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Relative Values
for
Physicians
Relative Value Studies, Inc.
2004
CPT only ©2003 American Medical Association. All Rights Reserved. ©2003 Ingenix, Inc.
Introduction
Intr
odu
ctio
n
User Guide
Its long history and careful development make
Relative Values for Physicians
the most accurate and comprehensive relative value system available. Use of
Relative Values for Physicians
spans North America and several European countries. In this relative value system, values are provided for physician services contained in the American Medical Association's (AMA)
Physicians’ Current Procedural Terminology
(CPT) system, as well as Medicare's HCPCS Level II (National) codes. Additional codes, as recommended by physicians,
have been included in this system and assigned relative values to address special reimbursement issues.
Relative Values for Physicians
provides a user-friendly coded listing of physician services with unit values. The accompanying instruction guidelines and modifiers explain the application of these procedure descriptors and unit values in medical practice. All sections of the book may be used by any or all physicians. Appropriate surgery descriptors are not confined to use by surgeons, nor is the Medicine section confined to use by internists or primary care physicians.
Definitions of Terms in
Relative Values for Physicians
Column Descriptions
(1) UPD
This column indicates the date the procedure was updated for
Relative Values for Physicians
. Prior to 2000 (99.2), the number following the decimal indicated whether the change occurred in the first or second official update of that year.
Relative Values for Physicians
is now an annual publication and as such is updated once each year. For the year 2004 the update stamp will read 040; for 2003, 030; etc.). The update stamp is removed after three years.
(2) TYPE
Indicates code type or AMA change:
M
Indicates a code that has been deleted from the CPT book. The CPT copyright remains with the AMA.
▲
The triangle indicates a CPT code identifier reflecting a change in the CPT code description.
●
The circle indicates a CPT code identifier reflecting that the code was added to the CPT book.
+
The plus indicates an add-on code. Add-on codes describe additional intra-service work associated with the primary procedure. They are performed by the same physician on the same date of service as the primary service/procedure, and must never be reported as a stand-alone code.
*
Indicates the procedure is modifier 51 exempt. Codes identified as exempt from modifier 51 are not subject to multiple procedure rules. No reimbursement reduction or modifier 51 is applied.
R
Indicates a code that has been developed by Relative Value Studies, Inc. (RVSI). These descriptions and the unit value information appear under certain unlisted procedures. See the
Relative Values for Physicians
with CPT
(1) (2) (3) (4) (5) (6) (7)
UPD (Type) Code Description Units Anes Global
020 *
31500 Intubation, endotracheal, emergency procedure
1.5 0 000
2 — Relative Values for Physicians
Introduction
CPT only ©2003 American Medical Association. All Rights Reserved. ©2003 Ingenix, Inc.
Introd
uction
Codes section (page 4) for a full explanation. A complete listing of R codes can be found in the R Code Crosswalk (see page 687).
If the column is blank, no special consideration for the code is required.
(3) CODE
Indicates the numerical code for the procedure. The AMA holds copyright to CPT codes. Relative Value Studies, Inc. holds copyright to codes designated as "R" in the Type column. These codes are clearly identified by three numeric, two alpha-digit codes (e.g., 328AA, 471AA, etc.) in the R Code Crosswalk on page 687.
(4) DESCRIPTION
Provides a description of the procedure. The AMA holds copyright to CPT codes and descriptions. Relative Value Studies, Inc. (RVSI) holds copyright to codes and descriptions designated as "R" in the Type column. These codes are clearly identified by three numeric, two alpha-digit codes (e.g., 328AA, 471AA, etc.) in the R Code Crosswalk on page 687.
(5) UNITS
The numerical relative value assigned to the procedure. Special notations for this column include:
BR
By Report: Procedures denoted BR (by report) in the Units column indicate a variance too great to establish a relative value.
RNE
Relativity Not Established: Procedures denoted RNE in the Units column indicate a procedure that is new or uncommon.
xx.x (I)
Interim Value: Interim relative values (designated by the letter "I") have been established by the editor upon receipt of input that is below accepted
Relative Values for Physicians
confidence levels. The decision has been made to publish these values as a guideline for keeping pace with the rapid changes in procedure technology. Any reimbursement disagreements should be resolved by treating I codes as BR or RNE.
xx.x (I-02)
Date stamped value: Some procedures flagged as an interim value will have a date stamp, e.g., I-02, which means:
• The procedure is new and considered to be technically difficult.
• Physicians may require special training to perform the procedure.
• The value of the procedure will automatically decline at the end of the year of the date stamp.
(6) ANES
Anesthesia Unit Value: Base value for general anesthesia, if required, for the procedure. (See Guidelines in the Anesthesia section.)
(7) GLOBAL
Global Period: Number of days for postoperative care when any subsequent care should be considered part of the original procedure. (See Guidelines in the Surgery section.)
The Global Period
In 2002, the editorial board of
Relative Values for Physicians
elected to change the global period days within the product to reflect those assigned in the current Medicare Physician Fee Schedule. This change was made to make the payment systems more consistent with one another. The editorial board believes that this change has made the burden on the provider and the payer lighter in interpreting the rules in the
Relative Values for Physicians
dataset.
The methodology used to crosswalk the new data into the 2002
Relative Values for Physicians
was based upon which global services existed in the previous dataset and which were to be included in the 2002 dataset. Unit values were adjusted using primarily percentages. The percentages assigned reflected generally accepted values for the postoperative period relative to global periods. Codes were increased in value by 30 percent when
Relative Values for Physicians
had previously assigned a value of 0 (zero) to the global period and the global period was changed to either 10 or 90 days. Codes were decreased in value by 30 percent when
Relative Values for Physicians
had previously assigned a global period and the global period was changed to a 0 (zero).
There are some instances where the Medicare Physician Fee Schedule uses a letter designation for the global period; these were adopted as well. The following definitions were incorporated into
Relative Values for Physicians
:
MMM
Describes services furnished in uncomplicated maternity care. This includes antepartum, delivery, and postpartum care. The usual global surgical concept does not apply.
XXX
Indicates that the global surgery concept does not apply.
YYY
Indicates that the global period is to be set by the local carrier.
ZZZ
Indicates that the code is an add-on service and therefore is treated in the global period of the other procedure that is billed in conjunction with a ZZZ code. Do not bill these codes with modifier 51. They should not be reduced.
The last area in which adjustments were made are those in which the global period was changed but not eliminated or was increased but not from zero. In those instances, adjustments were made based on the number of visits and
©2003 Ingenix, Inc. CPT only ©2003 American Medical Association. All Rights Reserved.
An
esth
esia
Anesthesia
Guidelines
I. General:
Values for anesthesia services are listed for each procedure in the Surgery section under the heading Anes and by CPT code in the Anesthesia section. These values are to be used only when the anesthesia is legally administered by or under the responsible supervision of a licensed physician. These values include usual pre- and postoperative visits, the administration of the anesthetic, and administration of fluids and/or blood incident to the anesthesia or surgery. Anesthesia services may be billed under the appropriate anesthesia code or, if the same physician performs both the surgical procedure and the anesthesia service, report the surgery code with modifier 47.
Note: Anesthesia unit values are determined in the same manner as unit values found in the other sections (e.g., Surgery, Radiology, Pathology, Medicine, and E/M). Please see The Research Behind Relative Value Units (in the Introduction) for a further explanation of our survey methodology.
Discussion of total values as derived from the base unit and time increment are discussed under Calculations of Total Anesthesia Values.
II. By Report (BR) Items:
BR in the value column indicates that the value of this service is to be determined by report, because the service is too unusual or variable to be assigned a unit value. A detailed clinical record is generally not necessary.
III. Unlisted Service or Procedure:
When an unlisted service or procedure is provided, the value should be substantiated by report (BR).
IV. Procedures Listed Without Specified Unit Values:
Procedures that have RNE (relativity not established) or BR (by report) in the Units column should be substantiated by report (see By Report items).
V. Materials Supplied By Physician:
Identify with CPT code 99070 or the appropriate HCPCS Level II code. The list of appropriately billable supplies for each CPT code is variable by contract. RVUs are not based on supply costs. However, traditional fees or conversion
factors may be constructed to account for supplies required for a given code.
VI. Stand-by Anesthesia:
When an anesthesiologist is requested by the attending physician to be present in the operating room to monitor vital signs and manage the patient from an anesthesia standpoint, even though the actual surgery is being done under local anesthesia, calculation will be the same as if general anesthesia had been administered (time + base value).
Stand-by anesthesia is generally accepted without justifying documentation for the following:
• Deliveries
• Subdural hematomas
• Femoral or brachial arterial embolectomies
• Patients with physical status 4 or 5 — the physi-cian must document the patient's condition (e.g., severe systemic disease, moribund patient)
• Insertion of a cardiac pacemaker
• Cataract extraction and/or lens implant
Stand-by anesthesia for other than the above generally requires documentation.
VII. More Than One Anesthesiologist:
When it is necessary to have a second anesthesiologist, the necessity should be substantiated by report (BR). It is recommended that the second anesthesiologist receive 5.0 base units plus time units (see Calculations of Total Anesthesia Values).
VIII. Physical Status Modifiers:
All anesthesia services are reported by use of the anesthesia five-digit procedure code (00100-01999) plus the addition of a physical status modifier. These modifying units may be added to the basic values. Other modifiers may be used if appropriate. A comprehensive listing of modifiers is provided in the Introduction.
26 — Relative Values for Physicians
Anesthesia
CPT only ©2003 American Medical Association. All Rights Reserved. ©2003 Ingenix, Inc.
An
esthesia
Physical status modifiers are represented by the letter P followed by a single digit defined below:
UnitValues
1 Healthy patient 0
2 Patient with mild systemic disease 0
3 Patient with severe systemic disease 1
4 Patient with severe systemic disease thatis a constant threat to life 2
5 A moribund patient who is not expectedto survive without the operation 3
6 A declared brain-dead patient whose organs arebeing removed for donor purposes 0
The above six levels are consistent with the American Society of Anesthesiologists' (ASA) ranking of patient physical status.
Example: 00100 P1
IX. Qualifying Circumstances:
Some circumstances warrant additional value due to unusual events. The following list of CPT codes and the corre-sponding anesthesia unit values may be listed if appropriate. More than one code may be neces-sary. The value listed is added to the existing anesthesia base.
UnitCPT Values
99100 Anesthesia for patient of extreme age, under one year or over seventy 1
99116 Anesthesia complicated by utilizationof total body hypothermia 5
99135 Anesthesia complicated by utilizationof controlled hypotension 5
99140 Anesthesia complicated by emergency* conditions (specify) 2
*An emergency is defined as existing when delay in treatment of a patient would lead to a significant increase in the threat to life or body part.
X. Anesthesia Services Where Time Units Are Not Allowed:
During the past several years
Relative Values for Physicians
(RVP) has listed a group of codes, for which anesthesiologists commonly perform the actual CPT service described in the Anesthesia Guidelines under the heading "Anesthesia Services Where Time Units Are Not Allowed." This listing was confusing relative to anesthesia values listed in the Surgery section of RVP and was incorrect in some circumstances.
To illustrate the problem we will take the case of a 54-year-old patient requiring injection of the hip joint (CPT code 20610). If the patient requires regional anesthesia while this service is provided by the orthopedic surgeon, the anesthesiologist should report the services he/she provides using code 01200 with time units added to the base unit of 4. If, on the other hand, the anesthesiologist performs the injection without anesthesia he/she would report code 20610 and would be reimbursed the anesthesia base of 3 with no time units allowed for the service. By reporting the services in this way, it would appear that anesthesia services are not allowed for the performance of the procedure. To add to the confusion in previous editions of RVP, the value listed in the Anesthesia section was not consistent with anesthesia values in the Surgery section.
To correct both issues, RVP was changed in 2003. The values now listed in the Surgery section are values that crosswalk to the anesthesia base value from the appropriate anesthesia code in the range 00100-01999. If there is no value assigned (BR) then the anesthesia service should be considered by report; if the service is assigned a value of 0 then no anesthesia base unit(s) should be allowed for the procedure if provided. For those surgical and medical services provided by the anesthesiologist, a list of codes and the corresponding values are listed in the table beginning on the next page.
With the requirements dictated to health care through HIPAA, it should be noted that reporting of anesthesia services related to general or regional anesthesia should only be allowed under current anesthesia codes 00100-01999 and anesthesia modifiers P1-P5 or 99100-99140. As such the anesthesia values assigned in the Surgery section are for reference in cross-walking those values assigned to the anesthesia base value from the Anesthesia section of the manual.
If the anesthesiologist is performing the actual service described by the listed CPT code then the service should be reported under the appropriate CPT code from the Medicine or the Surgery section. In such cases it is recommended that the values assigned to the code listed in this table be used to value the service.
NOTE: Values in the Surgery section under the heading Anes for these and other procedures are considered to be anesthesia base units and additional time units should be allowed for the administration of anesthesia if provided during the procedure by the anesthesiologist as provided in these guidelines.
©2003 Ingenix, Inc. CPT only ©2003 American Medical Association. All Rights Reserved.
Surgery
Su
rger
y
Guidelines
I. Surgical Package Definition and Global Values.
Surgical services, while having many elements in common, are by their nature variable services that must be tailored to the needs of each patient. For this reason, surgical procedures include a variety of services, but always include a defined set of services. The included services differ slightly for therapeutic and diagnostic procedures.
A. Therapeutic Surgical Procedures.
The relative
values for therapeutic surgical procedures are considered global and always include:
1. The immediate preoperative care that starts after the decision for surgery has been made in which there are no complications requiring extra stabilizing care. This would include a single, related E/M service on the date immediately prior to or on the date of the procedure inclusive of a history and physical. Additional value is warranted for preoperative services under the following circumstances:
a. Evaluation and management services unrelated to the primary procedure.
b. Services required to stabilize the patient for the primary procedure.
c. When procedures not usually part of the basic surgical procedure (e.g., bronchoscopy prior to chest surgery) are provided during the immediate preoperative period.
2. The surgical procedure, including local infiltration, metacarpal/metatarsal/digital block, or topical anesthesia, when used.
3. Normal uncomplicated follow-up care for the indicated global period. This includes dictating operative notes, talking with family, conferring with other physicians, writing orders, and evaluating the patient in the postanesthesia recovery area. Additional value is warranted for care rendered during
the global period when additional services are required due to:
a. An unusual circumstance, complication, exacerbation, recurrence.
b. Unrelated diseases or injuries treated during the follow-up period.
B.
Diagnostic Procedures.
Care for diagnostic procedures (e.g., endoscopy, injection procedures for radiography, etc.) includes only that care related to the diagnostic procedure itself. Care of the conditions for which the diagnostic procedures were performed or other concomitant conditions are not included, and may be listed separately. Follow-up care related to the diagnostic procedure is included for the indicated global period.
C.
Additional Surgical Procedures.
When an additional surgical procedure is carried out within the listed period of follow-up care for a previous surgery, the follow-up periods will continue concurrently to their normal terminations.
II.
Starred (*) Procedures:
The starred procedure designation has been deleted from the CPT coding nomenclature. Prior rules associated with starred procedures are no longer valid.
III.
Separate Procedures:
Procedures identified as separate are frequently included in the global value of other procedures. Listing of separate codes is not appropriate when a procedure is included in the global value of another (e.g., 29870 is not appropriate to list in conjunction with 29874).
IV.
Unusual Service or Procedure:
A service may necessitate use of the skills and time of the physician over and above listed services and values. If substantiated by report (BR), additional values may be warranted. Use modifier 22 to indicate these procedures.
46 — Relative Values for Physicians
Surgery
CPT only ©2003 American Medical Association. All Rights Reserved. ©2003 Ingenix, Inc.
Su
rgery
V.
Unlisted Service or Procedure:
When a service or procedure provided is not adequately identified, use of the unlisted procedure code for the related anatomical area is appropriate. Most codes of this nature have 99 for the last two digits. The value should be substantiated by report (BR).
VI. Procedures Without Specified Unit Values:
Procedures that have RNE (relativity not established) or BR (by report) in the units column should be substantiated by report (see By Report).
VII. By Report (BR):
The value of a procedure should be established for any by report circumstance by identifying a similar service and justifying value difference. When a report is indicated, the report should include the following:
• Accurate procedure definition or description
• Operative report
• Justification for procedural variance, when appropriate
• Similar procedure and value comparisons
• Justification for value difference
VIII.
Reduced Values:
Under some circumstances, value for a procedure may be reduced or eliminated. Use modifier 52 to identify reduced value services.
IX. Operating Microscope:
When an operating microscope is used to perform a procedure, report CPT code 69990 in addition to the primary code unless included as a service in the primary code.
X. Anesthesia By Surgeon:
Regional or general anesthesia provided by a surgeon should be indicated using modifier 47. The surgeon may receive a value for the procedure equal to the base anesthesia value listed in the Anes column. Anesthesia and surgery relative value units are based on different scales.
Note: Customary conversion factors for anesthesia are approximately 25 percent of surgery conversion factors.
XI. Preoperative, Surgery, and/or Postoperative Care Provided by Different Physicians
A. Surgical Care Only:
When a physician provides only the surgical care and another physician provides preoperative and postoperative care, this circumstance should be indicated by the use of modifier 54. A customary value of 70 percent of the listed value is allowed.
B. Postoperative Management Only:
If a physician provides the postoperative care only, the use of modifier 55 is warranted. A customary value of 30 percent of the listed value is appropriate.
C. Preoperative Management Only:
If a physician provides the preoperative care only, the use of modifier 56 is warranted. A customary value of 10 percent of the listed value is appropriate.
XII. Two Surgeons:
Under certain circumstances, the skills of two surgeons (usually with different skills) may be required in the management of a specific surgical problem (e.g., a urologist and a general surgeon in the creation of an ileal conduit, etc.). The procedure should be valued at the customary value of 125 percent of the value listed. The total value (125 percent) may be apportioned in relation to the responsibility and work done, provided the patient is made aware of the arrangement. Such procedures should be marked using modifier 62.
XIII. Surgical Team:
Under some circumstances, a highly complex procedure identified by a single code requires the services of several physicians, often of different specialties. These circumstances should be identified by adding modifier 66. The value should be supported by a report to include itemization of the services and personnel included in a global value. See Concurrent Care and Multiple Procedures for help in determining the global value.
XIV. Surgical Assistants:
An assistant surgeon, regardless of type, can provide other services on the same date. These services warrant a value of 100 percent of the values listed.
A. Assistant Surgeon:
When surgical assistance is provided by a qualified physician, the use of modifier 80 is appropriate. The use of this modifier customarily warrants 20 percent of the listed values.
B. Minimum Assistant Surgeon:
When minimal surgical assistance is provided, the use of modifier 81 is appropriate. The use of this modifier customarily warrants 10 percent of the listed values.
C. Assistant Surgeon (when a qualified resident surgeon is not available):
When a qualified resident surgeon is unavailable and a qualified nonresident surgeon provides surgical assistance, use of modifier 82 is appropriate. The use of this modifier customarily warrants 20 percent of the listed values.
Surgery
Relative Values for Physicians — 65
✚
Add-on Code *
Modifier 51 Exempt
▲
Revised code
●
New code
M
Deleted from CPT
R
RVSI Code
(I)
Interim Value
©2003 Ingenix, Inc. CPT only ©2003 American Medical Association. All Rights Reserved.
Su
rger
y
UPD Code Description Units Anes Global
040
20500
Injection of sinus tract; therapeutic (separate procedure) 0.5 3 010
040
20501
diagnostic (sinogram) 1.0 3 000
040
20520
Removal of foreign body in muscle or tendon sheath; simple 2.2 3 010
040
20525
deep or complicated 3.7 3 010
020
20526
Injection, therapeutic (eg, local anesthetic, corticosteroid), carpal tunnel
0.6 (I) 3 000
040
▲
20550
Injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar “fascia”)
0.4 3 000
040
▲
20551
single tendon origin/insertion 0.6 (I) 3 000
040
▲
20552
single or multiple trigger point(s), one or two muscle(s) 0.6 (I) 3 000
030
20553
single or multiple trigger point(s), three or more muscle(s)
1.8 (I) 3 000
040
20600
Arthrocentesis, aspiration and/or injection; small joint or bursa (eg, fingers, toes)
0.4 3 000
040
20605
intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa)
0.5 3 000
040
20610
major joint or bursa (eg, shoulder, hip, knee joint, subacromial bursa)
0.6 3 000
030
20612
Aspiration and/or injection of ganglion cyst(s) any location 0.6 (I) 3 000
020
20615
Aspiration and injection for treatment of bone cyst 3.7 3 010
040
20650
Insertion of wire or pin with application of skeletal traction, including removal (separate procedure)
2.0 4 010
020
****
20660
Application of cranial tongs, caliper, or stereotactic frame, including removal (separate procedure)
Note: Multiple procedure guidelines for reduction of value are not applicable for this code.
2.1 5 000
020
20661
Application of halo, including removal; cranial 4.7 5 090
020
20662
pelvic 6.5 6 090
020
20663
femoral 6.5 4 090
020
20664
Application of halo, including removal, cranial, 6 or more pins placed, for thin skull osteology (eg, pediatric patients, hydrocephalus, osteogenesis imperfecta), requiring general anesthesia
11.1 5 090
040
20665
Removal of tongs or halo applied by another physician 0.5 5 010
040
20670
Removal of implant; superficial, (eg, buried wire, pin or rod) (separate procedure)
2.0 3 010
020
20680
deep (eg, buried wire, pin, screw, metal band, nail, rod or plate)
5.2 5 090
66 — Relative Values for Physicians
Surgery
✚
Add-on Code *
Modifier 51 Exempt
▲
Revised code
●
New code
M
Deleted from CPT
R
RVSI Code
(I)
Interim Value
CPT only ©2003 American Medical Association. All Rights Reserved. ©2003 Ingenix, Inc.
Su
rgery
020
****
20690
Application of a uniplane (pins or wires in one plane), unilateral, external fixation system
Note: Multiple procedure guidelines for reduction of value are not applicable for this code.
6.5 3 090
020
****
20692
Application of a multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)
Note: Multiple procedure guidelines for reduction of value are not applicable for this code.
11.7 3 090
020
20693
Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))
5.9 3 090
020
20694
Removal, under anesthesia, of external fixation system 2.6 3 090
020
20802
Replantation, arm (includes surgical neck of humerus through elbow joint), complete amputation
65.0 6 090
020
20805
Replantation, forearm (includes radius and ulna to radial carpal joint), complete amputation
65.0 6 090
020
20808
Replantation, hand (includes hand through metacarpophalangeal joints), complete amputation
60.0 6 090
020
20816
Replantation, digit, excluding thumb (includes metacarpophalangeal joint to insertion of flexor sublimis tendon), complete amputation
28.0 6 090
020
20822
Replantation, digit, excluding thumb (includes distal tip to sublimis tendon insertion), complete amputation
20.0 6 090
020
20824
Replantation, thumb (includes carpometacarpal joint to MP joint), complete amputation
32.0 6 090
020
20827
Replantation, thumb (includes distal tip to MP joint), complete amputation
27.5 6 090
020
20838
Replantation, foot, complete amputation 65.0 8 090
020
****
20900
Bone graft, any donor area; minor or small (eg, dowel or button)
Note: Multiple procedure guidelines for reduction of value are not applicable for this code.
3.1 3 090
020
****
20902
major or large
Note: Multiple procedure guidelines for reduction of value are not applicable for this code.
6.8 6 090
020
****
20910
Cartilage graft; costochondral
Note: Multiple procedure guidelines for reduction of value are not applicable for this code.
6.2 6 090
020
****
20912
nasal septum
Note: Multiple procedure guidelines for reduction of value are not applicable for this code.
6.2 5 090
020
****
20920
Fascia lata graft; by stripper
Note: Multiple procedure guidelines for reduction of value are not applicable for this code.
2.6 4 090
UPD Code Description Units Anes Global
Surgery
Relative Values for Physicians — 129
✚
Add-on Code *
Modifier 51 Exempt
▲
Revised code
●
New code
M
Deleted from CPT
R
RVSI Code
(I)
Interim Value
©2003 Ingenix, Inc. CPT only ©2003 American Medical Association. All Rights Reserved.
Su
rger
y
UPD Code Description Units Anes Global
30420
including major septal repair 26.2 5 090
020
30430
Rhinoplasty, secondary; minor revision (small amount of nasal tip work)
8.5 5 090
020
30435
intermediate revision (bony work with osteotomies) 16.3 5 090
020
30450
major revision (nasal tip work and osteotomies) 20.8 5 090
020
30460
Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columellar lengthening; tip only
17.8 5 090
020
30462
tip, septum, osteotomies 32.5 5 090
040
30465
Repair of nasal vestibular stenosis (eg, spreader grafting, lateral nasal wall reconstruction)
18.5 5 090
30520
Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft
11.0 5 090
020
30540
Repair choanal atresia; intranasal 17.8 5 090
020
30545
transpalatine 22.6 5 090
040
30560
Lysis intranasal synechia 1.2 5 010
30580
Repair fistula; oromaxillary (combine with 31030 if antrotomy is included)
10.0 5 090
30600
oronasal 10.0 5 090
30620
Septal or other intranasal dermatoplasty (does not include obtaining graft)
10.0 5 090
30630
Repair nasal septal perforations 11.0 5 090
040
30801
Cautery and/or ablation, mucosa of turbinates, unilateral or bilateral, any method, (separate procedure); superficial
1.0 5 010
020
30802
intramural 1.6 5 010
040
30901
Control nasal hemorrhage, anterior, simple (limited cautery and/or packing) any method
1.0 5 000
040
30903
Control nasal hemorrhage, anterior, complex (extensive cautery and/or packing) any method
1.5 5 000
040
30905
Control nasal hemorrhage, posterior, with posterior nasal packs and/or cautery, any method; initial
2.9 5 000
040
30906
subsequent 2.3 5 000
020
30915
Ligation arteries; ethmoidal 16.3 5 090
020
30920
internal maxillary artery, transantral 19.5 5 090
020
30930
Fracture nasal turbinate(s), therapeutic 0.7 5 010
020
30999
Unlisted procedure, nose BR 5 YYY
040
31000
Lavage by cannulation; maxillary sinus (antrum puncture or natural ostium)
1.3 5 010
130 — Relative Values for Physicians
Surgery
✚
Add-on Code *
Modifier 51 Exempt
▲
Revised code
●
New code
M
Deleted from CPT
R
RVSI Code
(I)
Interim Value
CPT only ©2003 American Medical Association. All Rights Reserved. ©2003 Ingenix, Inc.
Su
rgery
040
31002
sphenoid sinus 1.3 5 010
31020
Sinusotomy, maxillary (antrotomy); intranasal 5.5 5 090
030
31030
radical (Caldwell-Luc) without removal of antrochoanal polyps
13.5 5 090
030
31032
radical (Caldwell-Luc) with removal of antrochoanal polyps
14.0 5 090
030
31040
Pterygomaxillary fossa surgery, any approach 20.0 7 090
31050
Sinusotomy, sphenoid, with or without biopsy; 8.5 5 090
31051
with mucosal stripping or removal of polyp(s) 10.0 5 090
31070
Sinusotomy frontal; external, simple (trephine operation) 10.5 5 090
020
31075
transorbital, unilateral (for mucocele or osteoma, Lynch type)
16.0 5 090
030
31080
obliterative without osteoplastic flap, brow incision (includes ablation)
16.5 7 090
030
31081
obliterative, without osteoplastic flap, coronal incision (includes ablation)
16.5 7 090
030
31084
obliterative, with osteoplastic flap, brow incision 24.0 7 090
030
31085
obliterative, with osteoplastic flap, coronal incision 24.0 7 090
030
31086
nonobliterative, with osteoplastic flap, brow incision 18.0 7 090
030
31087
nonobliterative, with osteoplastic flap, coronal incision 18.0 7 090
020
31090
Sinusotomy, unilateral, three or more paranasal sinuses (frontal, maxillary, ethmoid, sphenoid)
25.0 5 090
31200
Ethmoidectomy; intranasal, anterior 7.0 5 090
31201
intranasal, total 11.5 5 090
31205
extranasal, total 14.5 5 090
030
31225
Maxillectomy; without orbital exenteration 22.5 7 090
020
31230
with orbital exenteration (en bloc) 28.0 7 090
31231
Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure)
1.2 5 000
31233
Nasal/sinus endoscopy, diagnostic with maxillary sinusoscopy (via inferior meatus or canine fossa puncture)
2.6 5 000
31235
Nasal/sinus endoscopy, diagnostic with sphenoid sinusoscopy (via puncture of sphenoidal face or cannulation of ostium)
4.5 5 000
31237
Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement (separate procedure)
3.2 5 000
020
31238
with control of nasal hemorrhage 5.4 5 000
020
31239
with dacryocystorhinostomy 12.0 5 010
UPD Code Description Units Anes Global
Surgery
Relative Values for Physicians — 201
✚
Add-on Code *
Modifier -51 Exempt
▲
Revised code
●
New code
M
Deleted from CPT
R
RVSI Code
(I)
Interim Value
©2003 Ingenix, Inc. CPT only ©2003 American Medical Association. All Rights Reserved.
Su
rger
y
UPD Code Description Units Anes Global
020
49560
Repair initial incisional or ventral hernia; reducible 15.0 6 090
030
49561
incarcerated or strangulated 18.6 7 090
020
49565
Repair recurrent incisional or ventral hernia; reducible 16.9 6 090
030
49566
incarcerated or strangulated 20.5 7 090
020
++++
49568
Implantation of mesh or other prosthesis for incisional or ventral hernia repair (List separately in addition to code for the incisional or ventral hernia repair)
Note: This code is an add-on procedure and as such is valued appropriately. Multiple procedure guidelines for reduction of value are not applicable.
2.0 0 ZZZ
020
49570
Repair epigastric hernia (eg, preperitoneal fat); reducible (separate procedure)
5.2 4 090
020
49572
incarcerated or strangulated 8.8 4 090
020
49580
Repair umbilical hernia, under age 5 years; reducible 9.1 4 090
020
49582
incarcerated or strangulated 12.7 4 090
020
49585
Repair umbilical hernia, age 5 years or over; reducible 10.4 4 090
020
49587
incarcerated or strangulated 14.0 4 090
020
49590
Repair spigelian hernia 11.7 4 090
020
49600
Repair of small omphalocele, with primary closure 13.7 7 090
020
49605
Repair of large omphalocele or gastroschisis; with or without prosthesis
33.8 7 090
020
49606
with removal of prosthesis, final reduction and closure, in operating room
27.3 7 090
020
49610
Repair of omphalocele (Gross type operation); first stage 15.6 7 090
020
49611
second stage 15.6 7 090
020
49650
Laparoscopy, surgical; repair initial inguinal hernia 11.1 (I) 6 090
020
49651
repair recurrent inguinal hernia 13.7 (I) 6 090
020
49659
Unlisted laparoscopy procedure, hernioplasty, herniorrhaphy, herniotomy
BR 6 YYY
020
49900
Suture, secondary, of abdominal wall for evisceration or dehiscence
8.1 6 090
040
49904
Omental flap, extra-abdominal (eg, for reconstruction of sternal and chest wall defects)
15.4 (I) 13 090
030
++++
49905
Omental flap, intra-abdominal (List separately in addition to code for primary procedure)
Note: This code is an add-on procedure and as such is valued appropriately. Multiple procedure guidelines for reduction of value are not applicable.
12.6 0 ZZZ
49906
Free omental flap with microvascular anastomosis 32.0 7 090
202 — Relative Values for Physicians
Surgery
✚
Add-on Code *
Modifier -51 Exempt
▲
Revised code
●
New code
M
Deleted from CPT
R
RVSI Code
(I)
Interim Value
CPT only ©2003 American Medical Association. All Rights Reserved. ©2003 Ingenix, Inc.
Su
rgery
020
49999
Unlisted procedure, abdomen, peritoneum and omentum BR 7 YYY
50010
Renal exploration, not necessitating other specific procedures 15.0 7 090
50020
Drainage of perirenal or renal abscess; open 13.5 7 090
50021
percutaneous 5.0 6 000
50040
Nephrostomy, nephrotomy with drainage 18.0 7 090
50045
Nephrotomy, with exploration 18.0 7 090
50060
Nephrolithotomy; removal of calculus 20.0 7 090
50065
secondary surgical operation for calculus 25.0 7 090
50070
complicated by congenital kidney abnormality 25.0 7 090
50075
removal of large staghorn calculus filling renal pelvis and calyces (including anatrophic pyelolithotomy)
26.0 7 090
50080
Percutaneous nephrostolithotomy or pyelostolithotomy, with or without dilation, endoscopy, lithotripsy, stenting or basket extraction; up to 2 cm
20.0 7 090
50081
over 2 cm 23.0 7 090
50100
Transection or repositioning of aberrant renal vessels (separate procedure)
16.3 15 090
50120
Pyelotomy; with exploration 19.0 7 090
50125
with drainage, pyelostomy 19.0 7 090
50130
with removal of calculus (pyelolithotomy, pelviolithotomy, including coagulum pyelolithotomy)
20.0 7 090
50135
complicated (eg, secondary operation, congenital kidney abnormality)
25.0 7 090
040
50200
Renal biopsy; percutaneous, by trocar or needle 2.8 6 000
020
50205
by surgical exposure of kidney 10.4 7 090
020
50220
Nephrectomy, including partial ureterectomy, any open approach including rib resection;
21.0 7 090
50225
complicated because of previous surgery on same kidney 23.7 7 090
50230
radical, with regional lymphadenectomy and/or vena caval thrombectomy
32.5 7 090
50234
Nephrectomy with total ureterectomy and bladder cuff; through same incision
24.0 7 090
50236
through separate incision 28.0 7 090
50240
Nephrectomy, partial 24.0 7 090
50280
Excision or unroofing of cyst(s) of kidney 16.0 7 090
50290
Excision of perinephric cyst 16.0 6 090
UPD Code Description Units Anes Global
Surgery
Relative Values for Physicians — 169
✚
Add-on Code *
Modifier 51 Exempt
▲
Revised code
●
New code
M
Deleted from CPT
R
RVSI Code
(I)
Interim Value
©2003 Ingenix, Inc. CPT only ©2003 American Medical Association. All Rights Reserved.
Su
rger
y
UPD Code Description Units Anes Global
39503
Repair, neonatal diaphragmatic hernia, with or without chest tube insertion and with or without creation of ventral hernia
22.0 7 090
030
39520
Repair, diaphragmatic hernia (esophageal hiatal); transthoracic
17.0 12 090
030
39530
combined, thoracoabdominal 19.0 12 090
030
39531
combined, thoracoabdominal, with dilation of stricture (with or without gastroplasty)
19.0 12 090
39540
Repair, diaphragmatic hernia (other than neonatal), traumatic; acute
19.0 7 090
39541
chronic 19.0 7 090
39545
Imbrication of diaphragm for eventration, transthoracic or transabdominal, paralytic or nonparalytic
12.0 12 090
040
39560
Resection, diaphragm; with simple repair (eg, primary suture) 20.0 7 090
040
39561
with complex repair (eg, prosthetic material, local muscle flap)
26.0 7 090
030
39599
Unlisted procedure, diaphragm BR 12 YYY
40490
Biopsy of lip 0.6 5 000
020
40500
Vermilionectomy (lip shave), with mucosal advancement 10.7 5 090
020
40510
Excision of lip; transverse wedge excision with primary closure
9.8 5 090
020
40520
V-excision with primary direct linear closure 9.0 5 090
020
40525
full thickness, reconstruction with local flap (eg, Estlander or fan)
10.3 5 090
40527
full thickness, reconstruction with cross lip flap (Abbe-Estlander)
20.0 5 090
020
40530
Resection of lip, more than one-fourth, without reconstruction
9.4 5 090
020
40650
Repair lip, full thickness; vermilion only 3.9 5 090
020
40652
up to half vertical height 5.2 5 090
020
40654
over one-half vertical height, or complex 7.8 5 090
40700
Plastic repair of cleft lip/nasal deformity; primary, partial or complete, unilateral
16.0 6 090
40701
primary bilateral, one stage procedure 24.0 6 090
40702
primary bilateral, one of two stages 14.0 6 090
40720
secondary, by recreation of defect and reclosure 16.0 6 090
40761
with cross lip pedicle flap (Abbe-Estlander type), including sectioning and inserting of pedicle
25.0 6 090
020
40799
Unlisted procedure, lips BR 5 YYY
170 — Relative Values for Physicians
Surgery
✚
Add-on Code *
Modifier 51 Exempt
▲
Revised code
●
New code
M
Deleted from CPT
R
RVSI Code
(I)
Interim Value
CPT only ©2003 American Medical Association. All Rights Reserved. ©2003 Ingenix, Inc.
Su
rgery
040
40800
Drainage of abscess, cyst, hematoma, vestibule of mouth; simple
1.0 5 010
020
40801
complicated 2.0 5 010
040
40804
Removal of embedded foreign body, vestibule of mouth; simple
1.0 5 010
020
40805
complicated 2.0 5 010
40806
Incision of labial frenum (frenotomy) 1.5 5 000
020
40808
Biopsy, vestibule of mouth 0.9 5 010
020
40810
Excision of lesion of mucosa and submucosa, vestibule of mouth; without repair
0.8 5 010
020
40812
with simple repair 1.2 5 010
020
40814
with complex repair 2.6 5 090
020
40816
complex, with excision of underlying muscle 3.9 5 090
020
40818
Excision of mucosa of vestibule of mouth as donor graft 2.6 5 090
020
40819
Excision of frenum, labial or buccal (frenumectomy, frenulectomy, frenectomy)
2.0 5 090
020
40820
Destruction of lesion or scar of vestibule of mouth by physical methods (eg, laser, thermal, cryo, chemical)
0.7 5 010
020
40830
Closure of laceration, vestibule of mouth; 2.5 cm or less 1.0 5 010
020
40831
over 2.5 cm or complex 1.6 5 010
40840
Vestibuloplasty; anterior 8.0 5 090
40842
posterior, unilateral 8.0 5 090
40843
posterior, bilateral 10.0 5 090
40844
entire arch 12.0 5 090
020
40845
complex (including ridge extension, muscle repositioning)
14.0 5 090
020
40899
Unlisted procedure, vestibule of mouth BR 5 YYY
040
41000
Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; lingual
1.0 5 010
040
41005
sublingual, superficial 1.0 5 010
020
41006
sublingual, deep, supramylohyoid 1.0 5 090
020
41007
submental space 1.0 5 090
020
41008
submandibular space 1.0 5 090
020
41009
masticator space 1.0 5 090
020
41010
Incision of lingual frenum (frenotomy) 1.8 5 010
UPD Code Description Units Anes Global
Surgery
Relative Values for Physicians — 201
✚
Add-on Code *
Modifier -51 Exempt
▲
Revised code
●
New code
M
Deleted from CPT
R
RVSI Code
(I)
Interim Value
©2003 Ingenix, Inc. CPT only ©2003 American Medical Association. All Rights Reserved.
Su
rger
y
UPD Code Description Units Anes Global
020
49560
Repair initial incisional or ventral hernia; reducible 15.0 6 090
030
49561
incarcerated or strangulated 18.6 7 090
020
49565
Repair recurrent incisional or ventral hernia; reducible 16.9 6 090
030
49566
incarcerated or strangulated 20.5 7 090
020
++++
49568
Implantation of mesh or other prosthesis for incisional or ventral hernia repair (List separately in addition to code for the incisional or ventral hernia repair)
Note: This code is an add-on procedure and as such is valued appropriately. Multiple procedure guidelines for reduction of value are not applicable.
2.0 0 ZZZ
020
49570
Repair epigastric hernia (eg, preperitoneal fat); reducible (separate procedure)
5.2 4 090
020
49572
incarcerated or strangulated 8.8 4 090
020
49580
Repair umbilical hernia, under age 5 years; reducible 9.1 4 090
020
49582
incarcerated or strangulated 12.7 4 090
020
49585
Repair umbilical hernia, age 5 years or over; reducible 10.4 4 090
020
49587
incarcerated or strangulated 14.0 4 090
020
49590
Repair spigelian hernia 11.7 4 090
020
49600
Repair of small omphalocele, with primary closure 13.7 7 090
020
49605
Repair of large omphalocele or gastroschisis; with or without prosthesis
33.8 7 090
020
49606
with removal of prosthesis, final reduction and closure, in operating room
27.3 7 090
020
49610
Repair of omphalocele (Gross type operation); first stage 15.6 7 090
020
49611
second stage 15.6 7 090
020
49650
Laparoscopy, surgical; repair initial inguinal hernia 11.1 (I) 6 090
020
49651
repair recurrent inguinal hernia 13.7 (I) 6 090
020
49659
Unlisted laparoscopy procedure, hernioplasty, herniorrhaphy, herniotomy
BR 6 YYY
020
49900
Suture, secondary, of abdominal wall for evisceration or dehiscence
8.1 6 090
040
49904
Omental flap, extra-abdominal (eg, for reconstruction of sternal and chest wall defects)
15.4 (I) 13 090
030
++++
49905
Omental flap, intra-abdominal (List separately in addition to code for primary procedure)
Note: This code is an add-on procedure and as such is valued appropriately. Multiple procedure guidelines for reduction of value are not applicable.
12.6 0 ZZZ
49906
Free omental flap with microvascular anastomosis 32.0 7 090
202 — Relative Values for Physicians
Surgery
✚
Add-on Code *
Modifier -51 Exempt
▲
Revised code
●
New code
M
Deleted from CPT
R
RVSI Code
(I)
Interim Value
CPT only ©2003 American Medical Association. All Rights Reserved. ©2003 Ingenix, Inc.
Su
rgery
020
49999
Unlisted procedure, abdomen, peritoneum and omentum BR 7 YYY
50010
Renal exploration, not necessitating other specific procedures 15.0 7 090
50020
Drainage of perirenal or renal abscess; open 13.5 7 090
50021
percutaneous 5.0 6 000
50040
Nephrostomy, nephrotomy with drainage 18.0 7 090
50045
Nephrotomy, with exploration 18.0 7 090
50060
Nephrolithotomy; removal of calculus 20.0 7 090
50065
secondary surgical operation for calculus 25.0 7 090
50070
complicated by congenital kidney abnormality 25.0 7 090
50075
removal of large staghorn calculus filling renal pelvis and calyces (including anatrophic pyelolithotomy)
26.0 7 090
50080
Percutaneous nephrostolithotomy or pyelostolithotomy, with or without dilation, endoscopy, lithotripsy, stenting or basket extraction; up to 2 cm
20.0 7 090
50081
over 2 cm 23.0 7 090
50100
Transection or repositioning of aberrant renal vessels (separate procedure)
16.3 15 090
50120
Pyelotomy; with exploration 19.0 7 090
50125
with drainage, pyelostomy 19.0 7 090
50130
with removal of calculus (pyelolithotomy, pelviolithotomy, including coagulum pyelolithotomy)
20.0 7 090
50135
complicated (eg, secondary operation, congenital kidney abnormality)
25.0 7 090
040
50200
Renal biopsy; percutaneous, by trocar or needle 2.8 6 000
020
50205
by surgical exposure of kidney 10.4 7 090
020
50220
Nephrectomy, including partial ureterectomy, any open approach including rib resection;
21.0 7 090
50225
complicated because of previous surgery on same kidney 23.7 7 090
50230
radical, with regional lymphadenectomy and/or vena caval thrombectomy
32.5 7 090
50234
Nephrectomy with total ureterectomy and bladder cuff; through same incision
24.0 7 090
50236
through separate incision 28.0 7 090
50240
Nephrectomy, partial 24.0 7 090
50280
Excision or unroofing of cyst(s) of kidney 16.0 7 090
50290
Excision of perinephric cyst 16.0 6 090
UPD Code Description Units Anes Global
Surgery
Relative Values for Physicians — 215
✚
Add-on Code *
Modifier 51 Exempt
▲
Revised code
●
New code
M
Deleted from CPT
R
RVSI Code
(I)
Interim Value
©2003 Ingenix, Inc. CPT only ©2003 American Medical Association. All Rights Reserved.
Su
rger
y
UPD Code Description Units Anes Global
020
54000
Slitting of prepuce, dorsal or lateral (separate procedure); newborn
1.0 3 010
020
54001
except newborn 1.8 3 010
020
54015
Incision and drainage of penis, deep 1.7 3 010
040
54050
Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; chemical
0.5 3 010
040
54055
electrodesiccation 1.0 3 010
020
54056
cryosurgery 1.0 3 010
020
54057
laser surgery 2.0 3 010
020
54060
surgical excision 2.0 3 010
020
54065
Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), extensive (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery)
2.7 3 010
020
54100
Biopsy of penis; (separate procedure) 0.7 3 000
020
54105
deep structures 1.4 3 010
020
54110
Excision of penile plaque (Peyronie disease); 10.8 3 090
020
54111
with graft to 5 cm in length 24.1 3 090
020
54112
with graft greater than 5 cm in length 26.7 3 090
020
54115
Removal foreign body from deep penile tissue (eg, plastic implant)
7.2 3 090
020
54120
Amputation of penis; partial 13.0 3 090
54125
complete 20.0 4 090
54130
Amputation of penis, radical; with bilateral inguinofemoral lymphadenectomy
28.0 6 090
54135
in continuity with bilateral pelvic lymphadenectomy, including external iliac, hypogastric and obturator nodes
34.0 8 090
020
54150
Circumcision, using clamp or other device; newborn 1.7 3 010
020
54152
except newborn 1.0 3 010
020
54160
Circumcision, surgical excision other than clamp, device or dorsal slit; newborn
0.7 3 010
020
54161
except newborn 2.7 3 010
020
54162
Lysis or excision of penile post-circumcision adhesions 4.0 (I) 3 010
020
54163
Repair incomplete circumcision 3.7 (I) 3 010
020
54164
Frenulotomy of penis 3.3 (I) 3 010
040
54200
Injection procedure for Peyronie disease; 0.7 3 010
020
54205
with surgical exposure of plaque 6.5 3 090
216 — Relative Values for Physicians
Surgery
✚
Add-on Code *
Modifier 51 Exempt
▲
Revised code
●
New code
M
Deleted from CPT
R
RVSI Code
(I)
Interim Value
CPT only ©2003 American Medical Association. All Rights Reserved. ©2003 Ingenix, Inc.
Su
rgery
54220
Irrigation of corpora cavernosa for priapism 1.8 3 000
020
54230
Injection procedure for corpora cavernosography 1.0 3 000
020
54231
Dynamic cavernosometry, including intracavernosal injection of vasoactive drugs (eg, papaverine, phentolamine)
2.8 3 000
020
54235
Injection of corpora cavernosa with pharmacologic agent(s) (eg, papaverine, phentolamine)
1.0 3 000
030
54240
Penile plethysmography 1.0 000
54250
Nocturnal penile tumescence and/or rigidity test 2.0 000
020
54300
Plastic operation of penis for straightening of chordee (eg, hypospadias), with or without mobilization of urethra
10.4 3 090
54304
Plastic operation on penis for correction of chordee or for first stage hypospadias repair with or without transplantation of prepuce and/or skin flaps
14.0 3 090
54308
Urethroplasty for second stage hypospadias repair (including urinary diversion); less than 3 cm
14.0 3 090
54312
greater than 3 cm 16.0 3 090
54316
Urethroplasty for second stage hypospadias repair (including urinary diversion) with free skin graft obtained from site other than genitalia
18.0 3 090
54318
Urethroplasty for third stage hypospadias repair to release penis from scrotum (eg, third stage Cecil repair)
10.0 3 090
54322
One stage distal hypospadias repair (with or without chordee or circumcision); with simple meatal advancement (eg, Magpi, V-flap)
12.0 3 090
54324
with urethroplasty by local skin flaps (eg, flip-flap, prepucial flap)
14.0 3 090
54326
with urethroplasty by local skin flaps and mobilization of urethra
16.0 3 090
54328
with extensive dissection to correct chordee and urethroplasty with local skin flaps, skin graft patch, and/or island flap
20.5 3 090
54332
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
23.0 3 090
54336
One stage perineal hypospadias repair requiring extensive dissection to correct chordee and urethroplasty by use of skin graft tube and/or island flap
26.5 3 090
54340
Repair of hypospadias complications (ie, fistula, stricture, diverticula); by closure, incision, or excision, simple
10.5 3 090
54344
requiring mobilization of skin flaps and urethroplasty with flap or patch graft
16.0 3 090
54348
requiring extensive dissection and urethroplasty with flap, patch or tubed graft (includes urinary diversion)
20.0 3 090
UPD Code Description Units Anes Global
Surgery
Relative Values for Physicians — 233
✚
Add-on Code *
Modifier -51 Exempt
▲
Revised code
●
New code
M
Deleted from CPT
R
RVSI Code
(I)
Interim Value
©2003 Ingenix, Inc. CPT only ©2003 American Medical Association. All Rights Reserved.
Su
rger
y
UPD Code Description Units Anes Global
040
61000
Subdural tap through fontanelle, or suture, infant, unilateral or bilateral; initial
2.0 5 000
040
61001
subsequent taps 1.4 5 000
040
61020
Ventricular puncture through previous burr hole, fontanelle, suture, or implanted ventricular catheter/reservoir; without injection
2.0 5 000
040
61026
with injection of medication or other substance for diagnosis or treatment
3.0 5 000
040
61050
Cisternal or lateral cervical (C1-C2) puncture; without injection (separate procedure)
2.5 5 000
040
61055
with injection of medication or other substance for diagnosis or treatment (eg, C1-C2)
4.1 5 000
040
61070
Puncture of shunt tubing or reservoir for aspiration or injection procedure
1.6 5 000
040
61105
Twist drill hole for subdural or ventricular puncture; 13.0 9 090
040
****
61107
for implanting ventricular catheter or pressure recording device
Note: Multiple procedure guidelines for reduction of value are not applicable for this code.
10.7 9 000
020
61108
for evacuation and/or drainage of subdural hematoma 26.0 9 090
020
61120
Burr hole(s) for ventricular puncture (including injection of gas, contrast media, dye, or radioactive material)
13.0 9 090
020
61140
Burr hole(s) or trephine; with biopsy of brain or intracranial lesion
28.6 9 090
020
61150
with drainage of brain abscess or cyst 28.6 9 090
020
61151
with subsequent tapping (aspiration) of intracranial abscess or cyst
29.3 9 090
61154
Burr hole(s) with evacuation and/or drainage of hematoma, extradural or subdural
22.0 9 090
61156
Burr hole(s); with aspiration of hematoma or cyst, intracerebral
21.5 9 090
040
****
61210
for implanting ventricular catheter, reservoir, EEG electrode(s) or pressure recording device (separate procedure)
Note: Multiple procedure guidelines for reduction of value are not applicable for this code.
8.0 9 000
020
61215
Insertion of subcutaneous reservoir, pump or continuous infusion system for connection to ventricular catheter
9.1 9 090
61250
Burr hole(s) or trephine, supratentorial, exploratory, not followed by other surgery
15.0 9 090
61253
Burr hole(s) or trephine, infratentorial, unilateral or bilateral 25.5 9 090
61304
Craniectomy or craniotomy, exploratory; supratentorial 35.0 11 090
234 — Relative Values for Physicians
Surgery
✚
Add-on Code *
Modifier -51 Exempt
▲
Revised code
●
New code
M
Deleted from CPT
R
RVSI Code
(I)
Interim Value
CPT only ©2003 American Medical Association. All Rights Reserved. ©2003 Ingenix, Inc.
Su
rgery
61305
infratentorial (posterior fossa) 37.0 13 090
61312
Craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural
36.0 11 090
61313
intracerebral 38.0 11 090
61314
Craniectomy or craniotomy for evacuation of hematoma, infratentorial; extradural or subdural
45.0 13 090
61315
intracerebellar 49.0 13 090
040
++++
61316
Incision and subcutaneous placement of cranial bone graft (List separately in addition to code for primary procedure)
Note: This code is an add-on procedure and as such is valued appropriately. Multiple procedure guidelines for reduction of value are not applicable.
1.1 (I) 0 ZZZ
61320
Craniectomy or craniotomy, drainage of intracranial abscess; supratentorial
32.0 11 090
61321
infratentorial 35.0 13 090
040
61322
Craniectomy or craniotomy, decompressive, with or without duraplasty, for treatment of intracranial hypertension, without evacuation of associated intraparenchymal hematoma; without lobectomy
22.7 (I) 11 090
040
61323
with lobectomy 23.9 (I) 11 090
61330
Decompression of orbit only, transcranial approach 30.0 11 090
61332
Exploration of orbit (transcranial approach); with biopsy 40.0 11 090
61333
with removal of lesion 40.0 11 090
61334
with removal of foreign body 40.0 11 090
030
61340
Subtemporal cranial decompression (pseudotumor cerebri, slit ventricle syndrome)
22.0 11 090
61343
Craniectomy, suboccipital with cervical laminectomy for decompression of medulla and spinal cord, with or without dural graft (eg, Arnold-Chiari malformation)
45.0 13 090
61345
Other cranial decompression, posterior fossa 19.5 13 090
61440
Craniotomy for section of tentorium cerebelli (separate procedure)
26.0 13 090
61450
Craniectomy, subtemporal, for section, compression, or decompression of sensory root of gasserian ganglion
35.0 13 090
61458
Craniectomy, suboccipital; for exploration or decompression of cranial nerves
39.0 13 090
61460
for section of one or more cranial nerves 38.0 11 090
61470
for medullary tractotomy 38.0 11 090
61480
for mesencephalic tractotomy or pedunculotomy 38.0 11 090
61490
Craniotomy for lobotomy, including cingulotomy 25.0 11 090
UPD Code Description Units Anes Global
Surgery
Relative Values for Physicians — 257
✚
Add-on Code *
Modifier -51 Exempt
▲
Revised code
●
New code
M
Deleted from CPT
R
RVSI Code
(I)
Interim Value
©2003 Ingenix, Inc. CPT only ©2003 American Medical Association. All Rights Reserved.
Su
rger
y
UPD Code Description Units Anes Global
020
65125
Modification of ocular implant with placement or replacement of pegs (eg, drilling receptacle for prosthesis appendage) (separate procedure)
7.8 5 090
020
65130
Insertion of ocular implant secondary; after evisceration, in scleral shell
15.0 5 090
020
65135
after enucleation, muscles not attached to implant 16.3 5 090
020
65140
after enucleation, muscles attached to implant 19.5 5 090
020
65150
Reinsertion of ocular implant; with or without conjunctival graft
14.3 5 090
020
65155
with use of foreign material for reinforcement and/or attachment of muscles to implant
15.6 5 090
020
65175
Removal of ocular implant 9.8 5 090
040
65205
Removal of foreign body, external eye; conjunctival superficial 0.7 5 000
040
65210
conjunctival embedded (includes concretions), subconjunctival, or scleral nonperforating
0.8 5 000
040
65220
corneal, without slit lamp 0.8 5 000
040
65222
corneal, with slit lamp 1.2 5 000
020
65235
Removal of foreign body, intraocular; from anterior chamber of eye or lens
19.5 5 090
020
65260
from posterior segment, magnetic extraction, anterior or posterior route
26.0 5 090
020
65265
from posterior segment, nonmagnetic extraction 26.0 5 090
040
65270
Repair of laceration; conjunctiva, with or without nonperforating laceration sclera, direct closure
2.6 5 010
020
65272
conjunctiva, by mobilization and rearrangement, without hospitalization
3.9 5 090
020
65273
conjunctiva, by mobilization and rearrangement, with hospitalization
6.5 5 090
020
65275
cornea, nonperforating, with or without removal foreign body
10.1 5 090
020
65280
cornea and/or sclera, perforating, not involving uveal tissue
18.2 5 090
020
65285
cornea and/or sclera, perforating, with reposition or resection of uveal tissue
19.5 5 090
020
65286
application of tissue glue, wounds of cornea and/or sclera 13.0 5 090
020
65290
Repair of wound, extraocular muscle, tendon and/or Tenon’s capsule
13.0 5 090
020
65400
Excision of lesion, cornea (keratectomy, lamellar, partial), except pterygium
10.4 5 090
040
65410
Biopsy of cornea 6.0 5 000
258 — Relative Values for Physicians
Surgery
✚
Add-on Code *
Modifier -51 Exempt
▲
Revised code
●
New code
M
Deleted from CPT
R
RVSI Code
(I)
Interim Value
CPT only ©2003 American Medical Association. All Rights Reserved. ©2003 Ingenix, Inc.
Su
rgery
020
65420
Excision or transposition of pterygium; without graft 6.5 5 090
020
65426
with graft 9.1 5 090
040
65430
Scraping of cornea, diagnostic, for smear and/or culture 0.6 5 000
040
65435
Removal of corneal epithelium; with or without chemocauterization (abrasion, curettage)
1.0 5 000
020
65436
with application of chelating agent (eg, EDTA) 2.6 5 090
020
65450
Destruction of lesion of cornea by cryotherapy, photocoagulation or thermocauterization
1.7 5 090
020
65600
Multiple punctures of anterior cornea (eg, for corneal erosion, tattoo)
7.8 5 090
65710
Keratoplasty (corneal transplant); lamellar 24.0 6 090
65730
penetrating (except in aphakia) 29.5 6 090
65750
penetrating (in aphakia) 35.0 6 090
65755
penetrating (in pseudophakia) 25.0 6 090
020
65760
Keratomileusis 22.4 5 XXX
020
65765
Keratophakia 24.5 6 XXX
020
65767
Epikeratoplasty 19.6 5 XXX
65770
Keratoprosthesis 30.0 6 090
020
65771
Radial keratotomy 9.8 5 XXX
65772
Corneal relaxing incision for correction of surgically induced astigmatism
17.0 5 090
65775
Corneal wedge resection for correction of surgically induced astigmatism
22.0 5 090
040
●
65780
Ocular surface reconstruction; amniotic membrane transplantation
7.2 (I) 5 090
040
●
65781
limbal stem cell allograft (eg, cadaveric or living donor) 11.0 (I) 5 090
040
●
65782
limbal conjunctival autograft (includes obtaining graft) 9.5 (I) 5 090
040
65800
Paracentesis of anterior chamber of eye (separate procedure); with diagnostic aspiration of aqueous
3.0 5 000
040
65805
with therapeutic release of aqueous 2.5 5 000
65810
with removal of vitreous and/or discission of anterior hyaloid membrane, with or without air injection
10.0 5 090
65815
with removal of blood, with or without irrigation and/or air injection
15.0 5 090
020
65820
Goniotomy 13.7 4 090
020
65850
Trabeculotomy ab externo 20.8 5 090
UPD Code Description Units Anes Global
©2003 Ingenix, Inc. CPT only ©2003 American Medical Association. All Rights Reserved.
Radiology
Rad
iolo
gy
Guidelines
I. General:
Listed values for radiology procedures apply only when these services are performed by or under the supervision of a physician.
A. Total:
The unit value listed on the 00 line represents the global value of the procedure. The five-digit code is used to represent this service, including the professional services and technical value of providing that service. Professional and technical components are defined below.
B. Professional:
The unit value listed on the 26 line is used to value only the professional component of a service. Modifier 26 is added to the procedure code to designate the professional component. The professional component includes examination of the patient, when indicated; performance and/or supervision of the procedure; interpretation and written report of the examination; and consultation with referring physicians.
C. Technical:
The unit value listed on the TC line is used to designate the technical value of providing the service. Modifier TC may be used to designate this component. The technical component includes personnel, materials, space, equipment, and other allocated facility overhead normally included in providing the service. Note: Modifier TC is not a CPT modifier and may not be accepted by all payers. Check with the specific payer prior to use of this HCPCS Level II modifier.
II. Supervision and Interpretation Only:
A code designated as "Supervision and Interpretation Only" is used to indicate radiological services provided by a radiologist and staff in conjunction with component surgical services provided by either the radiologist or another physician (e.g., injection, insertion of catheter). When a physician other than the radiologist performed the component service, the other physician should list separately the appropriate component procedure code and the radiologist should bill using the appropriate supervision and interpretation only code. If the radiologist and staff provide both portions
of the service, the CPT book requires reporting with the supervision and interpretation code and the appropriate component procedure code. Check with the payer for appropriate reporting.
III. Complete Procedures:
Procedures designated as complete procedures are used to denote radiological services that are performed by the radiologist and staff only. If other physicians provide some part of the procedure, see Supervision and Interpretation Only.
IV. Unlisted Services or Procedure:
A service or procedure that is not identified by a particular code should be listed using the appropriate unlisted procedure code. These codes often have 99 as the final two digits. Values should be substantiated by report (see By Report).
V. Procedures Without Specified Unit Values:
Procedures that have RNE (relativity not established) or BR (by report) in the units column should be substantiated by report (see By Report).
VI. Unusual Service or Procedure:
When a procedure of an unusual nature is performed, modifier 22 should be added and the value substantiated by report (see By Report).
VII By Report:
The value of a procedure should be established for any by report circumstance by identifying a similar service and justifying value difference. Procedures that require a report should include the following:
• Accurate definition
• Clinical history
• Related procedure values
• Reason for value adjustment
VIII. Separate or Multiple Procedures:
Multiple radiology procedures performed on the same date should be designated by separate entries. Customarily each procedure is allowed 100 percent of the listed value.
IX. Reduced Value:
If a physician elects to reduce the value of a procedure, modifier 52 should be added to
274 — Relative Values for Physicians
Radiology
✚
Add-on Code *
Modifier -51 Exempt
▲
Revised code
●
New code
M
Deleted from CPT
R
RVSI Code
(I)
Interim Value
CPT only ©2003 American Medical Association. All Rights Reserved. ©2003 Ingenix, Inc.
Rad
iology
the procedure code. Modifier 52 and the appropriate code may be used to indicate a limited or follow-up computerized axial tomography (CT) scan.
X. Services or Procedures Listed in Other Sections:
Services or procedures provided by a radiologist may be listed in another section of the book (e.g., consultations listed in Medicine). The radiologist should use these procedure codes following the guidelines appropriate to that section.
Note: The conversion factor for each section generally differs.
XI. Modifiers:
A comprehensive listing of modifiers is provided in the Introduction. Value adjustments significant to radiology and modifiers are detailed in the guidelines above.
XII. Unit Values and Dyes:
Lower cost dyes are included in the unit value. Higher cost/special dyes (e.g., non-ionic dyes), however, are not included in the unit value. Code 99070 or the appropriate HCPCS Level II code should be used to report the use of these higher cost dyes.
Magnetic Resonance Imaging (MRI)
The MRI codes listed and their corresponding unit values reflect current changes to existing expanded MRI procedures and the common practice of using 25 or more slices for each MRI service performed.
©2003 Ingenix, Inc. CPT only ©2003 American Medical Association. All Rights Reserved.
Pathology and Laboratory
Pat
hol
ogy
Guidelines
I. General:
Values in this section include recording of the specimen, performance of the test, and reporting of the result. They do not include specimen collection and transfer or individual patient administrative services.
A. Total:
The unit value listed on the 00 line represents the global value of the procedure. The five-digit procedure code is used to represent this service, including the professional services and technical cost of providing that service. Professional and technical components are described below.
B. Professional:
The unit value listed on the 26 line is used to value only the professional component of a service. Modifier 26 is added to the procedure code to designate the professional component. The professional component includes examination of the patient, when indicated; performance and/or supervision of the procedure or lab test; interpretation and/or written report concerning the examination or lab test; and consultation with referring physicians.
C. Technical:
The unit value listed on the TC line is used to designate the technical value of providing the service. Modifier TC may be used to designate this component. The technical component includes personnel, materials, space, equipment, and other allocated facility overhead normally included in providing the service. Note: Modifier TC is not a CPT modifier and may not be accepted by all payers. Check with the specific payer prior to use of this HCPCS Level II modifier.
II. Unlisted Service or Procedure:
A service or procedure that is not identified by a particular code should be listed using the appropriate unlisted procedure code. These codes often have 99 as the final two digits. Values should be substantiated by report (see By Report).
III. Procedures Without Specified Unit Values:
Procedures that have RNE (relativity not established) or BR (by
report) in the units column should be substantiated by report (see By Report).
IV. Unusual Service or Procedure:
When a procedure of unusual nature is performed, modifier 22 should be added and value substantiated by report (see By Report).
V. By Report:
The value of a procedure should be established for any by report circumstance by identifying a similar service and justifying the difference. Procedures that require a report should include the following:
• Accurate definition
• Clinical history
• Related procedure values
• Reason for value adjustment
VI. Reference (Outside) Laboratory:
The laboratory tests and services listed in this section, when performed by other than the physician, require the use of the applicable procedure number with modifier 90.
VII. Collection and Handling:
Procedure codes for the collection and handling of samples for laboratory and pathology tests are listed in Medicine (codes 99000 and 99001), Surgery (codes 36415, 36416, 36540, 36600), and HCPCS (code G0001). See Guidelines for each appropriate section and use the appropriate conversion factor.
VIII. Separate or Multiple Procedures:
Multiple procedures performed on the same date should be designated by separate entries. Customarily each procedure is allowed 100 percent of the listed value.
IX. Reduced Value:
If a physician elects to reduce the value of a procedure, modifier 52 should be added to the procedure code.
X. Consultation:
Several consultation codes are listed for various types of pathology consults (e.g., 80500, 80502, 88321–88332). Medicine codes may also be used if appropriate (see Services or Procedures Listed in Other Sections).
328 — Relative Values for Physicians
Pathology and Laboratory
✚
Add-on Code *
Modifier 51 Exempt
▲
Revised code
●
New code
M
Deleted from CPT
R
RVSI Code
(I)
Interim Value
CPT only ©2003 American Medical Association. All Rights Reserved. ©2003 Ingenix, Inc.
Path
ology
XI. Services or Procedures Listed in Other Sections:
Services or procedures provided by a pathologist may be listed in another section of the book (e.g., consultations listed in Medicine). The pathologist should use these procedure codes following the guidelines appropriate to that section.
Note: The conversion factor for each section generally differs.
XII. Modifiers:
A comprehensive listing of modifiers is provided in the Introduction. Value adjustments significant to pathology and laboratory and modifiers for those adjustments are listed in this section.
©2003 Ingenix, Inc. CPT only ©2003 American Medical Association. All Rights Reserved.
Medicine
Med
icin
e
Guidelines
I. General:
Some of the procedures in this section include a total value and professional and technical components.
A. Total:
The unit value listed on the 00 line represents the global value of the procedure. The five-digit procedure code is used to represent this service, including the professional services and technical cost of providing that service. Professional and technical components are described below.
B. Professional:
The unit value listed on the 26 line is used to value only the professional component of a service. Modifier 26 is added to the procedure code to designate the professional component. The professional component includes examination of the patient, when indicated; performance and/or supervision of the procedure or lab test; interpretation and/or written report concerning the examination or lab test; and consultation with referring physicians.
C. Technical:
The unit value listed on the TC line is used to designate the technical value of providing the service. Modifier TC may be used to designate this component. The technical component includes personnel, materials, space, equipment, and other allocated facility overhead normally included in providing the service. Note: Modifier TC is not a CPT modifier and may not be accepted by all payers. Check with the specific payer prior to use of this HCPCS Level II modifier.
II. Separate Procedures:
Procedures identified as separate are frequently included in the global value of other procedures. Listing of a separate procedure code and full value is appropriate if the procedure is not included in the global value of another. Listing of separate procedure codes is not appropriate when the procedure is included in the global value of another.
III. Unusual Service or Procedure:
A service may necessitate skills and time of the physician over and above listed services and values. If substantiated by
report (BR), additional values may be warranted. Use modifier 22 to indicate these procedures.
IV. Unlisted Service or Procedure:
When a service or procedure provided is not adequately identified, use of the unlisted procedure code for the related anatomical area is appropriate. Most codes of this nature have 99 for the last two digits. Value should be substantiated by report (BR).
V. Procedures Without Specified Unit Values:
Procedures that have RNE (relativity not established) or BR (by report) in the units column should be substantiated by report (see By Report).
VI. By Report:
The value of a procedure should be established for any by report circumstance by identifying a similar service and justifying value difference. When a report is indicated, the report should include the following:
• Accurate procedure definition or description
• Operative report
• Justification for procedural variance, when appropriate
• Similar procedure and value
• Justification for value difference
VII. Reduced Values:
Under some circumstances, a value for a procedure may be reduced or eliminated. Use modifier 52 to identify reduced value services.
VIII. Concurrent Care:
Concurrent care designates a circumstance where separate procedures or services are provided by two or more physicians on the same date. The CPT book has deleted modifier 75 and does not require any special reporting for concurrent care.
IX. Multiple Modifiers:
If circumstances require the use of more than one modifier with any one procedure code, modifier 99 should be added to the procedure code. Other modifiers are attached to the procedure code and listed separately with appropriate values for each.
420 — Relative Values for Physicians
Medicine
✚
Add-on Code *
Modifier -51 Exempt
▲
Revised code
●
New code
M
Deleted from CPT
R
RVSI Code
(I)
Interim Value
CPT only ©2003 American Medical Association. All Rights Reserved. ©2003 Ingenix, Inc.
Med
icine
X. Materials Supplied By Physician:
Use CPT code 99070 or the appropriate HCPCS Level II code. The list of appropriately billable supplies for each CPT code is variable by contract. RVUs are not based on supply costs. However, traditional fees or conversion factors may be constructed to account for supplies required for a given code.
©2003 Ingenix, Inc. CPT only ©2003 American Medical Association. All Rights Reserved.
Evaluation and Management
E/M
Guidelines
I. General:
Visits, examinations, consultations, and similar services as listed in this section reflect the wide variations required in time and skill. The following alphabetical list of definitions is included to aid in the determination of the correct code for the service provided. Documentation for each aspect of the service performed should be included in the patient record to substantiate the level of service. The listed relativities for each code group apply only when these services are performed by or under the responsible supervision of a physician.
Chief Complaint:
A concise statement describing the symptom, problem, condition, diagnosis, or other factor that is the reason for the encounter.
Classification of Service:
Each code in this section is grouped into a category. The groupings are defined by place (e.g., office, hospital, nursing home, etc.) and type of service (e.g., consultation, preventive, etc.). Some of the codes are grouped into subcategories (e.g., new patient, established patient, initial, etc.). Each code in the group represents a different level of service defined by the clinical components of a patient encounter for E/M (see Levels of Service).
Components:
Each level of service recognizes seven components. The components include history, physical examination, medical decision making, counseling, coordination of care, nature of presenting problem, and time (see Levels of Service, Key Components, History, Physical Examination, Medical Decision Making, Counseling, Problem, and Time).
Concurrent Care:
The provision of similar services (e.g., hospital visits) to the same patient by more than one physician on the same day. The CPT book has deleted modifier 75 and does not require any special reporting for concurrent care.
Consultation:
There are three categories for consultation: outpatient, inpatient, and confirmatory. Any physician may use an appropriate consultation code on any patient for any problem including one that has been previously evaluated by the consulting physician provided the following criteria are met:
The attending physician or appropriate source requests that the physician render advice or opinion regarding the evaluation and/or management of a specific problem.
• The need for the consultation, the consultant's opinion, and any services ordered or performed must be well documented in the patient's record.
• The information is communicated to the requesting physician or appropriate source.
Counseling:
A discussion with the patient and/or family concerning one or more of the following:
• Diagnostic results, impressions, and/or recommended diagnostic studies
• Prognosis
• Risks and benefits of management options
• Instructions for management and/or follow-up
• Importance of compliance with chosen management
• Risk factor reduction
• Patient and family education (see Key Components and Time)
Established Patient:
A patient who has received professional services from a physician or another physician in the same specialty within the same group within the last three years. In the instance a physician is covering for or is on call for another physician, the patient is classified as an established patient if the other physician or a member of the providing physician specialty group has provided services for the patient within the last three years.
Family History:
A review of medical events in the patient's family that includes significant information about:
• The health status or cause of death of parents, siblings, and children
478 — Relative Values for Physicians
Evaluation and Management
CPT only ©2003 American Medical Association. All Rights Reserved. ©2003 Ingenix, Inc.
E/M
• Specific diseases related to problems identified in the chief complaint or history of the present illness, and/or system review
• Diseases of family members that may be hereditary or place the patient at risk
History:
This key component relates to the type of history obtained during a patient encounter. The four types of history are defined as follows:
•
Problem focused:
Brief history of present illness or problem as related to the chief complaint
•
Expanded problem focused:
Brief history of present illness relating to chief complaint and pertinent system review
•
Detailed:
Extended history of present illness related to chief complaint, an extended system review, and pertinent past, family, and/or social history
•
Comprehensive:
Extended history of present illness related to chief complaint, complete system review, and complete past, family, and social history
History of Present Illness:
A chronological description of the development of the patient's present illness from the first sign and/or symptom to the present. This includes a description of location, quality, severity, timing, context, modifying factors, and associated signs and symptoms significantly related to the presenting problem.
Key Components:
Those components that are used primarily to determine the appropriate code level. These components include medical decision making, physical examination, and history (see History, Physical Examination, Medical Decision Making). Time is not considered a key component unless counseling constitutes more than 50 percent of the face-to-face patient/physician encounter (see Time, Counseling).
Levels of Service:
Each category and subcategory contains two to seven levels of service indicated by code. The services include examinations, evaluations, treatments, conferences with or concerning patients, preventative pediatric and adult health supervision, and similar services. Each level of service recognizes seven clinical components. Three of these components are considered key components (see Components of Service, History, Physical Examination, and Medical Decision Making). All physicians may use each level of service.
Medical Decision Making:
The complexity of establishing a diagnosis or selecting a management option. Medical decision making is divided into four categories. The level of medical decision making is
determined using documentation in the patient record for three subcategories including: number of possible diagnoses and or the number of management options considered; the amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed; and the risk of significant complications, morbidity and/or mortality, as well as comorbidities, associated with the patient's presenting problem, the diagnostic procedure, and/or the possible management options. The following four classifications for level of medical decision making are used in determining the proper code.
•
Straightforward:
Minimal number of possible diagnoses or management options, minimal or no amount and/or complexity of data to be reviewed, and minimal risk of complications and/or morbidity or mortality
•
Low Complexity:
Limited number of possible diagnoses or management options, limited amount and/or complexity of data to be reviewed, and low risk of complications and/or morbidity or mortality
•
Moderate Complexity:
Multiple number of possible diagnoses or management options, moderate amount and/or complexity of data to be reviewed, and moderate risk of complications and/or morbidity or mortality
•
High Complexity:
Extensive number of possible diagnoses or management options, extensive amount and/or complexity of data to be reviewed, and high risk of complications and/or morbidity or mortality
Nature of Presenting Problem:
A presenting problem is a disease, condition, illness, injury, symptom, sign, finding, complaint, or other reason for the encounter, with or without a diagnosis being established at the time of the encounter. The E/M codes recognize five types of presenting problems that are defined as follows:
•
Minimal:
A problem that may not require the presence of the physician, but service is provided under the physician's supervision
•
Self-limited or minor:
A problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status, or has a good prognosis with management/compliance
•
Low severity:
A problem where the risk of morbidity without treatment is low; there is little to no risk of mortality without treatment; full recovery without functional impairment is expected
©2003 Ingenix, Inc. CPT only ©2003 American Medical Association. All Rights Reserved.
Category II Codes
Cat
egor
y II
C
odes
Category II codes are supplemental tracking codes that were added to the CPT book in 2004. These codes were developed to track performance measurement and are intended to facilitate data collection related to quality of care. The coding of performance measures that support compliance with quality of care requirements, as well as state and federal law, allows the health care provider to identify performance of these measures and tests without the need for record abstraction or chart review.
Category II codes are alphanumeric codes that consist of four digits followed by an alpha character. Services and procedures or test results described by these codes are typically included as part of evaluation and management services and/or laboratory tests and procedures. For this
reason, relative values do not apply to these services, procedures, and tests.
Relative Values for Physicians
designates these codes as 0.0. Because these performance measures are included in the relative values for evaluation and management and/or laboratory services codes, relative values will not be developed for Category II codes.
The use of these codes is optional. The codes are not required for correct coding and may not be used as a substitute for Category I codes.
Category II codes are published twice a year (January 1 and July 1). The most current listing may be obtained at www.ama-assn.org/go/cpt.
UPD Code Description Units
040
●
0001F
Blood pressure, measured 0.0
040
●
0002F
Tobacco use, smoking, assessed 0.0
040
●
0003F
Tobacco use, non-smoking, assessed 0.0
040
●
0004F
Tobacco use cessation intervention, counseling 0.0
040
●
0005F
Tobacco use cessation intervention, pharmacologic therapy 0.0
040
●
0006F
Statin therapy, prescribed 0.0
040
●
0007F
Beta-blocker therapy, prescribed 0.0
040
●
0008F
ACE inhibitor therapy, prescribed 0.0
040
●
0009F
Anginal symptoms and level of activity, assessed 0.0
040
●
0010F
Anginal symptoms and level of activity, assessed using a standardized instrument (e.g., Canadian Cardiovascular Society Classification-CCSC- System, Seattle Angina Questionnaire-SAQ)
0.0
040
●
0011F
Oral antiplatelet therapy prescribed (e.g., aspirin, clopidogrel/Plavix, or combination of aspirin and dipyidamole/Aggrenox)
0.0
©2003 Ingenix, Inc. CPT only ©2003 American Medical Association. All Rights Reserved.
Category III Codes
Cat
egor
y II
I C
odes
This section contains a set of temporary CPT codes for emerging technology, services, and procedures. Category III codes will allow data collection for these services/procedures. Use of unlisted codes does not offer the opportunity for the collection of specific data. If a Category III code is available, this code must be reported instead of a Category I unlisted code. This is an activity that is critically important in the evaluation of health care delivery and the formation of public and private policy. The use of the codes in this section will allow physicians and other qualified health care professionals, insurers, health services researchers, and health policy experts to identify emerging technology, services, and procedures for clinical efficacy, utilization and outcomes.
The inclusion of a service or procedure in this section neither implies nor endorses clinical efficacy, safety or the applicability to clinical practice. The codes in this section do not conform to the usual requirements for Category I codes established by the CPT Editorial Panel. For Category I codes, the Panel requires that the service/procedure be performed by many health care professionals in clinical practice in multiple locations and that FDA approval, as appropriate, has already been received. The nature of emerging technology, services, and procedures is such that these requirements may not be met. For these reasons, temporary codes for emerging technology, services and procedures have been placed in a separate section of the
Relative Values for Physicians
and CPT books and the codes are differentiated from Category I codes by the use of alphanumeric characters.
Services/procedures described in this section make use of alphanumeric characters. These codes have an alpha character as the fifth character in the string, preceded by four digits. The digits are not intended to reflect the placement of the code in the Category I section nomenclature. Codes in this section may or may not eventually receive a Category I code. In either case, a given Category III code will be archived after five years of its inception unless it is demonstrated that a temporary code is still needed. New codes in this section are released semi-annually via the AMA/CPT internet site, to expedite dissemination for reporting. The full set of temporary codes for emerging technology, services, and procedures is published annually in the CPT book. RVSI will use the same methodology for unit value development for these Category III codes as it does for Category I codes.
502 — Relative Values for Physicians
Category III Codes
✚
Add-on Code *
Modifier 51 Exempt
▲
Revised code
●
New code
M
Deleted from CPT
R
RVSI Code
(I)
Interim Value
CPT only ©2003 American Medical Association. All Rights Reserved. ©2003 Ingenix, Inc.
Category III
Cod
es
UPD Code Description Units
040
0001T
Endovascular repair of infrarenal abdominal aortic aneurysm or dissection, modular bifurcated prosthesis (two docking limbs)
RNE
040
M
0002T
Endovascular repair of infrarenal abdominal aortic aneurysm or dissection; aorto-uni-iliac or aorto-unifemoral prosthesis
Note: This code has been deleted. To report, use 34805.
RNE
020
0003T
Cervicography RNE
020
0005T
Transcatheter placement of extracranial cerebrovascular artery stent(s), percutaneous; initial vessel
RNE
020
++++
0006T
each additional vessel (List separately in addition to code for primary procedure
Note: This code is an add-on procedure and as such is valued appropriately. Multiple procedure guidelines for reduction of value are not applicable.
RNE
020
0007T
Transcatheter placement of extracranial cerebrovascular artery stent(s), percutaneous, radiological supervision and interpretation, each vessel
RNE
020
0008T
Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with suturing of the esophagogastric junction
RNE
020
0009T
Endometrial cryoablation with ultrasonic guidance RNE
020
0010T
Tuberculosis test, cell mediated immunity measurement of gamma interferon antigen response
RNE
030
0012T
Arthroscopy, knee, surgical, implantation of osteochondral graft(s) for treatment of articular surface defect; autografts
RNE
030
0013T
allografts RNE
030
0014T
Meniscal transplantation, medial or lateral, knee (any method) RNE
020
0016T
Destruction of localized lesion of choroid (eg, choroidal neovascularization), transpupillary thermotherapy
RNE
020
0017T
Destruction of macular drusen, photocoagulation RNE
020
0018T
Delivery of high power, focal magnetic pulses for direct stimulation to cortical neurons
RNE
020
0019T
Extracorporeal shock wave therapy; involving musculoskeletal system RNE
020
0020T
involving plantar fascia RNE
020
0021T
Insertion of transcervical or transvaginal fetal oximetry sensor RNE
020
0023T
Infectious agent drug susceptibility phenotype prediction using genotypic comparison to known genotypic/phenotypic database, HIV 1
RNE
020
0024T
Non-surgical septal reduction therapy (eg, alcohol ablation), for hypertrophic obstructive cardiomyopathy; with coronary arteriograms, with or without temporary pacemaker
RNE
040
M
0025T
Determination of corneal thickness (eg, pachymetry) with interpretation and report, bilateral
Note: This code has been deleted. To report, use code 76514.
RNE
©2003 Ingenix, Inc.
HCPCS
HC
PC
S
Relative Values for Physicians
includes a listing of HCPCS Level II codes as they relate to physician services. The following is a list of these codes as developed by the Centers for Medicare and Medicaid Services (CMS) for the current year. The editors are researching a methodology for assigning values to all HCPCS codes. Many of these procedures have relative values or value guidelines for use with the conversion factor used for Medicine. Other codes list or include the cost of medical equipment and supplies. These codes are supplied in the comprehensive listing for your convenience. Values for most codes cannot be determined under the current relative value structure. The editors are researching fees for these procedures with the intention of publishing a fee range for each medical equipment or supply code in the future. A relative value is not available for procedures with an RNE (relativity not established) in the Units column. These codes should be treated as by report codes, and substantiating documentation should accompany the code submission.
The
Current Procedural Terminology
, Fourth Edition, (CPT) copyrighted by the American Medical Association is a listing of descriptive terms and numeric identifying codes and modifiers for reporting medical services and procedures performed by health care professionals. The CMS Healthcare Common Procedure Coding System (HCPCS) includes CPT descriptive terms and numeric identifying codes and modifiers for reporting medical services and procedures and other materials contained in the CPT book that are copyrighted by the American Medical Association. Participants will be authorized to use copies of CPT material in HCPCS only for the purposes directly related to participating in CMS programs. Permission for any other use must be obtained from the AMA.
Note: The D codes for HCPCS are not included in this publication. These codes are related to dental procedures and have no unit values assigned.
HCPCS Disclaimer
HCPCS is designed to promote uniform medical services reporting and statistical data collection. Inclusion of a service, product, or supply does not constitute endorsement by the HCPCS editorial panel that it is non-investigational or is commonly and customarily recognized as appropriate for medical care and treatment. Inclusion or exclusion of a
procedure, product, or supply does not imply any health insurance coverage or reimbursement policy.
Level II (HCPCS/National) Modifiers
A1 Dressing for one wound
A2 Dressing for two wounds
A3 Dressing for three wounds
A4 Dressing for four wounds
A5 Dressing for five wounds
A6 Dressing for six wounds
A7 Dressing for seven wounds
A8 Dressing for eight wounds
A9 Dressing for nine or more wounds
AA Anesthesia services performed personally by anes-thesiologist
AD Medical supervision by a physician: more than four concurrent anesthesia procedures
AH Clinical psychologist
AJ Clinical social worker
AM Physician, team member service
AP Determination of refractive state was not performed in the course of diagnostic ophthalmological exami-nation
AS Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery
AT Acute treatment (this modifier should be used when reporting service 98940, 98941, 98942)
AU Item furnished in conjunction with a urological, ostomy, or tracheostomy supply
AV Item furnished in conjunction with a prosthetic device, prosthetic or orthotic
506 — Relative Values for Physicians
HCPCS
©2003 Ingenix, Inc.
HC
PC
S
AW Item furnished in conjunction with a surgical dress-ing
AX Item furnished in conjunction with dialysis services
BA Item furnished in conjunction with parenteral or enteral nutrition (PEN) services
BO Orally administered nutrition, not by feeding tube
BP The beneficiary has been informed of the purchase and rental options and has elected to purchase the item
BR The beneficiary has been informed of the purchase and rental options and has elected to rent the item
BU The beneficiary has been informed of the purchase and rental options and after 30 days has not informed the supplier of his/her decision
CA Procedure payable only in the inpatient setting when performed emergently on an outpatient who expires prior to admission
CB Service ordered by a renal dialysis facility (rdf) phy-sician as part of the esrd beneficiary's dialysis bene-fit, is not part of the composite rate, and is separately reimbursable
CC Procedure code change (use CC when the proce-dure code submitted was changed either for admin-istrative reasons or because an incorrect code was filed)
E1 Upper left, eyelid
E2 Lower left, eyelid
E3 Upper right, eyelid
E4 Lower right, eyelid
EJ Subsequent claims for a defined course of therapy, e.g., EPO, sodium hyaluronate, infliximab
EM Emergency reserve supply (for ESRD benefit only)
EP Service provided as part of Medicaid early periodic screening diagnosis and treatment (EPSDT) pro-gram
ET Emergency services
EY No physician or other licensed health care provider order for this item or service
F1 Left hand, second digit
F2 Left hand, third digit
F3 Left hand, fourth digit
F4 Left hand, fifth digit
F5 Right hand, thumb
F6 Right hand, second digit
F7 Right hand, third digit
F8 Right hand, fourth digit
F9 Right hand, fifth digit
FA Left hand, thumb
FP Service provided as part of Medicaid family plan-ning program
G1 Most recent urea reduction ratio (URR) reading of less than 60
G2 Most recent urea reduction ration (URR) reading of 60 to 64.9
G3 Most recent urea reduction ratio (URR) reading of 65 to 69.9
G4 Most recent urea reduction ratio (URR) reading of 70 to 74.9
G5 Most recent urea reduction ratio (URR) reading of 75 or greater
G6 ESRD patient for whom less than six dialysis ses-sions have been provided in a month
G7 Pregnancy resulted from rape or incest or preg-nancy certified by physician as life threatening
G8 Monitored anesthesia care (MAC) for deep com-plex, complicated, or markedly invasive surgical procedure
G9 Monitored anesthesia care for patient who has his-tory of severe cardio-pulmonary condition
GA Waiver of liability statement on file
GB Claim being re-submitted for payment because it is no longer covered under a global payment demon-stration
GC This service has been performed in part by a resi-dent under the direction of a teaching physician
GE This service has been performed by a resident with-out the presence of a teaching physician under the primary care exception
GF Non-physician (e.g. nurse practitioner (np), certi-fied registered nurse anaesthetist (crna), certified registered nurse (crn), clinical nurse specialist (cns), physician assistant (pa)) services in a critical access hospital
HCPCS
Relative Values for Physicians — 577
▲
Revised code
●
New code
M
Deleted from HCPCS
R
RVSI Code
(I)
Interim Value
©2003 Ingenix, Inc.
HC
PC
S
UPD Code Description Units
H0001
Alcohol and/or drug assessment RNE
030
H0002
Behavioral health screening to determine eligibility for admission to treatment program
RNE
H0003
Alcohol and/or drug screening; laboratory analysis of specimens for presence of alcohol and/or drugs
RNE
030
H0004
Behavioral health counseling and therapy, per 15 minutes RNE
H0005
Alcohol and/or drug services; group counseling by a clinician RNE
H0006
Alcohol and/or drug services; case management RNE
H0007
Alcohol and/or drug services; crisis intervention (outpatient) RNE
H0008
Alcohol and/or drug services; sub-acute detoxification (hospital inpatient) RNE
H0009
Alcohol and/or drug services; acute detoxification (hospital inpatient) RNE
H0010
Alcohol and/or drug services; sub-acute detoxification (residential addiction program inpatient)
RNE
H0011
Alcohol and/or drug services; acute detoxification (residential addiction program inpatient)
RNE
H0012
Alcohol and/or drug services; sub-acute detoxification (residential addiction program outpatient)
RNE
H0013
Alcohol and/or drug services; acute detoxification (residential addiction program outpatient)
RNE
H0014
Alcohol and/or drug services; ambulatory detoxification RNE
H0015
Alcohol and/or drug services; intensive outpatient (treatment program that operates at least 3 hours/day and at least 3 days/week and is based on an individualized treatment plan), including assessment, counseling; crisis intervention, and activity therapies or education
RNE
H0016
Alcohol and/or drug services; medical/somatic (medical intervention in ambulatory setting)
RNE
030
H0017
Behavioral health; residential (hospital residential treatment program), without room and board, per diem
RNE
030
H0018
Behavioral health; short-term residential (non-hospital residential treatment program), without room and board, per diem
RNE
030
H0019
Behavioral health; long-term residential (non-medial, non-acute care in a residential treatment program where stay is typically longer than 30 days), without room and board, per diem
RNE
H0020
Alcohol and/or drug services; methadone administration and/or service (provision of the drug by a licensed program)
RNE
H0021
Alcohol and/or drug training service (for staff and personnel not employed by providers)
RNE
H0022
Alcohol and/or drug intervention service (planned facilitation) RNE
030
H0023
Behavioral health outreach service (planned approach to reach a targeted population)
RNE
578 — Relative Values for Physicians
HCPCS
▲
Revised code
●
New code
M
Deleted from HCPCS
R
RVSI Code
(I)
Interim Value
©2003 Ingenix, Inc.
HC
PC
S
030
H0024
Behavioral health prevention information dissemination service (one-way direct or non-direct contact with service audiences to affect knowledge and attitude)
RNE
030
H0025
Behavioral health prevention education service (delivery of services with target population to affect knowledge, attitude and/or behavior)
RNE
H0026
Alcohol and/or drug prevention process service, community-based (delivery of services to develop skills of impactors)
RNE
H0027
Alcohol and/or drug prevention environmental service (broad range of external activities geared toward modifying systems in order to mainstream prevention through policy and law)
RNE
H0028
Alcohol and/or drug prevention problem identification and referral service (e.g., student assistance and employee assistance programs), does not include assessment
RNE
H0029
Alcohol and/or drug prevention alternatives service (services for populations that exclude alcohol and other drug use e.g., alcohol free social events)
RNE
030
H0030
Behavioral health hotline service RNE
030
H0031
Mental health assessment, by non-physician RNE
030
H0032
Mental health service plan development by non-physician RNE
030
H0033
Oral medication administration, direct observation RNE
030
H0034
Medication training and support, per 15 minutes RNE
030
H0035
Mental health partial hospitalization, treatment, less than 24 hours RNE
030
H0036
Community psychiatric supportive treatment, face-to-face, per 15 minutes RNE
030
H0037
Community psychiatric supportive treatment program, per diem RNE
030
H0038
Self-help/peer services, per 15 minutes RNE
030
H0039
Assertive community treatment, face-to-face, per 15 minutes RNE
030
H0040
Assertive community treatment program, per diem RNE
030
H0041
Foster care, child, non-therapeutic, per diem RNE
030
H0042
Foster care, child, non-therapeutic, per month RNE
030
H0043
Supported housing, per diem RNE
030
H0044
Supported housing, per month RNE
030
H0045
Respite care services, not in the home, per diem RNE
030
H0046
Mental health services, not otherwise specified RNE
030
H0047
Alcohol and/or other drug abuse services, not otherwise specified RNE
030
H0048
Alcohol and/or other drug testing: collection and handling only, specimens other than blood
RNE
020
H1000
Prenatal care, at-risk assessment RNE
UPD Code Description Units
HCPCS
Relative Values for Physicians — 645
▲
Revised code
●
New code
M
Deleted from HCPCS
R
RVSI Code
(I)
Interim Value
©2003 Ingenix, Inc.
HC
PC
S
UPD Code Description Units
P9021
Red blood cells, each unit RNE
P9022
Red blood cells, washed, each unit RNE
P9023
Plasma, pooled multiple donor, solvent/detergent treated, frozen, each unit RNE
P9031
Platelets, leukocytes reduced, each unit RNE
P9032
Platelets, irradiated, each unit RNE
P9033
Platelets, leukocytes reduced, irradiated, each unit RNE
P9034
Platelets, pheresis, each unit RNE
P9035
Platelets, pheresis, leukocytes reduced, each unit RNE
P9036
Platelets, pheresis, irradiated, each unit RNE
P9037
Platelets, pheresis, leukocytes reduced, irradiated, each unit RNE
P9038
Red blood cells, irradiated, each unit RNE
P9039
Red blood cells, deglycerolized, each unit RNE
P9040
Red blood cells, leukocytes reduced, irradiated, each unit RNE
020
P9041
Infusion, albumin (human), 5%, 50 ml RNE
020
P9043
Infusion, plasma protein fraction (human), 5%, 50 ml RNE
P9044
Plasma, cryoprecipitate reduced, each unit RNE
020
P9045
Infusion, albumin (human), 5%, 250 ml RNE
020
P9046
Infusion, albumin (human), 25%, 20 ml RNE
020
P9047
Infusion, albumin (human), 25%, 50 ml RNE
020
P9048
Infusion, plasma protein fraction (human), 5%, 250 ml RNE
020
P9050
Granulocytes, pheresis, each unit RNE
040
●
P9051
Whole blood or red blood cells, leukocytes reduced, CMV-negative, each unit
RNE
040
●
P9052
Platelets, HLA-matched leukocytes reduced, apheresis/pheresis, each unit RNE
040
●
P9053
Platelets, pheresis, leukocytes reduced, CMV-negative, irradiated, each unit RNE
040
●
P9054
Whole blood or red blood cells, leukocytes reduced, frozen, deglycerol, washed, each unit
RNE
040
●
P9055
Platelets, leukocytes reduced, CMV-negative, apheresis/pheresis, each unit RNE
040
●
P9056
Whole blood, leukocytes reduced, irradiated, each unit RNE
040
●
P9057
Red blood cells, frozen/deglycerolized/washed, leukocytes reduced, irradiated, each unit
RNE
040
●
P9058
Red blood cells, leukocytes reduced, CMV-negative, irradiated, each unit RNE
040
●
P9059
Fresh frozen plasma between 8-24 hours of collection, each unit RNE
646 — Relative Values for Physicians
HCPCS
▲
Revised code
●
New code
M
Deleted from HCPCS
R
RVSI Code
(I)
Interim Value
©2003 Ingenix, Inc.
HC
PC
S
040
●
P9060
Fresh frozen plasma, donor retested, each unit RNE
P9603
Travel allowance one way in connection with medically necessary laboratory specimen collection drawn from homebound or nursing home bound patient; prorated miles actually travelled
RNE
P9604
Travel allowance one way in connection with medically necessary laboratory specimen collection drawn from homebound or nursing home bound patient; prorated trip charge
RNE
040
P9612
Catheterization for collection of specimen, single patient, all places of service
1.0 (I)
040
P9615
Catheterization for collection of specimen(s) (multiple patients) 1.0 (I)
Q0035 0026TC
Cardiokymography 5.92.53.4
Q0081
Infusion therapy, using other than chemotherapeutic drugs, per visit RNE
Q0083
Chemotherapy administration by other than infusion technique only (e.g., subcutaneous, intramuscular, push), per visit
RNE
Q0084
Chemotherapy administration by infusion technique only, per visit RNE
Q0085
Chemotherapy administration by both infusion technique and other technique(s) (e.g., subcutaneous, intramuscular, push), per visit
RNE
040
M
Q0086
Physical therapy evaluation/treatment, per visit
This code has been deleted.
RNE
Q0091
Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory
2.8
Q0092
Set-up portable x-ray equipment 2.6
040
Q0111
Wet mounts, including preparations of vaginal, cervical or skin specimens 1.5 (I)
040
Q0112
All potassium hydroxide (KOH) preparations 1.5 (I)
040
Q0113
Pinworm examination 2.0 (I)
040
Q0114
Fern test 2.7 (I)
040
Q0115
Post-coital direct, qualitative examinations of vaginal or cervical mucous 3.7 (I)
Q0136
Injection, epoetin alpha, (for non ESRD use), per 1,000 units RNE
040
●
Q0137
Injection, darbepoetin alfa, 1 mcg (non-ESRD use) RNE
030
Q0144
Azithromycin dihydrate, oral, capsules/powder, 1 gram RNE
Q0163
Diphenhydramine HCl, 50 mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at time of chemotherapy treatment not to exceed a 48-hour dosage regimen
RNE
Q0164
Prochlorperazine maleate, 5 mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48-hour dosage regimen
RNE
UPD Code Description Units
©2003 Ingenix, Inc. CPT only ©2003 American Medical Association. All Rights Reserved.
R Code Crosswalk
R C
ode
Cro
ssw
alk
The editors have decided to include some descriptions and unit values not found in the standard coding nomenclature in order to assist users in addressing reimbursement issues that the standard nomenclature may not cover.
When a procedure or service provided is not adequately identified, use of an unlisted procedure code for the related anatomical area is usually appropriate. Most codes of this nature have 99 for the last two digits. The editors have decided to list under several unlisted service/procedure codes some R code descriptions and unit values that might help the user with reimbursement. These codes are clearly identified by an "Rx" in the Type column.
The editors will continue to expand the coding system to further simplify the reimbursement process. Such codes will have a separate designation. Payers and physicians may use either the separate code or the CPT code indicated including the description and value listed in
Relative Values for Physicians
. Many new or uncommon procedures may require an operative report based upon the individual case, physician and/or payer. (Note: Payers and providers may or may not contractually require specific use of nomenclature. Communicate your questions to the individual payer or physician, as appropriate.) A complete R code crosswalk appears below.
Code
Modif
ier CPTReferral
UPD Unit AnesGlobal Period
Long Descriptions
328AA 32999
144.0 (I) 15 YYY Lung Transplant, double (bilateral sequential or en bloc); with bronchoplasty
471AA 47399
152.0 (I) 30 YYY Liver allotransplantation; with aorto-hepatic arterial conduit
471AB 47399
156.0 (I) 30 YYY Liver allotransplantation; with port-hepatic venous conduit
471AC 47399
148.0 (I) 30 YYY Liver allotransplantation; with choledochojejunostomy
471AD 47399
152.0 (I) 30 YYY Liver allotransplantation; with take down of portocaval shunt
471AE 47399
148.0 (I) 30 YYY Liver allotransplantation; with take down splenorenal shunt, proximal
471AF 47399
148.0 (I) 30 YYY Liver allotransplantation; with take down splenorenal shunt, distal
471AG 47399
148.0 (I) 30 YYY Liver allotransplantation; with mesocaval shunt
471AH 47399
150.0 (I) 30 YYY Liver allotransplantation; with splenectomy for hyperslenism
©2003 Ingenix, Inc. CPT only ©2003 American Medical Association. All Rights Reserved.
Procedural Index
Ind
ex
This index is intended to direct the user to a general area. Please refer to your CPT index for a more specific procedural description and/or code reference.
Abdomen
Excision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22900Other Procedures . . . . . . . . . . . . . . . . . . . . . . . . 22999
Abdomen, Peritoneum, and Omentum
Excision . . . . . . . . . . . . . . . . . . . . . . . . . 49180-49255Hernioplasty, Herniorrhaphy, Herniotomy
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49491-49611Incision. . . . . . . . . . . . . . . . . . . . . . . . . . 49000-49085Introduction and Revision . . . . . . . . . . . 49400-49429Laparoscopy - Hernia Repair . . . . . . . . . 49650-49659Laparoscopy - Other. . . . . . . . . . . . . . . . 49320-49329Other Procedures . . . . . . . . . . . . . . . . . . 49904-49999Suture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49900
Accessory Sinuses
Endoscopy . . . . . . . . . . . . . . . . . . . . . . . 31231-31294Excision . . . . . . . . . . . . . . . . . . . . . . . . . 31200-31230Incision. . . . . . . . . . . . . . . . . . . . . . . . . . 31000-31090Other Procedures . . . . . . . . . . . . . . . . . . . . . . . . 31299
Allergy and Clinical Immunology
Allergen Immunotherapy . . . . . . . . . . . . 95115-95199Allergy Testing . . . . . . . . . . . . . . . . . . . . 95004-95078
Anatomic Pathology
. . . . . . . . . . . . . . . . . . 88000-88099
Anesthesia
Abdomen Lower. . . . . . . . . . . . . . . . . . . . . . . . 00800-00882Upper. . . . . . . . . . . . . . . . . . . . . . . . 00700-00797
ArmForearm, Wrist, and Hand. . . . . . . . 01810-01860Upper Arm and Elbow. . . . . . . . . . . 01710-01782
Burn Excisions or Debridement . . . . . . . 01951-01953Head . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00100-00222Intrathoracic. . . . . . . . . . . . . . . . . . . . . . 00500-00580Leg
Knee and Popliteal Area . . . . . . . . . 01320-01444Lower Leg Below Knee . . . . . . . . . . 01462-01522Upper Leg Except Knee. . . . . . . . . . 01200-01274
Neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00300-00352
Obstetric . . . . . . . . . . . . . . . . . . . . . . . . . 01958-01969Other Anesthesia Procedures . . . . . . . . . 01990-01999
Pelvis . . . . . . . . . . . . . . . . . . . . . . . . 01112-01190Perineum . . . . . . . . . . . . . . . . . . . . . 00902-00952Radiological Procedures . . . . . . . . . . 01905-01933Shoulder and Axilla . . . . . . . . . . . . . 01610-01682Spine and Spinal Cord . . . . . . . . . . . 00600-00797Thorax . . . . . . . . . . . . . . . . . . . . . . . 00400-00474
Anus
Destruction . . . . . . . . . . . . . . . . . . . . . . . 46900-46942Endoscopy . . . . . . . . . . . . . . . . . . . . . . . . 46600-46615Excision. . . . . . . . . . . . . . . . . . . . . . . . . . 46200-46320Incision . . . . . . . . . . . . . . . . . . . . . . . . . . 46020-46083Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . 46500Other Procedures. . . . . . . . . . . . . . . . . . . . . . . . 46999Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . 46700-46762Suture . . . . . . . . . . . . . . . . . . . . . . . . . . . 46945-46946
Appendix
Excision. . . . . . . . . . . . . . . . . . . . . . . . . . 44950-44960Incision . . . . . . . . . . . . . . . . . . . . . . . . . . 44900-44901Laparoscopy . . . . . . . . . . . . . . . . . . . . . . 44970-44979
Application of Casts and Strapping
Body and Upper Extremity . . . . . . . . . . . 29000-29280Lower Extremity . . . . . . . . . . . . . . . . . . . 29305-29590Other Procedures. . . . . . . . . . . . . . . . . . . . . . . . 29799Removal or Repair . . . . . . . . . . . . . . . . . . 29700-29750
Arteries and Veins
Adjuvant Techniques. . . . . . . . . . . . . . . . 35685-35686Aneurysm or Excision Repair . . . . . . . . . 35001-35162Angioscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35400Arterial. . . . . . . . . . . . . . . . . . . . . . . . . . . 36600-36660Arterial Embolectomy or Thrombectomy34001-34203Arterial Transposition . . . . . . . . . . . . . . . 35691-35697Bypass Graft, In-Situ Vein . . . . . . . . . . . . 35582-35587Bypass Graft, Vein . . . . . . . . . . . . . . . . . . 35500-35572Bypass Graft, With Other Than Vein. . . . 35600-35671Central Venous Access . . . . . . . . . . . . . . 36555-36597Composite Graft . . . . . . . . . . . . . . . . . . . 35681-35683Endoscopy . . . . . . . . . . . . . . . . . . . . . . . . 37500-37501Endovascular Repair Abdominal Aortic Aneurysm . .
34800-34834
690 — Relative Values for Physicians
Procedural Index
CPT only ©2003 American Medical Association. All Rights Reserved. ©2003 Ingenix, Inc.
Ind
ex
Endovascular Repair Iliac Aneurysm . . . . . . . . . 34900Exploration. . . . . . . . . . . . . . . . . . . . . . . 35700-35907In-Situ Vein Bypass. . . . . . . . . . . . . . . . . 35582-35587Intervascular Cannulization or Shunt . . 36800-36870Intravascular Ultrasound . . . . . . . . . . . . 37250-37251Intraosseous . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36680Ligation and Other Procedures . . . . . . . 37565-37799Portal Decompression . . . . . . . . . . . . . . 37140-37183Repair Arteriovenous Fistula . . . . . . . . . 35180-35190Repair Other Blood Vessel . . . . . . . . . . . 35201-35286Thromboendarterectomy . . . . . . . . . . . . 35301-35390Transcatheter . . . . . . . . . . . . . . . . . . . . . 37195-37209Transcatheter Therapy and Biopsy . . . . . . . . . . . 37200Transluminal Angioplasty . . . . . . . . . . . 35450-35476Transluminal Atherectomy. . . . . . . . . . . 35480-35495Vascular Injections . . . . . . . . . . . . . . . . . 36000-36299Venipuncture . . . . . . . . . . . . . . . . . . . . . 36400-36550Venous Reconstruction . . . . . . . . . . . . . 34501-34530Venous Thrombectomy . . . . . . . . . . . . . 34401-34490
Arthroscopy
. . . . . . . . . . . . . . . . . . . . . . . . . 29800-29999
Auditory System
External Ear . . . . . . . . . . . . . . . . . . . . . . 69000-69399Inner Ear . . . . . . . . . . . . . . . . . . . . . . . . 69801-69949Middle Ear . . . . . . . . . . . . . . . . . . . . . . . 69400-69799Other Procedures . . . . . . . . . . . . . . . . . . . . . . . . 69979Temporal Bone, Middle Fossa
Approach . . . . . . . . . . . . . . . . . . . . . 69950-69970
Back and Flank
Excision . . . . . . . . . . . . . . . . . . . . . . . . . 21920-21935
Biliary Tract
Endoscopy . . . . . . . . . . . . . . . . . . . . . . . 47550-47556Excision . . . . . . . . . . . . . . . . . . . . . . . . . 47600-47716Incision. . . . . . . . . . . . . . . . . . . . . . . . . . 47400-47490Introduction . . . . . . . . . . . . . . . . . . . . . . 47500-47530Laparoscopy . . . . . . . . . . . . . . . . . . . . . . 47560-47579Other Procedures . . . . . . . . . . . . . . . . . . . . . . . . 47999Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . 47720-47900
Biofeedback
. . . . . . . . . . . . . . . . . . . . . . . . . 90901-90911
Bladder
Endoscopy . . . . . . . . . . . . . . . . . . . . . . . 52000-52010Excision . . . . . . . . . . . . . . . . . . . . . . . . . . 5150051597Incision. . . . . . . . . . . . . . . . . . . . . . . . . . . 5100051080Introduction . . . . . . . . . . . . . . . . . . . . . . . 5160051720Laparoscopy . . . . . . . . . . . . . . . . . . . . . . . 5199051992Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5180051980Ureter and Pelvis Surgery . . . . . . . . . . . . 52320-52355Urethra and Bladder Surgery . . . . . . . . . 52204-52318Urodynamics . . . . . . . . . . . . . . . . . . . . . . 5172551798Vesical, Neck, Prostate Surgery . . . . . . . 52400-52700
Bone Marrow Transplantation
. . . . . . . . . . 38204-38242
Breast
Excision . . . . . . . . . . . . . . . . . . . . . . . . . 19100-19272
Incision . . . . . . . . . . . . . . . . . . . . . . . . . . 19000-19030Introduction . . . . . . . . . . . . . . . . . . . . . . 19290-19295Other Procedures . . . . . . . . . . . . . . . . . . . . . . . 19499Repair, Revision or Reconstruction. . . . . 19316-19396
Cardiovascular
Cardiac Catheterization. . . . . . . . . . . . . . 93501-93572Cardiography. . . . . . . . . . . . . . . . . . . . . . 93000-93278Echocardiography . . . . . . . . . . . . . . . . . . 93303-93350Intracardiac ElectrophysiologicalProcedures. . . . . . . . . . . . . . . . . . . . . . . . 93600-93662Other Procedures . . . . . . . . . . . . . . . . . . 93797-93799Other Vascular Studies . . . . . . . . . . . . . . 93701-93790Peripheral Arterial Disease
Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . 93668Repair of Septal Defect . . . . . . . . . . . . . . 93580-93581Therapeutic Services . . . . . . . . . . . . . . . . 92950-92998
Care Plan Oversight Services
. . . . . . . . . . . . 99374-99380
Case Management Services
Team Conferences . . . . . . . . . . . . . . . . . . 99361-99362Telephone Calls . . . . . . . . . . . . . . . . . . . . 99371-99373
Central Nervous System Assessments/Tests
96100-96117
Cervix Uteri
Endoscopy. . . . . . . . . . . . . . . . . . . . . . . . 57452-57461Excision. . . . . . . . . . . . . . . . . . . . . . . . . . 57500-57556Manipulation. . . . . . . . . . . . . . . . . . . . . . 57800-57820Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . 57700-57720
Chemistry
. . . . . . . . . . . . . . . . . . . . . . . . . . . 82000-84999
Chemotherapy Administration
. . . . . . . . . .96400–96549
Chemotherapy Administration
. . . . . . . . . . . 96400-96549
Chiropractic Manipulative Treatment
. . . . . 98940-98943
Clinical Treatment Management
Clinical Brachytherapy . . . . . . . . . . . . . . 77750-77799Clinical Intracavitary Hyperthermia . . . . . . . . . 77620Hyperthermia . . . . . . . . . . . . . . . . . . . . . 77600-77615
Consultations
Confirmatory Consultations . . . . . . . . . . 99271-99275Follow-Up Inpatient Consultations . . . . 99261-99263Initial Inpatient Consultations . . . . . . . . 99251-99255Office or Other Outpatient
Consultations . . . . . . . . . . . . . . . . . . 99241-99245
Consultations (Clinical Pathology)
. . . . . . . 80500-80502
Corpus Uteri
Excision. . . . . . . . . . . . . . . . . . . . . . . . . . 58100-58294Introduction . . . . . . . . . . . . . . . . . . . . . . 58300-58353Laparoscopy and Hysteroscopy. . . . . . . . 58545-58579Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . 58400-58540