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Code Code Description 0054T 0055T Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on CT/MRI images 0274T Percutaneous laminotomy/laminectomy (intralaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, multiple levels, unilateral or bilateral; cervical or thoracic 0275T Percutaneous laminotomy/laminectomy (intralaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, multiple levels, unilateral or bilateral; lumbar 11920-11922 Correct color defects of skin 15819 Cervicoplasty 15820-15823 Revision of eyelid 15824-15829 Rhytidectomy 15830 Excision, excessive skin and subcutaneous tissue 15832-15836 Excision, excessive skin and subcutaneous tissue 15837 Excision, excessive skin and subcutaneous tissue 15838 Excision, excessive skin and subcutaneous tissue ; submental fat pad 15839 Excision, excessive skin and subcutaneous tissue (includes lipectomy), other area 15840-15845 Graft for facial nerve paralysis 15847 Excision, excessive skin and subcutaneous tissue 15876 Suction assisted lipectomy; head and neck 15877 Suction assisted lipectomy; trunk 15878-15879 Suction assisted lipectomy; upper or lower extremity 19300 Mastectomy for gynecomastia 19316 Mastopexy 19318 Reduction mammaplasty 19324-19328 Breast procedures and reconstruction 19330-19369 Breast procedures and reconstruction 19380 Revision of reconstructed breast 19396 Preparation of moulage for custom breast implant 20985 Computer-assisted surgical navigational procedure for musculoskeletal procedures, image-less 21083 Impression and custom preparation; palatal lift prosthesis 21087 Impression and custom preparation; palatal lift prosthesis 21120-21123 Genioplasty [includes codes 21120, 21121, 21122, 21123] 21125-21127 Augmentation, mandibular body or angle 21137-21139 Reduction forehead 21141-21147 Reconstruction midface, LeFort I [includes codes 21141, 21142, 21143, 21145, 21146, 21147] 21150-21151 Reconstruction midface, LeFort II 21154-21155 Reconstruction midface, LeFort III 21159-21160 Reconstruction midface, LeFort III 21172 Reconstruction superior-lateral orbital rim and lower forehead 21175 Reconstruction, bifrontal, superiorlateral orbital rims and lower forehead 21179-21180 Reconstruction, entire or majority of forehead and/or supraorbital rims 21182-21184 Reconstruction of orbital walls, rims, forehead, nasoethmoid complex 21188 Reconstruction midface, osteotomies (other than LeFort type) and bone grafts (includes obtaining autografts) 21193-21196 Reconstruction of mandibular rami [includes codes 21193, 21194, 21195, 21196] 21208-21209 Osteoplasty, facial bones; augmentation OR reduction 21210 Graft, bone; nasal, maxillary or malar areas 21230 Graft; rib cartilage, autogenous, to face, chin, nose or ear 21235 Graft; ear cartilage, autogenous, to nose or ear 21244 Reconstruction of mandible, extraoral, with transosteal bone plate CPT Codes Reviewed by HealthLink Medical Management with AIM 1 21270 Malar augmentation, prosthetic material 21275 Secondary revision of orbitocraniofacial reconstruction 21740-21743 Reconstructive repair of pectus excavatum or carinatum 22526-22527 Percutaneous intradiscal electrothermal annulopl

asty [IDET] 22533 Arthrodesis, lateral extracavitary technique, including minimal diskectomy to prepare interspace; lumbar 22534 “Arthrodesis, lateral extracavitary technique, including minimal diskectomy to prepare interspace; thoracic or lumbar, each additional vertebral segment” 22548 Arthrodesis, anterior transoral or extraoral technique, clivus-C1-C2 (atlas-axis), with or without excision of odontoid process 22551 “Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2” 22552 “Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2, each additional interspace” 22554 “Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); cervical below C2” 22558 Lumbar spine fusion 22585 “Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each 22590 Arthrodesis, posterior technique, craniocervical (occiput-C2) 22595 Arthrodesis, posterior technique, atlas-axis (C1-C2) 22600 Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment 22612 Lumbar spine fusion 22614 22630 Lumbar spine fusion 22633 prepare interspace (other than for decompression), single interspace and segment; lumbar 22634 prepare interspace (other than for decompression), single interspace and segment; each additional interspace and segment 22856 “Total disc arthroplasty (arti�cial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); single interspace, cervical” 22857 “Total disc arthroplasty (arti�cial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), lumbar, single interspace” 22858 Total disc arthroplasty (arti�cial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal 22862 22865 27130 Total hip arthroplasty 27132 Conversion of previous hip surgery to total hip arthroplasty 27134-27138 Revision of total hip arthroplasty 27279 “Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone 27280 Arthrodesis, open, sacroiliac joint, including obtaining bone graft, including instrumentation, when performed 27412 Autologous chondrocyte implantation, knee 27415 27416 Osteochondral autograft(s), knee, open (eg, mosaicplasty) includes harvesting of autograft[s]) 27445 Arthroplasty, knee, hinge prosthesis 27447 Arthroplasty, knee, condyle and plateau; medial AND lateral 27486-27487 Revision of total knee arthroplasty 29866 Arthroscopy, knee, surgical;osteochondral autograft(s) (eg. Mosaicplasty) includes harvesting of the autograft 29867 Arthroscopy, knee, surgical;osteochondral autograft(s) (eg. Mosaicplasty) 29868 Arthroscopy, knee, surgical, meniscal transplantation (includes arthrotomy f

or meniscal insertion), medial or lateral 30120 Excision or surgical planing of skin of nose for rhinophyma 30400 Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip 30410 Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip 21245-21246 Reconstruction of mandible or maxilla 21248-21249 Reconstruction of mandible or maxilla 21255 Reconstruction zygomatic arch and glenoid fossa 21256 Reconstruction of orbit with osteotomies 2 30430 Rhinoplasty, secondary; minor revision (small amount of nasal tip work) 30435 Rhinoplasty, secondary; intermediate revision (bony work with osteotomies) 30450 Rhinoplasty, secondary; major revision (nasal tip work and osteotomies) 30465 Repair nasal stenosis 30520 Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft 30620 Intranasal reconstruction 31237 Nasal/sinus endoscopy, surg 31253 “Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including frontal sinus exploration, with removal of tissue from frontal sinus, when performed” 31254 Nasal/sinus endoscopy, surgical, with ethmoidectomy, partial (anterior) 31255 Removal of ethmoid sinus 31256 Nasal/sinus endoscopy, surgical, with maxillary antrostomy 31257 Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotomy 31259 “Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotomy, with removal of tissue from the sphenoid sinus” 31267 Endoscopy, maxillary sinus 31276 Nasal/sinus endoscopy, surgical with frontal sinus exploration, with our without removal of tissue from frontal sinus 31287 Nasal/sinus endoscopy, surgical with sphenoidotomy 31288 Nasal/sinus endoscopy, surg 31295 Nasal/sinus endoscopy, surgical; with dilation of maxillary sinus ostium (eg, balloon dilation), transnasal or via canine fossa 31296 Nasal/sinus endoscopy, surgical; with dilation of frontal sinus ostium (eg, balloon dilation) 31297 Nasal/sinus endoscopy, surgical; with dilation of sphenoid sinus ostium (eg, balloon dilation) 31298 Nasal/sinus endoscopy, surgical; with dilation of frontal and sphenoid sinus ostia (eg, balloon dilation) 33202-33203 Insertion of epicardial electrode(s) 33207-33208 Insertion of new or replacement of permanent pacemaker 33211 Insertion or replacement of temporary transvenous dual chamber pacing electrodes 33213 Insertion of pacemaker pulse generator ; w existing dual leads 33214 Upgrade of implanted pacemaker system 33216 Insertion of a single transvenous electrode 33217 Insertion of 2 transvenous electrodes 33224-33225 Insertion of pacing electrode 33226 Repositioning of previously implanted cardiac venous system 33230-33231 33240 33249 33270 33271 33927 Implantation of a total replacement heart system 33928 Removal and replacement of total replacement heart system 33929 Removal of a total replacement heart system 33975-33976 Insertion of ventricular assist device 33979 Insertion of ventricular assist device; implantable intracorporeal, single ventricle 33981 Replacement of extracorporeal ventricular assist device 33982-33983 Replacement of ventricular assist

device pump(s) 33990-33991 Insertion of ventricular assist device, percutaneous 33992 Removal of percutaneous ventricular assist device 33993 Repositioning of percutaneous ventricular assist device 36465 “Injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; single incompetent extremity truncal vein.” 36466 “Injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; multiple incompetent truncal veins.” 36468 Injection(s) of sclerosant for spider veins (telangiectasia), limb or trunk 36470 Injection of sclerosing solution; single vein 30420 Rhinoplasty, primary; including major septal repair 3 36471 Injection of sclerosing solution; multiple veins, same leg 36473 “Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, 36474 “Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; subsequent vein(s) treated in a single extremity, each through separate access sites” 36475 “Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, 36476 “Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; subsequent vein(s) treated in a single extremity, each through separate access sites” 36478 “Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; �rst vein treated” 36479 “Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; subsequent vein(s) treated in a single extremity, each through separate access sites” 36482 Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (eg, cyanoacrylate) remote from the access 36483 Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (eg, cyanoacrylate) remote from the access site, inclusive of all imaging guidance and monitoring, percutaneous; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure) 37241 Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance neces - sary to complete the intervention; venous, other than hemorrhage (eg, congenital or acquired venous malformations, venous and capillary hemangiomas, 37799 41512 Tongue base suspension, permanent suture technique 41530 Submucosal ablation of the tongue base, radiofrequency, one or more sites, per session 42145 Palatopharyngoplasty (eg, uvulopalatopharyngoplasty, uvulopharyngoplasty) 43644 Lap gastric bypass/roux-en-y 43645 LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDU 43770 “Laparoscopy, surgical, ga

stric restrictive procedure; placement of adjustable gastric band (gastric band and subcutaneous port components)” 43771 Laparoscopy, surgical, gastric restrictive procedure; revision of adjustable gastric restrictive device component only 43772 Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device component only 43773 Laparoscopy, surgical, gastric restrictive procedure; removal and replacement of adjustable gastric restrictive device component only 43774 Lap remov adj gast band/port 43775 Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (ie, sleeve gastrectomy) 43842 V-band gastroplasty 43843 Gastroplasty w/o v-band 43845 “Gastric restrictive procedure with partial gastrectomy, pylorus-preserving duodenoileostomy and ileoileostomy (50 to 100 cm common channel) to limit absorption (biliopancreatic diversion with duodenal switch)” 43846 Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less) Roux-en-Y gastroenterostomy 43847 Gastric restrictive procedure, with gastric bypass for morbid obesity; with small intestin 43848 Revision gastroplasty 43886 Gastric restrictive procedure, open; revision of subcutaneous port component only 43887 Gastric restrictive procedure, open; removal of subcutaneous port component only 43888 Gastric restrictive procedure, open; removal and replacement of subcutaneous port component only 54360 Plastic operation on penis to correct angulation 54440 Plastic operation on penis for injury 56800 Plastic repair of introitus 56805 Clitoroplasty for intersex state 56810 Perineoplasty, repair of perineum, nonobstetrical 57291-57292 57335 Vaginoplasty for intersex state 62287 Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, any method utilizing needle based technique to remove disc material level(s), when performed, single or multiple levels, lumbar 63001 “Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy” 63005 Removal of spinal lamina 4 63012 Removal of spinal lamina 63015 “Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy” 63017 Removal of spinal lamina 63020 Laminotomy (hemilaminectomy), with decompression of nerve root(s) 63030 Low back disk surgery 63042 Laminotomy, single lumbar 63045 “Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s]” 63047 Removal of spinal lamina 63048 “Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s]” 63056 Decompress spinal cord 64615 “Chemodenervation of muscle(s); muscle(s) innervated by facial, trigeminal, cervical spinal and accessory nerves, bilateral (eg, for chronic migraine)” 64716 Neuroplasty and/or transposition; cranial nerve 64732-64742 Transection or avulsion (nerves of face) 64864-64865 Suture of facial nerve 64866-64870 Anastomosis (facial nerves) 67900-67908 Repair bow or eyelid 69090 Ear piercing 69300 Otoplasty, pr

otruding ear, with or without size reduction 69399 69710 Implant/replace hearing aid 69714-69718 Implant/replace hearing aid 69930 Cochlear device implantation, with or without mastoidectomy 69955 Total facial nerve decompression and/or repair 70544 MRA Head without contrast 70545 MRA Head with contrast 70546 MRA Head with & without contrast 70547 MRA Neck without contrast 70548 MRA Neck with contrast 70549 MRA Neck with & without contrast 70551 MRI Brain without contrast 70552 MRI Brain with contrast 70553 MRI Brain with & without contrast 72141 MRI Cervical Spine without contrast 72142 MRI Cervical Spine with contrast 72146 MRI Thoracic Spine without contrast 72147 MRI Thoracic Spine with contrast 72148 MRI Lumbar Spine without contrast 72149 MRI Lumbar Spine with contrast 72156 MRI Cervical Spine with & without contrast 72157 MRI Thoracic Spine with & without contrast 72158 MRI Lumbar Spine with & without contrast 75557 Cardiac magnetic resonance imaging for morphology and function without contrast material; 75559 Cardiac magnetic resonance imaging for morphology and function without contrast material; with stress imaging 75561 “Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences” 75563 “Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; with stress imaging” 75571 Computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium 75574 “Computed tomographic angiography, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3D image postprocessing” 5 78459 Myocardial imaging, positron emission tomography (PET), metabolic evaluation 78491 Myocardial imaging, positron emission tomography (PET), perfusion; single study at rest or stress 78492 Myocardial PET, perfusion mulitple studies at rest or stress 78608 Brain PET, metabolic 78609 Brain PET, perfusion 78811 PET limited area (head, neck, chest) 78812 PET Skull base to mid-thigh 78813 PET whole Body 78814 PET with CT, limited area (head, neck, chest) 78815 PET with CT, Skull base to mid-thigh 78816 PET with CT, whole Body 81162 BRCA1, BRCA2 gene analysis 81163-81167 BRCA1, BRCA2 gene analysis 81211-81215 BRCA1, BRCA2 gene analysis 81216-81217 BRCA1, BRCA2 gene analysis 81321-81323 PTEN (phosphatase and tensin homolog) gene analysis 81324-81326 PMP22 (peripheral myelin protein 22) 81432-81433 Hereditary breast cancer-related disorders gene analysis 81440 Nuclear encoded mitochondrial genes 81445 Targeted genomic sequence analysis panel 81448 Hereditary peripheral neuropathies genomic sequence analysis 81455 Targeted genomic sequence analysis panel 90283 Immune globulin, (IgIV), human, for intravenous use 92507 Treatment of speech individual 92508 Treatment of speech group 92521 92522 Evaluation of speech sound production 92523 Evaluation of speech sound production 92524 Behavioral and qualitative analysis of voice and resonance 92526 Treatment of swallowing dysfunction and/or oral function for feeding 96999 97035 Ultra sound therapy 97001 PT evaluation (code deleted 12/31/16) 97002 PT re-evaluation

(code deleted 12/31/2016) 97003 OT evaluation (code deleted 12/31/16) 97004 OT re-evaluation (code deleted 12/31/2016) 97035 Ultra sound therapy 97110 Therapeutic exercises 97113 Aquatic therapy 97140 Manual therapy 97161 Physical therapy evaluation-low complexity 97162 Physical therapy evaluation-moderate complexity 97163 Physical therapy evaluation-high complexity 97164 Re-evaluation of physical therapy established plan of care 97165 Occupational therapy evaluation-low complexity 97166 Occupational therapy evaluation-moderate complexity 97167 Occupational therapy evaluation-high complexity 97168 Re-evaluation of occupational therapy established plan of care 97530 Therapeutic activities 97532 Cognitive skills development 97605 Negative pressure wound therapy (eg, vacuum assisted drainage collection). 6 97606 Negative pressure wound therapy (eg, vacuum assisted drainage collection), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area greater than 50 square centimeters 99183 99503 Home visit for respiratory therapy care (eg, bronchodilator, oxygen therapy, respiratory a 99505 Home visit for stoma care and maintenance including colostomy and cystostomy 99506 Home visit for intramuscular injections 99600 Unlisted home visit service or procedure 99601 Home infusion/specialty drug administration, per visit (up to 2 hours) 99602 “Home infusion/specialty drug administration, per visit (up to 2 hours); each additional hour (List separately in addition to code for primary procedure)” A0430 Ambulance service, conventional air services, transport A0431 Ambulance service, conventional air services, transport A0435 Fixed wing air mileage A0436 Rotary wing air mileage A0999 Unlisted ambulance service A0888 Noncovered ambulance mileage, per mile C1721-C1722 C1772 Infusion pump, programmable (implantable) C1777 C1789 Prosthesis, breast (implantable) C1882 Cardioverter-de�brillator, other than single or dual chamber C1891 Infusion pump, nonprogrammable, permanent (implantable) C1895-C1896 C2626 Infusion pump, nonprogrammable, temporary (implantable) C9130 Injection, immune globulin (Bivigam), 500 mg C9727 Insertion of implants into the soft palate; minimum of three implants D7948-D7950 LeFort II or LeFort III D7995 Synthetic graft - mandible or facial bones E0218 Water circulating cold pad with pump E0236 Pump for water circulating pad E0470 BIPAP Respiratory Assist Device without backup rate/Nasal or Facial Mask E0471 BIPAP Respiratory Assist Device with backup rate/Nasal or Facial Mask E0601 CPAP Respiratory Assist Device E0720 Transcutaneous Electrical Nerve Stimulation (TENS), two leads E0730 Transcutaneous Electrical Nerve Stimulation (TENS), four or more leads E0745 Neuromuscular stimulator, electronic shock unit E0747 Osteogenesis stimulator; electrical, noninvasive, other than spinal applications E0748 Osteogenesis stimulator; electrical, noninvasive, spinal applications E0760 Osteogenic stimulator, low intensity ultrasound, noninvasive E0782 Infusion pump, implantable, non-programmable (includes all components, e.g., pump, catheter, connectors, etc. E0783 Infusion pump, implantable, programmable (includes all components, e.g., pump, catheter, connectors,

etc.) E0784 External ambulatory infusion pump, insulin E1230 Power operated vehicle, 3-4 wheel E1239 Ped power wheelchair NOS E2402 Neg press wound therapy pump G0151 G0152 G0153 G0157 G0158 G0162 Skilled services by a registered nurse (RN) for management and evaluation of the plan of care; each 15 minutes G0163 Skilled services by a licensed nurse (LPN OR RN) for the observation and assessment of the patient’s condition, each 15 minutes 7 G0277 Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval G0299 Direct skilled nursing services of a registered nurse (RN) in the home health or hospice setting, each 15 minutes G0300 Direct skilled nursing services of a licensed practical nurse (LPN) in the home health or hospice setting, each 15 minutes G0448 J0585     for    migraine    use    ONLY J1438 Injection, etanercept, 25 mg J1459 Injection, immune globulin (Privigen), intravenous, non-lyophilized (e.g., liquid), 500 mg J1555 Injection, immune globulin (Cuvitru), 100 mg J1556 Injection, immune globulin (Bivigam), 500 mg J1557 Injection, immune globulin, (Gammaplex), intravenous, non-lyophilized (e.g. liquid), 500 mg J1559 Injection, immune globulin (Hizentra), 100 mg J1561 Injection, immune globulin, (Gamunex-C/Gammaked), non-lyophilized (e.g. liquid), 500 mg J1562 Injection, immune globulin (Vivaglobin), 100 mg J1566 J1568 Injection, immune globulin, (Octagam), intravenous, non-lyophilized (e.g. liquid), 500 mg J1569 Injection, immune globulin, (Gammagard Liquid), non-lyophilized (e.g. liquid), 500 mg J1572 Injection, immune globulin, (Flebogamma/Flebogamma DIF), intravenous, non-lyophilized (e.g. liquid); 500 mg J1599 J1745 J9025 Injection, azacitidine, 1 mg J9035 ONLY) J9041 Injection, bortezomib, 0.1 mg J9228 Injection, ipilimumab, 1 mg [Yervoy] J9264 ONLY) J9271 Injection, pembrolizumab, 1 mg [Keytruda] J9299 Injection, nivolumab, 1 mg J9303 Injection, panitumumab, 10 mg J9305 Injection, pemetrexed, 10 mg J9310 ONLY) J9312 Injection, rituximab, 10 mg [Rituxan]--replace J9310 J9395 Injection, fulvestrant, 25 mg K0010 - K0014 Motorized Power Wheelchair K0606 Automatic external de�brillator, with integrated electrocardiogram analysis, garment type K0800 Power Operated Vehicle, Group 1 Standard, Patient Weight Capacity up to and inculding 300 pounds K0800 - K0802 Power Operated Vehicle, Scooter, Group 1 Standard Patient K0801 Power Operated Vehicle, Group 1 Standard, Patient Weight Capacity 301-450 pounds K0802 Power Operated Vehicle, Group 1 Standard, Patient Weight Capacity 451-600 pounds K0806 Power Operated Vehicle, Group 2 Standard, Patient Weight Capacity up to and inculding 300 pounds K0806 - K0808 Power Operated Vehicle, Scooter, Group 2 Standard Patient K0807 Power Operated Vehicle, Group 2 Standard, Patient Weight Capacity 301-450 pounds K0808 Power Operated Vehicle, Group 2 Standard, Patient Weight Capacity 451-600 pounds K0812 Power Operated Vehicle, Scooter, NOC K0813 - K0816 Power Wheelchair, Group 1, Standard Up to and including 300 pounds K0820 - K0843 Power Wheelchair, Group 2, Standard K0848 - K0864 Power Wheelchair, Group 3, Standard K0868 - K0886 Power Wheelchair, Group 4, Standard K0890 - K0891 Power Wheelchair, Group 5, Pediatric K0898 Power W

heeler, not otherwise classi�ed K0899 Power mobility device, not coded by DME PDAC L5000 - L5020 Partial Foot Prosthesis L5050- L5060 Ankle Prosthesis L5100 - L5105 Below Knee Prosthesis 8 S9097 Home visit for wound care S9123 Nursing care, in the home; by registered nurse, per hour L5150 - L5160 Knee Disarticulation Prosthesis L5200 - L5230 Above Knee Prosthesis L5301 Below Knee, molded socket, shin, each foot, endoskeletal system L5311 Knee disarticulation, molded socket, external knee joints, shin, SACH foot, endoskeletal system L5321 Above Knee, molded socket, open end, SACH foot, endoskeletal system, single axis knee L5400 - L5460 L5500 - L5505 Initial prosthesis L5510 - L5600 Preparatory prosthesis L5856 “Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type” L5857 “Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing phase only, includes electronic sensor(s), any type” L5858 “Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, stance phase only, includes electronic sensor(s), any type” L5859 includes any type motor(s)” L5973 L6025 Partial Hand Myoelectric Prosthesis L6925 Wrist Myoelectric Prosthesis L6935 Below Elbow Myoelectric Prosthesis L6945 Elbow Myoelectric Prosthesis L6955 Above Elbow Myoelectric Prosthesis L6965 Shoulder Myoelectric Prosthesis L6975 Interscapular-thoracic Myoelectric Prosthesis L7007 - L7008 Adult electric hand Myoelectric Prosthesis L7009 Electric hook, switch or Myoelectric Prosthesis, adult L7045 Electric hook, switch or Myoelectric Prosthesis, pediatrict L7180 - L7181 Electronic Elbow, Myoelectric Prosthesis L7190 - L7191 Electronic Elbow, adolescent & chid, Myoelectric Prosthesis L8600 Implantable breast prosthesis, silicone or equal L8614 COCHLEAR DEVICE/SYSTEM (Special Coverage Instructions Apply. See CIM: 65-14 and MCM: 2130) L8619 COCHLEAR IMPLANT EXTERNAL SPEECH PROCESSOR, REPLAC L8690-L8694 Auditory osseointegrated device Q5004 Hospice care provided in skilled nursing facility (SNF) Q5005 Hospice care provided in inpatient hospital Q5006 Hospice care provided in inpatient hospice facility Q5007 Hospice care provided in long term acute care facility (LTCH) S2066-S2068 Breast reconstruction S2080 Laser-assisted uvulopalatoplasty (LAUP) S2112 Arthroscopy, knee, surgical for harvesting of cartilage (chondrocyte cells) S2202 Echosclerotherapy S2342 “Nasal endoscopy for post-operative debridement following functional endoscopic sinus surgery, nasal and/or sinus cavity(s), unilateral or bilateral” S2348 “Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, using radiofrequency energy, single or multiple levels, lumbar [DISC nucleoplasty]” S5180 Home health respiratory therapy S5181 Home health respiratory therapy S5502 Home infusion therapy, catheter care/maintenance, implated access device. S5522 Home infusion therapy, insertion of peripherally inserted central venous catheter (PICC S5523 Home infusion therapy, insertion of midline central venous catheter. S8092 Electron beam computed tom

ography (also known as ultrafast CT, cine CT) 9 S9124 Nursing care, in the home; by licensed practical nurse, per hour S9128 Speech therapy, in the home, S9129 Occupational therapy, in the S9131 PT in the home per diem S9152 Speech therapy, re-evaluation S9325 Home infusion therapy, pain management infusion; per diem S9326 Home infusion therapy, continuous pain management infusion; per diem S9327 Home infusion therapy, intermittent pain management infusion; per diem S9328 Home infusion therapy, implanted pump pain management infusion; per diem S9329 Home infusion therapy, chemotherapy infusion, per diem S9330 Home infusion therapy, continuous chemotherapy infusion, per diem S9331 Home infusion therapy, intermittent chemotherapy infusion, per diem S9336 Home infusion therapy, continuous anticoagulant infusion therapy S9338 Home infusion therapy, immunotherapy therapy; per diem S9345 Home infusion therapy, anti-hemophilic agent infusion therapy , per diem S9346 Home infusion therapy, alpha-1-proteinase inhibitor (e.g., prolastin); per diem S9348 Home infusion therapy, sympathomimetic/inotropic agent infusion therapy (e.g., dobutamine); per diem S9351 Home infusion therapy, continuous anti-emetic infusion therapy; per diem S9353 Home infusion therapy, continuous insulin infusion therapy; per diem S9357 Home infusion therapy, enzyme replacement intravenous therapy; per diem S9361 Home infusion therapy, diuretic intravenous therapy; per diem S9363 Home infusion therapy, anti-spasmotic therapy; per diem S9364 Home infusion therapy, total parenteral nutrition (tpn); per diem S9365 Home infusion therapy, total parenteral nutrition (tpn); per diem S9366 Home infusion therapy, total parenteral nutrition (tpn); per diem S9367 Home infusion therapy, total parenteral nutrition (tpn); per diem S9368 Home infusion therapy, total parenteral nutrition (tpn); per diem S9372 Home therapy, intermittent anticoagulant injection therapy (e.g., Heparin), per diem S9373-S9377 Home infusion therapy, hydration therapy; per diem (includes codes S9373, S9374, S9375, S9376, S9377) S9379 Home infusion therapy, infusion therapy not otherwise classi�ed; per diem S9490 Home infusion therapy, corticosteroid infusion; per diem S9494 home infusion therapy, antibiotic, antiviral, or antifungal therapy; per diem S9497 home infusion therapy, antibiotic, antiviral, or antifungal therapy; per diem S9500 Home infusion therapy, antibiotic, antiviral, or antifungal therapy, once every 24 hours, per diem S9501 Home infusion therapy, antibiotic, antiviral, or antifungal therapy, once every 12 hours, per diem S9502 Home infusion therapy, antibiotic, antiviral, or antifungal therapy, once every 8 hours, per diem S9503 Home infusion therapy, antibiotic, antiviral, or antifungal therapy, once every 6 hours, per diem S9504 Home infusion therapy, antibiotic, antiviral, or antifungal therapy, once every 4 hours, per diem S9960-S9961 Nonemergency transport, one way T1000 Private duty/independent nursing service(s), licensed, up to 15 minutes T1001 Nursing assessment/evaluation T1002 RN services, up to 15 minutes T1003 LPN/LVN services, up to 15 minutes T1030 Nursing care, in the home, by registered nurse, per diem T1031 Nursing care, in the home, by licensed practical nurse, per diem