Local Coverage Determination (LCD): Immune Globulins (L34771)

Transcription

1 Local Coverage Determination (LCD): Immune Globulins (L34771) Contractor Information Contractor Name Wisconsin Physicians Service Insurance Corporation LCD Information Document Information LCD ID L34771 Original ICD-9 LCD ID L30147 LCD Title Immune Globulins Original Effective Date For services performed on or after 10/01/2015 AMA CPT / ADA CDT / AHA NUBC Copyright Statement CPT only copyright American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright American Dental Association. All rights Revision Effective Date For services performed on or after 10/01/2015 Revision Ending Date N/A Retirement Date N/A Notice Period Start Date N/A Notice Period End Date N/A

2 reserved. CDT and CDT-2010 are trademarks of the American Dental Association. UB-04 Manual. OFFICIAL UB-04 DATA SPECIFICATIONS MANUAL, 2014, is copyrighted by American Hospital Association ( AHA ), Chicago, Illinois. No portion of OFFICIAL UB-04 MANUAL may be reproduced, sorted in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior express, written consent of AHA. Health Forum reserves the right to change the copyright notice from time to time upon written notice to Company. CMS National Coverage Policy Jurisdiction "8" Notice: Jurisdiction "8" comprises the states of Indiana and Michigan. WPS is responsible for claims payment and Local Coverage Determination (LCD) development for this jurisdiction. This LCD was created as a part of the legacy transition (7/16/2012-8/20/2012); and, is a consolidation of the previous legacy contractors policies. Coverage of each LCD begins when the state/contract number combination officially is integrated into the Jurisdiction. On the CMS MCD, this date is known as either the Original Effective Date or the Revision Effective Date. The following table details the official effective dates for each state/contract number combination. ST Legacy A Contractor & Contract Number Legacy B Contractor & Contract Number J "8" MAC A Contractor & Contract Number J "8" MAC B Contractor & Contract Number J "8" Effective Date IN NGS: WPS: /20/12 MI WPS: WPS: /16/12 IN NGS: WPS: /23/12 MI NGS: WPS: /23/12 CMS Pub Medicare Benefit Policy Manual, Chapter 15 Covered Medical and Other Health Services, Section 50.6 Coverage of Intravenous Immune Globulin for Treatment of Primary Immune Deficiency Diseases in the Home.

3 CMS Pub , Medicare National Coverage Determination (NCD) Manual, Chapter 1, Part 4, Section Intravenous Immune Globulin for the Treatment of Autoimmune Mucocutaneous Blistering Diseases. CMS Pub , Medicare Claims Processing Manual, Chapter 17 Drugs and Biologicals, Section 80.6 Intravenous Immune Globulin (Change Requests 2149, 3745, 4244, 5635, 5643, and 5981). Coverage Guidance Coverage Indications, Limitations, and/or Medical Necessity Immune serums (immune globulin) provide passive immunity to infectious disease. The protection will be of rapid onset, but of short duration (1-3 months). Immune sera are obtained from pooled human plasma of either general population donors or hyperimmunized donors. It may be administered either by intravenous (IV) or intramuscular (IM) injection. A. Immune globulin is available in broad-spectrum form, or disease-specific hyperimmune serum. 1. Gamma Globulin; intramuscular (IM) IG, Gamma Globulin, ISG, Gamastan, Gammar, (J1460, J1560) is indicated for the following conditions: a. Hepatitis A exposure. b. Measles (Rubeola): for a susceptible patient (has not been vaccinated and has not had measles and is at high risk for complication) who has been exposed less than three days prior to treatment. c. Rubella: for a woman in early pregnancy, who is exposed to the virus and does not have immunity. d. Varicella: for passive immunization in immunosuppressed patients when varicella zoster immunoglobulin is not available. e. Immunoglobulin deficiency: for prevention of serious infection when circulating IgG levels are low. Prophylactic therapy, especially against infections due to encapsulated bacteria, is often effective in Bruton-type, sex-linked congenital agammaglobulinemia, agammaglobulinemia associated with thymoma and acquired agammaglobulinemia. 2. Specific hyperimmune serum globulin includes several different disease-specific drugs. a. Hepatitis B serum (CPT 90371) is indicated post-exposure for transient prevention of hepatitis B infection. b. Rabies serum (CPT 90375, 90376) is indicated post-exposure for transient prevention of rabies infection when the patient has not been completely immunized with the vaccination. c. Vaccinia serum (CPT 90393) is indicated for transient prevention of or

4 modification of aberrant infections induced by vaccinia (smallpox) vaccine, the vaccinia virus, such as eczema vaccinatum, some cases of progressive vaccinia, and possibly ocular vaccinia. d. Varicella-zoster serum (CPT 90396) is indicated for transient prevention of varicella-zoster infection in exposed, susceptible individuals who have a greater risk of complications from varicella. Documentation in the progress notes must indicate one of the following complicating conditions to verify medical necessity: Personal history of leukemia or lymphoma - HIV infection - Current immunosuppressive therapy - A newborn with exposure to chickenpox (the documentation must indicate why the newborn is at increased risk; e.g., if the mother was exposed within 5 days of delivery). e. Tetanus serum (J1670) is indicated for transient protection against tetanus postexposure to tetanus. Documentation in the progress notes must identify the following: - The wound is other than a clean minor wound, and the date of the injury; - The active immunization with tetanus toxoid is unknown or uncertain; or - The patient has received either less than 2 prior doses of tetanus toxoid; or two prior doses of tetanus toxoid, but there has been a delay of 24 hours or more between the time of injury and the initiation of tetanus prophylaxis. f. Cytomegalovirus immune globulin intravenous (human) per vial (J0850) is indicated for the prophylaxis of cytomegalovirus disease associated with transplantation of kidney, lung, liver, heart, stem cell and pancreas. In transplants of these organs other than kidney from CMV seropositive donors into seronegative recipients, prophylactic CMV-IGIV should be considered in combination with ganciclovir. g. Hepatitis B immune globulin (HepaGam B) (J1571) intramuscular, 0.5 ml is indicated for the treatment of acute exposure to blood containing HBsAg, perinatal exposure of infants born to HBsAg positive mothers, sexual exposure to HBsAg-positive persons and household exposure to persons with acute HBV infection. h. Hepatitis B immune globulin (HepaGam B) (J1573) intravenously is indicated for the prevention of Hepatitis B recurrence following a liver transplantation, in HBsAg-positive liver transplant patients. i. Crotalidae polyvalent immune FAB (OVINE), (CroFab) (J0840) CroFab is indicated for the management of patients with minimal or moderate North American rattlesnake envenomation. Early use of CroFab (within 6 hours of snakebite) is advised to prevent clinical deterioration and the occurrence of systemic coagulation abnormalities.

5 B. Intravenous immune globulin (Sandoglobulin, Venoglobulin-I, Privigen, Gamunex, Octagam, Gammagard liquid, Flebogamma/Flebogamma DIF, Carimune, Gammaplex, Bivigam) (J1459, J1557, J1561, J1566, J1568, J1569, J1572, J1599) provides immediate antibody levels. IVIG may be indicated for the following conditions: 1. Immunodeficiency Syndrome: to include congenital agammaglobulinemia such as x- linked agammaglobulinemia, common variable hypoglobulinemia, x-linked immunodeficiency with hyper IGM, combined immunodeficiency. 2. Primary thrombocytopenia. 3. Alloimmune thrombocytopenia, refractoriness to platelet transfusions. Routine use is not indicated. IVIG may have a role in patients with severe thrombocytopenia of documented immune basis for whom other modalities are unsuccessful or contraindicated. 4. Post-transfusion purpura. IVIG may be considered as first-line therapy in severely affected patients. 5. Lymphoid Leukemia with either hypogammaglobulinemia or recurrent bacterial infections. 6. Autoimmune hemolytic anemia. Routine use is not indicated. IVIG may have a role in patients with warm-type AIHA that does not respond to corticosteroids. 7. Immune-mediated neutropenia. Routine use is not indicated. IVIG may have a role in severe illness that does not respond to other modalities or when the latter are contraindicated. 8. Multiple Myeloma. Routine use is not indicated. It may have a role in patients with stable (plateau phase) disease and high risk of recurrent infections. 9. Pediatric intractable epilepsy. Routine use is not indicated. IVIG may have a role in certain syndromes as a last resort, especially in patients who may be candidates for surgical resection. 10. Guillian-Barré syndrome. IVIG is recommended as an equivalent alternative to plasma exchange in children and adults. 11. Myasthenia gravis (MG). Routine use is not indicated. IVIG may be considered in patients with severe MG to treat acute severe decompensation when other treatments have been unsuccessful or are contraindicated. 12. Eaton-Lambert Syndrome. This is an immune-mediated, myasthenia-like syndrome. Treatment with IVIG is directed at decreasing the autoimmune response.

6 13. Polyneuropathy, chronic inflammatory demyelinating. IVIG is recommended as an equivalent alternative to plasma exchange in adults. 14. Multifocal motor neuropathy. The routine use of IVIG is not usually recommended. IVIG may be considered in patients who have progressive, symptomatic multifocal motor neuropathy that has been diagnosed on the basis of electrophysiologic findings that rule out other possible conditions that may not respond to this treatment. 15. Dermatomyositis. Routine use is not indicated. IVIG may be used for patients with severe active illness for whom other interventions have been unsuccessful or intolerable. 16. Polymyositis. Routine use is not indicated. IVIG may be used for patients with severe active illness for whom other interventions have been unsuccessful or intolerable. 17. Systemic lupus erythematosus (SLE). Routine use is not indicated. IVIG may be used for patients with severe active SLE for whom other interventions have been unsuccessful or intolerable. 18. Systemic sclerosis dermatomyositis overlap syndrome. Routine use is not indicated. IVIG may be used for patients with severe active illness for whom other interventions have been unsuccessful or intolerable. 19. Kawasaki disease. 20. Severe Vasculitic Syndromes, systemic (polyarteritis nodosa), Churg-Strauss Vasculitis and livedoid vasculitis (atrophie blanche). Evidence does not support routine use of IVIG. IVIG may be used for patients with severe active illness for whom other interventions have been unsuccessful or intolerable. 21. Toxic Epidermal Necrolysis and Stevens-Johnson Syndrome. Evidence does not support routine use of IVIG. It will be covered if it is refractory to conventional therapy. 22. Pemphigoid gestationis that is refractory to conventional therapy. 23. Pyoderma gangrenosum that is refractory to conventional therapy. 24. Neonatal alloimmune thrombocytopenia. Routine use of IVIG is not recommended. It is recommended in severely thrombocytopenic, symptomatic neonates who are at high risk of developing intracranial hemorrhage when other interventions have been unsuccessful become intolerable or are contra-indicated. 25. IVIG may be indicated for high-risk pregnant women who have had a history of a previously affected infant with fetal-neonatal thrombocytopenia. 26. Wiskott-Aldrich Syndrome.

7 27. Anemia due to pure red cell aplasia. 28. Human Immunodeficiency Virus (HIV) infection. IVIG will be covered for patients infected with HIV to reduce significant bacterial infection when all of the following coverage indicators are present: a) age less than 13 years old; b) evidence of either qualitative or quantitative humoral immunologic defects and c) current bacterial infections, despite appropriate antimicrobial prophylaxis. Dosage Guidelines: 400 mg/kg body weight given every 28 days. 29. Autoimmune mucocutaneous blistering disease is covered by a National Coverage Determination (See PUB 100-3: Medicare National Coverage Determination Manual Chapter1, Part 4 Section 250.3). 30. Stiff-man syndrome. IVIG may be used for patients with severe active illness for whom other interventions have been unsuccessful or intolerable. 31. Desensitization for a pre-kidney transplantation in patients with a panel reactive antibody (PRA) of 80% or below (V49.83). Use in patients with a PRA of % is considered to be experimental/ investigation and is therefore not covered. Post transplantation to prevent rejection remains covered without regard to antibody levels. Coding Information Bill Type Codes: Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims. N/A Revenue Codes: Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

8 N/A CPT/HCPCS Codes Group 1 Paragraph: N/A Group 1 Codes: HEPATITIS B IMMUNE GLOBULIN (HBIG), HUMAN, FOR INTRAMUSCULAR USE RABIES IMMUNE GLOBULIN (RIG), HUMAN, FOR INTRAMUSCULAR AND/OR SUBCUTANEOUS USE RABIES IMMUNE GLOBULIN, HEAT-TREATED (RIG-HT), HUMAN, FOR INTRAMUSCULAR AND/OR SUBCUTANEOUS USE VACCINIA IMMUNE GLOBULIN, HUMAN, FOR INTRAMUSCULAR USE VARICELLA-ZOSTER IMMUNE GLOBULIN, HUMAN, FOR INTRAMUSCULAR USE INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); INITIAL, UP TO 1 HOUR INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); SUBCUTANEOUS OR INTRAMUSCULAR INJECTION, CROTALIDAE POLYVALENT IMMUNE FAB (OVINE), UP TO 1 J0840 GRAM INJECTION, CYTOMEGALOVIRUS IMMUNE GLOBULIN INTRAVENOUS J0850 (HUMAN), PER VIAL INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, NON- J1459 LYOPHILIZED (E.G. LIQUID), 500 MG J1460 INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 1 CC J1556 INJECTION, IMMUNE GLOBULIN (BIVIGAM), 500 MG INJECTION, IMMUNE GLOBULIN, (GAMMAPLEX), INTRAVENOUS, NON- J1557 LYOPHILIZED (E.G. LIQUID), 500 MG J1560 INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, OVER 10 CC INJECTION, IMMUNE GLOBULIN, (GAMUNEX-C/GAMMAKED), NON- J1561 LYOPHILIZED (E.G. LIQUID), 500 MG INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, LYOPHILIZED (E.G. J1566 POWDER), NOT OTHERWISE SPECIFIED, 500 MG INJECTION, IMMUNE GLOBULIN, (OCTAGAM), INTRAVENOUS, NON- J1568 LYOPHILIZED (E.G. LIQUID), 500 MG INJECTION, IMMUNE GLOBULIN, (GAMMAGARD LIQUID), NON- J1569 LYOPHILIZED, (E.G. LIQUID), 500 MG

9 INJECTION, HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B), J1571 INTRAMUSCULAR, 0.5 ML INJECTION, IMMUNE GLOBULIN, (FLEBOGAMMA/FLEBOGAMMA DIF), J1572 INTRAVENOUS, NON-LYOPHILIZED (E.G. LIQUID), 500 MG INJECTION, HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B), INTRAVENOUS, J ML INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, NON-LYOPHILIZED (E.G. J1599 LIQUID), NOT OTHERWISE SPECIFIED, 500 MG J1670 INJECTION, TETANUS IMMUNE GLOBULIN, HUMAN, UP TO 250 UNITS ICD-10 Codes that Support Medical Necessity Group 1 Paragraph: Diagnosis codes must be coded to the highest level of specificity. J1460, J1560 Group 1Codes ICD-10 Code Description D80.0 Hereditary hypogammaglobulinemia D80.1 Nonfamilial hypogammaglobulinemia D80.2 Selective deficiency of immunoglobulin A [IgA] D80.3 Selective deficiency of immunoglobulin G [IgG] subclasses D80.4 Selective deficiency of immunoglobulin M [IgM] D80.5 Immunodeficiency with increased immunoglobulin M [IgM] D81.0 Severe combined immunodeficiency [SCID] with reticular dysgenesis D81.1 Severe combined immunodeficiency [SCID] with low T- and B-cell numbers D81.2 Severe combined immunodeficiency [SCID] with low or normal B-cell numbers D81.6 Major histocompatibility complex class I deficiency D81.7 Major histocompatibility complex class II deficiency D81.89 Other combined immunodeficiencies D83.0 Common variable immunodeficiency with predominant abnormalities of B-cell numbers and function D83.2 Common variable immunodeficiency with autoantibodies to B- or T-cells D83.8 Other common variable immunodeficiencies D83.9 Common variable immunodeficiency, unspecified Z20.5 Contact with and (suspected) exposure to viral hepatitis Showing 1 to 17 of 17 entries in Group 1

10 Group 2 Paragraph: J1460, J1560 Rubella: for a woman in early pregnancy, who is exposed to the virus and does not have immunity, requires two diagnosis codes Z33.1 AND Z20.4 Group 2Codes ICD-10 Code Description Z20.4 Contact with and (suspected) exposure to rubella Z33.1 Pregnant state, incidental Showing 1 to 2 of 2 entries in Group 2 Group 3 Paragraph: Group 3Codes ICD-10 Code Description Z20.5 Contact with and (suspected) exposure to viral hepatitis Showing 1 to 1 of 1 entries in Group 3 Group 4 Paragraph: 90375, Group 4Codes ICD-10 Code Description Z20.3 Contact with and (suspected) exposure to rabies Showing 1 to 1 of 1 entries in Group 4 Group 5 Paragraph: Group 5Codes ICD-10 Code Description Z20.4 Contact with and (suspected) exposure to rubella Showing 1 to 1 of 1 entries in Group 5 Group 6 Paragraph: Group 6Codes

11 ICD-10 Code Description Z Contact with and (suspected) exposure to varicella Showing 1 to 1 of 1 entries in Group 6 Group 7 Paragraph: J1670 Use A -initial, D - subsequent or S -sequela, for those codes which require a 7th character. Group 7Codes ICD-10 Description Code S01.00XA Unspecified open wound of scalp, initial S01.01XA Laceration without foreign body of scalp, initial S01.02XA Laceration with foreign body of scalp, initial S01.03XA Puncture wound without foreign body of scalp, initial S01.04XA Puncture wound with foreign body of scalp, initial S01.101A Unspecified open wound of right eyelid and periocular area, initial S01.102A Unspecified open wound of left eyelid and periocular area, initial Laceration without foreign body of right eyelid and periocular area, initial S01.111A S01.112A Laceration without foreign body of left eyelid and periocular area, initial S01.121A Laceration with foreign body of right eyelid and periocular area, initial S01.122A Laceration with foreign body of left eyelid and periocular area, initial Puncture wound without foreign body of right eyelid and periocular area, initial S01.131A Puncture wound without foreign body of left eyelid and periocular area, initial S01.132A Puncture wound with foreign body of right eyelid and periocular area, initial S01.141A Puncture wound with foreign body of left eyelid and periocular area, initial S01.142A S01.151A Open bite of right eyelid and periocular area, initial S01.152A Open bite of left eyelid and periocular area, initial S01.20XA Unspecified open wound of nose, initial S01.21XA Laceration without foreign body of nose, initial S01.22XA Laceration with foreign body of nose, initial S01.23XA Puncture wound without foreign body of nose, initial S01.24XA Puncture wound with foreign body of nose, initial S01.25XA Open bite of nose, initial S01.301A Unspecified open wound of right ear, initial S01.302A Unspecified open wound of left ear, initial

12 S01.311A S01.312A S01.321A S01.322A S01.331A S01.332A S01.341A S01.342A S01.351A S01.352A S01.401A S01.402A S01.411A S01.412A S01.421A S01.422A S01.431A S01.432A S01.441A S01.442A S01.451A S01.452A S01.501A S01.502A S01.511A S01.512A S01.521A S01.522A S01.531A S01.532A S01.541A S01.542A S01.551A Laceration without foreign body of right ear, initial Laceration without foreign body of left ear, initial Laceration with foreign body of right ear, initial Laceration with foreign body of left ear, initial Puncture wound without foreign body of right ear, initial Puncture wound without foreign body of left ear, initial Puncture wound with foreign body of right ear, initial Puncture wound with foreign body of left ear, initial Open bite of right ear, initial Open bite of left ear, initial Unspecified open wound of right cheek and temporomandibular area, initial Unspecified open wound of left cheek and temporomandibular area, initial Laceration without foreign body of right cheek and temporomandibular area, initial Laceration without foreign body of left cheek and temporomandibular area, initial Laceration with foreign body of right cheek and temporomandibular area, initial Laceration with foreign body of left cheek and temporomandibular area, initial Puncture wound without foreign body of right cheek and temporomandibular area, initial Puncture wound without foreign body of left cheek and temporomandibular area, initial Puncture wound with foreign body of right cheek and temporomandibular area, initial Puncture wound with foreign body of left cheek and temporomandibular area, initial Open bite of right cheek and temporomandibular area, initial Open bite of left cheek and temporomandibular area, initial Unspecified open wound of lip, initial Unspecified open wound of oral cavity, initial Laceration without foreign body of lip, initial Laceration without foreign body of oral cavity, initial Laceration with foreign body of lip, initial Laceration with foreign body of oral cavity, initial Puncture wound without foreign body of lip, initial Puncture wound without foreign body of oral cavity, initial Puncture wound with foreign body of lip, initial Puncture wound with foreign body of oral cavity, initial Open bite of lip, initial

13 S01.552A Open bite of oral cavity, initial S01.80XA Unspecified open wound of other part of head, initial S01.81XA Laceration without foreign body of other part of head, initial S01.82XA Laceration with foreign body of other part of head, initial S01.83XA Puncture wound without foreign body of other part of head, initial S01.84XA Puncture wound with foreign body of other part of head, initial S01.85XA Open bite of other part of head, initial S01.90XA Unspecified open wound of unspecified part of head, initial S01.91XA Laceration without foreign body of unspecified part of head, initial S01.92XA Laceration with foreign body of unspecified part of head, initial S01.93XA Puncture wound without foreign body of unspecified part of head, initial S01.94XA Puncture wound with foreign body of unspecified part of head, initial S01.95XA Open bite of unspecified part of head, initial Ocular laceration and rupture with prolapse or loss of intraocular tissue, unspecified S05.20XA eye, initial Ocular laceration and rupture with prolapse or loss of intraocular tissue, right eye, S05.21XA initial Ocular laceration and rupture with prolapse or loss of intraocular tissue, left eye, S05.22XA initial Ocular laceration without prolapse or loss of intraocular tissue, unspecified eye, S05.30XA initial Ocular laceration without prolapse or loss of intraocular tissue, right eye, initial S05.31XA Ocular laceration without prolapse or loss of intraocular tissue, left eye, initial S05.32XA Penetrating wound of orbit with or without foreign body, unspecified eye, initial S05.40XA S05.41XA Penetrating wound of orbit with or without foreign body, right eye, initial S05.42XA Penetrating wound of orbit with or without foreign body, left eye, initial S05.50XA Penetrating wound with foreign body of unspecified eyeball, initial S05.51XA Penetrating wound with foreign body of right eyeball, initial S05.52XA Penetrating wound with foreign body of left eyeball, initial S05.60XA Penetrating wound without foreign body of unspecified eyeball, initial S05.61XA Penetrating wound without foreign body of right eyeball, initial S05.62XA Penetrating wound without foreign body of left eyeball, initial S05.71XA Avulsion of right eye, initial S05.72XA Avulsion of left eye, initial S05.8X1A Other injuries of right eye and orbit, initial S05.8X2A Other injuries of left eye and orbit, initial S05.91XA Unspecified injury of right eye and orbit, initial S05.92XA Unspecified injury of left eye and orbit, initial S08.0XXA Avulsion of scalp, initial S08.111A Complete traumatic amputation of right ear, initial

14 S08.112A Complete traumatic amputation of left ear, initial S08.119A Complete traumatic amputation of unspecified ear, initial S08.121A Partial traumatic amputation of right ear, initial S08.122A Partial traumatic amputation of left ear, initial S08.129A Partial traumatic amputation of unspecified ear, initial S08.811A Complete traumatic amputation of nose, initial S08.812A Partial traumatic amputation of nose, initial S08.89XA Traumatic amputation of other parts of head, initial S09.12XA Laceration of muscle and tendon of head, initial S09.20XA Traumatic rupture of unspecified ear drum, initial S09.21XA Traumatic rupture of right ear drum, initial S09.22XA Traumatic rupture of left ear drum, initial S09.301A Unspecified injury of right middle and inner ear, initial S09.302A Unspecified injury of left middle and inner ear, initial S09.309A Unspecified injury of unspecified middle and inner ear, initial S09.311A Primary blast injury of right ear, initial S09.312A Primary blast injury of left ear, initial S09.313A Primary blast injury of ear, bilateral, initial S09.391A Other specified injury of right middle and inner ear, initial S09.392A Other specified injury of left middle and inner ear, initial S09.399A Other specified injury of unspecified middle and inner ear, initial S09.8XXA Other specified injuries of head, initial S09.90XA Unspecified injury of head, initial S09.91XA Unspecified injury of ear, initial S09.93XA Unspecified injury of face, initial S11.011A Laceration without foreign body of larynx, initial S11.012A Laceration with foreign body of larynx, initial S11.013A Puncture wound without foreign body of larynx, initial S11.014A Puncture wound with foreign body of larynx, initial S11.015A Open bite of larynx, initial S11.019A Unspecified open wound of larynx, initial S11.021A Laceration without foreign body of trachea, initial S11.022A Laceration with foreign body of trachea, initial S11.023A Puncture wound without foreign body of trachea, initial S11.024A Puncture wound with foreign body of trachea, initial S11.025A Open bite of trachea, initial S11.029A Unspecified open wound of trachea, initial S11.031A Laceration without foreign body of vocal cord, initial S11.032A Laceration with foreign body of vocal cord, initial S11.033A Puncture wound without foreign body of vocal cord, initial S11.034A Puncture wound with foreign body of vocal cord, initial S11.035A Open bite of vocal cord, initial

15 S11.039A Unspecified open wound of vocal cord, initial S11.10XA Unspecified open wound of thyroid gland, initial S11.11XA Laceration without foreign body of thyroid gland, initial S11.12XA Laceration with foreign body of thyroid gland, initial S11.13XA Puncture wound without foreign body of thyroid gland, initial S11.14XA Puncture wound with foreign body of thyroid gland, initial S11.15XA Open bite of thyroid gland, initial S11.20XA Unspecified open wound of pharynx and cervical esophagus, initial Laceration without foreign body of pharynx and cervical esophagus, initial S11.21XA S11.22XA Laceration with foreign body of pharynx and cervical esophagus, initial Puncture wound without foreign body of pharynx and cervical esophagus, initial S11.23XA Puncture wound with foreign body of pharynx and cervical esophagus, initial S11.24XA S11.25XA Open bite of pharynx and cervical esophagus, initial S11.80XA Unspecified open wound of other specified part of neck, initial S11.81XA Laceration without foreign body of other specified part of neck, initial S11.82XA Laceration with foreign body of other specified part of neck, initial Puncture wound without foreign body of other specified part of neck, initial S11.83XA S11.84XA Puncture wound with foreign body of other specified part of neck, initial S11.85XA Open bite of other specified part of neck, initial S11.89XA Other open wound of other specified part of neck, initial S11.93XA Puncture wound without foreign body of unspecified part of neck, initial S11.94XA Puncture wound with foreign body of unspecified part of neck, initial S11.95XA Open bite of unspecified part of neck, initial S16.2XXA Laceration of muscle, fascia and tendon at neck level, initial S21.001A Unspecified open wound of right breast, initial S21.002A Unspecified open wound of left breast, initial S21.011A Laceration without foreign body of right breast, initial S21.012A Laceration without foreign body of left breast, initial S21.021A Laceration with foreign body of right breast, initial S21.022A Laceration with foreign body of left breast, initial S21.031A Puncture wound without foreign body of right breast, initial S21.032A Puncture wound without foreign body of left breast, initial S21.041A Puncture wound with foreign body of right breast, initial S21.042A Puncture wound with foreign body of left breast, initial S21.051A Open bite of right breast, initial S21.052A Open bite of left breast, initial Unspecified open wound of right front wall of thorax without penetration into S21.101A thoracic cavity, initial

16 S21.102A S21.109A S21.111A S21.112A S21.119A S21.121A S21.122A S21.129A S21.131A S21.132A S21.139A S21.141A S21.142A S21.149A S21.151A S21.152A S21.159A S21.201A S21.202A S21.209A S21.211A S21.212A Unspecified open wound of left front wall of thorax without penetration into thoracic cavity, initial Unspecified open wound of unspecified front wall of thorax without penetration into thoracic cavity, initial Laceration without foreign body of right front wall of thorax without penetration into thoracic cavity, initial Laceration without foreign body of left front wall of thorax without penetration into thoracic cavity, initial Laceration without foreign body of unspecified front wall of thorax without penetration into thoracic cavity, initial Laceration with foreign body of right front wall of thorax without penetration into thoracic cavity, initial Laceration with foreign body of left front wall of thorax without penetration into thoracic cavity, initial Laceration with foreign body of unspecified front wall of thorax without penetration into thoracic cavity, initial Puncture wound without foreign body of right front wall of thorax without penetration into thoracic cavity, initial Puncture wound without foreign body of left front wall of thorax without penetration into thoracic cavity, initial Puncture wound without foreign body of unspecified front wall of thorax without penetration into thoracic cavity, initial Puncture wound with foreign body of right front wall of thorax without penetration into thoracic cavity, initial Puncture wound with foreign body of left front wall of thorax without penetration into thoracic cavity, initial Puncture wound with foreign body of unspecified front wall of thorax without penetration into thoracic cavity, initial Open bite of right front wall of thorax without penetration into thoracic cavity, initial Open bite of left front wall of thorax without penetration into thoracic cavity, initial Open bite of unspecified front wall of thorax without penetration into thoracic cavity, initial Unspecified open wound of right back wall of thorax without penetration into thoracic cavity, initial Unspecified open wound of left back wall of thorax without penetration into thoracic cavity, initial Unspecified open wound of unspecified back wall of thorax without penetration into thoracic cavity, initial Laceration without foreign body of right back wall of thorax without penetration into thoracic cavity, initial Laceration without foreign body of left back wall of thorax without penetration into thoracic cavity, initial

17 S21.219A Laceration without foreign body of unspecified back wall of thorax without penetration into thoracic cavity, initial S21.221A Laceration with foreign body of right back wall of thorax without penetration into thoracic cavity, initial S21.222A Laceration with foreign body of left back wall of thorax without penetration into thoracic cavity, initial S21.229A Laceration with foreign body of unspecified back wall of thorax without penetration into thoracic cavity, initial S21.231A Puncture wound without foreign body of right back wall of thorax without penetration into thoracic cavity, initial S21.232A Puncture wound without foreign body of left back wall of thorax without penetration into thoracic cavity, initial S21.239A Puncture wound without foreign body of unspecified back wall of thorax without penetration into thoracic cavity, initial S21.241A Puncture wound with foreign body of right back wall of thorax without penetration into thoracic cavity, initial S21.242A Puncture wound with foreign body of left back wall of thorax without penetration into thoracic cavity, initial S21.249A Puncture wound with foreign body of unspecified back wall of thorax without penetration into thoracic cavity, initial S21.251A Open bite of right back wall of thorax without penetration into thoracic cavity, initial S21.252A Open bite of left back wall of thorax without penetration into thoracic cavity, initial S21.259A Open bite of unspecified back wall of thorax without penetration into thoracic cavity, initial S28.1XXA Traumatic amputation (partial) of part of thorax, except breast, initial S28.211A Complete traumatic amputation of right breast, initial S28.212A Complete traumatic amputation of left breast, initial S28.221A Partial traumatic amputation of right breast, initial S28.222A Partial traumatic amputation of left breast, initial S29.021A Laceration of muscle and tendon of front wall of thorax, initial S29.022A Laceration of muscle and tendon of back wall of thorax, initial S31.000A Unspecified open wound of lower back and pelvis without penetration into retroperitoneum, initial S31.010A Laceration without foreign body of lower back and pelvis without penetration into retroperitoneum, initial S31.020A Laceration with foreign body of lower back and pelvis without penetration into retroperitoneum, initial S31.030A Puncture wound without foreign body of lower back and pelvis without penetration into retroperitoneum, initial S31.040A Puncture wound with foreign body of lower back and pelvis without penetration into retroperitoneum, initial

18 S31.050A S31.100A S31.101A S31.102A S31.103A S31.104A S31.105A S31.110A S31.111A S31.112A S31.113A S31.114A S31.115A S31.120A S31.121A S31.122A S31.123A S31.124A S31.125A S31.130A S31.131A S31.132A Open bite of lower back and pelvis without penetration into retroperitoneum, initial Unspecified open wound of abdominal wall, right upper quadrant without penetration into peritoneal cavity, initial Unspecified open wound of abdominal wall, left upper quadrant without penetration into peritoneal cavity, initial Unspecified open wound of abdominal wall, epigastric region without penetration into peritoneal cavity, initial Unspecified open wound of abdominal wall, right lower quadrant without penetration into peritoneal cavity, initial Unspecified open wound of abdominal wall, left lower quadrant without penetration into peritoneal cavity, initial Unspecified open wound of abdominal wall, periumbilic region without penetration into peritoneal cavity, initial Laceration without foreign body of abdominal wall, right upper quadrant without penetration into peritoneal cavity, initial Laceration without foreign body of abdominal wall, left upper quadrant without penetration into peritoneal cavity, initial Laceration without foreign body of abdominal wall, epigastric region without penetration into peritoneal cavity, initial Laceration without foreign body of abdominal wall, right lower quadrant without penetration into peritoneal cavity, initial Laceration without foreign body of abdominal wall, left lower quadrant without penetration into peritoneal cavity, initial Laceration without foreign body of abdominal wall, periumbilic region without penetration into peritoneal cavity, initial Laceration of abdominal wall with foreign body, right upper quadrant without penetration into peritoneal cavity, initial Laceration of abdominal wall with foreign body, left upper quadrant without penetration into peritoneal cavity, initial Laceration of abdominal wall with foreign body, epigastric region without penetration into peritoneal cavity, initial Laceration of abdominal wall with foreign body, right lower quadrant without penetration into peritoneal cavity, initial Laceration of abdominal wall with foreign body, left lower quadrant without penetration into peritoneal cavity, initial Laceration of abdominal wall with foreign body, periumbilic region without penetration into peritoneal cavity, initial Puncture wound of abdominal wall without foreign body, right upper quadrant without penetration into peritoneal cavity, initial Puncture wound of abdominal wall without foreign body, left upper quadrant without penetration into peritoneal cavity, initial Puncture wound of abdominal wall without foreign body, epigastric region without penetration into peritoneal cavity, initial

19 Puncture wound of abdominal wall without foreign body, right lower quadrant S31.133A without penetration into peritoneal cavity, initial Puncture wound of abdominal wall without foreign body, left lower quadrant S31.134A without penetration into peritoneal cavity, initial Puncture wound of abdominal wall without foreign body, periumbilic region S31.135A without penetration into peritoneal cavity, initial Puncture wound of abdominal wall with foreign body, right upper quadrant without S31.140A penetration into peritoneal cavity, initial Puncture wound of abdominal wall with foreign body, left upper quadrant without S31.141A penetration into peritoneal cavity, initial Puncture wound of abdominal wall with foreign body, epigastric region without S31.142A penetration into peritoneal cavity, initial Puncture wound of abdominal wall with foreign body, right lower quadrant without S31.143A penetration into peritoneal cavity, initial Puncture wound of abdominal wall with foreign body, left lower quadrant without S31.144A penetration into peritoneal cavity, initial Puncture wound of abdominal wall with foreign body, periumbilic region without S31.145A penetration into peritoneal cavity, initial Open bite of abdominal wall, right upper quadrant without penetration into S31.150A peritoneal cavity, initial Open bite of abdominal wall, left upper quadrant without penetration into S31.151A peritoneal cavity, initial Open bite of abdominal wall, epigastric region without penetration into peritoneal S31.152A cavity, initial Open bite of abdominal wall, right lower quadrant without penetration into S31.153A peritoneal cavity, initial Open bite of abdominal wall, left lower quadrant without penetration into S31.154A peritoneal cavity, initial Open bite of abdominal wall, periumbilic region without penetration into peritoneal S31.155A cavity, initial S31.20XA Unspecified open wound of penis, initial S31.21XA Laceration without foreign body of penis, initial S31.22XA Laceration with foreign body of penis, initial S31.23XA Puncture wound without foreign body of penis, initial S31.24XA Puncture wound with foreign body of penis, initial S31.25XA Open bite of penis, initial S31.30XA Unspecified open wound of scrotum and testes, initial S31.31XA Laceration without foreign body of scrotum and testes, initial S31.32XA Laceration with foreign body of scrotum and testes, initial S31.33XA Puncture wound without foreign body of scrotum and testes, initial S31.34XA Puncture wound with foreign body of scrotum and testes, initial S31.35XA Open bite of scrotum and testes, initial S31.40XA Unspecified open wound of vagina and vulva, initial

20 S31.41XA Laceration without foreign body of vagina and vulva, initial S31.42XA Laceration with foreign body of vagina and vulva, initial S31.43XA Puncture wound without foreign body of vagina and vulva, initial S31.44XA Puncture wound with foreign body of vagina and vulva, initial S31.45XA Open bite of vagina and vulva, initial S31.551A Open bite of unspecified external genital organs, male, initial S31.552A Open bite of unspecified external genital organs, female, initial S31.805A Open bite of unspecified buttock, initial S31.809A Unspecified open wound of unspecified buttock, initial S31.811A Laceration without foreign body of right buttock, initial S31.812A Laceration with foreign body of right buttock, initial S31.813A Puncture wound without foreign body of right buttock, initial S31.814A Puncture wound with foreign body of right buttock, initial S31.815A Open bite of right buttock, initial S31.819A Unspecified open wound of right buttock, initial S31.821A Laceration without foreign body of left buttock, initial S31.822A Laceration with foreign body of left buttock, initial S31.823A Puncture wound without foreign body of left buttock, initial S31.824A Puncture wound with foreign body of left buttock, initial S31.825A Open bite of left buttock, initial S31.829A Unspecified open wound of left buttock, initial S31.831A Laceration without foreign body of anus, initial S31.832A Laceration with foreign body of anus, initial S31.833A Puncture wound without foreign body of anus, initial S31.834A Puncture wound with foreign body of anus, initial S31.835A Open bite of anus, initial S31.839A Unspecified open wound of anus, initial S38.211A Complete traumatic amputation of female external genital organs, initial S38.212A Partial traumatic amputation of female external genital organs, initial S38.221A Complete traumatic amputation of penis, initial S38.222A Partial traumatic amputation of penis, initial S38.231A Complete traumatic amputation of scrotum and testis, initial S38.232A Partial traumatic amputation of scrotum and testis, initial S38.3XXA Transection (partial) of abdomen, initial S39.021A Laceration of muscle, fascia and tendon of abdomen, initial S39.022A Laceration of muscle, fascia and tendon of lower back, initial S39.023A Laceration of muscle, fascia and tendon of pelvis, initial S40.251A Superficial foreign body of right shoulder, initial S40.252A Superficial foreign body of left shoulder, initial S40.271A Other superficial bite of right shoulder, initial S40.272A Other superficial bite of left shoulder, initial S41.001A Unspecified open wound of right shoulder, initial

21 S41.002A S41.011A S41.012A S41.021A S41.022A S41.031A S41.032A S41.041A S41.042A S41.051A S41.052A S41.059A S41.101A S41.102A S41.111A S41.112A S41.121A S41.122A S41.131A S41.132A S41.141A S41.142A S41.151A S41.152A S46.021A S46.022A S46.121A S46.122A S46.221A S46.222A S46.321A S46.322A S46.329A S46.821A Unspecified open wound of left shoulder, initial Laceration without foreign body of right shoulder, initial Laceration without foreign body of left shoulder, initial Laceration with foreign body of right shoulder, initial Laceration with foreign body of left shoulder, initial Puncture wound without foreign body of right shoulder, initial Puncture wound without foreign body of left shoulder, initial Puncture wound with foreign body of right shoulder, initial Puncture wound with foreign body of left shoulder, initial Open bite of right shoulder, initial Open bite of left shoulder, initial Open bite of unspecified shoulder, initial Unspecified open wound of right upper arm, initial Unspecified open wound of left upper arm, initial Laceration without foreign body of right upper arm, initial Laceration without foreign body of left upper arm, initial Laceration with foreign body of right upper arm, initial Laceration with foreign body of left upper arm, initial Puncture wound without foreign body of right upper arm, initial Puncture wound without foreign body of left upper arm, initial Puncture wound with foreign body of right upper arm, initial Puncture wound with foreign body of left upper arm, initial Open bite of right upper arm, initial Open bite of left upper arm, initial Laceration of muscle(s) and tendon(s) of the rotator cuff of right shoulder, initial Laceration of muscle(s) and tendon(s) of the rotator cuff of left shoulder, initial Laceration of muscle, fascia and tendon of long head of biceps, right arm, initial Laceration of muscle, fascia and tendon of long head of biceps, left arm, initial Laceration of muscle, fascia and tendon of other parts of biceps, right arm, initial Laceration of muscle, fascia and tendon of other parts of biceps, left arm, initial Laceration of muscle, fascia and tendon of triceps, right arm, initial Laceration of muscle, fascia and tendon of triceps, left arm, initial Laceration of muscle, fascia and tendon of triceps, unspecified arm, initial Laceration of other muscles, fascia and tendons at shoulder and upper arm level, right arm, initial

22 S46.822A S46.921A S46.922A S48.011A S48.012A S48.021A S48.022A S48.111A S48.112A S48.119A S48.121A S48.122A S48.129A S48.911A S48.912A S48.921A S48.922A S51.001A S51.002A S51.011A S51.012A S51.021A S51.022A S51.031A S51.032A S51.041A S51.042A S51.051A S51.052A S51.801A Laceration of other muscles, fascia and tendons at shoulder and upper arm level, left arm, initial Laceration of unspecified muscle, fascia and tendon at shoulder and upper arm level, right arm, initial Laceration of unspecified muscle, fascia and tendon at shoulder and upper arm level, left arm, initial Complete traumatic amputation at right shoulder joint, initial Complete traumatic amputation at left shoulder joint, initial Partial traumatic amputation at right shoulder joint, initial Partial traumatic amputation at left shoulder joint, initial Complete traumatic amputation at level between right shoulder and elbow, initial Complete traumatic amputation at level between left shoulder and elbow, initial Complete traumatic amputation at level between unspecified shoulder and elbow, initial Partial traumatic amputation at level between right shoulder and elbow, initial Partial traumatic amputation at level between left shoulder and elbow, initial Partial traumatic amputation at level between unspecified shoulder and elbow, initial Complete traumatic amputation of right shoulder and upper arm, level unspecified, initial Complete traumatic amputation of left shoulder and upper arm, level unspecified, initial Partial traumatic amputation of right shoulder and upper arm, level unspecified, initial Partial traumatic amputation of left shoulder and upper arm, level unspecified, initial Unspecified open wound of right elbow, initial Unspecified open wound of left elbow, initial Laceration without foreign body of right elbow, initial Laceration without foreign body of left elbow, initial Laceration with foreign body of right elbow, initial Laceration with foreign body of left elbow, initial Puncture wound without foreign body of right elbow, initial Puncture wound without foreign body of left elbow, initial Puncture wound with foreign body of right elbow, initial Puncture wound with foreign body of left elbow, initial Open bite, right elbow, initial Open bite, left elbow, initial Unspecified open wound of right forearm, initial

23 S51.802A S51.811A S51.812A S51.821A S51.822A S51.831A S51.832A S51.841A S51.842A S51.851A S51.852A S56.021A S56.022A S56.121A S56.122A S56.123A S56.124A S56.125A S56.126A S56.127A S56.128A S56.221A S56.222A S56.321A S56.322A S56.421A S56.422A Unspecified open wound of left forearm, initial Laceration without foreign body of right forearm, initial Laceration without foreign body of left forearm, initial Laceration with foreign body of right forearm, initial Laceration with foreign body of left forearm, initial Puncture wound without foreign body of right forearm, initial Puncture wound without foreign body of left forearm, initial Puncture wound with foreign body of right forearm, initial Puncture wound with foreign body of left forearm, initial Open bite of right forearm, initial Open bite of left forearm, initial Laceration of flexor muscle, fascia and tendon of right thumb at forearm level, initial Laceration of flexor muscle, fascia and tendon of left thumb at forearm level, initial Laceration of flexor muscle, fascia and tendon of right index finger at forearm level, initial Laceration of flexor muscle, fascia and tendon of left index finger at forearm level, initial Laceration of flexor muscle, fascia and tendon of right middle finger at forearm level, initial Laceration of flexor muscle, fascia and tendon of left middle finger at forearm level, initial Laceration of flexor muscle, fascia and tendon of right ring finger at forearm level, initial Laceration of flexor muscle, fascia and tendon of left ring finger at forearm level, initial Laceration of flexor muscle, fascia and tendon of right little finger at forearm level, initial Laceration of flexor muscle, fascia and tendon of left little finger at forearm level, initial Laceration of other flexor muscle, fascia and tendon at forearm level, right arm, initial Laceration of other flexor muscle, fascia and tendon at forearm level, left arm, initial Laceration of extensor or abductor muscles, fascia and tendons of right thumb at forearm level, initial Laceration of extensor or abductor muscles, fascia and tendons of left thumb at forearm level, initial Laceration of extensor muscle, fascia and tendon of right index finger at forearm level, initial Laceration of extensor muscle, fascia and tendon of left index finger at forearm level, initial

24 S56.423A S56.424A S56.425A S56.426A S56.427A S56.428A S56.521A S56.522A S56.821A S56.822A S56.921A S56.922A S58.011A S58.012A S58.019A S58.021A S58.022A S58.111A S58.112A S58.121A S58.122A S58.129A S58.911A S58.912A S58.921A S58.922A S61.001A Laceration of extensor muscle, fascia and tendon of right middle finger at forearm level, initial Laceration of extensor muscle, fascia and tendon of left middle finger at forearm level, initial Laceration of extensor muscle, fascia and tendon of right ring finger at forearm level, initial Laceration of extensor muscle, fascia and tendon of left ring finger at forearm level, initial Laceration of extensor muscle, fascia and tendon of right little finger at forearm level, initial Laceration of extensor muscle, fascia and tendon of left little finger at forearm level, initial Laceration of other extensor muscle, fascia and tendon at forearm level, right arm, initial Laceration of other extensor muscle, fascia and tendon at forearm level, left arm, initial Laceration of other muscles, fascia and tendons at forearm level, right arm, initial Laceration of other muscles, fascia and tendons at forearm level, left arm, initial Laceration of unspecified muscles, fascia and tendons at forearm level, right arm, initial Laceration of unspecified muscles, fascia and tendons at forearm level, left arm, initial Complete traumatic amputation at elbow level, right arm, initial Complete traumatic amputation at elbow level, left arm, initial Complete traumatic amputation at elbow level, unspecified arm, initial Partial traumatic amputation at elbow level, right arm, initial Partial traumatic amputation at elbow level, left arm, initial Complete traumatic amputation at level between elbow and wrist, right arm, initial Complete traumatic amputation at level between elbow and wrist, left arm, initial Partial traumatic amputation at level between elbow and wrist, right arm, initial Partial traumatic amputation at level between elbow and wrist, left arm, initial Partial traumatic amputation at level between elbow and wrist, unspecified arm, initial Complete traumatic amputation of right forearm, level unspecified, initial Complete traumatic amputation of left forearm, level unspecified, initial Partial traumatic amputation of right forearm, level unspecified, initial Partial traumatic amputation of left forearm, level unspecified, initial Unspecified open wound of right thumb without damage to nail, initial

25 S61.002A S61.011A S61.012A S61.021A S61.022A S61.031A S61.032A S61.041A S61.042A S61.051A S61.052A S61.101A S61.102A S61.111A S61.112A S61.121A S61.122A S61.131A S61.132A S61.141A S61.142A S61.151A S61.152A S61.200A S61.201A S61.202A S61.203A Unspecified open wound of left thumb without damage to nail, initial Laceration without foreign body of right thumb without damage to nail, initial Laceration without foreign body of left thumb without damage to nail, initial Laceration with foreign body of right thumb without damage to nail, initial Laceration with foreign body of left thumb without damage to nail, initial Puncture wound without foreign body of right thumb without damage to nail, initial Puncture wound without foreign body of left thumb without damage to nail, initial Puncture wound with foreign body of right thumb without damage to nail, initial Puncture wound with foreign body of left thumb without damage to nail, initial Open bite of right thumb without damage to nail, initial Open bite of left thumb without damage to nail, initial Unspecified open wound of right thumb with damage to nail, initial Unspecified open wound of left thumb with damage to nail, initial Laceration without foreign body of right thumb with damage to nail, initial Laceration without foreign body of left thumb with damage to nail, initial Laceration with foreign body of right thumb with damage to nail, initial Laceration with foreign body of left thumb with damage to nail, initial Puncture wound without foreign body of right thumb with damage to nail, initial Puncture wound without foreign body of left thumb with damage to nail, initial Puncture wound with foreign body of right thumb with damage to nail, initial Puncture wound with foreign body of left thumb with damage to nail, initial Open bite of right thumb with damage to nail, initial Open bite of left thumb with damage to nail, initial Unspecified open wound of right index finger without damage to nail, initial Unspecified open wound of left index finger without damage to nail, initial Unspecified open wound of right middle finger without damage to nail, initial Unspecified open wound of left middle finger without damage to nail, initial

26 S61.204A S61.205A S61.206A S61.207A S61.208A S61.210A S61.211A S61.212A S61.213A S61.214A S61.215A S61.216A S61.217A S61.218A S61.220A S61.221A S61.222A S61.223A S61.224A S61.225A S61.226A S61.227A S61.228A Unspecified open wound of right ring finger without damage to nail, initial Unspecified open wound of left ring finger without damage to nail, initial Unspecified open wound of right little finger without damage to nail, initial Unspecified open wound of left little finger without damage to nail, initial Unspecified open wound of other finger without damage to nail, initial Laceration without foreign body of right index finger without damage to nail, initial Laceration without foreign body of left index finger without damage to nail, initial Laceration without foreign body of right middle finger without damage to nail, initial Laceration without foreign body of left middle finger without damage to nail, initial Laceration without foreign body of right ring finger without damage to nail, initial Laceration without foreign body of left ring finger without damage to nail, initial Laceration without foreign body of right little finger without damage to nail, initial Laceration without foreign body of left little finger without damage to nail, initial Laceration without foreign body of other finger without damage to nail, initial Laceration with foreign body of right index finger without damage to nail, initial Laceration with foreign body of left index finger without damage to nail, initial Laceration with foreign body of right middle finger without damage to nail, initial Laceration with foreign body of left middle finger without damage to nail, initial Laceration with foreign body of right ring finger without damage to nail, initial Laceration with foreign body of left ring finger without damage to nail, initial Laceration with foreign body of right little finger without damage to nail, initial Laceration with foreign body of left little finger without damage to nail, initial Laceration with foreign body of other finger without damage to nail, initial

27 S61.230A S61.231A S61.232A S61.233A S61.234A S61.235A S61.236A S61.237A S61.238A S61.240A S61.241A S61.242A S61.243A S61.244A S61.245A S61.246A S61.247A S61.248A S61.250A S61.251A S61.252A S61.253A S61.254A S61.255A S61.256A S61.257A Puncture wound without foreign body of right index finger without damage to nail, initial Puncture wound without foreign body of left index finger without damage to nail, initial Puncture wound without foreign body of right middle finger without damage to nail, initial Puncture wound without foreign body of left middle finger without damage to nail, initial Puncture wound without foreign body of right ring finger without damage to nail, initial Puncture wound without foreign body of left ring finger without damage to nail, initial Puncture wound without foreign body of right little finger without damage to nail, initial Puncture wound without foreign body of left little finger without damage to nail, initial Puncture wound without foreign body of other finger without damage to nail, initial Puncture wound with foreign body of right index finger without damage to nail, initial Puncture wound with foreign body of left index finger without damage to nail, initial Puncture wound with foreign body of right middle finger without damage to nail, initial Puncture wound with foreign body of left middle finger without damage to nail, initial Puncture wound with foreign body of right ring finger without damage to nail, initial Puncture wound with foreign body of left ring finger without damage to nail, initial Puncture wound with foreign body of right little finger without damage to nail, initial Puncture wound with foreign body of left little finger without damage to nail, initial Puncture wound with foreign body of other finger without damage to nail, initial Open bite of right index finger without damage to nail, initial Open bite of left index finger without damage to nail, initial Open bite of right middle finger without damage to nail, initial Open bite of left middle finger without damage to nail, initial Open bite of right ring finger without damage to nail, initial Open bite of left ring finger without damage to nail, initial Open bite of right little finger without damage to nail, initial Open bite of left little finger without damage to nail, initial

28 S61.258A S61.300A S61.301A S61.302A S61.303A S61.304A S61.305A S61.306A S61.307A S61.308A S61.310A S61.311A S61.312A S61.313A S61.314A S61.315A S61.316A S61.317A S61.318A S61.320A S61.321A S61.322A S61.323A S61.324A S61.325A S61.326A Open bite of other finger without damage to nail, initial Unspecified open wound of right index finger with damage to nail, initial Unspecified open wound of left index finger with damage to nail, initial Unspecified open wound of right middle finger with damage to nail, initial Unspecified open wound of left middle finger with damage to nail, initial Unspecified open wound of right ring finger with damage to nail, initial Unspecified open wound of left ring finger with damage to nail, initial Unspecified open wound of right little finger with damage to nail, initial Unspecified open wound of left little finger with damage to nail, initial Unspecified open wound of other finger with damage to nail, initial Laceration without foreign body of right index finger with damage to nail, initial Laceration without foreign body of left index finger with damage to nail, initial Laceration without foreign body of right middle finger with damage to nail, initial Laceration without foreign body of left middle finger with damage to nail, initial Laceration without foreign body of right ring finger with damage to nail, initial Laceration without foreign body of left ring finger with damage to nail, initial Laceration without foreign body of right little finger with damage to nail, initial Laceration without foreign body of left little finger with damage to nail, initial Laceration without foreign body of other finger with damage to nail, initial Laceration with foreign body of right index finger with damage to nail, initial Laceration with foreign body of left index finger with damage to nail, initial Laceration with foreign body of right middle finger with damage to nail, initial Laceration with foreign body of left middle finger with damage to nail, initial Laceration with foreign body of right ring finger with damage to nail, initial Laceration with foreign body of left ring finger with damage to nail, initial Laceration with foreign body of right little finger with damage to nail, initial

29 S61.327A S61.328A S61.330A S61.331A S61.332A S61.333A S61.334A S61.335A S61.336A S61.337A S61.338A S61.340A S61.341A S61.342A S61.343A S61.344A S61.345A S61.346A S61.347A S61.348A S61.350A S61.351A S61.352A S61.353A S61.354A Laceration with foreign body of left little finger with damage to nail, initial Laceration with foreign body of other finger with damage to nail, initial Puncture wound without foreign body of right index finger with damage to nail, initial Puncture wound without foreign body of left index finger with damage to nail, initial Puncture wound without foreign body of right middle finger with damage to nail, initial Puncture wound without foreign body of left middle finger with damage to nail, initial Puncture wound without foreign body of right ring finger with damage to nail, initial Puncture wound without foreign body of left ring finger with damage to nail, initial Puncture wound without foreign body of right little finger with damage to nail, initial Puncture wound without foreign body of left little finger with damage to nail, initial Puncture wound without foreign body of other finger with damage to nail, initial Puncture wound with foreign body of right index finger with damage to nail, initial Puncture wound with foreign body of left index finger with damage to nail, initial Puncture wound with foreign body of right middle finger with damage to nail, initial Puncture wound with foreign body of left middle finger with damage to nail, initial Puncture wound with foreign body of right ring finger with damage to nail, initial Puncture wound with foreign body of left ring finger with damage to nail, initial Puncture wound with foreign body of right little finger with damage to nail, initial Puncture wound with foreign body of left little finger with damage to nail, initial Puncture wound with foreign body of other finger with damage to nail, initial Open bite of right index finger with damage to nail, initial Open bite of left index finger with damage to nail, initial Open bite of right middle finger with damage to nail, initial Open bite of left middle finger with damage to nail, initial Open bite of right ring finger with damage to nail, initial

30 S61.355A S61.356A S61.357A S61.358A S61.401A S61.402A S61.411A S61.412A S61.421A S61.422A S61.431A S61.432A S61.441A S61.442A S61.451A S61.452A S61.501A S61.502A S61.511A S61.512A S61.521A S61.522A S61.531A S61.532A S61.541A S61.542A S61.551A S61.552A S66.021A S66.022A S66.029A S66.120A S66.121A S66.122A S66.123A Open bite of left ring finger with damage to nail, initial Open bite of right little finger with damage to nail, initial Open bite of left little finger with damage to nail, initial Open bite of other finger with damage to nail, initial Unspecified open wound of right hand, initial Unspecified open wound of left hand, initial Laceration without foreign body of right hand, initial Laceration without foreign body of left hand, initial Laceration with foreign body of right hand, initial Laceration with foreign body of left hand, initial Puncture wound without foreign body of right hand, initial Puncture wound without foreign body of left hand, initial Puncture wound with foreign body of right hand, initial Puncture wound with foreign body of left hand, initial Open bite of right hand, initial Open bite of left hand, initial Unspecified open wound of right wrist, initial Unspecified open wound of left wrist, initial Laceration without foreign body of right wrist, initial Laceration without foreign body of left wrist, initial Laceration with foreign body of right wrist, initial Laceration with foreign body of left wrist, initial Puncture wound without foreign body of right wrist, initial Puncture wound without foreign body of left wrist, initial Puncture wound with foreign body of right wrist, initial Puncture wound with foreign body of left wrist, initial Open bite of right wrist, initial Open bite of left wrist, initial Laceration of long flexor muscle, fascia and tendon of right thumb at wrist and hand level, initial Laceration of long flexor muscle, fascia and tendon of left thumb at wrist and hand level, initial Laceration of long flexor muscle, fascia and tendon of unspecified thumb at wrist and hand level, initial Laceration of flexor muscle, fascia and tendon of right index finger at wrist and hand level, initial Laceration of flexor muscle, fascia and tendon of left index finger at wrist and hand level, initial Laceration of flexor muscle, fascia and tendon of right middle finger at wrist and hand level, initial Laceration of flexor muscle, fascia and tendon of left middle finger at wrist and hand level, initial

31 S66.124A S66.125A S66.126A S66.127A S66.128A S66.129A S66.221A S66.222A S66.229A S66.320A S66.321A S66.322A S66.323A S66.324A S66.325A S66.326A S66.327A S66.328A S66.329A S66.421A S66.422A S66.429A Laceration of flexor muscle, fascia and tendon of right ring finger at wrist and hand level, initial Laceration of flexor muscle, fascia and tendon of left ring finger at wrist and hand level, initial Laceration of flexor muscle, fascia and tendon of right little finger at wrist and hand level, initial Laceration of flexor muscle, fascia and tendon of left little finger at wrist and hand level, initial Laceration of flexor muscle, fascia and tendon of other finger at wrist and hand level, initial Laceration of flexor muscle, fascia and tendon of unspecified finger at wrist and hand level, initial Laceration of extensor muscle, fascia and tendon of right thumb at wrist and hand level, initial Laceration of extensor muscle, fascia and tendon of left thumb at wrist and hand level, initial Laceration of extensor muscle, fascia and tendon of unspecified thumb at wrist and hand level, initial Laceration of extensor muscle, fascia and tendon of right index finger at wrist and hand level, initial Laceration of extensor muscle, fascia and tendon of left index finger at wrist and hand level, initial Laceration of extensor muscle, fascia and tendon of right middle finger at wrist and hand level, initial Laceration of extensor muscle, fascia and tendon of left middle finger at wrist and hand level, initial Laceration of extensor muscle, fascia and tendon of right ring finger at wrist and hand level, initial Laceration of extensor muscle, fascia and tendon of left ring finger at wrist and hand level, initial Laceration of extensor muscle, fascia and tendon of right little finger at wrist and hand level, initial Laceration of extensor muscle, fascia and tendon of left little finger at wrist and hand level, initial Laceration of extensor muscle, fascia and tendon of other finger at wrist and hand level, initial Laceration of extensor muscle, fascia and tendon of unspecified finger at wrist and hand level, initial Laceration of intrinsic muscle, fascia and tendon of right thumb at wrist and hand level, initial Laceration of intrinsic muscle, fascia and tendon of left thumb at wrist and hand level, initial Laceration of intrinsic muscle, fascia and tendon of unspecified thumb at wrist and hand level, initial

32 S66.520A S66.521A S66.522A S66.523A S66.524A S66.525A S66.526A S66.527A S66.528A S66.529A S66.821A S66.822A S66.829A S66.921A S66.922A S66.929A S68.011A S68.012A S68.019A S68.021A S68.022A S68.029A S68.110A Laceration of intrinsic muscle, fascia and tendon of right index finger at wrist and hand level, initial Laceration of intrinsic muscle, fascia and tendon of left index finger at wrist and hand level, initial Laceration of intrinsic muscle, fascia and tendon of right middle finger at wrist and hand level, initial Laceration of intrinsic muscle, fascia and tendon of left middle finger at wrist and hand level, initial Laceration of intrinsic muscle, fascia and tendon of right ring finger at wrist and hand level, initial Laceration of intrinsic muscle, fascia and tendon of left ring finger at wrist and hand level, initial Laceration of intrinsic muscle, fascia and tendon of right little finger at wrist and hand level, initial Laceration of intrinsic muscle, fascia and tendon of left little finger at wrist and hand level, initial Laceration of intrinsic muscle, fascia and tendon of other finger at wrist and hand level, initial Laceration of intrinsic muscle, fascia and tendon of unspecified finger at wrist and hand level, initial Laceration of other specified muscles, fascia and tendons at wrist and hand level, right hand, initial Laceration of other specified muscles, fascia and tendons at wrist and hand level, left hand, initial Laceration of other specified muscles, fascia and tendons at wrist and hand level, unspecified hand, initial Laceration of unspecified muscle, fascia and tendon at wrist and hand level, right hand, initial Laceration of unspecified muscle, fascia and tendon at wrist and hand level, left hand, initial Laceration of unspecified muscle, fascia and tendon at wrist and hand level, unspecified hand, initial Complete traumatic metacarpophalangeal amputation of right thumb, initial Complete traumatic metacarpophalangeal amputation of left thumb, initial Complete traumatic metacarpophalangeal amputation of unspecified thumb, initial Partial traumatic metacarpophalangeal amputation of right thumb, initial Partial traumatic metacarpophalangeal amputation of left thumb, initial Partial traumatic metacarpophalangeal amputation of unspecified thumb, initial Complete traumatic metacarpophalangeal amputation of right index finger, initial

33 S68.111A S68.112A S68.113A S68.114A S68.115A S68.116A S68.117A S68.118A S68.119A S68.120A S68.121A S68.122A S68.123A S68.124A S68.125A S68.126A S68.127A S68.128A S68.129A S68.411A S68.412A S68.419A S68.421A S68.422A S68.429A S68.511A Complete traumatic metacarpophalangeal amputation of left index finger, initial Complete traumatic metacarpophalangeal amputation of right middle finger, initial Complete traumatic metacarpophalangeal amputation of left middle finger, initial Complete traumatic metacarpophalangeal amputation of right ring finger, initial Complete traumatic metacarpophalangeal amputation of left ring finger, initial Complete traumatic metacarpophalangeal amputation of right little finger, initial Complete traumatic metacarpophalangeal amputation of left little finger, initial Complete traumatic metacarpophalangeal amputation of other finger, initial Complete traumatic metacarpophalangeal amputation of unspecified finger, initial Partial traumatic metacarpophalangeal amputation of right index finger, initial Partial traumatic metacarpophalangeal amputation of left index finger, initial Partial traumatic metacarpophalangeal amputation of right middle finger, initial Partial traumatic metacarpophalangeal amputation of left middle finger, initial Partial traumatic metacarpophalangeal amputation of right ring finger, initial Partial traumatic metacarpophalangeal amputation of left ring finger, initial Partial traumatic metacarpophalangeal amputation of right little finger, initial Partial traumatic metacarpophalangeal amputation of left little finger, initial Partial traumatic metacarpophalangeal amputation of other finger, initial Partial traumatic metacarpophalangeal amputation of unspecified finger, initial Complete traumatic amputation of right hand at wrist level, initial Complete traumatic amputation of left hand at wrist level, initial Complete traumatic amputation of unspecified hand at wrist level, initial Partial traumatic amputation of right hand at wrist level, initial Partial traumatic amputation of left hand at wrist level, initial Partial traumatic amputation of unspecified hand at wrist level, initial Complete traumatic transphalangeal amputation of right thumb, initial

34 S68.512A S68.519A S68.521A S68.522A S68.529A S68.610A S68.611A S68.612A S68.613A S68.614A S68.615A S68.616A S68.617A S68.618A S68.619A S68.620A S68.621A S68.622A S68.623A S68.624A S68.625A S68.626A S68.627A S68.628A S68.629A S68.711A S68.712A S68.719A S68.721A S68.722A S68.729A S71.011A Complete traumatic transphalangeal amputation of left thumb, initial Complete traumatic transphalangeal amputation of unspecified thumb, initial Partial traumatic transphalangeal amputation of right thumb, initial Partial traumatic transphalangeal amputation of left thumb, initial Partial traumatic transphalangeal amputation of unspecified thumb, initial Complete traumatic transphalangeal amputation of right index finger, initial Complete traumatic transphalangeal amputation of left index finger, initial Complete traumatic transphalangeal amputation of right middle finger, initial Complete traumatic transphalangeal amputation of left middle finger, initial Complete traumatic transphalangeal amputation of right ring finger, initial Complete traumatic transphalangeal amputation of left ring finger, initial Complete traumatic transphalangeal amputation of right little finger, initial Complete traumatic transphalangeal amputation of left little finger, initial Complete traumatic transphalangeal amputation of other finger, initial Complete traumatic transphalangeal amputation of unspecified finger, initial Partial traumatic transphalangeal amputation of right index finger, initial Partial traumatic transphalangeal amputation of left index finger, initial Partial traumatic transphalangeal amputation of right middle finger, initial Partial traumatic transphalangeal amputation of left middle finger, initial Partial traumatic transphalangeal amputation of right ring finger, initial Partial traumatic transphalangeal amputation of left ring finger, initial Partial traumatic transphalangeal amputation of right little finger, initial Partial traumatic transphalangeal amputation of left little finger, initial Partial traumatic transphalangeal amputation of other finger, initial Partial traumatic transphalangeal amputation of unspecified finger, initial Complete traumatic transmetacarpal amputation of right hand, initial Complete traumatic transmetacarpal amputation of left hand, initial Complete traumatic transmetacarpal amputation of unspecified hand, initial Partial traumatic transmetacarpal amputation of right hand, initial Partial traumatic transmetacarpal amputation of left hand, initial Partial traumatic transmetacarpal amputation of unspecified hand, initial Laceration without foreign body, right hip, initial

35 S71.012A S71.021A S71.022A S71.031A S71.032A S71.041A S71.042A S71.051A S71.052A S71.101A S71.102A S71.111A S71.112A S71.121A S71.122A S71.131A S71.132A S71.141A S71.142A S71.151A S71.152A S76.021A S76.022A S76.121A S76.122A S76.221A S76.222A S76.321A S76.322A S76.821A S76.822A S76.921A S76.922A S78.011A S78.012A S78.021A Laceration without foreign body, left hip, initial Laceration with foreign body, right hip, initial Laceration with foreign body, left hip, initial Puncture wound without foreign body, right hip, initial Puncture wound without foreign body, left hip, initial Puncture wound with foreign body, right hip, initial Puncture wound with foreign body, left hip, initial Open bite, right hip, initial Open bite, left hip, initial Unspecified open wound, right thigh, initial Unspecified open wound, left thigh, initial Laceration without foreign body, right thigh, initial Laceration without foreign body, left thigh, initial Laceration with foreign body, right thigh, initial Laceration with foreign body, left thigh, initial Puncture wound without foreign body, right thigh, initial Puncture wound without foreign body, left thigh, initial Puncture wound with foreign body, right thigh, initial Puncture wound with foreign body, left thigh, initial Open bite, right thigh, initial Open bite, left thigh, initial Laceration of muscle, fascia and tendon of right hip, initial Laceration of muscle, fascia and tendon of left hip, initial Laceration of right quadriceps muscle, fascia and tendon, initial Laceration of left quadriceps muscle, fascia and tendon, initial Laceration of adductor muscle, fascia and tendon of right thigh, initial Laceration of adductor muscle, fascia and tendon of left thigh, initial Laceration of muscle, fascia and tendon of the posterior muscle group at thigh level, right thigh, initial Laceration of muscle, fascia and tendon of the posterior muscle group at thigh level, left thigh, initial Laceration of other specified muscles, fascia and tendons at thigh level, right thigh, initial Laceration of other specified muscles, fascia and tendons at thigh level, left thigh, initial Laceration of unspecified muscles, fascia and tendons at thigh level, right thigh, initial Laceration of unspecified muscles, fascia and tendons at thigh level, left thigh, initial Complete traumatic amputation at right hip joint, initial Complete traumatic amputation at left hip joint, initial Partial traumatic amputation at right hip joint, initial

36 S78.022A S78.111A S78.112A S78.121A S78.122A S78.911A S78.912A S78.921A S78.922A S81.001A S81.002A S81.011A S81.012A S81.021A S81.022A S81.031A S81.032A S81.041A S81.042A S81.051A S81.052A S81.801A S81.802A S81.811A S81.812A S81.821A S81.822A S81.831A S81.832A S81.841A S81.842A S81.851A S81.852A S86.021A S86.022A S86.029A Partial traumatic amputation at left hip joint, initial Complete traumatic amputation at level between right hip and knee, initial Complete traumatic amputation at level between left hip and knee, initial Partial traumatic amputation at level between right hip and knee, initial Partial traumatic amputation at level between left hip and knee, initial Complete traumatic amputation of right hip and thigh, level unspecified, initial Complete traumatic amputation of left hip and thigh, level unspecified, initial Partial traumatic amputation of right hip and thigh, level unspecified, initial Partial traumatic amputation of left hip and thigh, level unspecified, initial Unspecified open wound, right knee, initial Unspecified open wound, left knee, initial Laceration without foreign body, right knee, initial Laceration without foreign body, left knee, initial Laceration with foreign body, right knee, initial Laceration with foreign body, left knee, initial Puncture wound without foreign body, right knee, initial Puncture wound without foreign body, left knee, initial Puncture wound with foreign body, right knee, initial Puncture wound with foreign body, left knee, initial Open bite, right knee, initial Open bite, left knee, initial Unspecified open wound, right lower leg, initial Unspecified open wound, left lower leg, initial Laceration without foreign body, right lower leg, initial Laceration without foreign body, left lower leg, initial Laceration with foreign body, right lower leg, initial Laceration with foreign body, left lower leg, initial Puncture wound without foreign body, right lower leg, initial Puncture wound without foreign body, left lower leg, initial Puncture wound with foreign body, right lower leg, initial Puncture wound with foreign body, left lower leg, initial Open bite, right lower leg, initial Open bite, left lower leg, initial Laceration of right Achilles tendon, initial Laceration of left Achilles tendon, initial Laceration of unspecified Achilles tendon, initial

37 S86.121A S86.122A S86.221A S86.222A S86.321A S86.322A S86.821A S86.822A S86.921A S86.922A S88.011A S88.012A S88.021A S88.022A S88.111A S88.112A S88.121A S88.122A S88.911A S88.912A S88.921A S88.922A S91.011A S91.012A S91.021A S91.022A S91.031A Laceration of other muscle(s) and tendon(s) of posterior muscle group at lower leg level, right leg, initial Laceration of other muscle(s) and tendon(s) of posterior muscle group at lower leg level, left leg, initial Laceration of muscle(s) and tendon(s) of anterior muscle group at lower leg level, right leg, initial Laceration of muscle(s) and tendon(s) of anterior muscle group at lower leg level, left leg, initial Laceration of muscle(s) and tendon(s) of peroneal muscle group at lower leg level, right leg, initial Laceration of muscle(s) and tendon(s) of peroneal muscle group at lower leg level, left leg, initial Laceration of other muscle(s) and tendon(s) at lower leg level, right leg, initial Laceration of other muscle(s) and tendon(s) at lower leg level, left leg, initial Laceration of unspecified muscle(s) and tendon(s) at lower leg level, right leg, initial Laceration of unspecified muscle(s) and tendon(s) at lower leg level, left leg, initial Complete traumatic amputation at knee level, right lower leg, initial Complete traumatic amputation at knee level, left lower leg, initial Partial traumatic amputation at knee level, right lower leg, initial Partial traumatic amputation at knee level, left lower leg, initial Complete traumatic amputation at level between knee and ankle, right lower leg, initial Complete traumatic amputation at level between knee and ankle, left lower leg, initial Partial traumatic amputation at level between knee and ankle, right lower leg, initial Partial traumatic amputation at level between knee and ankle, left lower leg, initial Complete traumatic amputation of right lower leg, level unspecified, initial Complete traumatic amputation of left lower leg, level unspecified, initial Partial traumatic amputation of right lower leg, level unspecified, initial Partial traumatic amputation of left lower leg, level unspecified, initial Laceration without foreign body, right ankle, initial Laceration without foreign body, left ankle, initial Laceration with foreign body, right ankle, initial Laceration with foreign body, left ankle, initial Puncture wound without foreign body, right ankle, initial

38 S91.032A S91.041A S91.042A S91.051A S91.052A S91.101A S91.102A S91.104A S91.105A S91.111A S91.112A S91.114A S91.115A S91.121A S91.122A S91.124A S91.125A S91.131A S91.132A S91.134A S91.135A S91.141A S91.142A S91.144A S91.145A S91.151A Puncture wound without foreign body, left ankle, initial Puncture wound with foreign body, right ankle, initial Puncture wound with foreign body, left ankle, initial Open bite, right ankle, initial Open bite, left ankle, initial Unspecified open wound of right great toe without damage to nail, initial Unspecified open wound of left great toe without damage to nail, initial Unspecified open wound of right lesser toe(s) without damage to nail, initial Unspecified open wound of left lesser toe(s) without damage to nail, initial Laceration without foreign body of right great toe without damage to nail, initial Laceration without foreign body of left great toe without damage to nail, initial Laceration without foreign body of right lesser toe(s) without damage to nail, initial Laceration without foreign body of left lesser toe(s) without damage to nail, initial Laceration with foreign body of right great toe without damage to nail, initial Laceration with foreign body of left great toe without damage to nail, initial Laceration with foreign body of right lesser toe(s) without damage to nail, initial Laceration with foreign body of left lesser toe(s) without damage to nail, initial Puncture wound without foreign body of right great toe without damage to nail, initial Puncture wound without foreign body of left great toe without damage to nail, initial Puncture wound without foreign body of right lesser toe(s) without damage to nail, initial Puncture wound without foreign body of left lesser toe(s) without damage to nail, initial Puncture wound with foreign body of right great toe without damage to nail, initial Puncture wound with foreign body of left great toe without damage to nail, initial Puncture wound with foreign body of right lesser toe(s) without damage to nail, initial Puncture wound with foreign body of left lesser toe(s) without damage to nail, initial Open bite of right great toe without damage to nail, initial

39 S91.152A S91.153A S91.154A S91.155A S91.156A S91.159A S91.201A S91.202A S91.203A S91.204A S91.205A S91.206A S91.209A S91.211A S91.212A S91.213A S91.214A S91.215A S91.216A S91.219A S91.221A S91.222A S91.223A S91.224A S91.225A S91.226A S91.229A Open bite of left great toe without damage to nail, initial Open bite of unspecified great toe without damage to nail, initial Open bite of right lesser toe(s) without damage to nail, initial Open bite of left lesser toe(s) without damage to nail, initial Open bite of unspecified lesser toe(s) without damage to nail, initial Open bite of unspecified toe(s) without damage to nail, initial Unspecified open wound of right great toe with damage to nail, initial Unspecified open wound of left great toe with damage to nail, initial Unspecified open wound of unspecified great toe with damage to nail, initial Unspecified open wound of right lesser toe(s) with damage to nail, initial Unspecified open wound of left lesser toe(s) with damage to nail, initial Unspecified open wound of unspecified lesser toe(s) with damage to nail, initial Unspecified open wound of unspecified toe(s) with damage to nail, initial Laceration without foreign body of right great toe with damage to nail, initial Laceration without foreign body of left great toe with damage to nail, initial Laceration without foreign body of unspecified great toe with damage to nail, initial Laceration without foreign body of right lesser toe(s) with damage to nail, initial Laceration without foreign body of left lesser toe(s) with damage to nail, initial Laceration without foreign body of unspecified lesser toe(s) with damage to nail, initial Laceration without foreign body of unspecified toe(s) with damage to nail, initial Laceration with foreign body of right great toe with damage to nail, initial Laceration with foreign body of left great toe with damage to nail, initial Laceration with foreign body of unspecified great toe with damage to nail, initial Laceration with foreign body of right lesser toe(s) with damage to nail, initial Laceration with foreign body of left lesser toe(s) with damage to nail, initial Laceration with foreign body of unspecified lesser toe(s) with damage to nail, initial Laceration with foreign body of unspecified toe(s) with damage to nail, initial

40 S91.231A S91.232A S91.233A S91.234A S91.235A S91.236A S91.239A S91.241A S91.242A S91.243A S91.244A S91.245A S91.246A S91.249A S91.251A S91.252A S91.254A S91.255A S91.301A S91.302A S91.311A S91.312A S91.321A S91.322A S91.331A S91.332A S91.341A S91.342A S91.351A Puncture wound without foreign body of right great toe with damage to nail, initial Puncture wound without foreign body of left great toe with damage to nail, initial Puncture wound without foreign body of unspecified great toe with damage to nail, initial Puncture wound without foreign body of right lesser toe(s) with damage to nail, initial Puncture wound without foreign body of left lesser toe(s) with damage to nail, initial Puncture wound without foreign body of unspecified lesser toe(s) with damage to nail, initial Puncture wound without foreign body of unspecified toe(s) with damage to nail, initial Puncture wound with foreign body of right great toe with damage to nail, initial Puncture wound with foreign body of left great toe with damage to nail, initial Puncture wound with foreign body of unspecified great toe with damage to nail, initial Puncture wound with foreign body of right lesser toe(s) with damage to nail, initial Puncture wound with foreign body of left lesser toe(s) with damage to nail, initial Puncture wound with foreign body of unspecified lesser toe(s) with damage to nail, initial Puncture wound with foreign body of unspecified toe(s) with damage to nail, initial Open bite of right great toe with damage to nail, initial Open bite of left great toe with damage to nail, initial Open bite of right lesser toe(s) with damage to nail, initial Open bite of left lesser toe(s) with damage to nail, initial Unspecified open wound, right foot, initial Unspecified open wound, left foot, initial Laceration without foreign body, right foot, initial Laceration without foreign body, left foot, initial Laceration with foreign body, right foot, initial Laceration with foreign body, left foot, initial Puncture wound without foreign body, right foot, initial Puncture wound without foreign body, left foot, initial Puncture wound with foreign body, right foot, initial Puncture wound with foreign body, left foot, initial Open bite, right foot, initial

41 S91.352A S96.021A S96.022A S96.121A S96.122A S96.221A S96.222A S96.821A S96.822A S96.921A S96.922A S98.011A S98.012A S98.021A S98.022A S98.111A S98.112A S98.121A S98.122A S98.131A S98.132A S98.141A S98.142A S98.211A S98.212A S98.219A S98.221A S98.222A S98.229A S98.311A S98.312A Open bite, left foot, initial Laceration of muscle and tendon of long flexor muscle of toe at ankle and foot level, right foot, initial Laceration of muscle and tendon of long flexor muscle of toe at ankle and foot level, left foot, initial Laceration of muscle and tendon of long extensor muscle of toe at ankle and foot level, right foot, initial Laceration of muscle and tendon of long extensor muscle of toe at ankle and foot level, left foot, initial Laceration of intrinsic muscle and tendon at ankle and foot level, right foot, initial Laceration of intrinsic muscle and tendon at ankle and foot level, left foot, initial Laceration of other specified muscles and tendons at ankle and foot level, right foot, initial Laceration of other specified muscles and tendons at ankle and foot level, left foot, initial Laceration of unspecified muscle and tendon at ankle and foot level, right foot, initial Laceration of unspecified muscle and tendon at ankle and foot level, left foot, initial Complete traumatic amputation of right foot at ankle level, initial Complete traumatic amputation of left foot at ankle level, initial Partial traumatic amputation of right foot at ankle level, initial Partial traumatic amputation of left foot at ankle level, initial Complete traumatic amputation of right great toe, initial Complete traumatic amputation of left great toe, initial Partial traumatic amputation of right great toe, initial Partial traumatic amputation of left great toe, initial Complete traumatic amputation of one right lesser toe, initial Complete traumatic amputation of one left lesser toe, initial Partial traumatic amputation of one right lesser toe, initial Partial traumatic amputation of one left lesser toe, initial Complete traumatic amputation of two or more right lesser toes, initial Complete traumatic amputation of two or more left lesser toes, initial Complete traumatic amputation of two or more unspecified lesser toes, initial Partial traumatic amputation of two or more right lesser toes, initial Partial traumatic amputation of two or more left lesser toes, initial Partial traumatic amputation of two or more unspecified lesser toes, initial Complete traumatic amputation of right midfoot, initial Complete traumatic amputation of left midfoot, initial

42 S98.319A S98.321A S98.322A S98.329A S98.911A S98.912A S98.919A S98.921A S98.922A S98.929A T07 Complete traumatic amputation of unspecified midfoot, initial Partial traumatic amputation of right midfoot, initial Partial traumatic amputation of left midfoot, initial Partial traumatic amputation of unspecified midfoot, initial Complete traumatic amputation of right foot, level unspecified, initial Complete traumatic amputation of left foot, level unspecified, initial Complete traumatic amputation of unspecified foot, level unspecified, initial Partial traumatic amputation of right foot, level unspecified, initial Partial traumatic amputation of left foot, level unspecified, initial Partial traumatic amputation of unspecified foot, level unspecified, initial Unspecified multiple injuries Showing 1 to 918 of 918 entries in Group 7 Group 8 Paragraph: J0850 Group 8Codes ICD-10 Code Description Z76.82 Awaiting organ transplant status Z94.0 Kidney transplant status Z94.1 Heart transplant status Z94.4 Liver transplant status Z94.81 Bone marrow transplant status Z94.83 Pancreas transplant status Z94.84 Stem cells transplant status Showing 1 to 7 of 7 entries in Group 8 Group 9 Paragraph: J1571 Group 9Codes ICD-10 Code Description Z20.5 Contact with and (suspected) exposure to viral hepatitis Showing 1 to 1 of 1 entries in Group 9 Group 10 Paragraph: J1573 Group 10Codes

43 ICD-10 Code Description B16.1 Acute hepatitis B with delta-agent without hepatic coma B16.2 Acute hepatitis B without delta-agent with hepatic coma B16.9 Acute hepatitis B without delta-agent and without hepatic coma B17.0 Acute delta-(super) infection of hepatitis B carrier B18.0 Chronic viral hepatitis B with delta-agent B18.1 Chronic viral hepatitis B without delta-agent B19.10 Unspecified viral hepatitis B without hepatic coma B19.11 Unspecified viral hepatitis B with hepatic coma Z22.51 Carrier of viral hepatitis B Showing 1 to 9 of 9 entries in Group 10 Group 11 Paragraph: J0840 Group 11Codes ICD-10 Code Description T63.011A Toxic effect of rattlesnake venom, accidental (unintentional), initial T63.012A Toxic effect of rattlesnake venom, intentional self-harm, initial T63.013A Toxic effect of rattlesnake venom, assault, initial T63.014A Toxic effect of rattlesnake venom, undetermined, initial Showing 1 to 4 of 4 entries in Group 11 Group 12 Paragraph: J1459, J1556, J1557, J1561, J1566, J1568, J1569, J1572, J1599 Group 12Codes ICD-10 Code Description B20 Human immunodeficiency virus [HIV] disease C88.2 Heavy chain disease C88.3 Immunoproliferative small intestinal disease C88.8 Other malignant immunoproliferative diseases C88.9 Malignant immunoproliferative disease, unspecified C90.00 Multiple myeloma not having achieved remission C90.01 Multiple myeloma in remission C90.02 Multiple myeloma in relapse C90.10 Plasma cell leukemia not having achieved remission C90.11 Plasma cell leukemia in remission C90.12 Plasma cell leukemia in relapse C90.20 Extramedullary plasmacytoma not having achieved remission

44 C90.22 Extramedullary plasmacytoma in relapse C90.30 Solitary plasmacytoma not having achieved remission C90.32 Solitary plasmacytoma in relapse C91.10 Chronic lymphocytic leukemia of B-cell type not having achieved remission C91.12 Chronic lymphocytic leukemia of B-cell type in relapse C91.Z0 Other lymphoid leukemia not having achieved remission C91.Z2 Other lymphoid leukemia, in relapse D47.3 Essential (hemorrhagic) thrombocythemia D59.0 Drug-induced autoimmune hemolytic anemia D59.1 Other autoimmune hemolytic anemias D60.0 Chronic acquired pure red cell aplasia D60.1 Transient acquired pure red cell aplasia D60.8 Other acquired pure red cell aplasias D60.9 Acquired pure red cell aplasia, unspecified D61.1 Drug-induced aplastic anemia D61.2 Aplastic anemia due to other external agents D61.3 Idiopathic aplastic anemia D61.89 Other specified aplastic anemias and other bone marrow failure syndromes D69.3 Immune thrombocytopenic purpura D69.41 Evans syndrome D69.42 Congenital and hereditary thrombocytopenia purpura D69.49 Other primary thrombocytopenia D69.51 Posttransfusion purpura D69.59 Other secondary thrombocytopenia D70.8 Other neutropenia D80.0 Hereditary hypogammaglobulinemia D80.1 Nonfamilial hypogammaglobulinemia D80.2 Selective deficiency of immunoglobulin A [IgA] D80.3 Selective deficiency of immunoglobulin G [IgG] subclasses D80.4 Selective deficiency of immunoglobulin M [IgM] D80.5 Immunodeficiency with increased immunoglobulin M [IgM] D81.0 Severe combined immunodeficiency [SCID] with reticular dysgenesis D81.1 Severe combined immunodeficiency [SCID] with low T- and B-cell numbers D81.2 Severe combined immunodeficiency [SCID] with low or normal B-cell numbers D81.6 Major histocompatibility complex class I deficiency D81.7 Major histocompatibility complex class II deficiency D81.89 Other combined immunodeficiencies D82.0 Wiskott-Aldrich syndrome D83.0 Common variable immunodeficiency with predominant abnormalities of B-cell numbers and function D83.2 Common variable immunodeficiency with autoantibodies to B- or T-cells D83.8 Other common variable immunodeficiencies

45 G25.82 Stiff-man syndrome G Generalized idiopathic epilepsy and epileptic syndromes, not intractable, with status epilepticus G Generalized idiopathic epilepsy and epileptic syndromes, intractable, with status epilepticus G Generalized idiopathic epilepsy and epileptic syndromes, intractable, without status epilepticus G Other generalized epilepsy and epileptic syndromes, intractable, with status epilepticus G Other generalized epilepsy and epileptic syndromes, intractable, without status epilepticus G61.0 Guillain-Barre syndrome G61.81 Chronic inflammatory demyelinating polyneuritis G61.89* Other inflammatory polyneuropathies G70.00 Myasthenia gravis without (acute) exacerbation G70.01 Myasthenia gravis with (acute) exacerbation G70.80 Lambert-Eaton syndrome, unspecified L10.0 Pemphigus vulgaris L10.1 Pemphigus vegetans L10.2 Pemphigus foliaceous L10.3 Brazilian pemphigus [fogo selvagem] L10.4 Pemphigus erythematosus L10.5 Drug-induced pemphigus L10.81 Paraneoplastic pemphigus L10.89 Other pemphigus L10.9 Pemphigus, unspecified L12.0 Bullous pemphigoid L12.1 Cicatricial pemphigoid L12.30 Acquired epidermolysis bullosa, unspecified L12.31 Epidermolysis bullosa due to drug L12.35 Other acquired epidermolysis bullosa L12.8 Other pemphigoid L12.9 Pemphigoid, unspecified L13.8 Other specified bullous disorders L14 Bullous disorders in diseases classified elsewhere L51.1 Stevens-Johnson syndrome L51.2 Toxic epidermal necrolysis [Lyell] L51.3 Stevens-Johnson syndrome-toxic epidermal necrolysis overlap syndrome L88 Pyoderma gangrenosum L90.1 Anetoderma of Schweninger-Buzzi L90.2 Anetoderma of Jadassohn-Pellizzari L90.6 Striae atrophicae

46 M30.0 Polyarteritis nodosa M30.1 Polyarteritis with lung involvement [Churg-Strauss] M30.2 Juvenile polyarteritis M30.3 Mucocutaneous lymph node syndrome [Kawasaki] M31.30 Wegener's granulomatosis without renal involvement M31.31 Wegener's granulomatosis with renal involvement M31.7 Microscopic polyangiitis M32.0 Drug-induced systemic lupus erythematosus M32.10 Systemic lupus erythematosus, organ or system involvement unspecified M32.11 Endocarditis in systemic lupus erythematosus M32.12 Pericarditis in systemic lupus erythematosus M32.13 Lung involvement in systemic lupus erythematosus M32.14 Glomerular disease in systemic lupus erythematosus M32.15 Tubulo-interstitial nephropathy in systemic lupus erythematosus M32.19 Other organ or system involvement in systemic lupus erythematosus M32.8 Other forms of systemic lupus erythematosus M32.9 Systemic lupus erythematosus, unspecified M33.00 Juvenile dermatopolymyositis, organ involvement unspecified M33.01 Juvenile dermatopolymyositis with respiratory involvement M33.02 Juvenile dermatopolymyositis with myopathy M33.09 Juvenile dermatopolymyositis with other organ involvement M33.10 Other dermatopolymyositis, organ involvement unspecified M33.11 Other dermatopolymyositis with respiratory involvement M33.12 Other dermatopolymyositis with myopathy M33.19 Other dermatopolymyositis with other organ involvement M33.20 Polymyositis, organ involvement unspecified M33.21 Polymyositis with respiratory involvement M33.22 Polymyositis with myopathy M33.29 Polymyositis with other organ involvement M33.90 Dermatopolymyositis, unspecified, organ involvement unspecified M33.91 Dermatopolymyositis, unspecified with respiratory involvement M33.92 Dermatopolymyositis, unspecified with myopathy M33.99 Dermatopolymyositis, unspecified with other organ involvement M35.5 Multifocal fibrosclerosis M35.8 Other specified systemic involvement of connective tissue M36.0 Dermato(poly)myositis in neoplastic disease O Supervision of other high risk pregnancies, first trimester O Supervision of other high risk pregnancies, second trimester O Supervision of other high risk pregnancies, third trimester O Supervision of other high risk pregnancies, unspecified trimester P61.0 Transient neonatal thrombocytopenia Z48.21 Encounter for aftercare following heart transplant

47 Z48.23 Encounter for aftercare following liver transplant Z48.24 Encounter for aftercare following lung transplant Z Encounter for aftercare following heart-lung transplant Z Encounter for aftercare following bone marrow transplant Z76.82 Awaiting organ transplant status Z94.0 Kidney transplant status Z94.1 Heart transplant status Z94.2 Lung transplant status Z94.3 Heart and lungs transplant status Z94.4 Liver transplant status Z94.81 Bone marrow transplant status Z94.83 Pancreas transplant status Z94.84 Stem cells transplant status Group 12 Medical Necessity ICD-10 Codes Asterisk Explanation: *Note: G61.89 should be used to indicate multifocal motor neuropathy Showing 1 to 145 of 145 entries in Group 12 ICD-10 Codes that DO NOT Support Medical Necessity Group 1 Paragraph: Any not listed as covered Group 1 Codes: N/A Additional ICD-10 Information N/A General Information Associated Information Documentation Requirements Medical records must include the indications to support using IVIG. For those indications stating routine use is not indicated, the medical record must document the interventions that were unsuccessful or the reason they were not tolerated.

48 Documentation must support objective response for continued coverage. Medical Records must be made available to the Contractor upon request. Utilization Guidelines Sources of Information and Basis for Decision Abel, E.A., & Bystryn, J.C. (July 2003). Vesiculobullous diseases update. Branch, D.W., Porter, T.F. Paidas, M.J. Belfort, M.A. & Gonik, B. (Oct 2001). Obstetric uses of intravenous immunoglobulin: successes, failures, and promises. J of Allergy Clin Immunol. 108: Bussel, J.B. (Jun 2001). Alloimmune thrombocytopenis in the fetus and newborn. Semin Thromb Hemost. (3): Callen, J.P. & Jorizzo, J.L. (Mar 2000). Skin signs of systemic disease. Best Practice of Medicine. CytoGam Cytomegalovirus Immune Globulin Intravenous (Human) (CMV-IGIV) package insert. Fischer, M., Fiedler, E., Marsch, W.C., & Wohlrab, J. (2002). Antitumor necrosis factor-alpha antibodies (infliximab) in the treatment of a patient with toxic epidermal necrolysis. British Journal of Dermatology. 146 (4): Gebel, H.M. & Halloran, P.F. (2010). Making sense of desensitization. American Journal of Transplantation. 10: 1-2. Jordan, S.C., Toyoda, M., Jahwaji, J., & Vo, A.A. (2011). Clinical aspects of intravenous immunoglobulin use in solid organ transplant recipients. American Journal of Transplantation. 1: Kreuter, A. & et al. (Oct 2004). Pulsed intravenous immunoglobulin therapy in livedoid vasculitis: an open trial evaluating 9 consecutive patients. Journal of American Academic Dermatology. 51 (4). Montgomery R.A. (2010). Renal transplantation across HLA and ABO antibody barriers: integrating paired donation into desensitization protocols. American Journal of Transplantation. 10: 1-9. Rutter, A. & Luger, T. (June 2001). High-dose intravenous immunoglubulins: an approach to treat severe immune-mediated and autoimmune diseases of the skin. J of Am Acad Dermatology Silver, R.M., Porter, T.F., Branch, Esplin, M.S., & Scott, J.R. (May 2000). Neonatal alloimmune thrombocytopenia: antenatal management. Am J Obstet Gynecol. 182 (5):

49 Contractor Advisory Committee Meeting Notes Meeting Date: Wisconsin 05/15/2009 Illinois 05/13/2009 Michigan 05/06/2009 Minnesota 05/21/2009 J5 MAC 06/04/2009 Open LCD Meeting 04/15/09 Start Date of Comment Period 06/04/2009 End Date of Comment Period 07/20/2009 Start Date of Notice Period 06/01/2012 Revision History Information Please note: Most Revision History entries effective on or before 01/24/2013 display with a Revision History Number of "R1" at the bottom of this table. However, there may be LCDs where these entries will display as a separate and distinct row. Revision History Date 10/01/2015 R1 Revision History Number Revision History Explanation 01/01/2015 Annual review done 12/04/2014. Formatting and grammar changes made. Updated sources of information. No change in coverage. Reason(s) for Change Other Associated Documents Attachments N/A Related Local Coverage Documents N/A Related National Coverage Documents

50 N/A Public Version(s) Updated on 12/19/2014 with effective dates 10/01/ N/A Updated on 03/04/2014 with effective dates 10/01/ N/A Keywords N/A Read the LCD Disclaimer opens in new window