Attachment A. Code Beginning Review

Transcription

1 Attachment A ICD-10-CM Mental Disorders Diagnosis Codes and s Subject to Certification of Admission/Concurrent/Continued Stay Review Based on the Admitting Diagnosis Code This list contains principal diagnosis codes for psychiatric services Category of Service 21. If a code from this list is used as the principal diagnosis code, general care hospitals that are not enrolled for COS 21 may only bill for a maximum of three days of emergency psychiatric care using COS 20. F /01/2015 Personality change due to known physiological condition F /01/2015 Paranoid schizophrenia F /01/2015 Disorganized schizophrenia F /01/2015 Catatonic schizophrenia F /01/2015 Residual schizophrenia F /01/2015 Schizophreniform disorder F /01/2015 Other schizophrenia F /01/2015 Schizophrenia, unspecified F21 10/01/2015 Schizotypal disorder F22 10/01/2015 Delusional disorders F23 10/01/2015 Brief psychotic disorder F24 10/01/2015 Shared psychotic disorder F /01/2015 Schizoaffective disorder, unspecified F28 10/01/2015 Other psychotic disorder not due to a substance or known physiological condition F29 10/01/2015 Unspecified psychosis not due to a substance or known physiological condition F /01/2015 Manic episode without psychotic symptoms, unspecified F /01/2015 Manic episode without psychotic symptoms, mild F /01/2015 Manic episode without psychotic symptoms, moderate F /01/2015 Manic episode, severe, without psychotic symptoms F /01/2015 Manic episode, severe with psychotic symptoms F /01/2015 Manic episode in partial remission F /01/2015 Manic episode in full remission F /01/2015 Other manic episodes F /01/2015 Manic episode, unspecified F /01/2015 Bipolar disorder, current episode manic without psychotic features, unspecified F /01/2015 Bipolar disorder, current episode manic without psychotic features, mild F /01/2015 Bipolar disorder, current episode manic without psychotic features, moderate 1

2 Attachment A F /01/2015 Bipolar disorder, current episode manic without psychotic features, severe F /01/2015 Bipolar disorder, current episode manic severe with psychotic features F /01/2015 Bipolar disorder, current episode depressed, mild or moderate severity, unspecified F /01/2015 Bipolar disorder, current episode depressed, mild F /01/2015 Bipolar disorder, current episode depressed, moderate F /01/2015 Bipolar disorder, current episode depressed, severe, without psychotic features F /01/2015 Bipolar disorder, current episode depressed, severe, with psychotic features F /01/2015 Bipolar disorder, current episode mixed, unspecified F /01/2015 Bipolar disorder, current episode mixed, mild F /01/2015 Bipolar disorder, current episode mixed, moderate F /01/2015 Bipolar disorder, current episode mixed, severe, without psychotic features F /01/2015 Bipolar disorder, current episode mixed, severe, with psychotic features F /01/2015 Bipolar disorder, in partial remission, most recent episode manic F /01/2015 Bipolar disorder, in full remission, most recent episode manic F /01/2015 Bipolar disorder, in partial remission, most recent episode depressed F /01/2015 Bipolar disorder, in full remission, most recent episode depressed F /01/2015 Bipolar disorder, in partial remission, most recent episode mixed F /01/2015 Bipolar disorder, in full remission, most recent episode mixed F /01/2015 Other bipolar disorder F /01/2015 Bipolar disorder, unspecified F /01/2015 Major depressive disorder, single episode, mild F /01/2015 Major depressive disorder, single episode, moderate F /01/2015 Major depressive disorder, single episode, severe without psychotic features F /01/2015 Major depressive disorder, single episode, severe with psychotic features F /01/2015 Major depressive disorder, single episode, in partial remission F /01/2015 Major depressive disorder, single episode, in full remission F /01/2015 Other depressive episodes F /01/2015 Major depressive disorder, single episode, unspecified 2

3 Attachment A F /01/2015 Major depressive disorder, recurrent, mild F /01/2015 Major depressive disorder, recurrent, moderate F /01/2015 Major depressive disorder, recurrent, severe without psychotic features F /01/2015 Major depressive disorder, recurrent, severe with psychotic symptoms F /01/2015 Major depressive disorder, recurrent, in remission, unspecified F /01/2015 Major depressive disorder, recurrent, in partial remission F /01/2015 Major depressive disorder, recurrent, in full remission F /01/2015 Major depressive disorder, recurrent, unspecified F /01/2015 Cyclothymic disorder F /01/2015 Dysthymic disorder F /01/2015 Other persistent mood [affective] disorders F39 10/01/2015 Unspecified mood [affective] disorder F /01/2015 Agoraphobia, unspecified F /01/2015 Agoraphobia w/ panic disorder F /01/2015 Agoraphobia w/o panic disorder F /01/2015 Social phobia, unspecified F /01/2015 Social phobia, generalized F /01/2015 Arachnophobia F /01/2015 Other animal type phobia F /01/2015 Fear of thunderstorms F /01/2015 Other natural environment type phobia F /01/2015 Fear of blood F /01/2015 Fear of injections and transfusions F /01/2015 Fear of other medical care F /01/2015 Fear of injury F /01/2015 Claustrophobia F /01/2015 Acrophobia F /01/2015 Fear of bridges F /01/2015 Fear of flying F /01/2015 Other situational type phobia F /01/2015 Androphobia F /01/2015 Gynephobia F /01/2015 Other specified phobia F /01/2015 Other phobic anxiety disorders F /01/2015 Phobic anxiety disorder, unspecified F /01/2015 Panic disorder [episodic paroxysmal anxiety] w/o agoraphobia F /01/2015 Generalized anxiety disorder F /01/2015 Other mixed anxiety disorders F /01/2015 Other spcified anxiety disorders 3

4 Attachment A F /01/2015 Anxiety disorder, unspecified F42 10/01/2015 Obsessive-compulsive disorder F /01/2015 Acute stress reaction F /01/2015 Post-traumatic stress disorder, unspecified F /01/2015 Post-traumatic stress disorder, acute F /01/2015 Post-traumatic stress disorder, chronic F /01/2015 Adjustment disorder, unspecified F /01/2015 Adjustment disorder w/ depressed mood F /01/2015 Adjustment disorder w/ anxiety F /01/2015 Adjustment disorder with mixed anxiety and depressed mood F /01/2015 Adjustment disorder w/ disturbance of conduct F /01/2015 Adjustment disorder w/ mixed disturbance of emotions and conduct F /01/2015 Adjustment disorder w/ other symptoms F /01/2015 Other reactions to severe stress F /01/2015 Reaction to severe stress, unspecified F /01/2015 Dissociative amnesia F /01/2015 Dissociative fugue F /01/2015 Dissociative stupor F /01/2015 Conversion disorder w/ motor symptom or deficit F /01/2015 Conversion disorder w/ seizures or convulsions F /01/2015 Conversion disorder w/ sensory symptom or deficit F /01/2015 Conversion disorder w/ mixed symptom presentation F /01/2015 Dissociative identity disorder F /01/2015 Other dissociative and conversion disorders F /01/2015 Dissociative and conversion disorder, unspecified F /01/2015 Somatization disorder F /01/2015 Undifferentiated somatoform disorder F /01/2015 Hypochondriacal disorder, unspecified F /01/2015 Hypochondriasis F /01/2015 Body dysmorphic disorder F /01/2015 Other hypochondriacal disorders F /01/2015 Pain disorder exlusively relatd to psychological factors F /01/2015 Other somatoform disorders F /01/2015 Somatoform disorder, unspecified F /01/2015 Depersonalization-derealization syndrome F /01/2015 Other specified nonpsychotic mental disorders F /01/2015 Nonpsychotic mental disorder, unspecified F /01/2015 Eating disorder, unspecified F /01/2015 Primary insomnia F /01/2015 Adjustment insomnia 4

5 Attachment A F /01/2015 Paradoxical insomnia F /01/2015 Other insomnia not due to a substance or known physiological condition F /01/2015 Primary hypersomnia F /01/2015 Insufficient sleep syndrome F /01/2015 Other hypersomnia not due to a substance or known physiological condition F /01/2015 Sleepwalking F /01/2015 Sleep terrors F /01/2015 Nightmare disorder F /01/2015 Other sleep disorders not due to a substance or known physiological condition F /01/2015 Sleep disorder not due to a substance or known physiological condition, unspecified F /01/2015 Hypoactive sexual desire disorder F /01/2015 Sexual aversion disorder F /01/2015 Male erectile disorder F /01/2015 Female sexual arousal disorder F /01/2015 Female orgasmic disorder F /01/2015 Male orgasmic disorder F /01/2015 Premature ejaculation F /01/2015 Dyspareunia not due to a substance or known physiological condition F /01/2015 Other sexual dysfunction not due to a substance or known physiological condition F /01/2015 Unspecified sexual dysfunction not due to a substance or know physiological condition F /01/2015 Paranoid personality disorder F /01/2015 Schizoid personality disorder F /01/2015 Antisocial personality disorder F /01/2015 Borderline personality disorder F /01/2015 Histrionic personality disorder F /01/2015 Obsessive-compulsive personality disorder F /01/2015 Avoidant personality disorder F /01/2015 Dependent personality disorder F /01/2015 Narcissistic personality disorder F /01/2015 Other specific personality disorders F /01/2015 Personality disorder, unspecified F /01/2015 Pathological gambling F /01/2015 Pyromania F /01/2015 Kleptomania 5

6 Attachment A F /01/2015 Trichotillomania F /01/2015 Intermittent explosive disorder F /01/2015 Other impulse disorders F /01/2015 Impulse disorder, unspecified F /01/2015 Gender identity disorder in adolescence and adulthood F /01/2015 Gender identity disorder in childhood F /01/2015 Other gender identity disorders F /01/2015 Fetishism F /01/2015 Transvestic fetishism F /01/2015 Exhibitionism F /01/2015 Voyeurism F /01/2015 Pedophilia F /01/2015 Sadomasochism, unspecified F /01/2015 Sexual masochism F /01/2015 Sexual sadism F /01/2015 Frotteurism F /01/2015 Other paraphilias F /01/2015 Parahilia, unspecified F66 10/01/2015 Other sexual disorders F /01/2015 Factitious disorder, unspecified F /01/2015 Factitious disorder w/ predominantly psychological signs and symptoms F /01/2015 Fatitious disorder w/ predominantly physical signs and symptoms F /01/2015 Other specified disorders of adult personality and behavior F69 10/01/2015 Unspecified disorder of adult personality and behavior F70 10/01/2015 Mild intellectual disabilities F71 10/01/2015 Moderate intellectual disabilities F72 10/01/2015 Severe intellectual disabilities F73 10/01/2015 Profound intellectual disabilities F78 10/01/2015 Other intellectual disabilities F79 10/01/2015 Unspecified intellectual disabilities F /01/2015 Phonological disorder F /01/2015 Expressive language disorder F /01/2015 Mixed receptive-expressive language disorder F /01/2015 Speech and language developmental delay due to hearing loss F /01/2015 Other developmental disorders of speech and language F /01/2015 Developmental disorder of speech and language, unspecified F /01/2015 Specific reading disorder F /01/2015 Mathematics disorder F /01/2015 Other developmental disorders of scholastic skills 6

7 Attachment A F /01/2015 Developmental disorder of scholastic skills, unspecified F82 10/01/2015 Specific developmental disorder of motor function F /01/2015 Autistic disorder F /01/2015 Other childhood disintegrative disorder F /01/2015 Asperger's Syndrome F /01/2015 Other pervasive developmental disorders F /01/2015 Pervasive developmental disorder, unspecified F88 10/01/2015 Other disorders of psychological development F89 10/01/2015 Unspecified disorder of pyschological development F /01/2015 Attention-deficit hyperactivity disorder, predominantly inattentive type F /01/2015 Attention-deficit hyperactivity disorder, predominantly hyperactive type F /01/2015 Attention-deficit hyperactivity disorder, combined type F /01/2015 Attention-deficit hyperactivity disorder, other type F /01/2015 Attention-deficit hyperactivity disorder, unspecified type F /01/2015 Conduct disorder confined to family context F /01/2015 Conduct disorder, childhood-onset type F /01/2015 Conduct disorder, adolescent-onset type F /01/2015 Oppositional defiant disorder F /01/2015 Other conduct disorders F /01/2015 Conduct disorder, unspecified F /01/2015 Separation anxiety disorder of childhood F /01/2015 Other childhood emotional disorders F /01/2015 Childhood emotional disorder, unspecified F /01/2015 Selective mutism F /01/2015 Reactive attachment disorder of childhood F /01/2015 Disinhibited attachment disorder of childhood F /01/2015 Other childhood disorders of social functioning F /01/2015 Childhood disorder of social functioning, unspecified F /01/2015 Transient tic disorder F /01/2015 Chronic motor or vocal tic disorder F /01/2015 Tourette's disorder F /01/2015 Tic disorder, unspecified F /01/2015 Enuresis not due to a substance or known physiological condition F /01/2015 Encopresis not due to a substance or known physiological condition F /01/2015 Stereotyped movement disorder F /01/2015 Adult onset fluency disorder F /01/2015 Other specified behavioral and emotional disorders with onset 7

8 Attachment A usually occurring in childhood and adolescence F /01/2015 Unspecified behavioral and emotional disorders w/ onset usually occurring in childhood and adolescence F99 10/01/2015 Mental disorder, not otherwise specified H /01/2015 Central auditory processing disorder R /01/2015 Restlessness and agitation R /01/2015 Unhappiness R /01/2015 Hostility R /01/2015 Violent behavior R /01/2015 State of emotional shock and stress, unspecified R /01/2015 Low self-esteem R /01/2015 Worries R /01/2015 Dyslexia and alexia Z /01/2015 Personal history of sex reassignment 8

9 Attachment B ICD-10-CM Mental Disorders Diagnosis Codes and s Subject to Certification of Admission/Concurrent/Continued Stay Review Based on the Admitting Diagnosis Code This list contains principal diagnosis codes for medical services Category of Service 20 or psychiatric services Category of Service 21. If a code from this list is used as the principal diagnosis code, general care hospitals that are not enrolled for COS 21 may only bill for a maximum of three days of emergency psychiatric care using COS 20. All codes are subject to 60-day detox readmission review except for those identified with an asterisk. Code Beginning Review F /01/2015 Vascular dementia w/o behavioral disturbance F /01/2015 Vascular dementia w/ behavioral disturbance F /01/2015 Unspecified dementia w/o behavioral disturbance F05 10/01/2015 Delirium due to known physiological condition *F /01/2015 Postconcussional syndrome *F /01/2015 Other personality and behavioral disorders due to known physiological condition *F /01/2015 Unspecified personality and behavioral disorder due to known physiological condition *F09 10/01/2015 Unspecified mental disorder due to known physiological condition *F /01/2015 Alcohol abuse, uncomplicated *F /01/2015 Alcohol abuse with intoxication, uncomplicated F /01/2015 Alcohol abuse with intoxication delirium *F /01/2015 Alcohol abuse with intoxication, unspecified F /01/2015 Alcohol abuse w/ alcohol-induced mood disorder F /01/2015 Alcohol abuse w/ alcohol-induced psychotic disorder w/ delusions F /01/2015 Alcohol abuse w/ alcohol-induced psychotic disorder w/ hallucinations F /01/2015 Alcohol abuse w/ unspecified alcohol-induced disorder F /01/2015 Alcohol abuse w/ alcohol-induced anxiety disorder F /01/2015 Alcohol abuse w/ alcohol-induced sexual dysfunction F /01/2015 Alcohol abuse w/ alcohol-induced sleep disorder F /01/2015 Alcohol abuse w/ other alcohol-induced disorder F /01/2015 Alcohol abuse w/ unspecified alcohol-induced disorder *F /01/2015 Alcohol dependence, uncomplicated *F /01/2015 Alcohol dependence, in remission *F /01/2015 Alcohol dependence with intoxication, uncomplicated 1

10 Attachment B Code Beginning Review F /01/2015 Alcohol dependence with intoxication delirium *F /01/2015 Alcohol dependence w/ intoxication, unspecified F /01/2015 Alcohol dependence w/ withdrawal, uncomplicated F /01/2015 Alcohol dependence w/ withdrawal delirium F /01/2015 Alcohol dependence w/ withdrawal w/ perceptual disturbance F /01/2015 Alcohol dependence w/ withdrawal, unspecified F /01/2015 Alcohol dependence w/ alcohol-induced mood disorder F /01/2015 Alcohol dependence w/ alcohol-induced psychotic disorder w/ delusions F /01/2015 Alcohol dependence w/ alcohol-induced psychotic disorder w/ hallucinations F /01/2015 Alcohol dependence w/ alcohol-induced psychotic disorder, unspecified F /01/2015 Alcohol dependence w/ alcohol-induced persisting amnestic disorder F /01/2015 Alcohol dependence w/ alcohol-induced persisting dementia F /01/2015 Alcohol dependence w/ alcohol-induced anxiety disorder F /01/2015 Alcohol dependence w/ alcohol-induced sexual dysfunction F /01/2015 Alcohol dependence w/ alcohol-induced sleep disorder F /01/2015 Alcohol dependence w/ other alcohol-induced disorder F /01/2015 Alcohol dependence w/ unspecified alcohol-induced disorder F /01/2015 Alcohol use, unspecified with intoxication, uncomplicated F /01/2015 Alcohol use, unspecified with intoxication delirium F /01/2015 Alcohol use, unspecified w/ intoxication, unspecified F /01/2015 Alcohol use, unspecified with alcohol-induced mood disorder F /01/2015 Alcohol use, unspecified w/ alcohol-induced psychotic disorder w/ delusions F /01/2015 Alcohol use, unspecified w/ alcohol-induced psychotic disorder w/ hallucinations F /01/2015 Alcohol use, unspecified w/ alcohol-induced psychotic disorder, unspecified F /01/2015 Alcohol use, unspecified w/ alcohol-induced persisting amnestic disorder F /01/2015 Alcohol use, unsp with alcohol-induced persisting dementia (Alcohol use, unspecified with alcohol-induced persisting dementia) F /01/2015 Alcohol use, unspecified w/ alcohol-induced anxiety disorder F /01/2015 Alcohol use, unspecified w/ alcohol-induced sexual dysfunction F /01/2015 Alcohol use, unspecified w/ alcohol-induced sleep disorder 2

11 Attachment B Code Beginning Review F /01/2015 Alcohol use, unspecified w/ other alcohol-induced disorder F /01/2015 Alcohol use, unspecified w/ unspecified alcohol-induced disorder *F /01/2015 Opioid abuse, uncomplicated *F /01/2015 Opioid abuse with intoxication, uncomplicated F /01/2015 Opioid abuse w/ intoxication delirium F /01/2015 Opioid abuse with intoxication with perceptual disturbance *F /01/2015 Opioid abuse with intoxication, unspecified F /01/2015 Opioid abuse w/ opioid-induced mood disorder F /01/2015 Opioid abuse w/ opioid-induced psychotic disorder w/ delusions F /01/2015 Opioid abuse w/ opioid-induced psychotic disorder w/ hallucinations F /01/2015 Opioid abuse w/ opioid-induced psychotic disorder, unspecified F /01/2015 Opioid abuse with opioid-induced sexual dysfunction F /01/2015 Opioid abuse w/ opioid-induced sleep disorder F /01/2015 Opioid abuse with other opioid-induced disorder F /01/2015 Opioid abuse with unspecified opioid-induced disorder F /01/2015 Opioid dependence, uncomplicated *F /01/2015 Opioid dependence, in remission F /01/2015 Opioid dependence with intoxication, uncomplicated F /01/2015 Opioid dependence with intoxication delirium F /01/2015 Opioid dependence with intoxication with perceptual disturbance F /01/2015 Opioid dependence with intoxication, unspecified F /01/2015 Opioid dependence with withdrawal F /01/2015 Opioid dependence with opioid-induced mood disorder F /01/2015 Opioid dependence with opioid-induced psychotic disorder with delusions F /01/2015 Opioid dependence with opioid-induced psychotic disorder with hallucinations F /01/2015 Opioid dependence with opioid-induced psychotic disorder, unspecified F /01/2015 Opioid dependence with opioid-induced sexual dysfunction F /01/2015 Opioid dependence w/ opioid-induced sleep disorder F /01/2015 Opioid dependence with other opioid-induced disorder F /01/2015 Opioid dependence with unspecified opioid-induced disorder *F /01/2015 Opioid use, unspecified, uncomplicated F /01/2015 Opioid use, unspecified w/ intoxication, uncomplicated F /01/2015 Opioid use, unspecified w/ intoxication delirium 3

12 Attachment B Code Beginning Review F /01/2015 Opioid use, unspecified with intoxication with perceptual disturbance F /01/2015 Opioid use, unspecified w/ intoxication, unspecified F /01/2015 Opioid use, unspecified w/ withdrawal F /01/2015 Opioid use, unspecified w/ opioid-induced mood disorder F /01/2015 Opioid use, unsp w opioid-induc psych disorder w delusions (Opioid use, unspecified with opioid-induced psychotic disorder with delusions) F /01/2015 Oth psychoactv sub use, unsp w psych disorder w hallucin (Other psychoactive substance use, unspecified with psychoactive substance-induced psychotic disorder with hallucinations) F /01/2015 Opioid use, unspecified with opioid-induced psychotic disorder, unspecified F /01/2015 Opioid use, unspecified with opioid-induced sexual dysfunction F /01/2015 Opioid use, unspecified w/ opioid-induced sleep disorder F /01/2015 Opioid use, unspecified with other opioid-induced disorder F /01/2015 Opioid use, unsp with unspecified opioid-induced disorder (Opioid use, unspecified with unspecified opioid-induced disorder) *F /01/2015 Cannabis abuse, uncomplicated F /01/2015 Cannabis abuse w/ intoxication, uncomplicated F /01/2015 Cannabis abuse w/ intoxication delirium F /01/2015 Cannabis abuse with intoxication with perceptual disturbance F /01/2015 Cannabis abuse w/ intoxication, unspecified F /01/2015 Cannabis abuse w/ psychotic disorder w/ delusions F /01/2015 Cannabis abuse w/ psychotic disorder w/ hallucinations F /01/2015 Cannabis abuse with psychotic disorder, unspecified F /01/2015 Cannabis abuse with cannabis-induced anxiety disorder F /01/2015 Cannabis abuse with other cannabis-induced disorder F /01/2015 Cannabis abuse with unspecified cannabis-induced disorder *F /01/2015 Cannabis dependence, uncomplicated *F /01/2015 Cannabis dependence, in remission F /01/2015 Cannabis dependence with intoxication, uncomplicated F /01/2015 Cannabis dependence with intoxication delirium F /01/2015 Cannabis dependence with intoxication with perceptual disturbance F /01/2015 Cannabis dependence with intoxication, unspecified F /01/2015 Cannabis dependence with psychotic disorder with delusions F /01/2015 Cannabis dependence with psychotic disorder with 4

13 Attachment B Code Beginning Review hallucinations F /01/2015 Cannabis dependence with psychotic disorder, unspecified F /01/2015 Cannabis dependence with cannabis-induced anxiety disorder F /01/2015 Cannabis dependence with other cannabis-induced disorder F /01/2015 Cannabis dependence with unspecified cannabis-induced disorder *F /01/2015 Cannabis use, unspecified, uncomplicated F /01/2015 Cannabis use, unspecified w/ intoxication, uncomplicated F /01/2015 Cannabis use, unspecified w/ intoxication delirium F /01/2015 Cannabis use, unspecified with intoxication with perceptual disturbance F /01/2015 Cannabis use, unspecified w/ intoxication, unspecified F /01/2015 Cannabis use, unspecified w/ psychotic disorder w/ delusions F /01/2015 Cannabis use, unspecified w/ psychotic disorder w/ hallucinations F /01/2015 Cannabis use, unspecified with psychotic disorder, unspecified F /01/2015 Cannabis use, unspecified with anxiety disorder F /01/2015 Cannabis use, unspecified with other cannabis-induced disorder F /01/2015 Cannabis use, unsp with unsp cannabis-induced disorder (Cannabis use, unspecified with unspecified cannabis-induced disorder) *F /01/2015 Sedative, hypnotic or anxiolytic abuse, uncomplicated *F /01/2015 Sedative, hypnotic or anxiolytic abuse with intoxication, uncomplicated F /01/2015 Sedative, hypnotic or anxiolytic abuse w/ intoxication delirium F /01/2015 Sedative, hypnotic or anxiolytic abuse w intoxication, unsp (Sedative, hypnotic or anxiolytic abuse with intoxication, unspecified F /01/2015 Sedative, hypnotic or anxiolytic abuse w/ sedative, hypnotic or anxiolytic-induced mood disorder F /01/2015 Sedative, hypnotic or anxiolytic abuse w/ sedative, hypnotic or anxiolytic-induced psychotic disorder w/ delusions F /01/2015 Sedative, hypnotic or anxiolytic abuse w/ sedative, hypnotic or anxiolytic-induced psychotic disorder w/ hallucinations F /01/2015 Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-induced psychotic disorder, unspecified F /01/2015 Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-induced anxiety disorder 5

14 Attachment B Code Beginning Review F /01/2015 Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-induced sexual dysfunction F /01/2015 Sedative, hypnotic or anxiolytic abuse w/ sedative, hypnotic or anxiolytic-induced sleep disorder F /01/2015 Sedative, hypnotic or anxiolytic abuse with other sedative, hypnotic or anxiolytic-induced disorder F /01/2015 Sedative, hypnotic or anxiolytic abuse w unsp disorder (Sedative, hypnotic or anxiolytic abuse with unspecified sedative, hypnotic or anxiolytic-induced disorder) *F /01/2015 Sedative, hypnotic or anxiolytic dependence, uncomplicated *F /01/2015 Sedative, hypnotic or anxiolytic dependence, in remission F /01/2015 Sedative, hypnotic or anxiolytic dependence with intoxication, uncomplicated F /01/2015 Sedative, hypnotic or anxiolytic dependence with intoxication delirium F /01/2015 Sedative, hypnotic or anxiolytic dependence with intoxication, unspecified F /01/2015 Sedative, hypnotic or anxiolytic dependence with withdrawal, uncomplicated F /01/2015 Sedative, hypnotic or anxiolytic dependence with withdrawal delirium F /01/2015 Sedative, hypnotic or anxiolytic dependence with withdrawal with perceptual disturbance F /01/2015 Sedative, hypnotic or anxiolytic dependence with withdrawal, unspecified F /01/2015 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced mood disorder F /01/2015 Sedative, hypnotic or anxiolytic dependence w/ sedative, hypnotic or anxiolytic-induced psychotic disorder w/ delusions F /01/2015 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced psychotic disorder with hallucinations F /01/2015 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced psychotic disorder, unspecified F /01/2015 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced persisting amnestic disorder F /01/2015 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced persisting dementia F /01/2015 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced anxiety disorder 6

15 Attachment B Code Beginning Review F /01/2015 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced sexual dysfunction F /01/2015 Sedative, hypnotic or anxiolytic dependence w/ sedative, hypnotic or anxiolytic-induced sleep disorder F /01/2015 Sedative, hypnotic or anxiolytic dependence with other sedative, hypnotic or anxiolytic-induced disorder F /01/2015 Sedative, hypnotic or anxiolytic dependence with unspecified sedative, hypnotic or anxiolytic-induced disorder *F /01/2015 Sedative, hypnotic or anxiolytic use, unspecified, uncomplicated F /01/2015 Sedatv/hyp/anxiolytc use, unsp w intoxication, uncomplicated (Sedative, hypnotic or anxiolytic use, unspecified with intoxication, uncomplicated) F /01/2015 Sedative, hypnotic or anxiolytic use, unspecified w/ intoxication delirium F /01/2015 Sedatv/hyp/anxiolytc use, unsp w intoxication, unsp (Sedative, hypnotic or anxiolytic use, unspecified with intoxication, unspecified) F /01/2015 Sedative, hypnotic or anxiolytic use, unspecified w/ withdrawal, uncomplicated F /01/2015 Sedative, hypnotic or anxiolytic use, unspecified w/ withdrawal delirium F /01/2015 Sedative, hypnotic or anxiolytic use, unspecified w/ withdrawal w/ perceptual disturbances F /01/2015 Sedative, hypnotic or anxiolytic use, unspecified w/ withdrawal, unspecified F /01/2015 Sedative, hypnotic or anxiolytic use, unspecified w/ sedative, hypnotic or anxiolytic-induced mood disorder F /01/2015 Sedative, hypnotic or anxiolytic use, unspecified w/ sedative, hypnotic or anxiolytic-induced psychotic disorder w/ delusions F /01/2015 Sedative, hypnotic or anxiolytic use unspecified w/ sedative, hypnotic or anxiolytic-induced psychotic disorder w/ hallucinations F /01/2015 Sedative, hypnotic or anxiolytic use, unspecified with sedative, hypnotic or anxiolytic-induced psychotic disorder, unspecified F /01/2015 Sedative, hypnotic or anxiolytic use, unspecified w/ sedative, hypnotic or anxiolytic-induced persisting amnestic disorder F /01/2015 Sedative, hypnotic or anxiolytic use, unspecified w/ sedative, hypnotic or anxiolytic-induced persisting dementia 7

16 Attachment B Code Beginning Review F /01/2015 Sedative, hypnotic or anxiolytic use, unspecified with sedative, hypnotic or anxiolytic-induced anxiety disorder F /01/2015 Sedative, hypnotic or anxiolytic use, unspecified with sedative, hypnotic or anxiolytic-induced sexual dysfunction F /01/2015 Sedative, hypnotic or anxiolytic use, unspecified w/ sedative, hypnotic or anxiolytic-induced sleep disorder F /01/2015 Sedative, hypnotic or anxiolytic use, unspecified with other sedative, hypnotic or anxiolytic-induced disorder F /01/2015 Sedative, hypnotic or anxiolytic use, unsp w unsp disorder (Sedative, hypnotic or anxiolytic use, unspecified with unspecified sedative, hypnotic or anxiolytic-induced disorder) *F /01/2015 Cocaine abuse, uncomplicated *F /01/2015 Cocaine abuse with intoxication, uncomplicated F /01/2015 Cocaine abuse w/ intoxication w/ delirium F /01/2015 Cocaine abuse with intoxication with perceptual disturbance F /01/2015 Cocaine abuse with intoxication, unspecified F /01/2015 Cocaine abuse w/ cocaine-induced mood disorder F /01/2015 Cocaine abuse w/ cocaine-induced psychotic disorder w/ delusions F /01/2015 cocaine abuse w/ cocaine-induced psychotic disorder w/ hallucinations F /01/2015 Cocaine abuse with cocaine-induced psychotic disorder, unspecified F /01/2015 Cocaine abuse with cocaine-induced anxiety disorder F /01/2015 Cocaine abuse with cocaine-induced sexual dysfunction F /01/2015 Cocaine abuse w/ cocaine-induced sleep disorder F /01/2015 Cocaine abuse with other cocaine-induced disorder F /01/2015 Cocaine abuse with unspecified cocaine-induced disorder F /01/2015 Cocaine dependence, uncomplicated *F /01/2015 Cocaine dependence, in remission F /01/2015 Cocaine dependence with intoxication, uncomplicated F /01/2015 Cocaine dependence with intoxication delirium F /01/2015 Cocaine dependence with intoxication with perceptual disturbance F /01/2015 Cocaine dependence with intoxication, unspecified F /01/2015 Cocaine dependence with withdrawal F /01/2015 Cocaine dependence with cocaine-induced mood disorder F /01/2015 Cocaine dependence with cocaine-induced psychotic disorder with delusions F /01/2015 Cocaine dependence with cocaine-induced psychotic disorder with hallucinations 8

17 Attachment B Code Beginning Review F /01/2015 Cocaine dependence with cocaine-induced psychotic disorder, unspecified F /01/2015 Cocaine dependence with cocaine-induced anxiety disorder F /01/2015 Cocaine dependence with cocaine-induced sexual dysfunction F /01/2015 Cocaine dependence w/ cocaine-induced sleep disorder F /01/2015 Cocaine dependence with other cocaine-induced disorder F /01/2015 Cocaine dependence with unspecified cocaine-induced disorder *F /01/2015 Cocaine use, unspecified, uncomplicated F /01/2015 Cocaine use, unspecified with intoxication, uncomplicated F /01/2015 Cocaine use, unspecified w/ intoxication delirium F /01/2015 Cocaine use, unspecified with intoxication with perceptual disturbance F /01/2015 Cocaine use, unspecified with intoxication, unspecified F /01/2015 Cocaine use, unspecified w/ cocaine-induced mood disorder F /01/2015 Cocaine use, unspecified w/ cocaine-induced psychotic disorder w/ delusions F /01/2015 Cocaine use, unspecified w/ cocaine-induced psychotic disorder w/ hallucinations F /01/2015 Cocaine use, unspecified with cocaine-induced psychotic disorder, unspecified F /01/2015 Cocaine use, unspecified with cocaine-induced anxiety disorder F /01/2015 Cocaine use, unspecified with cocaine-induced sexual dysfunction F /01/2015 Cocaine use, unspecified w/ cocaine-induced sleep disorder F /01/2015 Cocaine use, unspecified with other cocaine-induced disorder F /01/2015 Cocaine use, unsp with unspecified cocaine-induced disorder (Cocaine use, unspecified with unspecified cocaine-induced disorder) *F /01/2015 Other stimulant abuse, uncomplicated F /01/2015 Other stimulant abuse with intoxication, uncomplicated F /01/2015 Other stimulant use, unspecified with intoxication delirium F /01/2015 Other stimulant abuse with intoxication with perceptual disturbance F /01/2015 Other stimulant abuse with intoxication, unspecified F /01/2015 Other stimulant abuse w/ stimulant-induced mood disorder F /01/2015 Other stimulant abuse w/ stimulant-induced psychotic disorder w/ delusions 9

18 Attachment B Code Beginning Review F /01/2015 Oth stimulant abuse w stim-induce psych disorder w hallucin (Other stimulant abuse with stimulant-induced psychotic disorder with hallucinations) F /01/2015 Other stimulant abuse with stimulant-induced psychotic disorder, unspecified F /01/2015 Other stimulant abuse with stimulant-induced anxiety disorder F /01/2015 Other stimulant abuse with stimulant-induced sexual dysfunction F /01/2015 Other stimulant abuse w/ stimulant-induced sleep disorder F /01/2015 Other stimulant abuse with other stimulant-induced disorder F /01/2015 Other stimulant abuse with unsp stimulant-induced disorder (Other stimulant abuse with unspecified stimulant-induced disorder) *F /01/2015 Other stimulant dependence, uncomplicated *F /01/2015 Other stimulant dependence, in remission F /01/2015 Other stimulant dependence with intoxication with perceptual disturbance F /01/2015 Other stimulant dependence with stimulant-induced psychotic disorder, unspecified F /01/2015 Other stimulant dependence with stimulant-induced anxiety disorder F /01/2015 Other stimulant dependence with stimulant-induced sexual dysfunction F /01/2015 Other stimulant dependence w/ stimulant-induced sleep disorder F /01/2015 Other stimulant dependence with other stimulant-induced disorder *F /01/2015 Other stimulant use, unspecified, uncomplicated F /01/2015 Other stimulant use, unsp with intoxication, uncomplicated (Other stimulant use, unspecified with intoxication, uncomplicated) F /01/2015 Other stimulant use, unspecified w/ intoxication delirium F /01/2015 Other stimulant use, unspecified with intoxication with perceptual disturbance F /01/2015 Other stimulant use, unsp with intoxication, unspecified (Other stimulant use, unspecified with intoxication, unspecified) F /01/2015 Other stimulant use, unspecified w/ withdrawal F /01/2015 Other stimulant use, unspecified w/ stimulant-induced mood disorder F /01/2015 Other stimulant use, unspecified w/ stimulant-induced psychotic disorder w/ delusions 10

19 Attachment B Code Beginning Review F /01/2015 Oth stim use, unsp w stim-induce psych disorder w hallucin (Other stimulant use, unspecified with stimulant-induced psychotic disorder with hallucinations) F /01/2015 Other stimulant use, unspecified with stimulant-induced psychotic disorder, unspecified F /01/2015 Other stimulant use, unspecified with stimulant-induced anxiety disorder F /01/2015 Other stimulant use, unspecified with stimulant-induced sexual dysfunction F /01/2015 Other stimulant use, unspecified w/ stimulant-induced sleep disorder F /01/2015 Other stimulant use, unspecified with other stimulant-induced disorder F /01/2015 Oth stimulant use, unsp with unsp stimulant-induced disorder (Other stimulant use, unspecified with unspecified stimulantinduced disorder) *F /01/2015 Hallucinogen abuse, uncomplicated F /01/2015 Hallucinogen abuse with intoxication, uncomplicated F /01/2015 Hallucinogen abuse w/ intoxication w/ delirium F /01/2015 Hallucinogen abuse with intoxication with perceptual disturbance F /01/2015 Hallucinogen abuse with intoxication, unspecified F /01/2015 Hallucinogen abuse w/ hallucinogen-induced mood disorder F /01/2015 Hallucinogen abuse w/ hallucinogen-induced psychotic disorder w/ delusions F /01/2015 Hallucinogen abuse w/ hallucinogen-induced psychotic disorder w/ hallucinations F /01/2015 Hallucinogen abuse with hallucinogen-induced psychotic disorder, unspecified F /01/2015 Hallucinogen abuse with hallucinogen-induced anxiety disorder F /01/2015 Hallucinogen abuse with hallucinogen persisting perception disorder F /01/2015 Hallucinogen abuse with other hallucinogen-induced disorder F /01/2015 Hallucinogen abuse with unsp hallucinogen-induced disorder (Hallucinogen abuse with unspecified hallucinogen-induced disorder) F /01/2015 Hallucinogen dependence, uncomplicated *F /01/2015 Hallucinogen dependence, in remission F /01/2015 Hallucinogen dependence with intoxication, uncomplicated F /01/2015 Hallucinogen dependence w/ intoxication w/ delirium 11

20 Attachment B Code Beginning Review F /01/2015 Hallucinogen dependence with intoxication, unspecified F /01/2015 Hallucinogen dependence w/ hallucinogen-induced mood disorder F /01/2015 Hallucinogen dependence with hallucinogen-induced psychotic disorder with delusions F /01/2015 Hallucinogen dependence with hallucinogen-induced psychotic disorder with hallucinations F /01/2015 Hallucinogen dependence with hallucinogen-induced psychotic disorder, unspecified F /01/2015 Hallucinogen dependence with hallucinogen-induced anxiety disorder F /01/2015 Hallucinogen dependence with hallucinogen persisting perception disorder (flashbacks) F /01/2015 Hallucinogen dependence with other hallucinogen-induced disorder F /01/2015 Hallucinogen dependence with unspecified hallucinogeninduced disorder *F /01/2015 Hallucinogen use, unspecified, uncomplicated F /01/2015 Hallucinogen use, unsp with intoxication, uncomplicated (Hallucinogen use, unspecified with intoxication, uncomplicated) F /01/2015 Hallucinogen use, unspecified w/ intoxication w/ delirium F /01/2015 Hallucinogen use, unspecified with intoxication, unspecified F /01/2015 Hallucinogen use, unspecified w/ hallucinogen-induced mood disorder F /01/2015 Hallucinogen use, unspecified w/ hallucinogen-induced psychotic disorder w/ delusions F /01/2015 Hallucinogen use, unspecified w/ hallucinogen-induced psychotic disorder w/ hallucinations F /01/2015 Hallucinogen use, unspecified with hallucinogen-induced psychotic disorder F /01/2015 Hallucinogen use, unspecified with hallucinogen-induced anxiety disorder F /01/2015 Hallucinogen use, unspecified with hallucinogen persisting perception disorder F /01/2015 Hallucinogen use, unspecified with other hallucinogeninduced disorder F /01/2015 Hallucinogen use, unsp w unsp hallucinogen-induced disorder (Hallucinogen use, unspecified with unspecified hallucinogeninduced disorder F /01/2015 Nicotine dependence unspecified, w/ withdrawal 12

21 Attachment B Code Beginning Review F /01/2015 Nicotine dependence, unspecified, with other nicotine-induced disorders F /01/2015 Nicotine dependence, unsp, w unsp nicotine-induced disorders (Nicotine dependence, unspecified, with unspecified nicotineinduced disorders F /01/2015 Nicotine dependence, cigarettes, w/ withdrawal F /01/2015 Nicotine dependence, other tobacco product, with other nicotine-induced disorders F /01/2015 Nicotine dependence, cigarettes, w unsp disorders (Nicotine dependence, cigarettes, with unspecified nicotine-induced disorders) F /01/2015 Nicotine dependence, chewing tobacco, w/ withdrawal F /01/2015 Inhalant abuse with inhalant-induced psychotic disorder, unspecified F /01/2015 Nicotine dependence, chewing tobacco, w unsp disorders (Nicotine dependence, chewing tobacco, with unspecified nicotine-induced disorders) F /01/2015 Nicotine dependence, other tobacco product, w/ withdrawal F /01/2015 Inhalant abuse with inhalant-induced anxiety disorder F /01/2015 Nicotine dependence, oth tobacco product, w unsp disorders (Nicotine dependence, other tobacco product, with unspecified nicotine-induced disorders) *F /01/2015 Inhalant abuse, uncomplicated F /01/2015 Inhalant abuse with intoxication, uncomplicated F /01/2015 Inhalant abuse with intoxication delirium F /01/2015 Inhalant abuse with intoxication, unspecified F /01/2015 Inhalant abuse w/ inhalant-induced mood disorder F /01/2015 Inhalant abuse w/ inhalant-induced psychotic disorder w/ delusions F /01/2015 Inhalant abuse w/ inhalant-induced psychotic disorder w/ hallucinations F /01/2015 Inhalant abuse with inhalant-induced psychotic disorder, unspecified F /01/2015 Inhalant abuse with inhalant-induced dementia F /01/2015 Inhalant dependence with inhalant-induced anxiety disorder *F /01/2015 Inhalant abuse with other inhalant-induced disorder F /01/2015 Inhalant abuse with unspecified inhalant-induced disorder *F /01/2015 Inhalant dependence, uncomplicated *F /01/2015 Inhalant dependence, in remission F /01/2015 Inhalant dependence with intoxication, uncomplicated F /01/2015 Inhalant dependence with intoxication delirium 13

22 Attachment B Code Beginning Review F /01/2015 Other psychoactive substance dependence with intoxication, unspecified F /01/2015 Inhalant dependence with inhalant-induced mood disorder F /01/2015 Inhalant dependence with inhalant-induced psychotic disorder with delusions F /01/2015 Inhalant dependence with inhalant-induced psychotic disorder with hallucinations F /01/2015 Inhalant dependence with inhalant-induced psychotic disorder, unspecified F /01/2015 Inhalant dependence with inhalant-induced dementia F /01/2015 Inhalant dependence with inhalant-induced anxiety disorder F /01/2015 Inhalant dependence with other inhalant-induced disorder F /01/2015 Inhalant dependence with unspecified inhalant-induced disorder F /01/2015 Inhalant use, unspecified, uncomplicated F /01/2015 Inhalant use, unspecified with intoxication, uncomplicated F /01/2015 Inhalant use, unspecified w/ intoxication w/ delirium F /01/2015 Inhalant use, unspecified with intoxication, unspecified F /01/2015 Inhalant use, unspecified w/ inhalant-induced mood disorder F /01/2015 Inhalant use, unspecified w/ inhalant-induced psychotic disorder w/ delusions F /01/2015 Inhalant use, unspecified w/ inhalant-induced psychotic disorder w/ hallucinations F /01/2015 Inhalant use, unspecified with inhalant-induced psychotic disorder, unspecified F /01/2015 Inhalant use, unsp with inhalant-induced persisting dementia (Inhalant use, unspecified with inhalant-induced persisting dementia) F /01/2015 Inhalant use, unspecified with inhalant-induced anxiety disorder F /01/2015 Inhalant use, unspecified with other inhalant-induced disorder F /01/2015 Inhalant use, unsp with unsp inhalant-induced disorder (Inhalant use, unspecified with unspecified inhalant-induced disorder) *F /01/2015 Other psychoactive substance abuse, uncomplicated F /01/2015 Other psychoactive substance abuse with intoxication, uncomplicated F /01/2015 Other psychoactive substance abuse w/ intoxication delirium F /01/2015 Other psychoactive substance abuse with intoxication with perceptual disturbances F /01/2015 Other psychoactive substance abuse with intoxication, 14

23 Attachment B Code Beginning Review unspecified F /01/2015 Other psychoactive substance abuse w/ psychoactive substance-induced mood disorder F /01/2015 Oth psychoactv substance abuse w psych disorder w delusions (Other psychoactive substance abuse with psychoactive substance-induced psychotic disorder with delusions) F /01/2015 Other psychoactive substance abuse w/ psychoactive substance-induced psychotic disorder w/ hallucinations F /01/2015 Other psychoactive substance abuse with psychoactive substance-induced psychotic disorder, unspecified F /01/2015 Other psychoactive substance abuse w/ psychoactive substance-induced persisting amnestic disorder F /01/2015 Other psychoactive substance abuse w/ psychoactive substance-induced persisting dementia F /01/2015 Other psychoactive substance abuse with psychoactive substance-induced anxiety disorder F /01/2015 Other psychoactive substance abuse with psychoactive substance-induced sexual dysfunction F /01/2015 Other psychoactive substance abuse w/ psychoactive substance-induced sleep disorder F /01/2015 Other psychoactive substance abuse with other psychoactive substance F /01/2015 Oth psychoactive substance abuse w unsp disorder (Other psychoactive substance abuse with unspecified psychoactive substance-induced disorder) *F /01/2015 Other psychoactive substance dependence, uncomplicated *F /01/2015 Other psychoactive substance dependence, in remission F /01/2015 Other psychoactive substance dependence with intoxication, uncomplicated *F /01/2015 (Other psychoactive substance dependence with intoxication delirium F /01/2015 Other psychoactive substance dependence with intoxication with perceptual disturbance F /01/2015 Other psychoactive substance dependence with intoxication, unspecified F /01/2015 Other psychoactive substance dependence with withdrawal, uncomplicated F /01/2015 Other psychoactive substance dependence with withdrawal delirium F /01/2015 Other psychoactive substance dependence with withdrawal with perceptual disturbance 15

24 Attachment B Code Beginning Review F /01/2015 Other psychoactive substance dependence with withdrawal, unspecified F /01/2015 Other psychoactive substance dependence with psychoactive substance-induced mood disorder F /01/2015 Other psychoactive substance dependence with psychoactive substance-induced psychotic disorder with delusions F /01/2015 Other psychoactive substance dependence with psychoactive substance-induced psychotic disorder with hallucinations F /01/2015 Other psychoactive substance dependence with psychoactive substance-induced psychotic disorder, unspecified F /01/2015 Other psychoactive substance dependence with psychoactive substance-induced persisting amnestic disorder F /01/2015 Other psychoactive substance dependence with psychoactive substance-induced persisting dementia F /01/2015 Other psychoactive substance dependence with psychoactive substance-induced anxiety disorder F /01/2015 Other psychoactive substance dependence with psychoactive substance-induced sexual dysfunction F /01/2015 Other psychoactive substance dependence w/ psychoactive substance-induced sleep disorder F /01/2015 Other psychoactive substance dependence with other psychoactive substance-induced disorder *F /01/2015 Other psychoactive substance use, unspecified, uncomplicated F /01/2015 Other psychoactive substance use, unspecified with intoxication, uncomplicated F /01/2015 Oth psychoactive substance use, unsp w intox w delirium (Other psychoactive substance use, unspecified with intoxication with delirium) F /01/2015 Other psychoactive substance use, unspecified with intoxication with perceptual disturbance F /01/2015 Oth psychoactive substance use, unsp with intoxication, unsp (Other psychoactive substance use, unspecified with intoxication, unspecified) F /01/2015 Other psychoactive substance use, unspecified w/ withdrawal, uncomplicated F /01/2015 Other psychoactive substance use, unspecified w/ withdrawal delirium F /01/2015 Other psychoactive substance use, unspecified w/ withdrawal perceptual disturbance F /01/2015 Other psychoactive substance use, unspecified w/ withdrawal, unspecified 16

25 Attachment B Code Beginning Review F /01/2015 Other psychoactive substance use, unspecified w/ psychoactive substance-induced mood disorder F /01/2015 Oth psychoactv sub use, unsp w psych disorder w delusions (Other psychoactive substance use, unspecified with psychoactive substance-induced psychotic disorder with delusions) F /01/2015 Opioid abuse w/ opioid-induced psychotic disorder w/ hallucinations F /01/2015 Other psychoactive substance use, unspecified with psychoactive substance-induced psychotic disorder, unspecified F /01/2015 Other psychoactive substance use, unspecified w/ psychoactive substance-induced persisting amnestic disorder F /01/2015 Other psychoactive substance use, unspecified w/ psychoactive substance-induced persisting dementia F /01/2015 Other psychoactive substance use, unspecified with psychoactive substance-induced anxiety disorder F /01/2015 Other psychoactive substance use, unspecified with psychoactive substance-induced sexual dysfunction F /01/2015 Other psychoactive substance use, unspecified w/ psychoactive substance-induced sleep disorder F /01/2015 Other psychoactive substance use, unspecified with other psychoactive substance-induced disorder F /01/2015 Other psychoactive substance use, unspecified with unspecified psychoactive substance-induced disorder *F /01/2015 Pain disorder with related psychological factors *F /01/2015 Pseudobulbar affect *F /01/2015 Anorexia nervosa, unspecified *F /01/2015 Anorexia nervosa, restricting type *F /01/2015 Anorexia nervosa, binge eating/purging type *F /01/2015 Bulimia nervosa *F /01/2015 Other eating disorders *F /01/2015 Vaginismus not due to a substance or known physiological condition *F54 10/01/2015 Psychological and behavioral factors associated w/ disorders or diseases classified elsewhere *F /01/2015 Abuse of antacids *F /01/2015 Abuse of herbal or folk remedies *F /01/2015 Abuse of laxatives *F /01/2015 Abuse of steroids or hormones *F /01/2015 Abuse of vitamins 17

26 Attachment B Code Beginning Review *F /01/2015 Abuse of other non-psychoactive substances *F59 10/01/2015 Unspecified behavioral syndromes associated with physiological disturbances and physical factors *F /01/2015 Rumination disorder of infancy *F /01/2015 Other feeding disorders of infancy and early childhood *F /01/2015 Pica of infancy and childhood *G /01/2015 Tension-type headache, unspecified *R /01/2015 Blood alcohol level of less than 20mg/100ml 18

27 Attachment C ICD-10-CM Diagnosis Codes Subject to Certification of Admission/Concurrent/Continued Stay Review Based on the Admitting Diagnosis Code A /01/2015 Sepsis due to streptococcus, group A A /01/2015 Sepsis due to streptococcus, group B A /01/2015 Sepsis due to streptococcus pneumoniae A /01/2015 Sepsis due to Streptococcus pneumoniae A /01/2015 Other streptococcal sepsis A /01/2015 Streptococcal sepsis, unspecified A /01/2015 Sepsis due to methicillin susceptible staphylococcus aureus A /01/2015 Sepsis due to other specified staphylococcus A /01/2015 Sepsis due to unspecified staphylococcus A /01/2015 Sepsis due to Hemophilus influenzae A /01/2015 Sepsis due to anaerobes A /01/2015 Gram-negative sepsis, unspecified A /01/2015 Sepsis due to Escherichia coli [E. coli] A /01/2015 Sepsis due to pseudomonas A /01/2015 Sepsis due to serratia A /01/2015 Other Gram-negative sepsis A /01/2015 Sepsis due to Enterococcus A /01/2015 Other specified sepsis A /01/2015 Sepsis, unspecified organism A /01/2015 Actinomycotic sepsis D /01/2015 Iron deficiency anemia secondary to blood loss (chronic) D /01/2015 Iron deficiency anemia, unspecified D /01/2015 Anemia, unspecified E /01/2015 Type 1 diabetes mellitus w/ ketoacidosis w/o coma E /01/2015 Type 1 diabetes mellitus w/ other diabetic arthropathy E /01/2015 Type 1 diabetes mellitus w/ diabetic dermatitis E /01/2015 Type 1 diabetes mellitus w/ foot ulcer E /01/2015 Type 1 diabetes mellitus w/ other skin ulcer E /01/2015 Type 1 diabetes mellitus w/ other skin complications E /01/2015 Type 1 diabetes mellitus w/ periodontal disease E /01/2015 Type 1 diabetes mellitus w/ other oral complications E /01/2015 Type 1 diabetes mellitus w/ hypoglycemia w/o coma E /01/2015 Type 1 diabetes mellitus w/ hyperglycemia E /01/2015 Type 1 diabetes mellitus w/ other specified complication E /01/2015 Type 1 diabetes mellitus w/o complications 1

28 Attachment C E /01/2015 Type 2 diabetes mellitus w/ hyperosmolarity w/o nonketotic hyperglycemic-hyperosmolar coma (NKHHC) E /01/2015 Type 2 diabetes mellitus w/ hyperosmolarity w/ coma E /01/2015 Type 2 diabetes mellitus w/ other diabetic arthropathy E /01/2015 Type 2 diabetes mellitus w/ diabetic dermatitis E /01/2015 Type 2 diabetes mellitus w/ foot ulcer E /01/2015 Type 2 diabetes mellitus w/ other skin ulcer E /01/2015 Type 2 diabetes mellitus w/ other skin complications E /01/2015 Type 2 diabetes mellitus w/ periodontal disease E /01/2015 Type 2 diabetes mellitus w/ other oral complications E /01/2015 Type 2 diabetes mellitus w/ hypoglycemia E /01/2015 Type 2 diabetes mellitus w/ hyperglycemia E /01/2015 Type 2 diabetes mellitus w/ other specified complication E /01/2015 Type 2 diabetes mellitus w/o complications E /01/2015 Other specified diabetes mellitus w/ hyperosmolarity w/o nonketotic hyperglycemic-hyperosmolar coma (NKHHC) E /01/2015 Other specified diabetes mellitus w/ hyperosmolarity w/ coma E /01/2015 Other specified diabetes mellitus w/ ketoacidosis w/o coma E /01/2015 Other specified diabetes mellitus w/ other diabetic arthropathy E /01/2015 Other specified diabetes mellitus w/ diabetic dermatitis E /01/2015 Other specified diabetes mellitus w/ foot ulcer E /01/2015 Other specified diabetes mellitus w/ other skin ulcer E /01/2015 Other specified diabetes mellitus w/ other skin complications E /01/2015 Other specified diabetes mellitus w/ periodontal disease E /01/2015 Other specified diabetes mellitus w/ other oral complications E /01/2015 Other specified diabetes mellitus w/ hypoglycemia w/o coma E /01/2015 Other specified diabetes mellitus with hyperglycemia E /01/2015 Other specified diabetes mellitus w/ other specified complication E /01/2015 Other specified diabetes mellitus without complications E /01/2015 Dehydration E /01/2015 Hypovolemia E /01/2015 Volume depletion, unspecified E /01/2015 Hypo-osmolality and hyponatremia E /01/2015 Hyperkalemia E /01/2015 Hypokalemia G /01/2015 Epilepsy, unspecified, not intractable, w/ status epilepticus G /01/2015 Epilepsy, unspecified, not intractable, w/o status epilepticus I10 10/01/2015 Essential (primary) hypertension I /01/2015 Hypertensive chronic kidney disease w/ stage 5 chronic kidney disease or end stage renal disease 2

29 Attachment C I /01/2015 Unstable angina I /01/2015 ST elevation (STEMI) myocardial infarction involving other coronary artery of anterior wall I /01/2015 STEMI) myocardial infarction involving left main coronary artery I /01/2015 ST elevation (STEMI) myocardial infarction involving other coronary artery of anterior wall I /01/2015 ST elevation (STEMI) myocardial infarction involving right coronary artery I /01/2015 ST elevation (STEMI) myocardial infarction involving other coronary artery of inferior wall I /01/2015 STEMI involving oth sites (ST elevation (STEMI) myocardial infarction involving other sites) I /01/2015 ST elevation (STEMI) myocardial infarction of unspecified site I /01/2015 Non-ST elevation (NSTEMI) myocardial infarction I /01/2015 Subsequent ST elevation (STEMI) myocardial infarction of anterior wa I /01/2015 Subsequent ST elevation (STEMI) myocardial infarction of inferior wall I /01/2015 Subsequent ST elevation (STEMI) myocardial infarction of other sites I /01/2015 Subsequent ST elevation (STEMI) myocardial infarction of unspecified site I /01/2015 Acute coronary thrombosis not resulting in myocardial infarction I /01/2015 Dressler's syndrome I /01/2015 Other forms of acute ischemic heart disease I /01/2015 Acute ischemic heart disease, unspecified I /01/2015 Left ventricular failure I /01/2015 Unspecified systolic (congestive) heart failure I /01/2015 Acute systolic (congestive) heart failure I /01/2015 Chronic systolic (congestive) heart failure I /01/2015 Acute on chronic systolic (congestive) heart failure I /01/2015 Unspecified diastolic (congestive) heart failure I /01/2015 Acute diastolic (congestive) heart failure I /01/2015 Chronic diastolic (congestive) heart failure I /01/2015 Acute on chronic diastolic (congestive) heart failure I /01/2015 Unspecified combined systolic (congestive) and diastolic (congestive) heart failure I /01/2015 Acute combined systolic (congestive) and diastolic (congestive) heart failure I /01/2015 Chronic combined systolic (congestive) and diastolic (congestive) heart failure 3

30 Attachment C I /01/2015 Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure I /01/2015 Heart failure, unspecified I /01/2015 Acute embolism and thrombosis of superior vena cava I /01/2015 Chronic embolism and thrombosis of superior vena cava I /01/2015 Acute embolism and thrombosis of other thoracic veins I /01/2015 Chronic embolism and thrombosis of other thoracic veins I /01/2015 Acute embolism and thrombosis of unspecified deep veins of right lower extremity I /01/2015 Acute embolism and thrombosis of unspecified deep veins of left lower extremity I /01/2015 Acute embolism and thrombosis of unspecified deep veins of lower extremity, bilateral I /01/2015 Acute embolism and thrombosis of unspecified deep veins of unspecified lower extremity I /01/2015 Acute embolism and thrombosis of right femoral vein I /01/2015 Acute embolism and thrombosis of left femoral vein I /01/2015 Acute embolism and thrombosis of femoral vein, bilateral I /01/2015 Acute embolism and thrombosis of unspecified femoral vein I /01/2015 Acute embolism and thrombosis of right iliac vein I /01/2015 Acute embolism and thrombosis of left iliac vein I /01/2015 Acute embolism and thrombosis of iliac vein, bilateral I /01/2015 Acute embolism and thrombosis of unspecified iliac vein I /01/2015 Acute embolism and thrombosis of right popliteal vein I /01/2015 Acute embolism and thrombosis of left popliteal vein I /01/2015 Acute embolism and thrombosis of popliteal vein, bilateral I /01/2015 Acute embolism and thrombosis of unspecified popliteal vein I /01/2015 Acute embolism and thrombosis of right tibial vein I /01/2015 Acute embolism and thrombosis of let tibial vein I /01/2015 Acute embolism and thrombosis of tibial vein, bilateral I /01/2015 Acute embolism and thrombosis of unspecified tibial vein I /01/2015 Acute embolism and thrombosis of other specified deep vein of right lower extremity I /01/2015 Acute embolism and thrombosis of other specified deep vein of left lower extremity I /01/2015 Acute embolism and thrombosis of other specified deep vein of lower extremity, bilateral I /01/2015 Acute embolism and thrombosis of other specified deep vein of unspecified lower extremity I82.4Y1 10/01/2015 Acute embolism and thrombosis of unspecified deep veins of right proximal lower extremity 4

31 Attachment C I82.4Y2 10/01/2015 Acute embolism and thrombosis of unspecified deep veins of left proximal lower extremity I82.4Y3 10/01/2015 Acute embolism and thrombosis of unspecified deep veins of proximal lower extremity, bilateral I82.4Y9 10/01/2015 Acute embolism and thrombosis of unspecified deep veins of unspecified proximal lower extremity I82.4Z1 10/01/2015 Acute embolism and thrombosis of unspecified deep veins of right distal lower extremity I82.4Z2 10/01/2015 Acute embolism and thrombosis of unspecified deep veins of left distal lower extremity I82.4Z3 10/01/2015 Acute embolism and thrombosis of unspecified deep veins of distal lower extremity, bilateral I82.4Z9 10/01/2015 Acute embolism and thrombosis of unspecified deep veins of unspecified distal lower extremity I /01/2015 Chronic embolism and thrombosis of unspecified deep veins of right lower extremity I /01/2015 Chronic embolism and thrombosis of unspecified deep veins of left lower extremity I /01/2015 Chronic embolism and thrombosis of unspecified deep veins of lower extremity, bilateral I /01/2015 Chronic embolism and thrombosis of unspecified deep veins of unspecified lower extremity I /01/2015 Chronic embolism and thrombosis of right femoral vein I /01/2015 Chronic embolism and thrombosis of left femoral vein I /01/2015 Chronic embolism and thrombosis of femoral vein, bilateral I /01/2015 Chronic embolism and thrombosis of unspecified femoral vein I /01/2015 Chronic embolism and thrombosis of right iliac vein I /01/2015 Chronic embolism and thrombosis of left iliac vein I /01/2015 Chronic embolism and thrombosis of iliac vein, bilateral I /01/2015 Chronic embolism and thrombosis of unspecified iliac vein I /01/2015 Chronic embolism and thrombosis of right popliteal vein I /01/2015 Chronic embolism and thrombosis of left popliteal vein I /01/2015 Chronic embolism and thrombosis of popliteal vein, bilateral I /01/2015 Chronic embolism and thrombosis of unspecified popliteal vein I /01/2015 Chronic embolism and thrombosis of right tibial vein I /01/2015 Chronic embolism and thrombosis of left tibial vein I /01/2015 Chronic embolism and thrombosis of tibial vein, bilateral I /01/2015 Chronic embolism and thrombosis of unspecified tibial vein I /01/2015 Chronic embolism and thrombosis of other specified deep vein of right lower extremity I /01/2015 Chronic embolism and thrombosis of other specified deep vein of left lower extremity 5

32 Attachment C I /01/2015 Chronic embolism and thrombosis of other specified deep vein of lower extremity, bilateral I /01/2015 Chronic embolism and thrombosis of other specified deep vein of unspecified lower extremity I82.5Y1 10/01/2015 Chronic embolism and thrombosis of unspecified deep veins of right proximal lower extremity I82.5Y2 10/01/2015 Chronic embolism and thrombosis of unspecified deep veins of left proximal lower extremity I82.5Y3 10/01/2015 Chronic embolism and thrombosis of unspecified deep veins of proximal lower extremity, bilateral I82.5Y9 10/01/2015 Chronic embolism and thrombosis of unspecified deep veins of unspecified proximal lower extremity I82.5Z1 10/01/2015 Chronic embolism and thrombosis of unspecified deep veins of right distal lower extremity I82.5Z2 10/01/2015 Chronic embolism and thrombosis of unspecified deep veins of left distal lower extremity I825Z3 10/01/2015 Chronic embolism and thrombosis of unspecified deep veins of distal lower extremity, bilateral I82.5Z9 10/01/2015 Chronic embolism and thrombosis of unspecified deep veins of unspecified distal lower extremity I /01/2015 Acute embolism and thrombosis of unspecified veins of right upper extremity I /01/2015 Acute embolism and thrombosis of unspecified veins of left upper extremity I /01/2015 Acute embolism and thrombosis of unspecified veins of upper extremity, bilateral I /01/2015 Acute embolism and thrombosis of unspecified veins of unspecified upper extremity I /01/2015 Acute embolism and thrombosis of superficial veins of right upper extremity I /01/2015 Acute embolism and thrombosis of superficial veins of left upper extremity I /01/2015 Acute embolism and thrombosis of superficial veins of upper extremity, bilateral I /01/2015 Acute embolism and thrombosis of superficial veins of unspecified upper extremity I /01/2015 Acute embolism an thrombosis of deep veins of right upper extremity I /01/2015 Acute embolism and thrombosis of deep veins of left upper extremity I /01/2015 Acute embolism and thrombosis of deep veins of upper extremity, bilateral I /01/2015 Acute embolism and thrombosis of deep veins of unspecified 6

33 Attachment C upper extremity I /01/2015 Chronic embolism and thrombosis of unspecified veins of right upper extremity I /01/2015 Chronic embolism and thrombosis of unspecified veins of left upper extremity I /01/2015 Chronic embolism and thrombosis of unspecified veins of upper extremity, bilateral I /01/2015 Chronic embolism and thrombosis of unspecified veins of unspecified upper extremity I /01/2015 Chronic embolism and thrombosis of superficial veins of right upper extremity I /01/2015 Chronic embolism and thrombosis of superficial veins of left upper extremity I /01/2015 Chronic embolism and thrombosis of superficial veins of upper extremity, bilateral I /01/2015 Chronic embolism and thrombosis of superficial veins of unspecified upper extremity I /01/2015 Chronic embolism and thrombosis of deep veins of right upper extremity I /01/2015 Chronic embolism and thrombosis of deep veins of left upper extremity I /01/2015 Chronic embolism and thrombosis of deep veins of upper extremity, bilateral I /01/2015 Chronic embolism and thrombosis of deep veins of unspecified upper extremity I /01/2015 Embolism and thrombosis of superficial veins of right lower extremities I /01/2015 Embolism and thrombosis of superficial veins of left lower extremities I /01/2015 Embolism and thrombosis of superficial veins of lower extremities, bilateral I /01/2015 Embolism and thrombosis of superficial veins of unspecified lower extremities I /01/2015 Acute embolism and thrombosis of other specified veins I /01/2015 Chronic embolism and thrombosis of other specified veins I /01/2015 Acute embolism and thrombosis of unspecified vein I /01/2015 Chronic embolism and thrombosis of unspecified vein I82.A11 10/01/2015 Acute embolism and thrombosis of right axillary vein I82.A12 10/01/2015 Acute embolism and thrombosis of left axillary vein I82.A13 10/01/2015 Acute embolism and thrombosis of axillary vein, bilateral I82.A19 10/01/2015 Acute embolism and thrombosis of unspecified axillary vein I82.A21 10/01/2015 Chronic embolism and thrombosis of right axillary vein 7

34 Attachment C I82.A22 10/01/2015 Chronic embolism and thrombosis of left axillary vein I82.A23 10/01/2015 Chronic embolism and thrombosis of axillary vein, bilateral I82.A29 10/01/2015 Chronic embolism and thrombosis of unspecified axillary vein I82.B11 10/01/2015 Acute embolism and thrombosis of right subclavian vein I82.B12 10/01/2015 Acute embolism and thrombosis of left subclavian vein I82.B13 10/01/2015 Acute embolism and thrombosis of subclavian vein, bilateral I82.B19 10/01/2015 Acute embolism and thrombosis of unspecified subclavian vein I82.B21 10/01/2015 Chronic embolism and thrombosis of right subclavian vein I82.B22 10/01/2015 Chronic embolism and thrombosis of left subclavian vein I82.B23 10/01/2015 Chronic embolism and thrombosis of subclavian vein, bilateral I82.B29 10/01/2015 Chronic embolism and thrombosis of unspecified subclavian vein I82.C11 10/01/2015 Acute embolism and thrombosis of right internal jugular vein I82.C12 10/01/2015 Acute embolism and thrombosis of left internal jugular vein I82.C13 10/01/2015 Acute embolism and thrombosis of internal jugular vein, bilateral I82.C19 10/01/2015 Acute embolism and thrombosis of unspecified internal jugular vein I82.C21 10/01/2015 Chronic embolism and thrombosis of right internal jugular vein I82.C22 10/01/2015 Chronic embolism and thrombosis of left internal jugular vein I82.C23 10/01/2015 Chronic embolism and thrombosis of internal jugular vein, bilateral I82.C29 10/01/2015 Chronic embolism and thrombosis of unspecified internal jugular vein J /01/2015 Other pneumonia, unspecified organism J /01/2015 Pneumonia, unspecified organism J40 10/01/2015 Bronchitis, not specified as acute or chronic J /01/2015 Chronic obstructive pulmonary disease with acute lower respiratory infection J /01/2015 Chronic obstructive pulmonary disease w/ (acute) exacerbation J /01/2015 Chronic obstructive pulmonary disease, unspecified J /01/2015 Mild intermittent asthma, uncomplicated J /01/2015 Mild intermittent asthma w/ (acute) exacerbation J /01/2015 Mild intermittent asthma w/ status asthmaticus J /01/2015 Mild persistent asthma, uncomplicated J /01/2015 Mild persistent asthma w/ (acute) exacerbation J /01/2015 Mild persistent asthma w/ status asthmaticus J /01/2015 Moderate persistent asthma, uncomplicated J /01/2015 Moderate persistent asthma w/ (acute) exacerbation J /01/2015 Moderate persistent asthma w/ status asthmaticus 8

35 Attachment C J /01/2015 Severe persistent asthma, uncomplicated J /01/2015 Severe persistent asthma w/ (acute) exacerbation J /01/2015 Severe persistent asthma w/ status asthmaticus J /01/2015 Unspecified asthma with (acute) exacerbation J /01/2015 Unspecified asthma with status asthmaticus J /01/2015 Unspecified asthma, uncomplicated J /01/2015 Exercise induced bronchospasm J /01/2015 Cough variant asthma J /01/2015 Other asthma K /01/2015 Gastro-esophageal reflux disease w/o esophagitis K /01/2015 Acute gastritis w/o bleeding K /01/2015 Chronic superficial gastritis without bleeding K /01/2015 Other gastritis w/o bleeding K /01/2015 Gastritis, unspecified w/o bleeding K /01/2015 Gastroduodenitis, unspecified, w/o bleeding K /01/2015 Eosinophilic gastritis or gastroenteritis K /01/2015 Other specified noninfective gastroenteritis and colitis K /01/2015 Noninfective gastroenteritis and colitis, unspecified K /01/2015 Alcoholic fibrosis and sclerosis of liver K /01/2015 Alcoholic cirrhosis of liver w/o ascites K /01/2015 Alcoholic cirrhosis of liver w/ ascites L /01/2015 Pressure ulcer of left upper back, stage 4 L /01/2015 Pressure ulcer of unspecified elbow, unstageable L /01/2015 Pressure ulcer of unspecified elbow, stage 3 L /01/2015 Pressure ulcer of unspecified elbow, stage 1 L /01/2015 Pressure ulcer of unspecified elbow, stage 2 L /01/2015 Pressure ulcer of unspecified elbow, stage 4 L /01/2015 Pressure ulcer of unspecified elbow, unspecified stage L /01/2015 Pressure ulcer of right elbow, unstageable L /01/2015 Pressure ulcer of right elbow, stage 1 L /01/2015 Pressure ulcer of right elbow, stage 2 L /01/2015 Pressure ulcer of right elbow, stage 3 L /01/2015 Pressure ulcer of right elbow, stage 4 L /01/2015 Pressure ulcer of right elbow, unspecified stage L /01/2015 Pressure ulcer of left elbow, unstageable L /01/2015 Pressure ulcer of left elbow, stage 1 L /01/2015 Pressure ulcer of left elbow, stage 2 L /01/2015 Pressure ulcer of left elbow, stage 3 L /01/2015 Pressure ulcer of left elbow, stage 4 9

36 Attachment C L /01/2015 Pressure ulcer of left elbow, unspecified stage L /01/2015 Pressure ulcer of unspecified part of back, unstageable L /01/2015 Pressure ulcer of unspecified part of back, stage 1 L /01/2015 Pressure ulcer of unspecified part of back, stage 2 L /01/2015 Pressure ulcer of unspecified part of back, stage 3 L /01/2015 Pressure ulcer of unspecified part of back, stage 4 L /01/2015 Pressure ulcer of unspecified part of back, unspecified stage L /01/2015 Pressure ulcer of right upper back, unstageable L /01/2015 Pressure ulcer of right upper back, stage 1 L /01/2015 Pressure ulcer of right upper back, stage 2 L /01/2015 Pressure ulcer of right upper back, stage 3 L /01/2015 Pressure ulcer of right upper back, stage 4 L /01/2015 Pressure ulcer of right upper back, unspecified stage L /01/2015 Pressure ulcer of left upper back, unstageable L /01/2015 Pressure ulcer of left upper back, stage 1 L /01/2015 Pressure ulcer of left upper back, stage 2 L /01/2015 Pressure ulcer of left upper back, stage 3 L /01/2015 Pressure ulcer of left upper back, unspecified stage L /01/2015 Pressure ulcer of right lower back, unstageable L /01/2015 Pressure ulcer of right lower back, stage 1 L /01/2015 Pressure ulcer of right lower back, stage 2 L /01/2015 Pressure ulcer of right lower back, stage 3 L /01/2015 Pressure ulcer of right lower back, stage 4 L /01/2015 Pressure ulcer or right lower back, unspecified stage L /01/2015 Pressure ulcer of left lower back, unstageable L /01/2015 Pressure ulcer of left lower back, stage 1 L /01/2015 Pressure ulcer of left lower back, stage 2 L /01/2015 Pressure ulcer of left lower back, stage 3 L /01/2015 Pressure ulcer of left lower back, stage 4 L /01/2015 Pressure ulcer of left lower back, unspecified stage L /01/2015 Pressure ulcer of sacral region, unstageable L /01/2015 Pressure ulcer of sacral region, stage 1 L /01/2015 Pressure ulcer of sacral region, stage 2 L /01/2015 Pressure ulcer of sacral region, stage 3 L /01/2015 Pressure ulcer of sacral region, stage 4 L /01/2015 Pressure ulcer of sacral region, unspecified stage L /01/2015 Pressure ulcer of unspecified hip, unstageable L /01/2015 Pressure ulcer of unspecified hip, stage 1 L /01/2015 Pressure ulcer of unspecified hip, stage 2 10

37 Attachment C L /01/2015 Pressure ulcer of unspecified hip, stage 3 L /01/2015 Pressure ulcer of unspecified hip, stage 4 L /01/2015 Pressure ulcer of unspecified hip, unspecified stage L /01/2015 Pressure ulcer of right hip, unstageable L /01/2015 Pressure ulcer of right hip, stage 1 L /01/2015 Pressure ulcer of right hip, stage 2 L /01/2015 Pressure ulcer of right hip, stage 3 L /01/2015 Pressure ulcer of right hip, stage 4 L /01/2015 Pressure ulcer of right hip, unspecified stage L /01/2015 Presure ulcer of left hip, unstageable L /01/2015 Pressure ulcer of left hip, stage 1 L /01/2015 Pressure ulcer of left hip, stage 2 L /01/2015 Pressure ulcer of left hip, stage 3 L /01/2015 Pressure ulcer of left hip, stage 4 L /01/2015 Pressure ulcer of left hip, unspecified stage L /01/2015 Pressure ulcer of unspecified buttock, unstageable L /01/2015 Pressure ulcer of unspecified buttock, stage 1 L /01/2015 Pressure ulcer of unspecified buttock, stage 2 L /01/2015 Pressure ulcer of unspecified buttock, stage 3 L /01/2015 Pressure ulcer of unspecified buttock, stage 4 L /01/2015 Pressure ulcer of unspecified buttock, unspecified stage L /01/2015 Pressure ulcer of right buttock, unstageable L /01/2015 Pressure ulcer of right buttock, stage 1 L /01/2015 Pressure ulcer of right buttock, stage 2 L /01/2015 Pressure ulcer of right buttock, stage 3 L /01/2015 Pressure ulcer of right buttock, stage 4 L /01/2015 Pressure ulcer of right buttock, unspecified stage L /01/2015 Pressure ulcer of left buttock, unstageable L /01/2015 Pressure ulcer of left buttock, stage 1 L /01/2015 Pressure ulcer of left buttock, stage 2 L /01/2015 Pressure ulcer of left buttock, stage 3 L /01/2015 Pressure ulcer of left buttock, stage 4 L /01/2015 Pressure ulcer of left buttock, unspecified stage L /01/2015 Pressure ulcer of contiguous site of back, buttock, and hip, unspecified stage L /01/2015 Pressure ulcer of contiguous site of back, buttock, and hip, stage 1 L /01/2015 Pressure ulcer of contiguous site of back, buttock, and hip, stage 2 L /01/2015 Pressure ulcer of contiguous site of back, buttock, and hip, stage 11

38 Attachment C 3 L /01/2015 Pressure ulcer of contiguous site of back, buttock, and hip, stage 4 L /01/2015 Pressure ulcer of contiguous site of back, buttock, and hip, unstageable L /01/2015 Pressure ulcer of unspecified ankle, unstageable L /01/2015 Pressure ulcer of unspecified ankle, stage 1 L /01/2015 Pressure ulcer of unspecified ankle, stage 2 L /01/2015 Pressure ulcer of unspecified ankle, stage 3 L /01/2015 Pressure ulcer of unspecified ankle, stage 4 L /01/2015 Pressure ulcer of right ankle, unstageable L /01/2015 Pressure ulcer of right ankle, stage 1 L /01/2015 Pressure ulcer of right ankle, stage 2 L /01/2015 Pressure ulcer of right ankle, stage 3 L /01/2015 Pressure ulcer of right ankle, stage 4 L /01/2015 Pressure ulcer of right ankle, unspecified stage L /01/2015 Pressure ulcer of left ankle, unstageable L /01/2015 Pressure ulcer of left ankle, stage 1 L /01/2015 Pressure ulcer of left ankle, stage 2 L /01/2015 Pressure ulcer of left ankle, stage 3 L /01/2015 Pressure ulcer of left ankle, stage 4 L /01/2015 Pressure ulcer of left ankle, unspecified stage L /01/2015 Pressure ulcer of unspecified heel, unstageable L /01/2015 Pressure ulcer of unspecified heel, stage 1 L /01/2015 Pressure ulcer of unspecified heel, stage 2 L /01/2015 Pressure ulcer of unspecified heel, stage 3 L /01/2015 Pressure ulcer of unspecified heel, stage 4 L /01/2015 Pressure ulcer of unspecified heel, unspecified stage L /01/2015 Pressure ulcer of right heel, unstageable L /01/2015 Pressure ulcer of right heel, stage 1 L /01/2015 Pressure ulcer of right heel, stage 2 L /01/2015 Pressure ulcer of right heel, stage 3 L /01/2015 Pressure ulcer of right heel, stage 4 L /01/2015 Pressure ulcer of right heel, unspecified stage L /01/2015 Pressure ulcer of left heel, unstageable L /01/2015 Pressure ulcer of left heel, stage 1 L /01/2015 Pressure ulcer of left heel, stage 2 L /01/2015 Pressure ulcer of left heel, stage 3 L /01/2015 Pressure ulcer of left heel, stage 4 L /01/2015 Pressure ulcer of left heel, unspecified stage 12

39 Attachment C L /01/2015 Pressure ulcer of head, unstageable L /01/2015 Pressure ulcer of head, stage 1 L /01/2015 Pressure ulcer of head, stage 2 L /01/2015 Pressure ulcer of head, stage 3 L /01/2015 Pressure ulcer of head, stage 4 L /01/2015 Pressure ulcer of head, unspecified stage L /01/2015 Pressure ulcer of other site, unstageable L /01/2015 Pressure ulcer of other site, stage 1 L /01/2015 Pressure ulcer of other site, stage 2 L /01/2015 Pressure ulcer of other site, stage 3 L /01/2015 Pressure ulcer of other site, stage 4 L /01/2015 Pressure ulcer of other site, unspecified stage L /01/2015 Pressure ulcer of unspecified site, unspecified stage L /01/2015 Pressure ulcer of unspecified site, stage 1 L /01/2015 Pressure ulcer of unspecified site, stage 2 L /01/2015 Pressure ulcer of unspecified site, stage 3 L /01/2015 Pressure ulcer of unspecified site, stage 4 L /01/2015 Pressure ulcer of unspecified site, unstageable L /01/2015 Non-pressure chronic ulcer of unspecified thigh limited to breakdown of skin L /01/2015 Non-pressure chronic ulcer of unspecified thigh w/ fat layer exposed L /01/2015 Non-pressure chronic ulcer of unspecified thigh w/ necrosis of muscle L /01/2015 Non-pressure chronic ulcer of unspecified thigh w/ necrosis of bone L /01/2015 Non-pressure chronic ulcer of unspecified thigh w/ unspecified severity L /01/2015 Non-pressure chronic ulcer of right thigh limited to breakdown of skin L /01/2015 Non-pressure chronic ulcer of right thigh w/ fat layer exposed L /01/2015 Non-pressure chronic ulcer of right thigh w/ necrosis of muscle L /01/2015 Non-pressure chronic ulcer of right thigh w/ necrosis of bone L /01/2015 Non-pressure chronic ulcer of right thigh w/ unspecified severity L /01/2015 Non-pressure chronic ulcer of left thigh limited to breakdown of skin L /01/2015 Non-pressure chronic ulcer of left thigh w/ fat layer exposed L /01/2015 Non-pressure chronic ulcer of left thigh w/ necrosis of muscle L /01/2015 Non-pressure chronic ulcer of left thigh w/ necrosis of bone L /01/2015 Non-pressure chronic ulcer of left thigh w/ unspecified severity L /01/2015 Non-pressure chronic ulcer of unspecified calf limited to 13

40 Attachment C breakdown of skin L /01/2015 Non-pressure chronic ulcer of unspecified calf w/ fat layer exposed L /01/2015 Non-pressure chronic ulcer of unspecified calf w/ necrosis of muscle L /01/2015 Non-pressure chronic ulcer of unspecified calf w/ necrosis of bone L /01/2015 Non-pressure chronic ulcer of unspecified calf w/ unspecified severity L /01/2015 Non-pressure chronic ulcer of right calf limited to breakdown of skin L /01/2015 Non-pressure chronic ulcer of right calf w/ fat layer exposed L /01/2015 Non-pressure chronic ulcer of right calf w/ necrosis of muscle L /01/2015 Non-pressure chronic ulcer of right calf w/ necrosis of bone L /01/2015 Non-pressure chronic ulcer of right calf w/ unspecified severity L /01/2015 Non-pressure chronic ulcer of left calf limited to breakdown of skin L /01/2015 Non-pressure chronic ulcer of left calf w/ fat layer exposed L /01/2015 Non-pressure chronic ulcer of left calf w/ necrosis of muscle L /01/2015 Non-pressure chronic ulcer of left calf w/ necrosis of bone L /01/2015 Non-pressure chronic ulcer of left calf w/ unspecified severity L /01/2015 Non-pressure chronic ulcer of unspecified ankle limited to breakdown of skin L /01/2015 Non-pressure chronic ulcer of unspecified ankle w/ fat layer exposed L /01/2015 Non-pressure chronic ulcer of unspecified ankle w/ necrosis of muscle L /01/2015 Non-pressure chronic ulcer of unspecified ankle w/ necrosis of bone L /01/2015 Non-pressure chronic ulcer of unspecified ankle w/ unspecified severity L /01/2015 Non-pressure chronic ulcer of right ankle limited to breakdown of skin L /01/2015 Non-pressure chronic ulcer of right ankle w/ fat layer exposed L /01/2015 Non-pressure chronic ulcer of right ankle w/ necrosis of muscle L /01/2015 Non-pressure chronic ulcer of right ankle w/ necrosis of bone L /01/2015 Non-pressure chronic ulcer of right ankle w/ unspecified severity L /01/2015 Non-pressure chronic ulcer of left ankle limited to breakdown of skin L /01/2015 Non-pressure chronic ulcer of left ankle w/ fat layer exposed L /01/2015 Non-pressure chronic ulcer of left ankle w/ necrosis of muscle L /01/2015 Non-pressure chronic ulcer of left ankle w/ necrosis of bone 14

41 Attachment C L /01/2015 Non-pressure chronic ulcer of left ankle w/ unspecified severity L /01/2015 Non-pressure chronic ulcer of unspecified heel and midfoot limited to breakdown of skin L /01/2015 Non-pressure chronic ulcer of unspecified heel and midfoot w/ fat layer exposed L /01/2015 Non-pressure chronic ulcer of unspecified heel and midfoot w/ necrosis of muscle L /01/2015 Non-pressure chronic ulcer of unspecified heel and midfoot w/ necrosis of bone L /01/2015 Non-pressure chronic ulcer of unspecified heel and midfoot w/ unspecified severity L /01/2015 Non-pressure chronic ulcer of right heel and midfoot limited to breakdown of skin L /01/2015 Non-pressure chronic ulcer of right heel and midfoot w/ fat layer exposed L /01/2015 Non-pressure chronic ulcer of right heel and midfoot w/ necrosis of muscle L /01/2015 Non-pressure chronic ulcer of right heel and midfoot w/ necrosis of bone L /01/2015 Non-pressure chronic ulcer of right heel and midfoot w/ unspecified severity L /01/2015 Non-pressure chronic ulcer of left heel and midfoot limited to breakdown of skin L /01/2015 Non-pressure chronic ulcer of left heel and midfoot w/ fat layer exposed L /01/2015 Non-pressure chronic ulcer of left heel and midfoot w/ necrosis of muscle L /01/2015 Non-pressure chronic ulcer of left heel and midfoot w/ necrosis of bone L /01/2015 Non-pressure chronic ulcer of left heel and midfoot w/ unspecified severity L /01/2015 Non-pressure chronic ulcer of other part of unspecified foot limited to breakdown of skin L /01/2015 Non-pressure chronic ulcer of other part of unspecified foot w/ fat layer exposed L /01/2015 Non-pressure chronic ulcer of other part of unspecified foot w/ necrosis of muscle L /01/2015 Non-pressure chronic ulcer of other part of unspecified foot w/ necrosis of bone L /01/2015 Non-pressure chronic ulcer of other part of unspecified foot w/ unspecified severity L /01/2015 Non-pressure chronic ulcer of other part of right foot limited to breakdown of skin 15

42 Attachment C L /01/2015 Non-pressure chronic ulcer of other part of right foot w/ fat layer exposed L /01/2015 Non-pressure chronic ulcer of other part of right foot w/ necrosis of muscle L /01/2015 Non-pressure chronic ulcer of other part of right foot w/ necrosis of bone L /01/2015 Non-pressure chronic ulcer of other part of right foot w/ unspecified severity L /01/2015 Non-pressure chronic ulcer of other part of left foot limited to breakdown of skin L /01/2015 Non-pressure chronic ulcer of other part of left foot w/ fat layer exposed L /01/2015 Non-pressure chronic ulcer of other part of left foot w/ necrosis of muscle L /01/2015 Non-pressure chronic ulcer of other part of left foot w/ necrosis of bone L /01/2015 Non-pressure chronic ulcer of other part of left foot w/ unspecified severity L /01/2015 Non-pressure chronic ulcer of other part of unspecified lower leg limited to breakdown of skin L /01/2015 Non-pressure chronic ulcer of other part of unspecified lower leg w/ fat layer exposed L /01/2015 Non-pressure chronic ulcer of other part of unspecified lower leg w/ necrosis of muscle L /01/2015 Non-pressure chronic ulcer of other part of unspecified lower leg w/ necrosis of bone L /01/2015 Non-pressure chronic ulcer of other part of unspecified lower leg w/ unspecified severity L /01/2015 Non-pressure chronic ulcer of other part of right lower leg limited to breakdown of skin L /01/2015 Non-pressure chronic ulcer of other part of right lower leg w/ fat layer exposed L /01/2015 Non-pressure chronic ulcer of other part of right lower leg w/ necrosis of muscle L /01/2015 Non-pressure chronic ulcer of other part of right lower leg w/ necrosis of bone L /01/2015 Non-pressure chronic ulcer of other part of right lower leg w/ unspecified severity L /01/2015 Non-pressure chronic ulcer of other part of left lower leg limited to breakdown of skin L /01/2015 Non-pressure chronic ulcer of other part of left lower leg w/ fat layer exposed L /01/2015 Non-pressure chronic ulcer of other part of left lower leg w/ 16

43 Attachment C necrosis of muscle L /01/2015 Non-pressure chronic ulcer of other part of left lower leg w/ necrosis of bone L /01/2015 Non-pressure chronic ulcer of other part of left lower leg w/ unspecified severity L /01/2015 Non-pressure chronic ulcer of unspecified part of unspecified lower leg limited to breakdown of skin L /01/2015 Non-pressure chronic ulcer of unspecified part of unspecified lower leg w/ fat layer exposed L /01/2015 Non-pressure chronic ulcer of unspecified part of unspecified lower leg w/ necrosis of muscle L /01/2015 Non-pressure chronic ulcer of unspecified part of unspecified lower leg w/ necrosis of bone L /01/2015 Non-pressure chronic ulcer of unspecified part of unspecified lower leg w/ unspecified severity L /01/2015 Non-pressure chronic ulcer of unspecified part of right lower leg limited to breakdown of skin L /01/2015 Non-pressure chronic ulcer of unspecified part of right lower leg w/ fat layer exposed L /01/2015 Non-pressure chronic ulcer of unspecified part of right lower leg w/ necrosis of muscle L /01/2015 Non-pressure chronic ulcer of unspecified part of right lower leg w/ necrosis of bone L /01/2015 Non-pressure chronic ulcer of unspecified part of right lower leg w/ unspecified severity L /01/2015 Non-pressure chronic ulcer of unspecified part of left lower leg limited to breakdown of skin L /01/2015 Non-pressure chronic ulcer of unspecified part of left lower leg w/ fat layer exposed L /01/2015 Non-pressure chronic ulcer of unspecified part of left lower leg w/ necrosis of muscle L /01/2015 Non-pressure chronic ulcer of unspecified part of left lower leg w/ necrosis of bone L /01/2015 Non-pressure chronic ulcer of unspecified part of left lower leg w/ unspecified severity L /01/2015 Non-pressure chronic ulcer of buttock limited to breakdown of skin L /01/2015 Non-pressure chronic ulcer of buttock w/ fat layer exposed L /01/2015 Non-pressure chronic ulcer of buttock w/ necrosis of muscle L /01/2015 Non-pressure chronic ulcer of buttock w/ necrosis of bone L /01/2015 Non-pressure chronic ulcer of buttock w/ unspecified severity L /01/2015 Non-pressure chronic ulcer of back limited to breakdown of skin L /01/2015 Non-pressure chronic ulcer of back w/ fat layer exposed 17

44 Attachment C L /01/2015 Non-pressure chronic ulcer of back w/ necrosis of muscle L /01/2015 Non-pressure chronic ulcer of back w/ necrosis of bone L /01/2015 Non-pressure chronic ulcer of back w/ unspecified severity M /01/2015 Osteoarthritis of knee, unspecified M /01/2015 Low back pain N /01/2015 Chronic kidney disease, stage 1 N /01/2015 Chronic kidney disease, Stage 2 (mild) N /01/2015 Chronic kidney disease, Stage 3 (moderate) N /01/2015 Chronic kidney disease, Stage 4 (severe) N /01/2015 Chronic kidney disease, Stage 5 N /01/2015 End stage renal disease N /01/2015 Chronic kidney disease, unspecified N /01/2015 Urinary tract infection, site not specified R /01/2015 Dyspnea, unspecified R /01/2015 Shortness of breath R /01/2015 Other forms of dyspnea R /01/2015 Periodic breathing R /01/2015 Snoring R /01/2015 Other abnormalities of breathing R /01/2015 Intercostal pain R /01/2015 Other chest pain R /01/2015 Chest pain, unspecified R /01/2015 Acute abdomen R /01/2015 Pain localized to other parts of lower abdomen, right lower quadrant pain R /01/2015 Pain localized to other parts of lower abdomen, left lower quadrant pain R /01/2015 Unspecified abdominal pain R /01/2015 Vomiting, unspecified R /01/2015 Vomiting w/o nausea R /01/2015 Projectile vomiting R /01/2015 Nausea w/ vomiting, unspecified R /01/2015 Malignant ascites R /01/2015 Other ascites R42 10/01/2015 Dizziness and giddiness R55 10/01/2015 Syncope and collapse R /01/2015 Unspecified convulsions R /01/2015 Anorexia 18

45 Attachment D APR DRG Codes Subject to Prepayment Review For Inpatient Discharges On and After July 1, 2014 APR DRG Severity of Illness Indicator Beginning Review /01/14 Seizure (Note: No review of patients < 17 years of age) /01/14 Migraine and Other Headaches /01/14 Hypertension /01/14 Chest Pain /01/14 Other Esophageal Disorders (Note: No review of newborns 0-28 days of age) /01/14 Non-bacterial Gastroenteritis, Nausea and Vomiting (Note: No review of newborns 0-28 days of age) /01/14 Abdominal Pain (Note: No review of newborns 0-28 days of age) /01/14 Other Back and Neck Disorders, Fractures and Injuries /01/14 Menstrual and Other Female Reproductive System Disorders /01/14 Cesarean Delivery /01/14 Dilation and Curettage, Aspiration Curettage or Hysterotomy for Obstetric Diagnoses /01/14 Opioid Abuse and Dependence (Note: No review of newborns 0-28 days of age) /01/14 Cocaine Abuse and Dependence (Note: No review of newborns 0-28 days of age) /01/14 Alcohol Abuse and Dependence (Note: No review of newborns 0-28 days of age) /01/14 Other Drug Abuse and Dependence (Note: No review of newborns 0-28 days of age) /01/14 Extensive Procedure Unrelated to Principal Diagnosis /01/14 Non-Extensive OR procedure Unrelated to Principal Diagnosis 1

46 Attachment E ICD-10-CM DIAGNOSIS CODES Subject to Prepayment Review Based on the Admitting Diagnosis Code A DRG or per diem-reimbursed claim for a one-day stay that contains an Admitting Diagnosis code below may be subject to prepayment review when the discharge or transfer occurs on the same calendar date as the admission, or occurs on the date following the admission. E /01/2015 Morbid (severe) obesity due to excess calories J /01/2015 Acute bronchiolitis due to other specified organisms J /01/2015 Acute bronchiolitis due to human metapneumovirus J /01/2015 Acute bronchiolitis, unspecified K /01/2015 Unspecified acute appendicitis K /01/2015 Other acute appendicitis K /01/2015 Acute pancreatitis, unspecified K /01/2015 Idiopathic acute pancreatitis K /01/2015 Biliary acute pancreatitis K /01/2015 Alcohol induced acute pancreatitis K /01/2015 Drug induced acute pancreatitis K /01/2015 Other acute pancreatitis K /01/2015 Gastrointestinal hemorrhage, unspecified L /01/2015 Cellulitis of unspecified part of limb L /01/2015 Acute lymphangitis of unspecified part of limb L /01/2015 Cutaneous abscess of right lower limb L /01/2015 Cutaneous abscess of left lower limb L /01/2015 Cutaneous abscess of limb, unspecified L /01/2015 Cellulitis of right lower limb L /01/2015 Cellulitis of left lower limb L /01/2015 Acute lymphangitis of right lower limb L /01/2015 Acute lymphangitis of left lower limb R /01/2015 Altered mental status, unspecified R /01/2015 Disorientation, unspecified 1

47 Attachment F ICD-10 CM Procedure Codes Subject to Prior Authorization Review Based on Elective Admissions for the Planned Procedure Code All elective admissions for ICD-10-PCS procedure codes identified on Attachment F require prior authorization review. Hospitals enrolled as Long Term Acute Care (LTAC) hospitals are exempt from this type of review. Coronary Artery Bypass Surgery Code Beginning Review /01/2015 Bypass Coronary Artery, One Site from Coronary Artery with Autologous Venous Tissue, Open /01/2015 Bypass Coronary Artery, One Site from Right Internal Mammary with Autologous Venous Tissue, Open /01/2015 Bypass Coronary Artery, One Site from Left Internal Mammary with Autologous Venous Tissue, Open C 10/01/2015 Bypass Coronary Artery, One Site from Thoracic Artery with Autologous Venous Tissue, Open F 10/01/2015 Bypass Coronary Artery, One Site from Abdominal Artery with Autologous Venous Tissue, Open W 10/01/2015 Bypass Coronary Artery, One Site from Aorta with Autologous Venous Tissue, Open 02100A3 10/01/2015 Bypass Coronary Artery, One Site from Coronary Artery with Autologous Arterial Tissue, Open 02100A8 10/01/2015 Bypass Coronary Artery, One Site from Right Internal Mammary with Autologous Arterial Tissue, Open 02100A9 10/01/2015 Bypass Coronary Artery, One Site from Left Internal Mammary with Autologous Arterial Tissue, Open 02100AC 10/01/2015 Bypass Coronary Artery, One Site from Thoracic Artery with Autologous Arterial Tissue, Open 02100AF 10/01/2015 Bypass Coronary Artery, One Site from Abdominal Artery with Autologous Arterial Tissue, Open 02100AW 10/01/2015 Bypass Coronary Artery, One Site from Aorta with Autologous Arterial Tissue, Open 02100J3 10/01/2015 Bypass Coronary Artery, One Site from Coronary Artery with Synthetic Substitute, Open 02100J8 10/01/2015 Bypass Coronary Artery, One Site from Right Internal Mammary with Synthetic Substitute, Open 02100J9 10/01/2015 Bypass Coronary Artery, One Site from Left Internal Mammary with Synthetic Substitute, Open 02100JC 10/01/2015 Bypass Coronary Artery, One Site from Thoracic Artery with Synthetic Substitute, Open 02100JF 10/01/2015 Bypass Coronary Artery, One Site from Abdominal Artery with Synthetic Substitute, Open 1

48 Attachment F Code Beginning Review 02100JW 10/01/2015 Bypass Coronary Artery, One Site from Aorta with Synthetic Substitute, Open 02100K3 10/01/2015 Bypass Coronary Artery, One Site from Coronary Artery with Nonautologous Tissue Substitute, Open 02100K8 10/01/2015 Bypass Coronary Artery, One Site from Right Internal Mammary with Nonautologous Tissue Substitute, Open 02100K9 10/01/2015 Bypass Coronary Artery, One Site from Left Internal Mammary with Nonautologous Tissue Substitute, Open 02100KC 10/01/2015 Bypass Coronary Artery, One Site from Thoracic Artery with Nonautologous Tissue Substitute, Open 02100KF 10/01/2015 Bypass Coronary Artery, One Site from Abdominal Artery with Nonautologous Tissue Substitute, Open 02100KW 10/01/2015 Bypass Coronary Artery, One Site from Aorta with Nonautologous Tissue Substitute, Open 02100Z3 10/01/2015 Bypass Coronary Artery, One Site from Coronary Artery, Open 02100Z8 10/01/2015 Bypass Coronary Artery, One Site from Right Internal Mammary, Open 02100Z9 10/01/2015 Bypass Coronary Artery, One Site from Left Internal Mammary, Open 02100ZC 10/01/2015 Bypass Coronary Artery, One Site from Thoracic Artery, Open 02100ZF 10/01/2015 Bypass Coronary Artery, One Site from Abdominal Artery, Open /01/2015 Bypass Coronary Artery, One Site from Coronary Artery with Autologous Venous Tissue, Percutaneous Endoscopic /01/2015 Bypass Coronary Artery, One Site from Right Internal Mammary with Autologous Venous Tissue, Percutaneous Endoscopic /01/2015 Bypass Coronary Artery, One Site from Left Internal Mammary with Autologous Venous Tissue, Percutaneous Endoscopic C 10/01/2015 Bypass Coronary Artery, One Site from Thoracic Artery with Autologous Venous Tissue, Percutaneous Endoscopic F 10/01/2015 Bypass Coronary Artery, One Site from Abdominal Artery with Autologous Venous Tissue, Percutaneous Endoscopic W 10/01/2015 Bypass Coronary Artery, One Site from Aorta with Autologous Venous Tissue, Percutaneous Endoscopic 2

49 Attachment F Code Beginning Review 02104A3 10/01/2015 Bypass Coronary Artery, One Site from Coronary Artery with Autologous Arterial Tissue, Percutaneous Endoscopic 02104A8 10/01/2015 Bypass Coronary Artery, One Site from Right Internal Mammary with Autologous Arterial Tissue, Percutaneous Endoscopic 02104A9 10/01/2015 Bypass Coronary Artery, One Site from Left Internal Mammary with Autologous Arterial Tissue, Percutaneous Endoscopic 02104AC 10/01/2015 Bypass Coronary Artery, One Site from Thoracic Artery with Autologous Arterial Tissue, Percutaneous Endoscopic 02104AF 10/01/2015 Bypass Coronary Artery, One Site from Abdominal Artery with Autologous Arterial Tissue, Percutaneous Endoscopic 02104AW 10/01/2015 Bypass Coronary Artery, One Site from Aorta with Autologous Arterial Tissue, Percutaneous Endoscopic 02104J3 10/01/2015 Bypass Coronary Artery, One Site from Coronary Artery with Synthetic Substitute, Percutaneous Endoscopic 02104J8 10/01/2015 Bypass Coronary Artery, One Site from Right Internal Mammary with Synthetic Substitute, Percutaneous Endoscopic 02104J9 10/01/2015 Bypass Coronary Artery, One Site from Left Internal Mammary with Synthetic Substitute, Percutaneous Endoscopic 02104JC 10/01/2015 Bypass Coronary Artery, One Site from Thoracic Artery with Synthetic Substitute, Percutaneous Endoscopic 02104JF 10/01/2015 Bypass Coronary Artery, One Site from Abdominal Artery with with Synthetic Substitute, Percutaneous Endoscopic / 02104JW 10/01/2015 Bypass Coronary Artery, One Site from Aorta with Synthetic Substitute, Percutaneous Endoscopic 02104K3 10/01/2015 Bypass Coronary Artery, One Site from Coronary Artery with Nonautologous Tissue Substitute, Percutaneous Endoscopic 02104K8 10/01/2015 Bypass Coronary Artery, One Site from Right Internal Mammary with Nonautologous Tissue Substitute, Percutaneous Endoscopic 02104K9 10/01/2015 Bypass Coronary Artery, One Site from Left Internal Mammary with Nonautologous Tissue Substitute, Percutaneous Endoscopic 02104KC 10/01/2015 Bypass Coronary Artery, One Site from Thoracic Artery with Nonautologous Tissue Substitute, Percutaneous Endoscopic 3

50 Attachment F Code Beginning Review 02104KF 10/01/2015 Bypass Coronary Artery, One Site from Abdominal Artery with Nonautologous Tissue Substitute, Percutaneous Endoscopic 02104KW 10/01/2015 Bypass Coronary Artery, One Site from Aorta with Nonautologous Tissue Substitute, Percutaneous Endoscopic 02104Z3 10/01/2015 Bypass Coronary Artery, One Site from Coronary Artery, Percutaneous Endoscopic 02104Z8 10/01/2015 Bypass Coronary Artery, One Site from Right Internal Mammary, Percutaneous Endoscopic 02104Z9 10/01/2015 Bypass Coronary Artery, One Site from Left Internal Mammary, Percutaneous Endoscopic 02104ZC 10/01/2015 Bypass Coronary Artery, One Site from Thoracic Artery, Percutaneous Endoscopic 02104ZF 10/01/2015 Bypass Coronary Artery, One Site from Abdominal Artery, Percutaneous Endoscopic /01/2015 Bypass Coronary Artery, Two Sites from Coronary Artery with Autologous Venous Tissue, Open /01/2015 Bypass Coronary Artery, Two Sites from Right Internal Mammary with Autologous Venous Tissue, Open /01/2015 Bypass Coronary Artery, Two Sites from Left Internal Mammary with Autologous Venous Tissue, Open C 10/01/2015 Bypass Coronary Artery, Two Sites from Thoracic Artery with Autologous Venous Tissue, Open F 10/01/2015 Bypass Coronary Artery, Two Sites from Abdominal Artery with Autologous Venous Tissue, Open W 10/01/2015 Bypass Coronary Artery, Two Sites from Aorta with Autologous Venous Tissue, Open 02110A3 10/01/2015 Bypass Coronary Artery, Two Sites from Coronary Artery with Autologous Arterial Tissue, Open 02110A8 10/01/2015 Bypass Coronary Artery, Two Sites from Right Internal Mammary with Autologous Arterial Tissue, Open 02110A9 10/01/2015 Bypass Coronary Artery, Two Sites from Left Internal Mammary with Autologous Arterial Tissue, Open 02110AC 10/01/2015 Bypass Coronary Artery, Two Sites from Thoracic Artery with Autologous Arterial Tissue, Open 02110AF 10/01/2015 Bypass Coronary Artery, Two Sites from Abdominal Artery with Autologous Arterial Tissue, Open 02110AW 10/01/2015 Bypass Coronary Artery, Two Sites from Aorta with Autologous Arterial Tissue, Open 02110J3 10/01/2015 Bypass Coronary Artery, Two Sites from Coronary Artery with Synthetic Substitute, Open 02110J8 10/01/2015 Bypass Coronary Artery, Two Sites from Right Internal 4

51 Attachment F Code Beginning Review Mammary with Synthetic Substitute, Open 02110J9 10/01/2015 Bypass Coronary Artery, Two Sites from Left Internal Mammary with Synthetic Substitute, Open 02110JC 10/01/2015 Bypass Coronary Artery, Two Sites from Thoracic Artery with Synthetic Substitute, Open 02110JF 10/01/2015 Bypass Coronary Artery, Two Sites from Abdominal Artery with Synthetic Substitute, Open 02110JW 10/01/2015 Bypass Coronary Artery, Two Sites from Aorta with Synthetic Substitute, Open 02110K3 10/01/2015 Bypass Coronary Artery, Two Sites from Coronary Artery with Nonautologous Tissue Substitute, Open 02110K8 10/01/2015 Bypass Coronary Artery, Two Sites from Right Internal Mammary with Nonautologous Tissue Substitute, Open 02110K9 10/01/2015 Bypass Coronary Artery, Two Sites from Left Internal Mammary with Nonautologous Tissue Substitute, Open 02110KC 10/01/2015 Bypass Coronary Artery, Two Sites from Thoracic Artery with Nonautologous Tissue Substitute, Open 02110KF 10/01/2015 Bypass Coronary Artery, Two Sites from Abdominal Artery with Nonautologous Tissue Substitute, Open 02110KW 10/01/2015 Bypass Coronary Artery, Two Sites from Aorta with Nonautologous Tissue Substitute, Open 02110Z3 10/01/2015 Bypass Coronary Artery, Two Sites from Coronary Artery, Open 02110Z8 10/01/2015 Bypass Coronary Artery, Two Sites from Right Internal Mammary, Open 02110Z9 10/01/2015 Bypass Coronary Artery, Two Sites from Left Internal Mammary, Open 02110ZC 10/01/2015 Bypass Coronary Artery, Two Sites from Thoracic Artery, Open 02110ZF 10/01/2015 Bypass Coronary Artery, Two Sites from Abdominal Artery, Open /01/2015 Bypass Coronary Artery, Two Sites from Coronary Artery with Autologous Venous Tissue, Percutaneous Endoscopic /01/2015 Bypass Coronary Artery, Two Sites from Right Internal Mammary with Autologous Venous Tissue, Percutaneous Endoscopic /01/2015 Bypass Coronary Artery, Two Sites from Left Internal Mammary with Autologous Venous Tissue, Percutaneous Endoscopic C 10/01/2015 Bypass Coronary Artery, Two Sites from Thoracic Artery with Autologous Venous Tissue, Percutaneous Endoscopic 5

52 Attachment F Code Beginning Review F 10/01/2015 Bypass Coronary Artery, Two Sites from Abdominal Artery with Autologous Venous Tissue, Percutaneous Endoscopic W 10/01/2015 (Bypass Coronary Artery, Two Sites from Aorta with Autologous Venous Tissue, Percutaneous Endoscopic 02114A3 10/01/2015 Bypass Coronary Artery, Two Sites from Coronary Artery with Autologous Arterial Tissue, Percutaneous Endoscopic 02114A8 10/01/2015 Bypass Coronary Artery, Two Sites from Right Internal Mammary with Autologous Arterial Tissue, Percutaneous Endoscopic 02114A9 10/01/2015 Bypass Coronary Artery, Two Sites from Left Internal Mammary with Autologous Arterial Tissue, Percutaneous Endoscopic 02114AC 10/01/2015 Bypass Coronary Artery, Two Sites from Thoracic Artery with Autologous Arterial Tissue, Percutaneous Endoscopic 02114AF 10/01/2015 Bypass Coronary Artery, Two Sites from Abdominal Artery with Autologous Arterial Tissue, Percutaneous Endoscopic 02114AW 10/01/2015 (Bypass Coronary Artery, Two Sites from Aorta with Autologous Arterial Tissue, Percutaneous Endoscopic 02114J3 10/01/2015 Bypass Coronary Artery, Two Sites from Coronary Artery with Synthetic Substitute, Percutaneous Endoscopic 02114J8 10/01/2015 Bypass Coronary Artery, Two Sites from Right Internal Mammary with Synthetic Substitute, Percutaneous Endoscopic 02114J9 10/01/2015 Bypass Coronary Artery, Two Sites from Left Internal Mammary with Synthetic Substitute, Percutaneous Endoscopic 02114JC 10/01/2015 Bypass Coronary Artery, Two Sites from Thoracic Artery with Synthetic Substitute, Percutaneous Endoscopic 02114JF 10/01/2015 Bypass Coronary Artery, Two Sites from Abdominal Artery with Synthetic Substitute, Percutaneous Endoscopic 02114JW 10/01/2015 (Bypass Coronary Artery, Two Sites from Aorta with Synthetic Substitute, Percutaneous Endoscopic 02114K3 10/01/2015 Bypass Coronary Artery, Two Sites from Coronary Artery with Nonautologous Tissue Substitute, Percutaneous Endoscopic 02114K8 10/01/2015 Bypass Coronary Artery, Two Sites from Right Internal Mammary with Nonautologous Tissue Substitute, 6

53 Attachment F Code Beginning Review Percutaneous Endoscopic 02114K9 10/01/2015 Bypass Coronary Artery, Two Sites from Left Internal Mammary with Nonautologous Tissue Substitute, Percutaneous Endoscopic 02114KC 10/01/2015 Bypass Coronary Artery, Two Sites from Thoracic Artery with Nonautologous Tissue Substitute, Percutaneous Endoscopic 02114KF 10/01/2015 Bypass Coronary Artery, Two Sites from Abdominal Artery with Nonautologous Tissue Substitute, Percutaneous Endoscopic 02114KW 10/01/2015 Bypass Coronary Artery, Two Sites from Aorta with Nonautologous Tissue Substitute, Percutaneous Endoscopic 02114Z3 10/01/2015 Bypass Coronary Artery, Two Sites from Coronary Artery, Percutaneous Endoscopic 02114Z8 10/01/2015 Bypass Coronary Artery, Two Sites from Right Internal Mammary, Percutaneous Endoscopic 02114Z9 10/01/2015 Bypass Coronary Artery, Two Sites from Left Internal Mammary, Percutaneous Endoscopic 02114ZC 10/01/2015 Bypass Coronary Artery, Two Sites from Thoracic Artery, Percutaneous Endoscopic 02114ZF 10/01/2015 Bypass Coronary Artery, Two Sites from Abdominal Artery, Percutaneous Endoscopic /01/2015 Bypass Coronary Artery, Three Sites from Coronary Artery with Autologous Venous Tissue, Open /01/2015 Bypass Coronary Artery, Three Sites from Right Internal Mammary with Autologous Venous Tissue, Open /01/2015 Bypass Coronary Artery, Three Sites from Left Internal Mammary with Autologous Venous Tissue, Open C 10/01/2015 Bypass Coronary Artery, Three Sites from Thoracic Artery with Autologous Venous Tissue, Open F 10/01/2015 Bypass Coronary Artery, Three Sites from Abdominal Artery with Autologous Venous Tissue, Open W 10/01/2015 Bypass Coronary Artery, Three Sites from Aorta with Autologous Venous Tissue, Open ) 02120A3 10/01/2015 Bypass Coronary Artery, Three Sites from Coronary Artery with Autologous Arterial Tissue, Open 02120A8 10/01/2015 Bypass Coronary Artery, Three Sites from Right Internal Mammary with Autologous Arterial Tissue, Open 02120A9 10/01/2015 Bypass Coronary Artery, Three Sites from Left Internal Mammary with Autologous Arterial Tissue, Open 02120AC 10/01/2015 Bypass Coronary Artery, Three Sites from Thoracic Artery with Autologous Arterial Tissue, Open 02120AF 10/01/2015 Bypass Coronary Artery, Three Sites from Abdominal Artery 7

54 Attachment F Code Beginning Review with Autologous Arterial Tissue, Open 02120AW 10/01/2015 Bypass Coronary Artery, Three Sites from Aorta with Autologous Arterial Tissue, Open ) 02120J3 10/01/2015 Bypass Coronary Artery, Three Sites from Coronary Artery with Synthetic Substitute, Open 02120J8 10/01/2015 Bypass Coronary Artery, Three Sites from Right Internal Mammary with Synthetic Substitute, Open 02120J9 10/01/2015 Bypass Coronary Artery, Three Sites from Left Internal Mammary with Synthetic Substitute, Open 02120JC 10/01/2015 Bypass Coronary Artery, Three Sites from Thoracic Artery with Synthetic Substitute, Open 02120JF 10/01/2015 Bypass Coronary Artery, Three Sites from Abdominal Artery with Synthetic Substitute, Open 02120JW 10/01/2015 Bypass Coronary Artery, Three Sites from Aorta with Synthetic Substitute, Open ) 02120K3 10/01/2015 Bypass Coronary Artery, Three Sites from Coronary Artery with Nonautologous Tissue Substitute, Open 02120K8 10/01/2015 Bypass Coronary Artery, Three Sites from Right Internal Mammary with Nonautologous Tissue Substitute, Open 02120K9 10/01/2015 Bypass Coronary Artery, Three Sites from Left Internal Mammary with Nonautologous Tissue Substitute, Open 02120KC 10/01/2015 Bypass Coronary Artery, Three Sites from Thoracic Artery with Nonautologous Tissue Substitute, Open 02120KF 10/01/2015 Bypass Coronary Artery, Three Sites from Abdominal Artery, Open 02120KW 10/01/2015 Bypass Coronary Artery, Three Sites from Aorta with Nonautologous Tissue Substitute, Open ) 02120Z3 10/01/2015 Bypass Coronary Artery, Three Sites from Coronary Artery, Open 02120Z8 10/01/2015 Bypass Coronary Artery, Three Sites from Right Internal Mammary, Open 02120Z9 10/01/2015 Bypass Coronary Artery, Three Sites from Left Internal Mammary, Open 02120ZC 10/01/2015 Bypass Coronary Artery, Three Sites from Thoracic Artery, Open 02120ZF 10/01/2015 Bypass Coronary Artery, Three Sites from Abdominal Artery, Open /01/2015 Bypass Coronary Artery, Three Sites from Coronary Artery with Autologous Venous Tissue, Percutaneous Endoscopic /01/2015 Bypass Coronary Artery, Three Sites from Right Internal Mammary with Autologous Venous Tissue, Percutaneous 8

55 Attachment F Code Beginning Review Endoscopic /01/2015 Bypass Coronary Artery, Three Sites from Left Internal Mammary with Autologous Venous Tissue, Percutaneous Endoscopic C 10/01/2015 Bypass Coronary Artery, Three Sites from Thoracic Artery with Autologous Venous Tissue, Percutaneous Endoscopic F 10/01/2015 Bypass Coronary Artery, Three Sites from Abdominal Artery with Autologous Venous Tissue, Percutaneous Endoscopic W 10/01/2015 Bypass Coronary Artery, Three Sites from Aorta with Autologous Venous Tissue, Percutaneous Endoscopic ) 02124A3 10/01/2015 Bypass Coronary Artery, Three Sites from Coronary Artery with Autologous Arterial Tissue, Percutaneous Endoscopic 02124A8 10/01/2015 Bypass Coronary Artery, Three Sites from Right Internal Mammary with Autologous Arterial Tissue, Percutaneous Endoscopic 02124A9 10/01/2015 Bypass Coronary Artery, Three Sites from Left Internal Mammary with Autologous Arterial Tissue, Percutaneous Endoscopic 02124AC 10/01/2015 Bypass Coronary Artery, Three Sites from Thoracic Artery with Autologous Arterial Tissue, Percutaneous Endoscopic 02124AF 10/01/2015 Bypass Coronary Artery, Three Sites from Abdominal Artery with Autologous Arterial Tissue, Percutaneous Endoscopic 02124AW 10/01/2015 Bypass Coronary Artery, Three Sites from Aorta with Autologous Arterial Tissue, Percutaneous Endoscopic ) 02124J3 10/01/2015 Bypass Coronary Artery, Three Sites from Coronary Artery with Synthetic Substitute, Percutaneous Endoscopic 02124J8 10/01/2015 Bypass Coronary Artery, Three Sites from Right Internal Mammary with Synthetic Substitute, Percutaneous Endoscopic 02124J9 10/01/2015 Bypass Coronary Artery, Three Sites from Left Internal Mammary with Synthetic Substitute, Percutaneous Endoscopic 02124JC 10/01/2015 Bypass Coronary Artery, Three Sites from Thoracic Artery with Synthetic Substitute, Percutaneous Endoscopic 02124JF 10/01/2015 Bypass Coronary Artery, Three Sites from Abdominal Artery with Synthetic Substitute, Percutaneous Endoscopic 02124JW 10/01/2015 Bypass Coronary Artery, Three Sites from Aorta with 9

56 Attachment F Code Beginning Review Synthetic Substitute, Percutaneous Endoscopic ) 02124K3 10/01/2015 Bypass Coronary Artery, Three Sites from Coronary Artery with Nonautologous Tissue Substitute, Percutaneous Endoscopic 02124K8 10/01/2015 Bypass Coronary Artery, Three Sites from Right Internal Mammary with Nonautologous Tissue Substitute, Percutaneous Endoscopic 02124K9 10/01/2015 Bypass Coronary Artery, Three Sites from Left Internal Mammary with Nonautologous Tissue Substitute, Percutaneous Endoscopic 02124KC 10/01/2015 Bypass Coronary Artery, Three Sites from Thoracic Artery with Nonautologous Tissue Substitute, Percutaneous Endoscopic 02124KF 10/01/2015 Bypass Coronary Artery, Three Sites from Abdominal Artery with Nonautologous Tissue Substitute, Percutaneous Endoscopic 02124KW 10/01/2015 Bypass Coronary Artery, Three Sites from Aorta with Nonautologous Tissue Substitute, Percutaneous Endoscopic ) 02124Z3 10/01/2015 Bypass Coronary Artery, Three Sites from Coronary Artery, Percutaneous Endoscopic 02124Z8 10/01/2015 Bypass Coronary Artery, Three Sites from Right Internal Mammary, Percutaneous Endoscopic 02124Z9 10/01/2015 Bypass Coronary Artery, Three Sites from Left Internal Mammary, Percutaneous Endoscopic 02124ZC 10/01/2015 Bypass Coronary Artery, Three Sites from Thoracic Artery, Percutaneous Endoscopic 02124ZF 10/01/2015 Bypass Coronary Artery, Three Sites from Abdominal Artery, Percutaneous Endoscopic /01/2015 Bypass Coronary Artery, Four or More Sites from Coronary Artery with Autologous Venous Tissue, Open /01/2015 Bypass Coronary Artery, Four or More Sites from Right Internal Mammary with Autologous Venous Tissue, Open /01/2015 Bypass Coronary Artery, Four or More Sites from Left Internal Mammary with Autologous Venous Tissue, Open C 10/01/2015 Bypass Coronary Artery, Four or More Sites from Thoracic Artery with Autologous Venous Tissue, Open F 10/01/2015 Bypass Coronary Artery, Four or More Sites from Abdominal Artery with Autologous Venous Tissue, Open W 10/01/2015 Bypass Coronary Artery, Four or More Sites from Aorta with Autologous Venous Tissue, Open 02130A3 10/01/2015 Bypass Coronary Artery, Four or More Sites from Coronary 10

57 Attachment F Code Beginning Review Artery with Autologous Arterial Tissue, Open 02130A8 10/01/2015 Bypass Coronary Artery, Four or More Sites from Right Internal Mammary with Autologous Arterial Tissue, Open 02130A9 10/01/2015 Bypass Coronary Artery, Four or More Sites from Left Internal Mammary with Autologous Arterial Tissue, Open 02130AC 10/01/2015 Bypass Coronary Artery, Four or More Sites from Thoracic Artery with Autologous Arterial Tissue, Open 02130AF 10/01/2015 Bypass Coronary Artery, Four or More Sites from Abdominal Artery with Autologous Arterial Tissue, Open 02130AW 10/01/2015 Bypass Coronary Artery, Four or More Sites from Aorta with Autologous Arterial Tissue, Open 02130J3 10/01/2015 Bypass Coronary Artery, Four or More Sites from Coronary Artery with Synthetic Substitute, Open 02130J8 10/01/2015 Bypass Coronary Artery, Four or More Sites from Right Internal Mammary with Synthetic Substitute, Open 02130J9 10/01/2015 Bypass Coronary Artery, Four or More Sites from Left Internal Mammary with Synthetic Substitute, Open 02130JC 10/01/2015 Bypass Coronary Artery, Four or More Sites from Thoracic Artery with Synthetic Substitute, Open 02130JF 10/01/2015 Bypass Coronary Artery, Four or More Sites from Abdominal Artery with Synthetic Substitute, Open 02130JW 10/01/2015 Bypass Coronary Artery, Four or More Sites from Aorta with Synthetic Substitute, Open 02130K3 10/01/2015 Bypass Coronary Artery, Four or More Sites from Coronary Artery with Nonautologous Tissue Substitute, Open 02130K8 10/01/2015 Bypass Coronary Artery, Four or More Sites from Right Internal Mammary with Nonautologous Tissue Substitute, Open 02130K9 10/01/2015 Bypass Coronary Artery, Four or More Sites from Left Internal Mammary with Nonautologous Tissue Substitute, Open 02130KC 10/01/2015 Bypass Coronary Artery, Four or More Sites from Thoracic Artery with Nonautologous Tissue Substitute, Open 02130KF 10/01/2015 Bypass Coronary Artery, Four or More Sites from Abdominal Artery with Nonautologous Tissue Substitute, Open 02130KW 10/01/2015 Bypass Coronary Artery, Four or More Sites from Aorta with Nonautologous Tissue Substitute, Open 02130Z3 10/01/2015 Bypass Coronary Artery, Four or More Sites from Coronary Artery, Open 02130Z8 10/01/2015 Bypass Coronary Artery, Four or More Sites from Right Internal Mammary, Open 02130Z9 10/01/2015 Bypass Coronary Artery, Four or More Sites from Left 11

58 Attachment F Code Beginning Review Internal Mammary, Open 02130ZC 10/01/2015 Bypass Coronary Artery, Four or More Sites from Thoracic Artery, Open 02130ZF 10/01/2015 Bypass Coronary Artery, Four or More Sites from Abdominal Artery, Open /01/2015 Bypass Coronary Artery, Four or More Sites from Coronary Artery with Autologous Venous Tissue, Percutaneous Endoscopic /01/2015 Bypass Coronary Artery, Four or More Sites from Right Internal Mammary with Autologous Venous Tissue, Percutaneous Endoscopic /01/2015 Bypass Coronary Artery, Four or More Sites from Left Internal Mammary with Autologous Venous Tissue, Percutaneous Endoscopic C 10/01/2015 Bypass Coronary Artery, Four or More Sites from Thoracic Artery with Autologous Venous Tissue, Percutaneous Endoscopic F 10/01/2015 Bypass Coronary Artery, Four or More Sites from Abdominal Artery with Autologous Venous Tissue, Percutaneous Endoscopic W 10/01/2015 Bypass Coronary Artery, Four or More Sites from Aorta with Autologous Venous Tissue, Percutaneous Endoscopic 02134A3 10/01/2015 Bypass Coronary Artery, Four or More Sites from Coronary Artery with Autologous Arterial Tissue, Percutaneous Endoscopic 02134A8 10/01/2015 Bypass Coronary Artery, Four or More Sites from Right Internal Mammary with Autologous Arterial Tissue, Percutaneous Endoscopic 02134A9 10/01/2015 Bypass Coronary Artery, Four or More Sites from Left Internal Mammary with Autologous Arterial Tissue, Percutaneous Endoscopic 02134AC 10/01/2015 Bypass Coronary Artery, Four or More Sites from Thoracic Artery with Autologous Arterial Tissue, Percutaneous Endoscopic 02134AF 10/01/2015 Bypass Coronary Artery, Four or More Sites from Abdominal Artery with Autologous Arterial Tissue, Percutaneous Endoscopic 02134AW 10/01/2015 Bypass Coronary Artery, Four or More Sites from Aorta with Autologous Arterial Tissue, Percutaneous Endoscopic 02134J3 10/01/2015 Bypass Coronary Artery, Four or More Sites from Coronary Artery with Synthetic Substitute, Percutaneous Endoscopic 12

59 Attachment F Code Beginning Review 02134J8 10/01/2015 Bypass Coronary Artery, Four or More Sites from Right Internal Mammary with Synthetic Substitute, Percutaneous Endoscopic 02134J9 10/01/2015 Bypass Coronary Artery, Four or More Sites from Left Internal Mammary with Synthetic Substitute, Percutaneous Endoscopic 02134JC 10/01/2015 Bypass Coronary Artery, Four or More Sites from Thoracic Artery with Synthetic Substitute, Percutaneous Endoscopic 02134JF 10/01/2015 Bypass Coronary Artery, Four or More Sites from Abdominal Artery with Synthetic Substitute, Percutaneous Endoscopic 02134JW 10/01/2015 Bypass Coronary Artery, Four or More Sites from Aorta with Synthetic Substitute, Percutaneous Endoscopic 02134K3 10/01/2015 Bypass Coronary Artery, Four or More Sites from Coronary Artery with Nonautologous Tissue Substitute, Percutaneous Endoscopic 02134K8 10/01/2015 Bypass Coronary Artery, Four or More Sites from Right Internal Mammary with Nonautologous Tissue Substitute, Percutaneous Endoscopic 02134K9 10/01/2015 Bypass Coronary Artery, Four or More Sites from Left Internal Mammary with Nonautologous Tissue Substitute, Percutaneous Endoscopic 02134KC 10/01/2015 Bypass Coronary Artery, Four or More Sites from Thoracic Artery with Nonautologous Tissue Substitute, Percutaneous Endoscopic 02134KF 10/01/2015 Bypass Coronary Artery, Four or More Sites from Abdominal Artery with Nonautologous Tissue Substitute, Percutaneous Endoscopic 02134KW 10/01/2015 Bypass Coronary Artery, Four or More Sites from Aorta with Nonautologous Tissue Substitute, Percutaneous Endoscopic 02134Z3 10/01/2015 Bypass Coronary Artery, Four or More Sites from Coronary Artery, Percutaneous Endoscopic 02134Z8 10/01/2015 Bypass Coronary Artery, Four or More Sites from Right Internal Mammary, Percutaneous Endoscopic 02134Z9 10/01/2015 Bypass Coronary Artery, Four or More Sites from Left Internal Mammary, Percutaneous Endoscopic 02134ZC 10/01/2015 Bypass Coronary Artery, Four or More Sites from Thoracic Artery, Percutaneous Endoscopic 02134ZF 10/01/2015 Bypass Coronary Artery, Four or More Sites from Abdominal Artery, Percutaneous Endoscopic 13

60 Attachment F Back Surgery 0R530ZZ 10/01/2015 Destruction of Cervical Vertebral Disc, Open 0R533ZZ 10/01/2015 Destruction of Cervical Vertebral Disc, Percutaneous 0R534ZZ 10/01/2015 Destruction of Cervical Vertebral Disc, Percutaneous Endoscopic 0R550ZZ 10/01/2015 Destruction of Cervicothoracic Vertebral Disc, Open 0R553ZZ 10/01/2015 Destruction of Cervicothoracic Vertebral Disc, Percutaneous 0R554ZZ 10/01/2015 Destruction of Cervicothoracic Vertebral Disc, Percutaneous Endoscopic 0R590ZZ 10/01/2015 Destruction of Thoracic Vertebral Disc, Open 0R593ZZ 10/01/2015 Destruction of Thoracic Vertebral Disc, Percutaneous 0R594ZZ 10/01/2015 Destruction of Thoracic Vertebral Disc, Percutaneous Endoscopic 0R5B0ZZ 10/01/2015 Destruction of Thoracolumbar Vertebral Disc, Open 0R5B3ZZ 10/01/2015 Destruction of Thoracolumbar Vertebral Disc, Percutaneous 0R5B4ZZ 10/01/2015 Destruction of Thoracolumbar Vertebral Disc, Percutaneous Endoscopic 0RB30ZZ 10/01/2015 Excision of Cervical Vertebral Disc, Open 0RB33ZZ 10/01/2015 Excision of Cervical Vertebral Disc, Percutaneous 0RB34ZZ 10/01/2015 Excision of Cervical Vertebral Disc, Percutaneous Endoscopic 0RB50ZZ 10/01/2015 Excision of Cervicothoracic Vertebral Disc, Open 0RB53ZZ 10/01/2015 Excision of Cervicothoracic Vertebral Disc, Percutaneous 0RB54ZZ 10/01/2015 Excision of Cervicothoracic Vertebral Disc, Percutaneous Endoscopic 0RB90ZZ 10/01/2015 Excision of Thoracic Vertebral Disc, Open 0RB93ZZ 10/01/2015 Excision of Thoracic Vertebral Disc, Percutaneous 0RB94ZZ 10/01/2015 Excision of Thoracic Vertebral Disc, Percutaneous Endoscopic 0RBB0ZZ 10/01/2015 Excision of Thoracolumbar Vertebral Disc, Open 0RBB3ZZ 10/01/2015 Excision of Thoracolumbar Vertebral Disc, Percutaneous 0RBB4ZZ 10/01/2015 Excision of Thoracolumbar Vertebral Disc, Percutaneous Endoscopic 14

61 Attachment F 0RG /01/2015 Fusion of Cervical Vertebral Joint with Autologous Tissue Substitute, Anterior, Anterior Column, Open 0RG /01/2015 Fusion of Cervical Vertebral Joint with Autologous Tissue Substitute, Posterior, Posterior Column, Open 0RG107J 10/01/2015 Fusion of Cervical Vertebral Joint with Autologous Tissue Substitute, Posterior, Anterior Column, Open 0RG10A0 10/01/2015 Fusion of Cervical Vertebral Joint with Interbody Fusion Device, Anterior, Anterior Column, Open 0RG10A1 10/01/2015 Fusion of Cervical Vertebral Joint with Interbody Fusion Device, Posterior, Posterior Column, Open 0RG10AJ 10/01/2015 Fusion of Cervical Vertebral Joint with Interbody Fusion Device, Posterior, Anterior Column, Open 0RG10J0 10/01/2015 Fusion of Cervical Vertebral Joint with Synthetic Substitute, Anterior, Anterior Column, Open 0RG10J1 10/01/2015 Fusion of Cervical Vertebral Joint with Synthetic Substitute, Posterior, Posterior Column, Open 0RG10JJ 10/01/2015 Fusion of Cervical Vertebral Joint with Synthetic Substitute, Posterior, Anterior Column, Open 0RG10K0 10/01/2015 Fusion of Cervical Vertebral Joint with Nonautologous Tissue Substitute, Anterior, Anterior Column, Open 0RG10K1 10/01/2015 Fusion of Cervical Vertebral Joint with Nonautologous Tissue Substitute, Posterior, Posterior Column, Open 0RG10KJ 10/01/2015 Fusion of Cervical Vertebral Joint with Nonautologous Tissue Substitute, Posterior, Anterior Column, Open 0RG10Z0 10/01/2015 Fusion of Cervical Vertebral Joint, Anterior, Anterior Column, Open 0RG10Z1 10/01/2015 Fusion of Cervical Vertebral Joint, Posterior, Posterior Column, Open 0RG10ZJ 10/01/2015 Fusion of Cervical Vertebral Joint, Posterior, Anterior Column, Open 0RG /01/2015 Fusion of Cervical Vertebral Joint with Autologous Tissue Substitute, Anterior, Anterior Column, Percutaneous 0RG /01/2015 Fusion of Cervical Vertebral Joint with Autologous Tissue Substitute, Posterior, Posterior Column, 15

62 Attachment F Percutaneous 0RG137J 10/01/2015 Fusion of Cervical Vertebral Joint with Autologous Tissue Substitute, Posterior, Anterior Column, Percutaneous 0RG13A0 10/01/2015 Fusion of Cervical Vertebral Joint with Interbody Fusion Device, Anterior, Anterior Column, Percutaneous 0RG13A1 10/01/2015 Fusion of Cervical Vertebral Joint with Interbody Fusion Device, Posterior, Posterior Column, Percutaneous 0RG13AJ 10/01/2015 Fusion of Cervical Vertebral Joint with Interbody Fusion Device, Posterior, Anterior Column, Percutaneous 0RG13J0 10/01/2015 Fusion of Cervical Vertebral Joint with Synthetic Substitute, Anterior, Anterior Column, Percutaneous 0RG13J1 10/01/2015 Fusion of Cervical Vertebral Joint with Synthetic Substitute, Posterior, Posterior Column, Percutaneous 0RG13JJ 10/01/2015 Fusion of Cervical Vertebral Joint with Synthetic Substitute, Posterior, Anterior Column, Percutaneous 0RG13K0 10/01/2015 Fusion of Cervical Vertebral Joint with Nonautologous Tissue Substitute, Anterior, Anterior Column, Percutaneous 0RG13K1 10/01/2015 Fusion of Cervical Vertebral Joint with Nonautologous Tissue Substitute, Posterior, Posterior Column, Percutaneous 0RG13KJ 10/01/2015 Fusion of Cervical Vertebral Joint with Nonautologous Tissue Substitute, Posterior, Anterior Column, Percutaneous 0RG13Z0 10/01/2015 Fusion of Cervical Vertebral Joint, Anterior, Anterior Column, Percutaneous 0RG13Z1 10/01/2015 Fusion of Cervical Vertebral Joint, Posterior, Posterior Column, Percutaneous 0RG13ZJ 10/01/2015 Fusion of Cervical Vertebral Joint, Posterior, Anterior Column, Percutaneous 0RG /01/2015 Fusion of Cervical Vertebral Joint with Autologous Tissue Substitute, Anterior, Anterior Column, Percutaneous Endoscopic 0RG /01/2015 Fusion of Cervical Vertebral Joint with Autologous Tissue Substitute, Posterior, Posterior Column, Percutaneous Endoscopic 0RG147J 10/01/2015 Fusion of Cervical Vertebral Joint with Autologous Tissue Substitute, Posterior, Anterior Column, 16

63 Attachment F Percutaneous Endoscopic 0RG14A0 10/01/2015 Fusion of Cervical Vertebral Joint with Interbody Fusion Device, Anterior, Anterior Column, Percutaneous Endoscopic 0RG14A1 10/01/2015 Fusion of Cervical Vertebral Joint with Interbody Fusion Device, Posterior, Posterior Column, Percutaneous Endoscopic 0RG14AJ 10/01/2015 Fusion of Cervical Vertebral Joint with Interbody Fusion Device, Posterior, Anterior Column, Percutaneous Endoscopic 0RG14J0 10/01/2015 Fusion of Cervical Vertebral Joint with Synthetic Substitute, Anterior, Anterior Column, Percutaneous Endoscopic 0RG14J1 10/01/2015 Fusion of Cervical Vertebral Joint with Synthetic Substitute, Posterior, Posterior Column, Percutaneous Endoscopic 0RG14JJ 10/01/2015 Fusion of Cervical Vertebral Joint with Synthetic Substitute, Posterior, Anterior Column, Percutaneous Endoscopic 0RG14K0 10/01/2015 Fusion of Cervical Vertebral Joint with Nonautologous Tissue Substitute, Anterior, Anterior Column, Percutaneous Endoscopic 0RG14K1 10/01/2015 Fusion of Cervical Vertebral Joint with Nonautologous Tissue Substitute, Posterior, Posterior Column, Percutaneous Endoscopic 0RG14KJ 10/01/2015 Fusion of Cervical Vertebral Joint with Nonautologous Tissue Substitute, Posterior, Anterior Column, Percutaneous Endoscopic 0RG14Z0 10/01/2015 Fusion of Cervical Vertebral Joint, Anterior, Anterior Column, Percutaneous Endoscopic 0RG14Z1 10/01/2015 Fusion of Cervical Vertebral Joint, Posterior, Posterior Column, Percutaneous Endoscopic 0RG14ZJ 10/01/2015 Fusion of Cervical Vertebral Joint, Posterior, Anterior Column, Percutaneous Endoscopic 0RG /01/2015 Fusion of 2 or more Cervical Vertebral Joints with Autologous Tissue Substitute, Anterior, Anterior Column, Open 0RG /01/2015 Fusion of 2 or more Cervical Vertebral Joints with Autologous Tissue Substitute, Posterior, Posterior Column, Open 0RG207J 10/01/2015 Fusion of 2 or more Cervical Vertebral Joints with Autologous Tissue Substitute, Posterior, Anterior Column, Open 0RG20A0 10/01/2015 Fusion of 2 or more Cervical Vertebral Joints with Interbody 17

64 Attachment F Fusion Device, Anterior, Anterior Column, Open 0RG20A1 10/01/2015 Fusion of 2 or more Cervical Vertebral Joints with Interbody Fusion Device, Posterior, Posterior Column, Open 0RG20AJ 10/01/2015 Fusion of 2 or more Cervical Vertebral Joints with Interbody Fusion Device, Posterior, Anterior Column, Open 0RG20J0 10/01/2015 Fusion of 2 or more Cervical Vertebral Joints with Synthetic Substitute, Anterior, Anterior Column, Open 0RG20J1 10/01/2015 Fusion of 2 or more Cervical Vertebral Joints with Synthetic Substitute, Posterior, Posterior Column, Open 0RG20JJ 10/01/2015 Fusion of 2 or more Cervical Vertebral Joints with Synthetic Substitute, Posterior, Anterior Column, Open 0RG20K0 10/01/2015 Fusion of 2 or more Cervical Vertebral Joints with Nonautologous Tissue Substitute, Anterior, Anterior Column, Open 0RG20K1 10/01/2015 Fusion of 2 or more Cervical Vertebral Joints with Nonautologous Tissue Substitute, Posterior, Posterior Column, Open 0RG20KJ 10/01/2015 Fusion of 2 or more Cervical Vertebral Joints with Nonautologous Tissue Substitute, Posterior, Anterior Column, Open 0RG20Z0 10/01/2015 Fusion of 2 or more Cervical Vertebral Joints, Anterior, Anterior Column, Open 0RG20Z1 10/01/2015 Fusion of 2 or more Cervical Vertebral Joints, Posterior, Posterior Column, Open 0RG20ZJ 10/01/2015 Fusion of 2 or more Cervical Vertebral Joints, Posterior, Anterior Column, Open 0RG /01/2015 Fusion of 2 or more Cervical Vertebral Joints with Autologous Tissue Substitute, Anterior, Anterior Column, Percutaneous 0RG /01/2015 Fusion of 2 or more Cervical Vertebral Joints with Autologous Tissue Substitute, Posterior, Posterior Column, Percutaneous 0RG237J 10/01/2015 Fusion of 2 or more Cervical Vertebral Joints with Autologous Tissue Substitute, Posterior, Anterior Column, Percutaneous 0RG23A0 10/01/2015 Fusion of 2 or more Cervical Vertebral Joints with Interbody Fusion Device, Anterior, Anterior Column, Percutaneous 18

65 Attachment F 0RG23A1 10/01/2015 Fusion of 2 or more Cervical Vertebral Joints with Interbody Fusion Device, Posterior, Posterior Column, Percutaneous 0RG23AJ 10/01/2015 Fusion of 2 or more Cervical Vertebral Joints with Interbody Fusion Device, Posterior, Anterior Column, Percutaneous 0RG23J0 10/01/2015 Fusion of 2 or more Cervical Vertebral Joints with Synthetic Substitute, Anterior, Anterior Column, Percutaneous 0RG23J1 10/01/2015 Fusion of 2 or more Cervical Vertebral Joints with Synthetic Substitute, Posterior, Posterior Column, Percutaneous 0RG23JJ 10/01/2015 Fusion of 2 or more Cervical Vertebral Joints with Synthetic Substitute, Posterior, Anterior Column, Percutaneous 0RG23K0 10/01/2015 Fusion of 2 or more Cervical Vertebral Joints with Nonautologous Tissue Substitute, Anterior, Anterior Column, Percutaneous 0RG23K1 10/01/2015 Fusion of 2 or more Cervical Vertebral Joints with Nonautologous Tissue Substitute, Posterior, Posterior Column, Percutaneous 0RG23KJ 10/01/2015 Fusion of 2 or more Cervical Vertebral Joints with Nonautologous Tissue Substitute, Posterior, Anterior Column, Percutaneous 0RG23Z0 10/01/2015 Fusion of 2 or more Cervical Vertebral Joints, Anterior, Anterior Column, Percutaneous 0RG23Z1 10/01/2015 Fusion of 2 or more Cervical Vertebral Joints, Posterior, Posterior Column, Percutaneous 0RG23ZJ 10/01/2015 Fusion of 2 or more Cervical Vertebral Joints, Posterior, Anterior Column, Percutaneous 0RG /01/2015 Fusion of 2 or more Cervical Vertebral Joints with Autologous Tissue Substitute, Anterior, Anterior Column, Percutaneous Endoscopic 0RG /01/2015 Fusion of 2 or more Cervical Vertebral Joints with Autologous Tissue Substitute, Posterior, Posterior Column, Percutaneous Endoscopic 0RG247J 10/01/2015 Fusion of 2 or more Cervical Vertebral Joints with Autologous Tissue Substitute, Posterior, Anterior Column, Percutaneous Endoscopic 0RG24A0 10/01/2015 Fusion of 2 or more Cervical Vertebral Joints with Interbody Fusion Device, Anterior, Anterior Column, Percutaneous Endoscopic 0RG24A1 10/01/2015 Fusion of 2 or more Cervical Vertebral Joints with Interbody Fusion Device, Posterior, Posterior Column, 19

66 Attachment F Percutaneous Endoscopic 0RG24AJ 10/01/2015 Fusion of 2 or more Cervical Vertebral Joints with Interbody Fusion Device, Posterior, Anterior Column, Percutaneous Endoscopic 0RG24J0 10/01/2015 Fusion of 2 or more Cervical Vertebral Joints with Synthetic Substitute, Anterior, Anterior Column, Percutaneous Endoscopic 0RG24J1 10/01/2015 Fusion of 2 or more Cervical Vertebral Joints with Synthetic Substitute, Posterior, Posterior Column, Percutaneous Endoscopic 0RG24JJ 10/01/2015 Fusion of 2 or more Cervical Vertebral Joints with Synthetic Substitute, Posterior, Anterior Column, Percutaneous Endoscopic 0RG24K0 10/01/2015 Fusion of 2 or more Cervical Vertebral Joints with Nonautologous Tissue Substitute, Anterior, Anterior Column, Percutaneous Endoscopic 0RG24K1 10/01/2015 Fusion of 2 or more Cervical Vertebral Joints with Nonautologous Tissue Substitute, Posterior, Posterior Column, Percutaneous Endoscopic 0RG24KJ 10/01/2015 Fusion of 2 or more Cervical Vertebral Joints with Nonautologous Tissue Substitute, Posterior, Anterior Column, Percutaneous Endoscopic 0RG24Z0 10/01/2015 Fusion of 2 or more Cervical Vertebral Joints, Anterior, Anterior Column, Percutaneous Endoscopic 0RG24Z1 10/01/2015 Fusion of 2 or more Cervical Vertebral Joints, Posterior, Posterior Column, Percutaneous Endoscopic 0RG24ZJ 10/01/2015 Fusion of 2 or more Cervical Vertebral Joints, Posterior, Anterior Column, Percutaneous Endoscopic 0RG /01/2015 Fusion of Cervicothoracic Vertebral Joint with Autologous Tissue Substitute, Anterior, Anterior Column, Open 0RG /01/2015 Fusion of Cervicothoracic Vertebral Joint with Autologous Tissue Substitute, Posterior, Posterior Column, Open 0RG407J 10/01/2015 Fusion of Cervicothoracic Vertebral Joint with Autologous Tissue Substitute, Posterior, Anterior Column, Open 0RG40A0 10/01/2015 Fusion of Cervicothoracic Vertebral Joint with Interbody Fusion Device, Anterior, Anterior Column, Open 0RG40A1 10/01/2015 Fusion of Cervicothoracic Vertebral Joint with Interbody 20

67 Attachment F Fusion Device, Posterior, Posterior Column, Open 0RG40AJ 10/01/2015 Fusion of Cervicothoracic Vertebral Joint with Interbody Fusion Device, Posterior, Anterior Column, Open 0RG40J0 10/01/2015 Fusion of Cervicothoracic Vertebral Joint with Synthetic Substitute, Anterior, Anterior Column, Open 0RG40J1 10/01/2015 Fusion of Cervicothoracic Vertebral Joint with Synthetic Substitute, Posterior, Posterior Column, Open 0RG40JJ 10/01/2015 Fusion of Cervicothoracic Vertebral Joint with Synthetic Substitute, Posterior, Anterior Column, Open 0RG40K0 10/01/2015 Fusion of Cervicothoracic Vertebral Joint with Nonautologous Tissue Substitute, Anterior, Anterior Column, Open 0RG40K1 10/01/2015 Fusion of Cervicothoracic Vertebral Joint with Nonautologous Tissue Substitute, Posterior, Posterior Column, Open 0RG40KJ 10/01/2015 Fusion of Cervicothoracic Vertebral Joint with Nonautologous Tissue Substitute, Posterior, Anterior Column, Open 0RG40Z0 10/01/2015 Fusion of Cervicothoracic Vertebral Joint, Anterior, Anterior Column, Open 0RG40Z1 10/01/2015 Fusion of Cervicothoracic Vertebral Joint, Posterior, Posterior Column, Open 0RG40ZJ 10/01/2015 Fusion of Cervicothoracic Vertebral Joint, Posterior, Anterior Column, Open 0RG /01/2015 Fusion of Cervicothoracic Vertebral Joint with Autologous Tissue Substitute, Anterior, Anterior Column, Percutaneous 0RG /01/2015 Fusion of Cervicothoracic Vertebral Joint with Autologous Tissue Substitute, Posterior, Posterior Column, Percutaneous 0RG437J 10/01/2015 Fusion of Cervicothoracic Vertebral Joint with Autologous Tissue Substitute, Posterior, Anterior Column, Percutaneous 0RG43A0 10/01/2015 Fusion of Cervicothoracic Vertebral Joint with Interbody Fusion Device, Anterior, Anterior Column, Percutaneous 0RG43A1 10/01/2015 Fusion of Cervicothoracic Vertebral Joint with Interbody Fusion Device, Posterior, Posterior Column, Percutaneous 21

68 Attachment F 0RG43AJ 10/01/2015 Fusion of Cervicothoracic Vertebral Joint with Interbody Fusion Device, Posterior, Anterior Column, Percutaneous 0RG43J0 10/01/2015 Fusion of Cervicothoracic Vertebral Joint with Synthetic Substitute, Anterior, Anterior Column, Percutaneous 0RG43J1 10/01/2015 Fusion of Cervicothoracic Vertebral Joint with Synthetic Substitute, Posterior, Posterior Column, Percutaneous 0RG43JJ 10/01/2015 Fusion of Cervicothoracic Vertebral Joint with Synthetic Substitute, Posterior, Anterior Column, Percutaneous 0RG43K0 10/01/2015 Fusion of Cervicothoracic Vertebral Joint with Nonautologous Tissue Substitute, Anterior, Anterior Column, Percutaneous 0RG43K1 10/01/2015 Fusion of Cervicothoracic Vertebral Joint with Nonautologous Tissue Substitute, Posterior, Posterior Column, Percutaneous 0RG43KJ 10/01/2015 Fusion of Cervicothoracic Vertebral Joint with Nonautologous Tissue Substitute, Posterior, Anterior Column, Percutaneous 0RG43Z0 10/01/2015 Fusion of Cervicothoracic Vertebral Joint, Anterior, Anterior Column, Percutaneous 0RG43Z1 10/01/2015 Fusion of Cervicothoracic Vertebral Joint, Posterior, Posterior Column, Percutaneous 0RG43ZJ 10/01/2015 Fusion of Cervicothoracic Vertebral Joint, Posterior, Anterior Column, Percutaneous 0RG /01/2015 Fusion of Cervicothoracic Vertebral Joint with Autologous Tissue Substitute, Anterior, Anterior Column, Percutaneous Endoscopic 0RG /01/2015 Fusion of Cervicothoracic Vertebral Joint with Autologous Tissue Substitute, Posterior, Posterior Column, Percutaneous Endoscopic 0RG447J 10/01/2015 Fusion of Cervicothoracic Vertebral Joint with Autologous Tissue Substitute, Posterior, Anterior Column, Percutaneous Endoscopic 0RG44A0 10/01/2015 Fusion of Cervicothoracic Vertebral Joint with Interbody Fusion Device, Anterior, Anterior Column, Percutaneous Endoscopic 0RG44A1 10/01/2015 Fusion of Cervicothoracic Vertebral Joint with Interbody Fusion Device, Posterior, Posterior Column, Percutaneous Endoscopic 0RG44AJ 10/01/2015 Fusion of Cervicothoracic Vertebral Joint with Interbody Fusion Device, Posterior, Anterior Column, 22

69 Attachment F Percutaneous Endoscopic 0RG44J0 10/01/2015 Fusion of Cervicothoracic Vertebral Joint with Synthetic Substitute, Anterior, Anterior Column, Percutaneous Endoscopic 0RG44J1 10/01/2015 Fusion of Cervicothoracic Vertebral Joint with Synthetic Substitute, Posterior, Posterior Column, Percutaneous Endoscopic 0RG44JJ 10/01/2015 Fusion of Cervicothoracic Vertebral Joint with Synthetic Substitute, Posterior, Anterior Column, Percutaneous Endoscopic 0RG44K0 10/01/2015 Fusion of Cervicothoracic Vertebral Joint with Nonautologous Tissue Substitute, Anterior, Anterior Column, Percutaneous Endoscopic 0RG44K1 10/01/2015 Fusion of Cervicothoracic Vertebral Joint with Nonautologous Tissue Substitute, Posterior, Posterior Column, Percutaneous Endoscopic 0RG44KJ 10/01/2015 Fusion of Cervicothoracic Vertebral Joint with Nonautologous Tissue Substitute, Posterior, Anterior Column, Percutaneous Endoscopic 0RG44Z0 10/01/2015 Fusion of Cervicothoracic Vertebral Joint, Anterior, Anterior Column, Percutaneous Endoscopic 0RG44Z1 10/01/2015 Fusion of Cervicothoracic Vertebral Joint, Posterior, Posterior Column, Percutaneous Endoscopic 0RG44ZJ 10/01/2015 Fusion of C-thor Jt, Post Appr A Col, Perc Endo (Fusion of Cervicothoracic Vertebral Joint, Posterior, Anterior Column, Percutaneous Endoscopic ) 0RG /01/2015 Fusion of Thoracic Vertebral Joint with Autologous Tissue Substitute, Anterior, Anterior Column, Open 0RG /01/2015 Fusion of Thoracic Vertebral Joint with Autologous Tissue Substitute, Posterior, Posterior Column, Open 0RG607J 10/01/2015 Fusion of Thoracic Vertebral Joint with Autologous Tissue Substitute, Posterior, Anterior Column, Open 0RG60A0 10/01/2015 Fusion of Thoracic Vertebral Joint with Interbody Fusion Device, Anterior, Anterior Column, Open 0RG60A1 10/01/2015 Fusion of Thoracic Vertebral Joint with Interbody Fusion Device, Posterior, Posterior Column, Open 0RG60AJ 10/01/2015 Fusion of Thoracic Vertebral Joint with Interbody Fusion 23

70 Attachment F Device, Posterior, Anterior Column, Open 0RG60J0 10/01/2015 Fusion of Thoracic Vertebral Joint with Synthetic Substitute, Anterior, Anterior Column, Open 0RG60J1 10/01/2015 Fusion of Thoracic Vertebral Joint with Synthetic Substitute, Posterior, Posterior Column, Open 0RG60JJ 10/01/2015 Fusion of Thoracic Vertebral Joint with Synthetic Substitute, Posterior, Anterior Column, Open 0RG60K0 10/01/2015 Fusion of Thoracic Vertebral Joint with Nonautologous Tissue Substitute, Anterior, Anterior Column, Open 0RG60K1 10/01/2015 Fusion of Thoracic Vertebral Joint with Nonautologous Tissue Substitute, Posterior, Posterior Column, Open 0RG60KJ 10/01/2015 Fusion of Thoracic Vertebral Joint with Nonautologous Tissue Substitute, Posterior, Anterior Column, Open 0RG60Z0 10/01/2015 Fusion of Thoracic Vertebral Joint, Anterior, Anterior Column, Open 0RG60Z1 10/01/2015 Fusion of Thoracic Vertebral Joint, Posterior, Posterior Column, Open 0RG60ZJ 10/01/2015 Fusion of Thoracic Vertebral Joint, Posterior, Anterior Column, Open 0RG /01/2015 Fusion of Thoracic Vertebral Joint with Autologous Tissue Substitute, Anterior, Anterior Column, Percutaneous 0RG /01/2015 Fusion of Thoracic Vertebral Joint with Autologous Tissue Substitute, Posterior, Posterior Column, Percutaneous 0RG637J 10/01/2015 Fusion of Thoracic Vertebral Joint with Autologous Tissue Substitute, Posterior, Anterior Column, Percutaneous 0RG63A0 10/01/2015 Fusion of Thoracic Vertebral Joint with Interbody Fusion Device, Anterior, Anterior Column, Percutaneous 0RG63A1 10/01/2015 Fusion of Thoracic Vertebral Joint with Interbody Fusion Device, Posterior, Posterior Column, Percutaneous 0RG63AJ 10/01/2015 Fusion of Thoracic Vertebral Joint with Interbody Fusion Device, Posterior, Anterior Column, Percutaneous 0RG63J0 10/01/2015 Fusion of Thoracic Vertebral Joint with Synthetic Substitute, Anterior, Anterior Column, Percutaneous 0RG63J1 10/01/2015 Fusion of Thoracic Vertebral Joint with Synthetic Substitute, 24

71 Attachment F Posterior, Posterior Column, Percutaneous 0RG63JJ 10/01/2015 Fusion of Thoracic Vertebral Joint with Synthetic Substitute, Posterior, Anterior Column, Percutaneous 0RG63K0 10/01/2015 Fusion of Thoracic Vertebral Joint with Nonautologous Tissue Substitute, Anterior, Anterior Column, Percutaneous 0RG63K1 10/01/2015 Fusion of Thoracic Vertebral Joint with Nonautologous Tissue Substitute, Posterior, Posterior Column, Percutaneous 0RG63KJ 10/01/2015 Fusion of Thoracic Vertebral Joint with Nonautologous Tissue Substitute, Posterior, Anterior Column, Percutaneous 0RG63Z0 10/01/2015 Fusion of Thoracic Vertebral Joint, Anterior, Anterior Column, Percutaneous 0RG63Z1 10/01/2015 Fusion of Thoracic Vertebral Joint, Posterior, Posterior Column, Percutaneous 0RG63ZJ 10/01/2015 Fusion of Thoracic Vertebral Joint, Posterior, Anterior Column, Percutaneous 0RG /01/2015 Fusion of Thoracic Vertebral Joint with Autologous Tissue Substitute, Anterior, Anterior Column, Percutaneous Endoscopic 0RG /01/2015 Fusion of Thoracic Vertebral Joint with Autologous Tissue Substitute, Posterior, Posterior Column, Percutaneous Endoscopic 0RG647J 10/01/2015 Fusion of Thoracic Vertebral Joint with Autologous Tissue Substitute, Posterior, Anterior Column, Percutaneous Endoscopic 0RG64A0 10/01/2015 Fusion of Thoracic Vertebral Joint with Interbody Fusion Device, Anterior, Anterior Column, Percutaneous Endoscopic 0RG64A1 10/01/2015 Fusion of Thoracic Vertebral Joint with Interbody Fusion Device, Posterior, Posterior Column, Percutaneous Endoscopic 0RG64AJ 10/01/2015 Fusion of Thoracic Vertebral Joint with Interbody Fusion Device, Posterior, Anterior Column, Percutaneous Endoscopic 0RG64J0 10/01/2015 Fusion of Thoracic Vertebral Joint with Synthetic Substitute, Anterior, Anterior Column, Percutaneous Endoscopic 0RG64J1 10/01/2015 Fusion of Thoracic Vertebral Joint with Synthetic Substitute, Posterior, Posterior Column, Percutaneous Endoscopic 25

72 Attachment F 0RG64JJ 10/01/2015 Fusion of Thoracic Vertebral Joint with Synthetic Substitute, Posterior, Anterior Column, Percutaneous Endoscopic 0RG64K0 10/01/2015 Fusion of Thoracic Vertebral Joint with Nonautologous Tissue Substitute, Anterior, Anterior Column, Percutaneous Endoscopic 0RG64K1 10/01/2015 Fusion of Thoracic Vertebral Joint with Nonautologous Tissue Substitute, Posterior, Posterior Column, Percutaneous Endoscopic 0RG64KJ 10/01/2015 Fusion of Thoracic Vertebral Joint with Nonautologous Tissue Substitute, Posterior, Anterior Column, Percutaneous Endoscopic 0RG64Z0 10/01/2015 Fusion of Thoracic Vertebral Joint, Anterior, Anterior Column, Percutaneous Endoscopic 0RG64Z1 10/01/2015 Fusion of Thoracic Vertebral Joint, Posterior, Posterior Column, Percutaneous Endoscopic 0RG64ZJ 10/01/2015 Fusion of Thoracic Vertebral Joint, Posterior, Anterior Column, Percutaneous Endoscopic 0RG /01/2015 Fusion of 2 to 7 Thoracic Vertebral Joints with Autologous Tissue Substitute, Anterior, Anterior Column, Open 0RG /01/2015 Fusion of 2 to 7 Thoracic Vertebral Joints with Autologous Tissue Substitute, Posterior, Posterior Column, Open 0RG707J 10/01/2015 Fusion of 2 to 7 Thoracic Vertebral Joints with Autologous Tissue Substitute, Posterior, Anterior Column, Open 0RG70A0 10/01/2015 Fusion of 2 to 7 Thoracic Vertebral Joints with Interbody Fusion Device, Anterior, Anterior Column, Open 0RG70A1 10/01/2015 Fusion of 2 to 7 Thoracic Vertebral Joints with Interbody Fusion Device, Posterior, Posterior Column, Open 0RG70AJ 10/01/2015 Fusion of 2 to 7 Thoracic Vertebral Joints with Interbody Fusion Device, Posterior, Anterior Column, Open 0RG70J0 10/01/2015 Fusion of 2 to 7 Thoracic Vertebral Joints with Synthetic Substitute, Anterior, Anterior Column, Open 0RG70J1 10/01/2015 Fusion of 2 to 7 Thoracic Vertebral Joints with Synthetic Substitute, Posterior, Posterior Column, Open 0RG70JJ 10/01/2015 Fusion of 2 to 7 Thoracic Vertebral Joints with Synthetic Substitute, Posterior, Anterior Column, Open 26

73 Attachment F 0RG70K0 10/01/2015 Fusion of 2 to 7 Thoracic Vertebral Joints with Nonautologous Tissue Substitute, Anterior, Anterior Column, Open 0RG70K1 10/01/2015 Fusion of 2 to 7 Thoracic Vertebral Joints with Nonautologous Tissue Substitute, Posterior, Posterior Column, Open 0RG70KJ 10/01/2015 Fusion of 2 to 7 Thoracic Vertebral Joints with Nonautologous Tissue Substitute, Posterior, Anterior Column, Open 0RG70Z0 10/01/2015 Fusion of 2 to 7 Thoracic Vertebral Joints, Anterior, Anterior Column, Open 0RG70Z1 10/01/2015 Fusion of 2 to 7 Thoracic Vertebral Joints, Posterior, Posterior Column, Open 0RG70ZJ 10/01/2015 Fusion of 2 to 7 Thoracic Vertebral Joints, Posterior, Anterior Column, Open 0RG /01/2015 Fusion of 2 to 7 Thoracic Vertebral Joints with Autologous Tissue Substitute, Anterior, Anterior Column, Percutaneous 0RG /01/2015 Fusion of 2 to 7 Thoracic Vertebral Joints with Autologous Tissue Substitute, Posterior, Posterior Column, Percutaneous 0RG737J 10/01/2015 Fusion of 2 to 7 Thoracic Vertebral Joints with Autologous Tissue Substitute, Posterior, Anterior Column, Percutaneous 0RG73A0 10/01/2015 Fusion of 2 to 7 Thoracic Vertebral Joints with Interbody Fusion Device, Anterior, Anterior Column, Percutaneous 0RG73A1 10/01/2015 Fusion of 2 to 7 Thoracic Vertebral Joints with Interbody Fusion Device, Posterior, Posterior Column, Percutaneous 0RG73AJ 10/01/2015 Fusion of 2 to 7 Thoracic Vertebral Joints with Interbody Fusion Device, Posterior, Anterior Column, Percutaneous 0RG73J0 10/01/2015 Fusion of 2 to 7 Thoracic Vertebral Joints with Synthetic Substitute, Anterior, Anterior Column, Percutaneous 0RG73J1 10/01/2015 Fusion of 2 to 7 Thoracic Vertebral Joints with Synthetic Substitute, Posterior, Posterior Column, Percutaneous 0RG73JJ 10/01/2015 Fusion of 2 to 7 Thoracic Vertebral Joints with Synthetic Substitute, Posterior, Anterior Column, Percutaneous 0RG73K0 10/01/2015 Fusion of 2 to 7 Thoracic Vertebral Joints with 27

74 Attachment F Nonautologous Tissue Substitute, Anterior, Anterior Column, Percutaneous 0RG73K1 10/01/2015 Fusion of 2 to 7 Thoracic Vertebral Joints with Nonautologous Tissue Substitute, Posterior, Posterior Column, Percutaneous 0RG73KJ 10/01/2015 Fusion of 2 to 7 Thoracic Vertebral Joints with Nonautologous Tissue Substitute, Posterior, Anterior Column, Percutaneous 0RG73Z0 10/01/2015 Fusion of 2 to 7 Thoracic Vertebral Joints, Anterior, Anterior Column, Percutaneous 0RG73Z1 10/01/2015 Fusion of 2 to 7 Thoracic Vertebral Joints, Posterior, Posterior Column, Percutaneous 0RG73ZJ 10/01/2015 Fusion of 2 to 7 Thoracic Vertebral Joints, Posterior, Anterior Column, Percutaneous 0RG /01/2015 Fusion of 2 to 7 Thoracic Vertebral Joints with Autologous Tissue Substitute, Anterior, Anterior Column, Percutaneous Endoscopic 0RG /01/2015 Fusion of 2 to 7 Thoracic Vertebral Joints with Autologous Tissue Substitute, Posterior, Posterior Column, Percutaneous Endoscopic 0RG747J 10/01/2015 Fusion of 2 to 7 Thoracic Vertebral Joints with Autologous Tissue Substitute, Posterior, Anterior Column, Percutaneous Endoscopic 0RG74A0 10/01/2015 Fusion of 2 to 7 Thoracic Vertebral Joints with Interbody Fusion Device, Anterior, Anterior Column, Percutaneous Endoscopic 0RG74A1 10/01/2015 Fusion of 2 to 7 Thoracic Vertebral Joints with Interbody Fusion Device, Posterior, Posterior Column, Percutaneous Endoscopic 0RG74AJ 10/01/2015 Fusion of 2 to 7 Thoracic Vertebral Joints with Interbody Fusion Device, Posterior, Anterior Column, Percutaneous Endoscopic 0RG74J0 10/01/2015 Fusion of 2 to 7 Thoracic Vertebral Joints with Synthetic Substitute, Anterior, Anterior Column, Percutaneous Endoscopic 0RG74J1 10/01/2015 Fusion of 2 to 7 Thoracic Vertebral Joints with Synthetic Substitute, Posterior, Posterior Column, Percutaneous Endoscopic 0RG74JJ 10/01/2015 Fusion of 2 to 7 Thoracic Vertebral Joints with Synthetic Substitute, Posterior, Anterior Column, Percutaneous Endoscopic 0RG74K0 10/01/2015 Fusion of 2 to 7 Thoracic Vertebral Joints with Nonautologous Tissue Substitute, Anterior, Anterior Column, Percutaneous Endoscopic 28

75 Attachment F 0RG74K1 10/01/2015 Fusion of 2 to 7 Thoracic Vertebral Joints with Nonautologous Tissue Substitute, Posterior, Posterior Column, Percutaneous Endoscopic 0RG74KJ 10/01/2015 Fusion of 2 to 7 Thoracic Vertebral Joints with Nonautologous Tissue Substitute, Posterior, Anterior Column, Percutaneous Endoscopic 0RG74Z0 10/01/2015 Fusion of 2 to 7 Thoracic Vertebral Joints, Anterior, Anterior Column, Percutaneous Endoscopic 0RG74Z1 10/01/2015 Fusion of 2 to 7 Thoracic Vertebral Joints, Posterior, Posterior Column, Percutaneous Endoscopic 0RG74ZJ 10/01/2015 Fusion of 2 to 7 Thoracic Vertebral Joints, Posterior, Anterior Column, Percutaneous Endoscopic 0RG /01/2015 Fusion of 8 or more Thoracic Vertebral Joints with Autologous Tissue Substitute, Anterior, Anterior Column, Open 0RG /01/2015 Fusion of 8 or more Thoracic Vertebral Joints with Autologous Tissue Substitute, Posterior, Posterior Column, Open 0RG807J 10/01/2015 Fusion of 8 or more Thoracic Vertebral Joints with Autologous Tissue Substitute, Posterior, Anterior Column, Open 0RG80A0 10/01/2015 Fusion of 8 or more Thoracic Vertebral Joints with Interbody Fusion Device, Anterior, Anterior Column, Open 0RG80A1 10/01/2015 Fusion of 8 or more Thoracic Vertebral Joints with Interbody Fusion Device, Posterior, Posterior Column, Open 0RG80AJ 10/01/2015 Fusion of 8 or more Thoracic Vertebral Joints with Interbody Fusion Device, Posterior, Anterior Column, Open 0RG80J0 10/01/2015 Fusion of 8 or more Thoracic Vertebral Joints with Synthetic Substitute, Anterior, Anterior Column, Open 0RG80J1 10/01/2015 Fusion of 8 or more Thoracic Vertebral Joints with Synthetic Substitute, Posterior, Posterior Column, Open 0RG80JJ 10/01/2015 Fusion of 8 or more Thoracic Vertebral Joints with Synthetic Substitute, Posterior, Anterior Column, Open 0RG80K0 10/01/2015 Fusion of 8 or more Thoracic Vertebral Joints with Nonautologous Tissue Substitute, Anterior, 29

76 Attachment F Anterior Column, Open 0RG80K1 10/01/2015 Fusion of 8 or more Thoracic Vertebral Joints with Nonautologous Tissue Substitute, Posterior, Posterior Column, Open 0RG80KJ 10/01/2015 Fusion of 8 or more Thoracic Vertebral Joints with Nonautologous Tissue Substitute, Posterior, Anterior Column, Open 0RG80Z0 10/01/2015 Fusion of 8 or more Thoracic Vertebral Joints, Anterior, Anterior Column, Open 0RG80Z1 10/01/2015 Fusion of 8 or more Thoracic Vertebral Joints, Posterior, Posterior Column, Open 0RG80ZJ 10/01/2015 Fusion of 8 or more Thoracic Vertebral Joints, Posterior, Anterior Column, Open 0RG /01/2015 Fusion of 8 or more Thoracic Vertebral Joints with Autologous Tissue Substitute, Anterior, Anterior Column, Percutaneous 0RG /01/2015 Fusion of 8 or more Thoracic Vertebral Joints with Autologous Tissue Substitute, Posterior, Posterior Column, Percutaneous 0RG837J 10/01/2015 Fusion of 8 or more Thoracic Vertebral Joints with Autologous Tissue Substitute, Posterior, Anterior Column, Percutaneous 0RG83A0 10/01/2015 Fusion of 8 or more Thoracic Vertebral Joints with Interbody Fusion Device, Anterior, Anterior Column, Percutaneous 0RG83A1 10/01/2015 Fusion of 8 or more Thoracic Vertebral Joints with Interbody Fusion Device, Posterior, Posterior Column, Percutaneous 0RG83AJ 10/01/2015 Fusion of 8 or more Thoracic Vertebral Joints with Interbody Fusion Device, Posterior, Anterior Column, Percutaneous 0RG83J0 10/01/2015 Fusion of 8 or more Thoracic Vertebral Joints with Synthetic Substitute, Anterior, Anterior Column, Percutaneous 0RG83J1 10/01/2015 Fusion of 8 or more Thoracic Vertebral Joints with Synthetic Substitute, Posterior, Posterior Column, Percutaneous 0RG83JJ 10/01/2015 Fusion of 8 or more Thoracic Vertebral Joints with Synthetic Substitute, Posterior, Anterior Column, Percutaneous 0RG83K0 10/01/2015 Fusion of 8 or more Thoracic Vertebral Joints with Nonautologous Tissue Substitute, Anterior, Anterior Column, Percutaneous 0RG83K1 10/01/2015 Fusion of 8 or more Thoracic Vertebral Joints with 30

77 Attachment F Nonautologous Tissue Substitute, Posterior, Posterior Column, Percutaneous 0RG83KJ 10/01/2015 Fusion of 8 or more Thoracic Vertebral Joints with Nonautologous Tissue Substitute, Posterior, Anterior Column, Percutaneous 0RG83Z0 10/01/2015 Fusion of 8 or more Thoracic Vertebral Joints, Anterior, Anterior Column, Percutaneous 0RG83Z1 10/01/2015 Fusion of 8 or more Thoracic Vertebral Joints, Posterior, Posterior Column, Percutaneous 0RG83ZJ 10/01/2015 Fusion of 8 or more Thoracic Vertebral Joints, Posterior, Anterior Column, Percutaneous 0RG /01/2015 Fusion of 8 or more Thoracic Vertebral Joints with Autologous Tissue Substitute, Anterior, Anterior Column, Percutaneous Endoscopic 0RG /01/2015 Fusion of 8 or more Thoracic Vertebral Joints with Autologous Tissue Substitute, Posterior, Posterior Column, Percutaneous Endoscopic 0RG847J 10/01/2015 Fusion of 8 or more Thoracic Vertebral Joints with Autologous Tissue Substitute, Posterior, Anterior Column, Percutaneous Endoscopic 0RG84A0 10/01/2015 Fusion of 8 or more Thoracic Vertebral Joints with Interbody Fusion Device, Anterior, Anterior Column, Percutaneous Endoscopic 0RG84A1 10/01/2015 Fusion of 8 or more Thoracic Vertebral Joints with Interbody Fusion Device, Posterior, Posterior Column, Percutaneous Endoscopic 0RG84AJ 10/01/2015 Fusion of 8 or more Thoracic Vertebral Joints with Interbody Fusion Device, Posterior, Anterior Column, Percutaneous Endoscopic 0RG84J0 10/01/2015 Fusion of 8 or more Thoracic Vertebral Joints with Synthetic Substitute, Anterior, Anterior Column, Percutaneous Endoscopic 0RG84J1 10/01/2015 Fusion of 8 or more Thoracic Vertebral Joints with Synthetic Substitute, Posterior, Posterior Column, Percutaneous Endoscopic 0RG84JJ 10/01/2015 Fusion of 8 or more Thoracic Vertebral Joints with Synthetic Substitute, Posterior, Anterior Column, Percutaneous Endoscopic 0RG84K0 10/01/2015 Fusion of 8 or more Thoracic Vertebral Joints with Nonautologous Tissue Substitute, Anterior, Anterior Column, Percutaneous Endoscopic 0RG84K1 10/01/2015 Fusion of 8 or more Thoracic Vertebral Joints with Nonautologous Tissue Substitute, Posterior, Posterior Column, Percutaneous Endoscopic 31

78 Attachment F 0RG84KJ 10/01/2015 Fusion of 8 or more Thoracic Vertebral Joints with Nonautologous Tissue Substitute, Posterior, Anterior Column, Percutaneous Endoscopic 0RG84Z0 10/01/2015 Fusion of 8 or more Thoracic Vertebral Joints, Anterior, Anterior Column, Percutaneous Endoscopic 0RG84Z1 10/01/2015 Fusion of 8 or more Thoracic Vertebral Joints, Posterior, Posterior Column, Percutaneous Endoscopic 0RG84ZJ 10/01/2015 Fusion of 8 or more Thoracic Vertebral Joints, Posterior, Anterior Column, Percutaneous Endoscopic 0RGA070 10/01/2015 Fusion of Thoracolumbar Vertebral Joint with Autologous Tissue Substitute, Anterior, Anterior Column, Open 0RGA071 10/01/2015 Fusion of Thoracolumbar Vertebral Joint with Autologous Tissue Substitute, Posterior, Posterior Column, Open 0RGA07J 10/01/2015 Fusion of Thoracolumbar Vertebral Joint with Autologous Tissue Substitute, Posterior, Anterior Column, Open 0RGA0A0 10/01/2015 Fusion of Thoracolumbar Vertebral Joint with Interbody Fusion Device, Anterior, Anterior Column, Open 0RGA0A1 10/01/2015 Fusion of Thoracolumbar Vertebral Joint with Interbody Fusion Device, Posterior, Posterior Column, Open 0RGA0AJ 10/01/2015 Fusion of Thoracolumbar Vertebral Joint with Interbody Fusion Device, Posterior, Anterior Column, Open 0RGA0J0 10/01/2015 Fusion of Thoracolumbar Vertebral Joint with Synthetic Substitute, Anterior, Anterior Column, Open 0RGA0J1 10/01/2015 Fusion of Thoracolumbar Vertebral Joint with Synthetic Substitute, Posterior, Posterior Column, Open 0RGA0JJ 10/01/2015 Fusion of Thoracolumbar Vertebral Joint with Synthetic Substitute, Posterior, Anterior Column, Open 0RGA0K0 10/01/2015 Fusion of Thoracolumbar Vertebral Joint with Nonautologous Tissue Substitute, Anterior, Anterior Column, Open 0RGA0K1 10/01/2015 Fusion of Thoracolumbar Vertebral Joint with Nonautologous Tissue Substitute, Posterior, Posterior Column, 32

79 Attachment F Open 0RGA0KJ 10/01/2015 Fusion of Thoracolumbar Vertebral Joint with Nonautologous Tissue Substitute, Posterior, Anterior Column, Open 0RGA0Z0 10/01/2015 Fusion of Thoracolumbar Vertebral Joint, Anterior, Anterior Column, Open 0RGA0Z1 10/01/2015 Fusion of Thoracolumbar Vertebral Joint, Posterior, Posterior Column, Open 0RGA0ZJ 10/01/2015 Fusion of Thoracolumbar Vertebral Joint, Posterior, Anterior Column, Open 0RGA370 10/01/2015 Fusion of Thoracolumbar Vertebral Joint with Autologous Tissue Substitute, Anterior, Anterior Column, Percutaneous 0RGA371 10/01/2015 Fusion of Thoracolumbar Vertebral Joint with Autologous Tissue Substitute, Posterior, Posterior Column, Percutaneous 0RGA37J 10/01/2015 Fusion of Thoracolumbar Vertebral Joint with Autologous Tissue Substitute, Posterior, Anterior Column, Percutaneous 0RGA3A0 10/01/2015 Fusion of Thoracolumbar Vertebral Joint with Interbody Fusion Device, Anterior, Anterior Column, Percutaneous 0RGA3A1 10/01/2015 Fusion of Thoracolumbar Vertebral Joint with Interbody Fusion Device, Posterior, Posterior Column, Percutaneous 0RGA3AJ 10/01/2015 Fusion of Thoracolumbar Vertebral Joint with Interbody Fusion Device, Posterior, Anterior Column, Percutaneous 0RGA3J0 10/01/2015 Fusion of Thoracolumbar Vertebral Joint with Synthetic Substitute, Anterior, Anterior Column, Percutaneous 0RGA3J1 10/01/2015 Fusion of Thoracolumbar Vertebral Joint with Synthetic Substitute, Posterior, Posterior Column, Percutaneous 0RGA3JJ 10/01/2015 Fusion of Thoracolumbar Vertebral Joint with Synthetic Substitute, Posterior, Anterior Column, Percutaneous 0RGA3K0 10/01/2015 Fusion of Thoracolumbar Vertebral Joint with Nonautologous Tissue Substitute, Anterior, Anterior Column, Percutaneous 0RGA3K1 10/01/2015 Fusion of Thoracolumbar Vertebral Joint with Nonautologous Tissue Substitute, Posterior, Posterior Column, Percutaneous 0RGA3KJ 10/01/2015 Fusion of Thoracolumbar Vertebral Joint with Nonautologous 33

80 Attachment F Tissue Substitute, Posterior, Anterior Column, Percutaneous 0RGA3Z0 10/01/2015 Fusion of Thoracolumbar Vertebral Joint, Anterior, Anterior Column, Percutaneous 0RGA3Z1 10/01/2015 Fusion of Thoracolumbar Vertebral Joint, Posterior, Posterior Column, Percutaneous 0RGA3ZJ 10/01/2015 Fusion of Thoracolumbar Vertebral Joint, Posterior, Anterior Column, Percutaneous 0RGA470 10/01/2015 Fusion of Thoracolumbar Vertebral Joint with Autologous Tissue Substitute, Anterior, Anterior Column, Percutaneous Endoscopic 0RGA471 10/01/2015 Fusion of Thoracolumbar Vertebral Joint with Autologous Tissue Substitute, Posterior, Posterior Column, Percutaneous Endoscopic 0RGA47J 10/01/2015 Fusion of Thoracolumbar Vertebral Joint with Autologous Tissue Substitute, Posterior, Anterior Column, Percutaneous Endoscopic 0RGA4A0 10/01/2015 Fusion of Thoracolumbar Vertebral Joint with Interbody Fusion Device, Anterior, Anterior Column, Percutaneous Endoscopic 0RGA4A1 10/01/2015 Fusion of Thoracolumbar Vertebral Joint with Interbody Fusion Device, Posterior, Posterior Column, Percutaneous Endoscopic 0RGA4AJ 10/01/2015 Fusion of Thoracolumbar Vertebral Joint with Interbody Fusion Device, Posterior, Anterior Column, Percutaneous Endoscopic 0RGA4J0 10/01/2015 Fusion of Thoracolumbar Vertebral Joint with Synthetic Substitute, Anterior, Anterior Column, Percutaneous Endoscopic 0RGA4J1 10/01/2015 Fusion of Thoracolumbar Vertebral Joint with Synthetic Substitute, Posterior, Posterior Column, Percutaneous Endoscopic 0RGA4JJ 10/01/2015 Fusion of Thoracolumbar Vertebral Joint with Synthetic Substitute, Posterior, Anterior Column, Percutaneous Endoscopic 0RGA4K0 10/01/2015 Fusion of Thoracolumbar Vertebral Joint with Nonautologous Tissue Substitute, Anterior, Anterior Column, Percutaneous Endoscopic 0RGA4K1 10/01/2015 Fusion of Thoracolumbar Vertebral Joint with Nonautologous Tissue Substitute, Posterior, Posterior Column, Percutaneous Endoscopic 0RGA4KJ 10/01/2015 Fusion of Thoracolumbar Vertebral Joint with Nonautologous Tissue Substitute, Posterior, Anterior Column, Percutaneous Endoscopic 34

81 Attachment F 0RGA4Z0 10/01/2015 Fusion of Thoracolumbar Vertebral Joint, Anterior, Anterior Column, Percutaneous Endoscopic 0RGA4Z1 10/01/2015 Fusion of Thoracolumbar Vertebral Joint, Posterior, Posterior Column, Percutaneous Endoscopic 0RGA4ZJ 10/01/2015 Fusion of Thoracolumbar Vertebral Joint, Posterior, Anterior Column, Percutaneous Endoscopic 0RT30ZZ 10/01/2015 Resection of Cervical Vertebral Disc, Open 0RT40ZZ 10/01/2015 Resection of Cervicothoracic Vertebral Joint, Open 0RT50ZZ 10/01/2015 Resection of Cervicothoracic Vertebral Disc, Open 0RT90ZZ 10/01/2015 Resection of Thoracic Vertebral Disc, Open 0RTB0ZZ 10/01/2015 Resection of Thoracolumbar Vertebral Disc, Open 0S520ZZ 10/01/2015 Destruction of Lumbar Vertebral Disc, Open 0S523ZZ 10/01/2015 Destruction of Lumbar Vertebral Disc, Percutaneous 0S524ZZ 10/01/2015 Destruction of Lumbar Vertebral Disc, Percutaneous Endoscopic 0S540ZZ 10/01/2015 Destruction of Lumbosacral Disc, Open 0S543ZZ 10/01/2015 Destruction of Lumbosacral Disc, Percutaneous 0S544ZZ 10/01/2015 Destruction of Lumbosacral Disc, Percutaneous Endoscopic 0SB20ZZ 10/01/2015 Excision of Lumbar Vertebral Disc, Open 0SB23ZZ 10/01/2015 Excision of Lumbar Vertebral Disc, Percutaneous 0SB24ZZ 10/01/2015 Excision of Lumbar Vertebral Disc, Percutaneous Endoscopic 0SB40ZZ 10/01/2015 Excision of Lumbosacral Disc, Open 0SB43ZZ 10/01/2015 Excision of Lumbosacral Disc, Percutaneous 0SB44ZZ 10/01/2015 Excision of Lumbosacral Disc, Percutaneous Endoscopic 0SG /01/2015 Fusion of Lumbar Vertebral Joint with Autologous Tissue Substitute, Anterior, Anterior Column, Open 0SG /01/2015 Fusion of Lumbar Vertebral Joint with Autologous Tissue Substitute, Posterior, Posterior Column, Open 0SG007J 10/01/2015 Fusion of Lumbar Vertebral Joint with Autologous Tissue Substitute, Posterior, Anterior Column, Open 0SG00A0 10/01/2015 Fusion of Lumbar Vertebral Joint with Interbody Fusion Device, Anterior, Anterior Column, Open 0SG00A1 10/01/2015 Fusion of Lumbar Vertebral Joint with Interbody Fusion Device, Posterior, Posterior Column, Open 35

82 Attachment F 0SG00AJ 10/01/2015 Fusion of Lumbar Vertebral Joint with Interbody Fusion Device, Posterior, Anterior Column, Open 0SG00J0 10/01/2015 Fusion of Lumbar Vertebral Joint with Synthetic Substitute, Anterior, Anterior Column, Open 0SG00J1 10/01/2015 Fusion of Lumbar Vertebral Joint with Synthetic Substitute, Posterior, Posterior Column, Open 0SG00JJ 10/01/2015 Fusion of Lumbar Vertebral Joint with Synthetic Substitute, Posterior, Anterior Column, Open 0SG00K0 10/01/2015 Fusion of Lumbar Vertebral Joint with Nonautologous Tissue Substitute, Anterior, Anterior Column, Open 0SG00K1 10/01/2015 Fusion of Lumbar Vertebral Joint with Nonautologous Tissue Substitute, Posterior, Posterior Column, Open 0SG00KJ 10/01/2015 Fusion of Lumbar Vertebral Joint with Nonautologous Tissue Substitute, Posterior, Anterior Column, Open 0SG00Z0 10/01/2015 Fusion of Lumbar Vertebral Joint, Anterior, Anterior Column, Open 0SG00Z1 10/01/2015 Fusion of Lumbar Vertebral Joint, Posterior, Posterior Column, Open 0SG00ZJ 10/01/2015 Fusion of Lumbar Vertebral Joint, Posterior, Anterior Column, Open 0SG /01/2015 Fusion of Lumbar Vertebral Joint with Autologous Tissue Substitute, Anterior, Anterior Column, Percutaneous 0SG /01/2015 Fusion of Lumbar Vertebral Joint with Autologous Tissue Substitute, Posterior, Posterior Column, Percutaneous 0SG037J 10/01/2015 Fusion of Lumbar Vertebral Joint with Autologous Tissue Substitute, Posterior, Anterior Column, Percutaneous 0SG03A0 10/01/2015 Fusion of Lumbar Vertebral Joint with Interbody Fusion Device, Anterior, Anterior Column, Percutaneous 0SG03A1 10/01/2015 Fusion of Lumbar Vertebral Joint with Interbody Fusion Device, Posterior, Posterior Column, Percutaneous 0SG03AJ 10/01/2015 Fusion of Lumbar Vertebral Joint with Interbody Fusion Device, Posterior, Anterior Column, Percutaneous 0SG03J0 10/01/2015 Fusion of Lumbar Vertebral Joint with Synthetic Substitute, Anterior, Anterior Column, Percutaneous 36

83 Attachment F 0SG03J1 10/01/2015 Fusion of Lumbar Vertebral Joint with Synthetic Substitute, Posterior, Posterior Column, Percutaneous 0SG03JJ 10/01/2015 Fusion of Lumbar Vertebral Joint with Synthetic Substitute, Posterior, Anterior Column, Percutaneous 0SG03K0 10/01/2015 Fusion of Lumbar Vertebral Joint with Nonautologous Tissue Substitute, Anterior, Anterior Column, Percutaneous 0SG03K1 10/01/2015 Fusion of Lumbar Vertebral Joint with Nonautologous Tissue Substitute, Posterior, Posterior Column, Percutaneous 0SG03KJ 10/01/2015 Fusion of Lumbar Vertebral Joint with Nonautologous Tissue Substitute, Posterior, Anterior Column, Percutaneous 0SG03Z0 10/01/2015 Fusion of Lumbar Vertebral Joint, Anterior, Anterior Column, Percutaneous 0SG03Z1 10/01/2015 Fusion of Lumbar Vertebral Joint, Posterior, Posterior Column, Percutaneous 0SG03ZJ 10/01/2015 Fusion of Lumbar Vertebral Joint, Posterior, Anterior Column, Percutaneous 0SG /01/2015 Fusion of Lumbar Vertebral Joint with Autologous Tissue Substitute, Anterior, Anterior Column, Percutaneous Endoscopic 0SG /01/2015 Fusion of Lumbar Vertebral Joint with Autologous Tissue Substitute, Posterior, Posterior Column, Percutaneous Endoscopic 0SG047J 10/01/2015 Fusion of Lumbar Vertebral Joint with Autologous Tissue Substitute, Posterior, Anterior Column, Percutaneous Endoscopic 0SG04A0 10/01/2015 Fusion of Lumbar Vertebral Joint with Interbody Fusion Device, Anterior, Anterior Column, Percutaneous Endoscopic 0SG04A1 10/01/2015 Fusion of Lumbar Vertebral Joint with Interbody Fusion Device, Posterior, Posterior Column, Percutaneous Endoscopic 0SG04AJ 10/01/2015 Fusion of Lumbar Vertebral Joint with Interbody Fusion Device, Posterior, Anterior Column, Percutaneous Endoscopic 0SG04J0 10/01/2015 Fusion of Lumbar Vertebral Joint with Synthetic Substitute, Anterior, Anterior Column, Percutaneous Endoscopic 0SG04J1 10/01/2015 Fusion of Lumbar Vertebral Joint with Synthetic Substitute, Posterior, Posterior Column, Percutaneous 37

84 Attachment F Endoscopic 0SG04JJ 10/01/2015 Fusion of Lumbar Vertebral Joint with Synthetic Substitute, Posterior, Anterior Column, Percutaneous Endoscopic 0SG04K0 10/01/2015 Fusion of Lumbar Vertebral Joint with Nonautologous Tissue Substitute, Anterior, Anterior Column, Percutaneous Endoscopic 0SG04K1 10/01/2015 Fusion of Lumbar Vertebral Joint with Nonautologous Tissue Substitute, Posterior, Posterior Column, Percutaneous Endoscopic 0SG04KJ 10/01/2015 Fusion of Lumbar Vertebral Joint with Nonautologous Tissue Substitute, Posterior, Anterior Column, Percutaneous Endoscopic 0SG04Z0 10/01/2015 Fusion of Lumbar Vertebral Joint, Anterior, Anterior Column, Percutaneous Endoscopic 0SG04Z1 10/01/2015 Fusion of Lumbar Vertebral Joint, Posterior, Posterior Column, Percutaneous Endoscopic 0SG04ZJ 10/01/2015 Fusion of Lumbar Vertebral Joint, Posterior, Anterior Column, Percutaneous Endoscopic 0SG /01/2015 Fusion of 2 or more Lumbar Vertebral Joints with Autologous Tissue Substitute, Anterior, Anterior Column, Open 0SG /01/2015 Fusion of 2 or more Lumbar Vertebral Joints with Autologous Tissue Substitute, Posterior, Posterior Column, Open 0SG107J 10/01/2015 Fusion of 2 or more Lumbar Vertebral Joints with Autologous Tissue Substitute, Posterior, Anterior Column, Open 0SG10A0 10/01/2015 Fusion of 2 or more Lumbar Vertebral Joints with Interbody Fusion Device, Anterior, Anterior Column, Open 0SG10A1 10/01/2015 Fusion of 2 or more Lumbar Vertebral Joints with Interbody Fusion Device, Posterior, Posterior Column, Open 0SG10AJ 10/01/2015 Fusion of 2 or more Lumbar Vertebral Joints with Interbody Fusion Device, Posterior, Anterior Column, Open 0SG10J0 10/01/2015 Fusion of 2 or more Lumbar Vertebral Joints with Synthetic Substitute, Anterior, Anterior Column, Open 0SG10J1 10/01/2015 Fusion of 2 or more Lumbar Vertebral Joints with Synthetic Substitute, Posterior, Posterior Column, Open 0SG10JJ 10/01/2015 Fusion of 2 or more Lumbar Vertebral Joints with Synthetic 38

85 Attachment F Substitute, Posterior, Anterior Column, Open 0SG10K0 10/01/2015 Fusion of 2 or more Lumbar Vertebral Joints with Nonautologous Tissue Substitute, Anterior, Anterior Column, Open 0SG10K1 10/01/2015 Fusion of 2 or more Lumbar Vertebral Joints with Nonautologous Tissue Substitute, Posterior, Posterior Column, Open 0SG10KJ 10/01/2015 Fusion of 2 or more Lumbar Vertebral Joints with Nonautologous Tissue Substitute, Posterior, Anterior Column, Open 0SG10Z0 10/01/2015 Fusion of 2 or more Lumbar Vertebral Joints, Anterior, Anterior Column, Open 0SG10Z1 10/01/2015 Fusion of 2 or more Lumbar Vertebral Joints, Posterior, Posterior Column, Open 0SG10ZJ 10/01/2015 Fusion of 2 or more Lumbar Vertebral Joints, Posterior, Anterior Column, Open 0SG /01/2015 Fusion of 2 or more Lumbar Vertebral Joints with Autologous Tissue Substitute, Anterior, Anterior Column, Percutaneous 0SG /01/2015 Fusion of 2 or more Lumbar Vertebral Joints with Autologous Tissue Substitute, Posterior, Posterior Column, Percutaneous 0SG137J 10/01/2015 Fusion of 2 or more Lumbar Vertebral Joints with Autologous Tissue Substitute, Posterior, Anterior Column, Percutaneous 0SG13A0 10/01/2015 Fusion of 2 or more Lumbar Vertebral Joints with Interbody Fusion Device, Anterior, Anterior Column, Percutaneous 0SG13A1 10/01/2015 Fusion of 2 or more Lumbar Vertebral Joints with Interbody Fusion Device, Posterior, Posterior Column, Percutaneous 0SG13AJ 10/01/2015 Fusion of 2 or more Lumbar Vertebral Joints with Interbody Fusion Device, Posterior, Anterior Column, Percutaneous 0SG13J0 10/01/2015 Fusion of 2 or more Lumbar Vertebral Joints with Synthetic Substitute, Anterior, Anterior Column, Percutaneous 0SG13J1 10/01/2015 Fusion of 2 or more Lumbar Vertebral Joints with Synthetic Substitute, Posterior, Posterior Column, Percutaneous 0SG13JJ 10/01/2015 Fusion of 2 or more Lumbar Vertebral Joints with Synthetic Substitute, Posterior, Anterior Column, Percutaneous 39

86 Attachment F 0SG13K0 10/01/2015 Fusion of 2 or more Lumbar Vertebral Joints with Nonautologous Tissue Substitute, Anterior, Anterior Column, Percutaneous 0SG13K1 10/01/2015 Fusion of 2 or more Lumbar Vertebral Joints with Nonautologous Tissue Substitute, Posterior, Posterior Column, Percutaneous 0SG13KJ 10/01/2015 Fusion of 2 or more Lumbar Vertebral Joints with Nonautologous Tissue Substitute, Posterior, Anterior Column, Percutaneous 0SG13Z0 10/01/2015 Fusion of 2 or more Lumbar Vertebral Joints, Anterior, Anterior Column, Percutaneous 0SG13Z1 10/01/2015 Fusion of 2 or more Lumbar Vertebral Joints, Posterior, Posterior Column, Percutaneous 0SG13ZJ 10/01/2015 Fusion of 2 or more Lumbar Vertebral Joints, Posterior, Anterior Column, Percutaneous 0SG /01/2015 Fusion of 2 or more Lumbar Vertebral Joints with Autologous Tissue Substitute, Anterior, Anterior Column, Percutaneous Endoscopic 0SG /01/2015 Fusion of 2 or more Lumbar Vertebral Joints with Autologous Tissue Substitute, Posterior, Posterior Column, Percutaneous Endoscopic 0SG147J 10/01/2015 Fusion of 2 or more Lumbar Vertebral Joints with Autologous Tissue Substitute, Posterior, Anterior Column, Percutaneous Endoscopic 0SG14A0 10/01/2015 Fusion of 2 or more Lumbar Vertebral Joints with Interbody Fusion Device, Anterior, Anterior Column, Percutaneous Endoscopic 0SG14A1 10/01/2015 Fusion of 2 or more Lumbar Vertebral Joints with Interbody Fusion Device, Posterior, Posterior Column, Percutaneous Endoscopic 0SG14AJ 10/01/2015 Fusion of 2 or more Lumbar Vertebral Joints with Interbody Fusion Device, Posterior, Anterior Column, Percutaneous Endoscopic 0SG14J0 10/01/2015 Fusion of 2 or more Lumbar Vertebral Joints with Synthetic Substitute, Anterior, Anterior Column, Percutaneous Endoscopic 0SG14J1 10/01/2015 Fusion of 2 or more Lumbar Vertebral Joints with Synthetic Substitute, Posterior, Posterior Column, Percutaneous Endoscopic 0SG14JJ 10/01/2015 Fusion of 2 or more Lumbar Vertebral Joints with Synthetic Substitute, Posterior, Anterior Column, Percutaneous Endoscopic 0SG14K0 10/01/2015 Fusion of 2 or more Lumbar Vertebral Joints with Nonautologous Tissue Substitute, Anterior, 40

87 Attachment F Anterior Column, Percutaneous Endoscopic 0SG14K1 10/01/2015 Fusion of 2 or more Lumbar Vertebral Joints with Nonautologous Tissue Substitute, Posterior, Posterior Column, Percutaneous Endoscopic 0SG14KJ 10/01/2015 Fusion of 2 or more Lumbar Vertebral Joints with Nonautologous Tissue Substitute, Posterior, Anterior Column, Percutaneous Endoscopic 0SG14Z0 10/01/2015 Fusion of 2 or more Lumbar Vertebral Joints, Anterior, Anterior Column, Percutaneous Endoscopic 0SG14Z1 10/01/2015 Fusion of 2 or more Lumbar Vertebral Joints, Posterior, Posterior Column, Percutaneous Endoscopic 0SG14ZJ 10/01/2015 Fusion of 2 or more Lumbar Vertebral Joints, Posterior, Anterior Column, Percutaneous Endoscopic 0SG /01/2015 Fusion of Lumbosacral Joint with Autologous Tissue Substitute, Anterior, Anterior Column, Open 0SG /01/2015 Fusion of Lumbosacral Joint with Autologous Tissue Substitute, Posterior, Posterior Column, Open 0SG307J 10/01/2015 Fusion of Lumbosacral Joint with Autologous Tissue Substitute, Posterior, Anterior Column, Open 0SG30A0 10/01/2015 Fusion of Lumbosacral Joint with Interbody Fusion Device, Anterior, Anterior Column, Open 0SG30A1 10/01/2015 Fusion of Lumbosacral Joint with Interbody Fusion Device, Posterior, Posterior Column, Open 0SG30AJ 10/01/2015 Fusion of Lumbosacral Joint with Interbody Fusion Device, Posterior, Anterior Column, Open 0SG30J0 10/01/2015 Fusion of Lumbosacral Joint with Synthetic Substitute, Anterior, Anterior Column, Open 0SG30J1 10/01/2015 Fusion of Lumbosacral Joint with Synthetic Substitute, Posterior, Posterior Column, Open 0SG30JJ 10/01/2015 Fusion of Lumbosacral Joint with Synthetic Substitute, Posterior, Anterior Column, Open 0SG30K0 10/01/2015 Fusion of Lumbosacral Joint with Nonautologous Tissue Substitute, Anterior, Anterior Column, Open 0SG30K1 10/01/2015 Fusion of Lumbosacral Joint with Nonautologous Tissue Substitute, Posterior, Posterior Column, Open 0SG30KJ 10/01/2015 Fusion of Lumbosacral Joint with Nonautologous Tissue 41

88 Attachment F Substitute, Posterior, Anterior Column, Open 0SG30Z0 10/01/2015 Fusion of Lumbosacral Joint, Anterior, Anterior Column, Open 0SG30Z1 10/01/2015 Fusion of Lumbosacral Joint, Posterior, Posterior Column, Open 0SG30ZJ 10/01/2015 Fusion of Lumbosacral Joint, Posterior, Anterior Column, Open 0SG /01/2015 Fusion of Lumbosacral Joint with Autologous Tissue Substitute, Anterior, Anterior Column, Percutaneous 0SG /01/2015 Fusion of Lumbosacral Joint with Autologous Tissue Substitute, Posterior, Posterior Column, Percutaneous 0SG337J 10/01/2015 Fusion of Lumbosacral Joint with Autologous Tissue Substitute, Posterior, Anterior Column, Percutaneous 0SG33A0 10/01/2015 Fusion of Lumbosacral Joint with Interbody Fusion Device, Anterior, Anterior Column, Percutaneous 0SG33A1 10/01/2015 Fusion of Lumbosacral Joint with Interbody Fusion Device, Posterior, Posterior Column, Percutaneous 0SG33AJ 10/01/2015 Fusion of Lumbosacral Joint with Interbody Fusion Device, Posterior, Anterior Column, Percutaneous 0SG33J0 10/01/2015 Fusion of Lumbosacral Joint with Synthetic Substitute, Anterior, Anterior Column, Percutaneous 0SG33J1 10/01/2015 Fusion of Lumbosacral Joint with Synthetic Substitute, Posterior, Posterior Column, Percutaneous 0SG33JJ 10/01/2015 Fusion of Lumbosacral Joint with Synthetic Substitute, Posterior, Anterior Column, Percutaneous 0SG33K0 10/01/2015 Fusion of Lumbosacral Joint with Nonautologous Tissue Substitute, Anterior, Anterior Column, Percutaneous 0SG33K1 10/01/2015 Fusion of Lumbosacral Joint with Nonautologous Tissue Substitute, Posterior, Posterior Column, Percutaneous 0SG33KJ 10/01/2015 Fusion of Lumbosacral Joint with Nonautologous Tissue Substitute, Posterior, Anterior Column, Percutaneous 0SG33Z0 10/01/2015 Fusion of Lumbosacral Joint, Anterior, Anterior Column, Percutaneous 42

89 Attachment F 0SG33Z1 10/01/2015 Fusion of Lumbosacral Joint, Posterior, Posterior Column, Percutaneous 0SG33ZJ 10/01/2015 Fusion of Lumbosacral Joint, Posterior, Anterior Column, Percutaneous 0SG /01/2015 Fusion of Lumbosacral Joint with Autologous Tissue Substitute, Anterior, Anterior Column, Percutaneous Endoscopic 0SG /01/2015 Fusion of Lumbosacral Joint with Autologous Tissue Substitute, Posterior, Posterior Column, Percutaneous Endoscopic 0SG347J 10/01/2015 Fusion of Lumbosacral Joint with Autologous Tissue Substitute, Posterior, Anterior Column, Percutaneous Endoscopic 0SG34A0 10/01/2015 Fusion of Lumbosacral Joint with Interbody Fusion Device, Anterior, Anterior Column, Percutaneous Endoscopic 0SG34A1 10/01/2015 Fusion of Lumbosacral Joint with Interbody Fusion Device, Posterior, Posterior Column, Percutaneous Endoscopic 0SG34AJ 10/01/2015 Fusion of Lumbosacral Joint with Interbody Fusion Device, Posterior, Anterior Column, Percutaneous Endoscopic 0SG34J0 10/01/2015 Fusion of Lumbosacral Joint with Synthetic Substitute, Anterior, Anterior Column, Percutaneous Endoscopic 0SG34J1 10/01/2015 Fusion of Lumbosacral Joint with Synthetic Substitute, Posterior, Posterior Column, Percutaneous Endoscopic 0SG34JJ 10/01/2015 Fusion of Lumbosacral Joint with Synthetic Substitute, Posterior, Anterior Column, Percutaneous Endoscopic 0SG34K0 10/01/2015 Fusion of Lumbosacral Joint with Nonautologous Tissue Substitute, Anterior, Anterior Column, Percutaneous Endoscopic 0SG34K1 10/01/2015 Fusion of Lumbosacral Joint with Nonautologous Tissue Substitute, Posterior, Posterior Column, Percutaneous Endoscopic 0SG34KJ 10/01/2015 Fusion of Lumbosacral Joint with Nonautologous Tissue Substitute, Posterior, Anterior Column, Percutaneous Endoscopic 0SG34Z0 10/01/2015 Fusion of Lumbosacral Joint, Anterior, Anterior Column, Percutaneous Endoscopic 0SG34Z1 10/01/2015 Fusion of Lumbosacral Joint, Posterior, Posterior Column, Percutaneous Endoscopic 43

90 Attachment F 0SG34ZJ 10/01/2015 Fusion of Lumbosacral Joint, Posterior, Anterior Column, Percutaneous Endoscopic 0SG704Z 10/01/2015 Fusion of Right Sacroiliac Joint with Internal Fixation Device, Open 0SG70JZ 10/01/2015 Fusion of Right Sacroiliac Joint with Synthetic Substitute, Open 0SG70KZ 10/01/2015 Fusion of Right Sacroiliac Joint with Nonautologous Tissue Substitute, Open 0SG70ZZ 10/01/2015 Fusion of Right Sacroiliac Joint, Open 0SG734Z 10/01/2015 Fusion of Right Sacroiliac Joint with Internal Fixation Device, Percutaneous 0SG737Z 10/01/2015 Fusion of Right Sacroiliac Joint with Autologous Tissue Substitute, Percutaneous 0SG73JZ 10/01/2015 Fusion of Right Sacroiliac Joint with Synthetic Substitute, Percutaneous 0SG73KZ 10/01/2015 Fusion of Right Sacroiliac Joint with Nonautologous Tissue Substitute, Percutaneous 0SG73ZZ 10/01/2015 Fusion of Right Sacroiliac Joint, Percutaneous 0SG744Z 10/01/2015 Fusion of Right Sacroiliac Joint with Internal Fixation Device, Percutaneous Endoscopic 0SG747Z 10/01/2015 Fusion of Right Sacroiliac Joint with Autologous Tissue Substitute, Percutaneous Endoscopic 0SG74JZ 10/01/2015 Fusion of Right Sacroiliac Joint with Synthetic Substitute, Percutaneous Endoscopic 0SG74KZ 10/01/2015 Fusion of Right Sacroiliac Joint with Nonautologous Tissue Substitute, Percutaneous Endoscopic 0SG74ZZ 10/01/2015 Fusion of Right Sacroiliac Joint, Percutaneous Endoscopic 0SG804Z 10/01/2015 Fusion of Left Sacroiliac Joint with Internal Fixation Device, Open 0SG807Z 10/01/2015 Fusion of Left Sacroiliac Joint with Autologous Tissue Substitute, Open 0SG80JZ 10/01/2015 Fusion of Left Sacroiliac Joint with Synthetic Substitute, Open 0SG80KZ 10/01/2015 Fusion of Left Sacroiliac Joint with Nonautologous Tissue Substitute, Open 0SG80ZZ 10/01/2015 Fusion of Left Sacroiliac Joint, Open 0SG834Z 10/01/2015 Fusion of Left Sacroiliac Joint with Internal Fixation Device, Percutaneous 0SG837Z 10/01/2015 Fusion of Left Sacroiliac Joint with Autologous Tissue Substitute, Percutaneous 0SG83JZ 10/01/2015 Fusion of Left Sacroiliac Joint with Synthetic Substitute, Percutaneous 0SG83KZ 10/01/2015 Fusion of Left Sacroiliac Joint with Nonautologous Tissue 44

91 Attachment F Substitute, Percutaneous 0SG83ZZ 10/01/2015 Fusion of Left Sacroiliac Joint, Percutaneous 0SG844Z 10/01/2015 Fusion of Left Sacroiliac Joint with Internal Fixation Device, Percutaneous Endoscopic 0SG847Z 10/01/2015 Fusion of Left Sacroiliac Joint with Autologous Tissue Substitute, Percutaneous Endoscopic 0SG84JZ 10/01/2015 Fusion of Left Sacroiliac Joint with Synthetic Substitute, Percutaneous Endoscopic 0SG84KZ 10/01/2015 Fusion of Left Sacroiliac Joint with Nonautologous Tissue Substitute, Percutaneous Endoscopic 0SG84ZZ 10/01/2015 Fusion of Left Sacroiliac Joint, Percutaneous Endoscopic 0ST20ZZ 10/01/2015 Resection of Lumbar Vertebral Disc, Open 0ST40ZZ 10/01/2015 Resection of Lumbosacral Disc, Open 3E0U0GB 10/01/2015 Introduction of Recombinant Bone Morphogenetic Protein into Joints, Open 3E0U3GB 10/01/2015 Introduction of Recombinant Bone Morphogenetic Protein into Joints, Percutaneous 3E0V0GB 10/01/2015 Introduction of Recombinant Bone Morphogenetic Protein into Bones, Open 3E0V3GB 10/01/2015 Introduction of Recombinant Bone Morphogenetic Protein into Bones, Percutaneous 0SG707Z 10/01/2015 Fusion of R Sacroiliac Jt with Autol Sub, Open (Fusion of Right Sacroiliac Joint with Autologous Tissue Substitute, Open ) 45