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ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.

0)
FIRST CASE RATE
RVS CODE

DESCRIPTION

Case Rate

Professional Fee

Health Care
Institution Fee

Integumentary System
Skin, Subcutaneous and Accessory Structures
Incision and Drainage
10060
10080
10120
10140
10160
10180
11000
11010
11011

11012
11040
11041
11042
11043
11044

11050

11051

11052

11100

11300
11301
11302
11303
11305
11306
11307
11308
11310
11311
11312
11313

11400
11401

Incision and drainage of abscess (e.g., carbuncle, suppurative hidradenitis,


cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia)
Incision and drainage of pilonidal cyst
Incision and removal of foreign body, subcutaneous tissues
Incision and drainage of hematoma, seroma, or fluid collection
Puncture aspiration of abscess, hematoma, bulla, or cyst
Incision and drainage, complex, postoperative wound infection
Excision - Debridement
Debridement of extensive eczematous or infected skin
Debridement including removal of foreign material associated w/ open
fracture(s) and/or dislocation(s); skin and subcutaneous tissues
Debridement including removal of foreign material associated w/ open
fracture(s) and/or dislocation(s); skin, subcutaneous tissue, muscle fascia,
and muscle
Debridement including removal of foreign material associated w/ open
fracture(s) and/or dislocation(s); skin, subcutaneous tissue, muscle fascia,
muscle, and bone
Debridement; skin, partial thickness
Debridement; skin, full thickness
Debridement; skin, and subcutaneous tissue
Debridement; skin, subcutaneous tissue, and muscle
Debridement; skin, subcutaneous tissue, muscle, and bone
Pairing or Curettement
Paring or curettement of benign hyperkeratotic skin lesion w/ or w/o
chemical cauterization (such as verrucae or clavi) not extending through the
stratum corneum (e.g., callus or wart) w/ or w/o local anesthesia; single
lesion
Paring or curettement of benign hyperkeratotic skin lesion w/ or w/o
chemical cauterization (such as verrucae or clavi) not extending through the
stratum corneum (e.g., callus or wart) w/ or w/o local anesthesia; two to
four lesions
Paring or curettement of benign hyperkeratotic skin lesion w/ or w/o
chemical cauterization (such as verrucae or clavi) not extending through the
stratum corneum (e.g., callus or wart) w/ or w/o local anesthesia; more
than four lesions
Biopsy
Biopsy of skin, subcutaneous tissue and/or mucous membrane (including
simple closure), unless otherwise listed; single or multiple lesion
Shaving of Epidermal or Dermal Lesions
Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs;
lesion diameter 0.5 cm or less
Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs;
lesion diameter 0.6 to 1.0 cm
Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs;
lesion diameter 1.1 to 2.0 cm
Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs;
lesion diameter over 2.0 cm
Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet,
genitalia; lesion diameter 0.5 cm or less
Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet,
genitalia; lesion diameter 0.6 to 1.0 cm
Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet,
genitalia; lesion diameter 1.1 to 2.0 cm
Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet,
genitalia; lesion diameter over 2.0 cm
Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose
,lips, mucous membrane; lesion diameter 0.5 cm or less
Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose
,lips, mucous membrane; lesion diameter 0.6 to 1.0 cm
Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose
,lips, mucous membrane; lesion diameter 1.1 to 2.0 cm
Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose
,lips, mucous membrane; lesion diameter over 2.0 cm
Excision-Benign Lesions
Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms
or legs; lesion diameter 0.5 cm or less
Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms
or legs; lesion diameter 0.6 to 1.0 cm

Page 1 of 113

3,640

840

2,800

3,640
3,640
3,640
3,640
5,560

840
840
840
840
1,260

2,800
2,800
2,800
2,800
4,300

10,540

5,040

5,500

10,540

5,040

5,500

11,980

5,880

6,100

12,120

6,720

5,400

3,640
3,640
5,680
8,020
8,020

840
840
1,680
2,520
2,520

2,800
2,800
4,000
5,500
5,500

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

3,640

840

2,800

5,560

1,260

4,300

3,700

1,344

2,356

8,020

2,520

5,500

8,440

2,940

5,500

5,560

1,260

4,300

3,700

1,344

2,356

8,020

2,520

5,500

8,440

2,940

5,500

3,700

1,344

2,356

8,020

2,520

5,500

8,440

2,940

5,500

8,260

3,360

4,900

3,640

840

2,800

3,640

840

2,800

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE
11402
11403
11404
11406
11420
11421
11422
11423
11424
11426
11440
11441
11442
11443
11444
11446
11450
11462
11470

11600

DESCRIPTION

Case Rate

Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms
or legs; lesion diameter 1.1 to 2.0 cm
Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms
or legs; lesion diameter 2.1 to 3.0 cm
Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms
or legs; lesion diameter 3.1 to 4.0 cm
Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms
or legs; lesion diameter over 4.0 cm
Excision, benign lesion, except skin tag (unless listed elsewhere), scalp, neck,
hands, feet, genitalia; lesion diameter 0.5 cm or less
Excision, benign lesion, except skin tag (unless listed elsewhere), scalp, neck,
hands, feet, genitalia; lesion diameter 0.6 to 1.0 cm
Excision, benign lesion, except skin tag (unless listed elsewhere), scalp, neck,
hands, feet, genitalia; lesion diameter 1.1 to 2.0 cm
Excision, benign lesion, except skin tag (unless listed elsewhere), scalp, neck,
hands, feet, genitalia; lesion diameter 2.1 to 3.0 cm
Excision, benign lesion, except skin tag (unless listed elsewhere), scalp, neck,
hands, feet, genitalia; lesion diameter 3.1 to 4.0 cm
Excision, benign lesion, except skin tag (unless listed elsewhere), scalp, neck,
hands, feet, genitalia; lesion diameter over 4.0 cm
Excision, other benign lesion (unless listed elsewhere), face, ears, eyelids,
nose, lips, mucous membrane; lesion diameter 0.5 cm or less
Excision, other benign lesion (unless listed elsewhere), face, ears, eyelids,
nose, lips, mucous membrane; lesion diameter 0.6 to 1.0 cm
Excision, other benign lesion (unless listed elsewhere), face, ears, eyelids,
nose, lips, mucous membrane; lesion diameter 1.1 to 2.0 cm
Excision, other benign lesion (unless listed elsewhere), face, ears, eyelids,
nose, lips, mucous membrane; lesion diameter 2.1 to 3.0 cm
Excision, other benign lesion (unless listed elsewhere), face, ears, eyelids,
nose, lips, mucous membrane; lesion diameter 3.1 to 4.0 cm
Excision, other benign lesion (unless listed elsewhere), face, ears, eyelids,
nose, lips, mucous membrane; lesion diameter over 4.0 cm
Excision of skin and subcutaneous tissue for hidradenitis, axillary
Excision of skin and subcutaneous tissue for hidradenitis, inguinal
Excision of skin and subcutaneous tissue for hidradenitis, perianal, perineal
or umbilical
Excision - Malignant Lesions
Excision, malignant lesion, trunk, arms, or legs; lesion diameter 0.5 cm or
less

Professional Fee

Health Care
Institution Fee

3,640

840

2,800

3,640

840

2,800

3,640

840

2,800

3,640

840

2,800

3,640

840

2,800

3,640

840

2,800

3,640

840

2,800

3,640

840

2,800

3,640

840

2,800

3,640

840

2,800

4,108

1,008

3,100

4,108

1,008

3,100

4,108

1,008

3,100

4,108

1,008

3,100

4,108

1,008

3,100

4,108

1,008

3,100

8,020
8,020

2,520
2,520

5,500
5,500

8,020

2,520

5,500

5,560

1,260

4,300

11601

Excision, malignant lesion, trunk, arms, or legs; lesion diameter 0.6 to 1.0 cm

5,560

1,260

4,300

11602

Excision, malignant lesion, trunk, arms, or legs; lesion diameter 1.1 to 2.0 cm

5,560

1,260

4,300

11603

Excision, malignant lesion, trunk, arms, or legs; lesion diameter 2.1 to 3.0 cm

5,560

1,260

4,300

11604

Excision, malignant lesion, trunk, arms, or legs; lesion diameter 3.1 to 4.0 cm

5,560

1,260

4,300

11606

Excision, malignant lesion, trunk, arms, or legs; lesion diameter over 4.0 cm

5,560

1,260

4,300

5,680

1,680

4,000

5,680

1,680

4,000

5,680

1,680

4,000

5,680

1,680

4,000

5,680

1,680

4,000

5,680

1,680

4,000

5,680

1,680

4,000

5,680

1,680

4,000

5,680

1,680

4,000

5,680

1,680

4,000

5,680

1,680

4,000

5,680

1,680

4,000

11620
11621
11622
11623
11624
11626
11640
11641
11642
11643
11644
11646

Excision, malignant lesion, scalp, neck, hands, feet, genitalia; lesion


diameter 0.5 cm or less
Excision, malignant lesion, scalp, neck, hands, feet, genitalia; lesion
diameter 0.6 to 1.0 cm
Excision, malignant lesion, scalp, neck, hands, feet, genitalia; lesion
diameter 1.1 to 2.0 cm
Excision, malignant lesion, scalp, neck, hands, feet, genitalia; lesion
diameter 2.1 to 3.0 cm
Excision, malignant lesion, scalp, neck, hands, feet, genitalia; lesion
diameter 3.1 to 4.0 cm
Excision, malignant lesion, scalp, neck, hands, feet, genitalia; lesion
diameter over 4.0 cm
Excision, malignant lesion, face, ears, eyelids, nose, lips; lesion diameter 0.5
cm or less
Excision, malignant lesion, face, ears, eyelids, nose, lips; lesion diameter 0.6
to 1.0 cm
Excision, malignant lesion, face, ears, eyelids, nose, lips; lesion diameter 1.1
to 2.0 cm
Excision, malignant lesion, face, ears, eyelids, nose, lips; lesion diameter 2.1
to 3.0 cm
Excision, malignant lesion, face, ears, eyelids, nose, lips; lesion diameter 3.1
to 4.0 cm
Excision, malignant lesion, face, ears, eyelids, nose, lips; lesion diameter
over 4.0 cm
Nails

Page 2 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE
11720
11721
11730
11740
11750
11752
11755
11760
11762
11765
11770

DESCRIPTION

3,640
5,560
3,640
3,640

840
1,260
840
840

Health Care
Institution Fee
2,800
4,300
2,800
2,800

3,640

840

2,800

9,300

2,100

7,200

3,640

840

2,800

5,560
9,300
3,640
5,680

1,260
2,100
840
1,680

4,300
7,200
2,800
4,000

Case Rate

Debridement of nail(s) by any method(s); one to five


Debridement of nail(s) by any method(s); six or more
Avulsion of nail plate, partial or complete
Evacuation of subungual hematoma
Excision of nail and nail matrix, partial or complete (e.g., ingrown or
deformed nail) for permanent removal
Excision of nail and nail matrix, partial or complete (e.g., ingrown or
deformed nail) for permanent removal w/ amputation of tuft of distal
phalanx
Biopsy of nail unit, any method (e.g., plate, bed, matrix, hyponychium,
proximal and lateral nail folds)
Repair of nail bed
Reconstruction of nail bed w/ graft
Wedge excision of skin of nail fold (e.g., for ingrown toenail)
Excision of pilonidal cyst or sinus
Repair

Professional Fee

12001

Simple repair of superficial wounds of scalp, neck, axillae, external genitalia,


trunk and/or extremities (including hands and feet); 2.5 cm or less

3,640

840

2,800

12002

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

5,560

1,260

4,300

12004

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

5,680

1,680

4,000

12005

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

5,680

1,680

4,000

12006

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

5,680

1,680

4,000

12007

Simple repair of superficial wounds of scalp, neck, axillae, external genitalia,


trunk and/or extremities (including hands and feet); over 30.0 cm

5,680

1,680

4,000

5,680

1,680

4,000

9,300

2,100

7,200

9,552

2,352

7,200

8,020

2,520

5,500

8,020

2,520

5,500

8,020

2,520

5,500

8,020

2,520

5,500

3,640

840

2,800

5,560

1,260

4,300

5,680

1,680

4,000

5,680

1,680

4,000

5,680

1,680

4,000

5,680

1,680

4,000

5,680

1,680

4,000

9,300

2,100

7,200

8,020

2,520

5,500

8,440

2,940

5,500

8,260

3,360

4,900

10,880

3,780

7,100

5,680

1,680

4,000

12011
12013
12014
12015
12016
12017
12018
12031
12032
12034
12035
12036
12037
12041
12042
12044
12045
12046
12047
12051

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
Layer closure of wounds of scalp, axillae, trunk, and/or extremities
(excluding hands and feet); 2.5 cm or less
Layer closure of wounds of scalp, axillae, trunk, and/or extremities
(excluding hands and feet); 2.6 cm to 7.5 cm
Layer closure of wounds of scalp, axillae, trunk, and/or extremities
(excluding hands and feet); 7.6 cm to 12.5 cm
Layer closure of wounds of scalp, axillae, trunk, and/or extremities
(excluding hands and feet); 12.6 cm to 20.0 cm
Layer closure of wounds of scalp, axillae, trunk, and/or extremities
(excluding hands and feet); 20.1 cm to 30.0 cm
Layer closure of wounds of scalp, axillae, trunk, and/or extremities
(excluding hands and feet); over 30.0 cm
Layer closure of wounds of neck, hands, feet and/or external genitalia; 2.5
cm or less
Layer closure of wounds of neck, hands, feet and/or external genitalia; 2.6
cm to 7.5 cm
Layer closure of wounds of neck, hands, feet and/or external genitalia; 7.6
cm to 12.5 cm
Layer closure of wounds of neck, hands, feet and/or external genitalia; 12.6
cm to 20.0 cm
Layer closure of wounds of neck, hands, feet and/or external genitalia; 20.1
cm to 30.0 cm
Layer closure of wounds of neck, hands, feet and/or external genitalia; over
30.0 cm
Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous
membrances; 2.5 cm or less

Page 3 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE
12052
12053
12054
12055
12056
12057

14000
14001
14020
14021

DESCRIPTION

Case Rate

Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous
membrances; 2.6 cm to 5.0 cm
Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous
membrances; 5.1 cm to 7.5 cm
Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous
membrances; 7.6 cm to 12.5 cm
Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous
membrances; 12.6 cm to 20.0 cm
Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous
membrances; 20.1 cm to 30.0 cm
Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous
membrances; over 30.0 cm
Adjacent Tissue Transfer or Rearrangement
Adjacent tissue transfer or rearrangement, trunk; defect 10 sq cm or less
Adjacent tissue transfer or rearrangement, trunk; defect 10.1 sq cm to 30.0
sq cm
Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect
10 sq cm or less
Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect
10.1 sq cm to 30.0 sq cm

Professional Fee

Health Care
Institution Fee

5,680

1,680

4,000

8,020

2,520

5,500

8,020

2,520

5,500

8,260

3,360

4,900

8,260

3,360

4,900

9,700

4,200

5,500

12,120

6,720

5,400

12,120

6,720

5,400

10,540

5,040

5,500

11,980

5,880

6,100

14040

Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth,


neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less

12,120

6,720

5,400

14041

Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth,


neck, axillae, genitalia, hands and/or feet; defect 10.1 sq cm to 30.0 sq cm

18,000

8,400

9,600

18,000

8,400

9,600

18,000

8,400

9,600

18,000

8,400

9,600

27,120

15,120

12,000

8,260

3,360

4,900

8,260

3,360

4,900

21,940

9,240

12,700

21,940

9,240

12,700

21,940

9,240

12,700

30,740

13,440

17,300

30,300

16,800

13,500

30,300
30,300

16,800
16,800

13,500
13,500

14060
14061
14300
14350

15050

Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips;


defect 10 sq cm or less
Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips;
defect 10.1 sq cm to 30.0 sq cm
Adjacent tissue transfer or rearrangement, more than 30 sq cm, unusual or
complicated, any area
Filleted finger or toe flap, including preparation of recipient site
Free Skin Grafts
Pinch graft, single or multiple, to cover small ulcer, tip or digit, or other
minimal open area (except on face), up to defect size 2 cm diameter

15570

Split graft, trunk, scalp, arms, legs, hands, and/or feet (except multiple
digits); 100 sq cm or less, or each one percent of body area of infants and
children (except 15050)
Split graft, face, eyelids, mouth, neck, ears, orbits, genitalia, and/or multiple
digits; 100 sq cm or less, or each one percent of body area of infants and
children (except 15050)
Full thickness graft, free, including direct closure of donor site, trunk; 20 sq
cm or less
Full thickness graft, free, including direct closure of donor site, scalp, arms,
and/or legs; 20 sq cm or less
Full thickness graft, free, including direct closure of donor site, forehead,
cheeks, chin, mouth, neck, axillae, genitalia, hands, and/or feet; 20 sq cm or
less
Full thickness graft, free, including direct closure of donor site, nose, ears,
eyelids, and/or lips; 20 sq cm or less
Application of allograft, skin
Application of xenograft, skin
Flaps (Skin and/or Deep Tissues)
Formation of direct or tubed pedicle, w/ or w/o transfer; trunk

15572

Formation of direct or tubed pedicle, w/ or w/o transfer; scalp, arms, or legs

15100

15120
15200
15220
15240
15260
15350
15400

15574
15576
15580
15650
15732
15734
15736
15738
15740
15750

Formation of direct or tubed pedicle, w/ or w/o transfer; forehead, cheeks,


chin, mouth, neck, axillae, genitalia, hands or feet
Formation of direct or tubed pedicle, w/ or w/o transfer; eyelids, nose, ears,
lips or intraoral
Cross finger flap, including free graft to donor site
Transfer, intermediate, of any pedicle flap (e.g., abdomen to wrist,
"Walking" tube), any location
Muscle, myocutaneous, or fasciocutaneous flap; head and neck (e.g.,
temporalis, masseter, sternocleidomastoid, levator scapulae)
Muscle, myocutaneous, or fasciocutaneous flap; trunk
Muscle, myocutaneous, or fasciocutaneous flap; upper extremity
Muscle, myocutaneous, or fasciocutaneous flap; lower extremity
Other Flaps and Grafts
Flap; island pedicle
Flap; neurovascular pedicle

Page 4 of 113

18,000

8,400

9,600

30,740

13,440

17,300

30,740

13,440

17,300

30,300

16,800

13,500

21,940

9,240

12,700

21,940

9,240

12,700

47,340

26,040

21,300

47,340
47,340
47,340

26,040
26,040
26,040

21,300
21,300
21,300

38,640
38,640

21,840
21,840

16,800
16,800

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE

DESCRIPTION

38,640
38,640
38,640

21,840
21,840
21,840

21,940

9,240

12,700

21,940

9,240

12,700

15820
15822
15823

Free muscle flap w/ or w/o skin graft w/ microvascular anastomosis


Free skin flap w/ microvascular anastomosis
Free fascial flap w/ microvascular anastomosis
Graft; composite (e.g., full thickness of external ear or nasal ala), including
primary closure, donor area
Graft; derma-fat-fascia
Other Procedures
Blepharoplasty, lower eyelid
Blepharoplasty, upper eyelid;
Blepharoplasty, upper eyelid; with excessive skin weighting down lid

Health Care
Institution Fee
16,800
16,800
16,800

10,120
10,120
11,980

4,620
4,620
5,880

5,500
5,500
6,100

15840

Graft for facial nerve paralysis; free fascia graft (including obtaining fascia)

30,300

16,800

13,500

15841

Graft for facial nerve paralysis; free muscle graft (including obtaining graft)

30,300

16,800

13,500

15842

Graft for facial nerve paralysis; free muscle graft by microsurgical technique

38,640

21,840

16,800

15845

Graft for facial nerve paralysis; regional muscle transfer


Pressure Ulcers (Decubitus Ulcers)

30,300

16,800

13,500

15920

Excision, coccygeal pressure ulcer, w/ coccygectomy; w/ primary suture

30,740

13,440

17,300

15922
15931
15933
15934
15935

Excision, coccygeal pressure ulcer, w/ coccygectomy; w/ flap closure


Excision, sacral pressure ulcer, w/ primary suture
Excision, sacral pressure ulcer, w/ primary suture w/ ostectomy
Excision, sacral pressure ulcer, w/ skin flap closure
Excision, sacral pressure ulcer, w/ skin flap closure w/ ostectomy

30,300
21,940
30,740
12,120
30,300

16,800
9,240
13,440
6,720
16,800

13,500
12,700
17,300
5,400
13,500

15936

Excision, sacral pressure ulcer, w/ muscle or myocutaneous flap closure

38,440

19,740

18,700

37,800

21,000

16,800

12,120

6,720

5,400

21,940

9,240

12,700

30,740
30,300

13,440
16,800

17,300
13,500

38,440

19,740

18,700

11,980
21,940
21,940

5,880
9,240
9,240

6,100
12,700
12,700

30,740

13,440

17,300

31,140

17,640

13,500

38,440

19,740

18,700

8,260
30,740

3,360
13,440

4,900
17,300

9,700

4,200

5,500

15756
15757
15758
15760
15770

Case Rate

15950
15951
15952

Excision, sacral pressure ulcer, w/ muscle or myocutaneous flap closure w/


ostectomy
Excision, ischial pressure ulcer, w/ primary suture
Excision, ischial pressure ulcer, w/ primary suture w/ ostectomy
(ischiectomy)
Excision, ischial pressure ulcer, w/ skin flap closure
Excision, ischial pressure ulcer, w/ skin flap closure w/ ostectomy
Excision, ischial pressure ulcer, w/ ostectomy, w/ muscle or myocutaneous
flap closure
Excision, trochanteric pressure ulcer, w/ primary suture
Excision, trochanteric pressure ulcer, w/ primary suture w/ ostectomy
Excision, trochanteric pressure ulcer, w/ skin flap closure

15953

Excision, trochanteric pressure ulcer, w/ skin flap closure; w/ ostectomy

15937
15940
15941
15944
15945
15946

15956
15958
16010
16035
16040

17000

Excision, trochanteric pressure ulcer, w/ muscle or myocutaneous flap


closure
Excision, trochanteric pressure ulcer, w/ muscle or myocutaneous flap
closure; w/ ostectomy
Burns, Local Treatment
Dressings and/or debridement, initial or subsequent
Escharotomy
Excision burn wound, w/o skin grafting, employing alloplastic dressing (e.g.,
synthetic mesh), any anatomic site
Destruction, Benign or Premalignant Lesions
Destruction by any method, including laser, w/ or w/o surgical curettement,
all benign facial lesions or premalignant lesions in any location, or benign
lesions other than cutaneous vascular proliferative lesions, including local
anesthesia; any number of lesions

17200

Destruction by any method, including laser, of benign skin lesions other


than cutaneous vascular proliferative lesions on any area other than the
face, including local anesthesia; any number of lesions
Destruction of cutaneous vascular proliferative lesions (e.g., laser
technique)
Destruction by any method of flat warts or molluscum contagiosum, milia,
all lesions
Electosurgical destruction of multiple fibrocutaneous tags; all lesions

17250

Chemical cauterization of granulation tissue (proud flesh, sinus or fistula)

17100
17106
17110

17260
17261
17262

Destruction, Malignant Lesions, Any Method


Destruction, malignant lesion, any method, trunk, arms or legs; lesion
diameter 0.5 cm or less
Destruction, malignant lesion, any method, trunk, arms or legs; lesion
diameter 0.6 to 1.0 cm
Destruction, malignant lesion, any method, trunk, arms or legs; lesion
diameter 1.1 to 2.0 cm

Page 5 of 113

Professional Fee

N/A

N/A

N/A

N/A

N/A

N/A

6,000
N/A

2,200
N/A

N/A

3,800
N/A

N/A

N/A

5,680

1,680

4,000

5,680

1,680

4,000

5,680

1,680

4,000

5,680

1,680

4,000

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE
17263
17264
17266
17270
17271
17272
17273
17274
17276
17280
17281
17282
17283
17284
17286

17304

DESCRIPTION

Case Rate

Destruction, malignant lesion, any method, trunk, arms or legs; lesion


diameter 2.1 to 3.0 cm
Destruction, malignant lesion, any method, trunk, arms or legs; lesion
diameter 3.1 to 4.0 cm
Destruction, malignant lesion, any method, trunk, arms or legs; lesion
diameter over 4.0 cm
Destruction, malignant lesion, any method, scalp, neck, hands, feet,
genitalia; lesion diameter 0.5 cm or less
Destruction, malignant lesion, any method, scalp, neck, hands, feet,
genitalia; lesion diameter 0.6 to 1.0 cm
Destruction, malignant lesion, any method, scalp, neck, hands, feet,
genitalia; lesion diameter 1.1 to 2.0 cm
Destruction, malignant lesion, any method, scalp, neck, hands, feet,
genitalia; lesion diameter 2.1 to 3.0 cm
Destruction, malignant lesion, any method, scalp, neck, hands, feet,
genitalia; lesion diameter 3.1 to 4.0 cm
Destruction, malignant lesion, any method, scalp, neck, hands, feet,
genitalia; lesion diameter over 4.0 cm
Destruction, malignant lesion, any method, face, ears, eyelids, nose, lips,
mucous membrane; lesion diameter 0.5 cm or less
Destruction, malignant lesion, any method, face, ears, eyelids, nose, lips,
mucous membrane; lesion diameter 0.6 to 1.0 cm
Destruction, malignant lesion, any method, face, ears, eyelids, nose, lips,
mucous membrane; lesion diameter 1.1 to 2.0 cm
Destruction, malignant lesion, any method, face, ears, eyelids, nose, lips,
mucous membrane; lesion diameter 2.1 to 3.0 cm
Destruction, malignant lesion, any method, face, ears, eyelids, nose, lips,
mucous membrane; lesion diameter 3.1 to 4.0 cm
Destruction, malignant lesion, any method, face, ears, eyelids, nose, lips,
mucous membrane; lesion diameter over 4.0 cm
Mohs Micrographic Surgery
Chemosurgery (Mohs micrographic technique), including removal of all
gross tumor, surgical excision of tissue specimens, mapping, color coding of
specimens, microscopic examination of specimens by the surgeon, and
complete histopathologic preparation; first stage, fresh tissue technique, up
to 5 specimens

Professional Fee

Health Care
Institution Fee

5,680

1,680

4,000

5,680

1,680

4,000

5,680

1,680

4,000

5,680

1,680

4,000

5,680

1,680

4,000

5,680

1,680

4,000

5,680

1,680

4,000

5,680

1,680

4,000

5,680

1,680

4,000

9,300

2,100

7,200

9,300

2,100

7,200

9,300

2,100

7,200

9,300

2,100

7,200

9,300

2,100

7,200

9,300

2,100

7,200

8,020

2,520

5,500

3,640
9,700

840
4,200

2,800
5,500

3,640
5,560

840
1,260

2,800
4,300

8,440

2,940

5,500

8,260

3,360

4,900

8,020

2,520

5,500

Breast

Incision

19000
19020

8,020

2,520

5,500

19140
19160
19162
19180
19182

Puncture aspiration of cyst of breast;


Mastotomy w/ exploration or drainage of abscess, deep
Excision
Biopsy of breast; needle core
Biopsy of breast; incisional
Nipple exploration, w/ or w/o excision of a solitary lactiferous duct or a
papilloma lactiferous duct
Excision of lactiferous duct fistula
Excision of cyst, fibroadenoma, or other benign or malignant tumor
aberrant breast tissue, duct lesion or nipple lesion (except 19140), male or
female, one or more lesions
Excision of breast lesion identified by preoperative placement of
radiological marker; single lesion
Mastectomy for gynecomastia
Mastectomy, partial
Mastectomy, partial with axillary lymphadenectomy
Mastectomy, simple, complete
Mastectomy, subcutaneous

22,000
22,000
22,000
22,000
22,000

8,800
8,800
8,800
8,800
8,800

13,200
13,200
13,200
13,200
13,200

19200

Mastectomy, radical, including pectoral muscles, axillary lymph nodes

22,000

8,800

13,200

22,000

8,800

13,200

22,000

8,800

13,200

46,500

25,200

21,300

55,000

33,600

21,400

58,800

37,800

21,000

37,800

21,000

16,800

37,800

21,000

16,800

30,300

16,800

13,500

37,800

21,000

16,800

19100
19101
19110
19112
19120
19125

19220
19240
19260
19271
19272
19340
19342
19350
19357

Mastectomy, radical, including pectoral muscles, axillary and internal


mammary lymph nodes (Urban type operation)
Mastectomy, modified radical, including axillary lymph nodes, w/ or w/o
pectoralis minor muscle, but excluding pectoralis major muscle
Excision of chest wall tumor including ribs
Excision of chest wall tumor involving ribs, w/ plastic reconstruction; w/o
mediastinal lymphadenectomy
Excision of chest wall tumor involving ribs, w/ plastic reconstruction; w/
mediastinal lymphadenectomy
Immediate insertion of breast prosthesis following mastopexy, mastectomy
or in reconstruction
Delayed insertion of breast prosthesis following mastopexy, mastectomy or
in reconstruction
Nipple/areola reconstruction
Breast reconstruction, immediate or delayed, with tissue expander,
including subsequent expansion

Page 6 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE
19361
19364
19366

DESCRIPTION

Case Rate

Breast reconstruction with latissimus dorsi flap, with or without prosthetic


implant
Breast reconstruction with free flap
Breast reconstruction with other technique

Professional Fee

Health Care
Institution Fee

55,000

33,600

21,400

55,000
55,000

33,600
33,600

21,400
21,400

19367

Breast reconstruction with transverse rectus abdominis myocutaneous flap


(TRAM), single pedicle, including closure of donor site;

55,000

33,600

21,400

19369

Breast reconstruction with transverse rectus abdominis myocutaneous flap


(TRAM), double pedicle, including closure of donor site

55,000

33,600

21,400

30,300
37,800

16,800
21,000

13,500
16,800

4,108
3,504

1,008
504

3,100
3,000

10,880

3,780

7,100

18,000

8,400

9,600

9,700

4,200

5,500

12,540
23,300
30,740

7,140
12,600
13,440

5,400
10,700
17,300

8,020

2,520

5,500

5,560

1,260

4,300

9,300

2,100

7,200

9,300

2,100

7,200

19370
19371

20615

Open periprosthetic capsulotomy, breast


Periprosthetic capsulectomy, breast
Musculoskeletal System
General
Excision
Biopsy, muscle
Biopsy, muscle, percutaneous needle
Biopsy, bone, trocar, or needle; superficial (e.g., ilium, sternum, spinous
process, ribs)
Biopsy, bone, trocar, or needle; deep (vertebral body, femur)
Biopsy, excisional; superficial (e.g., ilium, sternum, spinous process, ribs,
trochanter of femur)
Biopsy, excisional; deep (e.g., humerus, ischium, femur)
Biopsy, vertebral body, open; thoracic
Biopsy, vertebral body, open; lumbar or cervical
Introduction or Removal
Removal of foreign body in muscle or tendon sheath
Arthrocentesis, aspiration and/or injection; small joint, bursa or ganglion
cyst (e.g., fingers, toes)
Arthrocentesis, aspiration and/or injection; intermediate joint, bursa or
ganglion cyst (e.g., temporomandibular, acromioclavicular, wrist, elbow or
ankle, olecranon bursa)
Arthrocentesis, aspiration and/or injection; major joint or bursa (e.g.,
shoulder, hip, knee joint, subacromial bursa)
Aspiration and injection for treatment of bone cyst

8,260

3,360

4,900

20650

Insertion of wire or pin w/ application of skeletal traction, including removal

8,020

2,520

5,500

20660

Application of cranial tongs, caliper, or stereotactic frame, including removal

9,868

4,368

5,500

20661
20662
20663
20670

Application of halo, including removal; cranial


Application of halo, including removal; pelvic
Application of halo, including removal; femoral
Removal of implant; superficial (e.g., buried wire, pin or rod)
Removal of implant; deep (e.g., buried wire, pin, screw, metal band, nail,
rod or plate)
Application of a uniplane (pins or wires in one plane), unilateral, external
fixation system
Application of multiplane (pins or wires in more than one plane), unilateral,
external fixation system (e.g., llizarov, Monticelli type)
Replantation
Replantation, arm (includes surgical neck of humerus through elbow joint),
complete amputation
Replantation, forearm (includes radius and ulna to radial carpal joint),
complete amputation
Replantation, hand (includes hand through metacarpophalangeal joint(s),
complete amputation
Replantation, digit, excluding thumb (includes metacarpophalangeal joint to
insertion of flexor sublimis tendon), complete amputation
Replantation, digit, excluding thumb (includes distal tip to sublimis tendon
insertion), complete amputation
Replantation, thumb (includes carpometacarpal joint to MP joint), complete
amputation

8,608
23,300
21,940
10,540

3,108
12,600
9,240
5,040

5,500
10,700
12,700
5,500

11,980

5,880

6,100

12,120

6,720

5,400

39,280

20,580

18,700

9,300

2,100

7,200

40,320

23,520

16,800

40,320

23,520

16,800

23,300

12,600

10,700

23,300

12,600

10,700

30,300

16,800

13,500

20827

Replantation, thumb (includes distal tip to MP joint), complete amputation

23,300

12,600

10,700

20838

Replantation, foot, complete amputation


Grafts (or Implants)
Bone graft, any donor area; minor or small (e.g., dowel or button)
Bone graft, any donor area; major or large
Cartilage graft; costochondral
Cartilage graft; nasal septum
Fascia lata graft; by stripper
Fascia lata graft; by incision and area exposure, complex or sheet
Tendon graft, form a distance (e.g., palmaris, toe extensor, plantaris)
Tissue grafts, other (e.g., paratenon, fat, dermis)

37,800

21,000

16,800

10,540
18,000
12,120
12,120
9,700
12,120
10,960
9,700

5,040
8,400
6,720
6,720
4,200
6,720
5,460
4,200

5,500
9,600
5,400
5,400
5,500
5,400
5,500
5,500

20200
20206
20220
20225
20240
20245
20250
20251
20520
20600
20605
20610

20680
20690
20692

20802
20805
20808
20816
20822
20824

20900
20902
20910
20912
20920
20922
20924
20926

Page 7 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE

DESCRIPTION

20930
20931

Allograft for spine surgery only; morselized


Allograft for spine surgery only; structural

12,120
18,420

6,720
8,820

Health Care
Institution Fee
5,400
9,600

20936

Autograft for spine surgery only (includes harvesting the graft); local (e.g.,
ribs, spinous process, or laminar fragments) obtained from same incision

10,540

5,040

5,500

20937

Autograft for spine surgery only (includes harvesting the graft); morselized
(through separate skin or fascial incision)

10,540

5,040

5,500

20938

Autograft for spine surgery only (includes harvesting the graft); structural,
bicortical or tricortical (through separate skin or fascial incision)

18,000

8,400

9,600

37,800
37,800
20,980

21,000
21,000
10,080

16,800
16,800
10,900

27,120

15,120

12,000

37,800

21,000

16,800

30,300
23,300

16,800
12,600

13,500
10,700

27,120

15,120

12,000

9,700

4,200

5,500

9,700

4,200

5,500

23,300

12,600

10,700

18,000

8,400

9,600

18,000

8,400

9,600

18,000

8,400

9,600

18,000
18,000
18,000
23,300
18,000
21,940
23,300
30,300
30,300
30,300
30,300

8,400
8,400
8,400
12,600
8,400
9,240
12,600
16,800
16,800
16,800
16,800

9,600
9,600
9,600
10,700
9,600
12,700
10,700
13,500
13,500
13,500
13,500

18,000
46,500

8,400
25,200

9,600
21,300

30,300

16,800

13,500

30,300

16,800

13,500

30,300

16,800

13,500

46,500

25,200

21,300

18,000

8,400

9,600

46,500

25,200

21,300

30,300

16,800

13,500

53,400

29,400

24,000

46,500

25,200

21,300

46,500

25,200

21,300

46,500

25,200

21,300

46,500

25,200

21,300

20955
20956
20957
20962
20969
20970
20972
20973
20982

Case Rate

Other Procedures
Bone graft w/ microvascular anastomosis; fibula
Bone graft w/ microvascular anastomosis; iliac crest
Bone graft w/ microvascular anastomosis; metatarsal
Bone graft w/ microvascular anastomosis; other than fibula, iliac crest, or
metatarsal
Free osteocutaneous flap w/ microvascular anastomosis; other than iliac
crest, metatarsal, or great toe
Free osteocutaneous flap w/ microvascular anastomosis; iliac crest
Free osteocutaneous flap w/ microvascular anastomosis; metatarsal
Free osteocutaneous flap w/ microvascular anastomosis; great toe w/ web
space
Ablation, bone tumor(s) (e.g., osteoid osteoma, metastasis) radiofrequency,
percutaneous, including computed tomographic guidance

21025

Head
Incision
Arthrotomy, temporomandibular joint
Excision
Radical resection of tumor (e.g., malignant neoplasm), soft tissue of face or
scalp
Excision of bone (e.g., for osteomyelitis or bone abscess); mandible

21026

Excision of bone (e.g., for osteomyelitis or bone abscess); facial bone(s)

21010
21015

21029
21030
21031
21032
21034
21040
21041
21044
21045
21050
21060
21070
21120
21121
21122
21123
21125
21127
21137
21138
21139
21141
21142
21143
21145
21146

Removal by contouring of benign tumor of facial bone (e.g., fibrous


dysplasia)
Excision of benign tumor or cyst of facial bone other than mandible
Excision of torus mandibularis
Excision of maxillary torus palatinus
Excision of malignant tumor of facial bone other than mandible
Excision of benign cyst or tumor of mandible; simple
Excision of benign cyst or tumor of mandible; complex
Excision of malignant tumor of mandible
Excision of malignant tumor of mandible radical resection
Condylectomy, temporomandibular joint
Meniscectomy, partial or complete, temporomandibular joint
Coronoidectomy
Repair, Revision, and/or Reconstruction
Genioplasty; augmentation (autograft, allograft, prosthetic material)
Genioplasty; sliding osteotomy, single piece
Genioplasty; sliding osteotomies, two or more osteotomies (e.g., wedge
excision or bone wedge reversal for asymmetrical chin)
Genioplasty; sliding, augmentation w/ interpositional bone grafts (includes
obtaining autografts)
Augmentation, mandibular body or angle; prosthetic material
Augmentation, mandibular body or angle; w/ bone graft, onlay or
interpositional (includes obtaining autograft)
Reduction forehead; contouring only
Reduction forehead; contouring and application of prosthetic material or
bone graft (includes obtaining autograft)
Reduction forehead; contouring and setback of anterior frontal sinus wall
Reconstruction midface, LeFort I; single piece, segment movement in any
direction (e.g., for Long Face Syndrome), w/o bone graft
Reconstruction midface, LeFort I; two pieces, segment movement in any
direction, w/o bone graft
Reconstruction midface, LeFort I; three or more pieces, segment movement
in any direction, w/o bone graft
Reconstruction midface, LeFort I; single piece, segment movement in any
direction, requiring bone grafts (includes obtaining autografts)
Reconstruction midface, LeFort I; two pieces, segment movement in any
direction, requiring bone grafts (includes obtaining autografts) (e.g.,
ungrafted unilateral alveolar cleft)

Page 8 of 113

Professional Fee

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE

21147

21150
21151
21154
21155
21159

21160

DESCRIPTION

Case Rate

Reconstruction midface, LeFort I; three or more pieces, segment movement


in any direction, requiring bone grafts (includes obtaining autografts) (e.g.,
ungrafted bilateral alveolar cleft or multiple osteotomies)
Reconstruction midface, LeFort II; anterior intrusion (e.g., Treacher-Collins
Syndrome)
Reconstruction midface, LeFort II; any direction, requiring bone grafts
(includes obtaining autografts)
Reconstruction midface, LeFort III (extracranial), any type, requiring bone
grafts (includes obtaining autografts); w/o LeFort I
Reconstruction midface, LeFort III (extracranial), any type, requiring bone
grafts (includes obtaining autografts); w/ LeFort I
Reconstruction midface, LeFort III (extra and intracranial) w/ forehead
advancement (e.g., mono bloc), requiring bone grafts (includes obtaining
autografts); w/o LeFort I
Reconstruction midface, LeFort III (extra and intracranial) w/ forehead
advancement (e.g., mono bloc), requiring bone grafts (includes obtaining
autografts); w/ LeFort I

Professional Fee

Health Care
Institution Fee

55,000

33,600

21,400

55,000

33,600

21,400

55,000

33,600

21,400

58,800

37,800

21,000

55,000

33,600

21,400

55,000

33,600

21,400

46,500

25,200

21,300

21172

Reconstruction superior-lateral orbital rim and lower forehead,


advancement or alteration, w/ or w/o grafts (includes obtaining autografts)

55,000

33,600

21,400

21175

Reconstruction, bifrontal, superior-lateral orbital rims and lower forehead,


advancement or alteration (e.g., plagiocephaly, trigonocephaly,
brachycephaly), w/ or w/o grafts (includes obtaining autografts)

55,000

33,600

21,400

55,000

33,600

21,400

55,000

33,600

21,400

53,400

29,400

24,000

46,500

25,200

21,300

53,400

29,400

24,000

55,000

33,600

21,400

55,000

33,600

21,400

46,500

25,200

21,300

55,000

33,600

21,400

46,500

25,200

21,300

55,000

33,600

21,400

30,300
46,500

16,800
25,200

13,500
21,300

21179
21180
21181

21182

21183

Reconstruction, entire or majority of forehead and/or supraorbital rims; w/


grafts (allograft or prosthetic material)
Reconstruction, entire or majority of forehead and/or supraorbital rims; w/
autograft (includes obtaining grafts)
Reconstruction by contouring of benign tumor of cranial bones (e.g., fibrous
dysplasia), extracranial
Reconstruction of orbital walls, rims, forehead, nasoethmoid complex
following intra-and extracranial excision of benign tumor of cranial bone
(e.g., fibrous dysplasia), w/ multiple autografts (includes obtaining grafts);
total area of bone grafting less
Reconstruction of orbital walls, rims, forehead, nasoethmoid complex
following intra-and extracranial excision of benign tumor of cranial bone
(e.g., fibrous dysplasia), w/ multiple autografts (includes obtaining grafts);
total area of bone grafting greater than 40 cm2 but less than 80 cm2

21198
21206

Reconstruction of orbital walls, rims, forehead, nasoethmoid complex


following intra-and extracranial excision of benign tumor of cranial bone
(e.g., fibrous dysplasia), w/ multiple autografts (includes obtaining grafts);
total area of bone grafting greater than 80 cm2
Reconstruction midface, osteotomies (other than LeFort type) and bone
grafts (includes obtaining autografts)
Reconstruction of mandibular rami, horizontal, vertical, "C", or "L"
osteotomy; w/o bone graft
Reconstruction of mandibular rami, horizontal, vertical, "C", or "L"
osteotomy; w/ bone graft (includes obtaining graft)
Reconstruction of mandibular rami and/or body, sagittal split; w/o internal
rigid fixation
Reconstruction of mandibular rami and/or body, sagittal split; w/ internal
rigid fixation
Osteotomy, mandible, segmental
Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)

21210

Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)

46,500

25,200

21,300

21215

Graft, bone; mandible (includes obtaining graft)


Graft; rib cartilage, autogenous, to face, chin, nose or ear (includes
obtaining graft)

55,000

33,600

21,400

46,500

25,200

21,300

Graft; ear cartilage, autogenous, to nose or ear (includes obtaining graft)

30,300

16,800

13,500

46,500

25,200

21,300

46,500

25,200

21,300

55,000

33,600

21,400

46,500

25,200

21,300

53,400

29,400

24,000

55,000

33,600

21,400

21184

21188
21193
21194
21195
21196

21230
21235

21242

Arthroplasty, temporomandibular joint, w/ or w/o autograft (includes


obtaining graft)
Arthroplasty, temporomandibular joint, w/ allograft

21243

Arthroplasty, temporomandibular joint, w/ prosthetic joint replacement

21240

21245

Reconstruction of mandible, extraoral, w/ transosteal bone plate (e.g.,


mandibular staple bone plate)
Reconstruction of mandible or maxilla, subperiosteal implant partial

21246

Reconstruction of mandible or maxilla, subperiosteal implant complete

21244

Page 9 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE
21247
21248
21249
21255
21256
21260
21267
21300
21315
21325
21330
21335
21336
21337
21338
21339
21340
21343
21344
21345
21346
21347
21348
21355

DESCRIPTION

Case Rate

Reconstruction of mandibular condyle w/ bone and cartilage autografts


(includes obtaining grafts) (e.g., for hemifacial microsomia)
Reconstruction of mandible or maxilla, endosteal implant (e.g. blade,
cylinder); partial
Reconstruction of mandible or maxilla, endosteal implant (e.g. blade,
cylinder); complete
Reconstruction of zygomatic arch and glenoid fossa w/ bone and cartilage
(includes obtaining autografts)
Reconstruction of orbit w/ osteotomies (extracranial) and w/ bone grafts
(includes obtaining autografts) (e.g., micro-ophthalmia)
Periorbital osteotomies for orbital hypertelorism, w/ bone grafts
Orbital repositioning, periorbital osteotomies, unilateral, w/ bone grafts;
extracranial approach
Fracture and/or Dislocation
Closed treatment of skull fracture w/o operation
Closed treatment of nasal bone fracture
Open treatment of nasal fracture; uncomplicated
Open treatment of nasal fracture; complicated, w/ internal and/or external
skeletal fixation
Open treatment of nasal fracture; w/ concomitant open treatment of
fractured septum
Open treatment of nasal septal fracture, w/ or w/o stabilization
Closed treatment of nasal septal fracture
Open treatment of nasoethmoid fracture; w/o external fixation
Open treatment of nasoethmoid fracture; w/ external fixation
Percutaneous treatment of nasoethmoid complex fracture, w/ splint, wire
or headcap fixation, including repair of canthal ligaments and/or the
nasolacrimal apparatus
Open treatment of depressed frontal sinus fracture
Open treatment of complicated (e.g., comminuted or involving posterior
wall) frontal sinus fracture, via coronal or multiple approaches
Closed treatment of nasomaxillary complex fracture (LeFort II type), w/
interdental wire fixation or fixation of denture or splint
Open treatment of nasomaxillary complex fracture (LeFort II type); w/
wiring and/or local fixation
Open treatment of nasomaxillary complex fracture (LeFort II type);
requiring multiple open approaches
Open treatment of nasomaxillary complex fracture (LeFort II type); w/ bone
grafting (includes obtaining graft)
Percutaneous treatment of fracture of malar area, including zygomatic arch
and malar tripod, w/ manipulation

Professional Fee

Health Care
Institution Fee

55,000

33,600

21,400

55,000

33,600

21,400

63,000

42,000

21,000

55,000

33,600

21,400

55,000

33,600

21,400

55,000

33,600

21,400

55,000

33,600

21,400

10,540
10,540
12,120

5,040
5,040
6,720

5,500
5,500
5,400

12,120

6,720

5,400

12,120

6,720

5,400

12,120
10,540
12,120
18,000

6,720
5,040
6,720
8,400

5,400
5,500
5,400
9,600

21,940

9,240

12,700

21,940

9,240

12,700

23,300

12,600

10,700

22,660

11,760

10,900

23,300

12,600

10,700

30,300

16,800

13,500

37,800

21,000

16,800

21,940

9,240

12,700

21356

Open treatment of depressed zygomatic arch fracture (e.g., Gilles approach)

23,300

12,600

10,700

21360

Open treatment of depressed malar fracture, including zygomatic arch and


malar tripod

30,300

16,800

13,500

21365

Open treatment of complicated (e.g., comminuted or involving cranial nerve


foramina) fracture(s) of malar area, including zygomatic arch and malar
tripod; w/ internal fixation and multiple surgical approaches

37,800

21,000

16,800

46,500

25,200

21,300

20,980

10,080

10,900

21366
21385

Open treatment of complicated (e.g., comminuted or involving cranial nerve


foramina) fracture(s) of malar area, including zygomatic arch and malar
tripod; w/ bone grafting (includes obtaining graft)
Open treatment of orbital floor "blowout" fracture; transantral approach
(Caldwell-Luc type operation)

21386

Open treatment of orbital floor "blowout" fracture; periorbital approach

18,000

8,400

9,600

21387

Open treatment of orbital floor "blowout" fracture; combined approach

37,800

21,000

16,800

31,580

14,280

17,300

31,580

14,280

17,300

18,000
20,980
31,580

8,400
10,080
14,280

9,600
10,900
17,300

31,580

14,280

17,300

21390
21395
21400
21406
21407
21408
21421
21422

Open treatment of orbital floor "blowout" fracture; periorbital approach,


w/ alloplastic or other implant
Open treatment of orbital floor "blowout" fracture; periorbital approach w/
bone graft (includes obtaining graft)
Closed treatment of fracture of orbit, except "blowout"
Open treatment of fracture of orbit, except "blowout"; w/o implant
Open treatment of fracture of orbit, except "blowout"; w/ implant
Open treatment of fracture of orbit, except "blowout"; w/ bone grafting
(includes obtaining graft)
Closed treatment of palatal or maxillary fracture (LeFort I type), w/
interdental wire fixation or fixation of denture or splint
Open treatment of palatal or maxillary fracture (LeFort I type)

Page 10 of 113

12,120

6,720

5,400

20,980

10,080

10,900

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE
21423
21431
21432
21433

21435

21436
21440
21445
21450
21452
21453
21454
21461
21462
21465
21470

DESCRIPTION

Case Rate

Open treatment of palatal or maxillary fracture (LeFort I type) complicated


(comminuted or involving cranial nerve foramina), multiple approaches
Closed treatment of craniofacial separation (LeFort III type) using
interdental wire fixation of denture or splint
Open treatment of craniofacial separation (LeFort III type); w/ wiring and/or
internal fixation
Open treatment of craniofacial separation (LeFort III type); complicated
(e.g., comminuted or involving cranial nerve foramina); multiple surgical
approaches
Open treatment of craniofacial separation (LeFort III type); complicated,
utilizing internal and/or external fixation techniques (e.g., head cap, halo
device, and/or intermaxillary fixation)
Open treatment of craniofacial separation (LeFort III type); complicated,
multiple surgical approaches, internal fixation, w/ bone grafting (includes
obtaining graft)
Closed treatment of mandibular or maxillary alveolar ridge fracture
Open treatment of mandibular or maxillary alveolar ridge fracture
Closed treatment of mandibular fracture
Percutaneous treatment of mandibular fractue, w/ external fixation
Closed treatment of mandibular fracture; w/ interdental fixation
Open treatment of mandibular fracture; w/ external fixation
Open treatment of mandibular fracture; w/o interdental fixation
Open treatment of mandibular fracture; w/ interdental fixation
Open treatment of mandibular condylar fracture
Open treatment of complicated mandibular fracture by multiple surgical
approaches including internal fixation, interdental fixation, and/or wiring of
dentures or splints

Professional Fee

Health Care
Institution Fee

23,300

12,600

10,700

12,120

6,720

5,400

23,300

12,600

10,700

18,000

8,400

9,600

23,300

12,600

10,700

46,500

25,200

21,300

12,120
18,000
18,000
23,300
14,960
22,660
22,660
23,300
30,300

6,720
8,400
8,400
12,600
7,560
11,760
11,760
12,600
16,800

5,400
9,600
9,600
10,700
7,400
10,900
10,900
10,700
13,500

37,800

21,000

16,800

9,700

4,200

5,500

21480

Closed treatment of temporomandibular dislocation; initial or subsequent

21485

Closed treatment of temporomandibular dislocation; complicated (e.g.,


recurrent requiring intermaxillary fixation or splinting), initial or subsequent

20,980

10,080

10,900

21490
21493
21495
21497

Open treatment of temporomandibular dislocation


Closed treatment of hyoid fracture
Open treatment of hyoid fracture
Interdental wiring, for condition other than fracture

30,300
18,000
23,300
12,120

16,800
8,400
12,600
6,720

13,500
9,600
10,700
5,400

5,680

1,680

4,000

8,020

2,520

5,500

4,108

1,008

3,100

5,680
8,020

1,680
2,520

4,000
5,500

9,700

4,200

5,500

30,300

16,800

13,500

10,540
20,980
37,180
37,800
27,120
12,288
37,800

5,040
10,080
18,480
21,000
15,120
6,888
21,000

5,500
10,900
18,700
16,800
12,000
5,400
16,800

18,000
23,300
18,000
27,120
23,300

8,400
12,600
8,400
15,120
12,600

9,600
10,700
9,600
12,000
10,700

8,020
10,960
20,980
9,868
21,940

2,520
5,460
10,080
4,368
9,240

5,500
5,500
10,900
5,500
12,700

21550
21555

Neck (Soft Tissues) and Thorax


Incision
Incision and drainage, deep abscess or hematoma, soft tissues of neck or
thorax
Incision and drainage, deep abscess or hematoma, soft tissues of neck or
thorax w/ partial rib ostectomy
Incision, deep, w/ opening of bone cortex (e.g., for osteomyelitis or bone
abscess), thorax
Excision
Biopsy, soft tissue of neck or thorax
Excision tumor, soft tissue of neck or thorax; subcutaneous

21556

Excision tumor, soft tissue of neck or thorax; deep, subfascial, intramuscular

21501
21502
21510

21557
21600
21610
21615
21616
21620
21627
21630
21700
21705
21720
21740
21750
21800
21805
21810
21820
21825

Radical resection of tumor (e.g., malignant neoplasm), soft tissue of neck or


thorax
Excision of rib, partial
Costotransversectomy
Excision first and/or cervical rib
Excision first and/or cervical rib w/ sympathectomy
Ostectomy of sternum, partial
Sternal debridement
Radical resection of sternum;
Repair, Revision, and/or Reconstruction
Division of scalenus anticus; w/o resection of cervical rib
Division of scalenus anticus; w/ resection of cervical rib
Division of sternocleidomastoid for torticollis, open operation
Reconstructive repair of pectus excavatum or carinatum
Closure of sternotomy separation w/ or w/o debridement
Fracture and/or Dislocation
Closed treatment of rib fracture
Open treatment of rib fracture w/o fixation
Treatment of rib fracture requiring external fixation ("flail chest")
Closed treatment of sternum fracture
Open treatment of sternum fracture w/ or w/o skeletal fixation
Back and Flank
Excision

Page 11 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE

DESCRIPTION

3,504
5,680

504
1,680

21935

Biopsy, soft tissue of back or flank


Excision, tumor, soft tissue of back or flank
Radical resection of tumor (e.g., malignant neoplasm), soft tissue of back or
flank
Spine (Vertebral Column)
Excision

Health Care
Institution Fee
3,000
4,000

23,300

12,600

10,700

22100

Partial excision of posterior vertebral component (e.g., spinous process,


lamina or facet) for intrinsic bony lesion, single vertebral segment; cervical

27,120

15,120

12,000

22101

Partial excision of posterior vertebral component (e.g., spinous process,


lamina or facet) for intrinsic bony lesion, single vertebral segment; thoracic

27,120

15,120

12,000

22102

Partial excision of posterior vertebral component (e.g., spinous process,


lamina or facet) for intrinsic bony lesion, single vertebral segment; lumbar

27,120

15,120

12,000

46,500

25,200

21,300

30,300

16,800

13,500

30,300

16,800

13,500

46,500

25,200

21,300

46,500

25,200

21,300

46,500

25,200

21,300

53,400

29,400

24,000

53,400

29,400

24,000

53,400

29,400

24,000

23,300

12,600

10,700

30,740

13,440

17,300

38,860

20,160

18,700

38,640

21,840

16,800

37,800

21,000

16,800

40,320

23,520

16,800

21920
21930

22110

22112

22114

22210
22212
22214
22220
22222
22224
22305
22310
22325

22326

22327

22548

Case Rate

Partial excision of vertebral body, for intrinsic bony lesion, w/o


decompression of spinal cord or nerve root(s), single vertebral segment;
cervical
Partial excision of vertebral body, for intrinsic bony lesion, w/o
decompression of spinal cord or nerve root(s), single vertebral segment;
thoracic
Partial excision of vertebral body, for intrinsic bony lesion, w/o
decompression of spinal cord or nerve root(s), single vertebral segment;
lumbar
Osteotomy
Osteotomy of spine, posterior or posterolateral approach, one vertebral
segment; cervical
Osteotomy of spine, posterior or posterolateral approach, one vertebral
segment; thoracic
Osteotomy of spine, posterior or posterolateral approach, one vertebral
segment; lumbar
Osteotomy of spine, including diskectomy, anterior approach, single
vertebral segment; cervical
Osteotomy of spine, including diskectomy, anterior approach, single
vertebral segment; thoracic
Osteotomy of spine, including diskectomy, anterior approach, single
vertebral segment; lumbar
Fracture and/or Dislocation
Closed treatment of vertebral process fracture(s)
Closed treatment of vertebral body fracture(s), requiring and including
casting or bracing
Open treatment and/or reduction of vertebral fracture(s) and/or
dislocation(s), posterior approach, one fractured vertebrae or dislocated
segment; lumbar
Open treatment and/or reduction of vertebral fracture(s) and/or
dislocation(s), posterior approach, one fractured vertebrae or dislocated
segment; cervical
Open treatment and/or reduction of vertebral fracture(s) and/or
dislocation(s), posterior approach, one fractured vertebrae or dislocated
segment; thoracic
Anterior or Anterolateral Approach Technique
Arthrodesis, anterior transoral or extraoral technique, clivus-C1-C2 (atlasaxis), w/ or w/o excision of odontoid process

Professional Fee

22554

Arthrodesis, anterior interbody technique, including minimal diskectomy to


prepare interspace (other than for decompression); cervical below C2

53,400

29,400

24,000

22556

Arthrodesis, anterior interbody technique, including minimal diskectomy to


prepare interspace (other than for decompression); thoracic

46,500

25,200

21,300

22558

Arthrodesis, anterior interbody technique, including minimal diskectomy to


prepare interspace (other than for decompression); lumbar

46,500

25,200

21,300

53,400
53,400

29,400
29,400

24,000
24,000

53,400

29,400

24,000

22590
22595
22600

Posterior, Posterolateral or Lateral Transverse Process Technique


Arthrodesis; posterior technique, craniocervical (occiput-C2)
Arthrodesis, posterior technique, atlas-axis (C1-C2)
Arthrodesis, posterior or posterolateral technique, single level; cervical
below C2 segment

22610

Arthrodesis, posterior or posterolateral technique, single level; cervical


below C2 segment thoracic (w/ or w/o lateral transverse technique)

30,300

16,800

13,500

22612

Arthrodesis, posterior or posterolateral technique, single level; cervical


below C2 segment lumbar (w/ or w/o lateral transverse technique)

30,300

16,800

13,500

Page 12 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE

DESCRIPTION

40,320

23,520

Health Care
Institution Fee
16,800

58,800

37,800

21,000

63,000

42,000

21,000

67,200

46,200

21,000

55,000

33,600

21,400

58,800

37,800

21,000

67,200

46,200

21,000

55,000

33,600

21,400

53,400

29,400

24,000

54,660

30,660

24,000

58,800

37,800

21,000

67,200

46,200

21,000

55,000
58,800
67,200

33,600
37,800
46,200

21,400
21,000
21,000

55,000

33,600

21,400

22849

Anterior instrumentation; 2 to 3 vertebral segments


Anterior instrumentation; 4 to 7 vertebral segments
Anterior instrumentation; 8 or more vertebral segments
Pelvic fixation (attachment of caudal end of instrumentation to pelvic bony
structures) other than sacrum
Reinsertion of spinal fixation device

53,400

29,400

24,000

22850

Removal of posterior nonsegmental instrumentation (e.g., Harrington rod)

21,940

9,240

12,700

58,800

37,800

21,000

27,120
30,300

15,120
16,800

12,000
13,500

23,300

12,600

10,700

20,980

10,080

10,900

27,120
18,000
14,960

15,120
8,400
7,560

12,000
9,600
7,400

20,980

10,080

10,900

23,300

12,600

10,700

20,980

10,080

10,900

3,504
5,680
8,020

504
1,680
2,520

3,000
4,000
5,500

37,800

21,000

16,800

23,300

12,600

10,700

27,120

15,120

12,000

27,120
21,820

15,120
10,920

12,000
10,900

30,740

13,440

17,300

23,300
27,960
27,540

12,600
15,960
15,540

10,700
12,000
12,000

22630
22800
22802
22804
22808
22810
22812

22840
22841
22842
22843
22844
22845
22846
22847
22848

22851
22852
22855

22900

Case Rate

Arthrodesis, posterior interbody technique, single interspace; lumbar


Spine Deformity (e.g. Scoliosis, Kyphosis)
Arthrodesis, posterior, for spinal deformity, w/ or w/o cast; up to 6
vertebral segments
Arthrodesis, posterior, for spinal deformity, w/ or w/o cast; 7 to 12 vertebral
segments
Arthrodesis, posterior, for spinal deformity, w/ or w/o cast; 13 or more
vertebral segments
Arthrodesis, anterior, for spinal deformity, w/ or w/o cast; 2 to 3 vertebral
segments
Arthrodesis, anterior, for spinal deformity, w/ or w/o cast; 4 to 7 vertebral
segments
Arthrodesis, anterior, for spinal deformity, w/ or w/o cast; 8 or more
vertebral segments
Spinal Instrumentation
Posterior non-segmental instrumentation (e.g., single Harrington rod
technique)
Internal spinal fixation by wiring of spinous processes
Posterior segmental instrumentation (e.g., pedicle fixation, dual rods w/
multiple hooks and sublaminal wires); 3 to 6 vertebral segments
Posterior segmental instrumentation (e.g., pedicle fixation, dual rods w/
multiple hooks and sublaminal wires); 7 to 12 vertebral segments
Posterior segmental instrumentation (e.g., pedicle fixation, dual rods w/
multiple hooks and sublaminal wires); 13 or more vertebral segments

Application of prosthetic device (e.g., metal cages, methylmethacrylate) to


vertebral defect or interspace
Removal of posterior segmental instrumentation
Removal of anterior instrumentation
Abdomen
Excision
Excision, abdominal wall tumor, subfascial (e.g., desmoid)

Professional Fee

Shoulder
Incision

23120
23125
23130

Removal of subdeltoid (or intratendinous) calcareous deposits, open


method
Capsular contracture release (Sever type procedure)
Incision and drainage, shoulder area; deep abscess or hematoma
Incision and drainage, shoulder area; infected bursa
Incision, deep, w/ opening of cortex (e.g., for osteomyelitis or bone
abscess), shoulder area
Arthrotomy, glenohumeral joint, for infection, w/ exploration, drainage, or
removal of foreign body
Arthrotomy, acromioclavicular, sternoclavicular joint, for infection, w/
exploration, drainage, or removal of foreign body
Excision
Biopsy, soft tissue of shoulder area
Excision, tumor, shoulder area; subcutaneous
Excision, tumor, shoulder area; deep, subfascial, or intramuscular
Radical resection of tumor (e.g., malignant neoplasm), soft tissue of
shoulder area
Arthrotomy w/ biopsy, glenohumeral joint
Arthrotomy w/ biopsy, or w/ excision of torn cartilage, acromioclavicular,
sternoclavicular joint
Arthrotomy w/ synovectomy; glenohumeral joint
Arthrotomy w/ synovectomy; sternoclavicular joint
Arthrotomy, glenohumeral joint, w/ joint exploration, w/ or w/o removal of
loose or foreign body
Claviculectomy; partial
Claviculectomy; total
Acromioplasty or acromionectomy, partial

23140

Excision or curettage of bone cyst or benign tumor of clavicle or scapula

20,980

10,080

10,900

23145

Excision or curettage of bone cyst or benign tumor of clavicle or scapula w/


autograft (includes obtaining graft)

22,240

11,340

10,900

23000
23020
23030
23031
23035
23040
23044
23065
23075
23076
23077
23100
23101
23105
23106
23107

Page 13 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE

DESCRIPTION

Case Rate

Professional Fee

Health Care
Institution Fee

23146

Excision or curettage of bone cyst or benign tumor of clavicle or scapula w/


allograft

22,240

11,340

10,900

23150

Excision or curettage of bone cyst or benign tumor of proximal humerus

30,740

13,440

17,300

31,580

14,280

17,300

31,580

14,280

17,300

20,980
21,820

10,080
10,920

10,900
10,900

23,300

12,600

10,700

21,400

10,500

10,900

21,652

10,752

10,900

21,820

10,920

10,900

21,820
27,120
27,120
27,540
37,180

10,920
15,120
15,120
15,540
18,480

10,900
12,000
12,000
12,000
18,700

40,320

23,520

16,800

53,400

29,400

24,000

23155
23156
23170
23172
23174
23180
23182
23184
23190
23195
23200
23210
23220
23221

Excision or curettage of bone cyst or benign tumor of proximal humerus w/


autograft (includes obtaining graft)
Excision or curettage of bone cyst or benign tumor of proximal humerus w/
allograft
Sequestrectomy (e.g., for osteomyelitis or bone abscess), clavicle
Sequestrectomy (e.g., for osteomyelitis or bone abscess), scapula
Sequestrectomy (e.g., for osteomyelitis or bone abscess), humeral head to
surgical neck
Partial excision (craterization, saucerization,or diaphysectomy) of bone
(e.g., for osteomyelitis), clavicle
Partial excision (craterization, saucerization,or diaphysectomy) of bone
(e.g., for osteomyelitis), scapula
Partial excision (craterization, suacerization, or diaphysectomy) of bone
(e.g., for osteomyelitis), proximal humerus
Ostectomy of scapula, partial (e.g., superior medial angle)
Resection humeral head
Radical resection for tumor; clavicle
Radical resection for tumor; scapula
Radical resection for tumor, proximal humerus
Radical resection for tumor, proximal humerus w/ autograft (includes
obtaining graft)

23222

Radical resection for tumor, proximal humerus w/ prosthetic replacement

23330

Introduction or Removal
Removal of foreign body, shoulder; subcutaneous

5,560

1,260

4,300

23331

Removal of foreign body, shoulder; deep (e.g., Neer prosthesis removal)

12,900

6,300

6,600

23332

Removal of foreign body, shoulder; complicated , including "total shoulder"

14,960

7,560

7,400

22,240
23,300
27,120
21,940
23,080
20,980
22,240
21,148

11,340
12,600
15,120
9,240
12,180
10,080
11,340
10,248

10,900
10,700
12,000
12,700
10,900
10,900
10,900
10,900

23,300

12,600

10,700

21,940
20,980

9,240
10,080

12,700
10,900

37,800

21,000

16,800

38,860
38,860
37,180

20,160
20,160
18,480

18,700
18,700
18,700

23455
23460
23462

Repair, Revision, and/or Reconstruction


Muscle transfer, any type, shoulder or upper arm single
Muscle transfer, any type, shoulder or upper arm multiple
Scapulopexy (e.g., Sprengels deformity or for paralysis)
Tenomyotomy, shoulder area; single
Tenomyotomy, shoulder area; multiple through same incision
Repair of ruptured musculotendinous cuff (e.g., rotator cuff); acute
Repair of ruptured musculotendinous cuff (e.g., rotator cuff); chronic
Coracoacromial ligament release, w/ or w/o acromioplasty
Repair of complete shoulder (rotator) cuff avulsion, chronic (includes
acromioplasty)
Tenodesis of long tendon of biceps
Resection or transplantation of long tendon of biceps
Capsulorrhaphy, anterior; Putti-Platt procedure or Magnuson type
operation
Capsulorrhaphy, anterior; Bankart type operation w/ or w/o stapling
Capsulorrhaphy, anterior, any type; w/ bone block
Capsulorrhaphy, anterior, any type; w/ coracoid process transfer

23465

Capsulorrhaphy for recurrent dislocation, posterior, w/ or w/o bone block

37,800

21,000

16,800

23466
23470

Capsulorrhaphy w/ any type multi-directional instability


Arthroplasty w/ proximal humeral implant (e.g., Neer type operation)
Arthroplasty w/ glenoid and proximal humeral replacement (e.g. total
shoulder)
Osteotomy, clavicle, w/ or w/o internal fixation;

40,320
48,180

23,520
26,880

16,800
21,300

53,400

29,400

24,000

27,120

15,120

12,000

28,380

16,380

12,000

27,120

15,120

12,000

27,120

15,120

12,000

23395
23397
23400
23405
23406
23410
23412
23415
23420
23430
23440
23450

23472
23480
23485
23490
23491
23500
23515
23520
23530
23532
23540

Osteotomy, clavicle, w/ or w/o internal fixation; w/ bone graft for nonunion


or malunion (includes obtaining graft and/or necessary fixation)
Prophylactic treatment (nailing, pinning, plating or wiring) w/ or w/o
methylmethacrylate; clavicle
Prophylactic treatment (nailing, pinning, plating or wiring) w/ or w/o
methylmethacrylate; proximal humerus and humeral head
Fracture and/or Dislocation
Closed treatment of clavicular fracture
Open treatment of clavicular fracture, w/ or w/o internal or external
fixation
Closed treatment of sternoclavicular dislocation
Open treatment of sternoclavicular disloction, acute or chronic
Open treatment of sternoclavicular disloction, acute or chronic w/ fascial
graft (includes obtaining graft)
Closed treatment of acromioclavicular dislocation

Page 14 of 113

8,020

2,520

5,500

12,456

7,056

5,400

10,880
20,980

3,780
10,080

7,100
10,900

27,120

15,120

12,000

8,020

2,520

5,500

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE

DESCRIPTION
Open treatment of acromioclavicular dislocation, acute or chronic
Open treatment of acromioclavicular dislocation, acute or chronic w/ fascial
graft (includes obtaining graft)
Closed treatment of scapular fracture
Open treatment of scapular fracture (body, glenoid or acromion) w/ or w/o
internal fixation

21,940

9,240

Health Care
Institution Fee
12,700

20,980

10,080

10,900

8,020

2,520

5,500

20,980

10,080

10,900

23600

Closed treatment of proximal humeral (surgical or anatomical neck) fracture

10,540

5,040

5,500

23615

Open treatment of proximal humeral (surgical or anatomical neck) fracture,


w/ or w/o internal or external fixation, w/ or w/o repair of tuberosity(-ies);

23,300

12,600

10,700

47,340

26,040

21,300

9,700

4,200

5,500

23,300

12,600

10,700

10,540
41,160
27,120

5,040
24,360
15,120

5,500
16,800
12,000

11,980

5,880

6,100

27,120

15,120

12,000

12,120

6,720

5,400

27,120

15,120

12,000

9,700

4,200

5,500

12,456

7,056

5,400

37,180

18,480

18,700

30,300
27,120

16,800
15,120

13,500
12,000

3,100

23550
23552
23570
23585

Case Rate

23650
23657
23660

Open treatment of proximal humeral (surgical or anatomical neck) fracture,


w/ or w/o internal or external fixation, w/ or w/o repair of tuberosity(-ies);
w/ proximal humeral prosthetic replacement
Closed treatment of greater tuberosity fracture
Open treatment of greater tuberosity fracture, w/ or w/o internal or
external fixation
Closed treatment of shoulder dislocation
Thoracoscopy, surgical; w/ wedge resection of lung, single or mutiple
Open treatment of acute shoulder dislocation

23665

Closed treatment of shoulder dislocation,/ fracture of greater tuberosity

23616
23620
23630

23670
23675
23680

23700
23800
23802
23900
23920

Open treatment of shoulder dislocation, w/ fracture of greater tuberosity,


w/ or w/o internal or external fixation
Closed treatment of shoulder dislocation, w/ surgical or anatomical neck
fracture
Open treatment of shoulder dislocation, w/ surgical or anatomical neck
fracture, w/ or w/o internal or external fixation
Manipulation
Manipulation under anesthesia, shoulder joint, including application of
fixation apparatus (dislocation excluded)
Arthrodesis
Arthrodesis, shoulder joint w/ or w/o local bone graft
Arthrodesis, shoulder joint w/ primary autogenous graft (includes obtaining
graft)
Amputation
Interthoracoscapular amputation (forequarter)
Disarticulation of shoulder
Humerus (Upper Arm) and Elbow
Incision

Professional Fee

23930

Incision and drainage, upper arm or elbow area deep abscess or hematoma

4,108

1,008

23931

5,560

1,260

4,300

21,940

9,240

12,700

22,360

9,660

12,700

20,980

10,080

10,900

24065
24075

Incision and drainage, upper arm or elbow area infected bursa


Incision, deep, w/ opening of bone cortex (e.g., for osteomyelitis of bone
abscess), humerus or elbow
Arthrotomy, elbow, for infection, w/ exploration, drainage or removal of
foreign body
Arthrotomy of the elbow, w/ capsular excision for capsular release
Excision
Biopsy, soft tissue of upper arm or elbow area
Excision, tumor, upper arm or elbow area subcutaneous

3,504
5,680

504
1,680

3,000
4,000

24076

Excision, tumor, upper arm or elbow area deep, subfascial or intramuscular

8,020

2,520

5,500

23,300

12,600

10,700

20,980

10,080

10,900

21,820

10,920

10,900

23,300
8,260
20,980

12,600
3,360
10,080

10,700
4,900
10,900

23,080

12,180

10,900

23,080

12,180

10,900

21,148

10,248

10,900

21,820

10,920

10,900

21,820

10,920

10,900

20,980

10,080

10,900

20,980

10,080

10,900

23935
24000
24006

24077
24100
24101
24102
24105
24110
24115
24116
24120
24125
24126
24130
24134

Radical resection of tumor (e.g., malignant neoplasm), soft tissue of upper


arm or elbow area
Arthrotomy, elbow w/ synovial biopsy only
Arthrotomy, elbow w/ joint exploration, w/ or w/o biopsy, w/ or w/o
removal of loose or foreign body
Arthrotomy, elbow w/ synovectomy
Excision, olecranon bursa
Excision or curettage of bone cyst or benign tumor, humerus
Excision or curettage of bone cyst or benign tumor, humerus w/ autograft
(includes obtaining graft)
Excision or curettage of bone cyst or benign tumor, humerus w/ allograft
Excision or curettage of bone cyst or benign tumor of head or neck of radius
or olecranon process
Excision or curettage of bone cyst or benign tumor of head or neck of radius
or olecranon process w/ autograft (includes obtaining graft)
Excision or curettage of bone cyst or benign tumor of head or neck of radius
or olecranon process w/ allograft
Excision, radial head
Sequestrectomy (e.g., for osteomyelitis or bone abscess), shaft or distal
humerus

Page 15 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE

DESCRIPTION

Case Rate

Professional Fee

Health Care
Institution Fee

24136

Sequestrectomy (e.g., for osteomyelitis or bone abscess), radial head or


neck

20,980

10,080

10,900

24138

Sequestrectomy (e.g., for osteomyelitis or bone abscess), olecranon process

20,980

10,080

10,900

20,980

10,080

10,900

20,980

10,080

10,900

20,980

10,080

10,900

21,400

10,500

10,900

23,080

12,180

10,900

30,300

16,800

13,500

23,300

12,600

10,700

27,120

15,120

12,000

27,120

15,120

12,000

21,940
22,360
8,272

9,240
9,660
2,772

12,700
12,700
5,500

23,300
20,980
21,940

12,600
10,080
9,240

10,700
10,900
12,700

27,120

15,120

12,000

30,740

13,440

17,300

27,120

15,120

12,000

8,260

3,360

4,900

20,980

10,080

10,900

12,120

6,720

5,400

10,540

5,040

5,500

12,120

6,720

5,400

12,120

6,720

5,400

12,120

6,720

5,400

24140
24145
24147
24149
24150
24151
24152
24153
24155
24160
24164
24200
24301
24305
24310
24320
24330
24331
24340
24341
24342
24350
24351
24352
24354
24356
24360
24361
24362
24363
24365
24366
24400
24410
24420
24430

Partial excision (craterization, saucerization, or diaphysectomy) of bone


(e.g., for osteomyelitis), humerus
Partial excision (craterization, saucerization, or diaphysectomy) of bone
(e.g., for osteomyelitis), radial head or neck
Partial excision (craterization, saucerization, or diaphysectomy) of bone
(e.g., for osteomyelitis), olecranon process
Radical resection of capsule, soft tissue, and heterotopic bone, elbow, w/
contracture release
Radical resection for tumor, shaft or distal humerus
Radical resection for tumor, shaft or distal humerus w/ autograft (includes
obtaining graft)
Radical resection for tumor, radial head or neck
Radical resection for tumor, radial head or neck w/ autograft (includes
obtaining graft)
Resection of elbow joint (arthrectomy)
Introduction or Removal
Implant removal elbow joint
Implant removal radial head
Removal of foreign body, upper arm or elbow area
Repair, Revision, and/or Reconstruction
Muscle or tendon transfer, any type, upper arm or elbow, single
Tendon lengthening, upper arm or elbow, single, each
Tenotomy, open, elbow to shoulder, single, each
Tenoplasty, w/ muscle transfer, w/ or w/o free graft, elbow to shoulder,
single (Seddon-Brookes type procedure)
Flexor-plasty, elbow (e.g., Steindler type advancement)
Flexor-plasty, elbow (e.g., Steindler type advancement) w/ extensor
advancement
Tenodesis of biceps tendon at elbow
Repair, tendon or muscle, upper arm or elbow, each tendon or muscle,
primary or secondary (excludes rotator cuff)
Reinsertion of ruptured biceps or triceps tendon, distal, w/ or w/o tendon
graft
Fasciotomy, lateral or medial (e.g., "tennis elbow" or epicondylitis);
Fasciotomy, lateral or medial (e.g., "tennis elbow" or epicondylitis); w/
extensor origin detachment
Fasciotomy, lateral or medial (e.g., "tennis elbow" or epicondylitis); w/
annular ligament resection
Fasciotomy, lateral or medial (e.g., "tennis elbow" or epicondylitis); w/
stripping
Fasciotomy, lateral or medial (e.g., "tennis elbow" or epicondylitis); w/
partial ostectomy
Arthroplasty, elbow w/ membrane
Arthroplasty, elbow w/ membrane w/ distal humeral prosthetic
replacement
Arthroplasty, elbow w/ membrane w/ implant and fascia lata ligament
reconstruction
Arthroplasty, elbow w/ membrane w/ distal humerus and proximal ulnar
prosthetic replacement ("total elbow")
Arthroplasty, radial head
Arthroplasty, radial head w/ implant
Osteotomy, humerus, w/ or w/o internal fixation
Multiple osteotomies w/ realignment on intramedullary rod, humeral shaft
(Sofield type procedure)
Osteoplasty, humerus (e.g., shortening or lengthening)
Repair of non-union or malunion, humerus; w/o graft (e.g., compression
technique);

12,120

6,720

5,400

27,120

15,120

12,000

37,180

18,480

18,700

27,120

15,120

12,000

38,640

21,840

16,800

21,940
27,120
20,980

9,240
15,120
10,080

12,700
12,000
10,900

20,980

10,080

10,900

23,300

12,600

10,700

23,080

12,180

10,900

24435

Repair of non-union or malunion, humerus; w/o graft (e.g., compression


technique); w/ iliac or other autograft (includes obtaining graft)

27,120

15,120

12,000

24470

Hemiepiphyseal arrest (e.g., for cubitus varus or valgus, distal humerus)

22,360

9,660

12,700

24495

Decompression fasciotomy, forearm, w/ brachial artery exploration


Prophylactic treatment (nailing, pinning, plating or wiring), w/ or w/o
methylmethacrylate, humerus
Fracture and/or Dislocation
Closed treatment of humeral shaft fracture
Open treatment of humeral shaft fracture w/ plate/screws, w/ or w/o
cerclage

27,120

15,120

12,000

20,980

10,080

10,900

24498
24500
24515

Page 16 of 113

10,120

4,620

5,500

30,740

13,440

17,300

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE
24516
24530
24538
24545
24546
24560
24566
24575
24576
24579
24582
24586

24587
24600
24615
24620
24635

DESCRIPTION

Case Rate

Open treatment of humeral shaft fracture, w/ insertion of intramedullary


implant, w/ or w/o cerclage and/or locking screws
Closed treatment of supracondylar or transcondylar humeral fracture, w/ or
w/o intercondylar extension
Percutaneous skeletal fixation of supracondylar or transcondylar humeral
fracture, w/ or w/o intercondylar extension
Open treatment of humeral supracondylar or transcondylar fracture, w/ or
w/o internal or external fixation w/o intercondylar extension
Open treatment of humeral supracondylar or transcondylar fracture, w/ or
w/o internal or external fixation w/ intercondylar extension
Closed treatment of humeral epicondylar fracture, medial or lateral;
Percutaneous skeletal fixation of humeral epicondylar fracture, medial or
lateral, w/ manipulation
Open treatment of humeral epicondylar fracture, medial or lateral, w/ or
w/o internal or external fixation
Closed treatment of humeral condylar fracture, medial or lateral
Open treatment of humeral condylar fracture, medial or lateral, w/ or w/o
internal or external fixation
Percutaneous skeletal fixation of humeral condylar fracture, medial or
lateral, w/ manipulation
Open treatment of periarticular fracture and/or dislocation of the elbow
(fracture distal humerus and proximal ulna and/or proximal radius)
Open treatment of periarticular fracture and/or dislocation of the elbow
(fracture distal humerus and proximal ulna and/or proximal radius) w/
implant arthroplasty
Treatment of closed elbow dislocation
Open treatment of acute or chronic elbow dislocation
Closed treatment of Monteggia type of fracture dislocation at elbow
(fracture proximal end of ulna w/ dislocation of radial head)
Open treatment of Monteggia type of fracture dislocation at elbow
(fracture proximal end of ulna w/ dislocation of radial head), w/ or w/o
internal or external fixation

24640

Closed treatment of radial head subluxation in child, "nursemaid elbow"

24650

Closed treatment of radial head or neck fracture


Open treatment of radial head or neck fracture, w/ or w/o internal fixation
or radial head excision

24665
24666
24670
24685
24800
24802
24900
24920
24925
24930
24931
24935
24940

25000
25020
25023
25028
25031
25035
25040

Professional Fee

Health Care
Institution Fee

30,740

13,440

17,300

10,120

4,620

5,500

27,120

15,120

12,000

12,456

7,056

5,400

32,000

14,700

17,300

10,880

3,780

7,100

27,120

15,120

12,000

18,000

8,400

9,600

10,880

3,780

7,100

18,000

8,400

9,600

27,120

15,120

12,000

22,660

11,760

10,900

37,800

21,000

16,800

10,540
23,300

5,040
12,600

5,500
10,700

10,880

3,780

7,100

21,940

9,240

12,700
4,000

5,680

1,680

10,880

3,780

7,100

20,980

10,080

10,900

27,120

15,120

12,000

Closed treatment of ulnar fracture, proximal end (olecranon process)


Open treatment of ulnar fracture proximal end (olecranon process), w/ or
w/o internal or external fixation
Arthrodesis
Arthrodesis, elbow joint w/ or w/o local autograft or allograft
Arthrodesis, elbow joint w/ autograft (includes obtaining graft other than
locally obtained)
Amputation
Amputation, arm through humerus w/ primary closure
Amputation, arm through humerus w/ primary closure open, circular
(guillotine)
Amputation, arm through humerus w/ primary closure secondary closure or
scar revision
Amputation, arm through humerus w/ primary closure re-amputation
Amputation, arm through humerus w/ primary closure w/ implant
Stump elongation, upper extremity
Cineplasty, upper extremity, complete procedure
Forearm and Wrist
Incision

10,880

3,780

7,100

21,940

9,240

12,700

27,120

15,120

12,000

28,380

16,380

12,000

18,000

8,400

9,600

12,120

6,720

5,400

10,960

5,460

5,500

14,960
14,960
12,120
27,120

7,560
7,560
6,720
15,120

7,400
7,400
5,400
12,000

Tendon sheath incision at radial styloid (e.g., for deQuervains disease)

10,540

5,040

5,500

18,000

8,400

9,600

14,960

7,560

7,400

10,880

3,780

7,100

10,120

4,620

5,500

12,120

6,720

5,400

10,120

4,620

5,500

Open treatment of radial head or neck fracture, w/ or w/o internal fixation


or radial head excision w/ radial head prosthetic replacement

Decompression fasciotomy, forearm and/or wrist, flexor or extensor


compartment
Decompression fasciotomy, forearm and/or wrist, flexor or extensor
compartment w/ debridement of nonviable muscle and/or nerve
Incision and drainage, forearm and/or wrist deep abscess or hematoma
Incision and drainage, forearm and/or wrist deep abscess or hematoma
infected bursa
Incision, deep, w/ opening of bone cortex (e.g., for osteomyelitis or bone
abscess), forearm and/or wrist
Arthrotomy, radiocarpal or midcarpal joint, w/ exploration, drainage, or
removal of foreign body

Page 17 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE

DESCRIPTION

Case Rate

Professional Fee

Health Care
Institution Fee

25065
25075

Excision
Biopsy, soft tissue of forearm and/or wrist
Excision, tumor, forearm and/or wrist area subcutaneous

3,504
5,680

504
1,680

3,000
4,000

25076

Excision, tumor, forearm and/or wrist area deep, subfascial or intramuscular

8,020

2,520

5,500

23,300

12,600

10,700

15,380
11,044

7,980
5,544

7,400
5,500

12,540

7,140

5,400

20,980

10,080

10,900

20,980

10,080

10,900

8,020
8,260

2,520
3,360

5,500
4,900

21,820

10,920

10,900

18,420

8,820

9,600

25105

Radical resection of tumor (e.g. malignant neoplasm), soft tissue of forearm


and/or wrist area
Capsulotomy, wrist (e.g., for contracture)
Arthrotomy, wrist joint w/ biopsy
Arthrotomy, wrist joint w/ joint exploration, w/ or w/o biopsy, w/ or w/o
removal of loose or foreign body
Arthrotomy, wrist joint w/ synovectomy

25107

Arthrotomy, distal radioulnar joint for repair of triangle cartilage complex

25110
25111

Excision, lesion of tendon sheath, forearm and/or wrist


Excision of ganglion, wrist (dorsal or volar)
Radical excision of bursa, synovia of wrist, or forearm tendon sheaths (e.g.,
tenosynovitis, fungus, Tbc, or other granulomas, rheumatoid arthritis);
flexors

25077
25085
25100
25101

25115

25116
25118
25119
25120
25125
25126
25130
25135
25136
25145
25150
25151
25170
25210
25215
25230
25240
25248
25250
25251
25260
25263
25265
25270
25272
25274
25280
25290

Radical excision of bursa, synovia of wrist, or forearm tendon sheaths (e.g.,


tenosynovitis, fungus, Tbc, or other granulomas, rheumatoid arthritis);
extensors, w/ or w/o transposition of dorsal retinaculum
Synovectomy, extensor tendon sheath, wrist, single compartment
Synovectomy, extensor tendon sheath, wrist, single compartment w/
resection of distal ulna
Excision or curettage of bone cyst or benign tumor of radius or ulna
(excluding head or neck of radius and olecranon process)
Excision or curettage of bone cyst or benign tumor of radius or ulna
(excluding head or neck of radius and olecranon process) w/ autograft
(includes obtaining graft)
Excision or curettage of bone cyst or benign tumor of radius or ulna
(excluding head or neck of radius and olecranon process) w/ allograft
Excision or curettage of bone cyst or benign tumor of carpal bones
Excision or curettage of bone cyst or benign tumor of carpal bones w/
autograft (includes obtaining graft)
Excision or curettage of bone cyst or benign tumor of carpal bones w/
allograft
Sequestrectomy (e.g., for osteomyelitis or bone abscess), forearm and/or
wrist
Partial excision (craterization, saucerization, or diaphysectomy) of bone
(e.g., for osteomyelitis); ulna
Partial excision (craterization, saucerization, or diaphysectomy) of bone
(e.g., for osteomyelitis); radius
Radical resection for tumor, radius or ulna
Carpectomy one bone
Carpectomy all bones of proximal row
Radial styloidectomy
Excision distal ulna partial or complete (e.g., Darrach type or matched
resection)
Introduction or Removal
Exploration w/ removal of deep foreign body, forearm or wrist
Removal of wrist prosthesis
Removal of wrist prosthesis complicated, including "total wrist"
Repair, Revision, and/or Reconstruction
Repair, tendon or muscle, flexor, forearm and/or wrist primary, single, each
tendon or muscle
Repair, tendon or muscle, flexor, forearm and/or wrist secondary, single,
each tendon or muscle
Repair, tendon or muscle, flexor, forearm and/or wrist secondary, w/ free
graft (includes obtaining graft), each tendon or muscle
Repair, tendon or muslce, extensor, forearm and/or wrist primary, single,
each tendon or muscle
Repair, tendon or muslce, extensor, forearm and/or wrist secondary, single,
each tendon or muscle
Repair, tendon or muscle, extensor, secondary, w/ tendon graft (includes
obtaining graft), forearm and/or wrist, each tendon or muscle
Lengthening or shortening of flexor or extensor tendon, forearm and/or
wrist, single, each tendon
Tenotomy, open, flexor or extensor tendon, forearm and/or wrist, single,
each tendon

Page 18 of 113

9,952

4,452

5,500

21,940

9,240

12,700

20,980

10,080

10,900

21,820

10,920

10,900

21,820

10,920

10,900

9,952

4,452

5,500

12,900

6,300

6,600

12,900

6,300

6,600

21,940

9,240

12,700

21,940

9,240

12,700

21,940

9,240

12,700

27,120
5,932
22,360
10,540

15,120
1,932
9,660
5,040

12,000
4,000
12,700
5,500

10,540

5,040

5,500

8,260
21,940
30,740

3,360
9,240
13,440

4,900
12,700
17,300

10,540

5,040

5,500

8,260

3,360

4,900

10,120

4,620

5,500

10,540

5,040

5,500

8,260

3,360

4,900

10,540

5,040

5,500

10,880

3,780

7,100

10,880

3,780

7,100

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE
25295
25300
25301
25310
25312

DESCRIPTION

Case Rate
8,260

3,360

4,900

10,960
10,540

5,460
5,040

5,500
5,500

20,980

10,080

10,900

Tendon transplantation or transfer, flexor or extensor, forearm and/or


wrist, single w/ tendon graft(s) (includes obtaining graft), each tendon

21,820

10,920

10,900

30,300

16,800

13,500

37,180

18,480

18,700

27,120

15,120

12,000

30,300

16,800

13,500

31,140

17,640

13,500

27,960

15,960

12,000

18,000
21,940
18,420
23,300

8,400
9,240
8,820
12,600

9,600
12,700
9,600
10,700

30,740

13,440

17,300

27,960

15,960

12,000

27,120
27,960
27,120
27,960

15,120
15,960
15,120
15,960

12,000
12,000
12,000
12,000

20,980

10,080

10,900

23,300

12,600

10,700

30,740

13,440

17,300

27,960

15,960

12,000

21,940
30,740

9,240
13,440

12,700
17,300

23,720

13,020

10,700

30,300
27,120
27,120
27,120
31,580

16,800
15,120
15,120
15,120
14,280

13,500
12,000
12,000
12,000
17,300

37,800

21,000

16,800

27,960

15,960

12,000

40,320
20,980

23,520
10,080

16,800
10,900

30,740

13,440

17,300

21,940

9,240

12,700

21,940

9,240

12,700

37,180

18,480

18,700

9,700

4,200

5,500

21,940

9,240

12,700

9,700

4,200

5,500

25449
25450
25455

Epiphyseal arrest by epiphysiodesis or stapling distal radius and ulna

25316
25320
25332
25335
25337
25350
25355
25360
25365
25370
25375
25390
25391
25392
25393
25400
25405
25415
25420
25425
25426
25440
25441
25442
25443
25444
25445
25446
25447

25490
25491
25492
25500
25515
25520

Health Care
Institution Fee

Tenolysis, flexor or extensor tendon, forearm and/or wrist, single each


tendon
Tenodesis at wrist flexors of fingers
Tenodesis at wrist extensors of fingers
Tendon transplantation or transfer, flexor or extensor, forearm and/or
wrist, single each tendon

Flexor origin slide (e.g. for cerebral palsy, Volkmann contracture), forearm
and/or wrist
Flexor origin slide (e.g. for cerebral palsy, Volkmann contracture), forearm
and/or wrist w/ tendon(s) transfer
Capsulorrhaphy or reconstruction, wrist, any method (e.g., capsulodesis,
ligament repair, tendon transfer or graft) (includes synovectomy,
capsulotomy and open reduction) for carpal instability
Arthroplasty, wrist, w/ or w/o interposition, w/ or w/o external or internal
fixation
Centralization of wrist on ulna (e.g., radial club hand)
Reconstruction for stabilization of unstable distal ulna or distal radioulnar
joint, secondary by soft tissue stabilization (e.g., tendon transfer, tendon
graft or weave, or tenodesis) w/ or w/o open reduction of distal radioulnar
joint
Osteotomy, radius distal third
Osteotomy, radius middle or proximal third
Osteotomy ulna
Osteotomy radius and ulna
Multiple osteotomies, w/ realignment on intramedullary rod (Sofield type
procedure) radius or ulna
Multiple osteotomies, w/ realignment on intramedullary rod (Sofield type
procedure) radius and ulna
Osteoplasty, radius or ulna shortening
Osteoplasty, radius or ulna lengthening w/ autograft
Osteoplasty, radius and ulna shortening
Osteoplasty, radius and ulna lengthening w/ autograft
Repair of nonunion or malunion, radius or ulna w/o graft (compression
technique)
Repair of nonunion or malunion, radius or ulna w/ iliac or other autograft
(includes obtaining graft)
Repair of nonunion or malunion, radius and ulna w/o graft (e.g.
compression technique)
Repair of nonunion or malunion, radius and ulna w/ iliac or other autograft
(includes obtaining graft)
Repair of defect w/ autograft radius or ulna
Repair of defect w/ autograft radius and ulna
Repair of nonunion, scaphoid (navicular) bone, w/ or w/o radial
styloidectomy (includes obtaining graft and necessary fixation)
Arthroplasty w/ prosthetic replacement distal radius
Arthroplasty w/ prosthetic replacement distal ulna
Arthroplasty w/ prosthetic replacement scaphoid (navicular)
Arthroplasty w/ prosthetic replacement lunate
Arthroplasty w/ prosthetic replacement trapezium
Arthroplasty w/ prosthetic replacement distal radius and partial or entire
carpus ("total wrist")
Arthroplasty w/ prosthetic replacement Interposition arthroplasty,
intercarpal or carpometacarpal joints
Revision of arthroplasty, including removal of implant, wrist joint
Epiphyseal arrest by epiphysiodesis or stapling distal radius or ulna

25315

Professional Fee

Prophylactic treatment (nailing, pinning, plating or wiring) w/ or w/o


methylmethacrylate radius
Prophylactic treatment (nailing, pinning, plating or wiring) w/ or w/o
methylmethacrylate ulna
Prophylactic treatment (nailing, pinning, plating or wiring) w/ or w/o
methylmethacrylate radius and ulna
Fracture and/or Dislocation
Closed treatment of radial shaft fracture
Open treatment of radial shaft fracture, w/ or w/o internal or external
fixation
Closed treatment of radial shaft fracture, w/ dislocation of distal radio-ulnar
joint (Galeazzi fracture/dislocation)

Page 19 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE

25525

DESCRIPTION

Case Rate

Open treatment of radial shaft fracture, w/ internal and/or external fixation


and closed treatment of dislocation of distal radio-ulnar joint (Galeazzi
fracture/dislocation), w/ or w/o percutaneous skeletal fixation

Professional Fee

Health Care
Institution Fee

20,980

10,080

10,900

22,660

11,760

10,900

25675
25676

Open treatment of radial shaft fracture, w/ internal and/or external fixation


and open treatment, w/ or w/o internal or external fixation of distal radioulnar joint (Galleazi fracture/dislocation), includes repair of triangular
cartilage
Closed treatment of ulnar shaft fracture
Open treatment of ulnar shaft fracture, w/ or w/o internal or external
fixation
Closed treatment of radial and ulnar shaft fractures
Open treatment of radial and ulnar shaft fractures, w/ internal or external
fixation of radius or ulna
Open treatment of radial and ulnar shaft fractures, w/ internal or external
fixation of radius and ulna
Closed treatment of distal radial fracture (e.g., Colles or Smith type) or
epiphyseal separation, w/ or w/o fracture of ulnar styloid
Percutaneous skeletal fixation of distal radial fracture (e.g., Colles or Smith
type) or epiphyseal separation, w/ or w/o fracture of ulnar styloid ,
requiring manipulation, w/ or w/o external fixation
Open treatment of distal radial fracture (e.g., Colles or Smith type) or
epiphyseal separation, w/ or w/o fracture of ulnar styloid, w/ or w/o
internal or external fixation
Closed treatment of carpal scaphoid (navicular) fracture
Open treatment of carpal scaphoid (navicular) fracture, w/ or w/o internal
or external fixation
Closed treatment of carpal bone fracture (excluding carpal scaphoid
(navicular))
Open treatment of carpal bone fracture (excluding carpal scaphoid
(navicular)), each bone
Closed treatment of ulnar styloid fracture
Closed treatment of radiocarpal or intercarpal dislocation, one or more
bones
Open treatment of radiocarpal or intercarpal dislocation, one or more
bones
Closed treatment of distal radioulnar dislocation
Open treatment of distal radioulnar dislocation, acute or chronic

25680

Closed treatment of trans-scaphoperilunar type of fracture dislocation

25685
25690
25695

20,980
8,260
21,940

10,080
3,360
9,240

10,900
4,900
12,700

18,000

8,400

9,600

21,820

10,920

10,900

21,820

10,920

10,900

12,900
14,960

6,300
7,560

6,600
7,400

21,820

10,920

10,900

25900

Open treatment of trans-scaphoperilunar type of fracture dislocation


Closed treatment of lunate dislocation
Open treatment of lunate dislocation
Arthrodesis
Arthrodesis, wrist joint (including radiocarpal and/or ulnocarpal fusion) w/o
bone graft
Arthrodesis, wrist joint (including radiocarpal and/or ulnocarpal fusion) w/
sliding graft
Arthrodesis, wrist joint (including radiocarpal and/or ulnocarpal fusion) w/
iliac or other autograft (includes obtaining graft)
Intercarpal fusion w/o bone graft
Intercarpal fusion w/ autograft (includes obtaining graft)
Distal radioulnar joint arthrodesis and segmental resection of ulna (e.g.
Sauve-Kapandji procedure), w/ or w/o bone graft
Amputation
Amputation, forearm, through, radius and ulna

18,000

8,400

9,600

25905

Amputation, forearm, through, radius and ulna open, circular (guillotine)

12,120

6,720

5,400

10,960

5,460

5,500

14,960
37,800
14,960
8,440
14,960
14,960
8,440
14,960

7,560
21,000
7,560
2,940
7,560
7,560
2,940
7,560

7,400
16,800
7,400
5,500
7,400
7,400
5,500
7,400

3,504
4,108
8,020
10,880

504
1,008
2,520
3,780

3,000
3,100
5,500
7,100

25526
25530
25545
25560
25574
25575
25600
25611

25620
25622
25628
25630
25645
25650
25660
25670

25800
25805
25810
25820
25825
25830

25907
25909
25915
25920
25922
25924
25927
25929
25931

26010
26011
26020
26025

Amputation, forearm, through, radius and ulna secondary closure or scar


revision
Amputation, forearm, through, radius and ulna re-amputation
Krukenberg procedure
Disarticulation through wrist
Disarticulation through wrist secondary closure or scar revision
Disarticulation through wrist re-amputation
Transmetacarpal amputation
Transmetacarpal amputation secondary closure or scar revision
Transmetacarpal amputation re-amputation
Hands and Fingers
Incision
Drainage of finger abscess simple
Drainage of finger abscess; complicated (e.g., felon)
Drainage of tendon sheath, one digit and/or palm
Drainage of palmar bursa single, ulnar or radial

Page 20 of 113

8,260

3,360

4,900

18,000

8,400

9,600

9,700

4,200

5,500

27,960

15,960

12,000

27,120

15,120

12,000

8,260

3,360

4,900

23,300

12,600

10,700

23,300

12,600

10,700

8,260

3,360

4,900

21,820

10,920

10,900

8,260

3,360

4,900

21,904

11,004

10,900

8,440

2,940

5,500

8,260

3,360

4,900

18,000

8,400

9,600

8,260
21,820

3,360
10,920

4,900
10,900

8,260

3,360

4,900

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE

DESCRIPTION

10,540

5,040

21,940

9,240

12,700

14,960
21,940
12,120
12,120
10,540
9,700

7,560
9,240
6,720
6,720
5,040
4,200

7,400
12,700
5,400
5,400
5,500
5,500

10,880

3,780

7,100

10,880

3,780

7,100

8,260

3,360

4,900

26100
26105
26110

Drainage of palmar bursa single, multiple or complicated


Inicision, deep, w/ opening of bone cortex (e.g., for osteomyelitis or bone
abscess), hand or finger
Decompression fingers and/or hand, injection injury (e.g., grease gun)
Decompressive fasciotomy, hand (excludes 26035)
Fasciotomy, palmar, for Dupuytrens contracture percutaneous
Fasciotomy, palmar, for Dupuytrens contracture open, partial
Tendon sheath incision (e.g., for trigger finger)
Tenotomy, percutaneous, single, each digit
Arthrotomy, w/ exploration, drainage, or removal of foreign body
carpometacarpal joint
Arthrotomy, w/ exploration, drainage, or removal of foreign body
metacarpophalangeal joint
Arthrotomy, w/ exploration, drainage, or removal of foreign body
interphalangeal joint, each
Excision
Arthrotomy w/ synovial biopsy carpometacarpal joint
Arthrotomy w/ synovial biopsy metacarpophalangeal joint
Arthrotomy w/ synovial biopsy interphalangeal joint, each

Health Care
Institution Fee
5,500

12,120
12,900
11,980

6,720
6,300
5,880

5,400
6,600
6,100

26115

Excision, tumor or vascular malformation, hand or finger subcutaneous

20,980

10,080

10,900

23,300

12,600

10,700

27,120

15,120

12,000

27,120

15,120

12,000

22,660

11,760

10,900

8,260

3,360

4,900

22,660

11,760

10,900

12,984

6,384

6,600

12,984

6,384

6,600

15,380

7,980

7,400

11,980

5,880

6,100

8,440
8,260
15,380
12,624

2,940
3,360
7,980
7,224

5,500
4,900
7,400
5,400

21,940

9,240

12,700

12,120

6,720

5,400

15,380

7,980

7,400

21,940

9,240

12,700

15,380

7,980

7,400

26030
26034
26035
26037
26040
26045
26055
26060
26070
26075
26080

26116
26117
26121
26123

26125

26130
26135
26140
26145
26160
26170
26180
26185
26200
26205
26210
26215
26230
26235
26236
26250
26255
26260
26261
26262
26350
26352

Case Rate

Excision, tumor or vascular malformation, hand or finger deep, subfascial,


intramuscular
Radical resection of tumor (e.g., malignant neoplasm), soft tissue of hand or
finger
Fasciectomy, palm only, w/ or w/o Z-plasty, other local tissue
rearrangement, or skin grafting (includes obtaining graft)
Fasciectomy, partial palmar w/ release of single digit including proximal
interphalangeal joint, w/ or w/o Z-plasty, other local tissue rearrangement,
or skin grafting (includes obtaining graft)
Fasciectomy, partial palmar w/ release of single digit including proximal
interphalangeal joint, w/ or w/o Z-plasty, other local tissue rearrangement,
or skin grafting (includes obtaining graft) each additional digit (List
separately in addition to code for primary procedure
Synovectomy, capometacarpal joint
Synovectomy, metacarpophalangeal joint including intrinsic release and
extensor hood reconstruction, each digit
Synovectomy, proximal interphalangeal joint, including extensor
reconstruction, each interphalangeal joint
Synovectomy tendon sheath, radical (tenosynovectomy), flexor, palm or
finger, single, each digit
Excision of lesion of tendon sheath or capsule (e.g., cyst, mucous cyst, or
ganglion), hand or finger
Excision of tendon, palm, flexor, single , each
Excision of tendon, finger, flexor
Sesamoidectomy, thumb or finger
Excision or curettage of bone cyst or benign tumor of metacarpal
Excision or curettage of bone cyst or benign tumor of metacarpal w/
autograft (includes obtaining graft)
Excision or curettage of bone cyst or benign tumor of proximal, middle or
distal phalanx of finger
Excision or curettage of bone cyst or benign tumor of proximal, middle or
distal phalanx of finger w/ autograft (includes obtaining graft)
Partial excision (craterization, saucerization, or diaphysectomy) of bone (e.g.
for osteomyelitis) metacarpal
Partial excision (craterization, saucerization, or diaphysectomy) of bone (e.g.
for osteomyelitis) proximal or middle phalanx of finger
Partial excision (craterization, saucerization, or diaphysectomy) of bone (e.g.
for osteomyelitis) distal phalanx of finger
Radical resection (ostectomy) for tumor, metacarpal;
Radical resection (ostectomy) for tumor, metacarpal; w/ autograft (includes
obtaining graft)
Radical resection (ostectomy) for tumor, proximal or middle phalanx of
finger;
Radical resection (ostectomy) for tumor, proximal or middle phalanx of
finger; w/ autograft (includes obtaining graft)
Radical resection (ostectomy) for tumor, distal phalanx of finger
Repair, Revision, and/or Reconstruction
Flexor tendon repair or advancement, single, not in "no mans land" primary
or secondary w/o free graft, each tendon
Flexor tendon repair or advancement, single, not in "no mans land"
secondary w/ free graft (includes obtaining graft), each tendon

Page 21 of 113

Professional Fee

12,120

6,720

5,400

23,636

12,936

10,700

32,000

14,700

17,300

30,740

13,440

17,300

31,580

14,280

17,300

23,080

12,180

10,900

12,120

6,720

5,400

10,540

5,040

5,500

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE
26356
26357
26358
26370
26372
26373
26390
26392
26410
26412
26415
26416
26418
26420
26426
26428
26432
26433
26434
26437
26440
26442
26445
26449
26450
26455
26460
26471
26474
26476
26477
26478
26479
26480
26483
26485
26489
26490
26492
26494
26496
26497
26498
26499
26500
26502
26504
26508

DESCRIPTION

Case Rate

Flexor tendon repair or advancement, single, in "no mans land" primary,


each tendon
Flexor tendon repair or advancement, single, in "no mans land" secondary,
each tendon
Flexor tendon repair or advancement, single, in "no mans land" secondary
w/ free graft (includes obtaining graft), each tendon
Profundus tendon repair or advancement, w/ intact sublimis primary
Profundus tendon repair or advancement, w/ intact sublimis secondary w/
free graft (includes obtaining graft)
Profundus tendon repair or advancement, w/ intact sublimis secondary w/o
free graft
Flexor tendon excision, implantation of plastic tube or rod for delayed
tendon graft, hand or finger
Removal of tube or rod and insertion of flexor tendon graft (includes
obtaining graft), hand or finger
Extensor tendon repair, dorsum of hand, single, primary or secondary w/o
free graft, each tendon
Extensor tendon repair, dorsum of hand, single, primary or secondary w/
free graft (includes obtaining graft), each tendon
Extensor tendon excision, implantation of plastic tube or rod for delayed
extensor tendon graft, hand or finger
Removal of tube or rod and insertion of extensor tendon graft (includes
obtaining graft), hand or finger
Extensor tendon repair, dorsum of finger, single, primary or secondary w/o
free graft, each tendon
Extensor tendon repair, dorsum of finger, single, primary or secondary w/
free graft (includes obtaining graft), each tendon
Extensor tendon repair, central slip repair, secondary (boutonniere
deformity) using local tissues
Extensor tendon repair, central slip repair, secondary (boutonniere
deformity) w/ free graft (includes obtaining graft)
Extensor tendon repair, distal insertion ("mallet finger"), closed splinting w/
or w/o percutaneous pinning
Extensor tendon repair, distal insertion ("mallet finger"), open, primary or
secondary repair w/o graft
Extensor tendon repair, distal insertion ("mallet finger"), open, primary or
secondary repair w/ free graft (includes obtaining graft)
Extensor tendon realignment, hand
Tenolysis, simple, flexor tendon palm or finger, single, each tendon
Tenolysis, simple, flexor tendon palm and finger, each tendon
Tenolysis, extensor tendon, dorsum of hand or finger; each tendon
Tenolysis, complex, extensor tendon, dorsum of hand or finger, including
hand and forearm
Tenotomy, flexor, single, palm, open, each
Tenotomy, flexor, single, finger, open, each
Tenotomy, extensor, hand or finger, single, open, each
Tenodesis for proximal interphalangeal joint stabilization
Tenodesis for distal joint stabilizaton
Tendon lengthening, extensor, hand or finger, single, each
Tendon shortening, extensor, hand or finger, single, each
Tendon lengthening, flexor, hand or finger, single, each
Tendon lengthening, flexor, hand or finger, single, each tendon shortening,
flexor, hand or finger, single, each
Tendon lengthening, flexor, hand or finger, single, each tendon transfer or
transplant, carpometacarpal area or dorsum of hand, single w/o free graft,
each
Tendon lengthening, flexor, hand or finger, single, each w/ free tendon
graft (includes obtaining graft), each tendon
Tendon transfer or transplant, palmar, single, each tendon w/o free tendon
graft
Tendon transfer or transplant, palmar, single, each tendon w/ free tendon
graft (includes obtaining graft), each tendon
Opponensplasty sublimis tendon transfer type
Opponensplasty tendon transfer w/ graft (includes obtaining graft)
Opponensplasty hypothenar muscle transfer
Opponensplasty other methods
Tendon trasfer to restore intrinsic function ring and small finger
Tendon trasfer to restore intrinsic function all four fingers
Correction claw finger,other methods
Tendon pulley reconstruction w/ local tissues
Tendon pulley reconstruction w/ tendon or fascial graft (includes obtaining
graft)
Tendon pulley reconstruction w/ tendon prosthesis
Thenar muscle release for thumb contracture

Page 22 of 113

Professional Fee

Health Care
Institution Fee

10,880

3,780

7,100

10,880

3,780

7,100

10,880

3,780

7,100

10,880

3,780

7,100

10,540

5,040

5,500

11,132

4,032

7,100

10,880

3,780

7,100

10,880

3,780

7,100

8,260

3,360

4,900

8,260

3,360

4,900

10,880

3,780

7,100

8,692

3,192

5,500

8,260

3,360

4,900

8,260

3,360

4,900

8,260

3,360

4,900

8,260

3,360

4,900

8,260

3,360

4,900

8,260

3,360

4,900

10,880

3,780

7,100

10,540
8,020
8,440
8,020

5,040
2,520
2,940
2,520

5,500
5,500
5,500
5,500

8,440

2,940

5,500

8,440
8,440
8,440
8,260
10,880
8,440
8,440
8,440

2,940
2,940
2,940
3,360
3,780
2,940
2,940
2,940

5,500
5,500
5,500
4,900
7,100
5,500
5,500
5,500

8,440

2,940

5,500

8,440

2,940

5,500

10,880

3,780

7,100

8,260

3,360

4,900

8,260

3,360

4,900

10,540
10,960
10,540
10,540
8,428
18,000
21,940
10,880

5,040
5,460
5,040
5,040
3,528
8,400
9,240
3,780

5,500
5,500
5,500
5,500
4,900
9,600
12,700
7,100

10,120

4,620

5,500

12,900
8,428

6,300
3,528

6,600
4,900

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE
26510
26516
26517
26518
26520
26525
26530
26531
26535
26536
26540

DESCRIPTION
Cross intrinsic transfer
Capsulodesis for M-P joint stabilization single digit
Capsulodesis for M-P joint stabilization two digits
Capsulodesis for M-P joint stabilization three or four digits
Capsulectomy or capsulotomy for contracture metacarpophalangeal joint,
single, each
Capsulectomy or capsulotomy for contracture interphalangeal joint, single,
each
Arthroplasty, metacarpophalangeal joint single, each joint
Arthroplasty, metacarpophalangeal joint w/ prosthetic implant, single, each
joint
Arthroplasty interphalangeal joint, single, each joint
Arthroplasty interphalangeal joint, single, each joint w/ prosthetic implant,
single, each joint

10,960
10,540
12,120
18,000

5,460
5,040
6,720
8,400

Health Care
Institution Fee
5,500
5,500
5,400
9,600

10,880

3,780

7,100

5,628

3,752

1,876

4,788

3,192

1,596

Repair of collateral ligament, metacarpophalangeal or interphalangeal joint

Case Rate

26555
26556
26560

Reconstruction, collateral ligament, metacarpophalangeal joint, single; w/


tendon or fascial graft (includes obtainig graft)
Reconstruction, collateral ligament, metacarpophalangeal joint, single, w/
local tissue (e.g., adductor advancement)
Reconstruction, collateral ligament, interphalangeal joint, single, including
graft, each joint
Repair non-union, metacarpal or phalanx, (includes obtaining bone graft w/
or w/o external or internal fixation)
Repair and reconstruction, finger, volar plate, interphalangeal joint
Pollicization of a digit
Toe-to-hand transfer w/ microvascular anastmosis great toe "wrap-around"
w/ bone graft
Toe-to-hand transfer w/ microvascular anastmosis other than great toe,
single
Toe-to-hand transfer w/ microvascular anastmosis other than great toe,
double
Positional change of other finger
Free toe joint transfer w/ microvascular anastomosis
Repair of syndactyly (web finger) each web space w/ skin flaps

26561

Repair of syndactyly (web finger) each web space w/ skin flaps and grafts

26541
26542
26545
26546
26548
26550
26551
26553
26554

Professional Fee

8,020

2,520

5,500

18,000

8,400

9,600

20,980

10,080

10,900

8,428

3,528

4,900

8,428

3,528

4,900

8,428

3,528

4,900

10,880

3,780

7,100

10,540

5,040

5,500

8,428
20,980

3,528
10,080

4,900
10,900

30,300

16,800

13,500

30,740

13,440

17,300

27,120

15,120

12,000

14,960
27,120
18,000

7,560
15,120
8,400

7,400
12,000
9,600

20,980

10,080

10,900

30,740

13,440

17,300

23,300
23,300
23,300
20,980
20,980
23,300
30,740
30,740
20,980
21,820

12,600
12,600
12,600
10,080
10,080
12,600
13,440
13,440
10,080
10,920

10,700
10,700
10,700
10,900
10,900
10,700
17,300
17,300
10,900
10,900

21,820

10,920

10,900

26600

Repair of syndactyly (web finger) each web space complex (e.g., involving
bone, nails)
Osteotomy for correction of deformity metacarpal
Osteotomy for correction of deformity phalanx of finger
Osteoplasty for lengthening of metacarpal or phalanx
Repair cleft hand
Repair bifid digit
Reconstruction of supernumerary digit, soft tissue and bone
Repair macrodactylia
Repair, intrinsic muscles of hand (specify)
Release, intrinsic muscles of hand (specify)
Excision of constricting ring of finger, w/ multiple Z-plasties
Release of scar contracture, flexor or extensor, w/ skin grafts,
rearrangement flaps, or Z-plasties, hand and/or finger
Fracture and/or Dislocation
Closed treatment of metacarpal fracture, single

10,120

4,620

5,500

26607

Closed treatment of metacarpal fracture, w/ internal or external fixation

12,900

6,300

6,600

26608

Percutaneous skeletal fixation of metacarpal fracture, each bone


Open treatment of metacarpal fracture, single, w/ or w/o internal or
external fixation, each bone
Closed treatment of carpometacarpal dislocation, thumb
Closed tratment of carpometacarpal fracture dislocation, thumb (Bennett
fracture)

12,120

6,720

5,400

12,120

6,720

5,400

10,540

5,040

5,500

12,120

6,720

5,400

14,960

7,560

7,400

14,960

7,560

7,400

10,540

5,040

5,500

14,960

7,560

7,400

10,540

5,040

5,500

26562
26565
26567
26568
26580
26585
26587
26590
26591
26593
26596
26597

26615
26641
26645
26650
26665
26670
26676
26685

Percutaneous skeletal fixation of carpometacarpal fracture dislocation,


thumb (Bennett fracture), w/ manipulation, w/ or w/o external fixation
Open treatment of carpometacarpal fracture dislocation, thumb (Bennett
fracture), w/ or w/o internal or external fixation
Closed treatment of carpometacarpal dislocation, other than thumb
(Bennett fracture); single
Percutaneous skeletal fixation of carpometacarpal dislocation, other than
thumb (Bennett fracture), single, w/ manipulation
Open treatment of carpometacarpal dislocation, other than thumb (Bennett
fracture) single, w/ or w/o internal or external fixation

Page 23 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE
26686

DESCRIPTION

Case Rate

Open treatment of carpometacarpal dislocation, other than thumb (Bennett


fracture) single, complex, multiple or delayed reduction

Professional Fee

Health Care
Institution Fee

11,980

5,880

6,100

Closed treatment of metacarpophalangeal dislocation, single


Percutaneous skeletal fixation of metacarpophalangeal dislocation, single,
w/ manipulation
Open treatment of metacarpophalangeal dislocation, single, w/ or w/o
internal or external fixation
Closed treatment of phalangeal shaft fracture, proximal or middle phalanx,
finger or thumb
Percutaneous skeletal fixation of unstable phalangeal shaft fracture,
proximal or middle phalanx, finger or thumb, w/ manipulation, each
Open treatment of phalangeal shaft fracture, proximal or middle phalanx,
finger or thumb, w/ or w/o internal or external fixation, each
Closed treatment of articular fracture, involving metacarpophalangeal or
interphalangeal joint
Open treatment of articular fracture, involving metacarpophalangeal or
interphalangeal joint, w/ or w/o internal or external fixation, each
Closed treatment of distal phalangeal fracture, finger or thumb
Percutaneous skeletal fixation of distal phalangeal fracture, finger or thumb,
each
Open treatment of distal phalangeal fracture, finger or thumb, w/ or w/o
internal or external fixation, each
Closed treatment of interphalangeal joint dislocation, single
Percutaneous skeletal fixation of interphalangeal joint dislocation, single, w/
manipulation
Open treatment of interphalangeal joint dislocation, w/ or w/o internal or
external fixation, single
Arthrodesis

10,540

5,040

5,500

14,960

7,560

7,400

12,540

7,140

5,400

10,120

4,620

5,500

14,960

7,560

7,400

14,960

7,560

7,400

10,120

4,620

5,500

12,540

7,140

5,400

10,120

4,620

5,500

14,960

7,560

7,400

12,120

6,720

5,400

10,880

3,780

7,100

12,540

7,140

5,400

12,540

7,140

5,400

26820

Fusion in opposition, thumb, w/ autogenous graft (includes obtaining graft)

21,820

10,920

10,900

26841

Arthrodesis, carpometacarpal joint, thumb, w/ or w/o internal fixation

20,980

10,080

10,900

20,980

10,080

10,900

21,940

9,240

12,700

20,980

10,080

10,900

20,980

10,080

10,900

21,820

10,920

10,900

20,980

10,080

10,900

21,820

10,920

10,900

12,120

6,720

5,400

11,980

5,880

6,100

21,940

9,240

12,700

6,720

5,400

26700
26706
26715
26720
26727
26735
26740
26746
26750
26756
26765
26770
26776
26785

26842
26843
26844
26850
26852
26860
26862

26910
26951
26952

Arthrodesis, carpometacarpal joint, thumb, w/ or w/o internal fixation w/


autograft (includes obtaining graft)
Arthrodesis, carpometacarpal joint, digits, other than thumb
Arthrodesis, carpometacarpal joint, digits, other than thumb;w/ autograft
(includes obtaining graft)
Arthrodesis, metacarpophalangeal joint, w/ or w/o internal fixation
Arthrodesis, metacarpophalangeal joint, w/ or w/o internal fixation w/
autograft (includes obtaining graft)
Arthrodesis, interphalangeal joint, w/ or w/o internal fixation
Arthrodesis, interphalangeal joint, w/ or w/o internal fixation w/ autograft
(includes obtaining graft)
Amputation
Amputation, metacarpal, w/ finger or thumb (ray amputation), single, w/ or
w/o interosseous transfer
Amputation, finger or thumb, primary or secondary, any joint or phalanx,
single, including neurectomies w/ direct closure
Amputation, finger or thumb, primary or secondary, any joint or phalanx,
single, including neurectomies w/ local advancement flaps (V-Y, hood)
Incision

26990

Incision and drainage, pelvis or hip joint area deep abscess or hematoma

12,120

26991

Incision and drainage, pelvis or hip joint area infected bursa


Incision, deep, w/ opening of bone cortex (e.g., for osteomyelitis or bone
abscess), pelvis and/or hip joint
Tenotomy, adductor of hip, subcutaneous, closed
Tenotomy, adductor of hip, subcutaneous, open
Tenotomy, adductor, subcutaneous, open, w/ obturator neurectomy
Tenotomy, iliopsoas, open
Tenotomy, abductors of hip, open
Fasciotomy, hip or thigh, any type
Arthrotomy, hip, for infection, w/ drainage
Arthrotomy, hip, w/ exploration or removal of loose or foreign body
Hip joint denervation, intrapelvic or extrapelvic intra-articular branches of
sciatic, femoral, or obturator nerves

12,120

6,720

5,400

23,300

12,600

10,700

12,120
14,960
30,740
23,300
23,300
21,820
30,740
30,740

6,720
7,560
13,440
12,600
12,600
10,920
13,440
13,440

5,400
7,400
17,300
10,700
10,700
10,900
17,300
17,300

30,300

16,800

13,500

37,800

21,000

16,800

3,504

504

3,000

26992
27000
27001
27003
27005
27006
27025
27030
27033
27035

27036

27040

Capsulectomy or capsulotomy of hip, w/ or w/o excision of heterotopic


bone, w/ release of hip flexor muscles (ie, gluteus medius, gluteus minimus,
tensor fascia latae, rectus femoris, sartorius, iliopsoas)
Excision
Biopsy, soft tissue of pelvis and hip area

Page 24 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE
27047
27048
27049
27050
27052
27054
27060
27062
27065
27066
27067
27070
27071

DESCRIPTION

5,680
8,260

1,680
3,360

Health Care
Institution Fee
4,000
4,900

37,800

21,000

16,800

27,960
37,180
31,140
27,120
27,120

15,960
18,480
17,640
15,120
15,120

12,000
18,700
13,500
12,000
12,000

27,960

15,960

12,000

30,300

16,800

13,500

31,140

17,640

13,500

46,500

25,200

21,300

46,500

25,200

21,300

38,860

20,160

18,700

38,860

20,160

18,700

37,180

18,480

18,700

31,140

17,640

13,500

31,560

18,060

13,500

15,380

7,980

7,400

14,960
30,300

7,560
16,800

7,400
13,500

38,020

19,320

18,700

22,660
23,300

11,760
12,600

10,900
10,700

30,740

13,440

17,300

30,740

13,440

17,300

30,740
30,740
37,180
37,180

13,440
13,440
18,480
18,480

17,300
17,300
18,700
18,700

37,180

18,480

18,700

53,400

29,400

24,000

55,080

31,080

24,000

55,000

33,600

21,400

38,640

21,840

16,800

38,640

21,840

16,800

27,960
30,300

15,960
16,800

12,000
13,500

Case Rate

Excision, tumor, pelvis and hip area subcutaneous


Excision, tumor, pelvis and hip area deep, subfascial, intramuscular
Radical resection of tumor (e.g., malignant neoplasm), soft tissue of pelvis
and hip area
Arthrotomy w/ biopsy sacroiliac joint
Arthrotomy w/ biopsy hip joint
Arthrotomy w/ synovectomy, hip joint
Excision; ischial bursa
Excision; trochanteric bursa or calcification
Excision of bone cyst or benign tumor; superficial (wing of ilium, symphysis
pubis, or greater trochanter of femur) w/ or w/o autograft
Excision of bone cyst or benign tumor; deep, w/ or w/o autograft
Excision of bone cyst or benign tumor; w/ autograft requiring separate
incision
Partial excision (craterization, saucerization) (e.g., for osteomyelitis);
superficial (e.g., wing of ilium, symphysis pubis or greater trochanter of
femur)
Partial excision (craterization, saucerization) (e.g., for osteomyelitis); deep

Professional Fee

27140
27146

Radical resection of tumor or infection; wing of ilium, one pubic or ischial


ramus or symphysis pubis
Radical resection of tumor or infection; ilium, including acetabulum, both
pubic rami, or ischium and acetabulum
Radical resection of tumor or infection; innominate bone, total
Radical resection of tumor or infection; ischial tuberosity and greater
trochanter of femur
Radical resection of tumor or infection; ischial tuberosity and greater
trochanter of femur, w/ skin flaps
Coccygectomy, primary
Introduction or Removal
Removal of foreign body, pelvis or hip
Removal of hip prosthesis
Removal of hip prosthesis complicated, including "total hip" and
methlmethacrylate, when applicable
Repair, Revision, and/or Reconstruction
Hamstring recession, proximal
Adductor transfer to ischium
Transfer external oblique muscle to greater trochanter including fascial or
tendon extension (graft)
Transfer paraspinal muscle to hip (includes fascial or tendon extension
graft)
Transfer iliopsoas; to greater trochanter
Transfer iliopsoas; to femoral neck
Acetabuloplasty; (e.g., Whitman, Colonna, Haygroves, or cup type)
Acetabuloplasty; resection femoral head (Girdlestone procedure)
Partial hip replacement, prosthesis (e.g., femoral stem prosthesis, bipolar
arthroplasty)
Arthroplasty, acetabular and proximal femoral prosthetic replacement
(total hip replacement), w/ or w/o autograft or allograft
Conversion of previous hip surgery to total hip replacement, w/ or w/o
autograft or allograft
Revision of total hip arthroplasty; both components, w/ or w/o autograft or
allograft
Revision of total hip arthroplasty; acetabular component only, w/ or w/o
autograft or allograft
Revision of total hip arthroplasty; femoral component only, w/ or w/o
allograft
Osteotomy and transfer of greater trochanter
Osteotomy , iliac, acetabular or innominate bone

27147

Osteotomy , iliac, acetabular or innominate bone w/ open reduction of hip

31,140

17,640

13,500

27151

Osteotomy , iliac, acetabular or innominate bone w/ femoral osteotomy

37,180

18,480

18,700

38,020

19,320

18,700

37,800
31,140

21,000
17,640

16,800
13,500

37,180

18,480

18,700

31,140

17,640

13,500

23,300

12,600

10,700

30,300

16,800

13,500

27075
27076
27077
27078
27079
27080
27086
27090
27091
27097
27098
27100
27105
27110
27111
27120
27122
27125
27130
27132
27134
27137
27138

27175

Osteotomy , iliac, acetabular or innominate bone w/ femoral osteotomy


and w/ open reduction of hip
Osteotomy, pelvis, bilateral (e.g., for congenital malformation)
Osteotomy, femoral neck
Osteotomy, intertrochanteric or subtrochanteric including internal or
external fixation and/or cast
Bone graft, femoral head, neck, intertrochanteric or subtrochanteric area
(includes obtaining bone graft)
Treatment of slipped femoral epiphysis; by traction, w/o reduction

27176

Treatment of slipped femoral epiphysis; by single or multiple pinning, in situ

27156
27158
27161
27165
27170

Page 25 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE
27177
27178
27179
27181
27185
27187

DESCRIPTION

Case Rate

Open treatment of slipped femoral epiphysis; single of multiple pinning or


bone graft (includes obtaining graft)
Open treatment of slipped femoral epiphysis; closed manipulation w/ single
or multiple pinning
Open treatment of slipped femoral epiphysis; osteoplasty of femoral neck
(Heyman type procedure)
Open treatment of slipped femoral epiphysis; osteotomy and internal
fixation
Epiphyseal arrest by epiphysiodesis or stapling, greater trochanter
Prophylactic treatment (nailing, pinning, plating, or wiring) w/ or w/o
methylmethacrylate, femoral neck and proximal femur
Fracture and/or Dislocation

Professional Fee

Health Care
Institution Fee

31,140

17,640

13,500

31,140

17,640

13,500

31,140

17,640

13,500

37,180

18,480

18,700

27,960

15,960

12,000

31,140

17,640

13,500

27193

Closed treatment of pelvic ring fracture, dislocation, diastasis or subluxation

27,960

15,960

12,000

27200
27202

Closed treatment of coccygeal fracture


Open treatment of coccygeal fracture
Open treatment of iliac spine(s), tuberosity avulsion, or iliac wing fracture(s)
(e.g., pelvic fracture(s) w/c do not disrupt the pelvic ring), w/ internal
fixation
Percutaneous skeletal fixation of posterior pelvic ring fracture and/or
dislocation (includes ilium, sacroiliac joint and/or sacrum)
Open treatment of anterior ring fracture and/or dislocation w/ internal
fixation (includes pubic symphysis and/or rami)
Open treatment of posterior ring fracture and/or dislocation w/ internal
fixation (includes ilium, sacroiliac joint and/or sacrum)
Closed treatment of acetabulum (hip socket) fracture(s)
Open treatment of posterior or anterior acetabular wall fracture, w/
internal fixation
Open treatment of acetabular fracture(s) involving anterior or posterior
(one) column, or a fracture running transversely across the acetabulum, w/
internal fixation
Open treatment of acetabular fracture(s) involving anterior and posterior
(two) columns, includes T-fracture and both column fracture w/ complete
articular detachment, or single column or transverse fracture w/ associated
acetabular wall fracture, w/ inte
Closed treatment of femoral fracture, proximal end, neck
Percutaneous skeletal fixation of femoral fracture, proximal end, neck,
undisplaced, mildly displaced, or impacted fracture
Open treatment of femoral fracture, proximal end, neck, internal fixation or
prosthetic replacement (direct fracture exposure)
Closed treatment of intertrochanteric, pertrochanteric, or subtrochanteric
femoral fracture

14,960
22,660

7,560
11,760

7,400
10,900

37,800

21,000

16,800

40,320

23,520

16,800

46,500

25,200

21,300

46,500

25,200

21,300

30,740

13,440

17,300

38,640

21,840

16,800

40,320

23,520

16,800

46,500

25,200

21,300

23,300

12,600

10,700

46,500

25,200

21,300

46,500

25,200

21,300

23,300

12,600

10,700

46,500

25,200

21,300

31,140

17,640

13,500

23,300

12,600

10,700

27,120

15,120

12,000

23,300
37,180

12,600
18,480

10,700
18,700

40,320

23,520

16,800

27215
27216
27217
27218
27220
27226
27227

27228
27230
27235
27236
27238
27244

27245
27246
27248
27250
27253
27254

Open treatment of intertrochanteric, pertrochanteric, or subtrochanteric


femoral fracture w/ plate/screw type implant, w/ or w/o cerclage
Open treatment of intertrochanteric, pertrochanteric, or subtrochanteric
femoral fracture w/ intramedullary implant, w/ or w/o interlocking screws
and/or cerclage
Closed treatment of greater trochanteric fracture
Open treatment of greater trochanteric fracture, w/ or w/o internal or
external fixation
Closed treatment of hip dislocation, traumatic
Open treatment of hip dislocation, traumatic, w/o internal fixation
Open treatment of hip dislocation, traumatic w/ acetabular wall and
femoral head fracture, w/ or w/o internal or external fixation

27258

Open treatment of spontaneous hip dislocation (developmental, including


congenital or pathological), replacement of femoral head in acetabulum
(including tenotomy, etc)

30,300

16,800

13,500

27259

Open treatment of spontaneous hip dislocation (developmental, including


congenital or pathological), replacement of femoral head in acetabulum
(including tenotomy, etc) w/ femoral shaft shortening

37,180

18,480

18,700

18,000

8,400

9,600

37,800
27,960
37,800

21,000
15,960
21,000

16,800
12,000
16,800

40,320

23,520

16,800

46,500
30,300

25,200
16,800

21,300
13,500

27265
27280
27282
27284
27286
27290
27295

Closed treatment of post hip arthroplasty dislocation


Arthrodesis
Arthrodesis, sacroiliac joint (including obtaining graft)
Arthrodesis, symphysis pubis (including obtaining graft)
Arthrodesis, hip joint (includes obtaining graft)
Arthrodesis, hip joint (includes obtaining graft) w/ subtrochanteric
osteotomy
Amputation
Interpelviabdominal amputation (hindquarter amputation)
Disarticulation of hip

Page 26 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE

DESCRIPTION

Case Rate

27323
27327

Femur (Thigh Region) and Knee Joint


Incision
Incision and drainage of deep abscess, infected bursa, or hematoma, thigh
or knee region
Incision, deep, w/ opening of bone cortex (e.g., for osteomyelitis or bone
abscess), femur or knee
Fasciotomy, iliotibial (tenotomy), open
Tenotomy, subcutaneous, closed, adductor or hamstring; single
Tenotomy, subcutaneous, closed, adductor or hamstring; multiple
Arthrotomy, knee, for infection, w/ exploration, drainage or removal of
foreign body
Neurectomy, hamstring muscle
Neurectomy, popliteal (gastrocnemius)
Excision
Biopsy, soft tissue of thigh or knee area
Excision, tumor, thigh or knee area; subcutaneous

27328

Excision, tumor, thigh or knee area; deep, subfascial, or intramuscular

27301
27303
27305
27306
27307
27310
27315
27320

27340
27345
27350
27355

Radical resection of tumor (e.g., malignant neoplasm), soft tissue of thigh or


knee area
Arthrotomy, knee; w/ synovial biopsy only
Arthrotomy, knee; w/ joint exploration, w/ or w/o biopsy, w/ or w/o
removal of loose or foreign bodies
Arthrotomy, knee, w/ excision of semilunar cartilage (meniscectomy);
medial or lateral
Arthrotomy, knee, w/ excision of semilunar cartilage (meniscectomy);
medial and lateral
Arthrotomy, knee, w/ synovectomy; anterior or posterior
Arthrotomy, knee, w/ synovectomy; anterior and posterior including
popliteal area
Excision, prepatellar bursa
Excision of synovial cyst of popliteal space (Bakers cyst)
Patellectomy or hemipatellectomy
Excision or curettage of bone cyst or benign tumor of femur

27356

Excision or curettage of bone cyst or benign tumor of femur w/ allograft

27329
27330
27331
27332
27333
27334
27335

27357
27358
27360
27365
27372
27380
27381
27385
27386
27390
27391
27392
27393
27394
27395
27396
27397
27400
27403
27405
27407
27409
27418
27420
27422
27424

Excision or curettage of bone cyst or benign tumor of femur w/ autograft


(includes obtaining graft)
Excision or curettage of bone cyst or benign tumor of femur w/ internal
fixation
Partial excision (craterization, saucerization, or diaphysectomy) of bone
(e.g., for osteomyelitis), femur, proximal tibia and/or fibula
Radical resection of tumor, bone, femur or knee
Introduction or Removal
Removal of foreign body, deep, thigh region or knee area
Repair, Revision, and/or Reconstruction
Suture of infrapatellar tendon; primary
Suture of infrapatellar tendon; secondary reconstruction, including fascial
or tendon graft
Suture of quadriceps or hamstring muscle rupture; primary
Suture of quadriceps or hamstring muscle rupture; secondary
reconstruction, including fascial or tendon graft
Tenotomy, open, hamstring, knee to hip; single
Tenotomy, open, hamstring, knee to hip; multiple, one leg
Tenotomy, open, hamstring, knee to hip; multiple, bilateral
Lengthening of hamstring tendon; single
Lengthening of hamstring tendon; multiple, one leg
Lengthening of hamstring tendon; multiple, bilateral
Transplant, hamstring tendon to patella; single
Transplant, hamstring tendon to patella; multiple
Tendon or muscle transfer, hamstrings to femur (e.g. Eggers type
procedure)
Arthrotomy w/ open meniscus repair
Repair, primary, torn ligament and/or capsule, knee; collateral
Repair, primary, torn ligament and/or capsule, knee; cruciate
Repair, primary, torn ligament and/or capsule, knee; collateral and cruciate
ligaments
Anterior tibial tubercleplasty (e.g., for chondromalacia patellae)
Reconstruction for recurrent dislocating patella; (e.g. Hauser type
procedure)
Reconstruction for recurrent dislocating patella; w/ extensor realignment
and/or muscle advancement or release (e.g. Campbell, Goldwaite type
procedure)
Reconstruction for recurrent dislocating patella; w/ patellectomy

Page 27 of 113

Professional Fee

Health Care
Institution Fee

8,260

3,360

4,900

23,300

12,600

10,700

18,000
18,000
21,820

8,400
8,400
10,920

9,600
9,600
10,900

27,120

15,120

12,000

23,300
23,300

12,600
12,600

10,700
10,700

3,504
5,680

504
1,680

3,000
4,000

8,020

2,520

5,500

27,120

15,120

12,000

20,980

10,080

10,900

23,300

12,600

10,700

31,580

14,280

17,300

27,960

15,960

12,000

13,152

6,552

6,600

23,300

12,600

10,700

14,960
20,980
30,740
22,240

7,560
10,080
13,440
11,340

7,400
10,900
17,300
10,900

23,720

13,020

10,700

23,720

13,020

10,700

27,120

15,120

12,000

23,720

13,020

10,700

27,120

15,120

12,000

18,000

8,400

9,600

23,300

12,600

10,700

27,120

15,120

12,000

32,000

14,700

17,300

27,120

15,120

12,000

18,000
21,940
20,980
23,300
21,940
20,980
23,300
22,360

8,400
9,240
10,080
12,600
9,240
10,080
12,600
9,660

9,600
12,700
10,900
10,700
12,700
10,900
10,700
12,700

23,300

12,600

10,700

27,960
27,120
30,300

15,960
15,120
16,800

12,000
12,000
13,500

37,800

21,000

16,800

22,660

11,760

10,900

23,080

12,180

10,900

30,740

13,440

17,300

30,740

13,440

17,300

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE

DESCRIPTION

27425
27427

Lateral retinacular release (any method)


Ligamentous reconstruction (augmentation), knee; extra-articular

21,820
30,300

10,920
16,800

Health Care
Institution Fee
10,900
13,500

27428

Ligamentous reconstruction (augmentation), knee; intra-articular (open)

31,140

17,640

13,500

37,180

18,480

18,700

27,120
30,740
30,740
31,140
37,800

15,120
13,440
13,440
17,640
21,000

12,000
17,300
17,300
13,500
16,800

Case Rate

Professional Fee

27430
27435
27437
27438
27440

Ligamentous reconstruction (augmentation), knee; intra-articular (open)


and extra-articular
Quadricepsplasty (e.g. Bennett or Thompson type)
Capsulotomy, knee, posterior capsular release
Arthroplasty, patella; w/o prosthesis
Arthroplasty, patella; w/ prosthesis
Arthroplasty, knee, tibial plateau

27441

Arthroplasty, knee, tibial plateau w/ debridement and partial synovectomy

38,640

21,840

16,800

27442

Arthroplasty, knee, femoral condyles or tibial plateaus

38,640

21,840

16,800

27443

Arthroplasty, knee, femoral condyles or tibial plateaus w/ debridement and


partial synovectomy

39,480

22,680

16,800

27445

Arthroplasty, knee, constrained prosthesis (e.g., Walldius type)

46,500

25,200

21,300

27446

Arthroplasty, knee, condyle and plateau; medial or lateral compartment

39,480

22,680

16,800

27447

Arthroplasty, knee, condyle and plateau; medial and lateral compartments


w/ or w/o patella resurfacing ("total knee replacement")

40,320

23,520

16,800

18,420
23,300

8,820
12,600

9,600
10,700

27,120

15,120

12,000

27,120

15,120

12,000

27,120

15,120

12,000

27,120
27,120

15,120
15,120

12,000
12,000

37,180

18,480

18,700

31,580

14,280

17,300

27,960

15,960

12,000

27475

Osteotomy, femur, shaft or supracondylar; w/o fixation


Osteotomy, femur, shaft or supracondylar; w/ fixation
Osteotomy, multiple, femoral shaft, w/ realignment on intramedullary rod
(Sofield type procedure)
Osteotomy, proximal tibia, including fibular excision or osteotomy (includes
correction of genu varus (bowleg) or genu valgus (knock-knee)); before
epiphyseal closure
Osteotomy, proximal tibia, including fibular excision or osteotomy (includes
correction of genu varus (bowleg) or genu valgus (knock-knee)); after
epiphyseal closure
Osteoplasty, femur; shortening (excluding 64876)
Osteoplasty, femur; lengthening
Osteoplasty, femur; combined, lengthening and shortening w/ femoral
segment transfer
Repair, nonunion or malunion, femur, distal to head and neck; w/o graft
(e.g., compression technique)
Repair, nonunion or malunion, femur, distal to head and neck; w/ iliac or
other autogenous bone graft (includes obtaining graft)
Epiphyseal arrest by epiphysiodesis or stapling; distal femur

30,740

13,440

17,300

27477

Epiphyseal arrest by epiphysiodesis or stapling; tibia and fibula, proximal

23,300

12,600

10,700

27,120

15,120

12,000

30,740

13,440

17,300

27429

27448
27450
27454
27455

27457
27465
27466
27468
27470
27472

27479
27485

Epiphyseal arrest by epiphysiodesis or stapling; combined distal femur,


proximal tibia and fibula
Arrest, hemiepiphyseal, distal femur or proximal leg (e.g., for genu varus or
valgus)

27486

Revision of total knee arthroplasty, w/ or w/o allograft; one component

53,400

29,400

24,000

27487

Revision of total knee arthroplasty, w/ or w/o allograft; all components

55,000

33,600

21,400

37,180

18,480

18,700

30,740

13,440

17,300

20,980

10,080

10,900

27488
27495
27496

Removal of knee prosthesis, including "total knee" methylmethacrylate and


insertion of spacer, when applicable
Prophylactic treatment (nailing, pinning, plating or writing) w/ or w/o
methylmethacrylate, femur
Decompression fasciotomy, thigh and/or knee, one compartment (flexor or
extensor or adductor)

27497

Decompression fasciotomy, thigh and/or knee, one compartment (flexor or


extensor or adductor) w/ debridement of nonviable muscle and/or nerve

21,820

10,920

10,900

27498

Decompression fasciotomy, thigh and/or knee, multiple compartments

21,820

10,920

10,900

23,300

12,600

10,700

14,960

7,560

7,400

18,420

8,820

9,600

18,420

8,820

9,600

27499

27501
27502
27503

Decompression fasciotomy, thigh and/or knee, multiple compartments w/


debridement of nonviable muscle and/or nerve
Fracture and/or Dislocation
Closed treatment of supracondylar or transcondylar femoral fracture w/ or
w/o intercondylar extension
Closed treatment of femoral shaft fracture, w/ or w/o skin or skeletal
traction
Closed treatment of supracondylar or transcondylar femoral fracture w/ or
w/o intercondylar extension, w/ or w/o skin or skeletal traction

Page 28 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE
27506
27507
27509
27510
27511
27513
27514
27516
27519
27520
27524
27530
27535
27536
27538
27540
27550

DESCRIPTION

Case Rate

Open treatment of femoral shaft fracture, w/ or w/o external fixation, w/


insertion of intramedullary implant, w/ or w/o cerclage and/or locking
screws
Open treatment of femoral shaft fracture w/ plate/screws, w/ or w/o
cerclage
Percutaneous skeletal fixation of femoral fracture, distal end, medial or
lateral condyle, or supracondylar or transcondylar, w/ or w/o intercondylar
extension, or distal femoral epiphyseal separation
Closed treatment of femoral fracture, distal end, medial or lateral condyle
Open treatment of femoral supracondylar or transcondylar fracture w/o
intercondylar extension, w/ or w/o internal or external fixation
Open treatment of femoral supracondylar or transcondylar fracture w/
intercondylar extension, w/ or w/o internal or external fixation
Open treatment of femoral fracture, distal end, medial or lateral condyle,
w/ or w/o internal or external fixation
Closed treatment of distal femoral epiphyseal separation
Open treatment of distal femoral epiphyseal separation, w/ or w/o internal
or external fixation
Closed treatment of patellar fracture
Open treatment of patellar fracture, w/ internal fixation and/or partial or
complete patellectomy and soft tissue repair
Closed treatment of tibial fracture, proximal (plateau)
Open treatment of tibial fracture, proximal (plateau); unicondylar, w/ or
w/o internal or external fixation
Open treatment of tibial fracture, proximal (plateau); bicondylar, w/ or w/o
internal fixation
Closed treatment of intercondylar spine(s) and/or tuberosity fracture(s) of
knee
Open treatment of intercondylar spine(s) and/or tuberosity fracture(s) of
the knee, w/ or w/o internal or external fixation
Closed treatment of knee dislocation

Professional Fee

Health Care
Institution Fee

30,740

13,440

17,300

30,740

13,440

17,300

37,180

18,480

18,700

18,420

8,820

9,600

37,180

18,480

18,700

37,800

21,000

16,800

30,740

13,440

17,300

23,300

12,600

10,700

22,660

11,760

10,900

20,980

10,080

10,900

20,980

10,080

10,900

18,420

8,820

9,600

30,740

13,440

17,300

27,120

15,120

12,000

10,540

5,040

5,500

21,820

10,920

10,900

10,540

5,040

5,500

27556

Open treatment of knee dislocation, w/ or w/o internal or external fixation;


w/o primary ligamentous repair or augmentation/reconstruction

27,120

15,120

12,000

27557

Open treatment of knee dislocation, w/ or w/o internal or external fixation;


w/ primary ligamentous repair

27,960

15,960

12,000

27558

Open treatment of knee dislocation, w/ or w/o internal or external fixation;


w/ primary ligamentous repair, w/ augmentation/reconstruction

37,800

21,000

16,800

20,980

10,080

10,900

27,120

15,120

12,000

30,740

13,440

17,300

30,300

16,800

13,500

23,300

12,600

10,700

23,300

12,600

10,700

11,980

5,880

6,100

22,660
27,120

11,760
15,120

10,900
12,000

27560
27566
27580
27590
27591
27592
27594
27596
27598

Closed treatment of patellar dislocation


Open treatment of patellar dislocation, w/ or w/o partial or total
patellectomy
Arthrodesis
Fusion of knee, any technique
Amputation
Amputation, thigh, through femur, any level;
Amputation, thigh, through femur, any level; immediate fitting technique
including first cast
Amputation, thigh, through femur, any level; open, circular (guillotine)
Amputation, thigh, through femur, any level; secondary closure or scar
revision
Amputation, thigh, through femur, any level; re-amputaion
Disarticulation at knee
Leg (Tibia and Fibula) and Ankle Joint
Incision

27600

Decompression fasciotomy, leg; anterior and/or lateral compartments only

8,020

2,520

5,500

27601

Decompression fasciotomy, leg; posterior compartments(s) only


Decompression fasciotomy, leg; anterior and/or lateral, and posterior
compartment(s)
Incision and drainage, leg or ankle; deep abscess or hematoma
Incision and drainage, leg or ankle; infected bursa
Tenotomy, Achilles tendon, subcutaneous ; local anesthesia
Tenotomy, Achilles tendon, subcutaneous ; general anesthesia
Incision, deep, w/ opening of bone cortex (e.g., for osteomyelitis or bone
abscess), leg or ankle
Arthrotomy, ankle, for infection, w/ exploration, drainage, or removal of
foreign body
Arthrotomy, ankle, posterior capsular release, w/ or w/o Achilles tendon
lengthening
Excision
Biopsy, soft tissue of leg or ankle area

8,020

2,520

5,500

8,260

3,360

4,900

4,108
5,680
12,540
18,420

1,008
1,680
7,140
8,820

3,100
4,000
5,400
9,600

20,980

10,080

10,900

21,940

9,240

12,700

22,660

11,760

10,900

3,504

504

3,000

27602
27603
27604
27605
27606
27607
27610
27612
27613

Page 29 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE

DESCRIPTION

Case Rate

Professional Fee

Health Care
Institution Fee

27654
27656

Radical resection of tumor (e.g., malignant neoplasm), soft tissue of leg or


ankle area
Excision, tumor, leg or ankle area; subcutaneous
Excision, tumor, leg or ankle area; deep, subfascial or intramuscular
Arthrotomy, ankle, w/ joint exploration, w/ or w/o biopsy, w/ or w/o
removal of loose or foreign body
Arthrotomy, ankle, w/ synovectomy
Arthrotomy, ankle, w/ synovectomy including tenosynovectomy
Excision of lesion of tendon sheath or capsule (e.g., cyst or ganglion), leg
and/or ankle
Excision or curettage of bone cyst or benign tumor, tibia or fibula
Excision or curettage of bone cyst or benign tumor, tibia or fibula w/
autograft(includes obtaining graft)
Excision or curettage of bone cyst or benign tumor, tibia or fibula w/
allograft
Partial excision (craterization, saucerization, or diaphysectomy) of bone
(e.g., for osteomyelitis or exostosis); tibia
Partial excision (craterization, saucerization, or diaphysectomy) of bone
(e.g., for osteomyelitis or exostosis); fibula
Radical resection of tumor, bone; tibia
Radical resection of tumor, bone; fibula
Radical resection of tumor, bone; talus or calcaneus
Repair, Revision, and/or Reconstruction
Repair, primary, open or percutaneous, ruptured Achilles tendon
Repair, primary, open or percutaneous, ruptured Achilles tendon w/ graft
(includes obtaining graft)
Repair, secondary, ruptured Achilles tendon, w/ or w/o graft
Repair, fascial defect of leg

27658

Repair or suture of flexor tendon of leg; primary, w/o graft, single, each

15,380

7,980

7,400

27659

Repair or suture of flexor tendon of leg; secondary w/ or w/o graft, single


tendon, each

18,000

8,400

9,600

27664

Repair or suture of extensor tendon of leg; primary, w/o graft, single, each

15,380

7,980

7,400

18,000

8,400

9,600

18,000
22,360
18,000

8,400
9,660
8,400

9,600
12,700
9,600

21,940

9,240

12,700

18,000

8,400

9,600

18,000

8,400

9,600

14,960

7,560

7,400

18,420

8,820

9,600

15,380

7,980

7,400

27615
27618
27619
27620
27625
27626
27630
27635
27637
27638
27640
27641
27645
27646
27647
27650
27652

27665
27675
27676
27680
27681
27685
27686
27687
27690
27692
27695
27696
27698
27700
27702
27703
27704
27705
27707
27709
27712
27715
27720
27722
27724
27725
27727
27730

Repair or suture of extensor tendon of leg; secondary w/ or w/o graft, single


tendon, each
Repair for dislocating peroneal tendons; w/o fibular osteotomy
Repair for dislocating peroneal tendons; w/ fibular osteotomy
Tenolysis, including tibia, fibula, and ankle flexor; single
Tenolysis, including tibia, fibula, and ankle flexor; multiple (through same
incision), each
Lengthening or shortening of tendon, leg or ankle; single
Lengthening or shortening of tendon, leg or ankle; multiple (through same
incision), each
Gastrocnemius recession (e.g., Strayer procedure)
Transfer or transplant of single tendon (w/ muscle redirection or rerouting);
superficial (e.g., anterior tibial extensors into midfoot)
Transfer or transplant of single tendon (w/ muscle redirection or rerouting);
each additional tendon
Suture, primary, torn, ruptured or severed ligament, ankle; collateral
Suture, primary, torn, ruptured or severed ligament, ankle; both collateral
ligaments
Suture, secondary repair, torn, ruptured or severed ligament, ankle,
collateral (e.g. Watson-Jones procedure)
Arthroplasty, ankle;
Arthroplasty, ankle; w/ implant ("total ankle")
Arthroplasty, ankle; secondary reconstruction, total ankle
Removal of ankle implant
Osteotomy; tibia
Osteotomy; fibula
Osteotomy; tibia and fibula
Osteotomy; multiple, w/ realignment on intramedullary rod (e.g. Sofield
type procedure)
Osteoplasty, tibia and fibula, lengthening
Repair of nonunion or malunion, tibia; w/o graft, (e.g., compression
technique)
Repair of nonunion or malunion, tibia; w/o graft, (e.g., compression
technique) w/ sliding graft
Repair of nonunion or malunion, tibia; w/o graft, (e.g., compression
technique) w/ iliac or other autograft (includes obtaining graft)
Repair of nonunion or malunion, tibia; w/o graft, (e.g., compression
technique) by synostosis, w/ fibula, any method
Repair of congenital pseudarthrosis, tibia
Epiphyseal arrest by epiphysiodesis or stapling; distal tibia

Page 30 of 113

20,980

10,080

10,900

5,680
8,020

1,680
2,520

4,000
5,500

12,900

6,300

6,600

18,420
21,940

8,820
9,240

9,600
12,700
4,000

5,680

1,680

14,960

7,560

7,400

21,940

9,240

12,700

21,940

9,240

12,700

18,420

8,820

9,600

18,000

8,400

9,600

23,300
22,660
23,300

12,600
11,760
12,600

10,700
10,900
10,700

21,940

9,240

12,700

23,300

12,600

10,700

21,820
5,680

10,920
1,680

10,900
4,000

18,000

8,400

9,600

23,300

12,600

10,700

18,000

8,400

9,600

27,120
31,140
37,180
21,820
21,940
18,000
22,660

15,120
17,640
18,480
10,920
9,240
8,400
11,760

12,000
13,500
18,700
10,900
12,700
9,600
10,900

23,720

13,020

10,700

27,960

15,960

12,000

18,000

8,400

9,600

20,980

10,080

10,900

21,820

10,920

10,900

22,660

11,760

10,900

23,300
21,820

12,600
10,920

10,700
10,900

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE

DESCRIPTION

27732

Epiphyseal arrest by epiphysiodesis or stapling; distal fibula

20,980

10,080

Health Care
Institution Fee
10,900

27734

Epiphyseal arrest by epiphysiodesis or stapling; distal tibia and fibula

23,300

12,600

10,700

27740

Epiphyseal arrest by epiphysiodesis or stapling, combined, proximal and


distal tibia and fibula

23,300

12,600

10,700

22,660

11,760

10,900

31,160

13,860

17,300

12,120

6,720

5,400

12,120

6,720

5,400

21,820

10,920

10,900

22,660

11,760

10,900

27,120

15,120

12,000

10,960

5,460

5,500

12,120

6,720

5,400

10,960

5,460

5,500

22,660

11,760

10,900

27742
27745
27750
27752
27756
27758
27759
27760
27766
27780
27784
27786
27792
27808
27814
27816
27822

27823

Case Rate

Epiphyseal arrest by epiphysiodesis or stapling, combined, proximal and


distal tibia and fibula and distal femur
Prophylactic treatment (nailing, pinning, plating or wiring) w/ or w/o
methylmethacrylate, tibia
Fracture and/or Dislocation
Closed treatment of tibial shaft fracture (w/ or w/o fibular fracture)
Closed treatment of tibial shaft fracture (with or without fibular fracture);
with manipulation, with or without skeletal traction
Percutaneous skeletal fixation of tibial shaft fracture (w/ or w/o fibular
fracture) (e.g., pins or screws)
Open treatment of tibial shaft fracture (w/ or w/o fibular fracture) w/
plate/screws, w/ or w/o cerclage
Open treatment of tibial shaft fracture (w/ or w/o fibular fracture) by
intramedullary implant, w/ or w/o interlocking screws and/or cerclage
Closed treatment of medial malleolus fracture
Open treatment of medial malleolus fracture, w/ or w/o internal or external
fixation
Closed treatment of proximal fibula or shaft fracture
Open treatment of proximal fibula or shaft fracture, w/ or w/o internal or
external fixation
Closed treatment of distal fibular fracture (lateral malleolus)
Open treatment of distal fibular fracture (lateral malleolus), w/ or w/o
internal or external fixation w/o manipulation
Closed treatment of bimalleolar ankle fracture, (including Potts)
Open treatment of bimalleolar ankle fracture, w/ or w/o internal or external
fixation
Closed treatment of trimalleolar ankle fracture
Open treatment of trimalleolar ankle fracture, w/ or w/o internal or
external fixation, medial and/or lateral malleolus; w/o fixation of posterior
lip
Open treatment of trimalleolar ankle fracture, w/ or w/o internal or
external fixation, medial and/or lateral malleolus; w/ fixation of posterior lip

Professional Fee

10,540

5,040

5,500

20,980

10,080

10,900

12,900

6,300

6,600

23,300

12,600

10,700

23,300

12,600

10,700

23,300

12,600

10,700

23,300

12,600

10,700

10,540

5,040

5,500

20,980

10,080

10,900

21,940

9,240

12,700

21,820

10,920

10,900

20,980

10,080

10,900

10,960

5,460

5,500

11,980

5,880

6,100

10,960

5,460

5,500

22,660

11,760

10,900

23,720

13,020

10,700

18,000
21,400

8,400
10,500

9,600
10,900

30,300

16,800

13,500

30,740

13,440

17,300
9,600

27882

Closed treatment of fracture of weight bearing articular portion of distal


tibia (e.g., pilon or tibial plafond)
Open treatment of fracture of weight bearing articular surface/portion of
distal tibia (e.g., pilon or tibial plafond), w/ internal or external fixation; of
fibula only
Open treatment of fracture of weight bearing articular surface/portion of
distal tibia (e.g., pilon or tibial plafond), w/ internal or external fixation; of
tibia only
Open treatment of fracture of weight bearing articular surface/portion of
distal tibia (e.g., pilon or tibial plafond), w/ internal or external fixation; of
both tibia and fibula
Open treatment of distal tibiofibular joint (syndesmosis) disruption, w/ or
w/o internal or external fixation
Closed treatment of proximal tibiofibular joint dislocation
Open treatment of proximal tibiofibular joint dislocation, w/ or w/o internal
or external fixation, or w/ excision of proximal fibula
Closed treatment of ankle dislocation
Open treatment of ankle dislocation, w/ or w/o percutaneous skeletal
fixation; w/o repair or internal fixation
Open treatment of ankle dislocation, w/ or w/o percutaneous skeletal
fixation; w/ repair or internal or external fixation
Arthrodesis
Arthrodesis, ankle, any method
Arthrodesis, tibiofibular joint, proximal or distal
Amputation
Amputation, leg, through tibia and fibula;
Amputation, leg, through tibia and fibula; w/ immediate fitting technique
including application of first cast
Amputation, leg, through tibia and fibula; open, circular (guillotine)

18,000

8,400

27884

Amputation, leg, through tibia and fibula; secondary closure or scar revision

12,120

6,720

5,400

27886

Amputation, leg, through tibia and fibula; re-amputation


Amputation, ankle, through malleoli of tibia and fibula (Syme, Pirogoff type
procedures), w/ plastic closure and resection of nerves

23,300

12,600

10,700

23,300

12,600

10,700

27824
27826

27827

27828
27829
27830
27832
27840
27846
27848
27870
27871
27880
27881

27888

Page 31 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE
27889

27892
27893
27894

28001
28002
28003
28005
28008
28010
28011
28020
28022
28024
28030
28035

DESCRIPTION

21,940

9,240

Health Care
Institution Fee
12,700

18,000

8,400

9,600

18,000

8,400

9,600

18,420

8,820

9,600

5,680

1,680

4,000

8,260

3,360

4,900

9,700

4,200

5,500

10,540

5,040

5,500

12,120
8,260
10,540

6,720
3,360
5,040

5,400
4,900
5,500

12,900

6,300

6,600

8,260

3,360

4,900

8,260

3,360

4,900

11,132
18,000

4,032
8,400

7,100
9,600

Case Rate

Ankle disarticulation
Other Procedures
Decompression fasciotomy, leg; anterior and/or lateral compartments only,
w/ debridement of nonviable muscle and/or nerve
Decompression fasciotomy, leg; posterior compartment(s) only, w/
debridement of nonviable muscle and/or nerve
Decompression fasciotomy, leg; anterior and/or lateral, and posterior
compartment(s), w/ debridement of nonviable muscle and/or nerve
Foot and Toes
Incision
Incision and drainage, infected bursa, foot
Incision and drainage, infected bursa, foot deep dissection below fascia, for
deep infection of foot, w/ or w/o tendon sheath involvement; single bursal
space, specify
Incision and drainage, infected bursa, foot multiple areas
Incision, deep, w/ opening of bone cortex (e.g. for osteomyelitis or bone
abscess), foot
Fasciotomy, foot and/or toe
Tenotomy, subcutaneous, toe; single
Tenotomy, subcutaneous, toe; multiple
Arthrotomy, w/ exploration, drainage, or removal of loose or foreign body;
intertarsal or tarsometatarsal joint
Arthrotomy, w/ exploration, drainage, or removal of loose or foreign body;
metatarsophalangeal joint
Arthrotomy, w/ exploration, drainage, or removal of loose or foreign body;
interphalangeal joint
Neurectomy of intrinsic musculature of foot
Tarsal tunnel release (posterior tibial nerve decompression)
Excision

Professional Fee

28043

Excision, tumor, foot subcutaneous

5,680

1,680

4,000

28045

Excision, tumor, foot deep, subfascial, intramuscular

8,020

2,520

5,500

28046

Radical resection of tumor (e.g., malignant neoplasm), soft tissue of foot

37,800

21,000

16,800

28050
28052
28054
28060
28062
28070
28072
28080
28086
28088

Arthrotomy for synovial biopsy; intertarsal or tarsometatarsal joint


Arthrotomy for synovial biopsy; metatarsophalangeal joint
Arthrotomy for synovial biopsy; interphalangeal joint
Fasciectomy, excision of plantar fascia; partial
Fasciectomy, excision of plantar fascia; radical
Synovectomy; intertarsal or tarsometatarsal joint, each
Synovectomy; metatarsophalangeal joint, each
Excision of interdigital (Morton) neuroma, single, each
Synovectomy, tendon sheath, foot flexor
Synovectomy, tendon sheath, foot extensor
Excision of lesion of tendon or fibrous sheath or capsule (including
synovectomy) (cyst or ganglion) foot
Excision of lesion of tendon or fibrous sheath or capsule (including
synovectomy) (cyst or ganglion) toes

10,120
10,120
9,700
9,700
10,960
11,980
10,960
5,680
10,960
10,960

4,620
4,620
4,200
4,200
5,460
5,880
5,460
1,680
5,460
5,460

5,500
5,500
5,500
5,500
5,500
6,100
5,500
4,000
5,500
5,500

8,440

2,940

5,500

8,260

3,360

4,900

Excision or curettage of bone cyst or benign tumor, talus or calcaneus

15,380

7,980

7,400

21,940

9,240

12,700

21,940

9,240

12,700

15,380

7,980

7,400

21,940

9,240

12,700

21,940

9,240

12,700

28090
28092
28100
28102
28103
28104
28106
28107

Excision or curettage of bone cyst or benign tumor, talus or calcaneus w/


iliac or other autograft (includes obtaining graft)
Excision or curettage of bone cyst or benign tumor, talus or calcaneus w/
allograft
Excision or curettage of bone cyst or benign tumor, talus or metatarsal
bones, except tarsal or calcaneus;
Excision or curettage of bone cyst or benign tumor, talus or metatarsal
bones, except tarsal or calcaneus; w/ iliac or other autograft (includes
obtaining graft)
Excision or curettage of bone cyst or benign tumor, talus or metatarsal
bones, except tarsal or calcaneus; w/ allograft

28108

Excision or curettage of bone cyst or benign tumor, phalanges of foot

14,960

7,560

7,400

28110
28111

Ostectomy, partial excision, fifth metatarsal head (bunionette)


Ostectomy, complete excision; first metatarsal head
Ostectomy, complete excision; other metatarsal head (second, third or
fourth)
Ostectomy, complete excision; fifth metatarsal head

21,940
18,420

9,240
8,820

12,700
9,600

18,420

8,820

9,600

18,000

8,400

9,600

20,980

10,080

10,900

28112
28113
28114

Ostectomy, complete excision; all metatarsal heads, w/ partial proximal


phalangectomy, excluding first metatarsal (e.g. Clayton type procedure)

Page 32 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE

DESCRIPTION

15,380
15,380
14,960

7,980
7,980
7,560

21,940

9,240

12,700

18,000

8,400

9,600

18,000

8,400

9,600

28126
28130
28140
28150
28153

Ostectomy, excision of tarsal coalition


Ostectomy, calcaneus;
Ostectomy, calcaneus; for spur, w/ or w/o plantar fascial release
Partial excision (craterization, saucerization, sequestrectomy, or
diaphysectomy) of bone (e.g., for osteomyelitis or talar bossing); talus or
calcaneus
Partial excision (craterization, saucerization, or diaphysectomy) of bone
(e.g., for osteomyelitis or tarsal bossing), tarsal or metatarsal bone, except
talus or calcaneus
Partial excision (craterization, saucerization, or diaphysectomy) of bone
(e.g., for osteomyelitis or dorsal bossing), phalanx of toe
Resection, partial or complete, phalangeal base, single toe, each
Talectomy (astragalectomy)
Metatarsectomy
Phalangectomy of toe, single, each
Resection, head of phalanx, toe

Health Care
Institution Fee
7,400
7,400
7,400

12,540
22,660
18,000
12,120
12,120

7,140
11,760
8,400
6,720
6,720

5,400
10,900
9,600
5,400
5,400

28160

Hemiphalangectomy or interphalangeal joint excision, toe, single, each

10,540

5,040

5,500

28171

Radical resection of tumor, bone; tarsal (except talus or calcaneus)

30,740

13,440

17,300

28173
28175

Radical resection of tumor, bone; metatarsal


Radical resection of tumor, bone; phalanx of toe
Repair, Revision, and/or Reconstruction
Repair or suture of tendon, foot, flexor, single; primary or secondary, w/o
free graft, each tendon
Repair or suture of tendon, foot, flexor, single; secondary w/ free graft, each
tendon (includes obtaining graft)
Repair or suture of tendon, foot, extensor, single; primary or secondary,
each tendon
Repair or suture of tendon, foot, extensor, single; secondary w/ free graft,
each tendon (includes obtaining graft)
Tenolysis, flexor, foot; single
Tenolysis, flexor, foot; multiple (through same incision)
Tenolysis, extensor, foot; single
Tenolysis, extensor, foot; multiple (through same incision)
Tenotomy, open, flexor; foot, single or multiple;
Tenotomy, open, flexor; foot, single or multiple; toe, single
Tenotomy, open, extensor, foot or toe
Advancement of posterior tibial tendon w/ excision of accessory navicular
bone (e.g. Kidner type procedure)
Tenotomy, lengthening, or release, abductor hallucis muscle
Division of plantar fascia and muscle (e.g. Steindler stripping)
Capsulotomy, midfoot; medial release only
Capsulotomy, midfoot; w/ tendon lengthening

22,660
21,940

11,760
9,240

10,900
12,700

18,000

8,400

9,600

18,000

8,400

9,600

12,540

7,140

5,400

12,540

7,140

5,400

10,880
10,960
10,880
10,960
10,960
10,880
11,132

3,780
5,460
3,780
5,460
5,460
3,780
4,032

7,100
5,500
7,100
5,500
5,500
7,100
7,100

18,420

8,820

9,600

12,540
12,540
12,540
18,000

7,140
7,140
7,140
8,400

5,400
5,400
5,400
9,600

20,980

10,080

10,900

12,120

6,720

5,400

12,120

6,720

5,400

12,900

6,300

6,600

20,980

10,080

10,900

15,380

7,980

7,400

21,940

9,240

12,700

15,380

7,980

7,400

20,980

10,080

10,900

21,820

10,920

10,900

21,820

10,920

10,900

22,660

11,760

10,900

22,660

11,760

10,900

22,660

11,760

10,900

28116
28118
28119
28120

28122
28124

28200
28202
28208
28210
28220
28222
28225
28226
28230
28232
28234
28238
28240
28250
28260
28261
28262
28264
28270
28272
28280
28285
28286
28288
28290
28292
28293
28294
28296
28297

Case Rate

Capsulotomy, midfoot; extensive, including posterior talotibial capsulotomy


and tendon(s) lengthening as for resistant clubfoot deformity
Capsulotomy, midtarsal (e.g. Heyman type procedure)
Capsulotomy; metatarsophalangeal joint, w/ or w/o tenorrhaphy, single,
each joint
Capsulotomy; interphalangeal joint, single each joint
Webbing operation (create syndactylism of toes) (e.g. Kelikian type
procedure)
Hammertoe operation, one toe (e.g., interphalangeal fusion, filleting,
phalangectomy)
Cock-up fifth toe operation w/ plastic skin closure (e.g. Ruiz-Mora type
procedure)
Ostectomy, partial, exostectomy or condylectomy, single, metatarsal head,
first through fifth, each metatarsal head
Hallux valgus (bunion) correction, w/ or w/o sesamoidectomy; simple
exostectomy (e.g. Silver type procedure)
Hallux valgus (bunion) correction, w/ or w/o sesamoidectomy; Keller,
McBride, or Mayo type procedure
Hallux valgus (bunion) correction, w/ or w/o sesamoidectomy; resection of
joint w/ implant
Hallux valgus (bunion) correction, w/ or w/o sesamoidectomy; w/ tendon
transplants (Joplin type procedure)
Hallux valgus (bunion) correction, w/ or w/o sesamoidectomy; w/
metatarsal osteotomy (e.g., Mitchell, Chevron, or concentric type
procedures)
Hallux valgus (bunion) correction, w/ or w/o sesamoidectomy; Lapidus type
procedure

Page 33 of 113

Professional Fee

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE

DESCRIPTION

Case Rate

Professional Fee

Health Care
Institution Fee

28298

Hallux valgus (bunion) correction, w/ or w/o sesamoidectomy; by phalanx


osteotomy

23,080

12,180

10,900

28299

Hallux valgus (bunion) correction, w/ or w/o sesamoidectomy; by other


methods (e.g., double osteotomy)

23,080

12,180

10,900

21,400

10,500

10,900

20,980
15,380

10,080
7,980

10,900
7,400

18,420

8,820

9,600

28300
28302
28304
28305

Osteotomy; calcaneus (e.g. Dwyer or Chambers type procedure), w/ or w/o


internal fixation
Osteotomy; talus
Osteotomy, midtarsal bones, other than calcaneus or talus;
Osteotomy, midtarsal bones, other than calcaneus or talus; w/ autograft
(includes obtaining graft)(e.g. Fowler type)

28306

Osteotomy, metatarsal, base or shaft, single, w/ or w/o lenghtening, for


shortening or angular correction; first metatarsal

22,360

9,660

12,700

28307

Osteotomy, metatarsal, base or shaft, single, w/ or w/o lenghtening, for


shortening or angular correction; first metatarsal w/ autograft

22,360

9,660

12,700

28308

Osteotomy, metatarsal, base or shaft, single, w/ or w/o lenghtening, for


shortening or angular correction; other than first metatarsal

22,360

9,660

12,700

21,940

9,240

12,700

18,420

8,820

9,600

14,960

7,560

7,400

22,360

9,660

12,700

12,540

7,140

5,400

21,940

9,240

12,700

14,960

7,560

7,400

12,120
12,540
21,940
22,360
15,380

6,720
7,140
9,240
9,660
7,980

5,400
5,400
12,700
12,700
7,400

10,960
11,980

5,460
5,880

5,500
6,100

18,000

8,400

9,600

22,360

9,660

12,700

10,960

5,460

5,500

9,700

4,200

5,500

28315

Osteotomy, metatarsals, multiple, for cavus foot (e.g. Swanson type


procedure)
Osteotomy for shortening, angular or rotational correction; proximal
phalanx, first toe
Osteotomy for shortening, angular or rotational correction; other
phalanges, any toe
Reconstruction, angular deformity of toe (overlapping second toe, fifth toe,
curly toes), soft tissue procedures only
Sesamoidectomy, first toe

28320

Repair of nonunion or malunion; tarsal bones (e.g., calcaneus, talus)

28309
28310
28312
28313

28430

Repair of nonunion or malunion; metatarsal, w/ or w/o bone graft (includes


obtaining graft)
Reconstruction, toe, macrodactyly; soft tissue resection
Reconstruction, toe, macrodactyly; requiring bone resection
Reconstruction, toe(s); polydactyly
Reconstruction, toe(s); syndactyly, w/ or w/o skin graft(s)
Reconstruction, cleft foot
Fracture and/or Dislocation
Closed treatment of calcaneal fracture
Percutaneous skeletal fixation of calcaneal fracture, w/ manipulation
Open treatment of calcaneal fracture, w/ or w/o internal or external
fixation;
Open treatment of calcaneal fracture, w/ or w/o internal or external
fixation; w/ primary iliac or other autogenous bone graft (includes obtaining
graft)
Closed treatment of talus fracture

28436

Percutaneous skeletal fixation of talus fracture, w/ manipulation

28445

Open treatment of talus fracture, w/ or w/o internal or external fixation

15,380

7,980

7,400

28450

11,132

4,032

7,100

11,980

5,880

6,100

10,120

4,620

5,500

28470

Treatment of tarsal bone fracture (except talus and calcaneus)


Percutaneous skeletal fixation of tarsal bone fracture (except talus and
calcaneus), w/ manipulation
Open treatment of tarsal bone fracture (except talus and calcaneus), w/ or
w/o internal or external fixation
Closed treatment of metatarsal fracture

10,880

3,780

7,100

28476

Percutaneous skeletal fixation of metatarsal fracture, w/ manipulation

8,260

3,360

4,900

10,880

3,780

7,100

10,120

4,620

5,500

10,540

5,040

5,500

12,120

6,720

5,400

10,120

4,620

5,500

12,120

6,720

5,400

8,260

3,360

4,900

28322
28340
28341
28344
28345
28360
28400
28406
28415
28420

28456
28465

28485
28490
28496
28505
28510
28525
28530

Open treatment of metatarsal fracture, w/ or w/o internal or external


fixation
Closed treatment of fracture great toe, phalanx or phalanges
Percutaneous skeletal fixation of fracture great toe, phalanx or phalanges,
w/ manipulation
Open treatment of fracture great toe, phalanx or phalanges, w/ or w/o
internal or external fixation
Closed treatment of fracture, phalanx or phalanges, other than great toe
Open treatment of fracture, phalanx or phalanges, other than great toe, w/
or w/o internal or external fixation
Closed treatment of sesamoid fracture

Page 34 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE

DESCRIPTION

28531

Open treatment of sesamoid fracture, w/ or w/o internal fixation

10,120

4,620

Health Care
Institution Fee
5,500

28540

Closed treatment of tarsal bone dislocation, other than talotarsal

8,260

3,360

4,900

12,540

7,140

5,400

12,540

7,140

5,400

10,880

3,780

7,100

12,540

7,140

5,400

18,000

8,400

9,600

10,960

5,460

5,500

12,540

7,140

5,400

18,000

8,400

9,600

Case Rate

28705
28715
28725

Percutaneous skeletal fixation of tarsal bone dislocation, other than


talotarsal ,w/ manipulation
Open treatment of tarsal bone dislocation, w/ or w/o internal or external
fixation
Closed treatment of talotarsal joint dislocation
Percutaneous skeletal fixation of talotarsal joint dislocation, w/
manipulation
Open treatment of talotarsal joint dislocation, w/ or w/o internal or
external fixation
Closed treatment of tarsometatarsal joint dislocation
Percutaneous skeletal fixation of tarsometatarsal joint dislocation, w/
manipulation
Open treatment of tarsometatarsal joint dislocation, w/ or w/o internal or
external fixation
Closed treatment of metatarsophalangeal joint dislocation
Percutaneous skeletal fixation of metatarsophalangeal joint dislocation, w/
manipulation
Open treatment of metatarsophalangeal joint dislocation, w/ or w/o
internal or external fixation
Closed treatment of interphalangeal joint dislocation
Percutaneous skeletal fixation of interphalangeal joint dislocation, w/
manipulation
Open treatment of interphalangeal joint dislocation, w/ or w/o internal or
external fixation
Arthrodesis
Pantalar arthrodesis
Triple arthrodesis
Subtalar arthrodesis

28730

Arthrodesis, midtarsal or tarsometatarsal, multiple or transverse;

28546
28555
28570
28576
28585
28600
28606
28615
28630
28636
28645
28660
28666
28675

28735
28737
28740
28750
28755

28760

28800
28802
28805
28810
28820
28825

Arthrodesis, midtarsal or tarsometatarsal, multiple or transverse; w/


osteotomy as for flatfoot correction
Arthrodesis, midtarsal navicular-cuneiform, w/ tendon lengthening and
advancement (e.g. Miller type procedure)
Arthrodesis, midtarsal or tarsometatarsal, single joint
Arthrodesis, great toe; metatarsophalangeal joint
Arthrodesis, great toe; interphalangeal joint
Arthrodesis, great toe, interphalangeal joint, w/ extensor hallucis longus
transfer to first metatarsal neck (e.g. Jones type procedure)
Amputation
Amputation, foot; midtarsal (e.g. Chopart type procedure)
Deep disection below fascia, for deep infection of foot, w/ or w/o tendon
shealth involvement; single bursal space specify
Deep disection below fascia, for deep infection of foot, w/ or w/o tendon
shealth involvement; transmetatarsal
Amputation, metatarsal, w/ toe, single
Amputation, toe; metatarsophalangeal joint
Amputation, toe; interphalangeal joint
Body and Upper Extremity
Casts

Professional Fee

8,260

3,360

4,900

12,540

7,140

5,400

18,000

8,400

9,600

10,880

3,780

7,100

12,540

7,140

5,400

18,000

8,400

9,600

27,120
27,960
27,120

15,120
15,960
15,120

12,000
12,000
12,000

23,300

12,600

10,700

23,080

12,180

10,900

21,940

9,240

12,700

18,420
18,420
15,380

8,820
8,820
7,980

9,600
9,600
7,400

22,240

11,340

10,900

23,300

12,600

10,700

8,260

3,360

4,900

21,820

10,920

10,900

12,120
18,000
12,120

6,720
8,400
6,720

5,400
9,600
5,400

29000

Application of halo type body cast (see 20661-20663 for insertion)

10,540

5,040

5,500

29010
29015
29020
29025
29035

Application of Risser jacket, localizer, body; only


Application of Risser jacket, localizer, body; including head
Application of turnbuckle jacket, body; only
Application of turnbuckle jacket, body; including head
Application of body cast, shoulder to hips;

10,540
10,540
10,540
10,540
10,540

5,040
5,040
5,040
5,040
5,040

5,500
5,500
5,500
5,500
5,500

29040

Application of body cast, shoulder to hips; including head, Minerva type

10,540

5,040

5,500

29044
29046
29055
29058

Application of body cast, shoulder to hips; including one thigh


Application of body cast, shoulder to hips; including both thighs
Application of body cast, shoulder to hips; shoulder spica
Application of body cast, shoulder to hips; plaster Velpeau

12,120
12,120
9,300
5,560

6,720
6,720
2,100
1,260

5,400
5,400
7,200
4,300

29065

Application of body cast, shoulder to hips; shoulder to hand (long arm)

5,680

1,680

4,000

29075

Application of body cast, shoulder to hips; elbow to finger (short arm)

5,560

1,260

4,300

Page 35 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE
29085

DESCRIPTION

Case Rate

Application of body cast, shoulder to hips; hand and lower forearm


(gauntlet)

Professional Fee

Health Care
Institution Fee

5,560

1,260

4,300

8,020
8,440
8,020
8,440
8,440
8,020
8,020

2,520
2,940
2,520
2,940
2,940
2,520
2,520

5,500
5,500
5,500
5,500
5,500
5,500
5,500

8,020

2,520

5,500

29435
29445

Application of hip spica cast; one leg


Application of hip spica cast; one and one-half spica or both legs
Application of long leg cast (thigh to toes);
Application of long leg cast (thigh to toes); walker or ambulatory type
Application of long leg cast brace
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 rigid total contact leg cast

8,020
5,680

2,520
1,680

5,500
4,000

29450

Application of clubfoot cast w/ molding or manipulation, long or short leg

5,680

1,680

4,000

18,000

8,400

9,600

20,980
18,000

10,080
8,400

10,900
9,600

Lower Extremity
Casts

29305
29325
29345
29355
29358
29365
29405
29425

29804
29815

Arthroscopy
Arthroscopy, temporomandibular joint, diagnostic, w/ or w/o synovial
biopsy
Arthroscopy, temporomandibular joint, surgical
Arthroscopy, shoulder, diagnostic, w/ or w/o synovial biopsy

29819

Arthroscopy, shoulder, surgical; w/ removal of loose body or foreign body

21,940

9,240

12,700

29820
29821
29822
29823

Arthroscopy, shoulder, surgical; synovectomy, partial


Arthroscopy, shoulder, surgical; synovectomy, complete
Arthroscopy, shoulder, surgical; debridement, limited
Arthroscopy, shoulder, surgical; debridement, extensive
Arthroscopy, shoulder, surgical; w/ lysis and resection of adhesions, w/ or
w/o manipulation

20,980
21,820
20,980
23,300

10,080
10,920
10,080
12,600

10,900
10,900
10,900
10,700

30,740

13,440

17,300
12,000

29800

29825
29826

Arthroscopy, shoulder, surgical; decompression of subacromial space w/


partial acromioplasty, w/ or w/o coracoacromial release

27,120

15,120

29830

Arthroscopy, elbow, dianostic, with or without synovial biopsy

18,000

8,400

9,600

29834

Arthroscopy, elbow, surgical; w/ removal of loose body or foreign body

21,940

9,240

12,700

29835
29836
29837
29838
29840
29843
29844
29845

Arthroscopy, elbow, surgical; synovectomy, partial


Arthroscopy, elbow, surgical; synovectomy, complete
Arthroscopy, elbow, surgical; debridement, limited
Arthroscopy, elbow, surgical; debridement, extensive
Arthroscopy, wrist, diagnostic, with or without synovial biopsy
Arthroscopy, wrist, surgical; for infection, lavage and drainage
Arthroscopy, wrist, surgical; synovectomy, partial
Arthroscopy, wrist, surgical; synovectomy, complete
Arthroscopy, wrist, surgical; excision and/or repair of triangular
fibrocartilage and/or joint debridement

20,980
21,820
20,980
23,300
12,120
21,940
20,980
21,820

10,080
10,920
10,080
12,600
6,720
9,240
10,080
10,920

10,900
10,900
10,900
10,700
5,400
12,700
10,900
10,900

23,300

12,600

10,700

29847

Arthroscopy, wrist, surgical; internal fixation for fracture or instability

23,300

12,600

10,700

29848

Arthroscopy, wrist, surgical; w/ release of transverse carpal ligament

23,300

12,600

10,700

29850

Arthroscopically aided treatment of intercondylar spine(s) and/or tuberosity


fracture(s) of the knee, w/ or w/o manipulation; w/o internal or external
fixation (includes arthroscopy)

27,120

15,120

12,000

29851

Arthroscopically aided treatment of intercondylar spine(s) and/or tuberosity


fracture(s) of the knee, w/ or w/o manipulation; w/ internal or external
fixation (includes arthroscopy)

27,120

15,120

12,000

29855

Arthroscopically aided treatment of tibial fracture, proximal (plateau);


unicondylar, w/ or w/o internal or external fixation (includes arthroscopy)

27,120

15,120

12,000

29856

Arthroscopically aided treatment of tibial fracture, proximal (plateau);


bicondylar, w/ or w/o internal or external fixation (includes arthroscopy)

27,960

15,960

12,000

29870
29871

Arthroscopy, knee, diagnostic, w/ or w/o synovial biopsy


Arthroscopy, knee, surgical; for infection, lavage and drainage

18,000
20,980

8,400
10,080

9,600
10,900

29874

Arthroscopy, knee, surgical; for removal of loose body or foreign body (e.g.,
osteochondritis dissecans fragmentation, chondral fragmentation)

21,940

9,240

12,700

30,740

13,440

17,300

31,580

14,280

17,300

29846

29875
29876

Arthroscopy, knee, surgical; synovectomy, limited (e.g., plica or shelf


resection)
Arthroscopy, knee, surgical; synovectomy, major, two or more
compartments (e.g., medial or lateral)

Page 36 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE
29877
29879
29880
29881

DESCRIPTION

Case Rate

Arthroscopy, knee, surgical; debridement/shaving of articular cartilage


(chondroplasty)
Arthroscopy, knee, surgical; abrasion arthroplasty (includes chondroplasty
where necessary) or multiple drilling
Arthroscopy, knee, surgical; w/ meniscectomy (medial AND lateral, including
any meniscal shaving)
Arthroscopy, knee, surgical; w/ meniscectomy (medial OR lateral, including
any meniscal shaving)

Professional Fee

Health Care
Institution Fee

23,300

12,600

10,700

23,300

12,600

10,700

30,740

13,440

17,300

30,740

13,440

17,300

29882

Arthroscopy, knee, surgical; w/ meniscus repair (medial OR lateral)

27,120

15,120

12,000

29883

Arthroscopy, knee, surgical; w/ meniscus repair (medial AND lateral)

30,300

16,800

13,500

29884

Arthroscopy, knee, surgical; w/ lysis of adhesions, w/ or w/o manipulation

23,300

12,600

10,700

23,300

12,600

10,700

27,120

15,120

12,000

23,300

12,600

10,700

37,180

18,480

18,700

38,860

20,160

18,700

21,940

9,240

12,700

20,980

10,080

10,900

20,980

10,080

10,900

21,820

10,920

10,900

5,560
5,560

1,260
1,260

4,300
4,300

5,680
8,020
9,700

1,680
2,520
4,200

4,000
5,500
5,500

9,700

4,200

5,500

29885
29886
29887
29888
29889
29894
29895
29897
29898

30000
30020
30100
30110
30115
30117
30118

Arthroscopy, knee, surgical; drilling for osteochondritis dissecans w/ bone


grafting, w/ or w/o internal fixation (including debridement of base of
lesion)
Arthroscopy, knee, surgical; drilling for intact osteochondritis dissecans
lesion
Arthroscopy, knee, surgical; drilling for intact osteochondritis dissecans
lesion w/ internal fixation
Arthroscopically aided anterior cruciate ligament repair/augmentation or
reconstruction
Arthroscopically aided posterior cruciate ligament repair/augmentation or
reconstruction
Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; w/ removal of
loose body or foreign body
Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; synovectomy,
partial
Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; debridement,
limited
Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; debridement,
extensive
Respiratory System
Nose
Incision
Drainage abscess or hematoma, nasal, internal approach
Drainage abscess or hematoma, nasal septum
Excision
Biopsy, intranasal
Excision, nasal polyp(s), simple
Excision, nasal polyp(s), extensive
Excision or destruction, any method (including laser), intranasal lesion;
internal approach
Excision or destruction, any method (including laser), intranasal lesion;
external approach (lateral rhinotomy)
Excision turbinate, partial or complete
Submucous resection turbinate, partial or complete
Removal of Foreign Body
Removal foreign body, intranasal; requiring general anesthesia
Removal foreign body, intranasal; by lateral rhinotomy
Rhinoplasty for nasal deformity secondary to congenital cleft tip and/or
palate, including columellar lengthening; tip only

9,700

4,200

5,500

12,900
12,900

6,300
6,300

6,600
6,600

8,020
8,020

2,520
2,520

5,500
5,500

30,300

16,800

13,500

30,300

16,800

13,500

37,800

21,000

16,800

12,900

6,300

6,600

30540
30545
30560

Rhinoplasty for nasal vestibular stenosis


Repair
Septoplasty or submucous resection, w/ or w/o cartilage scoring, contouring
or replacement w/ graft
Repair choanal atresia; intranasal
Repair choanal atresia; transpalatine
Lysis intranasal synechia

12,900
18,000
8,260

6,300
8,400
3,360

6,600
9,600
4,900

30580

Repair fistula; oromaxillary (combine w/ 31030 if antrotomy is included)

12,120

6,720

5,400

30600
30630

Repair fistula; oronasal


Repair nasal septal perforations
Destruction
Cauterization and/or ablation, mucosa of turbinates, unilateral or bilateral,
any method, ; superficial

12,120
12,120

6,720
6,720

5,400
5,400

9,700

4,200

5,500

30130
30140
30310
30320
30460
30462
30465
30520

30801

Rhinoplasty for nasal deformity secondary to congenital cleft tip and/or


palate, including columellar lengthening; tip, septum, osteotomies

Page 37 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE
30802

30905
30915
30920
30930

DESCRIPTION

Case Rate

Cauterization and/or ablation, mucosa of turbinates, unilateral or bilateral,


any method, ; intramural
Other Procedures
Control nasal hemorrhage, posterior, w/ posterior nasal packs and/or
cauterization, any method; initial
Ligation arteries; ethmoidal
Ligation arteries; internal maxillary artery, transantral
Fracture nasal turbinate(s), therapeutic
Accessory Sinuses
Incision

Professional Fee

Health Care
Institution Fee

9,700

4,200

5,500

8,020

2,520

5,500

12,120
12,120
9,700

6,720
6,720
4,200

5,400
5,400
5,500

31000

Lavage by cannulation; maxillary sinus (antrum puncture or natural ostium)

9,300

2,100

7,200

31002
31020

8,020
9,700

2,520
4,200

5,500
5,500

12,120

6,720

5,400

31084

Lavage by cannulation; sphenoid sinus


Sinusotomy, maxillary (antrotomy); intranasal
Sinusotomy, maxillary (antrotomy); radical (Caldwell-Luc) w/o removal of
antrochoanal polyps
Sinusotomy, maxillary (antrotomy); radical (Caldwell-Luc) w/ removal of
antrochoanal polyps
Pterygomaxillary fossa surgery, any approach
Sinusotomy, sphenoid, w/ or w/o biopsy;
Sinusotomy, sphenoid, w/ or w/o biopsy; w/ mucosal stripping or removal
of polyp(s)
Sinusotomy frontal; external, simple (trephine operation)
Sinusotomy frontal; transorbital, unilateral (for mucocele or osteoma, Lynch
type)
Sinusotomy frontal; obliterative w/o osteoplastic flap, brow incision
(includes ablation)
Sinusotomy frontal; obliterative, w/o osteoplastic flap, coronal inicision
(includes ablation)
Sinusotomy frontal; obliterative, w/ osteoplastic flap, brow incision

31085

31030
31032

12,120

6,720

5,400

23,300
23,300

12,600
12,600

10,700
10,700

23,300

12,600

10,700

12,120

6,720

5,400

12,120

6,720

5,400

12,120

6,720

5,400

12,120

6,720

5,400

12,120

6,720

5,400

Sinusotomy frontal; obliterative, w/ osteoplastic flap, coronal incision

23,300

12,600

10,700

31086

Sinusotomy frontal; nonobliterative, w/ osteoplastic flap, brow incision

23,300

12,600

10,700

31087

Sinusotomy frontal; nonobliterative, w/ osteoplastic flap, coronal incision

23,300

12,600

10,700

31090

Sinusotomy combined, three or more sinuses


Excision
Ethmoidectomy; intranasal, anterior
Ethmoidectomy; intranasal, total
Ethmoidectomy; extranasal, total
Maxillectomy; w/o orbital exenteration
Maxillectomy; w/ orbital exenteration (en bloc)
Endoscopy
Nasal endoscopy, diagnostic, unilateral or bilateral
Nasal/sinus endoscopy, diagnostic w/ maxillary sinusoscopy (via inferior
meatus or canine fossa puncture)
Nasal/sinus endoscopy, diagnostic w/ sphenoid sinusoscopy (via puncture of
sphenoidal face or cannulation of ostium)

23,300

12,600

10,700

12,120
12,120
12,120
46,500
53,400

6,720
6,720
6,720
25,200
29,400

5,400
5,400
5,400
21,300
24,000

10,540

5,040

5,500

10,540

5,040

5,500

10,540

5,040

5,500

31237

Nasal/sinus endoscopy, surgical; w/ biopsy, polypectomy or debridement

12,120

6,720

5,400

31238
31239
31240

Nasal/sinus endoscopy, surgical; w/ control of epistaxis


Nasal/sinus endoscopy, surgical; w/ dacrylocystorhinostomy
Nasal/sinus endoscopy, surgical; w/ concha bullosa resection

12,120
12,120
18,000

6,720
6,720
8,400

5,400
5,400
9,600

31254

Nasal/sinus endoscopy, surgical; w/ ethmoidectomy, partial (anterior)

18,000

8,400

9,600

18,000

8,400

9,600

18,000

8,400

9,600

18,000

8,400

9,600

18,000

8,400

9,600

18,000

8,400

9,600

18,000

8,400

9,600

18,000

8,400

9,600

18,000

8,400

9,600

18,000

8,400

9,600

31040
31050
31051
31070
31075
31080
31081

31200
31201
31205
31225
31230
31231
31233
31235

31255
31256
31267

31276
31287
31288
31290
31291
31292

Nasal/sinus endoscopy, surgical; w/ ethmoidectomy, total (anterior and


posterior)
Nasal/sinus endoscopy, surgical, w/ maxillary antrostomy
Nasal/sinus endoscopy, surgical, w/ maxillary antrostomy w/ removal of
tissue from maxillary sinus
Nasal/sinus endoscopy, surgical w/ frontal sinus exploration, w/ or w/o
removal of tissue from frontal sinus
Nasal/sinus endoscopy, surgical, w/ sphenoidotomy
Nasal/sinus endoscopy, surgical, w/ removal of tissure from the sphenoid
sinus
Nasal/sinus endoscopy, surgical, w/ repair of cerebrospinal fluid leak;
ethmoid region
Nasal/sinus endoscopy, surgical, sphenoid region
Nasal/sinus endoscopy, surgical; w/ medial or inferior orbital wall
decompression

Page 38 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE

DESCRIPTION

Case Rate

31360
31365
31367
31368
31370
31375
31380
31382

Nasal/sinus endoscopy, surgical; w/ medial orbital wall and inferior orbital


wall decompression
Nasal/sinus endoscopy, surgical; w/ optic nerve decompression
Larynx
Excision
Laryngotomy (thyrotomy, laryngofissure); w/ removal of tumor or
laryngocele, cordectomy
Laryngectomy; total, w/o radical neck dissection
Laryngectomy; total, w/ radical neck dissection
Laryngectomy; subtotal supraglottic, w/o radical neck dissection
Laryngectomy; subtotal supraglottic, w/ radical neck dissection
Partial laryngectomy (hemilaryngectomy); horizontal
Partial laryngectomy (hemilaryngectomy); laterovertical
Partial laryngectomy (hemilaryngectomy); anterovertical
Partial laryngectomy (hemilaryngectomy); antero-latero-vertical

31390
31395
31400
31420

31293
31294

31300

Professional Fee

Health Care
Institution Fee

18,000

8,400

9,600

23,300

12,600

10,700

18,000

8,400

9,600

31,140
37,800
37,180
38,860
31,140
31,140
31,140
31,140

17,640
21,000
18,480
20,160
17,640
17,640
17,640
17,640

13,500
16,800
18,700
18,700
13,500
13,500
13,500
13,500

Pharyngolaryngectomy, w/ radical neck dissection; w/o reconstruction

37,800

21,000

16,800

46,500
30,300
23,300

25,200
16,800
12,600

21,300
13,500
10,700

31515
31520

Pharyngolaryngectomy, w/ radical neck dissection; w/ reconstruction


Arytenoidectomy or arytenoidopexy, external approach
Epiglottidectomy
Endoscopy
Laryngoscopy direct, w/ or w/o tracheoscopy; for aspiration
Laryngoscopy direct, w/ or w/o tracheoscopy; diagnostic, newborn

8,020
9,700

2,520
4,200

5,500
5,500

31525

Laryngoscopy direct, w/ or w/o tracheoscopy; diagnostic, except newborn

8,020

2,520

5,500

31526

Laryngoscopy direct, w/ or w/o tracheoscopy; diagnostic, w/ operating


microscope

9,700

4,200

5,500

31527

Laryngoscopy direct, w/ or w/o tracheoscopy; w/ insertion of obturator

8,020

2,520

5,500

31528

Laryngoscopy direct, w/ or w/o tracheoscopy; w/ dilatation, initial

8,020

2,520

5,500

31529

Laryngoscopy direct, w/ or w/o tracheoscopy; w/ dilatation, subsequent

8,020

2,520

5,500

31530

12,120

6,720

5,400

12,120

6,720

5,400

31535

Laryngoscopy, direct, operative, w/ foreign body removal;


Laryngoscopy, direct, operative, w/ foreign body removal; w/ operating
microscope
Laryngoscopy, direct, operative, w/ biopsy;

12,120

6,720

5,400

31536

Laryngoscopy, direct, operative, w/ biopsy; w/ operating microscope

12,120

6,720

5,400

12,120

6,720

5,400

12,120

6,720

5,400

30,300

16,800

13,500

30,300

16,800

13,500

12,120

6,720

5,400

12,120

6,720

5,400

12,120
12,120
12,120
12,120
12,120

6,720
6,720
6,720
6,720
6,720

5,400
5,400
5,400
5,400
5,400

30,300

16,800

13,500

30,300

16,800

13,500

30,300
30,300
30,300

16,800
16,800
16,800

13,500
13,500
13,500

30,300

16,800

13,500

30,300

16,800

13,500

23,300

12,600

10,700

12,120
12,540
7,140
12,540

6,720
7,140
4,760
7,140

5,400
5,400
2,380
5,400

31531

31540
31541
31560
31561
31570
31571
31575
31576
31577
31578
31579
31580
31582
31584
31586
31587
31588
31590
31595

31600
31601
31603
31605

Laryngoscopy, direct, operative, w/ excision of tumor and/or stripping of


vocal cords or epiglottis;
Laryngoscopy, direct, operative, w/ excision of tumor and/or stripping of
vocal cords or epiglottis; w/ operating microscope
Laryngoscopy, direct, operative, w/ arytenoidectomy;
Laryngoscopy, direct, operative, w/ arytenoidectomy; w/ operating
microscope
Laryngoscopy, direct, w/ injection into vocal cord(s), therapeutic;
Laryngoscopy, direct, w/ injection into vocal cord(s), therapeutic; w/
operating microscope
Laryngoscopy, flexible fiberoptic; diagnostic
Laryngoscopy, flexible fiberoptic; w/ biopsy
Laryngoscopy, flexible fiberoptic; w/ removal of foreign body
Laryngoscopy, flexible fiberoptic; w/ removal of lesion
Laryngoscopy, flexible or rigid fiberoptic, w/ stroboscopy
Repair
Laryngoplasty; for laryngeal web, two stage, w/ keel insertion and removal
Laryngoplasty; for laryngeal stenosis, w/ graft or core mold, including
tracheotomy
Laryngoplasty; w/ open reduction of fracture
Laryngoplasty; w/ closed manipulative reduction
Laryngoplasty, cricoid split
Laryngoplasty, not otherwise specified (e.g., for burns, reconstruction after
partial laryngectomy)
Laryngeal reinnervation by neuromuscular pedicle
Destruction
Section recurrent laryngeal nerve, therapeutic , unilateral
Trachea and Bronchi
Incision
Tracheostomy, planned ;
Tracheostomy, planned ; under two years
Tracheostomy, emergency procedure; transtracheal
Tracheostomy, emergency procedure; cricothyroid membrane

Page 39 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE

DESCRIPTION

31610

Tracheostomy, fenestration procedure with skin flaps

12,540

7,140

Health Care
Institution Fee
5,400

31611

Construction of tracheoesophageal fistula and subsequent insertion of an


alaryngeal speech prosthesis (e.g., voice button, Blom-Singer prosthesis)

14,960

7,560

7,400

12,900

6,300

6,600

12,120
14,960

6,720
7,560

5,400
7,400

12,120

6,720

5,400

10,960

5,460

5,500

10,960

5,460

5,500

10,960

5,460

5,500

10,960

5,460

5,500

18,000

8,400

9,600

31612
31613
31614
31615
31622
31625
31628
31629
31630

Case Rate

Tracheal puncture, percutaneous w/ transtracheal aspiration and/or


injection
Tracheostoma revision; simple, w/o flap rotation
Tracheostoma revision; complex, w/ flap rotation
Endoscopy
Tracheobronchoscopy through established tracheostomy incision
Bronchoscopy; diagnostic, (flexible or rigid), w/ or w/o cell washing or
brushing
Bronchoscopy; w/ biopsy
Bronchoscopy; w/ transbronchial lung biopsy, w/ or w/o fluoroscopic
guidance
Bronchoscopy; w/ transbronchial needle aspiration biopsy
Bronchoscopy; w/ tracheal or bronchial dilation or closed reduction of
fracture

Professional Fee

31631

Bronchoscopy; w/ tracheal dilation and placement of tracheal stent

18,000

8,400

9,600

31635

Bronchoscopy; w/ removal of foreign body


Bronchoscopy; diagnostic, (flexible or rigid),w/ placement of bronchial
stents
Bronchoscopy; w/ excision of tumor
Bronchoscopy; w/ destruction of tumor or relief of stenosis by any method
other than excision (e.g., laser)
Bronchoscopy; w/ placement of catheters for intracavitary radioelement
application

18,000

8,400

9,600

31636
31640
31641
31643

31645

Bronchoscopy; w/ therapeutic aspiration of tracheobronchial tree, (e.g.,


drainage of lung abscess)

18,000

8,400

9,600

30,300

16,800

13,500

30,300

16,800

13,500

18,000

8,400

9,600

23,300

12,600

10,700

5,560

1,260

4,300

23,300

12,600

10,700

37,800
37,800
53,400
55,000
55,000
55,000
46,500
53,400
37,800
55,000
23,300
37,800
8,440
9,700

21,000
21,000
29,400
33,600
33,600
33,600
25,200
29,400
21,000
33,600
12,600
21,000
2,940
4,200

16,800
16,800
24,000
21,400
21,400
21,400
21,300
24,000
16,800
21,400
10,700
16,800
5,500
5,500

1,260

840

420

10,540

5,040

5,500

10,540

5,040

5,500

7,980

5,320

2,660

12,120
18,420
31,140
37,800

6,720
8,820
17,640
21,000

5,400
9,600
13,500
16,800

37,800

21,000

16,800

37,800
37,800

21,000
21,000

16,800
16,800

32120
32124

Introduction
Catheterization for bronchography, w/ or w/o instillation of contrast
material
Catheterization w/ bronchial brush biopsy
Repair
Tracheoplasty; cervical
Tracheoplasty; tracheopharyngeal fistulization, each stage
Tracheoplasty; intrathoracic
Carinal reconstruction
Bronchoplasty; graft repair
Bronchoplasty; excision stenosis and anastomosis
Excision tracheal stenosis and anastomosis; cervical
Excision tracheal stenosis and anastomosis; cervicothoracic
Excision of tracheal tumor or carcinoma; cervical
Excision of tracheal tumor or carcinoma; thoracic
Suture of tracheal wound or injury; cervical
Suture of tracheal wound or injury; intrathoracic
Surgical closure tracheostomy or fistula w/o plastic repair
Surgical closure tracheostomy or fistula with plastic repair
Lungs and Pleura
Incision
Thoracentesis, puncture of pleural cavity for aspiration, initial or
subsequent
Thoracentesis w/ insertion of tube w/ or w/o water seal (e.g., for
pneumothorax)
Chemical pleurodesis (e.g., for recurrent or persistent pneumothorax)
Tube thoracostomy w/ or w/o water seal (e.g., for abscess, hemothorax,
empyema)
Thoracostomy; w/ rib resection for empyema
Thoracostomy; w/ open flap drainage for empyema
Thoracotomy, limited, for biopsy of lung or pleura
Thoracotomy, major; w/ exploration and biopsy
Thoracotomy, major; w/ control of traumatic hemorrhage and/or repair of
lung tear
Thoracotomy, major; for postoperative complications
Thoracotomy, major; w/ open intrapleural pneumonolysis

32140

Thoracotomy, major; w/ cyst(s) removal, w/ or w/o a pleural procedure

37,800

21,000

16,800

32141

Thoracotomy, major; w/ excision-plication of bullae, w/ or w/o a pleural


procedure

41,160

24,360

16,800

31710
31717
31750
31755
31760
31766
31770
31775
31780
31781
31785
31786
31800
31805
31820
31825

32000
32002
32005
32020
32035
32036
32095
32100
32110

Page 40 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE
32150
32151
32160
32200
32215
32220
32225
32310
32320
32400
32402
32405
32420
32440

DESCRIPTION

Case Rate

Thoracotomy, major; w/ removal of intrapleural foreign body or fibrin


deposit
Thoracotomy, major; w/ removal of intrapulmonary foreign body
Thoracotomy major; w/ cardiac massage
Pneumonostomy, w/ open drainage of abscess or cyst
Pleural scarification for repeat pneumothorax
Decortication, pulmonary ; total
Decortication, pulmonary ; partial
Excision
Pleurectomy, parietal
Decortication and parietal pleurectomy
Biopsy, pleura; percutaneous needle
Biopsy, pleura; open
Biopsy, lung or mediastinum, percutaneous needle
Pneumonocentesis, puncture of lung for aspiration
Removal of lung, total pneumonectomy

Professional Fee

Health Care
Institution Fee

38,440

19,740

18,700

38,440
38,440
10,120
38,640
38,440
30,300

19,740
19,740
4,620
21,840
19,740
16,800

18,700
18,700
5,500
16,800
18,700
13,500

37,800
37,800
5,560
37,180
8,440
5,560
46,500

21,000
21,000
1,260
18,480
2,940
1,260
25,200

16,800
16,800
4,300
18,700
5,500
4,300
21,300

32442

Removal of lung, total pneumonectomy w/ resection of segment of trachea


followed by broncho-tracheal anastomosis (sleeve pneumonectomy)

55,080

31,080

24,000

32445

Removal of lung, total pneumonectomy extrapleural

55,080

31,080

24,000

32480

Removal of lung, other than total pneumonectomy; single lobe (lobectomy)

41,160

24,360

16,800

46,500

25,200

21,300

46,500

25,200

21,300

55,080

31,080

24,000

53,400

29,400

24,000

41,160

24,360

16,800

40,320

23,520

16,800

53,400
53,400

29,400
29,400

24,000
24,000

32482
32484
32486

32488

32491

Removal of lung, other than total pneumonectomy; two lobes


(bilobectomy)
Removal of lung, other than total pneumonectomy; single segment
(segmentectomy)
Removal of lung, other than total pneumonectomy; w/ circumferential
resection of segment of bronchus followed by broncho-bronchial
anastomosis (sleeve lobectomy)
Removal of lung, other than total pneumonectomy; all remaining lung
following previous removal of a portion of lung (completion
pneumonectomy)
Removal of lung, other than total pneumonectomy; excision-plication of
emphysematous lung(s) (bullous or non-bullous) for lung volume reduction,
sternal split or transthoracic approach, w/ or w/o any pleural procedure

32520
32522

Removal of lung, other than total pneumonectomy; wedge resection, single


or multiple
Resection of lung; w/ resection of chest wall
Resection of lung; w/ reconstruction of chest wall, w/o prothesis

32525

Resection of lung; w/ major reconstruction of chest wall, w/ prosthesis

53,400

29,400

24,000

32540

38,440

19,740

18,700

11,980
12,900
12,120
12,120
12,120
12,120
12,120
12,120

5,880
6,300
6,720
6,720
6,720
6,720
6,720
6,720

6,100
6,600
5,400
5,400
5,400
5,400
5,400
5,400

12,120

6,720

5,400

32660

Extrapleural enucleation of empyema (empyemectomy)


Endoscopy
Thoracoscopy, diagnostic ; lungs and pleural space, w/o biopsy
Thoracoscopy, diagnostic ; lungs and pleural space, w/ biopsy
Thoracoscopy, diagnostic ; pericardial sac, w/o biopsy
Thoracoscopy, diagnostic ; pericardial sac, w/ biopsy
Thoracoscopy, diagnostic ; mediastinal space, w/o biopsy
Thoracoscopy, diagnostic ; mediastinal space, w/ biopsy
Thoracoscopy, surgical; w/ pleurodesis, any method
Thoracoscopy, surgical; w/ partial pulmonary decortication
Thoracoscopy, surgical; w/ total pulmonary decortication, including
intrapleural pneumonolysis
Thoracoscopy, surgical; w/ removal of intrapleural foreign body or firbin
deposit
Thoracoscopy, surgical; w/ control of traumatic hemorrhage
Thoracoscopy, surgical; w/ excision-plication of bullae, including any pleural
procedure
Thoracoscopy, surgical; w/ parietal pleurectomy
Thoracoscopy, surgical; w/ removal of clot or foreign body from pericardial
sac
Thoracoscopy, surgical; w/ creation of percardial window or partial
resection of pericardial sac for drainage
Thoracoscopy, surgical; w/ total pericardiectomy

32661

32500

32601
32602
32603
32604
32605
32606
32650
32651
32652
32653

12,120

6,720

5,400

30,300

16,800

13,500

41,160

24,360

16,800

38,640

21,840

16,800

38,640

21,840

16,800

38,640

21,840

16,800

41,160

24,360

16,800

Thoracoscopy, surgical; w/ excision of pericardial cyst, tumor, or mass

41,160

24,360

16,800

32662

Thoracoscopy, surgical; w/ excision of mediastinal cyst, tumor, or mass

41,160

24,360

16,800

32663
32664
32665

Thoracoscopy, surgical; w/ lobectomy, total or segmental


Thoracoscopy, surgical; w/ thoracic sympathectomy
Thoracoscopy, surgical; w/ esophagomyotomy (Heller type)
Repair
Repair lung hernia through chest wall

46,500
41,160
41,160

25,200
24,360
24,360

21,300
16,800
16,800

23,300

12,600

10,700

32654
32655
32656
32658
32659

32800

Page 41 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE
32810
32815
32820
32850
32851
32852
32853
32854
32900
32905
32906

DESCRIPTION

Case Rate

Closure of chest wall following open flap drainage for empyema (Clagett
type procedure)
Open closure of major bronchial fistula
Major reconstruction, chest wall (posttraumatic)
Lung Transplant
Donor pneumonectomy(ies) w/ preparation and maintenance of allograft
(cadaver)
Lung transplant, single; w/o cardiopulmonary bypass
Lung transplant, single; w/ cardiopulmonary bypass
Lung transplant, double (bilateral sequential or en bloc); w/o
cardiopulmonary bypass
Lung transplant, double (bilateral sequential or en bloc); w/
cardiopulmonary bypass
Surgical Relapse Therapy; Thoracoplasty
Resection of ribs, extrapleural, all stages
Thoracoplasty, Schede type or extrapleural (all stages);
Thoracoplasty, Schede type or extrapleural (all stages); w/ closure of
bronchial fistula

Professional Fee

Health Care
Institution Fee

23,300

12,600

10,700

46,500
46,500

25,200
25,200

21,300
21,300

55,000

33,600

21,400

63,000
64,680

42,000
43,680

21,000
21,000

65,520

44,520

21,000

65,520

44,520

21,000

46,500
46,500

25,200
25,200

21,300
21,300

46,500

25,200

21,300

30,300

16,800

13,500

5,560

1,260

4,300

8,020
9,700

2,520
4,200

5,500
5,500

32940

Pneumonolysis, extraperiosteal, including filling or packing procedures

32960

33010
33015

Pneumothorax, therapeutic, intrapleural injection of air


Cardiovascular System
Heart and Pericardium
Pericardium
Pericardiocentesis
Tube pericardiostomy

33020

Pericardiotomy for removal of clot or foreign body (primary procedure)

18,000

8,400

9,600

33025
33030
33031
33050

Creation of pericardial window or partial resection for drainage


Pericardiectomy, subtotal or complete; w/o cardiopulmonary bypass
Pericardiectomy, subtotal or complete; w/ cardiopulmonary bypass
Excision of pericardial cyst or tumor
Cardiac Tumor
Excision of intracardiac tumor, resection w/ cardiopulmonary bypass
Resection of external cardiac tumor
Pacemaker or Defibrillator
Insertion of permanent pacemaker w/ epicardial electrode(s); by
thoracotomy
Insertion of permanent pacemaker w/ epicardial electrode(s); by xiphoid
approach
Insertion or replacement of permanent pacemaker w/ transvenous
electrode(s); atrial
Insertion or replacement of permanent pacemaker w/ transvenous
electrode(s); ventricular
Insertion or replacement of permanent pacemaker w/ transvenous
electrode(s); atrial and ventricular
Insertion or placement of temporary transvenous single chamber cardiac
electrodes
Insertion or replacement of temporary transvenous dual chamber cardiac
electrodes
Insertion or replacement of pacemaker pulse generator only; single
chamber

32,000
46,500
58,800
37,800

14,700
25,200
37,800
21,000

17,300
21,300
21,000
16,800

60,900
39,900

39,900
23,100

21,000
16,800

21,400

10,500

10,900

21,400

10,500

10,900

18,000

8,400

9,600

18,000

8,400

9,600

21,400

10,500

10,900

9,700

4,200

5,500

9,700

4,200

5,500

9,700

4,200

5,500

Insertion or replacement of pacemaker pulse generator only; dual chamber

12,900

6,300

6,600

32,000

14,700

17,300

12,900

6,300

6,600

33120
33130
33200
33201
33206
33207
33208
33210
33211
33212
33213

33214

33216

Upgrade of implanted pacemaker system, conversion of single chamber


system to dual chamber system (includes removal of previously placed
pulse generator, testing of existing lead, insertion of new lead, insertion of
new pulse generator)
Insertion, replacement or repositioning of permanent transvenous
electrode(s) only (15 days or more after initial insertion); single chamber,
atrial or ventricular

33217

Insertion, replacement or repositioning of permanent transvenous


electrode(s) only (15 days or more after initial insertion); dual chamber

18,000

8,400

9,600

33218

Repair of single transvenous electrode for a single chamber, permanent


pacemaker or single chamber pacing cardioverter-defibrillator

23,300

12,600

10,700

33220

Repair of two transvenous electrode for a dual chamber, permanent


pacemaker or dual chamber pacing cardioverter-defibrillator

23,300

12,600

10,700

18,000

8,400

9,600

18,000

8,400

9,600

33222
33223

Revision or relocation of skin pocket for pacemaker


Revision or relocation of skin pocket for single or dual chamber pacing
cardioverter-defibrillator

Page 42 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE
33233
33234
33235
33236
33237
33238
33240
33241
33243
33244
33245
33246

33249

DESCRIPTION
Removal of transvenous pacemaker pulse generator
Removal of permanent of transvenous pacemaker electrode(s); single lead
system, atrial or ventricular
Removal of permanent of transvenous pacemaker electrode(s); dual lead
chamber
Removal of permanent epicardial pacemaker and electrodes by
thoracotomy; single lead system, atrial or ventricular
Removal of permanent epicardial pacemaker and electrodes by
thoracotomy; dual lead chamber
Removal of permanent transvenous electrode(s) by thoracotomy
Insertion or replacement of implantable cardioverter-defibrillator pulse
generator

12,900

6,300

Health Care
Institution Fee
6,600

23,300

12,600

10,700

32,000

14,700

17,300

30,300

16,800

13,500

37,600

18,900

18,700

30,300

16,800

13,500

18,000

8,400

9,600

Removal of implantable cardioverter-defibrillator pulse generator

18,000

8,400

9,600

30,300

16,800

13,500

30,300

16,800

13,500

12,900

6,300

6,600

21,400

10,500

10,900

18,000

8,400

9,600

Case Rate

Removal of implantable cardioverter-defibrillator pulse generator and/or


lead system; by thoracotomy
Removal of implantable cardioverter-defibrillator pulse generator and/or
lead system; by transvenous extraction
Implantation or replacement of implantable cardioverter-defibrillator pads
by thoracotomy, w/ or w/o sensing electrodes;
Implantation or replacement of implantable cardioverter-defibrillator pads
by thoracotomy, w/ or w/o sensing electrodes; w/ insertion of implantable
cardioverter-defibrillator pulse generator
Implantation or replacement of implantable cardioverter-defibrillator pads
by thoracotomy, w/ or w/o sensing electrodes; w/ insertion of cardiodefibrillator pulse generator

Professional Fee

33250

Operative ablation of supraventicular arrhythmogenic focus or pathway


(e.g., Wolff-Parkinson-White, A-V node reentry), tract(s) and/or focus (foci);
w/o cardiopulmonary bypass

37,600

18,900

18,700

33251

Operative ablation of supraventicular arrhythmogenic focus or pathway


(e.g., Wolff-Parkinson-White, A-V node reentry), tract(s) and/or focus (foci);
w/ cardiopulmonary bypass

53,400

29,400

24,000

58,800

37,800

21,000

58,800

37,800

21,000

46,500
58,800

25,200
37,800

21,300
21,000

46,500

25,200

21,300

58,800

37,800

21,000

30,300

16,800

13,500

58,800
58,800

37,800
37,800

21,000
21,000

46,500

25,200

21,300

63,000
63,000

42,000
42,000

21,000
21,000

53,400
53,400

29,400
29,400

24,000
24,000

55,000

33,600

21,400

58,800

37,800

21,000

53,400

29,400

24,000

58,800

37,800

21,000

55,000

33,600

21,400

58,800

37,800

21,000

33300
33305

Operative incisions and reconstruction of atria for treatment of atrial


fibrillation or atrial flutter (e.g., maze procedure)
Operative ablation of ventricular arrhythmogenic focus w/ cardiopulmonary
bypass
Wounds of the Heart and Great Vessels
Repair of cardiac wound; w/o bypass
Repair of cardiac wound; w/ cardiopulmonary bypass

33310

Cardiotomy, exploratory (includes removal of foreign body); w/o bypass

33253
33261

33315
33320
33321
33322
33330
33332
33335
33400
33401
33403
33404
33405
33406
33411
33412

Cardiotomy, exploratory (includes removal of foreign body); w/


cardiopulmonary bypass
Suture repair of aorta or great vessels; w/o shunt or cardiopulmonary
bypass
Suture repair of aorta or great vessels; w/ shunt bypass
Suture repair of aorta or great vessels; w/ cardiopulmonary bypass
Insertion of graft, aorta or great vessels; w/o shunt, or cardiopulmonary
bypass
Insertion of graft, aorta or great vessels; w/ shunt bypass
Insertion of graft, aorta or great vessels; w/ cardiopulmonary bypass
Aortic Valve
Valvuloplasty, aortic valve; open, w/ cardiopulmonary bypass
Valvuloplasty, aortic valve; open, w/ inflow occlusion
Valvuloplasty, aortic valve; using transventricular dilation, w/
cardiopulmonary bypass
Construction of apica-aortic conduit
Replacement, aortic valve, w/ cardiopulmonary bypass; w/ prosthetic valve
other than homograft
Replacement, aortic valve, w/ cardiopulmonary bypass; w/ homograft valve
(freehand)
Replacement, aortic valve; w/ aortic annulus enlargement, noncoronary
cusp
Replacement, aortic valve; w/ transventricular aortic annulus enlargement
(Konno procedure)

Page 43 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE
33413
33414

33415

DESCRIPTION

Case Rate

Replacement, aortic valve; w/ translocation of autologous pulmonary valve


w/ hemograft repacement of pulmonary valve (Ross procedure)
Repair of left ventricular outflow tract obstruction by patch enlargement of
the outflow tract
Resection or incision of subvalvular tissue for discrete subaortic stenosis
(e.g., asymmetric septal hypertrophy)

33420
33422
33425

Ventriculomyotomy (-myectomy) for idiopathic hypertrophic subaortic


stenosis (e.g., asymmetric septal hypertrophy)
Aortoplasty (gusset) for supravalvular stenosis
Mitral Valve
Valvotomy, mitral valve; closed heart
Valvotomy, mitral valve; open heart, w/ cardiopulmonary bypass
Valvuloplasty, mitral valve, w/ cardiopulmonary bypass;

33426

Valvuloplasty, mitral valve, w/ cardiopulmonary bypass; w/ prosthetic ring

33416
33417

Professional Fee

Health Care
Institution Fee

71,400

50,400

21,000

46,500

25,200

21,300

46,500

25,200

21,300

55,000

33,600

21,400

46,500

25,200

21,300

37,800
53,400
55,000

21,000
29,400
33,600

16,800
24,000
21,400

57,100

35,700

21,400

58,800

37,800

21,000

46,500

25,200

21,300

46,500
53,400
55,000
53,400
58,800

25,200
29,400
33,600
29,400
37,800

21,300
24,000
21,400
24,000
21,000

30,300
23,300
46,500
46,500
53,400

16,800
12,600
25,200
25,200
29,400

13,500
10,700
21,300
21,300
24,000

46,500

25,200

21,300

53,400

29,400

24,000

46,500

25,200

21,300

30,300

16,800

13,500

33502

Valvuloplasty, mitral valve, w/ cardiopulmonary bypass; radical


reconstruction, w/ or w/o ring
Replacement, mitral valve, w/ cardiopulmonary bypass
Tricuspid Valve
Valvectomy, tricuspid valve, w/ cardiopulmonary bypass
Valvuloplasty, tricuspid valve; w/o ring insertion
Valvuloplasty, tricuspid valve; w/ ring insertion
Replacement, tricuspid valve, w/ cardiopulmonary bypass
Tricuspid valve repositioning and plication for Ebstein anomaly
Pulmonary Valve
Valvotomy, pulmonary valve, closed heart; transventricular
Valvotomy, pulmonary valve, closed heart; via pulmonary artery
Valvotomy, pulmonary valve, open heart; w/ inflow occlusion
Valvotomy, pulmonary valve, open heart; w/ cardiopulmonary bypass
Replacement, pulmonary valve
Right ventricular resection for infundibular stenosis, with or without
commisurotomy
Outflow tract augmentation (gusset), w/ or w/o commissurotomy or
infundibular resection
Coronary Artery Anomalies
Repair of coronary arteriovenous or arteriocardiac chamber fistula; w/
cardiopulmonary bypass
Repair of coronary arteriovenous or arteriocardiac chamber fistula; w/o
cardiopulmonary bypass
Repair of anomalous coronary artery; by ligation

30,300

16,800

13,500

33503

Repair of anomalous coronary artery; by graft, w/o cardiopulmonary bypass

46,500

25,200

21,300

33504

Repair of anomalous coronary artery; by graft, w/ cardiopulmonary bypass

53,400

29,400

24,000

53,400

29,400

24,000

53,400

29,400

24,000

53,400
53,400
55,000
58,800
58,800
58,800

29,400
29,400
33,600
37,800
37,800
37,800

24,000
24,000
21,400
21,000
21,000
21,000

53,400

29,400

24,000

33427
33430
33460
33463
33464
33465
33468
33470
33471
33472
33474
33475
33476
33478

33500
33501

33505
33506
33510
33511
33512
33513
33514
33516
33517

Repair of anomalous coronary artery; with construction of intrapulmonary


artery tunnel (Takeuchi procedure)
Repair of anomalous coronary artery; by translocation from pulmonary
artery to aorta
Venous Grafting Only for Coronary Artery Bypass
Coronary artery bypass, vein only; single coronary venous graft
Coronary artery bypass, vein only; two coronary venous grafts
Coronary artery bypass, vein only; three coronary venous grafts
Coronary artery bypass, vein only; four coronary venous grafts
Coronary artery bypass, vein only; five coronary venous grafts
Coronary artery bypass, vein only; six or more coronary venous grafts
Combined Arterial-Venous Grafting for Coronary Bypass
Coronary artery bypass, using venous graft(s) and arterial graft(s); single
vein graft (list separately in addition to code for arterial graft)

33518

Coronary artery bypass, using venous graft(s) and arterial graft(s); two
venous grafts (list separately in addition to code for arterial graft)

53,400

29,400

24,000

33519

Coronary artery bypass, using venous graft(s) and arterial graft(s); three
venous grafts (list separately in addition to code for arterial graft)

55,000

33,600

21,400

33521

Coronary artery bypass, using venous graft(s) and arterial graft(s); four
venous grafts (list separately in addition to code for arterial graft)

58,800

37,800

21,000

33522

Coronary artery bypass, using venous graft(s) and arterial graft(s); five
venous grafts (list separately in addition to code for arterial graft)

58,800

37,800

21,000

Page 44 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE
33523

33530

DESCRIPTION

Case Rate

Coronary artery bypass, using venous graft(s) and arterial graft(s); six or
more venous grafts (list separately in addition to code for arterial graft)
Reoperation, coronary artery bypass procedure or valve procedure, more
than one month after original operation (list separately in addition to code
for primary procedure)
Arterial Grafting for Coronary Artery Bypass

Professional Fee

Health Care
Institution Fee

58,800

37,800

21,000

63,000

42,000

21,000

33533

Coronary artery bypass, using arterial graft(s); single arterial graft

53,400

29,400

24,000

33534

Coronary artery bypass, using arterial graft(s); two coronary arterial grafts

53,400

29,400

24,000

33535

Coronary artery bypass, using arterial graft(s); three coronary arterial grafts

55,000

33,600

21,400

58,800

37,800

21,000

63,000

42,000

21,000

63,000

42,000

21,000

9,700

4,200

5,500

33536
33542
33545

33572

Coronary artery bypass, using arterial graft(s); four or more coronary


arterial grafts
Myocardial resection (e.g., ventricular aneurysmectomy)
Repair of postinfarction ventricular septal defect, w/ or w/o myocardial
resection
Coronary Endarterectomy
Coronary endarterectomy, open, any method, of left anterior descending,
circumflex, or right coronary artery performed in conjuction w/ coronary
artery bypass graft procedure, each vessel (list separately in addition to
primary procedure)
Single Ventricle and Other Complex Cardiac Anomalies

33600

Closure of atrioventricular valve (mitral or tricuspid) by suture or patch

46,500

25,200

21,300

33602

Closure of semilunar valve (aortic or pulmonary) by suture or patch

46,500

25,200

21,300

33606

Anastomosis of pulmonary artery to aorta (Damus-Kaye-Stansel procedure)

53,400

29,400

24,000

33608

Repair of complex cardiac anomaly other than pulmonary atresia with


ventricular septal defect by construction or replacemnet of conduit from
right or left ventricle to pulmonary artery

55,000

33,600

21,400

33610

Repair of complex cardiac anomalies (e.g., single ventricle with subaortic


obstruction) by surgical enlargement of interventricular septal defect

55,000

33,600

21,400

33611

Repair of double outlet right ventricle with intraventricular tunnel repair

55,000

33,600

21,400

33612

Repair of double outlet right ventricle with intraventricular tunnel repair


with repair of right ventricular outflow tract obstruction

55,000

33,600

21,400

55,000

33,600

21,400

55,000

33,600

21,400

63,000

42,000

21,000

46,500

25,200

21,300

53,400

29,400

24,000

55,000

33,600

21,400

55,000

33,600

21,400

55,000

33,600

21,400

58,800
46,500

37,800
25,200

21,000
21,300

55,000

33,600

21,400

55,000

33,600

21,400

21,400
55,000

10,500
33,600

10,900
21,400

33615
33617

33619

33641
33645
33647
33660
33665
33670
33681
33684
33688
33690
33692

Repair of complex cardiac anomalies (e.g., tricuspid atresia) by closure of


atrial septal defect and anastomosis of atria or vena cava to pulmonary
artery (simple Fontan procedure)
Repair of complex cardiac anomalies (e.g., single ventricle) by modified
Fontan procedure
Repair of single ventricle w/ aortic outflow obstruction and aortic arch
hypoplasia (hypoplastic left heart syndrome) (e.g., Norwood procedure)
Septal Defect
Repair atrial septal defect, secundum, w/ cardiopulmonary bypass, w/ or
w/o patch
Direct or patch closure, sinus venosus, w/ or w/o anomalous pulmonary
venous drainage
Repair of atrial septal defect and ventricular septal defect, w/ direct or
patch closure
Repair of incomplete or partial atrioventricular canal (ostium primum atrial
septal defect), w/ or w/o atrioventricular valve repair
Repair of intermediate or transitional atrioventricular canal, w/ or w/o
atrioventricular valve repair
Repair of complete atrioventricular canal, w/ or w/o prosthetic valve
Closure of ventricular septal defect, w/ or w/o patch;
Closure of ventricular septal defect, w/ or w/o patch; with pulmonary
valvotomy or infundibular resection (acyanotic)
Closure of ventricular septal defect, w/ or w/o patch; with removal of
pulmonary artery band, w/ or w/o gusset
Banding of pulmonary artery
Complete repair of tetralogy of Fallot w/o pulmonary atresia;

Page 45 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE
33694
33697

33702
33710

DESCRIPTION

Case Rate

Complete repair of tetralogy of Fallot w/o pulmonary atresia; with


transannular patch
Complete repair of tetralogy of Fallot w/ pulmonary atresia including
construction of conduit right ventricle to pulmonary artery and closure of
ventricular septal defect
Sinus of Valsalva
Repair sinus of Valsalva fistula, w/ cardiopulmonary bypass
Repair sinus of Valsalva fistula, w/ cardiopulmonary bypass with repair of
ventricular septal defect

Professional Fee

Health Care
Institution Fee

55,000

33,600

21,400

55,000

33,600

21,400

46,500

25,200

21,300

55,000

33,600

21,400

33720

Repair sinus of Valsalva aneurysm, with cardiopulmonary bypass

53,400

29,400

24,000

33722

Closure of aortico-left ventricular tunnel


Total Anomalous Pulmonary Venous Drainage
Complete repair of anomalous venous return (supracardiac, intracardiac, or
infracardiac types)
Repair of cor triatum or supravalvular mitra ring by resection of left atrial
membrane
Shunting Procedures
Atrial septectomy or septostomy; closed heart (Blalock-Hanlon type
operation)

53,400

29,400

24,000

55,000

33,600

21,400

55,000

33,600

21,400

21,400

10,500

10,900

33736

Atrial septectomy or septostomy; open heart w/ cardiopulmonary bypass

46,500

25,200

21,300

33737

Atrial septectomy or septostomy; open heart w/ inflow occlusion

46,500

25,200

21,300

33750

Shunt; subclavian to pulmonary artery (Blalock- Taussig type operation)

30,300

16,800

13,500

33764

Shunt; central, w/ prosthetic graft


Shunt; superior vena cava to pulmonary artery for flow to one lung (classical
Glenn procedure)
Shunt; superior vena cava to pulmonary artery for flow to both lungs
(bidirectional Glenn procedure)
Transposition of Great Vessels
Repair of transposition of great arteries w/ ventricular septal defect and
subpulmonary stenosis; w/o surgical enlargement of ventricular septal
defect
Repair of transposition of great arteries w/ ventricular septal defect and
subpulmonary stenosis; with surgical enlagement of ventricular septal
defect

23,300

12,600

10,700

30,300

16,800

13,500

46,500

25,200

21,300

58,800

37,800

21,000

58,800

37,800

21,000

33730
33732

33735

33766
33767

33770

33771

33774

Repair of transposition of the great arteries, atrial baffle procedure (e.g.,


Mustard or Senning type) w/ cardiopulmonary bypass

58,800

37,800

21,000

33775

Repair of transposition of the great arteries, atrial baffle procedure (e.g.,


Mustard or Senning type) w/ removal of pulmonary band

60,900

39,900

21,000

33776

Repair of transposition of the great arteries, atrial baffle procedure (e.g.,


Mustard or Senning type) w/ closure of ventricular septal defect

60,900

39,900

21,000

33777

Repair of transposition of the great arteries, atrial baffle procedure (e.g.,


Mustard or Senning type) w/ repair of subpulmonic obstruction

60,900

39,900

21,000

33778

Repair of transposition of the great arteries, aortic pulmonary artery


reconstruction (e.g., Jatene type)

63,000

42,000

21,000

33779

Repair of transposition of the great arteries, aortic pulmonary artery


reconstruction (e.g., Jatene type) w/ removal of pulmonary band

65,100

44,100

21,000

33780

Repair of transposition of the great arteries, aortic pulmonary artery


reconstruction (e.g., Jatene type) w/ closure of ventricular septal defect

71,400

50,400

21,000

33781

Repair of transposition of the great arteries, aortic pulmonary artery


reconstruction (e.g., Jatene type) w/ repair of subpulmonic obstruction

71,400

50,400

21,000

58,800
55,000

37,800
33,600

21,000
21,400

21,400

10,500

10,900

21,400
23,300

10,500
12,600

10,900
10,700

33802
33803

Truncus Arteriosus
Total repair, truncus arteriosus (Rastelli type operation)
Reimplantation of an anomalous pulmonary artery
Aortic Anomalies
Aortic suspension (aortopexy) for tracheal decompression (e.g., for
tracheomalacia)
Division of aberrant vessel (vascular ring)
Division of aberrant vessel (vascular ring) w/ reanastomosis

33814

Division of aberrant vessel (vascular ring) w/ cardiopulmonary bypass

46,500

25,200

21,300

33820
33822

Repair of patent ductus arteriosus; by ligation


Repair of patent ductus arteriosus; by division, under 18 years

32,000
30,300

14,700
16,800

17,300
13,500

33786
33788
33800

Page 46 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE

DESCRIPTION
Repair of patent ductus arteriosus; by division, 18 years and older
Excision of coarctation of aorta, w/ or w/o associated patent ductus
arteriosus; w/ direct anastomosis
Excision of coarctation of aorta, w/ or w/o associated patent ductus
arteriosus; with graft
Excision of coarctation of aorta, w/ or w/o associated patent ductus
arteriosus; repair using either left subclavian artery or prosthetic material as
gusset for enlargement
Repair of hypoplastic or interrupted aortic arch using autogenous or
prosthetic material; w/o cardiopulmonary bypass
Repair of hypoplastic or interrupted aortic arch using autogenous or
prosthetic material; w/ cardiopulmonary bypass
Thoracic Aortic Aneurysm
Ascending aorta graft, w/ cardiopulmonary bypass, w/ or w/o valve
suspension;
Ascending aorta graft, w/ cardiopulmonary bypass, w/ or w/o valve
suspension; w/ coronary reconstruction
Ascending aorta graft, w/ cardiopulmonary bypass, w/ or w/o valve
suspension; w/ aortic root replacement using composite prosthesis and
coronary reconstruction
Transverse arch graft, w/ cardiopulmonary bypass
Descending thoracic aorta graft, w/ or w/o bypass
Repair of thoracoabdominal aortic aneurysm w/ graft, w/ or w/o
cardiopulmonary bypass
Pulmonary Artery
Pulmonary artery embolectomy; w/ cardiopulmonary bypass
Pulmonary artery embolectomy; w/o cardiopulmonary bypass
Pulmonary endarterectomy, w/ or w/o embolectomy, w/ cardiopulmonary
bypass

30,300

16,800

Health Care
Institution Fee
13,500

30,300

16,800

13,500

30,300

16,800

13,500

30,300

16,800

13,500

30,300

16,800

13,500

46,500

25,200

21,300

55,000

33,600

21,400

58,800

37,800

21,000

71,400

50,400

21,000

71,400
63,000

50,400
42,000

21,000
21,000

71,400

50,400

21,000

46,500
30,300

25,200
16,800

21,300
13,500

53,400

29,400

24,000

33917

Repair of pulmonary artery stenosis by reconstruction w/ patch or graft

53,400

29,400

24,000

33918

Repair of pulmonary atresia w/ ventricular septal defect, by unifocalization


of pulmonary arteries; w/o cardiopulmonary bypass

30,300

16,800

13,500

33919

Repair of pulmonary atresia w/ ventricular septal defect, by unifocalization


of pulmonary arteries; w/ cardiopulmonary bypass

46,500

25,200

21,300

33920

Repair of pulmonary atresia w/ ventricular septal defect, by construction or


replacement of conduit from right or left ventricle to pulmonary artery

58,800

37,800

21,000

46,500

25,200

21,300

18,000

8,400

9,600

46,500

25,200

21,300

33935

Transection of pulmonary artery w/ cardiopulmonary bypass


Ligation and takedown of a systemic-to-pulmonary artery shunt, performed
in conjuction w/ a congenital heart procedure (List separately in addition to
code for primary procedure)
Heart/Lung Transplantation
Donor cardiectomy-pneumonectomy, w/ preparation and maintenance of
allograft
Heart-lung transplant w/ recipient cardiectomy-pneumonectomy

75,600

54,600

21,000

33940

Donor cardiectomy, w/ preparation and maintenance of allograft

46,500

25,200

21,300

33945

Heart transplant, w/ or w/o recipient cardiectomy


Cardiac Assist
Insertion of intra-aortic balloon assist device through the femoral artery,
open approach
Removal of intra-aortic balloon assist device including repair of femoral
artery w/ or w/o graft

75,600

54,600

21,000

12,900

6,300

6,600

9,700

4,200

5,500

33973

Insertion of intra-aortic balloon assist device through the ascending aorta

21,400

10,500

10,900

33974

Removal of intra-aortic balloon assist device from the ascending aorta,


including repair of the ascending aorta, w/ or w/o graft

30,300

16,800

13,500

33975

Implantation of ventricular assist device; single ventricle support

46,500

25,200

21,300

33976
33977
33978

Implantation of ventricular assist device; biventricular support


Removal of ventricular assist device; single ventricle support
Removal of ventricular assist device; biventricular support
Arteries and Veins
Embolectomy/Thrombectomy, Arterial, with or Without Catheter
Embolectomy or thrombectomy, w/ or w/o catheter; carotid, subclavian or
innominate artery, by neck incision
Embolectomy or thrombectomy, w/ or w/o catheter; innominate,
subclavian artery, by thoracic incision

55,000
37,800
46,500

33,600
21,000
25,200

21,400
16,800
21,300

32,000

14,700

17,300

32,000

14,700

17,300

33824
33840
33845
33851
33852
33853

33860
33861
33863
33870
33875
33877
33910
33915
33916

33922
33924

33930

33970
33971

34001
34051

Case Rate

Page 47 of 113

Professional Fee

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE
34101
34111
34151
34201
34203

34401
34421
34451
34471

DESCRIPTION

Case Rate

Embolectomy or thrombectomy, w/ or w/o catheter; axillary, brachial,


innominate, subclavian artery, by arm incision
Embolectomy or thrombectomy, w/ or w/o catheter; radial or ulnar artery,
by arm incision
Embolectomy or thrombectomy, w/ or w/o catheter; renal, celiac,
mesentery, aortoiliac artery, by abdominal incision
Embolectomy or thrombectomy, w/ or w/o catheter; femoropopliteal,
aortoiliac artery, by leg incision
Embolectomy or thrombectomy, w/ or w/o catheter; popliteal-tibioperoneal artery, by leg incision
Venous, Direct or With Catheter
Thrombectomy, direct or w/ catheter; vena cava, iliac vein, by abdominal
incision
Thrombectomy, direct or w/ catheter; vena cava, iliac, femoropopliteal vein,
by leg incision
Thrombectomy, direct or w/ catheter; vena cava, iliac, femoropopliteal vein,
by abdominal and leg incision
Thrombectomy, direct or w/ catheter; subclavian vein, by neck incision

Professional Fee

Health Care
Institution Fee

23,300

12,600

10,700

23,300

12,600

10,700

30,300

16,800

13,500

23,300

12,600

10,700

23,300

12,600

10,700

30,300

16,800

13,500

32,000

14,700

17,300

37,600

18,900

18,700

32,000

14,700

17,300

23,300

12,600

10,700

30,300
30,300
30,300
30,300
30,300

16,800
16,800
16,800
16,800
16,800

13,500
13,500
13,500
13,500
13,500

34501
34502
34510
34520
34530

Thrombectomy, direct or w/ catheter; axillary and subclavian vein, by arm


incision
Venous Reconstruction
Valvuloplasty, femoral vein
Reconstruction of vena cava, any method
Venous valve transposition, any vein donor
Cross-over vein graft to venous sytem
Saphenopopliteal vein anastomosis
Direct Repair of Aneurysm or Excision (Partial or Total) and Graft Insertion
for Aneurysm, False Aneurysm, Ruptured Aneurysm, and Associated
Occlusive Disease

35001

Direct repair of aneurysm, false aneurysm, or excision (partial or total) and


graft insertion, w/ or w/o patch graft; for aneurysm and associated
occlusive disease, carotid, subclavian artery, by neck incision

23,300

12,600

10,700

35002

Direct repair of aneurysm, false aneurysm, or excision (partial or total) and


graft insertion, w/ or w/o patch graft; for ruptured aneurysm, carotid,
subclavian artery, by neck incision

30,300

16,800

13,500

35005

Direct repair of aneurysm, false aneurysm, or excision (partial or total) and


graft insertion, w/ or w/o patch graft; for aneurysm, false aneurysm, and
associated occlusive disease, vertebral artery

30,300

16,800

13,500

35011

Direct repair of aneurysm, false aneurysm, or excision (partial or total) and


graft insertion, w/ or w/o patch graft; for aneurysm and associated
occlusive disease, axillary-brachial artery, by arm incision

18,000

8,400

9,600

23,300

12,600

10,700

23,300

12,600

10,700

30,300

16,800

13,500

34490

35013

35021

35022

Direct repair of aneurysm, false aneurysm, or excision (partial or total) and


graft insertion, w/ or w/o patch graft; for ruptured aneurysm, axillarybrachial artery, by arm incision
Direct repair of aneurysm, false aneurysm, or excision (partial or total) and
graft insertion, w/ or w/o patch graft; for aneurysm, false aneurysm, and
associated occlusive disease, innominate, subclavian artery, by thoracic
incision
Direct repair of aneurysm, false aneurysm, or excision (partial or total) and
graft insertion, w/ or w/o patch graft; for ruptured aneurysm, innominate,
subclavian artery, by thoracic insertion

35045

Direct repair of aneurysm, false aneurysm, or excision (partial or total) and


graft insertion, w/ or w/o patch graft; for aneurysm, false aneurysm, and
associated occlusive disease, radial or ulnar artery

18,000

8,400

9,600

35081

Direct repair of aneurysm, false aneurysm, or excision (partial or total) and


graft insertion, w/ or w/o patch graft; for aneurysm, false aneurysm, and
associated occlusive disease, abdominal aorta

46,500

25,200

21,300

53,400

29,400

24,000

53,400

29,400

24,000

35082

35091

Direct repair of aneurysm, false aneurysm, or excision (partial or total) and


graft insertion, w/ or w/o patch graft; for ruptured aneurysm, abdominal
aorta
Direct repair of aneurysm, false aneurysm, or excision (partial or total) and
graft insertion, w/ or w/o patch graft; for aneurysm, false aneurysm, and
associated occlusive disease, abdominal aorta involving visceral vessels
(mesenteric, celiac, renal)

Page 48 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE

DESCRIPTION

Case Rate

Professional Fee

Health Care
Institution Fee

35092

Direct repair of aneurysm, false aneurysm, or excision (partial or total) and


graft insertion, w/ or w/o patch graft; for ruptured aneurysm, abdominal
aorta involving visceral vessels (mesenteric, celiac, renal)

55,000

33,600

21,400

35102

Direct repair of aneurysm, false aneurysm, or excision (partial or total) and


graft insertion, w/ or w/o patch graft; for aneurysm, false aneurysm, and
associated occlusive disease, abdominal aorta involving iliac vessels
(common, hypogastric, external)

46,500

25,200

21,300

35103

Direct repair of aneurysm, false aneurysm, or excision (partial or total) and


graft insertion, w/ or w/o patch graft; for ruptured aneurysm, abdominal
aorta involving iliac vessels (common, hypogastric, external)

53,400

29,400

24,000

35111

Direct repair of aneurysm, false aneurysm, or excision (partial or total) and


graft insertion, w/ or w/o patch graft; for aneurysm, false aneurysm, and
associated occlusive disease, splenic artery

46,500

25,200

21,300

35112

Direct repair of aneurysm, false aneurysm, or excision (partial or total) and


graft insertion, w/ or w/o patch graft; for ruptured aneurysm, splenic artery

53,400

29,400

24,000

35121

Direct repair of aneurysm, false aneurysm, or excision (partial or total) and


graft insertion, w/ or w/o patch graft; for aneurysm, false aneurysm, and
associated occlusive disease, hepatic, celiac, renal, or mesenteric artery

46,500

25,200

21,300

35122

Direct repair of aneurysm, false aneurysm, or excision (partial or total) and


graft insertion, w/ or w/o patch graft; for ruptured aneurysm, hepatic,
celiac, renal, or mesenteric artery

53,400

29,400

24,000

35131

Direct repair of aneurysm, false aneurysm, or excision (partial or total) and


graft insertion, w/ or w/o patch graft; for aneurysm, false aneurysm, and
associated occlusive disease, iliac artery (common, hypogastric, external)

23,300

12,600

10,700

30,300

16,800

13,500

23,300

12,600

10,700

30,300

16,800

13,500

30,300

16,800

13,500

37,800

21,000

16,800

30,300

16,800

13,500

37,800

21,000

16,800

35132

35141

35142

35151

35152

35161

35162

Direct repair of aneurysm, false aneurysm, or excision (partial or total) and


graft insertion, w/ or w/o patch graft; for ruptured aneurysm, iliac artery
(common, hypogastric, external)
Direct repair of aneurysm, false aneurysm, or excision (partial or total) and
graft insertion, w/ or w/o patch graft; for aneurysm, false aneurysm, and
associated occlusive disease, common femoral artery (profunda femoris,
superficial femoral)
Direct repair of aneurysm, false aneurysm, or excision (partial or total) and
graft insertion, w/ or w/o patch graft; for ruptured aneurysm, common
femoral artery (profunda femoris, superficial femoral)
Direct repair of aneurysm, false aneurysm, or excision (partial or total) and
graft insertion, w/ or w/o patch graft; for aneurysm, false aneurysm, and
associated occlusive disease, popliteal artery
Direct repair of aneurysm, false aneurysm, or excision (partial or total) and
graft insertion, w/ or w/o patch graft; for ruptured aneurysm, popliteal
artery
Direct repair of aneurysm, false aneurysm, or excision (partial or total) and
graft insertion, w/ or w/o patch graft; for aneurysm, false aneurysm, and
associated occlusive disease, other arteries
Direct repair of aneurysm, false aneurysm, or excision (partial or total) and
graft insertion, w/ or w/o patch graft; for ruptured aneurysm, other arteries

35180
35182
35184

Repair Arteriovenous Fistula


Repair, congenital arteriovenous fistula; head and neck
Repair, congenital arteriovenous fistula; thorax and abdomen
Repair, congenital arteriovenous fistula; extremities

23,300
30,300
23,300

12,600
16,800
12,600

10,700
13,500
10,700

35188

Repair, acquired or traumatic arteriovenous fistula; head and neck

23,300

12,600

10,700

35189

Repair, acquired or traumatic arteriovenous fistula; thorax and abdomen

30,300

16,800

13,500

35190

Repair, acquired or traumatic arteriovenous fistula; extremities


Repair Blood Vessel Other Than for Fistula, With or Without Patch
Angioplasty
Repair blood vessel, direct; neck
Repair blood vessel, direct; upper extremity
Repair blood vessel, direct; hand, finger
Repair blood vessel, direct; intrathoracic, w/ bypass
Repair blood vessel, direct; intrathoracic, w/o bypass
Repair blood vessel, direct; intra-abdominal
Repair blood vessel, direct; lower extremity
Repair blood vessel w/ vein graft; neck
Repair blood vessel w/ vein graft; upper extremity

23,300

12,600

10,700

18,000
18,000
18,000
46,500
30,300
18,000
18,000
23,300
18,000

8,400
8,400
8,400
25,200
16,800
8,400
8,400
12,600
8,400

9,600
9,600
9,600
21,300
13,500
9,600
9,600
10,700
9,600

35201
35206
35207
35211
35216
35221
35226
35231
35236

Page 49 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE

DESCRIPTION

35241
35246
35251
35256
35261
35266
35271

Repair blood vessel w/ vein graft; intrathoracic, w/ bypass


Repair blood vessel w/ vein graft; intrathoracic, w/o bypass
Repair blood vessel w/ vein graft; intra-abdominal
Repair blood vessel w/ vein graft; lower extremity
Repair blood vessel w/ graft other than vein; neck
Repair blood vessel w/ graft other than vein; upper extremity
Repair blood vessel w/ graft other than vein; intrathoracic, w/ bypass

46,500
30,300
23,300
18,000
23,300
18,000
46,500

25,200
16,800
12,600
8,400
12,600
8,400
25,200

Health Care
Institution Fee
21,300
13,500
10,700
9,600
10,700
9,600
21,300

35276

Repair blood vessel w/ graft other than vein; intrathoracic, w/o bypass

30,300

16,800

13,500

35281
35286

23,300
18,000

12,600
8,400

10,700
9,600

37,600

18,900

18,700

37,600

18,900

18,700

35321
35331

Repair blood vessel w/ graft other than vein; intra-abdominal


Repair blood vessel w/ graft other than vein; lower extremity
Thromboendarterectomy
Thromboendarterectomy, w/ or w/o patch graft; carotid, vertebral,
subclavian, by neck incision
Thromboendarterectomy, w/ or w/o patch graft; subclavian, innominate, by
thoracic incision
Thromboendarterectomy, w/ or w/o patch graft; axillary-brachial
Thromboendarterectomy, w/ or w/o patch graft; abdominal aorta

37,600
37,600

18,900
18,900

18,700
18,700

35341

Thromboendarterectomy, w/ or w/o patch graft; mesenteric, celiac, or renal

37,600

18,900

18,700

35351
35355

Thromboendarterectomy, w/ or w/o patch graft; iliac


Thromboendarterectomy, w/ or w/o patch graft; iliofemoral

30,300
30,300

16,800
16,800

13,500
13,500

35361

Thromboendarterectomy, w/ or w/o patch graft; combined aortoiliac

46,500

25,200

21,300

35363

Thromboendarterectomy, w/ or w/o patch graft; combined aortoiliofemoral

23,300

12,600

10,700

35371

Thromboendarterectomy, w/ or w/o patch graft; common femoral

23,300

12,600

10,700

35372

Thromboendarterectomy, w/ or w/o patch graft; deep (profunda) femoral

23,300

12,600

10,700

30,300

16,800

13,500

35301
35311

35381

Case Rate

Thromboendarterectomy, w/ or w/o patch graft; femoral and/or popliteal,


and/or tibioperoneal
Transluminal Angioplasty Open

Professional Fee

35450

Transluminal balloon angioplasty, open; renal or other visceral artery

21,400

10,500

10,900

35452
35454
35456

Transluminal balloon angioplasty, open; aortic


Transluminal balloon angioplasty, open; iliac
Transluminal balloon angioplasty, open; femoral-popliteal
Transluminal balloon angioplasty, open; brachiocephalic trunk or branches,
each vessel

21,400
21,400
21,400

10,500
10,500
10,500

10,900
10,900
10,900

21,400

10,500

10,900

35459

Transluminal balloon angioplasty, open; tibioperoneal trunk and branches

21,400

10,500

10,900

35460

Transluminal balloon angioplasty, open; venous


Percutaneous
Transluminal balloon angioplasty, percutaneous; tibioperoneal trunk or
branches, each vessel

21,400

10,500

10,900

12,900

6,300

6,600

35471

Transluminal balloon angioplasty, percutaneous; renal or visceral artery

12,900

6,300

6,600

35472
35473

Transluminal balloon angioplasty, percutaneous; aortic


Transluminal balloon angioplasty, percutaneous; iliac

12,900
12,900

6,300
6,300

6,600
6,600

35474

Transluminal balloon angioplasty, percutaneous; femoral-popliteal

12,900

6,300

6,600

12,900

6,300

6,600

12,900

6,300

6,600

35458

35470

35475
35476

Transluminal balloon angioplasty, percutaneous; branchiocephalic trunk or


branches, each vessel
Transluminal balloon angioplasty, percutaneous; venous
Transluminal Atherectomy Open

35480

Transluminal peripheral atherectomy, open; renal or other visceral artery

23,300

12,600

10,700

35481
35482
35483

23,300
23,300
23,300

12,600
12,600
12,600

10,700
10,700
10,700

23,300

12,600

10,700

23,300

12,600

10,700

21,400

10,500

10,900

35491
35492

Transluminal peripheral atherectomy, open; aortic


Transluminal peripheral atherectomy, open; iliac
Transluminal peripheral atherectomy, open; femoral-popliteal
Transluminal peripheral atherectomy, open; brachiocephalic trunk or
branches, each vessel
Transluminal peripheral atherectomy, open; tibioperoneal trunk and
branches
Percutaneous
Transluminal peripheral atherectomy, percutaneous; renal or other visceral
artery
Transluminal peripheral atherectomy, percutaneous; aortic
Transluminal peripheral atherectomy, percutaneous; iliac

21,400
21,400

10,500
10,500

10,900
10,900

35493

Transluminal peripheral atherectomy, percutaneous; femoral-popliteal

21,400

10,500

10,900

35494

Transluminal peripheral atherectomy, percutaneous; branchiocephalic


trunk or branches, each vessel

21,400

10,500

10,900

35484
35485

35490

Page 50 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE
35495
35501
35506
35507
35508
35509
35511
35515
35516
35518
35521
35526
35531
35533
35536
35541
35546
35548
35549
35551
35556
35558
35560
35563
35565
35566
35571

DESCRIPTION

Case Rate

Transluminal peripheral atherectomy, percutaneous; tibioperoneal trunk


and branches
Vein
Bypass graft, w/ vein; carotid
Bypass graft, w/ vein; carotid-subclavian
Bypass graft, w/ vein; subclavian-carotid
Bypass graft, w/ vein; carotid-vertebral
Bypass graft, w/ vein; carotid-carotid
Bypass graft, w/ vein; subclavian-subclavian
Bypass graft, w/ vein; subclavian-vertebral
Bypass graft, w/ vein; subclavian-axillary
Bypass graft, w/ vein; axillary-axillary
Bypass graft, w/ vein; axillary-femoral
Bypass graft, w/ vein; aortosubclavian or carotid
Bypass graft, w/ vein; aortoceliac or aortomesenteric
Bypass graft, w/ vein; axillary-femoral-femoral
Bypass graft, w/ vein; splenorenal
Bypass graft, w/ vein; aortoiliac or bi-iliac
Bypass graft, w/ vein; aortofemoral or bifemoral
Bypass graft, w/ vein; aortoilliofemoral, unilateral
Bypass graft, w/ vein; aortoilliofemoral, bilateral
Bypass graft, w/ vein; aortofemoral - popliteal
Bypass graft, w/ vein; femoral - popliteal
Bypass graft, w/ vein; femoral-femoral
Bypass graft, w/ vein; aortorenal
Bypass graft, w/ vein; ilioiliac
Bypass graft, w/ vein; iliofemoral
Bypass graft, w/ vein; femoral - anterior tibial, posterior tibial, peroneal
artery or other distal vessels
Bypass graft, w/ vein; popliteal-tibial, peroneal artery or other distal vessels

35601
35606
35612
35616
35621
35623
35626

In - Situ Vein
In-situ vein bypass; aortofemoral-popliteal (only femoral-popliteal portion
in-situ)
In-situ vein bypass;femoral-popliteal
In-situ vein bypass; femoral-anterior tibial, posterior tibial, or peroneal
artery
In-situ vein bypass; popliteal -tibial, peroneal
Other Than Vein
Bypass graft, with other than vein; carotid
Bypass graft, with other than vein; carotid-subclavian
Bypass graft, with other than vein; subclavian-subclavian
Bypass graft, with other than vein; subclavian-axillary
Bypass graft, with other than vein; axillary-femoral
Bypass graft, with other than vein; axillary-popliteal or -tibial
Bypass graft, with other than vein; aortosubclavian or carotid

35631

Bypass graft, with other than vein; aortoceliac, aortomesenteric, aortorenal

35582
35583
35585
35587

Professional Fee

Health Care
Institution Fee

21,400

10,500

10,900

37,600
37,600
37,600
37,600
37,600
37,600
37,600
37,600
37,600
37,600
46,500
46,500
46,500
46,500
46,500
46,500
46,500
46,500
46,500
30,300
23,300
37,800
30,300
30,300

18,900
18,900
18,900
18,900
18,900
18,900
18,900
18,900
18,900
18,900
25,200
25,200
25,200
25,200
25,200
25,200
25,200
25,200
25,200
16,800
12,600
21,000
16,800
16,800

18,700
18,700
18,700
18,700
18,700
18,700
18,700
18,700
18,700
18,700
21,300
21,300
21,300
21,300
21,300
21,300
21,300
21,300
21,300
13,500
10,700
16,800
13,500
13,500

30,300

16,800

13,500

23,300

12,600

10,700

46,500

25,200

21,300

37,800

21,000

16,800

37,800

21,000

16,800

37,800

21,000

16,800

37,600
37,600
37,600
37,600
37,600
37,600
46,500

18,900
18,900
18,900
18,900
18,900
18,900
25,200

18,700
18,700
18,700
18,700
18,700
18,700
21,300

46,500

25,200

21,300

46,500

25,200

21,300

46,500
37,600
37,600
46,500
37,600
46,500
37,600
30,300
23,300
30,300
30,300

25,200
18,900
18,900
25,200
18,900
25,200
18,900
16,800
12,600
16,800
16,800

21,300
18,700
18,700
21,300
18,700
21,300
18,700
13,500
10,700
13,500
13,500

30,300

16,800

13,500

23,300
46,500

12,600
25,200

10,700
21,300

35691

Bypass graft, with other than vein; splenorenal (splenic to renal arterial
anastomosis)
Bypass graft, with other than vein; aortoiliac or bi-iliac
Bypass graft, with other than vein; carotid-vertebral
Bypass graft, with other than vein; subclavian-vertebral
Bypass graft, with other than vein; aortofemoral or bifemoral
Bypass graft, with other than vein; axillary-axillary
Bypass graft, with other than vein; aortofemoral-popliteal
Bypass graft, with other than vein; axillary-femoral-femoral
Bypass graft, with other than vein; femoral-popliteal
Bypass graft, with other than vein; femoral-femoral
Bypass graft, with other than vein; ilioiliac
Bypass graft, with other than vein; iliofemoral
Bypass graft, with other than vein; femoral-anterior tibial, posterior tibial,
or peroneal artery
Bypass graft, with other than vein; popliteal-tibial or -peroneal artery
Bypass graft; composite
Arterial Transposition
Transposition and/or reimplantation; vertebral to carotid artery

37,600

18,900

18,700

35693

Transposition and/or reimplantation; vertebral to subclavian artery

37,600

18,900

18,700

35694

Transposition and/or reimplantation; subclavian to carotid artery

37,600

18,900

18,700

35695

Transposition and/or reimplantation; carotid to subclavian artery

37,600

18,900

18,700

35636
35641
35642
35645
35646
35650
35651
35654
35656
35661
35663
35665
35666
35671
35681

Page 51 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE

35700

35701
35721
35741
35761

DESCRIPTION

Case Rate

Exploration
Reoperation, femoral-popliteal or femoral (popliteal) -anterior
tibial,posterior tibial, peroneal artery or other distal vessels, more than one
month after original operation (List separately in addition to code for
primary procedure)
Exploration (not followed by surgical repair), w/ or w/o lysis of artery;
carotid artery
Exploration (not followed by surgical repair), w/ or w/o lysis of artery;
femoral artery
Exploration (not followed by surgical repair), w/ or w/o lysis of artery;
popliteal artery
Exploration (not followed by surgical repair), w/ or w/o lysis of artery; other
vessels

Professional Fee

Health Care
Institution Fee

18,000

8,400

9,600

18,000

8,400

9,600

18,000

8,400

9,600

18,000

8,400

9,600

18,000

8,400

9,600

35800

Exploration for postoperative hemorrhage, thrombosis or infection; neck

9,700

4,200

5,500

35820

Exploration for postoperative hemorrhage, thrombosis or infection; chest

18,000

8,400

9,600

18,000

8,400

9,600

9,700

4,200

5,500

23,300
23,300

12,600
12,600

10,700
10,700

23,300

12,600

10,700

30,300
30,300
37,800
30,300

16,800
16,800
21,000
16,800

13,500
13,500
16,800
13,500

3,640

840

2,800

9,300

2,100

7,200

8,020

2,520

5,500

8,020
8,020

2,520
2,520

5,500
5,500

8,440

2,940

5,500

8,440
9,300
9,300

2,940
2,100
2,100

5,500
7,200
7,200

8,260

3,360

4,900

9,300

2,100

7,200

9,300

2,100

7,200

9,300

2,100

7,200

36013
36014

Exploration for postoperative hemorrhage, thrombosis or infection;


abdomen
Exploration for postoperative hemorrhage, thrombosis or infection;
extremity
Repair of graft-enteric fistula
Thrombectomy of arterial or venous graft;
Thrombectomy of arterial or venous graft; w/ revision of arterial or venous
graft
Excision of infected graft; neck
Excision of infected graft; extremity
Excision of infected graft; thorax
Excision of infected graft; abdomen
Vascular Injection Procedures Intravenous
Introduction of catheter, superior or inferior vena cava
Selective catheter placement, venous system; first order branch (e.g., renal
vein, jugular vein)
Selective catheter placement, venous system; second order, or more
selective, branch (e.g., left adrenal vein, petrosal sinus)
Introduction of catheter, right heart or main pulmonary artery
Selective catheter placement, left or right pulmonary artery

36015

Selective catheter placement, segmental or subsegmental pulmonary artery

35840
35860
35870
35875
35876
35901
35903
35905
35907
36010
36011
36012

36100
36120
36140
36145
36200
36215
36216

Intra-Arterial-Intra-Aortic
Introduction of needle or intracatheter, carotid or vertebral artery
Introduction of needle or intracatheter; retrograde brachial artery
Introduction of needle or intracatheter; extremity artery
Introduction of needle or intracatheter; arteriovenous shunt created for
dialysis (cannula, fistula, or graft)
Introduction of catheter, aorta
Selective catheter placement, arterial system; each first order thoracic or
brachiocephalic branch, w/in a vascular family
Selective catheter placement, arterial system; initial second order thoracic
or brachiocephalic branch, w/in a vascular family

36217

Selective catheter placement, arterial system; initial third order or more


selective thoracic or brachiocephalic branch, w/in a vascular family

8,020

2,520

5,500

36245

Selective catheter placement, arterial system; each first order abdominal,


pelvic, or lower extremity artery branch, w/in a vascular family

9,300

2,100

7,200

36246

Selective catheter placement, arterial system; initial second order


abdominal, pelvic or lower extremity artery branch, w/in a vascular family

9,300

2,100

7,200

8,020

2,520

5,500

23,300

12,600

10,700

9,700
9,700

4,200
4,200

5,500
5,500

3,640
5,680
9,300

840
1,680
2,100

2,800
4,000
7,200

9,700

4,200

5,500

36247
36260
36261
36262
36430
36450
36481
36488

Selective catheter placement, arterial system; initial third order or more


selective abdominal, pelvic or lower extremity artery branch, w/in a vascular
family
Insertion of implantable intra-arterial infusion pump (e.g., for
chemotherapy of liver)
Revision of implanted intra-arterial infusion pump
Removal of implanted intra-arterial infusion pump
Venous
Outpatient Transfusion of Blood or Blood Products; one or more units
Exchange transfusion, blood
Percutaneous portal vein catheterization by any method
Placement of central venous catheter (subclavian, jugular, or other vein)
(e.g., for central venous pressure, hyperalimentation, hemodialysis, or
chemotherapy); percutaneous or cutdown

Page 52 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE

DESCRIPTION

3,640
3,640
9,700

840
840
4,200

3,640

840

2,800

5,680

1,680

4,000

36781

Catheterization of umbilical vein for diagnosis or therapy, newborn


Therapeutic apheresis
Insertion of peripherally inserted central venous catheter (PICC)
Arterial
Arterial catheterization for prolonged infusion therapy (chemotherapy),
cutdown
Catheterization, umbilical artery, newborn, for diagnosis or therapy
Intervascular Cannulization or Shunt
Percutaneousportal vein catheterization by any method

Health Care
Institution Fee
2,800
2,800
5,500

9,300

2,100

7,200

36800

Insertion of cannula for hemodialysis, other purpose ; vein to vein

9,300

2,100

7,200

9,700

4,200

5,500

9,700

4,200

5,500

9,700

4,200

5,500

18,000

8,400

9,600

12,900

6,300

6,600

12,900

6,300

6,600

9,700

4,200

5,500

8,260
9,300

3,360
2,100

4,900
7,200

30,300
37,800
30,300
37,600

16,800
21,000
16,800
18,900

13,500
16,800
13,500
18,700

37,800

21,000

16,800

53,400

29,400

24,000

46,500

25,200

21,300

46,500

25,200

21,300

8,260
8,020

3,360
2,520

4,900
5,500

8,020

2,520

5,500

9,700

4,200

5,500

46,500

25,200

21,300

46,500

25,200

21,300

23,300

12,600

10,700

5,680
5,680
18,000

1,680
1,680
8,400

4,000
4,000
9,600

21,940

9,240

12,700

9,300
9,300
18,000
21,400
18,000
12,900

2,100
2,100
8,400
10,500
8,400
6,300

7,200
7,200
9,600
10,900
9,600
6,600

36510
36511
36568
36640
36660

36810
36815
36821
36822
36825
36830
36832
36834
36835
37140
37145
37160
37180
37181

37182

37184

37187

37200
37201
37202
37203

37204

37205
37207
37565
37600
37605
37606
37607
37609
37615
37616
37617
37618

Case Rate

Insertion of cannula for hemodialysis, other purpose ; arteriovenous,


external (e.g. Scribner type)
Insertion of cannula for hemodialysis, other purpose ; arteriovenous,
external revision, or closure
Arteriovenous anastomosis, direct, any site (e.g., Cimino type)
Insertion of cannula(s) for prolonged extracorporeal circulation for
cardiopulmonary insufficiency (ECMO)
Creation of arteriovenous fistula by other than direct arteriovenous
anastomosis ; autogenous graft
Creation of arteriovenous fistula by other than direct arteriovenous
anastomosis ; nonautogenous graft
Revision of an arteriovenous fistula, w/ or w/o thrombectomy, autogenous
or nonautogenous graft
Plastic repair of arteriovenous aneurysm
Insertion of Thomas shunt
Portal Decompression Procedures
Venous anastomosis; portocaval
Venous anastomosis; renoportal
Venous anastomosis; caval-mesenteric
Venous anastomosis; splenorenal, proximal
Venous anastomosis; splenorenal, distal (selective decompression of
esophagogastric varices, any technique)
Insertion of transvenous intrahepatic portosystemic shunt(s) (TIPS) includes
venous access, hepatic and portal vein catheterization, portography,
hemodynamic evaluation, intrahepatic tract formation/dilatation, stent
placement and all associated imaging guidance and documentation)
Primary percutaneous transluminal mechanical thrombectomy, noncoronary, arterial or arterial bypass graft including fluoroscopic guidance
and intraprocedural pharmacological thrombolytic injections; one or more
vessels
Percutaneous transluminal mechanical thrombectomy, veins, including
intraprocedural pharmacological thrombolytic injections and fluoroscopic
guidance; one or more vessels
Transcatheter Procedures
Transcatheter biopsy
Transcatheter therapy, infusion for thrombolysis other than coronary
Transchatheter therapy, infusion other than for thrombolysis, any type
(e.g., spasmolytic, vasoconstrictive)
Transcatheter retrieval, percutaneous, of intravascular foreign body (e.g.,
fractured venous or arterial catheter)
Transcatheter occlusion or embolization (e.g., for tumor destruction, to
achieve hemostasis, to occlude a vascular malformation), percutaneous, any
method, non-central nervous system, non-head or neck
Transcatheter placement of an intravascular stent(s), (non-coronary vessel),
percutaneous; initial vessel
Transcatheter placement of an intravascular stent(s), (non-coronary vessel),
open; initial vessel
Ligation and Other Procedures
Ligation, internal jugular vein
Ligation; external carotid artery
Ligation; internal or common carotid artery
Ligation; internal or common carotid artery, w/ gradual occlusion, as w/
Selverstone or Crutchfield camp
Ligation or banding of angioaccess arteriovenous fistula
Ligation or biopsy, temporal artery
Ligation, major artery (e.g., post-traumatic, rupture); neck
Ligation, major artery (e.g., post-traumatic, rupture); chest
Ligation, major artery (e.g., post-traumatic, rupture); abdomen
Ligation, major artery (e.g., post-traumatic, rupture); extremity

Page 53 of 113

Professional Fee

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE
37620
37650
37660
37700
37720
37730

DESCRIPTION

Case Rate

Interruption, partial or complete, of inferior vena cava by suture, ligation,


plication, clip, extravascular, intravascular (umbrella device)
Ligation of femoral vein
Ligation of common iliac vein
Ligation and division of long saphenous vein at saphenofemoral junction, or
distal interruptions
Ligation and division and complete stripping of long or short saphenous
veins
Ligation and division and complete stripping of long and short saphenous
veins

Professional Fee

Health Care
Institution Fee

23,300

12,600

10,700

9,300
12,900

2,100
6,300

7,200
6,600

9,300

2,100

7,200

12,900

6,300

6,600

18,000

8,400

9,600

37735

Ligation and division and complete stripping of long or short saphenous


veins w/ radical excision of ulcer and skin graft and/or interruption of
communicating veins of lower leg, w/ excision of deep fascia

21,400

10,500

10,900

37760

Ligation of perforators, subfascial, radical (Linton type), w/ or w/o skin graft

21,400

10,500

10,900

37780

Ligation and division of short saphenous vein at saphenopopliteal junction

9,700

4,200

5,500

37788
37790

Penile revascularization, artery, w/ or w/o vein graft


Penile venous occlusive procedure
Hemic and Lymphatic System
Spleen
Excision
Splenectomy; total
Splenectomy; partial
Splenectomy; total, en bloc for extensive disease, in conjuction w/ other
procedure
Repair

46,500
23,300

25,200
12,600

21,300
10,700

30,740
23,300

13,440
12,600

17,300
10,700

32,000

14,700

17,300

38115

Repair of ruptured spleen (splenorrhaphy) w/ or w/o partial splenectomy

30,300

16,800

13,500

38120

Laparoscopy
Laparoscopy, surgical; splenectomy
Bone Marrow or Stem Cell Services and Procedures

30,740

13,440

17,300

38205

Blood-derived hematopoietic progenitor cell harvesting for transplantation

10,880

3,780

7,100

38220
38230

Bone marrow aspiration or biopsy


Bone marrow harvesting for transplantation
Bone marrow or peripheral blood derived peripheral stem cell
transplantation
Lymph Nodes and Lymphatic Channels
Incision
Drainage of lymph node abscess or lymphadenitis
Suture and/or ligation of thoracic duct; cervical approach
Suture and/or ligation of thoracic duct; thoracic approach
Suture and/or ligation of thoracic duct; abdominal approach
Excision
Biopsy or excision or lymph node(s); superficial
Biopsy or excision or lymph node(s); by needle, superficial (e.g., cervical,
inguinal, axillary)
Biopsy or excision or lymph node(s); deep cervical node(s)
Biopsy or excision or lymph node(s); deep cervical node(s) w/ excision
scalene fat pad
Biopsy or excision or lymph node(s); deep axillary node(s)
Biopsy or excision or lymph node(s); internal mammary node(s)
Dissection, deep jugular node(s)
Excision of cystic hygroma, axillary or cervical; w/o deep neurovascular
dissection
Excision of cystic hygroma, axillary or cervical; w/ deep neurovascular
dissection
Laparoscopy
Laparoscopy, surgical; with retroperitoneal lymph node sampling (biopsy),
single or multiple

10,880
18,000

3,780
8,400

7,100
9,600

37,800

21,000

16,800

8,260
30,300
30,300
30,300

3,360
16,800
16,800
16,800

4,900
13,500
13,500
13,500

5,680

1,680

4,000

5,680

1,680

4,000

8,260

3,360

4,900

9,300

2,100

7,200

9,300
9,300
21,940

2,100
2,100
9,240

7,200
7,200
12,700

37,800

21,000

16,800

46,500

25,200

21,300

27,120

15,120

12,000

38571

Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy

30,300

16,800

13,500

38572

Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy and periaortic lymph node sampling (biopsy), single or multiple

58,800

37,800

21,000

27,120
30,300
30,300
23,300

15,120
16,800
16,800
12,600

12,000
13,500
13,500
10,700

38100
38101
38102

38240

38300
38380
38381
38382
38500
38505
38510
38520
38525
38530
38542
38550
38555

38570

38700
38720
38724
38740

Radical Lymphadenectomy (Radical Resection of Lymph Nodes)


Suprahyoid lymphadenectomy
Cervical lymphadenectomy (complete)
Cervical lymphadenectomy (modified radical neck dissection)
Axillary lymphadenectomy; superficial

Page 54 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE
38745
38746
38747
38760

38765
38770
38780

39000
39010

39200
39220
39400
39501
39502
39503
39520
39530

DESCRIPTION
Axillary lymphadenectomy; complete
Thoracic lymphadenectomy, regional, including mediastinal and
peritracheal nodes
Abdominal lymphadenectomy, regional, including celiac, para-aortic and
venal caval nodes

30,300

16,800

Health Care
Institution Fee
13,500

37,800

21,000

16,800

23,300

12,600

10,700

Inguinofemoral lymphadenectomy, superficial, including Cloquet's node

23,300

12,600

10,700

23,300

12,600

10,700

37,800

21,000

16,800

37,800

21,000

16,800

18,000

8,400

9,600

23,300

12,600

10,700

37,800
41,160

21,000
24,360

16,800
16,800

14,960

7,560

7,400

37,800

21,000

16,800

40,320

23,520

16,800

40,320

23,520

16,800

40,320

23,520

16,800

40,320

23,520

16,800

Case Rate

Inguinofemoral lymphadenectomy, superficial, in continuity w/ pelvic


lymphadenectomy, including external iliac, hypogastric, and obturator
nodes
Pelvic lymphadenectomy, including external iliac, hypogastric, and
obturator nodes
Retroperitoneal transabdominal lymphadenectomy, extensive, including
pelvic, aortic, and renal nodes
Mediastinum and Diaphragm
Mediastinum
Incision
Mediastinotomy with exploration, drainage, removal of foreign body, or
biopsy; cervical approach
Mediastinotomy with exploration, drainage, removal of foreign body, or
biopsy; transthoracic approach, including either transthoracic or median
sternotomy
Excision
Excision of mediastinal cyst
Excision of mediastinal tumor
Endoscopy
Mediastinoscopy, with or without biopsy
Diaphragm Repair
Repair, laceration of diaphragm, any approach
Repair, paraesophageal hiatus hernia, transabdominal, with or without
fundoplasty, vagotomy, and/or pyloroplasty, except neonatal
Repair, neonatal diaphragmatic hernia, with or without chest tube insertion
and with or without creation of ventral hernia
Repair, diaphragmatic hernia (esophageal hiatal); transthoracic
Repair, diaphragmatic hernia (esophageal hiatal); combined,
thoracoabdominal

Professional Fee

39531

Repair, diaphragmatic hernia (esophageal hiatal); combined,


thoracoabdominal, with dilation of stricture (with or without gastroplasty)

40,320

23,520

16,800

39540

Repair, diaphragmatic hernia (other than neonatal), traumatic; acute

40,320

23,520

16,800

39541

Repair, diaphragmatic hernia (other than neonatal), traumatic; chronic

46,500

25,200

21,300

40,320

23,520

16,800

5,560
8,020
8,020
8,020

1,260
2,520
2,520
2,520

4,300
5,500
5,500
5,500

23,300

12,600

10,700

30,740

13,440

17,300

8,260

3,360

4,900

9,700
9,700

4,200
4,200

5,500
5,500

9,700

4,200

5,500

37,800

21,000

16,800

37,800

21,000

16,800

30,300

16,800

13,500

30,300

16,800

13,500

37,800

21,000

16,800

40650
40652

Imbrication of diaphragm for eventration, transthoracic or transabdominal,


paralytic or nonparalytic
Digestive System
Lips
Excision
Biopsy of lip
Vermilionectomy (lip shave), w/ mucosal advancement
Excision of lip; transverse wedge excision w/ primary closure
V-excision w/ primary defect linear closure;
V-excision w/ primary defect linear closure; full thickness, reconstruction w/
local flap (e.g., Estlander or fan)
V-excision w/ primary defect linear closure; full thickness, reconstruction w/
cross lip flap (e.g. Abbe-Estlander)
Resection of lip, more than one-fourth, w/o reconstruction
Repair (Cheiloplasty)
Repair lip, full thickness; vermilion only
Repair lip, full thickness; up to half vertical height

40654

Repair lip, full thickness; over one-half vertical height, or complex

39545

40490
40500
40510
40520
40525
40527
40530

40700
40701
40702
40720
40761

Plastic repair of cleft lip/nasal deformity; primary, partial or complete,


unilateral
Plastic repair of cleft lip/nasal deformity; primary bilateral, one stage
procedure
Plastic repair of cleft lip/nasal deformity; primary bilateral, one of two
stages
Plastic repair of cleft lip/nasal deformity; secondary, by recreation of defect
and reclosure
Plastic repair of cleft lip/nasal deformity; w/ cross lip pedicle flap (AbbeEstlander type), including sectioning and inserting of pedicle

Page 55 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE

DESCRIPTION

Case Rate

Professional Fee

Health Care
Institution Fee

5,680

1,680

4,000

40808

Vestibule of Mouth
Incision
Drainage of abscess, cyst, hematoma, vestibule of mouth
Excision, Destruction
Biopsy, vestibule of mouth

5,680

1,680

4,000

40810

Excision of lesion of mucosa and submucosa, vestibule of mouth

5,680

1,680

4,000

40818

8,440

2,940

5,500

9,300

2,100

7,200

40830
40831
40840
40842
40843
40844

Excision of mucosa of vestibule of mouth as donor graft


Excision of frenum, labial or buccal (frenumectomy, frenulectomy,
frenectomy)
Repair
Closure of laceration, vestibule of mouth; 2.5 cm or less
Closure of laceration, vestibule of mouth; over 2.5 cm or complex
Vestibuloplasty; anterior
Vestibuloplasty; posterior, unilateral
Vestibuloplasty; posterior, bilateral
Vestibuloplasty; entire arch

5,680
5,680
12,120
12,120
12,120
18,000

1,680
1,680
6,720
6,720
6,720
8,400

4,000
4,000
5,400
5,400
5,400
9,600

40845

Vestibuloplasty; complex (including ridge extension, muscle repositioning)

18,000

8,400

9,600

5,680

1,680

4,000

5,680

1,680

4,000

5,680

1,680

4,000

5,680

1,680

4,000

5,680

1,680

4,000

5,680

1,680

4,000

5,680

1,680

4,000

5,680

1,680

4,000

5,680

1,680

4,000

5,680

1,680

4,000

5,560
5,560
5,560
9,300
9,300
9,300
9,300
9,300
9,300
8,260
10,880
37,800

1,260
1,260
1,260
2,100
2,100
2,100
2,100
2,100
2,100
3,360
3,780
21,000

4,300
4,300
4,300
7,200
7,200
7,200
7,200
7,200
7,200
4,900
7,100
16,800

37,800

21,000

16,800

37,800

21,000

16,800

40,320

23,520

16,800

46,500

25,200

21,300

53,400

29,400

24,000

9,700

4,200

5,500

9,700
9,700

4,200
4,200

5,500
5,500

9,700

4,200

5,500

40800

40819

Tongue and Floor of Mouth


41000
41005
41006
41007
41008
41009
41015
41016
41017
41018
41100
41105
41108
41110
41112
41113
41114
41115
41116
41120
41130
41135
41140
41145
41150
41153
41155

41250
41251
41252
41500

Incision
Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or
floor of mouth; lingual
Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or
floor of mouth; sublingual, superficial
Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or
floor of mouth; sublingual, deep, supramylohyoid
Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or
floor of mouth; submental space
Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or
floor of mouth; submandibular space
Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or
floor of mouth; masticator space
Extraoral incision and drainage of abscess,cyst,or hematoma of floor of
mouth; sublingual
Extraoral incision and drainage of abscess,cyst,or hematoma of floor of
mouth; submental
Extraoral incision and drainage of abscess,cyst,or hematoma of floor of
mouth; submandibular
Extraoral incision and drainage of abscess,cyst,or hematoma of floor of
mouth; masticator space
Excision
Biopsy of tongue; anterior two-thirds
Biopsy of tongue; posterior one-third
Biopsy of floor of mouth
Excision of lesion of tongue w/o closure
Excision of lesion of tongue w/ closure; anterior two-thirds
Excision of lesion of tongue w/ closure; posterior one-third
Excision of lesion of tongue w/ closure; w/ local tongue flap
Excision of lingual frenum (frenectomy)
Excision, lesion of floor of mouth
Glossectomy; less than one-half tongue
Glossectomy; hemiglossectomy
Glossectomy; partial, w/ unilateral radical neck dissection
Glossectomy; complete or total, w/ or w/o tracheostomy, w/o radical neck
dissection
Glossectomy; complete or total, w/ or w/o tracheostomy, w/ unilateral
radical neck dissection
Glossectomy; composite procedure w/ resection floor of mouth and
mandibular resection, w/o radical neck dissection
Glossectomy; composite procedure w/ resection floor of mouth, w/
suprahyoid neck dissection
Glossectomy; composite procedure w/ resection floor of mouth,
mandibular resection, and radical neck dissection (Commando type)
Repair
Repair of laceration 2.5 cm or less; floor of mouth and/or anterior twothirds of tongue
Repair of laceration 2.5 cm or less; posterior one-third of tongue
Repair of laceration of tongue, floor of mouth, over 2.6 cm or complex
Other Procedures
Frenoplasty (surgical revision of frenum, eg, w/ Z-plasty)

Page 56 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE

DESCRIPTION

Case Rate

Professional Fee

Health Care
Institution Fee

41510

Suture of tongue to lip for micrognathia (Douglas type procedure)

9,700

4,200

5,500

41520

Frenoplasty (surgical revision of frenum, eg, w/ Z-plasty)


Dentoalveolar Structures
Incision
Drainage of abscess, cyst, hematoma from dentoalveolar structures
Removal of embedded foreign body from dentoalveolar structures; soft
tissues

9,700

4,200

5,500

5,680

1,680

4,000

3,640

840

2,800

Removal of embedded foreign body from dentoalveolar structures; bone

3,640

840

2,800

8,020
8,020
8,020
8,020

2,520
2,520
2,520
2,520

5,500
5,500
5,500
5,500

8,020

2,520

5,500

8,020
8,260
8,260

2,520
3,360
3,360

5,500
4,900
4,900

8,260
18,000
18,000

3,360
8,400
8,400

4,900
9,600
9,600

8,020

2,520

5,500

5,560
5,680
9,300
9,300
20,980
12,120

1,260
1,680
2,100
2,100
10,080
6,720

4,300
4,000
7,200
7,200
10,900
5,400

23,300

12,600

10,700

10,540

5,040

5,500

12,120
18,000
20,980

6,720
8,400
10,080

5,400
9,600
10,900

21,820

10,920

10,900

22,660

11,760

10,900

23,300
23,300
30,740
23,300
23,300
23,300
12,120

12,600
12,600
13,440
12,600
12,600
12,600
6,720

10,700
10,700
17,300
10,700
10,700
10,700
5,400

5,680
5,680
5,680
5,680
9,300

1,680
1,680
1,680
1,680
2,100

4,000
4,000
4,000
4,000
7,200

9,300

2,100

7,200

5,560
5,560
9,300
9,300

1,260
1,260
2,100
2,100

4,300
4,300
7,200
7,200

23,300

12,600

10,700

30,300

16,800

13,500

30,300

16,800

13,500

30,300

16,800

13,500

41800
41805
41806

42180
42182
42200

Excision, Destruction
Gingivectomy, excision gingiva
Operculectomy, excision pericoronal tissues
Excision of fibrous tuberosities, dentoalveolar structures
Excision of osseous tuberosities, dentoalveolar structures
Excision of lesion or or tumor (except listed above), dentoalveolar
structures
Excision of hyperplastic alveolar mucosa
Alveolectomy, including curettage of osteitis or sequestrectomy
Destruction of lesion (except excision), dentoalveolar structures
Other Procedures
Periodontal mucosal grafting
Gingivoplasty
Alveoloplasty
Palate and Uvula
Incision
Drainage of abscess of palate, uvula
Excision, Destruction
Biopsy of palate, uvula
Excision, lesion of palate , uvula; w/o closure
Excision, lesion of palate , uvula; w/ simple primary closure
Excision, lesion of palate , uvula; w/ local flap closure
Resection of palate or extensive resection of lesion
Uvulectomy, excision of uvula
Palatopharyngoplasty (e.g., uvulopalatopharyngoplasty,
uvulopharyngoplasty)
Destruction of lesion, palate or uvula (thermal, cryo or chemical)
Repair
Repair, laceration of palate; up to 2 cm
Repair, laceration of palate; over 2 cm or complex
Palatoplasty for cleft palate, soft and/or hard palate only

42205

Palatoplasty for cleft palate, w/ closure of alveolar ridge; soft tissue only

41820
41821
41822
41823
41825
41828
41830
41850
41870
41872
41874

42000
42100
42104
42106
42107
42120
42140
42145
42160

42210
42215
42220
42225
42226
42227
42235
42260

42300
42310
42320
42325
42326
42330
42400
42405
42408
42409
42410
42415
42420
42425

Palatoplasty for cleft palate, w/ closure of alveolar ridge; w/ bone graft to


alveolar ridge (includes obtaining graft)
Palatoplasty for cleft palate; major revision
Palatoplasty for cleft palate; secondary lengthening procedure
Palatoplasty for cleft palate; attachment pharyngeal flap
Lengthening of palate, and pharyngeal flap
Lengthening of palate, w/ island flap
Repair of anterior palate, including vomer flap
Repair of nasolabial fistula
Salivary Gland and Ducts
Incision
Drainage of abscess; parotid
Drainage of abscess; submaxillary or sublingual, intraoral
Drainage of abscess; submaxillary, external
Fistulization of sublingual salivary cyst (ranula);
Fistulization of sublingual salivary cyst (ranula); w/ prosthesis
Sialolithotomy; submandibular (submaxillary), sublingual or parotid,
intraoral
Excision
Biopsy of salivary gland; needle
Biopsy of salivary gland; incisional
Excision of sublingual salivary cyst (ranula)
Marsupialization of sublingual salivary cyst (ranula)
Excision of parotid tumor or parotid gland; lateral lobe, w/o nerve
dissection
Excision of parotid tumor or parotid gland; lateral lobe, w/ dissection and
preservation of facial nerve
Excision of parotid tumor or parotid gland; total, w/ dissection and
preservation of facial nerve
Excision of parotid tumor or parotid gland; total, en bloc removal w/
sacrifice of facial nerve

Page 57 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE
42426
42440
42450

DESCRIPTION

Case Rate

Excision of parotid tumor or parotid gland; total, w/ unilateral radical neck


dissection
Excision of submandibular (submaxillary) gland
Excision of sublingual gland
Repair

Professional Fee

Health Care
Institution Fee

37,800

21,000

16,800

18,000
18,000

8,400
8,400

9,600
9,600

42500

Plastic repair of salivary duct, sialodochoplasty; primary or simple

18,000

8,400

9,600

42505

Plastic repair of salivary duct, sialodochoplasty; secondary or complicated

18,000

8,400

9,600

42507

Parotid duct diversion, bilateral (Wilke type procedure);


Parotid duct diversion, bilateral (Wilke type procedure); w/ excision of one
submandibular gland
Parotid duct diversion, bilateral (Wilke type procedure); w/ excision of both
submandibular glands
Parotid duct diversion, bilateral (Wilke type procedure); w/ ligation of both
submandibular (Whartons) ducts
Other Procedures
Closure salivary fistula
Ligation salivary duct, intraoral
Pharynx, Adenoids, and Tonsils
Incision
Incision and drainage abscess; peritonsillar
Incision and drainage abscess; retropharyngeal or parapharyngeal, intraoral
approach
Incision and drainage abscess; retropharyngeal or parapharyngeal, external
approach
Excision, Destruction
Biopsy; oropharynx
Biopsy; hypopharynx
Biopsy; nasopharynx, visible lesion, simple
Biopsy; nasopharynx, survey for unknown primary lesion
Excision or destruction of lesion of pharynx, any method
Removal of foreign body from pharynx
Excision branchial cleft cyst or vestige, confined to skin and subcutaneous
tissues
Excision branchial cleft cyst, vestige, or fistula, extending beneath
subcutaneous tissues and/or into pharynx
Tonsillectomy and adenoidectomy
Tonsillectomy, primary or secondary
Adenoidectomy, primary
Adenoidectomy, secondary
Radical resection of tonsil, tonsillar pillars, and/or retromolar trigone; w/o
closure
Radical resection of tonsil, tonsillar pillars, and/or retromolar trigone;
closure w/ local flap (e.g., tongue, buccal)
Radical resection of tonsil, tonsillar pillars, and/or retromolar trigone;
closure w/ other flap
Excision of tonsil tags
Excision or destruction lingual tonsil, any method
Limited pharyngectomy

18,000

8,400

9,600

18,000

8,400

9,600

18,000

8,400

9,600

18,000

8,400

9,600

8,260
8,260

3,360
3,360

4,900
4,900

8,260

3,360

4,900

8,260

3,360

4,900

8,260

3,360

4,900

8,020
8,020
8,020
8,020
8,020
8,020

2,520
2,520
2,520
2,520
2,520
2,520

5,500
5,500
5,500
5,500
5,500
5,500

18,000

8,400

9,600

18,000

8,400

9,600

18,000
18,000
18,000
18,000

8,400
8,400
8,400
8,400

9,600
9,600
9,600
9,600

10,540

5,040

5,500

12,120

6,720

5,400

12,120

6,720

5,400

8,020
8,020
37,800

2,520
2,520
21,000

5,500
5,500
16,800

46,500

25,200

21,300

Resection of pharyngeal wall requiring closure w/ myocutaneous flap


Repair
Suture pharynx for wound or injury
Pharyngoplasty (plastic or reconstructive operation on pharynx)
Pharyngoesophageal repair
Other Procedures
Pharyngostomy (fistulization of pharynx, external for feeding)
Esophagus
Incision
Esophagotomy, cervical approach, w/ removal of foreign body
Cricopharyngeal myotomy
Esophagotomy, thoracic approach, w/ removal of foreign body
Excision

53,400

29,400

24,000

20,980
20,980
23,300

10,080
10,080
12,600

10,900
10,900
10,700

8,020

2,520

5,500

12,120
18,000
37,800

6,720
8,400
21,000

5,400
9,600
16,800

43100

Excision of lesion, esophagus, w/ primary repair; cervical approach

23,300

12,600

10,700

43101

Excision of lesion, esophagus, w/ primary repair; thoracic or abdominal


approach

37,800

21,000

16,800

43107

Total or near esophagectomy, w/o thoracotomy; w/ pharyngogastrostomy


or cervical esophagogastrostomy, w/ or w/o pyloroplasty (transhiatal)

55,000

33,600

21,400

42508
42509
42510
42600
42665

42700
42720
42725
42800
42802
42804
42806
42808
42809
42810
42815
42820
42825
42830
42835
42842
42844
42845
42860
42870
42890
42892
42894
42900
42950
42953
42955

43020
43030
43045

Resection of lateral pharyngeal wall or pyriform sinus, direct closure by


advancement of lateral and posterior pharyngeal walls

Page 58 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE
43108

43112

43113

DESCRIPTION

Case Rate

Total or near esophagectomy, w/o thoracotomy; w/ colon interposition or


small bowel reconstruction, including bowel mobilization, preparation and
anastomosis(es)
Total or near total esophagectomy, w/ thoracotomy; w/
pharyngogastrostomy, or cervical esophagogastrostomy, w/ or w/o
pyloroplasty
Total or near total esophagectomy, w/ thoracotomy; w/ colon interposition
or small bowel reconstruction, including bowel mobilization, preparation
and anastomosis(es)

Professional Fee

Health Care
Institution Fee

58,800

37,800

21,000

59,640

38,640

21,000

63,000

42,000

21,000

43116

Partial esophagectomy, cervical, w/ free intestinal graft, including


microvascular anastomosis, obtaining the graft and intestinal reconstruction

55,000

33,600

21,400

43117

Partial esophagectomy, distal two-thirds, w/ thoracotomy and separate


abdominal incision, w/ or w/o proximal gastrectomy; w/ thoracic
esophagogastrotomy, w/ or w/o pyloroplasty (Ivor Lewis)

55,000

33,600

21,400

58,800

37,800

21,000

55,000

33,600

21,400

55,000

33,600

21,400

58,800

37,800

21,000

46,500

25,200

21,300

23,300

12,600

10,700

37,800

21,000

16,800

10,540

5,040

5,500

43118

43121

43122

Partial esophagectomy, distal two-thirds, w/ thoracotomy and separate


abdominal incision, w/ or w/o proximal gastrectomy; w/ colon interposition
or small bowel reconstruction, including bowel mobilization, preparation,
and anastomosis(ses)
Partial esophagectomy, distal two-thirds, w/ thoracotomy only, w/ or w/o
proximal gastrectomy, w/ thoracic esophagogastrostomy, w/ or w/o
pyloroplasty
Partial esophagectomy, thoracoabdominal or abdominal approach, w/ or
w/o proximal gastrectomy; w/ esophagogastrotomy, w/ or w/o pyloroplasty

43202

Partial esophagectomy, thoracoabdominal or abdominal approach, w/ or


w/o proximal gastrectomy; w/ colon interposition or small bowel
reconstruction, including bowel mobilization, preparation, and
anastomosis(ses)
Total or partial esophagectomy, w/o reconstruction (any approach), w/
cervical esophagostomy
Diverticulectomy of hypopharynx, or esophagus, w/ or w/o myotomy;
cervical approach
Diverticulectomy of hypopharynx, or esophagus, w/ or w/o myotomy;
thoracic approach
Endoscopy
Esophagoscopy, rigid or flexible; diagnostic, w/ or w/o collection of
specimen(s) by brushing or washing
Esophagoscopy, rigid or flexible; w/ biopsy, single or multiple

10,540

5,040

5,500

43204

Esophagoscopy, rigid or flexible; w/ injection sclerosis of esophageal varices

14,960

7,560

7,400

43205

Esophagoscopy, rigid or flexible; w/ band ligation of esophageal varices

14,960

7,560

7,400

43215

Esophagoscopy, rigid or flexible; w/ removal of foreign body


Esophagoscopy, rigid or flexible; w/ removal of tumor(s), polyp(s), or other
lesion(s) by hot biopsy forceps or bipolar cautery
Esophagoscopy, rigid or flexible; w/ removal of tumor(s), polyp(s), or other
lesion(s) by snare technique

14,960

7,560

7,400

11,980

5,880

6,100

12,120

6,720

5,400

Esophagoscopy, rigid or flexible; w/ insertion of plastic tube or stent

18,000

8,400

9,600

18,000

8,400

9,600

18,000

8,400

9,600

14,960

7,560

7,400

18,000

8,400

9,600

10,540

5,040

5,500

10,540

5,040

5,500

43123

43124
43130
43135

43200

43216
43217
43219
43220
43226
43227
43228
43234
43235

Esophagoscopy, rigid or flexible; w/ balloon dilation (less than 30 mm


diameter)
Esophagoscopy, rigid or flexible; w/ insertion of guide wire followed by
dilation over guide wire
Esophagoscopy, rigid or flexible; w/ control of bleeding, any method
Esophagoscopy, rigid or flexible; w/ ablation of tumor(s) polyp(s), or other
lesion(s), not amenable to removal by hot biopsy forceps, bipolar cautery or
snare technique
Upper gastrointestinal endoscopy, simple primary examination ( e.g. w/
small diameter flexible endoscope)
Upper gastrointestinal endoscopy including esophagus, stomach, and either
the duodenum and/or jejunum as appropriate; diagnostic, w/ or w/o
collection of specimen(s) by brushing or washing

43239

Upper gastrointestinal endoscopy including esophagus, stomach, and either


the duodenum and/or jejunum as appropriate; w/ biopsy, single or multiple

10,540

5,040

5,500

43241

Upper gastrointestinal endoscopy including esophagus, stomach, and either


the duodenum and/or jejunum as appropriate; w/ transendoscopic tube or
catheter placement

12,120

6,720

5,400

Page 59 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE

DESCRIPTION

Case Rate

Professional Fee

Health Care
Institution Fee

43243

Upper gastrointestinal endoscopy including esophagus, stomach, and either


the duodenum and/or jejunum as appropriate; w/ injection sclerosis of
esophageal and/or gastric varices

14,960

7,560

7,400

43244

Upper gastrointestinal endoscopy including esophagus, stomach, and either


the duodenum and/or jejunum as appropriate; w/ band ligation of
esophageal and/or gastric varices

14,960

7,560

7,400

43245

Upper gastrointestinal endoscopy including esophagus, stomach, and either


the duodenum and/or jejunum as appropriate; w/ dilation of gastric outlet
for obstruction, any method

18,000

8,400

9,600

43246

Upper gastrointestinal endoscopy including esophagus, stomach, and either


the duodenum and/or jejunum as appropriate; w/ directed placement of
percutaneous gastrostomy tube

18,000

8,400

9,600

43247

Upper gastrointestinal endoscopy including esophagus, stomach, and either


the duodenum and/or jejunum as appropriate; w/ removal or foreign body

14,960

7,560

7,400

43248

Upper gastrointestinal endoscopy including esophagus, stomach, and either


the duodenum and/or jejunum as appropriate; w/ insertion of guide wire
followed by dilation of esophagus over guide wire

18,000

8,400

9,600

43249

Upper gastrointestinal endoscopy including esophagus, stomach, and either


the duodenum and/or jejunum as appropriate; w/ ballon dilation of
esophagus (less than 30 mm diameter)

18,000

8,400

9,600

43250

Upper gastrointestinal endoscopy including esophagus, stomach, and either


the duodenum and/or jejunum as appropriate; w/ removal of tumor(s),
polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery

11,980

5,880

6,100

43251

Upper gastrointestinal endoscopy including esophagus, stomach, and either


the duodenum and/or jejunum as appropriate; w/ removal of tumor(s),
polyp(s), or other lesion(s) by snare technique

12,120

6,720

5,400

43255

Upper gastrointestinal endoscopy including esophagus, stomach, and either


the duodenum and/or jejunum as appropriate; w/ control of bleeding, any
method

14,960

7,560

7,400

43258

Upper gastrointestinal endoscopy including esophagus, stomach, and either


the duodenum and/or jejunum as appropriate; w/ ablation of tumor(s),
polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps,
bipolar cautery or snare technique

18,000

8,400

9,600

14,960

7,560

7,400

20,980

10,080

10,900

20,980

10,080

10,900

21,820

10,920

10,900

43259
43260
43261
43262

Upper gastrointestinal endoscopy including esophagus, stomach, and either


the duodenum and/or jejunum as appropriate; w/ endoscopic ultrasound
examination
Endoscopic retrograde cholangiopancreatography (ERCP); diagnostic, w/ or
w/o collection of specimen(s) by brushing or washing
Endoscopic retrograde cholangiopancreatography (ERCP); w/ biopsy, single
or multiple
Endoscopic retrograde cholangiopancreatography (ERCP); w/
sphincterotomy/papillotomy

43263

Endoscopic retrograde cholangiopancreatography (ERCP); w/ pressure


measurement of sphincter of Oddi (pancreatic duct or common bile duct)

21,820

10,920

10,900

43264

Endoscopic retrograde cholangiopancreatography (ERCP); w/ endoscopic


retrograde removal of stone(s) from biliary and/or pancreatic ducts

23,300

12,600

10,700

43265

Endoscopic retrograde cholangiopancreatography (ERCP); w/ endoscopic


retrograde destruction, lithotripsy of stone(s), any method

30,740

13,440

17,300

43267

Endoscopic retrograde cholangiopancreatography (ERCP); w/ endoscopic


retrograde insertion of nasobiliary or nasopancreatic drainage tube

22,660

11,760

10,900

43268

Endoscopic retrograde cholangiopancreatography (ERCP); w/ endoscopic


retrograde insertion of tube or stent into bile or pancreatic duct

22,660

11,760

10,900

43269

Endoscopic retrograde cholangiopancreatography (ERCP); w/ endoscopic


retrograde removal of foreign body and/or change of tube or stent

22,660

11,760

10,900

43271

Endoscopic retrograde cholangiopancreatography (ERCP); w/ endoscopic


retrograde balloon dilation of ampulla, biliary and/or pancreatic duct(s)

23,300

12,600

10,700

Page 60 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE

43272

DESCRIPTION

Case Rate

Endoscopic retrograde cholangiopancreatography (ERCP); w/ ablation of


tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy
forceps, bipolar cautery or snare technique

Professional Fee

Health Care
Institution Fee

23,300

12,600

10,700

46,500

25,200

21,300

30,300

16,800

13,500

30,300

16,800

13,500

46,500

25,200

21,300

53,400

29,400

24,000

46,500

25,200

21,300

43324

Laparoscopy
Laparoscopy, surgical, esophagogastic fundoplasty (e.g., Nissen, Toupet
procedures)
Repair
Esophagoplasty, (plastic repair or reconstruction), cervical approach; w/o
repair of tracheoesophageal fistula
Esophagoplasty, (plastic repair or reconstruction), cervical approach; w/
repair of tracheoesophageal fistula
Esophagoplasty, (plastic repair or reconstruction), thoracic approach; w/o
repair of tracheoesophageal fistula
Esophagoplasty, (plastic repair or reconstruction), thoracic approach; w/
repair of tracheoesophageal fistula
Esophagogastrostomy (cardioplasty), w/ or w/o vagotomy and pyloroplasty,
transabdominal or transthoracic approach
Esophagogastric fundoplasty (e.g., Nissen, Belsey IV, Hill procedures)

46,500

25,200

21,300

43325

Esophagogastric fundoplasty; w/ fundic patch (Thal-Nissen procedure)

46,500

25,200

21,300

43326
43330
43331
43340
43341

Esophagogastric fundoplasty; w/ gastroplasty (e.g., Collis)


Esophagomyotomy (Heller type); abdominal approach
Esophagomyotomy (Heller type); thoracic approach
Esophagojejunostomy (w/o total gastrectomy); abdominal approach
Esophagojejunostomy (w/o total gastrectomy); thoracic approach

48,600
37,800
46,500
37,800
46,500

27,300
21,000
25,200
21,000
25,200

21,300
16,800
21,300
16,800
21,300

43350

Esophagostomy, fistulization of esophagus, external; abdominal approach

23,300

12,600

10,700

43351

Esophagostomy, fistulization of esophagus, external; thoracic approach

30,300

16,800

13,500

43352

Esophagostomy, fistulization of esophagus, external; cervical approach

12,120

6,720

5,400

43360

Gastrointestinal reconstruction for previous esophagectomy, for obstructing


esophageal lesion or fistula, or for previous esophageal exclusion; w/
stomach, w/ or w/o pyloroplasty

58,800

37,800

21,000

43361

Gastrointestinal reconstruction for previous esophagectomy, for obstructing


esophageal lesion or fistula, or for previous esophageal exclusion; w/ colon
interposition or small bowel reconstruction, including bowel mobilization,
preparation, and anastomosis(es)

63,000

42,000

21,000

37,800
37,800

21,000
21,000

16,800
16,800

37,800

21,000

16,800

12,120

6,720

5,400

37,800

21,000

16,800

12,120

6,720

5,400

37,800

21,000

16,800

8,260

3,360

4,900

8,260
8,260

3,360
3,360

4,900
4,900

8,260

3,360

4,900

43280

43300
43305
43310
43312
43320

43400
43401

43453
43456

Ligation, direct, esophageal varices


Transection of esophagus w/ repair, for esophageal varices
Ligation or stapling at gastroesophageal junction for pre-existing esophageal
perforation
Suture of esophageal wound or injury; cervical approach
Suture of esophageal wound or injury; transthoracic or transabdominal
approach
Closure of esophagostomy or fistula; cervical approach
Closure of esophagostomy or fistula; transthoracic or transabdominal
approach
Manipulation
Dilation of esophagus, by unguided sound or bougie, single or multiple
passes
Dilation of esophagus, over guide wire
Dilation of esophagus, by balloon or dilator, retrograde

43458

Dilation of esophagus w/ balloon (30 mm diameter or larger) for achalasia

43460
43496

Esophagogastric tamponade, w/ balloon (Sengstaaken type)


Free jejunum transfer w/ microvascular anastomosis
Stomach
Incision
Gastrotomy; w/ exploration or foreign body removal
Gastrotomy; w/ suture repair of bleeding ulcer
Gastrotomy; w/ suture repair of pre-existing esophagogastric laceration
(e.g., Mallory-Weiss)
Gastrotomy; w/ esophageal dilation and insertion of permanent
intraluminal tube (e.g., Celestin or Mousseaux-Barbin)

9,700
58,800

4,200
37,800

5,500
21,000

30,300
38,020

16,800
19,320

13,500
18,700

38,020

19,320

18,700

38,020

19,320

18,700

43520

Pyloromyotomy, cutting of pyloric muscle (Fredet-Ramstedt type operation)

38,020

19,320

18,700

43600
43605
43610

Excision
Biopsy of stomach; by capsule, tube, peroral (one or more specimens)
Biopsy of stomach; by laparotomy
Excision, local; ulcer or benign tumor of stomach

8,260
30,300
38,020

3,360
16,800
19,320

4,900
13,500
18,700

43405
43410
43415
43420
43425

43450

43500
43501
43502
43510

Page 61 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE
43611
43620
43621
43622
43631
43632
43633
43634
43638
43639

DESCRIPTION

38,020
63,000
67,200
67,200
55,000
55,000
63,000
63,000

19,320
42,000
46,200
46,200
33,600
33,600
42,000
42,000

Health Care
Institution Fee
18,700
21,000
21,000
21,000
21,400
21,400
21,000
21,000

63,000

42,000

21,000

67,200

46,200

21,000

37,800

21,000

16,800

46,500

25,200

21,300

18,000

8,400

9,600

21,940

9,240

12,700

18,000

8,400

9,600

8,020
5,560

2,520
1,260

5,500
4,300

37,800
63,000
46,500
53,400
37,800

21,000
42,000
25,200
29,400
21,000

16,800
21,000
21,300
24,000
16,800

Case Rate

Excision, local; malignant tumor of stomach


Gastrectomy, total; w/ esophagoenterostomy
Gastrectomy, total; w/ Roux-en-Y reconstruction
Gastrectomy, total; w/ formation of intestinal pouch, any type
Gastrectomy, partial, distal; w/ gastroduodenostomy
Gastrectomy, partial, distal; w/ gastrojejunostomy
Gastrectomy, partial, distal; w/ Roux-en-Y reconstruction
Gastrectomy, partial, distal; w/ formation of intestinal pouch
Gastrectomy, partial, proximal, thoracic or abdominal approach including
esophagogastrostomy, w/ vagotomy;
Gastrectomy, partial, proximal, thoracic or abdominal approach including
esophagogastrostomy, w/ vagotomy; w/ pyloroplasty or pyloromyotomy

Professional Fee

43800
43810
43820
43825
43830

Vagotomy including pyloroplasty, w/ or w/o gastrostomy; truncal or


selective
Vagotomy including pyloroplasty, w/ or w/o gastrostomy; parietal cell
(highly selective)
Laparoscopy
Laparoscopy, surgical; transection of vagus nerves, truncal
Laparoscopy, surgical; transection of vagus nerve, selective or highly
selective
Laparoscopy, surgical; gastrostomy, without construction of gastric tube
(e.g., Stamm Procedure)
Percutaneous placement of gastrostomy tube
Change of gastrostomy tube
Other Procedures
Pyloroplasty
Gastroduodenostomy
Gastrojejunostomy; w/o vagotomy
Gastrojejunostomy; w/ vagotomy, any type
Gastrostomy, temporary (tube, rubber or plastic) ;

43831

Gastrostomy, temporary (tube, rubber or plastic) ; neonatal, for feeding

37,800

21,000

16,800

43832

Gastrostomy, permanent, w/ construction of gastric tube


Gastrorrhaphy, suture of perforated duodenal or gastric ulcer, wound, or
injury
Gastric restrictive procedure, w/o gastric bypass, for morbid obesity;
vertical-banded gastroplasty
Gastric restrictive procedure, w/o gastric bypass, for morbid obesity; other
than vertical-banded gastroplasty

37,800

21,000

16,800

46,500

25,200

21,300

55,000

33,600

21,400

58,800

37,800

21,000

58,800

37,800

21,000

58,800

37,800

21,000

58,800

37,800

21,000

58,800

37,800

21,000

63,000

42,000

21,000

58,800

37,800

21,000

63,000

42,000

21,000

46,500
58,800

25,200
37,800

21,300
21,000

58,800
53,400

37,800
29,400

21,000
24,000

37,800

21,000

16,800

43640
43641
43651
43652
43653
43750
43760

43840
43842
43843
43846
43847
43848
43850
43855
43860

43865
43870
43880

44005
44010
44020

Gastric restrictive procedure, w/ gastric bypass for morbid obesity; w/ short


limb (less than 100 cm) Roux-en-Y gastroenterostomy
Gastric restrictive procedure, w/ gastric bypass for morbid obesity; w/ small
bowel reconstruction to limit absorption
Revision of gastric restrictive procedure for morbid obesity
Revision of gastroduodenal anastomosis (gastroduodenostomy) w/
reconstruction; w/o vagotomy
Revision of gastroduodenal anastomosis (gastroduodenostomy) w/
reconstruction; w/ vagotomy
Revision of gastrojejunal anastomosis (gastrojejunostomy) w/
reconstruction, w/ or w/o partial gastrectomy or bowel resection; w/o
vagotomy
Revision of gastrojejunal anastomosis (gastrojejunostomy) w/
reconstruction, w/ or w/o partial gastrectomy or bowel resection; w/
vagotomy
Closure of gastrostomy, surgical
Closure of gastrocolic fistula
Intestines (Except Rectum)
Incision
Enterolysis (freeing of intestinal adhesion)
Duodenotomy, for exploration, biopsy(s), or foreign body removal
Enterotomy, small bowel, other than duodenum; for exploration, biopsy(s),
or foreign body removal;

44021

Enterotomy, small bowel, other than duodenum; for exploration, biopsy(s),


or foreign body removal; for decompression (e.g., Baker tube)

37,800

21,000

16,800

44025

Colotomy, for exploration, biopsy(s), or foreign body removal

37,800

21,000

16,800

44050

Reduction of volvulus, intussusception, internal hernia, by laparotomy

53,400

29,400

24,000

44055

Correction of malrotation by lysis of duodenal bands and/or reduction of


midgut volvulus (e.g., Ladd procedure)

55,000

33,600

21,400

Page 62 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE
44100
44110
44111

DESCRIPTION

Case Rate

Excision
Biopsy of intestine by capsule, tube, peroral (one or more specimens)
Excision of one or more lessions of small or large bowel not requiring
anastomosis, exteriorization, or fistulization; single enterotomy
Excision of one or more lessions of small or large bowel not requiring
anastomosis, exteriorization, or fistulization; multiple enterotomies

Professional Fee

Health Care
Institution Fee

18,000

8,400

9,600

37,800

21,000

16,800

46,500

25,200

21,300

44120

Enterectomy, resection of small intestine; single resection and anastomosis

46,500

25,200

21,300

44125

Enterectomy, resection of small intestine; w/ enterostomy


Enteroenterostomy, anastomosis of intestine, w/ or w/o cutaneous
enterostomy
Colectomy, partial; w/ anastomosis
Colectomy, partial; w/ skin level cecostomy or colostomy
Colectomy, partial; w/ end colostomy and closure of distal segment
(Hartmann type procedure)
Colectomy, partial; w/ resection, w/ colostomy or ileostomy and creation of
mucofistula

46,500

25,200

21,300

53,400

29,400

24,000

58,800
58,800

37,800
37,800

21,000
21,000

58,800

37,800

21,000

58,800

37,800

21,000

Colectomy, partial; w/ coloproctostomy (low pelvic anastomosis)

56,680

35,280

21,400

58,800

37,800

21,000

63,000

42,000

21,000

63,000

42,000

21,000

63,000

42,000

21,000

67,200

46,200

21,000

67,200

46,200

21,000

67,200
67,200
67,200

46,200
46,200
46,200

21,000
21,000
21,000

44130
44140
44141
44143
44144
44145
44146
44147
44150
44151
44152
44153
44155
44156
44160

Colectomy, partial; w/ coloproctostomy (low pelvic anastomosis), w/


colostomy
Colectomy, partial; abdominal and transanal approach
Colectomy, total, abdominal, w/o proctectomy; w/ ileostomy or
ileoproctostomy
Colectomy, total, abdominal, w/o proctectomy; w/ continent ileostomy
Colectomy, total, abdominal, w/o proctectomy; w/ rectal mucosectomy,
ileoanal anastomosis, w/ or w/o loop ileostomy
Colectomy, total, abdominal, w/o proctectomy; w/ rectal mucosectomy,
ileoanal anastomosis, creation of ileal reservior (S or J), w/ or w/o loop
ileostomy
Colectomy, total, abdominal, w/ proctectomy; w/ ileostomy
Colectomy, total, abdominal, w/ proctectomy; w/ continent ileostomy
Colectomy w/ removal of terminal ileum and ileocolostomy
Laparsocopy

44180

Laparoscopy, surgical, enterolysis (freeing of intestinal adhesion)

18,000

8,400

9,600

44186

Laparoscopy, surgical; jejunostomy (e.g., for decompression or feeding;

12,120

6,720

5,400

44187

Laparoscopy, surgical; jejunostomy (e.g., for decompression or feeding);


ileostomy or jejunostomy, non-tube

12,120

6,720

5,400

44188
44202
44204
44205
44206
44207
44208
44210

44211

44212
44227

Laparoscopy, surgical, colostomy or skin level cecostomy


Laparoscopy, surgical; enterectomy, resection of small intestine, single
resection and anastomosis
Laparoscopy, surgical; colectomy, partial, with anastomosis
Laparoscopy, surgical; colectomy, partial, with removal of terminal ileum
with ileocolostomy
Laparoscopy, surgical; colectomy, partial, with end colostomy and closure of
distal segment (Hartmann type procedure)
Laparoscopy, surgical; colectomy, partial, with anastomosis, with
coloproctostomy (low pelvic anastomosis)
Laparoscopy, surgical; colectomy, partial, with anastomosis, with
coloproctostomy (low pelvic anastomosis) with colostomy
Laparoscopy, surgical; colectomy, total, abdominal, without protectomy,
with ileostomy or ileoproctostomy
Laparoscopy, surgical; colectomy, total, abdominal, with protectomy, with
ileo-anal anastomosis, creation of ileal reservoir (S or J), with loop
ileostomy, with or without rectal mucosectomy
Laparoscopy, surgical; colectomy, total, abdominal, with protectomy, with
ileostomy
Laparoscopy, surgical; closure of enterostomy, large or small intestine, with
resection and anastomosis
Enterostomy - External Fistulization of Intestines

18,000

8,400

9,600

23,300

12,600

10,700

37,800

21,000

16,800

58,800

37,800

21,000

37,800

21,000

16,800

55,000

33,600

21,400

58,800

37,800

21,000

55,000

33,600

21,400

58,800

37,800

21,000

55,000

33,600

21,400

23,300

12,600

10,700

44300

Enterostomy or cecostomy, tube (e.g., for decompression or feeding)

18,000

8,400

9,600

44310
44312
44314
44316
44320

Ileostomy or jejunostomy, non- tube


Revision of ileostomy; simple (release of superficial scar)
Revision of ileostomy; complicated (reconstruction in-depth)
Continent ileostomy (Koch procedure)
Colostomy or skin level cecostomy;

21,820
23,300
21,820
30,300
23,300

10,920
12,600
10,920
16,800
12,600

10,900
10,700
10,900
13,500
10,700

Page 63 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE
44322
44340
44345
44346

44360

DESCRIPTION

Case Rate

Colostomy or skin level cecostomy; w/ multiple biopsies (e.g., for


Hirschsprung disease)
Revision of colostomy; simple (release of superficial scar)
Revision of colostomy; complicated (reconstruction in - depth )
Revision of colostomy; w/ repair of paracolostomy hernia
Endoscopy, Small Bowel and Stomal
Small intestinal endoscopy, enteroscopy, beyond second portion of
duodenum, not including ileum; diagnostic, w/ or w/o collection of
specimen(s) by brushing or washing

Professional Fee

Health Care
Institution Fee

30,300

16,800

13,500

23,300
30,300
30,300

12,600
16,800
16,800

10,700
13,500
13,500

14,960

7,560

7,400

44361

Small intestinal endoscopy, enteroscopy, beyond second portion of


duodenum, not including ileum; w/ biopsy, single or multiple

14,960

7,560

7,400

44363

Small intestinal endoscopy, enteroscopy, beyond second portion of


duodenum, not including ileum; w/ removal of foreign body

18,000

8,400

9,600

44364

Small intestinal endoscopy, enteroscopy, beyond second portion of


duodenum, not including ileum; w/ removal of tumor(s), polyp(s), or other
lesions(s) by snare technique

18,000

8,400

9,600

44365

Small intestinal endoscopy, enteroscopy, beyond second portion of


duodenum, not including ileum; w/ removal of tumor(s), polyp(s), or other
lesion(s) by hot biopsy forceps or bipolar cautery

18,000

8,400

9,600

44366

Small intestinal endoscopy, enteroscopy, beyond second portion of


duodenum, not including ileum; w/ control of bleeding, any method

18,000

8,400

9,600

21,940

9,240

12,700

21,940

9,240

12,700

21,940

9,240

12,700

18,000

8,400

9,600

18,000

8,400

9,600

21,940

9,240

12,700

14,960

7,560

7,400

14,960

7,560

7,400

14,960

7,560

7,400

14,960

7,560

7,400

14,960

7,560

7,400

14,960
18,000
18,000

7,560
8,400
8,400

7,400
9,600
9,600

18,000

8,400

9,600

21,940

9,240

12,700

21,940

9,240

12,700

8,020

2,520

5,500

37,800

21,000

16,800

37,800

21,000

16,800

44369

44372

44373

44376
44377
44378
44380
44382
44385
44386
44388
44389
44390
44391
44392
44393
44394
44500

44602
44603

Small intestinal endoscopy, enteroscopy, beyond second portion of


duodenum, not including ileum; w/ ablation of tumor(s), polyp(s), or other
lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or
snare tenchnique
Small intestinal endoscopy, enteroscopy, beyond second portion of
duodenum, not including ileum; w/ placement of percutaneous
jejunostomy tube
Small intestinal endoscopy, enteroscopy, beyond second portion of
duodenum, not including ileum; w/ conversion of percutaneous
gastrostomy tube to percutaneous jejunostomy tube
Small intestinal endoscopy, enteroscopy beyond second portion of
duodenum, including ileum; diagnostic, w/ or w/o collection of specimen(s)
by brushing or washing
Small intestinal endoscopy, enteroscopy beyond second portion of
duodenum, including ileum;w/ biopsy, single or multiple
Small intestinal endoscopy, enteroscopy beyond second portion of
duodenum, including ileum;w/ control of bleeding, any method
Ileoscopy, through stoma; diagnostic, w/ or w/o collection of specimen(s) by
brushing or washing
Ileoscopy, through stoma; w/ biopsy, single or multiple
Endoscopic evaluation of small intestinal (abdominal or pelvic) pouch;
diagnostic, w/ or w/o collection of specimen(s) by brushing or washing
Endoscopic evaluation of small intestinal (abdominal or pelvic) pouch; w/
biopsy, single or multiple
Colonoscopy through stoma; diagnostic, w/ or w/o collection of specimen(s)
by brushing or washing
Colonoscopy through stoma; w/ biopsy, single or multiple
Colonoscopy through stoma; w/ removal of foreign body
Colonoscopy through stoma; w/ control of bleeding, any method
Colonoscopy through stoma; w/ removal of tumor(s), polyp(s), or other
lesion(s) by hot biopsy forceps or bipolar cautery
Colonoscopy through stoma; w/ ablation of tumor(s), polyp(s), or other
lesion(s) not amenable to removal by hot biopsy forceps, bipolar caurtery
or snare technique
Colonoscopy through stoma; w/ removal of tumor(s), polyp(s), or other
lesion(s) by snare technique
Introduction
Introduction of long gastrointestinal tube (e.g., Miller-Abbott)
Repair
Suture of small intestine (enterorrhaphy) for perforated ulcer, diverticulum,
wound, injury or rupture; single perforation
Suture of small intestine (enterorrhaphy) for perforated ulcer, diverticulum,
wound, injury or rupture; multiple perforation

Page 64 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE

DESCRIPTION

Case Rate

Professional Fee

Health Care
Institution Fee

44604

Suture of large intestine (colorrhaphy) for perforated ulcer, diverticulum,


wound, injury or rupture (single or multiple perforations); w/o colostomy

37,800

21,000

16,800

44605

Suture of large intestine (colorrhaphy) for perforated ulcer, diverticulum,


wound, injury or rupture (single or multiple perforations); w/ colostomy

37,800

21,000

16,800

37,800

21,000

16,800

30,300

16,800

13,500

30,300

16,800

13,500

30,300
30,300

16,800
16,800

13,500
13,500

44640
44650

Intestinal stricturoplasty (enterotomy and enterorrhaphy) w/ or w/o


dilation, for intestinal obstruction
Closure of enterostomy, large or small intestine;
Closure of enterostomy, large or small intestine; w/ resection and
anastomosis
Closure of intestinal cutaneous fistula
Closure of enteroenteric or enterocolic fistula

44660

Closure of enterovesical fistula; w/o intestinal or bladder resection

37,800

21,000

16,800

44661

Closure of enterovesical fistula; w/ bowel and/or bladder resection

37,800

21,000

16,800

18,000

8,400

9,600

18,000

8,400

9,600

12,120

6,720

5,400

10,540

5,040

5,500

24,000

9,600

14,400

24,000

9,600

14,400

24,000

9,600

14,400

30,300
18,000

16,800
8,400

13,500
9,600

30,300

16,800

13,500

44615
44620
44625

44950

Meckel's Diverticulum and the Mesentery


Excision
Excision of Meckels diverticulum (diverticulectomy) or omphalomesenteric
duct
Excision of lesion of mesentery
Suture
Suture of mesentery
Appendix
Incision
Incision and drainage of appendiceal abscess, transabdominal
Excision
Appendectomy;

44960

Appendectomy; for ruptured appendix w/ abscess or generalized peritonitis

44800
44820
44850

44900

44970

45000
45005
45020

Laparoscopy
Laparoscopy, surgical; appendectomy
Rectum
Incision
Transrectal drainage of pelvic abscess
Incision and drainage of submucosal abscess, rectum
Incision and drainage of deep supralevator, pelvirectal, or retrorectal
abscess
Excision

45100

Biopsy of anorectal wall, anal approach (e.g., congenital megacolon)

23,300

12,600

10,700

45108

Anorectal myomectomy

30,300

16,800

13,500

45110

Proctectomy; complete, combined abdominoperineal, w/ colostomy

55,000

33,600

21,400

45111

Proctectomy; partial resection of rectum, transabdominal approach


Proctectomy, combined abdominoperineal, pull-through procedure (e.g.,
colo-anal anastomosis)

55,000

33,600

21,400

55,000

33,600

21,400

45112
45113

Proctectomy, partial, w/ rectal mucosectomy, ileoanal anastomosis,


creation of ileal reservoir (S or J), w/ or w/o loop ileostomy

58,800

37,800

21,000

45114

Proctectomy, partial, w/ anastomosis; abdominal and transsacral approach

58,800

37,800

21,000

55,000

33,600

21,400

58,800

37,800

21,000

45116
45120

Proctectomy, partial, w/ anastomosis; transsacral approach only (Kraske


type)
Proctectomy, complete (for congenital megacolon), abdominal and perineal
approach; w/ pull-through procedure and anastomosis (e.g., Swenson,
Duhamel, or Soave type operation)

45121

Proctectomy, complete (for congenital megacolon), abdominal and perineal


approach; w/ subtotal or total colectomy, w/ multiple biopsies

58,800

37,800

21,000

45123

Proctectomy, partial, w/o anastomosis, perineal approach

55,000

33,600

21,400

45130

Excision of rectal procidentia, w/ anatomosis; perineal approach

53,400

29,400

24,000

55,000

33,600

21,400

12,120

6,720

5,400

55,000

33,600

21,400

18,000

8,400

9,600

18,000

8,400

9,600

45135
45150
45160
45170
45190

Excision of rectal procidentia, w/ anatomosis; abdominal and perineal


approach
Division of stricture of rectum
Excision of rectal tumor by proctotomy, transsacral or transcoccygeal
approach
Excision of rectal tumor, transanal approach
Destruction
Destruction of rectal tumor, any method (e.g., electrodesiccation) transanal
approach

Page 65 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE

45300

DESCRIPTION

Case Rate

Endoscopy
Proctosigmoidoscopy, rigid; diagnostic, w/ or w/o collection of specimen(s)
by brushing or washing
Proctosigmoidoscopy, rigid; w/ dilation, any method
Proctosigmoidoscopy, rigid; w/ biopsy, single or multiple
Proctosigmoidoscopy, rigid; w/ removal of foreign body
Proctosigmoidoscopy, rigid; w/ removal of single tumor, polyp, or other
lesion by hot biopsy forceps or bipolar cautery
Proctosigmoidoscopy, rigid; w/ removal of single tumor, polyp, or other
lesion by snare technique

Professional Fee

Health Care
Institution Fee

8,020

2,520

5,500

9,700
8,020
8,260

4,200
2,520
3,360

5,500
5,500
4,900

9,700

4,200

5,500

9,700

4,200

5,500

10,540

5,040

5,500

10,540

5,040

5,500

10,540

5,040

5,500

10,540

5,040

5,500

8,260

3,360

4,900

8,260
9,700

3,360
4,200

4,900
5,500

9,700

4,200

5,500

45334

Proctosigmoidoscopy, rigid; w/ control of bleeding, any method


Proctosigmoidoscopy, rigid; w/ ablation of tumor(s), polyp(s), or other
lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or
snare technique (e.g., laser)
Proctosigmoidoscopy, rigid; w/ decompression of volvulus
Sigmoidoscopy, flexible; diagnostic, w/ or w/o collection of specimen(s) by
brushing or washing
Sigmoidoscopy, flexible; w/ biopsy, single or multiple
Sigmoidoscopy, flexible; w/ removal of foreign body
Sigmoidoscopy, flexible; w/ removal of tumor(s), polyp(s), or other lesion(s)
by hot biopsy forceps or bipolar cautery
Sigmoidoscopy, flexible; w/ control of bleeding, any method

10,540

5,040

5,500

45337

Sigmoidoscopy, flexible; w/ decompression of volvulus, any method

12,120

6,720

5,400

10,540

5,040

5,500

11,980

5,880

6,100

10,540

5,040

5,500

12,120

6,720

5,400

12,120

6,720

5,400

12,120

6,720

5,400

18,000

8,400

9,600

45303
45305
45307
45308
45309
45315
45317
45320
45321
45330
45331
45332
45333

45338
45339
45355
45378
45379
45380
45382

Proctosigmoidoscopy, rigid; w/ removal of multiple tumors, polyps or other


lesions by hot biopsy forceps, bipolar cautery or snare technique

Sigmoidoscopy, flexible; w/ removal of tumor(s), polyp(s), or other lesion(s)


by snare technique
Sigmoidoscopy, flexible; w/ ablation of tumor(s), polyp(s), or other lesion(s)
not amenable to removal by hot biopsy forceps, bipolar cautery or snare
technique
Colonoscopy, rigid or flexible, transabdominal via colotomy, single or
multiple
Colonoscopy, flexible, proximal to splenic flexure; diagnostic, w/ or w/o
collection of specimen(s) by brushing or washing, w/ or w/o colon
decompression
Colonoscopy, flexible, proximal to splenic flexure; w/ removal of foreign
body
Colonoscopy, flexible, proximal to splenic flexure; w/ biopsy, single or
multiple
Colonoscopy, flexible, proximal to splenic flexure; w/ control of bleeding,
any method

45383

Colonoscopy, flexible, proximal to splenic flexure; w/ ablation of tumor(s),


polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps,
bipolar cautery or snare technique

14,960

7,560

7,400

45384

Colonoscopy, flexible, proximal to splenic flexure; w/ removal of tumor(s),


polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery

14,960

7,560

7,400

18,000

8,400

9,600

55,000

33,600

21,400

45385

45395

Colonoscopy, flexible, proximal to splenic flexure; w/ removal of tumor(s),


polyp(s), or other lesion(s) by snare technique
Laparoscopy
Laparoscopy, surgical; proctectomy, complete combined abdominoperineal,
with colostomy

45397

Laparoscopy, surgical; protectomy, combined abdominoperineal pull


through procedure (e.g., colo-anal anastomosis), with creation of colonic
reservoir (e.g., J-pouch), with diverting enterostomy, when performed

55,000

33,600

21,400

45400

Laparoscopy, surgical; proctopexy (for prolapse)

27,120

15,120

12,000

45402

Laparoscopy, surgical; proctopexy (for prolapse), with sigmoid resection

30,300

16,800

13,500

45500
45505
45540
45541
45550
45560
45562

Repair
Proctoplasty; for stenosis
Proctoplasty; for prolapse of mucous membrane
Proctopexy for prolapse; abdominal approach
Proctopexy for prolapse; perineal approach
Proctopexy combined w/ sigmoid resection, abdominal approach
Repair of rectocele
Exploration, repair and presacral drainage for rectal injury;

18,000
18,000
27,120
27,120
30,300
18,000
23,300

8,400
8,400
15,120
15,120
16,800
8,400
12,600

9,600
9,600
12,000
12,000
13,500
9,600
10,700

45563

Exploration, repair and presacral drainage for rectal injury; w/ colostomy

27,120

15,120

12,000

45800

Closure of rectovesical fistula;

30,300

16,800

13,500

Page 66 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE
45805
45820
45825
45905
45910
45915

46040
46045
46050
46060
46070
46080
46083
46200
46210
46211
46220
46221
46230
46250
46255
46257
46258
46260
46261
46262

DESCRIPTION

37,800
30,300
37,800

21,000
16,800
21,000

Health Care
Institution Fee
16,800
13,500
16,800

8,260
8,260
8,260

3,360
3,360
3,360

4,900
4,900
4,900

8,260

3,360

4,900

9,700

4,200

5,500

8,260

3,360

4,900

9,700

4,200

5,500

9,700
9,700
8,020

4,200
4,200
2,520

5,500
5,500
5,500

8,260
8,260
9,700
8,260
12,120
12,120
12,120
12,120
12,120

3,360
3,360
4,200
3,360
6,720
6,720
6,720
6,720
6,720

4,900
4,900
5,500
4,900
5,400
5,400
5,400
5,400
5,400

12,120

6,720

5,400

12,120

6,720

5,400

12,120

6,720

5,400

12,120

6,720

5,400

Case Rate

Closure of rectovesical fistula; w/ colostomy


Closure of rectourethral fistula;
Closure of rectourethral fistula; w/ colostomy
Manipulation
Dilation of anal sphincter under anesthesia other than local
Dilation of rectal stricture under anesthesia other than local
Removal of fecal impaction or foreign body under anesthesia
Anus
Incision
Incision and drainage of ischiorectal and/or perirectal abscess
Incision and drainage of intramural, intramuscular, or submucosal abscess,
transanal, under anesthesia
Incision and drainage, perianal abscess, superficial
Incision and drainage of ischiorectal or intramural abscess, w/ fistulectomy
or fistulotomy, submuscular, w/ or w/o placement of seton
Incision, anal septum (infant)
Sphincterotomy, anal, division of sphincter
Incision of thrombosed hemorrhoid, external
Excision
Fissurectomy, w/ or w/o sphincterotomy
Cryptectomy; single
Cryptectomy; multiple
Papillectomy or excision of single tag, anus
Hemorrhoidectomy, by simple ligature (e.g., rubber band)
Excision of external hemorrhoid tags and/or multiple papillae
Hemorrhoidectomy, external, complete
Hemorrhoidectomy, internal and external, simple;
Hemorrhoidectomy, internal and external, simple; w/ fissurectomy
Hemorrhoidectomy, internal and external, simple; w/ fistulectomy, w/ or
w/o fissurectomy
Hemorrhoidectomy, internal and external, complex or extensive;
Hemorrhoidectomy, internal and external, complex or extensive; w/
fissurectomy
Hemorrhoidectomy, internal and external, complex or extensive; w/
fistulectomy, w/ or w/o fissurectomy

Professional Fee

46270

Surgical treatment of anal fistula (fistulectomy/fistulotomy); subcutaneous

12,120

6,720

5,400

46275

Surgical treatment of anal fistula (fistulectomy/fistulotomy); submuscular

12,120

6,720

5,400

46280

Surgical treatment of anal fistula (fistulectomy/fistulotomy); complex or


multiple, w/ or w/o placement of seton

12,120

6,720

5,400

46285

Surgical treatment of anal fistula (fistulectomy/fistulotomy); second stage

12,120

6,720

5,400

46288
46320

Closure of anal fistula w/ rectal advancement flap


Enucleation or excision of external thrombotic hemorrhoid
Endoscopy
Anoscopy; diagnostic, w/ or w/o collection of specimen(s) by brushing or
washing
Anoscopy; w/ dilation, any method
Anoscopy; w/ biopsy, single or multiple
Anoscopy; w/ removal of foreign body
Anoscopy; w/ removal of single tumor, polyp, or other lesion by hot biopsy
forceps or bipolar cautery
Anoscopy; w/ removal of single tumor, polyp or other lesion by snare
technique

18,000
12,120

8,400
6,720

9,600
5,400

5,680

1,680

4,000

5,680
5,680
5,680

1,680
1,680
1,680

4,000
4,000
4,000

8,020

2,520

5,500

8,260

3,360

4,900

46600
46604
46606
46608
46610
46611
46612

Anoscopy; w/ removal of multiple tumor, polyps, or other lesions by hot


biopsy forceps, bipolar cautery or snare technique

8,260

3,360

4,900

46614

Anoscopy; w/ control of bleeding, any method

8,020

2,520

5,500

46615

Anoscopy; w/ ablation of tumor(s), polyp(s), or other lesion(s) not amenable


to removal by hot biopsy forceps, bipolar cautery or snare technique

9,700

4,200

5,500

12,900
23,300

6,300
12,600

6,600
10,700

23,300

12,600

10,700

37,800

21,000

16,800

37,800

21,000

16,800

46,500

25,200

21,300

46700
46705
46715
46716
46730
46735

Repair
Anoplasty, plastic operation for stricture; adult
Anoplasty, plastic operation for stricture; infant
Repair of low imperforate anus; w/ anoperineal fistula ("cut-back"
procedure)
Repair of low imperforate anus; w/ transportation of anoperineal or
anovestibular fistula
Repair of high imperforate anus w/o fistula; perineal or sacroperineal
approach
Repair of high imperforate anus w/o fistula; combined transabdominal and
sacroperineal approaches

Page 67 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE
46740
46742
46744

DESCRIPTION

Case Rate

Repair of high imperforate anus w/ rectourethral or rectovaginal fistula;


perineal or sacroperineal approach
Repair of high imperforate anus w/ rectourethral or rectovaginal fistula;
combined transabdominal and sacroperineal approaches
Repair of cloacal anomaly by anorectovaginoplasty and urethroplasty,
sacroperineal approach

Professional Fee

Health Care
Institution Fee

30,300

16,800

13,500

53,400

29,400

24,000

58,800

37,800

21,000

46746

Repair of cloacal anomaly by anorectovaginoplasty and urethroplasty,


combined abdominal and sacroperineal approach;

63,000

42,000

21,000

46748

Repair of cloacal anomaly by anorectovaginoplasty and urethroplasty,


combined abdominal and sacroperineal approach; w/ vaginal lengthening
by intestinal graft or pedicle flaps

63,000

42,000

21,000

46750
46751

Sphincteroplasty, anal, for incontinence or prolapse; adult


Sphincteroplasty, anal, for incontinence or prolapse; child

14,960
23,300

7,560
12,600

7,400
10,700

46753

Graft (Thiersch operation) for rectal incontinence and/or prolapse

9,700

4,200

5,500

46754

Removal of Thiersch wire or suture, anal canal

46760

Sphincteroplasty, anal, for incontinence, adult; muscle transplant

8,260

3,360

4,900

40,320

23,520

16,800

20,980

10,080

10,900

40,320

23,520

16,800

8,260

3,360

4,900

8,260

3,360

4,900

8,260

3,360

4,900

8,260

3,360

4,900

8,260

3,360

4,900

9,700

4,200

5,500

9,700
9,700
9,700
9,700
9,700

4,200
4,200
4,200
4,200
4,200

5,500
5,500
5,500
5,500
5,500

9,700

4,200

5,500

8,260

3,360

4,900

8,020
18,000

2,520
8,400

5,500
9,600

18,000

8,400

9,600

18,000
53,400
55,000
46,500
53,400

8,400
29,400
33,600
25,200
29,400

9,600
24,000
21,400
21,300
24,000

46,500

25,200

21,300

55,000

33,600

21,400

55,000

33,600

21,400

18,000

8,400

9,600

47300

Sphincteroplasty, anal, for incontinence, adult; levator muscle imbrication


(Park posterior anal repair)
Sphincteroplasty, anal, for incontinence, adult; implantation artificial
sphincter
Destruction
Destruction of lesion(s), anus (e.g., condyloma, papilloma, molluscum
contagiosum, herpetic vesicle), simple; chemical
Destruction of lesion(s), anus (e.g., condyloma, papilloma, molluscum
contagiosum, herpetic vesicle), simple; electrodesiccation
Destruction of lesion(s), anus (e.g., condyloma, papilloma, molluscum
contagiosum, herpetic vesicle), simple; cryosurgery
Destruction of lesion(s), anus (e.g., condyloma, papilloma, molluscum
contagiosum, herpetic vesicle), simple; laser surgery
Destruction of lesion(s), anus (e.g., condyloma, papilloma, molluscum
contagiosum, herpetic vesicle), simple; surgical excision
Destruction of lesion(s), anus (e.g., condyloma, papilloma, molluscum
contagiosum, herpetic vesicle), extensive, any method
Destruction of hemorrhoids, any method; internal
Destruction of hemorrhoids, any method; external
Destruction of hemorrhoids, any method; internal and external
Cryosurgery of rectal tumor; benign
Cryosurgery of rectal tumor; malignant
Curettage or cauterization of anal fissure, including dilation of anal
sphincter
Suture
Ligation of internal hemorrhoids
Liver
Incision
Biopsy of liver, needle; percutaneous
Hepatotomy for drainage of abscess or cyst, one or two stages
Laparotomy, w/ aspiration and/or injection of hepatic parasitic (e.g.,
amoebic or echinococcal) cyst(s) or abscess(es)
Excision
Biopsy of liver, wedge
Hepatectomy, resection of liver; partial lobectomy
Hepatectomy, resection of liver; trisegmentectomy
Hepatectomy, resection of liver; total left lobectomy
Hepatectomy, resection of liver; total right lobectomy
Donor hepatectomy, w/ preparation and maintenance of allograft; partial,
from living donor
Liver allotransplantation; orthotopic, partial or whole, from cadaver or living
donor, any age
Liver allotransplantation; heterotopic, partial or whole, from cadaver or
living donor, any age
Repair
Marsupialization of cyst or abscess of liver

47350

Management of liver hemorrhage; simple suture of liver wound or injury

23,300

12,600

10,700

47360

Management of liver hemorrhage; complex suture of liver wound or injury,


w/ or w/o hepatic artery ligation

46,500

25,200

21,300

47361

Management of liver hemorrhage; exploration of hepatic wound, extensive


debridement, coagulation and/or suture, w/ or w/o packing of liver

37,800

21,000

16,800

46761
46762

46900
46910
46916
46917
46922
46924
46934
46935
46936
46937
46938
46940
46945

47000
47010
47015
47100
47120
47122
47125
47130
47134
47135
47136

Page 68 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE
47362

47370

DESCRIPTION

Case Rate

Management of liver hemorrhage; re-exploration of hepatic wound for


removal of packing
Laparoscopy
Laparoscopy, surgical, ablation of one or more liver tumor(s);
radiofrequency

Professional Fee

Health Care
Institution Fee

37,800

21,000

16,800

18,000

8,400

9,600

47371

Laparoscopy, surgical, ablation of one or more liver tumor(s); cryosurgical

18,000

8,400

9,600

47380
47381

Other Procedures
Ablation, open, of or more liver tumor(s); radiofrequency
Ablation, open, of or more liver tumor(s); cryosurgical

9,700
9,700

4,200
4,200

5,500
5,500

47382

Ablation, one or more liver tumor(s), percutaneous radiofrequency

9,700

4,200

5,500

53,400

29,400

24,000

37,800

21,000

16,800

46,500

25,200

21,300

46,500

25,200

21,300

30,300

16,800

13,500

30,300

16,800

13,500

30,300

16,800

13,500

30,300

16,800

13,500

8,020
8,260

2,520
3,360

5,500
4,900

23,300

12,600

10,700

23,300

12,600

10,700

23,300

12,600

10,700

23,300

12,600

10,700

23,300

12,600

10,700

31,000

12,400

18,600

31,000

12,400

18,600

31,000
31,000

12,400
12,400

18,600
18,600

47400
47420

47425
47460
47480
47490
47510
47511
47525
47530
47552
47553

47554

47555

47556

47560

Biliary Tract
Incision
Hepaticotomy or hepaticostomy w/ exploration, drainage, or removal of
calculus
Choledochotomy or choledochostomy w/ exploration, drainage, or removal
of calculus, w/ or w/o cholecystotomy; w/o transduodenal sphincterotomy
or sphincteroplasty
Choledochotomy or choledochostomy w/ exploration, drainage, or removal
of calculus, w/ or w/o cholecystotomy; w/ transduodenal sphincterotomy or
sphincteroplasty
Transduodenal sphincterotomy or sphincteroplasty, w/ or w/o
transduodenal extraction of calculus
Cholecystotomy or cholecystostomy w/ exploration, drainage, or removal of
calculus
Percutaneous cholecystostomy
Introduction
Introduction of percutaneous transhepatic catheter for biliary drainage
Introduction of percutaneous transhepatic stent for internal and external
biliary drainage
Change of percutaneous biliary drainage catheter
Revision and/or reinsertion of transhepatic tube
Endoscopy
Biliary endoscopy, percutaneous via T- tube or other tract; diagnostic, w/ or
w/o collection of specimen(s) by brushing and/or washing
Biliary endoscopy, percutaneous via T- tube or other tract; diagnostic, w/ or
w/o collection of specimen(s) by brushing and/or washing w/ biopsy, single
or multiple
Biliary endoscopy, percutaneous via T- tube or other tract; diagnostic, w/ or
w/o collection of specimen(s) by brushing and/or washing w/ removal of
stone(s)
Biliary endoscopy, percutaneous via T- tube or other tract; diagnostic, w/ or
w/o collection of specimen(s) by brushing and/or washing w/ dilation of
biliary duct stricture(s) w/o stent
Biliary endoscopy, percutaneous via T- tube or other tract; diagnostic, w/ or
w/o collection of specimen(s) by brushing and/or washing w/ dilation of
biliary duct stricture(s) w/ stent
Laparoscopy

Laparoscopy, surgical; with guided transhepatic cholangiography, without


biopsy

47562
47563

Laparoscopy, surgical; with guided transhepatic cholangiography, with


biopsy
Laparoscopy, surgical; cholecystectomy (any method)
Laparoscopy, surgical; cholecystectomy with cholangiography

47564

Laparoscopy, surgical; cholecystectomy with exploration of common duct

46,500

25,200

21,300

47570

Laparoscopy, surgical; cholecystoenterostomy


Excision
Cholecystectomy;
Cholecystectomy; w/ cholangiography
Cholecystectomy w/ exploration of common duct;
Cholecystectomy w/ exploration of common duct; w/
choledochoenterostomy

31,000

12,400

18,600

31,000
31,000
46,500

12,400
12,400
25,200

18,600
18,600
21,300

53,400

29,400

24,000

46,500

25,200

21,300

47561

47600
47605
47610
47612
47620

Cholecystectomy w/ exploration of common duct; w/ transduodenal


sphincterotomy or sphincteroplasty, w/ or w/o cholangiography

Page 69 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE

DESCRIPTION

Case Rate

Professional Fee

Health Care
Institution Fee

47720
47721
47740
47741

Biliary duct stone extraction, percutaneous via T-tube tract, basket, or


snare (e.g., Burhenne technique)
Exploration for congenital atresia of bile ducts, w/o repair, w/ or w/o liver
biopsy, w/ or w/o cholangiography
Portoenterostomy (e.g., Kasai procedure)
Excision of bile duct tumor, w/ or w/o primary repair of bile duct;
extrahepatic
Excision of bile duct tumor, w/ or w/o primary repair of bile duct;
intrahepatic
Excision of choledochal cyst
Anastomosis, choledochal cyst, w/o excision
Repair
Cholecystoenterostomy; direct
Cholecystoenterostomy; w/ gastroenterostomy
Roux-en-Y
Roux-en-Y w/ gastroenterostomy

47760

Anastomosis, of extrahepatic biliary ducts and gastrointestinal tract

46,500

25,200

21,300

47765

Anastomosis, of intrahepatic ducts and gastrointestinal tract


Anastomosis, Roux-en-Y, of extrahepatic biliary ducts and gastrointestinal
tract
Anastomosis, Roux-en-Y, of intrahepatic biliary ducts and gastrointestinal
tract
Reconstruction, plastic, of extrahepatic biliary ducts w/ end-to-end
anastomosis
Placement of choledochal stent
U-tube hepaticoenterostomy
Suture of extrahepatic biliary duct for pre-existing injury
Pancreas
Incision
Placement of drains, peripancreatic, for acute pancreatitis;
Placement of drains, peripancreatic, for acute pancreatitis; w/
cholecystostomy, gastrostomy, and jejunostomy
Resection or debridement of pancreas and peripancreatic tissue for acute
necrotizing pancreatitis
Removal of pancreatic calculus
Excision
Biopsy of pancreas, open, any method (e.g., fine needle aspiration, needle
core biopsy, wedge biopsy)
Biopsy of pancreas, percutaneous needle
Excision of lesion of pancreas (e.g., cyst, adenoma)
Pancreatectomy, distal subtotal, w/ or w/o splenectomy; w/o
pancreaticojejunostomy
Pancreatectomy, distal subtotal, w/ or w/o splenectomy; w/
pancreaticojejunostomy
Pancreatectomy, distal, near-total w/ preservation of duodenum (Child-type
procedure)
Excision of ampulla of Vater

53,400

29,400

24,000

46,500

25,200

21,300

53,400

29,400

24,000

46,500

25,200

21,300

37,800
37,800
46,500

21,000
21,000
25,200

16,800
16,800
21,300

23,300

12,600

10,700

46,500

25,200

21,300

46,500

25,200

21,300

37,800

21,000

16,800

12,120

6,720

5,400

9,700
30,300

4,200
16,800

5,500
13,500

46,500

25,200

21,300

53,400

29,400

24,000

53,400

29,400

24,000

46,500

25,200

21,300

47630
47700
47701
47711
47712
47715
47716

47780
47785
47800
47801
47802
47900

48000
48001
48005
48020
48100
48102
48120
48140
48145
48146
48148

23,300

12,600

10,700

53,400

29,400

24,000

55,000

33,600

21,400

55,000

33,600

21,400

58,800

37,800

21,000

55,000
46,500

33,600
25,200

21,400
21,300

37,800
46,500
53,400
53,400

21,000
25,200
29,400
29,400

16,800
21,300
24,000
24,000

48150

Pancreatectomy, proximal subtotal w/ total duodenectomy, partial


gastrectomy, choledochoenterostomy and gastrojejunostomy (Whippletype procedure); w/ pancreatojejunostomy

58,800

37,800

21,000

48152

Pancreatectomy, proximal subtotal w/ total duodenectomy, partial


gastrectomy, choledochoenterostomy and gastrojejunostomy (Whippletype procedure); w/o pancreatojejunostomy

55,000

33,600

21,400

63,000

42,000

21,000

58,800

37,800

21,000

63,000

42,000

21,000

63,000

42,000

21,000

55,000

33,600

21,400

30,300
23,300
46,500

16,800
12,600
25,200

13,500
10,700
21,300

46,500

25,200

21,300

48500
48510
48520

Pancreatectomy, proximal subtotal w/ near total duodenectomy,


choledochoenterostomy and duodenojejunostomy (pylorus-sparing,
Whipple-type procedure); w/ pancreatojejunostomy
Pancreatectomy, proximal subtotal w/ near total duodenectomy,
choledochoenterostomy and duodenojejunostomy (pylorus-sparing,
Whipple-type procedure); w/o pancreatojejunostomy
Pancreatectomy, total
Pancreatectomy, total or subtotal, w/ autologous transplantation of
pancreas or pancreatic islets
Pancreaticojejunostomy, side-to-side anastomosis (Puestow-type
operation)
Repair
Marsupialization of cyst of pancreas
External drainage, psuedocyst of pancreas
Internal anastomosis of pacreatic cyst to gastrointestinal tract; direct

48540

Internal anastomosis of pacreatic cyst to gastrointestinal tract; Roux-en-Y

48153

48154
48155
48160
48180

Page 70 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE

DESCRIPTION
Pancreatorrhaphy for trauma
Duodenal exclusion w/ gastrojejunostomy for pancreatic trauma
Pancreas Transplantation
Donor pancreatectomy, w/ preparation and maintenance of allograft from
cadaver donor, w/ or w/o duodenal segment for transplantation
Transplantation of pancreatic allograft
Removal of transplanted pancreatic allograft
Abdomen, Peritoneum, and Omentum
Incision

53,400
53,400

29,400
29,400

Health Care
Institution Fee
24,000
24,000

30,300

16,800

13,500

30,300
23,300

16,800
12,600

13,500
10,700

49000

Exploratory laparotomy, exploratory celiotomy w/ or w/o biopsy(s)

23,300

12,600

10,700

49010

Exploration, retroperitoneal area w/ or w/o biopsy(s)


Drainage of peritoneal abscess or localized peritonitis, exclusive of
appendiceal abscess; open
Drainage of peritoneal abscess or localized peritonitis, exclusive of
appendiceal abscess; percutaneous
Drainage of subdiaphargmatic or subphrenic abscess
Drainage of retroperitoneal abscess
Peritoneocentesis, abdominal paracentesis, or peritoneal lavage (diagnostic
or therapeutic)
Removal of peritoneal foreign body from peritoneal cavity
Excision, Destruction

23,300

12,600

10,700

23,300

12,600

10,700

8,260

3,360

4,900

23,300
23,300

12,600
12,600

10,700
10,700

8,020

2,520

5,500

23,300

12,600

10,700

8,260

3,360

4,900

37,800

21,000

16,800

53,400

29,400

24,000

46,500

25,200

21,300

23,300

12,600

10,700

9,700
9,700

4,200
4,200

5,500
5,500

5,680

1,680

4,000

48545
48547
48550
48554
48556

49020
49021
49040
49060
49080
49085
49180
49200
49201
49215

49220

49250
49255

Case Rate

Biopsy, abdominal or retroperitoneal mass, percutaneous needle


Excision or destruction by any method of intra-abdominal or retroperitoneal
tumors or cysts or endometriomas;
Excision or destruction by any method of intra-abdominal or retroperitoneal
tumors or cysts or endometriomas; extensive
Excision of presacral or sacrococcygeal tumor
Staging celiotomy (laparotomy) for Hodgkins disease or lymphoma (includes
splenectomy, needle or open biopsies of both liver lobes, possibly also
removal of abdominal nodes, abdominal node and/or bone marrow
biopsies, ovarian repositioning)
Umbilectomy, omphalectomy, excision of umbilicus
Omentectomy, epiploectomy, resection of omentum
Laparoscopy

49320

Laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or


without collection of specimen(s) by brushing or washing

49321

Laparoscopy, surgical; with biopsy (single or multiple)

49322

Laparoscopy, surgical; with aspiration of cavity or cyst (single or multiple)

49323

Laparoscopy, surgical; with drainage of lymphocele to peritoneal cavity

Professional Fee

9,700

4,200

5,500

12,120

6,720

5,400

8,260

3,360

4,900

Introduction, Revision, and/or Removal


49420

Insertion of intraperitoneal cannula or catheter for drainage or dialysis

8,260

3,360

4,900

49425

Insertion of peritoneal-venous shunt


Repair Hernioplasty, Herniorrhaphy, Herniotomy
Repair initial inguinal hernia, under age 6 months, w/ or w/o
hydrocelectomy; reducible
Repair initial inguinal hernia, under age 6 months, w/ or w/o
hydrocelectomy; incarcerated
Repair initial inguinal hernia, under age 6 months, w/ or w/o
hydrocelectomy; strangulated
Repair initial inguinal hernia, age 6 months to under 5 years, w/ or w/o
hydrocelectomy; reducible
Repair initial inguinal hernia, age 6 months to under 5 years, w/ or w/o
hydrocelectomy; incarcerated
Repair initial inguinal hernia, age 6 months to under 5 years, w/ or w/o
hydrocelectomy; strangulated
Repair initial inguinal hernia, age 5 years or over; reducible
Repair initial inguinal hernia, age 5 years or over; incarcerated
Repair initial inguinal hernia, age 5 years or over; strangulated
Repair recurrent inguinal hernia, any age; reducible
Repair recurrent inguinal hernia, any age; incarcerated
Repair recurrent inguinal hernia, any age; strangulated
Repair inguinal hernia, sliding, any age
Repair lumbar hernia
Repair initial femoral hernia, any age; reducible
Repair initial femoral hernia, any age; incarcerated
Repair initial femoral hernia, any age; strangulated
Repair recurrent femoral hernia; reducible

18,000

8,400

9,600

21,000

8,400

12,600

21,000

8,400

12,600

21,000

8,400

12,600

21,000

8,400

12,600

21,000

8,400

12,600

21,000

8,400

12,600

21,000
21,000
21,000
21,000
21,000
21,000
21,000
21,000
21,000
21,000
21,000
21,000

8,400
8,400
8,400
8,400
8,400
8,400
8,400
8,400
8,400
8,400
8,400
8,400

12,600
12,600
12,600
12,600
12,600
12,600
12,600
12,600
12,600
12,600
12,600
12,600

49495
49496
49497
49500
49501
49502
49505
49507
49509
49520
49521
49522
49525
49540
49550
49553
49554
49555

Page 71 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE
49557
49558
49560
49561
49562
49565
49566
49567
49570
49572
49573
49580
49582
49583
49585
49587
49588
49590
49600
49605
49606
49610
49611
49650
49651
49900
49905
49906

50010
50020
50040
50045
50060
50065
50070
50075

DESCRIPTION
Repair recurrent femoral hernia; incarcerated
Repair recurrent femoral hernia; strangulated
Repair initial incisional hernia; reducible
Repair initial incisional hernia; incarcerated
Repair initial incisional hernia; strangulated
Repair recurrent incisional hernia; reducible
Repair recurrent incisional hernia; incarcerated
Repair recurrent incisional hernia; strangulated
Repair epigastric hernia (e.g., preperitoneal fat); reducible
Repair epigastric hernia (e.g., preperitoneal fat); incarcerated
Repair epigastric hernia (e.g., preperitoneal fat); strangulated
Repair umbilical hernia, under age 5 years; reducible
Repair umbilical hernia, under age 5 years; incarcerated
Repair umbilical hernia, under age 5 years; strangulated
Repair umbilical hernia, age 5 years or over; reducible
Repair umbilical hernia, age 5 years or over; incarcerated
Repair umbilical hernia, age 5 years or over; strangulated
Repair spigelian hernia
Repair of small omphalocele, w/ primary closure
Repair large omphalocele or gastroschisis; w/ or w/o prosthesis
Repair large omphalocele or gastroschisis; w/ removal of prosthesis, final
reduction and closure, in operating room
Repair of omphalocele (Gross type operation); first stage
Repair of omphalocele (Gross type operation); second stage
Laparoscopy
Laparoscopy, surgical; repair of initial inguinal hernia
Laparoscopy, surgical; repair of recurrent inguinal hernia
Other Procedures

21,000
21,000
21,000
21,000
21,000
21,000
21,000
21,000
21,000
21,000
21,000
21,000
21,000
21,000
21,000
21,000
21,000
21,000
23,300
37,800

8,400
8,400
8,400
8,400
8,400
8,400
8,400
8,400
8,400
8,400
8,400
8,400
8,400
8,400
8,400
8,400
8,400
8,400
12,600
21,000

Health Care
Institution Fee
12,600
12,600
12,600
12,600
12,600
12,600
12,600
12,600
12,600
12,600
12,600
12,600
12,600
12,600
12,600
12,600
12,600
12,600
10,700
16,800

30,300

16,800

13,500

23,300
30,300

12,600
16,800

10,700
13,500

21,000
21,000

8,400
8,400

12,600
12,600

Suture, secondary, of abdominal wall for evisceration or dehiscence

18,000

8,400

9,600

23,300

12,600

10,700

30,300

16,800

13,500

20,980
18,000
18,000
18,000
27,120
30,300
27,120

10,080
8,400
8,400
8,400
15,120
16,800
15,120

10,900
9,600
9,600
9,600
12,000
13,500
12,000

37,800

21,000

16,800

Case Rate

Omental flap (e.g., for reconstruction of sternal and chest wall defects) (list
separately in addition to code for primary procedure)
Free omental flap w/ microvascular anastomosis
Urinary System
Kidney
Incision
Renal exploration, not necessitating other specific procedures
Drainage of perirenal or renal abscess
Nephrostomy, nephrotomy w/ drainage
Nephrotomy, w/ exploration
Nephrolithotomy; removal of calculus
Nephrolithotomy; secondary surgical operation for calculus
Nephrolithotomy; complicated by congenital kidney abnormality
Nephrolithotomy; removal of large staghorn calculus filling renal pelvis and
calyces (including anatrophic pyelolithotomy)

Professional Fee

50080

Percutaneous nephrostolithotomy or pyelostolithotomy, w/ or w/o dilation,


endoscopy, lithotripsy, stenting, or basket extraction; up to 2 cm

30,300

16,800

13,500

50081

Percutaneous nephrostolithotomy or pyelostolithotomy, w/ or w/o dilation,


endoscopy, lithotripsy, stenting, or basket extraction; over 2 cm

30,300

16,800

13,500

30,300
18,000
18,000

16,800
8,400
8,400

13,500
9,600
9,600

23,300

12,600

10,700

31,580

14,280

17,300

8,020
18,000

2,520
8,400

5,500
9,600

27,120

15,120

12,000

30,300

16,800

13,500

30,300

16,800

13,500

30,300

16,800

13,500

30,300

16,800

13,500

50100
50120
50125
50130
50135
50200
50205
50220
50225

50230
50234
50236

Transection or repositioning of aberrant renal vessels


Pyelotomy; w/ exploration
Pyelotomy; w/ drainage, pyelostomy
Pyelotomy; w/ removal of calculus (pyelolithotomy, pelviolithotomy,
including coagulum pyelolithotomy)
Pyelotomy; complicated (e.g., secondary operation, congenital kidney
abnormality)
Excision
Renal biopsy; percutaneous, by trocar or needle
Renal biopsy; by surgical exposure of kidney
Nephrectomy, including partial ureterectomy, any approach including rib
resection;
Nephrectomy, including partial ureterectomy, any approach including rib
resection; complicated because of previous surgery on same kidney
Nephrectomy, including partial ureterectomy, any approach including rib
resection; radical, w/ regional lymphadenectomy and/or vena caval
thrombectomy
Nephrectomy w/ total ureterectomy and bladder cuff; through same
incision
Nephrectomy w/ total ureterectomy and bladder cuff; through separate
incision

Page 72 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE
50240

DESCRIPTION

Case Rate

Nephrectomy, partial
Ablation, open, one or more renal mass lesion(s), cryosurgical, including
intraoperative ultrasound, if performed
Excision or unroofing of cyst(s) of kidney
Excision of perinephric cyst
Renal Transplantation
Donor nephrectomy, w/ preparation and maintenance of allograft; from
living donor
Recipient nephrectomy
Renal allotransplantation, implantation of graft; excluding donor and
recipient nephrectomy

27,120

50365

50250

Professional Fee
15,120

Health Care
Institution Fee
12,000

9,700

4,200

5,500

20,980
20,980

10,080
10,080

10,900
10,900

27,120

15,120

12,000

23,300

12,600

10,700

46,500

25,200

21,300

Renal allotransplantation, implantation of graft; w/ recipient nephrectomy

61,320

40,320

21,000

50370
50380

Removal of transplanted renal allograft


Renal autotransplantation, reimplantation of kidney
Introduction

30,300
53,400

16,800
29,400

13,500
24,000

50390

Aspiration and/or injection of renal cyst or pelvis by needle, percutaneous

5,680

1,680

4,000

50391

Instillation of therapeutic agent into renal pelvis and/or ureter through


established nephrostomy, pyelostomy or ureterostomy tube

9,700

4,200

5,500

9,700

4,200

5,500

9,700

4,200

5,500

8,260

3,360

4,900

30,300

16,800

13,500

37,180

18,480

18,700

23,300
18,000

12,600
8,400

10,700
9,600

23,300

12,600

10,700

30,300

16,800

13,500

30,300

16,800

13,500

10,540
9,700
30,300
27,120

5,040
4,200
16,800
15,120

5,500
5,500
13,500
12,000

27,120

15,120

12,000

23,300

12,600

10,700

23,300

12,600

10,700

30,300

16,800

13,500

8,692

3,192

5,500

8,260

3,360

4,900

10,880

3,780

7,100

8,104

2,604

5,500

50280
50290
50320
50340
50360

50392
50393
50395

50400

50405

50500
50520
50525
50526
50540

50541
50542
50543
50544
50545
50546
50547
50548

50551

50553

50555

50557

Introduction of intracatheter or catheter into renal pelvis for drainage


and/or injection, percutaneous
Introduction of ureteral catheter or stent into ureter through renal pelvis
for drainage and/or injection, percutaneous
Introduction of guide into renal pelvis and/or ureter w/ dilation to establish
nephrostomy tract, percutaneous
Repair
Pyeloplasty (Foley Y-pyeloplasty), plastic operation on renal pelvis, w/ or
w/o plastic operation on ureter, nephropexy, nephrostomy, pyelostomy, or
ureteral splinting; simple
Pyeloplasty (Foley Y-pyeloplasty), plastic operation on renal pelvis, w/ or
w/o plastic operation on ureter, nephropexy, nephrostomy, pyelostomy, or
ureteral splinting; complicated (congenital kidney abnormality, secondary
pyeloplasty, solitary kidney, calycoplasty)
Nephrorrhaphy, suture of kidney wound or injury
Closure of nephrocutaneous or pyelocutaneous fistula
Closure of nephrovisceral fistula (e.g., renocolic), including visceral repair;
abdominal approach
Closure of nephrovisceral fistula (e.g., renocolic), including visceral repair;
thoracic approach
Symphysiotomy for horseshoe kidney w/ or w/o pyeloplasty and/or other
plastic procedure, unilateral or bilateral (one operation)
Laparoscopy
Laparoscopy, surgical; ablation of renal cysts
Laparoscopy, surgical; ablation of renal mass lesion(s)
Laparoscopy, surgical; partial nephrectomy
Laparoscopy, surgical; pyeloplasty
Laparoscopy, surgical; radical nephrectomy (includes removal of Gerotas
fascia and surrounding fatty tissue, removal of regional lymph nodes and
adrenalectomy)
Laparoscopy, surgical; nephrectomy, including partial ureterectomy
Laparoscopy, surgical; donor nephrectomy (including cold preservation),
from living donor
Laparoscopy, surgical; nephrectomy with total ureterectomy
Endoscopy
Renal endoscopy through established nephrostomy or pyelostomy, w/ or
w/o irrigation, instillation, or ureteropyelography, exclusive of radiologic
service;
Renal endoscopy through established nephrostomy or pyelostomy, w/ or
w/o irrigation, instillation, or ureteropyelography, exclusive of radiologic
service; w/ ureteral catheterization, w/ or w/o dilation of ureter
Renal endoscopy through established nephrostomy or pyelostomy, w/ or
w/o irrigation, instillation, or ureteropyelography, exclusive of radiologic
service; w/ biopsy
Renal endoscopy through established nephrostomy or pyelostomy, w/ or
w/o irrigation, instillation, or ureteropyelography, exclusive of radiologic
service; w/ fulguration and/or incision, w/ or w/o biopsy

Page 73 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE

DESCRIPTION

Case Rate

Professional Fee

Health Care
Institution Fee

50559

Renal endoscopy through established nephrostomy or pyelostomy, w/ or


w/o irrigation, instillation, or ureteropyelography, exclusive of radiologic
service; w/ insertion of radioactive substance w/ or w/out biopsy and/or
fulguration

8,356

2,856

5,500

50561

Renal endoscopy through established nephrostomy or pyelostomy, w/ or


w/o irrigation, instillation, or ureteropyelography, exclusive of radiologic
service; w/ removal of foreign body or calculus

9,700

4,200

5,500

50570

Renal endoscopy through nephrotomy or pyelotomy, w/ or w/o irrigation,


instillation, or ureteropyelography, exclusive of radiologic service;

8,260

3,360

4,900

50572

Renal endoscopy through nephrotomy or pyelotomy, w/ or w/o irrigation,


instillation, or ureteropyelography, exclusive of radiologic service; w/
ureteral catheterization, w/ or w/o dilation of ureter

8,260

3,360

4,900

50574

Renal endoscopy through nephrotomy or pyelotomy, w/ or w/o irrigation,


instillation, or ureteropyelography, exclusive of radiologic service; w/ biopsy

8,260

3,360

4,900

50575

Renal endoscopy through nephrotomy or pyelotomy, w/ or w/o irrigation,


instillation, or ureteropyelography, exclusive of radiologic service; w/
endopyelotomy (includes cystoscopy, ureteroscopy, dilation of ureter and
ureteral pelvic junction, incision of ureteral pelvic junction and insertion of
endopyelotomy stent)

9,700

4,200

5,500

50576

Renal endoscopy through nephrotomy or pyelotomy, w/ or w/o irrigation,


instillation, or ureteropyelography, exclusive of radiologic service; w/
fulguration and/or incision, w/ or w/o biopsy

9,700

4,200

5,500

50578

Renal endoscopy through nephrotomy or pyelotomy, w/ or w/o irrigation,


instillation, or ureteropyelography, exclusive of radiologic service; w/
insertion of radioactive substance, w/ or w/o biopsy and/or fulguration

9,700

4,200

5,500

9,700

4,200

5,500

50590

Renal endoscopy through nephrotomy or pyelotomy, w/ or w/o irrigation,


instillation, or ureteropyelography, exclusive of radiologic service; w/
removal of foreign body or calculus
Other Procedures
Lithotripsy, extracorporeal shock wave

18,000

8,400

9,600

50592

Ablation, one or more renal tumor(s), percutaneous, unilateral frequency

9,700

4,200

5,500

12,120
12,120
21,820
20,980
21,820

6,720
6,720
10,920
10,080
10,920

5,400
5,400
10,900
10,900
10,900

21,820

10,920

10,900

20,980

10,080

10,900

21,820

10,920

10,900

50580

50700

Ureter
Ureterotomy w/ exploration or drainage
Ureterotomy for insertion of indwelling stent, all types
Ureterolithotomy; upper one-third of ureter
Ureterolithotomy; middle one-third of ureter
Ureterolithotomy; lower one-third of ureter
Excision
Ureterectomy, w/ bladder cuff
Ureterectomy, total, ectopic ureter, combination abdominal, vaginal and/or
perineal approach
Repair
Ureteroplasty, plastic operation on ureter (e.g., stricture)

50715

Ureterolysis, w/ or w/o repositioning of ureter for retroperitoneal fibrosis

21,820

10,920

10,900

50722

20,980

10,080

10,900

23,300

12,600

10,700

22,660

11,760

10,900

22,660

11,760

10,900

50740
50750
50760

Ureterolysis for ovarian vein syndrome


Ureterolysis for retrocaval ureter, w/ reanastomosis of upper urinary tract
or vena cava
Revision of urinary-cutaneous anastomosis (any type urostomy);
Revision of urinary-cutaneous anastomosis (any type urostomy); w/ repair
of fascial defect and hernia
Ureteropyelostomy, anastomosis of ureter and renal pelvis
Ureterocalycostomy, anastomosis of ureter to renal calyx
Ureteroureterostomy

23,300
27,120
21,820

12,600
15,120
10,920

10,700
12,000
10,900

50770

Transureteroureterostomy, anastomosis of ureter to contralateral ureter

27,120

15,120

12,000

50780

Ureteroneocystostomy; anastomosis of single ureter to bladder

27,120

15,120

12,000

50782

Ureteroneocystostomy; anastomosis of duplicated ureter to bladder

30,300

16,800

13,500

50783
50785
50800

Ureteroneocystostomy; w/ extensive ureteral tailoring


Ureteroneocystostomy; w/ vesico-psoas hitch or bladder flap
Ureteroenterostomy, direct anastomosis of ureter to intestine

37,800
30,300
30,740

21,000
16,800
13,440

16,800
13,500
17,300

50810

Ureterosigmoidostomy, w/ creation of sigmoid bladder and establishment


of abdominal or perineal colostomy, including bowel anastomosis

37,800

21,000

16,800

50815

Ureterocolon conduit, including bowel anastomosis

37,800

21,000

16,800

50600
50605
50610
50620
50630
50650
50660

50725
50727
50728

Page 74 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE
50820
50825
50830
50840
50845
50860
50900
50920
50930
50940
50945
50947
50948

DESCRIPTION

Case Rate

Ureteroileal conduit (ileal bladder), including bowel anastomosis (Bricker


operation)
Continent diversion, including bowel anastomosis using any segment of
small and/or large bowel (Kock pouch or Camey enterocystoplasty
Urinary undiversion (e.g., taking down of ureteroileal conduit,
ureterosigmoidostomy or ureteroenterostomy w/ ureteroureterostomy or
ureteroneocystostomy)
Replacement of all or part of ureter by bowel segment, including bowel
anastomosis
Cutaneous appendico-vesicostomy
Ureterostomy, transplantation of ureter to skin
Ureterorrhaphy, suture of ureter
Closure of ureterocutaneous fistula
Closure of ureterovisceral fistula (including visceral repair)
Deligation of ureter
Laparoscopy
Laparoscopy, surgical; ureterolithotomy
Laparoscopy, surgical; ureteroneocystostomy with cystoscopy and ureteral
stent placement
Laparoscopy, surgical; ureteroneocystostomy without cystoscopy and
ureteral stent placement
Endoscopy

Professional Fee

Health Care
Institution Fee

40,320

23,520

16,800

46,500

25,200

21,300

37,800

21,000

16,800

37,800

21,000

16,800

30,300
20,980
18,000
20,980
23,300
21,820

16,800
10,080
8,400
10,080
12,600
10,920

13,500
10,900
9,600
10,900
10,700
10,900

21,940

9,240

12,700

23,300

12,600

10,700

23,300

12,600

10,700

50951

Ureteral endoscopy through established ureterostomy, w/ or w/o irrigation,


instillation, or ureteropyelography, exclusive of radiologic service;

8,260

3,360

4,900

50953

Ureteral endoscopy through established ureterostomy, w/ or w/o irrigation,


instillation, or ureteropyelography, exclusive of radiologic service; w/
ureteral catheterization, w/ or w/o dilation of ureter

8,260

3,360

4,900

50955

Ureteral endoscopy through established ureterostomy, w/ or w/o irrigation,


instillation, or ureteropyelography, exclusive of radiologic service; w/ biopsy

8,260

3,360

4,900

50957

Ureteral endoscopy through established ureterostomy, w/ or w/o irrigation,


instillation, or ureteropyelography, exclusive of radiologic service; w/
fulguration and/or incision, w/ or w/o biopsy

10,880

3,780

7,100

50959

Ureteral endoscopy through established ureterostomy, w/ or w/o irrigation,


instillation, or ureteropyelography, exclusive of radiologic service; w/
insertion of radioactive substance, w/ or w/o biopsy and/or fulguration (not
including provision of material)

9,700

4,200

5,500

50961

Ureteral endoscopy through established ureterostomy, w/ or w/o irrigation,


instillation, or ureteropyelography, exclusive of radiologic service; w/
removal of foreign body or calculus

11,980

5,880

6,100

50970

Ureteral endoscopy through ureterotomy, w/ or w/o irrigation, instillation,


or ureteropyelography, exclusive of radiologic service;

8,260

3,360

4,900

50972

Ureteral endoscopy through ureterostomy, w/ or w/o irrigation, instillation,


or ureteropyelography, exclusive of radiologic service; w/ ureteral
catheterization, w/ or w/o dilation of ureter

8,260

3,360

4,900

50974

Ureteral endoscopy through ureterostomy, w/ or w/o irrigation, instillation,


or ureteropyelography, exclusive of radiologic service; w/ biopsy

8,260

3,360

4,900

10,880

3,780

7,100

9,700

4,200

5,500

11,980

5,880

6,100

5,680

1,680

4,000

9,700

4,200

5,500

9,700

4,200

5,500

9,700
10,540

4,200
5,040

5,500
5,500

50976

50978

50980

51010
51020

Ureteral endoscopy through ureterostomy, w/ or w/o irrigation, instillation,


or ureteropyelography, exclusive of radiologic service; w/ fulguration
and/or incision, w/ or w/o biopsy
Ureteral endoscopy through ureterostomy, w/ or w/o irrigation, instillation,
or ureteropyelography, exclusive of radiologic service; w/ insertion of
radioactive substance, w/ or w/o biopsy and/or fulguration (not including
provision of material)
Ureteral endoscopy through ureterostomy, w/ or w/o irrigation, instillation,
or ureteropyelography, exclusive of radiologic service; w/ removal of foreign
body or calculus
Bladder
Incision
Aspiration of bladder; by trocar or intracatheter w/ insertion of suprapubic
catheter
Cystotomy or cystostomy; w/ fulguration and/or insertion of radioactive
material

51030

Cystotomy or cystostomy; w/ cryosurgical destruction of intravesical lesion

51040
51045

Cystostomy, cystotomy w/ drainage


Cystotomy, w/ insertion of ureteral catheter or stent

Page 75 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE
51050
51060
51065
51080

DESCRIPTION

Case Rate

Cystolithotomy, cystotomy w/ removal of calculus, w/o vesical neck


resection
Transvesical ureterolithotomy
Cystotomy, w/ stone basket extraction and/or ultrasonic or electrohydraulic
fragmentation of ureteral calculus
Drainage of perivesical or prevesical space abscess
Excision

Professional Fee

Health Care
Institution Fee

12,540

7,140

5,400

21,820

10,920

10,900

21,820

10,920

10,900

10,540

5,040

5,500

51500

Excision of urachal cyst or sinus, w/ or w/o umbilical hernia repair

30,300

16,800

13,500

51520

Cystotomy; for simple excision of vesical neck

20,980

10,080

10,900

51525

Cystotomy; for excision of bladder diverticulum, single or multiple

27,120

15,120

12,000

51530
51535
51550

Cystotomy; for excision of bladder tumor


Cystotomy for excision, incision, or repair of ureterocele
Cystectomy, partial
Cystectomy, complicated (e.g., postradiation, previous surgery, difficult
location)
Cystectomy, partial, w/ reimplantation of ureter(s) into bladder
(ureteroneocystostomy)
Cystectomy, complete;
Cystectomy, complete; w/ bilateral pelvic lymphadenectomy, including
external iliac, hypogastric, and obturator nodes
Cystectomy, complete, w/ ureterosigmoidostomy or ureterocutaneous
transplantations;
Cystectomy, complete, w/ ureterosigmoidostomy or ureterocutaneous
transplantations; w/ bilateral pelvic lymphadenectomy, including external
iliac, hypogastric, and obturator nodes
Cystectomy, complete, w/ ureteroileal conduit or sigmoid bladder, including
bowel anastomosis;

27,120
23,300
30,740

15,120
12,600
13,440

12,000
10,700
17,300

37,800

21,000

16,800

30,300

16,800

13,500

37,800

21,000

16,800

46,500

25,200

21,300

40,320

23,520

16,800

53,400

29,400

24,000

55,920

31,920

24,000

51555
51565
51570
51575
51580
51585
51590

51595

Cystectomy, complete, w/ ureteroileal conduit or sigmoid bladder, including


bowel anastomosis; w/ bilateral pelvic lymphadenectomy, including
external iliac, hypogastric, and obturator nodes

55,840

34,440

21,400

51596

Cystectomy, complete, w/ continent diversion, any technique, using any


segment of small and/or large bowel to construct neobladder

58,800

37,800

21,000

51597

Pelvic exenteration, complete, for vesical, prostatic or urethral malignancy,


w/ removal of bladder and ureteral transplantations, w/ or w/o
hysterectomy and/or abdominoperineal resection of rectum and colon and
colostomy, or any combination thereof

71,400

50,400

21,000

Introduction
51600

Injection procedure for cystography or voiding urethrocystography

8,020

2,520

5,500

51720

Bladder instillation of anticarcinogenic agent


Repair

8,020

2,520

5,500

51800

Cystoplasty or cystourethroplasty, plastic operation on bladder and/or


vesical neck (anterior Y-plasty, vesical fundus resection), any procedure, w/
or w/o wedge resection of posterior vesical neck

20,980

10,080

10,900

51820

Cystourethroplasty w/ unilateral or bilateral ureteroneocystostomy

27,120

15,120

12,000

20,980

10,080

10,900

30,740

13,440

17,300

20,980

10,080

10,900

12,120
10,880
23,300
23,300
30,300
30,300
30,740
12,120

6,720
3,780
12,600
12,600
16,800
16,800
13,440
6,720

5,400
7,100
10,700
10,700
13,500
13,500
17,300
5,400

30,300

16,800

13,500

30,300

16,800

13,500

8,260

3,360

4,900

51840
51841
51845
51860
51880
51900
51920
51925
51940
51960
51980
51990
51992
52000

Anterior vesicourethropexy, or urethropexy (Marshall-Marchetti-Krantz


type)
Anterior vesicourethropexy, or urethropexy (Marshall-Marchetti-Krantz
type) complicated (e.g., secondary repair)
Abdomino-vaginal vesical neck suspension, w/ or w/o endoscopic control
(e.g., Stamey, Raz, modified Pereyra)
Cystorrhaphy, suture of bladder wound, injury or rupture
Closure of cystostomy
Closure of vesicovaginal fistula, abdominal approach
Closure of vesicouterine fistula;
Closure of vesicouterine fistula; w/ hysterectomy
Closure of bladder exstrophy
Enterocystoplasty, including bowel anastomosis
Cutaneous vesicostomy
Laparoscopy
Laparoscopy, surgical; urethral suspension for stress incontinence
Laparoscopy, surgical; sling operation for stress incontinence (e.g., fascia or
synthetic)
Endoscopy - Cystoscopy, Urethroscopy, Cystourethroscopy
Cystourethroscopy

Page 76 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE

DESCRIPTION

Case Rate

Professional Fee

Health Care
Institution Fee

52005

Cystourethroscopy, w/ ureteral catheterization, w/ or w/o irrigation,


instillation, or ureteropyelography, exclusive of radiologic service;

9,700

4,200

5,500

52007

Cystourethroscopy, w/ ureteral catheterization, w/ or w/o irrigation,


instillation, or ureteropyelography, exclusive of radiologic service; w/ brush
biopsy of ureter and/or renal pelvis

8,260

3,360

4,900

52010

Cystourethroscopy, w/ ejaculatory duct catheterization, w/ or w/o


irrigation, instillation, or duct radiography, exclusive of radiologic service

8,260

3,360

4,900

Transurethral Surgery

52204

Urethra and Bladder


Transurethral Surgery, Urethra and Bladder
Cystourethroscopy, w/ biopsy

10,540

5,040

5,500

52214

Cystourethroscopy, w/ fulguration (including cryosurgery or laser surgery)


of trigone, bladder neck, prostatic fossa, urethra, or periurethral glands

11,980

5,880

6,100

52224

Cystourethroscopy, w/ fulguration (including cryosurgery or laser surgery)


or treatment of MINOR (less than 0.5 cm) lesion(s) w/ or w/o biopsy

11,980

5,880

6,100

52234

Cystourethroscopy, w/ fulguration (including cryosurgery or laser surgery)


and/or resection of; SMALL bladder tumor(s) (0.5 cm to 2.0 cm)

20,980

10,080

10,900

52235

Cystourethroscopy, w/ fulguration (including cryosurgery or laser surgery)


and/or resection of MEDIUM bladder tumor(s) (2.0 to 5.0 cm)

22,240

11,340

10,900

23,300

12,600

10,700

30,740

13,440

17,300

11,980

5,880

6,100

8,020

2,520

5,500

12,900
12,900
12,540

6,300
6,300
7,140

6,600
6,600
5,400

12,120

6,720

5,400

8,020

2,520

5,500

8,020

2,520

5,500

10,540

5,040

5,500

11,980

5,880

6,100

21,940

9,240

12,700

21,940

9,240

12,700

12,120

6,720

5,400

10,540

5,040

5,500

18,000

8,400

9,600

21,940

9,240

12,700

11,980

5,880

6,100

18,000

8,400

9,600

9,700

4,200

5,500

10,540

5,040

5,500

52270
52275
52276

Cystourethroscopy, w/ fulguration (including cryosurgery or laser surgery)


and/or resection of LARGE bladder tumor(s)
Cystourethroscopy w/ insertionof radioactive substance, w/ or w/o biopsy
or fulguration
Cystourethroscopy, w/ dilation of bladder for interstitial cystitis; general or
conduction (spinal) anesthesia
Cystourethroscopy, w/ dilation of bladder for interstitial cystitis; local
anesthesia
Cystourethroscopy, w/ internal urethrotomy; female
Cystourethroscopy, w/ internal urethrotomy; male
Cystourethroscopy w/ direct vision internal urethrotomy

52277

Cystourethroscopy, w/ resection of external sphincter (sphincterotomy)

52240
52250
52260
52265

52281
52283

52285

52290
52300
52301
52305
52310
52317
52318

52320
52325
52327
52330

Cystourethroscopy, w/ calibration and/or dilation of urethral stricture or


stenosis, w/ or w/o meatotomy and injection procedure for cystography,
male or female
Cystourethroscopy, w/ steroid injection into stricture
Cystourethroscopy, for treatment of the female urethral syndrome w/ any
or all of the following: urethral meatotomy, urethral dilation, internal
urethrotomy, lysis of urethrovaginal septal fibrosis, lateral incisions of the
bladder neck, and fulguration of polyp(s) of urethra, bladder neck, and/or
trigone
Cystourethroscopy; w/ ureteral meatotomy, unilateral or bilateral
Cystourethroscopy; w/ resection or fulguration of orthotopic ureterocele(s),
unilateral or bilateral
Cystourethroscopy; w/ resection or fulguration of ectopic ureterocele(s),
unilateral or bilateral
Cystourethroscopy; w/ incision or resection of orifice of bladder
diverticulum, single or multiple
Cystourethroscopy, w/ removal of foreign body, calculus, or ureteral stent
from urethra or bladder
Litholapaxy: crushing or fragmentation of calculus by any means in bladder
and removal of fragments; simple or small (less than 2.5 cm)
Litholapaxy: crushing or fragmentation of calculus by any means in bladder
and removal of fragments; complicated or large (over 2.5 cm)
Ureter and Pelvis
Ureter and Pelvis
Cystourethroscopy (including ureteral catheterization); w/ removal of
ureteral calculus
Cystourethroscopy (including ureteral catheterization); w/ fragmentation of
ureteral calculus (e.g., ultrasonic or electro-hydraulic technique)
Cystourethroscopy (including ureteral catheterization); w/ subureteric
injection of implant material
Cystourethroscopy (including ureteral catheterization); w/ manipulation,
w/o removal of ureteral calculus

Page 77 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE
52332
52334

DESCRIPTION

Case Rate

Cystourethroscopy, w/ insertion of indwelling ureteral stent (e.g., Gibbons


or double-J type)
Cystourethroscopy w/ insertion of ureteral guide wire through kidney to
establish a percutaneous nephrostomy, retrograde

Professional Fee

Health Care
Institution Fee

10,540

5,040

5,500

9,700

4,200

5,500

52335

Cystourethroscopy, w/ ureteroscopy and/or pyeloscopy (includes dilation


of the ureter and/or pyeloureteral junction by any method);

12,120

6,720

5,400

52336

Cystourethroscopy, w/ ureteroscopy and/or pyeloscopy (includes dilation


of the ureter and/or pyeloureteral junction by any method); w/ removal or
manipulation of calculus (ureteral catheterization is included)

12,120

6,720

5,400

21,940

9,240

12,700

21,940

9,240

12,700

12,120

6,720

5,400

21,940

9,240

12,700

23,300
23,300

12,600
12,600

10,700
10,700

12,120

6,720

5,400

37,800

21,000

16,800

18,000

8,400

9,600

21,940

9,240

12,700

21,940

9,240

12,700

20,980

10,080

10,900

37,800

21,000

16,800

20,980

10,080

10,900

27,120

15,120

12,000

27,120

15,120

12,000

37,800

21,000

16,800

18,000

8,400

9,600

52450
52500

Cystourethroscopy, w/ ureteroscopy and/or pyeloscopy (includes dilation


of the ureter and/or pyeloureteral junction by any method); w/ lithotripsy
(ureteral catheterization is included)
Cystourethroscopy, w/ ureteroscopy and/or pyeloscopy (includes dilation
of the ureter and/or pyeloureteral junction by any method); w/ biopsy
and/or fulguration of lesion
Cystourethroscopy, w/ ureteroscopy and/or pyeloscopy (includes dilation
of the ureter and/or pyeloureteral junction by any method); w/ resection of
tumor
Vesical Neck and Prostate
Vesical Neck and Prostate
Cystourethroscopy w/ incision, fulguration, or resection of congenital
posterior urethral valves, or congenital obstructive hypertrophic mucosal
folds
Transurethral incision of prostate
Transurethral resection of bladder neck

52510

Transurethral balloon dilation of the prostatic urethra, any method

52337

52338

52339

52340

52601

52606
52612
52614
52620
52630
52640

Transurethral electrosurgical resection of prostate, including control of


postoperative bleeding, complete (vasectomy, meatomy,
cystourethroscopy, urethral calibration and/or dilation, and internal
urethrotomy are included)
Transurethral fulguration for postoperative bleeding occuring after the
usual follow-up time
Transurethral resection of prostate; first stage of two-stage resection
(partial resection)
Transurethral resection of prostate; second stage of two-stage resection
(resection completed)
Transurethral resection; of residual obstructive tissue after 90 days
postoperative
Transurethral resection; of regrowth of obstructive tissue longer than one
year postoperative
Transurethral resection; of postoperative bladder neck contracture

53000

Non-contact laser coagulation of prostate, including control of


postoperative bleeding, complete (vasectomy, meatotomy,
cystourethroscopy, urethral calibration and/or dilation, and internal
urethrotomy are included)
Contact laser vaporization w/ or w/o transurethral resection of prostate,
including control of postoperative bleeding, complete (vasectomy,
meatotomy, cystourethroscopy, urethral calibration and/or dilation, and
internal urethrotomy are included)
High intensity focused ultrasound (HIFU) of the prostate including
transurethral resection of the prostate (TURP)
Transurethral drainage of prostatic abscess
Urethra
Incision
Urethrotomy or urethrostomy, external ; pendulous urethra

5,680

1,680

4,000

53010

Urethrotomy or urethrostomy, external ; perineal urethra, external

8,260

3,360

4,900

53020
53025
53040
53060
53080

Meatotomy, cutting of meatus ; except infant


Meatotomy, cutting of meatus ; infant
Drainage of deep periurethral abscess
Drainage of Skenes gland abscess or cyst
Drainage of perineal urinary extravasation
Excision
Biopsy of urethra
Urethrectomy, total, including cystostomy; female
Urethrectomy, total, including cystostomy; male
Excision of fulguration of carcinoma of urethra
Excision of urethral diverticulum ; female
Excision of urethral diverticulum ; male

5,560
8,260
9,300
5,560
8,020

1,260
3,360
2,100
1,260
2,520

4,300
4,900
7,200
4,300
5,500

5,560
21,940
21,820
9,700
18,000
14,960

1,260
9,240
10,920
4,200
8,400
7,560

4,300
12,700
10,900
5,500
9,600
7,400

52647

52648

52649
52700

53200
53210
53215
53220
53230
53235

Page 78 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE

DESCRIPTION
Marsupialization of urethral diverticulum, male or female
Excision of bulbourethral gland (Cowpers gland)
Excision or fulguration; urethral polyp(s), distal urethra
Excision or fulguration; urethral caruncle
Skene's glands
Skene's glands urethral prolapse
Repair
Urethroplasty; first stage, for fistula, diverticulum, or stricture (e.g.,
Johannsen type)
Urethroplasty; second stage (formation of urethra), including urinary
diversion
Urethroplasty, one-stage reconstruction of male anterior urethra
Urethroplasty, transpubic or perineal, one stage, for reconstruction or
repair of prostatic or membranous urethra
Urethroplasty, two-stage reconstruction or repair of prostatic or
membranous urethra; first stage
Urethroplasty, two-stage reconstruction or repair of prostatic or
membranous urethra; second stage
Urethroplasty, reconstruction of female urethra
Operation for correction of male urinary incontinence, w/ or w/o
introduction of prosthesis
Removal of perineal prosthesis introduced for continence
Urethroplasty w/ tubularization of posterior urethra and/or lower bladder
for incontinence (e.g., Tenago, Leadbetter procedure)
Operation for correction of urinary incontinence w/ placement of inflatable
urethral or bladder neck sphincter, including placement of pump and/or
reservoir
Removal, repair, or replacement of inflatable sphincter including pump
and/or reservoir and/or cuff

9,300
12,120
5,560
5,560
5,560
9,300

2,100
6,720
1,260
1,260
1,260
2,100

Health Care
Institution Fee
7,200
5,400
4,300
4,300
4,300
7,200

30,300

16,800

13,500

27,120

15,120

12,000

14,960

7,560

7,400

40,320

23,520

16,800

37,800

21,000

16,800

27,120

15,120

12,000

18,000

8,400

9,600

18,000

8,400

9,600

18,000

8,400

9,600

31,140

17,640

13,500

37,180

18,480

18,700

40,320

23,520

16,800

53449

Surgical correction of hydraulic abnormality of inflatable sphincter device

18,000

8,400

9,600

53450

8,260

3,360

4,900

8,260

3,360

4,900

53502
53505
53510

Urethromeatoplasty, w/ mucosal advancement


Urethromeatoplasty, w/ partial excision of distal urethral segment
(Richardson type procedure)
Urethrorrhaphy, suture of urethral wound or injury, female
Urethrorrhaphy, suture of urethral wound or injury; penile
Urethrorrhaphy, suture of urethral wound or injury; perineal

9,700
9,700
10,540

4,200
4,200
5,040

5,500
5,500
5,500

53515

Urethrorrhaphy, suture of urethral wound or injury; prostatomembranous

10,540

5,040

5,500

53520

Closure of urethrostomy or urethrocutaneous fistula, male


Manipulation

8,020

2,520

5,500

53600

Dilation of urethral stricture by passage of sound or urethral dilator, male

5,680

1,680

4,000

5,680

1,680

4,000

5,680

1,680

4,000

37,800

21,000

16,800

37,800

21,000

16,800

3,640

840

2,800

3,640

840

2,800

3,504
9,300

504
2,100

3,000
7,200

53240
53250
53260
53265
53270
53275
53400
53405
53410
53415
53420
53425
53430
53440
53442
53443
53445
53447

53460

53605
53665

53850

Case Rate

Dilation of urethral stricture or vesical neck, male, general or conduction


(spinal) anesthesia
Dilation of female urethra, general or conduction (spinal) anesthesia
Other Procedures
Transurethral destruction of prostate tissue; by microwave thermotherapy
i.e. Transurethral Microwave Thermotherapy (TUMT)

Professional Fee

54100
54110

Transurethral destruction of prostate tissue; by radiofrequncy ablation i.e.,


Transurethral Needle Ablation (TUNA), transurethral laser incision of the
prostate (TULIP)
Male Genital System
Penis
Incision
Incision and drainage of penis
Destruction
Destruction of lesion(s), penis (e.g., condyloma, papilloma, molluscum
contagiosum, herpetic vesicle), any method
Excision
Biopsy of penis
Excision of penile plaque (Peyronie disease);

54111

Excision of penile plaque (Peyronie disease); w/ graft to 5 cm in length

10,540

5,040

5,500

54112

Excision of penile plaque (Peyronie disease); w/ graft greater than 5 cm in


length

11,980

5,880

6,100

54115

Removal of foreign body from deep penile tissue (e.g., plastic implant)

8,260

3,360

4,900

54120
54125

Amputation of penis; partial


Amputation of penis; complete

10,540
21,400

5,040
10,500

5,500
10,900

54130

Amputation of penis, radical; w/ bilateral inguinofemoral lymphadenectomy

37,800

21,000

16,800

53852

54015
54050

Page 79 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE
54135

DESCRIPTION

Case Rate

Amputation of penis, radical; in continuity w/ bilateral pelvic


lymphadenectomy, including external iliac, hypogastric and obturator nodes

Professional Fee

Health Care
Institution Fee

46,500

25,200

21,300

1,260
1,260

840
840

420
420

1,260

840

420

1,260

840

420

54200

Circumcision, using clamp or other device; newborn


Circumcision, using clamp or other device; except newborn
Circumcision, surgical excision other than clamp, device or dorsal slit;
newborn
Circumcision, surgical excision other than clamp, device or dorsal slit; except
newborn
Introduction
Injection procedure for Peyronie disease;

5,560

1,260

4,300

54205

Injection procedure for Peyronie disease;w/ surgical exposure of plaque

5,680

1,680

4,000

54220

Irrigation of corpora cavernosa for priapism


Repair
Plastic operation of penis for straightening of chordee (e.g., hypospadias),
w/ or w/o mobilization of urethra

8,020

2,520

5,500

9,700

4,200

5,500

14,960

7,560

7,400

23,300

12,600

10,700

23,300

12,600

10,700

23,300

12,600

10,700

12,120

6,720

5,400

27,120

15,120

12,000

54150
54152
54160
54161

54300
54304
54308
54312
54316
54318
54322

Plastic operation on penis for correction of chordee or for first stage


hypospadias repair w/ or w/o transplantation of prepuce and/or skin flaps
Urethroplasty for second stage hypospadias repair (including urinary
diversion); less than 3 cm
Urethroplasty for second stage hypospadias repair (including urinary
diversion); greater than 3 cm
Urethroplasty for second stage hypospadias repair (including urinary
diversion) w/ free skin graft obtained from site other than genitalia
Urethroplasty for third stage hypospadias repair to release penis from
scrotum (e.g., third stage Cecil repair)
One stage distal hypospadias repair (w/ or w/o chordee or circumcision); w/
simple meatal advancement (e.g., Magpi, V-flap)

54324

One stage distal hypospadias repair (w/ or w/o chordee or circumcision); w/


urethroplasty by local skin flaps (e.g., flip-flap, prepucial flap)

27,120

15,120

12,000

54326

One stage distal hypospadias repair (w/ or w/o chordee or circumcision); w/


urethroplasty by local skin flaps and mobilization of urethra

27,120

15,120

12,000

30,300

16,800

13,500

37,180

18,480

18,700

37,180

18,480

18,700

37,180

18,480

18,700

18,000

8,400

9,600

20,980

10,080

10,900

37,800

21,000

16,800

30,300

16,800

13,500

37,180

18,480

18,700

37,800

21,000

16,800

12,120

6,720

5,400

12,120

6,720

5,400

8,260

3,360

4,900

12,120

6,720

5,400

3,504
5,680

504
1,680

3,000
4,000

54328

54332

54336
54340
54344

54348

54352

54380
54385
54390
54420
54430
54435
54440

54500
54505

One stage distal hypospadias repair (w/ or w/o chordee or circumcision); w/


extensive dissection to correct chordee and urethroplasty w/ local skin
flaps, skin graft patch, and/or island flap
One stage proximal penile or penoscrotal hypospadias repair requiring
extensive dissection to correct chordee and urethroplasty by use of skin
graft tube and/or island flap
One stage perineal hypospadias repair requiring extensive dissection to
correct chordee and urethroplasty by use of skin graft tube and/or island
flap
Repair of hypospadias complications (ie, fistula, stricture, diverticula); by
closure, incision, or excision, simple
Repair of hypospadias complications (ie, fistula, stricture, diverticula);
requiring mobilization of skin flaps and urethroplasty w/ flap or patch graft
Repair of hypospadias complications (ie, fistula, stricture, diverticula);
requiring extensive dissection and urethroplasty w/ flap, patch or tubed
graft (includes urinary diversion)
Repair of hypospadias cripple requiring extensive dissection and excision of
previously constructed structures including re-release of chordee and
reconstruction of urethra and penis by use of local skin as grafts and island
flaps and skin brought in as flaps or grafts
Plastic operation on penis for epispadias distal to external sphincter;
Plastic operation on penis for epispadias distal to external sphincter;w/
incontinence
Plastic operation on penis for epispadias distal to external sphincter;w/
exstrophy of bladder
Corpora cavernosa-saphenous vein shunt (priapism operation), unilateral or
bilateral
Corpora cavernosa-corpus spongiosum shunt (priapism operation),
unilateral or bilateral
Corpora cavernosa-glans penis fistulization (e.g., biopsy needle, Winter
procedure, rongeur, or punch) for priapism
Plastic operation of penis for injury
Testis
Excision
Biopsy of testis, needle
Biopsy of testis, incisional

Page 80 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE
54510
54520
54530
54535
54550
54560
54600
54620
54640
54650
54670
54680
54690
54692

54700
54800
54820
54830
54840
54860
54861

DESCRIPTION

5,680

1,680

Health Care
Institution Fee
4,000

10,540

5,040

5,500

10,960
12,540
10,540
12,540

5,460
7,140
5,040
7,140

5,500
5,400
5,500
5,400

10,960

5,460

5,500

9,300
10,540

2,100
5,040

7,200
5,500

12,540

7,140

5,400

9,700
8,260

4,200
3,360

5,500
4,900

9,700
11,980

4,200
5,880

5,500
6,100

4,108

1,008

3,100

3,504
9,300
5,680
8,020
9,300
8,440

504
2,100
1,680
2,520
2,100
2,940

3,000
7,200
4,000
5,500
7,200
5,500

Case Rate

Excision of local lesion of testis


Orchiectomy, simple (including subcapsular), w/ or w/o testicular
prosthesis, scrotal or inguinal approach
Orchiectomy, radical, for tumor; inguinal approach
Orchiectomy, radical, for tumor; w/ abdominal exploration
Exploration for undescended testis (inguinal or scrotal area)
Exploration for undescended testis w/ abdominal exploration
Repair
Reduction of torsion of testis, surgical, w/ or w/o fixation of contralateral
testis
Fixation of contralateral testis
Orchiopexy, inguinal approach, w/ or w/o hernia repair
Orchiopexy, abdominal approach, for intra-abdominal testis (e.g., FowlerStephens)
Suture or repair of testicular injury
Transplantation of testis(es) to thigh (because of scrotal destruction)
Laparoscopy
Laparoscopy, surgical; orchiectomy
Laparoscopy, surgical; orchiopexy for intra-abdominal testis
Epididymis
Incision
Incision and drainage of epididymis, testis and/or scrotal space (e.g.,
abscess or hematoma)
Excision
Biopsy of epididymis, needle
Exploration of epididymis, w/ or w/o biopsy
Excision of local lesion of epidydimis
Excision of spermatocele, w/ or w/o epididymectomy
Epididymectomy; unilateral
Epididymectomy; bilateral
Repair

Professional Fee

54900

Epididymovasostomy, anastomosis of epididymis to vas deferens; unilateral

10,540

5,040

5,500

54901

Epididymovasostomy, anastomosis of epididymis to vas deferens; bilateral

18,000

8,400

9,600

3,504

504

3,000

9,700
18,000

4,200
8,400

5,500
9,600

9,700

4,200

5,500

3,504
9,300
9,300
4,108

504
2,100
2,100
1,008

3,000
7,200
7,200
3,100

5,560

1,260

4,300

5,680

1,680

4,000

Tunica Vaginalis
55000
55040
55041
55060

55100
55101
55110
55120
55150
55175

Incision
Puncture aspiration of hydrocele, tunica vaginalis, w/ or w/o injection of
medication
Excision
Excision of hydrocele; unilateral
Excision of hydrocele; bilateral
Repair
Repair of tunica vaginalis hydrocele (Bottle type)
Scrotum
Incision
Drainage of scrotal wall abscess
Drainage and debridement of Fourniers gangrene of the scrotum
Scrotal exploration
Removal of foreign body in scrotum
Excision
Resection of scrotum
Repair
Scrotoplasty
Vas Deferens
Incision

55200

Vasotomy, cannulization w/ or w/o incision of vas, unilateral or bilateral

5,680

1,680

4,000

55250

Vasectomy, unilateral or bilateral


Repair
Vasovasostomy, vasovasorrhaphy
Spermatic Cord
Excision
Excision of hydrocele of spermatic cord, unilateral
Excision of lesion of spermatic cord
Excision of varicocele or ligation of spermatic veins for varicocele;
Excision of varicocele or ligation of spermatic veins for varicocele;
abdominal approach
Excision of varicocele or ligation of spermatic veins for varicocele; w/ hernia
repair
Laparoscopy
Laparoscopy, surgical; with ligation of spermatic veins for varicocele
Seminal Vesicles
Incision

4,000

1,000

3,000

10,540

5,040

5,500

9,700
8,260
12,900

4,200
3,360
6,300

5,500
4,900
6,600

14,960

7,560

7,400

14,960

7,560

7,400

14,960

7,560

7,400

55400

55500
55520
55530
55535
55540
55550

Page 81 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE
55600
55650
55680

55700
55720

55801
55810
55812
55815

55821

55831
55840
55842
55845

55859

DESCRIPTION

10,120

4,620

Health Care
Institution Fee
5,500

18,000
18,000

8,400
8,400

9,600
9,600

9,300
5,680

2,100
1,680

7,200
4,000

38,860

20,160

18,700

46,500

25,200

21,300

48,180

26,880

21,300

48,180

26,880

21,300

38,860

20,160

18,700

30,300

16,800

13,500

46,500

25,200

21,300

48,180

26,880

21,300

48,180

26,880

21,300

18,000

8,400

9,600

Case Rate

Vesiculotomy;
Excision
Vesiculectomy, any approach
Excision of Mullerian duct cyst
Prostate
Incision
Biopsy, prostate; needle or punch, single or multiple, any approach
Prostatotomy, external drainage of prostatic abscess, any approach
Excision
Prostatectomy, perineal, subtotal (including control of postoperative
bleeding, vasectomy, meatotomy, urethral calibration and/or dilation, and
internal urethrotomy)
Prostatectomy, perineal radical;
Prostatectomy, perineal radical; w/ lymph node biopsy(s) (limited pelvic
lymphadenectomy)
Prostatectomy, perineal radical; w/ bilateral pelvic lymphadenectomy,
including external iliac, hypogastric and obturator nodes
Prostatectomy (including control of postoperative bleeding, vasectomy,
meatotomy, urethral calibration and/or dilation, and internal urethrotomy);
suprapubic, subtotal, one or two stages
Prostatectomy (including control of postoperative bleeding, vasectomy,
meatotomy, urethral calibration and/or dilation, and internal urethrotomy);
retropubic, subtotal
Prostatectomy, retropubic radical, w/ or w/o nerve sparing;
Prostatectomy, retropubic radical, w/ or w/o nerve sparing; w/ lymph node
biopsy(s) (limited pelvic lymphadenectomy)
Prostatectomy, retropubic radical, w/ or w/o nerve sparing; w/ bilateral
pelvic lymphadenectomy, including external iliac, hypogastric, and
obturator nodes
Transperineal placement of needles, catheters or pellets into prostate for
interstitial radioelement application, with or without cystoscopy, ultrasound
or CT scan guidance

Professional Fee

55860

Exposure of prostate, any approach, for insertion of radioactive substance;

9,700

4,200

5,500

55862

Exposure of prostate, any approach, for insertion of radioactive substance;


w/ lymph node biopsy(s) (limited pelvic lymphadenectomy)

18,000

8,400

9,600

23,300

12,600

10,700

46,500

25,200

21,300

55,000

33,600

21,400

5,560
9,300
9,700
9,300

1,260
2,100
4,200
2,100

4,300
7,200
5,500
7,200

9,300

2,100

7,200

9,300
12,120
23,300
27,120

2,100
6,720
12,600
15,120

7,200
5,400
10,700
12,000

30,300

16,800

13,500

55865

55866
55873

56405
56420
56440
56441
56501
56605
56620
56625
56630
56631

Exposure of prostate, any approach, for insertion of radioactive substance;


w/ bilateral pelvic lymphadenectomy, including external iliac, hypogastric
and obturator nodes
Laparoscopy
Laparoscopy, surgical prostatectomy, retropubic radical, including nerve
sparing
Other Procedures
Cryosurgical ablation of the prostate (cryotherapy of the prostate)
Female Genital System
Vulva, Perineum and Introitus
Incision
Incision and drainage of vulva or perineal abscess
Incision and drainage of Bartholins gland abscess
Marsupialization of Bartholins gland cyst
Lysis of labial adhesions
Destruction
Destruction of lesion(s), vulva; any method
Excision
Biopsy of vulva or perineum ; one lesion
Vulvectomy simple; partial
Vulvectomy simple; complete
Vulvectomy, radical, partial;
Vulvectomy, radical, partial; w/ unilateral inguinofemoral
lymphadenectomy

56632

Vulvectomy, radical, partial; w/ bilateral inguinofemoral lymphadenectomy

37,800

21,000

16,800

56633

Vulvectomy, radical, complete;


Vulvectomy, radical, complete; w/ unilateral inguinofemoral
lymphadenectomy
Vulvectomy, radical, complete; w/ bilateral inguinofemoral
lymphadenectomy
Vulvectomy, radical, complete, w/ inguinofemoral, iliac, and pelvic
lymphadenectomy
Partial hymenectomy or revision of hymenal ring
Hymenotomy, simple incision
Excision of Bartholins gland or cyst

46,500

25,200

21,300

53,400

29,400

24,000

55,000

33,600

21,400

58,800

37,800

21,000

9,700
9,300
9,700

4,200
2,100
4,200

5,500
7,200
5,500

56634
56637
56640
56700
56720
56740

Page 82 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE

DESCRIPTION

Case Rate

Professional Fee

Health Care
Institution Fee

57230

Vagina
Incision
Colpotomy; w/ exploration
Colpocentesis
Destruction of vaginal lesion(s)
Biopsy of vaginal mucosa
Colpectomy, obliteration of vagina; partial
Colpectomy, obliteration of vagina; complete
Colpocleisis (Le Fort type)
Excision of vaginal septum
Excision of vaginal cyst or tumor
Introduction
Insertion of uterine tandems and/or vaginal ovoids for clinical
brachytherapy
Repair
Colporrhaphy, suture of injury of vagina (nonobsterical)
Colpoperineorrhaphy, suture of injury of vagina and/or perineum
(nonobstetrical)
Plastic operation on urethral sphincter, vaginal approach (e.g., Kelly urethral
plication)
Plastic repair of urethrocele

12,120

6,720

5,400

57240

Anterior colporrhaphy, repair of cystocele w/ or w/o repair of urethrocele

20,980

10,080

10,900

57250
57260
57265
57268
57270
57280
57282

Posterior colporrhaphy, repair of rectocele w/ or w/o perineorrhaphy


Combined anteroposterior colporrhaphy;
Combined anteroposterior colporrhaphy; w/ enterocele repair
Repair of enterocele, vaginal approach
Repair of enterocele, abdominal approach
Colpopexy, abdominal approach
Sacrospinous ligament fixation for prolapse of vagina
Paravaginal defect repair (including repair of cystocele, stress urinary
incontinence, and/or incomplete vaginal prolapse)
Sling operation for stress incontinence (e.g., fascia or synthetic)
Pereyra procedure, including anterior colporrhaphy
Closure of rectovaginal fistula; vaginal or transanal approach
Closure of rectovaginal fistula; abdominal approach
Closure of rectovaginal fistula; abdominal approach, w/ concomitant
colostomy
Closure of urethrovaginal fistula;
Closure of urethrovaginal fistula; w/ bulbocavernosus transplant
Closure of vesicovaginal fistula; vaginal approach
Closure of vesicovaginal fistula; transvesical and vaginal approach
Manipulation
Removal of impacted vaginal foreign body under anesthesia
Laparoscopy
Laparoscopy, surgical, colpopexy (suspension of vaginal apex)
Endoscopy
Colposcopy (Vaginoscopy)
Colposcopy; w/ biopsy(s) of the cervix and/or endocervical curettage
Colposcopy; w/ loop electrode excision procedure of the cervix
Cervix Uteri
Excision

20,980
23,300
30,300
23,300
27,120
27,120
27,120

10,080
12,600
16,800
12,600
15,120
15,120
15,120

10,900
10,700
13,500
10,700
12,000
12,000
12,000

27,120

15,120

12,000

30,300
30,300
20,980
23,300

16,800
16,800
10,080
12,600

13,500
13,500
10,900
10,700

30,300

16,800

13,500

20,980
30,300
23,300
30,300

10,080
16,800
12,600
16,800

10,900
13,500
10,700
13,500

8,260

3,360

4,900

27,120

15,120

12,000

8,020
8,260
9,700

2,520
3,360
4,200

5,500
4,900
5,500

57000
57020
57061
57100
57108
57110
57120
57130
57135
57155
57200
57210
57220

57284
57288
57289
57300
57305
57307
57310
57311
57320
57330
57415
57425
57452
57454
57460

12,120
5,680
5,680
5,680
23,300
30,300
27,120
9,300
9,700

6,720
1,680
1,680
1,680
12,600
16,800
15,120
2,100
4,200

5,400
4,000
4,000
4,000
10,700
13,500
12,000
7,200
5,500

9,700

4,200

5,500

8,020

2,520

5,500

10,540

5,040

5,500

12,120

6,720

5,400

57500

Biopsy, single or multiple, or local excision of lesion, w/ or w/o fulguration

5,680

1,680

4,000

57510

5,680

1,680

4,000

9,700

4,200

5,500

12,900

6,300

6,600

57530
57540

Cauterization of cervix; any method


Conization of cervix, w/ or w/o fulguration, w/ or w/o dilation and
curettage, w/ or w/o repair; cold knife or laser
Conization of cervix, w/ or w/o fulguration, w/ or w/o dilation and
curettage, w/ or w/o repair; loop electrode excision
Trachelectomy (cervicectomy), amputation of cervix
Excision of cervical stump, abdominal approach;

18,000
30,300

8,400
16,800

9,600
13,500

57545

Excision of cervical stump, abdominal approach; w/ pelvic floor repair

37,800

21,000

16,800

57550

Excision of cervical stump, vaginal approach;


Excision of cervical stump, vaginal approach; w/ anterior and/or posterior
repair
Excision of cervical stump, vaginal approach; w/ repair of enterocele
Repair
Cerclage of uterine cervix, nonobstetrical
Trachelorrhaphy, plastic repair of uterine cervix, vaginal approach
Corpus Uteri
Excision
Endometrial sampling (biopsy) w/ or w/o endocervical sampling (biopsy),
w/o cervical dilation, any method

23,300

12,600

10,700

37,800

21,000

16,800

39,900

23,100

16,800

9,700
18,000

4,200
8,400

5,500
9,600

11,000

4,400

6,600

57520
57522

57555
57556
57700
57720

58100

Page 83 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE
58120
58140
58145
58150
58152
58180
58200

58210

58240

58260
58262
58263
58267
58270
58275
58280
58285
58300
58345
58346
58400
58410
58520
58540
58600

58545
58550
58552
58555
58558
58559
58560
58561
58562
58563
58565

58660

DESCRIPTION

11,000

4,400

Health Care
Institution Fee
6,600

23,300

12,600

10,700

18,000

8,400

9,600

30,000

12,000

18,000

30,000

12,000

18,000

30,000

12,000

18,000

30,000

12,000

18,000

55,000

33,600

21,400

71,400

50,400

21,000

30,300
30,300

16,800
16,800

13,500
13,500

37,800

21,000

16,800

46,500

25,200

21,300

46,500
37,800

25,200
21,000

21,300
16,800

46,500

25,200

21,300

46,500

25,200

21,300

2,000

800

1,200

18,000

8,400

9,600

9,700

4,200

5,500

23,300

12,600

10,700

27,120

15,120

12,000

Hysterorrhaphy, repair of ruptured uterus (nonobstetrical)


Hysteroplasty, repair of uterine anomaly (Strassman type)
Ligation or transection of fallopian tube(s), abdominal or vaginal approach,
unilateral or bilateral
Laparoscopy
Laparoscopy, surgical, myomectomy, excision; intramural myomas and/or
removal of surface myomas
Laparoscopy surgical, with vaginal hysterectomy;
Laparoscopy surgical, with vaginal hysterectomy; with removal of tube(s)
and/or ovary(s)
Hysteroscopy, diagnostic
Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or
polypectomy, with or without D&C

23,300
37,800

12,600
21,000

10,700
16,800

4,000

1,000

3,000

23,300

12,600

10,700

30,300

16,800

13,500

30,300

16,800

13,500

9,700

4,200

5,500

12,900

6,300

6,600

Hysteroscopy, surgical; with lysis of intrauterine adhesions (any method)

18,000

8,400

9,600

Case Rate

Dilation and curettage


Myomectomy, excision of fibroid tumor of uterus, single or multiple ;
abdominal approach
Myomectomy, excision of fibroid tumor of uterus, single or multiple ;
vaginal approach
Total abdominal hysterectomy (corpus and cervix), w/ or w/o removal of
tube(s), w/ or w/o removal of ovary(s);
Total abdominal hysterectomy (corpus and cervix), w/ or w/o removal of
tube(s), w/ or w/o removal of ovary(s); w/ colpo-urethrocystopexy
(Marshall-Marchetti-Krantz type)
Supracervical abdominal hysterectomy (subtotal hysterectomy), w/ or w/o
removal of tube(s), w/ or w/o removal of ovary(s)
Total abdominal hysterectomy, including partial vaginectomy, w/ paraaortic and pelvic lymph node sampling, w/ or w/o removal of tube(s), w/ or
w/o removal of ovary(s)
Radical abdominal hysterectomy, w/ bilateral total pelvic lymphadenectomy
and para-aortic lymph node sampling (biopsy), w/ or w/o removal of
tube(s), w/ or w/o removal of ovary(s)
Pelvic exenteration for gynecologic malignancy, w/ total abdominal
hysterectomy or cervicectomy, w/ or w/o removal of tube(s), w/ or w/o
removal of ovary(s), w/ removal of bladder and ureteral transplantations,
and/or abdominoperineal resection of rectum and colon and colostomy, or
any combination thereof
Vaginal hysterectomy;
Vaginal hysterectomy; w/ removal of tube(s), and/or ovary(s)
Vaginal hysterectomy; w/ removal of tube(s), and/or ovary(s), w/ repair of
enterocele
Vaginal hysterectomy; w/ colpo-urethrocystopexy (Marshall-MarchettiKrantz type, Pereyra type, w/ or w/o endoscopic control)
Vaginal hysterectomy; w/ repair of enterocele
Vaginal hysterectomy, w/ total or partial colpectomy;
Vaginal hysterectomy, w/ total or partial colpectomy; w/ repair of
enterocele
Vaginal hysterectomy, radical (Schauta type operation)
Introduction
Insertion of intrauterine device (IUD)
Transcervical introduction of fallopian tube catheter for diagnosis and/or reestablishing patency (any method), w/ or w/o hysterosalpingography
Insertion of heyman capsules for brachytherapy
Repair
Uterine suspension, w/ or w/o shortening of round ligaments, w/ or w/o
shortening of sacrouterine ligaments;
Uterine suspension, w/ or w/o shortening of round ligaments, w/ or w/o
shortening of sacrouterine ligaments; w/ presacral sympathectomy

Hysteroscopy, surgical; with division or resection of intrauterine septum


(any method)
Hysteroscopy, surgical; with removal of leiomyomata
Hysteroscopy, surgical; with removal of impacted foreign body
Hysteroscopy, surgical; with endometrial ablation (e.g., endometrial
resection, electrosurgical ablation thermoablation)
Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce
occlusion by placement of permanent implants
Oviduct
Laparoscopy
Laparoscopy, surgical; with lysis of adhesions (salphingolysis, ovariolysis)

Page 84 of 113

Professional Fee

18,000

8,400

9,600

23,300
12,900

12,600
6,300

10,700
6,600

12,120

6,720

5,400

5,680

1,680

4,000

21,400

10,500

10,900

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE

DESCRIPTION

Case Rate

Professional Fee

Health Care
Institution Fee

58800

Laparoscopy, surgical; with removal of adnexal structures (partial or total


oophorectomy and/or salpingectomy)
Laparoscopy, surgical; with fulguration or excision of lesions of the ovary,
pelvic viscera, or peritoneal surface by any method
Laparoscopy, surgical; with fulguration of oviducts (with or without
transection)
Laparoscopy, surgical; with occlusion of oviducts by device (e.g., band, clip,
or Falope ring)
Laparoscopy, surgical; with fimbrioplasty
Laparoscopy, surgical; with salphingostomy (salpingoneostomy)
Excision
Salpingectomy, complete or partial, unilateral or bilateral
Salpingo-oophorectomy, complete or partial, unilateral or bilateral
Repair
Lysis of adhesions (salpingolysis, ovariolysis)
Tubotubal anastomosis
Fimbrioplasty
Salpingostomy (salpingoneostomy)
Ovary
Incision
Drainage of ovarian cyst(s), unilateral or bilateral ; vaginal approach

20,980

10,080

10,900

58805

Drainage of ovarian cyst(s), unilateral or bilateral ; abdominal approach

20,980

10,080

10,900

58820
58822
58825

Drainage of ovarian abscess; vaginal approach


Drainage of ovarian abscess; abdominal approach
Transposition, ovary(s)
Excision
Biopsy of ovary, unilateral or bilateral
Wedge resection or bisection of ovary, unilateral or bilateral
Ovarian cystectomy, unilateral or bilateral
Oophorectomy, partial or total, unilateral or bilateral;
Oophorectomy, partial or total, unilateral or bilateral; for ovarian
malignancy, w/ para-aortic and pelvic lymph node biopsies, peritoneal
washings, peritoneal biopsies, diaphragmatic assessments, w/ or w/o
salpingectomy(s), w/ or w/o omentectomy
Resection of ovarian malignancy w/ bilateral salpingo-oophorectomy and
omentectomy;
Resection of ovarian malignancy w/ bilateral salpingo-oophorectomy and
omentectomy; w/ total abdominal hysterectomy, pelvic and limited paraaortic lymphadenectomy
Resection of ovarian malignancy w/ bilateral salpingo-oophorectomy and
omentectomy; w/ radical dissection for debulking
Laparotomy, for staging or restaging of ovarian malignancy ("second look"),
w/ or w/o omentectomy, peritoneal washing, biopsy of abdominal and
pelvic peritoneum, diaphragmatic assessment w/ pelvic and limited paraaortic lymphadenectomy
Maternity Care and Delivery
Excision
Hysterotomy, abdominal (e.g., for hydatidiform mole, abortion)
Surgical treatment of ectopic pregnancy; tubal or ovarian, requiring
salpingectomy and/or oophorectomy, abdominal or vaginal approach
Surgical treatment of ectopic pregnancy; tubal or ovarian, w/o
salpingectomy and/or oophorectomy
Surgical treatment of ectopic pregnancy; abdominal pregnancy
Surgical treatment of ectopic pregnancy; interstitial, uterine pregnancy
requiring total hysterectomy
Surgical treatment of ectopic pregnancy; interstitial, uterine pregnancy w/
partial resection of uterus
Surgical treatment of ectopic pregnancy; cervical, w/ evacuation
Laparoscopy
Laparoscopic treatment of ectopic pregnancy; w/o salpingectomy and/or
oophorectomy
Laparoscopic treatment of ectopic pregnancy; w/ salpingectomy and/or
oophorectomy
Repair
Cerclage of cervix, during pregnancy; vaginal
Cerclage of cervix, during pregnancy; abdominal
Hysterorrhaphy of ruptured uterus
Vaginal Delivery, Antepartum and Postpartum Care
Vaginal delivery only (w/ episiotomy)
Breech extraction
Cesarean Delivery
Cesarean section, primary
Cesarean delivery

20,980
20,980
20,980

10,080
10,080
10,080

10,900
10,900
10,900

18,000
18,000
23,300
18,000

8,400
8,400
12,600
8,400

9,600
9,600
10,700
9,600

30,300

16,800

13,500

53,400

29,400

24,000

55,000

33,600

21,400

58,800

37,800

21,000

27,120

15,120

12,000

23,300

12,600

10,700

27,120

15,120

12,000

27,120

15,120

12,000

46,500

25,200

21,300

37,800

21,000

16,800

37,600

18,900

18,700

30,300

16,800

13,500

27,120

15,120

12,000

27,120

15,120

12,000

18,000
18,000
30,300

8,400
8,400
16,800

9,600
9,600
13,500

9,700
12,120

4,200
6,720

5,500
5,400

19,000
19,000

7,600
7,600

11,400
11,400

58661
58662
58670
58671
58672
58673
58700
58720
58740
58750
58760
58770

58900
58920
58925
58940
58943

58950
58951
58952

58960

59100
59120
59121
59130
59135
59136
59140
59150
59151
59320
59325
59350
59409
59411
59513
59514

Page 85 of 113

53,400

29,400

24,000

14,960

7,560

7,400

14,960

7,560

7,400

12,900

6,300

6,600

21,400
23,300

10,500
12,600

10,900
10,700

20,980
23,300

10,080
12,600

10,900
10,700

23,300
18,000
23,300
23,300

12,600
8,400
12,600
12,600

10,700
9,600
10,700
10,700

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE

DESCRIPTION

30,000

12,000

12,120

6,720

5,400

19,000

7,600

11,400

11,000
11,000

4,400
4,400

6,600
6,600

12,120

6,720

5,400

3,504

504

3,000

8,260
8,260
20,980
31,000

3,360
3,360
10,080
12,400

4,900
4,900
10,900
18,600

31,000

12,400

18,600

31,000

12,400

18,600

31,000

12,400

18,600

60240

Subtotal or total hysterectomy after cesarean delivery


Delivery After Previous Cesarean Delivery
Vaginal delivery only, after previous cesarean delivery (w/ or w/o
episiotomy)
Cesarean delivery only, following attempted vaginal delivery after previous
cesarean delivery;
Abortion
Treatment of incomplete abortion, any trimester, completed surgically
Manual vacuum aspiration for spontaneous abortion
Other Procedures
Uterine evacuation and curettage for hydatidiform mole
Endocrine System
Thyroid Gland
Incision
Incision and drainage of thyroglossal cyst, infected
Excision
Aspiration and/or injection, thyroid cyst
Biopsy thyroid, percutaneous core needle
Excision of cyst or adenoma of thyroid , or transection of isthmus
Partial thyroid lobectomy, unilateral; w/ or w/o isthmusectomy
Partial thyroid lobectomy, unilateral; w/ contralateral subtotal lobectomy,
including isthmusectomy
Total thyroid lobectomy, unilateral; w/ or w/o isthmusectomy
Total thyroid lobectomy, unilateral; w/ contralateral subtotal lobectomy,
including isthmusectomy
Thyroidectomy, total or complete

Health Care
Institution Fee
18,000

31,000

12,400

18,600

60252

Thyroidectomy, total or subtotal for malignancy; w/ limited neck dissection

31,000

12,400

18,600

60254

Thyroidectomy, total or subtotal for malignancy; w/ radical neck dissection

46,500

25,200

21,300

31,000

12,400

18,600

46,500

25,200

21,300

46,500
20,980
23,300

25,200
10,080
12,600

21,300
10,900
10,700

30,740
27,120

13,440
15,120

17,300
12,000

39,900

23,100

16,800

30,300
39,900

16,800
23,100

13,500
16,800

39,900

23,100

16,800

39,900

23,100

16,800

30,300

16,800

13,500

37,600

18,900

18,700

30,300
37,800

16,800
21,000

13,500
16,800

30,300

16,800

13,500

5,680

1,680

4,000

59525
59612
59620
59812
59814
59870

60000
60001
60100
60200
60210
60212
60220
60225

60260
60270
60271
60280
60281

60500
60502
60505
60512
60520
60521
60522
60540
60545
60600
60605

60650

61000
61020
61050
61105
61106

Case Rate

Thyroidectomy, removal of all remaining thyroid tissue following previous


removal of a portion of thyroid
Thyroidectomy, including substernal thyroid gland; sternal split or
transhoracic approach
Thyroidectomy, including substernal thyroid gland; cervical approach
Excision of thyroglossal duct cyst or sinus;
Excision of thyroglossal duct cyst or sinus; recurrent
Parathyroid, Thymus, Adrenal
Glands, and Carotid Body
Excision
Parathyroidectomy or exploration of parathyroid(s);
Parathyroidectomy or exploration of parathyroid(s); re-exploration
Parathyroidectomy or exploration of parathyroid(s); w/ mediastinal
exploration, sternal split or transthoracic approach
Parathyroid autotransplantation
Thymectomy, partial or total; transcervical approach
Thymectomy, partial or total; sternal split or transthoracic approach, w/o
radical mediastinal dissection
Thymectomy, partial or total; sternal split or transthoracic approach, w/
radical mediastinal dissection
Adrenalectomy, partial or complete, or exploration of adrenal gland w/ or
w/o biopsy, transabdominal, lumbar or dorsal;
Adrenalectomy, partial or complete, or exploration of adrenal gland w/ or
w/o biopsy, transabdominal, lumbar or dorsal; w/ excision of adjacent
retroperitoneal tumor
Excision of carotid body tumor; w/o excision of carotid artery
Excision of carotid body tumor; w/ excision of carotid artery
Laparoscopy
Laparoscopy, surgical, with adrenalectomy, partial or complete, or
exploration of adrenal gland with or without biopsy, transabdominal,
lumbar or dorsal
Nervous System
Skull, Meninges, and Brain
Injection, Drainage, or Aspiration
Subdural tap through fontanelle, or suture, infant, unilateral or bilateral
Ventricular puncture through previous burr hole, fontanelle, suture, or
implanted ventricular catheter/reservoir
Cisternal or lateral cervical (C1-C2) puncture
Twist Drill, Burr Hole(s), or Trephine
Twist drill hole for subdural or ventricular puncture; not followed by other
surgery
Twist drill hole for subdural or ventricular puncture; followed by other
surgery

Page 86 of 113

Professional Fee

5,680

1,680

4,000

10,540

5,040

5,500

18,000

8,400

9,600

18,420

8,820

9,600

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE
61107
61108

DESCRIPTION

Case Rate

Twist drill hole for subdural or ventricular puncture; for implanting


venticular catheter or pressure recording device
Twist drill hole for subdural or ventricular puncture; for evacuation and/or
drainage of subdural hematoma

Professional Fee

Health Care
Institution Fee

30,300

16,800

13,500

37,800

21,000

16,800

61120

Burr hole(s) for ventricular puncture (including injection of gas, contrast


media, dye, or radioactive material); not followed by other surgery

23,300

12,600

10,700

61130

Burr hole(s) for ventricular puncture (including injection of gas, contrast


media, dye, or radioactive material); followed by other surgery

22,240

11,340

10,900

37,800
37,800

21,000
21,000

16,800
16,800

37,800

21,000

16,800

37,800
23,300
30,300

21,000
12,600
16,800

16,800
10,700
13,500

61304

Burr hole(s) or trephine; w/ biopsy of brain or intracranial lesion


Burr hole(s) or trephine; w/ drainage of brain abscess or cyst
Burr hole(s) w/ evacuation and/or drainage of hematoma, extradural or
subdural
Burr hole(s); w/ aspiration of hematoma or cyst, intracerebral
Burr hole(s) or trephine, supratentorial
Burr hole(s) or trephine, infratentorial, unilateral or bilateral
Craniectomy or Craniotomy
Craniectomy or craniotomy, exploratory; supratentorial

37,800

21,000

16,800

61305

Craniectomy or craniotomy, exploratory; infratentorial (posterior fossa)

46,500

25,200

21,300

46,500

25,200

21,300

46,500

25,200

21,300

53,400

29,400

24,000

53,400

29,400

24,000

61140
61150
61154
61156
61250
61253

61312
61313
61314
61315

Craniectomy or craniotomy for evacuation of hematoma, supratentorial;


extradural or subdural
Craniectomy or craniotomy for evacuation of hematoma, supratentorial;
intracerebral
Craniectomy or craniotomy for evacuation of hematoma, infratentorial;
extradural or subdural
Craniectomy or craniotomy for evacuation of hematoma, infratentorial;
intracerebellar

61320

Craniectomy or craniotomy, drainage of intracranial abscess; supratentorial

46,500

25,200

21,300

61321

Craniectomy or craniotomy, drainage of intracranial abscess; infratentorial

53,400

29,400

24,000

61330
61332
61333

Decompression of orbit only, transcranial approach


Exploration of orbit (transcranial approach); w/ biopsy
Exploration of orbit (transcranial approach); w/ removal of lesion

46,500
53,400
53,400

25,200
29,400
29,400

21,300
24,000
24,000

61334

Exploration of orbit (transcranial approach); w/ removal of foreign body

53,400

29,400

24,000

61340

37,800

21,000

16,800

53,400

29,400

24,000

46,500
46,500

25,200
25,200

21,300
21,300

53,400

29,400

24,000

53,400

29,400

24,000

61460
61470

Other cranial decompression (e.g., subtemporal), supratentorial


Craniectomy, suboccipital w/ cervical laminectomy for decompression of
medulla and spinal cord, w/ or w/o dural graft (e.g., Arnold-Chiari
malformation)
Other cranial decompression, posterior fossa
Craniotomy for section of tentorium cerebelli
Craniectomy, subtemporal, for section, compression, or decompression of
sensory root of gasserian ganglion
Craniectomy, suboccipital; for exploration or decompression of cranial
nerves
Craniectomy, suboccipital; for section of one or more cranial nerves
Craniectomy, suboccipital; for medullary tractotomy

55,000
55,000

33,600
33,600

21,400
21,400

61480

Craniectomy, suboccipital; for mesencephalic tractotomy or pedunculotomy

55,000

33,600

21,400

61490

Craniotomy for lobotomy, including cingulotomy

46,500

25,200

21,300

55,000
37,800

33,600
21,000

21,400
16,800

55,000

33,600

21,400

63,000

42,000

21,000

53,400

29,400

24,000

53,400

29,400

24,000

65,100

44,100

21,000

67,200

46,200

21,000

71,400

50,400

21,000

71,400

50,400

21,000

61343
61345
61440
61450
61458

Anterior Cranial Fossa

61500
61501
61510
61512
61514
61516
61518
61519
61520
61521

Craniectomy; w/ excision of tumor or other bone lesion of skull


Craniectomy; for osteomyelitis
Craniectomy, trephination, bone flap craniotomy; for excision of brain
tumor, supratentorial, except meningioma
Craniectomy, trephination, bone flap craniotomy; for excision of
meningioma, supratentorial
Craniectomy, trephination, bone flap craniotomy; for excision of brain
abscess, supratentorial
Craniectomy, trephination, bone flap craniotomy; for excision or
fenestration of cyst, supratentorial
Craniectomy for excision of brain tumor, infratentorial or posterior fossa;
except meningioma, cerebellopontine angle tumor, or midline tumor at
base of skull
Craniectomy for excision of brain tumor, infratentorial or posterior fossa;
meningioma
Craniectomy for excision of brain tumor, infratentorial or posterior fossa;
cerebellopontine angle tumor
Craniectomy for excision of brain tumor, infratentorial or posterior fossa;
midline tumor at base of skull

Page 87 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE
61522
61524
61526
61530
61531
61533
61534
61535
61536
61538
61539

DESCRIPTION

Case Rate

Craniectomy, infratentorial or posterior fossa; for excision of brain abscess


Craniectomy, infratentorial or posterior fossa; for excision or fenestration of
cyst,
Craniectomy, bone flap craniotomy, transtemporal (mastoid) for excision of
cerebellopontine angle tumor;
Craniectomy, bone flap craniotomy, transtemporal (mastoid) for excision of
cerebellopontine angle tumor; combined w/ middle/posterior fossa
craniotomy/ craniectomy
Subdural implantation of strip electrodes through one or more burr or
trephine hole(s) for long term seizure monitoring
Craniotomy w/ elevation of bone flap; for subdural implantation of an
electrode array, for long term seizure monitoring
Craniotomy w/ elevation of bone flap; for excision of epileptogenic focus
w/o electrocorticography during surgery
Craniotomy w/ elevation of bone flap; for removal of epidural or subdural
electrode array, w/o excision of cerebral tissue
Craniotomy w/ elevation of bone flap; for excision of cerebral epileptogenic
focus, w/ electrocorticography during surgery (includes removal of
electrode array)
Craniotomy w/ elevation of bone flap; for lobectomy w/
electrocorticography during surgery, temporal lobe
Craniotomy w/ elevation of bone flap; for lobectomy w/
electrocorticography during surgery, other than temporal lobe, partial or
total

Professional Fee

Health Care
Institution Fee

55,000

33,600

21,400

55,000

33,600

21,400

75,600

54,600

21,000

75,600

54,600

21,000

53,400

29,400

24,000

53,400

29,400

24,000

53,400

29,400

24,000

53,400

29,400

24,000

55,000

33,600

21,400

53,400

29,400

24,000

53,400

29,400

24,000

61541

Craniotomy w/ elevation of bone flap; for transection of corpus callosum

53,400

29,400

24,000

61542

Craniotomy w/ elevation of bone flap; for total hemispherectomy


Craniotomy w/ elevation of bone flap; for partial or subtotal
hemispherectomy
Craniotomy w/ elevation of bone flap; for excision of coagulation of choroid
plexus

67,200

46,200

21,000

63,000

42,000

21,000

53,400

29,400

24,000

Craniotomy w/ elevation of bone flap; for excision of craniopharyngioma

63,000

42,000

21,000

63,000

42,000

21,000

63,000

42,000

21,000

37,800
46,500
46,500
46,500

21,000
25,200
25,200
25,200

16,800
21,300
21,300
21,300

58,800

37,800

21,000

58,800

37,800

21,000

58,800

37,800

21,000

58,800

37,800

21,000

53,400

29,400

24,000

55,500

31,500

24,000

75,600

54,600

21,000

75,600

54,600

21,000

63,000

42,000

21,000

63,000

42,000

21,000

63,000

42,000

21,000

63,000

42,000

21,000

61543
61544
61545

61570

Craniotomy for hypophysectomy or excision of pituitary tumor, intracranial


approach
Hypophysectomy or excision of pituitary tumor, transnasal or transseptal
approach, nonstereotactic
Craniectomy for craniosynostosis; single cranial suture
Craniectomy for craniosynostosis; multiple cranial sutures
Craniotomy for craniosynostosis; frontal or parietal bone flap
Craniotomy for craniosynostosis; bifrontal bone flap
Extensive craniectomy for multiple cranial suture craniosynostosis (e.g.,
cloverleaf skull); not requiring bone grafts
Extensive craniectomy for multiple cranial suture craniosynostosis (e.g.,
cloverleaf skull); recontouring w/ multiple osteotomies and bone autografts
(e.g., barrel-stave procedure) (includes obtaining grafts)
Excision, intra and extracranial, benign tumor of cranial bone (e.g., fibrous
dysplasia); w/o optic nerve decompression
Excision, intra and extracranial, benign tumor of cranial bone (e.g., fibrous
dysplasia); w/ optic nerve decompression
Craniectomy or craniotomy; w/ excision of foreign body from brain

61571

Craniectomy or craniotomy; w/ treatment of penetrating wound of brain

61546
61548
61550
61552
61556
61557
61558
61559
61563
61564

61575
61576

61580

61581

61582

61583

Transoral approach to skull base, brain stem or upper spinal cord for biopsy,
decompression or excision of lesion;
Transoral approach to skull base, brain stem or upper spinal cord for biopsy,
decompression or excision of lesion; requiring splitting of tongue and/or
mandible (including tracheostomy)
Surgery of Skull Base Approach Procedures
Anterior Cranial Fossa
Craniofacial approach to anterior cranial fossa; extradural, including lateral
rhinotomy, ethmoidectomy, sphenoidectomy, w/o maxillectomy or orbital
exenteration
Craniofacial approach to anterior cranial fossa; extradural, including lateral
rhinotomy, orbital exenteration, ethmoidectomy, sphenoidectomy and/or
maxillectomy
Craniofacial approach to anterior cranial fossa; extradural, including
unilateral or bifrontal craniotomy, elevation of frontal lobe(s), osteotomy of
base of anterior cranial fossa
Craniofacial approach to anterior cranial fossa; intradural, including
unilateral or bifrontal craniotomy, elevation or resection of frontal lobe,
osteotomy of base of anterior cranial fossa

Page 88 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE
61584

61585
61586

DESCRIPTION

Case Rate

Orbitocranial approach to anterior cranial fossa, extradural, including


supraorbital ridge osteotomy and elevation of frontal and/or temporal
lobe(s); w/o orbital exenteration
Orbitocranial approach to anterior cranial fossa, extradural, including
supraorbital ridge osteotomy and elevation of frontal and/or temporal
lobe(s); w/ orbital exenteration
Bicoronal, transzygomatic and/or LeFort I osteotomy approach to anterior
cranial fossa w/ or w/o internal fixation, w/o bone graft

Professional Fee

Health Care
Institution Fee

63,000

42,000

21,000

63,000

42,000

21,000

63,000

42,000

21,000

71,400

50,400

21,000

71,400

50,400

21,000

67,200

46,200

21,000

71,400

50,400

21,000

71,400

50,400

21,000

71,400

50,400

21,000

71,400

50,400

21,000

67,200

46,200

21,000

67,200

46,200

21,000

71,400

50,400

21,000

71,400

50,400

21,000

71,400

50,400

21,000

71,400

50,400

21,000

71,400

50,400

21,000

71,400

50,400

21,000

63,000

42,000

21,000

71,400

50,400

21,000

71,400

50,400

21,000

Middle Cranial Fossa

61590

61591

61592

Infratemporal pre-auricular approach to middle cranial fossa


(parapharyngeal space, infratemporal and midline skull base, nasopharynx),
w/ or w/o disarticulation of the mandible, including parotidectomy,
craniotomy, decompression and/or mobilization of th
Infratemporal post-auricular approach to middle cranial fossa (internal
auditory meatus, petrous apex, tentorium, cavernous sinus, parasellar area,
infratemporal fossa) inlcuding mastoidectomy, resection of sigmoid sinus,
w/ or w/o decompression and/or mo
Orbitocranial zygomatic approach to middle cranial fossa (cavernous sinus
and carotid artery, clivus, basilar artery or petrous apex) including
osteotomy of zygoma, craniotomy, extra- or intradural elevation of
temporal lobe
Posterior Cranial Fossa

61595

61596

61597

61598

61600
61601

Transtemporal approach to posterior cranial fossa, jugular foramen or


midline skull base, including mastoidectomy, decompression of sigmoid
sinus and/or facial nerve, w/ or w/o mobilization
Transcochlear approach to posterior cranial fossa, jugular foramen or
midline skull base, including labyrinthectomy, decompression, w/ or w/o
mobilization of facial nerve and/or petrous carotid artery
Transcondylar (far lateral) approach to posterior cranial fossa, jugular
foramen or midline skull base, including occiptal condylectomy,
mastoidectomy, resection of C1-C3 vertebral body(s), decompression of
vertebral artery, w/ or w/o mobilization
Transpetrosal approach to posterior cranial fossa, clivus or framen magnum,
including ligation of superior petrosal sinus and/or sigmoid sinus
Definite Procedures
Base of Anterior Cranial Fossa
Resection or excision of neoplastic, vascular or infectious lesion of base of
anterior cranial fossa; extradural
Resection or excision of neoplastic, vascular or infectious lesion of base of
anterior cranial fossa; intradural, including dural repair,w/ or w/o graft
Base of Middle Cranial Fossa

61605
61606

61607

61608
61609
61610
61611
61612
61613

Resection or excision of neoplastic, vascular or infectious lesion of


infratemporal fossa, parapharyngeal space, petrous apex; extradural
Resection or excision of neoplastic, vascular or infectious lesion of
infratemporal fossa, parapharyngeal space, petrous apex; intradural,
including dural repair, w/ or w/o graft
Resection or excision of neoplastic, vascular or infectious lesion of parasellar
area, cavernous sinus, clivus or midline skull base; extradural
Resection or excision of neoplastic, vascular or infectious lesion of parasellar
area, cavernous sinus, clivus or midline skull base; intradural, including dural
repair, w/ or w/o graft
Transection or ligation, carotid artery in cavernous sinus; w/o repair
Transection or ligation, carotid artery in cavernous sinus; w/ repair by
anastomosis or graft
Transection or ligation , carotid artery in petrous canal; w/o repair
Transection or ligation , carotid artery in petrous canal; w/ repair by
anastomosis or graft
Obliteration of carotid aneurysm, arteriovenous malformation, or carotidcavernous fistula by dissection w/in cavernous sinus
Base of Posterior Cranial Fossa

61615

Resection or excision of neoplastic, vascular or infectious lesion of base of


posterior cranial fossa, jugular foramen, foramen magnum, or CI-C3
vertebral bodies; extradural

71,400

50,400

21,000

61616

Resection or excision of neoplastic, vascular or infectious lesion of base of


posterior cranial fossa, jugular foramen, foramen magnum, or CI-C3
vertebral bodies; intradural, including dural repair, w/ or w/o graft

71,400

50,400

21,000

Repair and / or Reconstruction of Surgical Defects of Skull Base

Page 89 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE

61618

61619

DESCRIPTION

Case Rate

Secondary repair of dura for CSF leak, anterior, middle or posterior cranial
fossa following surgery of the skull base; by free tissue graft (e.g.,
pericranium, fascia, tensor fascia lata, adipose tissue, homologous or
synthetic grafts)
Secondary repair of dura for CSF leak, anterior, middle or posterior cranial
fossa following surgery of the skull base; by local or regionalized
vascularized pedicle flap or myocutaneous flap (including galea,temporalis,
frontalis or occipitalis muscle)
Endovascular Therapy

Professional Fee

Health Care
Institution Fee

67,200

46,200

21,000

63,000

42,000

21,000

61624

Transcatheter oclussion or embolization (e.g., for tumor destruction, to


achieve hemostasis, to occlude a vascular malformation), percutaneous, any
method; central nervous system (intracranial, spinal cord)

71,400

50,400

21,000

61626

Transcatheter oclussion or embolization (e.g., for tumor destruction, to


achieve hemostasis, to occlude a vascular malformation), percutaneous, any
method; non-central nervous system, head or neck (extracranial,
brachiocephalic branch)

55,000

33,600

21,400

Surgery for Aneurym, Arteriovenous Malformation or Vascular Disease


61680

Surgery of intracranial arteriovenous malformation; supratentorial, simple

63,000

42,000

21,000

61682

Surgery of intracranial arteriovenous malformation; supratentorial, complex

71,400

50,400

21,000

61684

Surgery of intracranial arteriovenous malformation; infratentorial, simple

63,000

42,000

21,000

61686

Surgery of intracranial arteriovenous malformation; infratentorial, complex

71,400

50,400

21,000

61690
61692

Surgery of intracranial arteriovenous malformation; dural, simple


Surgery of intracranial arteriovenous malformation; dural, complex

55,000
63,000

33,600
42,000

21,400
21,000

61700

Surgery of intracranial aneurysm, intracranial approach; carotid circulation

71,400

50,400

21,000

61702

Surgery of intracranial aneurysm, intracranial approach; vertebral-basilar


circulation

75,600

54,600

21,000

61703

Surgery of intracranial aneurysm, cervical approach by application of


occluding clamp to cervical carotid artery (Selverstone-Crutchfield type)

23,300

12,600

10,700

71,400

50,400

21,000

37,800

21,000

16,800

63,000

42,000

21,000

67,200

46,200

21,000

67,200

46,200

21,000

67,200

46,200

21,000

63,000

42,000

21,000

63,000

42,000

21,000

63,000

42,000

21,000

63,000

42,000

21,000

30,300

16,800

13,500

61705
61708
61710
61711
61712

61720

61735
61750
61751
61760
61770

Surgery of aneurysm, vascular malformation or carotid-cavernous fistula; by


intracranial and cervical occlusion of carotid artery
Surgery of aneurysm, vascular malformation or carotid-cavernous fistula; by
intracranial electrothrombosis
Surgery of aneurysm, vascular malformation or carotid-cavernous fistula; by
intra-arterial embolization, injection procedure or balloon catheter
Anastomosis, arterial, extracranial-intracranial (e.g., middle
cerebral/cortical) arteries
Microdissection, intracranial or spinal procedure (list separately in addition
to code for primary procedure)
Stereotaxis
Creation of lesion by stereotactic method, including burr hole(s) and
localizing and recording techniques, single or multiple stages; globus
pallidus or thalamus
Creation of lesion by stereotactic method, including burr hole(s) and
localizing and recording techniques, single or multiple stages; subcortical
structure(s) other than globus pallidus or thalamus
Stereotactic biopsy, aspiration, or excision,including burr hole(s), for
intracranial lesion;
Stereotactic biopsy, aspiration, or excision,including burr hole(s), for
intracranial lesion; w/ computerized axial tomography
Stereotactic implantation of depth electrodes into the cerebrum for long
term seizure monitoring
Stereotactic localization , any method, including burr hole(s), w/ insertion of
catheter(s) for brachytherapy

61790

Creation of lesion by stereotactic method, percutaneous, by neurolytic


agent (e.g., alcohol, thermal, electrical, radiofrequency); gasserian ganglion

37,800

21,000

16,800

61791

Creation of lesion by stereotactic method, percutaneous, by neurolytic


agent (e.g., alcohol, thermal, electrical, radiofrequency); trigeminal
medullary tract

37,800

21,000

16,800

61793

Stereotactic radiosurgery (particle beam,gamma ray or linear accelerator)

63,000

42,000

21,000

61795

Stereotactic computer assisted volumetric intracranial procedure


Neurostimulators (Intracranial)

63,000

42,000

21,000

Page 90 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE

DESCRIPTION

Case Rate

62000

Twist drill or burr hole(s) for implantation of neurostimulator electrodes;


cortical
Twist drill or burr hole(s) for implantation of neurostimulator electrodes;
subcortical
Craniectomy or craniotomy for implantation of neurostimulator electrodes,
cerebral; cortical
Craniectomy or craniotomy for implantation of neurostimulator electrodes,
cerebral; subcortical
Craniectomy for implantation of neurostimulator electrodes, cerebellar;
cortical
Craniectomy for implantation of neurostimulator electrodes, cerebellar;
subcortical
Incision and subcutaneous placement of cranial neurostimulator pulse
generator or receiver, direct or inductive coupling
Repair
Elevation of depressed skull fracture; simple, extradural

62005

Elevation of depressed skull fracture; compound or comminuted, extradural

61850
61855
61860
61865
61870
61875
61885

62010
62100
62115
62116
62117
62120
62121
62140
62141
62142
62143
62145
62146
62147

Elevation of depressed skull fracture; w/ repair of dura and /or debridement


of brain
Craniotomy for repair of dural /CSF leak, including surgery for
rhinorrhea/otorrhea
Reduction of craniomegalic skull (e.g., treated hydrocephalus); not requiring
bone grafts or cranioplasty
Reduction of craniomegalic skull (e.g., treated hydrocephalus); w/ simple
cranioplasty
Reduction of craniomegalic skull (e.g., treated hydrocephalus); requiring
craniotomy and reconstruction w/ or w/o bone graft (includes obtaining
grafts)
Repair of encephalocele, skull vault, including cranioplasty
Craniotomy for repair of encephalocele , skull base
Cranioplasty for skull defect; up to 5 cm diameter
Cranioplasty for skull defect; larger than 5 cm diameter
Removal of bone flap or prosthetic plate of skull
Replacement of bone flap or prosthetic plate of skull
Cranioplasty for skull defect w/ reparative brain surgery
Cranioplasty w/ autograft (includes obtaining bone grafts); up to 5 cm
diameter
Cranioplasty w/ autograft (includes obtaining bone grafts); larger than 5 cm
diameter
Neuroendoscopy

Professional Fee

Health Care
Institution Fee

53,400

29,400

24,000

67,200

46,200

21,000

58,800

37,800

21,000

46,500

25,200

21,300

58,800

37,800

21,000

67,200

46,200

21,000

37,800

21,000

16,800

30,300

16,800

13,500

37,800

21,000

16,800

46,500

25,200

21,300

71,400

50,400

21,000

37,800

21,000

16,800

46,500

25,200

21,300

53,400

29,400

24,000

58,800
55,000
30,300
30,300
30,300
30,300
53,400

37,800
33,600
16,800
16,800
16,800
16,800
29,400

21,000
21,400
13,500
13,500
13,500
13,500
24,000

53,400

29,400

24,000

55,000

33,600

21,400

62160

Neuroendoscopy, intracranial, for placement or replacement of ventricular


catheter and attachment to shunt system or external drainage

37,800

21,000

16,800

62161

Neuroendoscopy, intracranial; with dissection of adhesions, fenestration of


septum pellucidum or intraventricular cyst (including placement,
replacement or removal of ventricular catheter)

46,500

25,200

21,300

62162

Neuroendoscopy, intracranial; with fenestration or excision of colloid cyst,


including placement of external ventricular catheter for drainage

46,500

25,200

21,300

46,500

25,200

21,300

46,500

25,200

21,300

62180

Neuroendoscopy, intracranial; with retrieval of foreign body


Neuroendoscopy, intracranial; with excision of pituitary tumor, transnasal
or transphenoidal approach
CSF Shunt
Ventriculocisternostomy (Torkildsen type operation)

37,800

21,000

16,800

62190

Creation of shunt; subarachnoid/subdural-atrial, -jugular, -auricular

23,300

12,600

10,700

23,300

12,600

10,700

37,800
46,500
30,300
30,300

21,000
25,200
16,800
16,800

16,800
21,300
13,500
13,500

23,300

12,600

10,700

12,900
12,900
5,680

6,300
6,300
1,680

6,600
6,600
4,000

5,560

1,260

4,300

23,300

12,600

10,700

62163
62165

62192
62200
62201
62220
62223
62230

62268
62269
62270
62272
62287

Creation of shunt; subarachnoid/subdural-peritonial, -pleural, other


terminus
Ventriculocisternostomy, third ventricle;
Ventriculocisternostomy, third ventricle; stereotactic method
Creation of shunt; ventriculo-atrial, -jugular,-auricular
Creation of shunt; ventriculo-peritonial,-pleural, other terminus
Replacement or revision of CSF (VP) shunt, obstructed valve, or distal
catheter in shunt system
Spine and Spinal Cord
Injection, Drainage or Aspiration
Percutaneous aspiration, spinal cord cyst or syrinx
Biopsy of spinal cord, percutaneous needle
Spinal puncture, lumbar, diagnostic
Spinal puncture , therapeutic, for drainage of spinal fluid (by needle or
catheter)
Aspiration procedure, percutaneous, of nucleus pulposus of intervertebral
disk, any method, single or multiple levels, lumbar

Page 91 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE

DESCRIPTION

Case Rate

Professional Fee

Health Care
Institution Fee

Catheter Implantation
62350

Implantation, revision or repositioning of intrathecal or epidural catheter,


for implantable reservoir or implantable infusion pump; w/o laminectomy

18,000

8,400

9,600

62351

Implantation, revision or repositioning of intrathecal or epidural catheter,


for implantable reservoir or implantable infusion pump; w/ laminectomy

37,800

21,000

16,800

9,700

4,200

5,500

18,000

8,400

9,600

23,300

12,600

10,700

46,500

25,200

21,300

55,000

33,600

21,400

53,400

29,400

24,000

37,800

21,000

16,800

37,800

21,000

16,800

53,400

29,400

24,000

55,000

33,600

21,400

53,400

29,400

24,000

46,500

25,200

21,300

55,000

33,600

21,400

46,500

25,200

21,300

53,400

29,400

24,000

46,500

25,200

21,300

62360
62361
62362

62464

63001

63003

63005

63011

63012

63015

63016

63017

63020

63030

63040

63042

Reservior/ Pump Implantation


Implantation or replacement of device for intrathecal or epidural drug
infusion; subcutaneous reservoir
Implantation or replacement of device for intrathecal or epidural drug
infusion; non-programmable pump
Implantation or replacement of device for intrathecal or epidural drug
infusion; programmable pump, including preparation of pump, w/ or w/o
programming
Implantation or replacement of device for intrathecal or epidural drug
infusion; with excision of brain tumor, including placement of external
ventricular catheter for drainage
Posterior Extradural Laminotomy or Laminectomy for Exploration/
Decompression of Neural Elements or Excision of Herniated Intervertebral
Disks
Laminectomy w/ exploration and/or decompression of spinal cord and/or
cauda equina, w/o facetectomy, foraminotomy or diskectomy, (e.g., spinal
stenosis), one or two vertebral segments; cervical
Laminectomy w/ exploration and/or decompression of spinal cord and/or
cauda equina, w/o facetectomy, foraminotomy or diskectomy, (e.g., spinal
stenosis), one or two vertebral segments; thoracic
Laminectomy w/ exploration and/or decompression of spinal cord and/or
cauda equina, w/o facetectomy, foraminotomy or diskectomy, (e.g., spinal
stenosis), one or two vertebral segments; lumbar,except for
spondylolisthesis
Laminectomy w/ exploration and/or decompression of spinal cord and/or
cauda equina, w/o facetectomy, foraminotomy or diskectomy, (e.g., spinal
stenosis), one or two vertebral segments; sacral
Laminectomy w/ removal of abnormal facets and/or pars inter-articularis
w/ decompression of cauda equina and nerve roots for spondylolisthesis,
lumbar (Gill type procedure)
Laminectomy w/ exploration and/or decompression of spinal cord and/or
cauda equina, w/o facetectomy, foraminotomy or diskectomy, (e.g., spinal
stenosis) , more than 2 vertebral segments; cervical
Laminectomy w/ exploration and/or decompression of spinal cord and/or
cauda equina, w/o facetectomy, foraminotomy or diskectomy, (e.g., spinal
stenosis) , more than 2 vertebral segments; thoracic
Laminectomy w/ exploration and/or decompression of spinal cord and/or
cauda equina, w/o facetectomy, foraminotomy or diskectomy, (e.g., spinal
stenosis) , more than 2 vertebral segments; lumbar
Laminotomy (hemilaminectomy), w/ decompression of nerve root (s),
including partial facetectomy , foraminotomy and/or excision of herniated
intervertebral disk; one interspace, cervical
Laminotomy (hemilaminectomy), w/ decompression of nerve root (s),
including partial facetectomy , foraminotomy and/or excision of herniated
intervertebral disk; one interspace,lumbar
Laminotomy (hemilaminectomy), w/ decompression of nerve root (s),
including partial facetectomy , foraminotomy and/or excision or herniated
intervertebral disk; re-exploration; cervical
Laminotomy (hemilaminectomy), w/ decompression of nerve root (s),
including partial facetectomy , foraminotomy and/or excision or herniated
intervertebral disk; re-exploration; lumbar

63045

Laminectomy, facetectomy and foraminotomy (unilateral or bilateral w/


decompression of spinal cord, cauda equina and/or nerve root(s), ( eg,
spinal or lateral recess stenosis), single vertebral segment; cervical

55,000

33,600

21,400

63046

Laminectomy, facetectomy and foraminotomy (unilateral or bilateral w/


decompression of spinal cord, cauda equina and/or nerve root(s), ( eg,
spinal or lateral recess stenosis), single vertebral segment; thoracic

53,400

29,400

24,000

63047

Laminectomy, facetectomy and foraminotomy (unilateral or bilateral w/


decompression of spinal cord, cauda equina and/or nerve root(s), ( eg,
spinal or lateral recess stenosis), single vertebral segment; lumbar

46,500

25,200

21,300

Transpedicular or Costovertebral Approach for Posterolateral Extradural


Exploration/ Decompression

Page 92 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE

DESCRIPTION

Case Rate

Professional Fee

Health Care
Institution Fee

63055

Transpedicular approach w/ decompression of spinal cord, equina and/ or


nerve root(s) (e.g., herniated intervetebral disk), single segment; thoracic

53,400

29,400

24,000

63056

Transpedicular approach w/ decompression of spinal cord, equina and/ or


nerve root(s) (e.g., herniated intervetebral disk), single segment; lumbar

46,500

25,200

21,300

53,400

29,400

24,000

55,000

33,600

21,400

37,800

21,000

16,800

55,000

33,600

21,400

53,400

29,400

24,000

46,500

25,200

21,300

53,400

29,400

24,000

58,800

37,800

21,000

53,400

29,400

24,000

55,000

33,600

21,400

55,000

33,600

21,400

55,000

33,600

21,400

53,400
53,400
57,520

29,400
29,400
36,120

24,000
24,000
21,400

55,000

33,600

21,400

53,400

29,400

24,000

55,000

33,600

21,400

53,400

29,400

24,000

55,000

33,600

21,400

53,400

29,400

24,000

49,020

27,720

21,300

55,000

33,600

21,400

53,400

29,400

24,000

46,500

25,200

21,300

55,000

33,600

21,400

53,400

29,400

24,000

46,500

25,200

21,300

37,800

21,000

16,800

55,000

33,600

21,400

63064

63075
63077
63081

63085

63087

63090

63170
63172
63173
63180
63182
63185
63190
63191
63194
63195
63196
63197
63198
63199
63200
63250
63251
63252
63265
63266
63267
63268
63270

Costovertebral approach w/ decompression of spinal cord or nerve root(s),


(e.g., herniated intervertebral disk), thoracic; single segment
Anterior or Anterolateral Approach for Extradural
Exploration/Decompression
Diskectomy, anterior, w/ decompression of spinal cord and/ or nerve
root(s), including osteophytectomy; cervical, single interspace
Diskectomy, anterior, w/ decompression of spinal cord and/ or nerve
root(s), including osteophytectomy; thoracic, single interspace
Vertebral corpectomy (vertebral body resection), partial or complete,
anterior approach w/ decompression of spinal cord and/ or nerve root(s);
cervical, single segment
Vertebral corpectomy (vertebral body resection), partial or complete,
transthoracic approach w/ decompression of spinal cord and/ or nerve
root(s); thoracic, single segment
Vertebral corpectomy (vertebral body resection), partial or complete,
combined thoracolumbar approach w/ decompression of spinal cord, cauda
equina or nerve root(s), lower thoracic or lumbar; single segment
Vertebral corpectomy (vertebral body resection), partial or complete,
transperitoneal or retroperitoneal approach w/ decompression of spinal
cord, cauda equina or nerve root(s), lower thoracic, lumbar, or sacral; single
segment
Incision
Laminectomy w/ myelotomy (e.g., Bischof or DREZ type), cervical thoracic,
or thoracolumbar
Laminectomy w/ drainage of intramedullary cyst/ syrinx; to subarachnoid
space
Laminectomy w/ drainage of intramedullary cyst/ syrinx; to peritoneal space
Laminectomy and section of dentate ligaments, w/ or w/o dural graft,
cervical; one of two segments
Laminectomy and section of dentate ligaments, w/ or w/o dural graft,
cervical; more than two segments
Laminectomy w/ rhizotomy; one or two segments
Laminectomy w/ rhizotomy; more than two segments
Laminectomy w/ section of spinal accessory nerve
Laminectomy w/ cordotomy, w/ section of one spinothalamic tract, one
stage; cervical
Laminectomy w/ cordotomy, w/ section of one spinothalamic tract, one
stage; thoracic
Laminectomy w/ cordotomy w/ section of both spinothalamic tracts, one
stage; cervical
Laminectomy w/ cordotomy w/ section of both spinothalamic tracts, one
stage; thoracic
Laminectomy w/ cordotomy w/ section of both spinothalamic tracts, two
stages w/in 14 days; cervical
Laminectomy w/ cordotomy w/ section of both spinothalamic tracts, two
stages w/in 14 days; thoracic
Laminectomy, w/ release of tethered spinal cord, lumbar
Excision by Laminectomy of Lesion Other Than Herniated Disk
Laminectomy for excision or occlusion of arteriovenous malformation of
spinal cord; cervical
Laminectomy for excision or occlusion of arteriovenous malformation of
spinal cord; thoracic
Laminectomy for excision or occlusion of arteriovenous malformation of
spinal cord; thoracolumbar
Laminectomy for excision or evacuation of intraspinal lesion other than
neoplasm; extradural; cervical
Laminectomy for excision or evacuation of intraspinal lesion other than
neoplasm; extradural; thoracic
Laminectomy for excision or evacuation of intraspinal lesion other than
neoplasm; extradural; lumbar
Laminectomy for excision or evacuation of intraspinal lesion other than
neoplasm; extradural; sacral
Laminectomy for excision of intraspinal lesion other than neoplasm;
intradural; cervical

Page 93 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE

DESCRIPTION

Case Rate

63650

Laminectomy for excision of intraspinal lesion other than neoplasm;


intradural; thoracic
Laminectomy for excision of intraspinal lesion other than neoplasm;
intradural; lumbar
Laminectomy for excision of intraspinal lesion other than neoplasm;
intradural; sacral
Laminectomy for biopsy/ excision of intraspinal neoplasm; extradural,
cervical
Laminectomy for biopsy/ excision of intraspinal neoplasm; extradural,
extradural, thoracic
Laminectomy for biopsy/ excision of intraspinal neoplasm; extradural,
extradural, lumbar
Laminectomy for biopsy/ excision of intraspinal neoplasm; extradural,
extradural, sacral
Laminectomy for biopsy/ excision of intraspinal neoplasm; extradural,
intradural, extramedullary, cervical
Laminectomy for biopsy/ excision of intraspinal neoplasm; extradural,
intradural, extramedullarry, thoracic
Laminectomy for biopsy/ excision of intraspinal neoplasm; extradural,
intradural, extramedullary, lumbar
Laminectomy for biopsy/ excision of intraspinal neoplasm; extradural,
intradural, sacral
Laminectomy for biopsy/ excision of intraspinal neoplasm; extradural,
intradural, intramedullary, cervical
Laminectomy for biopsy/ excision of intraspinal neoplasm; extradural,
intradural, intramedullary, thoracic
Laminectomy for biopsy/ excision of intraspinal neoplasm; extradural,
intradural, intramedullary, thoracolumbar
Laminectomy for biopsy/ excision of intraspinal neoplasm; extradural,
combined extradural-intradural lesion, any level
Excision, Anterior or Anterolateral Approach, Intraspinal Lesion
Vertebral corpectomy (vertebral body resection), partial or complete, for
excision of intraspinal lesion, single segment; extradural, cervical
Vertebral corpectomy (vertebral body resection), partial or complete, for
excision of intraspinal lesion, single segment; extradural, thoracic by
transthoracic approach
Vertebral corpectomy (vertebral body resection), partial or complete, for
excision of intraspinal lesion, single segment; extradural, thoracic by
thoracolumbar approach
Vertebral corpectomy (vertebral body resection), partial or complete, for
excision of intraspinal lesion, single segment; extradural, lumbar or sacral by
transperitoneal or retroperitoneal approach
Vertebral corpectomy (vertebral body resection), partial or complete, for
excision of intraspinal lesion, single segment; intradural, cervical
Vertebral corpectomy (vertebral body resection), partial or complete, for
excision of intraspinal lesion, single segment; intradural, thoracic by
transthoracic approach
Vertebral corpectomy (vertebral body resection), partial or complete, for
excision of intraspinal lesion, single segment; intradural, thoracic by
thoracolumbar approach
Vertebral corpectomy (vertebral body resection), partial or complete, for
excision of intraspinal lesion, single segment; intradural, lumbar or sacral by
transperitoneal or retroperitoneal approach
Stereotaxis
Creation of lesion of spinal cord by stereotactic method, percutaneous, any
modality (including stimulation and/ or recording)
Stereotactic stimulation of spinal cord, percutaneous, separate procedure
not followed by other surgery
Stereotactic biopsy, aspiration, or excision of lesion, spinal cord
Neurostimulators (Spinal)
Percutaneous implantation of neurostimulator electrodes; epidural

63655

Laminectomy for implantation of neurostimulator electrodes; epidural

63271
63272
63273
63275
63276
63277
63278
63280
63281
63282
63283
63285
63286
63287
63290

63300
63301

63302

63303
63304
63305

63306

63307

63600
63610
63615

63685
63700
63702
63704
63706
63707
63709
63710

Incision and subscutaneous placement of spinal neurostimulator pulse


generator or receiver, direct or inductive coupling
Repair
Repair of meningocele; less than 5 cm diameter
Repair of meningocele; larger than 5 diameter
Repair of myelomeningocele; less than 5 cm diameter
Repair of myelomeningocele; larger than 5 diameter
Repair of dural/ CSF leak, not requiring laminectomy
Repair of dural/ CSF leak or pseudomeningocele, w/ laminectomy
Dural graft, spinal
Shunt, Spinal CSF

Page 94 of 113

Professional Fee

Health Care
Institution Fee

53,400

29,400

24,000

46,500

25,200

21,300

37,800

21,000

16,800

55,000

33,600

21,400

53,400

29,400

24,000

46,500

25,200

21,300

37,800

21,000

16,800

58,800

37,800

21,000

55,000

33,600

21,400

53,400

29,400

24,000

46,500

25,200

21,300

58,800

37,800

21,000

55,000

33,600

21,400

53,400

29,400

24,000

46,500

25,200

21,300

55,000

33,600

21,400

53,400

29,400

24,000

53,400

29,400

24,000

53,400

29,400

24,000

55,000

33,600

21,400

53,400

29,400

24,000

53,400

29,400

24,000

53,400

29,400

24,000

30,300

16,800

13,500

30,300

16,800

13,500

37,600

18,900

18,700

8,020

2,520

5,500

46,500

25,200

21,300

21,820

10,920

10,900

30,300
37,180
37,800
46,500
30,300
46,500
46,500

16,800
18,480
21,000
25,200
16,800
25,200
25,200

13,500
18,700
16,800
21,300
13,500
21,300
21,300

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE
63740
63741

DESCRIPTION

Case Rate

Creation of shunt, lumbar, subarachnoid-peritoneal, -pleural, or other;


including laminectomy
Creation of shunt, lumbar, subarachnoid-peritoneal, -pleural, or other;
percutaneous, not requiring laminectomy

Professional Fee

Health Care
Institution Fee

30,300

16,800

13,500

23,300

12,600

10,700

Extracranial Nerves, Peripheral Nerves, and Autonomic Nervous System


Neuroplasty (Exploration, Neurolysis or Nerve Decompression)

64702
64704
64708
64712
64713
64714
64716
64718
64719
64721
64722
64726

Neuroplasty; digital, one or both, same digit


Neuroplasty; nerve of hand or foot
Neuroplasty, major peripheral nerve, arm or leg; other than specified
Neuroplasty, major peripheral nerve, arm or leg; sciatic nerve
Neuroplasty, major peripheral nerve, arm or leg; brachial plexus
Neuroplasty, major peripheral nerve, arm or leg; lumbar plexus
Neuroplasty and/or transposition; cranial nerve (specify)
Neuroplasty and/or transposition; ulnar nerve at elbow
Neuroplasty and/or transposition; ulnar nerve at wrist
Neuroplasty and/or transposition; median nerve at carpal tunnel
Decompression; unspecified nerve(s) (specify)
Decompression; plantar digital nerve

12,120
12,120
18,000
20,980
20,980
20,980
37,800
18,000
18,000
18,000
18,000
18,000

6,720
6,720
8,400
10,080
10,080
10,080
21,000
8,400
8,400
8,400
8,400
8,400

5,400
5,400
9,600
10,900
10,900
10,900
16,800
9,600
9,600
9,600
9,600
9,600

64727

Internal neurolysis, requiring use of operating microscope (list separately in


addition to code for neuroplasty) (Neuroplasty inlcudes external neurolysis)

30,300

16,800

13,500

9,700
9,700
9,700
9,700
9,700
12,120
9,700
12,120
21,940

4,200
4,200
4,200
4,200
4,200
6,720
4,200
6,720
9,240

5,500
5,500
5,500
5,500
5,500
5,400
5,500
5,400
12,700

21,940

9,240

12,700

18,000
9,700

8,400
4,200

9,600
5,500

18,000

8,400

9,600

18,000

8,400

9,600

37,800
30,300

21,000
16,800

16,800
13,500

8,020
8,020
8,020
8,020
9,700
8,020
8,020

2,520
2,520
2,520
2,520
4,200
2,520
2,520

5,500
5,500
5,500
5,500
5,500
5,500
5,500

9,700

4,200

5,500

8,020

2,520

5,500

18,000
18,000
18,000
18,000
12,120

8,400
8,400
8,400
8,400
6,720

9,600
9,600
9,600
9,600
5,400

20,980

10,080

10,900

18,000
8,020
18,000
18,000
18,000
8,020
18,000

8,400
2,520
8,400
8,400
8,400
2,520
8,400

9,600
5,500
9,600
9,600
9,600
5,500
9,600

20,980

10,080

10,900

18,000

8,400

9,600

64732
64734
64736
64738
64740
64742
64744
64746
64752
64755
64760
64761
64763
64766
64771
64772
64774
64776
64782
64784
64786
64788
64790
64792
64795
64802
64804
64809
64818
64820
64830
64831
64832
64834
64835
64836
64837
64840
64856
64857

Transection or Avulsion
Transection or avulsion of; supraorbital nerve
Transection or avulsion of; infraorbital nerve
Transection or avulsion of; mental nerve
Transection or avulsion of; inferior alveolar nerve by osteotomy
Transection or avulsion of; lingual nerve
Transection or avulsion of; facial nerve, differential or complete
Transection or avulsion of; greater occipital nerve
Transection or avulsion of; phrenic nerve
Transection or avulsion of; vagus nerve (vagotomy), transthoracic
Transection or avulsion of; vagi limited to proximal stomach (selective
proximal vagotomy, proximal gastric vagotomy, parietal cell vagotomy,
supra- or highly selective vagotomy)
Transection or avulsion of; vagus nerve (vagotomy), abdominal
Transection or avulsion of; pudendal nerve
Transection or avulsion of obturator nerve, extrapelvic, w/ or w/o adductor
tenotomy
Transection or avulsion of obturator nerve, intrapelvic, w/ or w/o adductor
tenotomy
Transection or avulsion of other cranial nerve, intradural
Transection or avulsion of other spinal nerve, extradural
Somatic Nerves
Excision of neuroma; cutaneous nerve, surgically identifiable
Excision of neuroma; digital nerve, one or both, same digit
Excision of neuroma; hand or foot, except digital nerve
Excision of neuroma; major peripheral nerve, except sciatic
Excision of neuroma; sciatic nerve
Excision of neurofibroma or neurolemmoma; cutaneous nerve
Excision of neurofibroma or neurolemmoma; major peripheral nerve
Excision of neurofibroma or neurolemmoma; extensive (including malignant
type)
Biopsy of nerve
Sympathetic Nerves
Sympathectomy, cervical
Sympathectomy, cervicothoracic
Sympathectomy, thoracolumbar
Sympathectomy, lumbar
Sympathectomy, digital arteries, w/ magnification, each digit
Neurorrhaphy
Microdissection and/or microrepair of nerve (list separately in addition to
code for nerve repair)
Suture of digital nerve, hand or foot; one nerve
Suture of digital nerve, hand or foot; each additional digital nerve
Suture of one nerve, hand or foot; common sensory nerve
Suture of one nerve, hand or foot; median motor thenar
Suture of one nerve, hand or foot; ulnar motor
Suture of each additional nerve, hand or foot
Suture of posterior tibial nerve
Suture of major peripheral nerve, arm or leg, except sciatic; including
transposition
Suture of major peripheral nerve, arm or leg, except sciatic; w/o
transposition

Page 95 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE

DESCRIPTION

64858
64859
64861
64862
64864
64865
64866
64868
64870

Suture of sciatic nerve


Suture of each additional major peripheral nerve
Suture of; brachial plexus
Suture of; lumbar plexus
Suture of facial nerve; extracranial
Suture of facial nerve; infratemporal, w/ or w/o grafting
Anastomosis; facial-spinal accessory
Anastomosis; facial-hypoglossal
Anastomosis; facial-phrenic
Neurorrhaphy w/ Nerve Graft

18,000
8,020
20,980
20,980
20,980
20,980
23,300
23,300
23,300

8,400
2,520
10,080
10,080
10,080
10,080
12,600
12,600
12,600

Health Care
Institution Fee
9,600
5,500
10,900
10,900
10,900
10,900
10,700
10,700
10,700

64885

Nerve graft (includes obtaining graft), head or neck; up to 4cm in length

23,300

12,600

10,700

64886

Nerve graft (includes obtaining graft), head or neck; more than 4 cm length

31,580

14,280

17,300

30,300

16,800

13,500

30,300

16,800

13,500

23,300

12,600

10,700

31,580

14,280

17,300

27,120

15,120

12,000

30,300

16,800

13,500

23,300

12,600

10,700

31,580

14,280

17,300

8,020
8,020
20,980
20,980

2,520
2,520
10,080
10,080

5,500
5,500
10,900
10,900

12,120
12,120
12,120
12,120
12,120

6,720
6,720
6,720
6,720
6,720

5,400
5,400
5,400
5,400
5,400

37,800

21,000

16,800

38,640

21,840

16,800

39,480

22,680

16,800

10,960

5,460

5,500

10,960

5,460

5,500

Case Rate

65091
65093
65101
65103
65105

Nerve graft (includes obtaining graft), single strand, hand or foot; up to 4


cm length
Nerve graft (includes obtaining graft), single strand, hand or foot; more than
4 cm length
Nerve graft (includes obtaining graft), single strand, arm or leg; up to 4 cm
length
Nerve graft (includes obtaining graft), single strand, arm or leg; more than 4
cm length
Nerve graft (includes obtaining graft), multiple strands (cable), hand or foot;
up to 4 cm length
Nerve graft (includes obtaining graft), multiple strands (cable), hand or foot;
more than 4 cm length
Nerve graft (includes obtaining graft), multiple strands (cable), arm or leg;
up to 4 cm length
Nerve graft (includes obtaining graft), multiple strands (cable), arm or leg;
more than 4 cm length
Nerve graft, each additional nerve; single strand
Nerve graft, each additional nerve; multiple strands (cable)
Nerve pedicle transfer; first stage
Nerve pedicle transfer; second stage
Eye and Ocular Adnexa
Eyeball
Removal of Eye
Evisceration of ocular contents; w/o implant
Evisceration of ocular contents; w/ implant
Enucleation of eye; w/o implant
Enucleation of eye; w/ implant, muscles not attached to implant
Enucleation of eye; w/ implant, muscles attached to implant

65110

Exenteration of orbit without skin graft, removal of orbital contents; only

64890
64891
64892
64893
64895
64896
64897
64898
64901
64902
64905
64907

65112
65114
65130
65135

Exenteration of orbit without skin graft, removal of orbital contents; w/


therapeutic removal of bone
Exenteration of orbit without skin graft, removal of orbital contents; w/
muscle or myocutaneous flap
Secondary Implant(s) Procedures
Insertion of ocular implant; after evisceration, in scleral shell
Insertion of ocular implant; after enucleation, muscles not attached to
implant

Professional Fee

65140

Insertion of ocular implant; after enucleation, muscles attached to implant

11,980

5,880

6,100

65150

Reinsertion of ocular implant; with or without conjunctival graft


Reinsertion of ocular implant; with use of foreign material for
reinforcement and/or attachment of muscles to implant
Removal of ocular implant
Removal of Foreign Body
Removal of foreign body, external eye; conjunctival, superficial
Removal of foreign body, external eye; subconjunctival or scleral, with slit
lamp
Removal of foreign body, external eye; cornea, with slit lamp
Removal of foreign body, intraocular; from anterior chamber or lens
Removal of foreign body, intraocular; from posterior segment, magnetic
extraction, anterior or posterior route
Removal of foreign body, intraocular; from posterior segment, nonmagnetic
extraction
Repair of Laceration
Repair of laceration; conjunctiva, w/ or w/o nonperforating laceration
sclera, direct closure
Repair of laceration; conjunctiva, by mobilization and rearrangement
Repair of laceration; cornea, nonperforating, w/ or w/o removal foreign
body

11,980

5,880

6,100

11,980

5,880

6,100

9,700

4,200

5,500

3,500

1,000

2,500

4,500

2,000

2,500

4,180
18,000

1,680
8,400

2,500
9,600

53,400

29,400

24,000

55,000

33,600

21,400

8,020

2,520

5,500

8,020

2,520

5,500

9,700

4,200

5,500

65155
65175
65205
65210
65222
65235
65260
65265

65270
65273
65275

Page 96 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE
65280
65285
65286
65290

DESCRIPTION

Case Rate

Repair of laceration; cornea and/or sclera, perforating, not involving uveal


tissue
Repair of laceration; cornea and/or sclera, perforating, w/ reposition or
resection of uveal tissue
Repair of laceration; application of tissue glue, wounds of cornea and/or
sclera
Repair of wound, extraocular muscle, tendon and/ or Tenons capsule

Professional Fee

Health Care
Institution Fee

20,980

10,080

10,900

23,300

12,600

10,700

9,700

4,200

5,500

9,700

4,200

5,500

Anterior Segment
Cornea
Excision

65400

Excision of lesion, cornea (keratectomy, lamellar, partial), except pterygium

8,260

3,360

4,900

65410
65420
65426

8,020
8,260
9,700

2,520
3,360
4,200

5,500
4,900
5,500

8,020

2,520

5,500

65710

Biopsy of cornea
Excision or transposition of pterygium; without graft
Excision or transposition of pterygium; with graft
Removal or Destruction
Destruction of lesion of cornea by cryotherapy, photocoagulation or
thermocauterization
Keratoplasty (corneal transplant); lamellar

30,300

16,800

13,500

65730

Keratoplasty (corneal transplant); penetrating (except in aphakia)

30,300

16,800

13,500

65750

Keratoplasty (corneal transplant); penetrating (in aphakia)

30,300

16,800

13,500

65755

Keratoplasty (corneal transplant); penetrating (in pseudophakia)

30,300

16,800

13,500

65760
65765
65767
65770
65771

Other Procedures
Keratomileusis
Keratophakia
Epikeratoplasty
Keratoprosthesis
Radial keratotomy

65772

65450

N/A

N/A

N/A

10,540
18,000
30,300
14,960

5,040
8,400
16,800
7,560

5,500
9,600
13,500
7,400

Corneal relaxing incision for correction of surgically induced astigmatism

14,960

7,560

7,400

65775

Corneal wedge resection for correction of surgically induced astigmatism

14,960

7,560

7,400

65780

Ocular surface reconstruction; amniotic membrane transplantation


Ocular surface reconstruction; limbal stem cell allograft (eg, cadaveric or
living donor)
Ocular surface reconstruction; limbal conjunctival autograft (includes
obtaining graft)
Anterior Chamber
Incision

30,300

16,800

13,500

30,300

16,800

13,500

30,300

16,800

13,500

65781
65782

65805

Paracentesis of anterior chamber of eye; w/ therapeutic release of aqueous

8,020

2,520

5,500

65810

Paracentesis of anterior chamber of eye; w/ removal of vitreous and/or


discission of anterior hyaloid membrane, w/ or w/o air injection

9,700

4,200

5,500

9,700

4,200

5,500

23,300
23,300

12,600
12,600

10,700
10,700

12,120

6,720

5,400

10,540

5,040

5,500

10,540

5,040

5,500

10,540

5,040

5,500

10,540

5,040

5,500

10,540

5,040

5,500

10,540
12,120
8,020

5,040
6,720
2,520

5,500
5,400
5,500

8,260
18,000

3,360
8,400

4,900
9,600

18,000

8,400

9,600

65815
65820
65850
65855
65860
65865
65870

Paracentesis of anterior chamber of eye; w/ removal of blood, w/ or w/o


irrigation and/or air injection
Goniotomy
Trabeculotomy ab externo
Trabeculoplasty by laser surgery, one or more sessions (defined treatment
series)
Severing adhesions of anterior segment, laser technique
Other Procedures
Severing adhesions of anterior segment of eye, incisional technique (w/ or
w/o injection of air or liquid); goniosynechiae
Severing adhesions of anterior segment of eye, incisional technique (w/ or
w/o injection of air or liquid); anterior synechiae, except goniosynechiae

66130
66150

Severing adhesions of anterior segment of eye, incisional technique (w/ or


w/o injection of air or liquid); posterior synechiae
Severing adhesions of anterior segment of eye, incisional technique (w/ or
w/o injection of air or liquid); corneovitreal adhesions
Removal of epithelial material, anterior segment eye
Removal of implanted material, anterior segment eye
Removal of blood clot, anterior segment eye
Anterior Sclera
Excision
Excision of lesion, sclera
Fistulization of sclera for glaucoma; trephination w/ iridectomy

66155

Fistulization of sclera for glaucoma; thermocauterization w/ iridectomy

65875
65880
65900
65920
65930

Page 97 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE

DESCRIPTION

Case Rate

Professional Fee

Health Care
Institution Fee

66600
66605

Fistulization of sclera for glaucoma; sclerectomy w/ punch or scissors, w/


iridectomy
Fistulization of sclera for glaucoma; iridencleisis or iridotasis
Fistulization of sclera for glaucoma; trabeculectomy ab externo in absence
of previous surgery
Fistulization of sclera for glaucoma; trabeculectomy ab externo w/ scarring
from previous ocular surgery or trauma (includes injection of antifibrotic
agents)
Aquenous shunt to extraocular reservoir (e.g., Molteno, Schocket, DenverKrupin)
Revision of aqueous shunt to extraocular reservoir
Repair or Revision
Repair of scleral staphyloma; w/o graft
Repair of scleral staphyloma; w/ graft
Revision or repair of operative wound of anterior segment, any type, early
or late, major or minor procedure
Iris, Ciliary Body
Incision
Iridotomy by stab incision; except transfixion
Iridotomy by stab incision; w/ transfixion as for iris bombe
Excision
Iridectomy, w/ corneoscleral or corneal section; for removal of lesion
Iridectomy, w/ corneoscleral or corneal section; w/ cyclectomy

66625

Iridectomy, w/ corneoscleral or corneal section; peripheral for glaucoma

12,120

6,720

5,400

66630

Iridectomy, w/ corneoscleral or corneal section; sector for glaucoma


Repair
Repair of iris, ciliary body (as for iridodialysis)
Suture of iris, ciliary body w/ retrieval of suture through small incision (e.g.,
McCannel suture)
Destruction
Ciliary body destruction; diathermy
Ciliary body destruction; cyclophotocoagulation
Ciliary body destruction; cryotherapy
Ciliary body destruction; cyclodialysis
Iridotomy/iridectomy by laser surgery (e.g., for glaucoma) ( one or more
sessions)
Iridoplasty by photocoagulation (one or more sessions) (e.g., for
improvement of vision, for widening of anterior chamber angle)

12,120

6,720

5,400

18,000

8,400

9,600

14,960

7,560

7,400

11,980
11,980
11,980
11,980

5,880
5,880
5,880
5,880

6,100
6,100
6,100
6,100

10,540

5,040

5,500

12,120

6,720

5,400

Destruction of cyst or lesion iris or ciliary body (nonexcisional procedure)

10,540

5,040

5,500

12,120

6,720

5,400

8,260

3,360

4,900

66160
66165
66170
66172
66180
66185
66220
66225
66250

66500
66505

66680
66682
66700
66710
66720
66740
66761
66762
66770

66820

66821
66825

Lens
Removal Cataract
Discission of secondary membranous cataract (opacified posterior lens
capsule and/or anterior hyaloid); stab incision technique (Ziegler or
Wheeler knife)
Discission of secondary membranous cataract (opacified posterior lens
capsule and/or anterior
hyaloid); laser surgery (e.g., YAG laser) (one or more stages)
Repositioning of intraocular lens prosthesis, requiring an incision

18,000

8,400

9,600

18,000

8,400

9,600

18,000

8,400

9,600

27,120

15,120

12,000

30,300

16,800

13,500

30,300

16,800

13,500

12,120
23,300

6,720
12,600

5,400
10,700

14,960

7,560

7,400

10,540
10,540

5,040
5,040

5,500
5,500

12,120
18,000

6,720
8,400

5,400
9,600

18,000

8,400

9,600

66830

Removal of secondary membranous cataract (opacified posterior lens


capsule and/or anterior hyaloid) w/ corneo-scleral section, w/ or w/o
iridectomy (iridocapsulotomy, iridocapsulectomy)

12,120

6,720

5,400

66840

Removal of lens material; aspiration technique, one or more stages

16,000

6,400

9,600

66850

Removal of lens material; phacofragmentation technique (mechanical or


ultrasonic) (e.g., phacoemulsification), w/ aspiration

16,000

6,400

9,600

66852

Removal of lens material; pars plana approach, with or without vitrectomy

16,000

6,400

9,600

66920
66930
66940

Removal of lens material; intracapsular


Removal of lens material; intracapsular, for dislocated lens
Removal of lens material; extracapsular

16,000
16,000
16,000

6,400
6,400
6,400

9,600
9,600
9,600

66982

Extracapsular cataract removal with insertion of intraocular lens prosthesis


(one stage procedure), manual or mechanical technique (eg, irrigation and
aspiration or phacoemulsification), complex, requiring devices or techniques
not generally used in routine cataract surgery (e.g. iris expansion device,
suture support for intraocular lens, or primary posterior capsullorhexis) or
performed on patients in the amblyogenic developmental stage

16,000

6,400

9,600

66983

Intracapsular cataract extraction w/ insertion of intraocular lens prosthesis


(one stage procedure)

16,000

6,400

9,600

Page 98 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE
66984
66985
66986
66987

DESCRIPTION

Case Rate

Extracapsular cataract removal w/ insertion of intraocular lens prosthesis


(one stage procedure), (e.g., irrigation and aspiration)
Insertion of intraocular lens prosthesis, not associated with cataract
removal
Exchange of intraocular lens
Extracapsular cataract removal w/ insertion of intraocular lens prosthesis
(one stage procedure), (e.g., phacoemulsification)
Other Procedures

Professional Fee

Health Care
Institution Fee

16,000

6,400

9,600

16,000

6,400

9,600

16,000

6,400

9,600

16,000

6,400

9,600

66991

Revision of failed filter; with or without explantation/exchange of shunt

37,800

21,000

16,800

66992
66993
66994
66995

Revision of failed filter; with excision of bleb cyst


Revision of failed filter; with choroidal tap
Revision of failed filter; with posterior sclerotomy
Revision of failed filter; with anterior chamber reformation
Revision of filtering bleb, needling technique; without injection of antimetabolite
Revision of filtering bleb, needling technique; with injection of antimetabolite
Release of scleral flap suture by laser suture lysis (new code)
Revision of overfiltering bleb (includes autologous blood injection,
cryotherapy, mattress sutures, etc.)

37,800
30,300
30,300
30,300

21,000
16,800
16,800
16,800

16,800
13,500
13,500
13,500

12,120

6,720

5,400

18,000

8,400

9,600

9,700

4,200

5,500

18,000

8,400

9,600

37,800

21,000

16,800

45,000

21,000

24,000

9,700

4,200

5,500

12,120

6,720

5,400

31,580

14,280

17,300

12,900

6,300

6,600

66996
66997
66998
66999

Posterior Segment
Vitreous

67005
67010
67015
67025
67027
67030
67031
67036
67038
67039
67040
67041
67042
67043
67044
67045
67046
67047

Removal of vitreous, anterior approach (open sky technique or limbal


incision); partial removal
Removal of vitreous, anterior approach (open sky technique or limbal
incision); subtotal removal w/ mechanical vitrectomy
Aspiration or release of vitreous, subretinal or choroidal fluid, pars plana
approach (posterior sclerotomy)
Injection of vitreous substitute, pars plana or limbal approach, (fluid-gas
exchange), w/ or w/o aspiration
Implantation of intravitreal drug delivery system (eg, ganciclovir implant),
includes concomitant removal of vitreous
Discission of vitreous strands (w/o removal), pars plana approach
Severing of vitreous strands, vitreous face adhesions, sheets, membranes or
opacities, laser surgery (one or more stages)
Vitrectomy, mechanical, pars plana approach;
Vitrectomy, mechanical, pars plana approach; w/ epiretinal membrane
stripping
Vitrectomy, mechanical, pars plana approach; w/ focal endolaser
photocoagulation
Vitrectomy, mechanical, pars plana approach; w/ endolaser panretinal
photocoagulation
Vitrectomy, mechanical, pars plana approach; with internal limiting
membrane (ILM) peeling
Vitrectomy, mechanical, pars plana approach; with radial optic nerve
neurotomy (RON)
Vitrectomy, mechanical, pars plana approach; with sheathotomy for branch
retinal vein occlusion
Vitrectomy, mechanical, pars plana approach; with macular translocation
(limited by retinotomy and/or scleral imbrication)
Vitrectomy, mechanical, pars plana approach; with macular translocation
(total)
Vitrectomy, mechanical, pars plana approach; with removal of subretinal
membranes
Vitrectomy, mechanical, pars plana approach; with removal of choroidal
neovascular membrane

10,540

5,040

5,500

46,500

25,200

21,300

46,500

25,200

21,300

46,500

25,200

21,300

46,500

25,200

21,300

46,500

25,200

21,300

46,500

25,200

21,300

46,500

25,200

21,300

46,500

25,200

21,300

46,500

25,200

21,300

46,500

25,200

21,300

46,500

25,200

21,300

67048

Vitrectomy, mechanical, pars plana approach; with endodrainage of


subretinal hemorrhage (with or without tPA injection)

46,500

25,200

21,300

67049

Vitrectomy, mechanical, pars plana approach; with removal of dropped IOL

46,500

25,200

21,300

46,500

25,200

21,300

46,500

25,200

21,300

37,800

21,000

16,800

46,500

25,200

21,300

37,180

18,480

18,700

67050
67051
67052

67101
67105

Vitrectomy, mechanical, pars plana approach; with phacofragmentation for


dropped lens material
Vitrectomy, mechanical, pars plana approach; with internal tamponade with
air, gas, silicone oil, perfluorocarbon liquid
Vitrectomy, mechanical, pars plana approach; with insertion of scleral
fixated intraocular lens, with or without anterior vitrectomy
Retina or Choroid
Repair
Repair of retinal detachment, one or more sessions; cryotherapy or
diathermy, w/ or w/o drainage of subretinal fluid
Repair of retinal detachment, one or more sessions; photocoagulation, w/
or w/o drainage of subretinal fluid

Page 99 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE

DESCRIPTION

Case Rate

Professional Fee

Health Care
Institution Fee

67107

Repair of retinal detachment; scleral buckling (such as lamellar scleral


dissection, imbrication or encircling procedure), w/ or w/o implant, w/ or
w/o cryotherapy, photocoagulation, and drainage of subretinal fluid

46,500

25,200

21,300

67108

Repair of retinal detachment; w/ vitrectomy, any method, w/ or w/o air or


gas tamponade, focal endolaser photocoagulation, cryotherapy, drainage of
subretinal fluid, scleral buckling, and/or removal of lens by same technique

46,500

25,200

21,300

30,300

16,800

13,500

46,500

25,200

21,300

12,120
12,120
20,980

6,720
6,720
10,080

5,400
5,400
10,900

67110
67112
67115
67120
67121

Repair of retinal detachment; by injection of air or other gas (e.g.,


pneumatic retinopexy)
Repair of retinal detachment; by scleral buckling or vitrectomy, on patient
having previous ipsilateral retinal detachment repair(s) using scleral
buckling or vitrectomy techniques
Release of encircling material (posterior segment)
Removal of implanted material, posterior segment; extraocular
Removal of implanted material, posterior segment; intraocular
Destruction

67208

Destruction of localized lesion of retina (e.g., maculopathy, choroidopathy,


small tumors), one or more sessions; cryotherapy, diathermy

12,120

6,720

5,400

67210

Destruction of localized lesion of retina (e.g., maculopathy, choroidopathy,


small tumors), one or more sessions; photocoagulation (laser or xenon arc)

12,120

6,720

5,400

67218

Destruction of localized lesion of retina (e.g., maculopathy, choroidopathy,


small tumors), one or more sessions; radiation by implantation of source
(includes removal of source)

12,120

6,720

5,400

67220

Destruction of localized lesion of choroid (e.g., choroidal


neovascularization); photocoagulation (e.g., laser), one or more sessions

12,120

6,720

5,400

67221

Destruction of localized lesion of choroid (e.g., choroidal


neovascularization); photodynamic therapy (includes intravenous infusions

12,120

6,720

5,400

67222

Destruction of localized lesion of choroid (e.g., choroidal


neovascularization); transpupillary thermotherapy

12,120

6,720

5,400

67227

Destruction of extensive or progressive retinopathy (e.g., diabetic


retinopathy), one or more sessions; cryotherapy, diathermy

12,120

6,720

5,400

67228

Destruction of extensive or progressive retinopathy (e.g., diabetic


retinopathy), one or more sessions; photocoagulation (laser or xenon arc)

12,120

6,720

5,400

12,120

6,720

5,400

10,120

4,620

5,500

12,120

6,720

5,400

12,120

6,720

5,400

18,000

8,400

9,600

18,000

8,400

9,600

18,000

8,400

9,600

18,000

8,400

9,600

21,940

9,240

12,700

11,980

5,880

6,100

22,660

11,760

10,900

18,000
9,700

8,400
4,200

9,600
5,500

9,700

4,200

5,500

Sclera
Repair

67250

Scleral reinforcement
Ocular Adnexa

67311
67312
67314

67316
67318
67320
67331
67332
67334
67340
67343
67345
67350

Extraocular Muscles
Strabismus surgery, recession or resection procedure (patient not
previously operated on); one horizontal muscle
Strabismus surgery, recession or resection procedure (patient not
previously operated on); two horizontal muscles
Strabismus surgery, recession or resection procedure (patient not
previously operated on); one vertical muscle (excluding superior oblique)
Strabismus surgery, recession or resection procedure (patient not
previously operated on); two or more vertical muscles (excluding superior
oblique)
Strabismus surgery, any procedure (patient not previously operated on),
superior oblique muscle
Transposition procedure (e.g., for paretic extraocular muscle), any
extraocular muscle (specify)
Strabismus surgery on patient w/ previous eye surgery or injury that did not
involve the extraocular muscles
Strabismus surgery on patient w/ scaring of extraocular muscles (e.g., prior
ocular injury, strabismus or retinal detachment surgery) or restrictive
myopathy (e.g., dysthyroid ophthalmopathy)
Strabismus surgery by posterior fixation suture technique, w/ or w/o muscle
recession
Strabismus surgery involving exploration and/or repair of detached
extraocular muscle(s)
Release of extensive scar tissue w/o detaching extraocular muscle
Chemodenervation of extraocular muscle
Other Procedures
Biopsy of extraocular muscle
Orbit

Page 100 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE

67400
67405
67412
67413
67414
67415
67420
67430
67440
67445
67550
67560
67570
67580
67581
67582
67583

DESCRIPTION

Case Rate

Exploration, Excision, Decompression


Orbitotomy w/o bone flap (frontal or transconjunctival approach); for
exploration, w/ or w/o biopsy
Orbitotomy w/o bone flap (frontal or transconjunctival approach); w/
drainage only
Orbitotomy w/o bone flap (frontal or transconjunctival approach); w/
removal of lesion
Orbitotomy w/o bone flap (frontal or transconjunctival approach); w/
removal of foreign body
Orbitotomy w/o bone flap (frontal or transconjunctival approach); w/
removal of bone for decompression
Fine needle aspiration of orbital contents
Orbitotomy w/ bone flap or window, lateral approach (e.g., Kroenlein); w/
removal of lesion
Orbitotomy w/ bone flap or window, lateral approach (e.g., Kroenlein); w/
removal of foreign body
Orbitotomy w/ bone flap or window, lateral approach (e.g., Kroenlein); w/
drainage
Orbitotomy w/ bone flap or window, lateral approach (e.g., Kroenlein); w/
removal of bone for decompression
Other Procedures
Orbital implant (implant outside muscle cone); insertion
Orbital implant (implant outside muscle cone); removal or revision
Optic nerve decompression (e.g., incision or fenestration of optic nerve
sheath)
Repair of anophthalmic socket; with insertion or removal of orbital implant
within muscle cone
Repair of anophthalmic socket; with exchange or orbital implant
Repair of anophthalmic socket; with exchange of orbital implant and
reattachment of muscles
Repair of anophthalmic socket; with fornix reconstruction using sutures

67830

Repair of anophthalmic socket; with fornix reconstruction using buccal


mucosal graft or amnion graft, including harvesting of graft
Repair of anophthalmic socket; with revision of implant and fornix
reconstruction using sutures
Repair of anophthalmic socket; with revision of implant and fornix
reconstruction using buccal mucosal graft, or amnion graft (including
harvesting of graft)
Eyelids
Incision
Blepharotomy, drainage of abscess, eyelid
Severing of tarsorrhaphy
Canthotomy
Excision
Excision of chalazion
Biopsy of eyelid
Repair of trichiasis; by electroepilation, electrosurgery, cryotherapy or laser
surgery
Repair of trichiasis; incision of lid margin

67835

Repair of trichiasis; incision of lid margin, with free mucous membrane graft

67584
67585
67586

67700
67710
67715
67800
67810
67825

67840
67875
67880
67882

Excision of lesion of eyelid (except chalazion) without closure or with simple


direct closure
Tarsorrhaphy
Temporary closure of eyelids suture (e.g., frost suture)
Construction of intermargin adhesions, median tarsorrhaphy, or
canthorrhaphy;
Construction of intermargin adhesions, median tarsorrhaphy, or
canthorrhaphy; with transportation of tarsal plate

Professional Fee

Health Care
Institution Fee

46,500

25,200

21,300

46,500

25,200

21,300

46,500

25,200

21,300

46,500

25,200

21,300

46,500

25,200

21,300

46,500

25,200

21,300

46,500

25,200

21,300

46,500

25,200

21,300

46,500

25,200

21,300

46,500

25,200

21,300

10,960
10,960

5,460
5,460

5,500
5,500

53,400

29,400

24,000

12,120

6,720

5,400

20,980

10,080

10,900

20,980

10,080

10,900

20,980

10,080

10,900

20,980

10,080

10,900

20,980

10,080

10,900

20,980

10,080

10,900

5,680
5,680
5,680

1,680
1,680
1,680

4,000
4,000
4,000

5,680
5,680

1,680
1,680

4,000
4,000

5,680

1,680

4,000

3,640

840

2,800

9,300

2,100

7,200

5,560

1,260

4,300

5,680

1,680

4,000

5,680

1,680

4,000

8,020

2,520

5,500

18,000

8,400

9,600

18,000

8,400

9,600

20,980

10,080

10,900

18,000

8,400

9,600

18,000

8,400

9,600

18,000

8,400

9,600

Repair (Brow Ptosis, Blepharoptosis, Lid retraction, Ectropion, Entropion)


67900
67901
67902
67903
67904
67906

Repair of brow ptosis (supraciliary, midforehead or coronal approach)


Repair of blepharoptosis; frontalis muscle technique with suture or other
material
Repair of blepharoptosis; frontalis muscle technique with fascial sling
(includes obtaining fascia)
Repair of blepharoptosis; (tarso) levator resection or advancement, internal
approach
Repair of blepharoptosis; (tarso) levator resection or advancement, external
approach
Repair of blepharoptosis; superior rectus technique with fascial sling
(includes obtaining fascia)

Page 101 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE
67908
67911
67912
67914
67915
67916
67917
67921
67922
67923
67924
67930
67935
67950
67961

67966

DESCRIPTION

Case Rate

Repair of blepharoptosis; conjunctivo-tarso-Mullers muscle-levator


resection (Fasanella-Servat type)
Repair of lid retraction (eyelid recession); without spacer
Correction of lagophthalmos, with implantation of upper eyelid load
Repair of ectropion; suture
Repair of ectropion; thermocauterization
Blepharoplasty, excision tarsal wedge
Blepharoplasty, extensive (e.g., Kuhnt-Szymanowski or tarsal strip
operations)
Repair of entropion; suture
Repair of entropion; thermocauterization
Blepharoplasty, excision tarsal wedge
Blepharoplasty, extensive (e.g., Wheeler operation)
Reconstruction
Suture of recent wound, eyelid, involving lid margin, tarsus, and/ or
palpebral conjunctiva direct closure; partial thickness
Suture of recent wound, eyelid, involving lid margin, tarsus, and/ or
palpebral conjunctiva direct closure; full thickness
Canthoplasty (reconstruction of canthus)
Excision and repair of eyelid, involving lid margin, tarsus, conjunctiva,
canthus, or full thickness, may include preparation for skin graft or pedicle
flap with adjacent tissue transfer or rearrangement; up to one-fourth of lid
margin
Excision and repair of eyelid, involving lid margin, tarsus, conjunctiva,
canthus, or full thickness, may include preparation for skin graft or pedicle
flap with adjacent tissue transfer or rearrangement; over one-fourth of lid
margin

Professional Fee

Health Care
Institution Fee

18,000

8,400

9,600

21,400
32,000
8,020
8,020
9,700

10,500
14,700
2,520
2,520
4,200

10,900
17,300
5,500
5,500
5,500

12,900

6,300

6,600

5,680
5,680
9,700
12,900

1,680
1,680
4,200
6,300

4,000
4,000
5,500
6,600

9,700

4,200

5,500

12,120

6,720

5,400

12,120

6,720

5,400

30,740

13,440

17,300

27,120

15,120

12,000

67971

Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap


from opposing eyelid; up to two-thirds of eyelid, one stage or first stage

30,300

16,800

13,500

67973

Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap


from opposing eyelid; total eyelid, lower, one stage or first stage

37,800

21,000

16,800

67974

Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap


from opposing eyelid; total eyelid, upper, one stage or first stage

37,800

21,000

16,800

30,300

16,800

13,500

5,680
8,020
8,020
8,020

1,680
2,520
2,520
2,520

4,000
5,500
5,500
5,500

10,540

5,040

5,500

12,120

6,720

5,400

14,960

7,560

7,400

18,000

8,400

9,600

14,960

7,560

7,400

21,940

9,240

12,700

18,000

8,400

9,600
6,100

68360

Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap


from opposing eyelid; second stage
Conjunctiva
Excision and/or Destruction
Biopsy of conjunctiva
Excision of lesion, conjunctiva; up to 1 cm
Excision of lesion, conjunctiva; over 1 cm
Excision of lesion, conjunctiva; with adjacent sclera
Conjunctivoplasty
Conjunctivoplasty; with conjunctival graft or extensive rearrangement
Conjunctivoplasty; with buccal mucous membrane graft (includes obtaining
graft)
Conjunctivoplasty reconstruction cul-de-sac; with conjunctival graft or
extensive rearrangement
Conjunctivoplasty reconstruction cul-de-sac; with buccal mucous membrane
graft (includes obtaining graft)
Repair of symblepharon; conjunctivoplasty, without graft
Repair of symblepharon; with free graft conjunctiva or buccal mucous
membrane (includes obtaining graft)
Repair of symblepharon; division of symblepharon, with or without
insertion of conformer or contact lens
Other Procedures
Conjunctival flap; bridge or partial

11,980

5,880

68362

Conjunctival flap; total (such as Gunderson thin flap or purse string flap)

11,980

5,880

6,100

68371

Harvesting conjunctival allograft, living donor


Lacrimal System
Incision
Incision, drainage of lacrimal gland
Incision, drainage of lacrimal sac (dacryocystostomy)
Snip incision of lacrimal punctum
Excision
Excision of lacrimal gland (dacryoadenectomy), except for tumor
Biopsy of lacrimal gland
Excision of lacrimal sac (dacryocystectomy)
Biopsy of lacrimal sac
Removal of foreign body or dacryolith, lacrimal passages
Excision of lacrimal gland tumor; frontal approach

20,980

10,080

10,900

5,680
5,680
5,680

1,680
1,680
1,680

4,000
4,000
4,000

12,120
5,680
12,120
5,680

6,720
1,680
6,720
1,680

5,400
4,000
5,400
4,000

67975

68100
68110
68115
68130
68320
68325
68326
68328
68330
68335
68340

68400
68420
68440
68500
68510
68520
68525
68530
68540

Page 102 of 113

N/A

N/A
18,000

N/A
8,400

9,600

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE

DESCRIPTION
Excision of lacrimal gland tumor; involving osteotomy
Repair
Plastic repair of canaliculi
Correction of everted punctum, cautery
Dacryocystorhinostomy (fistulization of lacrimal sac to nasal cavity)
Conjunctivorhinostomy (fistulization of conjunctiva to nasal cavity); without
tube
Conjunctivorhinostomy (fistulization of conjunctiva to nasal cavity); with
insertion of tube or stent
Closure of the lacrimal punctum; by thermocauterization, ligation, or laser
surgery
Closure of lacrimal fistula
Probing and/or Related Procedures
Probing of nasolacrimal duct; requiring general anesthesia
Probing of nasolacrimal duct; with insertion of tube or stent
Auditory System
External Ear
Incision
Drainage external ear, abscess or hematoma
Drainage external auditory canal, abscess
Excision
Biopsy external ear
Biopsy external auditory canal
Excision external ear; partial, simple repair
Excision external ear; complete amputation
Excision exostosis(es), external auditory canal
Excision soft tissue lesion, external auditory canal
Radical excision external auditory canal lesion; w/o neck dissection
Radical excision external auditory canal lesion; w/ neck dissection
Removal of Foreign Body

18,000

8,400

Health Care
Institution Fee
9,600

9,700
3,640
18,000

4,200
840
8,400

5,500
2,800
9,600

18,000

8,400

9,600

20,980

10,080

10,900

69200
69220

68550
68700
68705
68720
68745
68750
68760
68770
68811
68815

69000
69020
69100
69105
69110
69120
69140
69145
69150
69155

69222

69310
69320

Case Rate

Professional Fee

8,020

2,520

5,500

10,880

3,780

7,100

8,020
9,700

2,520
4,200

5,500
5,500

3,672
3,472

672
252

3,000
3,220

5,680
5,680
8,260
12,120
9,700
9,700
23,300
30,300

1,680
1,680
3,360
6,720
4,200
4,200
12,600
16,800

4,000
4,000
4,900
5,400
5,500
5,500
10,700
13,500

Removal foreign body from external auditory canal; w/ general anesthesia

9,300

2,100

7,200

Debridement, mastoidectomy cavity, simple (e.g., routine cleaning)


Debridement, mastoidectomy cavity, complex (e.g., w/ anesthesia or more
than routine cleaning)
Repair
Reconstruction of external auditory canal (meatoplasty) (e.g., for stenosis
due to trauma, infection)

8,020

2,520

5,500

9,700

4,200

5,500

23,300

12,600

10,700

23,300

12,600

10,700

5,812
5,680

1,512
1,680

4,300
4,000

5,680

1,680

4,000

8,020

2,520

5,500

8,260

3,360

4,900

8,260

3,360

4,900

18,000
9,700

8,400
4,200

9,600
5,500

20,980
23,300
23,300
23,300
23,300
46,500
8,020
30,300
30,300
30,300

10,080
12,600
12,600
12,600
12,600
25,200
2,520
16,800
16,800
16,800

10,900
10,700
10,700
10,700
10,700
21,300
5,500
13,500
13,500
13,500

Reconstruction external auditory canal for congenital atresia, single stage


Middle Ear

69601

Introduction
Eustachian tube inflation, transnasal; w/ catheterization
Eustachian tube catheterization, transtympanic
Incision
Myringotomy including aspiration and/or eustachian tube inflation
Myringotomy including aspiration and/or eustachian tube inflation
requiring general anesthesia
Tympanostomy (requiring insertion of ventilating tube), local or topical
anesthesia
Tympanostomy (requiring insertion of ventilating tube), w/ general
anesthesia
Middle ear exploration through postauricular or ear canal incision
Tympanolysis, transcanal
Excision
Transmastoid antrotomy ("simple" mastoidectomy)
Mastoidectomy; complete
Mastoidectomy; modified radical
Mastoidectomy; radical
Petrous apicectomy including radical mastoidectomy
Resection temporal bone, external approach
Excision aural polyp
Excision aural glomus tumor; transcanal
Excision aural glomus tumor; transmastoid
Excision aural glomus tumor; extended (extratemporal)
Repair
Revision mastoidectomy; resulting in complete mastoidectomy

23,300

12,600

10,700

69602

Revision mastoidectomy; resulting in modified radical mastoidectomy

31,580

14,280

17,300

69603
69604
69605

Revision mastoidectomy; resulting in radical mastoidectomy


Revision mastoidectomy; resulting in tympanoplasty
Revision mastoidectomy; w/ apicectomy
Tympanic membrane repair, w/ or w/o site preparation or perforation for
closure, w/ or w/o patch

23,300
23,300
23,300

12,600
12,600
12,600

10,700
10,700
10,700

12,120

6,720

5,400

69400
69405
69420
69421
69433
69436
69440
69450
69501
69502
69505
69511
69530
69535
69540
69550
69552
69554

69610

Page 103 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE

DESCRIPTION

69620

Myringoplasty (surgery confined to drumhead and donor area)

20,980

10,080

Health Care
Institution Fee
10,900

69631

Tympanoplasty w/o mastoidectomy (including canalplasty, atticotomy and/


or middle ear surgery), initial or revision; w/o ossicular chain reconstruction

30,740

13,440

17,300

69632

Tympanoplasty w/o mastoidectomy (including canalplasty, atticotomy and/


or middle ear surgery), initial or revision; w/ ossicular chain reconstruction
(e.g., postfenestration)

30,740

13,440

17,300

69633

Tympanoplasty w/o mastoidectomy (including canalplasty, atticotomy and/


or middle ear surgery), initial or revision; w/ ossicular chain reconstruction
and synthetic prosthesis (e.g., partial ossicular replacement prosthesis,
(PORP), total ossicular replacement prosthesis (TORP)

30,740

13,440

17,300

46,500

25,200

21,300

47,340

26,040

21,300

69637

Tympanoplasty w/ antrotomy or mastoidotomy (including canalplasty,


atticotomy, middle ear surgery, and/ or tympanic membrane repair); w/
ossicular chain reconstruction and synthetic prosthesis (e.g. partial ossicular
replacement prosthesis, (PORP), total ossicular replacement prosthesis
(TORP)

47,340

26,040

21,300

69641

Tympanoplasty w/ mastoidectomy (including canalplasty, middle ear


surgery, tympanic membrane repair); w/o ossicular chain reconstruction

46,500

25,200

21,300

69642

Tympanoplasty w/ mastoidectomy (including canalplasty, middle ear


surgery, tympanic membrane repair); w/ ossicular chain reconstruction

47,340

26,040

21,300

48,180

26,880

21,300

49,020

27,720

21,300

46,500

25,200

21,300

46,500

25,200

21,300

37,800

21,000

16,800

38,640

21,840

16,800

38,640

21,840

16,800

38,640
38,640
38,640
31,580
30,300

21,840
21,840
21,840
14,280
16,800

16,800
16,800
16,800
17,300
13,500

69700

Revision of stapedectomy or stapedotomy


Repair oval window fistula
Repair round window fistula
Mastoid obliteration
Tympanic neurectomy
Other Procedures
Closure postauricular fistula, mastoid

10,540

5,040

5,500

69720

Decompression facial nerve, intratemporal; lateral to geniculate ganglion

30,300

16,800

13,500

30,300

16,800

13,500

37,800

21,000

16,800

37,800

21,000

16,800

38,640

21,840

16,800

69635

69636

69643

69644

69645

69646
69650
69660
69661
69662
69666
69667
69670
69676

69725
69740
69745

69801

Case Rate

Tympanoplasty w/ antrotomy or mastoidotomy (including canalplasty,


atticotomy, middle ear surgery, and/ or tympanic membrane repair); w/o
ossicular chain reconstruction
Tympanoplasty w/ antrotomy or mastoidotomy (including canalplasty,
atticotomy, middle ear surgery, and/ or tympanic membrane repair); w/
ossicular chain reconstruction

Tympanoplasty w/ mastoidectomy (including canalplasty, middle ear


surgery, tympanic membrane repair); w/ intact or reconstructed wall, w/o
ossicular chain reconstruction
Tympanoplasty w/ mastoidectomy (including canalplasty, middle ear
surgery, tympanic membrane repair); w/ intact or reconstructed canal wall,
w/ ossicular chain reconstruction
Tympanoplasty w/ mastoidectomy (including canalplasty, middle ear
surgery, tympanic membrane repair); radical or complete, w/o ossicular
chain reconstruction
Tympanoplasty w/ mastoidectomy (including canalplasty, middle ear
surgery, tympanic membrane repair); radical or complete, w/ ossicular
chain reconstruction
Stapes mobilization
Stapedectomy or stapedotomy w/ reestablishment of ossicular continuity,
w/ or w/o use of foreign material;
Stapedectomy or stapedotomy w/ reestablishment of ossicular continuity,
w/ or w/o use of foreign material; w/ footplate drill out

Decompression facial nerve, intratemporal; including medial to geniculate


ganglion
Suture facial nerve, intratemporal, w/ or w/o graft or decompression;
lateral to geniculate ganglion
Suture facial nerve, intratemporal, w/ or w/o graft or decompression;
including medial to geniculate ganglion
Inner Ear
Incision and/or Destruction
Labyrinthotomy, w/ or w/o cryosurgery including other nonexcisional
destructive procedures or perfusion of vestbuloactive drugs (single or
multiple perfusions); transcanal

Professional Fee

69802

Labyrinthotomy, w/ or w/o cryosurgery including other nonexcisional


destructive procedures or perfusion of vestbuloactive drugs (single or
multiple perfusions); w/ mastoidectomy

39,480

22,680

16,800

69805

Endolymphatic sac operation; w/o shunt

46,500

25,200

21,300

Page 104 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE
69806
69820
69840
69905
69910
69915
69930
69950
69955
69960
69970

70010
70390

71090

72240

74300
74328
74329
74330
74340
74350
74355
74360
74363

74475

74480

74742
75600
75625
75630

DESCRIPTION

53,400
46,500
53,400

29,400
25,200
29,400

Health Care
Institution Fee
24,000
21,300
24,000

46,500
53,400
53,400

25,200
29,400
29,400

21,300
24,000
24,000

55,000

33,600

21,400

55,000
55,000
53,400
46,500

33,600
33,600
29,400
25,200

21,400
21,400
24,000
21,300

8,020

2,520

5,500

8,020

2,520

5,500

8,020

2,520

5,500

8,020

2,520

5,500

8,020

2,520

5,500

8,020

2,520

5,500

8,020

2,520

5,500

8,020

2,520

5,500

9,700

4,200

5,500

9,700

4,200

5,500

9,700

4,200

5,500

9,700

4,200

5,500

18,000

8,400

9,600

18,000

8,400

9,600

18,000

8,400

9,600

8,020

2,520

5,500

9,700
9,700

4,200
4,200

5,500
5,500

9,700

4,200

5,500

Case Rate

Endolymphatic sac operation; w/ shunt


Fenestration semicircular canal
Revision fenestration operation
Excision
Labyrinthectomy; transcanal
Labyrinthectomy; w/ mastoidectomy
Vestibular nerve section, translabyrinthine approach
ntroduction
Cochlear device implantation, w/ or w/o mastoidectomy
Temporal Bone, Middle Fossa Approach
Vestibular nerve section, transcranial approach
Total facial nerve decompression and/or repair (may include graft)
Decompression internal auditory canal
Removal of tumor, temporal bone
Radiology Services
Head and Neck
Myelography, brain, including spinal puncture and radiological supervision
and interpretation
Sialography; including duct catheterization and radiological supervision and
interpretation
Chest
Insertion pacemaker, fluoroscopy and radiography, radiological supervision
and interpretation
Spine and Pelvis
Myelography, spine, including spinal puncture and radiological supervision
and interpretation
Gastrointestinal Tract
Cholangiography and/or pancreatography, intraoperative, radiological
supervision and interpretation
Endoscopic catheterization of the biliary ductal system, radiological
supervision and interpretation
Endoscopic catheterization of the pancreatic ductal system, radiological
supervision and interpretation
Combined endoscopic catheterization of the biliary and pancreatic ductal
system, radiological supervision and interpretation
Introduction of long gastrointestinal tube (e.g., Miller-Abbott ), radiological
supervision and interpretation
Percutaneous placement of gastrostomy tube, radiological supervision and
interpretation
Percutaneous placement of enteroclysis tube, radiological supervision and
interpretation
Intraluminal dilation of strictures and/or obstructions, radiological
supervision and interpretation
Percutaneous transhepatic dilation of sbiliary duct stricture, radiological
supervision and interpretation
Urinary Tract
Introduction of intracatheter or catheter into renal pelvis for drainage
and/or injection, percutaneous, radiological supervision and interpretation
Introduction of ureteral catheter or stent into ureter through renal pelvis
for drainage and/or injection, percutaneous, radiological supervision and
interpretation
Gynecological and Obstetrical
Transcervical catheterization of fallopian tube, radiological supervision and
interpretation
Angiography
Aortography, thoracic, radiological supervision and interpretation
Aortography, abdominal, radiological supervision and interpretation
Aortography, abdominal plus bilateral iliofemoral lower extremity,
radiological supervision and interpretation

Professional Fee

75635

Computed tomographic angiography, abdominal aorta and bilateral


iliofemoral lower extremity, radiological supervision and interpretation

9,700

4,200

5,500

75650

Angiography, cervicocerebral, radiological supervision and interpretation

9,700

4,200

5,500

9,700

4,200

5,500

9,700

4,200

5,500

9,700

4,200

5,500

9,700

4,200

5,500

9,700

4,200

5,500

75658
75660
75662
75665
75671

Angiography, brachial retrograde, radiological supervision and


interpretation
Angiography, external carotid, unilateral, selective, radiological supervision
and interpretation
Angiography, external carotid, bilateral, selective, radiological supervision
and interpretation
Angiography, cerebral, radiological supervision and interpretation
Angiography, carotid, cerebral, bilateral, radiological supervision and
interpretation

Page 105 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE
75676
75680
75685
75705
75710
75716

DESCRIPTION

Case Rate

Angiography, carotid, cervical, unilateral, radiological supervision and


interpretation
Angiography, carotid, cervical, bilateral, radiological supervision and
interpretation
Angiography, vertebral, cervical and/or intracranial, radiological supervision
and interpretation
Angiography, spinal, radiological supervision and interpretation
Angiography, extremity, unilateral, radiological supervision and
interpretation
Angiography, extremity, bilateral, radiological supervision and
interpretation

Professional Fee

Health Care
Institution Fee

9,700

4,200

5,500

9,700

4,200

5,500

9,700

4,200

5,500

9,700

4,200

5,500

9,700

4,200

5,500

9,700

4,200

5,500

75722

Angiography, renal, unilateral, radiological supervision and interpretation

9,700

4,200

5,500

75724

Angiography, renal, bilateral, radiological supervision and interpretation

9,700

4,200

5,500

75726

Angiography, visceral, radiological supervision and interpretation

9,700

4,200

5,500

75731

Angiography, adrenal, unilateral, radiological supervision and interpretation

9,700

4,200

5,500

75733

Angiography, adrenal, bilateral, radiological supervision and interpretation

9,700

4,200

5,500

75736

Angiography, pelvis, radiological supervision and interpretation


Angiography, pulmonary, unilateral, radiological supervision and
interpretation
Angiography, pulmonary, bilateral, radiological supervision and
interpretation
Angiography, pulmonary, nonselective, radiological supervision and
interpretation

9,700

4,200

5,500

9,700

4,200

5,500

9,700

4,200

5,500

9,700

4,200

5,500

75756

Angiography, internal mammary, radiological supervision and interpretation

9,700

4,200

5,500

75757

Angiography, fluorescein (eye)


Angiography, arteriovenous shunt (e.g., dialysis patient), radiological
supervision and interpretation
Lymphangiography, extremity, unilateral, radiological supervision and
interpretation
Lymphangiography, extremity, bilateral, radiological supervision and
interpretation
Lymphangiography, pelvic/abdominal, unilateral , radiological supervision
and interpretation
Lymphangiography, pelvic/abdominal, bilateral, radiological supervision and
interpretation
Splenoportography, radiological supervision and interpretation
Venography, extremity, unilateral or bilateral, radiological supervision and
interpretation

3,500

500

3,000

9,700

4,200

5,500

9,700

4,200

5,500

9,700

4,200

5,500

9,700

4,200

5,500

9,700

4,200

5,500

9,700

4,200

5,500

9,700

4,200

5,500

75825

Venography, caval, inferior, radiological supervision and interpretation

9,700

4,200

5,500

75827

Venography, caval, superior, radiological supervision and interpretation

9,700

4,200

5,500

75831

Venography, renal, unilateral, radiological supervision and interpretation

9,700

4,200

5,500

75833

Venography, renal, bilateral, radiological supervision and interpretation

9,700

4,200

5,500

75840

Venography, adrenal, unilateral, radiological supervision and interpretation

9,700

4,200

5,500

75842

Venography, adrenal, bilateral, radiological supervision and interpretation

9,700

4,200

5,500

9,700

4,200

5,500

9,700

4,200

5,500

9,700
9,700

4,200
4,200

5,500
5,500

12,900

6,300

6,600

12,900

6,300

6,600

30,300

16,800

13,500

9,700

4,200

5,500

9,700

4,200

5,500

75741
75743
75746

75790
75801
75803
75805
75807
75810
75820

75860
75870
75872
75880
75885
75889

75900

75901

75902

Venography, venous sinus(e.g., petrosal and inferior sagittal) or jugular,


radiological supervision and interpretation
Venography, superior sagittal sinus, radiological supervision and
interpretation
Venography, epidural, radiological supervision and interpretation
Venography, orbital, radiological supervision and interpretation
Percutaneous transhepatic portography, radiological supervision and
interpretation
Hepatic venography, radiological supervision and interpretation
Transcatheter Procedures
Exchanged of a previously placed intravascular catheter during thrombolytic
therapy with contrast monitoring, radiological supervision and
interpretation
Mechanical removal of pericatheter obstructive material (e.g., fibrin sheath)
from central venous device via separate venous access, radiologic
supervision and interpretation
Mechanical removal of intraluminal (intracatheter) obstructive material
from central venous device through device lumen, radiologic supervision
and interpretation

Page 106 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE
75940
75945
75952

75953

75954

75956

75957

75958

75959

75960

75961
75962
75966
75970
75978
75980

75982

75984

75989

75992
75994
75995

76003
76012

DESCRIPTION

Case Rate

Percutaneous placement of IVC filter, radiologic supervision and


interpretation
Intravascular ultrasound (non-coronary-vessel), radiological supervision and
interpretation; initial vessel
Endovascular repair of infrarenal abdominal aortic aneurysm or dissection,
radiological supervision and interpretation
Placement of proximal or distal extension prosthesis for endovascular repair
of infrarenal aortic or iliac artery aneurysm, pseudoanuerysm, or
dissection, radiological supervision and interpretation
Endovascular repair of iliac artery aneurysm, pseudoaneurysm,
arteriovenous malformation, or trauma, radiological supervision and
interpretation
Endovascular repair of descending thoracic aorta (e.g., aneurysm,
psuedoaneurysm, dissection, penetrating ulcer, intramural hematoma, or
traumatic disruption); involving coverage of left subclavian artery origin,
initial endoprosthesis plus
descending thoracic aortic extension(s), if required, to level of celiac artery
origin, radiologic supervision and interpretation
Endovascular repair of descending thoracic aorta (e.g., aneurysm,
psuedoaneurysm, dissection, penetrating ulcer, intramural hematoma, or
traumatic disruption); not involving coverage of left subclavian artery
origin, initial endoprosthesis plus descending thoracic aortic extension(s), if
required, to level of celiac artery origin, radiologic supervision and
interpretation
Placement of proximal extension prosthesis for endovascular repair of
descending thoracic aorta (e.g., aneurysm, pseudoaneurysm, dissection,
penetrating ulcer, intramural hematoma, or traumatic disruption),
radiologic supervision and interpretation
Placement of distal extension prosthesis(s) (delayed) after endovascular
repair of descending thoracic aorta, as needed, to level of celiac origin,
radiological supervision and interpretation
Transcatheter induction of intravascular stent(s), (except coronary, carotid,
and vertebral vessel), percutaneous and/ or open, radiological supervision
and interpretation
Transcatheter retrieval, percutaneous, of intravascular foreign body (e.g.,
fractured venous or arterial catheter), radiological supervision and
interpretation
Transluminal balloon angioplasty, peripheral artery, radiological supervision
and interpretation
Transluminal balloon angioplasty, renal or other visceral artery, radiological
supervision and interpretation
Transcatheter biopsy, radiological supervision and interpretation
Transluminal balloon angioplasty, venous (e.g., subclavian stenosis)
radiological supervision and interpretation
Percutaneous transhepatic biliary drainage with contrast monitoring,
radiological supervision and interpretation
Percutaneous placement of drainagecatheter combined internal and
external billiary drainage or of a drainage stent for internal billiary drainage
in patients with an inoperable mechanical billiary obstruction, radiologic
supervision and interpretation.
Change of percutaneous tube or drainage catheter with contrast
monitoring (e.g., gastrointestinal system, genitourinary system, abscess),
radiologic supervision and interpretation
Radiological guidance for percutaneous drainage (abscess, cyst, fluid
collection), with placement of catheter and radiological supervision and
interpretation
Transluminal Atherectomy
Transluminal atherectomy, peripheral artery, radiological supervision and
interpretation
Transluminal atherectomy, renal, radiological supervision and interpretation
Transluminal atherectomy, visceral, radiological supervision and
interpretation
Other Procedures
Fluoroscopic guidance for needle placement (e.g., biopsy, aspiration,
injection, localization device)
Radiological supervision and interpretation, percutaneous vertebroplasty or
vertebral augmentation including cavity creation; under fluoroscopic
guidance

Page 107 of 113

Professional Fee

Health Care
Institution Fee

23,300

12,600

10,700

9,700

4,200

5,500

53,400

29,400

24,000

55,000

33,600

21,400

53,400

29,400

24,000

55,000

33,600

21,400

53,400

29,400

24,000

55,000

33,600

21,400

55,000

33,600

21,400

46,500

25,200

21,300

46,500

25,200

21,300

23,300

12,600

10,700

23,300

12,600

10,700

23,300

12,600

10,700

23,300

12,600

10,700

37,800

21,000

16,800

46,500

25,200

21,300

8,020

2,520

5,500

8,020

2,520

5,500

23,300

12,600

10,700

23,300

12,600

10,700

23,300

12,600

10,700

8,020

2,520

5,500

30,300

16,800

13,500

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE

DESCRIPTION

Case Rate

76013

Radiological supervision and interpretation, percutaneous vertebroplasty or


vertebral augmentation including cavity creation; under CT guidance

76080

Radiologic examination, abscess, fistula or sinus tract study, including


catheterization of lesion and radiological supervision and interpretation

76086
76095

76096
76355
76360
76362
76393
76394
76930
76932
76936
76940
76942
76965
76986

77261

77401
77401
77418
77421
77432

77600

77750

Mammary ductogram or galactogram, 1 or multiple duct, injection and


radiological supervision and interpretation
Stereotactic localization guidance for breast biopsy or needle placement
(e.g., for wire localization or for injection), one or more lesion, radiological
supervision and interpretation
Mammographic guidance for needle placement, breast (e.g., for wire
localization or for injection), each lesion, radiological supervision and
interpretation
Computed tomography guidance for stereotactic localization
Computed tomography guidance for needle placement (e.g., biopsy,
aspiration, injection, localization device), radiological supervision and
interpretation
Computed tomography guidance for visceral tissue ablation
Magnetic resonance guidance for needle placement (e.g., for biopsy, needle
aspiration, injection, or placement of localization device) radiological
supervision and interpretation
Magnetic resonance guidance for visceral tissue ablation
Ultrasonic Guidance Procedures
Ultrasonic guidance for pericardiocentesis, imaging supervision and
interpretation
Ultrasonic guidance for endomyocardial biopsy, imaging supervision and
interpretation
Ultrasound guided compression repair of arterial pseudoaneurysm or
arteriovenous fistulae (includes diagnostic ultrasound evaluation,
compression of lesion and imaging)
Ultrasonic guidance for visceral tissue ablation
Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection,
localization device), imaging supervision and interpretation
Ultrasonic guidance for interstitial radioelement application
Other Procedures
Ultrasonic guidance, intraoperative
Clinical Treatment Planning (External and Internal Sources)
Therapeutic radiology treatment planning; simple, intermediate or complex,
(Only one may be reported for a given course of therapy)
Radiation Oncology
Radiation treatment delivery (Linear Accelerator)
Radiation treatment delivery (Cobalt)
Intensity modulated treatment delivery, single or multiple fields/arcs, via
narrow spatially and temporally modulated beams, binary, dynamic MLC
per session
Stereoscopic X-ray guidance for localization of target volume for the
delivery of radiation therapy
Stereotactic radiation treatment management of cerebral lesion(s)
Hyperthermia
Hyperthermia for treatment of malignancy, one or more sessions during the
course of therapy including follow-up care for 90 days after procedure
Clinical Brachytherapy
Infusion or instillation of radioelement solution

Professional Fee

Health Care
Institution Fee

30,300

16,800

13,500

8,020

2,520

5,500

8,020

2,520

5,500

8,020

2,520

5,500

8,020

2,520

5,500

8,020

2,520

5,500

8,020

2,520

5,500

8,020

2,520

5,500

8,020

2,520

5,500

8,020

2,520

5,500

8,020

2,520

5,500

8,020

2,520

5,500

8,020

2,520

5,500

8,020

2,520

5,500

8,020

2,520

5,500

8,020

2,520

5,500

8,020

2,520

5,500

18,000

8,400

9,600

3,000
2,000

800
800

2,200
1,200

5,680

1,680

4,000

30,300

16,800

13,500

30,300

16,800

13,500

12,120

6,720

5,400

5,680

1,680

4,000

77761

Intracavitary radiation source application, 1 or more sources/ribbons


(Brachytherapy), one or more sessions during the course of therapy
including follow-up care for 90 days after procedure

18,000

8,400

9,600

77776

Interstitial radiation source application, 1 or more sources/ribbons


(Brachytherapy), one or more sessions during the course of therapy
including follow-up care for 90 days after procedure

18,000

8,400

9,600

5,680

1,680

4,000

9,700

4,200

5,500

3,640

840

2,800

77781
77789

79000

Remote after loading high intensity brachytherapy (RAHIB); 1 or more


source position or catheters per session
Surface application of radiation source (Brachytherapy), one or more
sessions during the course of therapy including follow-up care for 90 days
after procedure
Nuclear Medicine
Radiopharmaceutical (radioactive iodine) therapy

Page 108 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE

DESCRIPTION

Case Rate

79440

Radiopharmaceutical ablation of gland for thyroid carcinoma or metastases


of thyroid carcinoma
Radiopharmaceutical therapy, by intracavitary administration
Radiopharmaceutical therapy, by interstitial radioactive colloid
administration
Radiopharmaceutical therapy, by radiolabeled monoclonal antibody by
intravenous infusion
Radiopharmaceutical therapy, by intra-articular administration

79445

Radiopharmaceutical therapy, by intra-arterial particulate administration

79005
79200
79300
79403

88174

88331

Pathology Services
Cytopathology
Evaluation of aspirate (CT-guided biopsy) with or without preparation of
smears; immediate cytologic study to determine adequacy of specimen(s),
interpretation and report
Surgical Pathology
Pathology consultation during surgery; with frozen section(s), single block

90935

Pathology consultation during surgery; with frozen section(s), two (2) or


more blocks
Medicine Services
Dialysis
Hemodialysis procedure

90945

Dialysis procedure other than hemodialysis (e.g. peritoneal, hemofiltration)

88332

Professional Fee

Health Care
Institution Fee

8,020

2,520

5,500

9,700

4,200

5,500

9,700

4,200

5,500

8,020

2,520

5,500

8,020

2,520

5,500

8,020

2,520

5,500

5,680

1,680

4,000

5,680

1,680

4,000

9,700

4,200

5,500

4,000

500

3,500

4,000

500

3,500

8,260

3,360

4,900

8,260

3,360

4,900

8,260

3,360

4,900

8,260

3,360

4,900

30,300

16,800

13,500

23,300

12,600

10,700

30,300

16,800

13,500

30,300

16,800

13,500

30,300

16,800

13,500

53,400
53,400
53,400

29,400
29,400
29,400

24,000
24,000
24,000

21,400

10,500

10,900

21,400

10,500

10,900

30,300

16,800

13,500

12,900

6,300

6,600

18,000

8,400

9,600

Gastroenterology
91034

91037
91100
91105
92973
92975
92980

92981
92982
92986
92987
92990
92992
92993
92995
92997
93501
93503
93505
93508
93510
93511
93514
93524

Esophagus, gastroesophageal reflux test; with nasal catheter pH


electrode(s) placement, recording, analysis and interpretation
Esophageal function test, gastroesophageal reflux test with nasal catheter
intraluminal impedance electrode(s) placement, recording, analysis and
interpretation;
Intestinal bleeding tube, passage, positioning and monitoring
Gastric intubation, and aspiration or lavage for treatment (e.g., for ingested
poisons)
Cardiovascular Therapeutic Services
Percutaneous transluminal coronary thrombectomy
Thrombolysis, coronary; by intracoronary infusion, including coronary
angiography
Transcatheter placement of an intracoronary stent(s), percutaneous, with
or without other therapeutic interventions, any method; single vessel
Transcatheter placement of an intracoronary stent(s), percutaneous, with
or without other therapeutic interventions, any method; each additional
vessel
Percutaneous transluminal coronary balloon angioplasty, one or more
vessel
Percutaneous balloon valvuloplasty; aortic
Percutaneous balloon valvuloplasty; mitral
Percutaneous balloon valvuloplasty; pulmonary valve
Atrial septectomy or septostomy; transvenous method, balloon (e.g.,
Rashkind type) (includes cardiac catheterization)
Atrial septectomy or septostomy; blade method (Park septostomy)
(includes cardiac catheterization)
Percutaneous transluminal coronary atherectomy, by mechanical or other
method, with or without balloon angioplasty, one or more vessel
Percutaneous transluminal pulmonary balloon angioplasty, one or more
vessel
Cardiac Catheterization
Right heart catheterization
Insertion and placement of flow directed catheter (e.g., Swan-Ganz) for
monitoring purposes
Endomyocardial biopsy
Catheter placement in coronary artery(s), arterial coronary conduits and/or
venous coronary bypass grafts for coronary angiography without
concomitant left heart catheterization
Left heart catheterization, retrograde, from the brachial artery, axillary
artery or femoral artery; percutaneous
Left heart catheterization, retrograde, from the brachial artery, axillary
artery or femoral artery; by cutdown
Left heart catheterization by left ventricular puncture
Combined transseptal and retrograde left heart catheterization

Page 109 of 113

9,700

4,200

5,500

23,300

12,600

10,700

9,700

4,200

5,500

18,000

8,400

9,600

18,000

8,400

9,600

18,000
23,300

8,400
12,600

9,600
10,700

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE
93526
93527
93528
93529
93530
93531

DESCRIPTION

Case Rate

Combined right heart catheterization and retrograde left heart


catheterization
Combined right heart catheterization and transseptal left heart
catheterization through intact septum (with or without retrograde left heart
catheterization)
Combined right heart catheterization with left ventricular puncture (with or
without retrograde left heart catheterization)
Combined right heart catheterization and left heart catheterization through
existing septal opening (with or without retrograde left heart
catheterization)
Right heart catheterization, for congenital cardiac anomalies
Combined right heart catheterization and retrograde left heart
catheterization, for congenital cardiac anomalies

Professional Fee

Health Care
Institution Fee

23,300

12,600

10,700

23,300

12,600

10,700

23,300

12,600

10,700

23,300

12,600

10,700

18,000

8,400

9,600

23,300

12,600

10,700

93532

Combined right heart catheterization and transseptal left heart


catheterization through intact septum with or without retrograde left heart
catheterization, for congenital cardiac anomalies

9,700

4,200

5,500

93533

Combined right heart catheterization and transseptal left heart


catheterization through existing septal opening, with or without retrograde
left heart catheterization, for congenital cardiac anomalies

9,700

4,200

5,500

9,700

4,200

5,500

9,700

4,200

5,500

9,700

4,200

5,500

9,700

4,200

5,500

9,700

4,200

5,500

23,300

12,600

10,700

9,700

4,200

5,500

93539

93540
93541
93542

Injection procedure during cardiac catheterization; for selective


opacification of arterial conduits (e.g., internal mammary), whether native
or used bypass
Injection procedure during cardiac catheterization; for selective
opacification of aortocoronary venous bypass grafts, one or more coronary
arteries
Injection procedure during cardiac catheterization; for pulmonary
angiography
Injection procedure during cardiac catheterization; for selective right
ventricular or right atrial angiography

93543

Injection procedure during cardiac catheterization; for selective coronary


angiography (injection of radiopaque material may be by hand)

93544

Injection procedure during cardiac catheterization; for aortography

93545

Injection procedure during cardiac catheterization; for selective coronary


angiography (injection of radiopaque material may be by hand)
Imaging supervision

93555

Imaging supervision, interpretation and report for injection procedure(s)


during cardiac catheterization; ventricular and/or atrial angiography

9,700

4,200

5,500

93556

Imaging supervision, interpretation and report for injection procedure(s)


during cardiac catheterization; pulmonary angiography, aortography,
and/or selective coronary angiography including venous bypass grafts and
arterial conduits (whether native or used in bypass)

9,700

4,200

5,500

55,000

33,600

21,400

55,000

33,600

21,400

9,700
9,700
9,700
9,700
9,700

4,200
4,200
4,200
4,200
4,200

5,500
5,500
5,500
5,500
5,500

9,700

4,200

5,500

9,700

4,200

5,500

9,700

4,200

5,500

9,700

4,200

5,500

9,700

4,200

5,500

Repair of Septal Defect


93580
93581
93600
93602
93603
93610
93612
93615
93616
93618
93619

93620

Percutaneous transcatheter closure of congenital interatrial


communications (i.e., Fontan fenestration, atrial septal defect) with implant
Percutaneous transcatheter closure of congenital ventricular septal defect
with implant
Intracardiac Electrophysiological Procedures/Studies
Bundle of His recording
Intra-atrial recording
Right ventricular recording
Intra-atrial pacing
Intraventricular pacing
Esophageal recording of atrial electrogram with or without ventricular
electrogram(s);
Esophageal recording of atrial electrogram with or without ventricular
electrogram(s); with pacing
Induction of arrhythmia by electrical pacing
Comprehensive electrophysiologic evaluation with right atrial pacing and
recording, right ventricular pacing and recording, His bundle recording,
including insertion and repositioning of multiple electrode catheters,
without induction of arrhythmia
Comprehensive electrophysiologic evaluation including insertion and
repositioning of multiple electrode catheters with induction or attempted
induction of arrhythmia; with right atrial pacing and recording, His bundle
recording

Page 110 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE

DESCRIPTION

Case Rate

Professional Fee

Health Care
Institution Fee

93624

Electrophysiologic follow-up study with pacing and recording to test


effectiveness of therapy, including induction or attempted induction of
arrhythmia

9,700

4,200

5,500

93631

Intra-operative epicardial and endocardial pacing and mapping to localize


the site tachycardia or zone of slow conduction for surgical correction

9,700

4,200

5,500

93640

Electrophysiologic evaluation of single or dual chamber pacing cardioverterdefibrillator leads including defibrillation threshold evaluation (induction of
arrhythmia, evaluation of sensing and pacing for arrhythmia termination) at
time of initial implantation or replacement;

9,700

4,200

5,500

Page 111 of 113

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE

DESCRIPTION

Case Rate

Professional Fee

Health Care
Institution Fee

93641

Electrophysiologic evaluation of single or dual chamber pacing cardioverterdefibrillator leads including defibrillation threshold evaluation (induction of
arrhythmia, evaluation of sensing and pacing for arrhythmia termination) at
time of initial implantation or replacement; with testing of single or dual
chamber pacing cardioverter-defribrillator pulse generator

9,700

4,200

5,500

93642

Electrophysiologic evaluation of single or dual chamber pacing cardioverterdefibrillator (includes defibrillation threshold evaluation, induction of
arrhythmia, evaluation of sensing and pacing for arrhythmia termination,
and programming or reprogramming

9,700

4,200

5,500

9,700

4,200

5,500

9,700

4,200

5,500

9,700

4,200

5,500

9,700

4,200

5,500

7,280

1,680

5,600

5,560

1,260

4,300

8,020

2,520

5,500

5,560

1,260

4,300

3,640

840

2,800

8,020

2,520

5,500

1,500

600

900

2,150

860

1,290

650

260

390

6,500

2,600

3,900

8,000

3,200

4,800

5,000

2,000

3,000

6,500

2,600

3,900

1,750

500

1,250

93650

93651

93652

93660

Intracardiac catheter ablation of atrioventricular node function,


atrioventricular conduction for creation of complete heart block, with or
without temporary pacemaker placement
Intracardiac catheter ablation of arrhythmogenic focus; for treatment of
supraventricular tachycardia by ablation of fast or slow atrioventricular
pathways, accessory atrioventricular connections or other atrial foci, singly
or in combination
Intracardiac catheter ablation of arrhythmogenic focus; for treatment of
ventricular tachycardia
Evaluation of cardiovascular function with tilt table evaluation, with
continuous ECG monitoring and intermittent blood pressure monitoring,
with or without pharmacological intervention
Chemotherapy

96408
96440
96445
96450
96542

96567

ANC01
ANC02
59403

Chemotherapy administration
Chemotherapy administration into pleural cavity, requiring and including
thoracentesis
Chemotherapy administration into peritoneal cavity, requiring and including
peritoneocentesis
Chemotherapy administration into CNS, requiring and including spinal
puncture
Chemotherapy injection, subarachnoid or interventricular via subcutaneous
reservoir
Photodynamic Therapy
Photodynamic therapy by external application of light to destroy
premalignant and/or malignant lesions of the skin and adjacent mucosa
(e.g., lip) by activation of photosensitive drug(s), 1 or more phototherapy
exposure session
Benefit packages
Vaginal Delivery, Antepartum and Postpartum Care
Essential services during antenatal period (Antenatal Care Package)
Antenatal care services with intrapartum monitoring or labor watch
(without delivery) (infirmaries/dispensaries, birthing homes/maternity
clinics)
Intrapartum monitoring or labor watch (without delivery)
(infirmaries/dispensaries, birthing homes/maternity clinics)
Essential health services during antenatal, intrapartum and postpartum
period including antenatal care, intrapartum monitoring, normal delivery
postpartum care (Maternity Care Package) (hospitals)

MCP01

NSD01

99432
59402
87207
89221
89222
90375

Essential health services during antenatal, intrapartum and postpartum


period including antenatal care, intrapartum monitoring, normal delivery
postpartum care (Maternity Care Package) (infirmaries/dispensaries,
birthing homes/maternity clinics)
Essential health services during intrapartum period including intrapartum
monitoring, normal delivery and postpartum care (no antenatal care)
(Normal Spontaneous Delivery Package) (hospitals)
Essential health services during intrapartum period including intrapartum
monitoring, normal delivery and postpartum care (no antenatal care)
(Normal Spontaneous Delivery Package) (infirmaries/dispensaries, birthing
homes/maternity clinics)
Newborn Care
Newborn Care Package
Other packages
Routine obstetric care including antepartum care, vaginal delivery and/or
postpartum care for hospitals; with bilateral tubal ligation
Outpatient Malaria Package
Directly Observed Treatment Short-course; intensive phase
Directly Observed Treatment Short-course; continuation phase
Animal bite package

Page 112 of 113

N/A

N/A
600
2,500
1,500
3,000

N/A
600
2,500
1,500
3,000

ANNEX 2. LIST OF PROCEDURE CASE RATES (REVISION 2.0)


FIRST CASE RATE
RVS CODE

DESCRIPTION

99246

Outpatient HIV / AIDS Package

P0001
P0000

Referral package
Resuscitation package

Case Rate
7,500
per quarter
4,000
4,000

Page 113 of 113

Professional Fee

1,200
1,200

Health Care
Institution Fee
7,500
per quarter
2,800
2,800

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