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1 Local Coverage Determination (LCD): Injections - Tendon, Ligament, Ganglion Cyst, Tunnel Syndromes and Morton's Neuroma (L34218) Links in PDF documents are not guaranteed to work. To follow a web link, please use the MCD Website. Contractor Information Contractor Name Contract Type Contract Number Jurisdiction State(s) Noridian Healthcare Solutions, LLC A and B MAC MAC A J - E California - Entire State Noridian Healthcare Solutions, LLC A and B MAC MAC B J - E California - Northern Noridian Healthcare Solutions, LLC A and B MAC MAC B J - E California - Southern Noridian Healthcare Solutions, LLC A and B MAC MAC A J - E American Samoa Guam Hawaii Northern Mariana Islands Noridian Healthcare Solutions, LLC A and B MAC MAC B J - E American Samoa Guam Hawaii Northern Mariana Islands Noridian Healthcare Solutions, LLC A and B MAC MAC A J - E Nevada Noridian Healthcare Solutions, LLC A and B MAC MAC B J - E Nevada Noridian Healthcare Solutions, LLC A and B MAC MAC A J - E American Samoa California - Entire State Guam Hawaii Nevada Northern Mariana Islands Back to Top LCD Information Document Information LCD ID L34218 Original ICD-9 LCD ID L33716 Previous Proposed LCD DL34218 LCD Title Injections - Tendon, Ligament, Ganglion Cyst, Tunnel Syndromes and Morton's Neuroma AMA CPT / ADA CDT / AHA NUBC Copyright Statement Original Effective Date For services performed on or after 10/01/2015 Revision Effective Date For services performed on or after 10/01/2016 Revision Ending Date N/A Retirement Date N/A Notice Period Start Date N/A Notice Period End Date N/A Printed on 10/5/2016. Page 1 of 21

2 CPT only copyright American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright American Dental Association. All rights reserved. CDT and CDT-2016 are trademarks of the American Dental Association. UB-04 Manual. OFFICIAL UB-04 DATA SPECIFICATIONS MANUAL, 2014, is copyrighted by American Hospital Association ( AHA ), Chicago, Illinois. No portion of OFFICIAL UB-04 MANUAL may be reproduced, sorted in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior express, written consent of AHA. Health Forum reserves the right to change the copyright notice from time to time upon written notice to Company. CMS National Coverage Policy Title XVIII of the Social Security Act, 1862(a)(1)(A) allows coverage and payment for only those services that are considered to be medically reasonable and necessary. Title XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim. CMS Manual System, Pub , Medicare National Coverage Determinations Manual, Chapter 1, Part 2, Coverage Guidance Coverage Indications, Limitations, and/or Medical Necessity This policy addresses the injection of chemical substances, such as local anesthetics, steroids, sclerosing agents and/or neurolytic agents into ganglion cysts, tendon sheaths, tendon origins/insertions, ligaments, costochondral areas, or near nerves of the feet (e.g., Morton's neuroma) to affect therapy for a pathological condition. Note: the term "Morton's neuroma" is used in this policy generically to refer to a swollen inflamed nerve in the ball of the foot, including the more specific conditions of Morton's neuroma (lesion within the third intermetatarsal space), Heuter's neuroma (first intermetatarsal space), Hauser's neuroma (second intermetatarsal space) and Iselin's neuroma (fourth intermetatarsal space). This policy applies to each. Injection of a carpal tunnel is indicated for the patient with a mild case of the carpal tunnel syndrome if oral nonsteroidal anti-inflammatory drugs (NSAIDs) and orthoses have failed or are contraindicated. Note that this procedure has its own CPT code, Injection of a tarsal tunnel is indicated for the patient with a mild case of tarsal tunnel syndrome if oral NSAIDs and orthoses have failed or are contraindicated. Though there are many similarities between this and carpal tunnel syndrome, the best apparent CPT code is Injection into tendon sheaths, ligaments, tendon origins or insertions, ganglion cysts, or neuromas may be indicated to relieve pain or dysfunction resulting from inflammation or other pathological changes. Proper use of this modality with local anesthetics and/or steroids should be short-term, as part of an overall management plan including diagnostic evaluation, in order to clearly identify and properly treat the primary cause. Noncoverage for prolotherapy, joint sclerotherapy and ligamentous injections with sclerosing agents is found in the CMS Manual System, Pub , Medicare National Coverage Determinations (Internet-only Manual). The signs or symptoms that justify these treatments should be resolved after one to three injections (see reference 2 below, under "Sources of Information and Basis for Decision"). Injections beyond three must be Printed on 10/5/2016. Page 2 of 21

3 justified by the clinical record indicating a logical reason for failure of the prior therapy and why further treatment can reasonably be expected to succeed. A recurrence may justify a second course of therapy. Injection therapies for tarsal tunnel syndromes (which include any so-called "Baxter's injections") and for Morton's neuroma (64455) do not involve the structures described by CPT code and or direct injection into other peripheral nerves but rather the focal injection of tissue surrounding a specific focus of inflammation on the foot. Tarsal Tunnel Syndrome therapy should be billed with CPT code Occasionally, injections of alcohol are used for nerve sclerosing (e.g. in heel for nerve entrapment and neuromas in the foot). The procedure involves 4-10% alcohol injected every 7-10 days to decrease pain associated with nerve entrapment. Noridian would not expect more than six consecutive procedures to be billed. CPT code is used to describe this service. Injections for plantar fasciitis are addressed by and ICD-10-CM M72.2. Injections for calcaneal spurs are addressed as are other tendon origin/insertions by Injections to include both the plantar fascia and the area around a calcaneal spur, are to be reported using a single Medical necessity for injections of more than two sites at one session or for frequent or repeated injections is questionable. Such injections are likely to result in a request for medical records which must evidence careful justification of necessity. "Dry needling" of ganglion cysts, ligaments, neuromas, tendon sheaths and their origins/insertions are noncovered procedures. Note: Nerve blocks are contraindicated and not covered for peripheral diabetic neuropathy. Compliance with the provisions in this policy is subject to monitoring by post payment data analysis and subsequent medical review. Back to Top Coding Information Bill Type : Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims. 999x Not Applicable Revenue : Contractors may specify Revenue to help providers identify those Revenue typically used to report this service. In most instances Revenue are purely advisory. Unless specified in the policy, services reported under other Revenue are equally subject to this coverage determination. Complete absence of all Revenue indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Not Applicable CPT/HCPCS Group 1 Paragraph: N/A Group 1 : INJECTION, THERAPEUTIC (EG, LOCAL ANESTHETIC, CORTICOSTEROID), CARPAL TUNNEL INJECTION, ENZYME (EG, COLLAGENASE), PALMAR FASCIAL CORD (IE, DUPUYTREN'S CONTRACTURE) INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR "FASCIA") INJECTION(S); SINGLE TENDON ORIGIN/INSERTION Printed on 10/5/2016. Page 3 of 21

4 20612 ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION MANIPULATION, PALMAR FASCIAL CORD (IE, DUPUYTREN'S CORD), POST ENZYME INJECTION (EG, COLLAGENASE), SINGLE CORD INJECTION(S), ANESTHETIC AGENT AND/OR STEROID, PLANTAR COMMON DIGITAL NERVE(S) (EG, MORTON'S NEUROMA) ICD-10 that Support Medical Necessity Group 1 Paragraph: These are the only covered ICD-10-CM codes That support medical necessity: Group 1 : ICD-10 G56.01 Carpal tunnel syndrome, right upper limb G56.02 Carpal tunnel syndrome, left upper limb G56.03 Carpal tunnel syndrome, bilateral upper limbs G57.51 Tarsal tunnel syndrome, right lower limb G57.52 Tarsal tunnel syndrome, left lower limb G57.53 Tarsal tunnel syndrome, bilateral lower limbs G57.61* Lesion of plantar nerve, right lower limb G57.62* Lesion of plantar nerve, left lower limb G57.63* Lesion of plantar nerve, bilateral lower limbs M08.1 Juvenile ankylosing spondylitis M Disorder of ligament, right shoulder M Disorder of ligament, left shoulder M Disorder of ligament, right elbow M Disorder of ligament, left elbow M Disorder of ligament, right wrist M Disorder of ligament, left wrist M Disorder of ligament, right hand M Disorder of ligament, left hand M Disorder of ligament, right hip M Disorder of ligament, left hip M Disorder of ligament, right ankle M Disorder of ligament, left ankle M Disorder of ligament, right foot M Disorder of ligament, left foot M24.28 Disorder of ligament, vertebrae M Osteophyte, right shoulder M Osteophyte, left shoulder M Osteophyte, right elbow M Osteophyte, left elbow M Osteophyte, right wrist M Osteophyte, left wrist M Osteophyte, right hand M Osteophyte, left hand M Osteophyte, right hip M Osteophyte, left hip M Osteophyte, right knee M Osteophyte, left knee M Osteophyte, right ankle M Osteophyte, left ankle M Osteophyte, right foot M Osteophyte, left foot M35.7 Hypermobility syndrome M45.0 Ankylosing spondylitis of multiple sites in spine M45.1 Ankylosing spondylitis of occipito-atlanto-axial region M45.2 Ankylosing spondylitis of cervical region Printed on 10/5/2016. Page 4 of 21

5 M45.3 Ankylosing spondylitis of cervicothoracic region M45.4 Ankylosing spondylitis of thoracic region M45.5 Ankylosing spondylitis of thoracolumbar region M45.6 Ankylosing spondylitis lumbar region M45.7 Ankylosing spondylitis of lumbosacral region M45.8 Ankylosing spondylitis sacral and sacrococcygeal region M46.01 Spinal enthesopathy, occipito-atlanto-axial region M46.02 Spinal enthesopathy, cervical region M46.03 Spinal enthesopathy, cervicothoracic region M46.04 Spinal enthesopathy, thoracic region M46.05 Spinal enthesopathy, thoracolumbar region M46.06 Spinal enthesopathy, lumbar region M46.07 Spinal enthesopathy, lumbosacral region M46.08 Spinal enthesopathy, sacral and sacrococcygeal region M46.09 Spinal enthesopathy, multiple sites in spine M46.1 Sacroiliitis, not elsewhere classified M46.81 Other specified inflammatory spondylopathies, occipito-atlanto-axial region M46.82 Other specified inflammatory spondylopathies, cervical region M46.83 Other specified inflammatory spondylopathies, cervicothoracic region M46.84 Other specified inflammatory spondylopathies, thoracic region M46.85 Other specified inflammatory spondylopathies, thoracolumbar region M46.86 Other specified inflammatory spondylopathies, lumbar region M46.87 Other specified inflammatory spondylopathies, lumbosacral region M46.88 Other specified inflammatory spondylopathies, sacral and sacrococcygeal region M46.89 Other specified inflammatory spondylopathies, multiple sites in spine M48.8X1 Other specified spondylopathies, occipito-atlanto-axial region M48.8X2 Other specified spondylopathies, cervical region M48.8X3 Other specified spondylopathies, cervicothoracic region M48.8X4 Other specified spondylopathies, thoracic region M48.8X5 Other specified spondylopathies, thoracolumbar region M48.8X6 Other specified spondylopathies, lumbar region M48.8X7 Other specified spondylopathies, lumbosacral region M48.8X8 Other specified spondylopathies, sacral and sacrococcygeal region M49.81 Spondylopathy in diseases classified elsewhere, occipito-atlanto-axial region M49.82 Spondylopathy in diseases classified elsewhere, cervical region M49.83 Spondylopathy in diseases classified elsewhere, cervicothoracic region M49.84 Spondylopathy in diseases classified elsewhere, thoracic region M49.85 Spondylopathy in diseases classified elsewhere, thoracolumbar region M49.86 Spondylopathy in diseases classified elsewhere, lumbar region M49.87 Spondylopathy in diseases classified elsewhere, lumbosacral region M49.88 Spondylopathy in diseases classified elsewhere, sacral and sacrococcygeal region M49.89 Spondylopathy in diseases classified elsewhere, multiple sites in spine M53.2X8 Spinal instabilities, sacral and sacrococcygeal region M53.3 Sacrococcygeal disorders, not elsewhere classified M Other myositis, right shoulder M Other myositis, left shoulder M Other myositis, right upper arm M Other myositis, left upper arm M Other myositis, right forearm M Other myositis, left forearm M Other myositis, right hand M Other myositis, left hand M Other myositis, right thigh M Other myositis, left thigh M Other myositis, right lower leg M Other myositis, left lower leg M Other myositis, right ankle and foot Printed on 10/5/2016. Page 5 of 21

6 M Other myositis, left ankle and foot M60.88 Other myositis, other site M60.89 Other myositis, multiple sites M Calcific tendinitis, right upper arm M Calcific tendinitis, left upper arm M Calcific tendinitis, right forearm M Calcific tendinitis, left forearm M Calcific tendinitis, right hand M Calcific tendinitis, left hand M Calcific tendinitis, right thigh M Calcific tendinitis, left thigh M Calcific tendinitis, right lower leg M Calcific tendinitis, left lower leg M Calcific tendinitis, right ankle and foot M Calcific tendinitis, left ankle and foot M65.28 Calcific tendinitis, other site M65.29 Calcific tendinitis, multiple sites M Trigger thumb, right thumb M Trigger thumb, left thumb M Trigger finger, right index finger M Trigger finger, left index finger M Trigger finger, right middle finger M Trigger finger, left middle finger M Trigger finger, right ring finger M Trigger finger, left ring finger M Trigger finger, right little finger M Trigger finger, left little finger M65.4 Radial styloid tenosynovitis [de Quervain] M Other synovitis and tenosynovitis, right shoulder M Other synovitis and tenosynovitis, left shoulder M Other synovitis and tenosynovitis, right upper arm M Other synovitis and tenosynovitis, left upper arm M Other synovitis and tenosynovitis, right forearm M Other synovitis and tenosynovitis, left forearm M Other synovitis and tenosynovitis, right hand M Other synovitis and tenosynovitis, left hand M Other synovitis and tenosynovitis, right thigh M Other synovitis and tenosynovitis, left thigh M Other synovitis and tenosynovitis, right lower leg M Other synovitis and tenosynovitis, left lower leg M Other synovitis and tenosynovitis, right ankle and foot M Other synovitis and tenosynovitis, left ankle and foot M65.88 Other synovitis and tenosynovitis, other site M65.89 Other synovitis and tenosynovitis, multiple sites M66.0 Rupture of popliteal cyst M Rupture of synovium, right shoulder M Rupture of synovium, left shoulder M Rupture of synovium, right elbow M Rupture of synovium, left elbow M Rupture of synovium, right wrist M Rupture of synovium, left wrist M Rupture of synovium, right hand M Rupture of synovium, left hand M Rupture of synovium, right finger(s) M Rupture of synovium, left finger(s) M Rupture of synovium, right hip M Rupture of synovium, left hip M Rupture of synovium, right ankle Printed on 10/5/2016. Page 6 of 21

7 M Rupture of synovium, left ankle M Rupture of synovium, right foot M Rupture of synovium, left foot M Rupture of synovium, right toe(s) M Rupture of synovium, left toe(s) M66.18 Rupture of synovium, other site M Spontaneous rupture of extensor tendons, right shoulder M Spontaneous rupture of extensor tendons, left shoulder M Spontaneous rupture of extensor tendons, right upper arm M Spontaneous rupture of extensor tendons, left upper arm M Spontaneous rupture of extensor tendons, right forearm M Spontaneous rupture of extensor tendons, left forearm M Spontaneous rupture of extensor tendons, right hand M Spontaneous rupture of extensor tendons, left hand M Spontaneous rupture of extensor tendons, right thigh M Spontaneous rupture of extensor tendons, left thigh M Spontaneous rupture of extensor tendons, right lower leg M Spontaneous rupture of extensor tendons, left lower leg M Spontaneous rupture of extensor tendons, right ankle and foot M Spontaneous rupture of extensor tendons, left ankle and foot M66.28 Spontaneous rupture of extensor tendons, other site M66.29 Spontaneous rupture of extensor tendons, multiple sites M Spontaneous rupture of flexor tendons, right shoulder M Spontaneous rupture of flexor tendons, left shoulder M Spontaneous rupture of flexor tendons, right upper arm M Spontaneous rupture of flexor tendons, left upper arm M Spontaneous rupture of flexor tendons, right forearm M Spontaneous rupture of flexor tendons, left forearm M Spontaneous rupture of flexor tendons, right hand M Spontaneous rupture of flexor tendons, left hand M Spontaneous rupture of flexor tendons, right thigh M Spontaneous rupture of flexor tendons, left thigh M Spontaneous rupture of flexor tendons, right lower leg M Spontaneous rupture of flexor tendons, left lower leg M Spontaneous rupture of flexor tendons, right ankle and foot M Spontaneous rupture of flexor tendons, left ankle and foot M66.38 Spontaneous rupture of flexor tendons, other site M66.39 Spontaneous rupture of flexor tendons, multiple sites M Spontaneous rupture of other tendons, right shoulder M Spontaneous rupture of other tendons, left shoulder M Spontaneous rupture of other tendons, right upper arm M Spontaneous rupture of other tendons, left upper arm M Spontaneous rupture of other tendons, right forearm M Spontaneous rupture of other tendons, left forearm M Spontaneous rupture of other tendons, right hand M Spontaneous rupture of other tendons, left hand M Spontaneous rupture of other tendons, right thigh M Spontaneous rupture of other tendons, left thigh M Spontaneous rupture of other tendons, right lower leg M Spontaneous rupture of other tendons, left lower leg M Spontaneous rupture of other tendons, right ankle and foot M Spontaneous rupture of other tendons, left ankle and foot M66.88 Spontaneous rupture of other tendons, other M66.89 Spontaneous rupture of other tendons, multiple sites M Transient synovitis, right shoulder M Transient synovitis, left shoulder M Transient synovitis, right elbow Printed on 10/5/2016. Page 7 of 21

8 M Transient synovitis, left elbow M Transient synovitis, right wrist M Transient synovitis, left wrist M Transient synovitis, right hand M Transient synovitis, left hand M Transient synovitis, right hip M Transient synovitis, left hip M Transient synovitis, right knee M Transient synovitis, left knee M Transient synovitis, right ankle and foot M Transient synovitis, left ankle and foot M67.38 Transient synovitis, other site M67.39 Transient synovitis, multiple sites M Ganglion, right shoulder M Ganglion, left shoulder M Ganglion, right elbow M Ganglion, left elbow M Ganglion, right wrist M Ganglion, left wrist M Ganglion, right hand M Ganglion, left hand M Ganglion, right hip M Ganglion, left hip M Ganglion, right knee M Ganglion, left knee M Ganglion, right ankle and foot M Ganglion, left ankle and foot M67.48 Ganglion, other site M67.49 Ganglion, multiple sites M67.51 Plica syndrome, right knee M67.52 Plica syndrome, left knee M Other specified disorders of synovium, right shoulder M Other specified disorders of synovium, left shoulder M Other specified disorders of tendon, right shoulder M Other specified disorders of tendon, left shoulder M Other specified disorders of synovium, right elbow M Other specified disorders of synovium, left elbow M Other specified disorders of tendon, right elbow M Other specified disorders of tendon, left elbow M Other specified disorders of synovium, right wrist M Other specified disorders of synovium, left wrist M Other specified disorders of tendon, right wrist M Other specified disorders of tendon, left wrist M Other specified disorders of synovium, right hand M Other specified disorders of synovium, left hand M Other specified disorders of tendon, right hand M Other specified disorders of tendon, left hand M Other specified disorders of synovium, right hip M Other specified disorders of synovium, left hip M Other specified disorders of tendon, right hip M Other specified disorders of tendon, left hip M Other specified disorders of synovium, right knee M Other specified disorders of synovium, left knee M Other specified disorders of tendon, right knee M Other specified disorders of tendon, left knee M Other specified disorders of synovium, right ankle and foot M Other specified disorders of synovium, left ankle and foot M Other specified disorders of tendon, right ankle and foot Printed on 10/5/2016. Page 8 of 21

9 M Other specified disorders of tendon, left ankle and foot M67.88 Other specified disorders of synovium and tendon, other site M67.89 Other specified disorders of synovium and tendon, multiple sites M Crepitant synovitis (acute) (chronic), right wrist M Crepitant synovitis (acute) (chronic), left wrist M Crepitant synovitis (acute) (chronic), right hand M Crepitant synovitis (acute) (chronic), left hand M70.11 Bursitis, right hand M70.12 Bursitis, left hand M70.21 Olecranon bursitis, right elbow M70.22 Olecranon bursitis, left elbow M70.31 Other bursitis of elbow, right elbow M70.32 Other bursitis of elbow, left elbow M70.41 Prepatellar bursitis, right knee M70.42 Prepatellar bursitis, left knee M70.51 Other bursitis of knee, right knee M70.52 Other bursitis of knee, left knee M70.61 Trochanteric bursitis, right hip M70.62 Trochanteric bursitis, left hip M70.71 Other bursitis of hip, right hip M70.72 Other bursitis of hip, left hip M71.21 Synovial cyst of popliteal space [Baker], right knee M71.22 Synovial cyst of popliteal space [Baker], left knee M Other bursal cyst, right shoulder M Other bursal cyst, left shoulder M Other bursal cyst, right elbow M Other bursal cyst, left elbow M Other bursal cyst, right wrist M Other bursal cyst, left wrist M Other bursal cyst, right hand M Other bursal cyst, left hand M Other bursal cyst, right hip M Other bursal cyst, left hip M Other bursal cyst, right ankle and foot M Other bursal cyst, left ankle and foot M71.38 Other bursal cyst, other site M71.39 Other bursal cyst, multiple sites M Calcium deposit in bursa, right elbow M Calcium deposit in bursa, left elbow M Calcium deposit in bursa, right wrist M Calcium deposit in bursa, left wrist M Calcium deposit in bursa, right hand M Calcium deposit in bursa, left hand M Calcium deposit in bursa, right hip M Calcium deposit in bursa, left hip M Calcium deposit in bursa, right knee M Calcium deposit in bursa, left knee M Calcium deposit in bursa, right ankle and foot M Calcium deposit in bursa, left ankle and foot M71.48 Calcium deposit in bursa, other site M71.49 Calcium deposit in bursa, multiple sites M Other bursitis, not elsewhere classified, right elbow M Other bursitis, not elsewhere classified, left elbow M Other bursitis, not elsewhere classified, right wrist M Other bursitis, not elsewhere classified, left wrist M Other bursitis, not elsewhere classified, right hand M Other bursitis, not elsewhere classified, left hand Printed on 10/5/2016. Page 9 of 21

10 M Other bursitis, not elsewhere classified, right hip M Other bursitis, not elsewhere classified, left hip M Other bursitis, not elsewhere classified, right knee M Other bursitis, not elsewhere classified, left knee M Other bursitis, not elsewhere classified, right ankle and foot M Other bursitis, not elsewhere classified, left ankle and foot M71.58 Other bursitis, not elsewhere classified, other site M Other specified bursopathies, right shoulder M Other specified bursopathies, left shoulder M Other specified bursopathies, right elbow M Other specified bursopathies, left elbow M Other specified bursopathies, right wrist M Other specified bursopathies, left wrist M Other specified bursopathies, right hand M Other specified bursopathies, left hand M Other specified bursopathies, right hip M Other specified bursopathies, left hip M Other specified bursopathies, right knee M Other specified bursopathies, left knee M Other specified bursopathies, right ankle and foot M Other specified bursopathies, left ankle and foot M71.88 Other specified bursopathies, other site M71.89 Other specified bursopathies, multiple sites M72.0 Palmar fascial fibromatosis [Dupuytren] M72.1 Knuckle pads M72.2 Plantar fascial fibromatosis M72.4 Pseudosarcomatous fibromatosis M75.01 Adhesive capsulitis of right shoulder M75.02 Adhesive capsulitis of left shoulder M Incomplete rotator cuff tear or rupture of right shoulder, not specified as traumatic M Incomplete rotator cuff tear or rupture of left shoulder, not specified as traumatic M Complete rotator cuff tear or rupture of right shoulder, not specified as traumatic M Complete rotator cuff tear or rupture of left shoulder, not specified as traumatic M75.21 Bicipital tendinitis, right shoulder M75.22 Bicipital tendinitis, left shoulder M75.31 Calcific tendinitis of right shoulder M75.32 Calcific tendinitis of left shoulder M75.41 Impingement syndrome of right shoulder M75.42 Impingement syndrome of left shoulder M75.51 Bursitis of right shoulder M75.52 Bursitis of left shoulder M75.81 Other shoulder lesions, right shoulder M75.82 Other shoulder lesions, left shoulder M76.01 Gluteal tendinitis, right hip M76.02 Gluteal tendinitis, left hip M76.11 Psoas tendinitis, right hip M76.12 Psoas tendinitis, left hip M76.21 Iliac crest spur, right hip M76.22 Iliac crest spur, left hip M76.31 Iliotibial band syndrome, right leg M76.32 Iliotibial band syndrome, left leg M76.41 Tibial collateral bursitis [Pellegrini-Stieda], right leg M76.42 Tibial collateral bursitis [Pellegrini-Stieda], left leg M76.51 Patellar tendinitis, right knee M76.52 Patellar tendinitis, left knee M76.61 Achilles tendinitis, right leg M76.62 Achilles tendinitis, left leg M76.71 Peroneal tendinitis, right leg Printed on 10/5/2016. Page 10 of 21

11 M76.72 Peroneal tendinitis, left leg M Anterior tibial syndrome, right leg M Anterior tibial syndrome, left leg M Posterior tibial tendinitis, right leg M Posterior tibial tendinitis, left leg M Other specified enthesopathies of right lower limb, excluding foot M Other specified enthesopathies of left lower limb, excluding foot M77.01 Medial epicondylitis, right elbow M77.02 Medial epicondylitis, left elbow M77.11 Lateral epicondylitis, right elbow M77.12 Lateral epicondylitis, left elbow M77.21 Periarthritis, right wrist M77.22 Periarthritis, left wrist M77.31 Calcaneal spur, right foot M77.32 Calcaneal spur, left foot M77.41 Metatarsalgia, right foot M77.42 Metatarsalgia, left foot M77.51 Other enthesopathy of right foot M77.52 Other enthesopathy of left foot M77.8 Other enthesopathies, not elsewhere classified M79.1 Myalgia M79.7 Fibromyalgia M94.0 Chondrocostal junction syndrome [Tietze] S03.1XXS Dislocation of septal cartilage of nose, sequela S03.41XA Sprain of jaw, right side, initial S03.41XD Sprain of jaw, right side, subsequent S03.41XS Sprain of jaw, right side, sequela S03.42XA Sprain of jaw, left side, initial S03.42XD Sprain of jaw, left side, subsequent S03.42XS Sprain of jaw, left side, sequela S03.43XA Sprain of jaw, bilateral, initial S03.43XD Sprain of jaw, bilateral, subsequent S03.43XS Sprain of jaw, bilateral, sequela S03.8XXA Sprain of joints and ligaments of other parts of head, initial S03.8XXD Sprain of joints and ligaments of other parts of head, subsequent S03.8XXS Sprain of joints and ligaments of other parts of head, sequela S13.4XXA Sprain of ligaments of cervical spine, initial S13.4XXD Sprain of ligaments of cervical spine, subsequent S13.4XXS Sprain of ligaments of cervical spine, sequela S13.5XXA Sprain of thyroid region, initial S13.5XXD Sprain of thyroid region, subsequent S13.5XXS Sprain of thyroid region, sequela S13.8XXA Sprain of joints and ligaments of other parts of neck, initial S13.8XXD Sprain of joints and ligaments of other parts of neck, subsequent S13.8XXS Sprain of joints and ligaments of other parts of neck, sequela S16.1XXA Strain of muscle, fascia and tendon at neck level, initial S16.1XXD Strain of muscle, fascia and tendon at neck level, subsequent S16.1XXS Strain of muscle, fascia and tendon at neck level, sequela S23.3XXA Sprain of ligaments of thoracic spine, initial S23.3XXD Sprain of ligaments of thoracic spine, subsequent S23.3XXS Sprain of ligaments of thoracic spine, sequela S23.41XA Sprain of ribs, initial S23.41XD Sprain of ribs, subsequent S23.41XS Sprain of ribs, sequela S23.420A Sprain of sternoclavicular (joint) (ligament), initial S23.420D Sprain of sternoclavicular (joint) (ligament), subsequent S23.420S Sprain of sternoclavicular (joint) (ligament), sequela Printed on 10/5/2016. Page 11 of 21

12 S23.421A Sprain of chondrosternal joint, initial S23.421D Sprain of chondrosternal joint, subsequent S23.421S Sprain of chondrosternal S23.428A Other sprain of sternum, initial S23.428D Other sprain of sternum, subsequent S23.428S Other sprain of sternum, sequela S23.8XXA Sprain of other specified parts of thorax, initial S23.8XXD Sprain of other specified parts of thorax, subsequent S23.8XXS Sprain of other specified parts of thorax, sequela S29.011A Strain of muscle and tendon of front wall of thorax, initial S29.011D Strain of muscle and tendon of front wall of thorax, subsequent S29.011S Strain of muscle and tendon of front wall of thorax, sequela S29.012A Strain of muscle and tendon of back wall of thorax, initial S29.012D Strain of muscle and tendon of back wall of thorax, subsequent S29.012S Strain of muscle and tendon of back wall of thorax, sequela S33.4XXS Traumatic rupture of symphysis pubis, sequela S33.5XXA Sprain of ligaments of lumbar spine, initial S33.5XXD Sprain of ligaments of lumbar spine, subsequent S33.5XXS Sprain of ligaments of lumbar spine, sequela S33.6XXA Sprain of sacroiliac joint, initial S33.6XXD Sprain of sacroiliac joint, subsequent S33.6XXS Sprain of sacroiliac S33.8XXA Sprain of other parts of lumbar spine and pelvis, initial S33.8XXD Sprain of other parts of lumbar spine and pelvis, subsequent S33.8XXS Sprain of other parts of lumbar spine and pelvis, sequela S39.011A Strain of muscle, fascia and tendon of abdomen, initial S39.011D Strain of muscle, fascia and tendon of abdomen, subsequent S39.011S Strain of muscle, fascia and tendon of abdomen, sequela S39.012A Strain of muscle, fascia and tendon of lower back, initial S39.012D Strain of muscle, fascia and tendon of lower back, subsequent S39.012S Strain of muscle, fascia and tendon of lower back, sequela S39.013A Strain of muscle, fascia and tendon of pelvis, initial S39.013D Strain of muscle, fascia and tendon of pelvis, subsequent S39.013S Strain of muscle, fascia and tendon of pelvis, sequela S43.411A Sprain of right coracohumeral (ligament), initial S43.411D Sprain of right coracohumeral (ligament), subsequent S43.411S Sprain of right coracohumeral (ligament), sequela S43.412A Sprain of left coracohumeral (ligament), initial S43.412D Sprain of left coracohumeral (ligament), subsequent S43.412S Sprain of left coracohumeral (ligament), sequela S43.421A Sprain of right rotator cuff capsule, initial S43.421D Sprain of right rotator cuff capsule, subsequent S43.421S Sprain of right rotator cuff capsule, sequela S43.422A Sprain of left rotator cuff capsule, initial S43.422D Sprain of left rotator cuff capsule, subsequent S43.422S Sprain of left rotator cuff capsule, sequela S43.431A Superior glenoid labrum lesion of right shoulder, initial S43.431D Superior glenoid labrum lesion of right shoulder, subsequent S43.431S Superior glenoid labrum lesion of right shoulder, sequela S43.432A Superior glenoid labrum lesion of left shoulder, initial S43.432D Superior glenoid labrum lesion of left shoulder, subsequent S43.432S Superior glenoid labrum lesion of left shoulder, sequela S43.491A Other sprain of right shoulder joint, initial S43.491D Other sprain of right shoulder joint, subsequent S43.491S Other sprain of right shoulder S43.492A Other sprain of left shoulder joint, initial S43.492D Other sprain of left shoulder joint, subsequent S43.492S Other sprain of left shoulder Printed on 10/5/2016. Page 12 of 21

13 S43.51XA S43.51XD S43.51XS S43.52XA S43.52XD S43.52XS S43.61XA S43.61XD S43.61XS S43.62XA S43.62XD S43.62XS S43.81XA S43.81XD S43.81XS S43.82XA S43.82XD S43.82XS S46.011A S46.011D S46.011S S46.012A S46.012D S46.012S S46.111A S46.111D S46.111S S46.112A S46.112D S46.112S S46.211A S46.211D S46.211S S46.212A S46.212D S46.212S S46.311A S46.311D S46.311S S46.312A S46.312D S46.312S S46.811A S46.811D S46.811S S46.812A S46.812D S46.812S S53.21XS S53.22XS S53.31XS S53.32XS S53.411A S53.411D Sprain of right acromioclavicular joint, initial Sprain of right acromioclavicular joint, subsequent Sprain of right acromioclavicular Sprain of left acromioclavicular joint, initial Sprain of left acromioclavicular joint, subsequent Sprain of left acromioclavicular Sprain of right sternoclavicular joint, initial Sprain of right sternoclavicular joint, subsequent Sprain of right sternoclavicular Sprain of left sternoclavicular joint, initial Sprain of left sternoclavicular joint, subsequent Sprain of left sternoclavicular Sprain of other specified parts of right shoulder girdle, initial Sprain of other specified parts of right shoulder girdle, subsequent Sprain of other specified parts of right shoulder girdle, sequela Sprain of other specified parts of left shoulder girdle, initial Sprain of other specified parts of left shoulder girdle, subsequent Sprain of other specified parts of left shoulder girdle, sequela Strain of muscle(s) and tendon(s) of the rotator cuff of right shoulder, initial Strain of muscle(s) and tendon(s) of the rotator cuff of right shoulder, subsequent Strain of muscle(s) and tendon(s) of the rotator cuff of right shoulder, sequela Strain of muscle(s) and tendon(s) of the rotator cuff of left shoulder, initial Strain of muscle(s) and tendon(s) of the rotator cuff of left shoulder, subsequent Strain of muscle(s) and tendon(s) of the rotator cuff of left shoulder, sequela Strain of muscle, fascia and tendon of long head of biceps, right arm, initial Strain of muscle, fascia and tendon of long head of biceps, right arm, subsequent Strain of muscle, fascia and tendon of long head of biceps, right arm, sequela Strain of muscle, fascia and tendon of long head of biceps, left arm, initial Strain of muscle, fascia and tendon of long head of biceps, left arm, subsequent Strain of muscle, fascia and tendon of long head of biceps, left arm, sequela Strain of muscle, fascia and tendon of other parts of biceps, right arm, initial Strain of muscle, fascia and tendon of other parts of biceps, right arm, subsequent Strain of muscle, fascia and tendon of other parts of biceps, right arm, sequela Strain of muscle, fascia and tendon of other parts of biceps, left arm, initial Strain of muscle, fascia and tendon of other parts of biceps, left arm, subsequent Strain of muscle, fascia and tendon of other parts of biceps, left arm, sequela Strain of muscle, fascia and tendon of triceps, right arm, initial Strain of muscle, fascia and tendon of triceps, right arm, subsequent Strain of muscle, fascia and tendon of triceps, right arm, sequela Strain of muscle, fascia and tendon of triceps, left arm, initial Strain of muscle, fascia and tendon of triceps, left arm, subsequent Strain of muscle, fascia and tendon of triceps, left arm, sequela Strain of other muscles, fascia and tendons at shoulder and upper arm level, right arm, initial Strain of other muscles, fascia and tendons at shoulder and upper arm level, right arm, subsequent Strain of other muscles, fascia and tendons at shoulder and upper arm level, right arm, sequela Strain of other muscles, fascia and tendons at shoulder and upper arm level, left arm, initial Strain of other muscles, fascia and tendons at shoulder and upper arm level, left arm, subsequent Strain of other muscles, fascia and tendons at shoulder and upper arm level, left arm, sequela Traumatic rupture of right radial collateral ligament, sequela Traumatic rupture of left radial collateral ligament, sequela Traumatic rupture of right ulnar collateral ligament, sequela Traumatic rupture of left ulnar collateral ligament, sequela Radiohumeral (joint) sprain of right elbow, initial Radiohumeral (joint) sprain of right elbow, subsequent Printed on 10/5/2016. Page 13 of 21

14 S53.411S S53.412A S53.412D S53.412S S53.421A S53.421D S53.421S S53.422A S53.422D S53.422S S53.431A S53.431D S53.431S S53.432A S53.432D S53.432S S53.441A S53.441D S53.441S S53.442A S53.442D S53.442S S53.491A S53.491D S53.491S S53.492A S53.492D S53.492S S56.011A S56.011D S56.011S S56.012A S56.012D S56.012S S56.111A S56.111D S56.111S S56.112A S56.112D S56.112S S56.113A S56.113D S56.113S S56.114A S56.114D S56.114S S56.115A S56.115D S56.115S S56.116A S56.116D S56.116S S56.117A Radiohumeral (joint) sprain of right elbow, sequela Radiohumeral (joint) sprain of left elbow, initial Radiohumeral (joint) sprain of left elbow, subsequent Radiohumeral (joint) sprain of left elbow, sequela Ulnohumeral (joint) sprain of right elbow, initial Ulnohumeral (joint) sprain of right elbow, subsequent Ulnohumeral (joint) sprain of right elbow, sequela Ulnohumeral (joint) sprain of left elbow, initial Ulnohumeral (joint) sprain of left elbow, subsequent Ulnohumeral (joint) sprain of left elbow, sequela Radial collateral ligament sprain of right elbow, initial Radial collateral ligament sprain of right elbow, subsequent Radial collateral ligament sprain of right elbow, sequela Radial collateral ligament sprain of left elbow, initial Radial collateral ligament sprain of left elbow, subsequent Radial collateral ligament sprain of left elbow, sequela Ulnar collateral ligament sprain of right elbow, initial Ulnar collateral ligament sprain of right elbow, subsequent Ulnar collateral ligament sprain of right elbow, sequela Ulnar collateral ligament sprain of left elbow, initial Ulnar collateral ligament sprain of left elbow, subsequent Ulnar collateral ligament sprain of left elbow, sequela Other sprain of right elbow, initial Other sprain of right elbow, subsequent Other sprain of right elbow, sequela Other sprain of left elbow, initial Other sprain of left elbow, subsequent Other sprain of left elbow, sequela Strain of flexor muscle, fascia and tendon of right thumb at forearm level, initial Strain of flexor muscle, fascia and tendon of right thumb at forearm level, subsequent Strain of flexor muscle, fascia and tendon of right thumb at forearm level, sequela Strain of flexor muscle, fascia and tendon of left thumb at forearm level, initial Strain of flexor muscle, fascia and tendon of left thumb at forearm level, subsequent Strain of flexor muscle, fascia and tendon of left thumb at forearm level, sequela Strain of flexor muscle, fascia and tendon of right index finger at forearm level, initial Strain of flexor muscle, fascia and tendon of right index finger at forearm level, subsequent Strain of flexor muscle, fascia and tendon of right index finger at forearm level, sequela Strain of flexor muscle, fascia and tendon of left index finger at forearm level, initial Strain of flexor muscle, fascia and tendon of left index finger at forearm level, subsequent Strain of flexor muscle, fascia and tendon of left index finger at forearm level, sequela Strain of flexor muscle, fascia and tendon of right middle finger at forearm level, initial Strain of flexor muscle, fascia and tendon of right middle finger at forearm level, subsequent Strain of flexor muscle, fascia and tendon of right middle finger at forearm level, sequela Strain of flexor muscle, fascia and tendon of left middle finger at forearm level, initial Strain of flexor muscle, fascia and tendon of left middle finger at forearm level, subsequent Strain of flexor muscle, fascia and tendon of left middle finger at forearm level, sequela Strain of flexor muscle, fascia and tendon of right ring finger at forearm level, initial Strain of flexor muscle, fascia and tendon of right ring finger at forearm level, subsequent Strain of flexor muscle, fascia and tendon of right ring finger at forearm level, sequela Strain of flexor muscle, fascia and tendon of left ring finger at forearm level, initial Strain of flexor muscle, fascia and tendon of left ring finger at forearm level, subsequent Strain of flexor muscle, fascia and tendon of left ring finger at forearm level, sequela Strain of flexor muscle, fascia and tendon of right little finger at forearm level, initial Printed on 10/5/2016. Page 14 of 21

15 S56.117D Strain of flexor muscle, fascia and tendon of right little finger at forearm level, subsequent S56.117S Strain of flexor muscle, fascia and tendon of right little finger at forearm level, sequela S56.118A Strain of flexor muscle, fascia and tendon of left little finger at forearm level, initial S56.118D Strain of flexor muscle, fascia and tendon of left little finger at forearm level, subsequent S56.118S Strain of flexor muscle, fascia and tendon of left little finger at forearm level, sequela S56.211A Strain of other flexor muscle, fascia and tendon at forearm level, right arm, initial S56.211D Strain of other flexor muscle, fascia and tendon at forearm level, right arm, subsequent S56.211S Strain of other flexor muscle, fascia and tendon at forearm level, right arm, sequela S56.212A Strain of other flexor muscle, fascia and tendon at forearm level, left arm, initial S56.212D Strain of other flexor muscle, fascia and tendon at forearm level, left arm, subsequent S56.212S Strain of other flexor muscle, fascia and tendon at forearm level, left arm, sequela S56.311A Strain of extensor or abductor muscles, fascia and tendons of right thumb at forearm level, initial S56.311D Strain of extensor or abductor muscles, fascia and tendons of right thumb at forearm level, subsequent S56.311S Strain of extensor or abductor muscles, fascia and tendons of right thumb at forearm level, sequela S56.312A Strain of extensor or abductor muscles, fascia and tendons of left thumb at forearm level, initial S56.312D Strain of extensor or abductor muscles, fascia and tendons of left thumb at forearm level, subsequent S56.312S Strain of extensor or abductor muscles, fascia and tendons of left thumb at forearm level, sequela S56.411A Strain of extensor muscle, fascia and tendon of right index finger at forearm level, initial S56.411D Strain of extensor muscle, fascia and tendon of right index finger at forearm level, subsequent S56.411S Strain of extensor muscle, fascia and tendon of right index finger at forearm level, sequela S56.412A Strain of extensor muscle, fascia and tendon of left index finger at forearm level, initial S56.412D Strain of extensor muscle, fascia and tendon of left index finger at forearm level, subsequent S56.412S Strain of extensor muscle, fascia and tendon of left index finger at forearm level, sequela S56.413A Strain of extensor muscle, fascia and tendon of right middle finger at forearm level, initial S56.413D Strain of extensor muscle, fascia and tendon of right middle finger at forearm level, subsequent S56.413S Strain of extensor muscle, fascia and tendon of right middle finger at forearm level, sequela S56.414A Strain of extensor muscle, fascia and tendon of left middle finger at forearm level, initial S56.414D Strain of extensor muscle, fascia and tendon of left middle finger at forearm level, subsequent S56.414S Strain of extensor muscle, fascia and tendon of left middle finger at forearm level, sequela S56.415A Strain of extensor muscle, fascia and tendon of right ring finger at forearm level, initial S56.415D Strain of extensor muscle, fascia and tendon of right ring finger at forearm level, subsequent S56.415S Strain of extensor muscle, fascia and tendon of right ring finger at forearm level, sequela S56.416A Strain of extensor muscle, fascia and tendon of left ring finger at forearm level, initial S56.416D Strain of extensor muscle, fascia and tendon of left ring finger at forearm level, subsequent S56.416S Strain of extensor muscle, fascia and tendon of left ring finger at forearm level, sequela S56.417A Strain of extensor muscle, fascia and tendon of right little finger at forearm level, initial S56.417D Strain of extensor muscle, fascia and tendon of right little finger at forearm level, subsequent S56.417S Strain of extensor muscle, fascia and tendon of right little finger at forearm level, sequela S56.418A Strain of extensor muscle, fascia and tendon of left little finger at forearm level, initial S56.418D Strain of extensor muscle, fascia and tendon of left little finger at forearm level, subsequent S56.418S Strain of extensor muscle, fascia and tendon of left little finger at forearm level, sequela S56.511A Strain of other extensor muscle, fascia and tendon at forearm level, right arm, initial S56.511D Strain of other extensor muscle, fascia and tendon at forearm level, right arm, subsequent Printed on 10/5/2016. Page 15 of 21

16 S56.511S S56.512A S56.512D S56.512S S56.811A S56.811D S56.811S S56.812A S56.812D S56.812S S63.311S S63.312S S63.321S S63.322S S63.331S S63.332S S63.391S S63.392S S63.410S S63.411S S63.412S S63.413S S63.414S S63.415S S63.416S S63.417S S63.418S S63.420S S63.421S S63.422S S63.423S S63.424S S63.425S S63.426S S63.427S S63.428S S63.430S S63.431S S63.432S Strain of other extensor muscle, fascia and tendon at forearm level, right arm, sequela Strain of other extensor muscle, fascia and tendon at forearm level, left arm, initial Strain of other extensor muscle, fascia and tendon at forearm level, left arm, subsequent Strain of other extensor muscle, fascia and tendon at forearm level, left arm, sequela Strain of other muscles, fascia and tendons at forearm level, right arm, initial Strain of other muscles, fascia and tendons at forearm level, right arm, subsequent Strain of other muscles, fascia and tendons at forearm level, right arm, sequela Strain of other muscles, fascia and tendons at forearm level, left arm, initial Strain of other muscles, fascia and tendons at forearm level, left arm, subsequent Strain of other muscles, fascia and tendons at forearm level, left arm, sequela Traumatic rupture of collateral ligament of right wrist, sequela Traumatic rupture of collateral ligament of left wrist, sequela Traumatic rupture of right radiocarpal ligament, sequela Traumatic rupture of left radiocarpal ligament, sequela Traumatic rupture of right ulnocarpal (palmar) ligament, sequela Traumatic rupture of left ulnocarpal (palmar) ligament, sequela Traumatic rupture of other ligament of right wrist, sequela Traumatic rupture of other ligament of left wrist, sequela Traumatic rupture of collateral ligament of right index finger at metacarpophalangeal and Traumatic rupture of collateral ligament of left index finger at metacarpophalangeal and Traumatic rupture of collateral ligament of right middle finger at metacarpophalangeal and Traumatic rupture of collateral ligament of left middle finger at metacarpophalangeal and Traumatic rupture of collateral ligament of right ring finger at metacarpophalangeal and Traumatic rupture of collateral ligament of left ring finger at metacarpophalangeal and Traumatic rupture of collateral ligament of right little finger at metacarpophalangeal and Traumatic rupture of collateral ligament of left little finger at metacarpophalangeal and Traumatic rupture of collateral ligament of other finger at metacarpophalangeal and Traumatic rupture of palmar ligament of right index finger at metacarpophalangeal and Traumatic rupture of palmar ligament of left index finger at metacarpophalangeal and Traumatic rupture of palmar ligament of right middle finger at metacarpophalangeal and Traumatic rupture of palmar ligament of left middle finger at metacarpophalangeal and Traumatic rupture of palmar ligament of right ring finger at metacarpophalangeal and Traumatic rupture of palmar ligament of left ring finger at metacarpophalangeal and Traumatic rupture of palmar ligament of right little finger at metacarpophalangeal and Traumatic rupture of palmar ligament of left little finger at metacarpophalangeal and Traumatic rupture of palmar ligament of other finger at metacarpophalangeal and interphalangeal Traumatic rupture of volar plate of right index finger at metacarpophalangeal and interphalangeal Traumatic rupture of volar plate of left index finger at metacarpophalangeal and interphalangeal Printed on 10/5/2016. Page 16 of 21