upper GI endoscopy Y A2 11.7812 $498.69

43255 Operative upper GI endoscopy Y A2 11.7812 $498.69

43256 Uppr gi endoscopy w/stent Y A2 27.2035 $1,151.50

43257 Uppr gi scope w/thrml txmnt Y A2 23.8908 $1,011.27

43258 Operative upper GI endoscopy Y A2 11.7812 $498.69

43259 Endoscopic ultrasound exam Y A2 11.7812 $498.69

43260 Endo cholangiopancreatograph Y A2 22.871 $968.11

43261 Endo cholangiopancreatograph Y A2 22.871 $968.11

43262 Endo cholangiopancreatograph Y A2 22.871 $968.11

43263 Endo cholangiopancreatograph Y A2 22.871 $968.11

43264 Endo cholangiopancreatograph Y A2 22.871 $968.11

43265 Endo cholangiopancreatograph Y A2 22.871 $968.11

43267 Endo cholangiopancreatograph Y A2 22.871 $968.11

43268 Endo cholangiopancreatograph Y A2 27.2035 $1,151.50

43269 Endo cholangiopancreatograph Y A2 27.2035 $1,151.50

43271 Endo cholangiopancreatograph Y A2 22.871 $968.11

43272 Endo cholangiopancreatograph Y A2 22.871 $968.11

43273 Endoscopic pancreatoscopy Y G2 22.871 $968.11

43450 Dilate esophagus Y A2 6.1328 $259.60

43453 Dilate esophagus Y A2 6.1328 $259.60

43456 Dilate esophagus Y A2 6.1328 $259.60

43458 Dilate esophagus Y A2 11.7812 $498.69

43653 Laparoscopy gastrostomy Y A2 44.7246 $1,893.15

43752 Nasal/orogastric w/stent N G2 1.1698 $49.52

43753 Tx gastro intub w/asp N G2 0.6316 $26.73

43754 Dx gastr intub w/asp spec N G2 0.6316 $26.73

43755 Dx gastr intub w/asp specs N G2 0.8884 $37.61

43756 Dx duod intub w/asp spec N G2 1.1698 $49.52

43757 Dx duod intub w/asp specs N G2 1.1698 $49.52

43760 Change gastrostomy tube Y A2 2.1942 $92.88

43761 Reposition gastrostomy tube Y A2 7.8534 $332.43

43870 Repair stomach opening Y A2 23.8908 $1,011.27

43886 Revise gastric port open Y G2 20.437 $865.08

43887 Remove gastric port open Y G2 4.8714 $206.20

43888 Change gastric port open Y G2 20.437 $865.08

44100 Biopsy of bowel Y A2 11.7812 $498.69

44312 Revision of ileostomy Y A2 20.437 $865.08

44340 Revision of colostomy Y A2 20.437 $865.08

44360 Small bowel endoscopy Y A2 9.527 $403.27

Date Printed: 3/14/2013 @ 8:00 PM Page 40 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

44361 Small bowel endoscopy/biopsy Y A2 9.527 $403.27

44363 Small bowel endoscopy Y A2 9.527 $403.27

44364 Small bowel endoscopy Y A2 14.848 $628.50

44365 Small bowel endoscopy Y A2 14.848 $628.50

44366 Small bowel endoscopy Y A2 14.848 $628.50

44369 Small bowel endoscopy Y A2 14.848 $628.50

44370 Small bowel endoscopy/stent Y A2 27.2035 $1,151.50

44372 Small bowel endoscopy Y A2 14.848 $628.50

44373 Small bowel endoscopy Y A2 14.848 $628.50

44376 Small bowel endoscopy Y A2 9.527 $403.27

44377 Small bowel endoscopy/biopsy Y A2 9.527 $403.27

44378 Small bowel endoscopy Y A2 14.848 $628.50

44379 S bowel endoscope w/stent Y A2 27.2035 $1,151.50

44380 Small bowel endoscopy Y A2 9.527 $403.27

44382 Small bowel endoscopy Y A2 9.527 $403.27

44383 Ileoscopy w/stent Y A2 27.2035 $1,151.50

44385 Endoscopy of bowel pouch Y A2 8.734 $369.70

44386 Endoscopy bowel pouch/biop Y A2 8.734 $369.70

44388 Colonoscopy Y A2 8.734 $369.70

44389 Colonoscopy with biopsy Y A2 8.734 $369.70

44390 Colonoscopy for foreign body Y A2 8.734 $369.70

44391 Colonoscopy for bleeding Y A2 8.734 $369.70

44392 Colonoscopy & polypectomy Y A2 8.734 $369.70

44393 Colonoscopy lesion removal Y A2 8.734 $369.70

44394 Colonoscopy w/snare Y A2 8.734 $369.70

44397 Colonoscopy w/stent Y A2 27.2035 $1,151.50

44500 Intro gastrointestinal tube Y G2 5.9217 $250.66

44701 Intraop colon lavage add-on N N1

45000 Drainage of pelvic abscess Y A2 22.9144 $969.94

45005 Drainage of rectal abscess Y A2 22.9144 $969.94

45020 Drainage of rectal abscess Y A2 15.0188 $635.73

45100 Biopsy of rectum Y A2 22.9144 $969.94

45108 Removal of anorectal lesion Y A2 22.9144 $969.94

45150 Excision of rectal stricture Y A2 22.9144 $969.94

45160 Excision of rectal lesion Y A2 22.9144 $969.94

45171 Exc rect tum transanal part Y G2 22.9144 $969.94

45172 Exc rect tum transanal full Y G2 22.9144 $969.94

45190 Destruction rectal tumor Y A2 22.9144 $969.94

45300 Proctosigmoidoscopy dx Y P3 $62.54

45303 Proctosigmoidoscopy dilate Y P2 10.3308 $437.29

45305 Proctosigmoidoscopy w/bx Y A2 10.3308 $437.29

45307 Proctosigmoidoscopy fb Y A2 22.4689 $951.09

45308 Proctosigmoidoscopy removal Y A2 10.3308 $437.29

45309 Proctosigmoidoscopy removal Y A2 10.3308 $437.29

45315 Proctosigmoidoscopy removal Y A2 10.3308 $437.29

45317 Proctosigmoidoscopy bleed Y A2 10.3308 $437.29

45320 Proctosigmoidoscopy ablate Y A2 22.4689 $951.09

45321 Proctosigmoidoscopy volvul Y A2 22.4689 $951.09

45327 Proctosigmoidoscopy w/stent Y A2 27.2035 $1,151.50

45330 Diagnostic sigmoidoscopy Y P3 $73.33

45331 Sigmoidoscopy and biopsy Y A2 5.9086 $250.11

45332 Sigmoidoscopy w/fb removal Y A2 5.9086 $250.11

45333 Sigmoidoscopy & polypectomy Y A2 5.9086 $250.11

45334 Sigmoidoscopy for bleeding Y A2 10.3308 $437.29

45335 Sigmoidoscopy w/submuc inj Y A2 5.9086 $250.11

45337 Sigmoidoscopy & decompress Y A2 5.9086 $250.11

45338 Sigmoidoscopy w/tumr remove Y A2 5.9086 $250.11

45339 Sigmoidoscopy w/ablate tumr Y A2 10.3308 $437.29

Date Printed: 3/14/2013 @ 8:00 PM Page 41 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

45340 Sig w/balloon dilation Y A2 10.3308 $437.29

45341 Sigmoidoscopy w/ultrasound Y A2 5.9086 $250.11

45342 Sigmoidoscopy w/us guide bx Y A2 10.3308 $437.29

45345 Sigmoidoscopy w/stent Y A2 27.2035 $1,151.50

45355 Surgical colonoscopy Y A2 8.734 $369.70

45378 Diagnostic colonoscopy Y A2 8.734 $369.70

45379 Colonoscopy w/fb removal Y A2 8.734 $369.70

45380 Colonoscopy and biopsy Y A2 8.734 $369.70

45381 Colonoscopy submucous inj Y A2 8.734 $369.70

45382 Colonoscopy/control bleeding Y A2 8.734 $369.70

45383 Lesion removal colonoscopy Y A2 8.734 $369.70

45384 Lesion remove colonoscopy Y A2 8.734 $369.70

45385 Lesion removal colonoscopy Y A2 8.734 $369.70

45386 Colonoscopy dilate stricture Y A2 8.734 $369.70

45387 Colonoscopy w/stent Y A2 27.2035 $1,151.50

45391 Colonoscopy w/endoscope us Y A2 8.734 $369.70

45392 Colonoscopy w/endoscopic fnb Y A2 8.734 $369.70

45500 Repair of rectum Y A2 22.9144 $969.94

45505 Repair of rectum Y A2 30.9056 $1,308.20

45520 Treatment of rectal prolapse Y P2 0.9172 $38.82

45541 Correct rectal prolapse Y G2 30.9056 $1,308.20

45560 Repair of rectocele Y A2 30.9056 $1,308.20

45900 Reduction of rectal prolapse Y A2 5.7224 $242.22

45905 Dilation of anal sphincter Y A2 22.9144 $969.94

45910 Dilation of rectal narrowing Y A2 22.9144 $969.94

45915 Remove rectal obstruction Y A2 15.0188 $635.73

45990 Surg dx exam anorectal Y A2 22.9144 $969.94

46020 Placement of seton Y A2 22.9144 $969.94

46030 Removal of rectal marker Y A2 5.7224 $242.22

46040 Incision of rectal abscess Y A2 22.9144 $969.94

46045 Incision of rectal abscess Y A2 22.9144 $969.94

46050 Incision of anal abscess Y A2 5.7224 $242.22

46060 Incision of rectal abscess Y A2 22.9144 $969.94

46070 Incision of anal septum Y G2 15.0188 $635.73

46080 Incision of anal sphincter Y A2 22.9144 $969.94

46083 Incise external hemorrhoid Y CH P3 $83.15

46200 Removal of anal fissure Y A2 22.9144 $969.94

46220 Excise anal ext tag/papilla Y A2 15.0188 $635.73

46221 Ligation of hemorrhoid(s) Y P3 $118.86

46230 Removal of anal tags Y A2 22.9144 $969.94

46250 Remove ext hem groups 2+ Y A2 22.9144 $969.94

46255 Remove int/ext hem 1 group Y A2 22.9144 $969.94

46257 Remove in/ex hem grp & fiss Y A2 22.9144 $969.94

46258 Remove in/ex hem grp w/fistu Y A2 22.9144 $969.94

46260 Remove in/ex hem groups 2+ Y A2 22.9144 $969.94

46261 Remove in/ex hem grps & fiss Y A2 22.9144 $969.94

46262 Remove in/ex hem grps w/fist Y A2 22.9144 $969.94

46270 Remove anal fist subq Y A2 22.9144 $969.94

46275 Remove anal fist inter Y A2 22.9144 $969.94

46280 Remove anal fist complex Y A2 22.9144 $969.94

46285 Remove anal fist 2 stage Y A2 22.9144 $969.94

46288 Repair anal fistula Y A2 22.9144 $969.94

46320 Removal of hemorrhoid clot Y P3 $80.04

46500 Injection into hemorrhoid(s) Y P3 $114.31

46505 Chemodenervation anal musc Y G2 22.9144 $969.94

46600 Diagnostic anoscopy N P2 0.6316 $26.73

46604 Anoscopy and dilation Y CH P3 $391.08

46606 Anoscopy and biopsy Y P3 $122.21

Date Printed: 3/14/2013 @ 8:00 PM Page 42 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

46608 Anoscopy remove for body Y A2 5.9086 $250.11

46610 Anoscopy remove lesion Y A2 22.4689 $951.09

46611 Anoscopy Y A2 10.3308 $437.29

46612 Anoscopy remove lesions Y A2 22.4689 $951.09

46614 Anoscopy control bleeding Y P3 $62.07

46615 Anoscopy Y A2 22.4689 $951.09

46700 Repair of anal stricture Y A2 22.9144 $969.94

46706 Repr of anal fistula w/glue Y A2 30.9056 $1,308.20

46707 Repair anorectal fist w/plug Y G2 30.9056 $1,308.20

46750 Repair of anal sphincter Y A2 30.9056 $1,308.20

46753 Reconstruction of anus Y A2 22.9144 $969.94

46754 Removal of suture from anus Y A2 22.9144 $969.94

46760 Repair of anal sphincter Y A2 30.9056 $1,308.20

46761 Repair of anal sphincter Y A2 30.9056 $1,308.20

46762 Implant artificial sphincter Y A2 30.9056 $1,308.20

46900 Destruction anal lesion(s) Y P2 2.6477 $112.07

46910 Destruction anal lesion(s) Y P3 $121.73

46916 Cryosurgery anal lesion(s) Y P2 1.4 $59.26

46917 Laser surgery anal lesions Y A2 20.6797 $875.35

46922 Excision of anal lesion(s) Y A2 20.6797 $875.35

46924 Destruction anal lesion(s) Y A2 20.6797 $875.35

46930 Destroy internal hemorrhoids Y P3 $100.17

46940 Treatment of anal fissure Y P3 $92.74

46942 Treatment of anal fissure Y P3 $90.34

46945 Remove by ligat int hem grp Y P3 $149.05

46946 Remove by ligat int hem grps Y A2 22.9144 $969.94

46947 Hemorrhoidopexy by stapling Y A2 30.9056 $1,308.20

47000 Needle biopsy of liver Y A2 9.1181 $385.96

47001 Needle biopsy liver add-on N N1

47382 Percut ablate liver rf Y G2 53.5857 $2,268.23

47500 Injection for liver x-rays N N1

47505 Injection for liver x-rays N N1

47510 Insert catheter bile duct Y A2 29.3168 $1,240.95

47511 Insert bile duct drain Y A2 29.3168 $1,240.95

47525 Change bile duct catheter Y A2 15.1986 $643.34

47530 Revise/reinsert bile tube Y A2 15.1986 $643.34

47552 Biliary endoscopy thru skin Y A2 29.3168 $1,240.95

47553 Biliary endoscopy thru skin Y A2 29.3168 $1,240.95

47554 Biliary endoscopy thru skin Y A2 29.3168 $1,240.95

47555 Biliary endoscopy thru skin Y A2 29.3168 $1,240.95

47556 Biliary endoscopy thru skin Y A2 29.3168 $1,240.95

47560 Laparoscopy w/cholangio Y A2 36.6358 $1,550.76

47561 Laparo w/cholangio/biopsy Y A2 36.6358 $1,550.76

47562 Laparoscopic cholecystectomy Y G2 44.7246 $1,893.15

47563 Laparo cholecystectomy/graph Y G2 44.7246 $1,893.15

47564 Laparo cholecystectomy/explr Y G2 44.7246 $1,893.15

47630 Remove bile duct stone Y A2 29.3168 $1,240.95

48102 Needle biopsy pancreas Y A2 9.1181 $385.96

49080 Puncture peritoneal cavity Y A2 5.2088 $220.48

49081 Removal of abdominal fluid Y A2 5.2088 $220.48

49180 Biopsy abdominal mass Y A2 9.1181 $385.96

49250 Excision of umbilicus Y A2 24.9768 $1,057.24

49320 Diag laparo separate proc Y A2 36.6358 $1,550.76

49321 Laparoscopy biopsy Y A2 36.6358 $1,550.76

49322 Laparoscopy aspiration Y A2 36.6358 $1,550.76

49324 Lap insert tunnel ip cath Y G2 36.6358 $1,550.76

49325 Lap revision perm ip cath Y G2 36.6358 $1,550.76

49326 Lap w/omentopexy add-on Y G2 36.6358 $1,550.76

Date Printed: 3/14/2013 @ 8:00 PM Page 43 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

49327 Lap ins device for rt Y G2 36.6358 $1,550.76

49400 Air injection into abdomen N N1

49402 Remove foreign body adbomen Y A2 24.9768 $1,057.24

49411 Ins mark abd/pel for rt perq N P3 $285.17

49418 Insert tun ip cath perc Y G2 28.7055 $1,215.08

49419 Insert tun ip cath w/port Y A2 34.5668 $1,463.18

49421 Ins tun ip cath for dial opn Y G2 28.7055 $1,215.08

49422 Remove tunneled ip cath Y A2 21.7851 $922.14

49423 Exchange drainage catheter Y G2 15.1986 $643.34

49424 Assess cyst contrast inject N N1

49426 Revise abdomen-venous shunt Y A2 24.9768 $1,057.24

49427 Injection abdominal shunt N N1

49429 Removal of shunt Y G2 21.7851 $922.14

49435 Insert subq exten to ip cath Y G2 15.1986 $643.34

49436 Embedded ip cath exit-site Y G2 15.1986 $643.34

49440 Place gastrostomy tube perc Y G2 11.7812 $498.69

49441 Place duod/jej tube perc Y G2 11.7812 $498.69

49442 Place cecostomy tube perc Y G2 22.9144 $969.94

49446 Change g-tube to g-j perc Y G2 11.7812 $498.69

49450 Replace g/c tube perc Y G2 5.9217 $250.66

49451 Replace duod/jej tube perc Y G2 5.9217 $250.66

49452 Replace g-j tube perc Y G2 5.9217 $250.66

49460 Fix g/colon tube w/device Y G2 5.9217 $250.66

49465 Fluoro exam of g/colon tube N N1

49495 Rpr ing hernia baby reduc Y A2 30.9069 $1,308.26

49496 Rpr ing hernia baby blocked Y A2 30.9069 $1,308.26

49500 Rpr ing hernia init reduce Y A2 30.9069 $1,308.26

49501 Rpr ing hernia init blocked Y A2 30.9069 $1,308.26

49505 Prp i/hern init reduc >5 yr Y A2 30.9069 $1,308.26

49507 Prp i/hern init block >5 yr Y A2 30.9069 $1,308.26

49520 Rerepair ing hernia reduce Y A2 30.9069 $1,308.26

49521 Rerepair ing hernia blocked Y A2 30.9069 $1,308.26

49525 Repair ing hernia sliding Y A2 30.9069 $1,308.26

49540 Repair lumbar hernia Y A2 30.9069 $1,308.26

49550 Rpr rem hernia init reduce Y A2 30.9069 $1,308.26

49553 Rpr fem hernia init blocked Y A2 30.9069 $1,308.26

49555 Rerepair fem hernia reduce Y A2 30.9069 $1,308.26

49557 Rerepair fem hernia blocked Y A2 30.9069 $1,308.26

49560 Rpr ventral hern init reduc Y A2 30.9069 $1,308.26

49561 Rpr ventral hern init block Y A2 30.9069 $1,308.26

49565 Rerepair ventrl hern reduce Y A2 30.9069 $1,308.26

49566 Rerepair ventrl hern block Y A2 30.9069 $1,308.26

49568 Hernia repair w/mesh Y A2 30.9069 $1,308.26

49570 Rpr epigastric hern reduce Y A2 30.9069 $1,308.26

49572 Rpr epigastric hern blocked Y A2 30.9069 $1,308.26

49580 Rpr umbil hern reduc < 5 yr Y A2 30.9069 $1,308.26

49582 Rpr umbil hern block < 5 yr Y A2 30.9069 $1,308.26

49585 Rpr umbil hern reduc > 5 yr Y A2 30.9069 $1,308.26

49587 Rpr umbil hern block > 5 yr Y A2 30.9069 $1,308.26

49590 Repair spigelian hernia Y A2 30.9069 $1,308.26

49600 Repair umbilical lesion Y A2 30.9069 $1,308.26

49650 Lap ing hernia repair init Y A2 44.7246 $1,893.15

49651 Lap ing hernia repair recur Y A2 44.7246 $1,893.15

49652 Lap vent/abd hernia repair Y G2 66.5906 $2,818.71

49653 Lap vent/abd hern proc comp Y G2 66.5906 $2,818.71

49654 Lap inc hernia repair Y G2 66.5906 $2,818.71

49655 Lap inc hern repair comp Y G2 66.5906 $2,818.71

49656 Lap inc hernia repair recur Y G2 66.5906 $2,818.71

Date Printed: 3/14/2013 @ 8:00 PM Page 44 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

49657 Lap inc hern recur comp Y G2 66.5906 $2,818.71

50080 Removal of kidney stone Y G2 42.989 $1,819.68

50081 Removal of kidney stone Y G2 42.989 $1,819.68

50200 Renal biopsy perq Y A2 9.1181 $385.96

50382 Change ureter stent percut Y G2 24.6219 $1,042.22

50384 Remove ureter stent percut Y G2 16.5657 $701.21

50385 Change stent via transureth Y G2 24.6219 $1,042.22

50386 Remove stent via transureth Y P2 6.898 $291.99

50387 Change ext/int ureter stent Y G2 15.1986 $643.34

50389 Remove renal tube w/fluoro Y G2 6.898 $291.99

50390 Drainage of kidney lesion Y A2 9.1181 $385.96

50391 Instll rx agnt into rnal tub Y CH P3 $35.47

50392 Insert kidney drain Y A2 16.5657 $701.21

50393 Insert ureteral tube Y A2 24.6219 $1,042.22

50394 Injection for kidney x-ray N N1

50395 Create passage to kidney Y A2 24.6219 $1,042.22

50396 Measure kidney pressure Y A2 1.9658 $83.21

50398 Change kidney tube Y A2 15.1986 $643.34

50551 Kidney endoscopy Y A2 6.898 $291.99

50553 Kidney endoscopy Y A2 24.6219 $1,042.22

50555 Kidney endoscopy & biopsy Y A2 6.898 $291.99

50557 Kidney endoscopy & treatment Y A2 24.6219 $1,042.22

50561 Kidney endoscopy & treatment Y A2 24.6219 $1,042.22

50562 Renal scope w/tumor resect Y G2 6.898 $291.99

50570 Kidney endoscopy Y G2 6.898 $291.99

50572 Kidney endoscopy Y G2 6.898 $291.99

50574 Kidney endoscopy & biopsy Y G2 6.898 $291.99

50575 Kidney endoscopy Y G2 34.6431 $1,466.41

50576 Kidney endoscopy & treatment Y G2 16.5657 $701.21

50580 Kidney endoscopy & treatment Y G2 16.5657 $701.21

50590 Fragmenting of kidney stone Y G2 48.1808 $2,039.45

50592 Perc rf ablate renal tumor Y G2 53.5857 $2,268.23

50593 Perc cryo ablate renal tum Y G2 53.5857 $2,268.23

50684 Injection for ureter x-ray N N1

50686 Measure ureter pressure Y P2 1.0965 $46.41

50688 Change of ureter tube/stent Y A2 15.1986 $643.34

50690 Injection for ureter x-ray N N1

50727 Revise ureter Y G2 18.9297 $801.28

50947 Laparo new ureter/bladder Y A2 44.7246 $1,893.15

50948 Laparo new ureter/bladder Y A2 44.7246 $1,893.15

50951 Endoscopy of ureter Y A2 6.898 $291.99

50953 Endoscopy of ureter Y A2 6.898 $291.99

50955 Ureter endoscopy & biopsy Y A2 24.6219 $1,042.22

50957 Ureter endoscopy & treatment Y A2 24.6219 $1,042.22

50961 Ureter endoscopy & treatment Y A2 24.6219 $1,042.22

50970 Ureter endoscopy Y A2 6.898 $291.99

50972 Ureter endoscopy & catheter Y A2 6.898 $291.99

50974 Ureter endoscopy & biopsy Y A2 16.5657 $701.21

50976 Ureter endoscopy & treatment Y A2 16.5657 $701.21

50980 Ureter endoscopy & treatment Y A2 24.6219 $1,042.22

51020 Incise & treat bladder Y A2 24.6219 $1,042.22

51030 Incise & treat bladder Y A2 24.6219 $1,042.22

51040 Incise & drain bladder Y A2 24.6219 $1,042.22

51045 Incise bladder/drain ureter Y A2 6.898 $291.99

51050 Removal of bladder stone Y A2 24.6219 $1,042.22

51065 Remove ureter calculus Y A2 24.6219 $1,042.22

51080 Drainage of bladder abscess Y A2 19.2522 $814.93

51100 Drain bladder by needle Y P3 $22.53

Date Printed: 3/14/2013 @ 8:00 PM Page 45 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

51101 Drain bladder by trocar/cath Y P2 1.0965 $46.41

51102 Drain bl w/cath insertion Y A2 18.9297 $801.28

51500 Removal of bladder cyst Y A2 30.9069 $1,308.26

51520 Removal of bladder lesion Y A2 24.6219 $1,042.22

51535 Repair of ureter lesion Y G2 24.6219 $1,042.22

51600 Injection for bladder x-ray N N1

51605 Preparation for bladder xray N N1

51610 Injection for bladder x-ray N N1

51700 Irrigation of bladder Y P3 $36.42

51701 Insert bladder catheter N P2 0.6316 $26.73

51702 Insert temp bladder cath N P2 0.6316 $26.73

51703 Insert bladder cath complex Y P2 1.0965 $46.41

51705 Change of bladder tube Y P3 $38.34

51710 Change of bladder tube Y A2 5.9217 $250.66

51715 Endoscopic injection/implant Y A2 30.0914 $1,273.74

51720 Treatment of bladder lesion Y P3 $38.58

51725 Simple cystometrogram Y CH P3 $85.55

51726 Complex cystometrogram Y A2 2.9971 $126.86

51727 Cystometrogram w/up Y P2 2.9971 $126.86

51728 Cystometrogram w/vp Y P2 2.9971 $126.86

51729 Cystometrogram w/vp&up Y P2 2.9971 $126.86

51736 Urine flow measurement N P3 $15.58

51741 Electro-uroflowmetry first Y P3 $18.21

51784 Anal/urinary muscle study Y P2 1.0965 $46.41

51785 Anal/urinary muscle study Y A2 1.9658 $83.21

51792 Urinary reflex study Y P2 1.0965 $46.41

51797 Intraabdominal pressure test Y CH P3 $57.51

51798 Us urine capacity measure N P3 $13.42

51880 Repair of bladder opening Y A2 24.6219 $1,042.22

51992 Laparo sling operation Y A2 44.7246 $1,893.15

52000 Cystoscopy Y A2 6.898 $291.99

52001 Cystoscopy removal of clots Y A2 16.5657 $701.21

52005 Cystoscopy & ureter catheter Y A2 24.6219 $1,042.22

52007 Cystoscopy and biopsy Y A2 24.6219 $1,042.22

52010 Cystoscopy & duct catheter Y A2 6.898 $291.99

52204 Cystoscopy w/biopsy(s) Y A2 24.6219 $1,042.22

52214 Cystoscopy and treatment Y A2 24.6219 $1,042.22

52224 Cystoscopy and treatment Y A2 24.6219 $1,042.22

52234 Cystoscopy and treatment Y A2 24.6219 $1,042.22

52235 Cystoscopy and treatment Y A2 24.6219 $1,042.22

52240 Cystoscopy and treatment Y A2 24.6219 $1,042.22

52250 Cystoscopy and radiotracer Y A2 24.6219 $1,042.22

52260 Cystoscopy and treatment Y A2 16.5657 $701.21

52265 Cystoscopy and treatment Y CH P3 $193.63

52270 Cystoscopy & revise urethra Y A2 16.5657 $701.21

52275 Cystoscopy & revise urethra Y A2 24.6219 $1,042.22

52276 Cystoscopy and treatment Y A2 24.6219 $1,042.22

52277 Cystoscopy and treatment Y A2 24.6219 $1,042.22

52281 Cystoscopy and treatment Y A2 16.5657 $701.21

52282 Cystoscopy implant stent Y A2 34.6431 $1,466.41

52283 Cystoscopy and treatment Y A2 24.6219 $1,042.22

52285 Cystoscopy and treatment Y A2 16.5657 $701.21

52290 Cystoscopy and treatment Y A2 24.6219 $1,042.22

52300 Cystoscopy and treatment Y A2 24.6219 $1,042.22

52301 Cystoscopy and treatment Y A2 24.6219 $1,042.22

52305 Cystoscopy and treatment Y A2 24.6219 $1,042.22

52310 Cystoscopy and treatment Y A2 16.5657 $701.21

52315 Cystoscopy and treatment Y A2 24.6219 $1,042.22

Date Printed: 3/14/2013 @ 8:00 PM Page 46 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

52317 Remove bladder stone Y A2 24.6219 $1,042.22

52318 Remove bladder stone Y A2 24.6219 $1,042.22

52320 Cystoscopy and treatment Y A2 24.6219 $1,042.22

52325 Cystoscopy stone removal Y A2 24.6219 $1,042.22

52327 Cystoscopy inject material Y A2 34.6431 $1,466.41

52330 Cystoscopy and treatment Y A2 24.6219 $1,042.22

52332 Cystoscopy and treatment Y A2 24.6219 $1,042.22

52334 Create passage to kidney Y A2 24.6219 $1,042.22

52341 Cysto w/ureter stricture tx Y A2 24.6219 $1,042.22

52342 Cysto w/up stricture tx Y A2 24.6219 $1,042.22

52343 Cysto w/renal stricture tx Y A2 24.6219 $1,042.22

52344 Cysto/uretero stricture tx Y A2 24.6219 $1,042.22

52345 Cysto/uretero w/up stricture Y A2 24.6219 $1,042.22

52346 Cystouretero w/renal strict Y A2 24.6219 $1,042.22

52351 Cystouretero & or pyeloscope Y A2 24.6219 $1,042.22

52352 Cystouretero w/stone remove Y A2 24.6219 $1,042.22

52353 Cystouretero w/lithotripsy Y A2 34.6431 $1,466.41

52354 Cystouretero w/biopsy Y A2 24.6219 $1,042.22

52355 Cystouretero w/excise tumor Y A2 24.6219 $1,042.22

52400 Cystouretero w/congen repr Y A2 24.6219 $1,042.22

52402 Cystourethro cut ejacul duct Y A2 24.6219 $1,042.22

52450 Incision of prostate Y A2 24.6219 $1,042.22

52500 Revision of bladder neck Y A2 24.6219 $1,042.22

52601 Prostatectomy (TURP) Y A2 34.6431 $1,466.41

52630 Remove prostate regrowth Y A2 34.6431 $1,466.41

52640 Relieve bladder contracture Y A2 24.6219 $1,042.22

52647 Laser surgery of prostate Y A2 42.989 $1,819.68

52648 Laser surgery of prostate Y A2 42.989 $1,819.68

52649 Prostate laser enucleation Y G2 42.989 $1,819.68

52700 Drainage of prostate abscess Y A2 24.6219 $1,042.22

53000 Incision of urethra Y A2 19.4946 $825.19

53010 Incision of urethra Y A2 19.4946 $825.19

53020 Incision of urethra Y A2 19.4946 $825.19

53025 Incision of urethra Y R2 19.4946 $825.19

53040 Drainage of urethra abscess Y A2 19.4946 $825.19

53060 Drainage of urethra abscess Y P3 $58.23

53080 Drainage of urinary leakage Y A2 19.4946 $825.19

53085 Drainage of urinary leakage Y G2 19.4946 $825.19

53200 Biopsy of urethra Y A2 19.4946 $825.19

53210 Removal of urethra Y A2 30.0914 $1,273.74

53215 Removal of urethra Y A2 19.4946 $825.19

53220 Treatment of urethra lesion Y A2 30.0914 $1,273.74

53230 Removal of urethra lesion Y A2 30.0914 $1,273.74

53235 Removal of urethra lesion Y A2 19.4946 $825.19

53240 Surgery for urethra pouch Y A2 30.0914 $1,273.74

53250 Removal of urethra gland Y A2 19.4946 $825.19

53260 Treatment of urethra lesion Y A2 19.4946 $825.19

53265 Treatment of urethra lesion Y A2 19.4946 $825.19

53270 Removal of urethra gland Y A2 19.4946 $825.19

53275 Repair of urethra defect Y A2 19.4946 $825.19

53400 Revise urethra stage 1 Y A2 30.0914 $1,273.74

53405 Revise urethra stage 2 Y A2 30.0914 $1,273.74

53410 Reconstruction of urethra Y A2 30.0914 $1,273.74

53420 Reconstruct urethra stage 1 Y A2 30.0914 $1,273.74

53425 Reconstruct urethra stage 2 Y A2 30.0914 $1,273.74

53430 Reconstruction of urethra Y A2 30.0914 $1,273.74

53431 Reconstruct urethra/bladder Y A2 30.0914 $1,273.74

53440 Male sling procedure N CH J8 141.6995 $5,998.00

Date Printed: 3/14/2013 @ 8:00 PM Page 47 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

53442 Remove/revise male sling Y A2 30.0914 $1,273.74

53444 Insert tandem cuff N CH J8 141.6995 $5,998.00

53445 Insert uro/ves nck sphincter N CH J8 241.3804 $10,217.39

53446 Remove uro sphincter Y A2 30.0914 $1,273.74

53447 Remove/replace ur sphincter N CH J8 241.3804 $10,217.39

53449 Repair uro sphincter Y A2 30.0914 $1,273.74

53450 Revision of urethra Y A2 30.0914 $1,273.74

53460 Revision of urethra Y A2 19.4946 $825.19

53502 Repair of urethra injury Y A2 19.4946 $825.19

53505 Repair of urethra injury Y A2 30.0914 $1,273.74

53510 Repair of urethra injury Y A2 19.4946 $825.19

53515 Repair of urethra injury Y A2 30.0914 $1,273.74

53520 Repair of urethra defect Y A2 30.0914 $1,273.74

53600 Dilate urethra stricture Y P3 $27.32

53601 Dilate urethra stricture Y CH P3 $32.11

53605 Dilate urethra stricture Y A2 16.5657 $701.21

53620 Dilate urethra stricture Y P3 $40.74

53621 Dilate urethra stricture Y P3 $43.13

53660 Dilation of urethra Y CH P3 $31.63

53661 Dilation of urethra Y CH P3 $30.67

53665 Dilation of urethra Y A2 19.4946 $825.19

53850 Prostatic microwave thermotx Y CH P3 $1,239.87

53852 Prostatic rf thermotx Y CH P3 $1,167.98

53855 Insert prost urethral stent Y P2 1.9658 $83.21

53860 Transurethral rf treatment Y G2 18.9297 $801.28

54000 Slitting of prepuce Y A2 19.4946 $825.19

54001 Slitting of prepuce Y A2 19.4946 $825.19

54015 Drain penis lesion Y A2 19.2522 $814.93

54050 Destruction penis lesion(s) Y P2 0.9172 $38.82

54055 Destruction penis lesion(s) Y P3 $50.08

54056 Cryosurgery penis lesion(s) Y P2 0.9172 $38.82

54057 Laser surg penis lesion(s) Y A2 20.6797 $875.35

54060 Excision of penis lesion(s) Y A2 20.6797 $875.35

54065 Destruction penis lesion(s) Y A2 20.6797 $875.35

54100 Biopsy of penis Y A2 16.113 $682.05

54105 Biopsy of penis Y A2 21.9487 $929.07

54110 Treatment of penis lesion Y A2 32.2247 $1,364.04

54111 Treat penis lesion graft Y A2 32.2247 $1,364.04

54112 Treat penis lesion graft Y A2 32.2247 $1,364.04

54115 Treatment of penis lesion Y A2 19.2522 $814.93

54120 Partial removal of penis Y A2 32.2247 $1,364.04

54150 Circumcision w/regionl block Y A2 22.236 $941.23

54160 Circumcision neonate Y A2 22.236 $941.23

54161 Circum 28 days or older Y A2 22.236 $941.23

54162 Lysis penil circumic lesion Y A2 22.236 $941.23

54163 Repair of circumcision Y A2 22.236 $941.23

54164 Frenulotomy of penis Y A2 22.236 $941.23

54200 Treatment of penis lesion Y P3 $47.45

54205 Treatment of penis lesion Y A2 32.2247 $1,364.04

54220 Treatment of penis lesion Y A2 1.9658 $83.21

54230 Prepare penis study N N1

54231 Dynamic cavernosometry Y P3 $45.53

54235 Penile injection Y P3 $32.59

54240 Penis study Y P3 $24.20

54250 Penis study Y P3 $7.67

54300 Revision of penis Y A2 32.2247 $1,364.04

54304 Revision of penis Y A2 32.2247 $1,364.04

54308 Reconstruction of urethra Y A2 32.2247 $1,364.04

Date Printed: 3/14/2013 @ 8:00 PM Page 48 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

54312 Reconstruction of urethra Y A2 32.2247 $1,364.04

54316 Reconstruction of urethra Y A2 32.2247 $1,364.04

54318 Reconstruction of urethra Y A2 32.2247 $1,364.04

54322 Reconstruction of urethra Y A2 32.2247 $1,364.04

54324 Reconstruction of urethra Y A2 32.2247 $1,364.04

54326 Reconstruction of urethra Y A2 32.2247 $1,364.04

54328 Revise penis/urethra Y A2 32.2247 $1,364.04

54340 Secondary urethral surgery Y A2 32.2247 $1,364.04

54344 Secondary urethral surgery Y A2 32.2247 $1,364.04

54348 Secondary urethral surgery Y A2 32.2247 $1,364.04

54352 Reconstruct urethra/penis Y A2 32.2247 $1,364.04

54360 Penis plastic surgery Y A2 32.2247 $1,364.04

54380 Repair penis Y A2 32.2247 $1,364.04

54385 Repair penis Y A2 32.2247 $1,364.04

54400 Insert semi-rigid prosthesis N CH J8 141.6995 $5,998.00

54401 Insert self-contd prosthesis N CH J8 241.3804 $10,217.39

54405 Insert multi-comp penis pros N CH J8 241.3804 $10,217.39

54406 Remove muti-comp penis pros Y A2 32.2247 $1,364.04

54408 Repair multi-comp penis pros Y A2 32.2247 $1,364.04

54410 Remove/replace penis prosth N CH J8 241.3804 $10,217.39

54415 Remove self-contd penis pros Y A2 32.2247 $1,364.04

54416 Remv/repl penis contain pros N CH J8 241.3804 $10,217.39

54420 Revision of penis Y A2 32.2247 $1,364.04

54435 Revision of penis Y A2 32.2247 $1,364.04

54440 Repair of penis Y A2 32.2247 $1,364.04

54450 Preputial stretching Y A2 2.9971 $126.86

54500 Biopsy of testis Y A2 14.3964 $609.39

54505 Biopsy of testis Y A2 22.236 $941.23

54512 Excise lesion testis Y A2 22.236 $941.23

54520 Removal of testis Y A2 22.236 $941.23

54522 Orchiectomy partial Y A2 22.236 $941.23

54530 Removal of testis Y A2 30.9069 $1,308.26

54550 Exploration for testis Y A2 30.9069 $1,308.26

54560 Exploration for testis Y G2 22.236 $941.23

54600 Reduce testis torsion Y A2 22.236 $941.23

54620 Suspension of testis Y A2 22.236 $941.23

54640 Suspension of testis Y A2 30.9069 $1,308.26

54660 Revision of testis Y A2 22.236 $941.23

54670 Repair testis injury Y A2 22.236 $941.23

54680 Relocation of testis(es) Y A2 22.236 $941.23

54690 Laparoscopy orchiectomy Y A2 44.7246 $1,893.15

54692 Laparoscopy orchiopexy Y G2 66.5906 $2,818.71

54700 Drainage of scrotum Y A2 22.236 $941.23

54800 Biopsy of epididymis Y A2 4.3075 $182.33

54830 Remove epididymis lesion Y A2 22.236 $941.23

54840 Remove epididymis lesion Y A2 22.236 $941.23

54860 Removal of epididymis Y A2 22.236 $941.23

54861 Removal of epididymis Y A2 22.236 $941.23

54865 Explore epididymis Y A2 22.236 $941.23

54900 Fusion of spermatic ducts Y A2 22.236 $941.23

54901 Fusion of spermatic ducts Y A2 22.236 $941.23

55000 Drainage of hydrocele Y P3 $46.01

55040 Removal of hydrocele Y A2 30.9069 $1,308.26

55041 Removal of hydroceles Y A2 30.9069 $1,308.26

55060 Repair of hydrocele Y A2 22.236 $941.23

55100 Drainage of scrotum abscess Y A2 12.6328 $534.73

55110 Explore scrotum Y A2 22.236 $941.23

55120 Removal of scrotum lesion Y A2 22.236 $941.23

Date Printed: 3/14/2013 @ 8:00 PM Page 49 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

55150 Removal of scrotum Y A2 22.236 $941.23

55175 Revision of scrotum Y A2 22.236 $941.23

55180 Revision of scrotum Y A2 22.236 $941.23

55200 Incision of sperm duct Y A2 22.236 $941.23

55250 Removal of sperm duct(s) Y A2 22.236 $941.23

55300 Prepare sperm duct x-ray N N1

55400 Repair of sperm duct Y A2 22.236 $941.23

55450 Ligation of sperm duct Y P3 $141.86

55500 Removal of hydrocele Y A2 22.236 $941.23

55520 Removal of sperm cord lesion Y A2 22.236 $941.23

55530 Revise spermatic cord veins Y A2 22.236 $941.23

55535 Revise spermatic cord veins Y A2 30.9069 $1,308.26

55540 Revise hernia & sperm veins Y A2 30.9069 $1,308.26

55550 Laparo ligate spermatic vein Y A2 44.7246 $1,893.15

55600 Incise sperm duct pouch Y R2 22.236 $941.23

55680 Remove sperm pouch lesion Y A2 22.236 $941.23

55700 Biopsy of prostate Y A2 13.3543 $565.27

55705 Biopsy of prostate Y A2 13.3543 $565.27

55706 Prostate saturation sampling Y G2 13.3543 $565.27

55720 Drainage of prostate abscess Y A2 24.6219 $1,042.22

55725 Drainage of prostate abscess Y A2 24.6219 $1,042.22

55860 Surgical exposure prostate Y G2 18.9297 $801.28

55870 Electroejaculation Y P3 $56.07

55873 Cryoablate prostate Y CH J8 148.617 $6,290.81

55875 Transperi needle place pros N A2 34.6431 $1,466.41

55876 Place rt device/marker pros N P3 $50.32

55920 Place needles pelvic for rt Y G2 24.9768 $1,057.24

56405 I & D of vulva/perineum Y P3 $36.18

56420 Drainage of gland abscess Y CH P3 $46.97

56440 Surgery for vulva lesion Y A2 19.4744 $824.33

56441 Lysis of labial lesion(s) Y A2 19.4744 $824.33

56442 Hymenotomy Y A2 19.4744 $824.33

56501 Destroy vulva lesions sim Y P3 $48.89

56515 Destroy vulva lesion/s compl Y A2 20.6797 $875.35

56605 Biopsy of vulva/perineum Y P3 $28.04

56606 Biopsy of vulva/perineum Y P3 $11.50

56620 Partial removal of vulva Y A2 19.4744 $824.33

56625 Complete removal of vulva Y A2 19.4744 $824.33

56700 Partial removal of hymen Y A2 19.4744 $824.33

56740 Remove vagina gland lesion Y A2 19.4744 $824.33

56800 Repair of vagina Y A2 19.4744 $824.33

56805 Repair clitoris Y G2 19.4744 $824.33

56810 Repair of perineum Y A2 19.4744 $824.33

56820 Exam of vulva w/scope Y P3 $36.66

56821 Exam/biopsy of vulva w/scope Y CH P3 $47.21

57000 Exploration of vagina Y A2 19.4744 $824.33

57010 Drainage of pelvic abscess Y A2 19.4744 $824.33

57020 Drainage of pelvic fluid Y A2 6.5922 $279.04

57022 I & d vaginal hematoma pp Y R2 12.6328 $534.73

57023 I & d vag hematoma non-ob Y A2 19.2522 $814.93

57061 Destroy vag lesions simple Y P3 $44.57

57065 Destroy vag lesions complex Y A2 19.4744 $824.33

57100 Biopsy of vagina Y P3 $29.24

57105 Biopsy of vagina Y A2 19.4744 $824.33

57130 Remove vagina lesion Y A2 19.4744 $824.33

57135 Remove vagina lesion Y A2 19.4744 $824.33

57150 Treat vagina infection Y P3 $17.97

57155 Insert uteri tandems/ovoids Y A2 6.5922 $279.04

Date Printed: 3/14/2013 @ 8:00 PM Page 50 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

57156 Ins vag brachytx device Y G2 3.3856 $143.31

57160 Insert pessary/other device Y P3 $29.71

57170 Fitting of diaphragm/cap Y P2 0.1194 $5.05

57180 Treat vaginal bleeding Y A2 1.509 $63.87

57200 Repair of vagina Y A2 19.4744 $824.33

57210 Repair vagina/perineum Y A2 19.4744 $824.33

57220 Revision of urethra Y A2 42.7236 $1,808.45

57230 Repair of urethral lesion Y A2 33.6791 $1,425.60

57240 Repair bladder & vagina Y A2 33.6791 $1,425.60

57250 Repair rectum & vagina Y A2 33.6791 $1,425.60

57260 Repair of vagina Y A2 33.6791 $1,425.60

57265 Extensive repair of vagina Y A2 42.7236 $1,808.45

57267 Insert mesh/pelvic flr addon Y A2 33.6791 $1,425.60

57268 Repair of bowel bulge Y A2 33.6791 $1,425.60

57287 Revise/remove sling repair Y G2 33.6791 $1,425.60

57288 Repair bladder defect Y A2 42.7236 $1,808.45

57289 Repair bladder & vagina Y A2 33.6791 $1,425.60

57291 Construction of vagina Y A2 33.6791 $1,425.60

57295 Revise vag graft via vagina Y G2 19.4744 $824.33

57300 Repair rectum-vagina fistula Y A2 33.6791 $1,425.60

57320 Repair bladder-vagina lesion Y G2 33.6791 $1,425.60

57400 Dilation of vagina Y A2 19.4744 $824.33

57410 Pelvic examination Y A2 19.4744 $824.33

57415 Remove vaginal foreign body Y A2 19.4744 $824.33

57420 Exam of vagina w/scope Y P3 $37.86

57421 Exam/biopsy of vag w/scope Y P3 $49.36

57426 Revise prosth vag graft lap Y G2 19.4744 $824.33

57452 Exam of cervix w/scope Y P3 $35.47

57454 Bx/curett of cervix w/scope Y P3 $44.33

57455 Biopsy of cervix w/scope Y P3 $46.25

57456 Endocerv curettage w/scope Y P3 $44.57

57460 Bx of cervix w/scope leep Y P3 $125.33

57461 Conz of cervix w/scope leep Y P3 $134.44

57500 Biopsy of cervix Y P3 $58.23

57505 Endocervical curettage Y P3 $39.30

57510 Cauterization of cervix Y P3 $40.50

57511 Cryocautery of cervix Y CH P3 $49.13

57513 Laser surgery of cervix Y A2 19.4744 $824.33

57520 Conization of cervix Y A2 19.4744 $824.33

57522 Conization of cervix Y A2 19.4744 $824.33

57530 Removal of cervix Y A2 33.6791 $1,425.60

57550 Removal of residual cervix Y A2 33.6791 $1,425.60

57556 Remove cervix repair bowel Y A2 42.7236 $1,808.45

57558 D&c of cervical stump Y A2 19.4744 $824.33

57700 Revision of cervix Y A2 19.4744 $824.33

57720 Revision of cervix Y A2 19.4744 $824.33

57800 Dilation of cervical canal Y P3 $21.33

58100 Biopsy of uterus lining Y P3 $35.23

58110 Bx done w/colposcopy add-on N N1

58120 Dilation and curettage Y A2 19.4744 $824.33

58145 Myomectomy vag method Y A2 33.6791 $1,425.60

58301 Remove intrauterine device Y P3 $32.35

58321 Artificial insemination Y P3 $29.24

58322 Artificial insemination Y P3 $30.67

58323 Sperm washing Y P3 $5.27

58340 Catheter for hysterography N N1

58345 Reopen fallopian tube Y R2 19.4744 $824.33

58346 Insert heyman uteri capsule Y A2 19.4744 $824.33

Date Printed: 3/14/2013 @ 8:00 PM Page 51 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

58350 Reopen fallopian tube Y A2 33.6791 $1,425.60

58353 Endometr ablate thermal Y A2 33.6791 $1,425.60

58356 Endometrial cryoablation Y P3 $1,200.09

58545 Laparoscopic myomectomy Y A2 36.6358 $1,550.76

58546 Laparo-myomectomy complex Y A2 44.7246 $1,893.15

58550 Laparo-asst vag hysterectomy Y A2 66.5906 $2,818.71

58552 Laparo-vag hyst incl t/o Y G2 44.7246 $1,893.15

58555 Hysteroscopy dx sep proc Y A2 21.733 $919.94

58558 Hysteroscopy biopsy Y A2 21.733 $919.94

58559 Hysteroscopy lysis Y A2 21.733 $919.94

58560 Hysteroscopy resect septum Y A2 35.5353 $1,504.17

58561 Hysteroscopy remove myoma Y A2 35.5353 $1,504.17

58562 Hysteroscopy remove fb Y A2 21.733 $919.94

58563 Hysteroscopy ablation Y A2 35.5353 $1,504.17

58565 Hysteroscopy sterilization Y A2 42.7236 $1,808.45

58600 Division of fallopian tube Y G2 33.6791 $1,425.60

58615 Occlude fallopian tube(s) Y G2 19.4744 $824.33

58660 Laparoscopy lysis Y A2 44.7246 $1,893.15

58661 Laparoscopy remove adnexa Y A2 44.7246 $1,893.15

58662 Laparoscopy excise lesions Y A2 44.7246 $1,893.15

58670 Laparoscopy tubal cautery Y A2 44.7246 $1,893.15

58671 Laparoscopy tubal block Y A2 44.7246 $1,893.15

58672 Laparoscopy fimbrioplasty Y A2 44.7246 $1,893.15

58673 Laparoscopy salpingostomy Y A2 44.7246 $1,893.15

58800 Drainage of ovarian cyst(s) Y A2 19.4744 $824.33

58805 Drainage of ovarian cyst(s) Y G2 33.6791 $1,425.60

58820 Drain ovary abscess open Y A2 33.6791 $1,425.60

58900 Biopsy of ovary(s) Y A2 19.4744 $824.33

58970 Retrieval of oocyte Y A2 3.3856 $143.31

58974 Transfer of embryo Y A2 3.3856 $143.31

58976 Transfer of embryo Y A2 3.3856 $143.31

59000 Amniocentesis diagnostic Y P3 $50.80

59001 Amniocentesis therapeutic Y R2 6.5922 $279.04

59012 Fetal cord puncture prenatal Y G2 3.3856 $143.31

59015 Chorion biopsy Y P3 $44.33

59020 Fetal contract stress test Y P3 $23.24

59025 Fetal non-stress test Y P3 $12.70

59070 Transabdom amnioinfus w/us Y G2 1.509 $63.87

59072 Umbilical cord occlud w/us Y G2 3.3856 $143.31

59076 Fetal shunt placement w/us Y G2 3.3856 $143.31

59100 Remove uterus lesion Y R2 33.6791 $1,425.60

59150 Treat ectopic pregnancy Y G2 44.7246 $1,893.15

59151 Treat ectopic pregnancy Y G2 44.7246 $1,893.15

59160 D & c after delivery Y A2 19.4744 $824.33

59200 Insert cervical dilator Y P3 $27.80

59300 Episiotomy or vaginal repair Y P3 $64.22

59320 Revision of cervix Y A2 19.4744 $824.33

59412 Antepartum manipulation Y G2 19.4744 $824.33

59414 Deliver placenta Y G2 19.4744 $824.33

59812 Treatment of miscarriage Y A2 19.4744 $824.33

59820 Care of miscarriage Y A2 19.4744 $824.33

59821 Treatment of miscarriage Y A2 19.4744 $824.33

59840 Abortion Y A2 19.4744 $824.33

59841 Abortion Y A2 19.4744 $824.33

59866 Abortion (mpr) Y G2 3.3856 $143.31

59870 Evacuate mole of uterus Y A2 19.4744 $824.33

59871 Remove cerclage suture Y A2 19.4744 $824.33

60000 Drain thyroid/tongue cyst Y A2 7.5315 $318.80

Date Printed: 3/14/2013 @ 8:00 PM Page 52 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

60100 Biopsy of thyroid Y P3 $36.66

60200 Remove thyroid lesion Y A2 48.0198 $2,032.63

60210 Partial thyroid excision Y G2 48.0198 $2,032.63

60212 Partial thyroid excision Y G2 48.0198 $2,032.63

60220 Partial removal of thyroid Y G2 48.0198 $2,032.63

60225 Partial removal of thyroid Y G2 48.0198 $2,032.63

60280 Remove thyroid duct lesion Y A2 48.0198 $2,032.63

60281 Remove thyroid duct lesion Y A2 48.0198 $2,032.63

60300 Aspir/inj thyroid cyst Y P3 $53.92

61000 Remove cranial cavity fluid Y R2 7.0747 $299.46

61001 Remove cranial cavity fluid Y R2 7.0747 $299.46

61020 Remove brain cavity fluid Y A2 7.0747 $299.46

61026 Injection into brain canal Y A2 7.0747 $299.46

61050 Remove brain canal fluid Y A2 7.0747 $299.46

61055 Injection into brain canal Y A2 7.0747 $299.46

61070 Brain canal shunt procedure Y A2 5.9217 $250.66

61215 Insert brain-fluid device Y A2 39.8529 $1,686.93

61330 Decompress eye socket Y G2 42.299 $1,790.47

61334 Explore orbit/remove object Y G2 42.299 $1,790.47

61770 Incise skull for treatment Y G2 35.0613 $1,484.11

61781 Scan proc cranial intra N N1

61782 Scan proc cranial extra N N1

61783 Scan proc spinal N N1

61790 Treat trigeminal nerve Y A2 17.8674 $756.31

61791 Treat trigeminal tract Y A2 12.0974 $512.07

61880 Revise/remove neuroelectrode Y G2 19.4458 $823.12

61885 Insrt/redo neurostim 1 array N CH J8 322.5018 $13,651.18

61886 Implant neurostim arrays N CH J8 443.4685 $18,771.58

61888 Revise/remove neuroreceiver Y A2 29.4193 $1,245.29

62160 Neuroendoscopy add-on N N1

62194 Replace/irrigate catheter Y A2 7.0747 $299.46

62225 Replace/irrigate catheter Y A2 15.1986 $643.34

62230 Replace/revise brain shunt Y A2 39.8529 $1,686.93

62252 Csf shunt reprogram N P3 $30.43

62263 Epidural lysis mult sessions Y A2 12.0974 $512.07

62264 Epidural lysis on single day Y A2 12.0974 $512.07

62267 Interdiscal perq aspir dx Y G2 4.3075 $182.33

62268 Drain spinal cord cyst Y A2 7.0747 $299.46

62269 Needle biopsy spinal cord Y A2 9.1181 $385.96

62270 Spinal fluid tap diagnostic Y A2 3.6902 $156.20

62272 Drain cerebro spinal fluid Y A2 3.6902 $156.20

62273 Inject epidural patch Y A2 7.0747 $299.46

62280 Treat spinal cord lesion Y A2 7.0747 $299.46

62281 Treat spinal cord lesion Y A2 12.0974 $512.07

62282 Treat spinal canal lesion Y A2 12.0974 $512.07

62284 Injection for myelogram N N1

62287 Percutaneous diskectomy Y A2 35.0613 $1,484.11

62290 Inject for spine disk x-ray N N1

62291 Inject for spine disk x-ray N N1

62292 Injection into disk lesion Y R2 7.0747 $299.46

62294 Injection into spinal artery Y A2 7.0747 $299.46

62310 Inject spine c/t Y A2 7.0747 $299.46

62311 Inject spine l/s (cd) Y A2 7.0747 $299.46

62318 Inject spine w/cath c/t Y A2 7.0747 $299.46

62319 Inject spine w/cath l/s (cd) Y A2 12.0974 $512.07

62350 Implant spinal canal cath Y A2 39.8529 $1,686.93

62355 Remove spinal canal catheter Y A2 12.0974 $512.07

62360 Insert spine infusion device Y A2 39.8529 $1,686.93

Date Printed: 3/14/2013 @ 8:00 PM Page 53 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

62361 Implant spine infusion pump Y CH J8 286.3545 $12,121.10

62362 Implant spine infusion pump Y CH J8 286.3545 $12,121.10

62365 Remove spine infusion device Y A2 35.0613 $1,484.11

62367 Analyze spine infusion pump N P3 $16.77

62368 Analyze spine infusion pump N P3 $23.00

63600 Remove spinal cord lesion Y A2 17.8674 $756.31

63610 Stimulation of spinal cord Y A2 17.8674 $756.31

63615 Remove lesion of spinal cord Y R2 17.8674 $756.31

63650 Implant neuroelectrodes N CH J8 82.8451 $3,506.75

63655 Implant neuroelectrodes N J8 120.6589 $5,107.37

63661 Remove spine eltrd perq aray Y G2 19.4458 $823.12

63662 Remove spine eltrd plate Y G2 19.4458 $823.12

63663 Revise spine eltrd perq aray Y CH J8 82.8451 $3,506.75

63664 Revise spine eltrd plate Y CH J8 82.8451 $3,506.75

63685 Insrt/redo spine n generator N CH J8 322.5018 $13,651.18

63688 Revise/remove neuroreceiver Y A2 29.4193 $1,245.29

63744 Revision of spinal shunt Y A2 39.8529 $1,686.93

63746 Removal of spinal shunt Y A2 12.0974 $512.07

64400 N block inj trigeminal Y P3 $51.76

64402 N block inj facial Y P3 $48.65

64405 N block inj occipital Y P3 $40.98

64408 N block inj vagus Y P3 $36.90

64410 N block inj phrenic Y A2 2.5957 $109.87

64412 N block inj spinal accessor Y P3 $71.17

64413 N block inj cervical plexus Y P3 $47.93

64415 N block inj brachial plexus Y A2 3.6902 $156.20

64416 N block cont infuse b plex Y G2 7.0747 $299.46

64417 N block inj axillary Y A2 3.6902 $156.20

64418 N block inj suprascapular Y P3 $62.54

64420 N block inj intercost sng Y A2 3.6902 $156.20

64421 N block inj intercost mlt Y A2 7.0747 $299.46

64425 N block inj ilio-ing/hypogi Y P3 $47.21

64430 N block inj pudendal Y A2 7.0747 $299.46

64435 N block inj paracervical Y P3 $57.99

64445 N block inj sciatic sng Y P3 $55.60

64446 N blk inj sciatic cont inf Y G2 7.0747 $299.46

64447 N block inj fem single Y P3 $46.73

64448 N block inj fem cont inf Y G2 7.0747 $299.46

64449 N block inj lumbar plexus Y G2 7.0747 $299.46

64450 N block other peripheral Y P3 $40.98

64455 N block inj plantar digit Y P3 $14.14

64479 Inj foramen epidural c/t Y A2 7.0747 $299.46

64480 Inj foramen epidural add-on Y A2 3.6902 $156.20

64483 Inj foramen epidural l/s Y A2 7.0747 $299.46

64484 Inj foramen epidural add-on Y A2 3.6902 $156.20

64490 Inj paravert f jnt c/t 1 lev Y G2 7.0747 $299.46

64491 Inj paravert f jnt c/t 2 lev Y G2 2.5957 $109.87

64492 Inj paravert f jnt c/t 3 lev Y G2 2.5957 $109.87

64493 Inj paravert f jnt l/s 1 lev Y G2 7.0747 $299.46

64494 Inj paravert f jnt l/s 2 lev Y G2 2.5957 $109.87

64495 Inj paravert f jnt l/s 3 lev Y G2 2.5957 $109.87

64505 N block spenopalatine gangl Y P3 $35.47

64508 N block carotid sinus s/p Y P3 $22.53

64510 N block stellate ganglion Y A2 7.0747 $299.46

64517 N block inj hypogas plxs Y A2 7.0747 $299.46

64520 N block lumbar/thoracic Y A2 7.0747 $299.46

64530 N block inj celiac pelus Y A2 7.0747 $299.46

64553 Implant neuroelectrodes N CH J8 82.8451 $3,506.75

Date Printed: 3/14/2013 @ 8:00 PM Page 54 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

64555 Implant neuroelectrodes N J8 82.8451 $3,506.75

64560 Implant neuroelectrodes N J8 82.8451 $3,506.75

64561 Implant neuroelectrodes N CH J8 82.8451 $3,506.75

64565 Implant neuroelectrodes N J8 82.8451 $3,506.75

64566 Neuroeltrd stim post tibial Y G2 2.5957 $109.87

64568 Inc for vagus n elect impl N J8 519.6534 $21,996.41

64569 Revise/repl vagus n eltrd Y G2 19.4458 $823.12

64570 Remove vagus n eltrd Y G2 35.0613 $1,484.11

64575 Implant neuroelectrodes N CH J8 120.6589 $5,107.37

64577 Implant neuroelectrodes N CH J8 120.6589 $5,107.37

64580 Implant neuroelectrodes N CH J8 120.6589 $5,107.37

64581 Implant neuroelectrodes N CH J8 120.6589 $5,107.37

64585 Revise/remove neuroelectrode Y A2 19.4458 $823.12

64590 Insrt/redo pn/gastr stimul N CH J8 322.5018 $13,651.18

64595 Revise/rmv pn/gastr stimul Y A2 29.4193 $1,245.29

64600 Injection treatment of nerve Y A2 12.0974 $512.07

64605 Injection treatment of nerve Y A2 17.8674 $756.31

64610 Injection treatment of nerve Y A2 17.8674 $756.31

64611 Chemodenerv saliv glands Y P3 $39.78

64612 Destroy nerve face muscle Y P3 $58.95

64613 Destroy nerve neck muscle Y P3 $54.64

64614 Destroy nerve extrem musc Y P3 $62.31

64620 Injection treatment of nerve Y A2 12.0974 $512.07

64622 Destr paravertebrl nerve l/s Y A2 12.0974 $512.07

64623 Destr paravertebral n add-on Y A2 7.0747 $299.46

64626 Destr paravertebrl nerve c/t Y A2 12.0974 $512.07

64627 Destr paravertebral n add-on Y A2 2.5957 $109.87

64630 Injection treatment of nerve Y A2 7.0747 $299.46

64632 N block inj common digit Y P3 $27.80

64640 Injection treatment of nerve Y P3 $81.48

64650 Chemodenerv eccrine glands Y P3 $57.03

64653 Chemodenerv eccrine glands Y P3 $63.26

64680 Injection treatment of nerve Y A2 12.0974 $512.07

64681 Injection treatment of nerve Y A2 12.0974 $512.07

64702 Revise finger/toe nerve Y A2 17.8674 $756.31

64704 Revise hand/foot nerve Y A2 17.8674 $756.31

64708 Revise arm/leg nerve Y G2 17.8674 $756.31

64712 Revision of sciatic nerve Y G2 17.8674 $756.31

64713 Revision of arm nerve(s) Y G2 17.8674 $756.31

64714 Revise low back nerve(s) Y G2 17.8674 $756.31

64716 Revision of cranial nerve Y A2 17.8674 $756.31

64718 Revise ulnar nerve at elbow Y A2 17.8674 $756.31

64719 Revise ulnar nerve at wrist Y A2 17.8674 $756.31

64721 Carpal tunnel surgery Y A2 17.8674 $756.31

64722 Relieve pressure on nerve(s) Y A2 17.8674 $756.31

64726 Release foot/toe nerve Y A2 17.8674 $756.31

64727 Internal nerve revision Y A2 17.8674 $756.31

64732 Incision of brow nerve Y A2 17.8674 $756.31

64734 Incision of cheek nerve Y A2 17.8674 $756.31

64736 Incision of chin nerve Y A2 17.8674 $756.31

64738 Incision of jaw nerve Y A2 17.8674 $756.31

64740 Incision of tongue nerve Y A2 17.8674 $756.31

64742 Incision of facial nerve Y A2 17.8674 $756.31

64744 Incise nerve back of head Y A2 17.8674 $756.31

64746 Incise diaphragm nerve Y A2 17.8674 $756.31

64761 Incision of pelvis nerve Y G2 17.8674 $756.31

64763 Incise hip/thigh nerve Y G2 17.8674 $756.31

64766 Incise hip/thigh nerve Y G2 35.0613 $1,484.11

Date Printed: 3/14/2013 @ 8:00 PM Page 55 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

64771 Sever cranial nerve Y A2 17.8674 $756.31

64772 Incision of spinal nerve Y A2 17.8674 $756.31

64774 Remove skin nerve lesion Y A2 17.8674 $756.31

64776 Remove digit nerve lesion Y A2 17.8674 $756.31

64778 Digit nerve surgery add-on Y A2 17.8674 $756.31

64782 Remove limb nerve lesion Y A2 17.8674 $756.31

64783 Limb nerve surgery add-on Y A2 17.8674 $756.31

64784 Remove nerve lesion Y A2 17.8674 $756.31

64786 Remove sciatic nerve lesion Y A2 35.0613 $1,484.11

64787 Implant nerve end Y A2 17.8674 $756.31

64788 Remove skin nerve lesion Y A2 17.8674 $756.31

64790 Removal of nerve lesion Y A2 17.8674 $756.31

64792 Removal of nerve lesion Y A2 35.0613 $1,484.11

64795 Biopsy of nerve Y A2 17.8674 $756.31

64802 Remove sympathetic nerves Y A2 17.8674 $756.31

64820 Remove sympathetic nerves Y G2 17.8674 $756.31

64821 Remove sympathetic nerves Y A2 27.1987 $1,151.29

64822 Remove sympathetic nerves Y G2 27.1987 $1,151.29

64823 Remove sympathetic nerves Y G2 27.1987 $1,151.29

64831 Repair of digit nerve Y A2 35.0613 $1,484.11

64832 Repair nerve add-on Y A2 35.0613 $1,484.11

64834 Repair of hand or foot nerve Y A2 35.0613 $1,484.11

64835 Repair of hand or foot nerve Y A2 35.0613 $1,484.11

64836 Repair of hand or foot nerve Y A2 35.0613 $1,484.11

64837 Repair nerve add-on Y A2 35.0613 $1,484.11

64840 Repair of leg nerve Y A2 35.0613 $1,484.11

64856 Repair/transpose nerve Y A2 35.0613 $1,484.11

64857 Repair arm/leg nerve Y A2 35.0613 $1,484.11

64858 Repair sciatic nerve Y A2 35.0613 $1,484.11

64859 Nerve surgery Y A2 35.0613 $1,484.11

64861 Repair of arm nerves Y A2 35.0613 $1,484.11

64862 Repair of low back nerves Y A2 35.0613 $1,484.11

64864 Repair of facial nerve Y A2 35.0613 $1,484.11

64865 Repair of facial nerve Y A2 35.0613 $1,484.11

64870 Fusion of facial/other nerve Y A2 35.0613 $1,484.11

64872 Subsequent repair of nerve Y A2 35.0613 $1,484.11

64874 Repair & revise nerve add-on Y A2 35.0613 $1,484.11

64876 Repair nerve/shorten bone Y A2 35.0613 $1,484.11

64885 Nerve graft head or neck Y A2 35.0613 $1,484.11

64886 Nerve graft head or neck Y A2 35.0613 $1,484.11

64890 Nerve graft hand or foot Y A2 35.0613 $1,484.11

64891 Nerve graft hand or foot Y A2 35.0613 $1,484.11

64892 Nerve graft arm or leg Y A2 35.0613 $1,484.11

64893 Nerve graft arm or leg Y A2 35.0613 $1,484.11

64895 Nerve graft hand or foot Y A2 35.0613 $1,484.11

64896 Nerve graft hand or foot Y A2 35.0613 $1,484.11

64897 Nerve graft arm or leg Y A2 35.0613 $1,484.11

64898 Nerve graft arm or leg Y A2 35.0613 $1,484.11

64901 Nerve graft add-on Y A2 35.0613 $1,484.11

64902 Nerve graft add-on Y A2 35.0613 $1,484.11

64905 Nerve pedicle transfer Y A2 35.0613 $1,484.11

64907 Nerve pedicle transfer Y A2 35.0613 $1,484.11

64910 Nerve repair w/allograft Y G2 35.0613 $1,484.11

65091 Revise eye Y A2 38.3708 $1,624.20

65093 Revise eye with implant Y A2 38.3708 $1,624.20

65101 Removal of eye Y A2 38.3708 $1,624.20

65103 Remove eye/insert implant Y A2 38.3708 $1,624.20

65105 Remove eye/attach implant Y A2 38.3708 $1,624.20

Date Printed: 3/14/2013 @ 8:00 PM Page 56 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

65110 Removal of eye Y A2 38.3708 $1,624.20

65112 Remove eye/revise socket Y A2 38.3708 $1,624.20

65114 Remove eye/revise socket Y A2 38.3708 $1,624.20

65125 Revise ocular implant Y G2 25.3533 $1,073.18

65130 Insert ocular implant Y A2 25.3533 $1,073.18

65135 Insert ocular implant Y A2 25.3533 $1,073.18

65140 Attach ocular implant Y A2 38.3708 $1,624.20

65150 Revise ocular implant Y A2 25.3533 $1,073.18

65155 Reinsert ocular implant Y A2 38.3708 $1,624.20

65175 Removal of ocular implant Y A2 19.0333 $805.66

65205 Remove foreign body from eye N P3 $18.93

65210 Remove foreign body from eye N P3 $24.92

65220 Remove foreign body from eye N G2 1.315 $55.66

65222 Remove foreign body from eye N P3 $27.08

65235 Remove foreign body from eye Y A2 15.8195 $669.62

65260 Remove foreign body from eye Y A2 4.6051 $194.93

65265 Remove foreign body from eye Y A2 21.3578 $904.05

65270 Repair of eye wound Y A2 19.0333 $805.66

65272 Repair of eye wound Y A2 23.6808 $1,002.38

65275 Repair of eye wound Y A2 23.6808 $1,002.38

65280 Repair of eye wound Y A2 21.3578 $904.05

65285 Repair of eye wound Y A2 38.7337 $1,639.56

65286 Repair of eye wound Y CH P3 $303.38

65290 Repair of eye socket wound Y A2 23.6997 $1,003.18

65400 Removal of eye lesion Y A2 15.8195 $669.62

65410 Biopsy of cornea Y A2 15.8195 $669.62

65420 Removal of eye lesion Y A2 15.8195 $669.62

65426 Removal of eye lesion Y A2 23.6808 $1,002.38

65430 Corneal smear N CH P3 $39.54

65435 Curette/treat cornea Y P3 $30.19

65436 Curette/treat cornea Y P3 $136.35

65450 Treatment of corneal lesion N G2 2.164 $91.60

65600 Revision of cornea Y P3 $157.20

65710 Corneal transplant Y A2 36.0588 $1,526.33

65730 Corneal transplant Y A2 36.0588 $1,526.33

65750 Corneal transplant Y A2 36.0588 $1,526.33

65755 Corneal transplant Y A2 36.0588 $1,526.33

65756 Corneal trnspl endothelial Y G2 36.0588 $1,526.33

65757 Prep corneal endo allograft N N1

65770 Revise cornea with implant Y CH J8 166.0519 $7,028.81

65772 Correction of astigmatism Y A2 15.8195 $669.62

65775 Correction of astigmatism Y A2 15.8195 $669.62

65778 Cover eye w/membrane Y G2 15.8195 $669.62

65779 Cover eye w/membrane suture Y G2 15.8195 $669.62

65780 Ocular reconst transplant Y A2 36.0588 $1,526.33

65781 Ocular reconst transplant Y A2 36.0588 $1,526.33

65782 Ocular reconst transplant Y A2 36.0588 $1,526.33

65800 Drainage of eye Y A2 7.3589 $311.49

65805 Drainage of eye Y A2 23.6808 $1,002.38

65810 Drainage of eye Y A2 23.6808 $1,002.38

65815 Drainage of eye Y A2 23.6808 $1,002.38

65820 Relieve inner eye pressure Y A2 23.6808 $1,002.38

65850 Incision of eye Y A2 23.6808 $1,002.38

65855 Laser surgery of eye Y P3 $125.81

65860 Incise inner eye adhesions Y P3 $116.46

65865 Incise inner eye adhesions Y A2 15.8195 $669.62

65870 Incise inner eye adhesions Y A2 23.6808 $1,002.38

65875 Incise inner eye adhesions Y A2 23.6808 $1,002.38

Date Printed: 3/14/2013 @ 8:00 PM Page 57 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

65880 Incise inner eye adhesions Y A2 15.8195 $669.62

65900 Remove eye lesion Y A2 2.7589 $116.78

65920 Remove implant of eye Y A2 23.6808 $1,002.38

65930 Remove blood clot from eye Y A2 23.6808 $1,002.38

66020 Injection treatment of eye Y A2 15.8195 $669.62

66030 Injection treatment of eye Y A2 15.8195 $669.62

66130 Remove eye lesion Y A2 23.6808 $1,002.38

66150 Glaucoma surgery Y A2 23.6808 $1,002.38

66155 Glaucoma surgery Y A2 23.6808 $1,002.38

66160 Glaucoma surgery Y A2 23.6808 $1,002.38

66165 Glaucoma surgery Y A2 23.6808 $1,002.38

66170 Glaucoma surgery Y A2 23.6808 $1,002.38

66172 Incision of eye Y A2 23.6808 $1,002.38

66174 Translum dil eye canal Y A2 39.1634 $1,657.75

66175 Trnslum dil eye canal w/stnt Y A2 39.1634 $1,657.75

66180 Implant eye shunt Y A2 39.1634 $1,657.75

66185 Revise eye shunt Y A2 23.6808 $1,002.38

66220 Repair eye lesion Y A2 38.7337 $1,639.56

66225 Repair/graft eye lesion Y A2 39.1634 $1,657.75

66250 Follow-up surgery of eye Y A2 15.8195 $669.62

66500 Incision of iris Y A2 2.7589 $116.78

66505 Incision of iris Y A2 7.3589 $311.49

66600 Remove iris and lesion Y A2 23.6808 $1,002.38

66605 Removal of iris Y A2 23.6808 $1,002.38

66625 Removal of iris Y A2 7.3589 $311.49

66630 Removal of iris Y A2 23.6808 $1,002.38

66635 Removal of iris Y A2 23.6808 $1,002.38

66680 Repair iris & ciliary body Y A2 23.6808 $1,002.38

66682 Repair iris & ciliary body Y A2 23.6808 $1,002.38

66700 Destruction ciliary body Y A2 15.8195 $669.62

66710 Ciliary transsleral therapy Y A2 15.8195 $669.62

66711 Ciliary endoscopic ablation Y A2 15.8195 $669.62

66720 Destruction ciliary body Y A2 15.8195 $669.62

66740 Destruction ciliary body Y A2 23.6808 $1,002.38

66761 Revision of iris Y P3 $133.24

66762 Revision of iris Y CH P3 $181.16

66770 Removal of inner eye lesion Y CH P3 $196.74

66820 Incision secondary cataract Y G2 7.3589 $311.49

66821 After cataract laser surgery Y A2 5.2302 $221.39

66825 Reposition intraocular lens Y A2 23.6808 $1,002.38

66830 Removal of lens lesion Y A2 7.3589 $311.49

66840 Removal of lens material Y A2 14.3197 $606.14

66850 Removal of lens material Y A2 28.8511 $1,221.24

66852 Removal of lens material Y A2 28.8511 $1,221.24

66920 Extraction of lens Y A2 28.8511 $1,221.24

66930 Extraction of lens Y A2 28.8511 $1,221.24

66940 Extraction of lens Y A2 14.3197 $606.14

66982 Cataract surgery complex Y A2 22.51 $952.83

66983 Cataract surg w/iol 1 stage Y A2 22.51 $952.83

66984 Cataract surg w/iol 1 stage Y A2 22.51 $952.83

66985 Insert lens prosthesis Y A2 22.51 $952.83

66986 Exchange lens prosthesis Y A2 22.51 $952.83

66990 Ophthalmic endoscope add-on N N1

67005 Partial removal of eye fluid Y A2 21.3578 $904.05

67010 Partial removal of eye fluid Y A2 38.7337 $1,639.56

67015 Release of eye fluid Y A2 38.7337 $1,639.56

67025 Replace eye fluid Y A2 38.7337 $1,639.56

67027 Implant eye drug system Y A2 38.7337 $1,639.56

Date Printed: 3/14/2013 @ 8:00 PM Page 58 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

67028 Injection eye drug Y P3 $41.94

67030 Incise inner eye strands Y A2 21.3578 $904.05

67031 Laser surgery eye strands Y A2 5.2302 $221.39

67036 Removal of inner eye fluid Y A2 38.7337 $1,639.56

67039 Laser treatment of retina Y A2 38.7337 $1,639.56

67040 Laser treatment of retina Y A2 38.7337 $1,639.56

67041 Vit for macular pucker Y G2 38.7337 $1,639.56

67042 Vit for macular hole Y G2 38.7337 $1,639.56

67043 Vit for membrane dissect Y G2 38.7337 $1,639.56

67101 Repair detached retina Y P3 $300.50

67105 Repair detached retina Y P2 5.2302 $221.39

67107 Repair detached retina Y A2 38.7337 $1,639.56

67108 Repair detached retina Y A2 38.7337 $1,639.56

67110 Repair detached retina Y P3 $320.63

67112 Rerepair detached retina Y A2 38.7337 $1,639.56

67113 Repair retinal detach cplx Y G2 38.7337 $1,639.56

67115 Release encircling material Y A2 21.3578 $904.05

67120 Remove eye implant material Y A2 21.3578 $904.05

67121 Remove eye implant material Y A2 38.7337 $1,639.56

67141 Treatment of retina Y A2 4.6051 $194.93

67145 Treatment of retina Y CH P3 $191.95

67208 Treatment of retinal lesion Y P2 4.6051 $194.93

67210 Treatment of retinal lesion Y CH P3 $220.70

67218 Treatment of retinal lesion Y A2 21.3578 $904.05

67220 Treatment of choroid lesion Y P2 4.6051 $194.93

67221 Ocular photodynamic ther Y P3 $106.40

67225 Eye photodynamic ther add-on Y P3 $8.15

67227 Treatment of retinal lesion Y A2 21.3578 $904.05

67228 Treatment of retinal lesion Y P2 5.2302 $221.39

67229* Tr retinal les preterm inf Y R2 5.2302 $221.39

67250 Reinforce eye wall Y A2 19.0333 $805.66

67255 Reinforce/graft eye wall Y A2 21.3578 $904.05

67311 Revise eye muscle Y A2 23.6997 $1,003.18

67312 Revise two eye muscles Y A2 23.6997 $1,003.18

67314 Revise eye muscle Y A2 23.6997 $1,003.18

67316 Revise two eye muscles Y A2 23.6997 $1,003.18

67318 Revise eye muscle(s) Y A2 23.6997 $1,003.18

67320 Revise eye muscle(s) add-on Y A2 23.6997 $1,003.18

67331 Eye surgery follow-up add-on Y A2 23.6997 $1,003.18

67332 Rerevise eye muscles add-on Y A2 23.6997 $1,003.18

67334 Revise eye muscle w/suture Y A2 23.6997 $1,003.18

67335 Eye suture during surgery Y A2 23.6997 $1,003.18

67340 Revise eye muscle add-on Y A2 23.6997 $1,003.18

67343 Release eye tissue Y A2 23.6997 $1,003.18

67345 Destroy nerve of eye muscle Y P3 $81.00

67346 Biopsy eye muscle Y A2 14.635 $619.48

67400 Explore/biopsy eye socket Y A2 19.0333 $805.66

67405 Explore/drain eye socket Y A2 25.3533 $1,073.18

67412 Explore/treat eye socket Y A2 19.0333 $805.66

67413 Explore/treat eye socket Y A2 25.3533 $1,073.18

67414 Explr/decompress eye socket Y G2 38.3708 $1,624.20

67415 Aspiration orbital contents Y A2 19.0333 $805.66

67420 Explore/treat eye socket Y A2 38.3708 $1,624.20

67430 Explore/treat eye socket Y A2 38.3708 $1,624.20

67440 Explore/drain eye socket Y A2 38.3708 $1,624.20

67445 Explr/decompress eye socket Y A2 38.3708 $1,624.20

67450 Explore/biopsy eye socket Y A2 38.3708 $1,624.20

67500 Inject/treat eye socket N G2 2.164 $91.60

Date Printed: 3/14/2013 @ 8:00 PM Page 59 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

67505 Inject/treat eye socket Y P3 $27.08

67515 Inject/treat eye socket Y P3 $28.76

67550 Insert eye socket implant Y A2 38.3708 $1,624.20

67560 Revise eye socket implant Y A2 25.3533 $1,073.18

67570 Decompress optic nerve Y A2 38.3708 $1,624.20

67700 Drainage of eyelid abscess Y P2 3.1191 $132.03

67710 Incision of eyelid Y P3 $123.65

67715 Incision of eyelid fold Y A2 19.0333 $805.66

67800 Remove eyelid lesion Y P3 $49.36

67801 Remove eyelid lesions Y P3 $59.91

67805 Remove eyelid lesions Y P3 $77.40

67808 Remove eyelid lesion(s) Y A2 19.0333 $805.66

67810 Biopsy of eyelid Y CH P3 $110.47

67820 Revise eyelashes N P3 $15.82

67825 Revise eyelashes Y P3 $49.60

67830 Revise eyelashes Y A2 7.788 $329.66

67835 Revise eyelashes Y A2 19.0333 $805.66

67840 Remove eyelid lesion Y P3 $132.52

67850 Treat eyelid lesion Y P3 $102.80

67875 Closure of eyelid by suture Y G2 7.788 $329.66

67880 Revision of eyelid Y A2 15.8195 $669.62

67882 Revision of eyelid Y A2 19.0333 $805.66

67900 Repair brow defect Y A2 25.3533 $1,073.18

67901 Repair eyelid defect Y A2 19.0333 $805.66

67902 Repair eyelid defect Y A2 25.3533 $1,073.18

67903 Repair eyelid defect Y A2 19.0333 $805.66

67904 Repair eyelid defect Y A2 19.0333 $805.66

67906 Repair eyelid defect Y A2 19.0333 $805.66

67908 Repair eyelid defect Y A2 19.0333 $805.66

67909 Revise eyelid defect Y A2 19.0333 $805.66

67911 Revise eyelid defect Y A2 19.0333 $805.66

67912 Correction eyelid w/implant Y A2 19.0333 $805.66

67914 Repair eyelid defect Y A2 19.0333 $805.66

67915 Repair eyelid defect Y P3 $150.73

67916 Repair eyelid defect Y A2 19.0333 $805.66

67917 Repair eyelid defect Y A2 19.0333 $805.66

67921 Repair eyelid defect Y A2 19.0333 $805.66

67922 Repair eyelid defect Y P3 $146.18

67923 Repair eyelid defect Y A2 19.0333 $805.66

67924 Repair eyelid defect Y A2 19.0333 $805.66

67930 Repair eyelid wound Y P3 $152.89

67935 Repair eyelid wound Y A2 19.0333 $805.66

67938 Remove eyelid foreign body N P2 2.164 $91.60

67950 Revision of eyelid Y A2 19.0333 $805.66

67961 Revision of eyelid Y A2 19.0333 $805.66

67966 Revision of eyelid Y A2 19.0333 $805.66

67971 Reconstruction of eyelid Y A2 19.0333 $805.66

67973 Reconstruction of eyelid Y A2 25.3533 $1,073.18

67974 Reconstruction of eyelid Y A2 19.0333 $805.66

67975 Reconstruction of eyelid Y A2 19.0333 $805.66

68020 Incise/drain eyelid lining Y P3 $44.09

68040 Treatment of eyelid lesions N P3 $21.81

68100 Biopsy of eyelid lining Y P3 $79.80

68110 Remove eyelid lining lesion Y P3 $105.20

68115 Remove eyelid lining lesion Y A2 19.0333 $805.66

68130 Remove eyelid lining lesion Y A2 15.8195 $669.62

68135 Remove eyelid lining lesion Y P3 $56.79

68200 Treat eyelid by injection N P3 $16.06

Date Printed: 3/14/2013 @ 8:00 PM Page 60 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

68320 Revise/graft eyelid lining Y A2 25.3533 $1,073.18

68325 Revise/graft eyelid lining Y A2 25.3533 $1,073.18

68326 Revise/graft eyelid lining Y A2 19.0333 $805.66

68328 Revise/graft eyelid lining Y A2 25.3533 $1,073.18

68330 Revise eyelid lining Y A2 23.6808 $1,002.38

68335 Revise/graft eyelid lining Y A2 25.3533 $1,073.18

68340 Separate eyelid adhesions Y A2 19.0333 $805.66

68360 Revise eyelid lining Y A2 23.6808 $1,002.38

68362 Revise eyelid lining Y A2 23.6808 $1,002.38

68371 Harvest eye tissue alograft Y A2 23.6808 $1,002.38

68400 Incise/drain tear gland Y P2 3.1191 $132.03

68420 Incise/drain tear sac Y P3 $155.52

68440 Incise tear duct opening Y P3 $44.33

68500 Removal of tear gland Y A2 25.3533 $1,073.18

68505 Partial removal tear gland Y A2 25.3533 $1,073.18

68510 Biopsy of tear gland Y A2 19.0333 $805.66

68520 Removal of tear sac Y A2 25.3533 $1,073.18

68525 Biopsy of tear sac Y A2 19.0333 $805.66

68530 Clearance of tear duct Y P2 3.1191 $132.03

68540 Remove tear gland lesion Y A2 19.0333 $805.66

68550 Remove tear gland lesion Y A2 25.3533 $1,073.18

68700 Repair tear ducts Y A2 19.0333 $805.66

68705 Revise tear duct opening Y CH P3 $104.96

68720 Create tear sac drain Y A2 25.3533 $1,073.18

68745 Create tear duct drain Y A2 25.3533 $1,073.18

68750 Create tear duct drain Y A2 25.3533 $1,073.18

68760 Close tear duct opening Y P3 $89.62

68761 Close tear duct opening Y P3 $63.26

68770 Close tear system fistula Y A2 25.3533 $1,073.18

68801 Dilate tear duct opening N P2 1.315 $55.66

68810 Probe nasolacrimal duct Y A2 3.1191 $132.03

68811 Probe nasolacrimal duct Y A2 19.0333 $805.66

68815 Probe nasolacrimal duct Y A2 19.0333 $805.66

68816 Probe nl duct w/balloon Y G2 19.0333 $805.66

68840 Explore/irrigate tear ducts N P3 $52.24

68850 Injection for tear sac x-ray N N1

69000 Drain external ear lesion Y P2 1.3573 $57.45

69005 Drain external ear lesion Y P3 $94.66

69020 Drain outer ear canal lesion Y P2 1.3573 $57.45

69100 Biopsy of external ear Y P3 $50.08

69105 Biopsy of external ear canal Y P3 $78.60

69110 Remove external ear partial Y A2 16.113 $682.05

69120 Removal of external ear Y A2 23.5618 $997.35

69140 Remove ear canal lesion(s) Y A2 23.5618 $997.35

69145 Remove ear canal lesion(s) Y A2 16.113 $682.05

69150 Extensive ear canal surgery Y A2 7.5315 $318.80

69200 Clear outer ear canal N P2 0.6316 $26.73

69205 Clear outer ear canal Y A2 21.9487 $929.07

69210 Remove impacted ear wax N CH P3 $19.65

69220 Clean out mastoid cavity Y P2 0.9172 $38.82

69222 Clean out mastoid cavity Y P3 $120.06

69300 Revise external ear Y A2 23.5618 $997.35

69310 Rebuild outer ear canal Y A2 42.299 $1,790.47

69320 Rebuild outer ear canal Y A2 42.299 $1,790.47

69400 Inflate middle ear canal Y P3 $83.39

69401 Inflate middle ear canal Y P3 $45.53

69405 Catheterize middle ear canal Y P3 $115.02

69420 Incision of eardrum Y CH P3 $101.13

Date Printed: 3/14/2013 @ 8:00 PM Page 61 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

69421 Incision of eardrum Y A2 15.8572 $671.22

69424 Remove ventilating tube Y P3 $70.45

69433 Create eardrum opening Y P3 $101.37

69436 Create eardrum opening Y A2 15.8572 $671.22

69440 Exploration of middle ear Y A2 23.5618 $997.35

69450 Eardrum revision Y A2 42.299 $1,790.47

69501 Mastoidectomy Y A2 42.299 $1,790.47

69502 Mastoidectomy Y A2 23.5618 $997.35

69505 Remove mastoid structures Y A2 42.299 $1,790.47

69511 Extensive mastoid surgery Y A2 42.299 $1,790.47

69530 Extensive mastoid surgery Y A2 42.299 $1,790.47

69540 Remove ear lesion Y P3 $117.66

69550 Remove ear lesion Y A2 42.299 $1,790.47

69552 Remove ear lesion Y A2 42.299 $1,790.47

69601 Mastoid surgery revision Y A2 42.299 $1,790.47

69602 Mastoid surgery revision Y A2 42.299 $1,790.47

69603 Mastoid surgery revision Y A2 42.299 $1,790.47

69604 Mastoid surgery revision Y A2 42.299 $1,790.47

69605 Mastoid surgery revision Y A2 42.299 $1,790.47

69610 Repair of eardrum Y P3 $156.72

69620 Repair of eardrum Y A2 23.5618 $997.35

69631 Repair eardrum structures Y A2 42.299 $1,790.47

69632 Rebuild eardrum structures Y A2 42.299 $1,790.47

69633 Rebuild eardrum structures Y A2 42.299 $1,790.47

69635 Repair eardrum structures Y A2 42.299 $1,790.47

69636 Rebuild eardrum structures Y A2 42.299 $1,790.47

69637 Rebuild eardrum structures Y A2 42.299 $1,790.47

69641 Revise middle ear & mastoid Y A2 42.299 $1,790.47

69642 Revise middle ear & mastoid Y A2 42.299 $1,790.47

69643 Revise middle ear & mastoid Y A2 42.299 $1,790.47

69644 Revise middle ear & mastoid Y A2 42.299 $1,790.47

69645 Revise middle ear & mastoid Y A2 42.299 $1,790.47

69646 Revise middle ear & mastoid Y A2 42.299 $1,790.47

69650 Release middle ear bone Y A2 23.5618 $997.35

69660 Revise middle ear bone Y A2 42.299 $1,790.47

69661 Revise middle ear bone Y A2 42.299 $1,790.47

69662 Revise middle ear bone Y A2 42.299 $1,790.47

69666 Repair middle ear structures Y A2 42.299 $1,790.47

69667 Repair middle ear structures Y A2 42.299 $1,790.47

69670 Remove mastoid air cells Y A2 42.299 $1,790.47

69676 Remove middle ear nerve Y A2 42.299 $1,790.47

69700 Close mastoid fistula Y A2 42.299 $1,790.47

69711 Remove/repair hearing aid Y A2 42.299 $1,790.47

69714 Implant temple bone w/stimul Y CH J8 177.1433 $7,498.30

69715 Temple bne implnt w/stimulat Y CH J8 177.1433 $7,498.30

69717 Temple bone implant revision Y CH J8 177.1433 $7,498.30

69718 Revise temple bone implant Y CH J8 177.1433 $7,498.30

69720 Release facial nerve Y A2 42.299 $1,790.47

69740 Repair facial nerve Y A2 42.299 $1,790.47

69745 Repair facial nerve Y A2 42.299 $1,790.47

69801 Incise inner ear Y CH P3 $86.51

69802 Incise inner ear Y G2 23.5618 $997.35

69805 Explore inner ear Y A2 42.299 $1,790.47

69806 Explore inner ear Y A2 42.299 $1,790.47

69820 Establish inner ear window Y A2 42.299 $1,790.47

69840 Revise inner ear window Y A2 42.299 $1,790.47

69905 Remove inner ear Y A2 42.299 $1,790.47

69910 Remove inner ear & mastoid Y A2 42.299 $1,790.47

Date Printed: 3/14/2013 @ 8:00 PM Page 62 of 63
HCPCS 

Code Short Descriptor

Subject To 

Multiple 

Procedure 

Discounting

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum AA -- Proposed ASC Covered Surgical Procedures for CY 2012 (Including 

Surgical Procedures for Which Payment is Packaged) 

69915 Incise inner ear nerve Y A2 42.299 $1,790.47

69930 Implant cochlear device Y CH J8 600.6346 $25,424.26

69990 Microsurgery add-on N N1

C9716 Radiofrequency energy to anu Y G2 30.9056 $1,308.20

C9724 EPS gast cardia plic Y G2 23.8908 $1,011.27

C9725 Place endorectal app Y G2 5.7224 $242.22

C9726 Rxt breast appl place/remov Y G2 24.2182 $1,025.13

C9727 Insert palate implants Y G2 7.5315 $318.80

C9728 Place device/marker, non pro N R2 12.4155 $525.54

C9800* Dermal filler inj px/suppl Y R2 4.8714 $206.20

G0104** CA screen;flexi sigmoidscope N P3 $73.33

G0105** Colorectal scrn; hi risk ind Y A2 7.7959 $329.99

G0121** Colon ca scrn not hi rsk ind Y A2 7.7959 $329.99

G0127 Trim nail(s) Y P3 $11.26

G0186 Dstry eye lesn,fdr vssl tech Y R2 4.6051 $194.93

G0247 Routine footcare pt w lops Y CH P3 $37.14

G0259 Inject for sacroiliac joint N N1

G0260 Inj for sacroiliac jt anesth Y A2 7.0747 $299.46

G0268 Removal of impacted wax md N N1

G0269 Occlusive device in vein art N N1

G0289 Arthro, loose body + chondro N N1

G0364 Bone marrow aspirate &biopsy N P3 $4.31

NOTE 1: The Medicare program payment is 80 percent of the total payment amount and beneficiary coinsurance is 20 percent of 

the total payment amount. Sections 4104 and 10406 of the Affordable Care Act (ACA) waive coinsurance and the Part B deductible 

for most preventive services. These preventive services are identified with a double asterisk (**).

NOTE 2: Proposed payment indicators for "office-based" procedures (P2, P3) are based on a comparison of the proposed rates 

according to the ASC standard ratesetting methodology and the MPFS proposed rates. Under current law, the MPFS payment 

rates will have a negative update for CY 2012. For a discussion of those rates, we refer readers to the CY 2012 MPFS proposed 

rule.

*: Asterisked codes(*) indicate that the procedure’s "office-based" designation is temporary because we have insufficient claims 

data. We will reconsider this designation when new claims data become available.

Date Printed: 3/14/2013 @ 8:00 PM Page 63 of 63
HCPCS 

Code Short Descriptor

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

0042T Ct perfusion w/contrast cbf N1

0073T Delivery comp imrt Z2 6.0383 $255.60

0126T Chd risk imt study N1

0159T Cad breast mri N1

0174T Cad cxr with interp N1

0175T Cad cxr remote N1

0182T Hdr elect brachytherapy Z2 9.2473 $391.43

0185T Comptr probability analysis N1

70010 Contrast x-ray of brain N1

70015 Contrast x-ray of brain N1

70030 X-ray eye for foreign body Z3 $14.62

70100 X-ray exam of jaw Z3 $17.97

70110 X-ray exam of jaw Z3 $19.41

70120 X-ray exam of mastoids Z3 $19.17

70130 X-ray exam of mastoids Z2 0.6016 $25.47

70134 X-ray exam of middle ear Z3 $27.32

70140 X-ray exam of facial bones Z3 $14.38

70150 X-ray exam of facial bones Z3 $21.09

70160 X-ray exam of nasal bones Z3 $17.49

70170 X-ray exam of tear duct N1

70190 X-ray exam of eye sockets Z3 $17.97

70200 X-ray exam of eye sockets Z3 $21.33

70210 X-ray exam of sinuses Z3 $16.06

70220 X-ray exam of sinuses Z3 $19.17

70240 X-ray exam pituitary saddle Z3 $14.38

70250 X-ray exam of skull Z3 $17.73

70260 X-ray exam of skull Z3 $21.57

70300 X-ray exam of teeth Z3 $6.23

70310 X-ray exam of teeth Z2 0.4358 $18.45

70320 Full mouth x-ray of teeth Z2 0.4358 $18.45

70328 X-ray exam of jaw joint Z3 $15.58

70330 X-ray exam of jaw joints Z2 0.6016 $25.47

70332 X-ray exam of jaw joint N1

70336 Magnetic image jaw joint Z2 4.5196 $191.31

70350 X-ray head for orthodontia Z3 $8.15

70355 Panoramic x-ray of jaws Z3 $7.19

70360 X-ray exam of neck Z3 $13.42

70370 Throat x-ray & fluoroscopy Z2 1.1698 $49.52

70371 Speech evaluation complex Z3 $37.38

70373 Contrast x-ray of larynx N1

70380 X-ray exam of salivary gland Z3 $22.05

70390 X-ray exam of salivary duct N1

70450 Ct head/brain w/o dye Z3 $99.45

70460 Ct head/brain w/dye Z3 $129.40

70470 Ct head/brain w/o & w/dye Z3 $159.60

70480 Ct orbit/ear/fossa w/o dye Z2 2.5705 $108.81

70481 Ct orbit/ear/fossa w/dye Z2 4.0122 $169.83

70482 Ct orbit/ear/fossa w/o&w/dye Z2 4.4724 $189.31

70486 Ct maxillofacial w/o dye Z2 2.5705 $108.81

70487 Ct maxillofacial w/dye Z3 $165.83

70488 Ct maxillofacial w/o & w/dye Z2 4.4724 $189.31

70490 Ct soft tissue neck w/o dye Z2 2.5705 $108.81

70491 Ct soft tissue neck w/dye Z3 $158.16

70492 Ct sft tsue nck w/o & w/dye Z2 4.4724 $189.31

70496 Ct angiography head Z2 4.5395 $192.15

70498 Ct angiography neck Z2 4.5395 $192.15

70540 Mri orbit/face/neck w/o dye Z2 4.5196 $191.31

70542 Mri orbit/face/neck w/dye Z2 5.7993 $245.48

70543 Mri orbt/fac/nck w/o & w/dye Z2 7.1603 $303.09

70544 Mr angiography head w/o dye Z2 4.5196 $191.31

70545 Mr angiography head w/dye Z2 5.7993 $245.48

70546 Mr angiograph head w/o&w/dye Z2 7.1603 $303.09

70547 Mr angiography neck w/o dye Z2 4.5196 $191.31

70548 Mr angiography neck w/dye Z2 5.7993 $245.48

70549 Mr angiograph neck w/o&w/dye Z2 7.1603 $303.09

70551 Mri brain w/o dye Z2 4.5196 $191.31

70552 Mri brain w/dye Z2 5.7993 $245.48

70553 Mri brain w/o & w/dye Z2 7.1603 $303.09

Addendum BB -- Proposed ASC Covered Ancillary Services Integral to Covered 

Surgical Procedures for CY 2012 (Including Ancillary Services for Which Payment 

is Packaged)

Date Printed: 3/14/2013 @ 8:00 PM Page 1 of 24
HCPCS 

Code Short Descriptor

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum BB -- Proposed ASC Covered Ancillary Services Integral to Covered 

Surgical Procedures for CY 2012 (Including Ancillary Services for Which Payment 

is Packaged)

70554 Fmri brain by tech Z2 4.5196 $191.31

70555 Fmri brain by phys/psych Z2 4.5196 $191.31

70557 Mri brain w/o dye Z2 4.5196 $191.31

70558 Mri brain w/dye Z2 5.7993 $245.48

70559 Mri brain w/o & w/dye Z2 7.1603 $303.09

71010 Chest x-ray Z3 $10.30

71015 Chest x-ray Z3 $14.38

71020 Chest x-ray Z3 $13.90

71021 Chest x-ray Z3 $17.25

71022 Chest x-ray Z3 $22.77

71023 Chest x-ray and fluoroscopy Z3 $34.99

71030 Chest x-ray Z3 $22.05

71034 Chest x-ray and fluoroscopy Z3 $46.01

71035 Chest x-ray Z3 $18.93

71040 Contrast x-ray of bronchi N1

71060 Contrast x-ray of bronchi N1

71090 X-ray & pacemaker insertion N1

71100 X-ray exam of ribs Z3 $15.34

71101 X-ray exam of ribs/chest Z3 $18.69

71110 X-ray exam of ribs Z3 $19.41

71111 X-ray exam of ribs/chest Z3 $26.60

71120 X-ray exam of breastbone Z3 $15.58

71130 X-ray exam of breastbone Z3 $18.69

71250 Ct thorax w/o dye Z2 2.5705 $108.81

71260 Ct thorax w/dye Z3 $161.27

71270 Ct thorax w/o & w/dye Z2 4.4724 $189.31

71275 Ct angiography chest Z2 4.5395 $192.15

71550 Mri chest w/o dye Z2 4.5196 $191.31

71551 Mri chest w/dye Z2 5.7993 $245.48

71552 Mri chest w/o & w/dye Z2 7.1603 $303.09

72010 X-ray exam of spine Z3 $38.82

72020 X-ray exam of spine Z3 $11.26

72040 X-ray exam of neck spine Z3 $19.89

72050 X-ray exam of neck spine Z3 $26.60

72052 X-ray exam of neck spine Z3 $35.47

72069 X-ray exam of trunk spine Z3 $18.69

72070 X-ray exam of thoracic spine Z3 $16.06

72072 X-ray exam of thoracic spine Z3 $18.93

72074 X-ray exam of thoracic spine Z3 $23.96

72080 X-ray exam of trunk spine Z3 $17.73

72090 X-ray exam of trunk spine Z3 $25.40

72100 X-ray exam of lower spine Z3 $21.09

72110 X-ray exam of lower spine Z3 $28.52

72114 X-ray exam of lower spine Z3 $40.50

72120 X-ray exam of lower spine Z2 0.6016 $25.47

72125 Ct neck spine w/o dye Z2 2.5705 $108.81

72126 Ct neck spine w/dye Z3 $162.23

72127 Ct neck spine w/o & w/dye Z2 4.4724 $189.31

72128 Ct chest spine w/o dye Z2 2.5705 $108.81

72129 Ct chest spine w/dye Z3 $162.23

72130 Ct chest spine w/o & w/dye Z2 4.4724 $189.31

72131 Ct lumbar spine w/o dye Z2 2.5705 $108.81

72132 Ct lumbar spine w/dye Z3 $161.75

72133 Ct lumbar spine w/o & w/dye Z2 4.4724 $189.31

72141 Mri neck spine w/o dye Z2 4.5196 $191.31

72142 Mri neck spine w/dye Z2 5.7993 $245.48

72146 Mri chest spine w/o dye Z2 4.5196 $191.31

72147 Mri chest spine w/dye Z2 5.7993 $245.48

72148 Mri lumbar spine w/o dye Z2 4.5196 $191.31

72149 Mri lumbar spine w/dye Z2 5.7993 $245.48

72156 Mri neck spine w/o & w/dye Z2 7.1603 $303.09

72157 Mri chest spine w/o & w/dye Z2 7.1603 $303.09

72158 Mri lumbar spine w/o & w/dye Z2 7.1603 $303.09

72170 X-ray exam of pelvis Z3 $12.70

72190 X-ray exam of pelvis Z3 $22.53

72191 Ct angiograph pelv w/o&w/dye Z2 4.5395 $192.15

72192 Ct pelvis w/o dye Z2 2.5705 $108.81

72193 Ct pelvis w/dye Z3 $153.13

Date Printed: 3/14/2013 @ 8:00 PM Page 2 of 24
HCPCS 

Code Short Descriptor

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum BB -- Proposed ASC Covered Ancillary Services Integral to Covered 

Surgical Procedures for CY 2012 (Including Ancillary Services for Which Payment 

is Packaged)

72194 Ct pelvis w/o & w/dye Z2 4.4724 $189.31

72195 Mri pelvis w/o dye Z2 4.5196 $191.31

72196 Mri pelvis w/dye Z2 5.7993 $245.48

72197 Mri pelvis w/o & w/dye Z2 7.1603 $303.09

72200 X-ray exam sacroiliac joints Z3 $15.10

72202 X-ray exam sacroiliac joints Z3 $17.97

72220 X-ray exam of tailbone Z3 $14.62

72240 Contrast x-ray of neck spine N1

72255 Contrast x-ray thorax spine N1

72265 Contrast x-ray lower spine N1

72270 Contrast x-ray spine N1

72275 Epidurography N1

72285 X-ray c/t spine disk N1

72291 Perq verte/sacroplsty fluor N1

72292 Perq verte/sacroplsty ct N1

72295 X-ray of lower spine disk N1

73000 X-ray exam of collar bone Z3 $14.62

73010 X-ray exam of shoulder blade Z3 $15.58

73020 X-ray exam of shoulder Z3 $11.50

73030 X-ray exam of shoulder Z3 $14.86

73040 Contrast x-ray of shoulder N1

73050 X-ray exam of shoulders Z3 $20.61

73060 X-ray exam of humerus Z3 $14.62

73070 X-ray exam of elbow Z3 $14.62

73080 X-ray exam of elbow Z3 $17.97

73085 Contrast x-ray of elbow N1

73090 X-ray exam of forearm Z3 $13.90

73092 X-ray exam of arm infant Z3 $17.73

73100 X-ray exam of wrist Z3 $16.06

73110 X-ray exam of wrist Z3 $20.37

73115 Contrast x-ray of wrist N1

73120 X-ray exam of hand Z3 $13.90

73130 X-ray exam of hand Z3 $17.01

73140 X-ray exam of finger(s) Z3 $18.45

73200 Ct upper extremity w/o dye Z2 2.5705 $108.81

73201 Ct upper extremity w/dye Z3 $158.16

73202 Ct uppr extremity w/o&w/dye Z2 4.4724 $189.31

73206 Ct angio upr extrm w/o&w/dye Z2 4.5395 $192.15

73218 Mri upper extremity w/o dye Z2 4.5196 $191.31

73219 Mri upper extremity w/dye Z2 5.7993 $245.48

73220 Mri uppr extremity w/o&w/dye Z2 7.1603 $303.09

73221 Mri joint upr extrem w/o dye Z2 4.5196 $191.31

73222 Mri joint upr extrem w/dye Z2 5.7993 $245.48

73223 Mri joint upr extr w/o&w/dye Z2 7.1603 $303.09

73500 X-ray exam of hip Z3 $12.70

73510 X-ray exam of hip Z3 $19.65

73520 X-ray exam of hips Z3 $19.65

73525 Contrast x-ray of hip N1

73530 X-ray exam of hip N1

73540 X-ray exam of pelvis & hips Z3 $23.72

73542 X-ray exam sacroiliac joint N1

73550 X-ray exam of thigh Z3 $13.90

73560 X-ray exam of knee 1 or 2 Z3 $15.34

73562 X-ray exam of knee 3 Z3 $19.41

73564 X-ray exam knee 4 or more Z3 $22.29

73565 X-ray exam of knees Z3 $18.21

73580 Contrast x-ray of knee joint N1

73590 X-ray exam of lower leg Z3 $13.42

73592 X-ray exam of leg infant Z3 $17.01

73600 X-ray exam of ankle Z3 $14.62

73610 X-ray exam of ankle Z3 $17.49

73615 Contrast x-ray of ankle N1

73620 X-ray exam of foot Z3 $14.14

73630 X-ray exam of foot Z3 $16.53

73650 X-ray exam of heel Z3 $14.38

73660 X-ray exam of toe(s) Z3 $16.53

73700 Ct lower extremity w/o dye Z2 2.5705 $108.81

73701 Ct lower extremity w/dye Z3 $160.32

Date Printed: 3/14/2013 @ 8:00 PM Page 3 of 24
HCPCS 

Code Short Descriptor

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum BB -- Proposed ASC Covered Ancillary Services Integral to Covered 

Surgical Procedures for CY 2012 (Including Ancillary Services for Which Payment 

is Packaged)

73702 Ct lwr extremity w/o&w/dye Z2 4.4724 $189.31

73706 Ct angio lwr extr w/o&w/dye Z2 4.5395 $192.15

73718 Mri lower extremity w/o dye Z2 4.5196 $191.31

73719 Mri lower extremity w/dye Z2 5.7993 $245.48

73720 Mri lwr extremity w/o&w/dye Z2 7.1603 $303.09

73721 Mri jnt of lwr extre w/o dye Z2 4.5196 $191.31

73722 Mri joint of lwr extr w/dye Z2 5.7993 $245.48

73723 Mri joint lwr extr w/o&w/dye Z2 7.1603 $303.09

74000 X-ray exam of abdomen Z3 $11.02

74010 X-ray exam of abdomen Z3 $19.17

74020 X-ray exam of abdomen Z3 $19.17

74022 X-ray exam series abdomen Z3 $23.24

74150 Ct abdomen w/o dye Z2 2.5705 $108.81

74160 Ct abdomen w/dye Z2 4.0122 $169.83

74170 Ct abdomen w/o & w/dye Z2 4.4724 $189.31

74175 Ct angio abdom w/o & w/dye Z2 4.5395 $192.15

74176 Ct abd & pelvis Z3 $96.57

74177 Ct abd & pelv w/contrast CH Z2 7.7175 $326.67

74178 Ct abd & pelv 1/>regns Z3 $243.71

74181 Mri abdomen w/o dye Z2 4.5196 $191.31

74182 Mri abdomen w/dye Z2 5.7993 $245.48

74183 Mri abdomen w/o & w/dye Z2 7.1603 $303.09

74190 X-ray exam of peritoneum N1

74210 Contrst x-ray exam of throat Z3 $43.85

74220 Contrast x-ray esophagus CH Z2 1.1519 $48.76

74230 Cine/vid x-ray throat/esoph Z3 $46.97

74235 Remove esophagus obstruction N1

74240 X-ray exam upper gi tract Z2 1.1519 $48.76

74241 X-ray exam upper gi tract Z2 1.1519 $48.76

74245 X-ray exam upper gi tract Z2 1.8824 $79.68

74246 Contrst x-ray uppr gi tract Z2 1.1519 $48.76

74247 Contrst x-ray uppr gi tract Z2 1.1519 $48.76

74249 Contrst x-ray uppr gi tract Z2 1.8824 $79.68

74250 X-ray exam of small bowel Z2 1.1519 $48.76

74251 X-ray exam of small bowel Z2 1.8824 $79.68

74260 X-ray exam of small bowel Z2 1.1519 $48.76

74261 Ct colonography dx Z2 2.5705 $108.81

74262 Ct colonography dx w/dye Z2 4.0122 $169.83

74270 Contrast x-ray exam of colon Z2 1.1519 $48.76

74280 Contrast x-ray exam of colon Z2 1.8824 $79.68

74283 Contrast x-ray exam of colon Z2 1.1519 $48.76

74290 Contrast x-ray gallbladder CH Z2 1.1519 $48.76

74291 Contrast x-rays gallbladder CH Z2 1.1519 $48.76

74300 X-ray bile ducts/pancreas N1

74301 X-rays at surgery add-on N1

74305 X-ray bile ducts/pancreas N1

74320 Contrast x-ray of bile ducts N1

74327 X-ray bile stone removal N1

74328 X-ray bile duct endoscopy N1

74329 X-ray for pancreas endoscopy N1

74330 X-ray bile/panc endoscopy N1

74340 X-ray guide for GI tube N1

74355 X-ray guide intestinal tube N1

74360 X-ray guide gi dilation N1

74363 X-ray bile duct dilation N1

74400 Contrst x-ray urinary tract Z3 $63.02

74410 Contrst x-ray urinary tract Z3 $63.50

74415 Contrst x-ray urinary tract Z3 $80.52

74420 Contrst x-ray urinary tract Z2 2.4272 $102.74

74425 Contrst x-ray urinary tract N1

74430 Contrast x-ray bladder N1

74440 X-ray male genital tract N1

74445 X-ray exam of penis N1

74450 X-ray urethra/bladder N1

74455 X-ray urethra/bladder N1

74470 X-ray exam of kidney lesion N1

74475 X-ray control cath insert N1

74480 X-ray control cath insert N1

Date Printed: 3/14/2013 @ 8:00 PM Page 4 of 24
HCPCS 

Code Short Descriptor

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum BB -- Proposed ASC Covered Ancillary Services Integral to Covered 

Surgical Procedures for CY 2012 (Including Ancillary Services for Which Payment 

is Packaged)

74485 X-ray guide gu dilation N1

74710 X-ray measurement of pelvis Z3 $15.10

74740 X-ray female genital tract N1

74742 X-ray fallopian tube N1

74775 X-ray exam of perineum Z2 2.4272 $102.74

75557 Cardiac mri for morph Z2 4.5196 $191.31

75559 Cardiac mri w/stress img Z2 4.5196 $191.31

75561 Cardiac mri for morph w/dye Z3 $300.50

75563 Card mri w/stress img & dye Z2 7.1603 $303.09

75565 Card mri veloc flow mapping N1

75571 Ct hrt w/o dye w/ca test Z2 0.6316 $26.73

75572 Ct hrt w/3d image Z2 3.4956 $147.97

75573 Ct hrt w/3d image congen Z2 3.4956 $147.97

75574 Ct angio hrt w/3d image Z2 3.4956 $147.97

75600 Contrast x-ray exam of aorta N1

75605 Contrast x-ray exam of aorta N1

75625 Contrast x-ray exam of aorta N1

75630 X-ray aorta leg arteries N1

75635 Ct angio abdominal arteries N1

75650 Artery x-rays head & neck N1

75658 Artery x-rays arm N1

75660 Artery x-rays head & neck N1

75662 Artery x-rays head & neck N1

75665 Artery x-rays head & neck N1

75671 Artery x-rays head & neck N1

75676 Artery x-rays neck N1

75680 Artery x-rays neck N1

75685 Artery x-rays spine N1

75705 Artery x-rays spine N1

75710 Artery x-rays arm/leg N1

75716 Artery x-rays arms/legs N1

75722 Artery x-rays kidney N1

75724 Artery x-rays kidneys N1

75726 Artery x-rays abdomen N1

75731 Artery x-rays adrenal gland N1

75733 Artery x-rays adrenals N1

75736 Artery x-rays pelvis N1

75741 Artery x-rays lung N1

75743 Artery x-rays lungs N1

75746 Artery x-rays lung N1

75756 Artery x-rays chest N1

75774 Artery x-ray each vessel N1

75791 Av dialysis shunt imaging N1

75801 Lymph vessel x-ray arm/leg N1

75803 Lymph vessel x-ray arms/legs N1

75805 Lymph vessel x-ray trunk N1

75807 Lymph vessel x-ray trunk N1

75809 Nonvascular shunt x-ray N1

75810 Vein x-ray spleen/liver N1

75820 Vein x-ray arm/leg N1

75822 Vein x-ray arms/legs N1

75825 Vein x-ray trunk N1

75827 Vein x-ray chest N1

75831 Vein x-ray kidney N1

75833 Vein x-ray kidneys N1

75840 Vein x-ray adrenal gland N1

75842 Vein x-ray adrenal glands N1

75860 Vein x-ray neck N1

75870 Vein x-ray skull N1

75872 Vein x-ray skull N1

75880 Vein x-ray eye socket N1

75885 Vein x-ray liver N1

75887 Vein x-ray liver N1

75889 Vein x-ray liver N1

75891 Vein x-ray liver N1

75893 Venous sampling by catheter N1

75894 X-rays transcath therapy N1

75896 X-rays transcath therapy N1

Date Printed: 3/14/2013 @ 8:00 PM Page 5 of 24
HCPCS 

Code Short Descriptor

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum BB -- Proposed ASC Covered Ancillary Services Integral to Covered 

Surgical Procedures for CY 2012 (Including Ancillary Services for Which Payment 

is Packaged)

75898 Follow-up angiography N1

75901 Remove cva device obstruct N1

75902 Remove cva lumen obstruct N1

75940 X-ray placement vein filter N1

75945 Intravascular us N1

75946 Intravascular us add-on N1

75960 Transcath iv stent rs&i N1

75961 Retrieval broken catheter N1

75962 Repair arterial blockage N1

75964 Repair artery blockage each N1

75966 Repair arterial blockage N1

75968 Repair artery blockage each N1

75970 Vascular biopsy N1

75978 Repair venous blockage N1

75980 Contrast xray exam bile duct N1

75982 Contrast xray exam bile duct N1

75984 Xray control catheter change N1

75989 Abscess drainage under x-ray N1

76000 Fluoroscope examination N1

76001 Fluoroscope exam extensive N1

76010 X-ray nose to rectum Z3 $12.94

76080 X-ray exam of fistula N1

76098 X-ray exam breast specimen N1

76100 X-ray exam of body section Z2 1.0152 $42.97

76101 Complex body section x-ray Z3 $92.50

76102 Complex body section x-rays Z3 $133.00

76120 Cine/video x-rays Z3 $41.22

76125 Cine/video x-rays add-on N1

76376 3d render w/o postprocess N1

76377 3d rendering w/postprocess N1

76380 CAT scan follow-up study Z2 1.4484 $61.31

76496 Fluoroscopic procedure Z2 1.1698 $49.52

76497 Ct procedure Z2 1.4484 $61.31

76498 Mri procedure Z2 4.5196 $191.31

76499 Radiographic procedure Z2 0.6016 $25.47

76506 Echo exam of head Z2 0.8431 $35.69

76510 Ophth us b & quant a Z3 $54.64

76511 Ophth us quant a only Z3 $34.27

76512 Ophth us b w/non-quant a Z3 $28.04

76513 Echo exam of eye water bath Z3 $39.78

76514 Echo exam of eye thickness Z3 $3.35

76516 Echo exam of eye Z3 $31.63

76519 Echo exam of eye Z3 $35.23

76529 Echo exam of eye Z3 $30.91

76536 Us exam of head and neck Z2 1.2851 $54.40

76604 Us exam chest Z2 0.8431 $35.69

76645 Us exam breast(s) Z2 0.8431 $35.69

76700 Us exam abdom complete Z2 1.2851 $54.40

76705 Echo exam of abdomen Z2 1.2851 $54.40

76770 Us exam abdo back wall comp Z2 1.2851 $54.40

76775 Us exam abdo back wall lim Z2 1.2851 $54.40

76776 Us exam k transpl w/doppler Z2 1.2851 $54.40

76800 Us exam spinal canal Z2 1.2851 $54.40

76801 Ob us < 14 wks single fetus Z2 1.2851 $54.40

76802 Ob us < 14 wks addl fetus Z3 $19.89

76805 Ob us >/= 14 wks sngl fetus Z2 1.2851 $54.40

76810 Ob us >/= 14 wks addl fetus Z3 $35.71

76811 Ob us detailed sngl fetus Z3 $69.01

76812 Ob us detailed addl fetus Z2 0.8431 $35.69

76813 Ob us nuchal meas 1 gest Z2 0.8431 $35.69

76814 Ob us nuchal meas add-on Z3 $23.00

76815 Ob us limited fetus(s) Z2 0.8431 $35.69

76816 Ob us follow-up per fetus Z2 0.8431 $35.69

76817 Transvaginal us obstetric Z2 0.8431 $35.69

76818 Fetal biophys profile w/nst Z3 $51.04

76819 Fetal biophys profil w/o nst Z3 $37.86

76820 Umbilical artery echo Z3 $13.42

76821 Middle cerebral artery echo Z2 0.8431 $35.69

Date Printed: 3/14/2013 @ 8:00 PM Page 6 of 24
HCPCS 

Code Short Descriptor

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum BB -- Proposed ASC Covered Ancillary Services Integral to Covered 

Surgical Procedures for CY 2012 (Including Ancillary Services for Which Payment 

is Packaged)

76825 Echo exam of fetal heart Z3 $98.73

76826 Echo exam of fetal heart Z3 $63.02

76827 Echo exam of fetal heart Z3 $25.40

76828 Echo exam of fetal heart Z3 $13.66

76830 Transvaginal us non-ob Z2 1.2851 $54.40

76831 Echo exam uterus Z3 $65.66

76856 Us exam pelvic complete Z2 1.2851 $54.40

76857 Us exam pelvic limited Z2 0.8431 $35.69

76870 Us exam scrotum Z2 1.2851 $54.40

76872 Us transrectal Z2 1.2851 $54.40

76873 Echograp trans r pros study Z2 1.2851 $54.40

76881 Us xtr non-vasc complete Z2 1.2851 $54.40

76882 Us xtr non-vasc lmtd Z3 $7.43

76885 Us exam infant hips dynamic Z2 0.8431 $35.69

76886 Us exam infant hips static Z2 0.8431 $35.69

76930 Echo guide cardiocentesis N1

76932 Echo guide for heart biopsy N1

76936 Echo guide for artery repair Z2 1.4363 $60.80

76937 Us guide vascular access N1

76940 Us guide tissue ablation N1

76941 Echo guide for transfusion N1

76942 Echo guide for biopsy N1

76945 Echo guide villus sampling N1

76946 Echo guide for amniocentesis N1

76948 Echo guide ova aspiration N1

76950 Echo guidance radiotherapy N1

76965 Echo guidance radiotherapy N1

76970 Ultrasound exam follow-up Z2 0.8431 $35.69

76975 GI endoscopic ultrasound N1

76977** Us bone density measure Z3 $4.07

76998 Us guide intraop N1

76999 Echo examination procedure Z2 0.8431 $35.69

77001 Fluoroguide for vein device N1

77002 Needle localization by xray N1

77003 Fluoroguide for spine inject N1

77011 Ct scan for localization N1

77012 Ct scan for needle biopsy N1

77013 Ct guide for tissue ablation N1

77014 Ct scan for therapy guide N1

77021 Mr guidance for needle place N1

77022 Mri for tissue ablation N1

77031 Stereotact guide for brst bx N1

77032 Guidance for needle breast N1

77053 X-ray of mammary duct N1

77054 X-ray of mammary ducts N1

77071 X-ray stress view Z3 $23.72

77072 X-rays for bone age Z3 $9.83

77073 X-rays bone length studies Z3 $17.25

77074 X-rays bone survey limited Z3 $33.55

77075 X-rays bone survey complete Z2 1.0152 $42.97

77076 X-rays bone survey infant Z2 1.0152 $42.97

77077 Joint survey single view Z3 $17.73

77078** Ct bone density axial Z2 0.9575 $40.53

77079** Ct bone density peripheral Z3 $24.68

77080** Dxa bone density axial Z3 $32.59

77081** Dxa bone density/peripheral Z3 $12.22

77082 Dxa bone density vert fx Z3 $13.90

77083** Radiographic absorptiometry Z3 $10.30

77084 Magnetic image bone marrow Z2 4.5196 $191.31

77280 Set radiation therapy field Z2 1.4009 $59.30

77285 Set radiation therapy field Z2 3.4689 $146.84

77290 Set radiation therapy field Z2 3.4689 $146.84

77295 Set radiation therapy field Z3 $188.83

77299 Radiation therapy planning Z2 1.4009 $59.30

77300 Radiation therapy dose plan Z3 $25.40

77301 Radiotherapy dose plan imrt Z2 12.4155 $525.54

77305 Teletx isodose plan simple Z3 $18.93

77310 Teletx isodose plan intermed Z3 $25.40

Date Printed: 3/14/2013 @ 8:00 PM Page 7 of 24
HCPCS 

Code Short Descriptor

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum BB -- Proposed ASC Covered Ancillary Services Integral to Covered 

Surgical Procedures for CY 2012 (Including Ancillary Services for Which Payment 

is Packaged)

77315 Teletx isodose plan complex Z3 $41.70

77321 Special teletx port plan Z3 $35.23

77326 Brachytx isodose calc simp Z2 1.4009 $59.30

77327 Brachytx isodose calc interm Z3 $91.30

77328 Brachytx isodose plan compl Z3 $115.02

77331 Special radiation dosimetry Z3 $12.94

77332 Radiation treatment aid(s) Z3 $34.75

77333 Radiation treatment aid(s) Z3 $9.11

77334 Radiation treatment aid(s) Z3 $60.15

77336 Radiation physics consult Z3 $31.87

77338 Design mlc device for imrt Z2 3.4689 $146.84

77370 Radiation physics consult Z2 1.4009 $59.30

77371 Srs multisource Z2 99.4751 $4,210.68

77399 External radiation dosimetry Z2 1.4009 $59.30

77401 Radiation treatment delivery Z3 $15.10

77402 Radiation treatment delivery Z2 1.2774 $54.07

77403 Radiation treatment delivery Z2 1.2774 $54.07

77404 Radiation treatment delivery Z2 1.2774 $54.07

77406 Radiation treatment delivery Z2 1.2774 $54.07

77407 Radiation treatment delivery Z2 1.2774 $54.07

77408 Radiation treatment delivery Z2 2.2195 $93.95

77409 Radiation treatment delivery Z2 2.2195 $93.95

77411 Radiation treatment delivery Z2 2.2195 $93.95

77412 Radiation treatment delivery Z2 2.2195 $93.95

77413 Radiation treatment delivery Z2 2.2195 $93.95

77414 Radiation treatment delivery Z2 2.2195 $93.95

77416 Radiation treatment delivery Z2 2.2195 $93.95

77417 Radiology port film(s) N1

77418 Radiation tx delivery imrt Z2 6.0383 $255.60

77421 Stereoscopic x-ray guidance N1

77422 Neutron beam tx simple Z2 2.2195 $93.95

77423 Neutron beam tx complex Z2 2.2195 $93.95

77435 Sbrt management N1

77470 Special radiation treatment Z3 $48.89

77520 Proton trmt simple w/o comp Z2 13.3989 $567.16

77522 Proton trmt simple w/comp Z2 13.3989 $567.16

77523 Proton trmt intermediate Z2 17.5276 $741.93

77525 Proton treatment complex Z2 17.5276 $741.93

77600 Hyperthermia treatment Z2 5.2577 $222.55

77605 Hyperthermia treatment Z2 5.2577 $222.55

77610 Hyperthermia treatment Z2 5.2577 $222.55

77615 Hyperthermia treatment Z2 5.2577 $222.55

77620 Hyperthermia treatment Z2 5.2577 $222.55

77750 Infuse radioactive materials Z3 $70.45

77761 Apply intrcav radiat simple Z3 $122.21

77762 Apply intrcav radiat interm Z3 $140.67

77763 Apply intrcav radiat compl Z3 $182.84

77776 Apply interstit radiat simpl Z3 $124.61

77777 Apply interstit radiat inter Z3 $129.88

77778 Apply interstit radiat compl Z3 $187.15

77785 Hdr brachytx 1 channel Z3 $111.43

77786 Hdr brachytx 2-12 channel Z3 $275.34

77787 Hdr brachytx over 12 chan Z2 9.2473 $391.43

77789 Apply surface radiation Z3 $37.86

77790 Radiation handling N1

77799 Radium/radioisotope therapy Z2 4.4066 $186.53

78000 Thyroid single uptake Z2 1.4184 $60.04

78001 Thyroid multiple uptakes Z2 1.4184 $60.04

78003 Thyroid suppress/stimul Z2 1.4184 $60.04

78006 Thyroid imaging with uptake Z2 2.9759 $125.97

78007 Thyroid image mult uptakes Z2 2.9759 $125.97

78010 Thyroid imaging Z2 1.749 $74.03

78011 Thyroid imaging with flow Z2 1.749 $74.03

78015 Thyroid met imaging Z2 3.7843 $160.19

78016 Thyroid met imaging/studies Z2 3.7843 $160.19

78018 Thyroid met imaging body Z2 3.7843 $160.19

78020 Thyroid met uptake N1

78070 Parathyroid nuclear imaging Z2 2.9759 $125.97

Date Printed: 3/14/2013 @ 8:00 PM Page 8 of 24
HCPCS 

Code Short Descriptor

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum BB -- Proposed ASC Covered Ancillary Services Integral to Covered 

Surgical Procedures for CY 2012 (Including Ancillary Services for Which Payment 

is Packaged)

78075 Adrenal nuclear imaging Z2 6.5434 $276.98

78099 Endocrine nuclear procedure Z2 1.749 $74.03

78102 Bone marrow imaging ltd Z2 3.4804 $147.32

78103 Bone marrow imaging mult Z2 3.4804 $147.32

78104 Bone marrow imaging body Z2 3.4804 $147.32

78110 Plasma volume single Z2 5.9086 $250.11

78111 Plasma volume multiple Z2 5.9086 $250.11

78120 Red cell mass single Z2 5.9086 $250.11

78121 Red cell mass multiple Z2 5.9086 $250.11

78122 Blood volume Z2 5.9086 $250.11

78130 Red cell survival study Z2 5.9086 $250.11

78135 Red cell survival kinetics Z2 5.9086 $250.11

78140 Red cell sequestration Z2 5.9086 $250.11

78185 Spleen imaging Z2 3.4804 $147.32

78190 Platelet survival kinetics Z2 2.377 $100.62

78191 Platelet survival Z2 2.377 $100.62

78195 Lymph system imaging Z2 3.4804 $147.32

78199 Blood/lymph nuclear exam Z2 3.4804 $147.32

78201 Liver imaging Z2 3.8979 $164.99

78202 Liver imaging with flow Z2 3.8979 $164.99

78205 Liver imaging (3D) Z2 3.8979 $164.99

78206 Liver image (3d) with flow Z2 3.8979 $164.99

78215 Liver and spleen imaging Z2 3.8979 $164.99

78216 Liver & spleen image/flow Z2 3.8979 $164.99

78220 Liver function study Z2 3.8979 $164.99

78223 Hepatobiliary imaging Z2 3.8979 $164.99

78230 Salivary gland imaging Z2 3.2408 $137.18

78231 Serial salivary imaging Z2 3.2408 $137.18

78232 Salivary gland function exam Z2 3.2408 $137.18

78258 Esophageal motility study Z2 3.2408 $137.18

78261 Gastric mucosa imaging Z2 3.2408 $137.18

78262 Gastroesophageal reflux exam Z2 3.2408 $137.18

78264 Gastric emptying study Z2 3.2408 $137.18

78270 Vit B-12 absorption exam Z2 2.377 $100.62

78271 Vit b-12 absrp exam int fac Z2 2.377 $100.62

78272 Vit b-12 absorp combined Z2 2.377 $100.62

78278 Acute GI blood loss imaging Z2 3.2408 $137.18

78282 GI protein loss exam Z2 3.2408 $137.18

78290 Meckels divert exam Z2 3.2408 $137.18

78291 Leveen/shunt patency exam Z2 3.2408 $137.18

78299 GI nuclear procedure Z2 3.2408 $137.18

78300 Bone imaging limited area Z2 3.2937 $139.42

78305 Bone imaging multiple areas Z2 3.2937 $139.42

78306 Bone imaging whole body Z2 3.2937 $139.42

78315 Bone imaging 3 phase Z2 3.2937 $139.42

78320 Bone imaging (3D) Z2 3.2937 $139.42

78399 Musculoskeletal nuclear exam Z2 3.2937 $139.42

78414 Non-imaging heart function Z2 3.9603 $167.64

78428 Cardiac shunt imaging Z2 3.9603 $167.64

78445 Vascular flow imaging Z2 2.2701 $96.09

78451 Ht muscle image spect sing Z2 9.1371 $386.76

78452 Ht muscle image spect mult Z2 9.1371 $386.76

78453 Ht muscle image planar sing Z2 9.1371 $386.76

78454 Ht musc image planar mult Z2 9.1371 $386.76

78456 Acute venous thrombus image Z2 2.2701 $96.09

78457 Venous thrombosis imaging Z2 2.2701 $96.09

78458 Ven thrombosis images bilat Z2 2.2701 $96.09

78459 Heart muscle imaging (PET) Z2 12.439 $526.53

78466 Heart infarct image Z2 3.9603 $167.64

78468 Heart infarct image (ef) Z2 3.9603 $167.64

78469 Heart infarct image (3D) Z2 3.9603 $167.64

78472 Gated heart planar single Z2 3.9603 $167.64

78473 Gated heart multiple Z2 3.9603 $167.64

78481 Heart first pass single Z2 3.9603 $167.64

78483 Heart first pass multiple Z2 3.9603 $167.64

78491 Heart image (pet) single Z2 12.439 $526.53

78492 Heart image (pet) multiple Z2 12.439 $526.53

78494 Heart image spect Z2 3.9603 $167.64

Date Printed: 3/14/2013 @ 8:00 PM Page 9 of 24
HCPCS 

Code Short Descriptor

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum BB -- Proposed ASC Covered Ancillary Services Integral to Covered 

Surgical Procedures for CY 2012 (Including Ancillary Services for Which Payment 

is Packaged)

78496 Heart first pass add-on N1

78499 Cardiovascular nuclear exam Z2 3.9603 $167.64

78580 Lung perfusion imaging Z2 2.6643 $112.78

78584 Lung V/Q image single breath Z2 4.2234 $178.77

78585 Lung V/Q imaging Z2 4.2234 $178.77

78586 Aerosol lung image single Z2 2.6643 $112.78

78587 Aerosol lung image multiple Z2 2.6643 $112.78

78588 Perfusion lung image Z2 4.2234 $178.77

78591 Vent image 1 breath 1 proj Z2 2.6643 $112.78

78593 Vent image 1 proj gas Z2 2.6643 $112.78

78594 Vent image mult proj gas Z2 2.6643 $112.78

78596 Lung differential function Z2 4.2234 $178.77

78599 Respiratory nuclear exam Z2 2.6643 $112.78

78600 Brain image < 4 views Z2 3.1546 $133.53

78601 Brain image w/flow < 4 views Z2 8.1621 $345.49

78605 Brain image 4+ views Z2 3.1546 $133.53

78606 Brain image w/flow 4 + views Z2 8.1621 $345.49

78607 Brain imaging (3D) Z2 8.1621 $345.49

78608 Brain imaging (PET) Z2 13.7006 $579.93

78610 Brain flow imaging only Z2 3.1546 $133.53

78630 Cerebrospinal fluid scan Z2 8.1621 $345.49

78635 CSF ventriculography Z2 8.1621 $345.49

78645 CSF shunt evaluation Z2 3.1546 $133.53

78647 Cerebrospinal fluid scan Z2 8.1621 $345.49

78650 CSF leakage imaging Z2 8.1621 $345.49

78660 Nuclear exam of tear flow Z2 3.1546 $133.53

78699 Nervous system nuclear exam Z2 3.1546 $133.53

78700 Kidney imaging morphol Z2 4.2849 $181.38

78701 Kidney imaging with flow Z2 4.2849 $181.38

78707 K flow/funct image w/o drug Z2 4.2849 $181.38

78708 K flow/funct image w/drug Z2 4.2849 $181.38

78709 K flow/funct image multiple Z2 4.2849 $181.38

78710 Kidney imaging (3D) Z2 4.2849 $181.38

78725 Kidney function study Z2 2.377 $100.62

78730 Urinary bladder retention Z2 1.4184 $60.04

78740 Ureteral reflux study Z2 4.2849 $181.38

78761 Testicular imaging w/flow Z2 4.2849 $181.38

78799 Genitourinary nuclear exam Z2 4.2849 $181.38

78800 Tumor imaging limited area Z2 3.7843 $160.19

78801 Tumor imaging mult areas Z2 6.5434 $276.98

78802 Tumor imaging whole body Z2 6.5434 $276.98

78803 Tumor imaging (3D) Z2 6.5434 $276.98

78804 Tumor imaging whole body Z2 12.8657 $544.59

78805 Abscess imaging ltd area Z2 6.5434 $276.98

78806 Abscess imaging whole body Z2 6.5434 $276.98

78807 Nuclear localization/abscess Z2 6.5434 $276.98

78808 Iv inj ra drug dx study N1

78811 Pet image ltd area Z2 13.7006 $579.93

78812 Pet image skull-thigh Z2 13.7006 $579.93

78813 Pet image full body Z2 13.7006 $579.93

78814 Pet image w/ct lmtd Z2 13.7006 $579.93

78815 Pet image w/ct skull-thigh Z2 13.7006 $579.93

78816 Pet image w/ct full body Z2 13.7006 $579.93

78999 Nuclear diagnostic exam Z2 1.4184 $60.04

79005 Nuclear rx oral admin Z3 $35.47

79101 Nuclear rx iv admin Z3 $38.10

79200 Nuclear rx intracav admin Z3 $46.01

79300 Nuclr rx interstit colloid Z2 3.0751 $130.17

79403 Hematopoietic nuclear tx Z3 $58.47

79440 Nuclear rx intra-articular Z3 $39.54

79445 Nuclear rx intra-arterial Z2 3.0751 $130.17

79999 Nuclear medicine therapy Z2 3.0751 $130.17

90371 Hep b ig im K2 $112.16

90375 Rabies ig im/sc K2 $159.86

90376 Rabies ig heat treated K2 $154.18

90378 Rsv mab im 50mg CH N1

90385 Rh ig minidose im N1

90396 Varicella-zoster ig im K2 $129.48

Date Printed: 3/14/2013 @ 8:00 PM Page 10 of 24
HCPCS 

Code Short Descriptor

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum BB -- Proposed ASC Covered Ancillary Services Integral to Covered 

Surgical Procedures for CY 2012 (Including Ancillary Services for Which Payment 

is Packaged)

90476 Adenovirus vaccine type 4 CH N1

90585 Bcg vaccine percut K2 $112.46

90632 Hep a vaccine adult im N1

90633 Hep a vacc ped/adol 2 dose N1

90634 Hep a vacc ped/adol 3 dose N1

90636 Hep a/hep b vacc adult im N1

90645 Hib vaccine hboc im N1

90646 Hib vaccine prp-d im N1

90647 Hib vaccine prp-omp im N1

90648 Hib vaccine prp-t im N1

90655** Flu vaccine no preserv 6-35m L1

90656** Flu vaccine no preserv 3 & > L1

90657** Flu vaccine 3 yrs im L1

90660** Flu vaccine nasal L1

90662** Flu vacc prsv free inc antig L1

90665 Lyme disease vaccine im N1

90669** Pneumococcal vacc 7 val im L1

90670** Pneumococcal vacc 13 val im L1

90675 Rabies vaccine im K2 $190.82

90676 Rabies vaccine id K2 $107.83

90680 Rotovirus vacc 3 dose oral CH N1

90681 Rotavirus vacc 2 dose oral K2 $100.56

90690 Typhoid vaccine oral N1

90691 Typhoid vaccine im N1

90692 Typhoid vaccine h-p sc/id N1

90696 Dtap-ipv vacc 4-6 yr im N1

90698 Dtap-hib-ip vaccine im N1

90700 Dtap vaccine < 7 yrs im N1

90701 Dtp vaccine im N1

90702 Dt vaccine < 7 im N1

90703 Tetanus vaccine im N1

90704 Mumps vaccine sc N1

90705 Measles vaccine sc N1

90706 Rubella vaccine sc N1

90707 Mmr vaccine sc N1

90708 Measles-rubella vaccine sc N1

90710 Mmrv vaccine sc N1

90712 Oral poliovirus vaccine N1

90713 Poliovirus ipv sc/im N1

90714 Td vaccine no prsrv >/= 7 im N1

90715 Tdap vaccine >7 im N1

90717 Yellow fever vaccine sc N1

90718 Td vaccine > 7 im N1

90719 Diphtheria vaccine im N1

90720 Dtp/hib vaccine im N1

90721 Dtap/hib vaccine im N1

90732** Pneumococcal vaccine L1

90733 Meningococcal vaccine sc K2 $104.49

90734 Meningococcal vaccine im K2 $83.39

90735 Encephalitis vaccine sc K2 $100.16

90740** Hepb vacc ill pat 3 dose im F4

90743** Hep b vacc adol 2 dose im F4

90744** Hepb vacc ped/adol 3 dose im F4

90746** Hep b vaccine adult im F4

90747** Hepb vacc ill pat 4 dose im F4

90749 Vaccine toxoid N1

A4218 Sterile saline or water N1

A4220 Infusion pump refill kit N1

A4248 Chlorhexidine antisept N1

A4262 Temporary tear duct plug N1

A4263 Permanent tear duct plug N1

A4270 Disposable endoscope sheath N1

A4300 Cath impl vasc access portal N1

A4301 Implantable access syst perc N1

A4305 Drug delivery system >=50 ML N1

A4306 Drug delivery system <=50 ml N1

A4641 Radiopharm dx agent noc N1

A4642 In111 satumomab N1

Date Printed: 3/14/2013 @ 8:00 PM Page 11 of 24
HCPCS 

Code Short Descriptor

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum BB -- Proposed ASC Covered Ancillary Services Integral to Covered 

Surgical Procedures for CY 2012 (Including Ancillary Services for Which Payment 

is Packaged)

A4648 Implantable tissue marker N1

A4650 Implant radiation dosimeter N1

A9500 Tc99m sestamibi N1

A9501 Technetium TC-99m teboroxime N1

A9502 Tc99m tetrofosmin N1

A9503 Tc99m medronate N1

A9504 Tc99m apcitide N1

A9505 TL201 thallium N1

A9507 In111 capromab N1

A9508 I131 iodobenguate, dx N1

A9509 Iodine I-123 sod iodide mil N1

A9510 Tc99m disofenin N1

A9512 Tc99m pertechnetate N1

A9516 Iodine I-123 sod iodide mic N1

A9521 Tc99m exametazime N1

A9524 I131 serum albumin, dx N1

A9526 Nitrogen N-13 ammonia N1

A9527 Iodine I-125 sodium iodide H2 $19.91

A9528 Iodine I-131 iodide cap, dx N1

A9529 I131 iodide sol, dx N1

A9531 I131 max 100uCi N1

A9532 I125 serum albumin, dx N1

A9536 Tc99m depreotide N1

A9537 Tc99m mebrofenin N1

A9538 Tc99m pyrophosphate N1

A9539 Tc99m pentetate N1

A9540 Tc99m MAA N1

A9541 Tc99m sulfur colloid N1

A9542 In111 ibritumomab, dx N1

A9544 I131 tositumomab, dx N1

A9546 Co57/58 N1

A9547 In111 oxyquinoline N1

A9548 In111 pentetate N1

A9550 Tc99m gluceptate N1

A9551 Tc99m succimer N1

A9552 F18 fdg N1

A9553 Cr51 chromate N1

A9554 I125 iothalamate, dx N1

A9555 Rb82 rubidium N1

A9556 Ga67 gallium N1

A9557 Tc99m bicisate N1

A9558 Xe133 xenon 10mci N1

A9559 Co57 cyano N1

A9560 Tc99m labeled rbc N1

A9561 Tc99m oxidronate N1

A9562 Tc99m mertiatide N1

A9566 Tc99m fanolesomab N1

A9567 Technetium TC-99m aerosol N1

A9568 Technetium tc99m arcitumomab N1

A9569 Technetium TC-99m auto WBC N1

A9570 Indium In-111 auto WBC N1

A9571 Indium IN-111 auto platelet N1

A9572 Indium In-111 pentetreotide N1

A9576 Inj prohance multipack N1

A9577 Inj multihance N1

A9578 Inj multihance multipack N1

A9579 Gad-base MR contrast NOS,1ml N1

A9580 Sodium fluoride F-18 N1

A9581 Gadoxetate disodium inj N1

A9582 Iodine I-123 iobenguane CH N1

A9583 Gadofosveset trisodium inj CH N1

A9698 Non-rad contrast materialNOC N1

C1713 Anchor/screw bn/bn,tis/bn N1

C1714 Cath, trans atherectomy, dir N1

C1715 Brachytherapy needle N1

C1716 Brachytx, non-str, Gold-198 H2 $70.25

C1717 Brachytx, non-str,HDR Ir-192 H2 $219.93

C1719 Brachytx, NS, Non-HDRIr-192 H2 $31.14

Date Printed: 3/14/2013 @ 8:00 PM Page 12 of 24
HCPCS 

Code Short Descriptor

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum BB -- Proposed ASC Covered Ancillary Services Integral to Covered 

Surgical Procedures for CY 2012 (Including Ancillary Services for Which Payment 

is Packaged)

C1721 AICD, dual chamber N1

C1722 AICD, single chamber N1

C1724 Cath, trans atherec,rotation N1

C1725 Cath, translumin non-laser N1

C1726 Cath, bal dil, non-vascular N1

C1727 Cath, bal tis dis, non-vas N1

C1728 Cath, brachytx seed adm N1

C1729 Cath, drainage N1

C1730 Cath, EP, 19 or few elect N1

C1731 Cath, EP, 20 or more elec N1

C1732 Cath, EP, diag/abl, 3D/vect N1

C1733 Cath, EP, othr than cool-tip N1

C1749 Endo, colon, retro imaging J7

C1750 Cath, hemodialysis,long-term N1

C1751 Cath, inf, per/cent/midline N1

C1752 Cath,hemodialysis,short-term N1

C1753 Cath, intravas ultrasound N1

C1754 Catheter, intradiscal N1

C1755 Catheter, intraspinal N1

C1756 Cath, pacing, transesoph N1

C1757 Cath, thrombectomy/embolect N1

C1758 Catheter, ureteral N1

C1759 Cath, intra echocardiography N1

C1760 Closure dev, vasc N1

C1762 Conn tiss, human(inc fascia) N1

C1763 Conn tiss, non-human N1

C1764 Event recorder, cardiac N1

C1765 Adhesion barrier N1

C1766 Intro/sheath,strble,non-peel N1

C1767 Generator, neuro non-recharg N1

C1768 Graft, vascular N1

C1769 Guide wire N1

C1770 Imaging coil, MR, insertable N1

C1771 Rep dev, urinary, w/sling N1

C1772 Infusion pump, programmable N1

C1773 Ret dev, insertable N1

C1776 Joint device (implantable) N1

C1777 Lead, AICD, endo single coil N1

C1778 Lead, neurostimulator N1

C1779 Lead, pmkr, transvenous VDD N1

C1780 Lens, intraocular (new tech) N1

C1781 Mesh (implantable) N1

C1782 Morcellator N1

C1783 Ocular imp, aqueous drain de N1

C1784 Ocular dev, intraop, det ret N1

C1785 Pmkr, dual, rate-resp N1

C1786 Pmkr, single, rate-resp N1

C1787 Patient progr, neurostim N1

C1788 Port, indwelling, imp N1

C1789 Prosthesis, breast, imp N1

C1813 Prosthesis, penile, inflatab N1

C1814 Retinal tamp, silicone oil N1

C1815 Pros, urinary sph, imp N1

C1816 Receiver/transmitter, neuro N1

C1817 Septal defect imp sys N1

C1818 Integrated keratoprosthesis N1

C1819 Tissue localization-excision N1

C1820 Generator neuro rechg bat sy N1

C1821 Interspinous implant N1

C1874 Stent, coated/cov w/del sys N1

C1875 Stent, coated/cov w/o del sy N1

C1876 Stent, non-coa/non-cov w/del N1

C1877 Stent, non-coat/cov w/o del N1

C1878 Matrl for vocal cord N1

C1879 Tissue marker, implantable N1

C1880 Vena cava filter N1

C1881 Dialysis access system N1

C1882 AICD, other than sing/dual N1

Date Printed: 3/14/2013 @ 8:00 PM Page 13 of 24
HCPCS 

Code Short Descriptor

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum BB -- Proposed ASC Covered Ancillary Services Integral to Covered 

Surgical Procedures for CY 2012 (Including Ancillary Services for Which Payment 

is Packaged)

C1883 Adapt/ext, pacing/neuro lead N1

C1884 Embolization Protect syst N1

C1885 Cath, translumin angio laser N1

C1887 Catheter, guiding N1

C1888 Endovas non-cardiac abl cath N1

C1891 Infusion pump,non-prog, perm N1

C1892 Intro/sheath,fixed,peel-away N1

C1893 Intro/sheath, fixed,non-peel N1

C1894 Intro/sheath, non-laser N1

C1895 Lead, AICD, endo dual coil N1

C1896 Lead, AICD, non sing/dual N1

C1897 Lead, neurostim test kit N1

C1898 Lead, pmkr, other than trans N1

C1899 Lead, pmkr/AICD combination N1

C1900 Lead, coronary venous N1

C2614 Probe, perc lumb disc N1

C2615 Sealant, pulmonary, liquid N1

C2616 Brachytx, non-str,Yttrium-90 H2 $16,126.38

C2617 Stent, non-cor, tem w/o del N1

C2618 Probe, cryoablation N1

C2619 Pmkr, dual, non rate-resp N1

C2620 Pmkr, single, non rate-resp N1

C2621 Pmkr, other than sing/dual N1

C2622 Prosthesis, penile, non-inf N1

C2625 Stent, non-cor, tem w/del sy N1

C2626 Infusion pump, non-prog,temp N1

C2627 Cath, suprapubic/cystoscopic N1

C2628 Catheter, occlusion N1

C2629 Intro/sheath, laser N1

C2630 Cath, EP, cool-tip N1

C2631 Rep dev, urinary, w/o sling N1

C2634 Brachytx, non-str, HA, I-125 H2 $54.90

C2635 Brachytx, non-str, HA, P-103 H2 $23.87

C2636 Brachy linear, non-str,P-103 H2 $35.49

C2638 Brachytx, stranded, I-125 H2 $43.21

C2639 Brachytx, non-stranded,I-125 H2 $34.65

C2640 Brachytx, stranded, P-103 H2 $73.65

C2641 Brachytx, non-stranded,P-103 H2 $64.30

C2642 Brachytx, stranded, C-131 H2 $117.47

C2643 Brachytx, non-stranded,C-131 H2 $74.52

C2698 Brachytx, stranded, NOS H2 $43.21

C2699 Brachytx, non-stranded, NOS H2 $23.87

C8900 MRA w/cont, abd Z2 5.7993 $245.48

C8901 MRA w/o cont, abd Z2 4.5196 $191.31

C8902 MRA w/o fol w/cont, abd Z2 7.1603 $303.09

C8903 MRI w/cont, breast, uni Z2 5.7993 $245.48

C8904 MRI w/o cont, breast, uni Z2 4.5196 $191.31

C8905 MRI w/o fol w/cont, brst, un Z2 7.1603 $303.09

C8906 MRI w/cont, breast, bi Z2 5.7993 $245.48

C8907 MRI w/o cont, breast, bi Z2 4.5196 $191.31

C8908 MRI w/o fol w/cont, breast, Z2 7.1603 $303.09

C8909 MRA w/cont, chest Z2 5.7993 $245.48

C8910 MRA w/o cont, chest Z2 4.5196 $191.31

C8911 MRA w/o fol w/cont, chest Z2 7.1603 $303.09

C8912 MRA w/cont, lwr ext Z2 5.7993 $245.48

C8913 MRA w/o cont, lwr ext Z2 4.5196 $191.31

C8914 MRA w/o fol w/cont, lwr ext Z2 7.1603 $303.09

C8918 MRA w/cont, pelvis Z2 5.7993 $245.48

C8919 MRA w/o cont, pelvis Z2 4.5196 $191.31

C8920 MRA w/o fol w/cont, pelvis Z2 7.1603 $303.09

C8931 MRA, w/dye, spinal canal Z2 5.7993 $245.48

C8932 MRA, w/o dye, spinal canal Z2 4.5196 $191.31

C8933 MRA, w/o&w/dye, spinal canal Z2 7.1603 $303.09

C8934 MRA, w/dye, upper extremity Z2 5.7993 $245.48

C8935 MRA, w/o dye, upper extr Z2 4.5196 $191.31

C8936 MRA, w/o&w/dye, upper extr Z2 7.1603 $303.09

C9113 Inj pantoprazole sodium, via N1

C9121 Injection, argatroban K2 $18.71

Date Printed: 3/14/2013 @ 8:00 PM Page 14 of 24
HCPCS 

Code Short Descriptor

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum BB -- Proposed ASC Covered Ancillary Services Integral to Covered 

Surgical Procedures for CY 2012 (Including Ancillary Services for Which Payment 

is Packaged)

C9248 Inj, clevidipine butyrate K2 $6.03

C9250 Artiss fibrin sealant K2 $121.80

C9254 Injection, lacosamide K2 $0.15

C9257 Bevacizumab injection K2 $1.47

C9270 Gammaplex IVIG K2 $37.29

C9272 Inj, denosumab K2 $14.52

C9273 Sipuleucel-T, per infusion K2 $32,860.00

C9274 Crotalidae Poly Immune Fab K2 $2,111.36

C9275 Hexaminolevulinate HCl K2 $636.00

C9276 Cabazitaxel injection K2 $135.05

C9277 Lumizyme, 1 mg K2 $14.83

C9279 Injection, ibuprofen K2 $1.39

C9280 Injection, eribulin mesylate K2 $901.00

C9281 Injection, pegloticase K2 $304.75

C9282 Inj, ceftaroline fosamil K2 $0.72

C9352 Neuragen nerve guide, per cm N1

C9353 Neurawrap nerve protector,cm N1

C9354 Veritas collagen matrix, cm2 N1

C9355 Neuromatrix nerve cuff, cm N1

C9356 TenoGlide tendon prot, cm2 N1

C9358 SurgiMend, fetal K2 $11.09

C9359 Implnt,bon void filler-putty N1

C9360 SurgiMend, neonatal K2 $11.59

C9361 NeuroMend nerve wrap CH N1

C9362 Implnt,bon void filler-strip CH N1

C9363 Integra Meshed Bil Wound Mat K2 $19.17

C9364 Porcine implant, Permacol CH N1

C9367 Endoform Dermal Template K2 $4.35

C9399 Unclassified drugs or biolog K7

E0616 Cardiac event recorder N1

E0749 Elec osteogen stim implanted N1

E0782 Non-programble infusion pump N1

E0783 Programmable infusion pump N1

E0785 Replacement impl pump cathet N1

E0786 Implantable pump replacement N1

G0130** Single energy x-ray study Z3 $15.82

G0173 Linear acc stereo radsur com Z2 43.8918 $1,857.90

G0251 Linear acc based stero radio Z2 11.6706 $494.00

G0288 Recon, CTA for surg plan N1

G0339 Robot lin-radsurg com, first Z2 43.8918 $1,857.90

G0340 Robt lin-radsurg fractx 2-5 Z2 33.0358 $1,398.37

J0120 Tetracyclin injection N1

J0129 Abatacept injection K2 $20.26

J0130 Abciximab injection K2 $515.32

J0132 Acetylcysteine injection K2 $2.67

J0133 Acyclovir injection N1

J0135 Adalimumab injection K2 $394.16

J0150 Injection adenosine 6 MG N1

J0152 Adenosine injection K2 $89.99

J0171 Adrenalin epinephrine inject N1

J0180 Agalsidase beta injection K2 $133.65

J0200 Alatrofloxacin mesylate N1

J0205 Alglucerase injection K2 $41.19

J0207 Amifostine K2 $314.05

J0210 Methyldopate hcl injection K2 $39.24

J0215 Alefacept K2 $35.86

J0220 Alglucosidase alfa injection K2 $155.84

J0256 Alpha 1 proteinase inhibitor K2 $3.79

J0278 Amikacin sulfate injection N1

J0280 Aminophyllin 250 MG inj N1

J0282 Amiodarone HCl N1

J0285 Amphotericin B N1

J0287 Amphotericin b lipid complex K2 $8.76

J0288 Ampho b cholesteryl sulfate K2 $13.74

J0289 Amphotericin b liposome inj K2 $14.77

J0290 Ampicillin 500 MG inj N1

J0295 Ampicillin sodium per 1.5 gm N1

J0300 Amobarbital 125 MG inj CH K2 $23.38

Date Printed: 3/14/2013 @ 8:00 PM Page 15 of 24
HCPCS 

Code Short Descriptor

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum BB -- Proposed ASC Covered Ancillary Services Integral to Covered 

Surgical Procedures for CY 2012 (Including Ancillary Services for Which Payment 

is Packaged)

J0330 Succinycholine chloride inj N1

J0348 Anidulafungin injection K2 $1.29

J0360 Hydralazine hcl injection N1

J0364 Apomorphine hydrochloride N1

J0365 Aprotonin, 10,000 kiu N1

J0380 Inj metaraminol bitartrate N1

J0390 Chloroquine injection N1

J0400 Aripiprazole injection N1

J0456 Azithromycin N1

J0461 Atropine sulfate injection N1

J0470 Dimecaprol injection N1

J0475 Baclofen 10 MG injection K2 $200.54

J0476 Baclofen intrathecal trial K2 $72.18

J0480 Basiliximab K2 $2,027.27

J0500 Dicyclomine injection N1

J0515 Inj benztropine mesylate CH N1

J0520 Bethanechol chloride inject N1

J0558 PenG benzathine/procaine inj N1

J0561 Penicillin g benzathine inj N1

J0583 Bivalirudin K2 $2.54

J0585 Injection,onabotulinumtoxinA K2 $5.38

J0586 AbobotulinumtoxinA K2 $7.41

J0587 Inj, rimabotulinumtoxinB K2 $10.33

J0592 Buprenorphine hydrochloride N1

J0594 Busulfan injection K2 $16.29

J0595 Butorphanol tartrate 1 mg N1

J0597 C-1 esterase, berinert K2 $27.53

J0598 C-1 esterase, cinryze K2 $43.78

J0600 Edetate calcium disodium inj K2 $192.07

J0610 Calcium gluconate injection N1

J0620 Calcium glycer & lact/10 ML N1

J0630 Calcitonin salmon injection CH N1

J0636 Inj calcitriol per 0.1 mcg N1

J0637 Caspofungin acetate K2 $12.13

J0638 Canakinumab injection K2 $87.45

J0640 Leucovorin calcium injection N1

J0641 Levoleucovorin injection K2 $1.78

J0670 Inj mepivacaine HCL/10 ml N1

J0690 Cefazolin sodium injection N1

J0692 Cefepime HCl for injection N1

J0694 Cefoxitin sodium injection N1

J0696 Ceftriaxone sodium injection N1

J0697 Sterile cefuroxime injection N1

J0698 Cefotaxime sodium injection N1

J0702 Betamethasone acet&sod phosp N1

J0706 Caffeine citrate injection N1

J0710 Cephapirin sodium injection N1

J0713 Inj ceftazidime per 500 mg N1

J0715 Ceftizoxime sodium / 500 MG N1

J0718 Certolizumab pegol inj K2 $3.99

J0720 Chloramphenicol sodium injec N1

J0725 Chorionic gonadotropin/1000u N1

J0735 Clonidine hydrochloride CH N1

J0740 Cidofovir injection K2 $740.09

J0743 Cilastatin sodium injection N1

J0744 Ciprofloxacin iv N1

J0745 Inj codeine phosphate /30 MG N1

J0760 Colchicine injection N1

J0770 Colistimethate sodium inj N1

J0775 Collagenase, clost hist inj K2 $37.51

J0780 Prochlorperazine injection N1

J0795 Corticorelin ovine triflutal K2 $5.06

J0800 Corticotropin injection K2 $2,395.22

J0833 Cosyntropin injection NOS K2 $99.76

J0834 Cosyntropin cortrosyn inj CH N1

J0850 Cytomegalovirus imm IV /vial K2 $922.07

J0878 Daptomycin injection K2 $0.45

J0881 Darbepoetin alfa, non-esrd K2 $2.98

Date Printed: 3/14/2013 @ 8:00 PM Page 16 of 24
HCPCS 

Code Short Descriptor

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum BB -- Proposed ASC Covered Ancillary Services Integral to Covered 

Surgical Procedures for CY 2012 (Including Ancillary Services for Which Payment 

is Packaged)

J0885 Epoetin alfa, non-esrd K2 $9.57

J0894 Decitabine injection K2 $30.71

J0895 Deferoxamine mesylate inj N1

J0900 Testosterone enanthate inj N1

J0945 Brompheniramine maleate inj CH N1

J1000 Depo-estradiol cypionate inj N1

J1020 Methylprednisolone 20 MG inj N1

J1030 Methylprednisolone 40 MG inj N1

J1040 Methylprednisolone 80 MG inj N1

J1051 Medroxyprogesterone inj N1

J1060 Testosterone cypionate 1 ML N1

J1070 Testosterone cypionat 100 MG N1

J1080 Testosterone cypionat 200 MG N1

J1094 Inj dexamethasone acetate N1

J1100 Dexamethasone sodium phos N1

J1110 Inj dihydroergotamine mesylt N1

J1120 Acetazolamid sodium injectio N1

J1160 Digoxin injection N1

J1162 Digoxin immune fab (ovine) K2 $583.90

J1165 Phenytoin sodium injection N1

J1170 Hydromorphone injection N1

J1180 Dyphylline injection N1

J1190 Dexrazoxane HCl injection K2 $274.42

J1200 Diphenhydramine hcl injectio N1

J1205 Chlorothiazide sodium inj K2 $272.64

J1212 Dimethyl sulfoxide 50% 50 ML K2 $82.68

J1230 Methadone injection N1

J1240 Dimenhydrinate injection N1

J1245 Dipyridamole injection N1

J1250 Inj dobutamine HCL/250 mg N1

J1260 Dolasetron mesylate N1

J1265 Dopamine injection N1

J1267 Doripenem injection N1

J1270 Injection, doxercalciferol N1

J1290 Ecallantide injection K2 $275.28

J1300 Eculizumab injection K2 $183.71

J1320 Amitriptyline injection N1

J1324 Enfuvirtide injection N1

J1325 Epoprostenol injection N1

J1327 Eptifibatide injection K2 $20.31

J1330 Ergonovine maleate injection N1

J1335 Ertapenem injection N1

J1364 Erythro lactobionate /500 MG N1

J1380 Estradiol valerate 10 MG inj N1

J1410 Inj estrogen conjugate 25 MG K2 $94.03

J1430 Ethanolamine oleate 100 mg K2 $147.14

J1436 Etidronate disodium inj N1

J1438 Etanercept injection K2 $203.01

J1440 Filgrastim 300 mcg injection K2 $238.72

J1441 Filgrastim 480 mcg injection K2 $376.20

J1450 Fluconazole N1

J1451 Fomepizole, 15 mg K2 $6.76

J1453 Fosaprepitant injection K2 $1.71

J1455 Foscarnet sodium injection CH K2 $13.06

J1457 Gallium nitrate injection CH N1

J1458 Galsulfase injection K2 $338.26

J1459 Inj IVIG privigen 500 mg K2 $34.45

J1460 Gamma globulin 1 CC inj K2 $17.91

J1559 Hizentra injection K2 $7.15

J1560 Gamma globulin > 10 CC inj K2 $179.06

J1561 Gamunex injection K2 $36.91

J1562 Vivaglobin, inj K2 $7.11

J1566 Immune globulin, powder K2 $30.62

J1568 Octagam injection K2 $55.80

J1569 Gammagard liquid injection K2 $37.67

J1570 Ganciclovir sodium injection CH K2 $62.51

J1571 Hepagam b im injection K2 $57.07

J1572 Flebogamma injection K2 $35.04

Date Printed: 3/14/2013 @ 8:00 PM Page 17 of 24
HCPCS 

Code Short Descriptor

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum BB -- Proposed ASC Covered Ancillary Services Integral to Covered 

Surgical Procedures for CY 2012 (Including Ancillary Services for Which Payment 

is Packaged)

J1573 Hepagam b intravenous, inj K2 $57.07

J1580 Garamycin gentamicin inj N1

J1590 Gatifloxacin injection N1

J1595 Injection glatiramer acetate K2 $95.57

J1599 Ivig non-lyophilized, NOS N1

J1600 Gold sodium thiomaleate inj N1

J1610 Glucagon hydrochloride/1 MG K2 $95.59

J1620 Gonadorelin hydroch/ 100 mcg CH K2 $94.82

J1626 Granisetron hcl injection N1

J1630 Haloperidol injection N1

J1631 Haloperidol decanoate inj N1

J1640 Hemin, 1 mg K2 $8.33

J1642 Inj heparin sodium per 10 u N1

J1644 Inj heparin sodium per 1000u N1

J1645 Dalteparin sodium N1

J1650 Inj enoxaparin sodium N1

J1652 Fondaparinux sodium N1

J1655 Tinzaparin sodium injection N1

J1670 Tetanus immune globulin inj K2 $222.97

J1680 Human fibrinogen conc inj K2 $71.52

J1700 Hydrocortisone acetate inj N1

J1710 Hydrocortisone sodium ph inj N1

J1720 Hydrocortisone sodium succ i N1

J1730 Diazoxide injection CH N1

J1740 Ibandronate sodium injection K2 $144.36

J1742 Ibutilide fumarate injection K2 $129.32

J1743 Idursulfase injection K2 $446.45

J1745 Infliximab injection K2 $58.90

J1750 Inj iron dextran K2 $11.59

J1756 Iron sucrose injection CH N1

J1786 Imuglucerase injection K2 $41.19

J1790 Droperidol injection N1

J1800 Propranolol injection N1

J1815 Insulin injection N1

J1817 Insulin for insulin pump use N1

J1830 Interferon beta-1b / .25 MG K2 $197.14

J1835 Itraconazole injection CH K2 $359.59

J1840 Kanamycin sulfate 500 MG inj N1

J1850 Kanamycin sulfate 75 MG inj N1

J1885 Ketorolac tromethamine inj N1

J1890 Cephalothin sodium injection N1

J1930 Lanreotide injection K2 $29.92

J1931 Laronidase injection K2 $25.08

J1940 Furosemide injection N1

J1945 Lepirudin K2 $299.56

J1950 Leuprolide acetate /3.75 MG K2 $547.54

J1953 Levetiracetam injection N1

J1956 Levofloxacin injection N1

J1960 Levorphanol tartrate inj N1

J1980 Hyoscyamine sulfate inj N1

J1990 Chlordiazepoxide injection N1

J2001 Lidocaine injection N1

J2010 Lincomycin injection N1

J2020 Linezolid injection K2 $33.99

J2060 Lorazepam injection N1

J2150 Mannitol injection N1

J2170 Mecasermin injection K2 $20.18

J2175 Meperidine hydrochl /100 MG N1

J2180 Meperidine/promethazine inj N1

J2185 Meropenem N1

J2210 Methylergonovin maleate inj N1

J2248 Micafungin sodium injection K2 $1.02

J2250 Inj midazolam hydrochloride N1

J2260 Inj milrinone lactate / 5 MG N1

J2270 Morphine sulfate injection N1

J2271 Morphine so4 injection 100mg N1

J2275 Morphine sulfate injection N1

J2278 Ziconotide injection K2 $6.48

Date Printed: 3/14/2013 @ 8:00 PM Page 18 of 24
HCPCS 

Code Short Descriptor

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum BB -- Proposed ASC Covered Ancillary Services Integral to Covered 

Surgical Procedures for CY 2012 (Including Ancillary Services for Which Payment 

is Packaged)

J2280 Inj, moxifloxacin 100 mg N1

J2300 Inj nalbuphine hydrochloride N1

J2310 Inj naloxone hydrochloride N1

J2315 Naltrexone, depot form K2 $2.77

J2320 Nandrolone decanoate 50 MG CH N1

J2323 Natalizumab injection K2 $9.88

J2325 Nesiritide injection K2 $43.93

J2353 Octreotide injection, depot K2 $113.48

J2354 Octreotide inj, non-depot N1

J2355 Oprelvekin injection K2 $240.88

J2357 Omalizumab injection K2 $20.64

J2358 Olanzapine long-acting inj K2 $2.70

J2360 Orphenadrine injection N1

J2370 Phenylephrine hcl injection N1

J2400 Chloroprocaine hcl injection N1

J2405 Ondansetron hcl injection N1

J2410 Oxymorphone hcl injection N1

J2425 Palifermin injection K2 $11.15

J2426 Paliperidone palmitate inj K2 $6.45

J2430 Pamidronate disodium /30 MG N1

J2440 Papaverin hcl injection N1

J2469 Palonosetron hcl K2 $18.51

J2501 Paricalcitol N1

J2503 Pegaptanib sodium injection K2 $1,002.20

J2504 Pegademase bovine, 25 iu K2 $242.67

J2505 Injection, pegfilgrastim 6mg K2 $2,527.87

J2510 Penicillin g procaine inj CH N1

J2513 Pentastarch 10% solution K2 $158.76

J2515 Pentobarbital sodium inj N1

J2540 Penicillin g potassium inj N1

J2543 Piperacillin/tazobactam N1

J2550 Promethazine hcl injection N1

J2560 Phenobarbital sodium inj N1

J2562 Plerixafor injection K2 $278.36

J2590 Oxytocin injection N1

J2597 Inj desmopressin acetate CH K2 $3.93

J2650 Prednisolone acetate inj N1

J2670 Totazoline hcl injection N1

J2675 Inj progesterone per 50 MG N1

J2680 Fluphenazine decanoate 25 MG N1

J2690 Procainamide hcl injection N1

J2700 Oxacillin sodium injeciton CH N1

J2710 Neostigmine methylslfte inj N1

J2720 Inj protamine sulfate/10 MG N1

J2724 Protein c concentrate K2 $12.50

J2725 Inj protirelin per 250 mcg CH K2 $27.03

J2730 Pralidoxime chloride inj K2 $88.57

J2760 Phentolaine mesylate inj CH K2 $56.35

J2765 Metoclopramide hcl injection N1

J2770 Quinupristin/dalfopristin K2 $157.23

J2778 Ranibizumab injection K2 $398.10

J2780 Ranitidine hydrochloride inj N1

J2783 Rasburicase K2 $183.08

J2785 Regadenoson injection K2 $51.36

J2788 Rho d immune globulin 50 mcg K2 $24.81

J2790 Rho d immune globulin inj K2 $82.16

J2791 Rhophylac injection K2 $5.09

J2792 Rho(D) immune globulin h, sd K2 $18.83

J2793 Rilonacept injection K2 $23.63

J2794 Risperidone, long acting K2 $4.93

J2795 Ropivacaine HCl injection N1

J2796 Romiplostim injection K2 $44.84

J2800 Methocarbamol injection N1

J2805 Sincalide injection CH N1

J2810 Inj theophylline per 40 MG N1

J2820 Sargramostim injection K2 $23.62

J2850 Inj secretin synthetic human K2 $26.97

J2910 Aurothioglucose injeciton N1

Date Printed: 3/14/2013 @ 8:00 PM Page 19 of 24
HCPCS 

Code Short Descriptor

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum BB -- Proposed ASC Covered Ancillary Services Integral to Covered 

Surgical Procedures for CY 2012 (Including Ancillary Services for Which Payment 

is Packaged)

J2916 Na ferric gluconate complex N1

J2920 Methylprednisolone injection N1

J2930 Methylprednisolone injection N1

J2941 Somatropin injection K2 $56.09

J2950 Promazine hcl injection N1

J2993 Reteplase injection K2 $1,332.35

J2995 Inj streptokinase /250000 IU K2 $47.57

J2997 Alteplase recombinant K2 $39.22

J3000 Streptomycin injection N1

J3010 Fentanyl citrate injeciton N1

J3030 Sumatriptan succinate / 6 MG N1

J3070 Pentazocine injection N1

J3095 Televancin injection K2 $1.96

J3101 Tenecteplase injection K2 $51.95

J3105 Terbutaline sulfate inj N1

J3120 Testosterone enanthate inj N1

J3130 Testosterone enanthate inj N1

J3140 Testosterone suspension inj N1

J3150 Testosteron propionate inj N1

J3230 Chlorpromazine hcl injection N1

J3240 Thyrotropin injection K2 $1,034.03

J3243 Tigecycline injection K2 $1.22

J3246 Tirofiban HCl K2 $8.83

J3250 Trimethobenzamide hcl inj N1

J3260 Tobramycin sulfate injection N1

J3262 Tocilizumab injection K2 $3.47

J3265 Injection torsemide 10 mg/ml N1

J3280 Thiethylperazine maleate inj N1

J3285 Treprostinil injection K2 $60.08

J3300 Triamcinolone A inj PRS-free K2 $3.17

J3301 Triamcinolone acet inj NOS N1

J3302 Triamcinolone diacetate inj N1

J3303 Triamcinolone hexacetonl inj N1

J3310 Perphenazine injeciton K2 $30.91

J3315 Triptorelin pamoate K2 $193.59

J3350 Urea injection K2 $82.18

J3355 Urofollitropin, 75 iu K2 $63.60

J3357 Ustekinumab injection K2 $112.30

J3360 Diazepam injection N1

J3364 Urokinase 5000 IU injection N1

J3365 Urokinase 250,000 IU inj K2 $449.09

J3370 Vancomycin hcl injection N1

J3385 Velaglucerase alfa K2 $349.88

J3396 Verteporfin injection K2 $9.55

J3410 Hydroxyzine hcl injection N1

J3411 Thiamine hcl 100 mg N1

J3415 Pyridoxine hcl 100 mg N1

J3420 Vitamin b12 injection N1

J3430 Vitamin k phytonadione inj N1

J3465 Injection, voriconazole K2 $6.02

J3470 Hyaluronidase injection N1

J3471 Ovine, up to 999 USP units N1

J3472 Ovine, 1000 USP units N1

J3473 Hyaluronidase recombinant N1

J3475 Inj magnesium sulfate N1

J3480 Inj potassium chloride N1

J3485 Zidovudine N1

J3486 Ziprasidone mesylate N1

J3487 Zoledronic acid K2 $219.00

J3488 Reclast injection K2 $218.47

J3490 Drugs unclassified injection N1

J3530 Nasal vaccine inhalation N1

J3590 Unclassified biologics N1

J7030 Normal saline solution infus N1

J7040 Normal saline solution infus N1

J7042 5% dextrose/normal saline N1

J7050 Normal saline solution infus N1

J7060 5% dextrose/water N1

Date Printed: 3/14/2013 @ 8:00 PM Page 20 of 24
HCPCS 

Code Short Descriptor

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum BB -- Proposed ASC Covered Ancillary Services Integral to Covered 

Surgical Procedures for CY 2012 (Including Ancillary Services for Which Payment 

is Packaged)

J7070 D5w infusion N1

J7100 Dextran 40 infusion N1

J7110 Dextran 75 infusion N1

J7120 Ringers lactate infusion N1

J7130 Hypertonic saline solution N1

J7184 Wilate injection K2 $70.14

J7185 Xyntha inj K2 $1.05

J7186 Antihemophilic viii/vwf comp K2 $0.90

J7187 Humate-P, inj K2 $0.87

J7189 Factor viia K2 $1.50

J7190 Factor viii K2 $0.87

J7191 Factor VIII (porcine) K2 $1.17

J7192 Factor viii recombinant NOS K2 $1.09

J7193 Factor IX non-recombinant K2 $0.88

J7194 Factor ix complex K2 $0.85

J7195 Factor IX recombinant K2 $1.13

J7196 Antithrombin recombinant K2 $101.40

J7197 Antithrombin iii injection K2 $2.48

J7198 Anti-inhibitor K2 $1.57

J7308 Aminolevulinic acid hcl top K2 $138.70

J7309 Methyl aminolevulinate, top K2 $68.27

J7310 Ganciclovir long act implant K2 $16,640.00

J7311 Fluocinolone acetonide implt K2 $18,980.00

J7312 Dexamethasone intra implant K2 $194.17

J7321 Hyalgan/supartz inj per dose K2 $88.80

J7323 Euflexxa inj per dose K2 $147.16

J7324 Orthovisc inj per dose K2 $167.00

J7325 Synvisc or Synvisc-One K2 $11.81

J7335 Capsaicin 8% patch K2 $25.55

J7500 Azathioprine oral 50mg N1

J7501 Azathioprine parenteral K2 $104.77

J7502 Cyclosporine oral 100 mg N1

J7504 Lymphocyte immune globulin K2 $542.36

J7505 Monoclonal antibodies K2 $1,112.14

J7506 Prednisone oral N1

J7507 Tacrolimus oral per 1 MG N1

J7509 Methylprednisolone oral N1

J7510 Prednisolone oral per 5 mg N1

J7511 Antithymocyte globuln rabbit K2 $387.17

J7513 Daclizumab, parenteral K2 $516.41

J7515 Cyclosporine oral 25 mg N1

J7516 Cyclosporin parenteral 250mg N1

J7517 Mycophenolate mofetil oral N1

J7518 Mycophenolic acid N1

J7520 Sirolimus, oral N1

J7525 Tacrolimus injection K2 $136.85

J7599 Immunosuppressive drug noc N1

J7674 Methacholine chloride, neb N1

J7799 Non-inhalation drug for DME N1

J8501 Oral aprepitant K2 $5.90

J8510 Oral busulfan K2 $3.59

J8520 Capecitabine, oral, 150 mg K2 $6.81

J8521 Capecitabine, oral, 500 mg K2 $22.48

J8530 Cyclophosphamide oral 25 MG N1

J8540 Oral dexamethasone N1

J8560 Etoposide oral 50 MG K2 $34.34

J8562 Oral fludarabine phosphate K2 $79.44

J8597 Antiemetic drug oral NOS N1

J8600 Melphalan oral 2 MG N1

J8610 Methotrexate oral 2.5 MG N1

J8700 Temozolomide K2 $9.31

J8705 Topotecan oral K2 $76.40

J9000 Doxorubicin hcl injection N1

J9001 Doxorubicin hcl liposome inj K2 $504.27

J9010 Alemtuzumab injection K2 $577.60

J9015 Aldesleukin injection K2 $915.45

J9017 Arsenic trioxide injection K2 $40.13

J9020 Asparaginase injection K2 $62.07

Date Printed: 3/14/2013 @ 8:00 PM Page 21 of 24
HCPCS 

Code Short Descriptor

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum BB -- Proposed ASC Covered Ancillary Services Integral to Covered 

Surgical Procedures for CY 2012 (Including Ancillary Services for Which Payment 

is Packaged)

J9025 Azacitidine injection K2 $5.16

J9027 Clofarabine injection K2 $114.37

J9031 Bcg live intravesical vac K2 $114.38

J9033 Bendamustine injection K2 $18.15

J9035 Bevacizumab injection K2 $58.72

J9040 Bleomycin sulfate injection N1

J9041 Bortezomib injection K2 $39.60

J9045 Carboplatin injection N1

J9050 Carmustine injection K2 $172.56

J9055 Cetuximab injection K2 $49.52

J9060 Cisplatin 10 MG injection N1

J9065 Inj cladribine per 1 MG K2 $23.59

J9070 Cyclophosphamide 100 MG inj N1

J9098 Cytarabine liposome inj K2 $479.02

J9100 Cytarabine hcl 100 MG inj N1

J9120 Dactinomycin injection K2 $529.42

J9130 Dacarbazine 100 mg inj N1

J9150 Daunorubicin injection K2 $13.16

J9151 Daunorubicin citrate inj K2 $56.58

J9155 Degarelix injection K2 $2.79

J9160 Denileukin diftitox inj K2 $1,559.54

J9171 Docetaxel injection K2 $20.84

J9175 Elliotts b solution per ml N1

J9178 Inj, epirubicin hcl, 2 mg K2 $1.87

J9181 Etoposide injection N1

J9185 Fludarabine phosphate inj CH N1

J9190 Fluorouracil injection N1

J9200 Floxuridine injection K2 $36.60

J9201 Gemcitabine hcl injection K2 $111.40

J9202 Goserelin acetate implant K2 $195.16

J9206 Irinotecan injection CH N1

J9207 Ixabepilone injection K2 $62.53

J9208 Ifosfomide injection K2 $31.21

J9209 Mesna injection N1

J9211 Idarubicin hcl injection K2 $46.43

J9212 Interferon alfacon-1 inj CH N1

J9214 Interferon alfa-2b inj K2 $16.19

J9215 Interferon alfa-n3 inj K2 $20.87

J9216 Interferon gamma 1-b inj K2 $549.62

J9217 Leuprolide acetate suspnsion K2 $210.96

J9218 Leuprolide acetate injeciton K2 $4.88

J9219 Leuprolide acetate implant K2 $4,728.88

J9225 Vantas implant K2 $3,223.57

J9226 Supprelin LA implant K2 $15,184.53

J9230 Mechlorethamine hcl inj K2 $154.88

J9245 Inj melphalan hydrochl 50 MG K2 $1,272.01

J9250 Methotrexate sodium inj N1

J9260 Methotrexate sodium inj N1

J9261 Nelarabine injection K2 $110.19

J9263 Oxaliplatin K2 $8.36

J9264 Paclitaxel protein bound K2 $9.21

J9265 Paclitaxel injection CH N1

J9266 Pegaspargase injection K2 $2,675.40

J9268 Pentostatin injection K2 $1,068.16

J9270 Plicamycin (mithramycin) inj N1

J9280 Mitomycin 5 MG inj K2 $20.36

J9293 Mitoxantrone hydrochl / 5 MG K2 $33.95

J9300 Gemtuzumab ozogamicin inj K2 $2,637.02

J9302 Ofatumumab injection K2 $45.41

J9303 Panitumumab injection K2 $85.62

J9305 Pemetrexed injection K2 $51.37

J9307 Pralatrexate injection K2 $165.63

J9310 Rituximab injection K2 $599.16

J9315 Romidepsin injection K2 $219.30

J9320 Streptozocin injection K2 $264.81

J9328 Temozolomide injection K2 $4.86

J9330 Temsirolimus injection K2 $49.87

J9340 Thiotepa injection K2 $106.54

Date Printed: 3/14/2013 @ 8:00 PM Page 22 of 24
HCPCS 

Code Short Descriptor

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum BB -- Proposed ASC Covered Ancillary Services Integral to Covered 

Surgical Procedures for CY 2012 (Including Ancillary Services for Which Payment 

is Packaged)

J9351 Topotecan injection K2 $19.30

J9355 Trastuzumab injection K2 $69.06

J9357 Valrubicin injection K2 $946.64

J9360 Vinblastine sulfate inj N1

J9370 Vincristine sulfate 1 MG inj N1

J9390 Vinorelbine tartrate inj N1

J9395 Injection, Fulvestrant K2 $81.81

J9600 Porfimer sodium injection K2 $3,017.82

J9999 Chemotherapy drug N1

L8600 Implant breast silicone/eq N1

L8603 Collagen imp urinary 2.5 ml N1

L8604 Dextranomer/hyaluronic acid N1

L8606 Synthetic implnt urinary 1ml N1

L8609 Artificial cornea N1

L8610 Ocular implant N1

L8612 Aqueous shunt prosthesis N1

L8613 Ossicular implant N1

L8614 Cochlear device N1

L8630 Metacarpophalangeal implant N1

L8631 MCP joint repl 2 pc or more N1

L8641 Metatarsal joint implant N1

L8642 Hallux implant N1

L8658 Interphalangeal joint spacer N1

L8659 Interphalangeal joint repl N1

L8670 Vascular graft, synthetic N1

L8682 Implt neurostim radiofq rec N1

L8690 Aud osseo dev, int/ext comp N1

L8699 Prosthetic implant NOS N1

P9041 Albumin (human),5%, 50ml K2 $20.37

P9045 Albumin (human), 5%, 250 ml K2 $67.07

P9046 Albumin (human), 25%, 20 ml K2 $29.16

P9047 Albumin (human), 25%, 50ml K2 $70.39

Q0138 Ferumoxytol, non-esrd K2 $0.69

Q0163 Diphenhydramine HCl 50mg N1

Q0164 Prochlorperazine maleate 5mg N1

Q0166 Granisetron hcl 1 mg oral N1

Q0167 Dronabinol 2.5mg oral N1

Q0169 Promethazine HCl 12.5mg oral N1

Q0171 Chlorpromazine HCl 10mg oral N1

Q0173 Trimethobenzamide HCl 250mg N1

Q0175 Perphenazine 4mg oral N1

Q0177 Hydroxyzine pamoate 25mg N1

Q0179 Ondansetron hcl 8 mg oral N1

Q0180 Dolasetron mesylate oral N1

Q0515 Sermorelin acetate injection K2 $1.76

Q2004 Bladder calculi irrig sol N1

Q2009 Fosphenytoin inj PE N1

Q2017 Teniposide, 50 mg K2 $316.52

Q2035** Afluria vacc, 3 yrs & >, im L1

Q2036** Flulaval vacc, 3 yrs & >, im L1

Q2037** Fluvirin vacc, 3 yrs & >, im L1

Q2038** Fluzone vacc, 3 yrs & >, im L1

Q2039** NOS flu vacc, 3 yrs & >, im L1

Q2040 Incobotulinumtoxin A K2 $5.57

Q3025 IM inj interferon beta 1-a K2 $220.75

Q4100 Skin substitute, NOS N1

Q4101 Apligraf K2 $34.06

Q4102 Oasis wound matrix K2 $4.68

Q4103 Oasis burn matrix CH N1

Q4104 Integra BMWD K2 $15.45

Q4105 Integra DRT K2 $10.95

Q4106 Dermagraft K2 $39.39

Q4107 Graftjacket K2 $92.79

Q4108 Integra matrix K2 $20.95

Q4110 Primatrix K2 $31.67

Q4111 Gammagraft K2 $7.17

Q4112 Cymetra injectable K2 $334.07

Q4113 Graftjacket xpress K2 $334.07

Date Printed: 3/14/2013 @ 8:00 PM Page 23 of 24
HCPCS 

Code Short Descriptor

CY 2012 

Comment 

Indicator

CY 2012 

Payment 

Indicator

CY 2012 

Payment 

Weight 

CY 2012 

Payment 

Addendum BB -- Proposed ASC Covered Ancillary Services Integral to Covered 

Surgical Procedures for CY 2012 (Including Ancillary Services for Which Payment 

is Packaged)

Q4114 Integra flowable wound matri K2 $972.75

Q4115 Alloskin K2 $6.07

Q4116 Alloderm K2 $31.11

Q4118 Matristem micromatrix K2 $3.13

Q4119 Matristem wound matrix K2 $6.04

Q4121 Theraskin K2 $20.32

Q9951 LOCM >= 400 mg/ml iodine,1ml N1

Q9953 Inj Fe-based MR contrast,1ml N1

Q9954 Oral MR contrast, 100 ml N1

Q9955 Inj perflexane lip micros,ml N1

Q9956 Inj octafluoropropane mic,ml N1

Q9957 Inj perflutren lip micros,ml N1

Q9958 HOCM <=149 mg/ml iodine, 1ml N1

Q9959 HOCM 150-199mg/ml iodine,1ml N1

Q9960 HOCM 200-249mg/ml iodine,1ml N1

Q9961 HOCM 250-299mg/ml iodine,1ml N1

Q9962 HOCM 300-349mg/ml iodine,1ml N1

Q9963 HOCM 350-399mg/ml iodine,1ml N1

Q9964 HOCM>= 400mg/ml iodine, 1ml N1

Q9965 LOCM 100-199mg/ml iodine,1ml N1

Q9966 LOCM 200-299mg/ml iodine,1ml N1

Q9967 LOCM 300-399mg/ml iodine,1ml N1

Q9968 Visualization adjunct CH N1

V2630 Anter chamber intraocul lens N1

V2631 Iris support intraoclr lens N1

V2632 Post chmbr intraocular lens N1

V2785 Corneal tissue processing F4

V2790 Amniotic membrane N1

NOTE 1: The Medicare program payment is 80 percent of the total payment amount and beneficiary coinsurance is 20 

percent of the total payment amount. Sections 4104 and 10406 of the Affordable Care Act (ACA) waive coinsurance and 

the Part B deductible for most preventive services. These preventive services are identified with a double asterisk (**).

NOTE 2: In general, payment indicators for radiology services (Z2, Z3) are based on a comparison of the proposed rates 

according to the ASC standard ratesetting methodology and the MPFS proposed rates. Under current law, the MPFS 

payment rates will have a negative update for CY 2012. For a discussion of those rates, we refer readers to the CY 2012 

MPFS proposed rule.

Date Printed: 3/14/2013 @ 8:00 PM Page 24 of 24
Indicator Payment Indicator Definition

A2 Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment 

weight.

D5 Deleted/discontinued code; no payment made.

F4 Corneal tissue acquisition, hepatitis B vaccine; paid at reasonable cost.

G2 Non office-based surgical procedure added in CY 2008 or later; payment based on 

OPPS relative payment weight.

H2 Brachytherapy source paid separately when provided integral to a surgical procedure on 

ASC list; payment based on OPPS rate.

J7 OPPS pass-through device paid separately when provided integral to a surgical 

procedure on ASC list; payment contractor-priced.

J8 Device-intensive procedure; paid at adjusted rate.

K2 Drugs and biologicals paid separately when provided integral to a surgical procedure on 

ASC list; payment based on OPPS rate.

K7 Unclassified drugs and biologicals; payment contractor-priced.

L1 Influenza vaccine; pneumococcal vaccine. Packaged item/service; no separate 

payment made. 

L6 New Technology Intraocular Lens (NTIOL); special payment.

M5 Quality measurement code used for reporting purposes only; no payment made.

N1 Packaged service/item; no separate payment made.

P2 Office-based surgical procedure added to ASC list in CY 2008 or later with MPFS 

nonfacility PE RVUs; payment based on OPPS relative payment weight.

P3 Office-based surgical procedure added to ASC list in CY 2008 or later with MPFS 

nonfacility PE RVUs; payment based on MPFS nonfacility PE RVUs.

R2 Office-based surgical procedure added to ASC list in CY 2008 or later without MPFS 

nonfacility PE RVUs; payment based on OPPS relative payment weight.

Z2 Radiology service paid separately when provided integral to a surgical procedure on 

ASC list; payment based on OPPS relative payment weight.

Z3 Radiology service paid separately when provided integral to a surgical procedure on 

ASC list; payment based on MPFS nonfacility PE RVUs.

Addendum DD1 -- Proposed ASC Payment Indicators for CY 2012

Date Printed: 3/14/2013 @ 8:00 PM Page 1 of 1
CI Comment Indicator Meanings

CH

Active HCPCS code in current year and next calendar year, payment indicator 

assignment has changed; or active HCPCS code that is newly recognized as payable 

in ASC; or active HCPCS code that is discontinued at the end of the current calendar 

year.

NI

New code for the next calendar year or existing code with substantial revision to its 

code descriptor in the next calendar year, interim payment indicator assignment; 

comments will be accepted on the interim payment indicator for the new code.

Addendum DD2 -- Proposed ASC Comment Indicators for CY 2012