Procedure Codes. CT Angiography, Head, with contrast material(s), including noncontrast images, if performed, and image postprocessing 70496

Transcription

1 Procedure Codes 2015 Prominence Health Plan v3 DIAGNOSTIC RADIOLOGY CT CT Head or Brain 70450, 70460, CT Orbits, Sella, Posterior-Fossa, IACs 70480, 70481, CT Maxillofacial (Sinuses) 70486, 70487, CT Neck 70490, 70491, CT Chest 71250, 71260, CT Cervical Spine 72125, 72126, CT Thoracic Spine 72128, 72129, CT Lumbar Spine 72131, 72132, CT Pelvis 72192, 72193, CT Upper Extremity 73200, 73201, CT Lower Extremity 73700, 73701, CT Abdomen 74150, 74160, CT Abdomen and Pelvis 74176, 74177, CT colonography, diagnostic, including image postprocessing; without and with contrast 74261, CT colonography, screening, including image postprocessing CT Limited Study or Follow-up Low-dose computed tomography for lung cancer screening S8032 CTA CT Angiography, Head, with contrast material(s), including noncontrast images, if performed, and image postprocessing CT Angiography, Neck, with contrast material(s), including noncontrast images, if performed, and image postprocessing CT Angiography, Chest, with contrast material(s), including noncontrast images, if performed, and image postprocessing CT Angiography, Pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing CT Angiography, Upper Extremity, with contrast material(s), including noncontrast images, if performed, and image postprocessing CT Angiography, Lower Extremity, with contrast material(s), including noncontrast images, if performed, and image postprocessing CT Angiography, Abdomen and Pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing CT Angiography, Abdomen, with contrast material(s), including noncontrast images, if performed, and image postprocessing CT, heart, without contrast material, with quantitative evaluation of coronary calcium CT, heart, with contrast material, for evaluation of cardiac structure and morphology (including 3D image postprocessing, assessment of cardiac function, and evaluation of venous structures, if performed) CT, heart, with contrast material, for evaluation of cardiac structure and morphology in the setting of congenital heart disease (including 3D image postprocessing, assessment of LV cardiac function, RV structure and function and evaluation of venous structures, if performed) CTAngiography, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3D postprocessing (including evaluation of cardiac structures and morphology, assessment of cardiac function, and evaluation of venous structures, if performed) CT Angiography, Abdominal Aorta and Bilateral Iliofemoral Lower Exremity Runoff, with contrast material(s), including noncontrast images, if performed, and image postprocessing MRA MRA Brain 70544, 70545, MRA Neck 70547, 70548, MRA Chest 71555, C8909, C8910, C8911 1

2 MRA Spinal Canal and Contents MRA Pelvis MRA Upper Extremity MRA Lower Extremity MRA Abdomen 72159, C8931, C8932, C , C8918, C8919, C , C8934, C8935, C , C8912, C8913, C , C8900, C8901, C8902 MRI MRI TMJs -Temporomandibular joint(s) MRI Orbits, Face, Neck 70540, 70542, MRI Brain (including brain stem) 70551, 70552, MRI Brain, functional 70554, MRI Chest 71550, 71551, MRI Cervical Spine 72141, 72142, MRI Thoracic Spine 72146, 72147, MRI Lumbar Spine 72148, 72149, MRI Pelvis 72195, 72196, MRI Upper Extremity Other than Joint 73218, 73219, MRI Upper Extremity, Joint (Shoulder, Elbow, Wrist) 73221, 73222, MRI Lower Extremity Other than Joint 73718, 73719, MRI Lower Extremity, Joint (Knee, Hip Joint, Ankle) 73721, 73722, MRI Abdomen 74181, 74182, MRI Cardiac for Morphology and Function without contrast MRI Cardiac for Morphology and Function without contrast; with stress imaging MRI Cardiac for Morphology and Function w/o contrast material(s), followed by contrast material(s) and further sequences MRI Cardiac for Morphology and Function w/o contrast material(s), followed by contrast material(s) and further sequences; with stress imaging MRI Cardiac for velocity flow mapping MRI Breast - Unilateral without and/or with contrast 77058, C8903, C8904, C8905 MRI Breast - Bilateral without and/or with contrast 77059, C8906, C8907, C8908 MRI - Bone Marrow Blood Supply Nuclear Medicine Cardiac Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic) Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or reinjection Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic) Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or reinjection Myocardial Imaging, infarct avid, planar; qualitative or quantitative Myocardial Imaging with ejection fraction, first pass technique Myocardial Imaging, tomographic SPECT with or without quantification Cardiac Blood Pool Imaging, gated equilibrium; planar, single study Rest or Stress, wall motion study + ejection fraction, w/ or w/o quantitative processing Cardiac Blood Pooling Imaging, multiple studies, wall motion study plus ejection fraction, at rest or stress, w/ or w/o additional quantification Cardiac Blood Pool Imaging, planar, first pass technique, single study, rest or stress, wall motion study + ejection fraction, w/ or w/o quantification Cardiac Blood Pool Imaging, multiple studies, rest and stress, wall motion study + ejection fraction, w/ or w/o quantification Cardiac Blood Pool Imaging, gated equilibrium, SPECT; planar, single study rest or stress, wall motion study + ejection fraction, w/ or w/o quantitative processing Cardiac Blood Pool Imaging, gated equilibrium; single study at rest w/ rt. ventricular ejection fraction by first pass technique

3 PET PET Myocardial Imaging, Metabolic Evaluation PET Myocardial Imaging, Perfusion at Rest or Stress PET Myocardial Imaging, Perfusion at Rest or Stress, Multiple Studies PET Brain, Metabolic Evaluation PET Brain, Perfusion Evaluation PET; limited area (eg, chest, head/neck) PET; skull base to mid-thigh PET; whole body PET with concurrent CT for attenuation correction and anatomical localization imaging; limited area (eg, chest, head/neck) PET with concurrent CT for attenuation correction and anatomical localization imaging; skull base to mid-thigh PET with concurrent CT for attenuation correction and anatomical localization imaging; whole body PET imaging whole body for Melanoma for Noncovered Indications G0219 PET imaging, any site, not otherwise specified G0235 PET imaging, Breast Cancer Imaging, Diagnosis and/or Surgical Planning G0252 RADIATION THERAPY 2D3D Therapeutic radiology treatment planning; simple Therapeutic radiology treatment planning; intermediate Therapeutic radiology treatment planning; complex Teletherapy isodose plan; simple (1 or 2 unmodified ports directed to a single area of interest), includes basic dosimetry calculation(s) Teletherapy isodose plan; complex (multiple treatment areas, tangential ports, the use of wedges, blocking, rotational beam, or special beam considerations), includes basic dosimetry calculation(s) Special teletherapy port plan, particles, hemibody, total body Radiation treatment delivery, superficial and/or ortho voltage, per day Radiation treatment delivery, >1 MeV; simple Radiation treatment delivery, >1 MeV; intermediate Radiation treatment delivery, >1 MeV; complex Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks: up to G6003 5MeV Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks: 6-10MeV G6004 Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks: 11-19MeV G6005 Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks: 20MeV or greater G6006 Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks: up to 5MeV G6007 Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks: 6-10MeV G6008 Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks: 11-19MeV G6009 Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks: 20MeV or greater G6010 Radiation treatment delivery, 3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; up to 5MeV G6011 Radiation treatment delivery, 3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 6-10MeV G6012 Radiation treatment delivery, 3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 11-19MeV G6013 Radiation treatment delivery, 3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 20MeV or greater G6014 Brachytherapy Brachytherapy isodose plan; simple (calculation[s] made from 1 to 4 sources, or remote afterloading brachytherapy, 1 channel), includes basic dosimetry calculation(s)

4 Brachytherapy isodose plan; intermediate (calculation[s] made from 5 to 10 sources, or remote afterloading brachytherapy, 2-12 channels), includes basic dosimetry calculation(s) Brachytherapy isodose plan; complex (calculation[s] made from over 10 sources, or remote afterloading brachytherapy, over 12 channels), includes basic dosimetry calculation(s) Intraoperative radiation treatment delivery, x-ray, single treatment session Intraoperative radiation treatment delivery, electrons, single treatment session Infusion or instillation of radioelement solution (includes 3 months follow-up care) Intracavitary radiation source application; simple Intracavitary radiation source application; intermediate Intracavitary radiation source application; complex Interstitial radiation source application; simple Interstitial radiation source application; intermediate Interstitial radiation source application; complex Remote afterloading high dose rate brachytherapy; 1 channel Remote afterloading high dose rate brachytherapy; 2-12 channels Remote afterloading high dose rate brachytherapy; over 12 channels Surface applications of radiation source High dose rate electronic brachytherapy, per fraction 0182T Destruction/reduction of malignant breast tumor with externally applied focused microwave, including interstitial placement of disposable catheter with combined temperature monitoring probe and microwave focusing sensocatheter under 0301T ultrasound thermotherapy guidance Low dose rate (LDR) prostate brachytherapy services, composite rate G0458 IMRT Intensity modulated radiotherapy plan, including dose-volume histograms for target and critical structure partial tolerance specifications Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed; simple Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed; complex Intensity modulated treatment delivery, single or multiple fields/arcs, via narrow spatially and temporally modulated beams, G6015 binary, dynamic MLC, per treatment session Compensator-based beam modulation treatment delivery of inverse planned treatment using 3 or more high resolution (milled or cast) compensator, convergent beam modulated fields, per treatment session G6016 Neutron Therapy High energy neutron radiation treatment delivery; single treatment area using a single port or parallel-opposed ports with no blocks or simple blocking High energy neutron radiation treatment delivery; 1 or more isocenter(s) with coplanar or non-coplanar geometry with blocking and / or wedge, and / /or compensator(s) Proton Beam Proton treatment delivery; simple, without compensation Proton treatment delivery; simple, with compensation Proton treatment delivery; intermediate Proton treatment delivery; complex Stereotactic Radiosurgery Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; linear accelerator based Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions Image guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session, or G0339 first session of fractionated treatment Image guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum five sessions per course G0340 of treatment 4

5 MUSCULOSKELETAL Spine Surgery OSTEOTOMY OF SPINE, POSTERIOR OR POSTEROLATERAL APPROACH, 3 COLUMNS, 1 VERTEBRAL SEGMENT (EG, PEDICLE/VERTEBRAL BODY SUBTRACTION); LUMBAR OSTEOTOMY OF SPINE, POSTERIOR OR POSTEROLATERAL APPROACH, 3 COLUMNS, 1 VERTEBRAL SEGMENT (EG, PEDICLE/VERTEBRAL BODY SUBTRACTION); EACH ADDITIONAL VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) OSTEOTOMY OF SPINE, POSTERIOR OR POSTEROLATERAL APPROACH, 1 VERTEBRAL SEGMENT; CERVICAL OSTEOTOMY OF SPINE, POSTERIOR OR POSTEROLATERAL APPROACH, 1 VERTEBRAL SEGMENT; LUMBAR OSTEOTOMY OF SPINE, POSTERIOR OR POSTEROLATERAL APPROACH, 1 VERTEBRAL SEGMENT; EACH ADDITIONAL VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION TO PRIMARY PROCEDURE) OSTEOTOMY OF SPINE, INCLUDING DISCECTOMY, ANTERIOR APPROACH, SINGLE VERTEBRAL SEGMENT; CERVICAL OSTEOTOMY OF SPINE, INCLUDING DISCECTOMY, ANTERIOR APPROACH, SINGLE VERTEBRAL SEGMENT; LUMBAR OSTEOTOMY OF SPINE, INCLUDING DISCECTOMY, ANTERIOR APPROACH, SINGLE VERTEBRAL SEGMENT; EACH ADDITIONAL VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; lumbosacral Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; each additional cervicothoracic or lumbosacral vertebral body (List separately in addition to code for primary procedure) Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; lumbar Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; each additional thoracic or lumbar vertebral body (List separately in addition to code for primary procedure) PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE, 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION (EG, KYPHOPLASTY); EACH ADDITIONAL THORACIC OR LUMBAR VERTEBRAL BODY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) PERCUTANEOUS INTRADISCAL ELECTROTHERMAL ANNULOPLASTY, UNILATERAL OR BILATERAL INCLUDING FLUOROSCOPIC GUIDANCE; SINGLE LEVEL PERCUTANEOUS INTRADISCAL ELECTROTHERMAL ANNULOPLASTY, UNILATERAL OR BILATERAL INCLUDING FLUOROSCOPIC GUIDANCE; 1 OR MORE ADDITIONAL LEVELS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) ARTHRODESIS, LATERAL EXTRACAVITARY TECHNIQUE, INCLUDING MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); LUMBAR ARTHRODESIS, LATERAL EXTRACAVITARY TECHNIQUE, INCLUDING MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); THORACIC OR LUMBAR, EACH ADDITIONAL VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) ARTHRODESIS, ANTERIOR TRANSORAL OR EXTRAORAL TECHNIQUE, CLIVUS-C1-C2 (ATLAS-AXIS), WITH OR WITHOUT EXCISION OF ODONTOID PROCESS ARTHRODESIS, ANTERIOR INTERBODY, INCLUDING DISC SPACE PREPARATION, DISCECTOMY, OSTEOPHYTECTOMY AND DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOTS; CERVICAL BELOW C ARTHRODESIS, ANTERIOR INTERBODY, INCLUDING DISC SPACE PREPARATION, DISCECTOMY, OSTEOPHYTECTOMY AND DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOTS; CERVICAL BELOW C2, EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR SEPARATE PROCEDURE) Arthrodesis, Anterior Interbody Technique, Including Minimal Discectomy To Prepare Interspace (Other Than For Decompression); Cervical Below C

6 ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); LUMBAR ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Arthrodesis, pre-sacral interbody technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft when performed, L5-S1 interspace ARTHRODESIS, POSTERIOR TECHNIQUE, CRANIOCERVICAL (OCCIPUT-C2) ARTHRODESIS, POSTERIOR TECHNIQUE, ATLAS-AXIS (C1-C2) ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE LEVEL; CERVICAL BELOW C2 SEGMENT ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE LEVEL; LUMBAR (WITH LATERAL TRANSVERSE TECHNIQUE, WHEN PERFORMED) ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE LEVEL; EACH ADDITIONAL VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) ARTHRODESIS, POSTERIOR INTERBODY TECHNIQUE, INCLUDING LAMINECTOMY AND/OR DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE; LUMBAR ARTHRODESIS, POSTERIOR INTERBODY TECHNIQUE, INCLUDING LAMINECTOMY AND/OR DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE; EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) ARTHRODESIS, COMBINED POSTERIOR OR POSTEROLATERAL TECHNIQUE WITH POSTERIOR INTERBODY TECHNIQUE INCLUDING LAMINECTOMY AND/OR DISCECTOMY SUFFICIENT TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE AND SEGMENT; LUMBAR ARTHRODESIS, COMBINED POSTERIOR OR POSTEROLATERAL TECHNIQUE WITH POSTERIOR INTERBODY TECHNIQUE INCLUDING LAMINECTOMY AND/OR DISCECTOMY SUFFICIENT TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE AND SEGMENT; EACH ADDITIONAL INTERSPACE AND SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) POSTERIOR NON-SEGMENTAL INSTRUMENTATION (EG, HARRINGTON ROD TECHNIQUE, PEDICLE FIXATION ACROSS 1 INTERSPACE, ATLANTOAXIAL TRANSARTICULAR SCREW FIXATION, SUBLAMINAR WIRING AT C1, FACET SCREW FIXATION) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Internal spinal fixation by wiring of spinous processes (List separately in addition to code for primary procedure) Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segments (List separately in addition to code for primary procedure) Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 7 to 12 vertebral segments (List separately in addition to code for primary procedure) Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 13 or more vertebral segments (List separately in addition to code for primary procedure) Anterior instrumentation; 2 to 3 vertebral segments (List separately in addition to code for primary procedure) Anterior instrumentation; 4 to 7 vertebral segments (List separately in addition to code for primary procedure) Anterior instrumentation; 8 or more vertebral segments (List separately in addition to code for primary procedure) Pelvic fixation (attachment of caudal end of instrumentation to pelvic bony structures) other than sacrum (List separately in addition to code for primary procedure) REINSERTION OF SPINAL FIXATION DEVICE REMOVAL OF POSTERIOR NONSEGMENTAL INSTRUMENTATION (EG, HARRINGTON ROD) APPLICATION OF INTERVERTEBRAL BIOMECHANICAL DEVICE(S) (EG, SYNTHETIC CAGE(S), METHYLMETHACRYLATE) TO VERTEBRAL DEFECT OR INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) REMOVAL OF POSTERIOR SEGMENTAL INSTRUMENTATION REMOVAL OF ANTERIOR INSTRUMENTATION Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); single interspace, cervical TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, INCLUDING DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE, LUMBAR Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); second level, cervical (List separately in addition to code for primary procedure)

7 REVISION INCLUDING REPLACEMENT OF TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, SINGLE INTERSPACE; CERVICAL REVISION INCLUDING REPLACEMENT OF TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, SINGLE INTERSPACE; LUMBAR REMOVAL OF TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, SINGLE INTERSPACE; CERVICAL REMOVAL OF TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, SINGLE INTERSPACE; LUMBAR Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; cervical LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; LUMBAR, EXCEPT FOR SPONDYLOLISTHESIS LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; SACRAL LAMINECTOMY WITH REMOVAL OF ABNORMAL FACETS AND/OR PARS INTER-ARTICULARIS WITH DECOMPRESSION OF CAUDA EQUINA AND NERVE ROOTS FOR SPONDYLOLISTHESIS, LUMBAR (GILL TYPE PROCEDURE) LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), MORE THAN 2 VERTEBRAL SEGMENTS; CERVICAL LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), MORE THAN 2 VERTEBRAL SEGMENTS; LUMBAR LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC; 1 INTERSPACE, CERVICAL LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC; 1 INTERSPACE, LUMBAR LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC; EACH ADDITIONAL INTERSPACE, CERVICAL OR LUMBAR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC, REEXPLORATION, SINGLE INTERSPACE; CERVICAL LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC, REEXPLORATION, SINGLE INTERSPACE; LUMBAR LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC, REEXPLORATION, SINGLE INTERSPACE; EACH ADDITIONAL CERVICAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC, REEXPLORATION, SINGLE INTERSPACE; EACH ADDITIONAL LUMBAR INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; CERVICAL LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; LUMBAR Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; each additional segment, cervical, thoracic, or lumbar (List separately in addition to code for primary procedure) LAMINOPLASTY, CERVICAL, WITH DECOMPRESSION OF THE SPINAL CORD, 2 OR MORE VERTEBRAL SEGMENTS;

8 LAMINOPLASTY, CERVICAL, WITH DECOMPRESSION OF THE SPINAL CORD, 2 OR MORE VERTEBRAL SEGMENTS; WITH RECONSTRUCTION OF THE POSTERIOR BONY ELEMENTS (INCLUDING THE APPLICATION OF BRIDGING BONE GRAFT AND NON-SEGMENTAL FIXATION DEVICES (EG, WIRE, SUTURE, MINI-PLATES), WHEN PERFORMED) TRANSPEDICULAR APPROACH WITH DECOMPRESSION OF SPINAL CORD, EQUINA AND/OR NERVE ROOT(S) (EG, HERNIATED INTERVERTEBRAL DISC), SINGLE SEGMENT; LUMBAR (INCLUDING TRANSFACET, OR LATERAL EXTRAFORAMINAL APPROACH) (EG, FAR LATERAL HERNIATED INTERVERTEBRAL DISC) TRANSPEDICULAR APPROACH WITH DECOMPRESSION OF SPINAL CORD, EQUINA AND/OR NERVE ROOT(S) (EG, HERNIATED INTERVERTEBRAL DISC), SINGLE SEGMENT; EACH ADDITIONAL SEGMENT, THORACIC OR LUMBAR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) DISCECTOMY, ANTERIOR, WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S), INCLUDING OSTEOPHYTECTOMY; CERVICAL, SINGLE INTERSPACE DISCECTOMY, ANTERIOR, WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S), INCLUDING OSTEOPHYTECTOMY; CERVICAL, EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, ANTERIOR APPROACH WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S); CERVICAL, SINGLE SEGMENT VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, ANTERIOR APPROACH WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S); CERVICAL, EACH ADDITIONAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, COMBINED THORACOLUMBAR APPROACH WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA OR NERVE ROOT(S), LOWER THORACIC OR LUMBAR; SINGLE SEGMENT VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, COMBINED THORACOLUMBAR APPROACH WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA OR NERVE ROOT(S), LOWER THORACIC OR LUMBAR; EACH ADDITIONAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, TRANSPERITONEAL OR RETROPERITONEAL APPROACH WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA OR NERVE ROOT(S), LOWER THORACIC, LUMBAR, OR SACRAL; SINGLE SEGMENT VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, TRANSPERITONEAL OR RETROPERITONEAL APPROACH WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA OR NERVE ROOT(S), LOWER THORACIC, LUMBAR, OR SACRAL; EACH ADDITIONAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) LAMINECTOMY AND SECTION OF DENTATE LIGAMENTS, WITH OR WITHOUT DURAL GRAFT, CERVICAL; 1 OR SEGMENTS LAMINECTOMY AND SECTION OF DENTATE LIGAMENTS, WITH OR WITHOUT DURAL GRAFT, CERVICAL; MORE THAN 2 SEGMENTS LAMINECTOMY WITH RHIZOTOMY; 1 OR 2 SEGMENTS LAMINECTOMY WITH RHIZOTOMY; MORE THAN 2 SEGMENTS LAMINECTOMY WITH SECTION OF SPINAL ACCESSORY NERVE LAMINECTOMY WITH CORDOTOMY, WITH SECTION OF 1 SPINOTHALAMIC TRACT, 1 STAGE; CERVICAL LAMINECTOMY WITH CORDOTOMY, WITH SECTION OF BOTH SPINOTHALAMIC TRACTS, 1 STAGE; CERVICAL LAMINECTOMY WITH CORDOTOMY WITH SECTION OF BOTH SPINOTHALAMIC TRACTS, 2 STAGES WITHIN 14 DAYS; CERVICAL LAMINECTOMY, WITH RELEASE OF TETHERED SPINAL CORD, LUMBAR Osteoplastic reconstruction of dorsal spinal elements, following primary intraspinal procedure (List separately in addition to code for primary procedure) REMOVAL OF TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, EACH ADDITIONAL INTERSPACE, CERVICAL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) REVISION INCLUDING REPLACEMENT OF TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, EACH ADDITIONAL INTERSPACE, CERVICAL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, INCLUDING DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), EACH ADDITIONAL INTERSPACE, LUMBAR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) T 0098T 0163T

9 REMOVAL OF TOTAL DISC ARTHROPLASTY, (ARTIFICIAL DISC), ANTERIOR APPROACH, EACH ADDITIONAL INTERSPACE, LUMBAR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) ARTHRODESIS, PRE-SACRAL INTERBODY TECHNIQUE, INCLUDING INSTRUMENTATION, IMAGING (WHEN PERFORMED), AND DISCECTOMY TO PREPARE INTERSPACE, LUMBAR; SINGLE INTERSPACE ARTHRODESIS, PRE-SACRAL INTERBODY TECHNIQUE, INCLUDING INSTRUMENTATION, IMAGING (WHEN PERFORMED), AND DISCECTOMY TO PREPARE INTERSPACE, LUMBAR; EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) POSTERIOR VERTEBRAL JOINT(S) ARTHROPLASTY (EG, FACET JOINT[S] REPLACEMENT), INCLUDING FACETECTOMY, LAMINECTOMY, FORAMINOTOMY, AND VERTEBRAL COLUMN FIXATION, INJECTION OF BONE CEMENT, WHEN PERFORMED, INCLUDING FLUOROSCOPY, SINGLE LEVEL, LUMBAR SPINE PLACEMENT OF A POSTERIOR INTRAFACET IMPLANT(S), UNILATERAL OR BILATERAL, INCLUDING IMAGING AND PLACEMENT OF BONE GRAFT(S) OR SYNTHETIC DEVICE(S), SINGLE LEVEL; CERVICAL PLACEMENT OF A POSTERIOR INTRAFACET IMPLANT(S), UNILATERAL OR BILATERAL, INCLUDING IMAGING AND PLACEMENT OF BONE GRAFT(S) OR SYNTHETIC DEVICE(S), SINGLE LEVEL; LUMBAR PLACEMENT OF A POSTERIOR INTRAFACET IMPLANT(S), UNILATERAL OR BILATERAL, INCLUDING IMAGING AND PLACEMENT OF BONE GRAFT(S) OR SYNTHETIC DEVICE(S), SINGLE LEVEL; EACH ADDITIONAL VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Arthrodesis, pre-sacral interbody technique, including disc space preparation, discetomy, with posterior instumentation, with image guidance, includes bone graft, when performed, lumbar, L4-L5 interspace (List separately in addition to code for primary procedure) Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection), cervical, three or more levels 0164T 0195T 0196T 0202T 0219T 0221T 0222T 0309T 0375T Spine Pain Management Injection(S); Single Or Multiple Trigger Point(S), 1 Or 2 Muscle(S) INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLE(S) INJECTION PROCEDURE FOR SACROILIAC JOINT, ANESTHETIC/STEROID, WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED Injection procedure for discography, each level; lumbar Injection procedure for discography, each level; cervical or thoracic Injection procedure for chemonucleolysis, including discography, intervertebral disc, single or multiple levels, lumbar INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (INCLUDING ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INCLUDES CONTRAST FOR LOCALIZATION WHEN PERFORMED, EPIDURAL OR SUBARACHNOID; CERVICAL OR THORACIC INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (INCLUDING ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INCLUDES CONTRAST FOR LOCALIZATION WHEN PERFORMED, EPIDURAL OR SUBARACHNOID; LUMBAR OR SACRAL (CAUDAL) INJECTION(S), INCLUDING INDWELLING CATHETER PLACEMENT, CONTINUOUS INFUSION OR INTERMITTENT BOLUS, OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (INCLUDING ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDES CONTRAST FOR LOCALIZATION WHEN PERFORMED, EPIDURAL OR SUBARACHNOID; CERVICAL OR THORACIC INJECTION(S), INCLUDING INDWELLING CATHETER PLACEMENT, CONTINUOUS INFUSION OR INTERMITTENT BOLUS, OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (INCLUDING ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDES CONTRAST FOR LOCALIZATION WHEN PERFORMED, EPIDURAL OR SUBARACHNOID; LUMBAR OR SACRAL (CAUDAL) Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; without laminectomy Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; with laminectomy Removal of previously implanted intrathecal or epidural catheter Implantation or replacement of device for intrathecal or epidural drug infusion; subcutaneous reservoir IMPLANTATION OR REPLACEMENT OF DEVICE FOR INTRATHECAL OR EPIDURAL DRUG INFUSION; NONPROGRAMMABLE PUMP

10 IMPLANTATION OR REPLACEMENT OF DEVICE FOR INTRATHECAL OR EPIDURAL DRUG INFUSION; PROGRAMMABLE PUMP, INCLUDING PREPARATION OF PUMP, WITH OR WITHOUT PROGRAMMING REMOVAL OF SUBCUTANEOUS RESERVOIR OR PUMP, PREVIOUSLY IMPLANTED FOR INTRATHECAL OR EPIDURAL INFUSION PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY, EPIDURAL Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural REMOVAL OF SPINAL NEUROSTIMULATOR ELECTRODE PERCUTANEOUS ARRAY(S), INCLUDING FLUOROSCOPY, WHEN PERFORMED REMOVAL OF SPINAL NEUROSTIMULATOR ELECTRODE PLATE/PADDLE(S) PLACED VIA LAMINOTOMY OR LAMINECTOMY, INCLUDING FLUOROSCOPY, WHEN PERFORMED Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling Injection, anesthetic agent; greater occipital nerve Injection, anesthetic agent; sciatic nerve, single Injection, anesthetic agent; other peripheral nerve or branch INJECTION, ANESTHETIC AGENT AND/OR STEROID, TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE LEVEL INJECTION, ANESTHETIC AGENT AND/OR STEROID, TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) INJECTION, ANESTHETIC AGENT AND/OR STEROID, TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE LEVEL INJECTION, ANESTHETIC AGENT AND/OR STEROID, TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SINGLE LEVEL NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Injection, anesthetic agent; lumbar or thoracic (paravertebral sympathetic DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) NERVES INNERVATING THAT JOINT) WITH ULTRASOUND GUIDANCE, CERVICAL OR THORACIC; SINGLE LEVEL T

11 NERVES INNERVATING THAT JOINT) WITH ULTRASOUND GUIDANCE, CERVICAL OR THORACIC; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) NERVES INNERVATING THAT JOINT) WITH ULTRASOUND GUIDANCE, CERVICAL OR THORACIC; THIRD AND ANY 0215T ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) NERVES INNERVATING THAT JOINT) WITH ULTRASOUND GUIDANCE, LUMBAR OR SACRAL; SINGLE LEVEL NERVES INNERVATING THAT JOINT) WITH ULTRASOUND GUIDANCE, LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) NERVES INNERVATING THAT JOINT) WITH ULTRASOUND GUIDANCE, LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) INJECTION(S), ANESTHETIC AGENT AND/OR STEROID, TRANSFORAMINAL EPIDURAL, WITH ULTRASOUND 0228T GUIDANCE, CERVICAL OR THORACIC; SINGLE LEVEL INJECTION(S), ANESTHETIC AGENT AND/OR STEROID, TRANSFORAMINAL EPIDURAL, WITH ULTRASOUND GUIDANCE, CERVICAL OR THORACIC; EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR 0229T PRIMARY PROCEDURE) INJECTION(S), ANESTHETIC AGENT AND/OR STEROID, TRANSFORAMINAL EPIDURAL, WITH ULTRASOUND 0230T GUIDANCE, LUMBAR OR SACRAL; SINGLE LEVEL INJECTION(S), ANESTHETIC AGENT AND/OR STEROID, TRANSFORAMINAL EPIDURAL, WITH ULTRASOUND GUIDANCE, LUMBAR OR SACRAL; EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR 0231T PRIMARY PROCEDURE) INJECTION PROCEDURE FOR SACROILIAC JOINT; PROVISION OF ANESTHETIC, STEROID AND/OR OTHER G0260 THERAPEUTIC AGENT, WITH OR WITHOUT ARTHROGRAPHY 0214T 0216T 0217T 0218T MEDICAL ONCOLOGY NOTE: All Oral Chemotherapy must be submitted for review, including drugs with codes not otherwise specified. HCPCS INJECTION, RAMUCIRUMAB, 5 MG INJECTION, PEMBROLIZUMAB, 1 MG INJECTION, BEVACIZUMAB, 0.25 MG INJECTION, BELINOSTAT, 10 MG INJECTION, AMIFOSTINE, 500 MG INJECTION, LEUCOVORIN CALCIUM, PER 50 MG INJECTION, LEVOLEUCOVORIN CALCIUM, 0.5 MG INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE) INJECTION, EPOETIN ALFA, (FOR NON-ESRD USE), 1000 UNITS INJECTIN, EPOETIN BETA, 1 MICROGRAM, (FOR NON ESRD USE) INJECTION, DECITABINE, 1 MG INJECTION, DENOSUMAB, 1 MG INJECTION, DOLASETRON MESYLATE, 10 MG INJECTION, FILGRASTIM (G-CSF), 1 MICROGRAM INJECTION, TBO-FILGRASTIM, 5 MICROGRAMS INJECTION, LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), PER 3.75 MG INJECTION, OCTREOTIDE, DEPOT FORM FOR INTRAMUSCULAR INJECTION, 1 MG INJECTION, OPRELVEKIN, 5 MG INJECTION, PAMIDRONATE DISODIUM, PER 30 MG INJECTION, PEGFILGRASTIM, 6 MG INJECTION, SARGRAMOSTIM (GM-CSF), 50 MCG INJECTION, TRIPTORELIN PAMOATE, 3.75 MG INJECTION, ZOLEDRONIC ACID, 1 MG UNCLASSIFIED DRUGS Everolimus, oral, 0.25 mg APREPITANT, ORAL, 5 MG BUSULFAN, ORAL, 2 MG 11 C9025 C9027 C9257 C9442 J0207 J0640 J0641 J0881 J0885 J0888 J0894 J0897 J1260 J1442 J1446 J1950 J2353 J2355 J2430 J2505 J2820 J3315 J3489 J3490 J7527 J8501 J8510

12 CABERGOLINE, ORAL, 0.25 MG CAPECITABINE, ORAL, 150 MG CAPECITABINE, ORAL, 500 MG CYCLOPHOSPHAMIDE, ORAL, 25 MG ETOPOSIDE; ORAL, 50 MG FLUDARABINE PHOSPHATE, ORAL, 10 MG GEFITINIB, ORAL, 250 MG ANTIEMETIC DRUG, ORAL, NOT OTHERWISE SPECIFIED MELPHALAN, ORAL, 2 MG METHOTREXATE, ORAL, 2.5 MG NABILONE, ORAL, 1 MG TEMOZOLOMIDE, ORAL, 5 MG TOPOTECAN, ORAL, 0.25 MG PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG INJECTION, ALEMTUZUMAB, 10 MG INJECTION, ALDESLEUKIN, PER SINGLE USE VIAL INJECTION, ARSENIC TRIOXIDE, 1 MG Injection, asparaginase (Erwinaze), 1,000 IU INJECTION, ASPARAGINASE, 10,000 UNITS INJECTION, AZACITIDINE, 1 MG INJECTION, CLOFARABINE, 1 MG BCG (INTRAVESICAL) PER INSTILLATION INJECTION, BENDAMUSTINE HCL, 1 MG INJECTION, BEVACIZUMAB, 10 MG INJECTION, BLEOMYCIN SULFATE, 15 UNITS INJECTION, BORTEZOMIB, 0.1 MG Injection, brentuximab vedotin, 1 mg INJECTION, CABAZITAXEL, 1 MG INJECTION, CARBOPLATIN, 50 MG INJECTION, CARFILZOMIB, 1 MG INJECTION, CARMUSTINE, 100 MG INJECTION, CETUXIMAB, 10 MG INJECTION, CISPLATIN, POWDER OR SOLUTION, 10 MG INJECTION, CLADRIBINE, PER 1 MG CYCLOPHOSPHAMIDE, 100 MG INJECTION, CYTARABINE LIPOSOME, 10 MG INJECTION, CYTARABINE, 100 MG INJECTION, DACTINOMYCIN, 0.5 MG DACARBAZINE, 100 MG INJECTION, DAUNORUBICIN, 10 MG INJECTION, DAUNORUBICIN CITRATE, LIPOSOMAL FORMULATION, 10 MG INJECTION, DEGARELIX, 1 MG INJECTION, DENILEUKIN DIFTITOX, 300 MICROGRAMS INJECTION, DIETHYLSTILBESTROL DIPHOSPHATE, 250 MG INJECTION, DOCETAXEL, 1 MG INJECTION, ELLIOTTS' B SOLUTION, 1 ML INJECTION, EPIRUBICIN HCL, 2 MG INJECTION, ERIBULIN MESYLATE, 0.1 MG INJECTION, ETOPOSIDE, 10 MG INJECTION, FLUDARABINE PHOSPHATE, 50 MG INJECTION, FLUOROURACIL, 500 MG INJECTION, FLOXURIDINE, 500 MG INJECTION, GEMCITABINE HYDROCHLORIDE, 200 MG GOSERELIN ACETATE IMPLANT, PER 3.6 MG INJECTION, IRINOTECAN, 20 MG INJECTION, IXABEPILONE, 1 MG INJECTION, IFOSFAMIDE, 1 GRAM INJECTION, MESNA, 200 MG INJECTION, IDARUBICIN HYDROCHLORIDE, 5 MG J8515 J8520 J8521 J8530 J8560 J8562 J8565 J8597 J8600 J8610 J8650 J8700 J8705 J8999 J9000 J9010 J9015 J9017 J9019 J9020 J9025 J9027 J9031 J9033 J9035 J9040 J9041 J9042 J9043 J9045 J9047 J9050 J9055 J9060 J9065 J9070 J9098 J9100 J9120 J9130 J9150 J9151 J9155 J9160 J9165 J9171 J9175 J9178 J9179 J9181 J9185 J9190 J9200 J9201 J9202 J9206 J9207 J9208 J9209 J

13 INJECTION, INTERFERON ALFACON-1, RECOMBINANT, 1 MICROGRAM INJECTION, INTERFERON, ALFA-2A, RECOMBINANT, 3 MILLION UNITS INJECTION, INTERFERON, ALFA-2B, RECOMBINANT, 1 MILLION UNITS INJECTION, INTERFERON, ALFA-N3, (HUMAN LEUKOCYTE DERIVED), 250,000 IU INJECTION, INTERFERON, GAMMA 1-B, 3 MILLION UNITS LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG LEUPROLIDE ACETATE, PER 1 MG LEUPROLIDE ACETATE IMPLANT, 65 MG HISTRELIN IMPLANT (VANTAS), 50 MG HISTRELIN IMPLANT (SUPPRELIN LA), 50 MG INJECTION, IPILIMUMAB, 1 MG INJECTION, MECHLORETHAMINE HYDROCHLORIDE, (NITROGEN MUSTARD), 10 MG INJECTION, MELPHALAN HYDROCHLORIDE, 50 MG METHOTREXATE SODIUM, 5 MG METHOTREXATE SODIUM, 50 MG INJECTION, NELARABINE, 50 MG INJECTION, OMACETAXINE MEPESUCCINATE, 0.01 MG INJECTION, OXALIPLATIN, 0.5 MG INJECTION, PACLITAXEL PROTEIN-BOUND PARTICLES, 1 MG INJECTION, PEGASPARGASE, PER SINGLE DOSE VIAL INJECTION, PACLITAXEL, 1 MG INJECTION, PENTOSTATIN, 10 MG INJECTION, PLICAMYCIN, 2.5 MG MITOMYCIN, 5 MG INJECTION, MITOXANTRONE HYDROCHLORIDE, PER 5 MG INJECTION, GEMTUZUMAB OZOGAMICIN, 5 MG INJECTION, OBINUTUZUMAB, 10 MG INJECTION, OFATUMUMAB, 10 MG INJECTION, PANITUMUMAB, 10 MG INJECTION, PEMETREXED, 10 MG INJECTION, PERTUZUMAB, 1 MG INJECTION, PRALATREXATE, 1 MG INJECTION, RITUXIMAB, 100 MG INJECTION, ROMIDEPSIN, 1 MG INJECTION, STREPTOZOCIN, 1 GRAM INJECTION, TEMOZOLOMIDE, 1 MG INJECTION, TEMSIROLIMUS, 1 MG INJECTION, THIOTEPA, 15 MG INJECTION, TOPOTECAN, 0.1 MG INJECTION, ADO-TRASTUZUMAB EMTANSINE, 1 MG INJECTION, TRASTUZUMAB, 10 MG INJECTION, VALRUBICIN, INTRAVESICAL, 200 MG INJECTION, VINBLASTINE SULFATE, 1 MG VINCRISTINE SULFATE, 1 MG INJECTION, VINCRISTINE SULFATE LIPOSOME, 1 MG INJECTION, VINORELBINE TARTRATE, 10 MG INJECTION, FULVESTRANT, 25 MG INJECTION, ZIV-AFLIBERCEPT, 1 MG INJECTION, PORFIMER SODIUM, 75 MG NOT OTHERWISE CLASSIFIED, ANTINEOPLASTIC DRUGS SIPULEUCEL-T, MINIMUM OF 50 MILLION AUTOLOGOUS CD54+ CELLS ACTIVATED WITH PAP-GM-CSF, INCLUDING LEUKAPHERESIS AND ALL OTHER PREPARATORY PROCEDURES, PER INFUSION INJECTION, DOXORUBICIN HYDROCHLORIDE, LIPOSOMAL, IMPORTED LIPODOX, 10 MG INJECTION, DOXORUBICIN HYDROCHLORIDE, LIPOSOMAL, NOT OTHERWISE SPECIFIED, 10 MG IMATINIB, 100 MG MERCAPTOPURINE, ORAL, 50 MG EXEMESTANE, 25 MG ANASTROZOLE, ORAL, 1 MG CHLORAMBUCIL, ORAL, 2 MG J9212 J9213 J9214 J9215 J9216 J9217 J9218 J9219 J9225 J9226 J9228 J9230 J9245 J9250 J9260 J9261 J9262 J9263 J9264 J9266 J9267 J9268 J9270 J9280 J9293 J9300 J9301 J9302 J9303 J9305 J9306 J9307 J9310 J9315 J9320 J9328 J9330 J9340 J9351 J9354 J9355 J9357 J9360 J9370 J9371 J9390 J9395 J9400 J9600 J9999 Q2043 Q2049 Q2050 S0088 S0108 S0156 S0170 S

14 DOLASETRON MESYLATE, ORAL 50 MG (FOR CIRCUMSTANCES FALLING UNDER THE MEDICARE STATUTE, USE S0174 Q0180) FLUTAMIDE, ORAL, 125 MG S0175 HYDROXYUREA, ORAL, 500 MG S0176 LOMUSTINE, ORAL, 10 MG S0178 MEGESTROL ACETATE, ORAL, 20 MG S0179 PROCARBAZINE HYDROCHLORIDE, ORAL, 50 MG S0182 PROCHLORPERAZINE MALEATE, ORAL, 5 MG (FOR CIRCUMSTANCES FALLING UNDER THE MEDICARE STATUTE, USE Q Q0165) S0183 TAMOXIFEN CITRATE, ORAL, 10 MG S0187 TRANSPLANT Bone Marrow Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor Hematopoietic progenitor cell (HPC); autologous transplantation Hematopoietic progenitor cell (HPC); HPC boost