Appendix H: Procedures Requiring TARs
The document begins on the next page.
Medi-Cal Treatment Authorizations and Claims Processing, Appendices
H1
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TAR and Non-Benefit: Introduction to List
1
The TAR and Non-Benefit List: Codes (10000 – 99999) contains CPT-4 codes and descriptions with
numbers indicating benefit restrictions. Any code in the CPT-4 book currently valid for Medi-Cal but not
on the TAR and Non-Benefit List is a Medi-Cal benefit without the listed restrictions. If you are uncertain
about the authorization requirements, or suspect that this list contains an error, contact the EDS Provider
Support Center (PSC) at 1-800-541-5555.
Note: Refer to the CPT-4 book for complete descriptions of the listed codes.
Non-Benefit (1)
Codes marked with a “1” either are not Medi-Cal benefits or are not
reimbursable, even though the service is a benefit. For example,
immunization injections are benefits of Medi-Cal, but CPT-4 codes
90700 – 90747 are marked a “1” because Medi-Cal requires providers
to bill immunizations using the HCPCS codes in the Injections: List of
Codes section in the appropriate Part 2 manual.
Medi-Cal will not reimburse any provider for codes marked with a “1.”
Requires TAR, Primary
Surgeon/Provider (2)
Codes marked with a “2” (Requires TAR, Primary Surgeon/Provider)
require a Treatment Authorization Request (TAR) for the primary
surgeon or provider whether performed on an inpatient or outpatient
basis. Podiatrists should refer to the Podiatry Services section in the
appropriate Part 2 manual for prior authorization requirements.
Anesthesiologists and assistant surgeons do not need a TAR for
services marked with a “2.”
Non-Benefit,
Assistant Surgeon (3)
Medi-Cal will not reimburse assistant surgeon services for codes
marked with a “3” (Non-Benefit, Assistant Surgeon). Do not bill the
assistant surgeon modifier for codes marked with a “3.”
Non-Benefit,
Medi-Cal will not reimburse anesthesia services for codes marked
with
a “4” (Non-Benefit, Anesthesiologist). Do not bill anesthesia modifiers
with codes marked with a “4.”
Anesthesiologist (4)
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Ambulatory Surgical (5)
Codes marked with a “5” (Ambulatory Surgical) are routinely
performed on an outpatient basis. A TAR is required when a primary
surgeon or provider performs these services in an inpatient setting.
TAR approval will be granted only when there is documentation of a
medical condition making an outpatient setting inappropriate.
Anesthesiologists and assistant surgeons do not need a TAR for
services marked with a “5.”
Inpatient Hospitalization
Stay: Prior Authorization
Reminder
Authorization for an inpatient hospital stay must be obtained, even
if the procedure being performed does not require a TAR.
Authorization may be requested by either the physician performing the
procedure or the hospital providing the inpatient stay.
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TAR and Non-Benefit List: Codes 10000 – 19999
Code
Benefit
Restrictions
Description
ANESTHESIA
Anesthesia services should be billed using the appropriate five-digit
CPT-4 anesthesia code (00100 – 01999) and the appropriate
anesthesia modifier. Refer to the Anesthesia section in the
appropriate Part 2 manual for more detailed information.
SURGERY
INTEGUMENTARY SYSTEM
10040
10060
10061
10080
10081
10120
10121
10140
10160
11000
11001
11055
11056
11057
11100
11101
SKIN, SUBCUTANEOUS
AND ACCESSORY STRUCTURES
Incision and Drainage
Acne surgery................................................................ 2, 3
Incision/drainage abscess, simple or single ................ 3, 5
Incision/drainage abscess, complicated or multiple......... 5
Incision/drainage pilonidal cyst, simple........................ 3, 5
Incision/drainage pilonidal cyst, complicated................... 5
Incision/removal foreign body, simple.......................... 3, 5
Incision/removal foreign body, complicated ..................... 5
Incision/drainage hematoma, simple ........................... 3, 5
Puncture aspiration ...................................................... 3, 5
Excision – Debridement
Debridement of extensive eczematous
or infected skin ........................................................... 3
Debridement of extensive eczematous
or infected skin; each additional 10% of the body
surface (List separately in addition to code for
primary procedure) ..................................................... 3
Paring or Cutting
Paring or cutting of benign hyperkeratotic lesion
(e.g., corn or callus); single lesion .............................. 3
Paring or cutting of benign hyperkeratotic lesion
(e.g., corn or callus); two to four lesions..................... 3
Paring or cutting of benign hyperkeratotic lesion
(e.g., corn or callus); four or more lesions .................. 3
Biopsy
Biopsy skin, subcutaneous tissue,
mucous membrane................................................. 3, 5
Biopsy skin, subcutaneous tissue,
mucous membrane; each separate/additional
lesion (List separately in addition to code for
primary procedure) ............................................. 3, 4, 5
Benefit Restriction Descriptions:
1
2
Code
11200
11201
11300
11301
11302
11303
11305
11306
11307
11308
11310
11311
11312
11313
11400
11401
11402
11403
11404
11406
11420
11421
11422
11423
11424
11426
11440
11441
11442
11443
11444
11446
11450
11451
11462
11463
11470
11471
Non-Benefit
Requires TAR,
Primary Surgeon/Provider
1
Description
Benefit
Restrictions
Excision – Benign Lesions
Excision, skin tags, up to 15 ............................................3
Excision, skin tags, each additional 10 lesions
(List separately in addition to code for primary
procedure) ..............................................................3, 4
Shaving, epidermal or dermal lesion, 0.5 cm or less .......3
Shaving, epidermal or dermal lesion, 0.6 or 1.0 cm.........3
Shaving, epidermal or dermal lesion, 1.1 or 2.0 cm.........3
Shaving, epidermal or dermal lesion, over 2.0 cm...........3
Shaving, epidermal or dermal lesion, 0.5 cm or less .......3
Shaving, epidermal or dermal lesion, 0.6 to 1.0 cm.........3
Shaving, epidermal or dermal lesion, 1.1 to 2.0 cm.........3
Shaving, epidermal or dermal lesion, over 2.0 cm ..........3
Shaving, epidermal or dermal lesion, 0.5 cm or less ......3
Shaving, epidermal or dermal lesion, 0.6 to 1.0 cm ........3
Shaving, epidermal or dermal lesion, 1.1 to 2.0 cm ........3
Shaving, epidermal or dermal lesion, over 2.0 cm ..........3
Excision, benign lesion, 0.5 cm or less ............................3
Excision, benign lesion, 0.6 to 1.0 cm..............................3
Excision, benign lesion, 1.1 to 2.0 cm..............................3
Excision, benign lesion, 2.1 to 3.0 cm..............................3
Excision, benign lesion, 3.1 to 4.0 cm..............................3
Excision, benign lesion, over 4.0 cm................................3
Excision, benign lesion, 0.5 cm or less ............................3
Excision, benign lesion, 0.6 to 1.0 cm..............................3
Excision, benign lesion, 1.1 to 2.0 cm..............................3
Excision, benign lesion, 2.1 to 3.0 cm..............................3
Excision, benign lesion, 3.1 to 4.0 cm..............................3
Excision, benign lesion, over 4.0 cm................................3
Excision, benign lesion, 0.5 cm or less ............................3
Excision, benign lesion, 0.6 to 1.0 cm..............................3
Excision, benign lesion, 1.1 to 2.0 cm..............................3
Excision, benign lesion, 2.1 to 3.0 cm..............................3
Excision, benign lesion, 3.1 to 4.0 cm..............................3
Excision, benign lesion, over 4.0 cm................................3
Excision, skin, hidradenitis, axillary,
primary suture.........................................................3, 5
Excision, skin, hidradenitis, axillary, other ...................3, 5
Excision, skin, hidradenitis, inguinal, primary ..............3, 5
Excision, skin, hidradenitis, inguinal, other ..................3, 5
Excision, skin, hidradenitis, perianal,
perineal, primary.....................................................3, 5
Excision, skin, hidradenitis, perianal,
perineal, other.........................................................3, 5
3
4
5
Assistant Surgeon services not payable
Anesthesiology services not payable
Ambulatory Surgical
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Benefit
Restrictions
Code
Description
11600
11601
11602
11603
11604
11606
11620
11621
11622
11623
11624
11626
11640
11641
11642
11643
11644
11646
Excision – Malignant Lesions
Excision, malignant lesion, 0.5 cm or less ................... 3, 5
Excision, malignant lesion, 0.6 to 1.0 cm..................... 3, 5
Excision, malignant lesion, 1.1 to 2.0 cm..................... 3, 5
Excision, malignant lesion, 2.1 to 3.0 cm......................... 5
Excision, malignant lesion, 3.1 to 4.0 cm......................... 5
Excision, malignant lesion, over 4.0 cm........................... 5
Excision, malignant lesion, 0.5 cm or less .................. 3, 5
Excision, malignant lesion, 0.6 to 1.0 cm..................... 3, 5
Excision, malignant lesion, 1.1 to 2.0 cm..................... 3, 5
Excision, malignant lesion, 2.1 to 3.0 cm......................... 5
Excision, malignant lesion, 3.1 to 4.0 cm......................... 5
Excision, malignant lesion, over 4.0 cm........................... 5
Excision, malignant lesion, 0.5 cm or less ................... 3, 5
Excision, malignant lesion, 0.6 to 1.0 cm..................... 3, 5
Excision, malignant lesion, 1.1 to 2.0 cm..................... 3, 5
Excision, malignant lesion, 2.1 to 3.0 cm......................... 5
Excision, malignant lesion, 3.1 to 4.0 cm......................... 5
Excision, malignant lesion, over 4.0 cm........................... 5
11740
11750
11752
11755
11760
11762
11765
Nails
Trimming of nondystrophic nails, any number ................. 1
Avulsion nail plate, simple, single .................................... 3
Avulsion nail plate, each additional plate (List
separately in addition to code for primary
procedure) .............................................................. 3, 4
Evacuation subungual hematoma................................ 3, 5
Excision, nail, nail matrix.............................................. 2, 3
Excision, nail, nail matrix, with amputation .................. 2, 3
Biopsy, nail unit, any method ........................................... 3
Repair of nail bed......................................................... 3, 5
Reconstruction of nail bed with graft................................ 5
Wedge excision of skin and nail fold............................ 3, 4
11770
11771
11772
Miscellaneous
Excision, pilonidal cyst or sinus, simple........................... 3
Excision, pilonidal cyst or sinus, extensive ...................... 2
Excision, pilonidal cyst or sinus, complicated .................. 2
11719
11730
11732
11900
11901
11920
11921
11922
11950
11951
11952
11954
11960
Introduction
Injection, intralesional, up to
and including 7 lesions ............................................... 3
Injection, intralesional, more than 7 lesions ................. 3, 4
Tattooing .......................................................................... 1
Tattooing .......................................................................... 1
Tattooing .......................................................................... 1
Subcutaneous injection, filling material............................ 1
Subcutaneous injection, filling material............................ 1
Subcutaneous injection, filling material............................ 1
Subcutaneous injection, filling material............................ 1
Insertion, tissue expander(s) for other than breast .......... 2
Benefit Restriction Descriptions:
1
2
Code
Description
Benefit
Restrictions
11980
Introduction (continued)
Replacement, tissue expander
with permanent prosthesis..........................................2
Removal, tissue expander(s)
without prosthesis insertion ........................................2
Insertion, implantable contraceptive capsules .........3, 4, 5
Removal without reinsertion,
implantable contraceptive capsules....................3, 4, 5
Removal with reinsertion,
implantable contraceptive capsules............................3
Subcutaneous hormone pellet implantation ...............3
12001
12002
12004
12005
12006
12007
12011
12013
12014
12015
12016
12017
12018
12020
12021
Repair – Simple
Repair, simple, superficial, 2.5 cm or less ...................3, 5
Repair, simple, superficial, 2.6 cm to 7.5 cm ...............3, 5
Repair, simple, superficial, 7.6 cm to 12.5 cm .............3, 5
Repair, simple, superficial, 12.6 to 20.0 cm .................3, 5
Repair, simple, superficial, 20.1 to 30.0 cm .................3, 5
Repair, simple, superficial, over 30.0 cm .....................3, 5
Repair, simple, superficial, 2.5 cm or less ...................3, 5
Repair, simple, superficial, 2.6 to 5.0 cm .....................3, 5
Repair, simple, superficial, 5.1 to 7.5 cm .....................3, 5
Repair, simple, superficial, 7.6 to 12.5 cm ...................3, 5
Repair, simple, superficial, 12.6 to 20.0 cm .................3, 5
Repair, simple, superficial, 20.1 to 30.0 cm .....................5
Repair, simple, superficial, over 30.0 cm .........................5
Treatment, superficial wound dehiscence, simple .......3, 5
Treatment, superficial wound dehiscence, packing .....3, 5
12031
12032
12034
12035
12036
12037
12041
12042
12044
12045
12046
12047
12051
12052
12053
12054
12055
12056
12057
Repair – Intermediate
Repair, intermediate, 2.5 cm or less ............................3, 5
Repair, intermediate, 2.6 to 7.5 cm..............................3, 5
Repair, intermediate, 7.6 to 12.5 cm............................3, 5
Repair, intermediate, 12.6 to 20.0 cm..........................3, 5
Repair, intermediate, 20.1 to 30.0 cm..........................3, 5
Repair, intermediate, over 30.0 cm..................................5
Repair, intermediate, 2.5 cm or less ............................3, 5
Repair, intermediate, 2.6 to 7.5 cm..............................3, 5
Repair, intermediate, 7.6 to 12.5 cm............................3, 5
Repair, intermediate, 12.6 to 20.0 cm..........................3, 5
Repair, intermediate, 20.1 to 30.0 cm..........................3, 5
Repair, intermediate, over 30.0 cm..............................3, 5
Repair, intermediate, 2.5 cm or less ............................3, 5
Repair, intermediate, 2.6 to 5.0 cm..............................3, 5
Repair, intermediate, 5.1 to 7.5 cm..............................3, 5
Repair, intermediate, 7.6 to 12.5 cm............................3, 5
Repair, intermediate, 12.6 to 20.0 cm..............................5
Repair, intermediate, 20.1 to 30.0 cm..............................5
Repair, intermediate, over 30.0 cm..................................5
11970
11971
11975
11976
11977
Non-Benefit
Requires TAR,
Primary Surgeon/Provider
3
4
5
Assistant Surgeon services not payable
Anesthesiology services not payable
Ambulatory Surgical
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Code
13100
13101
13102
13120
13121
13122
13131
13132
13150
13151
13152
15101
15121
15201
15221
15241
15261
Benefit
Restrictions
Description
Repair – Complex
Repair, complex, trunk; 1.1 to 2.5 cm .......................... 3, 5
Repair, complex, trunk; 2.6 to 7.5 cm .............................. 5
Repair, complex, trunk; each additional 5 cm
or less ......................................................................... 3
Repair, complex, scalp, arms, legs; 1.1 to 2.5 cm ....... 3, 5
Repair, complex, scalp, arms, legs; 2.6 to 7.5 cm ....... 3, 5
Repair, complex, scalp, arms, legs; each additional
5 cm or less ................................................................ 3
Repair, complex, 1.1 to 2.5 cm .................................... 3, 5
Repair, complex, 2.6 to 7.5 cm ........................................ 5
Repair, complex, face, 1.0 cm or less......................... 3, 5
Repair, complex, face, 1.1 to 2.5 cm ........................... 3, 5
Repair, complex, 2.6 to 7.5 cm ........................................ 5
Free Skin Grafts
Split graft, trunk, scalp, each additional 100 sq cm,
or each additional one percent of body area
of infants and children, or part thereof........................ 4
Split graft, face, scalp, eyelids, mouth, neck, ears,
orbits, genitalia, hands, feet, and/or multiple
digits; each additional 100 sq cm, or each
additional one percent of body area of infants
and children, or part thereof ....................................... 4
Full thickness graft, trunk,
each additional 20 sq cm............................................ 4
Full thickness graft, scalp,
each additional 20 sq cm............................................ 4
Full thickness graft, forehead,
each additional 20 sq cm............................................ 4
Full thickness graft, nose, eyelids,
each additional 20 sq cm............................................ 4
15775
15776
Other Grafts
Punch graft for hair transplant.......................................... 1
Punch graft for hair transplant.......................................... 1
15780
15781
15782
15783
15787
Miscellaneous Procedures
Dermabrasion, total face.................................................. 2
Dermabrasion, segmental, face ....................................... 2
Dermabrasion, regional, other than face.......................... 2
Dermabrasion, superficial, any site.................................. 3
Abrasion, each additional four lesions or less ................. 4
Code
15852
15860
15876
15877
15878
15879
15999
Pressure Ulcers (Decubitus Ulcers)
Unlisted procedure, excision pressure ulcer ....................2
15845
15850
15851
16020
16025
16030
1
2
Benefit
Restrictions
Miscellaneous Procedures (continued)
Chemical peel, facial; epidermal ......................................2
Chemical peel, facial; dermal...........................................2
Chemical peel, nonfacial; epidermal ................................2
Chemical peel, nonfacial; dermal.....................................2
Salabrasion, 20 sq cm or less..........................................2
Salabrasion, over 20 sq cm .............................................2
Cervicoplasty ...................................................................1
Blepharoplasty, lower lid ..................................................2
Blepharoplasty, lower eyelid, herniated fat pad ...............2
Blepharoplasty, upper eyelid............................................2
Blepharoplasty, upper eyelid, excessive skin ..................2
Rhytidectomy, forehead ...................................................1
Rhytidectomy, neck..........................................................1
Rhytidectomy, frown lines ................................................1
Rhytidectomy, cheek, chin and neck ...............................1
Rhytidectomy ...................................................................1
Excision, excessive skin, abdomen .................................1
Excision, excessive skin, thigh.........................................1
Excision, excessive skin, leg............................................1
Excision, excessive skin, hip............................................1
Excision, excessive skin, buttock.....................................1
Excision, excessive skin, arm ..........................................1
Excision, excessive skin, forearm and hand ....................1
Excision, excessive skin, submental fat pad....................1
Excision, excessive skin ..................................................1
Graft for facial nerve paralysis, free fascia graft ..............2
Graft for facial nerve paralysis, free muscle graft ............2
Graft for facial nerve paralysis; free muscle flap by
microsurgical technique................................................2
Graft for facial nerve paralysis,
regional muscle transfer .............................................2
Removal of sutures under anesthesia,
same surgeon.............................................................1
Removal of sutures under anesthesia,
other surgeon .........................................................3, 5
Dressing change under anesthesia .................................1
I.V. injection of agent to test blood flow in flap.................5
Suction assisted lipectomy, head and neck .....................1
Suction assisted lipectomy, trunk.....................................1
Suction assisted lipectomy, arm ......................................1
Suction assisted lipectomy, leg........................................1
15788
15789
15792
15793
15810
15811
15819
15820
15821
15822
15823
15824
15825
15826
15828
15829
15831
15832
15833
15834
15835
15836
15837
15838
15839
15840
15841
15842
16000
16010
Benefit Restriction Descriptions:
Description
Non-Benefit
Requires TAR,
Primary Surgeon/Provider
Burns, Local Treatment
Initial treatment, first degree burn ............................3, 4, 5
Dressings/debridement burn,
under anesthesia, small..............................................3
Dressing/debridement burn,
without anesthesia, small .......................................4, 5
Dressing/debridement burn,
without anesthesia, medium .......................................4
Dressing/debridement burn,
without anesthesia, large............................................4
3
4
5
Assistant Surgeon services not payable
Anesthesiology services not payable
Ambulatory Surgical
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Code
17000
17003
17004
17106
17107
17108
17110
17111
17250
17260
17261
17262
17263
17264
17266
Benefit
Restrictions
Description
Destruction
Destruction by any method, including laser, with or
without surgical curettement, all benign or
premalignant lesions (e.g., actinic keratoses) other
than skin tags or cutaneous vascular proliferative
lesions, including local anesthesia; first lesion ........... 3
Destruction by any method, including laser, with or
without surgical curettement, all benign or
premalignant lesions (e.g., actinic keratoses) other
than skin tags or cutaneous vascular proliferative
lesions, including local anesthesia; second through
14 lesions, each ......................................................... 3
Destruction by any method, including laser, with or
without surgical curettement, all benign or
premalignant lesions (e.g., actinic keratoses) other
than skin tags or cutaneous vascular proliferative
lesions, including local anesthesia, 15 or
more lesions ............................................................... 3
Destruction, cutaneous vascular proliferative
lesions, less 10 sq cm ................................................ 3
Destruction, cutaneous vascular proliferative
lesions, 10 – 50 sq cm................................................ 3
Destruction, cutaneous vascular proliferative
lesions, over 50 sq cm................................................ 3
Destruction by any method of flat warts, molluscum
contagiosum, or milia; up to 14 lesions ...................... 3
Destruction by any method of flat warts, molluscum
contagiosum, or milia; 15 or more lesions .................. 3
Chemical cauterization of granulation tissue ............... 3, 4
Destruction, malignant lesion, trunk or limbs,
less than 0.5 cm ......................................................... 3
Destruction, malignant lesion, trunk or limbs,
0.6 – 1.0 cm................................................................ 3
Destruction, malignant lesion, trunk or limbs,
1.1 – 2.0 cm................................................................ 3
Destruction, malignant lesion, trunk or limbs,
2.1 – 3.0 cm................................................................ 3
Destruction, malignant lesion, trunk or limbs,
3.1 – 4.0 cm................................................................ 3
Destruction, malignant lesion, trunk or limbs,
over 4.0 cm................................................................. 3
Benefit Restriction Descriptions:
1
2
Code
17270
17271
17272
17273
17274
17276
17280
17281
17282
17283
17284
17286
17304
17305
17306
17307
17310
17340
17360
17380
17999
Non-Benefit
Requires TAR,
Primary Surgeon/Provider
Description
Benefit
Restrictions
Destruction (continued)
Destruction, malignant lesion, scalp, neck, etc.,
less than 0.5 cm .........................................................3
Destruction, malignant lesion, scalp, neck, etc.,
0.6 – 1.0 cm................................................................3
Destruction, malignant lesion, scalp, neck, etc.,
1.1 – 2.0 cm................................................................3
Destruction, malignant lesion, scalp, neck, etc.,
2.1 – 3.0 cm................................................................3
Destruction, malignant lesion, scalp, neck, etc.,
3.1 – 4.0 cm................................................................3
Destruction, malignant lesion, scalp, neck, etc.,
over 4.0 cm.................................................................3
Destruction, malignant lesion, face, ears, etc.,
less than 0.5 cm .........................................................3
Destruction, malignant lesion, face, ears, etc.,
0.6 – 1.0 cm................................................................3
Destruction, malignant lesion, face, ears, etc.,
1.1 – 2.0 cm................................................................3
Destruction, malignant lesion, face, ears, etc.,
2.1 – 3.0 cm................................................................3
Destruction, malignant lesion, face, ears, etc.,
3.1 – 4.0 cm................................................................3
Destruction, malignant lesion, face, ears, etc.,
over 4.0 cm.................................................................3
Chemosurgery (Mohs’); first stage, fresh tissue
technique, up to 5 specimens.................................2, 3
Chemosurgery (Mohs’); second stage,
fixed/fresh tissue, up to 5 specimens .....................2, 3
Chemosurgery (Mohs’); third stage,
fixed/fresh tissue, up to 5 specimens .....................2, 3
Chemosurgery (Mohs’); additional stage(s),
up to 5 specimens ..................................................2, 3
Chemosurgery (Mohs’); more than 5
specimens, any stage.............................................2, 3
Cryotherapy for acne................................................2, 3, 4
Chemical exfoliation for acne...................................2, 3, 4
Electrolysis.......................................................................1
Unlisted procedure, skin, mucous membrane..................2
3
4
5
Assistant Surgeon services not payable
Anesthesiology services not payable
Ambulatory Surgical
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Code
19000
19001
19020
19030
19100
19101
19102
19110
19112
19120
19126
19140
19160
19162
19180
19182
19200
19220
19240
19260
19271
19272
19290
19291
19295
Benefit
Restrictions
Description
BREAST
Incision
Puncture aspiration, breast cyst................................... 4, 5
Puncture, each additional cyst (List separately in
addition to code for primary procedure).................. 4, 5
Mastotomy, exploration/drainage of abscess............... 3, 5
Injection procedure, mammary ductogram .................. 3, 5
Excision
Biopsy of breast; percutaneous, needle core, not
using imaging guidance .................................. 3, 4, 5
Biopsy of breast; open, incisional.................................... 5
Biopsy of breast; percutaneous, needle core, using
imaging guidance .................................................... 3
Nipple exploration ............................................................ 5
Excision lactiferous duct fistula........................................ 5
Excision of cyst, fibroadenoma, or other benign or
malignant tumor, aberrant breast tissue, duct lesion,
nipple or areolar lesion (except 19140), open, male
or female, one or more lesions ................................... 5
Excision of breast lesion identified by preoperative
placement of radiological marker; open, each
additional lesion.......................................................... 4
Mastectomy for gynecomastia ......................................... 2
Mastectomy, partial.......................................................... 2
Mastectomy, partial; with axillary lymphadenectomy ....... 2
Mastectomy, simple, complete......................................... 2
Mastectomy, subcutaneous ............................................. 2
Mastectomy, radical ......................................................... 2
Mastectomy, radical, urban type ...................................... 2
Mastectomy, modified radical .......................................... 2
Excision, chest wall tumor................................................ 2
Excision, chest wall tumor, with plastic reconstruction .... 2
Excision, chest wall tumor, with mediastinal
lymphadenectomy ...................................................... 2
Code
19316
19318
19324
19325
19328
19330
19340
19342
19350
19355
19357
19361
19364
19366
19367
19368
19369
19370
19371
19380
19396
19499
Description
Benefit
Restrictions
Repair and Reconstruction
Mastopexy........................................................................1
Reduction mammaplasty .................................................2
Mammaplasty, augmentation, no implant ........................2
Mammaplasty, augmentation, with implant......................2
Removal of intact mammary implant................................2
Removal of implant material ............................................2
Immediate insertion of breast prosthesis
after mastectomy ........................................................2
Delayed insertion of breast prosthesis
after mastectomy ........................................................2
Nipple/areola reconstruction ............................................2
Correction inverted nipples ..............................................1
Breast reconstruction .......................................................2
Breast reconstruction .......................................................2
Breast reconstruction, free flap ........................................2
Breast reconstruction, other technique ............................2
Breast reconstruction with TRAM, single pedicle.............2
Breast reconstruction with TRAM, single pedicle;
with microvascular anastomosis.................................2
Breast reconstruction with TRAM, double pedicle ...........2
Open periprosthetic capsulotomy, breast ........................2
Periprosthetic capsulectomy, breast ................................2
Revision reconstructed breast .........................................2
Preparation, moulage for custom breast implant .............2
Unlisted procedure, breasts .............................................2
Introduction
Preoperative placement of needle
localization wire, breast .............................................. 3
Preoperative placement of needle localization
wire, breast, each additional lesion ........................ 3, 4
Image guided placement, metallic localization clip,
percutaneous, during breast biopsy....................... 3
Benefit Restriction Descriptions:
1
2
Non-Benefit
Requires TAR,
Primary Surgeon/Provider
3
4
5
Assistant Surgeon services not payable
Anesthesiology services not payable
Ambulatory Surgical
2 – TAR and Non-Benefit List: Codes 10000 – 19999
November 2001
tar and non cd2
TAR and Non-Benefit List: Codes 20000 – 29999
Code
Benefit
Restrictions
Description
SURGERY (continued)
MUSCULOSKELETAL SYSTEM
20000
20005
20200
20205
20206
20220
20225
20240
20245
20250
20251
20500
20501
20520
20525
20550
20600
20605
20610
20615
20650
20660
20665
20670
20680
20690
20692
20693
20694
GENERAL
Incision
Incision, soft tissue abscess, superficial .......................... 5
Incision, soft tissue abscess, deep or complicated.......... 5
Excision
Biopsy, muscle, superficial........................................... 3, 5
Biopsy, muscle, deep....................................................... 5
Biopsy, muscle, percutaneous needle ..................... 3, 4, 5
Biopsy, bone, trocar or needle, superficial................... 3, 5
Biopsy, bone, trocar or needle, deep ............................... 5
Biopsy, bone, excisional, superficial (e.g., ilium,
sternum, spinous process, ribs, trochanter
of femur) ................................................................. 3, 5
Biopsy, excisional, deep .................................................. 5
Biopsy, vertebral body, open, thoracic............................. 5
Biopsy, vertebral body, open, lumbar or cervical ............. 5
Introduction or Removal
Injection, sinus tract, therapeutic ................................. 3, 5
Injection, sinus tract, diagnostic ................................... 3, 5
Removal of foreign body in muscle, simple ................. 3, 5
Removal of foreign body in muscle,
deep or complicated ................................................... 5
Injection, tendon sheath, ligament, trigger point .......... 3, 5
Arthrocentesis, aspiration and/or injection,
small joint.................................................................... 3
Arthrocentesis, aspiration and/or injection,
intermediate joint ........................................................ 3
Arthrocentesis, aspiration and/or injection,
major joint ................................................................... 3
Aspiration/injection for treatment of bone cyst ............. 3, 5
Insertion of wire or pin with
application of skeletal traction .................................... 3
Application of cranial tongs or caliper .......................... 3, 5
Removal of tongs or halo, applied by
another physician ................................................... 3, 5
Removal of implant, superficial .................................... 3, 5
Removal of implant, deep ................................................ 5
Application of a uniplane, unilateral,
external fixation system .............................................. 3
Application of a multiplane, unilateral,
external fixation system .............................................. 3
Adjustment or revision of external fixation system........... 3
Removal, under anesthesia,
of external fixation system .......................................... 3
Benefit Restriction Descriptions:
1
2
1
Benefit
Restrictions
Code
Description
20900
20910
20912
20920
20926
Grafts (or Implants)
Bone graft, any donor area, minor or small......................5
Cartilage graft, costochondral ..........................................5
Cartilage graft, nasal septum ...........................................5
Fascia lata graft, by stripper.............................................5
Tissue graft ......................................................................5
20950
20974
20979
20999
Miscellaneous
Monitoring of interstitial fluid pressure .........................3, 4
Electrical stimulation to aid bone healing,
noninvasive.............................................................3, 5
Low intensity ultrasound stimulation to aid bone
healing, noninvasive (nonoperative).......................3
Unlisted procedure, musculoskeletal
system, general ..........................................................2
21010
HEAD
Incision
Arthrotomy, temporomandibular joint ...............................2
21050
21060
21070
Excision
Condylectomy, temporomandibular joint..........................2
Meniscectomy, temporomandibular joint .........................2
Coronoidectomy...............................................................2
21076
21077
21079
21080
21081
21082
21083
21084
21085
21086
Non-Benefit
Requires TAR,
Primary Surgeon/Provider
Introduction or Removal
Impression and custom preparation;
surgical obturator prosthesis ......................................1
Impression and custom preparation;
orbital prosthesis ........................................................1
Impression and custom preparation;
interium obturator prosthesis ......................................1
Impression and custom preparation;
definitive obturator prosthesis.....................................1
Impression and custom preparation;
mandibular resection prosthesis.................................1
Impression and custom preparation;
palatal augmentation prosthesis.................................1
Impression and custom preparation;
palatal lift prosthesis ...................................................1
Impression and custom preparation;
speech aid prosthesis.................................................1
Impression and custom preparation;
oral surgical splint.......................................................1
Impression and custom preparation;
auricular prosthesis ....................................................1
3
4
5
Assistant Surgeon services not payable
Anesthesiology services not payable
Ambulatory Surgical
2 – TAR and Non-Benefit List: Codes 20000 – 29999
January 2001
tar and non cd2
2
Code
21087
21088
21089
21116
21125
21299
Benefit
Restrictions
Description
Introduction or Removal (continued)
Impression and custom preparation;
nasal prosthesis.......................................................... 1
Impression and custom preparation;
facial prosthesis.......................................................... 1
Unlisted maxillofacial prosthetic procedure ..................... 1
Injection procedure, temporomandibular
arthrography ....................................................... 3, 4, 5
Repair, Revision, or Reconstruction
Augmentation, mandibular body or angle;
prosthetic procedure................................................... 1
Unlisted craniofacial/maxillofacial procedure................... 2
21337
21355
21440
21499
Fracture and/or Dislocation
Treatment closed/open nasal fracture,
without manipulation................................................... 5
Manipulative treatment, nasal bone fracture................ 3, 5
Manipulative treatment, nasal bone fracture,
stabilization............................................................. 3, 5
Open treatment nasal fracture, uncomplicated ................ 5
Open treatment nasal fracture, complicated,
skeletal fixation ........................................................... 5
Open treatment nasal fracture
with fractured septum ................................................. 5
Treatment closed nasal septal fracture........................ 3, 5
Manipulative treatment of closed or open fracture........... 3
Manipulative treatment of alveolar ridge fracture............. 3
Unlisted orthopedic procedure, head ............................... 2
21550
NECK (SOFT TISSUE) AND THORAX
Excision
Biopsy, soft tissue, neck/thorax ................................... 3, 5
21310
21315
21320
21325
21330
21335
21700
21705
21720
21725
21740
Repair, Revision or Reconstruction
Division, scalenus anticus; without resection
of cervical rib .............................................................. 2
Division, scalenus anticus; with resection
of cervical rib .............................................................. 2
Division, sternocleidomastoid for torticollis,
without cast application .............................................. 2
Division, sternocleidomastoid for torticollis,
with cast application ................................................... 2
Reconstructive repair, pectus excavatum
or carinatum................................................................ 2
Benefit Restriction Descriptions:
1
2
Benefit
Restrictions
Code
Description
21800
Fracture and/or Dislocation
Treatment rib fracture, closed, uncomplicated.................5
21899
Miscellaneous
Unlisted procedure, neck or thorax ..................................2
21920
21925
BACK AND FLANK
Excision
Biopsy, soft tissue back/flank, superficial.........................5
Biopsy, soft tissue back/flank, deep.................................5
22103
22116
22216
22226
22328
22505
22585
Non-Benefit
Requires TAR,
Primary Surgeon/Provider
SPINE (VERTEBRAL COLUMN)
Excision
Partial excision of posterior vertebral
component for intrinsic bony lesion, single
vertebral segment; each additional segment..............4
Partial excision of vertebral body for intrinsic
bony lesion, without decompression of
spinal cord or nerve root(s), single vertebral
segment; each additional vertebral segment..............4
Osteotomy
Osteotomy of spine, posterior or posterolateral
approach, one vertebral segment;
each additional vertebral segment..............................4
Osteotomy of spine, including diskectomy,
anterior approach, single vertebral segment;
each additional vertebral segment..............................4
Fracture and/or Dislocation
Open treatment and/or reduction of vertebral
fracture(s) and/or dislocation(s); posterior
approach, each additional fractured vertebrae or
dislocated segment.....................................................4
Manipulation
Manipulation of spine requiring anesthesia,
any region ...................................................................3
Arthrodesis
Arthrodesis, anterior interbody technique, including
minimal diskectomy to prepare interspace;
each additional interspace..........................................4
3
4
5
Assistant Surgeon services not payable
Anesthesiology services not payable
Ambulatory Surgical
2 – TAR and Non-Benefit List: Codes 20000 – 29999
October 1999
tar and non cd2
3
Code
22614
22632
Benefit
Restrictions
Description
Posterior, Posterolateral or
Lateral Transverse Process Technique
Arthrodesis, posterior or posterolateral
technique; each additional
vertebral segment....................................................... 4
Arthrodesis, posterior interbody technique; each
additional interspace................................................... 4
Code
22899
22900
ABDOMEN
Excision
Excision, abdominal wall tumor, subfascial ..................... 2
22999
Miscellaneous
Unlisted procedure, abdomen, musculoskeletal .............. 2
23675
23929
Miscellaneous
Unlisted procedure, shoulder ...........................................2
23505
23520
23540
23545
23570
23575
23600
23605
23000
23031
SHOULDER
Incision
Removal of subdeltoid (or intratendinous)
calcareous deposits, any method ............................ 2
Incision and drainage, shoulder area;
infected bursa ............................................................. 3
23620
23625
23630
23065
23066
Excision
Biopsy, soft tissues, shoulder, superficial ................ 3, 4, 5
Biopsy, soft tissue, shoulder, deep .................................. 5
23650
23330
23350
Introduction or Removal
Removal foreign body, shoulder, subcutaneous.......... 3, 5
Injection procedure for shoulder arthrography ................. 3
23665
23412
23415
23420
23440
23470
23472
23490
23491
Repair, Revision or Reconstruction
Repair, ruptured supraspinatus tendon, chronic .............. 2
Coracoacromial ligament release .................................... 2
Reconstruction of complete shoulder (rotator)
cuff avulsion, chronic (includes acromioplasty) ... 2
Resection or transplantation, long tendon of biceps ........ 2
Arthroplasty, glenohumeral joint; hemiarthroplasty .... 2
Arthroplasty, glenohumeral joint; total shoulder
(glenoid and proximal humeral replacement
[e.g. total shoulder]) ................................................. 2
Prophylactic treatment, clavicle ....................................... 5
Prophylactic treatment, proximal
humerus...................................................................... 5
23655
23931
24065
24066
24076
24100
24101
24105
Benefit Restriction Descriptions:
1
2
Benefit
Restrictions
Fracture and/or Dislocation
Treatment closed clavicular fracture,
no manipulation ..........................................................5
Treatment closed clavicular fracture,
with manipulation........................................................5
Treatment closed sternoclavicular dislocation,
no manipulation ..........................................................5
Treatment closed sternoclavicular dislocation,
with manipulation........................................................5
Treatment closed acromioclavicular dislocation,
no manipulation ......................................................3, 5
Treatment closed acromioclavicular dislocation,
with manipulation....................................................3, 5
Treatment closed scapular fracture,
no manipulation ..........................................................5
Treatment closed scapular fracture,
with manipulation........................................................5
Treatment closed humeral fracture,
no manipulation ..........................................................5
Treatment closed humeral fracture,
with manipulation........................................................5
Closed treatment of greater humeral tuberosity
fracture, without manipulation ...............................5
Treatment closed greater tuberosity fracture,
with manipulation........................................................5
Open treatment of greater humeral tuberosity fracture,
with or without internal or external fixation...........5
Treatment closed shoulder dislocation,
no anesthesia .........................................................4, 5
Closed treatment closed shoulder dislocation,
anesthesia ..................................................................5
Closed treatment of shoulder dislocation,
with fracture of greater humeral tuberosity,
with manipulation .....................................................5
Treatment closed shoulder dislocation, surgical ..............5
23500
23525
Other Procedures
Unlisted procedure, spine ................................................ 2
Description
Non-Benefit
Requires TAR,
Primary Surgeon/Provider
HUMERUS (UPPER ARM) AND ELBOW
Incision
Incision and drainage, upper arm or elbow area;
bursa..........................................................................3
Excision
Biopsy arm/elbow, soft tissues, superficial .................3, 5
Biopsy, arm/elbow, soft tissues, deep (subfascial or
intramuscular)...........................................................5
Excision, tumor, deep, facial, intramuscular ....................2
Arthrotomy, elbow; with synovial biopsy only...................5
Arthrotomy, elbow; with joint exploration..........................5
Excision, olecranon bursa................................................2
3
4
5
Assistant Surgeon services not payable
Anesthesiology services not payable
Ambulatory Surgical
2 – TAR and Non-Benefit List: Codes 20000 – 29999
October 1999
tar and non cd2
4
Code
Benefit
Restrictions
Description
24220
Introduction or Removal
Removal arm/elbow foreign body, subcutaneous....... 3, 5
Removal arm/elbow foreign body, deep (subfascial
or intramuscular) ...................................................... 5
Injection procedure for elbow arthrography ..................... 3
24310
Repair, Revision and Reconstruction
Tenotomy, open, elbow to shoulder, each tendon.......... 5
24200
24201
24500
24505
24530
24535
24560
24565
24576
24577
24600
24605
24620
24640
24650
24655
24670
24675
24999
25040
Fracture and/or Dislocation
Treatment closed humeral shaft fracture,
without manipulation............................................... 4, 5
Treatment closed humeral fracture,
with manipulation........................................................ 5
Treatment closed supracondylar fracture,
without manipulation............................................... 4, 5
Treatment closed supracondylar fracture,
manipulation ............................................................... 5
Treatment closed epicondylar fracture,
without manipulation................................................... 5
Treatment closed epicondylar fracture,
with manipulation........................................................ 5
Treatment closed condylar fracture,
without manipulation................................................... 5
Treatment closed condylar fracture,
with manipulation........................................................ 5
Treatment closed elbow dislocation,
without anesthesia.................................................. 4, 5
Treatment closed elbow dislocation,
with anesthesia........................................................... 5
Treatment closed Monteggia type fracture,
dislocation................................................................... 5
Treatment radial head subluxation in child ...................... 5
Treatment closed radial head or neck fracture,
without manipulation................................................... 5
Treatment closed radial head or neck fracture,
with manipulation........................................................ 5
Treatment closed ulnar fracture, olecranon,
without manipulation................................................... 5
Treatment closed ulnar fracture, olecranon,
manipulation ............................................................... 5
Miscellaneous
Unlisted procedure, humerus or elbow ............................ 2
FOREARM AND WRIST
Incision
Arthrotomy, radiocarpal or midcarpal joint,
with exploration, drainage, or removal
of foreign body............................................................ 3
Benefit Restriction Descriptions:
1
2
Code
Description
Benefit
Restrictions
25075
25076
25085
25100
25101
25115
Excision
Biopsy, forearm, soft tissues, superficial.....................3, 5
Biopsy, forearm, soft tissues, deep (subfascial or
intramuscular)...........................................................5
Excision, tumor, subcutaneous ........................................2
Excision, tumor, deep ......................................................2
Capsulotomy, wrist (e.g., contracture) ...........................2
Arthrotomy, wrist joint; with biopsy...................................5
Arthrotomy, wrist joint; with joint exploration ....................5
Radical excision of bursa/synovia of wrist; flexors...........3
25246
25248
Introduction or Removal
Injection procedure for wrist arthrography........................3
Exploration with removal of deep foreign body ................5
25260
25270
25272
25290
25295
25350
25355
25360
25365
Repair, Revision or Reconstruction
Repair, tendon/muscle, flexor, primary, single.................5
Repair, tendon/muscle, extensor, primary, single............5
Repair, tendon/muscle, extensor, secondary, single .......5
Tenotomy, open, single....................................................5
Tenolysis, single tendon, each tendon.............................5
Osteotomy, radius, distal third .........................................2
Osteotomy, radius, middle or proximal third ....................2
Osteotomy, ulna ...............................................................2
Osteotomy, radius and ulna .............................................2
25065
25066
25675
25680
25690
Fracture and/or Dislocation
Treatment closed radial shaft fracture .............................5
Treatment closed radial shaft fracture,
with manipulation....................................................3, 5
Treatment closed ulnar shaft fracture ..............................5
Treatment closed ulnar shaft fracture,
with manipulation....................................................3, 5
Treatment closed radial and ulnar shaft fracture .............5
Treatment closed radial and ulnar fractures,
manipulation ...............................................................5
Treatment closed distal radial fracture.............................5
Treatment closed distal radial fracture,
with manipulation....................................................3, 5
Treatment closed carpal scaphoid fracture..................3, 5
Treatment closed carpal scaphoid fracture,
manipulation ...........................................................3, 5
Treatment closed carpal bone fracture ............................5
Treatment closed carpal bone fracture,
with manipulation....................................................3, 5
Treatment closed ulnar styloid fracture........................3, 5
Treatment closed carpal dislocation,
with manipulation....................................................3, 5
Treatment closed distal radioulnar dislocation.............3, 5
Treatment closed trans-scaphoperilunar fracture ............5
Treatment lunate dislocation, with manipulation ..........3, 5
25999
Miscellaneous
Unlisted procedure, forearm or wrist ................................2
25500
25505
25530
25535
25560
25565
25600
25605
25622
25624
25630
25635
25650
25660
Non-Benefit
Requires TAR,
Primary Surgeon/Provider
3
4
5
Assistant Surgeon services not payable
Anesthesiology services not payable
Ambulatory Surgical
2 – TAR and Non-Benefit List: Codes 20000 – 29999
October 1999
tar and non cd2
5
Benefit
Restrictions
Code
Description
26010
26011
26020
26025
26030
26055
26060
HAND AND FINGERS
Incision
Drainage of finger abscess, simple.............................. 3, 5
Drainage of finger abscess, complicated ......................... 5
Drainage of tendon sheath, digit and/or palm, each ........ 5
Drainage of palmar bursa; single, bursa .......................... 5
Drainage of palmar bursa; multiple bursa ........................ 5
Tendon sheath incision (e.g., for trigger finger) ............... 5
Tenotomy, percutaneous, single, each digit .................... 5
Code
26450
26455
26460
26476
26477
26520
26100
26105
26110
26115
26116
26125
26130
26135
26140
26145
26170
26180
26200
26210
Excision
Arthrotomy with biopsy;
carpometacarpal joint, each ....................................... 5
Arthrotomy with biopsy;
metacarpophalangeal joint, each................................ 5
Arthrotomy with synovial biopsy;
interphalangeal joint ................................................... 5
Excision, tumor; subcutaneous .................................... 2, 3
Excision, tumor; deep, subfascial,
intramuscular .............................................................. 2
Fasciectomy, each additional digit ................................... 4
Synovectomy, carpometacarpal joint ............................... 5
Synovectomy, metacarpophalangeal joint ....................... 5
Synovectomy, proximal interphalangeal joint................... 5
Synovectomy tendon sheath, radical
(tenosynovectomy), flexor tendon, palm
and/or finger, each tendon.......................................... 5
Excision of tendon, palm, flexor, single, (separate
procedure) each ......................................................... 5
Excision of tendon, finger, flexor (separate
procedure), each tendon ............................................ 5
Excision/curettage bone cyst/benign tumor,
metacarpal.................................................................. 5
Excision/curettage bone cyst/benign tumor phalanx........ 5
26525
26600
26605
26607
26670
26675
26676
26700
26705
26706
26720
26725
26350
26352
26358
26410
26412
26418
26432
26433
26440
26445
Repair, Revision or Reconstruction
Repair or advancement, flexor tendon not in digital
flexor tendon sheath (e.g., no man’s land);
primary or secondary without free graft,
each tendon................................................................ 5
Flexor tendon repair, secondary ...................................... 5
Flexor tendon repair, single, secondary, each ................. 5
Repair, extensor tendon, hand, primary or
secondary; without free graft, each tendon ................ 5
Extensor tendon repair, dorsum of hand,
single, with free graft .................................................. 5
Repair, extensor tendon, finger, primary or
secondary; without free graft, each tendon ................ 5
Closed treatment of distal extensor tendon
insertion, with or without percutaneous pinning
(e.g., mallet finger)...................................................... 5
Repair of extensor tendon, distal insertion, primary
or secondary; without graft (e.g., mallet finger) .......... 5
Tenolysis, flexor tendon, palm OR finger; each
tendon......................................................................... 5
Tenolysis, extensor tendon, hand or finger; each
tendon......................................................................... 5
Benefit Restriction Descriptions:
1
2
26740
26742
26750
26755
26756
26765
26770
26775
26776
Non-Benefit
Requires TAR,
Primary Surgeon/Provider
Description
Benefit
Restrictions
Repair, Revision or Reconstruction (continued)
Tenotomy, flexor, palm, open, each tendon.....................5
Tenotomy, flexor, finger, open, each tendon....................5
Tenotomy, extensor, hand or finger, open, each
tendon.........................................................................5
Lengthening of tendon, extensor, hand or finger,
each tendon................................................................5
Shortening of tendon, extensor, hand or finger,
each tendon................................................................5
Capsulectomy or capsulotomy;
metacarpophalangeal joint, each joint ........................5
Capsulectomy or capsulotomy; interphalangeal joint,
each joint ....................................................................5
Fractures and/or Dislocations
Treatment closed metacarpal fracture, single,.................5
Treatment closed metacarpal fracture,
single, manipulation....................................................5
Treatment closed metacarpal fracture,
single, manipulation....................................................5
Treatment closed carpometacarpal
dislocation, single ...............................................3, 4, 5
Treatment closed carpometacarpal
dislocation, anesthesia ...........................................3, 5
Treatment closed carpometacarpal
dislocation, pinning .....................................................3
Treatment closed metacarpophalangeal
dislocation, no anesthesia ..................................3, 4, 5
Treatment closed metacarpophalangeal
dislocation, anesthesia ...........................................3, 5
Treatment closed metacarpophalangeal
dislocation...............................................................3, 5
Treatment closed phalangeal shaft fracture,
without manipulation...............................................3, 5
Treatment closed phalangeal shaft fracture,
manipulation ...........................................................3, 5
Treatment closed articular fracture,
without manipulation, each joint .............................3, 5
Treatment closed articular fracture,
with manipulation....................................................3, 5
Treatment closed distal phalangeal fracture,
without manipulation...............................................3, 5
Treatment closed distal phalangeal fracture,
manipulation ...........................................................3, 5
Treatment closed distal phalangeal fracture,
pinning ........................................................................5
Open treatment distal phalangeal fracture.......................5
Treatment closed interphalangeal joint
dislocation, no anesthesia ..................................3, 4, 5
Treatment closed interphalangeal joint
dislocation, anesthesia ...........................................3, 5
Treatment closed interphalangeal joint
dislocation, pinning .................................................3, 5
3
4
5
Assistant Surgeon services not payable
Anesthesiology services not payable
Ambulatory Surgical
2 – TAR and Non-Benefit List: Codes 20000 – 29999
October 1999
tar and non cd2
6
Code
26861
26863
26989
Benefit
Restrictions
Description
Arthrodesis
Arthrodesis, with or without internal fixation;
interphalangeal joint, each additional
interphalangeal joint (List separately in
addition to code for primary procedure)...................... 4
Arthrodesis, with or without internal fixation;
interphalangeal joint, with autograft (includes
obtaining graft), each additional joint
(List separately in addition to code for primary
procedure) .................................................................. 4
Miscellaneous
Unlisted procedure, hands or fingers ............................... 2
Description
27275
Manipulation
Manipulation, hip joint, requiring
general anesthesia .....................................................3
27299
27323
27324
27328
26991
27000
27001
27040
27041
27048
27086
27093
27095
27096
27130
27132
27134
27137
27138
27175
27200
27250
27256
27257
27265
PELVIS AND HIP JOINT
Incision
Incision and drainage, pelvis or hip joint,
infected bursa ............................................................. 3
Tenotomy, adductor of hip, percutaneous (separate
procedure) .................................................................. 3
Tenotomy, adductor of hip, open ..................................... 3
Excision
Biopsy; soft tissues, superficial........................................ 5
Biopsy; soft tissues, deep, subfascial or
intramuscular .............................................................. 5
Excision, tumor, deep, subfacial, intramuscular .............. 2
Introduction and/or Removal
Removal of foreign body, pelvis or hip;
subcutaneous tissue................................................... 3
Injection procedure for hip arthrography;
without anesthesia.................................................. 3, 4
Injection procedure for hip arthrography;
with anesthesia........................................................... 3
Injection procedure for sacroiliac joint,
arthrography and/or anesthetic/steroid.................. 3
Repair, Revision or Reconstruction
Arthroplasty, total hip replacement .................................. 2
Conversion, previous hip surgery
to total hip replacement .............................................. 2
Revision, total hip arthroplasty, both components ........... 2
Revision, total hip arthroplasty,
acetabular component only ........................................ 2
Revision, total hip arthroplasty,
femoral component only ............................................. 2
Treatment, slipped femoral epiphysis; by traction............ 4
27370
27418
27420
27422
27424
27425
27427
27428
27429
27437
27438
27440
27441
27442
27443
27445
27446
27447
27455
27457
27486
27487
Fractures and/or Dislocations
Treatment closed coccygeal fracture ............................... 5
Treatment, closed hip dislocation;
without anesthesia...................................................... 4
Treatment congenital hip dislocation ............................... 5
Treatment congenital hip dislocation, manipulation......... 5
Treatment, atraumatic hip dislocation;
without anesthesia...................................................... 4
Benefit Restriction Descriptions:
1
2
Benefit
Restrictions
Code
Non-Benefit
Requires TAR,
Primary Surgeon/Provider
Miscellaneous
Unlisted procedure, pelvis or hip joint ..............................2
FEMUR (THIGH REGION) AND KNEE JOINT
Excision
Biopsy, thigh, soft tissues, superficial ..........................3, 5
Biopsy, thigh, soft tissues, deep (subfascial or
intramuscular).............................................................5
Excision, tumor; deep, subfascial, intramuscular.............2
Introduction and/or Removal
Injection procedure for knee arthrography ...................3, 5
Anterior tibial tubercleplasty
(e.g., Maquet type procedure) ....................................2
Reconstruction of dislocating patella; (e.g., Hauser
type procedure)...........................................................2
Reconstruction of dislocating patella with extensor
realignment and/or muscle advancement or
release (e.g., Campbell, Goldwaite type
procedure) ..................................................................2
Reconstruction for recurrent dislocating patella;
with patellectomy ........................................................2
Lateral retinacular release ...............................................2
Ligamentous reconstruction, knee; extra-articular ...........2
Ligamentous reconstruction, knee; intra-articular ............2
Ligamentous reconstruction, knee;
intra-articular and extra-articular.................................2
Arthroplasty, patella; without prosthesis ..........................2
Arthroplasty, patella; with prosthesis ...............................2
Arthroplasty, knee, tibial plateau......................................2
Arthroplasty, knee, tibial plateau; with debridement
and partial synovectomy.............................................2
Arthroplasty, femoral condyles
or tibial plateau(s), knee .............................................2
Arthroplasty, knee, femoral condyles or
tibial plateaus; with debridement and
partial synovectomy....................................................2
Arthroplasty, knee, hinge prosthesis (e.g., Walldius
type)............................................................................2
Arthroplasty, knee, condyle and plateau ..........................2
Arthroplasty, knee, total knee replacement......................2
Osteotomy, proximal tibia; before epiphyseal closure .....2
Osteotomy, proximal tibia; after epiphyseal closure ........2
Revision of total knee arthroplasty; one component ........2
Revision of total knee arthroplasty; femoral and entire
tibial component .........................................................2
3
4
5
Assistant Surgeon services not payable
Anesthesiology services not payable
Ambulatory Surgical
2 – TAR and Non-Benefit List: Codes 20000 – 29999
January 2001
tar and non cd2
7
Code
27520
27530
27532
27550
27560
27562
Benefit
Restrictions
Description
Fractures and/or Dislocations
Treatment closed patellar fracture ................................... 5
Treatment closed tibial fracture, proximal ........................ 5
Treatment closed tibial fracture, proximal,
manipulation ............................................................... 5
Treatment of closed knee dislocation;
without anesthesia...................................................... 4
Treatment closed patellar dislocation;
without anesthesia.................................................. 4, 5
Treatment closed patellar dislocation;
with anesthesia........................................................... 5
27570
Manipulation
Manipulation of knee joint under general anesthesia ...... 3
27599
Miscellaneous
Unlisted procedure, femur or knee................................... 2
27604
27605
27606
27613
27614
27618
27619
27648
27692
27700
27702
27703
LEG (tibia and fibula) and ANKLE JOINT
Incision
Incision and drainage, leg or ankle; infected bursa ......... 3
Tenotomy, percutaneous, Achilles tendon (separate
procedure); local anesthesia .................................. 3, 4
Tenotomy, achilles tendon, subcutaneous;
general anesthesia ..................................................... 3
Excision
Biopsy, lower leg, soft tissue; superficial ..................... 3, 5
Biopsy, lower leg, soft tissues, deep (subfascial or
intramuscular)............................................................. 5
Excision, tumor, leg or ankle area; subcutaneous
tissue ...................................................................... 2, 3
Excision, tumor, deep, subfascial
or intramuscular.......................................................... 2
Introduction or Removal
Injection procedure for ankle arthrography .................. 3, 5
Repair, Revision or Reconstruction
Transfer or transplant of tendon; each additional
tendon (List in addition to code for primary
procedure) .................................................................. 4
Arthroplasty, ankle ........................................................... 2
Arthroplasty, ankle; with implant ...................................... 2
Arthroplasty, ankle; revision, total ankle .......................... 2
Code
27750
27752
27760
27762
27780
27781
Benefit Restriction Descriptions:
1
2
Benefit
Restrictions
27840
27842
Fractures and/or Dislocations (continued)
Treatment closed distal fibular fracture............................5
Treatment closed distal fibular fracture,
with manipulation........................................................5
Open treatment distal fibular fracture, with fixation..........5
Treatment closed bimalleolar ankle fracture ....................5
Treatment closed bimalleolar ankle fracture,
manipulation ...............................................................5
Treatment closed trimalleolar ankle fracture....................5
Treatment closed trimalleolar ankle fracture,
manipulation ...............................................................5
Treatment proximal tibiofibular joint dislocation ...........4, 5
Treatment proximal tibiofibular dislocation,
anesthesia ..................................................................5
Treatment ankle dislocation .........................................4, 5
Treatment ankle dislocation, with anesthesia ..................5
27860
Manipulation
Manipulation ankle under general anesthesia .............3, 5
27899
Miscellaneous
Unlisted procedure, leg or ankle ......................................2
27786
27788
27792
27808
27810
27816
27818
27830
27831
28001
28002
28003
28008
28010
28011
28020
28022
28024
28043
28045
28090
28092
Fractures and/or Dislocations
Treatment closed tibial shaft fracture............................... 5
Treatment closed tibial shaft fracture, manipulation ........ 5
Treatment closed distal tibial fracture .............................. 5
Treatment closed distal tibial fracture,
with manipulation........................................................ 5
Treatment closed proximal fibula/shaft fracture ............... 5
Treatment closed proximal fibula/shaft fracture,
with manipulation........................................................ 5
Description
28190
28192
Non-Benefit
Requires TAR,
Primary Surgeon/Provider
FOOT
Incision
Incision and drainage, bursa, foot................................3, 5
Incision and drainage below fascia, with or without
tendon sheath involvement, foot; single bursal
space ..........................................................................3
Deep dissection below fascia; multiple areas ..................3
Fasciotomy, foot and/or toe .............................................3
Tenotomy, percutaneous, toe; single tendon...................3
Tenotomy, percutaneous, toe; multiple tendons ..............3
Arthrotomy, including exploration, drainage, or
removal of loose or foreign body; intertarsal or
tarsometatarsal joint ...................................................5
Arthrotomy, metatarsophalangeal joint ........................3, 5
Arthrotomy, interphalangeal joint .................................3, 5
Excision
Excision, tumor, foot; subcutaneous tissue......................3
Excision, tumor, deep, subfascial, intramuscular.............2
Excision of lesion, tendon, tendon sheath, or
capsule (including synovectomy) (e.g., cyst or
ganglion); foot.............................................................2
Excision of lesion, tendon, tendon sheath, or
capsule (including synovectomy) (e.g., cyst or
ganglion); toe(s), each............................................2, 3
Introduction and/or Removal
Removal foreign body, subcutaneous..........................3, 5
Removal foreign body, deep ............................................5
3
4
5
Assistant Surgeon services not payable
Anesthesiology services not payable
Ambulatory Surgical
2 – TAR and Non-Benefit List: Codes 20000 – 29999
October 1999
tar and non cd2
8
Code
28200
28208
28272
28285
28286
28288
28289
28290
28292
28293
28294
28296
28297
28298
28299
28306
28308
28310
28312
28313
28315
28340
28341
28344
28345
28360
Benefit
Restrictions
Description
Repair, Revision or Reconstruction
Repair tendon, flexor, foot; primary or secondary
without free graft, each tendon ................................... 5
Repair tendon, extensor, foot; primary or secondary,
each tendon................................................................ 5
Capsulotomy; interphalangeal
joint, each joint (separate procedure) ......................... 3
Correction, hammertoe (e.g. interphalangeal fusion,
partial or total phalangectomy) ................................... 2
Correction, cock-up fifth toe, with plastic skin closure
(e.g., Ruiz-Mora type procedure)................................ 2
Ostectomy, partial, exostectomy or condylectomy,
metatarsal head, each metatarsal head ................. 2, 3
Hallux rigidus correction with cheilectomy,
debridement and capsular release of the first
metatarsophalangeal joint .......................................... 2
Correction, hallux valgus (bunion), with or without
sesamoidectomy; simple exostectomy (e.g.,
Silver type procedure) ................................................ 2
Hallux valgus correction................................................... 2
Hallux valgus correction, resection joint, implant............. 2
Correction, hallux valgus (bunion), with or without
sesamoidectomy; with tendon transplants (e.g.,
Joplin type procedure) ................................................ 2
Hallux valgus correction, metatarsal osteotomy .............. 2
Hallux valgus correction, Lapidus type ............................ 2
Hallux valgus correction, phalanx osteotomy................... 2
Hallux valgus correction, by other methods ..................... 2
Osteotomy, with or without lengthening, shortening or
angular correction, metatarsal; first metatarsal .......... 2
Osteotomy, with or without lengthening, shortening
or angular correction, metatarsal; other than first
metatarsal, each ......................................................... 2
Osteotomy, shortening, angular or rotational
correction; proximal phalanx, first toe (separate
procedure) .................................................................. 2
Osteotomy other phalanges, any toe ............................... 2
Reconstruction, angular deformity of toe, soft tissue
procedures only (e.g. overlapping second toe,
fifth toe, curly toes) ..................................................... 2
Sesamoidectomy, first toe ............................................... 2
Reconstruction, toe, macrodactyly,
soft tissue resection.................................................... 2
Reconstruction, toe, macrodactyly,
requiring bone resection ............................................. 2
Reconstruction, toe, polydactyly ...................................... 2
Reconstruction, toe, syndactyly,
with or w/out skin grafts, each web............................. 2
Reconstruction, cleft foot ................................................. 2
Code
28405
28430
28435
28436
28450
28455
28456
28465
28470
28475
28476
28485
28490
28495
28496
28510
28515
28530
28540
28545
28546
28570
28575
28600
28605
28606
28630
28635
28660
28665
28899
Benefit Restriction Descriptions:
1
2
Non-Benefit
Requires TAR,
Primary Surgeon/Provider
Description
Benefit
Restrictions
Fracture and/or Dislocation
Treatment closed calcaneal fracture,
with manipulation........................................................5
Treatment closed talus fracture ...................................3, 5
Treatment closed talus fracture, with manipulation......3, 5
Percutaneous skeletal fixation of talus fracture,
with manipulation .......................................................3
Treatment closed tarsal bone fracture .............................5
Treatment closed tarsal bone fracture,
with manipulation....................................................3, 5
Percutaneous skeletal fixation of tarsal bone
fracture, with manipulation, each................................3
Open treatment of closed or
open tarsal bone fracture............................................3
Treatment closed metatarsal fracture ..........................3, 5
Treatment closed metatarsal fracture,
with manipulation....................................................3, 5
Treatment closed metatarsal fracture, with pin ............3, 5
Open treatment metatarsal fracture .................................5
Treatment closed fracture great toe.............................3, 5
Treatment closed fracture great toe,
with manipulation....................................................3, 5
Treatment closed fracture great toe, with pin...............3, 5
Treatment closed fracture other toe.............................3, 5
Treatment closed fracture other toe,
with manipulation....................................................3, 5
Treatment closed sesamoid fracture............................3, 4
Treatment closed tarsal bone dislocation ................3, 4, 5
Treatment closed tarsal bone dislocation,
with anesthesia.......................................................3, 5
Percutaneous skeletal fixation tarsal bone
dislocation, with manipulation.....................................3
Treatment closed talotarsal joint dislocation ............3, 4, 5
Treatment closed talotarsal joint dislocation,
anesthesia ..............................................................3, 5
Treatment closed tarsometatarsal
joint dislocation ...................................................3, 4, 5
Treatment closed tarsometatarsal
joint dislocation, with anesthesia ............................3, 5
Percutaneous skeletal fixation of tarsometatarsal
joint dislocation, with manipulation .............................3
Treatment closed metatarsophalangeal
joint dislocation ...................................................3, 4, 5
Treatment closed metatarsophalangeal
joint dislocation; with anesthesia ............................3, 5
Treatment closed interphalangeal
joint dislocation ...................................................3, 4, 5
Treatment closed interphalangeal dislocation;
anesthesia ..............................................................3, 5
Other Procedures
Unlisted procedure, foot or toes...................................2
3
4
5
Assistant Surgeon services not payable
Anesthesiology services not payable
Ambulatory Surgical
2 – TAR and Non-Benefit List: Codes 20000 – 29999
April 2002
tar and non cd2
9
Code
Benefit
Restrictions
Description
29049
29055
29058
29065
29075
29085
APPLICATION OF CASTS AND STRAPPING
Body and Upper Extremity Casts
Application of Risser jacket, localizer, body..................... 3
Application of Risser jacket, localizer, including head ..... 3
Application of turnbuckle jacket, body.............................. 3
Application of turnbuckle jacket, including head .............. 3
Application of body cast, shoulder to hips........................ 3
Application of body cast, shoulder to hips;
including head ............................................................ 3
Application of body cast, shoulder to hips; one thigh....... 3
Application of body cast, shoulder to hips;
both thighs .................................................................. 3
Application; plaster figure of eight.................................... 3
Application; shoulder spica .............................................. 3
Application; plaster Velpeau ............................................ 3
Application; shoulder to hand........................................... 3
Application; elbow to finger .............................................. 3
Application; hand and lower forearm ............................... 3
29105
29125
29126
29130
29131
Splints
Application of long arm splint ........................................... 3
Application of short arm splint; static ............................... 3
Application of short arm splint; dynamic .......................... 3
Application of finger splint; static ..................................... 3
Application of finger splint; dynamic................................. 3
29200
29220
29240
29260
29280
Strapping – Any Age
Strapping; thorax.......................................................... 3, 4
Strapping; low back...................................................... 3, 4
Strapping; shoulder...................................................... 3, 4
Strapping; elbow or wrist.............................................. 3, 4
Strapping; hand or finger ............................................. 3, 4
29305
29325
29345
29355
29358
29365
29405
29425
29435
29440
29450
Lower Extremity Casts
Application of hip spica cast; one leg............................... 3
Application of hip spica cast; both legs............................ 3
Application of long leg cast .............................................. 3
Application of long leg cast; ambulatory type................... 3
Application of long leg cast brace .................................... 3
Application of cylinder cast .............................................. 3
Application of short leg cast ............................................. 3
Application of short leg cast; ambulatory type ................. 3
Application of patellar tendon bearing cast ...................... 3
Adding walker to previously applied cast ..................... 3, 4
Application of clubfoot cast, long or short leg .................. 3
29010
29015
29020
29025
29035
29040
29044
29046
Benefit Restriction Descriptions:
1
2
Benefit
Restrictions
Code
Description
29505
29515
Splints
Application of long leg splint ............................................3
Application of short leg splint ...........................................3
29520
29530
29540
29550
29580
29590
Strapping – Any Age
Strapping; hip...............................................................3, 4
Strapping; knee............................................................3, 4
Strapping; ankle ...........................................................3, 4
Strapping; toes.................................................................3
Unna boot ....................................................................3, 4
Denis-Browne splint strapping .....................................3, 4
29700
29705
29710
29715
29720
29730
29740
29750
Removal or Repair
Removal or bivalving; gauntlet, boot or body cast .......3, 4
Removal or bivalving; full arm or full leg cast...............3, 4
Removal or bivalving; shoulder or hip spica ................3, 4
Removal or bivalving; turnbuckle jacket.......................3, 4
Repair of spica, body cast or jacket .............................3, 4
Windowing of cast........................................................3, 4
Wedging of cast ...........................................................3, 4
Wedging of clubfoot cast..............................................3, 4
29799
Miscellaneous
Unlisted procedure, casting or strapping .....................2, 3
29800
29804
29815
29819
29820
29821
29822
29823
29825
29826
29830
29834
29835
29836
29837
29838
29840
Non-Benefit
Requires TAR,
Primary Surgeon/Provider
ARTHROSCOPY
Arthroscopy, temporomandibular joint, diagnostic ...........1
Arthroscopy, temporomandibular joint, surgical...............1
Arthroscopy, shoulder, diagnostic................................3, 5
Arthroscopy, shoulder, removal loose body.................3, 5
Arthroscopy, shoulder, synovectomy ...............................1
Arthroscopy, shoulder, synovectomy, complete...............1
Arthroscopy, shoulder, debridement ................................1
Arthroscopy, shoulder, debridement ................................1
Arthroscopy, shoulder, lysis of adhesions........................1
Arthroscopy, shoulder, decompression of
subacromial space..................................................3, 5
Arthroscopy, elbow, diagnostic ....................................3, 5
Arthroscopy, elbow, removal loose body .....................3, 5
Arthroscopy, elbow, synovectomy....................................1
Arthroscopy, synovectomy, complete ..............................1
Arthroscopy, debridement, limited ...................................1
Arthroscopy, elbow, debridement.....................................1
Arthroscopy, wrist, diagnostic ......................................3, 5
3
4
5
Assistant Surgeon services not payable
Anesthesiology services not payable
Ambulatory Surgical
2 – TAR and Non-Benefit List: Codes 20000 – 29999
April 2002
tar and non cd2
10
Code
29843
29844
29845
29846
29847
29848
29860
29861
29862
29863
29870
29871
29874
29875
29876
29877
29879
29880
29881
29882
29883
29884
29885
29886
29887
29891
29892
29893
29894
29895
29897
29898
29909
Benefit
Restrictions
Description
ARTHROSCOPY (continued)
Arthroscopy, wrist, surgical .......................................... 3, 5
Arthroscopy, wrist, synovectomy, partial...................... 3, 5
Arthroscopy, wrist, synovectomy, complete................. 3, 5
Arthroscopy, wrist, excision cartilage........................... 3, 5
Arthroscopy, wrist, internal fixation .............................. 3, 5
Endoscopy, wrist, surgical, with
release of carpal ligament ...................................... 3, 5
Arthroscopy, hip, diagnostic with or without
synovial biopsy (separate procedure)......................... 3
Arthroscopy, hip, surgical; with removal of loose
body or foreign body................................................... 3
Arthroscopy, hip, surgical; with debridement/shaving of
articular cartilage (chondroplasty), abrasion
arthroplasty, and/or resection of labrum ..................... 3
Arthroscopy, hip, surgical; with synovectomy .................. 3
Arthroscopy, knee, diagnostic...................................... 3, 5
Arthroscopy, knee, surgical;
for infection/lavage/drainage ...................................... 3
Arthroscopy, knee, surgical, removal loose body ........ 3, 5
Arthroscopy, knee, surgical, synovectomy,
limited ..................................................................... 3, 5
Arthroscopy, knee, surgical, synovectomy,
major....................................................................... 3, 5
Arthroscopy, knee, surgical, debridement cartilage ..... 3, 5
Arthroscopy, knee, surgical, abrasion arthroplasty ...... 3, 5
Arthroscopy, knee, surgical, meniscectomy
(medial and lateral)................................................. 3, 5
Arthroscopy, knee, surgical, meniscectomy
(medial or lateral).................................................... 3, 5
Arthroscopy, knee, surgical, meniscus repair
(medial or lateral).................................................... 3, 5
Arthroscopy, knee, surgical, meniscus repair
(medial and lateral)................................................. 3, 5
Arthroscopy, knee, surgical, lysis of adhesions ........... 3, 5
Arthroscopy, knee, surgical, drilling for
osteochondritis dissecans ...................................... 3, 5
Arthroscopy, knee, surgical, drilling for intact
osteochondritis dissecans lesion............................ 3, 5
Arthroscopy, knee, surgical, drilling for intact
osteochondritis dissecans lesion with
internal fixation ....................................................... 3, 5
Arthroscopy, ankle, surgical; excision of osteochondral
defect of talus and/or tibia, including drilling of the
defect.......................................................................... 3
Arthroscopically aided repair of large osteochondritis
dissecans lesion, talar dome fracture, or tibial plafond
fracture, with or without internal fixation (includes
arthroscopy)................................................................ 3
Endoscopic plantar fasciotomy ........................................ 3
Arthroscopy, ankle, surgical, removal loose body........ 3, 5
Arthroscopy, ankle, surgical, synovectomy...................... 1
Arthroscopy, ankle, surgical, debridement,
limited ......................................................................... 1
Arthroscopy, ankle, surgical, debridement,
extensive .................................................................... 1
Unlisted procedure, arthroscopy .................................. 2, 3
Benefit Restriction Descriptions:
1
2
Non-Benefit
Requires TAR,
Primary Surgeon/Provider
3
4
5
Assistant Surgeon services not payable
Anesthesiology services not payable
Ambulatory Surgical
2 – TAR and Non-Benefit List: Codes 20000 – 29999
October 1999
tar and non cd3
TAR and Non-Benefit List: Codes 30000 – 39999
Code
Benefit
Restrictions
Description
SURGERY (continued)
30801
RESPIRATORY SYSTEM
30000
30020
30100
30110
30115
30120
30124
30130
30140
30200
30210
30220
30300
30310
30320
30400
30410
30420
30430
30435
30450
30460
30462
30465
30520
30560
30600
30620
30802
NOSE
Incision
Drainage abscess or hematoma, nasal ....................... 3, 5
Drainage abscess or hematoma, nasal septum....... 3, 4, 5
Excision
Biopsy, intranasal............................................................. 5
Excision, nasal polyp(s), simple....................................... 3
Excision of nose polyp(s), extensive................................ 3
Excision, skin of nose for rhinophyma ............................. 3
Excision, dermoid cyst, nose, subcutaneous ................... 3
Excision turbinate, partial or complete,
any method............................................................. 2, 3
Submucous resection turbinate, partial or complete,
any method............................................................. 2, 3
Introduction
Injection into turbinates ............................................ 3, 4, 5
Displacement therapy .............................................. 3, 4, 5
Insertion nasal septal prosthesis ................................. 2, 3
Removal, Foreign Body
Removal foreign body, intranasal;
office type procedure .............................................. 3, 4
Removal foreign body, intranasal,
with anesthesia....................................................... 3, 5
Removal foreign body, intranasal,
by lateral rhinotomy ................................................ 3, 5
Repair
Rhinoplasty, primary; lateral and alar
cartilages and/or elevation of nasal tip ....................... 2
Rhinoplasty, primary; complete........................................ 2
Rhinoplasty, primary;
including major septal repair....................................... 2
Rhinoplasty, secondary, minor revision ....................... 2, 3
Rhinoplasty, secondary, intermediate revision ............ 2, 3
Rhinoplasty, secondary, major revision ........................... 2
Rhinoplasty for nasal deformity, secondary ..................... 2
Rhinoplasty for nasal deformity, secondary,
with columellar lengthening ....................................... 2
Repair of nasal vestibular stenosis.............................. 2
Septoplasty or submucous resection ............................... 2
Lysis intranasal synechia ............................................. 3, 5
Repair fistula, oronasal .................................................... 5
Reconstruction, functional, internal nose ......................... 5
Benefit Restriction Descriptions:
Code
1
2
30901
30903
30905
30906
30930
30999
31000
31002
31020
31030
31032
31040
31050
31051
31070
31075
31080
31081
31084
31085
31086
31087
31090
Non-Benefit
Requires TAR,
Primary Surgeon/Provider
1
Description
Benefit
Restrictions
Destruction
Cauterization and/or ablation, mucosa
of turbinates; superficial..............................................3
Cauterization and/or ablation, mucosa
of turbinates; intramural..............................................3
Other Procedures
Control nasal hemorrhage, anterior, simple.............3, 4, 5
Control nasal hemorrhage, anterior, complex..........3, 4, 5
Control nasal hemorrhage, posterior; initial .....................3
Control nasal hemorrhage, posterior; subsequent...........3
Fracture nasal turbinate ...............................................3, 5
Unlisted procedure, nose .................................................2
ACCESSORY SINUSES
Incision
Lavage by cannulation, maxillary sinus .......................3, 5
Lavage by cannulation, sphenoid sinus .......................3, 5
Sinusotomy, maxillary, intranasal ................................3, 5
Sinusotomy, maxillary; radical
without antrochoanal polyp removal ...........................2
Sinusotomy, maxillary; radical
with antrochoanal polyp removal ................................2
Pterygomaxillary fossa surgery, any approach ................2
Sinusotomy, sphenoid......................................................2
Sinusotomy, sphenoid, with mucosal
stripping or removal, polyp(s) .....................................2
Sinusotomy frontal; external, simple ................................2
Sinusotomy frontal; transorbital, unilateral.......................2
Sinusotomy frontal; obliterative without
osteoplastic flap, brow incision ...................................2
Sinusotomy frontal; obliterative without
osteoplastic flap, coronal incision ...............................2
Sinusotomy frontal; obliterative with
osteoplastic flap, brow incision ...................................2
Sinusotomy frontal; obliterative with
osteoplastic flap, coronal incision ...............................2
Sinusotomy frontal; nonobliterative with
osteoplastic flap, brow incision ...................................2
Sinusotomy frontal; nonobliterative with
osteoplastic flap, coronal incision ...............................2
Sinusotomy, unilateral, three or more paranasal sinuses
(frontal, maxillary, ethmoid, sphenoid)........................2
3
4
5
Assistant Surgeon services not payable
Anesthesiology services not payable
Ambulatory Surgical
2 – TAR and Non-Benefit List: Codes 30000 – 39999
November 2001
tar and non cd3
2
Benefit
Restrictions
Code
Description
31231
31233
Nasal endoscopy, diagnostic ........................................... 3
Nasal/sinus endoscopy, diagnostic
with maxillary sinusoscopy ......................................... 3
Nasal/sinus endoscopy, diagnostic
with sphenoid sinusoscopy......................................... 3
Nasal/sinus endoscopy, surgical;
with biopsy, polypectomy or debridement .................. 3
Nasal/sinus endoscopy, surgical;
control of epistaxis...................................................... 3
Nasal/sinus endoscopy, surgical;
with dacryocystorhinostomy ....................................... 3
Nasal/sinus endoscopy, surgical;
with concha bullosa resection..................................... 3
Nasal/sinus endoscopy, surgical;
with ethmoidectomy, partial ........................................ 3
Nasal/sinus endoscopy,
surgical; with ethmoidectomy, total............................. 3
Nasal/sinus endoscopy, surgical,
with maxillary antrostomy ........................................... 3
Nasal/sinus endoscopy, surgical, with maxillary
antrostomy; with removal of tissue from
maxillary sinus ............................................................ 3
Nasal/sinus endoscopy, surgical
with frontal sinus exploration ...................................... 3
Nasal/sinus endoscopy, surgical,
with sphenoidotomy.................................................... 3
Nasal/sinus endoscopy, surgical,
with sphenoidotomy, with removal
of sphenoid sinus tissue ............................................. 3
Nasal/sinus endoscopy, surgical, with cerebrospinal
fluid leak repair, ethmoid region ................................. 3
Nasal/sinus endoscopy, surgical, with cerebrospinal
fluid leak repair, sphenoid region................................ 3
Nasal/sinus endoscopy, surgical, with
medial or inferior orbital wall decompression ............. 3
Nasal/sinus endoscopy, surgical, with medial
and inferior orbital wall decompression ...................... 3
Nasal/sinus endoscopy, surgical, with optic
nerve decompression ................................................. 3
31235
31237
31238
31239
31240
31254
31255
31256
31267
31276
31287
31288
31290
31291
31292
31293
31294
Code
31505
31510
31511
31512
31513
31515
31520
31525
31526
31527
31528
31529
31530
31531
31535
31536
31540
31541
31560
31561
31570
31571
31575
31576
31577
31578
31579
31299
Other Procedures
Unlisted procedure, accessory sinuses ........................... 2
31585
31500
31502
LARYNX
Introduction
Intubation, endotracheal, emergency procedure ........ 3, 4
Tracheotomy tube change prior to
establishment of fistula tract ....................................... 1
Benefit Restriction Descriptions:
1
2
31599
Non-Benefit
Requires TAR,
Primary Surgeon/Provider
Description
Benefit
Restrictions
Endoscopy
Laryngoscopy, indirect, diagnostic ...........................3, 4, 5
Laryngoscopy, indirect, with biopsy .........................3, 4, 5
Laryngoscopy, indirect,
with removal foreign body.......................................3, 5
Laryngoscopy, indirect, with removal lesion ................3, 5
Laryngoscopy, indirect, with vocal cord injection .....3, 4, 5
Laryngoscopy, direct, for aspiration .............................3, 5
Laryngoscopy, direct, diagnostic, newborn ......................3
Laryngoscopy, direct, diagnostic,
except newborn ......................................................3, 5
Laryngoscopy, direct, diagnostic,
with operating scope...............................................3, 5
Laryngoscopy, direct, with insertion of obturator..........3, 5
Laryngoscopy, direct, with dilatation, initial ..................3, 5
Laryngoscopy, direct, with dilatation, subsequent .......3, 5
Laryngoscopy, direct, operative, foreign body .............3, 5
Laryngoscopy, direct, operative, with microscope .......3, 5
Laryngoscopy, direct, operative, with biopsy ...............3, 5
Laryngoscopy, direct, operative,
with biopsy, microscope .........................................3, 5
Laryngoscopy, direct, operative,
excision of tumor ....................................................3, 5
Laryngoscopy, direct, operative,
excision tumor, scope.............................................3, 5
Laryngoscopy, direct, operative,
with arytenoidectomy ..................................................5
Laryngoscopy, direct, operative,
arytenoidectomy, microscope .....................................5
Laryngoscopy, direct, injection
into cords, therapeutic ................................................5
Laryngoscopy, direct, injection into cords,
microscope .................................................................5
Laryngoscopy, flexible fiberscopic, diagnostic .............3, 5
Laryngoscopy, flexible fiberscopic, with biopsy............3, 5
Laryngoscopy, flexible fiberscopic,
removal foreign body ..............................................3, 5
Laryngoscopy, flexible fiberscopic,
removal lesion ........................................................3, 5
Laryngoscopy, flexible or rigid fiberoptic,
with stroboscopy.........................................................3
Repair
Treatment of closed laryngeal fracture;
without manipulation...............................................3, 4
Other Procedures
Unlisted procedure, larynx ...............................................2
3
4
5
Assistant Surgeon services not payable
Anesthesiology services not payable
Ambulatory Surgical
2 – TAR and Non-Benefit List: Codes 30000 – 39999
October 1999
tar and non cd3
3
Code
31600
31601
31603
31605
31610
31612
31613
31614
31615
31622
31623
31624
31625
31628
31629
31630
31631
31635
31640
31641
31643
31645
31646
31656
Benefit
Restrictions
Description
TRACHEA AND BRONCHI
Incision
Tracheostomy, planned ................................................... 3
Tracheostomy, planned; under two years ........................ 3
Tracheostomy, emergency procedure; transthacheal...... 3
Tracheostomy, emergency procedure;
cricothyroid membrane ............................................... 3
Tracheostomy, fenestration procedure
with skin flaps ............................................................. 3
Tracheal puncture, percutaneous with
transtracheal aspiration and/or injection ..................... 3
Tracheostoma revision; simple, without flap rotation ....... 3
Tracheostoma revision; complex, with flap rotation ......... 3
Endoscopy
Tracheobronchoscopy through
tracheostomy incision ................................................. 3
Bronchoscopy, (rigid or flexible); diagnostic, with
or without cell washing ........................................... 3, 5
Bronchoscopy, with brushing or protected
brushings .................................................................... 3
Bronchoscopy, with bronchial alveolar lavage ................. 3
Bronchoscopy, diagnostic with biopsy ......................... 3, 5
Bronchoscopy, diagnostic,
transbronchial lung biopsy...................................... 3, 5
Bronchoscopy, transbronchial
needle aspiration biopsy......................................... 3, 5
Bronchoscopy, tracheal or bronchial dilation ............... 3, 5
Bronchoscopy, tracheal dilation/placement
of tracheal stent .......................................................... 3
Bronchoscopy, removal of foreign body....................... 3, 5
Bronchoscopy, excision of tumor ................................. 3, 5
Bronchoscopy, destruction of tumor ............................ 3, 5
Bronchoscopy, with placement of catheter(s) for
intracavitary radioelement application ........................ 3
Bronchoscopy, therapeutic aspiration
tracheobronchial tree.............................................. 3, 5
Bronchoscopy, therapeutic aspiration, subsequent ..... 3, 5
Bronchoscopy, injection contrast material ................... 3, 5
Code
32000
32002
32005
32020
32400
32402
32405
32420
32491
32501
32601
32602
32603
32604
32605
32606
32650
32651
32652
31700
31708
31710
31715
31717
31720
31725
31730
31899
Introduction
Catheterization, transglottic ............................................. 3
Instillation contrast material
laryngography/bronchography ................................ 3, 5
Catheterization for bronchography............................... 3, 5
Transtracheal injection bronchography........................ 3, 5
Catheterization bronchial brush biopsy........................ 3, 5
Catheter aspiration (separate procedure);
nasotracheal ....................................................... 3, 4, 5
Catheter aspiration; tracheobronchial
with fiberscope, bedside ......................................... 3, 4
Transtracheal (percutaneous) introduction
needle wire dilator .................................................. 3, 4
32653
32654
32655
32656
Description
Benefit
Restrictions
LUNGS AND PLEURA
Incision
Thoracentesis, puncture of pleural
cavity for aspiration, initial or subsequent...................3
Thoracentesis, insertion of tube
with or without water seal ...........................................3
Chemical pleurodesis...................................................3, 4
Tube thoracostomy with or without water seal .................3
Excision
Biopsy, pleura; percutaneous needle...........................3, 4
Biopsy, pleura; open ....................................................3, 4
Biopsy, lung or mediastinum,
percutaneous needle ..............................................3, 4
Pneumonocentesis, puncture of lung for aspiration.........3
Removal of lung, other than total pneumonectomy;
excision-plication of emphysematous lung(s)
(bullous or non-bullous) for lung volume reduction.....1
Resection and repair of portion of bronchus
(bronchoplasty) when performed at time
of lobectomy or segmentectomy.................................4
Endoscopy
Thoracoscopy, diagnostic; lungs
and pleural space, without biopsy ..............................3
Thoracoscopy, diagnostic; lungs
and pleural space, with biopsy ...................................3
Thoracoscopy, diagnostic;
pericardial sac, without biopsy....................................3
Thoracoscopy, diagnostic;
pericardial sac, with biopsy.........................................3
Thoracoscopy, diagnostic;
mediastinal space, without biopsy ..............................3
Thoracoscopy, diagnostic;
mediastinal space, with biopsy ...................................3
Thoracoscopy, surgical;
with pleurodesis, any method .....................................3
Thoracoscopy, surgical; with
partial pulmonary decortication...................................3
Thoracoscopy, surgical; with total pulmonary
decortication, including intrapleural pneumonolysis ...3
Thoracoscopy, surgical; with removal of
intrapleural foreign body or fibrin deposit ...................3
Thoracoscopy, surgical; with control of
traumatic hemorrhage ................................................3
Thoracoscopy, surgical; with excision-plication
of bullae including any pleural procedure ...................3
Thoracoscopy, surgical; with parietal pleurectomy ..........3
Suture
Unlisted procedure, trachea, bronchi ............................... 2
Benefit Restriction Descriptions:
1
2
Non-Benefit
Requires TAR,
Primary Surgeon/Provider
3
4
5
Assistant Surgeon services not payable
Anesthesiology services not payable
Ambulatory Surgical
2 – TAR and Non-Benefit List: Codes 30000 – 39999
January 2001
tar and non cd3
4
Code
32657
32658
32659
32660
32661
32662
32663
32664
32665
Benefit
Restrictions
Description
Endoscopy (continued)
Thoracoscopy, surgical; with
wedge resection of lung.............................................. 3
Thoracoscopy, surgical; with removal of
clot or foreign body from pericardial sac..................... 3
Thoracoscopy, surgical; with creation of
pericardial window or partial resection
of pericardial sac for drainage .................................... 3
Thoracoscopy, surgical; with total pericardectomy .......... 3
Thoracoscopy, surgical; with excision of
pericardial cyst, tumor, or mass.................................. 3
Thoracoscopy, surgical; with excision of
mediastinal cyst, tumor, or mass ................................ 3
Thoracoscopy, surgical; with lobectomy .......................... 3
Thoracoscopy, surgical;
with thoracic sympathectomy ..................................... 3
Thoracoscopy, surgical; with esophagomyotomy ............ 3
Code
33517
33518
33519
33521
33522
33523
33533
33534
32850
32851
32852
32853
32854
Lung Transplantation
Donor pneumonectomy with preparation
and maintenance of allograft ...................................... 1
Lung transplant, single, without
cardiopulmonary bypass............................................. 2
Lung transplant, single, with
cardiopulmonary bypass............................................. 2
Lung transplant, double, without
cardiopulmonary bypass............................................. 2
Lung transplant, double, with
cardiopulmonary bypass............................................. 2
33535
33536
33737
33924
32960
32997
Surgical Collapse Therapy; Thoracoplasty
Pneumothorax, therapeutic,
intrapleural injection of air........................................... 3
Total lung lavage (unilateral)............................................ 1
33930
32999
Other Procedures
Unlisted procedure, lungs and pleura .............................. 2
33940
33945
33960
CARDIOVASCULAR SYSTEM
33010
33011
33140
33141
HEART AND PERICARDIUM
Pericardium
Pericardiocentesis; initial ................................................. 3
Pericardiocentesis; subsequent ....................................... 3
Transmyocardial Revascularization
Transmyocardial laser revascularization,
by thoracotomy ........................................................... 1
Heart TMR with other procedure...................................... 1
Benefit Restriction Descriptions:
33935
1
2
33961
33999
Non-Benefit
Requires TAR,
Primary Surgeon/Provider
Description
Benefit
Restrictions
Combined Arterial-Venous Grafting for Coronary Bypass
Coronary artery bypass, venous/arterial
graft; single vein graft .................................................2
Coronary artery bypass, venous/arterial
grafts; two venous grafts ............................................2
Coronary artery bypass, venous/arterial
grafts; three venous grafts..........................................2
Coronary artery bypass, venous/arterial
grafts; four venous grafts............................................2
Coronary artery bypass, venous/arterial
grafts; five venous grafts ............................................2
Coronary artery bypass, venous/arterial
grafts; six or more venous grafts ................................2
Arterial Grafting for Coronary Artery Bypass
Coronary artery bypass, using arterial graft;
single arterial graft ......................................................2
Coronary artery bypass, using arterial grafts;
two coronary arterial grafts .........................................2
Coronary artery bypass, using arterial grafts;
three coronary arterial grafts.......................................2
Coronary artery bypass, using arterial grafts;
four or more coronary arterial grafts ...........................2
Shunting Procedures
Atrial sepectomy or sepostomy; open heart
with inflow occlusion ...................................................2
Pulmonary Artery
Ligation and takedown of a systemic-to-pulmonary
artery shunt, performed in conjunction
with a congenital heart procedure ..............................4
Heart/Lung Transplantation
Donor cardiectomy-pneumonectomy,
with allograft care .......................................................1
Heart-lung transplant, with recipient
cardiectomy-pneumonectomy.....................................2
Donor cardiectomy, with allograft care.............................1
Heart transplant ...............................................................2
Prolonged extracorporeal circulation for
cardiopulmonary insufficiency, initial 24 hours ...........1
Prolonged extracorporeal circulation for
cardiopulmonary insufficiency,
each additional 24 hours (List separately in
addition to code for primary procedure)......................1
Other Procedures
Unlisted procedure, cardiac surgery............................2
3
4
5
Assistant Surgeon services not payable
Anesthesiology services not payable
Ambulatory Surgical
2 – TAR and Non-Benefit List: Codes 30000 – 39999
April 2002
tar and non cd3
5
Code
35390
36000
36005
36010
36011
36012
36013
36014
36015
Benefit
Restrictions
Description
ARTERIES AND VEINS
Thromboendarterectomy
Reoperation, carotid, thromboendarterectomy, more
than one month after original operation (List
separately in addition to code for primary
procedure) .................................................................. 4
VASCULAR INJECTION PROCEDURES
Intravenous
Introduction of needle or intracatheter, vein..................... 3
Injection contrast venography, introduction of
needle or intracatheter................................................ 3
Introduction of catheter, superior or inferior vena cava.... 3
Selective catheter placement, first order branch.............. 3
Selective catheter placement, second order.................... 3
Introduction of catheter, right heart .................................. 3
Selective catheter placement, left or right
pulmonary artery......................................................... 3
Selective catheter placement, segmental or
subsegmental pulmonary artery ................................. 3
Code
36400
36405
36406
36410
36415
36420
36425
36430
36440
36450
36455
36460
36468
36469
36470
36471
36488
36489
36100
36120
36140
36145
36160
36218
36248
36260
36299
Intra-Arterial/Intra-Aortic
Introduction of needle/intracatheter,
carotid/vertebral artery................................................ 3
Introduction of needle/intracatheter,
retrograde brachial artery ........................................... 3
Introduction of needle/intracatheter, extremity artery....... 3
Introduction of needle/intracatheter,
arteriovenous shunt .................................................... 3
Introduction of needle/intracatheter,
aortic, translumbar...................................................... 3
Selective catheter placement, arterial system,
additional second order, third order, and beyond,
thoracic or brachiocephalic branch, within a
vascular family (List in addition to code for
initial second or third order vessel as
appropriate) ................................................................ 4
Selective catheter placement, arterial system,
additional second order, third order, and beyond,
abdominal, pelvic, or lower extremity artery
branch, within a vascular family (List in addition
to code for initial second or third order vessel as
appropriate) ................................................................ 4
Insertion of implantable intra-arterial infusion pump ........ 2
Unlisted procedure, vascular injection ............................. 2
36490
36491
36493
36500
36510
36520
36521
36522
36540
36550
Venous
Venipuncture, under age three years...............................3
Venipuncture, under age three years; scalp vein.............3
Venipuncture, under age three years; other vein .............3
Venipuncture, over age three years, non-routine.........3, 4
Routine venipuncture for collection of specimen(s) .........1
Venipuncture, cutdown, under age one year ...................3
Venipuncture, cutdown, age one year or over .................3
Transfusion, blood or blood components.........................1
Push transfusion, blood, two years or under................3, 4
Exchange transfusion, blood, newborn............................4
Exchange transfusion, blood, other than newborn...........4
Transfusion, intrauterine, fetal .........................................4
Single or multiple injections of
sclerosing solutions, limb or trunk ..............................1
Single or multiple injections of
sclerosing solutions, face ...........................................1
Injection of sclerosing solution; single vein ..................3, 4
Injection of sclerosing solution; multiple veins .............3, 4
Placement of central venous catheter,
under age two years ...................................................3
Placement of central venous catheter,
over age two years .....................................................3
Placement of central venous catheter,
under age two years ...................................................3
Placement of central venous catheter,
over age two years .....................................................3
Repositioning of central venous catheter.........................3
Venous catheterization for organ blood sampling........3, 4
Catheterization of umbilical vein, newborn ..................3, 4
Therapeutic apheresis .........................................2, 3, 4, 5
Therapeutic apheresis; with extracorporeal affinity
column adsorption and plasma reinfusion ..............2, 3
Photopheresis, extracorporeal .........................................1
Collection of blood specimen from a partially or
completely implantable venous access device...........3
Declotting by thrombolytic agent of implanted
vascular access device or catheter ............................3
Arterial
Arterial puncture, withdrawal of blood for diagnosis ........4
Arterial catheterization, for sampling, cutdown ................4
Arterial catheterization, for chemotherapy, cutdown ........4
Catheterization, umbilical artery.......................................4
36680
Intraosseous
Placement of needle for intraosseous infusion ................4
36822
36823
1
2
Benefit
Restrictions
36600
36625
36640
36660
36800
Benefit Restriction Descriptions:
Description
Non-Benefit
Requires TAR,
Primary Surgeon/Provider
Intervascular Cannulization or Shunt
Insertion of cannula for hemodialysis,
other purpose (separate procedure) ...........................3
Insertion of cannula(s) for prolonged
ECMO (separate procedure)...................................2, 3
Insertion of arterial and venous cannula(s) for
isolated extracorporeal circulation and regional
chemotherapy perfusion to an extremity, with or
without hyperthermia, with removal of cannula(s)
and repair of arteriotomy and venotomy sites.............3
3
4
5
Assistant Surgeon services not payable
Anesthesiology services not payable
Ambulatory Surgical
2 – TAR and Non-Benefit List: Codes 30000 – 39999
May 2002
tar and non cd3
6
Code
37195
37205
37206
37207
37208
37250
37251
37700
37720
37730
37735
37760
37780
37785
37788
37790
37799
Benefit
Restrictions
Description
Transcatheter Therapy and Biopsy
Thrombolysis, cerebral, by intravenous infusion.............. 3
Transcatheter placement of intravascular
stent(s); initial vessel .................................................. 1
Transcatheter placement of intravascular
stent(s); each add....................................................... 1
Transcatheter placement of intravascular
stent(s) open; initial vessel ......................................... 1
Transcatheter placement of intravascular
stent(s); each add....................................................... 1
Intravascular Ultrasound Services
Intravascular ultrasound (non-coronary vessel) during
diagnostic evaluation and/or therapeutic intervention;
initial vessel ................................................................ 3
Intravascular ultrasound (non-coronary vessel) during
therapeutic intervention; each additional vessel..... 3, 4
Ligation and Other Procedures
Ligation/division long saphenous vein ............................. 2
Ligation/division/complete stripping saphenous vein....... 2
Ligation/division/stripping saphenous veins..................... 2
Ligation/division/stripping saphenous veins,
with excision ............................................................... 2
Ligation perforators .......................................................... 2
Ligation/division short saphenous vein ........................ 2, 3
Ligation/division secondary varicose veins .................. 2, 3
Penile revascularization, artery,
with or without vein graft............................................. 1
Penile venous occlusive procedure ................................. 1
Unlisted procedure, vascular surgery .............................. 2
Description
38300
LYMPH NODES AND LYMPHATIC CHANNELS
Incision
Drainage of lymph node abscess; simple ........................3
38500
38505
38510
38520
38525
38530
38589
38790
38792
38999
38129
38200
Introduction
Injection procedure for splenoportography ...................... 3
38230
38231
38240
38241
BONE MARROW OR STEM CELL
TRANSPLANTATION SERVICES
Bone marrow harvesting for transplantation .................... 2
Blood-derived peripheral stem cell harvesting
for transplantation, per collection............................ 2, 3
Bone marrow or blood derived peripheral stem
cell transplantation; allogenic ................................. 3, 4
Bone marrow or blood derived peripheral stem
cell transplantation; autologous .............................. 3, 4
Benefit Restriction Descriptions:
1
2
Excision
Biopsy/excision lymph node; open, superficial ............3, 5
Biopsy/excision lymph node;
by needle, superficial..........................................3, 4, 5
Biopsy/excision lymph node; open, deep cervical ...........5
Biopsy/excision lymph node; open, deep cervical,
with excision ...............................................................5
Biopsy/excision lymph node; open, deep axillary.............5
Biopsy/excision lymph node; open, internal
mammary node(s).......................................................5
Laparoscopy
Unlisted laparoscopy procedure,
lymphatic system ........................................................2
RADICAL LYMPHADENECTOMY
(RADICAL RESECTION OF LYMPH NODES)
Introduction
Injection procedure; lymphangiography .......................3, 5
Injection procedure; for
identification of sentinel node .....................................3
Unlisted procedure, hemic or lymphatic system ..............2
MEDIASTINUM AND DIAPHRAGM
HEMIC AND LYMPHATIC SYSTEMS
SPLEEN
Laparoscopy
Unlisted laparoscopy procedure, spleen.......................... 2
Benefit
Restrictions
Code
39499
39502
39520
39530
39531
39541
39599
Non-Benefit
Requires TAR,
Primary Surgeon/Provider
MEDIASTINUM
Repair
Unlisted procedure, mediastinum ....................................2
DIAPHRAGM
Repair
Repair, paraesophageal hiatus hernia,
transabdominal ...........................................................2
Repair, diaphragmatic hernia; transthoracic ....................2
Repair, diaphragmatic hernia; combined,
thoracoabdominal .......................................................2
Repair, diaphragmatic hernia; combined,
thoracoabdominal, with dilation of stricture ................2
Repair, diaphragmatic hernia, traumatic; chronic ............2
Unlisted procedure, diaphragm........................................2
3
4
5
Assistant Surgeon services not payable
Anesthesiology services not payable
Ambulatory Surgical
2 – TAR and Non-Benefit List: Codes 30000 – 39999
December 2001
tar and non cd4
TAR and Non-Benefit List: Codes 40000 – 49999
Code
Benefit
Restrictions
Description
SURGERY (continued)
DIGESTIVE SYSTEM
40490
LIPS
Excision
Biopsy of lip.................................................................. 3, 5
40799
Other Procedures
Unlisted procedure, lips ................................................... 2
40800
40801
40804
40805
40806
VESTIBULE OF MOUTH
Incision
Drainage abscess/cyst, mouth, simple ........................ 3, 5
Drainage abscess/cyst, mouth, complicated................ 3, 5
Removal embedded foreign body, simple.................... 3, 5
Removal embedded foreign body, complicated............... 3
Incision labial frenum ....................................................... 1
40808
40810
40812
40816
40819
40820
Excision
Biopsy, vestibule of mouth ............................................... 3
Excision lesion mucosa/submucosa ................................ 1
Excision lesion mucosa/submucosa, simple repair ......... 3
Excision lesion mucosa/submucosa, complex................. 3
Excision frenum, labial or buccal ..................................... 3
Destruction lesion/scar by physical methods ................... 3
40830
40899
Repair
Closure of laceration, vestibule of
mouth, 2.5 cm or less ................................................. 3
Other Procedures
Unlisted procedure, vestibule of mouth............................ 2
41000
41005
41007
41008
41009
41010
41016
41017
41018
Benefit Restriction Descriptions:
1
2
Benefit
Restrictions
Code
Description
41100
41105
41108
41115
41116
Excision
Biopsy tongue, anterior 2/3 ..........................................3, 5
Biopsy tongue, posterior 1/3 ........................................3, 5
Biopsy floor of mouth ...................................................3, 5
Excision lingual frenum ....................................................1
Excision, lesion of floor of mouth .....................................3
41250
41251
Repair
Repair of laceration, 2.5 cm or less,
anterior 2/3 of tongue .................................................3
Repair of laceration, 2.5 cm or less,
posterior 1/3 of tongue................................................3
41500
41510
41520
41599
Other Procedures
Fixation, tongue, mechanical, other than suture ..............2
Suture, tongue to lip for micrognathia ..............................2
Frenoplasty ......................................................................3
Unlisted procedure, tongue, floor of mouth......................2
41800
DENTOALVEOLAR STRUCTURES
Incision
Drainage of abscess from dentoalveolar structures.........3
41830
Excision, Destruction
Gingivectomy, each quadrant ..........................................3
Operculectomy, excision pericoronal tissues...................3
Excision of fibrous tuberosities,
dentoalveolar structures .............................................3
Excision of osseous tuberosities,
dentoalveolar structures .............................................3
Excision of lesion, dentoalveolar structures;
without repair ..............................................................3
Excision of lesion, dentoalveolar structures;
with simple repair........................................................3
Excision of hyperplastic alveolar mucosa,
each quadrant (specify) ..............................................3
Alveolectomy, including curettage of osteitis ...................3
41870
41872
41874
41899
Other Procedures
Peridontal mucosal grafting .............................................3
Gingivoplasty, each quadrant (specify) ............................3
Alveoplasty, each quadrant (specify) ...............................3
Unlisted procedure, dentoalveolar structures ..................2
41820
41821
41822
41823
41825
41826
41828
TONGUE, FLOOR OF MOUTH
Incision
Intraoral incision and drainage of abcess; lingual ............ 3
Intraoral incision and drainage of abcess;
sublingual, superficial ................................................. 3
Intraoral incision and drainage of abcess;
submental space ........................................................ 3
Intraoral incision and drainage of abcess;
submandibular space ................................................. 3
Intraoral incision and drainage of abcess;
masticator space ........................................................ 3
Incision lingual frenum ..................................................... 1
Extraoral incision and drainage of abcess;
submental ................................................................... 3
Extraoral incision and drainage of abcess;
submandibular ............................................................ 3
Extraoral incision and drainage of abcess;
masticator space ........................................................ 3
1
Non-Benefit
Requires TAR,
Primary Surgeon/Provider
3
4
5
Assistant Surgeon services not payable
Anesthesiology services not payable
Ambulatory Surgical
2 – TAR and Non-Benefit List: Codes 40000 – 49999
October 1999
tar and non cd4
2
Benefit
Restrictions
Code
Description
42000
PALATE, UVULA
Incision
Drainage of abscess of palate, uvula............................... 3
42100
42140
42145
42160
Excision
Biopsy of palate, uvula.................................................... 3
Uvulectomy, excision of uvula...................................... 2, 3
Palatopharyngoplasty ...................................................... 2
Destruction of lesion, palate or uvula............................... 3
42180
42280
42281
Repair
Repair, laceration of palate, up to 2 cm ........................... 3
Maxillary impression for palatal prosthesis ...................... 3
Insertion of pin-retained palatal prosthesis ...................... 3
42299
Other Procedures
Unlisted procedure, palate, uvula .................................... 2
Code
42820
42821
42825
42826
42830
42831
42835
42836
42860
42870
42960
42962
42970
42320
42330
42335
SALIVARY GLANDS AND DUCTS
Incision
Drainage of abscess; parotid, simple............................... 3
Drainage of abscess;
submaxillary or sublingual, intraoral ........................... 3
Drainage of abscess; submaxillary, external ................... 3
Sialolithotomy; submandibular, uncomplicated................ 3
Sialolithotomy; submandibular, complicated.................... 3
42400
42405
Excision
Biopsy salivary gland, needle .................................. 3, 4, 5
Biopsy salivary gland, incisional .................................. 3, 5
42550
42650
42660
42699
Other Procedures
Injection procedure for sialography.............................. 3, 5
Dilation salvitory duct ....................................................... 3
Dilation and catheterization of salivary duct..................... 3
Unlisted procedure, salivary glands or ducts ................... 2
42700
42720
PHARYNX, ADENOIDS, AND TONSILS
Incision
Incision and drainage abscess; peritonsillar .................... 3
Incision and drainage abscess; retropharyngeal ............. 3
42300
42310
42800
42802
42804
42806
42808
42809
42810
42815
Excision
Biopsy, oropharynx ...................................................... 3, 5
Biopsy, hypopharynx.................................................... 3, 5
Biopsy, nasopharynx, visible lesion ............................. 3, 5
Biopsy, nasopharynx, for unknown primary lesion........... 5
Excision or destruction of pharynx lesion......................... 5
Removal foreign body from pharynx ............................ 3, 5
Excision branchial cleft cyst, in skin............................. 2, 3
Excision branchial cleft cyst,
beneath subcutaneous tissues ............................... 2, 3
42972
42999
43200
43202
43204
43205
43215
43216
43217
43219
43220
43226
43227
43228
43231
43232
43234
43235
43239
43240
43241
Benefit Restriction Descriptions:
1
2
Non-Benefit
Requires TAR,
Primary Surgeon/Provider
Description
Benefit
Restrictions
Excision (continued)
Tonsillectomy/adenoidectomy, under 12 years............2, 3
Tonsillectomy/adenoidectomy, 12 years and over .......2, 3
Tonsillectomy, under 12 years .....................................2, 3
Tonsillectomy, 12 years and over ................................2, 3
Adenoidectomy, primary, under 12 years ....................2, 3
Adenoidectomy, primary, 12 years and over................2, 3
Adenoidectomy, secondary, under 12 years................2, 3
Adenoidectomy, secondary, 12 years and over ...........2, 3
Excision tonsil tags ......................................................2, 3
Excision or destruction lingual tonsil ............................2, 3
Control oropharyngeal hemorrhage; simple.....................3
Control oropharyngeal hemorrhage;
with surgical intervention ............................................3
Control of nasopharyngeal hemorrhage, primary or
secondary; simple.......................................................3
Control of nasopharyngeal hemorrhage,
primary or secondary; with secondary
surgical intervention....................................................3
Other Procedures
Unlisted procedure, pharynx, adenoids or tonsils ............2
ESOPHAGUS
Endoscopy
Esophagoscopy, diagnostic .........................................3, 5
Esophagoscopy, with biopsy, single or multiple...........3, 5
Esophagoscopy, with injection sclerosis
esophageal varices.................................................3, 5
Esophagoscopy, with band ligation
of esophageal varices.................................................3
Esophagoscopy, with removal foreign body.................3, 5
Esophagoscopy, with lesion removal,
by forceps or cautery ..................................................3
Esophagoscopy, with lesion removal, by snare ...........3, 5
Esophagoscopy, with insertion plastic tube/stent ............5
Esophagoscopy, with balloon dilation ..........................3, 5
Esophagoscopy, with guide wire insertion
followed by dilation over guide wire ........................3, 5
Esophagoscopy, with control of bleeding.....................3, 5
Esophagoscopy, for ablation of lesion .........................3, 5
Esophagoscopy, with endoscopic ultrasound
examination...............................................................3
Esophagoscopy, with transendoscopic ultrasoundguided intramural or transmural fine needle
aspiration/biopsy(s)..................................................3
Upper gastrointestinal endoscopy,
simple primary exam ..............................................3, 5
Upper gastrointestinal endoscopy, diagnostic,
including esophagus, stomach
and duodenum and/or jejunum...............................3, 5
Upper gastrointestinal endoscopy, including
esophagus, stomach and duodenum
and/or jejunum, with biopsy ....................................3, 5
Upper gastrointestinal endoscopy, with transmural
drainage of pseudocyst ...........................................3
Upper gastrointestinal endoscopy, with transendoscopic
intraluminal tube or catheter placement .............3, 5
3
4
5
Assistant Surgeon services not payable
Anesthesiology services not payable
Ambulatory Surgical
2 – TAR and Non-Benefit List: Codes 40000 – 49999
November 2001
tar and non cd4
3
Code
Benefit
Restrictions
Description
43271
43272
Endoscopy (continued)
Upper gastrointestinal endoscopy, with
transendoscopic ultrasound-guided
intramural or transmural fine needle
aspiration/biopsy(s) .................................................... 3
Upper gastrointestinal endoscopy, including
esophagus, stomach and duodenum and/or
jejunum, with injection sclerosis of varices................. 3
Upper gastrointestinal endoscopy, including
esophagus, stomach and duodenum, with
band ligation of varices............................................... 3
Upper gastrointestinal endoscopy with gastric
outlet dilation, including esophagus, stomach
and duodenum and/or jejunum............................... 3, 5
Upper gastrointestinal endoscopy, including
esophagus, stomach and duodenum
and/or jejunum, with tube placement...................... 3, 5
Upper gastrointestinal endoscopy, including
esophagus, stomach and duodenum
and/or jejunum, with removal of foreign body............. 5
Upper gastrointestinal endoscopy, including
esophagus, stomach and duodenum,
guide wire insertion..................................................... 3
Upper gastrointestinal endoscopy, including
esophagus, stomach and duodenum,
removal of lesions, by forceps or cautery ................... 3
Upper gastrointestinal endoscopy, including
esophagus, stomach and duodenum,
removal of lesions, by snare................................... 3, 5
Upper gastrointestinal endoscopy, with
transendoscopic stent placement
(includes predilation) .................................................. 3
Upper gastrointestinal endoscopy, including
esophagus, stomach and duodenum,
endoscopic ultrasound................................................ 3
ERCP, diagnostic, with biopsy ......................................... 3
ERCP with sphincterotomy/papillotomy ........................... 3
ERCP with pressure measurement of
sphincter of Oddi ........................................................ 3
ERCP with stone removal, ducts ..................................... 3
ERCP with stone destruction ........................................... 1
ERCP with nasobiliary drainage tube insertion................ 3
ERCP with tube or stent insertion into duct ................. 3, 4
ERCP with foreign body removal and/or
change of tube/stent ................................................... 3
ERCP with balloon dilation of ampulla, duct .................... 3
ERCP with ablation of lesions.......................................... 3
43289
Laparoscopy
Unlisted laparoscopy procedure, esophagus................... 2
43450
43453
43456
43458
43460
43499
Manipulation
Dilation of esophagus by unguided sound or bougie ....... 3
Dilation of esophagus over guide wire ............................. 3
Dilation of esophagus; retrograde.................................... 3
Dilation of esophagus with balloon for achalasia ............. 3
Esophagogastric tamponade, with balloon ...................... 3
Unlisted procedure, esophagus ....................................... 2
43242
43243
43244
43245
43246
43247
43248
43250
43251
43256
43259
43261
43262
43263
43264
43265
43267
43268
43269
Description
43600
STOMACH
Excision
Biopsy stomach, peroral ..........................................3, 4, 5
43659
Laparoscopy
Unlisted laparoscopy procedure, stomach.......................2
43750
43752
43760
43761
43842
43843
43846
43847
43848
43999
44100
44121
44132
44133
44135
44136
44209
44340
44360
44361
44363
44364
44365
Benefit Restriction Descriptions:
1
2
Benefit
Restrictions
Code
Non-Benefit
Requires TAR,
Primary Surgeon/Provider
Introduction
Percutaneous placement gastrostomy tube.....................5
Naso- or oro-gastric tube placement, necessitating
physician’s skill ...........................................................3
Change of gastrostomy tube ............................................3
Repositioning of gastric feeding tube, any method,
through the duodenum for enteric nutrition.................3
Suture
Gastric restrictive procedure, without gastric bypass,
for morbid obesity; vertical-banded gastroplasty ........2
Gastric restrictive procedure, without gastric bypass,
for morbid obesity; other than vertical-banded
gastroplasty ................................................................2
Gastric restrictive procedure, with gastric bypass,
for morbid obesity; with short limb Roux-en-Y
gastroenterostomy......................................................2
Gastric restrictive procedure, with gastric bypass,
for morbid obesity; with small bowel reconstruction
to limit absorption .......................................................2
Revision of gastric restrictive procedure for
morbid obesity (separate procedure)..........................1
Unlisted procedure, stomach ...........................................2
INTESTINES (EXCEPT RECTUM)
Excision
Biopsy intestine, peroral...........................................3, 4, 5
Enterectomy, resection of small intestine;
each additional resection and anastomosis................4
Donor enterectomy, open; from cadaver
donor ..........................................................................1
Donor enterectomy, open; partial, from living
donor ..........................................................................1
Intestinal allotransplantation; from cadaver donor ...........2
Intestinal allotransplantation; from living donor................1
Laparoscopy
Unlisted laparoscopy procedure, intestine
(except rectum)...........................................................2
Enterostomy – external fistulization of intestines
Revision of colostomy; simple..........................................3
Endoscopy, small bowel and stomal
Small intestinal endoscopy, diagnostic ........................3, 5
Small intestinal endoscopy; with biopsy.......................3, 5
Small intestinal endoscopy; with removal of
foreign body............................................................3, 5
Small intestinal endoscopy; with removal of
lesion(s) by snare ...................................................3, 5
Small intestinal endoscopy; with removal of
lesion(s) by forceps or cautery....................................3
3
4
5
Assistant Surgeon services not payable
Anesthesiology services not payable
Ambulatory Surgical
2 – TAR and Non-Benefit List: Codes 40000 – 49999
March 2002
tar and non cd4
4
Code
44366
44369
44370
44372
44373
44376
44377
44378
44379
44380
44382
44383
44385
44386
44388
44389
44390
44391
44392
44393
44394
44397
Benefit
Restrictions
Description
Endoscopy, small bowel and stomal (continued)
Small intestinal endoscopy; with control of bleeding........ 3
Small intestinal endoscopy; with ablation of lesion(s)...... 3
Small intestinal endoscopy; with transendoscopic
stent placement (includes predilation) ........................ 3
Small intestinal endoscopy; percutaneous
jejunostomy tube ........................................................ 3
Small intestinal endoscopy; gastrostomy to
jejunostomy tube .................................................... 3, 4
Small intestinal endoscopy, including ileum;
diagnostic ................................................................... 3
Small intestinal endoscopy, including ileum; with
biopsy ......................................................................... 3
Small intestinal endoscopy, including ileum; with
control of bleeding ...................................................... 3
Small intestinal endoscopy; with transendoscopic
stent placement (includes predilation) ........................ 3
Ileoscopy through stoma; diagnostic........................ 3, 4, 5
Ileoscopy through stoma; with biopsy ...................... 3, 4, 5
Ileoscopy, through stoma; with transendoscopic
stent placement (includes predilation) ........................ 3
Endoscopic evaluation small intestine pouch;
diagnostic ........................................................... 3, 4, 5
Endoscopic evaluation small intestine pouch;
with biopsy.............................................................. 3, 5
Colonoscopy through stoma; diagnostic .................. 3, 4, 5
Colonoscopy through stoma; with biopsy ................ 3, 4, 5
Colonoscopy through stoma; with foreign body
removal............................................................... 3, 4, 5
Colonoscopy through stoma; with control of
bleeding .................................................................. 3, 4
Colonoscopy through stoma; removal of lesion(s)
by forceps or cautery .............................................. 3, 4
Colonoscopy through stoma; ablation of lesion(s) ....... 3, 5
Colonoscopy through stoma; removal of lesion(s)
by snare...................................................................... 3
Colonoscopy through stoma; with transendoscopic
stent placement (includes predilation) ........................ 3
44500
Introduction
Gastrointestinal tube introduction .................................... 3
44799
Suture
Unlisted procedure, intestine ........................................... 2
Code
45300
45303
45305
45307
45308
45309
45315
45317
45320
45321
45327
45330
45331
45332
45333
45334
45337
45338
45339
45341
45342
45345
45355
45378
45379
45380
45382
45383
45384
45385
45387
44899
44979
45005
45100
MECKEL'S DIVERTICULUM AND THE MESENTERY
Excision
Unlisted procedure, Meckel's diverticulum and
mesentery................................................................... 2
Benefit
Restrictions
Endoscopy
Proctosigmoidoscopy, rigid; diagnostic........................3, 5
Proctosigmoidoscopy, rigid; with dilation .....................3, 5
Proctosigmoidoscopy, rigid; with biopsy ......................3, 5
Proctosigmoidoscopy, rigid; foreign body removal ......3, 5
Proctosigmoidoscopy, rigid; single lesion
removal by forceps or cautery ....................................3
Proctosigmoidoscopy, rigid; single lesion
removal by snare ........................................................3
Proctosigmoidoscopy, rigid; multiple lesion
removal, by forceps, cautery or snare ....................3, 5
Proctosigmoidoscopy, rigid; with control of bleeding .......5
Proctosigmoidoscopy, rigid; with ablation
of lesion(s) ..........................................................3, 4, 5
Proctosigmoidoscopy, rigid; decompression
of volvulus...................................................................3
Proctosigmoidoscopy, rigid; with transendoscopic
stent placement (includes predilation) .......................3
Sigmoidoscopy, flexible; diagnostic .............................3, 5
Sigmoidoscopy, flexible; with biopsy............................3, 5
Sigmoidoscopy, flexible; with removal of
foreign body............................................................3, 5
Sigmoidoscopy, flexible; with removal of
lesion(s) by forceps or cautery................................3, 5
Sigmoidoscopy, flexible; control of bleeding ....................3
Sigmoidoscopy, flexible; with decompression
of volvulus...................................................................3
Sigmoidoscopy, flexible; lesion removal, by snare ..........3
Sigmoidoscopy, flexible; ablation of lesion(s) ..................3
Sigmoidoscopy, flexible; with endoscopic ultrasound
examination ................................................................3
Sigmoidoscopy, flexible; with transendoscopic
ultrasound guided intramural or transmural fine
aspiration/biopsy(s) ...................................................3
Sigmoidoscopy, flexible; with transendoscopic stent
placement (includes predilation).................................3
Colonoscopy, via colotomy ..............................................3
Colonoscopy, flexible; diagnostic.................................3, 5
Colonoscopy, flexible; with removal of foreign body ....3, 5
Colonoscopy, flexible; with biopsy ...............................3, 5
Colonoscopy, flexible; with control of bleeding ................3
Colonoscopy, flexible; with ablation of lesion(s) ..........3, 5
Colonoscopy, flexible; removal of
lesion(s) by forceps or cautery....................................3
Colonoscopy, flexible; removal of lesion(s), by snare......5
Colonoscopy, flexible; with transendoscopic stent
placement (includes predilation).................................3
45505
45520
Repair
Proctoplasty; for prolapse of mucous membrane ............2
Perirectal injection sclerosing solution .........................3, 5
45900
45905
45910
45915
45999
Manipulation
Reduction of procidentia under anesthesia......................3
Dilation of anal sphincter under anesthesia .....................3
Dilation of rectal stricture under anesthesia.....................3
Removal of fecal impaction under anesthesia .................3
Unlisted procedure, rectum..............................................2
Laparoscopy
Unlisted laparoscopy procedure, appendix...................... 2
RECTUM
Incision
Incision and drainage of submucosal abscess,
rectum......................................................................... 3
Description
Excision
Biopsy anorectal wall ................................................... 3, 5
Benefit Restriction Descriptions:
1
2
Non-Benefit
Requires TAR,
Primary Surgeon/Provider
3
4
5
Assistant Surgeon services not payable
Anesthesiology services not payable
Ambulatory Surgical
2 – TAR and Non-Benefit List: Codes 40000 – 49999
November 2001
tar and non cd4
5
Code
46030
46040
46045
46050
46080
46083
Benefit
Restrictions
Description
ANUS
Incision
Removal seton, other marker................................... 3, 4, 5
Incision and drainage of ischiorectal abscess ................. 3
Incision and drainage of intramural abscess
under anesthesia ........................................................ 3
Incision and drainage of perianal abscess, superficial .... 3
Sphincterotomy, anal, division of sphincter...................... 3
Incision thrombosed hemorrhoid, external................... 3, 5
Description
46762
Repair
Sphincteroplasty, anal, implantation
artificial sphincter........................................................1
46940
46942
Destruction
Destruction lesions, anus, simple, chemical ............3, 4, 5
Destruction lesions, anus, simple,
electrodesiccation...................................................3, 5
Destruction lesions, anus, simple, cyrosurgery........3, 4, 5
Destruction lesions, anus, simple, laser surgery......3, 4, 5
Destruction lesions, anus, simple, surgical excision ....3, 5
Destruction lesions, anus, extensive, any method.......3, 5
Destruction hemorrhoids, any method, internal ...........3, 5
Destruction hemorrhoids, any method, external ..........3, 5
Destruction hemorrhoids, any method,
internal/external ......................................................3, 5
Curettage/cauterization anal fissure, initial ..................3, 5
Curettage/cauterization anal fissure, subsequent........3, 5
46945
46946
Suture
Ligation internal hemorrhoids, single procedure ..........3, 5
Ligation internal hemorrhoids, multiple procedure .......3, 5
46999
Other Procedures
Unlisted procedure, anus .................................................2
46900
46910
46916
46917
46922
46924
46934
46935
46936
46270
46275
46280
46285
46288
46320
Excision
Fissurectomy, with or without sphincterotomy ................. 2
Cryptectomy; single ......................................................... 3
Cryptectomy; multiple ...................................................... 2
Papillectomy/excision single tag, anus ............................ 3
Hemorrhoidectomy, simple ligature ................................. 3
Excision external hemorrhoid tags................................... 3
Hemorrhoidectomy, external, complete ....................... 2, 3
Hemorrhoidectomy, internal and external, simple............ 2
Hemorrhoidectomy, internal and external,
simple; fissurectomy ................................................... 2
Hemorrhoidectomy, internal and external,
simple; fistulectomy .................................................... 2
Hemorrhoidectomy, internal and external,
complex or extensive.................................................. 2
Hemorrhoidectomy, internal and external,
complex or extensive; fissurectomy............................ 2
Hemorrhoidectomy, internal and external,
complex or extensive; fistulectomy............................. 2
Surgical treatment of anal fistula; subcutaneous ......... 2, 3
Surgical treatment of anal fistula; submuscular ............... 2
Surgical treatment of anal fistula; complex or multiple .... 2
Surgical treatment of anal fistula; second stage .......... 2, 3
Closure of anal fistula with rectal advancement flap........ 2
Excision external thrombotic hemorrhoid..................... 3, 5
47379
46500
Introduction
Injection sclerosing solution, hemorrhoids ................... 3, 5
Endoscopy
Anoscopy, diagnostic ................................................... 3, 5
Anoscopy, diagnostic, with dilation .............................. 3, 5
Anoscopy, diagnostic, with biopsy ............................... 3, 5
Anoscopy, diagnostic, with removal of foreign body .... 3, 5
Anoscopy, diagnostic, with removal of
lesion by forceps or cautery.................................... 3, 5
Anoscopy, diagnostic, with single lesion
removal by snare .................................................... 3, 5
Anoscopy, diagnostic, multiple lesion removal ............ 3, 5
Anoscopy, diagnostic, with control of bleeding ................ 5
Anoscopy, diagnostic, with ablation of lesion............... 3, 5
47133
46200
46210
46211
46220
46221
46230
46250
46255
46257
46258
46260
46261
46262
46600
46604
46606
46608
46610
46611
46612
46614
46615
Benefit Restriction Descriptions:
1
2
Benefit
Restrictions
Code
47000
47001
47134
47135
47136
47399
Non-Benefit
Requires TAR,
Primary Surgeon/Provider
LIVER
Incision
Biopsy of liver, needle; percutaneous ..............................3
Biopsy of liver, needle; when done for indicated
purpose at time of other major procedure (List
separately in addition to code for primary
procedure) ..................................................................4
Other Procedures
Unlisted laparoscopic procedure, liver .............................2
Excision
Donor hepatectomy, with preparation and
maintenance of allograft; from cadaver donor ............1
Donor hepatectomy, with preparation
and maintenance of allograft;
partial, from living donor .............................................2
Liver allotransplantation; orthotopic, partial or
whole, from cadaver or living donor, any age .............2
Liver allotransplantation; heterotopic, partial or
whole, from cadaver or living donor, any age .............1
Unlisted procedure, liver ...............................................2
3
4
5
Assistant Surgeon services not payable
Anesthesiology services not payable
Ambulatory Surgical
2 – TAR and Non-Benefit List: Codes 40000 – 49999
March 2002
tar and non cd4
6
Code
47500
47505
47510
47511
47550
47552
47553
47554
47555
47556
47562
47563
47564
47579
47600
47605
47610
47612
47620
Benefit
Restrictions
Description
BILIARY TRACT
Introduction
Injection for percutaneous transhepatic
cholangiography ......................................................... 3
Injection for cholangiography through existing catheter... 3
Introduction of percutaneous transhepatic catheter......... 3
Introduction of percutaneous transhepatic stent .............. 3
Endoscopy
Biliary endoscopy, intraoperative (choledochoscopy)
(List separately in addition to code for primary
procedure) .............................................................. 3, 4
Biliary endoscopy, percutaneous, diagnostic............... 3, 4
Biliary endoscopy, percutaneous, with biopsy ................. 3
Biliary endoscopy, percutaneous,
with removal of stones................................................ 3
Biliary endoscopy, percutaneous, with dilation
of biliary duct, without stent ........................................ 3
Biliary endoscopy, percutaneous, with dilation
of biliary duct, with stent ............................................. 3
Laparoscopy
Laparoscopy, surgical; cholecystectomy ......................... 2
Laparoscopy, surgical; cholecystectomy with
cholangiography ......................................................... 2
Laparoscopy, surgical; cholecystectomy
with exploration of common duct ................................ 2
Unlisted laparoscopy procedure, biliary tract ................... 2
Excision
Cholecystectomy.............................................................. 2
Cholecystectomy; with cholangiography.......................... 2
Cholecystectomy with exploration of common duct ......... 2
Cholecystectomy with exploration of common duct;
choledochoenterostomy ............................................. 2
Cholecystectomy with exploration of common duct;
transduodenal sphincterotomy or sphincteroplasty .... 2
Description
49002
49080
49081
ABDOMEN, PERITONEUM, AND OMENTUM
Incision
Reopening recent laparotomy incision.............................1
Peritoneocentesis, initial ..................................................3
Peritoneocentesis, subsequent....................................3, 4
49180
49250
49329
49400
49420
49421
49423
49424
49427
49505
49520
49525
49540
49550
49555
49560
49565
49568
47999
Other Procedures
Unlisted procedure, biliary tract ....................................... 2
48102
48160
PANCREAS
Excision
Biopsy of pancreas, percutaneous needle....................... 3
Pancreatectomy, total or subtotal, with transplantation ... 1
49570
49580
49585
49590
49600
Introduction
Injection procedure for intraoperative
pancreatography (List separately in addition to
code for primary procedure) ................................... 3, 4
49650
48400
48554
48556
Pancreas Transplantation
Donor pancreatectomy, with preparation
and maintenance of allograft ...................................... 1
Transplantation of pancreatic allograft............................. 1
Removal of transplanted pancreatic allograft................... 1
48999
Repair
Unlisted procedure, pancreas .......................................... 2
48550
Benefit Restriction Descriptions:
1
2
Benefit
Restrictions
Code
49651
49659
49999
Non-Benefit
Requires TAR,
Primary Surgeon/Provider
Excision and Destruction
Biopsy, abdominal/retroperitoneal mass,
percutaneous needle ..............................................3, 5
Umbilectomy, omphalectomy...........................................1
Laparoscopy
Unlisted laparoscopy procedure, abdomen,
peritoneum and omentum...........................................2
Introduction and Revision
Injection of air or contrast into peritoneal cavity.......3, 4, 5
Insertion intraperitoneal cannula, temporary............3, 4, 5
Insertion intraperitoneal cannula, permanent...............3, 5
Exchange of previously placed abscess or cyst drainage
catheter under radiological guidance (separate
procedure) ..................................................................3
Contrast injection for assessment of abscess or cyst via
previously placed catheter (separate procedure) .......3
Injection, evaluation of previously placed
peritoneal-venous shunt .........................................3, 4
Hernioplasty, Herniorrhaphy, Herniotomy
Repair inguinal hernia, age 5 years or older, reducible ...2
Repair recurrent inguinal hernia, any age, reducible .......2
Repair inguinal hernia, sliding, any age ...........................2
Repair lumbar hernia .......................................................2
Repair initial femoral hernia, any age, reducible..............2
Repair recurrent femoral hernia, reducible ......................2
Repair initial incisional or ventral hernia, reducible..........2
Repair recurrent incisional or ventral hernia,
reducible .....................................................................2
Implantation of mesh or other prosthesis for
incisional or ventral hernia repair (List separately
in addition to code for the incisional or ventral hernia
repair) .........................................................................4
Repair epigastric hernia, reducible ..................................2
Repair umbilical hernia, age under 5 years; reducible.....2
Repair umbilical hernia, age 5 years or over; reducible...2
Repair spigelian hernia ....................................................2
Repair small omphalocele, with primary closure..............2
Laparoscopy
Laparoscopy, surgical; repair initial inguinal
hernia..........................................................................2
Laparoscopy, surgical; repair recurrent inguinal hernia ...2
Unlisted laparoscopy procedure, herninoplasty,
herniorrhaphy, herniotomy..........................................2
Suture
Unlisted procedure, abdomen, peritoneum
and omentum..............................................................2
3
4
5
Assistant Surgeon services not payable
Anesthesiology services not payable
Ambulatory Surgical
2 – TAR and Non-Benefit List: Codes 40000 – 49999
May 2001
tar and non cd5
TAR and Non-Benefit List: Codes 50000 – 59999
Code
Benefit
Restrictions
Description
Code
50300
50320
50340
50360
50365
50380
50684
KIDNEY
50686
Excision
Renal biopsy; percutaneous, by trocar or needle ........ 3, 4
50688
50690
50949
Laparoscopy
Unlisted laparoscopy procedure, ureter ......................2
Renal Transplantation
Donor nephrectomy, from cadaver donor ........................ 1
Donor nephrectomy, open from living donor
(excluding preparation and maintenance of
allograft)...................................................................... 2
Recipient nephrectomy .................................................... 2
Renal allotransplantation, implantation of graft;
excluding donor and recipient nephrectomy............... 2
Renal transplant with recipient nephrectomy ................... 2
Renal autotransplantation, reimplantation ....................... 2
50396
50398
50540
Suture
Symphysiotomy, horseshoe kidney ................................. 2
50393
50394
50395
50547
50549
50551
50553
50555
50557
50559
50561
50570
50572
50574
50575
50576
50578
50580
Benefit
Restrictions
URINARY SYSTEM
Introduction
Aspiration/injection renal cyst/pelvis, by needle....... 3, 4, 5
Introduction catheter into renal pelvis,
percutaneous.......................................................... 3, 4
Introduction uretral catheter into ureter,
percutaneous.......................................................... 3, 4
Injection for pyelography through tube..................... 3, 4, 5
Introduction of guide into renal pelvis,
percutaneous.............................................................. 3
Manometric studies through tube............................. 3, 4, 5
Change nephrosotomy or pyelostomy tube ............. 3, 4, 5
50390
50392
Description
URETER
Introduction
Injection procedure through ureterostomy/
indwelling catheter..............................................3, 4, 5
Manometric studies through
ureterostomy/indwelling catheter ........................3, 4, 5
Change of ureterostomy tube...................................3, 4, 5
Injection procedure visualization ilial conduit ...........3, 4, 5
SURGERY (continued)
50200
1
Laparoscopy
Laparoscopy, surgical; donor nephrectomy from
living donor (excluding preparation and
maintenance of allograft) ............................................ 2
Unlisted laparoscopy procedure, renal ............................ 2
Endoscopy
Renal endoscopy, through established
nephrostomy/pyelostomy........................................ 3, 5
Renal endoscopy, ureteral catheterization................... 3, 5
Renal endoscopy, with biopsy ..................................... 3, 5
Renal endoscopy, with fulguration ............................... 3, 5
Renal endoscopy, insertion radioactive substance...... 3, 5
Renal endoscopy, removal foreign body/calculus........ 3, 5
Renal endoscopy, through nephrotomy or
pyelotomy ........................................................... 3, 4, 5
Renal endoscopy, with ureteral catheterization ....... 3, 4, 5
Renal endoscopy, with biopsy ................................. 3, 4, 5
Renal endoscopy, with endopyelotomy ....................... 3, 4
Renal endoscopy, with fulguration ........................... 3, 4, 5
Renal endoscopy, insertion of radioactive
substance ........................................................... 3, 4, 5
Renal endoscopy, removal foreign body/calculus.... 3, 4, 5
Benefit Restriction Descriptions:
1
2
50951
50953
50955
50957
50959
50961
50970
50972
50974
50976
50978
50980
51000
51005
51010
51020
51030
51040
51045
51600
51605
51610
51700
51705
51710
51715
51720
Non-Benefit
Requires TAR,
Primary Surgeon/Provider
Endoscopy
Ureteral endoscopy through ureterostomy...............3, 4, 5
Ureteral endoscopy, with ureteral catheterization ....3, 4, 5
Ureteral endoscopy, with biopsy ..............................3, 4, 5
Ureteral endoscopy, with fulguration........................3, 4, 5
Ureteral endoscopy, insertion radioactive
substance ...........................................................3, 4, 5
Ureteral endoscopy, removal foreign
body/calculus......................................................3, 4, 5
Ureteral endoscopy through ureterotomy.................3, 4, 5
Ureteral endoscopy, with ureteral catheterization ....3, 4, 5
Ureteral endoscopy, with biopsy ..............................3, 4, 5
Ureteral endoscopy, with fulguration........................3, 4, 5
Ureteral endoscopy, insertion radioactive
substance ...........................................................3, 4, 5
Ureteral endoscopy, removal foreign
body/calculus......................................................3, 4, 5
BLADDER
Incision
Aspiration bladder, needle .......................................3, 4, 5
Aspiration bladder, trocar or intracatheter................3, 4, 5
Aspiration bladder, insertion suprapubic catheter....3, 4, 5
Cystotomy/cystostomy with
fulguration/insertion radioactive..................................5
Cystotomy/cystostomy/cryosurgical destruction lesion ....5
Cystostomy, cystotomy with drainage..............................5
Cystotomy, insertion ureteral catheter .............................5
Introduction
Injection procedure cystography/voiding
urethrocystography .............................................3, 4, 5
Injection procedure and placement of chain ............3, 4, 5
Injection procedure for retrograde
urethrocystography .............................................3, 4, 5
Bladder irrigation, simple .........................................3, 4, 5
Change cystostomy tube, simple .....................................5
Change cystostomy tube, complicated ........................3, 5
Endoscopic injection of implant material,
urethra and/or bladder neck ...................................2, 3
Bladder instillation anticarcinogenic agent...............3, 4, 5
3
4
5
Assistant Surgeon services not payable
Anesthesiology services not payable
Ambulatory Surgical
2 – TAR and Non-Benefit List: Codes 50000 – 59999
November 2001
tar and non cd5
2
Code
51725
51726
51736
51741
51772
51785
51792
51795
51797
Benefit
Restrictions
Description
Urodynamics
Simple cystometrogram ................................................... 5
Complex cystometrogram ................................................ 5
Simple uroflowmetry ........................................................ 5
Complex uroflowmetry ..................................................... 5
Urethral pressure profile studies ...................................... 5
Needle electromyography studies, anal or
urethral sphincter........................................................ 5
Stimulus evoked response............................................... 5
Voiding pressure studies, bladder voiding ....................... 5
Voiding pressure studies, intra-abdominal
voiding pressure ......................................................... 5
Code
52320
52325
52327
52330
52332
52334
52341
52000
52005
52007
52010
52204
52214
52224
52250
52260
52265
52270
52275
52276
52277
52281
52282
52283
52285
52290
52300
52305
52310
52315
52317
52318
Endoscopy – Cystoscopy, Urethroscopy, Cystourethoscopy
Cystourethroscopy ....................................................... 3, 5
Cystourethroscopy, ureteral catheterization ................ 3, 5
Cystourethroscopy, ureteral catheterization,
brush biopsy ............................................................... 5
Cystourethroscopy, ejaculatory duct catheterization ... 3, 5
Transurethral Surgery (Urethra and Bladder)
Cystourethroscopy, with biopsy ................................... 3, 5
Cystourethroscopy, fulguration .................................... 3, 5
Cystourethroscopy, fulguration minor lesions .............. 3, 5
Cystourethroscopy, insertion radioactive substance.... 3, 5
Cystourethroscopy, dilation bladder,
general anesthesia ................................................. 3, 5
Cystourethroscopy, dilation bladder,
local anesthesia.................................................. 3, 4, 5
Cystourethroscopy, internal urethrotomy, female ........ 3, 5
Cystourethroscopy, internal urethrotomy, male ........... 3, 5
Cystourethroscopy, direct vision internal
urethrotomy ............................................................ 3, 5
Cystourethroscopy, resection external sphincter ......... 3, 5
Cystourethroscopy, with calibration and/or
dilation of urethral stricture or stenosis, with or
without meatotomy, with or without injection
procedure for cystography, male or female ............ 3, 5
Cystourethroscopy, with insertion of urethral
stent............................................................................ 3
Cystourethroscopy, steroid injection into stricture ....... 3, 5
Cystourethroscopy, treatment female
urethral syndrome................................................... 3, 5
Cystourethroscopy, ureteral meatotomy ...................... 3, 5
Cystourethroscopy, with resection orfulguration of
orthotopic ureterocele(s),unilateral or bilateral ....... 3, 5
Cystourethroscopy, resection bladder diverticulum ..... 3, 5
Cystourethroscopy, removal calculus/foreign
body, simple ............................................................... 3
Cystourethroscopy, removal calculus/foreign
body, complicated....................................................... 3
Litholapaxy, crushing or fragmentation of calculus
by any means in bladder and removal of
fragments; simple or small (less than 2.5 cm) ............ 3
Litholapaxy, complicated or large .................................... 3
Benefit Restriction Descriptions:
1
2
52342
52343
52344
52345
52346
52351
52352
52353
52354
52355
52510
52601
52606
52612
52614
52620
52630
52640
52647
52648
52700
Non-Benefit
Requires TAR,
Primary Surgeon/Provider
Description
Benefit
Restrictions
Transurethral Surgery (Ureter and Pelvis)
Cystourethroscopy; removal ureteral calculus .............3, 5
Cystourethroscopy; fragmentation ureteral calculus ....3, 5
Cystourethroscopy; with subureteric injection
of implant material ......................................................1
Cystourethroscopy; manipulation.................................3, 5
Cystourethroscopy, insertion of indwelling
ureteral stent...........................................................3, 5
Cystourethroscopy, insertion of ureteral
guide wire, retrograde.................................................3
Transurethral Surgery (Vesical Neck and Prostate)
Cystourethroscopy; with treatment of ureteral
stricture .....................................................................3
Cystourethroscopy; with treatment of ureteropelvic
junction stricture ......................................................3
Cystourethroscopy; with treatment of intra-renal
stricture .....................................................................3
Cystourethroscopy with ureteroscopy; with treatment
of ureteral stricture...................................................3
Cystourethroscopy with ureteroscopy; with
treatment of ureteropelvic junction
stricture .....................................................................3
Cystourethroscopy with ureteroscopy; with
treatment of intra-renal stricture .............................3
Cystourethroscopy; diagnostic ................................3, 5
Cystourethroscopy; with removal
or manipulation of calculus .....................................3
Cystourethroscopy; with lithotripsy.............................3
Cystourethroscopy; with biopsy and
/or fulguration of lesion........................................3, 5
Cystourethroscopy; with resection of tumor ..............3
Transurethral balloon dilation, prostatic urethra...............1
Transurethral electrosurgical resection of prostate,
including control of postoperative bleeding,
complete (vasectomy, meatotomy,
cystourethroscopy, urethral calibration and/or
dilation, and internal urethrotomy are included) .........2
Transurethral fulguration for postoperative bleeding .......3
Transurethral resection of prostate, first stage ................2
Transurethral resection of prostate, second stage...........2
Transurethral resection, residual obstructive tissue.....2, 3
Transurethral resection, regrowth of
obstructive tissue........................................................2
Transurethral resection, postoperative bladder
neck contracture .........................................................2
Non-contact laser coagulation of prostate .......................2
Contact laser vaporization with or without
transurethral resection of prostate..............................2
Transurethral drainage of prostatic abscess....................3
3
4
5
Assistant Surgeon services not payable
Anesthesiology services not payable
Ambulatory Surgical
2 – TAR and Non-Benefit List: Codes 50000 – 59999
January 2001
tar and non cd5
3
Code
Benefit
Restrictions
Description
53020
53025
53040
53060
53080
URETHRA
Incision
Urethrotomy/urethrostomy, external, pendulous
urethra .................................................................... 3, 5
Urethrotomy/urethrostomy, external, perineal
urethra .................................................................... 3, 5
Meatotomy, cutting of meatus...................................... 3, 5
Meatotomy, cutting of meatus, infant ........................... 3, 5
Drainage of deep periurethral abscess ............................ 3
Drainage of Skene's gland abscess................................. 3
Drainage of perineal urinary extravasation ...................... 3
53200
53230
53235
53240
53250
53260
53265
53270
53275
Excision
Biopsy urethra.............................................................. 3, 5
Excision urethral diverticulum, female ............................. 5
Excision urethral diverticulum, male ................................ 5
Marsupialization urethral diverticulum ......................... 3, 5
Excision bulbourethral gland............................................ 5
Excision/fulguration, urethral polyp .............................. 3, 5
Excision/fulguration, urethral caruncle ......................... 3, 5
Excision/fulguration, Skene's glands ........................... 3, 5
Excision/fulguration, urethral prolapse......................... 3, 5
53460
Repair
Urethromeatoplasty, with excision of urethral segment ... 3
53502
Suture
Urethrorrhaphy, suture of urethral wound, female ........... 3
53000
53010
53600
53601
53605
53620
53621
53660
53661
53665
53670
53675
53850
53852
53899
Manipulation
Dilation urethral stricture, male, initial .......................... 3, 5
Dilation urethral stricture, male, subsequent............ 3, 4, 5
Dilation urethral stricture, male, general anesthesia.... 3, 5
Dilation urethral stricture, male, initial ...................... 3, 4, 5
Dilation urethral stricture, male, subsequent............ 3, 4, 5
Dilation female urethra, initial................................... 3, 4, 5
Dilation female urethra, subsequent ........................ 3, 4, 5
Dilation female urethra, anesthesia ............................. 3, 5
Catheterization, simple ............................................ 3, 4, 5
Catheterization, complicated.................................... 3, 4, 5
Transurethral destruction of prostate tissue;
by microwave thermotherapy ..................................... 1
Transurethral destruction of prostate tissue;
by radiofrequency thermotherapy ............................... 1
Unlisted procedure, urinary system ................................. 2
Benefit Restriction Descriptions:
1
2
Code
Description
Benefit
Restrictions
MALE GENITAL SYSTEM
54000
54001
54015
54050
54055
54056
54057
54060
54065
54100
54105
54120
54125
54130
54135
54150
54152
54160
54161
54200
54220
54230
54231
54235
54240
54250
Non-Benefit
Requires TAR,
Primary Surgeon/Provider
PENIS
Incision
Slitting prepuce, dorsal/lateral, newborn..................3, 4, 5
Slitting of prepuce, dorsal/lateral, except newborn ......3, 5
Incision and drainage of penis, deep ...............................3
Destruction
Destruction lesions, penis, simple, chemical ...............3, 5
Destruction lesions, penis, simple,
electrodesiccation...................................................3, 5
Destruction lesions, penis, simple, cryosurgery.......3, 4, 5
Destruction lesions, penis, simple, laser surgery.....3, 4, 5
Destruction lesions, penis, simple, surgical
excision...................................................................3, 5
Destruction lesions, penis, extensive, any method ......3, 5
Excision
Biopsy of penis; (separate procedure) .........................3, 5
Biopsy of penis; deep structures..................................3, 5
Amputation penis, partial .................................................2
Amputation penis, complete.............................................2
Amputation penis, radical.................................................2
Amputation penis, radical; in continuity with pelvic
lymphadenectomy.......................................................2
Circumcision, clamp procedure, newborn........................1
Circumcision, clamp procedure, except newborn ....2, 3, 4
Circumcision, surgical excision, other than clamp,
device or dorsal slit, newborn .....................................1
Circumcision, surgical excision, other than clamp,
device or dorsal slit, except newborn .....................2, 3
Introduction
Injection procedure Peyronie disease..........................3, 4
Irrigation corpora cavernosa priapism..........................3, 5
Injection procedure corpora cavernosography.........2, 3, 5
Dynamic cavernosometry, with vasocactive
drug injection ..............................................................1
Injection corpora cavernosa.............................................1
Penile plethysmography...................................................5
Nocturnal penile tumescence test................................2, 3
3
4
5
Assistant Surgeon services not payable
Anesthesiology services not payable
Ambulatory Surgical
2 – TAR and Non-Benefit List: Codes 50000 – 59999
January 2001
tar and non cd5
4
Code
54340
54360
54400
54401
54402
54405
54407
54409
54450
54500
54505
54510
54512
54520
54530
54535
54620
54660
54692
54699
Benefit
Restrictions
Description
Repair
Repair of hypospadias complications, simple .................. 3
Plastic operation on penis to correct angulation .............. 2
Insertion penile prosthesis, non-inflatable ....................... 2
Insertion penile prosthesis, inflatable............................... 1
Removal/replacement of non-inflatable/inflatable
penile prosthesis......................................................... 2
Insertion inflatable penile prosthesis................................ 1
Removal/repair/replacement inflatable
penile prosthesis......................................................... 2
Surgical correction abnormality inflatable
penile prosthesis......................................................... 2
Manipulation
Foreskin manipulation...................................................... 1
TESTIS
Excision
Biopsy testis, needle ................................................ 3, 4, 5
Biopsy testis, incisional ................................................ 3, 5
Excision local lesion testis ........................................... 2, 3
Excision extraparenchymal lesion of testis ............... 3
Orchiectomy, simple ........................................................ 2
Orchiectomy, radical, for tumor, inguinal approach ......... 2
Orchiectomy, radical, for tumor, with
abdominal exploration ................................................ 2
Repair
Fixation of contralateral testis .......................................... 2
Insertion testicular prosthesis .......................................... 1
Laparoscopy
Laparoscopy, surgical; orchiopexy for
intra-abdominal testis ................................................. 3
Unlisted laparoscopy procedure, testis ............................ 2
54700
EPIDIDYMIS
Incision
Incision/drainage epididymis........................................ 3, 5
54800
54820
54830
54840
54860
54861
Excision
Biopsy epididymis, needle ....................................... 3, 4, 5
Exploration epididymis ..................................................... 5
Excision local lesion epididymis....................................... 5
Excision spermatocele ..................................................... 5
Epididymectomy, unilateral .............................................. 5
Epididymectomy, bilateral ................................................ 5
54900
54901
Repair
Epididymovasostomy, anastomosis
epididymis to vas deferens; unilateral ........................ 1
Epididymovasostomy, anastomosis
epididymis to vas deferens; bilateral .......................... 1
Benefit Restriction Descriptions:
1
2
Benefit
Restrictions
Code
Description
55000
TUNICA VAGINALIS
Incision
Puncture aspiration hydrocele .....................................3, 5
55040
55041
Excision
Excision, hydrocele; unilateral .........................................2
Excision, hydrocele; bilateral ...........................................2
55060
Repair
Repair of tunica vaginalis hydrocele ................................2
55100
55110
55120
SCROTUM
Incision
Drainage scrotal wall abscess .....................................3, 5
Scrotal exploration ...........................................................5
Removal foreign body in scrotum ....................................5
55175
55180
Repair
Scrotoplasty; simple.........................................................2
Scrotoplasty; complicated ................................................2
55200
VAS DEFERENS
Incision
Vastotomy ....................................................................2, 3
55250
Excision
Vasectomy ...................................................................3, 5
55300
Introduction
Vastotomy ....................................................................3, 5
55400
Repair
Vasovasostomy, vasovasorrhaphy ..................................1
55450
Suture
Ligation vas deferens...................................................3, 5
55500
55520
55530
55535
55540
55550
55559
Non-Benefit
Requires TAR,
Primary Surgeon/Provider
SPERMATIC CORD
Excision
Excision, hydrocele of spermatic cord, unilateral.............2
Excision, lesion of spermatic cord....................................2
Excision, varicocele or ligation, spermatic veins..............2
Excision, varicocele or ligation, spermatic veins,
abdominal ...................................................................2
Excision, varicocele or ligation, spermatic veins,
with hernia ..................................................................2
Laparoscopy
Laparoscopy, surgical, with ligation of spermatic
veins for varicocele.....................................................2
Unlisted laparoscopy procedure, spermatic cord.............2
3
4
5
Assistant Surgeon services not payable
Anesthesiology services not payable
Ambulatory Surgical
2 – TAR and Non-Benefit List: Codes 50000 – 59999
November 2001
tar and non cd5
5
Benefit
Restrictions
Code
Description
55600
55605
SEMINAL VESICLES
Incision
Vesiculotomy.................................................................... 2
Vesiculotomy, complicated .............................................. 2
55650
55680
Excision
Vesiculectomy, any approach .......................................... 2
Excision, Mullerian duct cyst............................................ 2
55700
PROSTATE
Incision
Biopsy prostate, needle or punch ................................ 3, 5
Description
56800
Repair
Plastic repair of introitus...................................................2
57020
57022
57023
55870
55873
55899
Other Procedures
Electroejaculation............................................................. 1
Cryosurgical ablation of the prostate ............................... 1
Unlisted procedure, male genital system .................... 2
55970
55980
INTERSEX SURGERY
Intersex surgery, male to female...................................... 1
Intersex surgery, female to male...................................... 1
57061
57065
57100
57105
57106
57107
57109
56405
56420
56440
56441
VULVA AND INTROITUS
Incision
Incision and drainage of vulva or perineal abscess ......... 3
Incision/drainage Bartholin's gland abscess ................ 3, 5
Marsupialization Bartholin's gland cyst ........................ 3, 5
Lysis of labial adhesions .................................................. 3
56501
56515
Destruction
Destruction lesions, vulva, simple................................ 3, 5
Destruction lesions, vulva, extensive............................... 5
56605
56606
56700
56720
56740
Excision
Biopsy of vulva or perineum, one lesion .......................... 3
Biopsy of vulva or perineum, each separate
additional lesion (List separately in addition to
code for primary procedure) ................................... 3, 4
Partial hymenectomy or revision of hymenal ring ............ 3
Hymenotomy, simple incision ......................................... 3
Excision Bartholin's gland/cyst..................................... 3, 5
Benefit Restriction Descriptions:
1
2
Benefit
Restrictions
Code
57110
57111
57112
57120
57130
57135
Non-Benefit
Requires TAR,
Primary Surgeon/Provider
VAGINA
Incision
Colpocentesis ..............................................................3, 5
Incision and drainage of vaginal hematoma;
post-obstetrical ...........................................................1
Incision and drainage of vaginal hematoma;
non-obstetrical ............................................................1
Destruction
Destruction vaginal lesions, simple..............................3, 5
Destruction vaginal lesions, extensive .........................3, 5
Excision
Biopsy vaginal mucosa, simple....................................3, 5
Biopsy vaginal mucosa, extensive ...................................5
Vaginectomy, partial removal of vaginal wall ...................2
Vaginectomy, partial removal of vaginal wall; with
removal of paravaginal tissue (radical
vaginectomy) ..............................................................2
Vaginectomy, partial removal of vaginal wall; with
removal of paravaginal tissue (radical
vaginectomy) with bilateral total pelvic
lymphadenectomy and para-aortic lymph node
sampling (biopsy) .......................................................2
Vaginectomy, complete removal of vaginal wall ..............2
Vaginectomy, complete removal of vaginal wall;
with removal of paravaginal tissue (radical
vaginectomy) ..............................................................2
Vaginectomy, complete removal of vaginal wall;
with removal of paravaginal tissue (radical
vaginectomy) with bilateral total pelvic
lymphadenectomy and para-aortic lymph node
sampling (biopsy) .......................................................2
Colpocleisis......................................................................2
Excision vaginal septum ..................................................5
Excision vaginal cyst/tumor..............................................5
3
4
5
Assistant Surgeon services not payable
Anesthesiology services not payable
Ambulatory Surgical
2 – TAR and Non-Benefit List: Codes 50000 – 59999
April 2002
tar and non cd5
6
Code
Benefit
Restrictions
Description
57170
57180
VAGINA (continued)
Introduction
Irrigation/application medicament ............................ 3, 4, 5
Fitting and insertion of pessary or other
intravaginal support device................................. 3, 4, 5
Diaphragm fitting...................................................... 3, 4, 5
Introduction hemostatic agent.................................. 3, 4, 5
57200
57210
57291
57292
Repair
Colporrhaphy, suture of vaginal injury ............................. 5
Colpoperineorrhaphy ....................................................... 5
Construction artificial vagina ............................................ 2
Construction artificial vagina, with graft ........................... 2
57150
57160
57400
57410
57415
57452
57454
57460
57500
57505
57510
57511
57513
57520
57522
57530
57540
57545
57550
57555
57556
Manipulation
Dilation vagina under anesthesia..................................... 3
Pelvic exam under anesthesia ..................................... 3, 5
Removal of impacted vaginal foreign body under
anesthesia .................................................................. 3
Endoscopy
Colposcopy .............................................................. 3, 4, 5
Colposcopy, with biopsy of cervix and/or
endocervical curettage ....................................... 3, 4, 5
Colposcopy with loop electrode, excision
procedure of the cervix ........................................... 3, 4
CERVIX UTERI
Excision
Biopsy cervix................................................................ 3, 5
Endocervical curettage ............................................ 3, 4, 5
Cauterization of cervix, electro or thermal ............... 3, 4, 5
Cauterization of cervix, cryocautery......................... 3, 4, 5
Cauterization of cervix, laser ablation .......................... 3, 5
Conization of cervix, with/without fulguration
dilation/curettage repair .............................................. 3
Conization of cervix; loop electrode excision ............... 2, 3
Trachelectomy, amputation of cervix ............................... 2
Excision, cervical stump, abdominal approach................ 2
Excision, cervical stump, abdominal approach,
pelvic floor repair ........................................................ 2
Excision, cervical stump, vaginal approach ..................... 2
Excision, cervical stump, vaginal approach,
anterior and/or posterior repair ................................... 2
Excision, cervical stump, vaginal approach,
repair of enterocele..................................................... 2
Benefit Restriction Descriptions:
1
2
Benefit
Restrictions
Code
Description
57700
CERVIX UTERI (continued)
Repair
Cerclage uterine cervix ....................................................5
57800
57820
Manipulation
Dilation cervical canal ..................................................3, 5
Dilation and curettage of cervical stump ..........................3
58100
58120
58150
58152
58180
58200
58210
58260
58262
58267
58270
58275
58280
58285
Non-Benefit
Requires TAR,
Primary Surgeon/Provider
CORPUS UTERI
Excision
Endometrial sampling with or without
endocervical sampling, without
cervical dilation, any method ..................................3, 5
Dilation and curettage, diagnostic....................................3
Total abdominal hysterectomy (corpus and cervix)
with or without removal of tube(s), with or
without removal of ovary(s);........................................2
Total abdominal hysterectomy (corpus and cervix)
with or without removal of tube(s), with or
without removal of ovary(s); with colpourethrocystopexy (e.g., Marshall-MarchettiKrantz, Burch).............................................................2
Supracervical abdominal hysterectomy ...........................2
Total abdominal hysterectomy, including partial
vaginectomy, with para-aortic and pelvic
lymph node sampling..................................................2
Radical abdominal hysterectomy, with bilateral
total pelvic lymphadenectomy and para-aortic
lymph node sampling..................................................2
Vaginal hysterectomy.......................................................2
Vaginal hysterectomy; with removal of tube(s),
and/or ovary(s)............................................................2
Vaginal hysterectomy; with colpo-urethrocystopexy ........2
Vaginal hysterectomy; with repair of enterocele ..............2
Vaginal hysterectomy; with total or partial colpectomy ....2
Vaginal hysterectomy; with total or partial colpectomy,
with repair of enterocele .............................................2
Vaginal hysterectomy, radical ..........................................2
3
4
5
Assistant Surgeon services not payable
Anesthesiology services not payable
Ambulatory Surgical
2 – TAR and Non-Benefit List: Codes 50000 – 59999
January 2001
tar and non cd5
7
Code
58300
58301
58321
58322
58323
58340
58345
58350
58353
58400
58410
58540
58550
58555
58558
58559
58561
58262
58563
58578
58579
58600
58607 °
58611
58670
Benefit
Restrictions
Description
Introduction
Insertion of intrauterine device..................................... 3, 5
Removal of intrauterine device .................................... 3, 5
Artificial insemination, intra-cervical................................. 1
Artificial insemination, intra-uterine .................................. 1
Sperm washing for artificial insemination......................... 1
Catherization and introduction of saline or
contrast material for hysterosonography
or hysterosalpingography ....................................... 3, 5
Transcervical introduction of fallopian tube catheter ....... 1
Chromotubation of oviduct, including materials ........... 3, 5
Endometrial ablation, thermal,
without hysteroscopic guidance.................................. 3
Repair
Uterine suspension .......................................................... 1
Uterine suspension .......................................................... 1
Hysteroplasty, repair uterine anomaly ............................. 1
Laparoscopy/Hysteroscopy
Laparoscopy, surgical; with vaginal hysterectomy
with or without removal of tube(s), with or
without removal of ovary(s) (laparoscopic
assisted vaginal hysterectomy) .................................. 2
Hysteroscopy, diagnostic (separate procedure) .............. 3
Hysteroscopy, surgical; with sampling (biopsy)
of endometrium and/or polypectomy, with or
without D & C.............................................................. 3
Hysteroscopy, surgical; with lysis of intrauterine
adhesions (any method) ............................................. 3
Hysteroscopy, surgical; with removal of
leiomyomata ............................................................... 3
Hysteroscopy, surgical; with removal of impacted
foreign body................................................................ 3
Hysteroscopy, surgical; with endometrial ablation
(any method) .............................................................. 3
Unlisted laparoscopy procedure, uterus ...................... 2, 3
Unlisted hysteroscopy procedure, uterus..................... 2, 3
OVIDUCT/OVARY
Incision
Ligation/transection fallopian tubes ................................. 5
Transection fallopian tube, minilaparotomy ..................... 1
Ligation or transection of fallopian tube(s) when
done at the time of a cesarean section or
intra-abdominal surgery (not a separate
procedure) (List separately in addition to code
for primary procedure) ................................................ 4
Laparoscopy
Laparoscopy, surgical; with fulguration of oviducts
(with or without transection)........................................ 3
Code
58679
58700
58720
Excision
Salpingectomy .................................................................2
Salpingo-oophorectomy ...................................................2
58750
58752
58760
58770
Repair
Tubotubal anastomosis....................................................1
Tubouterine implantation .................................................1
Fimbrioplasty....................................................................1
Salpingostomy .................................................................1
58800
58820
58825
OVARY
Incision
Drainage of ovarian cyst, vaginal approach.....................3
Drainage of ovarian abscess, vaginal approach, open ....3
Transposition, ovary.........................................................1
58940
58943
Excision
Oophorectomy..................................................................2
Oophorectomy................................................................2
58672
58673
58970
58974
58976
IN VITRO FERTILIZATION
Oocyte retrieval ................................................................1
Embryo transfer, intrauterine............................................1
Gamete, zygote or embryo intrafallopian
transfer, any method...................................................1
58999
Other Procedures
Unlisted procedure, female genital system,
nonobstetrical .............................................................2
59000
59012
59015
59020
59021 °
59025
59030
59050
Refer to HCPCS code Z1030 in the Pregnancy section of the
appropriate Part 2 manual.
Benefit Restriction Descriptions:
1
2
Benefit
Restrictions
Laparoscopy (continued)
Laparoscopy, surgical; with occlusion of oviducts
by device (e.g. band, clip or Falope ring) ...................3
Laparoscopy, surgical; with fimbrioplasty ..................1
Laparoscopy, surgical; with salpingostomy
(salpingoneostomy)..................................................1
Unlisted laparoscopy procedure, oviduct, ovary ..............2
58671
59051
°
Description
Non-Benefit
Requires TAR,
Primary Surgeon/Provider
MATERNITY CARE AND DELIVERY
Antepartum Services
Amniocentesis, any method.....................................3, 4, 5
Cordocentesis, any method .........................................3, 4
Chorionic villus sampling .................................................1
Fetal contraction stress test .....................................3, 4, 5
Non-oxytocin stress test...................................................1
Fetal non-stress test ........................................................5
Fetal scalp blood sampling ..........................................3, 4
Fetal monitoring during labor by consulting
physician (i.e., non-attending physician) with
written report, supervision and interpretation .........3, 4
Fetal monitoring during labor by consulting
physician (i.e., non-attending physician) with
written report, interpretation only ............................3, 4
3
4
5
Assistant Surgeon services not payable
Anesthesiology services not payable
Ambulatory Surgical
2 – TAR and Non-Benefit List: Codes 50000 – 59999
December 2001
tar and non cd5
8
Code
Benefit
Restrictions
Description
MATERNITY CARE AND DELIVERY (continued)
59160
Excision
Laparoscopic treatment of ectopic pregnancy ................. 3
Laparoscopic treatment of ectopic pregnancy;
salpingectomy............................................................. 3
Curettage, postpartum ..................................................... 3
59200
Introduction
Insertion cervical dilator ................................................... 1
59300
Repair
Episiotomy, other than attending physician ..................... 3
59150
59151
59410
59412
59425
59426
59430
59515
59525
59614
59622
59812
59820
59821
59830
59840
59841
59850
59851
59855
59856
59857
59866
59870
59898
59899
Vaginal Delivery, Antepartum and Postpartum Care
Vaginal delivery only (with or without episiotomy
and/or forceps); including postpartum care ................ 1
External cephalic version ................................................. 1
Antepartum care, 4 to 6 visits .......................................... 1
Antepartum care, 7 or more visits .................................... 1
Postpartum care only ....................................................... 1
Cesarean delivery only; including postpartum care ......... 1
Subtotal or total hysterectomy after cesarean
delivery (List separately in addition to code
for primary procedure) ................................................ 4
Delivery After Previous Cesarean Delivery
Vaginal delivery only, after previous cesarean
delivery (with or without episiotomy and/or
forceps); including postpartum care ........................... 1
Cesarean delivery only, following attempted
vaginal delivery after previous cesarean
delivery; including postpartum care ............................ 1
Abortion
Treatment of spontaneous abortion, any trimester .......... 3
Treatment of missed abortion; first trimester ................... 3
Treatment of missed abortion; second trimester.............. 3
Treatment of septic abortion ............................................ 3
Induced abortion, dilation and curettage.......................... 3
Induced abortion, dilation and evacuation ....................... 3
Induced abortion, intra-amniotic injection ........................ 3
Induced abortion, intra-amniotic injection;
dilation and curettage ................................................. 3
Induced abortion, by one or more vaginal
suppositories .............................................................. 3
Induced abortion; with dilation and curettage
and/or evacuation ....................................................... 3
Induced abortion; with hysterotomy ................................. 3
Other Procedures
Multifetal pregnancy reduction(s) (MPR) ......................... 1
Uterine evacuation and curettage for
hydatidiform mole ....................................................... 3
Unlisted laparoscopy procedure, maternity
care and delivery ........................................................ 2
Unlisted procedure, maternity care and delivery ........ 2
Benefit Restriction Descriptions:
1
2
Non-Benefit
Requires TAR,
Primary Surgeon/Provider
3
4
5
Assistant Surgeon services not payable
Anesthesiology services not payable
Ambulatory Surgical
2 – TAR and Non-Benefit List: Codes 50000 – 59999
December 2001
tar and non cd6
TAR and Non-Benefit List: Codes 60000 – 69999
Code
Benefit
Restrictions
Description
SURGERY (continued)
60000
60001
60100
60200
60699
Excision
Aspiration and/or injection, thyroid cyst ....................... 3, 4
Biopsy, thyroid, percutaneous needle.......................... 3, 4
Excision cyst/adenoma thyroid ........................................ 5
Unlisted procedure, endocrine system............................. 2
60659
Laparoscopy
Laparoscopy, surgical, with adrenalectomy,
partial or complete, or exploration of adrenal
gland with or without biopsy, transabdominal,
lumbar or dorsal.......................................................... 2
Unlisted laparoscopy procedure, endocrine
system ........................................................................ 2
62252
CSF Shunt
Reprogramming of programmable CSF shunt .................3
61865
61870
61875
61880
61885
61886
NERVOUS SYSTEM
61000
61001
61020
61026
61050
61055
61070
61105
61107
61108
61151
61720
61793
SKULL, MENINGES, AND BRAIN
Puncture for Injection, Drainage, or Aspiration
Subdural tap; initial ...................................................... 3, 4
Subdural tap; subsequent ............................................ 3, 4
Ventricular puncture; without injection ......................... 3, 4
Ventricular puncture; with injection .................................. 3
Cisternal or lateral cervical puncture
without injection ...................................................... 3, 4
Cisternal or lateral cervical puncture; with injection ......... 3
Puncture of shunt tubing for aspiration or injection...... 3, 4
Twist Drill, Burr Holes or Trephine
Twist drill hole for subdural or ventricular puncture ......... 3
Twist drill hole for puncture; implant catheter .................. 3
Twist drill hole for puncture; evacuate hematoma ........... 3
Burr hole(s) or trephine; subsequent tapping
of abscess/cyst ........................................................... 3
62263
62268
62269
62270
62272
62273
62280
62281
Stereotaxis
Creation of lesion by stereotactic method, including
burr hole(s) and localizing and recording
techniques, single or multiple stages; globus
pallidus or thalamus.................................................... 2
Stereotactic radiosurgery (particle beam, gamma
ray or linear accelerator), one or more
sessions...................................................................... 2
Benefit Restriction Descriptions:
1
2
Benefit
Restrictions
61888
61860
THYROID GLAND
Incision
Incision and drainage of thyroglossal cyst, infected......... 3
Description
Neurostimulators, Intracranial
Burr holes, implantation neurostimulator electrodes;
cortical ........................................................................1
Craniectomy or craniotomy for implantation of
neurostimulator electrodes; cortical............................1
Craniectomy or craniotomy for implantation of
neurostimulator electrodes; subcortical ......................1
Craniectomy, implantation neurostimulator electrodes;
cortical ........................................................................1
Craniectomy, implantation neurostimulator electrodes;
subcortical ..................................................................1
Revision/removal intracranial neurostimulator
electrodes ...................................................................1
Incision and subcutaneous placement of cranial
neurostimulator pulse generator or receiver, direct
or inductive coupling; with connection to a single
electrode array............................................................2
Incision and subcutaneous placement of cranial
neurostimulator pulse generator or receiver,
direct or inductive coupling; with connection to
two or more electrode arrays ......................................3
Revision or removal/cranial neurostimulator....................2
61850
ENDOCRINE SYSTEM
60650
Code
1
Non-Benefit
Requires TAR,
Primary Surgeon/Provider
SPINE AND SPINAL CORD
Injection, Drainage, or Aspiration
Percutaneous lysis of epidural adhesions using
solution injection or mechanical means including
radiologic localization (includes contrast
when administered) ....................................................3
Percutaneous aspiration, spinal cord cyst or syrinx.....3, 4
Biopsy of spinal cord, percutaneous needle ................3, 4
Spinal puncture, lumbar, diagnostic.........................3, 4, 5
Spinal puncture, therapeutic, drainage
of spinal fluid.......................................................3, 4, 5
Injection, lumbar epidural, of blood or clot patch .........3, 4
Injection/infusion of neurolytic substance, with or
without other therapeutic substance;
subarachnoid ..............................................................3
Injection of neurolytic substance; epidural, cervical,
thoracic .......................................................................3
3
4
5
Assistant Surgeon services not payable
Anesthesiology services not payable
Ambulatory Surgical
2 – TAR and Non-Benefit List: Codes 60000 – 69999
April 2002
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2
Code
62282
62292
62310
62311
62318
62319
Benefit
Restrictions
Description
Injection, Drainage, or Aspiration (continued)
Injection/infusion of neurolytic substance with or
without other therapeutic substance; epidural,
lumbar, sacral (caudal) ............................................... 3
Injection procedure chemonucleolysis, lumbar ................ 3
Injection, single (not via indwelling catheter), not
including neurolytic substances, with or without
contrast (for either localization or epidurography), of
diagnostic or therapeutic substance(s) (including
aenesthetic, antispasmodic, opioid, steroid, other
solution), epidural or subarachnoid; cervical or
thoracic ....................................................................... 3
Injection, single (not via indwelling catheter), not
including neurolytic substances, with or without
contrast (for either localization or epidurography), of
diagnostic or therapeutic substance(s) (including
aenesthetic, antispasmodic, opioid, steroid, other
solution), epidural or subarachnoid; lumbar, sacral
(caudal)....................................................................... 3
Injection, including catheter placement, continuous
infusion or intermittent bolus, not including
neurolytic substances, with or without contrast
(for either localization or epidurography), of
diagnostic or therapeutic substance(s) (including
anesthetic, antispasmodic, opioid, steroid, other
solution), epidural or subarachnoid;
cervical or thoracic...................................................... 3
Injection, including catheter placement, continuous
infusion or intermittent bolus, not including
neurolytic substances, with or without contrast
(for either localization or epidurography), of
diagnostic or therapeutic substance(s) (including
anesthetic, antispasmodic, opioid, steroid, other
solution), epidural or subarachnoid;
lumbar, sacral (caudal) ............................................... 3
Description
63048
Posterior Extradural Laminotomy or Laminectomy
for Exploration/Decompression of Neural Elements
or Excision of Herniated Intervertebral Disks
Laminectomy, facetectomy and foraminotomy, each
additional segment, cervical, thoracic, or lumbar
(List separately in addition to code for primary
procedure) ..................................................................4
63057
63066
63076
63078
63082
63086
63088
63091
62367
62368
Reservoir/Pump Implantation
Electronic analysis of programmable, implanted
pump for intrathecal or epidural drug
infusion; without reprogramming ................................ 3
Electronic analysis of programmable, implanted
pump for intrathecal or epidural drug
infusion; with reprogramming ..................................... 3
63308
63600
63610
63650
63655
63685
Benefit Restriction Descriptions:
1
2
Benefit
Restrictions
Code
Non-Benefit
Requires TAR,
Primary Surgeon/Provider
Transpedicular or Costovertebral Approach for
Posterolateral Extradural Exploration/Decompression
Transpedicular approach with decompression, each
additional segment, thoracic or lumbar (List
separately in addition to code for primary
procedure) ..................................................................4
Costovertebral approach with decompression, each
additional segment (List separately in addition to
code for primary procedure.........................................4
Anterior or Anterolateral Approach for Extradural
Exploration/Decompression
Diskectomy, anterior, with decompression;
cervical, each additional interspace (List separately
in addition to code for primary procedure) ..................4
Diskectomy, anterior, with decompression;
thoracic, each additional interspace (List separately in
in addition to code for primary procedure) .....................4
Vertebral corpectomy, cervical, each additional
segment (List separately in addition to code for
primary procedure) .....................................................4
Vertebral corpectomy, thoracic, each additional
segment (List separately in addition to code for
primary procedure) .....................................................4
Vertebral corpectomy, combined approach,
additional segment (List separately in addition to
code for primary procedure) .......................................4
Vertebral corpectomy, partial or complete,
additional segment (List separately in addition to
code for primary procedure) .......................................4
Excision, Anterior or Anterolateral Approach,
Intraspinal Lesion
Vertebral corpectomy, intraspinal lesion, each additional
segment (List separately in addition to codes for
single segment) ..........................................................4
Stereotaxis
Creation of lesion of spinal cord, percutaneous...............4
Stereotactic stimulation of spinal cord, percutaneous......4
Neurostimulators, Spinal
Percutaneous implantation of neurostimulator electrode
array, epidural.............................................................2
Laminectomy for implantation of neurostimulator
electrodes, plate/paddle, epidural...............................2
Incision/subcutaneous placement of spinal
neurostimulator pulse generator/receiver ...................2
3
4
5
Assistant Surgeon services not payable
Anesthesiology services not payable
Ambulatory Surgical
2 – TAR and Non-Benefit List: Codes 60000 – 69999
March 2001
tar and non cd6
3
Code
64400
64402
64405
64408
64410
64412
64413
64415
64417
64418
64420
64421
64425
64430
64435
64445
64450
64470
64472
64475
64476
64479
64480
64483
64484
Benefit
Restrictions
Description
EXTRACRANIAL NERVES, PERIPHERAL NERVES,
AND AUTONOMIC NERVOUS SYSTEM
Somatic Nerves
Injection, anesthetic agent; trigeminal nerve ............... 3, 4
Injection, anesthetic agent; facial nerve....................... 3, 4
Injection, anesthetic agent; greater occipital nerve...... 3, 4
Injection, anesthetic agent; vagus nerve ..................... 3, 4
Injection, anesthetic agent; phrenic nerve ................... 3, 4
Injection, anesthetic agent; spinal accessory nerve .... 3, 4
Injection, anesthetic agent; cervical plexus ................. 3, 4
Injection, anesthetic agent; brachial plexus ................. 3, 4
Injection, anesthetic agent; axillary nerve .................... 3, 4
Injection, anesthetic agent; suprascapular nerve ........ 3, 4
Injection, anesthetic agent; intercostal
nerve, singular ........................................................ 3, 4
Injection, anesthetic agent; intercostal
nerves, multiple ...................................................... 3, 4
Injection, anesthetic agent; ilioinguinal,
iliohypogastric nerves ............................................. 3, 4
Injection, anesthetic agent; pudendal nerve ................ 3, 4
Injection, anesthetic agent; paracervical nerve............ 3, 4
Injection, anesthetic agent; sciatic nerve ..................... 3, 4
Injection, anesthetic agent; other peripheral nerve ...... 3, 4
Injection, anesthetic agent and/or steroid,
paravertebral facet joint or facet joint nerve;
cervical or thoracic, single level.................................. 3
Injection, anesthetic agent and/or steroid,
paravertebral facet joint or facet joint nerve;
cervical or thoracic, each additional level................... 3
Injection, anesthetic agent and/or steroid,
paravertebral facet joint or facet joint nerve;
lumbar or sacral, single level ...................................... 3
Injection, anesthetic agent and/or steroid,
paravertebral facet joint or facet joint nerve;
lumbar or sacral, each additional level (List
separately in addition to code for primary
procedure) .............................................................. 3, 4
Injection, anesthetic agent and/or steroid,
transforaminal epidural; cervical or thoracic,
single level.................................................................. 3
Injection, anesthetic agent and/or steroid,
transforaminal epidural; cervical or thoracic,
each additional level ................................................... 3
Injection, anesthetic agent and/or steroid,
transforaminal epidural; lumbar or sacral,
single level.................................................................. 3
Injection, anesthetic agent and/or steroid,
transforaminal epidural; lumbar or sacral,
each additional level).................................................. 3
Code
64505
64508
64510
64520
64530
64550
64553
64555
64560
64565
64573
64575
64577
64580
64590
64595
64600
64605
64610
64612
64613
64614
64620
64622
64623
Benefit Restriction Descriptions:
1
2
Non-Benefit
Requires TAR,
Primary Surgeon/Provider
Description
Benefit
Restrictions
EXTRACRANIAL NERVES, PERIPHERAL NERVES,
AND AUTONOMIC NERVOUS SYSTEM (continued)
Sympathetic Nerves
Injection, anesthetic agent; sphenopalatine
ganglion ..................................................................3, 4
Injection, anesthetic agent; carotid sinus .....................3, 4
Injection, anesthetic agent; stellate ganglion ...............3, 4
Injection, anesthetic agent; lumbar or thoractic ...........3, 4
Injection, anesthetic agent; celiac plexus.....................3, 4
Neurostimulators, Peripheral Nerve
Application surface neurostimulator.................................1
Percutaneous implantation neurostimulator electrodes;
cranial nerve ...............................................................1
Percutaneous implantation neurostimulator electrodes;
peripheral nerve..........................................................1
Percutaneous implantation neurostimulator electrodes;
autonomic nerve .........................................................1
Percutaneous implantation neurostimulator electrodes;
neuromuscular............................................................1
Implantation neurostimulator electrodes;
cranial nerve ...............................................................1
Implantation neurostimulator electrodes;
peripheral nerve..........................................................1
Implantation neurostimulator electrodes;
autonomic nerve .........................................................1
Implantation neurostimulator electrodes;
neuromuscular............................................................1
Incision/subcutaneous placement neurostimulator
generator/receiver ......................................................1
Revision/removal peripheral neurostimulator
generator/receiver ......................................................1
Destruction by Neurolytic Agent, Somatic Nerves
Destruction by neurolytic agent; supraorbital
branch.....................................................................3, 4
Destruction by neurolytic agent; 2nd and 3rd
division branches at foramen ovale ........................3, 4
Destruction by neurolytic agent; 2nd and 3rd
division branches at foramen ovale under
radiologic monitoring ..............................................3, 4
Chemodenervation of muscles(s); muscle(s)
innervated by facial nerve.......................................3, 4
Chemodenervation of muscle(s); cervical
spinal muscle(s)......................................................3, 4
Chemodenervation of muscle(s); extremity(s)
and/or trunk muscle(s)............................................3, 4
Destruction by neurolytic agent; intercostal nerve .......3, 4
Destruction by neurolytic agent,
paravertebral facet joint nerve; lumbar
or sacral, single level ..............................................3, 4
Destruction by neurolytic agent; paravertebral
facet joint nerve; lumbar or sacral, each additional
level ........................................................................3, 4
3
4
5
Assistant Surgeon services not payable
Anesthesiology services not payable
Ambulatory Surgical
2 – TAR and Non-Benefit List: Codes 60000 – 69999
April 2002
tar and non cd6
4
Code
Benefit
Restrictions
Description
Code
Destruction by Neurolytic Agent, Somatic Nerves
(continued)
64626
64627
64630
64640
Destruction by neurolytic agent; paravertebral
facet joint nerve; cervical or thoracic, single
level ............................................................................ 3
Destruction by neurolytic agent; paravertebral
facet joint nerve; cervical or thoracic, each
additonal level............................................................. 3
Destruction by neurolytic agent; pudendal nerve......... 3, 4
Destruction by neurolytic agent; other
peripheral nerve/branch.......................................... 3, 4
64680
64721
64727
64774
64776
64778
64782
64783
64784
64786
64787
64788
64790
64795
64832
64837
64859
64999
Neuroplasty
(Exploration, Neurolysis or Nerve Decompression)
Neurolysis, carpal tunnel.................................................. 2
Internal neurolysis, requiring use of
operating microscope ................................................. 4
Excision – Somatic Nerves
Excision of neuroma, cutaneous nerve............................ 5
Excision of neuroma, digital nerve,
one or both, same digit ............................................... 5
Excision of neuroma; digital nerve,
each additional digit (List separately in addition
to code for primary procedure) ................................... 5
Excision of neuroma; hand or foot ................................... 5
Excision of neuroma; hand or foot,
each additional nerve (List separately in addition
to code for primary procedure) ................................... 5
Excision of neuroma, major peripheral nerve .................. 5
Excision of neuroma, sciatic nerve .................................. 5
Implantation nerve end into bone or muscle .................... 5
Excision of neurofibroma/neurolemmoma,
cutaneous nerve ......................................................... 5
Excision of neurofibroma/neurolemmoma,
major peripheral nerve................................................ 5
Biopsy of nerve ................................................................ 5
Neurorrhaphy
Suture of digital nerve, hand or foot; each additional
digital nerve (List separately in addition to
code for primary procedure) ....................................... 4
Suture of each additional nerve, hand or foot (List
separately in addition to code for primary
procedure) .................................................................. 4
Suture of each additional major peripheral nerve (List
separately in addition to code for primary
procedure) .................................................................. 4
Benefit
Restrictions
EYE AND OCULAR ADNEXA
65125
EYEBALL
Secondary Implant Procedures
Modification of ocular implant ......................................3, 4
65265
Removal of Ocular Foreign Body
Removal foreign body, external eye, conjunctival........3, 5
Removal foreign body, external eye, subconjunctival ......3, 5
Removal foreign body, external eye, corneal...............3, 5
Removal foreign body, external eye, corneal,
slit lamp ..................................................................3, 5
Removal foreign body, intraocular, anterior
chamber or lens..........................................................5
Removal foreign body, intraocular, posterior
segment, magnet........................................................5
Removal foreign body, intraocular, posterior segment ....5
65400
65410
65420
ANTERIOR SEGMENT – CORNEA
Excision
Excision lesion, cornea ................................................3, 5
Biopsy cornea ..............................................................3, 5
Excision/transposition pterygium .....................................3
65205
65210
65220
65222
65235
Destruction by Neurolytic Agent, Sympathetic Nerves
Destruction by neurolytic agent; celiac plexus ............. 3, 4
Description
65260
65450
65600
Removal or Destruction
Scraping cornea, diagnostic.........................................3, 5
Removal corneal epithelium.........................................3, 5
Removal corneal epithelium, application
chelating agent .......................................................3, 5
Destruction lesion of cornea ........................................3, 5
Multiple punctures of anterior cornea...............................5
65760
65765
65770
65771
65772
65775
Other Procedures
Keratomileusis .................................................................1
Keratophakia....................................................................1
Keratoprosthesis ..............................................................1
Radial Keratotomy ...........................................................1
Corneal relaxing incision..................................................1
Corneal wedge resection .................................................1
65430
65435
65436
65800
65805
65810
65815
65820
65850
65855
ANTERIOR SEGMENT – ANTERIOR CHAMBER
Incision
Paracentesis anterior chamber, diagnostic
aspiration ................................................................3, 5
Paracentesis anterior chamber, therapeutic
release aqueous .....................................................3, 5
Paracentesis anterior chamber, removal vitreous........3, 5
Paracentesis anterior chamber, removal of blood ...........5
Goniotomy........................................................................5
Trabeculotomy ab externo ...............................................5
Trabeculoplasty by laser surgery .....................................5
Other Procedures
Unlisted procedure, nervous system................................ 2
Benefit Restriction Descriptions:
1
2
Non-Benefit
Requires TAR,
Primary Surgeon/Provider
3
4
5
Assistant Surgeon services not payable
Anesthesiology services not payable
Ambulatory Surgical
2 – TAR and Non-Benefit List: Codes 60000 – 69999
January 2001
tar and non cd6
5
Code
65865
65870
65875
65880
65900
65920
65930
66020
66030
Benefit
Restrictions
Description
Other Procedures
Severing adhesions anterior segment,
goniosynechiae........................................................... 5
Severing adhesions anterior segment, anterior
synechiae ................................................................... 5
Severing adhesions anterior segment, posterior
synechiae ................................................................... 5
Severing adhesions anterior segment, corneovitreal
adhesions ................................................................... 5
Removal epithelial downgrowth, anterior chamber .......... 5
Removal implanted material, anterior segment ............... 5
Removal blood clot, anterior segment ............................. 5
Injection, anterior chamber, air or liquid....................... 3, 5
Injection, anterior chamber, medication ....................... 3, 5
Code
66130
66150
66155
66160
66165
66170
66220
66225
Repair
Repair scleral staphyloma................................................ 5
Repair scleral staphyloma, with graft ............................... 5
66250
Revision Operative Wound
Revision/repair operative wound anterior segment.......... 5
66500
66505
66600
66605
66625
66630
66635
ANTERIOR SEGMENT – IRIS, CILIARY BODY
Iridotomy, Iridectomy
Iridotomy by stab incision................................................. 5
Iridotomy by stab incision, with transfixion....................... 5
Iridectomy, removal of lesion ........................................... 5
Iridectomy, with cyclectomy ............................................. 5
Iridectomy, peripheral for glaucoma................................. 5
Iridectomy, sector for glaucoma....................................... 5
Iridectomy, "optical" ......................................................... 5
66680
66682
Repair
Repair iris, ciliary body..................................................... 5
Suture iris, ciliary body..................................................... 5
66761
66762
66770
Destruction
Iridotomy by photocoagulation ..................................... 3, 5
Iridoplasty by photocoagulation ................................... 3, 5
Destruction cyst/lesion iris/ciliary body ............................ 5
66820 *
66821 *
Benefit
Restrictions
66999
Removal Cataract
Removal secondary membranous cataract .....................2
Removal lens material, aspiration technique ...................2
Removal lens material, phacofragmentation
technique ....................................................................2
Removal of lens material, pars plana approach...............2
Extraction lens, intracapsular...........................................2
Extraction lens, intracapsular, dislocated lens .................2
Extraction lens, extracapsular..........................................2
Extracapsular cataract removal/insertion
intraocular lens, manual or
mechanical technique, complex..............................1
Intracapsular cataract extraction/insertion
intraocular lens ...........................................................2
Extracapsular cataract removal/insertion
intraocular lens ...........................................................2
Insertion/exchange intraocular lens not
associated with concurrent cataract removal .............2
Unlisted procedure, anterior segment of eye ...................2
67005
67010
67015
67025
67030
67031
67036
67038
67040
POSTERIOR SEGMENT – VITREOUS
Removal of vitreous, partial removal................................5
Removal of vitreous, subtotal removal.............................5
Aspiration/release vitreous...............................................5
Injection vitreous substitute..............................................5
Discission vitreous strands ..............................................5
Severing vitreous strands ................................................5
Vitrectomy, mechanical....................................................5
Vitrectomy, epiretinal membrane stripping.......................5
Vitrectomy, endolaser panretinal photocoagulation .........5
66830 *
66840 *
66850 *
66852
66920 *
66930 *
66940 *
66982 *
66983 *
66984 *
ANTERIOR SEGMENT – ANTERIOR SCLERA
Excision
Excision lesion, sclera ..................................................... 5
Fistulization of sclera for glaucoma,
trephination/iridectomy ............................................... 5
Fistulization of sclera for glaucoma,
thermocauterization .................................................... 5
Fistulization of sclera for glaucoma, sclerectomy ............ 5
Fistulization of sclera for glaucoma, iridencleisis............. 5
Fistulization of sclera for glaucoma,
trabeculectomy ab externo ......................................... 5
Description
66985 *
67101
67105
67141
67145
*
POSTERIOR SEGMENT – RETINAL DETACHMENT
Repair
Repair of retinal detachment; cryotherapy
or diathermy................................................................3
Repair of retinal detachment; photocoagulation,
with or without drainage of subretinal fluid .................3
Prophylaxis
Prophylaxis retinal detachment, cryotherapy,
diathermy....................................................................5
Prophylaxis retinal detachment, photocoagulation ..........5
Assistant surgeons must have a valid TAR to be reimbursed for
their services when billing for these procedures.
ANTERIOR SEGMENT – LENS
Incision
Discission secondary membranous cataract,
stab incisional ............................................................. 5
Discission secondary membranous cataract,
laser surgery............................................................... 5
Benefit Restriction Descriptions:
1
2
Non-Benefit
Requires TAR,
Primary Surgeon/Provider
3
4
5
Assistant Surgeon services not payable
Anesthesiology services not payable
Ambulatory Surgical
2 – TAR and Non-Benefit List: Codes 60000 – 69999
November 2001
tar and non cd6
6
Code
Benefit
Restrictions
Description
67218
67227
67228
67299
POSTERIOR SEGMENT – OTHER PROCEDURES
Destruction – Retina, Choroid
Destruction of localized lesion of retina (e.g., macular
edema, tumors), one or more sessions,
cryotherapy/diathermy ................................................ 5
Destruction of localized lesion of retina (e.g., macular
edema, tumors), photocoagulation ............................ 5
Destruction localized retinal lesion, radiation................... 5
Destruction retinopathy, cryotherapy/diathermy............... 5
Destruction retinopathy, photocoagulation....................... 5
Unlisted procedure, posterior segment ............................ 2
67250
67255
Scleral Repair
Scleral reinforcement ....................................................... 5
Scleral reinforcement, with graft ...................................... 5
67208
67210
67345
Ocular Adnexa – Extraocular Muscles
Strabismus surgery, recession or resection
procedure; one horizontal muscle .............................. 2
Strabismus surgery, two horizontal muscles.................... 2
Strabismus surgery, one vertical muscle ......................... 2
Strabismus surgery, two or more vertical muscles .......... 2
Strabismus surgery, any procedure, superior oblique
muscle ........................................................................ 2
Transposition procedure (e.g., for paretic extraocular
muscle), any extraocular muscle (specify) ................. 2
Strabismus surgery on patient with previous eye surgery
or injury that did not involve the extraocular
muscles ...................................................................... 2
Strabismus surgery on patient with scarring of
extraocular muscles (e.g., prior ocular injury,
strabismus or retinal detachment surgery) or
restrictive myopathy (e.g., dysthyroid
ophthalmopathy)......................................................... 2
Strabismus surgery by posterior fixation suture technique,
with or without muscle recession................................ 2
Placement of adjustable suture(s) during strabismus
surgery, including postoperative adjustment(s)
of suture(s) ............................................................. 4, 5
Strabismus surgery involving exploration and/or repair of
detached extraocular muscle(s) ................................. 2
Release extensive scar tissue without detaching
extraocular muscle ..................................................... 2
Chemodenervation of extraocular muscle ....................... 3
67350
67399
Other Procedures
Biopsy extraocular muscle ............................................... 5
Unlisted procedure, ocular muscle................................... 2
67415
OCULAR ADNEXA – ORBIT
Exploration, Excision, Decompression
Fine needle aspiration of orbital contents ........................ 3
67311
67312
67314
67316
67318
67320
67331
67332
67334
67335
67340
67343
67500
67505
67515
67550
67560
67599
Benefit
Restrictions
Code
Description
67700
67710
67715
67720 º
OCULAR ADNEXA – EYELIDS
Incision
Blepharotomy, drainage of abscess, eyelid .................3, 5
Severing of tarsorrhaphy..............................................3, 5
Canthotomy..................................................................3, 5
Botulinum injection for blepharospasm ............................1
67800
67801
67805
67808
67810
67820
67825
67830
67835
67840
67850
67880
67882
67901
67902
67903
67904
67906
67908
67909
67911
º
Excision or Removal of Lesion
Involving More Than Skin
Excision chalazion, single ............................................3, 5
Excision chalazion, multiple .........................................3, 5
Excision chalazion, multiple, different lids....................3, 5
Excision chalazion, general anesthesia ...........................5
Biopsy of eyelid ............................................................3, 5
Correction of trichiasis; epilation,
by forceps only........................................................3, 5
Correction of trichiasis; epilation,
by other than forceps ..............................................3, 5
Correction trichiasis, incision lid margin...........................5
Correction trichiasis, incision lid margin, with graft ..........5
Excision lesion of eyelids .............................................3, 5
Destruction lesion of lid margin....................................3, 5
Tarsorrhaphy
Construction intermarginal adhesions..............................5
Construction intermarginal adhesions,
transpose tarsal plate .................................................5
Repair of Brow Ptosis, Blepharoptosis, Lid Retraction
Repair, blepharoptosis; frontalis muscle
technique, suture ........................................................2
Repair, blepharoptosis; frontalis muscle
technique, fascial sling ...............................................2
Repair, blepharoptosis; levator
resection/advancement, internal.................................2
Repair, blepharoptosis; levator
resection/advancement, external................................2
Repair, blepharoptosis; superior rectus
technique, fascial sling ...............................................2
Repair, blepharoptosis; conjunctivo-tarso-Muller's
muscle-levator resection.............................................2
Reduction, overcorrection of ptosis..................................2
Correction, lid retraction...................................................2
Refer to HCPCS code X7040 in the Injections section of the
appropriate Part 2 manual.
Other Procedures
Retrobulbar injection, medication................................. 3, 5
Retrobulbar injection, alcohol....................................... 3, 5
Injection therapeutic agent into Tenon's capsule......... 3, 5
Orbital implant, insertion .................................................. 5
Orbital implant, removal/revision...................................... 5
Other Procedures (continued)
Unlisted procedure, orbit.................................................. 2
Benefit Restriction Descriptions:
1
2
Non-Benefit
Requires TAR,
Primary Surgeon/Provider
3
4
5
Assistant Surgeon services not payable
Anesthesiology services not payable
Ambulatory Surgical
2 – TAR and Non-Benefit List: Codes 60000 – 69999
November 2001
tar and non cd6
7
Code
67914
67915
67916
67917
67921
67922
67923
67924
Benefit
Restrictions
Description
Repair Ectropion, Entropion
Repair ectropion, suture............................................... 2, 3
Repair ectropion, thermocauterization ......................... 2, 3
Repair ectropion, blepharoplasty, excision
tarsal wedge ............................................................... 2
Repair ectropion, blepharoplasty, extensive .................... 2
Repair entropion, suture .............................................. 2, 3
Repair entropion, thermocauterization......................... 2, 3
Repair entropion, blepharoplasty, excision
tarsal wedge ............................................................... 2
Repair entropion, blepharoplasty, extensive.................... 2
67971
67973
67974
67975
Reconstructive Surgery, Blepharoplasty
Involving More Than Skin
Suture recent wound, eyelid, partial thickness............. 3, 5
Suture recent wound, eyelid, full thickness...................... 5
Removal embedded foreign body, eyelid......................... 5
Canthoplasty .................................................................... 2
Excision and repair, eyelid; up to one-fourth of
lid margin .................................................................... 2
Excision and repair, eyelid; over one-fourth of
lid margin .................................................................... 2
Reconstruction, eyelid, up to two-thirds of eyelid............. 2
Reconstruction, eyelid, total eyelid, lower........................ 2
Reconstruction, eyelid, total eyelid, upper ....................... 2
Reconstruction, eyelid, second stage .............................. 2
67999
Other Procedures
Unlisted procedure, eyelids.............................................. 2
68020
68040
OCULAR ADNEXA – CONJUNCTIVA
Incision, Drainage
Incision conjunctiva, drainage cyst .............................. 3, 5
Expression conjunctival follicles .................................. 3, 5
68100
68110
68115
68130
68135
Excision, Destruction
Biopsy conjunctiva ....................................................... 3, 5
Excision lesion, conjunctiva, up to 1 cm ...................... 3, 5
Excision lesion, conjunctiva, over 1 cm ........................... 5
Excision lesion, conjunctiva, with adjacent sclera ........... 5
Destruction lesion, conjunctiva .................................... 3, 5
68200
Injection
Subconjunctival injection ............................................. 3, 5
67930
67935
67938
67950
67961
67966
68320
68325
68326
68328
68330
68335
68340
Benefit
Restrictions
Code
Description
68360
68362
68399
Other Procedures
Conjunctival flap, partial...................................................5
Conjunctival flap, total......................................................5
Unlisted procedure, conjunctiva................................... 2, 5
68400
68420
68440
OCULAR ADNEXA – LACRIMAL SYSTEM
Incision
Incision/drainage lacrimal gland.......................................5
Incision/drainage lacrimal sac..........................................5
Snip incision lacrimal punctum.....................................3, 5
68500
68505
68510
68520
68525
68530
68540
68550
Excision
Excision lacrimal gland, total............................................5
Excision lacrimal gland, partial.........................................5
Biopsy lacrimal gland .......................................................5
Excision lacrimal sac........................................................5
Biopsy lacrimal sac ..........................................................5
Removal of foreign body ..................................................5
Excision lacrimal gland tumor, frontal approach ..............5
Excision lacrimal gland tumor, osteotomy........................5
68700
68705
68720
68745
68750
68760
68761
68770
Repair
Plastic repair of canaliculi ................................................2
Correction everted punctum, cautery...........................3, 5
Dacryocystorhinostomy....................................................5
Conjunctivorhinostomy, without tube ...............................5
Conjunctivorhinostomy, insertion of tube .........................5
Closure lacrimal punctum ............................................3, 5
Closure lacrimal punctum, by plug, each .........................3
Closure lacrimal fistual.....................................................5
68840
68850
Probing and Related Procedures
Dilation of lacrimal punctum, with or
without irrigation .........................................................3
Probing of nasolacrimal duct, with or
without irrigation .....................................................3, 4
Probing lacrimal canaliculi ...........................................3, 5
Injection contrast medium for dacryocystography........3, 5
68899
Other Procedures
Unlisted procedure, lacrimal system ................................2
68801
68810
Conjunctivoplasty
Conjunctivoplasty, conjunctival graft................................ 5
Conjunctivoplasty, buccal mucous membrane graft ........ 5
Conjunctivoplasty, reconstruction cul-de-sac................... 5
Conjunctivoplasty, reconstruction cul-de-sac
with buccal mucous membrane graft.......................... 5
Repair symblepharon, conjunctivoplasty ......................... 5
Repair symblepharon, free graft conjunctiva ................... 5
Repair symblepharon, division symblepharon ................. 5
Benefit Restriction Descriptions:
1
2
Non-Benefit
Requires TAR,
Primary Surgeon/Provider
3
4
5
Assistant Surgeon services not payable
Anesthesiology services not payable
Ambulatory Surgical
2 – TAR and Non-Benefit List: Codes 60000 – 69999
April 2002
tar and non cd6
8
Code
Benefit
Restrictions
Description
Benefit
Restrictions
Code
Description
69714
69715
69717
69718
69799
temporal bone.............................................................1
Implantation; without mastoidectomy...............................1
Implantation; with mastoidectomy....................................1
Replacement; without mastoidectomy .............................1
Replacement; with mastoidectomy ..................................1
Unlisted procedure, middle ear ........................................2
AUDITORY SYSTEM
69000
69005
69020
69090
EXTERNAL EAR
Incision
Drainage external ear, simple ...................................... 3, 5
Drainage external ear, complicated ................................. 5
Drainage external auditory canal, abscess .................. 3, 5
Ear piercing...................................................................... 1
69930
69100
69105
69110
69120
69140
69145
Excision
Biopsy external ear ...................................................... 3, 5
Biopsy external auditory canal ..................................... 3, 5
Excision external ear, partial........................................ 3, 5
Excision external ear, complete amputation .................... 5
Excision exostosis............................................................ 5
Excision soft tissue lesion................................................ 5
INNER EAR
Insertion
Cochlear device implantation...........................................2
69949
Other Procedures
Unlisted procedure, inner ear...........................................2
69979
69210
69220
69222
Removal Foreign Body
Removal foreign body, external ear canal ............... 3, 4, 5
Removal foreign body, external ear canal,
anesthesia .............................................................. 3, 5
Removal impacted cerumen ........................................ 3, 5
Debridement, mastoidectomy cavity, simple.................... 3
Debridement, mastoidectomy cavity, complex................. 3
TEMPORAL BONE, MIDDLE FOSSA APPROACH
Other Procedures
Unlisted procedure, temporal bone..................................2
69300
Repair
Otoplasty protruding ear .................................................. 2
69399
Other Procedures
Unlisted procedure, external ear...................................... 2
69200
69205
69405
69410
MIDDLE EAR
Introduction
Eustachian tube inflation, transnasal;
with catheterization............................................. 3, 4, 5
Eustachian tube inflation, transnasal;
without catheterization........................................ 3, 4, 5
Eustachian tube catheterization, transtympanic ...... 3, 4, 5
Focal application phase control substance...................... 1
69420
69421
69424
69433
69436
69440
69450
Incision
Myringotomy ................................................................ 3, 5
Myringotomy, requiring general anesthesia ..................... 1
Ventilating tube removal .......................................... 3, 4, 5
Tympanostomy, local or topical anesthesia ................. 3, 4
Tympanostomy, general anesthesia ................................ 3
Middle ear exploration...................................................... 5
Tympanolysis, transcanal ................................................ 5
69610
69620
Repair
Tympanic membrane repair ......................................... 3, 5
Myringoplasty................................................................... 5
69710
69711
Other Procedures
Implantation bone conduction device, temporal bone ..... 1
Removal/repair bone conduction device,
69400
69401
Benefit Restriction Descriptions:
1
2
Non-Benefit
Requires TAR,
Primary Surgeon/Provider
3
4
5
Assistant Surgeon services not payable
Anesthesiology services not payable
Ambulatory Surgical
2 – TAR and Non-Benefit List: Codes 60000 – 69999
November 2001
tar and non cd7
TAR and Non-Benefit List: Codes 70000 – 79999
Code
Benefit
Restrictions
Description
RADIOLOGY
70336
70371
70496
70498
70540
70542
70543
70544
70545
70546
70547
70548
70549
70551
70552
70553
71275
71550
71551
71552
71555
72141
72142
72146
72147
72148
72149
72156
72157
72158
72159
DIAGNOSTIC RADIOLOGY (DIAGNOSTIC IMAGING)
Head and Neck
MRI of jaw joint(s) ............................................................ 1
Dynamic pharyngeal and speech evaluation ................... 1
Computed tomographic angiography, head..................... 1
Computed tomographic angiography, neck ..................... 1
Magnetic resonance imaging, orbit, face and neck,
without contrast .......................................................... 2
Magnetic resonance imaging, orbit, face, and neck;
with contrast ............................................................... 2
Magnetic resonance imaging, orbit, face, and neck;
with and without contrast ............................................ 2
Magnetic resonance angiography, head;
without contrast .......................................................... 2
Magnetic resonance angiography, head; with contrast.... 2
Magnetic resonance angiography, head;
with and without contrast ............................................ 2
Magnetic resonance angiography, neck;
without contrast .......................................................... 2
Magnetic resonance angiography, neck; with contrast .... 2
Magnetic resonance angiography, neck; with and
without contrast .......................................................... 2
Magnetic resonance imaging, brain and brain stem,
without contrast .......................................................... 2
Magnetic resonance imaging, brain, with
contrast....................................................................... 2
Magnetic resonance imaging, brain (including brain
stem); with and without contrast ................................. 2
Chest
Computed tomographic angiography, chest .................... 1
Magnetic resonance imaging, chest; without contrast ..... 2
Magnetic resonance imaging, chest; with contrast .......... 2
Magnetic resonance imaging, chest; with and
without contrast .......................................................... 2
Magnetic resonance angiography, chest ......................... 1
Spine and Pelvis
Magnetic resonance imaging, spinal canal and
contents, cervical; without contrast............................. 2
Magnetic resonance imaging, spinal canal and
contents, cervical; with contrast ................................. 2
Magnetic resonance imaging, spinal canal and
contents, thoracic; without contrast ............................ 2
Magnetic resonance imaging, spinal canal and
contents, thoracic; with contrast ................................ 2
Magnetic resonance imaging, spinal canal and
contents, lumbar; without contrast.............................. 2
Magnetic resonance imaging, spinal canal and
contents, lumbar; with contrast .................................. 2
Magnetic resonance imaging, spinal canal and
contents, with and without contrast; cervical .............. 2
Magnetic resonance imaging, spinal canal and
contents, without contrast; thoracic ............................ 2
Magnetic resonance imaging, spinal canal and
contents, with and without; lumbar ............................. 2
Benefit Restriction Descriptions:
Code
1
2
72191
72195
72196
72197
72198
73206
73218
73219
73220
73221
73222
73223
73225
73706
73718
73719
73720
73721
73722
73723
73725
74175
74181
74182
74183
74185
Non-Benefit
Requires TAR,
Primary Surgeon/Provider
1
Description
Benefit
Restrictions
Spine and Pelvis (continued)
Magnetic resonance angiography, spinal canal and
contents, with or without contrast material(s) .............1
Computed tomographic angiography, pelvis, with and
without contrast ..........................................................1
Magnetic resonance imaging, pelvis; without contrast.....2
Magnetic resonance imaging, pelvis; with contrast..........2
Magnetic resonance imaging, pelvis; with and without
contrast.......................................................................2
Magnetic resonance angiography, pelvis,
with or without contrast ...............................................1
Upper Extremities
Computed tomographic angiography, upper
extremity .....................................................................1
Magnetic resonance imaging, upper extremity,
other than joint; without contrast.................................2
Magnetic resonance imaging, upper extremity,
other than joint; with contrast......................................2
Magnetic resonance imaging, upper extremity,
other than joint; with and without contrast ..................2
Magnetic resonance imaging, any joint,
upper extremity; without contrast................................2
Magnetic resonance imaging, any joint of upper
extremity; with contrast ...............................................2
Magnetic resonance imaging, any joint of upper
extremity; with and without contrast............................2
Magnetic resonance angiography, upper extremity .........1
Lower Extremities
Computed tomographic angiography, lower
extremity .....................................................................1
Magnetic resonance imaging, lower extremity
other than joint; without contrast.................................2
Magnetic resonance imaging, lower extremity
other than joint; with contrast......................................2
Magnetic resonance imaging, lower extremity
other than joint; with and without contrast ..................2
Magnetic resonance imaging, any joint of
lower extremity; without contrast ................................2
Magnetic resonance imaging, any joint of lower extremity;
with contrast ...............................................................2
Magnetic resonance imaging, any joint of lower extremity;
with and without contrast ............................................2
Magnetic resonance angiography, lower extremity..........1
Abdomen
Computed tomographic angiography, abdomen ..............1
Magnetic resonance imaging, abdomen;
without contrast ..........................................................2
Magnetic resonance imaging, abdomen; with contrast....2
Magnetic resonance imaging, abdomen; with
and without contrast ...................................................2
Magnetic resonance angiography, abdomen...................1
3
4
5
Assistant Surgeon services not payable
Anesthesiology services not payable
Ambulatory Surgical
2 – TAR and Non-Benefit List: Codes 70000 – 79999
November 2001
tar and non cd7
2
Code
74742
75552
75553
75554
75555
75556
75635
75946
75960
76070
76078
76093
76094
76390
76400
76499
Benefit
Restrictions
Description
DIAGNOSTIC RADIOLOGY (DIAGNOSTIC IMAGING)
(continued)
Gynecological and Obstetrical
Transcervical catheterization fallopian tube,
radiological ................................................................. 1
Heart
Cardiac magnetic resonance imaging,
for morphology, without contrast material................... 1
Cardiac magnetic resonance imaging,
for morphology, with contrast material........................ 1
Cardiac magnetic resonance imaging for function,
with or without morphology; complete study............... 1
Cardiac magnetic resonance imaging for function,
with or without morphology; limited study................... 1
Cardiac magnetic resonance imaging,
for velocity flow mapping ............................................ 1
Benefit
Restrictions
Code
Description
76945
76948
(includes diagnostic ultrasound evaluation,
compression of lesion and imaging) ...........................1
Ultrasonic guidance for chorionic villus sampling ............1
Ultrasonic guidance for aspiration of ova.........................1
76977
Other Procedures
Ultrasound bone density measurement and
interpretation, peripheral site(s), any method .............1
Aorta and Arteries
Computed tomographic angiography, abdominal aorta
and bilateral iliofemoral lower
extremity runoff........................................................... 1
77620
RADIATION ONCOLOGY
Hyperthermia
Hyperthermia, superficial .................................................2
Hyperthermia, deep..........................................................1
Hyperthermia generated by interstitial probe,
5 or fewer applicators .................................................2
Hyperthermia generated by interstitial probe,
more than 5 applicators ..............................................2
Hyperthermia generated by intracavitary probe ...............1
Transcatheter Procedures
Intravascular ultrasound (non-coronary vessel),
radiological supervision and interpretation;
each additional non-coronary vessel (List
separately in addition to code for primary
procedure) .................................................................. 4
Transcatheter introduction intravascular stent,
each vessel................................................................. 1
78267
78268
NUCLEAR MEDICINE
Gastrointestinal System
Urea breath test, C-14; acquisition for analysis ..........1
Urea breath test, C-14; analysis....................................1
Other Procedures
Computerized tomography, bone mineral density
study, one or more sites ............................................. 1
Radiographic absorptiometry (photodensitometry), one
or more sites............................................................... 1
Magnetic resonance imaging, breast, without
and/or with contrast material(s); unilateral.................. 2
Magnetic resonance imaging, breast, without
and/or with contrast material(s); bilateral.................... 2
Magnetic resonance spectroscopy .................................. 1
Magnetic resonance imaging, bone marrow blood
supply ......................................................................... 1
Unlisted diagnostic radiologic procedure ......................... 2
77600
77605
77610
77615
78350
78351
78459
78469
78491
78492
78607
78608
76604
DIAGNOSTIC ULTRASOUND
Chest
Echography, chest ........................................................... 1
76800
Spinal Canal
Echography, spinal cord and contents............................. 1
76818
76819
Pelvis
Fetal biophysical profile; with non-stress testing.............. 1
Fetal biophysical profile; without stress or
non-stress testing ....................................................... 1
76936
Ultrasonic Guidance Procedures
Ultrasound guided compression repair of arterial
pseudo-aneurysm or arteriovenous fistulae
Benefit Restriction Descriptions:
1
2
78609
78647
Non-Benefit
Requires TAR,
Primary Surgeon/Provider
Musculoskeletal System
Bone density study one or more sites;
single photon absorptiometry .....................................1
Bone density study; dual photon absorptiometry,
one or more sites........................................................1
Cardiovascular System
Myocardial imaging, positron emission
tomography (PET), metabolic evaluation ...................2
Myocardial imaging, infarct avid, planar;
tomographic SPECT with or without quantification.....1
Myocardial imaging, positron emission
tomography (PET), perfusion; single study
at rest or stress...........................................................1
Myocardial imaging, positron emission
tomography (PET), perfusion; multiple studies
at rest and/or stress....................................................1
Nervous System
Brain imaging, tomographic (SPECT)..............................1
Brain imaging, positron emission tomography (PET);
metabolic evaluation...................................................2
Brain imaging, PET; perfusion evaluation........................2
Cerebrospinal fluid flow, imaging;
tomographic (SPECT) ................................................1
3
4
5
Assistant Surgeon services not payable
Anesthesiology services not payable
Ambulatory Surgical
2 – TAR and Non-Benefit List: Codes 70000 – 79999
December 2001
tar and non cd7
3
Benefit
Restrictions
Code
Description
78710
Genitourinary System
Kidney imaging, tomographic (SPECT) ........................... 1
78803
78807
78810
78890
78891
Miscellaneous Studies
Radiopharmaceutical localization of tumor;
tomographic (SPECT) ................................................ 1
Radiopharmaceutical localization of abscess;
tomographic (SPECT) ................................................ 1
Tumor imaging, positron emission tomography
(PET), metabolic evaluation ....................................... 2
Generation automated data, not to exceed
30 minutes .................................................................. 1
Generation automated data, exceeding
30 minutes .................................................................. 1
Benefit Restriction Descriptions:
1
2
Non-Benefit
Requires TAR,
Primary Surgeon/Provider
3
4
5
Assistant Surgeon services not payable
Anesthesiology services not payable
Ambulatory Surgical
2 – TAR and Non-Benefit List: Codes 70000 – 79999
November 2001
tar and non cd8
TAR and Non-Benefit List: Codes 80000 – 89999
Code
Benefit
Restrictions
Description
PATHOLOGY AND LABORATORY
Code
83013
80050
ORGAN- OR DISEASE-ORIENTED PANELS
General health panel........................................................ 1
83014
80103
DRUG TESTING
Drug analysis, tissue prep................................................ 1
83937
84061
84449
84586
80439
80440
EVOCATIVE/SUPPRESSION TESTING
ACTH stimulation panel for adrenal insufficiency ............ 1
ACTH stimulation panel for 21 hydroxylase deficiency.... 1
ACTH stimulation panel for
3 beta-hydroxydehydrogenase deficiency .................... 1
Aldosterone suppression evaluation panel ...................... 1
Calcitonin stimulation panel ............................................. 1
Corticotropic releasing hormone stimulation panel .......... 1
Chorionic gonadotrophin stimulation panel;
testosterone response ................................................ 1
Chorionic gonadotrophin stimulation panel;
estradiol response ...................................................... 1
Renal vein renin stimulation panel ................................... 1
Peripheral vein renin stimulation panel ............................ 1
Combined rapid anterior pituitary evaluation panel.......... 1
Dexamethasone suppression panel, 48 hour .................. 1
Glucagon tolerance panel; for insulinoma........................ 1
Glucagon tolerance panel; for pheochromocytoma ......... 1
Gonadotrophin releasing hormone stimulation panel ...... 1
Growth hormone stimulation panel .................................. 1
Growth hormone suppression panel ................................ 1
Insulin-induced C-peptide suppression panel .................. 1
Insulin tolerance panel; for ACTH insufficiency ............... 1
Insulin tolerance panel; for growth hormone deficiency... 1
Metyrapone panel ............................................................ 1
Thyrotropin releasing hormone (TRH)
stimulation panel; one hour ........................................ 1
TRH stimulation panel; two hour...................................... 1
TRH stimulation panel; for hyperprolactemia................... 1
80500
80502
CONSULTATIONS
Clinical pathology consultation; limited ............................ 1
Clinical pathology consultation; comprehensive .............. 1
81020
URINALYSIS
Urinalysis; two or three glass test .................................... 1
80400
80402
80406
80408
80410
80412
80414
80415
80416
80417
80418
80420
80422
80424
80426
80428
80430
80432
80434
80435
80436
80438
82075
82190
82731
82757
CHEMISTRY AND TOXICOLOGY
Alcohol, breath ................................................................. 1
Atomic absorption spectroscopy, each analyte................ 1
Fetal fibronectin, cervicovaginal secretions, semiquantitative ................................................................. 1
Fructose, semen .............................................................. 1
Benefit Restriction Descriptions:
1
2
86005
86890
86891
86910
86911
86915
86950
86965
86985
87904
88000
88005
88007
88012
88014
88016
88020
88025
88027
88028
88029
88036
88037
88040
88045
88099
Non-Benefit
Requires TAR,
Primary Surgeon/Provider
1
Description
Benefit
Restrictions
CHEMISTRY AND TOXICOLOGY (continued)
Helicobacter pylori; analysis for urease activity (mass
spectrometry)..............................................................2
Helicobacter pylori; drug administration and sample
collection.....................................................................2
Osteocalcin ......................................................................1
Phosphatase, acid; total, forensic examination................1
Transcortin .......................................................................1
Vasoactive intestinal peptide ...........................................1
TRANSFUSION MEDICINE
Allergen specific IgE; qualitative,
multiallergen screen ...................................................1
Autologous blood or component, collection
processing and storage; predeposited .......................1
Autologus blood or component, collection
processing and storage; intra- or postoperative .........1
Blood typing; for paternity testing, ABO, Rh and MN,
per individual ..............................................................1
Blood typing, for paternity testing, each additional
antigen system ...........................................................1
Bone marrow, modification or treatment to eliminate
cell (e.g., T-cells, metastatic carcinoma) ....................2
Leukocyte transfusion ......................................................1
Pooling of platelets or other blood products.....................1
Splitting of blood or blood products, each unit .................1
MICROBIOLOGY
Infectious agent phenotype analysis by nucleic acid
(DNA or RNA) with drug resistance tissue culture
analysis, HIV 1; each additional drug (after 10), up
to 5 drugs ..................................................................1
ANATOMIC PATHOLOGY
Postmortem Examination
Autopsy, gross .................................................................1
Autopsy, gross, with brain ................................................1
Autopsy, gross, with brain and spinal cord ......................1
Autopsy, gross, infant with brain ......................................1
Autopsy, gross, stillborn with brain ..................................1
Autopsy, macerated stillborn............................................1
Autopsy, without brain......................................................1
Autopsy, with brain...........................................................1
Autopsy, with brain and spinal cord .................................1
Autopsy, infant with brain .................................................1
Autopsy, stillborn with brain .............................................1
Autopsy, limited, regional.................................................1
Autopsy, limited, single organ ..........................................1
Autopsy, forensic examination .........................................1
Autopsy, coroner’s call.....................................................1
Unlisted autopsy ..............................................................1
3
4
5
Assistant Surgeon services not payable
Anesthesiology services not payable
Ambulatory Surgical
2 – TAR and Non-Benefit List: Codes 80000 – 89999
November 2001
tar and non cd8
2
Benefit
Restrictions
Code
Description
88125
88182
Cytopathology
Cytopathology, forensic ................................................... 1
Flow cytometry; cell cycle or DNA analysis ..................... 1
88365
SURGICAL PATHOLOGY
Tissue hybridization ......................................................... 1
89250
89251
89252
89253
89254
89255
89256
89257
89258
89259
89260
89261
89264
89300
89310
89320
89321
89325
89329
89330
OTHER PROCEDURES
Culture and fertilization of oocyte(s) ................................ 1
Culture and fertilization of oocyte(s);
with co-culture of embryos.......................................... 1
Assisted oocyte fertilization, microtechnique
(any method) .............................................................. 1
Assisted embryo hatching, microtechniques
(any method) .............................................................. 1
Oocyte identification from follicular fluid........................... 1
Preparation of embryo for transfer (any method) ............. 1
Preparation of cyropreserved embryos for
transfer (includes thaw) .............................................. 1
Sperm identification from aspiration (other
than seminal fluid) ...................................................... 1
Cryopreservation; embryo................................................ 1
Cryopreservation; sperm................................................. 1
Sperm isolation; simple prep (e.g., sperm wash
and swim-up) for insemination or diagnosis
with semen analysis ................................................... 1
Sperm isolation; complex prep (e.g., per col
gradient, albumin gradient) for insemination
or diagnosis with semen analysis ............................... 1
Sperm identification from testis tissue, fresh or
cryopreserved............................................................. 1
Semen analysis; presence/motility of sperm.................... 1
Semen analysis; motility and count.................................. 1
Semen analysis; complete ............................................... 1
Semen analysis; presence and/or motility of sperm .. 1
Sperm antibodies ............................................................. 1
Sperm evaluation ............................................................. 1
Sperm evaluation; cervical mucus
penetration test........................................................... 1
Benefit Restriction Descriptions:
1
2
Non-Benefit
Requires TAR,
Primary Surgeon/Provider
3
4
5
Assistant Surgeon services not payable
Anesthesiology services not payable
Ambulatory Surgical
2 – TAR and Non-Benefit List: Codes 80000 – 89999
November 2001
tar and non cd9
TAR and Non-Benefit List: Codes 90000 – 99999
Code
Benefit
Restrictions
Description
MEDICINE
90586
IMMUNIZATION INJECTIONS (Immunizations are
reimbursable with Level III HCPCS codes. See
Injections: List of Codes and Injections:
Medi-Cal Vaccines Code List in this manual.)
90281
90283
90287
90288
90291
90296
90371
90375
90376
90378
90379
90384
90385
90386
90389
90393
90396
90399
90471
90472
90476
90477
90581
90585
Code
90632
90633
Immune Globulin
Immune globulin (IG), human, for intramuscular
use .............................................................. 1
Immune globulin (IGIV), human, for intravenous
use.............................................................................. 1
Botulinum antitoxin, equine, any route............................. 1
Botulism immune globulin, human for intravenous
use.............................................................................. 1
Cytomegalovirus immune globulin (CMV-IGIV),
human, for intravenous use ........................................ 1
Diphtheria antitoxin, equine, any route ............................ 1
Hepatitis B immune globulin (HBIG), human, for
intramuscular use ....................................................... 1
Rabies immune globulin (RIG), human, for
intramuscular and/or subcutaneous use..................... 1
Rabies immune globulin, heat-treated (RIG-HT),
human, for intramuscular and/or subcutaneous
use.............................................................................. 1
Respiratory syncytial virus immune globulin
(RSV-IgIM), for intramuscular use, 50 mg, each .... 1
Respiratory syncytial virus immune globulin
(RSV-IGIV), human, for intravenous use.................... 1
Rho(D) immune globulin (RhIG), human, full-dose
for intramuscular use .................................................. 1
Rho(D) immune globulin (RhIG), human, mini-dose
for intramuscular use
Rho(D) immune globulin (RhIGIV), human, for
intravenous use .......................................................... 1
Tetanus immune globulin (TIG), human, for
intramuscular use ....................................................... 1
Vaccinia immune globulin, human, for intramuscular
use.............................................................................. 1
Varicella-zoster immune globulin, human, for
intramuscular use
Unlisted immune globulin................................................. 1
90634
Administration for Vaccines/Toxoids
Immunization administration (includes percutaneous,
intradermal, subcutaneous, intramuscular and jet
injections and/or intranasal or oral administration);
one vaccine (single or combination
vaccine/toxoid)............................................................ 1
Immunization administration (includes percutaneous,
intradermal, subcutaneous, intramuscular and jet
injections and/or intranasal or oral administration);
each additional vaccine (single or combination
vaccines/toxoids) ........................................................ 1
90693
Vaccines/Toxoids
Adenovirus vaccine, type 4, live, for oral use................... 1
Adenovirus vaccine, type 7, live, for oral use................... 1
Anthrax vaccine, for subcutaneous use ........................... 1
Bacillus Calmette-Guerin vaccine (BCG) for
tuberculosis, live, for percutaneous use ..................... 1
Benefit Restriction Descriptions:
1
2
90636
90645
90646
90647
90648
90657
90658
90659
90660
90665
90669
90675
90676
90680
90690
90691
90692
90700
90701
90702
90703
90704
90705
90706
90707
90708
90709
90710
Non-Benefit
Requires TAR,
Primary Surgeon/Provider
1
Description
Benefit
Restrictions
Vaccines/Toxoids (continued)
Bacillus Calmette-Guerin vaccine (BCG) for
bladder cancer, live, for intravesical use ....................1
Hepatitis A vaccine, adult dosage, for intramuscular
use..............................................................................1
Hepatitis A vaccine, pediatric/adolescent dosage-2
dose schedule, for intramuscular use.........................1
Hepatitis A vaccine, pediatric/adolescent dosage-3
dose schedule, for intramuscular use.........................1
Hepatitis A and hepatitis B vaccine (HepA-HepB),
adult dosage, for intramuscular use
Hemophilus influenza b vaccine (Hib), HbOC
conjugate (4 dose schedule), for intramuscular
use..............................................................................1
Hemophilus influenza b vaccine (Hib), PRP-D
conjugate, for booster use only, intramuscular
use..............................................................................1
Hemophilus influenza b vaccine (Hib), PRP-OMP
conjugate (3 dose schedule), for intramuscular
use..............................................................................1
Hemophilus influenza b vaccine (Hib), PRP-T
conjugate (4 dose schedule), for intramuscular
use..............................................................................1
Influenza virus vaccine, split virus, 6 – 35 months
dosage, for intramuscular or jet injection use .............1
Influenza virus vaccine, split virus, 3 years and above
dosage, for intramuscular or jet injections use ...........1
Influenza virus vaccine, whole virus, for
intramuscular or jet injection use ................................1
Influenza virus vaccine, live, for intranasal use................1
Lyme disease vaccine, adult dosage, for
intramuscular use .......................................................1
Pneumococcal conjugate vaccine, polyvalent,
for children under five years,
for intramuscular use ..................................................1
Rabies vaccine, for intramuscular use .............................1
Rabies vaccine, for intradermal use.................................1
Rotavirus vaccine, tetravalent, live, for oral use ..............1
Typhoid vaccine, live, oral................................................1
Typhoid vaccine, Vi capsular polysaccharide
(ViCPs), for intramuscular use
Typhoid vaccine, heat- and phenol-inactivated
(H-P), for subcutaneous or intradermal use
Typhoid vaccine, acetone-killed, dried (AKD), for
subcutaneous or jet injection use (U.S. military) ........1
Immunization, active; DTaP .............................................1
Immunization, active; DPT ...............................................1
Immunization, DT, for individuals under seven years,
for intramuscular use ...............................................1
Tetanus toxoid adsorbed, for intramuscular or jet
injection use................................................................1
Immunization, mumps......................................................1
Immunization, measles ....................................................1
Immunization, rubella.......................................................1
Immunization, measles, mumps and rubella (MMR)........1
Immunization, measles and rubella .................................1
Immunization, rubella and mumps ...................................1
Immunization, active; MMR and varicella ........................1
3
4
5
Assistant Surgeon services not payable
Anesthesiology services not payable
Ambulatory Surgical
2 – TAR and Non-Benefit List: Codes 90000 – 99999
November 2001
tar and non cd9
2
Code
90712
90713
90716
90717
90718
90719
90720
90721
90723
90725
90727
90732
90733
90735
90740
90743
90744
90746
90747
90748
90782
90783
90784
90788
90845
90846
90847
90849
90857
90865
90875
90876
90882
Benefit
Restrictions
Description
Vaccines/Toxoids (continued)
Immunization, poliovirus .................................................. 1
Immunization, poliomyelitis .............................................. 1
Immunization, active; varicella vaccine............................ 1
Immunization, yellow fever............................................... 1
Immunization, tetanus and diphtheria .............................. 1
Immunization, diphtheria.................................................. 1
Immunization, active; DTP and HIB ................................. 1
Immunization, active; diphtheria, tetanus toxoids, and
acellular pertussis vaccine (DTaP) and Hemophilus
influenza B (HIB) vaccine ........................................... 1
Immunization, inactivated, DtaP-HepB-IPV ................. 1
Immunization, cholera...................................................... 1
Immunization, plague....................................................... 1
Immunization, pneumococcal, polyvalent ........................ 1
Immunization, meningococcal polysaccharide ................ 1
Immunization, active; Japanese encephalitis virus
vaccine ....................................................................... 1
Immunization, hepatitis B vaccine,
dialysis or immunosuppressed .............................. 1
Immunization, hepatitis B vaccine, adolescent........... 1
Immunization, active, hepatitis B vaccine;
pediatric/adolescent................................................. 1
Immunization, active, hepatitis B vaccine;
adult ........................................................................... 1
Immunization, active, hepatitis B vaccine; dialysis
or immunosuppressed patient .................................... 1
Immunization, active, hepatitis B and Hemophilus
influenza b (HepB-Hib) vaccine ................................. 1
THERAPEUTIC INJECTIONS
Therapeutic injection of medication,
subcutaneous or intramuscular .................................. 1
Therapeutic injection of medication, intra-arterial ............ 1
Therapeutic injection of medication, intravenous............. 1
Intramuscular injection of antibiotic.................................. 1
PSYCHIATRY
Psychiatric Therapeutic Procedures
Psychoanalysis ................................................................ 1
Family psychotherapy (without the patient present)......... 1
Family psychotherapy (conjoint psychotherapy) (with
patient present)........................................................... 1
Multiple-family group psychotherapy ............................... 1
Interactive group psychotherapy...................................... 1
Narcosynthesis for psychiatric diagnostic and therapeutic
purposes (e.g., sodium amobarbital [Amytal]
interview) .................................................................... 1
Other Psychiatric Therapy
Individual psychophysiological therapy incorporating
biofeedback training by any modality (face-to-face
with the patient); 20-30 minutes ................................. 1
Individual psychophysiological therapy incorporating
biofeedback training by any modality (face-to-face
with the patient); 45-50 minutes ................................. 1
Environmental intervention .............................................. 1
Benefit Restriction Descriptions:
1
2
Benefit
Restrictions
Code
Description
90885
Psychiatric evaluation of hospital records, other
psychiatric reports, psychometric and/or projective
tests, and other accumulated data
for medical diagnostic purposes .................................1
Interpretation of results to family......................................1
Preparation of report of psychiatric status .......................1
90887
90889
90901
90911
BIOFEEDBACK
Biofeedback training by any modality...............................1
Biofeedback training, perineal muscles, anorectal or
urethral sphincter, including EMG and/or manometry 1
OPHTHALMOLOGY
92015
92020
92065
OPHTHALMOLOGICAL DIAGNOSTIC AND
TREATMENT SERVICES
Special Ophthalmological Services
Determination of refractive state ......................................1
Gonioscopy ......................................................................4
Orthoptic/pleoptic training ................................................1
92287
Other Specialized Services
External ocular photography with interpretation
and report for documentation
of medical progress ....................................................1
Special anterior segment photography with
interpretation and report; with specular
endothelial microscopy and cell count........................1
Anterior segment photography with fluorescein ...............1
92326
Contact Lens Services
Replacement of contact lens............................................1
92285
92286
92340
92341
92342
92352
92353
92354
92355
92358
92370
92371
92390
92391
92392
92393
92395
92396
Non-Benefit
Requires TAR,
Primary Surgeon/Provider
Spectacle Services
(Including Prosthesis for Aphakia)
Fitting of glasses, monofocal ...........................................1
Fitting of glasses, bifocal..................................................1
Fitting of glasses, multifocal.............................................1
Fitting of spectacle prosthesis for aphakia, monofocal ....1
Fitting of spectacle prosthesis for aphakia, multifocal......1
Fitting of spectacle mounted low vision aid......................1
Fitting of spectacle mounted low vision aid;
telescopic or other compound lens system ................1
Prosthesis service for aphakia, temporary.......................1
Repair and refitting spectacles, except for aphakia .........1
Repair and refitting spectacles, for aphakia.....................1
Supply of Materials
Supply of spectacles, except prosthesis for
aphakia/low vision aid.................................................1
Supply of contact lens, except prosthesis for aphakia .....1
Supply of low vision aids..................................................1
Supply of ocular prosthesis..............................................1
Supply of permanent prosthesis for aphakia,
spectacles...................................................................1
Supply of permanent prosthesis for aphakia,
contact lens ................................................................1
3
4
5
Assistant Surgeon services not payable
Anesthesiology services not payable
Ambulatory Surgical
2 – TAR and Non-Benefit List: Codes 90000 – 99999
November 2001
tar and non cd9
3
Benefit
Restrictions
Code
Description
92548
SPECIAL OTORHINOLARYNGOLOGIC SERVICES
Vestibular Function Tests with Recording
Computerized dynamic posturography ............................ 1
92567
92583
92584
92592
92593
92596
Audiologic Function Tests with Medical
Diagnostic Evaluation
Tympanometry (impedance testing) ................................ 1
Select picture audiometry ................................................ 1
Electrocochleography ...................................................... 1
Hearing aid check, monaural ........................................... 1
Hearing aid check, binaural ............................................. 1
Ear protector attenuation measurements......................... 1
92979
92980
92981
92982
92984
92995
92996
92997
92998
93226
93232
93271
93278
CARDIOVASCULAR
Therapeutic Services
Intravascular ultrasound (coronary vessel or
graft) during therapeutic intervention
including imaging supervision,
interpretation and report; each additional
vessel ......................................................................... 4
Transcatheter placement of an intracoronary
stent(s), percutaneous; single vessel ......................... 2
Transcatheter placement of an intracoronary
stent(s), percutaneous; each additional
vessel (List separately in addition to code
for primary procedure) ............................................ 2, 4
Percutaneous transluminal coronary balloon
angioplasty; single ...................................................... 2
Percutaneous transluminal coronary angioplasty;
each additional vessel (List separately in
addition to code for primary procedure).................. 2, 4
Percutaneous transluminal, coronary atherectomy,
by mechanical or other method, with or
without balloon angioplasty; single vessel.................. 2
Percutaneous transluminal, coronary atherectomy,
by mechanical or other method, with or
without balloon angioplasty; each additional
vessel (List separately in addition
to code for primary procedure). .................................. 2
Percutaneous transluminal pulmonary artery
balloon angioplasty; single vessel .............................. 1
Percutaneous transluminal pulmonary artery
balloon angioplasty; each additional vessel ............... 1
Cardiography
ECG monitoring, 24 hours, scanning analysis
with report................................................................... 1
ECG monitoring, 24 hours., microprocessor-based
analysis w/report......................................................... 1
Patient demand single or multiple event recording
with presymptom memory loop, per 30-day
period of time; monitoring, receipt of
transmissions, and analysis........................................ 1
Signal-averaged electrocardiography,
with or without ECG.................................................... 1
Benefit Restriction Descriptions:
1
2
Code
93313
93314
93316
93317
93501
93505
93508
93510
93511
93514
93524
93526
93527
93528
93529
93530
93531
93532
93533
93536
93539
93540
93541
93542
Non-Benefit
Requires TAR,
Primary Surgeon/Provider
Description
Benefit
Restrictions
Echocardiography
Echocardiography, placement of
transesophageal probe only .......................................1
Echocardiography, interpretation and report only ............1
Transesophageal echocardiography for
congenital cardiac anomalies; placement
of transesophageal probe only ...................................1
Transesophageal echocardiography for
congenital cardiac anomalies; image
acquisition, interpretation and report only...................1
Cardiac Catheterization
Right heart catheterization ...............................................2
Endomyocardial biopsy....................................................2
Catheter placement in coronary artery(s), arterial
coronary conduit(s), and/or venous coronary
bypass graft(s) for coronary angiography
without concomitant left heart catheterization ............2
Left heart catheterization, percutaneous..........................2
Left heart catheterization, by cutdown .............................2
Left heart catheterization by left ventricular puncture ......2
Combined transseptal and retrograde left heart
catheterization ............................................................2
Combined right heart catheterization and
retrograde left heart catheterization............................2
Combined right heart catheterization and
transseptal left heart catheterization
through intact septum .................................................2
Combined right heart catheterization with
left ventricular puncture ..............................................2
Combined right heart catheterization and left heart
catheterization through existing septal opening .........2
Right heart catheterization, for congenital cardiac
anomalies ...................................................................2
Combined right heart catheterization and
retrograde left heart catheterization,
for congenital cardiac anomalies ................................2
Combined right heart catheterization and
transseptal left heart catheterization
through intact septum with or without
retrograde left heart catheterization,
for congenital cardiac anomalies ................................2
Combined right heart catheterization and
transseptal left heart catheterization
through existing septal opening, with or
without retrograde left heart catheterization,
for congenital cardiac anomalies ................................2
Percutaneous insertion of intra-aortic balloon catheter....2
Injection procedure during cardiac catheterization;
for selective opacification of arterial conduits .............2
Injection procedure during cardiac catheterization;
for selective opacification of aortocoronary
venous bypass grafts..................................................2
Injection procedure during cardiac catheterization;
for pulmonary angiography .........................................2
Injection procedure during cardiac catheterization;
right-sided angiography ..............................................2
3
4
5
Assistant Surgeon services not payable
Anesthesiology services not payable
Ambulatory Surgical
2 – TAR and Non-Benefit List: Codes 90000 – 99999
October 1999
tar and non cd9
4
Code
93543
93544
93545
93600
93602
93603
93607
93610
93612
93618
93619
93620
93621
93622
93668
93720
93721
93722
93731
93732
93733
93734
93735
93736
Benefit
Restrictions
Description
Cardiac Catheterization (continued)
Injection procedure during cardiac catheterization;
left-sided angiography ................................................ 2
Injection procedure, cardiac
catheterization/aortography ........................................ 2
Injection procedure, cardiac catheterization/
coronary angiography................................................. 2
Intracardiac Electrophysiological Procedures
Bundle of His recording.................................................... 2
Intra-atrial recording......................................................... 2
Right ventricular recording ............................................... 2
Left ventricular recording ................................................. 2
Intra-atrial pacing ............................................................. 2
Intraventricular pacing...................................................... 2
Induction of arrhythmia by electrical pacing..................... 2
Comprehensive electrophysiologic evaluation, with
right atrial pacing and recording, right ventricular
pacing and recording, His bundle recording, including
insertion and repositioning of multiple electrode
catheters; without induction or attempted induction
of arrhythmia............................................................... 2
Comprehensive electrophysiologic evaluation, with
right atrial pacing and recording, right ventricular
pacing and recording, His bundle recording, including
insertion and repositioning of multiple electrode
catheters; with induction or attempted induction of
arrhythmia................................................................... 2
Comprehensive electrophysiologic evaluation,
with left atrial recordings from coronary sinus or
left atrium, with or without pacing, with induction
or attempted induction of arrhythmia .......................... 2
Comprehensive electrophysiologic evaluation,
with left ventricle recordings, with or without pacing,
with induction or attempted induction of arrhythmia ... 2
Peripheral Arterial Disease Rehabilitation
Peripheral arterial disease (PAD) rehabilitation,
per session................................................................ 1
Other Vascular Studies
Plethysmography, total body; with interpretation
and report ................................................................... 1
Plethysmography, total body; without
interpretation and report ............................................. 1
Plethysmography, total body; interpretation and
report only................................................................... 1
Electronic analysis of dual-chamber pacemaker
system; without reprogramming ................................. 5
Electronic analysis of dual-chamber pacemaker
system; with reprogramming ...................................... 5
Electronic analysis of dual-chamber internal
pacemaker system, telephonic analysis ..................... 5
Electronic analysis of single-chamber pacemaker
system; without reprogramming ................................. 5
Electronic analysis of single-chamber pacemaker
system; with reprogramming ...................................... 5
Electronic analysis of single-chamber internal
pacemaker system, telephonic analysis ..................... 5
Benefit Restriction Descriptions:
1
2
Code
93740
93760
93762
93770
93784
93786
93788
93790
93797
93798
93980
93981
Description
Benefit
Restrictions
Other Vascular Studies (continued)
Temperature gradient studies ..........................................1
Thermogram, cephalic .....................................................1
Thermogram, peripheral ..................................................1
Determination of venous pressure ...................................1
Ambulatory blood pressure monitoring ............................1
Ambulatory blood pressure monitoring, recording ...........1
Ambulatory blood pressure monitoring, scanning
analysis.......................................................................1
Ambulatory blood pressure monitoring, physician
review .........................................................................1
Other Procedures
Physician services, outpatient cardiac rehab, w/out
continuous ECG .........................................................1
Physician services, outpatient cardiac rehab,
w/continuous ECG......................................................1
NON-INVASIVE VASCULAR DIAGNOSTIC STUDIES
Visceral and Penile Vascular Studies
Duplex scan, arterial inflow, venous outflow, penile
vessels, complete .......................................................2
Duplex scan, arterial inflow, venous outflow, penile
vessels, follow-up .......................................................2
94761
94762
PULMONARY
Prolonged postexposure evaluation of bronchospasm
with multiple spirometric determinations after
antigen, cold air, methacholine or other chemical
agent, with subsequent spirometrics ..........................1
Airway closing volume .....................................................1
Intermittent positive pressure breathing treatment,
initial ...........................................................................2
Intermittent positive pressure breathing treatment,
subsequent .................................................................2
Ear or pulse oximetry, multiple.........................................1
Ear or pulse oximetry, continuous....................................1
95078
ALLERGY AND CLINICAL IMMUNOLOGY
Allergy Testing
Provocative test ...............................................................1
94070
94370
94650
94651
95117
95120
95125
95130
Non-Benefit
Requires TAR,
Primary Surgeon/Provider
ALLERGEN IMMUNOTHERAPY
Professional services for allergen immunotherapy
not including provision of allergenic
extracts; two or more injections ..................................1
Professional services for allergen immunotherapy;
single injection ............................................................1
Professional services for allergen immunotherapy;
multiple injections .......................................................1
Professional services for allergen immunotherapy;
single stinging insect venom.......................................1
3
4
5
Assistant Surgeon services not payable
Anesthesiology services not payable
Ambulatory Surgical
2 – TAR and Non-Benefit List: Codes 90000 – 99999
November 2001
tar and non cd9
5
Code
95131
95132
95133
95134
95144
95145
95146
95147
95148
95149
95165
95170
95921
95922
95923
Benefit
Restrictions
Description
ALLERGEN IMMUNOTHERAPY (continued)
Professional services for allergen immunotherapy;
two stinging insect venom .......................................... 1
Professional services for allergen immunotherapy;
three stinging insect venom........................................ 1
Professional services for allergen immunotherapy;
four stinging insect venom.......................................... 1
Professional services for allergen immunotherapy;
five stinging insect venom .......................................... 1
Professional services for supervision/provision of
antigens, for allergen immunotherapy;
single dose vials ......................................................... 1
Professional services for the supervision and
provision of antigens for allergen immunotherapy;
single stinging insect venom ...................................... 1
Professional services for the supervision and
provision of antigens for allergen immunotherapy;
two single stinging insect venom ................................ 1
Professional services for the supervision
and provision of antigens for allergen
immunotherapy; three single stinging
insect venoms............................................................. 1
Professional services for the supervision
and provision of antigens for allergen
immunotherapy; four single stinging
insect venoms............................................................. 1
Professional services for the supervision
and provision of antigens for allergen
immunotherapy; five single stinging
insect venoms............................................................. 1
Professional services for the supervision
and provision of antigens for allergen
immunotherapy; single or multiple dose antigens ...... 1
Professional services for supervision/provision of
antigens for allergen immunotherapy; whole body
extract of insect or arthropod...................................... 1
NEUROLOGY AND NEUROMUSCULAR
PROCEDURES
Sleep Testing
Testing of autonomic nervous system function;
cardiovagal innervation (parasympathetic function),
including two or more of the following: heart rate
response to deep breathing with recorded R-R
interval, Valsalva ratio, and 30:15 ratio ...................... 1
Testing of autonomic nervous system function;
vasomotor adrenergic innervation
(sympathetic adrenergic function), including
beat-to-beat blood pressure and R-R
interval changes during Valsalva maneuver
and at least five minutes of passive tilt....................... 1
Testing of autonomic nervous system function;
sudomotor, including one or more of the following:
quantitative sudomotor axon reflex test (QSART),
silastic sweat imprint, thermoregulatory sweat test,
and changes in sympathetic skin potential ................. 1
Benefit Restriction Descriptions:
1
2
Code
95933
95954
95958
95961
95962
96570
96571
Description
Benefit
Restrictions
Sleep Testing (continued)
Orbicularis oculi reflex......................................................1
Pharmacological or physical activation requiring
physician attendance during EEG recording of
activation phase..........................................................1
Wada activation test.........................................................5
Functional cortical mapping; initial hour
of physician attendance..............................................1
Functional cortical mapping; each additional hour
of physician attendance..............................................1
PHOTODYNAMIC THERAPY
Photodynamic therapy by endoscopic application of
light; first 30 minutes ...............................................1
Photodynamic therapy by endoscopic application
of light; each additional 15 minutes........................1
96910
96912
96999
SPECIAL DERMATOLOGICAL PROCEDURES
Actinotherapy (UV light) ...................................................5
Microscopic examination of hairs plucked or
clipped by the examiner (excluding hair
collected by the patient) to determine telogen
and anagen counts, or structural hair shaft
abnormality .................................................................1
Photochemotherapy (Goeckerman) .................................5
PUVA therapy ..................................................................5
Dermatological procedure, unlisted .................................2
97001
97002
97003
97004
PHYSICAL MEDICINE AND REHABILITATION
Physical therapy evaluation .............................................1
Physical therapy re-evaluation .........................................1
Occupational therapy evaluation......................................1
Occupational therapy re-evaluation .................................1
96900
96902
97012
97014
97016
97018
97020
97022
97024
97026
97028
Modalities
Application of a modality to one or more areas;
hot or cold packs ........................................................2
Traction, mechanical........................................................2
Electrical stimulation ........................................................2
Vasopneumatic devices ...................................................2
Paraffin bath.....................................................................2
Microwave........................................................................2
Whirlpool ..........................................................................2
Diathermy.........................................................................2
Infrared.............................................................................2
Ultraviolet .........................................................................2
97032
97033
97034
97035
97036
97039
Constant Attendance
Application of modality; electrical stimulation...................2
Application of modality; iontophoresis..............................2
Application of modality; contrast baths ............................2
Application of modality; ultrasound ..................................2
Application of modality; Hubbard tank .............................2
Unlisted modality..............................................................2
97010
Non-Benefit
Requires TAR,
Primary Surgeon/Provider
3
4
5
Assistant Surgeon services not payable
Anesthesiology services not payable
Ambulatory Surgical
2 – TAR and Non-Benefit List: Codes 90000 – 99999
December 2001
tar and non cd9
6
Code
97110
97112
97113
97116
97124
97139
97140
97150
97504
97520
97530
97535
97537
97542
97545
97546
97601
97602
Benefit
Restrictions
Description
Therapeutic Procedures
Therapeutic procedure, one or more areas,
each 15 minutes; therapeutic exercises ..................... 2
Therapeutic procedure, one or more areas,
each 15 minutes; neuromuscular reeducation............ 2
Therapeutic procedure, one or more areas,
each 15 minutes; aquatic therapy with
therapeutic exercises.................................................. 2
Therapeutic procedure, one or more areas,
each 15 minutes; gait training
(includes stair climbing) .............................................. 2
Therapeutic procedure, one or more areas,
each 15 minutes; massage......................................... 2
Therapeutic procedure, one or more areas,
each 15 minutes; unlisted procedure.......................... 2
Manual therapy techniques, one or more regions,
each 15 minutes ......................................................... 2
Therapeutic procedure(s), group
(2 or more individuals) ................................................ 2
Orthotics fitting and training, upper and/or
lower extremities, each 15 minutes ............................ 1
Prosthetic training; upper and/or lower
extremities, each 15 minutes...................................... 1
Therapeutic activities, direct (one on one) patient
contact by the provider, each 15 minutes................... 2
Self care/home management training, direct one
on one contact by provider, each 15 minutes............. 1
Community/work reintegration training, direct one
on one contact by provider, each 15 minutes............. 1
Wheelchair management/propulsion training,
each 15 minutes ......................................................... 1
Work hardening/conditioning, initial two hours................. 1
Work hardening/conditioning, each additional hour ......... 1
Active Wound Care Management
Removal of devitalized tissue from wound; selective
debridement................................................................ 1
Removal of devitalized tissue from wound;
non-selective debridement ......................................... 1
Description
98926
98927
98928
98929
OMT; three to four body regions ......................................1
OMT; five to six body regions ..........................................1
OMT; seven to eight body regions ...................................1
OMT; nine to ten body regions.........................................1
98943
CHIROPRACTIC MANIPULATIVE TREATMENT
Chiropractic manipulative treatment (CMT);
extraspinal, one or more regions ................................1
99082
99090
SPECIAL SERVICES AND REPORTS
Miscellaneous Services
Handling of lab specimen, from office..............................1
Handling of lab specimen, from other than office.............1
Handling of lab specimen, involving devices ...................1
Postoperative follow-up visit included in global service ...1
Services requested after office hours ..............................1
Services requested between 10 p.m. and 8 a.m..............1
Services requested on Sundays and holidays .................1
Services provided at request of patient............................1
Office services on emergency basis ................................1
Educational supplies provided to patient .........................1
Medical testimony ............................................................1
Physician education services in group setting .................1
Special reports with more information than
standard form .............................................................1
Unusual travel ..................................................................2
Analysis of data in computers ..........................................1
99100
99116
99135
99140
QUALIFYING CIRCUMSTANCES FOR ANESTHESIA
Anesthesia for patient of extreme age .............................1
Anesthesia complicated by total body hypothermia .........1
Anesthesia complicated by controlled hypotension .........1
Anesthesia complicated by emergency conditions ..........1
99000
99001
99002
99024
99050
99052
99054
99056
99058
99071
99075
99078
99080
99172
99173
99175
99183
97703
97750
Tests and Measurements
Checkout for orthotic/prosthetic use,
established patient, each 15 minutes ......................... 1
Physical performance test or measurement,
with written report, each 15 minutes........................... 2
99185
99186
99190
99191
97780
97781
Other Procedures
Acupuncture, one or more needles; without
electrical stimulation ................................................... 1
Acupuncture, one or more needles; with electrical
stimulation .................................................................. 1
97804
MEDICAL NUTRITION THERAPY
Medical nutrition therapy; initial assessment,
individual..................................................................... 1
Medical nutrition therapy; re-assessment,
individual..................................................................... 1
Medical nutrition therapy; group....................................... 1
98925
OSTEOPATHIC MANIPULATIVE TREATMENT
OMT; one to two body regions ......................................... 1
97802
97803
Benefit Restriction Descriptions:
1
2
Benefit
Restrictions
Code
99192
Non-Benefit
Requires TAR,
Primary Surgeon/Provider
Other Services
Visual function screening .................................................1
Screening test of visual acuity, quantitative,
bilateral .......................................................................1
Ipecac administration .......................................................1
Physician attendance and supervision of
hyperbaric oxygen therapy, per session .....................2
Hypothermia, regional ......................................................2
Hypothermia, total body ...................................................2
Assembly and operation of pump with oxygenator
or heat exchanger, each hour.....................................1
Assembly and operation of pump with oxygenator
or heat exchanger, 3/4 hour .......................................1
Assembly and operation of pump with oxygenator
or heat exchanger, 1/2 hour .......................................1
3
4
5
Assistant Surgeon services not payable
Anesthesiology services not payable
Ambulatory Surgical
2 – TAR and Non-Benefit List: Codes 90000 – 99999
December 2001
tar and non cd9
7
Benefit
Restrictions
Code
Description
99288
EVALUATION AND MANAGEMENT
Miscellaneous
Direct advance life support .............................................. 1
99295
99296
99297
99298
99358
99359
Neonatal Intensive Care
Initial neonatal intensive care, per day, for the
evaluation and management of a critically
ill neonate or infant ..................................................... 1
Subsequent neonatal intensive care, per day, for the
evaluation and management of critically ill
and unstable neonate or infant ................................... 1
Subsequent neonatal intensive care, per day, for the
evaluation and management of a critically ill
though stable neonate or infant .................................. 1
Subsequent neonatal intensive care, per day, for the
evaluation and management of the recovering
very low birth weight infant (less than
1500 grams) ............................................................... 1
PROLONGED SERVICES
Prolonged E & M service before and/or after direct patient
care; first hour............................................................. 1
Prolonged E & M service before and/or after direct patient
care; each additional 30 minutes................................ 1
Description
99397
Preventive medicine, established, 65+ years ..................1
99401
99402
99403
99404
99361
99362
99371
99372
99373
Telephone Calls
Telephone call, simple ..................................................... 1
Telephone call, intermediate............................................ 1
Telephone call, complex .................................................. 1
99412
99420
Other Preventive Medicine Services
Health risk assessment....................................................1
99450
99455
99374
99375
99377
99378
99379
99380
CARE PLAN OVERSIGHT SERVICES
Physician supervision of a patient under care of home
health agency (patient not present); 15-29 minutes ... 1
Physician supervision of a patient under care of home
health agency (patient not present); 30 minutes or
more ........................................................................... 1
Physician supervision of a hospice patient (patient not
present); 15-29 minutes.............................................. 1
Physician supervision of a hospice patient (patient not
present); 30 minutes or more ..................................... 1
Physician supervision of a nursing facility patient (patient
not present); 15-29 minutes........................................ 1
Physician supervision of a nursing facility patient (patient
not present); 30 minutes or more ............................... 1
99385
99386
99387
PREVENTIVE MEDICINE SERVICES
New Patient
Preventive medicine, new, 18 – 39 years ........................ 1
Preventive medicine, new, 40 – 64 years ........................ 1
Preventive medicine, new, 65+ years .............................. 1
99395
99396
Established Patient
Preventive medicine, established, 18 – 39 years............. 1
Preventive medicine, established, 40 – 64 years............. 1
Benefit Restriction Descriptions:
1
2
COUNSELING AND/OR RISK FACTOR
REDUCTION INTERVENTION
Preventive Medicine, Individual Counseling
Preventive medicine counseling, individual;
approximately 15 minutes...........................................1
Preventive medicine counseling, individual;
approximately 30 minutes...........................................1
Preventive medicine counseling, individual;
approximately 45 minutes...........................................1
Preventive medicine counseling, individual;
approximately 60 minutes...........................................1
Preventive Medicine, Group Counseling
Preventive medicine counseling,
approximately 30 minutes...........................................1
Group counseling, 60 minutes .........................................1
99411
99435
CASE MANAGEMENT SERVICES
Team Conferences
Medical conference, 30 minutes ...................................... 1
Medical conference, 60 minutes ...................................... 1
Benefit
Restrictions
Code
99456
Non-Benefit
Requires TAR,
Primary Surgeon/Provider
NEWBORN CARE
History and examination of the normal
newborn infant, including the preparation
of medical records ......................................................1
SPECIAL EVALUATION AND
MANAGEMENT SERVICES
Basic Life and/or Disability Evaluation Services
Basic life and/or disability examination ............................1
Work Related or Medical Disability
Evaluation Services
Work related or medical disability examination
by the treating physician .............................................1
Work related or medical disability examination
by other than the treating physician............................1
3
4
5
Assistant Surgeon services not payable
Anesthesiology services not payable
Ambulatory Surgical
2 – TAR and Non-Benefit List: Codes 90000 – 99999
November 2001