Procedure Codes 2015 Prominence Health Plan v3 DIAGNOSTIC RADIOLOGY CT CT Head or Brain 70450, 70460, 70470 CT Orbits, Sella, Posterior-Fossa, IACs 70480, 70481, 70482 CT Maxillofacial (Sinuses) 70486, 70487, 70488 CT Neck 70490, 70491, 70492 CT Chest 71250, 71260, 71270 CT Cervical Spine 72125, 72126, 72127 CT Thoracic Spine 72128, 72129, 72130 CT Lumbar Spine 72131, 72132, 72133 CT Pelvis 72192, 72193, 72194 CT Upper Extremity 73200, 73201, 73202 CT Lower Extremity 73700, 73701, 73702 CT Abdomen 74150, 74160, 74170 CT Abdomen and Pelvis 74176, 74177, 74178 CT colonography, diagnostic, including image postprocessing; without and with contrast 74261, 74262 CT colonography, screening, including image postprocessing 74263 CT Limited Study or Follow-up 76380 Low-dose computed tomography for lung cancer screening S8032 CTA CT Angiography, Head, with contrast material(s), including noncontrast images, if performed, and image postprocessing 70496 CT Angiography, Neck, with contrast material(s), including noncontrast images, if performed, and image postprocessing 70498 CT Angiography, Chest, with contrast material(s), including noncontrast images, if performed, and image postprocessing 71275 CT Angiography, Pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing 72191 CT Angiography, Upper Extremity, with contrast material(s), including noncontrast images, if performed, and image 73206 postprocessing CT Angiography, Lower Extremity, with contrast material(s), including noncontrast images, if performed, and image 73706 postprocessing CT Angiography, Abdomen and Pelvis, with contrast material(s), including noncontrast images, if performed, and image 74174 postprocessing CT Angiography, Abdomen, with contrast material(s), including noncontrast images, if performed, and image 74175 postprocessing CT, heart, without contrast material, with quantitative evaluation of coronary calcium 75571 CT, heart, with contrast material, for evaluation of cardiac structure and morphology (including 3D image postprocessing, 75572 assessment of cardiac function, and evaluation of venous structures, if performed) CT, heart, with contrast material, for evaluation of cardiac structure and morphology in the setting of congenital heart disease (including 3D image postprocessing, assessment of LV cardiac function, RV structure and function and evaluation 75573 of venous structures, if performed) CTAngiography, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3D postprocessing (including evaluation of cardiac structures and morphology, assessment of cardiac function, and evaluation 75574 of venous structures, if performed) CT Angiography, Abdominal Aorta and Bilateral Iliofemoral Lower Exremity Runoff, with contrast material(s), including 75635 noncontrast images, if performed, and image postprocessing MRA MRA Brain 70544, 70545, 70546 MRA Neck 70547, 70548, 70549 MRA Chest 71555, C8909, C8910, C8911 1
MRA Spinal Canal and Contents MRA Pelvis MRA Upper Extremity MRA Lower Extremity MRA Abdomen 72159, C8931, C8932, C8933 72198, C8918, C8919, C8920 73225, C8934, C8935, C8936 73725, C8912, C8913, C8914 74185, C8900, C8901, C8902 MRI MRI TMJs -Temporomandibular joint(s) 70336 MRI Orbits, Face, Neck 70540, 70542, 70543 MRI Brain (including brain stem) 70551, 70552, 70553 MRI Brain, functional 70554, 70555 MRI Chest 71550, 71551, 71552 MRI Cervical Spine 72141, 72142, 72156 MRI Thoracic Spine 72146, 72147, 72157 MRI Lumbar Spine 72148, 72149, 72158 MRI Pelvis 72195, 72196, 72197 MRI Upper Extremity Other than Joint 73218, 73219, 73220 MRI Upper Extremity, Joint (Shoulder, Elbow, Wrist) 73221, 73222, 73223 MRI Lower Extremity Other than Joint 73718, 73719, 73720 MRI Lower Extremity, Joint (Knee, Hip Joint, Ankle) 73721, 73722, 73723 MRI Abdomen 74181, 74182, 74183 MRI Cardiac for Morphology and Function without contrast 75557 MRI Cardiac for Morphology and Function without contrast; with stress imaging 75559 MRI Cardiac for Morphology and Function w/o contrast material(s), followed by contrast material(s) and further sequences 75561 MRI Cardiac for Morphology and Function w/o contrast material(s), followed by contrast material(s) and further sequences; 75563 with stress imaging MRI Cardiac for velocity flow mapping 75565 MRI Breast - Unilateral without and/or with contrast 77058, C8903, C8904, C8905 MRI Breast - Bilateral without and/or with contrast 77059, C8906, C8907, C8908 MRI - Bone Marrow Blood Supply 77084 Nuclear Medicine Cardiac Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic) Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or reinjection Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic) Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or 78454 pharmacologic) and/or redistribution and/or reinjection Myocardial Imaging, infarct avid, planar; qualitative or quantitative 78466 Myocardial Imaging with ejection fraction, first pass technique 78468 Myocardial Imaging, tomographic SPECT with or without quantification 78469 Cardiac Blood Pool Imaging, gated equilibrium; planar, single study Rest or Stress, wall motion study + ejection fraction, w/ or w/o quantitative processing 78472 Cardiac Blood Pooling Imaging, multiple studies, wall motion study plus ejection fraction, at rest or stress, w/ or w/o additional quantification 78473 Cardiac Blood Pool Imaging, planar, first pass technique, single study, rest or stress, wall motion study + ejection fraction, w/ or w/o quantification 78481 Cardiac Blood Pool Imaging, multiple studies, rest and stress, wall motion study + ejection fraction, w/ or w/o quantification 78483 Cardiac Blood Pool Imaging, gated equilibrium, SPECT; planar, single study rest or stress, wall motion study + ejection fraction, w/ or w/o quantitative processing Cardiac Blood Pool Imaging, gated equilibrium; single study at rest w/ rt. ventricular ejection fraction by first pass technique 2 78451 78452 78453 78494 78496
PET PET Myocardial Imaging, Metabolic Evaluation 78459 PET Myocardial Imaging, Perfusion at Rest or Stress 78491 PET Myocardial Imaging, Perfusion at Rest or Stress, Multiple Studies 78492 PET Brain, Metabolic Evaluation 78608 PET Brain, Perfusion Evaluation 78609 PET; limited area (eg, chest, head/neck) 78811 PET; skull base to mid-thigh 78812 PET; whole body 78813 PET with concurrent CT for attenuation correction and anatomical localization imaging; limited area (eg, chest, head/neck) 78814 PET with concurrent CT for attenuation correction and anatomical localization imaging; skull base to mid-thigh 78815 PET with concurrent CT for attenuation correction and anatomical localization imaging; whole body 78816 PET imaging whole body for Melanoma for Noncovered Indications G0219 PET imaging, any site, not otherwise specified G0235 PET imaging, Breast Cancer Imaging, Diagnosis and/or Surgical Planning G0252 RADIATION THERAPY 2D3D Therapeutic radiology treatment planning; simple 77261 Therapeutic radiology treatment planning; intermediate 77262 Therapeutic radiology treatment planning; complex 77263 Teletherapy isodose plan; simple (1 or 2 unmodified ports directed to a single area of interest), includes basic dosimetry calculation(s) 77306 Teletherapy isodose plan; complex (multiple treatment areas, tangential ports, the use of wedges, blocking, rotational beam, or special beam considerations), includes basic dosimetry calculation(s) 77307 Special teletherapy port plan, particles, hemibody, total body 77321 Radiation treatment delivery, superficial and/or ortho voltage, per day 77401 Radiation treatment delivery, >1 MeV; simple 77402 Radiation treatment delivery, >1 MeV; intermediate 77407 Radiation treatment delivery, >1 MeV; complex 77412 Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks: up to G6003 5MeV Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks: 6-10MeV G6004 Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks: 11-19MeV G6005 Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks: 20MeV or greater G6006 Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks: up to 5MeV G6007 Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks: 6-10MeV G6008 Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks: 11-19MeV G6009 Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks: 20MeV or greater G6010 Radiation treatment delivery, 3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; up to 5MeV G6011 Radiation treatment delivery, 3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 6-10MeV G6012 Radiation treatment delivery, 3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 11-19MeV G6013 Radiation treatment delivery, 3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 20MeV or greater G6014 Brachytherapy Brachytherapy isodose plan; simple (calculation[s] made from 1 to 4 sources, or remote afterloading brachytherapy, 1 channel), includes basic dosimetry calculation(s) 77316 3
Brachytherapy isodose plan; intermediate (calculation[s] made from 5 to 10 sources, or remote afterloading brachytherapy, 2-12 channels), includes basic dosimetry calculation(s) 77317 Brachytherapy isodose plan; complex (calculation[s] made from over 10 sources, or remote afterloading brachytherapy, over 12 channels), includes basic dosimetry calculation(s) 77318 Intraoperative radiation treatment delivery, x-ray, single treatment session 77424 Intraoperative radiation treatment delivery, electrons, single treatment session 77425 Infusion or instillation of radioelement solution (includes 3 months follow-up care) 77750 Intracavitary radiation source application; simple 77761 Intracavitary radiation source application; intermediate 77762 Intracavitary radiation source application; complex 77763 Interstitial radiation source application; simple 77776 Interstitial radiation source application; intermediate 77777 Interstitial radiation source application; complex 77778 Remote afterloading high dose rate brachytherapy; 1 channel 77785 Remote afterloading high dose rate brachytherapy; 2-12 channels 77786 Remote afterloading high dose rate brachytherapy; over 12 channels 77787 Surface applications of radiation source 77789 High dose rate electronic brachytherapy, per fraction 0182T Destruction/reduction of malignant breast tumor with externally applied focused microwave, including interstitial placement of disposable catheter with combined temperature monitoring probe and microwave focusing sensocatheter under 0301T ultrasound thermotherapy guidance Low dose rate (LDR) prostate brachytherapy services, composite rate G0458 IMRT Intensity modulated radiotherapy plan, including dose-volume histograms for target and critical structure partial tolerance specifications 77301 Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed; simple 77385 Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed; complex 77386 Intensity modulated treatment delivery, single or multiple fields/arcs, via narrow spatially and temporally modulated beams, G6015 binary, dynamic MLC, per treatment session Compensator-based beam modulation treatment delivery of inverse planned treatment using 3 or more high resolution (milled or cast) compensator, convergent beam modulated fields, per treatment session G6016 Neutron Therapy High energy neutron radiation treatment delivery; single treatment area using a single port or parallel-opposed ports with no blocks or simple blocking High energy neutron radiation treatment delivery; 1 or more isocenter(s) with coplanar or non-coplanar geometry with blocking and / or wedge, and / /or compensator(s) 77422 77423 Proton Beam Proton treatment delivery; simple, without compensation 77520 Proton treatment delivery; simple, with compensation 77522 Proton treatment delivery; intermediate 77523 Proton treatment delivery; complex 77525 Stereotactic Radiosurgery Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course 32701 of treatment Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting 77371 of 1 session; multi-source Cobalt 60 based Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting 77372 of 1 session; linear accelerator based Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire 77373 course not to exceed 5 fractions Image guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session, or G0339 first session of fractionated treatment Image guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum five sessions per course G0340 of treatment 4
MUSCULOSKELETAL Spine Surgery OSTEOTOMY OF SPINE, POSTERIOR OR POSTEROLATERAL APPROACH, 3 COLUMNS, 1 VERTEBRAL SEGMENT 22207 (EG, PEDICLE/VERTEBRAL BODY SUBTRACTION); LUMBAR OSTEOTOMY OF SPINE, POSTERIOR OR POSTEROLATERAL APPROACH, 3 COLUMNS, 1 VERTEBRAL SEGMENT (EG, PEDICLE/VERTEBRAL BODY SUBTRACTION); EACH ADDITIONAL VERTEBRAL SEGMENT (LIST SEPARATELY 22208 IN ADDITION TO CODE FOR PRIMARY PROCEDURE) OSTEOTOMY OF SPINE, POSTERIOR OR POSTEROLATERAL APPROACH, 1 VERTEBRAL SEGMENT; CERVICAL 22210 OSTEOTOMY OF SPINE, POSTERIOR OR POSTEROLATERAL APPROACH, 1 VERTEBRAL SEGMENT; LUMBAR 22214 OSTEOTOMY OF SPINE, POSTERIOR OR POSTEROLATERAL APPROACH, 1 VERTEBRAL SEGMENT; EACH 22216 ADDITIONAL VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION TO PRIMARY PROCEDURE) OSTEOTOMY OF SPINE, INCLUDING DISCECTOMY, ANTERIOR APPROACH, SINGLE VERTEBRAL SEGMENT; 22220 CERVICAL OSTEOTOMY OF SPINE, INCLUDING DISCECTOMY, ANTERIOR APPROACH, SINGLE VERTEBRAL SEGMENT; 22224 LUMBAR OSTEOTOMY OF SPINE, INCLUDING DISCECTOMY, ANTERIOR APPROACH, SINGLE VERTEBRAL SEGMENT; EACH ADDITIONAL VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY 22226 PROCEDURE) Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, 22511 inclusive of all imaging guidance; lumbosacral Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; each additional cervicothoracic or lumbosacral vertebral body (List separately in addition 22512 to code for primary procedure) Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all 22514 imaging guidance; lumbar Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all 22515 imaging guidance; each additional thoracic or lumbar vertebral body (List separately in addition to code for primary procedure) PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE, 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION (EG, KYPHOPLASTY); EACH ADDITIONAL THORACIC OR LUMBAR VERTEBRAL BODY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) PERCUTANEOUS INTRADISCAL ELECTROTHERMAL ANNULOPLASTY, UNILATERAL OR BILATERAL INCLUDING FLUOROSCOPIC GUIDANCE; SINGLE LEVEL PERCUTANEOUS INTRADISCAL ELECTROTHERMAL ANNULOPLASTY, UNILATERAL OR BILATERAL INCLUDING FLUOROSCOPIC GUIDANCE; 1 OR MORE ADDITIONAL LEVELS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) ARTHRODESIS, LATERAL EXTRACAVITARY TECHNIQUE, INCLUDING MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); LUMBAR ARTHRODESIS, LATERAL EXTRACAVITARY TECHNIQUE, INCLUDING MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); THORACIC OR LUMBAR, EACH ADDITIONAL VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) ARTHRODESIS, ANTERIOR TRANSORAL OR EXTRAORAL TECHNIQUE, CLIVUS-C1-C2 (ATLAS-AXIS), WITH OR WITHOUT EXCISION OF ODONTOID PROCESS ARTHRODESIS, ANTERIOR INTERBODY, INCLUDING DISC SPACE PREPARATION, DISCECTOMY, OSTEOPHYTECTOMY AND DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOTS; CERVICAL BELOW C2 22525 22526 22527 22533 22534 22548 22551 ARTHRODESIS, ANTERIOR INTERBODY, INCLUDING DISC SPACE PREPARATION, DISCECTOMY, OSTEOPHYTECTOMY AND DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOTS; CERVICAL BELOW C2, EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR SEPARATE PROCEDURE) Arthrodesis, Anterior Interbody Technique, Including Minimal Discectomy To Prepare Interspace (Other Than For Decompression); Cervical Below C2 22552 22554 5
ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); LUMBAR 22558 ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN 22585 ADDITION TO CODE FOR PRIMARY PROCEDURE) Arthrodesis, pre-sacral interbody technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft when performed, L5-S1 interspace 22586 ARTHRODESIS, POSTERIOR TECHNIQUE, CRANIOCERVICAL (OCCIPUT-C2) 22590 ARTHRODESIS, POSTERIOR TECHNIQUE, ATLAS-AXIS (C1-C2) 22595 ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE LEVEL; CERVICAL BELOW C2 SEGMENT 22600 ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE LEVEL; LUMBAR (WITH LATERAL TRANSVERSE TECHNIQUE, WHEN PERFORMED) 22612 ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE LEVEL; EACH ADDITIONAL VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 22614 ARTHRODESIS, POSTERIOR INTERBODY TECHNIQUE, INCLUDING LAMINECTOMY AND/OR DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE; LUMBAR 22630 ARTHRODESIS, POSTERIOR INTERBODY TECHNIQUE, INCLUDING LAMINECTOMY AND/OR DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE; EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) ARTHRODESIS, COMBINED POSTERIOR OR POSTEROLATERAL TECHNIQUE WITH POSTERIOR INTERBODY TECHNIQUE INCLUDING LAMINECTOMY AND/OR DISCECTOMY SUFFICIENT TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE AND SEGMENT; LUMBAR ARTHRODESIS, COMBINED POSTERIOR OR POSTEROLATERAL TECHNIQUE WITH POSTERIOR INTERBODY TECHNIQUE INCLUDING LAMINECTOMY AND/OR DISCECTOMY SUFFICIENT TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE AND SEGMENT; EACH ADDITIONAL INTERSPACE AND SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 22632 22633 22634 POSTERIOR NON-SEGMENTAL INSTRUMENTATION (EG, HARRINGTON ROD TECHNIQUE, PEDICLE FIXATION ACROSS 1 INTERSPACE, ATLANTOAXIAL TRANSARTICULAR SCREW FIXATION, SUBLAMINAR WIRING AT C1, FACET SCREW FIXATION) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Internal spinal fixation by wiring of spinous processes (List separately in addition to code for primary procedure) 22841 Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segments (List separately in addition to code for primary procedure) 22842 Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 7 to 12 vertebral segments (List separately in addition to code for primary procedure) 22843 Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 13 or more vertebral segments (List separately in addition to code for primary procedure) 22844 Anterior instrumentation; 2 to 3 vertebral segments (List separately in addition to code for primary procedure) 22845 Anterior instrumentation; 4 to 7 vertebral segments (List separately in addition to code for primary procedure) 22846 Anterior instrumentation; 8 or more vertebral segments (List separately in addition to code for primary procedure) 22847 Pelvic fixation (attachment of caudal end of instrumentation to pelvic bony structures) other than sacrum (List separately in 22848 addition to code for primary procedure) REINSERTION OF SPINAL FIXATION DEVICE 22849 REMOVAL OF POSTERIOR NONSEGMENTAL INSTRUMENTATION (EG, HARRINGTON ROD) 22850 APPLICATION OF INTERVERTEBRAL BIOMECHANICAL DEVICE(S) (EG, SYNTHETIC CAGE(S), METHYLMETHACRYLATE) TO VERTEBRAL DEFECT OR INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE 22851 FOR PRIMARY PROCEDURE) REMOVAL OF POSTERIOR SEGMENTAL INSTRUMENTATION 22852 REMOVAL OF ANTERIOR INSTRUMENTATION 22855 Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); single interspace, cervical 22856 TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, INCLUDING DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE, LUMBAR 22857 Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); second level, cervical (List separately 22858 in addition to code for primary procedure) 6 22840
REVISION INCLUDING REPLACEMENT OF TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, SINGLE INTERSPACE; CERVICAL REVISION INCLUDING REPLACEMENT OF TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, SINGLE INTERSPACE; LUMBAR REMOVAL OF TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, SINGLE INTERSPACE; CERVICAL REMOVAL OF TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, SINGLE INTERSPACE; LUMBAR Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; cervical LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; LUMBAR, EXCEPT FOR SPONDYLOLISTHESIS LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; SACRAL LAMINECTOMY WITH REMOVAL OF ABNORMAL FACETS AND/OR PARS INTER-ARTICULARIS WITH DECOMPRESSION OF CAUDA EQUINA AND NERVE ROOTS FOR SPONDYLOLISTHESIS, LUMBAR (GILL TYPE PROCEDURE) LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), MORE THAN 2 VERTEBRAL SEGMENTS; CERVICAL LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), MORE THAN 2 VERTEBRAL SEGMENTS; LUMBAR LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC; 1 INTERSPACE, CERVICAL LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC; 1 INTERSPACE, LUMBAR LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC; EACH ADDITIONAL INTERSPACE, CERVICAL OR LUMBAR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC, REEXPLORATION, SINGLE INTERSPACE; CERVICAL LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC, REEXPLORATION, SINGLE INTERSPACE; LUMBAR LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC, REEXPLORATION, SINGLE INTERSPACE; EACH ADDITIONAL CERVICAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC, REEXPLORATION, SINGLE INTERSPACE; EACH ADDITIONAL LUMBAR INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; CERVICAL LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; LUMBAR Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; each additional segment, cervical, thoracic, or lumbar (List separately in addition to code for primary procedure) LAMINOPLASTY, CERVICAL, WITH DECOMPRESSION OF THE SPINAL CORD, 2 OR MORE VERTEBRAL SEGMENTS; 22861 22862 22864 22865 63001 63005 63011 63012 63015 63017 63020 63030 63035 63040 63042 63043 63044 63045 63047 63048 63050 7
LAMINOPLASTY, CERVICAL, WITH DECOMPRESSION OF THE SPINAL CORD, 2 OR MORE VERTEBRAL SEGMENTS; WITH RECONSTRUCTION OF THE POSTERIOR BONY ELEMENTS (INCLUDING THE APPLICATION OF BRIDGING BONE GRAFT AND NON-SEGMENTAL FIXATION DEVICES (EG, WIRE, SUTURE, MINI-PLATES), WHEN PERFORMED) TRANSPEDICULAR APPROACH WITH DECOMPRESSION OF SPINAL CORD, EQUINA AND/OR NERVE ROOT(S) (EG, HERNIATED INTERVERTEBRAL DISC), SINGLE SEGMENT; LUMBAR (INCLUDING TRANSFACET, OR LATERAL 63056 EXTRAFORAMINAL APPROACH) (EG, FAR LATERAL HERNIATED INTERVERTEBRAL DISC) TRANSPEDICULAR APPROACH WITH DECOMPRESSION OF SPINAL CORD, EQUINA AND/OR NERVE ROOT(S) (EG, HERNIATED INTERVERTEBRAL DISC), SINGLE SEGMENT; EACH ADDITIONAL SEGMENT, THORACIC OR LUMBAR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) DISCECTOMY, ANTERIOR, WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S), INCLUDING OSTEOPHYTECTOMY; CERVICAL, SINGLE INTERSPACE DISCECTOMY, ANTERIOR, WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S), INCLUDING OSTEOPHYTECTOMY; CERVICAL, EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, ANTERIOR APPROACH WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S); CERVICAL, SINGLE SEGMENT VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, ANTERIOR APPROACH WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S); CERVICAL, EACH ADDITIONAL SEGMENT 63082 (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, COMBINED THORACOLUMBAR APPROACH WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA OR NERVE ROOT(S), 63087 LOWER THORACIC OR LUMBAR; SINGLE SEGMENT VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, COMBINED THORACOLUMBAR APPROACH WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA OR NERVE ROOT(S), 63088 LOWER THORACIC OR LUMBAR; EACH ADDITIONAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, TRANSPERITONEAL OR RETROPERITONEAL APPROACH WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA OR NERVE 63090 ROOT(S), LOWER THORACIC, LUMBAR, OR SACRAL; SINGLE SEGMENT VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, TRANSPERITONEAL OR RETROPERITONEAL APPROACH WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA OR NERVE 63091 ROOT(S), LOWER THORACIC, LUMBAR, OR SACRAL; EACH ADDITIONAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) LAMINECTOMY AND SECTION OF DENTATE LIGAMENTS, WITH OR WITHOUT DURAL GRAFT, CERVICAL; 1 OR 2 63180 SEGMENTS LAMINECTOMY AND SECTION OF DENTATE LIGAMENTS, WITH OR WITHOUT DURAL GRAFT, CERVICAL; MORE 63182 THAN 2 SEGMENTS LAMINECTOMY WITH RHIZOTOMY; 1 OR 2 SEGMENTS 63185 LAMINECTOMY WITH RHIZOTOMY; MORE THAN 2 SEGMENTS 63190 LAMINECTOMY WITH SECTION OF SPINAL ACCESSORY NERVE 63191 LAMINECTOMY WITH CORDOTOMY, WITH SECTION OF 1 SPINOTHALAMIC TRACT, 1 STAGE; CERVICAL 63194 LAMINECTOMY WITH CORDOTOMY, WITH SECTION OF BOTH SPINOTHALAMIC TRACTS, 1 STAGE; CERVICAL 63196 LAMINECTOMY WITH CORDOTOMY WITH SECTION OF BOTH SPINOTHALAMIC TRACTS, 2 STAGES WITHIN 14 DAYS; CERVICAL 63198 LAMINECTOMY, WITH RELEASE OF TETHERED SPINAL CORD, LUMBAR 63200 Osteoplastic reconstruction of dorsal spinal elements, following primary intraspinal procedure (List separately in addition to 63295 code for primary procedure) REMOVAL OF TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, EACH ADDITIONAL INTERSPACE, CERVICAL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) REVISION INCLUDING REPLACEMENT OF TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, EACH ADDITIONAL INTERSPACE, CERVICAL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, INCLUDING DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), EACH ADDITIONAL INTERSPACE, LUMBAR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 8 63051 63057 63075 63076 63081 0095T 0098T 0163T
REMOVAL OF TOTAL DISC ARTHROPLASTY, (ARTIFICIAL DISC), ANTERIOR APPROACH, EACH ADDITIONAL INTERSPACE, LUMBAR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) ARTHRODESIS, PRE-SACRAL INTERBODY TECHNIQUE, INCLUDING INSTRUMENTATION, IMAGING (WHEN PERFORMED), AND DISCECTOMY TO PREPARE INTERSPACE, LUMBAR; SINGLE INTERSPACE ARTHRODESIS, PRE-SACRAL INTERBODY TECHNIQUE, INCLUDING INSTRUMENTATION, IMAGING (WHEN PERFORMED), AND DISCECTOMY TO PREPARE INTERSPACE, LUMBAR; EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) POSTERIOR VERTEBRAL JOINT(S) ARTHROPLASTY (EG, FACET JOINT[S] REPLACEMENT), INCLUDING FACETECTOMY, LAMINECTOMY, FORAMINOTOMY, AND VERTEBRAL COLUMN FIXATION, INJECTION OF BONE CEMENT, WHEN PERFORMED, INCLUDING FLUOROSCOPY, SINGLE LEVEL, LUMBAR SPINE PLACEMENT OF A POSTERIOR INTRAFACET IMPLANT(S), UNILATERAL OR BILATERAL, INCLUDING IMAGING AND PLACEMENT OF BONE GRAFT(S) OR SYNTHETIC DEVICE(S), SINGLE LEVEL; CERVICAL PLACEMENT OF A POSTERIOR INTRAFACET IMPLANT(S), UNILATERAL OR BILATERAL, INCLUDING IMAGING AND PLACEMENT OF BONE GRAFT(S) OR SYNTHETIC DEVICE(S), SINGLE LEVEL; LUMBAR PLACEMENT OF A POSTERIOR INTRAFACET IMPLANT(S), UNILATERAL OR BILATERAL, INCLUDING IMAGING AND PLACEMENT OF BONE GRAFT(S) OR SYNTHETIC DEVICE(S), SINGLE LEVEL; EACH ADDITIONAL VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Arthrodesis, pre-sacral interbody technique, including disc space preparation, discetomy, with posterior instumentation, with image guidance, includes bone graft, when performed, lumbar, L4-L5 interspace (List separately in addition to code for primary procedure) Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection), cervical, three or more levels 0164T 0195T 0196T 0202T 0219T 0221T 0222T 0309T 0375T Spine Pain Management Injection(S); Single Or Multiple Trigger Point(S), 1 Or 2 Muscle(S) 20552 INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLE(S) 20553 INJECTION PROCEDURE FOR SACROILIAC JOINT, ANESTHETIC/STEROID, WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED 27096 Injection procedure for discography, each level; lumbar 62290 Injection procedure for discography, each level; cervical or thoracic 62291 Injection procedure for chemonucleolysis, including discography, intervertebral disc, single or multiple levels, lumbar 62292 INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (INCLUDING ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INCLUDES CONTRAST FOR LOCALIZATION WHEN PERFORMED, EPIDURAL OR 62310 SUBARACHNOID; CERVICAL OR THORACIC INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (INCLUDING ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INCLUDES CONTRAST FOR LOCALIZATION WHEN PERFORMED, EPIDURAL OR 62311 SUBARACHNOID; LUMBAR OR SACRAL (CAUDAL) INJECTION(S), INCLUDING INDWELLING CATHETER PLACEMENT, CONTINUOUS INFUSION OR INTERMITTENT BOLUS, OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (INCLUDING ANESTHETIC, ANTISPASMODIC, 62318 OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDES CONTRAST FOR LOCALIZATION WHEN PERFORMED, EPIDURAL OR SUBARACHNOID; CERVICAL OR THORACIC INJECTION(S), INCLUDING INDWELLING CATHETER PLACEMENT, CONTINUOUS INFUSION OR INTERMITTENT BOLUS, OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (INCLUDING ANESTHETIC, ANTISPASMODIC, 62319 OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDES CONTRAST FOR LOCALIZATION WHEN PERFORMED, EPIDURAL OR SUBARACHNOID; LUMBAR OR SACRAL (CAUDAL) Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; without laminectomy 62350 Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; with laminectomy 62351 Removal of previously implanted intrathecal or epidural catheter 62355 Implantation or replacement of device for intrathecal or epidural drug infusion; subcutaneous reservoir 62360 IMPLANTATION OR REPLACEMENT OF DEVICE FOR INTRATHECAL OR EPIDURAL DRUG INFUSION; NONPROGRAMMABLE PUMP 62361 9
IMPLANTATION OR REPLACEMENT OF DEVICE FOR INTRATHECAL OR EPIDURAL DRUG INFUSION; PROGRAMMABLE PUMP, INCLUDING PREPARATION OF PUMP, WITH OR WITHOUT PROGRAMMING 62362 REMOVAL OF SUBCUTANEOUS RESERVOIR OR PUMP, PREVIOUSLY IMPLANTED FOR INTRATHECAL OR EPIDURAL INFUSION 62365 PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY, EPIDURAL 63650 Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural 63655 REMOVAL OF SPINAL NEUROSTIMULATOR ELECTRODE PERCUTANEOUS ARRAY(S), INCLUDING FLUOROSCOPY, WHEN PERFORMED 63661 REMOVAL OF SPINAL NEUROSTIMULATOR ELECTRODE PLATE/PADDLE(S) PLACED VIA LAMINOTOMY OR LAMINECTOMY, INCLUDING FLUOROSCOPY, WHEN PERFORMED 63662 Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling 63685 Injection, anesthetic agent; greater occipital nerve 64405 Injection, anesthetic agent; sciatic nerve, single 64445 Injection, anesthetic agent; other peripheral nerve or branch 64450 INJECTION, ANESTHETIC AGENT AND/OR STEROID, TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE LEVEL 64479 INJECTION, ANESTHETIC AGENT AND/OR STEROID, TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION 64480 TO CODE FOR PRIMARY PROCEDURE) INJECTION, ANESTHETIC AGENT AND/OR STEROID, TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE LEVEL 64483 INJECTION, ANESTHETIC AGENT AND/OR STEROID, TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO 64484 CODE FOR PRIMARY PROCEDURE) NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR 64490 THORACIC; SINGLE LEVEL NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Injection, anesthetic agent; lumbar or thoracic (paravertebral sympathetic 64520 DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE 64633 (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN 64634 ADDITION TO CODE FOR PRIMARY PROCEDURE) DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE 64635 (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN 64636 ADDITION TO CODE FOR PRIMARY PROCEDURE) NERVES INNERVATING THAT JOINT) WITH ULTRASOUND GUIDANCE, CERVICAL OR THORACIC; SINGLE LEVEL 10 64491 64492 64493 64494 64495 0213T
NERVES INNERVATING THAT JOINT) WITH ULTRASOUND GUIDANCE, CERVICAL OR THORACIC; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) NERVES INNERVATING THAT JOINT) WITH ULTRASOUND GUIDANCE, CERVICAL OR THORACIC; THIRD AND ANY 0215T ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) NERVES INNERVATING THAT JOINT) WITH ULTRASOUND GUIDANCE, LUMBAR OR SACRAL; SINGLE LEVEL NERVES INNERVATING THAT JOINT) WITH ULTRASOUND GUIDANCE, LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) NERVES INNERVATING THAT JOINT) WITH ULTRASOUND GUIDANCE, LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) INJECTION(S), ANESTHETIC AGENT AND/OR STEROID, TRANSFORAMINAL EPIDURAL, WITH ULTRASOUND 0228T GUIDANCE, CERVICAL OR THORACIC; SINGLE LEVEL INJECTION(S), ANESTHETIC AGENT AND/OR STEROID, TRANSFORAMINAL EPIDURAL, WITH ULTRASOUND GUIDANCE, CERVICAL OR THORACIC; EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR 0229T PRIMARY PROCEDURE) INJECTION(S), ANESTHETIC AGENT AND/OR STEROID, TRANSFORAMINAL EPIDURAL, WITH ULTRASOUND 0230T GUIDANCE, LUMBAR OR SACRAL; SINGLE LEVEL INJECTION(S), ANESTHETIC AGENT AND/OR STEROID, TRANSFORAMINAL EPIDURAL, WITH ULTRASOUND GUIDANCE, LUMBAR OR SACRAL; EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR 0231T PRIMARY PROCEDURE) INJECTION PROCEDURE FOR SACROILIAC JOINT; PROVISION OF ANESTHETIC, STEROID AND/OR OTHER G0260 THERAPEUTIC AGENT, WITH OR WITHOUT ARTHROGRAPHY 0214T 0216T 0217T 0218T MEDICAL ONCOLOGY NOTE: All Oral Chemotherapy must be submitted for review, including drugs with codes not otherwise specified. HCPCS INJECTION, RAMUCIRUMAB, 5 MG INJECTION, PEMBROLIZUMAB, 1 MG INJECTION, BEVACIZUMAB, 0.25 MG INJECTION, BELINOSTAT, 10 MG INJECTION, AMIFOSTINE, 500 MG INJECTION, LEUCOVORIN CALCIUM, PER 50 MG INJECTION, LEVOLEUCOVORIN CALCIUM, 0.5 MG INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE) INJECTION, EPOETIN ALFA, (FOR NON-ESRD USE), 1000 UNITS INJECTIN, EPOETIN BETA, 1 MICROGRAM, (FOR NON ESRD USE) INJECTION, DECITABINE, 1 MG INJECTION, DENOSUMAB, 1 MG INJECTION, DOLASETRON MESYLATE, 10 MG INJECTION, FILGRASTIM (G-CSF), 1 MICROGRAM INJECTION, TBO-FILGRASTIM, 5 MICROGRAMS INJECTION, LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), PER 3.75 MG INJECTION, OCTREOTIDE, DEPOT FORM FOR INTRAMUSCULAR INJECTION, 1 MG INJECTION, OPRELVEKIN, 5 MG INJECTION, PAMIDRONATE DISODIUM, PER 30 MG INJECTION, PEGFILGRASTIM, 6 MG INJECTION, SARGRAMOSTIM (GM-CSF), 50 MCG INJECTION, TRIPTORELIN PAMOATE, 3.75 MG INJECTION, ZOLEDRONIC ACID, 1 MG UNCLASSIFIED DRUGS Everolimus, oral, 0.25 mg APREPITANT, ORAL, 5 MG BUSULFAN, ORAL, 2 MG 11 C9025 C9027 C9257 C9442 J0207 J0640 J0641 J0881 J0885 J0888 J0894 J0897 J1260 J1442 J1446 J1950 J2353 J2355 J2430 J2505 J2820 J3315 J3489 J3490 J7527 J8501 J8510
CABERGOLINE, ORAL, 0.25 MG CAPECITABINE, ORAL, 150 MG CAPECITABINE, ORAL, 500 MG CYCLOPHOSPHAMIDE, ORAL, 25 MG ETOPOSIDE; ORAL, 50 MG FLUDARABINE PHOSPHATE, ORAL, 10 MG GEFITINIB, ORAL, 250 MG ANTIEMETIC DRUG, ORAL, NOT OTHERWISE SPECIFIED MELPHALAN, ORAL, 2 MG METHOTREXATE, ORAL, 2.5 MG NABILONE, ORAL, 1 MG TEMOZOLOMIDE, ORAL, 5 MG TOPOTECAN, ORAL, 0.25 MG PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG INJECTION, ALEMTUZUMAB, 10 MG INJECTION, ALDESLEUKIN, PER SINGLE USE VIAL INJECTION, ARSENIC TRIOXIDE, 1 MG Injection, asparaginase (Erwinaze), 1,000 IU INJECTION, ASPARAGINASE, 10,000 UNITS INJECTION, AZACITIDINE, 1 MG INJECTION, CLOFARABINE, 1 MG BCG (INTRAVESICAL) PER INSTILLATION INJECTION, BENDAMUSTINE HCL, 1 MG INJECTION, BEVACIZUMAB, 10 MG INJECTION, BLEOMYCIN SULFATE, 15 UNITS INJECTION, BORTEZOMIB, 0.1 MG Injection, brentuximab vedotin, 1 mg INJECTION, CABAZITAXEL, 1 MG INJECTION, CARBOPLATIN, 50 MG INJECTION, CARFILZOMIB, 1 MG INJECTION, CARMUSTINE, 100 MG INJECTION, CETUXIMAB, 10 MG INJECTION, CISPLATIN, POWDER OR SOLUTION, 10 MG INJECTION, CLADRIBINE, PER 1 MG CYCLOPHOSPHAMIDE, 100 MG INJECTION, CYTARABINE LIPOSOME, 10 MG INJECTION, CYTARABINE, 100 MG INJECTION, DACTINOMYCIN, 0.5 MG DACARBAZINE, 100 MG INJECTION, DAUNORUBICIN, 10 MG INJECTION, DAUNORUBICIN CITRATE, LIPOSOMAL FORMULATION, 10 MG INJECTION, DEGARELIX, 1 MG INJECTION, DENILEUKIN DIFTITOX, 300 MICROGRAMS INJECTION, DIETHYLSTILBESTROL DIPHOSPHATE, 250 MG INJECTION, DOCETAXEL, 1 MG INJECTION, ELLIOTTS' B SOLUTION, 1 ML INJECTION, EPIRUBICIN HCL, 2 MG INJECTION, ERIBULIN MESYLATE, 0.1 MG INJECTION, ETOPOSIDE, 10 MG INJECTION, FLUDARABINE PHOSPHATE, 50 MG INJECTION, FLUOROURACIL, 500 MG INJECTION, FLOXURIDINE, 500 MG INJECTION, GEMCITABINE HYDROCHLORIDE, 200 MG GOSERELIN ACETATE IMPLANT, PER 3.6 MG INJECTION, IRINOTECAN, 20 MG INJECTION, IXABEPILONE, 1 MG INJECTION, IFOSFAMIDE, 1 GRAM INJECTION, MESNA, 200 MG INJECTION, IDARUBICIN HYDROCHLORIDE, 5 MG J8515 J8520 J8521 J8530 J8560 J8562 J8565 J8597 J8600 J8610 J8650 J8700 J8705 J8999 J9000 J9010 J9015 J9017 J9019 J9020 J9025 J9027 J9031 J9033 J9035 J9040 J9041 J9042 J9043 J9045 J9047 J9050 J9055 J9060 J9065 J9070 J9098 J9100 J9120 J9130 J9150 J9151 J9155 J9160 J9165 J9171 J9175 J9178 J9179 J9181 J9185 J9190 J9200 J9201 J9202 J9206 J9207 J9208 J9209 J9211 12
INJECTION, INTERFERON ALFACON-1, RECOMBINANT, 1 MICROGRAM INJECTION, INTERFERON, ALFA-2A, RECOMBINANT, 3 MILLION UNITS INJECTION, INTERFERON, ALFA-2B, RECOMBINANT, 1 MILLION UNITS INJECTION, INTERFERON, ALFA-N3, (HUMAN LEUKOCYTE DERIVED), 250,000 IU INJECTION, INTERFERON, GAMMA 1-B, 3 MILLION UNITS LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG LEUPROLIDE ACETATE, PER 1 MG LEUPROLIDE ACETATE IMPLANT, 65 MG HISTRELIN IMPLANT (VANTAS), 50 MG HISTRELIN IMPLANT (SUPPRELIN LA), 50 MG INJECTION, IPILIMUMAB, 1 MG INJECTION, MECHLORETHAMINE HYDROCHLORIDE, (NITROGEN MUSTARD), 10 MG INJECTION, MELPHALAN HYDROCHLORIDE, 50 MG METHOTREXATE SODIUM, 5 MG METHOTREXATE SODIUM, 50 MG INJECTION, NELARABINE, 50 MG INJECTION, OMACETAXINE MEPESUCCINATE, 0.01 MG INJECTION, OXALIPLATIN, 0.5 MG INJECTION, PACLITAXEL PROTEIN-BOUND PARTICLES, 1 MG INJECTION, PEGASPARGASE, PER SINGLE DOSE VIAL INJECTION, PACLITAXEL, 1 MG INJECTION, PENTOSTATIN, 10 MG INJECTION, PLICAMYCIN, 2.5 MG MITOMYCIN, 5 MG INJECTION, MITOXANTRONE HYDROCHLORIDE, PER 5 MG INJECTION, GEMTUZUMAB OZOGAMICIN, 5 MG INJECTION, OBINUTUZUMAB, 10 MG INJECTION, OFATUMUMAB, 10 MG INJECTION, PANITUMUMAB, 10 MG INJECTION, PEMETREXED, 10 MG INJECTION, PERTUZUMAB, 1 MG INJECTION, PRALATREXATE, 1 MG INJECTION, RITUXIMAB, 100 MG INJECTION, ROMIDEPSIN, 1 MG INJECTION, STREPTOZOCIN, 1 GRAM INJECTION, TEMOZOLOMIDE, 1 MG INJECTION, TEMSIROLIMUS, 1 MG INJECTION, THIOTEPA, 15 MG INJECTION, TOPOTECAN, 0.1 MG INJECTION, ADO-TRASTUZUMAB EMTANSINE, 1 MG INJECTION, TRASTUZUMAB, 10 MG INJECTION, VALRUBICIN, INTRAVESICAL, 200 MG INJECTION, VINBLASTINE SULFATE, 1 MG VINCRISTINE SULFATE, 1 MG INJECTION, VINCRISTINE SULFATE LIPOSOME, 1 MG INJECTION, VINORELBINE TARTRATE, 10 MG INJECTION, FULVESTRANT, 25 MG INJECTION, ZIV-AFLIBERCEPT, 1 MG INJECTION, PORFIMER SODIUM, 75 MG NOT OTHERWISE CLASSIFIED, ANTINEOPLASTIC DRUGS SIPULEUCEL-T, MINIMUM OF 50 MILLION AUTOLOGOUS CD54+ CELLS ACTIVATED WITH PAP-GM-CSF, INCLUDING LEUKAPHERESIS AND ALL OTHER PREPARATORY PROCEDURES, PER INFUSION INJECTION, DOXORUBICIN HYDROCHLORIDE, LIPOSOMAL, IMPORTED LIPODOX, 10 MG INJECTION, DOXORUBICIN HYDROCHLORIDE, LIPOSOMAL, NOT OTHERWISE SPECIFIED, 10 MG IMATINIB, 100 MG MERCAPTOPURINE, ORAL, 50 MG EXEMESTANE, 25 MG ANASTROZOLE, ORAL, 1 MG CHLORAMBUCIL, ORAL, 2 MG J9212 J9213 J9214 J9215 J9216 J9217 J9218 J9219 J9225 J9226 J9228 J9230 J9245 J9250 J9260 J9261 J9262 J9263 J9264 J9266 J9267 J9268 J9270 J9280 J9293 J9300 J9301 J9302 J9303 J9305 J9306 J9307 J9310 J9315 J9320 J9328 J9330 J9340 J9351 J9354 J9355 J9357 J9360 J9370 J9371 J9390 J9395 J9400 J9600 J9999 Q2043 Q2049 Q2050 S0088 S0108 S0156 S0170 S0172 13
DOLASETRON MESYLATE, ORAL 50 MG (FOR CIRCUMSTANCES FALLING UNDER THE MEDICARE STATUTE, USE S0174 Q0180) FLUTAMIDE, ORAL, 125 MG S0175 HYDROXYUREA, ORAL, 500 MG S0176 LOMUSTINE, ORAL, 10 MG S0178 MEGESTROL ACETATE, ORAL, 20 MG S0179 PROCARBAZINE HYDROCHLORIDE, ORAL, 50 MG S0182 PROCHLORPERAZINE MALEATE, ORAL, 5 MG (FOR CIRCUMSTANCES FALLING UNDER THE MEDICARE STATUTE, USE Q0164 - Q0165) S0183 TAMOXIFEN CITRATE, ORAL, 10 MG S0187 TRANSPLANT Bone Marrow Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor 38240 Hematopoietic progenitor cell (HPC); autologous transplantation 38241 Hematopoietic progenitor cell (HPC); HPC boost 38243 14