**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 0100TProsth retina receive&gen Y G2 38.7337 $1,639.56 0101TExtracorp shockwv tx hi enrg Y G2 30.378 $1,285.87 0102TExtracorp shockwv tx anesth Y G2 30.378 $1,285.87 0123TScleral fistulization Y G2 23.6808 $1,002.38 0124T*Conjunctival drug placement Y R2 2.7589 $116.78 0186TSuprachoroidal drug delivery Y G2 21.3578 $904.05 0190TPlace intraoc radiation src Y G2 21.3578 $904.05 0191TInsert ant segment drain int Y G2 39.1634 $1,657.75 0192TInsert ant segment drain ext Y G2 39.1634 $1,657.75 0200TPerq sacral augmt unilat inj Y G2 30.378 $1,285.87 0201TPerq sacral augmt bilat inj Y G2 30.378 $1,285.87 0213TNjx paravert w/us cer/thor Y CH R2 7.0747 $299.46 0214TNjx paravert w/us cer/thor Y CH R2 2.5957 $109.87 0215TNjx paravert w/us cer/thor Y CH R2 2.5957 $109.87 0216TNjx paravert w/us lumb/sac Y CH R2 7.0747 $299.46 0217TNjx paravert w/us lumb/sac Y CH R2 2.5957 $109.87 0218TNjx 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 0228TNjx tfrml eprl w/us cer/thor Y G2 7.0747 $299.46 0229TNjx tfrml eprl w/us cer/thor Y G2 3.6902 $156.20 0230TNjx tfrml eprl w/us lumb/sac Y G2 7.0747 $299.46 0231TNjx tfrml eprl w/us lumb/sac Y G2 3.6902 $156.20 0232T*Njx platelet plasma N R2 0.6316 $26.73 0238TTrluml perip athrc iliac art Y G2 98.3094 $4,161.34 0249TLigation hemorrhoid w/us Y G2 15.0188 $635.73 0250TInsert bronchial valve Y G2 27.2989 $1,155.54 0251TRemov bronchial valve Y G2 9.7594 $413.11 0252TRemov bronch valve addl Y G2 9.7594 $413.11 0253TInsert aqueous drain device Y G2 23.6808 $1,002.38 0260THypthrm bdy neonate 28d/< N N1 0261THypthrm 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 10040Acne 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 10180Complex 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 11043Deb musc/fascia 20 sq cm/< Y A2 2.6477 $112.07 11044 Deb bone 20 sq cm/< Y A2 8.0762 $341.86 11045Deb subq tissue add-on Y G2 2.6477 $112.07 11046Deb musc/fascia add-on Y G2 2.6477 $112.07 11047Deb bone add-on Y G2 8.0762 $341.86 11055Trim skin lesion Y P3 $23.72 11056Trim skin lesions 2 to 4 Y CH P3 $25.88 

## Ad**dendum A**

**A -- Proposed A** **SC 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** 

## Ad**dendum A**

**A -- Proposed A** **SC Covered Surgical Procedures for CY 2012 (Including Surgical Procedures for Which Payment is Packaged)** 

11057Trim skin lesions over 4 Y CH P3 $28.76 11100Biopsy

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 11300Shave skin lesion Y CH P3 $34.99 11301 Shave skin lesion Y P2 0.9172 $38.82 11302Shave skin lesion Y P2 0.9172 $38.82 11303Shave skin lesion Y CH P3 $57.99 11305Shave skin lesion Y CH P3 $31.39 11306Shave skin lesion Y P2 0.9172 $38.82 11307Shave skin lesion Y P2 0.9172 $38.82 11308Shave skin lesion Y P2 0.9172 $38.82 11310Shave skin lesion Y P2 0.9172 $38.82 11311 Shave skin lesion Y P2 0.9172 $38.82 11312Shave skin lesion Y P2 0.9172 $38.82 11313Shave 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** 

## Ad**dendum A**

**A -- Proposed A** **SC 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 11719Trim 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 11755Biopsy

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 11765Excision 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 11920Correct skin color defects Y P3 $78.12 11921 Correct skin color defects Y P3 $87.47 11922Correct skin color defects Y P3 $29.71 11950Therapy

for contour defects Y P3 $27.32 11951 Therapy

for contour defects Y P3 $40.50 11952Therapy

for contour defects Y CH P3 $53.92 11954Therapy

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 12005Repair 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 12015Repair 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 12018Repair superficial wound(s) Y A2 3.0787 $130.32 12020Closure 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** 

## Ad**dendum A**

**A -- Proposed A** **SC 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 13160Late closure of wound Y A2 20.437 $865.08 14000Skin tissue rearrangement Y A2 16.1914 $685.37 14001 Skin tissue rearrangement Y A2 16.1914 $685.37 14020Skin tissue rearrangement Y A2 16.1914 $685.37 14021 Skin tissue rearrangement Y A2 16.1914 $685.37 14040Skin tissue rearrangement Y A2 16.1914 $685.37 14041 Skin tissue rearrangement Y A2 16.1914 $685.37 14060Skin 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 14302Skin tissue rearrange add-on Y G2 20.437 $865.08 14350Skin tissue rearrangement Y A2 20.437 $865.08 15002Wound prep trk/arm/leg Y A2 4.8714 $206.20 15003Wound prep addl 100 cm Y A2 4.8714 $206.20 15004Wound prep f/n/hf/g Y A2 3.0787 $130.32 15005Wnd prep f/n/hf/g addl cm Y A2 4.8714 $206.20 15040 Harvest cultured skin graft Y A2 3.0787 $130.32 15050Skin pinch graft Y A2 3.0787 $130.32 15100Skin 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 15115Epidrm 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 15120Skn 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 15135Derm autograft face/nck/hf/g Y A2 16.1914 $685.37 15136Derm autograft f/n/hf/g add Y A2 16.1914 $685.37 15150Cult 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 15152Cult epiderm graft t/a/l +% Y A2 4.8714 $206.20 15155Cult epiderm graft f/n/hf/g Y A2 4.8714 $206.20 15156Cult epidrm grft f/n/hfg add Y A2 4.8714 $206.20 15157Cult 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** 

## Ad**dendum A**

**A -- Proposed A** **SC Covered Surgical Procedures for CY 2012 (Including Surgical Procedures for Which Payment is Packaged)** 

15170Acell graft trunk/arms/legs Y G2 4.8714 $206.20 15171 Acell graft t/arm/leg add-on Y G2 3.0787 $130.32 15175Acellular graft f/n/hf/g Y G2 4.8714 $206.20 15176Acell graft f/n/hf/g add-on Y G2 4.8714 $206.20 15200Skin full graft trunk Y A2 16.1914 $685.37 15201 Skin full graft trunk add-on Y A2 16.1914 $685.37 15220Skin full graft sclp/arm/leg Y A2 16.1914 $685.37 15221 Skin full graft add-on Y A2 4.8714 $206.20 15240Skin full grft face/genit/hf Y A2 16.1914 $685.37 15241 Skin full graft add-on Y A2 3.0787 $130.32 15260Skin full graft een & lips Y A2 16.1914 $685.37 15261 Skin full graft add-on Y A2 16.1914 $685.37 15300Apply

skinallogrft t/arm/lg Y A2 4.8714 $206.20 15301 Apply

sknallogrft t/a/l addl Y A2 4.8714 $206.20 15320Apply

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 15330Aply

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 15335Apply

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

acell grft f/n/hf/g add Y A2 4.8714 $206.20 15340Apply

cult skin substitute Y G2 3.0787 $130.32 15341 Apply

cult skin sub add-on Y G2 3.0787 $130.32 15360Apply

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 15365Apply

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

cult derm f/hf/g add Y G2 3.0787 $130.32 15400Apply

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 15420Apply

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 15430Apply

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 15600Skin graft Y A2 20.437 $865.08 15610Skin graft Y A2 20.437 $865.08 15620Skin graft Y A2 20.437 $865.08 15630Skin graft Y A2 20.437 $865.08 15650Transfer 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 15734Muscle-skin graft trunk Y A2 20.437 $865.08 15736Muscle-skin graft arm Y A2 20.437 $865.08 15738Muscle-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 15760Composite skin graft Y A2 20.437 $865.08 15770 Derma-fat-fascia graft Y A2 20.437 $865.08 15775Hair transplant punch grafts Y A2 1.1378 $48.16 15776 Hair transplant punch grafts Y A2 1.1378 $48.16 15780Abrasion treatment of skin Y P3 $345.79 15781 Abrasion treatment of skin Y P2 4.5706 $193.47 15782Abrasion treatment of skin Y P2 4.5706 $193.47 15783Abrasion treatment of skin Y P2 2.6477 $112.07 15786Abrasion lesion single Y P2 0.9172 $38.82 15787Abrasion 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** 

## Ad**dendum A**

**A -- Proposed A** **SC Covered Surgical Procedures for CY 2012 (Including Surgical Procedures for Which Payment is Packaged)** 

15788Chemical peel face epiderm Y P2 0.9172 $38.82 15789Chemical peel face dermal Y P2 1.4 $59.26 15792Chemical peel nonfacial Y P2 1.4 $59.26 15793Chemical peel nonfacial Y P2 0.9172 $38.82 15819Plastic 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 15825Removal of neck wrinkles Y A2 20.437 $865.08 15826 Removal of brow wrinkles Y A2 20.437 $865.08 15828Removal of face wrinkles Y A2 20.437 $865.08 15829Removal 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 15835Excise 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 15838Excise excessive skin tissue Y G2 16.113 $682.05 15839Excise excessive skin tissue Y A2 16.113 $682.05 15840Graft 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 15845Skin 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 15860Test for blood flow in graft N G2 0.6316 $26.73 15876Suction assisted lipectomy Y A2 20.437 $865.08 15877Suction assisted lipectomy Y A2 20.437 $865.08 15878Suction assisted lipectomy Y A2 20.437 $865.08 15879Suction 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 15935Remove 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 15945Remove 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 15958Remove 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 16025Dress/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** 

## Ad**dendum A**

**A -- Proposed A** **SC 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 17003Destruct premalg les 2-14 Y P3 $2.88 17004 Destroy premlg lesions 15+ Y P3 $69.73 17106Destruction of skin lesions Y P2 2.6477 $112.07 17107Destruction of skin lesions Y P2 2.6477 $112.07 17108Destruction 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 17250Chemical 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 17263Destruction of skin lesions Y P2 1.4 $59.26 17264 Destruction of skin lesions Y P2 1.4 $59.26 17266Destruction 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 17273Destruction of skin lesions Y CH P3 $88.66 17274 Destruction of skin lesions Y CH P3 $100.41 17276Destruction 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 17283Destruction of skin lesions Y CH P3 $98.97 17284 Destruction of skin lesions Y CH P3 $109.27 17286Destruction 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 17313Mohs 1 stage t/a/l Y P2 5.0323 $213.01 17314Mohs addl stage t/a/l Y CH P3 $174.21 17315Mohs surg addl block Y P3 $32.35 17340Cryotherapy of skin Y P3 $14.62 17360Skin 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 19100Bx 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 19103Bx breast percut w/device Y A2 14.3964 $609.39 19105Cryosurg 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 19125Excision 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 19295Place breast clip percut N N1 19296Place po breast cath for rad Y A2 57.8024 $2,446.72 19297Place breast cath for rad Y A2 57.8024 $2,446.72 19298Place 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** 

## Ad**dendum A**

**A -- Proposed A** **SC 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 19303Mast simple complete Y A2 31.7198 $1,342.67 19304Mast subq Y A2 31.7198 $1,342.67 19316Suspension of breast Y A2 31.7198 $1,342.67 19318Reduction of large breast Y A2 42.2696 $1,789.23 19324 Enlarge breast Y A2 42.2696 $1,789.23 19325Enlarge breast with implant Y A2 57.8024 $2,446.72 19328Removal 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 19350Breast reconstruction Y A2 24.2182 $1,025.13 19355Correct inverted nipple(s) Y A2 31.7198 $1,342.67 19357Breast reconstruction Y A2 57.8024 $2,446.72 19366Breast reconstruction Y A2 31.7198 $1,342.67 19370Surgery 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 19396Design 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 20200Muscle biopsy Y A2 16.113 $682.05 20205Deep muscle biopsy Y A2 16.113 $682.05 20206Needle biopsy muscle Y A2 7.631 $323.01 20220Bone biopsy

trocar/needle Y A2 8.0762 $341.86 20225Bone biopsy

trocar/needle Y A2 16.113 $682.05 20240Bone biopsy

excisional Y A2 21.9487 $929.07 20245Bone biopsy

excisional Y A2 21.9487 $929.07 20250Open 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 20525Removal of foreign body Y A2 21.9487 $929.07 20526Ther 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 20555Place ndl musc/tis for rt Y R2 30.378 $1,285.87 20600 Drain/inject joint/bursa Y P3 $20.37 20605Drain/inject joint/bursa Y P3 $23.24 20610 Drain/inject joint/bursa Y P3 $34.03 20612Aspirate/inj ganglion cyst Y P3 $22.77 20615Treatment of bone cyst Y P3 $99.45 20650 Insert and remove bone pin Y A2 30.378 $1,285.87 20662Application of pelvis brace Y R2 20.7775 $879.49 20663Application of thigh brace Y R2 30.378 $1,285.87 20665Removal 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 20690Apply

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

bone fixation device Y A2 30.378 $1,285.87 20693Adjust bone fixation device Y A2 30.378 $1,285.87 20694 Remove bone fixation device Y A2 20.7775 $879.49 20696Comp 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** 

## Ad**dendum A**

**A -- Proposed A** **SC Covered Surgical Procedures for CY 2012 (Including Surgical Procedures for Which Payment is Packaged)** 

20697Comp 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 20973Bone/skin graft great toe Y R2 53.6228 $2,269.80 20975Electrical bone stimulation N N1 20979Us bone stimulation N CH P3 $20.37 20982Ablate bone tumor(s) perq Y G2 44.2257 $1,872.03 20985Cptr-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 21015Resect face tum < 2 cm Y CH G2 16.113 $682.05 21016 Resect face tum + cm Y G2 21.9487 $929.07 21025Excision of bone lower jaw Y A2 42.299 $1,790.47 21026 Excision of facial bone(s) Y A2 42.299 $1,790.47 21029Contour 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 21048Remove 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 21073Mnpj of tmj w/anesth Y P3 $172.54 21076Prepare face/oral prosthesis Y P3 $326.38 21077Prepare face/oral prosthesis Y P3 $805.65 21079Prepare 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 21083Prepare face/oral prosthesis Y P3 $561.94 21084 Prepare face/oral prosthesis Y P3 $632.40 21085Prepare face/oral prosthesis Y P3 $273.66 21086Prepare face/oral prosthesis Y P3 $597.89 21087Prepare face/oral prosthesis Y P3 $594.29 21088Prepare face/oral prosthesis Y R2 42.299 $1,790.47 21100Maxillofacial 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** 

## Ad**dendum A**

**A -- Proposed A** **SC Covered Surgical Procedures for CY 2012 (Including Surgical Procedures for Which Payment is Packaged)** 

21123 Reconstruction of chin Y A2 23.5618 $997.35 21125Augmentation lower jaw bone Y A2 23.5618 $997.35 21127Augmentation lower jaw bone Y A2 42.299 $1,790.47 21137 Reduction of forehead Y G2 23.5618 $997.35 21138Reduction of forehead Y G2 42.299 $1,790.47 21139Reduction 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 21198Reconstr lwr jaw segment Y G2 42.299 $1,790.47 21199Reconstr lwr jaw w/advance Y G2 42.299 $1,790.47 21206 Reconstruct upper jaw bone Y A2 42.299 $1,790.47 21208Augmentation of facial bones Y A2 42.299 $1,790.47 21209Reduction of facial bones Y A2 42.299 $1,790.47 21210 Face bone graft Y A2 42.299 $1,790.47 21215Lower jaw bone graft Y A2 42.299 $1,790.47 21230 Rib cartilage graft Y A2 42.299 $1,790.47 21235Ear 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 21245Reconstruction of jaw Y A2 42.299 $1,790.47 21246 Reconstruction of jaw Y A2 42.299 $1,790.47 21248Reconstruction of jaw Y A2 42.299 $1,790.47 21249Reconstruction 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 21270Augmentation cheek bone Y A2 42.299 $1,790.47 21275Revision 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 21295Revision of jaw muscle/bone Y A2 7.5315 $318.80 21296 Revision of jaw muscle/bone Y A2 23.5618 $997.35 21310Treatment of nose fracture Y A2 1.0193 $43.15 21315Treatment of nose fracture Y A2 15.8572 $671.22 21320Treatment of nose fracture Y A2 15.8572 $671.22 21325Treatment of nose fracture Y A2 23.5618 $997.35 21330Treatment of nose fracture Y A2 23.5618 $997.35 21335Treatment of nose fracture Y A2 23.5618 $997.35 21336Treat nasal septal fracture Y A2 24.5925 $1,040.98 21337Treat nasal septal fracture Y A2 15.8572 $671.22 21338Treat nasoethmoid fracture Y A2 23.5618 $997.35 21339Treat nasoethmoid fracture Y A2 23.5618 $997.35 21340Treatment of nose fracture Y A2 42.299 $1,790.47 21345Treat nose/jaw fracture Y A2 23.5618 $997.35 21355Treat cheek bone fracture Y A2 42.299 $1,790.47 21356Treat cheek bone fracture Y A2 23.5618 $997.35 21360Treat cheek bone fracture Y G2 23.5618 $997.35 21390Treat eye socket fracture Y G2 42.299 $1,790.47 21400Treat eye socket fracture Y A2 7.5315 $318.80 21401 Treat eye socket fracture Y A2 15.8572 $671.22 21406Treat eye socket fracture Y G2 42.299 $1,790.47 21407Treat eye socket fracture Y G2 42.299 $1,790.47 21421 Treat mouth roof fracture Y A2 23.5618 $997.35 21440Treat dental ridge fracture Y P3 $302.18 21445Treat dental ridge fracture Y A2 23.5618 $997.35 21450Treat 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** 

## Ad**dendum A**

**A -- Proposed A** **SC Covered Surgical Procedures for CY 2012 (Including Surgical Procedures for Which Payment is Packaged)** 

21452Treat lower jaw fracture Y A2 15.8572 $671.22 21453Treat lower jaw fracture Y A2 42.299 $1,790.47 21454Treat lower jaw fracture Y A2 23.5618 $997.35 21461 Treat lower jaw fracture Y A2 42.299 $1,790.47 21462Treat lower jaw fracture Y A2 42.299 $1,790.47 21465Treat lower jaw fracture Y A2 42.299 $1,790.47 21480 Reset dislocated jaw Y A2 1.0193 $43.15 21485Reset dislocated jaw Y A2 15.8572 $671.22 21490 Repair dislocated jaw Y A2 42.299 $1,790.47 21495Treat 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 21550Biopsy

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 21555Exc 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 21558Resect 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 21685Hyoid 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 21725Revision of neck muscle Y A2 1.3573 $57.45 21800Treatment of rib fracture Y A2 1.5056 $63.73 21805Treatment of rib fracture Y A2 24.5925 $1,040.98 21820Treat sternum fracture Y A2 1.5056 $63.73 21920Biopsy

soft tissue of back Y P3 $124.13 21925Biopsy

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 21935Resect 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 22305Treat spine process fracture Y A2 1.5056 $63.73 22310Treat spine fracture Y A2 4.6747 $197.88 22315Treat spine fracture Y A2 17.5202 $741.61 22505Manipulation 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 22523Percut kyphoplasty thor Y G2 82.0766 $3,474.22 22524 Percut kyphoplasty lumbar Y G2 82.0766 $3,474.22 22525Percut 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 22905Resect 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** 

## Ad**dendum A**

**A -- Proposed A** **SC Covered Surgical Procedures for CY 2012 (Including Surgical Procedures for Which Payment is Packaged)** 

23031 Drain shoulder bursa Y A2 19.2522 $814.93 23035Drain 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 23065Biopsy

shoulder tissues Y P3 $89.86 23066Biopsy

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 23075Exc 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 23078Resect shoulder tum > 5 cm Y G2 21.9487 $929.07 23100Biopsy

of shoulder joint Y A2 20.7775 $879.49 23101 Shoulder joint surgery Y A2 30.378 $1,285.87 23105Remove 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 23125Removal 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 23145Removal 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 23155Removal 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 23195Removal 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 23395Muscle transfer shoulder/arm Y A2 44.2257 $1,872.03 23397Muscle 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 23415Release 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 23455Repair 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 23465Repair 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 23485Revision 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** 

## Ad**dendum A**

**A -- Proposed A** **SC Covered Surgical Procedures for CY 2012 (Including Surgical Procedures for Which Payment is Packaged)** 

23500Treat clavicle fracture Y A2 1.5056 $63.73 23505Treat clavicle fracture Y A2 17.5202 $741.61 23515Treat clavicle fracture Y A2 62.8575 $2,660.70 23520Treat clavicle dislocation Y A2 4.6747 $197.88 23525Treat clavicle dislocation Y A2 4.6747 $197.88 23530Treat clavicle dislocation Y A2 46.3836 $1,963.37 23532Treat clavicle dislocation Y A2 24.5925 $1,040.98 23540Treat clavicle dislocation Y A2 1.5056 $63.73 23545Treat clavicle dislocation Y A2 4.6747 $197.88 23550Treat clavicle dislocation Y A2 46.3836 $1,963.37 23552Treat clavicle dislocation Y A2 46.3836 $1,963.37 23570Treat shoulder blade fx Y A2 1.5056 $63.73 23575Treat shoulder blade fx Y A2 4.6747 $197.88 23585Treat scapula fracture Y A2 62.8575 $2,660.70 23600Treat humerus fracture Y P2 1.5056 $63.73 23605Treat humerus fracture Y A2 17.5202 $741.61 23615Treat humerus fracture Y A2 62.8575 $2,660.70 23616Treat humerus fracture Y A2 62.8575 $2,660.70 23620Treat humerus fracture Y P2 1.5056 $63.73 23625Treat humerus fracture Y A2 17.5202 $741.61 23630Treat humerus fracture Y A2 62.8575 $2,660.70 23650Treat shoulder dislocation Y A2 1.5056 $63.73 23655Treat shoulder dislocation Y A2 14.5437 $615.62 23660Treat shoulder dislocation Y A2 46.3836 $1,963.37 23665Treat dislocation/fracture Y A2 4.6747 $197.88 23670Treat dislocation/fracture Y A2 62.8575 $2,660.70 23675Treat dislocation/fracture Y A2 1.5056 $63.73 23680Treat 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 23935Drain 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 24065Biopsy

arm/elbow soft tissue Y P3 $121.26 24066Biopsy

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 24075Exc 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 24079Resect arm/elbow tum > 5 cm Y G2 21.9487 $929.07 24100Biopsy

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 24105Removal of elbow bursa Y A2 20.7775 $879.49 24110 Remove humerus lesion Y A2 20.7775 $879.49 24115Remove/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 24125Remove/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** 

## Ad**dendum A**

**A -- Proposed A** **SC Covered Surgical Procedures for CY 2012 (Including Surgical Procedures for Which Payment is Packaged)** 

24138Remove elbow bone lesion Y A2 30.378 $1,285.87 24140 Partial removal of arm bone Y A2 30.378 $1,285.87 24145Partial removal of radius Y A2 30.378 $1,285.87 24147Partial removal of elbow Y A2 30.378 $1,285.87 24149Radical resection of elbow Y G2 30.378 $1,285.87 24152 Resect radius tumor Y G2 44.2257 $1,872.03 24155Removal 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 24300Manipulate elbow w/anesth Y G2 14.5437 $615.62 24301 Muscle/tendon transfer Y A2 30.378 $1,285.87 24305Arm 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 24332Tenolysis 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 24345Repr 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 24358Repair elbow w/deb open Y G2 30.378 $1,285.87 24359Repair 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 24365Reconstruct 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 24435Repair humerus with graft Y A2 82.0766 $3,474.22 24470 Revision of elbow joint Y A2 44.2257 $1,872.03 24495Decompression of forearm Y A2 30.378 $1,285.87 24498Reinforce humerus Y A2 82.0766 $3,474.22 24500Treat humerus fracture Y A2 1.5056 $63.73 24505Treat humerus fracture Y A2 1.5056 $63.73 24515Treat humerus fracture Y A2 62.8575 $2,660.70 24516Treat humerus fracture Y A2 62.8575 $2,660.70 24530Treat humerus fracture Y A2 1.5056 $63.73 24535Treat humerus fracture Y A2 4.6747 $197.88 24538Treat humerus fracture Y A2 24.5925 $1,040.98 24545Treat humerus fracture Y A2 62.8575 $2,660.70 24546Treat humerus fracture Y A2 62.8575 $2,660.70 24560Treat humerus fracture Y A2 1.5056 $63.73 24565Treat humerus fracture Y A2 1.5056 $63.73 24566Treat humerus fracture Y A2 24.5925 $1,040.98 24575Treat humerus fracture Y A2 62.8575 $2,660.70 24576Treat 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** 

## Ad**dendum A**

**A -- Proposed A** **SC Covered Surgical Procedures for CY 2012 (Including Surgical Procedures for Which Payment is Packaged)** 

24577Treat humerus fracture Y A2 1.5056 $63.73 24579Treat humerus fracture Y A2 62.8575 $2,660.70 24582Treat humerus fracture Y A2 24.5925 $1,040.98 24586Treat elbow fracture Y A2 62.8575 $2,660.70 24587Treat elbow fracture Y A2 62.8575 $2,660.70 24600Treat elbow dislocation Y A2 1.5056 $63.73 24605Treat elbow dislocation Y A2 14.5437 $615.62 24615Treat elbow dislocation Y A2 62.8575 $2,660.70 24620Treat elbow fracture Y A2 17.5202 $741.61 24635Treat elbow fracture Y A2 62.8575 $2,660.70 24640Treat elbow dislocation Y CH P3 $58.23 24650Treat radius fracture Y P2 1.5056 $63.73 24655Treat radius fracture Y A2 4.6747 $197.88 24665Treat radius fracture Y A2 46.3836 $1,963.37 24666Treat radius fracture Y A2 62.8575 $2,660.70 24670Treat ulnar fracture Y A2 1.5056 $63.73 24675Treat ulnar fracture Y A2 1.5056 $63.73 24685Treat 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 24925Amputation 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 25023Decompress forearm 1 space Y A2 30.378 $1,285.87 25024 Decompress forearm 2 spaces Y A2 30.378 $1,285.87 25025Decompress forearm 2 spaces Y A2 30.378 $1,285.87 25028Drainage of forearm lesion Y A2 20.7775 $879.49 25031 Drainage of forearm bursa Y A2 20.7775 $879.49 25035Treat forearm bone lesion Y A2 20.7775 $879.49 25040 Explore/treat wrist joint Y A2 30.378 $1,285.87 25065Biopsy

forearm soft tissues Y P3 $122.21 25066Biopsy

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 25075Exc 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 25078Resect forearm/wrist tum3+cm Y G2 21.9487 $929.07 25085 Incision of wrist capsule Y A2 20.7775 $879.49 25100Biopsy

of wrist joint Y A2 20.7775 $879.49 25101 Explore/treat wrist joint Y A2 30.378 $1,285.87 25105Remove wrist joint lining Y A2 30.378 $1,285.87 25107 Remove wrist joint cartilage Y A2 30.378 $1,285.87 25109Excise 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 25115Remove wrist/forearm lesion Y A2 20.7775 $879.49 25116 Remove wrist/forearm lesion Y A2 20.7775 $879.49 25118Excise wrist tendon sheath Y A2 30.378 $1,285.87 25119Partial removal of ulna Y A2 30.378 $1,285.87 25120 Removal of forearm lesion Y A2 30.378 $1,285.87 25125Remove/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 25135Remove & 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** 

## Ad**dendum A**

**A -- Proposed A** **SC Covered Surgical Procedures for CY 2012 (Including Surgical Procedures for Which Payment is Packaged)** 

25145Remove 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 25215Removal 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 25248Remove 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 25259Manipulate 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 25265Repair 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 25275Repair 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 25295Release 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 25310Transplant forearm tendon Y A2 30.378 $1,285.87 25312Transplant forearm tendon Y A2 44.2257 $1,872.03 25315Revise 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 25335Realignment 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 25355Revision of radius Y A2 44.2257 $1,872.03 25360 Revision of ulna Y A2 44.2257 $1,872.03 25365Revise radius & ulna Y A2 82.0766 $3,474.22 25370 Revise radius or ulna Y A2 44.2257 $1,872.03 25375Revise radius & ulna Y A2 44.2257 $1,872.03 25390Shorten radius or ulna Y A2 44.2257 $1,872.03 25391 Lengthen radius or ulna Y A2 82.0766 $3,474.22 25392Shorten radius & ulna Y A2 30.378 $1,285.87 25393Lengthen 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 25405Repair/graft radius or ulna Y A2 82.0766 $3,474.22 25415Repair radius & ulna Y A2 82.0766 $3,474.22 25420 Repair/graft radius & ulna Y A2 82.0766 $3,474.22 25425Repair/graft radius or ulna Y A2 82.0766 $3,474.22 25426 Repair/graft radius & ulna Y A2 44.2257 $1,872.03 25430Vasc 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 25445Reconstruct wrist joint Y A2 56.2694 $2,381.83 25446Wrist 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** 

## Ad**dendum A**

**A -- Proposed A** **SC 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 25449Remove wrist joint implant Y A2 38.7078 $1,638.46 25450 Revision of wrist joint Y A2 44.2257 $1,872.03 25455Revision 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 25500Treat fracture of radius Y P2 1.5056 $63.73 25505Treat fracture of radius Y A2 4.6747 $197.88 25515Treat fracture of radius Y A2 46.3836 $1,963.37 25520Treat fracture of radius Y A2 4.6747 $197.88 25525Treat fracture of radius Y A2 46.3836 $1,963.37 25526Treat fracture of radius Y A2 46.3836 $1,963.37 25530Treat fracture of ulna Y P2 1.5056 $63.73 25535Treat fracture of ulna Y A2 1.5056 $63.73 25545Treat fracture of ulna Y A2 46.3836 $1,963.37 25560Treat fracture radius & ulna Y P2 1.5056 $63.73 25565Treat fracture radius & ulna Y A2 4.6747 $197.88 25574Treat fracture radius & ulna Y A2 62.8575 $2,660.70 25575Treat fracture radius/ulna Y A2 62.8575 $2,660.70 25600Treat fracture radius/ulna Y P2 1.5056 $63.73 25605Treat fracture radius/ulna Y A2 4.6747 $197.88 25606Treat fx distal radial Y A2 24.5925 $1,040.98 25607Treat fx rad extra-articul Y A2 62.8575 $2,660.70 25608Treat fx rad intra-articul Y A2 62.8575 $2,660.70 25609Treat fx radial 3+ frag Y A2 62.8575 $2,660.70 25622Treat wrist bone fracture Y P2 1.5056 $63.73 25624Treat wrist bone fracture Y A2 4.6747 $197.88 25628Treat wrist bone fracture Y A2 46.3836 $1,963.37 25630Treat wrist bone fracture Y P2 1.5056 $63.73 25635Treat wrist bone fracture Y A2 1.5056 $63.73 25645Treat wrist bone fracture Y A2 46.3836 $1,963.37 25650Treat wrist bone fracture Y P2 1.5056 $63.73 25651 Pin ulnar styloid fracture Y G2 24.5925 $1,040.98 25652Treat fracture ulnar styloid Y G2 46.3836 $1,963.37 25660Treat wrist dislocation Y A2 1.5056 $63.73 25670Treat wrist dislocation Y A2 24.5925 $1,040.98 25671 Pin radioulnar dislocation Y A2 24.5925 $1,040.98 25675Treat wrist dislocation Y A2 1.5056 $63.73 25676Treat wrist dislocation Y A2 24.5925 $1,040.98 25680Treat wrist fracture Y A2 1.5056 $63.73 25685Treat wrist fracture Y A2 24.5925 $1,040.98 25690Treat wrist dislocation Y A2 17.5202 $741.61 25695Treat wrist dislocation Y A2 24.5925 $1,040.98 25800 Fusion of wrist joint Y A2 82.0766 $3,474.22 25805Fusion/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 25825Fuse hand bones with graft Y A2 82.0766 $3,474.22 25830 Fusion radioulnar jnt/ulna Y A2 82.0766 $3,474.22 25907Amputation follow-up surgery Y A2 20.7775 $879.49 25922Amputate hand at wrist Y A2 20.7775 $879.49 25929Amputation 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 26025Drainage 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** 

## Ad**dendum A**

**A -- Proposed A** **SC 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 26034Treat hand bone lesion Y A2 16.318 $690.72 26035Decompress fingers/hand Y G2 16.318 $690.72 26037Decompress fingers/hand Y G2 16.318 $690.72 26040 Release palm contracture Y A2 16.318 $690.72 26045Release 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 26075Explore/treat finger joint Y A2 16.318 $690.72 26080 Explore/treat finger joint Y A2 16.318 $690.72 26100Biopsy

hand joint lining Y A2 16.318 $690.72 26105Biopsy

finger joint lining Y A2 16.318 $690.72 26110Biopsy

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 26115Exc 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 26118Exc 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 26125Release palm contracture Y A2 16.318 $690.72 26130 Remove wrist joint lining Y A2 16.318 $690.72 26135Revise finger joint each Y A2 27.1987 $1,151.29 26140 Revise finger joint each Y A2 16.318 $690.72 26145Tendon 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 26185Remove finger bone Y A2 16.318 $690.72 26200 Remove hand bone lesion Y A2 16.318 $690.72 26205Remove/graft bone lesion Y A2 27.1987 $1,151.29 26210 Removal of finger lesion Y A2 16.318 $690.72 26215Remove/graft finger lesion Y A2 16.318 $690.72 26230 Partial removal of hand bone Y A2 16.318 $690.72 26235Partial removal finger bone Y A2 16.318 $690.72 26236Partial 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 26340Manipulate 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 26358Repair/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 26415Excision hand/finger tendon Y A2 27.1987 $1,151.29 26416Graft hand or finger tendon Y A2 27.1987 $1,151.29 26418Repair 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** 

## Ad**dendum A**

**A -- Proposed A** **SC 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 26428Repair/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 26445Release hand/finger tendon Y A2 16.318 $690.72 26449Release 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 26476Tendon lengthening Y A2 16.318 $690.72 26477Tendon shortening Y A2 16.318 $690.72 26478Lengthening of hand tendon Y A2 16.318 $690.72 26479Shortening of hand tendon Y A2 16.318 $690.72 26480Transplant hand tendon Y A2 27.1987 $1,151.29 26483Transplant/graft hand tendon Y A2 27.1987 $1,151.29 26485Transplant palm tendon Y A2 27.1987 $1,151.29 26489Transplant/graft palm tendon Y A2 27.1987 $1,151.29 26490 Revise thumb tendon Y A2 27.1987 $1,151.29 26492Tendon 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 26499Revision 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 26508Release thumb contracture Y A2 16.318 $690.72 26510Thumb 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 26525Release 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 26535Revise 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 26545Reconstruct finger joint Y A2 27.1987 $1,151.29 26546 Repair nonunion hand Y A2 27.1987 $1,151.29 26548Reconstruct finger joint Y A2 27.1987 $1,151.29 26550Construct thumb replacement Y A2 27.1987 $1,151.29 26555Positional 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 26565Correct metacarpal flaw Y A2 27.1987 $1,151.29 26567Correct finger deformity Y A2 27.1987 $1,151.29 26568Lengthen 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** 

## Ad**dendum A**

**A -- Proposed A** **SC 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 26600Treat metacarpal fracture Y P2 1.5056 $63.73 26605Treat metacarpal fracture Y A2 1.5056 $63.73 26607Treat metacarpal fracture Y A2 17.5202 $741.61 26608Treat metacarpal fracture Y A2 24.5925 $1,040.98 26615Treat metacarpal fracture Y A2 46.3836 $1,963.37 26641 Treat thumb dislocation Y P2 1.5056 $63.73 26645Treat thumb fracture Y A2 4.6747 $197.88 26650Treat thumb fracture Y A2 24.5925 $1,040.98 26665Treat thumb fracture Y A2 46.3836 $1,963.37 26670Treat hand dislocation Y P2 1.5056 $63.73 26675Treat hand dislocation Y A2 1.5056 $63.73 26676Pin hand dislocation Y A2 24.5925 $1,040.98 26685Treat hand dislocation Y A2 24.5925 $1,040.98 26686Treat hand dislocation Y A2 62.8575 $2,660.70 26700Treat knuckle dislocation Y P2 1.5056 $63.73 26705Treat knuckle dislocation Y A2 1.5056 $63.73 26706Pin knuckle dislocation Y A2 17.5202 $741.61 26715Treat knuckle dislocation Y A2 24.5925 $1,040.98 26720Treat finger fracture each Y P2 1.5056 $63.73 26725Treat finger fracture each Y P2 1.5056 $63.73 26727Treat finger fracture each Y A2 24.5925 $1,040.98 26735Treat finger fracture each Y A2 24.5925 $1,040.98 26740Treat finger fracture each Y P2 1.5056 $63.73 26742Treat finger fracture each Y A2 1.5056 $63.73 26746Treat finger fracture each Y A2 24.5925 $1,040.98 26750Treat finger fracture each Y P2 1.5056 $63.73 26755Treat finger fracture each Y G2 1.5056 $63.73 26756Pin finger fracture each Y A2 24.5925 $1,040.98 26765Treat finger fracture each Y A2 24.5925 $1,040.98 26770Treat finger dislocation Y G2 1.5056 $63.73 26775Treat finger dislocation Y P3 $156.24 26776Pin finger dislocation Y A2 24.5925 $1,040.98 26785Treat finger dislocation Y A2 24.5925 $1,040.98 26820Thumb fusion with graft Y A2 27.1987 $1,151.29 26841 Fusion of thumb Y A2 27.1987 $1,151.29 26842Thumb 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 26910Amputate metacarpal bone Y A2 27.1987 $1,151.29 26951 Amputation of finger/thumb Y A2 16.318 $690.72 26952Amputation 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** 

## Ad**dendum A**

**A -- Proposed A** **SC 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 27035Denervation of hip joint Y A2 30.378 $1,285.87 27040Biopsy

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 27045Exc 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 27048Exc hip/pelv tum deep < 5 cm Y G2 16.113 $682.05 27049Resect hip/pelv tum < 5 cm Y G2 16.113 $682.05 27050Biopsy

of sacroiliac joint Y A2 20.7775 $879.49 27052 Biopsy

of hip joint Y A2 20.7775 $879.49 27059Resect 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 27065Remove 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 27098Transfer tendon to pelvis Y A2 30.378 $1,285.87 27100Transfer of abdominal muscle Y A2 44.2257 $1,872.03 27105Transfer of spinal muscle Y A2 44.2257 $1,872.03 27110Transfer of iliopsoas muscle Y A2 44.2257 $1,872.03 27111 Transfer of iliopsoas muscle Y A2 44.2257 $1,872.03 27193Treat pelvic ring fracture Y A2 1.5056 $63.73 27194Treat pelvic ring fracture Y A2 14.5437 $615.62 27200Treat tail bone fracture Y P2 1.5056 $63.73 27202Treat tail bone fracture Y A2 46.3836 $1,963.37 27220Treat hip socket fracture Y G2 1.5056 $63.73 27230Treat thigh fracture Y A2 1.5056 $63.73 27238Treat thigh fracture Y A2 4.6747 $197.88 27246Treat thigh fracture Y A2 4.6747 $197.88 27250Treat hip dislocation Y A2 1.5056 $63.73 27252Treat hip dislocation Y A2 14.5437 $615.62 27256Treat hip dislocation Y G2 1.5056 $63.73 27257Treat hip dislocation Y A2 14.5437 $615.62 27265Treat hip dislocation Y A2 1.5056 $63.73 27266Treat hip dislocation Y A2 14.5437 $615.62 27267Cltx thigh fx Y G2 1.5056 $63.73 27275Manipulation 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 27323Biopsy

thigh soft tissues Y A2 8.0762 $341.86 27324Biopsy

thigh soft tissues Y A2 21.9487 $929.07 27325Neurectomy

hamstring Y A2 17.8674 $756.31 27326Neurectomy

popliteal Y A2 17.8674 $756.31 27327 Exc thigh/knee les sc < 3 cm Y CH G2 21.9487 $929.07 27328Exc thigh/knee tum deep <5cm Y G2 16.113 $682.05 27329Resect thigh/knee tum < 5 cm Y G2 16.113 $682.05 27330Biopsy

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** 

## Ad**dendum A**

**A -- Proposed A** **SC 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 27335Remove knee joint lining Y A2 30.378 $1,285.87 27337 Exc thigh/knee les sc 3+ cm Y G2 21.9487 $929.07 27339Exc thigh/knee tum deep 5+cm Y G2 21.9487 $929.07 27340 Removal of kneecap bursa Y A2 20.7775 $879.49 27345Removal 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 27355Remove 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 27358Remove 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 27385Repair 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 27393Lengthening of thigh tendon Y A2 30.378 $1,285.87 27394Lengthening of thigh tendons Y A2 30.378 $1,285.87 27395Lengthening of thigh tendons Y A2 44.2257 $1,872.03 27396Transplant of thigh tendon Y A2 30.378 $1,285.87 27397Transplants 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 27405Repair of knee ligament Y A2 44.2257 $1,872.03 27407 Repair of knee ligament Y A2 82.0766 $3,474.22 27409Repair of knee ligaments Y A2 82.0766 $3,474.22 27416Osteochondral knee autograft Y G2 44.2257 $1,872.03 27418Repair 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 27425Lat retinacular release open Y A2 30.378 $1,285.87 27427 Reconstruction knee Y A2 82.0766 $3,474.22 27428Reconstruction knee Y A2 82.0766 $3,474.22 27429Reconstruction 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 27438Revise 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 27475Surgery to stop leg growth Y G2 30.378 $1,285.87 27479Surgery to stop leg growth Y G2 30.378 $1,285.87 27496Decompression of thigh/knee Y A2 30.378 $1,285.87 27497Decompression of thigh/knee Y A2 20.7775 $879.49 27498Decompression 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** 

## Ad**dendum A**

**A -- Proposed A** **SC Covered Surgical Procedures for CY 2012 (Including Surgical Procedures for Which Payment is Packaged)** 

27499Decompression of thigh/knee Y A2 30.378 $1,285.87 27500Treatment of thigh fracture Y A2 4.6747 $197.88 27501 Treatment of thigh fracture Y A2 1.5056 $63.73 27502Treatment of thigh fracture Y A2 17.5202 $741.61 27503Treatment of thigh fracture Y A2 1.5056 $63.73 27508Treatment of thigh fracture Y A2 1.5056 $63.73 27509Treatment of thigh fracture Y A2 24.5925 $1,040.98 27510Treatment of thigh fracture Y A2 4.6747 $197.88 27516Treat thigh fx growth plate Y A2 1.5056 $63.73 27517Treat thigh fx growth plate Y A2 1.5056 $63.73 27520Treat kneecap fracture Y A2 1.5056 $63.73 27530Treat knee fracture Y A2 1.5056 $63.73 27532Treat knee fracture Y A2 17.5202 $741.61 27538Treat knee fracture(s) Y A2 1.5056 $63.73 27550Treat knee dislocation Y A2 1.5056 $63.73 27552Treat knee dislocation Y A2 14.5437 $615.62 27560Treat kneecap dislocation Y A2 1.5056 $63.73 27562Treat kneecap dislocation Y A2 14.5437 $615.62 27566Treat kneecap dislocation Y A2 46.3836 $1,963.37 27570 Fixation of knee joint Y A2 14.5437 $615.62 27594Amputation 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 27603Drain 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 27607Treat 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 27613Biopsy

lower leg soft tissue Y P3 $117.90 27614Biopsy

lower leg soft tissue Y A2 21.9487 $929.07 27615Resect leg/ankle tum < 5 cm Y G2 16.113 $682.05 27616 Resect leg/ankle tum 5+ cm Y G2 21.9487 $929.07 27618Exc leg/ankle tum < 3 cm Y CH G2 16.113 $682.05 27619Exc leg/ankle tum deep <5 cm Y G2 16.113 $682.05 27620 Explore/treat ankle joint Y A2 30.378 $1,285.87 27625Remove 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 27635Remove lower leg bone lesion Y A2 30.378 $1,285.87 27637 Remove/graft leg bone lesion Y A2 30.378 $1,285.87 27638Remove/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 27658Repair of leg tendon each Y A2 20.7775 $879.49 27659Repair of leg tendon each Y A2 20.7775 $879.49 27664 Repair of leg tendon each Y A2 30.378 $1,285.87 27665Repair 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** 

## Ad**dendum A**

**A -- Proposed A** **SC Covered Surgical Procedures for CY 2012 (Including Surgical Procedures for Which Payment is Packaged)** 

27675Repair 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 27685Revision 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 27695Repair of ankle ligament Y A2 30.378 $1,285.87 27696 Repair of ankle ligaments Y A2 30.378 $1,285.87 27698Repair 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 27745Reinforce tibia Y A2 82.0766 $3,474.22 27750Treatment of tibia fracture Y A2 1.5056 $63.73 27752Treatment of tibia fracture Y A2 17.5202 $741.61 27756Treatment of tibia fracture Y A2 24.5925 $1,040.98 27758Treatment of tibia fracture Y A2 46.3836 $1,963.37 27759Treatment of tibia fracture Y A2 62.8575 $2,660.70 27760Cltx medial ankle fx Y A2 1.5056 $63.73 27762Cltx med ankle fx w/mnpj Y A2 17.5202 $741.61 27766Optx medial ankle fx Y A2 46.3836 $1,963.37 27767Cltx post ankle fx Y P2 1.5056 $63.73 27768Cltx post ankle fx w/mnpj Y G2 1.5056 $63.73 27769Optx post ankle fx Y G2 46.3836 $1,963.37 27780Treatment of fibula fracture Y A2 1.5056 $63.73 27781 Treatment of fibula fracture Y A2 17.5202 $741.61 27784Treatment of fibula fracture Y A2 46.3836 $1,963.37 27786Treatment of ankle fracture Y A2 1.5056 $63.73 27788Treatment of ankle fracture Y A2 1.5056 $63.73 27792Treatment of ankle fracture Y A2 46.3836 $1,963.37 27808Treatment of ankle fracture Y A2 1.5056 $63.73 27810Treatment of ankle fracture Y A2 1.5056 $63.73 27814Treatment of ankle fracture Y A2 46.3836 $1,963.37 27816Treatment of ankle fracture Y A2 1.5056 $63.73 27818Treatment of ankle fracture Y A2 4.6747 $197.88 27822Treatment of ankle fracture Y A2 46.3836 $1,963.37 27823Treatment of ankle fracture Y A2 62.8575 $2,660.70 27824Treat lower leg fracture Y A2 1.5056 $63.73 27825Treat lower leg fracture Y A2 17.5202 $741.61 27826Treat lower leg fracture Y A2 46.3836 $1,963.37 27827Treat lower leg fracture Y A2 62.8575 $2,660.70 27828Treat lower leg fracture Y A2 62.8575 $2,660.70 27829Treat lower leg joint Y A2 46.3836 $1,963.37 27830Treat 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** 

## Ad**dendum A**

**A -- Proposed A** **SC Covered Surgical Procedures for CY 2012 (Including Surgical Procedures for Which Payment is Packaged)** 

27832Treat lower leg dislocation Y A2 46.3836 $1,963.37 27840Treat ankle dislocation Y A2 1.5056 $63.73 27842Treat ankle dislocation Y A2 14.5437 $615.62 27846Treat ankle dislocation Y A2 46.3836 $1,963.37 27848Treat 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 27884Amputation follow-up surgery Y A2 20.7775 $879.49 27889Amputation of foot at ankle Y A2 30.378 $1,285.87 27892 Decompression of leg Y A2 30.378 $1,285.87 27893Decompression 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 28002Treatment of foot infection Y A2 20.7775 $879.49 28003Treatment of foot infection Y A2 20.7775 $879.49 28005Treat 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 28035Decompression of tibia nerve Y A2 17.8674 $756.31 28039Exc 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 28045Exc 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 28050Biopsy

of foot joint lining Y A2 20.7836 $879.75 28052 Biopsy

of foot joint lining Y A2 20.7836 $879.75 28054Biopsy

of toe joint lining Y A2 20.7836 $879.75 28055Neurectomy

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 28088Excise 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 28108Removal 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 28113Part 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 28118Removal of heel bone Y A2 20.7836 $879.75 28119Removal 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** 

## Ad**dendum A**

**A -- Proposed A** **SC 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 28126Partial 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 28153Partial 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 28175Resect 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 28208Repair 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 28225Release 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 28238Revision 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 28285Repair of hammertoe Y A2 20.7836 $879.75 28286 Repair of hammertoe Y A2 20.7836 $879.75 28288Partial removal of foot bone Y A2 20.7836 $879.75 28289Repair hallux rigidus Y A2 20.7836 $879.75 28290Correction of bunion Y A2 30.505 $1,291.25 28292Correction of bunion Y A2 30.505 $1,291.25 28293Correction of bunion Y A2 30.505 $1,291.25 28294Correction of bunion Y A2 30.505 $1,291.25 28296Correction of bunion Y A2 30.505 $1,291.25 28297Correction of bunion Y A2 30.505 $1,291.25 28298Correction of bunion Y A2 30.505 $1,291.25 28299Correction 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** 

## Ad**dendum A**

**A -- Proposed A** **SC 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 28315Removal 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 28345Repair webbed toe(s) Y A2 20.7836 $879.75 28400Treatment of heel fracture Y A2 1.5056 $63.73 28405Treatment of heel fracture Y A2 17.5202 $741.61 28406Treatment of heel fracture Y A2 24.5925 $1,040.98 28415Treat heel fracture Y A2 62.8575 $2,660.70 28420Treat/graft heel fracture Y A2 46.3836 $1,963.37 28430Treatment of ankle fracture Y P2 1.5056 $63.73 28435Treatment of ankle fracture Y A2 1.5056 $63.73 28436Treatment of ankle fracture Y A2 24.5925 $1,040.98 28445Treat ankle fracture Y A2 46.3836 $1,963.37 28446Osteochondral talus autogrft Y G2 53.6228 $2,269.80 28450Treat midfoot fracture each Y P2 1.5056 $63.73 28455Treat midfoot fracture each Y P2 1.5056 $63.73 28456Treat midfoot fracture Y A2 24.5925 $1,040.98 28465Treat midfoot fracture each Y A2 46.3836 $1,963.37 28470Treat metatarsal fracture Y P2 1.5056 $63.73 28475Treat metatarsal fracture Y P2 1.5056 $63.73 28476Treat metatarsal fracture Y A2 24.5925 $1,040.98 28485Treat metatarsal fracture Y A2 46.3836 $1,963.37 28490Treat big toe fracture Y P2 1.5056 $63.73 28495Treat big toe fracture Y P2 1.5056 $63.73 28496Treat big toe fracture Y A2 24.5925 $1,040.98 28505Treat big toe fracture Y A2 24.5925 $1,040.98 28510Treatment of toe fracture Y CH P3 $53.44 28515Treatment of toe fracture Y P2 1.5056 $63.73 28525Treat toe fracture Y A2 24.5925 $1,040.98 28530Treat sesamoid bone fracture Y CH P3 $50.32 28531 Treat sesamoid bone fracture Y A2 24.5925 $1,040.98 28540Treat foot dislocation Y P2 1.5056 $63.73 28545Treat foot dislocation Y A2 24.5925 $1,040.98 28546Treat foot dislocation Y A2 24.5925 $1,040.98 28555Repair foot dislocation Y A2 46.3836 $1,963.37 28570Treat foot dislocation Y P2 1.5056 $63.73 28575Treat foot dislocation Y A2 17.5202 $741.61 28576Treat foot dislocation Y A2 24.5925 $1,040.98 28585Repair foot dislocation Y A2 24.5925 $1,040.98 28600Treat foot dislocation Y P2 1.5056 $63.73 28605Treat foot dislocation Y A2 1.5056 $63.73 28606Treat foot dislocation Y A2 24.5925 $1,040.98 28615Repair foot dislocation Y A2 46.3836 $1,963.37 28630Treat toe dislocation Y CH P3 $59.91 28635Treat toe dislocation Y A2 14.5437 $615.62 28636Treat toe dislocation Y A2 24.5925 $1,040.98 28645Repair toe dislocation Y A2 24.5925 $1,040.98 28660Treat toe dislocation Y P3 $44.33 28665Treat toe dislocation Y A2 14.5437 $615.62 28666Treat toe dislocation Y A2 24.5925 $1,040.98 28675Repair of toe dislocation Y A2 24.5925 $1,040.98 28705Fusion of foot bones Y A2 53.6228 $2,269.80 28715Fusion of foot bones Y A2 82.0766 $3,474.22 28725Fusion 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** 

## Ad**dendum A**

**A -- Proposed A** **SC 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 28735Fusion 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 28755Fusion of big toe joint Y A2 20.7836 $879.75 28760 Fusion of big toe joint Y A2 53.6228 $2,269.80 28810Amputation toe & metatarsal Y A2 20.7836 $879.75 28820Amputation of toe Y A2 20.7836 $879.75 28825Partial amputation of toe Y A2 20.7836 $879.75 28890 High energy

eswt plantar f Y P3 $144.98 29000Application of body cast N G2 1.0665 $45.14 29010Application of body cast N CH P3 $93.22 29015Application of body cast N P2 2.5362 $107.35 29020Application of body cast N G2 1.0665 $45.14 29025Application of body cast N P2 1.0665 $45.14 29035Application of body cast N P2 2.5362 $107.35 29040Application of body cast N G2 1.0665 $45.14 29044Application of body cast N P2 2.5362 $107.35 29046Application of body cast N G2 2.5362 $107.35 29049Application of figure eight N CH P3 $41.46 29055Application of shoulder cast N CH P3 $101.61 29058Application of shoulder cast N CH P3 $31.39 29065Application of long arm cast N P3 $42.18 29075Application of forearm cast N P3 $40.74 29085Apply

hand/wrist cast N CH P3 $41.70 29086Apply

finger cast N CH P3 $36.90 29105Apply

long arm splint N CH P3 $36.66 29125Apply

forearm splint N P3 $30.67 29126Apply

forearm splint N CH P3 $34.51 29130Application of finger splint N P3 $14.62 29131 Application of finger splint N P3 $21.09 29200Strapping of chest N P3 $19.65 29240Strapping of shoulder N P3 $21.33 29260Strapping of elbow or wrist N P3 $21.57 29280Strapping of hand or finger N P3 $21.81 29305Application of hip cast N P2 2.5362 $107.35 29325Application of hip casts N P2 2.5362 $107.35 29345Application of long leg cast N P3 $55.12 29355Application of long leg cast N P3 $55.12 29358Apply

long leg cast brace N P3 $69.49 29365Application of long leg cast N P3 $51.52 29405Apply

short leg cast N P3 $35.71 29425Apply

short leg cast N P3 $34.27 29435Apply

short leg cast N P3 $49.84 29440Addition of walker to cast N P3 $23.96 29445Apply

rigid leg cast N P3 $47.93 29450Application of leg cast N P2 1.0665 $45.14 29505Application long leg splint N CH P3 $36.66 29515Application lower leg splint N P3 $29.48 29520Strapping of hip N P3 $20.37 29530Strapping of knee N P3 $21.09 29540Strapping of ankle and/or ft N P3 $15.10 29550Strapping of toes N P3 $15.34 29580Application of paste boot N P3 $21.81 29581 Apply

multlay comprs lwr leg N P2 1.0665 $45.14 29590Application 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** 

## Ad**dendum A**

**A -- Proposed A** **SC Covered Surgical Procedures for CY 2012 (Including Surgical Procedures for Which Payment is Packaged)** 

29705Removal/revision of cast N P3 $25.16 29710 Removal/revision of cast N P3 $37.62 29715Removal/revision of cast N CH P3 $35.47 29720 Repair of body cast N CH P3 $38.58 29730Windowing of cast N P3 $24.68 29740Wedging of cast N CH P3 $32.59 29750Wedging of clubfoot cast N CH P3 $35.71 29800Jaw arthroscopy/surgery Y A2 27.5786 $1,167.37 29804Jaw arthroscopy/surgery Y A2 27.5786 $1,167.37 29805Shoulder arthroscopy dx Y A2 27.5786 $1,167.37 29806Shoulder arthroscopy/surgery Y A2 45.4164 $1,922.43 29807Shoulder arthroscopy/surgery Y A2 45.4164 $1,922.43 29819Shoulder arthroscopy/surgery Y A2 45.4164 $1,922.43 29820Shoulder arthroscopy/surgery Y A2 45.4164 $1,922.43 29821 Shoulder arthroscopy/surgery Y A2 45.4164 $1,922.43 29822Shoulder arthroscopy/surgery Y A2 27.5786 $1,167.37 29823Shoulder arthroscopy/surgery Y A2 45.4164 $1,922.43 29824Shoulder arthroscopy/surgery Y A2 27.5786 $1,167.37 29825Shoulder arthroscopy/surgery Y A2 45.4164 $1,922.43 29826Shoulder arthroscopy/surgery Y A2 45.4164 $1,922.43 29827Arthroscop rotator cuff repr Y A2 45.4164 $1,922.43 29828Arthroscopy 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 29835Elbow 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 29838Elbow arthroscopy/surgery Y A2 27.5786 $1,167.37 29840Wrist arthroscopy Y A2 27.5786 $1,167.37 29843Wrist arthroscopy/surgery Y A2 27.5786 $1,167.37 29844Wrist arthroscopy/surgery Y A2 27.5786 $1,167.37 29845Wrist arthroscopy/surgery Y A2 27.5786 $1,167.37 29846Wrist arthroscopy/surgery Y A2 27.5786 $1,167.37 29847Wrist arthroscopy/surgery Y A2 45.4164 $1,922.43 29848Wrist endoscopy/surgery Y A2 27.5786 $1,167.37 29850Knee arthroscopy/surgery Y A2 27.5786 $1,167.37 29851 Knee arthroscopy/surgery Y A2 45.4164 $1,922.43 29855Tibial arthroscopy /surgery Y A2 45.4164 $1,922.43 29856Tibial 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 29866Autgrft implnt knee w/scope Y G2 45.4164 $1,922.43 29870Knee arthroscopy dx Y A2 27.5786 $1,167.37 29871 Knee arthroscopy/drainage Y A2 27.5786 $1,167.37 29873Knee arthroscopy/surgery Y A2 27.5786 $1,167.37 29874Knee arthroscopy/surgery Y A2 27.5786 $1,167.37 29875Knee arthroscopy/surgery Y A2 27.5786 $1,167.37 29876Knee arthroscopy/surgery Y A2 27.5786 $1,167.37 29877Knee arthroscopy/surgery Y A2 27.5786 $1,167.37 29879Knee arthroscopy/surgery Y A2 27.5786 $1,167.37 29880Knee 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 29883Knee arthroscopy/surgery Y A2 27.5786 $1,167.37 29884Knee arthroscopy/surgery Y A2 27.5786 $1,167.37 29885Knee 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** 

## Ad**dendum A**

**A -- Proposed A** **SC Covered Surgical Procedures for CY 2012 (Including Surgical Procedures for Which Payment is Packaged)** 

29886Knee arthroscopy/surgery Y A2 27.5786 $1,167.37 29887Knee arthroscopy/surgery Y A2 27.5786 $1,167.37 29888Knee arthroscopy/surgery Y A2 82.0766 $3,474.22 29889Knee arthroscopy/surgery Y A2 82.0766 $3,474.22 29891 Ankle arthroscopy/surgery Y A2 45.4164 $1,922.43 29892Ankle arthroscopy/surgery Y A2 82.0766 $3,474.22 29893Scope plantar fasciotomy Y A2 20.7836 $879.75 29894Ankle arthroscopy/surgery Y A2 27.5786 $1,167.37 29895Ankle arthroscopy/surgery Y A2 27.5786 $1,167.37 29897Ankle arthroscopy/surgery Y A2 27.5786 $1,167.37 29898Ankle arthroscopy/surgery Y A2 27.5786 $1,167.37 29899Ankle arthroscopy/surgery Y A2 45.4164 $1,922.43 29900Mcp 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 29904Subtalar arthro w/fb rmvl Y G2 27.5786 $1,167.37 29905Subtalar arthro w/exc Y G2 27.5786 $1,167.37 29906Subtalar arthro w/deb Y G2 27.5786 $1,167.37 29907Subtalar arthro w/fusion Y G2 45.4164 $1,922.43 29914 Hip arthro w/femoroplasty Y G2 45.4164 $1,922.43 29915Hip 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 30115Removal of nose polyp(s) Y A2 15.8572 $671.22 30117 Removal of intranasal lesion Y A2 15.8572 $671.22 30118Removal 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 30125Removal 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 30435Revision 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 30465Repair 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 30545Repair 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** 

## Ad**dendum A**

**A -- Proposed A** **SC 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 30802Ablate inf turbinate submuc Y A2 15.8572 $671.22 30901 Control of nosebleed Y CH P3 $37.86 30903Control of nosebleed Y A2 1.0193 $43.15 30905Control of nosebleed Y A2 1.0193 $43.15 30906 Repeat control of nosebleed Y A2 1.0193 $43.15 30915Ligation nasal sinus artery Y A2 25.2303 $1,067.97 30920Ligation upper jaw artery Y A2 25.2303 $1,067.97 30930Ther 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 31075Exploration 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 31085Removal 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 31205Removal of ethmoid sinus Y A2 42.299 $1,790.47 31231 Nasal endoscopy dx Y P2 1.8254 $77.27 31233Nasal/sinus endoscopy dx Y A2 1.8254 $77.27 31235Nasal/sinus endoscopy dx Y A2 20.0293 $847.82 31237Nasal/sinus endoscopy surg Y A2 20.0293 $847.82 31238Nasal/sinus endoscopy surg Y A2 20.0293 $847.82 31239Nasal/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 31255Removal 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 31276Sinus endoscopy surgical Y A2 28.3273 $1,199.07 31287Nasal/sinus endoscopy surg Y A2 28.3273 $1,199.07 31288Nasal/sinus endoscopy surg Y A2 28.3273 $1,199.07 31295Sinus endo w/balloon dil Y G2 28.3273 $1,199.07 31296Sinus endo w/balloon dil Y G2 28.3273 $1,199.07 31297Sinus 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 31502Change of windpipe airway N G2 1.313 $55.58 31505Diagnostic laryngoscopy Y P2 0.9861 $41.74 31510Laryngoscopy 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** 

## Ad**dendum A**

**A -- Proposed A** **SC Covered Surgical Procedures for CY 2012 (Including Surgical Procedures for Which Payment is Packaged)** 

31515Laryngoscopy for aspiration Y A2 20.0293 $847.82 31520 Dx laryngoscopy newborn Y G2 1.8254 $77.27 31525Dx laryngoscopy excl nb Y A2 20.0293 $847.82 31526Dx laryngoscopy w/oper scope Y A2 20.0293 $847.82 31527Laryngoscopy for treatment Y A2 28.3273 $1,199.07 31528Laryngoscopy and dilation Y A2 20.0293 $847.82 31529Laryngoscopy and dilation Y A2 20.0293 $847.82 31530Laryngoscopy w/fb removal Y A2 20.0293 $847.82 31531 Laryngoscopy w/fb & op scope Y A2 20.0293 $847.82 31535Laryngoscopy w/biopsy Y A2 20.0293 $847.82 31536Laryngoscopy w/bx & op scope Y A2 20.0293 $847.82 31540Laryngoscopy w/exc of tumor Y A2 20.0293 $847.82 31541 Larynscop w/tumr exc + scope Y A2 20.0293 $847.82 31545Remove vc lesion w/scope Y A2 28.3273 $1,199.07 31546 Remove vc lesion scope/graft Y A2 28.3273 $1,199.07 31560Laryngoscop w/arytenoidectom Y A2 28.3273 $1,199.07 31561 Larynscop remve cart + scop Y A2 28.3273 $1,199.07 31570Laryngoscope w/vc inj Y A2 20.0293 $847.82 31571 Laryngoscop w/vc inj + scope Y A2 28.3273 $1,199.07 31575Diagnostic laryngoscopy Y P3 $52.72 31576Laryngoscopy with biopsy Y A2 20.0293 $847.82 31577 Remove foreign body larynx Y A2 4.2293 $179.02 31578Removal of larynx lesion Y A2 28.3273 $1,199.07 31579Diagnostic 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 31588Revision of larynx Y A2 42.299 $1,790.47 31590 Reinnervate larynx Y A2 42.299 $1,790.47 31595Larynx 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 31615Visualization 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 31623Dx bronchoscope/brush Y A2 9.7594 $413.11 31624 Dx bronchoscope/lavage Y A2 9.7594 $413.11 31625Bronchoscopy w/biopsy(s) Y A2 9.7594 $413.11 31626Bronchoscopy w/markers Y G2 27.2989 $1,155.54 31627Navigational bronchoscopy N N1 31628Bronchoscopy /lung bx each Y A2 9.7594 $413.11 31629Bronchoscopy /needle bx each Y A2 9.7594 $413.11 31630Bronchoscopy 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 31633Bronchoscopy /needle bx addl Y G2 9.7594 $413.11 31634Bronch w/balloon occlusion Y G2 9.7594 $413.11 31635Bronchoscopy w/fb removal Y A2 9.7594 $413.11 31636Bronchoscopy bronch stents Y A2 27.2989 $1,155.54 31637Bronchoscopy stent add-on Y A2 9.7594 $413.11 31638Bronchoscopy revise stent Y A2 27.2989 $1,155.54 31640Bronchoscopy w/tumor excise Y A2 27.2989 $1,155.54 31641 Bronchoscopy treat blockage Y A2 27.2989 $1,155.54 31643Diag bronchoscope/catheter Y A2 9.7594 $413.11 31645Bronchoscopy 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** 

## Ad**dendum A**

**A -- Proposed A** **SC Covered Surgical Procedures for CY 2012 (Including Surgical Procedures for Which Payment is Packaged)** 

31646Bronchoscopy reclear airway Y A2 9.7594 $413.11 31656Bronchoscopy inj for x-ray Y A2 9.7594 $413.11 31715 Injection for bronchus x-ray N N1 31717Bronchial brush biopsy Y A2 4.2293 $179.02 31720Clearance 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 31755Repair of windpipe Y A2 42.299 $1,790.47 31820Closure of windpipe lesion Y A2 23.5618 $997.35 31825Repair 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 32405Biopsy

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 32422Thoracentesis 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 32960Therapeutic pneumothorax Y G2 5.2088 $220.48 32998Perq 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 33215Reposition 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 33218Repair 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 33225L 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 33235Removal 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 33249Eltrd/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 33508Endoscopic vein harvest N N1 34490 Removal of vein clot Y G2 38.6411 $1,635.64 35188Repair 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 35475Repair 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** 

## Ad**dendum A**

**A -- Proposed A** **SC Covered Surgical Procedures for CY 2012 (Including Surgical Procedures for Which Payment is Packaged)** 

35875Removal 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 36013Place catheter in artery N N1 36014 Place catheter in artery N N1 36015Place 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 36147Access av dial grft for eval Y P2 8.8399 $374.18 36148Access av dial grft for proc N N1 36160 Establish access to aorta N N1 36200 Place catheter in aorta N N1 36215Place catheter in artery N N1 36216Place catheter in artery N N1 36217Place catheter in artery N N1 36218Place catheter in artery N N1 36245Place catheter in artery N N1 36246Place catheter in artery N N1 36247Place catheter in artery N N1 36248Place 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 36400Bl draw < 3 yrs fem/jugular N N1 36405Bl draw < 3 yrs scalp vein N N1 36406Bl draw < 3 yrs other vein N N1 36410 Non-routine bl draw > 3 yrs N N1 36416Capillary

blood draw N N1 36420Vein access cutdown < 1 yr N R2 0.2547 $10.78 36425Vein access cutdown > 1 yr N R2 0.2547 $10.78 36430Blood transfusion service N P3 $23.72 36440Bl push transfuse 2 yr or < N R2 3.156 $133.59 36450Bl exchange/transfuse nb N R2 3.156 $133.59 36455Bl 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 36475Endovenous rf 1st vein Y A2 40.9473 $1,733.26 36476 Endovenous rf vein add-on Y A2 25.2303 $1,067.97 36478Endovenous laser 1st vein Y A2 25.2303 $1,067.97 36479Endovenous 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 36512Apheresis rbc N G2 11.0009 $465.66 36513Apheresis platelets N G2 11.0009 $465.66 36514Apheresis plasma N G2 11.0009 $465.66 36515Apheresis adsorp/reinfuse N P2 30.5575 $1,293.47 36516Apheresis 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** 

## Ad**dendum A**

**A -- Proposed A** **SC 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 36575Repair tunneled cv cath Y A2 5.9217 $250.66 36576 Repair tunneled cv cath Y A2 10.4623 $442.86 36578Replace 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 36585Replace picvad cath Y A2 23.5534 $996.99 36589Removal 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 36592Collect blood from picc N N1 36593Declot vascular device Y P3 $20.37 36595Mech remov tunneled cv cath Y G2 23.5534 $996.99 36596Mech 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 36600Withdrawal 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 36818Av fuse uppr arm cephalic Y A2 38.6411 $1,635.64 36819Av fuse uppr arm basilic Y A2 38.6411 $1,635.64 36820Av fusion/forearm vein Y A2 38.6411 $1,635.64 36821 Av fusion direct any site Y A2 38.6411 $1,635.64 36825Artery-vein autograft Y A2 38.6411 $1,635.64 36830Artery-vein nonautograft Y A2 38.6411 $1,635.64 36831 Open thrombect av fistula Y A2 38.6411 $1,635.64 36832Av fistula revision open Y A2 38.6411 $1,635.64 36833Av fistula revision Y A2 38.6411 $1,635.64 36835Artery 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 37185Prim art m-thrombect add-on Y G2 38.6411 $1,635.64 37186Sec art m-thrombect add-on Y G2 38.6411 $1,635.64 37187Venous mech thrombectomy Y G2 38.6411 $1,635.64 37188Venous m-thrombectomy add-on Y G2 38.6411 $1,635.64 37200Transcatheter 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** 

## Ad**dendum A**

**A -- Proposed A** **SC Covered Surgical Procedures for CY 2012 (Including Surgical Procedures for Which Payment is Packaged)** 

37203Transcatheter retrieval Y G2 28.3971 $1,202.02 37204Transcatheter 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 37607Ligation of a-v fistula Y A2 25.2303 $1,067.97 37609Temporal 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 37718Ligate/strip short leg vein Y A2 25.2303 $1,067.97 37722 Ligate/strip long leg vein Y A2 40.9473 $1,733.26 37735Removal of leg veins/lesion Y A2 40.9473 $1,733.26 37760Ligate leg veins radical Y A2 25.2303 $1,067.97 37761*Ligate leg veins open Y R2 25.2303 $1,067.97 37765Stab phleb veins xtr 10-20 Y P3 $258.09 37766Phleb veins - extrem 20+ Y P3 $288.76 37780 Revision of leg vein Y A2 25.2303 $1,067.97 37785Ligate/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 38204Bl donor search management N N1 38206 Harvest auto stem cells N G2 11.0009 $465.66 38220Bone marrow aspiration Y P3 $82.67 38221 Bone marrow biopsy Y P3 $81.00 38230Bone marrow collection N G2 30.5575 $1,293.47 38241 Bone marrow/stem transplant N G2 30.5575 $1,293.47 38242 Lymphocy

te infuse transplant N R2 11.0009 $465.66 38300 Drainage lymph node lesion Y A2 12.6328 $534.73 38305Drainage lymph node lesion Y A2 19.2522 $814.93 38308 Incision of lymph channels Y A2 23.8893 $1,011.21 38500Biopsy

/removal lymph nodes Y A2 23.8893 $1,011.21 38505Needle biopsy lymph nodes Y A2 7.631 $323.01 38510Biopsy

/removal lymph nodes Y A2 23.8893 $1,011.21 38520Biopsy

/removal lymph nodes Y A2 23.8893 $1,011.21 38525Biopsy

/removal lymph nodes Y A2 23.8893 $1,011.21 38530Biopsy

/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 38555Removal neck/armpit lesion Y A2 23.8893 $1,011.21 38570Laparoscopy

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 38745Remove 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 38794Access thoracic lymph duct N N1 38900 Io map of sent lymph node N N1 40490Biopsy

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** 

## Ad**dendum A**

**A -- Proposed A** **SC 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 40525Reconstruct 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 40805Removal foreign body mouth Y P3 $177.33 40806 Incision of lip fold Y P3 $98.25 40808Biopsy

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 40818Excise oral mucosa for graft Y A2 3.1429 $133.04 40819Excise lip or cheek fold Y A2 7.5315 $318.80 40820Treatment 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 40845Reconstruction of mouth Y A2 42.299 $1,790.47 41000 Drainage of mouth lesion Y P3 $78.36 41005Drainage of mouth lesion Y A2 3.1429 $133.04 41006Drainage of mouth lesion Y A2 23.5618 $997.35 41007Drainage of mouth lesion Y A2 15.8572 $671.22 41008Drainage of mouth lesion Y A2 15.8572 $671.22 41009Drainage of mouth lesion Y A2 3.1429 $133.04 41010 Incision of tongue fold Y A2 7.5315 $318.80 41015Drainage of mouth lesion Y A2 3.1429 $133.04 41016Drainage of mouth lesion Y A2 7.5315 $318.80 41017Drainage of mouth lesion Y A2 7.5315 $318.80 41018Drainage of mouth lesion Y A2 7.5315 $318.80 41019Place needles h&n for rt Y G2 23.5618 $997.35 41100Biopsy

of tongue Y P3 $81.72 41105Biopsy

of tongue Y P3 $81.96 41108Biopsy

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 41115Excision 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** 

## Ad**dendum A**

**A -- Proposed A** **SC Covered Surgical Procedures for CY 2012 (Including Surgical Procedures for Which Payment is Packaged)** 

41510Tongue to lip surgery Y A2 15.8572 $671.22 41512Tongue suspension Y G2 7.5315 $318.80 41520 Reconstruction tongue fold Y A2 7.5315 $318.80 41530Tongue base vol reduction Y CH P2 23.5618 $997.35 41800 Drainage of gum lesion Y A2 1.3573 $57.45 41805Removal 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 41825Excision 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 41828Excision of gum lesion Y P3 $129.16 41830 Removal of gum tissue Y P3 $181.40 41850Treatment of gum lesion Y R2 15.8572 $671.22 41870Gum 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 42100Biopsy

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 42145Repair palate pharynx/uvula Y A2 23.5618 $997.35 42160Treatment 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 42205Reconstruct cleft palate Y A2 42.299 $1,790.47 42210 Reconstruct cleft palate Y A2 42.299 $1,790.47 42215Reconstruct cleft palate Y A2 42.299 $1,790.47 42220 Reconstruct cleft palate Y A2 42.299 $1,790.47 42225Reconstruct cleft palate Y G2 42.299 $1,790.47 42226Lengthening of palate Y A2 42.299 $1,790.47 42227Lengthening of palate Y G2 42.299 $1,790.47 42235Repair 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 42305Drainage 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 42335Removal of salivary stone Y P3 $177.33 42340 Removal of salivary stone Y A2 15.8572 $671.22 42400Biopsy

of salivary

gland Y P3 $56.07 42405Biopsy

of salivary

gland Y A2 23.5618 $997.35 42408Excision of salivary cyst Y A2 15.8572 $671.22 42409Drainage of salivary cyst Y A2 15.8572 $671.22 42410 Excise parotid gland/lesion Y A2 42.299 $1,790.47 42415Excise parotid gland/lesion Y A2 42.299 $1,790.47 42420 Excise parotid gland/lesion Y A2 42.299 $1,790.47 42425Excise 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** 

## Ad**dendum A**

**A -- Proposed A** **SC 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 42505Repair salivary duct Y A2 42.299 $1,790.47 42507Parotid duct diversion Y A2 42.299 $1,790.47 42508Parotid duct diversion Y A2 42.299 $1,790.47 42509Parotid 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 42600Closure 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 42665Ligation 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 42725Drainage of throat abscess Y A2 42.299 $1,790.47 42800Biopsy

of throat Y P3 $75.72 42802 Biopsy

of throat Y A2 15.8572 $671.22 42804Biopsy

of upper nose/throat Y A2 15.8572 $671.22 42806Biopsy

of upper nose/throat Y A2 23.5618 $997.35 42808Excise pharynx lesion Y A2 23.5618 $997.35 42809Remove pharynx foreign body N G2 0.6316 $26.73 42810 Excision of neck cyst Y A2 23.5618 $997.35 42815Excision 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 42825Removal 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 42835Removal 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 42955Surgical opening of throat Y A2 23.5618 $997.35 42960Control throat bleeding Y A2 1.0193 $43.15 42962Control throat bleeding Y A2 42.299 $1,790.47 42970Control nose/throat bleeding Y R2 1.0193 $43.15 42972Control nose/throat bleeding Y A2 15.8572 $671.22 43030Throat 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 43205Esophagus endoscopy /ligation Y A2 11.7812 $498.69 43215Esophagus 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 43219Esophagus 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 43228Esoph 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** 

## Ad**dendum A**

**A -- Proposed A** **SC 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 43235Uppr 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 43238Uppr gi endoscopy w/us fn bx Y A2 11.7812 $498.69 43239Upper 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 43245Uppr gi scope dilate strictr Y A2 11.7812 $498.69 43246Place gastrostomy tube Y A2 11.7812 $498.69 43247Operative upper GI endoscopy Y A2 7.8534 $332.43 43248Uppr gi endoscopy /guide wire Y A2 7.8534 $332.43 43249Esoph 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 43255Operative 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 43258Operative upper GI endoscopy Y A2 11.7812 $498.69 43259Endoscopic 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 43265Endo cholangiopancreatograph Y A2 22.871 $968.11 43267 Endo cholangiopancreatograph Y A2 22.871 $968.11 43268Endo cholangiopancreatograph Y A2 27.2035 $1,151.50 43269Endo 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 43453Dilate esophagus Y A2 6.1328 $259.60 43456Dilate esophagus Y A2 6.1328 $259.60 43458Dilate esophagus Y A2 11.7812 $498.69 43653Laparoscopy

gastrostomy Y A2 44.7246 $1,893.15 43752 Nasal/orogastric w/stent N G2 1.1698 $49.52 43753Tx gastro intub w/asp N G2 0.6316 $26.73 43754 Dx gastr intub w/asp spec N G2 0.6316 $26.73 43755Dx gastr intub w/asp specs N G2 0.8884 $37.61 43756Dx duod intub w/asp spec N G2 1.1698 $49.52 43757Dx duod intub w/asp specs N G2 1.1698 $49.52 43760Change 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 43888Change gastric port open Y G2 20.437 $865.08 44100Biopsy

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 44360Small 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** 

## Ad**dendum A**

**A -- Proposed A** **SC 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 44363Small bowel endoscopy Y A2 9.527 $403.27 44364Small bowel endoscopy Y A2 14.848 $628.50 44365Small bowel endoscopy Y A2 14.848 $628.50 44366Small bowel endoscopy Y A2 14.848 $628.50 44369Small bowel endoscopy Y A2 14.848 $628.50 44370Small bowel endoscopy /stent Y A2 27.2035 $1,151.50 44372Small bowel endoscopy Y A2 14.848 $628.50 44373Small bowel endoscopy Y A2 14.848 $628.50 44376Small bowel endoscopy Y A2 9.527 $403.27 44377Small bowel endoscopy /biopsy Y A2 9.527 $403.27 44378Small bowel endoscopy Y A2 14.848 $628.50 44379S bowel endoscope w/stent Y A2 27.2035 $1,151.50 44380Small bowel endoscopy Y A2 9.527 $403.27 44382Small bowel endoscopy Y A2 9.527 $403.27 44383 Ileoscopy

w/stent Y A2 27.2035 $1,151.50 44385Endoscopy

of bowel pouch Y A2 8.734 $369.70 44386 Endoscopy

bowel pouch/biop Y A2 8.734 $369.70 44388Colonoscopy Y A2 8.734 $369.70 44389Colonoscopy with biopsy Y A2 8.734 $369.70 44390Colonoscopy for foreign body Y A2 8.734 $369.70 44391 Colonoscopy for bleeding Y A2 8.734 $369.70 44392Colonoscopy & polypectomy Y A2 8.734 $369.70 44393Colonoscopy lesion removal Y A2 8.734 $369.70 44394Colonoscopy w/snare Y A2 8.734 $369.70 44397Colonoscopy 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 45005Drainage of rectal abscess Y A2 22.9144 $969.94 45020 Drainage of rectal abscess Y A2 15.0188 $635.73 45100Biopsy

of rectum Y A2 22.9144 $969.94 45108Removal 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 45303Proctosigmoidoscopy dilate Y P2 10.3308 $437.29 45305Proctosigmoidoscopy w/bx Y A2 10.3308 $437.29 45307Proctosigmoidoscopy fb Y A2 22.4689 $951.09 45308Proctosigmoidoscopy removal Y A2 10.3308 $437.29 45309Proctosigmoidoscopy removal Y A2 10.3308 $437.29 45315Proctosigmoidoscopy removal Y A2 10.3308 $437.29 45317Proctosigmoidoscopy 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 45327Proctosigmoidoscopy 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 45332Sigmoidoscopy w/fb removal Y A2 5.9086 $250.11 45333Sigmoidoscopy & polypectomy Y A2 5.9086 $250.11 45334Sigmoidoscopy for bleeding Y A2 10.3308 $437.29 45335Sigmoidoscopy w/submuc inj Y A2 5.9086 $250.11 45337Sigmoidoscopy & decompress Y A2 5.9086 $250.11 45338Sigmoidoscopy w/tumr remove Y A2 5.9086 $250.11 45339Sigmoidoscopy 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** 

## Ad**dendum A**

**A -- Proposed A** **SC Covered Surgical Procedures for CY 2012 (Including Surgical Procedures for Which Payment is Packaged)** 

45340Sig w/balloon dilation Y A2 10.3308 $437.29 45341 Sigmoidoscopy w/ultrasound Y A2 5.9086 $250.11 45342Sigmoidoscopy w/us guide bx Y A2 10.3308 $437.29 45345Sigmoidoscopy w/stent Y A2 27.2035 $1,151.50 45355Surgical colonoscopy Y A2 8.734 $369.70 45378Diagnostic colonoscopy Y A2 8.734 $369.70 45379Colonoscopy w/fb removal Y A2 8.734 $369.70 45380Colonoscopy and biopsy Y A2 8.734 $369.70 45381 Colonoscopy submucous inj Y A2 8.734 $369.70 45382Colonoscopy /control bleeding Y A2 8.734 $369.70 45383Lesion removal colonoscopy Y A2 8.734 $369.70 45384Lesion remove colonoscopy Y A2 8.734 $369.70 45385Lesion removal colonoscopy Y A2 8.734 $369.70 45386Colonoscopy dilate stricture Y A2 8.734 $369.70 45387Colonoscopy w/stent Y A2 27.2035 $1,151.50 45391 Colonoscopy w/endoscope us Y A2 8.734 $369.70 45392Colonoscopy w/endoscopic fnb Y A2 8.734 $369.70 45500 Repair of rectum Y A2 22.9144 $969.94 45505Repair of rectum Y A2 30.9056 $1,308.20 45520Treatment 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 45905Dilation of anal sphincter Y A2 22.9144 $969.94 45910 Dilation of rectal narrowing Y A2 22.9144 $969.94 45915Remove rectal obstruction Y A2 15.0188 $635.73 45990Surg 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 46255Remove int/ext hem 1 group Y A2 22.9144 $969.94 46257 Remove in/ex hem grp & fiss Y A2 22.9144 $969.94 46258Remove 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 46275Remove anal fist inter Y A2 22.9144 $969.94 46280 Remove anal fist complex Y A2 22.9144 $969.94 46285Remove anal fist 2 stage Y A2 22.9144 $969.94 46288Repair 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 46505Chemodenervation anal musc Y G2 22.9144 $969.94 46600 Diagnostic anoscopy N P2 0.6316 $26.73 46604Anoscopy

and dilation Y CH P3 $391.08 46606Anoscopy

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** 

## Ad**dendum A**

**A -- Proposed A** **SC Covered Surgical Procedures for CY 2012 (Including Surgical Procedures for Which Payment is Packaged)** 

46608Anoscopy

remove for body Y A2 5.9086 $250.11 46610Anoscopy

remove lesion Y A2 22.4689 $951.09 46611 Anoscopy Y A2 10.3308 $437.29 46612Anoscopy

remove lesions Y A2 22.4689 $951.09 46614Anoscopy

control bleeding Y P3 $62.07 46615Anoscopy 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 46916Cryosurgery anal lesion(s) Y P2 1.4 $59.26 46917Laser 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 46940Treatment of anal fissure Y P3 $92.74 46942Treatment of anal fissure Y P3 $90.34 46945Remove 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 47525Change 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 47553Biliary

endoscopy thru skin Y A2 29.3168 $1,240.95 47554Biliary

endoscopy thru skin Y A2 29.3168 $1,240.95 47555Biliary

endoscopy thru skin Y A2 29.3168 $1,240.95 47556Biliary

endoscopy thru skin Y A2 29.3168 $1,240.95 47560Laparoscopy

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 47563Laparo cholecystectomy/graph Y G2 44.7246 $1,893.15 47564Laparo 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 49180Biopsy

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 49324Lap insert tunnel ip cath Y G2 36.6358 $1,550.76 49325Lap revision perm ip cath Y G2 36.6358 $1,550.76 49326Lap 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** 

## Ad**dendum A**

**A -- Proposed A** **SC Covered Surgical Procedures for CY 2012 (Including Surgical Procedures for Which Payment is Packaged)** 

49327Lap ins device for rt Y G2 36.6358 $1,550.76 49400Air 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 49424Assess cyst contrast inject N N1 49426 Revise abdomen-venous shunt Y A2 24.9768 $1,057.24 49427 Injection abdominal shunt N N1 49429Removal 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 49446Change 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 49465Fluoro exam of g/colon tube N N1 49495Rpr 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 49505Prp i/hern init reduc >5 yr Y A2 30.9069 $1,308.26 49507Prp 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 49525Repair 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 49555Rerepair 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 49565Rerepair 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 49585Rpr 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 49650Lap 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 49653Lap vent/abd hern proc comp Y G2 66.5906 $2,818.71 49654Lap inc hernia repair Y G2 66.5906 $2,818.71 49655Lap inc hern repair comp Y G2 66.5906 $2,818.71 49656Lap 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** 

## Ad**dendum A**

**A -- Proposed A** **SC Covered Surgical Procedures for CY 2012 (Including Surgical Procedures for Which Payment is Packaged)** 

49657Lap 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 50382Change ureter stent percut Y G2 24.6219 $1,042.22 50384 Remove ureter stent percut Y G2 16.5657 $701.21 50385Change stent via transureth Y G2 24.6219 $1,042.22 50386 Remove stent via transureth Y P2 6.898 $291.99 50387Change ext/int ureter stent Y G2 15.1986 $643.34 50389Remove 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 50395Create passage to kidney Y A2 24.6219 $1,042.22 50396Measure kidney pressure Y A2 1.9658 $83.21 50398Change kidney tube Y A2 15.1986 $643.34 50551 Kidney

endoscopy Y A2 6.898 $291.99 50553Kidney

endoscopy Y A2 24.6219 $1,042.22 50555Kidney

endoscopy & biopsy Y A2 6.898 $291.99 50557Kidney

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 50570Kidney

endoscopy Y G2 6.898 $291.99 50572 Kidney

endoscopy Y G2 6.898 $291.99 50574Kidney

endoscopy & biopsy Y G2 6.898 $291.99 50575Kidney

endoscopy Y G2 34.6431 $1,466.41 50576Kidney

endoscopy & treatment Y G2 16.5657 $701.21 50580Kidney

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 50593Perc cryo ablate renal tum Y G2 53.5857 $2,268.23 50684 Injection for ureter x-ray N N1 50686Measure ureter pressure Y P2 1.0965 $46.41 50688Change 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 50947Laparo new ureter/bladder Y A2 44.7246 $1,893.15 50948Laparo 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 50955Ureter 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 51065Remove 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** 

## Ad**dendum A**

**A -- Proposed A** **SC 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 51535Repair of ureter lesion Y G2 24.6219 $1,042.22 51600 Injection for bladder x-ray N N1 51605Preparation 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 51705Change of bladder tube Y P3 $38.34 51710Change of bladder tube Y A2 5.9217 $250.66 51715Endoscopic injection/implant Y A2 30.0914 $1,273.74 51720Treatment of bladder lesion Y P3 $38.58 51725Simple cystometrogram Y CH P3 $85.55 51726Complex cystometrogram Y A2 2.9971 $126.86 51727Cystometrogram w/up Y P2 2.9971 $126.86 51728Cystometrogram w/vp Y P2 2.9971 $126.86 51729Cystometrogram 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 51784Anal/urinary

muscle study Y P2 1.0965 $46.41 51785Anal/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 51798Us 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 52000Cystoscopy Y A2 6.898 $291.99 52001 Cystoscopy removal of clots Y A2 16.5657 $701.21 52005Cystoscopy & ureter catheter Y A2 24.6219 $1,042.22 52007Cystoscopy and biopsy Y A2 24.6219 $1,042.22 52010Cystoscopy & duct catheter Y A2 6.898 $291.99 52204Cystoscopy w/biopsy(s) Y A2 24.6219 $1,042.22 52214Cystoscopy and treatment Y A2 24.6219 $1,042.22 52224Cystoscopy and treatment Y A2 24.6219 $1,042.22 52234Cystoscopy and treatment Y A2 24.6219 $1,042.22 52235Cystoscopy and treatment Y A2 24.6219 $1,042.22 52240Cystoscopy and treatment Y A2 24.6219 $1,042.22 52250Cystoscopy and radiotracer Y A2 24.6219 $1,042.22 52260Cystoscopy and treatment Y A2 16.5657 $701.21 52265Cystoscopy and treatment Y CH P3 $193.63 52270Cystoscopy & revise urethra Y A2 16.5657 $701.21 52275Cystoscopy & revise urethra Y A2 24.6219 $1,042.22 52276Cystoscopy and treatment Y A2 24.6219 $1,042.22 52277Cystoscopy and treatment Y A2 24.6219 $1,042.22 52281 Cystoscopy and treatment Y A2 16.5657 $701.21 52282Cystoscopy implant stent Y A2 34.6431 $1,466.41 52283Cystoscopy and treatment Y A2 24.6219 $1,042.22 52285Cystoscopy and treatment Y A2 16.5657 $701.21 52290Cystoscopy and treatment Y A2 24.6219 $1,042.22 52300Cystoscopy and treatment Y A2 24.6219 $1,042.22 52301 Cystoscopy and treatment Y A2 24.6219 $1,042.22 52305Cystoscopy and treatment Y A2 24.6219 $1,042.22 52310Cystoscopy and treatment Y A2 16.5657 $701.21 52315Cystoscopy 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** 

## Ad**dendum A**

**A -- Proposed A** **SC 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 52318Remove bladder stone Y A2 24.6219 $1,042.22 52320Cystoscopy and treatment Y A2 24.6219 $1,042.22 52325Cystoscopy stone removal Y A2 24.6219 $1,042.22 52327Cystoscopy inject material Y A2 34.6431 $1,466.41 52330Cystoscopy and treatment Y A2 24.6219 $1,042.22 52332Cystoscopy and treatment Y A2 24.6219 $1,042.22 52334Create passage to kidney Y A2 24.6219 $1,042.22 52341 Cysto w/ureter stricture tx Y A2 24.6219 $1,042.22 52342Cysto w/up stricture tx Y A2 24.6219 $1,042.22 52343Cysto w/renal stricture tx Y A2 24.6219 $1,042.22 52344Cysto/uretero stricture tx Y A2 24.6219 $1,042.22 52345Cysto/uretero w/up stricture Y A2 24.6219 $1,042.22 52346Cystouretero w/renal strict Y A2 24.6219 $1,042.22 52351 Cystouretero & or pyeloscope Y A2 24.6219 $1,042.22 52352Cystouretero w/stone remove Y A2 24.6219 $1,042.22 52353Cystouretero w/lithotripsy Y A2 34.6431 $1,466.41 52354Cystouretero w/biopsy Y A2 24.6219 $1,042.22 52355Cystouretero w/excise tumor Y A2 24.6219 $1,042.22 52400Cystouretero w/congen repr Y A2 24.6219 $1,042.22 52402Cystourethro 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 52647Laser surgery of prostate Y A2 42.989 $1,819.68 52648Laser surgery of prostate Y A2 42.989 $1,819.68 52649Prostate 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 53085Drainage of urinary leakage Y G2 19.4946 $825.19 53200Biopsy

of urethra Y A2 19.4946 $825.19 53210 Removal of urethra Y A2 30.0914 $1,273.74 53215Removal of urethra Y A2 19.4946 $825.19 53220Treatment of urethra lesion Y A2 30.0914 $1,273.74 53230 Removal of urethra lesion Y A2 30.0914 $1,273.74 53235Removal of urethra lesion Y A2 19.4946 $825.19 53240Surgery for urethra pouch Y A2 30.0914 $1,273.74 53250 Removal of urethra gland Y A2 19.4946 $825.19 53260Treatment of urethra lesion Y A2 19.4946 $825.19 53265Treatment of urethra lesion Y A2 19.4946 $825.19 53270 Removal of urethra gland Y A2 19.4946 $825.19 53275Repair of urethra defect Y A2 19.4946 $825.19 53400 Revise urethra stage 1 Y A2 30.0914 $1,273.74 53405Revise 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 53425Reconstruct 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 53440Male 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** 

## Ad**dendum A**

**A -- Proposed A** **SC 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 53449Repair 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 53505Repair of urethra injury Y A2 30.0914 $1,273.74 53510 Repair of urethra injury Y A2 19.4946 $825.19 53515Repair 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 53605Dilate 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 53665Dilation 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 53860Transurethral rf treatment Y G2 18.9297 $801.28 54000Slitting of prepuce Y A2 19.4946 $825.19 54001 Slitting of prepuce Y A2 19.4946 $825.19 54015Drain penis lesion Y A2 19.2522 $814.93 54050 Destruction penis lesion(s) Y P2 0.9172 $38.82 54055Destruction penis lesion(s) Y P3 $50.08 54056Cryosurgery penis lesion(s) Y P2 0.9172 $38.82 54057Laser surg penis lesion(s) Y A2 20.6797 $875.35 54060 Excision of penis lesion(s) Y A2 20.6797 $875.35 54065Destruction penis lesion(s) Y A2 20.6797 $875.35 54100Biopsy

of penis Y A2 16.113 $682.05 54105Biopsy

of penis Y A2 21.9487 $929.07 54110Treatment of penis lesion Y A2 32.2247 $1,364.04 54111 Treat penis lesion graft Y A2 32.2247 $1,364.04 54112Treat penis lesion graft Y A2 32.2247 $1,364.04 54115Treatment of penis lesion Y A2 19.2522 $814.93 54120 Partial removal of penis Y A2 32.2247 $1,364.04 54150Circumcision w/regionl block Y A2 22.236 $941.23 54160Circumcision 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 54200Treatment of penis lesion Y P3 $47.45 54205Treatment of penis lesion Y A2 32.2247 $1,364.04 54220Treatment of penis lesion Y A2 1.9658 $83.21 54230 Prepare penis study N N1 54231 Dynamic cavernosometry Y P3 $45.53 54235Penile 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 54308Reconstruction 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** 

## Ad**dendum A**

**A -- Proposed A** **SC 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 54318Reconstruction 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 54328Revise penis/urethra Y A2 32.2247 $1,364.04 54340Secondary

urethral surgery Y A2 32.2247 $1,364.04 54344Secondary

urethral surgery Y A2 32.2247 $1,364.04 54348Secondary

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 54385Repair 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 54408Repair multi-comp penis pros Y A2 32.2247 $1,364.04 54410 Remove/replace penis prosth N CH J8 241.3804 $10,217.39 54415Remove 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 54435Revision 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 54500Biopsy

of testis Y A2 14.3964 $609.39 54505Biopsy

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 54522Orchiectomy

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 54620Suspension of testis Y A2 22.236 $941.23 54640Suspension 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 54690Laparoscopy

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 54800Biopsy

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 54865Explore 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** 

## Ad**dendum A**

**A -- Proposed A** **SC Covered Surgical Procedures for CY 2012 (Including Surgical Procedures for Which Payment is Packaged)** 

55150 Removal of scrotum Y A2 22.236 $941.23 55175Revision 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 55450Ligation 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 55535Revise spermatic cord veins Y A2 30.9069 $1,308.26 55540 Revise hernia & sperm veins Y A2 30.9069 $1,308.26 55550Laparo 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 55700Biopsy

of prostate Y A2 13.3543 $565.27 55705Biopsy

of prostate Y A2 13.3543 $565.27 55706Prostate saturation sampling Y G2 13.3543 $565.27 55720 Drainage of prostate abscess Y A2 24.6219 $1,042.22 55725Drainage of prostate abscess Y A2 24.6219 $1,042.22 55860Surgical exposure prostate Y G2 18.9297 $801.28 55870 Electroejaculation Y P3 $56.07 55873Cryoablate prostate Y CH J8 148.617 $6,290.81 55875Transperi needle place pros N A2 34.6431 $1,466.41 55876Place 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 56440Surgery 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 56515Destroy vulva lesion/s compl Y A2 20.6797 $875.35 56605Biopsy

of vulva/perineum Y P3 $28.04 56606Biopsy

of vulva/perineum Y P3 $11.50 56620 Partial removal of vulva Y A2 19.4744 $824.33 56625Complete 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 56805Repair 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 57065Destroy vag lesions complex Y A2 19.4744 $824.33 57100Biopsy

of vagina Y P3 $29.24 57105Biopsy

of vagina Y A2 19.4744 $824.33 57130 Remove vagina lesion Y A2 19.4744 $824.33 57135Remove vagina lesion Y A2 19.4744 $824.33 57150Treat 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** 

## Ad**dendum A**

**A -- Proposed A** **SC 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 57180Treat 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 57265Extensive repair of vagina Y A2 42.7236 $1,808.45 57267 Insert mesh/pelvic flr addon Y A2 33.6791 $1,425.60 57268Repair of bowel bulge Y A2 33.6791 $1,425.60 57287 Revise/remove sling repair Y G2 33.6791 $1,425.60 57288Repair bladder defect Y A2 42.7236 $1,808.45 57289Repair bladder & vagina Y A2 33.6791 $1,425.60 57291 Construction of vagina Y A2 33.6791 $1,425.60 57295Revise 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 57415Remove 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 57454Bx/curett of cervix w/scope Y P3 $44.33 57455Biopsy

of cervix w/scope Y P3 $46.25 57456 Endocerv curettage w/scope Y P3 $44.57 57460Bx of cervix w/scope leep Y P3 $125.33 57461 Conz of cervix w/scope leep Y P3 $134.44 57500Biopsy

of cervix Y P3 $58.23 57505Endocervical curettage Y P3 $39.30 57510Cauterization of cervix Y P3 $40.50 57511 Cryocautery of cervix Y CH P3 $49.13 57513Laser surgery of cervix Y A2 19.4744 $824.33 57520Conization of cervix Y A2 19.4744 $824.33 57522Conization 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 57558D&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 58100Biopsy

of uterus lining Y P3 $35.23 58110Bx done w/colposcopy add-on N N1 58120 Dilation and curettage Y A2 19.4744 $824.33 58145Myomectomy vag method Y A2 33.6791 $1,425.60 58301 Remove intrauterine device Y P3 $32.35 58321 Artificial insemination Y P3 $29.24 58322Artificial insemination Y P3 $30.67 58323Sperm washing Y P3 $5.27 58340Catheter for hysterography N N1 58345Reopen 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** 

## Ad**dendum A**

**A -- Proposed A** **SC 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 58545Laparoscopic myomectomy Y A2 36.6358 $1,550.76 58546Laparo-myomectomy complex Y A2 44.7246 $1,893.15 58550Laparo-asst vag hysterectomy Y A2 66.5906 $2,818.71 58552 Laparo-vag hyst incl t/o Y G2 44.7246 $1,893.15 58555Hysteroscopy 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 58565Hysteroscopy sterilization Y A2 42.7236 $1,808.45 58600 Division of fallopian tube Y G2 33.6791 $1,425.60 58615Occlude fallopian tube(s) Y G2 19.4744 $824.33 58660Laparoscopy

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 58670Laparoscopy

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 58673Laparoscopy

salpingostomy Y A2 44.7246 $1,893.15 58800 Drainage of ovarian cyst(s) Y A2 19.4744 $824.33 58805Drainage of ovarian cyst(s) Y G2 33.6791 $1,425.60 58820 Drain ovary

abscess open Y A2 33.6791 $1,425.60 58900Biopsy

of ovary(s) Y A2 19.4744 $824.33 58970 Retrieval of oocyte Y A2 3.3856 $143.31 58974Transfer of embryo Y A2 3.3856 $143.31 58976Transfer of embryo Y A2 3.3856 $143.31 59000Amniocentesis 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 59015Chorion biopsy Y P3 $44.33 59020 Fetal contract stress test Y P3 $23.24 59025Fetal non-stress test Y P3 $12.70 59070Transabdom 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 59150Treat 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 59412Antepartum manipulation Y G2 19.4744 $824.33 59414 Deliver placenta Y G2 19.4744 $824.33 59812Treatment of miscarriage Y A2 19.4744 $824.33 59820Care of miscarriage Y A2 19.4744 $824.33 59821 Treatment of miscarriage Y A2 19.4744 $824.33 59840Abortion Y A2 19.4744 $824.33 59841 Abortion Y A2 19.4744 $824.33 59866Abortion (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** 

## Ad**dendum A**

**A -- Proposed A** **SC Covered Surgical Procedures for CY 2012 (Including Surgical Procedures for Which Payment is Packaged)** 

60100Biopsy

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 60225Partial 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 60300Aspir/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 61070Brain 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 61782Scan proc cranial extra N N1 61783Scan proc spinal N N1 61790Treat 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 61888Revise/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 62225Replace/irrigate catheter Y A2 15.1986 $643.34 62230 Replace/revise brain shunt Y A2 39.8529 $1,686.93 62252Csf 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 62268Drain spinal cord cyst Y A2 7.0747 $299.46 62269Needle biopsy spinal cord Y A2 9.1181 $385.96 62270Spinal 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 62280Treat spinal cord lesion Y A2 7.0747 $299.46 62281 Treat spinal cord lesion Y A2 12.0974 $512.07 62282Treat spinal canal lesion Y A2 12.0974 $512.07 62284 Injection for myelogram N N1 62287Percutaneous 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 62355Remove 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** 

## Ad**dendum A**

**A -- Proposed A** **SC 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 62365Remove spine infusion device Y A2 35.0613 $1,484.11 62367Analyze spine infusion pump N P3 $16.77 62368Analyze spine infusion pump N P3 $23.00 63600 Remove spinal cord lesion Y A2 17.8674 $756.31 63610Stimulation of spinal cord Y A2 17.8674 $756.31 63615Remove 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 63688Revise/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 64405N block inj occipital Y P3 $40.98 64408N 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 64413N block inj cervical plexus Y P3 $47.93 64415N block inj brachial plexus Y A2 3.6902 $156.20 64416N block cont infuse b plex Y G2 7.0747 $299.46 64417N block inj axillary Y A2 3.6902 $156.20 64418N 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 64425N block inj ilio-ing/hypogi Y P3 $47.21 64430 N block inj pudendal Y A2 7.0747 $299.46 64435N block inj paracervical Y P3 $57.99 64445N block inj sciatic sng Y P3 $55.60 64446N blk inj sciatic cont inf Y G2 7.0747 $299.46 64447N block inj fem single Y P3 $46.73 64448N block inj fem cont inf Y G2 7.0747 $299.46 64449N block inj lumbar plexus Y G2 7.0747 $299.46 64450 N block other peripheral Y P3 $40.98 64455N 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 64505N block spenopalatine gangl Y P3 $35.47 64508N block carotid sinus s/p Y P3 $22.53 64510 N block stellate ganglion Y A2 7.0747 $299.46 64517N 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** 

## Ad**dendum A**

**A -- Proposed A** **SC 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 64566Neuroeltrd stim post tibial Y G2 2.5957 $109.87 64568 Inc for vagus n elect impl N J8 519.6534 $21,996.41 64569Revise/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 64585Revise/remove neuroelectrode Y A2 19.4458 $823.12 64590 Insrt/redo pn/gastr stimul N CH J8 322.5018 $13,651.18 64595Revise/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 64613Destroy 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 64623Destr paravertebral n add-on Y A2 7.0747 $299.46 64626Destr paravertebrl nerve c/t Y A2 12.0974 $512.07 64627Destr 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 64650Chemodenerv eccrine glands Y P3 $57.03 64653Chemodenerv 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 64708Revise 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 64718Revise ulnar nerve at elbow Y A2 17.8674 $756.31 64719Revise 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** 

## Ad**dendum A**

**A -- Proposed A** **SC 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 64778Digit nerve surgery add-on Y A2 17.8674 $756.31 64782 Remove limb nerve lesion Y A2 17.8674 $756.31 64783Limb 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 64788Remove 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 64795Biopsy

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 64835Repair 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 64858Repair sciatic nerve Y A2 35.0613 $1,484.11 64859Nerve 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 64865Repair of facial nerve Y A2 35.0613 $1,484.11 64870 Fusion of facial/other nerve Y A2 35.0613 $1,484.11 64872Subsequent 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 64885Nerve graft head or neck Y A2 35.0613 $1,484.11 64886Nerve 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 64893Nerve graft arm or leg Y A2 35.0613 $1,484.11 64895Nerve graft hand or foot Y A2 35.0613 $1,484.11 64896Nerve graft hand or foot Y A2 35.0613 $1,484.11 64897Nerve graft arm or leg Y A2 35.0613 $1,484.11 64898Nerve 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 64905Nerve pedicle transfer Y A2 35.0613 $1,484.11 64907Nerve 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 65105Remove 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** 

## Ad**dendum A**

**A -- Proposed A** **SC 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 65125Revise 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 65140Attach ocular implant Y A2 38.3708 $1,624.20 65150 Revise ocular implant Y A2 25.3533 $1,073.18 65155Reinsert ocular implant Y A2 38.3708 $1,624.20 65175Removal of ocular implant Y A2 19.0333 $805.66 65205Remove 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 65235Remove foreign body from eye Y A2 15.8195 $669.62 65260 Remove foreign body from eye Y A2 4.6051 $194.93 65265Remove 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 65275Repair of eye wound Y A2 23.6808 $1,002.38 65280 Repair of eye wound Y A2 21.3578 $904.05 65285Repair 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 65410Biopsy

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 65430Corneal smear N CH P3 $39.54 65435Curette/treat cornea Y P3 $30.19 65436Curette/treat cornea Y P3 $136.35 65450Treatment of corneal lesion N G2 2.164 $91.60 65600 Revision of cornea Y P3 $157.20 65710Corneal transplant Y A2 36.0588 $1,526.33 65730Corneal transplant Y A2 36.0588 $1,526.33 65750Corneal transplant Y A2 36.0588 $1,526.33 65755Corneal transplant Y A2 36.0588 $1,526.33 65756Corneal trnspl endothelial Y G2 36.0588 $1,526.33 65757Prep corneal endo allograft N N1 65770 Revise cornea with implant Y CH J8 166.0519 $7,028.81 65772Correction of astigmatism Y A2 15.8195 $669.62 65775Correction of astigmatism Y A2 15.8195 $669.62 65778Cover eye w/membrane Y G2 15.8195 $669.62 65779Cover eye w/membrane suture Y G2 15.8195 $669.62 65780Ocular reconst transplant Y A2 36.0588 $1,526.33 65781 Ocular reconst transplant Y A2 36.0588 $1,526.33 65782Ocular reconst transplant Y A2 36.0588 $1,526.33 65800 Drainage of eye Y A2 7.3589 $311.49 65805Drainage of eye Y A2 23.6808 $1,002.38 65810 Drainage of eye Y A2 23.6808 $1,002.38 65815Drainage 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 65855Laser 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** 

## Ad**dendum A**

**A -- Proposed A** **SC 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 66150Glaucoma surgery Y A2 23.6808 $1,002.38 66155Glaucoma surgery Y A2 23.6808 $1,002.38 66160Glaucoma surgery Y A2 23.6808 $1,002.38 66165Glaucoma surgery Y A2 23.6808 $1,002.38 66170Glaucoma surgery Y A2 23.6808 $1,002.38 66172 Incision of eye Y A2 23.6808 $1,002.38 66174Translum dil eye canal Y A2 39.1634 $1,657.75 66175Trnslum dil eye canal w/stnt Y A2 39.1634 $1,657.75 66180 Implant eye shunt Y A2 39.1634 $1,657.75 66185Revise eye shunt Y A2 23.6808 $1,002.38 66220 Repair eye lesion Y A2 38.7337 $1,639.56 66225Repair/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 66605Removal of iris Y A2 23.6808 $1,002.38 66625Removal of iris Y A2 7.3589 $311.49 66630 Removal of iris Y A2 23.6808 $1,002.38 66635Removal 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 66710Ciliary

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 66825Reposition 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 66982Cataract surgery complex Y A2 22.51 $952.83 66983Cataract surg w/iol 1 stage Y A2 22.51 $952.83 66984Cataract 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 66990Ophthalmic endoscope add-on N N1 67005Partial removal of eye fluid Y A2 21.3578 $904.05 67010 Partial removal of eye fluid Y A2 38.7337 $1,639.56 67015Release of eye fluid Y A2 38.7337 $1,639.56 67025Replace 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** 

## Ad**dendum A**

**A -- Proposed A** **SC 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 67039Laser treatment of retina Y A2 38.7337 $1,639.56 67040Laser treatment of retina Y A2 38.7337 $1,639.56 67041 Vit for macular pucker Y G2 38.7337 $1,639.56 67042Vit for macular hole Y G2 38.7337 $1,639.56 67043Vit for membrane dissect Y G2 38.7337 $1,639.56 67101 Repair detached retina Y P3 $300.50 67105Repair detached retina Y P2 5.2302 $221.39 67107 Repair detached retina Y A2 38.7337 $1,639.56 67108Repair 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 67115Release 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 67145Treatment of retina Y CH P3 $191.95 67208Treatment of retinal lesion Y P2 4.6051 $194.93 67210Treatment of retinal lesion Y CH P3 $220.70 67218Treatment of retinal lesion Y A2 21.3578 $904.05 67220Treatment of choroid lesion Y P2 4.6051 $194.93 67221 Ocular photodynamic ther Y P3 $106.40 67225Eye photodynamic ther add-on Y P3 $8.15 67227Treatment of retinal lesion Y A2 21.3578 $904.05 67228Treatment 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 67255Reinforce/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 67318Revise 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 67335Eye 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 67345Destroy nerve of eye muscle Y P3 $81.00 67346Biopsy

eye muscle Y A2 14.635 $619.48 67400 Explore/biopsy eye socket Y A2 19.0333 $805.66 67405Explore/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 67415Aspiration 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 67445Explr/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** 

## Ad**dendum A**

**A -- Proposed A** **SC 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 67805Remove eyelid lesions Y P3 $77.40 67808Remove eyelid lesion(s) Y A2 19.0333 $805.66 67810Biopsy

of eyelid Y CH P3 $110.47 67820 Revise eyelashes N P3 $15.82 67825Revise eyelashes Y P3 $49.60 67830 Revise eyelashes Y A2 7.788 $329.66 67835Revise eyelashes Y A2 19.0333 $805.66 67840 Remove eyelid lesion Y P3 $132.52 67850Treat eyelid lesion Y P3 $102.80 67875Closure 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 67908Repair eyelid defect Y A2 19.0333 $805.66 67909Revise eyelid defect Y A2 19.0333 $805.66 67911 Revise eyelid defect Y A2 19.0333 $805.66 67912Correction eyelid w/implant Y A2 19.0333 $805.66 67914 Repair eyelid defect Y A2 19.0333 $805.66 67915Repair 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 67935Repair eyelid wound Y A2 19.0333 $805.66 67938Remove 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 67975Reconstruction of eyelid Y A2 19.0333 $805.66 68020 Incise/drain eyelid lining Y P3 $44.09 68040Treatment of eyelid lesions N P3 $21.81 68100Biopsy

of eyelid lining Y P3 $79.80 68110 Remove eyelid lining lesion Y P3 $105.20 68115Remove eyelid lining lesion Y A2 19.0333 $805.66 68130 Remove eyelid lining lesion Y A2 15.8195 $669.62 68135Remove eyelid lining lesion Y P3 $56.79 68200Treat 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** 

## Ad**dendum A**

**A -- Proposed A** **SC 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 68325Revise/graft eyelid lining Y A2 25.3533 $1,073.18 68326 Revise/graft eyelid lining Y A2 19.0333 $805.66 68328Revise/graft eyelid lining Y A2 25.3533 $1,073.18 68330 Revise eyelid lining Y A2 23.6808 $1,002.38 68335Revise/graft eyelid lining Y A2 25.3533 $1,073.18 68340Separate 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 68505Partial removal tear gland Y A2 25.3533 $1,073.18 68510Biopsy

of tear gland Y A2 19.0333 $805.66 68520 Removal of tear sac Y A2 25.3533 $1,073.18 68525Biopsy

of tear sac Y A2 19.0333 $805.66 68530Clearance 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 68705Revise tear duct opening Y CH P3 $104.96 68720Create tear sac drain Y A2 25.3533 $1,073.18 68745Create tear duct drain Y A2 25.3533 $1,073.18 68750Create tear duct drain Y A2 25.3533 $1,073.18 68760Close tear duct opening Y P3 $89.62 68761 Close tear duct opening Y P3 $63.26 68770Close 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 68815Probe nasolacrimal duct Y A2 19.0333 $805.66 68816Probe 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 69005Drain external ear lesion Y P3 $94.66 69020 Drain outer ear canal lesion Y P2 1.3573 $57.45 69100Biopsy

of external ear Y P3 $50.08 69105Biopsy

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 69145Remove ear canal lesion(s) Y A2 16.113 $682.05 69150 Extensive ear canal surgery Y A2 7.5315 $318.80 69200Clear outer ear canal N P2 0.6316 $26.73 69205Clear outer ear canal Y A2 21.9487 $929.07 69210 Remove impacted ear wax N CH P3 $19.65 69220Clean out mastoid cavity Y P2 0.9172 $38.82 69222Clean 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 69405Catheterize 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** 

## Ad**dendum A**

**A -- Proposed A** **SC 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 69433Create eardrum opening Y P3 $101.37 69436Create 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 69505Remove 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 69603Mastoid surgery revision Y A2 42.299 $1,790.47 69604Mastoid surgery revision Y A2 42.299 $1,790.47 69605Mastoid 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 69635Repair 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 69645Revise 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 69700Close 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 69715Temple bne implnt w/stimulat Y CH J8 177.1433 $7,498.30 69717Temple bone implant revision Y CH J8 177.1433 $7,498.30 69718Revise 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 69745Repair 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 69805Explore 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 69905Remove 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** 

## Ad**dendum A**

**A -- Proposed A** **SC 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 69990Microsurgery add-on N N1 C9716Radiofrequency energy to anu Y G2 30.9056 $1,308.20 C9724EPS gast cardia plic Y G2 23.8908 $1,011.27 C9725Place endorectal app Y G2 5.7224 $242.22 C9726Rxt breast appl place/remov Y G2 24.2182 $1,025.13 C9727Insert palate implants Y G2 7.5315 $318.80 C9728Place 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 G0127Trim nail(s) Y P3 $11.26 G0186Dstry eye lesn,fdr vssl tech Y R2 4.6051 $194.93 G0247Routine footcare pt w lops Y CH P3 $37.14 G0259Inject for sacroiliac joint N N1 G0260Inj for sacroiliac jt anesth Y A2 7.0747 $299.46 G0268Removal of impacted wax md N N1 G0269Occlusive device in vein art N N1 G0289Arthro, loose body + chondro N N1 G0364Bone 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 

### Ad**dendum BB -- Proposed A SC Covered A** **ncillary Services Integral to Covered Surgical Procedures for CY 2012 (Including A** **ncillary 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** 

### Ad**dendum BB -- Proposed A SC Covered A** **ncillary Services Integral to Covered Surgical Procedures for CY 2012 (Including A** **ncillary 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** 

### Ad**dendum BB -- Proposed A SC Covered A** **ncillary Services Integral to Covered Surgical Procedures for CY 2012 (Including A** **ncillary 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** 

### Ad**dendum BB -- Proposed A SC Covered A** **ncillary Services Integral to Covered Surgical Procedures for CY 2012 (Including A** **ncillary 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** 

### Ad**dendum BB -- Proposed A SC Covered A** **ncillary Services Integral to Covered Surgical Procedures for CY 2012 (Including A** **ncillary 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** 

### Ad**dendum BB -- Proposed A SC Covered A** **ncillary Services Integral to Covered Surgical Procedures for CY 2012 (Including A** **ncillary 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** 

### Ad**dendum BB -- Proposed A SC Covered A** **ncillary Services Integral to Covered Surgical Procedures for CY 2012 (Including A** **ncillary 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** 

### Ad**dendum BB -- Proposed A SC Covered A** **ncillary Services Integral to Covered Surgical Procedures for CY 2012 (Including A** **ncillary 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** 

### Ad**dendum BB -- Proposed A SC Covered A** **ncillary Services Integral to Covered Surgical Procedures for CY 2012 (Including A** **ncillary 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** 

### Ad**dendum BB -- Proposed A SC Covered A** **ncillary Services Integral to Covered Surgical Procedures for CY 2012 (Including A** **ncillary 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** 

### Ad**dendum BB -- Proposed A SC Covered A** **ncillary Services Integral to Covered Surgical Procedures for CY 2012 (Including A** **ncillary 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** 

### Ad**dendum BB -- Proposed A SC Covered A** **ncillary Services Integral to Covered Surgical Procedures for CY 2012 (Including A** **ncillary 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** 

### Ad**dendum BB -- Proposed A SC Covered A** **ncillary Services Integral to Covered Surgical Procedures for CY 2012 (Including A** **ncillary 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** 

### Ad**dendum BB -- Proposed A SC Covered A** **ncillary Services Integral to Covered Surgical Procedures for CY 2012 (Including A** **ncillary 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** 

### Ad**dendum BB -- Proposed A SC Covered A** **ncillary Services Integral to Covered Surgical Procedures for CY 2012 (Including A** **ncillary 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** 

### Ad**dendum BB -- Proposed A SC Covered A** **ncillary Services Integral to Covered Surgical Procedures for CY 2012 (Including A** **ncillary 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 Cy

tomegalovirus 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** 

### Ad**dendum BB -- Proposed A SC Covered A** **ncillary Services Integral to Covered Surgical Procedures for CY 2012 (Including A** **ncillary 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** 

### Ad**dendum BB -- Proposed A SC Covered A** **ncillary Services Integral to Covered Surgical Procedures for CY 2012 (Including A** **ncillary 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** 

### Ad**dendum BB -- Proposed A SC Covered A** **ncillary Services Integral to Covered Surgical Procedures for CY 2012 (Including A** **ncillary 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** 

### Ad**dendum BB -- Proposed A SC Covered A** **ncillary Services Integral to Covered Surgical Procedures for CY 2012 (Including A** **ncillary 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** 

### Ad**dendum BB -- Proposed A SC Covered A** **ncillary Services Integral to Covered Surgical Procedures for CY 2012 (Including A** **ncillary 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** 

### Ad**dendum BB -- Proposed A SC Covered A** **ncillary Services Integral to Covered Surgical Procedures for CY 2012 (Including A** **ncillary 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 Cy

tarabine liposome inj K2 $479.02 J9100 Cy

tarabine 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** 

### Ad**dendum BB -- Proposed A SC Covered A** **ncillary Services Integral to Covered Surgical Procedures for CY 2012 (Including A** **ncillary 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** 

### Ad**dendum BB -- Proposed A SC Covered A** **ncillary Services Integral to Covered Surgical Procedures for CY 2012 (Including A** **ncillary 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; pay ment based on OPPS relative payment weight.

H2 Brachy

therapy 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. 

## Ad**dendum DD1 -- Proposed A SC Pay** **ment 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. 

## Ad**dendum DD2 -- Proposed A SC Comment Indicators for CY 2012**