Provider Update - April 1998 Print

Provider Update

Volume 15, Issue 2

April 1998

The New Secretary for the Department of Health and Hospitals

David Hood, the new Secretary for the Department of Health and Hospitals, has set forth a vision for the department�s upcoming year. Hood has outlined five key principles that will serve as a guide for his department�s efforts.

"We remain committed to several fundamental principles that have served us well for the past two years," Hood said. "These include running an honest and efficient department, doing what is clinically right, providing equitable benefits for the people we serve, operating within budget constraints, and being open and responsive to the citizens of the state."

"By adhering to these principles in everything we do, we continue progress toward building a public health system in Louisiana that not only serves the needs of our citizens but also one that will be emulated by other states," he said.

A key to this philosophy is to provide quality care in a cost-effective manner for all the people of the state. Hood also stressed his commitment to finding innovative ways to do things.

Hood is a 21-year veteran of state government. He started his career in state government in 1977 after serving six years as an officer in the U.S. Air Force. He first worked for the Department of Health and Human Resources for three years as the director of capital expenditures review. He then worked at the Legislative Fiscal Office for fifteen years prior to being appointed as undersecretary of DHH in 1996. 

Hood earned both his undergraduate and Master�s degrees from Louisiana State University in Baton Rouge. He received his undergraduate degree in journalism and his Master�s degree in Latin American studies/Political Science.

Global Surgery Policy

As you know, Louisiana Medicaid Program implemented a Global Surgery Policy effective July 10, 1996. The system programming that was implemented at the time this policy became effective prevented some reimbursements for concurrent care for recipients under the age of 21 during the Global Surgery Periods. System changes are being implemented to prevent the denial of concurrent care during the Global Surgery Periods for recipients under the age of 21.

Claim denials with error edits 690 and 691 for recipients to the age of 21 from providers other than the surgeon will be recycled within the near future.

Placement of Deleted 1998 HCPCS Codes in Non-Pay Status

The CPT codes which were deleted in the 1998 issuance of the Physician�s Current Procedural Terminology will be placed in non-pay status effective with date of service April 15, 1998. Please program your billing systems immediately to bill current codes if you have not already done so.

MEVS Vendors Approved

As the Plastic Identification Card and Medicaid Eligibility Verification System (MEVS) implementation continues to unfold, three telecommunications vendors have been approved to participate in this project. Providers are cautioned to be certain they are contracting with an approved vendor.

Vendor                   Medifax
Contact:                   Randy Bertrand, Regional Marketing Manager
Phone:                     1-800-444-4336, Ext. 4545
Email:                       marketing@medifax.com

Vendor:                  Envoy
Contact:                   Envoy Target Marketing Group
Phone:                     1-800-366-5716
Web Site:                 www.envoy-neic.com

Vendor:                  HealthNet Data Link
Contact:                   Gary Stafford
Phone:                      1-800-486-7352
Email:                       sales@healthdata.net

These vendors are marketing statewide and are available to call on the Medicaid provider community to discuss options for accessing MEVS. Other vendors may be approved as the project expands. Providers will be notified of any additions to this list of vendors through Remittance Advice messages and Provider Update articles. Provider awareness seminars are being offered in each DHH region as the regions implement Plastic Identification Cards. Please watch for invitation notices for these seminars in your region. Also, please remember that although plastic ID cards are being implemented regionally, MEVS was activated statewide effective April 1, 1998.Providers interested in accessing MEVS even prior to the implementation of plastic cards for the region should contact the vendors listed above to discuss available options and contracts.

Funding of CPT Code 59015

The Bureau of Health Services Financing is pleased to announce the funding of CPT code 59015 - Chorionic Villus Sampling, Any Method - effective for dates of service April 1, 1998. This procedure is restricted to physicians enrolled with a specialty of Maternal and Fetal Medicine (perinatologists). The fee for code 59015 is $113.85.�

To All DME Providers

Please note that the reimbursement rate for CPAP codes E0601 and K0193 have been adjusted from 80% to 100% of the Medicare fee allowables. This change is being made in an effort to ensure that the machines are available on a widespread, statewide basis for Medicaid recipients.

Notice to Pharmacy Providers

When a resident of a skilled nursing facility is in Medicare payment status, payment for prescription medications is the responsibility of the facility, as prescription services are included in the per diem paid by Medicare. A skilled nursing facility may contract with the pharmacy of their choice in order to obtain medications for the Medicare residents. If the resident�s payment status converts back to Medicaid, at that point the resident may exercise his right to utilize the pharmacy of his choice.When Medicare is the primary and Medicaid is the secondary payor for a resident, Medicare regulations govern the reimbursement.

LADUR Education Article

Pressure Ulcer Treatment in the Elderly

Condensed and Adapted By:  Tracy S. Hunter, Ph.D., R.Ph., 
Director, Division of Clinical Pharmacy Practice, Northeast Louisiana University

ISSUES . . . 
- Pressure ulcers are a serious condition in our elderly population, and can be difficult to treat. 
- The recommended treatment program for pressure ulcers should focus on education and quality improvement, as well as assessment, ulcer care, managing bacterial infection, and operative repair.

Pressure ulcers or sores are a serious condition in elderly patients and one that can be difficult to treat. However, early and effective treatment can lead to a speedy recovery and minimize the pain, disfigurement, and prolonged hospitalization often associated with the problem.

A pressure ulcer is any lesion caused by unrelieved pressure from a splint or other appliance or from the body itself when immobile in bed for extended periods of time. Decubitus ulcers (commonly called bedsores) are one type of pressure ulcer that occurs in bedridden patients. However, pressure ulcers can occur at any site, such as on the buttocks of patients confined to wheelchairs. If a patient is incontinent, the likelihood of developing an ulcer increases. The underlying tissue is damaged by reduced blood supply from pressure, shearing forces, friction and moisture. The most common sites for damage are usually over bony prominence such as sacrum, heels, and trochanter. 

Pressure ulcers can be put in the following grades or class based on degree of tissue damage. This classification is not a description of healing steps. 

Stage I: 
The nonblanchable erythema of intact skin, the heralding lesion of skin ulceration. In individuals with darker skin, discoloration of the skin, warmth, edema, induration, or hardness may be indicators. Stage I ulcers may be superficial, or they may be a sign of deeper tissue damage. Ulcers in this stage are not always reliably assessed, especially in patients with darkly pigmented skin.

Stage II: 
Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and appears as an abrasion, blister or shallow crater.

Stage III: 
Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer appears as a deep crater with or without undermining adjacent tissue.

Stage IV: 
Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule). Undermining and sinus tracts also may be associated with Stage IV pressure ulcers.

Extra vigilance is needed in assessing stages under certain circumstances. For example, when eschar is present, a pressure ulcer cannot be accurately accessed until the scab is removed. It may also be difficult to assess pressure ulcers on patients wearing casts, orthopedic devices, or support stockings. 

Assessment 

Assessment involves the entire individual, not just the ulcer. Initially, ulcers should be assessed for location, stage, size (based on length, width, and depth), sinus tracts, undermining, tunneling, exudate, necrotic tissue, and the presence or absence of granulation tissue and epithelialization. The patient�s progress should be monitored at least weekly and the treatment plan reevaluated as soon as evidence of deterioration in the wound or condition of the patient is noted. A clean pressure ulcer with adequate innervation and blood supply should show evidence of healing within 2 to 4 weeks. If no progress is observed, again evaluate the patient�s adherence to the plan, make necessary modifications, or reevaluate the plan. It is important to screen for nutritional deficiencies in the initial assessment in to ensure that the diet of the individual contains adequate nutrients to support healing. An abbreviated nutritional assessment should be performed at least every 3 months for individuals at risk for malnutrition such as those unable to take food by mouth or who experience an involuntary weight change. Increased dietary intake or vitamin and mineral supplementation should be encouraged for elderly patients. When dietary intake continues to be inadequate, impractical or impossible, nutritional support such as tube feeding may be used to bring the patient into positive nitrogen balance (approximately 30 to 35 calories/kg/day and 1.25 to 1.50 grams of protein/kg/day). As many as 2.00 grams of protein/kg/day may be needed. 

One should assess for pain related to the ulcer or its treatment in order to provide appropriate analgesia. Even though a patient may not express or respond to pain, caregivers should not assume that it does not exist. Pain can be managed by elimination or controlling the source of discomfort by covering wounds, adjusting support surfaces, or repositioning. Because pain may be especially acute during dressing changes and debridement, the caregiver should try to prevent such discomfort or take steps to relieve it. 

Methods of Care for Pressure Ulcers 

Treatment of the pressure ulcer involves debridement, wound cleaning, the application of dressings and possibly adjunctive therapy. In some cases, operative repair will be required.

Debridement
Since moist, devitalized tissue supports the growth of pathological organisms, the removal of such tissue involving the use of scalpel, scissors, or other sharp instruments might favorably improve the healing environment of a wound. Sharp, mechanical, enzymatic, and/or autolytic debridement techniques may be used when there is no urgent clinical need for drainage or removal of devitalized tissue. 

Sharp Debridement is the most rapid form of debridement and may be the most appropriate technique for removing areas of thick, adherent eshar and devitalized tissue in extensive ulcers or when there is an urgent need such as advancing cellulitis or sepsis. After sharp debridement, clean, dry dressings are used for a period of 8 to 24 hours, followed by moist dressing afterward.

Small wounds are sometimes debrided at bedside while extensive wounds are usually debrided in an operating room. When debriding extensive Stage IV ulcers in the operating room the surgeon should consider a bone biopsy in order to detect osteomyelitis.

Mechanical Debridement techniques include wet-to-dry dressings, hydrotherapy, wound irrigation, and dextranomers. 

Enzymatic Debridement is accomplished by applying topical debridement agents to devitalized tissue on the wound surface. Clean dry dressings may also be used in conjunction with mechanical and enzymatic debridement techniques.

Autolytic Debridement involves the use of synthetic dressings to cover a wound and allow devitalized tissue to self-digest from enzymes normally present in wound fluids. This technique should not be used if the wound is infected. 

Heel ulcers with dry eschar need not be debrided if they do not have edema, erythema, fluctuance, or drainage. Assess these wounds daily to monitor for complications that would require debridement. 

Wound Cleaning
Removal of all necrotic tissue, exudate, and metabolic wastes from the wound accelerates healing and decreases the potential for infection of pressure ulcers. The benefits of cleansing a wound with a cleansing solution and the mechanical means of delivering that solution should be weighted against the potential trauma to the wound bed as a result of cleansing. Minimal force when cleansing with gauze, sponge, or cloth decreases chemical or mechanical trauma during routine cleaning at dressing change. 

Normal saline should be used for cleansing most ulcers. Wounds should not be cleaned with skin cleanser or antiseptic agents such as povidone iodine, iodophor, sodium hypochlorite solution (Dakin�s Solution), hydrogen peroxide, or acetic acid because they are cytotoxic. Dilution is required to maintain the violability and phagocytic function of white blood cells exposed to these agents.

Proper irrigation pressure � 4 to 15 pounds per square inch (psi) � enhances cleansing without causing trauma to the wound bed. Pressure below 4 psi may not cleanse the wound effectively, and pressures greater than 15 psi may cause trauma and force bacteria into the wound tissue. Irrigation devices that deliver 8 psi of pressure are more effective in removing bacteria and preventing infection than a bulb syringe. Ulcers that contain thick exudate, slough or necrotic tissue may be cleansed by whirlpool treatment, noting that trauma can result if the wound is positioned too close to the high-pressure water jets. Whirlpool treatment should discontinue when the ulcer is clean.

Dressings
Pressure ulcers need dressings. To maintain the physiologic integrity of the wound, the ideal dressing should protect the wound, be biocompatible, and provide hydration. The type of dressing is determined by the condition of the ulcer bed and the desired dressing function. The goal is to keep the ulcer tissue continuously moist and the surrounding intact skin dry. Wet-to-dry dressings should be used only for debridement and are not the same as continuously moist saline dressing which keep the ulcer bed moist. 

Studies show no differences in healing outcomes of different types of moist wound dressings. Select a dressing that keeps the skin surrounding the ulcer intact and dry while keeping the ulcer bed moist. Excessive exudate may delay wound healing and soften surrounding tissue but the dressing should not desiccate the ulcer bed. When caregiver time is a consideration, film and hydrocolloid dressing requires less time than continuously moist saline gauze dressing. 

It is important to keep dressings intact. Dressings applied near the anus are difficult to keep intact and should be monitored. �Picture framing� by taping the edges of the dressing may reduce this problem. Clinicians should consider eliminating wound dead space by loosely filling all cavities with dressing material in order to prevent abscess formation. Over packing may increase pressure causing additional tissue damage, and should be avoided.

At this time, electrotherapy is the only adjunctive therapy with sufficient supporting evidence to warrant recommendation by the U.S. Department of Health and Human Services, Agency for Health Care, Policy and Research Panel. The recommended course of treatment with electrical stimulation is for Stage III and IV pressure ulcers that have proven unresponsive to conventional therapy. Electrical stimulation may also be useful for recalcitrant Stage II ulcers. Clinicians considering electrical stimulation therapy should ensure that they have proper equipment and trained personnel who follow protocols shown to be effective and safe in properly conducted clinical trials.

Managing Bacterial Colonization and Infection
Colonized bacteria are invariably found in Stage II, III and IV pressure ulcers. In most cases, effective wound cleansing and debridement prevents colonization from proceeding to clinical infection. Since all pressure ulcers are colonized, and swab cultures detect only the surface colonization and may not identify the organisms causing the tissue infection, do not use swab cultures to diagnose wound infection. If purulence or foul odor is present, more frequent cleansing and debridement may be needed. 

Consider a two-week trial of topical antibiotics for clean ulcers that are not healing or continuing to produce exudate after 2 to 4 weeks of optimal care. Monitor for allergic sensitization and other adverse reactions. Choose antibiotics known to be effective against gram-negative, gram positive and anaerobic organisms (e.g., silver sulfadiazine and triple antibiotic). 

Healing may be impaired if bacterial levels exceed 105 organisms per gram of tissue or if the patient has osteomyelitis. The clinician should perform a quantitative bacterial culture of the soft tissue and evaluate the patient for osteomyelitis when the ulcer does not respond to topical antibiotic therapy. When cultures are required to diagnose a soft tissue infection, the Center for Disease Control and Prevention Panel recommends obtaining fluid through needle aspiration or through ulcer biopsy. Examination of a bone biopsy specimen is the standard for diagnosing osteomyelitis. However, this invasive diagnostic technique is not always required. A combination of three positive tests (white blood cell count, erythrocyte sedimentation rate, and plain x-ray) can predict and can detect osteomyelitis almost 70% of the time. 

Systemic antibiotics are not required for pressure ulcers with only signs of local infection. Institute appropriate systemic antibiotic therapy for patients with bacteremia, sepsis, advancing cellulitis, or osteomyelitis. Urgent medical attention is required for patients who develop clinical signs of sepsis (unexplained fever, tachycardia, hypotension, deterioration in mental status). Do not use topical antiseptics (e.g., providone, iodine, iodophor, sodium hypochlorite, Dakin�s Solution, hydrogen peroxide, or acetic acid) to reduce bacteria in wound tissue. It is appropriate to rule out other causes of the symptoms, obtain blood cultures, and treat with antibiotics that will combat the organisms.

Infection Control 
In order to protect against cross contamination of microorganisms, follow body substance isolation precautions (BSI) or an equivalent system. Use clean gloves for each patient. When treating multiple ulcers on the same patient, attend to the most contaminated ulcer last (e.g. in the perianal region). Remove gloves and wash hands between patients. Use sterile (not just clean) instruments to debride ulcers. Following debridement, monitor the patient�s temperature and be alert to signs of bacteremia or sepsis, such as unexplained fever, tachycardia, hypotension, or deterioration in mental status. 

Complying with institutional infection-control guidelines, use clean dressings rather than sterile ones to treat pressure ulcers in health care facilities. Clean dressings may also be used in the home setting. Disposal of used dressing should be in a manner consistent with local regulations.

Establish and rigorously adhere to procedures such as strict adherence to BSI and good handwashing between patients in order to keep dressings clean and prevent cross-contamination. Do not store dressing supplies in multi-patient treatment carts taken to bedside. Individual patients should have their own dressing supplies that are protected from inadvertent environmental contamination by water damage, dust accumulation, or contact contaminants. Measures such as keeping dressing in the original package, storing in a clean dry place, and discarding the entire package if any of the dressings become wet, dirty, or contaminated, helps ensure that they remain clean. 

Caregivers must wash their hands before contact with the supply of clean dressings or dressing supplies. Remove from containers only the number of dressings necessary for each dressing change prior to treatment. Once the hands of the caregiver are soiled with wound secretions, they should not come in contact with the remaining dressings and other supplies until the gloves are removed and hands are washed. Dressings, instruments, and solutions should be obtained from suppliers who can ensure that shipment and handling will not expose the products to damage or contamination.

Operative Repair
When clean Stage III or Stage IV pressure ulcers do not respond to treatment, surgical repair may be considered. Candidates should be medically stable, adequately nourished, and able to tolerate operative blood loss and postoperative immobility. Additional considerations include quality of life, patient preferences, treatment goals, risk of recurrence, and expected rehabilitative outcomes. Preoperative patient counseling should include information about the procedures and the anticipated benefits and potential risks of each procedure. Correcting and controlling factors such as smoking, spasticity, levels of bacterial colonization, incontinence, and urinary tract infection that might impair healing should be addressed preoperatively. To minimize recurrence of the pressure ulcer, base the choice of operative technique on the individual patient�s needs and overall goals as well as on the specific site and extent of the ulcer. The surgeon should use the most effective and least traumatic method to repair the defect. Direct closure, skin grafting, skin flaps, musculocutaneous flaps, and free flaps methods may be used to close wounds. Prophylactic ischiectomy is not recommended because it often results in perineal ulcers and urethral fistulas, which are more threatening problems than ischial ulcers.Continued assessment is necessary to prevent recurrence of pressure ulcers. Caregivers should provide education and encourage adherence to measures for pressure reduction, daily skin examination and intermittent relief techniques. During postoperative care, minimize pressure to the operative site by use of an air-fluidized bed, a low-air-loss bed, or a Stryker frame for a minimum of 2 weeks. Assess postoperative viability of the surgical site as indicated. Increase periods of time the patient spends sitting or lying on the flap to increase its tolerance to pressure. To determine the degree of tolerance, monitor the flap for pallor, redness, or both that do not resolve after 10 minutes of pressure relief.

Conclusion
Effective pressure ulcer treatment is best achieved thorough a team approach involving patients, their families or caregivers, and health care providers. The clinician should discuss pressure ulcer treatment options with patients and their families, develop an effective plan of care that is consistent with patients� goals and wishes and encourage patients to be active participants in their care. The recommended treatment program should focus on education and quality improvement as well as assessment, ulcer care, managing bacterial infection, and operative repair.

References

Bergstron N, Bennett MA, Carlson CE, et al. �Pressure Ulcer Treatment. Clinical Practice Guideline.� Quick Reference Guide for Clinicians, No 15. Rockville, MD: U.S. Department of Health and Human Service, Agency for Health Care Policy and Research. AHCPR Pub. No. 95-0653. Dec. 1994. 

Notice to All Dental Providers

This is a reminder that since August 1, 1997, Medically Needy recipients (adults and children) are no longer eligible for any type of dental services billed on the ADA claim form. These medically needy recipients can be easily recognized by the TYPE CASE 20, 21, or 25 printed on the Medicaid eligibility paper ID cards. You will not be reimbursed for any dental services provided to these recipients after July 31, 1997. As always, adult recipients whose Medicaid number includes a �1� and a �7� in the third and fourth positions are not eligible for adult denture services.

Additionally, you are reminded that upon issuance of the plastic ID cards, updates will be made on a daily basis rather than a weekly basis. We strongly recommend that you check eligibility at least monthly through the REVS or MEVS eligibility systems. For additional information on the new plastic ID cards or the MEVS and REVS eligibility systems, please contact Provider Relations. 

Notice to Anesthesiologists and CRNAs

Recently a revised page 10-3 of the Chapter 15, Professional Services Manual was forwarded to you (reissued November 1, 1997). This manual page contained a list of anesthesia codes that are reimbursed on a flat fee basis. Code 36510 (catheterization of umbilical vein for diagnosis or therapy, newborn) was included on the list in error. Code 36510 is not an anesthesia code that is reimbursed as a flat fee. We are sorry for any inconvenience this may have caused you.

A revised manual page will be issued shortly.

Codes Payable to Certified Nurse Midwives

Effective for dates of service on or after March 1, 1998, additional codes have been added to the list of codes reimbursable to Certified Nurse Midwives. The following is a list of all codes reimbursable to Certified Nurse Midwives, and includes the codes payable prior to 3-1-98 as well as those made payable effective 3-1-98.

The codes that were made payable effective March 1, 1998 are indicated with an asterisk (*).

As a reminder to CNMs, please remember that lab codes (8000 range) are to be billed by the provider of the service (those who actually perform the test). If the lab sends a bill to the CNM rather than to Medicaid for payment, the CNM should refuse to pay and instruct the lab to bill Medicaid. For this reason, CNMs are encouraged to select labs which are enrolled as Medicaid providers. CNMs may not bill codes in the 8000 range for the ordering of lab tests.

*Codes added 3/1/98

Outpatient Procedures That Require Prior Approval When Performed As Inpatient 
On The 1st Or 2nd Day Of Hospitalization

ICD-9-cm proc                 Desc

0406 - OTHER CRANIAL OR PERIPHERAL GANGLIONECTO
0407 - OTHER EXCISION OR AVULSION OF CRANIAL AN
043 - SUTURE OF CRANIAL AND PERIPHERAL NERVES
0443 - RELEASE OF CARPAL TUNNEL
0449 - OTHER PERIPHERAL NERVE OR GANGION DECOM
046 - TRANSPOSITION OF CRANIAL AND PERIPHERAL
802 - SEVERING OF BLEPHARORRHAPHY0809 - OTHER INCISION OF EYELID
0820 - REMOVAL OF LESION OF EYELID, NOT OTHER
0821 - EXCISION OF CHALAZION0825 - DESTRUCTION OF LESION OF EYELID
0841 - REPAIR OF ENTROPION OR ECTROPION BY THER
0842 - REPAIR OF ENTROPION OR ECTROPION BY SUTU
0843 - REPAIR OF ENTROPION OR ECTROPION WITH WE
0844 - REPAIR OF ENTROPION OR ECTROPION WITH LI
0852 - BLEPHARORRHAPHY
0859 - OTHER ADJUSTMENT OF LID POSITION
0864 - RECONSTRUCTION OF EYELID WITH TARSOCONJU
0943 - PROBING OF NASOLACRIMAL DUCT
044 - OTHER FREE GRAFT TO CONJUNCTIVA
1099 - OTHER OPERATIONS ON CONJUNCTIVA
110 - MAGNETIC REMOVAL OF EMBEDDED FOREIGN BODY
1131 - TRANSPOSITION OF PTERYGIUM 
1132 - EXCISION OF PTERYGIUM WITH CORNEAL GRAFT
1139 - OTHER EXCISION OF PTERYGIUM
1149 - OTHER REMOVAL OR DESTRUCTION OF CORNAL
1211 - IRIDOTOMY WITH TRANSFIXION
1214 - OTHER IRIDECTOMY
1242 - EXCISION OF LESION OF IRIS
1284 - EXCISION OR DESTRUCTION OF LESION OF SCL
1319 - OTHER INTRACAPSULAR EXTRACTION OF LENS
132 - EXTRACAPSULAR EXTRACTION OF LENS BY LINE
133 - EXTRACAPSULAR EXTRACTION OF LENS BY SIMP
1341 - PHACOEMULSIFICATION AND ASPIRATION OF CA
1342 - MECHANICAL PHACOFRAGMENTATION AND ASPIRA
1359 - OTHER EXTRACAPSULAR EXTRACTION OF LENS
1362 - EXCISION OF PRIMARY MEMBRANOUS CATARACT
1365 - EXCISION OF SECONDARY MEMBRANE (AFTER CA)
1371 - INSERTION OF INTRAOCULAR LENS PROSTHESIS
1401 - REMOVAL OF FOREIGN BODY FROM POSTERIOR S
1402 - REMOVAL OF FOREIGN BODY FROM POSTERIOR S
1511 - RECESSION OF ONE EXTRAOCULAR MUSCLE
1512 - ADVANCEMENT OF ONE EXTRAOCULAR MUSCLE
1513 - RESECTION OF ONE EXTRAOCULAR MUSCLE
1519 - OTHER OPERATIONS ON ONE EXTRAOCULAR MUSC
1521 - LENGTHENING PROCEDURE ON ONE EXTRAOCULAR
1522 - SHORTENING PROCEDURE ON ONE EXTRAOCULAR
1529 - OTHER OPERATIONS ON ONE EXTRAOCULAR MUSC
153 - OPERATIONS ON TWO OR MORE EXTRAOCULAR MUSC
154 - OTHER OPERATIONS ON TWO OR MORE EXTRAOC
1631 - REMOVAL OF OCULAR CONTENTS WITH SYNCHRON
1639 - OTHER EVISCERATION OF EYEBALL
1642 - ENUCLEATION OF EYEBAL WITH OTHER SYNCHR
1649 - OTHER ENUCLEATION OF EYEBALL
1661 - SECONDARY INSERTION OF OCULAR IMPLANT
1662 - REVISION AND REINSERTION OF OCULAR IMPLANT
1671 - REMOVAL OF OCULAR IMPLANT
1809 - OTHER INCISION OF EXTERNAL EAR
1811 - OTOSCOPY
1829 - EXCISION OR DESTRUCTION OF OTHER LESION
1911 - STAPEDECTOMY WITH INCUS REPLACEMENT
1919 - OTHER STAPEDECTOMY
193 - OTHER OPERATIONS ON OSSICULAR CHAIN
194 - MYRINGOPLASTY
195 - OTHER TYMPANOPLASTY
1952 - TYPE II TYMPANOPLASTY
1953 - TYPE III TYMPANOPLASTY
1954 - TYPE IV TYMPANOPLASTY
1955 - TYPE V TYMPANOPLASTY
196 - REVISION OF TYMPANOPLASTY
2001 - MYRINGOTOMY WITH INSERTION OF TUBE
2009 - OTHER MYRINGOTOMY
2041 - SIMPLE MASTOIDECTOMY
208 - OPERATIONS ON EUSTACHIAN TUBE
2121 - RHINOSCOPY
2122 - BIOPSY OF NOSE
2131 - LOCAL EXCISION OR DESTRUCTION OF INTRANA
2132 - LOCAL EXCISION OR DESTRUCTION OF OTHER L
215 - SUBMUCOUS RESECTION OF NASAL SEPTUM
2162 - FRACTURE OF THE TURBINATES
2169 - OTHER TURBINECTOMY
217 - REDUCTION OF NASAL FRACTURE
2171 - CLOSED REDUCTION OF NASAL FRACTURE
2183 - TOTAL NASAL RECONSTRUCTION
2187 - OTHER RHINOPLASTY
2188 - OTHER SEPTOPLASTY
2199 - OTHER OPERATIONS ON THE NOSE
2200 - ASPIRATION AND LAVAGE OF NASAL SINUS, NO
2201 - PUNCTURE OF NASAL SINUS FOR ASPIRATION
2202 - ASPIRATION OR LAVAGE OF NASAL SINUS THRO
2263 - ETHMOIDECTOMY
230 - FORCEPS EXTRACTION OF TOOTH
2301 - EXTRACTION OF DECIDUOUS TOOTH
2309 - EXTRACTION OF OTHER TOOTH
231 - SURGICAL REMOVAL OF TOOTH
2311 - REMOVAL OF RESIDUAL ROOT
2319 - OTHER SURGICAL EXTRACTION OF TOOTH
232 - RESTORATION OF TOOTH BY FILLING
233 - RESTORATION OF TOOTH BY INLAY
234 - OTHER DENTAL RESTORATION
2341 - APPLICATION OF CROWN
2342 - INSERTION OF FIXED BRIDGE
2343 - INSERTION OF REMOVABLE BRIDGE
2349 - OTHER DENTAL RESTORATION
235 - IMPLANTATION OF TOOTH
245 - ALVEOLOPLASTY
2501 - NEEDLE BIOPSY OF TONGUE
2502 - OTHER BIOPSY OF TONGUE
2594 - OTHER GLOSSOTOMY
270 - DRAINAGE OF FACE AND FLOOR OF MOUTH
2741 - LABIAL FRENECTOMY
2742 - WIDE EXCISION OF LESION OF LIP
2743 - OTHER EXCISION OF LESION OR TISSUE OF LIP
2792 - INCISION OF MOUTH, UNSPECIFIED STRUCTURE
280 - INCISION AND DRAINAGE OF TONSIL AND PERI
282 - TONSILLECTOMY WITH ADENOIDECTOMY
283 - TONSILLECTORMY WITH ADENOIDECTOMY
284 - EXCISION OF TONSIL TAG
286 - ADENOIDECTOMY WITHOUT TONSILLECTOMY
2911 - PHARYNGOSCOPY
292 - EXCISION OF BRANCHIAL CLEFT CYST OR VEST
3009 - OTHER EXCISION OR DESTRUCTION OF LESION
10313 - OTHER INCISION OF LARYNX OR TRACHEA
3142 - LARYNGOSCOPY AND OTHER TRACHEOSCOPY
3143 - BIOPSY OF LARYNX
3144 - BIOPSY OF TRACHEA
3321 - BRONCHOSCOPY THROUGH ARTIFICIAL STOMA
3322 - FIBER-OPTIC BRONCHOSCOPY
3323 - OTHER BRONCHOSCOPY
3324 - ENDOSCOPIC BRONCHIAL BIOPSY
3409 - OTHER INCISION OF PLEURA
3797 - REPL CARDIVERT/DFIB LEAD
3821 - BIOPSY OF BLOOD VESSEL
3822 - PERCUTANEOUS ANGIOSCOPY
3859 - LIGATION AND STRIPPING OF LOWER LIMB VAR
3882 - OTHER SURGICAL OCCLUSION OF OTHER VESSEL
3889 - OTHER SURGICAL OCCLUSION OF LOWER LIMB V
4011 - BIOPSY OF LYMPHATIC STRUCTURE
4021 - EXCISION OF DEEP CERVICAL LYMPH NODE
4221 - OPERATIVE ESOPHAGOSCOPY BY INCISION
4222 - ESOPHAGSCOPY THROUGH ARTIFICAL STOMA
4223 - OTHER ESOPHAGOSCOPY
4224 - BIOPSY OF ESOPHAGUS
4232 - LOCAL EXCISION OF OTHER LESION OR TISSUE
4239 - OTHER DESTRUCTION OF LESION OR TISSUE OF
4292 - DILATION OF ESOPHAGUS
4342 - LOCAL EXCISION OF OTHER LESION OR TISSUE
4349 - OTHER DESTRUCTION OF LESION OR TISSUE OF
4411 - TRANSABDOMINAL GASTROSCOPY
4413 - OTHER GASTROSCOPY
4414 - BRUSH BIOPSY OF STOMACH
4415 - OTHER BIOPSY OF STOMACH
4493 - INSERT GASTRIC BALLOON
4494 - REMOVAL GASTRIC BALLOON
4513 - OTHER ENDOSCOPY OF SMALL INTESTINE
4514 - BRUSH BIOPSY OF SMALL INTESTINE
4524 - OTHER ENDOSCOPY OF LARGE INTESTINE
4525 - BRUSH BIOPSY OF LARGE INTESTINE
4526 - OTHER BIOPSY OF LARGE INTESTINE
4532 - OTHER DESTRUCTION OF LESION OF DUODENUM
4541 - LOCAL EXCISION OF LESION OR TISSUE OF LA
4595 - SM BOWEL - ANUS ANASTOMOS
4643 - OTHER REVISION OF STOMA OF LARGE INTESTINE
4823 - OTHER PROCTOSIGMOIDOSCOPY
4824 - BRUSH BIOPSY OF RECTUM
4825 - OTHER BIOPSY OF RECTUM
4835 - LOCAL EXCISION OF RECTAL LESION OR TISSUE
4881 - INCISION OF PERIRECTAL TISSUE
4901 - INCISION OF PERIANAL ABSCESS
4912 - ANAL FISTULECTOMY
493 - LOCAL EXCISION OR DESTRUCTION OF OTHER L
4945 - LIGATION OF HEMORRHOIDS
4946 - EXCISION OF HEMORRHOIDS
4947 - EVACUATION OF THROMBOSED HEMORRHOIDS
4949 - OTHER PROCEDURES ON HEMORRHOIDS
4951 - LEFT LATERAL ANAL SPHINCTERTOMY
4952 - POSTERIOR ANAL SPHINCTEROTOMY
4959 - OTHER ANAL SPHINCTEROTOMY
5011 - PERCUTANEOUS (NEEDLE) BIOPSY OF LIVER
5300 - UNILATERAL REPAIR OF INGUINAL HERNIA, NO
5301 - UNILATERAL REPAIR OF DIRECT INGUINAL HER
5302 - UNILATERAL REPAIR OF INDIRECT INGUINAL HER
5303 - UNILATERAL REPAIR OF DIRECT INGUINAL HER
5304 - UNILATERAL REPAIR OF INDIRECT INGUINAL HER
5305 - UNILATERAL REPAIR OF INGUINAL HERNIA WITH
5321 - UNILATERAL REPAIR OF FEMORAL HERNIA WITH
5329 - OTHER UNILATERAL FEMORAL HERNIORRHAPHY
5349 - OTHER UMBILICAL HERNIORRHAPHY
5359 - REPAIR OF OTHER HERNIA OF ANTERIOR ABDOM
5369 - REPAIR OF OTHER HERNIA OF ANTERIOR ABDOM
5421 - LAPAROSCOPY5423 - BIOPSY OF PERITONEUM
5425 - PERITONEAL LAVAGE
544 - EXCISION OR DESTRUCTION OF PERITONEAL TI
545 - LYSIS OF PERITONEAL ADHESIONS
5451 - LAPARASCOPE LYSIS OF PERITONEAL ADHES
5459 - OTHER LYSIS OF PERITONEAL ADHESIONS
5634 - OPEN BIOPSY OF URETER
5635 - ILEAL CONDUCT ENDOSCOPY
5731 - CYSTOSCOPY THROUGH ARTIFICAL STOMA
5732 - OTHER CYTOSCOPY
5749 - OTHER TRANSURETHRAL EXCISION OR DESTRUCT
5791 - SPHINCTEROTOMY OF BLADDER
5792 - DILATION OF BLADDER NECK
581 - URETHRAL MEATOTOMY
5821 - PERINEAL URETHROSCOPY
5822 - OTHER URETHROSCOPY
583 - EXCISION OR DESTRUCTION OF URETHRAL TISS
585 - RELEASE OF URETHRAL STRICTURE
586 - DILATION OF URETHRA
5903 - LAPAROS LYS OF PERINEAL OR PERIURET ADH
5912 - LAPAROS LYS OF PERIVESICAL ADHESIONS
5919 - OTHER INCISION OF PERVESICAL TISSUE
6011 - NEEDLE BIOPSY OF PROSTATE
610 - INCISION AND DRAINAGE OF SCROTUM AND TUN
612 - EXCISION OF HYDROCELE (OF TUNICA VAGINAL)
613 - EXCISION OR DESTRUCTION OF LESION OR TIS
6191 - PERCUTANEOUS ASPIRATION OF TUNICA VAGINA
620 - INCISION OF TESTIS
6211 - PERCUTANEOUS BIOPSY OF TESTIS
6212 - OTHER BIOPSY OF TESTIS
623 - UNILATERAL ORCHIECTOMY
6241 - REMOVAL OF BOTH TESTES AT SAME OPERATIVE
6242 - REMOVAL OF REMAINING TESTES
631 - EXCISION OF VARICOCELE AND HYDROCELE OF
6371 - LIGATION OF VAS DEFERENS
6373 - VASECTOMY
6392 - EPIDIDYMOTOMY
640 - CIRCUMCISION
642 - LOCAL EXCISION OR DESTRUCTION OF LESION
6491 - DORSAL OR LATERAL SLIT OF PREPUCE
6501 - LAPAROSCOPIC OOPHOROTOMY
6509 - OTHER OOPHOROTOMY
6511 - ASPIRATION BIOPSY OF OVARY
6512 - OTHER BIOPSY OF OVARY
6513 - LAPAROSCOPIC BIOPSY OF OVARY
6514 - OTHER LAPAROS DIAG PROC ON OVARIES
6523 - LAPAROS MARSUPIL OF OVATION CYST
6524 - LAPAROS WEDGE RESECTION OF OVARY
6525 - OTH LAPAROS LOC EXCIS OR DEST OF OVARY
6529 - OTHER LOCAL EXCISION OR DESTRUCTION OF O
6531 - LAPAROS UNILATERAL OOPHORECTOMY
6539 - OTHER UNILATERAL OOPHORECTOMY
6541 - LAPAROS UNILAT SALPINGO-OOPHORECTOMY
6549 - OTHER UNILATERAL SALPINGO-OOPHORECTOMY
6553 - LAPAROS REMOVAL OF BOTH OVARIES AT S.OP.
6554 - LAPAROS REMOVAL REMAINING OVARY
6563 - LAPAROS REMOVAL OF BOTH OVARIES & TUBES
6564 - LAPAROS REMOVAL OF REMAING OVARY & TUBE
6574 - LAPAROSCOPIC SIMPLE SUTURE OF OVARY
6575 - LAPAROSCOPIC REIMPLANTATION OF OVARY
658 - LYSIS OF ADHESIONS OF OVARY AND FALLOPIA
6581 - LAPAR LYS OF ADH OF OVARY AND FALL TUBE
6611 - BIOPSY OF FALLOPIAN TUBE
662 - BILATERAL ENDOSCOPIC DESTRUCTION OR OCCL
6621 - BILATERAL ENDOSCOPIC LIGATION AND CRUSHI
6622 - BILATERAL ENDOSCOPIC LIGATION AND DIVISI
6629 - OTHER BILATERAL ENDOSCOPIC DESTRUCTION
663 - OTHER BILATERAL DESTRUCTION OF OCCLUSION
6631 - OTHER BILATERAL LIGATION AND CRUSHING OF
6632 - OTHER BILATERAL LIGATION AND DIVISION OF
6639 - OTHER BILATERAL DESTRUCTION OR OCCLUSION
6661 - EXCISION OR DESTRUCTION OF LESION OF FAL
6692 - UNILATERAL DESTRUCTION OR OCCLUSION OF F
670 - DILATION OF CERVICAL CANAL
6711 - ENDOCERVICAL BIOPSY
6712 - OTHER CERVICAL BIOPSY
6732 - DESTRUCTION OF LESION OF CERVIX BY CAUTE
6733 - DESTRUCTION OF LESION OF CERVIX BY CRYOS
6739 - OTHER EXCISION OR DESTRUCTIO OF LESION
6823 - ENDOMETRTAL ABLATION
6901 - DILATION AND CURETTAGE FOR TERMINATION O
6909 - OTHER DILATION AND CURETTAGE OF UTERUS
6951 - ASPIRATION CURETTAGE OF UTERUS FOR TERMI
6952 - ASPIRATION CURETTAGE FOLLOWING DELIVERY
700 - CULDOCENTESIS
7011 - HYMENOTOMY
7014 - OTHER VAGINOTOMY
7024 - VAGINAL BIOPSY
7031 - HYMENECTOMY
7033 - EXCISION OR DESTRUCTION OF LESION OF VAG
7109 - OTHER INCISION OF VULVA AND PERINEUM
7111 - BIOPSY OF VULVA
7121 - PERCUTANEOUS ASPIRATION OF BARTHOLIN�S G
7122 - INCISION OF BARTHOLIN�S GLAND (CYST)
7123 - MARSUPIALIZATION OF BARTHOLIN�S GLAND (CY)
713 - OTHER LOCAL EXCISION OR DESTRUCTION OF V
7179 - OTHER REPAIR OF VULVA AND PERINEUM
750 - INTRA-AMNIOTIC INJECTION FOR ABORTION
762 - LOCAL EXCISION OR DESTRUCTION OF LESION
7671 - CLOSED REDUCTION OF MALAR AND ZYGOMATIC
7697 - REMOVAL OF INTERNAL FIXATION DEVICE FROM
7702 - SEQUESTRECTOMY OF HUMERUS
7723 - WEDGE OSTEOTOMY OF RADIUS AND ULNA
7724 - WEDGE OSTEOTOMY OF CARPALS AND METACARPA
7728 - WEDGE OSTEOTOMY OF TARSALS AND METATARSA
7733 - OTHER DIVISION OF RADIUS AND ULNA
7734 - OTHER DIVISION OF CARPALS AND METACARPALS
7738 - OTHER DIVISION OF TARSALS AND METATARSALS
7739 - OTHER DIVISION OF OTHER BONE, EXCEPT FAC
7752 - BUNIONECTOMY WITH SOFT TISSUE CORRECTION
7753 - OTHER BUNIONECTOMY WITH SOFT TISSUE CORR
7754 - EXCISION OF BUNIONETTE
7759 - OTHER BUNIONECTOMY
7788 - OTHER PARTIAL OSTECTOMY OF TARSALS AND M
7789 - OTHER PARTIAL OSTECTOMY OF OTHER BONE, E
779 - TOTAL OSTECTOMY
7838 - OTHER CHANGE IN BONE LENGTH OF TARSALS
7839 - OTHER CHANGE IN BONE LENGTH OF TARSALS
7858 - INTERNAL FIXATION OF TARSALS AND METATAR
786 - REMOVAL OF INTERNAL FIXATION DEVICE
7861 - REMOVAL OF INTERNAL FIXATION DEVICE FROM
7862 - REMOVAL OF INTERNAL FIXATION DEVICE FROM
7864 - REMOVAL OF INTERNAL FIXATION DEVICE FROM
7865 - REMOVAL OF INTERNAL FIXATION DEVICE FROM
7866 - REMOVAL OF INTERNAL FIXATION DEVICE FROM
7867 - REMOVAL OF INTERNAL FIXATION DEVICE FROM
7868 - REMOVAL OF INTERNAL FIXATION DEVICE FROM
8003 - ARTHROTOMY FOR REMOVAL OF PROSTHESIS OF
8012 - OTHER ARTHROTOMY OF ELBOW
8016 - OTHER ARTHROTOMY OF KNEE
8026 - ARTHROSCOPY OF KNEE
8043 - DIVISION OF JOINT CAPSULE, LIGAMENT, OR
8044 - DIVISION OF JOINT CAPSULE, LIGAMENT, OR
8048 - DIVISION OF JOINT CAPSULE, LIGAMENT, OR
8050 - IV DISC EXCS/DSTRUCT NOS
806 - EXCISION OF SEMILUNAR CARTILAGE OF KNEE
8073 - SYNOVECTOMY OF WRIST
8074 - SYNOVECTOMY OF HAND AND FINGER
8078 - SYNOVECTOMY OF FOOT AND TOE
8087 - OTHER LOCAL EXCISION OR DESTRUCTION OF L
809 - OTHER EXCISION OF JOINT
8094 - OTHER EXCISION OF JOINT OF HAND AND FINGER
8116 - METATARSOPHALANGEAL FUSION
8118 - OTHER FUSION OF THE TOE
8128 - INTERPHALANGEAL FUSION
8131 - ARTHROPLASTY OF FOOT AND TOE WITH SYNTHE
8139 - OTHER ARTHROPLASTY OF FOOT AND TOE
8171 - ARTHROPLASTY OF HAND AND FINGER WITH SYN
8179 - OTHER REPAIR OF HAND AND FINGER
8186 - ARTHROPLASTY OF CARPALS WITH SYNTHETIC P
8201 - EXPLORATION OF TENDON SHEATH OF HAND
8203 - BURSOTOMY OF HAND
8209 - OTHER INCISION OF SOFT TISSUE OF HAND
8211 - TENOTOMY OF HAND
8212 - FASCIOTOMY OF HAND
8221 - EXCISION OF LESION OF TENDON SHEATH OF H
8232 - EXCISION OF TENDON OF HAND FOR GRAFT
8233 - OTHER TENONECTOMY OF HAND
8235 - OTHER FASCIETOMY OF HAND
8251 - ADVANCEMENT OF TENDON WITH HAND
8279 - PLASTIC OPERATION ON HAND WITH OTHER GRA
8284 - REPAIR OF MALLET FINGER
8285 - OTHER TENODESIS OF HAND
8286 - OTHER TENOPLASTY OF HAND
8289 - OTHER PLASTIC OPERATIONS ON HAND
8291 - LYSIS OF ADHESIONS OF HAND
8301 - EXPLORATION OF TENDON SHEATH
8303 - BURSOTOMY
8309 - OTHER INCISION OF SOFT TISSUE
8314 - FASCIOTOMY
8321 - BIOPSY OF SOFT TISSUE
8331 - EXCISION OF LESION OF TENDON SHEATH
8339 - EXCISION OF LESION OF OTHER SOFT TISSUE
8341 - EXCISION OF TENDON FOR GRAFT
8342 - OTHER TENONECTOMY
8345 - OTHE MYECTOMY
835 - BURSECTOMY
8361 - SUTURE OF TENDON SHEATH
8364 - OTHER SUTURE OF TENDON
8387 - OTHER PLASTIC OPERATIONS ON MUSCLE
8388 - OTHER PLASTIC OPERATIONS ON TENDON
8391 - LYSIS OF ADHESIONS OF MUSCLE, TENDON, FA
8411 - AMPUTATION OF TOE
8412 - AMPUTATION THROUGH FOOT
850 - MASTOTOMY
8511 - PERCUTANEOUS (NEEDLE) BIOPSY OF BREAST
8512 - OTHER BIOPSY OF BREAST
8521 - LOCAL EXCISION OF LESION OF BREAST
8524 - EXCISION OF ECTOPIC BREAST TISSUE
8591 - ASPIRATION OF BREAST
8595 - INSRT BREAST TISS EXPAND
8596 - REMOV BREAST TISS EXPAND
8601 - ASPIRATION OF SKIN AND SUBCUTANEOUS TISS
8604 - OTHER INCISION WITH DRAINAGE OF SKIN AND
8605 - INCISION WITH REMOVAL OF FOREIGN BODY FR
8609 - OTHER INCISION OF SKIN AND SUBCUTANEOUS
8611 - BIOPSY OF SKIN AND SUBCUTANEOUS TISSUE
8621 - EXCISION OF PILONIDAL CYST OR SINUS
8622 - DEBRIDEMENT OF WOUND, INFECTION, OR BURN
8623 - REMOVAL OF NAIL, NAILBED, OR NAIL FOLD
8627 - DEBRID. NAIL, BED, FOLD
863 - OTHER LOCAL EXCISION OR DESTRUCTION OF L
8660 - FREE SKIN GRAFT TO HAND
8662 - OTHER SKIN GRAFT TO HAND
8686 - ONYCHOPLASTY
8689 - OTHER REPAIR AND RECONSTRUCTION OF SKIN
8693 - INSRT SKIN TISS EXPANDER
8782 - GAS CONTRAST HYSTEROSALPINGOGRAM
8926 - GYNECOLOGICAL EXAMINATION
9616 - OTHER VAGINAL DILATION
9622 - DILATION OF RECTUM
9623 - DILATION OF ANAL SPHINCTER
9625 - THERAPEUTIC DISTENTATION OF BLADDER
9649 - OTHER GENITOURINARY INSTILLATION
9659 - OTHER IRRIGATION OF WOUND
9739 - REMOVAL OF OTHER THERAPEUTIC DEVICE FROM
9802 - REMOVAL OF INTRALUMINAL FOREIGN BODY FRO
9803 - REMOVAL OF INTRALUMINAL FOREIGN BODY FRO
9804 - REMOVAL OF INTRALUMINAL FOREIGN BODY FRO
9805 - REMOVAL OF INTRALUMINAL FOREIGN BODY FRO
9814 - REMOVAL OF INTRALUMINAL FOREIGN BODY FRO
9815 - REMOVAL OF INTRALUMINAL FOREIGN BODY FRO
9821 - REMOVAL OF SUPERFICIAL FOREIGN BODY FROM
9822 - REMOVAL OF OTHER FOREIGN BODY WITHOUT IN
9827 - REMOVAL OF FOREIGN BODY WITHOUT INCISION
9985 - LOCALIZED HYPERTHERMIA
9986 - PLACED EXT. BONE STIM