Sr NO
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
Speciality
Burns Management
Cardiology
COVID-19
CTVS
Emergency Room Packages
ENT
General Medicine
General Surgery
Interventional Neuroradiology
Medical Oncology
Mental Disorders
Neo - natal Care
Neurosurgery
Obstetrics & Gynecology
Ophthalmology
Oral & Maxillofacial Surgery
Organ & Tissue Transplant
Orthopedics
Pediatric Medical Management
Pediatric Surgery
Plastic & Reconstructive Surgery
Polytrauma
Radiation Oncology
Surgical Oncology
Unspecified Package
Urology
Grand Total
OPEN
Sr No
1
2
3
4
Category
OPEN
Referral
Reserved
Grand Total
Count of Specialty
1449
101
42
1592
17
26
5
118
4
66
80
99
15
263
10
10
79
41
43
8
2
132
65
34
12
21
35
120
1
143
1449
Referral Reserved Grand Total
3
20
26
5
118
4
11
1
78
4
17
101
43
12
154
15
263
10
10
3
82
29
7
77
10
1
54
1
9
2
132
65
1
35
12
21
35
120
1
143
101
42
1592
Package Master and MDR for PRE-AUTH and CLAIM PROCESSING 02-02-2022
SL NO
1
2
3
4
5
6
7
Specialty
Burns Management
Burns Management
Burns Management
Burns Management
Burns Management
Burns Management
Burns Management
Specialty
Code
BM
BM
BM
BM
BM
BM
BM
Package
Code
Package Name
BM001 Thermal burns
BM001 Thermal burns
BM001 Thermal burns
BM001 Thermal burns
BM002 Scald burns
BM002 Scald burns
BM002 Scald burns
Procedure
Code
BM001A
BM001B
BM001C
BM001D
BM002A
BM002B
BM002C
Procedure Name
% Total Body Surface
Area Burns (TBSA) any %
(not requiring
admission).
Needs at least 5-6
dressing
% Total Body Surface
Area Burns (TBSA):
Upto 40 %; Includes %
TBSA skin grafted, flap
cover, follow-up
dressings etc. as
deemed necessary;
Surgical procedures are
required for deep burns
that are not amenable
to heal with dressings
% Total Body Surface
Area Burns (TBSA):
40% - 60 %; Includes
% TBSA skin grafted,
flap cover, follow-up
dressings etc. as
deemed necessary;
Surgical procedures are
required for deep burns
that are not amenable
to heal with dressings
% Total Body Surface
Area Burns (TBSA): >
60 %; Includes %
TBSA skin grafted, flap
cover, follow-up
dressings etc. as
deemed necessary;
Surgical procedures are
required for deep burns
that are not amenable
to heal with dressings
% Total Body Surface
Area Burns (TBSA) any %
(not requiring
admission).
Needs at least 5-6
dressing
% Total Body Surface
Area Burns (TBSA):
Upto 40 %; Includes %
TBSA skin grafted, flap
cover, follow-up
dressings etc. as
deemed necessary;
Surgical procedures are
required for deep burns
that are not amenable
to heal with dressings
% Total Body Surface
Area Burns (TBSA):
40% - 60 %; Includes
% TBSA skin grafted,
flap cover, follow-up
dressings etc. as
deemed necessary;
Surgical procedures are
required for deep burns
that are not amenable
to heal with dressings
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
7000
8400
NABH
Package
Cost
9100
Outside State
NABH
Package Cost
10150
Mandatory Documents - Pre
Authorization
A)Clinical Notes
B)MLC copy with number
C)Extent of burns visible on
photograph (with rule of 9 chart)
A)Clinical Notes.
B) MLC copy with number.
40000
48000
52000
58000
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
A)Post Treatment clinical
photograph.
B)lab tests or other diagnostic
procedures done as a part of
treatment.
C) Detailed clinical notes.
Reserved
A)Post Treatment clinical
photograph.
B)lab tests.
C)X-rays or other diagnostic
C) Extent of upto 40% burns
procedures done as a part of
visible on photograph (with rule of
treatment.
9 chart)
D)Detailed discharge summary.
OPEN
Y
A)Post Treatment clinical
photograph.
B)lab tests.
C) X-rays or other diagnostic
C) Extent of upto 40% - 60%
procedures done as a part of
burns visible on photograph (with
treatment.
rule of 9 chart)
D) Detailed discharge summary.
A)Clinical Notes.
B) MLC copy with number.
50000
60000
65000
72500
OPEN
Y
80000
96000
104000
116000
A)Clinical Notes.
B)MLC copy with number.
A)Post Treatment clinical
C) Extent > 60% burns visible on
photograph.
photograph (with rule of 9 chart)
B)lab tests.
C)X-rays or other diagnostic
procedures done as a part of
treatment.
D) Detailed discharge summary.
OPEN
Y
7000
40000
8400
48000
9100
52000
10150
A)Clinical Notes.
B)MLC copy with number.
C)Extent of burns visible on
photograph (with rule of 9 chart)
58000
A)Clinical Notes.
B) MLC copy with number.
C)Extent of upto 40% burns
visible on photograph (with rule of
9 chart)
A)Post Treatment clinical
photograph.
B) lab tests or other diagnostic
procedures done as a part of
treatment.
C) Detailed clinical notes.
A)Post Treatment clinical
photograph.
B) lab tests.
C) X-rays or other diagnostic
procedures done as a part of
treatment.
D)Detailed discharge summary.
Reserved
OPEN
Y
50000
60000
65000
72500
A)Clinical Notes.
B) MLC copy with number.
C)Extent of upto 40% - 60%
burns visible on photograph (with
rule of 9 chart)
A)Post Treatment clinical
photograph.
B) lab tests.
C) X-rays or other diagnostic
procedures done as a part of
treatment.
D)Detailed discharge summary.
OPEN
Y
SL NO
8
9
10
11
12
13
Specialty
Burns Management
Burns Management
Burns Management
Burns Management
Burns Management
Burns Management
Specialty
Code
BM
BM
BM
BM
BM
BM
Package
Code
Package Name
Procedure
Code
Procedure Name
BM002 Scald burns
% Total Body Surface
Area Burns (TBSA): >
60 %; Includes %
TBSA skin grafted, flap
cover, follow-up
BM002D dressings etc. as
deemed necessary;
Surgical procedures are
required for deep burns
that are not amenable
to heal with dressings
BM003 Flame burns
% Total Body Surface
Area Burns (TBSA) any %
BM003A (not requiring
admission).
Needs at least 5-6
dressing
BM003 Flame burns
BM003 Flame burns
BM003 Flame burns
BM003B
BM003C
BM003D
BM004 Electrical contact burns BM004A
% Total Body Surface
Area Burns (TBSA):
Upto 40 %; Includes %
TBSA skin grafted, flap
cover, follow-up
dressings etc. as
deemed necessary;
Surgical procedures are
required for deep burns
that are not amenable
to heal with dressings
% Total Body Surface
Area Burns (TBSA): 40
% - 60 %; Includes %
TBSA skin grafted, flap
cover, follow-up
dressings etc. as
deemed necessary;
Surgical procedures are
required for deep burns
that are not amenable
to heal with dressings
% Total Body Surface
Area Burns (TBSA): >
60 %; Includes %
TBSA skin grafted, flap
cover, follow-up
dressings etc. as
deemed necessary;
Surgical procedures are
required for deep burns
that are not amenable
to heal with dressings
Electrical contact burns:
Low voltage - without
part of limb / limb loss;
Includes % TBSA skin
grafted, flap cover,
follow-up dressings etc.
as deemed necessary;
Surgical procedures are
required for deep burns
that are not amenable
to heal with dressings
alone.
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
80000
96000
NABH
Package
Cost
104000
Outside State
NABH
Package Cost
116000
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
A)Post Treatment clinical
photograph.
A)Clinical Notes.
B) lab tests.
B) MLC copy with number.
C)X-rays or other diagnostic
C) Extent > 60% burns visible on
procedures done as a part of
photograph (with rule of 9 chart)
treatment.
D)Detailed discharge summary.
OPEN
Y
7000
40000
8400
48000
9100
52000
10150
58000
A)Clinical Notes.
B) MLC copy with number.
C) Extent of burns visible on
photograph (with rule of 9 chart)
A)Post Treatment clinical
photograph.
B)lab tests.
C)X-rays or other diagnostic
procedures done as a part of
treatment.
D)Detailed discharge summary.
A)Clinical Notes.
B)MLC copy with number.
C) Extent of upto 40% burns
visible on photograph (with rule of
9 chart)
A)Post Treatment clinical
photograph.
B) lab tests, X-rays or other
diagnostic procedures done as a
part of treatment.
C)Detailed discharge summary.
Reserved
OPEN
Y
50000
60000
65000
72500
A)Clinical Notes.
B)MLC copy with number.
C) Extent of upto 40% - 60%
burns visible on photograph (with
rule of 9 chart)
A)Post Treatment clinical
photograph.
B)lab tests.
C)X-rays or other diagnostic
procedures done as a part of
treatment.
D)Detailed discharge summary.
OPEN
Y
A)Clinical Notes
B)MLC copy with number.
80000
96000
104000
116000
C)Extent > 60% burns visible
on photograph (with rule of 9
chart)
A)Post Treatment clinical
photograph.
B) lab tests.
C) X-rays or other diagnostic
procedures done as a part of
treatment.
D)Detailed discharge summary.
OPEN
Y
30000
36000
39000
43500
A)Circumstances that led to low
voltage electrical contact burns.
B) MLC copy with number.
C)% burns visible on clinical
photograph (with rule of 9 chart)
A)Post Treatment clinical
photograph.
B)lab tests.
C)X-rays or other diagnostic
procedures done as a part of
treatment.
D)Detailed discharge summary.
OPEN
E)Detailed Procedure.
F) Operative Notes if surgery
done.
Y
SL NO
14
15
16
17
18
Specialty
Burns Management
Burns Management
Burns Management
Burns Management
Burns Management
Specialty
Code
BM
BM
BM
BM
BM
Package
Code
Package Name
Procedure
Code
BM004 Electrical contact burns BM004B
BM004 Electrical contact burns BM004C
BM004 Electrical contact burns BM004D
BM005 Chemical burns
BM005 Chemical burns
BM005A
BM005B
Procedure Name
Electrical contact burns:
Low voltage - with part
of limb / limb loss;
Includes % TBSA skin
grafted, flap cover,
follow-up dressings etc.
as deemed necessary;
Surgical procedures are
required for deep burns
that are not amenable
to heal with dressings
Electrical contact burns:
High voltage - with part
of limb / limb loss;
Includes % TBSA skin
grafted, flap cover,
follow-up dressings etc.
as deemed necessary;
Surgical procedures are
required for deep burns
that are not amenable
to heal with dressings
Electrical contact burns:
High voltage - without
part of limb / limb loss;
Includes % TBSA skin
grafted, flap cover,
follow-up dressings etc.
as deemed necessary;
Surgical procedures are
required for deep burns
that are not amenable
to heal with dressings
Chemical burns:
Without significant
facial scarring and/or
loss of function;
Includes % TBSA skin
grafted, flap cover,
follow-up dressings etc.
as deemed necessary;
Surgical procedures are
required for deep burns
that are not amenable
to heal with dressings
Chemical burns: With
significant facial
scarring and/or loss of
function; Includes %
TBSA skin grafted, flap
cover, follow-up
dressings etc. as
deemed necessary;
Surgical procedures are
required for deep burns
that are not amenable
to heal with dressings
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
40000
48000
NABH
Package
Cost
52000
Outside State
NABH
Package Cost
58000
Mandatory Documents - Pre
Authorization
A)Circumstances that led to low
voltage electrical contact burns.
B) MLC copy with number.
C) % burns visible on clinical
photograph (with rule of 9 chart)
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
A)Post Treatment clinical
photograph,.
B)lab tests.
C)X-rays or other diagnostic
procedures done as a part of
treatment.
D) Detailed discharge summary.
E)Detailed Procedure.
F) Operative Notes if surgery
done.
OPEN
Y
60000
72000
78000
87000
A)Post Treatment clinical
photograph.
B) lab tests.
A)Circumstances that led to High
C)X-rays or other diagnostic
voltage electrical contact burns.
procedures done as a part of
B) MLC copy with number.
treatment.
C) % burns visible on clinical
D) Detailed discharge summary.
photograph (with rule of 9 chart)
E)Detailed Procedure .
F) Operative Notes if surgery
done.
OPEN
Y
50000
60000
65000
72500
A)Post Treatment clinical
photograph.
B) lab tests.
A)Circumstances that led to High
C)X-rays or other diagnostic
voltage electrical contact burns.
procedures done as a part of
B)MLC copy with number. %
treatment.
burns visible on clinical
D) Detailed discharge summary.
photograph (with rule of 9 chart)
E)Detailed Procedure .
F) Operative Notes if surgery
done.
OPEN
Y
40000
48000
52000
58000
A)Circumstances that led to
chemical burns.
B)MLC copy with number.
C) % and area burnt visible on
clinical photograph
(with rule of 9 chart)
A)Post Treatment clinical
photograph showing treated burns.
B)lab tests.
C) X-rays or other diagnostic
procedures done as a part of
treatment.
OPEN
D)Detailed discharge summary.
E)Detailed Procedure .
F) Operative Notes if surgery
done.
Y
60000
72000
78000
87000
A)Circumstances that led to
chemical burns.
B)MLC copy with number.
C) % and area burnt visible on
clinical photograph
(with rule of 9 chart)
A)Post Treatment clinical
photograph showing treated burns.
B) lab tests.
C) X-rays or other diagnostic
procedures done as a part of
OPEN
treatment.
D)Detailed
discharge summary.
E)Detailed Procedure.
F)Operative Notes if surgery done.
Y
SL NO
19
20
21
Specialty
Burns Management
Burns Management
Emergency Room Packages
Specialty
Code
BM
BM
ER
Package
Code
Package Name
Post Burn Contracture
surgeries for
BM006
Functional
Improvement
Post Burn Contracture
surgeries for
BM006
Functional
Improvement
ER001
Laceration - Suturing /
Dressing
Procedure
Code
Procedure Name
Post Burn Contracture
surgeries for Functional
Improvement (Package
including splints,
pressure garments,
silicone - gel sheet and
physiotherapy):
Excluding Neck
contracture;
BM006A
Contracture release
with - Split thickness
Skin Graft (STSG) /
Full Thickness Skin
Graft (FTSG) / Flap
cover is done for each
joint with post operative regular
dressings
STSG /
Post Burnfor
Contracture
surgeries for Functional
Improvement (Package
including splints,
pressure garments,
silicone - gel sheet and
physiotherapy): Neck
contracture;
Contracture release
BM006B
with - Split thickness
Skin Graft (STSG) /
Full Thickness Skin
Graft (FTSG) / Flap
cover is done for each
joint with postoperative regular
dressings for STSG /
FTSG / Flap cover.
ER001A
Laceration - Suturing /
Dressing
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
50000
60000
NABH
Package
Cost
65000
Outside State
NABH
Package Cost
72500
Mandatory Documents - Pre
Authorization
A)Clinical history detailing the
burns - etiology.
B)treatment given .
C) resultant contractures left.
Functional disability to be detailed.
D) expected functional
improvement to be shared. Preop clinical photograph.
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
A)Post Treatment clinical
photograph.
B)Detailed discharge summary.
C)Detailed Procedure.
D) Operative Notes.
OPEN
Y
50000
60000
65000
72500
A)Clinical history detailing the
burns - etiology.
B) treatment given .
C) resultant contractures left.
D)Functional disability to be
detailed and expected functional
improvement to be shared.
E)Pre-op clinical
photograph.
A)Post Treatment clinical
photograph.
B)Detailed discharge summary.
C) Detailed Procedure.
D) Operative Notes.
OPEN
Y
2000
2400
2600
2900
A)Clinical notes .
A)Clinical notes with planned line B) discharge summary with
of treatment with pre-clinical
planned line of treatment .
photograph
C) post clinical photograph
OPEN
N
22
23
24
Emergency Room Packages
Emergency Room Packages
Emergency Room Packages
ER
ER
ER
ER002
ER002
ER003
Cardiopulmonary
emergency
ER002A
Cardiopulmonary
emergency
Emergency with
unstable
ER002B
cardiopulmonary status
with resuccitation
Animal bites
(Excluding Snake Bite)
ER003A
Emergency with stable
cardiopulmonary status
Animal bites (Excluding
Snake Bite)
2000
2400
2600
2900
A)Clinical notes with planned line A)Clinical notes.
of treatment.
B) discharge summary with
B) ECG
planned line of treatment
OPEN
Y
10000
1700
12000
2040
13000
2210
14500
2465
A)Clinical notes with planned line A)Clinical notes.
B) discharge summary with
of treatment.
planned line of treatment
B) ECG
OPEN
Y
A)Beneficiary signature .
B)thumb impession.
C)invoice .
A)Classification of bites with preD) bar code sticker of the vaccine. OPEN
clinical photograph
E) Clinical Notes with complete
treatment details given
N
25
Interventional
Neuroradiology
IN
IN001 Dural AVMs / AVFs
IN001A
Dural AVMs (per
sitting) with glue
70000
84000
91000
101500
A)Clinical notes.
B)CT.
C)MRI.
D) DSA confirming the diagnosis
A)Detailed Procedure .
B) Operative Notes..
C)Radiographic stills
D)photograph.
E)CT.
F)MRI.
G)Angio.
H) Invoice .
I) bar code of glue used.
J) Detailed Discharge Summary
OPEN
Y
SL NO
26
27
Specialty
Interventional
Neuroradiology
Interventional
Neuroradiology
Specialty
Code
IN
IN
Package
Code
Package Name
IN001 Dural AVMs / AVFs
IN001 Dural AVMs / AVFs
Procedure
Code
IN001B
IN001C
Procedure Name
Dural AVFs (per sitting)
with glue
Dural AVMs (per
sitting) with onyx
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
70000
150000
84000
180000
NABH
Package
Cost
91000
195000
Outside State
NABH
Package Cost
101500
217500
Mandatory Documents - Pre
Authorization
A)Clinical notes.
B)CT.
C)MRI.
D) DSA confirming the diagnosis
A)Clinical notes.
B)CT.
C)MRI.
D) DSA confirming the diagnosis
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
A)Detailed Procedure .
B) Operative Notes..
C)Radiographic stills
D)photograph.
E)CT.
F)MRI.
G)Angio.
H) Invoice .
I) bar code of glue used.
J) Detailed Discharge Summary
A)Detailed Procedure .
B) Operative Notes.
C) Radiographic stills
D)photograph.
E)CT.
F)MRI.
G)Angio.
H) Invoice .
I) bar code of Onyx used.
J) Detailed Discharge Summary
OPEN
Y
OPEN
Y
28
Interventional
Neuroradiology
IN
IN001 Dural AVMs / AVFs
IN001D
Dural AVFs (per sitting)
with onyx
150000
180000
195000
217500
A)Clinical notes.
B)CT.
C)MRI.
D) DSA confirming the diagnosis
A)Detailed Procedure .
B) Operative Notes.
C) Radiographic stills
D)photograph.
E)CT.
F)MRI.
G)Angio.
H) Invoice .
I) bar code of Onyx used.
J) Detailed Discharge Summary
OPEN
Y
29
Interventional
Neuroradiology
IN
IN002
Cerebral & Spinal
AVM embolization Using Histoacryl (per
sitting)
IN002A
Cerebral AVM
embolization - Using
Histoacryl
(per sitting)
100000
120000
130000
145000
A)Clinical notes.
B)CT.
C)MRI.
D) DSA confirming the diagnosis
A)Detailed Procedure .
B) Operative Notes.
C) Radiographic stills
D)photograph.
E)CT.
F)MRI.
G)Angio.
H) Invoice .
I) bar code of histoacryl used.
J) Detailed Discharge Summary
OPEN
Y
30
Interventional
Neuroradiology
IN
IN002
Cerebral & Spinal
AVM embolization Using Histoacryl (per
sitting)
IN002B
Spinal AVM
embolization - Using
Histoacryl
(per sitting)
100000
120000
130000
145000
A)Clinical notes.
B)CT.
C)MRI.
D) DSA confirming the diagnosis
A)Detailed Procedure .
B) Operative Notes.
C) Radiographic stills
D)photograph.
E)CT.
F)MRI.
G)Angio.
H) Invoice .
I) bar code of histoacryl used.
J) Detailed Discharge Summary
OPEN
Y
31
Interventional
Neuroradiology
IN
Coil embolization for
IN003
aneurysms
IN003A
Coil embolization for
aneurysms
100000
120000
130000
145000
A)Clinical notes.
B) CT Angio.
C)MRA.
D) DSA confirming the diagnosis
for which the procedure is done
A)Post procedure x-ray showing
coils.
B) Detailed Procedure /.
C)Operative Notes.
D) Invoice .
E) bar code of used coil .
F) balloon .
G)stent.
H) detailed discharge summary
OPEN
N
SL NO
32
Specialty
Interventional
Neuroradiology
Specialty
Code
IN
Package
Code
Package Name
Carotico-cavernous
IN004 Fistula (CCF)
embolization
Procedure
Code
IN004A
Procedure Name
Carotico-cavernous
Fistula (CCF)
embolization with coils.
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
30000
36000
NABH
Package
Cost
39000
Outside State
NABH
Package Cost
43500
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
A)Clinical notes .
B) CT.
C)MRI.
D) DSA confirming the diagnosis
A)Post procedure x-ray showing
coils.
B) Detailed Procedure .
C) Operative Notes.
D) Invoice .
E) bar code of used coil .
F) catheter .
G) other accessories.
H) detailed discharge summary
A)Clinical notes .
B) CT.
C)MRI.
D) DSA confirming the diagnosis
A)Post procedure x-ray showing
balloon.
B) Detailed Procedure .
C) Operative Notes.
D) Invoice .
E) bar code of used coil .
F) catheter .
G) other accessories.
H) detailed discharge summary
OPEN
Y
33
34
Interventional
Neuroradiology
Interventional
Neuroradiology
IN
IN
Carotico-cavernous
IN004 Fistula (CCF)
embolization
Pre-operative tumour
IN005 embolization
(per session)
IN004B
IN005A
Carotid-cavernous
Fistula (CCF)
embolization with
balloon
Pre-operative tumour
embolization
(per session)
64000
40000
76800
48000
83200
52000
92800
58000
A)Clinical notes .
B) CT.
C)MRI.
D) DSA confirming the diagnosis
OPEN
Y
A)Intra procedure clinical
photograph.
B)Detailed discharge summary.
C) Detailed Procedure .
OPEN
D)Operative Notes.
E)Invoices .
F) bar code of embolic agent used.
N
35
Interventional
Neuroradiology
IN
Intracranial balloon
IN006 angioplasty with
stenting
IN006A
Intracranial balloon
angioplasty with stenting
160000
192000
208000
232000
A)Clinical notes .
B) CT.
C)MRI.
D) DSA confirming the diagnosis
A)Intra procedure clinical
photograph.
B)Detailed discharge summary.
C)Detailed Procedure .
D) Operative Notes.
E) Invoices .
F )bar code of balloon.
G)stent
OPEN
N
36
Interventional
Neuroradiology
IN
Intracranial
IN007 thrombolysis / clot
retrieval
IN007A
Intracranial
thrombolysis / clot
retrieval
160000
192000
208000
232000
A)Clinical notes .
B) CT.
C)MRI.
D) DSA confirming the diagnosis
A)Intra procedure clinical
photograph.
B)Detailed discharge summary.
C)Detailed Procedure .
D) Operative Notes.
E) Invoices .
F ) bar code of thrombolytic
agentused.
OPEN
N
37
Interventional
Neuroradiology
IN
IN008 Balloon test occlusion
IN008A
Balloon test occlusion
70000
84000
91000
101500
A)Clinical notes .
B) CT.
C)MRI.
D) DSA confirming the diagnosis
A)Intra procedure clinical
photograph.
B) Detailed discharge summary.
C) Detailed Procedure .
D)Operative Notes.
OPEN
N
38
Interventional
Neuroradiology
IN
IN009
Parent vessel
occlusion - Basic
IN009A
Parent vessel occlusion Basic
30000
36000
39000
43500
A)Clinical notes .
B) CT.
C)MRI.
D) DSA confirming the diagnosis
A)Intra procedure still photograph
showing coil.
B) Detailed Procedure .
C) Operative Notes with
procedure deployed.
OPEN
D) detailed discharge summary.
E) invoice .
F)bar code of coil used
N
39
Interventional
Neuroradiology
IN
IN010 Vertebroplasty
IN010A
Vertebroplasty
40000
48000
52000
58000
A)Clinical notes.
B) CT.
C)MRI confirming the diagnosis.
D) need of procedure.
E) MLC.
F)FIR if traumatic
A)Intra procedure clinical
photograph.
B) Detailed discharge summary.
C)Detailed Procedure.
D) Operative Notes.
E)Invoices of cement used.
OPEN
N
SL NO
Specialty
Specialty
Code
Package
Code
Package Name
Procedure
Code
Procedure Name
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
NABH
Package
Cost
Outside State
NABH
Package Cost
40
Cardiology
MC
MC001
Right / Left Heart
Catheterization
MC001A
Right Heart
Catheterization
8000
9600
10400
11600
41
Cardiology
MC
MC001
Right / Left Heart
Catheterization
MC001B
Left Heart
Catheterization
8000
9600
10400
11600
42
Cardiology
MC
MC002
Catheter directed
Thrombolysis
MC002A
For Deep vein
thrombosis (DVT)
30800
36960
40040
44660
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
A)Discharge summary.
A)Clinical notes with planned line
B) Procedure.
of treatment.
C)Operative Notes.
B)ECG.
OPEN
D)Invoices of catherter .
C)ECHO
E) other accesories used.
Y
A)Discharge summary.
A)Clinical notes with planned line B) Procedure.
C)Operative Notes.
of treatment.
OPEN
D)Invoices of catherter .
B)ECG.
E) other accesories used.
C)ECHO
Y
Mandatory Documents - Pre
Authorization
A)Clinical notes .
B) doppler establishing presence
of DVT
A)Post procedure Colour Doppler
of affected limb/part.
B) invoice of catheter used.
C) invoice of the thrombolytic drug OPEN
(tPA) used.
D)Detailed Discharge Summary.
A)Clinical notes.
B)doppler establishing presence
of mesentric thrombosis
A)Post procedure Colour Doppler
of affected limb/part.
B)invoice of catheter used.
C)invoice of the thrombolytic drug OPEN
(tPA) used.
D)Detailed Discharge Summary.
Y
43
Cardiology
MC
MC002
Catheter directed
Thrombolysis
MC002B
For Mesenteric
Thrombosis
30800
36960
40040
44660
Y
44
45
Cardiology
Cardiology
MC
MC
MC002
Catheter directed
Thrombolysis
MC003 Balloon Dilatation
MC002C For Peripheral vessels
MC003A Coartication of Aorta
30800
38600
36960
46320
40040
50180
44660
55970
A)Clinical notes.
B) doppler establishing presence
of peripheral vessel thrombosis
A)ECHO.
B) CT angiogram report & stills
A)Post procedure Colour Doppler
of affected limb/part.
B)invoice of catheter used.
OPEN
C)invoice of the thrombolytic drug
(tPA) used.
D)Detailed Discharge Summary.
A)Procedure .
B) Operative Notes with images.
C)Post Procedure images .
D)Angiogram.
E)barcode of balloon used.
F)Detailed Discharge Summary
Y
OPEN
Y
46
Cardiology
MC
MC003 Balloon Dilatation
MC003B
Pulmonary Artrey
Stenosis
38600
46320
50180
55970
A)ECHO.
B) CT angiogram report & stills
A)Procedure .
B) Operative Notes with images.
C)Post Procedure images .
D)Angiogram.
E)barcode of balloon used.
F)Detailed Discharge Summary
OPEN
Y
47
Cardiology
MC
MC004
Balloon Pulmonary /
Aortic Valvotomy
MC004A
Balloon Pulmonary
Valvotomy
60000
72000
78000
87000
A)Procedure.
B) Operative notes with still
images.
A)Clinical notes with planned line
C) Post procedure stills of Echo
of treatment .
with report.
B)ECHO report with stills.
D)Invoice of blade .
E) balloon used,.
F)Detailed Discharge Summary .
OPEN
Y
48
Cardiology
MC
MC004
Balloon Pulmonary /
Aortic Valvotomy
MC004B
Balloon Aortic
Valvotomy
23400
28080
30420
33930
A)Procedure.
B) Operative notes with still
images.
A)Clinical notes with planned line
C) Post procedure stills of Echo
of treatment .
with report.
B)ECHO report with stills.
D)Invoice of blade .
E) balloon used,.
F)Detailed Discharge Summary .
OPEN
Y
SL NO
49
50
51
52
53
54
Specialty
Cardiology
Cardiology
Cardiology
Cardiology
Cardiology
Cardiology
Specialty
Code
MC
MC
MC
MC
MC
MC
Package
Code
MC005
MC006
Package Name
Balloon Mitral
Valvotomy
Balloon Atrial
Septostomy
MC007 ASD Device Closure
MC008 VSD Device Closure
MC009 PDA Device Closure
MC010 PDA stenting
Procedure
Code
MC005A
MC006A
Procedure Name
Balloon Mitral
Valvotomy
Balloon Atrial
Septostomy
MC007A ASD Device Closure
MC008A VSD Device Closure
MC009A PDA Device Closure
MC010A PDA stenting
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
60000
24400
75000
75000
33000
50000
72000
29280
90000
90000
39600
60000
NABH
Package
Cost
78000
31720
97500
97500
42900
65000
Outside State
NABH
Package Cost
87000
35380
108750
108750
47850
72500
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
A)Procedure.
B) Operative notes with still
images.
A)Clinical notes with planned line
C) Post procedure stills of Echo
of treatment .
with report.
B)ECHO report with stills.
D)Invoice of blade .
E) balloon used,.
F)Detailed Discharge Summary .
OPEN
A)Procedure.
B) Operative notes with still
images.
C) Post procedure stills of Echo
with report.
D)Invoice of blade .
E) balloon used,.
F)Detailed Discharge Summary .
OPEN
A)Procedure.
B) Operative notes with still
images.
C) Post procedure stills of Echo
with report.
D)Invoice of blade .
E) balloon used,.
F)Detailed Discharge Summary .
OPEN
A)Procedure.
B) Operative notes with still
images.
C) Post procedure stills of Echo
with report.
D)Invoice of blade .
E) balloon used,.
F)Detailed Discharge Summary .
OPEN
A)Procedure.
B) Operative notes with still
images.
C) Post procedure stills of Echo
with report.
D)Invoice of blade .
E) balloon used,.
F)Detailed Discharge Summary .
OPEN
A)Clinical notes.
B)ECHO .
C) doppler stills .
D) reports showing the
transposition of the great arteries
(TGA) & need of septostomy
A)Clinical notes.
B)ECHO report showing ASD
A)Clinical notes.
B) ECHO report showing VSD
A)Clinical notes.
B)ECHO report showing PDA
A)Clinical notes.
B)ECHO report .
C)Angio showing PDA
N
N
N
N
N
A)Procedure .
B)Operative notes with still images.
C)Post procedure stills of ECHO
with report.
D) Invoice of blade .
OPEN
E) barcode of stent used.
F) barcode of the stent used.
G)Detailed Discharge Summary .
N
55
56
Cardiology
Cardiology
MC
MC
MC011
MC012
PTCA, inclusive of
diagnostic angiogram
Electrophysiological
Study
MC011A
MC012A
PTCA, inclusive of
diagnostic angiogram
Electrophysiological
Study
92000
20000
110400
24000
119600
26000
133400
29000
A)ECG.
B)ECHO.
C)CAG stills showing blocks &
Reports
A)Procedure.
B)Operative notes with still images.
C) Angiogram report.
D)showing stent & post Stent flow
OPEN
.
E) barcode of the stents used.
F) Detailed Discharge Summary
A)Clinical notes with planned line
of treatment.
A)Discharge summary.
B) ECG.
B) EP study report
C)ECHO.
D)Serum Elctrolytes
N
OPEN
Y
YES
SL NO
57
Specialty
Cardiology
Specialty
Code
MC
Package
Code
Package Name
Electrophysiological
MC012
Study
Procedure
Code
Procedure Name
Electrophysiological
Study
MC012B
with Radio Frequency
Ablation
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
33000
39600
NABH
Package
Cost
42900
Outside State
NABH
Package Cost
47850
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
A)Clinical notes with planned line
of treatment.
B) ECG.
C)ECHO.
D)Serum Elctrolytes
A)Discharge summary.
B) EP study report.
C)Procedure .
D)Operative Notes
A)Clinical notes.
B)ECG.
C) ECHO.
D) CAG stills showing blaocks
justifying the procedure
A)Angiogram report with stills.
B)showing stent & post Stent flow
.
OPEN
C) barcode .
D) Invoice of the stent used
A)Clinical notes .
B) ECG .
C) Report by cardiologist
necessitating procedure
A)X Ray showing the pacemaker
in situ.
B) detailed discharge summary.
C)Detailed Procedure .
D) Operative Notes.
E) Invoice .
F) barcode of pacemaker
OPEN
Y
58
Cardiology
MC
Percutaneous
MC013 Transluminal Septal
Myocardial Ablation
Percutaneous
MC013A Transluminal Septal
Myocardial Ablation
34000
40800
44200
49300
N
59
60
61
62
Cardiology
Cardiology
Cardiology
Cardiology
MC
MC
MC
MC
Temporary
MC014 Pacemaker
implantation
Single Chamber
MC015 Permanent Pacemaker
Implantation
Double Chamber
MC016 Permanent Pacemaker
Implantation
MC017 Peripheral Angioplasty
Temporary Pacemaker
MC014A
implantation
Permanent Pacemaker
MC015A Implantation Single Chamber
Permanent Pacemaker
MC016A Implantation Double Chamber
MC017A Peripheral Angioplasty
19200
24500
33000
34500
23040
29400
39600
41400
24960
31850
42900
44850
27840
35525
47850
50025
A)Clinical notes.
B) ECG.
C) Report by cardiologist
necessitating procedure.
D) Angiogram if done
A)Clinical notes.
B) ECG.
C) Report by cardiologist
necessitating procedure.
D) Angiogram if done
A)ECHO.
B) Doppler.
C) Angio stills showing blocks &
Reports
A)X Ray showing the pacemaker
in situ.
B) Invoice .
C) Barcode of designated
pacemaker.
D)Detailed Procedure .
E) Operative Notes.
F)detailed discharge summary
A)X Ray showing the pacemaker
in situ.
B) Invoice .
C) Barcode of designated
pacemaker.
D)Detailed Procedure .
E) Operative Notes.
F)detailed discharge summary
A)Post op.
B) Angiogram report.
C)stills.
D) showing stent.
E) Implant .
F) barcode of stent used
OPEN
N
OPEN
N
OPEN
N
OPEN
N
63
Cardiology
MC
Bronchial artery
MC018 Embolisation
(for Haemoptysis)
Bronchial artery
MC018A Embolisation
(for Haemoptysis)
32800
39360
42640
47560
A)Clinical notes.
B) Chest X-Ray.
C) HRCT chest with CT
Pulmonary Angiogram & other
investigations
A)Check Angiography of same
bronchial artery after the
procedure.
B) Detailed discharge summary.
C) Detailed Procedure .
D) Operative Notes.
E) Hb.
F) Serum Creatinine
A)Clinical notes.
B) ECHO report justifying need
of procedure
A)Intra procedure clinical
photograph.
B) post procedure ECHO report.
C) Analysis of fluid removed.
A)Serial ECGs showing MI.
B) Cardiac markers - CPK-MB.
C) TROP I or TROP T
A)ECHO.
B) ECG.
C) Lab Investigation (TROP - T
report).
D) invoice .
E) barcode of thrombolytic agent
used
OPEN
N
64
65
Cardiology
Cardiology
MC
MC
MC019 Pericardiocentesis
MC020
Systemic
Thrombolysis (for MI)
MC019A Pericardiocentesis
MC020A
Systemic Thrombolysis
(for MI)
12100
17900
14520
21480
15730
23270
17545
25955
OPEN
N
OPEN
N
SL NO
66
67
Specialty
General Medicine
General Medicine
Specialty
Code
MG
MG
Package
Code
Package Name
MG001 Acute febrile illness
MG002 Severe sepsis
Procedure
Code
Procedure Name
MG001A Acute febrile illness
MG002A Severe sepsis
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
1800
5000
2160
6000
NABH
Package
Cost
2340
6500
Outside State
NABH
Package Cost
2610
7250
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) Examination findings.
d) Any investigations done.
e) Planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) Examination findings.
d) Any investigations done.
e) Planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
Reserved
OPEN
Y
68
General Medicine
MG
MG002 Severe sepsis
MG002B Septic shock
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) Examination findings.
d) Any investigations done.
e) Planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
OPEN
Y
69
70
General Medicine
General Medicine
MG
MG
MG003 Malaria
MG003 Malaria
MG003A Malaria
MG003B Complicated malaria
2000
1800
2400
2160
2600
2340
2900
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) Examination findings.
d) Any investigations done.
e) Planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) Examination findings.
d) Any investigations done.
e) Planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
Reserved
OPEN
Y
71
General Medicine
MG
MG004 Dengue fever
MG004A Dengue fever
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) Examination findings.
d) Any investigations done.
e) Planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
Referral
Y
72
General Medicine
MG
MG004 Dengue fever
Dengue hemorrhagic
MG004B
fever
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) Examination findings.
d) Any investigations done.
e) Planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
OPEN
Y
SL NO
73
Specialty
General Medicine
Specialty
Code
MG
Package
Code
Package Name
MG004 Dengue fever
Procedure
Code
Procedure Name
MG004C Dengue shock syndrome
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
1800
2160
NABH
Package
Cost
2340
Outside State
NABH
Package Cost
2610
Mandatory Documents - Pre
Authorization
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) Examination findings.
d) Any investigations done.
e) Planned line of management.
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
OPEN
Y
74
General Medicine
MG
MG005 Chikungunya fever
MG005A Chikungunya fever
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) Examination findings.
d) Any investigations done.
e) Planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
OPEN
N
75
76
General Medicine
General Medicine
MG
MG
MG006 Enteric fever
MG007
HIV with
complications
MG006A Enteric fever
MG007A HIV with complications
1800
1800
2160
2160
2340
2340
2610
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) Examination findings.
d) Any investigations done.
e) Planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) Examination findings.
d) Any investigations done.
e) Planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
Reserved
OPEN
N
77
General Medicine
MG
MG008 Leptospirosis
MG008A Leptospirosis
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) Examination findings.
d) Any investigations done.
e) Planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
OPEN
N
78
General Medicine
MG
MG009
Acute gastroenteritis
with dehydration
79
General Medicine
MG
Acute gastroenteritis
MG009
with dehydration
80
General Medicine
MG
MG010 Diarrohea
Acute gastroenteritis
MG009A with moderate
dehydration
1800
2160
2340
2610
Acute gastroenteritis
MG009B
with severe dehydration
1800
2160
2340
2610
MG010A Chronic diarrohea
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) Examination findings.
d) Any investigations done.
e) Planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) Examination findings.
d) Any investigations done.
e) Planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
a) Detailed Discharge Summary.
Clinical notes with planned line of b) Any other investigations done.
treatment.
Reserved
Reserved
Reserved
SL NO
81
82
83
Specialty
General Medicine
General Medicine
General Medicine
Specialty
Code
MG
MG
MG
Package
Code
Package Name
MG010 Diarrohea
MG011 Dysentery
MG012 Acute viral hepatitis
Procedure
Code
Procedure Name
MG010B Persistent diarrohea
MG011A Dysentery
MG012A Acute viral hepatitis
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
1800
1800
1800
2160
2160
2160
NABH
Package
Cost
Outside State
NABH
Package Cost
2340
2610
2340
2340
2610
2610
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Clinical notes with planned line
a) Detailed Discharge Summary.
of treatment.
b) Any other investigations done.
b) Stool examination.
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) Examination findings.
d) Any investigations done.
e) Planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
a) Clinical notes with planned line
of treatment.
b) LFT.
c) USG - Whole Abdomen.
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
a) Clinical notes with planned line
of treatment.
b) LFT.
c) USG - Whole Abdomen.
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
Reserved
Reserved
OPEN
N
84
General Medicine
MG
MG013 Chronic Hepatitis
MG013A Chronic Hepatitis
1800
2160
2340
2610
OPEN
N
85
General Medicine
MG
MG014 Liver abscess
MG014A Liver abscess
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) Examination findings.
d) Any investigations done.
e) Planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
OPEN
N
86
General Medicine
MG
MG015 Visceral leishmaniasis
MG015A Visceral leishmaniasis
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) Examination findings.
d) Any investigations done.
e) Planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
OPEN
N
87
General Medicine
MG
MG016 Pneumonia
MG016A Pneumonia
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) Examination findings.
d) Any investigations done.
e) Planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
OPEN
N
88
89
General Medicine
General Medicine
MG
MG
MG017 Severe pneumonia
MG018 Empyema
MG017A Severe pneumonia
MG018A Empyema
1800
1800
2160
2160
2340
2340
2610
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) Examination findings.
d) Any investigations done.
e) Planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
a) Clinical notes with planned line a) Post Treatment X-ray chest.
of treatment.
b) Detailed Discharge Summary.
b) CBC.
c) X ray chest.
OPEN
N
OPEN
N
SL NO
90
Specialty
General Medicine
Specialty
Code
MG
Package
Code
Package Name
MG019 Lung abscess
Procedure
Code
Procedure Name
MG019A Lung abscess
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
3000
3600
NABH
Package
Cost
3900
Outside State
NABH
Package Cost
4350
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Clinical notes with planned line
of treatment.
b) X-ray chest.
a) Post Treatment X-ray chest.
c) CBC.
b) Detailed Discharge Summary.
d) Any other investigations done.
e) Planned line of management.
OPEN
N
91
92
General Medicine
General Medicine
MG
MG
MG020
MG020
Pericardial / Pleural
tuberculosis
Pericardial / Pleural
tuberculosis
MG020A Pericardial tuberculosis
MG020B Pleural tuberculosis
1800
1800
2160
2160
2340
2340
2610
2610
a) Clinical notes detailing history.
a) Detailed ICPs.
b) Admission notes showing vitals.
b) Treatment details.
c) Examination findings.
c) Detailed discharge summary.
d) Investigations done.
d) All investigations reports.
a) Clinical notes detailing history.
a) Detailed ICPs.
b) Admission notes showing vitals.
b) Treatment details.
c) Examination findings.
c) Detailed discharge summary.
d) Investigations done.
d) All investigations reports.
Reserved
Referral
Y
93
94
General Medicine
General Medicine
MG
MG
MG021 Urinary Tract Infection MG021A Urinary Tract Infection
MG022 Viral encephalitis
MG022A Viral encephalitis
1800
1800
2160
2160
2340
2340
2610
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) Examination findings.
d) Any investigations done.
e) Planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) Examination findings.
d) Any investigations done.
e) Planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
a) Clinical notes with planned line
of treatment.
b) CBC.
c) X-ray of the affected joint.
a) Post treatment X-ray.
b) Radiological evidence.
c) CBC.
d) Detailed Discharge Summary.
Reserved
OPEN
N
95
General Medicine
MG
MG023 Septic Arthritis
MG023A Septic Arthritis
1800
2160
2340
2610
Referral
N
96
97
General Medicine
General Medicine
MG
MG
MG024
Skin and soft tissue
infections
Recurrent vomiting
MG025
with dehydration
MG024A
Skin and soft tissue
infections
Recurrent vomiting
MG025A
with dehydration
1800
1800
2160
2160
2340
2340
2610
2610
a) Detailed ICPs.
a) Clinical notes with planned line b) Treatment details.
of treatment.
c) Detailed discharge summary.
b) CBC.
d) All investigations reports
including CBC.
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) Examination findings.
d) Any investigations done.
e) Planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
Reserved
OPEN
N
SL NO
98
99
Specialty
General Medicine
General Medicine
Specialty
Code
MG
MG
Package
Code
Package Name
Pyrexia of unknown
MG026
origin
MG027 Bronchiectasis
Procedure
Code
Procedure Name
Pyrexia of unknown
MG026A
origin
MG027A Bronchiectasis
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
1800
3000
2160
3600
NABH
Package
Cost
2340
3900
Outside State
NABH
Package Cost
2610
4350
Mandatory Documents - Pre
Authorization
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) Examination findings.
d) Any investigations done.
e) Planned line of management.
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
a) X ray-Chest.
a) Post treatment X-ray.
b) Clinical notes with planned line b) Radiological evidence.
of treatment.
c) Detailed Discharge Summary.
d) Detailed ICPs.
e) Treatment details.
f) All investigations reports.
OPEN
OPEN
N
100
101
General Medicine
General Medicine
MG
MG
MG028 Acute bronchitis
MG029
Acute excaberation of
COPD
MG028A Acute bronchitis
MG029A
Acute excaberation of
COPD
1800
1800
2160
2160
2340
2340
2610
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) Examination findings.
d) Any investigations done.
e) Planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) Examination findings.
d) Any investigations done.
e) Planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
Reserved
OPEN
N
102
General Medicine
MG
Acute excaberation of
MG030 Interstitial Lung
Disease
Acute excaberation of
MG030A
Interstitial Lung Disease
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) Examination findings.
d) Any investigations done.
e) Planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
OPEN
N
103
General Medicine
MG
MG031 Endocarditis
MG031A Bacterial Endocarditis
1800
2160
2340
a) Clinical notes with planned line
of treatment.
b) ECHO.
c) CBC.
a) Blood culture reports.
b) Post treatment ECHO.
c) Detailed Discharge Summary.
d) Detailed ICPs.
e) Treatment details.
f) All investigations reports.
a) Clinical notes with planned line
of treatment.
b) ECHO.
c) CBC.
a) Blood culture reports.
b) Post treatment ECHO.
c) Detailed Discharge Summary.
d) Detailed ICPs.
e) Treatment details.
f) All investigations reports.
2610
OPEN
Y
104
General Medicine
MG
MG031 Endocarditis
MG031B Fungal Endocarditis
1800
2160
2340
2610
OPEN
Y
SL NO
105
106
107
108
109
Specialty
General Medicine
General Medicine
General Medicine
General Medicine
General Medicine
Specialty
Code
MG
MG
MG
MG
MG
Package
Code
Package Name
MG032 Vasculitis
MG033 Pancreatitis
MG033 Pancreatitis
MG034 Ascites
Acute transverse
MG035
myelitis
Procedure
Code
Procedure Name
MG032A Vasculitis
MG033A Acute pancreatitis
MG033B Chronic pancreatitis
MG034A Ascites
Acute transverse
MG035A
myelitis
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
1800
5000
5000
1800
1800
2160
6000
6000
2160
2160
NABH
Package
Cost
2340
6500
6500
2340
2340
Outside State
NABH
Package Cost
2610
7250
7250
2610
2610
Mandatory Documents - Pre
Authorization
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) Examination findings.
d) Any investigations done.
e) Planned line of management.
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
OPEN
N
a) Cliical notes.
b) Sr Amylase.
c) Lipase.
d) LFT.
e) CBC.
f) USG- abdomen.
a) Post treatment Sr Amylase.
b) Lipase.
c) LFT.
d) USG- abdomen Detailed
Discharge Summary.
a) Cliical notes.
b) Sr Amylase.
c) Lipase.
d) LFT.
e) CBC.
f) USG- abdomen.
a) Post treatment Sr Amylase.
b) Lipase.
c) LFT.
d) USG- abdomen Detailed
Discharge Summary.
a) Clinial notes.
b) LFT.
c) CBC.
d) USG- abdomen.
a) Ascitic Fluid Analysis.
b) Culture Report.
c) Detailed Discharge Summary.
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) Examination findings.
d) Any investigations done.
e) Planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
OPEN
Y
OPEN
Y
OPEN
OPEN
N
110
General Medicine
MG
MG036 Atrial Fibrillation
MG036A Atrial Fibrillation
1800
2160
2340
2610
a) Post treatment ECG.
a) Clinical notes with planned line
b) Detailed Discharge Summary.
of treatment.
c) Detailed ICPs.
b) ECG.
d) Treatment details.
c) Sr Electrolytes.
e) All investigations reports.
OPEN
N
111
General Medicine
MG
MG037 Cardiac Tamponade
MG037A Cardiac Tamponade
1800
2160
2340
2610
a) Clincal notes.
b) 2D echo.
a) Post treatment 2D echo.
b) Fluid Aspirated report.
c) Procedure notes.
d) Detailed Discharge Summary.
OPEN
N
112
General Medicine
MG
Congestive heart
MG038
failure
MG038A Congestive heart failure
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) Examination findings.
d) Any investigations done.
e) Planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
OPEN
N
113
General Medicine
MG
MG039 Asthma
MG039A Acute asthmatic attack
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) Examination findings.
d) Any investigations done.
e) Planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
OPEN
Y
SL NO
114
Specialty
General Medicine
Specialty
Code
MG
Package
Code
Package Name
MG039 Asthma
Procedure
Code
Procedure Name
MG039B Status asthmaticus
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
1800
2160
NABH
Package
Cost
2340
Outside State
NABH
Package Cost
2610
Mandatory Documents - Pre
Authorization
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) Examination findings.
d) Any investigations done.
e) Planned line of management.
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
Referral
Y
115
General Medicine
MG
MG040 Respiratory failure
Type 1 respiratory
MG040A
failure
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) Examination findings.
d) Any investigations done.
e) Planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
OPEN
Y
116
General Medicine
MG
MG040 Respiratory failure
Type 2 respiratory
MG040B
failure
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) Examination findings.
d) Any investigations done.
e) Planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
OPEN
Y
117
General Medicine
MG
MG040 Respiratory failure
Due to any cause
(pneumonia, asthma,
MG040C COPD, ARDS, foreign
body, poisoning, head
injury etc.)
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) Examination findings.
d) Any investigations done.
e) Planned line of management.
f) Copy of MLC.
g) FIR (if required).
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
OPEN
Y
118
General Medicine
MG
MG041 Upper GI bleeding
Upper GI bleeding
MG041A
(conservative)
3000
3600
3900
4350
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) Examination findings.
d) Any investigations done.
e) Planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
OPEN
Y
119
General Medicine
MG
MG041 Upper GI bleeding
Upper GI bleeding
MG041B
(endoscopic)
3000
3600
3900
4350
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) Examination findings.
d) Any investigations done.
e) Planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
OPEN
Y
120
General Medicine
MG
MG042 Lower GI hemorrhage
MG042A Lower GI hemorrhage
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) Examination findings.
d) Any investigations done.
e) Planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
OPEN
N
121
General Medicine
MG
MG043 Addison’s disease
MG043A Addison’s disease
1800
2160
2340
2610
a) Clincal notes.
b) Sr. Cortisol levels.
c) USG- abdomen.
a) Post treatment cortisol levels.
b) Detailed Discharge Summary.
OPEN
N
SL NO
122
123
Specialty
General Medicine
General Medicine
Specialty
Code
MG
MG
Package
Code
Package Name
MG044 Renal colic
MG045 AKI / Renal failure
Procedure
Code
Procedure Name
MG044A Renal colic
MG045A AKI / Renal failure
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
1800
3000
2160
3600
NABH
Package
Cost
2340
3900
Outside State
NABH
Package Cost
2610
4350
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) Examination findings.
d) Any investigations done.
e) Planned line of management
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) Examination findings.
d) Any investigations done.
e) Planned line of management
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
Reserved
OPEN
N
124
General Medicine
MG
MG046 Seizures
MG046A Seizures
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) Examination findings.
d) Any investigations done.
e) Planned line of management
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
OPEN
N
125
General Medicine
MG
MG047 Status epilepticus
MG047A Status epilepticus
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) Examination findings.
d) Any investigations done.
e) Planned line of management
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
OPEN
N
126
General Medicine
MG
Cerebrovascular
MG048
accident
Cerebrovascular
MG048A
accident
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) Examination findings.
d) Any investigations done.
e) Planned line of management
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
OPEN
N
127
General Medicine
MG
Cerebral sino-venous
MG049
thrombosis / Stroke
Cerebral sino-venous
MG049A
thrombosis
5000
6000
6500
7250
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) Examination findings.
d) Any investigations done.
e) Planned line of management
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
OPEN
Y
128
General Medicine
MG
Cerebral sino-venous
MG049
thrombosis / Stroke
MG049B Acute stroke
5000
6000
6500
7250
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) Examination findings.
d) Any investigations done.
e) Planned line of management
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
OPEN
Y
129
General Medicine
MG
Cerebral sino-venous
MG049
thrombosis / Stroke
MG049C Acute ischemic stroke
5000
6000
6500
7250
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) Examination findings.
d) Any investigations done.
e) Planned line of management
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
OPEN
Y
SL NO
130
Specialty
General Medicine
Specialty
Code
MG
Package
Code
Package Name
Cerebral sino-venous
MG049
thrombosis / Stroke
Procedure
Code
Procedure Name
Acute heamorrhagic
MG049D
stroke
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
5000
6000
NABH
Package
Cost
6500
Outside State
NABH
Package Cost
7250
Mandatory Documents - Pre
Authorization
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) Examination findings.
d) Any investigations done.
e) Planned line of management
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
OPEN
Y
131
General Medicine
MG
Immune mediated
MG050
CNS disorders
Immune mediated CNS
MG050A
disorders
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) Examination findings.
d) Any investigations done.
e) Planned line of management
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
OPEN
N
132
133
General Medicine
General Medicine
MG
MG
MG051 Hydrocephalus
MG052 Myxedema coma
MG051A Hydrocephalus
MG052A Myxedema coma
1800
1800
2160
2160
2340
2340
2610
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) Examination findings.
d) Any investigations done.
e) Planned line of management
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
a) Clinical notes with planned line
a) Post treatment Thyroid Profile.
of treatment.
b) Detailed Discharge Summary.
b) Throid profile.
c) USG- Thyroid Gland.
OPEN
N
OPEN
N
134
General Medicine
MG
MG053 Thyrotoxic crisis
MG053A Thyrotoxic crisis
1800
2160
2340
2610
a) Clinical notes with planned line
of treatment.
b) Throid profile.
c) USG- Thyroid Gland.
a) Radionuclide Iodine uptake
study.
b) Post treatment Thyroid Profile.
c) Detailed Discharge Summary.
OPEN
N
135
136
137
General Medicine
General Medicine
General Medicine
MG
MG
MG
MG054 Gout
MG055 Pneumothroax
Neuromuscular
MG056
disorders
MG054A Gout
MG055A Pneumothroax
Neuromuscular
MG056A
disorders
1800
1800
1800
2160
2160
2160
2340
2340
2340
2610
2610
2610
a) Clinical notes with planned line
of treatment.
Detailed Discharge Summary.
b) Sr.Uric acid.
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) Examination findings.
d) Any investigations done.
e) Planned line of management
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) Examination findings.
d) Any investigations done.
e) Planned line of management
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
Reserved
Reserved
OPEN
N
138
General Medicine
MG
MG057 Hypoglycemia
MG057A Hypoglycemia
1800
2160
2340
2610
a) Clincal notes.
b) Blood sugar level.
a) Post treatment Blood sugar
levels.
b) Hba1C.
c) Detailed Discharge Summary.
OPEN
N
SL NO
139
Specialty
General Medicine
Specialty
Code
MG
Package
Code
Package Name
MG058 Diabetic Foot
Procedure
Code
Procedure Name
MG058A Diabetic Foot
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
3000
3600
NABH
Package
Cost
3900
Outside State
NABH
Package Cost
4350
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Post treatment Blood sugar
a) Clincal profile.
levels.
b) Blood sugar level.
b) Hba1C.
c) CBC.
c) Photograph of the affected foot. OPEN
d) Photograph of the affected foot.
d) Detailed Discharge Summary.
N
140
General Medicine
MG
MG059 Diabetic ketoacidosis
MG059A Diabetic ketoacidosis
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) Examination findings.
d) Any investigations done.
e) Planned line of management
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
OPEN
N
141
General Medicine
MG
MG060 Electrolyte Imbalance
MG060A Hypercalcemia
3000
3600
3900
4350
a) Post treatment Serum Calcium.
a) Clinical notes with planned line b) Detailed Discharge Summary.
of treatment.
c) Detailed ICPs.
b) Serum Calcium.
d) Treatment details.
e) All investigations reports.
OPEN
Y
142
General Medicine
MG
MG060 Electrolyte Imbalance
MG060B Hypocalcemia
3000
3600
3900
4350
a) Post treatment Serum Calcium.
a) Clinical notes with planned line b) Detailed Discharge Summary.
of treatment.
c) Detailed ICPs.
b) Serum Calcium.
d) Treatment details.
e) All investigations reports.
OPEN
Y
143
General Medicine
MG
MG060 Electrolyte Imbalance
MG060C Hyponatremia
3000
3600
3900
4350
a) Post treatment Serum
Electrolytes.
a) Clinical notes with planned line b) Detailed Discharge Summary.
of treatment.
c) Detailed ICPs.
b) Serum Electrolytes.
d) Treatment details.
e) All investigations reports.
OPEN
Y
144
General Medicine
MG
MG060 Electrolyte Imbalance
MG060D Hypernatremia
3000
3600
3900
4350
a) Post treatment Serum
Electrolytes.
a) Clinical notes with planned line b) Detailed Discharge Summary.
of treatment.
c) Detailed ICPs.
b) Serum Electrolytes.
d) Treatment details.
e) All investigations reports.
OPEN
Y
145
General Medicine
MG
MG061
Hyperosmolar NonKetotic coma
MG061A
Hyperosmolar NonKetotic coma
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
Detailed ICPs, Treatment details,
c) Examination findings.
detailed discharge summary, All
d) Any investigations done.
investigations reports.
e) Planned line of management
OPEN
N
146
General Medicine
MG
MG062
Accelerated
hypertension
MG062A
Accelerated
hypertension
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
Detailed ICPs, Treatment details,
c) Examination findings.
detailed discharge summary, All
d) Any investigations done.
investigations reports.
e) Planned line of management
OPEN
N
SL NO
147
Specialty
General Medicine
Specialty
Code
MG
Package
Code
MG063
Package Name
Hypertensive
emergencies
Procedure
Code
MG063A
Procedure Name
Hypertensive
emergencies
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
1800
2160
NABH
Package
Cost
2340
Outside State
NABH
Package Cost
2610
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Clinical notes detailing history.
b) Admission notes showing vitals.
Detailed ICPs, Treatment details,
c) Examination findings.
detailed discharge summary, All
d) Any investigations done.
investigations reports.
e) Planned line of management
OPEN
N
148
General Medicine
MG
MG064 Severe anemia
MG064A Severe anemia
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) Examination findings.
d) Any investigations done.
e) Planned line of management
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
OPEN
N
149
150
General Medicine
General Medicine
MG
MG
MG065 Sickle cell Anemia
MG066 Anaphylaxis
MG065A Sickle cell Anemia
MG066A Anaphylaxis
1800
1800
2160
2160
2340
2340
2610
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) Examination findings.
d) Any investigations done.
e) Planned line of management
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
a) Clinical notes with planned line a) Detailed ICPs.
b) Treatment details.
of treatment.
c) Detailed discharge summary.
b) CBC.
d) All investigations reports.
Reserved
OPEN
N
151
152
153
General Medicine
General Medicine
General Medicine
MG
MG
MG
MG067 Heat stroke
Systematic lupus
MG068
erythematosus
MG069
Guillian Barre
Syndrome
MG067A Heat stroke
Systematic lupus
MG068A
erythematosus
MG069A
Guillian Barre
Syndrome
1800
1800
1800
2160
2160
2160
2340
2340
2340
2610
2610
2610
a) Clinical notes detailing history
leading to this hospitalization.
b) Admission notes showing vitals.
c) Examination findings.
d) Any investigations done.
e) Planned line of management.
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) Examination findings.
d) Any investigations done.
e) Planned line of management
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
a) Clinical notes.
b) Admission notes detailed the
need for High end histopathology
(Biopsies).
Report of test blocked.
c) Advanced serology
investigations.
Reserved
OPEN
N
OPEN
N
154
General Medicine
MG
MG070 Snake bite
MG070A Snake bite
1800
2160
2340
2610
a) Clinical notes detailing history
leading to this hospitalization.
b) Admission notes showing vitals.
c) Examination findings.
d) Any investigations done.
e) Planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
OPEN
N
SL NO
155
Specialty
General Medicine
Specialty
Code
MG
Package
Code
Package Name
MG071 Poisoning
Procedure
Code
Procedure Name
Acute
MG071A organophosphorus
poisoning
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
1800
2160
NABH
Package
Cost
2340
Outside State
NABH
Package Cost
2610
Mandatory Documents - Pre
Authorization
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) Neurological examination
findings
d) Any investigations done.
e) Planned line of management.
f) Copy of MLC.
g) FIR.
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
OPEN
Y
156
General Medicine
MG
MG071 Poisoning
MG071B Other poisonings
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) Neurological examination
findings
d) Any investigations done.
e) Planned line of management.
f) Copy of MLC.
g) FIR.
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
OPEN
Y
157
General Medicine
MG
Haemodialysis /
MG072
Peritoneal Dialysis
MG072A Haemodialysis Dialysis
1500
1800
1950
2175
a) Clinical notes detailing history
leading to this hospitalization.
b) Admission notes showing vitals.
c) Examination findings.
d) Any investigations done.
e) Planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
OPEN
Y
158
General Medicine
MG
MG072
Haemodialysis /
Peritoneal Dialysis
MG072B Peritoneal Dialysis
1500
1800
1950
2175
a) Detailed ICPs.
a) Clinical notes detailing history b) Treatment details.
c) Detailed discharge summary.
leading to this hospitalization.
b) Admission notes showing vitals. d) All investigations reports.
c) Examination findings.
d) Any investigations done.
e) Planned line of management.
OPEN
Y
159
160
161
General Medicine
General Medicine
General Medicine
MG
MG
MG
MG073 Plasmapheresis
MG074 Blood transfusion
MG074 Blood transfusion
MG073A Plasmapheresis
MG074A
MG074B
Whole Blood
transfusion
Blood component
including platelet
transfusion (RDP, PC,
SDP)
2000
2000
2000
2400
2400
2400
2600
2600
2600
2900
2900
2900
a) Detailed ICPs.
a) Clinical notes detailing history b) Treatment details.
c) Detailed discharge summary.
leading to this hospitalization.
b) Admission notes showing vitals. d) All investigations reports.
c) Examination findings.
d) Any investigations done.
e) Planned line of management.
OPEN
N
a) Clinical notes with planned line
of treatment.
b) Complete Hemogram, Blood
Group.
c) Planned line of treatment.
a) Detailed ICPs.
b) Post treatment Complete
hemogram.
c) Detailed Discharge Summary.
a) Clinical notes with planned line
of treatment.
b) Complete Hemogram, Blood
Group.
c) Planned line of treatment.
a) Detailed ICPs.
b) Post treatment Complete
hemogram.
c) Detailed Discharge Summary.
OPEN
Y
OPEN
Y
SL NO
162
Specialty
General Medicine
Specialty
Code
MG
Package
Code
Package Name
High end radiological
diagnostic
MG075 (CT, MRI, Imaging
including nuclear
imaging)
Procedure
Code
Procedure Name
High end radiological
diagnostic
MG075A (CT, MRI, Imaging
including nuclear
imaging)
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
5000
6000
NABH
Package
Cost
6500
Outside State
NABH
Package Cost
7250
Mandatory Documents - Pre
Authorization
a) Clinical notes detailing history
leading to this hospitalization.
b) Admission notes showing vitals.
c) Examination findings.
d) Any investigations done.
e) Planned line of management.
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
OPEN
N
163
General Medicine
MG
High end radiological
diagnostic
MG075 (CT, MRI, Imaging
including nuclear
imaging)
MG075B
FDG Whole body PET
Scan
18475
22170
24017
26788
A) Clinical notes
B) detailing history
C) Admission notes showing vitals
D) examination findings
E) any investigations done
F) planned line of management
19135
A) Clinical notes
B) detailing history
C) Admission notes showing vitals
D) examination findings
E) any investigations done
F) planned line of management
19575
A) Clinical notes
B) detailing history
C) Admission notes showing vitals
D) examination findings
E) any investigations done
F) planned line of management
A) Detailed ICPs
B) Treatment details
C) detailed discharge summary
D) All investigations reports.
OPEN
Y
164
General Medicine
MG
High end radiological
diagnostic
MG075 (CT, MRI, Imaging
including nuclear
imaging)
MG075C
Brain & Heart FDG
PET Scan
13197
15836
17156
A) Detailed ICPs
B) Treatment details
C) detailed discharge summary
D) All investigations reports.
OPEN
Y
165
General Medicine
MG
High end radiological
diagnostic
MG075 (CT, MRI, Imaging
including nuclear
imaging)
Gallium-68 Peptide
MG075D PET imaging for
Neuroendocrine Tumor
13500
16200
17550
A) Detailed ICPs
B) Treatment details
C) detailed discharge summary
D) All investigations reports.
OPEN
N
166
General Medicine
MG
High end
histopathology
MG076 (Biopsies) and
advanced serology
investigations
High end
histopathology
MG076A (Biopsies) and
advanced serology
investigations
5000
6000
6500
7250
a) Clinical notes detailing history
leading to this hospitalization.
b) Admission notes showing vitals.
c) Examination findings.
d) Any investigations done.
e) Planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) Detailed discharge summary.
d) All investigations reports.
OPEN
N
167
Mental Disorders
MM
MM001 Mental Retardation
MM001A Mental Retardation
1500
1800
1950
2175
A)Detailed history with chronicity.
A)Detailed treatment notes.
B) need for hospitalization.
B) all investigations done.
C) Admission under empanneled
C)detailed discharge summary.
Psychiatrist is a must.
OPEN
N
168
Mental Disorders
MM
Mental disorders MM002 Organic, including
symptomatic
Mental disorders MM002A Organic, including
symptomatic
1500
1800
1950
2175
A)Detailed history with chronicity.
A)Detailed treatment notes.
B) need for hospitalization.
B) all investigations done.
C) Admission under empanneled
C)detailed discharge summary.
Psychiatrist is a must.
OPEN
N
169
Mental Disorders
MM
Schizophrenia,
MM003 schizotypal and
delusional disorders
Schizophrenia,
MM003A schizotypal and
delusional disorders
1500
1800
1950
2175
A)Detailed history with chronicity.
A)Detailed treatment notes.
B) need for hospitalization.
B) all investigations done.
C) Admission under empanneled
C)detailed discharge summary.
Psychiatrist is a must.
OPEN
N
170
Mental Disorders
MM
Neurotic, stressMM004 related and
somatoform disorders
Neurotic, stress-related
MM004A and somatoform
disorders
1500
1800
1950
2175
A)Detailed history with chronicity.
A)Detailed treatment notes.
B) need for hospitalization.
B) all investigations done.
C) Admission under empanneled
C)detailed discharge summary.
Psychiatrist is a must.
OPEN
N
SL NO
171
Specialty
Mental Disorders
Specialty
Code
MM
Package
Code
Package Name
Mood (affective)
MM005
disorders
Procedure
Code
Procedure Name
Mood (affective)
MM005A
disorders
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
1500
1800
NABH
Package
Cost
1950
Outside State
NABH
Package Cost
2175
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
A)Detailed history with chronicity.
A)Detailed treatment notes.
B) need for hospitalization.
B) all investigations done.
C) Admission under empanneled
C)detailed discharge summary.
Psychiatrist is a must.
OPEN
N
172
173
174
175
Mental Disorders
Mental Disorders
Mental Disorders
Mental Disorders
MM
Behavioural
syndromes associated
MM006 with physiological
disturbances and
physical factors
Mental and
Behavioural disorders
due to psychoactive
substance use
Behavioural syndromes
associated with
MM006A physiological
disturbances and
physical factors
Mental and Behavioural
disorders due to
psychoactive substance
use
1500
MM007
MM
Pre - Electro
Pre - Electro
Convulsive Therapy
Convulsive Therapy
(ECT) and Pre (ECT) and Pre Transcranial Magnetic
Transcranial Magnetic
Stimulation (TMS)
Stimulation (TMS)
Package (Cognitive
Package (Cognitive
Tests, Complete
Tests, Complete
Haemogram, Liver
Haemogram, Liver
Function Test, Renal
Function Test, Renal
Function Test, Serum
Function Test, Serum
MM008A
MM008
Electrolytes, Electro
Electrolytes, Electro
Cardiogram (ECG),
Cardiogram (ECG), CT
CT / MRI Brain,
/ MRI Brain,
Electroencephalogram,
Electroencephalogram,
Thyroid Function
Thyroid Function Test,
Test, VDRL, HIV
VDRL, HIV Test,
Test, Vitamin B12
Vitamin B12 levels,
levels, Folate levels,
Folate levels, Lipid
Lipid Profile,
Profile, Homocysteine
Homocysteine levels)
levels)
10000
Electro Convulsive
MM009 Therapy (ECT) - per
session
3000
MM
Electro Convulsive
MM009A Therapy (ECT) - per
session
1950
2175
OPEN
N
MM
MM007A
1800
A)Detailed history with chronicity.
A)Detailed treatment notes.
B) need for hospitalization.
B) all investigations done.
C) Admission under empanneled
C)detailed discharge summary.
Psychiatrist is a must.
1500
1800
1950
2175
A)Detailed history of
psychoactive substanec with
chronicity.
B) need for hospitalization.
C) Admission under empanneled
Psychiatrist is a must.
A)Detailed treatment notes.
B) all investigations done.
C)detailed discharge summary.
OPEN
N
12000
13000
14500
A)Detailed history with chronicity.
B) need for specific treatment.
A)Detailed treatment notes.
C)expected results.
B) all investigations done.
D) Admission under empanneled C)detailed discharge summary.
Psychiatrist is a must
OPEN
N
3600
3900
4350
A)Detailed history with chronicity.
B) need for specific treatment.
A)Detailed treatment notes.
C)expected results.
B) all investigations done.
D) Admission under empanneled C)detailed discharge summary.
Psychiatrist is a must
OPEN
N
176
Mental Disorders
MM
Transcranial Magnetic
MM010 Stimulation (TMS) per session
Transcranial Magnetic
MM010A Stimulation (TMS) per session
1000
1200
1300
1450
A)Detailed history with chronicity.
B) need for specific treatment.
A)Detailed treatment notes.
C)expected results.
B) all investigations done.
D) Admission under empanneled C)detailed discharge summary.
Psychiatrist is a must
OPEN
N
SL NO
177
178
Specialty
Neo - natal Care
Neo - natal Care
Specialty
Code
MN
MN
Package
Code
Package Name
Basic neonatal care
package: Babies that
can be managed by
side of mother in
postnatal ward
without requiring
admission in
SNCU/NICU:
• Any newborn
needing feeding
support
MN001
• Babies requiring
closer monitoring or
short-term care for
conditions like:
o Birth asphyxia (need
for positive pressure
ventilation; no HIE)
o Moderate jaundice
requiring phototherapy
o Large for dates (>97
percentile) Babies
Special Neonatal Care
Package: Babies that
required admission to
SNCU or NICU:
Babies admitted for
short term care for
conditions like:
• Mild Respiratory
Distress/tachypnea
• Mild encephalopathy
• Severe jaundice
requiring intensive
MN002 phototherapy
• Haemorrhagic
disease of newborn
• Unwell baby
requiring monitoring
• Some dehydration
• Hypoglycaemia
Mother's stay and
food in the hospital
for breastfeeding,
family centred care
and (Kangaroo
Procedure
Code
Procedure Name
Basic neonatal care
package: Babies that
can be managed by side
of mother in postnatal
ward without requiring
admission in
SNCU/NICU:
• Any newborn needing
feeding support
• Babies requiring
closer monitoring or
MN001A
short-term care for
conditions like:
o Birth asphyxia (need
for positive pressure
ventilation; no HIE)
o Moderate jaundice
requiring phototherapy
o Large for dates (>97
percentile) Babies
o Small for gestational
age (less than 3rd
Special Neonatal Care
Package: Babies that
required admission to
SNCU or NICU:
Babies admitted for
short term care for
conditions like:
• Mild Respiratory
Distress/tachypnea
• Mild encephalopathy
• Severe jaundice
requiring intensive
MN002A phototherapy
• Haemorrhagic disease
of newborn
• Unwell baby requiring
monitoring
• Some dehydration
• Hypoglycaemia
Mother's stay and food
in the hospital for
breastfeeding, family
centred care and
(Kangaroo Mother
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
500
600
NABH
Package
Cost
650
Outside State
NABH
Package Cost
725
Mandatory Documents - Pre
Authorization
a) Detailed clinical notes (incl
trigger for hospitalization and
examiantion findings).
b) Supporting investigations.
c) Admission under neonatologist
in NICU (in major locations).
d) Under Pediatrician in smaller
locations is a must.
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Detailed ICPs (daily Treatment
details).
b) Detailed discharge summary.
OPEN
c) All investigations reports.
N
3000
3600
3900
4350
a) Clinical notes with planned line
of treatment (incl birth & past
history).
b) Investigation Reports
supporting diagnosis.
c) Planned line of treatment.
a) Detailed ICPs (daily Treatment
details).
b) Procedure.
c) Operative Notes (if applicable).
OPEN
d) Detailed Discharge Summary.
e) All investigations reports.
N
SL NO
Specialty
Specialty
Code
Package
Code
Package Name
Intensive Neonatal
Care Package
Babies with
birthweight 1500-1799
g
Procedure
Code
Procedure Name
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
NABH
Package
Cost
Outside State
NABH
Package Cost
179
Neo - natal Care
MN
• Need for mechanical
ventilation for less
than 24 hours or noninvasive respiratory
support (CPAP,
HFFNC)
Advanced Neonatal
Care Package:
Babies with
birthweight of 12001499 g
180
Neo - natal Care
MN
or
Babies of any
MN004 birthweight with at
least one of the
following conditions:
• Any condition
requiring invasive
ventilation longer than
24 hours
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
Intensive Neonatal Care
Package
Babies with birthweight
1500-1799 g
or
or
Babies of any
MN003 birthweight and at
least one of the
following conditions:
Mandatory Documents - Pre
Authorization
Babies of any
birthweight and at least
MN003A one of the following
conditions:
5000
6000
6500
7250
a) Detailed clinical notes (incl
trigger for hospitalization and
examiantion findings).
b) Supporting investigations.
c) Admission under neonatologist
in NICU (in major locations).
d) Under Pediatrician in smaller
locations is a must.
a) Detailed ICPs (daily Treatment
details).
b) Detailed discharge summary.
OPEN
c) All investigations reports.
• Need for mechanical
ventilation for less than
24 hours or noninvasive respiratory
support (CPAP,
HFFNC)
N
Advanced Neonatal
Care Package:
Babies with birthweight
of 1200-1499 g
or
Babies of any
birthweight with at least
MN004A one of the following
conditions:
• Any condition
requiring invasive
ventilation longer than
24 hours
6000
7200
7800
8700
a) Detailed clinical notes (incl
trigger for hospitalization and
examiantion findings).
b) Supporting investigations.
c) Admission under neonatologist
in NICU (in major locations).
d) Under Pediatrician in smaller
locations is a must.
a) Detailed ICPs (daily Treatment
details).
b) Detailed discharge summary.
OPEN
c) All investigations reports.
N
SL NO
Specialty
Specialty
Code
Package
Code
Procedure
Code
Package Name
Critical Care Neonatal
Package:
Babies with
birthweight of <1200
g
or
181
182
183
Neo - natal Care
Neo - natal Care
Neo - natal Care
MN
MN
Babies of any
birthweight with at
MN005 least one of the
following conditions:
• Severe Respiratory
Failure requiring High
Frequency Ventilation
or inhaled Nitric Oxide
(iNO)
• Multisystem failure
requiring multiple
organ support
Chronic Care
Package: If the baby
requires stay beyond
the upper limit of
usual stay in Package
no MN004A or
MN006 MN005A for
conditions like severe
BPD requiring
respiratory support,
severe NEC requiring
prolonged TPN
support
Procedure Name
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
NABH
Package
Cost
Outside State
NABH
Package Cost
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
Critical Care Neonatal
Package:
Babies with birthweight
of <1200 g
or
Babies of any
birthweight with at least
one of the following
MN005A conditions:
7000
8400
9100
10150
a) Detailed clinical notes (incl
trigger for hospitalization and
examiantion findings).
b) Supporting investigations.
c) Admission under neonatologist
in NICU (in major locations).
d) Under Pediatrician in smaller
locations is a must.
a) Detailed ICPs (daily Treatment
details).
b) Detailed discharge summary.
OPEN
c) All investigations reports.
• Severe Respiratory
Failure requiring High
Frequency Ventilation
or inhaled Nitric Oxide
(iNO)
• Multisystem failure
requiring multiple organ
support including
mechanical ventilation
Chronic Care Package:
If the baby requires
stay beyond the upper
limit of usual stay in
Package no MN004A
MN006A or MN005A for
conditions like severe
BPD requiring
respiratory support,
severe NEC requiring
prolonged TPN support
N
3000
3600
3900
4350
a) Claim number of having utilized
Package no MN004A or
MN005A.
b) Notes mentioning need for stay
beyond prescribed upper limit.
a) Detailed ICPs (daily Treatment
details).
b) Detailed discharge summary.
OPEN
c) All investigations reports.
a) Need of planned care.
b) Details of planned post
discharge care.
a) Detailed ICP with daily notes.
b) Vitals.
c) Drugs given.
d) Investigation reports Card with
pre.
e) Post admission general
conditions.
OPEN
f) Vital parameters.
g) Details of procedures.
h) Operations required for any
congenital heart conditions if any.
N
MN
High Risk Newborn
Post Discharge Care
MN007
Package (Protocol
Driven)
High Risk Newborn
Post Discharge Care
MN007A
Package
(Protocol Driven)
MN
Laser Therapy for
Retinopathy of
Prematurity
MN008
(Irrespective of no. of
eyes affected) - per
session
Laser Therapy for
Retinopathy of
Prematurity
MN008A
(Irrespective of no. of
eyes affected) - per
session
2400
2880
3120
3480
N
184
185
Neo - natal Care
Neo - natal Care
MN
Advanced Surgery for
MN009 Retinopathy of
Prematurity
Advanced Surgery for
MN009A Retinopathy of
Prematurity
1500
1800
1950
2175
a) Clinical notes and Fundoscope
reports.
b) Stills showing extent of ROP.
Details of Laser therapy done.
c) Need for procedure.
OPEN
N
15000
18000
19500
21750
a) Clinical notes.
b) Fundoscope reports.
c) Stills showing extent of ROP.
d) Need for surgery.
a) Detailed discharge summary.
b) Detailed Procedure.
c) Operative Notes.
d) Intra procedure clinical
photograph.
OPEN
N
SL NO
186
Specialty
Neo - natal Care
Specialty
Code
MN
Package
Code
Package Name
Ventriculoperitoneal
Shunt Surgery (VP) or
MN010 Omaya Reservoir or
External Drainage for
Hydrocephalus
Procedure
Code
Procedure Name
Ventriculoperitoneal
Shunt Surgery (VP) or
MN010A Omaya Reservoir or
External Drainage for
Hydrocephalus
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
20000
24000
NABH
Package
Cost
26000
Outside State
NABH
Package Cost
29000
Mandatory Documents - Pre
Authorization
a) Clinical history.
b) CT.
c) MRI.
d) Pre-op clinical photograph.
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Detailed discharge summary.
b) Detailed Procedure.
c) Operative Notes.
d) Intra procedure clinical
photograph.
OPEN
N
187
Medical Oncology
MO
MO001 CT for CA Breast
MO001A
Cyclophosphamide +
Epirubcin
7200
8640
9360
10440
a) CBC.
b) LFT.
c) RFT.
d) Biopsy report or surgical
pathology report of Modified
radical mastectomy or breast
conservation surgery.
e) ECG.
f) 2D-ECHO.
g) USG abdomen
h) pelvis.
i) CXR PA view or CECT chest
j) abdomen
k) pelvis in case of metastatic
disease
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
188
Medical Oncology
MO
MO001 CT for CA Breast
MO001B
Weekly Paclitaxel for
Adjuvant Therapy
5800
6960
7540
8410
a) CBC.
b) LFT.
c) RFT.
d) Biopsy report or surgical
pathology report of Modified
radical mastectomy or breast
conservation surgery.
e) ECG.
f) 2D-ECHO.
g) USG abdomen
h) pelvis.
i) CXR PA view or CECT chest
j) abdomen
k) pelvis in case of metastatic
disease
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
189
Medical Oncology
MO
MO001 CT for CA Breast
MO001C
Weekly Paclitaxel in
metastatic setting
5800
6960
7540
8410
a) CBC.
b) LFT.
c) RFT.
d) Biopsy report or surgical
pathology report of Modified
radical mastectomy or breast
conservation surgery.
e) ECG.
f) 2D-ECHO.
g) USG abdomen
h) pelvis.
i) CXR PA view or CECT chest
j) abdomen
k) pelvis in case of metastatic
disease
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
190
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
Package Name
MO001 CT for CA Breast
Procedure
Code
MO001D
Procedure Name
Cyclophosphamide +
Methotrexate + 5 - FU
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
3200
3840
NABH
Package
Cost
4160
Outside State
NABH
Package Cost
4640
Mandatory Documents - Pre
Authorization
a) CBC.
b) LFT.
c) RFT.
d) Biopsy report or surgical
pathology report of Modified
radical mastectomy or breast
conservation surgery.
e) ECG.
f) 2D-ECHO.
g) USG abdomen
h) pelvis.
i) CXR PA view or CECT chest
j) abdomen
k) pelvis in case of metastatic
disease
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
191
Medical Oncology
MO
MO001 CT for CA Breast
MO001E
Docetaxel +
Cyclophosphamide
19800
23760
25740
28710
a) CBC.
b) LFT.
c) RFT.
d) Biopsy report or surgical
pathology report of Modified
radical mastectomy or breast
conservation surgery.
e) ECG.
f) 2D-ECHO.
g) USG abdomen
h) pelvis.
i) CXR PA view or CECT chest
j) abdomen
k) pelvis in case of metastatic
disease
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
192
Medical Oncology
MO
MO001 CT for CA Breast
MO001F Trastuzumab
21200
25440
27560
30740
a) CBC.
b) LFT.
c) RFT.
d) Biopsy report or surgical
pathology report of Modified
radical mastectomy or breast
conservation surgery.
e) ECG.
f) 2D-ECHO.
g) USG abdomen
h) pelvis.
i) CXR PA view or CECT chest
j) abdomen
k) pelvis in case of metastatic
disease
BAR CODE OF THE DRUGS,
REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
DISCHARGE SUMMARY OF OPEN
INPATIENT DEPARTMENT,
DISCHARGE SUMMARY OF
DAY CARE DEPARTMENT,
CHARTS OF
CHEMOTHERAPY REGIMEN,
TRANFUSION SLIPS
Y
SL NO
193
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
Package Name
MO001 CT for CA Breast
Procedure
Code
Procedure Name
MO001G Tamoxifen
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
1200
1440
NABH
Package
Cost
1560
Outside State
NABH
Package Cost
Mandatory Documents - Pre
Authorization
1740
a) CBC.
b) LFT.
c) RFT.
d) Biopsy report or surgical
pathology report of Modified
radical mastectomy or breast
conservation surgery.
e) ECG.
f) 2D-ECHO.
g) USG abdomen
h) pelvis.
i) CXR PA view or CECT chest
j) abdomen
k) pelvis in case of metastatic
disease
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
194
Medical Oncology
MO
MO001 CT for CA Breast
MO001H Letrozole
3900
4680
5070
5655
a) CBC.
b) LFT.
c) RFT.
d) Biopsy report or surgical
pathology report of Modified
radical mastectomy or breast
conservation surgery.
e) ECG.
f) 2D-ECHO.
g) USG abdomen
h) pelvis.
i) CXR PA view or CECT chest
j) abdomen
k) pelvis in case of metastatic
disease
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
195
Medical Oncology
MO
MO001 CT for CA Breast
MO001I Carboplatin + Paclitaxel
14900
17880
19370
21605
a) CBC.
b) LFT.
c) RFT.
d) Biopsy report or surgical
pathology report of Modified
radical mastectomy or breast
conservation surgery.
e) ECG.
f) 2D-ECHO.
g) USG abdomen
h) pelvis.
i) CXR PA view or CECT chest
j) abdomen
k) pelvis in case of metastatic
disease
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
196
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
Package Name
MO001 CT for CA Breast
Procedure
Code
Procedure Name
MO001J Capecitabine
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
7400
8880
NABH
Package
Cost
9620
Outside State
NABH
Package Cost
10730
Mandatory Documents - Pre
Authorization
a) CBC.
b) LFT.
c) RFT.
d) Biopsy report or surgical
pathology report of Modified
radical mastectomy or breast
conservation surgery.
e) ECG.
f) 2D-ECHO.
g) USG abdomen
h) pelvis.
i) CXR PA view or CECT chest
j) abdomen
k) pelvis in case of metastatic
disease
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
197
Medical Oncology
MO
MO001 CT for CA Breast
MO001K
Carboplatin +
Gemcitabine
13900
16680
18070
20155
a) CBC.
b) LFT.
c) RFT.
d) Biopsy report or surgical
pathology report of Modified
radical mastectomy or breast
conservation surgery.
e) ECG.
f) 2D-ECHO.
g) USG abdomen
h) pelvis.
i) CXR PA view or CECT chest
j) abdomen
k) pelvis in case of metastatic
disease
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
198
Medical Oncology
MO
MO001 CT for CA Breast
MO001L
Cyclophosphamide +
Adriamycin
4500
5400
5850
6525
a) CBC.
b) LFT.
c) RFT.
d) Biopsy report or surgical
pathology report of Modified
radical mastectomy or breast
conservation surgery.
e) ECG.
f) 2D-ECHO.
g) USG abdomen
h) pelvis.
i) CXR PA view or CECT chest
j) abdomen
k) pelvis in case of metastatic
disease
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
199
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
Package Name
MO001 CT for CA Breast
Procedure
Code
Procedure Name
MO001M Fulvestrant
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
11000
13200
NABH
Package
Cost
14300
Outside State
NABH
Package Cost
15950
Mandatory Documents - Pre
Authorization
a) CBC.
b) LFT.
c) RFT.
d) Biopsy report or surgical
pathology report of Modified
radical mastectomy or breast
conservation surgery.
e) ER or PR positive .
f) mammography.
g) USG abdomen
h) pelvis.
i) CXR PA view or CECT chest
abdomen and pelvis
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
200
Medical Oncology
MO
MO001 CT for CA Breast
MO001N Paclitaxel
11800
14160
15340
17110
a) CBC.
b) LFT.
c) RFT.
d) Biopsy report or surgical
pathology report of Modified
radical mastectomy or breast
conservation surgery.
e) ER or PR positive .
f) mammography.
g) USG abdomen
h) pelvis.
i) CXR PA view or CECT chest
abdomen and pelvis
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
201
Medical Oncology
MO
MO001 CT for CA Breast
MO001O Exemestane
10400
12480
13520
15080
a) CBC.
b) LFT.
c) RFT.
d) Biopsy report
e) surgical pathology report of
Modified radical mastectomy
f) breast conservation surgery.
g) ER
h) PR positive .
i) mammography.
j) USG abdomen
k) pelvis.
l) CXR PA view
m) CECT chest abdomen and
pelvis
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
202
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
Package Name
CT for Metastatic
MO002 bone malignancy and
multiple myeloma
Procedure
Code
Procedure Name
MO002A Zoledronic Acid
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
4500
5400
NABH
Package
Cost
5850
Outside State
NABH
Package Cost
6525
Mandatory Documents - Pre
Authorization
a) RFT.
b) skeletal survey
c) bone scan
d) PET-CT showing bone
metastasis histopathology showing
myeloma.
e) lung cancer.
f) Breast cancer.
g) renal cancer or other cancer
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
N
203
Medical Oncology
MO
MO003 CT for CA Ovary
MO003A Cisplatin + Irinotecan
10200
12240
13260
14790
a) CBc.
b) LFT.
c) RFT.
d) RBS.
e) CA-125.
f) CECT Thorax.
g) abdomen
h) Pelvis.
i) HPR or cytology suggestive of
ovarian adenocarcinoma
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
204
Medical Oncology
MO
MO003 CT for CA Ovary
MO003B Lipodox + Carboplatin
17200
20640
22360
24940
a) CBc.
b) LFT.
c) RFT.
d) RBS.
e) CA-125.
f) CECT Thorax.
g) abdomen
h) Pelvis.
i) HPR or cytology suggestive of
ovarian adenocarcinoma
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
205
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
Package Name
MO003 CT for CA Ovary
Procedure
Code
Procedure Name
MO003C Etoposide
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
3400
4080
NABH
Package
Cost
4420
Outside State
NABH
Package Cost
4930
Mandatory Documents - Pre
Authorization
a) CBc.
b) LFT.
c) RFT.
d) RBS.
e) CA-125.
f) CECT Thorax.
g) abdomen
h) Pelvis.
i) HPR or cytology suggestive of
ovarian adenocarcinoma
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
206
Medical Oncology
MO
MO003 CT for CA Ovary
MO003D Irinotecan
8400
10080
10920
12180
a) CBc.
b) LFT.
c) RFT.
d) RBS.
e) CA-125.
f) CECT Thorax.
g) abdomen
h) Pelvis.
i) HPR or cytology suggestive of
ovarian adenocarcinoma
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
207
Medical Oncology
MO
MO003 CT for CA Ovary
MO003E Lipodox
14800
17760
19240
21460
a) CBc.
b) LFT.
c) RFT.
d) RBS.
e) CA-125.
f) CECT Thorax.
g) abdomen
h) Pelvis.
i) HPR or cytology suggestive of
ovarian adenocarcinoma
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
208
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
Package Name
MO003 CT for CA Ovary
Procedure
Code
MO003F
Procedure Name
Carboplatin +
Gemcitabine
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
13900
16680
NABH
Package
Cost
18070
Outside State
NABH
Package Cost
20155
Mandatory Documents - Pre
Authorization
a) CBc.
b) LFT.
c) RFT.
d) RBS.
e) CA-125.
f) CECT Thorax.
g) abdomen
h) Pelvis.
i) HPR or cytology suggestive of
ovarian adenocarcinoma
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
209
Medical Oncology
MO
MO003 CT for CA Ovary
MO003G Carboplatin + Paclitaxel
14700
17640
19110
21315
a) CBc.
b) LFT.
c) RFT.
d) RBS.
e) CA-125.
f) CECT Thorax.
g) abdomen
h) Pelvis.
i) HPR or cytology suggestive of
ovarian adenocarcinoma
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
210
Medical Oncology
MO
MO004
CT for Germ Cell
Tumor
MO004A Carboplatin (AUC 7)
5800
6960
7540
8410
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) Beta- HCG.
f) AFP.
g) LDH.
h) CECT Thorax.
i) Abdomen
j) Pelvis.
k) ECG.
l) Histopathology -testicular
seminoma
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
211
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
MO004
Package Name
CT for Germ Cell
Tumor
Procedure
Code
MO004B
Procedure Name
Bleomycin + Etoposide
+ Cisplatin
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
11600
13920
NABH
Package
Cost
15080
Outside State
NABH
Package Cost
16820
Mandatory Documents - Pre
Authorization
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) Beta-HCG.
f) AFP.
g) LDH.
h) CECT Thorax.
i) Abdomen
j) Pelvis.
k) ECG.
l) PFT DLCo.
m) Histopathology -Ovarian.
n) testicular.
o) mediastinal
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
212
Medical Oncology
MO
MO004
CT for Germ Cell
Tumor
MO004C Etoposide + Cisplatin
10000
12000
13000
14500
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) Beta- HCG.
f) AFP.
g) LDH.
h) CECT Thorax.
i) abdomen
j) Pelvis.
k) ECG.
l) Histopathology -Ovarian.
m) testicular.
n) mediastinal
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
213
Medical Oncology
MO
MO004
CT for Germ Cell
Tumor
MO004D
Gemcitabine +
Oxaliplatin
17500
21000
22750
25375
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) Beta- HCG.
f) AFP.
g) LDH.
h) CECT Thorax.
i) abdomen
j) Pelvis.
k) ECG.
l) Histopathology -Ovarian.
m) testicular.
n) mediastinal
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
214
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
MO004
Package Name
CT for Germ Cell
Tumor
Procedure
Code
Procedure Name
MO004E Gemcitabine + Paclitaxel
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
17500
21000
NABH
Package
Cost
22750
Outside State
NABH
Package Cost
25375
Mandatory Documents - Pre
Authorization
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) Beta- HCG.
f) AFP.
g) LDH.
h) CECT Thorax.
i) abdomen
j) Pelvis.
k) ECG.
l) Histopathology -Ovarian.
m) testicular.
n) mediastinal
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
215
Medical Oncology
MO
MO004
CT for Germ Cell
Tumor
MO004F
Paclitaxel + Ifosfamide
+ Cisplatin
24400
29280
31720
35380
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) Beta- HCG.
f) AFP.
g) LDH.
h) CECT Thorax.
i) abdomen
j) Pelvis.
k) ECG.
l) Histopathology -Ovarian.
m) testicular.
n) mediastinal
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
216
Medical Oncology
MO
MO004
CT for Germ Cell
Tumor
MO004G
Vinblastin + Ifosfamide
+ Cisplatin
12600
15120
16380
18270
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) Beta- HCG.
f) AFP.
g) LDH.
h) CECT Thorax.
i) abdomen
j) Pelvis.
k) ECG.
l) Histopathology -Ovarian.
m) testicular.
n) mediastinal
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
217
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
Package Name
CT for Gestational
MO005 Trophoblastic
Neoplasia
Procedure
Code
Procedure Name
MO005A EMA - CO
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
11400
13680
NABH
Package
Cost
14820
Outside State
NABH
Package Cost
16530
Mandatory Documents - Pre
Authorization
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) Beta- HCG.
f) CECT Thorax.
g) Abdomen
h) Pelvis
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
218
Medical Oncology
MO
CT for Gestational
MO005 Trophoblastic
Neoplasia
MO005B EMA - EP
12200
14640
15860
17690
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) Beta- HCG.
f) CECT Thorax.
g) Abdomen
h) Pelvis
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
219
Medical Oncology
MO
CT for Gestational
MO005 Trophoblastic
Neoplasia
MO005C Methotrexate
1100
1320
1430
1595
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) Beta- HCG.
f) CECT Thorax.
g) Abdomen
h) Pelvis
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
220
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
MO006
Package Name
CT for Cervical
Cancer
Procedure
Code
Procedure Name
MO006A Carboplatin + Paclitaxel
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
14900
17880
NABH
Package
Cost
19370
Outside State
NABH
Package Cost
21605
Mandatory Documents - Pre
Authorization
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax.
f) Abdomen
g) Pelvis.
h) histopathology
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
221
Medical Oncology
MO
MO006
CT for Cervical
Cancer
MO006B Cisplatin
2200
2640
2860
3190
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax.
f) Abdomen
g) Pelvis.
h) histopathology
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
222
Medical Oncology
MO
MO007
CT for Endometrial
Cancer
MO007A Carboplatin + Paclitaxel
14900
17880
19370
21605
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax.
f) Abdomen
g) Pelvis.
h) histopathology
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
223
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
MO007
Package Name
CT for Endometrial
Cancer
Procedure
Code
Procedure Name
MO007B Cisplatin + Doxorubicin
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
4200
5040
NABH
Package
Cost
5460
Outside State
NABH
Package Cost
6090
Mandatory Documents - Pre
Authorization
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax.
f) Abdomen
g) Pelvis.histopathology .
h) ECG.
i) 2D ECHO
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
224
Medical Oncology
MO
MO008 CT for Vulvar Cancer
MO008A Cisplatin + 5 FU
7600
9120
9880
11020
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) MRI pelvis.
f) histopathology
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
225
Medical Oncology
MO
MO008 CT for Vulvar Cancer
MO008B Cisplatin
2200
2640
2860
3190
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) MRI pelvis.
f) histopathology
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
226
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
Package Name
Procedure
Code
Procedure Name
VTC + ITMZ for
MO009 CT for Ewing Sarcoma MO009A Relapsed Ewing
Sarcoma
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
22400
26880
NABH
Package
Cost
29120
Outside State
NABH
Package Cost
32480
Mandatory Documents - Pre
Authorization
a) CBC.
b) Biochemistry.
c) PET CT
d) CT CHEST
e) BONE SCAN.
f) Bone marrow studies.
g) Biopsy.
h) ECG.
i) 2D-ECHO
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
227
Medical Oncology
MO
MO009 CT for Ewing Sarcoma MO009B EFT 2001
9700
11640
12610
14065
a) CBC.
b) Biochemistry.
c) PET CT
d) CT CHEST
e) BONE SCAN.
f) Bone marrow studies.
g) Biopsy.
h) ECG.
i) 2D-ECHO
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
228
Medical Oncology
MO
MO009 CT for Ewing Sarcoma MO009C VAC + IE
12500
15000
16250
18125
a) CBC.
b) Biochemistry.
c) PET CT
d) CT CHEST
e) BONE SCAN.
f) Bone marrow studies.
g) Biopsy.
h) ECG.
i) 2D-ECHO
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
229
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
MO010
Package Name
CT for Osteogenic
Sarcoma
Procedure
Code
MO010A
Procedure Name
Methotrexate +
Doxorubicin + Cisplatin
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
21800
26160
NABH
Package
Cost
28340
Outside State
NABH
Package Cost
31610
Mandatory Documents - Pre
Authorization
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) DTPA GFR.
f) NCCT chest.
g) MRI of the involved site.
h) 2D ECHO.
i) Pure tone
audiometry.histopathology
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
230
Medical Oncology
MO
MO010
CT for Osteogenic
Sarcoma
Methotrexate +
Doxorubicin + Cisplatin
MO010B
for Relapsed
Osteogenic Sarcoma
27000
32400
35100
39150
a) CBC.
b) Biochemistry.
c) CT CHEST.
d) BONE SCAN.
e) Biopsy.
f) ECG.
g) 2D-ECHO.
h) AUDIOMETRY.
i) GFR
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
231
Medical Oncology
MO
MO010
CT for Osteogenic
Sarcoma
MO010C OGS - 12
29600
35520
38480
42920
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) DTPA GFR.
f) NCCT chest.
g) MRI of the involved site.
h) 2D ECHO.
i) Pure tone
audiometry.histopathology
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
232
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
MO010
Package Name
CT for Osteogenic
Sarcoma
Procedure
Code
Procedure Name
MO010D OGS - 12
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
36200
43440
NABH
Package
Cost
47060
Outside State
NABH
Package Cost
52490
Mandatory Documents - Pre
Authorization
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) DTPA GFR.
f) 2D ECHO.
g) Pure tone.
h) histopathology
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
233
Medical Oncology
MO
MO011
CT for Soft Tissue
Sarcoma
MO011A
Gemcitabine +
Docetaxel
30900
37080
40170
44805
a) CBC.
b) LFT.
c) ECHO.
d) MRI of the involved part.
e) CECT Thorax.
f) abdomen
g) Pelvis.
h) histopathology
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
234
Medical Oncology
MO
MO011
CT for Soft Tissue
Sarcoma
MO011B
Ifosfamide+
Adriamycin
13700
16440
17810
19865
a) CBC.
b) LFT.
c) ECHO.
d) MRI of the involved part.
e) CECT Thorax.
f) abdomen
g) Pelvis.
h) histopathology
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
235
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
MO012
Package Name
CT for Metastatic
Melanoma
Procedure
Code
Procedure Name
MO012A Dacarbazine + Cisplatin
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
7100
8520
NABH
Package
Cost
9230
Outside State
NABH
Package Cost
10295
Mandatory Documents - Pre
Authorization
a) CBC.
b) RFT.
c) LFT.
d) RBS.
e) CECT Thorax.
f) Abdomen
g) Pelvis.
h) histopathology
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
236
Medical Oncology
MO
MO012
CT for Metastatic
Melanoma
MO012B Temozolamide
23100
27720
30030
33495
a) CBC.
b) RFT.
c) LFT.
d) RBS.
e) CECT Thorax.
f) abdomen
g) Pelvis
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
237
Medical Oncology
MO
MO013 CT for Anal Cancer
MO013A
CT for Anal Cancer (5
FU + Mitomycin C)
10500
12600
13650
15225
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax .
f) abdomen .
g) MRI Pelvis.
h) CEA.
i) Histopathology
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
238
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
Package Name
MO013 CT for Anal Cancer
Procedure
Code
MO013B
Procedure Name
Capecitabine +
Mitomycin C
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
13800
16560
NABH
Package
Cost
17940
Outside State
NABH
Package Cost
20010
Mandatory Documents - Pre
Authorization
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax .
f) abdomen .
g) MRI Pelvis.
h) CEA.
i) Histopathology
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
239
Medical Oncology
MO
MO013 CT for Anal Cancer
MO013C Cisplatin + 5 FU
7600
9120
9880
11020
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax .
f) abdomen .
g) Pelvis.
h) CEA.
i) Histopathology
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
240
Medical Oncology
MO
MO013 CT for Anal Cancer
MO013D Carboplatin + Paclitaxel
14900
17880
19370
21605
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax .
f) abdomen .
g) Pelvis.
h) CEA.
i) Histopathology
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
241
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
Package Name
MO013 CT for Anal Cancer
Procedure
Code
Procedure Name
MO013E Cisplatin + Paclitaxel
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
13300
15960
NABH
Package
Cost
17290
Outside State
NABH
Package Cost
19285
Mandatory Documents - Pre
Authorization
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax .
f) abdomen .
g) Pelvis.
h) CEA.
i) Histopathology
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
242
Medical Oncology
MO
MO014
CT for Colorectal
Cancer
MO014A
CT for Colorectal ( 5
FU + Leucovorin)
4700
5640
6110
6815
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax .
f) abdomen .
g) Pelvis.
h) CEA.
i) Histopathology .
j) Colonoscopy
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
243
Medical Oncology
MO
MO014
CT for Colorectal
Cancer
MO014B
Capecitabine +
Irinotecan
12500
15000
16250
18125
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax .
f) abdomen .
g) Pelvis.
h) CEA.
i) Histopathology
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
244
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
MO014
Package Name
CT for Colorectal
Cancer
Procedure
Code
Procedure Name
MO014C Folfox
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
11100
13320
NABH
Package
Cost
14430
Outside State
NABH
Package Cost
16095
Mandatory Documents - Pre
Authorization
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax .
f) abdomen .
g) Pelvis.
h) CEA.
i) Histopathology .
j) Colonoscopy
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
245
Medical Oncology
MO
MO014
CT for Colorectal
Cancer
MO014D Folfiri
8700
10440
11310
12615
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax .
f) abdomen .
g) Pelvis.
h) CEA.
i) Histopathology
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
246
Medical Oncology
MO
MO014
CT for Colorectal
Cancer
MO014E
Capecitabine +
Oxaliplatin
16500
19800
21450
23925
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax .
f) abdomen .
g) Pelvis.
h) CEA.
i) Histopathology .
j) Colonoscopy
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
247
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
MO014
Package Name
CT for Colorectal
Cancer
Procedure
Code
Procedure Name
MO014F Capecitabine
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
7200
8640
NABH
Package
Cost
9360
Outside State
NABH
Package Cost
10440
Mandatory Documents - Pre
Authorization
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax .
f) abdomen .
g) Pelvis.
h) CEA.
i) Histopathology .
j) Colonoscopy
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
248
Medical Oncology
MO
MO014
CT for Colorectal
Cancer
MO014G Capecitabine
7300
8760
9490
10585
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax .
f) abdomen .
g) Pelvis.
h) CEA.
i) Histopathology .
j) Colonoscopy
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
249
Medical Oncology
MO
MO014
CT for Colorectal
Cancer
MO014H Folfirinox
15100
18120
19630
21895
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax .
f) abdomen .
g) Pelvis.
h) CEA.
i) Histopathology .
j) Colonoscopy
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
250
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
MO015
Package Name
CT for Esophageal
Cancer
Procedure
Code
Procedure Name
MO015A Carboplatin + Paclitaxel
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
14900
17880
NABH
Package
Cost
19370
Outside State
NABH
Package Cost
21605
Mandatory Documents - Pre
Authorization
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax
f) abdomen .
g) Pelvis.
h) Histopathology .
i) UGI endoscospy
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
251
Medical Oncology
MO
MO015
CT for Esophageal
Cancer
MO015B Cisplatin + 5 FU
9600
11520
12480
13920
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax
f) abdomen .
g) Pelvis.
h) Histopathology .
i) UGI endoscospy
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
252
Medical Oncology
MO
MO015
CT for Esophageal
Cancer
MO015C Cisplatin + 5 FU
9600
11520
12480
13920
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax
f) abdomen .
g) Pelvis.
h) Histopathology .
i) UGI endoscospy
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
253
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
MO015
Package Name
CT for Esophageal
Cancer
Procedure
Code
MO015D
Procedure Name
Paclitaxel + Carboplatin
for definitive Non metastatic
(With RT)
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
25100
30120
NABH
Package
Cost
32630
Outside State
NABH
Package Cost
36395
Mandatory Documents - Pre
Authorization
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax
f) abdomen .
g) Pelvis.
h) Histopathology .
i) UGI endoscospy
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
254
Medical Oncology
MO
MO015
CT for Esophageal
Cancer
Paclitaxel + Carboplatin
MO015E for metastatic
(Without RT)
25100
30120
32630
36395
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax
f) abdomen .
g) Pelvis.
h) Histopathology .
i) UGI endoscospy
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
255
Medical Oncology
MO
MO016
CT for Esophageal /
Stomach Cancer
MO016A Cisplatin + Docetaxel
12100
14520
15730
17545
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax
f) abdomen .
g) Pelvis.
h) Histopathology .
i) UGI endoscospy
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
256
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
MO016
Package Name
CT for Esophageal /
Stomach Cancer
Procedure
Code
Procedure Name
MO016B Irinotecan
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
8300
9960
NABH
Package
Cost
10790
Outside State
NABH
Package Cost
12035
Mandatory Documents - Pre
Authorization
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax
f) abdomen .
g) Pelvis.
h) Histopathology .
i) UGI endoscospy
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
257
Medical Oncology
MO
MO016
CT for Esophageal /
Stomach Cancer
MO016C
CT for Esophageal /
Stomach Cancer - 5 FU
8000
9600
10400
11600
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax
f) abdomen .
g) Pelvis.
h) Histopathology .
i) UGI endoscospy
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
258
Medical Oncology
MO
MO016
CT for Esophageal /
Stomach Cancer
MO016D Capecitabine
7200
8640
9360
10440
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax
f) abdomen .
g) Pelvis.
h) Histopathology .
i) UGI endoscospy
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
259
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
MO016
Package Name
CT for Esophageal /
Stomach Cancer
Procedure
Code
Procedure Name
CAPOX - (CT for
MO016E Esophageal / Stomach
Cancer)
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
16500
19800
NABH
Package
Cost
21450
Outside State
NABH
Package Cost
23925
Mandatory Documents - Pre
Authorization
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax
f) abdomen .
g) Pelvis.
h) Histopathology .
i) UGI endoscospy
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
260
Medical Oncology
MO
MO016
CT for Esophageal /
Stomach Cancer
MO016F
Docetaxel + Cisplatin +
5 FU
16400
19680
21320
23780
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax
f) abdomen .
g) Pelvis.
h) Histopathology .
i) UGI endoscospy
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
261
Medical Oncology
MO
MO016
CT for Esophageal /
Stomach Cancer
MO016G
Docetaxel + Cisplatin +
Xeloda
19700
23640
25610
28565
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax
f) abdomen .
g) Pelvis.
h) Histopathology .
i) UGI endoscospy
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
262
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
MO016
Package Name
CT for Esophageal /
Stomach Cancer
Procedure
Code
MO016H
Procedure Name
Docetaxel + Oxaliplatin
+ 5 FU
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
20400
24480
NABH
Package
Cost
26520
Outside State
NABH
Package Cost
29580
Mandatory Documents - Pre
Authorization
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax
f) abdomen .
g) Pelvis.
h) Histopathology .
i) UGI endoscospy
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
263
Medical Oncology
MO
MO016
CT for Esophageal /
Stomach Cancer
MO016I
Docetaxel + Oxaliplatin
+ Xeloda
24900
29880
32370
36105
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax
f) abdomen .
g) Pelvis.
h) Histopathology .
i) UGI endoscospy
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
264
Medical Oncology
MO
MO016
CT for Esophageal /
Stomach Cancer
MO016J Folfiri
8700
10440
11310
12615
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax
f) abdomen .
g) Pelvis.
h) Histopathology .
i) UGI endoscospy
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
265
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
MO016
Package Name
CT for Esophageal /
Stomach Cancer
Procedure
Code
Procedure Name
MO016K Folfox
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
11100
13320
NABH
Package
Cost
14430
Outside State
NABH
Package Cost
16095
Mandatory Documents - Pre
Authorization
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax
f) abdomen .
g) Pelvis.
h) Histopathology .
i) UGI endoscospy
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
266
Medical Oncology
MO
MO016
CT for Esophageal /
Stomach Cancer
MO016L Paclitaxel
5800
6960
7540
8410
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax
f) abdomen .
g) Pelvis.
h) Histopathology .
i) UGI endoscospy
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
267
Medical Oncology
MO
MO017
CT for Hepatocellular
Carcinoma
MO017A Doxorubicin
10000
12000
13000
14500
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) Triphasic CECT Thorax .
f) abdomen .
g) Pelvis.
h) Histopathology .
i) AFP.
j) MRI
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
268
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
MO017
Package Name
CT for Hepatocellular
Carcinoma
Procedure
Code
Procedure Name
MO017B Sorafenib
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
7400
8880
NABH
Package
Cost
9620
Outside State
NABH
Package Cost
10730
Mandatory Documents - Pre
Authorization
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) Triphasic CECT Thorax .
f) abdomen .
g) Pelvis.
h) Histopathology .
i) AFP.
j) Lipid Profile.
k) Urine R/M.
l) 2D ECHO
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
269
Medical Oncology
MO
MO018
CT for Panceratic
Cancer
MO018A
Gemcitabine +
Nanopaclitaxel
23500
28200
30550
34075
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax .
f) abdomen .
g) Pelvis.
h) Histopathology
i) FNAC.
j) CA19.9.
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
270
Medical Oncology
MO
MO018
CT for Panceratic
Cancer
MO018B Gemcitabine
9000
10800
11700
13050
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax .
f) abdomen .
g) Pelvis.
h) Histopathology
i) FNAC.
j) CA19.9.
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
271
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
MO018
Package Name
CT for Panceratic
Cancer
Procedure
Code
Procedure Name
MO018C Gemcitabine
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
9000
10800
NABH
Package
Cost
11700
Outside State
NABH
Package Cost
13050
Mandatory Documents - Pre
Authorization
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax .
f) abdomen .
g) Pelvis.
h) Histopathology
i) FNAC.
j) CA19.9.
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
272
Medical Oncology
MO
MO018
CT for Panceratic
Cancer
MO018D Folfirinox
15500
18600
20150
22475
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax .
f) abdomen .
g) Pelvis.
h) Histopathology
i) FNAC.
j) CA19.9.
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
273
Medical Oncology
MO
MO018
CT for Panceratic
Cancer
MO018E Capecitabine
7400
8880
9620
10730
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax .
f) abdomen .
g) Pelvis.
h) Histopathology
i) FNAC.
j) CA19.9.
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
274
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
MO018
Package Name
CT for Panceratic
Cancer
Procedure
Code
MO018F
Procedure Name
Capecitabine +
Gemcitabine
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
31500
37800
NABH
Package
Cost
40950
Outside State
NABH
Package Cost
45675
Mandatory Documents - Pre
Authorization
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax .
f) abdomen .
g) Pelvis.
h) Histopathology
i) FNAC.
j) CA19.9.
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
275
Medical Oncology
MO
CT for Gall Bladder
MO019 Cancer /
Cholangiocarcinoma
MO019A Capecitabine
7300
8760
9490
10585
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax .
f) abdomen .
g) Pelvis.
h) Histopathology
i) FNAC.
j) CA19.9.
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
276
Medical Oncology
MO
CT for Gall Bladder
MO019 Cancer /
Cholangiocarcinoma
MO019B Cisplatin + Gemcitabine
10900
13080
14170
15805
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax .
f) abdomen .
g) Pelvis.
h) Histopathology
i) FNAC.
j) CA19.9.
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
277
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
Package Name
CT for Gall Bladder
MO019 Cancer /
Cholangiocarcinoma
Procedure
Code
Procedure Name
MO019C Folfiri
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
8900
10680
NABH
Package
Cost
11570
Outside State
NABH
Package Cost
12905
Mandatory Documents - Pre
Authorization
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax .
f) abdomen .
g) Pelvis.
h) Histopathology
i) FNAC.
j) CA19.9.
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
278
Medical Oncology
MO
CT for Gall Bladder
MO019 Cancer /
Cholangiocarcinoma
MO019D Gemcitabine
9000
10800
11700
13050
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax .
f) abdomen .
g) Pelvis.
h) Histopathology
i) FNAC.
j) CA19.9.
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
279
Medical Oncology
MO
CT for Gall Bladder
MO019 Cancer /
Cholangiocarcinoma
MO019E Gemcitabine
8900
10680
11570
12905
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax .
f) abdomen .
g) Pelvis.
h) Histopathology
i) FNAC.
j) CA19.9.
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
280
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
Package Name
CT for Gall Bladder
MO019 Cancer /
Cholangiocarcinoma
Procedure
Code
MO019F
Procedure Name
Oxaliplatin +
Gemcitabine
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
17100
20520
NABH
Package
Cost
22230
Outside State
NABH
Package Cost
24795
Mandatory Documents - Pre
Authorization
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax .
f) abdomen .
g) Pelvis.
h) Histopathology
i) FNAC.
j) CA19.9.
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
281
Medical Oncology
MO
CT for Gall Bladder
MO019 Cancer /
Cholangiocarcinoma
MO019G CAPIRI
12600
15120
16380
18270
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax .
f) abdomen .
g) Pelvis.
h) Histopathology
i) FNAC.
j) CA19.9.
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
282
Medical Oncology
MO
CT for Gall Bladder
MO019 Cancer /
Cholangiocarcinoma
MO019H Folfox
11300
13560
14690
16385
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax .
f) abdomen .
g) Pelvis.
h) Histopathology
i) FNAC.
j) CA19.9.
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
283
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
MO020
Package Name
CT for Gastointestinal
stromal tumor
Procedure
Code
Procedure Name
MO020A Imatinib
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
19400
23280
NABH
Package
Cost
25220
Outside State
NABH
Package Cost
28130
Mandatory Documents - Pre
Authorization
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax .
f) abdomen .
g) Pelvis.
h) Histopathology
i) FNAC.
j) Ckit-mutation (not mandatory)
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
284
Medical Oncology
MO
MO020
CT for Gastointestinal
stromal tumor
MO020B Sunitinib
24400
29280
31720
35380
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
a) CBC.
(PATHOLOGY, RADIOLOGY,
b) LFT.
MICROBIOLOGY,
c) RFT.
HEMATOLOGY,
d) RBS.
BIOCHEMISTRY,ETC.)
e) CECT Thorax .
c) DISCHARGE SUMMARY
f) abdomen .
OPEN
OF INPATIENT
g) Pelvis.
DEPARTMENT.
h) Histopathology
d) DISCHARGE SUMMARY
i) FNAC.
OF DAY CARE DEPARTMENT.
j) Ckit-mutation (not mandatory) e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
285
Medical Oncology
MO
MO021 CT for CA Brain
MO021A Temozolamide
13000
15600
16900
18850
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) MRI brain.
f) Histopathology
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
286
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
Package Name
MO021 CT for CA Brain
Procedure
Code
Procedure Name
MO021B Temozolamide
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
67600
81120
NABH
Package
Cost
87880
Outside State
NABH
Package Cost
98020
Mandatory Documents - Pre
Authorization
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) MRI brain.
f) Histopathology
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
287
Medical Oncology
MO
MO022 CT for Mesothelioma
MO022A Gemcitabine + Cisplatin
11100
13320
14430
16095
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax.
f) Abdomen
g) Pelvis.
h) histopathology
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
288
Medical Oncology
MO
MO022 CT for Mesothelioma
MO022B Pemetrexed + Cisplatin
9200
11040
11960
13340
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax.
f) Abdomen
g) Pelvis.
h) histopathology
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
289
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
Package Name
MO022 CT for Mesothelioma
Procedure
Code
MO022C
Procedure Name
Pemetrexed +
Carboplatin
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
10000
12000
NABH
Package
Cost
13000
Outside State
NABH
Package Cost
14500
Mandatory Documents - Pre
Authorization
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax.
f) Abdomen
g) Pelvis.
h) histopathology
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
290
Medical Oncology
MO
MO023
CT for Thymic
Carcinoma
MO023A Cisplatin + Etoposide
5300
6360
6890
7685
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax.
f) Abdomen
g) Pelvis.
h) histopathology .
i) ECHO
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
291
Medical Oncology
MO
MO023
CT for Thymic
Carcinoma
MO023B Cisplatin + Adriamycin
5000
6000
6500
7250
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax.
f) Abdomen
g) Pelvis.
h) histopathology .
i) ECHO
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
292
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
MO024
Package Name
CT for CA Head &
Neck
Procedure
Code
Procedure Name
MO024A Cisplatin + Docetaxel
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
12400
14880
NABH
Package
Cost
16120
Outside State
NABH
Package Cost
17980
Mandatory Documents - Pre
Authorization
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT
f) MR Face
g) neck.
h) histopathology -squamous
carcinoma.
i) Nasopharyngeal carcinoma
Pure tone audiometry
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
293
Medical Oncology
MO
MO024
CT for CA Head &
Neck
MO024B Cisplatin
9800
11760
12740
14210
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT
f) MR Face
g) neck.
h) histopathology -squamous
carcinoma.
i) nasopharyngeal carcinoma.
j) Pure tone audiometry
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
294
Medical Oncology
MO
MO024
CT for CA Head &
Neck
MO024C
Carboplatin +
Gemcitabine
14300
17160
18590
20735
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) histopathology-squamous
carcinoma.
f) nasopharyngeal carcinoma.
g) salivary gland
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
295
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
MO024
Package Name
CT for CA Head &
Neck
Procedure
Code
MO024D
Procedure Name
Docetaxel + Cisplatin +
5 FU
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
16500
19800
NABH
Package
Cost
21450
Outside State
NABH
Package Cost
23925
Mandatory Documents - Pre
Authorization
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) histopathology-squamous
carcinoma.
f) nasopharyngeal carcinoma.
g) salivary gland
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
296
Medical Oncology
MO
MO024
CT for CA Head &
Neck
MO024E Docetaxel
15000
18000
19500
21750
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) histopathology-squamous
carcinoma.
f) nasopharyngeal carcinoma.
g) salivary gland
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
297
Medical Oncology
MO
MO024
CT for CA Head &
Neck
MO024F Docetaxel
14400
17280
18720
20880
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT
f) MR Face
g) neck.
h) histopathology -squamous
carcinoma
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
298
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
MO024
Package Name
CT for CA Head &
Neck
Procedure
Code
Procedure Name
MO024G Etoposide + Carboplatin
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
7100
8520
NABH
Package
Cost
9230
Outside State
NABH
Package Cost
10295
Mandatory Documents - Pre
Authorization
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) histopathology esthesioneuroblastoma.
f) Neuroendocrine.
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
299
Medical Oncology
MO
MO024
CT for CA Head &
Neck
MO024H Etoposide + Cisplatin
9200
11040
11960
13340
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) histopathology esthesioneuroblastoma.
f) Neuroendocrine.
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
300
Medical Oncology
MO
MO024
CT for CA Head &
Neck
MO024I Gemcitabine
9200
11040
11960
13340
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) histopathology-squamous
carcinoma.
f) nasopharyngeal carcinoma.
g) salivary gland
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
301
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
MO024
Package Name
CT for CA Head &
Neck
Procedure
Code
Procedure Name
MO024J Gemcitabine + Cisplatin
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
11100
13320
NABH
Package
Cost
14430
Outside State
NABH
Package Cost
16095
Mandatory Documents - Pre
Authorization
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) histopathology-squamous
carcinoma.
f) nasopharyngeal carcinoma.
g) salivary gland
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
302
Medical Oncology
MO
MO024
CT for CA Head &
Neck
MO024K Paclitaxel + Carboplatin
7700
9240
10010
11165
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) histopathology-squamous
carcinoma.
f) nasopharyngeal carcinoma.
g) salivary gland
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
303
Medical Oncology
MO
MO024
CT for CA Head &
Neck
MO024L Paclitaxel + Carboplatin
15100
18120
19630
21895
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) histopathology-squamous
carcinoma.
f) nasopharyngeal carcinoma.
g) salivary gland
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
304
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
MO024
Package Name
CT for CA Head &
Neck
Procedure
Code
Procedure Name
MO024M Paclitaxel
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
5700
6840
NABH
Package
Cost
7410
Outside State
NABH
Package Cost
8265
Mandatory Documents - Pre
Authorization
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) histopathology-squamous
carcinoma.
f) salivary gland
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
305
Medical Oncology
MO
MO024
CT for CA Head &
Neck
MO024N Paclitaxel
12200
14640
15860
17690
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) histopathology-squamous
carcinoma.
f) nasopharyngeal carcinoma.
g) salivary gland
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
306
Medical Oncology
MO
MO024
CT for CA Head &
Neck
MO024O Carboplatin
2400
2880
3120
3480
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT
f) MR Face
g) neck.
h) histopathology -squamous
carcinoma.
i) nasopharyngeal carcinoma
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
307
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
MO024
Package Name
CT for CA Head &
Neck
Procedure
Code
Procedure Name
MO024P Cisplatin
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
2200
2640
NABH
Package
Cost
2860
Outside State
NABH
Package Cost
3190
Mandatory Documents - Pre
Authorization
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT
f) MR Face
g) neck.
h) histopathology -squamous
carcinoma.
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
308
Medical Oncology
MO
MO025
CT for Renal Cell
Cancer
MO025A Sunitinib
26400
31680
34320
38280
a) CBC.
b) RFT.
c) RBS.
d) CECT Thorax.
e) abdomen
f) Pelvis.
g) lipid profile.
h) 2 D ECHO.
i) TFT.
j) 24 hour urine protein
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
N
309
Medical Oncology
MO
MO026
CT for Ureter /
Bladder / Urethra
Cisplatin +
MO026A Methotrexate +
Vinblastin
6000
7200
7800
8700
a) CBC.
b) RFT.
c) LFT.
d) CECT Thorax.
e) abdomen
f) Pelvis.
g) histopathology
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
310
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
MO026
Package Name
CT for Ureter /
Bladder / Urethra
Procedure
Code
MO026B
Procedure Name
Carboplatin +
Gemcitabine
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
14300
17160
NABH
Package
Cost
18590
Outside State
NABH
Package Cost
20735
Mandatory Documents - Pre
Authorization
a) CBC.
b) RFT.
c) LFT.
d) CECT Thorax.
e) abdomen
f) Pelvis.
g) MRI.
h) histopathology
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
311
Medical Oncology
MO
MO026
CT for Ureter /
Bladder / Urethra
MO026C Cisplatin + Gemcitabine
11100
13320
14430
16095
a) CBC.
b) RFT.
c) LFT.
d) CECT Thorax.
e) abdomen
f) Pelvis.
g) MRI.
h) ECG.
i) 2D-ECHO
j) .Histopathology
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
312
Medical Oncology
MO
MO026
CT for Ureter /
Bladder / Urethra
MO026D Cisplatin + 5 FU
7800
9360
10140
11310
a) CBC.
b) RFT.
c) LFT.
d) CECT Thorax.
e) abdomen
f) Pelvis.
g) histopathology
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
313
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
MO026
Package Name
CT for Ureter /
Bladder / Urethra
Procedure
Code
Procedure Name
MO026E Cisplatin + Paclitaxel
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
13500
16200
NABH
Package
Cost
17550
Outside State
NABH
Package Cost
19575
Mandatory Documents - Pre
Authorization
a) CBC.
b) RFT.
c) LFT.
d) CECT Thorax.
e) abdomen
f) Pelvis.
g) histopathology
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
314
Medical Oncology
MO
MO026
CT for Ureter /
Bladder / Urethra
MO026F Docetaxel
14400
17280
18720
20880
a) CBC.
b) RFT.
c) LFT.
d) CECT Thorax.
e) abdomen
f) Pelvis.
g) histopathology
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
315
Medical Oncology
MO
MO026
CT for Ureter /
Bladder / Urethra
MO026G Gemcitabine + Paclitaxel
17500
21000
22750
25375
a) CBC.
b) RFT.
c) LFT.
d) CECT Thorax.
e) abdomen
f) Pelvis.
g) histopathology
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
316
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
MO026
Package Name
CT for Ureter /
Bladder / Urethra
Procedure
Code
Procedure Name
MO026H Gemcitabine
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
9200
11040
NABH
Package
Cost
11960
Outside State
NABH
Package Cost
13340
Mandatory Documents - Pre
Authorization
a) CBC.
b) RFT.
c) LFT.
d) CECT Thorax.
e) abdomen
f) Pelvis.
g) histopathology
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
317
Medical Oncology
MO
MO026
CT for Ureter /
Bladder / Urethra
Methotrexate +
MO026I Vinblastin +
Doxorubicin + Cisplatin
6600
7920
8580
9570
a) CBC.
b) RFT.
c) LFT.
d) CECT Thorax.
e) abdomen
f) Pelvis.
g) MRI.
h) histopathology.
i) ECG.
j) ECHO
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
318
Medical Oncology
MO
MO026
CT for Ureter /
Bladder / Urethra
MO026J Paclitaxel + Carboplatin
15100
18120
19630
21895
a) CBC.
b) RFT.
c) LFT.
d) CECT Thorax.
e) abdomen
f) Pelvis.
g) histopathology
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
319
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
MO026
Package Name
CT for Ureter /
Bladder / Urethra
Procedure
Code
Procedure Name
MO026K Paclitaxel
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
5700
6840
NABH
Package
Cost
7410
Outside State
NABH
Package Cost
8265
Mandatory Documents - Pre
Authorization
a) CBC.
b) RFT.
c) LFT.
d) CECT Thorax.
e) abdomen
f) Pelvis.
g) histopathology
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
320
Medical Oncology
MO
MO027 CT for CA Penis
MO027A Cisplatin + Paclitaxel
13500
16200
17550
19575
a) CBC.
b) RFT.
c) LFT.
d) CECT Thorax.
e) abdomen
f) Pelvis.
g) histopathology
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
321
Medical Oncology
MO
MO027 CT for CA Penis
MO027B
CT for CA Penis - 5
FU + Cisplatin
7800
9360
10140
11310
a) CBC.
b) RFT.
c) LFT.
d) CECT Thorax.
e) abdomen
f) Pelvis.
g) histopathology
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
322
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
Package Name
MO027 CT for CA Penis
Procedure
Code
Procedure Name
MO027C Capecitabine
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
7400
8880
NABH
Package
Cost
9620
Outside State
NABH
Package Cost
10730
Mandatory Documents - Pre
Authorization
a) CBC.
b) RFT.
c) LFT.
d) CECT Thorax.
e) abdomen
f) Pelvis.
g) histopathology
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
323
Medical Oncology
MO
MO027 CT for CA Penis
MO027D Paclitaxel + Carboplatin
15100
18120
19630
21895
a) CBC.
b) RFT.
c) LFT.
d) CECT Thorax.
e) abdomen
f) Pelvis.
g) histopathology
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
324
Medical Oncology
MO
MO027 CT for CA Penis
MO027E Paclitaxel
5700
6840
7410
8265
a) CBC.
b) RFT.
c) LFT.
d) CECT Thorax.
e) abdomen
f) Pelvis.
g) histopathology
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
325
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
Package Name
MO027 CT for CA Penis
Procedure
Code
Procedure Name
MO027F Paclitaxel
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
12200
14640
NABH
Package
Cost
15860
Outside State
NABH
Package Cost
17690
Mandatory Documents - Pre
Authorization
a) CBC.
b) RFT.
c) LFT.
d) CECT Thorax.
e) abdomen
f) Pelvis.
g) histopathology
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
326
Medical Oncology
MO
MO027 CT for CA Penis
MO027G Paclitaxel + Carboplatin
7900
9480
10270
11455
a) CBC.
b) RFT.
c) LFT.
d) CECT Thorax.
e) abdomen
f) Pelvis.
g) histopathology
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
327
Medical Oncology
MO
MO028 CT for CA Prostate
MO028A Docetaxel
11700
14040
15210
16965
a) CBC.
b) RFT.
c) LFT.
d) PSA.
e) ECG.
f) CECTThorax.
g) abdomen
h) Pelvis.
i) bone scan.
j) histopathology
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
328
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
Package Name
MO028 CT for CA Prostate
Procedure
Code
Procedure Name
MO028B Docetaxel
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
14100
16920
NABH
Package
Cost
18330
Outside State
NABH
Package Cost
20445
Mandatory Documents - Pre
Authorization
a) CBC.
b) RFT.
c) LFT.
d) PSA.
e) ECG.
f) CECTThorax.
g) abdomen
h) Pelvis.
i) bone scan.
j) histopathology
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
329
Medical Oncology
MO
MO028 CT for CA Prostate
MO028C Etoposide + Carboplatin
7100
8520
9230
10295
a) CBC.
b) RFT.
c) LFT.
d) PSA.
e) ECG.
f) CECTThorax.
g) abdomen
h) Pelvis.
i) bone scan.
j) histopathology
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
330
Medical Oncology
MO
MO028 CT for CA Prostate
MO028D LHRH Agonist
15300
18360
19890
22185
a) CBC.
b) RFT.
c) LFT.
d) PSA.
e) ECG.
f) CECTThorax.
g) abdomen
h) Pelvis.
i) bone scan.
j) histopathology
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
331
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
Package Name
MO028 CT for CA Prostate
Procedure
Code
MO028E
Procedure Name
Mitoxantrone +
Prednisolone
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
4200
5040
NABH
Package
Cost
5460
Outside State
NABH
Package Cost
6090
Mandatory Documents - Pre
Authorization
a) CBC.
b) RFT.
c) LFT.
d) PSA.
e) ECG.
f) CECTThorax.
g) abdomen
h) Pelvis.
i) bone scan.
j) histopathology
y
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
332
Medical Oncology
MO
MO028 CT for CA Prostate
MO028F Paclitaxel + Carboplatin
7700
9240
10010
11165
a) CBC.
b) RFT.
c) LFT.
d) PSA.
e) ECG.
f) CECTThorax.
g) abdomen
h) Pelvis.
i) bone scan.
j) histopathology
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
333
Medical Oncology
MO
MO028 CT for CA Prostate
MO028G Paclitaxel + Carboplatin
15100
18120
19630
21895
a) CBC.
b) RFT.
c) LFT.
d) PSA.
e) ECG.
f) CECTThorax.
g) abdomen
h) Pelvis.
i) bone scan.
j) histopathology
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
334
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
Package Name
MO028 CT for CA Prostate
Procedure
Code
Procedure Name
MO028H Docetaxel
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
14700
17640
NABH
Package
Cost
19110
Outside State
NABH
Package Cost
21315
Mandatory Documents - Pre
Authorization
a) CBC.
b) RFT.
c) LFT.
d) PSA.
e) ECG.
f) CECTThorax.
g) abdomen
h) Pelvis.
i) bone scan.
j) histopathology
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
335
Medical Oncology
MO
MO029
CT for B - Cell NHL High Grade
(Except Burkitt's &
PCNSL)
MO029A R - CEOP
26200
31440
34060
37990
a) CBC.
b) Biochemistry.
c) PET CT or CECT Chest
abdomen .
d) pelvis.
e) Bone marrow studies.
f) Biopsy or fluid flow.
g) PB cytometry.
h) ECG.
i) 2D-ECHO
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
336
Medical Oncology
MO
MO029
CT for B - Cell NHL High Grade
(Except Burkitt's &
PCNSL)
MO029B R - CHOP
27000
32400
35100
39150
a) CBC.
b) Biochemistry.
c) PET CT or CECT Chest
abdomen .
d) pelvis.
e) Bone marrow studies.
f) Biopsy or fluid flow.
g) PB cytometry.
h) ECG.
i) 2D-ECHO
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
337
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
MO030
Package Name
CT for High - Grade
NHL - B Cell
Procedure
Code
MO030A
Procedure Name
Rituxmab +
Dexamethasone +
High Dose Cytarabine
+ Cisplatin
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
34900
41880
NABH
Package
Cost
45370
Outside State
NABH
Package Cost
50605
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
a) CBC.
MICROBIOLOGY,
b) Biochemistry.
HEMATOLOGY,
c) PET CT or CECT Chest
BIOCHEMISTRY,ETC.)
abdomen
c) DISCHARGE SUMMARY
d) pelvis.
OPEN
OF INPATIENT
e) Bone marrow studies.
DEPARTMENT.
f) Biopsy or fluid flow cytometry. d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
N
338
Medical Oncology
MO
CT for Relapsed B Cell NHL - High
MO031 Grade
(Except Burkitt's &
PCNSL)
MO031A GDP - R
35300
42360
45890
51185
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
a) CBC.
MICROBIOLOGY,
b) Biochemistry.
HEMATOLOGY,
c) PET CT or CECT Chest
BIOCHEMISTRY,ETC.)
abdomen
c) DISCHARGE SUMMARY
d) pelvis.
OPEN
OF INPATIENT
e) Bone marrow studies.
DEPARTMENT.
f) Biopsy or fluid flow cytometry. d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
339
Medical Oncology
MO
CT for Relapsed B Cell NHL - High
MO031 Grade
(Except Burkitt's &
PCNSL)
MO031B ICE - R
31900
38280
41470
46255
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
a) CBC.
HEMATOLOGY,
b) Biochemistry.
BIOCHEMISTRY,ETC.)
c) PET CT or CECT Chest
c) DISCHARGE SUMMARY
OPEN
abdomen
OF INPATIENT
d) pelvis.
DEPARTMENT.
e) Bone marrow studies.
d) DISCHARGE SUMMARY
f) Biopsy or fluid flow cytometry. OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
340
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
Package Name
CT for PMBCL /
Burkitt's Lymphoma /
MO032
Seropositive
B - Cell NHLR
Procedure
Code
Procedure Name
EPOCH - (CT for
PMBCL / Burkitt's
MO032A Lymphoma /
Seropositive
B - Cell NHLR )
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
31700
38040
NABH
Package
Cost
41210
Outside State
NABH
Package Cost
45965
Mandatory Documents - Pre
Authorization
a) CBC.
b) Biochemistry.
c) PET CT or CECT Chest
abdomen
d) pelvis.
e) Bone marrow studies.
f) Biopsy or fluid flow cytometry.
g) ECG.
h) 2D-ECHO
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
N
341
Medical Oncology
MO
MO033 CT for Burkitt's NHL
Codox - M - IVAC /
MO033A GMALL / BFM /
Hyper CVAD
34500
41400
44850
50025
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
a) CBC.
(PATHOLOGY, RADIOLOGY,
b) Biochemistry.
MICROBIOLOGY,
c) PET CT or CECT Chest
HEMATOLOGY,
abdomen
BIOCHEMISTRY,ETC.)
d) pelvis.
c) DISCHARGE SUMMARY
OPEN
e) Bone marrow studies.
OF INPATIENT
f) Biopsy or fluid flow cytometry. DEPARTMENT.
g) ECG.
d) DISCHARGE SUMMARY
h) 2D-ECHO
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
N
342
Medical Oncology
MO
MO034
CT for Low Grade B Cell NHL
MO034A
Bendamustine +
Rituximab
30700
36840
39910
44515
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
a) CBC.
MICROBIOLOGY,
b) Biochemistry.
HEMATOLOGY,
c) PET CT or CECT Chest
BIOCHEMISTRY,ETC.)
abdomen
c) DISCHARGE SUMMARY
d) pelvis.
OPEN
OF INPATIENT
e) Bone marrow studies.
DEPARTMENT.
f) Biopsy or fluid flow cytometry. d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
343
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
MO034
Package Name
CT for Low Grade B Cell NHL
Procedure
Code
MO034B
Procedure Name
Lenalidomide +
Rituximab
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
27500
33000
NABH
Package
Cost
35750
Outside State
NABH
Package Cost
39875
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
a) CBC.
MICROBIOLOGY,
b) Biochemistry.
HEMATOLOGY,
c) PET CT or CECT Chest
BIOCHEMISTRY,ETC.)
abdomen
c) DISCHARGE SUMMARY
d) pelvis.
OPEN
OF INPATIENT
e) Bone marrow studies.
DEPARTMENT.
f) Biopsy or fluid flow cytometry. d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
344
Medical Oncology
MO
MO035
CT for Low Grade
NHL
MO035A Rituximab
24800
29760
32240
35960
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
a) CBC.
MICROBIOLOGY,
b) Biochemistry.
HEMATOLOGY,
c) PET CT or CECT Chest
BIOCHEMISTRY,ETC.)
abdomen
c) DISCHARGE SUMMARY
d) pelvis.
OPEN
OF INPATIENT
e) Bone marrow studies.
DEPARTMENT.
f) Biopsy or fluid flow cytometry. d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
345
Medical Oncology
MO
MO035
CT for Low Grade
NHL
MO035B
Rituximab +
Cyclophosphamide +
Vincristine +
Prednisolone
25800
30960
33540
37410
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
a) CBC,
MICROBIOLOGY,
b) Biochemistry,
HEMATOLOGY,
c) USG abdmen
BIOCHEMISTRY,ETC.)
d) Pelvis CECT Chest abdomen c) DISCHARGE SUMMARY
e) pelvis,
OPEN
OF INPATIENT
f) Bone marrow studies,
DEPARTMENT.
g) Biopsy or fluid flow cytometry. d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
346
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
Package Name
CT for Chronic
MO036 Lymphocytic
Leukemia
Procedure
Code
MO036A
Procedure Name
Fludarabine +
Cyclophosphamide
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
18100
21720
NABH
Package
Cost
23530
Outside State
NABH
Package Cost
26245
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
a) CBC.
MICROBIOLOGY,
b) Biochemistry.
HEMATOLOGY,
c) Chest X ay
BIOCHEMISTRY,ETC.)
d) USG abdomen
c) DISCHARGE SUMMARY
e) pelvis or CECT Chest abdomen
OPEN
OF INPATIENT
f) pelvis.
DEPARTMENT.
g) Bone marrow studies.
d) DISCHARGE SUMMARY
h) Biopsy or fluid flow cytometry
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
347
Medical Oncology
MO
CT for Chronic
MO036 Lymphocytic
Leukemia
MO036B
Rituxmab +
Chlorambucil
24900
29880
32370
36105
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
a) CBC.
MICROBIOLOGY,
b) Biochemistry.
HEMATOLOGY,
c) Chest X ay
BIOCHEMISTRY,ETC.)
d) USG abdomen
c) DISCHARGE SUMMARY
e) pelvis or CECT Chest abdomen
OPEN
OF INPATIENT
f) pelvis.
DEPARTMENT.
g) Bone marrow studies.
d) DISCHARGE SUMMARY
h) Biopsy or fluid flow cytometry
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
348
Medical Oncology
MO
CT for Chronic
MO036 Lymphocytic
Leukemia
Rituximab +
MO036C Fludarabine +
Cyclophosphamide
40700
48840
52910
59015
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
a) CBC.
MICROBIOLOGY,
b) Biochemistry.
HEMATOLOGY,
c) Chest X ay
BIOCHEMISTRY,ETC.)
d) USG abdomen
c) DISCHARGE SUMMARY
e) pelvis or CECT Chest abdomen
OPEN
OF INPATIENT
f) pelvis.
DEPARTMENT.
g) Bone marrow studies.
d) DISCHARGE SUMMARY
h) Biopsy or fluid flow cytometry
OF DAY CARE DEPARTMENT.
e) CHARTS OF
.
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
349
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
Package Name
CT for Chronic
MO036 Lymphocytic
Leukemia
Procedure
Code
Procedure Name
MO036D Lenalidomide
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
4800
5760
NABH
Package
Cost
6240
Outside State
NABH
Package Cost
6960
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
a) CBC.
MICROBIOLOGY,
b) Biochemistry.
HEMATOLOGY,
c) Chest X ay
BIOCHEMISTRY,ETC.)
d) USG abdomen
c) DISCHARGE SUMMARY
e) pelvis or CECT Chest abdomen
OPEN
OF INPATIENT
f) pelvis.
DEPARTMENT.
g) Bone marrow studies.
d) DISCHARGE SUMMARY
h) Biopsy or fluid flow cytometry
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
350
Medical Oncology
MO
MO037
CT for Peripheral T Cell Lymphoma
EPOCH - (CT for
MO037A Peripheral T - Cell
Lymphoma)
5000
6000
6500
7250
a) CBC.
b) Biochemistry.
c) LDH.
d) PET CECT or CECT chest
abdomen
e) pelvis.
f) Bone marrow studies.
g) Biopsy
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
351
Medical Oncology
MO
MO037
CT for Peripheral T Cell Lymphoma
CHOP - (CT for
MO037B Peripheral T - Cell
Lymphoma)
4000
4800
5200
5800
a) CBC.
b) Biochemistry.
c) LDH.
d) PET CECT or CECT chest
abdomen
e) pelvis.
f) Bone marrow studies.
g) Biopsy
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
352
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
MO037
Package Name
CT for Peripheral T Cell Lymphoma
Procedure
Code
Procedure Name
SMILE - (CT for
MO037C Peripheral T - Cell
Lymphoma)
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
19300
23160
NABH
Package
Cost
25090
Outside State
NABH
Package Cost
27985
Mandatory Documents - Pre
Authorization
a) CBC.
b) Biochemistry.
c) LDH.
d) PET CECT
e) CECT chest abdomen
f) pelvis.
g) Bone marrow studies.
h) Biopsy
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
353
Medical Oncology
MO
MO038
CT for NK - T Cell
Lymphoma
MO038A
GELOX - (CT for NK T Cell Lymphoma)
18900
22680
24570
27405
a) CBC.
b) Biochemistry.
c) LDH.
d) PET CECT
e) CECT chest abdomen
f) pelvis.
g) Bone marrow studies.
h) Biopsy
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
354
Medical Oncology
MO
MO038
CT for NK - T Cell
Lymphoma
MO038B
LVP- (CT for NK - T
Cell Lymphoma)
7600
9120
9880
11020
a) CBC.
b) Biochemistry.
c) LDH.
d) PET CECT
e) CECT chest abdomen
f) pelvis.
g) Bone marrow studies.
h) Biopsy
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
355
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
MO039
Package Name
CT for Hodgkin's
Lymphoma
Procedure
Code
MO039A
Procedure Name
COPP- (CT for
Hodgkin's Lymphoma)
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
3600
4320
NABH
Package
Cost
4680
Outside State
NABH
Package Cost
5220
Mandatory Documents - Pre
Authorization
a) CBC.
b) Biochemistry.
c) PET CT or CECT Chest
abdomen
d) pelvis.
e) Bone marrow studies.
f) node Biopsy.
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
356
Medical Oncology
MO
MO039
CT for Hodgkin's
Lymphoma
MO039B
ABVD- (CT for
Hodgkin's Lymphoma)
10200
12240
13260
14790
a) CBC.
b) Biochemistry.
c) PET CT or CECT Chest
abdomen
d) pelvis.
e) Bone marrow studies.
f) node Biopsy.
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
357
Medical Oncology
MO
MO039
CT for Hodgkin's
Lymphoma
MO039C
CT for Hodgkin's
Lymphoma - AEVD
10200
12240
13260
14790
a) CBC.
b) Biochemistry.
c) PET CT or CECT Chest
abdomen
d) pelvis.
e) Bone marrow studies.
f) node Biopsy.
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
358
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
MO040
Package Name
CT for Relapsed
Hodgkin Lymphoma
Procedure
Code
MO040A
Procedure Name
ICE- (CT for Relapsed
Hodgkin Lymphoma)
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
9700
11640
NABH
Package
Cost
12610
Outside State
NABH
Package Cost
14065
Mandatory Documents - Pre
Authorization
a) CBC.
b) Biochemistry.
c) LDH.
d) PET CECT or CECT chest
abdomen
e) pelvis.
f) Bone marrow studies.
g) Biopsy
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
359
Medical Oncology
MO
MO040
CT for Relapsed
Hodgkin Lymphoma
MINE- (CT for
MO040B Relapsed Hodgkin
Lymphoma)
9700
11640
12610
14065
a) CBC.
b) Biochemistry.
c) LDH.
d) PET CECT or CECT chest
abdomen
e) pelvis.
f) Bone marrow studies.
g) Biopsy
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
360
Medical Oncology
MO
MO040
CT for Relapsed
Hodgkin Lymphoma
MO040C PTCL - GDP
12500
15000
16250
18125
a) CBC.
b) Biochemistry
c) PET CT or CECT Chest
abdomen
d) pelvis.
e) Bone marrow studies.
f) node Biopsy.
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
361
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
MO041
Package Name
CT for Relapsed NHL
& HL
Procedure
Code
MO041A
Procedure Name
DHAP- (CT for
Relapsed NHL & HL)
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
11500
13800
NABH
Package
Cost
14950
Outside State
NABH
Package Cost
16675
Mandatory Documents - Pre
Authorization
a) CBC.
b) Biochemistry
c) PET CT or CECT Chest
abdomen
d) pelvis.
e) Bone marrow studies.
f) node Biopsy.
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
N
362
Medical Oncology
MO
MO042
CT for MM /
Amyloidosis / POEMS
MO042A
LD- (CT for MM /
Amyloidosis / POEMS)
6000
7200
7800
8700
a) CBC.
b) Biochemistry.
c) Serum protein electrophoresis.
d) Immunofixation.
e) Serum free light chain assay.
f) Bone marrow studies.
g) Skeletal survey.
h) Urine BJP
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
363
Medical Oncology
MO
MO042
CT for MM /
Amyloidosis / POEMS
MO042B POM DEX
6800
8160
8840
9860
a) CBC.
b) Biochemistry.
c) Serum protein electrophoresis.
d) Immunofixation.
e) Serum free light chain assay.
f) Bone marrow studies.
g) Skeletal survey.
h) Urine BJP
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
364
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
MO043
Package Name
CT for MM /
Amyloidosis
Procedure
Code
MO043A
Procedure Name
CTD- (CT for MM /
Amyloidosis)
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
4000
4800
NABH
Package
Cost
5200
Outside State
NABH
Package Cost
5800
Mandatory Documents - Pre
Authorization
a) CBC.
b) Biochemistry.
c) Serum protein electrophoresis.
d) Immunofixation.
e) Serum free light chain assay.
f) Bone marrow studies.
g) Skeletal survey.
h) Urine BJP
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
365
Medical Oncology
MO
MO043
CT for MM /
Amyloidosis
MO043B
MPT- (CT for MM /
Amyloidosis)
4100
4920
5330
5945
a) CBC.
b) Biochemistry.
c) Serum protein electrophoresis.
d) Immunofixation.
e) Serum free light chain assay.
f) Bone marrow studies.
g) Skeletal survey.
h) Urine BJP
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
366
Medical Oncology
MO
MO043
CT for MM /
Amyloidosis
MO043C
VCD - (CT for MM /
Amyloidosis)
14600
17520
18980
21170
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
a) CBC.
BIOCHEMISTRY,ETC.)
b) Biochemistry.
c) DISCHARGE SUMMARY
c) Serum protein electrophoresis.
OPEN
OF INPATIENT
d) Bone marrow studies.
DEPARTMENT.
e) skeletal survey.
d) DISCHARGE SUMMARY
f) Urine BJP.
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
367
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
MO043
Package Name
CT for MM /
Amyloidosis
Procedure
Code
MO043D
Procedure Name
CD - (CT for MM /
Amyloidosis)
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
13300
15960
NABH
Package
Cost
17290
Outside State
NABH
Package Cost
19285
Mandatory Documents - Pre
Authorization
a) CBC.
b) Biochemistry.
c) Serum protein electrophoresis.
d) Immunofixation.
e) Serum free light chain assay.
f) Bone marrow studies.
g) Skeletal survey.
h) Urine BJP
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
368
Medical Oncology
MO
MO043
CT for MM /
Amyloidosis
MO043E
VMP - (CT for MM /
Amyloidosis)
12600
15120
16380
18270
a) CBC.
b) Biochemistry.
c) Serum protein electrophoresis.
d) Immunofixation.
e) Serum free light chain assay.
f) Bone marrow studies.
g) Skeletal survey.
h) Urine BJP
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
369
Medical Oncology
MO
MO043
CT for MM /
Amyloidosis
MO043F
VRD - (CT for MM /
Amyloidosis)
17800
21360
23140
25810
a) CBC.
b) Biochemistry.
c) Serum protein electrophoresis.
d) Immunofixation.
e) Serum free light chain assay.
f) Bone marrow studies.
g) Skeletal survey.
h) Urine BJP
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
370
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
MO043
Package Name
CT for MM /
Amyloidosis
Procedure
Code
MO043G
Procedure Name
VID - (CT for MM /
Amyloidosis)
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
15000
18000
NABH
Package
Cost
19500
Outside State
NABH
Package Cost
21750
Mandatory Documents - Pre
Authorization
a) CBC.
b) Biochemistry.
c) Serum protein electrophoresis.
d) Immunofixation.
e) Serum free light chain assay.
f) Bone marrow studies.
g) Skeletal survey.
h) Urine BJP
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
371
Medical Oncology
MO
MO044
CT for Chronic
Myeloid Leukemia
Imatinib - (CT for
MO044A Chronic Myeloid
Leukema Per Cycle)
19400
23280
25220
28130
a) CBC.
b) RFT.
c) LFT.
d) MDC.
e) BONE MARROW.
f) BIOPSY.
g) CYTOGENETICS.
h) RQ PCR BCR ABL
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
N
372
Medical Oncology
MO
CT for
MO045 Myeloproliferative
Neoplasm
MO045A Hydroxurea
2200
2640
2860
3190
a) CBC.
b) RFT.
c) LFT.
d) MDC.
e) BONE MARROW .
f) CYTOGENETICS
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
N
SL NO
373
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
MO046
Package Name
CT for Acute Myeloid
Leukemia
Procedure
Code
Procedure Name
MO046A Consolidation
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
60000
72000
NABH
Package
Cost
78000
Outside State
NABH
Package Cost
87000
Mandatory Documents - Pre
Authorization
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) Bone marrow aspiration.
f) flow cytometry or Peripheral
blood flow cytometry.
g) cytogenetics.
h) Molecular
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
374
Medical Oncology
MO
MO046
CT for Acute Myeloid
Leukemia
MO046B Induction
96000
115200
124800
139200
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) Bone marrow aspiration.
f) flow cytometry or Peripheral
blood flow cytometry.
g) cytogenetics.
h) Molecular
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
375
Medical Oncology
MO
CT for Acute
MO047 Lymphoblastic
Leukemia
Consolidation
MO047A (Phase II, CNS
Therapy Reinduction)
160000
192000
208000
232000
a) CBC BIOCHEM.
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
376
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
Package Name
CT for Acute
MO047 Lymphoblastic
Leukemia
Procedure
Code
Procedure Name
MO047B Induction
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
80000
96000
NABH
Package
Cost
104000
Outside State
NABH
Package Cost
116000
Mandatory Documents - Pre
Authorization
a) CBC.
b) MDC.
c) HIV.
d) HBSAG.
e) HCV.
f) 2D ECHO.
g) NCCT CHEST.
h) BONE MARROW or
Peripheral bloodFLOW
CYTOMETRY.
i) CYTOGENETICS.
j) Molecular.
k) BIOPSY.
l) PET-CT or CECT chest
abdomen
m) Pelvis(if LBL)
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
377
Medical Oncology
MO
CT for Acute
MO047 Lymphoblastic
Leukemia
MO047C Maintenance
4000
4800
5200
5800
a) CBC.
b) MDC.
c) HIV.
d) HBSAG.
e) HCV.
f) BIOCHEM.
g) CSF CYTOMORPHOLOGY.
h) FLOW CYTOMETRY.
i) BONE MARROW FLOW
CYTOMETRY.
j) CYTOGENETICS.
k) NGS.
l) BIOPSY
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
378
Medical Oncology
MO
MO048
CT for Lymphoblastic
Lymphoma
Consolidation
MO048A (Phase II, CNS
Therapy Reinduction)
160000
192000
208000
232000
a) CBC BIOCHEM.
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
379
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
MO048
Package Name
CT for Lymphoblastic
Lymphoma
Procedure
Code
Procedure Name
MO048B Induction
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
80000
96000
NABH
Package
Cost
104000
Outside State
NABH
Package Cost
116000
Mandatory Documents - Pre
Authorization
a) CBC.
b) MDC.
c) HIV.
d) HBSAG.
e) HCV.
f) 2D ECHO.
g) NCCT CHEST.
h) BONE MARROW or
Peripheral bloodFLOW
CYTOMETRY.
i) CYTOGENETICS.
j) Molecular.
k) BIOPSY.
l) PET-CT or CECT chest
abdomen
m) Pelvis(if LBL)
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
380
Medical Oncology
MO
MO048
CT for Lymphoblastic
Lymphoma
MO048C Maintenance
4000
4800
5200
5800
a) CBC.
b) MDC.
c) HIV.
d) HBSAG.
e) HCV.
f) BIOCHEM.
g) CSF CYTOMORPHOLOGY.
h) FLOW CYTOMETRY.
i) BONE MARROW FLOW
CYTOMETRY.
j) CYTOGENETICS.
k) NGS.
l) BIOPSY
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
381
Medical Oncology
MO
MO049
CT for Acute
Promyelocytic
Leukemia
(High Risk)
MO049A High Risk Consolidation
32000
38400
41600
46400
a) CBC BIOCHEM
b) ECG BONEMARROW
c) RQPCR PML RARA
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
382
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
MO049
Package Name
CT for Acute
Promyelocytic
Leukemia
(High Risk)
Procedure
Code
Procedure Name
MO049B High Risk Induction
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
96000
115200
NABH
Package
Cost
124800
Outside State
NABH
Package Cost
139200
Mandatory Documents - Pre
Authorization
a) CBC.
b) MDC.
c) HIV.
d) HBSAG.
e) HCV.
f) BIOCHEM.
g) PT.
h) APTT.
i) FIBRINOGEN.
j) 2D ECHO.
k) NCCT CHEST.
l) BONE MARROW FLOW
CYTOMETRY.
m) CYTOGENETICS.
n) RQPCR PML RARA.
o) BIOPSY
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
383
Medical Oncology
MO
MO049
CT for Acute
Promyelocytic
Leukemia
(High Risk)
MO049C High Risk Maintenance
8000
9600
10400
11600
a) CBC.
b) MDC.
c) HIV.
d) HBSAG.
e) HCV.
f) BIOCHEM.
g) PT.
h) APTT.
i) FIBRINOGEN.
j) 2D ECHO.
k) NCCT CHEST.
l) BONE MARROW FLOW
CYTOMETRY.
m) CYTOGENETICS.
n) RQPCR PML RARA.
o) BIOPSY
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
384
Medical Oncology
MO
MO050
CT for Acute
Promyelocytic
Leukemia
(Low Risk)
MO050A Low Risk Consolidation
12000
14400
15600
17400
a)CBC LFT
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
385
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
MO050
Package Name
CT for Acute
Promyelocytic
Leukemia
(Low Risk)
Procedure
Code
Procedure Name
MO050B Low Risk Induction
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
80000
96000
NABH
Package
Cost
104000
Outside State
NABH
Package Cost
116000
Mandatory Documents - Pre
Authorization
a) CBC BIOCHEM.
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
386
Medical Oncology
MO
MO051 Febrile Neutopenia
MO051A First Line Antibiotics
28000
33600
36400
40600
a) CBC.
b) BIOCHEM.
c) ECG.
d) BONE MARROW.
e) RQ PCR.
f) PML RARA
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
387
Medical Oncology
MO
MO051 Febrile Neutopenia
MO051B
Second Line Antibiotics
and Antifungals
60000
72000
78000
87000
a) CBC.
b) LFT.
c) RQ
d) PCR.
e) PML RARA
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
388
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
Package Name
Chemotherapy
Complications MO052
Tumor Lysis
Syndrome
Procedure
Code
Procedure Name
Chemotherapy
MO052A Complications - Tumor
Lysis Syndrome
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
24000
28800
NABH
Package
Cost
31200
Outside State
NABH
Package Cost
34800
Mandatory Documents - Pre
Authorization
a) CBC.
b) LFT.
c) Serum Electrolytes
d) Blood Phosphate levels.
e) Uric Acid.
f) BUN
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
N
389
Medical Oncology
MO
Granulocyte Colony
MO053
Stimulating Factor Use
Granulocyte Colony
MO053A
Stimulating Factor Use
12800
15360
16640
18560
a) CBC.
b) Bone marrow.
c) RFT.
d) LFT
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
N
390
Medical Oncology
MO
MO054
CT for Langerhans
Cell Histiocytosis
MO054A
Langerhans Cell
Histiocytosis
(Histiocytosis Protocol Induction)
22400
26880
29120
32480
a) CBC.
b) RFT.
c) LFT.
d) MDC.
e) BONE MARROW.
f) BIOPSY.
g) SKELETAL SURVEY
h) PET CECT
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
391
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
MO054
Package Name
CT for Langerhans
Cell Histiocytosis
Procedure
Code
MO054B
Procedure Name
Langerhans Cell
Histiocytosis
(Histiocytosis Protocol Maintenance)
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
17000
20400
NABH
Package
Cost
22100
Outside State
NABH
Package Cost
24650
Mandatory Documents - Pre
Authorization
a) CBC.
b) RFT.
c) LFT.
d) MDC.
e) BONE MARROW.
f) SKELETAL SURVEY
g) PET CECT
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
392
Medical Oncology
MO
CT for Low Grade
MO055
Glioma
Vincristine +
MO055A
Carboplatin
5600
6720
7280
8120
a) CBC.
b) Biochemistry.
c) MRI.
d) Biopsy
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
393
Medical Oncology
MO
CT for Low Grade
MO055
Glioma
MO055B Vinblastin
1900
2280
2470
2755
a) CBC.
b) Biochemistry.
c) MRI.
d) Biopsy
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
394
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
Package Name
CT for
MO056 Medulloblastoma /
Brain PNET
Procedure
Code
Procedure Name
MO056A PACKER
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
4900
5880
NABH
Package
Cost
6370
Outside State
NABH
Package Cost
7105
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
a) CBC.
BIOCHEMISTRY,ETC.)
b) Biochemistry.
c) DISCHARGE SUMMARY
c) MRI (BRAIN AND SPINE).
OPEN
OF INPATIENT
d) Biopsy.
DEPARTMENT.
e) CSF CYTOLOGY.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
395
Medical Oncology
MO
CT for
MO056 Medulloblastoma /
Brain PNET
CET - (CT for
MO056B Medulloblastoma /
Brain PNET)
8300
9960
10790
12035
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
a) CBC.
BIOCHEMISTRY,ETC.)
b) Biochemistry.
c) DISCHARGE SUMMARY
c) MRI (BRAIN AND SPINE).
OPEN
OF INPATIENT
d) Biopsy.
DEPARTMENT.
e) CSF CYTOLOGY.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
396
Medical Oncology
MO
MO057 CT for Neuroblastoma
MO057A
Cabroplatin +
Etoposide +
Cyclophosphamide +
Doxorubicin
7900
9480
10270
11455
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
a) CBC.
MICROBIOLOGY,
b) Biochemistry.
HEMATOLOGY,
c) CECT
BIOCHEMISTRY,ETC.)
d) MRI.
c) DISCHARGE SUMMARY
e) BONE MARROW STUDIES.
OPEN
OF INPATIENT
f) MIBG OR BONE OR PET CT
DEPARTMENT.
SCAN.
d) DISCHARGE SUMMARY
g) BIOPSY.
OF DAY CARE DEPARTMENT.
h) FISH
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
397
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
Package Name
MO057 CT for Neuroblastoma
Procedure
Code
Procedure Name
MO057B RAPID COJEC
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
6800
8160
NABH
Package
Cost
8840
Outside State
NABH
Package Cost
9860
Mandatory Documents - Pre
Authorization
a) CBC.
b) Biochemistry.
c) CECT
d) MRI.
e) BONE MARROW STUDIES.
f) MIBG OR BONE OR PET
CT SCAN.
g) BIOPSY.
h) FISH
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
398
Medical Oncology
MO
MO057 CT for Neuroblastoma
MO057C RETINOID
2000
2400
2600
2900
a) CBC.
b) Biochemistry
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
399
Medical Oncology
MO
MO058 CT for Retinoblastoma MO058A JOE / COPE
7100
8520
9230
10295
a) CBC.
b) Biochemistry.
c) MRI (BRAIN AND
ORBITS).
d) CT (BRAIN AND ORBITS).
e) ULTRASONOGRAPHY.
f) BONE MARROW
g) CSF STUDIES
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
N
SL NO
400
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
MO059
Package Name
CT for
Rhabdomyosarcoma
Procedure
Code
MO059A
Procedure Name
VCD - (CT for
Rhabdomyosarcoma)
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
4800
5760
NABH
Package
Cost
6240
Outside State
NABH
Package Cost
6960
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
a) CBC.
HEMATOLOGY,
b) Biochemistry.
BIOCHEMISTRY,ETC.)
c) MRI OR CECT.
c) DISCHARGE SUMMARY
OPEN
d) BONE MARROW STUDIES. OF INPATIENT
e) BONE SCAN OR PET CT.
DEPARTMENT.
f) Biopsy
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
401
Medical Oncology
MO
MO059
CT for
Rhabdomyosarcoma
MO059B
VIE - (CT for
Rhabdomyosarcoma)
16200
19440
21060
23490
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
a) CBC.
HEMATOLOGY,
b) Biochemistry.
BIOCHEMISTRY,ETC.)
c) MRI OR CECT.
c) DISCHARGE SUMMARY
d) BONE MARROW STUDIES. OF INPATIENT
OPEN
e) BONE SCAN OR PET CT.
DEPARTMENT.
f) Biopsy
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
402
Medical Oncology
MO
MO060
CT for Relapse
Rhabdomyosarcoma
MO060A VTC + VAC
12200
14640
15860
17690
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
a) CBC.
MICROBIOLOGY,
b) Biochemistry.
HEMATOLOGY,
c) MRI OR CECT.
BIOCHEMISTRY,ETC.)
d) BONE MARROW STUDIES. c) DISCHARGE SUMMARY
e) BONE SCAN OR PET CT.
OPEN
OF INPATIENT
f) Biopsy.
DEPARTMENT.
g) 2D ECHO
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
N
SL NO
403
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
Package Name
MO061 CT for Wilms Tumor
Procedure
Code
Procedure Name
MO061A VINC + ACTIN. D
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
4350
5220
NABH
Package
Cost
5655
Outside State
NABH
Package Cost
6307
Mandatory Documents - Pre
Authorization
a) CBC.
b) Biochemistry.
c) CT CHEST ABDOMEN.
d) ULTRASONOGRAPHY.
e) BIOPSY
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
404
Medical Oncology
MO
MO061 CT for Wilms Tumor
MO061B
VINC + ACTIN. D +
DOX
4350
5220
5655
6307
a) CBC.
b) Biochemistry.
c) CT CHEST ABDOMEN.
d) ULTRASONOGRAPHY.
e) BIOPSY.
f) 2D ECHO
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
405
Medical Oncology
MO
MO061 CT for Wilms Tumor
MO061C
Cyclo + Dox + Etop +
Vinc + Actino . D
12300
14760
15990
17835
a) CBC.
b) Biochemistry.
c) CT CHEST ABDOMEN.
d) ULTRASONOGRAPHY.
e) BIOPSY.
f) 2D ECHO
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
406
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
Package Name
CT for Pediatric
MO062 Acute Lymphoblastic
Leukemia
Procedure
Code
Procedure Name
Consolidation
MO062A (Phase II, CNS
Therapy Reinduction)
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
208600
250320
NABH
Package
Cost
271180
Outside State
NABH
Package Cost
302470
Mandatory Documents - Pre
Authorization
a) CBC BIOCHEM.
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OF INPATIENT
OPEN
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
Y
407
Medical Oncology
MO
CT for Pediatric
MO062 Acute Lymphoblastic
Leukemia
MO062B Induction
72000
86400
93600
104400
a) CBC.
b) MDC.
c) HIV.
d) HBSAG.
e) HCV.
f) 2D ECHO.
g) NCCT CHEST.
h) BONE MARROW or
Peripheral bloodFLOW
CYTOMETRY.
i) CYTOGENETICS.
j) Molecular.
k) BIOPSY.
l) PET-CT or CECT chest
abdomen
m) Pelvis(if LBL)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OF INPATIENT
OPEN
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
Y
408
Medical Oncology
MO
CT for Pediatric
MO062 Acute Lymphoblastic
Leukemia
MO062C Maintenance
2500
3000
3250
3625
a) CBC.
b) MDC.
c) HIV.
d) HBSAG.
e) HCV.
f) BIOCHEM.
g) CSF CYTOMORPHOLOGY.
h) FLOW CYTOMETRY.
i) BONE MARROW FLOW
CYTOMETRY.
j) CYTOGENETICS.
k) NGS.
l) BIOPSY
BAR CODE OF THE DRUGS,
REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
OPEN
DISCHARGE SUMMARY OF
INPATIENT DEPARTMENT,
DISCHARGE SUMMARY OF
DAY CARE DEPARTMENT,
CHARTS OF
CHEMOTHERAPY REGIMEN
Y
409
Medical Oncology
MO
CT for Pediatric
MO063 Lymphoblastic
Lymphoma
Consolidation
MO063A (Phase II, CNS
Therapy Reinduction)
208600
250320
271180
302470
a) CBC BIOCHEM.
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OF INPATIENT
OPEN
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
Y
SL NO
410
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
Package Name
CT for Pediatric
MO063 Lymphoblastic
Lymphoma
Procedure
Code
Procedure Name
MO063B Induction
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
72000
86400
NABH
Package
Cost
93600
Outside State
NABH
Package Cost
104400
Mandatory Documents - Pre
Authorization
a) CBC.
b) MDC.
c) HIV.
d) HBSAG
e) HCV.
f) 2D ECHO.
g) NCCT CHEST.
h) BONE MARROW or
Peripheral bloodFLOW
CYTOMETRY.
i) CYTOGENETICS.
j) Molecular.
k) BIOPSY.
l) PET-CT or CECT chest
abdomen
m) Pelvis(if LBL)
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OF INPATIENT
OPEN
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
Y
411
Medical Oncology
MO
CT for Pediatric
MO063 Lymphoblastic
Lymphoma
MO063C Maintenance
2500
3000
3250
3625
a) CBC.
b) MDC.
c) HIV.
d) HBSAG.
e) HCV.
f) BIOCHEM.
g) CSF CYTOMORPHOLOGY.
h) FLOW CYTOMETRY.
i) BONE MARROW FLOW
CYTOMETRY.
j) CYTOGENETICS.
k) NGS.
l) BIOPSY
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OF INPATIENT
OPEN
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
Y
412
Medical Oncology
MO
CT for Pediatric
MO064 Acute Myeloid
Leukemia
MO064A
Consolidation - High
Dose Cytarabine
57600
69120
74880
83520
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) Bone marrow aspiration.
f) flow cytometry or Peripheral
blood flow cytometry.
g) cytogenetics.
h) Molecular
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OF INPATIENT
OPEN
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
Y
SL NO
413
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
Package Name
CT for Pediatric
MO064 Acute Myeloid
Leukemia
Procedure
Code
Procedure Name
MO064B Induction
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
94400
113280
NABH
Package
Cost
122720
Outside State
NABH
Package Cost
136880
Mandatory Documents - Pre
Authorization
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) Bone marrow aspiration.
f) flow cytometry or Peripheral
blood flow cytometry.
g) cytogenetics.
h) Molecular
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OF INPATIENT
OPEN
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
Y
414
Medical Oncology
MO
CT for Pediatric
MO064 Acute Myeloid
Leukemia
MO064C Induction
92800
111360
120640
134560
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) Bone marrow aspiration.
f) flow cytometry or Peripheral
blood flow cytometry.
g) cytogenetics.
h) Molecular
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OF INPATIENT
OPEN
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
Y
415
Medical Oncology
MO
CT for Pediatric
MO065 Acute Promyelocytic
Leukemia
MO065A Consolidation
36800
44160
47840
53360
a) CBC BIOCHEM
b) ECG BONEMARROW
c) RQPCR PML RARA
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
416
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
Package Name
CT for Pediatric
MO065 Acute Promyelocytic
Leukemia
Procedure
Code
Procedure Name
MO065B Induction
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
97600
117120
NABH
Package
Cost
126880
Outside State
NABH
Package Cost
141520
Mandatory Documents - Pre
Authorization
a) CBC BIOCHEM.
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
Y
417
Medical Oncology
MO
CT for Pediatric
MO065 Acute Promyelocytic
Leukemia
MO065C Maintenance
39300
47160
51090
56985
a) CBC.
b) MDC.
c) HIV.
d) HBSAG.
e) HCV.
f) BIOCHEM.
g) PT.
h) APTT.
i) FIBRINOGEN.
j) 2D ECHO.
k) NCCT CHEST.
l) BONE MARROW FLOW
CYTOMETRY.
m) CYTOGENETICS.
n) RQPCR PML RARA.
o) BIOPSY
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
418
Medical Oncology
MO
MO066
CT for Pediatric
Hodgkins Lymphoma
MO066A COPDAC
7800
9360
10140
11310
a) CBC.
b) Biochemistry.
c) PET CT or CECT Chest
abdomen
d) pelvis.
e) Bone marrow studies.
f) node Biopsy.
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
419
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
MO066
Package Name
CT for Pediatric
Hodgkins Lymphoma
Procedure
Code
Procedure Name
OPEA - (CT for
MO066B Pediatric Hodgkins
Lymphoma)
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
13000
15600
NABH
Package
Cost
16900
Outside State
NABH
Package Cost
18850
Mandatory Documents - Pre
Authorization
a) CBC.
b) Biochemistry.
c) PET CT or CECT Chest
abdomen
d) pelvis.
e) Bone marrow studies.
f) node Biopsy.
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
420
Medical Oncology
MO
CT for Pediatric
MO067 Hodgkins Lymphoma
Relapse
ICE - (CT for Pediatric
MO067A Hodgkins Lymphoma
Relapse)
21500
25800
27950
31175
a) CBC.
b) Biochemistry.
c) PET CT or CECT Chest
abdomen
d) pelvis.
e) Bone marrow studies.
f) node Biopsy.
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
Y
421
Medical Oncology
MO
CT for Pediatric
MO067 Hodgkins Lymphoma
Relapse
DECA - (CT for
MO067B Pediatric Hodgkins
Lymphoma Relapse)
17800
21360
23140
25810
a) CBC.
b) Biochemistry.
c) PET CT or CECT Chest
abdomen
d) pelvis.
e) Bone marrow studies.
f) node Biopsy.
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OF INPATIENT
OPEN
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
Y
SL NO
422
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
Package Name
CT for Pediatric
MO067 Hodgkins Lymphoma
Relapse
Procedure
Code
Procedure Name
IGVD - (CT for
MO067C Pediatric Hodgkins
Lymphoma Relapse)
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
34000
40800
NABH
Package
Cost
44200
Outside State
NABH
Package Cost
49300
Mandatory Documents - Pre
Authorization
a) CBC.
b) Biochemistry.
c) PET CT or CECT Chest
abdomen
d) pelvis.
e) Bone marrow studies.
f) node Biopsy.
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
Y
423
Medical Oncology
MO
MO068
CT for Pediatric Non
Hodgkins Lymphoma
MO068A
LMB 89 - 96 Consolidation
33500
40200
43550
48575
a) CBC.
b) Biochemistry.
c) PET CT or CECT Chest
abdomen
d) pelvis.
e) Bone marrow studies.
f) Biopsy or fluid flow cytometry.
g) ECG.
h) 2D-ECHO
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OF INPATIENT
OPEN
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
Y
424
Medical Oncology
MO
MO068
CT for Pediatric Non
Hodgkins Lymphoma
MO068B
LMB 89 - 96 Induction - COPADAM
33100
39720
43030
47995
a) CBC.
b) Biochemistry.
c) PET CT or CECT Chest
abdomen
d) pelvis.
e) Bone marrow studies.
f) Biopsy or fluid flow cytometry.
g) ECG.
h) 2D-ECHO
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OF INPATIENT
OPEN
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
Y
SL NO
425
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
MO068
Package Name
CT for Pediatric Non
Hodgkins Lymphoma
Procedure
Code
MO068C
Procedure Name
LMB 89 - 96 Maintenance
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
15400
18480
NABH
Package
Cost
20020
Outside State
NABH
Package Cost
22330
Mandatory Documents - Pre
Authorization
a) CBC.
b) Biochemistry.
c) PET CT or CECT Chest
abdomen
d) pelvis.
e) Bone marrow studies.
f) Biopsy or fluid flow cytometry.
g) ECG.
h) 2D-ECHO
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OF INPATIENT
OPEN
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
Y
426
Medical Oncology
MO
MO068
CT for Pediatric Non
Hodgkins Lymphoma
MO068D MCP - 842
13200
15840
17160
19140
a) CBC.
b) Biochemistry.
c) PET CT or CECT Chest
abdomen
d) pelvis.
e) Bone marrow studies.
f) Biopsy or fluid flow cytometry.
g) ECG.
h) 2D-ECHO
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OF INPATIENT
OPEN
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
Y
427
Medical Oncology
MO
MO069
PEDIATRICGCT/JEB
MO069A PEDIATRIC-GCT/JEB
10000
12000
13000
14500
a) CBC.
b) Biochemistry.
c) TUMOR MARKERS.
d) CECT CHEST
e) ABDOMEN.
f) Biopsy.
g) AUDIOMETRY.
h) GFR
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
N
SL NO
428
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
MO070
Package Name
CT for Pediatric
Hepatoblastoma
Procedure
Code
MO070A
Procedure Name
Carboplatin + Cisplatin
+ Doxorubicin
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
4900
5880
NABH
Package
Cost
6370
Outside State
NABH
Package Cost
7105
Mandatory Documents - Pre
Authorization
a) CBC.
b) Biochemistry.
c) CECT CHEST
d) ABDOMEN.
e) Biopsy.
f) ECG.
g) 2D-ECHO.
h) AUDIOMETRY.
i) GFR
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
429
Medical Oncology
MO
MO070
CT for Pediatric
Hepatoblastoma
MO070B Cisplatin
5600
6720
7280
8120
a) CBC.
b) Biochemistry.
c) S.AFP.
d) CECT CHEST
e) ABDOMEN.
f) Biopsy.
g) AUDIOMETRY.
h) GFR
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
430
Medical Oncology
MO
MO071 CT for CA Lung
MO071A Docetaxel
16200
19440
21060
23490
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax.
f) abdomen
g) Pelvis
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
431
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
Package Name
MO071 CT for CA Lung
Procedure
Code
Procedure Name
MO071B Erlotinib
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
13000
15600
NABH
Package
Cost
16900
Outside State
NABH
Package Cost
18850
Mandatory Documents - Pre
Authorization
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax.
f) Abdomen
g) Pelvis.
h) EGFR mutation positive
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
432
Medical Oncology
MO
MO071 CT for CA Lung
MO071C Gefitnib
11000
13200
14300
15950
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax.
f) Abdomen
g) Pelvis.
h) EGFR mutation positive
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
433
Medical Oncology
MO
MO071 CT for CA Lung
MO071D Paclitaxel + Carboplatin
15100
18120
19630
21895
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax.
f) abdomen
g) Pelvis.
h) histopathology (non small cell
carcinoma)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
434
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
Package Name
MO071 CT for CA Lung
Procedure
Code
MO071E
Procedure Name
Pemetrexed +
Carboplatin
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
10000
12000
NABH
Package
Cost
13000
Outside State
NABH
Package Cost
14500
Mandatory Documents - Pre
Authorization
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax.
f) abdomen
g) Pelvis.
h) histopathology (non small cell
– adenocarcinoma or
adenosquamous carcinoma
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
435
Medical Oncology
MO
MO071 CT for CA Lung
MO071F Topotecan
24600
29520
31980
35670
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax.
f) abdomen
g) Pelvis.
h) histopathology - Small Cell
Lung Carcinoma
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
436
Medical Oncology
MO
MO071 CT for CA Lung
MO071G Docetaxel
14600
17520
18980
21170
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
a) CBC.
MICROBIOLOGY,
b) LFT.
HEMATOLOGY,
c) RFT.
BIOCHEMISTRY,ETC.)
d) RBS.
c) DISCHARGE SUMMARY
e) CECT Thorax.
OPEN
OF INPATIENT
f) abdomen
DEPARTMENT.
g) Pelvis.
d) DISCHARGE SUMMARY
h) histopathology- Non Small cell
OF DAY CARE DEPARTMENT.
Lung cancer
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
437
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
Package Name
MO071 CT for CA Lung
Procedure
Code
Procedure Name
MO071H Etoposide + Carboplatin
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
7100
8520
NABH
Package
Cost
9230
Outside State
NABH
Package Cost
10295
Mandatory Documents - Pre
Authorization
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax.
f) abdomen
g) Pelvis.
h) histopathology - Small Cell
Lung Carcinoma
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
438
Medical Oncology
MO
MO071 CT for CA Lung
MO071I
Etoposide + Cisplatin
5500
6600
7150
7975
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax.
f) abdomen
g) Pelvis.
h) histopathology - Small Cell
Lung Carcinoma
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
439
Medical Oncology
MO
MO071 CT for CA Lung
MO071J Gemcitabine
8900
10680
11570
12905
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax.
f) abdomen
g) Pelvis.
h) histopathology (non small cell
carcinoma)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
440
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
Package Name
MO071 CT for CA Lung
Procedure
Code
MO071K
Procedure Name
Gemcitabine +
Carboplatin
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
14300
17160
NABH
Package
Cost
18590
Outside State
NABH
Package Cost
20735
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
a) CBC.
MICROBIOLOGY,
b) LFT.
HEMATOLOGY,
c) RFT.
BIOCHEMISTRY,ETC.)
d) RBS.
c) DISCHARGE SUMMARY
e) CECT Thorax.
OPEN
OF INPATIENT
f) abdomen
DEPARTMENT.
g) Pelvis.
d) DISCHARGE SUMMARY
h) histopathology- Non Small cell
OF DAY CARE DEPARTMENT.
Lung cancer
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
441
Medical Oncology
MO
MO071 CT for CA Lung
MO071L Gemcitabine + Cisplatin
11100
13320
14430
16095
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
a) CBC.
MICROBIOLOGY,
b) LFT.
HEMATOLOGY,
c) RFT.
BIOCHEMISTRY,ETC.)
d) RBS.
c) DISCHARGE SUMMARY
e) CECT Thorax.
OPEN
OF INPATIENT
f) abdomen
DEPARTMENT.
g) Pelvis.
d) DISCHARGE SUMMARY
h) histopathology- Non Small cell
OF DAY CARE DEPARTMENT.
Lung cancer
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
442
Medical Oncology
MO
MO071 CT for CA Lung
MO071M Paclitaxel
5800
6960
7540
8410
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
a) CBC.
MICROBIOLOGY,
b) LFT.
HEMATOLOGY,
c) RFT.
BIOCHEMISTRY,ETC.)
d) RBS.
c) DISCHARGE SUMMARY
e) CECT Thorax.
OPEN
OF INPATIENT
f) abdomen
DEPARTMENT.
g) Pelvis.
d) DISCHARGE SUMMARY
h) histopathology- Non Small cell
OF DAY CARE DEPARTMENT.
Lung cancer
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
443
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
Package Name
MO071 CT for CA Lung
Procedure
Code
Procedure Name
MO071N Paclitaxel
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
12000
14400
NABH
Package
Cost
15600
Outside State
NABH
Package Cost
17400
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
a) CBC.
MICROBIOLOGY,
b) LFT.
HEMATOLOGY,
c) RFT.
BIOCHEMISTRY,ETC.)
d) RBS.
c) DISCHARGE SUMMARY
e) CECT Thorax.
OPEN
OF INPATIENT
f) abdomen
DEPARTMENT.
g) Pelvis.
d) DISCHARGE SUMMARY
h) histopathology- Non Small cell
OF DAY CARE DEPARTMENT.
Lung cancer
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
444
Medical Oncology
MO
MO071 CT for CA Lung
MO071O Paclitaxel + Carboplatin
7900
9480
10270
11455
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax.
f) abdomen
g) Pelvis.
h) histopathology (non small cell
carcinoma)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
445
Medical Oncology
MO
MO071 CT for CA Lung
MO071P Paclitaxel + Cisplatin
13500
16200
17550
19575
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
a) CBC.
MICROBIOLOGY,
b) LFT.
HEMATOLOGY,
c) RFT.
BIOCHEMISTRY,ETC.)
d) RBS.
c) DISCHARGE SUMMARY
e) CECT Thorax.
OPEN
OF INPATIENT
f) abdomen
DEPARTMENT.
g) Pelvis.
d) DISCHARGE SUMMARY
h) histopathology- Non Small cell
OF DAY CARE DEPARTMENT.
Lung cancer
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
446
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
Package Name
MO071 CT for CA Lung
Procedure
Code
Procedure Name
MO071Q Pemetrexed + Cisplatin
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
9200
11040
NABH
Package
Cost
11960
Outside State
NABH
Package Cost
13340
Mandatory Documents - Pre
Authorization
a) CBC.
b) LFT.
c) RFT.
d) RBS.
e) CECT Thorax.
f) abdomen
g) Pelvis.
h) histopathology –
adenocarcinoma
i) adenosquamous carcinoma
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
OPEN
OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
447
Medical Oncology
MO
MO071 CT for CA Lung
MO071R Pemetrexed
7600
9120
9880
11020
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
a) CBC.
MICROBIOLOGY,
b) LFT.
HEMATOLOGY,
c) RFT.
BIOCHEMISTRY,ETC.)
d) RBS.
c) DISCHARGE SUMMARY
e) CECT Thorax.
OPEN
OF INPATIENT
f) abdomen
DEPARTMENT.
g) Pelvis.
d) DISCHARGE SUMMARY
h) histopathology (non small cell OF DAY CARE DEPARTMENT.
adenocarcinoma or
e) CHARTS OF
adenosquamous carcinoma)
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
448
Medical Oncology
MO
MO071 CT for CA Lung
MO071S
Vinorelbine +
Carboplatin
22800
27360
29640
33060
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
a) CBC.
MICROBIOLOGY,
b) LFT.
HEMATOLOGY,
c) RFT.
BIOCHEMISTRY,ETC.)
d) RBS.
c) DISCHARGE SUMMARY
e) CECT Thorax.
OPEN
OF INPATIENT
f) abdomen
DEPARTMENT.
g) Pelvis.
d) DISCHARGE SUMMARY
h) histopathology- Non Small cell
OF DAY CARE DEPARTMENT.
Lung cancer
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
SL NO
449
Specialty
Medical Oncology
Specialty
Code
MO
Package
Code
Package Name
MO071 CT for CA Lung
Procedure
Code
Procedure Name
MO071T Vinorelbine + Cisplatin
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
20600
24720
NABH
Package
Cost
26780
Outside State
NABH
Package Cost
29870
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
(PATHOLOGY, RADIOLOGY,
a) CBC.
MICROBIOLOGY,
b) LFT.
HEMATOLOGY,
c) RFT.
BIOCHEMISTRY,ETC.)
d) RBS.
c) DISCHARGE SUMMARY
e) CECT Thorax.
OPEN
OF INPATIENT
f) abdomen
DEPARTMENT.
g) Pelvis.
d) DISCHARGE SUMMARY
h) histopathology- Non Small cell
OF DAY CARE DEPARTMENT.
Lung cancer
e) CHARTS OF
CHEMOTHERAPY REGIMEN.
f) TRANFUSION SLIPS.
Y
450
Pediatric Medical
Management
MP
MP001
Febrile seizures / other
seizures
MP001A Febrile seizures
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) planned line management.
d) 1st seizure or past history.
a) Detailed ICPs.
b) Treatment details.
c) detailed discharge summary.
d) All investigations reports.
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) planned line management.
d) 1st seizure or past history.
a) Detailed ICPs.
b) Treatment details.
c) detailed discharge summary.
d) All investigations reports.
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) planned line management.
d) 1st seizure or past history.
a) Detailed ICPs.
b) Treatment details.
c) detailed discharge summary.
d) All investigations reports.
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) planned line management.
d) 1st seizure or past history.
a) Detailed ICPs.
b) Treatment details.
c) detailed discharge summary.
d) All investigations reports.
OPEN
Y
451
Pediatric Medical
Management
MP
MP001
Febrile seizures / other
seizures
MP001B Flury of seizures
1800
2160
2340
2610
OPEN
Y
452
Pediatric Medical
Management
MP
MP001
Febrile seizures / other
seizures
MP001C Neurocysticercosis
1800
2160
2340
2610
OPEN
Y
453
Pediatric Medical
Management
MP
MP001
Febrile seizures / other
seizures
MP001D Epilepsy
1800
2160
2340
2610
OPEN
Y
454
Pediatric Medical
Management
MP
Epileptic
MP002
encephalopathy
Epileptic
MP002A
encephalopathy
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) planned line management.
d) past h.
e) epilepsy.
a) Detailed ICPs.
b) Treatment details.
c) detailed discharge summary.
d) All investigations reports.
OPEN
N
455
Pediatric Medical
Management
MP
MP003 Acute encephalitis
MP003A
Infectious uncomplicated
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) examination findings (incl
neurological examination).
d) any investigations done.
e) planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) detailed discharge summary.
d) All investigations reports.
OPEN
Y
SL NO
456
Specialty
Pediatric Medical
Management
Specialty
Code
MP
Package
Code
Package Name
MP003 Acute encephalitis
Procedure
Code
MP003B
Procedure Name
Immune-mediated uncomplicated
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
1800
2160
NABH
Package
Cost
2340
Outside State
NABH
Package Cost
2610
Mandatory Documents - Pre
Authorization
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) examination findings (incl
neurological examination).
d) any investigations done.
e) planned line of management.
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Detailed ICPs.
b) Treatment details.
c) detailed discharge summary.
d) All investigations reports.
OPEN
Y
457
458
459
460
461
Pediatric Medical
Management
Pediatric Medical
Management
Pediatric Medical
Management
Pediatric Medical
Management
Pediatric Medical
Management
MP
MP
MP
MP
MP
Acute encephalitis
MP004
syndrome
MP005
MP005
MP005
MP005
Acute meningo
encephalitis / aseptic
meningitis / febrile
encephalopathy /
hypertensive
encehalopathy /
metabolic
encephalopathy /
hepatic
encephalopathy / brain
abcess
Acute meningo
encephalitis / aseptic
meningitis / febrile
encephalopathy /
hypertensive
encehalopathy /
metabolic
encephalopathy /
hepatic
encephalopathy / brain
abcess
Acute meningo
encephalitis / aseptic
meningitis / febrile
encephalopathy /
hypertensive
encehalopathy /
metabolic
encephalopathy /
hepatic
encephalopathy / brain
abcess
Acute meningo
encephalitis / aseptic
meningitis / febrile
encephalopathy /
hypertensive
encehalopathy /
metabolic
encephalopathy /
hepatic
encephalopathy / brain
abcess
Acute encephalitis
MP004A
syndrome
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) examination findings.
d) any investigations done.
e) planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) detailed discharge summary.
d) All investigations reports.
OPEN
N
MP005A
Acute meningo
encephalitis
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) examination findings.
d) any investigations done.
e) planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) detailed discharge summary.
d) All investigations reports.
OPEN
Y
MP005B Aseptic meningitis
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) examination findings.
d) any investigations done.
e) planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) detailed discharge summary.
d) All investigations reports.
OPEN
Y
MP005C Febrile encephalopathy
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) examination findings.
d) any investigations done.
e) planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) detailed discharge summary.
d) All investigations reports.
OPEN
Y
MP005D
Hypertensive
encehalopathy
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) examination findings.
d) any investigations done.
e) planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) detailed discharge summary.
d) All investigations reports.
OPEN
Y
SL NO
462
463
464
465
Specialty
Pediatric Medical
Management
Pediatric Medical
Management
Pediatric Medical
Management
Pediatric Medical
Management
Specialty
Code
MP
MP
MP
MP
Package
Code
Package Name
Acute meningo
encephalitis / aseptic
meningitis / febrile
encephalopathy /
hypertensive
MP005 encehalopathy /
metabolic
encephalopathy /
hepatic
encephalopathy / brain
abcess
Acute meningo
encephalitis / aseptic
meningitis / febrile
encephalopathy /
hypertensive
MP005 encehalopathy /
metabolic
encephalopathy /
hepatic
encephalopathy / brain
abcess
Acute meningo
encephalitis / aseptic
meningitis / febrile
encephalopathy /
hypertensive
MP005 encehalopathy /
metabolic
encephalopathy /
hepatic
encephalopathy / brain
abcess
MP006 Meningitis
Procedure
Code
Procedure Name
Metabolic
MP005E
encephalopathy
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
1800
2160
NABH
Package
Cost
2340
Outside State
NABH
Package Cost
2610
Mandatory Documents - Pre
Authorization
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) examination findings.
d) any investigations done.
e) planned line of management.
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Detailed ICPs.
b) Treatment details.
c) detailed discharge summary.
d) All investigations reports.
OPEN
Y
MP005F Hepatic encephalopathy
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) examination findings.
d) any investigations done.
e) planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) detailed discharge summary.
d) All investigations reports.
OPEN
Y
MP005G Brain abcess
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) examination findings.
d) any investigations done.
e) planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) detailed discharge summary.
d) All investigations reports.
OPEN
Y
MP006A Chronic meningitis
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) examination findings (incl
neurological examination).
d) any investigations done.
e) planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) detailed discharge summary.
d) All investigations reports.
OPEN
Y
466
Pediatric Medical
Management
MP
MP006 Meningitis
MP006B
Partially treated
pyogenic meningitis
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) examination findings (incl
neurological examination).
d) any investigations done.
e) planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) detailed discharge summary.
d) All investigations reports.
OPEN
Y
467
Pediatric Medical
Management
MP
MP006 Meningitis
MP006C Neuro tuberculosis
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) examination findings (incl
neurological examination).
d) any investigations done.
e) planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) detailed discharge summary.
d) All investigations reports.
OPEN
Y
SL NO
468
Specialty
Pediatric Medical
Management
Specialty
Code
MP
Package
Code
Package Name
MP006 Meningitis
Procedure
Code
MP006D
Procedure Name
Complicated bacterial
meningitis
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
1800
2160
NABH
Package
Cost
2340
Outside State
NABH
Package Cost
2610
Mandatory Documents - Pre
Authorization
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) examination findings (incl
neurological examination).
d) any investigations done.
e) planned line of management.
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Detailed ICPs.
b) Treatment details.
c) detailed discharge summary.
d) All investigations reports.
OPEN
Y
469
Pediatric Medical
Management
MP
MP006 Meningitis
MP006E Acute meningitis
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) examination findings (incl
neurological examination).
d) any investigations done.
e) planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) detailed discharge summary.
d) All investigations reports.
OPEN
Y
470
Pediatric Medical
Management
MP
MP007 Optic neuritis
MP007A Optic neuritis
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) fundus findings & photograph.
d) planned line management.
a) Detailed ICPs.
b) Treatment details.
c) detailed discharge summary.
d) All investigations reports.
OPEN
N
471
Pediatric Medical
Management
MP
Medical Management
MP008 for Raised intracranial
pressure
After Decompressive
craniotomy /
After Shunt procedure /
MP008A After other emergency
neuro surgical
procedures /
For ICP monitoring
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) examination findings (incl
neurological examination).
d) any investigations done.
e) planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) detailed discharge summary.
d) All investigations reports.
OPEN
N
472
Pediatric Medical
Management
MP
Intracranial
MP009
hemorrhage
MP009A Intracranial hemorrhage
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) examination findings (incl
neurological examination).
d) any investigations done.
e) planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) detailed discharge summary.
d) All investigations reports.
OPEN
N
473
Pediatric Medical
Management
MP
MP010
Intracranial space
occupying lesion
MP010A
Intracranial space
occupying lesion
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) examination findings.
d) any investigations done.
e) planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) detailed discharge summary.
d) All investigations reports.
OPEN
N
474
Pediatric Medical
Management
MP
Intracranial ring
enhancing lesion with
MP011
complication
(tuberculoma)
Intracranial ring
enhancing lesion with
MP011A
complication
(tuberculoma)
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) examination findings (incl
neurological examination).
d) any investigations done.
e) planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) detailed discharge summary.
d) All investigations reports.
OPEN
N
SL NO
475
Specialty
Pediatric Medical
Management
Specialty
Code
MP
Package
Code
Package Name
MP012 Cerebral herniation
Procedure
Code
Procedure Name
MP012A Cerebral herniation
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
1800
2160
NABH
Package
Cost
2340
Outside State
NABH
Package Cost
2610
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) examination findings (incl
neurological examination).
d) any investigations done.
e) planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) detailed discharge summary.
d) All investigations reports.
a) Clinical notes with planned line
of treatment (incl birth & past
history).
b) Investigation Reports
supporting diagnosis (including CT
head).
c) Planned line of treatment.
a) Detailed ICPs (daily Treatment
details).
b) Procedure .
c) Operative Notes (if applicable).
OPEN
d) Detailed Discharge Summary.
e) All investigations reports.
OPEN
N
476
Pediatric Medical
Management
MP
Acute neuroregression
/ Acute worsening in
MP013 neuro metabolic and
neurodegenerative
conditions
Acute neuroregression /
Acute worsening in
MP013A neuro metabolic and
neurodegenerative
conditions
1800
2160
2340
2610
N
477
Pediatric Medical
Management
MP
MP014
Acute demyelinating
myelopathy
MP014A
Acute demyelinating
myelopathy
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) examination findings.
d) any investigations done.
e) planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) detailed discharge summary.
d) All investigations reports.
OPEN
N
478
Pediatric Medical
Management
MP
MP015 Juvenile myasthenia
MP015A Juvenile myasthenia
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) examination findings.
d) any investigations done.
e) planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) detailed discharge summary.
d) All investigations reports.
OPEN
N
479
Pediatric Medical
Management
MP
MP016 Acute ataxia
MP016A Acute ataxia
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) examination findings (incl
neurological examination).
d) any investigations done.
e) planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) detailed discharge summary.
d) All investigations reports.
OPEN
N
480
Pediatric Medical
Management
MP
MP017 Acute ischemic stroke
MP017A Acute ischemic stroke
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) examination findings.
d) any investigations done.
e) planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) detailed discharge summary.
d) All investigations reports.
OPEN
N
481
Pediatric Medical
Management
MP
MP018 Wheezing
MP018A Wheezing
1800
2160
2340
2610
a) Detailed ICPs.
a) Clinical notes detailing history.
b) Treatment details.
b) Admission notes showing vitals.
c) detailed discharge summary.
c) planned line management.
d) All investigations reports.
OPEN
N
SL NO
482
Specialty
Pediatric Medical
Management
Specialty
Code
MP
Package
Code
Package Name
MP019 Chronic cough
Procedure
Code
Procedure Name
MP019A Chronic cough
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
1800
2160
NABH
Package
Cost
2340
Outside State
NABH
Package Cost
2610
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Clinical notes detailing history.
b) earlier Treatment done .
Detailed ICPs, Treatment details,
c) Admission notes showing vitals.
detailed discharge summary, All
d) planned line management.
investigations reports.
OPEN
N
483
Pediatric Medical
Management
MP
Acute urticaria /
MP020 Anaphylaxis acute
asthma
MP020A Acute urticaria
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) planned line management.
d) specify the trigger.
a) Detailed ICPs.
b) Treatment details.
c) detailed discharge summary.
d) All investigations reports.
OPEN
Y
484
Pediatric Medical
Management
MP
Acute urticaria /
MP020 Anaphylaxis acute
asthma
MP020B
Anaphylaxis acute
asthma
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) planned line management.
d) specify the trigger.
a) Detailed ICPs.
b) Treatment details.
c) detailed discharge summary.
d) All investigations reports.
OPEN
Y
485
Pediatric Medical
Management
MP
MP021 Acute abdomen
MP021A Acute abdomen
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) examination findings.
d) any investigations done.
e) planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) detailed discharge summary.
d) All investigations reports.
OPEN
N
486
Pediatric Medical
Management
MP
MP022 Celiac disease
MP022A Celiac disease
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) examination findings.
d) any investigations done.
e) planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) detailed discharge summary.
d) All investigations reports.
OPEN
N
487
Pediatric Medical
Management
MP
MP023
Unexplained
hepatosplenomegaly
MP023A
Unexplained
hepatosplenomegaly
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) examination findings.
d) any investigations done.
e) planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) detailed discharge summary.
d) All investigations reports.
OPEN
N
488
Pediatric Medical
Management
MP
MP024 Infantile cholestasis
MP024A Infantile cholestasis
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) examination findings.
d) any investigations done.
e) planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) detailed discharge summary.
d) All investigations reports.
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) planned line management.
d) investigations done.
a) Detailed ICPs.
b) Treatment details.
c) detailed discharge summary.
d) All investigations reports.
OPEN
N
489
Pediatric Medical
Management
MP
MP025
Acute
glomerulonephritis
MP025A
Acute
glomerulonephritis
1800
2160
2340
2610
OPEN
N
SL NO
490
Specialty
Pediatric Medical
Management
Specialty
Code
MP
Package
Code
MP026
Package Name
Nephrotic syndrome
with peritonitis
Procedure
Code
MP026A
Procedure Name
Nephrotic syndrome
with peritonitis
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
1800
2160
NABH
Package
Cost
2340
Outside State
NABH
Package Cost
2610
Mandatory Documents - Pre
Authorization
a) Clinical notes detailing history
including past history.
b) examination findindgs.
c) investigations done.
d) Admission notes showing vitals.
e) planned line management.
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Detailed ICPs.
b) Treatment details.
c) detailed discharge summary.
d) All investigations reports.
OPEN
N
491
Pediatric Medical
Management
MP
MP027
Haemolytic uremic
syndrome
MP027A
Haemolytic uremic
syndrome
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) examination findings.
d) any investigations done.
e) planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) detailed discharge summary.
d) All investigations reports.
OPEN
N
492
Pediatric Medical
Management
MP
MP028 CRRT
MP028A CRRT - (CRRT)
8000
9600
10400
11600
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) examination findings.
d) any investigations done.
e) planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) detailed discharge summary.
d) All investigations reports.
OPEN
N
493
Pediatric Medical
Management
MP
Global developmental
delay / Intellectual
MP029
disability of unknown
etiology
MP029A
Global developmental
delay
1800
2160
2340
2610
a) Clinical notes detailing birth.
b) subsequent history.
c) Admission notes showing vitals.
d) planned line management.
a) Detailed ICPs.
b) Treatment details.
c) detailed discharge summary.
d) All investigations reports.
a) Clinical notes detailing birth.
b) subsequent history.
c) Admission notes showing vitals.
d) planned line management.
a) Detailed ICPs.
b) Treatment details.
c) detailed discharge summary.
d) All investigations reports.
a) Clinical notes detailing history.
b) investigations done.
c) Admission notes showing vitals.
d) planned line management.
a) Detailed ICPs.
b) Treatment details.
c) detailed discharge summary.
d) All investigations reports.
OPEN
Y
494
Pediatric Medical
Management
MP
MP029
Global developmental
delay / Intellectual
disability of unknown
etiology
MP029B
Intellectual disability of
unknown etiology
1800
2160
2340
2610
OPEN
Y
495
Pediatric Medical
Management
MP
Rickets - requiring
MP030 admission for Work
Up
MP030A
Rickets - requiring
admission for Work Up
1800
2160
2340
2610
OPEN
N
496
Pediatric Medical
Management
MP
MP031
Acute severe
malnutrition
MP031A
Acute severe
malnutrition
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) examination findings.
d) any investigations done.
e) planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) detailed discharge summary.
d) All investigations reports.
OPEN
N
497
Pediatric Medical
Management
MP
MP032
Developmental and
behavioral disorders
MP032A
Developmental and
behavioral disorders
1800
2160
2340
2610
a) Clinical notes detailing history.
b) examination findings.
c) Admission notes showing
neurological examination.
d) any investigations done.
e) planned line management.
a) Detailed ICPs.
b) Treatment details.
c) detailed discharge summary.
d) All investigations reports.
OPEN
N
SL NO
498
Specialty
Pediatric Medical
Management
Specialty
Code
MP
Package
Code
Package Name
MP033 Short stature
Procedure
Code
Procedure Name
MP033A Short stature
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
1800
2160
NABH
Package
Cost
2340
Outside State
NABH
Package Cost
2610
Mandatory Documents - Pre
Authorization
a) Clinical notes detailing history.
b) parent's height .
c) Admission notes showing vitals.
d) planned line management.
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Detailed ICPs.
b) Treatment details.
c) detailed discharge summary.
d) All investigations reports.
OPEN
N
499
Pediatric Medical
Management
MP
MP034 Dysmorphic children
MP034A Dysmorphic children
1800
2160
2340
2610
a) Clinical notes detailing history.
b) investigations done .
c) Admission notes showing vitals.
d) planned line management.
a) Detailed ICPs.
b) Treatment details.
c) detailed discharge summary.
d) All investigations reports.
OPEN
N
500
Pediatric Medical
Management
MP
MP035 Floppy infant
MP035A Floppy infant
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) examination findings (incl
neurological examination).
d) any investigations done.
e) planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) detailed discharge summary.
d) All investigations reports.
OPEN
N
501
Pediatric Medical
Management
MP
MP036
Inborn errors of
metabolism
MP036A
Inborn errors of
metabolism
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) examination findings.
d) any investigations done.
e) planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) detailed discharge summary.
d) All investigations reports.
OPEN
N
502
Pediatric Medical
Management
MP
MP037 Wilson’s disease
MP037A Wilson’s disease
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) examination findings.
d) any investigations done.
e) planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) detailed discharge summary.
d) All investigations reports.
OPEN
N
503
Pediatric Medical
Management
MP
MP038 Rheumatoid arthritis
MP038A Rheumatoid arthritis
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) examination findings.
d) any investigations done.
e) planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) detailed discharge summary.
d) All investigations reports.
OPEN
N
504
505
Pediatric Medical
Management
Pediatric Medical
Management
MP
MP
MP039 Rheumatic fever
MP040 Cyanotic spells
MP039A Rheumatic fever
MP040A Cyanotic spells
1800
1800
2160
2160
2340
2340
2610
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) examination findings.
d) any investigations done.
e) planned line of management.
a) Clinical notes with planned line
of treatment (incl birth & past
history).
b) Investigation Reports
supporting diagnosis (including
ABG).
c) Planned line of treatment.
a) Detailed ICPs.
b) Treatment details.
c) detailed discharge summary.
d) All investigations reports.
OPEN
N
a) Detailed ICPs (daily Treatment
details).
b) Detailed Discharge Summary.
OPEN
c) All investigations reports.
Y
SL NO
506
507
508
Specialty
Pediatric Medical
Management
Pediatric Medical
Management
Pediatric Medical
Management
Specialty
Code
MP
MP
MP
Package
Code
Package Name
MP040 Cyanotic spells
MP040 Cyanotic spells
MP040 Cyanotic spells
Procedure
Code
MP040B
MP040C
MP040D
Procedure Name
Cyanotic spells with
CHD
Cyanotic spells with
Chest infection
Cyanotic spells with
Sepsis
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
1800
1800
1800
2160
2160
2160
NABH
Package
Cost
2340
2340
2340
Outside State
NABH
Package Cost
2610
2610
2610
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Clinical notes with planned line
of treatment (incl birth & past
history).
b) Investigation Reports
supporting diagnosis (including
ECHO, ABG).
c) Planned line of treatment.
a) Detailed ICPs (daily Treatment
details).
b) Detailed Discharge Summary.
c) All investigations reports
OPEN
(including 2D echo).
a) Clinical notes with planned line
of treatment (incl birth & past
history) Investigation Reports
supporting diagnosis (including
CBC, X-ray chest).
b) Planned line of treatment.
a) Detailed ICPs (daily Treatment
details).
b) Post treatment CBC and X-ray
chest.
OPEN
c) Detailed Discharge summary.
a) Clinical notes with planned line
of treatment (incl birth & past
history).
b) Investigation Reports
supporting diagnosis (including
CBC, ABG, Radiological
investigations).
c) Planned line of treatment.
Y
Y
a) Detailed ICPs (daily Treatment
details).
b) Post treatment CBC.
c) Radiological investigations.
OPEN
d) Detailed Discharge summary.
Y
509
Pediatric Medical
Management
MP
MP041
Immune haemolytic
anemia
MP041A
Immune haemolytic
anemia
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) examination findings.
d) any investigations done.
e) planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) detailed discharge summary.
d) All investigations reports.
OPEN
N
510
Pediatric Medical
Management
MP
Idiopathic
MP042 Thrombocytopenic
Purpura
Idiopathic
MP042A Thrombocytopenic
Purpura
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) examination findings.
d) any investigations done.
e) planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) detailed discharge summary.
d) All investigations reports.
OPEN
N
511
Pediatric Medical
Management
MP
MP043 Kawasaki Disease
MP043A Kawasaki Disease
1800
2160
2340
2610
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) examination findings.
d) any investigations done.
e) planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) detailed discharge summary.
d) All investigations reports.
OPEN
N
512
Pediatric Medical
Management
MP
MP044
Steven Johnson
syndrome
MP044A
Steven Johnson
syndrome
1800
2160
2340
2610
a) Clinical notes detailing history
(incl drug intake history).
b) Admission notes showing vitals.
c) examination findings.
d) any investigations done.
e) planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) detailed discharge summary.
d) All investigations reports.
OPEN
N
SL NO
513
Specialty
Pediatric Medical
Management
Specialty
Code
MP
Package
Code
Package Name
MP045 Trauma
Procedure
Code
Procedure Name
MP045A Trauma
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
1800
2160
NABH
Package
Cost
2340
Outside State
NABH
Package Cost
2610
Mandatory Documents - Pre
Authorization
a) Clinical notes detailing history .
b) examination findings describing
trauma.
c) MLC.
d) FIR.
e) Admission notes showing vitals.
f) planned line management.
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Detailed ICPs.
b) Treatment details.
c) detailed discharge summary.
d) All investigations reports.
OPEN
N
514
515
516
517
518
519
520
Pediatric Medical
Management
Radiation Oncology
Radiation Oncology
Radiation Oncology
Radiation Oncology
Radiation Oncology
Radiation Oncology
MP
MR
MR
Ketogenic diet
MP046 initiation in refractory
epilepsy
2D External Beam
Radiotherapy (6
MR001 Fractions) (Inclusive
of Simulation &
Planning Cost)
2D External Beam
Radiotherapy (6
MR001 Fractions) (Inclusive
of Simulation &
Planning Cost)
MR
2D External Beam
Radiotherapy (6
MR001 Fractions) (Inclusive
of Simulation &
Planning Cost)
MR
2D External Beam
Radiotherapy Palliative
MR002 (Upto 10 Fractions)
(Inclusive of
Simulation & Planning
Cost)
MR
MR
2D External Beam
Radiotherapy (25
MR003 Fractions) (Inclusive
of Simulation &
Planning Cost)
2D External Beam
Radiotherapy (25
MR003 Fractions) (Inclusive
of Simulation &
Planning Cost)
Ketogenic diet initiation
MP046A
in refractory epilepsy
MR001A Radical
MR001B Adjuvant
MR001C Neoadjuvant
MR002A Palliative
MR003A Radical
MR003B Adjuvant
1800
11000
11000
11000
15000
20000
20000
2160
13200
13200
13200
18000
24000
24000
2340
14300
14300
14300
19500
26000
26000
2610
15950
15950
15950
21750
29000
29000
a) Clinical notes detailing history.
b) Admission notes showing vitals.
c) examination findings (incl
neurological examination).
d) any investigations done.
e) planned line of management.
a) Detailed ICPs.
b) Treatment details.
c) detailed discharge summary.
d) All investigations reports.
OPEN
a) HPE report.
b) Clinical notes with planned line
of treatment (documents
Detailed Discahrge Summary (with
confirming the Procedure
OPEN
RT treatment and doses given).
indicated and details of RT
treatment plan).
a) HPE report.
b) Clinical notes with planned line
of treatment (documents
Detailed Discahrge Summary (with
confirming the Procedure
OPEN
RT treatment and doses given).
indicated and details of RT
treatment plan).
a) HPE report.
b) Clinical notes with planned line
of treatment (documents
Detailed Discahrge Summary (with
confirming the Procedure
OPEN
RT treatment and doses given).
indicated and details of RT
treatment plan).
a) HPE report.
b) Clinical notes with planned line
of treatment (documents
Detailed Discahrge Summary (with
confirming the Procedure
OPEN
RT treatment and doses given).
indicated and details of RT
treatment plan).
a) HPE report.
b) Clinical notes with planned line
of treatment (documents
Detailed Discahrge Summary (with
confirming the Procedure
OPEN
RT treatment and doses given).
indicated and details of RT
treatment plan).
a) HPE report.
b) Clinical notes with planned line
of treatment (documents
Detailed Discahrge Summary (with
confirming the Procedure
OPEN
RT treatment and doses given).
indicated and details of RT
treatment plan).
N
Y
Y
Y
N
Y
Y
SL NO
521
522
523
524
525
526
527
528
529
Specialty
Radiation Oncology
Radiation Oncology
Radiation Oncology
Radiation Oncology
Radiation Oncology
Radiation Oncology
Radiation Oncology
Radiation Oncology
Radiation Oncology
Specialty
Code
Package
Code
Package Name
MR
2D External Beam
Radiotherapy (25
MR003 Fractions) (Inclusive
of Simulation &
Planning Cost)
MR
Linear Accelerator,
External Beam
Radiotherapy 3D
MR004 CRT (6 Fractions)
(Inclusive of
Simulation & Planning
Cost)
MR
Linear Accelerator,
External Beam
Radiotherapy 3D
MR004 CRT (6 Fractions)
(Inclusive of
Simulation & Planning
Cost)
MR
Linear Accelerator,
External Beam
Radiotherapy 3D
MR004 CRT (6 Fractions)
(Inclusive of
Simulation & Planning
Cost)
MR
Linear Accelerator,
External Beam
Radiotherapy 3D
MR005 CRT (25 Fractions)
(Inclusive of
Simulation & Planning
Cost)
MR
Linear Accelerator,
External Beam
Radiotherapy 3D
MR005 CRT (25 Fractions)
(Inclusive of
Simulation & Planning
Cost)
MR
MR
MR
Linear Accelerator,
External Beam
Radiotherapy 3D
MR005 CRT (25 Fractions)
(Inclusive of
Simulation & Planning
Cost)
Linear Accelerator,
External Beam
Radiotherapy IMRT
(Intensity Modulated
MR006
Radiotherapy)
(20 Fractions)
(Inclusive of
Simulation & Planning
Linear Accelerator,
External Beam
Radiotherapy IMRT
(Intensity Modulated
MR006
Radiotherapy)
(20 Fractions)
(Inclusive of
Simulation & Planning
Procedure
Code
Procedure Name
MR003C Neoadjuvant
MR004A Radical
MR004B Adjuvant
MR004C Neoadjuvant
MR005A Radical
MR005B Adjuvant
MR005C Neoadjuvant
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
20000
21000
21000
21000
40000
40000
40000
24000
25200
25200
25200
48000
48000
48000
NABH
Package
Cost
26000
27300
27300
27300
52000
52000
52000
Outside State
NABH
Package Cost
29000
30450
30450
30450
58000
58000
58000
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) HPE report.
b) Clinical notes with planned line
of treatment (documents
Detailed Discahrge Summary (with
confirming the Procedure
OPEN
RT treatment and doses given).
indicated and details of RT
treatment plan).
a) HPE report.
b) Clinical notes with planned line
of treatment (documents
Detailed Discahrge Summary (with
confirming the Procedure
OPEN
RT treatment and doses given).
indicated and details of RT
treatment plan).
a) HPE report.
b) Clinical notes with planned line
of treatment (documents
Detailed Discahrge Summary (with
confirming the Procedure
OPEN
RT treatment and doses given).
indicated and details of RT
treatment plan).
a) HPE report.
b) Clinical notes with planned line
of treatment (documents
Detailed Discahrge Summary (with
confirming the Procedure
OPEN
RT treatment and doses given).
indicated and details of RT
treatment plan).
a) HPE report.
b) Clinical notes with planned line
of treatment (documents
Detailed Discahrge Summary (with
confirming the Procedure
OPEN
RT treatment and doses given).
indicated and details of RT
treatment plan).
a) HPE report.
b) Clinical notes with planned line
of treatment (documents
Detailed Discahrge Summary (with
confirming the Procedure
OPEN
RT treatment and doses given).
indicated and details of RT
treatment plan).
a) HPE report.
b) Clinical notes with planned line
of treatment (documents
Detailed Discahrge Summary (with
confirming the Procedure
OPEN
RT treatment and doses given).
indicated and details of RT
treatment plan).
Y
Y
Y
Y
Y
Y
Y
MR006A Radical
70000
84000
91000
101500
a) HPE report.
b) Clinical notes with planned line
of treatment (documents
Detailed Discahrge Summary (with
confirming the Procedure
OPEN
RT treatment and doses given).
indicated and details of RT
treatment plan).
Y
MR006B Adjuvant
70000
84000
91000
101500
a) HPE report.
b) Clinical notes with planned line
of treatment (documents
Detailed Discahrge Summary (with
confirming the Procedure
OPEN
RT treatment and doses given).
indicated and details of RT
treatment plan).
Y
SL NO
530
531
532
533
534
535
536
537
Specialty
Radiation Oncology
Radiation Oncology
Radiation Oncology
Radiation Oncology
Radiation Oncology
Radiation Oncology
Radiation Oncology
Radiation Oncology
Specialty
Code
MR
MR
MR
MR
MR
MR
MR
MR
Package
Code
MR006
MR007
MR007
MR007
MR008
MR008
MR008
MR009
Package Name
Linear Accelerator,
External Beam
Radiotherapy IMRT
(Intensity Modulated
Radiotherapy)
(20 Fractions)
(Inclusive of
Simulation & Planning
Linear Accelerator,
External Beam
Radiotherapy IMRT
(Intensity Modulated
Radiotherapy)
(6 Fractions)
(Inclusive of
Simulation & Planning
Linear Accelerator,
External Beam
Radiotherapy IMRT
(Intensity Modulated
Radiotherapy)
(6 Fractions)
(Inclusive of
Simulation & Planning
Linear Accelerator,
External Beam
Radiotherapy IMRT
(Intensity Modulated
Radiotherapy)
(6 Fractions)
(Inclusive of
Simulation & Planning
Linear Accelerator
External Beam
Radiotherapy IGRT
(Image Guided
radiotherapy) with 3D
CRT or IMRT
(20 Fractions)
(Inclusive of
Simulation & Planning
Linear Accelerator
External Beam
Radiotherapy IGRT
(Image Guided
radiotherapy) with 3D
CRT or IMRT
(20 Fractions)
(Inclusive of
Simulation & Planning
Linear Accelerator
External Beam
Radiotherapy IGRT
(Image Guided
radiotherapy) with 3D
CRT or IMRT
(20 Fractions)
(Inclusive of
Simulation & Planning
Linear Accelerator
External Beam
Radiotherapy IGRT
(Image Guided
radiotherapy) with 3D
CRT or IMRT
(6 Fractions)
(Inclusive of
Simulation & Planning
Procedure
Code
Procedure Name
MR006C Neoadjuvant
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
70000
84000
NABH
Package
Cost
91000
Outside State
NABH
Package Cost
101500
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) HPE report.
b) Clinical notes with planned line
of treatment (documents
Detailed Discahrge Summary (with
confirming the Procedure
OPEN
RT treatment and doses given).
indicated and details of RT
treatment plan).
Y
MR007A Radical
45000
54000
58500
65250
a) HPE report.
b) Clinical notes with planned line
of treatment (documents
Detailed Discahrge Summary (with
confirming the Procedure
OPEN
RT treatment and doses given).
indicated and details of RT
treatment plan).
Y
MR007B Adjuvant
45000
54000
58500
65250
a) HPE report.
b) Clinical notes with planned line
of treatment (documents
Detailed Discahrge Summary (with
confirming the Procedure
OPEN
RT treatment and doses given).
indicated and details of RT
treatment plan).
Y
MR007C Neoadjuvant
45000
54000
58500
65250
a) HPE report.
b) Clinical notes with planned line
of treatment (documents
Detailed Discahrge Summary (with
confirming the Procedure
OPEN
RT treatment and doses given).
indicated and details of RT
treatment plan).
Y
MR008A Radical
90000
108000
117000
130500
a) HPE report.
b) Clinical notes with planned line
of treatment (documents
Detailed Discahrge Summary (with
confirming the Procedure
OPEN
RT treatment and doses given).
indicated and details of RT
treatment plan).
Y
MR008B Adjuvant
90000
108000
117000
130500
a) HPE report.
b) Clinical notes with planned line
of treatment (documents
Detailed Discahrge Summary (with
confirming the Procedure
OPEN
RT treatment and doses given).
indicated and details of RT
treatment plan).
Y
MR008C Neoadjuvant
90000
108000
117000
130500
a) HPE report.
b) Clinical notes with planned line
of treatment (documents
Detailed Discahrge Summary (with
confirming the Procedure
OPEN
RT treatment and doses given).
indicated and details of RT
treatment plan).
Y
MR009A Radical
55000
66000
71500
79750
a) HPE report.
b) Clinical notes with planned line
of treatment (documents
Detailed Discahrge Summary (with
confirming the Procedure
OPEN
RT treatment and doses given).
indicated and details of RT
treatment plan).
Y
SL NO
538
539
540
541
542
543
544
545
546
Specialty
Radiation Oncology
Radiation Oncology
Radiation Oncology
Radiation Oncology
Radiation Oncology
Radiation Oncology
Radiation Oncology
Radiation Oncology
Radiation Oncology
Specialty
Code
MR
MR
MR
MR
MR
MR
MR
MR
MR
Package
Code
Package Name
Linear Accelerator
External Beam
Radiotherapy IGRT
(Image Guided
MR009 radiotherapy) with 3D
CRT or IMRT
(6 Fractions)
(Inclusive of
Simulation & Planning
Linear Accelerator
External Beam
Radiotherapy IGRT
(Image Guided
MR009 radiotherapy) with 3D
CRT or IMRT
(6 Fractions)
(Inclusive of
Simulation
& with
Planning
SRT / SBRT
IGRT
(Stereotacatic
radiotherapy)
MR010
(4 Fractions)
(Inclusive of
Simulation & Planning
Cost)
SRS with IGRT
(Stereotacatic
MR011 radiotherapy)
(Inclusive of
Simulation & Planning
Respiratory Gating
along with Linear
Accelerator planning
MR012 (5 Fractions)
(Inclusive of
Simulation & Planning
Cost)
MR013
MR013
MR013
MR013
Brachytherapy High
Dose Radiation
Brachytherapy High
Dose Radiation
Brachytherapy High
Dose Radiation
Brachytherapy High
Dose Radiation
Procedure
Code
Procedure Name
Adjuvant - (Linear
Accelerator External
Beam Radiotherapy
IGRT (Image Guided
MR009B radiotherapy) with 3D
CRT or IMRT
(6 Fractions)
(Inclusive of Simulation
& Planning Cost))
MR009C Neoadjuvant
MR010A
SRT / SBRT with
IGRT
(Stereotacatic
radiotherapy)
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
55000
66000
NABH
Package
Cost
71500
Outside State
NABH
Package Cost
79750
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) HPE report.
b) Clinical notes with planned line
of treatment (documents
Detailed Discahrge Summary (with
confirming the Procedure
OPEN
RT treatment and doses given).
indicated and details of RT
treatment plan).
Y
55000
100000
66000
120000
71500
130000
79750
145000
a) HPE report.
b) Clinical notes with planned line
of treatment (documents
Detailed Discahrge Summary (with
confirming the Procedure
OPEN
RT treatment and doses given).
indicated and details of RT
treatment plan).
a) HPE report.
b) Clinical notes with planned line
of treatment (documents
Detailed Discahrge Summary (with
confirming the Procedure
OPEN
RT treatment and doses given).
indicated and details of RT
treatment plan).
Y
N
SRS with IGRT
MR011A (Stereotacatic
radiotherapy)
Respiratory Gating
MR012A along with Linear
Accelerator planning
MR013A Intracavitory
MR013B Intraluminal
MR013C Endobiliary
MR013D Endobronchial
70000
80000
3500
3500
3500
3500
84000
96000
4200
4200
4200
4200
91000
104000
4550
4550
4550
4550
101500
116000
5075
5075
5075
5075
a) Biopsy.
b) HPE report of malignancy.
c) Justification of SRS.
Detailed Discahrge Summary (with
OPEN
RT treatment and doses given).
a) Clinical notes.
b) Documentary evidence
confirming the need of
Respiratory-gated radiotherapy
(tumours that move with
Detailed Discahrge Summary (with
OPEN
respiration during radiotherapy
RT treatment and doses given).
(lung, breast and upper abdominal
tumpurs).
a) HPE report.
b) Clinical notes with planned line
of treatment (documents
Detailed Discahrge Summary (with
confirming the Procedure
OPEN
RT treatment and doses given).
indicated and details of RT
treatment plan).
a) HPE report.
b) Clinical notes with planned line
of treatment (documents
Detailed Discahrge Summary (with
confirming the Procedure
OPEN
RT treatment and doses given).
indicated and details of RT
treatment plan).
a) HPE report.
b) Clinical notes with planned line
of treatment (documents
Detailed Discahrge Summary (with
confirming the Procedure
OPEN
RT treatment and doses given).
indicated and details of RT
treatment plan).
a) HPE report.
b) Clinical notes with planned line
of treatment (documents
Detailed Discahrge Summary (with
confirming the Procedure
OPEN
RT treatment and doses given)
indicated and details of RT
treatment plan).
N
N
Y
Y
Y
Y
SL NO
547
548
549
550
551
552
553
Specialty
Radiation Oncology
Radiation Oncology
Radiation Oncology
Orthopedics
Orthopedics
Orthopedics
Orthopedics
Specialty
Code
Package
Code
Package Name
Brachytherapy High
Dose Radiation
MR
MR013
MR
Brachytherapy High
Dose Radiation (5
doses)
MR014 (Inclusive of
Simulation, Planning
Cost, OT & other
charges )
MR
Brachytherapy High
Dose Radiation (5
doses)
MR014 (Inclusive of
Simulation, Planning
Cost, OT & other
charges )
SB
Fracture Conservative
SB001
Management Without plaster
SB
SB
SB
SB002 Application of Traction
SB002 Application of Traction
Application of P.O.P.
SB003
casts
Procedure
Code
MR013E
Procedure Name
CVS - (Brachytherapy
High Dose Radiation)
MR014A Interstitial
MR014B Surface Mould
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
3500
50000
42000
4200
60000
50400
NABH
Package
Cost
4550
65000
54600
Outside State
NABH
Package Cost
5075
72500
60900
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) HPE report.
b) Clinical notes with planned line
of treatment (documents
Detailed Discahrge Summary (with
confirming the Procedure
OPEN
RT treatment and doses given).
indicated and details of RT
treatment plan).
a) HPE report.
b) Clinical notes with planned line
of treatment (documents
Detailed Discahrge Summary (with
confirming the Procedure
OPEN
RT treatment and doses given).
indicated and details of RT
treatment plan).
a) HPE report.
b) Clinical notes with planned line
of treatment (documents
Detailed Discahrge Summary (with
confirming the Procedure
OPEN
RT treatment and doses given).
indicated and details of RT
treatment plan).
Y
Y
Y
Fracture - Conservative
SB001A Management Without plaster
SB002A
Skeletal Tractions with
pin
SB002B Skin Traction
SB003A Upper Limbs
2000
2000
700
3000
2400
2400
840
3600
2600
2600
910
3900
2900
A)Procedure.
A)Clinical notes with planned line
B)Operation notes.
of treatment including planned line
C)Post procedure X-ray films with OPEN
of treatment.
reports.
D)Detailed
B)X-ray films with reports
Discharge Summary.
2900
A)Clinical notes.
B)X-ray showing the
need of procedure.
C)Clinical photograph
of affected part.
1015
A)Clinical notes.
B)X-ray showing the
need of procedure.
C)Clinical
photograph of affected part.
4350
A)Clinical notes.
B)X-ray showing the
need of procedure.
C)Clinical
photograph of affected part.
A)Post Procedure clinical
photgraph with pins.
B)Detailed Procedure.
C)Operative Notes.
D)Detailed
discharge summary.
A)Post Procedure clinical
photgraph.
B)Detailed Procedure.
C)Operative Notes.
OPEN
Y
OPEN
D)Detailed discharge summary.
A)Post Procedure clinical
photgraph with POP cast.
B)Detailed
Procedure. C)Operative Notes.
N
Y
OPEN
D)Detailed discharge summary
Y
554
Orthopedics
SB
SB003
Application of P.O.P.
casts
SB003B Lower Limbs
3000
3600
3900
4350
A)Clinical notes and X-ray
showing the need of procedure.
B)Clinical photograph of
affected part.
A)Post Procedure clinical
photgraph with POP cast.
B)Detailed Procedure .
C)Operative Notes.
OPEN
D)Detailed discharge summary.
555
Orthopedics
SB
SB004
Application of P.O.P.
Spikas & Jackets
Spikas - (Application of
SB004A P.O.P. Spikas &
Jackets)
3500
4200
4550
5075
A)Clinical notes and X-ray
showing the need of procedure.
B)Clinical photograph of
affected part.
Y
A)Post Procedure clinical
photgraph with POP spika.
B)Detailed Procedure.
C)Operative Notes.
OPEN
D)Detailed discharge summary.
556
Orthopedics
SB
Application of P.O.P.
SB004
Spikas & Jackets
Jackets - (Application
SB004B of P.O.P. Spikas &
Jackets)
3500
4200
4550
5075
A)Clinical notes.
B) X-ray showing the
need of procedure.
C)Clinical
photograph of affected part.
A)Post Procedure clinical
photgraph with POP Jacket.
B)Detailed
Procedure. C)Operative Notes.
Y
OPEN
D)Detailed discharge summary.
Y
SL NO
557
Specialty
Orthopedics
Specialty
Code
SB
Package
Code
SB005
Package Name
External fixation of
Fracture
Procedure
Code
SB005A
Procedure Name
Long bone - (External
fixation of Fracture)
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
14000
16800
NABH
Package
Cost
18200
Outside State
NABH
Package Cost
20300
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
A)Post Procedure clinical
photgraph.
A)Clinical notes.
B)Detailed Procedure.
B)X-ray confirming the
C)Operative Note.
diagnosis.
D)Detailed
C)Clinical photograph of affected
discharge summary Invoice.
part.
OPEN
E)Barcode of implant.
558
559
560
561
562
563
564
Orthopedics
Orthopedics
Orthopedics
Orthopedics
Orthopedics
Orthopedics
Orthopedics
SB
SB
SB
SB
SB
SB
SB
SB005
SB005
SB005
SB006
SB007
SB007
SB007
External fixation of
Fracture
External fixation of
Fracture
External fixation of
Fracture
Percutaneous Fixation of Fracture
Elastic nailing for
fracture fixation
Elastic nailing for
fracture fixation
Elastic nailing for
fracture fixation
SB005B Small bone
SB005C
Pelvis - (External
fixation of Fracture)
SB005D Both bones - forearms
SB006A
SB007A
Percutaneous - Fixation
of Fracture
Femur - (Elastic nailing
for fracture fixation)
Humerus - (Elastic
SB007B nailing for fracture
fixation)
Forearm - (Elastic
SB007C nailing for fracture
fixation)
9500
14000
15000
3000
11000
11000
11000
11400
16800
18000
3600
13200
13200
13200
12350
18200
19500
3900
14300
14300
14300
Y
13775
A)Post Procedure clinical
photgraph.
A)Clinical notes.
B)X-ray confirming
B)Detailed Procedure.
the diagnosis.
C)Operative Notes.
C)Clinical photograph of affected
D)Detailed discharge
part.
summary Invoice.
E)Barcode of implant.
OPEN
20300
A)Post Procedure clinical
photgraph.
A)Clinical notes.
B)Detailed Procedure.
B)X-ray confirming
C)Operative Notes.
the diagnosis.
D)Detailed
C)Clinical photograph of affected
discharge summary.
part.
E)Invoice.
F)Barcode of implant.
OPEN
21750
A)Post Procedure clinical
photgraph.
A)Clinical notes.
B)Detailed Procedure.
B)X-ray confirming the
C)Operative Notes.
diagnosis.
OPEN
D)Detailed
C)Clinical photograph of affected
discharge summary Invoice.
part.
E)Barcode of
implant.
Y
4350
A)Procedure.
B)Operation notes.
A)Clinical notes with planned line
C)Post procedure X-ray films with
of treatment including planned line
OPEN
reports.
of treatment.
D)Stickers of implants
B)X-ray films with reports.
used.
E)Detailed
Discharge Summary.
N
15950
A)Procedure.
B)Operation notes.
A)Clinical notes with planned line
C)Post procedure X-ray films with
of treatment including planned line
OPEN
reports.
of treatment.
D)Stickers of implants
B)X-ray films with reports.
used.
E)Detailed
Discharge Summary.
Y
15950
A)Clinical notes with planned line
of treatment including planned line
of treatment.
B)X-ray films with
reports.
15950
Y
A)Procedure.
B)Operation notes.
C)Post procedure X-ray films with
OPEN
reports.
D)Stickers of implants
used. E)Detailed Discharge
Summary.
A)Procedure.
B)Operation notes.
A)Clinical notes with planned line
C)Post procedure X-ray films with
of treatment including planned line
OPEN
reports.
of treatment.
D)Stickers of implants
B)X-ray films with reports.
used.
E)Detailed
Discharge Summary.
Y
Y
Y
SL NO
565
566
567
Specialty
Orthopedics
Orthopedics
Orthopedics
Specialty
Code
SB
SB
SB
Package
Code
SB008
SB009
SB010
Package Name
Internal Fixation of
Small Bones
Fracture - Long Bones
- Metaphyseal - ORIF
Fixation of Diaphyseal
Fracture - Long Bone
Procedure
Code
SB008A
SB009A
SB010A
Procedure Name
Internal Fixation of
Small Bones
Fracture - Long Bones Metaphyseal - ORIF
Open Reduction
Internal Fixation
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
8500
12700
14900
10200
15240
17880
NABH
Package
Cost
11050
16510
19370
Outside State
NABH
Package Cost
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
12325
A)Post Procedure clinical
photgraph.
B)Post procedure X-rayshowing
A)Clinical notes.
implant.
B)X-ray
C)Detailed Procedure.
confirming the diagnosis.
OPEN
D)Operative Notes.
C)Clinical photograph of
E)Detailed
affected part.
discharge summary Invoice.
F)Barcode of
implant.
18415
A)Procedure.
A)Clinical notes with planned line B)Operation notes.
of treatment including planned line C)Post procedure X-ray films with
OPEN
of treatment.
reports.
B)X-ray films with reports.
D)Stickers of implants
used.
21605
A)Post procedure imaging study
(X Ray).
A)Clinical notes.
B)Post Procedure
B)radiological investigations
clinical photograph.
confirming the diagnosis (X-ray).
C)Detailed Procedure.
D)Operative Notes.
C)Clinical photograph of affected
part.
E)invoice.
F)Barcode of implant.
N
N
OPEN
Y
568
Orthopedics
SB
SB010
Fixation of Diaphyseal
Fracture - Long Bone
SB010B
Closed Reduction &
Fixation
18000
21600
23400
26100
A)Post procedure imaging study
(X Ray).
A)Clinical notes.
B)Post Procedure
B)radiological investigations
clinical photograph.
confirming the diagnosis (X-ray).
C)Detailed Procedure.
D)Operative Notes.
C)Clinical photograph of affected
part.
E)Invoice.
F)Barcode of implant.
17110
A)Post Procedure clinical
photgraph.
A)Clinical notes.
B)Post procedure X-ray.
B)X-ray confirming the
C)detailed Procedure.
D)Operative Notes.
OPEN
diagnosis.
C)Clinical photograph of affected
E)Detailed
part.
discharge summary. E)Invoice.
F)Barcode
of implant.
14500
A)Post procedure imaging study
(X Ray).
B)Post Procedure
A)Clinical notes.
clinical photgraph.
B)X-ray confirming the
C)Detailed Procedure.
OPEN
diagnosis.
D)Operative Notes.
C)Clinical photograph of affected
E)Detailed
part.
discharge summary. E)Invoice.
F)Barcode of
implant.
13340
A)Post procedure imaging study
(X Ray).
A)Clinical notes.
B)Post Procedure
B)X-ray confirming the
clinical photgraph.
diagnosis.
C)Detailed Procedure.
C)Clinical photograph of affected
D)Operative Notes.
part.
E)Detailed
discharge summary.
OPEN
Y
569
Orthopedics
SB
Surgery for
SB011 Comminuted Fracture
- Olecranon of Ulna
Plating - (Surgery for
SB011A Comminuted Fracture Olecranon of Ulna)
11800
14160
15340
N
570
571
Orthopedics
Orthopedics
SB
SB
SB012 Fracture Head radius
SB012 Fracture Head radius
SB012A
SB012B
Fixation - (Fracture
Head radius)
Excision - (Fracture
Head radius)
10000
9200
12000
11040
13000
11960
Y
OPEN
Y
SL NO
572
573
574
575
576
Specialty
Orthopedics
Orthopedics
Orthopedics
Orthopedics
Orthopedics
Specialty
Code
SB
SB
SB
SB
SB
Package
Code
Package Name
Fracture - Single Bone
SB013 - Forearm - ORIF Plating / Nailing
Fracture - Both Bones
SB014 - Forearm - ORIF Plating / Nailing
SB015
SB015
Fracture Condyle Humerus - ORIF
Fracture Condyle Humerus - ORIF
Fracture intercondylar
SB016 Humerus + olecranon
osteotomy
Procedure
Code
Procedure Name
Fracture - Single Bone SB013A Forearm - ORIF Plating / Nailing
Fracture - Both Bones SB014A Forearm - ORIF Plating / Nailing
SB015A Lateral Condyle
SB015B Medial Condyle
Fracture intercondylar
SB016A Humerus + olecranon
osteotomy
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
8900
12700
8500
8500
10680
15240
10200
10200
NABH
Package
Cost
11570
16510
11050
11050
Outside State
NABH
Package Cost
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
A)Post Procedure clinical
photgraph.
B)Post procedure X-rayshowing
A)Clinical notes.
implant.
B)X-ray confirming the
C)Detailed Procedure.
diagnosis.
D)Operative Notes .
C)Clinical photograph of affected
E)Detailed
part.
discharge summary. E)Invoice.
F)Barcode of
implant.
OPEN
18415
A)Post Procedure clinical
photgraph.
B)Post procedure X-rayshowing
A)Clinical notes.
implant.
B)X-ray confirming the
C)detailed Procedure.
diagnosis.
D)Operative Notes .
C)Clinical photograph of affected
E)Detailed
part.
discharge summary. E)Invoice.
F)Barcode of
implant.
OPEN
12325
A)Post Procedure clinical
photgraph.
B)Post procedure X-rayshowing
A)Clinical notes.
implant.
B)X-ray confirming the
C)Detailed Procedure.
diagnosis.
D)Operative Notes .
C)Clinical photograph of affected
E)Detailed
part.
discharge summary. E)Invoice.
F)Barcode of
implant.
OPEN
12325
A)Clinical notes.
B)X-ray confirming the
diagnosis.
C)Clinical photograph of affected
part.
OPEN
12905
A)Clinical notes.
B)X-ray confirming the
diagnosis.
C)Clinical photograph of affected
part.
N
N
Y
Y
A)Post Procedure X-ray showing
osteotomy as well as frature
maneged.
B)Detailed
Procedure. C)Operative Notes.
15100
18120
19630
21895
A)Clinical notes.
B)X-ray confirming the
OPEN
diagnosis.
C)Clinical photograph of affected D)Detailed discharge summary.
part.
E)Invoice.
F)Barcode
of implant.
N
577
578
579
Orthopedics
Orthopedics
Orthopedics
SB
SB
SB
SB017
Displaced Clavicle
Fracture
SB018 Fracture - Acetabulum
SB018 Fracture - Acetabulum
SB017A
Open Reduction
Internal Fixation
SB018A Single Approach
SB018B Combined Approach
20000
28000
33500
24000
33600
40200
26000
36400
43550
29000
A)Procedure.
B)Operation notes.
A)Clinical notes with planned line
C)Post procedure X-ray films with
of treatment including planned line
OPEN
reports.
of treatment.
D)Stickers of implants
B)X-ray films with reports.
used.
E)Detailed
Discharge Summary.
N
40600
A)Procedure.
B)Operation notes.
A)Clinical notes with planned line C)Procedure X-ray films with
of treatment including planned line reports.
of treatment.
D)Detailed Discharge
Summary.
B)X-ray films with reports.
E)Invoice.
F)Barcode of implant.
OPEN
Y
48575
A)Procedure.
A)Clinical notes with planned line
B)Operation notes.
of treatment including planned line
C)Procedure X-ray films with
of treatment.
reports.
B)X-ray films with reports.
D)Detailed Discharge.
OPEN
Y
SL NO
580
581
582
583
Specialty
Orthopedics
Orthopedics
Orthopedics
Orthopedics
Specialty
Code
SB
SB
SB
SB
Package
Code
Package Name
SB019 Fracture - Neck Femur
SB019 Fracture - Neck Femur
SB019 Fracture - Neck Femur
SB020 Ankle Fractures
Procedure
Code
Procedure Name
Closed Reduction and
SB019A Percutaneous Screw
Fixation
Intertrochanteric
SB019B Fracture with Dynamic
Hip Screw
Intertrochanteric
SB019C Fracture with Proximal
Femoral Nail
SB020A
Open Reduction
Internal Fixation
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
10000
15800
16100
14000
12000
18960
19320
16800
NABH
Package
Cost
13000
20540
20930
18200
Outside State
NABH
Package Cost
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
14500
A)Post procedure imaging study
(X Ray).
A)Clinical notes.
B)Post
B)X-ray confirming the
Procedure clinical photgraph.
C)Detailed
diagnosis.
C)Clinical photograph of affected Procedure. D)Operative Notes.
part.
E)Invoice.
F)Barcode of implant.
OPEN
22910
A)Post procedure imaging study
(X Ray).
A)Clinical notes.
B)Post
B)X-ray confirming the
Procedure clinical photgraph.
diagnosis.
C)Detailed
C)Clinical photograph of affected Procedure. D)Operative Notes.
part.
E)Invoice.
F)Barcode of implant.
OPEN
23345
A)Post procedure imaging study
(X Ray).
A)Clinical notes.
B)Post
B)X-ray confirming the
Procedure clinical photgraph.
diagnosis.
C)Detailed
C)Clinical photograph of affected Procedure. D)Operative Notes.
part.
E)Invoice.
F)Barcode of implant.
OPEN
Y
Y
Y
20300
A)Detailed discharge summary
A)Clinical notes.
Post Procedure clinical photgraph.
B)X-ray confirming the
B)Detailed
OPEN
Procedure. C)Operative Notes.
diagnosis.
C)Clinical photograph of affected
D)Invoice.
part.
E)Barcode of implant.
29000
A)Procedure.
B)Operation notes.
A)Clinical notes with planned line C)Post procedure X-ray films with
of treatment including planned line reports.
OPEN
of treatment.
C)Detailed Discharge Summary.
B)X-ray films with reports.
D)Invoice.
E)Barcode
of implant.
58000
A)Procedure.
A)Clinical notes with planned line
B)Operation notes.
of treatment including planned line
C)Post procedure X-ray films with OPEN
of treatment.
reports.
B)X-ray films with reports.
D)Detailed Discharge.
43500
A)Procedure.
A)Clinical notes with planned line
B)Operation notes.
of treatment including planned line
C)Post procedure X-ray films with OPEN
of treatment.
reports.
B)X-ray films with reports.
D)Detailed Discharge.
N
584
585
586
587
Orthopedics
Orthopedics
Orthopedics
Orthopedics
SB
SB
SB
SB
SB021
SB022
SB022
SB023
Cervical spine fixation
including odontoid
Dorsal and lumber
spine fixation
Dorsal and lumber
spine fixation
Bone grafting for Non
union
SB021A
SB022A
SB022B
SB023A
Cervical spine fixation
including odontoid
Anterior (Dorsal and
lumber spine fixation)
Posterior - (Dorsal and
lumber spine fixation)
Bone grafting for Non
union
20000
40000
30000
10000
24000
48000
36000
12000
26000
52000
39000
13000
14500
A)Post procedure imaging study
(X Ray).
A)Clinical notes detailing earlier
B)Post Procedure clinical
surgery that resulted in non-union
photgraphof donor.
and radiological investigations
C)Recipient sites.
confirming the diagnosis (X-ray of
D)Detailed Procedure.
affected joint). B)Clinical
E)Operative Notes.
photograph.
F)Detailed
discharge summary.
20300
A)Clinical notes.
B)X-ray confirming the
diagnosis.
C)Clinical photograph of affected
part.
N
Y
Y
OPEN
N
588
Orthopedics
SB
SB024
Arthorotomy of any
joint
SB024A
Arthorotomy of any
joint
14000
16800
18200
A)Clinical notes.
B)X-ray confirming the
diagnosis.
C)Clinical photograph of affected
part.
OPEN
N
SL NO
589
590
591
592
Specialty
Orthopedics
Orthopedics
Orthopedics
Orthopedics
Specialty
Code
SB
SB
SB
SB
Package
Code
Package Name
SB025 Arthrolysis of joint
SB025 Arthrolysis of joint
SB025 Arthrolysis of joint
SB026 Arthrodesis
Procedure
Code
Procedure Name
Elbow - (Arthrolysis of
SB025A
joint)
SB025B
SB025C
SB026A
Knee - (Arthrolysis of
joint)
Ankle - (Arthrolysis of
joint)
Ankle / Triple with
implant
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
15000
15000
15000
15000
18000
18000
18000
18000
NABH
Package
Cost
19500
19500
19500
19500
Outside State
NABH
Package Cost
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
21750
A)Post Procedure clinical
A)Clinical notes.
photgraph.
B)X-ray confirming the
B)Detailed Procedure.
diagnosis.
OPEN
C)Operative Notes.
C)Clinical photograph of affected
D)Post
part.
procedure imaging study (X Ray).
Y
21750
A)Post Procedure clinical
A)Clinical notes.
photgraph.
B)X-ray confirming the
B)Detailed Procedure.
diagnosis.
OPEN
C)Operative Notes.
C)Clinical photograph of affected
D)Post
part.
procedure imaging study (X Ray).
Y
21750
A)Post Procedure clinical
A)Clinical notes.
photgraph.
B)X-ray confirming the
B)Cetailed Procedure.
OPEN
diagnosis.
C)Operative Notes.
C)Clinical photograph of affected
D)Post
part.
procedure imaging study (X Ray).
Y
21750
A)Clinical notes detailing
indication. B)X-ray of ankle and
foot.
C)Clinical
photograph of affected part.
A)Post procedure X-ray.
B)Post Procedure clinical
photgraph.
C)Detailed Procedure.
D)Operative Notes.
OPEN
E)Detailed
Discharge summary.
F)Invoice.
G) Barcode of implant.
Y
593
Orthopedics
SB
SB026 Arthrodesis
SB026B Shoulder (Arthrodesis)
15000
18000
19500
21750
A)Clinical notes detailing
indication. B)X-ray of ankle and
foot.
C)Clinical
photograph of affected part.
A)Post procedure X-ray.
B)Post Procedure clinical
photgraph.
C)Detailed Procedure.
OPEN
D)Operative Notes.
E)Invoice.
F) Barcode of implant.
594
Orthopedics
SB
SB026 Arthrodesis
SB026C Wrist (Arthrodesis)
15000
18000
19500
21750
A)Clinical notes detailing
indication. B)X-ray of ankle and
foot.
C)Clinical
photograph of affected part.
E)Invoice.
F) Barcode of implant.
595
Orthopedics
SB
SB026 Arthrodesis
SB026D Knee (Arthrodesis)
15000
18000
19500
21750
A)Clinical notes detailing
indication. B)X-ray of ankle and
foot.
C)Clinical
photograph of affected part.
597
Orthopedics
Orthopedics
SB
SB
SB026 Arthrodesis
SB026 Arthrodesis
SB026E
SB026F
Hand (Arthrodesis)
Foot (Arthrodesis)
27000
27000
32400
32400
35100
35100
39150
39150
Y
A)Post procedure X-ray.
B)Post Procedure clinical
photgraph.
C)Detailed Procedure.
OPEN
D)Operative Notes.
E)Invoice.
F) Barcode of implant.
596
Y
A)Post procedure X-ray.
B)Post Procedure clinical
photgraph.
C)Detailed Procedure.
OPEN
D)Operative Notes.
A)Clinical notes detailing
indication. B)X-ray of ankle and
foot.
C)Clinical
photograph of affected part.
A)Post procedure X-ray.
B)Post Procedure clinical
photgraph.
OPEN
C)Detailed Procedure.
D)Operative Notes.
A)Clinical notes detailing
indication. B)X-ray of ankle and
foot.
C)Clinical
photograph of affected part.
A)Post procedure X-ray.
B)Post Procedure clinical
photgraph.
C)Detailed Procedure.
OPEN
D)Operative Notes.
E)Detailed
Discharge summary.
Y
Y
Y
SL NO
598
599
Specialty
Orthopedics
Orthopedics
Specialty
Code
SB
SB
Package
Code
Package Name
SB026 Arthrodesis
SB027 Disarticulation
Procedure
Code
SB026G
Procedure Name
Ankle / Triple without
implant
SB027A Hind quarter
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
15000
25000
18000
30000
NABH
Package
Cost
19500
32500
Outside State
NABH
Package Cost
21750
Mandatory Documents - Pre
Authorization
A)Clinical notes detailing
indication. B)X-ray of ankle and
foot.
C)Clinical
photograph of affected part.
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
A)Post procedure X-ray.
B)Post Procedure clinical
photgraph.
OPEN
C)Detailed Procedure.
D)Operative Notes.
E)Detailed
Discharge summary.
36250
A)Clinical notes justifying surgery
A)Post procedure X-ray.
with X Ray of affected limb.
B)Post Procedure clinical
photgraph.
B)Clinical photograph of affected
OPEN
C)Detailed Procedure.
part showing the gangrene.
D)Operative Notes.
C)Injury.
E)Detailed
D)Severe
Discharge summary.
anatomical deformity.
36250
A)Clinical notes justifying surgery
A)Post procedure X-ray.
with X Ray of affected limb.
B)Post Procedure clinical
photgraph.
B)Clinical photograph of affected
OPEN
C)Detailed Procedure.
part showing the gangrene.
D)Operative Notes.
C)Injury.
E)Detailed
D)Severe
Discharge summary.
anatomical deformity.
Y
Y
600
Orthopedics
SB
SB027 Disarticulation
SB027B Fore quarter
25000
30000
32500
Y
601
602
Orthopedics
Orthopedics
SB
SB
SB028
Closed reduction of
joint dislocation
Closed reduction of
SB028
joint dislocation
SB028A
Hip (Closed reduction
of joint dislocation)
Shoulder (Closed
SB028B reduction of joint
dislocation)
7400
5500
8880
6600
9620
7150
10730
7975
A)Clinical notes and X-ray
confirming the diagnosis.
B)Clinical
photograph of affected part.
A)Post procedure imaging study
(X Ray).
B)Post Procedure
clinical photgraph.
C)Detailed Procedure /
Operative Notes.
D)Detailed discharge
summary.
OPEN
A)Clinical notes.
B)X-ray confirming the
diagnosis.
C)Clinical photograph of
affected part.
A)Post procedure imaging study
(X Ray).
B)Post Procedure
clinical photgraph.
C)Detailed Procedure.
D)Operative Notes.
E)Detailed
discharge summary.
OPEN
Y
Y
603
Orthopedics
SB
SB028
Closed reduction of
joint dislocation
Elbow (Closed
SB028C reduction of joint
dislocation)
5500
6600
7150
7975
A)Clinical notes.
B)X-ray confirming the
diagnosis.
C)Clinical photograph of
affected part.
A)Post procedure imaging study
(X Ray).
B)Post Procedure
clinical photgraph.
C)Detailed Procedure.
D)Operative Notes.
E)Detailed
discharge summary.
A)Clinical notes.
B)X-ray confirming the
diagnosis.
C)Clinical photograph of
affected part.
A)Post procedure imaging study
(X Ray).
B)Post Procedure
clinical photgraph.
C)Detailed Procedure.
D)Operative Notes.
E)Detailed
discharge summary.
OPEN
Y
604
Orthopedics
SB
Closed reduction of
SB028
joint dislocation
Knee (Closed reduction
SB028D
of joint dislocation)
5500
6600
7150
7975
OPEN
Y
SL NO
605
Specialty
Orthopedics
Specialty
Code
SB
Package
Code
SB029
Package Name
Open Reduction of
Small Joint
Procedure
Code
SB029A
Procedure Name
Open Reduction of
Small Joint
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
8500
10200
NABH
Package
Cost
11050
Outside State
NABH
Package Cost
12325
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
A)Post procedure imaging study
A)Clinical.
(X Ray).
B)Radiological
B)Post Procedure
clinical photgraph.
investigations confirming the
diagnosis (X-ray of affected joint).
C)Detailed Procedure.
C)Clinical
D)Operative Notes.
E)Detailed
photograph of child.
discharge summary.
OPEN
N
606
Orthopedics
SB
SB030 Tension Band Wiring
SB030A Tension Band Wiring
13000
15600
16900
18850
A)Procedure.
B)Operation notes.
A)Clinical notes with planned line
C)Post procedure X-ray films
of treatment including planned line
with reports.
OPEN
of treatment.
D)Detailed Discharge
B)X-ray films with
Summary.
D)Invoice.
reports.
E)Barcode of implant.
N
607
608
609
610
Orthopedics
Orthopedics
Orthopedics
Orthopedics
SB
SB
SB
SB
SB031 Hemiarthroplasty
SB031 Hemiarthroplasty
SB031 Hemiarthroplasty
AC Joint
SB032 reconstruction /
Stabilization
SB031A
Unipolar
(Hemiarthroplasty)
SB031B Bipolar (Non - Modular)
SB031C Bipolar (Modular)
SB032A Rockwood Type - I
15000
15000
15000
20500
18000
18000
18000
24600
19500
19500
19500
26650
21750
A)Post Procedure clinical
photgraph.
B)Detailed discharge summary.
A)Clinical notes.
C)Detailed Procedure.
B)X-ray.
D)Operative Notes.
C)CT justifying the
E)Post op
X-ray showing the implant.
surgery.
F)Invoice.
G)Bar
code of implant.
OPEN
21750
A)Post Procedure clinical
photgraph.
B)Detailed discharge summary.
A)Clinical notes.
C)Detailed Procedure.
B)X-ray.
D)Operative Notes.
C)CT justifying the
E)Post op
X-ray showing the implant.
surgery.
F)Invoice.
G)Bar
code of implant.
OPEN
21750
A)Post Procedure clinical
photgraph.
B)Detailed discharge summary.
C)Detailed Procedure.
A)Clinical notes.
B)X-ray.
D)Operative Notes.
C)CT justifying the
E)Post op
X-ray showing the implant.
surgery.
F)Invoice.
G)Bar
code of implant.
OPEN
29725
A)Clinical notes detailing
Rockwood type of fracture.
B)X-ray.
A)Post-op X-ray of operated
limb.
B)Post Procedure clinical
photgraph.
C)Detailed Procedure.
D)Operative Notes.
C)MRI and justification of surgery
done.
E)Detailed Discharge summary.
E)Invoice.
F)Barcode of implant.
Y
Y
Y
OPEN
Y
SL NO
611
612
613
614
615
616
Specialty
Orthopedics
Orthopedics
Orthopedics
Orthopedics
Orthopedics
Orthopedics
Specialty
Code
SB
SB
SB
SB
SB
SB
Package
Code
Package Name
AC Joint
SB032 reconstruction /
Stabilization
AC Joint
SB032 reconstruction /
Stabilization
AC Joint
SB032 reconstruction /
Stabilization
AC Joint
SB032 reconstruction /
Stabilization
AC Joint
SB032 reconstruction /
Stabilization
SB033
Excision Arthoplasty
of Femur head
Procedure
Code
Procedure Name
SB032B Rockwood Type - II
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
20500
24600
NABH
Package
Cost
26650
Outside State
NABH
Package Cost
29725
Mandatory Documents - Pre
Authorization
A)Clinical notes detailing
Rockwood type of fracture.
B)X-ray.
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
A)Post-op X-ray of operated
limb.
B)Post Procedure clinical
photgraph.
C)Detailed Procedure.
D)Operative Notes.
OPEN
C)MRI and justification of surgery
E)Detailed Discharge summary.
done.
E)Invoice.
F)Barcode of implant.
SB032C Rockwood Type - III
20500
24600
26650
29725
A)Clinical notes detailing
Rockwood type of fracture.
B)X-ray.
A)Post-op X-ray of operated
limb.
B)Post Procedure clinical
photgraph.
C)Detailed Procedure.
D)Operative Notes.
Y
OPEN
C)MRI and justification of surgery
done.
E)Detailed Discharge summary.
E)Invoice.
F)Barcode of implant.
SB032D Rockwood Type - IV
20500
24600
26650
29725
A)Clinical notes detailing
Rockwood type of fracture.
B)X-ray.
A)Post-op X-ray of operated
limb.
B)Post Procedure clinical
photgraph.
C)Detailed Procedure.
D)Operative Notes.
Y
OPEN
C)MRI and justification of surgery
done.
E)Detailed Discharge summary.
E)Invoice.
F)Barcode of implant.
SB032E
Rockwood Type - V
20500
24600
26650
29725
A)Clinical notes detailing
Rockwood type of fracture.
B)X-ray.
A)Post-op X-ray of operated
limb.
B)Post Procedure clinical
photgraph.
C)Detailed Procedure.
D)Operative Notes.
Y
OPEN
C)MRI and justification of surgery
done.
E)Detailed Discharge summary.
E)Invoice.
F)Barcode of implant.
SB032F
Rockwood Type - VI
20500
24600
26650
29725
A)Clinical notes detailing
Rockwood type of fracture.
B)X-ray.
A)Post-op X-ray of operated
limb.
B)Post Procedure clinical
photgraph.
C)Detailed Procedure.
D)Operative Notes.
Y
OPEN
C)MRI and justification of surgery
done.
E)Detailed Discharge summary.
E)Invoice.
F)Barcode of implant.
SB033A
Excision Arthoplasty of
Femur head
17500
21000
22750
25375
A)Clinical notes detailing
indication and X-ray.
B)Clinical
photograph of affected part.
A)Post Procedure clinical
photgraph.
B)Detailed Procedure.
C)Operative Notes.
D)Detailed
discharge summary.
Y
OPEN
N
SL NO
617
Specialty
Orthopedics
Specialty
Code
SB
Package
Code
SB034
Package Name
Open Reduction of
CDH
Procedure
Code
SB034A
Procedure Name
Open Reduction of
CDH
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
20000
24000
NABH
Package
Cost
26000
Outside State
NABH
Package Cost
29000
Mandatory Documents - Pre
Authorization
A)Clinical and radiological
investigations confirming the
diagnosis (X-ray of both hips).
B)Clinical
photograph.
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
A)Post procedure imaging study
(X Ray).
B)Post Procedure
clinical photgraph.
C)Detailed Procedure.
D)Operative Notes.
OPEN
E)Detailed discharge summary.
N
618
Orthopedics
SB
SB035 Patellectomy
SB035A Patellectomy
11000
13200
14300
15950
A)Post procedure imaging study
(X Ray).
A)Clinical notes.
B)Post Procedure
B)X-ray of the patella
clinical photgraph.
justifying the procedure.
C)Detailed Procedure.
C)Clinical photograph
D)Operative Notes.
of affected part.
OPEN
E)Detailed discharge summary.
N
619
Orthopedics
SB
Arthroscopic
SB036 Meniscus Repair /
Meniscectomy
SB036A
Arthroscopic Meniscus
Repair / Meniscectomy
12000
14400
15600
17400
A)Clinical notes.
B) MRI justifying
procedure.
A)Intra operative still image.
B)post procedure
clinical photgraph.
C)Detailed Procedure.
D)Operative Notes.
E)Detailed
Discharge summary.
OPEN
N
620
621
Orthopedics
Orthopedics
SB
SB
SB037 Elbow replacement
SB038 Total Hip Replacement
SB037A Elbow replacement
SB038A
Cemented (Total Hip
Replacement)
35000
45000
42000
54000
45500
58500
50750
65250
A)Clinical notes.
B)X-ray.
C)CT justifying the surgery.
A)Post Procedure clinical
photgraph.
B)Detailed discharge summary.
C)Detailed Procedure.
D)Operative Notes.
OPEN
E)Post
op X-ray showing the implant.
F)invoice.
G)Bar
code of implant.
A)Clinical notes.
B)X-ray.
C)CT justifying the surgery.
A)Post Procedure X-ray showing
implant.
B)Detailed Procedure.
C)Operative Notes.
OPEN
D)Bar code of
implant used.
E)Detailed discharge summary.
A)Clinical notes.
B)X-ray.
C)CT justifying the surgery.
A)Post Procedure X-ray showing
implant.
B)Detailed Procedure.
OPEN
C)Operative Notes.
D)Bar code of
implant used.
E)Detailed discharge summary.
N
Y
622
Orthopedics
SB
SB038 Total Hip Replacement
SB038B Cementless
37000
44400
48100
53650
Y
623
Orthopedics
SB
SB038 Total Hip Replacement
SB038C
Hybrid (Total Hip
Replacement)
32000
38400
41600
46400
A)Clinical notes.
B)X-ray.
C)CT justifying the surgery.
A)Post Procedure X-ray showing
implant.
B)Detailed Procedure.
OPEN
C)Operative Notes.
D)Bar code of
implant cement.
E)Detailed discharge summary.
Y
SL NO
624
Specialty
Orthopedics
Specialty
Code
SB
Package
Code
Package Name
SB038 Total Hip Replacement
Procedure
Code
SB038D
Procedure Name
Revision - Total Hip
Replacement
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
140000
168000
NABH
Package
Cost
182000
Outside State
NABH
Package Cost
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
A)Clinical notes.
B)X-ray.
C)CT justifying the surgery.
A)Post Procedure X-ray showing
implant.
B)Detailed Procedure.
OPEN
C)Operative Notes.
D)Bar code of
implant cement.
E)Detailed discharge summary.
A)Clinical notes.
B)X-ray.
C)CT justifying the surgery.
A)Post Procedure clinical
photgraph.
B)Detailed discharge summary.
C)Detailed Procedure.
D)Operative Notes.
E)Post op
X-ray showing the implant.
F)invoice.
G)Bar code of
implant.
OPEN
188500
A)Clinical notes.
B)X-ray.
C)CT justifying the surgery.
A)Post Procedure clinical
photgraph.
B)Detailed discharge summary.
C)Detailed Procedure.
D)Operative Notes.
E)Post op
X-ray showing the implant.
F)invoice.
G)Bar code of
implant.
OPEN
82650
A)Post procedure imaging study
(X Ray).
B)Post
A)Clinical notes justifying need of
this surgery.
Procedure with implant. C)invoice.
B)X-ray.
C)MRI D)Barcode of implant.
OPEN
of affected part.
E)Detailed Procedure.
D)Biopsy.
F)Operative Notes.
E)Clinical
G)Histopathology of
excised tissue.
photograph of affected part.
H)Detailed Discharge
summary.
203000
Y
625
626
627
628
Orthopedics
Orthopedics
Orthopedics
Orthopedics
SB
SB
SB
SB
SB039
SB039
Total Knee
Replacement
Total Knee
Replacement
Bone Tumour
Excision (malignant)
including GCT + Joint
SB040
replacement
(depending upon type
of joint and implant)
Bone Tumour
SB041 Excision +
reconstruction
SB039A
SB039B
Primary - Total Knee
Replacement
Revision - Total Knee
Replacement
Bone Tumour Excision
(malignant) including
GCT + Joint
SB040A
replacement
(depending upon type
of joint and implant)
SB041A
Bone Tumour Excision
+ reconstruction
100000
130000
57000
30000
120000
156000
68400
36000
130000
169000
74100
39000
145000
43500
Y
Y
N
a) Post procedure imaging study
A)Clinical notes justifying need of (X Ray).
this surgery.
b) Post procedure clinical
photgraph.
B)X-ray.
C)MRI c) Detailed Procedure.
OPEN
of affected part.
d) Operative Note.
e) Detailed discharge summary.
D)Biopsy.
E)Clinical f) Invoice and barcode of implant.
photograph of affected part.
N
629
Orthopedics
SB
SB042
Bone Tumour
(benign) curettage /
Excision
and bone grafting
Bone Tumour (benign)
SB042A curettage / Excision and
bone grafting
20000
24000
26000
29000
a) Post procedure imaging study
(X Ray).
a) Clinical notes justifying need of b) Post Procedure clinical
photgraph of both donor.
this surgery.
c)Recipient sites.
b) X-ray.
d) Detailed Procedure.
c) MRI of affected part.
e) Operative Notes.
d) Biopsy.
e) Clinical photograph of affected f) Histopathology of curreted
tissue.
part.
g) Detailed Discharge summary.
OPEN
N
SL NO
630
Specialty
Orthopedics
Specialty
Code
SB
Package
Code
SB043
Package Name
Single Stage
Amputation
Procedure
Code
Procedure Name
SB043A Above Elbow
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
16334
19600
NABH
Package
Cost
21234
Outside State
NABH
Package Cost
23684
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) X Ray of affected limb.
A)Post Procedure clinical
b) Clinical notes.
c) Clinical photograph of affected photgraph.
B)Detailed Procedure.
part justifying the indication.
OPEN
C)Operative Notes.
d) MLC.
D)Detailed
e) FIR if traumatic.
discharge summary.
Y
631
Orthopedics
SB
SB043
Single Stage
Amputation
SB043B Below Elbow
16334
19600
21234
23684
a) X Ray of affected limb.
A)Post Procedure clinical
b) Clinical notes.
c) Clinical photograph of affected photgraph.
B)Detailed Procedure.
part justifying the indication.
OPEN
C)Operative Notes.
D)Detailed
d) MLC.
discharge summary.
e) FIR if traumatic.
Y
632
Orthopedics
SB
SB043
Single Stage
Amputation
SB043C Above Knee
16334
19600
21234
23684
a) X Ray of affected limb.
A)Post Procedure clinical
b) Clinical notes.
c) Clinical photograph of affected photgraph.
B)Detailed Procedure.
part justifying the indication.
OPEN
C)Operative Notes.
D)Detailed
d) MLC.
discharge summary.
e) FIR if traumatic.
Y
633
Orthopedics
SB
SB043
Single Stage
Amputation
SB043D Below Knee
16334
19600
21234
23684
a) X Ray of affected limb.
b) Clinical notes.
A)Post Procedure clinical
c) Clinical photograph of affected photgraph.
part justifying the indication.
B)Detailed Procedure.
OPEN
C)Operative Notes.
D)Detailed
d) MLC.
discharge summary.
e) FIR if traumatic.
Y
634
Orthopedics
SB
SB043
Single Stage
Amputation
SB043E
Foot
15000
18000
19500
21750
a) X Ray of affected limb.
A)Post Procedure clinical
b) Clinical notes.
c) Clinical photograph of affected photgraph.
B)Detailed Procedure.
part justifying the indication.
OPEN
C)Operative Notes.
D)Detailed
d) MLC.
discharge summary.
e) FIR if traumatic.
Y
635
Orthopedics
SB
SB043
Single Stage
Amputation
SB043F
Hand
15000
18000
19500
21750
a) X Ray of affected limb.
A)Post Procedure clinical
b) Clinical notes.
c) Clinical photograph of affected photgraph.
B)Detailed Procedure.
part justifying the indication.
OPEN
C)Operative Notes.
d) MLC.
D)Detailed
e) FIR if traumatic.
discharge summary.
Y
636
Orthopedics
SB
SB043
Single Stage
Amputation
SB043G Wrist
15000
18000
19500
21750
a) X Ray of affected limb.
A)Post Procedure clinical
b) Clinical notes.
c) Clinical photograph of affected photgraph.
part justifying the indication.
B)Detailed Procedure.
OPEN
C)Operative Notes.
D)Detailed
d) MLC.
discharge summary.
e) FIR if traumatic.
Y
637
Orthopedics
SB
SB044 Two Stage Amputation
SB044A Above Elbow
23200
27840
30160
33640
a) X Ray of affected limb.
A)Post Procedure clinical
b) Clinical notes.
c) Clinical photograph of affected photgraph.
part justifying the indication.
B)Detailed Procedure.
OPEN
C)Operative Notes.
d) MLC.
D)Detailed
e) FIR if traumatic.
discharge summary.
Y
SL NO
638
Specialty
Orthopedics
Specialty
Code
SB
Package
Code
Package Name
SB044 Two Stage Amputation
Procedure
Code
Procedure Name
SB044B Below Elbow
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
23200
27840
NABH
Package
Cost
30160
Outside State
NABH
Package Cost
33640
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) X Ray of affected limb.
A)Post Procedure clinical
b) Clinical notes.
c) Clinical photograph of affected photgraph.
B)Detailed Procedure.
part justifying the indication.
OPEN
C)Operative Notes.
d) MLC.
D)Detailed
e) FIR if traumatic.
discharge summary.
Y
639
Orthopedics
SB
SB044 Two Stage Amputation
SB044C Above Knee
23200
27840
30160
33640
a) X Ray of affected limb.
A)Post Procedure clinical
b) Clinical notes.
c) Clinical photograph of affected photgraph.
B)Detailed Procedure.
part justifying the indication.
OPEN
C)Operative Notes.
D)Detailed
d) MLC.
discharge summary.
e) FIR if traumatic.
Y
640
Orthopedics
SB
SB044 Two Stage Amputation
SB044D Below Knee
23200
27840
30160
33640
a) X Ray of affected limb.
A)Post Procedure clinical
b) Clinical notes.
c) Clinical photograph of affected photgraph.
B)Detailed Procedure.
part justifying the indication.
OPEN
C)Operative Notes.
D)Detailed
d) MLC.
discharge summary.
e) FIR if traumatic.
Y
641
Orthopedics
SB
SB044 Two Stage Amputation
SB044E
Foot
23200
27840
30160
33640
a) X Ray of affected limb.
b) Clinical notes.
A)Post Procedure clinical
c) Clinical photograph of affected photgraph.
part justifying the indication.
B)Detailed Procedure.
OPEN
C)Operative Notes.
D)Detailed
d) MLC.
discharge summary.
e) FIR if traumatic.
Y
642
Orthopedics
SB
SB044 Two Stage Amputation
SB044F
Hand
23200
27840
30160
33640
a) X Ray of affected limb.
A)Post Procedure clinical
b) Clinical notes.
c) Clinical photograph of affected photgraph.
B)Detailed Procedure.
part justifying the indication.
OPEN
C)Operative Notes.
D)Detailed
d) MLC.
discharge summary.
e) FIR if traumatic.
Y
643
Orthopedics
SB
SB044 Two Stage Amputation
SB044G Wrist
23200
27840
30160
33640
a) X Ray of affected limb.
A)Post Procedure clinical
b) Clinical notes.
c) Clinical photograph of affected photgraph.
B)Detailed Procedure.
part justifying the indication.
OPEN
C)Operative Notes.
d) MLC.
D)Detailed
e) FIR if traumatic.
discharge summary.
Y
644
Orthopedics
SB
SB045
Amputation - Fingers /
Toes
SB045A Finger(s)
10400
12480
13520
15080
a) X Ray of affected limb.
A)Post Procedure clinical
b) Clinical notes.
c) Clinical photograph of affected photgraph.
part justifying the indication.
B)Detailed Procedure.
OPEN
C)Operative Notes.
D)Detailed
d) MLC.
discharge summary.
e) FIR if traumatic.
Y
645
Orthopedics
SB
SB045
Amputation - Fingers /
Toes
SB045B Toe(s)
10400
12480
13520
15080
a) X Ray of affected limb.
A)Post Procedure clinical
b) Clinical notes.
c) Clinical photograph of affected photgraph.
part justifying the indication.
B)Detailed Procedure.
OPEN
C)Operative Notes.
d) MLC.
D)Detailed
e) FIR if traumatic.
discharge summary.
Y
SL NO
646
647
648
649
Specialty
Orthopedics
Orthopedics
Orthopedics
Orthopedics
Specialty
Code
SB
SB
SB
SB
Package
Code
SB046
SB046
SB047
Package Name
Tendon Grafting /
Repair
Tendon Grafting /
Repair
Tendon Release /
Tenotomy
SB048 Tenolysis
Procedure
Code
Procedure Name
SB046A Tendon Grafting
SB046B Tendon Repair
SB047A
Tendon Release /
Tenotomy
SB048A Tenolysis
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
15000
15000
5000
5000
18000
18000
6000
6000
NABH
Package
Cost
19500
19500
6500
6500
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
Outside State
NABH
Package Cost
Mandatory Documents - Pre
Authorization
21750
A)Clinical notes detailing
jusification of surgery.
B)Clinical
photograph of affected part.
A)Post Procedure clinical
photgraph of donor.
B)Receipent sites.
C)Detailed Procedure.
D)Operative Notes.
E)Detailed
discharge summary.
OPEN
21750
A)Clinical notes detailing
jusification of surgery.
B)Clinical
photograph of affected part.
A)Post Procedure clinical
photgraph.
B)Detailed Procedure.
C)Operative Notes.
D)Detailed
discharge summary.
OPEN
7250
A)Post Procedure clinical
A)Clinical notes.
photgraph.
B)justifying need of
B)Detailed Procedure.
surgery.
C)Operative Notes.
C)Clinical photograph of
D)Detailed
affected part.
discharge summary.
OPEN
7250
A)Post Procedure clinical
A)Clinical notes.
photgraph.
B)justifying need of
B)Detailed Procedure.
surgery.
C)Operative Notes including agent OPEN
C)Clinical photograph of used for lysis of tendon.
affected part.
D)Detailed discharge summary.
Y
Y
N
N
650
Orthopedics
SB
Reconstruction of
SB049 Cruciate Ligament
with implant and brace
SB049A
Anterior
(Reconstruction of
Cruciate Ligament with
implant and brace)
25700
30840
33410
37265
A)Post Procedure clinical
photgraph.
B)Detailed Procedure.
A)Clinical notes.
C)Operative Notes.
B)MRI scan of affected
D)Post proedure Xknee.
ray showing implant.
C)Clinical photograph of affected
E)Ensure brace is
part.
provided in package cost.
OPEN
F)Detailed Discharge summary.
651
Orthopedics
SB
Reconstruction of
SB049 Cruciate Ligament
with implant and brace
SB049B Posterior
25700
30840
33410
37265
A)Post Procedure clinical
photgraph.
B)Detailed Procedure.
A)Clinical notes.
C)Operative Notes.
B)MRI scan of affected
D)Post proedure Xknee.
ray showing implant.
C)Clinical photograph of affected
E)Ensure brace is
part.
provided in package cost.
Y
OPEN
F)Detailed Discharge summary.
652
653
654
Orthopedics
Orthopedics
Orthopedics
SB
SB
SB
SB050 Fasciotomy
Duputryen’s
SB051 Contracture release +
rehabilitation
SB052
Debridement &
Closure of injuries contused lacerated
wounds
SB050A Fasciotomy
Duputryen’s
SB051A Contracture release +
rehabilitation
SB052A
Anti-biotic + dressing minimum of 5 sessions
10500
8500
10900
12600
10200
13080
13650
11050
14170
Y
A)Clinical documents justifying
surgery with USG Evidence.
B)Clinical
photograph of affected part.
A)Detailed discharge summary.
B)Post Procedure
clinical photgraph.
C)Detailed Procedure.
D)Operative Notes.
OPEN
12325
A)Clinical notes.
B)Clinical
photograph of affected part
confirming the diagnosis.
A)Detailed discharge summary.
B)Post Procedure
clinical photgraph.
C)Detailed Procedure.
D)Operative Notes.
OPEN
15805
A)Post Procedure clinical
photgraph.
A)Clinical notes.
B)detailed Procedure.
B) X-ray confirming the
C)Operative Notes.
diagnosis.
D)Detailed
C)Clinical photograph of affected
discharge summary.
part.
E)Evidence of 5 sessions
dressing.
15225
N
N
OPEN
Y
SL NO
655
656
657
658
659
Specialty
Orthopedics
Orthopedics
Orthopedics
Orthopedics
Orthopedics
Specialty
Code
SB
SB
SB
SB
SB
Package
Code
SB052
SB053
SB054
Package Name
Debridement &
Closure of injuries contused lacerated
wounds
Sequestectomy /
Curettage
Spine deformity
correction
SB055 Osteotomy
SB055 Osteotomy
Procedure
Code
SB052B
SB053A
SB054A
Procedure Name
Anti-biotic + dressing minimum of 2 sessions
Sequestectomy /
Curettage
Spine deformity
correction
SB055A Long Bone
SB055B Small Bone
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
3000
10000
30000
20000
10000
3600
12000
36000
24000
12000
NABH
Package
Cost
3900
13000
39000
26000
13000
Outside State
NABH
Package Cost
4350
14500
43500
29000
14500
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
A)Post Procedure clinical
photgraph.
A)Clinical notes.
B)detailed Procedure.
B) X-ray confirming the
C)Operative Notes.
diagnosis.
D)Detailed
C)Clinical photograph of affected
discharge summary.
part.
E)Evidence of 2 sessions
dressing.
OPEN
A)Procedure.
A)Clinical notes with planned line
B)Operation notes.
of treatment including planned line
C)Post procedure X-ray films with
of treatment.
OPEN
reports.
B)X-ray films with
D)Detailed Discharge
reports.
Summary.
A)Procedure.
B)
Operation notes.
A)Clinical notes with planned line
C)Post procedure X-ray films with
of treatment including planned line
reports.
OPEN
of treatment.
D)Detailed Discharge
B)X-ray films
Summary.
with reports.
E)Invoice.
F)Barcode of implant.
A)Clinical notes.
B)X-ray of the affected
bone justifying the procedure.
C)Clinical
photograph of affected part.
A)Post procedure imaging study
(X Ray).
B)Post procedure
clinical photgraph.
C)Detailed Procedure.
OPEN
D)Operative Notes.
E)Detailed
discharge summary. F)invoice.
G)Barcode
of implant.
A)Clinical notes.
B)X-ray of the affected
bone justifying the procedure.
C)Clinical
photograph of affected part.
A)Post procedure imaging study
(X Ray).
B)Post procedure
clinical photgraph.
C)Detailed Procedure.
D)Operative Notes.
E)Detailed
discharge summary.
Y
N
N
Y
OPEN
Y
660
Orthopedics
SB
Pelvic Osteotomy and
SB056
fixation
Pelvic Osteotomy and
SB056A
fixation
20000
24000
26000
29000
A)Clinical notes.
B) X-ray of the patella
justifying the procedure.
C)Clinical
photograph of affected part.
A)Post procedure imaging study
(X Ray) showing the implant.
B)Post Procedure
clinical photgraph.
C)Detailed Procedure.
D)Operative Notes.
OPEN
E)Invoice.
F)Barcode of implant used.
E)Detailed discharge summary.
661
Orthopedics
SB
SB057 High Tibial Osteotomy
SB057A High Tibial Osteotomy
16000
19200
20800
23200
A)Clinical notes.
B)X-ray confirming the
diagnosis.
C)clinical photograph of
affected part.
A)Post procedure imaging study
(X Ray).
B)Post procedure
clinical photgraph.
C)detailed Procedure.
D)Operative Notes.
E)Detailed
discharge summary. E)invoice.
F)Barcode of implant.
N
OPEN
N
SL NO
662
Specialty
Orthopedics
Specialty
Code
SB
Package
Code
Package Name
SB058 Ilizarov Fixation
Procedure
Code
Procedure Name
SB058A Ilizarov Fixation
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
15000
18000
NABH
Package
Cost
19500
Outside State
NABH
Package Cost
21750
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
A)Post Procedure clinical
photgraph.
A)Clinical.
B)Post procedure X-ray showing
B)Radiological
implant.
C)Detailed Procedure.
investigation
OPEN
confirming the indication.
D)Operative Notes.
C)Clinical photograph of
E)Detailed
discharge summary. F)Invoice.
affected part.
G)Barcode of implant.
N
34365
A)Post procedure clinical
photograph.
B)Radiological
B)Intra procedure still pictures.
investigations confirming the
C)Detailed discharge summary.
diagnosis.
E)Detailed Procedure.
OPEN
C)Clinical photograph of affected F)Operative Notes.
G)Invoice.
part showing short limb as
compared to other limb.
H)Barcode
of implant.
7250
A)Procedure.
B)Operation notes.
A)Clinical notes with planned line
C)Post procedure X-ray films
of treatment including planned line
with reports.
of treatment.
D)Detailed
B)X-ray films with
Discharge Summary.
reports.
E)Invoice.
F)Barcode of implant.
21750
A)Procedure.
B)
A)Clinical notes with planned line
Operation notes.
of treatment including planned line
C)Post procedure X-ray films
of treatment.
OPEN
with reports.
B)X-ray films with
D)Detailed Discharge
reports.
Summary.
Y
21750
A)Procedure.
A)Clinical notes with planned line
B)Operation notes.
of treatment including planned line
C)Post procedure X-ray films
of treatment.
with reports.
B)X-ray films with
C)Detailed Discharge
reports.
Summary.
Y
A)Clinical.
663
Orthopedics
SB
Limb Lengthening /
SB059 Bone Transport by
Ilizarov
Limb Lengthening /
SB059A Bone Transport by
Ilizarov
23700
28440
30810
N
664
Orthopedics
SB
SB060
Growth Modulation
and fixation
SB060A
Growth Modulation and
fixation
5000
6000
6500
OPEN
N
665
666
667
Orthopedics
Orthopedics
Orthopedics
SB
SB
SB
SB061
SB061
SB062
Corrective Surgery for
foot deformities
Corrective Surgery for
foot deformities
Correction of club
foot per cast
SB061A Vertical Talus
SB061B Other foot deformities
SB062A
Correction of club foot
per cast
15000
15000
3000
18000
18000
3600
19500
19500
3900
4350
A)Clinical notes.
B)X-ray confirming the
diagnosis.
C)clinical photograph of
affected part.
A)Post Procedure clinical
photgraph with cast.
B)Detailed
Procedure. C)Operative Notes.
OPEN
OPEN
D)Detailed Discharge summary.
N
668
669
Orthopedics
Orthopedics
SB
SB
Corrective Surgery in
SB063 Club Foot / JESS
Fixator
Excision of
SB064 Osteochondroma /
Exostosis
Corrective Surgery in
SB063A Club Foot / JESS
Fixator
SB064A Osteochondroma
20000
10000
24000
12000
26000
13000
29000
A)Procedure .
A)Clinical notes with planned line B)Operation notes.
of treatment including planned line
C)Post procedure X-ray
of treatment.
films with reports.
B)X-ray films with
D)Detailed
reports.
Discharge Summary.
E)Barcode of implant.
14500
A)Clinical notes justifying surgery
with evidence from X-ray.
B)MRI scan of
affected part.
C)Clinical photograph of
affected part.
A)Post Procedure clinical
photgraph.
B)Detailed Procedure.
C)Operative Notes.
D) Detailed
Discharge summary. E)Histopath
of removed tissue.
OPEN
N
OPEN
Y
SL NO
670
671
Specialty
Orthopedics
Orthopedics
Specialty
Code
SB
SB
Package
Code
Package Name
Excision of
SB064 Osteochondroma /
Exostosis
SB065 Excision of Bursa
Procedure
Code
Procedure Name
SB064B Exostosis
SB065A Excision of Bursa
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
10000
3000
12000
3600
NABH
Package
Cost
13000
3900
Outside State
NABH
Package Cost
Mandatory Documents - Pre
Authorization
14500
A)Clinical notes justifying surgery
with evidence from X-ray.
B)MRI scan of
affected part.
C)Clinical photograph of
affected part.
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
A)Post Procedure clinical
photgraph.
B)Detailed Procedure.
C)Operative Notes.
D) Detailed
Discharge summary. E)Histopath
of removed tissue.
OPEN
A)Detailed discharge summary.
B)Post Procedure
clinical photgraph.
C)Detailed Procedure.
D)Operative Notes.
OPEN
Y
4350
A)Clinical notes detailing findings
confirming the diagnosis.
B)clinical
photograph of affected part.
18850
A)Intra Procedure still images.
A)Clinical notes justifying surgery
B)Detailed Procedure.
with evidence of MRI.
C)Operative Notes.
B)EMG.
D)Detailed
C)NCV.
Discharge summary.
OPEN
18850
A)Intra Procedure still images.
A)Clinical notes justifying surgery
B)Detailed Procedure.
with evidence of MRI.
C)Operative Notes.
B)EMG.
D)Detailed
C)NCV.
Discharge summary.
OPEN
18850
A)Intra Procedure still images.
A)Clinical notes justifying surgery
B)Detailed Procedure.
with evidence of MRI.
C)Operative Notes.
B)EMG.
D)Detailed
C)NCV.
Discharge summary.
OPEN
20010
A)Intra Procedure still images.
A)Clinical notes justifying surgery
B)Detailed Procedure.
with evidence of MRI.
C)Operative Notes.
B)EMG.
D)Detailed
C)NCV.
Discharge summary.
OPEN
4350
A)Procedure.
A)Clinical notes with planned line
B)Operation notes.
of treatment including planned line
C)Post procedure X-ray films
OPEN
of treatment.
with reports.
B)X-ray films with
D)Detailed Discharge
reports.
Summary.
14210
A)Clinical.
A)Detailed discharge summary.
B) radiological
B)Post Procedure
investigations confirming the need clinical photgraph.
of surgery.
C)detailed Procedure.
C) NCV report. D)Operative Notes.
N
672
673
674
675
676
677
678
Orthopedics
Orthopedics
Orthopedics
Orthopedics
Orthopedics
Orthopedics
Orthopedics
SB
SB
SB
SB
SB
SB
SB
SB066
SB066
SB066
Nerve Transposition /
Release / Neurolysis
Nerve Transposition /
Release / Neurolysis
Nerve Transposition /
Release / Neurolysis
SB067 Nerve Repair Surgery
SB068 Nerve root block
SB069
SB070
Exploration and Ulnar
nerve Repair
Implant Removal
under LA
SB066A Nerve Transposition
SB066B Nerve Release
SB066C Nerve Neurolysis
SB067A Nerve Repair Surgery
SB068A Nerve root block
SB069A
Exploration and Ulnar
nerve Repair
SB070A K - Wire
13000
13000
13000
13800
3000
9800
5000
15600
15600
15600
16560
3600
11760
6000
16900
16900
16900
17940
3900
12740
6500
Y
Y
Y
N
N
OPEN
N
7250
A)Clinical notes with planned line A)Procedure.
of treatment including planned line
B)Operation notes.
of treatment.
C)Post procedure X-ray
OPEN
B)X-ray films with films with reports.
D)Detailed Discharge Summary.
reports.
7250
A)Procedure.
A)Clinical notes with planned line
B)Operation notes.
of treatment including planned line
C)Post procedure X-ray films with
OPEN
of treatment.
reports.
B)X-ray films with
D)Detailed Discharge
reports.
Summary.
Y
21750
A)Procedure.
A)Clinical notes with planned line
B)Operation notes.
of treatment including planned line
C)Post procedure X-ray films
of treatment.
with reports.
B)X-ray films with
D)Detailed Discharge
reports.
Summary.
Y
Y
679
680
Orthopedics
Orthopedics
SB
SB
SB070
SB071
Implant Removal
under LA
Implant Removal
under RA / GA
SB070B Screw
SB071A Nail
5000
15000
6000
18000
6500
19500
OPEN
SL NO
681
682
Specialty
Orthopedics
Surgical Oncology
Specialty
Code
SB
SC
Package
Code
Package Name
Implant Removal
SB071
under RA / GA
SC001 Glossectomy
Procedure
Code
Procedure Name
SB071B Plate
SC001A Hemiglossectomy
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
15000
26134
18000
31360
NABH
Package
Cost
19500
33974
Outside State
NABH
Package Cost
21750
37894
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
A)Procedure.
A)Clinical notes with planned line
B)Operation notes.
of treatment including planned line
C)Post procedure X-ray films
of treatment.
with reports.
B)X-ray films with
D)Detailed Discharge
reports.
Summary.
OPEN
Y
a) Procedure.
a) Clinical notes with planned line
b) Operative Notes.
of treatment.
c) Post Procedure Photographs of
b) FNAC
surgical site.
OPEN
c) BIOPSY
d) HPE report.
d) CECT
e) Detailed Discharge Summary.
Y
683
Surgical Oncology
SC
SC001 Glossectomy
SC001B Total Glossectomy
32668
39201
42468
47368
a) Procedure.
a) Clinical notes with planned line
b) Operative Notes.
of treatment.
c) Post Procedure Photographs of
b) FNAC
surgical site.
OPEN
c) BIOPSY
d) HPE report.
d) CECT
e) Detailed Discharge Summary.
Y
684
Surgical Oncology
SC
SC002 Palatectomy
SC002A Soft palate
20000
24000
26000
29000
a) Clinical notes.
b) Biopsy.
c) Clinical photograph.
d) CT
e) MRI
a) Detailed Procedure.
b) Operative Notes.
c) Clinical photgraph showing scar.
d) Detailed discharge summary.
OPEN
e) HPE.
Y
685
Surgical Oncology
SC
SC002 Palatectomy
SC002B Hard palate
20000
24000
26000
29000
a) Clinical notes.
b) Biopsy.
c) Clinical photograph.
d) CT
e) MRI
a) Detailed Procedure.
b) Operative Notes.
c) Clinical photgraph showing scar.
d) Detailed discharge summary.
OPEN
e) HPE.
a) Clinical notes.
b) Biopsy.
c) CECT.
a) Detailed Procedure.
b) Operative Notes.
c) Clinical Photograph showing
scar.
d) HPE report.
e) Detailed discharge summary.
a) Clinical notes.
b) Biopsy.
c) CECT.
a) Detailed Procedure.
b) Operative Notes.
c) Clinical Photograph showing
scar.
d) HPE report.
e) Detailed discharge summary.
a) Clinical notes.
b) Biopsy.
c) CECT.
a) Detailed Procedure.
b) Operative Notes.
c) Clinical Photograph showing
scar.
d) HPE report.
e) Detailed discharge summary.
Y
686
Surgical Oncology
SC
SC003 Maxillectomy
SC003A Partial
27000
32400
35100
39150
OPEN
Y
687
Surgical Oncology
SC
SC003 Maxillectomy
SC003B Radical
33000
39600
42900
47850
OPEN
Y
688
Surgical Oncology
SC
SC003 Maxillectomy
SC003C Total
30000
36000
39000
43500
OPEN
Y
SL NO
689
Specialty
Surgical Oncology
Specialty
Code
SC
Package
Code
SC004
Package Name
Composite resection
(Oral Cavity)
Procedure
Code
SC004A
Procedure Name
Composite resection
(Oral Cavity)
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
43556
52267
NABH
Package
Cost
56622
Outside State
NABH
Package Cost
63156
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Clinical notes.
b) Biopsy.
c) CT reports.
d) Clinical photograph.
a) Detailed Procedure.
b) Operative Notes.
c) Clinical Photograph showing
scar.
d) HPE report.
e) Detailed discharge summary.
a) Clinical notes.
b) CECT.
c) OGD Scopy.
a) Barcode of Stent.
b) Detailed Procedure.
c) Operative Notes.
d) Detailed Discharge summary.
a) Clinical notes.
b) CECT.
c) OGD Scopy.
a) Barcode of Stent.
b) Detailed Procedure.
c) Operative Notes.
d) Detailed Discharge summary.
a) Clinical notes with planned line
of treatment.
b) FNAC
c) BIOPSY
d) CECT
a) Procedure.
b) Operative Notes.
c) Post Procedure Photographs of
surgical site.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
a) Clinical notes with planned line
of treatment.
b) FNAC
c) BIOPSY
d) CECT
a) Procedure.
b) Operative Notes.
c) Post Procedure Photographs of
surgical site.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
a) Clinical notes with planned line
of treatment.
b) FNAC
c) BIOPSY
d) CECT
a) Procedure.
b) Operative Notes.
c) Post Procedure Photographs of
surgical site.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
a) Clinical notes with planned line
of treatment.
b) FNAC
c) BIOPSY
d) CECT
a) Procedure.
b) Operative Notes.
c) Post Procedure Photographs of
surgical site.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
a) Clinical notes with planned line
of treatment.
b) FNAC
c) BIOPSY
d) CECT
a) Procedure.
b) Operative Notes.
c) Post Procedure Photographs of
surgical site.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
OPEN
N
690
Surgical Oncology
SC
SC005
Oesophageal /
Tracheal stenting
SC005A Oesophageal stenting
45000
54000
58500
65250
OPEN
Y
691
Surgical Oncology
SC
Oesophageal /
SC005
Tracheal stenting
SC005B Tracheal stenting
45000
54000
58500
65250
OPEN
Y
692
Surgical Oncology
SC
Transthoracic
SC006 esophagectomy: 2F /
3F
SC006A Open
65334
78400
84934
94734
Y
693
Surgical Oncology
SC
Transthoracic
SC006 esophagectomy: 2F /
3F
SC006B MIS
60000
72000
78000
87000
Y
694
Surgical Oncology
SC
SC007
Gastric pull-up /
Jejunal Graft
SC007A
Gastric pull-up / Jejunal
Graft
39200
47040
50960
56840
N
695
Surgical Oncology
SC
SC008
Radical Small Bowel
Resection
SC008A Open
33000
39600
42900
47850
Y
696
Surgical Oncology
SC
SC008
Radical Small Bowel
Resection
SC008B
Lap. - (Radical Small
Bowel Resection)
33000
39600
42900
47850
Y
SL NO
697
Specialty
Surgical Oncology
Specialty
Code
SC
Package
Code
SC009
Package Name
Intersphincteric
resection
Procedure
Code
Procedure Name
SC009A Open
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
40200
48240
NABH
Package
Cost
52260
Outside State
NABH
Package Cost
58290
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Clinical notes with planned line
of treatment.
b) FNAC
c) BIOPSY
d) CECT
a) Procedure.
b) Operative Notes.
c) Post Procedure Photographs of
surgical site.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
a) Clinical notes with planned line
of treatment.
b) FNAC
c) BIOPSY
d) CECT
a) Procedure.
b) Operative Notes.
c) Post Procedure Photographs of
surgical site.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
a) Clinical notes.
b) CT abdomen reports.
c) Biopsy.
a) Detailed Procedure.
b) Operative Notes.
c) Clinical Photograph showing
scar.
d) HPE report.
e) Detailed discharge summary.
a) Clinical notes.
b) CT abdomen reports.
c) Biopsy.
a) Detailed Procedure.
b) Operative Notes.
c) Clinical Photograph showing
scar.
d) HPE report.
e) Detailed discharge summary.
Y
698
Surgical Oncology
SC
SC009
Intersphincteric
resection
SC009B
Lap. - (Intersphincteric
resection)
40200
48240
52260
58290
Y
699
Surgical Oncology
SC
Surgery for
SC010 Abdominal wall
tumour
Abdominal wall tumour
SC010A
resection
25000
30000
32500
36250
OPEN
Y
700
Surgical Oncology
SC
Surgery for
SC010 Abdominal wall
tumour
Abdominal wall tumour
SC010B resection with
reconstruction
39000
46800
50700
56550
OPEN
Y
701
Surgical Oncology
SC
SC011
Exploratory
laparotomy f / b
diversion stoma /
bypass
SC011A
Exploratory laparotomy
f / b diversion stoma
30000
36000
39000
43500
a) Procedure.
b) Operative Notes.
a) Clinical notes with planned line
c) Post Procedure Photographs of
of treatment.
surgical site.
b) CECT.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
Y
702
Surgical Oncology
SC
SC011
Exploratory
laparotomy f / b
diversion stoma /
bypass
SC011B
Exploratory laparotomy
f / b diversion bypass
30000
36000
39000
43500
a) Procedure.
b) Operative Notes.
a) Clinical notes with planned line
c) Post Procedure Photographs of
of treatment.
surgical site.
b) CECT.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
Y
703
Surgical Oncology
SC
SC012
Abdominoperineal
resection
SC012A Open
43120
51744
56056
62524
a) Procedure.
a) Clinical notes with planned line
b) Operative Notes.
of treatment.
b) HPE report.
b) HPE
c) Detailed Discharge Summary.
OPEN
Y
704
Surgical Oncology
SC
SC012
Abdominoperineal
resection
Lap. SC012B (Abdominoperineal
resection)
39600
47520
51480
57420
a) Procedure.
a) Clinical notes with planned line
b) Operative Notes.
of treatment.
b) HPE report.
b) HPE
c) Detailed Discharge Summary.
OPEN
Y
SL NO
705
Specialty
Surgical Oncology
Specialty
Code
SC
Package
Code
Package Name
SC013 Omentectomy
Procedure
Code
Procedure Name
SC013A Omentectomy
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
22868
27441
NABH
Package
Cost
29728
Outside State
NABH
Package Cost
33158
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Procedure.
b) Operative Notes.
a) Clinical notes with planned line
c) Post Procedure Photographs of
of treatment.
surgical site.
OPEN
b) HPE
d) HPE report.
e) Detailed Discharge Summary.
N
706
Surgical Oncology
SC
SC014
Procedures Requiring
Bypass Techniques
SC014A
Procedures Requiring
Bypass Techniques
35000
42000
45500
50750
a) Procedure.
b) Operative Notes.
a) Clinical notes with planned line
c) Post Procedure Photographs of
of treatment.
surgical site.
b) HPE
OPEN
d) HPE report.
e) Detailed Discharge Summary.
N
707
Surgical Oncology
SC
SC015
Segmentectomy hepatobiliary system
SC015A
Segmentectomy hepatobiliary system
54446
65335
70779
78946
a) Clinical notes.
b) Biopsy.
c) CECT
d) MRI
a) Detailed Procedure.
b) Operative Notes.
c) Clinical Photograph showing
scar.
d) HPE report.
e) Detailed discharge summary.
a) Clinical notes.
b) CECT
c) MRI reports.
d) Biopsy.
a) Detailed Procedure.
b) Operative Notes.
c) Clinical Photograph showing
scar.
d) HPE report.
e) Detailed discharge summary.
a) Clinical notes.
b) CECT
c) MRI reports.
d) Biopsy.
a) Detailed Procedure.
b) Operative Notes.
c) Clinical Photograph showing
scar.
d) HPE report.
e) Detailed discharge summary.
a) Clinical notes.
b) CECT
c) MRI
d) Biopsy.
e) IHC report.
a) Detailed Procedure.
b) Operative Notes.
c) Clinical Photograph showing
scar.
d) HPE report.
e) Detailed discharge summary.
OPEN
N
708
Surgical Oncology
SC
SC016
Radical / Revision
Cholecystectomy
SC016A Radical
43120
51744
56056
62524
OPEN
Y
709
Surgical Oncology
SC
SC016
Radical / Revision
Cholecystectomy
SC016B Revision
39600
47520
51480
57420
OPEN
Y
710
Surgical Oncology
SC
SC017
Enucleation of
pancreatic neoplasm
SC017A
Enucleation of
pancreatic neoplasm
39600
47520
51480
57420
OPEN
N
711
Surgical Oncology
SC
SC018
Hepatoblastoma
Excision
SC018A
Hepatoblastoma
Excision
52200
62640
67860
75690
a) Procedure.
a) Clinical notes with planned line b) Operative Notes.
of treatment.
c) Post Procedure Photographs of
b) HPE
surgical site.
OPEN
c) CT
d) HPE report.
e) Detailed Discharge Summary.
N
712
Surgical Oncology
SC
SC019
Hemipelvectomy Internal
SC019A
Hemipelvectomy Internal
54000
64800
70200
78300
a) Procedure.
a) Clinical notes with planned line b) Operative Notes.
of treatment.
c) Post Procedure Photographs of
b) HPE
surgical site.
OPEN
c) CT
d) HPE report.
e) Detailed Discharge Summary.
N
SL NO
713
Specialty
Surgical Oncology
Specialty
Code
SC
Package
Code
Package Name
SC020 Pelvic Exenteration
Procedure
Code
Procedure Name
Anterior - Open (Pelvic
SC020A
Exenteration)
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
58800
70560
NABH
Package
Cost
76440
Outside State
NABH
Package Cost
85260
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Clinical notes with planned line
of treatment.
b) HPE
c) CT
a) Procedure.
b) Operative Notes.
c) HPE report.
d) Detailed Discharge Summary.
a) Clinical notes with planned line
of treatment.
b) HPE
c) CT
a) Procedure.
b) Operative Notes.
c) HPE report.
d) Detailed Discharge Summary.
a) Clinical notes with planned line
of treatment.
b) HPE
c) CT
a) Procedure.
b) Operative Notes.
c) HPE report.
d) Detailed Discharge Summary.
a) Clinical notes with planned line
of treatment.
b) HPE
c) CT
a) Procedure.
b) Operative Notes.
c) HPE report.
d) Detailed Discharge Summary.
OPEN
Y
714
Surgical Oncology
SC
SC020 Pelvic Exenteration
SC020B
Anterior - Lap. (Pelvic
Exenteration)
58800
70560
76440
85260
OPEN
Y
715
Surgical Oncology
SC
SC020 Pelvic Exenteration
SC020C Total - Open
64028
76833
83236
92840
OPEN
Y
716
Surgical Oncology
SC
SC020 Pelvic Exenteration
SC020D Total - Lap.
58800
70560
76440
85260
OPEN
Y
717
Surgical Oncology
SC
SC021 Wilms tumors: surgery
SC021A Wilms tumors: surgery
33000
39600
42900
47850
a) Procedure.
b) Operative Notes.
c) Post Procedure Photographs of
Clinical notes with planned line of
surgical site.
OPEN
treatment, Biopsy/HPE, CT
d) HPE report.
abdomen
e) Detailed Discharge Summary.
N
718
Surgical Oncology
SC
SC022
Ureteric end to end
anastomosis
SC022A
Ureteric end to end
anastomosis
24000
28800
31200
34800
a) Procedure.
b) Operative Notes.
a) CT KUB
c) Post Procedure Photographs of
b) Clinical notes with planned line
surgical site.
of treatment.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
N
719
Surgical Oncology
SC
SC023
Distal ureterectomy
with reimplantation
SC023A
Distal ureterectomy
with reimplantation
30000
36000
39000
43500
a) Procedure.
b) Operative Notes.
a) CT KUB
c) Post Procedure Photographs of
b) Clinical notes with planned line
surgical site.
of treatment.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
N
720
Surgical Oncology
SC
SC024 Radical cystectomy
SC024A
With continent
diversion - Open
98000
117600
127400
142100
a) Procedure.
a) HPE
b) Operative Notes.
b) Clinical notes with planned line c) Post Procedure Photographs of
of treatment.
surgical site.
OPEN
c) CT
d) HPE report.
e) Detailed Discharge Summary.
Y
721
Surgical Oncology
SC
SC024 Radical cystectomy
SC024B
With Ileal Conduit Open
95824
114988
124571
138944
a) Procedure.
a) HPE
b) Operative Notes.
b) Clinical notes with planned line c) Post Procedure Photographs of
of treatment.
surgical site.
OPEN
c) CT
d) HPE report.
e) Detailed Discharge Summary.
Y
SL NO
722
Specialty
Surgical Oncology
Specialty
Code
SC
Package
Code
Package Name
SC024 Radical cystectomy
Procedure
Code
SC024C
Procedure Name
With Ileal Conduit Lap.
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
88000
105600
NABH
Package
Cost
114400
Outside State
NABH
Package Cost
127600
Mandatory Documents - Pre
Authorization
a) HPE
b) Clinical notes with planned line
of treatment.
c) CT
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Procedure.
b) Operative Notes.
c) Post Procedure Photographs of
surgical site.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
Y
723
Surgical Oncology
SC
SC024 Radical cystectomy
SC024D With neobladder - Open
98000
117600
127400
142100
a) Procedure.
a) HPE
b) Operative Notes.
b) Clinical notes with planned line c) Post Procedure Photographs of
of treatment.
surgical site.
OPEN
c) CT
d) HPE report.
e) Detailed Discharge Summary.
Y
724
Surgical Oncology
SC
SC024 Radical cystectomy
SC024E
With neobladder - Lap
98000
117600
127400
142100
a) Procedure.
a) HPE
b) Operative Notes.
b) Clinical notes with planned line c) Post Procedure Photographs of
of treatment.
surgical site.
OPEN
c) CT
d) HPE report.
e) Detailed Discharge Summary.
Y
725
Surgical Oncology
SC
SC024 Radical cystectomy
SC024F
With
ureterosigmoidostomy Open
75000
90000
97500
108750
a) Procedure.
a) HPE
b) Operative Notes.
b) Clinical notes with planned line c) Post Procedure Photographs of
of treatment.
surgical site.
OPEN
c) CT
d) HPE report.
e) Detailed Discharge Summary.
Y
726
Surgical Oncology
SC
SC024 Radical cystectomy
With
SC024G ureterosigmoidostomy Lap
75000
90000
97500
108750
a) Procedure.
a) HPE
b) Operative Notes.
b) Clinical notes with planned line c) Post Procedure Photographs of
of treatment.
surgical site.
OPEN
c) CT
d) HPE report.
e) Detailed Discharge Summary.
Y
727
Surgical Oncology
SC
SC024 Radical cystectomy
SC024H
With ureterostomy Open
70000
84000
91000
101500
a) Procedure.
a) HPE
b) Operative Notes.
b) Clinical notes with planned line c) Post Procedure Photographs of
of treatment.
surgical site.
OPEN
c) CT
d) HPE report.
e) Detailed Discharge Summary.
Y
728
Surgical Oncology
SC
SC024 Radical cystectomy
SC024I
With ureterostomy Lap.
70000
84000
91000
101500
a) Procedure.
a) HPE
b) Operative Notes.
b) Clinical notes with planned line c) Post Procedure Photographs of
of treatment.
surgical site.
OPEN
c) CT
d) HPE report.
e) Detailed Discharge Summary.
Y
729
Surgical Oncology
SC
SC025 Channel TURP
SC025A Channel TURP
22800
27360
29640
33060
a) Clinical notes with planned line
of treatment.
b) PSA
c) USG- prostate.
a) Procedure.
b) Operative Notes.
c) HPE report.
d) Detailed Discharge Summary.
OPEN
N
SL NO
730
Specialty
Surgical Oncology
Specialty
Code
SC
Package
Code
Package Name
SC026 Radical Urethrectomy
Procedure
Code
Procedure Name
SC026A Radical Urethrectomy
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
30000
36000
NABH
Package
Cost
39000
Outside State
NABH
Package Cost
43500
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Procedure.
b) Operative Notes.
a) CT KUB.
c) Post Procedure Photographs of
b) Clinical notes with planned line
surgical site.
OPEN
of treatment.
d) HPE report.
e) Detailed Discharge Summary.
N
731
Surgical Oncology
SC
SC027
Penile preserving
surgery
(WLE, Glansectomy,
Laser)
SC027A
Penile preserving
surgery
(WLE, Glansectomy,
Laser)
25000
30000
32500
36250
a) Procedure.
a) HPE.
b) Operative Notes.
b) Clinical notes with planned line
c) HPE report.
of treatment.
d) Detailed Discharge Summary
OPEN
N
732
733
Surgical Oncology
Surgical Oncology
SC
SC
Excision of
SC028 undescended testicular
mass
SC029
Germ Cell Tumour
Excision
Excision of
SC028A undescended testicular
mass
SC029A
Germ Cell Tumour
Excision
24000
30000
28800
36000
31200
39000
34800
43500
a) Procedure.
a) CT
b) Operative Notes.
b) Clinical notes with planned line
c) HPE report.
of treatment.
d) Detailed Discharge Summary
a) Beta HCG.
b) AFP.
c) USG.
d) CT.
e) Clinical notes with planned line
of treatment.
OPEN
N
a) Procedure.
b) Operative Notes.
c) HPE report.
d) Detailed Discharge Summary
OPEN
N
734
Surgical Oncology
SC
SC030
Bilateral
salpingoophorectomy
SC030A Open
21000
25200
27300
30450
a) Procedure.
b) Operative Notes.
a) Clinical notes with planned line
c) Post Procedure Photographs of
of treatment.
surgical site.
b) HPE.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
Y
735
Surgical Oncology
SC
SC030
Bilateral
salpingoophorectomy
SC030B Lap.
21000
25200
27300
30450
a) Procedure.
b) Operative Notes.
a) Clinical notes with planned line
c) Post Procedure Photographs of
of treatment.
surgical site.
b) HPE.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
Y
736
Surgical Oncology
SC
SC031 Leiomyoma excision
SC031A Open
42000
50400
54600
60900
a) Procedure.
b) Operative Notes.
a) Clinical notes with planned line
c) Post Procedure Photographs of
of treatment.
surgical site.
b) USG.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
Y
737
Surgical Oncology
SC
SC031 Leiomyoma excision
SC031B MIS
42000
50400
54600
60900
a) Procedure.
b) Operative Notes.
a) Clinical notes with planned line
c) Post Procedure Photographs of
of treatment.
surgical site.
b) USG.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
Y
738
Surgical Oncology
SC
SC032 Radical Hysterectomy
SC032A
Class I radical
hysterectomy + bilateral
salpingoophorectomy +
BPLND - Lap.
27000
32400
35100
39150
a) Clinical notes with planned line
of treatment.
b) Biopsy.
c) CECT
d) MRI
a) Procedure.
b) Operative Notes.
c) Post Procedure Photographs of
surgical site.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
Y
SL NO
739
Specialty
Surgical Oncology
Specialty
Code
SC
Package
Code
Package Name
SC032 Radical Hysterectomy
Procedure
Code
SC032B
Procedure Name
Class I radical
hysterectomy + bilateral
salpingoophorectomy +
BPLND - Open
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
27000
32400
NABH
Package
Cost
35100
Outside State
NABH
Package Cost
39150
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Clinical notes with planned line
of treatment.
b) Biopsy.
c) CECT
d) MRI
a) Procedure.
b) Operative Notes.
c) Post Procedure Photographs of
surgical site.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
a) Clinical notes with planned line
of treatment.
b) Biopsy.
c) CECT
d) MRI
a) Procedure.
b) Operative Notes.
c) Post Procedure Photographs of
surgical site.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
a) Clinical notes with planned line
of treatment.
b) Biopsy.
c) CECT
d) MRI
a) Procedure.
b) Operative Notes.
c) Post Procedure Photographs of
surgical site.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
a) Clinical notes with planned line
of treatment.
b) Biopsy.
c) CECT
d) MRI
a) Procedure.
b) Operative Notes.
c) Post Procedure Photographs of
surgical site.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
a) Clinical notes with planned line
of treatment.
b) Biopsy.
c) CECT
d) MRI
a) Procedure.
b) Operative Notes.
c) Post Procedure Photographs of
surgical site.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
a) Clinical notes with planned line
of treatment.
b) Biopsy.
c) CECT
d) MRI
a) Procedure.
b) Operative Notes.
c) Post Procedure Photographs of
surgical site.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
a) Clinical notes.
b) CECT.
c) Biopsy.
a) Procedure.
b) Operative Notes.
c) Post Procedure Photographs of
surgical site.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
Y
740
Surgical Oncology
SC
SC032 Radical Hysterectomy
Class I radical
Hysterectomy +/SC032C bilateral
salpingoophorectomy Lap.
27000
32400
35100
39150
Y
741
Surgical Oncology
SC
SC032 Radical Hysterectomy
Class I radical
Hysterectomy +/SC032D bilateral
salpingoophorectomy Open
27000
32400
35100
39150
Y
742
Surgical Oncology
SC
SC032 Radical Hysterectomy
SC032E
Class II radical
hysterctomy + BPLND
27000
32400
35100
39150
Y
743
Surgical Oncology
SC
SC032 Radical Hysterectomy
SC032F
Class III radical
hysterctomy + BPLND
29400
35280
38220
42630
Y
744
Surgical Oncology
SC
SC032 Radical Hysterectomy
Hysterectomy +
bilateral
salpingoophorectomy +
SC032G
omentectomy +
peritonectomy and
organ resections
37024
44428
48131
53684
Y
745
Surgical Oncology
SC
SC033 Radical vaginectomy
SC033A Radical vaginectomy
30000
36000
39000
43500
N
746
Surgical Oncology
SC
Vulvectomy +
SC034 reconstruction
procedures
Vulvectomy +
SC034A reconstruction
procedures
36000
43200
46800
52200
a) Procedure.
a) Clinical notes with planned line b) Operative Notes.
of treatment.
c) Post Procedure Photographs of
b) Biopsy.
surgical site.
OPEN
c) HPE.
d) HPE report.
e) Detailed Discharge Summary.
N
SL NO
747
Specialty
Surgical Oncology
Specialty
Code
SC
Package
Code
Package Name
SC035 Radical Trachelectomy
Procedure
Code
Procedure Name
SC035A Radical Trachelectomy
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
40000
48000
NABH
Package
Cost
52000
Outside State
NABH
Package Cost
58000
Mandatory Documents - Pre
Authorization
a) Clinical notes.
b) CECT.
c) Biopsy.
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Procedure.
b) Operative Notes.
c) Post Procedure Photographs of
surgical site.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
N
748
Surgical Oncology
SC
SC036
Sacral Tumour
Excision
SC036A
Anterior + Posterior
approach
60000
72000
78000
87000
a) Procedure.
b) Operative Notes.
a) Clinical notes with planned line
c) Post Procedure Photographs of
of treatment.
surgical site.
b) HPE.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
Y
749
Surgical Oncology
SC
SC036
Sacral Tumour
Excision
SC036B Posterior approach
54000
64800
70200
78300
a) Procedure.
b) Operative Notes.
a) Clinical notes with planned line
c) Post Procedure Photographs of
of treatment.
surgical site.
b) HPE.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
Y
750
Surgical Oncology
SC
SC037
Resection of
nasopharyngeal tumour
SC037A
Resection of
nasopharyngeal tumour
40000
48000
52000
58000
a) Clinical notes.
b) Biopsy of primary.
c) CECT.
d) MRI.
a) Procedure.
b) Operative Notes.
c) Post Procedure Photographs of
surgical site.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
a) Clinical notes with planned line
of treatment.
b) HPE.
c) CT.
d) MRI.
a) Procedure.
b) Operative Notes.
c) Post Procedure Photographs of
surgical site.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
a) Clinical notes with planned line
of treatment.
b) HPE.
c) CT.
d) MRI.
a) Procedure.
b) Operative Notes.
c) Post Procedure Photographs of
surgical site.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
a) Clinical notes and Biopsy.
b) CECT film.
c) Report.
a) Procedure.
b) Operative Notes.
c) Post Procedure Photographs of
surgical site.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
a) Clinical notes and Biopsy.
b) CECT film.
c) Report.
a) Procedure.
b) Operative Notes.
c) Post Procedure Photographs of
surgical site.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
N
751
Surgical Oncology
SC
SC038 Total Pharyngectomy
SC038A Total Pharyngectomy
36000
43200
46800
52200
N
752
Surgical Oncology
SC
SC039
Parapharyngeal
Tumour Excision
SC039A
Parapharyngeal
Tumour Excision
35050
42060
45565
50822
N
753
Surgical Oncology
SC
SC040 Laryngectomy
Partial laryngectomy
SC040A
(voice preserving)
39000
46800
50700
56550
Y
754
Surgical Oncology
SC
SC040 Laryngectomy
SC040B Total Laryngectomy
39200
47040
50960
56840
Y
SL NO
755
Specialty
Surgical Oncology
Specialty
Code
SC
Package
Code
Package Name
SC041 Tracheal resection
Procedure
Code
Procedure Name
SC041A Tracheal resection
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
36000
43200
NABH
Package
Cost
46800
Outside State
NABH
Package Cost
52200
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Clinical notes.
b) CECT.
c) Biopsy confirming diagnosis.
a) Procedure.
b) Operative Notes.
c) Post Procedure Photographs of
surgical site.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
a) Clinical notes with planned line
of treatment.
b) HPE.
c) CT.
d) MRI.
a) Procedure.
b) Operative Notes.
c) Post Procedure Photographs of
surgical site.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
a) Clinical notes with planned line
of treatment.
b) HPE.
c) CT.
d) MRI.
a) Procedure.
b) Operative Notes.
c) Post Procedure Photographs of
surgical site.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
a) Clinical notes with planned line
of treatment.
b) HPE.
c) CT.
d) MRI.
a) Procedure.
b) Operative Notes.
c) Post Procedure Photographs of
surgical site.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
a) Cinical notes.
b) Radiological evidence for
indication.
a) Procedure.
b) Operative Notes.
c) Post Procedure Photographs of
surgical site.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
a) Clinical notes.
b) FNAC.
c) BIOPSY.
d) CECT.
a) Procedure.
b) Operative Notes.
c) Post Procedure Photographs of
surgical site.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
a) Cinical notes.
b) Radiological evidence for
indication.
a) Procedure.
b) Operative Notes.
c) Post Procedure Photographs of
surgical site.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
a) Cinical notes.
b) Radiological evidence for
indication.
a) Procedure.
b) Operative Notes.
c) Post Procedure Photographs of
surgical site.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
N
756
Surgical Oncology
SC
SC042
Tracheal / Carinal
resection
SC042A
Tracheal / Carinal
resection
58800
70560
76440
85260
N
757
Surgical Oncology
SC
Tracheal Stenosis
SC043 (End to end
Anastamosis) (Throat)
Tracheal Stenosis (End
SC043A to end Anastamosis)
(Throat)
36000
43200
46800
52200
N
758
Surgical Oncology
SC
SC044
Central airway tumour
debulking
SC044A
Central airway tumour
debulking
22800
27360
29640
33060
N
759
Surgical Oncology
SC
Diagnostic
SC045
thoracoscopy
SC045A Diagnostic thoracoscopy
15000
18000
19500
21750
N
760
Surgical Oncology
SC
SC046
Sleeve resection of
lung cancer
SC046A
Sleeve resection of lung
cancer
70000
84000
91000
101500
N
761
Surgical Oncology
SC
SC047 Mediastinoscopy
SC047A Diagnostic
22200
26640
28860
32190
Y
762
Surgical Oncology
SC
SC047 Mediastinoscopy
SC047B Staging
22200
26640
28860
32190
Y
SL NO
763
Specialty
Surgical Oncology
Specialty
Code
SC
Package
Code
SC048
Package Name
Removal of Chest
Wall Tumour
Procedure
Code
SC048A
Procedure Name
Chest Wall Tumour
Excision
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
36000
43200
NABH
Package
Cost
46800
Outside State
NABH
Package Cost
52200
Mandatory Documents - Pre
Authorization
a) Clinical notes with planned line
of treatment.
b) HPE.
c) CT.
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Procedure.
b) Operative Notes.
c) Post Procedure Photographs of
surgical site.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
Y
764
Surgical Oncology
SC
SC048
Removal of Chest
Wall Tumour
Removal of chest wall
SC048B tumour with
reconstruction
51000
61200
66300
73950
a) Procedure.
a) Clinical notes with planned line b) Operative Notes.
of treatment.
c) Post Procedure Photographs of
b) HPE.
surgical site.
OPEN
c) CT.
d) HPE report.
e) Detailed Discharge Summary.
Y
765
Surgical Oncology
SC
SC049
Pleurectomy
Decortication
SC049A
Pleurectomy
Decortication
39000
46800
50700
56550
a) Procedure.
a) Clinical notes with planned line b) Operative Notes.
of treatment.
c) Post Procedure Photographs of
b) HPE.
surgical site.
OPEN
c) CT.
d) HPE report.
e) Detailed Discharge Summary.
N
766
Surgical Oncology
SC
SC050 Chamberlain procedure
SC050A Chamberlain procedure
22200
26640
28860
32190
a) Procedure.
b) Operative Notes.
a) Clinical notes with planned line
c) Post Procedure Photographs of
of treatment.
surgical site.
b) CT Thorax.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
N
767
Surgical Oncology
SC
SC051
Extrapleural
pneumonectomy
SC051A
Extrapleural
pneumonectomy
66000
79200
85800
95700
a) Procedure.
a) Clinical notes with planned line b) Operative Notes.
of treatment.
c) Post Procedure Photographs of
b) HPE.
surgical site.
OPEN
c) CT.
d) HPE report.
e) Detailed Discharge Summary.
N
768
Surgical Oncology
SC
SC052 Pneumonectomy
SC052A Pneumonectomy
58800
70560
76440
85260
a) Procedure.
b) Operative Notes.
a) Clinical notes with planned line
c) Post Procedure Photographs of
of treatment.
surgical site.
OPEN
b) CT Thorax.
d) HPE report.
c) Biopsy.
e) Detailed Discharge Summary.
N
769
Surgical Oncology
SC
SC053 Lung metastectomy
SC053A Open
32668
39201
42468
47368
a) Clinical notes.
b) FNAC.
c) BIOPSY.
d) CECT.
a) Procedure.
b) Operative Notes.
c) Post Procedure Photographs of
surgical site.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
a) Clinical notes.
b) FNAC.
c) BIOPSY.
d) CECT.
a) Procedure.
b) Operative Notes.
c) Post Procedure Photographs of
surgical site.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
Y
770
Surgical Oncology
SC
SC053 Lung metastectomy
SC053B VATS
30000
36000
39000
43500
Y
SL NO
771
Specialty
Surgical Oncology
Specialty
Code
SC
Package
Code
Package Name
SC054 Thoracostomy
Procedure
Code
Procedure Name
SC054A Thoracostomy
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
19800
23760
NABH
Package
Cost
25740
Outside State
NABH
Package Cost
28710
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Procedure.
b) Operative Notes.
a) Clinical notes with planned line
c) Post Procedure Photographs of
of treatment.
surgical site.
OPEN
b) Clinical photograph.
d) HPE report.
e) Detailed Discharge Summary.
N
772
Surgical Oncology
SC
SC055
Mediastinal
lymphadenectomy
SC055A Open
36000
43200
46800
52200
a) Procedure.
b) Operative Notes.
a) Clinical notes with planned line
c) Post Procedure Photographs of
of treatment.
surgical site.
b) CT.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
Y
773
Surgical Oncology
SC
SC055
Mediastinal
lymphadenectomy
SC055B Video - assisted
36000
43200
46800
52200
a) Procedure.
b) Operative Notes.
a) Clinical notes with planned line
c) Post Procedure Photographs of
of treatment.
surgical site.
b) CT.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
Y
774
Surgical Oncology
SC
Mediastinal mass
SC056 excision with lung
resection
Mediastinal mass
SC056A excision with lung
resection
60900
73080
79170
88305
a) Procedure.
b) Operative Notes.
a) Clinical notes with planned line
c) Post Procedure Photographs of
of treatment and CT Thorax.
surgical site.
b) Biopsy.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
N
775
Surgical Oncology
SC
SC057
Segmental resection of
lung
SC057A Open
42000
50400
54600
60900
a) Procedure.
b) Operative Notes.
a) Clinical notes with planned line
c) Post Procedure Photographs of
of treatment and CT Thorax.
surgical site.
b) Biopsy.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
Y
776
Surgical Oncology
SC
SC057
Segmental resection of
lung
SC057B Thoracoscopic
42000
50400
54600
60900
a) Procedure.
b) Operative Notes.
a) Clinical notes with planned line
c) Post Procedure Photographs of
of treatment and CT Thorax.
surgical site.
b) Biopsy.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
Y
777
Surgical Oncology
SC
SC058 Wedge resection lung
SC058A Open
36000
43200
46800
52200
a) Procedure.
b) Operative Notes.
a) Clinical notes with planned line
c) Post Procedure Photographs of
of treatment and CT Thorax.
surgical site.
b) Biopsy.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
Y
778
Surgical Oncology
SC
SC058 Wedge resection lung
SC058B Thoracoscopic
36000
43200
46800
52200
a) Procedure.
b) Operative Notes.
a) Clinical notes with planned line
c) Post Procedure Photographs of
of treatment and CT Thorax.
surgical site.
b) Biopsy.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
Y
SL NO
779
Specialty
Surgical Oncology
Specialty
Code
SC
Package
Code
SC059
Package Name
Breast conserving
surgery
Procedure
Code
SC059A
Procedure Name
Breast conserving
surgery
(lumpectomy + axillary
surgery)
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
24600
29520
NABH
Package
Cost
31980
Outside State
NABH
Package Cost
35670
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Clinical notes.
b) Mammography.
c) FNAC.
d) BIOPSY.
e) CT.
f) MRI.
a) Procedure.
b) Operative Notes.
c) Post Procedure Photographs of
surgical site.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
a) Clinical notes.
b) Mammography.
c) FNAC.
d) BIOPSY.
e) CT.
f) MRI.
a) Procedure.
b) Operative Notes.
c) Post Procedure Photographs of
surgical site.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
Y
780
Surgical Oncology
SC
SC059
Breast conserving
surgery
SC059B
Breast conserving
surgery with Oncoplasty
24600
29520
31980
35670
Y
781
Surgical Oncology
SC
SC060
Axillary Sampling /
Sentinel Node Biopsy
SC060A
Axillary Sampling /
Sentinel Node Biopsy
16200
19440
21060
23490
a) Procedure.
b) Operative Notes.
a) FNAC.
c) Post Procedure Photographs of
b) Clinical notes with planned line
surgical site.
of treatment.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
N
782
Surgical Oncology
SC
SC061 Axillary dissection
SC061A Axillary dissection
19800
23760
25740
28710
a) Clinical notes.
b) FNAC.
c) BIOPSY.
d) CECT.
e) Chest X-ray.
a) Procedure.
b) Operative Notes.
c) Post Procedure Photographs of
surgical site.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
N
783
Surgical Oncology
SC
Scalp tumour excision
SC062 with skull bone
excision
SC062A
Scalp tumour excision
with skull bone excision
30000
36000
39000
43500
a) Procedure.
b) Operative Notes.
a) HPE.
c) Post Procedure Photographs of
b) Clinical notes with planned line
surgical site.
of treatment.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
N
784
Surgical Oncology
SC
SC063
Neuroblastoma
Excision
SC063A Neuroblastoma Excision
60000
72000
78000
87000
a) Procedure.
b) Operative Notes.
a) HPE.
c) Post Procedure Photographs of
b) Clinical notes with planned line
surgical site.
of treatment.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
N
785
Surgical Oncology
SC
Excision of Pinna for
Growths / Injuries SC064 Total Amputation &
Excision of External
Auditory Meatus
SC064A Growth - Squamous
21600
25920
28080
31320
a) Procedure.
b) Operative Notes.
a) HPE.
c) Post Procedure Photographs of
b) Clinical notes with planned line
surgical site.
of treatment.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
Y
786
Surgical Oncology
SC
Excision of Pinna for
Growths / Injuries SC064 Total Amputation &
Excision of External
Auditory Meatus
SC064B Growth - Basal
21600
25920
28080
31320
a) Procedure.
b) Operative Notes.
a) HPE.
c) Post Procedure Photographs of
b) Clinical notes with planned line
surgical site.
of treatment.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
Y
SL NO
787
Specialty
Surgical Oncology
Specialty
Code
SC
Package
Code
Package Name
Excision of Pinna for
Growths / Injuries SC064 Total Amputation &
Excision of External
Auditory Meatus
Procedure
Code
Procedure Name
SC064C Injury
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
21600
25920
NABH
Package
Cost
28080
Outside State
NABH
Package Cost
31320
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Procedure.
b) Operative Notes.
a) Clinical notes with planned line
c) Post Procedure Photographs of
of treatment.
surgical site.
OPEN
b) Clinical photograph.
d) HPE report.
e) Detailed Discharge Summary.
Y
788
Surgical Oncology
SC
SC065
Neck dissection comprehensive
SC065A
Neck dissection comprehensive
17424
20908
22651
25264
a) Clinical notes.
b) USG.
c) CT neck.
d) Biopsy.
e) FNAC.
a) Procedure.
b) Operative Notes.
c) Post Procedure Photographs of
surgical site.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
N
789
Surgical Oncology
SC
SC066
Benign Soft Tissue
Tumour - Excision
SC066A
Benign Soft Tissue
Tumour - Excision
12000
14400
15600
17400
a) Procedure.
b) Operative Notes.
a) HPE.
c) Post Procedure Photographs of
b) Clinical notes with planned line
surgical site.
of treatment.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
N
790
Surgical Oncology
SC
SC067
Malignant Soft Tissue
Tumour - Excision
SC067A
Malignant Soft Tissue
Tumour - Excision
24000
28800
31200
34800
a) Procedure.
b) Operative Notes.
a) HPE.
c) Post Procedure Photographs of
b) Clinical notes with planned line
surgical site.
of treatment.
OPEN
d) HPE report.
e) Detailed Discharge Summary.
N
791
Surgical Oncology
SC
SC068 Regional flap
SC068A Myocutaneous flap
30600
36720
39780
44370
a) Clinical notes
b) Biopsy of primary
a) Detailed Procedure.
b) Operative Notes.
c) Clinical photgraph showing scar.
OPEN
d) Detailed discharge summary.
a) Clinical notes
b) Biopsy of primary
a) Detailed Procedure.
b) Operative Notes.
c) Clinical photgraph showing scar.
OPEN
d) Detailed discharge summary.
Y
792
Surgical Oncology
SC
SC068 Regional flap
SC068B Fasciocutaneous flap
30600
36720
39780
44370
Y
793
Surgical Oncology
SC
SC069 Rotationplasty
SC069A Rotationplasty
45000
54000
58500
65250
a) Procedure.
b) Operative Notes.
c) Post Procedure Photographs of
Clinical notes with planned line of
surgical site.
OPEN
treatment.
d) Detailed Discharge Summary.
N
794
Surgical Oncology
SC
Bone tumors / soft
SC070 tissue sarcomas:
surgery
SC070A
Bone tumors / soft
tissue sarcomas: surgery
32668
39201
42468
47368
a) Procedure.
b) Operative Notes.
a) HPE.
c) Post Procedure Photographs of
b) Clinical notes with planned line
surgical site.
OPEN
of treatment.
d) HPE report.
e) Detailed Discharge Summary.
N
SL NO
795
Specialty
Surgical Oncology
Specialty
Code
SC
Package
Code
SC071
Package Name
Endoprosthesis
Revision
Procedure
Code
Procedure Name
SC071A Complete
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
39000
46800
NABH
Package
Cost
50700
Outside State
NABH
Package Cost
56550
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Procedure.
a) Clinical notes with planned line
b) Operative Notes.
of treatment.
c) Post Procedure Photographs of
b) Radiological evidence for
surgical site.
OPEN
indication.
d) Detailed Discharge Summary.
Y
796
Surgical Oncology
SC
SC071
Endoprosthesis
Revision
SC071B Partial
24000
28800
31200
34800
a) Procedure.
a) Clinical notes with planned line
b) Operative Notes.
of treatment.
c) Post Procedure Photographs of
b) Radiological evidence for
surgical site.
OPEN
indication.
d) Detailed Discharge Summary.
Y
797
Surgical Oncology
SC
Vertebral Tumour
SC072 Excision and
Reconstruction
Vertebral Tumour
SC072A Excision and
Reconstruction
54000
64800
70200
78300
a) Procedure.
a) Clinical notes with planned line
b) Operative Notes.
of treatment.
c) Post Procedure Photographs of
b) Radiological evidence for
surgical site.
OPEN
indication.
d) Detailed Discharge Summary.
N
798
Surgical Oncology
SC
799
Surgical Oncology
SC
800
Surgical Oncology
SC
801
Surgical Oncology
SC
a) Clinical notes.
b) Biopsy of primary with details
of earlier surgery done.
c) Establishing need of
microvascular reconstruction.
a) Detailed discharge summary.
b) Detailed Procedure.
c) Operative Notes.
d) Clinical Photograph showing
scar.
Microvascular
SC073 reconstruction (free
flaps)
Microvascular
SC073A reconstruction (free
flaps)
49000
58800
63700
71050
SC074 Vascular
Curopsy /
SC075
Sclerotherapy
SC074A Vascular reconstruction
57600
69120
74880
83520
Clincal notes.
Detailed Discharge Summary.
OPEN
SC075A Curopsy / Sclerotherapy
19200
23040
24960
27840
Clincal notes.
Detailed Discharge Summary.
OPEN
SC076 Chemo Port Insertion
SC076A Chemo Port Insertion
19600
23520
25480
28420
a) Procedure.
b) Operative Notes.
Clinical notes with planned line of c) Discharge summary.
treatment.
d) Invoice of Chemo port used.
OPEN
N
N
N
OPEN
N
802
Ophthalmology
SE
SE001 Ptosis Surgery
SE001A Ptosis Surgery
8000
9600
10400
11600
Clinical Photograph of affected
eye (Photographic record of the
patient should be maintained for
comparison. Photographs should
have be taken in primary position
as well as in lateral gazes)
a) Still image of the the procedure
with pt. ID.
b) date.
c) Detailed discharge summary.
Referral
d) detailed operative notes.
N
803
Ophthalmology
SE
SE002 Entropion correction
SE002A Entropion correction
6600
7920
8580
9570
a) Clinical notes.
b) Clinical Photograph.
a) Detailed discharge summary.
b) Still image of the the procedure
with pt. ID.
c) Date.
OPEN
d) operative notes.
a) Clinical notes.
b) Clinical Photograph.
a) Detailed discharge summary.
b) Still image of the the procedure
with pt. ID.
c) Date.
OPEN
d) operative notes.
a) Clinical notes.
b) FIR.
c) MLC in case of accident.
d) Clinical Photograph
a) Still image of the the procedure
with pt. ID.
b) Date.
c) operative note.
OPEN
d) Detailed discharge summary
N
804
Ophthalmology
SE
SE003 Ectropion correction
SE003A Ectropion correction
6500
7800
8450
9425
N
805
Ophthalmology
SE
SE004 Lid Tear Repair
SE004A Lid Tear Repair
5000
6000
6500
7250
N
SL NO
806
807
808
Specialty
Ophthalmology
Ophthalmology
Ophthalmology
Specialty
Code
SE
SE
SE
Package
Code
Package Name
SE005 Lid Abscess Drainage
SE006
Lid Tumor excision +
Lid Reconstruction
SE007 Chalazion Removal
Procedure
Code
Procedure Name
SE005A Lid Abscess Drainage
SE006A
Lid Tumor excision +
Lid Reconstruction
SE007A Chalazion Removal
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
3000
10000
2000
3600
12000
2400
NABH
Package
Cost
3900
13000
2600
Outside State
NABH
Package Cost
4350
14500
2900
Mandatory Documents - Pre
Authorization
a) Patient details.
b) Diagnosis.
c) doctors notes.
d) photo
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Discharge notes.
b) microbiology report.
c) Still image of the patient
OPEN
undergoing the procedure with
date stamp
a) Clinical notes.
b) Clinical Photograph of affected
part.
c) stated plan for lab investigation
of host tissue (HP/
Microbiology/other)
a) Still image of the the procedure
with pt. ID.
b) Date.
c) HP report.
OPEN
d) Procedure .
e) Operative Notes.
f) Detailed discharge summary
a) Patient details.
b) Diagnosis.
c) doctors notes.
d) photo
a) Discharge notes.
b) pathology report.
c) Still image of the patient
undergoing the procedure with
date stamp
a) Clinical notes detailing which
muscles affected.
b) indication justifying the need for
GA (if required).
c) Clinical Photograph
a) Still image of the the procedure
with pt. ID.
b) Date.
c) Procedure.
Referral
d) Operative Notes.
e) Detailed discharge summary
a) Clinical notes detailing which
muscles affected.
b) indication justifying the need for
GA (if required).
c) Clinical Photograph
a) Still image of the the procedure
with pt. ID.
b) Date.
c) Procedure.
Referral
d) Operative Notes.
e) Detailed discharge summary
N
N
OPEN
N
809
Ophthalmology
SE
SE008 Squint correction
SE008A Minor - upto 2 muscles
4000
4800
5200
5800
Y
810
Ophthalmology
SE
SE008 Squint correction
SE008B
Major - 3 or more
muscles (complex
surgery involving four
muscles or oblique
muscles)
14000
16800
18200
20300
Y
811
812
813
814
Ophthalmology
Ophthalmology
Ophthalmology
Ophthalmology
SE
SE
SE
SE
SE009
SE010
SE010
SE010
Conjunctival tumour
excision including
Amniotic Membrane
Graft
SE009A
Dacryocystorhinostom
y
Canaliculo
Dacryocystorhinostomy
SE010A
with Silicon Tube /
Stent
Dacryocystorhinostom
y
Dacryocystorhinostom
y
SE010B
SE010C
Conjunctival tumour
excision including
Amniotic Membrane
Graft
Canaliculo
Dacryocystorhinostomy
without Silicon Tube /
Stent
Dacryocystorhinostomy
with Silicon Tube /
Stent
7000
8000
8000
8000
8400
9600
9600
9600
9100
10400
10400
10400
10150
11600
11600
11600
a) Still image of the the procedure
with pt. ID.
a) Clinical notes.
b) Date.
b) Clinical Photograph of affected c) HP report.
OPEN
part.
d) detailed discharge summary.
e) detailed Procedure.
f) Operative Notes.
a) Dye disappearance test .
b) Tear meniscus height
measurement.
c) Probing and irrigation
a) Still image of the the procedure
with pt. ID.
b) Date.
OPEN
c) operative notes.
a) Dye disappearance test .
b) Tear meniscus height
measurement.
c) Probing and irrigation
a) Still image of the the procedure
with pt. ID.
b) Date.
OPEN
c) operative notes.
a) Clinical notes.
b) establishing lacrimal cancer
with Evidence of biopsy. Pre-op
clinical photograph.
a) Still image of the the procedure
with pt. ID.
b) Date.
c) operative notes.
OPEN
d) Detailed discharge summary
Invoice of implants
N
Y
Y
Y
SL NO
815
Specialty
Ophthalmology
Specialty
Code
Package
Code
Package Name
Dacryocystorhinostom
y
SE
SE010
SE
Corneal Ulcer
SE011
Management
Procedure
Code
Procedure Name
Dacryocystorhinostomy
SE010D without Silicon Tube /
Stent
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
8000
9600
NABH
Package
Cost
10400
Outside State
NABH
Package Cost
11600
Mandatory Documents - Pre
Authorization
a) Clinical notes.
b) establishing lacrimal cancer
with Evidence of biopsy. Pre-op
clinical photograph.
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Still image of the the procedure
with pt. ID.
b) Date.
c) operative notes.
OPEN
d) Detailed discharge summary
Invoice of implants
Y
816
817
Ophthalmology
Ophthalmology
SE
SE012 Corneal Grafting
Corneal Ulcer
SE011A
Management
SE012A Corneal Grafting
4000
8500
4800
10200
5200
11050
5800
12325
clinical presentation photo
a) Clinical notes detailing
Indication for corneal grafting and
supporting investigation.
b) Clinical Photograph.
c) details of donor cornea.
d) stated plan for lab investigation
of host tissue (HPE/
Microbiology/other).
Still image of the patient
undergoing the procedure with
date stamp
OPEN
N
a) Still image of the the procedure
with pt. ID.
b) Date.
c) operative notes.
OPEN
d) Detailed discharge summary
Y
818
Ophthalmology
SE
SE012 Corneal Grafting
SE012B
Corneal Graft - Follow
Up
819
Ophthalmology
SE
SE013
Corneal Collagen
Crosslinking
SE013A
Corneal Collagen
Crosslinking
820
821
822
Ophthalmology
Ophthalmology
Ophthalmology
SE
SE
SE
SE014
Pterygium +
Conjunctival Autograft
Corneo / Scleral /
SE015 Corneo scleral tear
repair
SE016
Corneal / Scleral
Patch Graft
SE014A
Pterygium +
Conjunctival Autograft
Corneo / Scleral /
SE015A Corneo scleral tear
repair
SE016A
Corneal / Scleral Patch
Graft
2000
2400
2600
2900
clinical notes
9000
10800
11700
13050
PENTACAM PROGRESSION
MAPS 3 to 6 months apart
5000
11500
3000
6000
13800
3600
6500
14950
3900
7250
16675
4350
Still image of the patient
undergoing the procedure with
date stamp
Still image of the patient
undergoing the procedure with
date stamp
OPEN
Y
OPEN
N
a) Clinical notes and Retinoscopy.
b) Corneal topography (not
mandatory).
c) Keratometry.
d) Clinical Photograph.
a) Still image of the the procedure
with pt. ID
b) Date.
c) detailed discharge summary.
Reserved
d) detailed operative notes.
a) Clinical notes.
b) FIR.
c) MLC (since injury).
d) USG B scan.
e) Clinical Photograph.
a) Still image of the the procedure
with pt. ID.
b) Date.
c) Detailed discharge summary.
OPEN
d) barcode of Intraocular Lens
used,operative notes.
preoperative clinical photo
a) operative notes.
b) Still image of the patient
undergoing the procedure with
date stamp
N
OPEN
N
823
Ophthalmology
SE
SE017
Scleral buckling
surgery
SE017A Scleral buckling surgery
15000
18000
19500
21750
Clinical notes
a) operative notes.
b) Detailed discharge summary.
c) Still image of the the procedure
with pt. ID.
Referral
d) Date.
N
824
Ophthalmology
SE
SE018
Scleral Buckle
Removal
SE018A Scleral Buckle Removal
5500
6600
7150
7975
a) Still image of the the procedure
a) Clinical notes with.
with pt. ID
b) Indication for removal.
b) Date.
c) stated plan for lab investigation c) operative notes.
OPEN
of host tissue (Microbiology).
d) Detailed discharge summary.
e) microbiological report .
N
SL NO
825
Specialty
Ophthalmology
Specialty
Code
SE
Package
Code
SE019
Package Name
Limbal Dermoid
Removal
Procedure
Code
SE019A
Procedure Name
Limbal Dermoid
Removal
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
1000
1200
NABH
Package
Cost
1300
Outside State
NABH
Package Cost
1450
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Clinical notes.
b) Indication for Limbal Dermoid
Removal like increase in dermoid
size.
c) increasing astigmatism.
d) visual deterioration.
e) central opacification of the
cornea.
f) Clinical Photograph.
a) Still image of the the procedure
with pt. ID
b) Date.
c) Detailed discharge summary.
OPEN
d) detailed operative notes.
a) Clinical notes detailing visual
impairment (Best corrected visual
acquity- BCVA) of cataract .
b) Ocular Biometry (A scan and
ketometry).
c) Clinical photo of affected part.
a) Detailed discharge summary.
b) operative notes.
c) Barcode of IOL used. Still
image of the the procedure with
pt. ID
d) Date.
N
826
Ophthalmology
SE
SE020 Cataract surgery
Phaco emulsification
SE020A with foldable
hydrophobic acrylic IOL
4500
5400
5850
6525
OPEN
Y
827
Ophthalmology
SE
SE020 Cataract surgery
SE020B
Cataract with foldable /
non-foldable IOL using
SICS technique
4000
4800
5200
5800
a) Clinical notes detailing visual
impairment (Best corrected visual
acquity- BCVA) of cataract .
b) Ocular Biometry (A scan and
ketometry).
c) Clinical photo of affected part.
a) Detailed discharge summary.
b) operative notes.
c) Barcode of IOL used. Still
image of the the procedure with
pt. ID
d) Date.
a) Clinical notes detailing
Indication for Lensectomy.
b) pediatric lens aspiration.
c) Membranectomy.
d) supporting investigation.
e) Clinical Photograph.
a) Still image of the the procedure
with pt. ID
b) Date.
c) Detailed discharge summary.
OPEN
d) detailed operative notes with
visual outcomes.
e) Barcode of IOL used
a) Clinical notes detailing
Indication for Lensectomy.
b) pediatric lens aspiration.
c) Membranectomy.
d) supporting investigation.
e) Clinical Photograph.
a) Still image of the the procedure
with pt. ID
b) Date.
c) Detailed discharge summary.
Referral
d) detailed operative notes with
visual outcomes.
e) Barcode of IOL used
a) Clinical notes detailing
Indication for Lensectomy.
b) pediatric lens aspiration.
c) Membranectomy.
d) supporting investigation.
e) Clinical Photograph.
a) Still image of the the procedure
with pt. ID
b) Date.
c) Detailed discharge summary.
OPEN
d) detailed operative notes with
visual outcomes.
e) Barcode of IOL used
Referral
Y
828
Ophthalmology
SE
SE021
Surgery for Pediatric
Cataract
SE021A Paediatric lensectomy
9200
11040
11960
13340
Y
829
Ophthalmology
SE
SE021
Surgery for Pediatric
Cataract
SE021B
Pediatric lens aspiration
with posterior
capsulotomy & anterior
vitrectomy
9200
11040
11960
13340
Y
830
Ophthalmology
SE
SE021
Surgery for Pediatric
Cataract
SE021C
Paediatric
Membranectomy &
anterior vitrectomy
9200
11040
11960
13340
Y
831
Ophthalmology
SE
SE022 Capsulotomy (YAG)
SE022A Capsulotomy (YAG)
1500
1800
1950
2175
a) Clinical notes detailing when
was cataract surgery was done.
b) notes mentioning indication for
this procedure with vision.
c) fundus.
d) Clinical photo of patient before
procedure.
a) procedure notes.
b) Detailed discharge summary.
c) Still image of the the procedure
with pt. ID
OPEN
d) Date.
N
SL NO
832
Specialty
Ophthalmology
Specialty
Code
SE
Package
Code
SE023
Package Name
SFIOL (inclusive of
Vitrectomy)
Procedure
Code
SE023A
Procedure Name
SFIOL (inclusive of
Vitrectomy)
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
15000
18000
NABH
Package
Cost
19500
Outside State
NABH
Package Cost
21750
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Still image of the patient
a) Clinical notes with planned line
undergoing the procedure with
of treatment.
date stamp operative notes.
b) Pre operative Clinical
b) Detailed discharge summary.
Photograph of affected part
c) Barcode of SFIOL.
Referral
N
833
Ophthalmology
SE
SE024
Secondary IOL / IOL
Exchange / Explant
SE024A
Secondary IOL / IOL
Exchange / Explant
5000
6000
6500
7250
a) Clinical notes.
b) pre operative documentation of
indication for intervention.
c) Clinical Photograph of affected
part
a) Still image of the patient
undergoing the procedure with
date stamp operative notes.
b) Detailed discharge summary.
c) Barcode of IOL.
a) Clinical notes.
b) pre operative documentation of
indication for intervention.
c) Clinical Photograph of affected
part
a) Still image of the patient
undergoing the procedure with
date stamp.
b) operative notes.
c) Detailed discharge summary
a) Clinical notes showing
Indication for Iridectomy(Laser).
b) Tonometry.
c) Gonioscopy.
d) clinical photo
a) Still image of the the procedure
with pt. ID.
b) Date.
c) procedure notes.
OPEN
d) Detailed discharge summary
OPEN
N
834
Ophthalmology
SE
SE025 IRIS Prolapse – Repair
SE025A IRIS Prolapse – Repair
4000
4800
5200
5800
OPEN
N
835
Ophthalmology
SE
SE026 Iridectomy
SE026A Iridectomy
2000
2400
2600
2900
N
836
837
838
839
Ophthalmology
Ophthalmology
Ophthalmology
Ophthalmology
SE
SE
SE
SE
SE027 Glaucoma Surgery
SE027 Glaucoma Surgery
SE027 Glaucoma Surgery
SE027 Glaucoma Surgery
SE027A
Cyclocryotherapy /
Cyclophotocoagulation
SE027B
Glaucoma Surgery
(Trabeculectomy only)
with or without
Mitomycin C, including
postoperative
medications for 12
weeks
(and wherever surgical
or laser procedures
required for bleb
augmentation and
anterior chamber
maintenance)
SE027C
SE027D
Glaucoma Shunt
Surgery
Pediatric Glaucoma
Surgery
3700
4440
4810
5365
a) Clinical notes establishing long
a) Detailed Procedure.
standing history of Glaucoma with
b) Operative Notes.
recent documentation of vision.
c) discharge summary.
b) reports of field of vision.
OPEN
Y
11000
13200
14300
15950
a) Clinical notes and IOP
measurement.
b) documentary evidence
supporting chronicity.
a) Still image of the the procedure
with pt. ID.
b) Date.
c) operative notes.
Referral
d) Detailed discharge summary.
e) ensure that post op medicine for
12 weeks is given.
a) Clinical notes and IOP
measurement.
b) documentary evidence
supporting chronicity.
c) Failed Trabeculectomy.
a) Still image of the patient
undergoing the procedure with
date stamp.
b) operative notes.
c) Detailed discharge summary .
a) Clinical notes and IOP
measurement.
b) documentary evidence of
paediatric glaucoma with
confirmation of diagnosis under
GA/Examination under
anaesthesia (EUA).
a) Still image of the patient
undergoing the procedure with
date stamp.
b) operative notes.
c) Detailed discharge summary .
Y
13000
15000
15600
18000
16900
19500
18850
21750
Referral
Y
Referral
Y
SL NO
840
841
842
843
844
Specialty
Ophthalmology
Ophthalmology
Ophthalmology
Ophthalmology
Ophthalmology
Specialty
Code
Package
Code
Package Name
Procedure
Code
SE
SE028
EUA for Confirmation
of Pediatric Glaucoma
SE028A
SE
SE
SE
SE
SE029
SE029
Retinal Laser
Photocoagulation
Retinal Laser
Photocoagulation
SE030 ROP Laser - Per Eye
SE031 Retinal Cryopexy
Procedure Name
EUA for Confirmation
of Pediatric Glaucoma
SE029A
For retinal tear repair
Per Eye Per Sitting
SE029B
Pan Retinal
Photocoagulation
(PRP) - Retinal Laser
including 3 sittings /
package of retino laser
photocoagulation
(3 sittings per eye for
both eyes)
SE030A ROP Laser - Per Eye
SE031A Retinal Cryopexy
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
3000
1500
3600
1800
NABH
Package
Cost
Outside State
NABH
Package Cost
3900
4350
1950
2175
Mandatory Documents - Pre
Authorization
a) Clinical notes.
b) documentary evidence .
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Still image of the patient
undergoing the procedure with
date stamp.
b) operative notes.
c) Detailed discharge summary
OPEN
with IOP.
d) Fundus.
e) Corneal diameter.
a) clinical notes .
b) supportive documents.
a) discharge summary.
b) clinical notes.
c) Still image of the the procedure
OPEN
with pt. ID.
d) Date.
a) clinical notes .
b) supportive documents.
a) Still image of the the procedure
with pt. ID.
b) Date.
c) discharge summary.
OPEN
d) clinical notes.
N
Y
8500
5000
3800
10200
6000
4560
11050
6500
4940
12325
7250
5510
Clinical notes
Clinical notes with Indication for
procedure
a) Discharge summary.
b) Still image of the patient
undergoing the procedure with
date stamp.
Y
OPEN
a) Detailed Procedure notes.
b) discharge summary.
c) Still image of the the procedure
OPEN
with pt. ID
d) Date.
N
N
845
846
Ophthalmology
Ophthalmology
SE
SE
Vitreoretinal Surgery
SE032 (with Silicon Oil
Insertion)
SOR (Silicon Oil
SE033
Removal)
Vitreoretinal Surgery
SE032A (with Silicon Oil
Insertion)
SOR (Silicon Oil
SE033A
Removal)
17900
9300
21480
11160
23270
12090
25955
13485
a) Clinical notes.
b) Clinical documents.
c) B Scan (optional).
a) Clinical notes..
b) Clinical documents
c) B Scan.
Detailed discharge summary,
operative notes, IOL sticker, Still
image of the the procedure with
pt. ID and date
OPEN
N
a) Detailed discharge summary.
b) operative notes.
c) sticker of IOL,Still image of the
the procedure with pt. ID.
OPEN
d) Date.
N
847
Ophthalmology
SE
SE034
Endophthalmitis
(excluding Vitrectomy)
SE034A
Endophthalmitis
(excluding Vitrectomy)
8000
9600
10400
11600
a) Still image of the patient
a) Clinical notes with planned line
undergoing the procedure with
of treatment.
date stamp.
b) Pre operative Clinical
b) operative notes.
Photograph of affected part.
c) Detailed discharge summary.
OPEN
N
848
Ophthalmology
SE
SE035 Enucleation
SE035A Without implant
8400
10080
10920
12180
a) Clinical notes establishing
Indication .
b) justifying enucleation.
c) supporting investigation.
d) Clinical Photograph.
e) Recommendation.
f) opinion of 2 ophthalmologists
for the procedure.
a) Intra procedure clinical
photograph.
b) detailed discharge summary.
c) operative notes.
OPEN
d) confirmation that specimen was
sent for histopathology.
Y
SL NO
849
Specialty
Ophthalmology
Specialty
Code
SE
Package
Code
Package Name
SE035 Enucleation
Procedure
Code
SE035B
Procedure Name
With implant
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
8000
9600
NABH
Package
Cost
10400
Outside State
NABH
Package Cost
11600
Mandatory Documents - Pre
Authorization
a) Clinical notes establishing
Indication .
b) justifying enucleation.
c) supporting investigation.
d) Clinical Photograph.
e) Recommendation.
f) opinion of 2 ophthalmologists
for the procedure.
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Still image of the the procedure
with pt. ID.
b) Date.
c) detailed discharge summary.
d) operative notes.
e) Invoice of implant.
OPEN
f) Confirmation.
g) declaration that the specimen
has been sent for histopathology.
h) report will be sent for filing later.
Y
850
Ophthalmology
SE
SE036 Evisceration
SE036A Evisceration
3800
4560
4940
5510
a) Detailed discharge summary.
a) Indication for Evisceration.
b) Still image of the the procedure
b) supporting investigation report.
with pt. ID.
c) Clinical Photograph.
c) Date.
d) Recommendation.
d) operative notes.
e) opinion of 2 ophthalmologists
e) Confirmation.
for the procedure.
OPEN
f) declaration that specimen sent
f) stated plan for lab investigation
for lab investigationmicrobio.
of host tissue (HP/
g) Path.
Microbiology/other).
h) report will be submitted.
N
851
Ophthalmology
SE
SE037 Exenteration
SE037A Exenteration
15000
18000
19500
21750
a) Indication for Exenteration.
b) supporting investigation.
c) (Biopsy / CT / MRI
establishing indication for
Exenteration) Clinical Photograph.
Recommendation.
d) opinion of 2 ophthalmologists
for the procedure.
a) Still image of the the procedure
with pt. ID
b) Date.
c) operative notes.
d) Histopathological exam report.
e) Detailed discharge summary.
OPEN
f) Confirmation.
g) declaration that the specimen
has been sent for histopathology.
h) report will be sent for filing later.
a) Clinical notes.
b) showing Indication for socket
reconstruction.
c) Clinical Photograph of affected
part.
a) Still image of the the procedure
with pt. ID
b) Date.
c) operative notes.
OPEN
d) Detailed discharge summary.
a) Clinical notes detailing
indication.
b) CT Scan.
c) Clinical Photograph.
d) stated plan for lab investigation
of host tissue (HP/
Microbiology/other).
a) Still image of the the procedure
with pt. ID.
b) Date.
c) HP Report of actual surgery.
OPEN
d) operative notes.
e) Lab (Histopath) report.
N
852
853
854
Ophthalmology
Ophthalmology
Ophthalmology
SE
SE
SE
Socket Reconstruction
SE038 including Amniotic
Membrane Graft
SE039 Orbitotomy
SE040
GA / EUA separate
add on package
Socket Reconstruction
SE038A including Amniotic
Membrane Graft
SE039A Orbitotomy
SE040A
GA / EUA separate add
on package
11200
14000
3000
13440
16800
3600
14560
18200
3900
16240
20300
4350
Clinical Notes justifying the need
for GA in the associated surgery
N
a) Clinical Notes for the
associated surgery.
b) disease along with Pre OP.
c) Operative and Anesthesia.
d) Post OP notes.
N
OPEN
N
SL NO
855
Specialty
Ophthalmology
Specialty
Code
SE
Package
Code
SE041
Package Name
Intravitreal injection
of Ranibizumab
Procedure
Code
SE041A
Procedure Name
Intravitreal injection of
Ranibizumab
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
2700
3240
NABH
Package
Cost
3510
Outside State
NABH
Package Cost
3915
Mandatory Documents - Pre
Authorization
a) Clinical Notes justifying the
Intravitreal Injection
b) OCT (Optical coherence
tomography)
c) FFA (Fundus Fluorescein
Angiography)
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Clinical Notes for the
associated surgery.
b) disease along with Pre OP.
c) Operative and Anesthesia.
OPEN
d) Post OP notes.
e) Invoice of Injection
f) Discharge Ticket
N
856
General Surgery
SG
SG001 Oesophagectomy
SG001A Oesophagectomy
28300
33960
36790
Clinical notes and
a) USG
b) CT
c) MRI
d) Biopsy
report confirming the diagnosis for
which the surgery is done.
a) Histopath
b) Intra procedure clinical
photograph
c) detailed discharge summary
d) Detailed Operative notes
Clinical notes and
a) X-ray
b) CT
c) MRI
d) UGIE
findings confirming the diagnosis
for which the surgery is done.
Biospy,
Picture of
a) removed esopahgus (Intra
procedure clinical photograph)
b) Scar photo (should be two
scars or one huge thoracolumbar
scar coverin both colon removal &
OPEN
esopagus replacement)
c) Detailed discharge summary
d) Detailed Operative notes
36250
a) Clinical notes
b) UGI Endoscopy
confirming the diagnosis.
a) Intra Operative Photograph
b) Histopathology report
c) Detailed Operative notes
d) detailed discharge summary.
36250
a) Clinical notes
b) UGI Endoscopy
confirming the diagnosis.
a) Intra Operative Photograph
b) Histopathology report
c) Detailed Operative notes
d) detailed discharge summary.
a) Clinical notes and
b) mandatory Biopsy
c) Endoscopy
d) CT Scan confirming the
diagnosis
e) Clinical photograph
a) Intra procedure clinical
photograph
b) Histopathology report
c) post procedure clinical
photograph
d) Detailed Operative notes
e) Detailed discharge summary
a) Clinical notes and
b) mandatory Biopsy Endoscopy
c) CT Scan confirming the
diagnosis
d) Clinical photograph
a) Intra procedure clinical
photograph
b) Histopathology report
c) post procedure clinical
photograph
d) Detailed Operative notes
e) Detailed discharge summary
a) Clinical notes
b) Endoscopy report Video
c) Biopsy
d) CT Scan
confirming the diagnosis for which
this surgery is done.
a) Intra procedure clinical
photograph
b) Histopathology report
c) post procedure clinical
photograph
d) Detailed Operative notes
e) Detailed discharge summary
41035
OPEN
N
857
General Surgery
SG
Operations for
SG002 Replacement of
Oesophagus by Colon
Operations for
SG002A Replacement of
Oesophagus by Colon
30500
36600
39650
44225
N
858
General Surgery
SG
SG003 Gastrectomy
Bleeding Ulcer - Partial
SG003A Gastrectomy without
Vagotomy
25000
30000
32500
OPEN
Y
859
General Surgery
SG
SG003 Gastrectomy
Bleeding Ulcer - Partial
SG003B Gastrectomy with
Vagotomy
25000
30000
32500
OPEN
Y
860
General Surgery
SG
SG003 Gastrectomy
SG003C
Partial Gastrectomy for
Carcinoma
30272
36326
39353
43894
OPEN
Y
861
General Surgery
SG
SG003 Gastrectomy
SG003D
Subtotal Gastrectomy
for Carcinoma
27800
33360
36140
40310
OPEN
Y
862
General Surgery
SG
SG003 Gastrectomy
SG003E
Total Gastrectomy Lap.
51600
61920
67080
74820
OPEN
Y
YES
SL NO
863
Specialty
General Surgery
Specialty
Code
SG
Package
Code
Package Name
SG003 Gastrectomy
Procedure
Code
SG003F
Procedure Name
Total Gastrectomy Open
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
56188
67425
NABH
Package
Cost
73044
Outside State
NABH
Package Cost
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Clinical notes
b) Endoscopy report Video
c) Biopsy
d) CT Scan
confirming the diagnosis for which
this surgery is done.
a) Intra procedure clinical
photograph
b) Histopathology report
c) post procedure clinical
photograph
d) Detailed Operative notes
e) Detailed discharge summary
a) Clinical notes
b) Endoscopy report Video
c) Biopsy
d) CT Scan
confirming the diagnosis for which
this surgery is done.
a) Intra procedure clinical
photograph
b) Histopathology report
c) post procedure clinical
photograph
d) Detailed Operative notes
e) Detailed discharge summary
a) Clinical notes
b) Endoscopy report
which confirming the diagnosis for
which this surgery is done.
a) Endoscopic intra operative
Photograph
b) Histopathology report
c) Detailed Operative notes
d) detailed discharge summary
OPEN
a) Clinical notes
b) Endoscopy report
which confirming the diagnosis for
which this surgery is done.
a) Endoscopic intra operative
Photograph
b) Histopathology report
c) Detailed Operative notes
d) detailed discharge summary
OPEN
a) Clinical notes
b) Endoscopy
confirming the diagnosis.
a) Intra procedure clinical
Photograph
b) Detailed discharge summary
c) Detailed Operative notes
26825
a) Clinical notes and
b) X Ray Erect
c) USG
d) CT Abdomen
confirming the diagnosis.
FIR/MLC in case of traumatic
aetiology.
a) Intra procedure clinical
photograph
b) Detailed Operative notes
c) detailed discharge summary
26825
a) Clinical notes and
b) X Ray Erect
c) USG
d) CT Abdomen
confirming the diagnosis.
FIR/MLC in case of traumatic
aetiology.
a) Intra procedure clinical
photograph
b) Detailed Operative notes
c) detailed discharge summary
a) Clinical notes
b) Endoscopy report
which confirming the diagnosis for
which this surgery is done.
a) Intra procedure clinical
Photograph
b) Detailed discharge summary
c) Detailed Operative notes
a) Clinical notes
b) Endoscopy report
confirming the diagnosis of
nfantile hypertrophic pyloric
stenosis.
a) Endoscopic still Photograph
b) Detailed discharge summary
c) Detailed Operative notes
81472
OPEN
Y
864
General Surgery
SG
SG004 Operative Gastrostomy
SG004A Operative Gastrostomy
15000
18000
19500
21750
OPEN
N
865
866
867
General Surgery
General Surgery
General Surgery
SG
SG
SG
SG005 Vagotomy
SG005 Vagotomy
SG006
Operation for
Bleeding Peptic Ulcer
SG005A G J Vagotomy
SG005B
SG006A
Vagotomy +
Pyloroplasty
Operation for Bleeding
Peptic Ulcer
23500
23500
22500
28200
28200
27000
30550
30550
29250
34075
34075
32625
Y
Y
OPEN
N
868
869
870
General Surgery
General Surgery
General Surgery
SG
SG
SG
SG007
SG007
Operation for Gastric /
Duodenal Perforation
Operation for Gastric /
Duodenal Perforation
SG008 Pyloroplasty
SG007A Gastric Perforation
SG007B Duodenal Perforation
SG008A Pyloroplasty
18500
18500
14000
22200
22200
16800
24050
24050
18200
20300
OPEN
Y
OPEN
Y
Referral
N
871
872
General Surgery
General Surgery
SG
SG
SG009 Pyloromyotomy
SG010 Gastrojejunostomy
SG009A Pyloromyotomy
SG010A Gastrojejunostomy
15000
20146
18000
24175
19500
26189
21750
29211
a) Clinical notes and Endoscopy a) intra operative photograph
report OR
b) Detailed Operative notes
b) Biopsy OR
c) detailed discharge summary
c) CT Scan
confirming the diagnosis for which
this surgery is done.
OPEN
N
OPEN
N
YES
SL NO
873
Specialty
General Surgery
Specialty
Code
SG
Package
Code
SG011
Package Name
CystoJejunostomy /
Cystogastrostomy
Procedure
Code
SG011A
Procedure Name
CystoJejunostomy Open
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
20000
24000
NABH
Package
Cost
26000
Outside State
NABH
Package Cost
29000
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Clinical notes and
b) USG
c) CT
confirming the diagnosis for which
procedure is needed.
a) Detailed discharge summary
b) post procedure clinical
photograph
c) Detailed Operative notes
d) scar photo
a) Clinical notes and
b) USG
c) CT
confirming the diagnosis for which
procedure is needed.
a) Detailed discharge summary
b) post procedure clinical
photograph
c) Detailed Operative notes
d) scar photo
a) Clinical notes and
b) USG
c) CT
confirming the diagnosis for which
procedure is needed.
a) Detailed discharge summary
b) post procedure clinical
photograph
c) Detailed Operative notes
d) scar photo
a) Clinical notes and
b) USG
c) CT
confirming the diagnosis for which
procedure is needed.
a) Detailed discharge summary
b) post procedure clinical
photograph
c) Detailed Operative notes
d) scar photo
a) Clinical notes and
b) Endoscopy report +/- Video
c) Biopsy
d) CT Scan
confirming the diagnosis for which
this surgery is done.
a) Intra procedure clinical
photograph
b) detailed discharge summary
c) Detailed Operative notes
a) Clinical notes and
b) Endoscopy
c) Biopsy
d) CT Scan
confirming the diagnosis for which
this surgery is done.
a) Histopath
b) Post procedure clinical
photograph
c) Detailed Operative notes
d) detailed discharge summary.
a) Clinical notes and
b) X ray
c) CT
d) MRI Abd
confirming the diagnosis.
a) Intra procedure clinical stills
b) Detailed Operative notes
c) Detailed discharge summary
a) Clinical notes and
b) USG Abd
c) CT
d) MRI
e) Endoscopic Ultrasound
- any one test confirming the
diagnosis.
a) USG
b) Intra operative clinical
photograph
c) Detailed Operative notes
d) Detailed discharge summary
e) histopath of removed part.
a) Clinical notes and
b) CT Scan
c) Endoscopy
d) Double balloon enteroscopy
confirming the diagnosis.
a) Intra operative clinical
photograph
b) Detailed Operative notes
c) scar photo
d) Detailed discharge summary
a) Clinical notes and
b) USG
c) CT
d) MRI report
confirming the diagnosis.
a) Histopath
b) Intra operative clinical
photograph
c) Detailed Operative notes
d) detailed discharge summary
OPEN
Y
874
General Surgery
SG
SG011
CystoJejunostomy /
Cystogastrostomy
SG011B
CystoJejunostomy Lap.
20000
24000
26000
29000
OPEN
Y
875
General Surgery
SG
SG011
CystoJejunostomy /
Cystogastrostomy
SG011C
Cystogastrostomy Open
20000
24000
26000
29000
OPEN
Y
876
General Surgery
SG
SG011
CystoJejunostomy /
Cystogastrostomy
SG011D Cystogastrostomy - Lap.
20000
24000
26000
29000
OPEN
Y
877
General Surgery
SG
SG012 Feeding Jejunostomy
SG012A Feeding Jejunostomy
13500
16200
17550
19575
OPEN
N
878
879
880
General Surgery
General Surgery
General Surgery
SG
SG
SG
SG013 Ileostomy
Congenital Atresia &
SG014 Stenosis of Small
Intestine
SG015
Operation for
Duplication of Intestine
SG013A Ileostomy
Congenital Atresia &
SG014A Stenosis of Small
Intestine
SG015A
Operation for
Duplication of Intestine
15246
23000
18000
18295
27600
21600
19819
29900
23400
22106
33350
26100
OPEN
N
OPEN
N
Referral
N
881
General Surgery
SG
SG016 Diverticulectomy
SG016A
Excision Duodenal
Diverticulum
20000
24000
26000
29000
OPEN
Y
882
General Surgery
SG
SG016 Diverticulectomy
SG016B
Excision Meckel's
Diverticulum
15000
18000
19500
21750
Referral
Y
SL NO
Specialty
Specialty
Code
Package
Code
Package Name
Procedure
Code
Procedure Name
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
NABH
Package
Cost
Outside State
NABH
Package Cost
Mandatory Documents - Pre
Authorization
a) Clinical notes
b) USG
confirming the diagnosis.
883
General Surgery
SG
SG017 Appendicectomy
SG017A Open
15000
18000
19500
21750
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Histopathology report
b) Intra procedure clinical
photograph of removed appendix
c) post procedure clinical
photograph
d) Detailed Operative notes
e) Detailed discharge summary
OPEN
Y
a) Clinical notes
b) USG
confirming the diagnosis.
884
General Surgery
SG
SG017 Appendicectomy
SG017B
Lap. (Appendicectomy)
15000
18000
19500
21750
a) Histopathology report
b) Intra procedure clinical
photograph of removed appendix
c) post procedure clinical
photograph
d) Detailed Operative notes
e) Detailed discharge summary
OPEN
Y
885
General Surgery
SG
SG018
Appendicular
Perforation
SG018A
Appendicular
Perforation
17500
21000
22750
25375
a) Clinical notes
b) X Ray Abdomen Erect
c) USG
confirming the diagnosis.
a) Histopath
b) Intra procedure clinical
photograph
c) detailed discharge summary
d) Detailed Operative notes
a) Clinical notes
b) USG
a) Intra Operative clinical
photograph
b) Detailed Operative notes
c) discharge summary.
OPEN
N
886
General Surgery
SG
SG019
Operative drainage of
Appendicular Abscess
SG019A
Operative drainage of
Appendicular Abscess
12000
14400
15600
17400
OPEN
N
887
General Surgery
SG
SG020 Total Colectomy
SG020A Open
24750
29700
32175
35887
a) Clinical notes and
b) CT Scan
c) Colonoscopy confirming the
diagnosis and need of surgery
d) Biopsy of the lsoion
a) Histopathology
b) Intra procedure clinical
photograph
c) detailed discharge summary
d) Detailed Operative notes
a) Clinical notes and
b) CT Scan
c) Colonoscopy confirming the
diagnosis and need of surgery
d) Biopsy of the lsoion
a) Histopathology
b) Intra procedure clinical
photograph
c) detailed discharge summary
d) Detailed Operative notes
a) Clinical notes and
b) CT Scan
c) Colonoscopy confirming the
diagnosis and need of surgery
d) Biopsy of the lsoion
a) Histopathology report and
b) Intra procedure Clinical
photograph of removed colon
c) Detailed discharge summary
d) Detailed Operative notes
a) Clinical notes and
b) CT Scan
c) Colonoscopy confirming the
diagnosis and need of surgery
d) Biopsy of the lsoion
a) Histopathology report and
b) Intra procedure Clinical
photograph of removed colon
c) Detailed discharge summary
d) Detailed Operative notes
a) Clinical notes and
b) CT Scan
c) Colonoscopy confirming the
diagnosis and need of surgery
d) Biopsy of the lsoion
a) Histopathology report and
b) Intra procedure Clinical
photograph of removed colon
c) Detailed discharge summary
d) Detailed Operative notes
OPEN
Y
888
General Surgery
SG
SG020 Total Colectomy
SG020B
Lap. - (Total
Colectomy)
24750
29700
32175
35887
OPEN
Y
889
General Surgery
SG
SG021 Hemi colectomy
SG021A Right - Open
27224
32668
35391
39474
OPEN
Y
890
General Surgery
SG
SG021 Hemi colectomy
SG021B
Right - Lap. - (Hemi
colectomy)
25000
30000
32500
36250
OPEN
Y
891
General Surgery
SG
SG021 Hemi colectomy
SG021C Left - Open
27224
32668
35391
39474
OPEN
Y
SL NO
892
Specialty
General Surgery
Specialty
Code
SG
Package
Code
Package Name
SG021 Hemi colectomy
Procedure
Code
SG021D
Procedure Name
Left - Lap. - (Hemi
colectomy)
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
25000
30000
NABH
Package
Cost
32500
Outside State
NABH
Package Cost
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Clinical notes and
b) CT Scan
c) Colonoscopy confirming the
diagnosis and need of surgery
d) Biopsy of the lsoion
a) Histopathology report and
b) Intra procedure Clinical
photograph of removed colon
c) Detailed discharge summary
d) Detailed Operative notes
a) Clinical notes and
b) X Ray Abdomen
c) CT Contrast
confirming the diagnosis.
a) Detailed discharge summary
b) X Ray Abdomen
c) Detailed Operative notes.
a) Clinical notes
b) CT
c) MRI
d) Colonoscopy
evidence of need of surgery.
a) Post procedure clinical
photograph
b) Detailed Operative notes
c) detailed surgery notes.
Clinical notes detailing why
colostomy was done? Clinical
photograph
a) Post procedure clinical
photograph
b) Detailed Operative notes
c) Detailed discharge summary
a) Clinical notes and
b) Barium X-rays
c) CT scan
d) Sigmoidoscopy
confirming the diagnosis.
a) Histopathology
b) Intra procedure clinical
photograph
c) Detailed Operative notes
d) detailed discharge summary
a) Clinical notes
b) Colonoscopy
c) CT
confirming the diagnosis,
a) Histopath
b) Intra procedure clinical
photograph
c) detailed discharge summary
d) Detailed Operative notes
a) Clinical notes
b) Colonoscopy
confirming the diagnosis of
prolapse.
a) Intra procedure clinical
photograph
b) detailed discharge summary
c) Detailed Operative notes
Referral
a) Clinical notes
b) Colonoscopy
confirming the diagnosis of
prolapse.
a) Intra procedure clinical
photograph
b) detailed discharge summary
c) Detailed Operative notes
Referral
a) Clinical notes
b) Colonoscopy
c) Biopsy
justifying surgery.
a) Histopath
b) Intra procedure clinical
photograph
c) Detailed Operative notes
d) detailed discharge summary
Referral
44999
a) Clinical notes
b) Biopsy
c) Colonoscopy
a) Histopathology report
b) post procedure clinical
photograph
c) Detailed Operative notes
d) detailed discharge summary
OPEN
41325
a) Clinical notes
b) Biopsy
c) Colonoscopy
a) Histopathology report
b) post procedure clinical
photograph
c) Detailed Operative notes
d) detailed discharge summary
OPEN
36250
OPEN
Y
893
General Surgery
SG
SG022
Operative
Management of
Volvulus of Large
Bowel
Operative Management
SG022A of Volvulus of Large
Bowel
25000
30000
32500
36250
OPEN
N
894
General Surgery
SG
SG023 Colostomy
SG023A Colostomy
15246
18295
19819
22106
OPEN
N
895
General Surgery
SG
SG024 Closure of stoma
SG024A Closure of stoma
15790
18948
20527
22895
OPEN
N
896
General Surgery
SG
SG025 Sigmoid Resection
SG025A Sigmoid Resection
21500
25800
27950
31175
OPEN
N
897
898
General Surgery
General Surgery
SG
SG
SG026
SG027
Perineal Procedure for
Rectal Prolapse
Abdominal Procedure
for Rectal Prolapse
SG026A
Perineal Procedure for
Rectal Prolapse
SG027A Open
14000
19000
16800
22800
18200
24700
20300
27550
OPEN
N
Y
899
General Surgery
SG
SG027
Abdominal Procedure
for Rectal Prolapse
Lap. - (Abdominal
SG027B Procedure for Rectal
Prolapse)
19000
22800
24700
27550
Y
900
901
902
General Surgery
General Surgery
General Surgery
SG
SG
SG
SG028 Rectal Polyp Excision
SG029
SG029
Anterior Resection of
rectum
Anterior Resection of
rectum
SG028A Rectal Polyp Excision
SG029A Open
SG029B
Lap. - (Anterior
Resection of rectum)
9600
31034
28500
11520
37240
34200
12480
40344
37050
13920
N
Y
Y
SL NO
903
Specialty
General Surgery
Specialty
Code
SG
Package
Code
Package Name
SG030 Resection Anastomosis
Procedure
Code
Procedure Name
SG030A Open
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
27224
32668
NABH
Package
Cost
35391
Outside State
NABH
Package Cost
39474
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Clinical notes
b) X Ray Abdomen Erect
c) USG
d) CT
confirming the diagnosis
a) Histopath of resected part
b) Intra procedure clinical
photograph
c) detailed discharge summary
d) Detailed Operative notes
a) Clinical notes
b) X Ray Abdomen Erect
c) USG
d) CT
confirming the diagnosis.
a) Histopath of resected part
b) Intra procedure clinical
photograph
c) detailed discharge summary
d) Detailed Operative notes
OPEN
Y
904
General Surgery
SG
SG030 Resection Anastomosis
SG030B
Lap. - (Resection
Anastomosis)
25000
30000
32500
36250
OPEN
Y
905
General Surgery
SG
SG031
Procedure for Fissure
in Ano
SG031A
Procedure for Fissure
in Ano
8000
9600
10400
a) Clinical notes
a) Detailed Operative notes
b) proctoscpic findings
b) detailed discharge summary
confirming the diagnosis for which
this surgery is done.
Referral
a) Post procedure clinical
photograph
b) Detailed Operative notes
c) detailed discharge summary
Referral
21750
a) Clinical notes
b) proctoscopy notes
confirming the diagnosis.
a) Post procedure clinical
photograph
b) Detailed Operative notes
c) detailed discharge summary
Referral
46400
a) Clinical notes
b) proctoscopy notes
confirming the diagnosis.
a) Histopath
b) Intra-operative clinical
photograph
c) Detailed Operative notes
Reserved
7250
a) Clinical notes
b) confirmation of Pilonidal sinus
on examination
a) Clinical notes
b) some imaging to show tract of
sinus
c) Clinical Photograph
confirming the diagnosis.
a) post procedure clinical
photograph
b) Detailed Operative notes
c) detailed discharge summary
d) Histopath of surreted material
Reserved
a) Clinical notes detailing original
pathology that led to peritonitis
supported by
b) X Ray
c) USG
d) CT Scan Abdomen
a) Intra procedure clinical
photograph
b) Analysis of fluid removed
c) Detailed discharge summary
d) Detailed Operative notes
describing management done of
pathology that led to peritonitis.
cautious about OT time; this
should take 2-3 hours.
a) Clinical notes describing the
original surgery that led to burst
abdomen
b) X Ray
c) USG
d) CT Abdomen
confirming the diagnosis for
which the surgery is done.
a) Clinical notes and
b) USG
c) CT
d) MRI
e) Biopsy
report confirming the
justification of surgery.
a) Intra procedure clinical
photograph
b) Detailed Operative notes
c) detailed discharge summary
11600
N
906
General Surgery
SG
SG032 Haemorroidectomy
SG032A without Stapler
15000
18000
19500
Y
907
General Surgery
SG
SG032 Haemorroidectomy
SG032B with Stapler
32000
38400
41600
Y
908
909
910
General Surgery
General Surgery
General Surgery
SG
SG
SG
SG033
SG034
SG035
Management of
Pilonidal Sinus
Exicision of Sinus and
Curettage
Exploratory
Laparotomy
SG033A
SG034A
Management of
Pilonidal Sinus
Exicision of Sinus and
Curettage
SG035A Exploratory Laparotomy
5000
5000
13000
6000
6000
15600
6500
6500
16900
7250
18850
OPEN
N
911
912
General Surgery
General Surgery
SG
SG
SG036
Closure of Burst
Abdomen
SG037 Hepatic Resection
SG036A
Closure of Burst
Abdomen
SG037A Open
15000
20000
18000
24000
19500
26000
21750
29000
OPEN
N
a) Histopath
b) Intra procedure clinical
photograph
c) detailed discharge summary
d) Detailed Operative notes
OPEN
Y
SL NO
913
Specialty
General Surgery
Specialty
Code
SG
Package
Code
Package Name
SG037 Hepatic Resection
Procedure
Code
SG037B
Procedure Name
Lap. - (Hepatic
Resection)
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
20000
24000
NABH
Package
Cost
26000
Outside State
NABH
Package Cost
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Clinical notes and
b) USG
c) CT
d) MRI
e) Biopsy
report confirming the
justification of surgery.
a) Histopath
b) Intra procedure clinical
photograph
c) detailed discharge summary
d) Detailed Operative notes
a) Clinical notes and
b) USG
c) CT
d) MRI report
confirming the diagnosis.
a) Histopath
b) Intra procedure clinical
photograph
c) detailed discharge summary
d) Detailed Operative notes
Referral
a) Intra procedure clinical
photograph
b) Detailed discharge summary
c) Detailed Operative notes
Referral
33060
a) Clinical notes and
b) USG
confirming the diagnosis
a) Intra procedure clinical
photograph
b) Detailed discharge summary
c) Detailed Operative notes
Referral
33060
a) Clinical notes and
b) USG
confirming the diagnosis
33060
a) Clinical notes and
b) USG
confirming the diagnosis
a) Intra procedure clinical
photograph
b) Detailed discharge summary
c) Detailed Operative notes
33060
a) Clinical notes and
b) USG
confirming the diagnosis
a) Intra procedure clinical
photograph
b) Detailed discharge summary
c) Detailed Operative notes
a) Clinical notes and
b) USG
c) CT Scan
confirming the diagnosis for which
the surgery is done.
a) Intra procedure clinical
photograph
b) Detailed discharge summary
c) Detailed Operative notes
a) Clinical notes and
b) USG
c) CT Scan
confirming the diagnosis for which
the surgery is done.
a) Intra procedure clinical
photograph
b) Detailed discharge summary
c) Detailed Operative notes
a) Clinical notes and
b) USG
c) CT Abdomen
a) Histopath
b) Detailed discharge summary
c) Scar photo
d) Detailed Operative notes
Referral
a) Clinical notes
b) USG
c) CT Scan
d) Lab investigations
confirming the diagnosis and
justifying the surgery.
a) Detailed Operative notes
b) Histopath
c) Detailed discharge summary
Referral
a) Clinical notes
b) USG
c) CT Scan
d) Lab investigations
confirming the diagnosis and
justifying the surgery.
a) Detailed Operative notes
b) Histopath
c) Detailed discharge summary
29000
OPEN
Y
914
General Surgery
SG
SG038
Abdominal Hydatid
Cyst (Single Organ)
SG038A
Abdominal Hydatid
Cyst (Single Organ)
15800
18960
20540
22910
N
915
General Surgery
SG
SG039 Cholecystectomy
SG039A
Without Exploration of
CBD - Open
22800
27360
29640
Y
916
General Surgery
SG
SG039 Cholecystectomy
SG039B
With Exploration of
CBD - Open
22800
27360
29640
Y
917
General Surgery
SG
SG039 Cholecystectomy
SG039C
Without Exploration of
CBD - Lap.
22800
27360
29640
OPEN
Y
918
General Surgery
SG
SG039 Cholecystectomy
SG039D
With Exploration of
CBD - Lap.
22800
27360
29640
Referral
Y
919
General Surgery
SG
SG040
Operative
Cholecystostomy
SG040A Open
10000
12000
13000
14500
OPEN
Y
920
General Surgery
SG
SG040
Operative
Cholecystostomy
SG040B
Lap. - (Operative
Cholecystostomy)
10000
12000
13000
14500
OPEN
Y
921
General Surgery
SG
SG041
Operation of
Choledochal Cyst
SG041A
Operation of
Choledochal Cyst
24500
29400
31850
35525
N
922
General Surgery
SG
SG042 Splenectomy
SG042A Open
25000
30000
32500
36250
Y
923
General Surgery
SG
SG042 Splenectomy
SG042B Lap. - (Splenectomy)
25000
30000
32500
36250
OPEN
Y
SL NO
924
Specialty
General Surgery
Specialty
Code
SG
Package
Code
SG043
Package Name
Bypass - Inoperable
Pancreas
Procedure
Code
SG043A
Procedure Name
Bypass - Inoperable
Pancreas
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
23500
28200
NABH
Package
Cost
30550
Outside State
NABH
Package Cost
34075
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
Clinical and radiological evidence
of inoperability.
(
a) Biopsy
b) ERCP.
c) MRCP
)
a) Histopathology report
b) Intra operative clinical
photograph
c) Detailed Operative notes and
d) Discharge summary.
a) Clinical notes and
b) Sr Amylase
c) CT
d) USG
e) ERCP
justifying the surgery.
a) Histopath
b) Intra procedure clinical
photograph
c) Detailed discharge summary
d) Detailed Operative notes
a) Clinical notes and
b) Sr Amylase
c) CT
d) USG
e) ERCP
justifying the surgery.
a) Histopath
b) Intra procedure clinical
photograph
c) Detailed discharge summary
d) Detailed Operative notes
a) Clinical notes and
b) USG-doppler
c) CT
d) MRI
report confirming the diagnosis for
which the surgery is done
a) Intra procedure clinical
photograph
b) Detailed discharge summary
c) Detailed Operative notes
a) Clinical notes and
b) USG
c) CT
d) MRI
e) Endoscopy
report confirming the diagnosis for
which the anastomosis is done.
a) Intra procedure clinical
photograph
b) Detailed discharge summary and
c) Detailed Operative notes
a) Clinical notes and
b) USG
c) CT
d) MRI
report confirming the diagnosis
a) Histopath
b) Intra procedure clinical
photograph
c) Detailed discharge summary and OPEN
d) Detailed Operative notes
a) Clinical notes and
b) X- Ray
c) USG
d) CT Abdomen
confirming the diagnosis.
a) Histopath
Referral
b) Intra procedure clinical
photograph
c) Detailed discharge summary and
d) Detailed Operative notes
OPEN
N
925
General Surgery
SG
SG044
Distal Pancreatectomy
with
Pancreatico
Jejunostomy
SG044A
Distal Pancreatectomy
with
Pancreatico
Jejunostomy
25000
30000
32500
36250
OPEN
N
926
General Surgery
SG
SG045
PancreaticoDuodenect
omy (Whipple's)
SG045A
PancreaticoDuodenecto
my (Whipple's)
32668
39201
42468
47368
OPEN
N
927
General Surgery
SG
SG046
Porto Caval
Anastomosis
SG046A
Porto Caval
Anastomosis
31500
37800
40950
45675
OPEN
N
928
General Surgery
SG
SG047
Mesenteric Caval
Anastomosis
SG047A
Mesenteric Caval
Anastomosis
28500
34200
37050
41325
OPEN
N
929
General Surgery
SG
SG048
Mesenteric Cyst –
Excision
SG048A
Mesenteric Cyst –
Excision
15000
18000
19500
21750
N
930
General Surgery
SG
SG049
Retroperitoneal
Tumor – Excision
SG049A
Retroperitoneal Tumor
– Excision
25046
30055
32559
36316
N
931
General Surgery
SG
SG050 Groin Hernia Repair
SG050A Inguinal - Open
14200
17040
18460
20590
a) Post procedure clinical
a) Clinical notes and
b) USG (specifying size of defect) photograph
b) Detailed discharge summary
c) Clinical photograph
c) Detailed Operative notes
d) Invoice of Mesh used
Referral
a) Post procedure clinical
a) Clinical notes and
b) USG (specifying size of defect) photograph
b) Detailed discharge summary
c) Clinical photograph
c) Detailed Operative notes
d) Invoice of Mesh used
Referral
Y
932
General Surgery
SG
SG050 Groin Hernia Repair
SG050B Inguinal - Lap.
14200
17040
18460
20590
Y
SL NO
933
Specialty
General Surgery
Specialty
Code
SG
Package
Code
Package Name
SG050 Groin Hernia Repair
Procedure
Code
Procedure Name
SG050C Femoral - Open
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
14200
17040
NABH
Package
Cost
18460
Outside State
NABH
Package Cost
20590
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Post procedure clinical
a) Clinical notes and
b) USG (specifying size of defect) photograph
b) Detailed discharge summary
c) Clinical photograph
c) Detailed Operative notes
d) Invoice of Mesh used
Referral
a) Post procedure clinical
a) Clinical notes and
b) USG (specifying size of defect) photograph
b) Detailed discharge summary
c) Clinical photograph
c) Detailed Operative notes
d) Invoice of Mesh used
Referral
a) Post procedure clinical
a) Clinical notes and
b) USG (specifying size of defect) photograph
b) Detailed discharge summary
c) Clinical photograph
c) Detailed Operative notes
d) Invoice of Mesh used
Referral
a) Post procedure clinical
a) Clinical notes and
b) USG (specifying size of defect) photograph
b) Detailed discharge summary
c) Clinical photograph
c) Detailed Operative notes
d) Invoice of Mesh used
Referral
a) Post procedure clinical
a) Clinical notes and
b) USG (specifying size of defect) photograph
b) Detailed discharge summary
c) Clinical photograph
c) Detailed Operative notes
d) Invoice of Mesh used
Referral
Y
934
General Surgery
SG
SG050 Groin Hernia Repair
SG050D Femoral - Lap
14200
17040
18460
20590
Y
935
General Surgery
SG
SG050 Groin Hernia Repair
SG050E Obturator - Lap.
20000
24000
26000
29000
Y
936
General Surgery
SG
SG051 Hernia - Ventral
SG051A Epigastric
17400
20880
22620
25230
Y
937
General Surgery
SG
SG051 Hernia - Ventral
SG051B Umbilical
17400
20880
22620
25230
Y
938
General Surgery
SG
SG051 Hernia - Ventral
SG051C Paraumbilical
17400
20880
22620
25230
a) Post procedure clinical
a) Clinical notes and
b) USG (specifying size of defect) photograph
b) Detailed discharge summary
c) Clinical photograph
c) Detailed Operative notes
d) Invoice of Mesh used
OPEN
Y
939
General Surgery
SG
SG051 Hernia - Ventral
SG051D Spigelian
17400
20880
22620
25230
a) Post procedure clinical
a) Clinical notes and
b) USG (specifying size of defect) photograph
b) Detailed discharge summary
c) Clinical photograph
c) Detailed Operative notes
d) Invoice of Mesh used
OPEN
Y
940
General Surgery
SG
SG052
Repair of Incisional
Hernia
SG052A
Repair of Incisional
Hernia
20000
24000
26000
29000
a) Clinical notes including info
about previous surgery in whose
incision this hernia has occurred
b) USG (specifying size of defect)
c) Clinical photograph
a) Post procedure clinical
photograph
b) Detailed discharge summary
c) Detailed Operative notes
d) Invoice of Mesh used
Referral
a) Clinical notes
b) X-ray
c) USG
d) UGI Endoscopy
a) Intra procedure clinical
photograph
b) Detailed Operative notes &
c) Discharge summary
Referral
a) Clinical notes
b) X-ray
c) USG
d) UGI Endoscopy
a) Intra procedure clinical
photograph
b) Detailed Operative notes &
c) Discharge summary
Referral
a) Clinical notes
b) X-ray
c) USG
d) UGI Endoscopy
a) Intra procedure clinical
photograph
b) Detailed Operative notes &
c) Discharge summary
Referral
N
941
General Surgery
SG
SG053
Hiatus Hernia Repair /
Fundoplication
SG053A
Hiatus Hernia Repair Open
23500
28200
30550
34075
Y
942
General Surgery
SG
SG053
Hiatus Hernia Repair /
Fundoplication
SG053B
Hiatus Hernia Repair Lap.
23500
28200
30550
34075
Y
943
General Surgery
SG
SG053
Hiatus Hernia Repair /
Fundoplication
SG053C Fundoplication - Open
23500
28200
30550
34075
Y
SL NO
944
Specialty
General Surgery
Procedure
Code
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
NABH
Package
Cost
Outside State
NABH
Package Cost
30550
34075
Specialty
Code
Package
Code
Package Name
SG
SG053
Hiatus Hernia Repair /
Fundoplication
SG054A Single Cyst
2000
2400
2600
2900
7000
8400
9100
10150
Procedure Name
SG053D Fundoplication - Lap.
23500
28200
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Clinical notes
b) X-ray
c) USG
d) UGI Endoscopy
a) Intra procedure clinical
photograph
b) Detailed Operative notes &
c) Discharge summary
Referral
Deailed Clinical notes
a) Intra procedure clinical
photograph
b) Detailed Operative notes &
c) Discharge summary
Reserved
Deailed Clinical notes
a) Intra procedure clinical
photograph
b) Detailed Operative notes &
c) Discharge summary
Reserved
a) Clinical notes
b) USG
report confirming the diagnosis
a) Histopath
b) Detailed Operative notes
c) Detailed discharge summary
Reserved
a) Clinical notes and
b) Scrotal USG
confirming the diagnosis.
a) Histopath
b) Intra procedure clinical
photograph
c) Detailed Operative notes
d) Detailed discharge summary
Reserved
a) Clinical notes and
b) USG
report confirming the diagnosis.
a) Histopath
b) Intra procedure clinical
photograph
c) Detailed Operative notes
d) Detailed discharge summary
Reserved
a) Clinical notes and
b) USG
report confirming the diagnosis.
a) Histopath
b) Intra procedure clinical
photograph
c) Detailed Operative notes
d) Detailed discharge summary
Reserved
a) Clinical notes detailing need of
surgery after vasectomy?
b) Evidence of When and where
was vasectomy done?
c) Is the EHCP equipped for
microsurgery?
a) Detailed discharge summary
Referral
b) Detailed Operative notes
Since this is microsurgery evaluate
time taken (2 hours+)
a) Clinical notes and
b) Describing Swelling in scrotum
c) USG of scrotum
d) FNAC
e) Tumour markers (if cancer of
prostate/testis etc. is the
indication) justification of
orchidectmy.
a) Histopath
b) Intra operative clinical
photograph
c) Detailed Operative notes
d) Detailed discharge summary
a) Clinical notes
b) USG
c) Biopsy
report confirming the diagnosis
for which the surgery is done.
a) Histopath
b) Intra procedure clinical
photograph
c) Detailed discharge summary
d) Detailed Operative notes
a) Clinical notes detailing the
original pathology thet has led to
this surgery with suporting
investigation reports.
b) FIR/MLC in case of traumatic
aetiology
c) Clinical Photograph
Photograph
a) Post procedure clinical
photograph
b) Detailed Operative notes
c) Detailed discharge summary
Y
945
General Surgery
SG
Excision of cyst /
SG054 Sebaceous Cysts over
scrotum
946
General Surgery
SG
Excision of cyst /
SG054 Sebaceous Cysts over
scrotum
SG054B Multiple Cysts
SG
Excision Filarial
SG055
Scrotum
Excision Filarial
SG055A
Scrotum
947
948
949
950
951
General Surgery
General Surgery
General Surgery
General Surgery
General Surgery
SG
SG
SG
SG
SG056
SG057
SG057
Operation for
Hydrocele (U/L)
Epididymal Cyst /
Nodule Excision
Epididymal Cyst /
Nodule Excision
SG058 Vasovasostomy
SG056A
Operation for
Hydrocele (U/L)
SG057A Epididymal Cyst exision
SG057B
Epididymal Nodule
excision
SG058A Vasovasostomy
6500
5000
4600
4600
12000
7800
6000
5520
5520
14400
8450
6500
5980
5980
15600
9425
7250
6670
6670
17400
N
952
953
General Surgery
General Surgery
SG
SG
SG059 Orchidectomy
SG060
Inguinal Node
(dissection) - U/L
SG059A Orchidectomy
SG060A
Inguinal Node
(dissection) - U/L
11200
16000
13440
19200
14560
20800
16240
23200
OPEN
OPEN
N
954
General Surgery
SG
SG061
Estlander Operation
(lip)
SG061A Estlander Operation (lip)
9300
11160
12090
13485
OPEN
N
SL NO
955
Specialty
General Surgery
Specialty
Code
SG
Package
Code
SG062
Package Name
Operation for
Carcinoma Lip
Procedure
Code
Procedure Name
SG062A Wedge Excision
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
19000
22800
NABH
Package
Cost
24700
Outside State
NABH
Package Cost
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Clinical notes
b) Biopsy report
c) Clinical Photograph
a) Histopath
b) Post procedure clinical
photograph
c) Detailed Operative notes
d) Detailed discharge summary
a) Clinical notes
b) Biopsy report
c) Clinical Photograph
a) Histopath
b) Post procedure clinical
photograph
c) Detailed Operative notes
d) Detailed discharge summary
a) Clinical notes
b) Biopsy report
c) Clinical Photograph
a) Histopath
b) Post procedure clinical
photograph
c) Detailed Operative notes
d) Detailed discharge summary
a) Clinical notes confirming the
diagnosis
b) Clinical Photograph
c) FNAC if done
a) Histopath
b) Post procedure clinical
photograph
c) Detailed Operative notes
d) Detailed discharge summary
a) Clinical notes
b) USG
c) CT
d) MRI
e) Clinical Photograph
report confirming the diagnosis
a) Histopath
b) Post procedure clinical
photograph
c) Detailed Operative notes
d) Detailed discharge summary
a) Clinical notes
b) Nasal Endoscopy
confirming the diagnosis for which
this surgery is done.
a) Post procedure Nasal
Endoscopy
b) Post procedure clinical
photograph
c) Intra procedure clinical
photograph
d) Detailed discharge summary
e) Detailed Operative notes
27550
OPEN
Y
956
General Surgery
SG
SG062
Operation for
Carcinoma Lip
SG062B
Wedge Excision and
Vermilionectomy
23800
28560
30940
34510
OPEN
Y
957
General Surgery
SG
SG062
Operation for
Carcinoma Lip
SG062C Cheek advancement
26800
32160
34840
38860
OPEN
Y
958
959
General Surgery
General Surgery
SG
SG
SG063
Complete Excision of
Growth from Tongue
only (inclusive of
Histopathology)
Excision of Growth
SG064 from Tongue with
neck node dissection
Complete Excision of
Growth from Tongue
SG063A only
(inclusive of
Histopathology)
Excision of Growth
SG064A from Tongue with neck
node dissection
9400
11280
12220
13630
OPEN
N
23500
28200
30550
34075
OPEN
N
960
General Surgery
SG
SG065
Microlaryngoscopic
Surgery
SG065A
Microlaryngoscopic
Surgery
18500
22200
24050
26825
OPEN
N
961
962
General Surgery
General Surgery
SG
SG
SG066
SG067
Submandibular Mass
Excision
Radical Neck
Dissection
SG066A
Submandibular Mass
Excision
SG067A Radical Neck Dissection
17400
22550
20880
27060
22620
29315
25230
32697
a) Clinical notes
b) USG
c) CT Scan confirming the
diagnosis for which the surgery is
done
d) Biopsy
e) FNAC
f) Clinical Photograph
a) Histopath
b) Post procedure clinical
photograph
c) Detailed Operative notes
d) Detailed discharge summary
a) Clinical notes
b) CT Scan
c) MRI Neck confirming the
diagnosis
d) Biopsy
e) Clinical Photograph
a) Histopath
b) Intra procedure clinical
photograph
c) Post procedure clinical
photograph
d) Detailed discharge summary
e) Detailed Operative notes
a) Clinical notes with
b) USG
c) CT Scan confirming diagnosis
d) Pre-op Clinical Photograph
a) Histopathology report
b) Post procedure clinical
photograph
c) Detailed Operative notes
d) Detailed discharge summary.
OPEN
N
OPEN
N
963
General Surgery
SG
SG068
Surgical removal of
Branchial Cyst
SG068A
Surgical removal of
Branchial Cyst
15000
18000
19500
21750
OPEN
N
SL NO
964
Specialty
General Surgery
Specialty
Code
SG
Package
Code
SG069
Package Name
Carotid Body tumour Excision
Procedure
Code
SG069A
Procedure Name
Carotid Body tumour Excision
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
20000
24000
NABH
Package
Cost
26000
Outside State
NABH
Package Cost
29000
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Clinical notes
b) USG Neck
c) Colour Doppler
confirming the diagnosis.
a) Intra procedure clinical
photograph
b) Detailed Operative notes
c) Histopathology
d) Detailed discharge summary
Referral
a) Clinical notes
b) Thyroid Function Test
c) FNAC
d) USG
confirming the diagnosis and
justifying the surgery.
a) Histopath report
b) Post procedure clinical
photograph
c) Detailed Operative notes
d) Detailed discharge summary
Referral
a) Clinical notes
b) Thyroid Function Test
c) FNAC
d) USG
confirming the diagnosis and
justifying the surgery.
a) Histopath report
b) Post procedure clinical
photograph
c) Detailed Operative notes
d) Detailed discharge summary
Referral
a) Clinical notes
b) FNAC
c) Biopsy
d) Thyroid Function Test
e) USG
confirming the diagnosis and need
for surgery
a) Histopath report
b) Post procedure clinical
photograph
c) Scar Photo
d) Detailed discharge summary
e) Detailed Operative notes
Referral
a) Clinical notes
b) USG
c) CT Scan
d) Nuclear Imaging
confirming the diagnosis.
a) Histopathology
b) Intra procedure clinical
photograph
c) Detailed discharge summary
d) Detailed Operative notes
Referral
a) Clinical notes
b) USG
c) CT Scan
d) Nuclear Imaging
confirming the diagnosis.
a) Histopathology
b) Intra procedure clinical
photograph
c) Detailed discharge summary
d) Detailed Operative notes
a) Clinical notes
b) Investigation report confirming
the need for surgery (CT/MRI)
c) Single-fiber electromyography
in case of myasthenia gravis
d) Clinical photograph
a) Histopath
b) Post procedure clinical
photograph
c) Detailed Operative notes
d) Detailed discharge summary
Referral
a) Clinical notes
b) Supporting Evidence of need of
surgery
c) EMG
d) Nerve conduction study
e) CT
f) MRI
g) Clinical Photograph
a) Intra procedure clinical
photograph
b) Detailed discharge summary
c) Detailed Operative notes
Referral
a) Clinical notes
b) Sono mammogram
c) Mamography showing breast
lump
d) FNAC report
a) Histopathology report
b) Intra operative clinical
photograph
c) Detailed Operative notes
d) Detailed discharge summary.
N
965
General Surgery
SG
SG070 Thyroidectomy
SG070A Hemi thyroidectomy
18512
22214
24065
26842
Y
966
General Surgery
SG
SG070 Thyroidectomy
SG070B Total thyroidectomy
21778
26133
28311
31578
Y
967
General Surgery
SG
SG070 Thyroidectomy
SG070C
Total Thyroidectomy
with Block Dissection
28000
33600
36400
40600
Y
968
General Surgery
SG
Excision of
SG071 Parathyroid Adenoma
/ Carcinoma
SG071A
Excision of Parathyroid
Adenoma
21070
25284
27391
30551
Y
969
General Surgery
SG
Excision of
SG071 Parathyroid Adenoma
/ Carcinoma
SG071B
Excision of Parathyroid
Carcinoma
21070
25284
27391
30551
OPEN
Y
970
General Surgery
SG
SG072 Thymectomy
SG072A Thymectomy
30000
36000
39000
43500
N
971
972
General Surgery
General Surgery
SG
SG
SG073 Sympathectomy
SG074
Breast Lump Excision
(Benign)
SG073A Sympathectomy
SG074A
Breast Lump Excision
(Benign)
15000
7000
18000
8400
19500
9100
21750
10150
N
OPEN
SL NO
973
Specialty
General Surgery
Specialty
Code
SG
Package
Code
Package Name
SG075 Mastectomy
Procedure
Code
Procedure Name
SG075A Simple Mastectomy
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
20000
24000
NABH
Package
Cost
26000
Outside State
NABH
Package Cost
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Clinical notes
b) Mammography
c) Biopsy confirming the diagnosis
d) Clinical Photograph
a) Histopath
b) Post procedure clinical
photograph
c) Detailed Operative notes
d) Detailed discharge summary
a) Clinical notes
b) Mammography
c) Biopsy
justifying surgery.
a) Histopath
b) Detailed discharge summary
c) Detailed Operative notes
21025
a) Clinical notes
b) Sonomammogram
report confirming the diagnosis.
a) Histopath
b) Detailed discharge summary
c) Detailed Operative notes
6960
a) Clinical notes
b) Detailing need of ICD
c) Clinical photograph
d) Chest X-Ray PA
a) Analysis report of drained fluid
b) Post procedure clinical
photograph
c) Detailed Operative notes
d) Detailed discharge summary
a) Clinical notes
b) X Ray
c) CT
d) MRI
e) confirming the diagnosis for
which the surgery is done.
f) Clinical photograph.
a) Pus C/S
b) Post procedure X Ray
c) Post procedure clinical
photograph
d) Detailed Operative notes
e) Detailed discharge summary
a) Clinical notes
b) X Ray
c) CT
d) MRI Chest confirming the
indication for this surgery.
e) Clinical Photograph
a) Post procedure clinical
photograph
b) Detailed Operative notes
c) Intra procedure clinical
photograph
d) Detailed discharge summary
a) Clinical notes
b) USG
c) CT Scan confirming the
diagnosis for which the surgery is
done
d) Biopsy
a) Histopathology
b) Detailed discharge summary
c) Detailed Operative notes
a) Clinical notes
b) CT Thorax confirming the
diagnosis
c) Biopsy
d) Cytology
a) Intra procedure clinical
photograph
b) Detailed Operative notes,
c) Histopath
d) Detailed discharge summary
e) Scar Photo
a) Clinical notes
b) CT Thorax confirming the
diagnosis
c) Biopsy
d) Cytology
a) Intra procedure clinical
photograph
b) Detailed Operative notes,
c) Histopath
d) Detailed discharge summary
e) Scar Photo
a) Clinical notes
b) CT Thorax confirming the
diagnosis
c) Biopsy
d) Cytology
a) Intra procedure clinical
photograph
b) Detailed Operative notes,
c) Histopath
d) Detailed discharge summary
e) Scar Photo
29000
Referral
Y
974
General Surgery
SG
SG075 Mastectomy
SG075B
Radical / Modified
Radical Mastectomy
27222
32666
35388
39471
OPEN
Y
975
976
General Surgery
General Surgery
SG
SG
SG076
SG077
Excision Mammary
Fistula
Intercostal drainage
Only
SG076A
SG077A
Excision Mammary
Fistula
Intercostal drainage
Only
14500
4800
17400
5760
18850
6240
Reserved
OPEN
N
977
978
General Surgery
General Surgery
SG
SG
SG078
Rib Resection &
Drainage
SG079 Thoracoplasty
SG078A
Rib Resection &
Drainage
SG079A Thoracoplasty
14000
30000
16800
36000
18200
39000
20300
43500
OPEN
N
Referral
N
979
980
General Surgery
General Surgery
SG
SG
SG080
Decortication
(Pleurectomy)
SG081 Lobectomy
SG080A
Decortication
(Pleurectomy)
SG081A Thoracoscopic
28000
27500
33600
33000
36400
35750
40600
39875
OPEN
N
OPEN
Y
981
General Surgery
SG
SG081 Lobectomy
SG081B Open - (Labectomy)
29946
35935
38929
43421
OPEN
Y
982
General Surgery
SG
SG082
Thoracoscopic
Segmental Resection
SG082A
Thoracoscopic
Segmental Resection
30000
36000
39000
43500
OPEN
N
SL NO
983
Specialty
General Surgery
Specialty
Code
SG
Package
Code
SG083
Package Name
Lung Hydatid Cyst
removal
Procedure
Code
SG083A
Procedure Name
Lung Hydatid Cyst
removal
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
20000
24000
NABH
Package
Cost
26000
Outside State
NABH
Package Cost
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Clinical notes
b) X Ray
c) CT
d) MRI Chest confirming the
diagnosis
e) Clinical Photograph
a) Post procedure clinical
photograph
b) Detailed Operative notes
c) Intra procedure clinical
photograph
d) Detailed discharge summary
e) Histopathology
Referral
a) Clinical notes
b) USG
report confirming large abscess.
a) C/S report of Wound or Pus
b) Intra operative clinical
photograph
c) Detailed Operative notes
d) Detailed discharge summary.
Reserved
a) Clinical notes
b) clinical photograph to confirm
diagnosis.
a) Histopath
b) Post procedure clinical
photograph
c) Detailed Operative notes
d) Detailed discharge summary
Reserved
a) Clinical notes
b) clinical photograph to confirm
diagnosis.
a) Histopath
b) Post procedure clinical
photograph
c) Detailed Operative notes
d) Detailed discharge summary
a) Clinical notes
b) clinical photograph to confirm
diagnosis.
a) Histopath
b) Post procedure clinical
photograph
c) Detailed Operative notes
d) Detailed discharge summary
a) Clinical notes
b) Clinical photograph of affected
part
c) Evidence of confirmed
diagnosis of Leprosy
a) Post procedure clinical
photograph
b) Detailed Operative notes
c) Detailed discharge summary
a) Clinical notes detailing the
original pathology that has led to
this surgery with supporting
investigation reports.
b) Clinical Photograph
a) Post procedure clinical
photograph
b) Detailed Operative notes
c) Detailed discharge summary
a) Clinical notes detailing the
original pathology that has led to
this surgery with supporting
investigation reports.
b) Clinical Photograph
a) Post procedure clinical
photograph
b) Detailed Operative notes
c) Detailed discharge summary
36250
a) Clinical notes
b) Clinical photograph of affected
part
c) Evidence of confirmed
diagnosis of Leprosy
a) Intra procedure clinical
photograph
b) Post procedure clinical
photograph (if flap taken from
other site; even of donor site)
c) Detailed Operative notes
d) Detailed discharge summary
19575
a) Clinical notes detailing time of
Burns
b) Clinical Photograph
a) Post procedure clinical
photograph
b) Detailed Operative notes
c) Detailed discharge summary
29000
N
984
985
986
General Surgery
General Surgery
General Surgery
SG
SG084
Incision & Drainage
of Abscess
SG
Lipoma / Cyst / other
SG085 cutaneous swellings
Excision
SG
Lipoma / Cyst / other
SG085 cutaneous swellings
Excision
SG084A
Incision & Drainage of
Abscess
SG085A Lipoma Excision
SG085B Cyst Excision
5000
5000
5000
6000
6000
6000
6500
6500
6500
7250
7250
7250
OPEN
Y
987
General Surgery
SG
Lipoma / Cyst / other
SG085 cutaneous swellings
Excision
SG085C
Other cutaneous
swellings Excision
5000
6000
6500
7250
OPEN
Y
988
989
General Surgery
General Surgery
SG
SG
SG086 Debridement of Ulcer
SG087
Flap Reconstructive
Surgery
SG086A Debridement of Ulcer
SG087A
Flap Reconstructive
Surgery
5000
36890
6000
44268
6500
47957
7250
53490
Reserved
OPEN
N
990
General Surgery
SG
SG088
Free Grafts - Wolfe
Grafts
SG088A
Free Grafts - Wolfe
Grafts
14000
16800
18200
20300
OPEN
N
991
General Surgery
SG
SG089
Tissue Reconstruction
Flap
SG089A
Tissue Reconstruction
Flap
25000
30000
32500
OPEN
N
992
General Surgery
SG
SG090
Split thickness skin
grafts
SG090A Small (< 4% TBSA)
13500
16200
17550
OPEN
Y
SL NO
993
Specialty
General Surgery
Specialty
Code
SG
Package
Code
Package Name
Split thickness skin
SG090
grafts
Procedure
Code
Procedure Name
SG090B Medium (4 - 8% TBSA)
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
13500
16200
NABH
Package
Cost
17550
Outside State
NABH
Package Cost
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
19575
a) Clinical notes detailing time of
Burns
b) Clinical Photograph
a) Post procedure clinical
photograph
b) Detailed Operative notes
c) Detailed discharge summary
19575
a) Clinical notes detailing time of
Burns
b) Clinical Photograph
a) Post procedure clinical
photograph
b) Detailed Operative notes
c) Detailed discharge summary
a) Clinical notes
b) Clinical Photograph
c) Medical records of previous
surgeries and indication of this
surgery
a) Post procedure clinical
photograph
b) Detailed Operative notes
c) Detailed discharge summary
a) Clinical notes
b) Clinical photograph of affected
part
c) Evidence of confirmed
diagnosis of Leprosy
a) Intra procedure clinical
photograph
b) Post procedure clinical
photograph
c) Detailed Operative notes
d) Detailed discharge summary
Referral
a) Clinical notes
b) Detailing history
c) Clinical Photograph
a) Histopathology report
b) Post procedure clinical
photograph
c) Detailed Operative notes
d) Detailed discharge summary.
Referral
Clinical notes detailing need for
AV shunt with supporting
Evidence of Creatinine/ RFT
a) Post Procedure clinical
photograph
b) Detailed Operative notes
c) Detailed discharge summary
a) Clinical notes
b) Duplex ultrasonography
c) Colour Doppler confirming the
diagnosis
d) pre-op clinical photograph
a) Detailed discharge summary
b) Post procedure clinical
photograph
c) Detailed Operative notes
Referral
a) Clinical notes
b) Duplex ultrasonography
c) Colour Doppler confirming the
diagnosis
d) pre-op clinical photograph
a) Detailed discharge summary
b) Post procedure clinical
photograph
c) Detailed Operative notes
Referral
a) Clinical notes
b) Clinical Photograph of
Enlarged lymph nodes
c) FNAC report
a) Histopathology report
b) Post procedure clinical
photograph
c) Detailed Operative notes
Clinical notes with supporting
investigations
a) Picture of specimen
b) Histopathology report
c) Discharge summary
Clinical notes with supporting
investigations
a) Picture of specimen
b) Histopathology report
c) Discharge summary
Clinical notes with supporting
investigations
a) Picture of specimen
b) Histopathology report
c) Discharge summary
Clinical notes with supporting
investigations
a) Picture of specimen
b) Histopathology report
c) Discharge summary
a) Earlier discharge summary
b) Clinical Notes
Invoice / Receipt of drugs and
consumables
OPEN
Y
994
General Surgery
SG
SG090
Split thickness skin
grafts
SG090C Large (> 8% TBSA)
13500
16200
17550
OPEN
Y
995
996
General Surgery
General Surgery
SG
SG
SG091
Skin Flaps - Rotation
Flaps
SG092 Tendon Transfer
SG091A
Skin Flaps - Rotation
Flaps
SG092A Tendon Transfer
11400
15000
13680
18000
14820
19500
16530
21750
OPEN
N
N
997
General Surgery
SG
SG093
Lymphatics Excision
of Subcutaneous
Tissues In
Lymphoedema
Lymphatics Excision of
SG093A Subcutaneous Tissues
In Lymphoedema
10000
12000
13000
14500
N
998
General Surgery
SG
SG094
AV Fistula without
prosthesis
SG094A
AV Fistula without
prosthesis
6000
7200
7800
8700
OPEN
N
999
1000
1001
General Surgery
General Surgery
General Surgery
SG
SG
SG
SG095
SG095
Management of
Varicose Veins
Management of
Varicose Veins
SG096 Biopsy
SG095A
SG095B
Management of
Varicose Veins
Laser ablation of
varicose veins
SG096A Lymph Node
14000
17250
5000
16800
20700
6000
18200
22425
6500
20300
25012
7250
N
N
OPEN
Y
1002
General Surgery
SG
SG096 Biopsy
SG096B Endometrial Aspiration
SG096 Biopsy
Cervix Cancer
SG096C screening (PAP +
Colposcopy)
2000
2400
2600
2900
OPEN
Y
1003
1004
General Surgery
General Surgery
SG
SG
SG096 Biopsy
SG096D Cervical (Neck)
1000
1200
1300
1450
OPEN
Y
2000
2400
2600
2900
OPEN
Y
1005
General Surgery
SG
SG096 Biopsy
SG096E Vulval
1006
General Surgery
SG
SG097 Stoma Management
SG097A
1500
1800
1950
2175
4500
5400
5850
6525
OPEN
Y
Stoma Management
follow up of Ileostomy
OPEN
Y
SL NO
1007
1008
Specialty
General Surgery
General Surgery
Specialty
Code
SG
SG
Package
Code
Package Name
SG097 Stoma Management
SG098 Foreign Body Removal
Procedure
Code
Procedure Name
SG097B
Stoma Management
follow up of Colostomy
SG098A Foreign Body Removal
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
4500
5400
NABH
Package
Cost
Outside State
NABH
Package Cost
5850
6525
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Earlier discharge summary
b) Clinical Notes
Invoice / Receipt of drugs and
consumables
a) Clinical notes
b) X-ray
c) USG report of the affected part
confirming the diagnosis
d) Still Photograph of the imaging.
a) Post procedure clinical
photograph
b) Detailed Operative notes
c) Detailed discharge summary
d) Relevant imaging study for
comparison
OPEN
Y
5000
6000
6500
7250
OPEN
N
1009
1010
General Surgery
ENT
SG
SL
SG099 Fistulectomy
SL001
Pinna surgery for
tumour / trauma
SG099A Fistulectomy
SL001A
Pinna surgery for
tumour
12000
8600
14400
10320
15600
11180
17400
A) Clinical notes
B) X-ray
C) USG report of the affected
part confirming the diagnosis
D) Still Photograph of the imaging
A) Post procedure clinical
photograph
B) Detailed Operative notes
C) detailed discharge summary
D) relevant imaging study for
comparison
a) History
b) Pre-op Clinical photograph
c) Biopsy
a) Histopath report
b) Post procedure clinical
photograph of affected part
c) Detailed Procedure
d) Operative Notes
e) Detailed discharge summary
a) History
b) Pre-op Clinical photograph
a) Post procedure clinical
photograph of affected part
b) Detailed Procedure
c) Operative Notes
d) Detailed discharge summary
12470
OPEN
N
Referral
Y
1011
ENT
SL
SL001
Pinna surgery for
tumour / trauma
SL001B
Pinna surgery for
trauma
8600
10320
11180
12470
OPEN
Y
1012
1013
ENT
ENT
SL
SL
SL002 Tympanoplasty
SL003
Stapedectomy /
tympanotomy
SL002A Tympanoplasty
SL003A Stapedectomy
12900
15480
16770
18705
a) Clinical notes
b) Audiogram
c) Tympanometry (or impedence
audiometry) as justification of
surgery
a) Clinical notes
b) Audiometry confirming
conductive deafness
13000
15600
16900
18850
a) Intra procedure clinical
photograph
b) Post procedure clinical
photograph of affected part
c) Detailed Procedure
d) Operative Notes
e) Detailed discharge summary
Invoice of graft used
Invoice of graft used
a) Intra procedure microscope
clinical photograph
b) Detailed Procedure
c) Operative Notes
d) Detailed discharge summary
Referral
N
OPEN
Y
1014
ENT
SL
SL003
Stapedectomy /
tympanotomy
SL003B
Tympanotomy
13000
15600
16900
a) Clinical notes
b) Audiometry confirming
conductive deafness
a) Intra procedure microscope
clinical photograph
b) Detailed Procedure
c) Operative Notes
d) Detailed discharge summary
a) Clinical notes confirming the
indication for the procedure with
imaging (X-ray/ CT) Evidence
b) Audiometry
a) Scar photo
b) Post procedure clinical
photograph
c) Detailed Procedure
d) Operative Notes
e) Detailed discharge summary
f) Histopath
Referral
a) Clinical notes confirming the
indication for the procedure with
imaging (X-ray/ CT) Evidence
b) Audiometry
a) Scar photo
b) Post procedure clinical
photograph
c) Detailed Procedure
d) Operative Notes
e) Detailed discharge summary
f) Histopath
Referral
18850
OPEN
Y
1015
ENT
SL
SL004 Mastoidectomy
SL004A Simple
28000
33600
36400
40600
Y
1016
ENT
SL
SL004 Mastoidectomy
SL004B
Radical
28000
33600
36400
40600
Y
SL NO
1017
Specialty
ENT
Specialty
Code
SL
Package
Code
SL005
Package Name
Myringotomy with or
without Grommet
Procedure
Code
Procedure Name
Unilateral SL005A (Myringotomy with or
without Grommet)
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
5660
6792
NABH
Package
Cost
7358
Outside State
NABH
Package Cost
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Clinical notes
b) Audiogram
justifying surgery.
a) Photograph of patient while
undergoing the procedure
b) Detailed Procedure
c) Operative Notes
d) Detailed discharge summary
a) Clinical notes
b) Audiogram
justifying surgery.
a) Photograph of patient while
undergoing the procedure
b) Detailed Procedure
c) Operative Notes
d) Detailed discharge summary
a) Clinical notes
b) Endoscopy findings
c) Clinical photograph
a) Endoscopic still images
b) Detailed discharge summary
c) Post procedure clinical
photograph of affected part
d) Detailed Procedure
e) Operative Notes.
8207
OPEN
Y
1018
ENT
SL
SL005
Myringotomy with or
without Grommet
SL005B
Bilateral
5000
6000
6500
7250
OPEN
Y
1019
ENT
SL
SL006 Endoscopic DCR
SL006A Endoscopic DCR
19300
23160
25090
27985
OPEN
N
1020
ENT
SL
SL007
Epistaxis treatment packing
SL007A
Epistaxis treatment packing
1800
2160
2340
2610
a) Clinical notes
b) Planned line of treatment
a) Clinical photograph
b) Detailed Discharge Summary
a) Clinical notes Indication for this
surgery with supporting medical
records
b) X-ray
c) MLC/FIR for traumatic injuries
and circumstances of the incident
which led to disfigurement
d) Clinical picture
a) Post procedure clinical
photograph of affected part
b) Detailed Procedure
c) Operative Notes
d) Detailed discharge summary
a) Indication for this surgery with
supporting medical records
b) MLC/FIR for traumatic injuries
c) Endoscopic picture
d) Clinical picture
a) Post procedure clinical
photograph of affected part
b) Detailed Procedure
c) Operative Notes.
d) Detailed discharge summary
a) MLC/FIR for traumatic injuries
and circumstances of the incident
which led to fracture
b) X Ray
c) CT
a) Post procedure X-ray
b) Post procedure clinical
photograph of affected part
c) Detailed Procedure
d) Operative Notes
e) Detailed discharge summary
OPEN
N
1021
ENT
SL
SL008
Functional septo
rhinoplasty
SL008A
Functional septo
rhinoplasty
21800
26160
28340
31610
OPEN
N
1022
ENT
SL
SL009 Septoplasty
SL009A Septoplasty
12000
14400
15600
17400
OPEN
N
1023
ENT
SL
SL010
Fracture - setting nasal
bone
SL010A
Fracture - setting nasal
bone
8000
9600
10400
11600
OPEN
N
1024
ENT
SL
SL011
Inferior turbinate
reduction under GA
SL011A
Inferior turbinate
reduction under GA
5700
6840
7410
8265
a) Intraoperative Stills
a) Clinical notes
b) EXAMINATION FINDINGS b) Post procedure clinical
photograph of affected part
c) Nasoendoscopy findings
c) Detailed discharge summary
d) Detailed Procedure
e) Operative Notes
OPEN
N
1025
ENT
SL
SL012 Open sinus surgery
SL012A Open sinus surgery
15000
18000
19500
21750
a) Clinical notes detailing
chronicity of sinusitis
b) Indications for surgery with
supporting CTpre-procedure
photograph
a) Post procedure Imaging
b) Post procedure clinical
photograph of affected part
c) Histopathology
d) Detailed Procedure
e) Operative Notes
f) Intra procedure clinical
photograph
OPEN
N
SL NO
Specialty
Specialty
Code
Package
Code
Package Name
Procedure
Code
Procedure Name
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
NABH
Package
Cost
Outside State
NABH
Package Cost
Mandatory Documents - Pre
Authorization
a) Clinical notes
b) CT
confirming the diagnosis.
1026
ENT
SL
SL013
Functional Endoscopic
Sinus (FESS)
SL013A
Functional Endoscopic
Sinus (FESS)
11000
13200
14300
15950
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Stills of procedure being done
b) Post procedure clinical
photograph
c) Detailed Procedure
d) Operative Notes
e) Detailed discharge summary
OPEN
N
Indications of this surgery with
clinical evidence (CT)
1027
ENT
SL
Ant. Ethmoidal /
SL014 sphenopalatine artery
ligation
SL014A
Ant. Ethmoidal artery
ligation - Open
15000
18000
19500
21750
Indications of this surgery with
clinical evidence (CT)
1028
ENT
SL
Ant. Ethmoidal /
SL014 sphenopalatine artery
ligation
SL014B
Ant. Ethmoidal artery
ligation - Endoscopic
15000
18000
19500
21750
Indications of this surgery with
clinical evidence (CT)
1029
ENT
SL
Ant. Ethmoidal /
SL014 sphenopalatine artery
ligation
SL014C
Sphenopalatine artery
ligation - Open
15000
18000
19500
21750
Indications of this surgery with
clinical evidence (CT)
1030
1031
ENT
ENT
SL
SL
Ant. Ethmoidal /
SL014 sphenopalatine artery
ligation
SL015 Adenoidectomy
SL014D
Sphenopalatine artery
ligation - Endoscopic
SL015A Adenoidectomy
15000
6000
18000
7200
19500
7800
21750
8700
a) Intraoperative photograph
b) X-ray of clips used
c) Post procedure clinical
photograph of affected part
d) Detailed Procedure
e) Operative Notes
f) Discharge summary.
OPEN
a) Intraoperative photograph
b) X-ray of clips used
c) Post procedure clinical
photograph of affected part
d) Detailed Procedure
e) Operative Notes
f) Discharge summary.
OPEN
a) Intraoperative photograph
b) X-ray of clips used
c) Post procedure clinical
photograph of affected part
d) Detailed Procedure
e) Operative Notes
f) Discharge summary.
OPEN
a) Intraoperative photograph
b) X-ray of clips used
c) Post procedure clinical
photograph of affected part
d) Detailed Procedure
e) Operative Notes
f) Discharge summary.
OPEN
Y
Y
Y
Y
a) Clinical notes with supporting
investigation reports
b) X Ray Adenoids
c) Clinical Photograph
a) Histopathology report
b) Post procedure clinical
photograph of affected part
c) Detailed Procedure
d) Operative Notes
e) Detailed discharge summary
a) Indication for surgery from
treating doctor with supporting
case history
b) Physical examination findings
c) Supporting investigation reports
d) Clinical Photograph
a) Histopathology report
b) Post procedure clinical
photograph of affected part
c) Detailed Procedure
d) Operative Notes
Referral
a) Indication for surgery from
treating doctor with supporting
case history
b) Physical examination findings
c) Supporting investigation reports
d) Clinical Photograph
a) Histopathology report
b) Post procedure clinical
photograph of affected part
c) Detailed Procedure
d) Operative Notes
Referral
a) Doctor's notes with presenting
complaints
b) Duration and physical
examination findings of oral cavity
and tonsils
c) Clinical photograph if possible
a) C/S of pus
b) Post procedure clinical
photograph of affected part
c) Detailed Procedure
d) Operative Notes
e) Detailed discharge summary
OPEN
N
1032
ENT
SL
SL016 Tonsillectomy
SL016A Tonsillectomy - U/L
7500
9000
9750
10875
Y
1033
ENT
SL
SL016 Tonsillectomy
SL016B
Tonsillectomy - B/L
7500
9000
9750
10875
Y
1034
ENT
SL
Peritonsillar abscess
SL017 drainage / intraoral
calculus removal
SL017A
Peritonsillar abscess
drainage
5800
6960
7540
8410
OPEN
Y
SL NO
1035
1036
Specialty
ENT
ENT
Specialty
Code
SL
SL
Package
Code
Package Name
Peritonsillar abscess
SL017 drainage / intraoral
calculus removal
Thyroglossal /
SL018 Branchial cyst / sinus /
fistula excision
Procedure
Code
SL017B
SL018A
Procedure Name
Intraoral calculus
removal
Thyroglossal cyst
excision
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
5800
15300
6960
18360
NABH
Package
Cost
7540
19890
Outside State
NABH
Package Cost
8410
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Doctor's notes with presenting
complaints
b) Duration and physical
examination findings of oral cavity
and tonsils
c) Clinical photograph if possible
a) C/S of pus
b) Post procedure clinical
photograph of affected part
c) Detailed Procedure
d) Operative Notes
e) Detailed discharge summary
Reserved
a) Clinical notes
b) Pre-operative clinical
photograph
a) Histopathology report
b) Post procedure clinical
photograph of affected part
c) Detailed Procedure
d) Operative Notes
e) Detailed discharge summary
Referral
a) Clinical notes
b) Pre-operative clinical
photograph
a) Histopathology report
b) Post procedure clinical
photograph of affected part
c) Detailed Procedure
d) Operative Notes
e) Detailed discharge summary
Referral
a) Clinical notes
b) Pre-operative clinical
photograph
a) Histopathology report
b) Post procedure clinical
photograph of affected part
c) Detailed Procedure
d) Operative Notes
e) Detailed discharge summary
Referral
a) Clinical notes
b) Pre-operative clinical
photograph
a) Histopathology report
b) Post procedure clinical
photograph of affected part
c) Detailed Procedure
d) Operative Notes
e) Detailed discharge summary
Referral
Clinical notes and pre-operative
clincial photograph
a) Histopathology report
b) Post procedure clinical
photograph of affected part
c) Detailed Procedure
d) Operative Notes
e) Detailed discharge summary
Referral
a) Clinical notes
b) Polysomnography (Sleep
Study)
c) CT
d) MRI
a) Post procedure clinical
photograph of affected part
b) Detailed Procedure
c) Operative Notes
d) Detailed discharge summary
a) CT Scan
b) Biopsy
c) Clinical notes with planned line
of treatment
d) Pre operative Clinical
Photograph of affected part.
a) Procedure
b) Operative Notes
c) Post Procedure Photograph of
affected part
d) Histopathology report
a) CT Scan
b) Biopsy
c) Clinical Photograph of affected
part
a) Procedure
b) Operative Notes
c) Post Procedure Photograph of
affected part
d) Histopathology report
OPEN
a) CT Scan
b) Biopsy
c) Clinical Photograph of affected
part
a) Procedure
b) Operative Notes
c) Post Procedure Photograph of
affected part
d) Histopathology report
OPEN
22185
Y
1037
ENT
SL
Thyroglossal /
SL018 Branchial cyst / sinus /
fistula excision
SL018B
Thyroglossal sinus
excision
15300
18360
19890
22185
Y
1038
ENT
SL
Thyroglossal /
SL018 Branchial cyst / sinus /
fistula excision
SL018C
Thyroglossal fistula
excision
15300
18360
19890
22185
Y
1039
ENT
SL
Thyroglossal /
SL018 Branchial cyst / sinus /
fistula excision
SL018D Branchial sinus excision
15300
18360
19890
22185
Y
1040
ENT
SL
Thyroglossal /
SL018 Branchial cyst / sinus /
fistula excision
SL018E
Branchial fistula excision
15300
18360
19890
22185
Y
1041
ENT
SL
SL019
Uvulopalatopharyngopl
asty (UPPP)
SL019A
Uvulopalatopharyngopla
sty (UPPP)
18600
22320
24180
26970
OPEN
N
1042
1043
1044
ENT
ENT
ENT
SL
Excision of tumour of
oral cavity / paranasal
SL020 sinus / laryngopharynx
with or without
reconstruction
SL
Excision of tumour of
oral cavity / paranasal
SL020 sinus / laryngopharynx
with or without
reconstruction
SL
Excision of tumour of
oral cavity / paranasal
SL020 sinus / laryngopharynx
with or without
reconstruction
SL020A
Excision of tumour of
oral cavity / paranasal
sinus / laryngopharynx
without reconstruction
SL020B
Excision of tumour of
oral cavity / paranasal
sinus / laryngopharynx
with pedicled flap
reconstruction
SL020C
Excision of tumour of
oral cavity / paranasal
sinus / laryngopharynx
with free flap
reconstruction
10000
36500
35050
12000
43800
42060
13000
47450
45565
14500
52925
50822
OPEN
Y
Y
Y
SL NO
1045
Specialty
ENT
Specialty
Code
SL
Package
Code
Package Name
SL021 Parotidectomy
Procedure
Code
Procedure Name
SL021A Total Parotidectomy
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
30708
36849
NABH
Package
Cost
39920
Outside State
NABH
Package Cost
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
44526
a) CT Scan
b) FNAC
c) Clinical Photograph of affected
part
a) Histopathology report
b) Post procedure clinical
photograph of affected part
c) Detailed Procedure
d) Operative Notes
e) Detailed discharge summary.
37578
a) CT Scan
b) FNAC
c) Clinical Photograph of affected
part
a) Histopathology report
b) Post procedure clinical
photograph of affected part
c) Detailed Procedure
d) Operative Notes
e) Detailed discharge summary.
13050
a) Clinical notes to establish
indication; Biopsy if tumour
b) Clinical Photograph of affected
part
a) Histopathology report
b) Post procedure clinical
photograph of affected part
c) Detailed Procedure
d) Operative Notes
e) Detailed discharge summary.
a) Clinical notes
b) Clinical photograph
c) MLC/FIR for traumatic injuries
and circumstances of the incident
which led to rupture of salivary
duct.
a) Histopathology report
b) Post procedure clinical
photograph of affected part
c) Detailed Procedure
d) Operative Notes
e) Detailed discharge summary.
a) Clinical notes to establish
indication; Biopsy if tumour
b) Clinical Photograph of affected
part
a) Histopathology report
b) Post procedure clinical
photograph of affected part
c) Detailed Procedure
d) Operative Notes
e) Detailed discharge summary.
OPEN
Y
1046
ENT
SL
SL021 Parotidectomy
SL021B
Superficial
Parotidectomy
25916
31099
33690
OPEN
Y
1047
ENT
SL
Removal of
SL022 Submandibular
Salivary gland
Removal of
SL022A Submandibular Salivary
gland
9000
10800
11700
OPEN
Y
1048
ENT
SL
Removal of
SL022 Submandibular
Salivary gland
SL022B
Removal of Ranula
9000
10800
11700
13050
OPEN
Y
1049
ENT
SL
Removal of
SL022 Submandibular
Salivary gland
SL
Rigid laryngoscopy /
bronchoscopy /
SL023
oesophagoscopy Diagnostic + / - biopsy
SL
Rigid laryngoscopy /
bronchoscopy /
SL023
oesophagoscopy Diagnostic + / - biopsy
SL022C
Removal of
Submandibular Lymph
node
9000
10800
11700
13050
OPEN
Y
1050
1051
1052
1053
ENT
ENT
ENT
ENT
SL
SL
SL023
Rigid laryngoscopy /
bronchoscopy /
oesophagoscopy Diagnostic + / - biopsy
Microlaryngeal
SL024 surgery with or
without laser
SL023A
SL023B
SL023C
SL024A
Rigid laryngoscopy Diagnostic + / - biopsy
Rigid bronchoscopy Diagnostic + / - biopsy
Rigid oesophagoscopy Diagnostic + / - biopsy
Microlaryngeal surgery
with or without laser
7000
7000
7000
17000
8400
8400
8400
20400
9100
9100
9100
22100
10150
10150
10150
24650
Clinical notes with planned line of a) Procedure Notes
treatment
b) Operative Notes
c) Post Procedure Photograph of OPEN
affected part
d) Histopathology report
Clinical notes with planned line of a) Procedure Notes
treatment
b) Operative Notes
c) Post Procedure Photograph of OPEN
affected part
d) Histopathology report
Clinical notes with planned line of a) Procedure Notes
treatment
b) Operative Notes
c) Post Procedure Photograph of OPEN
affected part
d) Histopathology report
a) Indication for surgery with
supporting investigation reports
b) Laryngoscopy findings
c) Laryngeal electromyography
a) Procedure Notes
b) Operative Notes
c) Post Procedure Photograph of
OPEN
affected part
d) Histopathology report
Clinical notes to establish
indication and justification of
surgery
Evidence through
a) CT
b) MRI
c) Biopsy
d) Clinical Photograph
a) Histopathology report in case of
tumours
b) Post procedure clinical
photograph of affected part
c) Detailed Procedure
OPEN
d) Operative Notes
e) Detailed discharge summary
Y
Y
Y
N
1054
ENT
SL
Open laryngeal
SL025 framework surgery /
Thyroplasty
Open laryngeal
SL025A framework surgery /
Thyroplasty
5000
6000
6500
7250
N
SL NO
1055
1056
1057
Specialty
ENT
ENT
ENT
Specialty
Code
SL
SL
SL
Package
Code
Package Name
Tracheostomy /
SL026
Tracheotomy
SL026
Tracheostomy /
Tracheotomy
SL027 Neck dissection
Procedure
Code
Procedure Name
SL026A Tracheostomy
SL026B
SL027A
Tracheotomy
Selective Benign neck
tumour excision
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
6000
6000
7200
7200
NABH
Package
Cost
7800
7800
Outside State
NABH
Package Cost
8700
8700
Mandatory Documents - Pre
Authorization
Clinical notes with planned line of a) Procedure Notes
treatment justifying indication
b) Operative Notes
c) Post Procedure Photograph of OPEN
affected part
d) Histopathology report
Clinical notes with planned line of a) Procedure Notes
treatment justifying indication
b) Operative Notes
c) Post Procedure Photograph of OPEN
affected part
d) Histopathology report
Indication for surgery with
supporting investigation reports
a) X-ray
b) CT
c) MRI
18800
22560
24440
27260
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
A. FNAC/ Biospy in case of
tumours
B. Clinical Photograph
a) Histopathology report
b) Post procedure Imaging
c) Post procedure clinical
photograph of affected part
d) Detailed Procedure
e) Operative Notes
f) Detailed discharge summary
Y
Y
OPEN
Y
1058
ENT
SL
SL027 Neck dissection
SL027B
Comprehensive Benign
neck tumour excision
Indication for surgery with
supporting investigation reports
a) X-ray
b) CT
c) MRI
18800
22560
24440
27260
A. FNAC/ Biospy in case of
tumours
B. Clinical Photograph
a) Histopathology report
b) Post procedure Imaging
c) Post procedure clinical
photograph of affected part
d) Detailed Procedure
e) Operative Notes
f) Detailed discharge summary
OPEN
Y
1059
ENT
SL
SL027 Neck dissection
SL027C
Selective Pharyngeal
diverticulum excision
Indication for surgery with
supporting investigation reports
a) X-ray
b) CT
c) MRI
18800
22560
24440
27260
A. FNAC/ Biospy in case of
tumours
B. Clinical Photograph
a) Histopathology report
b) Post procedure Imaging
c) Post procedure clinical
photograph of affected part
d) Detailed Procedure
e) Operative Notes
f) Detailed discharge summary
OPEN
Y
1060
ENT
SL
SL027 Neck dissection
Comprehensive
SL027D Pharyngeal
diverticulum excision
Indication for surgery with
supporting investigation reports
a) X-ray
b) CT
c) MRI
18800
22560
24440
27260
A. FNAC/ Biospy in case of
tumours
B. Clinical Photograph
a) Histopathology report
b) Post procedure Imaging
c) Post procedure clinical
photograph of affected part
d) Detailed Procedure
e) Operative Notes
f) Detailed discharge summary
OPEN
Y
1061
ENT
SL
Deep neck abscess
SL028 drainage/ Post trauma
neck exploration
SL028A
Deep neck abscess
drainage
16800
20160
21840
24360
a) Clinical notes
b) Clinical photograph
c) Investigation supporting
diagnosis
d) CT
a) C/S of pus
b) Post procedure clinical
photograph of affected part
c) Detailed Procedure
d) Operative Notes
e) Detailed discharge summary
a) Clinical notes
b) Clinical photograph
c) Investigation supporting
diagnosis
d) CT
a) C/S of pus
b) Post procedure clinical
photograph of affected part
c) Detailed Procedure
d) Operative Notes
e) Detailed discharge summary
OPEN
Y
1062
ENT
SL
Deep neck abscess
SL028 drainage/ Post trauma
neck exploration
SL028B
Post trauma neck
exploration
16800
20160
21840
24360
OPEN
Y
SL NO
1063
Specialty
ENT
Specialty
Code
SL
Package
Code
SL029
Package Name
Anterior skull base
surgery
Procedure
Code
SL029A
Procedure Name
Endoscopic CSF
Rhinorrhea Repair
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
30000
36000
NABH
Package
Cost
39000
Outside State
NABH
Package Cost
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
43500
a) Clinical notes with planned line
of treatment detailing aetiology
b) MLC/ FIR if traumatic
c) CT to confirm need of surgery
a) Procedure Notes
b) Operative Notes
c) Post Procedure Photograph of
affected part.
43500
a) Clinical notes with planned line
of treatment detailing aetiology
b) MLC/ FIR if traumatic
c) CT to confirm need of surgery
a) Procedure Notes
b) Operative Notes
c) Post Procedure Photograph of
affected part.
43500
a) Clinical notes with planned line
of treatment detailing aetiology
b) MLC/ FIR if traumatic
c) CT to confirm need of surgery
a) Procedure Notes
b) Operative Notes
c) Post Procedure Photograph of
affected part.
43500
a) Clinical notes with planned line
of treatment detailing aetiology
b) MLC/ FIR if traumatic
c) CT to confirm need of surgery
a) Procedure Notes
b) Operative Notes
c) Post Procedure Photograph of
affected part.
43500
a) Clinical notes with planned line
of treatment detailing aetiology
b) MLC/ FIR if traumatic
c) CT to confirm need of surgery
a) Procedure Notes
b) Operative Notes
c) Post Procedure Photograph of
affected part.
Clinical notes with planned line of
treatment and Coronal
a) CT
b)MRI
establishing diagnosis and
establishing need of surgery.
a) Procedure Notes
b) Operative Notes
c) Post Procedure Photograph of
affected part.
d) Histopathology report
Clinical notes with planned line of
treatment and Coronal
a) CT
b)MRI
establishing diagnosis and
establishing need of surgery.
a) Procedure Notes
b) Operative Notes
c) Post Procedure Photograph of
affected part.
d) Histopathology report
Clinical notes with planned line of
treatment and
a) CT
b) MRI
c) Biopsy
to establish the indication and
justify the surgery.
a) Procedure Notes
b) Operative Notes
c) Post Procedure Photograph of
affected part.
d) Histopathology report
Clinical notes with planned line of
treatment and
a) CT
b) MRI
c) Biopsy
to establish the indication and
justify the surgery.
a) Procedure Notes
b) Operative Notes
c) Post Procedure Photograph of
affected part.
d) Histopathology report
OPEN
Y
1064
ENT
SL
SL029
Anterior skull base
surgery
SL029B
Optic nerve
decompression
30000
36000
39000
OPEN
Y
1065
ENT
SL
SL029
Anterior skull base
surgery
SL029C
Orbital decompression
30000
36000
39000
OPEN
Y
1066
ENT
SL
SL029
Anterior skull base
surgery
SL029D Craniofacial resection
30000
36000
39000
OPEN
Y
1067
ENT
SL
SL029
Anterior skull base
surgery
SL029E
Maxillary swing
30000
36000
39000
OPEN
Y
1068
ENT
SL
SL030
Advanced anterior
skull base surgery
SL030A
Endoscopic
Hypophysectomy
39800
47760
51740
57710
OPEN
Y
1069
ENT
SL
SL030
Advanced anterior
skull base surgery
SL030B
Clival tumour excision
39800
47760
51740
57710
OPEN
Y
1070
ENT
SL
SL031
Lateral skull base
procedures
SL031A Subtotal petrosectomy
24700
29640
32110
35815
OPEN
Y
1071
ENT
SL
SL031
Lateral skull base
procedures
SL031B
Post-traumatic facial
nerve decompression
24700
29640
32110
35815
OPEN
Y
SL NO
1072
Specialty
ENT
Specialty
Code
SL
Package
Code
SL031
Package Name
Lateral skull base
procedures
Procedure
Code
SL031C
Procedure Name
CSF Otorrhoea repair
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
24700
29640
NABH
Package
Cost
32110
Outside State
NABH
Package Cost
35815
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
Clinical notes with planned line of
treatment and
a) CT
b) MRI
c) Biopsy
to establish the indication and
justify the surgery.
a) Procedure Notes
b) Operative Notes
c) Post Procedure Photograph of
affected part.
d) Histopathology report
a) Clinical notes with planned line
of treatment
b) Audiogram report justfying
surgery
c) CT- TEMPORAL BONE of
affected side
d) X-RAY BOTH MASTOIDS
a) Procedure Notes
b) Operative Notes
c) Post Procedure Photograph of
affected part.
d) Histopathology report
a) Clinical notes with planned line
of treatment
b) Audiogram report justfying
surgery
c) CT- TEMPORAL BONE of
affected side
d) X-RAY BOTH MASTOIDS
a) Procedure Notes
b) Operative Notes
c) Post Procedure Photograph of
affected part.
d) Histopathology report
a) Clinical notes with planned line
of treatment
b) Audiogram report justfying
surgery
c) CT- TEMPORAL BONE of
affected side
d) X-RAY BOTH MASTOIDS
a) Procedure Notes
b) Operative Notes
c) Post Procedure Photograph of
affected part.
d) Histopathology report
a) Clinical notes with planned line
of treatment
b) Audiogram report justfying
surgery
c) CT- TEMPORAL BONE of
affected side
d) X-RAY BOTH MASTOIDS
a) Procedure Notes
b) Operative Notes
c) Post Procedure Photograph of
affected part.
d) Histopathology report
a) MLC
b) FIR for traumatic injuries and
circumstances of the incident
which led to fracture
c) X Ray
d) CT
a) Procedure Notes
b) Operative Notes
c) Post Procedure Photograph of
affected part.
d) Histopathology report
a) MLC
b) FIR for traumatic injuries and
circumstances of the incident
which led to fracture
c) X Ray
d) CT
a) Procedure Notes
b) Operative Notes
c) Post Procedure Photograph of
affected part.
d) Histopathology report
a) MLC
b) FIR for traumatic injuries and
circumstances of the incident
which led to fracture
c) X Ray
d) CT
a) Procedure Notes
b) Operative Notes
c) Post Procedure Photograph of
affected part.
d) Histopathology report
OPEN
Y
1073
ENT
SL
SL032
Advanced lateral skull
base surgery
SL032A Fisch approach
39900
47880
51870
57855
OPEN
Y
1074
ENT
SL
SL032
Advanced lateral skull
base surgery
SL032B
Translabyrinthine
approach
39900
47880
51870
57855
OPEN
Y
1075
ENT
SL
SL032
Advanced lateral skull
base surgery
SL032C
Transcochlear approach
39900
47880
51870
57855
OPEN
Y
1076
ENT
SL
SL032
Advanced lateral skull
base surgery
SL032D
Temporal Bone
resection
39900
47880
51870
57855
OPEN
Y
1077
ENT
SL
SL033
Closed reduction /
intermaxillary fixation
for fracture of maxilla
/ mandible / zygoma
SL033A
Closed reduction for
fracture of maxilla
9200
11040
11960
13340
OPEN
Y
1078
ENT
SL
SL033
Closed reduction /
intermaxillary fixation
for fracture of maxilla
/ mandible / zygoma
SL033B
Closed reduction for
fracture of mandible
9200
11040
11960
13340
OPEN
Y
1079
ENT
SL
SL033
Closed reduction /
intermaxillary fixation
for fracture of maxilla
/ mandible / zygoma
SL033C
Closed reduction for
fracture of zygoma
9200
11040
11960
13340
OPEN
Y
SL NO
1080
Specialty
ENT
Specialty
Code
SL
Package
Code
Package Name
Closed reduction /
intermaxillary fixation
SL033
for fracture of maxilla
/ mandible / zygoma
Procedure
Code
Procedure Name
Closed reduction and
SL033D Intermaxillary fixation
for fracture of mandible
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
9200
11040
NABH
Package
Cost
11960
Outside State
NABH
Package Cost
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) MLC
b) FIR for traumatic injuries and
circumstances of the incident
which led to fracture
c) X Ray
d) CT
a) Procedure Notes
b) Operative Notes
c) Post Procedure Photograph of
affected part.
d) Histopathology report
a) MLC
b) FIR for traumatic injuries and
circumstances of the incident
which led to fracture
c) X Ray
d) CT
a) Procedure Notes
b) Operative Notes
c) Post Procedure Photograph of
affected part.
d) Histopathology report
a) MLC
b) FIR for traumatic injuries and
circumstances of the incident
which led to fracture
c) X Ray
d) CT
a) Procedure Notes
b) Operative Notes
c) Post Procedure Photograph of
affected part.
d) Histopathology report
a) MLC
b) FIR for traumatic injuries and
circumstances of the incident
which led to fracture
c) X Ray
d) CT
a) Procedure Notes
b) Operative Notes
c) Post Procedure Photograph of
affected part.
d) Histopathology report
1740
a) Clinical notes with planned line
of treatment
b) EXAMINATION FINDINGS
c) Nasoendoscopy findings
a) Procedure Notes
b) Operative Notes
c) Post Procedure Photograph of
affected part.
d) Histopathology report
1740
a) Clinical notes with planned line
of treatment
b) EXAMINATION FINDINGS
c) Nasoendoscopy findings
a) Procedure Notes
b) Operative Notes
c) Post Procedure Photograph of
affected part.
d) Histopathology report
1740
a) Clinical notes with planned line
of treatment
b) EXAMINATION FINDINGS
c) Nasoendoscopy findings
a) Procedure Notes
b) Operative Notes
c) Post Procedure Photograph of
affected part.
d) Histopathology report
1740
a) Clinical notes with planned line
of treatment
b) EXAMINATION FINDINGS
c) Nasoendoscopy findings
a) Procedure Notes
b) Operative Notes
c) Post Procedure Photograph of
affected part.
d) Histopathology report
a) Dental X-ray.
b) OPG (Orthopantomogram)
showing impacted tooth Clinical
Photograph.
a) Post procedure X-ray.
b) Extracted tooth.
c) Detailed Procedure.
d) Operative Notes.
13340
OPEN
Y
1081
ENT
SL
SL034
Open reduction and
internal fixation of
maxilla / mandible /
zygoma
Open reduction and
SL034A internal fixation of
maxilla
18000
21600
23400
26100
OPEN
Y
1082
ENT
SL
SL034
Open reduction and
internal fixation of
maxilla / mandible /
zygoma
SL034B
Open reduction and
internal fixation of
mandible
18000
21600
23400
26100
OPEN
Y
1083
ENT
SL
SL034
Open reduction and
internal fixation of
maxilla / mandible /
zygoma
SL034C
Open reduction and
internal fixation of
zygoma
18000
21600
23400
26100
OPEN
Y
1084
ENT
SL
Clinic based
SL035 therapeutic
interventions of ENT
SL035A Turbinate reduction
1200
1440
1560
OPEN
Y
1085
ENT
SL
Clinic based
SL035 therapeutic
interventions of ENT
SL035B
Biopsy
1200
1440
1560
OPEN
Y
1086
ENT
SL
Clinic based
SL035 therapeutic
interventions of ENT
SL035C
Intratympanic injections
1200
1440
1560
OPEN
Y
1087
1088
ENT
Oral & Maxillofacial Surgery
SL
SM
Clinic based
SL035 therapeutic
interventions of ENT
SM001
Extraction of impacted
tooth under LA
SL035D Wide bore aspiration
SM001A
Extraction of impacted
tooth under LA
1200
500
1440
600
1560
650
725
OPEN
Y
Reserved
SL NO
1089
Specialty
Oral & Maxillofacial Surgery
Specialty
Code
SM
Package
Code
Package Name
SM002 Sequestrectomy
Procedure
Code
Procedure Name
SM002A Sequestrectomy
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
5000
6000
NABH
Package
Cost
6500
Outside State
NABH
Package Cost
7250
Mandatory Documents - Pre
Authorization
OPG showing necrosed tissue.
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Post procedure clinical
photograph.
b) Detailed discharge summary.
c) Detailed Procedure.
d) Operative Notes.
e) HPE.
OPEN
N
1090
1091
1092
Oral & Maxillofacial Surgery
Oral & Maxillofacial Surgery
Oral & Maxillofacial Surgery
SM
SM
SM
TM joint ankylosis of
SM003
both jaws - under GA
SM004
SM004
Fixation of fracture of
jaw
Fixation of fracture of
jaw
TM joint ankylosis of
SM003A
both jaws - under GA
Closed reduction (1
SM004A jaw) using wires under LA
Open reduction (1 jaw)
SM004B and fixing of plates /
wire – under GA
15000
5000
12000
18000
6000
14400
19500
6500
15600
21750
7250
17400
a) Clinical Photograph.
b) X-Ray of affected area.
c) CT.
a) Circumstances that led to
fracture.
b) MLC copy with number.
c) Clinical Photograph.
d) X Ray Mandible.
a) Circumstances that led to
fracture.
b) MLC copy with number.
c) Clinical Photograph.
d) X Ray Mandible.
a) Post procedure clinical
photograph with mouth open.
b) X Ray.
c) Detailed discharge summary.
d) Detailed Procedure.
e) Operative Notes.
OPEN
N
a) Detailed Discharge Summary.
b) Detailed Procedure.
c) Operative Notes.
OPEN
d) Post procedure X ray mandible
showing wires used.
Y
a) Detailed Discharge Summary.
b) Detailed Procedure.
c) Operative Notes.
OPEN
d) Post procedure X ray mandible
showing wires used.
Y
1093
Oral & Maxillofacial Surgery
SM
Surgery for Cyst &
SM005 tumour of Maxilla /
Mandible
SM005A
Enucleation / excision /
marsupialization for
cyst & tumour of
Maxilla under LA
2500
3000
3250
3625
a) OPG.
b) CT Scan confirming the
diagnosis.
c) Biopsy.
d) FNAC if tumour.
e) Clinical Photograph.
a) Detailed discharge summary.
b) Detailed Procedure.
c) Operative Notes.
d) Histopath.
e) Post procedure clinical
photograph.
f) HPE.
a) OPG.
b) CT Scan confirming the
diagnosis.
c) Biopsy.
d) FNAC if tumour.
e) Clinical Photograph.
a) Detailed discharge summary.
b) Detailed Procedure.
c) Operative Notes.
d) Histopath.
e) Post procedure clinical
photograph.
f) HPE.
a) OPG.
b) CT Scan confirming the
diagnosis.
c) Biopsy.
d) FNAC if tumour.
e) Clinical Photograph.
a) Detailed discharge summary.
b) Detailed Procedure.
c) Operative Notes.
d) Histopath.
e) Post procedure clinical
photograph.
f) HPE.
a) Clinical notes.
b) Oral Biopsy confirming the
diagnosis.
c) Clinical Photograph.
a) Detailed Procedure.
b) Operative Notes detailing
grafting.
c) Detailed discharge summary.
d) Post procedure clinical
photograph.
OPEN
Y
1094
Oral & Maxillofacial Surgery
SM
Surgery for Cyst &
SM005 tumour of Maxilla /
Mandible
SM005B
Enucleation / excision /
marsupialization for
cyst & tumour of
Mandible under LA
2500
3000
3250
3625
OPEN
Y
1095
Oral & Maxillofacial Surgery
SM
Mandible Tumour
Resection and
SM006
reconstruction /
Cancer surgery
Mandible Tumour
Resection and
SM006A
reconstruction / Cancer
surgery
6000
7200
7800
8700
OPEN
N
1096
Oral & Maxillofacial Surgery
SM
Release of fibrous
bands & grafting - in
SM007
(OSMF) treatment
under GA
Release of fibrous
bands & grafting - in
SM007A
(OSMF) treatment
under GA
3000
3600
3900
4350
OPEN
N
SL NO
1097
1098
1099
1100
Specialty
Neurosurgery
Neurosurgery
Neurosurgery
Neurosurgery
Specialty
Code
SN
SN
SN
SN
Package
Code
Package Name
SN001 Depressed Fracture
SN002 CranioPlasty
SN002 CranioPlasty
SN003
Twist Drill
Craniostomy
Procedure
Code
Procedure Name
SN001A Depressed Fracture
SN002A
SN002B
CranioPlasty with
Endogenous graft
CranioPlasty with
Exogenous graft
SN003A Twist Drill Craniostomy
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
40000
25000
25000
15000
48000
30000
30000
18000
NABH
Package
Cost
52000
32500
32500
19500
Outside State
NABH
Package Cost
58000
36250
36250
21750
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Clinical notes.
b) CT confirming diagnosis.
a) Post procedure Imaging with
film (CT).
b) Post procedure Clinical
photgraph showing scar.
c) Detailed discharge summary.
d) Detailed Procedure.
e) Operative Notes.
a) CT.
b) MRI.
a) Post procedure Imaging wih film
(CT/Xray).
b) Post procedure Clinical
photgraph.
OPEN
c) Detailed Procedure.
d) Operative Notes.
a) CT.
b) MRI.
a) Post procedure Imaging wih film
(CT/Xray).
b) Post procedure Clinical
photgraph.
OPEN
c) Detailed Procedure.
d) Operative Notes.
a) Clinical notes.
b) CT.
a) Post procedure Imaging with
film (CT/MRI).
b) Post procedure Clinical
photgraph showing scar.
c) Detailed Procedure.
d) Operative Notes.
e) Discharge summary.
a) Clinical notes.
b) CT.
c) MRI establishing need of
surgery.
a) Post procedure Imaging with
film (CT).
b) Post procedure Clinical
photgraph showing scar.
c) Detailed discharge summary.
d) Detailed Procedure.
e) Operative Notes.
OPEN
N
Y
Y
OPEN
N
1101
1102
1103
1104
Neurosurgery
Neurosurgery
Neurosurgery
Neurosurgery
SN
SN
SN
SN
SN004 Craniostenosis
SN005 Meningocele
SN005 Meningocele
SN005 Meningocele
SN004A Craniostenosis
SN005A Anterior (Meningocele)
SN005B Lumbar
SN005C Occipital
28000
36000
36000
50000
33600
43200
43200
60000
36400
46800
46800
65000
40600
52200
52200
72500
a) Clinical notes.
b) CT.
c) MRI establishing need of
surgery.
a) Clinical notes.
b) CT.
c) MRI establishing need of
surgery.
a) Clinical notes.
b) CT.
c) MRI establishing need of
surgery.
a) Post procedure Imaging with
film (CT).
b) Post procedure Clinical
photgraph showing scar.
c) Detailed discharge summary
Detailed Procedure.
d) Operative Notes.
a) Post procedure Imaging with
film (CT).
b) Post procedure Clinical
photgraph showing scar.
c) Detailed discharge summary
Detailed Procedure.
d) Operative Notes.
a) Post procedure Imaging with
film (CT).
b) Post procedure Clinical
photgraph showing scar.
c) Detailed discharge summary
Detailed Procedure.
d) Operative Notes.
OPEN
N
Referral
Y
Referral
Y
Referral
Y
YES
SL NO
1105
Specialty
Neurosurgery
Specialty
Code
SN
Package
Code
SN006
Package Name
Surgery for tumour
meninges
Procedure
Code
Procedure Name
SN006A Gocussa
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
50000
60000
NABH
Package
Cost
65000
Outside State
NABH
Package Cost
72500
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Clinical notes.
b) CT supporting surgery.
a) Histopathology.
b) Post procedure Imaging with
film (CT).
c) Post procedure Clinical
photgraph showing scar.
d) Detailed Procedure.
e) Operative Notes.
f) Detailed discharge summary.
a) Clinical notes.
b) CT supporting surgery.
a) Histopathology.
b) Post procedure Imaging with
film (CT).
c) Post procedure Clinical
photgraph showing scar.
d) Detailed Procedure.
e) Operative Notes.
f) Detailed discharge summary.
a) Clinical notes.
b) CT.
c) MRI establishing need of
surgery.
a) Post procedure Imaging with
film (CT).
b) Post procedure Clinical
photgraph showing Post
procedure Clinical photgraph
showing scar.
c) Detailed discharge summary.
d) Detailed Procedure.
e) Operative Notes.
a) Clinical notes.
b) CT.
c) MRI establishing need of
surgery.
a) Post procedure Imaging with
film (CT).
b) Post procedure Clinical
photgraph showing Post
procedure Clinical photgraph
showing scar.
c) Detailed discharge summary.
d) Detailed Procedure.
e) Operative Notes.
a) Clinical notes.
b) CT.
c) MRI establishing need of
surgery.
a) Post procedure Imaging with
film (CT).
b) Post procedure Clinical
photgraph showing scar.
c) Detailed discharge summary.
d) Detailed Procedure.
e) Operative Notes.
a) Clinical notes.
b) CT.
c) MRI establishing need of
surgery.
a) Post procedure Imaging with
film (CT).
b) Post procedure Clinical
photgraph showing scar.
c) Detailed discharge summary.
d) Detailed Procedure.
e) Operative Notes.
a) Clinical notes.
b) CT.
c) MRI establishing need of
surgery.
a) Post procedure Imaging with
film (CT).
b) Post procedure Clinical
photgraph showing scar.
c) Detailed discharge summary.
d) Detailed Procedure.
e) Operative Notes.
OPEN
Y
1106
Neurosurgery
SN
SN006
Surgery for tumour
meninges
SN006B Posterior
50000
60000
65000
72500
OPEN
Y
1107
Neurosurgery
SN
SN007 Duroplasty
SN007A
Duroplasty with
Endogenous graft
12500
15000
16250
18125
OPEN
Y
1108
Neurosurgery
SN
SN007 Duroplasty
SN007B
Duroplasty with
Exogenous graft
15000
18000
19500
21750
OPEN
Y
1109
Neurosurgery
SN
SN008 Burr hole surgery
SN008A Burr hole
7000
8400
9100
10150
OPEN
Y
1110
Neurosurgery
SN
SN008 Burr hole surgery
Burr hole surgery with
SN008B chronic Sub Dural
Haematoma
25000
30000
32500
36250
OPEN
Y
1111
Neurosurgery
SN
Surgery for
SN009 Haematoma Intracranial
SN009A Head injuries
55000
66000
71500
79750
OPEN
Y
YES
SL NO
1112
1113
1114
Specialty
Neurosurgery
Neurosurgery
Neurosurgery
Specialty
Code
SN
SN
SN
Package
Code
Package Name
Surgery for
SN009 Haematoma Intracranial
Surgery for
SN009 Haematoma Intracranial
SN010
Excision of Brain
Abscess
Procedure
Code
Procedure Name
SN009B Hypertensive
SN009C Child - subdural
SN010A
Excision of Brain
Abscess
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
55000
55000
40000
66000
66000
48000
NABH
Package
Cost
71500
71500
52000
Outside State
NABH
Package Cost
79750
79750
58000
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Clinical notes.
b) CT.
c) MRI establishing need of
surgery.
a) Post procedure Imaging with
film (CT).
b) Post procedure Clinical
photgraph showing scar.
c) Detailed discharge summary.
d) Detailed Procedure.
e) Operative Notes.
a) Clinical notes.
b) CT.
c) MRI establishing need of
surgery.
a) Post procedure Imaging with
film (CT).
b) Post procedure Clinical
photgraph showing scar.
c) Detailed discharge summary.
d) Detailed Procedure.
e) Operative Notes.
a) Clinical notes.
b) CT.
a) Pus C/s.
b) Post procedure Imaging with
film (CT).
c) Post procedure Clinical
photgraph showing scar.
d) Detailed discharge summary.
e) Detailed Procedure.
f) Operative Notes.
a) Clinical notes.
b) CT.
a) Pus C/s.
b) Post procedure Imaging with
film (CT).
c) Post procedure Clinical
photgraph showing scar.
d) Detailed discharge summary.
e) Detailed Procedure.
f) Operative Notes.
a) Clinical notes.
b) EEG.
c) Neurologist report.
d) CT.
e) MRI.
a) Post procedure Imaging with
film (CT).
b) Post procedure Clinical
photgraph showing scar.
c) Detailed discharge summary.
d) Detailed Procedure.
e) Operative Notes.
OPEN
Y
YES
Y
YES
OPEN
OPEN
N
1115
Neurosurgery
SN
SN011 Abscess Tapping
SN011A Abscess Tapping
20000
24000
26000
29000
OPEN
N
1116
Neurosurgery
SN
SN012 Epilepsy Surgery
SN012A Epilepsy Surgery
50000
60000
65000
72500
OPEN
N
1117
Neurosurgery
SN
SN013 Brain Biopsy
SN013A Brain Biopsy
15000
18000
19500
21750
a) Histopathology.
a) Clinical notes.
b) Post procedure Clinical
b) CT.
photgraph showing scar.
c) MRI.
c) Detailed discharge summary.
d) Suspected differential diagnosis. d) Detailed Procedure.
e) Operative Notes.
OPEN
N
1118
Neurosurgery
SN
Excision of Orbital
SN014
Tumour
Excision of Orbital
SN014A
Tumour
40000
48000
52000
58000
a) Clinical notes.
b) CT.
c) MRI report.
a) Post procedure Imaging with
film (CT).
b) Post procedure Clinical
photgraph showing scar.
c) Detailed discharge summary.
d) Detailed Procedure.
e) Operative Notes.
f) HPE report.
OPEN
N
SL NO
1119
Specialty
Neurosurgery
Specialty
Code
SN
Package
Code
Package Name
Excision of Brain
SN015
Tumor Supratentorial
Procedure
Code
Procedure Name
SN015A Parasagital
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
50000
60000
NABH
Package
Cost
65000
Outside State
NABH
Package Cost
72500
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Clinical notes.
b) CT.
c) MRI.
a) Histopathology.
b) Post procedure Imaging with
film (CT).
c) Post procedure Clinical
photgraph showing scar.
d) Detailed discharge summary.
e)Detailed Procedure.
f) Operative Notes.
a) Clinical notes.
b) CT.
c) MRI.
a) Histopathology.
b) Post procedure Imaging with
film (CT).
c) Post procedure Clinical
photgraph showing scar.
d) Detailed discharge summary.
e)Detailed Procedure.
f) Operative Notes.
a) Clinical notes.
b) CT.
c) MRI.
a) Histopathology.
b) Post procedure Imaging with
film (CT).
c) Post procedure Clinical
photgraph showing scar.
d) Detailed discharge summary.
e)Detailed Procedure.
f) Operative Notes.
a) Clinical notes.
b) CT.
c) MRI.
a) Histopathology.
b) Post procedure Imaging with
film (CT).
c) Post procedure Clinical
photgraph showing scar.
d) Detailed discharge summary.
e)Detailed Procedure.
f) Operative Notes.
a) Clinical notes.
b) CT.
c) MRI.
a) Histopathology.
b) Post procedure Imaging with
film (CT).
c) Post procedure Clinical
photgraph showing scar.
d) Detailed discharge summary.
e)Detailed Procedure.
f) Operative Notes.
OPEN
Y
1120
Neurosurgery
SN
Excision of Brain
SN015
Tumor Supratentorial
SN015B Basal
50000
60000
65000
72500
OPEN
Y
1121
Neurosurgery
SN
Excision of Brain
SN015
Tumor Supratentorial
SN015C Brainstem
50000
60000
65000
72500
OPEN
Y
1122
Neurosurgery
SN
SN015
Excision of Brain
Tumor Supratentorial
SN015D C P Angle
50000
60000
65000
72500
OPEN
Y
1123
Neurosurgery
SN
Excision of Brain
SN015
Tumor Supratentorial
SN015E Supratentorial & others
55000
66000
71500
79750
OPEN
Y
1124
Neurosurgery
SN
SN016 Stereotactic Lesioning
SN016A Stereotactic Lesioning
60000
72000
78000
87000
a) Post procedure Imaging with
film (CT).
a) Clinical notes from neurologist. b) Post procedure Clinical
b) Psychiatriat.
photgraph showing scar.
c) MRI.
c) Detailed Procedure.
d) Operative Notes.
e) Detailed discharge summary.
OPEN
N
1125
Neurosurgery
SN
SN017
Trans Sphenoidal
Surgery
SN017A
Trans Sphenoidal
Surgery
50000
60000
65000
72500
a) Clinical notes.
b) MRI supporting surgery.
a) Histopathology.
b) Post procedure Imaging with
film (MRI).
c) Detailed Procedure.
d) Operative Notes.
e) Detailed discharge summary.
OPEN
N
YES
SL NO
1126
Specialty
Neurosurgery
Specialty
Code
SN
Package
Code
Package Name
SN018 Trans oral Surgery
Procedure
Code
Procedure Name
SN018A Trans oral Surgery
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
40000
48000
NABH
Package
Cost
52000
Outside State
NABH
Package Cost
58000
Mandatory Documents - Pre
Authorization
a) X ray.
b) MRI Spine.
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Post procedure Imaging with
film (X-ray).
b) Detailed discharge summary.
c) Detailed Procedure.
d) Operative Notes.
e) HPE report.
OPEN
N
1127
Neurosurgery
SN
SN019
Transoral surgery
(Anterior) and CV
Junction (Posterior
Sterilisation)
SN019A
Transoral surgery
(Anterior) and CV
Junction (Posterior
Sterilisation)
55000
66000
71500
79750
a) X ray.
b) MRI Spine.
a) Post procedure Imaging with
film (X-ray).
b) Detailed discharge summary.
c) Detailed Procedure.
d) Operative Notes.
e) HPE report.
OPEN
N
1128
Neurosurgery
SN
External Ventricular
SN020 Drainage (EVD)
including antibiotics
External Ventricular
SN020A Drainage (EVD)
including antibiotics
30000
36000
39000
43500
a) Clinical note.
b) CT.
a) Analysis.
b) C/S of pus.
c) Fluid removed.
d) Post procedure Imaging with
film (CT).
e) Post procedure Clinical
photgraph showing scar.
f) Detailed discharge summary.
g) Detailed Procedure.
h) Operative Notes.
OPEN
N
1129
Neurosurgery
SN
SN021 Ventricular Puncture
SN021A Ventricular Puncture
15000
18000
19500
a) Clinical notes.
b) CT justifying procedure.
a) Post procedure Imaging with
film (CT).
b) Post procedure Clinical
photgraph showing scar.
c) Detailed discharge summary.
d) Detailed Procedure.
e) Operative Notes.
43500
a) Clinical notes.
b) CT.
c) MRI.
a) Detailed discharge summary.
b) Detailed Procedure.
c) Operative Notes.
d) Clinical Photograph.
43500
a) Clinical notes.
b) CT.
c) MRI.
a) Detailed discharge summary.
b) Detailed Procedure.
c) Operative Notes.
d) Clinical Photograph.
43500
a) Clinical notes.
b) CT.
c) MRI.
a) Detailed discharge summary.
b) Detailed Procedure.
c) Operative Notes.
d) Clinical Photograph.
43500
a) Clinical notes.
b) CT.
c) MRI.
a) Detailed discharge summary.
b) Detailed Procedure.
c) Operative Notes.
d) Clinical Photograph.
21750
OPEN
N
1130
Neurosurgery
SN
SN022 Shunt Surgery
SN022A Ventriculo - peritoneal
30000
36000
39000
OPEN
Y
1131
Neurosurgery
SN
SN022 Shunt Surgery
SN022B Ventriculo - pleural
30000
36000
39000
OPEN
Y
1132
Neurosurgery
SN
SN022 Shunt Surgery
SN022C Ventriculo - atrial
30000
36000
39000
OPEN
Y
1133
Neurosurgery
SN
SN022 Shunt Surgery
SN022D Theco - peritoneal
30000
36000
39000
OPEN
Y
SL NO
1134
Specialty
Neurosurgery
Specialty
Code
SN
Package
Code
SN023
Package Name
Aneurysm Clipping
including angiogram
Procedure
Code
SN023A
Procedure Name
Aneurysm Clipping
including angiogram
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
50000
60000
NABH
Package
Cost
65000
Outside State
NABH
Package Cost
72500
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Clinical notes.
b) CT-angio.
c) MRA.
d) DSA.
a) Post procedure Imaging with
film (CT) showing clips.
b) Post procedure Clinical
photgraph showing scar.
c) Detailed discharge summary.
d) Detailed Procedure.
e) Operative Notes.
f) Invoice of all the clip(s) used.
a) Clinical notes.
b) MRA.
c) DSA report.
a) Post procedure Imaging with
film (CT).
b) Post procedure Clinical
photgraph showing scar.
c) Detailed discharge summary.
d) Detailed Procedure.
e) Operative Notes.
OPEN
N
1135
Neurosurgery
SN
Superficial Temporal
Artery (STA): middle
SN024 cerebral artery (MCA)
or (other EC - IC)
Bypass procedure
Superficial Temporal
Artery (STA): middle
SN024A cerebral artery (MCA)
or (other EC - IC)
Bypass procedure
60000
72000
78000
87000
OPEN
N
1136
Neurosurgery
SN
Arterio venous
SN025 malformation (AVM)
excision
SN025A Intracranial
50000
60000
65000
72500
a) Clinical notes.
b) MRA.
c) DSA report.
a) Post procedure Imaging with
film (CT).
b) Post procedure Clinical
photgraph showing Post
procedure Clinical photgraph
showing scar.
c) Detailed discharge summary.
d) Detailed Procedure.
e) Operative Notes.
OPEN
Y
1137
Neurosurgery
SN
Arterio venous
SN025 malformation (AVM)
excision
SN025B Intraspinal
50000
60000
65000
72500
a) Clinical notes.
b) MRA.
c) DSA report.
a) Post procedure Imaging with
film (CT).
b) Post procedure Clinical
photgraph showing Post
procedure Clinical photgraph
showing scar.
c) Detailed discharge summary.
d) Detailed Procedure.
e) Operative Notes.
OPEN
Y
1138
Neurosurgery
SN
Arterio venous
SN025 malformation (AVM)
excision
SN025C Scalp
25000
30000
32500
36250
a) Clinical notes.
b) MRA.
c) DSA report.
a) Post procedure Imaging with
film (CT).
b) Post procedure Clinical
photgraph showing Post
procedure Clinical photgraph
showing scar.
c) Detailed discharge summary.
d) Detailed Procedure.
e) Operative Notes.
OPEN
Y
1139
Neurosurgery
SN
Foramen Magnum
SN026
Decompression
Foramen Magnum
SN026A
Decompression
45000
54000
58500
65250
a) Clinical notes.
b) CT.
c) MRI.
a) Post procedure Clinical
photgraph showing scar.
b) Detailed discharge summary.
c) Detailed Procedure.
d) Operative Notes.
a) Clinical notes.
b) Indication for skull traction
supporting radiological evdience
(CT/MRI).
a) Clinical photgraph with traction
applied.
b) Detailed Procedure.
c) Operative Notes detailing
OPEN
weights applied.
d) Detailed discharge summary.
OPEN
N
1140
Neurosurgery
SN
SN027 Skull Traction
SN027A Skull Traction
8000
9600
10400
11600
N
YES
SL NO
1141
Specialty
Neurosurgery
Specialty
Code
SN
Package
Code
Package Name
Posterior Cervical
SN028 Discetomy without
implant
Procedure
Code
Procedure Name
Posterior Cervical
SN028A Discetomy without
implant
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
30000
36000
NABH
Package
Cost
39000
Outside State
NABH
Package Cost
43500
Mandatory Documents - Pre
Authorization
a) Clinical notes.
b) MRI.
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Post procedure Clinical
photgraph showing scar.
b) Detailed discharge summary.
c) Detailed Procedure.
d) Operative Notes.
OPEN
N
1142
Neurosurgery
SN
Posterior Cervical
SN029 Fusion with implant
(Lateral mass fixation)
Posterior Cervical
SN029A Fusion with implant
(Lateral mass fixation)
50000
60000
65000
72500
a) Clinical notes.
b) MRI.
a) Post procedure Clinical
photgraph showing scar.
b) Detailed discharge summary.
c) Detailed Procedure.
d) Operative Notes.
e) Cervical spine X-ray showing
implant.
OPEN
N
1143
Neurosurgery
SN
SN030
Cervical Disc Multiple
level without Fusion
SN030A
Cervical Disc Multiple
level without Fusion
40000
48000
52000
58000
a) Clinical notes.
b) MRI.
a) Post procedure Clinical
photgraph showing scar.
b) Detailed discharge summary.
c) Detailed Procedure.
d) Operative Notes.
e) Cervical spine X-ray.
OPEN
N
1144
Neurosurgery
SN
SN031
Excision of Cervical
Ribs
SN031A
Excision of Cervical
Ribs
20000
24000
26000
29000
a) X-Ray chest.
b) CT.
c) MRI confirming Diagnosis.
a) Post procedure Imaging with
film (X Ray) Detailed Procedure.
b) Operative Notes.
c) Post procedure scar photo.
d) Detailed discharge summary.
OPEN
N
1145
Neurosurgery
SN
Thoracic / Lumbar
SN032 Corpectomy with
fusion
SN032A
Thoracic Corpectomy
with fusion
60000
72000
78000
87000
a) Clinical notes.
b) MRI.
a) Post procedure Imaging with
film (X ray) showing the implants.
b) Post procedure Clinical
photgraph showing scar.
c) Detailed discharge summary.
d) Detailed Procedure.
e) Operative Notes.
a) Clinical notes.
b) MRI.
a) Post procedure Imaging with
film (X ray) showing the implants.
b) Post procedure Clinical
photgraph showing scar.
c) Detailed discharge summary.
d) Detailed Procedure.
e) Operative Notes.
OPEN
Y
1146
1147
1148
Neurosurgery
Neurosurgery
Neurosurgery
SN
SN
SN
Thoracic / Lumbar
SN032 Corpectomy with
fusion
SN033 Lumbar Discectomy
SN034 Laminectomy
SN032B
Lumbar Corpectomy
with fusion
SN033A Lumbar Discectomy
Laminectomy with
SN034A
Fusion
60000
30000
40000
72000
36000
48000
78000
39000
52000
87000
43500
58000
a) Clinical notes.
b) MRI establishing need of
surgery.
a) Clinical notes.
b) MRI establishing need of
surgery.
a) Post op MRI.
b) Post procedure Clinical
photgraph showing scar.
c) Detailed discharge summary
Detailed Procedure.
d) Operative Notes.
a) Post procedure X-ray showing
fixation & fusion.
b) Post procedure Clinical
photgraph showing scar.
c) Detailed discharge summary
Detailed Procedure.
d) Operative Notes.
OPEN
Y
OPEN
N
OPEN
Y
SL NO
1149
Specialty
Neurosurgery
Specialty
Code
SN
Package
Code
Package Name
SN034 Laminectomy
Procedure
Code
Procedure Name
Laminectomy with
SN034B
Fusion and fixation
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
40000
48000
NABH
Package
Cost
52000
Outside State
NABH
Package Cost
58000
Mandatory Documents - Pre
Authorization
a) Clinical notes.
b) MRI establishing need of
surgery.
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Post procedure X-ray showing
fixation & fusion.
b) Post procedure Clinical
photgraph showing scar.
OPEN
c) Detailed discharge summary
Detailed Procedure.
d) Operative Notes.
Y
1150
Neurosurgery
SN
SN035 Neurectomy
SN035A Neurectomy
16000
19200
20800
23200
a) Post procedure Clinical
photgraph showing scar.
b) Detailed discharge summary.
c) Detailed Procedure.
Clinical notes justifying the surgery.
d) Operative Notes.
OPEN
Y
1151
Neurosurgery
SN
SN035 Neurectomy
SN035B
Neurectomy Trigeminal
16500
19800
21450
23925
a) Post procedure Clinical
photgraph showing scar.
b) Detailed discharge summary.
c) Detailed Procedure.
Clinical notes justifying the surgery.
d) Operative Notes.
OPEN
Y
1152
Neurosurgery
SN
SN036 Micro discectomy
SN036A Cervical
40000
48000
52000
58000
a) Clinical notes.
b) MRI.
a) Intra procedure still photograph
Post procedure Clinical photgraph
showing scar.
b) Detailed discharge summary.
OPEN
c) Detailed Procedure.
d) Operative Notes.
a) Clinical notes.
b) MRI.
a) Intra procedure still photograph
Post procedure Clinical photgraph
showing scar.
b) Detailed discharge summary.
OPEN
c) Detailed Procedure.
d) Operative Notes.
a) Clinical notes.
b) MRI supporting surgery.
a) Post op X-ray with film.
b) Detailed discharge summary.
c) Detailed Procedure.
d) Operative Notes.
a) Clinical notes.
b) MRI supporting surgery.
a) Post op X-ray with film.
b) Detailed discharge summary.
c) Detailed Procedure.
d) Operative Notes.
a) Clinical notes.
b) MRI supporting surgery.
a) Post op X-ray with film.
b) Detailed discharge summary.
c) Detailed Procedure.
d) Operative Notes.
a) Clinical notes.
b) MRI supporting surgery.
a) Post procedure Clinical
photgraph showing scar.
b) Detailed discharge summary.
c) Detailed Procedure.
d) Operative Notes.
Y
1153
Neurosurgery
SN
SN036 Micro discectomy
SN036B Lumbar
40000
48000
52000
58000
Y
1154
Neurosurgery
SN
SN037
Surgery for Spinal
Canal Stenosis
SN037A
Surgery for Spinal
Canal Stenosis
45000
54000
58500
65250
OPEN
N
1155
Neurosurgery
SN
Spine SN038 Decompression &
Fusion
SN038A
Spine - Decompression
& Fusion
40000
48000
52000
58000
OPEN
Y
1156
Neurosurgery
SN
Spine SN038 Decompression &
Fusion
SN038B
Spine - Decompression
& Fusion with fixation
40000
48000
52000
58000
OPEN
Y
1157
Neurosurgery
SN
SN039
Spine - Extradural
Haematoma
SN039A
Spine - Extradural
Haematoma
30000
36000
39000
43500
OPEN
Y
SL NO
1158
Specialty
Neurosurgery
Specialty
Code
SN
Package
Code
SN039
Package Name
Spine - Extradural
Haematoma
Procedure
Code
Procedure Name
Spine - Extradural
SN039B Haematoma with
fixation
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
30000
36000
NABH
Package
Cost
39000
Outside State
NABH
Package Cost
43500
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Clinical notes.
b) MRI supporting surgery.
a) Post procedure Clinical
photgraph showing scar.
b) Detailed discharge summary.
c) Detailed Procedure.
d) Operative Notes.
a) Clinical notes.
b) MRI supporting surgery.
a) Post procedure Clinical
photgraph showing scar.
b) Detailed discharge summary.
c) Detailed Procedure.
d) Operative Notes.
a) Clinical notes.
b) MRI supporting surgery.
a) Post procedure Clinical
photgraph showing scar.
b) Detailed discharge summary.
c) Detailed Procedure.
d) Operative Notes.
OPEN
Y
1159
Neurosurgery
SN
SN040
Spine - Intradural
Haematoma
SN040A
Spine - Intradural
Haematoma
40000
48000
52000
58000
OPEN
Y
1160
Neurosurgery
SN
SN040
Spine - Intradural
Haematoma
Spine - Intradural
SN040B Haematoma with
fixation
40000
48000
52000
58000
OPEN
Y
1161
Neurosurgery
SN
SN041
Spine - Extradural
Tumour
SN041A
Spine - Extradural
Tumour
30000
36000
39000
43500
a) Clinical notes.
b) MRI supporting surgery.
a) Histopathology.
b) Biopsy report.
c) Post procedure Clinical
photgraph showing scar.
d) Detailed discharge summary.
e) Detailed Procedure.
f) Operative Notes.
OPEN
Y
1162
Neurosurgery
SN
SN041
Spine - Extradural
Tumour
SN041B
Spine - Extradural
Tumour with fixation
30000
36000
39000
43500
a) Clinical notes.
b) MRI supporting surgery.
a) Histopathology.
b) Biopsy report.
c) Post procedure Clinical
photgraph showing scar.
d) Detailed discharge summary.
e) Detailed Procedure.
f) Operative Notes.
OPEN
Y
1163
Neurosurgery
SN
SN042
Spine - Intradural
Tumour
SN042A
Spine - Intradural
Tumour
40000
48000
52000
58000
a) Clinical notes.
b) MRI supporting surgery.
a) Biopsy & HPE report.
b) Post procedure Clinical
photgraph showing scar.
c) Detailed discharge summary.
d) Detailed Procedure.
e) Operative Notes.
a) Clinical notes.
b) MRI supporting surgery.
a) Biopsy & HPE report.
b) Post procedure Clinical
photgraph showing scar.
c) Detailed discharge summary.
d) Detailed Procedure.
e) Operative Notes.
OPEN
Y
1164
Neurosurgery
SN
SN042
Spine - Intradural
Tumour
SN042B
Spine - Intradural
Tumour with fixation
40000
48000
52000
58000
OPEN
Y
1165
Neurosurgery
SN
SN043
Spine - Intramedullar
Tumour
SN043A
Spine - Intramedullar
Tumour
50000
60000
65000
72500
a) Clinical notes.
b) MRI supporting surgery.
a) Histopathology.
b) Post procedure Imaging with
film (X-ray/ CT).
c) Post procedure Clinical
photgraph showing scar.
d) Detailed Procedure.
e) Operative Notes.
f) Detailed discharge summary.
OPEN
Y
YES
SL NO
1166
Specialty
Neurosurgery
Specialty
Code
SN
Package
Code
SN043
Package Name
Spine - Intramedullar
Tumour
Procedure
Code
SN043B
Procedure Name
Spine - Intramedullar
Tumour with fixation
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
50000
60000
NABH
Package
Cost
65000
Outside State
NABH
Package Cost
72500
Mandatory Documents - Pre
Authorization
a) Clinical notes.
b) MRI supporting surgery.
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Histopathology.
b) Post procedure Imaging with
film (X-ray/ CT).
c) Post procedure Clinical
photgraph showing scar.
d) Detailed Procedure.
e) Operative Notes.
f) Detailed discharge summary.
OPEN
Y
1167
Neurosurgery
SN
SN044
R. F. Lesioning for
Trigeminal Neuralgia
SN044A
R. F. Lesioning for
Trigeminal Neuralgia
16500
19800
21450
23925
a) Clinical notes establishing
diagnosis of Trigeminal neuralgia.
b) Justification of local
neurectomy with MRI.
c) CT.
a) Intra procedure clinical CD.
b) Series of still photographs.
c) Detailed Procedure.
d) Operative Notes.
e) Detailed discharge summary.
f) Invoice of RF probe.
OPEN
N
1168
Neurosurgery
SN
SN045
Brachial Plexus –
Repair
SN045A Brachial Plexus – Repair
27000
32400
35100
39150
a) Clinical notes.
b) MRI report.
a) Detailed discharge summary.
b) Post procedure Clinical
photgraph showing scar.
c) Detailed Procedure.
d) Operative Notes.
OPEN
N
1169
Neurosurgery
SN
SN046 Carpal Tunnel Release
SN046A Carpal Tunnel Release
10000
12000
13000
14500
a) Clinical history.
b) MRI.
c) NCV.
a) Post procedure Clinical
photgraph showing scar.
b) Detailed discharge summary.
c) Detailed Procedure.
d) Operative Notes.
e) MRI Report.
a) Clinical notes.
b) NCV.
a) Detailed discharge summary.
b) Post procedure Clinical
photgraph showing scar.
c) Detailed Procedure.
d) Operative Notes.
a) Clinical notes.
b) MRI justifying surgery.
a) Post procedure Imaging with
film (CT).
b) Post procedure Clinical
photgraph showing scar.
c) Detailed discharge summary.
d) Detailed Procedure.
e) Operative Notes.
a) Clinical notes.
b) Nerve Conduction Velocity
(NCV).
c) Electromyography (EMG)
reports.
a) Detailed discharge summary.
b) Post procedure Clinical
photgraph showing scar.
c) Detailed Procedure.
d) Operative Notes.
a) Clinical notes.
b) Nerve Conduction Velocity
(NCV).
c) Electromyography (EMG)
reports.
a) Detailed discharge summary.
b) Post procedure Clinical
photgraph showing scar.
c) Detailed Procedure.
d) Operative Notes.
OPEN
N
1170
Neurosurgery
SN
SN047 Nerve Decompression
SN047A Nerve Decompression
16000
19200
20800
23200
OPEN
N
1171
Neurosurgery
SN
SN048
Cranial Nerve
Anastomosis
SN048A
Cranial Nerve
Anastomosis
32000
38400
41600
46400
OPEN
N
1172
Neurosurgery
SN
SN049
Peripheral Nerve
Surgery
SN049A Minor
15000
18000
19500
21750
OPEN
Y
1173
Neurosurgery
SN
SN049
Peripheral Nerve
Surgery
SN049B Major
30000
36000
39000
43500
OPEN
Y
YES
SL NO
1174
Specialty
Neurosurgery
Specialty
Code
SN
Package
Code
Package Name
Nerve Biopsy
SN050
excluding Hensens
Procedure
Code
Procedure Name
Nerve Biopsy excluding
SN050A
Hensens
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
7000
8400
NABH
Package
Cost
9100
Outside State
NABH
Package Cost
10150
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Clinical notes.
b) Reports of previous
investigations.
c) Treatment taken ruling out
Hensen's.
d) Differentials suspected.
e) Need for Nerve Biopsy.
a) HPE Report of Nerve Biopsy.
b) Detailed Proedure notes.
c) Detailed discharge summary.
a) Clinical notes.
b) Electromyography (EMG)
reports.
a) Histopathology.
b) Post procedure Clinical
photgraph showing scar.
c) Detailed discharge summary.
d) Detailed Procedure.
e) Operative Notes.
OPEN
N
1175
Neurosurgery
SN
Muscle Biopsy with
SN051
report
Muscle Biopsy with
SN051A
report
7000
8400
9100
10150
OPEN
N
1176
Neurosurgery
SN
SN052 Anterior Encephalocele
SN052A Anterior Encephalocele
50000
60000
65000
72500
a) Clinical notes.
b) CT.
c) MRI as Evidence.
a) Post procedure Imaging with
film (CT).
b) Post procedure Clinical
photgraph showing scar.
c) Detailed discharge summary.
d) Detailed Procedure.
e) Operative Notes.
OPEN
N
1177
Neurosurgery
SN
SN053 Spina Bifida Surgery
SN053A Spina Bifida Surgery
36000
43200
46800
52200
a) Clinical notes.
b) CT.
a) Post procedure Clinical
photgraph showing scar.
b) Detailed discharge summary.
c) Detailed Procedure.
d) Operative Notes.
a) Clinical notes.
b) CT.
c) MRI report.
d) Is the EHCP equipped with
Gamma Knife?
a) Intra procedure clinical
photograph.
b) Treating doctor's consultation
paper showing planning for RT
treatment.
c) The RT chart.
d) Detailed discharge summary.
a)Clinical notes establishing
indication.
b)USG Abdomen Pelvis/ CT/
MRI abdomen Pelvis.
a)Detailed Operative notes,HPE
Pic of specimen. Intraop stills with
date & patient ID.
Referral
b) Detailed discharge summary.
a)Clinical notes and USG
Abdomen .
b) Pelvis.
c) CT abdomen.
d)Pelvis establishing indication.
a)Histopathology.
b) Detailed Operative notes.
c)per op pic of specimen removed. Referral
d)Detailed Discharge Summary.
a)Clinical notes establishing
indication for the procedure.
b) USG uterus & adnexa.
c) Beta HCG.
a)Detailed Operative notes.
b) HPE if ectopic pregnancy or
salpingectomy for any other
indication.
c) Detailed discharge summary.
OPEN
N
1178
Neurosurgery
SN
Gamma Knife
radiosurgery (GKRS)
SN054 / SRS for tumours /
Arteriovenous
malformation (AVM)
Gamma Knife
radiosurgery (GKRS) /
SN054A SRS for tumours /
Arteriovenous
malformation (AVM)
75000
90000
97500
108750
OPEN
N
1179
Obstetrics & Gynecology
Lap. Salpingooophrectomy
SO
SO001
SO
Laparotomy and
proceed for Ovarian
SO002 Cancers. Omentomy
with Bilateral Salpingooophorectomy
SO001A
Lap. Salpingooophrectomy
14000
16800
18200
20300
N
1180
1181
1182
Obstetrics & Gynecology
Obstetrics & Gynecology
Obstetrics & Gynecology
SO
Laparoscopic tubal
surgeries
SO003 (for any indication
including ectopic
pregnancy)
SO
Procedure on
Fallopian Tube for
SO004
establishing Tubal
Patency
Laparotomy and
proceed for Ovarian
SO002A Cancers. Omentomy
with Bilateral Salpingooophorectomy
Laparoscopic tubal
surgeries
SO003A (for any indication
including ectopic
pregnancy)
Procedure on Fallopian
SO004A Tube for establishing
Tubal Patency
38000
45600
49400
55100
N
13900
16680
18070
20155
OPEN
N
11600
13920
15080
16820
a)Indication of the procedure
a)Detailed discharge summary.
preferably with record of previous
b) Detailed Operative notes. Intra
sterilization.
OPEN
procedure clinical photograph.
b) reason for non-availability.
N
YES
SL NO
1183
1184
Specialty
Obstetrics & Gynecology
Obstetrics & Gynecology
Specialty
Code
Package
Code
Package Name
Procedure
Code
SO
SO005
Laparotomy for broad
ligament haematoma
SO005A
SO
SO006
Abdominal
Myomectomy
SO006A
Procedure Name
Laparotomy for broad
ligament haematoma
Abdominal
Myomectomy
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
16000
20000
19200
24000
NABH
Package
Cost
Outside State
NABH
Package Cost
20800
23200
26000
29000
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a)Detailed discharge summary.
a)Clinical notes with physical
b) Detailed Operative notes. Intra
examination findings supported by
Referral
procedure clinical photograph.
evidence of hematoma (USG).
a)Clinical notes establishing
indication.
b)USG Abdomen Pelvis.
c) MRI abdomen. Pap smear.
a)Detailed Operative notes.
b)HPE.
c) Pic of specimen removedGross and Histopathology.
d)Detailed discharge summary
N
Referral
N
1185
1186
Obstetrics & Gynecology
Obstetrics & Gynecology
SO
SO
SO007
Hysteroscopic
myomectomies
SO008 Polypectomy
SO007A
Hysteroscopic
myomectomies
SO008A Polypectomy
9900
1500
11880
1800
12870
1950
14355
2175
a)physical examination findings
with indications for the procedure.
USG pelvis
b) MRI Pelvis
a)Detailed Operative notes.
b) HPE.
c) Intraop stills with date & patient Referral
ID.
d) Detailed discharge summary
a)Clinical notes with planned line
of treatment (including System
Examination).
b)Relavant Investigations (USG
Abdomen + Pelvis/ CT
abdomen+ Pelvis).
a)Procedure.
b)Operative Notes.
c) Intraop. Stills.
d)Pic of specimen.
e) Histopathology report.
f) Detailed Discharge Summary.
N
OPEN
N
1187
1188
Obstetrics & Gynecology
Obstetrics & Gynecology
SO
SO
SO009
Hysteroscopic
polypectomy
SO010 Hysterectomy
SO009A
SO010A
Hysteroscopic
polypectomy
Abdominal
Hysterectomy
7200
20000
8640
24000
9360
26000
10440
29000
a)Detailed Procedure.
a)Admission Notes comprising of b)Operative Notes together with
history.
indication of surgery.
b) Examination with indications
c)Intraop. stills with
date & patient ID.
for the procedure.
OPEN
c) Relavant Investigations
d)Pic off
(establishing diagnosis).
specimenremoved.HPE.
e)Progress notes.
d)USG showing polyp.
f)detailed discharge
summary.
a)Clinical notes with planned line
of treatment (including System
a)Histopathology.
Examination).
b) Detailed Discharge Summary
b) Relavant Investigations (USG
with Procedure.
Referral
Abdomen + Pelvis/ CT
c) Operative Notes.
abdomen+ Pelvis) confirming the
indication.
N
Y
1189
Obstetrics & Gynecology
SO
SO010 Hysterectomy
Abdominal
SO010B Hysterectomy +
Salpingo-oophorectomy
20000
24000
26000
29000
a) Admission Notes comprising of
history
b) examination with indications
for the procedure
c) Clinical notes with planned line
of treatment (clearly indicating
medical management tried and
failed or not indicated. If failed
documents proving duration of
treatment and failure. The medical
management should have been
tried for atleast 4-6 months
covering 1 course of hormone
cycle)
d) USG Abdomen
e) Pelvis
f) CT
g) MRI abdomen
h) Pelvis confirming the indication
i) Pap smear
j) EB
k) EAC
a) Detailed Procedure
b) Operative Notes together with
indication of surgery
c) Intraop. stills with date &
patient ID
Referral
d) pic off gross specimen removed
e) HPE
f) Progress notes
g) detailed discharge summary.
Y
SL NO
1190
Specialty
Obstetrics & Gynecology
Specialty
Code
SO
Package
Code
Package Name
SO010 Hysterectomy
Procedure
Code
SO010C
Procedure Name
Non descent vaginal
hysterectomy
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
20000
24000
NABH
Package
Cost
26000
Outside State
NABH
Package Cost
29000
Mandatory Documents - Pre
Authorization
a) Clinical notes with planned line
of treatment (clearly indicating
medical management tried and
failed or not indicated. If failed
documents proving duration of
treatment and failure. The medical
management should have been
tried for atleast 4-6 months
covering 1 course of hormone
cycle).
b) USG Abdomen .
c) Pelvis.
d) Pap smear.
e) EB.
f) EAC.
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Detailed Procedure.
b) Operative Notes together with
indication of surgery.
c) Intraop. stills with date &
patient ID.
d) pic off gross specimen removed Referral
.
e) HPE.
f) Progress notes.
g) detailed discharge summary.
Y
1191
Obstetrics & Gynecology
SO
SO010 Hysterectomy
SO010D
Vaginal hysterectomy
with anterior and
posterior
colpoperineorrhaphy
20000
24000
26000
29000
a) Clinical notes with planned line
of treatment (clearly indicating
medical management tried and
failed or not indicated with reason.
If failed documents proving
duration of treatment and failure.
The medical management should
have been tried for atleast 4-6
months covering 1 course of
hormone cycle).
b) Photographic documentation
with patient’s consent.
c) Pap smear ( EB/EAC is
optional )
a) Detailed Procedure.
b) Operative Notes together with
indication of surgery.
c) Intraop. stills with date &
patient ID.
Referral
d) pic off gross specimen removed.
e) HPE.
f) Progress notes.
g) detailed discharge summary.
Y
1192
Obstetrics & Gynecology
SO
SO010 Hysterectomy
Laparoscopic
SO010E
hysterectomy (TLH)
20000
24000
26000
29000
a) Clinical notes with planned line
of treatment and USG Abdomen . a) Histopathology.
b) Pelvis.
b) Detailed Discharge Summary
c) CT abdomen.
with Detailed operative notes
d) Pelvis confirming the indication.
Referral
Y
1193
Obstetrics & Gynecology
SO
SO010 Hysterectomy
SO010F
Laparoscopically
assisted vaginal
hysterectomy (LAVH)
20000
24000
26000
29000
a) Admission Notes comprising of
history.
b) examination(clearly indicating
medical management tried and
failed or not indicated, with
reason. If failed documents
proving duration of treatment and
failure. The medical management
should have been tried for atleast
4-6 months covering 1 course of
hormone cycle).
c) USG Abdomen.
d) Pelvis.
e) MRI abdomen.
f) Pelvis confirming the indication,.
g) Pap smear.
h) EB.
i) EAC.
a) Detailed Procedure.
b) Operative Notes together with
indication of surgery.
c) Intraop. stills with date &
patient ID.
d) pic off gross specimen removed Referral
.
e) HPE.
f) Progress notes.
g) detailed discharge summary.
Y
SL NO
1194
1195
1196
Specialty
Obstetrics & Gynecology
Obstetrics & Gynecology
Obstetrics & Gynecology
Specialty
Code
SO
SO
SO
Package
Code
SO011
Package Name
Caesarean
hysterectomy
SO012 Manchester Repair
SO013
Surgeries for Prolapse
- Sling Surgeries
Procedure
Code
Procedure Name
SO011A Caesarean hysterectomy
SO012A Manchester Repair
SO013A
Surgeries for Prolapse Sling Surgeries
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
20000
15000
28900
24000
18000
34680
NABH
Package
Cost
26000
19500
37570
Outside State
NABH
Package Cost
29000
21750
41905
Mandatory Documents - Pre
Authorization
a) Admission Notes comprising of
history.
b) examination (clearly indicating
medical management tried and
failed or not indicated with reason.
If failed documents proving
duration of treatment and failure.
The medical management should
have been tried for atleast 4-6
months covering 1 course of
hormone cycle).
c) detailed Ante natal care
records.
d) reasons for non-availability of
ANC records. Per op clinical pic
is optional
a) Admission Notes comprising of
history.
b) examination with indications
for the procedure.
c) Relavant Investigations
(establishing diagnosis).
a) Admission Notes comprising of
history.
b) examination with indications
for the procedure.
c) Relavant Investigations
(establishing diagnosis).
d) Photographic documentation of
degree.
e) severity of prolapse with
patient’s consent.
f) Pap smear.
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Detailed Procedure.
b) Operative Notes. Histopath of
uterus removed.
c) per op pic of specimen
removed.
d) status of the child at the time of
delivery.
OPEN
e) at the time of discharge;
progress notes.
f) Detailed discharge summary
N
a) Detailed Procedure.
b) Operative Notes.
c) Intraop. Stills.
d) Progress notes.
e) Detailed discharge summary
Referral
N
a) Detailed Procedure.
b) Operative Notes.
c) Intraop. stills .
d) Barcode of sling used.
e) progress notes,Detailed
discharge summary
Referral
N
1197
Obstetrics & Gynecology
SO
SO014 Hysterotomy
SO014A Hysterotomy
5000
6000
6500
7250
a) Admission Notes comprising of
history.
b) examination with indications
for the procedure,Relavant
Investigations (establishing
diagnosis).
c) USG - Obstetric confirming the
above package. Has medicolegal
compliance been done?
a) Detailed Procedure.
b) Operative Notes.
c) Intraop. stills with date &
patient ID.
d) HPE of specimen,Progress
notes.
e) Detailed discharge summary
OPEN
N
1198
Obstetrics & Gynecology
SO
SO015
Lap. Surgery for
Endometriosis
(Other than
Hysterectomy)
SO015A
Lap. Surgery for
Endometriosis
(Other than
Hysterectomy)
11200
13440
14560
16240
a) Detailed Procedure.
a) Admission Notes comprising of b) Operative Notes together with
history.
indication of surgery.
b) Examination.
c) Intraop. stills with date &
c) Relavant Investigations
patient ID.
(establishing diagnosis) USG.
d) pic off gross specimen removed
Referral
d) CT.
.
e) MRI.
e) HPE.
f) laparoscopy findings
f) Progress notes.
g) detailed discharge summary.
N
SL NO
1199
Specialty
Obstetrics & Gynecology
Specialty
Code
SO
Package
Code
SO016
Package Name
Diagnostic
hysteroscopy
Procedure
Code
Procedure Name
SO016A With biopsy
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
6000
7200
NABH
Package
Cost
7800
Outside State
NABH
Package Cost
8700
Mandatory Documents - Pre
Authorization
a) Admission Notes comprising of
history.
b) examination with indications
for the procedure.
c) Relavant Investigations
(establishing diagnosis).
d) USG uterus & adnexa .
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Detailed Procedure.
b) Operative Notes together with
indication of surgery.
c) Intraop. stills with date &
patient ID.
d) pic off gross specimen removed
OPEN
.
e) HPE of biopsy
specimen,Progress notes.
f) Detailed discharge summary.
Y
1200
Obstetrics & Gynecology
SO
SO016
Diagnostic
hysteroscopy
SO016B Without biopsy
6000
7200
7800
8700
a) Detailed Procedure.
b) Operative Notes together with
a) Admission Notes comprising of
indication of surgery.
history.
c) Intraop. stills with date &
b) examination with indications
patient ID.
for the procedure.
d) pic off gross specimen removed
c) Relavant Investigations
OPEN
.
(establishing diagnosis).
e) HPE of biopsy specimen.
d) USG uterus & adnexa .
f) Progress notes.
g) Detailed discharge summary.
Y
1201
Obstetrics & Gynecology
SO
SO017
Hysteroscopic IUCD
removal
SO017A
Hysteroscopic IUCD
removal
4700
5640
6110
6815
a) Clinical notes with details of
IUCD insertion (reason for non
availability of details).
b) indication for removing IUCD.
c) USG showing misplaced IUD.
a) Detailed Procedure.
b) Operative Notes together with
indication of surgery.
c) Intraop. stills with date &
patient ID.
d) pic off gross specimen removed
OPEN
.
e) HPE.
f) Progress notes.
g) detailed discharge summary.
a) Admission Notes comprising of
history.
b) examination with indications
for the procedure,Relavant
Investigations (establishing
diagnosis).
c) (USG Abdomen + Pelvis)optional.
a) Detailed Procedure.
b) Operative Notes.
c) Intraop. Stills.
d) Histopathology of curetted
material.
e) Progress notes.
f) Detailed discharge summary.
a) Admission Notes comprising of
history.
b) examination with indications
for the procedure.
c) Relavant Investigations
(establishing diagnosis).
d) USG abdomen and pelvis).
a) Detailed Procedure. Operative
Notes.
b) Intraop. Stills.
c) Histopathology of evacuated
material.
d) Progress notes.
e) Detailed discharge summary.
a) Admission Notes comprising of
history.
b) examination with indications
for the procedure.
c) Relavant Investigations
(establishing diagnosis).
a) Detailed Procedure.
b) Operative Notes.
c) Intraop. Stills.
d) Progress notes.
e) Detailed discharge summary.
a) Admission Notes comprising of
history.
b) examination with indications
for the procedure.
c) Relavant Investigations
(establishing diagnosis).
a) Detailed Procedure.
b) Operative Notes.
c) Intraop. Stills.
d) Progress notes.
e) Detailed discharge summary.
N
1202
1203
1204
1205
Obstetrics & Gynecology
Obstetrics & Gynecology
Obstetrics & Gynecology
Obstetrics & Gynecology
SO
SO
SO
SO
SO018
SO019
D&C
(Dilatation&curretage)
Dilation and
Evacuation (D&E)
SO020 Pyometra drainage
SO021
Intrauterine
transfusions
SO018A
SO019A
D&C
(Dilatation&curretage)
Dilation and Evacuation
(D&E)
SO020A Pyometra drainage
SO021A Intrauterine transfusions
3000
5000
5000
11000
3600
6000
6000
13200
3900
6500
6500
14300
4350
7250
7250
15950
Reserved
Reserved
OPEN
N
OPEN
N
SL NO
1206
Specialty
Obstetrics & Gynecology
Specialty
Code
SO
Package
Code
SO022
Package Name
Hysteroscopic
adhesiolysis
Procedure
Code
SO022A
Procedure Name
Hysteroscopic
adhesiolysis
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
6900
8280
NABH
Package
Cost
8970
Outside State
NABH
Package Cost
10005
Mandatory Documents - Pre
Authorization
a) Admission Notes comprising of
history.
b) examination with indications
for the procedure.
c) Relavant Investigations
(establishing diagnosis).
d) USG Abdomen Pelvis.
e) CT.
f) MRI Abdomen Pelvis.
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Detailed Procedure.
b) Operative Notes together with
indication of surgery.
c) Intraop. stills with date &
patient ID.
d) pic off gross specimen removed. OPEN
e) HPE.
f) Progress notes.
g) detailed discharge summary.
N
1207
Obstetrics & Gynecology
SO
SO023
Laparoscopic
adhesiolysis
SO023A
Laparoscopic
adhesiolysis
6000
7200
7800
8700
a) Detailed Procedure.
b) Operative Notes together with
a) Admission Notes comprising of
indication of surgery.
history.
c) Intraop. stills with date &
b) examination,.
patient ID,
c) Relavant Investigations
d) pic off gross specimen removed
(establishing diagnosis).
Referral
.
d) USG Abdomen.
e) HPE.
e) Pelvis (CT abdomen- Optional).
f) Progress notes.
g) detailed discharge summary.
N
1208
Obstetrics & Gynecology
SO
SO024
Trans - vaginal tape /
Trans-obturator tape
SO024A Trans-vaginal tape
15200
18240
19760
22040
a) Admission Notes comprising of
history.
b) examination with indications
for the procedure.
c) Relavant Investigations
(establishing diagnosis) .
a) Detailed Procedure.
b) Operative Notes.
c) Barcode of TVT.
d) TOT tape used; progress notes. Referral
e) Detailed discharge summary.
a) Admission Notes comprising of
history.
b) examination with indications
for the procedure.
c) Relavant Investigations
(establishing diagnosis) .
a) Detailed Procedure.
b) Operative Notes.
c) Barcode of TVT.
d) TOT tape used; progress notes. Referral
e) Detailed discharge summary.
a) Admission Notes comprising of
history.
b) examination with indications
for the procedure.
c) Relavant Investigations
(establishing diagnosis).
d) Photographic documentation
with patient’s consent.
a) Detailed Procedure.
b) Operative Notes.
c) Intraop. stills with date &
patient ID.
d) Barcode of mesh used.
e) progress notes.
f) Detailed discharge summary
summary.
a) Admission Notes comprising of
history.
b) examination with indications
for the procedure.
c) Relavant Investigations
(establishing diagnosis).
d) Photographic documentation
with patient’s consent.
a) Detailed Procedure.
b) Operative Notes.
c) Intraop. stills with date &
patient ID.
d) Barcode of mesh used.
e) progress notes.
f) Detailed discharge summary
summary.
Y
1209
Obstetrics & Gynecology
SO
SO024
Trans - vaginal tape /
Trans-obturator tape
SO024B Trans-obturator tape
15200
18240
19760
22040
Y
1210
Obstetrics & Gynecology
SO
SO025
Sacrocolpopexy
(Abdominal)
SO025A Open
23900
28680
31070
34655
Referral
Y
1211
Obstetrics & Gynecology
SO
SO025
Sacrocolpopexy
(Abdominal)
SO025B
Lap. - (Sacrocolpopexy
(Abdominal))
23900
28680
31070
34655
Referral
Y
SL NO
1212
1213
1214
Specialty
Obstetrics & Gynecology
Obstetrics & Gynecology
Obstetrics & Gynecology
Specialty
Code
SO
SO
SO
Package
Code
Package Name
LLETZ (including
SO026 PAP smear and
colposcopy)
SO027
SO028
Vaginal Sacrospinus
fixation with repair
Excision of Vaginal
Septum (vaginal route)
Procedure
Code
SO026A
SO027A
SO028A
Procedure Name
LLETZ (including PAP
smear and colposcopy)
Vaginal Sacrospinus
fixation with repair
Excision of Vaginal
Septum (vaginal route)
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
9900
15000
14500
11880
18000
17400
NABH
Package
Cost
12870
19500
18850
Outside State
NABH
Package Cost
14355
21750
21025
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Admission Notes comprising of
history.
b) examination with indications
for the procedure.
c) Relavant Investigations
(establishing diagnosis).
d) Evidence of cervical precancer (PAP smear) Colposcopiy.
e) Cervical Biopsy is optional.
a) Detailed Procedure.
b) Operative Notes.
c) Intraop. stills with date &
patient ID.
d) HPE of specimen.
e) Progress notes.
f) Detailed discharge summary.
a) Admission Notes comprising of
history.
b) examination with indications
for the procedure.
c) Relavant Investigations
(establishing diagnosis).
a) Detailed Procedure.
b) Operative Notes.
c) Intraop. Stills.
d) Progress notes.
e) Detailed discharge summary.
OPEN
N
Referral
N
a) Admission Notes comprising of
history.
b) examination with indications
for the procedure.
c) Relavant Investigations
(establishing diagnosis).
d) need of procedure (USG
Abdomen + Pelvis).
a) Detailed Procedure.
b) Operative Notes.
c) Intraop. Stills.
d) Progress notes.
e) Detailed discharge summary.
a) Admission Notes comprising of
history.
b) examination with indications
for the procedure.
c) need of procedure.
a) Detailed Procedure.
b) Operative Notes.
c) Intraop. Stills.
d) Progress notes.
e) Detailed discharge summary.
a) Admission Notes comprising of
history.
b) examination with indications
for the procedure.
c) Relavant Investigations
(establishing diagnosis).
d) clinical pic if feasible.
a) Detailed Procedure.
b) Operative Notes.
c) Intraop. Stills.
d) Progress notes, Detailed
discharge summary.
Referral
N
1215
1216
1217
Obstetrics & Gynecology
Obstetrics & Gynecology
Obstetrics & Gynecology
SO
SO
SO
SO029
SO030
SO031
Hymenectomy for
imperforate hymen
Anterior & Posterior
Colpoperineorrhapy
Vaginoplasty
(McIndoe procedure)
SO029A
SO030A
SO031A
Hymenectomy for
imperforate hymen
Anterior & Posterior
Colpoperineorrhapy
Vaginoplasty (McIndoe
procedure)
3000
8000
11000
3600
9600
13200
3900
10400
14300
4350
11600
15950
Reserved
OPEN
N
a) Admission Notes comprising of
history.
b) examination with indications
for the procedure.
c) Relavant Investigations
(establishing diagnosis).
d) need of procedure (USG
Abdomen + Pelvis).
a) Detailed Procedure.
b) Operative Notes.
c) Intraop. Stills.
d) Progress notes.
e) Detailed discharge summary.
a) Admission Notes comprising of
history.
b) examination with indications
for the procedure,
c) Relavant Investigations
(establishing diagnosis).
d) Cystoscopy.
e) Cystourethroscopy. Voiding
Cystourethrogram is optional.
a) Detailed Procedure.
b) Operative Notes.
c) Intraop. stills with date &
patient ID.
d) Progress notes.
e) detailed discharge
summary.detailed discharge
summary.
Referral
N
1218
Obstetrics & Gynecology
SO
SO032
Vaginal repair for
vesico-vaginal fistula
SO032A
Vaginal repair for
vesico-vaginal fistula
34000
40800
44200
49300
Referral
N
SL NO
1219
Specialty
Obstetrics & Gynecology
Specialty
Code
SO
Package
Code
SO033
Package Name
Rectovaginal fistula
repair
Procedure
Code
SO033A
Procedure Name
Rectovaginal fistula
repair
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
24000
28800
NABH
Package
Cost
31200
Outside State
NABH
Package Cost
34800
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Admission Notes comprising of
history.
b) examination with indications
for the procedure.
c) Relavant Investigations
(establishing diagnosis) .
a) Detailed Procedure.
b) Operative Notes.
c) Intraop. stills with date &
patient ID.
d) Progress notes.
e) detailed discharge summary.
a) Admission Notes comprising of
history.
b) examination with indications
for the procedure.
c) Relavant Investigations
(establishing diagnosis).
a) Detailed Procedure.
b) Operative Notes.
c) Intraop. stills with date &
patient ID.
d) Progress notes.
e) detailed discharge summary.
a) Admission Notes comprising of
history.
b) examination with indications
for the procedure.
c) Relavant Investigations
(establishing diagnosis) with
Evidence (biopsy). Clinical pic if
patient permits
a) Detailed Procedure.
b) Operative Notes.
c) Intra procedure clinical
photograph.
d) Stills.
e) Histopathology.
f) progress notes.
g) Detailed discharge summary.
Referral
N
1220
Obstetrics & Gynecology
SO
SO034
Vulval Hamatoma
drainage
SO034A
Vulval Hamatoma
drainage
3000
3600
3900
4350
OPEN
N
1221
Obstetrics & Gynecology
SO
SO035 Vulvectomy simple
SO035A Vulvectomy simple
15000
18000
19500
21750
Referral
N
1222
1223
1224
Obstetrics & Gynecology
Obstetrics & Gynecology
Obstetrics & Gynecology
SO
SO
SO
SO036
Radical Vulvectomy
with Inguinal and
Pelvic lymph node
disection
Abdomino Perineal
SO037 repair for Mullerian
Anomaly
Pelvic Abscess
SO038 Management including
Colpotomy
Radical Vulvectomy
SO036A with Inguinal and Pelvic
lymph node disection
Abdomino Perineal
SO037A repair for Mullerian
Anomaly
Pelvic Abscess
SO038A Management including
Colpotomy
38500
20000
1200
46200
24000
1440
50050
26000
1560
55825
29000
1740
a) Admission Notes comprising of
history.
b) examination with indications
for the procedure.
c) Relavant Investigations
(establishing diagnosis).
d) vulval biopsy.
e) CT/MRI for staging.
a) Detailed Procedure.
b) Operative Notes together with
indication of surgery.
c) Intraop. stills with date &
patient ID.
d) pic off gross specimen removed. OPEN
e) HPE.
f) Progress notes.
g) detailed discharge summary.
a) Admission Notes comprising of
history.
b) examination with indications
for the procedure.
c) Relavant Investigations
(establishing diagnosis).
d) (USG/ CT/ MRI).
a) Detailed Procedure.
b) Operative Notes.
c) Intraop. Stills.
d) Progress notes.
e) Detailed discharge summary.
a) Admission Notes comprising of
history.
b) examination with indications
for the procedure.
c) Relavant Investigations
(establishing diagnosis) .
d) USG Abdomen & Pelvis.
a) Detailed Procedure.
b) Operative Notes.
c) Intra procedure clinical
photograph.
d) stills; progress notes.
e) Detailed discharge summary.
N
OPEN
N
OPEN
N
1225
Obstetrics & Gynecology
SO
SO039
Diagnostic / Staging
laparoscopy
SO039A
Diagnostic / Staging
laparoscopy
9700
11640
12610
14065
a) Detailed Procedure.
b) Operative Notes together with
indication of surgery.
a) Admission Notes comprising of
c) Intraop. stills with date &
history.
patient ID.
b) Examination.
d) pic off gross specimen removed
OPEN
c) Relavant Investigations
.
(establishing diagnosis).
e) HPE.
f) Progress notes.
g) detailed discharge summary.
N
SL NO
1226
1227
1228
Specialty
Obstetrics & Gynecology
Obstetrics & Gynecology
Obstetrics & Gynecology
Specialty
Code
Package
Code
SO
SO040
SO
SO
SO040
SO041
Package Name
Laparotomy for
benign disorders
Laparotomy for
benign disorders
Laparoscopic
cystectomy
Procedure
Code
Procedure Name
SO040A Ectopic
SO040B PID
SO041A
Laparoscopic
cystectomy
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
14000
14000
15000
16800
16800
18000
NABH
Package
Cost
Outside State
NABH
Package Cost
18200
20300
18200
19500
20300
21750
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Detailed Procedure.
a) Admission Notes comprising of b) Operative Notes together with
history.
indication of surgery.
b) examination with indications
c) Intraop. stills with date &
for the procedure.
patient ID.
c) Clinical notes establishing
d) pic off gross specimen removed OPEN
ruptured ectopic with Evidence of .
beta hCG & USG.
e) HPE.
f) detailed discharge summary.
Mandatory Documents - Pre
Authorization
a) Admission Notes comprising of
history.
b) examination with indications
for the procedure.
c) Clinical notes establishing
ruptured ectopic with Evidence of
beta hCG & USG.
a) Detailed Procedure.
b) Operative Notes together with
indication of surgery.
c) Intraop. stills with date &
patient ID.
d) pic off gross specimen removed Referral
.
e) HPE.
f) detailed discharge summary.
a) Admission Notes comprising of
history.
b) Examination.
c) Relavant Investigations
(establishing diagnosis).
d) USG Abdomen Pelvis.
e) CT abdomen.
a) Detailed Procedure.
b) Operative Notes together with
indication of surgery.
c) Intraop. stills with date &
patient ID.
d) pic off gross specimen removed Referral
.
e) HPE.
f) detailed discharge summary.
a) Admission Notes comprising of
history.
b) examination with findings
establishing Cystocoele . Clinical
pic if feasible.
a) Detailed Procedure.
b) Operative Notes.
c) Intraop. Stills.
d) Progress notes.
e) Detailed discharge summary.
Y
Y
N
1229
1230
1231
Obstetrics & Gynecology
Obstetrics & Gynecology
Obstetrics & Gynecology
SO
SO
SO
SO042
Cystocele - Anterior
repair
SO043 Burch
SO043 Burch
SO042A
Cystocele - Anterior
repair
SO043A Abdominal (Burch)
SO043B Laparoscopic
6000
30000
30000
7200
36000
36000
7800
39000
39000
8700
43500
43500
a) Admission Notes comprising of
history .
b) examination with indications
for the procedure.
c) Relavant Investigations
(establishing diagnosis).
d) Urodynamic studies are
optional.
a) Admission Notes comprising of
history .
b) examination with indications
for the procedure.
c) Relavant Investigations
(establishing diagnosis).
d) Urodynamic studies are
optional.
Referral
N
a) Detailed Procedure .
b) Operative Notes.
c) Intraop. stills .
d) progress notes.
e) Detailed discharge summary.
OPEN
Y
a) Detailed Procedure .
b) Operative Notes.
c) Intraop. stills .
d) progress notes.
e) Detailed discharge summary.
OPEN
Y
1232
Obstetrics & Gynecology
SO
SO044
Electro Cauterisation /
Cryo Surgery
SO044A
Electro Cauterisation /
Cryo Surgery
4000
4800
5200
5800
a) Admission Notes comprising of
history.
b) examination with indications
for the procedure,Relavant
Investigations (establishing
diagnosis).
c) pap smear- optional.
a) Detailed Procedure .
b) Operative Notes.
c) Intraop. stills .
d) progress notes.
e) Detailed discharge summary.
OPEN
N
SL NO
1233
1234
Specialty
Obstetrics & Gynecology
Obstetrics & Gynecology
Specialty
Code
SO
SO
Package
Code
Package Name
EUA for (minor girls /
unmarried sexually
SO045
inactive / victims of
sexual abuse)
Hospitalisation for
SO046 Antenatal
Complications
Procedure
Code
Procedure Name
EUA for (minor girls /
unmarried sexually
SO045A
inactive / victims of
sexual abuse)
SO046A
Hospitalisation for
Antenatal Complications
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
2000
1800
2400
2160
NABH
Package
Cost
2600
2340
Outside State
NABH
Package Cost
2900
2610
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Admission Notes comprising of
history .
b) examination with indications
for the procedure.
c) Relavant Investigations
(establishing diagnosis).
d) and parental consent (incase of
minor girls) .
a) Detailed Procedure .
b) Operative Notes.
c) Intraop. stills .
d) progress notes.
e) Detailed discharge summary.
a) Admission Notes comprising of
history.
b) examination with indications
for the procedure.
c) Relavant Investigations
(establishing diagnosis).
a) Detailed Procedure .
b) Operative Notes.
c) Intraop. stills .
d) progress notes.
e) Detailed discharge summary.
a) Consulting notes giving the
indication for amniocentesis.
b) does the hospital have fetal
medicine expert?
a) Detailed Procedure.
b) Operative Notes.
c) Intraop. Stills.
d) Amniotic fluid analysis report.
e) Progress notes.
f) Detailed discharge summary.
a) Admission Notes comprising of
history.
b) examination with indications
for the procedure.
c) Relavant Investigations
(establishing diagnosis).
a) Procedure.
b) Operative Notes with report of
chorionic villi sampling.
c) Progress notes.
OPEN
d) Detailed discharge summary.
a) Admission Notes comprising of
history.
b) examination with indications
for the procedure.
c) Relavant Investigations
(establishing diagnosis).
Detailed Procedure.
Operative Notes.
Intraop. Stills.
report of cordocentesis.
Progress notes.
Detailed discharge summary.
Referral
N
OPEN
N
1235
Obstetrics & Gynecology
SO
SO047 Amniocentesis
SO047A Amniocentesis
14500
17400
18850
21025
OPEN
N
1236
1237
Obstetrics & Gynecology
Obstetrics & Gynecology
SO
SO
SO048
Chorionic villus
sampling
SO049 Cordocentesis
SO048A
Chorionic villus
sampling
SO049A Cordocentesis
14500
14500
17400
17400
18850
18850
21025
21025
N
OPEN
N
1238
Obstetrics & Gynecology
SO
SO050 McDonald's stitch
SO050A McDonald's stitch
4000
4800
5200
5800
a) Detailed Procedure.
a) Admission Notes comprising of
b) Operative Notes.
history.
c) Intraop. Stills.
b) ANC findings justifying cervical
d) Progress notes.
incompetence and the procedure.
e) Detailed discharge summary.
OPEN
N
1239
1240
Obstetrics & Gynecology
Obstetrics & Gynecology
SO
SO
SO051 Shirodkar's stitch
SO052
Medical management
of ectopic pregnancy
SO051A Shirodkar's stitch
SO052A
Medical management of
ectopic pregnancy
4000
1800
4800
2160
5200
2340
5800
2610
a) Detailed Procedure.
a) Admission Notes comprising of
b) Operative Notes.
history.
c) Intraop. Stills.
b) ANC findings justifying cervical
d) Progress notes.
incompetence and the procedure.
e) Detailed discharge summary.
a) Admission Notes comprising of
history.
b) examination with indications
for the procedure.
c) Relavant Investigations
(establishing diagnosis).
OPEN
N
a) Detailed Procedure.
b) Operative Notes.
c) Intraop. Stills.
d) Progress notes.
e) Detailed discharge summary.
Reserved
SL NO
1241
1242
1243
1244
1245
1246
Specialty
Obstetrics & Gynecology
Obstetrics & Gynecology
Obstetrics & Gynecology
Obstetrics & Gynecology
Obstetrics & Gynecology
Obstetrics & Gynecology
Specialty
Code
SO
SO
SO
SO
SO
SO
Package
Code
SO053
SO053
SO053
Package Name
Medical Termination
of Pregnancy
Medical Termination
of Pregnancy
Medical Termination
of Pregnancy
SO054 High risk delivery
SO054 High risk delivery
SO054 High risk delivery
Procedure
Code
Procedure Name
SO053A MTP upto 8 weeks
SO053B MTP 8 to 12 weeks
SO053C MTP > 12 weeks
SO054A Pre-mature delivery
Mothers with eclampsia
SO054B / imminent eclampsia /
severe pre-eclampsia
SO054C
Major Fetal
malformation requiring
intervention
immediately after birth
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
3500
5000
6500
11500
11500
11500
4200
6000
7800
13800
13800
13800
NABH
Package
Cost
4550
6500
8450
14950
14950
14950
Outside State
NABH
Package Cost
5075
7250
9425
16675
16675
16675
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Admission Notes comprising of
history.
b) examination with indications
for the procedure.
c) Relavant Investigations
(establishing diagnosis).
d) USG - Obstetric confirming the
above package. Has medicolegal
compliance been done.
a) Detailed Procedure.
b) Operative Notes.
c) Intraop. stills .
d) HPE of specimen.
e) Progress notes.
f) Detailed discharge summary.
a) Admission Notes comprising of
history.
b) examination with indications
for the procedure.
c) Relavant Investigations
(establishing diagnosis).
d) USG - Obstetric confirming the
above package. Has medicolegal
compliance been done?
a) Detailed Procedure.
b) Operative Notes.
c) Intraop. stills .
d) HPE of specimen.
e) Progress notes.
f) Detailed discharge summary.
a) Admission Notes comprising of
history.
b) examination with indications
for the procedure.
c) Relavant Investigations
(establishing diagnosis).
d) USG - Obstetric confirming the
above package. Has medicolegal
compliance been done?
a) Detailed Procedure.
b) Operative Notes.
c) Intraop. stills .
d) HPE of specimen.
e) Progress notes.
f) Detailed discharge summary.
a) Admission Notes comprising of
history.
b) detailed Ante natal care
records.
c) reasons for non-availability of
ANC records. Obstetric USG.
All high risk deliveries are to be
clubbed & case specific
documents required.
a) Detailed delivery notes.
b) PNC notes along with relevant
investigation details.
c) status of the child at the time of
delivery and at the time of
OPEN
discharge.
d) progress notes.
e) Detailed discharge summary.
a) Admission Notes comprising of
history.
b) detailed Ante natal care
records.
c) reasons for non-availability of
ANC records. Obstetric USG.
All high risk deliveries are to be
clubbed & case specific
documents required.
a) Detailed delivery notes.
b) PNC notes along with relevant
investigation details.
c) status of the child at the time of
delivery and at the time of
OPEN
discharge.
d) progress notes.
e) Detailed discharge summary.
a) Admission Notes comprising of
history.
b) detailed Ante natal care
records.
c) reasons for non-availability of
ANC records. Obstetric USG.
All high risk deliveries are to be
clubbed & case specific
documents required.
a) Detailed delivery notes.
b) PNC notes along with relevant
investigation details.
c) status of the child at the time of
delivery and at the time of
OPEN
discharge.
d) progress notes.
e) Detailed discharge summary.
Reserved
Reserved
Reserved
Y
Y
Y
SL NO
1247
1248
1249
Specialty
Obstetrics & Gynecology
Obstetrics & Gynecology
Obstetrics & Gynecology
Specialty
Code
SO
SO
SO
Package
Code
Package Name
SO054 High risk delivery
SO054 High risk delivery
SO055
Manual removal of
placenta
Procedure
Code
SO054D
Procedure Name
Mothers with severe
anaemia (<7 g/dL)
Other maternal and
fetal conditions as per
guidelines-eg previous
caesarean section,
SO054E
diabetes, severe growth
retardation, etc that
qualify for high risk
delivery.
SO055A
Manual removal of
placenta
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
11500
11500
8500
13800
13800
10200
NABH
Package
Cost
14950
14950
11050
Outside State
NABH
Package Cost
16675
16675
12325
Mandatory Documents - Pre
Authorization
a) Admission Notes comprising of
history.
b) detailed Ante natal care
records.
c) reasons for non-availability of
ANC records. Obstetric USG.
All high risk deliveries are to be
clubbed & case specific
documents required.
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Detailed delivery notes.
b) PNC notes along with relevant
investigation details.
c) status of the child at the time of
delivery and at the time of
OPEN
discharge.
d) progress notes.
e) Detailed discharge summary.
Y
a) Admission Notes comprising of
history.
b) detailed Ante natal care
records with special reference to
investigations supporting the
diagnosis.
c) reasons for non-availability of
ANC records. Obstetric USG.
All high risk deliveries are to be
clubbed & case specific
documents required.
a) Detailed delivery notes.
b) PNC notes along with relevant
investigation details.
c) status of the child at the time of
delivery and at the time of
OPEN
discharge.
d) progress notes.
e) Detailed discharge summary.
a) Clinical notes documenting
need of manual removal of
placenta.
b) use of Active Management of
Third Stage of Labor (AMTSL).
a) Detailed Procedure.
b) Operative Notes.
c) stills of placenta.
d) progress note Detailed
discharge summary.
e) Post natal course.
Y
OPEN
N
1250
Obstetrics & Gynecology
SO
SO056
Secondary suturing of
episiotomy
SO056A
Secondary suturing of
episiotomy
2500
3000
3250
3625
a) Admission Notes comprising of
history detailing when was first
surgery done? and examination
with indications for the procedure.
b) Physical examination findings
with indications for the procedure.
a) Detailed Procedure.
b) Operative Notes.
c) stills of placenta.
d) progress note Detailed
discharge summary.
e) Post natal course.
OPEN
N
1251
1252
1253
Obstetrics & Gynecology
Obstetrics & Gynecology
Obstetrics & Gynecology
SO
SO
SO
SO057 Caesarean Delivery
Re exploration after
SO058 laparotomy /
Caesarean Section
Re exploration after
SO058 laparotomy /
Caesarean Section
SO057A Caesarean Delivery
SO058A
SO058B
Re exploration after
Caesarean Section
Re exploration after
laparotomy
15000
14000
14000
18000
16800
16800
19500
18200
18200
21750
20300
20300
a) Admission Notes comprising of
history.
b) examination with detailed Ante
natal care records.
c) reasons for non-availability of
ANC records. Indications for the
procedure. USG Obstetrics with
Doppler is case specific &
optional. Labor charting, CTG if
available.
a) Detailed Procedure.
b) Operative Notes.
c) status of the child at the time of
delivery and at the time of
OPEN
discharge.
d) progress notes.
e) Detailed discharge summary.
a) Admission Notes comprising of
history.
b) examination with indications
for the procedure.
c) Relavant Investigations
(establishing diagnosis).
d) USG.
a) Detailed Procedure.
b) Operative Notes.
c) Intra procedure clinical
photograph.
d) stills; progress notes.
e) Detailed discharge summary.
a) Admission Notes comprising of
history.
b) examination with indications
for the procedure.
c) Relavant Investigations
(establishing diagnosis).
d) USG.
a) Detailed Procedure.
b) Operative Notes.
c) Intra procedure clinical
photograph.
d) stills; progress notes.
e) Detailed discharge summary.
N
OPEN
Y
OPEN
Y
SL NO
1254
1255
Specialty
Obstetrics & Gynecology
Obstetrics & Gynecology
Specialty
Code
SO
SO
Package
Code
SO059
SO059
Package Name
Vulvo vaginal cyst
enucleation / drainage
Vulvo vaginal cyst
enucleation / drainage
Procedure
Code
SO059A
SO059B
Procedure Name
Vulvo vaginal cyst
enucleation
Vulvo vaginal cyst
drainage
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
4700
4700
5640
5640
NABH
Package
Cost
6110
6110
Outside State
NABH
Package Cost
6815
6815
Mandatory Documents - Pre
Authorization
a) Admission Notes comprising of
history.
b) examination with indications
for the procedure.
c) Relavant Investigations
(establishing diagnosis).
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Detailed operative notes.
b) discharge summary.
c) histopathology report of tissue
removed.
a) Admission Notes comprising of
history.
b) examination with indications
a) Detailed operative notes.
for the procedure.
b) discharge summary.
c) Relavant Investigations
(establishing diagnosis).
OPEN
Y
OPEN
Y
1256
1257
1258
Plastic & Reconstructive
Surgery
Plastic & Reconstructive
Surgery
Plastic & Reconstructive
Surgery
SP
SP
SP
SP001
SP002
SP003
Pressure Sore –
Surgery
Diabetic Foot –
Surgery
Revascularization of
limb / digit
SP001A Pressure Sore – Surgery
SP002A Diabetic Foot – Surgery
SP003A
Revascularization of
limb / digit
30000
30000
35000
36000
36000
42000
39000
39000
45500
43500
43500
50750
A)Clinical notes detailing events
that led to pressure sores.
B)Clinical photograph.
A)Clinical notes with planned line
of treatment detailing diabetic foot
extent of damage.
B)Clinical photograph.
A) Clinical notes.
B) Clinical photograph.
C) Doppler.
D) If traumatic then MLC.
E) FIR report.
A)Post procedure clinical
photograph. B)Detailed
Procedure.
C)Operative
Notes.
D)Detailed
discharge summary.
OPEN
N
A)Post procedure clinical
photograph. B)Detailed Operative
OPEN
notes. C)Detailed discharge
summary.
N
A)Intra procedure clinical
photograph. B)Detailed discharge
summary. C)Detailed Procedure.
OPEN
D)Operative Notes.
N
1259
Plastic & Reconstructive
Surgery
SP
Ear Pinna
Reconstruction with
costal cartilage /
SP004
Prosthesis
(including the cost of
prosthesis / implants)
Ear Pinna
Reconstruction with
costal cartilage /
SP004A
Prosthesis
(including the cost of
prosthesis / implants)
30000
36000
39000
43500
A) Clinical notes.
B) Clinical photograph in case of
injury.
C) If traumatic then MLC.
D) FIR report.
E) Documents supporting if
indication is non-traumatic.
A) Clinical photograph of donor.
B) Recipient sites.
C) Intra operative clinical
photograph Invoice of Prosthesis.
D) Implant used.
E) Detailed discharge summary.
OPEN
N
1260
Plastic & Reconstructive
Surgery
SP
SP005
Scalp avulsion
reconstruction
SP005A
Scalp avulsion
reconstruction
50000
60000
65000
72500
A) Intra procedure clinical
A) Clinical notes detailing how
photograph.
avulsion occurred.
B) Post procedure clinical
B) Clinical Photograph.
photograph.
C) MLC copy with number since C) Detailed Procedure.
traumatic.
D) Operative Notes.
E) Detailed discharge summary.
OPEN
N
1261
Plastic & Reconstructive
Surgery
SP
Tissue Expander for
disfigurement
following burns /
SP006 trauma / congenital
deformity
(including cost of
expander / implant)
Tissue Expander for
SP006A disfigurement following
burns
50000
60000
65000
72500
a) Detailed Clinical notes of
original clinical event having led to
disfigurement or confirming details.
b) Invetsigations of congenital
event.
c) Clinical Photograph.
a) Detailed discharge summary.
b) Detailed Procedure.
c) Operative Notes.
d) Post procedure clinical
photograph.
e) Invoice of expander.
f) Implant used.
OPEN
Y
1262
Plastic & Reconstructive
Surgery
SP
Tissue Expander for
disfigurement
following burns /
SP006 trauma / congenital
deformity
(including cost of
expander / implant)
SP006B
Tissue Expander for
disfigurement following
trauma
50000
60000
65000
72500
a) Detailed discharge summary.
a) Detailed Clinical notes of
b) Detailed Procedure.
original clinical event having led to
c) Operative Notes.
disfigurement or confirming details.
d) Post procedure clinical
b) Invetsigations of congenital
photograph.
event.
e) Invoice of expander.
c) Clinical Photograph.
f) Implant used.
OPEN
Y
SL NO
1263
Specialty
Plastic & Reconstructive
Surgery
Specialty
Code
SP
Package
Code
Package Name
Tissue Expander for
disfigurement
following burns /
SP006 trauma / congenital
deformity
(including cost of
expander / implant)
Procedure
Code
SP006C
Procedure Name
Tissue Expander for
disfigurement following
congenital deformity
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
50000
60000
NABH
Package
Cost
65000
Outside State
NABH
Package Cost
72500
Mandatory Documents - Pre
Authorization
a) Detailed Clinical notes of
original clinical event having led to
disfigurement or confirming details.
b) Invetsigations of congenital
event.
c) Clinical Photograph.
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Detailed discharge summary.
b) Detailed Procedure.
c) Operative Notes.
d) Post procedure clinical
photograph.
e) Invoice of expander.
f) Implant used.
OPEN
Y
a) Clinical notes.
b) Clinical Photograph.
1264
Plastic & Reconstructive
Surgery
SP
SP007 Hemangioma
SP007A Sclerotherapy under GA
35000
42000
45500
50750
a) Post procedure clinical
photograph.
b) Invoice of sclerosing agent used.
c) Detailed discharge summary.
OPEN
d) Detailed Procedure.
e) Operative Notes.
Y
a) Clinical notes.
b) Clinical Photograph.
1265
Plastic & Reconstructive
Surgery
SP
SP007 Hemangioma
SP007B
Debulking
35000
42000
45500
50750
a) Post procedure clinical
photograph.
b) Invoice of sclerosing agent used.
c) Detailed discharge summary.
OPEN
d) Detailed Procedure.
e) Operative Notes.
Y
a) Clinical notes.
b) Clinical Photograph.
1266
Plastic & Reconstructive
Surgery
SP
SP007 Hemangioma
SP007C
Excision
35000
42000
45500
50750
a) Post procedure clinical
photograph.
b) Invoice of sclerosing agent used.
c) Detailed discharge summary.
OPEN
d) Detailed Procedure.
e) Operative Notes.
Y
1267
Plastic & Reconstructive
Surgery
SP
SP008 NPWT
SP008A NPWT
a) Clinical notes detailing events
that led to chronic.
b) Non healing woulds.
c) Clinical photograph.
2000
2400
2600
2900
a) Post procedure clinical
photograph with tube.
b) Pump.
c) Detailed discharge summary.
d) Detailed Procedure.
e) Operative Notes.
OPEN
N
1268
Pediatric Surgery
SS
SS001
Cleft Lip and Palate
Surgery (per stage)
SS001A
Cleft Lip and Palate
Surgery (per stage)
15000
18000
19500
21750
a) Clinical notes.
b) Clinical Photograph.
a) Detailed discharge summary.
b) Detailed Procedure.
c) Operative Notes.
d) Post procedure clinical
photograph.
a) Clinical notes.
b) Pre-op photograph.
a) Detailed discharge summary.
b) Detailed Procedure.
c) Operative Notes.
d) Post procedure clinical
photograph.
a) Clinical notes.
b) Pre-op photograph.
a) Detailed discharge summary.
b) Detailed Procedure.
c) Operative Notes.
d) Post procedure clinical
photograph.
Referral
N
1269
Pediatric Surgery
SS
SS002 Ankyloglossia
SS002A
Ankyloglossia Minor
5000
6000
6500
7250
OPEN
Y
1270
Pediatric Surgery
SS
SS002 Ankyloglossia
SS002B
Ankyloglossia Major
15000
18000
19500
21750
OPEN
Y
SL NO
1271
1272
Specialty
Pediatric Surgery
Pediatric Surgery
Specialty
Code
SS
SS
Package
Code
Package Name
SS003 Anti GERD Surgery
Gastrostomy +
SS004 Esophagoscopy +
Threading
Procedure
Code
SS003A
SS004A
Procedure Name
Anti GERD Surgery
Gastrostomy +
Esophagoscopy +
Threading
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
15000
20000
18000
24000
NABH
Package
Cost
19500
26000
Outside State
NABH
Package Cost
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Clinical notes.
b) UGI Endoscopy report.
a) Intra procedure clinical
photograph.
b) Detailed Procedure.
c) Operative Notes.
d) Detailed discharge summary.
a) USG
b) CT Abd.
c) Endoscopy.
d) Biopsy.
a) Detailed Procedure.
b) Operative Notes.
c) Post procedure clinical
photograph.
a) X Ray.
b) CT Scan Abdomen.
c) UGI contrast study confirming
the malrotation.
a) Histopathology.
b) Detailed Procedure.
c) Operative Notes.
d) Post procedure clinical
OPEN
photograph of the operated region.
a) Clinical notes.
b) USG.
c) CT Abd.
d) Endoscopic USG.
a) Histopathology.
b) Detailed Procedure.
c) Operative Notes.
d) Intra procedure clinical
photograph.
e) Detailed discharge summary.
a) Clinical notes.
b) Stills of.
c) X-ray Abdomen.
d) USG Abdomen.
a) Detailed Procedure.
b) Operative Notes.
c) Detailed discharge summary.
d) Post procedure X Ray
Abdomen.
a) Clinical notes.
b) Stills of.
c) X-ray Abdomen.
d) USG Abdomen.
a) Detailed Procedure.
b) Operative Notes.
c) Detailed discharge summary.
d) Post procedure X Ray
Abdomen.
36250
a) Clinical notes.
b) USG.
c) Dye test.
a) Histopathology.
b) Detailed Procedure.
c) Operative Notes.
d) Detailed discharge summary.
36250
a) Clinical notes.
b) USG.
c) Dye test.
a) Histopathology.
b) Detailed Procedure.
c) Operative Notes.
d) Detailed discharge summary.
14500
a) Clinical notes.
b) USG.
c) Dye test.
a) Histopathology.
b) Detailed Procedure.
c) Operative Notes.
d) Detailed discharge summary.
14500
a) Clinical notes.
b) USG.
c) Dye test.
a) Histopathology.
b) Detailed Procedure.
c) Operative Notes.
d) Detailed discharge summary.
21750
29000
OPEN
N
OPEN
N
1273
Pediatric Surgery
SS
SS005 Ladds Procedure
SS005A
Ladds Procedure
30000
36000
39000
43500
N
1274
Pediatric Surgery
SS
SS006
Duplication Cyst
Excision
SS006A
Duplication Cyst
Excision
20000
24000
26000
29000
OPEN
N
1275
Pediatric Surgery
SS
SS007 Intussusception
SS007A
Non – Operative
Reduction in infants
20000
24000
26000
29000
OPEN
Y
1276
Pediatric Surgery
SS
SS007 Intussusception
SS007B
Operative in infants
25000
30000
32500
36250
OPEN
Y
1277
Pediatric Surgery
SS
Surgery for
SS008
Hirschsprung’s Disease
SS008A
Myectomy
25000
30000
32500
OPEN
Y
1278
Pediatric Surgery
SS
SS008
Surgery for
Hirschsprung’s Disease
SS008B
Pull Through
25000
30000
32500
OPEN
Y
1279
Pediatric Surgery
SS
SS008
Surgery for
Hirschsprung’s Disease
SS008C
Rectal Biopsy - Punch
10000
12000
13000
OPEN
Y
1280
Pediatric Surgery
SS
SS008
Surgery for
Hirschsprung’s Disease
SS008D
Rectal Biopsy – Open
10000
12000
13000
OPEN
Y
SL NO
1281
Specialty
Pediatric Surgery
Specialty
Code
SS
Package
Code
Package Name
Surgery for
SS008
Hirschsprung’s Disease
Procedure
Code
SS008E
Procedure Name
Sphinecterotomy
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
15000
18000
NABH
Package
Cost
19500
Outside State
NABH
Package Cost
21750
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Clinical notes.
b) USG.
c) Dye test.
a) Histopathology.
b) Detailed Procedure.
c) Operative Notes.
d) Detailed discharge summary.
a) Clinical notes.
b) Sigmoidoscopy confirming
polyp.
a) Histopathology.
b) Detailed Procedure.
c) Operative Notes.
d) Detailed discharge summary.
a) Clinical notes.
b) Clinical Photograph.
c) Distal Cologram.
d) CT.
e) USG Abdomen.
f) Xray Lumbosacral spine
(inverted position).
a) Detailed Procedure.
b) Operative Notes.
c) Post procedure clinical
photograph.
d) Detailed discharge summary.
a) Clinical notes.
b) Clinical Photograph.
c) Distal Cologram.
d) CT.
e) USG Abdomen.
f) Xray Lumbosacral spine
(inverted position).
a) Detailed Procedure.
b) Operative Notes.
c) Post procedure clinical
photograph.
d) Detailed discharge summary.
a) Clinical notes.
b) Clinical Photograph.
c) Distal Cologram.
d) CT.
e) USG Abdomen.
f) Xray Lumbosacral spine
(inverted position).
a) Detailed Procedure.
b) Operative Notes.
c) Post procedure clinical
photograph.
d) Detailed discharge summary.
a) Clinical notes.
b) Clinical Photograph.
c) Distal Cologram.
d) CT.
e) USG Abdomen.
f) Xray Lumbosacral spine
(inverted position).
a) Detailed Procedure.
b) Operative Notes.
c) Post procedure clinical
photograph.
d) Detailed discharge summary.
a) Clinical notes.
b) Clinical Photograph.
c) Distal Cologram.
d) CT.
e) USG Abdomen.
f) Xray Lumbosacral spine
(inverted position).
a) Detailed Procedure.
b) Operative Notes.
c) Post procedure clinical
photograph.
d) Detailed discharge summary.
a) Clinical notes.
b) Clinical Photograph.
c) Distal Cologram.
d) CT.
e) USG Abdomen.
f) Xray Lumbosacral spine
(inverted position).
a) Detailed Procedure.
b) Operative Notes.
c) Post procedure clinical
photograph.
d) Detailed discharge summary.
a) Clinical notes and USG.
b) CT abdomen.
c) Pelvis delineating fistula tract.
a) Intra procedure clinical
photograph.
b) Detailed Procedure.
c) Operative Notes.
d) Detailed discharge summary.
OPEN
Y
1282
1283
1284
1285
1286
1287
1288
Pediatric Surgery
Pediatric Surgery
Pediatric Surgery
Pediatric Surgery
Pediatric Surgery
Pediatric Surgery
Pediatric Surgery
SS
SS
SS
SS
SS
SS
SS
Rectal Polypectomy SS009 Sigmoiescopic Under
GA
SS010
SS010
SS010
SS010
SS010
SS010
Ano Rectal
Malformation
Ano Rectal
Malformation
Ano Rectal
Malformation
Ano Rectal
Malformation
Ano Rectal
Malformation
Ano Rectal
Malformation
SS009A
SS010A
SS010B
SS010C
SS010D
SS010E
SS010F
Rectal Polypectomy Sigmoiescopic Under
GA
Abd - Perineal PSARP
Anoplasty
Cutback
PSARP
Redo - Pullthrough
Transposition
8000
25000
20000
20000
22000
25000
17500
9600
30000
24000
24000
26400
30000
21000
10400
32500
26000
26000
28600
32500
22750
11600
36250
29000
29000
31900
36250
25375
OPEN
N
OPEN
Y
OPEN
Y
OPEN
Y
OPEN
Y
OPEN
Y
OPEN
Y
1289
Pediatric Surgery
SS
SS011 Fecal Fistula Closure
SS011A
Fecal Fistula Closure
25000
30000
32500
36250
OPEN
N
SL NO
1290
Specialty
Pediatric Surgery
Specialty
Code
SS
Package
Code
Package Name
SS012 GI Tumor Excision
Procedure
Code
SS012A
Procedure Name
GI Tumor Excision
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
30000
36000
NABH
Package
Cost
39000
Outside State
NABH
Package Cost
43500
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Clinical notes.
b) USG.
c) CT.
d) Biopsy.
a) HPR.
b) Detailed Procedure.
c) Operative Notes.
d) Intra procedure clinical
photograph.
e) Detailed Procedure.
f) Operative Notes.
g) Detailed discharge summary.
a) Clinical notes.
b) Chest X-ray AP.
c) Lat.
d) USG.
e) CT scan stills.
a) Detailed Procedure.
b) Operative Notes.
c) Detailed discharge summary.
d) Foetal Cardiogram.
e) Xray Chest AP.
f) Lat stills.
a) Clinical notes.
b) Clinical Photograph.
a) Detailed Procedure.
b) Operative Notes.
c) Post procedure clinical
photograph.
d) Detailed discharge summary.
a) Clinical notes.
b) Clinical Photograph.
a) Detailed Procedure.
b) Operative Notes.
c) Post procedure clinical
photograph.
d) Detailed discharge summary.
a) Clinical notes.
b) USG.
c) Clinical Photograph.
a) Detailed Procedure.
b) Operative Notes.
c) Post procedure clinical
photograph showing scar.
d) Detailed Procedure.
e) Operative Notes.
a) Clinical notes.
b) USG.
c) MRI Abd.
a) Histopathology.
b) Detailed Procedure.
c) Operative Notes.
d) Intra procedure clinical
photograph.
e) Detailed discharge summary.
a) Clinical notes.
b) CT
c) MRI confirming the diagnosis.
d) Biopsy.
a) Histopathology.
b) Detailed Procedure.
c) Operative Notes.
d) Post procedure clinical
photograph showing scar.
a) Clinical notes.
b) X Ray.
c) CT Scan stills confirming the
diagnosis.
a) Detailed Procedure.
b) Operative Notes.
c) Post procedure X-ray stills.
d) Detailed discharge summary.
a) Clinical notes.
b) USG.
c) Clinical Photograph.
a) Detailed Procedure.
b) Operative Notes.
c) Post procedure clinical.
d) Photograph showing scar.
e) Detailed Procedure.
f) Operative Notes.
OPEN
N
1291
Pediatric Surgery
SS
SS013
Congenital
Diaphragmatic Hernia
SS013A
Congenital
Diaphragmatic Hernia
25000
30000
32500
36250
OPEN
N
1292
Pediatric Surgery
SS
SS014
Exomphalos /
Gastroschisis
SS014A
Exomphalos
25000
30000
32500
36250
OPEN
Y
1293
1294
Pediatric Surgery
Pediatric Surgery
SS
SS
SS014
Exomphalos /
Gastroschisis
SS015 Hernia & Hydrocele
SS014B
SS015A
Gastroschisis
Hernia & Hydrocele
25000
20000
30000
24000
32500
26000
36250
29000
OPEN
Y
OPEN
N
1295
1296
Pediatric Surgery
Pediatric Surgery
SS
SS
Retro - Peritoneal
SS016 Lymphangioma
Excision
Surgery for
SS017 Sacrococcygeal
Teratoma
SS016A
SS017A
Retro - Peritoneal
Lymphangioma Excision
Surgery for
Sacrococcygeal
Teratoma
25000
20000
30000
24000
32500
26000
36250
29000
OPEN
N
OPEN
N
1297
1298
Pediatric Surgery
Pediatric Surgery
SS
SS
SS018
Surgery for Congenital
Lobar Emphysema
SS019 Undescended Testis
SS018A
SS019A
Surgery for Congenital
Lobar Emphysema
Bilateral - Palpable +
Nonpalpable
25000
15000
30000
18000
32500
19500
36250
21750
OPEN
N
OPEN
Y
SL NO
1299
Specialty
Pediatric Surgery
Specialty
Code
SS
Package
Code
Package Name
SS019 Undescended Testis
Procedure
Code
SS019B
Procedure Name
Bilateral Palpable
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
15000
18000
NABH
Package
Cost
19500
Outside State
NABH
Package Cost
21750
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Clinical notes.
b) USG.
c) Clinical Photograph.
a) Detailed Procedure.
b) Operative Notes.
c) Post procedure clinical.
d) Photograph showing scar.
e) Detailed Procedure.
f) Operative Notes.
g) Detailed Discharge summary.
a) Clinical notes.
b) USG.
c) Clinical Photograph.
a) Detailed Procedure.
b) Operative Notes.
c) Post procedure clinical.
d) Photograph showing scar.
e) Detailed Procedure.
f) Operative Notes.
g) Detailed Discharge summary.
a) Clinical notes.
b) USG.
c) Clinical Photograph.
a) Detailed Procedure.
b) Operative Notes.
c) Post procedure clinical.
d) Photograph showing scar.
e) Detailed Procedure.
f) Operative Notes.
g) Detailed Discharge summary.
a) Clinical notes.
b) USG.
c) Clinical Photograph.
a) Detailed Procedure.
b) Operative Notes.
c) Post procedure clinical.
d) Photograph showing scar.
e) Detailed Procedure.
f) Operative Notes.
OPEN
Y
1300
Pediatric Surgery
SS
SS019 Undescended Testis
SS019C
Bilateral Non - Palpable
20000
24000
26000
29000
OPEN
Y
1301
1302
Pediatric Surgery
Pediatric Surgery
SS
SS019 Undescended Testis
SS019D
SS019E
Unilateral - Palpable
Reexploration / Second
Stage
SS
SS019 Undescended Testis
ST
Conservative
ST001 Management of Head
Injury
ST001A Severe
Conservative
ST001 Management of Head
Injury
ST001B
15000
20000
18000
24000
19500
26000
21750
29000
OPEN
Y
OPEN
Y
1303
1304
1305
1306
1307
Polytrauma
Polytrauma
Polytrauma
Polytrauma
Polytrauma
ST
ST
ST
ST
Head injury with
repair of FacioST002 Maxillary Injury &
fixations (including
implants)
Craniotomy and
ST003 evacuation of
Haematoma
Craniotomy and
evacuation of
ST003 Haematoma with
fixation of fracture of
long bone
ST002A
ST003A
ST003B
Depressed Fracture
Head injury with repair
of Facio-Maxillary
Injury & fixations
(including implants)
Subdural & Extradural
hematoma
Subdural & Extradural
hematoma along with
fixation of fracture of
single long bone
1000
5000
35000
50000
60000
1200
6000
42000
60000
72000
1300
6500
45500
65000
78000
1450
7250
50750
72500
87000
a) Clinical notes with planned line
Discharge summary.
of treatment
a) Clinical notes with planned line
of treatment including planned line
of treatment.
Discharge summary.
b) X-ray films with reports.
a) Clinical notes detailing the
injury.
b) Need of surgery.
c) MLC.
d) FIR with X-ray.
e) CT.
f) Pre-op clinical photograph.
a) Clinical notes detailing the
injury.
b) Need of surgery.
c) MLC.
d)FIR with X-ray.
e)CT.
f)MRI (of both head & affected
long bone).
a) Clinical notes detailing the
injury.
b) Need of surgery.
c) MLC.
d)FIR with X-ray.
e)CT.
f)MRI (of both head & affected
long bone).
OPEN
Y
OPEN
Y
a) Post- op Clinical Photograph
showing implant for fixation.
b) Repairs.
c) Detailed discharge summary.
d) Detailed operatives notes.
OPEN
N
a) Post- op Clinical Photograph
showing implant for fixation.
b) Repairs.
c) Detailed discharge summary.
d) Detailed operatives notes.
a) Post- op Clinical Photograph
showing implant for fixation.
b) Repairs.
c) Detailed discharge summary.
d) Detailed operatives notes.
OPEN
Y
YES
Y
YES
OPEN
SL NO
1308
1309
1310
1311
Specialty
Polytrauma
Polytrauma
Polytrauma
Polytrauma
Specialty
Code
ST
ST
ST
ST
Package
Code
Package Name
Craniotomy and
evacuation of
ST003 Haematoma with
fixation of fracture of
long bone
Craniotomy and
evacuation of
ST003 Haematoma with
fixation of fracture of
long bone
Management of Chest
ST004 injury with fracture of
Long bone
Management of Chest
ST004 injury with fracture of
Long bone
Procedure
Code
ST003C
Procedure Name
Subdural hematoma
along with fixation of
fracture of 2 or more
long bone.
Extradural hematoma
along with fixation of
ST003D
fracture of 2 or more
long bone.
Management of Chest
ST004A injury with fixation of
Single Long bone
ST004B
Management of Chest
injury with fixation of 2
or more Long bones
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
75000
75000
35000
45000
90000
90000
42000
54000
NABH
Package
Cost
97500
97500
45500
58500
Outside State
NABH
Package Cost
108750
108750
50750
65250
Mandatory Documents - Pre
Authorization
a) Clinical notes detailing the
injury.
b) Need of surgery.
c) MLC.
d)FIR with X-ray.
e)CT.
f)MRI (of both head & affected
long bone).
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Post- op Clinical Photograph
showing implant for fixation.
b) Repairs.
c) Detailed discharge summary.
d) Detailed operatives notes.
a) Clinical notes detailing the
injury.
b) Need of surgery.
c) MLC.
d)FIR with X-ray.
e)CT.
f)MRI (of both head & affected
long bone).
a) Post- op Clinical Photograph
showing implant for fixation.
b) Repairs.
c) Detailed discharge summary.
d) Detailed operatives notes.
a) Clinical notes detailing the
injury.
b) Need of surgery.
c) MLC.
d)FIR with X-ray.
e)CT.
f)MRI (of both chest & affected
long bone).
a) Intra- op Clinical Photograph.
b) X-rays showing chest injury
repair.
c) Implant for fixation.
d) Detailed discharge summary.
e) Detailed operatives notes.
a) Clinical notes detailing the
injury.
b) Need of surgery.
c) MLC.
d)FIR with X-ray.
e)CT.
f)MRI (of both chest & affected
long bone).
OPEN
Y
YES
Y
YES
OPEN
OPEN
Y
a) Intra- op Clinical Photograph.
b) X-rays showing chest injury
repair.
c) Implant for fixation.
d) Detailed discharge summary.
e) Detailed operatives notes.
OPEN
Y
1312
Polytrauma
ST
Management of
ST005 Visceral injury and
fracture long bone
ST005A
Surgical intervention for
Visceral injury and
fixation of fracture of
single long bone
30000
36000
39000
43500
a) Clinical notes detailing the
injury.
b) Need of surgery.
c) MLC.
d) FIR with X-ray.
e) CT.
f) MRI (of both affected viscera
& affected long bone).
a) Intra- op Clinical Photograph.
b) X-rays showing visceral injury
repair.
c) Implant for fixation.
d) Detailed discharge summary.
e) Detailed operatives notes.
YES
OPEN
Y
1313
Polytrauma
ST
Management of
ST005 Visceral injury and
fracture long bone
ST005B
Surgical intervention for
Visceral injury and
fixation of fracture of 2
or more long bones
45000
54000
58500
65250
a) Clinical notes detailing the
injury.
b) Need of surgery.
c) MLC.
d) FIR with X-ray.
e) CT.
f) MRI (of both affected viscera
& affected long bone).
a) Intra- op Clinical Photograph.
b) X-rays showing visceral injury
repair.
c) Implant for fixation.
d) Detailed discharge summary.
e) Detailed operatives notes.
a) Clinical notes detailing the
injury and need of surgery.
b) MLC
c) FIR with X-ray.
d) CT
a) Post- op Clinical Photograph
showing implant for fixation.
b) Detailed discharge summary.
c) Detailed operatives notes.
OPEN
Y
1314
Polytrauma
ST
Internal fixation of
ST006 Pelviacetabular
fracture
ST006A
Internal fixation of
Pelviacetabular fracture
40000
48000
52000
58000
OPEN
N
YES
SL NO
1315
Specialty
Polytrauma
Specialty
Code
ST
Package
Code
Package Name
Internal fixation with
Flap cover Surgery for
ST007
wound in compound
fracture
Procedure
Code
Procedure Name
Internal fixation with
Flap cover Surgery for
ST007A
wound in compound
fracture
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
40000
48000
NABH
Package
Cost
52000
Outside State
NABH
Package Cost
58000
Mandatory Documents - Pre
Authorization
a) Clinical notes.
b) PRE OP CLINICAL
PICTURE
c) X-RAY
d) CT
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Post- op Clinical Photograph
showing implant for fixation.
b) Flap cover.
c) Detailed discharge summary.
d) Detailed operatives notes.
OPEN
N
1316
1317
1318
1319
1320
1321
Polytrauma
Polytrauma
Polytrauma
Polytrauma
Polytrauma
Polytrauma
ST
ST
ST
ST
ST
ST
ST008
Emergency tendons
repair ± Peripheral
Nerve repair/
reconstructive surgery
Management of Nerve
ST009 Plexus / Tendon
injuries
Management of Nerve
ST009 Plexus / Tendon
injuries
Management of Nerve
ST009 Plexus / Tendon
injuries
Management of Nerve
ST009 Plexus / Tendon
injuries
Management of Nerve
ST009 Plexus / Tendon
injuries
ST008A
Emergency tendons
repair ± Peripheral
Nerve repair/
reconstructive surgery
Nerve Plexus injury
ST009A
repair
ST009B
ST009C
Nerve Plexus injury
reconstruction
Tendon injury repair
Tendon injury
ST009D
reconstruction
ST009E
Tendon Transfer
30000
50000
50000
50000
50000
50000
36000
60000
60000
60000
60000
60000
39000
65000
65000
65000
65000
65000
43500
72500
72500
72500
72500
72500
a) Clinical notes with planned line
of treatment detailing the injury.
b) Need of surgery.
c) MLC
d) FIR with X-ray
e) CT
f) MRI (of both chest & affected
long bone).
a) Clinical notes detailing the
injury.
b) Need of surgery.
c) MLC
d) FIR
e) Nerve conduction velocity
(NCV).
f) MRI
g) EMG(Electromyography).
a) Clinical notes detailing the
injury.
b) Need of surgery.
c) MLC
d) FIR
e) Nerve conduction velocity
(NCV).
f) MRI
g) EMG(Electromyography).
a) Clinical notes detailing the
injury.
b) Need of surgery.
c) MLC
d) FIR
e) Nerve conduction velocity
(NCV).
f) MRI
g) EMG(Electromyography).
a) Clinical notes detailing the
injury.
b) Need of surgery.
c) MLC
d) FIR
e) Nerve conduction velocity
(NCV).
f) MRI
g) EMG(Electromyography).
a) Clinical notes detailing the
injury.
b) Need of surgery.
c) MLC
d) FIR
e) Nerve conduction velocity
(NCV).
f) MRI
g) EMG(Electromyography).
a) Intra- op Clinical Photograph
showing tendon.
b) Nerve injury repair and
reconstruction.
c) Detailed discharge summary.
d) Detailed operatives notes.
OPEN
N
a) Intra operative still photograph.
b) Detailed discharge summary.
c) Detailed operatives notes.
OPEN
Y
YES
Y
YES
Y
YES
Y
YES
Y
YES
a) Intra operative still photograph.
b) Detailed discharge summary.
c) Detailed operatives notes.
OPEN
a) Intra operative still photograph.
b) Detailed discharge summary.
c) Detailed operatives notes.
OPEN
a) Intra operative still photograph.
b) Detailed discharge summary.
c) Detailed operatives notes.
OPEN
a) Intra operative still photograph.
b) Detailed discharge summary.
c) Detailed operatives notes.
OPEN
SL NO
1322
1323
1324
1325
Specialty
Polytrauma
Polytrauma
Urology
Urology
Specialty
Code
ST
ST
SU
SU
Package
Code
Package Name
Plexus injury along
ST010 with Vascular injury
repair / graft
Plexus injury along
ST010 with Vascular injury
repair / graft
SU001 Adrenalectomy
SU001 Adrenalectomy
Procedure
Code
Procedure Name
Plexus injury along with
ST010A
Vascular injury repair
ST010B
Plexus injury along with
Vascular injury graft
SU001A Open
SU001B Lap. - (Adrenalectomy)
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
60000
60000
27500
27500
72000
72000
33000
33000
NABH
Package
Cost
78000
78000
35750
35750
Outside State
NABH
Package Cost
87000
87000
39875
39875
Mandatory Documents - Pre
Authorization
a) Clinical notes detailing the
injury.
b) Need of surgery.
c) MLC
d) FIR
e) Nerve conduction velocity
(NCV).
f) MRI
g) MRA
h) EMG (Electromyography).
a) Clinical notes detailing the
injury.
b) Need of surgery.
c) MLC
d) FIR
e) Nerve conduction velocity
(NCV).
f) MRI
g) MRA
h) EMG (Electromyography).
a) Clinical notes confirming
diagnosis with Evidence of .
b) CT.
c) MRI.
d) FNAC.
e) Biopsy.
f) Sr. Cortisol.
g) Sr. electrolytes.
h) 24 hr urinary catacholamine
level.
i) sr. or urinary metanephrine
normetanephrine.
j) MIBG Scan.
k) DOTONOC scan.
a) Clinical notes confirming
diagnosis with Evidence of .
b) CT.
c) MRI.
d) FNAC.
e) Biopsy.
f) Sr. Cortisol.
g) Sr. electrolytes.
h) 24 hr urinary catacholamine
level.
i) sr. or urinary metanephrine
normetanephrine.
j) MIBG Scan.
k) DOTONOC scan.
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Intra operative still photograph.
b) Detailed discharge summary.
c) Detailed operatives notes.
OPEN
Y
YES
Y
YES
a) Intra operative still photograph.
b) Detailed discharge summary.
c) Detailed operatives notes.
OPEN
a) Histopathology.
b) Detailed discharge summary
detailed Procedure .
c) Operative Notes.
OPEN
Y
a) Histopathology.
b) Detailed discharge summary
detailed Procedure .
c) Operative Notes.
OPEN
Y
1326
Urology
SU
Renal Cyst deroofing
SU002
or Marsupialization
SU002A Open
25000
30000
32500
36250
a) Clinical notes and USG.
b) CT scan confirming the renal
cyst.
c) justification of the surgery.
a) Intra procedure still photograph.
b) detailed discharge summary.
c) detailed Procedure .
OPEN
d) Operative Notes.
a) Clinical notes and USG.
b) CT scan confirming the renal
cyst.
c) justification of the surgery.
a) Intra procedure still photograph.
b) detailed discharge summary.
c) detailed Procedure .
OPEN
d) Operative Notes.
Y
1327
Urology
SU
SU002
Renal Cyst deroofing
or Marsupialization
Lap. - (Renal Cyst
SU002B deroofing or
Marsupialization)
25000
30000
32500
36250
Y
SL NO
1328
1329
1330
1331
1332
1333
1334
Specialty
Urology
Urology
Urology
Urology
Urology
Urology
Urology
Specialty
Code
SU
SU
SU
SU
SU
SU
SU
Package
Code
Package Name
SU003 Nephrectomy
SU003 Nephrectomy
SU003 Nephrectomy
SU003 Nephrectomy
SU004
SU004
Nephrectomy - Partial
or Hemi
Nephrectomy - Partial
or Hemi
SU005 Nephrolithotomy
Procedure
Code
SU003A
SU003B
SU003C
SU003D
Procedure Name
For Benign pathology Open
For Benign pathology Lap.
Radical (Renal tumor) Open
Radical (Renal tumor) Lap.
SU004A Open
SU004B
Lap. - (Nephrectomy Partial or Hemi)
SU005A Open
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
27500
27500
29946
27500
45734
42000
30000
33000
33000
35935
33000
54880
50400
36000
NABH
Package
Cost
35750
35750
38929
35750
59454
54600
39000
Outside State
NABH
Package Cost
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Clinical notes.
b) USG.
c) CT confirming the need for
surgery .
d) FNAC.
e) Biopsy.
a) Histopathology.
b) Intra operative photograph.
Detailed discharge summary.
c) detailed Procedure .
d) Operative Notes.
a) Clinical notes.
b) USG.
c) CT confirming the need for
surgery .
d) FNAC.
e) Biopsy.
a) Histopathology.
b) Intra operative photograph.
Detailed discharge summary.
c) detailed Procedure .
d) Operative Notes.
a) Clinical notes.
b) CT.
c) MRI confirming the need for
surgery .
d) FNAC.
e) Biopsy.
a) Histopathology.
b) Intra operative photograph.
c) Post procedure X-ray. Detailed
discharge summary.
OPEN
d) detailed Procedure.
e) Operative Notes.
a) Clinical notes.
b) CT.
c) MRI confirming the need for
surgery .
d) FNAC.
e) Biopsy.
a) Histopathology.
b) Intra operative photograph.
c) Post procedure X-ray. Detailed
discharge summary.
OPEN
d) detailed Procedure.
e) Operative Notes.
66314
a) Clinical notes.
b) CT.
c) MRI confirming the need for
surgery.
a) Histopathology.
b) Intra operative photograph.
Detailed discharge summary.
c) detailed Procedure .
d) Operative Notes.
60900
a) Clinical notes.
b) CT.
c) MRI confirming the need for
surgery.
a) Histopathology.
b) Intra operative photograph.
Detailed discharge summary.
c) detailed Procedure .
d) Operative Notes.
39875
39875
43421
39875
43500
OPEN
Y
a) Clinical notes.
b) IVP.
c) NCCT.
d) CT-IVP confirming the
indication .
a) Post procedure Imaging (X
Ray/USG).
b) showing stone removed.
c) Detailed discharge summary.
d) detailed Procedure.
e) Operative Notes.
a) Clinical notes.
b) IVP.
c) NCCT.
d) CT-IVP confirming the
indication .
a) Post procedure Imaging (X
Ray/USG).
b) showing stone removed.
c) Detailed discharge summary.
d) detailed Procedure.
e) Operative Notes.
OPEN
Y
Y
Y
OPEN
Y
YES
Y
YES
OPEN
OPEN
Y
1335
Urology
SU
SU005 Nephrolithotomy
SU
Open
SU006 Nephrolithotomy Follow Up
SU005B
Anatrophic
(Nephrolithotomy)
30000
36000
39000
43500
OPEN
Y
1336
Urology
SU006A
Open Nephrolithotomy Follow Up
1000
1200
1300
1450
Earlier Discharge Summary
a) USG.
b) Urine Routine.
c) Drugs.
OPEN
N
SL NO
1337
Specialty
Urology
Specialty
Code
SU
Package
Code
SU007
Package Name
PCNL (Percutaneous
Nephrolithotomy)
Procedure
Code
SU007A
Procedure Name
PCNL (Percutaneous
Nephrolithotomy)
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
35000
42000
NABH
Package
Cost
45500
Outside State
NABH
Package Cost
50750
Mandatory Documents - Pre
Authorization
a) Clinical notes.
b) IVP.
c) NCCT.
d) CT-IVP confirming the
indication.
e) need for PCNL.
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Intra operative photograph.
Detailed discharge summary.
b) detailed Procedure.
c) Operative Notes.
OPEN
d) Post procedure Imaging (X
Ray/USG).
N
1338
Urology
SU
Nephrostomy SU008 Percutaneous
ultrasound guided
Nephrostomy SU008A Percutaneous
ultrasound guided
14000
16800
18200
20300
a) Intra procedure clinical
a) Clinical notes.
photograph.
b) USG confirming the indication . b) detailed discharge summary.
c) need of procedure.
c) detailed Procedure.
d) Operative Notes.
OPEN
N
1339
1340
1341
1342
1343
Urology
Urology
Urology
Urology
Urology
SU
SU
SU
SU
SU
SU009
SU010
SU010
SU011
SU011
Nephrostomy (PCN) Follow Up
Nephro ureterectomy
(Benign)
Nephro ureterectomy
(Benign)
Nephro ureterectomy
with cuff of bladder
Nephro ureterectomy
with cuff of bladder
SU009A
Nephrostomy (PCN) Follow Up
SU010A Open
SU010B
Lap. - (Nephro
ureterectomy (Benign))
SU011A Open
Lap. - (Nephro
SU011B ureterectomy with cuff
of bladder)
1200
27500
27500
27500
27500
1440
33000
33000
33000
33000
1560
35750
35750
35750
35750
1740
39875
39875
39875
39875
Earlier Discharge Summary
a) USG.
b) X-RAY KUB.
OPEN
N
a) Clinical notes.
b) CT.
c) CT-IVP.
d) MRI confirming the need for
surgery.
a) Histopathology.
b) Intra operative photograph.
Detailed discharge summary.
c) detailed Procedure.
d) Operative Notes.
a) Clinical notes.
b) CT.
c) CT-IVP.
d) MRI confirming the need for
surgery.
a) Histopathology.
b) Intra operative photograph.
Detailed discharge summary.
c) detailed Procedure.
d) Operative Notes.
a) Clinical notes.
b) CT.
c) CT-IVP.
d) MRI.
e) MRI Urogram confirming the
need for surgery.
a) Histopathology.
b) Intra operative photograph.
Detailed discharge summary.
c) detailed Procedure.
d) Operative Notes.
a) Clinical notes.
b) CT.
c) CT-IVP.
d) MRI.
e) MRI Urogram confirming the
need for surgery.
a) Histopathology.
b) Intra operative photograph.
Detailed discharge summary.
c) detailed Procedure.
d) Operative Notes.
a) Clinical notes.
b) USG.
c) CT confirming the diagnosis of
perinephric abscess.
a) Intra procedure still photograph.
b) detailed discharge summary.
c) detailed Procedure.
OPEN
d) Operative Notes.
a) Clinical notes.
b) USG.
c) CT confirming the diagnosis of
perinephric abscess.
a) Intra procedure still photograph.
b) detailed discharge summary.
c) detailed Procedure.
OPEN
d) Operative Notes.
a) Clinical notes.
b) IVP.
c) NCCT.
d) CT-IVP confirming the
indication .
a) Detailed discharge summary.
b) Post procedure Imaging (X
Ray/USG).
c) showing stone removed detailed
OPEN
Procedure.
d) Operative Notes.
OPEN
Y
OPEN
Y
OPEN
Y
OPEN
Y
1344
Urology
SU
SU013
Perinephric Abscess
drainage
SU013A Open
14000
16800
18200
20300
Y
1345
Urology
SU
SU013
Perinephric Abscess
drainage
SU013B Percutaneous
14000
16800
18200
20300
Y
1346
Urology
SU
Ureteroscopy + Stone
SU014 removal with
lithotripsy
SU014A Lower Ureter
28000
33600
36400
40600
Y
SL NO
1347
Specialty
Urology
Specialty
Code
SU
Package
Code
Package Name
Ureteroscopy + Stone
SU014 removal with
lithotripsy
Procedure
Code
Procedure Name
SU014B Upper Ureter
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
28000
33600
NABH
Package
Cost
36400
Outside State
NABH
Package Cost
40600
Mandatory Documents - Pre
Authorization
a) Clinical notes.
b) IVP.
c) NCCT.
d) CT-IVP confirming the
indication .
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Detailed discharge summary.
b) Post procedure Imaging (X
Ray/USG).
c) showing stone removed detailed
OPEN
Procedure.
d) Operative Notes.
Y
1348
Urology
SU
SU015
URSL / URSL - Laser
- Follow Up
SU015A
URSL / URSL - Laser Follow Up
1000
1200
1300
1450
Earlier Discharge Summary
a) USG.
b) Urine Routine.
c) Drugs.
OPEN
N
1349
Urology
SU
Extracoporeal shock SU016 wave Lithotripsy
(ESWL)
Extracoporeal shock wave Lithotripsy
SU016A
(ESWL) stone, with or
without stent (one side)
25000
30000
32500
36250
a) Clinical notes.
b) IVP.
c) NCCT.
d) CT-IVP confirming the
indication.
e) need for ESWL.
f) Is EHCP registered for ESWL?
a) Intra operative photograph.
Detailed discharge summary.
b) detailed Procedure .
c) Operative Notes.
OPEN
N
1350
Urology
SU
SU017 ESWL - Follow Up
SU017A ESWL - Follow Up
1000
1200
1300
1450
Earlier Discharge Summary
a) USG.
b) X-RAY KUB.
OPEN
N
1351
Urology
SU
SU018 Ureterolithotomy
SU018A Open
20000
24000
26000
29000
a) Clinical notes.
b) IVP.
c) NCCT.
d) CT-IVP confirming the
indication .
a) Detailed discharge summary.
b) detailed Procedure.
c) Operative Notes,Post
procedure Imaging (X Ray/USG). OPEN
d) showing stone removed.
a) Clinical notes.
b) IVP.
c) NCCT.
d) CT-IVP confirming the
indication .
a) Detailed discharge summary.
b) Post procedure Imaging (X
Ray/USG).
c) showing stone removed detailed
OPEN
Procedure.
d) Operative Notes.
Y
1352
Urology
SU
SU018 Ureterolithotomy
SU018B
Lap. (Ureterolithotomy)
20000
24000
26000
29000
Y
1353
Urology
Lap Ureterolithotomy Follow Up
SU
SU019
SU
Open
SU020 Ureterolithotomy Follow Up
SU019A
Lap Ureterolithotomy Follow Up
1000
1200
1300
1450
Earlier Discharge Summary
a) USG.
b) Urine Routine.
c) Drugs.
Earlier Discharge Summary
a) USG.
b) Urine Routine.
c) Drugs.
OPEN
N
1354
1355
1356
Urology
Urology
Urology
SU
SU
Pyeloplasty /
SU021 Pyeloureterostomy /
Pyelopyelostomy
Pyeloplasty /
SU021 Pyeloureterostomy /
Pyelopyelostomy
SU020A
Open Ureterolithotomy Follow Up
SU021A Pyeloplasty - Open
Pyeloplasty SU021B
Laparoscopic
1000
27500
27500
1200
33000
33000
1300
35750
35750
1450
39875
39875
a) Clinical notes.
b) IVP.
c) CT.
d) CT-IVP.
e) DTPA renal scan.
f) confirming indication.
g) the need for surgery.
a) Clinical notes.
b) IVP.
c) CT.
d) CT-IVP.
e) DTPA renal scan.
f) confirming indication.
g) the need for surgery.
OPEN
N
a) Intra operative photograph.
Detailed discharge summary.
b) detailed Procedure.
c) Operative Notes.
OPEN
Y
a) Intra operative photograph.
Detailed discharge summary.
b) detailed Procedure.
c) Operative Notes.
OPEN
Y
SL NO
1357
1358
1359
1360
Specialty
Urology
Urology
Urology
Urology
Specialty
Code
SU
SU
SU
SU
Package
Code
Package Name
Pyeloplasty /
SU021 Pyeloureterostomy /
Pyelopyelostomy
Pyeloplasty /
SU021 Pyeloureterostomy /
Pyelopyelostomy
Pyeloplasty /
SU021 Pyeloureterostomy /
Pyelopyelostomy
Pyeloplasty /
SU021 Pyeloureterostomy /
Pyelopyelostomy
Procedure
Code
SU021C
SU021D
SU021E
SU021F
Procedure Name
Pyeloureterostomy Open
Pyeloureterostomy Laparoscopic
Pyelopyelostomy Open
Pyelopyelostomy Laparoscopic
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
27500
27500
27500
27500
33000
33000
33000
33000
NABH
Package
Cost
35750
35750
35750
35750
Outside State
NABH
Package Cost
39875
39875
39875
39875
Mandatory Documents - Pre
Authorization
a) Clinical notes.
b) IVP.
c) CT.
d) CT-IVP.
e) DTPA renal scan.
f) confirming indication.
g) the need for surgery.
a) Clinical notes.
b) IVP.
c) CT.
d) CT-IVP.
e) DTPA renal scan.
f) confirming indication.
g) the need for surgery.
a) Clinical notes.
b) IVP.
c) CT.
d) CT-IVP.
e) DTPA renal scan.
f) confirming indication.
g) the need for surgery.
a) Clinical notes.
b) IVP.
c) CT.
d) CT-IVP.
e) DTPA renal scan.
f) confirming indication.
g) the need for surgery.
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Intra operative photograph.
Detailed discharge summary.
b) detailed Procedure.
c) Operative Notes.
OPEN
Y
a) Intra operative photograph.
Detailed discharge summary.
b) detailed Procedure.
c) Operative Notes.
OPEN
Y
a) Intra operative photograph.
Detailed discharge summary.
b) detailed Procedure.
c) Operative Notes.
OPEN
Y
a) Intra operative photograph.
Detailed discharge summary.
b) detailed Procedure.
c) Operative Notes.
OPEN
Y
1361
1362
1363
Urology
Urology
Urology
SU
SU
SU
SU022 Pyeloplasty
SU023 Ureterocalycostomy
SU023 Ureterocalycostomy
SU022A Pyeloplasty - Follow Up
SU023A
SU023B
Ureterocalycostomy Open
Ureterocalycostomy Laparoscopic
1500
25000
25000
1800
30000
30000
1950
32500
32500
2175
36250
36250
Earlier Discharge Summary
a) USG.
b) UFM.
c) Urine Routine.
a) Clinical notes.
b) IVP.
c) CT
d) CT-IVP
e) DTPA renal scan.
a) Intra operative photograph.
Detailed discharge summary.
b) detailed Procedure.
c) Operative Notes.
a) Clinical notes.
b) IVP.
c) CT
d) CT-IVP
e) DTPA renal scan.
a) Intra operative photograph.
Detailed discharge summary.
b) detailed Procedure.
c) Operative Notes.
OPEN
N
OPEN
Y
OPEN
Y
1364
Urology
SU
SU024 Pyelolithotomy
SU024A Open
28000
33600
36400
40600
a) Clinical notes.
b) IVP.
c) NCCT.
d) CT-IVP confirming the
indication .
a) Post procedure Imaging (X
Ray/USG).
b) showing stone removed.
c) Detailed discharge summary.
d) detailed Procedure.
e) Operative Notes.
a) Clinical notes.
b) IVP.
c) NCCT.
d) CT-IVP confirming the
indication .
a) Post procedure Imaging (X
Ray/USG).
b) showing stone removed.
c) Detailed discharge summary.
d) detailed Procedure.
e) Operative Notes.
OPEN
Y
1365
Urology
SU
SU024 Pyelolithotomy
SU024B Lap. - (Pyelolithotomy)
28000
33600
36400
40600
OPEN
Y
SL NO
1366
Specialty
Urology
Specialty
Code
SU
Package
Code
Package Name
Internal Ureterotomy
including cystoscopy
SU025
as an independent
procedure
Procedure
Code
Procedure Name
Internal Ureterotomy
including cystoscopy as
SU025A
an independent
procedure
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
10000
12000
NABH
Package
Cost
13000
Outside State
NABH
Package Cost
14500
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Endoscopic Intra procedure still
a) Clinical notes .
photograph.
b) Investigation reports confirming b) detailed discharge summary.
urethral stricture (RGU+/- MCU). c) Detailed Procedure.
OPEN
d) Operative Notes.
N
1367
Urology
SU
Ureterolysis for
retroperitoneal fibrosis
SU026
(with or without
omental wrapping)
SU026A Open
28000
33600
36400
40600
a) Clinical notes.
b) CT-IVP.
c) MRI Urogram confirming the
diagnosis for which the surgery is
done.
a) Intra procedure still photograph.
b) Detailed discharge summary.
c) detailed Procedure.
d) Operative Notes including
OPEN
details of omental wrapping if done.
Y
1368
1369
1370
1371
1372
1373
Urology
Urology
Urology
Urology
Urology
Urology
SU
SU
SU
SU
SU
SU
Ureterolysis for
retroperitoneal fibrosis
SU026
(with or without
omental wrapping)
SU027 Ureterostomy
SU028 Uretero-ureterostomy
SU028 Uretero-ureterostomy
SU029
SU029
Uretero-vaginal /
Uterine fistula repair
Uretero-vaginal /
Uterine fistula repair
Lap. - (Ureterolysis for
retroperitoneal fibrosis
SU026B
(with or without
omental wrapping))
SU027A
Ureterostomy
(Cutaneous)
SU028A Open
SU028B
SU029A
SU029B
Lap. - (Ureteroureterostomy)
Uretero - vaginal fistula
repair - Open
Uretero - Uterine fistula
repair - Open
28000
20000
25000
25000
25000
25000
33600
24000
30000
30000
30000
30000
36400
26000
32500
32500
32500
32500
40600
29000
36250
36250
36250
36250
a) Clinical notes.
b) CT-IVP.
c) MRI Urogram confirming the
diagnosis for which the surgery is
done.
a) Intra procedure still photograph.
b) Detailed discharge summary.
c) detailed Procedure.
d) Operative Notes including
OPEN
details of omental wrapping if done.
Y
a) Clinical notes.
b) CT.
c) MRI confirming the diagnosis
for ureterostomy.
d) need for creating a stoma for
ureter.
a) Post Procedure Clinical
Photograph stoma.
b) Detailed discharge summary.
c) detailed Procedure.
d) Operative Notes.
a) Clinical notes.
b) IVP.
c) CT.
d) CT-IVP.
e) DTPA renal scan.
a) Intra operative photograph.
b) Detailed discharge summary.
c) detailed Procedure.
d) Operative Notes.
a) Clinical notes.
b) IVP.
c) CT.
d) CT-IVP.
e) DTPA renal scan.
a) Intra operative photograph.
b) Detailed discharge summary.
c) detailed Procedure.
d) Operative Notes.
a) Clinical notes.
b) IVP.
c) CT-IVP .
d) cystoscopy .
e) vaginoscopy Scopy confirming
the diagnosis for which the surgery
is done.
a) Clinical notes.
b) IVP.
c) CT-IVP .
d) cystoscopy .
e) vaginoscopy Scopy confirming
the diagnosis for which the surgery
is done.
OPEN
N
OPEN
Y
OPEN
Y
a) Intra procedure still photograph.
b) Detailed discharge summary.
c) detailed Procedure.
OPEN
d) Operative Notes.
Y
a) Intra procedure still photograph.
b) Detailed discharge summary.
c) detailed Procedure.
OPEN
d) Operative Notes.
Y
SL NO
1374
1375
Specialty
Urology
Urology
Specialty
Code
SU
SU
Package
Code
SU029
SU029
Package Name
Uretero-vaginal /
Uterine fistula repair
Uretero-vaginal /
Uterine fistula repair
Procedure
Code
SU029C
SU029D
Procedure Name
Uretero - vaginal fistula
repair - Laparoscopic
Uretero - Uterine fistula
repair - Laparoscopic
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
25000
25000
30000
30000
NABH
Package
Cost
32500
32500
Outside State
NABH
Package Cost
36250
36250
Mandatory Documents - Pre
Authorization
a) Clinical notes.
b) IVP.
c) CT-IVP .
d) cystoscopy .
e) vaginoscopy Scopy confirming
the diagnosis for which the surgery
is done.
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Intra procedure still photograph.
b) Detailed discharge summary.
c) detailed Procedure.
OPEN
d) Operative Notes.
Y
a) Clinical notes.
b) IVP.
c) CT-IVP .
d) cystoscopy .
e) vaginoscopy Scopy confirming
the diagnosis for which the surgery
is done.
a) Intra procedure still photograph.
b) Detailed discharge summary.
c) detailed Procedure.
OPEN
d) Operative Notes.
a) Clinical notes.
b) CT-IVP.
c) MRI Urogram.
d) MCU confirming reflux.
e) need of surgery.
a) Intra procedure clinical
photograph.
b) Detailed discharge summary.
c) detailed Procedure.
d) Operative Notes.
Y
1376
Urology
SU
SU030 Ureteric reimplantation
SU030A Open
23000
27600
29900
33350
OPEN
Y
1377
Urology
SU
SU030 Ureteric reimplantation
Lap. - (Ureteric
SU030B
reimplantation)
23000
27600
29900
33350
a) Clinical notes.
b) CT-IVP.
c) MRI Urogram.
d) MCU confirming reflux.
e) need of surgery.
a) Intra procedure still photograph.
b) Detailed discharge summary.
c) detailed Procedure.
OPEN
d) Operative Notes.
Y
1378
Urology
SU
SU031
Boari flap for ureteric
stricture
SU031A Open
30000
36000
39000
43500
a) Clinical notes.
b) IVP.
c) CT-IVP.
d) MCU confirming the stricture
longer than 5 cms for which the
surgery is done.
a) Intra procedure still photograph.
b) Detailed discharge summary.
c) detailed Procedure.
d) Operative Notes including
OPEN
details of omental wrapping if done.
Y
1379
Urology
SU
SU031
Boari flap for ureteric
stricture
SU031B
Lap. - (Boari flap for
ureteric stricture)
30000
36000
39000
43500
a) Clinical notes.
b) IVP.
c) CT-IVP.
d) MCU confirming the stricture
longer than 5 cms for which the
surgery is done.
a) Intra procedure still photograph.
b) Detailed discharge summary.
c) detailed Procedure.
d) Operative Notes including
OPEN
details of omental wrapping if done.
Y
1380
1381
Urology
Urology
SU
SU
SU032
SU033
Ileal replacement for
ureteric stricture
DJ stenting including
cystoscopy, ureteric
catheterization,
retrograde pyelogram
SU032A
SU033A
Ileal replacement for
ureteric stricture
DJ stenting including
cystoscopy, ureteric
catheterization,
retrograde pyelogram
46000
9800
55200
11760
59800
12740
66700
14210
a) Clinical notes.
b) IVP.
c) CT-IVP.
d) MCU confirming the stricture
longer than 5 cms for which the
surgery is done.
a) Intra procedure still photograph.
b) Detailed discharge summary.
c) detailed Procedure.
d) Operative Notes including
OPEN
details of omental wrapping if done.
a) Post Procedure x-ray showing
stent.
b) detailed Procedure.
a) Clinical notes.
c) Operative Notes detailing
b) CT-IVP.
findings of cystoscopy.
c) IVP confirming the diagnosis.
d) the need of this surgery is done. d) Retrogradepyelogram.
e) ureteric catheterization.
f) detailed discharge summary.
N
OPEN
N
SL NO
1382
Specialty
Urology
Specialty
Code
SU
Package
Code
Package Name
SU034 DJ Stent Removal
Procedure
Code
Procedure Name
SU034A DJ Stent Removal
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
5000
6000
NABH
Package
Cost
6500
Outside State
NABH
Package Cost
7250
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Clinical notes with planned line
of treatment including planned line
of treatment.
b) X-ray films with reports.
discharge summary
c) Discharge Summary of DJ
Stenting .
OPEN
N
1383
Urology
SU
Ureterocele incision
including cystoscopy,
SU035 ureteric
catheterization,
retrograde pyelogram
Ureterocele incision
including cystoscopy,
SU035A
ureteric catheterization,
retrograde pyelogram
15000
18000
19500
21750
a) Clinical notes.
b) IVP.
c) CT-IVP confirming the
diagnosis for which the surgery is
done.
a) Evidence of cystoscopy.
b) ureteric catheterization.
c) retrograde pyelogram.
d) Detailed discharge summary.
e) detailed Procedure.
f) Operative Notes.
OPEN
N
1384
1385
1386
1387
Urology
Urology
Urology
Urology
SU
SU
SU
SU
Ureteric sampling
including cystoscopy,
SU036 ureteric
catheterization,
retrograde pyelogram
SU037
Acute management of
upper urinary tract
trauma –
conservative
SU038 Endopyelotomy
SU038 Endopyelotomy
SU036A
SU037A
SU038A
SU038B
Ureteric sampling
including cystoscopy,
ureteric catheterization,
retrograde pyelogram
Acute management of
upper urinary tract
trauma –
conservative
Retrograde with laser /
bugbee
Antegrade with laser /
bugbee
11000
2000
25000
25000
13200
2400
30000
30000
14300
2600
32500
32500
15950
2900
36250
36250
a) Evidence of cystoscopy.
a) Clinical notes.
b) ureteric catheterization.
b) Reports of all previous work
c) retrograde pyelogram.
up done (Xray/USG/CT Scan).
d) the diagnosis arrived at.
c) clinical diagnosis suspected for e) Detailed discharge summary.
this procedure.
f) detailed Procedure .
g) Operative Notes.
OPEN
N
a) Clinical notes detailing the case
history.
b) circumstances that led to
trauma.
c) presenting complaints.
d) local examination findings.
e) injuries sustained as result of
trauma.
f) USG.
g) CT Abdomen.
a) Reports of all investigations
done.
b) consultation paper of treating
doctor mentioning the final
diagnosis.
c) line of treatment.
d) Detailed discharge summary.
a) Clinical notes.
b) IVP.
c) CT.
d) CT-IVP.
e) DTPA renal scan.
f) is the hospital equipped with
Laser.
a) Intra operative photograph.
Detailed discharge summary.
b) detailed Procedure.
c) Operative Notes. If bugbee
electrode is billed.
d) insist on invoice.
e) barcode.
a) Clinical notes.
b) IVP.
c) CT.
d) CT-IVP.
e) DTPA renal scan.
f) is the hospital equipped with
Laser.
a) Intra operative photograph.
Detailed discharge summary.
b) detailed Procedure.
c) Operative Notes. If bugbee
electrode is billed.
d) insist on invoice.
e) barcode.
Earlier Discharge Summary
a) USG.
b) Urine Routine.
c) Drugs.
OPEN
N
OPEN
Y
OPEN
Y
1388
Urology
SU
SU039
Open Pyelolithotomy Follow Up
SU039A
Open Pyelolithotomy Follow Up
1200
1440
1560
1740
OPEN
N
1389
Urology
SU
Cystolithotomy SU040 Open, including
cystoscopy
SU040A
Open - including
cystoscopy
18500
22200
24050
26825
a) Clinical notes.
b) X ray KUB.
a) Detailed discharge summary.
c) USG.
b) detailed Procedure.
d) IVP.
c) Operative Notes.
e) NCCT confirming the diagnosis
of large bladder stone.
OPEN
N
SL NO
1390
Specialty
Urology
Specialty
Code
SU
Package
Code
SU041
Package Name
Cystolithotripsy /
Urethral Stone
endoscopic, including
cystoscopy
Procedure
Code
Procedure Name
Cystolithotripsy
SU041A endoscopic, including
cystoscopy
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
18500
22200
NABH
Package
Cost
24050
Outside State
NABH
Package Cost
26825
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Clinical notes.
b) X ray KUB.
a) Detailed discharge summary.
c) USG.
b) detailed Procedure.
d) IVP.
c) Operative Notes.
e) NCCT confirming the diagnosis
of large bladder stone.
OPEN
Y
1391
Urology
SU
SU041
Cystolithotripsy /
Urethral Stone
endoscopic, including
cystoscopy
Urethral Stone removal
SU041B endoscopic, including
cystoscopy
18500
22200
24050
26825
a) Clinical notes.
b) X ray KUB.
a) Detailed discharge summary.
c) USG.
b) detailed Procedure.
d) IVP.
c) Operative Notes.
e) NCCT confirming the diagnosis
of large bladder stone.
OPEN
Y
1392
Urology
SU
SU042 Diagnostic Cystoscopy
SU042A Diagnostic Cystoscopy
6500
7800
8450
9425
a) Clinical notes.
b) Reports of all work up done (
Xray/USG/CT Scan/MRI).
c) suspected differential diagnosis.
a) Intra procedure still photograph.
b) Detailed discharge summary
Detailed Procedure.
OPEN
c) Operative Notes.
N
1393
Urology
SU
SU043 Partial Cystectomy
SU043A Open
23000
27600
29900
33350
a) Clinical notes.
b) CT.
c) MRI confirming the indication.
d) need of this surgery with
supporting Evidence of the same
(FNAC/Biopsy).
a) Histopathology.
b) Detailed discharge summary.
c) detailed Procedure.
d) Operative Notes.
OPEN
Y
1394
Urology
SU
SU043 Partial Cystectomy
1395
Urology
SU
SU044
SU043B
Lap. - (Partial
Cystectomy)
26100
31320
33930
37845
SU044A
Partial Cystectomy Follow Up
1000
1200
1300
1450
a) Clinical notes.
b) CT.
c) MRI confirming the indication.
d) need of this surgery with
supporting Evidence of the same
(FNAC/Biopsy).
a) Histopathology.
b) Detailed discharge summary.
c) detailed Procedure.
d) Operative Notes.
Earlier Discharge Summary
USG
a) Clinical notes.
b) IVP.
c) CT IVP.
d) MRI.
e) Cystogram.
f) Cystoscopy.
g) confirming the indication for
which the surgery is done.
a) Intraoperative still images.
b) Post procedure Imaging.
c) Detailed discharge summary.
d) detailed Procedure.
e) Operative Notes.
OPEN
Y
1396
Urology
SU
SU045
Partial Cystectomy Follow Up
Augmentation
cystoplasty
Augmentation
cystoplasty
1397
Urology
SU
SU045
1398
Urology
SU
SU046 Deflux for VUR
SU
Bladder
SU047
Diverticulectomy
SU045A Open
SU045B
Lap. - (Augmentation
cystoplasty)
30000
36000
39000
43500
a) Clinical notes.
b) IVP.
c) CT IVP.
d) MRI.
e) Cystogram.
f) Cystoscopy.
g) confirming the indication for
which the surgery is done.
OPEN
N
OPEN
Y
a) Intraoperative still images.
b) Post procedure Imaging.
c) Detailed discharge summary.
d) detailed Procedure.
e) Operative Notes.
OPEN
30000
36000
39000
43500
SU046A Deflux for VUR
1200
1440
1560
1740
Clinical notes with planned line of
IVU
treatment
OPEN
Bladder
SU047A Diverticulectomy Follow Up
1000
1200
1300
1450
Earlier Discharge Summary
OPEN
Y
1399
Urology
USG
N
N
SL NO
1400
1401
1402
Specialty
Urology
Urology
Urology
Specialty
Code
SU
SU
SU
Package
Code
Package Name
Open bladder
diverticulectomy with
SU048
/ without ureteric reimplantation
Bladder injury repair
SU049 (with or without
urethral injury)
SU050
Bladder injury repair
with colostomy
(with or without
urethral injury)
Procedure
Code
Procedure Name
Open bladder
diverticulectomy with /
SU048A
without ureteric reimplantation
Bladder injury repair
SU049A (with or without
urethral injury)
SU050A
Bladder injury repair
with colostomy
(with or without
urethral injury)
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
25000
23000
27500
30000
27600
33000
NABH
Package
Cost
32500
29900
35750
Outside State
NABH
Package Cost
36250
33350
39875
Mandatory Documents - Pre
Authorization
a) Clinical notes.
b) USG.
c) CT.
d) MRI.
e) Cystoscopy confirming bladder
diverticulum.
f) need for surgery.
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Intra procedure clinical
photograph.
b) Detailed discharge summary.
c) detailed Procedure.
d) Operative Notes.
OPEN
N
a) Clinical notes.
b) USG.
c) CT.
d) MRI.
e) cystogram confirming the
diagnosis of bladder injury.
f) MLC.
g) FIR if traumatic.
a) Detailed discharge summary.
b) detailed Procedure.
c) Operative Notes.
a) Clinical notes.
b) USG.
c) CT.
d) MRI.
e) cystogram confirming the
diagnosis of bladder injury.
f) MLC.
g) FIR if traumatic.
a) Detailed discharge summary of
both surgeries.
b) detailed Procedure.
c) Operative Notes.
d) Post procedue pic of
Colostomy.
OPEN
N
OPEN
N
1403
1404
1405
Urology
Urology
Urology
SU
Extrophy Bladder
repair including
SU051 osteotomy if needed +
epispadias repair +
ureteric reimplant
Extrophy Bladder repair
including osteotomy if
SU051A needed + epispadias
repair + ureteric
reimplant
SU
Neurogenic bladder Package for
evaluation /
SU052 investigation (catheter
+ ultrasound + culture
+ RGU/ MCU) for 1
month (medicines -
Neurogenic bladder Package for evaluation
/ investigation (catheter
SU052A + ultrasound + culture
+ RGU/ MCU) for 1
month (medicines antibiotics)
SU
Y V Plasty of Bladder
SU053 Neck / Bladder Neck
Reconstruction
Y V Plasty of Bladder
SU053A Neck / Bladder Neck
Reconstruction
65000
78000
84500
94250
a) Clinical notes.
b) USG.
c) CT.
d) MRI confirming the diagnosis
of extrophy of bladder.
e) epispadias. Clinical Photograph
of affected part.
a) Post Procedure Clinical
Photograph of affected part.
b) detailed Procedure.
c) Operative Notes.
OPEN
N
14300
17160
18590
20735
a) Evidence of all investigations
a) Clinical notes detailing the case
done and still images of RGU.
history with previous work up.
b) MCU done with patient name
b) initial diagnosis.
& date.
OPEN
N
23000
27600
29900
33350
a) Clinical notes.
b) urethro Cystoscopy .
c) USG confirming the diagnosis.
21750
a) USG-KUB.
b) PVR.
c) Uroflometry.
a) Detailed Procedure.
b) Operative Notes.
c) detailed discharge summary.
OPEN
N
1406
1407
Urology
Urology
SU
SU
SU054
SU055
Bladder Neck incision
- Endoscopic
TURBT
(Transurethral
Resection of the
Bladder Tumor)
SU054A
SU055A
Bladder Neck incision Endoscopic
TURBT
(Transurethral
Resection of the
Bladder Tumor)
15000
27500
18000
33000
19500
35750
39875
Endoscopic picture
OPEN
N
a) Clinical notes.
b) USG.
c) CT.
d) MRI confirming the diagnosis
bladder tumour.
a) Histopathology.
b) Detailed discharge summary.
c) detailed Procedure.
d) Operative Notes.
a) Clinical notes.
b) USG.
c) CT.
d) MRI confirming the diagnosis
bladder tumour.
a) Intra procedure still photograph
Histopathology.
b) Detailed discharge summary.
c) detailed Procedure.
OPEN
d) Operative Notes.
OPEN
N
1408
Urology
SU
SU056 TURBT - Restage
SU056A TURBT - Restage
18000
21600
23400
26100
N
SL NO
1409
1410
1411
Specialty
Urology
Urology
Urology
Specialty
Code
SU
SU
SU
Package
Code
Package Name
Post TURBT - Check
Cystoscopy (Per
SU057
sitting) with cold-cup
biopsy
SU058 Urachal Cyst excision
SU058 Urachal Cyst excision
Procedure
Code
Procedure Name
Post TURBT - Check
SU057A Cystoscopy (Per sitting)
with cold-cup biopsy
SU058A
SU058B
Urachal Cyst excision Open
Urachal Cyst excision Laparoscopic
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
10000
18500
18500
12000
22200
22200
NABH
Package
Cost
13000
24050
24050
Outside State
NABH
Package Cost
14500
26825
26825
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Clinical notes.
b) Histopathology.
c) biopsy confirming the diagnosis
of bladder cancer.
a) Intra procedure still photograph.
b) detailed discharge summary.
c) detailed Procedure.
OPEN
d) Operative Notes.
a) Clinical notes.
b) USG.
c) CT.
d) MRI confirming the diagnosis
of Urachus.
a) Histopathology.
b) Detailed discharge summary.
c) detailed Procedure.
d) Operative Notes.
a) Clinical notes.
b) USG.
c) CT.
d) MRI confirming the diagnosis
of Urachus.
a) Histopathology.
b) Detailed discharge summary.
c) detailed Procedure.
d) Operative Notes.
N
OPEN
Y
OPEN
Y
1412
Urology
SU
SU059
VVF Repair - Follow
Up
SU059A VVF Repair - Follow Up
1500
1800
1950
2175
Earlier Discharge Summary
a) USG .
b) UFM .
c) Urine Routine.
OPEN
N
1413
Urology
SU
SU060
Intravesical BCG /
Mitomycin
SU060A Induction cycles
15000
18000
19500
21750
a) Detailed discharge summary.
a) Clinical notes.
b) Detailed Procedure.
b) Histopathology.
c) Operative Notes.
c) biopsy confirming the diagnosis
d) original bills of medicines
of bladder cancer.
administered.
OPEN
Y
1414
Urology
SU
SU060
Intravesical BCG /
Mitomycin
SU060B Maintenance
30000
36000
39000
43500
a) Detailed discharge summary.
a) Clinical notes.
b) Detailed Procedure.
b) Histopathology.
c) Operative Notes.
c) biopsy confirming the diagnosis
d) original bills of medicines
of bladder cancer.
administered.
OPEN
Y
1415
1416
Urology
Urology
SU
SU061
Suprapubic Drainage Closed / Trocar
Stress incontinence
surgery
SU
SU062
SU
Repair of stress
SU063 incontinence - Follow
Up
SU061A
SU062A
Suprapubic Drainage Closed / Trocar
Stress incontinence
surgery - Open
5000
23000
6000
27600
6500
29900
7250
33350
a) Clinical notes.
b) USG.
c) CT confirming the diagnosis for
which the surgery is done.
a) Detailed Procedure.
b) Operative Notes detailing how
mcuh urine was drained.
c) detailed discharge summary.
a) Clinical notes.
b) Cystoscopy.
c) USG.
d) Uro Dynamic study to
confirm the dignosis.
a) Detailed Procedure.
b) Operative Notes.
c) detailed discharge summary.
Earlier Discharge Summary
Clinical notes with planned line of
treatment
OPEN
N
OPEN
N
1417
1418
Urology
Urology
SU
Emergency
SU064 management of Acute
retention of Urine
Repair of stress
SU063A incontinence - Follow
Up
Emergency
SU064A management of Acute
retention of Urine
1000
2000
1200
2400
1300
2600
1450
2900
a) Evidence of simple
catheterization.
a) Clinical notes detailing chroniciy. b) details of how much urine
b) USG proving retention of urine. drained.
c) Detailed discharge summary
giving aetiology of retention.
OPEN
N
OPEN
N
1419
Urology
SU
SU065
Meatotomy /
Meatoplasty
SU065A Meatotomy
3500
4200
4550
5075
a) Clinical notes.
b) confirmed diagnosis of meatal
stenosis.
a) Detailed discharge summary.
b) detailed Procedure.
c) Operative Notes.
OPEN
Y
SL NO
1420
1421
1422
1423
1424
Specialty
Urology
Urology
Urology
Urology
Urology
Specialty
Code
Package
Code
SU
SU065
SU
SU
SU
SU
Package Name
Meatotomy /
Meatoplasty
SU066 Urethroplasty
SU066 Urethroplasty
SU066 Urethroplasty
SU066 Urethroplasty
Procedure
Code
Procedure Name
SU065B Meatoplasty
SU066A
Urethroplasty - End to
end
Urethroplasty SU066B Substitution - single
stage
SU066C
SU066D
Urethroplasty Substitution - two stage
Urethroplasty Transpubic
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
3500
28000
28000
41500
32000
4200
33600
33600
49800
38400
NABH
Package
Cost
Outside State
NABH
Package Cost
4550
5075
36400
36400
53950
41600
40600
40600
60175
46400
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Clinical notes.
b) confirmed diagnosis of meatal
stenosis.
a) Detailed discharge summary.
b) detailed Procedure.
c) Operative Notes.
a) Clinical notes.
b) ACU (Anterograde
urethrography).
c) micturating cysto-urethrogram
(MCU).
d) Retrograde urethrography
justifying the surgery.
a) Intra procedure clinical
photograph.
b) Detailed discharge summary.
c) detailed Procedure.
d) Operative Notes.
a) Clinical notes.
b) ACU (Anterograde
urethrography).
c) micturating cysto-urethrogram
(MCU).
d) Retrograde urethrography
justifying the surgery.
a) Intra procedure clinical
photograph.
b) Detailed discharge summary.
c) detailed Procedure.
d) Operative Notes.
a) Clinical notes.
b) ACU (Anterograde
urethrography).
c) micturating cysto-urethrogram
(MCU).
d) Retrograde urethrography
justifying the surgery.
a) Intra procedure clinical
photograph.
b) Detailed discharge summary.
c) detailed Procedure.
d) Operative Notes.
a) Clinical notes.
b) ACU (Anterograde
urethrography).
c) micturating cysto-urethrogram
(MCU).
d) Retrograde urethrography
justifying the surgery.
a) Intra procedure clinical
photograph.
b) Detailed discharge summary.
c) detailed Procedure.
d) Operative Notes.
OPEN
Y
OPEN
Y
OPEN
Y
OPEN
Y
OPEN
Y
1425
Urology
SU
SU067
Urethroplasty Follow
Up
SU067A
Urethroplasty Follow
Up
1000
1200
1300
1450
Earlier Discharge Summary
a) USG.
b) UFM.
c) Urine Routine.
OPEN
N
1426
Urology
SU
SU068 Urethral Dilatation
SU068A
Non endocopic as an
independent procedure
2000
2400
2600
2900
a) Detailed discharge summary.
a) Clinical notes.
b) Detailed Procedure.
b) Investigation reports confirming
c) Operative Notes detailing size
urethral stricture (RGU+/- MCU).
of dilators used.
OPEN
Y
1427
Urology
SU
SU068 Urethral Dilatation
SU068B
Endocopic as an
independent procedure
5000
6000
6500
7250
a) Endoscopic Intra procedure still
a) Clinical notes.
photograph.
b) Investigation reports confirming b) detailed discharge summary.
urethral stricture (RGU+/- MCU). c) Detailed Procedure.
OPEN
d) Operative Notes.
Y
1428
Urology
SU
SU069
Perineal Urethrostomy
without closure
SU069A
Perineal Urethrostomy
without closure
20000
24000
26000
29000
a) Clinical notes detailing the
pathology for which performed
with supporting Evidence of RGU
(Retrograde urethrography).
b) MCU.
a) Intra procedure clinical
photograph.
b) Detailed discharge summary.
c) detailed Procedure.
d) Operative Notes.
OPEN
N
SL NO
1429
1430
1431
1432
1433
Specialty
Urology
Urology
Urology
Urology
Urology
Specialty
Code
SU
SU
SU
SU
SU
Package
Code
SU070
Package Name
Post. Urethral Valve
fulguration
SU071 Hypospadias repair
SU071 Hypospadias repair
SU071 Hypospadias repair
SU071 Hypospadias repair
Procedure
Code
SU070A
Procedure Name
Post. Urethral Valve
fulguration
SU071A Single stage
SU071B
SU071C
SU071D
Two or more stage
(First Stage)
Two or more stage
(Intermediate Stage)
Two or more stage
(Final Stage)
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
14000
28000
12000
12000
30000
16800
33600
14400
14400
36000
NABH
Package
Cost
18200
36400
15600
15600
39000
Outside State
NABH
Package Cost
20300
40600
17400
17400
43500
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Clinical notes.
b) confirmation of stenosis of
posterir urethral valve by Voiding
cystourethrogram (preferred).
c) USG.
d) uroflowmetry.
a) Intra procedure clinical
photograph.
b) Post procedure Imaging (USG).
c) Detailed discharge summary.
OPEN
d) detailed Procedure.
e) Operative Notes
a) Clinical notes.
b) Clinical Photograph.
a) Post Procedure Clinical
Photograph of affected part.
b) detailed Procedure.
c) Operative Notes.
d) Detailed Procedure.
e) Operative Notes.
a) Clinical notes.
b) Clinical Photograph.
a) Post Procedure Clinical
Photograph of affected part.
b) detailed Procedure.
c) Operative Notes
a) Clinical notes.
b) Clinical Photograph.
c) evidence of stage 1 (Discharge
Summary).
a) Post Procedure Clinical
Photograph of affected part.
b) detailed Procedure.
c) Operative Notes
a) Clinical notes.
b) Clinical Photograph.
c) evidence of stage 1/2
(Discharge Summary).
a) Post Procedure Clinical
Photograph of affected part.
b) detailed Procedure.
c) Operative Notes
Discharge Summary
a) USG.
b) UFM .
c) Urine Routine.
N
OPEN
Y
OPEN
Y
OPEN
Y
OPEN
Y
1434
Urology
SU
SU072
Hypospadias Repair Follow Up
SU072A
Hypospadias Repair Follow Up
1000
1200
1300
1450
OPEN
N
1435
Urology
SU
Emergency
SU073 management of
Hematuria
Emergency
SU073A management of
Hematuria
2000
2400
2600
2900
Clinical notes detailing the
hematuria with urine report
showing frank or microscopic?
a) Evidence of investigations done
treatment given.
b) detailed discharge summary.
OPEN
N
1436
Urology
SU
SU074
Excision of Urethral
Caruncle
SU074A
Excision of Urethral
Caruncle
5000
6000
6500
7250
a) Histopathology.
a) Clinical notes.
b) Detailed discharge summary.
b) confirmed diagnosis of urethral
c) detailed Procedure.
carunclule.
d) Operative Notes.
OPEN
N
1437
1438
1439
Urology
Urology
Urology
SU
SU
SU
SU075
Urethrovaginal fistula
repair
Urethrorectal fistula
SU076
repair
Open simple
SU077 prostatetctomy for
BPH
SU075A
Urethrovaginal fistula
repair
Urethrorectal fistula
SU076A
repair
SU077A
Open simple
prostatetctomy for BPH
30000
40000
27500
36000
48000
33000
39000
52000
35750
43500
58000
39875
a) Clinical notes.
b) urethro Cystoscopy.
c) Vaginoscopy.
d) USG confirming the diagnosis.
a) Detailed Procedure.
b) Operative Notes.
c) detailed discharge summary.
OPEN
N
a) Clinical notes.
b) confirmation of fistula.
c) it's tract by Cystoscopy.
d) Sigmoidoscopy.
e) RGU.
f) MCU.
a) Detailed Procedure.
b) Operative Notes.
c) detailed discharge summary.
a) Clinical notes.
b) USG with prostate size.
c) Post Void Volume.
d) PSA.
e) Uroflometry.
a) Histopathology.
b) Detailed discharge summary.
c) detailed Procedure.
d) Operative Notes.
OPEN
N
OPEN
N
SL NO
1440
Specialty
Urology
Specialty
Code
SU
Package
Code
Package Name
SU078 Radical prostatectomy
Procedure
Code
Procedure Name
SU078A Open
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
50000
60000
NABH
Package
Cost
65000
Outside State
NABH
Package Cost
72500
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Clinical notes.
b) MRI.
c) CT prostrate.
d) PSA.
e) Biopsy.
a) Histopathology of prostate.
b) Detailed discharge summary.
c) detailed Procedure.
d) Operative Notes with details of OPEN
nodes removed.
a) Clinical notes.
b) MRI.
c) CT prostrate.
d) PSA.
e) Biopsy.
a) Histopathology of prostate.
b) Detailed discharge summary.
c) detailed Procedure.
d) Operative Notes with details of OPEN
nodes removed.
Y
1441
1442
1443
1444
Urology
Urology
Urology
Urology
SU
SU
SU
SU
SU078 Radical prostatectomy
SU079
Holmium Laser
Prostatectomy
TURP-Transurethral
SU080 Resection of the
Prostate, BPH
TURP-Transurethral
SU080 Resection of the
Prostate, BPH
SU078B
SU079A
Lap. - (Radical
prostatectomy)
Holmium Laser
Prostatectomy
SU080A Monopolar
SU080B Bipolar
50000
40000
27500
27500
60000
48000
33000
33000
65000
52000
35750
35750
72500
58000
39875
39875
Y
a) Clinical notes.
b) USG with prostate size.
c) Post Void Volume.
d) PSA.
e) uroflometry Is the hospital
registered for holmium laser.
a) Histopathology.
b) Detailed discharge summary.
c) detailed Procedure.
d) Operative Notes.
a) Clinical notes.
b) USG with prostate size.
c) Post Void Volume.
d) PSA.
e) Uroflometry.
a) Histopathology.
b) Detailed discharge summary.
c) detailed Procedure.
d) Operative Notes.
a) Clinical notes.
b) USG with prostate size.
c) Post Void Volume.
d) PSA.
e) Uroflometry.
a) Histopathology.
b) Detailed discharge summary.
c) detailed Procedure.
d) Operative Notes.
OPEN
N
OPEN
Y
OPEN
Y
1445
Urology
SU
SU081
Transrectal
Ultrasound guided
prostate biopsy
(minimum 12 core)
Transrectal Ultrasound
SU081A guided prostate biopsy
(minimum 12 core)
10000
12000
13000
14500
a) Histopathology showing
a) Clinical notes.
reporting of minimum 12 core
b) USG with prostate size.
samples of prostate.
c) Post Void Volume establishing
b) Detailed discharge summary.
suspicion of malignancy.
c) detailed Procedure.
d) PSA.
d) Operative Notes.
OPEN
N
1446
Urology
SU
SU082 Penectomy
SU082A Partial Penectomy
16334
19600
21234
23684
a) Clinical notes.
b) Biopsy findings.
a) Histopathology.
b) Detailed discharge summary.
c) detailed Procedure.
d) Operative Notes.
a) Clinical notes.
b) Biopsy findings.
a) Histopathology.
b) Detailed discharge summary.
c) detailed Procedure.
d) Operative Notes detailing
urethrostomy.
a) Color-flow penile Doppler
imaging.
b) USG (patients with high-flow
priapism).
a) Detailed discharge summary.
b) detailed Procedure.
c) Operative Notes.
a) Color-flow penile Doppler
imaging.
b) USG (patients with high-flow
priapism).
a) Detailed discharge summary.
b) detailed Procedure.
c) Operative Notes.
Earlier Discharge Summary
Clinical notes with planned line of
treatment
OPEN
Y
1447
1448
Urology
Urology
SU
SU
SU082 Penectomy
SU083 Surgery for Priapism
1449
Urology
SU
SU083 Surgery for Priapism
1450
Urology
SU
SU084
SU082B
Total Penectomy +
Perineal Urethrostomy
SU083A Aspiration
SU083B Shunt
27224
15000
32668
18000
35391
19500
39474
21750
15000
18000
19500
21750
1000
1200
1300
1450
OPEN
Y
OPEN
Y
OPEN
Y
Surgery for Priaprism Follow Up
SU084A
Surgery for Priaprism Follow Up
OPEN
N
SL NO
1451
1452
1453
1454
Specialty
Urology
Urology
Urology
Urology
Specialty
Code
SU
SU
SU
SU
Package
Code
Package Name
Penile prosthesis
SU085
insertion
SU086 Orchiectomy
SU086 Orchiectomy
Bilateral
SU087 Orchidectomy for
hormone ablation
Procedure
Code
Procedure Name
Penile prosthesis
SU085A
insertion
SU086A High inguinal
SU086B Simple
SU087A
Bilateral Orchidectomy
for hormone ablation
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
35000
15028
10000
10890
42000
18033
12000
13068
NABH
Package
Cost
45500
19536
13000
14157
Outside State
NABH
Package Cost
50750
21790
14500
15790
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Clinical notes with Previous
medical reports showing the
panectomy.
b) its indication.
a) Detailed discharge summary.
b) detailed Procedure.
c) Operative Notes.
d) Bar code of implant used.
a) Clinical notes.
b) USG.
c) CT.
d) Biopsy confirming testicular
cancer.
a) Histopathology.
b) Detailed discharge summary.
c) detailed Procedure.
d) Operative Notes.
a) Clinical notes.
b) USG.
c) CT.
d) Biopsy confirming testicular
cancer.
a) Histopathology.
b) Detailed discharge summary.
c) detailed Procedure.
d) Operative Notes.
a) Clinical notes.
b) USG.
c) CT.
d) Biopsy confirming bilateral
testicular cancer.
a) Histopathology.
b) Detailed discharge summary.
c) detailed Procedure.
d) Operative Notes.
a) Clinical notes.
b) USG confirming that
laparoscopy is needed for locating
the testes. Clinical Photograph of
affected part
a) Post Procedure Clinical
Photograph of affected part.
b) detailed Procedure.
c) Operative Notes.
d) Detailed discharge summary.
a) Clinical notes.
b) USG confirming location of
undescended testis.
c) Clinical Photograph of affected
part.
a) Post Procedure Clinical
Photograph of affected part.
b) detailed Procedure.
c) Operative Notes.
d) Detailed discharge summary.
a) Clinical notes.
b) USG confirming location of
undescended testis.
c) Clinical Photograph of affected
part.
a) Post Procedure Clinical
Photograph of affected part.
b) detailed Procedure.
c) Operative Notes.
d) Detailed discharge summary.
a) Clinical notes.
b) USG Scrotum.
a) Detailed discharge summary.
b) detailed Procedure.
c) Operative Notes.
a) Clinical notes.
b) USG Scrotum.
c) is the EHCP registred for
microsurgery?
a) Detailed discharge summary.
b) detailed Procedure.
c) Operative Notes.
a) Clinical notes.
b) USG.
c) CT.
d) Biopsy confirming bilateral
testicular cancer.
a) Histopathology.
b) Detailed discharge summary.
c) detailed Procedure.
d) Operative Notes.
OPEN
N
OPEN
Y
OPEN
Y
OPEN
N
1455
Urology
SU
SU088 Orchiopexy
SU088A
Orchiopexy with
laparoscopy
30000
36000
39000
43500
OPEN
Y
1456
Urology
SU
SU088 Orchiopexy
SU088B
Orchiopexy without
laparoscopy - U/L
15000
18000
19500
21750
OPEN
Y
1457
Urology
SU
SU088 Orchiopexy
SU088C
Orchiopexy without
laparoscopy - B/L
15000
18000
19500
21750
OPEN
Y
1458
1459
1460
Urology
Urology
Urology
SU
SU
SU
SU089
SU089
Surgical Correction of
Varicocele
Surgical Correction of
Varicocele
Radical
SU090 Retroperitoneal lymph
node dissection
SU089A Non Microsurgical
SU089B Microsurgical
SU090A Open
10000
15000
39746
12000
18000
47695
13000
19500
51669
14500
21750
57631
OPEN
Y
OPEN
Y
OPEN
Y
SL NO
1461
Specialty
Urology
Specialty
Code
SU
Package
Code
Package Name
Radical
SU090 Retroperitoneal lymph
node dissection
Procedure
Code
Procedure Name
Lap. - (Radical
SU090B Retroperitoneal lymph
node dissection)
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
36500
43800
NABH
Package
Cost
47450
Outside State
NABH
Package Cost
52925
Mandatory Documents - Pre
Authorization
a) Clinical notes.
b) USG.
c) CT.
d) Biopsy confirming bilateral
testicular cancer.
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
a) Histopathology.
b) Detailed discharge summary.
c) detailed Procedure.
d) Operative Notes.
OPEN
Y
1462
1463
Urology
Urology
SU
SU
Ilio-Inguinal
SU091
lymphadenectomy
Hysterectomy as part
SU092 of VVF / uterovaginal
fistula repair
Ilio-Inguinal
SU091A
lymphadenectomy
Hysterectomy as part
SU092A of VVF / uterovaginal
fistula repair
20146
5000
24175
6000
26189
6500
29211
7250
a) Clinical notes.
b) USG.
c) CT.
d) MRI.
e) Biopsy confirming the diagnosis
for which the surgery is done.
a) Clinical notes.
b) Cystoscopy.
c) Vaginoscopy.
d) CT – IVP.
e) IVP.
f) cystogram confirming the
diagnosis.
a) Histopathology.
b) Detailed discharge summary.
c) detailed Procedure.
d) Operative Notes.
OPEN
N
a) Histopathology.
b) Detailed Procedure.
c) Operative Notes.
d) detailed discharge summary.
OPEN
N
1464
1465
1466
Urology
Urology
Urology
SU
SU093 PCNL - Follow Up
SU093A PCNL - Follow Up
SU
Emergency
management of
Ureteric stone Package for
SU094 evaluation /
investigation
(ultrasound + culture)
for 3 weeks
(medicines).
Emergency
management of
Ureteric stone SU094A Package for evaluation
/ investigation
(ultrasound + culture)
for 3 weeks (medicines).
SU
SU095
Renal Transplant
SV
Surgical Correction of
Category - I
SV001
Congenital Heart
Disease
SV
Surgical Correction of
Category - I
SV001
Congenital Heart
Disease
1200
1440
1560
1740
Earlier Discharge Summary
a) USG.
b) Urine Routine.
c) Drugs.
OPEN
N
SU095A
Renal Transplant with
(Transplant surgery including
doner nephrectoy, indution,
Intervention for acute reject,
post transplant medication 1
to 12 Months)
3500
4200
4550
5075
a) Detailed reports of all
a) Clinical notes detailing the case
investigations done.
history with previous work up.
b) consultation paper of treating
b) initial diagnosis with stills of
doctor.
OPEN
ureteric stone.
c) culture & ABS report .
c) treatment done so far.
d) Evidence of 3 weeks medicines.
N
700000
840000
910000
1015000
a. Eligibility Criteria
b. Identification proof doner and
receipnt
c. NOC from THOT
(Transplantation of Human Organ
& Tissue)/ Concern authority
d. Clinical notes detailing history
e. Examination findings
f. Relevent investigation done.
g. Planned line of management
a. Treatement Details
b. Discharge Summery
c. OT Notes
d. All investigation reports
e. Post OT and USG and relative
photographs
A)Clinical notes.
B) ECHO.
C) doppler reports
A)Detailed discharge summary.
B) Detailed Operative notes.
C) barcode of Implant,.
D)if used.
A)Clinical notes.
B) ECHO.
C) doppler reports
A)Detailed discharge summary.
B) Detailed Operative notes.
C) barcode of Implant,.
D)if used.
A)Clinical notes.
B) ECHO.
C) doppler reports
A)Detailed discharge summary.
B) Detailed Operative notes.
C) barcode of Implant,.
D)if used.
OPEN
N
1467
CTVS
SV001A
Unifocalization of
MAPCA
100000
120000
130000
145000
OPEN
Y
1468
CTVS
Isolated Secundum
SV001B Atrial Septal Defect
(ASD) Repair
100000
120000
130000
145000
OPEN
Y
1469
CTVS
SV
SV001
Surgical Correction of
Category - I
Congenital Heart
Disease
SV001C Glenn procedure
100000
120000
130000
145000
OPEN
Y
SL NO
1470
Specialty
CTVS
Specialty
Code
Package
Code
Package Name
Procedure
Code
SV
SV001
Surgical Correction of
Category - I
Congenital Heart
Disease
SV001D
SV
Surgical Correction of
Category - I
SV001
Congenital Heart
Disease
Procedure Name
Pulmonary Artery
Banding
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
100000
120000
NABH
Package
Cost
Outside State
NABH
Package Cost
130000
145000
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
A)Clinical notes.
B) ECHO.
C) doppler reports
A)Detailed discharge summary.
B) Detailed Operative notes.
C) barcode of Implant,.
D)if used.
A)Clinical notes.
B) ECHO.
C) doppler reports
A)Detailed discharge summary.
B) Detailed Operative notes.
C) barcode of Implant,.
D)if used.
A)Clinical notes.
B) ECHO.
C) doppler reports
A)Detailed discharge summary.
B) Detailed Operative notes.
C) barcode of Implant,.
D)if used.
A)Clinical notes.
B) ECHO.
C) doppler reports
A)Detailed discharge summary.
B) Detailed Operative notes.
C) barcode of Implant,.
D)if used.
A)Clinical notes .
B) ECHO report
A)Detailed discharge summary.
B) Detailed Operative notes.
C) barcode of Implant.
D) if used.
A)Clinical notes .
B) ECHO report
A)Detailed discharge summary.
B) Detailed Operative notes.
C) barcode of Implant.
D) if used.
A)Clinical notes .
B) ECHO report
A)Detailed discharge summary.
B) Detailed Operative notes.
C) barcode of Implant.
D) if used.
A)Clinical notes .
B) ECHO report
A)Detailed discharge summary.
B) Detailed Operative notes.
C) barcode of Implant.
D) if used.
A)Clinical notes .
B) ECHO report
A)Detailed discharge summary.
B) Detailed Operative notes.
C) barcode of Implant.
D) if used.
A)Clinical notes .
B) ECHO report
A)Detailed discharge summary.
B) Detailed Operative notes.
C) barcode of Implant.
D) if used.
A)Clinical notes .
B) ECHO report
A)Detailed discharge summary.
B) Detailed Operative notes.
C) barcode of Implant.
D) if used.
A)Clinical notes .
B) ECHO report
A)Detailed discharge summary.
B) Detailed Operative notes.
C) barcode of Implant.
D) if used.
OPEN
Y
1471
CTVS
SV001E
Systemic - Pulmonary
shunt
100000
120000
130000
145000
OPEN
Y
1472
CTVS
Surgical Correction of
Category - I
Congenital Heart
Disease
SV
SV001
SV
Surgical Correction of
Category - I
SV001
Congenital Heart
Disease
SV
Surgical Correction of
Category - II
SV002
Congenital Heart
Disease
SV001F
Vascular Ring division
100000
120000
130000
145000
OPEN
Y
1473
CTVS
SV001G Coarctation repair
100000
120000
130000
145000
OPEN
Y
1474
CTVS
ASD closure + Partial
SV002A Anomalous Venous
Drainage Repair
120000
144000
156000
174000
OPEN
Y
1475
CTVS
Surgical Correction of
Category - II
Congenital Heart
Disease
SV
SV002
SV
Surgical Correction of
Category - II
SV002
Congenital Heart
Disease
SV
Surgical Correction of
Category - II
SV002
Congenital Heart
Disease
SV002B
ASD Closure + Mitral
procedure
120000
144000
156000
174000
OPEN
Y
1476
CTVS
SV002C
ASD Closure +
Tricuspid procedure
120000
144000
156000
174000
OPEN
Y
1477
CTVS
SV002D
ASD Closure +
Pulmonary procedure
120000
144000
156000
174000
OPEN
Y
1478
CTVS
Surgical Correction of
Category - II
Congenital Heart
Disease
SV
SV002
SV
Surgical Correction of
Category - II
SV002
Congenital Heart
Disease
SV002E
ASD Closure +
Infundibular procedure
120000
144000
156000
174000
OPEN
Y
1479
CTVS
SV002F
VSD closure
120000
144000
156000
174000
OPEN
Y
1480
CTVS
Surgical Correction of
Category - II
Congenital Heart
Disease
SV
SV002
SV
Surgical Correction of
Category - II
SV002
Congenital Heart
Disease
SV002G Infundibular PS repair
120000
144000
156000
174000
OPEN
Y
1481
CTVS
SV002H Valvular PS repair
120000
144000
156000
174000
OPEN
Y
SL NO
1482
1483
Specialty
CTVS
CTVS
Specialty
Code
Package
Code
Package Name
Procedure
Code
SV
SV002
Surgical Correction of
Category - II
Congenital Heart
Disease
SV002I
SV
Surgical Correction of
Category - II
SV002
Congenital Heart
Disease
SV002J
Procedure Name
Partial AV canal repair
Intermediate AV canal
repair
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
150000
150000
180000
180000
NABH
Package
Cost
Outside State
NABH
Package Cost
195000
217500
195000
217500
Mandatory Documents - Pre
Authorization
A)Clinical notes .
B) ECHO report
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
A)Detailed discharge summary.
B) Detailed Operative notes.
C) barcode of Implant.
D) if used.
.
A)Clinical notes .
B) ECHO report
A)Detailed discharge summary.
B) Detailed Operative notes.
C) barcode of Implant.
D) if used.
A)Clinical notes .
B) ECHO report
A)Detailed discharge summary.
B) Detailed Operative notes.
C) barcode of Implant.
D) if used.
A)Clinical notes .
B) ECHO report
A)Detailed discharge summary.
B) Detailed Operative notes.
C) barcode of Implant.
D) if used.
A)Clinical notes .
B) ECHO report
A)Detailed discharge summary.
B) Detailed Operative notes.
C) barcode of Implant.
D) if used.
A)Clinical notes .
B) ECHO report
A)Detailed discharge summary.
B) Detailed Operative notes.
C) barcode of Implant.
D) if used.
A)Clinical notes .
B) ECHO report
A)Detailed discharge summary.
B) Detailed Operative notes.
C) barcode of Implant.
D) if used.
A)ECHO .
B) Doppler Report
A)Detailed discharge summary.
B) Detailed Operative notes.
C) barcode of Implant.
D)if used.
A)ECHO .
B) Doppler Report
A)Detailed discharge summary.
B) Detailed Operative notes.
C) barcode of Implant.
D)if used.
A)ECHO .
B) Doppler Report
A)Detailed discharge summary.
B) Detailed Operative notes.
C) barcode of Implant.
D)if used.
A)ECHO .
B) Doppler Report
A)Detailed discharge summary.
B) Detailed Operative notes.
C) barcode of Implant.
D)if used.
A)ECHO .
B) Doppler Report
A)Detailed discharge summary.
B) Detailed Operative notes.
C) barcode of Implant.
D)if used.
OPEN
Y
OPEN
Y
1484
CTVS
Surgical Correction of
Category - II
Congenital Heart
Disease
SV
SV002
SV
Surgical Correction of
Category - II
SV002
Congenital Heart
Disease
SV
Surgical Correction of
Category - II
SV002
Congenital Heart
Disease
SV002K
Atrial septectomy +
Glenn
120000
144000
156000
174000
OPEN
Y
1485
CTVS
SV002L
Atrial septectomy + PA
Band
120000
144000
156000
174000
OPEN
Y
1486
CTVS
Sinus of Valsalva
SV002M aneurysm repair with
aortic valve procedure
120000
144000
156000
174000
OPEN
Y
1487
CTVS
Surgical Correction of
Category - II
Congenital Heart
Disease
SV
SV002
SV
Surgical Correction of
Category - II
SV002
Congenital Heart
Disease
SV
Surgical Correction of
Category - III
SV003
Congenital Heart
Disease
SV002N
Sinus of Valsalva
aneurysm repair
without aortic valve
procedure
120000
144000
156000
174000
OPEN
Y
1488
CTVS
SV002O
Sub-aortic membrane
resection
120000
144000
156000
174000
OPEN
Y
1489
CTVS
SV003A Ebstien repair
150000
180000
195000
217500
OPEN
Y
1490
CTVS
Surgical Correction of
Category - III
Congenital Heart
Disease
SV
SV003
SV
Surgical Correction of
Category - III
SV003
Congenital Heart
Disease
SV003B Double switch operation
150000
180000
195000
217500
OPEN
Y
1491
CTVS
SV003C Rastelli Procedure
150000
180000
195000
217500
OPEN
Y
1492
CTVS
Surgical Correction of
Category - III
Congenital Heart
Disease
SV
SV003
SV
Surgical Correction of
Category - III
SV003
Congenital Heart
Disease
SV003D Fontan procedure
175000
210000
227500
253750
OPEN
Y
1493
CTVS
SV003E
AP window repair
150000
180000
195000
217500
OPEN
Y
SL NO
1494
Specialty
CTVS
Specialty
Code
Package
Code
Package Name
Procedure
Code
Procedure Name
SV
SV003
Surgical Correction of
Category - III
Congenital Heart
Disease
SV003F
Arch interruption
Repair without VSD
closure
SV
Surgical Correction of
Category - III
SV003
Congenital Heart
Disease
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
150000
180000
NABH
Package
Cost
Outside State
NABH
Package Cost
195000
217500
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
A)ECHO .
B) Doppler Report
A)Detailed discharge summary.
B) Detailed Operative notes.
C) barcode of Implant.
D)if used.
A)ECHO .
B) Doppler Report
A)Detailed discharge summary.
B) Detailed Operative notes.
C) barcode of Implant.
D)if used.
A)ECHO .
B) Doppler Report
A)Detailed discharge summary.
B) Detailed Operative notes.
C) barcode of Implant.
D)if used.
A)ECHO .
B) Doppler Report
A)Detailed discharge summary.
B) Detailed Operative notes.
C) barcode of Implant.
D)if used.
A)ECHO .
B) Doppler Report
A)Detailed discharge summary.
B) Detailed Operative notes.
C) barcode of Implant.
D)if used.
A)ECHO .
B) Doppler Report
A)Detailed discharge summary.
B) Detailed Operative notes.
C) barcode of Implant.
D)if used.
A)ECHO .
B) Doppler Report
A)Detailed discharge summary.
B) Detailed Operative notes.
C) barcode of Implant.
D)if used.
A)ECHO .
B) Doppler Report
A)Detailed discharge summary.
B) Detailed Operative notes.
C) barcode of Implant.
D)if used.
A)ECHO .
B) Doppler Report
A)Detailed discharge summary.
B) Detailed Operative notes.
C) barcode of Implant.
D)if used.
A)ECHO .
B) Doppler Report
A)Detailed discharge summary.
B) Detailed Operative notes.
C) barcode of Implant.
D)if used.
A)ECHO .
B) Doppler Report
A)Detailed discharge summary.
B) Detailed Operative notes.
C) barcode of Implant.
D)if used.
A)ECHO .
B) Doppler Report
A)Detailed discharge summary.
B) Detailed Operative notes.
C) barcode of Implant.
D)if used.
OPEN
Y
1495
CTVS
Arch interruption
SV003G Repair with VSD
closure
150000
180000
195000
217500
OPEN
Y
1496
CTVS
Surgical Correction of
Category - III
Congenital Heart
Disease
SV
SV003
SV
Surgical Correction of
Category - III
SV003
Congenital Heart
Disease
SV
Surgical Correction of
Category - III
SV003
Congenital Heart
Disease
SV003H DORV Repair
150000
180000
195000
217500
OPEN
Y
1497
CTVS
SV003I
Supravalvular AS repair
150000
180000
195000
217500
OPEN
Y
1498
CTVS
SV003J
Konno procedure
150000
180000
195000
217500
OPEN
Y
1499
CTVS
Surgical Correction of
Category - III
Congenital Heart
Disease
SV
SV003
SV
Surgical Correction of
Category - III
SV003
Congenital Heart
Disease
SV
Surgical Correction of
Category - III
SV003
Congenital Heart
Disease
SV003K Norwood procedure
150000
180000
195000
217500
OPEN
Y
1500
CTVS
SV003L
VSD closure + RV PA conduit
150000
180000
195000
217500
OPEN
Y
1501
CTVS
SV003M VSD + Aortic procedure
150000
180000
195000
217500
OPEN
Y
1502
CTVS
Surgical Correction of
Category - III
Congenital Heart
Disease
SV
SV003
SV
Surgical Correction of
Category - III
SV003
Congenital Heart
Disease
SV003N VSD + Mitral procedure
150000
180000
195000
217500
OPEN
Y
1503
CTVS
SV003O
VSD + Tricuspid
procedure
150000
180000
195000
217500
OPEN
Y
1504
CTVS
Surgical Correction of
Category - III
Congenital Heart
Disease
SV
SV003
SV
Surgical Correction of
Category - III
SV003
Congenital Heart
Disease
SV003P
VSD + Pulmonary
procedure
150000
180000
195000
217500
OPEN
Y
1505
CTVS
SV003Q
VSD + Infundibular
procedure
150000
180000
195000
217500
OPEN
Y
SL NO
1506
Specialty
CTVS
Specialty
Code
Package
Code
Package Name
Procedure
Code
SV
SV003
Surgical Correction of
Category - III
Congenital Heart
Disease
SV003R
SV
Surgical Correction of
Category - III
SV003
Congenital Heart
Disease
Procedure Name
VSD + Coarctation
repair
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
150000
180000
NABH
Package
Cost
Outside State
NABH
Package Cost
195000
217500
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
A)ECHO .
B) Doppler Report
A)Detailed discharge summary.
B) Detailed Operative notes.
C) barcode of Implant.
D)if used.
A)ECHO .
B) Doppler Report
A)Detailed discharge summary.
B) Detailed Operative notes.
C) barcode of Implant.
D)if used.
A)ECHO .
B) Doppler Report
A)Detailed discharge summary.
B) Detailed Operative notes.
C) barcode of Implant.
D)if used.
A)ECHO .
B) Doppler Report
A)Detailed discharge summary.
B) Detailed Operative notes.
C) barcode of Implant.
D)if used.
A)ECHO .
B) Doppler Report
A)Detailed discharge summary.
B) Detailed Operative notes.
C) barcode of Implant.
D)if used.
A)ECHO .
B) Doppler Report
A)Detailed discharge summary.
B) Detailed Operative notes.
C) barcode of Implant.
D)if used.
A)ECHO .
B) Doppler Report
A)Detailed discharge summary.
B) Detailed Operative notes.
C) barcode of Implant.
D)if used.
A)ECHO .
B) Doppler Report
A)Detailed discharge summary.
B) Detailed Operative notes.
C) barcode of Implant.
D)if used.
OPEN
Y
1507
CTVS
SV003S
TAPVC Repair
150000
180000
195000
217500
OPEN
Y
1508
CTVS
Surgical Correction of
Category - III
Congenital Heart
Disease
SV
SV003
SV
Surgical Correction of
Category - III
SV003
Congenital Heart
Disease
SV
Surgical Correction of
Category - III
SV003
Congenital Heart
Disease
SV003T
Truncus arteriosus
repair
150000
180000
195000
217500
OPEN
Y
1509
CTVS
SV003U
Tetralogy of Fallot
Repair
150000
180000
195000
217500
OPEN
Y
1510
CTVS
SV003V
Complete AV canal
repair
170000
204000
221000
246500
OPEN
Y
1511
CTVS
Surgical Correction of
Category - III
Congenital Heart
Disease
SV
SV003
SV
Surgical Correction of
Category - III
SV003
Congenital Heart
Disease
SV
Surgical Correction of
Category - III
SV003
Congenital Heart
Disease
SV003Y Mustard Operation
SV
Coronary artery
bypass grafting
(CABG),
SV004
including intra
operative balloon
pump (if required)
Coronary artery bypass
grafting (CABG),
SV004A including intra operative
balloon pump (if
required)
SV003W Arterial switch operation
150000
180000
195000
217500
OPEN
Y
1512
CTVS
SV003X Senning Operation
150000
180000
195000
217500
OPEN
Y
1513
1514
1515
CTVS
CTVS
CTVS
SV
SV005 Single Valve Procedure
150000
180000
195000
217500
OPEN
Y
SV005A
Aortic Valve (Single
Valve Procedure)
175000
210000
227500
253750
A)ECHO.
B) CAG report stills showing
significant multiple blocks.
C) LVEF
A)Detailed Operation notes.
B) detailed discharge summary
A)Clinical notes.
B) ECHO.
C) Doppler report
A)Post op ECHO .
B) Detailed procedure notes.
C)detailed discharge summary.
D) Barcode of implant.
E) if used.
A)Clinical notes.
B) ECHO.
C) Doppler report
A)Post op ECHO .
B) Detailed procedure notes.
C)detailed discharge summary.
D) Barcode of implant.
E) if used.
A)Clinical notes.
B) ECHO.
C) Doppler report
A)Post op ECHO .
B) Detailed procedure notes.
C)detailed discharge summary.
D) Barcode of implant.
E) if used.
OPEN
N
119000
142800
154700
172550
OPEN
Y
1516
CTVS
SV
SV005 Single Valve Procedure
SV005B Mitral Valve
119000
142800
154700
172550
OPEN
Y
1517
CTVS
SV
SV005 Single Valve Procedure
SV005C Tricuspid Valve
119000
142800
154700
172550
OPEN
Y
SL NO
1518
Specialty
CTVS
Specialty
Code
Package
Code
SV
SV006
Package Name
Double Valve
Procedure
Procedure
Code
Procedure Name
SV006A Double Valve Procedure
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
142000
170400
NABH
Package
Cost
Outside State
NABH
Package Cost
184600
205900
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
A)Clinical notes.
B) ECHO.
C) doppler reports showing two
cardiac valves diseased
A)Detailed discharge summary.
B) Detailed Operative notes.
C)barcode of valves.
D)rings used
A)Clinical notes .
B)ECHO .
C)doppler reports showing three
cardiac valves diseased
A)Detailed discharge summary.
B) Detailed Operative notes.
C) barcode of valves.
D)rings used
A)Clinical notes.
B) ECHO.
C) doppler reports
A)Detailed discharge summary.
B) Detailed Operative notes.
A)Clinical notes.
B) ECHO report
A)Detailed procedure notes.
B) detailed discharge summary,.
C)Barcode of RV-PA conduit
OPEN
N
1519
CTVS
SV
SV007 Triple valve procedure
SV007A Triple valve procedure
SV
Closed Mitral
SV008 Valvotomy including
thoracotomy
Closed Mitral
SV008A Valvotomy including
thoracotomy
170000
204000
221000
246500
OPEN
N
1520
1521
1522
1523
CTVS
CTVS
CTVS
CTVS
SV
SV009 Ross Procedure
SV009A Ross Procedure
SV
Surgery for
Hypertrophic
SV010 Obstructive
Cardiomyopathy
(HOCM)
Surgery for
Hypertrophic
SV010A Obstructive
Cardiomyopathy
(HOCM)
SV
SV011
Pericardial window
(via thoracotomy)
SV011A
Pericardial window (via
thoracotomy)
57000
68400
74100
82650
OPEN
N
150000
180000
195000
217500
OPEN
N
111000
133200
144300
160950
A)Clinical notes.
B) ECHO report
A)Detailed discharge summary.
B) Detailed Operation notes,
OPEN
N
30000
36000
39000
43500
A)Detailed Operation notes.
A)Clinical notes.
B )Detailed Discharge summary
B) CT Chest establishing the
aetiology for which surgery is done
OPEN
N
1524
1525
1526
1527
1528
1529
1530
1531
CTVS
CTVS
CTVS
CTVS
CTVS
CTVS
CTVS
CTVS
SV
SV012 Pericardiectomy
SV012A Pericardiectomy
SV
Patent Ductus
Arteriosus (PDA)
SV013
Closure via
thoracotomy
Patent Ductus
SV013A Arteriosus (PDA)
Closure via thoracotomy
SV
SV
SV
SV
SV014
SV014
SV014
SV014
Aortic Root
Replacement Surgery
Aortic Root
Replacement Surgery
Aortic Root
Replacement Surgery
Aortic Root
Replacement Surgery
Aortic Root
Replacement Surgery
SV
SV014
SV
Aortic Arch
Replacement /
SV015 Thoracoabdominal
aneurysm Repair
using bypass
67000
80400
87100
97150
A)Detailed Operation notes.
A)Clinical notes an ECHO report B) Discharge summary
82650
A)Clinical notes.
B) ECHO report
OPEN
N
SV014A Bental Procedure
SV014B Aortic Dissection
SV014C Aortic Aneurysm
SV014D
SV014E
Valve sparing root
replacement
AVR + Root
enlargement
57000
150000
150000
150000
150000
150000
68400
180000
180000
180000
180000
180000
74100
195000
195000
195000
195000
195000
217500
217500
217500
217500
217500
A)Clinical notes.
B)ECHO report.
C) CT angio .
D) Angio .
E) MRI report
A)Clinical notes.
B)ECHO report.
C) CT angio .
D) Angio .
E) MRI report
A)Clinical notes.
B)ECHO report.
C) CT angio .
D) Angio .
E) MRI report
A)Clinical notes.
B)ECHO report.
C) CT angio .
D) Angio .
E) MRI report
A)Clinical notes.
B)ECHO report.
C) CT angio .
D) Angio .
E) MRI report
A)Detailed Operation notes.
B) Discharge summary
OPEN
N
A)Detailed discharge summary,.
B)Detailed Operation notes.
OPEN
Y
A)Detailed discharge summary,.
B)Detailed Operation notes.
OPEN
Y
A)Detailed discharge summary,.
B)Detailed Operation notes.
OPEN
Y
A)Detailed discharge summary,.
B)Detailed Operation notes.
OPEN
Y
A)Detailed discharge summary,.
B)Detailed Operation notes.
OPEN
Y
Aortic Arch
SV015A Replacement using
bypass
150000
180000
195000
217500
A)Clinical notes.
B) angio .
C) CT angio .
D) MRI reports
A)Detailed procedure notes.
B)detailed discharge summary
.
OPEN
Y
SL NO
1532
1533
Specialty
CTVS
CTVS
Specialty
Code
SV
SV
Package
Code
Package Name
Aortic Arch
Replacement /
SV015 Thoracoabdominal
aneurysm Repair
using bypass
SV016
Aortic Aneurysm
Repair
Procedure
Code
Procedure Name
Thoracoabdominal
SV015B aneurysm Repair using
bypass
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
150000
180000
NABH
Package
Cost
195000
Outside State
NABH
Package Cost
217500
Mandatory Documents - Pre
Authorization
A)Clinical notes.
B) angio .
C) CT angio .
D) MRI reports
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
A)Detailed procedure notes.
B)detailed discharge summary
OPEN
Y
SV016A
Aortic Aneurysm
Repair using
Cardiopulmonary
bypass (CPB)
120000
144000
156000
174000
A)Clinical notes.
B) ECHO.
A)Detailed procedure notes,.
C) Angio.
B)detailed discharge summary.
D) CT angio .
E) MRI reports showing aneurysm
OPEN
Y
1534
1535
1536
1537
CTVS
CTVS
CTVS
CTVS
SV
SV016
Aortic Aneurysm
Repair
Aortic Aneurysm
SV016B Repair using Left Heart
Bypass
SV
SV016
Aortic Aneurysm
Repair
Aortic Aneurysm
Repair without using
SV016C
Cardiopulmonary
bypass (CPB)
SV
Aortic Aneurysm
SV016
Repair
Aortic Aneurysm
SV016D Repair without using
Left Heart Bypass
SV
Aorto Iliac / Aorto
SV017 femoral bypass (Uni
and Bi)
SV
Aorto Iliac / Aorto
SV017 femoral bypass (Uni
and Bi)
SV017A Aorto Iliac bypass - U/L
120000
144000
156000
174000
A)Clinical notes.
B) ECHO.
A)Detailed procedure notes,.
C) Angio.
B)detailed discharge summary.
D) CT angio .
E) MRI reports showing aneurysm
OPEN
Y
65500
78600
85150
94975
A)Clinical notes angio .
B) CT angio .
C) MRI reports
A)Detailed procedure notes.
B) Detailed discharge summary
A)Clinical notes angio .
B) CT angio .
C) MRI reports
A)Detailed procedure notes.
B) Detailed discharge summary
A)Clinical notes.
B) MRA .
C) CT angio .
D) Angio reports
A)Detailed discharge summary.
B) Detailed Operative notes.
C) barcode of synthetic graft
A)Clinical notes.
B) MRA .
C) CT angio .
D) Angio reports
A)Detailed discharge summary.
B) Detailed Operative notes.
C) barcode of synthetic graft
A)Clinical notes.
B) MRA .
C) CT angio .
D) Angio reports
A)Detailed discharge summary.
B) Detailed Operative notes.
C) barcode of synthetic graft
A)Clinical notes.
B) MRA .
C) CT angio .
D) Angio reports
A)Detailed discharge summary.
B) Detailed Operative notes.
C) barcode of synthetic graft
A)Clinical notes.
B) ECHO report .
C) CT Chest report
A)Detailed Operation notes.
B) Discharge summary
A)Clinical notes.
B) ECHO report .
C) CT Chest report
A)Detailed Operation notes.
B) Discharge summary
A)Clinical notes
B)Angiogram .
C) CT Angiogram .
D)MRI reports
A)Detailed operative notes.
B) Discharge summary.
C) barcode of graft used.
A)Clinical notes
B)Angiogram .
C) CT Angiogram .
D)MRI reports
A)Detailed operative notes.
B) Discharge summary.
C) barcode of graft used.
A)Clinical notes
B)Angiogram .
C) CT Angiogram .
D)MRI reports
A)Detailed operative notes.
B) Discharge summary.
C) barcode of graft used.
A)Clinical notes
B)Angiogram .
C) CT Angiogram .
D)MRI reports
A)Detailed operative notes.
B) Discharge summary.
C) barcode of graft used.
OPEN
Y
65500
78600
85150
94975
OPEN
Y
64500
77400
83850
93525
OPEN
Y
1538
CTVS
SV017B
Aorto femoral bypass U/L
64500
77400
83850
93525
OPEN
Y
1539
CTVS
SV
Aorto Iliac / Aorto
SV017 femoral bypass (Uni
and Bi)
SV017C Aorto Iliac bypass - B/L
64500
77400
83850
93525
OPEN
Y
1540
1541
1542
1543
CTVS
CTVS
CTVS
CTVS
SV
SV
SV
SV
Aorto Iliac / Aorto
SV017 femoral bypass (Uni
and Bi)
Pulmonary
Embolectomy /
SV018
Thromboendarterecto
my
Pulmonary
Embolectomy /
SV018
Thromboendarterecto
my
SV019
Peripheral Arterial
Surgeries
SV017D
Aorto femoral bypass B/L
64500
77400
83850
93525
OPEN
Y
SV018A
Pulmonary
Embolectomy
Thromboendarterectom
SV018B
y
SV019A
Femoro - Femoral
Bypass
141000
141000
50000
169200
169200
60000
183300
183300
65000
204450
204450
72500
OPEN
Y
YES
Y
YES
OPEN
OPEN
Y
1544
CTVS
SV
SV019
Peripheral Arterial
Surgeries
SV019B
Carotid endearterectomy
50000
60000
65000
72500
OPEN
Y
1545
CTVS
SV
SV019
Peripheral Arterial
Surgeries
SV019C
Carotid Body Tumor
Excision
50000
60000
65000
72500
OPEN
Y
1546
CTVS
SV
SV019
Peripheral Arterial
Surgeries
SV019D
Thoracic Outlet
syndrome Repair
50000
60000
65000
72500
OPEN
Y
SL NO
1547
Specialty
CTVS
Specialty
Code
Package
Code
Package Name
Procedure
Code
Procedure Name
SV
SV019
Peripheral Arterial
Surgeries
SV019E
Carotid aneurysm repair
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
50000
60000
NABH
Package
Cost
Outside State
NABH
Package Cost
65000
72500
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
A)Clinical notes
B)Angiogram .
C) CT Angiogram .
D)MRI reports
A)Detailed operative notes.
B) Discharge summary.
C) barcode of graft used.
A)Clinical notes
B)Angiogram .
C) CT Angiogram .
D)MRI reports
A)Detailed operative notes.
B) Discharge summary.
C) barcode of graft used.
A)Clinical notes
B)Angiogram .
C) CT Angiogram .
D)MRI reports
A)Detailed operative notes.
B) Discharge summary.
C) barcode of graft used.
A)Clinical notes
B)Angiogram .
C) CT Angiogram .
D)MRI reports
A)Detailed operative notes.
B) Discharge summary.
C) barcode of graft used.
A)Clinical notes
B)Angiogram .
C) CT Angiogram .
D)MRI reports
A)Detailed operative notes.
B) Discharge summary.
C) barcode of graft used.
A)Clinical notes
B)Angiogram .
C) CT Angiogram .
D)MRI reports
A)Detailed operative notes.
B) Discharge summary.
C) barcode of graft used.
A)Clinical notes
B)Angiogram .
C) CT Angiogram .
D)MRI reports
A)Detailed operative notes.
B) Discharge summary.
C) barcode of graft used.
A)Clinical notes
B)Angiogram .
C) CT Angiogram .
D)MRI reports
A)Detailed operative notes.
B) Discharge summary.
C) barcode of graft used.
A)Clinical notes
B)Angiogram .
C) CT Angiogram .
D)MRI reports
A)Detailed operative notes.
B) Discharge summary.
C) barcode of graft used.
A)Clinical notes
B)Angiogram .
C) CT Angiogram .
D)MRI reports
A)Detailed operative notes.
B) Discharge summary.
C) barcode of graft used.
A)Clinical notes
B)Angiogram .
C) CT Angiogram .
D)MRI reports
A)Detailed operative notes.
B) Discharge summary.
C) barcode of graft used.
A)Clinical notes
B)Angiogram .
C) CT Angiogram .
D)MRI reports
A)Detailed operative notes.
B) Discharge summary.
C) barcode of graft used.
A)Clinical notes
B)Angiogram .
C) CT Angiogram .
D)MRI reports
A)Detailed operative notes.
B) Discharge summary.
C) barcode of graft used.
A)Clinical notes
B)Angiogram .
C) CT Angiogram .
D)MRI reports
A)Detailed operative notes.
B) Discharge summary.
C) barcode of graft used.
A)Clinical notes
B)Angiogram .
C) CT Angiogram .
D)MRI reports
A)Detailed operative notes.
B) Discharge summary.
C) barcode of graft used.
OPEN
Y
1548
CTVS
SV
SV019
Peripheral Arterial
Surgeries
SV019F
Subclavian aneurysm
repair
50000
60000
65000
72500
OPEN
Y
1549
CTVS
SV
SV019
Peripheral Arterial
Surgeries
SV019G Axillary aneurysm repair
50000
60000
65000
72500
OPEN
Y
1550
CTVS
SV
SV019
Peripheral Arterial
Surgeries
SV019H
Brachial aneurysm
repair
50000
60000
65000
72500
OPEN
Y
1551
CTVS
SV
SV019
Peripheral Arterial
Surgeries
SV019I
Femoral aneurysm
repair
50000
60000
65000
72500
OPEN
Y
1552
CTVS
SV
SV019
Peripheral Arterial
Surgeries
SV019J
Popliteal aneurysm
repair
50000
60000
65000
72500
OPEN
Y
1553
CTVS
SV
SV019
Peripheral Arterial
Surgeries
SV019K
Femoral - popliteal
Bypass
50000
60000
65000
72500
OPEN
Y
1554
CTVS
SV
SV019
Peripheral Arterial
Surgeries
SV019L
Axillo - Brachial Bypass
50000
60000
65000
72500
OPEN
Y
1555
CTVS
SV
SV019
Peripheral Arterial
Surgeries
SV019M Carotio - carotid Bypass
50000
60000
65000
72500
OPEN
Y
1556
CTVS
SV
SV019
Peripheral Arterial
Surgeries
SV019N
Carotido - subclavian
bypass
50000
60000
65000
72500
OPEN
Y
1557
CTVS
SV
SV019
Peripheral Arterial
Surgeries
SV019O
Carotido - axillary
bypass
50000
60000
65000
72500
OPEN
Y
1558
CTVS
SV
SV019
Peripheral Arterial
Surgeries
SV019P
Axillo - femoral bypass U/L
50000
60000
65000
72500
OPEN
Y
1559
CTVS
SV
SV019
Peripheral Arterial
Surgeries
SV019Q
Axillo - femoral bypass B/L
50000
60000
65000
72500
OPEN
Y
1560
CTVS
SV
SV019
Peripheral Arterial
Surgeries
SV019R Aorto - carotid bypass
50000
60000
65000
72500
OPEN
Y
1561
CTVS
SV
SV019
Peripheral Arterial
Surgeries
SV019S
Aorto - subclavian
bypass
50000
60000
65000
72500
OPEN
Y
SL NO
1562
Specialty
CTVS
Specialty
Code
Package
Code
Package Name
Procedure
Code
Procedure Name
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
NABH
Package
Cost
Outside State
NABH
Package Cost
Mandatory Documents - Pre
Authorization
A)Soon as documents are
uploaded.
B) confirm evidence of embolus.
C)Thrombus in duples USG.
D) Angio
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
A)Detailed discharge summary.
B) operative notes
SV
SV020 Thromboembolectomy
SV020A Thromboembolectomy
SV
Peripheral arterial
SV021 injury repair (without
bypass)
Peripheral arterial
SV021A injury repair (without
bypass)
Thoracotomy, Thoraco
SV022A
Abdominal Approach
30000
36000
39000
43500
SV023A Lung cyst exision
45000
54000
58500
65250
A)Clinical notes.
B) CT Chest establishing the
aetiology for which surgery is
done
A)Clinical notes.
B) CT Chest
65250
A)Clinical notes.
B) CT Chest
A)Detailed Operation notes.
B) Discharge summary
65250
A)Clinical notes.
B) CT Chest
A)Detailed Operation notes.
B) Discharge summary
OPEN
65250
A)Clinical notes.
B) CT Chest
A)Detailed Operation notes.
B) Discharge summary
OPEN
A)Clinical notes.
B) Pre-Op X-ray /.
C)CT Scan
A)HPE of resected tissue detailed
operation notes.
OPEN
B) discharge summary.
28000
33600
36400
40600
OPEN
N
1563
CTVS
1564
CTVS
SV
Thoracotomy,
SV022 Thoraco Abdominal
Approach
1565
CTVS
SV
SV023
SV
Lung surgery
SV023
including Thoracotomy
1566
1567
1568
1569
CTVS
CTVS
CTVS
CTVS
SV
SV
SV
Lung surgery
including Thoracotomy
Lung surgery
SV023
including Thoracotomy
SV023
Lung surgery
including Thoracotomy
SV024 Pulmonary Resection
30000
36000
39000
43500
A)Clinical notes with planned line
A)Detailed discharge summary .
of treatment.
B) operative notes
B) Doppler
OPEN
N
A)Detailed Operation notes.
B) Detailed Discharge summary
OPEN
A)Detailed Operation notes.
B) Discharge summary
OPEN
N
Y
SV023B Decortication
45000
54000
58500
OPEN
Y
SV023C Hydatid cyst
45000
54000
58500
Y
Other simple lung
SV023D procedure excluding
lung resection
45000
SV024A Pulmonary Resection
70000
54000
58500
Y
84000
91000
101500
N
1570
CTVS
Foreign Body
Removal with scope
SV
SV025
SV
Surgical Correction of
SV026
Bronchopleural Fistula
SV025A
Foreign Body Removal
with scope
20000
24000
26000
29000
65000
78000
84500
94250
A)Detailed Operative notes.
A)Clinical notes.
B) Detailed discharge summary.
B)Radiological evidence of foreign
C) Photograph of Removed
body
Foreign body
OPEN
N
1571
1572
1573
1574
CTVS
CTVS
CTVS
CTVS
Surgical Correction of
SV026A
Bronchopleural Fistula
SV
Space - Occupying
SV027 Lesion (SOL)
mediastinum
Space - Occupying
SV027A Lesion (SOL)
mediastinum
SV
Isolated Intercostal
Drainage and
Management of ICD,
SV028
Intercostal Block,
Antibiotics &
Physiotherapy
Isolated Intercostal
Drainage and
Management of ICD,
SV028A
Intercostal Block,
Antibiotics &
Physiotherapy
SV
SV029 Diaphragmatic Repair
SV029A Diaphragmatic Repair
A)Clinical notes.
B) CT Chest
A)Detailed operative notes .
B) discharge summary
A)Clinical notes.
B) CT Chest
A)Detailed discharge summary.
B) Detailed Operation notes.
C) HPE of SOL
OPEN
N
65500
78600
85150
94975
OPEN
N
10000
12000
13000
14500
A)Cl notes detailing need of ICD. A)Detailed procedure notes.
B) X-ray chest
B) Detailed discharge summary
OPEN
N
30000
36000
39000
43500
A)Clinical notes.
B) Chest XRAY.
C) CT Chest
A)Detailed procedure notes,.
B)detailed discharge summary.
A)Clinical notes.
B) ECHO report
A)Detailed Operation notes.
B) Discharge summary.
C)HPE report of tumor.
A)ECHO.
B) Doppler Report.
C) Detailed Operative notes
indicating need for Reoperation
A)Detailed discharge summary.
B) Detailed Operative notes.
C) barcode of Implant.
D) if used.
E) Ascertain the need for
reoperation.
A)Clinical notes.
B)ECHO .
C) Doppler report.
D) Detailed Operative notes
indicating need for Reoperation
A)Post op ECHO .
B) Detailed procedure notes.
C) detailed discharge summary.
D) Barcode of implant.
E) if used.
F)Ascertain the need for
reoperation.
OPEN
N
1575
CTVS
SV
SV030
Surgery for Cardiac
Tumour
SV030A
Surgery for Cardiac
Tumour
95000
114000
123500
137750
OPEN
N
1576
CTVS
SV
Immediate reoperation
SV031
(within 5 days)
Tetralogy of Fallot
SV031A
Repair
75000
90000
97500
108750
OPEN
Y
1577
CTVS
SV
SV031
Immediate reoperation
(within 5 days)
Aortic Valve
SV031B (Immediate reoperation
(within 5 days)
59500
71400
77350
86275
OPEN
Y
SL NO
1578
Specialty
CTVS
Specialty
Code
SV
Package
Code
SV031
Package Name
Immediate reoperation
(within 5 days)
Procedure
Code
Procedure Name
SV031C Mitral Valve
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
59500
71400
NABH
Package
Cost
77350
Outside State
NABH
Package Cost
86275
Mandatory Documents - Pre
Authorization
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
A)Clinical notes.
B)ECHO .
C) Doppler report.
D) Detailed Operative notes
indicating need for Reoperation
A)Post op ECHO .
B) Detailed procedure notes.
C) detailed discharge summary.
D) Barcode of implant.
E) if used.
F)Ascertain the need for
reoperation.
A)Clinical notes.
B)ECHO .
C) Doppler report.
D) Detailed Operative notes
indicating need for Reoperation
A)Post op ECHO .
B) Detailed procedure notes.
C) detailed discharge summary.
D) Barcode of implant.
E) if used.
F)Ascertain the need for
reoperation.
A)Clinical notes.
B) ECHO .
C) doppler reports.
D) Detailed Operative notes
indicating need for Reoperation
A)Detailed discharge summary.
B) Detailed Operative notes.
C) barcode of valves.
D)rings used.
E) Ascertain the need for
reoperation.
A)Clinical notes.
B) ECHO .
C) doppler reports.
D) Detailed Operative notes
indicating need for Reoperation
A)Detailed discharge summary.
B) Detailed Operative notes.
C) barcode of valves.
D)rings used.
E) Ascertain the need for
reoperation.
OPEN
Y
1579
CTVS
SV
SV031
Immediate reoperation
(within 5 days)
SV031D Tricuspid Valve
59500
71400
77350
86275
OPEN
Y
1580
CTVS
SV
SV031
Immediate reoperation
(within 5 days)
SV031E
Double Valve Procedure
71000
85200
92300
102950
OPEN
Y
1581
CTVS
SV
Immediate reoperation
SV031
(within 5 days)
SV031F
SV
Low Cardiac Output
syndrome requiring
SV032
IABP insertion post operatively
Low Cardiac Output
syndrome requiring
SV032A
IABP insertion post operatively
Triple valve procedure
85000
102000
110500
123250
OPEN
Y
1582
1583
1584
CTVS
CTVS
CTVS
SV
SV
SV033 Re-do sternotomy
SV034
Excessive bleeding
requiring re-exploration
SV033A Re-do sternotomy
SV034A
Excessive bleeding
requiring re-exploration
1585
Unspecified Package
US
US001 Unspecified Package
1586
COVID-19
CO
CO001
CO
Covid Treatment CO001
ICU
CO001B Covid Treatment - ICU
Covid Treatment - ICU
CO001C
with Ventilator
1587
COVID-19
Covid Treatment General Bed
1588
COVID-19
CO
Covid Treatment CO001
ICU with Ventilator
1589
COVID-19
CO
CO002 RTPCR Test
1590
COVID-19
CO
CO002 ANTIGEN Test
1591
Organ & Tissue Transplant
OT
OT001
Bone Marrow
Transplantation
US001A Unspecified Package
CO001A
Covid Treatment General Bed
50000
20000
10000
60000
24000
12000
65000
26000
13000
72500
A) Clinical notes with planned line A)Procedure.
of treatment
B) Operative Notes.
B) Indication for need of required C) Detailed Discharge Summary
Procedure
OPEN
29000
A) Clinical notes with planned line A)Procedure.
of treatment
B) Operative Notes.
B) Indication for need of required C) Detailed Discharge Summary
Procedure
OPEN
14500
A) Clinical notes with planned line A)Procedure.
of treatment
B) Operative Notes.
B) Indication for need of required C) Detailed Discharge Summary
Procedure
OPEN
A) Clinical notes with planned line
A) Procedure
of treatment
B) Operative Notes
B) Indication for need of required
C) Detailed Discharge Summary
Procedure
OPEN
Editable as
Editable as
Editable as per
Editable as per
per Actual
per Actual
Actual but
Actual but
but Limited
but Limited
Limited to
Limited to
to Balance in
to Balance in
Balance in Card
Balance in Card
Card
Card
1750
12000
2100
14400
2275
15600
2537
17400
13000
15600
16900
18850
CO002A RTPCR Test
450
450
450
450
CO002B ANTIGEN Test
100
100
100
100
OT001A
Bone Marrow
Transplantation
Rs 5 lakh for
Rs 5 lakh for
Male
Male Member
Member or
or Rs 10 Lakh
Rs 10 Lakh
for Female
for Female
Member of the
Member of
Family
the Family
A) Indication for need of required
Procedure
B) Covid +ve Test Report
A) Indication for need of required
Procedure
B) Covid +ve Test Report
A) Indication for need of required
Procedure
B) Covid +ve Test Report
Indication for need of required
procedure
Indication for need of required
procedure
Rs 5 lakh for
Rs 5 lakh for
Male
Male Member
Member or
or Rs 10 Lakh A) Clinical Documents
Rs 10 Lakh
for Female
B) Justification for Procedure
for Female
Member of the
Member of
Family
the Family
N
N
N
N
a) Treatment details.
b) Detailed discharge summary.
OPEN
a) Treatment details.
b) Detailed discharge summary.
OPEN
a) Treatment details.
b) Detailed discharge summary.
OPEN
Test Report
OPEN
Test Report
OPEN
A) Detail OT Notes
B) Detailed discharge summary
OPEN
Y
Y
Y
Y
Y
Y
YES
SL NO
1592
Specialty
Organ & Tissue Transplant
Specialty
Code
OT
Package
Code
Package Name
OT002 Liver Transplantation
Procedure
Code
Procedure Name
OT002A Liver Transplantation
Non-NABH NABH Entry
Level Package
Package
Cost
Cost
Rs 5 lakh for
Rs 5 lakh for
Male
Male Member
Member or
or Rs 10 Lakh
Rs 10 Lakh
for Female
for Female
Member of the
Member of
Family
the Family
NABH
Package
Cost
Outside State
NABH
Package Cost
Mandatory Documents - Pre
Authorization
Rs 5 lakh for
Rs 5 lakh for
Male
Male Member
Member or
or Rs 10 Lakh A) Clinical Documents
Rs 10 Lakh
for Female
B) Justification for Procedure
for Female
Member of the
Member of
Family
the Family
Pre-Auth for
Multiple
Mandatory Documents - Claim
More than
Remark Procedure
Processing
40,000 (Auto
s
Approved)
A) Detail OT Notes
B) Detailed discharge summary
OPEN
Y
YES
Implant Master
Implant /
High End
Consumable
Code
Specialty
Implant / High End Consumable
Name
FRA0001
Radiation Oncology
Additional fraction for 2D External
Beam Radiotherapy
MR003A, MR003B, MR003C
10
500
FRA0002
Radiation Oncology
Additional fraction for 2D External
Beam Radiotherapy
MR001A, MR001B, MR001C
18
500
FRA0003
Radiation Oncology
Additional Fraction for Linear
Accelerator, External Beam
Radiotherapy 3D CRT
MR005A, MR005B, MR005C
10
1,000
FRA0004
Radiation Oncology
Additional Fraction for Linear
Accelerator, External Beam
Radiotherapy 3D CRT
MR004A, MR004B, MR004C
18
1,000
FRA0005
Radiation Oncology
Additional Fraction for Linear
Accelerator, External Beam
Radiotherapy IMRT
MR006A, MR006B, MR006C
15
2,000
FRA0006
Radiation Oncology
Additional Fraction for Linear
Accelerator, External Beam
Radiotherapy IMRT
MR007A, MR007B, MR007C
18
2,000
FRA0007
Radiation Oncology
Additional Fraction for Linear
Accelerator External Beam
Radiotherapy IGRT with 3D CRT
or IMRT
MR008A, MR008B, MR008C
15
2,500
FRA0008
Radiation Oncology
Additional Fraction for Linear
Accelerator External Beam
Radiotherapy IGRT with 3D CRT
or IMRT
MR009A, MR009B, MR009C
18
2,500
FRA0009
Radiation Oncology
Additional Fraction for SRT/ SBRT
MR010A
with IGRT
4
11,000
FRA0010
Radiation Oncology
Additional Fraction for Respiratory
Gating along with Linear
Accelerator planning
10
3,500
FRA0011
Radiation Oncology
Additional Fraction for
MR014A, MR014B
Brachytherapy High Dose Radiation
15
1,250
IMP0001
IMP0002
IMP0003
Cardiology
Cardiology
Cardiology
MC007A
MC003A, MC003B, MC004A, MC004B
MC003A, MC003B, MC004A, MC004B
1
1
1
62,000
14,000
33,000
To be Editable
To be Editable
To be Editable
IMP0004
Cardiology
MC011A
3
8,700
To be Editable
IMP0005
Cardiology
ASD Device
Cardiac Balloon - Adult
Cardiac Balloon - Pediatric
Coronary Stent for PTCA - Bare
Metal
Coronary Stent for PTCA - Drug
Eluting
Procedure Code
MR012A
Maximum
Permissible
Multiplier
Implant
Price
Remark
MC011A
3
31,600
To be Editable
IMP0006
Cardiology
Double Chamber Pacemaker - Rate
Responsive
MC016A
1
75,000
To be Editable
IMP0007
Cardiology
PDA Device
MC009A
1
30,000
To be Editable
IMP0008
Cardiology
Peripheral Stent - Bare Metal
MC017A
1
21,000
To be Editable
MC015A
1
45,000
To be Editable
MC008A
1
72,000
To be Editable
SV001E, SV002A, SV002B, SV002C, SV002D, SV002E, SV002F, SV002G, SV002H, SV002I, SV002J, SV002K,
SV002L, SV002M, SV002N, SV002O, SV003A, SV003B, SV003C, SV003D, SV003E, SV003F, SV003G,
SV003H, SV003I, SV003J, SV003K, SV003L, SV003M, SV003N, SV003O, SV003P, SV003Q, SV003R,
SV003S, SV003T, SV003U, SV003V, SV003W, SV003X, SV003Y, SV031A
1
30,000
To be Editable
SV015A, SV015B
1
85,000
To be Editable
SV014A, SV014B, SV014C, SV014D, SV014E
1
100,000 To be Editable
SV015A, SV015B
SV017A, SV017B, SV017C, SV017D
1
1
85,000
35,000
To be Editable
To be Editable
Single Chamber Pacemaker - Rate
Responsive
VSD Device
IMP0009
Cardiology
IMP0010
Cardiology
IMP0011
CTVS
PTFE Patch - Thin
IMP0012
CTVS
IMP0013
CTVS
IMP0014
IMP0015
CTVS
CTVS
Arch Graft
Composite Aortic Valved conduit Mechanical
Coselli Graft
Dacron Graft - Bifurcated
IMP0016
CTVS
Dacron Graft - Straight
SV001D, SV016A, SV016B, SV016C, SV016D, SV019A, SV019B, SV019C, SV019D, SV019E, SV019F,
SV019G, SV019H, SV019I, SV019J, SV019K, SV019L, SV019M, SV019N, SV019O, SV019P, SV019Q,
SV019R, SV019S
1
30,000
To be Editable
1
40,000
To be Editable
IMP0017
CTVS
Mechanical Valve - Bileaflet
SV005A, SV005B, SV006A, SV007A, SV005C, SV002A, SV002B, SV002C, SV002D, SV002E, SV002F,
SV002G, SV002H, SV002I, SV002J, SV002K, SV002L, SV002M, SV002N, SV002O, SV003A, SV003B,
SV003C, SV003D, SV003E, SV003F, SV003G, SV003H, SV003I, SV003J, SV003K, SV003L, SV003M,
SV003N, SV003O, SV003P, SV003Q, SV003R, SV003S, SV003T, SV003U, SV003V, SV003W, SV003X,
SV003Y, SV031A, SV031B, SV031C, SV031D, SV031E, SV031F
IMP0018
CTVS
Mechanical Valve - Tilting Disc
SV005A, SV005B, SV006A, SV007A, SV005C, SV002A, SV002B, SV002C, SV002D, SV002E, SV002F,
SV002G, SV002H, SV002I, SV002J, SV002K, SV002L, SV002M, SV002N, SV002O, SV003A, SV003B,
SV003C, SV003D, SV003E, SV003F, SV003G, SV003H, SV003I, SV003J, SV003K, SV003L, SV003M,
SV003N, SV003O, SV003P, SV003Q, SV003R, SV003S, SV003T, SV003U, SV003V, SV003W, SV003X,
SV003Y, SV031A, SV031B, SV031C, SV031D, SV031E, SV031F
1
28,000
To be Editable
IMP0019
CTVS
Complex grafts other than Arch
Graft & Coseli Graft
SV015A, SV015B
1
85,000
To be Editable
Pericardial Patch
SV019A, SV019B, SV019C, SV019D, SV019E, SV019F, SV019G, SV019H, SV019I, SV019J, SV019K, SV019L,
SV019M, SV019N, SV019O, SV019P, SV019Q, SV019R, SV019S, SV002A, SV002B, SV002C, SV002D,
SV002E, SV002F, SV002G, SV002H, SV002I, SV002J, SV002K, SV002L, SV002M, SV002N, SV002O,
SV003A, SV003B, SV003C, SV003D, SV003E, SV003F, SV003G, SV003H, SV003I, SV003J, SV003K, SV003L,
SV003M, SV003N, SV003O, SV003P, SV003Q, SV003R, SV003S, SV003T, SV003U, SV003V, SV003W,
SV003X, SV003Y, SV031A
1
18,000
To be Editable
IMP0020
CTVS
Page 1
Implant Master
Implant /
High End
Consumable
Code
Specialty
IMP0021
CTVS
IMP0022
Procedure Code
Maximum
Permissible
Multiplier
PTFE Graft - Straight
SV019A, SV019B, SV019C, SV019D, SV019E, SV019F, SV019G, SV019H, SV019I, SV019J, SV019K, SV019L,
SV019M, SV019N, SV019O, SV019P, SV019Q, SV019R, SV019S
1
50,000
CTVS
RV - PA Conduit
SV009A, SV031A
1
120,000 To be Editable
IMP0023
CTVS
Tissue Valve
SV005A, SV005B, SV006A, SV007A, SV005C, SV002A, SV002B, SV002C, SV002D, SV002E, SV002F,
SV002G, SV002H, SV002I, SV002J, SV002K, SV002L, SV002M, SV002N, SV002O, SV003A, SV003B,
SV003C, SV003D, SV003E, SV003F, SV003G, SV003H, SV003I, SV003J, SV003K, SV003L, SV003M,
SV003N, SV003O, SV003P, SV003Q, SV003R, SV003S, SV003T, SV003U, SV003V, SV003W, SV003X,
SV003Y, SV031A, SV031B, SV031C, SV031D, SV031E, SV031F
1
70,000
To be Editable
IMP0024
CTVS
Valve Ring - Mitral
SV005B, SV006A, SV007A, SV002A, SV002B, SV002C, SV002D, SV002E, SV002F, SV002G, SV002H,
SV002I, SV002J, SV002K, SV002L, SV002M, SV002N, SV002O, SV003A, SV003B, SV003C, SV003D,
SV003E, SV003F, SV003G, SV003H, SV003I, SV003J, SV003K, SV003L, SV003M, SV003N, SV003O,
SV003P, SV003Q, SV003R, SV003S, SV003T, SV003U, SV003V, SV003W, SV003X, SV003Y, SV031A,
SV031C, SV031E, SV031F
1
35,000
To be Editable
IMP0025
CTVS
Valve Ring - Tricuspid
SV006A, SV007A, SV005C, SV002A, SV002B, SV002C, SV002D, SV002E, SV002F, SV002G, SV002H,
SV002I, SV002J, SV002K, SV002L, SV002M, SV002N, SV002O, SV003A, SV003B, SV003C, SV003D,
SV003E, SV003F, SV003G, SV003H, SV003I, SV003J, SV003K, SV003L, SV003M, SV003N, SV003O,
SV003P, SV003Q, SV003R, SV003S, SV003T, SV003U, SV003V, SV003W, SV003X, SV003Y, SV031A,
SV031D, SV031E, SV031F
1
35,000
To be Editable
IMP0026
ENT
Fibrin Glue
SL029A, SL029B, SL029C, SL029D, SL029E, SL030A, SL030B, SL031A, SL031B, SL031C, SL032A, SL032B,
SL032C, SL032D
1
9,000
IMP0027
ENT
Implant for Open laryngeal
framework surgery / Thyroplasty
(Keel / Stent)
SL025A
1
15,000
IMP0028
Ophthalmology
1
6,000
SL003A, SL003B
1
5,000
SL002A
1
7,000
SL002A
1
7,000
SL034A, SL034B, SL034C, ST002A
1
4,000
SG050E
SG032B
SG052A
SG050A, SG050B, SG050C, SG050D, SV029A
SG052A, SG051A, SG051B, SG051C, SG051D, SO025A, SO025B, SG050E
1
1
1
1
1
15,000
17,000
15,000
2,000
5,000
SO013A
1
5,000
SE035B
1
1,000
SE036A
1
1,000
IMP0029
ENT
IMP0030
ENT
IMP0031
ENT
IMP0032
ENT
IMP0033
IMP0034
IMP0035
IMP0036
IMP0037
General Surgery
General Surgery
General Surgery
General Surgery
General Surgery
IMP0038
Implant / High End Consumable
Name
Implant for "Vitreoretinal Surgery"
(IOL & Per flouro carbon liquid)
Piston for Stapedectomy /
Tympanotomy
Partial Ossicular Replacement
Prosthesis - Indian Titanium
Total Ossicular Replacement
Prosthesis - Indian Titanium
Implant for Open reduction and
internal fixation of maxilla /
mandible / zygoma
(Plates / Screws)
Tackers
Haemorroid Stapler
Mesh - 30 X 30
Mesh - 6 X 3 - Polypropylene
Mesh - 15 X 15
Obstetrics & Gynecology Sling
IMP0041
Ophthalmology
IMP0042
Ophthalmology
IMP0043
Ophthalmology
IMP0044
IMP0045
IMP0046
IMP0048
Ophthalmology
Ophthalmology
Ophthalmology
Ophthalmology
IMP0049
Ophthalmology
IMP0051
IMP0053
IMP0055
IMP0056
Ophthalmology
Urology
Urology
Cardiology
IMP0057
Cardiology
IMP0058
Cardiology
IMP0060
Orthopedics
IMP0061
Orthopedics
IMP0062
IMP0063
Orthopedics
Orthopedics
IMP0065
Orthopedics
IMP0066
Orthopedics
Implant for "Enucleation"
(Conformers + Plastic / silicon ball
type implant)
Implant for "Evisceration"
(Conformers + Plastic / silicon ball
type implant)
Foldable Hydrophobic intraocular
lens
IOL
Glue for Scleral fixated IOL
Non foldable IOL
Silicon Tube / Silicon stent
Valved / Non Valved Glaucoma tube
- shunt
Tissue graft - Cornea / Sclera
BIS standard sling for women
DJ Stent
Balloon & Accessories
Implant for "Electrophysiological
Study" includes - Steerable
decapolar catheter, Quadripolar
Catheter
Implant
Price
Remark
To be Editable
SE032A
SE020A, SE021A, SE021B, SE021C
1
3,000
SE024A
SE023A
SE020B
SE010A, SE010C
1
1
1
1
3,000
3,000
1,000
2,000
SE027C
1
7,000
SE019A
SU062A
SU016A, SU033A
MC005A
1
1
1
1
3,000
5,000
200
55,000
To be Editable
MC012A
1
46,000
To be Editable
Implant for "Electrophysiological
Study
with Radio Frequency Ablation"
MC012B
includes includes - Steerable
decapolar catheter, Quadripolar
Catheter, Radio Frequency Catheter
1
76,000
To be Editable
1
5,000
Cannulated Screws for Closed
Reduction and Percutaneous Screw
Fixation (neck femur)
Dynamic Hip Screw for
Intertrochanteric Fracture
External Fixator
Proximal Femoral Nail
SB019A
SB019B
1
5,000
SB005A, SB005B, SB005C, SB005D
SB019C
1
1
5,000
8,000
Implant for "Fracture - Acetabulum SB018A
Single Approach" - Recon Plate (2)
1
10,000
Implant for "Fracture - Acetabulum SB018B
Combined Approach" - Recon Plate
1
15,000
Page 2
Implant Master
Implant /
High End
Consumable
Code
Specialty
Implant / High End Consumable
Name
IMP0067
Orthopedics
Modular Custom Prosthesis for
Bone Tumour Excision - malignant
including GCT + Joint replacement
IMP0068
IMP0071
IMP0072
Surgical Oncology
Surgical Oncology
Surgical Oncology
IMP0073
Surgical Oncology
IMP0076
Neurosurgery
IMP0081
IMP0084
IMP0087
IMP0089
Polytrauma
Interventional
Neuroradiology
Interventional
Neuroradiology
Orthopedics
IMP0090
Orthopedics
IMP0092
Orthopedics
IMP0093
Orthopedics
IMP0094
Orthopedics
IMP0095
Orthopedics
IMP0096
Orthopedics
IMP0097
Orthopedics
IMP0098
Orthopedics
IMP0099
Orthopedics
IMP0100
Orthopedics
IMP0101
Orthopedics
IMP0102
Orthopedics
IMP0103
Orthopedics
IMP0104
Orthopedics
IMP0105
Orthopedics
IMP0106
Orthopedics
IMP0107
Orthopedics
IMP0108
Orthopedics
IMP0109
Orthopedics
IMP0110
Orthopedics
IMP0111
Orthopedics
IMP0112
Orthopedics
IMP0113
Orthopedics
IMP0114
Orthopedics
IMP0116
Orthopedics
IMP0117
IMP0118
Orthopedics
Orthopedics
Procedure Code
Maximum
Permissible
Multiplier
Implant
Price
Remark
SB040A
1
120,000
SC040A
SC076A
SC076A
1
1
1
30,000
15,000
25,000
SC073A
1
15,000
Clip for Aneurysm
SN023A
3
15,000
Implant for "One fracture of long
bone (with implants)"
ST004A
1
5,000
Coil for embolization of aneurysms
IN003A, IN004A
17
24,000
To be Editable
Balloon for Embolization
IN004B
1
11,000
To be Editable
SB026B
1
5,000
Voice prosthesis
Chemo Port - Adult
Chemo Port - Pediatric
Implant for Microvascular
reconstruction
Implant for Arthrodesis of Shoulder
(Screw / Plate)
Implant for Arthrodesis of Wrist
(Plate)
Implant for Ankle Fracture ORIF
(Tension Band Wire + Plate)
Implant for Bone Tumour Excision
+ reconstruction
(Plate)
Plate for ORIF - Diaphyseal fracture
- Long Bone
IM Nail for CR&F - Diaphyseal
fracture - Long Bone
Plate for Comminuted Fracture Olecranon of Ulna
SB026C
1
5,000
SB020A
1
5,000
SB041A
1
10,000
SB010A
1
6,000
SB010B
1
7,000
SB011A
1
8,000
Tension Band Wire for Comminuted
SB011B
Fracture - Olecranon of Ulna
1
2,000
1
7,000
Implants for Fracture - Both Bones Forearm - ORIF
(Plates & / or Nails)
Locking Plate for Metaphyseal
fracture - Long Bone
Implant for Fracture - Single Bones Forearm - ORIF
(Plate / Nail)
Implant for Fracture Head radius
(Plate / Screw)
Plate for High Tibial Osteotomy
Implant for Fracture Condyle Humerus - ORIF
Implant for Internal Fixation of
Small Bones
Implant for Limb Lengthening /
Bone Transport by Ilizarov
Implant for Ilizarov fixation
Implant for Open Reduction of
Small joints
(K - Wire)
Implant for Osteotomy - Long Bone
(Screw)
Implant for Percutaneous - Fixation
of Fracture
(K - Wire / Screw)
Implant & brace for Reconstruction
of ACL / PCL
(Bio screw / Endobutton / Suture
disc + Ethibond)
Implant for Fracture intercondylar
Humerus + olecranon osteotomy
(TBW + Plates)
Implant for Total Hip Replacement Cemented
Implant for Total Hip Replacement Cementless
Implant for Total Hip Replacement Hybrid
Implant for Unipolar
Hemiarthroplasty
Non - Modular - Non - Cemented
Modular - Cemented
SB014A
SB009A
2
1
SB013A
7,000
3,500
SB012A
1
5,000
SB057A
1
7,000
SB015A, SB015B
1
1,500
SB008A
1
1,500
SB059A
1
12,000
SB058A
1
10,000
SB029A
1
1,500
SB055A
1
5,000
SB006A
1
2,000
SB049A, SB049B
1
17,000
SB016A
1
11,000
SB038A
1
35,000
SB038B
1
60,000
45,000
SB038C
1
SB031A
1
3,000
SB031B
SB031C
1
1
7,000
20,000
IMP0119
Orthopedics
Implant for Total Knee Replacement SB039A
1
55,000
IMP0121
Orthopedics
Implant for Elbow Replacement
1
31,000
IMP0122
Orthopedics
Implant for Elastic Nailing of Femur
/ Humerus / Forearm
SB007A, SB007B, SB007C
(Elastic Nail)
1
5,000
IMP0123
Orthopedics
Implant for Growth Modulation &
Fixation (Plate)
SB060A
IMP0124
Orthopedics
Implant for AC Joint reconstruction
/ Stabilization
(Plate/ screw / Fibre wire /
reconstruction by tendon etc)
SB032A, SB032B, SB032C, SB032D, SB032E, SB032F
SB037A
6
Page 3
1
5,000
10,000
To be Editable
Implant Master
Implant /
High End
Consumable
Code
Specialty
IMP0125
Orthopedics
Implant for Cervical spine fixation
including odontoid (Screw)
SB021A
1
5,000
IMP0126
Orthopedics
Implant for Cervical spine fixation
including odontoid
(Odontoid Screw)
SB021A
1
20,000
IMP0127
Orthopedics
Implant for Cervical spine fixation
including odontoid (Cage)
SB021A
1
10,000
IMP0128
Orthopedics
JESS Fixator
SB063A
1
8,000
IMP0129
Orthopedics
Implant for Displaced Clavicle
Fracture (Plate)
SB017A
1
3,000
IMP0130
Orthopedics
Implant for Dorsal and lumber spine
fixation
SB022A, SB022B
(Plate including screw)
3
5,000
IMP0131
Orthopedics
SB022A, SB022B
1
10,000
IMP0132
Orthopedics
SB054A
2
5,000
IMP0133
Orthopedics
SB054A
1
10,000
IMP0134
Orthopedics
SB030A
1
2,000
IMP0135
Neurosurgery
SN034B
1
10,000
To be Editable
SN038B
1
10,000
To be Editable
SN041B
1
10,000
To be Editable
SN039B
1
10,000
To be Editable
SN042B
1
10,000
To be Editable
SN040B
1
10,000
To be Editable
SN043B
1
10,000
To be Editable
SL020A, SL020C
1
20,000
SB026D
1
10,000
SB026A
1
5,000
MC010A
1
8,700
To be Editable
MC010A
1
31,600
To be Editable
IN004A
1
120,000 To be Editable
MG072A, MG072B
MG001A, MG002B, MG003B, MG004A, MG004B, MG004C, MG005A, MG006A,
MG007A, MG008A, MG009A, MG009B, MG010A, MG010B, MG011A, MG012A,
MG013A, MG014A, MG015A, MG016A, MG017A, MG018A, MG020A, MG020B,
MG021A, MG022A, MG023A, MG024A, MG025A, MG026A, MG028A, MG029A,
MG030A, MG031A, MG031B, MG032A, MG034A, MG035A, MG036A, MG037A,
MG038A, MG039A, MG039B, MG040A, MG040B, MG040C, MG042A, MG043A,
MG044A, MG046A, MG047A, MG048A, MG050A, MG051A, MG052A, MG053A,
MG054A, MG055A, MG056A, MG057A, MG059A, MG061A, MG062A, MG063A,
MG064A, MG065A, MG066A, MG067A, MG068A, MG069A, MG070A, MG071A,
MG071B, MG072A
SN002B
MG013A
MG072A
SE041A
1
Implant / High End Consumable
Name
Implant for Dorsal and lumber spine
fixation (Cage)
Implant for Spine deformity
correction
(Plate including screw)
Implant for Spine deformity
correction
(Cage)
Implant for Tension Band Wiring
(Wire)
Implant for Laminectomy with
Fusion and fixation
Implant for Spine - Decompression
& Fusion with fixation
IMP0136
Neurosurgery
IMP0137
Neurosurgery
IMP0138
Neurosurgery
IMP0139
Neurosurgery
IMP0140
Neurosurgery
IMP0141
Neurosurgery
IMP0142
ENT
IMP0143
Orthopedics
IMP0144
Orthopedics
IMP0145
Cardiology
IMP0146
Cardiology
IMP0147
Interventional
Neuroradiology
IMP0148
General Medicine
IMP0149
General Medicine
Medicine/ Drug (Only incase of
patient admitted in ICU, HDU or
ICU with Ventilator)
IMP0150
IMP0151
IMP0152
IMP0153
Neurosurgery
General Medicine
General Medicine
Ophthalmology
Mesh
Albumin
Dialyzer Kit
Ranibizumab
IMP0154
Surgical Oncology
Implant for Spine - Extradural
Tumour with fixation
Implant for Spine - Extradural
Haematoma with fixation
Implant for Spine - Intradural
Tumour with fixation
Implant for Spine - Intradural
Haematoma with fixation
Implant for Spine - Intramedullar
Tumour with fixation
Implant for Excision of tumour of
oral cavity / paranasal sinus /
laryngopharynx
Implant for Arthrodesis of Knee
(Compression Assembly / Ilizarov)
Implant for Arthrodesis of Shoulder
(Screw / Plate)
Coronary Stent for PDA stenting Bare Metal
Coronary Stent for PDA stenting Drug Eluting
Implant for "Carotico-cavernous
Fistula (CCF) embolization with
coils.
[5 coils, guide catheter, microcatheter, micro-guidewire, general
items]Coil for embolization of
aneurysms"
Erythropoietin Stinulating Agency
Endo-Staplers
Procedure Code
SC001A, SC001B, SC002A,SC002B, SC003A, SC003B, SC003C, SC004A, SC005A, SC005B, SC006A,
SC006B, SC007A, SC008A, SC008B, SC009A, SC009B, SC010A, SC010B, SC011A, SC011B, SC012A,
SC012B, SC013A, SC014A, SC015A, SC016A, SC016B, SC017A, SC018A, SC019A, SC020A, SC020B,
SC020C, SC020D, SC021A, SC022A, SC023A, SC024A, SC024B, SC024C, SC024D, SC024E, SC024F,
SC024G, SC024H, SC024I, SC025A, SC026A, SC027A, SC028A, SC029A, SC030A, SC030B, SC031A,
SC031B, SC032A, SC032B, SC032C, SC032D, SC032E, SC032F, SC032G, SC033A,
SC034A, SC035A, SC036A, SC036B, SC037A, SC038A, SC039A, SC040A, SC040B, SC041A, SC042A,
SC043A, SC044A, SC045A, SC046A, SC047A, SC047B, SC048A, SC048B, SC049A, SC050A, SC051A,
SC052A, SC053A, SC053B, SC054A, SC055A, SC055B, SC056A, SC057A, SC057B, SC058A, SC058B,
SC059A, SC059B, SC060A, SC061A, SC062A, SC063A, SC064A, SC064B, SC064C, SC065A, SC066A,
SC067A, SC068A, SC068B, SC069A, SC070A, SC071A, SC071B, SC072A, SC073A, SC074A, SC075A, SC076A
Page 4
Maximum
Permissible
Multiplier
Implant
Price
-
1
1
1
1
1
1
Remark
To Be Editable
20,000
To be Editable
20,000
---
To be Editable
To be Editable
To be Editable
To be Editable
--
To be Editable
--
Implant Master
Implant /
High End
Consumable
Code
Specialty
IMP1001
General medicine,
Pediatric Medical
Management
Routine Ward
IMP1002
General medicine,
Pediatric Medical
Management
HDU
IMP1003
IMP1004
General medicine,
Pediatric Medical
Management
General medicine,
Pediatric Medical
Management
Implant / High End Consumable
Name
ICU Without Ventilator
ICU With Ventilator
Procedure Code
MG001A, MG002B, MG003B, MG004A, MG004B, MG004C, MG005A, MG006A,
MG007A, MG008A, MG009A, MG009B, MG010A, MG010B, MG011A, MG012A,
MG013A, MG014A, MG015A, MG016A, MG017A, MG018A, MG020A, MG020B,
MG021A, MG022A, MG023A, MG024A, MG025A, MG026A, MG028A, MG029A,
MG030A, MG031A, MG031B, MG032A, MG034A, MG035A, MG036A, MG037A,
MG038A, MG039A, MG039B, MG040A, MG040B, MG040C, MG042A, MG043A,
MG044A, MG046A, MG047A, MG048A, MG050A, MG051A, MG052A, MG053A,
MG054A, MG055A, MG056A, MG057A, MG059A, MG061A, MG062A, MG063A,
MG064A, MG065A, MG066A, MG067A, MG068A, MG069A, MG070A, MG071A,
MG071B, M P001A, MP001B, MP001C, MP001D, MP002A, MP003A, MP003B,
MP004A, MP005A, MP005B, MP005C, MP005D, MP005E, MP005F, MP005G,
MP006A, MP006B, MP006C, MP006D, MP006E, MP007A, MP008A, MP009A,
MP010A, MP011A, MP012A, MP013A, MP014A, MP015A, MP016A, MP017A,
MP018A, MP019A, MP020A, MP020B, MP021A, MP022A, MP023A, MP024A,
MP025A, MP026A, MP027A, MP029A, MP029B, MP030A, MP031A, MP032A,
MP033A, MP034A, MP035A, MP036A, MP037A, MP038A, MP039A, MP040A,
MP040B, M P040C, MP040D, MP041A, MP042A, MP043A, MP044A, MP045A,
MP046A,
MG001A, MG002B, MG003B, MG004A, MG004B, MG004C, MG005A, MG006A,
MG007A, MG008A, MG009A, MG009B, MG010A, MG010B, MG011A, MG012A,
MG013A, MG014A, MG015A, MG016A, MG017A, MG018A, MG020A, MG020B,
MG021A, MG022A, MG023A, MG024A, MG025A, MG026A, MG028A, MG029A,
MG030A, MG031A, MG031B, MG032A, MG034A, MG035A, MG036A, MG037A,
MG038A, MG039A, MG039B, MG040A, MG040B, MG040C, MG042A, MG043A,
MG044A, MG046A, MG047A, MG048A, MG050A, MG051A, MG052A, MG053A,
MG054A, MG055A, MG056A, MG057A, MG059A, MG061A, MG062A, MG063A,
MG064A, MG065A, MG066A, MG067A, MG068A, MG069A, MG070A, MG071A,
MG071B, M P001A, MP001B, MP001C, MP001D, MP002A, MP003A, MP003B,
MP004A, MP005A, MP005B, MP005C, MP005D, MP005E, MP005F, MP005G,
MP006A, MP006B, MP006C, MP006D, MP006E, MP007A, MP008A, MP009A,
MP010A, MP011A, MP012A, MP013A, MP014A, MP015A, MP016A, MP017A,
MP018A, MP019A, MP020A, MP020B, MP021A, MP022A, MP023A, MP024A,
MP025A, MP026A, MP027A, MP029A, MP029B, MP030A, MP031A, MP032A,
MP033A, MP034A, MP035A, MP036A, MP037A, MP038A, MP039A, MP040A,
MP040B, M P040C, MP040D, MP041A, MP042A, MP043A, MP044A, MP045A,
MP046A,
MG001A, MG002B, MG003B, MG004A, MG004B, MG004C, MG005A, MG006A,
MG007A, MG008A, MG009A, MG009B, MG010A, MG010B, MG011A, MG012A,
MG013A, MG014A, MG015A, MG016A, MG017A, MG018A, MG020A, MG020B,
MG021A, MG022A, MG023A, MG024A, MG025A, MG026A, MG028A, MG029A,
MG030A, MG031A, MG031B, MG032A, MG034A, MG035A, MG036A, MG037A,
MG038A, MG039A, MG039B, MG040A, MG040B, MG040C, MG042A, MG043A,
MG044A, MG046A, MG047A, MG048A, MG050A, MG051A, MG052A, MG053A,
MG054A, MG055A, MG056A, MG057A, MG059A, MG061A, MG062A, MG063A,
MG064A, MG065A, MG066A, MG067A, MG068A, MG069A, MG070A, MG071A,
MG071B, M P001A, MP001B, MP001C, MP001D, MP002A, MP003A, MP003B,
MP004A, MP005A, MP005B, MP005C, MP005D, MP005E, MP005F, MP005G,
MP006A, MP006B, MP006C, MP006D, MP006E, MP007A, MP008A, MP009A,
MP010A, MP011A, MP012A, MP013A, MP014A, MP015A, MP016A, MP017A,
MP018A, MP019A, MP020A, MP020B, MP021A, MP022A, MP023A, MP024A,
MP025A, MP026A, MP027A, MP029A, MP029B, MP030A, MP031A, MP032A,
MP033A, MP034A, MP035A, MP036A, MP037A, MP038A, MP039A, MP040A,
MP040B, M P040C, MP040D, MP041A, MP042A, MP043A, MP044A, MP045A,
MP046A,
MG001A, MG002B, MG003B, MG004A, MG004B, MG004C, MG005A, MG006A,
MG007A, MG008A, MG009A, MG009B, MG010A, MG010B, MG011A, MG012A,
MG013A, MG014A, MG015A, MG016A, MG017A, MG018A, MG020A, MG020B,
MG021A, MG022A, MG023A, MG024A, MG025A, MG026A, MG028A, MG029A,
MG030A, MG031A, MG031B, MG032A, MG034A, MG035A, MG036A, MG037A,
MG038A, MG039A, MG039B, MG040A, MG040B, MG040C, MG042A, MG043A,
MG044A, MG046A, MG047A, MG048A, MG050A, MG051A, MG052A, MG053A,
MG054A, MG055A, MG056A, MG057A, MG059A, MG061A, MG062A, MG063A,
MG064A, MG065A, MG066A, MG067A, MG068A, MG069A, MG070A, MG071A,
MG071B, M P001A, MP001B, MP001C, MP001D, MP002A, MP003A, MP003B,
MP004A, MP005A, MP005B, MP005C, MP005D, MP005E, MP005F, MP005G,
MP006A, MP006B, MP006C, MP006D, MP006E, MP007A, MP008A, MP009A,
MP010A, MP011A, MP012A, MP013A, MP014A, MP015A, MP016A, MP017A,
MP018A, MP019A, MP020A, MP020B, MP021A, MP022A, MP023A, MP024A,
MP025A, MP026A, MP027A, MP029A, MP029B, MP030A, MP031A, MP032A,
MP033A, MP034A, MP035A, MP036A, MP037A, MP038A, MP039A, MP040A,
MP040B, M P040C, MP040D, MP041A, MP042A, MP043A, MP044A, MP045A,
MP046A,
Page 5
Maximum
Permissible
Multiplier
-
Implant
Price
-
Remark
-
-
900
-
1,800
-
2,700