Wyo. Code R. 053-0021-9
Workers' Compensation Division
Chapter 9: Fee Schedules
Effective Date: 12/12/2017 to 05/23/2018
Rule Type: Superceded Rules & Regulations
Reference Number: 053.0021.9.12122017
Section 1. General Guidelines. Pursuant to Wyoming Statutes § 27-14-401(b), (e), and (g) medical and or hospital care shall be reviewed for appropriateness and reasonableness and shall be reimbursed according to the adopted schedule(s). The following guidelines are applicable to each section within this chapter.
(a) All claims shall be paid in accordance with the fee schedule in effect at the time of service.
(b) Certain services may be subject to preauthorization pursuant to Chapter 10 of these rules. These guidelines can be found at: http://www.wyomingworkforce.org/providers/preauth/
(c) The Division shall use accepted medical resources and publications to aid in adjudicating bills. This shall include, but not be limited to, the American Medical Association (AMA) (2017), Current Procedural Terminology codebook (CPT) (2017), the AMA Knowledge Base System (2017), and The American Academy of Orthopaedic Surgeons (2017), Complete Global Values Service Data for Orthopaedic Surgery Guidelines (2017), and the Division's medical advisors.
(d) The Division may change billed codes to achieve compliance with the current rules and regulations. The provider payment statement shall advise of code changes and the right to appeal.
(e) Codes designated as Relativity Not Establish (RNE), or By Report (BR) shall be assigned the unit value of a comparable procedure or procedures.
(f) In no case shall any provider bill for charges greater than those charged the general public for like services.
(g) The Division shall not pay more than the total billed amount.
(a) The Division adopts Optum360 (2017ed.) formerly known as Relative Values for Physicians (RVP), as published by Optum360, LLC, as authored by Relative Value Studies, Inc., insofar as it addresses medical matters under the Act unless otherwise defined in this chapter. The Division adopts Optum360 (2017 ed.) formerly known as the Relative Values for Dentists, (RVD), as published and authored by Relative Value Studies, Inc., Thornton, Colorado, insofar as it addresses dental matters under the Act. Adoption of the RVP and RVD shall be effective July 1, 2017. See Chapter 9, Section 1 for additional guidelines.
(i) The Division has determined that incorporation of the full text in these rules would be cumbersome or inefficient given the length or nature of the rules;
(ii) The incorporation by reference does not include any later amendments or editions of the incorporated matter beyond the applicable date identified in subsection a of this section;
(iii) The incorporated code, standard, rule or regulation is maintained at 1510 East Pershing, Cheyenne, WY 82002 and is available for public inspection and copying at cost at the same location.
(b) Each code incorporated by reference in these rules is further identified as follows:
(i) Optum 360, (2017 ed.), is adopted by the Division effective July 1, 2017.
(c) Conversion Factors. The Division adopts the following conversion factors.
| SPECIALTY GROUP | CONVERSION FACTOR |
|---|---|
| Anesthesia | $ 51.12 |
| Surgery | $ 120.21 |
| Radiology/Nuclear Medicine | $ 21.97 |
| Pathology/Laboratory | $ 15.23 |
| Medicine | $ 7.91 |
| Physical Medicine and | $ 6.39 |
| Evaluation and Management | $ 8.34 |
| Dental | $ 55.73 |
(d) Fees for Surgery.
(i) Surgical Assistants.
(A) MD assistants shall be paid 20% of the surgical allowance.
(B) Non-MD assistants shall be paid 15% of the surgical allowance.
(ii) Capsular Shrinkage Procedure. (Multiple procedure guidelines apply).
| Description | Unit |
|---|---|
| Shoulder | 16.4 |
| Elbow | 13.8 |
| Wrist | 10.7 |
| Hip | 15.6 |
| Knee | 17.6 |
| Ankle | 12.0 |
(e) Fees for Independent Medical Evaluations (IME), Permanent Partial Impairment Ratings (PPI), Medical Testimony and Deposition(s). See Chapter 10, and Chapter 9, Section 1 for additional guidelines. Medical bills must indicate total time spent on review of records, actual examination and writing of the report. The medical report must include a breakdown of the total time spent. Medical bills must also include time spent on travel, if applicable.
(i) Independent Medical Evaluations or Impairment Ratings. The Division shall pay according to the following fee schedule:
| Code | Time | Payment |
|---|---|---|
| 99455-99456 | 1st hour | $500.00 |
| Each additional 15 minutes | $ 62.50 |
(ii) Medical Testimony and Deposition Charges. The Division shall pay according to the following fee schedule:
| Code | Time | Payment |
|---|---|---|
| 99075 | 1st hour | $500.00 |
| Each additional 15 minutes | $ 62.50 |
Section 3. Fees for Home Health Nursing. The Division adopts the following fee schedule guidelines for home health nursing. This fee schedule is for long term daily care at home. This is a straight fee, no overtime, holiday rate, or shift differential shall be paid. See Chapter 10, and Chapter 9, Section 1 for additional guidelines.
| Type of Nursing | Hourly Rate |
|---|---|
| RN | $35.00 |
| LPN | $35.00 |
| CNA | $16.00 |
| *Attendant | *Federal minimum wage |
*Attendant care includes personal care for activities of daily living. A physician prescription and time limit is required. Attendant care shall be provided by individuals approved by the primary treating health care provider.
(a) The Division adopts the Wyoming Medicare rate of the Healthcare Common Procedure Coding System (HCPCS) as the rates were published as of January 1, 2015 for the payment of supplies, DME, orthotics and prosthetic devices prescribed by a health care provider. See Chapter 9, Section 1 for additional guidelines. The Division shall not pay for any supplies,
DME, orthotics, or prosthetics unless prescribed by the primary health care provider.
(i) The Division has determined that incorporation of the full text in these rules would be cumbersome or inefficient given the length or nature of the rules;
(ii) The incorporation by reference does not include any later amendments or editions of the incorporated matter beyond the applicable date identified in subsection a of this section;
(iii) The incorporated code, standard, rule or regulation is maintained at 1510 East Pershing, Cheyenne, WY 82002 and is available for public inspection and copying at cost at the same location.
(b) Each code incorporated by reference in these rules is further identified as follows:
(i) Reference to Wyoming Medicare rate of the Healthcare Common Procedure Coding System (HCPCS) is adopted by the Division and effective on January 1, 2015, found at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule.html
(c) Any related charges for supplies, DME, orthotics and prosthetics not listed in the Medicare HCPCS fee schedule shall be paid at eighty percent (80%) of billed charges. Charges deemed excessive shall require additional documentation for justification.
(i) Any single supply / implant charged at $1,000.00 or more shall require a suppliers' invoice. Reimbursement shall be at 130% of invoice cost. Shipping and handling charges shall not be reimbursed.
(ii) The Division shall not provide direct payment to suppliers or manufacturers for implantable items.
(d) The preceding fees are not intended to address newly developed items or technologies.
Section 5. Fees for Hearing Aids/Prescription Lenses. See Chapter 10, and Chapter 9, Section 1 for additional guidelines.
(a) The Division shall pay 130% of the supplier's/manufacturer's invoice price for hearing aids when the provider submits the invoice to the Division.
(b) The Division shall reimburse for frames and lenses as prescribed for compensable vision loss, or replacement due to a work-related accident, not to exceed 80% HCPCS usual and customary benchmarks as determined annually by the Division. The Division may demand additional documentation and justification for any charges deemed excessive by the Division.
(c) The Division shall reimburse an injured worker for the repair or comparable replacement of a hearing aid device or prescription lens damaged or destroyed in a work-related accident.
Section 6. Fees for Pharmacy Items. Pharmaceuticals must be billed with a National Drug Code (NDC). See Chapter 10, and Chapter 9, Section 1 for additional guidelines.
(a) Pharmaceuticals shall be reimbursed at the lower of:
(i) Average Wholesale Price (AWP) minus 10% plus a $5.00 dispensing fee; or
(ii) The provider’s usual and customary charge. In no case shall any provider bill for charges greater than those charged to the general public for like services. The Division reserves the right to review such charges and reimburse at the usual and customary rate if a discrepancy is found.
(b) Reimbursement shall be decreased by $2.50 per prescription if a paper claim is submitted unless:
(i) The provider has received prior approval from the Division to submit a claim on paper.
(ii) Electronic billing is unavailable at the time of service making it unreasonable to submit the claim through the online process.
(c) Over the counter items that do not have a valid NDC number shall be considered supplies and shall not be paid with an added dispensing fee. See Chapter 9, Section 4 for additional guidelines.
(d) If the pharmaceutical is a repackaged drug, as determined by the NDC for the product dispensed, reimbursement shall be calculated per Section 6(a) using the AWP of the lowest cost therapeutic equivalent product.
(e) If a pharmaceutical intended for outpatient use is dispensed through the office of a medical care provider, reimbursement will be calculated per Section 6(a) – (d), equivalent to the reimbursement provided to a retail pharmacy.
Section 7. Fees for Compounded Medications. – See Chapter 10, Section 7, and Chapter 9, Section 1 for additional guidelines.
(a) Physicians billing for compounded drugs must provide the pharmacy invoice. The Division shall pay 130% of the supplier’s/manufacturer’s invoice price.
(b) Compounding pharmacies that bill directly, shall be compensated for the drugs prescribed and related materials in accordance with Chapter 9, Section 6. The Division shall allow a fee for compounding services. Compounding medications shall be reimbursed per line item if each ingredient is determined to be coverable per Chapter 10, Section 7, Compound Prescription Medications.
Section 8. Fees for Ambulance Services. Ambulance services shall be paid the lesser of the billed charge or the maximum allowable rate for the code appropriate for the documented service. The maximum allowable rates are all-inclusive. Mileage shall be reimbursed per documented loaded statute mile. See Chapter 9, Section 1 for additional guidelines.
(a) The following codes shall be recognized by the Division:
| Code | Short Descriptor | Maximum Allowable |
|---|---|---|
| A0425 | Mileage, Ground | $9.18 per statute mile |
| A0426 | Advance Life Support - 1 | $342.93 |
| A0427 | Advance Life Support - 1, | $542.98 |
| A0428 | Basic Life Support | $285.78 |
| A0429 | Basic Life Support, Emergent | $457.25 |
| A0430 | Air, Fixed Wing | $3,350.00 |
| A0431 | Air, Rotary Wing | $3,900.66 |
| A0433 | Advance Life Support – 2 | $785.90 |
| A0434 | Specialty Care Transport | $928.79 |
| A0435 | Mileage, Air, Fixed Wing | $10.30 per statute mile |
| A0436 | Mileage, Air, Rotary Wing | $27.47 per statute mile |
Section 9. Facility Fees.
(a) Fees for Inpatient Hospital Services.
(i) Services or items shall be paid per usual and customary services pursuant to Chapter 9, Sections 1, 2, 4, 6, and 8 in addition to this section. Required documentation to support billed charges are as follows:
(I) Such items shall be reimbursed at 130% of invoice amount. Shipping and handling charges shall not be reimbursed.
(ii) Bills shall be audited for unidentified and unrelated services and/or items.
(iii) The Division shall provide a copy of the audit upon request.
(iv) Hospital Room Rates. The Division shall pay inpatient hospital room rates based upon an annual survey conducted by the Division. The hospital room rates for a semi-private and intensive care unit bed shall be at the usual and customary rates charged to the general public. Such rates shall be effective automatically on the first day of each calendar year.
(b) Fees for Injections, Rhizotomies and IV Sedation. Injection services shall be paid per the listed reimbursement rates shown in Table A. Reimbursement allowables are all inclusive to each procedural code. See Chapter 9, Section 1 of these Rules for additional guidelines.
(i) Refer to Table A for procedures done with guidance and/or sedation.
(ii) The Division shall pay 25% of the facility reimbursement base value for any injection(s) in addition to a primary code from Table A or any code from Table B. Added level codes shall be paid at 100% of the base value listed on Table A.
(c) Fees for Surgery Centers Other than for Injections. Surgical services shall be paid per the listed reimbursement rates shown in Table B. Reimbursement allowables are all inclusive unless otherwise specifically noted. Providers may note specific bill(s) with a written request for an audit to elect payment under the hospital fee schedule. See Chapter 9, Section 9, (a), Fees for Inpatient Hospital Services for required documentation for such audit. See Chapter 9, Section 1 for additional guidelines.
(i) The highest value procedure shall be considered the primary procedure and be paid at 100% of the allowable listed on Table B. Additional procedures shall then be paid at 50% of the allowable.
(ii) Invoices. The Division has defined a group of procedures that require surgery centers to provide suppliers' or manufacturers' invoice(s) for maximum reimbursement. They are distinguished by an asterisk (*) in Table B. The following standards shall be applied:
(A) Maximum reimbursement for asterisked procedures shall be the facility reimbursement allowable listed in Table B plus 130% of invoice amount. Shipping and handling charges shall not be reimbursed.
(B) The Division shall not provide direct payment to suppliers or manufacturers.
(C) The Division shall reimburse invoiced costs of an implant/device for any code marked with an asterisk on Table B and not otherwise recognized for payment.
(iii) 23-Hour Stay. Code 19999 is recognized as a 23-hour stay. Documentation supporting the medical necessity for the stay is required for reimbursement. Reimbursement shall be based on half of the average Wyoming semi- private hospital room rate. See (a)(iv) for guidelines.
Table A - INJECTION PROCEDURES FEE SCHEDULE FOR FACILITY
See Chapter 9, Section 9 (b), for additional guidelines on facility reimbursements and Chapter 9, Section 1 for general guidelines for fee schedules.
| CPT | SHORT DESCRIPTOR | AA | AB | AC | AD |
|---|---|---|---|---|---|
| *WITHOUT GUIDANCE & WITHOUT IV SEDATION | WITHOUT GUIDANCE & WITH IV SEDATION | *WITH GUIDANCE & WITHOUT IV SEDATION | *WITH GUIDANCE & WITH IV SEDATION | ||
| 20526 | Ther injection, carp tunnel | $237.55 | $985.22 | $321.04 | $1,068.71 |
| 20550 | Inj tendon sheath/ligament | $237.55 | $985.22 | $321.04 | $1,068.71 |
| 20551 | Inj tendon origin/insertion | $237.55 | $985.22 | $321.04 | $1,068.71 |
| 20552 | Inj trigger point, 1/2 muscl | $237.55 | $985.22 | $321.04 | $1,068.71 |
| 20553 | Inject trigger points, => 3 | $237.55 | $985.22 | $321.04 | $1,068.71 |
| 20600 | Drain/inject, joint/bursa | $237.55 | $985.22 | $321.04 | $1,068.71 |
| 20605 | Drain/inject, joint/bursa | $237.55 | $985.22 | $321.04 | $1,068.71 |
| 20610 | Drain/inject, joint/bursa | $237.55 | $985.22 | $321.04 | $1,068.71 |
| 20612 | Aspirate/inj ganglion cyst | $237.55 | $985.22 | $321.04 | $1,068.71 |
| 27096 | Inject sacroiliac joint w/ GUID | $480.05 | no code AB | $647.04 | $1,205.66 |
| 62264 | Epidural lysis on single day | no code AA | no code AB | $647.04 | $1,205.66 |
| 62270 | Spinal fluid tap, diagnostic | $480.05 | $1,038.67 | $647.04 | $1,205.66 |
| 62272 | Drain cerebro spinal fluid | $480.05 | $1,038.67 | $647.04 | $1,205.66 |
| 62273 | Inject epidural patch | $480.05 | $1,038.67 | $647.04 | $1,205.66 |
| 62280 | Treat spinal cord lesion | $480.05 | $1,038.67 | $647.04 | $1,205.66 |
| 62281 | Treat spinal cord lesion | $480.05 | $1,038.67 | $647.04 | $1,205.66 |
| 62282 | Treat spinal canal lesion | $480.05 | $1,038.67 | $647.04 | $1,205.66 |
| 62310 | Inject spine c/t | $480.05 | $1,038.67 | $647.04 | $1,205.66 |
| 62311 | Inject spine l/s (cd) | $480.05 | $1,038.67 | $647.04 | $1,205.66 |
| 62318 | Inject spine w/cath, c/t | $480.05 | $1,038.67 | $647.04 | $1,205.66 |
| 62319 | Inject spine w/cath l/s (cd) | $480.05 | $1,038.67 | $647.04 | $1,205.66 |
| 64400 | N block inj, trigeminal | $237.55 | $985.22 | $321.04 | $1,068.71 |
| 64402 | N block inj, facial | $237.55 | $985.22 | $321.04 | $1,068.71 |
| 64405 | N block inj, occipital | $354.56 | $1,038.67 | $438.05 | $1,185.72 |
| 64408 | N block inj, vagus | $237.55 | $985.22 | $321.04 | $1,068.71 |
| 64410 | N block inj, phrenic | $237.55 | $985.22 | $321.04 | $1,068.71 |
| 64412 | N block inj, spinal accessor | $354.56 | $1,038.67 | $438.05 | $1,185.72 |
| 64413 | N block inj, cervical | $354.56 | $1,038.67 | $438.05 | $1,185.72 |
| 64415 | N block brachial plexus, single | $354.56 | $1,038.67 | $438.05 | $1,185.72 |
| 64416 | N block cont infuse, b plex | $480.05 | $1,038.67 | $647.04 | $1,205.66 |
| 64417 | N block inj, axillary | $354.56 | $1,038.67 | $438.05 | $1,185.72 |
| 64418 | N block inj, suprascapular | $354.56 | $1,038.67 | $438.05 | $1,185.72 |
| 64420 | N block inj, intercost, sng | $354.56 | $1,038.67 | $438.05 | $1,185.72 |
| 64421 | N block inj, intercost, mlt | $480.05 | $1,038.67 | $647.04 | $1,205.66 |
| 64425 | N block inj, ilio-ing/hypogi | $354.56 | $1,038.67 | $438.05 | $1,185.72 |
| 64430 | N block inj, pudendal | $480.05 | $1,038.67 | $647.04 | $1,205.66 |
Table A - INJECTION PROCEDURES FEE SCHEDULE FOR FACILITY (cont.)
See Chapter 9, Section 9 (b), for additional guidelines on facility reimbursements and Chapter 9, Section 1 for general guidelines for fee schedules.
| CPT | SHORT DESCRIPTOR | AA | AB | AC | AD |
|---|---|---|---|---|---|
| *WITHOUT GUIDANCE & WITHOUT IV SEDATION | WITHOUT GUIDANCE & WITH IV SEDATION | *WITH GUIDANCE & WITHOUT IV SEDATION | *WITH GUIDANCE & WITH IV SEDATION | ||
| 64435 | N block inj, paracervical | $354.56 | $1,038.67 | $438.05 | $1,185.72 |
| 64445 | N block inj, sciatic, sng | $480.05 | $1,038.67 | $647.04 | $1,205.66 |
| 64447 | N block inj fem, single | $354.56 | $1,038.67 | $438.05 | $1,185.72 |
| 64448 | N block inj fem, cont inf | $480.05 | $1,038.67 | $647.04 | $1,205.66 |
| 64449 | N block inj, lumbar plexus | $480.05 | $1,038.67 | $647.04 | $1,205.66 |
| 64450 | N block, other peripheral | $354.56 | $1,038.67 | $438.05 | $1,185.72 |
| 64479 | Inj foramen epidural c/t | $480.05 | $1,038.67 | $647.04 | $1,205.66 |
| 64480 | Inj foramen added level | $ 120.01 for added level | no code AB | no code AC | no code AD |
| 64483 | Inj foramen epidural l/s | $480.05 | $1,038.67 | $647.04 | $1,205.66 |
| 64484 | Inj l/s added level | $ 120.01 for added level | no code AB | no code AC | no code AD |
| 64490 | Inj paravertebral c/t - fluor / CT | $120.01 for bilateral sid | no code AB | $647.04 | $1,205.66 |
| 64491 | Inj paravertebral c/t - Fluor / CT added level | $ 120.01 for added level | no code AB | no code AC | no code AD |
| 64492 | Inj paravertebral c/t - Fluor / CT 3 levels or more | $ 120.01 for added level | no code AB | no code AC | no code AD |
| 64493 | Inj paravertebral l/s - Fluor / CT | $120.01 for bilateral sid | no code AB | $647.04 | $1,205.66 |
| 64494 | Inj paravertebral l/s- Fluor / CT added level | $ 120.01 for added level | no code AB | no code AC | no code AD |
| 64495 | Inj paravertebral l/s- Fluor / CT 3 levels or more | $ 120.01 for added level | no code AB | no code AC | no code AD |
| 64505 | N block, spenopalatine gangl | $237.55 | $985.22 | $321.04 | $1,068.71 |
| 64508 | N block, carotid sinus s/p | $237.55 | $985.22 | $321.04 | $1,068.71 |
| 64510 | N block, stellate ganglion | $480.05 | no code AB | $647.04 | $1,205.66 |
| 64517 | N block inj, hypogas plxs | $480.05 | $1,038.67 | $647.04 | $1,205.66 |
| 64520 | N block, lumbar/thoracic | $480.05 | no code AB | $647.04 | $1,205.66 |
| 64530 | N block inj, celiac pelus | $480.05 | no code AB | $647.04 | $1,205.66 |
| 64600 | Injection treatment of nerve | $341.86 | $1,038.67 | $425.35 | $1,173.02 |
| 64612 | Destroy nerve, face muscle | $237.55 | $985.22 | $321.04 | $1,068.71 |
| 64613 | Destroy nerve, neck muscle | $354.56 | $1,038.67 | $438.05 | $1,185.72 |
| 64614 | Destroy nerve, extrem musc | $354.56 | $1,038.67 | $438.05 | $1,185.72 |
| 64620 | Injection treatment of nerve | $341.86 | $1,038.67 | $425.35 | $1,173.02 |
| 64630 | Injection treatment of nerve | $480.05 | $1,038.67 | $647.04 | $1,205.66 |
| 64633 | Destr paravertebrl nerve c/t | $480.05 | no code AB | $647.04 | $1,205.66 |
| 64634 | Destr c/t added level | $ 120.01 for added level | no code AB | no code AC | no code AD |
| 64635 | Destr paravertebrl nerve l/s | $480.05 | $1,038.67 | $647.04 | $1,205.66 |
Table A - INJECTION PROCEDURES FEE SCHEDULE FOR FACILITY (cont.)
See Chapter 9, Section 9 (b), for additional guidelines on facility reimbursements and Chapter 9, Section 1 for general guidelines for fee schedules.
| CPT | SHORT DESCRIPTOR | AA | AB | AC | AD |
|---|---|---|---|---|---|
| *WITHOUT GUIDANCE & WITHOUT IV SEDATION | WITHOUT GUIDANCE & WITH IV SEDATION | *WITH GUIDANCE & WITHOUT IV SEDATION | *WITH GUIDANCE & WITH IV SEDATION | ||
| 64636 | Destr l/s added level | $ 120.01 for added level | no code AB | no code AC | no code AD |
| 64640 | Injection treatment of nerve | $480.05 | $1,038.67 | $647.04 | $1,205.66 |
| 64680 | Injection treatment of nerve | $341.86 | $1,038.67 | $425.35 | $1,173.02 |
| 64681 | Injection treatment of nerve | $341.86 | $1,038.67 | $425.35 | $1,173.02 |
| 72285 | X-ray cervical / thoracic spine disk - Discogram -under fluoroscopy. PER SURGICAL EPISODE | no code AA | no code AB | $1,330.73 | $2,078.40 |
| 72295 | X-ray of lower spine disk - Discogram - under fluoroscopy. PER SURGICAL EPISODE | no code AA | no code AB | $1,330.73 | $2,078.40 |
| 0213T | Inj paravertebral c/t ultrasound | $120.01 for bilateral side | $1,038.67 | $647.04 | $1,205.66 |
| 0214T | Inj paravertebral c/t ultrasound added level | $ 120.01 for added level | no code AB | no code AC | no code AD |
| 0215T | Inj paravertebral c/t ultrasound 3 levels or more | $ 120.01 for added level | no code AB | no code AC | no code AD |
| 0216T | Inj paravertebral l/s ultrasound | $120.01 for bilateral side | $1,038.67 | $647.04 | $1,205.66 |
| 0217T | Inj paravertebral l/s ultrasound added level | $ 120.01 for added level | no code AB | no code AC | no code AD |
| 0218T | Inj paravertebral l/s ultrasound 3 levels or more | $ 120.01 for added level | no code AB | no code AC | no code AD |
* The Division shall pay 25% of the base value for each procedural code unless otherwise specified.
Table B - SURGERY CENTER PROCEDURES
See Chapter 9, Section 9 (c), for additional information on facility reimbursements and Chapter 9, Section 1 for general guidelines.
| CPT | Short Descriptor | B | |
|---|---|---|---|
| Facility Reimbursement | Invoice Required | ||
| 10060 | Drainage of skin abscess | $129.33 | |
| 10061 | Drainage of skin abscess | $129.33 | |
| 10120 | Remove foreign body | $251.19 | |
| 10121 | Remove foreign body | $1,546.95 | |
| 10140 | Drainage of hematoma/fluid | $1,165.80 | |
| 10180 | Complex drainage wound | $1,870.55 | |
| 11010 | Debride skin at fx site | $400.06 | |
| 11011 | Debride skin musc at fx site | $400.06 | |
| 11012 | Deb skin bone at fx site | $400.06 | |
| 11042 | Deb subq tissue 20 sq cm/< | $251.19 | |
| 11043 | Deb musc/fascia 20 sq cm/< | $251.19 | |
| 11044 | Deb bone 20 sq cm/< | $754.72 | |
| 11400 | Exc tr-ext b9+marg 0.5 < cm | $400.06 | |
| 11403 | Exc tr-ext b9+marg 2.1-3 cm | $754.72 | |
| 11404 | Exc tr-ext b9+marg 3.1-4 cm | $1,546.95 | |
| 11420 | Exc h-f-nk-sp b9+marg 0.5 < | $754.72 | |
| 11421 | Exc h-f-nk-sp b9+marg 0.6-1 | $754.72 | |
| 11422 | Exc h-f-nk-sp b9+marg 1.1-2 | $754.72 | |
| 11423 | Exc h-f-nk-sp b9+marg 2.1-3 | $1,546.95 | |
| 11440 | Exc face-mm b9+marg 0.5 < cm | $400.06 | |
| 11720 | Debride nail 1-5 | $79.81 | |
| 11730 | Removal of nail plate | $79.81 | |
| 11750 | Removal of nail bed | $400.06 | |
| 11752 | Remove nail bed/finger tip | $2,117.45 | |
| 11760 | Repair of nail bed | $108.51 | |
| 11762 | Reconstruction of nail bed | $1,526.43 | |
| 12001 | Repair superficial wound(s) | $108.51 | |
| 12020 | Closure of split wound | $448.46 | |
| 12032 | Intmd wnd repair s/a/t/ext | $294.49 | |
| 12034 | Intmd wnd repair s/tr/ext | $294.49 | |
| 12041 | Intmd wnd repair n-hf/genit | $108.51 | |
| 12042 | Intmd wnd repair n-hf/genit | $294.49 | |
| 12051 | Intmd wnd repair face/mm | $294.49 | |
| 13101 | Repair of wound or lesion | $448.46 | |
| 13102 | Repair wound/lesion add-on | $294.49 | |
| 13120 | Repair of wound or lesion | $294.49 | |
| 13121 | Repair of wound or lesion | $294.49 |
TABLE B, SURGERY CENTER PROCEDURES (cont.)
See Chapter 9, Section 9 (c), for additional information on facility reimbursements and Chapter 9, Section 1 for general guidelines.
| CPT | Short Descriptor | B | |
|---|---|---|---|
| Facility Reimbursement | Invoice Required | ||
| 13122 | Repair wound/lesion add-on | $108.51 | |
| 13131 | Repair of wound or lesion | $294.49 | |
| 13132 | Repair of wound or lesion | $448.46 | |
| 13152 | Repair of wound or lesion | $448.46 | |
| 13160 | Late closure of wound | $1,951.55 | |
| 14000 | Skin tissue rearrangement | $1,526.43 | |
| 14001 | Skin tissue rearrangement | $1,526.43 | |
| 14021 | Skin tissue rearrangement | $1,526.43 | |
| 14040 | Skin tissue rearrangement | $1,526.43 | |
| 14041 | Skin tissue rearrangement | $1,526.43 | |
| 15002 | Wound prep trk/arm/leg | $448.46 | |
| 15003 | Wound prep addl 100 cm | $448.46 | |
| 15004 | Wound prep f/n/hf/g | $294.49 | |
| 15050 | Skin pinch graft | $294.49 | |
| 15100 | Skin splt grft trnk/arm/leg | $1,951.55 | |
| 15101 | Skin splt grft t/a/l add-on | $1,951.55 | |
| 15120 | Skin splt a-grft fac/nck/hf/g | $1,951.55 | |
| 15121 | Skin splt a-grft f/n/hf/g add | $1,951.55 | |
| 15220 | Skin full graft sclp/arm/leg | $1,526.43 | |
| 15240 | Skin full grft face/genit/hf | $1,526.43 | |
| 15574 | Form skin pedicle flap | $1,951.55 | |
| 15620 | Skin graft | $1,951.55 | |
| 15760 | Composite skin graft | $1,951.55 | |
| 15850 | Removal of sutures | $251.19 | |
| 15851 | Removal of sutures | $251.19 | |
| 15852 | Dressing change not for burn | $59.15 | |
| 17111 | Destruct lesion 15 or more | $136.22 | |
| 20100 | Explore wound neck | $679.14 | |
| 20103 | Explore wound extremity | $1,165.80 | |
| 20520 | Removal of foreign body | $400.06 | |
| 20525 | Removal of foreign body | $2,117.45 | |
| 20555 | Place ndl musc/tis for rt | $2,953.24 | |
| 20670 | Removal of support implant | $1,546.95 | |
| 20680 | Removal of support implant | $2,117.45 | |
| 20690 | Apply bone fixation device | $2,953.24 | |
| 20693 | Adjust bone fixation device | $2,953.24 | |
| 20694 | Remove bone fixation device | $2,009.69 | |
| 20900 | Removal of bone for graft | $2,953.24 | |
| 20902 | Removal of bone for graft | $2,953.24 |
TABLE B, SURGERY CENTER PROCEDURES (cont.)
See Chapter 9, Section 9 (c), for additional information on facility reimbursements and Chapter 9, Section 1 for general guidelines.
| CPT | Short Descriptor | B | |
|---|---|---|---|
| Facility Reimbursement | Invoice Required | ||
| 20912 | Remove cartilage for graft | $1,951.55 | |
| 20924 | Removal of tendon for graft | $2,953.24 | |
| 20930 | Sp bone algrift morsel add-on | invoice only | * |
| 20931 | Sp bone algrift struct add-on | invoice only | * |
| 20936 | Sp bone agrift local add-on | $2,953.24 | |
| 20937 | Sp bone agrift morsel add-on | $2,953.24 | |
| 20938 | Sp bone agrift struct add-on | $2,953.24 | |
| 21320 | Treatment of nose fracture | $1,535.50 | |
| 21325 | Treatment of nose fracture | $2,265.44 | |
| 21330 | Treatment of nose fracture | $2,265.44 | |
| 21335 | Treatment of nose fracture | $2,265.44 | |
| 21356 | Treat cheek bone fracture | $2,265.44 | |
| 21365 | Treat cheek bone fracture | $4,099.33 | |
| 21385 | Treat eye socket fracture | $4,099.33 | |
| 21390 | Treat eye socket fracture | $4,099.33 | |
| 21407 | Treat eye socket fracture | $4,099.33 | |
| 21408 | Treat eye socket fracture | $4,099.33 | |
| 21462 | Treat lower jaw fracture | $4,099.33 | |
| 21555 | Exc neck les sc < 3 cm | $1,546.95 | |
| 21930 | Exc back les sc < 3 cm | $1,546.95 | |
| 22100 | Remove part of neck vertebra | $4,617.84 | |
| 22520 | Percut vertebroplasty thor | $2,953.24 | |
| 22521 | Percut vertebroplasty lumb | $2,953.24 | |
| 22524 | Percut kyphoplasty lumbar | $6,159.04 | * |
| 22526 | Idet single level | $2,953.24 | |
| 22527 | Idet 1 or more levels | $2,953.24 | |
| 22551 | Neck spine fuse&remov bel c2 | $4,617.84 | |
| 22552 | Addl neck spine fusion | $4,617.84 | |
| 22554 | Neck spine fusion | $4,617.84 | |
| 22556 | Thorax spine fusion | $4,617.84 | |
| 22558 | Lumbar spine fusion | $4,617.84 | |
| 22585 | Additional spinal fusion | $4,617.84 | |
| 22600 | Neck spine fusion | $4,617.84 | |
| 22610 | Thorax spine fusion | $4,617.84 | |
| 22612 | Lumbar spine fusion | $4,617.84 | |
| 22614 | Spine fusion extra segment | $4,617.84 | |
| 22630 | Lumbar spine fusion | $4,617.84 | |
| 22632 | Spine fusion extra segment | $4,617.84 |
TABLE B, SURGERY CENTER PROCEDURES (cont.)
See Chapter 9, Section 9 (c), for additional information on facility reimbursements and Chapter 9, Section 1 for general guidelines.
| CPT | Short Descriptor | B | |
|---|---|---|---|
| Facility Reimbursement | Invoice Required | ||
| 22633 | Lumbar spine fusion combined | $6,926.76 | |
| 22634 | Spine fusion extra segment | $6,926.76 | |
| 22830 | Exploration of spinal fusion | $4,617.84 | |
| 22840 | Insert spine fixation device | $4,617.84 | * |
| 22841 | Insert spine fixation device | $4,617.84 | * |
| 22842 | Insert spine fixation device | $4,617.84 | * |
| 22843 | Insert spine fixation device | $4,617.84 | * |
| 22844 | Insert spine fixation device | $4,617.84 | * |
| 22845 | Insert spine fixation device | $4,617.84 | * |
| 22846 | Insert spine fixation device | $4,617.84 | * |
| 22847 | Insert spine fixation device | $4,617.84 | * |
| 22848 | Insert pelv fixation device | $4,617.84 | * |
| 22849 | Reinsert spinal fixation | $4,617.84 | * |
| 22850 | Remove spine fixation device | $4,617.84 | |
| 22851 | Apply spine prosth device | $2,721.71 | * |
| 22852 | Remove spine fixation device | $4,617.84 | |
| 22855 | Remove spine fixation device | $4,617.84 | |
| 22856 | Cerv artific discectomy | $4,617.84 | * |
| 22857 | Lumbar artif discectomy | $4,617.84 | * |
| 23020 | Release shoulder joint | $2,953.24 | |
| 23030 | Drain shoulder lesion | $1,870.55 | |
| 23040 | Exploratory shoulder surgery | $2,953.24 | |
| 23044 | Exploratory shoulder surgery | $2,953.24 | |
| 23075 | Exc shoulder les sc < 3 cm | $1,546.95 | |
| 23076 | Exc shoulder tum deep < 5 cm | $1,546.95 | |
| 23100 | Biopsy of shoulder joint | $2,009.69 | |
| 23101 | Shoulder joint surgery | $2,953.24 | |
| 23105 | Remove shoulder joint lining | $2,953.24 | |
| 23106 | Incision of collarbone joint | $2,953.24 | |
| 23107 | Explore treat shoulder joint | $2,953.24 | |
| 23120 | Partial removal collar bone | $2,953.24 | |
| 23130 | Remove shoulder bone part | $4,323.74 | |
| 23140 | Removal of bone lesion | $2,009.69 | |
| 23145 | Removal of bone lesion | $2,953.24 | |
| 23330 | Remove shoulder foreign body | $754.72 | |
| 23331 | Remove shoulder foreign body | $2,117.45 | |
| 23405 | Incision of tendon & muscle | $2,953.24 | |
| 23410 | Repair rotator cuff acute | $3,669.13 | * |
TABLE B, SURGERY CENTER PROCEDURES (cont.)
See Chapter 9, Section 9 (c), for additional information on facility reimbursements and Chapter 9, Section 1, for general guidelines.
| CPT | Short Descriptor | B | |
|---|---|---|---|
| Facility Reimbursement | Invoice Required | ||
| 23412 | Repair rotator cuff chronic | $3,669.13 | * |
| 23415 | Release of shoulder ligament | $4,323.74 | |
| 23420 | Repair of shoulder | $3,669.13 | * |
| 23430 | Repair biceps tendon | $4,323.74 | |
| 23440 | Remove/transplant tendon | $2,953.24 | |
| 23450 | Repair shoulder capsule | $6,159.04 | * |
| 23455 | Repair shoulder capsule | $6,159.04 | * |
| 23460 | Repair shoulder capsule | $6,159.04 | * |
| 23462 | Repair shoulder capsule | $4,323.74 | |
| 23465 | Repair shoulder capsule | $6,159.04 | * |
| 23466 | Repair shoulder capsule | $4,323.74 | |
| 23470 | Reconstruct shoulder joint | $4,646.69 | * |
| 23472 | Reconstruct shoulder joint | $4,646.69 | * |
| 23485 | Revision of collar bone | $6,159.04 | * |
| 23515 | Treat clavicle fracture | $6,200.31 | |
| 23530 | Treat clavicle dislocation | $4,541.71 | |
| 23532 | Treat clavicle dislocation | $2,377.46 | |
| 23550 | Treat clavicle dislocation | $4,541.71 | |
| 23552 | Treat clavicle dislocation | $4,541.71 | |
| 23585 | Treat scapula fracture | $6,200.31 | |
| 23630 | Treat humerus fracture | $6,200.31 | |
| 23655 | Treat shoulder dislocation | $1,407.13 | |
| 23700 | Fixation of shoulder | $1,407.13 | |
| 23929 | Shoulder surgery procedure | $136.71 | |
| 23930 | Drainage of arm lesion | $1,870.55 | |
| 23931 | Drainage of arm bursa | $1,870.55 | |
| 24000 | Exploratory elbow surgery | $2,953.24 | |
| 24006 | Release elbow joint | $2,953.24 | |
| 24101 | Explore/treat elbow joint | $2,953.24 | |
| 24102 | Remove elbow joint lining | $2,953.24 | |
| 24105 | Removal of elbow bursa | $2,009.69 | |
| 24110 | Remove humerus lesion | $2,009.69 | |
| 24120 | Remove elbow lesion | $2,009.69 | |
| 24130 | Removal of head of radius | $2,953.24 | |
| 24140 | Partial removal of arm bone | $2,953.24 | |
| 24145 | Partial removal of radius | $2,953.24 | |
| 24147 | Partial removal of elbow | $2,953.24 | |
| 24164 | Remove radius head implant | $2,953.24 |
TABLE B, SURGERY CENTER PROCEDURES (cont.)
See Chapter 9, Section 9 (c), for additional information on facility reimbursements and Chapter 9, Section 1, for general guidelines.
| CPT | Short Descriptor | B | |
|---|---|---|---|
| Facility Reimbursement | Invoice Required | ||
| 24200 | Removal of arm foreign body | $400.06 | |
| 24201 | Removal of arm foreign body | $1,546.95 | |
| 24300 | Manipulate elbow w/anesth | $1,407.13 | |
| 24305 | Arm tendon lengthening | $2,953.24 | |
| 24340 | Repair of biceps tendon | $4,323.74 | |
| 24341 | Repair arm tendon/muscle | $4,323.74 | |
| 24342 | Repair of ruptured tendon | $4,323.74 | |
| 24343 | Repr elbow lat ligmnt w/tiss | $2,953.24 | |
| 24344 | Reconstruct elbow lat ligmnt | $6,159.04 | * |
| 24345 | Repr elbw med ligmnt w/tissu | $2,953.24 | |
| 24346 | Reconstruct elbow med ligmnt | $6,159.04 | * |
| 24357 | Repair elbow perc | $2,953.24 | |
| 24358 | Repair elbow w/deb open | $2,953.24 | |
| 24359 | Repair elbow deb/attach open | $2,953.24 | |
| 24360 | Reconstruct elbow joint | $3,757.97 | |
| 24365 | Reconstruct head of radius | $3,757.97 | |
| 24366 | Reconstruct head of radius | $4,646.69 | * |
| 24400 | Revision of humerus | $6,159.04 | * |
| 24430 | Repair of humerus | $6,159.04 | * |
| 24435 | Repair humerus with graft | $6,159.04 | * |
| 24545 | Treat humerus fracture | $6,200.31 | |
| 24546 | Treat humerus fracture | $6,200.31 | |
| 24575 | Treat humerus fracture | $6,200.31 | |
| 24579 | Treat humerus fracture | $6,200.31 | |
| 24582 | Treat humerus fracture | $2,377.46 | |
| 24586 | Treat elbow fracture | $6,200.31 | |
| 24605 | Treat elbow dislocation | $1,407.13 | |
| 24615 | Treat elbow dislocation | $6,200.31 | |
| 24655 | Treat radius fracture | $459.23 | |
| 24665 | Treat radius fracture | $4,541.71 | |
| 24666 | Treat radius fracture | $6,200.31 | |
| 24685 | Treat ulnar fracture | $4,541.71 | |
| 24800 | Fusion of elbow joint | $4,323.74 | |
| 25000 | Incision of tendon sheath | $2,009.69 | |
| 25001 | Incise flexor carpi radialis | $2,009.69 | |
| 25020 | Decompress forearm 1 space | $2,953.24 | |
| 25023 | Decompress forearm 1 space | $2,953.24 | |
| 25024 | Decompress forearm 2 spaces | $2,953.24 |
TABLE B, SURGERY CENTER PROCEDURES (cont.)
See Chapter 9, Section 9 (c), for additional information on facility reimbursements and Chapter 9, Section 1, for general guidelines.
| CPT | Short Descriptor | B | |
|---|---|---|---|
| Facility Reimbursement | Invoice Required | ||
| 25025 | Decompress forearm 2 spaces | $2,953.24 | |
| 25028 | Drainage of forearm lesion | $2,009.69 | |
| 25031 | Drainage of forearm bursa | $2,009.69 | |
| 25040 | Explore/treat wrist joint | $2,953.24 | |
| 25066 | Biopsy forearm soft tissues | $2,117.45 | |
| 25075 | Exc forearm les sc < 3 cm | $1,546.95 | |
| 25076 | Exc forearm tum deep < 3 cm | $1,546.95 | |
| 25085 | Incision of wrist capsule | $2,009.69 | |
| 25100 | Biopsy of wrist joint | $2,009.69 | |
| 25101 | Explore/treat wrist joint | $2,953.24 | |
| 25105 | Remove wrist joint lining | $2,953.24 | |
| 25107 | Remove wrist joint cartilage | $2,953.24 | |
| 25110 | Remove wrist tendon lesion | $2,009.69 | |
| 25111 | Remove wrist tendon lesion | $2,009.69 | |
| 25112 | Remove wrist tendon lesion | $2,009.69 | |
| 25115 | Remove wrist/forearm lesion | $2,009.69 | |
| 25116 | Remove wrist/forearm lesion | $2,009.69 | |
| 25118 | Excise wrist tendon sheath | $2,953.24 | |
| 25120 | Removal of forearm lesion | $2,953.24 | |
| 25126 | Remove/graft forearm lesion | $2,953.24 | |
| 25136 | Remove & graft wrist lesion | $2,953.24 | |
| 25150 | Partial removal of ulna | $2,953.24 | |
| 25151 | Partial removal of radius | $2,953.24 | |
| 25210 | Removal of wrist bone | $2,953.24 | |
| 25215 | Removal of wrist bones | $2,953.24 | |
| 25230 | Partial removal of radius | $2,953.24 | |
| 25240 | Partial removal of ulna | $2,953.24 | |
| 25248 | Remove forearm foreign body | $2,009.69 | |
| 25259 | Manipulate wrist w/anesthes | $1,724.73 | |
| 25260 | Repair forearm tendon/muscle | $2,953.24 | |
| 25263 | Repair forearm tendon/muscle | $2,953.24 | |
| 25270 | Repair forearm tendon/muscle | $2,953.24 | |
| 25272 | Repair forearm tendon/muscle | $2,953.24 | |
| 25274 | Repair forearm tendon/muscle | $2,953.24 | |
| 25275 | Repair forearm tendon sheath | $2,953.24 | |
| 25280 | Revise wrist/forearm tendon | $2,953.24 | |
| 25290 | Incise wrist/forearm tendon | $2,953.24 | |
| 25295 | Release wrist/forearm tendon | $2,009.69 |
TABLE B, SURGERY CENTER PROCEDURES (cont.)
See Chapter 9, Section 9 (c), for additional information on facility reimbursements and Chapter 9, Section 1, for general guidelines.
| CPT | Short Descriptor | B | |
|---|---|---|---|
| Facility Reimbursement | Invoice Required | ||
| 25300 | Fusion of tendons at wrist | $2,953.24 | |
| 25301 | Fusion of tendons at wrist | $2,953.24 | |
| 25310 | Transplant forearm tendon | $2,953.24 | |
| 25312 | Transplant forearm tendon | $4,323.74 | |
| 25320 | Repair/revise wrist joint | $4,323.74 | |
| 25337 | Reconstruct ulna/radioulnar | $4,323.74 | |
| 25360 | Revision of ulna | $4,323.74 | |
| 25390 | Shorten radius or ulna | $4,323.74 | |
| 25400 | Repair radius or ulna | $6,159.04 | * |
| 25405 | Repair/graft radius or ulna | $6,159.04 | * |
| 25415 | Repair radius & ulna | $6,159.04 | * |
| 25420 | Repair/graft radius & ulna | $6,159.04 | * |
| 25430 | Vasc graft into carpal bone | $4,323.74 | |
| 25431 | Repair nonunion carpal bone | $4,323.74 | |
| 25440 | Repair/graft wrist bone | $6,159.04 | * |
| 25447 | Repair wrist joints | $3,757.97 | |
| 25515 | Treat fracture of radius | $4,541.71 | |
| 25545 | Treat fracture of ulna | $4,541.71 | |
| 25575 | Treat fracture radius/ulna | $6,200.31 | |
| 25605 | Treat fracture radius/ulna | $459.23 | |
| 25606 | Treat fx distal radial | $2,377.46 | |
| 25607 | Treat fx rad extra-articul | $6,200.31 | |
| 25608 | Treat fx rad intra-articul | $6,200.31 | |
| 25609 | Treat fx radial 3+ frag | $6,200.31 | |
| 25622 | Treat wrist bone fracture | $136.71 | |
| 25628 | Treat wrist bone fracture | $4,541.71 | |
| 25645 | Treat wrist bone fracture | $4,541.71 | |
| 25651 | Pin ulnar styloid fracture | $2,377.46 | |
| 25652 | Treat fracture ulnar styloid | $4,541.71 | |
| 25660 | Treat wrist dislocation | $136.71 | |
| 25670 | Treat wrist dislocation | $2,377.46 | |
| 25671 | Pin radioulnar dislocation | $2,377.46 | |
| 25676 | Treat wrist dislocation | $2,377.46 | |
| 25685 | Treat wrist fracture | $2,377.46 | |
| 25695 | Treat wrist dislocation | $2,377.46 | |
| 25800 | Fusion of wrist joint | $6,159.04 | * |
| 25810 | Fusion/graft of wrist joint | $6,159.04 | * |
| 25820 | Fusion of hand bones | $4,323.74 |
TABLE B. SURGERY CENTER PROCEDURES (cont.)
See Chapter 9, Section 9 (c), for additional information on facility reimbursements and Chapter 9, Section 1, for general guidelines.
| CPT | Short Descriptor | B | |
|---|---|---|---|
| Facility Reimbursement | Invoice Required | ||
| 25825 | Fuse hand bones with graft | $6,159.04 | * |
| 26011 | Drainage of finger abscess | $1,165.80 | - |
| 26020 | Drain hand tendon sheath | $1,564.65 | - |
| 26037 | Decompress fingers/hand | $1,564.65 | - |
| 26040 | Release palm contracture | $1,564.65 | - |
| 26055 | Incise finger tendon sheath | $1,564.65 | - |
| 26060 | Incision of finger tendon | $1,564.65 | - |
| 26070 | Explore/treat hand joint | $1,564.65 | - |
| 26075 | Explore/treat finger joint | $1,564.65 | - |
| 26080 | Explore/treat finger joint | $1,564.65 | - |
| 26100 | Biopsy hand joint lining | $1,564.65 | - |
| 26105 | Biopsy finger joint lining | $1,564.65 | - |
| 26110 | Biopsy finger joint lining | $1,564.65 | - |
| 26113 | Exc hand tum deep 1.5 cm/> | $2,117.45 | - |
| 26115 | Exc hand les sc < 1.5 cm | $1,546.95 | - |
| 26116 | Exc hand tum deep < 1.5 cm | $1,546.95 | - |
| 26121 | Release palm contracture | $2,627.06 | - |
| 26123 | Release palm contracture | $2,627.06 | - |
| 26125 | Release palm contracture | $1,564.65 | - |
| 26130 | Remove wrist joint lining | $1,564.65 | - |
| 26140 | Revise finger joint each | $1,564.65 | - |
| 26145 | Tendon excision palm/finger | $1,564.65 | - |
| 26160 | Remove tendon sheath lesion | $1,564.65 | - |
| 26170 | Removal of palm tendon each | $1,564.65 | - |
| 26180 | Removal of finger tendon | $1,564.65 | - |
| 26185 | Remove finger bone | $1,564.65 | - |
| 26200 | Remove hand bone lesion | $1,564.65 | - |
| 26230 | Partial removal of hand bone | $1,564.65 | - |
| 26235 | Partial removal finger bone | $1,564.65 | - |
| 26236 | Partial removal finger bone | $1,564.65 | - |
| 26320 | Removal of implant from hand | $1,546.95 | - |
| 26340 | Manipulate finger w/anesth | $459.23 | - |
| 26350 | Repair finger/hand tendon | $2,627.06 | - |
| 26352 | Repair/graft hand tendon | $2,627.06 | - |
| 26356 | Repair finger/hand tendon | $2,627.06 | - |
| 26357 | Repair finger/hand tendon | $2,627.06 | - |
| 26358 | Repair/graft hand tendon | $2,627.06 | - |
| 26370 | Repair finger/hand tendon | $2,627.06 | - |
TABLE B, SURGERY CENTER PROCEDURES (cont.)
See Chapter 9, Section 9 (c), for additional information on facility reimbursements and Chapter 9, Section 1, for general guidelines.
| CPT | Short Descriptor | B | |
|---|---|---|---|
| Facility Reimbursement | Invoice Required | ||
| 26372 | Repair/graft hand tendon | $2,627.06 | |
| 26373 | Repair finger/hand tendon | $2,627.06 | |
| 26390 | Revise hand/finger tendon | $2,627.06 | |
| 26392 | Repair/graft hand tendon | $2,627.06 | |
| 26410 | Repair hand tendon | $1,564.65 | |
| 26412 | Repair/graft hand tendon | $2,627.06 | |
| 26418 | Repair finger tendon | $1,564.65 | |
| 26420 | Repair/graft finger tendon | $2,627.06 | |
| 26426 | Repair finger/hand tendon | $2,627.06 | |
| 26428 | Repair/graft finger tendon | $2,627.06 | |
| 26432 | Repair finger tendon | $1,564.65 | |
| 26433 | Repair finger tendon | $1,564.65 | |
| 26434 | Repair/graft finger tendon | $2,627.06 | |
| 26437 | Realignment of tendons | $1,564.65 | |
| 26440 | Release palm/finger tendon | $1,564.65 | |
| 26442 | Release palm & finger tendon | $2,627.06 | |
| 26445 | Release hand/finger tendon | $1,564.65 | |
| 26449 | Release forearm/hand tendon | $2,627.06 | |
| 26450 | Incision of palm tendon | $1,564.65 | |
| 26455 | Incision of finger tendon | $1,564.65 | |
| 26460 | Incise hand/finger tendon | $1,564.65 | |
| 26471 | Fusion of finger tendons | $1,564.65 | |
| 26474 | Fusion of finger tendons | $1,564.65 | |
| 26476 | Tendon lengthening | $1,564.65 | |
| 26477 | Tendon shortening | $1,564.65 | |
| 26478 | Lengthening of hand tendon | $1,564.65 | |
| 26479 | Shortening of hand tendon | $1,564.65 | |
| 26480 | Transplant hand tendon | $2,627.06 | |
| 26483 | Transplant/graft hand tendon | $2,627.06 | |
| 26485 | Transplant palm tendon | $2,627.06 | |
| 26489 | Transplant/graft palm tendon | $2,627.06 | |
| 26500 | Hand tendon reconstruction | $1,564.65 | |
| 26502 | Hand tendon reconstruction | $2,627.06 | |
| 26508 | Release thumb contracture | $1,564.65 | |
| 26516 | Fusion of knuckle joint | $2,627.06 | |
| 26520 | Release knuckle contracture | $1,564.65 | |
| 26525 | Release finger contracture | $1,564.65 | |
| 26530 | Revise knuckle joint | $3,757.97 |
TABLE B, SURGERY CENTER PROCEDURES (cont.)
See Chapter 9, Section 9 (c), for additional information on facility reimbursements and Chapter 9, Section 1, for general guidelines.
| CPT | Short Descriptor | B | |
|---|---|---|---|
| Facility Reimbursement | Invoice Required | ||
| 26535 | Revise finger joint | $3,757.97 | |
| 26536 | Revise/implant finger joint | $3,348.85 | * |
| 26540 | Repair hand joint | $1,564.65 | |
| 26541 | Repair hand joint with graft | $2,627.06 | |
| 26542 | Repair hand joint with graft | $1,564.65 | |
| 26545 | Reconstruct finger joint | $2,627.06 | |
| 26546 | Repair nonunion hand | $2,627.06 | |
| 26548 | Reconstruct finger joint | $2,627.06 | |
| 26565 | Correct metacarpal flaw | $2,627.06 | |
| 26593 | Release muscles of hand | $1,564.65 | |
| 26605 | Treat metacarpal fracture | $136.71 | |
| 26607 | Treat metacarpal fracture | $1,724.73 | |
| 26608 | Treat metacarpal fracture | $2,377.46 | |
| 26615 | Treat metacarpal fracture | $4,541.71 | |
| 26650 | Treat thumb fracture | $2,377.46 | |
| 26665 | Treat thumb fracture | $4,541.71 | |
| 26676 | Pin hand dislocation | $2,377.46 | |
| 26685 | Treat hand dislocation | $2,377.46 | |
| 26705 | Treat knuckle dislocation | $136.71 | |
| 26706 | Pin knuckle dislocation | $1,724.73 | |
| 26715 | Treat knuckle dislocation | $2,377.46 | |
| 26725 | Treat finger fracture each | $136.71 | |
| 26727 | Treat finger fracture each | $2,377.46 | |
| 26735 | Treat finger fracture each | $2,377.46 | |
| 26742 | Treat finger fracture each | $136.71 | |
| 26746 | Treat finger fracture each | $2,377.46 | |
| 26755 | Treat finger fracture each | $136.71 | |
| 26756 | Pin finger fracture each | $2,377.46 | |
| 26765 | Treat finger fracture each | $2,377.46 | |
| 26775 | Treat finger dislocation | $1,407.13 | |
| 26776 | Pin finger dislocation | $2,377.46 | |
| 26785 | Treat finger dislocation | $2,377.46 | |
| 26841 | Fusion of thumb | $2,627.06 | |
| 26842 | Thumb fusion with graft | $2,627.06 | |
| 26843 | Fusion of hand joint | $2,627.06 | |
| 26844 | Fusion/graft of hand joint | $2,627.06 | |
| 26850 | Fusion of knuckle | $2,627.06 | |
| 26852 | Fusion of knuckle with graft | $2,627.06 |
TABLE B, SURGERY CENTER PROCEDURES (cont.)
See Chapter 9, Section 9 (c), for additional information on facility reimbursements and Chapter 9, Section 1, for general guidelines.
| CPT | Short Descriptor | B | |
|---|---|---|---|
| Facility Reimbursement | Invoice Required | ||
| 26860 | Fusion of finger joint | $2,627.06 | |
| 26861 | Fusion of finger jnt add-on | $2,627.06 | |
| 26862 | Fusion/graft of finger joint | $2,627.06 | |
| 26863 | Fuse/graft added joint | $2,627.06 | |
| 26910 | Amputate metacarpal bone | $2,627.06 | |
| 26951 | Amputation of finger/thumb | $1,564.65 | |
| 26952 | Amputation of finger/thumb | $1,564.65 | |
| 26990 | Drainage of pelvis lesion | $2,009.69 | |
| 27006 | Incision of hip tendons | $2,953.24 | |
| 27062 | Remove femur lesion/bursa | $2,009.69 | |
| 27065 | Remove hip bone les super | $2,009.69 | |
| 27066 | Remove hip bone les deep | $2,953.24 | |
| 27216 | Treat pelvic ring fracture | $2,953.24 | |
| 27267 | Cltx thigh fx | $136.71 | |
| 27275 | Manipulation of hip joint | $1,407.13 | |
| 27280 | Fusion of sacroiliac joint | $4,617.84 | |
| 27301 | Drain thigh/knee lesion | $1,870.55 | |
| 27306 | Incision of thigh tendon | $2,009.69 | |
| 27310 | Exploration of knee joint | $2,953.24 | |
| 27324 | Biopsy thigh soft tissues | $2,117.45 | |
| 27327 | Exc thigh/knee les sc < 3 cm | $2,117.45 | |
| 27328 | Exc thigh/knee tum deep <5cm | $1,546.95 | |
| 27331 | Explore/treat knee joint | $2,953.24 | |
| 27332 | Removal of knee cartilage | $2,953.24 | |
| 27333 | Removal of knee cartilage | $2,953.24 | |
| 27334 | Remove knee joint lining | $2,953.24 | |
| 27335 | Remove knee joint lining | $2,953.24 | |
| 27340 | Removal of kneecap bursa | $2,009.69 | |
| 27345 | Removal of knee cyst | $2,009.69 | |
| 27347 | Remove knee cyst | $2,009.69 | |
| 27350 | Removal of kneecap | $2,953.24 | |
| 27360 | Partial removal leg bone(s) | $2,953.24 | |
| 27372 | Removal of foreign body | $2,117.45 | |
| 27380 | Repair of kneecap tendon | $2,953.24 | |
| 27381 | Repair/graft kneecap tendon | $2,953.24 | |
| 27385 | Repair of thigh muscle | $2,953.24 | |
| 27386 | Repair/graft of thigh muscle | $2,953.24 | |
| 27400 | Revise thigh muscles/tendons | $4,323.74 |
TABLE B, SURGERY CENTER PROCEDURES (cont.)
See Chapter 9, Section 9 (c), for additional information on facility reimbursements and Chapter 9, Section 1, for general guidelines.
| CPT | Short Descriptor | B | |
|---|---|---|---|
| Facility Reimbursement | Invoice Required | ||
| 27403 | Repair of knee cartilage | $2,953.24 | - |
| 27405 | Repair of knee ligament | $4,323.74 | - |
| 27407 | Repair of knee ligament | $6,159.04 | * |
| 27409 | Repair of knee ligaments | $6,159.04 | * |
| 27415 | Osteochondral knee allograft | $6,159.04 | * |
| 27416 | Osteochondral knee autograft | $4,323.74 | - |
| 27418 | Repair degenerated kneecap | $4,323.74 | - |
| 27420 | Revision of unstable kneecap | $4,323.74 | - |
| 27422 | Revision of unstable kneecap | $4,323.74 | - |
| 27424 | Revision/removal of kneecap | $4,323.74 | - |
| 27425 | Lat retinacular release open | $2,953.24 | - |
| 27427 | Reconstruction knee | $6,159.04 | * |
| 27428 | Reconstruction knee | $6,159.04 | * |
| 27429 | Reconstruction knee | $6,159.04 | * |
| 27438 | Revise kneecap with implant | $3,348.85 | * |
| 27446 | Revision of knee joint | $4,646.69 | * |
| 27447 | Total knee arthroplasty | $4,646.69 | * |
| 27486 | Revise/replace knee joint | $4,646.69 | * |
| 27520 | Treat kneecap fracture | $136.71 | - |
| 27524 | Treat kneecap fracture | $4,541.71 | - |
| 27562 | Treat kneecap dislocation | $1,407.13 | - |
| 27570 | Fixation of knee joint | $1,407.13 | - |
| 27603 | Drain lower leg lesion | $1,870.55 | - |
| 27604 | Drain lower leg bursa | $2,953.24 | - |
| 27605 | Incision of achilles tendon | $2,011.21 | - |
| 27606 | Incision of achilles tendon | $2,009.69 | - |
| 27610 | Explore/treat ankle joint | $2,953.24 | - |
| 27612 | Exploration of ankle joint | $2,953.24 | - |
| 27618 | Exc leg/ankle tum < 3 cm | $1,546.95 | - |
| 27619 | Exc leg/ankle tum deep <5 cm | $1,546.95 | - |
| 27620 | Explore/treat ankle joint | $2,953.24 | - |
| 27625 | Remove ankle joint lining | $2,953.24 | - |
| 27626 | Remove ankle joint lining | $2,953.24 | - |
| 27630 | Removal of tendon lesion | $2,009.69 | - |
| 27638 | Remove/graft leg bone lesion | $2,953.24 | - |
| 27640 | Partial removal of tibia | $2,953.24 | - |
| 27641 | Partial removal of fibula | $2,953.24 | - |
| 27650 | Repair achilles tendon | $4,323.74 | - |
TABLE B, SURGERY CENTER PROCEDURES (cont.)
See Chapter 9, Section 9 (c), for additional information on facility reimbursements and Chapter 9, Section 1, for general guidelines.
| CPT | Short Descriptor | B | |
|---|---|---|---|
| Facility Reimbursement | Invoice Required | ||
| 27652 | Repair/graft achilles tendon | $6,159.04 | * |
| 27654 | Repair of achilles tendon | $4,323.74 | |
| 27658 | Repair of leg tendon each | $2,009.69 | |
| 27659 | Repair of leg tendon each | $2,009.69 | |
| 27664 | Repair of leg tendon each | $2,953.24 | |
| 27665 | Repair of leg tendon each | $2,953.24 | |
| 27675 | Repair lower leg tendons | $2,009.69 | |
| 27676 | Repair lower leg tendons | $2,953.24 | |
| 27680 | Release of lower leg tendon | $2,953.24 | |
| 27685 | Revision of lower leg tendon | $2,953.24 | |
| 27687 | Revision of calf tendon | $2,953.24 | |
| 27690 | Revise lower leg tendon | $4,323.74 | |
| 27691 | Revise lower leg tendon | $4,323.74 | |
| 27695 | Repair of ankle ligament | $2,953.24 | |
| 27696 | Repair of ankle ligaments | $2,953.24 | |
| 27698 | Repair of ankle ligament | $2,953.24 | |
| 27700 | Revision of ankle joint | $3,757.97 | |
| 27707 | Incision of fibula | $2,953.24 | |
| 27720 | Repair of tibia | $4,541.71 | |
| 27726 | Repair fibula nonunion | $4,541.71 | |
| 27745 | Reinforce tibia | $6,159.04 | * |
| 27758 | Treatment of tibia fracture | $4,541.71 | |
| 27762 | Ctx med ankle fx w/mnpj | $1,724.73 | |
| 27766 | Optx medial ankle fx | $4,541.71 | |
| 27767 | Ctx post ankle fx | $136.71 | |
| 27768 | Ctx post ankle fx w/mnpj | $136.71 | |
| 27769 | Optx post ankle fx | $4,541.71 | |
| 27784 | Treatment of fibula fracture | $4,541.71 | |
| 27792 | Treatment of ankle fracture | $4,541.71 | |
| 27814 | Treatment of ankle fracture | $4,541.71 | |
| 27818 | Treatment of ankle fracture | $459.23 | |
| 27822 | Treatment of ankle fracture | $4,541.71 | |
| 27823 | Treatment of ankle fracture | $6,200.31 | |
| 27825 | Treat lower leg fracture | $1,724.73 | |
| 27827 | Treat lower leg fracture | $6,200.31 | |
| 27828 | Treat lower leg fracture | $6,200.31 | |
| 27829 | Treat lower leg joint | $4,541.71 | |
| 27842 | Treat ankle dislocation | $1,407.13 |
TABLE B, SURGERY CENTER PROCEDURES (cont.)
See Chapter 9, Section 9 (c), for additional information on facility reimbursements and Chapter 9, Section 1, for general guidelines.
| CPT | Short Descriptor | B | |
|---|---|---|---|
| Facility Reimbursement | Invoice Required | ||
| 28035 | Decompression of tibia nerve | $1,719.56 | |
| 28050 | Biopsy of foot joint lining | $2,011.21 | |
| 28060 | Partial removal foot fascia | $2,011.21 | |
| 28062 | Removal of foot fascia | $2,011.21 | |
| 28070 | Removal of foot joint lining | $2,011.21 | |
| 28072 | Removal of foot joint lining | $2,011.21 | |
| 28080 | Removal of foot lesion | $2,011.21 | |
| 28086 | Excise foot tendon sheath | $2,011.21 | |
| 28088 | Excise foot tendon sheath | $2,011.21 | |
| 28090 | Removal of foot lesion | $2,011.21 | |
| 28092 | Removal of toe lesions | $2,011.21 | |
| 28111 | Part removal of metatarsal | $2,011.21 | |
| 28112 | Part removal of metatarsal | $2,011.21 | |
| 28113 | Part removal of metatarsal | $2,011.21 | |
| 28116 | Revision of foot | $2,011.21 | |
| 28118 | Removal of heel bone | $2,011.21 | |
| 28119 | Removal of heel spur | $2,011.21 | |
| 28120 | Part removal of ankle/heel | $2,011.21 | |
| 28122 | Partial removal of foot bone | $2,011.21 | |
| 28124 | Partial removal of toe | $2,011.21 | |
| 28200 | Repair of foot tendon | $2,011.21 | |
| 28202 | Repair/graft of foot tendon | $2,011.21 | |
| 28208 | Repair of foot tendon | $2,011.21 | |
| 28210 | Repair/graft of foot tendon | $5,320.90 | |
| 28220 | Release of foot tendon | $2,011.21 | |
| 28222 | Release of foot tendons | $2,011.21 | |
| 28225 | Release of foot tendon | $2,011.21 | |
| 28226 | Release of foot tendons | $2,011.21 | |
| 28230 | Incision of foot tendon(s) | $2,011.21 | |
| 28232 | Incision of toe tendon | $2,011.21 | |
| 28234 | Incision of foot tendon | $2,011.21 | |
| 28238 | Revision of foot tendon | $5,320.90 | |
| 28270 | Release of foot contracture | $2,011.21 | |
| 28272 | Release of toe joint each | $2,011.21 | |
| 28285 | Repair of hammertoe | $2,011.21 | |
| 28289 | Repair hallux rigidus | $2,011.21 | |
| 28297 | Correction of bunion | $2,978.74 | |
| 28300 | Incision of heel bone | $5,320.90 |
TABLE B, SURGERY CENTER PROCEDURES (cont.)
See Chapter 9, Section 9 (c), for additional information on facility reimbursements and Chapter 9, Section 1, for general guidelines.
| CPT | Short Descriptor | B | |
|---|---|---|---|
| Facility Reimbursement | Invoice Required | ||
| 28302 | Incision of ankle bone | $2,011.21 | |
| 28304 | Incision of midfoot bones | $5,320.90 | |
| 28305 | Incise/graft midfoot bones | $5,320.90 | |
| 28306 | Incision of metatarsal | $2,011.21 | |
| 28307 | Incision of metatarsal | $2,011.21 | |
| 28308 | Incision of metatarsal | $2,011.21 | |
| 28310 | Revision of big toe | $2,011.21 | |
| 28315 | Removal of sesamoid bone | $2,011.21 | |
| 28320 | Repair of foot bones | $5,320.90 | |
| 28322 | Repair of metatarsals | $5,320.90 | |
| 28415 | Treat heel fracture | $6,200.31 | |
| 28446 | Osteochondral talus autograft | $5,320.90 | |
| 28450 | Treat midfoot fracture each | $136.71 | |
| 28465 | Treat midfoot fracture each | $4,541.71 | |
| 28470 | Treat metatarsal fracture | $136.71 | |
| 28476 | Treat metatarsal fracture | $2,377.46 | |
| 28485 | Treat metatarsal fracture | $4,541.71 | |
| 28496 | Treat big toe fracture | $2,377.46 | |
| 28505 | Treat big toe fracture | $2,377.46 | |
| 28515 | Treatment of toe fracture | $136.71 | |
| 28525 | Treat toe fracture | $2,377.46 | |
| 28531 | Treat sesamoid bone fracture | $2,377.46 | |
| 28546 | Treat foot dislocation | $2,377.46 | |
| 28555 | Repair foot dislocation | $4,541.71 | |
| 28576 | Treat foot dislocation | $2,377.46 | |
| 28585 | Repair foot dislocation | $2,377.46 | |
| 28606 | Treat foot dislocation | $2,377.46 | |
| 28615 | Repair foot dislocation | $4,541.71 | |
| 28636 | Treat toe dislocation | $2,377.46 | |
| 28645 | Repair toe dislocation | $2,377.46 | |
| 28666 | Treat toe dislocation | $2,377.46 | |
| 28675 | Repair of toe dislocation | $2,377.46 | |
| 28715 | Fusion of foot bones | $6,159.04 | * |
| 28725 | Fusion of foot bones | $5,320.90 | |
| 28730 | Fusion of foot bones | $5,320.90 | |
| 28740 | Fusion of foot bones | $5,320.90 | |
| 28750 | Fusion of big toe joint | $5,320.90 | |
| 28755 | Fusion of big toe joint | $2,011.21 |
TABLE B, SURGERY CENTER PROCEDURES (cont.)
See Chapter 9, Section 9 (c), for additional information on facility reimbursements and Chapter 9, Section 1, for general guidelines.
| CPT | Short Descriptor | B | |
|---|---|---|---|
| Facility Reimbursement | Invoice Required | ||
| 28805 | Amputation thru metatarsal | $2,011.21 | |
| 28820 | Amputation of toe | $2,011.21 | |
| 28825 | Partial amputation of toe | $2,011.21 | |
| 29581 | Apply multlay comprs lwr leg | $102.44 | |
| 29582 | Apply multlay comprs upr arm | $102.44 | |
| 29582 | Apply multlay comprs upr leg | $102.44 | |
| 29584 | Appl multlay comprs arm/hand | $102.44 | |
| 29800 | Jaw arthroscopy/surgery | $2,709.86 | |
| 29804 | Jaw arthroscopy/surgery | $2,709.86 | |
| 29805 | Shoulder arthroscopy dx | $2,709.86 | |
| 29806 | Shoulder arthroscopy/surgery | $5,194.58 | |
| 29807 | Shoulder arthroscopy/surgery | $5,194.58 | |
| 29819 | Shoulder arthroscopy/surgery | $5,194.58 | |
| 29820 | Shoulder arthroscopy/surgery | $5,194.58 | |
| 29821 | Shoulder arthroscopy/surgery | $5,194.58 | |
| 29822 | Shoulder arthroscopy/surgery | $2,709.86 | |
| 29823 | Shoulder arthroscopy/surgery | $5,194.58 | |
| 29824 | Shoulder arthroscopy/surgery | $2,709.86 | |
| 29825 | Shoulder arthroscopy/surgery | $5,194.58 | |
| 29826 | Shoulder arthroscopy/surgery | $2,709.86 | |
| 29827 | Arthroscop rotator cuff repr | $4,546.81 | * |
| 29828 | Arthroscopy biceps tenodesis | $5,194.58 | |
| 29830 | Elbow arthroscopy | $2,709.86 | |
| 29834 | Elbow arthroscopy/surgery | $2,709.86 | |
| 29835 | Elbow arthroscopy/surgery | $2,709.86 | |
| 29836 | Elbow arthroscopy/surgery | $2,709.86 | |
| 29837 | Elbow arthroscopy/surgery | $2,709.86 | |
| 29838 | Elbow arthroscopy/surgery | $2,709.86 | |
| 29840 | Wrist arthroscopy | $2,709.86 | |
| 29843 | Wrist arthroscopy/surgery | $2,709.86 | |
| 29844 | Wrist arthroscopy/surgery | $2,709.86 | |
| 29845 | Wrist arthroscopy/surgery | $2,709.86 | |
| 29846 | Wrist arthroscopy/surgery | $2,709.86 | |
| 29847 | Wrist arthroscopy/surgery | $5,194.58 | |
| 29848 | Wrist endoscopy/surgery | $2,709.86 | |
| 29850 | Knee arthroscopy/surgery | $2,709.86 | |
| 29851 | Knee arthroscopy/surgery | $5,194.58 | |
| 29855 | Tibial arthroscopy/surgery | $5,194.58 |
TABLE B, SURGERY CENTER PROCEDURES (cont.)
See Chapter 9, Section 9 (c), for additional information on facility reimbursements and Chapter 9, Section 1, for general guidelines.
| CPT | Short Descriptor | B | |
|---|---|---|---|
| Facility Reimbursement | Invoice Required | ||
| 29856 | Tibial arthroscopy/surgery | $5,194.58 | |
| 29860 | Hip arthroscopy dx | $5,194.58 | |
| 29861 | Hip arthro w/fb removal | $5,194.58 | |
| 29862 | Hip arthro w/debridement | $5,194.58 | |
| 29863 | Hip arthro w/synovectomy | $5,194.58 | |
| 29866 | Autgrft implnt knee w/scope | $5,194.58 | |
| 29867 | Allgrft implnt knee w/scope | $5,194.58 | |
| 29868 | Meniscal trnspl knee w/scpe | $5,194.58 | |
| 29870 | Knee arthroscopy dx | $2,709.86 | |
| 29871 | Knee arthroscopy/drainage | $2,709.86 | |
| 29873 | Knee arthroscopy/surgery | $2,709.86 | |
| 29874 | Knee arthroscopy/surgery | $2,709.86 | |
| 29875 | Knee arthroscopy/surgery | $2,709.86 | |
| 29876 | Knee arthroscopy/surgery | $2,709.86 | |
| 29877 | Knee arthroscopy/surgery | $2,709.86 | |
| 29879 | Knee arthroscopy/surgery | $2,709.86 | |
| 29880 | Knee arthroscopy/surgery | $2,709.86 | |
| 29881 | Knee arthroscopy/surgery | $2,709.86 | |
| 29882 | Knee arthroscopy/surgery | $2,709.86 | |
| 29883 | Knee arthroscopy/surgery | $2,709.86 | |
| 29884 | Knee arthroscopy/surgery | $2,709.86 | |
| 29885 | Knee arthroscopy/surgery | $5,194.58 | |
| 29886 | Knee arthroscopy/surgery | $2,709.86 | |
| 29887 | Knee arthroscopy/surgery | $2,709.86 | |
| 29888 | Knee arthroscopy/surgery | $6,159.04 | * |
| 29889 | Knee arthroscopy/surgery | $6,159.04 | * |
| 29891 | Ankle arthroscopy/surgery | $5,194.58 | |
| 29892 | Ankle arthroscopy/surgery | $6,159.04 | * |
| 29893 | Scope plantar fasciotomy | $2,011.21 | |
| 29894 | Ankle arthroscopy/surgery | $2,709.86 | |
| 29895 | Ankle arthroscopy/surgery | $2,709.86 | |
| 29897 | Ankle arthroscopy/surgery | $2,709.86 | |
| 29898 | Ankle arthroscopy/surgery | $2,709.86 | |
| 29904 | Subtalar arthro w/fb rmvl | $2,709.86 | |
| 29905 | Subtalar arthro w/exc | $2,709.86 | |
| 29906 | Subtalar arthro w/deb | $2,709.86 | |
| 29907 | Subtalar arthro w/fusion | $5,194.58 | |
| 30130 | Excise inferior turbinate | $1,535.50 |
TABLE B, SURGERY CENTER PROCEDURES (cont.)
See Chapter 9, Section 9 (c), for additional information on facility reimbursements and Chapter 9, Section 1, for general guidelines.
| CPT | Short Descriptor | B | |
|---|---|---|---|
| Facility Reimbursement | Invoice Required | ||
| 30140 | Resect inferior turbinate | $2,265.44 | |
| 30420 | Reconstruction of nose | $4,099.33 | |
| 30465 | Repair nasal stenosis | $4,099.33 | |
| 30520 | Repair of nasal septum | $2,265.44 | |
| 30560 | Release of nasal adhesions | $283.53 | |
| 30802 | Ablate inf turbinate submuc | $1,535.50 | |
| 30930 | Ther fx nasal inf turbinate | $1,535.50 | |
| 31254 | Revision of ethmoid sinus | $2,762.34 | |
| 31256 | Exploration maxillary sinus | $2,762.34 | |
| 31267 | Endoscopy maxillary sinus | $2,762.34 | |
| 31505 | Diagnostic laryngoscopy | $97.66 | |
| 31570 | Laryngoscope w/vc inj | $1,936.67 | |
| 31571 | Laryngoscop w/vc inj + scope | $2,762.34 | |
| 31575 | Diagnostic laryngoscopy | $169.69 | |
| 35207 | Repair blood vessel lesion | $3,735.34 | |
| 38230 | Bone marrow harvest allogen | $3,242.61 | |
| 38500 | Biopsy/removal lymph nodes | $2,300.42 | |
| 41899 | Dental surgery procedure | $97.47 | |
| 42145 | Repair palate pharynx/uvula | $2,265.44 | |
| 43235 | Uppr gi endoscopy diagnosis | $769.22 | |
| 43239 | Upper gi endoscopy biopsy | $769.22 | |
| 43248 | Uppr gi endoscopy/guide wire | $769.22 | |
| 45330 | Diagnostic sigmoidoscopy | $566.19 | |
| 45378 | Diagnostic colonoscopy | $852.79 | |
| 45380 | Colonoscopy and biopsy | $852.79 | |
| 45385 | Lesion removal colonoscopy | $852.79 | |
| 46221 | Ligation of hemorrhoid(s) | $502.05 | |
| 46260 | Remove in/ex hem groups 2+ | $2,224.36 | |
| 46500 | Injection into hemorrhoid(s) | $502.05 | |
| 49505 | Prp i/hern init reduc >5 yr | $2,997.23 | |
| 49507 | Prp i/hern init block >5 yr | $2,997.23 | |
| 49520 | Rerepair ing hernia reduce | $2,997.23 | |
| 49521 | Rerepair ing hernia blocked | $2,997.23 | |
| 49525 | Repair ing hernia sliding | $2,997.23 | |
| 49550 | Rpr rem hernia init reduce | $2,997.23 | |
| 49553 | Rpr fem hernia init blocked | $2,997.23 | |
| 49560 | Rpr ventral hern init reduc | $2,997.23 | |
| 49561 | Rpr ventral hern init block | $2,997.23 |
TABLE B, SURGERY CENTER PROCEDURES (cont.)
See Chapter 9, Section 9 (c), for additional information on facility reimbursements and Chapter 9, Section 1, for general guidelines.
| CPT | Short Descriptor | B | |
|---|---|---|---|
| Facility Reimbursement | Invoice Required | ||
| 49565 | Rerepair ventrl hern reduce | $2,997.23 | |
| 49566 | Rerepair ventrl hern block | $2,997.23 | |
| 49568 | Hernia repair w/mesh | $2,997.23 | |
| 49570 | Rpr epigastric hern reduce | $2,997.23 | |
| 49572 | Rpr epigastric hern blocked | $2,997.23 | |
| 49585 | Rpr umbil hern reduc > 5 yr | $2,997.23 | |
| 49587 | Rpr umbil hern block > 5 yr | $2,997.23 | |
| 49650 | Lap ing hernia repair init | $4,363.44 | |
| 49651 | Lap ing hernia repair recur | $4,363.44 | |
| 49652 | Lap vent/abd hernia repair | $6,513.92 | |
| 49653 | Lap vent/abd hern proc comp | $6,513.92 | |
| 49654 | Lap inc hernia repair | $6,513.92 | |
| 49655 | Lap inc hern repair comp | $6,513.92 | |
| 49656 | Lap inc hernia repair recur | $6,513.92 | |
| 49657 | Lap inc hern recur comp | $6,513.92 | |
| 50590 | Fragmenting of kidney stone | $4,741.07 | |
| 51040 | Incise & drain bladder | $2,393.58 | |
| 51045 | Incise bladder/drain ureter | $616.53 | |
| 51705 | Change of bladder tube | $177.48 | |
| 51726 | Complex cystometrogram | $290.23 | |
| 51741 | Electro-uroflowmetry first | $100.99 | |
| 51784 | Anal/urinary muscle study | $100.99 | |
| 51797 | Intraabdominal pressure test | $177.48 | |
| 52000 | Cystoscopy | $616.53 | |
| 52276 | Cystoscopy and treatment | $2,393.58 | |
| 52281 | Cystoscopy and treatment | $1,590.26 | |
| 52310 | Cystoscopy and treatment | $1,590.26 | |
| 52332 | Cystoscopy and treatment | $2,393.58 | |
| 54235 | Penile injection | $177.48 | |
| 54415 | Remove self-contd penis pros | $3,149.92 | |
| 54520 | Removal of testis | $2,143.10 | |
| 55520 | Removal of sperm cord lesion | $2,143.10 | |
| 55530 | Revise spermatic cord veins | $2,143.10 | |
| 57240 | Repair bladder & vagina | $3,268.41 | |
| 57267 | Insert mesh/pelvic flr addon | $3,268.41 | |
| 61885 | Insrt/redo neurostim 1 array | $2,776.18 | * |
| 61886 | Implant neurostim arrays | $3,067.33 | * |
| 62287 | Percutaneous discectomy | $3,288.46 |
TABLE B, SURGERY CENTER PROCEDURES (cont.)
See Chapter 9, Section 9 (c), for additional information on facility reimbursements and Chapter 9, Section 1, for general guidelines.
| CPT | Short Descriptor | B | |
|---|---|---|---|
| Facility Reimbursement | Invoice Required | ||
| 62292 | Injection into disk lesion | $678.44 | |
| 62350 | Implant spinal canal cath | $3,782.31 | |
| 62351 | Implant spinal canal cath | $4,617.84 | |
| 62355 | Remove spinal canal catheter | $1,165.02 | |
| 62361 | Implant spine infusion pump | $3,284.05 | * |
| 62362 | Implant spine infusion pump | $3,284.05 | * |
| 62365 | Remove spine infusion device | $3,288.46 | |
| 62367 | Analyze spine infus pump | $217.81 | |
| 62368 | Analyze sp inf pump w/reprog | $217.81 | |
| 63020 | Neck spine disk surgery | $4,617.84 | |
| 63030 | Low back disk surgery | $4,617.84 | |
| 63035 | Spinal disk surgery add-on | $4,617.84 | |
| 63040 | Laminotomy single cervical | $4,617.84 | |
| 63042 | Laminotomy single lumbar | $4,617.84 | |
| 63044 | Laminotomy addl lumbar | $4,617.84 | |
| 63045 | Removal of spinal lamina | $4,617.84 | |
| 63046 | Removal of spinal lamina | $4,617.84 | |
| 63047 | Removal of spinal lamina | $4,617.84 | |
| 63048 | Remove spinal lamina add-on | $4,617.84 | |
| 63056 | Decompress spinal cord | $4,617.84 | |
| 63075 | Neck spine disk surgery | $4,617.84 | |
| 63076 | Neck spine disk surgery | $4,617.84 | |
| 63081 | Removal of vertebral body | $4,617.84 | |
| 63267 | Excise intraspinal lesion | $4,617.84 | |
| 63650 | Implant neuroelectrodes | $2,588.19 | * |
| 63655 | Implant neuroelectrodes | $2,883.18 | * |
| 63661 | Remove spine eltrd perq aray | $1,885.92 | |
| 63662 | Remove spine eltrd plate | $1,885.92 | |
| 63663 | Revise spine eltrd perq aray | $2,588.19 | * |
| 63664 | Revise spine eltrd plate | $2,588.19 | * |
| 63685 | Insrt/redo spine n generator | $2,776.18 | * |
| 63688 | Revise/remove neuroreceiver | $2,830.74 | |
| 64555 | Implant neuroelectrodes | $2,588.19 | * |
| 64561 | Implant neuroelectrodes | $2,588.19 | * |
| 64565 | Implant neuroelectrodes | $2,588.19 | * |
| 64575 | Implant neuroelectrodes | $2,883.18 | * |
| 64580 | Implant neuroelectrodes | $2,883.18 | * |
| 64581 | Implant neuroelectrodes | $2,883.18 | * |
TABLE B, SURGERY CENTER PROCEDURES (cont.)
See Chapter 9, Section 9 (c), for additional information on facility reimbursements and Chapter 9, Section 1, for general guidelines.
| CPT | Short Descriptor | B | |
|---|---|---|---|
| Facility Reimbursement | Invoice Required | ||
| 64590 | Insrt/redo pn/gastr stimul | $2,776.18 | * |
| 64595 | Revise/rmv pn/gastr stimul | $2,830.74 | |
| 64702 | Revise finger/toe nerve | $1,719.56 | |
| 64704 | Revise hand/foot nerve | $1,719.56 | |
| 64708 | Revise arm/leg nerve | $1,719.56 | |
| 64712 | Revision of sciatic nerve | $1,719.56 | |
| 64714 | Revise low back nerve(s) | $1,719.56 | |
| 64718 | Revise ulnar nerve at elbow | $1,719.56 | |
| 64719 | Revise ulnar nerve at wrist | $1,719.56 | |
| 64721 | Carpal tunnel surgery | $1,719.56 | |
| 64722 | Relieve pressure on nerve(s) | $1,719.56 | |
| 64727 | Internal nerve revision | $1,719.56 | |
| 64771 | Sever cranial nerve | $1,719.56 | |
| 64772 | Incision of spinal nerve | $1,719.56 | |
| 64776 | Remove digit nerve lesion | $1,719.56 | |
| 64778 | Digit nerve surgery add-on | $1,719.56 | |
| 64782 | Remove limb nerve lesion | $1,719.56 | |
| 64783 | Limb nerve surgery add-on | $1,719.56 | |
| 64784 | Remove nerve lesion | $1,719.56 | |
| 64787 | Implant nerve end | $1,719.56 | |
| 64790 | Removal of nerve lesion | $1,719.56 | |
| 64831 | Repair of digit nerve | $3,288.46 | |
| 64832 | Repair nerve add-on | $3,288.46 | |
| 64834 | Repair of hand or foot nerve | $3,288.46 | |
| 64836 | Repair of hand or foot nerve | $3,288.46 | |
| 64837 | Repair nerve add-on | $3,288.46 | |
| 64856 | Repair/transpose nerve | $3,288.46 | |
| 64890 | Nerve graft hand or foot | $3,288.46 | |
| 64898 | Nerve graft arm or leg | $3,288.46 | |
| 64910 | Nerve repair w/allograft | $3,288.46 | |
| 65210 | Remove foreign body from eye | $96.38 | |
| 65222 | Remove foreign body from eye | $96.38 | |
| 65235 | Remove foreign body from eye | $1,512.88 | |
| 65260 | Remove foreign body from eye | $438.12 | |
| 65280 | Repair of eye wound | $1,960.28 | |
| 65285 | Repair of eye wound | $3,733.27 | |
| 65400 | Removal of eye lesion | $1,512.88 | |
| 65426 | Removal of eye lesion | $2,119.41 |
TABLE B - SURGERY CENTER PROCEDURES (cont.)
See Chapter 9, Section 9 (c), for additional information on facility reimbursements and Chapter 9, Section 1, for general guidelines.
| CPT | Short Descriptor | B | |
|---|---|---|---|
| Facility Reimbursement | Invoice Required | ||
| 65435 | Curette/treat cornea | $696.90 | |
| 65710 | Corneal transplant | $3,010.00 | * |
| 65730 | Corneal transplant | $3,010.00 | * |
| 65750 | Corneal transplant | $3,010.00 | * |
| 65755 | Corneal transplant | $3,010.00 | * |
| 65756 | Corneal trnspl endothelial | $3,010.00 | * |
| 65875 | Incise inner eye adhesions | $2,119.41 | |
| 66180 | Implant eye shunt | $3,784.41 | |
| 66250 | Follow-up surgery of eye | $1,512.88 | |
| 66761 | Revision of iris | $492.60 | |
| 66821 | After cataract laser surgery | $492.60 | |
| 66825 | Reposition intraocular lens | $2,119.41 | |
| 66830 | Removal of lens lesion | $657.07 | |
| 66840 | Removal of lens material | $1,512.88 | |
| 66852 | Removal of lens material | $2,820.30 | |
| 66920 | Extraction of lens | $2,820.30 | |
| 66930 | Extraction of lens | $2,820.30 | |
| 66982 | Cataract surgery complex | $2,173.65 | |
| 66983 | Cataract surg w/iol 1 stage | $2,173.65 | |
| 66984 | Cataract surg w/iol 1 stage | $2,173.65 | |
| 66985 | Insert lens prosthesis | $2,173.65 | |
| 67036 | Removal of inner eye fluid | $3,733.27 | |
| 67040 | Laser treatment of retina | $3,733.27 | |
| 67110 | Repair detached retina | $1,960.28 | |
| 67121 | Remove eye implant material | $3,733.27 | |
| 67225 | Eye photodynamic ther add-on | $438.12 | |
| 67314 | Revise eye muscle | $2,263.40 | |
| 67332 | Rerevise eye muscles add-on | $2,263.40 | |
| 67335 | Eye suture during surgery | $2,263.40 | |
| 67399 | Eye muscle surgery procedure | $2,263.40 | |
| 67820 | Revise eyelashes | $96.38 | |
| 67875 | Closure of eyelid by suture | $696.90 | |
| 67917 | Repair eyelid defect | $1,800.25 | |
| 67950 | Revision of eyelid | $1,800.25 | |
| 68320 | Revise/graft eyelid lining | $2,488.63 | |
| 68360 | Revise eyelid lining | $2,119.41 | |
| 68362 | Revise eyelid lining | $2,119.41 | |
| 69310 | Rebuild outer ear canal | $4,099.33 |
Table B - SURGERY CENTER PROCEDURES (cont.)
See Chapter 9, Section 9 (c), for additional information on facility reimbursements and Chapter 9, Section 1, for general guidelines.
| CPT | Short Descriptor | B | |
|---|---|---|---|
| Facility Reimbursement | Invoice Required | ||
| 69436 | Create eardrum opening | $1,535.50 | |
| 69620 | Repair of eardrum | $2,265.44 | |
| 69631 | Repair eardrum structures | $4,099.33 |