CDM Description
CDM Number
3010 3010 3010 3070
301010003-10003 301010004-10004 301010008-10008 309017001-17001
3070
309017002-17002 R&B NICU-INTERMEDIATE
R&B - Nursery, Newborn Level 3 (intermediate care)
173
4110.60
3070 3150 3150 3171 3171 3171 3171 3171 3172 3172 3172 3172 3172 3174 3290 3290 3290 3340 3340 3340 3380 3380 3380 3380 3380 3380 3380 3530 3530 3530 3530 3530
309017003-17003 315013001-13001 315013002-13002 308115003-15003 308115005-15005 308115006-15006 308115013-15013 308115015-15015 308215001-15001 308215008-15008 308215009-15009 308215014-15014 308215016-15016 308414004-14004 312018001-18001 312018002-18002 312018004-18004 314019001-19001 314019002-19002 314019003-19003 308516001-16001 308516002-16002 308516003-16003 308516004-16004 316020001-20001 316020006-20006 316020007-20007 317021001-21001 317021003-21003 317021004-21004 317021005-21005 353021006-21006
R&B - Nursery, Newborn Level 2 (continuing care) R&B - Intensive Care, Intermediate R&B - Semiprivate, Medical/Surgical/GYN R&B - Semiprivate, Medical/Surgical/GYN R&B - Semiprivate, Medical/Surgical/GYN R&B - Semiprivate, Pediatric R&B - Semiprivate, Medical/Surgical/GYN R&B - Intensive Care, Intermediate R&B - Semiprivate, Medical/Surgical/GYN R&B - Semiprivate, Medical/Surgical/GYN R&B - Semiprivate, Pediatric R&B - Semiprivate, Medical/Surgical/GYN R&B - Intensive Care, Intermediate R&B - Semiprivate, Medical/Surgical/GYN R&B - Semiprivate, Pediatric R&B - Semiprivate, Medical/Surgical/GYN R&B - Semiprivate, Pediatric R&B - Semiprivate, Psychiatric R&B - Semiprivate, Psychiatric R&B - Ward, Psychiatric R&B - Semiprivate, Obstetrics (OB) R&B - Semiprivate, Obstetrics (OB) R&B - Semiprivate, Obstetrics (OB) R&B - Semiprivate, Obstetrics (OB) R&B - Semiprivate, Obstetrics (OB) R&B - Semiprivate, Obstetrics (OB) R&B - Private, Obstetrics (OB) R&B - Nursery, Newborn Level 1 R&B - Nursery, Newborn Level 1 R&B - Nursery, Newborn Level 1 R&B - Nursery, Newborn Level 1 R&B - Nursery, Newborn Level 2 (continuing care) Unscheduled or emergency dialysis treatment for an ESRD patient in a hospital outpatient department that is not certified as an ESRD facility Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; with manipulation, with or without skin or skeletal traction, each Removal of embedded foreign body from dentoalveolar structures; soft tissues Cardioversion, elective, electrical conversion of arrhythmia; external Repair, tendon or muscle, flexor, forearm and/or wrist; primary, single, each tendon or muscle Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; with manipulation, with or without skin or skeletal traction, each Closed treatment of distal phalangeal fracture, finger or thumb; without manipulation, each Closed treatment of distal phalangeal fracture, finger or thumb; with manipulation, each Percutaneous skeletal fixation of distal phalangeal fracture, finger or thumb, each Closed treatment of interphalangeal joint dislocation, single, with manipulation; without anesthesia
172 206 121 121 121 123 131 206 121 121 123 131 206 131 123 121 133 134 124 154 122 122 132 132 122 132 112 171 171 171 171 172
2872.13 5939.39 4503.92 3393.36 3393.36 3393.36 3393.36 4503.92 3393.36 3393.36 3393.36 3393.36 4503.92 3393.36 3393.36 3393.36 3393.36 3393.36 3393.36 3393.36 3393.36 3393.36 3393.36 3393.36 3393.36 3393.36 3393.36 1619.56 809.78 809.78 809.78 3081.80
DAILY SERVICE 3010 ICU I DAILY SERVICE 3010 ICU M R&B ICU/TRAUMA R&B NICU N
R&B NICU-CONTINUE CARE DAILY SERVICE 3150 DOU S R&B 1-2 SEMI-PRIV MED/SURG DOU E R&B 1-2 SEMI-PRIV MED/SURG 3C E R&B 1-2 SEMI-PRIV GYN 3C G R&B 1-2 SEMI-PRIV PEDS 3C P R&B 3-4 SEMI-PRIV MED/SURG 3C R R&B SEMI-PRIV MED/SURG 3C TEL R&B 1-2 SEMI-PRIV MED/SURG 3D E R&B 1-2 SEMI-PRIV GYN 3D G R&B 1-2 SEMI-PRIV PEDS 3D P R&B 3-4 SEMI-PRIV MED/SURG 3D F R&B SEMI-PRIV MED/SURG 3D TEL R&B 3-4 SEMI-PRIV MED/SURG 2C R R&B 1-2 SEMI-PRIV PEDS 4D P R&B 1-2 SEMI-PRIV MED/SURG 4D E R&B 3-4 SEMI-PRIV PEDS 4D Z R&B 3-4 SEMI-PRIV PSYCHIATRIC C R&B 1-2 SEMI-PRIV PSYCHIATRIC K R&B PSYCHIATRIC WARD H R&B 1-2 SEMI-PRIV GYN 4C G R&B 1-2 SEMI-PRIV MED/SURG 4C E R&B 3-4 SEMI-PRIV GYN 4C Y R&B 3-4 SEMI-PRIV MED/SURG 4C R R&B 1-2 SEMI-PRIV OB 4B/4C O R&B 3-4 SEMI-PRIV OBS 4B/4C J R&B PRIVATE OB - 4DA R&B NEWBORN LEVEL I NSY B R&B NEWBORN LEV 1 ROOM IN 4CB A R&B NEWBORN LVL 1 - 4DB R&B NEWBORN LVL 1 - 4BB R&B NEWBORN LVL 2-CONTINUE CARE
4010
401000257-257 EMERG DIALYSIS ESRD PT
4010
401000725-725 PF CL TX PHAL SHFT FX W MNP, EA
4010
401001805-1805 PF REM DENTOALV EMB FB, SOFT TISS
4010
401002960-2960 PF CARDIOVERSION ELECTRIC EXT
4010
401005260-5260 PF REP TENDN/MUSCL FLEX/WRIST EA
4010
401006725-6725 CL TX PHAL SHFT FX W MNP, EA (F9)
4010
401006750-6750 CLTX D PHAL FX FGR/THMB WO M (F9)
4010
401006755-6755 CLTX D PHAL FX FGR/THMB W M (F9)
4010
401006756-6756 SK FIX DSTL PHAL FX FNGR, PRC, F9
4010
401006770-6770 CLTX IP JNT DISL W M WO ANE (F9)
Long Description
UB Revenue Code 201 202 208 174
Revenue Center
R&B - Intensive Care, Surgical R&B - Intensive Care, Medical R&B - Intensive Care, Trauma R&B - Nursery, Newborn Level 4 (intensive care)
CPT/HCPCS
Amount 6809.86 6809.86 9533.80 6162.04
450
G0257
2093.13
981
26725
953.91
981
41805
610.23
981
92960
345.36
981
25260
1976.61
450
26725F9
698.97
450
26750F9
698.97
450
26755F9
698.97
450
26756F9
8529.03
450
26770F9
698.97
1 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4010
401010021-10021 FINE NEEDLE ASP WO IMG GUIDE
4010
401010121-10121 INC & REM FB SQ, COMPL
4010
401010140-10140 I&D HEMATOMA/FLUID
4010
401010160-10160 PUNC ASP ABSC/HEMATOMA/CYST
4010
401011400-11400 EXC TR-EXT B9+MARG 0.5CM/<
4010
401011720-11720 DEBRIDE NAIL 1-5
4010
401011730-11730 SIMPLE AVULSE NAIL PLATE, SINGLE
4010 4010
401011760-11760 REPAIR NAIL BED 401011982-11982 REMOVE DRUG IMPLANT
4010
401011983-11983 REM/REINSERT DRUG DELIVERY IMPLNT
4010
401012045-12045 INT WND REP N-HF/GENIT 12.6-20CM
4010
401013120-13120 REPAIR, COMPLEX, S/A/L 1.1-2.5 CM
4010
401013122-13122 REP, COMPLEX S/A/L ADDTL =<5CM
4010 4010 4010 4010 4010 4010 4010 4010 4010 4010 4010 4010
401014000-14000 401014005-14005 401014010-14010 401014015-14015 401014020-14020 401014025-14025 401014030-14030 401014035-14035 401014040-14040 401014045-14045 401014050-14050 401014055-14055
4010
401015860-15860 TEST VASC FLOW IN FLAP/GRAFT
4010
401016020-16020 DRESS/DEBRID P-THICK BURN, SMALL
4010
401016030-16030 DRESS/DEBRID P-THICK BURN L
4010
401016725-16725 CL TX PHAL SHFT FX W MNP, EA (FA)
4010
401016750-16750 CLTX D PHAL FX FGR/THMB WO M (FA)
4010
401016756-16756 SK FIX DSTL PHAL FX FNGR, PRC, FA
4010
401016770-16770 CLTX IP JNT DISL W M WO ANE (FA)
4010
401016776-16776 SK FIX IP JT DISL SGL W M PC (FA)
4010
401017110-17110 DESTRUCT BENIGN =<14 LESIONS
4010
401019000-19000 PUNCT ASP BRST CYST - INITIAL
R&B ER ICU/MEDICAL R&B ER ICU/SURGICAL R&B ER ICU/TRAUMA R&B ER DOU R&B ER MED/SURG/GYN, 2 BEDS ISOL R&B ER TELE, 2 BEDS ISOLATION R&B ER PEDS, 2 BEDS ISOLATION R&B ER MED/SURG/GYN, 2 BEDS R&B ER MED/SURG/GYN, 3-4 BEDS R&B ER PEDS, 2 BEDS R&B ER PEDS, 3-4 BEDS R&B ER TELE, 2 BEDS
Long Description Fine needle aspiration biopsy, without imaging guidance; first lesion Incision and removal of foreign body, subcutaneous tissues; complicated Incision and drainage of hematoma, seroma or fluid collection Puncture aspiration of abscess, hematoma, bulla, or cyst Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.5 cm or less Debridement of nail(s) by any method(s); 1 to 5 Avulsion of nail plate, partial or complete, simple; single Repair of nail bed Removal, non-biodegradable drug delivery implant Removal with reinsertion, non-biodegradable drug delivery implant Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 12.6 cm to 20.0 cm Repair, complex, scalp, arms, and/or legs; 1.1 cm to 2.5 cm Repair, complex, scalp, arms, and/or legs; each additional 5 cm or less R&B - Intensive Care, Medical R&B - Intensive Care, Surgical R&B - Intensive Care, Trauma R&B - Intensive Care, Intermediate R&B - Semiprivate, Medical/Surgical/GYN R&B - Intensive Care, Intermediate R&B - Semiprivate, Pediatric R&B - Semiprivate, Medical/Surgical/GYN R&B - Semiprivate, Medical/Surgical/GYN R&B - Semiprivate, Pediatric R&B - Semiprivate, Pediatric R&B - Intensive Care, Intermediate Intravenous injection of agent (eg, fluorescein) to test vascular flow in flap or graft Dressings and/or debridement of partial-thickness burns, initial or subsequent; small (less than 5% total body surface area) Dressings and/or debridement of partial-thickness burns, initial or subsequent; large (eg, more than 1 extremity, or greater than 10% total body surface area) Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; with manipulation, with or without skin or skeletal traction, each Closed treatment of distal phalangeal fracture, finger or thumb; without manipulation, each Percutaneous skeletal fixation of distal phalangeal fracture, finger or thumb, each Closed treatment of interphalangeal joint dislocation, single, with manipulation; without anesthesia Percutaneous skeletal fixation of interphalangeal joint dislocation, single, with manipulation Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions Puncture aspiration of cyst of breast;
UB Revenue Code
CPT/HCPCS
450
10021
1087.80
450
10121
4718.16
450
10140
4325.55
450
10160
1023.54
450
11400
2004.99
450
11720
195.87
450
11730
591.33
450 450
11760 11982
1584.90 1155.06
450
11983
922.65
450
12045
1708.71
450
13120
1708.71
450
13122
337.81
202 201 208 206 121 206 123 121 131 123 133 206
Amount
6809.86 6809.86 9533.80 5939.39 3693.36 4803.92 3693.36 3393.36 3393.36 3393.36 3393.36 4503.92
450
15860
1155.06
450
16020
590.91
450
16030
1023.54
450
26725FA
698.97
450
26750FA
698.97
450
26756FA
8529.03
450
26770FA
698.97
450
26776FA
8529.03
450
17110
591.33
450
19000
1885.74
2 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4010
401020021-20021 PF FNA W/O IMAGE
4010
401020060-20060 PF I&D ABSCESS, SIMPLE
4010
401020061-20061 PF I&D ABSCESS, CMPLX/MULTI
4010 4010
401020080-20080 PF I&D PILONIDAL CYST, SIMPLE 401020103-20103 PF EXPL P WND,EXTREM
4010
401020120-20120 PF INCIS/REM FB, SC TISS, SMPL
4010
401020121-20121 PF INC & REM FB SQ, COMPL
4010
401020140-20140 PF I&D HEMATOMA/FLUID
4010
401020160-20160 PF PUNC ASP ABSC/HEMATOMA/CYST
4010
401020550-20550 INJ SGL TENDON SHTH/LIGAMENT
4010
401020604-20604 DRAIN/INJ SMALL JOINT/BURSA W/US
4010
401020606-20606 DRAIN/INJ INTER JOINT/BURSA W/US
4010
401020611-20611 DRAIN/INJ MAJOR JOINT/BURSA W/US
4010
401020670-20670 REMOVAL OF SUPPORT IMPLANT
4010
401020950-20950 MONITOR INTEST FLD PRESSURE
4010
401021301-21301 PF SHAVE LESION T/A/L 0.6-1.0 CM
4010
401021320-21320 CL TX NASAL BN FX W STABILIZ
4010
401021400-21400 PF EXC TR-EXT B9+MARG 0.5CM/<
4010
401021420-21420 PF EXC B9 LES S/N/H/F/G <=0.5CM
4010
401021440-21440 CL TX MAND/MAXILL ALVEOLAR FX
4010
401021451-21451 CL TX MANDIBULAR FX W MANIP
4010
401021480-21480 CL TX TMJ DISLOCATION, INITIAL
4010
401021720-21720 PF DEBRIDE NAIL 1-5
4010
401021730-21730 PF SIMPLE AVULSE NAIL PLATE, SNGL
4010
401021740-21740 PF EVAC SUBUNGUAL HEMATOMA
Long Description Fine needle aspiration biopsy, without imaging guidance; first lesion Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple Incision and drainage of pilonidal cyst; simple Exploration of penetrating wound; extremity Incision and removal of foreign body, subcutaneous tissues; simple Incision and removal of foreign body, subcutaneous tissues; complicated Incision and drainage of hematoma, seroma or fluid collection Puncture aspiration of abscess, hematoma, bulla, or cyst Injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar 'fascia') Arthrocentesis, aspiration and/or injection, small joint or bursa (eg, fingers, toes); with ultrasound guidance, with permanent recording and reporting Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); with ultrasound guidance, with permanent recording and reporting Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting Removal of implant; superficial (eg, buried wire, pin or rod) Monitoring of interstitial fluid pressure (includes insertion of device, eg, wick catheter technique, needle manometer technique) in detection of muscle compartment syndrome Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.6 to 1.0 cm Closed treatment of nasal bone fracture; with stabilization Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.5 cm or less Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 0.5 cm or less Closed treatment of mandibular or maxillary alveolar ridge fracture Closed treatment of mandibular fracture; with manipulation Closed treatment of temporomandibular dislocation; initial or subsequent Debridement of nail(s) by any method(s); 1 to 5 Avulsion of nail plate, partial or complete, simple; single Evacuation of subungual hematoma
UB Revenue Code
CPT/HCPCS
981
10021
216.24
981
10060
307.80
981
10061
567.18
981 981
10080 20103
325.29 1085.70
981
10120
329.43
981
10121
579.93
981
10140
373.20
981
10160
303.93
450
20550
808.02
450
20604
808.02
450
20606
1774.08
450
20611
808.02
450
20670
4718.16
450
20950
2004.99
981
11301
168.24
450
21320
7603.32
981
11400
257.19
981
11420
259.38
450
21440
5727.33
450
21451
3983.67
450
21480
698.97
981
11720
45.90
981
11730
159.57
981
11740
104.58
Amount
3 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4010
401021750-21750 PF REMOVAL OF NAIL BED
4010
401021760-21760 PF REPAIR NAIL BED
4010
401021765-21765 PF WEDGE EXC OF SKIN OF NAIL FOLD
4010
401021982-21982 PF REMOVE DRUG IMPLANT
4010
401022001-22001 PF SMPL REP S/N/A/G/TR/E <=2.5 CM
4010
401022002-22002 PF S REP S/N/A/G/TR/E 2.6-7.5 CM
4010
401022004-22004 PF S REP S/N/A/G/TR/E 7.6-12.5 CM
4010
401022005-22005 PF S REP S/N/A/G/TR/E 12.6-20.0CM
4010
401022006-22006 PF S REP S/N/A/G/TR/E 20.1-30.0CM
4010
401022007-22007 PF SMPL REP S/N/A/G/TR/E >30.0CM
4010
401022011-22011 PF SMPL REP FACE/MM <=2.5 CM
4010
401022013-22013 PF SMPL REP FACE/MM 2.6-5.0 CM
4010
401022014-22014 PF SMPL REP FACE/MM 5.1-7.5 CM
4010
401022015-22015 PF SMPL REP F/E/N/L/MM 7.6-12.5CM
4010
401022016-22016 PF SMPL REP FACE/MM 12.6-20.0 CM
4010
401022017-22017 PF SMPL REP F/E/N/L/MM 20.1-30 CM
4010
401022018-22018 PF SMPL REP FACE/MM >30.0 CM
4010
401022031-22031 PF REP INT WND S/A/T/EXT <=2.5 CM
4010
401022032-22032 PF REP INT WND S/A/T/EX 2.6-7.5CM
4010
401022034-22034 PF REP INT WND S/TR/EX 7.6-12.5CM
4010
401022035-22035 PF REP INT WND S/A/T/EX 12.6-20CM
4010
401022036-22036 PF REP INT WND S/A/T/EX 20.1-30CM
4010
401022037-22037 PF REP INT WND S/A/TR/EXT >30 CM
Long Description Excision of nail and nail matrix, partial or complete (eg, ingrown or deformed nail), for permanent removal Repair of nail bed Wedge excision of skin of nail fold (eg, for ingrown toenail) Removal, non-biodegradable drug delivery implant Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.6 cm to 7.5 cm Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 7.6 cm to 12.5 cm Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 12.6 cm to 20.0 cm Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 20.1 cm to 30.0 cm Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); over 30.0 cm Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 5.1 cm to 7.5 cm Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 7.6 cm to 12.5 cm Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 12.6 cm to 20.0 cm Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 20.1 cm to 30.0 cm Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; over 30.0 cm Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.5 cm or less Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.6 cm to 7.5 cm Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 7.6 cm to 12.5 cm Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 12.6 cm to 20.0 cm Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 20.1 cm to 30.0 cm Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); over 30.0 cm
UB Revenue Code
CPT/HCPCS
981
11750
451.50
981
11760
361.80
981
11765
300.30
981
11982
307.65
981
12001
137.67
981
12002
180.57
981
12004
225.33
981
12005
291.78
981
12006
358.17
981
12007
452.01
981
12011
170.52
981
12013
178.02
981
12014
229.47
981
12015
288.24
981
12016
394.17
981
12017
470.61
981
12018
533.91
981
12031
484.50
981
12032
618.93
981
12034
651.21
981
12035
755.37
981
12036
872.61
981
12037
1020.96
Amount
4 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
Long Description Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 2.5 cm or less Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 2.6 cm to 7.5 cm Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 7.6 cm to 12.5 cm Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 12.6 cm to 20.0 cm Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 20.1 cm to 30.0 cm Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; over 30.0 cm
UB Revenue Code
CPT/HCPCS
981
12041
475.74
981
12042
634.08
981
12044
676.65
981
12045
853.92
981
12046
966.84
981
12047
1078.35
981
12051
543.06
981
12052
644.79
981
12053
687.24
981
12054
699.24
981
12055
965.37
981
12056
1192.44
Amount
4010
401022041-22041 PF REP INT WND N/H/F/G <=2.5 CM
4010
401022042-22042 PF REP INT WND N/H/F/G 2.6-7.5 CM
4010
401022044-22044 PF REP INT WND N/H/F/G 7.6-12.5CM
4010
401022045-22045 PF REP INT WND N/H/F/G 12.6-20 CM
4010
401022046-22046 PF REP INT WND N/H/F/G 20.1-30 CM
4010
401022047-22047 PF REP INT WND N/H/F/G >30.0 CM
4010
401022051-22051 PF REP INT WND FACE/MM <=2.5 CM
4010
401022052-22052 PF REP INT WND FACE/MM 2.6-5.0 CM
4010
401022053-22053 PF REP INT WND FACE/MM 5.1-7.5 CM
4010
401022054-22054 PF REP INT WND FACE/MM 7.6-12.5CM
4010
401022055-22055 PF REP INT WND FACE/MM 12.6-20 CM
4010
401022056-22056 PF REP INT WND FACE/MM 20.1-30 CM
4010
401022057-22057 PF REP INT WND FACE/MM >30 CM
Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; over 30.0 cm
981
12057
1273.62
4010 4010
401023100-23100 PF CMPLX REP TRUNK 1.1-2.5 CM 401023101-23101 PF CMPLX REP TRUNK 2.6-7.5 CM
Repair, complex, trunk; 1.1 cm to 2.5 cm Repair, complex, trunk; 2.6 cm to 7.5 cm
981 981
13100 13101
650.79 803.49
4010
401023102-23102 PF CMPLX REP TRUNK ADDTL <=5 CM
Repair, complex, trunk; each additional 5 cm or less
981
13102
232.59
4010
401023120-23120 PF CMPLX REP S/A/L 1.1-2.5 CM
981
13120
748.77
4010
401023121-23121 PF CMPLX REPAIR S/A/L 2.6-7.5 CM
981
13121
844.98
4010
401023122-23122 PF CMPLX REP S/A/L ADDT <=5 CM
981
13122
267.72
4010
401023131-23131 PF CMPLX REP F/G/H/F 1.1-2.5 CM
981
13131
789.57
4010
401023132-23132 PF CMPLX REP F/G/H/F 2.6-7.5 CM
981
13132
994.65
4010
401023133-23133 PF C REP H/A/G/EXTR, ADDL <=5 CM
981
13133
412.20
4010
401023151-23151 PF CMPLX REP E/N/E/L 1.1-2.5 CM
981
13151
906.96
4010
401023152-23152 PF CMPLX REP E/N/E/L 2.6-7.5 CM
981
13152
1099.53
4010
401023153-23153 PF CMPLX REP E/N/E/L, ADDT <=5 CM
981
13153
444.12
4010
401023500-23500 CL TX CLAVICULAR FX WO MNP, BILAT
450
2350050
698.97
4010
401023505-23505 CL TX CLAVICULAR FX W MANIP, BOTH
450
2350550
4258.38
4010
401023620-23620 CL TX GR TUBEROSITY FX WO MNP, BI
450
2362050
698.97
Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 5.1 cm to 7.5 cm Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 7.6 cm to 12.5 cm Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 12.6 cm to 20.0 cm Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 20.1 cm to 30.0 cm
Repair, complex, scalp, arms, and/or legs; 1.1 cm to 2.5 cm Repair, complex, scalp, arms, and/or legs; 2.6 cm to 7.5 cm Repair, complex, scalp, arms, and/or legs; each additional 5 cm or less Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 1.1 cm to 2.5 cm Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 2.6 cm to 7.5 cm Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; each additional 5 cm or less Repair, complex, eyelids, nose, ears and/or lips; 1.1 cm to 2.5 cm Repair, complex, eyelids, nose, ears and/or lips; 2.6 cm to 7.5 cm Repair, complex, eyelids, nose, ears and/or lips; each additional 5 cm or less Closed treatment of clavicular fracture; without manipulation Closed treatment of clavicular fracture; with manipulation Closed treatment of greater humeral tuberosity fracture; without manipulation
5 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4010
401023650-23650 CL TX SHLDR DISL W M WO ANES, BI
4010
401023665-23665 CL TX SHLDR DISLOC & FX GT, W MAN
4010
401024200-24200 REM FB UPR ARM/ELBOW, SUBQ, BILAT
4010
401024500-24500 CL TX HUMERAL SHAFT FX WO M, BOTH
4010
401024530-24530 CL TX SC/TC HUMERUS FX WO MNP, BI
4010
401024535-24535 CL TX SC/TX HUMERUS SHFT FX W MAN
4010
401024600-24600 TX CL ELBOW DISL WO ANES, BILAT
4010
401024640-24640 CL TX NURSEMAID ELBOW W MNP, BI
4010
401025260-25260 REP TENDN/MUSCL FLEXOR/WRIST EA
4010
401025500-25500 CL TX RADIAL SHAFT FX WO MNP, BIL
4010
401025505-25505 CL TX RADIAL SHAFT FX W MANIP, BI
4010
401025565-25565 CL TX RAD/ULNA SHAFT FX W MNP, BI
4010
401025600-25600 CLTX D RAD FX/EPIPHYS SEP WO M,BI
4010
401025605-25605 CLTX D RAD FX/EPIPHYS SEP W M, BI
4010
401025624-25624 CLTX CARPAL SCAPHOID FX W MNP, BI
4010
401025635-25635 CLTX CARPL BN FX W MNP, EA, BOTH
4010
401025650-25650 CL TX ULNAR STYLOID FX, BILAT
4010
401025660-25660 CLTX RC/IC DISL 1+ BN W MNP, BOTH
4010
401025675-25675 CLTX DSTL RADIOULNAR DIS W M, BI
4010
401025690-25690 CL TX LUNATE DISLOC W MANIP, BOTH
4010
401025860-25860 PF TEST VASC FLOW IN FLAP/GRAFT
4010
401026000-26000 PF INITIAL TX 1ST DEGREE BURN
4010
401026011-26011 DRAIN FINGER ABSC,COMPLICATED
4010
401026020-26020 PF DRESS/DEBRID P-THICK BURN, SM
4010
401026025-26025 PF DRESS/DEBRID P-THICK BURN, MED
4010
401026030-26030 PF DRESS/DEBRID P-THICK BURN L
Long Description Closed treatment of shoulder dislocation, with manipulation; without anesthesia Closed treatment of shoulder dislocation, with fracture of greater humeral tuberosity, with manipulation Removal of foreign body, upper arm or elbow area; subcutaneous Closed treatment of humeral shaft fracture; without manipulation Closed treatment of supracondylar or transcondylar humeral fracture, with or without intercondylar extension; without manipulation Closed treatment of supracondylar or transcondylar humeral fracture, with or without intercondylar extension; with manipulation, with or without skin or skeletal traction Treatment of closed elbow dislocation; without anesthesia Closed treatment of radial head subluxation in child, nursemaid elbow, with manipulation Repair, tendon or muscle, flexor, forearm and/or wrist; primary, single, each tendon or muscle Closed treatment of radial shaft fracture; without manipulation Closed treatment of radial shaft fracture; with manipulation Closed treatment of radial and ulnar shaft fractures; with manipulation Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; without manipulation Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; with manipulation Closed treatment of carpal scaphoid (navicular) fracture; with manipulation Closed treatment of carpal bone fracture (excluding carpal scaphoid [navicular]); with manipulation, each bone Closed treatment of ulnar styloid fracture Closed treatment of radiocarpal or intercarpal dislocation, 1 or more bones, with manipulation Closed treatment of distal radioulnar dislocation with manipulation Closed treatment of lunate dislocation, with manipulation Intravenous injection of agent (eg, fluorescein) to test vascular flow in flap or graft Initial treatment, first degree burn, when no more than local treatment is required Drainage of finger abscess; complicated (eg, felon) Dressings and/or debridement of partial-thickness burns, initial or subsequent; small (less than 5% total body surface area) Dressings and/or debridement of partial-thickness burns, initial or subsequent; medium (eg, whole face or whole extremity, or 5% to 10% total body surface area) Dressings and/or debridement of partial-thickness burns, initial or subsequent; large (eg, more than 1 extremity, or greater than 10% total body surface area)
UB Revenue Code
CPT/HCPCS
450
2365050
526.51
450
23665
3883.80
450
2420050
4718.16
450
2450050
698.97
450
2453050
751.65
450
24535
4724.85
450
2460050
698.97
450
2464050
698.97
450
25260
9258.42
450
2550050
698.97
450
2550550
4258.38
450
2556550
1571.27
450
2560050
698.97
450
2560550
4258.38
450
2562450
4258.38
450
2563550
4258.38
450
2565050
698.97
450
2566050
698.97
450
2567550
698.97
450
2569050
4258.38
981
15860
333.09
981
16000
143.19
450
26011
4718.16
981
16020
171.93
981
16025
349.20
981
16030
417.27
Amount
6 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
Long Description Arthrotomy, with exploration, drainage, or removal of loose or foreign body; metacarpophalangeal joint, each Repair, extensor tendon, finger, primary or secondary; without free graft, each tendon Closed treatment of metacarpal fracture, single; with manipulation, each bone Percutaneous skeletal fixation of metacarpal fracture, each bone Closed treatment of carpometacarpal dislocation, thumb, with manipulation Closed treatment of carpometacarpal dislocation, other than thumb, with manipulation, each joint; without anesthesia Closed treatment of metacarpophalangeal dislocation, single, with manipulation; without anesthesia Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; with manipulation, with or without skin or skeletal traction, each Excision of Bartholin's gland or cyst Closed treatment of distal phalangeal fracture, finger or thumb; without manipulation, each Closed treatment of distal phalangeal fracture, finger or thumb; with manipulation, each Percutaneous skeletal fixation of distal phalangeal fracture, finger or thumb, each Closed treatment of interphalangeal joint dislocation, single, with manipulation; without anesthesia Percutaneous skeletal fixation of interphalangeal joint dislocation, single, with manipulation Excision, tumor, soft tissue of pelvis and hip area, subcutaneous; less than 3 cm Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions Closed treatment of femoral fracture, proximal end, neck; without manipulation Closed treatment of hip dislocation, traumatic; without anesthesia Treatment of spontaneous hip dislocation (developmental, including congenital or pathological), by abduction, splint or traction; without anesthesia, without manipulation
UB Revenue Code
CPT/HCPCS
450
26075
9258.42
450
26418
8529.03
450
2660550
698.97
450
2660850
8529.03
450
2664150
698.97
450
26670
752.16
450
26700
752.16
450
26725F1
698.97
450
5674050
7954.80
450
26750F1
698.97
450
26755F1
698.97
450
26756F1
8529.03
450
26770F1
698.97
450
26776F1
8529.03
981
27047
1122.60
981
17110
223.29
450
27230RT
752.16
450
2725050
752.16
450
27256
752.16
Amount
4010
401026075-26075 ARTHROTOMY EXPL/REM FB MCP JNT EA
4010
401026418-26418 REP EXT TEND,FNGR,WO FREE GRFT,EA
4010
401026605-26605 CL TX MC FX SGL W MNP, EA BN, BIL
4010
401026608-26608 PERC SKEL FIX MC FX, EA BONE, BI
4010
401026641-26641 CL TX CMC DISL THUMB W MNP, BOTH
4010
401026670-26670 CL TX CMC DISL W MNP WO ANES, EA
4010
401026700-26700 CL TX MCP DISL SGL W MNP WO ANES
4010
401026725-26725 CL TX PHAL SHFT FX W MNP, EA (F1)
4010
401026740-26740 EXCISE BARTHOLIN GL OR CYST (BIL)
4010
401026750-26750 CLTX D PHAL FX FGR/THMB WO M (F1)
4010
401026755-26755 CLTX D PHAL FX FGR/THMB W M (F1)
4010
401026756-26756 SK FIX DSTL PHAL FX FNGR, PRC, F1
4010
401026770-26770 CLTX IP JNT DISL W M WO ANE (F1)
4010
401026776-26776 SK FIX IP JT DISL SGL W M PC (F1)
4010
401027047-27047 PF EXC HIP/PELVIS LES SC < 3 CM
4010
401027110-27110 PF DESTRUCT BENIGN =<14 LESIONS
4010
401027230-27230 CL TX PROX FEM FX WO MANIP,RT
4010
401027250-27250 CL TX TRAUMA HIP DISL WO ANES, BI
4010
401027256-27256 TX HIP DISL ABD SPLNT/TRAC WO
4010
401027266-27266 CLTX POSTOP HIP DISL W ANE, BILAT
Closed treatment of post hip arthroplasty dislocation; requiring regional or general anesthesia
450
2726650
4258.38
4010
401027369-27369 KNEE ARTHROGRAPHY INJECTION
Injection procedure for contrast knee arthrography or contrast enhanced CT/MRI knee arthrography
450
27369
763.41
4010
401027500-27500 CL TX FEMORAL SHAFT FX WO MNP, BI
450
2750050
752.13
4010
401027502-27502 CL TX FEMORAL SHAFT FX W MNP, BI
450
2750250
4258.38
4010
401027510-27510 CLTX FEMUR FX/EPIPHYS SEP W M, BI
450
2751050
4258.38
4010
401027530-27530 CL TX PROX TIBIAL FX WO MNP, BOTH
450
2753050
698.97
4010
401027552-27552 CL TX KNEE DISLOC W ANES, BOTH
450
2755250
4258.38
Closed treatment of femoral shaft fracture, without manipulation Closed treatment of femoral shaft fracture, with manipulation, with or without skin or skeletal traction Closed treatment of femoral fracture, distal end, medial or lateral condyle, with manipulation Closed treatment of tibial fracture, proximal (plateau); without manipulation Closed treatment of knee dislocation; requiring anesthesia
7 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4010
401027562-27562 CL TX PATELLA DISLOCAT W ANES
4010
401027752-27752 CL TX TIBIA SHAFT FX W MNP, BILAT
4010
401027781-27781 CL TX PROX FIB/SHAFT FX W MNP, BI
4010
401027786-27786 CL TX DSTL FIBULAR FX WO MNP, BI
4010
401027810-27810 CLTX BIMALLEOLAR ANKL FRACT W MNP
4010
401027818-27818 CL TX TRIMALL ANKL FX W MNP, BOTH
4010
401027825-27825 CL TX WB DSTL TIB FX W MANIP
4010
401027840-27840 CL TX ANKLE DISLOC WO ANES, BILAT
4010
401028190-28190 REMOVE FOREIGN BODY, FOOT, SQ
4010
401028430-28430 CL TX TALUS FX WO MANIP, BILAT
4010
401028450-28450 TX TARSAL BONE FX WO MNP, EACH
4010
401028490-28490 CL TX FX GT PHALANX(S) WO MNP
4010
401028515-28515 CL TX FX PHALANX W MNP, EA
4010
401028540-28540 CL TX TARSAL BN DISL WO ANES, BIL
4010
401028630-28630 CL TX MTP JNT DISL WO ANES
4010
401028645-28645 REPAIR TOE DISLOCATION
4010
401028660-28660 CL TX IP JOINT DISL, WO ANESTH
4010
401028665-28665 CL TX IP JOINT DISL, W ANESTH T9
4010 4010
401029000-29000 PF PUNCT ASP BRST CYST - INITIAL 401029105-29105 APPLY LONG ARM SPLINT, BILAT
4010
401029125-29125 APPLY SHORT ARM SPLNT, STATIC, BI
4010
401029126-29126 APPLY SHORT ARM SPLINT, DYNAMIC
4010 4010 4010 4010 4010
401029280-29280 401029515-29515 401029580-29580 401029700-29700 401029705-29705
4010
401030000-30000 DRN ABSC/HEMATOMA, NASAL, INT
4010
401030550-30550 PF INJ SGL TENDON SHTH/LIGAMENT
4010
401030551-30551 PF INJ SNGL TENDON ORIGIN/INSERT
4010
401030552-30552 PF INJ TRIGGER POINT 1-2 MUSCLES
4010
401030553-30553 PF INJ TRIGGER POINTS =>3 MUSCLES
STRAPPING, HAND OR FINGER, BILAT APPLY SHORT LEG SPLINT, BILAT UNNA BOOT STRAPPING REM GAUNTLET BOOT OR BODY CAST REMOVE FULL ARM OR LEG CAST
Long Description Closed treatment of patellar dislocation; requiring anesthesia Closed treatment of tibial shaft fracture (with or without fibular fracture); with manipulation, with or without skeletal traction Closed treatment of proximal fibula or shaft fracture; with manipulation Closed treatment of distal fibular fracture (lateral malleolus); without manipulation Closed treatment of bimalleolar ankle fracture (eg, lateral and medial malleoli, or lateral and posterior malleoli, or medial and posterior malleoli); with manipulation Closed treatment of trimalleolar ankle fracture; with manipulation Closed treatment of fracture of weight bearing articular portion of distal tibia (eg, pilon or tibial plafond), with or without anesthesia; with skeletal traction and/or requiring manipulation Closed treatment of ankle dislocation; without anesthesia Removal of foreign body, foot; subcutaneous Closed treatment of talus fracture; without manipulation Treatment of tarsal bone fracture (except talus and calcaneus); without manipulation, each Closed treatment of fracture great toe, phalanx or phalanges; without manipulation Closed treatment of fracture, phalanx or phalanges, other than great toe; with manipulation, each Closed treatment of tarsal bone dislocation, other than talotarsal; without anesthesia Closed treatment of metatarsophalangeal joint dislocation; without anesthesia Open treatment of metatarsophalangeal joint dislocation, includes internal fixation, when performed Closed treatment of interphalangeal joint dislocation; without anesthesia Closed treatment of interphalangeal joint dislocation; requiring anesthesia Puncture aspiration of cyst of breast; Application of long arm splint (shoulder to hand) Application of short arm splint (forearm to hand); static Application of short arm splint (forearm to hand); dynamic Strapping; hand or finger Application of short leg splint (calf to foot) Strapping; Unna boot Removal or bivalving; gauntlet, boot or body cast Removal or bivalving; full arm or full leg cast Drainage abscess or hematoma, nasal, internal approach Injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar 'fascia') Injection(s); single tendon origin/insertion Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s) Injection(s); single or multiple trigger point(s), 3 or more muscles
UB Revenue Code
CPT/HCPCS
450
27562
526.51
450
2775250
4258.38
450
2778150
4261.02
450
2778650
698.97
450
27810
3883.80
450
2781850
4258.38
450
27825
3883.80
450
2784050
698.97
450
28190
3336.63
450
2843050
752.13
450
28450
752.16
450
28490
698.97
450
28515
752.13
450
2854050
752.16
450
28630
698.97
450
28645
9258.42
450
28660
752.16
450
28665T9
830.49
981 450
19000 2910550
135.84 437.76
450
2912550
349.86
450
29126
367.65
450 450 450 450 450
2928050 2951550 29580 29700 29705
111.30 437.76 437.76 772.17 772.17
450
30000
442.44
981
20550
122.28
981
20551
133.26
981
20552
119.64
981
20553
136.08
Amount
8 of 167 Updated on 1/22/2019
Revenue Center
4010
4010
Long Description
UB Revenue Code
CPT/HCPCS
401030600-30600 PF ASP/INJ SML JOINT/BURSA WO US
Arthrocentesis, aspiration and/or injection, small joint or bursa (eg, fingers, toes); without ultrasound guidance
981
20600
111.48
401030605-30605 PF ASP/INJ INT JOINT/BURSA WO US
Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); without ultrasound guidance
981
20605
116.73
981
20606
164.61
981
20610
143.31
981
20611
191.04
981
20612
131.28
981
20670
464.04
450
30901
349.86
450
30903
367.65
981
20950
283.59
981
41252
666.33
981
21310
83.61
981
21315
479.70
981
21440
1532.58
981
21480
98.73
450
31500
619.44
450
31530
4441.56
450
31575
511.38
450
31577
1265.94
450
31605
1609.56
981
32110
4466.31
450
3255550
2143.89
981
23330
476.97
981
23333
1426.17
450
23500LT
698.97
450
23505LT
4258.38
450
23620LT
698.97
CDM Number
CDM Description
4010
401030606-30606 PF DRN/INJ INTER JOINT/BURSA W US
4010
401030610-30610 PF ASP/INJ MAJ JOINT/BURSA WO US
4010
401030611-30611 PF DRN/INJ MAJOR JOINT/BURSA W US
4010
401030612-30612 PF ASPIRATE/INJECT GANGLION CYST
4010
401030670-30670 PF REMOVAL OF SUPPORT IMPLANT
4010
401030901-30901 CONTROL NASAL HEMORRH ANT SIMPLE
4010
401030903-30903 CONTROL NASAL HEMORRH ANT COMPLEX
4010
401030950-30950 PF MONITOR INTERST FLD PRESSURE
4010
401031252-31252 PF REP LAC TNGE FLR-MOUTH >2.6CM
4010
401031310-31310 PF CL TX NASAL BONE FX WO MNP
4010
401031315-31315 PF CL TX NASAL BN FX WO STABILIZ
4010
401031440-31440 PF CL TX MAND/MAXIL ALVLR RIDG FX
4010
401031480-31480 PF CL TX TMJ DISLOCATION, INITIAL
4010
401031500-31500 INTUBATION ET BY ED MD (EMERGENT)
4010
401031530-31530 LARYNGOSCOPY W/FB REMOVAL
4010
401031575-31575 DIAGNOSTIC LARYNGOSCOPY
4010
401031577-31577 LARYNGOSCOPY W/REM FOREIGN BODY
4010
401031605-31605 TRACHEOSTOMY EMER,CRICOTHYRD
4010
401032110-32110 PF EXPLORE/REPAIR CHEST
4010
401032555-32555 THORAC ASP PLEURA W IMG GUID, BI
4010
401033330-33330 PF REM FOREIGN BODY SHOULDER, SQ
4010
401033333-33333 PF REMOVE FB SHOULDER, DEEP
4010
401033500-33500 CL TX CLAVICULAR FX WO MANIP, LT
4010
401033505-33505 CL TX CLAVICULAR FX W MANIP, LT
4010
401033620-33620 CL TX GR TUBEROSITY FX WO MNP, LT
Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); with ultrasound guidance, with permanent recording and reporting Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting Aspiration and/or injection of ganglion cyst(s) any location Removal of implant; superficial (eg, buried wire, pin or rod) Control nasal hemorrhage, anterior, simple (limited cautery and/or packing) any method Control nasal hemorrhage, anterior, complex (extensive cautery and/or packing) any method Monitoring of interstitial fluid pressure (includes insertion of device, eg, wick catheter technique, needle manometer technique) in detection of muscle compartment syndrome Repair of laceration of tongue, floor of mouth, over 2.6 cm or complex Closed treatment of nasal bone fracture without manipulation Closed treatment of nasal bone fracture; without stabilization Closed treatment of mandibular or maxillary alveolar ridge fracture Closed treatment of temporomandibular dislocation; initial or subsequent Intubation, endotracheal, emergency procedure Laryngoscopy, direct, operative, with foreign body removal; Laryngoscopy, flexible; diagnostic Laryngoscopy, flexible; with removal of foreign body(s) Tracheostomy, emergency procedure; cricothyroid membrane Thoracotomy; with control of traumatic hemorrhage and/or repair of lung tear Thoracentesis, needle or catheter, aspiration of the pleural space; with imaging guidance Removal of foreign body, shoulder; subcutaneous Removal of foreign body, shoulder; deep (subfascial or intramuscular) Closed treatment of clavicular fracture; without manipulation Closed treatment of clavicular fracture; with manipulation Closed treatment of greater humeral tuberosity fracture; without manipulation
Amount
9 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4010
401033650-33650 PF CL TX SHLDR DISL W MNP WO ANES
4010
401033655-33655 PF CL TX SHLDR DISL W MNP/ANES
4010
401033665-33665 PF CL TX SHLDR DISL W FX GT W MNP
4010
401034200-34200 PF REM FB, UPPER ARM/ELBOW, SQ
4010
401034500-34500 PF CL TX HUMERAL SHAFT FX WO MNP
4010
401034505-34505 PF CL TX HUMERUS FX W MANIP
4010
401034530-34530 CL TX SC/TC HUMERUS FX WO MNP, LT
4010
401034535-34535 PF CL TX SC/TX HUMERUS FX W MNP
4010
401034600-34600 PF CL TX ELBOW DISLOCAT WO ANES
4010
401034605-34605 PF CL TX ELBOW DISLOCATION W ANES
4010
401034640-34640 PF CL TX NURSEMAID ELBOW W MNP
4010
401034650-34650 PF CL TX RADIAL HD/NECK FX WO MNP
4010
401034670-34670 PF CL TX ULNA FX PROX END WO MNP
4010
401035206-35206 REP BLOOD VESSEL, DIRECT, UPR EXT
4010
401035500-35500 PF CL TX RADIAL SHAFT FX WO MNP
4010
401035505-35505 PF CL TX RADIAL SHFT FX W MANIP
4010
401035530-35530 PF CL TX ULNA SHAFT FX WO MANIP
4010
401035535-35535 PF CL TX ULNA SHAFT FX W MANIP
4010
401035565-35565 PF CL TX RAD/ULNA SHAFT FX W MNP
4010
401035600-35600 PF CL TX D RDL FX/EPIPH SEP WO M
4010
401035605-35605 PF CL TX D RDL FX/EPIPH SEP W M
4010
401035622-35622 PF CL TX CARPAL SCAPHOID FX WO M
4010
401035624-35624 CLTX CARPAL SCAPHOID FX W MNP, LT
4010
401035635-35635 CLTX CARPL BN FX W MNP, EA, LT
4010
401035650-35650 CL TX ULNAR STYLOID FX, LT
4010
401035660-35660 CLTX RC/IC DISL 1+ BN W MNP, LT
4010
401035675-35675 CLTX DSTL RADIOULNAR DIS W M, LT
4010
401035690-35690 CL TX LUNATE DISLOC W MANIP, LT
Long Description Closed treatment of shoulder dislocation, with manipulation; without anesthesia Closed treatment of shoulder dislocation, with manipulation; requiring anesthesia Closed treatment of shoulder dislocation, with fracture of greater humeral tuberosity, with manipulation Removal of foreign body, upper arm or elbow area; subcutaneous Closed treatment of humeral shaft fracture; without manipulation Closed treatment of humeral shaft fracture; with manipulation, with or without skeletal traction Closed treatment of supracondylar or transcondylar humeral fracture, with or without intercondylar extension; without manipulation Closed treatment of supracondylar or transcondylar humeral fracture, with or without intercondylar extension; with manipulation, with or without skin or skeletal traction Treatment of closed elbow dislocation; without anesthesia Treatment of closed elbow dislocation; requiring anesthesia Closed treatment of radial head subluxation in child, nursemaid elbow, with manipulation Closed treatment of radial head or neck fracture; without manipulation Closed treatment of ulnar fracture, proximal end (eg, olecranon or coronoid process[es]); without manipulation Repair blood vessel, direct; upper extremity Closed treatment of radial shaft fracture; without manipulation Closed treatment of radial shaft fracture; with manipulation Closed treatment of ulnar shaft fracture; without manipulation Closed treatment of ulnar shaft fracture; with manipulation Closed treatment of radial and ulnar shaft fractures; with manipulation Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; without manipulation Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; with manipulation Closed treatment of carpal scaphoid (navicular) fracture; without manipulation Closed treatment of carpal scaphoid (navicular) fracture; with manipulation Closed treatment of carpal bone fracture (excluding carpal scaphoid [navicular]); with manipulation, each bone Closed treatment of ulnar styloid fracture Closed treatment of radiocarpal or intercarpal dislocation, 1 or more bones, with manipulation Closed treatment of distal radioulnar dislocation with manipulation Closed treatment of lunate dislocation, with manipulation
UB Revenue Code
CPT/HCPCS
981
23650
906.84
981
23655
1263.66
981
23665
1244.70
981
24200
441.90
981
24500
1031.43
981
24505
1410.54
450
24530LT
751.65
981
24535
1771.20
981
24600
1046.16
981
24605
1479.57
981
24640
289.29
981
24650
761.91
981
24670
831.60
450
35206
8724.69
981
25500
794.40
981
25505
1435.80
981
25530
754.20
981
25535
1424.16
981
25565
1475.94
981
25600
986.46
981
25605
1614.12
981
25622
877.98
450
25624LT
4258.38
450
25635LT
4258.38
450
25650LT
698.97
450
25660LT
698.97
450
25675LT
698.97
450
25690LT
4258.38
Amount
10 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4010 4010 4010
401035695-35695 PF OPEN TX LUNATE DISLOCATION 401036010-36010 PF DRAIN FINGER ABSCESS, SIMPLE 401036011-36011 PF DRAIN FINGER ABSC, COMPLICATED
4010
401036075-36075 PF ARTHRO EXPL/REM FB MCP JNT EA
4010
401036418-36418 PF EXTENSOR TENDON REPAIR EACH
4010
401036600-36600 PF CL TX MC FX SGL WO MNP, EA BN
4010
401036605-36605 PF CL TX MC FX SGL W MNP, EA BN
4010
401036608-36608 PERC SKEL FIX MC FX, EA BONE, LT
4010
401036641-36641 CL TX CMC DISLOC THUMB W MNP, LT
4010
401036670-36670 CL TX CMC DISL W MNP EA, WO ANES
4010
401036700-36700 PF CL TX MCP DISLOC SGL W MANIP
4010
401036720-36720 PF CL TX PHAL SHAFT FX WO MNP, EA
4010
401036725-36725 CL TX PHAL SHFT FX W MNP, EA (F2)
4010
401036740-36740 EXCISE BARTHOLIN GL OR CYST (RT)
4010
401036750-36750 PF CL TX D PHAL FX FGR/THMB WO M
4010
401036755-36755 PF CL TX D PHAL FX FGR/THMB W MNP
4010
401036756-36756 SK FIX DSTL PHAL FX FNGR, PRC, F2
4010
401036770-36770 PF CL TX IP JNT DISL W MNP WO ANE
4010
401036775-36775 PF CL TX IP JT DIS W MNP/ANE SNGL
4010
401036776-36776 PF PRC SK FIX IP JNT DISL SGL W M
4010
401037230-37230 CL TX PROX FEM FX WO MANIP,LT
4010
401037250-37250 PF CL TX TRAUMA HIP DISLOC WO ANE
4010
401037252-37252 PF CL TX TRAUMA HIP DISLOC W ANES
4010
401037256-37256 PF TX HIP DISL ABD SPLNT/TRAC WO
4010
401037257-37257 PF TX SPONTAN HIP DISL W MNP/ANES
4010
401037265-37265 PF CL TX POST HIP DISL WO ANES
4010
401037266-37266 CL TX POSTOP HIP DISL W ANES, RT
Long Description Open treatment of lunate dislocation Drainage of finger abscess; simple Drainage of finger abscess; complicated (eg, felon) Arthrotomy, with exploration, drainage, or removal of loose or foreign body; metacarpophalangeal joint, each Repair, extensor tendon, finger, primary or secondary; without free graft, each tendon Closed treatment of metacarpal fracture, single; without manipulation, each bone Closed treatment of metacarpal fracture, single; with manipulation, each bone Percutaneous skeletal fixation of metacarpal fracture, each bone Closed treatment of carpometacarpal dislocation, thumb, with manipulation Closed treatment of carpometacarpal dislocation, other than thumb, with manipulation, each joint; without anesthesia Closed treatment of metacarpophalangeal dislocation, single, with manipulation; without anesthesia Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; without manipulation, each Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; with manipulation, with or without skin or skeletal traction, each Excision of Bartholin's gland or cyst Closed treatment of distal phalangeal fracture, finger or thumb; without manipulation, each Closed treatment of distal phalangeal fracture, finger or thumb; with manipulation, each Percutaneous skeletal fixation of distal phalangeal fracture, finger or thumb, each Closed treatment of interphalangeal joint dislocation, single, with manipulation; without anesthesia Closed treatment of interphalangeal joint dislocation, single, with manipulation; requiring anesthesia Percutaneous skeletal fixation of interphalangeal joint dislocation, single, with manipulation Closed treatment of femoral fracture, proximal end, neck; without manipulation Closed treatment of hip dislocation, traumatic; without anesthesia Closed treatment of hip dislocation, traumatic; requiring anesthesia Treatment of spontaneous hip dislocation (developmental, including congenital or pathological), by abduction, splint or traction; without anesthesia, without manipulation Treatment of spontaneous hip dislocation (developmental, including congenital or pathological), by abduction, splint or traction; with manipulation, requiring anesthesia Closed treatment of post hip arthroplasty dislocation; without anesthesia Closed treatment of post hip arthroplasty dislocation; requiring regional or general anesthesia
UB Revenue Code 981 981 981
CPT/HCPCS
Amount
25695 26010 26011
1984.23 435.93 581.58
981
26075
1049.01
981
26418
1821.09
981
26600
879.33
981
26605
926.85
450
26608LT
8529.03
450
26641LT
698.97
981
26670
965.19
981
26700
950.58
981
26720
584.58
450
26725F2
698.97
450
56740RT
7954.80
981
26750
584.79
981
26755
858.39
450
26756F2
8529.03
981
26770
801.57
981
26775
1091.34
981
26776
1396.29
450
27230LT
752.16
981
27250
550.53
981
27252
2356.35
981
27256
723.09
981
27257
1134.93
981
27265
1249.08
450
27266RT
4258.38
11 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4010
401037369-37369 PF KNEE ARTHROGRAPHY INJECTION
4010
401037500-37500 CL TX FEMORAL SHAFT FX WO MNP, LT
4010
401037502-37502 PF CL TX FEMORAL SHAFT FX W MNP
4010
401037510-37510 PF CL TX FEMUR FX OR EPIPHYS SEP
4010
401037530-37530 PF CL TX TIBIAL FX, PROX, WO MNP
4010
401037550-37550 PF CL TX KNEE DISLOCATION WO ANES
4010
401037552-37552 CL TX KNEE DISLOC W ANES, LT
4010
401037560-37560 PF CL TX PATELLA DISL WO ANES
4010
401037562-37562 PF CL TX PATELLA DISLOCAT W ANES
4010
401037750-37750 PF CL TX TIBIAL SHAFT FX WO MNP
4010
401037752-37752 PF CL TX TIBIAL SHAFT FX W MNP
4010
401037760-37760 PF CL TX MEDIAL ANKLE FX WO MANIP
4010
401037781-37781 PF CL TX PROX FIB/SHAFT FX W MNP
4010
401037786-37786 PF CL TX DSTL FIBULAR FX WO MNP
4010
401037788-37788 PF CL TX DISTL FIBULAR FX W MNP
4010
401037808-37808 PF CLTX BIMALL ANKLE FX WO MNP
4010
401037810-37810 PF CLTX BIMALLEOLAR ANK FX W MNP
4010
401037816-37816 PF CL TX TRIMALL ANKLE FX WO MNP
4010
401037818-37818 CL TX TRIMALL ANKLE FX W MNP, LT
4010
401037825-37825 PF CL TX WB DSTL TIB FX W MNP
4010
401037840-37840 PF CL TX ANKLE DISLOCAT WO ANES
4010
401037842-37842 PF CL TX ANKLE DISLOC W ANESTH
4010
401038430-38430 CL TX TALUS FX WO MANIP, LT
4010
401038435-38435 PF CL TX TALUS FX, W MANIP
4010
401038450-38450 PF TX TARSAL BONE FX WO MNP, EACH
4010
401038470-38470 PF CL TX METATARSAL FX WO MNP, EA
Long Description Injection procedure for contrast knee arthrography or contrast enhanced CT/MRI knee arthrography Closed treatment of femoral shaft fracture, without manipulation Closed treatment of femoral shaft fracture, with manipulation, with or without skin or skeletal traction Closed treatment of femoral fracture, distal end, medial or lateral condyle, with manipulation Closed treatment of tibial fracture, proximal (plateau); without manipulation Closed treatment of knee dislocation; without anesthesia Closed treatment of knee dislocation; requiring anesthesia Closed treatment of patellar dislocation; without anesthesia Closed treatment of patellar dislocation; requiring anesthesia Closed treatment of tibial shaft fracture (with or without fibular fracture); without manipulation Closed treatment of tibial shaft fracture (with or without fibular fracture); with manipulation, with or without skeletal traction Closed treatment of medial malleolus fracture; without manipulation Closed treatment of proximal fibula or shaft fracture; with manipulation Closed treatment of distal fibular fracture (lateral malleolus); without manipulation Closed treatment of distal fibular fracture (lateral malleolus); with manipulation Closed treatment of bimalleolar ankle fracture (eg, lateral and medial malleoli, or lateral and posterior malleoli, or medial and posterior malleoli); without manipulation Closed treatment of bimalleolar ankle fracture (eg, lateral and medial malleoli, or lateral and posterior malleoli, or medial and posterior malleoli); with manipulation Closed treatment of trimalleolar ankle fracture; without manipulation Closed treatment of trimalleolar ankle fracture; with manipulation Closed treatment of fracture of weight bearing articular portion of distal tibia (eg, pilon or tibial plafond), with or without anesthesia; with skeletal traction and/or requiring manipulation Closed treatment of ankle dislocation; without anesthesia Closed treatment of ankle dislocation; requiring anesthesia, with or without percutaneous skeletal fixation Closed treatment of talus fracture; without manipulation Closed treatment of talus fracture; with manipulation Treatment of tarsal bone fracture (except talus and calcaneus); without manipulation, each Closed treatment of metatarsal fracture; without manipulation, each
UB Revenue Code
CPT/HCPCS
981
27369
126.75
450
27500LT
752.13
981
27502
2392.02
981
27510
2137.35
981
27530
891.39
981
27550
1472.82
450
27552LT
4258.38
981
27560
1054.71
981
27562
1474.29
981
27750
1006.08
981
27752
1559.16
981
27760
965.76
981
27781
1234.14
981
27786
907.32
981
27788
1213.11
981
27808
948.06
981
27810
1323.06
981
27816
911.16
450
27818LT
4258.38
981
27825
1548.75
981
27840
1160.85
981
27842
1559.19
450
28430LT
752.13
981
28435
908.37
981
28450
609.93
981
28470
656.94
Amount
12 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
Long Description
UB Revenue Code
CPT/HCPCS
Amount
4010
401038510-38510 PF CL TX FX PHALNX/PHALANG WO MNP
Closed treatment of fracture, phalanx or phalanges, other than great toe; without manipulation, each
981
28510
389.07
4010
401038515-38515 PF CL TX FX PHALANX W MNP, EA
Closed treatment of fracture, phalanx or phalanges, other than great toe; with manipulation, each
981
28515
455.94
4010
401038540-38540 CL TX TARSAL BN DISL WO ANES, LT
450
28540LT
752.16
4010
401038570-38570 PF CLTX TALOTARSAL JNT DIS WO ANE
981
28570
490.68
4010
401038630-38630 PF CL TX MTP JNT DISL WO ANES
981
28630
348.60
4010
401038660-38660 PF CL TX IP JOINT DISL WO ANESTH
981
28660
278.43
4010
401038665-38665 PF CL TX IP JOINT DISL, W ANESTH
981
28665
417.33
4010
401039105-39105 APPLICATION LONG ARM SPLINT, LEFT
450
29105LT
437.76
4010
401039125-39125 PF APPLY SHORT ARM SPLINT, STATIC
981
29125
125.25
4010
401039126-39126 PF APPLY SHRT ARM SPLINT, DYNAMIC
981
29126
154.32
4010 4010 4010 4010
401039130-39130 401039131-39131 401039240-39240 401039280-39280
981 981 981 450
29130 29131 29240 29280LT
89.19 102.84 58.41 111.30
4010
401039425-39425 PF APPLY WLKR SHORT LEG CAST
981
29425
179.58
4010
401039452-39452 REPLACE G-J TUBE PERC
450
49452
2602.23
4010
401039505-39505 APPLY LONG LEG SPLINT-RT
Application of long leg splint (thigh to ankle or toes)
450
29505RT
437.76
4010 4010 4010
401039515-39515 PF APPLY SHORT LEG SPLINT 401039530-39530 PF KNEE STRAPPING 401039540-39540 PF ANKLE/FOOT STRAPPING
981 981 981
29515 29530 29540
156.69 57.93 56.79
4010
401040000-40000 PF DRN ABSC/HEMATOMA NASAL, INT
981
30000
375.87
4010
401040300-40300 PF REM FOREIGN BODY, INTRANASAL
981
30300
339.54
4010
401040901-40901 PF CNTRL NASAL HEMORRH ANT SMPL
981
30901
175.68
4010
401040903-40903 PF CONTRL NASAL HEMORRH ANT CMPLX
Application of short leg splint (calf to foot) Strapping; knee Strapping; ankle and/or foot Drainage abscess or hematoma, nasal, internal approach Removal foreign body, intranasal; office type procedure Control nasal hemorrhage, anterior, simple (limited cautery and/or packing) any method Control nasal hemorrhage, anterior, complex (extensive cautery and/or packing) any method
981
30903
248.13
4010
401040905-40905 PF CNTRL NASAL HEMORR, POST, INIT
981
30905
333.21
4010
401041250-41250 REP LAC <=2.5CM FLR-MTH/ANT 2/3
450
41250
922.08
4010
401041500-41500 PF INTUBATION ENDOTRACHEAL, EMERG
Repair of laceration 2.5 cm or less; floor of mouth and/or anterior two-thirds of tongue Intubation, endotracheal, emergency procedure
981
31500
340.80
4010
401041511-41511 PF LARYNGOSCOPY IND W REM OF FB
Laryngoscopy, indirect; with removal of foreign body
981
31511
404.88
4010
401041530-41530 PF LARYNGOSCOPY W/FB REMOVAL
Laryngoscopy, direct, operative, with foreign body removal;
981
31530
618.57
4010
401041603-41603 PF TRACHEOSTOMY EMER, TRANSTRACHL
Tracheostomy, emergency procedure; transtracheal
981
31603
696.03
4010
401041605-41605 PF TRACHEOSTOMY EMER, CRICOTHYRD
981
31605
564.57
4010
401041805-41805 REM DENTOALV EMB FB, SOFT TISS
450
41805
3983.67
4010 4010 4010 4010
401041899-41899 401042000-42000 401042100-42100 401042160-42160
450 450 981 981
41899 42000 32100 32160
619.44 624.75 2485.05 2449.95
PF APPLY FINGER SPLINT, STATIC PF APPLY FINGER SPLINT, DYNAMIC PF STRAPPING, SHOULDER STRAPPING, HAND OR FINGER, LT
UNLIST PX DENTOALVEOLAR STRUCT DRAIN ABSC PALATE UVULA PF THORACOTOMY W EXPLORATION PF THORACOTOMY W CARDIAC MASSAGE
Closed treatment of tarsal bone dislocation, other than talotarsal; without anesthesia Closed treatment of talotarsal joint dislocation; without anesthesia Closed treatment of metatarsophalangeal joint dislocation; without anesthesia Closed treatment of interphalangeal joint dislocation; without anesthesia Closed treatment of interphalangeal joint dislocation; requiring anesthesia Application of long arm splint (shoulder to hand) Application of short arm splint (forearm to hand); static Application of short arm splint (forearm to hand); dynamic Application of finger splint; static Application of finger splint; dynamic Strapping; shoulder (eg, Velpeau) Strapping; hand or finger Application of short leg cast (below knee to toes); walking or ambulatory type Replacement of gastro-jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report
Control nasal hemorrhage, posterior, with posterior nasal packs and/or cautery, any method; initial
Tracheostomy, emergency procedure; cricothyroid membrane Removal of embedded foreign body from dentoalveolar structures; soft tissues Unlisted procedure, dentoalveolar structures Drainage of abscess of palate, uvula Thoracotomy; with exploration Thoracotomy; with cardiac massage
13 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4010
401042551-42551 PF INSERTION OF CHEST TUBE
4010
401042555-42555 THORACENT ASP PLEURA W IMG GUID
4010
401043010-43010 PF PERICARDIOCENTESIS, INITIAL
4010
401043210-43210 PF INS TEMP ELECTRD/PM CATH, SNGL
4010
401043500-43500 CL TX CLAVICULAR FX WO MANIP, RT
4010
401043505-43505 CL TX CLAVICULAR FX W MANIP, RT
4010
401043620-43620 CL TX GR TUBEROSITY FX WO MNP, RT
4010
401043650-43650 CL TX SHLDR DISL W MNP WO ANE, RT
4010
401043655-43655 CL TX SHLDR DISL W MNP/ANES, RT
4010
401043665-43665 CL TX SHLDR DISL & FX GT W M, RT
4010
401043762-43762 REPLACE G-TUBE WO TRACT REVISION
4010
401044500-44500 CL TX HUMERAL SHAFT FX WO MNP, RT
4010
401044530-44530 CL TX SC/TC HUMERUS FX WO MNP, RT
4010
401044605-44605 CL TX ELBOW DISLOCAT W ANES, RT
4010
401044640-44640 CL TX NURSEMAID ELBOW W MNP, RT
4010
401045005-45005 I&D OF SUBMUCOSAL ABSCESS, RECTUM
4010
401045332-45332 SIGMOIDOSCOPY W FB REMOVAL
4010
401045500-45500 CL TX RADIAL SHAFT FX WO MNP, RT
4010
401045505-45505 CL TX RADIAL SHAFT FX W MANIP, RT
4010
401045535-45535 CL TX ULNAR SHFT FX W MANIP, RT
4010
401045565-45565 CL TX RAD/ULNA SHAFT FX W MNP, RT
4010
401045600-45600 CLTX D RAD FX/EPIPHYS SEP WO M,RT
4010
401045605-45605 CLTX D RAD FX/EPIPHYS SEP W M, RT
4010
401045624-45624 CLTX CARPAL SCAPHOID FX W MNP, RT
4010
401045635-45635 CLTX CARPL BN FX W MNP, EA, RT
4010
401045650-45650 CL TX ULNAR STYLOID FX, RT
4010
401045660-45660 CLTX RC/IC DISL 1+ BN W MNP, RT
Long Description
UB Revenue Code
CPT/HCPCS
Tube thoracostomy, includes connection to drainage system (eg, water seal), when performed, open
981
32551
528.36
450
32555
2143.89
981
33010
327.81
981
33210
551.28
450
23500RT
698.97
450
23505RT
4258.38
450
23620RT
698.97
450
23650RT
526.51
450
23655RT
4258.38
450
23665RT
4258.38
450
43762
798.39
450
24500RT
698.97
450
24530RT
751.65
450
24605RT
4258.38
450
24640RT
698.97
450
45005
3069.75
450
45332
3277.41
450
25500RT
698.97
450
25505RT
4258.38
450
25535RT
698.97
450
25565RT
1571.27
450
25600RT
698.97
450
25605RT
4258.38
450
25624RT
4258.38
450
25635RT
4258.38
450
25650RT
698.97
450
25660RT
698.97
Thoracentesis, needle or catheter, aspiration of the pleural space; with imaging guidance Pericardiocentesis; initial Insertion or replacement of temporary transvenous single chamber cardiac electrode or pacemaker catheter Closed treatment of clavicular fracture; without manipulation Closed treatment of clavicular fracture; with manipulation Closed treatment of greater humeral tuberosity fracture; without manipulation Closed treatment of shoulder dislocation, with manipulation; without anesthesia Closed treatment of shoulder dislocation, with manipulation; requiring anesthesia Closed treatment of shoulder dislocation, with fracture of greater humeral tuberosity, with manipulation Replacement of gastrostomy tube, percutaneous, includes removal, when performed, without imaging or endoscopic guidance; not requiring revision of gastrostomy tract Closed treatment of humeral shaft fracture; without manipulation Closed treatment of supracondylar or transcondylar humeral fracture, with or without intercondylar extension; without manipulation Treatment of closed elbow dislocation; requiring anesthesia Closed treatment of radial head subluxation in child, nursemaid elbow, with manipulation Incision and drainage of submucosal abscess, rectum Sigmoidoscopy, flexible; with removal of foreign body(s) Closed treatment of radial shaft fracture; without manipulation Closed treatment of radial shaft fracture; with manipulation Closed treatment of ulnar shaft fracture; with manipulation Closed treatment of radial and ulnar shaft fractures; with manipulation Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; without manipulation Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; with manipulation Closed treatment of carpal scaphoid (navicular) fracture; with manipulation Closed treatment of carpal bone fracture (excluding carpal scaphoid [navicular]); with manipulation, each bone Closed treatment of ulnar styloid fracture Closed treatment of radiocarpal or intercarpal dislocation, 1 or more bones, with manipulation
Amount
14 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4010
401045675-45675 CLTX DSTL RADIOULNAR DIS W M, RT
4010
401045690-45690 CL TX LUNATE DISLOC W MANIP, RT
4010
401045900-45900 REDUCT OF PROCIDENTIA W ANESTH
4010
401045915-45915 REM FECAL IMPACTION/FB W ANES
4010
401046083-46083 INCISE THROMBOSED HEMORRHOID EXT
4010
401046555-46555 PF INS NON-TUNNEL CVC <5YR
4010
401046556-46556 PF INS NON-TUNNEL CVC =>5YR
4010
401046557-46557 PF INS TUNNEL CVC WO SQ PORT <5YR
4010
401046558-46558 PF INS TUNNEL CVC WO PORT =>5YR
4010
401046568-46568 PF INS PICC WO SQ PORT <5YR
4010
401046569-46569 PF INSERT PICC WO PORT/PUMP =>5YR
4010
401046600-46600 DIAGNOSTIC ANOSCOPY SPX
4010
401046608-46608 PERC SKEL FIX MC FX, EA BONE, RT
4010
401046620-46620 PF ART CATH-SMPL/MNTR/TRNSFUS,PRC
4010
401046641-46641 CL TX CMC DISLOC THUMB W MNP, RT
4010
401046680-46680 PF PLACE NDL INTRAOSSEOUS INFUS
4010
401046725-46725 CL TX PHAL SHFT FX W MNP, EA (F3)
4010
401046740-46740 EXCISE BARTHOLIN GL OR CYST (LT)
4010
401046750-46750 CLTX D PHAL FX FGR/THMB WO M (F3)
4010
401046755-46755 CLTX D PHAL FX FGR/THMB W M (F3)
4010
401046756-46756 SK FIX DSTL PHAL FX FNGR, PRC, F3
4010
401046770-46770 CLTX IP JNT DISL W M WO ANE (F3)
4010
401046775-46775 CLTX IP JT DISL W M/ANE SGL (F3)
4010
401046776-46776 SK FIX IP JT DISL SGL W M PC (F3)
4010
401047230-47230 CL TX PROX FEM FX WO MANIP,BIL
4010
401047250-47250 CL TX TRAUMA HIP DISL WO ANES, LT
4010
401047252-47252 CL TX TRAUMA HIP DISL W ANES, RT
Long Description Closed treatment of distal radioulnar dislocation with manipulation Closed treatment of lunate dislocation, with manipulation Reduction of procidentia under anesthesia Removal of fecal impaction or foreign body under anesthesia Incision of thrombosed hemorrhoid, external Insertion of non-tunneled centrally inserted central venous catheter; younger than 5 years of age Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older Insertion of tunneled centrally inserted central venous catheter, without subcutaneous port or pump; younger than 5 years of age Insertion of tunneled centrally inserted central venous catheter, without subcutaneous port or pump; age 5 years or older Insertion of peripherally inserted central venous catheter (PICC), without subcutaneous port or pump, without imaging guidance; younger than 5 years of age Insertion of peripherally inserted central venous catheter (PICC), without subcutaneous port or pump, without imaging guidance; age 5 years or older Anoscopy; diagnostic, including collection of specimen(s) by brushing or washing, when performed Percutaneous skeletal fixation of metacarpal fracture, each bone Arterial catheterization or cannulation for sampling, monitoring or transfusion; percutaneous Closed treatment of carpometacarpal dislocation, thumb, with manipulation Placement of needle for intraosseous infusion Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; with manipulation, with or without skin or skeletal traction, each Excision of Bartholin's gland or cyst Closed treatment of distal phalangeal fracture, finger or thumb; without manipulation, each Closed treatment of distal phalangeal fracture, finger or thumb; with manipulation, each Percutaneous skeletal fixation of distal phalangeal fracture, finger or thumb, each Closed treatment of interphalangeal joint dislocation, single, with manipulation; without anesthesia Closed treatment of interphalangeal joint dislocation, single, with manipulation; requiring anesthesia Percutaneous skeletal fixation of interphalangeal joint dislocation, single, with manipulation Closed treatment of femoral fracture, proximal end, neck; without manipulation Closed treatment of hip dislocation, traumatic; without anesthesia Closed treatment of hip dislocation, traumatic; requiring anesthesia
UB Revenue Code
CPT/HCPCS
450
25675RT
698.97
450
25690RT
4258.38
450
45900
2484.96
450
45915
3277.41
450
46083
803.37
981
36555
370.53
981
36556
377.70
981
36557
1024.77
981
36558
876.03
981
36568
307.56
981
36569
290.01
450
46600
349.86
450
26608RT
8529.03
981
36620
159.51
450
26641RT
698.97
981
36680
181.17
450
26725F3
698.97
450
56740LT
7954.80
450
26750F3
698.97
450
26755F3
698.97
450
26756F3
8529.03
450
26770F3
698.97
450
26775F3
772.17
450
26776F3
8529.03
450
2723050
752.16
450
27250LT
752.16
450
27252RT
4258.38
Amount
15 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
Long Description
4010
401047257-47257 TX SPONTAN HIP DISL W MNP/ANE, RT
Treatment of spontaneous hip dislocation (developmental, including congenital or pathological), by abduction, splint or traction; with manipulation, requiring anesthesia
4010
401047266-47266 CL TX POSTOP HIP DISL W ANES, LT
Closed treatment of post hip arthroplasty dislocation; requiring regional or general anesthesia
4010
401047500-47500 CL TX FEMORAL SHAFT FX WO MNP, RT
4010
401047502-47502 CL TX FEMORAL SHAFT FX W MNP, RT
4010
401047510-47510 CLTX FEMUR FX/EPIPHYS SEP W M, RT
4010
401047530-47530 CL TX PROX TIBIAL FX WO MNP, RT
4010
401047552-47552 CL TX KNEE DISLOC W ANES, RT
4010
401047560-47560 CL TX PATELLA DISL WO ANES, LT
4010
401047562-47562 CL TX PATELLA DISLOC W ANES, RT
4010 4010
401047565-47565 PF LIGATION INTERNAL JUGULAR VEIN 401047605-47605 PF LIGAT, INT/COMM CAROTID ARTERY
4010
401047752-47752 CL TX TIBIAL SHAFT FX W MNP, RT
4010
401047781-47781 CL TX PROX FIB/SHAFT FX W MNP, LT
4010
401047786-47786 CL TX DSTL FIBULAR FX WO MNP, RT
4010
401047788-47788 CLTX DSTL FIBULAR FX W MNP, RT
4010
401047808-47808 CLTX BIMALLEOLAR ANK FX WO M, RT
4010
401047810-47810 CLTX BIMALLEOLAR ANK FX W MNP, RT
4010
401047818-47818 CL TX TRIMALL ANKLE FX W MNP, RT
4010
401047825-47825 CL TX WB DSTL TIBIA FX W MNP, RT
4010
401047840-47840 CL TX ANKLE DISLOC WO ANES, RT
4010
401047842-47842 CL TX ANKLE DICLOC W ANES, RT
4010
401048430-48430 CL TX TALUS FX WO MANIP, RT
4010
401048490-48490 PF CL TX FX GT PHALANX(S) WO MNP
4010
401048540-48540 CL TX TARSAL BN DISL WO ANES, RT
4010
401049105-49105 APPLY LONG ARM SPLINT, RT
4010
401049125-49125 APPLY SHORT ARM SPLNT, STATIC, RT
4010 4010
401049130-49130 APPLY FINGER SPLINT, STATIC (F3) 401049280-49280 STRAPPING, HAND OR FINGER, RT
Closed treatment of femoral shaft fracture, without manipulation Closed treatment of femoral shaft fracture, with manipulation, with or without skin or skeletal traction Closed treatment of femoral fracture, distal end, medial or lateral condyle, with manipulation Closed treatment of tibial fracture, proximal (plateau); without manipulation Closed treatment of knee dislocation; requiring anesthesia Closed treatment of patellar dislocation; without anesthesia Closed treatment of patellar dislocation; requiring anesthesia Ligation, internal jugular vein Ligation; internal or common carotid artery Closed treatment of tibial shaft fracture (with or without fibular fracture); with manipulation, with or without skeletal traction Closed treatment of proximal fibula or shaft fracture; with manipulation Closed treatment of distal fibular fracture (lateral malleolus); without manipulation Closed treatment of distal fibular fracture (lateral malleolus); with manipulation Closed treatment of bimalleolar ankle fracture (eg, lateral and medial malleoli, or lateral and posterior malleoli, or medial and posterior malleoli); without manipulation Closed treatment of bimalleolar ankle fracture (eg, lateral and medial malleoli, or lateral and posterior malleoli, or medial and posterior malleoli); with manipulation Closed treatment of trimalleolar ankle fracture; with manipulation Closed treatment of fracture of weight bearing articular portion of distal tibia (eg, pilon or tibial plafond), with or without anesthesia; with skeletal traction and/or requiring manipulation Closed treatment of ankle dislocation; without anesthesia Closed treatment of ankle dislocation; requiring anesthesia, with or without percutaneous skeletal fixation Closed treatment of talus fracture; without manipulation Closed treatment of fracture great toe, phalanx or phalanges; without manipulation Closed treatment of tarsal bone dislocation, other than talotarsal; without anesthesia Application of long arm splint (shoulder to hand) Application of short arm splint (forearm to hand); static Application of finger splint; static Strapping; hand or finger
UB Revenue Code
CPT/HCPCS
450
27257RT
4258.38
450
27266LT
4258.38
450
27500RT
752.13
450
27502RT
4258.38
450
27510RT
4258.38
450
27530RT
698.97
450
27552RT
4258.38
450
27560LT
752.16
450
27562RT
698.97
981 981
37565 37605
2284.95 2486.25
450
27752RT
4258.38
450
27781LT
4261.02
450
27786RT
698.97
450
27788RT
698.97
450
27808RT
698.97
450
27810RT
3883.80
450
27818RT
4258.38
450
27825RT
4258.38
450
27840RT
698.97
450
27842RT
4258.38
450
28430RT
752.13
981
28490
401.40
450
28540RT
752.16
450
29105RT
437.76
450
29125RT
349.86
450 450
29130 29280RT
190.80 111.30
Amount
16 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
Long Description Replacement of gastrostomy or cecostomy (or other colonic) tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report Replacement of gastro-jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report
UB Revenue Code
CPT/HCPCS
450
49450
2602.23
981
49452
437.43
Amount
4010
401049450-49450 REP G/C TUBE PRC W FLUORO GUID
4010
401049452-49452 PF REPLACE G-J TUBE PERC
4010
401049505-49505 APPLY LONG LEG SPLINT-LT
Application of long leg splint (thigh to ankle or toes)
450
29505LT
437.76
4010
401049515-49515 APPLY SHORT LEG SPLINT, RT
450
29515RT
437.76
4010
401050800-50800 PF DR ABSC/CYST/HEMAT-MOUTH, SMPL
981
40800
433.65
4010
401050901-50901 CNTRL NASAL HEMOR ANT SMPL, BILAT
450
3090150
349.86
4010
401051250-51250 REP LAC FLR MTH/ANT 2/3, =<2.5CM
981
41250
492.90
4010
401051705-51705 CHANGE CYSTOSTOMY TUBE, SIMPLE
450
51705
803.37
4010
401051800-51800 PF DRN ABSC/CYST/HEMAT, DENTOALV
981
41800
484.35
4010 4010 4010 4010 4010
401051899-51899 401052000-52000 401052700-52700 401052809-52809 401053499-53499
981 981 981 981 981
41899 42000 42700 42809 43499
558.99 324.96 438.48 390.60 449.13
4010
401053500-53500 PF CL TX CLAVICULAR FX WO MANIP
Application of short leg splint (calf to foot) Drainage of abscess, cyst, hematoma, vestibule of mouth; simple Control nasal hemorrhage, anterior, simple (limited cautery and/or packing) any method Repair of laceration 2.5 cm or less; floor of mouth and/or anterior two-thirds of tongue Change of cystostomy tube; simple Drainage of abscess, cyst, hematoma from dentoalveolar structures Unlisted procedure, dentoalveolar structures Drainage of abscess of palate, uvula Incision and drainage abscess; peritonsillar Removal of foreign body from pharynx Unlisted procedure, esophagus Closed treatment of clavicular fracture; without manipulation
981
23500
700.77
401053752-53752 PF NASO/ORO-GASTRIC TUBE PLMT
Naso- or oro-gastric tube placement, requiring physician's skill and fluoroscopic guidance (includes fluoroscopy, image documentation and report)
981
43752
128.25
401053753-53753 PF TX GASTRO INTUBATION W ASP
Gastric intubation and aspiration(s) therapeutic, necessitating physician's skill (eg, for gastrointestinal hemorrhage), including lavage if performed
981
43753
67.83
981
43762
116.55
450
54220
802.80
450
54450
755.67
981
24500
1027.23
981
24530
1082.94
981
25560
793.08
981
25635
1183.89
981
25660
1292.31
981
25675
1235.46
981
25680
1633.23
981
25690
1481.94
981
45900
653.16
981
45915
717.81
981
46050
307.77
4010
4010
PF UNLIST PX DENTOALVEOLAR STRUCT PF DRAIN ABSC PALATE UVULA PF I&D ABSCESS, PERITONSILLAR PF REM FOREIGN BODY PHARYNX PF UNLISTED PROCEDURE ESOPHAGUS
4010
401053762-53762 PF REPLACE GTUBE WO TRACT REVIS
4010
401054220-54220 IRRIG CORPORA CAVERNOSA PRIAPISM
4010
401054450-54450 FORESKIN MANIPULATION
4010
401054500-54500 PF CLTX HUMERAL SHAFT FX WO MNP
4010
401054530-54530 PF CL TX SC/TC HUMERUS FX WO MNP
4010
401055560-55560 PF CL TX RAD+ULNA SHFT FX WO MNP
4010
401055635-55635 PF CLTX CARPL BN FX W MNP, EA
4010
401055660-55660 PF CLTX RC/IC DISL 1+ BN W MNP
4010
401055675-55675 PF CLTX DSTL RADIOULNAR DISL W M
4010
401055680-55680 PF CL TX TRANS-SPL FX DISL W MNP
4010
401055690-55690 PF CL TX LUNATE DISLOC W MANIP
4010
401055900-55900 PF REDUCT OF PROCIDENTIA W ANESTH
4010
401055915-55915 PF REM FECAL IMPACTION/FB W ANES
4010
401056050-56050 PF I&D PERIANAL ABSC, SUPERFICIAL
Replacement of gastrostomy tube, percutaneous, includes removal, when performed, without imaging or endoscopic guidance; not requiring revision of gastrostomy tract Irrigation of corpora cavernosa for priapism Foreskin manipulation including lysis of preputial adhesions and stretching Closed treatment of humeral shaft fracture; without manipulation Closed treatment of supracondylar or transcondylar humeral fracture, with or without intercondylar extension; without manipulation Closed treatment of radial and ulnar shaft fractures; without manipulation Closed treatment of carpal bone fracture (excluding carpal scaphoid [navicular]); with manipulation, each bone Closed treatment of radiocarpal or intercarpal dislocation, 1 or more bones, with manipulation Closed treatment of distal radioulnar dislocation with manipulation Closed treatment of trans-scaphoperilunar type of fracture dislocation, with manipulation Closed treatment of lunate dislocation, with manipulation Reduction of procidentia under anesthesia Removal of fecal impaction or foreign body under anesthesia Incision and drainage, perianal abscess, superficial
17 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4010 4010 4010
401056083-56083 PF INC THROMBOSED HEMORRHOID EXT 401056320-56320 PF REM HEMORRHOID CLOT, EXTERNAL 401056405-56405 I&D OF VULVA OR PERINEAL ABSCESS
4010
401056600-56600 PF DIAGNOSTIC ANOSCOPY SPX
4010
401056641-56641 PF CL TX CMC DISLOC THUMB W MNP
4010
401056725-56725 CL TX PHAL SHFT FX W MNP, EA (F4)
4010
401056740-56740 EXCISE BARTHOLIN'S GLAND OR CYST
4010
401056750-56750 CLTX D PHAL FX FGR/THMB WO M (F4)
4010
401056755-56755 CLTX D PHAL FX FGR/THMB W M (F4)
4010
401056756-56756 SK FIX DSTL PHAL FX FNGR, PRC, F4
4010
401056770-56770 CLTX IP JNT DISL W M WO ANE (F4)
4010
401056775-56775 CLTX IP JT DISL W M/ANE SGL (F4)
4010
401056776-56776 SK FIX IP JT DISL SGL W M PC (F4)
4010
401057230-57230 PF CL TX PROX FEM FX WO MANIP
4010
401057250-57250 CL TX TRAUMA HIP DISL WO ANES, RT
4010
401057310-57310 PF ARTHRO KNEE EXPL DRN/REM FB
4010
401057500-57500 PF CL TX FEMORAL SHAFT FX WO MNP
4010
401057530-57530 PF CL TX PROX TIBIAL FX WO MNP
4010
401057560-57560 CL TX PATELLA DISL WO ANES, RT
4010
401057781-57781 CL TX PROX FIB/SHAFT FX W MNP, RT
4010
401057810-57810 CLTX BIMALLEOLAR ANK FX W MNP, LT
4010
401057818-57818 PF CL TX TRIMALL ANKLE FX W MNP
4010 4010
401058190-58190 PF REMOVE FOREIGN BODY, FOOT, SQ 401058301-58301 REMOVE IUD
4010
401058430-58430 PF CL TX TALUS FX WO MANIP
4010
401058540-58540 PF CL TX TARSAL BN DISL WO ANES
4010
401059082-59082 PF ABDOMINAL PARACENTESIS WO IMG
4010
401059083-59083 PF ABD PARACENTESIS W IMG GUIDE
4010 4010 4010
401059105-59105 PF APPLY LONG ARM SPLINT 401059130-59130 APPLY FINGER SPLINT, STATIC (F4) 401059280-59280 PF STRAPPING, HAND OR FINGER
4010
401059450-59450 PF REP G/C TUBE PRC W FLUORO GUID
Long Description Incision of thrombosed hemorrhoid, external Excision of thrombosed hemorrhoid, external Incision and drainage of vulva or perineal abscess Anoscopy; diagnostic, including collection of specimen(s) by brushing or washing, when performed Closed treatment of carpometacarpal dislocation, thumb, with manipulation Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; with manipulation, with or without skin or skeletal traction, each Excision of Bartholin's gland or cyst Closed treatment of distal phalangeal fracture, finger or thumb; without manipulation, each Closed treatment of distal phalangeal fracture, finger or thumb; with manipulation, each Percutaneous skeletal fixation of distal phalangeal fracture, finger or thumb, each Closed treatment of interphalangeal joint dislocation, single, with manipulation; without anesthesia Closed treatment of interphalangeal joint dislocation, single, with manipulation; requiring anesthesia Percutaneous skeletal fixation of interphalangeal joint dislocation, single, with manipulation Closed treatment of femoral fracture, proximal end, neck; without manipulation Closed treatment of hip dislocation, traumatic; without anesthesia Arthrotomy, knee, with exploration, drainage, or removal of foreign body (eg, infection) Closed treatment of femoral shaft fracture, without manipulation Closed treatment of tibial fracture, proximal (plateau); without manipulation Closed treatment of patellar dislocation; without anesthesia Closed treatment of proximal fibula or shaft fracture; with manipulation Closed treatment of bimalleolar ankle fracture (eg, lateral and medial malleoli, or lateral and posterior malleoli, or medial and posterior malleoli); with manipulation Closed treatment of trimalleolar ankle fracture; with manipulation Removal of foreign body, foot; subcutaneous Removal of intrauterine device (IUD) Closed treatment of talus fracture; without manipulation Closed treatment of tarsal bone dislocation, other than talotarsal; without anesthesia Abdominal paracentesis (diagnostic or therapeutic); without imaging guidance Abdominal paracentesis (diagnostic or therapeutic); with imaging guidance Application of long arm splint (shoulder to hand) Application of finger splint; static Strapping; hand or finger Replacement of gastrostomy or cecostomy (or other colonic) tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report
UB Revenue Code 981 981 450
CPT/HCPCS
Amount
46083 46320 56405
336.48 347.52 938.58
981
46600
129.27
981
26641
1072.56
450
26725F4
698.97
450
56740
7954.80
450
26750F4
698.97
450
26755F4
698.97
450
26756F4
8529.03
450
26770F4
698.97
450
26775F4
772.17
450
26776F4
8529.03
981
27230
1479.18
450
27250RT
752.16
981
27310
2279.25
981
27500
1500.57
981
27530
886.11
450
27560RT
752.16
450
27781RT
4261.02
450
27810LT
3883.80
981
27818
1354.86
981 450
28190 58301
426.27 562.47
981
28430
665.43
981
28540
558.33
981
49082
235.35
981
49083
346.20
981 450 981
29105 29130 29280
186.93 190.80 63.45
981
49450
209.25
18 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
Long Description
UB Revenue Code
CPT/HCPCS
981
49465
98.37
Amount
4010
401059465-59465 PF FLUORO EXAM OF G/COLON TUBE
Contrast injection(s) for radiological evaluation of existing gastrostomy, duodenostomy, jejunostomy, gastro-jejunostomy, or cecostomy (or other colonic) tube, from a percutaneous approach including image documentation and report
4010
401059505-59505 PF APPLY LONG LEG SPLINT
Application of long leg splint (thigh to ankle or toes)
981
29505
157.50
4010
401061700-61700 PF S BLADDR IRRIG LAVAGE/INSTLL
981
51700
140.19
4010
401061701-61701 PF INSERT STRAIGHT CATHETER
981
51701
87.33
4010
401061702-61702 PF INS TEMP BLADDER CATH, SMPL
981
51702
95.46
4010
401061703-61703 PF INS TEMP BLADDER CATH COMPLEX
981
51703
256.05
4010
401061705-61705 PF CHANGE CYSTOSTOMY TUBE, SIMPLE
Bladder irrigation, simple, lavage and/or instillation Insertion of non-indwelling bladder catheter (eg, straight catheterization for residual urine) Insertion of temporary indwelling bladder catheter; simple (eg, Foley) Insertion of temporary indwelling bladder catheter; complicated (eg, altered anatomy, fractured catheter/balloon) Change of cystostomy tube; simple
981
51705
164.76
4010
401061798-61798 PF US PV RESIDUAL URINE
981
51798
62.88
4010
401062555-62555 PF THORAC ASP PLEURA W IMG GUID
981
32555
350.49
4010 4010
401064220-64220 PF IRRIG CORP CAVERNOSA PRIAPISM 401064402-64402 INJ ANESTH AGENT, FACIAL NERVE
981 450
54220 64402
421.26 922.08
4010
401064450-64450 PF FORESKIN MANIPULATION
981
54450
180.81
4010
401064700-64700 PF I&D EPIDIDYMIS, TESTIS/SCROTAL
981
54700
675.18
4010
401065100-65100 PF DRAIN SCROTAL WALL ABSCESS
981
55100
526.71
4010
401065205-65205 REM FB CONJUNCTIVA, SUPERFICIAL
450
65205
322.98
4010
401065210-65210 REM FB CONJUNCTIVA, EMBEDDED
450
65210
1155.06
4010
401065222-65222 REM FB CORNEAL W/SLIT LAMP
450
65222
367.65
4010 4010
401066405-66405 PF I&D VULVA/PERINEAL ABSCESS 401066420-66420 PF I&D BARTHOLIN'S GLAND ABSCESS
981 981
56405 56420
339.48 284.40
4010
401066725-66725 CL TX PHAL SHFT FX W MNP, EA (F5)
450
26725F5
698.97
4010
401066740-66740 CL TX ART FX MCP/IP JNT WO M-F2
450
26740F2
752.16
4010
401066750-66750 CLTX D PHAL FX FGR/THMB WO M (F5)
450
26750F5
698.97
4010
401066755-66755 CLTX D PHAL FX FGR/THMB W M (F5)
450
26755F5
698.97
4010
401066756-66756 SK FIX DSTL PHAL FX FNGR, PRC, F5
450
26756F5
8529.03
4010
401066770-66770 CLTX IP JNT DISL W M WO ANE (F5)
450
26770F5
698.97
4010
401066775-66775 CLTX IP JT DISL W M/ANE SGL (F5)
450
26775F5
772.17
4010
401066776-66776 SK FIX IP JT DISL SGL W M PC (F5)
450
26776F5
8529.03
4010
401067454-67454 PF COLPOSCOPY CERVIX W BX/CURETT
981
57454
422.22
4010
401068301-68301 PF REMOVE IUD
Thoracentesis, needle or catheter, aspiration of the pleural space; with imaging guidance Irrigation of corpora cavernosa for priapism Injection, anesthetic agent; facial nerve Foreskin manipulation including lysis of preputial adhesions and stretching Incision and drainage of epididymis, testis and/or scrotal space (eg, abscess or hematoma) Drainage of scrotal wall abscess Removal of foreign body, external eye; conjunctival superficial Removal of foreign body, external eye; conjunctival embedded (includes concretions), subconjunctival, or scleral nonperforating Removal of foreign body, external eye; corneal, with slit lamp Incision and drainage of vulva or perineal abscess Incision and drainage of Bartholin's gland abscess Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; with manipulation, with or without skin or skeletal traction, each Closed treatment of articular fracture, involving metacarpophalangeal or interphalangeal joint; without manipulation, each Closed treatment of distal phalangeal fracture, finger or thumb; without manipulation, each Closed treatment of distal phalangeal fracture, finger or thumb; with manipulation, each Percutaneous skeletal fixation of distal phalangeal fracture, finger or thumb, each Closed treatment of interphalangeal joint dislocation, single, with manipulation; without anesthesia Closed treatment of interphalangeal joint dislocation, single, with manipulation; requiring anesthesia Percutaneous skeletal fixation of interphalangeal joint dislocation, single, with manipulation Colposcopy of the cervix including upper/adjacent vagina; with biopsy(s) of the cervix and endocervical curettage Removal of intrauterine device (IUD)
981
58301
209.13
4010
401069000-69000 DRN EXT EAR ABSC/HEMATOMA, SMPL
Drainage external ear, abscess or hematoma; simple
450
69000
808.77
Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging
19 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
Long Description
4010
401069130-69130 APPLY FINGER SPLINT, STATIC (F5)
4010
401069209-69209 REM IMP CERUMEN IRRIG/LAVAGE UNI
4010
401069409-69409 PF VAGINAL DELIVERY ONLY
4010
401069414-69414 PF DELIVERY OF PLACENTA
4010
401071156-71156 PF BURR HOLES W ASP HEMAT/CYST,IC
4010
401071210-71210 PF PIERCE SKULL IMPLANT DEVICE
4010 4010
401072270-72270 PF SPINAL PUNCTURE, LUMBAR, DIAG 401072273-72273 PF INJ EPIDURAL BLOOD/CLOT PATCH
4010
401074400-74400 PF INJ ANESTH, TRIGEMINAL NERVE
4010
401074402-74402 PF INJ ANESTHETIC, FACIAL NERVE
Application of finger splint; static Removal impacted cerumen using irrigation/lavage, unilateral Vaginal delivery only (with or without episiotomy and/or forceps); Delivery of placenta Burr hole(s); with aspiration of hematoma or cyst, intracerebral Burr hole(s); for implanting ventricular catheter, reservoir, EEG electrode(s), pressure recording device, or other cerebral monitoring device Spinal puncture, lumbar, diagnostic Injection, epidural, of blood or clot patch Injection, anesthetic agent; trigeminal nerve, any division or branch Injection, anesthetic agent; facial nerve
4010
401074420-74420 PF INJ ANES, INTERCOSTAL NERV SGL
Injection, anesthetic agent; intercostal nerve, single
4010
401074450-74450 PF INJ ANESTH, OTHR PERIPH NERVE
4010
401075205-75205 PF REM FB CONJUNCTIVA, SUPERF
4010
401075210-75210 PF REM FB CONJUNCTIVA, EMBEDDED
4010
401075220-75220 PF REM FB CORNEAL WO SLIT LAMP
4010
401075222-75222 PF REM FB CORNEAL W SLIT LAMP
4010
401076725-76725 CL TX PHAL SHFT FX W MNP, EA (F6)
4010
401076740-76740 CL TX ART FX MCP/IP JNT WO M-F3
4010
401076750-76750 CLTX D PHAL FX FGR/THMB WO M (F6)
4010
401076755-76755 CLTX D PHAL FX FGR/THMB W M (F6)
4010
401076756-76756 SK FIX DSTL PHAL FX FNGR, PRC, F6
4010
401076770-76770 CLTX IP JNT DISL W M WO ANE (F6)
4010
401076775-76775 CLTX IP JT DISL W M/ANE SGL (F6)
4010
401076776-76776 SK FIX IP JT DISL SGL W M PC (F6)
4010
401076942-76942 US GUIDED NEEDLE PLACEMENT
4010
401077938-77938 PF REMOVE EMBEDDED FB EYELID
Injection, anesthetic agent; other peripheral nerve or branch Removal of foreign body, external eye; conjunctival superficial Removal of foreign body, external eye; conjunctival embedded (includes concretions), subconjunctival, or scleral nonperforating Removal of foreign body, external eye; corneal, without slit lamp Removal of foreign body, external eye; corneal, with slit lamp Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; with manipulation, with or without skin or skeletal traction, each Closed treatment of articular fracture, involving metacarpophalangeal or interphalangeal joint; without manipulation, each Closed treatment of distal phalangeal fracture, finger or thumb; without manipulation, each Closed treatment of distal phalangeal fracture, finger or thumb; with manipulation, each Percutaneous skeletal fixation of distal phalangeal fracture, finger or thumb, each Closed treatment of interphalangeal joint dislocation, single, with manipulation; without anesthesia Closed treatment of interphalangeal joint dislocation, single, with manipulation; requiring anesthesia Percutaneous skeletal fixation of interphalangeal joint dislocation, single, with manipulation Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation Removal of embedded foreign body, eyelid
4010
401079000-79000 PF DRN EXT EAR ABSC/HEMATOM, SMPL
4010 4010
401079020-79020 PF DRN EXT AUDITORY CANAL ABSCESS 401079130-79130 APPLY FINGER SPLINT, STATIC (F6)
4010
401079200-79200 PF REM FB EXT AUD CANAL WO ANES
4010
401079205-79205 PF REM FB EXT AUD CANAL W ANE
4010
401079209-79209 PF REMOVE IMPACTED EAR WAX UNI
UB Revenue Code 450
CPT/HCPCS
Amount
29130
190.80
450
69209
198.15
981
59409
2496.06
981
59414
280.59
981
61156
3829.20
981
61210
1105.11
981 981
62270 62273
244.83 359.94
981
64400
220.59
981
64402
247.47
981
64420
212.82
981
64450
144.69
981
65205
138.99
981
65210
167.67
981
65220
131.67
981
65222
164.82
450
26725F6
698.97
450
26740F3
752.16
450
26750F6
698.97
450
26755F6
698.97
450
26756F6
8529.03
450
26770F6
698.97
450
26775F6
772.17
450
26776F6
8529.03
402
76942
967.26
981
67938
370.65
Drainage external ear, abscess or hematoma; simple
981
69000
376.50
Drainage external auditory canal, abscess Application of finger splint; static Removal foreign body from external auditory canal; without general anesthesia Removal foreign body from external auditory canal; with general anesthesia Removal impacted cerumen using irrigation/lavage, unilateral
981 450
69020 29130
451.50 190.80
981
69200
149.01
981
69205
321.15
981
69209
41.31
20 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
Long Description Removal impacted cerumen requiring instrumentation, unilateral Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid)
UB Revenue Code
CPT/HCPCS
981
69210
102.48
981
90471
82.14
Amount
4010
401079210-79210 PF REM IMPACT EAR WAX W INSTR,UNI
4010
401080471-80471 PF IMMUNIZATION ADMIN 1 VACCINE
4010
401080935-80935 PF HEMODIALYSIS ONE EVAL PHYS/QHP
Hemodialysis procedure with single evaluation by a physician or other qualified health care professional
981
90935
225.69
4010
401080937-80937 PF HEMODIALYSIS REPEAT EVAL
Hemodialysis procedure requiring repeated evaluation(s) with or without substantial revision of dialysis prescription
981
90937
322.56
4010
401082950-82950 PF CPR
Cardiopulmonary resuscitation (eg, in cardiac arrest)
981
92950
579.66
981
93308
80.67
981
93882
77.01
981
93922
38.82
960
93926
74.67
981
93971
69.00
981
74235
194.40
981
94640
59.91
981
94660
118.32
981
94770
23.07
981
95992
116.67
981
96372
82.14
981
76512
168.18
981
76536
88.11
981
76604
84.69
4010
401083308-83308 PF TTE FOLLOW UP OR LIMITED STUDY
4010
401083882-83882 PF CAROTID DUPLX SCAN, UNIL/LIMIT
4010
401083922-83922 PF UPR/L XTREMITY ART 2 LEVELS
4010
401083926-83926 PF DUPLEX LE ART/BPG, UNIL/LIMIT
4010
401083971-83971 PF DUPLEX EXT VEINS, UNIL/LIMIT
4010
401084235-84235 PF REM FB ESOPH W BALN CATH S&I
4010
401084640-84640 PF AIRWAY INHALATION TREATMENT
4010
401084660-84660 PF CPAP INIT/MGMNT
4010
401084770-84770 PF CO2 EXPIRED GAS BY IR
4010
401085992-85992 PF CANALITH REPOSITION PX PER DAY
4010
401086372-86372 PF THER/PROPH/DIAG INJ SC/IM
4010
401086512-86512 PF DX OPHTHAL B-SCAN US
4010
401086536-86536 PF US EXAM OF HEAD AND NECK
4010
401086604-86604 PF US EXAM CHEST
Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, follow-up or limited study Duplex scan of extracranial arteries; unilateral or limited study Limited bilateral noninvasive physiologic studies of upper or lower extremity arteries, (eg, for lower extremity: ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus bidirectional, Doppler waveform recording and analysis at 1-2 levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus volume plethysmography at 1-2 levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries with transcutaneous oxygen tension measurements at 1-2 levels) Duplex scan of lower extremity arteries or arterial bypass grafts; unilateral or limited study Duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study Removal of foreign body(s), esophageal, with use of balloon catheter, radiological supervision and interpretation Pressurized or nonpressurized inhalation treatment for acute airway obstruction for therapeutic purposes and/or for diagnostic purposes such as sputum induction with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device Continuous positive airway pressure ventilation (CPAP), initiation and management Carbon dioxide, expired gas determination by infrared analyzer Canalith repositioning procedure(s) (eg, Epley maneuver, Semont maneuver), per day Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular Ophthalmic ultrasound, diagnostic; B-scan (with or without superimposed non-quantitative A-scan) Ultrasound, soft tissues of head and neck (eg, thyroid, parathyroid, parotid), real time with image documentation Ultrasound, chest (includes mediastinum), real time with image documentation
21 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4010
401086641-86641 PF US BREAST, UNI W IMG, COMPLETE
4010
401086642-86642 PF US BREAST, UNI W IMG, LIMITED
4010
401086705-86705 PF US ABDOMINAL W/IMG LIMITED
4010
401086706-86706 PF US ABDL AORTA SCREEN AAA
4010
401086725-86725 CL TX PHAL SHFT FX W MNP, EA (F7)
4010
401086750-86750 CLTX D PHAL FX FGR/THMB WO M (F7)
4010
401086755-86755 CLTX D PHAL FX FGR/THMB W M (F7)
4010
401086756-86756 SK FIX DSTL PHAL FX FNGR, PRC, F7
4010
401086775-86775 PF US RETROPERITONEAL W/IMG, LMTD
4010
401086776-86776 SK FIX IP JT DISL SGL W M PC (F7)
4010
401086815-86815 PF OB US LIMITED 1+ FETUS(S)
4010
401086817-86817 PF TRANSVAGINAL OB US
4010
401086830-86830 PF NON-OB TRANSVAG US
4010
401086856-86856 PF NON-OB PELVIC US, COMPLETE
4010
401086857-86857 PF US EXAM PELVIC LIMITED
4010
401086870-86870 PF US SCROTUM AND CONTENTS
4010
401086882-86882 PF US XTR NON-VASC LMTD
4010
401086937-86937 PF US GUIDE VASCULAR ACCESS
4010
401086942-86942 PF US GUIDED NEEDLE PLACEMENT S&I
4010
401087597-87597 PF SLCTV WND DEBRIDEM <=20SQ CM
Long Description Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; limited Ultrasound, abdominal, real time with image documentation; limited (eg, single organ, quadrant, follow-up) Ultrasound, abdominal aorta, real time with image documentation, screening study for abdominal aortic aneurysm (AAA) Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; with manipulation, with or without skin or skeletal traction, each Closed treatment of distal phalangeal fracture, finger or thumb; without manipulation, each Closed treatment of distal phalangeal fracture, finger or thumb; with manipulation, each Percutaneous skeletal fixation of distal phalangeal fracture, finger or thumb, each Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; limited Percutaneous skeletal fixation of interphalangeal joint dislocation, single, with manipulation Ultrasound, pregnant uterus, real time with image documentation, limited (eg, fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume), 1 or more fetuses Ultrasound, pregnant uterus, real time with image documentation, transvaginal Ultrasound, transvaginal Ultrasound, pelvic (nonobstetric), real time with image documentation; complete Ultrasound, pelvic (nonobstetric), real time with image documentation; limited or follow-up (eg, for follicles) Ultrasound, scrotum and contents Ultrasound, limited, joint or other nonvascular extremity structure(s) (eg, joint space, peri-articular tendon[s], muscle[s], nerve[s], other soft-tissue structure[s], or soft-tissue mass[es]), real-time with image documentation Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation Debridement (eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (eg, fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 sq cm or less
UB Revenue Code
CPT/HCPCS
981
76641
114.48
981
76642
106.65
981
76705
92.58
981
76706
87.00
450
26725F7
698.97
450
26750F7
698.97
450
26755F7
698.97
450
26756F7
8529.03
981
76775
450
26776F7
8529.03
981
76815
103.32
981
76817
119.67
981
76830
108.90
981
76856
108.90
981
76857
154.17
981
76870
101.07
981
76882
76.89
981
76937
44.85
981
76942
101.40
981
97597
72.81
Amount
90.30
22 of 167 Updated on 1/22/2019
Long Description
UB Revenue Code
CPT/HCPCS
401087598-87598 PF SLCTV WND DEBR, ADD <=20 SQ CM
Debridement (eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (eg, fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; each additional 20 sq cm, or part thereof
981
97598
34.17
4010
401087605-87605 PF NEG PRESS WOUND TX <=50 SQ CM
Negative pressure wound therapy (eg, vacuum assisted drainage collection), utilizing durable medical equipment (DME), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters
981
97605
81.60
4010
401089130-89130 APPLY FINGER SPLINT, STATIC (F7)
450
29130
190.80
4010
401089151-89151 PF MOD SED SAME PHYS/QHP <5 YRS
981
99151
72.36
401089152-89152 PF MOD SED SAME PHYS/QHP >=5 YRS
Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older
981
99152
38.16
4010
401089153-89153 PF MOD SED SAME PHYS/QHP ADDT 15M
Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List separately in addition to code for primary service)
981
99153
35.52
4010
401089209-89209 REM IMP CERUMEN IRRIG/LAVAGE, RT
450
69209RT
190.80
4010
401089210-89210 REM IMPACTED EAR WAX UNILAT, LT
450
69210LT
303.80
4010
401089281-89281 PF ER VISIT-LEVEL I
981
99281
65.25
Revenue Center
4010
4010
CDM Number
CDM Description
Application of finger splint; static Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient younger than 5 years of age
Removal impacted cerumen using irrigation/lavage, unilateral Removal impacted cerumen requiring instrumentation, unilateral Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor.
Amount
23 of 167 Updated on 1/22/2019
Revenue Center
4010
4010
Long Description
UB Revenue Code
CPT/HCPCS
401089282-89282 PF ER VISIT-LEVEL II
Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity.
981
99282
127.17
401089283-89283 PF ER VISIT-LEVEL III
Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity.
981
99283
190.05
981
99284
360.30
981
99285
531.18
981
99291
689.16
981
99292
345.39
450
92960
1794.33
260
96373
668.82
CDM Number
CDM Description
4010
401089284-89284 PF ER VISIT-LEVEL IV
4010
401089285-89285 PF ER VISIT-LEVEL V
4010
401089291-89291 PF CRITICAL CARE 30-74 MIN
4010
401089292-89292 PF CRITICAL CARE, ADDTL 30 MIN
4010
401092960-92960 CARDIOVERSION ELECTRIC EXT
4010
401096373-96373 THE/PROPH/DIAG INK IA
Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity, and require urgent evaluation by the physician, or other qualified health care professionals but do not pose an immediate significant threat to life or physiologic function. Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function. Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service) Cardioversion, elective, electrical conversion of arrhythmia; external Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intra-arterial
Amount
24 of 167 Updated on 1/22/2019
Revenue Center
UB Revenue Code
CPT/HCPCS
450
26725F8
698.97
450
26750F8
698.97
450
26755F8
698.97
450
26756F8
8529.03
450
26770F8
698.97
450
26775F8
772.17
450
26776F8
8529.03
450
97597
535.59
450
97605
591.33
450
29130
190.80
379
99151
132.74
401099152-99152 MOD SED SAME PHYS/QHP >=5 YRS
Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older
379
99152
285.47
401099153-99153 MOD SED SAME PHYS/QHP ADDT 15 MIN
Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List separately in addition to code for primary service)
379
99153
132.74
CDM Number
CDM Description
4010
401096725-96725 CL TX PHAL SHFT FX W MNP, EA (F8)
4010
401096750-96750 CLTX D PHAL FX FGR/THMB WO M (F8)
4010
401096755-96755 CLTX D PHAL FX FGR/THMB W M (F8)
4010
401096756-96756 SK FIX DSTL PHAL FX FNGR, PRC, F8
4010
401096770-96770 CLTX IP JNT DISL W M WO ANE (F8)
4010
401096775-96775 CLTX IP JT DISL W M/ANE SGL (F8)
4010
401096776-96776 SK FIX IP JT DISL SGL W M PC (F8)
4010
401097597-97597 SLCTV WOUND DEBRIDEM <=20 SQ CM
4010
401097605-97605 NEG PRESS WOUND TX <=50 SQ CM
4010
401099130-99130 APPLY FINGER SPLINT, STATIC (F8)
4010
401099151-99151 MOD SED SAME PHYS/QHP <5 YRS
4010
4010
Long Description Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; with manipulation, with or without skin or skeletal traction, each Closed treatment of distal phalangeal fracture, finger or thumb; without manipulation, each Closed treatment of distal phalangeal fracture, finger or thumb; with manipulation, each Percutaneous skeletal fixation of distal phalangeal fracture, finger or thumb, each Closed treatment of interphalangeal joint dislocation, single, with manipulation; without anesthesia Closed treatment of interphalangeal joint dislocation, single, with manipulation; requiring anesthesia Percutaneous skeletal fixation of interphalangeal joint dislocation, single, with manipulation Debridement (eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (eg, fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 sq cm or less Negative pressure wound therapy (eg, vacuum assisted drainage collection), utilizing durable medical equipment (DME), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters Application of finger splint; static Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient younger than 5 years of age
Amount
25 of 167 Updated on 1/22/2019
Long Description
UB Revenue Code
CPT/HCPCS
401099156-99156 MOD SED OTH PHYS/QHP >=5 YRS
Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; initial 15 minutes of intraservice time, patient age 5 years or older
379
99156
285.47
4010
401099157-99157 MOD SED OTH PHYS/QHP ADDT 15 MIN
Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; each additional 15 minutes intraservice time (List separately in addition to code for primary service)
379
99157
132.74
4010
401099210-99210 REM IMPACTED EAR WAX UNILAT, RT
450
69210RT
303.80
450
9928125
754.69
423000101-101 ER LEVEL II WITH PROCEDURE
Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity.
450
9928225
1282.97
423000102-102 ER LEVEL III WITH PROCEDURE
Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity.
450
9928325
1811.25
Revenue Center
4010
4010
4010
4010
CDM Number
CDM Description
423000100-100 ER LEVEL I WITH PROCEDURE
Removal impacted cerumen requiring instrumentation, unilateral Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor.
Amount
26 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4010
423000103-103 ER LEVEL IV WITH PROCEDURE
4010
423000104-104 ER LEVEL V WITH PROCEDURE
4010
423000105-105 CRITICAL CARE 30-74 MIN W/PROC
4010
423000106-106 MODIFIED TRAUMA ACTIVATION
4010
423000107-107 TRAUMA TEAM ACTIVATION FEE - E
4010
423000235-235 SVN TREATMENT
4010
423000241-241 URINE DIPSTICK
4010
423000700-700 URINE PREGNANCY TEST
4010
423000817-817 INTRAOSSEOUS INF NDL PLACEMNT
4010
423000818-818 CL TX RAD/ULNAR SHAFT FX W MNP
4010
423006000-6000 ER TRIAGE FEE
Long Description Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity, and require urgent evaluation by the physician, or other qualified health care professionals but do not pose an immediate significant threat to life or physiologic function. Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function. Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes Trauma response team associated with hospital critical care service Trauma response team associated with hospital critical care service Pressurized or nonpressurized inhalation treatment for acute airway obstruction for therapeutic purposes and/or for diagnostic purposes such as sputum induction with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, without microscopy Urine pregnancy test, by visual color comparison methods Placement of needle for intraosseous infusion Closed treatment of radial and ulnar shaft fractures; with manipulation Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor.
UB Revenue Code
CPT/HCPCS
450
9928425
2716.88
450
9928525
3950.01
450
9929125
4491.74
682
G0390
10250.00
682
G0390
16163.00
410
94640
529.41
307
81002
39.71
307
81025
152.99
450
36680
483.05
450
25565
1571.27
451
99281
262.13
Amount
27 of 167 Updated on 1/22/2019
Revenue Center
4010
4010
4010
Long Description
UB Revenue Code
CPT/HCPCS
423006001-6001 ER LEVEL I
Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor.
450
99281
754.69
423006002-6002 ER LEVEL II
Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity.
450
99282
1282.97
423006003-6003 ER LEVEL III
Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity.
450
99283
1811.25
450
99284
2716.88
450
99285
3950.01
CDM Number
4010
423006004-6004 ER LEVEL IV
4010
423006005-6005 ER LEVEL V
CDM Description
Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity, and require urgent evaluation by the physician, or other qualified health care professionals but do not pose an immediate significant threat to life or physiologic function. Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function.
Amount
28 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4010
423006006-6006 CRITICAL CARE 30-74 MIN
4010
423006113-6113 TISSUE ADHESIVE
4010
423006125-6125 CPAP INITIATION AND MANAGEMENT
4010 4010
423006128-6128 BLOOD TRANSFUSION 423006145-6145 ROUTINE VENIPUNCTURE
4010
423006154-6154 I & D ABSCESS, SIMPLE
4010
423006155-6155 I&D ABSCESS, COMPLICATED/MULTI
4010
423006156-6156 I&D PILONIDAL CYST, SIMPLE
4010
423006157-6157 INCIS/REM FB, SC TISS, SMPL
4010
423006158-6158 EVAC SUBUNGUAL HEMATOMA
4010
423006159-6159 REMOVAL OF NAIL BED
4010
423006160-6160 SMPL REP S/N/A/G/TR/E =<2.5CM
4010
423006161-6161 S REP S/N/A/G/TR/E 2.6-7.5CM
4010
423006162-6162 INT REP WND S/A/T/EXT =<2.5CM
4010
423006163-6163 INT REP WND N/H/F/G =<2.5 CM
4010
423006164-6164 INT REP WND F/E/N/L/MM =<2.5CM
4010
423006165-6165 INT WND REP FACE/MM 2.6-5.0 CM
4010
423006166-6166 DRESS/DEBRID P-THICK BURN, SMLL
4010
423006167-6167 ARTHROCENTESIS, ASPRTN MAJOR JT
4010
423006169-6169 CL TX NURSEMAID ELBOW W MNP
4010
423006171-6171 CL TX RADIAL SHAFT FX WO MNP
4010
423006176-6176 CL TX IP JT DIS W MNP/ANE SNGL
4010
423006180-6180 SPINAL PUNCTURE, LUMBAR, DIAG
4010
423006181-6181 CL TX SHLDR DISL W MNP WO ANES
4010
423006182-6182 CL TX SHLDR DISL W MNP/ANES
4010
423006185-6185 CNTRL NASAL HEMORRH ANT SMPL
4010
423006190-6190 S REP S/N/A/G/TR/E 7.6-12.5 CM
Long Description Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes
UB Revenue Code
CPT/HCPCS
450
99291
272 Continuous positive airway pressure ventilation (CPAP), initiation and management Transfusion, blood or blood components Collection of venous blood by venipuncture Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple Incision and drainage of pilonidal cyst; simple Incision and removal of foreign body, subcutaneous tissues; simple Evacuation of subungual hematoma Excision of nail and nail matrix, partial or complete (eg, ingrown or deformed nail), for permanent removal Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.6 cm to 7.5 cm Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.5 cm or less Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 2.5 cm or less Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm Dressings and/or debridement of partial-thickness burns, initial or subsequent; small (less than 5% total body surface area) Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance Closed treatment of radial head subluxation in child, nursemaid elbow, with manipulation Closed treatment of radial shaft fracture; without manipulation Closed treatment of interphalangeal joint dislocation, single, with manipulation; requiring anesthesia Spinal puncture, lumbar, diagnostic Closed treatment of shoulder dislocation, with manipulation; without anesthesia Closed treatment of shoulder dislocation, with manipulation; requiring anesthesia Control nasal hemorrhage, anterior, simple (limited cautery and/or packing) any method Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 7.6 cm to 12.5 cm
Amount
4491.74 120.75
410
94660
807.19
391 300
36430 36415
1128.95 49.30
450
10060
494.21
450
10061
592.65
450
10080
494.21
450
10120
856.80
450
11740
218.40
450
11750
1325.15
450
12001
373.20
450
12002
377.74
450
12031
990.68
450
12041
504.00
450
12051
990.68
450
12052
990.68
450
16020
421.34
450
20610
719.37
450
24640
526.51
450
25500
526.51
450
26775
4093.34
450
62270
1149.31
450
23650
526.51
450
23655
4093.34
450
30901
375.44
450
12004
374.99
29 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
Long Description Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm Initial treatment, first degree burn, when no more than local treatment is required Drainage of finger abscess; simple Closed treatment of metacarpal fracture, single; without manipulation, each bone Closed treatment of interphalangeal joint dislocation, single, with manipulation; without anesthesia Closed treatment of distal fibular fracture (lateral malleolus); without manipulation Application of long arm splint (shoulder to hand) Application of short arm splint (forearm to hand); static Application of short leg splint (calf to foot) Removal foreign body, intranasal; office type procedure Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older Injection, anesthetic agent; other peripheral nerve or branch Removal of foreign body, external eye; corneal, without slit lamp Removal foreign body from external auditory canal; without general anesthesia
UB Revenue Code
CPT/HCPCS
450
12013
376.51
450
16000
281.84
450
26010
494.21
450
26600
526.51
450
26770
526.51
450
27786
526.51
450
29105
372.41
450
29125
372.41
450
29515
372.41
450
30300
195.56
450
36556
3096.70
450
64450
1149.31
450
65220
291.78
450
69200
195.56
Amount
4010
423006192-6192 SMPL REP F/E/N/L/MM 2.6-5.0CM
4010
423006193-6193 TX 1ST DEGREE BURN INITIAL
4010
423006194-6194 DRAINAGE FINGER ABSCESS SIMPLE
4010
423006195-6195 CL TX METACARP FX SNGL WO MNP
4010
423006197-6197 CL TX IP JNT DISL W MNP WO ANE
4010
423006198-6198 CL TX DIST FIBULAR FX WO MNP
4010
423006201-6201 APPLICATION LONG ARM SPLINT
4010
423006202-6202 APPLY SHORT ARM SPLINT, STATIC
4010
423006205-6205 APPLY SHORT LEG SPLINT
4010
423006207-6207 REM FOREIGN BODY INTRANASAL
4010
423006208-6208 CVC PERC PLACEMENT > 5 YRS
4010
423006210-6210 NERVE BLOCK INJ PERIPH
4010
423006211-6211 REM FB CORNEAL WO SLIT LAMP
4010
423006212-6212 REM FB EXT AUD CANAL WO ANES
4010
423006214-6214 TRACHEOSTOMY EMER, TRANSTRACH
Tracheostomy, emergency procedure; transtracheal
450
31603
3983.67
4010
423006216-6216 INSERTION CHEST TUBE
Tube thoracostomy, includes connection to drainage system (eg, water seal), when performed, open
450
32551
1624.57
4010
423006220-6220 DELIVERY OF PLACENTA
450
59414
5730.10
4010
423006221-6221 REM FB CORNEAL W SLIT LAMP
450
65222
291.78
4010
423006223-6223 THORACOTOMY W CARDIAC MASSAGE
450
32160
1443.75
4010
423006227-6227 CVC PERC PLACEMENT < 5 YRS
450
36555
3096.70
450
36569
3096.70
450
51702
241.38
771
90471
9.00
450
12042
990.68
450
12032
990.68
450
51703
432.98
450
10160
494.21
450
51701
195.56
450
12011
383.52
4010
423006230-6230 INSERT PICC WO PORT/PUMP =>5YR
4010
423006233-6233 INSERT FOLEY CATHETER, SIMPLE
4010
423006236-6236 IMMUNIZATION ADMIN 1 VACCINE
4010
423006237-6237 INT REP WNDS N/H/F/G 2.6-7.5CM
4010
423006240-6240 INT REP WND S/A/T/E 2.6-7.5CM
4010
423006241-6241 INSERT FOLEY CATH, COMPLICATED
4010
423006244-6244 PUNCT ASP ABSC,HEMATOMA,BUL,CYST
4010
423006246-6246 INSERT STRAIGHT CATH
4010
423006247-6247 SMPL REP F/E/N/L/MM =<2.5CM
Delivery of placenta Removal of foreign body, external eye; corneal, with slit lamp Thoracotomy; with cardiac massage Insertion of non-tunneled centrally inserted central venous catheter; younger than 5 years of age Insertion of peripherally inserted central venous catheter (PICC), without subcutaneous port or pump, without imaging guidance; age 5 years or older Insertion of temporary indwelling bladder catheter; simple (eg, Foley) Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid) Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 2.6 cm to 7.5 cm Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.6 cm to 7.5 cm Insertion of temporary indwelling bladder catheter; complicated (eg, altered anatomy, fractured catheter/balloon) Puncture aspiration of abscess, hematoma, bulla, or cyst Insertion of non-indwelling bladder catheter (eg, straight catheterization for residual urine) Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less
30 of 167 Updated on 1/22/2019
Revenue Center
4010
CDM Number
CDM Description
423006248-6248 NG WITH SUCTION
4010
423006249-6249 INT REP WND S/A/T/E 12.6-20 CM
4010
423006252-6252 CL TX FEMORAL SHAFT FX W MNP
4010
423006254-6254 INT REP F/E/N/L/MM 5.1-7.5CM
4010
423006255-6255 CL TX D RAD FX/EPHPHYSL W MNP
4010
423006256-6256 TX CL ELBOW DISLOCAT WO ANES
4010
423006257-6257 INJ ANESTH, TRIGEMINAL NERVE
4010
423006258-6258 CMPLX REP S/A/L 2.6-7.5 CM
4010
423006259-6259 REP, COMPLEX S/A/L ADDTL =<5CM
4010
423006261-6261 CL TX NASAL BONE FX WO MNP
4010
423006262-6262 CL TX ELBOW DISLOCAT W ANES
4010
423006264-6264 SMPL REP F/E/N/L/MM 5.1-7.5CM
4010
423006265-6265 CMPLX REP F/G/H/F 2.6-7.5 CM
4010
423006266-6266 CL TX D PHAL FX FGR/THMB W MNP
4010
423006267-6267 TX SPONTAN HIP DISL W MNP/ANES
4010
423006268-6268 CL TX FEMUR FX OR EPIPHYS SEP
4010
423006270-6270 I & D ABSCESS, PERITONSILLAR
4010
423006277-6277 ER_INJ TRIGGER POINTS = >3
4010
423006278-6278 CL TX METACARPAL FX SNGL W MNP
4010
423006279-6279 ABD PARACENTESIS WO IMAGE GUIDE
4010
423006280-6280 ABD PARACENTESIS W IMAGING
4010 4010 4010
423006281-6281 I&D PERIANAL ABSC, SUPERFICIAL 423006282-6282 SIMPLE BLADDER IRRIGATE LAVAGE 423006284-6284 I&D VULVA/PERINEAL ABSCESS
4010
423007110-7110 HYDRATION, IV INF, INIT 31-60
4010
423007111-7111 HYDRATION, IV INFUS, EA ADDT HR
4010
423007112-7112 IV THERAPY INIT 16-90 MINS
Long Description
UB Revenue Code
CPT/HCPCS
Gastric intubation and aspiration(s) therapeutic, necessitating physician's skill (eg, for gastrointestinal hemorrhage), including lavage if performed
450
43753
395.46
450
12035
990.68
450
27502
3291.03
450
12053
990.68
450
25605
1571.27
450
24600
4093.34
450
64400
719.37
450
13121
990.68
450
13122
337.81
450
21310
307.62
450
24605
4093.34
450
12014
388.50
450
13132
1549.68
450
26755
526.51
450
27257
4093.34
450
27510
1571.27
450
42700
905.33
450
20553
643.65
450
26605
841.26
450
49082
1547.21
450
49083
1624.57
450 450 450
46050 51700 56405
2447.55 731.85 817.95
260
96360
362.03
260
96361
115.41
260
96365
576.09
Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 12.6 cm to 20.0 cm Closed treatment of femoral shaft fracture, with manipulation, with or without skin or skeletal traction Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 5.1 cm to 7.5 cm Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; with manipulation Treatment of closed elbow dislocation; without anesthesia Injection, anesthetic agent; trigeminal nerve, any division or branch Repair, complex, scalp, arms, and/or legs; 2.6 cm to 7.5 cm Repair, complex, scalp, arms, and/or legs; each additional 5 cm or less Closed treatment of nasal bone fracture without manipulation Treatment of closed elbow dislocation; requiring anesthesia Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 5.1 cm to 7.5 cm Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 2.6 cm to 7.5 cm Closed treatment of distal phalangeal fracture, finger or thumb; with manipulation, each Treatment of spontaneous hip dislocation (developmental, including congenital or pathological), by abduction, splint or traction; with manipulation, requiring anesthesia Closed treatment of femoral fracture, distal end, medial or lateral condyle, with manipulation Incision and drainage abscess; peritonsillar Injection(s); single or multiple trigger point(s), 3 or more muscles Closed treatment of metacarpal fracture, single; with manipulation, each bone Abdominal paracentesis (diagnostic or therapeutic); without imaging guidance Abdominal paracentesis (diagnostic or therapeutic); with imaging guidance Incision and drainage, perianal abscess, superficial Bladder irrigation, simple, lavage and/or instillation Incision and drainage of vulva or perineal abscess Intravenous infusion, hydration; initial, 31 minutes to 1 hour Intravenous infusion, hydration; each additional hour Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour
Amount
31 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4010
423007113-7113 EACH ADD HOUR,UP TO 8 HOU
4010
423007114-7114 IV INFUS, ADD SEQ NEW RX =<1HR
4010
423007115-7115 IV THERAPY CONCURRENT ONCE
4010
423007116-7116 INJ SUBQ/IM EACH
4010
423007117-7117 IV PUSH INITIAL DRUG
4010
423007118-7118 IV PUSH, ADDTL SEQ NEW DRUG
4010
423007119-7119 IV PUSH ADDL SEQ SAME DRUG>30MIN
4010
423007130-7130 IV INF HYDRATION INIT 31-60MIN
4010
423007132-7132 INITIAL IV INFUSION =<1 HR
4010
423007136-7136 THER/PROPH/DIAG INJ SC/IM
4010
423007137-7137 IV PUSH, SINGLE, OR INITIA
4010
423007138-7138 IV PUSH, ADDTL SEQ NEW DRUG
4010
423007139-7139 IV PUSH, ADDTL SEQ SAME DRUG
4010
423007146-7146 SREP F/E/N/L/MM,7.6-12.5CM
4010
423007152-7152 REP WND S,A,T 7.6-12.5
4010
423007155-7155 REP WND S,A,T 30.0 >CM
4010
423007158-7158 REP WND N,H,F,G 7.6-12.5
4010
423007165-7165 INT WND REP FACE/MM 7.6-12.5 CM
4010
423007166-7166 INT WND REP FACE/MM 12.6-20.0CM
4010
423007169-7169 SREP S/N/A/G/TR/E, 12.6-20.0CM
Long Description Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); additional sequential infusion of a new drug/substance, up to 1 hour Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); concurrent infusion Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of the same substance/drug provided in a facility Intravenous infusion, hydration; initial, 31 minutes to 1 hour Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of the same substance/drug provided in a facility Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 7.6 cm to 12.5 cm Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 7.6 cm to 12.5 cm Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); over 30.0 cm Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 7.6 cm to 12.5 cm Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 7.6 cm to 12.5 cm Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 12.6 cm to 20.0 cm Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 12.6 cm to 20.0 cm
UB Revenue Code
CPT/HCPCS
260
96366
576.09
260
96367
154.16
260
96368
45.29
450
96372
154.16
260
96374
227.68
260
96375
154.16
260
96376
154.16
260
96360XU
362.03
260
96365XU
576.09
260
9637259
154.16
260
96374XU
227.68
260
96375XU
154.16
260
96376XU
154.16
450
12015
361.20
450
12034
990.68
450
12037
4998.72
450
12044
990.68
450
12054
337.81
450
12055
990.68
450
12005
361.20
Amount
32 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
Long Description
4010
423007170-7170 SREP S/N/A/G/TR/E, 20.1-30.0CM
4010
423007171-7171 SMPL REP S/N/A/G/TR/E >30CM
4010
423007173-7173 CPLX REP E/N/E/L, 1.1-2.5CM/<
4010
423007174-7174 CMPLX REP E/N/E/L 2.6-7.5 CM
4010
423007181-7181 CMPLX REP TRUNK, 2.6-7.5CM
Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 20.1 cm to 30.0 cm Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); over 30.0 cm Repair, complex, eyelids, nose, ears and/or lips; 1.1 cm to 2.5 cm Repair, complex, eyelids, nose, ears and/or lips; 2.6 cm to 7.5 cm Repair, complex, trunk; 2.6 cm to 7.5 cm
4010
423007182-7182 REP COMPLEX TRUNK ADDTL =<5CM
Repair, complex, trunk; each additional 5 cm or less
4010
423007183-7183 CMPLX REP F/G/H/F 1.1-2.5 CM
4010
423007184-7184 CREP H/A/G/EXTR, EA ADD 5 CM/<
4010
423007187-7187 WEDGE EXC NAIL, FOLD
4010
423007188-7188 INJ-TRIGGER POINT 1/2 MUSCL
4010
423007189-7189 REM FB UPR ARM/ELBOW, SUBQ
4010
423007190-7190 CL TX ANKLE DISLOCAT WO ANES
4010
423007191-7191 DR ABSC CYST HEMAT-MOUTH SMPL
4010
423007192-7192 DR ABSC CYST HEMATOM - DENTOAL
4010 4010
423007193-7193 I&D BARTHOLIN'S GLAND ABSCESS 423008800-8800 S.A.N.E, EVIDENCE EXAM KIT
4010
423009033-9033 CL TX ANKLE DICLOC W ANESTH
4010
423010030-10030 GUIDE CATHET FLUID DRAINAGE
4010
423020600-20600 DRAIN/INJECT SM JNT/BURSA
4010
423020605-20605 DRAIN/INJ INTERM JNT/BURSA
4010
423025535-25535 CL TX ULNAR SHFT FX W MANIP
4010
423027788-27788 CL TX DISTL FIB FX W MANIP
4010 4010 4010
423029130-29130 APPLY FINGER SPLINT, STATIC 423029131-29131 APPLY FINGER SPLINT, DYNAMIC 423055100-55100 DRAINAGE OF SCROTAL WALL ABS
4010
423069210-69210 REMOVE IMPACTED EAR WAX, BILAT
4011 4011 4011 4011 4011
401100003-3 401100004-4 401100024-24 401100025-25 401100074-74
BASIC TRAUMA KIT TISSUE ADHESIVE ROUTINE VENIPUNCTURE BLOOD TRANSFUSION INTRAOSSEOUS INF NDL PLACEMNT
Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 1.1 cm to 2.5 cm Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; each additional 5 cm or less Wedge excision of skin of nail fold (eg, for ingrown toenail) Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s) Removal of foreign body, upper arm or elbow area; subcutaneous Closed treatment of ankle dislocation; without anesthesia Drainage of abscess, cyst, hematoma, vestibule of mouth; simple Drainage of abscess, cyst, hematoma from dentoalveolar structures Incision and drainage of Bartholin's gland abscess Closed treatment of ankle dislocation; requiring anesthesia, with or without percutaneous skeletal fixation Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst), soft tissue (eg, extremity, abdominal wall, neck), percutaneous Arthrocentesis, aspiration and/or injection, small joint or bursa (eg, fingers, toes); without ultrasound guidance Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); without ultrasound guidance Closed treatment of ulnar shaft fracture; with manipulation Closed treatment of distal fibular fracture (lateral malleolus); with manipulation Application of finger splint; static Application of finger splint; dynamic Drainage of scrotal wall abscess Removal impacted cerumen requiring instrumentation, unilateral Wound closure utilizing tissue adhesive(s) only Collection of venous blood by venipuncture Transfusion, blood or blood components Placement of needle for intraosseous infusion
UB Revenue Code
CPT/HCPCS
450
12006
337.81
450
12007
361.20
450
13151
1549.68
450
13152
1060.85
450
13101
1549.68
450
13102
990.68
450
13131
990.68
450
13133
990.68
450
11765
1087.80
450
20552
719.37
450
24200
4718.16
450
27840
526.51
450
40800
2004.99
450
41800
494.21
450 450
56420
467.05 899.75
450
27842
4093.34
450
10030
3336.63
450
20600
719.37
450
20605
719.37
450
25535
526.51
450
27788
597.72
450 450 450
29130 29131 55100
959.15 202.32 3201.23
450
6921050
303.80
G0168 36415 36430 36680
603.75 398.48 49.30 1128.95 483.05
272 450 300 391 450
Amount
33 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4011
401100103-103 ER LEVEL IV WITH PROCEDURE
4011
401100104-104 ER LEVEL V WITH PROCEDURE
4011
401100105-105 CRITICAL CARE 30-74 MINS W PROC
4011
401100106-106 MODIFIED TRAUMA ACTIVATION
4011
401100108-108 MOD ACTIVATION W/CRITICAL CARE
4011
401100109-109 TRAUMA TEAM ACTVTN W/CRITICAL CR
4011
401100119-119 EVAC SUBUNGUAL HEMATOMA
4011
401100120-120 REMOVAL OF NAIL BED
4011
401100121-121 SMPL REP S/N/A/G/TR/E =<2.5CM
4011
401100122-122 S. REP S/N/A/G/TR/E 2.6-7.5CM
4011
401100123-123 LAC REP LYR S,N,A,T,E 2.5DM OR <
4011
401100126-126 INT WND REP FACE/MM 2.6-5.0 CM
4011
401100127-127 DRESSING AND/OR DEBRIDEMENT
4011
401100128-128 ARTHROCENTESIS, ASPRIR MAJOR JNT
4011
401100137-137 CL TX IP JNT DISL W MNP/ANES
4011
401100139-139 CL TX MED MALLEOLUS FX WO MNP
Long Description Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity, and require urgent evaluation by the physician, or other qualified health care professionals but do not pose an immediate significant threat to life or physiologic function. Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function. Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes
UB Revenue Code
CPT/HCPCS
450
9928425
2716.88
450
9928525
3950.01
450
9929125
4491.74
682 Trauma response team associated with hospital critical care service Trauma response team associated with hospital critical care service Evacuation of subungual hematoma Excision of nail and nail matrix, partial or complete (eg, ingrown or deformed nail), for permanent removal Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.6 cm to 7.5 cm Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.5 cm or less Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm Dressings and/or debridement of partial-thickness burns, initial or subsequent; small (less than 5% total body surface area) Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance Closed treatment of interphalangeal joint dislocation, single, with manipulation; requiring anesthesia Closed treatment of medial malleolus fracture; without manipulation
Amount
8343.75
682
G0390
11275.00
682
G0390
17779.30
450
11740
218.40
450
11750
1325.15
450
12001
373.20
450
12002
377.74
450
12031
990.68
450
12052
990.68
450
16020
421.34
450
20610
856.47
450
26775
4093.34
450
27760
752.16
34 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4011
401100142-142 CLO TX SHLDR DISLOC W/MAN W/O ANE
4011
401100143-143 CL TX SHLDR DISLOC W MNP/ANES
4011
401100151-151 ART LINE INSERTION
4011
401100152-152 S. REP S/N/A/G/TR/E 7.6-12.5CM
4011
401100154-154 SMPL REP F/E/N/L/MM 2.6-5.0CM
4011
401100159-159 CL TX IP JNT DISL W MNP WO ANE
4011
401100163-163 APPLICATION LONG ARM SPLINT
4011
401100164-164 APPLICATION SHORT ARM SPLINT
4011
401100167-167 APPLICATION SHORT LEG SPLINT
4011
401100170-170 CVC PERC PLACEMENT > 5 YRS
4011
401100178-178 INSERTION CHEST TUBE
4011
401100185-185 THORACOTOMY W CARDIAC MASSAGE
4011
401100216-216 INSERT PICC WO PORT/PUMP >=5 YRS
4011
401100219-219 INSERTION FOLEY CATHETER
4011
401100221-221 CPAP INITIATION/MANAGEMENT
4011
401100222-222 IMMUNIZATION ADMIN 1 VACCINE
4011
401100223-223 LAC REP LYR N,H,F,G 2.6-7.5 CM
4011
401100224-224 URINE DIPSTICK
4011
401100225-225 URINE PREGNANCY TEST
4011
401100226-226 CL TX RAD HEAD/NECK FX WO MNP
4011
401100228-228 LAC REP LYR S,N,A,T,E 2.6-7.5 CM
4011
401100230-230 REP CMPLX S/A/L 1.1-2.5CM
4011
401100232-232 PUNCT ASP ASCESS,HEMA,BULLO,CYST
4011
401100234-234 INSERTION STRAIGHT CATHETER
4011
401100235-235 S. REP F/E/N/L/MM =<2.5CM
4011
401100236-236 NG WITH SUCTION
Long Description Closed treatment of shoulder dislocation, with manipulation; without anesthesia Closed treatment of shoulder dislocation, with manipulation; requiring anesthesia Arterial catheterization or cannulation for sampling, monitoring or transfusion; percutaneous Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 7.6 cm to 12.5 cm Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm Closed treatment of interphalangeal joint dislocation, single, with manipulation; without anesthesia Application of long arm splint (shoulder to hand) Application of short arm splint (forearm to hand); static Application of short leg splint (calf to foot) Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older Tube thoracostomy, includes connection to drainage system (eg, water seal), when performed, open Thoracotomy; with cardiac massage Insertion of peripherally inserted central venous catheter (PICC), without subcutaneous port or pump, without imaging guidance; age 5 years or older Insertion of temporary indwelling bladder catheter; simple (eg, Foley) Continuous positive airway pressure ventilation (CPAP), initiation and management Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid) Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 2.6 cm to 7.5 cm Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, without microscopy Urine pregnancy test, by visual color comparison methods Closed treatment of radial head or neck fracture; without manipulation Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.6 cm to 7.5 cm Repair, complex, scalp, arms, and/or legs; 1.1 cm to 2.5 cm Puncture aspiration of abscess, hematoma, bulla, or cyst Insertion of non-indwelling bladder catheter (eg, straight catheterization for residual urine) Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less Gastric intubation and aspiration(s) therapeutic, necessitating physician's skill (eg, for gastrointestinal hemorrhage), including lavage if performed
UB Revenue Code
CPT/HCPCS
450
23650
752.16
450
23655
4093.34
450
36620
1443.75
450
12004
374.99
450
12013
376.51
450
26770
526.51
450
29105
372.41
450
29125
372.41
450
29515
372.41
450
36556
2949.24
450
32551
1624.57
450
32160
1443.75
450
36569
3440.43
450
51702
241.38
410
94660
378.71
771
90471
9.00
450
12042
990.68
307
81002
39.71
307
81025
152.99
450
24650
526.51
450
12032
990.68
450
13120
990.68
450
10160
494.21
450
51701
195.56
450
12011
383.52
450
43753
395.46
Amount
35 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4011
401100237-237 LAC REP LYR S,A,T,E 12.6-20.0 CM
4011
401100600-600 TC DRN/INJECT SM JNT/BURSA
4011
401106116-6116 CL TX IP JNT DISL W MNP/ANES
4011
401106117-6117 REP INT WND FACE/MM 5.1-7.5CM
4011
401106118-6118 CLTX DSTL RDL FX/EPIPHYSL SEP
4011
401106121-6121 REPAIR COMPLEX S,A,L 2.6-7.5CM
4011
401106122-6122 REP COMPLEX S/A/L ADDTL =<5CM
4011
401106123-6123 CL TX TIBIAL SHAFT FX, WO MNP
4011
401106125-6125 CL TX ELBOW DISLOCAT W ANES
4011
401106127-6127 SMPL REP F/E/N/L/MM 5.1-7.5 CM
4011
401106128-6128 REP CMPLX F/G/H/F 2.6-7.5CM
4011
401106129-6129 TX SPONTAN HIP DISL W MNP/ANES
4011
401106130-6130 CL TX FEM FX DIS/MED/LAT W MNP
4011
401106133-6133 SMPL REP S/N/A/G/TR/E >30CM
4011
401106177-6177 INJ TRIGGER POINTS >=3 MUSCLES
4011
401106178-6178 CL TX MC FX SNGL, W MNP, EA
4011
401106183-6183 I&D EPIDIDYMIS TESTIS SP
4011
401106756-6756 PC SKTL FX D PHAL FX FNGR/THMB-F9
4011
401106775-6775 CL TX IP JNT DISL W M ANES-F9
4011
401108111-8111 HYDRATION, IV INFUS, EA ADDT HR
4011
401108112-8112 IV INF FOR THER,PROPH,DX,
4011
401108113-8113 EACH ADD HOUR, UP TO 8 H
4011
401108115-8115 IV INFUSION, CONCURRENT, IN
4011
401108116-8116 THER/PROPH/DIAG INJ SC/IM
Long Description Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 12.6 cm to 20.0 cm Arthrocentesis, aspiration and/or injection, small joint or bursa (eg, fingers, toes); without ultrasound guidance Closed treatment of interphalangeal joint dislocation, single, with manipulation; requiring anesthesia Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 5.1 cm to 7.5 cm Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; with manipulation Repair, complex, scalp, arms, and/or legs; 2.6 cm to 7.5 cm Repair, complex, scalp, arms, and/or legs; each additional 5 cm or less Closed treatment of tibial shaft fracture (with or without fibular fracture); without manipulation Treatment of closed elbow dislocation; requiring anesthesia Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 5.1 cm to 7.5 cm Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 2.6 cm to 7.5 cm Treatment of spontaneous hip dislocation (developmental, including congenital or pathological), by abduction, splint or traction; with manipulation, requiring anesthesia Closed treatment of femoral fracture, distal end, medial or lateral condyle, with manipulation Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); over 30.0 cm Injection(s); single or multiple trigger point(s), 3 or more muscles Closed treatment of metacarpal fracture, single; with manipulation, each bone Incision and drainage of epididymis, testis and/or scrotal space (eg, abscess or hematoma) Percutaneous skeletal fixation of distal phalangeal fracture, finger or thumb, each Closed treatment of interphalangeal joint dislocation, single, with manipulation; requiring anesthesia Intravenous infusion, hydration; each additional hour 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 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); concurrent infusion Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular
UB Revenue Code
CPT/HCPCS
450
12035
990.68
450
20600
719.37
450
26775
4093.34
450
12053
990.68
450
25605
1571.27
450
13121
990.68
450
13122
337.81
450
27750
526.51
450
24605
4093.34
450
12014
388.50
450
13132
1549.68
450
27257
4093.34
450
27510
1571.27
450
12007
361.20
450
20553
808.02
450
26605
841.26
450
54700
2228.19
450
26756F9
8529.03
450
26775F9
4093.34
260
96361
115.41
260
96365
576.09
260
96366
576.09
260
96368
45.29
450
96372
154.16
Amount
36 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4011
401108117-8117 IV PUSH, SINGLE, OR INITIA
4011
401108118-8118 IV PUSH, EA ADDTL SEQ NEW DRUG
4011
401108152-8152 WND REP S,A,T 7.6-12.5
4011
401108158-8158 WND REP N,H,F,G 7.6-12.5
4011
401108162-8162 INT WND REP FACE/MM =< 2.5 CM
4011
401108165-8165 INT WND REP FACE/MM 7.6-12.5 CM
4011
401108169-8169 SREP S/N/A/G/TR/E, 12.6-20.0CM
4011
401108170-8170 SREP S/N/A/G/TR/E, 20.1-30.0CM
4011
401108201-8201 SREP F/E/N/L/MM,7.6-12.5CM
4011
401108202-8202 SREP F/E/N/L/MM, 12.6-20.0CM
4011
401108203-8203 SREP F/E/N/L/MM, 20.1-30.0CM
4011
401108206-8206 CMPLX REP TRUNK, 2.6-7.5CM
4011
401108208-8208 REP CMPLX F/G/H/F 1.1-2.5CM
4011
401108211-8211 CPLX REP E/N/E/L, 1.1-2.5CM/<
4011
401108212-8212 CPLX E/N/E/L 2.6-7.5CM/<
4011
401108213-8213 CREP E/N/E/L, EA ADDTL 5 CM/<
4011
401108216-8216 VACCINE ADMIN, EACH ADDIT
4011
401108226-8226 CL TX ANKLE DICLOC W ANESTH
4011
401108228-8228 SPL AVULSE NP, SGL
4011
401108230-8230 INJ TRIGGER POINT 1/2 MUSCL
4011
401108249-8249 TC CL TX ULNAR SHFT FX W MAN
4011
401109130-9130 TC APPLY FINGER SPLINT, STATIC
4011
401110160-10160 PUNC ASP ABSC/HEMATOMA/CYST
4011
401112036-12036 INTMD WND REP S/A/T/EXT 20.1-30CM
Long Description Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 7.6 cm to 12.5 cm Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 7.6 cm to 12.5 cm Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 7.6 cm to 12.5 cm Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 12.6 cm to 20.0 cm Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 20.1 cm to 30.0 cm Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 7.6 cm to 12.5 cm Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 12.6 cm to 20.0 cm Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 20.1 cm to 30.0 cm Repair, complex, trunk; 2.6 cm to 7.5 cm Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 1.1 cm to 2.5 cm Repair, complex, eyelids, nose, ears and/or lips; 1.1 cm to 2.5 cm Repair, complex, eyelids, nose, ears and/or lips; 2.6 cm to 7.5 cm Repair, complex, eyelids, nose, ears and/or lips; each additional 5 cm or less Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) Closed treatment of ankle dislocation; requiring anesthesia, with or without percutaneous skeletal fixation Avulsion of nail plate, partial or complete, simple; single Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s) Closed treatment of ulnar shaft fracture; with manipulation Application of finger splint; static Puncture aspiration of abscess, hematoma, bulla, or cyst Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 20.1 cm to 30.0 cm
UB Revenue Code
CPT/HCPCS
260
96374
227.68
260
96375
154.16
450
12034
990.68
450
12044
990.68
450
12051
990.68
450
12054
337.81
450
12005
361.20
450
12006
337.81
450
12015
361.20
450
12016
337.81
450
12017
337.81
450
13101
1549.68
450
13131
990.68
450
13151
1549.68
450
13152
1549.68
450
13153
990.68
771
90472
106.41
450
27842
4093.34
450
11730
308.70
450
20552
719.37
450
25535
526.51
450
29130
959.15
450
10160
1023.54
450
12036
1708.71
Amount
37 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4011
401112037-12037 INT WND REP S/A/T/EXT 30+CM
4011
401112041-12041 INTMD WND REP N-HF/GENIT =<2.5CM
4011
401112042-12042 INT WND REP N-HF/GENIT 2.6-7.5CM
4011
401112055-12055 INTMD WND REP FACE/MM 12.6-20 CM
4011
401113122-13122 REPAIR COMPLEX S/A/L ADDTL =<5CM
4011
401113133-13133 CREP H/A/G/EXTR, EA ADD 5 CM/<
4011
401116020-16020 DRESS/DEBRID P-THICK BURN, SMALL
4011
401116756-16756 PC SKTL FX D PHAL FX FNGR/THMB-FA
4011
401116770-16770 CL TX IP JNT DISL W M WO ANES FA
4011
401116775-16775 CL TX IP JNT DISL W M ANES-FA
4011
401119130-19130 TC APPLY FNGR SPLNT, STATIC-FA
4011
401121480-21480 CL TX TMJ DISLOCATION, INITIAL
4011
401123505-23505 CL TX CLAVICULAR FX W MANIP, BOTH
4011
401123655-23655 CL TX SHLDR DISL W M ANES-BILAT
4011
401124500-24500 CL TX HUMERAL SHAFT FX WO M, BOTH
4011
401124577-24577 CL TX C HUMERUS FX W MANIP-BILAT
4011
401124605-24605 CL TX ELBOW DISLOC W ANES-BILAT
4011
401125505-25505 CL TX RADIAL SHFT FX W M-BILAT
4011
401125535-25535 TC CL TX ULN SHFT FX W M-BILAT
4011
401125565-25565 CL TX RAD & ULNA SHFT FX W M, BIL
4011
401125605-25605 CLTX DSTL RDL FX/EPIPHY SEP-BILAT
4011
401125650-25650 CLOSED TX OF ULNAR STYLOID FX-BIL
4011
401125680-25680 CL TX TRANS-SPL FX DISL W MNP, BI
4011
401126756-26756 PC SKTL FX D PHAL FX FNGR/THMB-F1
4011
401126775-26775 CL TX IP JNT DISL W M ANES-F1
4011
401127250-27250 CL TX TRAUMA DISLOC WO ANESTH
4011
401127252-27252 CLTX TRAUMA HIP DISL W ANE, BILAT
Long Description Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); over 30.0 cm Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 2.5 cm or less Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 2.6 cm to 7.5 cm Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 12.6 cm to 20.0 cm Repair, complex, scalp, arms, and/or legs; each additional 5 cm or less Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; each additional 5 cm or less Dressings and/or debridement of partial-thickness burns, initial or subsequent; small (less than 5% total body surface area) Percutaneous skeletal fixation of distal phalangeal fracture, finger or thumb, each Closed treatment of interphalangeal joint dislocation, single, with manipulation; without anesthesia Closed treatment of interphalangeal joint dislocation, single, with manipulation; requiring anesthesia Application of finger splint; static Closed treatment of temporomandibular dislocation; initial or subsequent Closed treatment of clavicular fracture; with manipulation Closed treatment of shoulder dislocation, with manipulation; requiring anesthesia Closed treatment of humeral shaft fracture; without manipulation Closed treatment of humeral condylar fracture, medial or lateral; with manipulation Treatment of closed elbow dislocation; requiring anesthesia Closed treatment of radial shaft fracture; with manipulation Closed treatment of ulnar shaft fracture; with manipulation Closed treatment of radial and ulnar shaft fractures; with manipulation Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; with manipulation Closed treatment of ulnar styloid fracture Closed treatment of trans-scaphoperilunar type of fracture dislocation, with manipulation Percutaneous skeletal fixation of distal phalangeal fracture, finger or thumb, each Closed treatment of interphalangeal joint dislocation, single, with manipulation; requiring anesthesia Closed treatment of hip dislocation, traumatic; without anesthesia Closed treatment of hip dislocation, traumatic; requiring anesthesia
UB Revenue Code
CPT/HCPCS
450
12037
8761.11
450
12041
1087.74
450
12042
1087.80
450
12055
1024.17
450
13122
337.81
450
13133
412.47
450
16020
590.91
450
26756FA
8529.03
450
26770FA
752.16
450
26775FA
4093.34
450
29130FA
959.15
450
21480
698.97
450
2350550
4258.38
450
2365550
4258.38
450
2450050
698.97
450
2457750
4258.38
450
2460550
4258.38
450
2550550
4258.38
450
2553550
698.97
450
2556550
4724.85
450
2560550
4258.38
450
2565050
698.97
450
2568050
752.16
450
26756F1
8529.03
450
26775F1
4093.34
450
27250
699.42
450
2725250
4258.38
Amount
38 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
Long Description
4011
401127257-27257 TX SPONT HIP DISL W M ANES-BILAT
Treatment of spontaneous hip dislocation (developmental, including congenital or pathological), by abduction, splint or traction; with manipulation, requiring anesthesia
4011
401127369-27369 KNEE ARTHROGRAPHY INJECTION
Injection procedure for contrast knee arthrography or contrast enhanced CT/MRI knee arthrography
4011
401127500-27500 CL TX FEMORAL SHAFT FX WO M-BILAT
4011
401127510-27510 CL TX FEM FX DIS/MED/LAT W M BIL
4011
401127530-27530 CL TX PROX TIBIAL FX WO MNP, BOTH
4011
401127552-27552 CL TX KNEE DISLOC W ANES, BOTH
4011
401127762-27762 CLTX MED ANKLE FX W/MNPJ BI
4011
401127788-27788 TC CL TX DISTL FIB FX W MANIP
4011
401127808-27808 CL FX BIMALLEOLAR ANKLE WO MNP RT
4011
401127810-27810 CLTX BIMALLEOLAR ANK FX W MNP, BI
4011
401127818-27818 CL TX TRIMALL ANKLE FX, W M-BILAT
4011
401127824-27824 CL TX WB DSTL TIB FX WO MNP-BILAT
4011
401127825-27825 CL TX WB DSTL TIB FX W MANIP
4011
401127831-27831 CL TX TIB-FIB JNT DISL W ANE-BIL
4011
401128490-28490 CL TX FX GT PHALANX(S) WO MNP
4011
401128545-28545 CL TX TARSAL BONE DIS W ANES,BI
4011
401128630-28630 CL TX MTP JNT DISL WO ANES
4011
401129105-29105 APPLY LONG ARM SPLINT, BILAT
4011
401129125-29125 APPL SHORT ARM SPLNT STATIC-BILAT
4011 4011 4011 4011
401129130-29130 401129515-29515 401129580-29580 401129705-29705
4011
401130901-30901 CONTROL NASAL HEMORRH ANT SIMPLE
4011
401131500-31500 INTUBATION ET BY ED MD (EMERGENT)
4011
401131530-31530 LARYNGOSCOPY W/FB REMOVAL
4011
401131575-31575 DIAGNOSTIC LARYNGOSCOPY
4011
401131605-31605 TRACHEOSTOMY EMERG, CRICOTHYROID
4011
401132110-32110 THORAC, CTRL HEM/REP LUNG TEAR-CA
4011
401132160-32160 THORACOTOMY W CARDIAC MASSAGE-CA
TC APPLY FNGR SPLNT, STATIC-F1 APPLY SHORT LEG SPLINT, BILAT UNNA BOOT STRAPPING-BILAT REMOVE FULL ARM OR LEG CAST-BILAT
Closed treatment of femoral shaft fracture, without manipulation Closed treatment of femoral fracture, distal end, medial or lateral condyle, with manipulation Closed treatment of tibial fracture, proximal (plateau); without manipulation Closed treatment of knee dislocation; requiring anesthesia Closed treatment of medial malleolus fracture; with manipulation, with or without skin or skeletal traction Closed treatment of distal fibular fracture (lateral malleolus); with manipulation Closed treatment of bimalleolar ankle fracture (eg, lateral and medial malleoli, or lateral and posterior malleoli, or medial and posterior malleoli); without manipulation Closed treatment of bimalleolar ankle fracture (eg, lateral and medial malleoli, or lateral and posterior malleoli, or medial and posterior malleoli); with manipulation Closed treatment of trimalleolar ankle fracture; with manipulation Closed treatment of fracture of weight bearing articular portion of distal tibia (eg, pilon or tibial plafond), with or without anesthesia; without manipulation Closed treatment of fracture of weight bearing articular portion of distal tibia (eg, pilon or tibial plafond), with or without anesthesia; with skeletal traction and/or requiring manipulation Closed treatment of proximal tibiofibular joint dislocation; requiring anesthesia Closed treatment of fracture great toe, phalanx or phalanges; without manipulation Closed treatment of tarsal bone dislocation, other than talotarsal; requiring anesthesia Closed treatment of metatarsophalangeal joint dislocation; without anesthesia Application of long arm splint (shoulder to hand) Application of short arm splint (forearm to hand); static Application of finger splint; static Application of short leg splint (calf to foot) Strapping; Unna boot Removal or bivalving; full arm or full leg cast Control nasal hemorrhage, anterior, simple (limited cautery and/or packing) any method Intubation, endotracheal, emergency procedure Laryngoscopy, direct, operative, with foreign body removal; Laryngoscopy, flexible; diagnostic Tracheostomy, emergency procedure; cricothyroid membrane Thoracotomy; with control of traumatic hemorrhage and/or repair of lung tear Thoracotomy; with cardiac massage
UB Revenue Code
CPT/HCPCS
450
2725750
4093.34
450
27369
763.41
450
2750050
698.97
450
2751050
1571.27
450
2753050
698.97
450
2755250
4258.38
450
2776250
4724.85
450
27788
597.72
450
27808RT
752.16
450
2781050
4724.85
450
2781850
4258.38
450
2782450
698.97
450
27825
3883.80
450
2783150
8529.03
450
28490
698.97
450
2854550
9258.42
450
28630
698.97
450
2910550
473.97
450
2912550
372.41
450 450 450 450
29130F1 2951550 2958050 2970550
959.15 473.97 437.76 772.17
450
30901
349.86
450
31500
619.44
450
31530
4441.56
450
31575
511.38
450
31605
1609.56
450
32110CA
3496.77
450
32160CA
3496.77
Amount
39 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4011
401132551-32551 INSERTION CHEST TUBE-BILAT
4011
401132555-32555 ASPIRATE PLEURA W/ IMAGING-BILAT
4011
401133505-33505 CL TX CLAVICULAR FX W MANIP, LT
4011
401133655-33655 CL TX SHLDR DISL W M ANES-LT
4011
401134500-34500 CL TX HUMERAL SHAFT FX WO MNP, LT
4011
401134577-34577 CL TX C HUMERUS FX W MANIP-LT
4011
401134605-34605 CL TX ELBOW DISLOC W ANES-LT
4011
401135505-35505 CL TX RADIAL SHFT FX W M-LT
4011
401135535-35535 TC CL TX ULN SHFT FX W M-LT
4011
401135565-35565 CL TX RAD & ULNA SHFT FX W M, LT
4011
401135605-35605 CLTX DSTL RDL FX/EPIPHY SEP-LT
4011
401135650-35650 CLOSED TX OF ULNAR STYLOID FX-LT
4011
401135680-35680 CL TX TRANS-SPL FX DISL W MNP, LT
4011
401136756-36756 PC SKTL FX D PHAL FX FNGR/THMB-F2
4011
401136775-36775 CL TX IP JNT DISL W M ANES-F2
4011
401137250-37250 CL TX TRAUMA HIP DISL WO ANES, LT
4011
401137252-37252 CL TX TRAUMA HIP DISL W ANES, LT
4011
401137257-37257 TX SPONT HIP DISL W M ANES-LT
4011
401137500-37500 CL TX FEMORAL SHAFT FX WO M-LT
4011
401137510-37510 CL TX FEM FX DIS/MED/LAT W M-LT
4011
401137530-37530 CL TX PROX TIBIAL FX WO MNP, LT
4011
401137552-37552 CL TX KNEE DISLOC W ANES, LT
4011
401137762-37762 CLTX MED ANKLE FX W/MNPJ LT
4011
401137788-37788 CL TX DISTL FIB FX W MNP-LT
4011
401137808-37808 CL FX BIMALLEOLAR ANKLE WO MNP LT
4011
401137810-37810 CLTX BIMALLEOLAR ANK FX W MNP, LT
4011
401137818-37818 CL TX TRIMALL ANKLE FX, W M-LT
Long Description
UB Revenue Code
CPT/HCPCS
Tube thoracostomy, includes connection to drainage system (eg, water seal), when performed, open
450
3255150
1624.57
450
3255550
2393.01
450
23505LT
4258.38
450
23655LT
4258.38
450
24500LT
698.97
450
24577LT
4258.38
450
24605LT
4258.38
450
25505LT
4258.38
450
25535LT
698.97
450
25565LT
4724.85
450
25605LT
4258.38
450
25650LT
698.97
450
25680LT
752.16
450
26756F2
8529.03
450
26775F2
4093.34
450
27250LT
752.16
450
27252LT
4258.38
450
27257LT
4093.34
450
27500LT
698.97
450
27510LT
1571.27
450
27530LT
698.97
450
27552LT
4258.38
450
27762LT
4724.85
450
27788LT
597.72
450
27808LT
752.16
450
27810LT
4724.85
450
27818LT
4258.38
Thoracentesis, needle or catheter, aspiration of the pleural space; with imaging guidance Closed treatment of clavicular fracture; with manipulation Closed treatment of shoulder dislocation, with manipulation; requiring anesthesia Closed treatment of humeral shaft fracture; without manipulation Closed treatment of humeral condylar fracture, medial or lateral; with manipulation Treatment of closed elbow dislocation; requiring anesthesia Closed treatment of radial shaft fracture; with manipulation Closed treatment of ulnar shaft fracture; with manipulation Closed treatment of radial and ulnar shaft fractures; with manipulation Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; with manipulation Closed treatment of ulnar styloid fracture Closed treatment of trans-scaphoperilunar type of fracture dislocation, with manipulation Percutaneous skeletal fixation of distal phalangeal fracture, finger or thumb, each Closed treatment of interphalangeal joint dislocation, single, with manipulation; requiring anesthesia Closed treatment of hip dislocation, traumatic; without anesthesia Closed treatment of hip dislocation, traumatic; requiring anesthesia Treatment of spontaneous hip dislocation (developmental, including congenital or pathological), by abduction, splint or traction; with manipulation, requiring anesthesia Closed treatment of femoral shaft fracture, without manipulation Closed treatment of femoral fracture, distal end, medial or lateral condyle, with manipulation Closed treatment of tibial fracture, proximal (plateau); without manipulation Closed treatment of knee dislocation; requiring anesthesia Closed treatment of medial malleolus fracture; with manipulation, with or without skin or skeletal traction Closed treatment of distal fibular fracture (lateral malleolus); with manipulation Closed treatment of bimalleolar ankle fracture (eg, lateral and medial malleoli, or lateral and posterior malleoli, or medial and posterior malleoli); without manipulation Closed treatment of bimalleolar ankle fracture (eg, lateral and medial malleoli, or lateral and posterior malleoli, or medial and posterior malleoli); with manipulation Closed treatment of trimalleolar ankle fracture; with manipulation
Amount
40 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
Long Description
UB Revenue Code
CPT/HCPCS
450
27824LT
698.97
450
27825LT
3883.80
450
27831LT
8529.03
450
28545LT
9258.42
450
29105LT
473.97
450
29125LT
372.41
450
29130F2
959.15
Amount
4011
401137824-37824 CL TX WB DSTL TIB FX WO MNP-LT
4011
401137825-37825 CL TX WB DSTL TIB FX W M-LT
4011
401137831-37831 CL TX TIB-FIB JNT DISL W ANE-LT
4011
401138545-38545 CL TX TARSAL BONE DIS W ANES,LT
4011
401139105-39105 APPLICATION LONG ARM SPLINT, LT
4011
401139125-39125 APPL SHORT ARM SPLNT STATIC-LT
4011
401139130-39130 TC APPLY FNGR SPLNT, STATIC-F2
Closed treatment of fracture of weight bearing articular portion of distal tibia (eg, pilon or tibial plafond), with or without anesthesia; without manipulation Closed treatment of fracture of weight bearing articular portion of distal tibia (eg, pilon or tibial plafond), with or without anesthesia; with skeletal traction and/or requiring manipulation Closed treatment of proximal tibiofibular joint dislocation; requiring anesthesia Closed treatment of tarsal bone dislocation, other than talotarsal; requiring anesthesia Application of long arm splint (shoulder to hand) Application of short arm splint (forearm to hand); static Application of finger splint; static
4011
401139505-39505 APPLY LONG LEG SPLINT-RT
Application of long leg splint (thigh to ankle or toes)
450
29505RT
473.97
4011 4011 4011
401139515-39515 APPLICATION SHORT LEG SPLINT, LT 401139580-39580 UNNA BOOT STRAPPING-LT 401139705-39705 REMOVE FULL ARM OR LEG CAST-LT
450 450 450
29515LT 29580LT 29705LT
473.97 437.76 772.17
4011
401141252-41252 REP LAC TNG FLR-MOUTH >2.60CM
Application of short leg splint (calf to foot) Strapping; Unna boot Removal or bivalving; full arm or full leg cast Repair of laceration of tongue, floor of mouth, over 2.6 cm or complex
450
41252
1609.56
4011
401142551-42551 INSERTION CHEST TUBE-LT
450
32551LT
1624.57
4011
401142555-42555 ASPIRATE PLEURA W/ IMAGING-LT
450
32555LT
2393.01
4011
401143505-43505 CL TX CLAVICULAR FX W MANIP, RT
450
23505RT
4258.38
4011
401143655-43655 CL TX SHLDR DISL W M ANES-RT
450
23655RT
4258.38
4011
401144500-44500 CL TX HUMERAL SHAFT FX WO MNP, RT
450
24500RT
698.97
4011
401144577-44577 CL TX C HUMERUS FX W MANIP-RT
450
24577RT
4258.38
4011
401144605-44605 CL TX ELBOW DISLOC W ANES-RT
450
24605RT
4258.38
4011
401144620-44620 CL TX MONTEGGIA ELB FX W MNP-RT
450
24620RT
4258.38
4011
401145300-45300 PROCTOSIGMOIDOSCOPY RIGID, DX
450
45300
2484.78
4011
401145505-45505 CL TX RADIAL SHFT FX W M-RT
450
25505RT
4258.38
4011
401145535-45535 TC CL TX ULN SHFT FX W M-RT
450
25535RT
698.97
4011
401145565-45565 CL TX RAD & ULNA SHFT FX W M, RT
450
25565RT
4724.85
4011
401145605-45605 CLTX DSTL RDL FX/EPIPHY SEP-RT
450
25605RT
4258.38
4011
401145650-45650 CLOSED TX OF ULNAR STYLOID FX-RT
450
25650RT
698.97
4011
401145680-45680 CL TX TRANS-SPL FX DISL W MNP, RT
450
25680RT
752.16
4011
401146756-46756 PC SKTL FX D PHAL FX FNGR/THMB-F3
450
26756F3
8529.03
4011
401146770-46770 CL TX IP JNT DISL W M WO ANES F3
450
26770F3
526.51
Tube thoracostomy, includes connection to drainage system (eg, water seal), when performed, open Thoracentesis, needle or catheter, aspiration of the pleural space; with imaging guidance Closed treatment of clavicular fracture; with manipulation Closed treatment of shoulder dislocation, with manipulation; requiring anesthesia Closed treatment of humeral shaft fracture; without manipulation Closed treatment of humeral condylar fracture, medial or lateral; with manipulation Treatment of closed elbow dislocation; requiring anesthesia Closed treatment of Monteggia type of fracture dislocation at elbow (fracture proximal end of ulna with dislocation of radial head), with manipulation Proctosigmoidoscopy, rigid; diagnostic, with or without collection of specimen(s) by brushing or washing Closed treatment of radial shaft fracture; with manipulation Closed treatment of ulnar shaft fracture; with manipulation Closed treatment of radial and ulnar shaft fractures; with manipulation Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; with manipulation Closed treatment of ulnar styloid fracture Closed treatment of trans-scaphoperilunar type of fracture dislocation, with manipulation Percutaneous skeletal fixation of distal phalangeal fracture, finger or thumb, each Closed treatment of interphalangeal joint dislocation, single, with manipulation; without anesthesia
41 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
Long Description
UB Revenue Code
CPT/HCPCS
450
26775F3
4093.34
450
27250RT
752.16
450
27252RT
4258.38
450
27257RT
4093.34
450
27500RT
698.97
450
27510RT
1571.27
450
27530RT
698.97
450
27552RT
4258.38
450
27762RT
4724.85
450
27788RT
597.72
450
2780850
752.16
450
27810RT
4724.85
450
27818RT
4258.38
450
27824RT
698.97
450
27825RT
3883.80
450
27831RT
8529.03
450
27842RT
4724.85
450
28545RT
9258.42
450
29105RT
473.97
450
29125RT
372.41
450
29130F3
959.15
Amount
4011
401146775-46775 CL TX IP JNT DISL W M ANES-F3
4011
401147250-47250 CL TX TRAUMA HIP DISL WO ANES, RT
4011
401147252-47252 CL TX TRAUMA HIP DISL W ANES, RT
4011
401147257-47257 TX SPONT HIP DISL W M ANES-RT
4011
401147500-47500 CL TX FEMORAL SHAFT FX WO M-RT
4011
401147510-47510 CL TX FEM FX DIS/MED/LAT W M-RT
4011
401147530-47530 CL TX PROX TIBIAL FX WO MNP, RT
4011
401147552-47552 CL TX KNEE DISLOC W ANES, RT
4011
401147762-47762 CLTX MED ANKLE FX W/MNPJ RT
4011
401147788-47788 CL TX DISTL FIB FX W MNP-RT
4011
401147808-47808 CL FX BIMALEOLAR ANKLE WO MNP BIL
4011
401147810-47810 CLTX BIMALLEOLAR ANK FX W MNP, RT
4011
401147818-47818 CL TX TRIMALL ANKLE FX, W M-RT
4011
401147824-47824 CL TX WB DSTL TIB FX WO MNP-RT
4011
401147825-47825 CL TX WB DSTL TIB FX W M-RT
4011
401147831-47831 CL TX TIB-FIB JNT DISL W ANE-RT
4011
401147842-47842 CL TX ANKLE DISLOC W ANES, RT
4011
401148545-48545 CL TX TARSAL BONE DIS W ANES,RT
4011
401149105-49105 APPLICATION LONG ARM SPLNT, RT
4011
401149125-49125 APPL SHORT ARM SPLNT STATIC-RT
4011
401149130-49130 TC APPLY FNGR SPLNT, STATIC-F3
Closed treatment of interphalangeal joint dislocation, single, with manipulation; requiring anesthesia Closed treatment of hip dislocation, traumatic; without anesthesia Closed treatment of hip dislocation, traumatic; requiring anesthesia Treatment of spontaneous hip dislocation (developmental, including congenital or pathological), by abduction, splint or traction; with manipulation, requiring anesthesia Closed treatment of femoral shaft fracture, without manipulation Closed treatment of femoral fracture, distal end, medial or lateral condyle, with manipulation Closed treatment of tibial fracture, proximal (plateau); without manipulation Closed treatment of knee dislocation; requiring anesthesia Closed treatment of medial malleolus fracture; with manipulation, with or without skin or skeletal traction Closed treatment of distal fibular fracture (lateral malleolus); with manipulation Closed treatment of bimalleolar ankle fracture (eg, lateral and medial malleoli, or lateral and posterior malleoli, or medial and posterior malleoli); without manipulation Closed treatment of bimalleolar ankle fracture (eg, lateral and medial malleoli, or lateral and posterior malleoli, or medial and posterior malleoli); with manipulation Closed treatment of trimalleolar ankle fracture; with manipulation Closed treatment of fracture of weight bearing articular portion of distal tibia (eg, pilon or tibial plafond), with or without anesthesia; without manipulation Closed treatment of fracture of weight bearing articular portion of distal tibia (eg, pilon or tibial plafond), with or without anesthesia; with skeletal traction and/or requiring manipulation Closed treatment of proximal tibiofibular joint dislocation; requiring anesthesia Closed treatment of ankle dislocation; requiring anesthesia, with or without percutaneous skeletal fixation Closed treatment of tarsal bone dislocation, other than talotarsal; requiring anesthesia Application of long arm splint (shoulder to hand) Application of short arm splint (forearm to hand); static Application of finger splint; static
4011
401149505-49505 APPLY LONG LEG SPLINT-LT
Application of long leg splint (thigh to ankle or toes)
450
29505LT
437.76
4011 4011 4011
401149515-49515 APPLY SHORT LEG SPLINT, RT 401149580-49580 UNNA BOOT STRAPPING-RT 401149705-49705 REMOVE FULL ARM OR LEG CAST-RT
Application of short leg splint (calf to foot) Strapping; Unna boot Removal or bivalving; full arm or full leg cast
450 450 450
29515RT 29580RT 29705RT
473.97 437.76 772.17
4011
401152551-52551 INSERTION CHEST TUBE-RT
Tube thoracostomy, includes connection to drainage system (eg, water seal), when performed, open
450
32551RT
1624.57
4011
401152555-52555 ASPIRATE PLEURA W/ IMAGING-RT
450
32555RT
2393.01
4011
401154220-54220 IRRIG CORPORA CAVERNOSA PRIAPISM
450
54220
802.80
Thoracentesis, needle or catheter, aspiration of the pleural space; with imaging guidance Irrigation of corpora cavernosa for priapism
42 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4011
401156756-56756 PC SKTL FX D PHAL FX FNGR/THMB-F4
4011
401156770-56770 CL TX IP JNT DISL W M WO ANES F4
4011
401156775-56775 CL TX IP JNT DISL W M ANES-F4
4011 4011
401159130-59130 TC APPLY FNGR SPLNT, STATIC-F4 401162270-62270 SPINAL PUNCTURE LUMBAR DIAGNOSTIC
4011
401166756-66756 PC SKTL FX D PHAL FX FNGR/THMB-F5
4011
401166770-66770 CL TX IP JNT DISL W M WO ANES F5
4011
401166775-66775 CL TX IP JNT DISL W M ANES-F5
4011
401169130-69130 TC APPLY FNGR SPLNT, STATIC-F5
4011
401176756-76756 PC SKTL FX D PHAL FX FNGR/THMB-F6
4011
401176770-76770 CL TX IP JNT DISL W M WO ANES F6
4011
401176775-76775 CL TX IP JNT DISL W M ANES-F6
4011
401186770-86770 CL TX IP JNT DISL W M WO ANES F7
4011
401186775-86775 CL TX IP JNT DISL W M ANES-F7
4011
401189130-89130 TC APPLY FNGR SPLNT, STATIC-F7
Long Description Percutaneous skeletal fixation of distal phalangeal fracture, finger or thumb, each Closed treatment of interphalangeal joint dislocation, single, with manipulation; without anesthesia Closed treatment of interphalangeal joint dislocation, single, with manipulation; requiring anesthesia Application of finger splint; static Spinal puncture, lumbar, diagnostic Percutaneous skeletal fixation of distal phalangeal fracture, finger or thumb, each Closed treatment of interphalangeal joint dislocation, single, with manipulation; without anesthesia Closed treatment of interphalangeal joint dislocation, single, with manipulation; requiring anesthesia Application of finger splint; static Percutaneous skeletal fixation of distal phalangeal fracture, finger or thumb, each Closed treatment of interphalangeal joint dislocation, single, with manipulation; without anesthesia Closed treatment of interphalangeal joint dislocation, single, with manipulation; requiring anesthesia Closed treatment of interphalangeal joint dislocation, single, with manipulation; without anesthesia Closed treatment of interphalangeal joint dislocation, single, with manipulation; requiring anesthesia Application of finger splint; static Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity.
UB Revenue Code
CPT/HCPCS
450
26756F4
8529.03
450
26770F4
526.51
450
26775F4
4093.34
450 450
29130F4 62270
959.15 1901.85
450
26756F5
8529.03
450
26770F5
526.51
450
26775F5
4093.34
450
29130F5
959.15
450
26756F6
8529.03
450
26770F6
526.51
450
26775F6
4093.34
360
26770F7
526.51
450
26775F7
4093.34
450
29130F7
959.15
450
99282
1221.88
450
99291
4491.74
450
99292
1817.39
Amount
4011
401190020-90020 ER LEVEL II
4011
401190060-90060 CRITICAL CARE 30-74 MINS
4011
401190061-90061 CRITICAL CARE EA ADD 30 MIN
4011
401192950-92950 CPR
Cardiopulmonary resuscitation (eg, in cardiac arrest)
450
92950
812.58
4011
401192977-92977 THROMBOLYSIS CORON, IV INFUS
450
92977
977.49
4011
401196367-96367 IV INF ADD SEQ NEW DRUG/SUB <=1HR
450
96367
185.97
4011
401196373-96373 THER/PROPH/DIAG INJ IA
260
96373
668.82
4011
401196756-96756 PC SKTL FX D PHAL FX FNGR/THMB-F8
Thrombolysis, coronary; by intravenous infusion Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); additional sequential infusion of a new drug/substance, up to 1 hour Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intra-arterial Percutaneous skeletal fixation of distal phalangeal fracture, finger or thumb, each
450
26756F8
8529.03
Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service)
43 of 167 Updated on 1/22/2019
Revenue Center
UB Revenue Code
CPT/HCPCS
360
26770F8
526.51
450
26775F8
4093.34
450
97597
535.59
450
29130F8
959.15
379
99151
132.74
401199152-99152 MOD SED SAME PHYS/QHP >=5 YRS
Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older
379
99152
285.47
401199153-99153 MOD SED SAME PHYS/QHP ADDT 15 MIN
Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List separately in addition to code for primary service)
379
99153
132.74
450
99285
3950.01
272
A6550
301.88
279 272
C1729
43.13 960.00
CDM Number
CDM Description
4011
401196770-96770 CL TX IP JNT DISL W M WO ANES F8
4011
401196775-96775 CL TX IP JNT DISL W M ANES-F8
4011
401197597-97597 SLCTV WOUND DEBRIDEM <=20 SQ CM
4011
401199130-99130 TC APPLY FNGR SPLNT, STATIC-F8
4011
401199151-99151 MOD SED SAME PHYS/QHP <5 YRS
4011
4011
4011
401199285-99285 EMERGENCY DEPT VISIT-LEVEL 5
4026
402600103-103 NS DOU VAC WOUND CARE SET
4027 4027
402700021-21 402700097-97
NS 3C TELEMETRY PER HOUR NS 3C FLEXISEAL CATHETER
Long Description Closed treatment of interphalangeal joint dislocation, single, with manipulation; without anesthesia Closed treatment of interphalangeal joint dislocation, single, with manipulation; requiring anesthesia Debridement (eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (eg, fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 sq cm or less Application of finger splint; static Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient younger than 5 years of age
Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function. Wound care set, for negative pressure wound therapy electrical pump, includes all supplies and accessories Catheter, drainage
Amount
44 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4027
402700301-301 NS 3C VAC WOUND CARE SET
4028
402800051-51
NS 3D VAC WOUND CARE SET
4029
402900010-10
NS MSO VAC WOUND CARE SET
4030
403009725-9725 NICU INIT INFANT HEAR'G SCRN-INPT
4030 4030 4030 4030 4030 4030 4030 4030
403010000-10000 403010001-10001 403010002-10002 403010003-10003 403010004-10004 403010005-10005 403010006-10006 403010007-10007
4032
403209723-9723 PP INIT INFANT HEARING SCRN-INPT
4034
403403502-3502 NS SICU VAC WOUND CARE SET
4035 4035 4035
403504108-4108 NS 4D LP TRAY 403504112-4112 NS 4D BILI EYE PATCH 403504113-4113 NS 4D BILI BLANKET
4037
403109724-9724 NUR INIT INFANT HEARING SCRN-INPT
Long Description Wound care set, for negative pressure wound therapy electrical pump, includes all supplies and accessories Wound care set, for negative pressure wound therapy electrical pump, includes all supplies and accessories Wound care set, for negative pressure wound therapy electrical pump, includes all supplies and accessories Initial infant (newborn) hearing screen - hospital inpatient
PROLACT+6 H2MF, PER ML 93901-30 PROLACT+8 H2MF, PER ML 93901-40 PROLACT+10 H2MF, PER ML 93901-50 PROLACT RTF 26, PER ML 95026-100 PROLACT RTF 28, PER ML 95028-100 PROLACT HM, PER ML 93000-118 PREMIELACT, PER ML 92003-10N PROLACT CR, PER ML 94000-10
4075
407500049-49
ALCOHOL/DRUG SCREENING (MCL)
4075
407500050-50
ALCOHOL/DRUG SRVC PER 15MIN (MCL)
4075
407500396-396 SBIRT AUDIT/DAST 15-30MIN (MCR)
4075
407500397-397 SBIRT AUDIT/DAST >30MIN (MCR)
4075 4075
407510008-10008 ADMIN FLU VIRUS VACCINE (MCR) 407510009-10009 ADMIN PNEUMONIA VACCINE (MCR)
4075
407511032-11032 HOSP OP CLN VISIT-NEW PT(Z1032ZL)
4075
407511034-11034 HOSP OP CLN VISIT-NEW PT (Z1034)
4075
407511036-11036 HOSP OUTPT CLINIC VISIT (Z1036)
4075
407531032-31032 HOSP OP CLN VISIT-EST PT(Z1032ZL)
4075
407531034-31034 HOSP OP CLN VISIT-EST PT (Z1034)
4075
407551032-51032 HOSP OP CLN VISIT-NEW PT (Z1032)
4075
407559000-59000 AMNIOCENTESIS, DIAGNOSTIC
4075
407559430-59430 HOSP OUTPT CLINIC VISIT (Z1038)
4075
407571032-71032 HOSP OP CLN VISIT-EST PT (Z1032)
4075
407576801-76801 OB US <14 WKS, SINGLE/1ST FETUS
UB Revenue Code
CPT/HCPCS
272
A6550
301.88
272
A6550
301.88
272
A6550
301.88
471
Z9725
73.31
270 270 270 270 270 270 270 270 Initial infant (newborn) hearing screen - hospital inpatient Wound care set, for negative pressure wound therapy electrical pump, includes all supplies and accessories
17.25 17.40 17.25 5.52 7.18 0.94 1.64 11.04
471
Z9725
73.31
272
A6550
301.88
272 271 271 Initial infant (newborn) hearing screen - hospital inpatient Alcohol and/or drug screening Alcohol and/or drug services, brief intervention, per 15 minutes Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., AUDIT, DAST), and brief intervention 15 to 30 minutes Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., AUDIT, DAST), and intervention, greater than 30 minutes Administration of influenza virus vaccine Administration of pneumococcal vaccine Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Amniocentesis; diagnostic Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (< 14 weeks 0 days), transabdominal approach; single or first gestation
Amount
66.88 9.38 10.94
471
Z9725
73.31
514
H0049
72.00
514
H0050
144.00
514
G0396
246.72
514
G0397
442.92
771 771
G0008 G0009
9.00 9.00
514
G0463TH
150.00
514
G0463TH
150.00
514
G0463TH
150.00
514
G0463TH
150.00
514
G0463TH
150.00
514
G0463TH
150.00
514
59000
2014.62
514
G0463TH
150.00
514
G0463TH
150.00
514
76801
400.62
45 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4075
407576802-76802 OB US <14 WKS,EA ADDL FETUS
4075
407576805-76805 OB US >=14 WKS, SNGL/1ST FETUS
4075
407576810-76810 OB US >+14 WKS,EA ADDL FETUS
4075
407576811-76811 OB US DETAILED, SINGLE/1ST FETUS
4075
407576817-76817 OB US, TRANSVAGINAL
4075
407580473-80473 IMMUN ADMIN ORAL/NASAL, 1 VACCINE
Long Description Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (< 14 weeks 0 days), transabdominal approach; each additional gestation Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> or = 14 weeks 0 days), transabdominal approach; single or first gestation Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> or = 14 weeks 0 days), transabdominal approach; each additional gestation Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation Ultrasound, pregnant uterus, real time with image documentation, transvaginal Immunization administration by intranasal or oral route; 1 vaccine (single or combination vaccine/toxoid)
4075
407586816-86816 US RE-EVAL ABNORMALITY PER FETUS
Ultrasound, pregnant uterus, real time with image documentation, follow-up (eg, re-evaluation of fetal size by measuring standard growth parameters and amniotic fluid volume, re-evaluation of organ system(s) suspected or confirmed to be abnormal on a previous scan), transabdominal approach, per fetus
4075
407586819-86819 FETAL BIOPHYS PROFILE WO NST
Fetal biophysical profile; without non-stress testing
4075
407590656-90656 VFC-IIV3 VACC NO PRSV 0.5ML IM
4075
407599024-99024 HOSP OUTPT CLINIC VISIT (POST-OP)
4075
407599201-99201 HOSP OUTPT CLINIC VISIT (99201)
4075
407599202-99202 HOSP OUTPT CLINIC VISIT (99202)
4075
407599203-99203 HOSP OUTPT CLINIC VISIT (99203)
4075
407599204-99204 HOSP OUTPT CLINIC VISIT (99204)
4075
407599205-99205 HOSP OUTPT CLINIC VISIT (99205)
4075
407599211-99211 HOSP OUTPT CLINIC VISIT (99211)
4075
407599212-99212 HOSP OUTPT CLINIC VISIT (99212)
4075
407599213-99213 HOSP OUTPT CLINIC VISIT (99213)
4075
407599214-99214 HOSP OUTPT CLINIC VISIT (99214)
4075
407599215-99215 HOSP OUTPT CLINIC VISIT (99215)
4075
407599408-99408 SBIRT AUDIT/DAST 15-30MIN (COMM)
4075
407599409-99409 SBIRT AUDIT/DAST 30+ MIN (COMM)
4075
433500102-102 STAPLE REMOVER
VFC - Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, 0.5 mL dosage, for intramuscular use (Administration Fee) Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; greater than 30 minutes
UB Revenue Code
CPT/HCPCS
402
76802
371.31
514
76805
400.62
402
76810
391.27
514
76811
400.62
514
76817
400.62
771
90473
9.00
514
76816
400.62
514
76819
400.62
771
90656SL
514
G0463
150.00
514
G0463
150.00
514
G0463
150.00
514
G0463
150.00
514
G0463
150.00
514
G0463
150.00
514
G0463
150.00
514
G0463
150.00
514
G0463
150.00
514
G0463
150.00
514
G0463
150.00
514
99408
246.72
514
99409
442.92
272
Amount
9.00
11.08 46 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4075 4075
433500104-104 SUTURE REMOVAL SET 433500108-108 DRESSING MINOR
4075
433501032-1032 CPSP INT OB VISIT <16W OF LMP
4075
433501034-1034 CPSP ANTEPARTUM VISITS 1-9
4075
433501036-1036 CPSP 10TH ANTEPARTUM VISIT
4075
433501038-1038 CPSP POSTPARTUM VISIT
4075
433501434-1434 CPSP INT OB VISIT >16W OF LMP
4075
433501727-7127 IMMUN ADMIN, EA ADDTL VACCINE
4075
433501727-1727 IMMUN ADMIN, EA ADDTL VACCINE
4075
433507126-7126 IMMUNIZATION ADMIN, 1 VACCINE
4075
433507500-7500 CLINIC EXAM RM (NURSE ONLY VISIT)
4075
433590715-90715 TDAP VACCINE =>7 YRS, IM
4075
433590716-90716 VFC-VARICELLA VACCINE (VARIVAX)
4075
433596372-96372 THER/PROPH/DIAG INJ SC/IM
4075
433599241-99241 HOSP OUTPT CLINIC VISIT (99241)
4075
433599242-99242 HOSP OUTPT CLINIC VISIT (99242)
4075
433599243-99243 HOSP OUTPT CLINIC VISIT (99243)
4075
433599244-99244 HOSP OUTPT CLINIC VISIT (99244)
4075
433599245-99245 HOSP OUTPT CLINIC VISIT (99245)
4075
433599384-99384 HOSP OUTPT CLINIC VISIT (99384)
4075
433599385-99385 HOSP OUTPT CLINIC VISIT (99385)
4075
433599386-99386 HOSP OUTPT CLINIC VISIT (99386)
4075
433599394-99394 HOSP OUTPT CLINIC VISIT (99394)
4075
433599395-99395 HOSP OUTPT CLINIC VISIT (99395)
Long Description
Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Prenatal care, at-risk enhanced service; antepartum management Postpartum care only Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 25 minutes are spent faceto-face with the patient and/or family. Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid) Hospital outpatient clinic visit for assessment and management of a patient Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), when administered to individuals 7 years or older, for intramuscular use VFC - Varicella virus vaccine (VAR), live, for subcutaneous use (Administration Fee) Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient
UB Revenue Code 272 272
CPT/HCPCS
Amount 50.60 31.65
514
G0463TH
206.63
514
G0463TH
150.00
514
H1001
150.00
514
59430
150.00
514
99214
150.00
771
90472
9.00
771
90472
9.00
771
90471
9.00
514
G0463
150.00
636
90715
9.00
771
90716SL
9.00
510
96372
86.25
514
G0463
150.00
514
G0463
150.00
514
G0463
150.00
514
G0463
150.00
514
G0463
150.00
514
G0463
150.00
514
G0463
150.00
514
G0463
150.00
514
G0463
150.00
514
G0463
150.00
47 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4075
433599396-99396 HOSP OUTPT CLINIC VISIT (99396)
4075
433599397-99397 HOSP OUTPT CLINIC VISIT (99397)
4075
435500201-201 OB EXAM RM LEVEL 1 - NEW PT
4075
435500202-202 OB EXAM RM LEVEL 2 - NEW PT
4075
435500203-203 OB EXAM RM LEVEL 3 - NEW PT
4075
435500204-204 OB EXAM RM LEVEL 4 - NEW PT
4075
435500211-211 OB EXAM RM LEVEL 1 - EST PT
4075
435500212-212 OB EXAM RM LEVEL 2 - EST PT
4075
435500213-213 OBS EXAM RM LEVEL 3 - EST PT
4075
435500214-214 OB EXAM RM LEVEL 4 - EST PT
4075
435500215-215 OB EXAM RM LEVEL 5 - EST PT
4075
435501435-1435 CPSP INIT NUTRITION ASMT, ADDT
4075
435501436-1436 CPSP INITIAL NUTRITION ASMT
4075
435501437-1437 CPSP NUTRIT RE-ASMT, ANTE, IND
4075
435501438-1438 CPSP F/U NUTRITION ASMT, GRP
4075
435501439-1439 CPSP NUTRITION ASMT-POSTPARTUM
4075
435501441-1441 CPSP INITIAL PSYCHOSOCIAL ASMT
4075
435501442-1442 CPSP INIT PSYCH-SOC ASMT, ADDT
4075
435501443-1443 CPSP PSY-SOC RE-ASMT/ANTE, IND
4075
435501444-1444 CPSP F/U PSYCHSOCIAL ASMT, GRP
4075
435501446-1446 CPSP HLTH ED ORIENTATION, INDV
4075 4075
435501447-1447 CPSP INITIAL HEALTH ED ASSMNT 435501448-1448 CPSP INIT HEALTH ED ASMT, ADDT
4075
435501449-1449 CPSP HLTH ED RE-ASMT/ANTE, IND
4075 4075
435501451-1451 CPSP PERINATAL ED, INDV 435501457-1457 CPSP INIT COMPREHENSIVE ASMT
4075
435590474-90474 IMMUN ADMIN ORAL/NASAL, EA ADDTL
Long Description Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes Medical nutrition therapy; re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes Medical nutrition therapy; group (2 or more individuals), each 30 minutes Medical nutrition therapy; re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes Health and behavior assessment (eg, health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient; initial assessment Health and behavior assessment (eg, health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient; initial assessment Health and behavior assessment (eg, health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient; re-assessment Health and behavior intervention, each 15 minutes, face-to-face; group (2 or more patients) Prenatal care, at risk enhanced service; care coordination Prenatal care, at-risk assessment Prenatal care, at-risk assessment Patient education, not otherwise classified, nonphysician provider, individual, per session Prenatal care, at-risk enhanced service; education Comprehensive multidisciplinary evaluation Immunization administration by intranasal or oral route; each additional vaccine (single or combination vaccine/toxoid)
UB Revenue Code
CPT/HCPCS
514
G0463
150.00
514
G0463
150.00
514
G0463
150.00
514
G0463
150.00
514
G0463
150.00
514
G0463
150.00
514
G0463
150.00
514
G0463
150.00
514
G0463
150.00
514
G0463
150.00
514
G0463
150.00
514
97802UA
25.23
514
97802UA
25.23
514
97803UA
25.23
514
97804UA
16.86
514
97803UB
25.23
514
96150UA
246.72
514
96150UA
246.72
514
96151UA
246.72
514
96153UA
96.06
514
H1002
25.23
514 514
H1000 H1000
25.23 25.23
514
S9445UA
25.23
514 514
H1003 H2000TH
25.23 407.49
771
90474
Amount
9.00
48 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
4076
407600049-49
ALCOHOL/DRUG SCREENING (MCL)
4076
407600050-50
ALCOHOL/DRUG SRVC PER 15MIN (MCL)
4076
407600396-396 SBIRT AUDIT/DAST 15-30MIN (MCR)
4076
407600397-397 SBIRT AUDIT/DAST >30MIN (MCR)
4076
407600463-463 HOSPITAL OUTPT CLINIC VISIT
4076 4076
407610008-10008 ADMIN FLU VIRUS VACCINE 407610009-10009 ADMIN PNEUMONIA VACCINE
4076
407620600-20600 DRN/INJ SMLL JNT/BURSA WO US GUID
4076
CDM Description
407620605-20605 DRN/INJ INT JNT/BURSA WO US GUIDE
4076
407620610-20610 DRN/INJ MAJOR JNT/BURSA WO US GD
4076
407623500-23500 CL TX CLAVICULAR FX WO MNP
4076
407623505-23505 CL TX CLAVICULAR FX W MNP
4076
407623520-23520 CL TX SCLAV DISLOC WO MNP
4076
407623540-23540 CL TX ACLAV DISLOC WO MNP
4076
407623570-23570 CL TX SCAPULAR FX WO MNP
4076
407623600-23600 CL TX PROX HUMERAL FX WO MNP
4076
407623620-23620 CL TX GR HUMER TUBEROSITY FX WO M
4076
407624500-24500 CL TX HUMERAL SHFT FX WO MNP
4076
407624505-24505 CL TX HUMERAL SHFT FX W MNP
4076
407624530-24530 CL TX SC/TC HUMERUS FX WO MNP
4076
407624535-24535 CL TX SC/TC HUMERUS FX W MNP
4076
407624560-24560 CL TX HUMERAL EC FX WO MNP
4076
407624576-24576 CL TX HUMERAL CONDYLAR FX WO MNP
4076
407624600-24600 CL TX ELBOW DISLOC WO ANES
4076
407624620-24620 CL TX MONTEGGIA ELBOW FX DISL W M
4076
407624640-24640 CL TX NURSEMAID ELBOW W MANIP
4076
407624650-24650 CL TX RADIAL HEAD/NECK FX WO MNP
4076
407624655-24655 CLTX RADIAL HEAD/NECK FX W MNP
Long Description Alcohol and/or drug screening Alcohol and/or drug services, brief intervention, per 15 minutes Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., AUDIT, DAST), and brief intervention 15 to 30 minutes Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., AUDIT, DAST), and intervention, greater than 30 minutes Hospital outpatient clinic visit for assessment and management of a patient Administration of influenza virus vaccine Administration of pneumococcal vaccine Arthrocentesis, aspiration and/or injection, small joint or bursa (eg, fingers, toes); without ultrasound guidance Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); without ultrasound guidance Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance Closed treatment of clavicular fracture; without manipulation Closed treatment of clavicular fracture; with manipulation Closed treatment of sternoclavicular dislocation; without manipulation Closed treatment of acromioclavicular dislocation; without manipulation Closed treatment of scapular fracture; without manipulation Closed treatment of proximal humeral (surgical or anatomical neck) fracture; without manipulation Closed treatment of greater humeral tuberosity fracture; without manipulation Closed treatment of humeral shaft fracture; without manipulation Closed treatment of humeral shaft fracture; with manipulation, with or without skeletal traction Closed treatment of supracondylar or transcondylar humeral fracture, with or without intercondylar extension; without manipulation Closed treatment of supracondylar or transcondylar humeral fracture, with or without intercondylar extension; with manipulation, with or without skin or skeletal traction Closed treatment of humeral epicondylar fracture, medial or lateral; without manipulation Closed treatment of humeral condylar fracture, medial or lateral; without manipulation Treatment of closed elbow dislocation; without anesthesia Closed treatment of Monteggia type of fracture dislocation at elbow (fracture proximal end of ulna with dislocation of radial head), with manipulation Closed treatment of radial head subluxation in child, nursemaid elbow, with manipulation Closed treatment of radial head or neck fracture; without manipulation Closed treatment of radial head or neck fracture; with manipulation
UB Revenue Code 510
CPT/HCPCS
Amount
H0049
72.00
510
H0050
144.00
510
G0396
246.72
510
G0397
442.92
510
G0463
372.90
771 771
G0008 G0009
129.60 129.60
510
20600
856.47
510
20605
856.47
510
20610
856.47
510
23500
752.16
510
23505
4724.85
510
23520
4724.85
510
23540
752.16
510
23570
752.16
510
23600
752.16
510
23620
752.16
510
24500
752.16
510
24505
4724.85
510
24530
752.16
510
24535
4724.85
510
24560
752.16
510
24576
752.16
510
24600
752.16
510
24620
4724.85
510
24640
752.16
510
24650
752.16
510
24655
4724.85
49 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4076
407624670-24670 CL TX ULNA FX PROXIMAL END WO MNP
4076
407624675-24675 CL TX ULNA FX PROXIMAL END W MNP
4076
407625500-25500 CL TX RADIAL SHAFT FX WO MNP
4076
407625505-25505 CL TX RADIAL SHFT FX W MNP
4076
407625520-25520 GALEAZZI FX/DISLOC
4076
407625530-25530 CL TX ULNAR SHAFT FX WO MNP
4076
407625535-25535 CL TX ULNAR SHFT FX W MNP
4076
407625560-25560 CLTX RADIAL & ULNA SHFT FX WO MNP
4076
407625565-25565 CL TX RADIAL & ULNA SHFT FX W MNP
4076
407625600-25600 CLTX DSTL RDL FX/EPIPHYS SEP WO M
4076
407625605-25605 CLTX DSTL RDL FX/EPIPHYSL SEP W M
4076
407625622-25622 CL TX CARPAL SCAPHOID FX WO MNP
4076
407625630-25630 CL TX CARPAL BONE FX WO MNP, EA
4076
407625635-25635 CLTX CARPAL BONE FX W MNP, EACH
4076
407625650-25650 CL TX ULNAR STYLOID FX
4076
407625675-25675 CLTX DSTL RADIOULNAR DISLOC W MNP
4076
407625680-25680 CL TX TRANS-SPL FX DISLOC W MNP
4076
407625690-25690 CL TX LUNATE DISLOC W MNP
4076
407626600-26600 CL TX MC FX SGL WO MNP, EA BONE
4076
407626605-26605 CL TX MC FX SGL W MNP, EA BONE
4076
407626641-26641 CL TX CMC DISLOC THUMB W MANIP
4076
407626645-26645 CL TX CMC FX DISLOC, THUMB W MNP
4076
407626670-26670 CL TX CMC DISL W MNP WO ANES, EA
4076
407626700-26700 CL TX MCP DISL SGL W MNP WO ANES
4076
407626720-26720 CL TX PHAL SHAFT FX WO MNP, EA
Long Description Closed treatment of ulnar fracture, proximal end (eg, olecranon or coronoid process[es]); without manipulation Closed treatment of ulnar fracture, proximal end (eg, olecranon or coronoid process[es]); with manipulation Closed treatment of radial shaft fracture; without manipulation Closed treatment of radial shaft fracture; with manipulation Closed treatment of radial shaft fracture and closed treatment of dislocation of distal radioulnar joint (Galeazzi fracture/dislocation) Closed treatment of ulnar shaft fracture; without manipulation Closed treatment of ulnar shaft fracture; with manipulation Closed treatment of radial and ulnar shaft fractures; without manipulation Closed treatment of radial and ulnar shaft fractures; with manipulation Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; without manipulation Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; with manipulation Closed treatment of carpal scaphoid (navicular) fracture; without manipulation Closed treatment of carpal bone fracture (excluding carpal scaphoid [navicular]); without manipulation, each bone Closed treatment of carpal bone fracture (excluding carpal scaphoid [navicular]); with manipulation, each bone Closed treatment of ulnar styloid fracture Closed treatment of distal radioulnar dislocation with manipulation Closed treatment of trans-scaphoperilunar type of fracture dislocation, with manipulation Closed treatment of lunate dislocation, with manipulation Closed treatment of metacarpal fracture, single; without manipulation, each bone Closed treatment of metacarpal fracture, single; with manipulation, each bone Closed treatment of carpometacarpal dislocation, thumb, with manipulation Closed treatment of carpometacarpal fracture dislocation, thumb (Bennett fracture), with manipulation Closed treatment of carpometacarpal dislocation, other than thumb, with manipulation, each joint; without anesthesia Closed treatment of metacarpophalangeal dislocation, single, with manipulation; without anesthesia Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; without manipulation, each
UB Revenue Code
CPT/HCPCS
510
24670
752.16
510
24675
4724.85
510
25500
752.16
510
25505
4724.85
510
25520
4724.85
510
25530
752.16
510
25535
752.16
510
25560
752.16
510
25565
4724.85
510
25600
752.16
510
25605
4724.85
510
25622
752.16
510
25630
752.16
510
25635
4724.85
510
25650
752.16
510
25675
752.16
510
25680
752.16
510
25690
4724.85
510
26600
752.16
510
26605
752.16
510
26641
752.16
510
26645
4724.85
510
26670
752.16
510
26700
752.16
510
26720
752.16
Amount
50 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4076
407626725-26725 CL TX PHALANG SHFT FX W MNP, EA
4076
407626740-26740 CL TX ART FX MCP/IP JNT WO M, EA
4076
407626742-26742 CL TX ART FX MCP/IP JNT W MNP, EA
4076
407626750-26750 CL TX D PHAL FX FGR/THMB WO M, EA
4076
407626755-26755 CL TX D PHAL FX FGR/THMB W M, EA
4076
407626770-26770 CL TX IP JNT DISLOC W MNP WO ANES
4076
407627246-27246 CL TX GTR TROCHNTRC FX WO MANIP
4076
407627256-27256 TX SP HIP DIS ABD SPLNT/TRAC WO M
4076
407627265-27265 CL TX POST HIP DISLOC WO ANES
4076
407627510-27510 CL TX FEMUR FX DSTL END W MNP
4076
407627516-27516 CL TX DSTL FEM EPIPHYS SEP WO MNP
4076
407627517-27517 CL TX DSTL FEM EPIPHYS SEP W MNP
4076
407627520-27520 CL TX PATELLAR FX WO MNP
4076
407627530-27530 CL TX PROX TIBIAL FX WO MNP
4076
407627538-27538 CL TX IC SP/TUBEROSITY FX OF KNEE
4076
407627560-27560 CL TX PATELLAR DISLOC WO ANES
4076
407627750-27750 CL TX TIBIAL SHFT FX WO MNP
4076
407627752-27752 CL TX TIBIAL SHFT FX W MNP
4076
407627760-27760 CL TX MEDIAL ANKLE FX WO MNP
4076
407627767-27767 CL TX POST ANKLE FX WO MNP
4076
407627780-27780 CL TX PROX FIBULA/SHAFT FX WO MNP
4076
407627786-27786 CL TX DISTL FIBULAR FX WO MNP
4076
407627788-27788 CL TX DISTL FIBULAR FX W MNP
4076
407627808-27808 CL TX BIMALLEOLAR ANKLE FX WO MNP
4076
407627810-27810 CL TX BIMALLEOLAR ANKLE FX W MNP
Long Description Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; with manipulation, with or without skin or skeletal traction, each Closed treatment of articular fracture, involving metacarpophalangeal or interphalangeal joint; without manipulation, each Closed treatment of articular fracture, involving metacarpophalangeal or interphalangeal joint; with manipulation, each Closed treatment of distal phalangeal fracture, finger or thumb; without manipulation, each Closed treatment of distal phalangeal fracture, finger or thumb; with manipulation, each Closed treatment of interphalangeal joint dislocation, single, with manipulation; without anesthesia Closed treatment of greater trochanteric fracture, without manipulation Treatment of spontaneous hip dislocation (developmental, including congenital or pathological), by abduction, splint or traction; without anesthesia, without manipulation Closed treatment of post hip arthroplasty dislocation; without anesthesia Closed treatment of femoral fracture, distal end, medial or lateral condyle, with manipulation Closed treatment of distal femoral epiphyseal separation; without manipulation Closed treatment of distal femoral epiphyseal separation; with manipulation, with or without skin or skeletal traction Closed treatment of patellar fracture, without manipulation Closed treatment of tibial fracture, proximal (plateau); without manipulation Closed treatment of intercondylar spine(s) and/or tuberosity fracture(s) of knee, with or without manipulation Closed treatment of patellar dislocation; without anesthesia Closed treatment of tibial shaft fracture (with or without fibular fracture); without manipulation Closed treatment of tibial shaft fracture (with or without fibular fracture); with manipulation, with or without skeletal traction Closed treatment of medial malleolus fracture; without manipulation Closed treatment of posterior malleolus fracture; without manipulation Closed treatment of proximal fibula or shaft fracture; without manipulation Closed treatment of distal fibular fracture (lateral malleolus); without manipulation Closed treatment of distal fibular fracture (lateral malleolus); with manipulation Closed treatment of bimalleolar ankle fracture (eg, lateral and medial malleoli, or lateral and posterior malleoli, or medial and posterior malleoli); without manipulation Closed treatment of bimalleolar ankle fracture (eg, lateral and medial malleoli, or lateral and posterior malleoli, or medial and posterior malleoli); with manipulation
UB Revenue Code
CPT/HCPCS
510
26725
752.16
510
26740
752.16
510
26742
4724.85
510
26750
752.16
510
26755
752.16
510
26770
752.16
510
27246
752.16
510
27256
752.16
510
27265
752.16
510
27510
4724.85
510
27516
752.16
510
27517
4724.85
510
27520
752.16
510
27530
752.16
510
27538
752.16
510
27560
752.16
510
27750
752.16
510
27752
4724.85
510
27760
752.16
510
27767
752.16
510
27780
752.16
510
27786
752.16
510
27788
752.16
510
27808
752.16
510
27810
4724.85
Amount
51 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
Long Description Closed treatment of trimalleolar ankle fracture; without manipulation Closed treatment of trimalleolar ankle fracture; with manipulation Closed treatment of fracture of weight bearing articular portion of distal tibia (eg, pilon or tibial plafond), with or without anesthesia; without manipulation Closed treatment of ankle dislocation; without anesthesia Closed treatment of calcaneal fracture; without manipulation Closed treatment of talus fracture; without manipulation Treatment of tarsal bone fracture (except talus and calcaneus); without manipulation, each Closed treatment of metatarsal fracture; without manipulation, each Closed treatment of fracture great toe, phalanx or phalanges; without manipulation Closed treatment of fracture great toe, phalanx or phalanges; with manipulation
UB Revenue Code
CPT/HCPCS
510
27816
752.16
510
27818
4724.85
510
27824
752.16
510
27840
752.16
510
28400
752.16
510
28430
752.16
510
28450
752.16
510
28470
752.16
510
28490
752.16
510
28495
752.16
Amount
4076
407627816-27816 CL TX TRIMALL ANKLE FX WO MNP
4076
407627818-27818 CL TX TRIMALL ANKLE FX W MNP
4076
407627824-27824 CL TX FX WB ART DSTL TIB WO MNP
4076
407627840-27840 CL TX ANKLE DISLOC WO ANES
4076
407628400-28400 CL TX CALCANEAL FX WO MNP
4076
407628430-28430 CL TX TALUS FX WO MNP
4076
407628450-28450 TX TARSAL BONE FX WO MNP, EA
4076
407628470-28470 CL TX METATARSAL FX WO MNP, EACH
4076
407628490-28490 CL TX FX GT PHALANX(S) WO MNP
4076
407628495-28495 CL TX GT PHALANX(S) FX W MNP
4076
407628510-28510 CL TX FX PHALNX/PHALANG WO M, EA
Closed treatment of fracture, phalanx or phalanges, other than great toe; without manipulation, each
510
28510
752.16
4076
407628515-28515 CL TX FX PHALANX(S) W MNP, EA
Closed treatment of fracture, phalanx or phalanges, other than great toe; with manipulation, each
510
28515
752.16
4076
407628540-28540 CL TX TARSAL BONE DISL WO ANES
510
28540
752.16
4076
407628600-28600 CL TX TMT JNT DISL WO ANES
510
28600
752.16
4076 4076 4076
407629035-29035 APPLY BODY CAST, SHOULDER TO HIPS 407629065-29065 APPLY LONG ARM CAST 407629075-29075 APPLY SHORT ARM CAST
Closed treatment of tarsal bone dislocation, other than talotarsal; without anesthesia Closed treatment of tarsometatarsal joint dislocation; without anesthesia Application of body cast, shoulder to hips; Application, cast; shoulder to hand (long arm) Application, cast; elbow to finger (short arm)
510 510 510
29035 29065 29075
830.49 830.49 830.49
4076
407629085-29085 APPLY GAUNTLET CAST
Application, cast; hand and lower forearm (gauntlet)
510
29085
473.97
4076 4076
407629086-29086 APPLY FINGER CAST 407629105-29105 APPLY LONG ARM SPLINT
510 510
29086 29105
473.97 473.97
4076
407629125-29125 APPLY SHORT ARM SPLINT, STATIC
510
29125
367.65
4076
407629126-29126 APPLY SHORT ARM SPLINT, DYNAMIC
510
29126
367.65
4076 4076 4076 4076 4076 4076 4076
407629130-29130 407629131-29131 407629200-29200 407629240-29240 407629260-29260 407629280-29280 407629305-29305
510 510 510 510 510 510 510
29130 29131 29200 29240 29260 29280 29305
195.87 195.87 473.97 367.65 111.30 111.30 830.49
4076
407629325-29325 APPLY HIP CAST 1.5 SPICA/2 LEGS
510
29325
830.49
4076 4076 4076
407629345-29345 APPLY LONG LEG CAST 407629365-29365 APPLY CYLINDER CAST 407629405-29405 APPLY SHORT LEG CAST
510 510 510
29345 29365 29405
830.49 830.49 830.49
4076
407629425-29425 APPLY SHORT LEG CAST, WALKING
510
29425
830.49
4076
407629435-29435 APPLY PATELLA TENDON BEARING CAST
510
29435
830.49
4076
407629450-29450 APPLY CLUBFT CAST, LONG/SHORT LEG
Application, cast; finger (eg, contracture) Application of long arm splint (shoulder to hand) Application of short arm splint (forearm to hand); static Application of short arm splint (forearm to hand); dynamic Application of finger splint; static Application of finger splint; dynamic Strapping; thorax Strapping; shoulder (eg, Velpeau) Strapping; elbow or wrist Strapping; hand or finger Application of hip spica cast; 1 leg Application of hip spica cast; 1 and one-half spica or both legs Application of long leg cast (thigh to toes); Application of cylinder cast (thigh to ankle) Application of short leg cast (below knee to toes); Application of short leg cast (below knee to toes); walking or ambulatory type Application of patellar tendon bearing (PTB) cast Application of clubfoot cast with molding or manipulation, long or short leg
510
29450
473.97
4076
407629505-29505 APPLY LONG LEG SPLINT
Application of long leg splint (thigh to ankle or toes)
510
29505
473.97
4076 4076
407629515-29515 APPLY SHORT LEG SPLINT 407629520-29520 HIP STRAPPING
Application of short leg splint (calf to foot) Strapping; hip
510 510
29515 29520
473.97 195.87
APPLY FINGER SPLINT, STATIC APPLY FINGER SPLINT, DYNAMIC THORAX STRAPPING SHOULDER STRAPPING ELBOW/WRIST STRAPPING HAND/FINGER STRAPPING APPLY HIP SPICA CAST 1 LEG
52 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4076 4076 4076 4076 4076 4076
407629530-29530 407629540-29540 407629550-29550 407629580-29580 407639065-39065 407639075-39075
4076
407639085-39085 APPLY GAUNTLET CAST BY PHYSICIAN
Application, cast; hand and lower forearm (gauntlet)
4076 4076
407639086-39086 APPLY FINGER CAST BY PHYSICIAN 407639105-39105 APPLY LONG ARM SPLINT BY PHYS
4076
407639126-39126 APP SHORT ARM SPLNT-DYNAMC BY PHY
4076 4076 4076 4076 4076 4076
407639130-39130 407639131-39131 407639280-39280 407639345-39345 407639365-39365 407639405-39405
4076
407639425-39425 APPLY WLKR SH LEG CAST BY PHYS
4076
407639435-39435 APPLY PTB CAST BY PHYSICIAN
4076
407639450-39450 APPLY CLUBFOOT CAST BY PHYSICIAN
4076
Amount 367.65 473.97 195.87 473.97 830.49 830.49
510
29085
473.97
Application, cast; finger (eg, contracture) Application of long arm splint (shoulder to hand) Application of short arm splint (forearm to hand); dynamic Application of finger splint; static Application of finger splint; dynamic Strapping; hand or finger Application of long leg cast (thigh to toes); Application of cylinder cast (thigh to ankle) Application of short leg cast (below knee to toes); Application of short leg cast (below knee to toes); walking or ambulatory type Application of patellar tendon bearing (PTB) cast Application of clubfoot cast with molding or manipulation, long or short leg
510 510
29086 29105
473.97 473.97
510
29126
367.65
510 510 510 510 510 510
29130 29131 29280 29345 29365 29405
195.87 195.87 111.30 830.49 830.49 830.49
510
29425
830.49
510
29435
830.49
510
29450
473.97
407639505-39505 APPLY LONG LEG SPLINT BY PHYS
Application of long leg splint (thigh to ankle or toes)
510
29505
473.97
4076 4076
407639515-39515 APPLY SHORT LEG SPLINT BY PHYS 407639740-39740 CAST WEDGING (NOT CLUBFT) BY PHYS
510 510
29515 29740
473.97 830.49
4076
407640670-40670 REMOVAL OF IMPLANT, SUPERFICIAL
510
20670
4718.16
4076
407649125-49125 APP SHORT ARM SPLNT-STATIC BY PHY
510
29125
367.65
4076
407661026-61026 BRAIN CANAL INJ W MEDS
Application of short leg splint (calf to foot) Wedging of cast (except clubfoot casts) Removal of implant; superficial (eg, buried wire, pin or rod) Application of short arm splint (forearm to hand); static Ventricular puncture through previous burr hole, fontanelle, suture, or implanted ventricular catheter/reservoir; with injection of medication or other substance for diagnosis or treatment
510
61026
1901.85
510
97605
591.33
771
90471
9.00
771
90472
9.00
260
96372
203.70
510
G0463
397.92
510
G0463
397.92
510
G0463
397.92
510
G0463
397.92
510
G0463
397.92
APPLY FNGR SPLINT, STATIC BY PHYS APPLY FNGR SPLINT-DYNAMIC BY PHYS HAND/FNGR STRAPPING BY PHYSICIAN APPLY LONG LEG CAST BY PHYSICIAN APPLY CYLINDER CAST BY PHYSICIAN APPLY SHORT LEG CAST BY PHYSICIAN
407687605-87605 NEG PRESS WND TX <=50 SQ CM
4076
407690471-90471 IMMUNIZATION ADMIN, 1 VACCINE
4076
407690472-90472 IMMUN ADMIN, EA ADDTL VACCINE
4076
407696372-96372 THER/PROPH/DIAG INJECTION, SC/IM
4076
407699024-99024 HOSP OP CLINIC VISIT-POSTOP F/U
4076
407699201-99201 HOSP OP CLINIC VISIT, NEW-LVL 1
4076
407699202-99202 HOSP OP CLINIC VISIT, NEW-LVL 2
4076
407699203-99203 HOSP OP CLINIC VISIT, NEW-LVL 3
4076
407699204-99204 HOSP OP CLINIC VISIT, NEW-LVL 4
Strapping; knee Strapping; ankle and/or foot Strapping; toes Strapping; Unna boot Application, cast; shoulder to hand (long arm) Application, cast; elbow to finger (short arm)
CPT/HCPCS 29530 29540 29550 29580 29065 29075
4076
KNEE STRAPPING ANKLE/FOOT STRAPPING TOES STRAPPING UNNA BOOT STRAPPING APPLY LONG ARM CAST BY PHYSICIAN APPLY SHORT ARM CAST BY PHYSICIAN
Long Description
UB Revenue Code 510 510 510 510 510 510
Negative pressure wound therapy (eg, vacuum assisted drainage collection), utilizing durable medical equipment (DME), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid) Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient
53 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4076
407699205-99205 HOSP OP CLINIC VISIT, NEW-LVL 5
4076
407699211-99211 HOSP OP CLINIC VISIT, EST-LVL 1
4076
407699212-99212 HOSP OP CLINIC VISIT, EST-LVL 2
4076
407699213-99213 HOSP OP CLINIC VISIT, EST-LVL 3
4076
407699214-99214 HOSP OP CLINIC VISIT, EST-LVL 4
4076
407699215-99215 HOSP OP CLINIC VISIT, EST-LVL 5
4076
407699241-99241 HOSP OP CLINIC CONSULT-LVL 1
4076
407699242-99242 HOSP OP CLINIC CONSULT-LVL 2
4076
407699243-99243 HOSP OP CLINIC CONSULT-LVL 3
4076
407699244-99244 HOSP OP CLINIC CONSULT-LVL 4
4076
407699245-99245 HOSP OP CLINIC CONSULT-LVL 5
4076
407699408-99408 SBIRT AUDIT/DAST 15-30MIN (COMM)
4076
407699409-99409 SBIRT AUDIT/DAST >30MIN (COMM)
4076
437500204-204 ORT EXAM RM LEVEL 4 - NEW
4077
407700396-396 SBIRT AUDIT/DAST 15-30MIN (MCR)
4077
407700397-397 SBIRT AUDIT/DAST >30MIN (MCR)
4077
407799408-99408 SBIRT AUDIT/DAST 15-30MIN (COMM)
4077
407799409-99409 SBIRT AUDIT/DAST >30MIN (COMM)
4077 4077
435000100-100 ST CATH TRAY 435000101-101 SUTURE REMOVAL SET
4077
435000201-201 PED EXAM RM LEVEL 1 - NEW PT
4077
435000202-202 PED EXAM RM LEVEL 2 - NEW PT
4077
435000203-203 PED EXAM RM LEVEL 3 - NEW PT
4077
435000204-204 PED EXAM RM LEVEL 4 - NEW PT
Long Description Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; greater than 30 minutes Hospital outpatient clinic visit for assessment and management of a patient Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., AUDIT, DAST), and brief intervention 15 to 30 minutes Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., AUDIT, DAST), and intervention, greater than 30 minutes Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; greater than 30 minutes
UB Revenue Code
CPT/HCPCS
510
G0463
397.92
510
G0463
397.92
510
G0463
397.92
510
G0463
397.92
510
G0463
397.92
510
G0463
397.92
510
G0463
150.00
510
G0463
150.00
510
G0463
150.00
510
G0463
150.00
510
G0463
150.00
510
99408
246.72
510
99409
442.92
510
G0463
150.00
515
G0396
246.72
515
G0397
442.92
515
99408
246.72
515
99409
442.92
272 272 Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient
Amount
51.75 50.60
515
G0463
150.00
515
G0463
150.00
515
G0463
150.00
515
G0463
150.00
54 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4077
435000205-205 PED EXAM RM LEVEL 5 - NEW PT
4077
435000211-211 PED EXAM RM LEVEL 1 - EST PT
4077
435000212-212 PED EXAM RM LEVEL 2 - EST PT
4077
435000213-213 PED EXAM RM LEVEL 3 - EST PT
4077
435000214-214 PED EXAM RM LEVEL 4 - EST PT
4077
435000215-215 PED EXAM RM LEVEL 5 - EST PT
4077
435001968-1968 THER/PROPH/DIAG INJ SC/IM
4077
435001969-1969 IMMUNIZATION ADMIN 1 VACCINE
4077
435001970-1970 IMMUN ADMIN, EA ADDTL VACCINE
4077
435002601-2601 PREV MED EXAM EST 1-4 YR
4077
435002654-2654 AEROSOL INHALATION TREATMENT
4077
435002900-2900 PREV MED EXAM EST INFANT <1 YR
4077
435007500-7500 CLINIC EXAM RM (FACILITY ONLY)
4077
435010084-10084 HIB VACC, PRP-OMP 3-DOSE IM
4077
435090660-90660 FLU VACCINE, LIVE, NASAL
4077
435099393-99393 PREV MED EXAM EST PT 5-11 YRS
4077
4078
435099394-99394 PREV MED EXAM EST PT 12-17 YRS
407800050-50
ALCOHOL/DRUG SRVC PER 15MIN (MCL)
UB Revenue Code
CPT/HCPCS
515
99205
123.00
515
G0463
150.00
515
G0463
150.00
515
G0463
150.00
515
G0463
150.00
515
G0463
150.00
510
96372
86.25
771
90471
9.00
771
90472
12.00
770
G0439
150.00
410
94640
529.41
515
G0439
150.00
510
G0463
150.00
636
90647
9.00
636
90660
9.00
770
G0439
150.00
Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; adolescent (age 12 through 17 years)
515
99394
150.00
Alcohol and/or drug services, brief intervention, per 15 minutes
510
H0050
144.00
Long Description Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 60 minutes are spent faceto-face with the patient and/or family. Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid) Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) Annual wellness visit, includes a personalized prevention plan of service (PPS), subsequent visit Pressurized or nonpressurized inhalation treatment for acute airway obstruction for therapeutic purposes and/or for diagnostic purposes such as sputum induction with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device Annual wellness visit, includes a personalized prevention plan of service (PPS), subsequent visit Hospital outpatient clinic visit for assessment and management of a patient Haemophilus influenzae type b vaccine (Hib), PRPOMP conjugate, 3 dose schedule, for intramuscular use Influenza virus vaccine, trivalent, live (LAIV3), for intranasal use Annual wellness visit, includes a personalized prevention plan of service (PPS), subsequent visit
Amount
55 of 167 Updated on 1/22/2019
Revenue Center
UB Revenue Code
CPT/HCPCS
510
G0396
246.72
510
G0397
442.92
510
G0463
150.00
510
10005
1998.72
510
11102
608.76
510
11104
608.76
510
11106
1083.57
510
17250
591.27
510
51700
803.37
510
51725
803.37
510
52000
1979.61
510
51720
756.15
510
95250
397.92
260
96365
668.79
331
96402
203.70
407897607-97607 NEG PRESS WND TX <=50 SQ CM
Negative pressure wound therapy, (eg, vacuum assisted drainage collection), utilizing disposable, non-durable medical equipment including provision of exudate management collection system, topical application(s), wound assessment, and instructions for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters
510
97607
1087.80
407899409-99409 SBIRT AUDIT/DAST >30MIN (COMM)
Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; greater than 30 minutes
510
99409
442.92
CDM Number
CDM Description
4078
407800396-396 SBIRT AUDIT/DAST 15-30MIN (MCR)
4078
407800397-397 SBIRT AUDIT/DAST >30MIN (MCR)
4078
407800463-463 CLINIC EXAM RM (FACILITY ONLY)
4078
407810005-10005 FNA BIOPSY W US GUIDE, 1ST LESION
4078
407811102-11102 TANGENTIAL SKIN BX, SNGL LESION
4078
407811104-11104 PUNCH SKIN BIOPSY, SINGLE LESION
4078
407811106-11106 INCISIONAL SKIN BX, SINGLE LESION
4078
407817250-17250 CHEMICAL CAUT OF GRANULATION TISS
4078
407841700-41700 BLADDER IRRIG SMPL LAV/INSTILL
4078
407841725-41725 CYSTOMETROGRAM SIMPLE
4078
407842000-42000 CYSTOURETHROSCOPY
4078
407861720-61720 BLADDR INSTLL OF ANTICARCINOGENIC
4078
407895250-95250 CONT GLUC MNTR PHYS/QHP EQP 72+HR
4078
407896365-96365 THER/PROPH/DIAG IV INF INIT =<1HR
4078
407896402-96402 CHEMO HORMON ANTINEOPL SQ/IM
4078
4078 4078 4078 4078 4078 4078 4078 4078 4078 4078 4078 4078
434000005-5 434000006-6 434000038-38 434000052-52 434000056-56 434000057-57 434000058-58 434000059-59 434000061-61 434000062-62 434000064-64
STAPLE REMOVER SUTURE REMOVAL KIT DRESSING SIMPLE ACE BANDAGE 6 INCH KERLIX FLUFFS KERLIX ROLL ABD PAD DRESSING 4X4 STERILE FOLEY CATH TRAY STERI STRIP 1/4 INCH PRE CUT STERILE SPONGE
4078
434000066-66
URINARY LEG BAG, EA
4078 4078
434000069-69 434000081-81
CENTRAL LINE DRESSING KIT TAPE,NON-WATERPROOF/18 SQ IN.
Long Description Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., AUDIT, DAST), and brief intervention 15 to 30 minutes Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., AUDIT, DAST), and intervention, greater than 30 minutes Hospital outpatient clinic visit for assessment and management of a patient Fine needle aspiration biopsy, including ultrasound guidance; first lesion Tangential biopsy of skin (eg, shave, scoop, saucerize, curette); single lesion Punch biopsy of skin (including simple closure, when performed); single lesion Incisional biopsy of skin (eg, wedge) (including simple closure, when performed); single lesion Chemical cauterization of granulation tissue (ie, proud flesh) Bladder irrigation, simple, lavage and/or instillation Simple cystometrogram (CMG) (eg, spinal manometer) Cystourethroscopy Bladder instillation of anticarcinogenic agent (including retention time) Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; physician or other qualified health care professional (office) provided equipment, sensor placement, hook-up, calibration of monitor, patient training, removal of sensor, and printout of recording Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour Chemotherapy administration, subcutaneous or intramuscular; hormonal anti-neoplastic
272 272 272 271 272 272 271 272 272 272 272 Urinary drainage bag, leg or abdomen, latex, with or without tube, with straps, each Tape, non-waterproof, per 18 square inches
Amount
20.00 35.20 17.40 11.50 5.75 4.31 15.81 7.91 57.50 11.08 15.81
272
A5112
11.50
272 272
A4450
121.76 9.49
56 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4078
434081002-81002 URINALYSIS BY DIPSTICK
4078
434090471-90471 IMMUNIZATION ADMIN 1 VACCINE
4078
434096372-96372 THER/PROPH/DIAG INJ SC/IM
4078
434099201-99201 SUR EXAM RM LEVEL 1 - NEW
4078
434099202-99202 SUR EXAM RM LEVEL 2 - NEW
4078
434099203-99203 SUR EXAM RM LEVEL 3 - NEW
4078
434099204-99204 SUR EXAM RM LEVEL 4 - NEW
4078
434099205-99205 SUR EXAM RM LEVEL 5 - NEW
4078
434099211-99211 SUR EXAM RM LEVEL 1 - EST
4078
434099212-99212 SUR EXAM RM LEVEL 2 - EST
4078
434099213-99213 SUR EXAM RM LEVEL 3 - EST
4078
434099214-99214 SUR EXAM RM LEVEL 4 - EST
4078
434099215-99215 SUR EXAM RM LEVEL 5 - EST
4078
434099241-99241 SURG EXAM RM LEVEL 1-CONSULT
4078
434099242-99242 SURG EXAM RM LEVEL 2-CONSULT
4078
434099243-99243 SURG EXAM RM LEVEL 3-CONSULT
4078
434099244-99244 SURG EXAM RM LEVEL 4-CONSULT
4078
434099245-99245 SURG EXAM RM LEVEL 5-CONSULT
4081
408100396-396 SBIRT AUDIT/DAST 15-30MIN (MCR)
4081
408100397-397 SBIRT AUDIT/DAST >30MIN (MCR)
4081
408190656-90656 IIV3 VACC NO PRSV 0.5ML IM (VFC)
4081
408199408-99408 SBIRT AUDIT/DAST 15-30MIN (COMM)
4081
408199409-99409 SBIRT AUDIT/DAST >30MIN (COMM)
Long Description Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, without microscopy Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid) Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., AUDIT, DAST), and brief intervention 15 to 30 minutes Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., AUDIT, DAST), and intervention, greater than 30 minutes VFC - Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, 0.5 mL dosage, for intramuscular use (Administration Fee) Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; greater than 30 minutes
UB Revenue Code
CPT/HCPCS
307
81002
15.00
771
90471
9.00
510
96372
86.25
510
G0463
150.00
510
G0463
150.00
510
G0463
150.00
510
G0463
150.00
510
G0463
150.00
510
G0463
150.00
510
G0463
150.00
510
G0463
150.00
510
G0463
150.00
510
G0463
150.00
510
G0463
150.00
510
G0463
150.00
510
G0463
150.00
510
G0463
150.00
510
G0463
150.00
514
G0396
246.72
514
G0397
442.92
771
90656SL
514
99408
246.72
514
99409
442.92
Amount
9.00
57 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4081
431000002-2
PREV VISIT E/M 12-17 YRS - NEW
4081
431000003-3
PREV VISIT E/M 18-39 YRS - NEW
4081
431000004-4
PREV VISIT E/M 40-64 YRS - NEW
4081
431000005-5
PREV VISIT E/M 65+ YRS - NEW
4081
431000006-6
PREV VISIT RE-E/M 12-17 YR-EST
4081
431000007-7
PREV VISIT RE-E/M 18-39 YR-EST
4081
431000008-8
PREV VISIT RE-E/M 40-64 YR-EST
4081
431000009-9
PREV VISIT RE-E/M 65+ YR - EST
4081
431000021-21
EXAM RM LEVEL 2 - CONSULT
4081
431000022-22
EXAM RM LEVEL 3 - CONSULT
4081
431000023-23
EXAM RM LEVEL 4 - CONSULT
4081
431000024-24
EXAM RM LEVEL 5 - CONSULT
4081
431000027-27
GYN EXAM RM LEVEL 1 - CONSULT
4081 4081 4081
431000189-189 GYN LEEP SUPPLIES 431000401-401 SUTURE REMOVAL SET 431000408-408 DRESSING MINOR
4081
431002001-2001 GYN EXAM RM LEVEL 1 - NEW PT
4081
431002002-2002 GYN EXAM RM LEVEL 2 - NEW PT
Long Description Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; adolescent (age 12 through 17 years) Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 1839 years Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 4064 years Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 65 years and older Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; adolescent (age 12 through 17 years) Annual wellness visit, includes a personalized prevention plan of service (PPS), subsequent visit Annual wellness visit, includes a personalized prevention plan of service (PPS), subsequent visit Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 65 years and older Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient
UB Revenue Code
CPT/HCPCS
514
99384
150.00
514
99385
150.00
514
99386
150.00
514
99387
150.00
514
99394
150.00
514
G0439
150.00
514
G0439
150.00
514
99397
150.00
514
G0463
150.00
514
G0463
150.00
514
G0463
150.00
514
G0463
150.00
514
G0463
150.00
272 272 272 Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient
Amount
181.50 50.60 31.65
514
G0463
150.00
514
G0463
150.00
58 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4081
431002003-2003 GYN EXAM RM LEVEL 3 - NEW PT
4081
431002004-2004 GYN EXAM RM LEVEL 4 - NEW PT
4081
431002005-2005 GYN EXAM RM LEVEL 5 - NEW PT
4081
431002011-2011 GYN EXAM RM LEVEL 1 - EST PT
4081
431002012-2012 GYN EXAM RM LEVEL 2 - EST PT
4081
431002013-2013 GYN EXAM RM LEVEL 3 - EST PT
4081
431002014-2014 GYN EXAM RM LEVEL 4 - EST PT
4081
431002015-2015 GYN EXAM RM LEVEL 5 - EST PT
4081
431007126-7126 IMMUNIZATION ADMIN 1 VACCINE
4081
431007500-7500 CLINIC EXAM RM (FACILITY ONLY)
4081
431008057-8057 MIRENA IUD 52MG (NDC 50419042101)
4081
431009777-9777 THERAPEUTIC OR DIAGNOSTIC INJ
4081
431090473-90473 IMMUNE ADMIN ORAL/NASAL 1 VAC
4081
431090660-90660 FLU VACCINE, LIVE, NASAL
4084
408400463-99201 HOSPITAL OUTPT CLINIC VISIT
4084
408400463-99215 HOSPITAL OUTPT CLINIC VISIT
4084
408400463-99241 HOSPITAL OUTPT CLINIC VISIT
4084
408400463-99242 HOSPITAL OUTPT CLINIC VISIT
4084
408400463-99243 HOSPITAL OUTPT CLINIC VISIT
4084
408400463-99244 HOSPITAL OUTPT CLINIC VISIT
4084
408400463-99245 HOSPITAL OUTPT CLINIC VISIT
4084
408400463-99202 HOSPITAL OUTPT CLINIC VISIT
4084
408400463-99203 HOSPITAL OUTPT CLINIC VISIT
4084
408400463-99204 HOSPITAL OUTPT CLINIC VISIT
4084
408400463-99205 HOSPITAL OUTPT CLINIC VISIT
4084
408400463-99211 HOSPITAL OUTPT CLINIC VISIT
4084
408400463-99212 HOSPITAL OUTPT CLINIC VISIT
4084
408400463-99213 HOSPITAL OUTPT CLINIC VISIT
4084
408400463-99214 HOSPITAL OUTPT CLINIC VISIT
4084
408410049-10049 ALCOHOL/DRUG SCREENING (MCAL)
Long Description Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid) Hospital outpatient clinic visit for assessment and management of a patient Levonorgestrel-releasing intrauterine contraceptive system (mirena), 52 mg Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular Immunization administration by intranasal or oral route; 1 vaccine (single or combination vaccine/toxoid) Influenza virus vaccine, trivalent, live (LAIV3), for intranasal use Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Alcohol and/or drug screening
UB Revenue Code
CPT/HCPCS
514
G0463
150.00
514
G0463
150.00
514
G0463
150.00
514
G0463
150.00
514
G0463
150.00
514
G0463
150.00
514
G0463
150.00
514
G0463
150.00
771
90471
9.00
510
G0463
150.00
636
J7298
1053.51
510
96372
86.25
771
90473
9.00
636
90660
9.00
510
G0463
372.90
510
G0463
372.90
510
G0463
372.90
510
G0463
372.90
510
G0463
372.90
510
G0463
372.90
510
G0463
372.90
510
G0463
372.90
510
G0463
372.90
510
G0463
372.90
510
G0463
372.90
510
G0463
372.90
510
G0463
372.90
510
G0463
372.90
510
G0463
372.90
510
H0049
72.00
Amount
59 of 167 Updated on 1/22/2019
Revenue Center
UB Revenue Code
CPT/HCPCS
771
90471
9.00
771
90472
9.00
510
G0396
246.72
510
G0397
442.92
408595976-95976 ANALYS NEUROSTIM IPG, SMPL PRGRMG
Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact group[s], interleaving, amplitude, pulse width, frequency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimulation, detection algorithms, closed loop parameters, and passive parameters) by physician or other qualified health care professional; with simple cranial nerve neurostimulator pulse generator/transmitter programming by physician or other qualified health care professional
920
95976
128.19
408595977-95977 ANALYS NEUROSTIM IPG, CMPLX PRGRM
Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact group[s], interleaving, amplitude, pulse width, frequency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimulation, detection algorithms, closed loop parameters, and passive parameters) by physician or other qualified health care professional; with complex cranial nerve neurostimulator pulse generator/transmitter programming by physician or other qualified health care professional
920
95977
405.51
510
99408
246.72
510
99409
442.92
510
96372
86.25
CDM Number
CDM Description
4084
408490471-90471 IMMUNIZATION ADMIN, 1 VACCINE
4084
408490472-90472 IMMUN ADMIN, EA ADDTL VACCINE
4085
408500396-396 SBIRT AUDIT/DAST 15-30MIN (MCR)
4085
408500397-397 SBIRT AUDIT/DAST >30MIN (MCR)
4085
4085
4085
408599408-99408 SBIRT AUDIT/DAST 15-30MIN (COMM)
4085
408599409-99409 SBIRT AUDIT/DAST >30MIN (COMM)
4085
432500002-2
THERAPEUTIC OR DIAGNOSTIC INJ
4085 4085 4085 4085 4085 4085
432500005-5 432500113-113 432500116-116 432500122-122 432500125-125 432500137-137
STAPLE REMOVER DRESSING SIMPLE GLUCOSE FINGER STICK SUPPLIES IV INF NS SOL 1000 CC IV SOL 5% D NS 1000CC LUMBAR PUNCTURE TRAY ADULT
4085
432500201-201 MED EXAM RM LEVEL 1 - NEW PT
4085
432500202-202 MED EXAM RM LEVEL 2 - NEW PT
4085
432500203-203 MED EXAM RM LEVEL 3 - NEW PT
4085
432500204-204 MED EXAM RM LEVEL 4 - NEW PT
4085
432500205-205 MED EXAM RM LEVEL 5 - NEW PT
Long Description Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid) Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., AUDIT, DAST), and brief intervention 15 to 30 minutes Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., AUDIT, DAST), and intervention, greater than 30 minutes
Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; greater than 30 minutes Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular
272 272 272 270 270 272 Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient
Amount
20.00 17.40 21.40 77.63 77.63 58.51
510
G0463
150.00
510
G0463
150.00
510
G0463
150.00
510
G0463
150.00
510
G0463
150.00
60 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4085
432500211-211 MED EXAM RM LEVEL 1 - EST PT
4085
432500212-212 MED EXAM RM LEVEL 2 - EST PT
4085
432500213-213 MED EXAM RM LEVEL 3 - EST PT
4085
432500214-214 MED EXAM RM LEVEL 4 - EST PT
4085
432500215-215 MED EXAM RM LEVEL 5 - EST PT
4085
432500216-216 MED EXAM RM LEVEL 1 - CONSULT
4085
432500217-217 MED EXAM RM LEVEL 2 - CONSULT
4085
432500218-218 MED EXAM RM LEVEL 3 - CONSULT
4085
432500219-219 MED EXAM RM LEVEL 4 - CONSULT
4085
432500220-220 MED EXAM RM LEVEL 5 - CONSULT
4085
432500746-746 URINALYSIS BY DIP STICK
4085
432500759-759 PNEUMOCOCCAL VACC =>2 YR SQ/IM
4085
432501607-1607 FLU VACC NO PRESERV =>3 YRS IM
4085
432501668-1668 ROTAVIRUS VACC 3 DOSE ORAL
4085
432501669-1669 TDAP VACCINE =>7 YRS IM
4085
432501725-1725 AEROSOL INHALATION TX
4085
432501760-1760 GLUCOSE, BLOOD BY MONITOR DVC
4085
432506810-6810 CLINIC EXAM RM (FACILITY ONLY)
4085
432507066-7066 IMMUNIZATION ADMIN 1 VACCINE
4085
432507067-7067 IMMUN ADM, EA ADDTL VACCINE
4085
432509067-9067 PNEUMOCOCCAL VACC 13 VAL IM
4085
432509921-9921 EXAM RM LVL 1-EST PT/NON PHYS
4085
432581025-81025 PREGNANCY TEST, URINE
4085
432587210-87210 WET MOUNT, KOH PREP
Long Description Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, without microscopy Pneumococcal polysaccharide vaccine, 23-valent (PPSV23), adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, 0.5 mL dosage, for intramuscular use Rotavirus vaccine, pentavalent (RV5), 3 dose schedule, live, for oral use Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), when administered to individuals 7 years or older, for intramuscular use Pressurized or nonpressurized inhalation treatment for acute airway obstruction for therapeutic purposes and/or for diagnostic purposes such as sputum induction with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device Glucose, blood by glucose monitoring device(s) cleared by the FDA specifically for home use Hospital outpatient clinic visit for assessment and management of a patient Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid) Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) Pneumococcal conjugate vaccine, 13 valent (PCV13), for intramuscular use Hospital outpatient clinic visit for assessment and management of a patient Urine pregnancy test, by visual color comparison methods Smear, primary source with interpretation; wet mount for infectious agents (eg, saline, India ink, KOH preps)
UB Revenue Code
CPT/HCPCS
510
G0463
150.00
510
G0463
150.00
510
G0463
150.00
510
G0463
150.00
510
G0463
150.00
510
G0463
150.00
510
G0463
150.00
510
G0463
150.00
510
G0463
150.00
510
G0463
150.00
307
81002
15.00
636
90732
246.93
636
90656
9.00
636
90680
9.00
636
90715
9.00
410
94640
529.41
510
82962
86.25
510
G0463
150.00
771
90471
9.00
771
90472
12.00
636
90670
9.00
510
G0463
150.00
307
81025
14.00
306
87210
31.00
Amount
61 of 167 Updated on 1/22/2019
Revenue Center 4085
CDM Number
CDM Description
432590657-90657 FLU VACCINE 6-35 MONTHS IM
4086
408600396-396 SBIRT AUDIT/DAST 15-30MIN (MCR)
4086
408600397-397 SBIRT AUDIT/DAST >30MIN (MCR)
4086
408600463-99245 HOSPITAL OUTPT CLINIC VISIT
4086
408600463-99211 HOSPITAL OUTPT CLINIC VISIT
4086
408600463-99205 HOSPITAL OUTPT CLINIC VISIT
4086
408600463-99204 HOSPITAL OUTPT CLINIC VISIT
4086
408600463-99203 HOSPITAL OUTPT CLINIC VISIT
4086
408600463-99202 HOSPITAL OUTPT CLINIC VISIT
4086
408600463-99201 HOSPITAL OUTPT CLINIC VISIT
4086
408600463-463 HOSPITAL OUTPT CLINIC VISIT
4086
408600463-99244 HOSPITAL OUTPT CLINIC VISIT
4086
408600463-99243 HOSPITAL OUTPT CLINIC VISIT
4086
408600463-99242 HOSPITAL OUTPT CLINIC VISIT
4086
408600463-99241 HOSPITAL OUTPT CLINIC VISIT
4086
408600463-99215 HOSPITAL OUTPT CLINIC VISIT
4086
408600463-99214 HOSPITAL OUTPT CLINIC VISIT
4086
408600463-99213 HOSPITAL OUTPT CLINIC VISIT
4086
408600463-99212 HOSPITAL OUTPT CLINIC VISIT
4086 4086 4086
408603822-3822 BONE MARROW, ASPIRATION ONLY 408613822-13822 DIAGNOSTIC BONE MARROW BIOPSIES 408636415-36415 ROUTINE VENIPUNCTURE
4086
408636591-36591 DRAW BLOOD OFF VENOUS DEVICE
4086
408636592-36592 COLL BLOOD FRM CENT/PERIPH CATH
4086
408636593-36593 DECLOT VASCULAR DEVICE
4086
408638222-38222 DX BONE MARROW BIOPSY & ASPIRAT
4086
408652270-52270 SPINAL PUNCTURE LUMBAR DIAGNOSTIC
4086
408683283-83283 PROGRAM EVAL IMPLNT DUAL LEAD
Long Description Influenza virus vaccine, trivalent (IIV3), split virus, 0.25 mL dosage, for intramuscular use Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., AUDIT, DAST), and brief intervention 15 to 30 minutes Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., AUDIT, DAST), and intervention, greater than 30 minutes Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Diagnostic bone marrow; aspiration(s) Diagnostic bone marrow; biopsy(ies) Collection of venous blood by venipuncture Collection of blood specimen from a completely implantable venous access device Collection of blood specimen using established central or peripheral catheter, venous, not otherwise specified Declotting by thrombolytic agent of implanted vascular access device or catheter Diagnostic bone marrow; biopsy(ies) and aspiration(s) Spinal puncture, lumbar, diagnostic Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report by a physician or other qualified health care professional; dual lead transvenous implantable defibrillator system
UB Revenue Code
CPT/HCPCS
636
90657
9.00
510
G0396
246.72
510
G0397
442.92
510
G0463
150.00
510
G0463
150.00
510
G0463
150.00
510
G0463
150.00
510
G0463
150.00
510
G0463
150.00
510
G0463
150.00
510
G0463
150.00
510
G0463
150.00
510
G0463
150.00
510
G0463
150.00
510
G0463
150.00
510
G0463
150.00
510
G0463
150.00
510
G0463
150.00
510
G0463
150.00
510 510 510
38220 38221 36415
3336.63 5009.61 9.00
510
36591
306.96
510
36592
306.96
510
36593
686.82
510
38222
4714.92
361
62270
1901.85
480
93283
132.09
Amount
62 of 167 Updated on 1/22/2019
Revenue Center
UB Revenue Code
CPT/HCPCS
480
93284
132.09
771
90471
149.91
408693279-93279 PM DEVICE PROGR EVAL SNGL LEAD
Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report by a physician or other qualified health care professional; single lead pacemaker system or leadless pacemaker system in one cardiac chamber
480
93279
132.09
408693280-93280 IMPLNTABLE/WEARABLE DEVICE EVAL
Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report by a physician or other qualified health care professional; dual lead pacemaker system
480
93280
132.09
408693288-93288 PM DEVICE EVAL IN PERSON
Interrogation device evaluation (in person) with analysis, review and report by a physician or other qualified health care professional, includes connection, recording and disconnection per patient encounter; single, dual, or multiple lead pacemaker system, or leadless pacemaker system
480
93288
132.09
408693291-93291 ILR DEVICE INTERROGATE
Interrogation device evaluation (in person) with analysis, review and report by a physician or other qualified health care professional, includes connection, recording and disconnection per patient encounter; subcutaneous cardiac rhythm monitor system, including heart rhythm derived data analysis
480
93291
61.14
408693922-93922 UP/LOW EXTREMITY ART STUDY 1-2LVL
Limited bilateral noninvasive physiologic studies of upper or lower extremity arteries, (eg, for lower extremity: ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus bidirectional, Doppler waveform recording and analysis at 1-2 levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus volume plethysmography at 1-2 levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries with transcutaneous oxygen tension measurements at 1-2 levels)
920
93922
367.65
CDM Number
CDM Description
4086
408683284-83284 PROGRAM EVAL IMPLNT MULTI LEAD
4086
408690471-90471 IMMUNIZATION ADMIN 1 VACCINE
4086
4086
4086
4086
4086
Long Description Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report by a physician or other qualified health care professional; multiple lead transvenous implantable defibrillator system Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid)
Amount
63 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4086
408693923-93923 UPR/LXTR ART STDY >=3+ LVLS
4086
408693924-93924 LWR XTR VASC STDY BILAT CMPLT
4086
408696360-96360 HYDRATION, IV INF, INIT 31-60
4086
408696361-96361 HYDRATION, IV INFUS,EA ADDT HR
4086
408696365-96365 INITIAL IV INFUSION =<1 HR
4086
408696366-96366 IV INFUSION, ADDTL HR
4086
408696367-96367 IV INF, ADDT SEQ NEW DRUG =<1HR
4086
408696368-96368 IV INFUSION, CONCURRENT
4086
408696372-96372 THER/PHOPH/DIAG INJ, SQ/IM
4086
408696374-96374 IV PUSH, SNGL/INITIAL DRUG
4086
408696375-96375 IV PUSH, ADDTL SEQ NEW DRUG
4086
408696376-96376 IV PUSH, ADDTL SEQ SAME DRUG
4086
408696401-96401 CHEMO NON-HORM ANTI-NEOPL SQ/IM
4086
408696402-96402 CHEMO HORMON ANTI-NEOPL SQ/IM
4086
408696409-96409 CHEMO IV PUSH, SNGL/INIT DRUG
Long Description Complete bilateral noninvasive physiologic studies of upper or lower extremity arteries, 3 or more levels (eg, for lower extremity: ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental blood pressure measurements with bidirectional Doppler waveform recording and analysis, at 3 or more levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental volume plethysmography at 3 or more levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental transcutaneous oxygen tension measurements at 3 or more levels), or single level study with provocative functional maneuvers (eg, measurements with postural provocative tests, or measurements with reactive hyperemia) Noninvasive physiologic studies of lower extremity arteries, at rest and following treadmill stress testing, (ie, bidirectional Doppler waveform or volume plethysmography recording and analysis at rest with ankle/brachial indices immediately after and at timed intervals following performance of a standardized protocol on a motorized treadmill plus recording of time of onset of claudication or other symptoms, maximal walking time, and time to recovery) complete bilateral study Intravenous infusion, hydration; initial, 31 minutes to 1 hour Intravenous infusion, hydration; each additional hour 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 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); additional sequential infusion of a new drug/substance, up to 1 hour Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); concurrent infusion Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of the same substance/drug provided in a facility Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic Chemotherapy administration, subcutaneous or intramuscular; hormonal anti-neoplastic Chemotherapy administration; intravenous, push technique, single or initial substance/drug
UB Revenue Code
CPT/HCPCS
920
93923
477.12
920
93924
477.12
260
96360
479.55
260
96361
115.41
260
96365
479.55
260
96366
104.58
260
96367
104.58
260
96368
43.13
260
96372
86.25
260
96374
327.30
260
96375
86.25
260
96376
86.25
331
96401
401.41
331
96402
165.95
331
96409
652.64
Amount
64 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4086
408696411-96411 CHEMO IV PUSH, ADDTL DRUG
4086
408696413-96413 CHEMO IV INFUSION =<1 HR, INIT
4086
408696415-96415 CHEMO IV INFUSION, ADDTL HR
4086
408696416-96416 CHEMO PROLONG INF 8+ HRS W/PUMP
4086
408696417-96417 CHEMO IV INF, ADDTL SEQ =<1 HR
4086
408696425-96425 CHEMO IA PROLONG INF >8H W/PUMP
4086
408696450-96450 CHEMO CNS (INTRATHECAL) W LP
4086
408696522-96522 REFILL/MAINT PUMP/RESVR SYST
4086
408696523-96523 IRRIG DRUG DELIVERY DEVICE
4086
408699408-99408 SBIRT AUDIT/DAST 15-30MIN (COMM)
4086
408699409-99409 SBIRT AUDIT/DAST >30MIN (COMM)
4086 4086 4086 4086
432503001-3001 432503002-3002 432503003-3003 432508005-8005
4086
432590003-90003 IV PUSH, SNGL/INITIAL DRUG
4086
432590015-90015 CHEMO ANTI-NEOPL SQ/IM INJ
4086
432590017-90017 CHEMO IV INF, ADDTL SEQ =<1 HR
4086
432590020-90020 CHEMO ANTI-NEOPL HORMON SQ/IM
4086
432590021-90021 CHEMO IV INFUSION, ADDTL HR
4086
432590022-90022 CHEMO IV PUSH, ADDTL DRUG
4086
432590023-90023 CHEMO IV PUSH, INITIAL DRUG
4086
432590024-90024 DECLOT VASCULAR DEVICE
4086
432590032-90032 IRRIG DRUG DELIVERY DEVICE
4086
432590035-90035 HYDRATION, IV INF, INIT 31-60
4086
432590036-90036 HYDRATION, IV INFUS, EA ADDT HR
4086
432590037-90037 INITIAL IV INFUSION =<1 HR
MINOR PROCEDURE LEVEL 1-1ST HR MINOR PRCDR LVL 1-ADDTL 30 MIN MINOR PROCEDURE LEVEL 2-1ST HR ROUTINE VENIPUNCTURE
Long Description Chemotherapy administration; intravenous, push technique, each additional substance/drug Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug Chemotherapy administration, intravenous infusion technique; each additional hour Chemotherapy administration, intravenous infusion technique; initiation of prolonged chemotherapy infusion (more than 8 hours), requiring use of a portable or implantable pump Chemotherapy administration, intravenous infusion technique; each additional sequential infusion (different substance/drug), up to 1 hour Chemotherapy administration, intra-arterial; infusion technique, initiation of prolonged infusion (more than 8 hours), requiring the use of a portable or implantable pump Chemotherapy administration, into CNS (eg, intrathecal), requiring and including spinal puncture Refilling and maintenance of implantable pump or reservoir for drug delivery, systemic (eg, intravenous, intra-arterial) Irrigation of implanted venous access device for drug delivery systems Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; greater than 30 minutes
Collection of venous blood by venipuncture Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic Chemotherapy administration, intravenous infusion technique; each additional sequential infusion (different substance/drug), up to 1 hour Chemotherapy administration, subcutaneous or intramuscular; hormonal anti-neoplastic Chemotherapy administration, intravenous infusion technique; each additional hour Chemotherapy administration; intravenous, push technique, each additional substance/drug Chemotherapy administration; intravenous, push technique, single or initial substance/drug Declotting by thrombolytic agent of implanted vascular access device or catheter Irrigation of implanted venous access device for drug delivery systems Intravenous infusion, hydration; initial, 31 minutes to 1 hour Intravenous infusion, hydration; each additional hour Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour
UB Revenue Code
CPT/HCPCS
331
96411
165.95
335
96413
652.64
335
96415
165.95
335
96416
1135.36
335
96417
401.41
335
96425
336.66
331
96450
977.49
510
96522
265.66
510
96523
198.15
510
99408
246.72
510
99409
442.92
510 510 510 300
36415
200.00 200.00 450.00 9.00
260
96374
327.30
331
96401
401.41
335
96417
401.41
331
96402
165.95
335
96415
165.95
331
96411
165.95
331
96409
652.64
510
36593
686.82
510
96523
198.15
260
96360
479.55
260
96361
115.41
260
96365
479.55
Amount
65 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4086
432590038-90038 IV INFUSION, ADDTL HR
4086
432590039-90039 IV INF, ADDTL SEQ NEW RX =<1HR
4086
432590040-90040 IV INFUSION, CONCURRENT
4086
432590042-90042 THER/PHOPH/DIAG INJ, SQ/IM
Long Description Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); additional sequential infusion of a new drug/substance, up to 1 hour Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); concurrent infusion
UB Revenue Code
CPT/HCPCS
260
96366
104.58
260
96367
104.58
260
96368
43.13
260
4086
432590043-90043 IV PUSH, ADDTL SEQ NEW DRUG
4086
432590044-90044 IV PUSH, ADDTL SEQ SAME DRUG
4086
432590591-90591 DRAW BLOOD OFF VENOUS DEVICE
4086
432599201-99201 HOSPITAL OUTPT CLINIC VISIT
4086
432599202-99202 HOSPITAL OUTPT CLINIC VISIT
4086
432599203-99203 EXAM RM LEVEL 3 - NEW PT
4086
432599204-99204 HOSPITAL OUTPT CLINIC VISIT
4086
432599205-99205 EXAM RM LEVEL 5 - NEW PT
4086
432599211-99211 HOSPITAL OUTPT CLINIC VISIT
4086
432599212-99212 HOSPITAL OUTPT CLINIC VISIT
4086
432599213-99213 EXAM RM LEVEL 3 - EST PT
4086
432599214-99214 HOSPITAL OUTPT CLINIC VISIT
4086
432599215-99215 HOSPITAL OUTPT CLINIC VISIT
4087
435500772-772 UTZ GUIDE FOR IV INSERTION
4087
435500773-773 UTZ GUIDE FOR VENOUS ACCESS
4087
435500775-775 PICC LINE KIT
4087
435506007-6007 PICC LINE INSERTION >=5 YRS
4090
409076818-76818 FETAL BPP W NON-STRESS TEST
Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of the same substance/drug provided in a facility Collection of blood specimen from a completely implantable venous access device Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting Catheter, infusion, inserted peripherally, centrally or midline (other than hemodialysis) Insertion of peripherally inserted central venous catheter (PICC), without subcutaneous port or pump, without imaging guidance; age 5 years or older Fetal biophysical profile; with non-stress testing
4090
409076819-76819 FETAL BPP WO NON-STRESS TEST
Fetal biophysical profile; without non-stress testing
Amount
86.25
260
96375
86.25
260
96376
86.25
510
36591
306.96
510
G0463
150.00
510
G0463
150.00
510
G0463
150.00
510
G0463
150.00
510
G0463
150.00
510
G0463
150.00
510
G0463
150.00
510
G0463
150.00
510
G0463
150.00
510
G0463
150.00
402
76937
82.50
402
76937
82.50
270
C1751
376.20
761
36569
2949.24
402
76818
400.62
402
76819
400.62
66 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4090
438501482-1482 NST PROCEDURE ROOM
4090
438501501-1501 NST NON STRESS TECH ONLY
4090
438501506-1506 ULTRASOUND,PREG UTERUS,LIMITED
4090 4090 4090 4090
438501510-1510 438501511-1511 438501512-1512 438501513-1513
4090
438501514-1514 NST CATH NON-INDWELLING
4090
438501601-1601 FETAL NON-STRESS TEST
4095
409500396-396 SBIRT AUDIT/DAST 15-30MIN (MCR)
4095
409500397-397 SBIRT AUDIT/DAST >30MIN (MCR)
NST 1ST SUBSEQUENT 1/2 HR NST 2ND SUBSEQUENT 1/2 HR NST ADD SUBSEQUENT 1/2 HRS NST AMNIOCENTESIS
4095
409599408-99408 SBIRT AUDIT/DAST 15-30MIN (COMM)
4095
409599409-99409 SBIRT AUDIT/DAST >30MIN (COMM)
4095
436500190-190 PREGNANCY TEST, URINE
4095
436502001-2001 FP EXAM RM LEVEL 1 - NEW PT
4095
436502002-2002 FP EXAM RM LEVEL 2 - NEW PT
4095
436502003-2003 FP EXAM RM LEVEL 3 - NEW PT
4095
436502004-2004 FP EXAM RM LEVEL 4 - NEW PT
4095
436502005-2005 FP EXAM RM LEVEL 5 - NEW PT
4095
436502011-2011 FP EXAM ROOM LEVEL 1 - EST PT
4095
436502012-2012 FP EXAM RM LEVEL 2 - EST PT
4095
436502013-2013 RP EXAM RM LEVEL 3 - EST PT
4095
436502014-2014 FP EXAM RM LEVEL 4 - EST PT
4095
436502015-2015 FP EXAM RM LEVEL 5 - EST PT
4095 4095
436503843-3843 F/P BLOOD GLUCOSE 436504144-4144 SCREENING PURE TONE AIR ONLY
Long Description Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 40 minutes are spent face-to-face with the patient and/or family. Fetal non-stress test Ultrasound, pregnant uterus, real time with image documentation, limited (eg, fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume), 1 or more fetuses
Amniocentesis; diagnostic Insertion of non-indwelling bladder catheter (eg, straight catheterization for residual urine) Fetal non-stress test Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., AUDIT, DAST), and brief intervention 15 to 30 minutes Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., AUDIT, DAST), and intervention, greater than 30 minutes Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; greater than 30 minutes Urine pregnancy test, by visual color comparison methods Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Glucose; blood, reagent strip Screening test, pure tone, air only
UB Revenue Code
CPT/HCPCS
510
99215
258.75
320
59025
498.00
402
76815
310.50
510 510 510 510
59000
130.81 130.81 130.81 2255.79
510
51701
322.98
920
59025
270.25
517
G0396
246.72
517
G0397
442.92
517
99408
246.72
517
99409
442.92
307
81025
14.00
517
G0463
150.00
517
G0463
150.00
517
G0463
150.00
517
G0463
150.00
517
G0463
150.00
517
G0463
150.00
517
G0463
150.00
517
G0463
150.00
517
G0463
150.00
517
G0463
150.00
301 471
82948 92551
8.00 30.00
Amount
67 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4095
436504146-4146 EKG W 12 LEADS, TRACING ONLY
4095
436504370-4370 PULSE OXIMETRY, SINGLE
4095
436507500-7500 CLINIC EXAM RM (FACILITY ONLY)
4095
436509778-9778 THERAPUTIC OR DIAGNOSTIC INJ
4095
436510020-10020 FP URINE DIPSTICK
4095
436510036-10036 DTAP VACCINE < 7 YRS IM
4095
436510038-10038 PNEUMOCOCCAL VACC 23 VAL =>2YR
4095
436510044-10044 FLU VACC, NO PRESRV =>3 YRS IM
4095
436510050-10050 TDAP VACCINE =>7 YRS, IM
4095
436510101-10101 IMMUNIZATION ADMIN 1 VACCINE
4095
436510102-10102 IMMUN ADMIN, EA ADDTL VACCINE
4095
436599381-99381 HOSP OUTPT CLINIC VISIT (99381)
4095
436599382-99382 HOSP OUTPT CLINIC VISIT (99382)
4095
436599383-99383 HOSP OUTPT CLINIC VISIT (99383)
4095
436599384-99384 PREV MED E&M 12-17 YR (99384)
4095
436599385-99385 INIT PREV MED E&M 18-39 YR-NEW
4095
436599386-99386 INIT PREV MED E&M 40-64 YR-NEW
Long Description Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report Noninvasive ear or pulse oximetry for oxygen saturation; single determination Hospital outpatient clinic visit for assessment and management of a patient Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, without microscopy Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP), when administered to individuals younger than 7 years, for intramuscular use Pneumococcal polysaccharide vaccine, 23-valent (PPSV23), adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, 0.5 mL dosage, for intramuscular use Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), when administered to individuals 7 years or older, for intramuscular use Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid) Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 1839 years Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 4064 years
UB Revenue Code
CPT/HCPCS
730
93005
188.31
460
94760
53.00
510
G0463
150.00
510
96372
86.25
307
81002
15.00
636
90700
9.00
636
90732
20.74
636
90656
9.00
636
90715
9.00
771
90471
9.00
771
90472
12.00
517
G0463
150.00
517
G0463
150.00
517
G0463
150.00
517
G0463
150.00
517
99385
150.00
517
99386
150.00
Amount
68 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4095
436599387-99387 INIT PREV MED E&M =>65 YR-NEW
4095
436599391-99391 HOSP OUTPT CLINIC VISIT (99391)
4095
436599392-99392 HOSP OUTPT CLINIC VISIT (99392)
4095
436599393-99393 PREV MED RE-E&M 5-11 YR-EST
4095
436599394-99394 PREV MED RE-E&M 12-17 YR-EST
4095
436599395-99395 PREV MED RE-E&M 18-39 YR-EST
4095
436599396-99396 PREV MED RE-E&M 40-64 YR-EST
4095
436599397-99397 PREV MED RE-E&M =>65 YR-EST
4230
401000003-3
OBSERVATION, ADDITIONAL HOUR(S)
4230
402500002-2
OBSERVATION, DIRECT ADMIT
4230 4230 4230
402500003-3 423000026-26 423000028-28
OBSERVATION, FIRST HOUR OBSERVATION, ADDITIONAL HOUR(S) OBSERVATION, FIRST HOUR
4400
401000012-12
CATH URETHRA NON-INDWELLING
4400 4400 4400 4400 4400 4400 4400 4400 4400 4400 4400 4400
401000014-14 401000015-15 401000016-16 401000020-20 401000021-21 401000030-30 401000041-41 401000901-901 401002101-2101 401002102-2102 401002104-2104 401002105-2105
SEPRAFILM BARRIER SOULTION MASTISOL DRAIN JACKSON PRATT SUCTI STERILE WATER/SALINE IRR,500ML STERILE WATER/SALINE IRR,500ML FETAL NON-STRESS TEST AMNIOCENTESIS DIAGNOSTIC L&D O2 THERAPY BALLOON POSTPARTUM , BAKRI RETRACTOR, MOBUIS SALINE LOCK FLUSH TPCL SKN ADHSV, PROPEN, DRMBND
Long Description Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 65 years and older Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Annual wellness visit, includes a personalized prevention plan of service (PPS), subsequent visit Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; adolescent (age 12 through 17 years) Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 18-39 years Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 40-64 years Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 65 years and older Hospital observation service, per hour Direct admission of patient for hospital observation care Hospital observation service, per hour Hospital observation service, per hour Hospital observation service, per hour Insertion of non-indwelling bladder catheter (eg, straight catheterization for residual urine)
Sterile water/saline, 500 ml Sterile water/saline, 500 ml Fetal non-stress test Amniocentesis; diagnostic
Wound closure utilizing tissue adhesive(s) only
UB Revenue Code
CPT/HCPCS
517
99387
150.00
517
G0463
150.00
517
G0463
150.00
770
G0439
150.00
517
99394
150.00
517
99395
150.00
517
99396
150.00
517
99397
150.00
762
G0378
186.85
762
G0379
1702.68
762 762 762
G0378 G0378 G0378
343.75 186.85 361.02
360
51701
93.59
272 272 272 272 272 720 360 271 272 272 272 510
A4217AU A4217AU 59025 59000
G0168
Amount
656.58 11.50 109.56 16.60 16.60 368.13 2255.79 22.64 911.40 1968.75 8.93 130.59
69 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4400
401002106-2106 AMNISURE PAMG-1 RAPID ASSAY
4400 4400 4400
401002107-2107 CERVICAL RIPENING BALLOON 401004061-4061 SURGIFOAM 1.0G ABSORB GEL 401004062-4062 ARISTA 3 GM
4400
401007011-7011 HYDRATION, IV INFUS, EA ADDT H
4400
401007013-7013 IV PUSH, SNGL OR INIT SUBST/RX
4400
401007014-7014 IV PUSH, EA ADD SEQ INTRA
4400
401007110-7110 HYDRATION, IV INF, INIT 31-60
4400
401009524-9524 THER/PROPH/DIAG INJ SC/IM
4400
401009525-9525 IV SUPPLIES
4400
401009527-9527 HOSPITAL OUTPT CLINIC VISIT
4400 4400 4400 4400 4400 4400 4400 4400 4400 4400 4400 4400 4400 4400 4400 4400 4400 4400 4400
401009528-9528 401009529-9529 401009530-9530 401009533-9533 401009534-9534 401009535-9535 401009538-9538 401009539-9539 401009540-9540 401009541-9541 401009542-9542 401009543-9543 401009544-9544 401009545-9545 401009546-9546 401009547-9547 401009548-9548 401009549-9549 401009550-9550
IV START AMINOFLUID INFUSION BREAST STIMULATION TEST NSVD NORMAL NSVD COMPLICATED NSVD HIGH RISK L&D SURG LEVEL III 1ST HOUR L&D SURG LEVEL III ADD 30 MIN L&D SURG LEVEL IV 1ST HOUR L&D SURG LEVEL IV ADD 30 MIN L&D RECOVERY LEVEL I 1ST HOUR L&D RECOVERY LEVEL I ADD 30 MIN L&D RECOVERY LEVEL II 1ST HOUR L&D RECOVERY LEVEL II ADD 30 MIN SUTURE LEVEL I SUTURE LEVEL II SUTURE LEVEL III (SKIN STAPLER) INTERNAL FETAL SCALP ELECTRODE INTRAUTERINE PRESSURE CATH
4400
401009551-9551 US PREG UTERUS LTD
4400
401009555-9555 HOSPITAL OUTPT CLINIC VISIT
4400 4400 4400
401009560-9560 FEMALE DRAINAGE CATH 401009561-9561 VACUUM DELIVERY DEVICE 401009570-9570 FLOSEAL 10ML
4400
401076801-76801 US OB 1ST TRIMESTER, SINGLE
4400
401076802-76802 US OB 1ST TRIMESTER, EA ADD GEST
Long Description Evaluation of cervicovaginal fluid for specific amniotic fluid protein(s) (eg, placental alpha microglobulin-1 [PAMG-1], placental protein 12 [PP12], alpha-fetoprotein), qualitative, each specimen
UB Revenue Code
CPT/HCPCS
301
84112
272 272 272 Intravenous infusion, hydration; each additional hour Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug Intravenous infusion, hydration; initial, 31 minutes to 1 hour Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular
Fetal contraction stress test
Ultrasound, pregnant uterus, real time with image documentation, limited (eg, fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume), 1 or more fetuses Hospital outpatient clinic visit for assessment and management of a patient
720
96361
115.41
260
96374
327.30
720
96375
63.00
720
96360
503.53
260
96372
90.56
720 272 272 920 720 720 720 360 360 360 360 710 710 710 710 272 272 272 272 272
92.07 G0463
59020
843.74 84.53 582.62 253.58 2698.76 3373.45 4049.65 2319.46 1160.56 2598.39 1298.37 323.01 163.01 556.96 279.24 27.17 93.59 120.75 253.58 253.58
402
76815
612.48
720
G0463
843.74
272 272 272 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (< 14 weeks 0 days), transabdominal approach; single or first gestation Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (< 14 weeks 0 days), transabdominal approach; each additional gestation
306.79
155.40 338.56 380.00
272 Hospital outpatient clinic visit for assessment and management of a patient
Amount
26.25 91.35 755.58
402
76801
706.39
402
76802
371.31
70 of 167 Updated on 1/22/2019
Long Description
UB Revenue Code
CPT/HCPCS
401076805-76805 OB US =>14 WKS, SNGL/1ST GEST
Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> or = 14 weeks 0 days), transabdominal approach; single or first gestation
402
76805
890.40
401076810-76810 OB US =>14 WKS, EA ADDTL GEST
Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> or = 14 weeks 0 days), transabdominal approach; each additional gestation
402
76810
371.31
401076811-76811 OB US, DETAILED, SNGL/1ST GEST
Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation
402
76811
706.39
401076812-76812 OB US, DETAILED, EA ADDTL GEST
Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; each additional gestation
402
76812
371.31
401076815-76815 OB US LIMITED 1+ FETUS
Ultrasound, pregnant uterus, real time with image documentation, limited (eg, fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume), 1 or more fetuses
402
76815
612.48
4400
401076816-76816 OB US FOLLOW UP PER FETUS
Ultrasound, pregnant uterus, real time with image documentation, follow-up (eg, re-evaluation of fetal size by measuring standard growth parameters and amniotic fluid volume, re-evaluation of organ system(s) suspected or confirmed to be abnormal on a previous scan), transabdominal approach, per fetus
402
76816
414.75
4400
401076817-76817 OB US, TRANSVAGINAL
402
76817
706.39
4400
401076818-76818 FETAL BPP W/NON-STRESS TEST
Ultrasound, pregnant uterus, real time with image documentation, transvaginal Fetal biophysical profile; with non-stress testing
402
76818
469.41
4400
401076819-76819 FETAL BPP WO NON-STRESS TEST
Fetal biophysical profile; without non-stress testing
402
76819
676.90
4400
401099204-99204 HOSPITAL OUTPT CLINIC VISIT
720
G0463
506.13
4400
401099205-99205 HOSPITAL OUTPT CLINIC VISIT
720
G0463
691.89
4400
401099214-99214 HOSPITAL OUTPT CLINIC VISIT
720
G0463
150.00
4400
401099215-99215 HOSPITAL OUTPT CLINIC VISIT
720
G0463
506.13
720
G0463
397.92
720
10005
1998.72
Revenue Center
4400
4400
4400
4400
4400
CDM Number
CDM Description
4400
440000463-463 HOSPITAL OUTPT VISIT-L&D TRIAGE
4400
440010005-10005 FNA BIOPSY W US GUIDE, 1ST LESION
4400 4400 4400
440044000-44000 R&B L&D OB, PRIVATE 440044005-44005 R&B L&D OB, 2 BEDS 440044015-44015 R&B L&D OB, 3-4 BEDS
4400
440049406-49406 IMG CATH FLUID DRN PERI/RETRO
4400 4400 4400
440056420-56420 I & D OF BARTHOLIN'S GLAND ABS 440059412-59412 EXT CEPHALIC VERSION 440069025-69025 FETAL NON-STRESS, ADDTL FETUS
4400
440076942-76942 US GUIDED NEEDLE PLACEMENT
4400
440081003-81003 AUTOM URINALYSIS WO MICRO
Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Fine needle aspiration biopsy, including ultrasound guidance; first lesion R&B - Private, Obstetrics (OB) R&B - Semiprivate, Obstetrics (OB) R&B - Semiprivate, Obstetrics (OB) Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst); peritoneal or retroperitoneal, percutaneous Incision and drainage of Bartholin's gland abscess External cephalic version, with or without tocolysis Fetal non-stress test Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, without microscopy
112 122 132
Amount
3393.36 3393.36 3393.36
720
49406
4717.83
720 720 720
56420 59412 5902559
446.73 7954.80 562.47
720
76942
967.26
307
81003QW
9.54
71 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4400
440086372-86372 THER/PROPH/DIAG INJ SC/IM, ADDTL
4400
440086818-86818 FETAL BPP W NST, ADDTL FETUS
4400
440090471-90471 IMMUNIZATION ADMIN 1 VACCINE
4410
417676818-76818 FETAL BPP W/NON-STRESS TEST
4410
417699205-99205 NEW PT 4 OR > STABLE CHRONIC, 21+
4420 4420 4420 4420 4420 4420 4420 4420
402000044-44 402000046-46 402000047-47 402000048-48 402000049-49 402000050-50 402000051-51 402000052-52
Long Description Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular Fetal biophysical profile; with non-stress testing Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid) Fetal biophysical profile; with non-stress testing Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 60 minutes are spent faceto-face with the patient and/or family.
MINOR LEVEL I FIRST HOUR RM 8 MINOR LEVEL II FIRST HOUR MINOR LEVEL II ADD 15 MINUTES MAJOR LEVEL III FIRST HOUR MAJOR LEVEL III ADD 15 MINUTES COMPLEX LEVEL IV FIRST HOUR COMPLEX LEVEL IV ADD 15 MINUTES OR SET-UP/CANCELLED CASE
4420
402001005-1005 PLATE 240-259 310-329
4420
402001039-1039 PLATE 100-109
4420
402001042-1042 PLATE MINI 4 HOLES WITH BAR
4420
402001059-1059 SCREW 950-999
4420
402001060-1060 SCREW LOCK 2.0 2.3 2.7X4-20MM
4420
402001067-1067 SCREW 1950-1999
4420
402001073-1073 BAR TRANSVERSE 3.5-5&6MM CLAMP
4420
402001118-1118 PLATE 950-999
4420
402001126-1126 PLATE VECTRA 1 LEVEL 1605
4420
402001127-1127 PLATE VECTRA 1 LEVEL 1722
4420
402001128-1128 PLATE VECTRA 1 LEVEL 1839
4420
402001130-1130 SCREW 187-199 250-269
4420
402001178-1178 VICRYL MESH WOVEN 12X12 VWML"
4420
402001196-1196 NAIL ELASTIC ALL SIZE 1.5-4.0MM
4420
402001215-1215 IMPLANT RADIESSE VOCAL 8044MO
4420 4420 4420 4420 4420 4420 4420
402001227-1227 402001248-1248 402001263-1263 402001265-1265 402001266-1266 402001268-1268 402001269-1269
BLADES TI HELICAL 80-120MM COLLECT BAG KIT 821732 BLADE-BUR 60-69 BLADE-BUR 90-99 BLADE-BUR 100-109 BLADE-BUR 130-139 BLADE-BUR 140-149
UB Revenue Code
CPT/HCPCS
260
9637259
203.70
402
7681859
400.62
771
90471
203.70
402
76818
447.06
510
99205
153.75
360 360 360 360 360 360 360 360 Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable)
921.47 3146.29 921.47 3619.48 1060.94 4142.48 2072.07 204.22
278
C1713
960.00
278
C1713
420.00
278
C1713
314.60
278
C1713
2925.00
278
C1713
293.80
278
C1713
5925.00
278 Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable)
1972.00
278
C1713
2925.00
278
C1713
4815.00
278
C1713
5166.00
278
C1713
5517.00
278
C1713
780.00
272 Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Material for vocal cord medialization, synthetic (implantable)
Amount
4088.93
278
C1713
834.30
278
C1878
1725.00
272 272 272 272 272 272 272
1824.00 164.00 260.00 380.00 420.00 540.00 580.00 72 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4420
402001277-1277 BLADE-BUR 450-469
4420
402001327-1327 PROSTH. VOICE MD INSERT 350
4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420
402001329-1329 402001359-1359 402001379-1379 402001385-1385 402001436-1436 402001437-1437 402001438-1438 402001444-1444 402001449-1449 402001480-1480 402001481-1481 402001482-1482 402001485-1485 402001494-1494 402001513-1513 402001524-1524 402001525-1525 402001542-1542 402001548-1548 402001549-1549 402001555-1555 402001563-1563 402001592-1592 402001616-1616 402001617-1617
4420
402001630-1630 INTRODUCER 163
4420 4420 4420 4420 4420 4420 4420 4420 4420 4420
402001637-1637 402001655-1655 402001656-1656 402001657-1657 402001662-1662 402001844-1844 402001859-1859 402001860-1860 402001877-1877 402001959-1959
4420
402001971-1971 PLATE 60-69
4420
402001972-1972 PLATE 1/3 TUBULAR LCP
4420
402001977-1977 PLATE 90-99
4420
402001985-1985 PLATE 3.5 ANTEROLATERAL TIBIA
4420
402001987-1987 PLATE 3.5 CURVED RECON RADIUS
4420
402001988-1988 PLATE 140-149
4420
402001991-1991 PLATE 3.5 LOCK PROXIMAL TIBIA
4420
402001993-1993 PLATE 430-449
4420
402001994-1994 PLATE 3.5 STRAIGHT RECON 4-8 HOLE
4420
402001996-1996 PLATE 330-349
4420
402001997-1997 PLATE 3.5MM PROXIMAL HUMERUS
4420
402001999-1999 PLATE 4.5 BROAD LC-DCP
CANULLA 8X4 ARTHREX AR6592084 CATHETER CHOLANGIOGRAM 104 STAPLER 410 CEMENT BONE 235 DENVER SPLINT 10-1500-05 DERMACARRIERS 00-2195-013-00 DERMACARRIERS 00-2195-012-00 CHEST DRAIN 3600-100 MYOSURE DEVICE DRAPE W/INCISE & POUCH 1061 DRAPE INSTRUMENT POUCH 1018 IOBAN 129X100" 6619" DRAPE NEURO TIBURON 9449 DRAPE ISOLATION 20X20" 1003" DRILL DIAMOND NEURO STRYKER DRILL BIT 90-99 DRILL BIT 70-79 DRILL BIT 450-469 DRILL BIT 550-569 DRILL BIT 370-389 ENDO-SCRUB 2 SHEATH 19-12010 ESMARK 4X9' 4409" GUIDE WIRE 101 ROD CARBON FIBER 11MM ROD ATTACHMENT - MULTIPIN CLAMP
TUBING IRR Y 28 CLIP LIGATING MED/LG 3200 CLIP LIGATING MED 2200 CLIP LIGATING SMALL 1200 MANIPUJECTOR UTERINE 6003 NERVE STIMULATOR VARI 85-62010 GELFILM PACKING NASAL KIT EPISTAT PINS DISP SKULL MAYFIELD A-1072 STAPLES PORSTH 246
Long Description
Tracheo-esophageal voice prosthesis, inserted by a licensed health care provider, any type
Adhesive, liquid or equal, any type, per oz
Disposable endoscope sheath, each Guide wire
Introducer/sheath, other than guiding, other than intracardiac electrophysiological, non-laser Closure device, vascular (implantable/insertable) Closure device, vascular (implantable/insertable) Closure device, vascular (implantable/insertable)
Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable)
UB Revenue Code 272 274 272 272 272 278 271 272 272 272 272 272 272 272 272 272 272 272 272 270 272 272 272 272 270 278 278 272 272 278 278 278 272 272 272 272 278 360
CPT/HCPCS
Amount 1380.00
L8509
A4364
A4270 C1769
C1894 C1760 C1760 C1760
1050.00 128.00 416.00 945.00 940.00 178.96 118.70 118.70 200.00 3555.00 26.15 6.55 88.00 114.85 16.59 512.00 380.00 300.00 1380.00 1680.00 1140.00 228.00 18.59 303.00 900.00 1266.30 652.00 112.00 24.39 17.00 14.51 129.15 197.40 336.00 283.76 117.50 1139.99
278
C1713
260.00
278
C1713
680.40
278
C1713
380.00
278
C1713
4198.50
278
C1713
1366.20
278
C1713
580.00
278
C1713
4050.00
278
C1713
1320.00
278
C1713
466.80
278
C1713
1020.00
278
C1713
4299.75
278
C1713
986.40
73 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4420
402002002-2002 PLATE 4.5 LOCK PROXIMAL TIBIA
4420
402002003-2003 PLATE 4.5 LOCKING CONDYLAR
4420
402002005-2005 PLATE 4.5 NARROW LCP 4-16 HOLE
4420
402002015-2015 PLATE 850-899
4420
402002019-2019 PLATE 2050-2099
4420
402002027-2027 PLATE 1100-1149
4420
402002031-2031 PLATE DISTAL LAT FIBULAR 16-20
4420
402002039-2039 PLATE EXT ART DISTAL HUMERAL 8
4420
402002058-2058 PLATE 70-79
4420
402002060-2060 PLATE 80-89
4420
402002061-2061 PLATE SMALL BOX
4420
402002066-2066 PLATE STRAIGHT 8 HOLE GOLD
4420
402002071-2071 PLATE 350-369
4420
402002073-2073 PLATE TIBIA MEDIAL DISTAL
4420
402002074-2074 PLATE 530-549
4420
402002076-2076 PLATE VOLAR MEDIAL COLUMN
4420
402002081-2081 PLATE 50-59
4420 4420 4420
402002083-2083 BURR HOLE COVER 10/14MM W/TAB 402002111-2111 RINGS FALOPE FRB-30 402002165-2165 SAW BLADE OSC/SAG 2296-003-511
4420
402002191-2191 SCREW 1500-1549
4420
402002195-2195 SCREW 100-109
4420
402002197-2197 SCREW 20-29
4420
402002199-2199 SCREW 2.7 TI CORTEX 6-20MM
4420
402002200-2200 SCREW 3.5 CONICAL PART THREAD
4420
402002205-2205 SCREW 110-119
4420
402002207-2207 SCREW 3.5MM CORTEX 10-60MM
4420
402002212-2212 SCREW 140-149
4420
402002213-2213 SCREW 4.0 CANC FULL THREAD
4420
402002214-2214 SCREW 4.0 CANC PART THREAD
4420
402002222-2222 SCREW 4MM SCHANZ 100-175MM
4420
402002225-2225 SCREW 5.0 CANN LOCKING 28-85MM
4420
402002226-2226 SCREW 5.0 CANN LOCKING 40-95MM
Long Description Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable)
UB Revenue Code
CPT/HCPCS
278
C1713
4028.40
278
C1713
4595.40
278
C1713
1395.90
278
C1713
2625.00
278
C1713
6225.00
278
C1713
3375.00
278
C1713
3420.09
278
C1713
4087.80
278
C1713
300.00
278
C1713
340.00
278
C1713
569.40
278
C1713
777.40
278
C1713
1080.00
278
C1713
4174.20
278
C1713
1620.00
278
C1713
3322.80
278
C1713
220.00
278 272 272 Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable)
Amount
844.80 272.24 147.40
278
C1713
4575.00
278
C1713
420.00
278
C1713
100.00
278
C1713
208.80
278
C1713
500.40
278
C1713
460.00
278
C1713
113.65
278
C1713
580.00
278
C1713
94.50
278
C1713
94.50
278
C1713
532.80
278
C1713
738.00
278
C1713
648.00
74 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4420
402002227-2227 SCREW 5.0 LOCKING 14-90MM
4420
402002229-2229 SCREW 5.0 LOCKING 26-100MM
4420
402002230-2230 SCREW 5MM SCHANZ 100-250MM
4420
402002232-2232 SCREW 6.5 CANC 16MM THREAD
4420
402002234-2234 SCREW 6.5 CANC 32MM THREAD
4420
402002238-2238 SCREW 6.5MM CANN 16MM THREAD
4420
402002239-2239 SCREW 6.5MM CANN 32MM THREAD
4420
402002241-2241 SCREW 6.5MM CANN FULL THREAD
4420
402002243-2243 SCREW 7.3 CANN LOCKING 20-145MM
4420
402002244-2244 SCREW 240-249 310-332
4420
402002247-2247 SCREW 7.3 TI CANN 32MM THREAD
4420
402002249-2249 SCREW CORTEX 4.5 14-70MM
4420
402002256-2256 SCREW 90-99
4420
402002257-2257 SCREWS 2.4 CORTEX 6-40MM
4420
402002318-2318 SCREW 850-899
4420
402002422-2422 SCREW 30-39
4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420
402002682-2682 402002691-2691 402002740-2740 402002759-2759 402002773-2773 402002777-2777 402002781-2781 402002783-2783 402002799-2799 402002818-2818 402002826-2826 402002848-2848 402002849-2849 402002851-2851 402002859-2859 402002878-2878
4420
402002901-2901 K-WIRE 10
4420 4420
402002909-2909 GUIDE PIN 31 402002917-2917 WIRE PASS DRILL DISP 261247
4420
402002921-2921 WASHER 13MM
4420 4420 4420 4420 4420 4420 4420 4420 4420
402002931-2931 402002968-2968 402002971-2971 402002972-2972 402002984-2984 402003041-3041 402003080-3080 402003091-3091 402003094-3094
CAMINO INTRACRANIAL KIT 110-4BC TUBE PE SHEEHY BUTTON 1013302 HIP STEM 4418 SURGICEL 3 X 4" 1943" CLAMP ADJUSTABLE CLAMP COMBINATION CLAMP 6 PIN CLAMP 4 PIN SKIN STAPLER 35W 528235 SHUNT COMPONENT CSF 4465 SHUNT LUMBAR PERITO NL8507210 ENDO STITCH 10 SUTURING 173016 ENDO STITCH 48 SUTURE 173023" RELOAD TRT75 LINEAR CUTTER THICK TUBE T-TUBE PE 10-26040 SHUNT COMPONENT CSF 154
CLIP LIGATING LARGE 4200 SHUNT COMPONENT CSF 804 KIT CRANIAL ACCESS 363 DRAIN EXT SYST II 82-1721 GRAFT VASCULAR V03070L V04070L CATHETER PASSER 8591-38 ELECTRODE SUBDERMAL 8227410 ELECTRODE 33 M LAP L-HOOK 20 ELECTRODE ROLLER 27050RG/6
Long Description Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable)
Joint device (implantable)
Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Guide wire Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Closure device, vascular (implantable/insertable)
Graft, vascular
UB Revenue Code
CPT/HCPCS
278
C1713
536.40
278
C1713
777.60
278
C1713
740.00
278
C1713
142.20
278
C1713
142.20
278
C1713
997.20
278
C1713
997.20
278
C1713
997.20
278
C1713
818.10
278
C1713
960.00
278
C1713
997.20
278
C1713
110.25
278
C1713
380.00
278
C1713
198.00
278
C1713
2625.00
278
C1713
140.00
272 272 278 272 272 272 278 278 272 278 272 272 272 272 278 272
C1776
Amount
4279.50 42.00 13254.00 244.31 1638.90 1989.90 3393.90 3167.10 30.22 13395.00 2063.34 1164.00 94.95 698.84 117.60 616.00
278
C1713
40.00
272 272
C1769
124.00 311.20
278
C1713
124.90
278 278 272 272 278 272 272 272 272
C1760
31.03 2412.00 1089.00 840.00 2166.00 392.00 336.00 100.00 580.00
C1768
75 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4420
402003112-3112 ANCHOR SUPER QUICK MITEK
4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420
402003118-3118 402003127-3127 402003129-3129 402003130-3130 402003136-3136 402003151-3151 402003158-3158 402003180-3180 402003209-3209 402003234-3234 402003237-3237 402003272-3272 402003282-3282 402003287-3287 402003352-3352 402003392-3392 402003474-3474 402003482-3482 402003485-3485 402003488-3488
4420
402003496-3496 STENT URETERAL METALIC 902
4420 4420 4420 4420 4420 4420
402003543-3543 402003546-3546 402003564-3564 402003602-3602 402003605-3605 402003638-3638
4420
402003639-3639 SUTURE DEVICE CAPIO 831-125
4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420
402003686-3686 402003708-3708 402003710-3710 402003724-3724 402004051-4051 402004055-4055 402004056-4056 402004064-4064 402004070-4070 402004079-4079 402004108-4108 402004167-4167 402004168-4168 402004175-4175 402004198-4198 402004209-4209 402004231-4231 402004254-4254 402004258-4258 402004270-4270 402004285-4285 402004286-4286 402004287-4287 402004297-4297
4420
402004302-4302 STENT URETERAL 144
4420 4420 4420
ENDO-STICH POLYSORB CTD BRD SYN A INSTURMENT ENDO BABCOCK 10MM CLAM STAPLE LOAD 140 STAPLE LOAD 160 SURGICEL 2 X 3" 1953" VERSAPORT 12MM PLUS 179097P STAPLE LOAD 151 STAPLER 160 DRAIN JACKSON 7&10MM X 20CM STAPLER 280 BLUNT PORT PLUS 179075P BONE CEMENT PALACOS R1X40 FOGARTY EMBO 75 FOGARTY EMB 51 SURGIFLOW 181 ENDO-PADDLE RETRACT 173046 TUBE SET DISP-ARTHROSCOPY PUMP PORT MRI 9.6 602680 SHUNT CAROTID PRUITT INAHARA ARCH BAR EDRICH PADGETT
Long Description Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable)
Catheter, thrombectomy/embolectomy Catheter, thrombectomy/embolectomy
Port, indwelling (implantable)
Stent, non-coronary, temporary, with delivery system
INTERCEED 4350 BLADE TRICUT 3.5 & 4.0MM CERVICAL CUP 60-6085-100 TROCAR/SLEEVE 20-29 N-TERFACE 12 X 12" 3810.144" SUTURE CAPIO SZ 0 833-137
UB Revenue Code
CPT/HCPCS
278
C1713
272 272 272 272 272 272 272 272 270 272 272 278 272 272 270 272 272 278 278 272 278
C1757 C1757
C1788
C2625
272 272 272 270 272 278 Repair device, urinary, incontinence, without sling graft Mesh (implantable) Guide wire Guide wire Guide wire
Amount 1422.00 244.00 316.00 588.00 672.00 143.84 686.76 634.20 672.00 24.99 882.00 237.01 300.00 300.00 204.00 543.00 1089.00 246.96 855.00 416.00 173.58 2706.00 781.00 796.00 392.00 100.00 24.52 114.32
278
C2631
973.89
278 272 272 272 272 272 278 272 272 272 272 272 272 278 272 272 272 272 272 278 278 278 272 278
C1781 C1769 C1769 C1769
36750.00 340.00 260.00 220.00 154.88 876.00 1428.88 173.40 1332.45 1443.00 92.00 328.00 264.40 1398.00 1371.00 828.00 483.00 1005.00 280.00 1050.00 819.00 1554.00 1341.00 372.00
Stent, non-coronary, temporary, without delivery system
278
C2617
432.00
402004314-4314 CEMENT ZIMMER 00-1101-002-00 402004317-4317 MESH SYNTHETIC 100-119 402004339-4339 PULSE LAVAGE 210114000
Mesh (implantable)
278 278 272
C1781
309.32 440.00 136.00
4420
402004403-4403 TISSUE BONE CANC CRSHD CMMTY
Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable)
278
C1713
1627.25
4420
402004406-4406 BONE GRAFT 908
MESH SYNTHETIC 12000-12499 GUIDE WIRE 80-89 GUIDE WIRE 60-69 GUIDE WIRE 50-59 SCISSOR TIPS MEDIFLEX ALL ABC HANDPIECE 130321 CLIP ANEURYSM SUGITA FENESTRATED PUMP HANDPIECE TUBE 250070500 OMAYA RESERVOIR FORCEPS PIRANHA BX 505-160 CATH FOLLEY 3 WAY INTRODUCER 7-10FR TRACH SHILEY 60 & 80XLTCD, CP TISSUE PATCH 10X15 1410015010 ELECTRODE 457 SHUNT COMPONENT CSF 276 REAMING ROD, STERILE TRACH TRAY PERC BLUE RHINO CATHETER URETERAL MESH SYNTHETIC 340-359 DURA GEN GRAFT ID2205 DURAFORM 3X3 80-1478 HANDPORT SMALL LD111 CLIP FILSHIE AVM 851J
Mesh (implantable)
Catheter, suprapubic/cystoscopic Mesh (implantable) Connective tissue, non-human (includes synthetic) Connective tissue, non-human (includes synthetic)
278
C1781
C2627 C1781 C1763 C1763
2724.00 76 of 167 Updated on 1/22/2019
CDM Description
CDM Number
4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420
402004407-4407 402004410-4410 402004412-4412 402004413-4413 402004414-4414 402004422-4422 402004431-4431 402004432-4432 402004434-4434 402004440-4440 402004448-4448 402004453-4453 402004455-4455 402004456-4456 402004457-4457 402004458-4458 402004467-4467 402004470-4470 402004471-4471 402004473-4473 402004475-4475 402004485-4485 402004488-4488 402004492-4492 402004495-4495 402004496-4496 402004507-4507 402004519-4519 402004523-4523
4420
402004525-4525 MONARC SLING SYSTEM 72403830
Repair device, urinary, incontinence, with sling graft
278
C1771
4047.00
4420 4420 4420 4420 4420 4420 4420 4420 4420 4420
402004526-4526 402004528-4528 402004529-4529 402004534-4534 402004540-4540 402004542-4542 402004552-4552 402004553-4553 402004558-4558 402004563-4563
Wound closure utilizing tissue adhesive(s) only
360 272 278 272 272 272 272 272 278 272
G0168
148.30 711.00 33600.00 1071.00 1358.28 1008.00 792.00 6394.50 441.60 316.51
4420
402004565-4565 SCREW RECON LG 5.5 ZIMMER
278
C1713
896.76
4420
402004566-4566 SCREW INTERLOCKING ZIMMER
278
C1713
648.00
4420
402004567-4567 SCREW 200-219 270-289
278
C1713
840.00
4420
402004572-4572 PLATE TIBIA 3.5-8 HOLE SYNTHES
278
C1713
4125.60
4420
402004575-4575 PLATE TIBIA 4.5-8 HOLE SYNTHES
278
C1713
4136.40
4420
402004587-4587 NAIL CANN PROX HUMERAL SYNTHES
278
C1713
5178.60
4420
402004589-4589 NAIL-EX AD LAT ENT RT & LT
278
C1713
4252.50
4420
402004592-4592 NAIL TIBIA EX SYNTHES
278
C1713
4023.00
4420
402004593-4593 NAIL LAT ENT FEM SYNTHES
278
C1713
4708.80
4420
402004594-4594 NAIL RET/ANT FEM SYNTHES
278
C1713
4590.00
4420
402004595-4595 NAIL TFN LONG SYNTHES
278
C1713
4905.90
4420
402004625-4625 ACF SPACER 5-12 17105-17209
BONE GRAFT 1426 MESH SYNTHETIC 380-399 MESH COMPOSIX EX 7X9 MESH COMPOSIX EX 10X14 MESH SYNTHETIC 180-199 250-265 CUTTER AGGRESSIVE 3.5MM-5.5MM SHUNT COMPONENT CSF 200 DRAIN BLAKE 19FR HUBLESS 2230 MEROGEL NASAL PACKING 15-17000 BLADE DERMATOME ZIM00880000010 HANDPIECE ABC 134003 ENDO RETRACTOR II 10MM 176647 PUTTY DBX 1CC 38010 SUTURE, LEVEL I GENERAL SUTURE,LEVEL III PLASTIC-NEURO-EY SUTURE, LEVEL II MULTIPACK MESH SEPRAMESH 3X6 5959360 MESH SEPRAMESH 8X12 5959812 SEPRAFILM BARRIER 4301-02 BLADE-BUR 187-199 250-269 CLIP APPLIER 100 TROCAR/SLEEVE 90-99 HARMONICS SCALPEL ACE36E DRAPE ARTHROSCOPY SHEET 3904 VERSAPORT 179070, 71, 74, 78P TISSUE RETRIEVER 70 LIGASURE ATLAS LS1037 MESH SYNTHETIC 200-219 266-292 CLIP APPLIER 160
ADHESIVE 0.5ML DPP6 ABC LAP PROBE 160656 MEDTRONIC SYNCROMED II 863720 STAPLER 340 LIGASURE V 5X37 LS1500 STAPLER 320 FORCEPS ALLIGATOR 3FR 210320 SEPRAFILM ADHESION PAK 5086-02 PUTTY DBX 0.5CC 38005 VAC WOUND CARE SET
Long Description
UB Revenue Code 278 278 278 278 278 272 272 272 272 272 272 272 272 272 272 272 278 278 272 272 272 272 272 272 272 272 272 278 272
Revenue Center
Mesh (implantable) Mesh (implantable) Mesh (implantable) Mesh (implantable)
Mesh (implantable) Mesh (implantable)
Mesh (implantable)
Infusion pump, programmable (implantable)
Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable)
278
CPT/HCPCS
C1781 C1781 C1781 C1781
C1781 C1781
C1781
C1772
Amount 4278.00 1170.00 1860.00 2550.00 780.00 219.28 800.00 80.00 357.00 156.00 380.00 873.00 883.97 30.19 102.64 132.83 879.00 3630.00 932.40 780.00 420.00 380.00 1674.00 76.00 207.31 294.00 1314.02 840.00 672.00
3165.00 77 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4420 4420 4420
402004628-4628 ROUTER TAPERED 1.7X16MM 402004630-4630 PERFORATOR BIT 5100-60-1 402004642-4642 NAIL END CAP SYNTHES
4420
402004657-4657 RODS 6001
4420 4420 4420 4420
402004660-4660 402004661-4661 402004662-4662 402004663-4663
4420
402004667-4667 PINS 101
4420
402004683-4683 HIP STEM 4956
4420 4420 4420 4420 4420 4420 4420 4420 4420 4420
402004722-4722 402004726-4726 402004739-4739 402004742-4742 402004744-4744 402004759-4759 402004762-4762 402004766-4766 402004767-4767 402004769-4769
4420
402004770-4770 GENERATOR RECHRGBL SYST 24573
4420 4420 4420
402004783-4783 BOVIE SUPPLIES 402004786-4786 BONE GRAFT INFUSE MED 7510400 402004794-4794 TOURNIQUET 12 60-7070-102-00"
4420
402004800-4800 SPACEMAKER BALLOON OMSPDBS2
4420
402004805-4805 SCREW MILAGRO ALL 8 & 9MM
4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420
402004814-4814 402004816-4816 402004850-4850 402004853-4853 402004854-4854 402004855-4855 402004857-4857 402004858-4858 402004859-4859 402004860-4860 402004861-4861 402004863-4863 402004864-4864 402004865-4865 402004866-4866 402005005-5005 402005007-5007 402005008-5008 402005009-5009 402005020-5020 402005030-5030 402005042-5042
4420
402005043-5043 STENT FRONTAL SINUS 70890932
4420 4420 4420
402005047-5047 TAPS 447 402005052-5052 PUTTY DBX 2.5 38025 402005059-5059 SURGICEL 4X 8" 1952"
4420
402005060-5060 SPACEMAKER BALLOON OMST10SB
4420 4420
402005066-5066 DRILL BIT 350-369 402005067-5067 GUIDE WIRE, SMOOTH
Long Description
Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable)
DRILL BIT 50-59 DRILL BIT 95 DRILL BIT 200-219 270-289 DRILL BIT 510-529
GUIDE PIN 10 GUIDE WIRE 390-409 BLADE-BUR 50-59 BLADE-BUR 30-39 BLADE-BUR 20-29 SURGIMEND 606-004-100 SURGIMEND 606-001-004 MESH SYNTHETIC 5000-5499 MESH SYNTHETIC 5500-5999 VNS THERAPY LEAD
DURASEAL KIT 20-2050 SURGICLIP PREM MED 134044 HIP SPICA FIBERGLASS CAST LONG ARM PLASTER CAST LONG ARM PLASTER SPLINT LONG LEG FIBERGLASS CAST LONG LEG PLASTER CAST LONG LEG PLASTER SPLINT SHORT ARM FIBERGLASS CAST SHORT ARM PLASTER CAST SHORT ARM PLASTER SPLINT SHORT LEG FIBERGLASS SPLI SHORT LEG PLASTER CAST SHORT LEG PLASTER SPLINT SHORT ARM FIBERGLASS SPLINT CANNULA ARTHREX 5.75X5 SUTURELASSO SD - ARTHREX NEEDLE, ARTHREX - SCORPION SLEEVE, STAR ARTHREX AR-1606V SURGICLIP PREMIUM 134046 JOINT COMPONENT 800-899 ENDOSCRUB SHEATH 4MM 19-12000
UB Revenue Code 272 272 278 278
CPT/HCPCS
299.46 525.00 662.40 C1713
272 272 272 272 Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Guide wire Guide wire
Connective tissue, non-human (includes synthetic) Connective tissue, non-human (includes synthetic) Mesh (implantable) Mesh (implantable) Lead, neurostimulator (implantable) Generator, neurostimulator (implantable), non highfrequency with rechargeable battery and charging system
Needle, sterile, any size, each
Disposable endoscope sheath, each Stent, non-coronary, temporary, with delivery system
278
C1713
590.40
278
C1713
14868.00
278 272 272 272 272 278 278 278 278 278
C1769 C1769
C1763 C1763 C1781 C1781 C1778
40.00 1200.00 220.00 140.00 100.00 8100.00 3240.00 15750.00 17250.00 15525.00
278
C1820
73721.00 62.35 14679.00 112.72
278
C1727
1140.00
278
C1713
1086.00
272 272 270 270 270 270 270 270 270 270 270 270 270 270 270 272 272 272 272 272 278 272 278
A4270
2454.00 1035.29 211.37 50.82 25.41 84.32 84.32 25.41 25.41 33.60 17.33 76.23 50.82 25.41 30.45 184.00 588.00 117.60 420.00 1035.29 2550.00 248.00
C2625
128.16
A4215
272 278 272 Catheter, balloon tissue dissector, non-vascular (insertable) Guide wire
15093.75 220.00 380.00 840.00 1560.00
272 278 272 Catheter, balloon tissue dissector, non-vascular (insertable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable)
Amount
1130.85 1440.00 289.84
272
C1727
672.71
272 272
C1769
1080.00 924.00
78 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4420 4420 4420 4420 4420 4420 4420
402005073-5073 402005076-5076 402005091-5091 402005092-5092 402005093-5093 402005098-5098 402005099-5099
4420
402005102-5102 PLATE CURVED 2.4MM 449.24
4420
402005103-5103 SCREW 350-369
4420 4420 4420
402005104-5104 HARMONIC SHEARS 9CM FCS9 402005134-5134 SURGIMEND 606-001-007 402005145-5145 SUTURE ENDO MINI IMVAS EJ10G
4420
402005170-5170 SLING SYSTEM MINIARC 720046-01
4420 4420 4420
402005211-5211 SUTURE RETRIEVER 30 402005304-5304 ABTHERA DRESSING SET 370605 402005305-5305 HOOK 5MM ELASTIC STAY
4420
402005312-5312 PLATE 1750-1799
4420 4420 4420 4420 4420
402005313-5313 402005315-5315 402005339-5339 402005341-5341 402005342-5342
4420
402005403-5403 PLATE 2.4 LCP VC DISTAL RADIUS
4420
402005405-5405 PLATE 70MM SS CALCANEAL
4420
402005409-5409 PLATE 2.0M 4-8 HOLE
4420
402005410-5410 PLATE 187-199 250-269
4420
402005414-5414 PLATE-T 2.0MM 3H HEAD 7H SHAFT
4420
402005415-5415 PLATE 410-429
4420
402005417-5417 PLEATE 2.4MM CONDYLAR 9 HOLE
4420
402005419-5419 PLATE 2.7MM LCP ALL SIZES
4420
402005423-5423 12 H CURVED PLATE ALL COLORS
4420
402005424-5424 PLATE 170-179
4420
402005425-5425 PLATE X, L, Y, DBL Y & BOX ALL
4420
402005426-5426 PREFORMED ORBITAL PLATES ALL
4420
402005434-5434 ANGLE REC PLATE 7X23H R&L BLUE
4420
402005435-5435 STRAIT PLATE 2.8MM 12 H GOLD
4420
402005441-5441 MINI PLATE 3X3 H MALLEABLE
4420
402005444-5444 BOX PLATE 4 HOLE
4420
402005446-5446 CURVED STRUT PLATE 8 HOLE
4420
402005456-5456 ANGLE PLATE 1.5MM 3X3 HOLE
4420
402005458-5458 DCP PLATE 1.5MM 2X2 HOLE
Long Description
BOWL, QUICK VAC MIXING CEMENT FEM BONE PREP KIT ZIM DRAIN JACKSON 100ML SU130-1305 VESSEL LOOPS SILICONE 01-1-002PBX VERSAPORT 11MM 179102P VERSAPORT 12MM 179103P VERSAPORT 12MM 179096P
WIRE CERCLAGE ALL GAUGES CERCLAGE WIRE 0.5 & 0.6MM 26 & BONE CANC CUBES 091968-013 JOINT COMPONENT 2100-2199 STEM RADIAL HEAD TR-S0906-S
Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable)
UB Revenue Code 272 272 272 270 272 272 272
CPT/HCPCS
Amount 277.75 558.26 22.52 9.71 148.09 148.09 197.48
278
C1713
1320.30
278
C1713
1080.00
Connective tissue, non-human (includes synthetic)
272 278 272
C1763
1992.00 12600.00 498.04
Repair device, urinary, incontinence, with sling graft
278
C1771
3576.00
272 272 272 Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable)
Joint device (implantable) Joint device (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable)
278
120.00 1102.50 39.69 C1713
5325.00
278 278 278 278 278
C1776 C1776
42.50 321.80 1191.00 6450.00 4890.00
278
C1713
3790.80
278
C1713
1571.40
278
C1713
954.00
278
C1713
780.00
278
C1713
1266.30
278
C1713
1260.00
278
C1713
1147.50
278
C1713
1150.20
278
C1713
954.18
278
C1713
700.00
278
C1713
778.41
278
C1713
3601.89
278
C1713
5035.95
278
C1713
3055.05
278
C1713
1035.09
278
C1713
742.14
278
C1713
1461.96
278
C1713
3795.80
278
C1713
1637.73
79 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4420
402005464-5464 PLATE RECTANGLE 2X2 H 55-06312
4420
402005470-5470 PLATE 2850-2899
4420
402005484-5484 PLATE LOCK FIBULA 02.112.142
4420
402005510-5510 SCREWS 2.0MM CORTEX 6-40
4420
402005511-5511 SCREWS 2.0MM IMF
4420
402005512-5512 SCREWS 2.7MM CORTEX 6-30MM
4420
402005513-5513 SCREWS 2.4MM LOCKING 6-30MM
4420
402005514-5514 SCREWS 3.5 LOCKING SELF TAPING
4420
402005515-5515 SCREW 80-89
4420
402005518-5518 SCREWS - ALL SIZES & TYPE
4420 4420 4420 4420 4420 4420 4420 4420
402005520-5520 402005612-5612 402005615-5615 402005624-5624 402005639-5639 402005640-5640 402005651-5651 402005656-5656
4420
402005666-5666 ANCHOR BIO AR 2324BSLM
4420
402005667-5667 ANCHOR BIO 3.0MM AR-1934BCF
4420
402005668-5668 FIBER TAPE 2MM AR-7237-7
4420
402005670-5670 PUSH LOCK KIT AR-1923DS
4420
402005673-5673 SCREW INTERFERENCE BIO AR-1380
4420 4420 4420 4420 4420 4420
402005682-5682 402005684-5684 402005685-5685 402005686-5686 402005697-5697 402005703-5703
4420
402005705-5705 K-WIRE 9 SMOOTH"
4420
402005706-5706 K-WIRE 9 THREADED"
4420
402005718-5718 GUIDE PIN 115
4420
402005720-5720 PLATE ANGLE 3X3 HOLE MATRIX
4420
402005721-5721 TEMPLATES MAND ALL MATRIX
SCREW CAN INTRFRNC AR-1390TB SLING ARM MEDIUM SURGIFOAM 8CM X 12.5CM VAC GRANUFOAM LARGE TENDON POST TIBIALUS LIFENET ACL KIL MITEK 232300 ANCHOR PUSHLOCK AR 1926PSP BIOTENODESIS KIT AR-1676DS
STAPLER 100 STAPLE LOAD 120 STAPLE LOAD 50 STAPLE LOAD 80 MESH SYNTHETIC 120-139 GUIDE WIRE 30-39
4420
402005722-5722 SCREW LOCKING 2.0 & 2.4 MATIRX
4420
402005724-5724 PLATE ANG RECON 7X23 MATRIX
4420
402005726-5726 SCREW LOCKING 2.0 301.876 ALL
4420 4420 4420 4420 4420 4420
402005727-5727 402005728-5728 402005734-5734 402005735-5735 402005739-5739 402005767-5767
PROSTH OSSICULAR ALTO ALL STAPLES PROSTH 299 SUTURE GRASPER 29 SHUNT COMPONENT CSF 139 LIGHT MAT 2X5 CM JOINT COMPONENT 700-799
Long Description Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Joint device (implantable) Slings
Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable)
Mesh (implantable) Guide wire Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Guide wire Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable)
UB Revenue Code
CPT/HCPCS
278
C1713
840.00
278
C1713
8625.00
278
C1713
1849.50
278
C1713
136.80
278
C1713
405.68
278
C1713
137.72
278
C1713
442.80
278
C1713
482.40
278
C1713
340.00
278
C1713
305.04
278 271 272 272 272 272 272 272
C1776 A4565
693.00 32.55 148.26 113.02 4095.00 1373.40 1449.00 315.00
278
C1713
1629.00
278
C1713
915.00
278
C1713
240.00
278
C1713
700.00
278
C1713
1050.00
272 272 272 272 278 272
C1781 C1769
420.00 504.00 210.00 336.00 520.00 140.00
278
C1713
12.82
278
C1713
24.00
272
C1769
460.00
278
C1713
1258.29
272 Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Ossicula implant Ossicula implant Aqueous shunt Joint device (implantable)
Amount
283.21
278
C1713
513.36
278
C1713
5019.21
278
C1713
439.20
278 278 272 278 271 278
L8613 L8613
960.30 897.00 116.00 555.96 230.16 2250.00
L8612 C1776
80 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4420
402005768-5768 GRAFT TENDON 2508
4420
402005780-5780 PLATE 1150-1199
4420
402005781-5781 PLATE RESIRB 851.542.01S
4420
402005783-5783 PLATE SYNPOR 08.510.1XXS
4420
402005785-5785 PLATE 550-569
4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420
402005791-5791 402005801-5801 402005810-5810 402005816-5816 402005819-5819 402005820-5820 402005822-5822 402005823-5823 402005826-5826 402005827-5827 402005834-5834 402005835-5835 402005836-5836
4420
402005838-5838 SCREW TRILOGY 6.5MM 6250 ALL
4420 4420 4420 4420
402005839-5839 402005840-5840 402005842-5842 402005847-5847
4420
402005849-5849 PLATE 1700-1749
4420
402005854-5854 DRILL BIT 100-109
SURGIMEND 606-001-002 JOINT COMPONENT 3600-3699 PORT 8 FR POWERPORT 4808060 JOINT COMPONENT 900-999 FORCEPS CUTTING GYRUS 920005 MESH PARIETEX 6X4 PC1510 MESH PARIETEX 4.8 PC020" MESH PARIETEX 8 PC020" SIGMOIDOSCOPE DISPOSABLE 53130 BLADE-BUR 120-129 SHUNT COMPONENT CSF 1308 DRESSING OWENS ALL SHUNT COMPONENT CSF 681
Long Description Connective tissue, human (includes fascia lata) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Connective tissue, non-human (includes synthetic) Joint device (implantable) Port, indwelling (implantable) Joint device (implantable)
402005855-5855 COAPTITE BULKING AGENT
4420 4420
402005905-5905 TISSUE TRAP OTOMED SP-2000 402005912-5912 NEURO MEND 1571
4420
402005914-5914 SCREW 570-589
4420
402005916-5916 TRANSCONNECTOR MATRIX 17-19MM
4420
402005918-5918 SCREW 1200-1249
4420 4420 4420
402005921-5921 ROD HARD 5.5MM NONCONTOURED 402005922-5922 ROD CURVED 5.5MM 04.636.0XX 402005925-5925 LOCKING CAP 04.632.000
4420
402005930-5930 ROD MIS SOFT 04.651.XXX
4420 4420
402005937-5937 JOINT COMPONENT 1500-1599 402005938-5938 JOINT COMPONENT 1600-1699
4420
402005949-5949 SCREW 70-79
4420
402005953-5953 SCREW 390-409
4420
402005955-5955 DRILL BIT 180-186
4420
402005964-5964 SCREW WRIGHT 4.3MM ALL
4420 4420
402005970-5970 BREAST IMPLANT SIZER-ALLERGAN 402005976-5976 DRILL BIT 370
4420
402005978-5978 PLATE 40-49
4420
402005988-5988 PLATE BIOMET 1.5 MESH PANEL
4420
402005990-5990 SCREW 50-59
CPT/HCPCS
Amount
C1762
7524.00
278
C1713
3525.00
278
C1713
3460.50
278
C1713
1023.00
278
C1713
1680.00
C1763 C1776 C1788 C1776
Mesh (implantable) Mesh (implantable) Mesh (implantable)
278 278 278 278 272 278 278 278 272 272 278 272 272
C1781 C1781 C1781
1350.00 10950.00 1377.00 2850.00 1650.00 1326.33 1821.48 3829.46 20.16 500.00 3924.00 12.54 2043.00
Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable)
278
C1713
300.00
BIPOLAR FORCEP 80-1274 DILATOR SINUS BALLOON 1650 TUBING HYSTEROSCOPY STORZ BIPOLAR FORCEP DISP 20-141K1
4420
UB Revenue Code 278
272 272 272 272 Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable)
278
1260.00 5475.00 522.38 184.00 C1713
272 Injectable bulking agent, collagen implant, urinary tract, 2.5 ml syringe, includes shipping and necessary supplies Connective tissue, human (includes fascia lata) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable)
420.00
278
L8603
1005.00
272 278
C1762
113.40 5523.00
278
C1713
1740.00
278 Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable)
278
3888.75 C1713
278 278 278 Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Joint device (implantable) Joint device (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable)
278
C1713
1173.00
278 278
C1776 C1776
4650.00 4950.00
278
C1713
300.00
278
C1713
1200.00
278
740.00 C1713
278 272 Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable)
3675.00 278.80 765.00 948.00
272 Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable)
5175.00
867.00 180.00 1110.00
278
C1713
180.00
278
C1713
3021.00
278
C1713
220.00
81 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4420
402005997-5997 SCREW 2450-2499
4420
402005998-5998 DRILL BIT 150-159
4420
402006006-6006 SECURE STRAP ABSORBABLE
4420
402006013-6013 PLATE 390-409
4420
402006015-6015 PLATE ACUMED CLAVICLE 6-13 HOL
4420
402006016-6016 PLATE ACUMED CLAVICLE 16 ONLY
4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420
402006044-6044 402006060-6060 402006069-6069 402006070-6070 402006079-6079 402006080-6080 402006090-6090 402006101-6101 402006111-6111 402006121-6121 402006134-6134
4420
402006135-6135 END CAP WRIGHT VALOR ALL
4420
402006136-6136 PLATE 1550-1599
4420
402006139-6139 PLATE SYNTHES DIA-META RADIUS
4420
402006145-6145 NAIL SYNTHES HINDFOOT ALL
4420
402006155-6155 PLATE 220-239 290-309
4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420
402006158-6158 402006159-6159 402006166-6166 402006178-6178 402006179-6179 402006207-6207 402006215-6215 402006216-6216 402006217-6217 402006238-6238 402006241-6241 402006242-6242 402006244-6244 402006246-6246 402006256-6256
4420
402006261-6261 PLATE 1250-1299
4420
402006263-6263 SCREW 120-129
4420
402006272-6272 SURGIMEND 606-004-102
4420
402006273-6273 SCREW 333-349
4420
402006275-6275 SCREW 220-239 290-309
4420
402006278-6278 PLATE VA 2.7/3.5 PROX OLEC
4420
402006279-6279 PLATE VA 2.7/3.5 OLECRANON
4420
402006282-6282 SCREW SYN METAPHYSEAL
4420
402006283-6283 SCREW 130-139
DISP. FALOPE RING APPLIER W/RI PROSTH GYRUS INCUS 14-085X HIP STEM 3694 JOINT COMPONENT 1900-1999 JOINT COMPONENT 4000-4199 JOINT COMPONENT 3300-3399 MESH PARIETEX ROUND 9CM PC09X ENDO-SHEARS LAPRA-TY SUTURE CLIPS TISSUE RETRIEVER 100 DRILL BIT 333-349
HOOK GYRUS 956010PC HTA BOSTON SCI 58021 LEAD CYBERONICS VNS 304-20 SCISSOR TIPS HOOK TENDON TIBIALIS SBI SXFTIBA MESH PHYSIO 15X20 PHY1520V MESH PROCEED PCDG1 JOINT COMPONENT 2500-2599 STEM RADIAL WRIGHT JOINT COMPONENT 1200-1299 MESH PRODEED PVPS INTRODUCER KIT AXCESS 490029 SPLINT INTRANASAL POSISEP LEAD NEUROSTIMULATOR 5349 EX FIX COMPONENT 170-179
Long Description Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable)
UB Revenue Code
CPT/HCPCS
278
C1713
272 Repair device, urinary, incontinence, with sling graft Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Ossicula implant Joint device (implantable) Joint device (implantable) Joint device (implantable) Joint device (implantable) Mesh (implantable)
Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Joint device (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable)
Lead, neurostimulator (implantable) Connective tissue, human (includes fascia lata) Mesh (implantable) Mesh (implantable) Joint device (implantable) Joint device (implantable) Joint device (implantable) Mesh (implantable)
Lead, neurostimulator (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Connective tissue, non-human (includes synthetic) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable)
Amount 7425.00 620.00
278
C1771
1614.00
278
C1713
1200.00
278
C1713
4000.50
278
C1713
4401.00
272 278 278 278 278 278 278 272 272 272 272
L8613 C1776 C1776 C1776 C1776 C1781
456.00 895.83 11082.00 5850.00 12300.00 10050.00 1015.50 291.90 292.00 420.00 1020.00
278
C1713
920.00
278
C1713
4725.00
278
C1713
5196.00
278
C1776
4986.00
278
C1713
900.00
272 272 278 272 278 278 278 278 278 278 278 270 270 278 272
C1778 C1762 C1781 C1781 C1776 C1776 C1776 C1781
C1778
1134.00 1370.00 22380.00 207.90 5550.00 1774.29 3145.50 7650.00 5382.00 3750.00 1081.50 133.60 844.66 16047.00 700.00
278
C1713
3825.00
278
C1713
500.00
278
C1763
10800.00
278
C1713
1020.00
278
C1713
900.00
278
C1713
3036.00
278
C1713
3413.52
278
C1713
200.64
278
C1713
540.00
82 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4420
402006298-6298 PLATE STRY FOOT CALCANEUS
4420
402006307-6307 K-WIRE 21
4420
402006311-6311 SCREW VA 2.4 LOCKING
4420
402006313-6313 PLATE VA 2.4/2.7 FUSION ST
4420
402006314-6314 PLATE VA 2.4/2.7 FUSION ALL
4420
402006315-6315 PLATE 1350-1399
4420
402006316-6316 PLATE VA 2.4/2.7 NAVIC/CUBOID
4420 4420 4420
402006318-6318 DRILL BIT 80-89 402006324-6324 JOINT COMPONENT 500-599 402006325-6325 HIP HEAD 1000
4420
402006328-6328 HIP MONO SLEEVE 163
4420
402006331-6331 DRILL BIT 530-549
4420
402006335-6335 PLATE 4.5 VA CURVED CONDYLAR
4420
402006337-6337 SCREW 5.0 VA LOCKING
4420
402006338-6338 SCREW5.0 VA CANN LOCKING
4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420
402006339-6339 402006340-6340 402006341-6341 402006345-6345 402006348-6348 402006354-6354 402006359-6359 402006360-6360 402006361-6361 402006363-6363 402006365-6365 402006371-6371 402006374-6374 402006383-6383 402006402-6402
4420
402006404-6404 PLATE STRYKER CLAVICLE
4420
402006408-6408 PLATE MATTA CURVED 14-16 HOLE
4420
402006414-6414 PLATE MATTA FLEX 12-14 HOLE
4420
402006424-6424 TEMPLATE 115
4420
402006429-6429 SCREW STRY 3.0 LOCKING
4420
402006434-6434 HIP STEM 1400
4420
402006435-6435 SCREW ACUTRAK ALL
4420 4420 4420 4420
402006436-6436 402006441-6441 402006443-6443 402006447-6447
4420
402006454-6454 GENERATOR RECHRGBL SYST 25000
4420 4420 4420 4420
402006456-6456 402006461-6461 402006465-6465 402006467-6467
DRILL BIT 220-239 290-309 GUIDE WIRE 40-49 GUIDE WIRE 70-79 TROCHAR THORACIC 118 KNEE FEMUR 5785 KNEE SLEEVE ADAPTOR 2140 JOINT COMPONENT 1800-1899 KNEE STEM 1536 KNEE STEM 975 KNEE AUGMENT 982 KNEE POLY 2746 KNEE TIBIA 4789 JOINT COMPONENT 3100-3199 AVNEXSTAT W/APLICATOR WITTMANN PATCH
GUIDE WIRE 10-20 COUNTERSINK 123 BREAST IMPLANT 875 TISSUE EXPANDER 1495
HARMONIC ACE 45 JOINT COMPONENT 1300-1399 SHOULDER HEAD 1460 JOINT COMPONENT 5800-5999
Long Description Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Prosthetic implant, not otherwise specified Prosthetic implant, not otherwise specified Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable)
UB Revenue Code
CPT/HCPCS
278
C1713
3934.80
278
C1713
84.00
278
C1713
531.52
278
C1713
3564.00
278
C1713
4356.00
278
C1713
4125.00
278
C1713
3300.00
272 278 278
L8699 L8699
340.00 1650.00 3000.00
278
C1713
652.00
272 Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Guide wire Guide wire
Joint device (implantable) Joint device (implantable) Joint device (implantable) Joint device (implantable) Joint device (implantable) Joint device (implantable) Joint device (implantable) Joint device (implantable) Adhesion barrier Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable)
1620.00
278
C1713
5980.89
278
C1713
744.92
278
C1713
759.00
272 272 272 272 272 278 278 278 278 278 278 278 278 278 272
C1769 C1769
C1776 C1776 C1776 C1776 C1776 C1776 C1776 C1776 C1765
Prosthesis, breast (implantable) Generator, neurostimulator (implantable), non highfrequency with rechargeable battery and charging system Joint device (implantable) Joint device (implantable) Joint device (implantable)
900.00 180.00 300.00 497.20 17355.00 6420.00 5550.00 4608.00 2925.00 2946.00 8238.00 14367.00 9450.00 360.00 3339.00
278
C1713
3600.00
278
C1713
3556.80
278
C1713
3186.00
272 Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Prosthetic implant, not otherwise specified Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Guide wire
Amount
483.00
278
C1713
480.00
278
L8699
4200.00
278
C1713
1344.00
272 272 278 272
C1769
60.00 492.00 2625.00 3139.50
278
C1820
75000.00
C1776 C1776 C1776
2179.80 4050.00 7131.00 17700.00
272 278 278 278
C1789
83 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420 4420
402006481-6481 402006490-6490 402006492-6492 402006494-6494 402006501-6501 402006509-6509 402006548-6548 402007029-7029 402007033-7033 402007046-7046 402007047-7047 402007456-7456 402007459-7459 402009053-9053 442000103-103 442000104-104 442000110-110 442000111-111 442000350-350 442001000-1000 442001013-1013 442001040-1040 442001230-1230 442001366-1366 442001368-1368 442001815-1815 442001897-1897 442003527-3527 442003530-3530
4420
442003635-3635 TRANSOBTURATOR SLING SYS 850411
Repair device, urinary, incontinence, with sling graft
4420
442003668-3668 UPHOLD LITE W CAPIO SLIM 831-817
Repair device, urinary, incontinence, with sling graft
4420
442010000-10000 INTERSTIM II NEUROSTIMULATOR 3058
4420 4420
442010001-10001 INTERSTIM PATIENT PROGRAMMER 3037 442010002-10002 LEAD NEUROSTIMULATOR 3889-28
4420
442010003-10003 LEAD INTRODUCER KIT 3550-18
4420 4420 4420
442010004-10004 TEST STIMULATION CABLE 357501 442010006-10006 TUNNELER CYBERONICS 402 442010007-10007 INTERSTIM ENS, MEDTRONIC 3531
4420
442010009-10009 GENERATOR CYBERONICS VNS 106
4420
442010010-10010 GENERATOR CYBERONICS VNS 102R
4420 4420
442010011-10011 TENDON ALLOGRAFT >/26CM 400260 442010012-10012 NEVRO PT PROGR NEUROSTIM PTRC1000
4420
442010013-10013 SENZA NEUROSTIMULATOR NIPG1500
4420
442010014-10014 SENZA NEUROSTIM CHARGER CHGR1000
4420 4420 4420
442010015-10015 70CM NEUROSTIMULATOR LEAD3005-70B 442010016-10016 N300 LEAD ANCHOR KIT ACCK5300 442010017-10017 IPG TEMPLATE KIT ACCK7100
4420
442010021-10021 EMERGENCY SCREW 3MM 04.503.113.01
4420
442010022-10022 EMERGENCY SCREW 4MM 04.503.114.01
4420
442010023-10023 SCREW SD 3MM 04.503.103.05
TENDON 1485 GUIDE WIRE 160-169 TAP 196 3GM ARISTA AH ABSORBABLE HEMOSTAT DERMAL REGEN MATRIX 2X2 INCH IORT TREATMENT BALOON 1500 TRANSCONNECTOR 2084 EVICEL 512 SURGICEL SNOW 2083 TATTOO NEEDLE 50 TATTOO PIGMENT 40 EXTRACTION BOLT 128 EXTRACTION REAMER TUBE 302 BLADE DERMATOME 67 VENTRICULAR BOLT ICP MONITOR KIT EVD CATHETER 668 CRANIAL LOOP, FIXATION SYSTEM S/L CRANIAL LOOP, FIXATION SYSTEM XL DIGITAL URETEROSCOPE, DISPOSABLE AMS700 LGX MS 18CM PS IZ 72404252 AMS700 RESVR 100ML IZ 720185-01 AMS SKW DEEP RETRACT SYS 72403867 AMS PENILE PROS ACC KIT 72401850 POLARIS ANTECHAMBER VALVE SPVA 0.6MM MESH IMPLANT 25-007-11-71 IMPL URINARY SPHINCTER PROSTH IMPL NEUROSTIM LEAD TEST KIT BONE ALLOGRAFT 5CC BL-1500-002 0.6MM MESH IMPLANT 25-007-10-71
Long Description
Guide wire
Connective tissue, non-human (includes synthetic)
Prosthesis, penile, inflatable Prosthesis, penile, inflatable
Mesh (implantable) Prosthesis, urinary sphincter (implantable) Lead, neurostimulator test kit (implantable) Mesh (implantable)
Generator, neurostimulator (implantable), nonrechargeable Patient programmer, neurostimulator Lead, neurostimulator (implantable) Introducer/sheath, other than guiding, other than intracardiac electrophysiological, non-laser
UB Revenue Code 272 272 272 272 278 272 272 272 272 272 272 272 272 272 272 272 278 278 272 278 278 270 270 278 278 278 278 278 278
CPT/HCPCS
C1781
4677.75 660.00 617.40 680.00 7260.00 4500.00 6252.00 1536.00 520.00 150.00 120.00 384.00 906.00 268.00 2124.00 2004.00 735.00 885.00 4500.00 27996.00 7008.00 1110.00 2271.00 9276.75 18711.00 44667.00 1560.00 7350.00 18711.00
278
C1771
2583.75
278
C1771
5676.00
278
C1767
33675.00
279 278
C1787 C1778
3810.00 10245.00
272
C1894
840.00
C1769
C1763
C1813 C1813
C1781 C1815 C1897
272 272 271 Generator, neurostimulator (implantable), nonrechargeable Generator, neurostimulator (implantable), nonrechargeable Connective tissue, human (includes fascia lata) Patient programmer, neurostimulator Generator, neurostimulator (implantable), high frequency, with rechargeable battery and charging system Generator, neurostimulator (implantable), high frequency, with rechargeable battery and charging system Lead, neurostimulator (implantable) Prosthetic implant, not otherwise specified Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable)
Amount
120.00 1362.00 1200.00
278
C1767
85896.00
278
C1767
64233.00
278 278
C1762 C1787
4575.00 3645.00
278
C1822
46566.00
278
C1822
5061.00
278 278 270
C1778 L8699
26622.00 606.00 405.00
278
C1713
106.05
278
C1713
106.05
278
C1713
530.25
84 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4420
442010024-10024 SCREW SD 4MM 04.503.104.05
4420
442010025-10025 EMERGENCY SCREW 4MM 04.503.114.05
4420
442010026-10026 STRGHT PLATE 2-H/12MM 04.503.062
4420
442010027-10027 STRAIGHT PLATE 4-HOLES 04.503.063
4420
442010028-10028 X-PLATE 04.503.064
4420
442010029-10029 BOX PLATE 14X14MM 04.503.065
4420
442010030-10030 Y-PLATE 5-H 04.503.067
4420
442010031-10031 DBL Y-PLATE 6-H/18MM 04.503.068
4420
442010032-10032 DBL Y-PLATE 6-H/21MM 04.503.069
4420
442010033-10033 ADAPTION PLATE 5-H 04.503.070
4420
442010034-10034 BOX PLATE 10X16MM 04.503.073
4420 4420 4420 4420 4420
442010035-10035 442010036-10036 442010037-10037 442010038-10038 442010039-10039
4420
442010041-10041 SCREW SD 3MM 04.503.103.01
4420
442010042-10042 SCREW SD 4MM 04.503.104.01
4420
442010043-10043 SCREW SD 5MM 04.503.105.01
4420 4420 4420 4420 4420 4420 4420
442010044-10044 442010045-10045 442010046-10046 442010047-10047 442010048-10048 442010049-10049 442010050-10050
4420
442010051-10051 PROCINCH ADJ LOOP IMPL 0234102060
4420
442010052-10052 ICONIX TT ANCHOR 2.3MM 3910500322
4420
442010053-10053 REELX STT ANCHOR 4.5MM 3910600062
4420
442010054-10054 AIR MENISCUS SYSTEM CURVED 4720
4420
442010055-10055 AXIOS SYS W 15X10 STENT M00553650
4420
442010056-10056 SENTIVA VNS GENERATOR, NEURO 1000
4420 4420 4420
442010057-10057 MENISCUS ALLOGRAFT, FRZN 430411 442010058-10058 AMS700 LGX MS PUMP 15CM 72404251 442010059-10059 8X12CM AXIS DERMIS 939812
4420
442010063-10063 NEUROSTIM GENERATOR, RECHG 97714
4420 4420 4420
442010064-10064 MEDTRONIC LEAD, NEUROSTIM 977C165 442010065-10065 SURGICAL LEAD ELEVATOR 3550-P4 442010066-10066 PT PROGRAMMER, NEUROSTIM 97740
4420
442010067-10067 NEUROSTIM CHARGING SYSTEM 97754
4420
442010068-10068 300CC BRST TISS EXPAND TEXP110RH
BURR-HOLE COVER 12MM 04.503.021 BURR-HOLE COVER 17MM 04.503.023 MESH 38X45MM/.4MM MALL 04.503.081 MESH 38X45MM/.4MM RIGD 04.503.082 MESH 38X45MM/.6MM RIGD 04.503.120
16-19.5CM AT WO CAL, FRZN 430521 BENGAL STACK CAGE 20MM 177306120 LAP SPECIMEN BAG 5X7 SB957 AMS700 RESERVOIR 65ML 72404155 AMS700 CXR MS PUMP 12CM 72404261 TRIAL LEAD KIT 50CM TLEAD1058-50B M8 LEAD ADAPTOR KIT MADP2008-25B
Long Description Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable)
Mesh (implantable) Mesh (implantable) Mesh (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Connective tissue, human (includes fascia lata) Prosthetic implant, not otherwise specified Prosthesis, penile, inflatable Prosthesis, penile, inflatable Lead, neurostimulator test kit (implantable) Lead, neurostimulator (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Stent, coated/covered, with delivery system Generator, neurostimulator (implantable), nonrechargeable Connective tissue, human (includes fascia lata) Prosthesis, penile, inflatable Connective tissue, human (includes fascia lata) Generator, neurostimulator (implantable), non highfrequency with rechargeable battery and charging system Lead, neurostimulator (implantable) Patient programmer, neurostimulator Generator, neurostimulator (implantable), non highfrequency with rechargeable battery and charging system Surgical supply; miscellaneous
UB Revenue Code
CPT/HCPCS
278
C1713
530.25
278
C1713
530.25
278
C1713
89.25
278
C1713
101.85
278
C1713
328.65
278
C1713
328.65
278
C1713
328.65
278
C1713
328.65
278
C1713
328.65
278
C1713
295.05
278
C1713
312.90
278 278 278 278 278
C1781 C1781 C1781
339.15 339.15 1861.65 1861.65 1861.65
278
C1713
106.05
278
C1713
106.05
278
C1713
106.05
278 278 272 278 278 278 278
C1762 L8699 C1813 C1813 C1897 C1778
5064.00 14943.00 210.00 6285.60 25413.36 2400.00 1620.00
278
C1713
1458.00
278
C1713
1191.00
278
C1713
1033.53
278
C1713
1517.25
278
C1874
13200.00
278
C1767
98781.00
278 278 278
C1762 C1813 C1762
18210.00 25110.54 9344.40
278
C1820
42335.43
278 278 278
C1778 C1787
19277.57 482.18 3570.00
278
C1820
4609.64
272
A4649
4896.00
Amount
85 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
4420 4420 4420 4420 4420 4420 4420
442010069-10069 442010070-10070 442010071-10071 442010072-10072 442010074-10074 442010075-10075 442010076-10076
4420
442010077-10077 GENERATOR, NEURO NON-RECHRG 37601
4420 4420 4420 4420
442010099-10099 442010100-10100 442010101-10101 442010102-10102
4420
442010103-10103 ARTHREX-TIGHTROPE AR-8925T
4420 4420 4420 4420 4420 4420
442010104-10104 442010105-10105 442010106-10106 442010107-10107 442010108-10108 442010109-10109
4420
442010110-10110 GEN,NEURO,NON HF RECHG BAT
4420
442010111-10111 GENERATOR NEURO NON-RECHARGE
4420 4420
442010112-10112 LEAD NEUROSTIMULATOR E1465 442010113-10113 LEAD NEUROSTIMULATOR SC-8352-70
4420
442010114-10114 GENERATOR, NEURO NON-RECHRG 97702
4420
442010115-10115 CATHETER INTRASPINAL 8780
4420
442010117-10117 NEUROSTIM GENERATOR, RECHG 97715
4420
442010118-10118 MEDTRONIC LEAD, NEUROSTIM 977C265
4420
442010119-10119 NEUROSTIM CHARGING SYSTEM 97755
4420
442010122-10122 PT PROGRAMMER, NEUROSTIM 97745
4420
442010123-10123 LEAD ADAPTOR (IMPLANT) 74002
4420 4420 4420
442010124-10124 NEURO ACCESSORY KIT 3550-29 442010125-10125 35CM TUNNELING TOOL SC-4254 442010126-10126 PASSING ELEVATOR SC-4230
4420
442010127-10127 PRECISION CHARGING SYS SC-6412-3
4420 4420
442010128-10128 LEAD NEUROSTIMULATOR SC-8336-50 442010129-10129 FREELINK REMOTE CONTROL SC-5562-1
4420
442010130-10130 SPECTRA WAVEWRITER IPG SC-1160
4420
442010131-10131 ARTHREX SUTURE ANCHOR AR-1927BCF
4420 4420 4420 4420 4420 4420
442010132-10132 442010133-10133 442010134-10134 442010135-10135 402001213-1213 402001508-1508
4420
402005749-5749 KNEE IMOBILIZER 24"
4425 4425
402500051-51 402500052-52
CDM Description 375CC BRST TISS EXPAND TEXP120RH 475CC BRST TISS EXPAND TEXP130RH 500CC BRST TISS EXPAND TEXP135RH 600CC BRST TISS EXPAND TEXP140RH 850CC BRST TISS EXPAND TEXP155RH 25X40CM HERNIA MESH IMPL 1152540 UROLIFT SYSTEM, IMPLANT UL400-4
AMS800 ACCESSORY KIT 720066-01 AMS800 CONTROL PUMP 72404127 AMS800 BALLOON 72400024 AMS800 CUFF 720157-01
AMNIOFILL 250MG AF-0250 MESH 190 X 130MM 25-007-13-71 AMNIOFILL 500MG AF-0500 AMNIOFILL 1000MG AF-1000 EPIFIX PER SQ CM[4X4.5CM] ES-4400 LEAD NEUROSTIMULATOR
1000 LASER FIBER M0068403940 SYMPHION RESECTING DEVICE FG-0201 SYMPHION FLUID MGMT ACCS FG-0202 CEREBROFLO EVD CATHETER 8-0 VICRYL TG-160-8 8" BANDAGE HONEYCOMB ELASTIC 6"
RECOVERY RM LEVEL III ADD 30 MIN RECOVERY LEVEL III FIRST HOUR
Long Description Surgical supply; miscellaneous Surgical supply; miscellaneous Surgical supply; miscellaneous Surgical supply; miscellaneous Surgical supply; miscellaneous Mesh (implantable) Prosthetic implant, not otherwise specified Generator, neurostimulator (implantable), nonrechargeable Prosthesis, urinary sphincter (implantable) Prosthesis, urinary sphincter (implantable) Prosthesis, urinary sphincter (implantable) Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) Connective tissue, human (includes fascia lata) Mesh (implantable) Connective tissue, human (includes fascia lata) Connective tissue, human (includes fascia lata) Epifix or epicord, per square centimeter Lead, neurostimulator (implantable) Generator, neurostimulator (implantable), non highfrequency with rechargeable battery and charging system Generator, neurostimulator (implantable), nonrechargeable Lead, neurostimulator (implantable) Lead, neurostimulator (implantable) Generator, neurostimulator (implantable), nonrechargeable Catheter, intraspinal Generator, neurostimulator (implantable), non highfrequency with rechargeable battery and charging system Lead, neurostimulator (implantable) Generator, neurostimulator (implantable), non highfrequency with rechargeable battery and charging system Patient programmer, neurostimulator Adaptor/extension, pacing lead or neurostimulator lead (implantable)
UB Revenue Code 272 272 272 272 272 278 278
CPT/HCPCS A4649 A4649 A4649 A4649 A4649 C1781 L8699
4896.00 4896.00 4896.00 4896.00 4896.00 64500.00 2925.00
C1767
53100.00
270 278 278 278
C1815 C1815 C1815
3657.00 17673.00 8394.00 18354.00
278
C1713
4485.00
278 278 278 278 278 278
C1762 C1781 C1762 C1762 Q4131 C1778
1725.00 20772.00 3450.00 6750.00 380.45 69000.00
278
C1820
75000.00
278
C1767
23.94
278 278
C1778 C1778
10.08 16045.50
278
C1767
45720.00
278
C1755
3300.00
278
C1820
42335.43
278
C1778
19277.57
278
C1820
4609.64
278
C1787
2295.18
278
C1883
2700.00
278
272 272 272 Generator, neurostimulator (implantable), non highfrequency with rechargeable battery and charging system Lead, neurostimulator (implantable) Patient programmer, neurostimulator Generator, neurostimulator (implantable), non highfrequency with rechargeable battery and charging system Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable)
Catheter, drainage
Knee orthosis, immobilizer, canvas longitudinal, prefabricated, off-the-shelf
Amount
450.00 900.00 126.75
278
C1820
4200.00
278 270
C1778 C1787
16045.50 3600.00
278
C1820
75000.00
278
C1713
1395.00
270 270 270 270 272 272 274 710 710
C1729
L1830
2774.61 2999.97 1199.97 1362.00 20.95 12.25 52.00 97.75 195.50
86 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4425 4425 4425 4425 4425 4425 4425 4450 4450 4450 4450 4450 4450 4470 4470 4470 4470 4470 4470 4470 4470 4470 4470 4470 4470 4470 4470 4470 4470 4470 4470 4470 4470 4470 4470 4470 4470 4470 4470 4470 4470
402500053-53 402500054-54 402500055-55 402500056-56 442500688-688 442500747-747 402500062-62 404000077-77 404000078-78 404000079-79 404000080-80 404000081-81 404000082-82 405000002-2 405000104-104 405000711-711 405002241-2241 405002320-2320 405002324-2324 405002878-2878 405003000-3000 405003338-3338 405003339-3339 405003392-3392 405003420-3420 405004554-4554 405005401-5401 405006010-6010 405006026-6026 405006050-6050 405006070-6070 405006080-6080 405006102-6102 405006158-6158 405006195-6195 405006200-6200 405006205-6205 405006261-6261 405006270-6270 405006276-6276 405007110-7110
4470
405007118-7118 FOLEY 3-WAY 24 FR 5CC
4470 4470 4470 4470 4470 4470 4470
405007182-7182 405007238-7238 405007325-7325 405007326-7326 405007385-7385 405007607-7607 405007621-7621
4470
405007631-7631 CVP CATHETER KIT
4470 4470 4470 4470 4470 4470 4470 4470
405007752-7752 405007766-7766 405007777-7777 405007805-7805 405007919-7919 405007934-7934 405007937-7937 405008000-8000
4470
405008003-8003 CRUTCHES
4470 4470
405008014-8014 IV TUBING 405008015-8015 HEPLOCK
RECOVERY RM LEV II ICU NSG ADD 30 RECOVERY LEV II ICU NRSG FIRST HR RECOVERY LEVEL I ADD 30 MIN RECOVERY LEVEL I FIRST HOUR RR INITIAL IV AND SUPPLIES RR GLUCOSE BLD REAG STRIP RR CUFF, TOURNIQUET 34" GENERAL ANES. 1ST HOUR GENERAL ANESTHESIA ADD 1/2 HOUR REGIONAL ANESTHESIA 1ST HOUR REGIONAL ANESTHESIA ADD 1/2 HOUR MAC SEDATION 1ST HOUR MAC/SEDATION ADD 1/2 HOUR CRANIAL ACCESS KIT VENODYNET FOLEY CATH ACE BANDAGE (2,4,6)" KERLIX ROLL FLUFFS TELFA BOX ABD PADS BOX STERI STRIP 1/4 INCH STERI STRIP 1/2 INCH 2 X 2 STERILE GAUZE BOX 4 X 3 BOX RED ROBINSON CATHETER CONDOM CATH 10/PKG IV SOL 5% D/W 1000 ML IV SOL 5% D/W 100ML IV SOL 5% D/W NS 1000ML IV SOL 5%D NS 1000ML IV SOL 5% D 1/2NS 500ML IV OLS 5% D/NS 1000ML IV SOL LACT RINGERS 1000 ML IV SOL NORMAL SALINE 1000 ML IV SOL NORMAL SALINE 500 ML IV SOL N/S 100ML STERILE WATER/SALINE IRR,500ML STERILE WATER/SALINE IRR,500ML STERILE WATER/SALINE IRR,500ML FOLEY 20 FR 30 CC
OPSITE MEDIUM 14 X 25 HUBER NDL W/TUBING SURGICEL 2 X 3 SURGICEL 4 X 8 CHEST TUBE 36 FR PARACENTESIS TRAY PRESSURE TRANSFUSION TUBE 84 IN
ABDUCTION PILLOW NASAL TAMPON ABDOMINAL BINDER SCROTAL SUPPORTER X-LARGE LANCING TRAY ASPIRATION TRAY CS TRAY SUTURE REMOVAL CRASH CART SUPPLIES
Long Description
Glucose; blood, reagent strip
Sterile water/saline, 500 ml Sterile water/saline, 500 ml Sterile water/saline, 500 ml Indwelling catheter; Foley type, three way for continuous irrigation, each
Surgical trays Catheter, infusion, inserted peripherally, centrally or midline (other than hemodialysis)
Surgical trays
Crutches underarm, other than wood, adjustable or fixed, pair, with pads, tips and handgrips
UB Revenue Code 710 710 710 710 272 301 272 370 370 370 370 370 370 272 271 272 271 272 272 272 271 272 272 272 272 272 272 270 270 270 270 270 270 270 270 270 270 272 272 272 272 272 272 272 272 272 272 272 272 278 271 272 271 271 272 272 272 272 270 272 270
CPT/HCPCS
82948
A4217AU A4217AU A4217AU A4346
A4550 C1751
A4550
E0114NU
Amount 291.81 583.63 171.06 340.69 77.63 19.80 139.00 2422.91 1213.69 558.18 278.30 558.18 278.30 1197.19 142.31 12.94 10.06 4.31 5.75 24.44 15.81 11.08 14.24 6.33 7.91 5.75 8.63 77.63 50.31 77.63 77.63 63.25 77.63 77.63 77.63 63.25 50.31 15.81 15.81 15.81 14.38 48.88 12.94 15.81 27.31 50.31 23.00 38.00 11.50 92.00 135.99 44.56 27.77 25.88 69.58 50.60 51.75 322.00 60.00 28.46 17.25
87 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4470 4470 4470 4470 4470 4470 4470 4470 4470 4470 4470 4470
405008023-8023 405009121-9121 405009122-9122 405009123-9123 405009124-9124 405009130-9130 405009131-9131 405009132-9132 405009133-9133 405009174-9174 405009183-9183 405009196-9196
4470
405009197-9197 CERVICAL COLLAR (SOFT)
4470 4470
405009198-9198 DRESSING SIMPLE 405009288-9288 THORACENTESIS TRAY
4470
405009290-9290 URINARY DRAINAGE BAG,EACH
4470 4470 4470 4470 4470 4470 4470 4470
405009300-9300 405009305-9305 405009320-9320 405009330-9330 405009400-9400 405009420-9420 405009905-9905 405014559-14559
4470
405014560-14560 IMMOBILIZER, KNEE
4470
405014561-14561 SPLINT WRIST, COCK-UP R/L
4470 4470 4470 4470 4470 4470
405014565-14565 405014566-14566 405014567-14567 405014579-14579 405014607-14607 405014608-14608
FINGER STICK GLUOSE SUPPLIES SHORT LEG SPLINT LONG LEG SPLINT FOREARM SPLINT SUTURE LEVEL I GENERAL CORDIS SUPPLIES ART LINE SUPPLIES CHEST TUBE RAPID INFUSER SUPPLIES PLEUREVAC ANGIO CATH SLING, ARM (S,M,L)
Long Description
Slings Cervical, flexible, non-adjustable, prefabricated, offthe-shelf (foam collar)
Urinary drainage bag, leg or abdomen, latex, with or without tube, with straps, each
4501
406011055-11055 CBC(HEMOGRAM)
4501
406011060-11060 CBC WITH DIFFERENTIAL
4501 4501 4501 4501
406011070-11070 406011080-11080 406011120-11120 406011130-11130
4501
406011145-11145 DIFFERENTIAL WBC
4501
406011160-11160 BLOOD SMEAR, MICROSCOPIC EXAM
4501
406011172-11172 RETICULOCYTE COUNT(AUTOMATED)
4501
406011180-11180 SMEAR,MALARIA,INCLUSION BODIES
4501
406011230-11230 SED RATE WESTERGREN, AUTOMATED
4501
406011310-11310 PMN COUNT-STOOL SMEAR
4501 4501 4501
406011320-11320 EOSINOPHIL COUNT-NASAL SMEAR 406011330-11330 EOSINOPHIL COUNT-SPUTUM SMEAR 406011331-11331 EOSINOPHIL SMEAR
HEMOGLOBIN (HGB) HEMATOCRIT (HCT) PLATELET COUNT ELECTRONIC WHITE BLOOD CELL COUNT
272
Knee orthosis, immobilizer, canvas longitudinal, prefabricated, off-the-shelf Wrist hand orthosis, wrist extension control cock-up, non molded, prefabricated, off-the-shelf
A4565 L0120
35.94 17.40 82.23
A5112
Blood count; blood smear, microscopic examination without manual differential WBC count Blood count; reticulocyte, automated Smear, primary source with interpretation; special stain for inclusion bodies or parasites (eg, malaria, coccidia, microsporidia, trypanosomes, herpes viruses) Sedimentation rate, erythrocyte; automated Smear, primary source with interpretation; Gram or Giemsa stain for bacteria, fungi, or cell types Nasal smear for eosinophils Nasal smear for eosinophils Nasal smear for eosinophils
12.94 51.75 25.88 58.51 51.75 57.50 50.60 69.13 27.31
274
L1830
123.63
274
L3908
44.56
272 272 272 272 272 271 Cell count, miscellaneous body fluids (eg, cerebrospinal fluid, joint fluid), except blood; with differential count Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC count Blood count; hemoglobin (Hgb) Blood count; hematocrit (Hct) Blood count; platelet, automated Blood count; leukocyte (WBC), automated Blood count; blood smear, microscopic examination with manual differential WBC count
Amount 21.40 31.63 31.63 27.50 143.75 155.69 87.11 81.94 269.96 231.44 74.95 12.94
272 272 272 272 272 272 272 271
CENTRAL LINE DRESSING KIT IV START KIT INFANT IV START KIT HUBER NEEDLE, STERILE SUTURE STAPLES LONG ARM SPLINT
406011015-11015 BODY FLUID CELL COUNT & DIFF
274
CPT/HCPCS
272 272
ST CATH TRAY SUBCLAVIAN DRESSING CHANGE TRA LUMBAR PUNCTURE TRAY ADULT LUMBAR PUNCTURE TRAY PEDS FOLEY CATH TRAY IRRIGATION TRAY INTRAOSEOUS IMMOBILIZER, SHOULDER
4501
UB Revenue Code 272 271 271 271 272 272 272 272 272 272 272 271
121.76 62.50 75.90 36.38 45.06 31.63
309
89051
23.40
305
85027
27.51
305
85025
33.06
305 305 305 305
85018 85014 85049 85048
10.05 10.05 18.99 10.80
305
85007
14.61
305
85008
14.61
305
85045
17.01
306
87207
25.47
305
85652
11.49
306
87205
18.15
309 309 309
89190 89190 89190
20.19 20.19 20.16
88 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4501
406011395-11395 BRONCHIO-ALVEOLAR LAV. CT DIFFF
4501
406011410-11410 CEREBROSPINAL FLD CELL CT DIFF
4501
406011430-11430 PERICARDIAL FL COUNT W/DIFF.
4501
406011450-11450 PERITONEAL FL COUNT WITH DIFF
4501
406011460-11460 PERITONEAL LAVAGE CELL COUNT
4501
406011470-11470 PERITONEAL LAVAGE COUNT W/DIFF
4501
406011490-11490 PLEURAL FL CELL COUNT W/DIFF
4501
406011510-11510 SYNOVIAL FL CELL COUNT W/DIFF
4501
406011570-11570 HEMOGLOBIN FETAL (KLEIHAUER)
4501 4501
406011680-11680 SKIN TEST-TUBERCULOSIS (PPD) 406011685-11685 SKIN TEST TB (EMPLOYEE)
4501
406011786-11786 FECAL OCCULT BLOOD
4502
406011351-11351 FERN TEST
4502
406012020-12020 CULTURE/SENSI ANAEROBIC
4502
406012030-12030 CULTURE ANAEROBIC ID PER ORGAN
4502
406012040-12040 CULTURE/SENSI BLOOD
4502
406012045-12045 CULTURE HOSPITAL ENVIRONMENTAL
4502
406012070-12070 CULTURE FUNGUS ANY SOURCE
4502
406012080-12080 CULTURE GC SCREEN
4502
406012110-12110 CULTURE/SENSI AEROBIC
4502
406012111-12111 CULT/SENS WOUND
4502
406012112-12112 CULTURE RECTAL FOR VRE
4502
406012115-12115 CUL/SENS SPUTUM EXPECTORATED
Long Description Cell count, miscellaneous body fluids (eg, cerebrospinal fluid, joint fluid), except blood; with differential count Cell count, miscellaneous body fluids (eg, cerebrospinal fluid, joint fluid), except blood; with differential count Cell count, miscellaneous body fluids (eg, cerebrospinal fluid, joint fluid), except blood; with differential count Cell count, miscellaneous body fluids (eg, cerebrospinal fluid, joint fluid), except blood; with differential count Cell count, miscellaneous body fluids (eg, cerebrospinal fluid, joint fluid), except blood; Cell count, miscellaneous body fluids (eg, cerebrospinal fluid, joint fluid), except blood; with differential count Cell count, miscellaneous body fluids (eg, cerebrospinal fluid, joint fluid), except blood; with differential count Cell count, miscellaneous body fluids (eg, cerebrospinal fluid, joint fluid), except blood; with differential count Hemoglobin or RBCs, fetal, for fetomaternal hemorrhage; differential lysis (Kleihauer-Betke) Skin test; tuberculosis, intradermal Skin test; tuberculosis, intradermal Blood, occult, by peroxidase activity (eg, guaiac), qualitative, feces, 1-3 simultaneous determinations, performed for other than colorectal neoplasm screening Smear, primary source with interpretation; wet mount for infectious agents (eg, saline, India ink, KOH preps) Culture, bacterial; any source, except blood, anaerobic with isolation and presumptive identification of isolates Culture, bacterial; anaerobic isolate, additional methods required for definitive identification, each isolate Culture, bacterial; blood, aerobic, with isolation and presumptive identification of isolates (includes anaerobic culture, if appropriate) Culture, bacterial; any other source except urine, blood or stool, aerobic, with isolation and presumptive identification of isolates Culture, fungi (mold or yeast) isolation, with presumptive identification of isolates; other source (except blood) Culture, presumptive, pathogenic organisms, screening only; Culture, bacterial; any other source except urine, blood or stool, aerobic, with isolation and presumptive identification of isolates Culture, bacterial; any other source except urine, blood or stool, aerobic, with isolation and presumptive identification of isolates Culture, presumptive, pathogenic organisms, screening only; Culture, bacterial; any other source except urine, blood or stool, aerobic, with isolation and presumptive identification of isolates
UB Revenue Code
CPT/HCPCS
309
89051
23.40
309
89051
23.40
309
89051
23.40
309
89051
23.40
309
89050
20.10
309
89051
23.40
309
89051
73.31
309
89051
23.40
305
85460
32.91
302 302
86580 86580
24.93 24.93
301
82272
13.83
306
87210
18.15
306
87075
40.20
306
87076
34.35
306
87040
43.86
306
87070
36.60
306
87102
35.70
306
87081
28.17
306
87070
36.60
306
87070
36.60
306
87081
28.17
306
87070
36.60
Amount
89 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4502
406012116-12116 CULT/SENS SPUTUM INDUCED
4502
406012130-12130 CULTURE/SENSI STOOL
4502
406012140-12140 CULTURE THROAT STREP SCREEN
4502 4502 4502 4502
406012160-12160 406012161-12161 406012163-12163 406012166-12166
4502
406012180-12180 GRAM STAIN
4502 4502
406012185-12185 HELICOBACTER PYLORI SCREEN 406012190-12190 MONO TEST
4502
406012290-12290 AFB STAIN (MICROBIOLOGY/KMC)
4502
406012340-12340 WET MOUNT
4502
406012360-12360 WET MOUNT INDIA INK
4502
406012370-12370 WET MOUNT KOH
4502
406012400-12400 SMEAR - PINWORM PREP
4502
406012420-12420 SMEAR PARASITE I.D.
CULTURE/SENSI URINE URO-CLIN UR CULT/SENS W/NOTIFY CULTURE/SENSI URINE-CATH CULTURE/SENSI URINE-SUPRAPUBIC
4502
406012470-12470 CRYPTO NEOFORM AG EIA
4502
406012500-12500 CULTURE BETA STREP CERVIX
4502
406012520-12520 CULTR FUNGI ISOL OTH SOURC NOT BL
4502
406012530-12530 RSV ANTIGEN-ELFA
4502
406012601-12601 CHLAMYDIA TRACH, RNA TMA
4502
406012602-12602 N.GONORRHOEAE, RNA TMA
Long Description Culture, bacterial; any other source except urine, blood or stool, aerobic, with isolation and presumptive identification of isolates Culture, bacterial; stool, aerobic, with isolation and preliminary examination (eg, KIA, LIA), Salmonella and Shigella species Culture, presumptive, pathogenic organisms, screening only; Culture, bacterial; quantitative colony count, urine Culture, bacterial; quantitative colony count, urine Culture, bacterial; quantitative colony count, urine Culture, bacterial; quantitative colony count, urine Smear, primary source with interpretation; Gram or Giemsa stain for bacteria, fungi, or cell types Helicobacter pylori; drug administration Heterophile antibodies; screening Smear, primary source with interpretation; fluorescent and/or acid fast stain for bacteria, fungi, parasites, viruses or cell types Smear, primary source with interpretation; wet mount for infectious agents (eg, saline, India ink, KOH preps) Smear, primary source with interpretation; wet mount for infectious agents (eg, saline, India ink, KOH preps) Smear, primary source with interpretation; wet mount for infectious agents (eg, saline, India ink, KOH preps) Pinworm exam (eg, cellophane tape prep) Smear, primary source with interpretation; special stain for inclusion bodies or parasites (eg, malaria, coccidia, microsporidia, trypanosomes, herpes viruses) Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzymelinked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative, multiple-step method; Cryptococcus neoformans Culture, presumptive, pathogenic organisms, screening only; Culture, fungi (mold or yeast) isolation, with presumptive identification of isolates; other source (except blood) Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzymelinked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative, multiple-step method; respiratory syncytial virus Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, amplified probe technique
UB Revenue Code
CPT/HCPCS
306
87070
36.60
306
87045
40.08
306
87081
28.17
306 306 306 306
87086 87086 87086 87086
34.29 34.29 60.38 34.29
306
87205
18.15
301 302
83014 86308
33.42 21.99
306
87206
22.83
306
87210
18.15
306
87210
18.15
306
87210
18.15
306
87172
18.15
306
87207
37.80
306
87327
39.45
306
87081
28.17
306
87102
35.70
301
87420
39.45
306
87491
94.41
306
87591
94.41
Amount
90 of 167 Updated on 1/22/2019
Long Description
UB Revenue Code
CPT/HCPCS
406012603-12603 INF AGENT AG.DETECT IMMUNOASSAY
Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzymelinked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]), qualitative or semiquantitative; multiple-step method, not otherwise specified, each organism
306
87449
25.59
4502
406012604-12604 CLOSTRIDIUM DIFFICLE TOXINS
Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzymelinked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative, multiple-step method; Clostridium difficile toxin(s)
306
87324
25.59
4502
406012607-12607 RAPID INFLUENZA TYPE-A TEST
Infectious agent antigen detection by immunoassay with direct optical observation; Influenza
306
87804QW
26.55
4502
406012608-12608 RAPID INFLUENZA TYPE-B TEST
Infectious agent antigen detection by immunoassay with direct optical observation; Influenza
306
87804QW
26.55
306
87880QW
21.00
306
87807QW
38.19
306
87015
27.48
306
87281
38.19
306
87086
33.21
306
87070
35.46
306
87070
35.46
306
87070
35.46
306
87070
35.46
306
87070
35.46
306
87070
35.46
306
87070
35.46
300
87181
6.90
300
87181
6.90
306
87147
20.85
306
87184
29.34
Revenue Center
4502
CDM Number
CDM Description
4502
406012609-12609 RAPID STREP-A SCREEN W/RLFX CULT
4502
406012610-12610 RAPID RSV
4502
406012700-12700 SPEC.CONC./MICROBIAL PATHOGENS
4502
406012710-12710 PNEUMOCYSTIS JEROVECII DFA STAIN
4502
406012730-12730 CUL/SENS URINE LOW COUNT PLATE
4502
406012740-12740 CULT/SENS BAL
4502
406012750-12750 CULT/SENS BRONCHIAL WASH
4502
406012760-12760 CULT/SENS CATH TIP
4502
406012770-12770 CULT/SENS CSF
4502
406012780-12780 CULT/SENS PERITONEAL FLUID
4502
406012790-12790 CULT/SENS PLEURAL FLUID
4502
406012800-12800 CULT/SENS SYNOVIAL FLUID
4502
406012990-12990 *BILLING BETA-LACTAMASE TEST
4502
406012990-12015 *BILLING BETA-LACTAMASE TEST
4502
406012993-12993 BILLING SEROLOGICAL TYPING
4502
406012994-12994 BILLING SUSCEPTIBILITY (K-B)
Infectious agent antigen detection by immunoassay with direct optical observation; Streptococcus, group A Infectious agent antigen detection by immunoassay with direct optical observation; respiratory syncytial virus Concentration (any type), for infectious agents Infectious agent antigen detection by immunofluorescent technique; Pneumocystis carinii Culture, bacterial; quantitative colony count, urine Culture, bacterial; any other source except urine, blood or stool, aerobic, with isolation and presumptive identification of isolates Culture, bacterial; any other source except urine, blood or stool, aerobic, with isolation and presumptive identification of isolates Culture, bacterial; any other source except urine, blood or stool, aerobic, with isolation and presumptive identification of isolates Culture, bacterial; any other source except urine, blood or stool, aerobic, with isolation and presumptive identification of isolates Culture, bacterial; any other source except urine, blood or stool, aerobic, with isolation and presumptive identification of isolates Culture, bacterial; any other source except urine, blood or stool, aerobic, with isolation and presumptive identification of isolates Culture, bacterial; any other source except urine, blood or stool, aerobic, with isolation and presumptive identification of isolates Susceptibility studies, antimicrobial agent; agar dilution method, per agent (eg, antibiotic gradient strip) Susceptibility studies, antimicrobial agent; agar dilution method, per agent (eg, antibiotic gradient strip) Culture, typing; immunologic method, other than immunofluorescence (eg, agglutination grouping), per antiserum Susceptibility studies, antimicrobial agent; disk method, per plate (12 or fewer agents)
Amount
91 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4502
406012995-12995 BILLING FUNGUS IDENTIFICATION
4502
406012996-12996 BILLING ANAEROBIC IDENTIFICATI
4502
406012997-12997 BILLING URINE IDENTIFICATION
4502
406012998-12998 BILLING AEROBIC IDENTIFICATION
4502
406012999-12999 BILLING SUSCEPTIBILITY (MIC)
4503
406011756-11756 BLOOD, OCCULT, OTHER SOURCES
4503
406020011-20011 ACUTE HEPATITIS PANEL
4503 4503 4503 4503 4503 4503 4503 4503 4503 4503 4503 4503 4503 4503 4503 4503 4503 4503
406020012-20012 406020013-20013 406020014-20014 406020031-20031 406020210-20210 406020215-20215 406020220-20220 406020230-20230 406020237-20237 406020240-20240 406020248-20248 406020250-20250 406020251-20251 406020252-20252 406020253-20253 406020260-20260 406020270-20270 406020275-20275
4503
406020285-20285 LIPID PNL (CARDIOVASCULAR EVAL)
4503
406020286-20286 HDL CHOLESTEROL
4503
406020304-20304 GAS BLD ART PH PC02 P02
4503
406020306-20306 BLOOD GAS ARTERIAL NEONATAL
4503
406020311-20311 GAS BLD CAPILLARY PH PC02 P02
4503
406020316-20316 GAS BLB CORD BLOOD PH PC02 P02
4503
406020321-20321 GAS BLD MIXED VENOUS PH PC02
4503
406020331-20331 GAS BLD VENOUS PH PC02 P02
4503
406020332-20332 GAS BLOOD CEN VENOUS PH PCO2 PO2
4503 4503 4503 4503
406020340-20340 406020341-20341 406020350-20350 406020370-20370
HEPATITIS A IGM AB HEPATITIS B CORE IGM AB HEPATITIS C IGG AB RUBELLA ANTIBODY. UREA NITROGEN (BUN) PNL CALCIUM,IONIZED CARBON DIOXIDE TOTAL CHLORIDE C REACTIVE PROTEIN CREATININE HEMOGLOBIN A1C GLUCOSE FASTING GLUCOSE TOLERANCE 1HR (50G) GLUCOSE 2 HR POST PRANDIAL GLUCOSE RANDOM PNL POTASSIUM PNL SODIUM PNL CREATININE CLEARANCE
GAS BLD VENOUS PH ONLY METHEMOGLOBIN,QUANT PH BODY FLUID EXCLUDING BLOOD GLUCOSE CSF
Long Description Culture, fungi, definitive identification, each organism; yeast Culture, bacterial; anaerobic isolate, additional methods required for definitive identification, each isolate Culture, bacterial; with isolation and presumptive identification of each isolate, urine Culture, bacterial; aerobic isolate, additional methods required for definitive identification, each isolate Susceptibility studies, antimicrobial agent; microdilution or agar dilution (minimum inhibitory concentration [MIC] or breakpoint), each multiantimicrobial, per plate Blood, occult, by peroxidase activity (eg, guaiac), qualitative; other sources Acute hepatitis panel This panel must include the following: Hepatitis A antibody (HAAb), IgM antibody (86709) Hepatitis B core antibody (HBcAb), IgM antibody (86705) Hepatitis B surface antigen (HBsAg) (87340) Hepatitis C antibody (86803) Hepatitis A antibody (HAAb), IgM antibody Hepatitis B core antibody (HBcAb); IgM antibody Hepatitis C antibody; Antibody; rubella Urea nitrogen; quantitative Calcium; ionized Carbon dioxide (bicarbonate) Chloride; blood C-reactive protein; Creatinine; blood Hemoglobin; glycosylated (A1C) Glucose; quantitative, blood (except reagent strip) Glucose; post glucose dose (includes glucose) Glucose; post glucose dose (includes glucose) Glucose; quantitative, blood (except reagent strip) Potassium; serum, plasma or whole blood Sodium; serum, plasma or whole blood Creatinine; clearance Lipid panel This panel must include the following: Cholesterol, serum, total (82465) Lipoprotein, direct measurement, high density cholesterol (HDL cholesterol) (83718) Triglycerides (84478) Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol) Gases, blood, any combination of pH, pCO2, pO2, CO2, HCO3 (including calculated O2 saturation); Gases, blood, any combination of pH, pCO2, pO2, CO2, HCO3 (including calculated O2 saturation); Gases, blood, any combination of pH, pCO2, pO2, CO2, HCO3 (including calculated O2 saturation); Gases, blood, any combination of pH, pCO2, pO2, CO2, HCO3 (including calculated O2 saturation); Gases, blood, any combination of pH, pCO2, pO2, CO2, HCO3 (including calculated O2 saturation); Gases, blood, any combination of pH, pCO2, pO2, CO2, HCO3 (including calculated O2 saturation); Gases, blood, any combination of pH, pCO2, pO2, CO2, HCO3 (including calculated O2 saturation); Gases, blood, pH only Hemoglobin; methemoglobin, quantitative pH; body fluid, not otherwise specified Glucose, body fluid, other than blood
UB Revenue Code
CPT/HCPCS
306
87106
43.86
306
87076
34.35
306
87088
27.84
306
87077
34.35
306
87186
36.75
301
82271
13.83
301
80074
202.41
301 301 301 302 301 301 301 301 302 301 301 301 301 301 301 301 301 301
86709 86705 86803 86762 84520 82330 82374 82435 86140 82565 83036 82947 82950 82950 82947 84132 84295 82575
47.85 50.01 60.66 61.17 16.11 58.08 20.79 19.53 21.99 21.78 41.25 16.68 19.53 20.19 16.68 19.53 20.46 40.17
301
80061
56.91
301
83718
34.80
301
82803
82.20
301
82803
82.20
301
82803
82.20
301
82803
82.20
301
82803
82.20
301
82803
82.20
301
82803
82.20
301 301 301 301
82800 83050 83986 82945
34.74 161.00 15.21 16.68
Amount
92 of 167 Updated on 1/22/2019
UB Revenue Code
CPT/HCPCS
301
84157
15.57
301
G0480
85.98
406020406-20406 ELECTROLYTE PANEL
Electrolyte panel This panel must include the following: Carbon dioxide (bicarbonate) (82374) Chloride (82435) Potassium (84132) Sodium (84295)
301
80051
29.82
406020411-20411 BASIC METABOLIC PANEL
Basic metabolic panel (Calcium, total) This panel must include the following: Calcium, total (82310) Carbon dioxide (bicarbonate) (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Potassium (84132) Sodium (84295) Urea nitrogen (BUN) (84520)
301
80048
35.94
4503
406020416-20416 COMPREHENSIVE METABOLIC PANEL
Comprehensive metabolic panel. This panel must include the following: Albumin (82040) Bilirubin, total (82247) Calcium, total (82310) Carbon dioxide (bicarbonate) (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Phosphatase, alkaline (84075) Potassium (84132) Protein, total (84155) Sodium (84295) Transferase, alanine amino (ALT) (SGPT) (84460) Transferase, aspartate amino (AST) (SGOT) (84450) Urea nitrogen (BUN) (84520)
301
80053
44.91
4503 4503 4503 4503 4503 4503 4503
406020420-20420 406020425-20425 406020426-20426 406020430-20430 406020440-20440 406020442-20442 406020445-20445
Gentamicin Gentamicin Gentamicin Lithium Phenobarbital Valproic acid (dipropylacetic acid); total Phenytoin; total
301 301 301 301 301 301 301
80170 80170 80170 80178 80184 80164 80185
69.63 69.63 69.63 28.08 48.66 119.31 56.31
Revenue Center
CDM Number
CDM Description
4503
406020380-20380 PROTEIN QUANT. OTHER THAN BLD.
4503
406020400-20400 ACETAMINOPHEN (EMIT)
4503
4503
GENTAMYCIN PEAK (EMIT) GENTAMYCIN TROUGH (EMIT) GENTAMYCIN RANDOM (EMIT) LITHIUM PHENOBARB QUANT. (EMIT) VALPORIC ACID DILANTIN (EMIT)
Long Description Protein, total, except by refractometry; other source (eg, synovial fluid, cerebrospinal fluid) Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrixmatched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 1-7 drug class(es), including metabolite(s) if performed
Amount
93 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
UB Revenue Code
CPT/HCPCS
301
G0480
30.15
Theophylline Vancomycin Vancomycin Vancomycin Troponin, quantitative Creatine kinase (CK), (CPK); MB fraction only Myoglobin Prostate specific antigen (PSA); total Amylase Chloride; urine Chloride; urine Creatinine; other source Creatinine; other source Osmolality; urine Protein, total, except by refractometry; urine Potassium; urine Potassium; urine Sodium; urine Sodium; urine Calcium; urine quantitative, timed specimen Albumin; urine (eg, microalbumin), quantitative Albumin; urine (eg, microalbumin), quantitative Creatinine; other source
301 301 301 301 301 301 301 301 301 301 301 301 301 301 301 301 301 301 301 301 301 301 301
80198 80202 80202 80202 84484 82553 83874 84153 82150 82436 82436 82570 82570 83935 84156 84133 84133 84300 84300 82340 82043 82043 82570
60.12 57.57 57.57 57.57 41.82 49.05 54.87 78.18 27.54 21.36 21.36 21.99 21.99 28.95 15.57 18.27 18.27 20.67 20.67 46.00 24.57 46.00 21.99
Long Description Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrixmatched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 1-7 drug class(es), including metabolite(s) if performed
Amount
4503
406020460-20460 SALICYLATE
4503 4503 4503 4503 4503 4503 4503 4503 4503 4503 4503 4503 4503 4503 4503 4503 4503 4503 4503 4503 4503 4503 4503
406020465-20465 406020470-20470 406020472-20472 406020475-20475 406020488-20488 406020490-20490 406020491-20491 406020497-20497 406020501-20501 406020510-20510 406020515-20515 406020520-20520 406020525-20525 406020540-20540 406020545-20545 406020550-20550 406020555-20555 406020560-20560 406020565-20565 406020580-20580 406020590-20590 406020596-20596 406020597-20597
4503
406020655-20655 ASSAY ALBUMIN URINE/OTH QUANT
Albumin; other source, quantitative, each specimen
301
82042
13.92
4503 4503 4503 4503 4503 4503 4503 4503 4503 4503 4503 4503
406020660-20660 406020665-20665 406020667-20667 406020670-20670 406020672-20672 406020675-20675 406020680-20680 406020683-20683 406020684-20684 406020685-20685 406020690-20690 406020693-20693
301 301 301 301 301 301 301 301 301 301 301 300
82150 82247 82310 82438 82465 82570 82945 83615 83690 84132 84302 84156
27.54 21.30 21.90 20.79 18.48 21.99 16.68 25.65 29.28 19.53 20.67 15.57
4503
406020696-20696 PROTEIN TOTAL BODY FLIUD
300
84157
15.57
4503 4503 4503 4503 4503 4503
406020697-20697 406020698-20698 406020700-20700 406020720-20720 406020730-20730 406020736-20736
Amylase Bilirubin; total Calcium; total Chloride; other source Cholesterol, serum or whole blood, total Creatinine; other source Glucose, body fluid, other than blood Lactate dehydrogenase (LD), (LDH); Lipase Potassium; serum, plasma or whole blood Sodium; other source Protein, total, except by refractometry; urine Protein, total, except by refractometry; other source (eg, synovial fluid, cerebrospinal fluid) Phosphorus inorganic (phosphate); Uric acid; other source Triglycerides Digoxin; total Gonadotropin, chorionic (hCG); qualitative Gonadotropin, chorionic (hCG); quantitative
301 301 301 301 301 301
84100 84560 84478 80162 84703 84702
20.16 20.19 24.45 56.40 31.92 63.99
THEOPHYLLINE VANCOMYCIN,PEAK VANCOMYCIN RANDOM VANOMYCIN,TROUGH TROPONIN-I CARDIAC MARKER CKBM MYOGLOBIN PROSTATIC SPECIFIC AG AMYLASE,URINE (DIASTASE) CHLORIDE URINE RANDOM CHLORIDE URINE 24 HR. CREATININE URINE RANDOM CREATININE URINE 24 HR. OSMOLALITY URINE URINE PROTEIN 24 HR. POTASSIUM URINE RANDOM POTASSIUM URINE3 24 HR. SODIUM URINE RANDOM SODIUM URINE 24 HR. CALCIUM URINE 24 HR. MICROALBUMIN,URINE,QUANT 24HR *MICROALBUMIN, URINE, QUANT CREATININE URINE, RANDOM
AMYLASE BODY FLUID BILTRUBIN TOTAL BODY FLUID CALCIUM BODY FLUID CHLORIDE BODY FLUID CHOLESTEROL, FLUID CREATININE BODY FLUID GLUCOSE BODY FLUID LDH BODY FLUID LIPASE, FLUID POTASSIUM BODY FLUID SODIUM BODY FLUID PROTEIN TOTAL, URINE, RANDOM
PHOSPHORUS BODY FLUID URIC ACID BODY FLUID TRIGLYCERIDE, FLUID DIGOXIN PREGNANCY TESTING, ROUTINE SER GONADOTROPIN CHORIONIC QUANT,F
94 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4503
406020740-20740 PREGNANCY TESTING, URINE
4503 4503 4503
406020758-20758 PARATHORMONE(PTH) 406020759-20759 THYROID STIMULATING HORMONE (TSH) 406020761-20761 FREE T4 (FREE THYROXINE)
4503
406020771-20771 TRICYCLIC DRUG SCREEN - URINE
4503
4503
4503
4503
4503
4503
406020778-20778 *DRUG SCREEN BARBITUATE UR
406020779-20779 *BENZODIAZAPINE URINE
406020780-20780 *COCAINE METABOLITE, URINE
406020781-20781 OPIATE SCREEN URINE (EMIT)
406020784-20784 *PHENCYCLIDINE (PCP) URINE
406020787-20787 *DRUG SCREEN THC, URINE
Long Description Urine pregnancy test, by visual color comparison methods Parathormone (parathyroid hormone) Thyroid stimulating hormone (TSH) Thyroxine; free Drug test(s), presumptive, any number of drug classes; any number of devices or procedures, (e.g., immunoassay) capable of being read by direct optical observation only (e.g., dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service Drug test(s), presumptive, any number of drug classes; any number of devices or procedures by instrumented chemistry analyzers utilizing immunoassay, enzyme assay, TOF, MALDI, LDTD, DESI, DART, GHPC, GC mass spectrometry), includes sample validation when performed, per date of service Drug test(s), presumptive, any number of drug classes; any number of devices or procedures by instrumented chemistry analyzers utilizing immunoassay, enzyme assay, TOF, MALDI, LDTD, DESI, DART, GHPC, GC mass spectrometry), includes sample validation when performed, per date of service Drug test(s), presumptive, any number of drug classes; any number of devices or procedures by instrumented chemistry analyzers utilizing immunoassay, enzyme assay, TOF, MALDI, LDTD, DESI, DART, GHPC, GC mass spectrometry), includes sample validation when performed, per date of service Drug test(s), presumptive, any number of drug classes; any number of devices or procedures by instrumented chemistry analyzers utilizing immunoassay, enzyme assay, TOF, MALDI, LDTD, DESI, DART, GHPC, GC mass spectrometry), includes sample validation when performed, per date of service Drug test(s), presumptive, any number of drug classes; any number of devices or procedures by instrumented chemistry analyzers utilizing immunoassay, enzyme assay, TOF, MALDI, LDTD, DESI, DART, GHPC, GC mass spectrometry), includes sample validation when performed, per date of service Drug test(s), presumptive, any number of drug classes; any number of devices or procedures by instrumented chemistry analyzers utilizing immunoassay, enzyme assay, TOF, MALDI, LDTD, DESI, DART, GHPC, GC mass spectrometry), includes sample validation when performed, per date of service
UB Revenue Code
CPT/HCPCS
307
81025
9.96
301 301 301
83970 84443 84439
175.38 71.40 38.31
301
G0477
308.97
301
G0479
308.97
301
G0479
308.97
301
G0479
308.97
301
G0479
308.97
301
G0479
308.97
301
G0479
308.97
Amount
95 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4503
406020791-20791 URINE ETOH SCREEN
4503
406020792-20792 URINE METHADONE SCREEN
4503
406020796-20796 *DRUG SCREEN AMPHET. UR (EMIT)
4503
406020803-20803 HEPATIC FUNCTION PANEL
4503
406020806-20806 KETONE(BETA-HYDROXYBUTYRATE)QUANT
4503 4503 4503 4503 4503
406020810-20810 406020813-20813 406020815-20815 406020817-20817 406020820-20820
4503
406020825-20825 RENAL FUNCTION PANEL
4503 4503 4503 4503 4503 4503 4503 4503 4503 4503 4503 4503
406020830-20830 406020831-20831 406020835-20835 406020840-20840 406020845-20845 406020846-20846 406020850-20850 406020855-20855 406020865-20865 406020875-20875 406020880-20880 406020881-20881
4503
406020885-20885 FETAL FIBRONECTIN, SEMI-QUANT
4503 4503
406020895-20895 FERRITIN 406020897-20897 IRON (FE)
ALBUMIN PREALBUMIN ALCOHOL, ETHYL AMMONIA,BLOOD AMYLASE
BILIRUBIN TOTAL BILIRUBIN DIRECT CALCIUM CARBAMAZEPINE (EMIT) CARBOXY HEMOGLOBIN CEA CHOLESTEROL,TOTAL CK CORTISOL, TOTAL AST (SGOT) ALT (SGPT) FSH
Long Description Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, DESI, GC-MS, GCMS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, DESI, GC-MS, GCMS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service Drug test(s), presumptive, any number of drug classes; any number of devices or procedures by instrumented chemistry analyzers utilizing immunoassay, enzyme assay, TOF, MALDI, LDTD, DESI, DART, GHPC, GC mass spectrometry), includes sample validation when performed, per date of service Hepatic function panel This panel must include the following: Albumin (82040) Bilirubin, total (82247) Bilirubin, direct (82248) Phosphatase, alkaline (84075) Protein, total (84155) Transferase, alanine amino (ALT) (SGPT) (84460) Transferase, aspartate amino (AST) (SGOT) (84450) Ketone body(s) (eg, acetone, acetoacetic acid, betahydroxybutyrate); quantitative Albumin; serum, plasma or whole blood Prealbumin Alcohols Ammonia Amylase Renal function panel This panel must include the following: Albumin (82040) Calcium, total (82310) Carbon dioxide (bicarbonate) (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Phosphorus inorganic (phosphate) (84100) Potassium (84132) Sodium (84295) Urea nitrogen (BUN) (84520) Bilirubin; total Bilirubin; direct Calcium; total Carbamazepine; total Carboxyhemoglobin; quantitative Carcinoembryonic antigen (CEA) Cholesterol, serum or whole blood, total Creatine kinase (CK), (CPK); total Cortisol; total Transferase; aspartate amino (AST) (SGOT) Transferase; alanine amino (ALT) (SGPT) Gonadotropin; follicle stimulating hormone (FSH) Fetal fibronectin, cervicovaginal secretions, semiquantitative Ferritin Iron
UB Revenue Code
CPT/HCPCS
301
80307
237.75
301
80307
308.97
301
G0479
308.97
301
80076
34.71
301
82010
34.71
301 301 301 301 301
82040 84134 80320 82140 82150
21.03 61.95 45.90 61.92 27.54
301
80069
36.90
301 301 301 301 301 301 301 301 301 301 301 301
82247 82248 82310 80156 82375 82378 82465 82550 82533 84450 84460 83001
21.30 21.30 21.90 61.86 52.38 80.61 18.48 27.69 69.30 21.99 22.50 78.96
301
82731
273.69
301 301
82728 83540
57.90 74.21
Amount
96 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4503 4503 4503 4503 4503 4503 4503 4503 4503 4503
406020899-20899 406020908-20908 406020909-20909 406020910-20910 406020915-20915 406020916-20916 406020920-20920 406020924-20924 406020925-20925 406020927-20927
4503
406020928-20928 VITAMIN D, 25 HYDROXY
4503 4503 4503
406020929-20929 FOLIC ACID,SERUM 406020931-20931 RHEUMATOID FACTOR 406020932-20932 AFP TUMOR MARKER
IRON BINDING CAPACITY(TIBC) LACTATE (LACTIC ACID) LACTIC(SEPSIS) LDH PNL LIPASE LH MAGNESIUM NATRIURETIC PEPTIDE OSMOLALITY BLOOD VITAMIN B12,SERUM
4503
406020934-20934 HEPATITIS B SURFACE AG
4503 4503
406020937-20937 PHOSPHATASE ALKALINE 406020940-20940 PHOSPHORUS PNL
4503
406020945-20945 PROTEIN TOTAL PNL
4503 4503 4503 4503 4503
406020947-20947 406020950-20950 406020952-20952 406020954-20954 406020955-20955
PROLACTIN TRIGLYCERIDE PNL *HIV-1 ANTB SYPHILIS (TREPONEMAL) ANTIBODIES URIC ACID PNL
4503
406020956-20956 HIV-1 AG W HIV-1/2 ANTIBODIES
4503
406021071-21071 GLUCOSE TOL 3 SPEC W/ GLUCOLA
4503
406021072-21072 GLUCOSE TOL EACH ADD SPECIMEN
4503 4503 4503 4503 4503 4503
406021131-21131 406021132-21132 406021133-21133 406021134-21134 406021135-21135 406021136-21136
4503
406021137-21137 GASES, BLOOD
4503
406021542-21542 DRUGS OF ABUSE PANEL W THC
4505
406011801-11801 PROTIME
4505
406011810-11810 PARTIAL THROMBOPLASTIN TIME PT
SODIUM, SERUM POTASSIUM, SERUM CHLORIDE, BLOOD GLUCOSE, BLOOD HEMOGLOBIN CALCIUM, IONIZED
Long Description Iron binding capacity Lactate (lactic acid) Lactate (lactic acid) Lactate dehydrogenase (LD), (LDH); Lipase Gonadotropin; luteinizing hormone (LH) Magnesium Natriuretic peptide Osmolality; blood Cyanocobalamin (Vitamin B-12); Vitamin D; 25 hydroxy, includes fraction(s), if performed Folic acid; serum Rheumatoid factor; quantitative Alpha-fetoprotein (AFP); serum Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzymelinked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative, multiple-step method; hepatitis B surface antigen (HBsAg) Phosphatase, alkaline; Phosphorus inorganic (phosphate); Protein, total, except by refractometry; serum, plasma or whole blood Prolactin Triglycerides Antibody; HIV-1 Antibody; Treponema pallidum Uric acid; blood Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzymelinked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative, multiple-step method; HIV-1 antigen(s), with HIV-1 and HIV-2 antibodies, single result Glucose; tolerance test (GTT), 3 specimens (includes glucose) Glucose; tolerance test, each additional beyond 3 specimens Sodium; serum, plasma or whole blood Potassium; serum, plasma or whole blood Chloride; blood Glucose; quantitative, blood (except reagent strip) Blood count; hemoglobin (Hgb) Calcium; ionized Gases, blood, any combination of pH, pCO2, pO2, CO2, HCO3 (including calculated O2 saturation); Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, DESI, GC-MS, GCMS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service Prothrombin time; Thromboplastin time, partial (PTT); plasma or whole blood
UB Revenue Code 301 301 301 301 301 301 301 301 301 301
CPT/HCPCS
Amount
83550 83605 83605 83615 83690 83002 83735 83880 83930 82607
79.06 45.39 45.39 25.65 29.28 78.69 28.47 144.24 28.08 64.05
301
82306
125.82
301 301 301
82746 86431 82105
62.46 24.12 36.09
301
87340
34.20
301 301
84075 84100
21.99 20.16
301
84155
43.13
301 301 302 301 301
84146 84478 86701 86780 84550
82.35 24.45 47.44 54.06 19.20
301
87389
98.31
301
82951
54.69
301
82952
16.65
301 301 301 301 301 301
84295 84132 82435 82947 85018 82330
20.46 19.53 19.53 16.68 10.05 58.08
301
82803
82.20
301
80307
239.43
305
85610
16.68
305
85730
25.50
97 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4505
406011811-11811 PTT-HEPARINIZED
4505 4505 4505 4505 4505 4505
406011825-11825 406011838-11838 406011850-11850 406011890-11890 406011895-11895 406011899-11899
4505
406011950-11950 SEMEN ANALYSIS PRESENCE/MOTLTY
4506
406011698-11698 URINALYSIS COMPLETE
4506
406011703-11703 UA DIPSTICK QUAL, W/O MICRO
4506
406011730-11730 SPECIFIC GRAVITY
4506
406011750-11750 CRYSTAL ID BODY FLUID
4522
407013034-13034 BONE MARROW IRON STAIN
4522
407013039-13039 PERIPH BLD SMEAR INTERP
4522 4522
407013040-13040 PATH GROSS EXAM 407013043-13043 PATH GROSS EXAM TECH
4522
407013053-13053 LEV II-SURG PATH GROS/MICRO
FIBRINOGEN,QUANTITATIVE FIBRIN DEGRAD. PRODUCTS,D-DIMER BLEEDING TIME TEMPLATE HEPARIN ASSAY (XA LMWH) HEPARIN ASSAY (XA UNFRACTIONATED) PROCALCITONIN
Long Description Thromboplastin time, partial (PTT); plasma or whole blood Fibrinogen; activity Fibrin degradation products, D-dimer; quantitative Bleeding time Heparin assay Heparin assay Procalcitonin (PCT) Semen analysis; sperm presence and motility of sperm, if performed Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, with microscopy Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, without microscopy Specific gravity (except urine) Crystal identification by light microscopy with or without polarizing lens analysis, tissue or any body fluid (except urine) Special stain including interpretation and report; Group II, all other (eg, iron, trichrome), except stain for microorganisms, stains for enzyme constituents, or immunocytochemistry and immunohistochemistry Blood smear, peripheral, interpretation by physician with written report Level I - Surgical pathology, gross examination only Level I - Surgical pathology, gross examination only Level II - Surgical pathology, gross and microscopic examination. Appendix, incidental; fallopian tube, sterilization; fingers/toes, amputation, traumatic; foreskin, newborn; hernia sac, any location; hydrocele sac; nerve; skin, plastic repair; sympathetic ganglion; testis, castration; vaginal mucosa, incidental; vas deferens, sterilization.
UB Revenue Code
CPT/HCPCS
305
85730
25.50
305 305 305 305 305 301
85384 85379 85002 85520 85520 84145
36.09 43.26 19.14 55.62 55.62 109.35
309
89321
49.59
307
81001
13.44
307
81003
9.54
301
84315
10.65
309
89060
30.39
312
88313TC
55.23
305
85060
70.89
312 312
88300 88300TC
36.09 36.09
312
88302TC
55.23
Amount
98 of 167 Updated on 1/22/2019
Revenue Center
4522
4522
Long Description
UB Revenue Code
CPT/HCPCS
407013055-13055 LEV III-SURG PATH GROS/MICRO
Level III - Surgical pathology, gross and microscopic examination. Abortion,induced;Abscess;Aneurysm arterial/ventricular;Anus,tag;Appendix,other than incidental;Artery,atheromatous plaque;Bartholin's gland cyst;Bone fragment(s),other than pathologic fracture;Bursa/synovial cyst;Carpal tunnel tissue;Cartilage,shavings;Cholesteatoma;Colon,colos tomy stoma;Conjunctiva-biopsy/pterygium; Cornea;Diverticulum-esophagus/small intestine;Dupuytren's contracture tissue;Femoral head,other than fracture;Fissure/fistula;Foreskin,other than newborn;Gallbladder;Ganglion cyst;Hematoma;Hemorrhoids;Hydatid of Morgagni;Intervertebral disc;Joint,loose body;Meniscus;Mucocele,salivary;NeuromaMorton's/traumatic;Pilonidal cyst/sinus;Polyps,inflammatory-nasal/sinusoidal;Skincyst/tag/debridement;Soft tissue,debridement;Soft tissue,lipoma;Spermatocele;Tendon/tendon sheath;testicular appendage;Thrombus or embolus;Tonsil and/or adenoids;Varicocele;Vas deferens, other than sterilization;Vein,varicosity
312
88304TC
119.04
407013057-13057 LEVEL IV-SURG PATH GROSS&MICRO
Level IV - Surgical pathology, gross and microscopic examination. Abort-spon;Artery;Bone marrw;Bone exostosis;Brain/mening not tumor resxn;Breast bx no micro surg margins red mammo;Bronchus;Cell block ;Cervix bx;Colon bx;Duodenm;Endocervx;Endometrm;Esophags bx;Extremty amp traum;Fallopian tb bx ectopic;Femoral head;Fingers/toes amp nontraum;Gingiva/oral mucosa;Heart vlve;Joint resxn;Kidney bx;Larynx bx;Leiomyoma myomectomy w/o uterus;Lip;Lung transbronch bx;Lymph node bx;Muscle;Nasal mucosa;Nasopharynx/oropharynx;Nerve bx;Odontogenic/dental cyst;Omentm;Ovary non-neo bx/wdg resxn;Parathyrd;Peritonm;Pituit tumor;Placent no 3rd trim;Pleura/pericard;Polyp cervic/endomet colorectl stomach/small int;Prostate ndle bx TUR;Saliv gland bx;Sinus paranasal;Skin not cyst/tag/debride/repr;Small intest bx;Soft tiss no mass/lipoma/debride;Spleen;Stomach bx;Synovium;Testis no tumor/bx/castrat;Thyroglssl duct/brachial cleft cyst;Tongue bx;Tonsil bx;Trachea;Ureter bx;Urthra;Urnry bladder bx;Uterus prolpse;Vagina/vulva/labia bx
312
88305TC
119.04
CDM Number
CDM Description
Amount
99 of 167 Updated on 1/22/2019
Long Description
UB Revenue Code
CPT/HCPCS
407013059-13059 LEVEL V-SURG PATH GROSS&MICRO
Level V - Surgical pathology, gross and microscopic examination. Adrenal resxn; Bone bx/curettings; Bone fragment pathologic fx; Brain bx; Brain/meninges tumor resxn; Breast excision of lesion requiring microscopic eval of surgical margins; Breast mastectomy - partial/simple; Cervix conization; Colon segmental resxn not for tumor; Extremity amputation non-traumatic; Eye enucleation; Kidney partial/total nephrectomy; Larynx partial/total resxn; Liver bx - needle/wedge; Liver partial resxn; Lung wedge bx; Lymph nodes regional resxn; Mediastinum mass; Myocardium bx; Odontogenic tumor; Ovary neoplastic w/w/o tube; Pancreas bx; Placenta 3rd trimester; Prostate except radical resxn; Salivary gland; Sentinel lymph node; Small intestine resxn not for tumor; Soft tissue mass except lipoma - bx/simple excision; Stomach subtotal/total resxn other than for tumor; Testis bx; Thymus tumor; Thyroid total/lobe; Ureter resxn; Urinary bladder TUR; Uterus not neoplastic/prolapse w/w/o tubes and ovaries
312
88307TC
186.48
4522
407013061-13061 LEV VI-SURG PATH GROS/MICRO
Level VI - Surgical pathology, gross and microscopic examination. Bone resection; Breast mastectomy with regional lymph nodes; Colon segmental resection for tumor; Colon total resection; Esophagus partial/total resection; Extremity disarticulation; Fetus with dissection; Larynx partial/total resection with regional lymph nodes; Lung total/lobe/segment resection; Pancreas total/subtotal resection; Prostate radical resection; Small intestine resection for tumor; Soft tissue tumor extensive resection; Stomach subtotal/total resection for tumor; Testis tumor; Tongue/tonsil resection for tumor; Urinary bladder partial/total resection; Uterus neoplastic with or without tubes and ovaries; Vulva total/subtotal resection.
312
88309TC
181.13
4522
407013063-13063 PATH FROZEN SECTION 1ST SPC TC
312
88331TC
119.04
4522
407013065-13065 PATH FROZEN SECT ADDNL TECH
312
88332TC
36.09
4522
407013066-13066 PATH CONSULTATION DURNING SURG
312
88329TC
55.23
4522
407013070-13070 PATH CONSULT, REFERRED SLIDES
312
88321
153.00
4522
407013100-13100 SP STAINS GROUP I
312
88312TC
55.23
4522
407013102-13102 SP STAINS GROUP II
312
88313TC
55.23
4522
407013105-13105 SP STAINS GROUP II - H&E STAIN
312
88313TC
55.23
4522
407013200-13200 DECALCIFICATION
Decalcification procedure (List separately in addition to code for surgical pathology examination)
312
88311TC
36.09
4522
407013325-13325 BONE MARROW BIOPSY NDL OR TRCR
Diagnostic bone marrow; biopsy(ies)
310
38221
Revenue Center
4522
CDM Number
CDM Description
Pathology consultation during surgery; first tissue block, with frozen section(s), single specimen Pathology consultation during surgery; each additional tissue block with frozen section(s) Pathology consultation during surgery; Consultation and report on referred slides prepared elsewhere Special stain including interpretation and report; Group I for microorganisms (eg, acid fast, methenamine silver) Special stain including interpretation and report; Group II, all other (eg, iron, trichrome), except stain for microorganisms, stains for enzyme constituents, or immunocytochemistry and immunohistochemistry Special stain including interpretation and report; Group II, all other (eg, iron, trichrome), except stain for microorganisms, stains for enzyme constituents, or immunocytochemistry and immunohistochemistry
Amount
1014.49
100 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4523
407013013-13013 CYTO-FLUIDS, SMEARS & INTERP
4523
407013016-13016 CYTO CONCENTRATE, SMEAR & INTERP
4523
407013017-13017 CYTO-CONCENTRATE, SMEAR & INTERP
4523
407013019-13019 LEV IV-SURG PATH GROSS&MICRO
4523
407013020-13020 CYTO FINE NEEDLE RAPID READ
4523
407013023-13023 CYTO FN INTERP AND REPORT
4523
407013027-13027 CYTO MISC SCREEN & INTERP TECH
4523
407013036-13036 CYTO-OTHER,PREP SCRN & INTERP
4523
407013068-13068 PATH CONSULT,CYTO EXAM, INITIAL
4523
407013069-13069 PATH CONSULT,CYTO EXAM,EACH ADDNL
4523
409014027-14027 INFECT AGNT BY NUCLEIC ACID,HPV
4523
409014028-14028 CYTOPATH,CX/VAG THINLAYER SCRN@M
4540
410017064-17064 ANTIHUMAN GLOBULIN DIRECT-IGG
4540
410017085-17085 *CORD BLOOD ABO & RH
4540
410017170-17170 FETAL BLOOD SCREEN
4540 4540
410017250-17251 UNIT SPLITTING OPEN/CLOSED SYS 410017250-17250 UNIT SPLITTING OPEN/CLOSED SYS
Long Description
UB Revenue Code
CPT/HCPCS
Cytopathology, fluids, washings or brushings, except cervical or vaginal; smears with interpretation
311
88104TC
55.23
311
88108
55.23
311
88108
55.23
312
88305TC
119.04
311
88172
55.23
311
88173TC
90.56
311
88160TC
55.23
311
88161TC
55.23
311
88333TC
55.23
311
88334TC
55.23
306
87624
38.80
311
88175
28.00
302
86880
58.94
Cytopathology, concentration technique, smears and interpretation (eg, Saccomanno technique) Cytopathology, concentration technique, smears and interpretation (eg, Saccomanno technique) Level IV - Surgical pathology, gross and microscopic examination. Abort-spon;Artery;Bone marrw;Bone exostosis;Brain/mening not tumor resxn;Breast bx no micro surg margins red mammo;Bronchus;Cell block ;Cervix bx;Colon bx;Duodenm;Endocervx;Endometrm;Esophags bx;Extremty amp traum;Fallopian tb bx ectopic;Femoral head;Fingers/toes amp nontraum;Gingiva/oral mucosa;Heart vlve;Joint resxn;Kidney bx;Larynx bx;Leiomyoma myomectomy w/o uterus;Lip;Lung transbronch bx;Lymph node bx;Muscle;Nasal mucosa;Nasopharynx/oropharynx;Nerve bx;Odontogenic/dental cyst;Omentm;Ovary non-neo bx/wdg resxn;Parathyrd;Peritonm;Pituit tumor;Placent no 3rd trim;Pleura/pericard;Polyp cervic/endomet colorectl stomach/small int;Prostate ndle bx TUR;Saliv gland bx;Sinus paranasal;Skin not cyst/tag/debride/repr;Small intest bx;Soft tiss no mass/lipoma/debride;Spleen;Stomach bx;Synovium;Testis no tumor/bx/castrat;Thyroglssl duct/brachial cleft cyst;Tongue bx;Tonsil bx;Trachea;Ureter bx;Urthra;Urnry bladder bx;Uterus prolpse;Vagina/vulva/labia bx Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy for diagnosis, first evaluation episode, each site Cytopathology, evaluation of fine needle aspirate; interpretation and report Cytopathology, smears, any other source; screening and interpretation Cytopathology, smears, any other source; preparation, screening and interpretation Pathology consultation during surgery; cytologic examination (eg, touch prep, squash prep), initial site Pathology consultation during surgery; cytologic examination (eg, touch prep, squash prep), each additional site Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), high-risk types (eg, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68) Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; with screening by automated system and manual rescreening or review, under physician supervision Antihuman globulin test (Coombs test); direct, each antiserum
300 Hemoglobin or RBCs, fetal, for fetomaternal hemorrhage; rosette Splitting of blood or blood products, each unit Splitting of blood or blood products, each unit
Amount
77.63
302
85461
50.31
381 381
86985 86985
40.25 40.25
101 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4540
410017255-17255 FRESH FROZEN PLASMA THAWING 1 UNI
4540 4540 4540 4540 4540
410017268-17268 410017270-17270 410017271-17271 410017285-17285 410017290-17290
4540
410017301-17301 COMPATABILITY TEST IMMED SPIN EA
4540 4540 4540 4540 4540 4540
410017309-17309 410017310-17310 410017314-17314 410017315-17315 410017320-17320 410017333-17333
4540
410017337-17337 BLOOD COMP(FFP ACDA-A FFP)STOR-PR
4540
410017338-17338 FRESH FROZEN PLASMA FFP EA UNIT
4540
410017339-17339 FFP STOR-PROC
4540
410017340-17340 FRESH FROZEN PLASMA SD FF EA UNIT
4540
410017343-17343 FRESH FROZEN PLASMA SD PEDS UNIT
4540
410017344-17344 FRESH FROZEN PLASMA DIVIDED EA UN
4540 4540 4540 4540
410017345-17345 410017358-17358 410017360-17360 410017361-17361
4540
410017470-17470 GLOBULIN RH IMMUNE EACH
4540
410017482-17482 TRN BLOOD CMV SCREEN
4540
410017484-17484 ANTIHUMAN GLOBULIN INDIRECT
4540
410017485-17485 DIRECT ANTIGLOBULIN TEST
4540
410017489-17489 RBC ANTIGEN TYPING
4540
410017492-17492 RBC ANTIGEN TYPING
4540
410017493-17493 ANTIHUMAN GLOBULIN INDIRECT/EA
4540
410017494-17494 RBC ANTIGEN TYPING CHARGE ONLY
4540
410017495-17495 RBC ANTIBODIES EACH PANEL
4540
410017496-17496 RBC ANTIBODIES ID EA
4540 4540 4540 4540 4540 4540 4540 4540 4540 4540 4540 4540 4540 4540
410017498-17498 410017499-17499 410017501-17501 410017502-17502 410017509-17509 410017519-17519 410017520-17520 410017524-17524 410017525-17525 410017529-17529 410017530-17530 410017534-17534 410017535-17535 410017539-17539
IRRADIATION BLOOD PRODUCTS/EAC SPLIT BLD/BLD PROD EA BLOOD COMP(RBC PEDS UNIT) STOR-PR CROSSMATCH ELECTRONIC CROSSMATCH BLOOD UNIT EACH
BLOOD COMP(CRYOPRECIP.) STOR-PROC CRYOPRECIPITATE EA UNIT CRYOPRECIPITATE POOLED BLOOD COMP(CRYOPRECIPITATE) STOR*PLATELETS EA UNIT PLATELET PHERESIS CONC PED UNIT
BLOOD COMP(RBC LR PCLR)STOR-PROC BLOOD COMP(RBC LR R3F) STOR-PROC RBC L/R PCLR RBC L/R R3F
BLOOD GROUP ABO RH TYPE PLATELET PHERESIS L/R PHLR BLOOD COMP(PLT LR PHLR) STOR-PROC FRESH FROZEN PLASMA THAWING EA UN BLOOD COMP(RBC R3) STOR-PROC RBC R3 BLOOD COMP(RBC R3D) STOR-PROC RBC R3D BLOOD COMP(RBC LR R3DF) STOR-PROC RBC L/R R3DF BLOOD COMP(RBC IRR R3I)STOR-PROC RBC IRRAD R3I BLOOD COMP(RBC IRR R3DI)STOR-PROC
Long Description Frozen blood, each unit; freezing (includes preparation) Irradiation of blood product, each unit Blood, split unit Red blood cells, leukocytes reduced, each unit Compatibility test each unit; electronic Compatibility test each unit; antiglobulin technique Compatibility test each unit; immediate spin technique Cryoprecipitate, each unit Cryoprecipitate, each unit Cryoprecipitate, each unit Cryoprecipitate, each unit Platelets, each unit Pooling of platelets or other blood products Fresh frozen plasma (single donor), frozen within 8 hours of collection, each unit Fresh frozen plasma (single donor), frozen within 8 hours of collection, each unit Fresh frozen plasma (single donor), frozen within 8 hours of collection, each unit Fresh frozen plasma (single donor), frozen within 8 hours of collection, each unit Fresh frozen plasma (single donor), frozen within 8 hours of collection, each unit Fresh frozen plasma (single donor), frozen within 8 hours of collection, each unit Red blood cells, leukocytes reduced, each unit Red blood cells, leukocytes reduced, each unit Red blood cells, leukocytes reduced, each unit Red blood cells, leukocytes reduced, each unit Rho(D) immune globulin (RhIg), human, full-dose, for intramuscular use Whole blood or red blood cells, leukocytes reduced, CMV-negative, each unit Antibody screen, RBC, each serum technique Antihuman globulin test (Coombs test); direct, each antiserum Blood typing, serologic; RBC antigens, other than ABO or Rh (D), each Blood typing, serologic; RBC antigens, other than ABO or Rh (D), each Antihuman globulin test (Coombs test); indirect, each antibody titer Blood typing, serologic; RBC antigens, other than ABO or Rh (D), each Antibody identification, RBC antibodies, each panel for each serum technique Antibody identification, RBC antibodies, each panel for each serum technique Blood typing, serologic; ABO Blood typing, serologic; Rh (D) Platelets, pheresis, leukocytes reduced, each unit Platelets, pheresis, leukocytes reduced, each unit Irradiation of blood product, each unit Red blood cells, each unit Red blood cells, each unit Red blood cells, each unit Red blood cells, each unit Red blood cells, leukocytes reduced, each unit Red blood cells, leukocytes reduced, each unit Red blood cells, irradiated, each unit Red blood cells, irradiated, each unit Red blood cells, irradiated, each unit
UB Revenue Code
CPT/HCPCS
302
86930
40.25
302 381 390 300 300
86945 P9011BL P9016 86923 86922
57.50 76.40 57.50 136.56 136.56
300
86920
92.00
399 387 387 390 384 302
P9012 P9012 P9012 P9012 P9019 86965
57.50 265.47 1587.21 57.50 81.44 927.19
390
P9017
57.50
383
P9017
85.02
399
P9017
57.50
383
P9017
85.02
383
P9017
45.50
383
P9017
85.02
390 390 381 381
P9016 P9016BL P9016 P9016
57.50 57.50 566.59 566.59
250
90384
273.13
381
P9051
7.19
302
86850
57.50
302
86880
58.94
302
86905
51.75
302
86905
51.75
302
86886
79.06
302
86905
51.75
302
86870
143.75
302
86870
143.75
302 302 384 399 302 390 381 390 381 390 381 390 381 390
86900 86901 P9035 P9035 86945 P9021 P9021 P9021 P9021 P9016BL P9016 P9038 P9038 P9038
44.56 44.56 1673.46 57.50 35.94 57.50 494.71 57.50 494.71 57.50 566.59 57.50 609.71 57.50
Amount
102 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4540
410017540-17540 RBC IRRAD R3DI
4540
410017544-17544 BLOOD COMP(RBC LR IRR R3FI)STOR-P
4540
410017545-17545 RBC L/R IRRAD R3FI
4540
410017549-17549 BLOOD COMP(RBC LR IRR R2FI)STOR-P
4540
410017550-17550 RBC L/R IRRAD R2FI
4540 4540 4540 4540 4540 4540 4540 4540 4540 4540 4540 4540 4540 4540 4540 4540 4540 4540
410017559-17559 410017560-17560 410017561-17561 410017562-17562 410017564-17564 410017565-17565 410017567-17567 410017568-17568 410017569-17569 410017570-17570 410017574-17574 410017575-17575 410017584-17584 410017585-17585 410017589-17589 410017590-17590 410017594-17594 410017595-17595
4540
410017597-17597 BLOOD COMP(PLT PHER LRR P1RI)STOR
4540
410017598-17598 BLOOD COMP(PLT PHER LR PHRI)STOR-
4540
410017599-17599 BLOOD COMP(PLT PHER LRR PFDI)STOR
4540
410017600-17660 PLATELET PHERESIS L/R IRRAD PFDI
4540
410017600-17600 PLATELET PHERESIS L/R IRRAD PFDI
4540
410017601-17601 PLATELET PHERESIS L/R IRRAD PHRI
4540
410017602-17602 PLATELET PHERESIS L/R IRRAD P1RI
4540
410017604-17604 BLOOD COMP(PLT PHER LR PFTI)STOR-
4540
410017605-17605 PLATELET PHERESIS L/R IRRAD PFTI
4540
410017610-17610 PLASMA FROZEN PHERESIS CFFP
4540 4540 4540 4540
410017614-17614 410017615-17615 410017619-17619 410017620-17620
4540
410017630-17630 RBC L/R IRR IPCF AS-1
4540
410017631-17631 BLOOD COMP(RBC LR IRR) IPCF AS-1
4540 4540 4540 4540 4540 4540 4540 4540 4540
410017632-17632 410017633-17633 410017634-17634 410017635-17635 410017636-17636 410017637-17637 410017638-17638 410017639-17639 410017640-17640
BLOOD COMP(PLT PHER PH)STOR-PROC PLATLET PHERESIS PH PLATELET PHERESIS PHD PLATELET PHERESIS PHT BLOOD COMP(PLT PHER PH1)STOR-PROC PLATELET PHERESIS PH1 BLOOD COMP(PLT PHER PHT)STOR-PROC BLOOD COMP(PLT PHER PHD)STOR-PROC BLOOD COMP(PLT PHER IRR IPH)STORPLATELET PHERESIS IRRAD IPH BLOOD COMP(PLT PHER IRR IPHI)STOR PLATLET PHERESIS IRR IPHI BLOOD COMP(PLT PHER LR PH1R)STORPLATELET PHERESIS L/R PH1R BLOOD COMP(PLT PHER LR PHRD) STOR PLATELET PHERESIS L/R PHRD BLOOD COMP(PLT PHER LR PHRT) STOR PLATELET PHERESIS L/R PHRT
BLOOD COMP(PLT PHER PHDI)STOR-PRO PLATELET PHERESIS IRRAD PHDI BLOOD COMP(PLT PHER PHTI)STOR-PRO PLATELET PHERESIS IRRAD PHTI
RBC AS-1 PCI BLOOD COMP (RBC AS-1 PCI) STOR-PR RBC IRR AS-1 IPC1 BLOOD COMP(RBC IRR IPC1)STOR-PROC RBC CPD PC21 BLOOD COMP (RBC PC21 CPD)STOR-PRO RBC IRR CPD BLOOD COMP(RBC IRR P21I CPD)STOR RBC PC CPDA-1
Long Description Red blood cells, irradiated, each unit Red blood cells, leukocytes reduced, irradiated, each unit Red blood cells, leukocytes reduced, irradiated, each unit Red blood cells, leukocytes reduced, irradiated, each unit Red blood cells, leukocytes reduced, irradiated, each unit Platelets, pheresis, each unit Platelets, pheresis, each unit Platelets, pheresis, each unit Platelets, pheresis, each unit Platelets, pheresis, each unit Platelets, pheresis, each unit Platelets, pheresis, each unit Platelets, pheresis, each unit Platelets, pheresis, irradiated, each unit Platelets, pheresis, irradiated, each unit Platelets, pheresis, irradiated, each unit Platelets, pheresis, irradiated, each unit Platelets, pheresis, leukocytes reduced, each unit Platelets, pheresis, leukocytes reduced, each unit Platelets, pheresis, leukocytes reduced, each unit Platelets, pheresis, leukocytes reduced, each unit Platelets, pheresis, leukocytes reduced, each unit Platelets, pheresis, leukocytes reduced, each unit Platelets, pheresis, leukocytes reduced, irradiated, each unit Platelets, pheresis, leukocytes reduced, irradiated, each unit Platelets, pheresis, leukocytes reduced, irradiated, each unit Platelets, pheresis, leukocytes reduced, irradiated, each unit Platelets, pheresis, leukocytes reduced, irradiated, each unit Platelets, pheresis, leukocytes reduced, irradiated, each unit Platelets, pheresis, leukocytes reduced, irradiated, each unit Platelets, pheresis, leukocytes reduced, irradiated, each unit Platelets, pheresis, leukocytes reduced, irradiated, each unit Plasma, pooled multiple donor, solvent/detergent treated, frozen, each unit Platelets, pheresis, irradiated, each unit Platelets, pheresis, irradiated, each unit Platelets, pheresis, irradiated, each unit Platelets, pheresis, irradiated, each unit Red blood cells, leukocytes reduced, irradiated, each unit Red blood cells, leukocytes reduced, irradiated, each unit Red blood cells, each unit Red blood cells, each unit Red blood cells, irradiated, each unit Red blood cells, irradiated, each unit Red blood cells, each unit Red blood cells, each unit Red blood cells, irradiated, each unit Red blood cells, irradiated, each unit Red blood cells, washed, each unit
UB Revenue Code 381
CPT/HCPCS
Amount
P9038
609.71
390
P9040
57.50
380
P9040BL
681.59
390
P9040
57.50
381
P9040
681.59
399 384 384 384 399 384 399 399 399 384 399 384 399 384 399 384 399 384
P9034 P9034 P9034 P9034 P9034 P9034 P9034 P9034 P9036 P9036 P9036 P9036 P9035 P9035 P9035 P9035 P9035 P9035
57.50 1472.21 1472.21 1472.21 57.50 1472.21 57.50 57.50 57.50 1788.46 57.50 897.21 57.50 1673.46 57.50 1673.46 57.50 1673.46
399
P9037
57.50
399
P9037
57.50
399
P9037
57.50
384
P9037
566.59
384
P9037
1788.46
384
P9037
1788.46
384
P9037
954.71
399
P9037
57.50
384
P9037
1788.46
383
P9023
85.02
399 384 399 384
P9036 P9036 P9036 P9036
57.50 1587.21 57.50 1587.21
381
P9040
681.59
390
P9040
907.48
381 390 381 390 381 390 381 390 381
P9021 P9021 P9038 P9038 P9021 P9021 P9038 P9038 P9022
494.71 57.50 609.71 57.50 494.71 57.50 609.71 57.50 494.71
103 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4540 4540 4540 4540 4540 4540 4540 4540 4540
410017641-17641 410017642-17642 410017643-17643 410017644-17644 410017645-17645 410017646-17646 410017647-17647 410017648-17648 410017649-17649
4540
410017650-17650 RBC L/R IRR WCRI WASHED
4540
410017651-17651 BLOOD COMP(RBC L/R IRR WCRI)STOR-
4540 4540
410017652-17652 RBC L/R PCF CPDA-1 410017653-17653 BLOOD COMP (RBC LR PCF)STOR-PROC
4540
410017654-17654 RBC L/R IRR PCFI CPDA-1
4540
410017655-17655 BLOOD COMP(RBC L/R IRR PCFI)STOR-
4540 4540
410017656-17656 RBC L/R P21R CPD 410017657-17657 BLOOD COMP(RBC L/R P21R)STOR-PROC
4540
410017658-17658 RBC L/R IRR P2RI CPD
4540
410017659-17659 BLOOD COMP(RBC L/R IRR P2RI)STOR-
4540 4540 4540 4540 4540
410017661-17661 410017662-17662 410017663-17663 410017664-17664 410017665-17665
4540
410017666-17666 RBC L/R IRR P5FI AS-5
4540
410017667-17667 BLOOD COMP(RBC L/R IRR P5FI)STOR-
4540 4540
410017668-17668 BLOOD(WHOLE) L/R WB1R 410017669-17669 BLOOD COMP(BLOOD WHOLE LR WBIR) S
4540
410017670-17670 BLOOD(WHOLE) LR IRR I- CHRG ONLY
4540
410017671-17671 BLOOD COMP(BLD WHOLE LR IRR IW1R)
4540 4540 4540 4540 4540 4540 4540 4540
410017672-17672 410017673-17673 410017674-17674 410017675-17675 410017678-17678 410017679-17679 410017680-17680 410017681-17681
4540
410017682-17682 BLOOD(WHOLE) L/R IRR IWBR CPDA-1
4540
410017683-17683 BLOOD COMP(BLD WHOLE LR IRR IWBR)
4540 4540 4540 4540 4540 4540 4540 4540
410017684-17684 410017685-17685 410017686-17686 410017687-17687 410017688-17688 410017689-17689 410017690-17690 410017691-17691
4540
410017692-17692 RBC L/R ACD-A IRR PC - CHRG ONLY
4540
410017693-17693 BLOOD COMP(RBC LR ACD-A IRR)STOR
BLOOD COMP(RBC PC) STOR & PROC RBC IRR IPC CPDA-1 BLOOD COMP(RBC IRR IPC) STOR-PROC RBC WC WASHED BLOOD COMP(RBC WC) STOR-PROC RBC IRR WASHED IWPC BLOOD COMP(RBC IRR IWPC)STOR-PROC RBC L/R WCLR WASHED BLOOD COMP(RBC L/R WCLR)STOR-PROC
BLOOD COMP(RBC L/R R3DF)STOR-PROC RBC IRR R3DI AS-3 BLOOD COMP(RBC IRR R3DI) STOR-PRO RBC L/R PC5F AS-5 BLOOD COMP(RBC L/R PC5F)STOR-PROC
BLOOD(WHOLE) WB CPDA-1 BLOOD COMP(BLOOD WHOLE WB1)STOR-P BLOOD(WHOLE) IRR CPD IWB1 BLOOD COMP(BLOOD WHOLE IRR IWB1)S BLOOD(WHOLE) IRR IWB CPDA-1 BLOOD COMP(BLOOD WHOLE IRR IWB)ST BLOOD(WHOLE) L/R WBLR CPDA-1 BLOOD COMP(BLOOD WHOLE L/R WBLR)S
RBC L/R AS-1(03311) BLOOD COMP(RBC LR-03311)STOR-PROC RBC L/R AS-1(03820) BLOOD COMP(RBC LR-03820)STOR-PROC RBC L/R AS-1 - CHRG ONLY BLOOD COMP(RBC LR AS-1)STOR-PROC RBC L/R ACD-A PC CHARGE ONLY BLOOD COMP(RBC LR ACD-A)STOR-PROC
Long Description Red blood cells, each unit Red blood cells, irradiated, each unit Red blood cells, irradiated, each unit Red blood cells, washed, each unit Red blood cells, washed, each unit Red blood cells, irradiated, each unit Red blood cells, irradiated, each unit Red blood cells, leukocytes reduced, each unit Red blood cells, leukocytes reduced, each unit Red blood cells, leukocytes reduced, irradiated, each unit Red blood cells, leukocytes reduced, irradiated, each unit Red blood cells, leukocytes reduced, each unit Red blood cells, leukocytes reduced, each unit Red blood cells, leukocytes reduced, irradiated, each unit Red blood cells, leukocytes reduced, irradiated, each unit Red blood cells, leukocytes reduced, each unit Red blood cells, leukocytes reduced, each unit Red blood cells, leukocytes reduced, irradiated, each unit Red blood cells, leukocytes reduced, irradiated, each unit Red blood cells, leukocytes reduced, each unit Red blood cells, irradiated, each unit Red blood cells, irradiated, each unit Red blood cells, leukocytes reduced, each unit Red blood cells, leukocytes reduced, each unit Red blood cells, leukocytes reduced, irradiated, each unit Red blood cells, leukocytes reduced, irradiated, each unit Blood (whole), for transfusion, per unit Blood (whole), for transfusion, per unit Whole blood, leukocytes reduced, irradiated, each unit Whole blood, leukocytes reduced, irradiated, each unit Blood (whole), for transfusion, per unit Blood (whole), for transfusion, per unit Blood (whole), for transfusion, per unit Blood (whole), for transfusion, per unit Blood (whole), for transfusion, per unit Blood (whole), for transfusion, per unit Blood (whole), for transfusion, per unit Blood (whole), for transfusion, per unit Whole blood, leukocytes reduced, irradiated, each unit Whole blood, leukocytes reduced, irradiated, each unit Red blood cells, leukocytes reduced, each unit Red blood cells, leukocytes reduced, each unit Red blood cells, leukocytes reduced, each unit Red blood cells, leukocytes reduced, each unit Red blood cells, leukocytes reduced, each unit Red blood cells, leukocytes reduced, each unit Red blood cells, leukocytes reduced, each unit Red blood cells, leukocytes reduced, each unit Red blood cells, leukocytes reduced, irradiated, each unit Red blood cells, leukocytes reduced, irradiated, each unit
UB Revenue Code 390 381 390 381 390 381 390 381 390
CPT/HCPCS
Amount
P9021 P9038 P9038 P9022 P9022 P9038 P9038 P9016 P9016
57.50 609.71 57.50 494.71 57.50 609.71 57.50 566.59 57.50
381
P9040
681.59
390
P9040
57.50
381 390
P9016 P9016
566.59 57.50
381
P9040
681.59
390
P9040
57.50
381 390
P9016 P9016
566.59 57.50
381
P9040
681.59
390
P9040
57.50
390 381 390 381 390
P9016 P9038 P9038 P9016 P9016
57.50 609.71 57.50 566.59 57.50
381
P9040
681.59
390
P9040
57.50
382 390
P9010 P9010
494.71 57.50
382
P9056
546.46
390
P9056
57.50
382 390 382 390 382 390 382 390
P9010 P9010 P9010 P9010 P9010 P9010 P9010 P9010
494.71 57.50 609.71 57.50 609.71 57.50 566.59 57.50
382
P9056
681.59
382
P9056
57.50
381 390 381 390 381 390 381 390
P9016 P9016 P9016 P9016 P9016 P9016 P9016 P9016
566.59 57.50 566.59 57.50 566.59 57.50 566.59 57.50
381
P9040
681.59
390
P9040
57.50
104 of 167 Updated on 1/22/2019
Revenue Center 4540 4540 4570
CDM Number
CDM Description
410017694-17694 RBC L/R CPDA-1 LV PC-CHRG ONLY 410017695-17695 BLOOD COMP(RBC LR CPDA-1)STOR-PRO 414000203-203 XR HEART CATH LEFT
4570
414000207-207 XR HEART CATH R/L COMBINED
4570
414000212-212 XR HEART CATH RIGHT (CONGENITAL)
4570
414000216-216 XR CL OMNIPAQUE 240 PER ML
4570
414000217-217 XR CL VISIPAQUE 320 PER ML
4570
414000218-218 XR CL ISOVUE 370 PER ML
4570 4570
414028158-28158 S EMBOLIZATION 2 414028159-28159 S EMBOLIZATION 3
4570
414028175-28175 S SPECIAL CATHETER 1
4570
414028176-28176 S SPECIAL CATHETER 2
4570
414028179-28179 S SPECIAL CATHETER 3
4570
414028212-28212 S II DRAPE
4570
414028215-28215 S VENA CAVA 3
4570 4570
414028226-28226 S MANIFOLDS 414028246-28246 S DRAINAGE CATH 2
4570
414028302-28302 S DRAINAGE BAG 2
4570 4570
414028307-28307 S VINYL CONNECTING TUBE 414028996-28996 TRANSLUM ANGIOPL NON-LASER CATH
4570
414036005-36005 XR INJECT VENOGRAM PROC ROOM
4570
414036010-36010 XR CATH VENA CAVA
4570
414036013-36013 MAIN PULMONARY ARTERY CATH
4570
414036140-36140 XR NON-SELECTIVE EXT VESSEL CATH
4570
414036200-36200 XR CATH AORTA
4570
414036215-36215 XR 1ST ORDER VESSEL ABOVE DIAPHRA
4570
414036216-36216 2ND ORDER VESSEL ABOVE DIAPHRAGM
4570
414036217-36217 XR 3RD ORDER VESS ABOVE DIAPHRAGM
4570
414036222-36222 XR PL CT CARO/INOM CER LT
Long Description Red blood cells, leukocytes reduced, each unit Red blood cells, leukocytes reduced, each unit Left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed Combined right and left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed Right heart catheterization, for congenital cardiac anomalies Low osmolar contrast material, 200-299 mg/ml iodine concentration, per ml Low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml Low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml
UB Revenue Code 381 390
CPT/HCPCS P9016 P9016
566.59 57.50
481
93452
9911.43
481
93453
9911.43
481
93530
9911.43
255
Q9966
5.66
255
Q9967
3.08
255
Q9967
3.08
278 278 Catheter, guiding (may include infusion/perfusion capability) Catheter, guiding (may include infusion/perfusion capability) Catheter, guiding (may include infusion/perfusion capability)
232.00 232.00
272
C1887
533.83
272
C1887
533.83
272
C1887
533.83
272 Retrieval device, insertable (used to retrieve fractured medical devices) Catheter, drainage Vacuum drainage collection unit and tubing kit, including all supplies needed for collection unit change, for use with implanted catheter, each Catheter, occlusion Injection procedure for extremity venography (including introduction of needle or intracatheter) Introduction of catheter, superior or inferior vena cava Introduction of catheter, right heart or main pulmonary artery Introduction of needle or intracatheter, upper or lower extremity artery Introduction of catheter, aorta Selective catheter placement, arterial system; each first order thoracic or brachiocephalic branch, within a vascular family Selective catheter placement, arterial system; initial second order thoracic or brachiocephalic branch, within a vascular family Selective catheter placement, arterial system; initial third order or more selective thoracic or brachiocephalic branch, within a vascular family Selective catheter placement, common carotid or innominate artery, unilateral, any approach, with angiography of the ipsilateral extracranial carotid circulation and all associated radiological supervision and interpretation, includes angiography of the cervicocerebral arch, when performed
Amount
530.88
278
C1773
769.50
272 272
C1729
196.06 561.21
272
A7048
117.60
272 272
C2628
55.44 987.00
361
36005
1412.95
361
36010
3391.32
361
36013
2137.91
361
36140
4132.56
361
36200
2888.66
361
36215
4890.17
361
36216
5337.26
361
36217
2161.36
361
36222LT
8724.69
105 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4570
414036223-36223 XR PL CT CARO/INOM EXT LT
4570
414036225-36225 XR PL CT SUBCLAVIAN ART LT
4570
414036226-36226 XR PL CT VERTEBRAL ART
4570
414036245-36245 XR 1ST ORDER VESSEL BELOW DIAPHRA
4570
414036246-36246 XR INTL 2ND ORDER ABD,PELV,LOW
4570
414036558-36558 INS TUNNELED CV CATH AGE 5/>
4570
414036569-36569 XR PICC LINE INSERT 5YR AND OLDER
4570
414036581-36581 XR REPLACE TUNNELED CV CATH
4570
414036584-36584 XR REPLACE PICC CATH
4570
414036589-36589 XR REMOVE TNL CV CATH
4570
414036598-36598 PORT PATENCY DYE STUDY
4570
414037193-37193 XR_EM ENDOVAS VENA CAVA FLTR
4570
414037197-37197 XR REMOVE INTRVAS FRGN BDY
Long Description Selective catheter placement, common carotid or innominate artery, unilateral, any approach, with angiography of the ipsilateral intracranial carotid circulation and all associated radiological supervision and interpretation, includes angiography of the extracranial carotid and cervicocerebral arch, when performed Selective catheter placement, subclavian or innominate artery, unilateral, with angiography of the ipsilateral vertebral circulation and all associated radiological supervision and interpretation, includes angiography of the cervicocerebral arch, when performed Selective catheter placement, vertebral artery, unilateral, with angiography of the ipsilateral vertebral circulation and all associated radiological supervision and interpretation, includes angiography of the cervicocerebral arch, when performed Selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery branch, within a vascular family Selective catheter placement, arterial system; initial second order abdominal, pelvic, or lower extremity artery branch, within a vascular family Insertion of tunneled centrally inserted central venous catheter, without subcutaneous port or pump; age 5 years or older Insertion of peripherally inserted central venous catheter (PICC), without subcutaneous port or pump, without imaging guidance; age 5 years or older Replacement, complete, of a tunneled centrally inserted central venous catheter, without subcutaneous port or pump, through same venous access Replacement, complete, of a peripherally inserted central venous catheter (PICC), without subcutaneous port or pump, through same venous access, including all imaging guidance, image documentation, and all associated radiological supervision and interpretation required to perform the replacement Removal of tunneled central venous catheter, without subcutaneous port or pump Contrast injection(s) for radiologic evaluation of existing central venous access device, including fluoroscopy, image documentation and report Retrieval (removal) of intravascular vena cava filter, endovascular approach including vascular access, vessel selection, and radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance (ultrasound and fluoroscopy), when performed Transcatheter retrieval, percutaneous, of intravascular foreign body (eg, fractured venous or arterial catheter), includes radiological supervision and interpretation, and imaging guidance (ultrasound or fluoroscopy), when performed
UB Revenue Code
CPT/HCPCS
361
36223LT
8744.83
361
36225LT
8724.69
361
36226
14301.63
361
36245
4680.09
361
36246
4317.39
361
36558
6910.14
361
36569
3096.70
361
36581
7259.51
361
36584
3220.76
361
36589
1768.20
361
36598
614.05
361
37193
4462.50
361
37197
8777.06
Amount
106 of 167 Updated on 1/22/2019
UB Revenue Code
CPT/HCPCS
481
37241LT
36787.02
481
37242LT
36787.02
481
37243LT
36787.02
414037244-37244 XR VASC EMBOLIZE/OCCLUDE BLD LT
Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; for arterial or venous hemorrhage or lymphatic extravasation
481
37244LT
36787.02
4570
414043750-43750 XR GASTROSTOMY TUBE PLACEMENT
Naso- or oro-gastric tube placement, requiring physician's skill and fluoroscopic guidance (includes fluoroscopy, image documentation and report)
361
43752
450.10
4570
414049423-49423 XR ABSCESS CATH EXCHANGE
361
49423
4733.61
4570
414050398-50398 XR CHANGE NEPHROSTOMY TUBE
361
50398
4733.61
4570
414061624-61624 XR TC EMBOLIZ/OCCUL CENT NERV SY
360
61624
2519.06
361
61626
30220.05
361
49440
3650.97
323
75605
8744.83
323
75625
8744.83
323
75705
8744.83
323
75710RT
8328.41
323
75726
8744.83
323
75736
8744.83
323
75774
1935.35
Revenue Center
CDM Number
CDM Description
4570
414037241-37241 XR VASC EMBOLIZE/OCCLUDE VEN LT
4570
414037242-37242 XR VASC EMBOLIZE/OCCLUDE ART LT
4570
414037243-37243 XR VASC EMBOLIZE/OCCLUDE ORGAN-LT
4570
4570
414061626-61626 XR TRANSCATHETER EMBOLIZ HEAD
4570
414074350-74350 XR PERCUT GASTROSTOMY TUBE PLACMN
4570
414075605-75605 XR AORTOGRAM THORACIC/AORTIC ARCH
4570
414075625-75625 XR AORTOGRAM ABDOMINAL
4570
414075705-75705 XR ANGIO SPINAL
4570
414075711-75711 XR ANGIO EXTREMITY RT
4570
414075726-75726 XR ANGIO VISCERAL SELECTIVE
4570
414075736-75736 XR ANGIO PELVIC SELECTIVE
4570
414075774-75774 XR ANGIO EACH ADDTNL VESSE
Long Description Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; venous, other than hemorrhage (eg, congenital or acquired venous malformations, venous and capillary hemangiomas, varices, varicoceles) Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; arterial, other than hemorrhage or tumor (eg, congenital or acquired arterial malformations, arteriovenous malformations, arteriovenous fistulas, aneurysms, pseudoaneurysms) Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; for tumors, organ ischemia, or infarction
Exchange of previously placed abscess or cyst drainage catheter under radiological guidance Change of nephrostomy or pyelostomy tube Transcatheter permanent occlusion or embolization (eg, for tumor destruction, to achieve hemostasis, to occlude a vascular malformation), percutaneous, any method; central nervous system (intracranial, spinal cord) Transcatheter permanent occlusion or embolization (eg, for tumor destruction, to achieve hemostasis, to occlude a vascular malformation), percutaneous, any method; non-central nervous system, head or neck (extracranial, brachiocephalic branch) Insertion of gastrostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report Aortography, thoracic, by serialography, radiological supervision and interpretation Aortography, abdominal, by serialography, radiological supervision and interpretation Angiography, spinal, selective, radiological supervision and interpretation Angiography, extremity, unilateral, radiological supervision and interpretation Angiography, visceral, selective or supraselective (with or without flush aortogram), radiological supervision and interpretation Angiography, pelvic, selective or supraselective, radiological supervision and interpretation Angiography, selective, each additional vessel studied after basic examination, radiological supervision and interpretation
Amount
107 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4570
414075809-75809 XR SHUNTOGRAM INDWELLING
4570
414075827-75827 XR VENA CAVAGRAM SUPERIOR
4570
414075894-75894 XR EMBOLIZATION TRANSCATHETER
4570
414075898-75898 XR ANGIO TRANSCATHETER THERAPY FU
Long Description Shuntogram for investigation of previously placed indwelling nonvascular shunt (eg, LeVeen shunt, ventriculoperitoneal shunt, indwelling infusion pump), radiological supervision and interpretation Venography, caval, superior, with serialography, radiological supervision and interpretation Transcatheter therapy, embolization, any method, radiological supervision and interpretation Angiography through existing catheter for follow-up study for transcatheter therapy, embolization or infusion, other than for thrombolysis
UB Revenue Code
CPT/HCPCS
320
75809
279.07
320
75827
2820.69
320
75894
10186.75
320
75898
1303.85
320
75984
995.95
Amount
4570
414075984-75984 XR CHANGE PERCUTANEOUS CATHETER
Change of percutaneous tube or drainage catheter with contrast monitoring (eg, genitourinary system, abscess), radiological supervision and interpretation
4570
414076080-76080 XR FISTULOGRAM OR SINUS TRACT
Radiologic examination, abscess, fistula or sinus tract study, radiological supervision and interpretation
320
76080
1006.37
414084224-84224 XR PL CT CARO ART RT
Selective catheter placement, internal carotid artery, unilateral, with angiography of the ipsilateral intracranial carotid circulation and all associated radiological supervision and interpretation, includes angiography of the extracranial carotid and cervicocerebral arch, when performed
361
36224RT
14301.63
4570
414085222-85222 XR PL CT CARO/INOM CER RT
Selective catheter placement, common carotid or innominate artery, unilateral, any approach, with angiography of the ipsilateral extracranial carotid circulation and all associated radiological supervision and interpretation, includes angiography of the cervicocerebral arch, when performed
361
36222RT
8744.83
4570
414093451-93451 XR HEART CATH RT
Right heart catheterization including measurement(s) of oxygen saturation and cardiac output, when performed
481
93451
9847.71
414093452-93452 XR HRT CATH W/VENTRCLGRPHY LT
Left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed
481
93452
9847.71
481
37241RT
36787.02
481
37242RT
36787.02
481
37243RT
36787.02
4570
4570
4570
414097241-97241 XR VASC EMBOLIZE/OCCLUDE VEN RT
4570
414097242-97242 XR VASC EMBOLIZE/OCCLUDE ART RT
4570
414097243-97243 XR VASC EMBOLIZE/OCCLUDE ORGAN-RT
Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; venous, other than hemorrhage (eg, congenital or acquired venous malformations, venous and capillary hemangiomas, varices, varicoceles) Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; arterial, other than hemorrhage or tumor (eg, congenital or acquired arterial malformations, arteriovenous malformations, arteriovenous fistulas, aneurysms, pseudoaneurysms) Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; for tumors, organ ischemia, or infarction
108 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4570
414097244-97244 XR VASC EMBOLIZE/OCCLUDE BLD RT
4570 4570 4570 4570 4570 4570 4570 4570 4570 4570 4570 4570 4570 4570 4570 4570 4570 4570 4570 4570 4570 4570
457001000-1000 457001001-1001 457001002-1002 457001003-1003 457001004-1004 457001005-1005 457001006-1006 457001007-1007 457001008-1008 457001009-1009 457001010-1010 457001011-1011 457001012-1012 457001013-1013 457001014-1014 457001015-1015 457001016-1016 457001017-1017 457001018-1018 457001019-1019 457001020-1020 457001021-1021
4570
457010030-10030 GUIDE CATHET FLUID DRAINAGE
4570
457010160-10160 PUNCT ASP - ABSC HEMAT CYST
4570
457022513-22513 PERC VERTEBRAL AUGMENT, THORACIC
4570
457022514-22514 PERC VERTEBRAL AUGMENT, LUMBAR
4570 4570
457022899-22899 UNLISTED PROCEDURE SPINE 457030200-30200 IR RENAL BIOPSY PERC, RIGHT
4570
457032550-32550 INSERT PLEURAL CATH
4570
457035045-35045 XR REP ANEURYSM, RAD/ULN ART-BOTH
4570
457036561-36561 INSERT TUNNELED CVAD W PORT >=5YR
4570
457036590-36590 REM TUNNELED CVAD W PORT/PUMP
4570
457036597-36597 REPOSIT CVC W FLUORO
THROMBECTOMY SYSTEM 106608-001 THROMBECTOMY SYSTEM 114610-001 THROMBECTOMY SYSTEM 111303-001 THROMBECTOMY SYSTEM 105041-001 THROMBECTOMY SYSTEM 106553-001 THROMBECTOMY SYSTEM 109676-001 THROMBECTOMY SYSTEM 109681-001 IMAGING CATHETER H7493932800180 IMAGING CATHETER H7495181160 SLIM IMPLANTABLE PORT 1618000 EMB PROTCT SYS CN-SPD2-US-040-190 EMBOLIC PROTECT SYS H749390711900 OCCL BALLOON CATH M003SRC03150 OCCL BALLOON CATH M003SRC04150 OCCL BALLOON CATH M003SRC04200 OCCL BALLOON CATH M003SRC05200 OCCL BALLOON CATH M003SRC05300 OCCL BALLOON CATH M003SSC07150 TREVO XP PROVUE RETRIEVER 80051 TREVO XP PROVUE RETRIEVER 93067 EMBOLIC PROTECT SYS H749501001500 EMBOLIC PROTECT SYS H749201001900
Long Description
UB Revenue Code
CPT/HCPCS
Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; for arterial or venous hemorrhage or lymphatic extravasation
481
37244RT
36787.02
278 278 278 278 278 278 278 278 278 278 278 278 278 278 278 278 278 278 278 278 278 278
C1757 C1757 C1757 C1757 C1757 C1757 C1757 C1753 C1753 C1788 C1884 C1884 C2628 C2628 C2628 C2628 C2628 C2628 C1757 C1757 C1884 C1884
5220.00 9450.00 6375.00 5025.00 5010.00 4890.00 5190.00 1971.00 1971.00 1398.00 3885.00 3885.00 3156.90 3156.90 3156.90 3156.90 3156.90 3156.90 23025.60 23025.60 240.00 3885.00
320
10030
1885.74
320
10160
1023.54
320
22513
18264.42
320
22514
18264.42
320 320
22899 50200RT
698.97 4718.16
320
32550
10013.52
481
3504550
14927.52
320
36561
8257.11
361
36590
2393.01
329
36597
2393.01
Catheter, thrombectomy/embolectomy Catheter, thrombectomy/embolectomy Catheter, thrombectomy/embolectomy Catheter, thrombectomy/embolectomy Catheter, thrombectomy/embolectomy Catheter, thrombectomy/embolectomy Catheter, thrombectomy/embolectomy Catheter, intravascular ultrasound Catheter, intravascular ultrasound Port, indwelling (implantable) Embolization protective system Embolization protective system Catheter, occlusion Catheter, occlusion Catheter, occlusion Catheter, occlusion Catheter, occlusion Catheter, occlusion Catheter, thrombectomy/embolectomy Catheter, thrombectomy/embolectomy Embolization protective system Embolization protective system Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst), soft tissue (eg, extremity, abdominal wall, neck), percutaneous Puncture aspiration of abscess, hematoma, bulla, or cyst 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 imaging guidance; thoracic 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 imaging guidance; lumbar Unlisted procedure, spine Renal biopsy; percutaneous, by trocar or needle Insertion of indwelling tunneled pleural catheter with cuff Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, radial or ulnar artery Insertion of tunneled centrally inserted central venous access device, with subcutaneous port; age 5 years or older Removal of tunneled central venous access device, with subcutaneous port or pump, central or peripheral insertion Repositioning of previously placed central venous catheter under fluoroscopic guidance
Amount
109 of 167 Updated on 1/22/2019
Revenue Center
4570
4570
Long Description
UB Revenue Code
CPT/HCPCS
457036901-36901 INTRO CATH, DIALYSIS CIRCUIT
Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s), injection(s) of contrast, all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava, fluoroscopic guidance, radiological supervision and interpretation and image documentation and report;
320
36901
2393.01
457036903-36903 INTRO CATH DIAL CIRC/STNT PERIPH
Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s), injection(s) of contrast, all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava, fluoroscopic guidance, radiological supervision and interpretation and image documentation and report; with transcatheter placement of intravascular stent(s), peripheral dialysis segment, including all imaging and radiological supervision and interpretation necessary to perform the stenting, and all angioplasty within the peripheral dialysis segment
320
36903
34112.82
320
36904
16877.97
320
36906
51706.14
481
36907
7960.41
320
37185
2572.23
CDM Number
CDM Description
4570
457036904-36904 THRMBC/NFS DIALYSIS CIRCUIT
4570
457036906-36906 THRMBC/NFS DIAL CIRC/STNT PERIPH
4570
457036907-36907 BALO ANGIOP CTR DIALYSIS SEG
4570
457037185-37185 IR ART M-THRMBC PRIMARY SBSQ VSSL
Percutaneous transluminal mechanical thrombectomy and/or infusion for thrombolysis, dialysis circuit, any method, including all imaging and radiological supervision and interpretation, diagnostic angiography, fluoroscopic guidance, catheter placement(s), and intraprocedural pharmacological thrombolytic injection(s); Percutaneous transluminal mechanical thrombectomy and/or infusion for thrombolysis, dialysis circuit, any method, including all imaging and radiological supervision and interpretation, diagnostic angiography, fluoroscopic guidance, catheter placement(s), and intraprocedural pharmacological thrombolytic injection(s); with transcatheter placement of intravascular stent(s), peripheral dialysis segment, including all imaging and radiological supervision and interpretation necessary to perform the stenting, and all angioplasty within the peripheral dialysis circuit Transluminal balloon angioplasty, central dialysis segment, performed through dialysis circuit, including all imaging and radiological supervision and interpretation required to perform the angioplasty Primary percutaneous transluminal mechanical thrombectomy, noncoronary, non-intracranial, arterial or arterial bypass graft, including fluoroscopic guidance and intraprocedural pharmacological thrombolytic injection(s); second and all subsequent vessel(s) within the same vascular family (List separately in addition to code for primary mechanical thrombectomy procedure)
Amount
110 of 167 Updated on 1/22/2019
Revenue Center
4570
CDM Number
CDM Description
457037186-37186 IR ART THROMBECTOMY 2NDARY ADD-ON
4570
457037187-37187 IR VENOUS MECH THROMBECTOMY-BILAT
4570
457037188-37188 IR VENOUS M-THRMBC REPEAT-BILAT
4570
457037215-37215 XR TRANSCATH STNT CCA W/EPS, BI
4570
457037221-37221 IR ILIAC REVASC W/STENT
4570
457037223-37223 IR ILIAC REVASC W/STENT ADD-ON
4570
457037226-37226 IR FEM/POPL REVASC W/STENT
4570
457037230-37230 IR TIB/PERO REVASC W/STENT
4570
457037234-37234 IR TIB/PERO REVASC W/STENT ADD-ON
4570
457040200-40200 IR RENAL BIOPSY PERC, LEFT
4570
457045045-45045 XR REP ANEURYSM, RAD/ULN ART-LT
4570
457047187-47187 IR VENOUS MECH THROMBECTOMY-LEFT
Long Description
UB Revenue Code
CPT/HCPCS
Secondary percutaneous transluminal thrombectomy (eg, nonprimary mechanical, snare basket, suction technique), noncoronary, nonintracranial, arterial or arterial bypass graft, including fluoroscopic guidance and intraprocedural pharmacological thrombolytic injections, provided in conjunction with another percutaneous intervention other than primary mechanical thrombectomy
320
37186
5347.71
320
3718750
17797.71
320
3718850
8724.69
320
3721550
3496.77
481
37221
36787.02
481
37223
546.96
481
37226
36787.02
481
37230
56072.01
481
37234
707.04
320
50200LT
4718.16
481
35045LT
14927.52
320
37187LT
17797.71
Percutaneous transluminal mechanical thrombectomy, vein(s), including intraprocedural pharmacological thrombolytic injections and fluoroscopic guidance Percutaneous transluminal mechanical thrombectomy, vein(s), including intraprocedural pharmacological thrombolytic injections and fluoroscopic guidance, repeat treatment on subsequent day during course of thrombolytic therapy Transcatheter placement of intravascular stent(s), cervical carotid artery, open or percutaneous, including angioplasty, when performed, and radiological supervision and interpretation; with distal embolic protection Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed Renal biopsy; percutaneous, by trocar or needle Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, radial or ulnar artery Percutaneous transluminal mechanical thrombectomy, vein(s), including intraprocedural pharmacological thrombolytic injections and fluoroscopic guidance
Amount
111 of 167 Updated on 1/22/2019
Revenue Center
UB Revenue Code
CPT/HCPCS
320
37188LT
8724.69
320
37215LT
3496.77
481
37252
3903.57
481
37253
586.38
481
47490
10189.17
320
47531
10182.18
457047536-47536 XR EXCHANGE BILIARY DRN CATH, PRC
Exchange of biliary drainage catheter (eg, external, internal-external, or conversion of internal-external to external only), percutaneous, including diagnostic cholangiography when performed, imaging guidance (eg, fluoroscopy), and all associated radiological supervision and interpretation
361
47536
7711.68
457047539-47539 XR PLMT BIL DUCT STNT WO CATH PRC
Placement of stent(s) into a bile duct, percutaneous, including diagnostic cholangiography, imaging guidance (eg, fluoroscopy and/or ultrasound), balloon dilation, catheter exchange(s) and catheter removal(s) when performed, and all associated radiological supervision and interpretation; new access, without placement of separate biliary drainage catheter
361
47539
15710.55
320
49185
1885.74
329
49460
2602.23
320
50433
5934.96
CDM Number
CDM Description
4570
457047188-47188 IR VENOUS M-THRMBC REPEAT-LEFT
4570
457047215-47215 XR TRANSCATH STENT CCA W/EPS, LT
4570
457047252-47252 IR IVUS NONCORONARY 1ST VESSEL
4570
457047253-47253 IR IVUS NONCORONARY EA ADDL
4570
457047490-47490 PERCUTANEOUS CHOLECYSTOSTOMY
4570
457047531-47531 XR INJ FOR CHOLANGIOGRAM, EXIST
4570
4570
4570
457049185-49185 SCLEROTX FLUID COLLECTION
4570
457049460-49460 FIX G/COLON TUBE W/DEVICE
4570
457050433-50433 XR PLMT NEPHROURETERAL CATH, NEW
Long Description Percutaneous transluminal mechanical thrombectomy, vein(s), including intraprocedural pharmacological thrombolytic injections and fluoroscopic guidance, repeat treatment on subsequent day during course of thrombolytic therapy Transcatheter placement of intravascular stent(s), cervical carotid artery, open or percutaneous, including angioplasty, when performed, and radiological supervision and interpretation; with distal embolic protection Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation; initial noncoronary vessel Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation; each additional noncoronary vessel Cholecystostomy, percutaneous, complete procedure, including imaging guidance, catheter placement, cholecystogram when performed, and radiological supervision and interpretation Injection procedure for cholangiography, percutaneous, complete diagnostic procedure including imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation; existing access
Sclerotherapy of a fluid collection (eg, lymphocele, cyst, or seroma), percutaneous, including contrast injection(s), sclerosant injection(s), diagnostic study, imaging guidance (eg, ultrasound, fluoroscopy) and radiological supervision and interpretation when performed Mechanical removal of obstructive material from gastrostomy, duodenostomy, jejunostomy, gastrojejunostomy, or cecostomy (or other colonic) tube, any method, under fluoroscopic guidance including contrast injection(s), if performed, image documentation and report Placement of nephroureteral catheter, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation, new access
Amount
112 of 167 Updated on 1/22/2019
Revenue Center
UB Revenue Code
CPT/HCPCS
320
50435
1857.78
320
50693
9438.78
457050694-50694 XR PLMT URE STENT PRQ WO CATH
Placement of ureteral stent, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg, ultrasound and/or fluoroscopy), and all associated radiological supervision and interpretation; new access, without separate nephrostomy catheter
361
50694
9438.78
457050695-50695 XR PLMT URETERAL STENT PRQ W CATH
Placement of ureteral stent, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg, ultrasound and/or fluoroscopy), and all associated radiological supervision and interpretation; new access, with separate nephrostomy catheter
361
50695
9438.78
481
35045RT
14927.52
320
37187RT
17797.71
320
37188RT
8724.69
320
37215RT
3496.77
320 320
5020050 60300
4718.16 1885.74
481
77002
967.26
481
93454
9911.43
481
93458
9911.43
CDM Number
CDM Description
4570
457050435-50435 CHANGE NEPHROSTOMY CATHETER
4570
457050693-50693 XR PLMT URE STNT PRC, EXIST NEPH
4570
4570
4570
457055045-55045 XR REP ANEURYSM, RAD/ULN ART-RT
4570
457057187-57187 IR VENOUS MECH THROMBECTOMY-RIGHT
4570
457057188-57188 IR VENOUS M-THRMBC REPEAT-RIGHT
4570
457057215-57215 XR TRANSCATH STENT CCA W/EPS, RT
4570 4570
457060200-60200 IR RENAL BIOPSY PERC, BILATERAL 457060300-60300 ASPIR/INJ THYROID CYST
4570
457077002-77002 XR FLUORO GUID NDL LOCALIZATION
4570
457093454-93454 XR CORONARY ANGIOGRAPHY S&I
4570
457093458-93458 XR LT HRT ARTERY/VENTRICLE ANGIO
Long Description Exchange nephrostomy catheter, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation Placement of ureteral stent, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg, ultrasound and/or fluoroscopy), and all associated radiological supervision and interpretation; pre-existing nephrostomy tract
Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, radial or ulnar artery Percutaneous transluminal mechanical thrombectomy, vein(s), including intraprocedural pharmacological thrombolytic injections and fluoroscopic guidance Percutaneous transluminal mechanical thrombectomy, vein(s), including intraprocedural pharmacological thrombolytic injections and fluoroscopic guidance, repeat treatment on subsequent day during course of thrombolytic therapy Transcatheter placement of intravascular stent(s), cervical carotid artery, open or percutaneous, including angioplasty, when performed, and radiological supervision and interpretation; with distal embolic protection Renal biopsy; percutaneous, by trocar or needle Aspiration and/or injection, thyroid cyst Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device) Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed
Amount
113 of 167 Updated on 1/22/2019
Revenue Center
UB Revenue Code
CPT/HCPCS
481
93460
9911.43
331
96420
1041.51
331
96450
977.49
457099152-99152 MOD SED SAME PHYS/QHP >=5 YRS
Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older
372
99152
285.47
457099153-99153 MOD SED SAME PHYS/QHP EA ADDT 15M
Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List separately in addition to code for primary service)
372
99153
132.74
457099156-99156 MOD SED OTHER PHYS/QHP >=5 YRS
Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; initial 15 minutes of intraservice time, patient age 5 years or older
372
99156
285.47
457099157-99157 MOD SED OTH PHYS/QHP EA ADDT 15M
Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; each additional 15 minutes intraservice time (List separately in addition to code for primary service)
372
99157
132.74
730
93005
197.73
730
93005
197.73
483
93307
1538.32
483
93308
837.76
731
93225
279.30
CDM Number
CDM Description
4570
457093460-93460 XR R&L HRT ART/VENTRICLE ANGIO
4570
457096420-96420 IR CHEMO ADMIN, IA, PUSH
4570
457096450-96450 CHEMO CNS (INTRATHECAL) W LP
4570
4570
4570
4570
4590
411003005-3005 12 LEAD EKG, TRACING ONLY
4590
459093005-93005 12 LEAD ECG, TRACING ONLY
4592
411102723-2723 TTE W/O DOPPLER COMPLETE
4592
411102724-2724 TTE 2D/FOLLOW UP OR LIMITED
4592
411103275-3275 ECG UP TO 48 HRS RECORDING
Long Description Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed Chemotherapy administration, intra-arterial; push technique Chemotherapy administration, into CNS (eg, intrathecal), requiring and including spinal puncture
Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, without spectral or color Doppler echocardiography Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, follow-up or limited study External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; recording (includes connection, recording, and disconnection)
Amount
114 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4592
411103325-3325 DOPPLER COLOR FLOW VELOCITY
4592
411106624-6624 ECHO T THORAC 2D/LTD FU
4592
411106995-6995 TTE W/DOPPLER COMPLETE
4592
411106996-6996 DOPPLER ECHOCARDIOGRAM TECH
4592
411106997-6997 ECHO 2D COMPLETE
4592
411106999-6999 ECHO 2D LMTD KFMG
4592
411107001-7001 STRESS TTE COMPLETE
4592
411107002-7002 ECHO TRANSESOPHAGEAL COMPLETE
4592
411107006-7006 TTE W/DOPPLER COMPLETE
4592
459208921-8921 TTE W/WO FOL W CONTR CONG, COMPL
4592
459208924-8924 2D TTE W/WO FOL W/CONT F-UP/LMTD
4592
459208925-8925 TEE 2D W/WO FOL W CONTRAST, COMPL
4592
459208926-8926 TEE W/WO FOL W/CONT CONG, GLOBAL
Long Description Doppler echocardiography color flow velocity mapping (List separately in addition to codes for echocardiography) Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, follow-up or limited study Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler echocardiography, and with color flow Doppler echocardiography Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in addition to codes for echocardiographic imaging); complete Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, without spectral or color Doppler echocardiography Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, follow-up or limited study Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report; including performance of continuous electrocardiographic monitoring, with supervision by a physician or other qualified health care professional Echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-mode recording); including probe placement, image acquisition, interpretation and report Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler echocardiography, and with color flow Doppler echocardiography Transthoracic echocardiography with contrast, or without contrast followed by with contrast, for congenital cardiac anomalies; complete Transthoracic echocardiography with contrast, or without contrast followed by with contrast, real-time with image documentation (2D), includes M-mode recording, when performed, follow-up or limited study Transesophageal echocardiography (TEE) with contrast, or without contrast followed by with contrast, real time with image documentation (2D) (with or without M-mode recording); including probe placement, image acquisition, interpretation and report Transesophageal echocardiography (TEE) with contrast, or without contrast followed by with contrast, for congenital cardiac anomalies; including probe placement, image acquisition, interpretation and report
UB Revenue Code
CPT/HCPCS
483
93325
459.36
483
93308
837.76
483
93306
1487.49
480
93320
541.88
480
93307
705.81
480
93308
948.75
483
93351
1538.32
483
93312
2200.80
483
93306
1538.32
483
C8921
2384.97
483
C8924
1491.93
483
C8925
2297.79
483
C8926
2297.79
Amount
115 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4592
459208928-8928 STRESS TTE W/WO FOL W CONTRAST
4592
459208929-8929 TTE W DOPPLER/CONTRAST, COMPLETE
4592
459208930-8930 STRESS TTE W CONTRAST, COMPLETE
4592
459293017-93017 CVSLR STRESS TEST, TRACING ONLY
4592
459293226-93226 ECG UP TO 48 HR SCAN ANALYSIS RPT
4592
459293303-93303 TTE CONGENITAL ABN, COMPLETE
4592
459293308-93308 TTE F-UP OR LMTD
4592
459293315-93315 TEE CONGENITAL ABN, GLOBAL
4592
459293320-93320 DOPPLER ECHO, COMPLETE
4592
459293325-93325 DOPPLER COLOR FLOW
4592
459293350-93350 TTE 2D STRESS W INT & RPT
4592
459299152-99152 MOD SED SAME PHYS/QHP >=5 YRS
Long Description Transthoracic echocardiography with contrast, or without contrast followed by with contrast, real-time with image documentation (2D), includes M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report Transthoracic echocardiography with contrast, or without contrast followed by with contrast, real-time with image documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler echocardiography, and with color flow Doppler echocardiography Transthoracic echocardiography, with contrast, or without contrast followed by with contrast, real-time with image documentation (2D), includes M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report; including performance of continuous electrocardiographic monitoring, with physician supervision Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; tracing only, without interpretation and report External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; scanning analysis with report Transthoracic echocardiography for congenital cardiac anomalies; complete Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, follow-up or limited study Transesophageal echocardiography for congenital cardiac anomalies; including probe placement, image acquisition, interpretation and report Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in addition to codes for echocardiographic imaging); complete Doppler echocardiography color flow velocity mapping (List separately in addition to codes for echocardiography) Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report; Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older
UB Revenue Code
CPT/HCPCS
483
C8928
2297.79
483
C8929
2297.79
483
C8930
2297.79
482
93017
812.58
731
93226
349.86
483
93303
1572.93
483
93308
790.20
483
93315
1572.93
483
93320
730.34
483
93325
459.36
483
93350
1572.93
372
99152
285.47
Amount
116 of 167 Updated on 1/22/2019
Long Description
UB Revenue Code
CPT/HCPCS
459299153-99153 MOD SED SAME PHYS/QHP EA ADDT 15M
Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List separately in addition to code for primary service)
372
99153
132.74
459299156-99156 MOD SED OTHER PHYS/QHP >=5 YRS
Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; initial 15 minutes of intraservice time, patient age 5 years or older
372
99156
285.47
4592
459299157-99157 MOD SED OTH PHYS/QHP EA ADDT 15M
Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; each additional 15 minutes intraservice time (List separately in addition to code for primary service)
372
99157
132.74
4620
413002719-2719 EEG AWAKE/ASLEEP
740
95819
679.97
4620
413002722-2722 EEG COMA OR SLEEP ONLY
740
95822
679.97
4620 4620 4620 4620 4620 4620 4620 4620
413005907-5907 413005908-5908 413005909-5909 413005910-5910 413005911-5911 413005912-5912 413005913-5913 413009727-9727
922 922 922 922 922 922 922 471
95907 95908 95909 95910 95911 95912 95913 Z9727
169.82 780.51 780.51 780.51 1404.54 1404.54 1404.54 92.98
4620
413095831-95831 MUSCLE TEST EXTRMTY/TRUNK
920
95831
92.99
4620
462095812-95812 EEG EXTENDED MONITORING 41-60 MIN
740
95812
780.51
4620
462095813-95813 EEG EXTENDED MONITORING >1 HOUR
740
95813
780.51
4620
462095816-95816 EEG AWAKE & DROWSY
740
95816
780.51
4620
462095819-95819 EEG AWAKE & ASLEEP
740
95819
812.58
4620
462095822-95822 EEG, COMA OR SLEEP ONLY
740
95822
812.58
4620
462095824-95824 EEG CEREBRAL BRAIN DEATH EVAL
740
95824
1555.38
4620
462095827-95827 EEG, ALL NIGHT RECORDING
740
95827
1454.67
4620
462095886-95886 MUSC TEST DONE W/NCS, COMPLETE
922
95886
230.52
4620
462095950-95950 CEREBR SEIZURE 8-CH EEG, EA 24HR
740
95950
1454.67
Revenue Center
4592
4592
CDM Number
CDM Description
NVR CNDJ TST 1-2 STUDIES NRV CNDJ TST 3-4 STUDIES NRV CNDJ TST 5-6 STUDIES NRV CNDJ TEST 7-8 STUDIES NRV CNDJ TEST 9-10 STUDIES NRV CNDJ TEST 11-12 STUDIES NRV CNDJ TEST 13/> STUDIES INFANT HEARING RESCREEN,O/P
Electroencephalogram (EEG); including recording awake and asleep Electroencephalogram (EEG); recording in coma or sleep only Nerve conduction studies; 1-2 studies Nerve conduction studies; 3-4 studies Nerve conduction studies; 5-6 studies Nerve conduction studies; 7-8 studies Nerve conduction studies; 9-10 studies Nerve conduction studies; 11-12 studies Nerve conduction studies; 13 or more studies Infant Hearing Re-Screen - Outpatient Muscle testing, manual with report; extremity (excluding hand) or trunk Electroencephalogram (EEG) extended monitoring; 41-60 minutes Electroencephalogram (EEG) extended monitoring; greater than 1 hour Electroencephalogram (EEG); including recording awake and drowsy Electroencephalogram (EEG); including recording awake and asleep Electroencephalogram (EEG); recording in coma or sleep only Electroencephalogram (EEG); cerebral death evaluation only Electroencephalogram (EEG); all night recording Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels Monitoring for identification and lateralization of cerebral seizure focus, electroencephalographic (eg, 8 channel EEG) recording and interpretation, each 24 hours
Amount
117 of 167 Updated on 1/22/2019
Revenue Center
4620
4620
Long Description
UB Revenue Code
CPT/HCPCS
462095951-95951 CEREBR SEIZURE 16/>CH EEG, EA 24H
Monitoring for localization of cerebral seizure focus by cable or radio, 16 or more channel telemetry, combined electroencephalographic (EEG) and video recording and interpretation (eg, for presurgical localization), each 24 hours
740
95951
3024.06
462095953-95953 CEREB SEIZ PORT 16+CH EEG, EA 24H
Monitoring for localization of cerebral seizure focus by computerized portable 16 or more channel EEG, electroencephalographic (EEG) recording and interpretation, each 24 hours, unattended
740
95953
1454.67
255
Q9963
3.15
255
Q9963
3.15
255
Q9963
3.15
255
Q9967
3.08
255
Q9967
3.08
255
Q9967
3.08
255
Q9967
3.08
255
Q9967
3.08
255
Q9967
0.17
255
A9579
277.13
255
A9579
277.13
255
A9579
277.13
361
19281LT
1702.50
361
19283LT
1702.50
361
20501
9087.34
320
20610
719.37
361
32555RT
2144.01
CDM Number
CDM Description
4630
414000230-230 S HOCM 17.2 250ML/ML
4630
414000240-240 S HOCM 305-399 30ML PER ML
4630
414000241-241 S HOCM 305-399 120ML PER ML
4630
414000250-250 S ISOVUE 370 100ML
4630
414000252-252 S ISOVUE 370 75ML
4630
414000253-253 S ISOVUE 370 125ML
4630
414000254-254 S ISOVUE 300 50ML
4630
414000255-255 S ISOVUE 300 100ML
4630
414000256-256 S ISOVUE 300 75ML
4630
414000265-265 S MULTIHANCE 20ML
4630
414000266-266 S MULTIHANCE 15ML
4630
414000267-267 S MULTIHANCE 10ML
4630
414019281-19281 XR PERQ DVICE BREAST 1ST IM LT
4630
414019283-19283 XR PERQ DEV BREAST 1ST STR LT
4630
414020501-20501 INJECT FISTULOGRAM PROC ROOM
4630
414020610-20610 XR JOINT MAJOR ASPIRATION SC
4630
414022555-22555 XR ASPIRATE PLEURA W/IMGNG,RT
4630 4630 4630 4630 4630 4630 4630 4630 4630 4630 4630 4630
414028037-28037 414028060-28060 414028079-28079 414028084-28084 414028088-28088 414028094-28094 414028096-28096 414028155-28155 414028217-28217 414028220-28220 414028222-28222 414028255-28255
S BIOPSY NEEDLE 3 S DIAGNOSTIC CATH 1 S BS CARDIAC CATH 6F MPB2 S CLOSURE DEVICE S ACCESSORIES 1 S DIAGNOSTIC CATHETER 2 S DIAGNOSTIC CATHETER 3 S DOUBLE CONTRAST SUPER XL S LP TRAY S MAMMO ACCUGRID S MAMMO CORETAINER S NEEDLE 1
High osmolar contrast material, 350-399 mg/ml iodine concentration, per ml High osmolar contrast material, 350-399 mg/ml iodine concentration, per ml High osmolar contrast material, 350-399 mg/ml iodine concentration, per ml Low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml Low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml Low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml Low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml Low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml Low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml Injection, gadolinium-based magnetic resonance contrast agent, not otherwise specified (NOS), per ml Injection, gadolinium-based magnetic resonance contrast agent, not otherwise specified (NOS), per ml Injection, gadolinium-based magnetic resonance contrast agent, not otherwise specified (NOS), per ml Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including mammographic guidance Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including stereotactic guidance Injection of sinus tract; diagnostic (sinogram) Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance Thoracentesis, needle or catheter, aspiration of the pleural space; with imaging guidance
Closure device, vascular (implantable/insertable)
Needle, sterile, any size, each
272 272 272 278 272 272 272 272 272 272 272 272
C1760
A4215
Amount
849.43 208.95 208.95 129.68 126.05 78.70 78.70 65.00 61.44 100.17 100.17 40.95
118 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4630
414028262-28262 S SHEATHS 4F 11 W/MINI WIRE
4630
414028263-28263 S INTRODUCERS 1
4630
414028264-28264 S INTRODUCERS 2
4630
414028265-28265 S INTRODUCERS 3
4630 4630
414028281-28281 S NEEDLE 3 414028291-28291 S SYRINGE SPECTRIS
4630
414028348-28348 S CENTRAL LINE 1
4630 4630 4630
414028436-28436 S MAX CORE BIOPSY 18 X 10 414028442-28442 S BIOPSY NEEDLE 2 414028453-28453 S MAMMO 2
4630
414028457-28457 S RETRIEVAL 3
4630
414029009-29009 S HOCM 150-199 MG/ML IODINE 1M
4630 4630 4630 4630 4630 4630
414029010-29010 414029013-29013 414029015-29015 414029016-29016 414029023-29023 414029025-29025
4630
414032555-32555 XR ASPIRATE PLEURA W/ IMGNG,LEFT
4630
414037191-37191 XR INS ENDOVAS VENA CAVA FIL
4630
414040202-40202 XR SCRN MAMMO DIR DIGITAL BIL
4630
414040204-40204 XR DIAG MAMMO 2-D DIGITAL BIL
4630
414040206-40206 XR MAMMO LT UNILATREAL DIGITAL
4630
414049450-49450 XR GASTROSTOMY TUB REPLACED
4630
414049465-49465 XR CONTRAST INJ OF ANY GI TUBE
4630
414058340-58340 INJ HYSTEROSALPINGOGRAM PROC ROOM
4630
414060328-60328 XR TMJ UNILATERAL RT
4630
414061100-61100 XR RIBS RT
4630
414061101-61101 XR RIBS WITH CHEST 1V RT
4630
414062270-62270 LUMBAR PUNCTURE PROCEDURE
4630
414062284-62284 XR INJ SPINAL MYELOGRAM PROC R
4630 4630 4630
414063000-63000 XR CLAVICLE RT 414063010-63010 XR SCAPULA RT 414063020-63020 XR SHOULDER 1 VIEW RT
S GUIDEWIRE 2 S DRAINAGE CATHETER 3 S VORTEX 018 COIL S COIL PUSHER S GUIDEWIRE 3 S PERMACATH
Long Description Introducer/sheath, other than guiding, other than intracardiac electrophysiological, non-laser Introducer/sheath, other than guiding, other than intracardiac electrophysiological, non-laser Introducer/sheath, other than guiding, other than intracardiac electrophysiological, non-laser Introducer/sheath, other than guiding, other than intracardiac electrophysiological, non-laser Needle, sterile, any size, each Catheter, infusion, inserted peripherally, centrally or midline (other than hemodialysis)
Tissue marker, implantable, any type, each Retrieval device, insertable (used to retrieve fractured medical devices) High osmolar contrast material, 150-199 mg/ml iodine concentration, per ml Guide wire Guide wire
Guide wire Catheter, hemodialysis/peritoneal, long-term Thoracentesis, needle or catheter, aspiration of the pleural space; with imaging guidance Insertion of intravascular vena cava filter, endovascular approach including vascular access, vessel selection, and radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance (ultrasound and fluoroscopy), when performed Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (cad) when performed Diagnostic mammography, including computer-aided detection (cad) when performed; bilateral Diagnostic mammography, including computer-aided detection (cad) when performed; unilateral Replacement of gastrostomy or cecostomy (or other colonic) tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report Contrast injection(s) for radiological evaluation of existing gastrostomy, duodenostomy, jejunostomy, gastro-jejunostomy, or cecostomy (or other colonic) tube, from a percutaneous approach including image documentation and report Catheterization and introduction of saline or contrast material for saline infusion sonohysterography (SIS) or hysterosalpingography Radiologic examination, temporomandibular joint, open and closed mouth; unilateral Radiologic examination, ribs, unilateral; 2 views Radiologic examination, ribs, unilateral; including posteroanterior chest, minimum of 3 views Spinal puncture, lumbar, diagnostic Injection procedure for myelography and/or computed tomography, lumbar Radiologic examination; clavicle, complete Radiologic examination; scapula, complete Radiologic examination, shoulder; 1 view
UB Revenue Code
CPT/HCPCS
272
C1894
378.00
272
C1894
275.96
272
C1894
275.96
272
C1894
275.96
272 272
A4215
45.68 68.99
272
C1751
557.88
272 272 278
A4648
199.08 46.20 236.40
272
C1773
1008.00
255
Q9959
4.15
272 272 272 272 272 278
C1769 C1769
C1769 C1750
494.57 494.57 500.01 684.60 910.35 1686.00
361
32555LT
1624.57
320
37191
11915.30
403
G0202
324.78
401
G0204
315.00
401
G0206LT
250.00
320
49450
1731.89
320
49465
483.78
361
58340
657.20
320
70328RT
172.39
320
71100RT
251.23
320
71101RT
356.25
361
62270
1149.31
320
62284
794.64
320 320 320
73000RT 73010RT 73020RT
243.90 294.35 181.01
Amount
119 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4630
414063030-63030 XR SHOULDER COMPLETE RT
4630
414063060-63060 XR HUMERUS 2 V RT
4630
414063070-63070 XR ELBOW 2 VIEWS RT
4630
414063080-63080 XR ELBOW COMPLETE RT
4630 4630
414063090-63090 XR FOREARM RT 414063100-63100 XR WRIST LIMITED 2 VIEW RT
4630
414063110-63110 XR WRIST COMP 3 VIEWS RT
4630 4630
414063120-63120 XR HAND LIMITED RT 414063130-63130 XR HAND COMPLETE RT
4630
414063140-63140 XR FINGERS RT
4630 4630 4630
414063550-63550 XR FEMUR 2V RT 414063560-63560 XR KNEE LMTD 1 OR 2 V RT 414063562-63562 XR KNEE MIN 3 VIEW RT
4630
414063564-63564 XR KNEE COMP 4 VIEWS RT
4630
414063590-63590 XR TIBIA/FIBULA 2V RT
4630
414063592-63592 XR LOWER EXT INFANT 2V RT
4630
414063600-63600 XR ANKLE LIMITED 2 VIEW RT
4630
414063610-63610 XR ANKLE COMPLETE 3V RT
4630
414063620-63620 XR FOOT LIMITED 2V RT
4630
414063630-63630 XR FOOT COMPLETE 3V RT
4630
414063650-63650 XR CALCAEUS 2V (HEEL) RT
4630
414063660-63660 XR TOES MIN 3V RT
4630
414065820-65820 XR VENOGRAM EXTREMITY RT
4630
414070100-70100 XR MANDIBLE LIMITED
4630
414070110-70110 XR MANDIBLE COMPLETE
4630
414070140-70140 FACIAL BONES LIMITED
4630
414070150-70150 XR FACIAL BONES COMPLETE
4630
414070160-70160 NASAL BONES COMP MIN 3V
4630
414070200-70200 XR ORBITS COMP MIN 4V
4630
414070210-70210 PARANASAL SINUSES XRAY
4630
414070220-70220 PARANASAL SINUSES COMPLETE
4630
414070250-70250 SKULL LIMITED
4630
414070260-70260 SKULL COMPLETE
4630
414070328-70328 XR TMJ UNILATERAL LT
4630
414070330-70330 XR TM JOINTS BILATERAL
4630 4630 4630
414070355-70355 XR ORTHOPANTOGRAM(PANOREX) 414070360-70360 NECK FOR SOFT TISSUES 414071010-71010 CHEST SINGLE VIEW
4630
414071020-71020 CHEST TWO VIEW
4630
414071100-71100 XR RIBS LT
Long Description Radiologic examination, shoulder; complete, minimum of 2 views Radiologic examination; humerus, minimum of 2 views Radiologic examination, elbow; 2 views Radiologic examination, elbow; complete, minimum of 3 views Radiologic examination; forearm, 2 views Radiologic examination, wrist; 2 views Radiologic examination, wrist; complete, minimum of 3 views Radiologic examination, hand; 2 views Radiologic examination, hand; minimum of 3 views Radiologic examination, finger(s), minimum of 2 views Radiologic examination, femur, 2 views Radiologic examination, knee; 1 or 2 views Radiologic examination, knee; 3 views Radiologic examination, knee; complete, 4 or more views Radiologic examination; tibia and fibula, 2 views Radiologic examination; lower extremity, infant, minimum of 2 views Radiologic examination, ankle; 2 views Radiologic examination, ankle; complete, minimum of 3 views Radiologic examination, foot; 2 views Radiologic examination, foot; complete, minimum of 3 views Radiologic examination; calcaneus, minimum of 2 views Radiologic examination; toe(s), minimum of 2 views Venography, extremity, unilateral, radiological supervision and interpretation Radiologic examination, mandible; partial, less than 4 views Radiologic examination, mandible; complete, minimum of 4 views Radiologic examination, facial bones; less than 3 views Radiologic examination, facial bones; complete, minimum of 3 views Radiologic examination, nasal bones, complete, minimum of 3 views Radiologic examination; orbits, complete, minimum of 4 views Radiologic examination, sinuses, paranasal, less than 3 views Radiologic examination, sinuses, paranasal, complete, minimum of 3 views Radiologic examination, skull; less than 4 views Radiologic examination, skull; complete, minimum of 4 views Radiologic examination, temporomandibular joint, open and closed mouth; unilateral Radiologic examination, temporomandibular joint, open and closed mouth; bilateral Orthopantogram (eg, panoramic X-ray) Radiologic examination; neck, soft tissue Radiologic examination, chest; single view, frontal Radiologic examination, chest, 2 views, frontal and lateral; Radiologic examination, ribs, unilateral; 2 views
UB Revenue Code
CPT/HCPCS
320
73030RT
325.11
320
73060RT
215.05
320
73070RT
209.64
320
73080RT
402.64
320 320
73090RT 73100RT
321.21 363.17
320
73110RT
440.38
320 320
73120RT 73130RT
539.35 507.91
320
73140RT
204.32
320 320 320
73550RT 73560RT 73562RT
267.41 321.30 661.44
320
73564RT
347.83
320
73590RT
350.69
320
73592RT
181.01
320
73600RT
307.65
320
73610RT
431.32
320
73620RT
527.27
320
73630RT
522.92
320
73650RT
257.70
320
73660RT
199.97
320
75820RT
2234.87
320
70100
181.01
320
70110
481.95
320
70140
259.35
320
70150
486.15
320
70160
181.01
320
70200
355.95
320
70210
181.01
320
70220
502.49
320
70250
382.43
320
70260
546.00
320
70328LT
181.01
320
70330
181.01
320 320 324
70355 70360 71010
289.80 181.01 181.01
324
71020
206.30
320
71100LT
251.23
Amount
120 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
Long Description Radiologic examination, ribs, unilateral; including posteroanterior chest, minimum of 3 views Radiologic examination, ribs, bilateral; 3 views Radiologic examination; sternum, minimum of 2 views Radiologic examination, spine, single view, specify level Radiologic examination, spine, single view, specify level Radiologic examination, spine, single view, specify level
UB Revenue Code
CPT/HCPCS
320
71101LT
356.25
320
71110
389.55
320
71120
378.63
320
72020
200.55
320
72020
200.55
320
72020
200.55
Amount
4630
414071101-71101 XR RIBS WITH CHEST 1V LT
4630
414071110-71110 RIBS BILATERAL
4630
414071120-71120 STERNUM
4630
414072020-72020 XR CERVICAL SPINE SINGLE VIEW
4630
414072021-72021 XR THORACIC SPINE SINGEL VIEW
4630
414072022-72022 XR LUMBAR SPINE SINGLE VIEW
4630
414072040-72040 XR CERVICAL SPINE LIMITED 3V
Radiologic examination, spine, cervical; 2 or 3 views
320
72040
392.70
4630
414072042-72042 XR C-SPINE FLEX/EXT/NEUT 3 VIEW
Radiologic examination, spine, cervical; 2 or 3 views
320
72040
392.70
4630
414072050-72050 XR CERVICAL SPINE COMPLETE 5V
Radiologic examination, spine, cervical; 4 or 5 views
320
72050
779.11
4630
414072052-72052 SPINE CERVICAL W/FLEX&EXTENS7V
320
72052
791.70
4630 4630
414072070-72070 XR THORACIC SPINE 414072072-72072 XR THORACIC SSPINE 3 VIEWS
320 320
72070 72072
421.83 456.08
4630
414072080-72080 XR THORACIC-LUMBAR JCT
320
72080
457.35
4630
414072100-72100 XR LUMBAR SPINE LIMITED
320
72100
482.36
4630
414072110-72110 XR LUMBOSACRAL SPINE W OBLIQUES
320
72110
831.72
4630
414072114-72114 XR LUMBOSACRAL SPINE W OBL & BEND
320
72114
687.10
4630
414072120-72120 XR LUMBOSACRAL SPINE BENDING VIEW
320
72120
303.45
4630
414072170-72170 PELVIS LIMITED AP
320
72170
256.05
4630
414072190-72190 PELVIS COMPLETE 3V
320
72190
345.19
4630
414072200-72200 XR SACROILIAC JOINTS 2 VIEWS
320
72200
227.85
4630
414072202-72202 SACROLIAC JOINTS 3V
320
72202
244.65
4630
414072220-72220 SACRUM & COCCYX 2V
320
72220
422.56
4630
414072240-72240 XR CERVICAL MYELOGRAM W/CI INJ
320
72240
1999.65
4630
414072265-72265 XR LUMBAR MYELOGRAM W/SPINAL INJ
320
72265
1999.65
4630 4630 4630
414073000-73000 XR CLAVICLE LT 414073010-73010 XR SCAPULA LT 414073020-73020 XR SHOULDER 1 VIEW LT
320 320 320
73000LT 73010LT 73020LT
243.90 294.35 181.01
4630
414073030-73030 XR SHOULDER COMPLETE LT
320
73030LT
325.11
4630
414073050-73050 ACJ, BILATERAL, W/WO WEIG
320
73050
181.01
4630
414073060-73060 XR HUMERUS 2 V LT
320
73060LT
215.05
4630
414073070-73070 XR ELBOW 2 VIEWS LT
320
73070LT
209.64
4630
414073080-73080 XR ELBOW COMPLETE LT
320
73080LT
402.64
4630
414073090-73090 XR FOREARM LT
320
73090LT
321.21
4630
414073092-73092 XR UPPER EXT INFANT 2V LT
320
73092LT
181.01
4630
414073100-73100 XR WRIST LIMITED 2 VIEW LT
320
73100LT
363.17
4630
414073110-73110 XR WRIST COMP 3 VIEWS LT
320
73110LT
440.38
4630
414073120-73120 XR HAND LIMITED LT
320
73120LT
539.35
Radiologic examination, spine, cervical; 6 or more views Radiologic examination, spine; thoracic, 2 views Radiologic examination, spine; thoracic, 3 views Radiologic examination, spine; thoracolumbar junction, minimum of 2 views Radiologic examination, spine, lumbosacral; 2 or 3 views Radiologic examination, spine, lumbosacral; minimum of 4 views Radiologic examination, spine, lumbosacral; complete, including bending views, minimum of 6 views Radiologic examination, spine, lumbosacral; bending views only, 2 or 3 views Radiologic examination, pelvis; 1 or 2 views Radiologic examination, pelvis; complete, minimum of 3 views Radiologic examination, sacroiliac joints; less than 3 views Radiologic examination, sacroiliac joints; 3 or more views Radiologic examination, sacrum and coccyx, minimum of 2 views Myelography, cervical, radiological supervision and interpretation Myelography, lumbosacral, radiological supervision and interpretation Radiologic examination; clavicle, complete Radiologic examination; scapula, complete Radiologic examination, shoulder; 1 view Radiologic examination, shoulder; complete, minimum of 2 views Radiologic examination; acromioclavicular joints, bilateral, with or without weighted distraction Radiologic examination; humerus, minimum of 2 views Radiologic examination, elbow; 2 views Radiologic examination, elbow; complete, minimum of 3 views Radiologic examination; forearm, 2 views Radiologic examination; upper extremity, infant, minimum of 2 views Radiologic examination, wrist; 2 views Radiologic examination, wrist; complete, minimum of 3 views Radiologic examination, hand; 2 views
121 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4630
414073130-73130 XR HAND COMPLETE LT
4630
414073140-73140 XR FINGERS LT
4630 4630
414073560-73560 XR KNEE LMTD 1 OR 2 V LT 414073562-73562 XR KNEE MIN 3 VIEW LT
4630
414073564-73564 XR KNEE COMP 4 VIEWS LT
4630
414073590-73590 XR TIBIA/FIBULA 2V LT
4630
414073592-73592 XR LOWER EXT INFANT 2V LT
4630
414073600-73600 XR ANKLE LIMITED 2 VIEW LT
4630
414073610-73610 XR ANKLE COMPLETE 3V LT
4630
414073620-73620 XR FOOT LIMITED 2V LT
4630
414073630-73630 XR FOOT COMPLETE 3V LT
4630
414073650-73650 XR CALCAEUS 2V (HEEL) LT
4630
414073660-73660 XR TOES MIN 3V LT
Long Description Radiologic examination, hand; minimum of 3 views Radiologic examination, finger(s), minimum of 2 views Radiologic examination, knee; 1 or 2 views Radiologic examination, knee; 3 views Radiologic examination, knee; complete, 4 or more views Radiologic examination; tibia and fibula, 2 views Radiologic examination; lower extremity, infant, minimum of 2 views Radiologic examination, ankle; 2 views Radiologic examination, ankle; complete, minimum of 3 views Radiologic examination, foot; 2 views Radiologic examination, foot; complete, minimum of 3 views Radiologic examination; calcaneus, minimum of 2 views Radiologic examination; toe(s), minimum of 2 views Radiologic examination, abdomen; complete acute abdomen series, including supine, erect, and/or decubitus views, single view chest Radiologic examination; esophagus Swallowing function, with cineradiography/videoradiography
UB Revenue Code 320
CPT/HCPCS
Amount
73130LT
507.91
320
73140LT
204.32
320 320
73560LT 73562LT
321.30 661.44
320
73564LT
347.83
320
73590LT
350.69
320
73592LT
181.01
320
73600LT
307.65
320
73610LT
431.32
320
73620LT
527.27
320
73630LT
522.92
320
73650LT
257.70
320
73660LT
199.97
320
74022
370.65
320
74220
515.88
320
74230
404.61
4630
414074022-74022 XR ACUTE ABDOMEN COMP. W/CHEST
4630
414074220-74220 ESOPHAGUS
4630
414074230-74230 THROAT CINERADIOGRAM
4630
414074240-74240 XR UGI WITHOUT KUB
Radiologic examination, gastrointestinal tract, upper; with or without delayed images, without KUB
320
74240
483.85
4630
414074241-74241 XR UGI WITH KUB
Radiologic examination, gastrointestinal tract, upper; with or without delayed images, with KUB
320
74241
634.73
4630
414074245-74245 XR UGI SERIES WITH SMALL BOWEL
Radiologic examination, gastrointestinal tract, upper; with small intestine, includes multiple serial images
320
74245
954.45
414074247-74247 XR UGI AIR CONTRAST WITH KUB
Radiological examination, gastrointestinal tract, upper, air contrast, with specific high density barium, effervescent agent, with or without glucagon; with or without delayed images, with KUB
320
74247
681.45
320
74249
483.85
320
74250
548.10
320
74270
900.38
320
74280
893.90
320
74330
427.35
320
74400
825.50
320
74420
825.50
320
74430
825.50
320
74450
825.50
320
74455
825.50
320
74740
1006.37
4630
4630
414074249-74249 XR UGI AIR CONTRAST W/SM BOW
4630
414074250-74250 SMALL BOWEL XRAYS
4630
414074270-74270 XR BARIUM ENEMA SINGLE CONTRAS
4630
414074280-74280 COLON W/BARIUM ENEMA W/AIR
4630
414074330-74330 XR ERCP PANCREATIC DUCT SYSTEM
4630
414074400-74400 UROGRAPHY EXCRETORY IVP
4630
414074420-74420 UROGRAPHY RETROGRADE W/WO/KUB
4630
414074430-74430 XR CYSTOGRAM
4630
414074450-74450 XR URETHROCYSTOGRAM RETROGRADE
4630
414074455-74455 XR VCUG
4630
414074740-74740 HYSTEROSALPINGOGRAM
Radiological examination, gastrointestinal tract, upper, air contrast, with specific high density barium, effervescent agent, with or without glucagon; with small intestine follow-through Radiologic examination, small intestine, includes multiple serial images; Radiologic examination, colon; contrast (eg, barium) enema, with or without KUB Radiologic examination, colon; air contrast with specific high density barium, with or without glucagon Combined endoscopic catheterization of the biliary and pancreatic ductal systems, radiological supervision and interpretation Urography (pyelography), intravenous, with or without KUB, with or without tomography Urography, retrograde, with or without KUB Cystography, minimum of 3 views, radiological supervision and interpretation Urethrocystography, retrograde, radiological supervision and interpretation Urethrocystography, voiding, radiological supervision and interpretation Hysterosalpingography, radiological supervision and interpretation
122 of 167 Updated on 1/22/2019
Revenue Center
UB Revenue Code
CPT/HCPCS
320
75820LT
2820.69
320
76000
918.50
320
76010
679.98
320
77072
181.01
320
77073
151.82
320
77074
279.07
320
77075
1330.35
320
77080
290.99
401
77051
138.84
320
76098
1268.64
329
76140
181.01
329
76140
181.01
320
77001
3231.71
320
77075
1330.35
414096222-96222 XR PL CT CARO/INOM CER BILAT
Selective catheter placement, common carotid or innominate artery, unilateral, any approach, with angiography of the ipsilateral extracranial carotid circulation and all associated radiological supervision and interpretation, includes angiography of the cervicocerebral arch, when performed
320
3622250
8744.83
414096224-96224 XR PL CT CARO ART BILAT
Selective catheter placement, internal carotid artery, unilateral, with angiography of the ipsilateral intracranial carotid circulation and all associated radiological supervision and interpretation, includes angiography of the extracranial carotid and cervicocerebral arch, when performed
320
3622450
14301.63
361
19281RT
1702.50
361
19283RT
1702.50
320
19001
483.05
361
38222
4718.16
CDM Number
CDM Description
4630
414075820-75820 XR VENOGRAM EXTREMITY LT
4630
414076000-76000 XR FLUOROSCOPY GUIDANCE
4630
414076010-76010 XR FOREIGN BODY NOSE TO RECTUM
4630
414076020-76020 BONE AGE XRAY STUDY
4630
414076040-76040 XR BONE LENGHT (SCANOGRAM)
4630
414076061-76061 XR OSSEOUS SERVEY LIMITED
4630
414076062-76062 XR BONE SURVEY COMPLETE METS
4630
414076075-76075 XR BONE DENSITY DEXA
4630
414076085-76085 XR MAMMOGRAPHY DIGITAL IMAGES
4630
414076098-76098 XR SPECIMEN SURGICAL
4630
414076141-76141 CHEST 1 VIEW CONSULT READ KCPHD
4630
414076142-76142 CHEST 2 VIEWS CONSULT READ KCPHD
4630
414077001-77001 FLUORO GUIDE FOR VENOUS ACCESS
4630
414077075-77075 XR BONE SURVEY COMPLETE M.
4630
4630
4630
414097281-97281 XR PERQ DVICE BREAST 1ST IM RT
4630
414097283-97283 XR PERQ DEV BREAST 1ST STR RT
4630
463019001-19001 XR PUNCT ASP BRST CYST-EA ADDTL
4630
463038222-38222 DX BONE MARROW BX & ASPIR
Long Description Venography, extremity, unilateral, radiological supervision and interpretation Fluoroscopy, up to 1 hour physician or other qualified health care professional time Radiologic examination from nose to rectum for foreign body, single view, child Bone age studies Bone length studies (orthoroentgenogram, scanogram) Radiologic examination, osseous survey; limited (eg, for metastases) Radiologic examination, osseous survey; complete (axial and appendicular skeleton) Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine) Computer-aided detection (computer algorithm analysis of digital image data for lesion detection) with further review for interpretation, with or without digitization of film radiographic images; diagnostic mammography Radiological examination, surgical specimen Consultation on X-ray examination made elsewhere, written report Consultation on X-ray examination made elsewhere, written report Fluoroscopic guidance for central venous access device placement, replacement (catheter only or complete), or removal (includes fluoroscopic guidance for vascular access and catheter manipulation, any necessary contrast injections through access site or catheter with related venography radiologic supervision and interpretation, and radiographic documentation of final catheter position) Radiologic examination, osseous survey; complete (axial and appendicular skeleton)
Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including mammographic guidance Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including stereotactic guidance Puncture aspiration of cyst of breast; each additional cyst Diagnostic bone marrow; biopsy(ies) and aspiration(s)
Amount
123 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4630
463043502-43502 XR OR HIP W/PELV UNIL 2-3 VW RT
4630
463053503-53503 XR OR HIP W/PELV UNIL 4+ VW LT
4630
463062082-62082 XR ENTIRE SPINE 2-3 VW, AP/LAT
4630
463063501-63501 XR HIP W/PELVIS UNILAT 1 VW RT
4630
463063502-63502 XR HIP W/PELVIS UNIL 2-3 VW RT
4630
463063503-63503 XR HIP W PELV UNI MIN 4 VIEWS RT
4630
463063521-63521 XR HIPS W/PELVIS BI 2V, INFANT
4630 4630 4630 4630 4630
463063551-63551 463063552-63552 463071045-71045 463071046-71046 463071047-71047
4630
463072081-72081 XR ENTIRE SPINE 1 VIEW
4630
463072082-72082 XR ENTIRE SPI 2-3 VW, SCOLIOSIS
4630
463073501-73501 XR HIP W/PELVIS UNILAT 1 VW LT
4630
463073502-73502 XR HIP W/PELVIS UNIL 2-3 VW LT
4630
463073521-73521 XR HIPS W/PELVIS BILAT 2 VIEWS
4630
463073522-73522 XR HIPS W/PELVIS BIL 3-4 VIEWS
4630 4630 4630 4630
463073551-73551 463073552-73552 463074018-74018 463074019-74019
4630
463074021-74021 XR ABDOMEN 3+ VIEWS
4630
463077065-77065 XR DIAG MAMMO INCL CAD, UNILAT LT
4630
463077066-77066 XR DIAG MAMMO INCL CAD, BILAT
4630
463077067-77067 XR SCRN MAMMO INCL CAD, BILAT
4630
463087065-87065 XR DIAG MAMMO INCL CAD, UNILAT RT
4650
416016803-16803 NM SUP,IN111 OXYQIN,PER 0.5 MCI
4650
416016806-16806 NM SUP, IN111 PENTETR PER MCI
4650
416016808-16808 NM SUP, TC99 SULFUR COLLOID UD
4650
416016810-16810 NM SUP, I-131 CAPSUL PER 1-5 MCI
4650
416016813-16813 NM SUP, TC99 MDP, DOSE TO 30 MCI
4650
416016815-16815 NM SUP, TC99 MAA UD
4650
416016818-16818 NM SUP, TC99 DTPA UD
XR FEMUR 1 VIEW RT XR FEMUR MIN 2 VIEWS RT XR CHEST 1 VIEW XR CHEST 2 VIEWS XR CHEST 3 VIEWS
XR FEMUR 1 VIEW LT XR FEMUR MIN 2 VIEWS LT XR ABDOMEN 1 VIEW XR ABDOMEN 2 VIEWS
Long Description Radiologic examination, hip, unilateral, with pelvis when performed; 2-3 views Radiologic examination, hip, unilateral, with pelvis when performed; minimum of 4 views Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); 2 or 3 views Radiologic examination, hip, unilateral, with pelvis when performed; 1 view Radiologic examination, hip, unilateral, with pelvis when performed; 2-3 views Radiologic examination, hip, unilateral, with pelvis when performed; minimum of 4 views Radiologic examination, hips, bilateral, with pelvis when performed; 2 views Radiologic examination, femur; 1 view Radiologic examination, femur; minimum 2 views Radiologic examination, chest; single view Radiologic examination, chest; 2 views Radiologic examination, chest; 3 views Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); one view Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); 2 or 3 views Radiologic examination, hip, unilateral, with pelvis when performed; 1 view Radiologic examination, hip, unilateral, with pelvis when performed; 2-3 views Radiologic examination, hips, bilateral, with pelvis when performed; 2 views Radiologic examination, hips, bilateral, with pelvis when performed; 3-4 views Radiologic examination, femur; 1 view Radiologic examination, femur; minimum 2 views Radiologic examination, abdomen; 1 view Radiologic examination, abdomen; 2 views Radiologic examination, abdomen; 3 or more views Diagnostic mammography, including computer-aided detection (CAD) when performed; unilateral Diagnostic mammography, including computer-aided detection (CAD) when performed; bilateral Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed Diagnostic mammography, including computer-aided detection (CAD) when performed; unilateral Indium In-111 oxyquinoline, diagnostic, per 0.5 millicurie Indium In-111 pentetreotide, diagnostic, per study dose, up to 6 millicuries Technetium Tc-99m sulfur colloid, diagnostic, per study dose, up to 20 millicuries Iodine I-131 sodium iodide capsule(s), therapeutic, per millicurie Technetium Tc-99m medronate, diagnostic, per study dose, up to 30 millicuries Technetium Tc-99m macroaggregated albumin, diagnostic, per study dose, up to 10 millicuries Technetium Tc-99m pentetate, diagnostic, per study dose, up to 25 millicuries
UB Revenue Code
CPT/HCPCS
320
73502RT
215.37
320
73503LT
356.67
320
72082
356.67
320
73501RT
215.37
320
73502RT
215.37
320
73503RT
356.67
320
73521
356.67
320 320 320 320 320
73551RT 73552RT 71045TC 71046TC 71047TC
215.37 215.37 217.41 217.41 217.41
320
72081
215.37
320
72082
356.67
320
73501LT
215.37
320
73502LT
215.37
320
73521
356.67
320
73522
356.67
320 320 320 320
73551LT 73552LT 74018TC 74019TC
215.37 215.37 217.41 415.35
320
74021TC
415.35
401
77065LT
138.84
401
77066
138.84
403
77067
138.84
401
77065RT
138.84
343
A9547
1252.76
343
A9572
4410.75
343
A9541
302.25
344
A9517
304.69
343
A9503
145.92
343
A9540
130.65
343
A9539
95.96
Amount
124 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4650
416016826-16826 NM SUP, TC99 SESTAMIBI, PER DOSE
4650
416016833-16833 NM SUP,I-123 CAPSUL, PER 100UCI
4650
416016836-16836 NM SUP,TC99 MEBROFENIN UD
4650
416016846-16846 NM SUP, TC99 MERTIATIDE UD
4650
416016855-16855 NM SUP, TC 99M PRETECHNETATE
4650
416078014-78014 NM THYRD IMG W/SNGL OR > UP
4650
416078070-78070 NM PARATHYROID IMAGING
4650 4650 4650
416078195-78195 NM LYMPHATICS AND LYMPH GLAND IMG 416078202-78202 NM LIVER IMAGING W/FLOW 416078215-78215 NUC MED LIVER/SPLEEN IMAGE STA
4650
416078226-78226 HEPATOBILIARY SYSTEM IMAGING
4650
416078231-78231 NM SALIVARY GLAND IMAGE W/SERI
4650
416078264-78264 NM GASTRIC EMPTYING STUDY
4650 4650 4650
416078278-78278 NM GI BLOOD LOSS IMAGING 416078306-78306 NUC MED BONE IMAGING WHOLEBDY 416078315-78315 NM BONE SCAN W/VASCULAR FLOW
4650
416078451-78451 NM MYOCARDIAL PERF SNGL W/ST
4650
416078453-78453 NM MYOCARDIAL,PLANAR,SING W/ST
4650
416078454-78454 NM MYOCARDIAL, PLANAR, MULT W/ST
4650
416078460-78460 NM MYOCARDIAL PREFUSION IMAGIN
4650
416078461-78461 NM(MUGA)MUOCARDIAL PERFUSION S
4650
416078464-78464 NM MYOCARDIAL PERF SINGLE SPECT
Long Description Technetium Tc-99m sestamibi, diagnostic, per study dose Iodine I-123 sodium iodide, diagnostic, per 100 microcuries, up to 999 microcuries Technetium Tc-99m mebrofenin, diagnostic, per study dose, up to 15 millicuries Technetium Tc-99m mertiatide, diagnostic, per study dose, up to 15 millicuries Technetium Tc-99m pertechnetate, diagnostic, per millicurie Thyroid imaging (including vascular flow, when performed); with single or multiple uptake(s) quantitative measurement(s) (including stimulation, suppression, or discharge, when performed) Parathyroid planar imaging (including subtraction, when performed); Lymphatics and lymph nodes imaging Liver imaging; with vascular flow Liver and spleen imaging; static only Hepatobiliary system imaging, including gallbladder when present; Salivary gland imaging; with serial images Gastric emptying imaging study (eg, solid, liquid, or both); Acute gastrointestinal blood loss imaging Bone and/or joint imaging; whole body Bone and/or joint imaging; 3 phase study 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, 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 pharmacologic) and/or redistribution and/or rest 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 pharmacologic) and/or redistribution and/or rest reinjection 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)
UB Revenue Code
CPT/HCPCS
343
A9500
428.49
343
A9516
727.58
343
A9537
285.87
343
A9562
673.79
343
A9512
159.60
341
78014
917.64
341
78070
917.64
341 341 341
78195 78202 78215
1732.50 1238.53 1238.53
341
78226
1238.53
341
78231
1011.51
341
78264
1698.05
341 341 341
78278 78306 78315
1571.85 1740.00 1875.30
341
78451
2554.40
341
78453
2677.54
341
78454
2677.54
341
78453
2677.54
341
78454
2677.54
341
78451
2682.12
Amount
125 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
Long Description 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 rest reinjection Pulmonary ventilation (eg, aerosol or gas) and perfusion imaging Kidney imaging morphology; with vascular flow and function, single study without pharmacological intervention Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s); whole body, single day imaging
UB Revenue Code
CPT/HCPCS
341
78452
2915.94
341
78582
1325.23
341
78707
1311.47
341
78802
1979.73
Amount
4650
416078465-78465 NM MYOCARDIAL PERF MULTI SPECT
4650
416078582-78582 NM LUNG VENTILAT&PERFUS IMAGI
4650
416078707-78707 KIDNEY W/FLOW & FUNCTION STUDY
4650
416078802-78802 TUMOR LOCALIZATION COMPLETE
4650
416079020-79020 NM THYROID ABLATION
Radiopharmaceutical therapy, by oral administration
342
79005
932.51
4650
416093015-93015 NM STRESS TEST
Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; tracing only, without interpretation and report
482
93017
609.60
4650
465078018-78018 NM THYROID METS, WHOLE BODY
Thyroid carcinoma metastases imaging; whole body
341
78018
1286.97
341
78804
3983.88
615
70544
3971.36
615
70545
3670.80
610
7371850
2889.60
610
73718LT
2889.60
610
73720LT
6584.03
610
73721LT
3954.98
610
73723LT
6785.10
610
73721RT
1269.97
610
73721LT
3954.98
610
73723RT
6584.03
610
73721RT
3954.98
610
73721LT
3954.98
610
73723RT
6584.03
4650
465078804-78804 NM RP LOC TUMR IMG WHOLE BDY =>2D
4660
466000034-34
MRV HEAD WO
4660
466000037-37
MRV HEAD WITH
4660
466000038-38
MR LOWER EXTS WO CONT BILAT
4660
466000039-39
MR LOWER EXT WO CONT LT
4660
466000041-41
MR LOWER EXT WO/W CONT LT
4660
466000049-49
MR LOWER JOINT WO CONT LT
4660
466000051-51
MR LWR JT WO/W CONT LT
4660
466000053-53
MR HIP WO CONT RT
4660
466000054-54
MR HIP WO CONT LT
4660
466000056-56
MR HIP WO/W CONT RT
4660
466000059-59
MR KNEE WO CONT RT
4660
466000060-60
MR KNEE WO CONT LT
4660
466000062-62
MR KNEE WO/W CONTR RT
Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s); whole body, requiring 2 or more days imaging Magnetic resonance angiography, head; without contrast material(s) Magnetic resonance angiography, head; with contrast material(s) Magnetic resonance (eg, proton) imaging, lower extremity other than joint; without contrast material(s) Magnetic resonance (eg, proton) imaging, lower extremity other than joint; without contrast material(s) Magnetic resonance (eg, proton) imaging, lower extremity other than joint; without contrast material(s), followed by contrast material(s) and further sequences Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material(s), followed by contrast material(s) and further sequences Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material(s), followed by contrast material(s) and further sequences Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material(s), followed by contrast material(s) and further sequences
126 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4660
466000063-63
MR KNEE WO/W CONT LT
4660
466000069-69
MR ANKLE WO/W CONT LT
4660
466063218-63218 MR UPPER EXT WO CONT RT
4660
466063220-63220 MR UPPER EXTREMITY WO OR W-RT
4660
466063221-63221 MR UPPER EXT JOINT WO CON-RT
4660
466063222-63222 MR UPPER EXT JOINT W CONT RT
4660
466063223-63223 MR UPPER EXT JOINT WO&W C-RT
4660
466070543-70543 MR ORBIT/FACIAL/NECK WO&W CONTR
4660
466070544-70544 MRA HEAD WO CONTRAST
4660
466070547-70547 MRA NECK WO CONTRAST
4660
466070548-70548 MRA NECK W CONTRAST
4660
466070549-70549 MRA NECK WO & W CONTRAST
4660
466070551-70551 MR BRAIN WO CONTRAST
4660
466070552-70552 MR BRAIN WITH CONTRAST
4660
466070553-70553 MR BRAIN WO&W CONTRAST
4660
466072141-72141 MRI,CERVICAL SPINE,W/O CONTRAST
4660
466072142-72142 MRI,CERVICAL SPINE,W/CONTRAST
4660
466072146-72146 MRI,THORACIC SPINE,W/O CONTRAST
4660
466072147-72147 MRI THORACIC SPINE,W/CONTRAST
4660
466072148-72148 MRI,LUMBAR SPINE,W/O CONTRAST
4660
466072149-72149 MRI,LUMBAR SPINE, W/CONTRAST
Long Description Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material(s), followed by contrast material(s) and further sequences Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material(s), followed by contrast material(s) and further sequences Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; without contrast material(s) Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; without contrast material(s), followed by contrast material(s) and further sequences Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast material(s) Magnetic resonance (eg, proton) imaging, any joint of upper extremity; with contrast material(s) Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast material(s), followed by contrast material(s) and further sequences Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; without contrast material(s), followed by contrast material(s) and further sequences Magnetic resonance angiography, head; without contrast material(s) Magnetic resonance angiography, neck; without contrast material(s) Magnetic resonance angiography, neck; with contrast material(s) Magnetic resonance angiography, neck; without contrast material(s), followed by contrast material(s) and further sequences Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material Magnetic resonance (eg, proton) imaging, brain (including brain stem); with contrast material(s) Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material, followed by contrast material(s) and further sequences Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; without contrast material Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; with contrast material(s) Magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; without contrast material Magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; with contrast material(s) Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; without contrast material Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; with contrast material(s)
UB Revenue Code
CPT/HCPCS
610
73723LT
6584.03
610
73723LT
6584.03
610
73218RT
3083.85
610
73220RT
6979.35
614
73221RT
3731.63
610
73222RT
1790.71
610
73223RT
2164.59
610
70543
5782.70
615
70544
3971.36
615
70547
2770.95
615
70548
3807.30
615
70549
4748.10
611
70551
3983.34
611
70552
4043.55
611
70553
7539.00
612
72141
3968.72
612
72142
4027.80
612
72146
3919.81
612
72147
3835.65
612
72148
3914.32
612
72149
4474.05
Amount
127 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4660
466072156-72156 MRI,CERVICAL SPINE,W/WO CONTRAST
4660
466072157-72157 MRI,THORACIC SPINE,W/WO CONTRAST
4660
466072158-72158 MRI,LUMBAR SPINE,W/WO CONTRAST
4660
466072195-72195 MR PELVIS WO CONTRAST
4660
466072196-72196 MRI PELVIS W/CONT
4660
466072197-72197 MR PELVIS WO & W CONTRAST
4660
466073218-73218 MR UPPER EXT WO CONT LT
4660
466073220-73220 MR UPPER EXTREMITY WO OR W-LT
4660
466073221-73221 MR UPPER EXT JOINT WO CON-LT
4660
466073222-73222 MR UPPER EXT JOINT W CONT LT
4660
466073223-73223 MR UPPER EXT JOINT WO&W C-LT
4660
466073718-73718 MR LOWER EXT WO CONT RT
4660
466073719-73719 MR LOWER EXT W CONT LT
4660
466073720-73720 MR LOWER EXT WO/W CONT RT
4660
466073721-73721 MR LOWER JOINT WO CONT RT
4660
466073723-73723 MR LWR JT WO/W CONT RT
4660
466074181-74181 MR ABDOMEN WO CONTRAST
4660
466074183-74183 MR ABDOMEN WO & W CONTRAST
4660
466076376-76376 MRI SAG/COR/3-D RECONSTRUCT
4670
416100029-29
US VEIN MAPPING BILATERAL
Long Description Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; cervical Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; thoracic Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; lumbar Magnetic resonance (eg, proton) imaging, pelvis; without contrast material(s) Magnetic resonance (eg, proton) imaging, pelvis; with contrast material(s) Magnetic resonance (eg, proton) imaging, pelvis; without contrast material(s), followed by contrast material(s) and further sequences Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; without contrast material(s) Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; without contrast material(s), followed by contrast material(s) and further sequences Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast material(s) Magnetic resonance (eg, proton) imaging, any joint of upper extremity; with contrast material(s) Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast material(s), followed by contrast material(s) and further sequences Magnetic resonance (eg, proton) imaging, lower extremity other than joint; without contrast material(s) Magnetic resonance (eg, proton) imaging, lower extremity other than joint; with contrast material(s) Magnetic resonance (eg, proton) imaging, lower extremity other than joint; without contrast material(s), followed by contrast material(s) and further sequences Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material(s), followed by contrast material(s) and further sequences Magnetic resonance (eg, proton) imaging, abdomen; without contrast material(s) Magnetic resonance (eg, proton) imaging, abdomen; without contrast material(s), followed by with contrast material(s) and further sequences 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; not requiring image postprocessing on an independent workstation Duplex scan of extremity veins including responses to compression and other maneuvers; complete bilateral study
UB Revenue Code
CPT/HCPCS
612
72156
7311.15
612
72157
7291.94
612
72158
7617.71
610
72195
1333.47
610
72196
1790.71
610
72197
6015.45
610
73218LT
3083.85
610
73220LT
6979.35
610
73221LT
3731.63
610
73222LT
1790.71
610
73223LT
2164.59
610
73718RT
2889.60
610
73719LT
1790.71
610
73720RT
6584.03
610
73721RT
3954.98
610
73723RT
6785.10
610
74181
3725.22
610
74183
6979.22
610
76376
166.32
402
93970
554.18
Amount
128 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4670
416100030-30
US VEIN MAPPING UNLTRL LEFT
4670
416100090-90
US VEIN MAPPING UNILAT RIGHT
4670
416121552-21552 US NECK/THORAX SOFT TISSUE BX SC
4670
416133926-33926 US ARTERIAL LOW EXTREMITY RT
4670
416133931-33931 US ARTERIAL UPPER EXT RT
4670
416133971-33971 US VENOUS EXTREMITY RT
4670
416136642-36642 US BREAST LIMITED, BILAT
4670
416136645-36645 US BREAST COMPLETE, BILAT
4670
416138222-38222 US BONE MARROW ASPIRATION SC
4670
416149083-49083 US ABD PARACENTESS W/IMGNG
4670
416150202-50202 US RENAL BIOPSY
4670
416156642-56642 US BREAST LIMITED, RT
4670
416156880-56880 US EXTREMITY NON-VASCULAR RT
4670
416166645-66645 US BREAST COMPLETE, RT
4670
416175987-75987 US ABSCESS DRAIN GUIDANCE
4670
416176506-76506 US INTRACRANIAL
4670
416176536-76536 US SOFT TISSUE NECK/HEAD
4670
416176604-76604 US CHEST
4670
416176642-76642 US BREAST LIMITED, LT
4670
416176645-76645 US BREAST COMPLETE, LT
4670
416176700-76700 US ABDOMEN COMPLETE SONOGRAM
4670
416176701-76701 US ABDOMEN LIMITED ASCITES
Long Description Duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study Duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study Biopsy, soft tissue of neck or thorax Duplex scan of lower extremity arteries or arterial bypass grafts; unilateral or limited study Duplex scan of upper extremity arteries or arterial bypass grafts; unilateral or limited study Duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; limited Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete Diagnostic bone marrow; aspiration(s) Abdominal paracentesis (diagnostic or therapeutic); with imaging guidance Renal biopsy; percutaneous, by trocar or needle Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; limited Ultrasound, limited, joint or other nonvascular extremity structure(s) (eg, joint space, peri-articular tendon[s], muscle[s], nerve[s], other soft-tissue structure[s], or soft-tissue mass[es]), real-time with image documentation Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete Radiological guidance (ie, fluoroscopy, ultrasound, or computed tomography), for percutaneous drainage (eg, abscess, specimen collection), with placement of catheter, radiological supervision and interpretation Echoencephalography, real time with image documentation (gray scale) (for determination of ventricular size, delineation of cerebral contents, and detection of fluid masses or other intracranial abnormalities), including A-mode encephalography as secondary component where indicated Ultrasound, soft tissues of head and neck (eg, thyroid, parathyroid, parotid), real time with image documentation Ultrasound, chest (includes mediastinum), real time with image documentation Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; limited Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete Ultrasound, abdominal, real time with image documentation; complete Ultrasound, abdominal, real time with image documentation; limited (eg, single organ, quadrant, follow-up)
UB Revenue Code
CPT/HCPCS
402
93971LT
1013.25
402
93971RT
1013.25
402
21550
4419.05
921
93926RT
391.27
921
93931RT
391.27
920
93971RT
391.27
402
7664250
322.62
402
7664150
322.62
361
38220
4718.16
402
49083
2447.79
361
50200
2811.02
402
76642RT
322.62
402
76882RT
254.36
402
76641RT
322.62
402
75989
309.10
402
76506
254.36
402
76536
618.70
402
76604
488.16
402
76642LT
322.62
402
76641LT
322.62
402
76700
543.99
402
76705
608.51
Amount
129 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
Long Description Ultrasound, abdominal, real time with image documentation; limited (eg, single organ, quadrant, follow-up) Ultrasound, abdominal, real time with image documentation; limited (eg, single organ, quadrant, follow-up) Ultrasound, abdominal, real time with image documentation; limited (eg, single organ, quadrant, follow-up) Ultrasound, abdominal, real time with image documentation; limited (eg, single organ, quadrant, follow-up)
UB Revenue Code
CPT/HCPCS
402
76705
608.51
402
76705
608.51
402
76705
608.51
402
76705
608.51
Amount
4670
416176705-76705 US GALLBLADDER SONOGRAM
4670
416176706-76706 US PANCREAS SONOGRAM
4670
416176707-76707 US LIVER SONOGRAM
4670
416176708-76708 US SPLEEN SONOGRAM
4670
416176709-76709 US RENAL
Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; complete
402
76770
777.29
4670
416176770-76770 US AORTA SONOGRAM
Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; complete
402
76770
777.29
4670
416176775-76775 US RETROPERITONEAL W/IMAGE, LTD
Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; limited
402
76775
612.08
4670
416176800-76800 US SPINAL
402
76800
391.27
4670
416176801-76801 US OB <14WKS 1ST GESTATION
402
76801
600.81
4670
416176802-76802 US OB <14WKS ADD'L GESTATION
402
76802
254.36
4670
416176805-76805 US OB SONOGRAM COMPLETE
402
76805
459.93
4670
416176806-76806 US OB LIMITED
402
76815
612.48
416176810-76810 US OB MULTIPLE GESTATIONS
Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> or = 14 weeks 0 days), transabdominal approach; each additional gestation
402
76810
391.27
4670
416176816-76816 US OB FOLLOW-UP
Ultrasound, pregnant uterus, real time with image documentation, follow-up (eg, re-evaluation of fetal size by measuring standard growth parameters and amniotic fluid volume, re-evaluation of organ system(s) suspected or confirmed to be abnormal on a previous scan), transabdominal approach, per fetus
402
76816
414.75
4670
416176817-76817 US OB TRANSVAGINAL
402
76817
631.05
4670
416176830-76830 US TRANSVAGINAL SONOGRAM
402
76830
649.25
4670
416176856-76856 US PELVIC SONOGRAM NON-OB
402
76856
648.24
4670
416176857-76857 US OB PELVIC NON-OB FOLLICLES
402
76857
438.55
4670
416176870-76870 US SCROTAL SONOGRAM
402
76870
618.67
4670
416176880-76880 US EXTREMITY NON-VASCULAR LT
402
76882LT
254.36
4670
Ultrasound, spinal canal and contents Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (< 14 weeks 0 days), transabdominal approach; single or first gestation Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (< 14 weeks 0 days), transabdominal approach; each additional gestation Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> or = 14 weeks 0 days), transabdominal approach; single or first gestation Ultrasound, pregnant uterus, real time with image documentation, limited (eg, fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume), 1 or more fetuses
Ultrasound, pregnant uterus, real time with image documentation, transvaginal Ultrasound, transvaginal Ultrasound, pelvic (nonobstetric), real time with image documentation; complete Ultrasound, pelvic (nonobstetric), real time with image documentation; limited or follow-up (eg, for follicles) Ultrasound, scrotum and contents Ultrasound, limited, joint or other nonvascular extremity structure(s) (eg, joint space, peri-articular tendon[s], muscle[s], nerve[s], other soft-tissue structure[s], or soft-tissue mass[es]), real-time with image documentation
130 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4670
416176885-76885 US HIPS INFANT
4670
416176934-76934 US PARACENTESIS GUI
4670
416176935-76935 US THORACENTESIS GUDIANCE
4670
416176937-76937 UTZ GUIDE FOR VENOUS ACCESS
4670
416176938-76938 US CYST ASPIRATION GUIDE
4670
416176940-76940 US GUIDE, TISSUE ABLATION
4670
416176942-76942 US NEEDLE BIOPSY GUIDANCE
4670
416176943-76943 US NEEDLE LOCALIZATION
4670
416176986-76986 US INTRAOPERATIVE
4670
416193880-93880 US CAROTID DOPPLER BILATE
4670
416193882-93882 US CAROTID DOPPLER UNILAT
4670
416193886-93886 US TRANSCRANIAL DOPPLER COMPLETE
4670
416193922-93922 US ANKLE BRACHIAL INDEX LT
4670
416193925-93925 US ARTERIAL LOWER EXT BILAT
4670
416193926-93926 US ARTERIAL LOW EXTREMITY LT
4670
416193930-93930 US ARTERIAL UPPER EXT BILAT
4670
416193931-93931 US ARTERIAL UPPER EXT LT
4670
416193970-93970 US VENOUS EXTREMITY BILAT COMPLET
4670
416193971-93971 US VENOUS EXTREMITY LT
4670
416193975-93975 US ARTERIAL/VEN IN/OUT FL BILAT
Long Description Ultrasound, infant hips, real time with imaging documentation; dynamic (requiring physician or other qualified health care professional manipulation) Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation Ultrasound guidance for, and monitoring of, parenchymal tissue ablation Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation Ultrasonic guidance, intraoperative Duplex scan of extracranial arteries; complete bilateral study Duplex scan of extracranial arteries; unilateral or limited study Transcranial Doppler study of the intracranial arteries; complete study Limited bilateral noninvasive physiologic studies of upper or lower extremity arteries, (eg, for lower extremity: ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus bidirectional, Doppler waveform recording and analysis at 1-2 levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus volume plethysmography at 1-2 levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries with transcutaneous oxygen tension measurements at 1-2 levels) Duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study Duplex scan of lower extremity arteries or arterial bypass grafts; unilateral or limited study Duplex scan of upper extremity arteries or arterial bypass grafts; complete bilateral study Duplex scan of upper extremity arteries or arterial bypass grafts; unilateral or limited study Duplex scan of extremity veins including responses to compression and other maneuvers; complete bilateral study Duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; complete study
UB Revenue Code
CPT/HCPCS
402
76885
254.36
402
76942
967.26
402
76942
967.26
402
76937
887.46
402
76942
967.26
402
76940
430.82
402
76942
967.26
402
76942
967.26
402
76998
418.11
921
93880
830.82
921
93882
799.58
921
93886
790.20
921
93922
262.06
921
93925
1148.70
921
93926LT
769.02
921
93930
1274.70
921
93931LT
889.14
920
93970
1340.46
921
93971LT
1022.86
921
93975
1373.66
Amount
131 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4670
416195583-95583 US BX BREAST 1ST LESION US IM
4670
467020030-20030 US GUIDE CATHET FLUID DRAINAGE
4670
467020160-20160 US PUNCT ASP - ABSC HEMAT CYST
4670
467027534-27534 US PLACE BIL DRN CATH, INT/EXT
4670
467032513-32513 US PERC VERTEBRAL AUG, THORACIC
4670
467032514-32514 US PERC VERTEBRAL AUG, LUMBAR
4670
467032899-32899 US UNLISTED PROCEDURE, SPINE
4670
467042555-42555 US ASPIRATE PLEURA W/ IMAGING
4670
467042557-42557 US INSERT CATH PLEURA W/ IMAGE
4670
467059185-59185 US SCLEROTX FLUID COLLECTION
4670
467070300-70300 US ASPIR/INJ THYROID CYST
4670
467093981-93981 US DUPLX FLOW PENIL VESSEL FU/LMT
4680
416200016-16
CT LOWER EXTS WO CONT BILAT
4680
416200017-17
CT LOWER EXT WO CONT LT
4680
416200018-18
CT LOWER EXTS W CONT BILAT
4680
416200019-19
CT LOWER EXT W/CONT LT
Long Description Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including ultrasound guidance Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst), soft tissue (eg, extremity, abdominal wall, neck), percutaneous Puncture aspiration of abscess, hematoma, bulla, or cyst Placement of biliary drainage catheter, percutaneous, including diagnostic cholangiography when performed, imaging guidance (eg, ultrasound and/or fluoroscopy), and all associated radiological supervision and interpretation; internal-external 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 imaging guidance; thoracic 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 imaging guidance; lumbar Unlisted procedure, spine Thoracentesis, needle or catheter, aspiration of the pleural space; with imaging guidance Pleural drainage, percutaneous, with insertion of indwelling catheter; with imaging guidance Sclerotherapy of a fluid collection (eg, lymphocele, cyst, or seroma), percutaneous, including contrast injection(s), sclerosant injection(s), diagnostic study, imaging guidance (eg, ultrasound, fluoroscopy) and radiological supervision and interpretation when performed Aspiration and/or injection, thyroid cyst Duplex scan of arterial inflow and venous outflow of penile vessels; follow-up or limited study Computed tomography, lower extremity; without contrast material Computed tomography, lower extremity; without contrast material Computed tomography, lower extremity; with contrast material(s) Computed tomography, lower extremity; with contrast material(s) Incision and drainage of hematoma, seroma or fluid collection Puncture aspiration of abscess, hematoma, bulla, or cyst Biopsy, bone, trocar, or needle; superficial (eg, ilium, sternum, spinous process, ribs) Biopsy, bone, trocar, or needle; deep (eg, vertebral body, femur)
UB Revenue Code
CPT/HCPCS
361
19083
2419.26
402
10030
1885.74
402
10160
1023.54
402
47534
7711.68
402
22513
18264.42
402
22514
18264.42
402
22899
698.97
402
32555
2393.01
402
32557
2393.01
402
49185
1885.74
402
60300
1885.74
920
93981
400.62
352
7370050
1515.74
352
73700LT
1515.74
352
7370150
2325.40
352
73701LT
2325.40
361
10140
5630.10
361
10160
494.21
361
20220
2299.10
361
20225
4419.05
Amount
4680
416210141-10141 CT HEMATOMA DRAINAGE SC
4680
416210161-10161 CT HEMATOMA ASPIRATION SC
4680
416220221-20221 CT BONE BIOSPY SUPERFICIAL SC
4680
416220226-20226 CT BONE BIOPSY DEEP SC
4680
416232021-32021 CT CHEST TUBE INSERTION
Tube thoracostomy, includes connection to drainage system (eg, water seal), when performed, open
361
32551
1624.57
4680
416232406-32406 CT LUNG/MEDIASTINUM BX
Biopsy, lung or mediastinum, percutaneous needle;
361
32405
2811.02
132 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4680
416232557-32557 CT PLEURAL DRAIN W/INDWEL CATH
4680
416233706-33706 CT ANGIO LOWER EXT W/WO BIL
4680
416243200-43200 CT UPPER EXT W/O CONT- LT
4680
416243206-43206 CT ANGIO UPPER EXT W/WO C-LT
4680
416247001-47001 CT LIVER BIOPSY
4680
416247009-47009 CT LIVER CYST ASPIRATION PROC RM
4680
416250201-50201 CT RENAL BX, PERC NEEDLE
4680
416250380-50380 CT RENAL CYST/PELVIS ASP/INJ
4680
416252555-52555 CT ASPIRATE PLEURA W/IMGNG
4680
416253200-53200 CT UPPER EXT W/O CONT- RT
4680
416253201-53201 CT UPPER EXT W/CONT-RT
4680
416253202-53202 CT UPPER EXT W/WO CONT-RT
4680
416253206-53206 CT ANGIO UPPER EXT W/WO C-RT
4680
416253706-53706 CT ANGIO LOWER EXT W/WO C-RT
4680
416259083-59083 CT ABD PARACENTESIS W IMG GUID
4680
416270450-70450 CT BRAIN W/O CONTRAST
4680
416270460-70460 CT BRAIN WITH CONTRAST
4680
416270470-70470 CT BRAIN W/WO CONTRAST
4680
416270490-70490 CT NECK SOFT TISSUE WO/CONT
4680
416270491-70491 CT NECK SOFT TISSUE W/CONT
4680
416270492-70492 CT NECK SOFT TISSUE W/WO CONT
4680
416270496-70496 CT ANGIO HEAD W/WO CONTRAST
4680
416270498-70498 CT ANGIO NECK W/WO CONTRAST
4680
416270510-70510 CT FACE,SINUS,MAXILLA W/O
4680
416270511-70511 CT FACE,SINUS,MAXILLA W CONT
4680
416270512-70512 CT FACE,SINUS,MAXILLA W/WO
Long Description Pleural drainage, percutaneous, with insertion of indwelling catheter; with imaging guidance Computed tomographic angiography, lower extremity, with contrast material(s), including noncontrast images, if performed, and image postprocessing Computed tomography, upper extremity; without contrast material Computed tomographic angiography, upper extremity, with contrast material(s), including noncontrast images, if performed, and image postprocessing Biopsy of liver, needle; percutaneous Hepatotomy, for open drainage of abscess or cyst, 1 or 2 stages Renal biopsy; percutaneous, by trocar or needle Aspiration and/or injection of renal cyst or pelvis by needle, percutaneous Thoracentesis, needle or catheter, aspiration of the pleural space; with imaging guidance Computed tomography, upper extremity; without contrast material Computed tomography, upper extremity; with contrast material(s) Computed tomography, upper extremity; without contrast material, followed by contrast material(s) and further sections Computed tomographic angiography, upper extremity, with contrast material(s), including noncontrast images, if performed, and image postprocessing Computed tomographic angiography, lower extremity, with contrast material(s), including noncontrast images, if performed, and image postprocessing Abdominal paracentesis (diagnostic or therapeutic); with imaging guidance Computed tomography, head or brain; without contrast material Computed tomography, head or brain; with contrast material(s) Computed tomography, head or brain; without contrast material, followed by contrast material(s) and further sections Computed tomography, soft tissue neck; without contrast material Computed tomography, soft tissue neck; with contrast material(s) Computed tomography, soft tissue neck; without contrast material followed by contrast material(s) and further sections Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image postprocessing Computed tomographic angiography, neck, with contrast material(s), including noncontrast images, if performed, and image postprocessing Computed tomography, maxillofacial area; without contrast material Computed tomography, maxillofacial area; with contrast material(s) Computed tomography, maxillofacial area; without contrast material, followed by contrast material(s) and further sections
UB Revenue Code
CPT/HCPCS
361
32557
1624.56
352
7370650
3405.15
352
73200LT
1509.90
352
73206LT
1336.42
350
47000
2811.02
360
47010
2993.30
361
50200
2811.02
361
50390
2811.02
361
32555
1547.21
352
73200RT
1509.90
352
73201RT
1675.80
352
73202TCRT
1297.40
352
73206RT
1336.42
352
73706RT
3405.15
350
49083
2602.23
351
70450
1694.95
351
70460
1957.62
351
70470
2481.90
351
70490
1725.36
351
70491
2004.08
351
70492
2738.40
351
70496
2177.76
351
70498
2173.16
351
70486
1848.16
351
70487
2079.90
350
70488
1297.40
Amount
133 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4680
416270530-70530 CT MASTOIDS ORBIT SELLA W/O
4680
416270531-70531 CT MASTOIDS ORBIT SELLA WITH
4680
416270532-70532 CT MASTOIDS ORBIT SELLA W/WO
4680
416271250-71250 CT CHEST W/ O CONT
4680
416271260-71260 CT CHEST W/CONT
4680
416271270-71270 CT CHEST W/WO
4680
416271275-71275 CT ANGIO CHEST
4680
416272125-72125 CT C-SPINE WO/CONT
4680
416272126-72126 CT C-SPINE W/CONT
4680
416272128-72128 CT T-SPINE WO CONT
4680
416272129-72129 CT T-SPINE W/CONT
4680
416272131-72131 CT L-SPINE WO/CONT
4680
416272132-72132 CT L-SPINE W/CONT
4680
416272133-72133 CT L-SPINE W/WO CONT
4680
416272192-72192 CT PELVIS W/O CONT
4680
416272193-72193 CT PELVIS W/CONT
4680
416272194-72194 CT PELVIS W/WO CONT
4680
416273201-73201 CT UPPER EXT W/CONT-LT
4680
416273202-73202 CT UPPER EXT W/WO CONT-LT
4680
416273206-73206 CT ANGIO UPPER EXT W/WO C-BILAT
4680
416273700-73700 CT LOWER EXT WO CONT RT
4680
416273701-73701 CT LOWER EXT W/CONTR RT
4680
416273702-73702 CT LOWER EXT W/WO CONT LT
4680
416273706-73706 CT ANGIO LOWER EXT W/WO C-LT
Long Description Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; with contrast material(s) Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material, followed by contrast material(s) and further sections Computed tomography, thorax; without contrast material Computed tomography, thorax; with contrast material(s) Computed tomography, thorax; without contrast material, followed by contrast material(s) and further sections Computed tomographic angiography, chest (noncoronary), with contrast material(s), including noncontrast images, if performed, and image postprocessing Computed tomography, cervical spine; without contrast material Computed tomography, cervical spine; with contrast material Computed tomography, thoracic spine; without contrast material Computed tomography, thoracic spine; with contrast material Computed tomography, lumbar spine; without contrast material Computed tomography, lumbar spine; with contrast material Computed tomography, lumbar spine; without contrast material, followed by contrast material(s) and further sections Computed tomography, pelvis; without contrast material Computed tomography, pelvis; with contrast material(s) Computed tomography, pelvis; without contrast material, followed by contrast material(s) and further sections Computed tomography, upper extremity; with contrast material(s) Computed tomography, upper extremity; without contrast material, followed by contrast material(s) and further sections Computed tomographic angiography, upper extremity, with contrast material(s), including noncontrast images, if performed, and image postprocessing Computed tomography, lower extremity; without contrast material Computed tomography, lower extremity; with contrast material(s) Computed tomography, lower extremity; without contrast material, followed by contrast material(s) and further sections Computed tomographic angiography, lower extremity, with contrast material(s), including noncontrast images, if performed, and image postprocessing
UB Revenue Code
CPT/HCPCS
351
70480
683.82
351
70481
1170.61
351
70482
1297.40
352
71250
1418.55
352
71260
2450.50
352
71270
1829.10
352
71275
3047.10
352
72125
2895.00
352
72126
3409.56
352
72128
2860.27
352
72129
3355.80
352
72131
2315.32
352
72132
3019.80
352
72133
2614.50
352
72192
2193.63
352
72193
2544.15
352
72194
1297.40
352
73201LT
1675.80
352
73202TCLT
1297.40
352
7320650
1336.42
352
73700RT
1515.74
352
73701RT
2325.40
352
73702LT
1297.40
352
73706LT
3405.15
Amount
134 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4680
416274150-74150 CT ANDOMEN W/O CONT
4680
416274160-74160 CT ABDOMEN W/CONT
4680
416274170-74170 CT ABDOMEN W/WO CONT
4680
416274174-74174 CT ANGIO ABDOMEN &PELV W/WO
4680
416274175-74175 CT ANGIO ABDOMEN W/WO CONTRAST
4680
416274176-74176 CT ABD & PELVIS W/O CONTRAST
4680
416274177-74177 CT ABD & PELVIS W/CONTAST
4680
416274178-74178 CT ABD & PELVIS, W/WO
4680
416275635-75635 CT ANGIO ABD & ILIOFEM RUNOFFS
4680
416275988-75988 CT NEEDLE GUID W DRAINAGE CATH
4680
416276360-76360 CT NEEDLE BX GUIDANCE
4680
416276365-76365 CT GUIDE BX ASP, INJ, LOCALIZ
4680
416276375-76375 CT 3D RENDERING
4680
416276377-76377 CT 3-D RENDERING WORKSTATION
4680
468000421-421 CT PERFUSION W/CONTRAST CBF
4680
468030030-30030 CT GUIDE CATH FLUID DRN,SOFT TISS
4680
468059082-59082 CT ABD PARACENTESIS WO IMG GUID
Long Description Computed tomography, abdomen; without contrast material Computed tomography, abdomen; with contrast material(s) Computed tomography, abdomen; without contrast material, followed by contrast material(s) and further sections Computed tomographic angiography, abdomen and pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing Computed tomographic angiography, abdomen, with contrast material(s), including noncontrast images, if performed, and image postprocessing Computed tomography, abdomen and pelvis; without contrast material Computed tomography, abdomen and pelvis; with contrast material(s) Computed tomography, abdomen and pelvis; without contrast material in one or both body regions, followed by contrast material(s) and further sections in one or both body regions Computed tomographic angiography, abdominal aorta and bilateral iliofemoral lower extremity runoff, with contrast material(s), including noncontrast images, if performed, and image postprocessing Radiological guidance (ie, fluoroscopy, ultrasound, or computed tomography), for percutaneous drainage (eg, abscess, specimen collection), with placement of catheter, radiological supervision and interpretation Computed tomography guidance for needle placement (eg, biopsy, aspiration, injection, localization device), radiological supervision and interpretation Computed tomography guidance for needle placement (eg, biopsy, aspiration, injection, localization device), radiological supervision and interpretation 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; not requiring image postprocessing on an independent workstation 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; requiring image postprocessing on an independent workstation Cerebral perfusion analysis using computed tomography with contrast administration, including post-processing of parametric maps with determination of cerebral blood flow, cerebral blood volume, and mean transit time Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst), soft tissue (eg, extremity, abdominal wall, neck), percutaneous Abdominal paracentesis (diagnostic or therapeutic); without imaging guidance
UB Revenue Code
CPT/HCPCS
352
74150
1999.85
352
74160
2472.34
352
74170
3042.90
352
74174
5573.13
352
74175
2439.85
352
74176
4148.29
352
74177
5399.30
352
74178
6273.38
352
75635
2987.02
350
75989
1913.10
350
77012
2928.35
350
77012
2928.35
350
76376
1344.75
350
76377
194.25
350
0042T
1632.00
350
10030
2004.99
350
49082
2602.23
Amount
135 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4680
468059405-59405 CT IMAGE CATH FLUID COLL/DRN VISC
4680
468059406-59406 CT IMG CATH FLUID COLL PERI/RETRO
4680
468059407-59407 CT IMG CATH FLUID COLL TRNS/VGNL
4720
418000001-1
Long Description Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst); visceral (eg, kidney, liver, spleen, lung/mediastinum), percutaneous Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst); peritoneal or retroperitoneal, percutaneous Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst); peritoneal or retroperitoneal, transvaginal or transrectal
02 THERAPY PER HOUR
4720
418000040-40
CHEST PT, INIT OR EVAL
4720
418000200-200 VENT ASSIST & MGT 1ST DAY
4720
418000201-201 VENT ASSIST & MGT SUBSQ
4720
418000212-212 AIRWAY INHALATION TREATMENT
4720
418000303-303 AREOSOL - EVAL
4720
418000366-366 ARTERIAL PUNCTURE BLOOD FOR DX
4720
418000502-502 SINGLE DETERMIN. PULSE OXIMETY
4720
418000503-503 CO EXPIRED GAS BY IR
4720
418000506-506 SPUTUM INDUCTION
4720
418000507-507 INTUBATION ET EMERGENT
4720
418000512-512 PULSE OX MULTIPLE
4720
418000591-591 CELL SAVER RECLAMATION - BLOOD
4720
418000701-701 CHEST PT, SUBSEQUENT
4720
418000900-900 POS AIRWAY PRESSURE CPAP SUB
4720
418000901-901 POS AIRWAY PRESSURE CPAP INT
4720
418000930-930 TOTAL VITAL CAPACITY
4720
418000940-940 SURFACTANT ADMIN THRU TUBE
4720
418000950-950 CARDIOPULMONARY RESUSCITATION
4720
418000952-952 CBT 1ST HOUR
UB Revenue Code
CPT/HCPCS
350
49405
4718.16
350
49406
4718.16
350
49407
4718.16
271 Manipulation chest wall, such as cupping, percussing, and vibration to facilitate lung function; initial demonstration and/or evaluation Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; hospital inpatient/observation, initial day Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; hospital inpatient/observation, each subsequent day Pressurized or nonpressurized inhalation treatment for acute airway obstruction for therapeutic purposes and/or for diagnostic purposes such as sputum induction with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device Arterial puncture, withdrawal of blood for diagnosis Noninvasive ear or pulse oximetry for oxygen saturation; single determination Carbon dioxide, expired gas determination by infrared analyzer Pressurized or nonpressurized inhalation treatment for acute airway obstruction for therapeutic purposes and/or for diagnostic purposes such as sputum induction with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device Intubation, endotracheal, emergency procedure Noninvasive ear or pulse oximetry for oxygen saturation; multiple determinations (eg, during exercise)
46.07
410
94667
233.10
410
94002
1991.00
410
94003
1979.25
412
94640
177.48
412
94664
529.41
410
36600
322.98
460
94760
96.74
460
94770
708.56
412
94640
177.48
361
31500
633.58
460
94761
123.90
272 Manipulation chest wall, such as cupping, percussing, and vibration to facilitate lung function; subsequent Continuous positive airway pressure ventilation (CPAP), initiation and management Continuous positive airway pressure ventilation (CPAP), initiation and management Vital capacity, total Intrapulmonary surfactant administration by a physician or other qualified health care professional through endotracheal tube
Amount
840.00
410
94668
138.22
410
94660
468.30
410
94660
468.30
460
94150
177.51
460
94610
193.41
Cardiopulmonary resuscitation (eg, in cardiac arrest)
410
92950
633.58
Continuous inhalation treatment with aerosol medication for acute airway obstruction; first hour
410
94644
352.89
136 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4720
418000953-953 CBT EACH ADDL HOUR
4720
418000960-960 CATHETER ASPIRATION
4720
418086891-86891 CELL SAVER-BLOOD RECLAMATION
4720
418086892-86892 CRASH CALLS (NEWBORN)
4720
418086894-86894 CRASH CALL WITH PPV
4720
418094010-94010 SPIROMETRY
4720
472031625-31625 BRONCHOSCOPY W/BIOPSY(S)
4720
472031652-31652 BRONCH EBUS SAMPLNG 1/2 NODE
4720
472031653-31653 BRONCH EBUS SAMPLNG 3/> NODE
4720
472031654-31654 BRONCH EBUS IVNTJ PERPH LES
Long Description Continuous inhalation treatment with aerosol medication for acute airway obstruction; each additional hour Catheter aspiration; nasotracheal Autologous blood or component, collection processing and storage; intra- or postoperative salvage Attendance at delivery (when requested by the delivering physician or other qualified health care professional) and initial stabilization of newborn Delivery/birthing room resuscitation, provision of positive pressure ventilation and/or chest compressions in the presence of acute inadequate ventilation and/or cardiac output Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement(s), with or without maximal voluntary ventilation Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial or endobronchial biopsy(s), single or multiple sites Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with endobronchial ultrasound (EBUS) guided transtracheal and/or transbronchial sampling (eg, aspiration[s]/biopsy[ies]), one or two mediastinal and/or hilar lymph node stations or structures Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with endobronchial ultrasound (EBUS) guided transtracheal and/or transbronchial sampling (eg, aspiration[s]/biopsy[ies]), 3 or more mediastinal and/or hilar lymph node stations or structures Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transendoscopic endobronchial ultrasound (EBUS) during bronchoscopic diagnostic or therapeutic intervention(s) for peripheral lesion(s) (List separately in addition to code for primary procedure[s]) Oxygen uptake, expired gas analysis; rest, indirect
UB Revenue Code
CPT/HCPCS
410
94645
325.75
410
31720
529.41
302
86891
1560.42
722
99464
254.78
720
99465
626.96
460
94010
167.07
361
31625
3675.00
361
31652
7055.70
361
31653
7055.70
361
31654
722.22
460 999 272
94690 C1757
175.42 175.42 1157.53
360
31620
921.04
361
31622
2482.61
360
31629
6193.58
Amount
4730 4730 4730
40804305-4305 OXYGEN UPTAKE REST INDIRECT 408000012-12 BRONCHOSCOPY TECH TIME 15 MINS EA 408000098-98 FOGERTY CATHETER
4730
408001620-1620 ENDOBRONCHIAL US ADD-ON
4730
408001621-1621 DX BRONCHOSCOPE/WASH
4730
408001629-1629 NEEDLE ASPIRAION
4730
408004004-4004 PRE/POST SPIROMETRY
Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration
460
94060
627.65
4730
408004005-4005 TOTAL VITAL CAPACITY
Vital capacity, total
460
94150
431.69
4730
408004010-4010 SPIROMETRY
Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement(s), with or without maximal voluntary ventilation
460
94010
295.81
4730
408004260-4260 PF_THORACIC GAS VOLUME
Thoracic gas volume
460
94260
188.31
Catheter, thrombectomy/embolectomy Endobronchial ultrasound (EBUS) during bronchoscopic diagnostic or therapeutic intervention(s) (List separately in addition to code for primary procedure[s]) Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; diagnostic, with cell washing, when performed Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial needle aspiration biopsy(s), trachea, main stem and/or lobar bronchus(i)
137 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
Long Description
UB Revenue Code
CPT/HCPCS
Diffusing capacity (eg, carbon monoxide, membrane)
460
94729
333.50
460
94727
175.42
460
94360
207.00
460
94370
353.63
460
94726
780.51
CDM Description
Amount
4730
408004300-4300 CO DIFFUSION CAPACITY
4730
408004350-4350 PULM FUNCTION TEST BY GAS
4730
408004360-4360 PF_DETERMIN OF RESIST TO AIRFL
4730
408004370-4370 PF DETERMINATION CLOSING VOL
4730
408004380-4380 PULM FUNCT TST PLETHYSMOGRAP
4730
408004390-4390 CO/ MEMBANE DIFFUSE CAPACITY
Diffusing capacity (eg, carbon monoxide, membrane)
460
94729
211.08
4730
408004612-4612 FUNCTIONAL RESIDUAL CAPACITY
Functional residual capacity or residual volume: helium method, nitrogen open circuit method, or other method
460
94240
204.13
4730
408004615-4615 CO DIFFUSION CAPACITY RESULT
Diffusing capacity (eg, carbon monoxide, membrane)
460
94729
212.75
460
94070
517.50
460
94240
140.88
410
94640
529.41
272 272
A4215
407.54 20.67
460
94618TC
367.65
510
G0463
212.98
510
G0463
485.29
510
G0463
150.00
510
G0463
276.44
510
G0463
276.44
510
G0463
363.79
391 391 391 270 710 710 272 272 272 272 272 272 272 272 272 272
36430 36430 36430
651.43 977.15 1302.84 63.25 359.38 179.69 525.00 621.00 580.00 440.00 200.00 512.00 2400.00 785.40 93.30 87.15
4730
408004621-4621 EVALUATION OF WHEEZING
4730
408004623-4623 FUNCTIONAL RESIDUAL CAPACITY
4730
408004640-4640 AIRWAY INHALATION TREATMENT
4730 4730
408004804-4804 STERILE NEEDLE 408004805-4805 MIP/MEP
4730
473094618-94618 PULMONARY STRESS TESTING
4760
476000001-1
HOSPITAL OUTPT CLINIC VISIT
4760
476000004-4
HOSPITAL OUTPT CLINIC VISIT
4760
476000006-6
HOSPITAL OUTPT CLINIC VISIT
4760
476000007-7
HOSPITAL OUTPT CLINIC VISIT
4760
476000008-8
HOSPITAL OUTPT CLINIC VISIT
4760
476000009-9
HOSPITAL OUTPT CLINIC VISIT
4760 4760 4760 4760 4760 4760 4760 4760 4760 4760 4760 4760 4760 4760 4760 4760
476000297-297 476000298-298 476000299-299 476000302-302 476000303-303 476000304-304 476000365-365 476000366-366 476000367-367 476000369-369 476000375-375 476000378-378 476000410-410 476000413-413 476000414-414 476000417-417
BLOOD TRANSFUSION 1-3 HRS BLOOD TRANSFUSION 4-6 HRS BLOOD TRANSFUSION 7+ HRS IV INF NS SOL 500ML, STERILE RECOVERY ROOM 1ST HOUR RECOVERY ROOM ADDTL 30 MIN SPHINCTERTOME GUIDEWIRE NEEDLE KNIFE CYTOLOGY BRUSH SCLEROTHERAPY NEEDLE EXTRACTION BALLOON GOLD PROBE BIOPSY FORCEPS MULTI-BAND LIGATOR CAPTIFLEX SNARE BIOPSY FORCEP
Gas dilution or washout for determination of lung volumes and, when performed, distribution of ventilation and closing volumes Determination of resistance to airflow, oscillatory or plethysmographic methods Determination of airway closing volume, single breath tests Plethysmography for determination of lung volumes and, when performed, airway resistance
Bronchospasm provocation evaluation, multiple spirometric determinations as in 94010, with administered agents (eg, antigen[s], cold air, methacholine) Functional residual capacity or residual volume: helium method, nitrogen open circuit method, or other method Pressurized or nonpressurized inhalation treatment for acute airway obstruction for therapeutic purposes and/or for diagnostic purposes such as sputum induction with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device Needle, sterile, any size, each Pulmonary stress testing (eg, 6-minute walk test), including measurement of heart rate, oximetry, and oxygen titration, when performed Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Hospital outpatient clinic visit for assessment and management of a patient Transfusion, blood or blood components Transfusion, blood or blood components Transfusion, blood or blood components
Guide wire Guide wire
Needle, sterile, any size, each
C1769 C1769
A4215
138 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
4760 4760 4760 4760 4760 4760 4760 4760 4760 4760 4760 4760 4760 4760
476000418-418 476000419-419 476000422-422 476000424-424 476000425-425 476000426-426 476000427-427 476000429-429 476000482-482 476000490-490 476000491-491 476000492-492 476000495-495 476000497-497
4760
CDM Description CENTRAL LINE KIT CRE BALLOON AND SYRINGE HUBER NEEDLE LITHOTRIPTOR PEG KIT RESLOUTION CLIPS SPIDER-NET THERAPEUTIC PHLEBOTOMY KIT SPOT INK TREATMENT ROOM LVL 1-1ST HOUR TREATMENT RM LVL 1-ADDTL 30MIN TREATMENT ROOM LVL 2-1ST HOUR GASTRO PROCEDURE LVL 1-1ST HR GASTRO PROCEDURE LVL 2-1ST HR
476000500-500 MOD SED GASTRO ENDO SRVC >=5 YRS
4760
476000520-520 INITAL IV INFUSION =<1 HR
4760
476000521-521 IV PUSH, SNGL OR INITIAL DRUG
4760
476000522-522 HYDRATION, IV INF, INIT 31-60
4760
476000530-530 IV INFUSION, EA ADDTL HOUR
4760
476000531-531 IV INF, ADDTL SEQ NEW RX =<1HR
4760
476000532-532 IV PUSH, ADDTL SEQ NEW DRUG
4760
476000533-533 IV PUSH, ADDTL SEQ SAME DRUG
4760
476000534-534 HYDRATION, IV INFUS, EA ADDT H
4760
476000540-540 THER/PROPH/DIAG INJ, SC/IM
4760
476000775-775 PICC LINE KIT
4760
476004826-4826 ERCP STENT STRIGHT
4760
476004837-4837 ESSURE IMPLANT-UNILATERAL, ESS305
4760
476004838-4838 ESSURE IMPLANT-BILATERAL, ESS305
4760
476095180-95180 RAPID DESENSITIZATION PER HOUR
Long Description
Needle, sterile, any size, each
Moderate sedation services provided by the same physician or other qualified health care professional performing a gastrointestinal endoscopic service that sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time; patient age 5 years or older (additional time may be reported with 99153, as appropriate) Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug Intravenous infusion, hydration; initial, 31 minutes to 1 hour Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); additional sequential infusion of a new drug/substance, up to 1 hour Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of the same substance/drug provided in a facility Intravenous infusion, hydration; each additional hour Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular Catheter, infusion, inserted peripherally, centrally or midline (other than hemodialysis) Stent, non-coated/non-covered, with delivery system Permanent implantable contraceptive intratubal occlusion device(s) and delivery system Permanent implantable contraceptive intratubal occlusion device(s) and delivery system Rapid desensitization procedure, each hour (eg, insulin, penicillin, equine serum)
UB Revenue Code 272 272 272 272 272 272 272 272 272 761 761 761 750 750
CPT/HCPCS
A4215
Amount 41.25 750.00 26.50 852.00 870.00 700.00 325.00 47.30 105.00 1200.00 500.00 2200.00 2200.00 3500.00
379
G0500
285.47
260
96365
280.24
260
96374
146.82
260
96360
548.66
260
96366
101.34
260
96367
146.82
260
96375
146.82
260
96376
146.82
260
96361
115.41
260
96372
146.82
272
C1751
493.08
278
C1876
460.00
278
A4264
1875.00
278
A4264
3750.00
940
95180
922.08
139 of 167 Updated on 1/22/2019
Revenue Center
UB Revenue Code
CPT/HCPCS
260
96368
53.88
331
96409
628.80
331
96411
185.97
335
96413
977.49
335
96415
185.97
476099152-99152 MOD SED SAME PHYS/QHP >=5 YRS
Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older
379
99152
285.47
476099153-99153 MOD SED SAME PHYS/QHP ADDT 15 MIN
Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List separately in addition to code for primary service)
379
99153
132.74
476099156-99156 MOD SED OTH PHYS/QHP >=5 YRS
Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; initial 15 minutes of intraservice time, patient age 5 years or older
379
99156
285.47
476099157-99157 MOD SED OTH PHYS/QHP ADDT 15 MIN
Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; each additional 15 minutes intraservice time (List separately in addition to code for primary service)
379
99157
132.74
274
L1499
200.00
274
L4360
168.00
274
L3760
174.42
274
L1686
2106.78
274
L2624
1147.20
CDM Number
CDM Description
4760
476096368-96368 IV CONCURRENT INFUSION
4760
476096409-96409 CHEMO ADM IV PUSH, SNGL/INIT DRUG
4760
476096411-96411 CHEMO ADMIN IV PUSH, EA ADDT DRUG
4760
476096413-96413 CHEMO IV INF <=1H, SNGL/INIT DRUG
4760
476096415-96415 CHEMO ADMIN IV INFUS, EA ADDTL HR
4760
4760
4760
4760
4770
420000007-7
REMOVAL AND REAPPLY VEST
4770
420003067-3067 CAM WALKER BOOT
4770
420004009-4009 HINGED ELBOW BRACE
4770
420004012-4012 PREBAF POST HO
4770
420004013-4013 ADJ XTNSN HIP JNT EA
Long Description Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); concurrent infusion Chemotherapy administration; intravenous, push technique, single or initial substance/drug Chemotherapy administration; intravenous, push technique, each additional substance/drug Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug Chemotherapy administration, intravenous infusion technique; each additional hour
Spinal orthotic, not otherwise specified Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise Elbow orthosis (eo), with adjustable position locking joint(s), prefabricated, item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise Hip orthotic (HO), abduction control of hip joint, postoperative hip abduction type, prefabricated, includes fitting and adjustment Addition to lower extremity, pelvic control, hip joint, adjustable flexion, extension, abduction control, each
Amount
140 of 167 Updated on 1/22/2019
Revenue Center
UB Revenue Code
CPT/HCPCS
274
L2830
325.47
274 274 274
L8440 L3999 L3999
145.35 367.50 203.13
274
L0810
5957.36
274
L0859
2110.20
274
L1499
400.00
274
L0200
1789.02
420004032-4032 LOS SAGITTAL RIGID PANEL CUS
Lumbar sacral orthotic (LSO), sagittal-coronal control, lumbar flexion, rigid posterior frame/panels, lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to T9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, anterior panel, pendulous abdomen design, custom fabricated
274
L0636
3272.66
420004033-4033 TLSO 2PC PL SHELL W/LINER
Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, two piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, lateral strength is enhanced by overlapping plastic, restricts gross trunk motion in the sagittal, coronal, and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated
274
L0486
3894.90
420004034-4034 LSO SAGITTAL RIGID PANEL CUS
Lumbar sacral orthotic (LSO), sagittal-coronal control, lumbar flexion, rigid posterior frame/panels, lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to T9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, anterior panel, pendulous abdomen design, custom fabricated
274
L0636
3272.66
420004035-4035 LOS SAGIT RIDIG PANEL PREFAB
Lumbar-sacral orthotic (LSO), sagittal-coronal control, lumbar flexion, rigid posterior frame/panel(s), lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, anterior panel, pendulous abdomen design, prefabricated, includes fitting and adjustment
274
L0635
2210.72
CDM Number
CDM Description
4770
420004014-4014 SOFT MOLD ABOVE KNEE
4770 4770 4770
420004017-4017 SHRINKER BELOW KNEE 420004019-4019 UNLISTED ULTRA SLING 420004021-4021 SPLINT HAND SOFT
4770
420004025-4025 CERVHALO W JKT VEST
4770
420004026-4026 MRI COMPATIBALE HALO SYSTM
4770
420004028-4028 HALO REAPPLY RINGS/PINS
4770
420004031-4031 SOMI-MINERVA W/C-T
4770
4770
4770
4770
Long Description Addition to lower extremity orthotic, soft interface for molded plastic, above knee section Prosthetic shrinker, below knee, each Upper limb orthotic, not otherwise specified Upper limb orthotic, not otherwise specified Halo procedure, cervical halo incorporated into jacket vest Addition to halo procedure, magnetic resonance image compatible systems, rings and pins, any material Spinal orthotic, not otherwise specified Cervical, multiple post collar, occipital/mandibular supports, adjustable cervical bars, and thoracic extension
Amount
141 of 167 Updated on 1/22/2019
Revenue Center
4770
4770
Long Description
UB Revenue Code
CPT/HCPCS
420004036-4036 TLSO 2PC PL SHELL W/LINER
Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, two piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, lateral strength is enhanced by overlapping plastic, restricts gross trunk motion in the sagittal, coronal, and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated
274
L0486
3894.90
420004039-4039 ASPEN TLOS W 4 PLSTC SHELLS
Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, modular segmented spinal system, four rigid plastic shells, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment
274
L0464
2687.64
274
L1832
1886.26
274
L1844
3672.38
274
L1845
2132.70
420
G8978GPCH
0.01
420
G8978GPCI
0.01
420
G8978GPCJ
0.01
420
G8978GPCK
0.01
420
G8978GPCL
0.01
420
G8978GPCM
0.01
420
G8979GPCH
0.01
420
G8979GPCI
0.01
CDM Number
CDM Description
4770
420004049-4049 KO ADJ JNT POS RIGID SUP
4770
420004050-4050 KO W/ADJ JT ROT CNTRL MOLD
4770
420005041-5041 KO W/ADJ FLEX/EXT ROTAT
4770
420006011-6011 MOBILITY CURRENT STATUS-CH
4770
420006012-6012 MOBILITY CURRENT STATUS-CI
4770
420006013-6013 MOBILITY CURRENT STATUS-CJ
4770
420006014-6014 MOBILITY CURRENT STATUS-CK
4770
420006015-6015 MOBILITY CURRENT STATUS-CL
4770
420006016-6016 MOBILITY CURRENT STATUS-CM
4770
420006022-6022 MOBILITY GOAL STATUS-CH
4770
420006023-6023 MOBILITY GOAL STATUS-CI
Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise Knee orthotic (KO), single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated Knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise Mobility: walking & moving around functional limitation, current status, at therapy episode outset and at reporting intervals Mobility: walking & moving around functional limitation, current status, at therapy episode outset and at reporting intervals Mobility: walking & moving around functional limitation, current status, at therapy episode outset and at reporting intervals Mobility: walking & moving around functional limitation, current status, at therapy episode outset and at reporting intervals Mobility: walking & moving around functional limitation, current status, at therapy episode outset and at reporting intervals Mobility: walking & moving around functional limitation, current status, at therapy episode outset and at reporting intervals Mobility: walking & moving around functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Mobility: walking & moving around functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting
Amount
142 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4770
420006024-6024 MOBILITY GOAL STATUS-CJ
4770
420006032-6032 MOBILITY D/C STATUS-CH
4770
420006033-6033 MOBILITY D/C STATUS-CI
4770
420006034-6034 MOBILITY D/C STATUS-CJ
4770
420007822-7822 SPEECH/HEAR THRPY INDIV 30 MIN
4770
420007823-7823 SPEECH/HEAR THRPY INDIV 45 MIN
4770
420007830-7830 EVAL OF SPEECH FLUENCY 15 MIN
4770
420007831-7831 EVAL OF SPEECH FLUENCY 30 MIN
4770
420007832-7832 EVAL OF SPEECH FLUENCY 45 MIN
4770
420007834-7834 EVAL OF SPEECH FLUENCY 75 MIN
4770
420007835-7835 EVAL OF SPEECH FLUENCY 90 MIN
4770
420007836-7836 EVAL OF SPEECH FLUENCY 120 MIN
4770
420007840-7840 EVAL SPEECH PRODUCTION 15 MIN
4770
420007841-7841 EVAL SPEECH PRODUCTION 30 MIN
4770
420007842-7842 EVAL SPEECH PRODUCTION 45 MIN
4770
420007843-7843 EVAL SPEECH PRODUCTION 60 MIN
4770
420007845-7845 EVAL SPEECH PRODUCTION 90 MIN
4770
420007846-7846 EVAL SPEECH PRODUCTION 120 MIN
4770
420007850-7850 SPEECH SOUND LANG COMP 15 MIN
4770
420007851-7851 SPEECH SOUND LANG COMP 30 MIN
4770
420007852-7852 SPEECH SOUND LANG COMP 45 MIN
Long Description Mobility: walking & moving around functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Mobility: walking & moving around functional limitation, discharge status, at discharge from therapy or to end reporting Mobility: walking & moving around functional limitation, discharge status, at discharge from therapy or to end reporting Mobility: walking & moving around functional limitation, discharge status, at discharge from therapy or to end reporting Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual Evaluation of speech fluency (eg, stuttering, cluttering) Evaluation of speech fluency (eg, stuttering, cluttering) Evaluation of speech fluency (eg, stuttering, cluttering) Evaluation of speech fluency (eg, stuttering, cluttering) Evaluation of speech fluency (eg, stuttering, cluttering) Evaluation of speech fluency (eg, stuttering, cluttering) Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria): Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria): Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria): Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria): Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria): Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria): Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (eg, receptive and expressive language) Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (eg, receptive and expressive language) Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (eg, receptive and expressive language)
UB Revenue Code
CPT/HCPCS
420
G8979GPCJ
0.01
420
G8980GPCH
0.01
420
G8980GPCI
0.01
420
G8980GPCJ
0.01
440
92507GN
330.00
440
92507GN
495.00
444
92521GN
165.00
444
92521GN
330.00
444
92521GN
495.00
444
92521GN
825.00
444
92521GN
990.00
444
92521GN
1155.00
444
92522GN
165.00
444
92522GN
330.00
444
92522GN
495.00
444
92522GN
660.00
444
92522GN
990.00
444
92522GN
1155.00
444
92523GN
165.00
444
92523GN
330.00
444
92523GN
495.00
Amount
143 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4770
420007853-7853 SPEECH SOUND LANG COMP 60 MIN
4770
420007854-7854 SPEECH SOUND LANG COMP 75 MIN
4770
420007855-7855 SPEECH SOUND LANG COMP 90 MIN
4770
420007856-7856 SPEECH SOUND LANG COMP 120 MIN
4770
420007870-7870 TX SWALLOWING DYSFUNCTION15
4770
420007871-7871 TX SWALLOWING DYSFUNCTION 30
4770
420007872-7872 TX SWALLOWING DYSFUNCTION 45
4770
420007873-7873 TX SWALLOWING DYSFUNCTION 60
4770
420007881-7881 EVAL SWALLOWING FUNCTION 30
4770
420007882-7882 EVAL SWALLOWING FUNCTION 45
4770
420007883-7883 EVAL SWALLOWING FUNCTION 60
4770
420007884-7884 EVAL SWALLOWING FUNCTION 75
4770
420007885-7885 EVAL SWALLOWING FUNCTION 90
4770
420007886-7886 EVAL SWALLOWING FUNCTION 120
4770
420007891-7891 MOTION FLUORO SWALLOW FCN 30
4770
420007892-7892 MOTION FLUORO SWALLOW FCN 45
4770
420007893-7893 MOTION FLUORO SWALLOW FCN 60
4770 4770
420008021-8021 PT EVAL - 45 420008022-8022 PT EVAL - 60
4770
420008029-8029 BALANCE/NEURO 15 MIN
4770
420008030-8030 GAIT TRAINING THERAPY EA 15 MINS
4770
420008031-8031 THER ACT (DYNAMIC) 1 ON 1-15 MIN
4770
420008035-8035 WHEELCHAIR MANAGEMENT 15 MIN
4770
420008050-8050 THERABAND PER FOOT
4770
420008052-8052 WOODEN CANE
Long Description Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (eg, receptive and expressive language) Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (eg, receptive and expressive language) Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (eg, receptive and expressive language) Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (eg, receptive and expressive language) Treatment of swallowing dysfunction and/or oral function for feeding Treatment of swallowing dysfunction and/or oral function for feeding Treatment of swallowing dysfunction and/or oral function for feeding Treatment of swallowing dysfunction and/or oral function for feeding Evaluation of oral and pharyngeal swallowing function Evaluation of oral and pharyngeal swallowing function Evaluation of oral and pharyngeal swallowing function Evaluation of oral and pharyngeal swallowing function Evaluation of oral and pharyngeal swallowing function Evaluation of oral and pharyngeal swallowing function Motion fluoroscopic evaluation of swallowing function by cine or video recording Motion fluoroscopic evaluation of swallowing function by cine or video recording Motion fluoroscopic evaluation of swallowing function by cine or video recording Physical therapy evaluation Physical therapy evaluation Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities Therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing) Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes Wheelchair management (eg, assessment, fitting, training), each 15 minutes Exercise equipment Cane, includes canes of all materials, adjustable or fixed, with tip
UB Revenue Code
CPT/HCPCS
444
92523GN
660.00
444
92523GN
825.00
444
92523GN
990.00
444
92523GN
1155.00
440
92526GN
165.00
440
92526GN
330.00
440
92526GN
495.00
440
92526GN
660.00
444
92610GN
165.00
444
92610GN
330.00
444
92610GN
495.00
444
92610GN
660.00
444
92610GN
825.00
444
92610GN
1155.00
444
92611GN
330.00
444
92611GN
495.00
444
92611GN
660.00
424 424
97001GP 97001GP
330.62 330.62
420
97112GP
165.31
420
97116GP
165.31
420
97530GP
165.31
420
97542GP
165.31
272
A9300
7.50
273
E0100
75.00
Amount
144 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
Long Description
UB Revenue Code
CPT/HCPCS
Amount
4770
420008053-8053 AXILLARY CURTCHES
Crutches underarm, other than wood, adjustable or fixed, pair, with pads, tips and handgrips
272
E0114
60.00
4770
420008055-8055 CPM UNIT EACH DAY W/PAD
Static progressive stretch knee device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories
279
E1811
365.20
4770
420008089-8089 PT EVAL - 30 MIN
424
97001GP
330.62
4770
420009004-9004 MANUAL THERAPY EA 15 MINS
420
97140GP
165.31
4770
420009025-9025 THERAPEUTIC EXERCISES EA 15 MINS
420
97110GP
165.31
274
L0472
324.66
420
G0515GP
165.31
274
S1040
430
G8978GOCN
0.01
430
G8979GOCN
0.01
430
G8980GOCN
0.01
430
G8981GOCN
0.01
430
G8982GOCN
0.01
430
G8983GOCN
0.01
430
G8984GOCN
0.01
430
G8985GOCN
0.01
430
G8986GOCN
0.01
430
G8987GOCN
0.01
4770
4770
477000472-472 TLSO JEWETT HYPEREXTENSION BRACE
477000515-515 DEVELOP COGNITIVE SKILLS EA 15MIN
4770
477001040-1040 CRANIAL REMOLDING ORTHOSIS
4770
477002978-2978 OT MOBILITY CURRENT STATUS-CN
4770
477002979-2979 OT MOBILITY GOAL STATUS-CN
4770
477002980-2980 OT MOBILITY D/C STATUS-CN
4770
477002981-2981 OT BODY POS CURRENT STATUS-CN
4770
477002982-2982 OT BODY POS GOAL STATUS-CN
4770
477002983-2983 OT BODY POS D/C STATUS-CN
4770
477002984-2984 OT CARRY CURRENT STATUS-CN
4770
477002985-2985 OT CARRY GOAL STATUS-CN
4770
477002986-2986 OT CARRY D/C STATUS-CN
4770
477002987-2987 OT SELF CARE CURRENT STATUS-CN
Physical therapy evaluation Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, hyperextension, rigid anterior and lateral frame extends from symphysis pubis to sternal notch with two anterior components (one pubic and one sternal), posterior and lateral pads with straps and closures, limits spinal flexion, restricts gross trunk motion in sagittal, coronal, and transverse planes, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact, each 15 minutes Cranial remolding orthotic, pediatric, rigid, with soft interface material, custom fabricated, includes fitting and adjustment(s) Mobility: walking & moving around functional limitation, current status, at therapy episode outset and at reporting intervals Mobility: walking & moving around functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Mobility: walking & moving around functional limitation, discharge status, at discharge from therapy or to end reporting Changing & maintaining body position functional limitation, current status, at therapy episode outset and at reporting intervals Changing & maintaining body position functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Changing & maintaining body position functional limitation, discharge status, at discharge from therapy or to end reporting Carrying, moving & handling objects functional limitation, current status, at therapy episode outset and at reporting intervals Carrying, moving and handling objects, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Carrying, moving & handling objects functional limitation, discharge status, at discharge from therapy or to end reporting Self care functional limitation, current status, at therapy episode outset and at reporting intervals
12000.00
145 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4770
477002988-2988 OT SELF CARE GOAL STATUS-CN
4770
477002989-2989 OT SELF CARE D/C STATUS-CN
4770
477002990-2990 OT OTHER PT/OT CURRENT STATUS-CN
4770
477002991-2991 OT OTHER PT/OT GOAL STATUS-CN
4770
477002992-2992 OT OTHER PT/OT D/C STATUS-CN
4770
477002993-2993 OT SUB PT/OT CURRENT STATUS-CN
4770
477002994-2994 OT SUB PT/OT GOAL STATUS-CN
4770
477002995-2995 OT SUB PT/OT D/C STATUS-CN
4770
477003978-3978 OT MOBILITY CURRENT STATUS-CM
4770
477003979-3979 OT MOBILITY GOAL STATUS-CM
4770
477003980-3980 OT MOBILITY D/C STATUS-CM
4770
477003981-3981 OT BODY POS CURRENT STATUS-CM
4770
477003982-3982 OT BODY POS GOAL STATUS-CM
4770
477003983-3983 OT BODY POS D/C STATUS-CM
4770
477003984-3984 OT CARRY CURRENT STATUS-CM
4770
477003985-3985 OT CARRY GOAL STATUS-CM
4770
477003986-3986 OT CARRY D/C STATUS-CM
4770
477003987-3987 OT SELF CARE CURRENT STATUS-CM
4770
477003988-3988 OT SELF CARE GOAL STATUS-CM
4770
477003989-3989 OT SELF CARE D/C STATUS-CM
4770
477003990-3990 OT OTHER PT/OT CURRENT STATUS-CM
Long Description Self care functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Self care functional limitation, discharge status, at discharge from therapy or to end reporting Other physical or occupational therapy primary functional limitation, current status, at therapy episode outset and at reporting intervals Other physical or occupational therapy primary functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Other physical or occupational therapy primary functional limitation, discharge status, at discharge from therapy or to end reporting Other physical or occupational therapy subsequent functional limitation, current status, at therapy episode outset and at reporting intervals Other physical or occupational therapy subsequent functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Other physical or occupational therapy subsequent functional limitation, discharge status, at discharge from therapy or to end reporting Mobility: walking & moving around functional limitation, current status, at therapy episode outset and at reporting intervals Mobility: walking & moving around functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Mobility: walking & moving around functional limitation, discharge status, at discharge from therapy or to end reporting Changing & maintaining body position functional limitation, current status, at therapy episode outset and at reporting intervals Changing & maintaining body position functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Changing & maintaining body position functional limitation, discharge status, at discharge from therapy or to end reporting Carrying, moving & handling objects functional limitation, current status, at therapy episode outset and at reporting intervals Carrying, moving and handling objects, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Carrying, moving & handling objects functional limitation, discharge status, at discharge from therapy or to end reporting Self care functional limitation, current status, at therapy episode outset and at reporting intervals Self care functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Self care functional limitation, discharge status, at discharge from therapy or to end reporting Other physical or occupational therapy primary functional limitation, current status, at therapy episode outset and at reporting intervals
UB Revenue Code
CPT/HCPCS
430
G8988GOCN
0.01
430
G8989GOCN
0.01
430
G8990GOCN
0.01
430
G8991GOCN
0.01
430
G8992GOCN
0.01
430
G8993GOCN
0.01
430
G8994GOCN
0.01
430
G8995GOCN
0.01
430
G8978GOCM
0.01
430
G8979GOCM
0.01
430
G8980GOCM
0.01
430
G8981GOCM
0.01
430
G8982GOCM
0.01
430
G8983GOCM
0.01
430
G8984GOCM
0.01
430
G8985GOCM
0.01
430
G8986GOCM
0.01
430
G8987GOCM
0.01
430
G8988GOCM
0.01
430
G8989GOCM
0.01
430
G8990GOCM
0.01
Amount
146 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4770
477003991-3991 OT OTHER PT/OT GOAL STATUS-CM
4770
477003992-3992 OT OTHER PT/OT D/C STATUS-CM
4770
477003993-3993 OT SUB PT/OT CURRENT STATUS-CM
4770
477003994-3994 OT SUB PT/OT GOAL STATUS-CM
4770
477003995-3995 OT SUB PT/OT D/C STATUS-CM
4770
477004978-4978 OT MOBILITY CURRENT STATUS-CL
4770
477004979-4979 OT MOBILITY GOAL STATUS-CL
4770
477004980-4980 OT MOBILITY D/C STATUS-CL
4770
477004981-4981 OT BODY POS CURRENT STATUS-CL
4770
477004982-4982 OT BODY POS GOAL STATUS-CL
4770
477004983-4983 OT BODY POS D/C STATUS-CL
4770
477004984-4984 OT CARRY CURRENT STATUS-CL
4770
477004985-4985 OT CARRY GOAL STATUS-CL
4770
477004986-4986 OT CARRY D/C STATUS-CL
4770
477004987-4987 OT SELF CARE CURRENT STATUS-CL
4770
477004988-4988 OT SELF CARE GOAL STATUS-CL
4770
477004989-4989 OT SELF CARE D/C STATUS-CL
4770
477004990-4990 OT OTHER PT/OT CURRENT STATUS-CL
4770
477004991-4991 OT OTHER PT/OT GOAL STATUS-CL
4770
477004992-4992 OT OTHER PT/OT D/C STATUS-CL
Long Description Other physical or occupational therapy primary functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Other physical or occupational therapy primary functional limitation, discharge status, at discharge from therapy or to end reporting Other physical or occupational therapy subsequent functional limitation, current status, at therapy episode outset and at reporting intervals Other physical or occupational therapy subsequent functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Other physical or occupational therapy subsequent functional limitation, discharge status, at discharge from therapy or to end reporting Mobility: walking & moving around functional limitation, current status, at therapy episode outset and at reporting intervals Mobility: walking & moving around functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Mobility: walking & moving around functional limitation, discharge status, at discharge from therapy or to end reporting Changing & maintaining body position functional limitation, current status, at therapy episode outset and at reporting intervals Changing & maintaining body position functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Changing & maintaining body position functional limitation, discharge status, at discharge from therapy or to end reporting Carrying, moving & handling objects functional limitation, current status, at therapy episode outset and at reporting intervals Carrying, moving and handling objects, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Carrying, moving & handling objects functional limitation, discharge status, at discharge from therapy or to end reporting Self care functional limitation, current status, at therapy episode outset and at reporting intervals Self care functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Self care functional limitation, discharge status, at discharge from therapy or to end reporting Other physical or occupational therapy primary functional limitation, current status, at therapy episode outset and at reporting intervals Other physical or occupational therapy primary functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Other physical or occupational therapy primary functional limitation, discharge status, at discharge from therapy or to end reporting
UB Revenue Code
CPT/HCPCS
430
G8991GOCM
0.01
430
G8992GOCM
0.01
430
G8993GOCM
0.01
430
G8994GOCM
0.01
430
G8995GOCM
0.01
430
G8978GOCL
0.01
430
G8979GOCL
0.01
430
G8980GOCL
0.01
430
G8981GOCL
0.01
430
G8982GOCL
0.01
430
G8983GOCL
0.01
430
G8984GOCL
0.01
430
G8985GOCL
0.01
430
G8986GOCL
0.01
430
G8987GOCL
0.01
430
G8988GOCL
0.01
430
G8989GOCL
0.01
430
G8990GOCL
0.01
430
G8991GOCL
0.01
430
G8992GOCL
0.01
Amount
147 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4770
477004993-4993 OT SUB PT/OT CURRENT STATUS-CL
4770
477004994-4994 OT SUB PT/OT GOAL STATUS-CL
4770
477004995-4995 OT SUB PT/OT D/C STATUS-CL
4770
477005978-5978 OT MOBILITY CURRENT STATUS-CK
4770
477005979-5979 OT MOBILITY GOAL STATUS-CK
4770
477005980-5980 OT MOBILITY D/C STATUS-CK
4770
477005981-5981 OT BODY POS CURRENT STATUS-CK
4770
477005982-5982 OT BODY POS GOAL STATUS-CK
4770
477005983-5983 OT BODY POS D/C STATUS-CK
4770
477005984-5984 OT CARRY CURRENT STATUS-CK
4770
477005985-5985 OT CARRY GOAL STATUS-CK
4770
477005986-5986 OT CARRY D/C STATUS-CK
4770
477005987-5987 OT SELF CARE CURRENT STATUS-CK
4770
477005988-5988 OT SELF CARE GOAL STATUS-CK
4770
477005989-5989 OT SELF CARE D/C STATUS-CK
4770
477005990-5990 OT OTHER PT/OT CURRENT STATUS-CK
4770
477005991-5991 OT OTHER PT/OT GOAL STATUS-CK
4770
477005992-5992 OT OTHER PT/OT D/C STATUS-CK
4770
477005993-5993 OT SUB PT/OT CURRENT STATUS-CK
4770
477005994-5994 OT SUB PT/OT GOAL STATUS-CK
Long Description Other physical or occupational therapy subsequent functional limitation, current status, at therapy episode outset and at reporting intervals Other physical or occupational therapy subsequent functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Other physical or occupational therapy subsequent functional limitation, discharge status, at discharge from therapy or to end reporting Mobility: walking & moving around functional limitation, current status, at therapy episode outset and at reporting intervals Mobility: walking & moving around functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Mobility: walking & moving around functional limitation, discharge status, at discharge from therapy or to end reporting Changing & maintaining body position functional limitation, current status, at therapy episode outset and at reporting intervals Changing & maintaining body position functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Changing & maintaining body position functional limitation, discharge status, at discharge from therapy or to end reporting Carrying, moving & handling objects functional limitation, current status, at therapy episode outset and at reporting intervals Carrying, moving and handling objects, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Carrying, moving & handling objects functional limitation, discharge status, at discharge from therapy or to end reporting Self care functional limitation, current status, at therapy episode outset and at reporting intervals Self care functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Self care functional limitation, discharge status, at discharge from therapy or to end reporting Other physical or occupational therapy primary functional limitation, current status, at therapy episode outset and at reporting intervals Other physical or occupational therapy primary functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Other physical or occupational therapy primary functional limitation, discharge status, at discharge from therapy or to end reporting Other physical or occupational therapy subsequent functional limitation, current status, at therapy episode outset and at reporting intervals Other physical or occupational therapy subsequent functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting
UB Revenue Code
CPT/HCPCS
430
G8993GOCL
0.01
430
G8994GOCL
0.01
430
G8995GOCL
0.01
430
G8978GOCK
0.01
430
G8979GOCK
0.01
430
G8980GOCK
0.01
430
G8981GOCK
0.01
430
G8982GOCK
0.01
430
G8983GOCK
0.01
430
G8984GOCK
0.01
430
G8985GOCK
0.01
430
G8986GOCK
0.01
430
G8987GOCK
0.01
430
G8988GOCK
0.01
430
G8989GOCK
0.01
430
G8990GOCK
0.01
430
G8991GOCK
0.01
430
G8992GOCK
0.01
430
G8993GOCK
0.01
430
G8994GOCK
0.01
Amount
148 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4770
477005995-5995 OT SUB PT/OT D/C STATUS-CK
4770
477006978-6978 OT MOBILITY CURRENT STATUS-CJ
4770
477006979-6979 OT MOBILITY GOAL STATUS-CJ
4770
477006980-6980 OT MOBILITY D/C STATUS-CJ
4770
477006981-6981 OT BODY POS CURRENT STATUS-CJ
4770
477006982-6982 OT BODY POS GOAL STATUS-CJ
4770
477006983-6983 OT BODY POS D/C STATUS-CJ
4770
477006984-6984 OT CARRY CURRENT STATUS-CJ
4770
477006985-6985 OT CARRY GOAL STATUS-CJ
4770
477006986-6986 OT CARRY D/C STATUS-CJ
4770
477006987-6987 OT SELF CARE CURRENT STATUS-CJ
4770
477006988-6988 OT SELF CARE GOAL STATUS-CJ
4770
477006989-6989 OT SELF CARE D/C STATUS-CJ
4770
477006990-6990 OT OTHER PT/OT CURRENT STATUS-CJ
4770
477006991-6991 OT OTHER PT/OT GOAL STATUS-CJ
4770
477006992-6992 OT OTHER PT/OT D/C STATUS-CJ
4770
477006993-6993 OT SUB PT/OT CURRENT STATUS-CJ
4770
477006994-6994 OT SUB PT/OT GOAL STATUS-CJ
4770
477006995-6995 OT SUB PT/OT D/C STATUS-CJ
4770
477007978-7978 OT MOBILITY CURRENT STATUS-CI
Long Description Other physical or occupational therapy subsequent functional limitation, discharge status, at discharge from therapy or to end reporting Mobility: walking & moving around functional limitation, current status, at therapy episode outset and at reporting intervals Mobility: walking & moving around functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Mobility: walking & moving around functional limitation, discharge status, at discharge from therapy or to end reporting Changing & maintaining body position functional limitation, current status, at therapy episode outset and at reporting intervals Changing & maintaining body position functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Changing & maintaining body position functional limitation, discharge status, at discharge from therapy or to end reporting Carrying, moving & handling objects functional limitation, current status, at therapy episode outset and at reporting intervals Carrying, moving and handling objects, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Carrying, moving & handling objects functional limitation, discharge status, at discharge from therapy or to end reporting Self care functional limitation, current status, at therapy episode outset and at reporting intervals Self care functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Self care functional limitation, discharge status, at discharge from therapy or to end reporting Other physical or occupational therapy primary functional limitation, current status, at therapy episode outset and at reporting intervals Other physical or occupational therapy primary functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Other physical or occupational therapy primary functional limitation, discharge status, at discharge from therapy or to end reporting Other physical or occupational therapy subsequent functional limitation, current status, at therapy episode outset and at reporting intervals Other physical or occupational therapy subsequent functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Other physical or occupational therapy subsequent functional limitation, discharge status, at discharge from therapy or to end reporting Mobility: walking & moving around functional limitation, current status, at therapy episode outset and at reporting intervals
UB Revenue Code
CPT/HCPCS
430
G8995GOCK
0.01
430
G8978GOCJ
0.01
430
G8979GOCJ
0.01
430
G8980GOCJ
0.01
430
G8981GOCJ
0.01
430
G8982GOCJ
0.01
430
G8983GOCJ
0.01
430
G8984GOCJ
0.01
430
G8985GOCJ
0.01
430
G8986GOCJ
0.01
430
G8987GOCJ
0.01
430
G8988GOCJ
0.01
430
G8989GOCJ
0.01
430
G8990GOCJ
0.01
430
G8991GOCJ
0.01
430
G8992GOCJ
0.01
430
G8993GOCJ
0.01
430
G8994GOCJ
0.01
430
G8995GOCJ
0.01
430
G8978GOCI
0.01
Amount
149 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4770
477007980-7980 OT MOBILITY D/C STATUS-CI
4770
477007981-7981 OT BODY POS CURRENT STATUS-CI
4770
477007982-7982 OT BODY POS GOAL STATUS-CI
4770
477007983-7983 OT BODY POS D/C STATUS-CI
4770
477007984-7984 OT CARRY CURRENT STATUS-CI
4770
477007985-7985 OT CARRY GOAL STATUS-CI
4770
477007986-7986 OT CARRY D/C STATUS-CI
4770
477007987-7987 OT SELF CARE CURRENT STATUS-CI
4770
477007988-7988 OT SELF CARE GOAL STATUS-CI
4770
477007989-7989 OT SELF CARE D/C STATUS-CI
4770
477007990-7990 OT OTHER PT/OT CURRENT STATUS-CI
4770
477007991-7991 OT OTHER PT/OT GOAL STATUS-CI
4770
477007992-7992 OT OTHER PT/OT D/C STATUS-CI
4770
477007993-7993 OT SUB PT/OT CURRENT STATUS-CI
4770
477007994-7994 OT SUB PT/OT GOAL STATUS-CI
4770
477007995-7995 OT SUB PT/OT D/C STATUS-CI
4770
477008001-8001 HARD PROTECT HELMET PREFAB
4770
477008978-8978 OT MOBILITY CURRENT STATUS-CH
4770
477008979-8979 OT MOBILITY GOAL STATUS-CH
4770
477008980-8980 OT MOBILITY D/C STATUS-CH
4770
477008981-8981 OT BODY POS CURRENT STATUS-CH
Long Description Mobility: walking & moving around functional limitation, discharge status, at discharge from therapy or to end reporting Changing & maintaining body position functional limitation, current status, at therapy episode outset and at reporting intervals Changing & maintaining body position functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Changing & maintaining body position functional limitation, discharge status, at discharge from therapy or to end reporting Carrying, moving & handling objects functional limitation, current status, at therapy episode outset and at reporting intervals Carrying, moving and handling objects, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Carrying, moving & handling objects functional limitation, discharge status, at discharge from therapy or to end reporting Self care functional limitation, current status, at therapy episode outset and at reporting intervals Self care functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Self care functional limitation, discharge status, at discharge from therapy or to end reporting Other physical or occupational therapy primary functional limitation, current status, at therapy episode outset and at reporting intervals Other physical or occupational therapy primary functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Other physical or occupational therapy primary functional limitation, discharge status, at discharge from therapy or to end reporting Other physical or occupational therapy subsequent functional limitation, current status, at therapy episode outset and at reporting intervals Other physical or occupational therapy subsequent functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Other physical or occupational therapy subsequent functional limitation, discharge status, at discharge from therapy or to end reporting Helmet, protective, hard, prefabricated, includes all components and accessories Mobility: walking & moving around functional limitation, current status, at therapy episode outset and at reporting intervals Mobility: walking & moving around functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Mobility: walking & moving around functional limitation, discharge status, at discharge from therapy or to end reporting Changing & maintaining body position functional limitation, current status, at therapy episode outset and at reporting intervals
UB Revenue Code
CPT/HCPCS
430
G8980GOCI
0.01
430
G8981GOCI
0.01
430
G8982GOCI
0.01
430
G8983GOCI
0.01
430
G8984GOCI
0.01
430
G8985GOCI
0.01
430
G8986GOCI
0.01
430
G8987GOCI
0.01
430
G8988GOCI
0.01
430
G8989GOCI
0.01
430
G8990GOCI
0.01
430
G8991GOCI
0.01
430
G8992GOCI
0.01
430
G8993GOCI
0.01
430
G8994GOCI
0.01
430
G8995GOCI
0.01
270
A8001
430
G8978GOCH
0.01
430
G8979GOCH
0.01
430
G8980GOCH
0.01
430
G8981GOCH
0.01
Amount
122.68
150 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4770
477008982-8982 OT BODY POS GOAL STATUS-CH
4770
477008983-8983 OT BODY POS D/C STATUS-CH
4770
477008984-8984 OT CARRY CURRENT STATUS-CH
4770
477008985-8985 OT CARRY GOAL STATUS-CH
4770
477008986-8986 OT CARRY D/C STATUS-CH
4770
477008987-8987 OT SELF CARE CURRENT STATUS-CH
4770
477008988-8988 OT SELF CARE GOAL STATUS-CH
4770
477008989-8989 OT SELF CARE D/C STATUS-CH
4770
477008990-8990 OT OTHER PT/OT CURRENT STATUS-CH
4770
477008991-8991 OT OTHER PT/OT GOAL STATUS-CH
4770
477008992-8992 OT OTHER PT/OT D/C STATUS-CH
4770
477008993-8993 OT SUB PT/OT CURRENT STATUS-CH
4770
477008994-8994 OT SUB PT/OT GOAL STATUS-CH
4770
477008995-8995 OT SUB PT/OT D/C STATUS-CH
4770
477013994-13994 SUB PT/OT GOAL STATUS-CM
4770
477013995-13995 SUB PT/OT D/C STATUS-CM
4770
477014993-14993 SUB PT/OT CURRENT STATUS-CL
4770
477014994-14994 SUB PT/OT GOAL STATUS-CL
4770
477015993-15993 SUB PT/OT CURRENT STATUS-CK
4770
477015994-15994 SUB PT/OT GOAL STATUS-CK
Long Description Changing & maintaining body position functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Changing & maintaining body position functional limitation, discharge status, at discharge from therapy or to end reporting Carrying, moving & handling objects functional limitation, current status, at therapy episode outset and at reporting intervals Carrying, moving and handling objects, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Carrying, moving & handling objects functional limitation, discharge status, at discharge from therapy or to end reporting Self care functional limitation, current status, at therapy episode outset and at reporting intervals Self care functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Self care functional limitation, discharge status, at discharge from therapy or to end reporting Other physical or occupational therapy primary functional limitation, current status, at therapy episode outset and at reporting intervals Other physical or occupational therapy primary functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Other physical or occupational therapy primary functional limitation, discharge status, at discharge from therapy or to end reporting Other physical or occupational therapy subsequent functional limitation, current status, at therapy episode outset and at reporting intervals Other physical or occupational therapy subsequent functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Other physical or occupational therapy subsequent functional limitation, discharge status, at discharge from therapy or to end reporting Other physical or occupational therapy subsequent functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Other physical or occupational therapy subsequent functional limitation, discharge status, at discharge from therapy or to end reporting Other physical or occupational therapy subsequent functional limitation, current status, at therapy episode outset and at reporting intervals Other physical or occupational therapy subsequent functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Other physical or occupational therapy subsequent functional limitation, current status, at therapy episode outset and at reporting intervals Other physical or occupational therapy subsequent functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting
UB Revenue Code
CPT/HCPCS
430
G8982GOCH
0.01
430
G8983GOCH
0.01
430
G8984GOCH
0.01
430
G8985GOCH
0.01
430
G8986GOCH
0.01
430
G8987GOCH
0.01
430
G8988GOCH
0.01
430
G8989GOCH
0.01
430
G8990GOCH
0.01
430
G8991GOCH
0.01
430
G8992GOCH
0.01
430
G8993GOCH
0.01
430
G8994GOCH
0.01
430
G8995GOCH
0.01
420
G8994GPCM
0.01
420
G8995GPCM
0.01
420
G8993GPCL
0.01
420
G8994GPCL
0.01
420
G8993GPCK
0.01
420
G8994GPCK
0.01
Amount
151 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4770
477017993-17993 SUB PT/OT CURRENT STATUS-CI
4770
477018993-18993 SUB PT/OT CURRENT STATUS-CH
4770
477087127-87127 OT DEV COGNITIVE SKILLS EA 15 MIN
4770
477097110-97110 OT THERAPEUTIC EXERCISE EA 15 MIN
4770
477097112-97112 OT NEUROMUSCULAR RE-ED EA 15 MIN
4770
477097140-97140 OT MANUAL THERAPY EA 15 MINS
4770
477097161-97161 PT EVAL LOW COMPLEX 20 MIN
4770
477097162-97162 PT EVAL MOD COMPLEX 30 MIN
4770
477097164-97164 PT RE-EVAL EST PLAN OF CARE
Long Description Other physical or occupational therapy subsequent functional limitation, current status, at therapy episode outset and at reporting intervals Other physical or occupational therapy subsequent functional limitation, current status, at therapy episode outset and at reporting intervals Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact, each 15 minutes Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes Physical therapy evaluation: low complexity, requiring these components: A history with no personal factors and/or comorbidities that impact the plan of care; An examination of body system(s) using standardized tests and measures addressing 12 elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; A clinical presentation with stable and/or uncomplicated characteristics; and Clinical decision making of low complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 20 minutes are spent face-to-face with the patient and/or family. Physical therapy evaluation: moderate complexity, requiring these components: A history of present problem with 1-2 personal factors and/or comorbidities that impact the plan of care; An examination of body systems using standardized tests and measures in addressing a total of 3 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; An evolving clinical presentation with changing characteristics; and Clinical decision making of moderate complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 30 minutes are spent face-toface with the patient and/or family. Re-evaluation of physical therapy established plan of care, requiring these components: An examination including a review of history and use of standardized tests and measures is required; and Revised plan of care using a standardized patient assessment instrument and/or measurable assessment of functional outcome Typically, 20 minutes are spent face-to-face with the patient and/or family.
UB Revenue Code
CPT/HCPCS
420
G8993GPCI
0.01
420
G8993GPCH
0.01
430
G0515GO
165.31
430
97110GO
165.31
430
97112GO
165.31
430
97140GO
165.31
424
97161
330.62
424
97162
330.62
424
97164
330.62
Amount
152 of 167 Updated on 1/22/2019
Revenue Center
4770
4770
Long Description
UB Revenue Code
CPT/HCPCS
477097165-97165 OT EVAL LOW COMPLEXITY 30 MIN
Occupational therapy evaluation, low complexity, requiring these components: An occupational profile and medical and therapy history, which includes a brief history including review of medical and/or therapy records relating to the presenting problem; An assessment(s) that identifies 1-3 performance deficits (ie, relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and Clinical decision making of low complexity, which includes an analysis of the occupational profile, analysis of data from problem-focused assessment(s), and consideration of a limited number of treatment options. Patient presents with no comorbidities that affect occupational performance. Modification of tasks or assistance (eg, physical or verbal) with assessment(s) is not necessary to enable completion of evaluation component. Typically, 30 minutes are spent face-to-face with the patient and/or family.
434
97165GO
288.54
477097166-97166 OT EVAL MOD COMPLEXITY 45 MIN
Occupational therapy evaluation, moderate complexity, requiring these components: An occupational profile and medical and therapy history, which includes an expanded review of medical and/or therapy records and additional review of physical, cognitive, or psychosocial history related to current functional performance; An assessment(s) that identifies 3-5 performance deficits (ie, relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and Clinical decision making of moderate analytic complexity, which includes an analysis of the occupational profile, analysis of data from detailed assessment(s), and consideration of several treatment options. Patient may present with comorbidities that affect occupational performance. Minimal to moderate modification of tasks or assistance (eg, physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component. Typically, 45 minutes are spent face-to-face with the patient and/or family.
434
97166GO
288.54
CDM Number
CDM Description
Amount
153 of 167 Updated on 1/22/2019
Revenue Center
4770
CDM Number
CDM Description
477097167-97167 OT EVAL HIGH COMPLEXITY 60 MIN
4770
477097168-97168 OT RE-EVAL EST PLAN CARE
4770
477097530-97530 OT THER ACTIVITY-DYNAMIC EA 15MIN
4770
477097533-97533 OT SENSORY INTEGRATION EA 15 MINS
4770
477097535-97535 OT SELF CARE MGT TRAING EA 15 MIN
4770
477097542-97542 OT WHEELCHAIR MGT EA 15 MINS
4770
477097760-97760 OT INIT ORTHOTIC TRAIN EA 15 MIN
4770
477097761-97761 OT INIT PROSTHETIC TRAIN EA 15MIN
4770
477097763-97763 OT SUBSQ ORTH/PROSTH MGT EA 15MIN
4870
409012365-12365 P CARINII BY IF----------@M
Long Description
UB Revenue Code
CPT/HCPCS
Occupational therapy evaluation, high complexity, requiring these components: An occupational profile and medical and therapy history, which includes review of medical and/or therapy records and extensive additional review of physical, cognitive, or psychosocial history related to current functional performance; An assessment(s) that identifies 5 or more performance deficits (ie, relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and Clinical decision making of high analytic complexity, which includes an analysis of the patient profile, analysis of data from comprehensive assessment(s), and consideration of multiple treatment options. Patient presents with comorbidities that affect occupational performance. Significant modification of tasks or assistance (eg, physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component. Typically, 60 minutes are spent face-to-face with the patient and/or family.
434
97167GO
288.54
434
97168GO
197.07
430
97530GO
165.31
430
97533GO
165.31
430
97535GO
165.31
430
97542GO
165.31
430
97760GO
165.31
430
97761GO
165.31
430
97763GO
165.31
312
88346
80.00
Re-evaluation of occupational therapy established plan of care, requiring these components: An assessment of changes in patient functional or medical status with revised plan of care; An update to the initial occupational profile to reflect changes in condition or environment that affect future interventions and/or goals; and A revised plan of care. A formal reevaluation is performed when there is a documented change in functional status or a significant change to the plan of care is required. Typically, 30 minutes are spent face-to-face with the patient and/or family. Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact, each 15 minutes Self-care/home management training (eg, activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact, each 15 minutes Wheelchair management (eg, assessment, fitting, training), each 15 minutes Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(ies), lower extremity(ies) and/or trunk, initial orthotic(s) encounter, each 15 minutes Prosthetic(s) training, upper and/or lower extremity(ies), initial prosthetic(s) encounter, each 15 minutes Orthotic(s)/prosthetic(s) management and/or training, upper extremity(ies), lower extremity(ies), and/or trunk, subsequent orthotic(s)/prosthetic(s) encounter, each 15 minutes Immunofluorescence, per specimen; initial single antibody stain procedure
Amount
154 of 167 Updated on 1/22/2019
Revenue Center
4870
CDM Number
CDM Description
409013400-13400 IMMUNOHISTOCHEMISTRY @CLARIENT
4870
409013401-13401 FLOWCYTOMETRY/TC,ADD-ON@CLARIENT
4870
409013402-13402 TUMOR IMMUNOHISTOCHEM @CLARIENT
4870
409013403-13403 KRAS GENE ANALYSIS @CLARIENT
4870
409013404-13404 INSITU HYBRIDIZATION @CLARIENT
4870
409013405-13405 FLOWCYTOMETRY/TC1 MARKER@CLARIENT
Long Description
UB Revenue Code
CPT/HCPCS
Immunohistochemistry or immunocytochemistry, per specimen; initial single anitbody stain procedure
309
88342TC
57.58
309
88185
12.00
309
88360TC
57.58
309
81275
327.16
309
8836726
53.00
309
88184
62.00
309
88367TC
177.52
309
88237
176.47
309
88264
174.14
309
88189
75.00
309
88312TC
72.37
309
88280
35.07
300
36415
20.70
300
36416
7.00
301 301
82776 84443
15.95 15.95
301
83021
15.95
301 302
86039 86611
18.03 21.45
302
86256
26.96
302
86694
66.82
306
87186
59.00
306
87797
53.00
306
87188
59.00
306
87107
50.00
Flow cytometry, cell surface, cytoplasmic, or nuclear marker, technical component only; each additional marker (List separately in addition to code for first marker) Morphometric analysis, tumor immunohistochemistry (eg, Her-2/neu, estrogen receptor/progesterone receptor), quantitative or semiquantitative, per specimen, each single antibody stain procedure; manual KRAS (Kirsten rat sarcoma viral oncogene homolog) (eg, carcinoma) gene analysis; variants in exon 2 (eg, codons 12 and 13) Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), using computerassisted technology, per specimen; initial single probe stain procedure Flow cytometry, cell surface, cytoplasmic, or nuclear marker, technical component only; first marker
4870
409013406-13406 INSITU HYBRIDIZATION,TC@CLARIENT
4870
409013407-13407 TISSUE CULT,BONE MARROW @CLARIENT
4870
409013408-13408 CHROMOSOME ANALYSIS,20-25@CLARIEN
Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), using computerassisted technology, per specimen; initial single probe stain procedure Tissue culture for neoplastic disorders; bone marrow, blood cells Chromosome analysis; analyze 20-25 cells
4870
409013410-13410 FLOWCYTOMETRY/READ,16&>@CLARIENT
Flow cytometry, interpretation; 16 or more markers
4870
409013411-13411 SPECIAL STAINS/TC @CLARIENT
4870
409013412-13412 CHROMOSOME KARYOTYPE STDY@CLARIEN
4870
409014000-14002 COLL,PROCESS,PKG FOR REFERRAL
4870
409014003-14003 COLL & HANDLING NEWBORN SCREEN
4870 4870
409014018-14018 GALACTOSE-1-PHOS URIDYL TRANSF @W 409014019-14019 THYROID STIM HORMONE, NBS @W
4870
409014020-14020 HEMOGLOBIN CHROMATOGRAPHY, NBS @W
4870 4870
409014034-14034 ANA TITER & PATTERN IFA @M 409014035-14035 BARTONELLA HENSLAE AB TITER EA @M
4870
409014036-14036 ENDOMYSIAL AB IGA TITER . . .@M
4870
409014037-14037 HSV IGM TITER . . . . . . . .@M
4870
409014040-14040 SUSCEPTIBILITY MIC YEAST @UTHSCSA
4870
409014041-14041 FUNGAL ID BY DNA PROBE @UTHSCSA
4870
409014042-14042 SYSCEPTIBILITY, MIC MOLD @UTHSCSA
4870
409014043-14043 FUNGAL ID, EACH, MOLD @UTHSCSA
Special stain including interpretation and report; Group I for microorganisms (eg, acid fast, methenamine silver) Chromosome analysis; additional karyotypes, each study Collection of venous blood by venipuncture Collection of capillary blood specimen (eg, finger, heel, ear stick) Galactose-1-phosphate uridyl transferase; screen Thyroid stimulating hormone (TSH) Hemoglobin fractionation and quantitation; chromatography (eg, A2, S, C, and/or F) Antinuclear antibodies (ANA); titer Antibody; Bartonella Fluorescent noninfectious agent antibody; titer, each antibody Antibody; herpes simplex, non-specific type test Susceptibility studies, antimicrobial agent; microdilution or agar dilution (minimum inhibitory concentration [MIC] or breakpoint), each multiantimicrobial, per plate Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; direct probe technique, each organism Susceptibility studies, antimicrobial agent; macrobroth dilution method, each agent Culture, fungi, definitive identification, each organism; mold
Amount
155 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
Long Description
UB Revenue Code
CPT/HCPCS
Level IV - Surgical pathology, gross and microscopic examination. Abort-spon;Artery;Bone marrw;Bone exostosis;Brain/mening not tumor resxn;Breast bx no micro surg margins red mammo;Bronchus;Cell block ;Cervix bx;Colon bx;Duodenm;Endocervx;Endometrm;Esophags bx;Extremty amp traum;Fallopian tb bx ectopic;Femoral head;Fingers/toes amp nontraum;Gingiva/oral mucosa;Heart vlve;Joint resxn;Kidney bx;Larynx bx;Leiomyoma myomectomy w/o uterus;Lip;Lung transbronch bx;Lymph node bx;Muscle;Nasal mucosa;Nasopharynx/oropharynx;Nerve bx;Odontogenic/dental cyst;Omentm;Ovary non-neo bx/wdg resxn;Parathyrd;Peritonm;Pituit tumor;Placent no 3rd trim;Pleura/pericard;Polyp cervic/endomet colorectl stomach/small int;Prostate ndle bx TUR;Saliv gland bx;Sinus paranasal;Skin not cyst/tag/debride/repr;Small intest bx;Soft tiss no mass/lipoma/debride;Spleen;Stomach bx;Synovium;Testis no tumor/bx/castrat;Thyroglssl duct/brachial cleft cyst;Tongue bx;Tonsil bx;Trachea;Ureter bx;Urthra;Urnry bladder bx;Uterus prolpse;Vagina/vulva/labia bx
312
88305
184.61
312
88346
330.93
312
88348
484.46
312
88321
65.00
306
87206
12.00
306
87015
30.00
302
86317
15.00
302
86331
16.25
302
86171
16.25
302
86003
5.14
301
83655
4.25
306
87075
25.80
301
80299
57.66
301
80299
164.70
302 301 301
86706 84153 84154
6.25 5.00 5.00
Amount
4870
409014092-14092 *LIGHT MICROSCOPY .------@R
4870
409014093-14093 IMMUNOFLUORESENCE STUDIES@R
4870
409014094-14094 ELECTRON MICROSCOPY-CEDAR@R
4870
409014095-14095 PATH CONSULT-SIMPLE-UCLA.......@N
4870
409015040-15040 AFB SMEAR----------------@Q
4870
409015041-15041 AFB CULTURE,CONC&ISOL----@Q
4870
409016774-16774 COCCI PPTN-KCHD----------@Q
4870
409016775-16775 COCCI AGAR GEL-KCHD------@Q
4870
409016776-16776 COCCI CF-KCHD------------@Q
4870
409025135-25135 ALLERGN,EACH.............@M
4870
409025172-25172 LEAD,BLOOD...............@M
4870
409025200-25200 CHLAMYDIA CULTURE........@M
4870
409025210-25210 FLUCONAZOLE,SERUM........@M
4870
409025212-25212 POSACONAZOLE,SERUM.............@M
4870 4870 4870
409025230-25230 HEPATITIS B SURFACE AB QN@M 409025243-25243 PSA TOTAL, PNL . . . . . . .@M 409025244-25244 PSA FREE, PNL . . . . . . .@M
Immunofluorescence, per specimen; initial single antibody stain procedure Electron microscopy, diagnostic Consultation and report on referred slides prepared elsewhere Smear, primary source with interpretation; fluorescent and/or acid fast stain for bacteria, fungi, parasites, viruses or cell types Concentration (any type), for infectious agents Immunoassay for infectious agent antibody, quantitative, not otherwise specified Immunodiffusion; gel diffusion, qualitative (Ouchterlony), each antigen or antibody Complement fixation tests, each antigen Allergen specific IgE; quantitative or semiquantitative, crude allergen extract, each Lead Culture, bacterial; any source, except blood, anaerobic with isolation and presumptive identification of isolates Quantitation of therapeutic drug, not elsewhere specified Quantitation of therapeutic drug, not elsewhere specified Hepatitis B surface antibody (HBsAb) Prostate specific antigen (PSA); total Prostate specific antigen (PSA); free
4870
409025280-25280 T4 T8 PANEL..............@M
T cells; absolute CD4 and CD8 count, including ratio
302
86360
25.00
4870 4870 4870 4870
409025310-25310 409025320-25320 409025330-25330 409025336-25336
302 302 302 301
86160 86160 86162 83880
6.50 6.50 7.20 85.00
4870
409025340-25340 CULTURE,VIRAL COMP.......@M
306
87252
16.00
4870
409025400-25400 CA 125 II.................@M
Complement; antigen, each component Complement; antigen, each component Complement; total hemolytic (CH50) Natriuretic peptide Virus isolation; tissue culture inoculation, observation, and presumptive identification by cytopathic effect Immunoassay for tumor antigen, quantitative; CA 125
302
86304
8.00
COMPLEMENT C3............@M COMPLEMENT C4............@M COMPLEMENT CH50 TOTAL....@M PROBNP, N-TERMINAL . . . @M
156 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4870
409025410-25410 DNA ANTIBODIES,NATIVE....@M
4870 4870 4870
409025415-25415 NUCLEOTIDASE,5'----------------@M 409025420-25420 H.PYLORI IGG QUAL........@M 409025440-25440 IMMUNOGLOBULIN E.........@M
4870
409025460-25460 CANCER ANTIGEN 15-3......@M
4870
409025486-25486 M TUBERCULOSIS COMPLEX,RESP,PCR@M
4870
409025487-25487 M TUBERCULOSIS COMPLEX,NON-RESP@M
4870 4870
409025490-25490 VARICELLA-ZOSTER IGG AB..@M 409025500-25500 ANTI STREPTOLYSIN O......@M
4870
409025522-25522 PROTEIN ELECTO PNL ITEM..@M
4870
409025524-25524 PROTEIN TOT,PROT ELEC PNL@M
4870
409025532-25532 PROTEIN ELEC,URINE CHG...@M
4870
409025534-25534 PROTEIN TOT,URINE CHG....@M
4870
409025540-25540 BORDETELLA PERTUSSIS CULT@M
4870
409025562-25562 EBV VIRAL CAPSID AB ........@M
4870
409025563-25563 EBV NUCLEAR ANTIGEN . . . . @M
4870
409025570-25570 PROTEIN C ACTIVITY.......@M
4870
409025590-25590 PROTEIN S ACTIVITY.......@M
4870
409025600-25600 IMMUNOGLOBLULIN A........@M
4870
409025616-25616 ALBUMIN (IGG SYNTHESIS/INDEX)
4870
409025617-25617 GAMMAGLOBULIN G(IGG SYTH/INDEX)
4870
409025618-25618 NEPHELOMETRY (IGG SYN/INDEX). .@M
4870
409025620-25620 IMMUNOGLOBULIN G.........@M
4870
409025630-25630 IMMUNOGLOBLULIN M........@M
4870
409025642-25642 IMMUNOGLOBULIN PNL CHG...@M
4870
409025655-25655 LEGIONELLA ANTIGEN,URINE,EIA---@M
4870
409025662-25662 TISSUE CULT FOR CHRM ANAL@M
4870
409025666-25666 CHROMOSOME ANAL ADDL KARO@M
4870
409025676-25676 CYTOGENETICS INTERP AND REPORT@M
4870 4870
409025680-25680 FOLIC ACID,RBC...........@M 409025695-25695 T4 TOTAL . . . . . . . . . @M
Long Description Deoxyribonucleic acid (DNA) antibody; native or double stranded Nucleotidase 5'Antibody; Helicobacter pylori Gammaglobulin (immunoglobulin); IgE Immunoassay for tumor antigen, quantitative; CA 153 (27.29) Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria tuberculosis, amplified probe technique Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria tuberculosis, amplified probe technique Antibody; varicella-zoster Antistreptolysin 0; titer Protein; electrophoretic fractionation and quantitation, serum Protein, total, except by refractometry; serum, plasma or whole blood Protein; electrophoretic fractionation and quantitation, serum Protein, total, except by refractometry; urine Culture, presumptive, pathogenic organisms, screening only; Antibody; Epstein-Barr (EB) virus, viral capsid (VCA) Antibody; Epstein-Barr (EB) virus, nuclear antigen (EBNA) Clotting inhibitors or anticoagulants; protein C, activity Clotting inhibitors or anticoagulants; protein S, free Gammaglobulin (immunoglobulin); IgA, IgD, IgG, IgM, each Albumin; serum, plasma or whole blood Gammaglobulin (immunoglobulin); IgA, IgD, IgG, IgM, each Nephelometry, each analyte not elsewhere specified Gammaglobulin (immunoglobulin); IgA, IgD, IgG, IgM, each Gammaglobulin (immunoglobulin); IgA, IgD, IgG, IgM, each Gammaglobulin (immunoglobulin); IgA, IgD, IgG, IgM, each Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzymelinked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]), qualitative or semiquantitative; multiple-step method, not otherwise specified, each organism Tissue culture for non-neoplastic disorders; lymphocyte Chromosome analysis; count 15-20 cells, 2 karyotypes, with banding Cytogenetics and molecular cytogenetics, interpretation and report Folic acid; RBC Thyroxine; total
UB Revenue Code
CPT/HCPCS
302
86225
6.00
301 302 301
83915 86677 82785
52.61 10.00 7.20
301
86300
9.90
306
87556
133.00
306
87556
133.00
302 302
86787 86060
4.80 3.50
309
84165
3.92
301
84155
3.91
309
84165
6.58
301
84156
6.59
306
87081
22.64
302
86665
8.25
302
86664
8.25
305
85303
15.00
305
85306
15.00
301
82784
4.50
301
82040
5.62
301
82784
5.62
301
83883
5.61
301
82784
5.50
301
82784
4.50
301
82784
7.06
306
87449
11.65
306
88230
88.19
311
88262
88.19
309
88291
23.62
301 301
82747 84436
5.00 4.40
Amount
157 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4870
409025705-25705 H PYLORI AG DET EIA, STOOL. . @M
4870 4870 4870 4870 4870 4870 4870 4870
409025710-25710 409025739-25739 409025750-25750 409025752-25752 409025753-25753 409025758-25758 409025760-25760 409025770-25770
4870
409025780-25780 THYROID PEROXIDASE AB . . . . .@M
4870 4870
409025790-25790 THYROGLOBULIN AB.........@M 409025800-25800 TOXOPLASMA IGG AB........@M
GAMMA GLUTAMYL TRANSFERAS@M FACTOR VIII ACTIVITY,
[email protected] COPPER,SERUM...................@M CITRIC ACID,URINE..............@M OXALATE,URINE..................@M CYSTINE, QUANT, URINE TESTOSTERONE,TOTAL.......@M TOXOPLASMA IGM AB........@M
Long Description
UB Revenue Code
CPT/HCPCS
Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzymelinked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative, multiple-step method; Helicobacter pylori, stool
306
87338
10.00
301 300 301 301 301 300 301 302
82977 85240 82525 82507 83945 82131 84403 86778
2.01 32.00 8.00 10.00 13.08 13.48 7.00 9.80
302
86376
7.98
302 302
86800 86777
4.80 9.08
301
80074
29.02
Glutamyltransferase, gamma (GGT) Clotting; factor VIII (AHG), 1-stage Copper Citrate Oxalate Amino acids; single, quantitative, each specimen Testosterone; total Antibody; Toxoplasma, IgM Microsomal antibodies (eg, thyroid or liver-kidney), each Thyroglobulin antibody Antibody; Toxoplasma
Amount
4870
409025825-25825 ACUTE HEPATITIS PANEL..........@M
Acute hepatitis panel This panel must include the following: Hepatitis A antibody (HAAb), IgM antibody (86709) Hepatitis B core antibody (HBcAb), IgM antibody (86705) Hepatitis B surface antigen (HBsAg) (87340) Hepatitis C antibody (86803)
4870 4870 4870 4870 4870
409025830-25830 409025840-25840 409025850-25850 409025860-25860 409025870-25870
Hepatitis A antibody (HAAb) Hepatitis A antibody (HAAb), IgM antibody Hepatitis B core antibody (HBcAb); total Hepatitis B core antibody (HBcAb); IgM antibody Hepatitis Be antibody (HBeAb)
302 302 302 302 302
86708 86709 86704 86705 86707
7.20 6.40 6.40 6.00 6.40
Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzymelinked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative, multiple-step method; hepatitis Be antigen (HBeAg)
306
87350
6.40
302
87522
69.00
301
82941
8.00
302
83520
10.00
301 301 301 301 301 302 302 302 302 302 302 302 301 301 301 301 302
86682 82164 82024 83003 84702 86644 86644 86645 86695 86696 86695 86696 82627 80158 80158 84681 86334
55.30 9.00 10.00 6.40 66.40 7.00 12.60 12.60 3.33 3.33 4.43 4.43 7.20 22.00 13.86 8.00 11.71
302
86335
11.71
301
82710
12.96
HEPATITIS A AB,TOTAL.....@M HEPATITIS A IGM AB.......@M HEPATITIS B CORE AB TOTAL@M HEPATITIS B CORE IGM AB..@M HEPATITIS BE AB..........@M
4870
409025880-25880 HEPATITIS BE ANTIGEN.....@M
4870
409025904-25904 HCV RNA VIRAL LOAD PCR . . . .@M
4870
409025920-25920 GASTRIN..................@M
4870
409025925-25925 CYCLIC CITRULLINATED PEPTIDE,AB@M
4870 4870 4870 4870 4870 4870 4870 4870 4870 4870 4870 4870 4870 4870 4870 4870 4870
409025940-25940 409025960-25960 409025970-25970 409025980-25980 409025981-25981 409025990-25990 409026022-26022 409026024-26024 409026092-26092 409026094-26094 409026102-26102 409026104-26104 409026110-26110 409026120-26120 409026125-26125 409026130-26130 409026145-26145
4870
409026155-26155 IMMUNOFIXATION,URINE..........@M
4870
409026170-26170 FECAL FAT,QUAL...........@M
CYSTICERCUS AB IGG-BLOOD.@M ANGIOTENSIN-1-CONVERT ENZ@M ADRENOCORTICOTROPHIC HORM@M HUMAN GROWTH HORMONE.....@M BETA-HCG QUANT,TUMOR MARKER....@M CYTOMEGALOVIRUS IGG AB...@M CYTOMEGALOVRS IGG PNL CHG@M CYTOMEGALOVRS IGM PNL CHG@M HERPES SIMP 1 IGG CHG....@M HERPES SIMPLEX 2 IGG CHG.@M HERPES SIMPLEX 1 IGM CHG.@M HERPES SIMPLEX 2 IGM CHG.@M DHEA SULFATE.............@M CYCLOSPORINE A...........@M CYCLOSPORIN A TROUGH C-PEPTIDE................@M IMMUNOFIXATION,SERUM.........@M
Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, quantification, includes reverse transcription when performed Gastrin Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative, not otherwise specified Antibody; helminth, not elsewhere specified Angiotensin I - converting enzyme (ACE) Adrenocorticotropic hormone (ACTH) Growth hormone, human (HGH) (somatotropin) Gonadotropin, chorionic (hCG); quantitative Antibody; cytomegalovirus (CMV) Antibody; cytomegalovirus (CMV) Antibody; cytomegalovirus (CMV), IgM Antibody; herpes simplex, type 1 Antibody; herpes simplex, type 2 Antibody; herpes simplex, type 1 Antibody; herpes simplex, type 2 Dehydroepiandrosterone-sulfate (DHEA-S) Cyclosporine Cyclosporine C-peptide Immunofixation electrophoresis; serum Immunofixation electrophoresis; other fluids with concentration (eg, urine, CSF) Fat or lipids, feces; quantitative
158 of 167 Updated on 1/22/2019
Long Description
UB Revenue Code
CPT/HCPCS
Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzymelinked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative, multiple-step method; hepatitis B surface antigen (HBsAg)
302
87340
3.50
301
82103
8.00
302
86235
7.20
302
86235
7.21
301 301 301 301
83525 84206 86336 82397
6.50 92.00 78.00 96.00
409026275-26275 BILE ACIDS,FRACTIONATED&TOTAL @M
Mass spectrometry and tandem mass spectrometry (eg, MS, MS/MS, MALDI, MS-TOF, QTOF), non-drug analyte(s) not elsewhere specified, qualitative or quantitative, each specimen
301
83789
9.30
4870
409026277-26277 BILE ACIDS,FRAC & TTL,PREG.....@M
Mass spectrometry and tandem mass spectrometry (eg, MS, MS/MS, MALDI, MS-TOF, QTOF), non-drug analyte(s) not elsewhere specified, qualitative or quantitative, each specimen
301
83789
9.30
4870 4870 4870 4870
409026278-26278 409026279-26279 409026280-26280 409026305-26305
301 301 301 301
83735 84105 84560 82670
3.64 4.76 4.76 9.00
4870
409026320-26320 HLA-B27 ANTIGEN..........@M
302
86812
13.50
4870
409026325-26325 ENDOMYSIAL AB IGA W/REFLX TITER@M
302
86255
10.00
4870
409026326-26326 ENDOMYSIAL AB IGA TITER CHRG @M
302
86256
88.00
4870
409026350-26350 CATECHOLAMINES,FRAC U24HR@M
301
82384
13.46
4870
409026371-26371 *CHLAMYDIA TRACHOMATIS,DNA SDA
306
87491
20.00
4870
409026382-26382 CRYOGLOBULIN EVALUATION -----@M
301
82595
17.50
4870
409026390-26390 GLUCOSE-6-PHOSPHATE DEHYD@M
301
82955
5.81
4870
409026420-26420 SJOGREN'S ANTIBODIES.....@M
302
86235
11.00
4870
409026439-26439 HIV-1 RNA,QUANT, REAL-TIME PCR @M
306
87536
65.00
4870 4870 4870 4870 4870 4870 4870 4870 4870 4870 4870
409026465-26465 409026480-26480 409026530-26530 409026542-26542 409026544-26544 409026545-26545 409026552-26552 409026554-26554 409026555-26555 409026580-26580 409026600-26600
301 301 301 302 302 302 302 302 302 302 301
83835 83835 82085 86658 86658 86658 86658 86658 86658 86618 82232
40.00 16.88 5.97 6.83 13.40 13.42 4.58 12.66 12.66 6.50 8.00
Revenue Center
CDM Number
CDM Description
4870
409026180-26180 HEPATITIS B SURF AG......@M
4870
409026220-26220 ALPHA-1-ANTITYRPSIN......@M
4870
409026262-26262 SN ANTIBODY PNL CHG......@M
4870
409026264-26264 RNP ANTIBODY PNL CHG.....@M
4870 4870 4870 4870
409026270-26270 409026272-26272 409026273-26273 409026274-26274
4870
INSULIN LEVEL............@M PROINSULIN..........@M INHIBIN A...........@M INHIBIN B...........@M
MAGNESIUM UR 24HR...@M PHOS,INORGANIC,UR24H@M URIC ACID 24HR URINE.....@M ESTRADIOL,SERUM----------------@M
METANEPHRINES, FRACT, PLASMA @M METANEPHRINES,FRAC,UR 24H@M ALDOLASE.................@M COXSACKIE A VIRUS GRP CHG@M COXSACKIE A AB,CSF,CHG.@M COXSACKIE A AB,CSF,CHG..@M COXSACKIE B AB (1-6) CHG.@M COXSACKIE B AB (1-6)CSF CHG.@M COXSACKIE B AB (1-6)CSF CHG..@M LYME DISEASE AB SCREEN...@M BETA-2-MICROGLOBULIN.....@M
Alpha-1-antitrypsin; total Extractable nuclear antigen, antibody to, any method (eg, nRNP, SS-A, SS-B, Sm, RNP, Sc170, J01), each antibody Extractable nuclear antigen, antibody to, any method (eg, nRNP, SS-A, SS-B, Sm, RNP, Sc170, J01), each antibody Insulin; total Proinsulin Inhibin A Chemiluminescent assay
Magnesium Phosphorus inorganic (phosphate); urine Uric acid; other source Estradiol HLA typing; A, B, or C (eg, A10, B7, B27), single antigen Fluorescent noninfectious agent antibody; screen, each antibody Fluorescent noninfectious agent antibody; titer, each antibody Catecholamines; fractionated Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique Cryoglobulin, qualitative or semi-quantitative (eg, cryocrit) Glucose-6-phosphate dehydrogenase (G6PD); quantitative Extractable nuclear antigen, antibody to, any method (eg, nRNP, SS-A, SS-B, Sm, RNP, Sc170, J01), each antibody Infectious agent detection by nucleic acid (DNA or RNA); HIV-1, quantification, includes reverse transcription when performed Metanephrines Metanephrines Aldolase Antibody; enterovirus (eg, coxsackie, echo, polio) Antibody; enterovirus (eg, coxsackie, echo, polio) Antibody; enterovirus (eg, coxsackie, echo, polio) Antibody; enterovirus (eg, coxsackie, echo, polio) Antibody; enterovirus (eg, coxsackie, echo, polio) Antibody; enterovirus (eg, coxsackie, echo, polio) Antibody; Borrelia burgdorferi (Lyme disease) Beta-2 microglobulin
Amount
159 of 167 Updated on 1/22/2019
UB Revenue Code
CPT/HCPCS
302
86255
6.28
302
86255
6.00
301 301 302 302 301 302 301 302 302 302 301 301 301 300
83916 83873 86738 86738 84244 86765 84466 86147 86147 86147 82530 84480 84481 86747
12.00 11.20 9.22 7.65 12.00 3.25 5.60 4.35 4.35 4.35 9.60 5.00 5.04 12.25
409026872-26872 CLOSTRIDIUM DIFF TOXINS QUAL..@M
Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzymelinked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative, multiple-step method; Clostridium difficile toxin(s)
306
8732490
8.80
409026873-26873 CLOSTRIDIUM DIFF TOXINS EIA..@M
Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzymelinked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]), qualitative or semiquantitative; multiple-step method, not otherwise specified, each organism
306
87449
8.80
4870
409026875-26875 CLOSTRIDIUM DIFFICILE TOXINS @M
Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzymelinked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative, multiple-step method; Clostridium difficile toxin(s)
306
87324
10.27
4870
409026876-26876 CLOSTRIDIUM DIFF TOX B,QUAL,PRC@M
306
87493
60.00
4870
409026883-26883 DIHYDROTESTOSTERONE (DHT).....@M
301
G0480
33.75
4870
409026898-26898 HCV GENOTYPE BY NUCLEIC ACID..@M
300
87902
85.36
4870
409026920-26920 ETHYLENE GLYCOL..........@M
301
82693
13.63
Revenue Center
CDM Number
CDM Description
4870
409026610-26610 MITOCHONDRIAL ANTIBODIES.@M
4870
409026620-26620 SMOOTH MUSCLE ANTIBODIES.@M
4870 4870 4870 4870 4870 4870 4870 4870 4870 4870 4870 4870 4870 4870
409026636-26636 409026637-26637 409026642-26642 409026644-26644 409026690-26690 409026700-26700 409026720-26720 409026733-26733 409026734-26734 409026735-26735 409026740-26740 409026800-26800 409026805-26805 409026829-26829
4870
4870
OLIGOCLONAL BANDING(CSF)-------@M MYELIN BASIC PROTEIN(CSF)------@M MYCOPLASMA ANTIBODY IGM.......@M MYCOPLASMA ANTIBODY IGG.......@M RENIN ACTIVITY...........@M RUBEOLA VIRUS IGG AB.....@M TRANSFERRIN..............@M CARDIOLIPIN IGA ANTIBODY. . . .@M CARDIOLIPIN IGG ANTIBODY. . . .@M CARDIOLIPIN IGM ANTIBODY. . .@M CORTISOL,FREE,URINE,24H........@M T3,TOTAL.................@M TRIIODOTHYRONINE,FREE(T3)------@M PARVOVIRUS B-19 IMMUNOGLOB, EACH
Long Description Fluorescent noninfectious agent antibody; screen, each antibody Fluorescent noninfectious agent antibody; screen, each antibody Oligoclonal immune (oligoclonal bands) Myelin basic protein, cerebrospinal fluid Antibody; mycoplasma Antibody; mycoplasma Renin Antibody; rubeola Transferrin Cardiolipin (phospholipid) antibody, each Ig class Cardiolipin (phospholipid) antibody, each Ig class Cardiolipin (phospholipid) antibody, each Ig class Cortisol; free Triiodothyronine T3; total (TT-3) Triiodothyronine T3; free Antibody; parvovirus
Infectious agent detection by nucleic acid (DNA or RNA); Clostridium difficile, toxin gene(s), amplified probe technique Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrixmatched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 1-7 drug class(es), including metabolite(s) if performed Infectious agent genotype analysis by nucleic acid (DNA or RNA); Hepatitis C virus Ethylene glycol
Amount
160 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4870 4870 4870 4870 4870
409026970-26970 409027010-27010 409027020-27020 409027021-27021 409027030-27030
4870
409027045-27045 ITRACONAZOLE . . . . . . . .@M
4870
409027082-27082 PLATELET AB SCREEN,EA,@M
4870
409027083-27083 ANTI-MULLERIAN HORMONE......@M
4870 4870
409027084-27084 ANTI-MULLERIAN HORMONE MALE...@M 409027085-27085 ANTI-MULLERIAN HORMONE FEMALE..@M
4870
409027092-27092 HIV1 REVERSE TRANSCRIPTASE & PROB
4870
409027093-27093 HIV-1 AB
ALDOSTERONE..............@M HOMOCYSTEINE,CARDIOVSCLR.......@M ALCOHOL,METHYL...........@M ALCOHOL,ISOPROPYL....@M CERULOPLASMIN............@M
4870
409027097-27097 HIV-1 AG WITH HIV-1 & HIV-2 AB
4870 4870 4870 4870 4870 4870
409027099-27099 409027100-27100 409027105-27105 409027106-27106 409027107-27107 409027120-27120
4870
409027130-27130 CARBOHYDRATE ANTIGEN 19-9@M
4870
409027180-27180 HYDROXYPROGESTERONE, 17-D @W
HIV-2 AB TACROLIMUS...............@M TESTOSTERONE TOTAL, PNL .......@M TESTOSTERONE FREE, PNL ........@M TESTOSTERONE,TOTAL,FEMALE & YOUTH THYROID STIM IMMUNOGLOB..@M
Long Description Aldosterone Homocysteine Volatiles (eg, acetic anhydride, diethylether) Volatiles (eg, acetic anhydride, diethylether) Ceruloplasmin Quantitation of therapeutic drug, not elsewhere specified Antibody identification; platelet antibodies Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative, not otherwise specified Chemiluminescent assay Chemiluminescent assay Infectious agent detection by nucleic acid (DNA or RNA); HIV-1, amplified probe technique, includes reverse transcription when performed Antibody; HIV-1 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzymelinked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative, multiple-step method; HIV-1 antigen(s), with HIV-1 and HIV-2 antibodies, single result Antibody; HIV-2 Tacrolimus Testosterone; total Testosterone; free Testosterone; total Thyroid stimulating immune globulins (TSI) Immunoassay for tumor antigen, other antigen, quantitative (eg, CA 50, 72-4, 549), each Hydroxyprogesterone, 17-d
UB Revenue Code 301 301 301 301 301
CPT/HCPCS
Amount
82088 83090 84600 84600 82390
12.65 11.90 7.82 6.97 5.00
300
80299
57.66
302
86022
14.55
301
83520
40.00
301 301
82397 82397
40.00 40.00
306
87535
250.00
302
86701
12.50
302
87389
18.14
302 301 301 301 301 301
86702 80197 84403 84402 84403 84445
12.50 20.85 6.00 6.00 8.00 28.90
301
86316
8.00
301
83498
15.95
301
83789
16.00
4870
409027181-27181 TANDEM MASS SPEC, QUANT(MS/MS)@W
Mass spectrometry and tandem mass spectrometry (eg, MS, MS/MS, MALDI, MS-TOF, QTOF), non-drug analyte(s) not elsewhere specified, qualitative or quantitative, each specimen
4870
409027182-27182 BIOTINIDASE . . . . . . . . @W
Biotinidase, each specimen
301
82261
15.95
409027183-27183 IMMUNOREACTIVE TRYPSINOGEN . . @W
Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; qualitative or semiquantitative, multiple step method
301
83516
15.95
301
81381
148.00
306
87255
8.00
301 302 301 300 301
86021 86021 84432 82365 84144
10.00 10.00 13.80 13.60 8.00
306
87491
25.00
306
87591
25.00
302
86592
2.48
4870
4870
409027190-27190 HLA-B 5701 TYPING..............@M
4870
409027200-27200 CULTURE, HSV, RAPID..........@M
4870 4870 4870 4870 4870
409027205-27205 409027206-27206 409027207-27207 409027209-27209 409027213-27213
4870
409027216-27216 C.TRACH,AMP PROBE TECHNIQUE . .@M
4870
409027217-27217 N.GONORRHEA, AMP PROBE ...@M
4870
409027220-27220 RPR W/REFL TITER & CONFIRM.....@M
MYELOPEROXIDASE AUTOANTIBODIES.@M PR3 IGG AUTOANTIBODIES.........@M THYROGLOBULIN..................@M KIDNEY STONE ANALYSIS.......@M PROGESTERONE.................@M
HLA Class I typing, high resolution (ie, alleles or allele groups); one allele or allele group (eg, B*57:01P), each Virus isolation; including identification by nonimmunologic method, other than by cytopathic effect (eg, virus specific enzymatic activity) Antibody identification; leukocyte antibodies Antibody identification; leukocyte antibodies Thyroglobulin Calculus; infrared spectroscopy Progesterone Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, amplified probe technique Syphilis test, non-treponemal antibody; qualitative (eg, VDRL, RPR, ART)
161 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
Long Description
UB Revenue Code
CPT/HCPCS
Amount
4870
409027221-27221 RPR(MONITOR) W/REFL TITER...@M
Syphilis test, non-treponemal antibody; qualitative (eg, VDRL, RPR, ART)
302
86592
2.48
4870
409027222-27222 RPR TITER REFLEX.....@M
Syphilis test, non-treponemal antibody; quantitative
302
86593
2.42
4870
409027242-27242 PH, BODY FLUID, EXCEPT BLOOD
301
83986
2.17
301
82306
15.00
302
86790
31.40
306
87798
40.00
301
81241
38.00
301 301
83498 83498
14.43 35.00
301
83519
35.00
301 301 301
86803 86038 83010
5.00 3.00 7.20
301
83021
3.00
305 305 305
85014 85018 85041
3.00 3.00 3.00
306
88230
135.80
311
88262
135.80
301
83516
7.20
301
82652
12.00
306
87109
12.80
306
87899
41.16
301 301 305 301
86706 84305 85660 84425
4.00 16.20 3.61 10.50
305
85300
15.00
301
82785
11.84
302
86003
5.16
302
86003
5.78
302 301 301 301 301 301 301 301 301 301
8632990 83010 82172 82247 82977 84460 82172 82247 82977 83010
53.96 43.96 53.96 33.96 43.96 33.95 41.66 41.67 41.67 41.67
4870 4870 4870 4870 4870 4870 4870 4870 4870 4870 4870 4870 4870 4870 4870 4870
pH; body fluid, not otherwise specified Vitamin D; 25 hydroxy, includes fraction(s), if 409027245-27245 VITAMIN D, 25-HYDROXY. . . . @M performed 409027251-27251 AB TO VIRUS(WEST NILE)IGG,IGM @M Antibody; virus, not elsewhere specified Infectious agent detection by nucleic acid (DNA or 409027261-27261 INF AGENT DET DNA BY PCR, EACH @M RNA), not otherwise specified; amplified probe technique, each organism F5 (coagulation Factor V) (eg, hereditary 409027300-27300 FACTOR V LEIDEN MUTATION......@M hypercoagulability) gene analysis, Leiden variant 409027320-27320 HYDROXYPROGESTERONE, 17-D.....@M Hydroxyprogesterone, 17-d 409027322-27322 17-HYDROXYPROGESTERONE NEO/INF @M Hydroxyprogesterone, 17-d Immunoassay for analyte other than infectious agent 409027326-27326 GAD-65 AUTOANTIBODY @M antibody or infectious agent antigen; quantitative, by radioimmunoassay (eg, RIA) 409027328-27328 HEPATITIS C ANTIBODY @M Hepatitis C antibody; 409027330-27330 ANA SCREEN IFA W/REFL TO TITER @Q Antinuclear antibodies (ANA); 409027335-27335 HAPTOGLOBIN QUANT.............@M Haptoglobin; quantitative Hemoglobin fractionation and quantitation; 409027341-27341 CHROMATOGRAPHY,HEMOGLOBINOPATHY@M chromatography (eg, A2, S, C, and/or F) 409027342-27342 HEMATOCRIT, HEMOGLOBIN PNL...@M Blood count; hematocrit (Hct) 409027343-27343 HEMOGLOBIN, HEMOGLOBIN PNL....@M Blood count; hemoglobin (Hgb) 409027344-27344 RBC, AUTOMATED, HEMOGLOBIN PNL @M Blood count; red blood cell (RBC), automated Tissue culture for non-neoplastic disorders; 409027351-27351 TISSUE CULTURE,CHROMO ANALYSIS @M lymphocyte Chromosome analysis; count 15-20 cells, 2 409027352-27352 CHROMO ANALYSIS ADDL KAROTYPES @M karyotypes, with banding Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; qualitative or semiquantitative, multiple step method
4870
409027354-27354 ACTIN(SMOOTH MUSCLE) AB IGG....@M
4870
409027361-27361 VIT D, 1,25 DIHYDROXY LC/MS/MS @M
4870
409027362-27362 MYCOPLASMA HOMINIS/UREAPLASMA CUL
4870
409027363-27363 S.PNEUMONIAE ANTIGENS, UR...@M
4870 4870 4870 4870
409027364-27364 409027365-27365 409027370-27370 409027377-27377
4870
409027380-27380 CLOT INHIB/ANTICOAG, ATIII.....@M
4870
409027391-27391 IMMUNOGLOB E,RESPIRATORY PNL...@M
4870
409027392-27392 ALLERGN,EA,RESPIRATORY PNL.....@M
4870
409027396-27396 IGE QUANT,ALLERGY SPECIFIC,QNT.@M
4870 4870 4870 4870 4870 4870 4870 4870 4870 4870
409027401-27401 409027402-27402 409027403-27403 409027404-27404 409027405-27405 409027406-27406 409027411-27411 409027412-27412 409027413-27413 409027414-27414
4870
409027415-27415 ALPHA 2-MACROGLOBULINS QN @LABCOR
Nephelometry, each analyte not elsewhere specified
302
83883
41.66
4870
409027416-27416 ALANINE AMINOTRANSFERASE @LABCORP
Transferase; alanine amino (ALT) (SGPT)
301
84460
41.67
HEPATITIS B SURF AB QUAL...@M SOMATOMEDIN...................@M SICKLING OF RBC, REDUCTION ....@M VITAMIN B1(THIAMINE)...........@M
ALPHA 2-MACROGLOBULINS QN @M HAPTOGLOBINS, QN . . . . . . .@M APOLIPOPROTEIN A-1 . . . . . . @M BILI T FIBROSURE . . . . . . . @M GAMMA GLUTAMYLTRANSFERASE . @M ALANINE AMINO TRANSFERASE @M APOLIPOPROTEIN A-1 @LABCORP BILIRUBIN, TOTAL @LABCORP GAMMAGLUTAMYLTRANSFERASE @LABCORP HAPTOGLOBINS, QN@LABCORP
Vitamin D; 1, 25 dihydroxy, includes fraction(s), if performed Culture, mycoplasma, any source Infectious agent antigen detection by immunoassay with direct optical observation; not otherwise specified Hepatitis B surface antibody (HBsAb) Somatomedin Sickling of RBC, reduction Thiamine (Vitamin B-1) Clotting inhibitors or anticoagulants; antithrombin III, activity Gammaglobulin (immunoglobulin); IgE Allergen specific IgE; quantitative or semiquantitative, crude allergen extract, each Allergen specific IgE; quantitative or semiquantitative, crude allergen extract, each Immunodiffusion; not elsewhere specified Haptoglobin; quantitative Apolipoprotein, each Bilirubin; total Glutamyltransferase, gamma (GGT) Transferase; alanine amino (ALT) (SGPT) Apolipoprotein, each Bilirubin; total Glutamyltransferase, gamma (GGT) Haptoglobin; quantitative
162 of 167 Updated on 1/22/2019
UB Revenue Code
CPT/HCPCS
409027500-27500 HIV-1 GENOTYPE . . . . . . . @M
Infectious agent genotype analysis by nucleic acid (DNA or RNA); HIV-1, reverse transcriptase and protease regions
306
87901
70.40
409027600-27600 ASPERGILLUS ANTIGEN EIA,SERUM..@M
Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzymelinked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative, multiple-step method; Aspergillus
306
87305
80.00
4870
409027603-27603 ASPERGILLUS ANTIGEN,EIA,BAL....@M
Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzymelinked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative, multiple-step method; Aspergillus
306
87305
172.64
4870
409027605-27605 T3 UPTAKE . . . . . . . . . . .@M
301
84479
3.00
4870
409027607-27607 GLOMERULAR BASEMENT MEMB. AB(IGG)
301
83520
30.00
4870 4870 4870
409027609-27609 C1 INHIBITOR,FUNCTIONAL........@M 409027616-27616 PLATELET ANTIBODY, SRA.........@M 409027617-27617 PLATELET AB, HEPARIN INDUCED...@M
302 302 302
86161 86022 86022
15.30 168.57 168.57
4870
409027625-27625 IMMUNOGLOBULIN G SUBCLASS 4....@M
301
82787
10.00
4870
409027700-27700 HCV VIRAL LOAD (QUANT RNA),KCHD
302
87522
70.00
4870
409027800-27800 TB, QUANTIFERON GOLD, KCHD.....@Q
302
86480
34.00
4870
409027801-27801 QUANTIFERON-TB GOLD (QUEST)...@M
302
86480
34.00
4870
409028012-28012 PTT, LUPUS PANEL. . . . . .@M
305
85730
12.25
4870
409028020-28020 DRVVT,LUPUS PANEL........@M
305
85613
12.24
4870
409028061-28061 HERPES SIMPLES VIR, AMP PROBE @M
306
87529
30.00
4870
409028065-28065 VDRL,CSF..........@M
302
86592
8.98
4870
409028070-28070 VORICONAZOLE LEVEL.....@M
301
80299
148.79
4870
409028075-28075 CRYPTOCOCCUS AG, BLD OR CSF .@M
302
86403
9.61
4870
409028080-28080 EXTRACTABLE NUCLEAR AG, SCL-70 @M
302
86235
10.26
4870
409028085-28085 HTLV 1/2 AB, EIA . . . . . . .@M
302
86790
24.57
4870
409028086-28086 HTLV I/II AB CONFIRM,WESTERN BLOT
302
86689
71.93
4870
409028090-28090 ANTINUCLEAR AB, CENTROMERE B @M
302
86235
9.09
4870
409028101-28101 OVA & PARASITES, SMEARS, CONC,@M\
306
87177
2.68
4870
409028102-28102 COMPLEX SPECIAL STAIN FOR O&P @M
306
87209
2.68
4870
409028110-28110 MTHFR, DNA MUTATION ANALYSIS @M
301
81291
75.00
4870
409028120-28120 METHYLMALONIC ACID . . . . . @M
301
83921
14.00
Revenue Center
4870
4870
CDM Number
CDM Description
Long Description
Thyroid hormone (T3 or T4) uptake or thyroid hormone binding ratio (THBR) Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative, not otherwise specified Complement; functional activity, each component Antibody identification; platelet antibodies Antibody identification; platelet antibodies Gammaglobulin (immunoglobulin); immunoglobulin subclasses (eg, IgG1, 2, 3, or 4), each Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, quantification, includes reverse transcription when performed Tuberculosis test, cell mediated immunity antigen response measurement; gamma interferon Tuberculosis test, cell mediated immunity antigen response measurement; gamma interferon Thromboplastin time, partial (PTT); plasma or whole blood Russell viper venom time (includes venom); diluted Infectious agent detection by nucleic acid (DNA or RNA); Herpes simplex virus, amplified probe technique Syphilis test, non-treponemal antibody; qualitative (eg, VDRL, RPR, ART) Quantitation of therapeutic drug, not elsewhere specified Particle agglutination; screen, each antibody Extractable nuclear antigen, antibody to, any method (eg, nRNP, SS-A, SS-B, Sm, RNP, Sc170, J01), each antibody Antibody; virus, not elsewhere specified Antibody; HTLV or HIV antibody, confirmatory test (eg, Western Blot) Extractable nuclear antigen, antibody to, any method (eg, nRNP, SS-A, SS-B, Sm, RNP, Sc170, J01), each antibody Ova and parasites, direct smears, concentration and identification Smear, primary source with interpretation; complex special stain (eg, trichrome, iron hemotoxylin) for ova and parasites MTHFR (5,10-methylenetetrahydrofolate reductase) (eg, hereditary hypercoagulability) gene analysis, common variants (eg, 677T, 1298C) Organic acid, single, quantitative
Amount
163 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
Long Description Infectious agent detection by nucleic acid (DNA or RNA); hepatitis B virus, quantification Zinc Fluorescent noninfectious agent antibody; screen, each antibody Antibody; Treponema pallidum Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, DESI, GC-MS, GCMS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service
UB Revenue Code
CPT/HCPCS
306
87517
70.00
301
84630
9.24
301
86255
9.00
309
86780
6.00
301
80307
47.74
Amount
4870
409028125-28125 HEP B VIRUS, QUANTIFICATION @M
4870
409028130-28130 ZINC . . . . . . . . . . . . @M
4870
409028131-28131 DNA AB (DS) CRITHIDIA,IFA
4870
409028132-28132 FTA-ABS.....@M
4870
409028133-28133 CARISOPRODOL SCR/W RFLX...@M
4870
409028134-28134 KAPPA/LAMBDA LC, TOTAL........@M
Nephelometry, each analyte not elsewhere specified
301
83883
12.50
4870
409028135-28135 VITAMIN A (RETINOL) . . . . . .@M
301
84590
11.20
4870
409028137-28137 MEPROBAMATE, QUANT, URINE..@M
Vitamin A Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrixmatched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 1-7 drug class(es), including metabolite(s) if performed
301
G0480
96.45
4870
409028138-28138 CRITHIDIA TITER
301
86256
22.70
4870 4870
409028139-23139 CARISOPRODOL/MEPROBAMATE...@M 409028140-28140 TOCOPHEROL ALPHA (VITAMIN E). .@M
301 301
80369 84446
92.00 11.20
4870
409028145-28145 HIV-1, AMPLIFIED PROBE . . . . @M
306
87535
90.00
4870 4870 4870
409028150-28150 PHOSPHATASE,ALKALINE,ISOENZYMES@M 409028156-28156 BETA 2 GLYCOPROTEINS 1 AB, EA, @M 409028157-28157 PHOSPHATIDYLSERINE AB, EA...@M
301 302 302
84080 86146 86148
4.05 78.00 14.86
301
83516
12.50
302 302 302 301 301
86148 86146 86147 80361 80324
50.45 50.45 50.45 22.02 47.04
Fluorescent noninfectious agent antibody; titer, each antibody Skeletal muscle relaxants; 1 or 2 Tocopherol alpha (Vitamin E) Infectious agent detection by nucleic acid (DNA or RNA); HIV-1, amplified probe technique, includes reverse transcription when performed Phosphatase, alkaline; isoenzymes Beta 2 Glycoprotein I antibody, each Anti-phosphatidylserine (phospholipid) antibody
4870
409028161-28161 IMM ASSAY FOR ANALYTE,NOT INF,@M
Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; qualitative or semiquantitative, multiple step method
4870 4870 4870 4870 4870
409028162-28162 409028163-28163 409028164-28164 409028166-28166 409028167-28167
Anti-phosphatidylserine (phospholipid) antibody Beta 2 Glycoprotein I antibody, each Cardiolipin (phospholipid) antibody, each Ig class Opiates, 1 or more Amphetamines; 1 or 2
PHOSPHATIDYLSERINE AB W INTERP CH BETA-2 GLYCOPROTEIN AB W INTERP C CARDIOLIPIN AB W INTERP ITEM CHG OPIATE CONFIRMATION, GC/MS, URINE AMPHETAMINES CONFIRMATION...@M
164 of 167 Updated on 1/22/2019
UB Revenue Code
CPT/HCPCS
301
80307
50.82
301
80324
26.00
301
80375
275.03
302 302
86735 86735
6.00 37.57
301
81240
38.00
306
87498
95.00
305
85246
60.00
306
87497
70.00
302
86671
25.00
302
86376
27.82
301
80299
18.00
301
83519
28.00
302
86757
15.00
409028315-28315 HISTOPLASMA AG,QUANT,EIA,MVISTA..
Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzymelinked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative, multiple-step method; Histoplasma capsulatum
306
87385
142.50
4870
409028330-28330 LC/MS/MS, CLOZAPINE . . .@M
Mass spectrometry and tandem mass spectrometry (eg, MS, MS/MS, MALDI, MS-TOF, QTOF), non-drug analyte(s) not elsewhere specified, qualitative or quantitative, each specimen
301
83789
6.60
4870
409028340-28340 LIPOPROTEIN (A) . . . . . . .@M
301
83695
12.00
4870
409028365-28365 CHROMOGRANIN A
Lipoprotein (a) Immunoassay for tumor antigen, other antigen, quantitative (eg, CA 50, 72-4, 549), each
302
86316
40.00
4870
409028405-28405 ADENOSINE DEAMINASE,SPECTROPH..@M
Spectrophotometry, analyte not elsewhere specified
301
84311
125.39
4870 4870
409028407-28407 ALPHA-1-ANTITRYPSIN,FECES.....@M 409028409-28409 CALPROTECTIN,STOOL.......@M
301 301
82103 83993
25.38 90.00
4870
409028410-28410 ABL MUTATION, T315I VARIANT @M
Alpha-1-antitrypsin; total Calprotectin, fecal Molecular pathology procedure, Level 2 (eg, 2-10 SNPs, 1 methylated variant, or 1 somatic variant [typically using nonsequencing target variant analysis], or detection of a dynamic mutation disorder/triplet repeat)
319
81401
454.55
4870
409028411-28411 JAK2 MUTATION, V617F VARIANT @M
319
81270
200.00
Revenue Center
CDM Number
CDM Description
4870
409028168-28168 DRUG MONITORING PANEL-6 W/RFLX..@
4870
409028169-28169 AMPHETAMINES CONFIRM CHG ONLY..@M
4870
409028176-28176 TPMT ACTIVITY.....@M
4870 4870
409028178-28178 MUMPS VIRUS AB IGG...@M 409028179-28179 MUMPS VIRUS AB IGM...@M
4870
409028180-28180 PROTHROMBIN (FAC II)GENE MUT @M
4870
409028190-28190 ENTEROVIRUS RNA, AMP PROBE . . @M
4870
409028200-28200 VON WILLIBRAND FACTOR ANTIGEN @M
4870
409028210-28210 CMV, DNA, QUANT PCR @M
4870
409028237-28237 S. CEREVISIAE IGG, FUNGUS AB @M
4870
409028250-28250 LIVER-KIDNEY MICROSOMAL IGG . .@M
4870
409028253-28253 LEVITIRACETAM . . . . . . . .@M
4870
409028264-28264 PTH-RELATED PROTEIN (PTH-RP) . @M
4870
409028276-28276 RICKETTSIA, TYPHUS (MURINE)AB @M
4870
Long Description Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, DESI, GC-MS, GCMS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service Amphetamines; 1 or 2 Drug(s) or substance(s), definitive, qualitative or quantitative, not otherwise specified; 1-3 Antibody; mumps Antibody; mumps F2 (prothrombin, coagulation factor II) (eg, hereditary hypercoagulability) gene analysis, 20210G>A variant Infectious agent detection by nucleic acid (DNA or RNA); enterovirus, amplified probe technique, includes reverse transcription when performed Clotting; factor VIII, VW factor antigen Infectious agent detection by nucleic acid (DNA or RNA); cytomegalovirus, quantification Antibody; fungus, not elsewhere specified Microsomal antibodies (eg, thyroid or liver-kidney), each Quantitation of therapeutic drug, not elsewhere specified Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative, by radioimmunoassay (eg, RIA) Antibody; Rickettsia
JAK2 (Janus kinase 2) (eg, myeloproliferative disorder) gene analysis, p.Val617Phe (V617F) variant
Amount
165 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
Long Description Infectious agent detection by nucleic acid (DNA or RNA); influenza virus, for multiple types or subtypes, includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, first 2 types or sub-types Infectious agent detection by nucleic acid (DNA or RNA); influenza virus, for multiple types or subtypes, includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, first 2 types or sub-types BCR/ABL1 (t(9;22)) (eg, chronic myelogenous leukemia) translocation analysis; major breakpoint, qualitative or quantitative BCR/ABL1 (t(9;22)) (eg, chronic myelogenous leukemia) translocation analysis; minor breakpoint, qualitative or quantitative BCR/ABL1 (t(9;22)) (eg, chronic myelogenous leukemia) translocation analysis; major breakpoint, qualitative or quantitative BCR/ABL1 (t(9;22)) (eg, chronic myelogenous leukemia) translocation analysis; minor breakpoint, qualitative or quantitative Infectious agent genotype analysis by nucleic acid (DNA or RNA); HIV-1, other region (eg, integrase, fusion) Elastase, pancreatic (EL-1), fecal, qualitative or semiquantitative Human epididymis protein 4 (HE4)
UB Revenue Code
CPT/HCPCS
306
87502
75.00
306
87502
195.00
319
81206
49.50
319
81207
49.50
319
81206
101.34
319
81207
101.34
306
87906
70.40
301
82656
55.00
301
86305
150.00
Amount
4870
409028450-28450 INFLUENZA A/B RNA QUAL RT PCR.@M
4870
409028452-28452 INFLUENZA A H1N1,RT-PCR.......@M
4870
409028458-28458 BCR ABL1 GENE MAJOR BP P210, QN@M
4870
409028459-28459 BCR ABL1 GENE MINOR BP P190, QN@M
4870
409028460-28460 P210 BCR ABL1 GENE MAJOR BP CHG@M
4870
409028461-28461 P190 BCR ABL1 GENE MINOR BP CHG@M
4870
409028463-28463 HIV-1 INTEGRASE GENOTYPE.@M
4870
409028470-28470 ELASTASE PANCREATIC EL1-1,FECAL@M
4870
409029010-29010 HUMAN EPIDIDYMIS PROTEIN 4(HE4)
4870
409029020-29020 GLIADIN ANTIBODY IGA IMMUNO ASSAY
Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; qualitative or semiquantitative, multiple step method
301
83516
8.00
4870
409029022-29022 GLIADIN ANTIBODY IGG IMMUNO ASSAY
Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; qualitative or semiquantitative, multiple step method
301
83516
8.00
4870 4870
409029030-29030 ANTIBODY SCREEN,EA MEDIA.....@ARC 409029031-29031 ANTIBODY ELUTION(RBC),EA.....@ARC
302 302
86850 86860
95.00 210.00
4870
409029032-29032 DIRECT ANTIGLOBULIN(DAT),EA..@ARC
302
86880
35.00
4870 4870
409029033-29033 ABO TYPE,EA..................@ARC 409029034-29034 RH PHENOTYPING,EA............@ARC
302 302
86900 86906
60.00 107.00
4870
409029035-29035 PRETREATMENT W ENZYMES,RBC,EA@ARC
302
86971
62.00
4870
409029036-29036 DIFFERENTIAL/AUTO ADS,EA.....@ARC
302
86978
145.00
4870
409029037-29037 AB ID/EA PANEL & MEDIA.......@ARC
302
86870
115.00
4870
409029038-29038 RH TYPE......................@ARC
302
86901
40.00
4870
409029040-29040 RBC AG,OTHER THAN ABO/D......@ARC
302
86905
75.00
4870
409029041-29041 PRETREATMENT W DRUGS,RBC,EA.@ARC
302
86970
120.00
4870 4870 4870 4870
409029042-29042 409029100-29100 409029101-29101 409029102-29102
302 301 301 301
86999 80339 80154 80171
25.00 51.23 40.28 22.61
4870
409029103-29103 ACETAZOLAMIDE LEVEL...@NMS
301
80375
126.00
GEL RED CELL PREP,CHG,EA,@ARC ETHOSUXIMIDE LEVEL...@M CLONAZEPAM LEVEL...@M GABAPENTIN LEVEL...@M
Antibody screen, RBC, each serum technique Antibody elution (RBC), each elution Antihuman globulin test (Coombs test); direct, each antiserum Blood typing, serologic; ABO Blood typing, serologic; Rh phenotyping, complete Pretreatment of RBCs for use in RBC antibody detection, identification, and/or compatibility testing; incubation with enzymes, each Pretreatment of serum for use in RBC antibody identification; by differential red cell absorption using patient RBCs or RBCs of known phenotype, each absorption Antibody identification, RBC antibodies, each panel for each serum technique Blood typing, serologic; Rh (D) Blood typing, serologic; RBC antigens, other than ABO or Rh (D), each Pretreatment of RBCs for use in RBC antibody detection, identification, and/or compatibility testing; incubation with chemical agents or drugs, each Unlisted transfusion medicine procedure Antiepileptics, not otherwise specified; 1-3 Benzodiazepines Gabapentin, whole blood, serum, or plasma Drug(s) or substance(s), definitive, qualitative or quantitative, not otherwise specified; 1-3
166 of 167 Updated on 1/22/2019
Revenue Center
CDM Number
CDM Description
4870
409029104-29104 NITRAZEPAM LEVEL...@NMS
4870
409029105-29105 LACOSAMIDE LEVEL...@M
4870 4870 4870 4870 4870 4870 4870 4870 4870 4870 4870 4870 4870 4870 4870 4870 4870 4870 4870 4870 4870 4870 4870 4870 4870 4870 4870 4870 4870
409029106-29106 409029107-29107 409029108-29108 409029109-29109 409029110-29110 409029111-29111 409029112-29112 409029113-29113 409029114-29114 409029115-29115 409029116-29116 409029117-29117 409029119-29119 409029120-29120 409029121-29121 409029122-29122 409029123-29123 409029124-29124 409029125-29125 409029126-29126 409029127-29127 409029128-29128 409029129-29129 409029130-29130 409029132-29132 409029133-29133 409029134-29134 409029135-29135 409029136-29136
RUFINAMIDE LEVEL...@M PREGABALIN LEVEL...@M LAMOTRIGINE LEVEL...@M CLOBAZAM LEVEL...@M TOPIRAMATE LEVEL...@M LORAZEPAM LEVEL...@M OXCARBAZEPINE METABOLITE...@M DIAZEPAM AND METABOLITE...@M METHSUXIMIDE LEVEL...@NMS FOSPHENYTOIN LEVEL...@NMS STIRIPENTOL LEVEL...@NMS VIGABATRIN LEVEL...@NMS STONERISK URINE AMMONIUM CHG...@M STONERISK URINE CALCIUM CHG...@M STONERISK UR CITRIC ACID CHG...@M STONERISK UR CREATININE CHG...@M STONERISK URINE MAGNESIUM CHG..@M STONERISK URINE OXALATE CHG...@M STONERISK URINE PH CHARGE...@M STONERISK URINE PHOSPHATE CHG..@M STONERISK URINE POTASSIUM CHG..@M STONERISK URINE SODIUM CHG...@M STONERISK URINE SULFATE CHG...@M STONERISK URINE URIC ACID CHG..@M IBD PANEL- PR3-AB CHG...@M IBD PANEL- ANCA SCREEN CHG...@M IBD PANEL- ASCA(IGG) CHG...@M IBD PANEL- ASCA(IGM) CHG...@M IBD PANEL- MPO-AB CHG...@M
Long Description Benzodiazepines; 1-12 Quantitation of therapeutic drug, not elsewhere specified Antiepileptics, not otherwise specified; 1-3 Pregabalin Lamotrigine Benzodiazepines; 1-12 Topiramate Benzodiazepines; 1-12 Oxcarbazepine Benzodiazepines; 1-12 Antiepileptics, not otherwise specified; 1-3 Phenytoin; total Antiepileptics, not otherwise specified; 1-3 Antiepileptics, not otherwise specified; 1-3 Ammonia Calcium; urine quantitative, timed specimen Citrate Creatinine; other source Magnesium Oxalate pH; body fluid, not otherwise specified Phosphorus inorganic (phosphate); urine Potassium; urine Sodium; urine Sulfate, urine Uric acid; other source Antibody identification; leukocyte antibodies Antibody identification; leukocyte antibodies Antibody; fungus, not elsewhere specified Antibody; fungus, not elsewhere specified Antibody identification; leukocyte antibodies
4870
409029201-29201 MYOSITIS ASSESSR COMP CHARGE...@M
Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; qualitative or semiquantitative, multiple step method
4870
409029202-29202 MYOSITIS ASSESS COMP CHG 2...@M
Extractable nuclear antigen, antibody to, any method (eg, nRNP, SS-A, SS-B, Sm, RNP, Sc170, J01), each antibody
UB Revenue Code 301
CPT/HCPCS
Amount
80346
153.00
301
80299
67.00
301 301 301 301 301 301 301 301 301 301 301 301 301 301 301 301 301 301 301 301 301 301 301 301 301 301 301 301 301
80339 80366 80175 80346 80201 80346 80183 80346 80339 80185 80339 80339 82140 82340 82507 82570 83735 83945 83986 84105 84133 84300 84392 84560 86021 86021 86671 86671 86021
55.91 112.00 8.00 180.50 20.00 56.00 27.00 98.00 74.00 54.00 226.00 150.00 8.34 8.34 8.34 8.34 8.33 8.33 8.33 8.33 8.33 8.33 8.33 8.33 62.27 62.27 62.28 62.28 62.28
301
83516
68.32
301
86235
68.32
167 of 167 Updated on 1/22/2019
