2014 General Surgery Medicare Reimbursement Coding Guide Effective January 1, 2014

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1 2014 General Surgery Medicare Reimbursement Coding Guide Effective January 1, 2014 Medicare National Average s and Allowables (Not Adjusted For Geography) CPT * ADRENALECTOMY Adrenalectomy, partial or complete, or exploration of adrenal gland with or without biopsy, transabdominal, lumbar or dorsal (separate procedure); Adrenalectomy, partial or complete, or exploration of adrenal gland with or without biopsy, transabdominal, lumbar or dorsal (separate procedure); with excision of adjacent retroperitoneal tumor Laparoscopy, surgical, with adrenalectomy, partial or complete, or exploration of adrenal gland with or without biopsy, transabdominal, lumbar or dorsal APPENDECTOMY Appendectomy; $ Appendectomy; when done for indicated purpose at time of other major procedure (not as separate procedure) (List separately in addition to code for primary procedure) Appendectomy; for ruptured appendix with abscess or generalized peritonitis BARIATRIC LAPAROSCOPIC GASTRIC BYPASS Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less) Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and small intestine reconstruction to limit absorption BARIATRIC LAPAROSCOPIC GASTRIC BANDING ** $1, Inpatient, not reimbursed in outpatient or $1, Inpatient, not reimbursed in outpatient or $1, Inpatient, not reimbursed in outpatient or Peritoneal and Abdominal $85.97 NA NA Unlisted laparoscopy procedure, stomach Carrier Priced Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (eg, gastric band and subcutaneous port components) Laparoscopy, surgical, gastric restrictive procedure; revision of adjustable gastric restrictive device component only $1, Packaged into Payment for Other Services $ Inpatient, not reimbursed in outpatient or $1, Inpatient, not reimbursed in outpatient or $1, Inpatient, not reimbursed in outpatient or $1, Level I Laparoscopy Laparoscopy $2, $5, $1, Inpatient, not reimbursed in outpatient or

2 CPT * Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device component only Laparoscopy, surgical, gastric restrictive procedure; removal and replacement of adjustable gastric restrictive device component only Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device and subcutaneous port components BARIATRIC LAPAROSCOPIC SLEEVE GASTRECTOMY ** $ Inpatient, not reimbursed in outpatient or $1, Inpatient, not reimbursed in outpatient or $ Inpatient, not reimbursed in outpatient or Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (ie, sleeve gastrectomy) Carrier Priced Inpatient Procedure, not reimbursed in outpatient or MISCELLANEOUS GASTRIC PROCEDURE (INCLUDING REVISIONS) Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical-banded gastroplasty Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than vertical-banded gastroplasty Gastric restrictive procedure with partial gastrectomy, pyloruspreserving duodenoileostomy and ileoileostomy (50 to 100 cm common channel) to limit absorption (biliopancreatic diversion with duodenal switch) Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less) Roux-en-Y gastroenterostomy Gastric restrictive procedure, with gastric bypass for morbid obesity; with small intestine reconstruction to limit absorption Revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric restrictive device (separate procedure) Revision of gastrojejunal anastomosis (gastrojejunostomy) with reconstruction, with or without partial gastrectomy or intestine resection; without vagotomy Revision of gastrojejunal anastomosis (gastrojejunostomy) with reconstruction, with or without partial gastrectomy or intestine resection; with vagotomy Gastric restrictive procedure, open; revision of subcutaneous port component only $ $1, Inpatient Procedure, not reimbursed in outpatient or $1, Inpatient Procedure, not reimbursed in outpatient or $1, Inpatient Procedure, not reimbursed in outpatient or $1, Inpatient Procedure, not reimbursed in outpatient or $1, Inpatient Procedure, not reimbursed in outpatient or $1, Inpatient Procedure, not reimbursed in outpatient or $1, Inpatient Procedure, not reimbursed in outpatient or $1, Inpatient Procedure, not reimbursed in outpatient or Level IV Skin Repair $2, $1, Gastric restrictive procedure, open; removal of subcutaneous port component only Gastric restrictive procedure, open; removal and replacement of subcutaneous port component only $ $ Unlisted procedure, stomach Carrier Priced S2083+ Radiological examination, gastrointestinal tract, upper, air contrast, with specific high density barium, effervescent agent, with or without glucagon; with or without delayed films, without KUB Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device) Adjustment of gastric band diameter via subcutaneous port by injection or aspiration of saline CHOLECYSTECTOMY $35.11 (Professional Fee) $28.30 (Professional Fee) Laparoscopy, surgical; cholecystectomy $ Laparoscopy, surgical; cholecystectomy with cholangiography $ Laparoscopy, surgical; cholecystectomy with exploration of common duct 0277 NA Skin Repair Level IV Skin Repair Level I Upper GI Level II Digestive Radiology NA $1, $ $2, $1, $ $ $83.54 Packaged into Payment for Other Services Packaged Service/ Item Carrier Priced NA NA NA NA $1, Level II Laparoscopy Level II Laparoscopy Level II Laparoscopy $3, $2, $3, $2, $3, $2, Cholecystectomy; $1, Inpatient, not reimbursed in outpatient or Cholecystectomy; with cholangiography $1, Inpatient, not reimbursed in outpatient or Cholecystectomy with exploration of common duct; $1, Inpatient, not reimbursed in outpatient or

3 CPT * Cholecystectomy with exploration of common duct; with choledochoenterostomy Cholecystectomy with exploration of common duct; with transduodenal sphincterotomy or sphincteroplasty, with or without cholangiography COLECTOMY ** $1, Inpatient, not reimbursed in outpatient or $1, Inpatient, not reimbursed in outpatient or Colectomy, partial; with anastomosis $1, Inpatient, not reimbursed in outpatient or Colectomy, partial; with skin level cecostomy or colostomy $1, Inpatient, not reimbursed in outpatient or Colectomy, partial; with end colostomy and closure of distal segment (Hartmann type procedure) Colectomy, partial; with resection, with colostomy or ileostomy and creation of mucofistula $1, Inpatient, not reimbursed in outpatient or $1, Inpatient, not reimbursed in outpatient or Colectomy, partial; with coloproctostomy (low pelvic anastomosis) $1, Inpatient, not reimbursed in outpatient or Colectomy, partial; with coloproctostomy (low pelvic anastomosis), with colostomy $2, Inpatient, not reimbursed in outpatient or Colectomy, partial; abdominal and transanal approach $1, Inpatient, not reimbursed in outpatient or Colectomy, total, abdominal, without proctectomy; with ileostomy or ileoproctostomy Colectomy, total, abdominal, without proctectomy; with continent ileostomy $1, Inpatient, not reimbursed in outpatient or $2, Inpatient, not reimbursed in outpatient or Colectomy, total, abdominal, with proctectomy; with ileostomy $2, Inpatient, not reimbursed in outpatient or Colectomy, total, abdominal, with proctectomy; with continent ileostomy Colectomy, total, abdominal, with proctectomy; with ileoanal anastomosis, includes loop ileostomy, and rectal mucosectomy, when performed Colectomy, total, abdominal, with proctectomy; with ileoanal anastomosis, creation of ileal reservoir (S or J), includes loop ileostomy, and rectal mucosectomy, when performed Colectomy, partial, with removal of terminal ileum with ileocolostomy CYSTECTOMY $2, Inpatient, not reimbursed in outpatient or $2, Inpatient, not reimbursed in outpatient or $2, Inpatient, not reimbursed in outpatient or $1, Inpatient, not reimbursed in outpatient or Cystectomy, partial; simple $ Inpatient, not reimbursed in outpatient or Cystectomy, partial; complicated (eg, postradiation, previous surgery, difficult location) Cystectomy, partial, with reimplantation of ureter(s) into bladder (ureteroneocystostomy) $1, Inpatient, not reimbursed in outpatient or $1, Inpatient, not reimbursed in outpatient or Cystectomy, complete; (separate procedure) $1, Inpatient, not reimbursed in outpatient or Cystectomy, complete; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes Cystectomy, complete, with ureterosigmoidostomy or ureterocutaneous transplantations; Cystectomy, complete, with ureterosigmoidostomy or ureterocutaneous transplantations; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes Cystectomy, complete, with ureteroileal conduit or sigmoid bladder, including intestine anastomosis; Cystectomy, complete, with ureteroileal conduit or sigmoid bladder, including intestine anastomosis; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes Cystectomy, complete, with continent diversion, any open technique, using any segment of small and/or large intestine to construct neobladder $1, Inpatient, not reimbursed in outpatient or $1, Inpatient, not reimbursed in outpatient or $2, Inpatient, not reimbursed in outpatient or $1, Inpatient, not reimbursed in outpatient or $2, Inpatient, not reimbursed in outpatient or $2, Inpatient, not reimbursed in outpatient or

4 CPT * ESOPHAGECTOMY Total or near total esophagectomy, without thoracotomy; with pharyngogastrostomy or cervical esophagogastrostomy, with or without pyloroplasty (transhiatal) Total or near total esophagectomy, without thoracotomy; with colon interposition or small intestine reconstruction, including intestine mobilization, preparation and anastomosis(es) Total or near total esophagectomy, with thoracotomy; with pharyngogastrostomy or cervical esophagogastrostomy, with or without pyloroplasty Total or near total esophagectomy, with thoracotomy; with colon interposition or small intestine reconstruction, including intestine mobilization, preparation, and anastomosis(es) Partial esophagectomy, cervical, with free intestinal graft, including microvascular anastomosis, obtaining the graft and intestinal reconstruction Partial esophagectomy, distal two-thirds, with thoracotomy and separate abdominal incision, with or without proximal gastrectomy; with thoracic esophagogastrostomy, with or without pyloroplasty (Ivor Lewis) Partial esophagectomy, distal two-thirds, with thoracotomy and separate abdominal incision, with or without proximal gastrectomy; with colon interposition or small intestine reconstruction, including intestine mobilization, preparation, and anastomosis(es) Partial esophagectomy, distal two-thirds, with thoracotomy only, with or without proximal gastrectomy, with thoracic esophagogastrostomy, with or without pyloroplasty Partial esophagectomy, thoracoabdominal or abdominal approach, with or without proximal gastrectomy; with esophagogastrostomy, with or without pyloroplasty Partial esophagectomy, thoracoabdominal or abdominal approach, with or without proximal gastrectomy; with colon interposition or small intestine reconstruction, including intestine mobilization, preparation, and anastomosis(es) Total or partial esophagectomy, without reconstruction (any approach), with cervical esophagostomy GASTRECTOMY ** $2, Inpatient, not reimbursed in outpatient or $4, Inpatient, not reimbursed in outpatient or $2, Inpatient, not reimbursed in outpatient or $4, Inpatient, not reimbursed in outpatient or $5, Inpatient, not reimbursed in outpatient or $2, Inpatient, not reimbursed in outpatient or $3, Inpatient, not reimbursed in outpatient or $2, Inpatient, not reimbursed in outpatient or $2, Inpatient, not reimbursed in outpatient or $4, Inpatient, not reimbursed in outpatient or $3, Inpatient, not reimbursed in outpatient or Gastrectomy, total; with esophagoenterostomy $2, Inpatient, not reimbursed in outpatient or Gastrectomy, total; with Roux-en-Y reconstruction $2, Inpatient, not reimbursed in outpatient or Gastrectomy, total; with formation of intestinal pouch, any type $2, Inpatient, not reimbursed in outpatient or Gastrectomy, partial, distal; with gastroduodenostomy $1, Inpatient, not reimbursed in outpatient or Gastrectomy, partial, distal; with gastrojejunostomy $2, Inpatient, not reimbursed in outpatient or Gastrectomy, partial, distal; with Roux-en-Y reconstruction $1, Inpatient, not reimbursed in outpatient or Gastrectomy, partial, distal; with formation of intestinal pouch $2, Inpatient, not reimbursed in outpatient or HEMORRHOID Incision of thrombosed hemorrhoid, external Excision of single external papilla or tag, anus Hemorrhoidectomy, internal, by rubber band ligation(s) Excision of multiple external papillae or tags, anus Hemorrhoidectomy, external, 2 or more columns/groups $ / $ $ / $ $ / $ $ / $ $ / $ Level II Urinary and Anal Level II Level I Anal/ Rectal Level II $ $ $1, $ $ $ $1, $784.40

5 CPT * Hemorrhoidectomy, internal and external, single column/group; Hemorrhoidectomy, internal and external, single column/group; with fissurectomy Hemorrhoidectomy, internal and external, single column/group; with fistulectomy, including fissurectomy, when performed Hemorrhoidectomy, internal and external, 2 or more columns/ groups; Hemorrhoidectomy, internal and external, 2 or more columns/ groups; with fissurectomy Hemorrhoidectomy, internal and external, 2 or more columns/ groups; with fistulectomy, including fissurectomy, when performed LAPAROSCOPIC COLECTOMY $ / $ $ $ $ $ $ ** Laparoscopy, surgical; colectomy, partial, with anastomosis $1, Inpatient, not reimbursed in outpatient or Laparoscopy, surgical; colectomy, partial, with removal of terminal ileum with ileocolostomy Laparoscopy, surgical; colectomy, partial, with end colostomy and closure of distal segment (Hartmann type procedure) Laparoscopy, surgical; colectomy, partial, with anastomosis, with coloproctostomy (low pelvic anastomosis) Laparoscopy, surgical; colectomy, partial, with anastomosis, with coloproctostomy (low pelvic anastomosis) with colostomy Laparoscopy, surgical; colectomy, total, abdominal, without proctectomy, with ileostomy or ileoproctostomy Laparoscopy, surgical; colectomy, total, abdominal, with proctectomy, with ileoanal anastomosis, creation of ileal reservoir (S or J), with loop ileostomy, includes rectal mucosectomy, when performed Laparoscopy, surgical; colectomy, total, abdominal, with proctectomy, with ileostomy OPEN AND LAPAROSCOPIC NEPHRECTOMY Nephrectomy, including partial ureterectomy, any open approach including rib resection; Nephrectomy, including partial ureterectomy, any open approach including rib resection; complicated because of previous surgery on same kidney Nephrectomy, including partial ureterectomy, any open approach including rib resection; radical, with regional lymphadenectomy and/or vena caval thrombectomy Nephrectomy with total ureterectomy and bladder cuff; through same incision Nephrectomy with total ureterectomy and bladder cuff; through separate incision $1, Inpatient, not reimbursed in outpatient or $1, Inpatient, not reimbursed in outpatient or $1, Inpatient, not reimbursed in outpatient or $2, Inpatient, not reimbursed in outpatient or $1, Inpatient, not reimbursed in outpatient or $2, Inpatient, not reimbursed in outpatient or $2, Inpatient, not reimbursed in outpatient or $1, Inpatient, not reimbursed in outpatient or $1, Inpatient, not reimbursed in outpatient or $1, Inpatient, not reimbursed in outpatient or $1, Inpatient, not reimbursed in outpatient or $1, Inpatient, not reimbursed in outpatient or Nephrectomy, partial $1, Inpatient, not reimbursed in outpatient or Laparoscopy, surgical; partial nephrectomy $1, Laparoscopy, surgical; radical nephrectomy (includes removal of Gerota s fascia and surrounding fatty tissue, removal of regional lymph nodes, and adrenalectomy) Level II Laparoscopy $3, $1, Inpatient, not reimbursed in outpatient or Laparoscopy, surgical; nephrectomy, including partial ureterectomy $1, Inpatient, not reimbursed in outpatient or Laparoscopy, surgical; nephrectomy with total ureterectomy $1, Inpatient, not reimbursed in outpatient or

6 CPT * PANCREATECTOMY Pancreatectomy, distal subtotal, with or without splenectomy; without pancreaticojejunostomy Pancreatectomy, distal subtotal, with or without splenectomy; with pancreaticojejunostomy Pancreatectomy, distal, near-total with preservation of duodenum (Child-type procedure) Pancreatectomy, proximal subtotal with total duodenectomy, partial gastrectomy, choledochoenterostomy and gastrojejunostomy (Whipple-type procedure); with pancreatojejunostomy Pancreatectomy, proximal subtotal with total duodenectomy, partial gastrectomy, choledochoenterostomy and gastrojejunostomy (Whipple-type procedure); without pancreatojejunostomy Pancreatectomy, proximal subtotal with near-total duodenectomy, choledochoenterostomy and duodenojejunostomy (pylorus-sparing, Whipple-type procedure); with pancreatojejunostomy Pancreatectomy, proximal subtotal with near-total duodenectomy, choledochoenterostomy and duodenojejunostomy (pylorus-sparing, Whipple-type procedure); without pancreatojejunostomy ** $1, Inpatient, not reimbursed in outpatient or $1, Inpatient, not reimbursed in outpatient or $1, Inpatient, not reimbursed in outpatient or $3, Inpatient, not reimbursed in outpatient or $2, Inpatient, not reimbursed in outpatient or $3, Inpatient, not reimbursed in outpatient or $2, Inpatient, not reimbursed in outpatient or Pancreatectomy, total $1, Inpatient, not reimbursed in outpatient or Pancreatectomy, total or subtotal, with autologous transplantation of pancreas or pancreatic islet cells PROSTATECTOMY Prostatectomy, perineal, subtotal (including control of postoperative bleeding, vasectomy, meatotomy, urethral calibration and/or dilation, and internal urethrotomy) Medicare Non-Covered Service $1, Inpatient, not reimbursed in outpatient or Prostatectomy, perineal radical; $1, Inpatient, not reimbursed in outpatient or Prostatectomy, perineal radical; with lymph node biopsy(s) (limited pelvic lymphadenectomy) Prostatectomy, perineal radical; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric and obturator nodes Prostatectomy (including control of postoperative bleeding, vasectomy, meatotomy, urethral calibration and/or dilation, and internal urethrotomy); suprapubic, subtotal, 1 or 2 stages Prostatectomy (including control of postoperative bleeding, vasectomy, meatotomy, urethral calibration and/or dilation, and internal urethrotomy); retropubic, subtotal $1, Inpatient, not reimbursed in outpatient or $1, Inpatient, not reimbursed in outpatient or $ Inpatient, not reimbursed in outpatient or $ Inpatient, not reimbursed in outpatient or Prostatectomy, retropubic radical, with or without nerve sparing; $1, Inpatient, not reimbursed in outpatient or Prostatectomy, retropubic radical, with or without nerve sparing; with lymph node biopsy(s) (limited pelvic lymphadenectomy) Prostatectomy, retropubic radical, with or without nerve sparing; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes Laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing, includes robotic assistance, when performed RECTAL Proctectomy; complete, combined abdominoperineal, with colostomy $1, Inpatient, not reimbursed in outpatient or $1, Inpatient, not reimbursed in outpatient or $1, Inpatient, not reimbursed in outpatient or $1, Inpatient, not reimbursed in outpatient or Proctectomy; partial resection of rectum, transabdominal approach $1, Inpatient, not reimbursed in outpatient or Proctectomy, combined abdominoperineal, pull-through procedure (eg, colo-anal anastomosis) Proctectomy, partial, with rectal mucosectomy, ileoanal anastomosis, creation of ileal reservoir (S or J), with or without loop ileostomy Proctectomy, partial, with anastomosis; abdominal and transsacral approach Proctectomy, partial, with anastomosis; transsacral approach only (Kraske type) $1, Inpatient, not reimbursed in outpatient or $2, Inpatient, not reimbursed in outpatient or $1, Inpatient, not reimbursed in outpatient or $1, Inpatient, not reimbursed in outpatient or

7 CPT * Proctectomy, combined abdominoperineal pull-through procedure (eg, colo-anal anastomosis), with creation of colonic reservoir (eg, J-pouch), with diverting enterostomy when performed Proctectomy, complete (for congenital megacolon), abdominal and perineal approach; with pull-through procedure and anastomosis (eg, Swenson, Duhamel, or Soave type operation) Proctectomy, complete (for congenital megacolon), abdominal and perineal approach; with subtotal or total colectomy, with multiple biopsies ** $2, Inpatient, not reimbursed in outpatient or $1, Inpatient, not reimbursed in outpatient or $1, Inpatient, not reimbursed in outpatient or Proctectomy, partial, without anastomosis, perineal approach $1, Inpatient, not reimbursed in outpatient or Pelvic exenteration for colorectal malignancy, with proctectomy (with or without colostomy), with removal of bladder and ureteral transplantations, and/or hysterectomy, or cervicectomy, with or without removal of tube(s), with or without removal of ovary(s), or any combination thereof $2, Inpatient, not reimbursed in outpatient or Excision of rectal procidentia, with anastomosis; perineal approach $1, Inpatient, not reimbursed in outpatient or Excision of rectal procidentia, with anastomosis; abdominal and perineal approach $1, Inpatient, not reimbursed in outpatient or Excision of ileoanal reservoir with ileostomy $1, Inpatient, not reimbursed in outpatient or Division of stricture of rectum $ Excision of rectal tumor by proctotomy, transsacral or transcoccygeal approach Excision of rectal tumor, transanal approach; not including muscularis propria (ie, partial thickness) Excision of rectal tumor, transanal approach; including muscularis propria (ie, full thickness) Destruction of rectal tumor (eg, electrodesiccation, electrosurgery, laser ablation, laser resection, cryosurgery) transanal approach Laparoscopy, surgical; proctectomy, complete, combined abdominoperineal, with colostomy Laparoscopy, surgical; proctectomy, combined abdominoperineal pull-through procedure (eg, colo-anal anastomosis), with creation of colonic reservoir (eg, J-pouch), with diverting enterostomy, when performed $1, $ $ $ Level IV $2, $1, $2, Inpatient, not reimbursed in outpatient or $2, Inpatient, not reimbursed in outpatient or Laparoscopy, surgical; proctopexy (for prolapse) $1, Inpatient, not reimbursed in outpatient or Laparoscopy, surgical; proctopexy (for prolapse), with sigmoid resection $1, Inpatient, not reimbursed in outpatient or Exploration, repair, and presacral drainage for rectal injury; $1, Inpatient, not reimbursed in outpatient or Exploration, repair, and presacral drainage for rectal injury; with colostomy Anorectal exam, surgical, requiring anesthesia (general, spinal, or epidural), diagnostic $1, Inpatient, not reimbursed in outpatient or $ Unlisted procedure, rectum Carrier Priced Anoplasty, plastic operation for stricture; adult $ Level II Level I Anal/ Rectal $1, $ $ Anoplasty, plastic operation for stricture; infant $ Inpatient, not reimbursed in outpatient or Repair of anal fistula with fibrin glue $

8 CPT * Repair of ileoanal pouch fistula/sinus (eg, perineal or vaginal), pouch advancement; transperineal approach Repair of ileoanal pouch fistula/sinus (eg, perineal or vaginal), pouch advancement; combined transperineal and transabdominal approach SPLENECTOMY ** $1, Inpatient, not reimbursed in outpatient or $2, Inpatient, not reimbursed in outpatient or Splenectomy; total (separate procedure) $1, Inpatient, not reimbursed in outpatient or Splenectomy; partial (separate procedure) $1, Inpatient, not reimbursed in outpatient or Splenectomy; total, en bloc for extensive disease, in conjunction with other procedure (List in addition to code for primary procedure) Laparoscopy, surgical, splenectomy $1, THORACIC DIAGNOSTIC Thoracotomy, with diagnostic biopsy(ies) of lung infiltrate(s) (eg, wedge, incisional), unilateral Thoracotomy, with diagnostic biopsy(ies) of lung nodule(s) or mass(es) (eg, wedge, incisional), unilateral $ Inpatient, not reimbursed in outpatient or Level II Laparoscopy $3, $ Inpatient, not reimbursed in outpatient or $ Inpatient, not reimbursed in outpatient or Thoracotomy, with biopsy(ies) of pleura $ Inpatient, not reimbursed in outpatient or Thoracotomy; with exploration $ Inpatient, not reimbursed in outpatient or Biopsy, pleura; percutaneous needle Biopsy, lung or mediastinum, percutaneous needle Thoracoscopy, diagnostic (separate procedure); lungs, pericardial sac, mediastinal or pleural space, without biopsy Thoracoscopy, diagnostic (separate procedure); pericardial sac, with biopsy Thoracoscopy, diagnostic (separate procedure); mediastinal space, with biopsy Thoracoscopy; with diagnostic biopsy(ies) of lung infiltrate(s) (eg, wedge, incisional), unilateral Thoracoscopy; with diagnostic biopsy(ies) of lung nodule(s) or mass(es) (eg, wedge, incisional), unilateral $90.63 / $ $ / $ Needle Biopsy/ Aspiration Except Bone Marrow Needle Biopsy/ Aspiration Except Bone Marrow $ Thoracoscopy $2, $ Thoracoscopy $2, $ Thoracoscopy $2, $ Thoracoscopy $2, $ Thoracoscopy $2, Thoracoscopy; with biopsy(ies) of pleura $ Thoracoscopy $2, THORACIC EXCISION Thoracotomy; with control of traumatic hemorrhage and/or repair of lung tear $ $ $ $ $1, Inpatient, not reimbursed in outpatient or Thoracotomy; for postoperative complications $ Inpatient, not reimbursed in outpatient or Thoracotomy; with cyst(s) removal, includes pleural procedure when performed Thoracotomy; with resection-plication of bullae, includes any pleural procedure when performed Thoracotomy; with removal of intrapleural foreign body or fibrin deposit $1, Inpatient, not reimbursed in outpatient or $1, Inpatient, not reimbursed in outpatient or $1, Inpatient, not reimbursed in outpatient or Thoracotomy; with removal of intrapulmonary foreign body $1, Inpatient, not reimbursed in outpatient or Thoracotomy; with cardiac massage $ Inpatient, not reimbursed in outpatient or Removal of lung, pneumonectomy; $1, Inpatient, not reimbursed in outpatient or

9 CPT * Removal of lung, pneumonectomy; with resection of segment of trachea followed by broncho-tracheal anastomosis (sleeve pneumonectomy) ** $3, Inpatient, not reimbursed in outpatient or Removal of lung, pneumonectomy; extrapleural $3, Inpatient, not reimbursed in outpatient or Removal of lung, other than pneumonectomy; single lobe (lobectomy) Removal of lung, other than pneumonectomy; 2 lobes (bilobectomy) Removal of lung, other than pneumonectomy; single segment (segmentectomy) Removal of lung, other than pneumonectomy; with circumferential resection of segment of bronchus followed by broncho-bronchial anastomosis (sleeve lobectomy) Removal of lung, other than pneumonectomy; with all remaining lung following previous removal of a portion of lung (completion pneumonectomy) Removal of lung, other than pneumonectomy; with resectionplication of emphysematous lung(s) (bullous or non-bullous) for lung volume reduction, sternal split or transthoracic approach, includes any pleural procedure, when performed Resection and repair of portion of bronchus (bronchoplasty) when performed at time of lobectomy or segmentectomy (List separately in addition to code for primary procedure) Thoracoscopy, surgical; with pleurodesis (eg, mechanical or chemical) $1, Inpatient, not reimbursed in outpatient or $1, Inpatient, not reimbursed in outpatient or $1, Inpatient, not reimbursed in outpatient or $2, Inpatient, not reimbursed in outpatient or $2, Inpatient, not reimbursed in outpatient or $1, Inpatient, not reimbursed in outpatient or $ Inpatient, not reimbursed in outpatient or $ Inpatient, not reimbursed in outpatient or Thoracoscopy, surgical; with partial pulmonary decortication $1, Inpatient, not reimbursed in outpatient or Thoracoscopy, surgical; with total pulmonary decortication, including intrapleural pneumonolysis Thoracoscopy, surgical; with removal of intrapleural foreign body or fibrin deposit $1, Inpatient, not reimbursed in outpatient or $1, Inpatient, not reimbursed in outpatient or Thoracoscopy, surgical; with control of traumatic hemorrhage $1, Inpatient, not reimbursed in outpatient or Thoracoscopy, surgical; with resection-plication of bullae, includes any pleural procedure when performed $ Inpatient, not reimbursed in outpatient or Thoracoscopy, surgical; with parietal pleurectomy $ Inpatient, not reimbursed in outpatient or Thoracoscopy, surgical; with removal of clot or foreign body from pericardial sac Thoracoscopy, surgical; with creation of pericardial window or partial resection of pericardial sac for drainage Thoracoscopy, surgical; with excision of pericardial cyst, tumor, or mass Thoracoscopy, surgical; with excision of mediastinal cyst, tumor, or mass $ Inpatient, not reimbursed in outpatient or $ Inpatient, not reimbursed in outpatient or $ Inpatient, not reimbursed in outpatient or $ Inpatient, not reimbursed in outpatient or Thoracoscopy, surgical; with lobectomy (single lobe) $1, Inpatient, not reimbursed in outpatient or Thoracoscopy, surgical; with thoracic sympathectomy $ Inpatient, not reimbursed in outpatient or Thoracoscopy, surgical; with esophagomyotomy (Heller type) $1, Inpatient, not reimbursed in outpatient or Thoracoscopy, surgical; with therapeutic wedge resection (eg, mass, nodule), initial unilateral Thoracoscopy, surgical; with therapeutic wedge resection (eg, mass or nodule), each additional resection, ipsilateral (List separately in addition to code for primary procedure) Thoracoscopy, surgical; with diagnostic wedge resection followed by anatomic lung resection (List separately in addition to code for primary procedure) $ Inpatient, not reimbursed in outpatient or $ Inpatient, not reimbursed in outpatient or $ Inpatient, not reimbursed in outpatient or

10 CPT * THORACIC HERNIA ** Repair lung hernia through chest wall $ Inpatient, not reimbursed in outpatient or THORACIC PLEURAL Thoracostomy; with open flap drainage for empyema $ Inpatient, not reimbursed in outpatient or Thoracotomy; with open intrapleural pneumonolysis $ Inpatient, not reimbursed in outpatient or Pneumonostomy, with open drainage of abscess or cyst $1, Inpatient, not reimbursed in outpatient or Pleural scarification for repeat pneumothorax $ Inpatient, not reimbursed in outpatient or Decortication, pulmonary (separate procedure); total $1, Inpatient, not reimbursed in outpatient or Decortication, pulmonary (separate procedure); partial $1, Inpatient, not reimbursed in outpatient or Pleurectomy, parietal (separate procedure) $ Inpatient, not reimbursed in outpatient or Decortication and parietal pleurectomy $1, Inpatient, not reimbursed in outpatient or Thoracotomy; with therapeutic wedge resection (eg, mass, nodule), initial Thoracotomy; with therapeutic wedge resection (eg, mass or nodule), each additional resection, ipsilateral (List separately in addition to code for primary procedure) Thoracotomy; with diagnostic wedge resection followed by anatomic lung resection (List separately in addition to code for primary procedure) $ Inpatient, not reimbursed in outpatient or $ Inpatient, not reimbursed in outpatient or $ Inpatient, not reimbursed in outpatient or Extrapleural enucleation of empyema (empyemectomy) $1, Inpatient, not reimbursed in outpatient or Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst); visceral (eg, kidney, liver, spleen, lung/mediastinum), percutaneous $ / $ Level IV Needle Biopsy/ Aspiration Except Bone Marrow $1, NOTES: + S-s are not valid for Medicare payment Modifier -26 Professional Component Multiple Procedure Discounting Multiple surgical procedures furnished during the same operative session are discounted. 50% is paid for any other surgical procedure(s) performed at the same time. The above National Average and ASC (Freestanding) s represent the reimbursement amounts paid directly to the facility for the technical portion of the procedure. The Physician (surgeon) would separately receive the professional fee (MPFS Allowable) for the procedure performed. ++ CY 2014 CPT Manual parenthetical instruction: CPT (Pneumonostomy; with percutaneous drainage of abscess or cyst) has been deleted CY For percutaneous image-guided draining of abscess or cyst of lungs or mediastinum by catheter placement, use CPT (Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst); visceral (eg, kidney, liver, spleen, lung/mediastinum), percutaneous); new code added for CY TABLE REFERENCES: * PFS Relative Value File, RVU14A ( ), effective January 1, 2014 ** January 2014 HOPPS Addenda A and B ( ), effective January 1, 2014 *** January 2014 ASC Addendum AA, BB, DD1, DD2, and EE (1-2-14), effective January 1, 2014 ICD-9-CM Volume 3 Hospital Procedure s Procedure * Description ADRENALECTOMY 7.22 Unilateral adrenalectomy 7.29 Other partial adrenalectomy 7.3 Bilateral adrenalectomy APPENDECTOMY Laparoscopic appendectomy Other appendectomy Laparoscopic incidental appendectomy Other incidental appendectomy BARIATRIC Laparoscopic vertical (sleeve) gastrectomy Open and other partial gastrectomy High gastric bypass

11 Procedure * Description Laparoscopic gastroenterostomy [Bypass: gastroduodenostomy, gastroenterostomy, gastrogastrostomy. Laproscopic gastrojujenostomy without gastrectomy NEC] Other gastroenterostomy without gastrectomy [Bypass: gastroduodenostomy, gastroenterostomy, gastrogastrostomy. Gastrojujenostomy without gastrectomy NOS] 44.5 Revision of gastric anastomosis Laparoscopic gastroplasty [Banding. Silastic vertical banding. Vertical banded gastroplasty (VBG)]** Other repair of stomach Laparoscopic gastric restrictive procedure Laparoscopic revision of gastric restrictive procedure Laparoscopic removal of gastric restrictive device(s) (Laparoscopic) adjustment of size of adjustable gastric restrictive device Other operations on stomach Isolation of segment of small intestine Small-to-small intestinal anastomosis 88.1x Other x-ray of abdomen CHOLECYSTECTOMY Other partial cholecystectomy Cholecystectomy Laparoscopic cholecystectomy Laparoscopic partial cholecystectomy COLECTOMY Multiple segmental resection of small intestine Other partial resection of small intestine Total removal of small intestine Open and other multiple segmental resection of large intestine Open and other cecectomy Open and other right hemicolectomy Open and other resection of transverse colon Open and other left hemicolectomy Open and other sigmoidectomy Other and unspecified partial excision of large intestine Open total intra-abdominal colectomy Other and unspecified total intra-abdominal colectomy Transsacral rectosigmoidectomy Other resection of rectum CYSTECTOMY 57.6 Partial cystectomy Radical cystectomy Other total cystectomy ESOPHAGECTOMY Esophagectomy, not otherwise specified Partial esophagectomy Total esophagectomy GASTRECTOMY 43.5 Partial gastrectomy with anastomosis to esophagus 43.6 Partial gastrectomy with anastomosis to duodenum 43.7 Partial gastrectomy with anastomosis to jejunum Partial gastrectomy with jejunal transposition Open and other partial gastrectomy Total gastrectomy with intestinal interposition

12 Procedure * Other total gastrectomy HEMORRHOID Cauterization of hemorrhoids Ligation of hemorrhoids Excision of hemorrhoids Other procedures on hemorrhoids LAPAROSCOPIC COLECTOMY Laparoscopic multiple segmental resection of large intestine Laparoscopic cecectomy Laparoscopic right hemicolectomy Laparoscopic resection of transverse colon Laparoscopic left hemicolectomy Laparoscopic sigmoidectomy Other laparoscopic partial excision of large intestine Laparoscopic total intra-abdominal colectomy OPEN AND LAPAROSCOPIC NEPHRECTOMY 55.4 Partial nephrectomy Nephroureterectomy Nephrectomy of remaining kidney Bilateral nephrectomy PANCREATECTOMY Proximal pancreatectomy Distal pancreatectomy Radical subtotal pancreatectomy 52.6 Total pancreatectomy 52.7 Radical pancreaticoduodenectomy PROSTATECTOMY 60.3 Suprapubic prostatectomy 60.4 Retropubic prostatectomy 60.5 Radical prostatectomy Local excision of lesion of prostate Perineal prostatectomy RECTAL Abdominoperineal resection of the rectum, not otherwise specified Laparoscopic abdominoperineal resection of the rectum Open abdominoperineal resection of the rectum Other abdominoperineal resection of the rectum Transsacral rectosigmoidectomy Anterior resection of rectum with synchronous colostomy Other anterior resection of rectum Posterior resection of rectum Other resection of rectum Other operations on rectum and perirectal tissue SPLENECTOMY Excision of lesion or tissue of spleen Partial splenectomy 41.5 Total splenectomy Excision of accessory spleen Transplantation of spleen Repair and plastic operations on spleen Description

13 Procedure * Description Other operations on spleen THORACIC Thoracoscopic excision of lesion or tissue of lung Plication of emphysematous bleb Lung volume reduction surgery Other local excision or destruction of lesion or tissue of lung Thoracoscopic segmental resection of lung Other and unspecified segmental resection of lung Thoracoscopic lobectomy of lung Other lobectomy of lung Thoracoscopic pneumonectomy Other and unspecified pneumonectomy 32.6 Radical dissection of thoracic structures 32.9 Other excision of lung Thoracoscopic lung biopsy Closed [endoscopic] biopsy of bronchus Open biopsy of bronchus Closed [percutaneous] [needle] biopsy of lung Closed endoscopic biopsy of lung Open biopsy of lung Other diagnostic procedures on lung or bronchus Thoracoscopic drainage of pleural cavity Thoracoscopic pleural biopsy Transpleural thoracoscopy Mediastinoscopy Biopsy of chest wall Other pleural biopsy Closed [percutaneous] [needle] biopsy of mediastinum Open mediastinal biopsy Biopsy of diaphragm Other diagnostic procedures on chest wall, pleura, and diaphragm Other diagnostic procedures on mediastinum 34.3 Excision or destruction of lesion or tissue of mediastinum 34.4 Excision or destruction of lesion of chest wall Decortication of lung Thoracoscopic decortication of lung Other excision of pleura NOTES: ** also any synchronous laparoscopic gastroenterostomy (44.38). The ICD-9-CM Hospital Procedure s listed above may be used in the MS-DRG s (See Inpatient DRG Payment s Table) The appropriate MS-DRG classification is also dependent on the diagnosis code, demographics, sex and possible co-conditions. TABLE REFERENCES: * 2014 Hospital ICD-9-CM Volume 3, 9th Revision, Clinical Modification, Sixth Edition

14 Inpatient DRG Payment s MS-DRG* ADRENALECTOMY MS-DRG Title Arithmetic Mean Length of Stay (Days) National Average Payment** 614 Adrenal and Pituitary w CC/MCC 5.9 $14, Adrenal and Pituitary w/o CC/MCC 2.7 $8, APPENDECTOMY 338 Appendectomy w Complicated Principal Diag w MCC 9.5 $18, Appendectomy w Complicated Principal Diag w CC 6.0 $9, Appendectomy w Complicated Principal Diag w/o CC/MCC 3.5 $6, Appendectomy w/o Complicated Principal Diag w MCC 6.3 $12, Appendectomy w/o Complicated Principal Diag w CC 3.5 $7, Appendectomy w/o Complicated Principal Diag w/o CC/MCC 1.9 $5, BARIATRIC 619 O.R. procedures for obesity w MCC 7.7 $20, O.R. procedures for obesity w CC 3.2 $11, O.R. procedures for obesity w/o CC/MCC 2.0 $9, Non-extensive O.R. procedure unrelated to principal diagnosis w MCC 11.2 $19, Non-extensive O.R. procedure unrelated to principal diagnosis w CC 6.4 $10, Non-extensive O.R. procedure unrelated to principal diagnosis w/o CC/MCC 3.0 $6, CHOLECYSTECTOMY 411 Cholecystectomy w C.D.E. w MCC 11.3 $20, Cholecystectomy w C.D.E. w CC 7.6 $13, Cholecystectomy w C.D.E. w/o CC/MCC 5.0 $9, Cholecystectomy Except by Laparoscope w/o C.D.E. w MCC 10.6 $20, Cholecystectomy Except by Laparoscope w/o C.D.E. w CC 6.7 $11, Cholecystectomy Except by Laparoscope w/o C.D.E. w/o CC/MCC 4.1 $7, Laparoscopic Cholecystectomy w/o C.D.E. w MCC 7.5 $14, Laparoscopic Cholecystectomy w/o C.D.E. w CC 5.0 $9, Laparoscopic Cholecystectomy w/o C.D.E. w/o CC/MCC 3.1 $7, COLECTOMY 329 Major Small and Large Bowel w MCC 14.6 $29, Major Small and Large Bowel w CC 8.5 $14, Major Small and Large Bowel w/o CC/MCC 4.9 $9, CYSTECTOMY 653 Major Bladder w MCC 15.4 $34, Major Bladder w CC 8.9 $17, Major Bladder w/o CC/MCC 5.5 $12, Major Male Pelvic w CC/MCC 4.1 $10, Major Male Pelvic w/o CC/MCC 1.6 $7, Other Female Reproductive System O.R. w CC/MCC 8.4 $15, Other Female Reproductive System O.R. w/o CC/MCC 2.8 $6, ESOPHAGECTOMY 133 Other Ear, Nose, Mouth and Throat O.R. w CC/MCC 5.3 $10, Other Ear, Nose, Mouth and Throat O.R. w/o CC/MCC 2.4 $5, Stomach, Esophageal and Duodenal Proc w MCC 14.9 $32, Stomach, Esophageal and Duodenal Proc w CC 8.0 $15, Stomach, Esophageal and Duodenal Proc w/o CC/MCC 3.4 $8, GASTRECTOMY 326 Stomach, Esophageal and Duodenal Proc w MCC 14.9 $32, Stomach, Esophageal and Duodenal Proc w CC 8.0 $15, Stomach, Esophageal and Duodenal Proc w/o CC/MCC 3.4 $8,563.09

15 MS-DRG* HEMORRHOID MS-DRG Title Arithmetic Mean Length of Stay (Days) National Average Payment** 347 Anal and Stomal w MCC 8.5 $14, Anal and Stomal w CC 5.1 $7, Anal and Stomal w/o CC/MCC 3.0 $5, LAPAROSCOPIC COLECTOMY 329 Major Small and Large Bowel w MCC 14.6 $29, Major Small and Large Bowel w CC 8.5 $14, Major Small and Large Bowel w/o CC/MCC 4.9 $9, OPEN AND LAPAROSCOPIC NEPHRECTOMY 656 Kidney and Ureter for Neoplasm w MCC 9.3 $20, Kidney and Ureter for Neoplasm w CC 5.4 $11, Kidney and Ureter for Neoplasm w/o CC/MCC 3.1 $8, Kidney and Ureter for Non-Neoplasm w MCC 10.3 $19, Kidney and Ureter for Non-Neoplasm w CC 5.6 $10, Kidney and Ureter for Non-Neoplasm w/o CC/MCC 2.8 $7, PANCREATECTOMY 405 Pancreas, Liver and Shunt w MCC 14.5 $31, Pancreas, Liver and Shunt w CC 7.6 $16, Pancreas, Liver and Shunt w/o CC/MCC 5.1 $11, Other Endocrine, Nutrit and Metab O.R. Proc w MCC 9.6 $19, Other Endocrine, Nutrit and Metab O.R. Proc w CC 7.2 $12, Other Endocrine, Nutrit and Metab O.R. Proc w/o CC/MCC 3.8 $7, PROSTATECTOMY 665 Prostatectomy w MCC 11.7 $18, Prostatectomy w CC 6.2 $9, Prostatectomy w/o CC/MCC 2.6 $5, Major Male Pelvic w CC/MCC 4.1 $10, Major Male Pelvic w/o CC/MCC 1.6 $7, RECTAL 332 Rectal Resection w MCC 13.2 $27, Rectal Resection w CC 7.4 $14, Rectal Resection w/o CC/MCC 4.3 $9, SPLENECTOMY 799 Splenectomy w MCC 12.9 $29, Splenectomy w CC 6.8 $14, Splenectomy w/o CC/MCC 3.5 $9, THORACIC 163 Major Chest w MCC 13.4 $29, Major Chest w CC 6.7 $15, Major Chest w/o CC/MCC 4.0 $10, Other Resp System O.R. w MCC 11.2 $21, Other Resp System O.R. w CC 6.6 $11, Other Resp System O.R. w/o CC/MCC 3.9 $7, Lymphoma and Leukemia w Major O.R. Procedure w MCC 17.1 $34, Lymphoma and Leukemia w Major O.R. Procedure w CC 6.9 $13, Lymphoma and Leukemia w Major O.R. Procedure w/o CC/MCC 2.8 $7, Extensive O.R. Procedure Unrelated To Principal Diagnosis w MCC 13.1 $28, Extensive O.R. Procedure Unrelated To Principal Diagnosis w CC 7.6 $16, Extensive O.R. Procedure Unrelated To Principal Diagnosis w/o CC/MCC 3.8 $10,127.24

16 NOTE: * One DRG per patient is assigned to each inpatient stay. TABLE REFERENCES: ** FY 2014 Final Rule, Federal Register, Vol. 78, No. 160, Monday, August 19, 2013, Table 1A-1E. National Average Payment is based upon the National Average Operating Standardized Amount ($5,370.28) plus the Capital Standard Federal Payment ($429.31). ICD-9-CM Diagnosis s Dx ** Description ADRENALECTOMY Benign neoplasm of adrenal gland 255.x* Disorders of the adrenal glands APPENDECTOMY Acute appendicitis with generalized peritonitis Acute appendicitis with peritoneal abscess Acute appendicitis without mention of peritonitis 541 Appendicitis, unqualified Abdominal pain, unspecified site BARIATRIC Overweight and obesity Morbid obesity Overweight Infection due to gastric band procedure Other complications of gastric band procedure Infection due to other bariatric procedure Other complication of other bariatric procedure Other digestive system complication V12.29 Personal history of other endocrine, metabolic, and immunity disorders V53.99 Fitting and adjustment, other device V85 Body Mass Index (BMI), Kilograms per meters squared V85.0 Body Mass Index less than 19, adult V85.1 Body Mass Index between 19-24, adult V85.2x* Body Mass Index between 25-29, adult V85.3x* Body Mass Index between 30-39, adult V85.4x* Body Mass Index 40 and over, adult V85.5x* Body Mass Index, pediatric Overweight and obesity CHOLECYSTECTOMY 574.xx* 575.xx* Cholelithiasis Other disorders of the gallbladder COLECTOMY 153.x* Malignant neoplasm of the colon Malignant carcinoid tumor of the ascending colon Malignant carcinoid tumor of the transverse colon Malignant carcinoid tumor of the descending colon Malignant carcinoid tumor of the sigmoid colon Benign carcinoid tumor of the ascending colon Benign carcinoid tumor of the transverse colon Benign carcinoid tumor of the descending colon Benign carcinoid tumor of the sigmoid colon Benign neoplasm of colon Carcinoma in situ of colon

17 Dx ** Description CYSTECTOMY 188.x* Malignant neoplasm of the bladder Unspecified disorder of the bladder ESOPHAGECTOMY 150.x* Malignant neoplasm of esophagus Benign neoplasm of esophagus Carcinoma in situ of esophagus Barrett s esophagus GASTRECTOMY 151.x* Malignant neoplasm of the stomach 531.xx* Gastric ulcer 532.xx* Duodenal ulcer HEMORRHOID 455.x* Hemorrhoids 569.4x* Other specified disorders of rectum and anus LAPAROSCOPIC COLECTOMY 153.x* Malignant neoplasm of the colon Benign neoplasm of colon Neoplasm of uncertain behavior of stomach, intestines, and rectum Intussusception Paralytic ileus Impaction of intestine, unspecified Unspecified intestinal obstruction Ulceration of intestine Perforation of intestine OPEN AND LAPAROSCOPIC NEPHRECTOMY 189.x* Malignant neoplasm of kidney and other and unspecified urinary organs Malignant carcinoid tumor of the kidney Neoplasm of uncertain behavior of kidney and ureter 593.x* Other disorders of kidney and ureter PANCREATECTOMY 157.x* Malignant neoplasm of pancreas 577.x* Diseases of the pancreas PROSTATECTOMY 185 Malignant neoplasm of prostrate Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS) Nodular prostate without urinary obstruction Nodular prostate with urinary obstruction Benign localized hyperplasia of prostate without urinary obstruction and other lower urinary tract symptoms (LUTS) Benign localized hyperplasia of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS) Cyst of prostate Hyperplasia of prostate, unspecified, without urinary obstruction and other lower urinary symptoms (LUTS) Hyperplasia of prostate, unspecified, with urinary obstruction and other lower urinary symptoms (LUTS) RECTAL Malignant neoplasm of rectosigmoid junction Malignant neoplasm of rectum Benign neoplasm of rectum and anal canal Neoplasm of uncertain behavior of stomach, intestines, and rectum 455.x* Hemorrhoids

18 Dx ** Rectal prolapse Ulcer of anus and rectum Anal or rectal pain Description SPLENECTOMY Malignant neoplasm of spleen, not elsewhere classified Secondary malignant neoplasm of other digestive organs and spleen Large cell lymphoma, spleen Hypersplenism Disease of spleen, unspecified Other diseases of spleen 865.xx* Injury to spleen THORACIC 162.x* Malignant neoplasm of trachea, bronchus, and lung Secondary malignant neoplasm of lung Neoplasm of uncertain behavior of trachea, bronchus, and lung Neoplasm of unspecified nature of respiratory system 492.x* Emphysema 510.x* Empyema 511.x* Pleurisy 512.xx* Pneumothorax and air leak 518.xx* Other diseases of lung 786.xx* Symptoms involving respiratory system and other chest symptoms Solitary pulmonary nodule Other nonspecific abnormal finding of lung field NOTES: * Check 4th or 5th digit. TABLE REFERENCES: ** 2014 Hospital ICD-9-CM Volume 1 and 2, 9th Revision, Clinical Modification, Sixth Edition Supply s Dx ** Description BARIATRIC-BAND ADJUSTMENTS A4208 A4215 J7030 J7040 J7050 Syringe with needle, sterile 3 cc, each Needle, sterile, any size, each Infusion, normal saline solution, 1000 cc Infusion, normal saline solution, sterile (500 ml=1 unit) Infusion, normal saline solution, 250 cc REFERENCE: CMS 2014 Alpha-Numeric File Updated 11/25/2013

19 Disclaimer: The information contained in this guide is provided to help you understand the reimbursement process. It is not intended to increase or maximize reimbursement by any payer. We strongly recommend that providers consult their payer organization with regard to local reimbursement policies. The information contained in this guide is provided for information purposes only and represents no statement, promise or guarantee by Covidien concerning levels of reimbursement, payment or charge. Similarly, all CPT and ICD-9-CM codes are supplied for information purposes only and represent no statement, promise or guarantee by Covidien that these codes will be appropriate or that reimbursement will be made. ICD-9-CM is based on the official version of the World Health Organization s Ninth Revision, International of Diseases. CPT codes and descriptions only are copyright 2013 American Medical Association. All rights reserved. CPT does not include fee schedules, relative values or related listings. The source for this information is the Centers for Medicare and Medicaid Services (CMS). Reimbursement rates reflected in this guide are Medicare National Average rates as published by CMS at the time of printing, and do not reflect provider payment adjustment factors such geographic adjustment, participation as a Disproportionate Share or Teaching Hospital, participation in the CMS Shared Service (ACO) program, or Value Base Purchasing adjustments. The content provided by CMS is updated frequently. It is the responsibility of the health services provider to confirm the appropriate coding required by their local Medicare Administrative Contractors (MACs), carriers, fiscal intermediaries and commercial payers. All Current Procedural Terminology (CPT) five-digit numeric codes, descriptions, numeric modifiers, instructions, guidelines and other material are copyright 2013 American Medical Association. All rights reserved. associations and values have been reviewed and validated by NMD Healthcare, Inc. COVIDIEN, COVIDIEN with logo, Covidien logo and positive results for life are U.S. and internationally registered trademarks of Covidien AG. * Trademark of its respective owner Covidien US Longbow Drive Boulder, CO [t] [us]