National Consumer Cost Tool (NCCT)
Procedure Volume Data Form
Complete this form if you received the NCCT mailing sent on April 16, 2012. When completing the form:

Include all payer volume (Medicare, Medicaid, commercial, self-pay)for the previous 12 months

Put “N/A” in the volume column if the procedure is not performed at your facility

Return one form for each facility (do not combine facility data)

Return the completed form by Tuesday, May 15, 2012

Email the completed form to: PremeraNCCT@premera.com
or fax it to: 425-918-5185 Attn: PIMS
For questions about this form or NCCT, call Physician and Provider Relations at 800-722-4714, option 4.
Location name :
Address:
Tax ID :
Contact name and phone number:
Inpatient Treatment Categories
Bariatric Surgery - Laparoscopic Gastric Bypass
Cardiac Angioplasty - w/ Drug Eluting Stent
Cardiac Defibrillator Implant w/o Cardiac Catheterization
Coronary Bypass (CABG) w/o Cardiac Catheterization
C-Section Delivery
Vaginal Delivery
Hip Replacement
Hysterectomy
Knee Replacement
Laminectomy - Inpatient
Spinal Fusion (Anterior)
Spinal Fusion (Posterior)
Removal of Plaque Build-Up in the Major Neck (Carotid) Arteries
Revision of Total Hip or Total Knee Replacement
Removal of Prostate Gland and Surrounding Tissue
Partial or Total Removal of Thyroid Gland
Outpatient Treatment Categories
ACL Repair by Arthroscopy
Back Surgery - Laminectomy
Bariatric Surgery (Lap Band)
Bladder Repair For Incontinence (Sling)
Breast Biopsy Percutaneous w/Imaging
Breast Biopsy w/Device
Breast Lumpectomy
Bunionectomy
Hammertoe Correction
Carpal Tunnel
Cataract Removal
Dilation & Curettage - D&C
MS-DRG
470
491
473
460
39
468
708
627
621
247
227
236
766 + 795
775 + 795
470
743
29888
63030, 63047
43770
57288
19102
19103
19301
28296, 28292
28285, 28270
64721
66984
58120
81.51, 81.52
81.54
CPT Code
ICD 9
Volume
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Volume
019184 (04-16-2012)
An Independent Licensee of the Blue Cross Blue Shield Association

National Consumer Cost Tool (NCCT)
Procedure Volume Data Form
Outpatient Treatment Categories
Hernia Inguinal Repair (Age 5+)
Knee Arthroscopy with Cartilage Repair
Laparoscopic Gall Bladder Removal
Laparoscopic Removal of Ovaries and/or Fallopian Tubes
Laparoscopic Tubal Block or Tubal Ligation
Left Heart Catheterization
Lithotripsy - Fragmenting of Kidney Stones
Nasal/Sinus - Corrective Surgery - Septoplasty
Nasal/Sinus - Endoscopy - Sinus Surgery
Shoulder Arthroscopy
Shoulder Arthroscopy with Rotator Cuff Repair
Tonsillectomy and/or Adenoidectomy, Under Age 12
Tonsillectomy and Adenoidectomy, Over Age 12
Tympanostomy and Myringotomy
Upper GI Endoscopy
Upper GI Endoscopy with Biopsy
Bronchoscopy
Urethra and Bladder Scope
Colonoscopy with Removal of Lesion(s)
Colonoscopy with Biopsy
Screening Colonoscopy
Hysteroscopy with Removal of Lesion(s) or Uterine Lining
Uterine Tissue Sample (Biopsy)
Repair of Umbilical Hernia (Age 5+)
Spinal Fusion of Neck - Front
Bladder Scope with Stent
Diagnostic Treatment Categories
CT Angiography, Abdomen w/o & w/ contrast
CT Angiography, Head w/o & w/ contrast
CT Angiography, Pelvis w/o & w/ contrast
Mammogram, Analog Unilateral
Mammogram, Analog Bilateral
Mammogram, Analog Bilateral 2 Views
Mammogram, Digital Screening Bilateral
Mammogram, Digital Diagnostic Bilateral
Mammogram, Digital Diagnostic Unilateral
CT Scan Abdomen w/o contrast
CT Scan Abdomen w/ contrast
CT Scan Abdomen w/o & w/ contrast
CT Scan Head/Brain w/o contrast
CT Scan Head/Brain w/ contrast
CT Scan Head/Brain w/o & w/ contrast
CT Scan Pelvis w/o contrast
CT Scan Pelvis w/contrast
CT Scan Pelvis w/o & w/ contrast
MRI Brain w/o contrast
MRI Brain w/ contrast
019184 (04-16-2012)
An Independent Licensee of the Blue Cross Blue Shield Association
CPT Code
49505
29877, 29880, 29881, 29882
47562, 47563
58661
58671
93510, 93452, 93458, 93459
50590
30520
31255, 31237, 31256, 31267, 31276
29826, 29806, 29807, 29822, 29823, 29824
29827
42820, 42825, 42830
42821, 42826, 42831
69420, 69421, 69433, 69436
43235
43239
31622, 31623, 31624, 31625, 31628, 31629
52000
45385, 45383, 45384
45380
45378
58563
58558
49585
22554
52332
74175
70496
72191
77055 (77051)
77056 (77051)
77057 (77052)
G0202 (77052)
G0204 (77051)
G0206 (77051)
74150
74160
74170
70450
70460
70470
72192
72193
72194
70551
70552
CPT Code Volume
Page 2 of 3
Volume

National Consumer Cost Tool (NCCT)
Procedure Volume Data Form
Diagnostic Treatment Categories
MRI Brain w/o & w/ contrast
MRI Lumbar Spine w/ contrast
MRI Lumbar Spine w/o contrast
MRI Lumbar Spine w/o & w/ contrast
MRI Neck Spine w/ contrast
MRI Neck Spine w/o contrast
MRI Neck Spine w/o & w/ contrast
MRI Orbit/Face/Neck w/ contrast
MRI Orbit/Face/Neck w/o contrast
MRI Orbit/Face/Neck w/o & w/ contrast
MRI Spine w/o contrast
MRI Spine w/ contrast
MRI Spine w/o & w/ contrast
MRI Lower Limb w/o contrast
MRI Lower Limb w/ contrast
MRI Lower Limb w/o & w/ contrast
MRI Upper Limb (Other Than Joint) w/o contrast
MRI Upper Limb (Other Than Joint) w/ contrast
MRI Upper Limb (Other Than Joint) w/o contrast & w/contrast
MRI Lower Limb with Joint w/o contrast
MRI Lower Limb with Joint w/ contrast
MRI Lower Limb with Joint w/o & w/ contrast
CT Scan of Mouth, Jaw, and Neck w/o contrast
CT Scan of Mouth, Jaw, and Neck w/ contrast
CT Scan of Mouth, Jaw, and Neck w/o & w/ contrast
CT Scan Chest w/o contrast
CT Scan Chest w/ contrast
CT Scan Chest w/o & w/ contrast
CT Scan of Lumbar Lower Spine w/o contrast
CT Scan of Lumbar Lower Spine w/ contrast
CT Scan of Lumbar Lower Spine w/o & w/ contrast
Bone Density study of Spine or Pelvis
Ultrasound of Head and Neck (e.g. Thyroid, Parathyroid, Parotid)
Ultrasound of Breast(s)
Ultrasound of Abdomen
Ultrasound of Pelvis
Bone and Joint Scan of Whole Body
PET Scan Image from Skull base to Mid-Thigh
PET Scan Image of Whole Body
72157
73718
73719
73720
73218
73219
73220
73721
73722
73723
70486
70553
72149
72148
72158
72142
72141
72156
70542
70540
70543
72146
72147
70487
70488
71250
71260
71270
72131
72132
72133
77080
76536
76645
76700
76856
78306
78815
78816
019184 (04-16-2012)
An Independent Licensee of the Blue Cross Blue Shield Association
CPT Code
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Volume