Notification

Multiple Surgery Payment Reduction


Notification Issue Date: 12/30/2019



Policy Attachment


Attachment to Policy # 11.00.10w


Attachment:B

Policy #:11.00.10w

Description:Healthcare Common Procedure Coding System (HCPCS) Codes To Which Multiple Surgery Payment Reduction Applies

Title:Multiple Surgery Payment Reduction


Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.


D3410
APICOECTOMY- ANTERIOR
D5931
OBTURATOR PROSTHESIS, SURGICAL
D5932
OBTURATOR PROSTHESIS, DEFINITIVE
D5933
OBTURATOR PROSTHESIS, MODIFICATION
D5936
OBTURATOR/PROSTHESIS, INTERIM
D5988
SURGICAL SPLINT
D5999
UNSPECIFIED MAXILLOFACIAL PROSTHESIS, BY REPORT
D6081
SCALING AND DEBRIDEMENT IN THE PRESENCE OF INFLAMMATION OR MUCOSITIS OF A SINGLE IMPLANT, INCLUDING CLEANING OF THE IMPLANT SURFACES, WITHOUT FLAP ENTRY AND CLOSURE
D7251
CORONECTOMY - INTENTIONAL PARTIAL TOOTH REMOVAL
D7260
OROLANTRAL FISTULA CLOSURE
D7261
PRIMARY CLOSURE OF A SINUS PERFORATION
D7285
INCISIONAL BIOPSY OF ORAL TISSUE-HARD (BONE, TOOTH)
D7286
INCISIONAL BIOPSY OF ORAL TISSUE-SOFT
D7287
EXFOLIATIVE CYTOLOGICAL SAMPLE COLLECTION
D7288
BRUSH BIOPSY - TRANSEPITHELIAL SAMPLE COLLECTION
D7295
HARVEST OF BONE FOR USE IN AUTOGENOUS GRAFTING PROCEDURE
D7296
corticotomy - one to three teeth or tooth spaces, per quadrant; This procedure involves creating multiple cuts, perforations, or removal of cortical, alveolar or basal bone of the jaw for the purpose of facilitating orthodontic repositioning of the dentition. This procedure includes flap entry and closure. Graft material and membrane, if used, should be reported separately
D7297
corticotomy - four or more teeth or tooth spaces, per quadrant; This procedure involves creating multiple cuts, perforations, or removal of cortical, alveolar or basal bone of the jaw for the purpose of facilitating orthodontic repositioning of the dentition. This procedure includes flap entry and closure. Graft material and membrane, if used, should be reported separately
D7410
EXCISION OF BENIGN LESION UP TO 1.25 CM
D7411
EXCISION OF BENIGN LESION GREATER THAN 1.25 CM
D7412
EXCISION OF BENIGN LESION, COMPLICATED
D7413
EXCISION OF MALIGNANT LESION UP TO 1.25 CM
D7414
EXCISION OF MALIGNANT LESION GREATER THAN 1.25 CM
D7415
EXCISION OF MALIGNANT LESION, COMPLICATED
D7440
EXCISION OF MALIGNANT TUMOR - LESION DIAMETER UP TO 1.25 CM
D7441
EXCISION OF MALIGNANT TUMOR - LESION DIAMETER GREATER THAN 1.25 CM
D7465
DESTRUCTION OF LESION(S) BY PHYSICAL OR CHEMICAL METHOD, BY REPORT
D7490
RADICAL RESECTION OF MAXILLA OR MANDIBLE
D7510
INCISION AND DRAINAGE OF ABSCESS - INTRAORAL SOFT TISSUE
D7511
INCISION AND DRAINAGE OF ABSCESS - INTRAORAL SOFT TISSUE - COMPLICATED (INCLUDES DRAINAGE OF MULTIPLE FASCIAL SPACES)
D7520
INCISION AND DRAINAGE OF ABSCESS - EXTRAORAL SOFT TISSUE
D7521
INCISION AND DRAINAGE OF ABSCESS - EXTRAORAL SOFT TISSUE - COMPLICATED (INCLUDES DRAINAGE OF MULTIPLE FASCIAL SPACES)
D7530
REMOVAL OF FOREIGN BODY FROM MUCOSA, SKIN, OR SUBCUTANEOUS ALVEOLAR TISSUE
D7540
REMOVAL OF REACTION-PRODUCING FOREIGN BODIES, MUSCULOSKELETAL SYSTEM
D7550
PARTIAL OSTECTOMY/SEQUESTRECTOMY FOR REMOVAL OF NONVITAL BONE
D7560
MAXILLARY SINUSOTOMY FOR REMOVAL OF TOOTH FRAGMENT OR FOREIGN BODY
D7610
MAXILLA - OPEN REDUCTION (TEETH IMMOBILIZED, IF PRESENT)
D7620
MAXILLA - CLOSED REDUCTION (TEETH IMMOBILIZED, IF PRESENT)
D7630
MANDIBLE - OPEN REDUCTION (TEETH IMMOBILIZED, IF PRESENT)
D7640
MANDIBLE - CLOSED REDUCTION (TEETH IMMOBILIZED, IF PRESENT)
D7650
MALAR AND/OR ZYGOMATIC ARCH - OPEN REDUCTION
D7660
MALAR AND/OR ZYGOMATIC ARCH - CLOSED REDUCTION
D7680
FACIAL BONES - COMPLICATED REDUCTION WITH FIXATION AND MULTIPLE SURGICAL APPROACHES
D7710
MAXILLA - OPEN REDUCTION
D7720
MAXILLA - CLOSED REDUCTION
D7730
MANDIBLE - OPEN REDUCTION
D7740
MANDIBLE - CLOSED REDUCTION
D7750
MALAR AND/OR ZYGOMATIC ARCH - OPEN REDUCTION
D7760
MALAR AND/OR ZYGOMATIC ARCH - CLOSED REDUCTION
D7780
FACIAL BONES - COMPLICATED REDUCTION WITH FIXATION AND MULTIPLE SURGICAL APPROACHES
D7810
OPEN REDUCTION OF DISLOCATION
D7820
CLOSED REDUCTION OF DISLOCATION
D7830
MANIPULATION UNDER ANESTHESIA
D7840
CONDYLECTOMY
D7850
SURGICAL DISCECTOMY, WITH/WITHOUT IMPLANT
D7852
DISC REPAIR
D7854
SYNOVECTOMY
D7856
MYOTOMY
D7858
JOINT RECONSTRUCTION
D7860
ARTHROTOMY
D7865
ARTHROPLASTY
D7870
ARTHROCENTESIS
D7871
NONARTHROSCOPIC LYSIS AND LAVAGE
D7872
ARTHROSCOPY - DIAGNOSIS, WITH OR WITHOUT BIOPSY
D7873
ARTHROSCOPY - SURGICAL: LAVAGE AND LYSIS OF ADHESIONS
D7874
ARTHROSCOPY - SURGICAL: DISC REPOSITIONING AND STABILIZATION
D7875
ARTHROSCOPY - SURGICAL: SYNOVECTOMY
D7876
ARTHROSCOPY - SURGICAL: DISCECTOMY
D7877
ARTHROSCOPY - SURGICAL: DEBRIDEMENT
D7899
UNSPECIFIED TMD THERAPY, BY REPORT
D7910
SUTURE OF RECENT SMALL WOUNDS UP TO 5 CM
D7911
COMPLICATED SUTURE - UP TO 5 CM
D7912
COMPLICATED SUTURE - GREATER THAN 5 CM
D7920
SKIN GRAFT (IDENTIFY DEFECT COVERED, LOCATION AND TYPE OF GRAFT)
D7940
OSTEOPLASTY - FOR ORTHOGNATHIC DEFORMITIES
D7941
OSTEOTOMY - MANDIBULAR RAMI
D7943
OSTEOTOMY - MANDIBULAR RAMI WITH BONE GRAFT; INCLUDES OBTAINING THE GRAFT
D7944
OSTEOTOMY-SEGMENTED OR SUBAPICAL
D7945
OSTEOTOMY - BODY OF MANDIBLE
D7946
LEFORT I (MAXILLA - TOTAL)
D7947
LEFORT I (MAXILLA - SEGMENTED)
D7948
LEFORT II OR LEFORT III (OSTEOPLASTY OF FACIAL BONES FOR MIDFACE HYPOPLASIA OR RETRUSION) - WITHOUT BONE GRAFT
D7949
LEFORT II OR LEFORT III - WITH BONE GRAFT
D7950
OSSEOUS, OSTEOPERIOSTEAL, OR CARTILAGE GRAFT OF THE MANDIBLE OR MAXILLA - AUTOGENOUS OR NONAUTOGENOUS, BY REPORT; THIS PROCEDURE IS FOR RIDGE AUGMENTATION OR RECONSTRUCTION TO INCREASE HEIGHT, WIDTH AND/OR VOLUME OF RESIDUAL ALVEOLAR RIDGE. IT INCLUDES OBTAINING GRAFT MATERIAL. PLACEMENT OF A BARRIER MEMBRANE, IF USED, SHOULD BE REPORTED SEPARATELY
D7951
SINUS AUGMENTATION WITH BONE OR BONE SUBSTITUTES
D7952
SINUS AUGMENTATION VIA A VERTICAL APPROACH
D7953
BONE REPLACEMENT GRAFT FOR RIDGE PRESERVATION - PER SITE; GRAFT IS PLACED IN AN EXTRACTION OR IMPLANT REMOVAL SITE AT THE TIME OF THE EXTRACTION OR REMOVAL TO PRESERVE RIDGE INTEGRITY (E.G., CLINICALLY INDICATED IN PREPARATION FOR IMPLANT RECONSTRUCTION OR WHERE ALVEOLAR CONTOUR IS CRITICAL TO PLANNED PROSTHETIC RECONSTRUCTION). DOES NOT INCLUDE OBTAINING GRAFT MATERIAL. MEMBRANE, IF USED SHOULD BE REPORTED SEPARATELY.
D7955
REPAIR OF MAXILLOFACIAL SOFT AND/OR HARD TISSUE DEFECT; RECONSTRUCTION OF SURGICAL, TRAUMATIC, OR CONGENITAL DEFECTS OF THE FACIAL BONES, INCLUDING THE MANDIBLE, MAY UTILIZE GRAFT MATERIALS IN CONJUNCTION WITH SOFT TISSUE PROCEDURES TO REPAIR AND RESTORE THE FACIAL BONES TO FORM AND FUNCTION. THIS DOES NOT INCLUDE OBTAINING THE GRAFT AND THESE PROCEDURES MAY REQUIRE MULTIPLE SURGICAL APPROACHES. THIS PROCEDURE DOES NOT INCLUDE EDENTULOUS MAXILLA AND MANDIBULAR RECONSTRUCTION FOR PROSTHETIC CONSIDERATIONS.
D7979
non - surgical sialolithotomy; A sialolith is removed from the gland or ductal portion of the gland without surgical incision into the gland or the duct of the gland; for example via manual manipulation, ductal dilation, or any other non-surgical method
D7980
SIALOLITHOTOMY
D7981
EXCISION OF SALIVARY GLAND, BY REPORT
D7982
SIALODOCHOPLASTY
D7983
CLOSURE OF SALIVARY FISTULA
D7990
EMERGENCY TRACHEOTOMY
D7991
CORONOIDECTOMY
D7997
APPLIANCE REMOVAL (NOT BY DENTIST WHO PLACED APPLIANCE), INCLUDES REMOVAL OF ARCHBAR
D7998
INTRAORAL PLACEMENT OF A FIXATION DEVICE NOT IN CONJUNCTION WITH A FRACTURE
G0104
Colorectal cancer screening; flexible sigmoidoscopy
G0105
Colorectal cancer screening; colonoscopy on individual at high risk
G0121
Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk
G0127
Trimming of dystrophic nails, any number
G0168
WOUND CLOSURE UTILIZING TISSUE ADHESIVE(S) ONLY
G0186
DESTRUCTION OF LOCALIZED LESION OF CHOROID (FOR EXAMPLE, CHOROIDAL NEOVASCULARIZATION); PHOTOCOAGULATION, FEEDER VESSEL TECHNIQUE (ONE OR MORE SESSIONS)
G0247
Routine foot care by a physician of a diabetic patient with diabetic sensory neuropathy resulting in a loss of protective sensation (LOPS) to include the local care of superficial wounds (i.e., superficial to muscle and fascia) and at least the following, if present: (1) local care of superficial wounds, (2) debridement of corns and calluses, and (3) trimming and debridement of nails
G0259
INJECTION PROCEDURE FOR SACROILIAC JOINT; ARTHROGRAPHY
G0260
INJECTION PROCEDURE FOR SACROILIAC JOINT; PROVISION OF ANESTHETIC, STEROID AND/OR OTHER THERAPEUTIC AGENT, WITH OR WITHOUT ARTHROGRAPHY
G0268
REMOVAL OF IMPACTED CERUMEN (ONE OR BOTH EARS) BY PHYSICIAN ON SAME DATE OF SERVICE AS AUDIOLOGIC FUNCTION TESTING
G0269
PLACEMENT OF OCCLUSIVE DEVICE INTO EITHER A VENOUS OR ARTERIAL ACCESS SITE, POST SURGICAL OR INTERVENTIONAL PROCEDURE (E.G., ANGIOSEAL PLUG, VASCULAR PLUG)
G0276
BLINDED PROCEDURE FOR LUMBAR STENOSIS, PERCUTANEOUS IMAGE-GUIDED LUMBAR DECOMPRESSION (PILD) OR PLACEBO-CONTROL, PERFORMED IN AN APPROVED COVERAGE WITH EVIDENCE DEVELOPMENT (CED) CLINICAL TRIAL
G0293
NONCOVERED SURGICAL PROCEDURE(S) USING CONSCIOUS SEDATION, REGIONAL, GENERAL OR SPINAL ANESTHESIA IN A MEDICARE QUALIFYING CLINICAL TRIAL, PER DAY
G0339
IMAGE GUIDED ROBOTIC LINEAR ACCELERATOR BASE STEREOTACTIC RADIOSURGERY, COMPLETE COURSE OF THERAPY IN ONE SESSION, OR FIRST SESSION OF FRACTIONATED TREATMENT
G0340
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 OF TREAT
G0341
PERCUTANEOUS ISLET CELL TRANSPLANT, INCLUDES PORTAL VEIN CATHERIZATION AND INFUSION
G0342
LAPAROSCOPY FOR ISLET CELL TRANSPLANT, INCLUDES PORTAL VEIN CATHERIZATION AND INFUSION
G0343
LAPAROTOMY FOR ISLET CELL TRANSPLANT, INCLUDES PORTAL VEIN CATHERIZATION AND INFUSION
G0412
OPEN TREATMENT OF ILIAC SPINE(S), TUBEROSITY AVULSION, OR ILIAC WING FRACTURE(S), UNILATERAL OR BILATERAL FOR PELVIC BONE FRACTURE PATTERNS WHICH DO NOT DISRUPT THE PELVIC RING INCLUDES INTERNAL FIXATION, WHEN PERFORMED
G0413
PERCUTANEOUS SKELETAL FIXATION OF POSTERIOR PELVIC BONE FRACTURE AND/OR DISLOCATION, FOR FRACTURE PATTERNS WHICH DISRUPT THE PELVIC RING, UNILATERAL OR BILATERAL, (INCLUDES ILIUM, SACROILIAC JOINT AND/OR SACRUM)
G0414
OPEN TREATMENT OF ANTERIOR PELVIC BONE FRACTURE AND/OR DISLOCATION FOR FRACTURE PATTERNS WHICH DISRUPT THE PELVIC RING, UNILATERAL OR BILATERAL, INCLUDES INTERNAL FIXATION WHEN PERFORMED (INCLUDES PUBIC SYMPHYSIS AND/OR SUPERIOR/INFERIOR RAMI)
G0415
OPEN TREATMENT OF POSTERIOR PELVIC BONE FRACTURE AND/OR DISLOCATION, FOR FRACTURE PATTERNS WHICH DISRUPT THE PELVIC RING, UNILATERAL OR BILATERAL, INCLUDES INTERNAL FIXATION, WHEN PERFORMED (INCLUDES ILIUM, SACROILIAC JOINT AND/OR SACRUM)
G0428
COLLAGEN MENISCUS IMPLANT PROCEDURE FOR FILLING MENISCAL DEFECTS (E.G., CMI, COLLAGEN SCAFFOLD, MENAFLEX)
G0429
DERMAL FILLER INJECTION(S) FOR THE TREATMENT OF FACIAL LIPODYSTROPHY SYNDROME (LDS) (E.G., AS A RESULT OF HIGHLY ACTIVE ANTIRETROVIRAL THERAPY)
G0448
INSERTION OR REPLACEMENT OF A PERMANENT PACING CARDIOVERTER-DEFIBRILLATOR SYSTEM WITH TRANSVENOUS LEAD(S), SINGLE OR DUAL CHAMBER WITH INSERTION OF PACING ELECTRODE, CARDIAC VENOUS SYSTEM, FOR LEFT VENTRICULAR PACING
G0455
PREPARATION WITH INSTILLATION OF FECAL MICROBIOTA BY ANY METHOD, INCLUDING ASSESSMENT OF DONOR SPECIMEN
G0516
Insertion of nonbiodegradable drug delivery implants, four or more (services for subdermal rod implant)
G0517
Removal of nonbiodegradable drug delivery implants, four or more (services for subdermal implants)
G0518
Removal with reinsertion, nonbiodegradable drug delivery implants, four or more (services for subdermal implants)
M0076
PROLOTHERAPY
M0301
FABRIC WRAPPING OF ABDOMINAL ANEURYSM
Q2026
INJECTION, RADIESSE, 0.1 ML
Q2028
INJECTION, SCULPTRA, 0.5 MG
S0390
Routine foot care; removal and/or trimming of corns, calluses and/or nails and preventive maintenance in specific medical conditions (e.g., diabetes), per visit
S0400
GLOBAL FEE FOR EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY TREATMENT OF KIDNEY STONE(S)
S0601
Screening proctoscopy
S0800
LASER IN SITU KERATOMILEUSIS (LASIK)
S0810
PHOTOREFRACTIVE KERATECTOMY (PRK)
S0812
PHOTOTHERAPEUTIC KERATECTOMY (PTK)
S2053
TRANSPLANTATION OF SMALL INTESTINE, AND LIVER ALLOGRAFTS
S2054
TRANSPLANTATION OF MULTIVISCERAL ORGANS
S2055
HARVESTING OF DONOR MULTIVISCERAL ORGANS, WITH PREPARATION AND MAINTENANCE OF ALLOGRAFTS; FROM CADAVER DONOR
S2060
LOBAR LUNG TRANSPLANTATION
S2061
DONOR LOBECTOMY (LUNG) FOR TRANSPLANTATION, LIVING DONOR
S2065
SIMULTANEOUS PANCREAS KIDNEY TRANSPLANTATION
S2066
BREAST RECONSTRUCTION WITH GLUTEAL ARTERY PERFORATOR (GAP) FLAP, INCLUDING HARVESTING OF THE FLAP, MICROVASCULAR TRANSFER, CLOSURE OF DONOR SITE AND SHAPING THE FLAP INTO A BREAST, UNILATERAL
S2067
BREAST RECONSTRUCTION OF A SINGLE BREAST WITH STACKED DEEP INFERIOR EPIGASTRIC PERFORATOR (DIEP) FLAP(S) AND/OR GLUTEAL ARTERY PERFORATOR (GAP) FLAP(S), INCLUDING HARVESTING OF THE FLAP(S), MICROVASCULAR TRANSFER, CLOSURE OF DONOR SITE(S) AND SHAPING THE FLAP INTO A BREAST
S2068
BREAST RECONSTRUCTION WITH DEEP INFERIOR EPIGASTRIC PERFORATOR (DIEP) FLAP OR SUPERFICIAL INFERIOR EPIGASTRIC ARTERY (SIEA) FLAP, INCLUDING HARVESTING OF THE FLAP, MICROVASCULAR TRANSFER, CLOSURE OF DONOR SITE AND SHAPING THE FLAP INTO A BREAST, UNILATERAL
S2070
CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH ENDOSCOPIC LASER TREATMENT OF URETERAL CALCULI (INCLUDES URETERAL CATHETERIZATION)
S2079
LAPAROSCOPIC ESOPHAGOMYOTOMY (HELLER TYPE)
S2080
LASER-ASSISTED UVULOPALATOPLASTY (LAUP)
S2083
ADJUSTMENT OF GASTRIC BAND DIAMETER VIA SUBCUTANOUS PORT BY INJECTION OR ASPIRATION OF SALINE
S2102
ISLET CELL TISSUE TRANSPLANT FROM PANCREAS; ALLOGENEIC
S2103
ADRENAL TISSUE TRANSPLANT TO BRAIN
S2107
ADOPTIVE IMMUNOTHERAPY, I.E., DEVELOPMENT OF SPECIFIC ANTITUMOR REACTIVITY (E.G., TUMOR-INFILTRATING LYMPHOCYTE THERAPY) PER COURSE OF TREATMENT
S2112
ARTHROSCOPY, KNEE, SURGICAL FOR HARVESTING OF CARTILAGE (CHONDROCYTE CELLS)
S2115
OSTEOTOMY, PERIACETABULAR, WITH INTERNAL FIXATION
S2117
ARTHROEREISIS, SUBTALAR
S2118
METAL-ON-METAL TOTAL HIP RESURFACING, INCLUDING ACETABULAR AND FEMORAL COMPONENTS
S2120
LOW DENSITY LIPOPROTEIN (LDL) APHERESIS USING HEPARIN-INDUCED EXTRACORPOREAL LDL PRECIPITATION
S2140
CORD BLOOD HARVESTING FOR TRANSPLANTATION, ALLOGENEIC
S2142
CORD BLOOD-DERIVED STEM-CELL TRANSPLANTATION, ALLOGENEIC
S2150
BONE MARROW OR BLOOD-DERIVED STEM CELLS (PERIPHERAL OR UMBILICAL), ALLOGENEIC OR AUTOLOGOUS, HARVESTING, TRANSPLANTATION, AND RELATED COMPLICATIONS; INCLUDING: PHERESIS AND CELL PREPARATION/STORAGE; MARROW ABLATIVE THERAPY; DRUGS, SUPPLIES, HOSPITALIZATION WITH OUTPATIENT FOLLOW-UP; MEDICAL/SURGICAL, DIAGNOSTIC, EMERGENCY, AND REHABILITATIVE SERVICES; AND THE NUMBER OF DAYS OF PRE-AND POST-TRANSPLANT CARE IN THE GLOBAL DEFINITION
S2202
ECHOSCLEROTHERAPY
S2205
MINIMALLY INVASIVE DIRECT CORONARY ARTERY BYPASS SURGERY INVOLVING MINI-THORACOTOMY OR MINI-STERNOTOMY SURGERY, PERFORMED UNDER DIRECT VISION; USING ARTERIAL GRAFT(S), SINGLE CORONARY ARTERIAL GRAFT
S2206
MINIMALLY INVASIVE DIRECT CORONARY ARTERY BYPASS SURGERY INVOLVING MINI-THORACOTOMY OR MINI-STERNOTOMY SURGERY, PERFORMED UNDER DIRECT VISION; USING ARTERIAL GRAFT(S), TWO CORONARY ARTERIAL GRAFTS
S2207
MINIMALLY INVASIVE DIRECT CORONARY ARTERY BYPASS SURGERY INVOLVING MINI-THORACOTOMY OR MINI-STERNOTOMY SURGERY, PERFORMED UNDER DIRECT VISION; USING VENOUS GRAFT ONLY, SINGLE CORONARY VENOUS GRAFT
S2208
MINIMALLY INVASIVE DIRECT CORONARY ARTERY BYPASS SURGERY INVOLVING MINI-THORACOTOMY OR MINI-STERNOTOMY SURGERY, PERFORMED UNDER DIRECT VISION; USING SINGLE ARTERIAL AND VENOUS GRAFT(S), SINGLE VENOUS GRAFT
S2209
MINIMALLY INVASIVE DIRECT CORONARY ARTERY BYPASS SURGERY INVOLVING MINI-THORACOTOMY OR MINI-STERNOTOMY SURGERY, PERFORMED UNDER DIRECT VISION; USING TWO ARTERIAL GRAFTS AND SINGLE VENOUS GRAFT
S2225
MYRINGOTOMY, LASER-ASSISTED
S2230
IMPLANTATION OF MAGNETIC COMPONENT OF SEMI-IMPLANTABLE HEARING DEVICE ON OSSICLES IN MIDDLE EAR
S2235
IMPLANTATION OF AUDITORY BRAIN STEM IMPLANT
S2260
INDUCED ABORTION, 17 TO 24 WEEKS, ANY SURGICAL METHOD
S2265
INDUCED ABORTION FOR FETAL INDICATION, 25 TO 28 WEEKS
S2266
INDUCED ABORTION FOR FETAL INDICATION, 29 TO 31 WEEKS
S2267
INDUCED ABORTION FOR FETAL INDICATION, 32 WEEKS OR GREATER
S2300
ARTHROSCOPY, SHOULDER, SURGICAL; WITH THERMALLY-INDUCED CAPSULORRHAPHY
S2325
HIP CORE DECOMPRESSION
S2340
CHEMODENERVATION OF ABDUCTOR MUSCLE(S) OF VOCAL CORD
S2341
CHEMODENERVATION OF ADDUCTOR MUSCLE(S) OF VOCAL CORD
S2342
NASAL ENDOSCOPY FOR POSTOPERATIVE DEBRIDEMENT FOLLOWING FUNCTIONAL ENDOSCOPIC SINUS SURGERY, NASAL AND/OR SINUS CAVITY(S), UNILATERAL OR BILATERAL
S2348
DECOMPRESSION PROCEDURE, PERCUTANEOUS, OF NUCLEUS PULPOSUS OF INTERVERTEBRAL DISC, USING RADIOFREQUENCY ENERGY, SINGLE OR MULTIPLE LEVELS, LUMBAR
S2350
DISKECTOMY, ANTERIOR, WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S), INCLUDING OSTEOPHYTECTOMY; LUMBAR, SINGLE INTERSPACE
S2400
REPAIR, CONGENITAL DIAPHRAGMATIC HERNIA IN THE FETUS USING TEMPORARY TRACHEAL OCCLUSION, PROCEDURE PERFORMED IN UTERO
S2401
REPAIR, URINARY TRACT OBSTRUCTION IN THE FETUS, PROCEDURE PERFORMED IN UTERO
S2402
REPAIR, CONGENITAL CYSTIC ADENOMATOID MALFORMATION IN THE FETUS, PROCEDURE PERFORMED IN UTERO
S2403
REPAIR, EXTRALOBAR PULMONARY SEQUESTRATION IN THE FETUS, PROCEDURE PERFORMED IN UTERO
S2404
REPAIR, MYELOMENINGOCELE IN THE FETUS, PROCEDURE PERFORMED IN UTERO
S2405
REPAIR OF SACROCOCCYGEAL TERATOMA IN THE FETUS, PROCEDURE PERFORMED IN UTERO
S2409
REPAIR, CONGENITAL MALFORMATION OF FETUS, PROCEDURE PERFORMED IN UTERO, NOT OTHERWISE CLASSIFIED
S2411
FETOSCOPIC LASER THERAPY FOR TREATMENT OF TWIN-TO-TWIN TRANSFUSION SYNDROME
S4011
IN VITRO FERTILIZATION; INCLUDING BUT NOT LIMITED TO IDENTIFICATION AND INCUBATION OF MATURE OOCYTES, FERTILIZATION WITH SPERM, INCUBATION OF EMBRYO(S), AND SUBSEQUENT VISUALIZATION FOR DETERMINATION OF DEVELOPMENT
S4013
COMPLETE CYCLE, GAMETE INTRAFALLOPIAN TRANSFER (GIFT), CASE RATE
S4014
COMPLETE CYCLE, ZYGOTE INTRAFALLOPIAN TRANSFER (ZIFT), CASE RATE
S4015
COMPLETE IN VITRO FERTILIZATION CYCLE, NOT OTHERWISE SPECIFIED, CASE RATE
S4016
FROZEN IN VITRO FERTILIZATION CYCLE, CASE RATE
S4017
INCOMPLETE CYCLE, TREATMENT CANCELLED PRIOR TO STIMULATION, CASE RATE
S4018
FROZEN EMBRYO TRANSFER PROCEDURE CANCELLED BEFORE TRANSFER, CASE RATE
S4020
IN VITRO FERTILIZATION PROCEDURE CANCELLED BEFORE ASPIRATION, CASE RATE
S4021
IN VITRO FERTILIZATION PROCEDURE CANCELLED AFTER ASPIRATION, CASE RATE
S4022
ASSISTED OOCYTE FERTILIZATION, CASE RATE
S4023
DONOR EGG CYCLE, INCOMPLETE, CASE RATE
S4025
DONOR SERVICES FOR IN VITRO FERTILIZATION (SPERM OR EMBRYO), CASE RATE
S4028
MICROSURGICAL EPIDIDYMAL SPERM ASPIRATION (MESA)
S4035
STIMULATED INTRAUTERINE INSEMINATION (IUI), CASE RATE
S4037
CRYOPRESERVED EMBRYO TRANSFER, CASE RATE
S4981
INSERTION OF LEVONORGESTREL-RELEASING INTRAUTERINE SYSTEM
S8030
SCLERAL APPLICATION OF TANTALUM RING(S) FOR LOCALIZATION OF LESIONS FOR PROTON BEAM THERAPY
S9034
EXTRACORPOREAL SHOCKWAVE LITHOTRIPSY FOR GALL STONES

Version Effective Date: 03/30/2020
Version Issued Date: 03/30/2020
Version Reissued Date: N/A

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