PhilHealth Circular No. 0035, s.2013 Annex 3 List of Medical Conditions and Procedures Allowed As Second Case Rate

ANNEX 3.
LIST OF MEDICAL CONDITIONS AND PROCEDURES ALLOWED AS SECOND CASE RATE ICD/RVS CODE
I60.0 I60.1 I60.2 I60.3 I60.4 I60.5 I60.6
SECOND CASE RATE

H Case Rate C Subarachnoid haemorrhage from carotid siphon and I 19,000 bifurcation Subarachnoid haemorrhage from middle cerebral 19,000 artery Subarachnoid haemorrhage from anterior 19,000 communicating artery Subarachnoid haemorrhage from posterior 19,000 communicating artery 19,000 Subarachnoid haemorrhage from basilar artery Subarachnoid haemorrhage from vertebral artery Subarachnoid haemorrhage from other intracranial arteries; Multiple involvement of intracranial arteries Subarachnoid haemorrhage from intracranial artery, unspecified; Congenital ruptured berry aneurysm NOS; Subarachnoid haemorrhage from cerebral artery NOS; Subarachnoid haemorrhage from communicating artery NOS Other subarachnoid haemorrhage; Meningeal haemorrhage; Rupture of cerebral arteriovenous malformation Subarachnoid haemorrhage, unspecified Intracerebral haemorrhage in hemisphere, subcortical; Deep intracerebral haemorrhage Intracerebral haemorrhage in hemisphere, cortical; Cerebral lobe haemorrhage; Superficial intracerebral haemorrhage Intracerebral haemorrhage in hemisphere, unspecified Intracerebral haemorrhage in brain stem Intracerebral haemorrhage in cerebellum Intracerebral haemorrhage, intraventricular Intracerebral haemorrhage, multiple localized Other intracerebral haemorrhage Intracerebral haemorrhage, unspecified Acute Subdural haemorrhage; Nontraumatic Subdural haemorrhage Nontraumatic extradural haemorrhage; Nontraumatic epidural haemorrhage Intracranial haemorrhage (nontraumatic), unspecified Cerebral infarction due to thrombosis of precerebral arteries Cerebral infarction due to embolism of precerebral arteries Cerebral infarction due to unspecified occlusion or stenosis of precerebral arteries Cerebral infarction due to thrombosis of cerebral arteries Cerebral infarction due to embolism of cerebral arteries 19,000 19,000
DESCRIPTION
Professional Fee 11,400 11,400 11,400 11,400 11,400 11,400 11,400
Health Care Institution Fee 7,600 7,600 7,600 7,600 7,600 7,600 7,600
I60.7
19,000
11,400
7,600
I60.8 I60.9 I61.0 I61.1 I61.2 I61.3 I61.4 I61.5 I61.6 I61.8 I61.9 I62.0 I62.1 I62.9 I63.0 I63.1 I63.2 I63.3 I63.4
19,000 19,000 19,000 19,000 19,000 19,000 19,000 19,000 19,000 19,000 19,000 19,000 19,000 19,000 14,000 14,000 14,000 14,000 14,000
11,400 11,400 11,400 11,400 11,400 11,400 11,400 11,400 11,400 11,400 11,400 11,400 11,400 11,400 8,400 8,400 8,400 8,400 8,400
7,600 7,600 7,600 7,600 7,600 7,600 7,600 7,600 7,600 7,600 7,600 7,600 7,600 7,600 5,600 5,600 5,600 5,600 5,600
Page 1 of 31
ANNEX 3. LIST OF MEDICAL CONDITIONS AND PROCEDURES ALLOWED AS SECOND CASE RATE ICD/RVS CODE
I63.5
SECOND CASE RATE DESCRIPTION

H Case Rate C I 14,000 14,000 14,000 14,000 14,000 14,000 Professional Fee 8,400 8,400 8,400 8,400 8,400 8,400 Health Care Institution Fee 5,600 5,600 5,600 5,600 5,600 5,600
Cerebral infarction due to unspecified occlusion or stenosis of cerebral arteries Cerebral infarction due to cerebral venous I63.6 thrombosis, nonpyogenic I63.8 Other cerebral infarction I63.9 Cerebral infarction, unspecified Other lacunar syndrome in unspecified cerebral I63.9+G46.7* infarction I64 Stroke, not specified as hemorrhage or infarction Acute transmural myocardial infarction of anterior wall [or duration of <4 weeks] KILLIPS stage unspecified; Acute transmural infarction of anterior wall NOS [or duration of <4 weeks] KILLIPS stage unspecified; Acute anteroapical transmural infarction [or Acute transmural myocardial infarction of inferior wall [or duration of <4 weeks] KILLIPS I; Acute transmural infarction of diaphragmatic wall [or duration of <4 weeks] KILLIPS I; Acute transmural infarction of inferior wall NOS [or duration of <4 weeks] Acute transmural myocardial infarction of other sites [or duration of <4 weeks] KILLIPS II; Acute apicallateral transmural infarction [or duration of <4 weeks] KILLIPS II; Acute basal-lateral transmural infarction [or duration of <4 weeks] KILLIPS I Acute transmural myocardial infarction of unspecified site; Transmural myocardial infarction NOS Acute subendocardial myocardial infarction; Nontransmural myocardial infarction NOS Acute myocardial infarction, unspecified [or duration of <4 weeks] KILLIPS I; Acute myocardial infarction NOS [or duration of <4 weeks] KILLIPS I Subsequent myocardial infarction of anterior wall; Acute Subsequent infarction of anterior wall NOS; Acute subsequent infarction of anteroapical wall; Acute subsequent infarction of anterolateral wall; Acute subsequent infarction of anteroseptal wall Subsequent myocardial infarction of inferior wall; Acute subsequent infarction of diaphragmatic wall; Acute subsequent infarction of inferior wall NOS; Acute subsequent infarction of inferolateral wall; Acute subsequent infarction of inferoposterior wall
I21.0
9,450
5,670
3,780
I21.1
9,450
5,670
3,780
I21.2
9,450
5,670
3,780
I21.3
9,450
5,670
3,780
I21.4
9,450
5,670
3,780
I21.9
9,450
5,670
3,780
I22.0
9,450
5,670
3,780
I22.1
9,450
5,670
3,780
Page 2 of 31
ANNEX 3. LIST OF MEDICAL CONDITIONS AND PROCEDURES ALLOWED AS SECOND CASE RATE ICD/RVS CODE SECOND CASE RATE DESCRIPTION
Subsequent myocardial infarction of other sites; Acute myocardial infarction of apical-lateral wall; Acute myocardial infarction of basal-lateral wall; Acute myocardial infarction of high lateral wall; Acute myocardial infarction of lateral wall NOS; Acut Subsequent myocardial infarction of unspecified site Haemopericardium as current complication following acute myocardial infarction Atrial septal defect as current complication following acute myocardial infarction Ventricular septal defect as current complication following acute myocardial infarction Rupture of cardiac wall without haemopericardium as current complication following acute myocardial infarction Rupture of chordae tendineae as current complication following acute myocardial infarction Rupture of papillary muscle as current complication following acute myocardial infarction Other current complications following acute myocardial infarction Dressler's syndrome; Postmyocardial infarction syndrome Embolism following abortion and ectopic and molar pregnancy; Embolism NOS; Air embolism; Amniotic fluid embolism; Blood-clot embolism; Pulmonary embolism; Pyaemic embolism; Septic or septicopyaemic embolism; Soap embolism Metabolic disorders following abortion and ectopic and molar pregnancy Complication following abortion and ectopic and molar pregnancy, unspecified Other intrapartum haemorrhage; Excessive intrapartum haemorrhage Rupture of uterus before on set of labour Rupture of uterus during labour; Rupture of uterus not stated as occuring before onset of labour Post partum inversion of uterus H Case Rate C I 9,450 Professional Fee Health Care Institution Fee
I22.8
5,670
3,780
I22.9
9,450
5,670
3,780
I23.0
9,450
5,670
3,780
I23.1
9,450
5,670
3,780
I23.2
9,450
5,670
3,780
I23.3
9,450
5,670
3,780
I23.4
9,450
5,670
3,780
I23.5
9,450
5,670
3,780
I23.8
9,450
5,670
3,780
I24.1
9,450
5,670
3,780
O08.2
4,650
2,790
1,860
O08.5 O08.9 O67.8 O71.0 O71.1 O71.2
4,650 4,650 4,650 4,650 4,650 4,650
2,790 2,790 2,790 2,790 2,790 2,790
1,860 1,860 1,860 1,860 1,860 1,860
Page 3 of 31
O71.3 O71.5 O71.7 O71.8 O71.9
SECOND CASE RATE

H Case Rate C Obstetric laceration of cervix; Annular detachment of I 4,650 cervix Other obstetric injury to pelvic organs; Obstetric 4,650 injury to bladder; Obstetric injury to urethra Obstetric haematoma of pelvis; Obstetric 4,650 haematoma of perineum; Obstetric haematoma of vagina; Obstetric haematoma of vulva Other specified obstetric trauma Obstetric trauma, unspecified Aspiration pneumonitis due to anaesthesia during labour and delivery; Inhalation of stomach contents or secretions NOS due to anaesthesia during labour and delivery; Mendelson's syndrome due to anaesthesia during labour and delivery Cardiac complications of anaesthesia during labour and delivery; Cardiac arrest due to anaesthesia during labour and delivery; Cardiac failure due to anaesthesia during labour and delivery Other complications of anaesthesia during labour and delivery Shock during or following labour and delivery; Obstetic shock Other specified complications of labour and delivery Complication of labour and delivery, unspecified Venous complication in the puerperium, unspecified; Puerperal phlebitis NOS; Puerperal phlebopathy NOS; Puerperal thrombosis NOS Debridement of extensive eczematous or infected skin Debridement including removal of foreign material associated w/ open fracture(s) and/or dislocation(s); skin and subcutaneous tissues Debridement including removal of foreign material associated w/ open fracture(s) and/or dislocation(s); skin, subcutaneous tissue, muscle fascia, and muscle Debridement including removal of foreign material associated w/ open fracture(s) and/or dislocation(s); skin, subcutaneous tissue, muscle fascia, muscle, and bone Debridement; skin, partial thickness Debridement; skin, full thickness Debridement; skin, and subcutaneous tissue Debridement; skin, subcutaneous tissue, and muscle 4,650 4,650
DESCRIPTION
Professional Fee 2,790 2,790 2,790 2,790 2,790
Health Care Institution Fee 1,860 1,860 1,860 1,860 1,860
O74.0
4,650
2,790
1,860
O74.2
4,650
2,790
1,860
O74.8 O75.1 O75.8 O75.9 O87.9 11000 11010
4,650 4,650 4,650 4,650 4,650 10,540 10,540
2,790 2,790 2,790 2,790 2,790 5,040 5,040
1,860 1,860 1,860 1,860 1,860 5,500 5,500
11011
11,980
5,880
6,100
11012 11040 11041 11042 11043
12,120 3,640 3,640 5,680 8,020
6,720 840 840 1,680 2,520
5,400 2,800 2,800 4,000 5,500
Page 4 of 31
11044 11720 11721 16010 21627 36430 49080 55250 58600 77401 77401
SECOND CASE RATE

H Case Rate C Debridement; skin, subcutaneous tissue, muscle, and I 8,020 bone Debridement of nail(s) by any method(s); one to five Debridement of nail(s) by any method(s); six or more Dressings and/or debridement, initial or subsequent Sternal debridement Outpatient Transfusion of Blood or Blood Products; one or more units Peritoneocentesis, abdominal paracentesis, or peritoneal lavage (diagnostic or therapeutic) Vasectomy, unilateral or bilateral Ligation or transection of fallopian tube(s), abdominal or vaginal approach, unilateral or bilateral Radiation treatment delivery (Linear Accelerator) Radiation treatment delivery (Cobalt) Intracavitary radiation source application, 1 or more sources/ribbons (Brachytherapy), one or more sessions during the course of therapy including follow-up care for 90 days after procedure Interstitial radiation source application, 1 or more sources/ribbons (Brachytherapy), one or more sessions during the course of therapy including follow-up care for 90 days after procedure Remote after loading high intensity brachytherapy (RAHIB); 1 or more source position or catheters per session Surface application of radiation source (Brachytherapy), one or more sessions during the course of therapy including follow-up care for 90 days after procedure Hemodialysis procedure Dialysis procedure other than hemodialysis (e.g. peritoneal, hemofiltration) Chemotherapy administration The following procedures if done on both sides during one confinement, the second procedure shall be considered as the second case rate and shall be reimbursed at 50% of the case rate for the procedure except for the (3) cataract package surgeries: Blepharoplasty, lower eyelid Blepharoplasty, upper eyelid; Blepharoplasty, upper eyelid; with excessive skin weighting down lid Mastectomy, partial; 3,640 5,560 8,260 12,288 3,640 8,020 4,000 4,000 3,000 2,000
DESCRIPTION
Professional Fee 2,520 840 1,260 3,360 6,888 840 2,520 1,000 1,000 800 800
Health Care Institution Fee 5,500 2,800 4,300 4,900 5,400 2,800 5,500 3,000 3,000 2,200 1,200
77761
18,000
8,400
9,600
77776
18,000
8,400
9,600
77781
5,680
1,680
4,000
77789 90935 90945 96408
9,700 4,000 4,000 7,280
4,200 500 500 1,680
5,500 3,500 3,500 5,600
15820 15822 15823 19160
5,060 5,060 5,990 11,000
4,048 4,048 4,792 8,800
1,012 1,012 1,198 2,200
Page 5 of 31
19162 19180 19182 19200 19220
SECOND CASE RATE

H Case Rate C I Mastectomy, partial; with axillary lymphadenectomy 11,000 Mastectomy, simple, complete Mastectomy, subcutaneous Mastectomy, radical, icnluding pectoral muscles, axillary lymph nodes Mastectomy, radical, including pectoral muscles, axillary and internal mammary lymph nodes (Urban type operation) Mastectomy, modified radical, including axillary lymph nodes, w/ or w/o pectoralis minor muscle, but excluding pectoralis major muscle Immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction Delayed insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction Nipple/areola reconstruction Breast reconstruction, immediate or delayed, with tissue expander, including subsequent expansion Breast reconstruction with latissimus dorsi flap, with or without prosthetic implant Breast reconstruction with free flap Breast reconstruction with other technique Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), single pedicle, including closure of donor site; Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), double pedicle, including closure of donor site Open periprosthetic capsulotomy, breast Periprosthetic capsulectomy, breast Open treatment of clavicular fracture, w/ or w/o internal or external fixation Closed treatment of sternoclavicular dislocation Open treatment of sternoclavicular disloction, acute or chronic; Open treatment of sternoclavicular disloction, w/ fascial graft (includes obtaining graft) Closed treatment of acromioclavicular dislocation Open treatment of acromioclavicular dislocation, acute or chronic; Open treatment of acromioclavicular dislocation, acute or chronic; w/ fascial graft (includes obtaining graft) Closed treatment of scapular fracture Open treatment of scapular fracture (body, glenoid or acromion) w/ or w/o internal fixation 11,000 11,000 11,000 11,000
DESCRIPTION
Professional Fee 8,800 8,800 8,800 8,800 8,800
Health Care Institution Fee 2,200 2,200 2,200 2,200 2,200
19240
11,000
8,800
2,200
19340 19342 19350 19357 19361 19364 19366 19367
18,900 18,900 15,150 18,900 27,500 27,500 27,500 27,500
15,120 15,120 12,120 15,120 22,000 22,000 22,000 22,000
3,780 3,780 3,030 3,780 5,500 5,500 5,500 5,500
19369 19370 19371 23515 23520 23530 23532 23540 23550 23552 23570 23585
27,500 15,150 18,900 6,228 5,440 10,490 13,560 4,010 10,970 10,490 4,010 10,490
22,000 12,120 15,120 4,982 4,352 8,392 10,848 3,208 8,776 8,392 3,208 8,392
5,500 3,030 3,780 1,246 1,088 2,098 2,712 802 2,194 2,098 802 2,098
Page 6 of 31
23600

Closed treatment of proximal humeral (surgical or anatomical neck) fracture Open treatment of proximal humeral (surgical or anatomical neck) fracture, w/ or w/o internal or external fixation, w/ or w/o repair of tuberosity(-ies); Open treatment of proximal humeral (surgical or anatomical neck) fracture, w/ or w/o internal or external fixation, w/ or w/o repair of tuberosity(-ies); w/ proximal humeral prosthetic replacement Closed treatment of greater tuberosity fracture Open treatment of greater tuberosity fracture, w/ or w/o internal or external fixation Closed treatment of shoulder dislocation Open treatment of acute shoulder dislocation Closed treatment of shoulder dislocation,/ fracture of greater tuberosity Open treatment of shoulder dislocation, w/ fracture of greater tuberosity, w/ or w/o internal or external fixation Closed treatment of shoulder dislocation, w/ surgical or anatomical neck fracture Open treatment of shoulder dislocation, w/ surgical or anatomical neck fracture, w/ or w/o internal or external fixation Manipulation under anesthesia, shoulder joint, including application of fixation apparatus (dislocation excluded) Interthoracoscapular amputation (forequarter) Disarticulation of shoulder; Closed treatment of humeral shaft fracture Open treatment of humeral shaft fracture w/ plate/screws, w/ or w/o cerclage Open treatment of humeral shaft fracture, w/ insertion of intramedullary implant, w/ or w/o cerclage and/or locking screws Closed treatment of supracondylar or transcondylar humeral fracture, w/ or w/o intercondylar extension Open treatment of humeral supracondylar or transcondylar fracture, w/ or w/o internal or external fixation; w/o intercondylar extension Open treatment of humeral supracondylar or transcondylar fracture, w/ or w/o internal or external fixation; w/ intercondylar extension Closed treatment of humeral epicondylar fracture, medial or lateral; Open treatment of humeral epicondylar fracture, medial or lateral, w/ or w/o internal or external fixation H Case Rate C I 5,270 Professional Fee 4,216 Health Care Institution Fee 1,054
23615
11,650
9,320
2,330
23616
23,670
18,936
4,734
23620 23630 23650 23660 23665 23670 23675 23680
4,850 11,650 5,270 13,560 5,990 13,560 6,060 13,560
3,880 9,320 4,216 10,848 4,792 10,848 4,848 10,848
970 2,330 1,054 2,712 1,198 2,712 1,212 2,712
23700 23900 23920 24500 24515 24516
4,850 15,150 13,560 5,060 15,370 15,370
3,880 12,120 10,848 4,048 12,296 12,296
970 3,030 2,712 1,012 3,074 3,074
24530
5,060
4,048
1,012
24545
6,228
4,982
1,246
24546 24560 24575
16,000 5,440 9,000
12,800 4,352 7,200
3,200 1,088 1,800
Page 7 of 31
24576 24579

Closed treatment of humeral condylar fracture, medial or lateral Open treatment of humeral condylar fracture, medial or lateral, w/ or w/o internal or external fixation Open treatment of periarticular fracture and/or dislocation of the elbow (fracture distal humerus and proximal ulna and/or proximal radius); Open treatment of periarticular fracture and/or dislocation of the elbow (fracture distal humerus and proximal ulna and/or proximal radius); w/ implant arthroplasty Treatment of closed elbow dislocation Open treatment of acute or chronic elbow dislocation Closed treatment of Monteggia type of fracture dislocation at elbow (fracture proximal end of ulna w/ dislocation of radial head) Open treatment of Monteggia type of fracture dislocation at elbow (fracture proximal end of ulna w/ dislocation of radial head), w/ or w/o internal or external fixation Closed treatment of radial head subluxation in child, "nursemaid elbow" Closed treatment of radial head or neck fracture Open treatment of radial head or neck fracture, w/ or w/o internal fixation or radial head excision; Open treatment of periarticular fracture and/or dislocation of the elbow (fracture distal humerus and proximal ulna and/or proximal radius); w/ radial head prosthetic replacement Closed treatment of ulnar fracture, proximal end (olecranon process) Open treatment of ulnar fracture proximal end (olecranon process), w/ or w/o internal or external fixation Amputation, arm through humerus; w/ primary closure Amputation, arm through humerus; open, circular (guillotine) Amputation, arm through humerus; secondary closure or scar revision Amputation, arm through humerus; re-amputation Amputation, arm through humerus; w/ implant Closed treatment of radial shaft fracture Open treatment of radial shaft fracture, w/ or w/o internal or external fixation H Case Rate C I 5,440 9,000 Professional Fee 4,352 7,200 Health Care Institution Fee 1,088 1,800
24586
11,330
9,064
2,266
24587 24600 24615 24620
18,900 5,270 11,650 5,440
15,120 4,216 9,320 4,352
3,780 1,054 2,330 1,088
24635
10,970
8,776
2,194
24640 24650 24665
2,840 5,440 10,490
2,272 4,352 8,392
568 1,088 2,098
24666
13,560
10,848
2,712
24670 24685 24900 24920 24925 24930 24931 25500 25515
5,440 10,970 9,000 6,060 5,480 7,480 7,480 4,850 10,970
4,352 8,776 7,200 4,848 4,384 5,984 5,984 3,880 8,776
1,088 2,194 1,800 1,212 1,096 1,496 1,496 970 2,194
Page 8 of 31
25520

Closed treatment of radial shaft fracture, w/ dislocation of distal radio-ulnar joint (Galeazzi fracture/dislocation) Open treatment of radial shaft fracture, w/ internal and/or external fixation and closed treatment of dislocation of distal radio-ulnar joint (Galeazzi fracture/dislocation), w/ or w/o percutaneous skeletal fixation Open treatment of radial shaft fracture, w/ internal and/or external fixation and open treatment, w/ or w/o internal or external fixation of distal radio-ulnar joint (Galleazi fracture/dislocation), includes repair of triangular cartilage Closed treatment of ulnar shaft fracture Open treatment of ulnar shaft fracture, w/ or w/o internal or external fixation Closed treatment of radial and ulnar shaft fractures Open treatment of radial and ulnar shaft fractures, w/ internal or external fixation; of radius or ulna Open treatment of radial and ulnar shaft fractures, w/ internal or external fixation; of radius and ulna Closed treatment of distal radial fracture (e.g., Colles or Smith type) or epiphyseal separation, w/ or w/o fracture of ulnar styloid Open treatment of distal radial fracture (e.g., Colles or Smith type) or epiphyseal separation, w/ or w/o fracture of ulnar styloid, w/ or w/o internal or external fixation Closed treatment of carpal scaphoid (navicular) fracture Open treatment of carpal scaphoid (navicular) fracture, w/ or w/o internal or external fixation Closed treatment of carpal bone fracture (excluding carpal scaphoid (navicular)) Open treatment of carpal bone fracture (excluding carpal scaphoid (navicular)), each bone Closed treatment of ulnar styloid fracture Closed treatment of radiocarpal or intercarpal dislocation, one or more bones Open treatment of radiocarpal or intercarpal dislocation, one or more bones Closed treatment of distal radioulnar dislocation Open treatment of distal radioulnar dislocation, acute or chronic Closed treatment of trans-scaphoperilunar type of fracture dislocation H Case Rate C I 4,850 Professional Fee Health Care Institution Fee 970
3,880
25525
10,490
8,392
2,098
25526
11,330
9,064
2,266
25530 25545 25560 25574
4,130 9,000 4,850 13,980
3,304 7,200 3,880 11,184
826 1,800 970 2,796
25575
13,560
10,848
2,712
25600
4,130
3,304
826
25620
11,650
9,320
2,330
25622 25628 25630 25645 25650 25660 25670 25675 25676 25680
4,130 10,910 4,130 10,952 4,220 4,130 9,000 4,130 10,910 4,130
3,304 8,728 3,304 8,762 3,376 3,304 7,200 3,304 8,728 3,304
826 2,182 826 2,190 844 826 1,800 826 2,182 826
Page 9 of 31
25685 25690 25695 25900 25905 25907 25909 25920 25922 25924 25927 25929 25931 26600 26607 26615 26641 26645 26665

Open treatment of trans-scaphoperilunar type of fracture dislocation Closed treatment of lunate dislocation Open treatment of lunate dislocation Amputation, forearm, through, radius and ulna; Amputation, forearm, through, open, circular (guillotine) Amputation, forearm, through, secondary closure or scar revision Amputation, forearm, through, re-amputation Disarticulation through wrist; Disarticulation through wrist; secondary closure or scar revision Disarticulation through wrist; re-amputation Transmetacarpal amputation; Transmetacarpal amputation; secondary closure or scar revision Transmetacarpal amputation; re-amputation Closed treatment of metacarpal fracture, single Closed treatment of metacarpal fracture, w/ internal or external fixation Open treatment of metacarpal fracture, single, w/ or w/o internal or external fixation, each bone Closed treatment of carpometacarpal dislocation, thumb Closed tratment of carpometacarpal fracture dislocation, thumb (Bennett fracture) Open treatment of carpometacarpal fracture dislocation, thumb (Bennett fracture), w/ or w/o internal or external fixation Closed treatment of carpometacarpal dislocation, other than thumb (Bennett fracture); single Open treatment of carpometacarpal dislocation, other than thumb (Bennett fracture); single, w/ or w/o Open treatment of carpometacarpal dislocation, other than thumb (Bennett fracture); single, internal or external fixation Open treatment of carpometacarpal dislocation, other than thumb (Bennett fracture); single, complex, multiple or delayed reduction Closed treatment of metacarpophalangeal dislocation, single Open treatment of metacarpophalangeal dislocation, single, w/ or w/o internal or external fixation Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb Open treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb, w/ or w/o internal or external fixation, each H Case Rate C I 10,490 4,130 10,970 9,000 6,060 5,480 7,480 7,480 4,220 7,480 7,480 4,220 7,480 5,060 6,450 6,060 5,270 6,060 7,480 Professional Fee 8,392 3,304 8,776 7,200 4,848 4,384 5,984 5,984 3,376 5,984 5,984 3,376 5,984 4,048 5,160 4,848 4,216 4,848 5,984 Health Care Institution Fee 2,098 826 2,194 1,800 1,212 1,096 1,496 1,496 844 1,496 1,496 844 1,496 1,012 1,290 1,212 1,054 1,212 1,496
26670
5,270
4,216
1,054
26685
5,270
4,216
1,054
26686 26700 26715 26720 26735
5,990 5,270 6,270 5,060 7,480
4,792 4,216 5,016 4,048 5,984
1,198 1,054 1,254 1,012 1,496
Page 10 of 31
26740 26746 26750 26765 26770 26785

Closed treatment of articular fracture, involving metacarpophalangeal or interphalangeal joint Open treatment of articular fracture, involving metacarpophalangeal or interphalangeal joint, w/ or w/o internal or external fixation, each Closed treatment of distal phalangeal fracture, finger or thumb Open treatment of distal phalangeal fracture, finger or thumb, w/ or w/o internal or external fixation, each Closed treatment of interphalangeal joint dislocation, single Open treatment of interphalangeal joint dislocation, w/ or w/o internal or external fixation, single Amputation, metacarpal, w/ finger or thumb (ray amputation), single, w/ or w/o interosseous transfer Amputation, finger or thumb, primary or secondary, any joint or phalanx, single, including neurectomies; w/ direct closure Amputation, finger or thumb, primary or secondary, any joint or phalanx, single, including neurectomies; w/ local advancement flaps (V-Y, hood) Treatment of slipped femoral epiphysis; by traction, w/o reduction Treatment of slipped femoral epiphysis; by single or multiple pinning, in situ Open treatment of slipped femoral epiphysis; single of multiple pinning or bone graft (includes obtaining graft) Open treatment of slipped femoral epiphysis; closed manipulation w/ single or multiple pinning Open treatment of slipped femoral epiphysis; osteoplasty of femoral neck (Heyman type procedure) Open treatment of slipped femoral epiphysis; osteotomy and internal fixation Open treatment of iliac spine(s), tuberosity avulsion, or iliac wing fracture(s) (e.g., pelvic fracture(s) w/c do not disrupt the pelvic ring), w/ internal fixation Open treatment of anterior ring fracture and/or dislocation w/ internal fixation (includes pubic symphysis and/or rami) Open treatment of posterior ring fracture and/or dislocation w/ internal fixation (includes ilium, sacroiliac joint and/or sacrum) Closed treatment of acetabulum (hip socket) fracture(s) H Case Rate C I 5,060 6,270 5,060 6,060 5,440 6,270 Professional Fee 4,048 5,016 4,048 4,848 4,352 5,016 Health Care Institution Fee 1,012 1,254 1,012 1,212 1,088 1,254
26910
6,060
4,848
1,212
26951
5,990
4,792
1,198
26952
10,970
8,776
2,194
27175 27176 27177
11,650 15,150 15,570
9,320 12,120 12,456
2,330 3,030 3,114
27178
15,570
12,456
3,114
27179 27181
15,570 18,590
12,456 14,872
3,114 3,718
27215
18,900
15,120
3,780
27217
23,250
18,600
4,650
27218 27220
23,250 15,370
18,600 12,296
4,650 3,074
Page 11 of 31
27226

Open treatment of posterior or anterior acetabular wall fracture, w/ internal fixation Open treatment of acetabular fracture(s) involving anterior or posterior (one) column, or a fracture running transversely across the acetabulum, w/ internal fixation Open treatment of acetabular fracture(s) involving anterior and posterior (two) columns, includes Tfracture and both column fracture w/ complete articular detachment, or single column or transverse fracture w/ associated acetabular wall fracture, w/ inte Closed treatment of femoral fracture, proximal end, neck Open treatment of femoral fracture, proximal end, neck, internal fixation or prosthetic replacement (direct fracture exposure) Closed treatment of intertrochanteric, pertrochanteric, or subtrochanteric femoral fracture Open treatment of intertrochanteric, pertrochanteric, or subtrochanteric femoral fracture; w/ plate/screw type implant, w/ or w/o cerclage Open treatment of intertrochanteric, pertrochanteric, or subtrochanteric femoral fracture; w/ intramedullary implant, w/ or w/o interlocking screws and/or cerclage Closed treatment of greater trochanteric fracture Open treatment of greater trochanteric fracture, w/ or w/o internal or external fixation Closed treatment of hip dislocation, traumatic Open treatment of hip dislocation, traumatic, w/o internal fixation Open treatment of hip dislocation, traumatic w/ acetabular wall and femoral head fracture, w/ or w/o internal or external fixation Open treatment of spontaneous hip dislocation (developmental, including congenital or pathological), replacement of femoral head in acetabulum (including tenotomy, etc); Open treatment of spontaneous hip dislocation (developmental, including congenital or pathological), replacement of femoral head in acetabulum (including tenotomy, etc); w/ femoral shaft shortening Closed treatment of post hip arthroplasty dislocation Interpelviabdominal amputation (hindquarter amputation) Disarticulation of hip H Case Rate C I 19,320 Professional Fee 15,456 Health Care Institution Fee 3,864
27227
20,160
16,128
4,032
27228
23,250
18,600
4,650
27230 27236
11,650 23,250
9,320 18,600
2,330 4,650
27238
11,650
9,320
2,330
27244
23,250
18,600
4,650
27245 27246 27248 27250 27253 27254
15,570 11,650 13,560 11,650 18,590 20,160
12,456 9,320 10,848 9,320 14,872 16,128
3,114 2,330 2,712 2,330 3,718 4,032
27258
15,150
12,120
3,030
27259
18,590
14,872
3,718
27265 27290 27295
9,000 23,250 15,150
7,200 18,600 12,120
1,800 4,650 3,030
Page 12 of 31
27501 27502
SECOND CASE RATE

H Case Rate C I Closed treatment of supracondylar or transcondylar 7,480 femoral fracture w/ or w/o intercondylar extension Closed treatment of femoral shaft fracture, w/ or w/o skin or skeletal traction Closed treatment of supracondylar or transcondylar femoral fracture w/ or w/o intercondylar extension, w/ or w/o skin or skeletal traction Open treatment of femoral shaft fracture, w/ or w/o external fixation, w/ insertion of intramedullary implant, w/ or w/o cerclage and/or locking screws Open treatment of femoral shaft fracture w/ plate/screws, w/ or w/o cerclage Closed treatment of femoral fracture, distal end, medial or lateral condyle Open treatment of femoral supracondylar or transcondylar fracture w/o intercondylar extension, w/ or w/o internal or external fixation Open treatment of femoral supracondylar or transcondylar fracture w/ intercondylar extension, w/ or w/o internal or external fixation Open treatment of femoral fracture, distal end, medial or lateral condyle, w/ or w/o internal or external fixation Closed treatment of distal femoral epiphyseal separation Open treatment of distal femoral epiphyseal separation, w/ or w/o internal or external fixation Closed treatment of patellar fracture Open treatment of patellar fracture, w/ internal fixation and/or partial or complete patellectomy and soft tissue repair Closed treatment of tibial fracture, proximal (plateau) Open treatment of tibial fracture, proximal (plateau); unicondylar, w/ or w/o internal or external fixation Open treatment of tibial fracture, proximal (plateau); bicondylar, w/ or w/o internal fixation Closed treatment of intercondylar spine(s) and/or tuberosity fracture(s) of knee Open treatment of intercondylar spine(s) and/or tuberosity fracture(s) of the knee, w/ or w/o internal or external fixation Closed treatment of knee dislocation 9,210
DESCRIPTION
Professional Fee
Health Care Institution Fee 1,496 1,842
5,984 7,368
27503
9,210
7,368
1,842
27506
15,370
12,296
3,074
27507 27510
15,370 9,210
12,296 7,368
3,074 1,842
27511
18,590
14,872
3,718
27513
18,900
15,120
3,780
27514 27516 27519 27520 27524 27530 27535
15,370 11,650 11,330 10,490 10,490 9,210 15,370
12,296 9,320 9,064 8,392 8,392 7,368 12,296
3,074 2,330 2,266 2,098 2,098 1,842 3,074
27536 27538 27540 27550
13,560 5,270 10,910 5,270
10,848 4,216 8,728 4,216
2,712 1,054 2,182 1,054
Page 13 of 31
Open treatment of knee dislocation, w/ or w/o internal or external fixation; w/o primary ligamentous repair or augmentation/reconstruction Open treatment of knee dislocation, w/ or w/o internal or external fixation; w/ primary ligamentous repair Open treatment of knee dislocation, w/ or w/o internal or external fixation; w/ primary ligamentous repair, w/ augmentation/reconstruction Closed treatment of patellar dislocation Open treatment of patellar dislocation, w/ or w/o partial or total patellectomy Amputation, thigh, through femur, any level; Amputation, thigh, through femur, any level; immediate fitting technique including first cast Amputation, thigh, through femur, any level; open, circular (guillotine) Amputation, thigh, through femur, any level; secondary closure or scar revision Amputation, thigh, through femur, any level; reamputaion Disarticulation at knee Closed treatment of tibial shaft fracture (w/ or w/o fibular fracture) Closed treatment of tibial shaft fracture (with or without fibular fracture); with manipulation, with or without skeletal traction Open treatment of tibial shaft fracture (w/ or w/o fibular fracture) w/ plate/screws, w/ or w/o cerclage Open treatment of tibial shaft fracture (w/ or w/o fibular fracture) by intramedullary implant, w/ or w/o interlocking screws and/or cerclage Closed treatment of medial malleolus fracture Open treatment of medial malleolus fracture, w/ or w/o internal or external fixation Closed treatment of proximal fibula or shaft fracture Open treatment of proximal fibula or shaft fracture, w/ or w/o internal or external fixation Closed treatment of distal fibular fracture (lateral malleolus) Open treatment of distal fibular fracture (lateral malleolus), w/ or w/o internal or external fixation w/o manipulation Closed treatment of bimalleolar ankle fracture, (including Potts) Open treatment of bimalleolar ankle fracture, w/ or w/o internal or external fixation Closed treatment of trimalleolar ankle fracture H Case Rate C I 13,560 Professional Fee Health Care Institution Fee 2,712
27556
10,848
27557
13,980
11,184
2,796
27558 27560 27566 27590 27591 27592 27594 27596 27598 27750 27752
18,900 10,490 13,560 15,150 11,650 11,650 5,990 11,330 13,560 6,060 6,060
15,120 8,392 10,848 12,120 9,320 9,320 4,792 9,064 10,848 4,848 4,848
3,780 2,098 2,712 3,030 2,330 2,330 1,198 2,266 2,712 1,212 1,212
27758
11,330
9,064
2,266
27759 27760 27766 27780 27784 27786 27792 27808 27814 27816
13,560 5,480 6,060 5,480 11,330 5,270 10,490 6,450 11,650 11,650
10,848 4,384 4,848 4,384 9,064 4,216 8,392 5,160 9,320 9,320
2,712 1,096 1,212 1,096 2,266 1,054 2,098 1,290 2,330 2,330
Page 14 of 31
Open treatment of trimalleolar ankle fracture, w/ or w/o internal or external fixation, medial and/or lateral malleolus; w/o fixation of posterior lip Open treatment of trimalleolar ankle fracture, w/ or w/o internal or external fixation, medial and/or lateral malleolus; w/ fixation of posterior lip Closed treatment of fracture of weight bearing articular portion of distal tibia (e.g., pilon or tibial plafond) Open treatment of fracture of weight bearing articular surface/portion of distal tibia (e.g., pilon or tibial plafond), w/ internal or external fixation; of fibula only Open treatment of fracture of weight bearing articular surface/portion of distal tibia (e.g., pilon or tibial plafond), w/ internal or external fixation; of tibia only Open treatment of fracture of weight bearing articular surface/portion of distal tibia (e.g., pilon or tibial plafond), w/ internal or external fixation; of both tibia and fibula Open treatment of distal tibiofibular joint (syndesmosis) disruption, w/ or w/o internal or external fixation Closed treatment of proximal tibiofibular joint dislocation Open treatment of proximal tibiofibular joint dislocation, w/ or w/o internal or external fixation, or w/ excision of proximal fibula Closed treatment of ankle dislocation Open treatment of ankle dislocation, w/ or w/o percutaneous skeletal fixation; w/o repair or internal fixation Open treatment of ankle dislocation, w/ or w/o percutaneous skeletal fixation; w/ repair or internal or external fixation Amputation, leg, through tibia and fibula; Amputation, leg, through tibia and fibula; w/ immediate fitting technique including application of first cast Amputation, leg, through tibia and fibula; open, circular (guillotine) Amputation, leg, through tibia and fibula; secondary closure or scar revision Amputation, leg, through tibia and fibula; reamputation Amputation, ankle, through malleoli of tibia and fibula (Syme, Pirogoff type procedures), w/ plastic closure and resection of nerves Ankle disarticulation H Case Rate C I 11,650 Professional Fee Health Care Institution Fee 2,330
27822
9,320
27823
11,650
9,320
2,330
27824
5,270
4,216
1,054
27826
10,490
8,392
2,098
27827
10,970
8,776
2,194
27828
10,910
8,728
2,182
27829 27830 27832 27840 27846
10,490 5,480 5,990 5,480 11,330
8,392 4,384 4,792 4,384 9,064
2,098 1,096 1,198 1,096 2,266
27848 27880 27881 27882 27884 27886 27888 27889
11,860 15,150 15,370 9,000 6,060 11,650 11,650 10,970
9,488 12,120 12,296 7,200 4,848 9,320 9,320 8,776
2,372 3,030 3,074 1,800 1,212 2,330 2,330 2,194
Page 15 of 31
28400 28415

Closed treatment of calcaneal fracture Open treatment of calcaneal fracture, w/ or w/o internal or external fixation; Open treatment of calcaneal fracture, w/ or w/o internal or external fixation; w/ primary iliac or other autogenous bone graft (includes obtaining graft) Closed treatment of talus fracture Open treatment of talus fracture, w/ or w/o internal or external fixation Treatment of tarsal bone fracture (except talus and calcaneus) Open treatment of tarsal bone fracture (except talus and calcaneus), w/ or w/o internal or external fixation Closed treatment of metatarsal fracture Open treatment of metatarsal fracture, w/ or w/o internal or external fixation Closed treatment of fracture great toe, phalanx or phalanges Open treatment of fracture great toe, phalanx or phalanges, w/ or w/o internal or external fixation Closed treatment of fracture, phalanx or phalanges, other than great toe Open treatment of fracture, phalanx or phalanges, other than great toe, w/ or w/o internal or external fixation Closed treatment of sesamoid fracture Open treatment of sesamoid fracture, w/ or w/o internal fixation Closed treatment of tarsal bone dislocation, other than talotarsal Open treatment of tarsal bone dislocation, w/ or w/o internal or external fixation Closed treatment of talotarsal joint dislocation Open treatment of talotarsal joint dislocation, w/ or w/o internal or external fixation Closed treatment of tarsometatarsal joint dislocation Open treatment of tarsometatarsal joint dislocation, w/ or w/o internal or external fixation Closed treatment of metatarsophalangeal joint dislocation Open treatment of metatarsophalangeal joint dislocation, w/ or w/o internal or external fixation Closed treatment of interphalangeal joint dislocation H Case Rate C 5,480 I 9,000 Professional Fee 4,384 7,200 Health Care Institution Fee 1,096 1,800
28420 28430 28445 28450 28465 28470 28485 28490 28505 28510 28525 28530 28531 28540 28555 28570 28585 28600 28615 28630 28645 28660
11,180 5,480 7,690 5,566 5,060 5,440 5,440 5,060 6,060 5,060 6,060 4,130 5,060 4,130 6,270 5,440 9,000 5,480 9,000 4,130 9,000 5,440
8,944 4,384 6,152 4,453 4,048 4,352 4,352 4,048 4,848 4,048 4,848 3,304 4,048 3,304 5,016 4,352 7,200 4,384 7,200 3,304 7,200 4,352
2,236 1,096 1,538 1,113 1,012 1,088 1,088 1,012 1,212 1,012 1,212 826 1,012 826 1,254 1,088 1,800 1,096 1,800 826 1,800 1,088
Page 16 of 31
28675 28800 28810 28820 28825 29058 29065 29075 29085 29305 29325 29345 29355 29358 29365 29405 29425 29435 29445 29450 49495 49496 49497 49500
SECOND CASE RATE

H Case Rate C I Open treatment of interphalangeal joint dislocation, 9,000 w/ or w/o internal or external fixation Amputation, foot; midtarsal (Chopart type procedure) Amputation, metatarsal, w/ toe, single Amputation, toe; metatarsophalangeal joint Amputation, toe; interphalangeal joint Application of body cast, shoulder to hips; plaster Velpeau Application of body cast, shoulder to hips; shoulder to hand (long arm) Application of body cast, shoulder to hips; elbow to finger (short arm) Application of body cast, shoulder to hips; hand and lower forearm (gauntlet) Application of hip spica cast; one leg Application of hip spica cast; one and one-half spica or both legs Application of long leg cast (thigh to toes); Application of long leg cast (thigh to toes); walker or ambulatory type Application of long leg cast brace Application of cylinder cast (thigh to ankle) Application of short leg cast (below knee to toes); Application of short leg cast (below knee to toes); walking or ambulatory type Application of patellar tendon bearing (PTB) cast Application of rigid total contact leg cast Application of clubfoot cast w/ molding or manipulation, long or short leg Repair initial inguinal hernia, under age 6 months, w/ or w/o hydrocelectomy; reducible Repair initial inguinal hernia, under age 6 months, w/ or w/o hydrocelectomy; incarcerated Repair initial inguinal hernia, under age 6 months, w/ or w/o hydrocelectomy; strangulated Repair initial inguinal hernia, age 6 months to under 5 years, w/ or w/o hydrocelectomy; reducible Repair initial inguinal hernia, age 6 months to under 5 years, w/ or w/o hydrocelectomy; incarcerated Repair initial inguinal hernia, age 6 months to under 5 years, w/ or w/o hydrocelectomy; strangulated Repair initial inguinal hernia, age 5 years or over; reducible Repair initial inguinal hernia, age 5 years or over; incarcerated 11,650 6,060 9,000 6,060 2,780 2,840 2,780 2,780 4,010 4,220 4,010 4,220 4,220 4,010 4,010 4,010 4,010 2,840 2,840 10,500 10,500 10,500 10,500
DESCRIPTION
Professional Fee
Health Care Institution Fee 1,800 2,330 1,212 1,800 1,212 556 568 556 556 802 844 802 844 844 802 802 802 802 568 568 2,100 2,100 2,100 2,100
7,200 9,320 4,848 7,200 4,848 2,224 2,272 2,224 2,224 3,208 3,376 3,208 3,376 3,376 3,208 3,208 3,208 3,208 2,272 2,272 8,400 8,400 8,400 8,400
49501
10,500
8,400
2,100
49502 49505 49507
10,500 10,500 10,500
8,400 8,400 8,400
2,100 2,100 2,100
Page 17 of 31
49509 49520 49521 49522 49525 49540 49550 49553 49554 49555 49557 49558 49560 49561 49562 49565 49566 49567 49590 49650 49651 54520 54530 54535 54550 54560 54600 54620 54640 54650 54670 54680 54690

Repair initial inguinal hernia, age 5 years or over; strangulated Repair recurrent inguinal hernia, any age; reducible Repair recurrent inguinal hernia, any age; incarcerated Repair recurrent inguinal hernia, any age; strangulated Repair inguinal hernia, sliding, any age Repair lumbar hernia Repair initial femoral hernia, any age; reducible Repair initial femoral hernia, any age; incarcerated Repair initial femoral hernia, any age; strangulated Repair recurrent femoral hernia; reducible Repair recurrent femoral hernia; incarcerated Repair recurrent femoral hernia; strangulated Repair initial incisional hernia; reducible Repair initial incisional hernia; incarcerated Repair initial incisional hernia; strangulated Repair recurrent incisional hernia; reducible Repair recurrent incisional hernia; incarcerated Repair recurrent incisional hernia; strangulated Repair spigelian hernia Laparoscopy, surgical; repair of initial inguinal hernia Laparoscopy, surgical; repair of recurrent inguinal hernia Orchiectomy, simple (including subcapsular), w/ or w/o testicular prosthesis, scrotal or inguinal approach Orchiectomy, radical, for tumor; inguinal approach Orchiectomy, radical, for tumor; w/ abdominal exploration Exploration for undescended testis (inguinal or scrotal area) Exploration for undescended testis w/ abdominal exploration Reduction of torsion of testis, surgical, w/ or w/o fixation of contralateral testis Fixation of contralateral testis Orchiopexy, inguinal approach, w/ or w/o hernia repair Orchiopexy, abdominal approach, for intraabdominal testis (e.g., Fowler-Stephens) Suture or repair of testicular injury Transplantation of testis(es) to thigh (because of scrotal destruction) Laparoscopy, surgical; orchiectomy H Case Rate C I 10,500 10,500 10,500 10,500 10,500 10,500 10,500 10,500 10,500 10,500 10,500 10,500 10,500 10,500 10,500 10,500 10,500 10,500 10,500 10,500 10,500 5,270 5,480 6,270 5,270 6,270 5,480 4,650 5,270 6,270 4,850 4,130 4,850 Professional Fee 8,400 8,400 8,400 8,400 8,400 8,400 8,400 8,400 8,400 8,400 8,400 8,400 8,400 8,400 8,400 8,400 8,400 8,400 8,400 8,400 8,400 4,216 4,384 5,016 4,216 5,016 4,384 3,720 4,216 5,016 3,880 3,304 3,880 Health Care Institution Fee 2,100 2,100 2,100 2,100 2,100 2,100 2,100 2,100 2,100 2,100 2,100 2,100 2,100 2,100 2,100 2,100 2,100 2,100 2,100 2,100 2,100 1,054 1,096 1,254 1,054 1,254 1,096 930 1,054 1,254 970 826 970
Page 18 of 31
54692 61330 61332 61333 61334 65091 65093 65101 65103 65105 65110 65112

Laparoscopy, surgical; orchiopexy for intraabdominal testis Decompression of orbit only, transcranial approach Exploration of orbit (transcranial approach); w/ biopsy Exploration of orbit (transcranial approach); w/ removal of lesion Exploration of orbit (transcranial approach); w/ removal of foreign body Evisceration of ocular contents; w/o implant Evisceration of ocular contents; w/ implant Enucleation of eye; w/o implant Enucleation of eye; w/ implant, muscles not attached to implant Enucleation of eye; w/ implant, muscles attached to implant Exenteration of orbit without skin graft, removal of orbital contents; only Exenteration of orbit without skin graft, removal of orbital contents; w/ therapeutic removal of bone Exenteration of orbit without skin graft, removal of orbital contents; w/ muscle or myocutaneous flap Insertion of ocular implant; after evisceration, in scleral shell Insertion of ocular implant; after enucleation, muscles not attached to implant Insertion of ocular implant; after enucleation, muscles attached to implant Reinsertion of ocular implant; with or without conjunctival graft Reinsertion of ocular implant; with use of foreign material for reinforcement and/or attachment of muscles to implant Removal of ocular implant Removal of foreign body, external eye; conjunctival, superficial Removal of foreign body, external eye; subconjunctival or scleral, with slit lamp Removal of foreign body, external eye; cornea, with slit lamp Removal of foreign body, intraocular; from anterior chamber or lens Removal of foreign body, intraocular; from posterior segment, magnetic extraction, anterior or posterior route Removal of foreign body, intraocular; from posterior segment, nonmagnetic extraction Repair of laceration; conjunctiva, w/ or w/o nonperforating laceration sclera, direct closure H Case Rate C I 5,990 23,250 26,700 26,700 26,700 6,060 6,060 6,060 6,060 6,060 18,900 19,320 Professional Fee 4,792 18,600 21,360 21,360 21,360 4,848 4,848 4,848 4,848 4,848 15,120 15,456 Health Care Institution Fee 1,198 4,650 5,340 5,340 5,340 1,212 1,212 1,212 1,212 1,212 3,780 3,864
65114 65130 65135 65140 65150 65155 65175 65205 65210 65222 65235 65260 65265 65270
19,740 5,480 5,480 5,990 5,990 5,990 4,850 1,820 4,010 4,010 9,000 26,700 27,500 4,010
15,792 4,384 4,384 4,792 4,792 4,792 3,880 1,456 3,208 3,208 7,200 21,360 22,000 3,208
3,948 1,096 1,096 1,198 1,198 1,198 970 364 802 802 1,800 5,340 5,500 802
Page 19 of 31
65273 65275 65280 65285 65286 65290 65450 65710 65730 65750 65755 65760 65765 65767 65770 65771 65772 65775 65780 65781 65782 65805
SECOND CASE RATE

H Case Rate C Repair of laceration; conjunctiva, by mobilization and I 4,010 rearrangement Repair of laceration; cornea, nonperforating, w/ or 4,850 w/o removal foreign body Repair of laceration; cornea and/or sclera, 10,490 perforating, not involving uveal tissue Repair of laceration; cornea and/or sclera, perforating, w/ reposition or resection of uveal tissue Repair of laceration; application of tissue glue, wounds of cornea and/or sclera Repair of wound, extraocular muscle, tendon and/ or Tenons capsule Destruction of lesion of cornea by cryotherapy, photocoagulation or thermocauterization Keratoplasty (corneal transplant); lamellar Keratoplasty (corneal transplant); penetrating (except in aphakia) Keratoplasty (corneal transplant); penetrating (in aphakia) Keratoplasty (corneal transplant); penetrating (in pseudophakia) Keratomileusis Keratophakia Epikeratoplasty Keratoprosthesis Radial keratotomy Corneal relaxing incision for correction of surgically induced astigmatism Corneal wedge resection for correction of surgically induced astigmatism Ocular surface reconstruction; amniotic membrane transplantation Ocular surface reconstruction; limbal stem cell allograft (eg, cadaveric or living donor) Ocular surface reconstruction; limbal conjunctival autograft (includes obtaining graft) Paracentesis of anterior chamber of eye; w/ therapeutic release of aqueous Paracentesis of anterior chamber of eye; w/ removal of vitreous and/or discission of anterior hyaloid membrane, w/ or w/o air injection Paracentesis of anterior chamber of eye; w/ removal of blood, w/ or w/o irrigation and/or air injection Goniotomy Trabeculotomy ab externo Trabeculoplasty by laser surgery, one or more sessions (defined treatment series) Severing adhesions of anterior segment, laser technique 11,650 4,850 4,850 4,010 15,150 15,150 15,150 15,150 9,000 5,270 9,000 15,150 7,480 7,480 7,480 15,150 15,150 15,150 4,010
DESCRIPTION
Professional Fee 3,208 3,880 8,392 9,320 3,880 3,880 3,208 12,120 12,120 12,120 12,120 7,200 4,216 7,200 12,120 5,984 5,984 5,984 12,120 12,120 12,120 3,208
Health Care Institution Fee 802 970 2,098 2,330 970 970 802 3,030 3,030 3,030 3,030 1,800 1,054 1,800 3,030 1,496 1,496 1,496 3,030 3,030 3,030 802
65810
4,850
3,880
970
65815 65820 65850 65855 65860
4,850 11,650 11,650 6,060 5,270
3,880 9,320 9,320 4,848 4,216
970 2,330 2,330 1,212 1,054
Page 20 of 31
65865

Severing adhesions of anterior segment of eye, incisional technique (w/ or w/o injection of air or liquid); goniosynechiae Severing adhesions of anterior segment of eye, incisional technique (w/ or w/o injection of air or liquid); anterior synechiae, except goniosynechiae Severing adhesions of anterior segment of eye, incisional technique (w/ or w/o injection of air or liquid); posterior synechiae Severing adhesions of anterior segment of eye, incisional technique (w/ or w/o injection of air or liquid); corneovitreal adhesions Removal of epithelial material, anterior segment eye Removal of implanted material, anterior segment eye Fistulization of scalera for glaucoma; trephination w/ iridectomy Fistulization of scalera for glaucoma; thermocauterization w/ iridectomy Fistulization of scalera for glaucoma; sclerectomy w/ punch or scissors, w/ iridectomy Fistulization of scalera for glaucoma; iridencleisis or iridotasis Fistulization of scalera for glaucoma; trabeculectomy ab externo in absence of previous surgery Fistulization of scalera for glaucoma; trabeculectomy ab externo w/ scarring from previous ocular surgery or trauma (includes injection of antifibrotic agents) Aquenous shunt to extraocular reservoir (e.g., Molteno, Schocket, Denver-Krupin) Revision of aqueous shunt to extraocular reservoir Repair of scleral staphyloma; w/o graft Repair of scleral staphyloma; w/ graft Iridotomy by stab incision; except transfixion Iridotomy by stab incision; w/ transfixion as for iris bombe Iridectomy, w/ corneoscleral or corneal section; for removal of lesion Iridectomy, w/ corneoscleral or corneal section; w/ cyclectomy Iridectomy, w/ corneoscleral or corneal section; peripheral for glaucoma Iridectomy, w/ corneoscleral or corneal section; sector for glaucoma Repair of iris, ciliary body (as for iridodialysis) Suture of iris, ciliary body w/ retrieval of suture through small incision (e.g., McCannel suture) H Case Rate C I 5,270 Professional Fee Health Care Institution Fee 1,054
4,216
65870
5,270
4,216
1,054
65875
5,270
4,216
1,054
65880 65900 65920 66150 66155 66160 66165 66170
5,270 5,270 6,060 9,000 9,000 9,000 9,000 9,000
4,216 4,216 4,848 7,200 7,200 7,200 7,200 7,200
1,054 1,054 1,212 1,800 1,800 1,800 1,800 1,800
66172
13,560
10,848
2,712
66180 66185 66220 66225 66500 66505 66600 66605 66625 66630 66680 66682
15,150 15,150 6,060 11,650 5,270 5,270 6,060 9,000 6,060 6,060 9,000 7,480
12,120 12,120 4,848 9,320 4,216 4,216 4,848 7,200 4,848 4,848 7,200 5,984
3,030 3,030 1,212 2,330 1,054 1,054 1,212 1,800 1,212 1,212 1,800 1,496
Page 21 of 31
66700 66710 66720 66740 66761 66762 66770

Ciliary body destruction; diathermy Ciliary body destruction; cyclophotocoagulation Ciliary body destruction; cryotherapy Ciliary body destruction; cyclodialysis Iridotomy/iridectomy by laser surgery (e.g., for glaucoma) ( one or more sessions) Iridoplasty by photocoagulation (one or more sessions) (e.g., for improvement of vision, for widening of anterior chamber angle) Destruction of cyst or lesion iris or ciliary body (nonexcisional procedure) Discission of secondary membranous cataract (opacified posterior lens capsule and/or anterior hyaloid); stab incision technique (Ziegler or Wheeler knife) Discission of secondary membranous cataract (opacified posterior lens capsule and/or anterior hyaloid); laser surgery (e.g., YAG laser) (one or more stages) Repositioning of intraocular lens prosthesis, requiring an incision Removal of secondary membranous cataract (opacified posterior lens capsule and/or anterior hyaloid) w/ corneo-scleral section, w/ or w/o iridectomy (iridocapsulotomy, iridocapsulectomy) Removal of lens material; aspiration technique, one or more stages Removal of lens material; phacofragmentation technique (mechanical or ultrasonic) (e.g., phacoemulsification), w/ aspiration Removal of lens material; pars plana approach, with or without vitrectomy Removal of lens material; intracapsular Removal of lens material; intracapsular, for dislocated lens Removal of lens material; extracapsular Extracapsular cataract removal with insertion of intraocular lens prosthesis (one stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in rout Intracapsular cataract extraction w/ insertion of intraocular lens prosthesis (one stage procedure) Extracapsular cataract removal w/ insertion of intraocular lens prosthesis (one stage procedure), (e.g., irrigation and aspiration) Insertion of intraocular lens prosthesis, not associated with cataract removal H Case Rate C 5,990 I 5,990 5,990 5,990 5,270 6,060 5,270 Professional Fee 4,792 4,792 4,792 4,792 4,216 4,848 4,216 Health Care Institution Fee 1,198 1,198 1,198 1,198 1,054 1,212 1,054
66820
6,060
4,848
1,212
66821
4,130
3,304
826
66825
9,000
7,200
1,800
66830
6,060
4,848
1,212
66840 66850 66852 66920 66930 66940
8,000 8,000 8,000 8,000 8,000 8,000
6,400 6,400 6,400 6,400 6,400 6,400
1,600 1,600 1,600 1,600 1,600 1,600
66982
8,000
6,400
1,600
66983*
16,000
6,400
9,600
66984* 66985
16,000 8,000
6,400 6,400
9,600 1,600
Page 22 of 31
66986 66987* 66991 66992 66993 66994 66995 66996 66997 66998 66999

Exchange of intraocular lens Extracapsular cataract removal w/ insertion of intraocular lens prosthesis (one stage procedure), (e.g., phacoemulsification) Revision of failed filter; with or without explantation/exchange of shunt Revision of failed filter; with excision of bleb cyst Revision of failed filter; with choroidal tap Revision of failed filter; with posterior sclerotomy Revision of failed filter; with anterior chamber reformation Revision of filtering bleb, needling technique; without injection of anti-metabolite Revision of filtering bleb, needling technique; with injection of anti-metabolite Release of scleral flap suture by laser suture lysis (new code) Revision of overfiltering bleb (includes autologous blood injection, cryotherapy, mattress sutures, etc.) Removal of vitreous, anterior approach (open sky technique or limbal incision); partial removal Removal of vitreous, anterior approach (open sky technique or limbal incision); subtotal removal w/ mechanical vitrectomy Aspiration or release of vitreous, subretinal or choroidal fluid, pars plana approach (posterior sclerotomy) Vitrectomy, mechanical, pars plana approach; Vitrectomy, mechanical, pars plana approach; w/ epiretinal membrane stripping Vitrectomy, mechanical, pars plana approach; w/ focal endolaser photocoagulation Vitrectomy, mechanical, pars plana approach; w/ endolaser panretinal photocoagulation Vitrectomy, mechanical, pars plana approach; with internal limiting membrane (ILM) peeling Vitrectomy, mechanical, pars plana approach; with radial optic nerve neurotomy (RON) Vitrectomy, mechanical, pars plana approach; with sheathotomy for branch retinal vein occlusion Vitrectomy, mechanical, pars plana approach; with macular translocation (limited by retinotomy and/or scleral imbrication) Vitrectomy, mechanical, pars plana approach; with macular translocation (total) Vitrectomy, mechanical, pars plana approach; with removal of subretinal membranes H Case Rate C 8,000 I 16,000 18,900 18,900 15,150 15,150 15,150 6,060 9,000 4,850 9,000 Professional Fee 6,400 6,400 15,120 15,120 12,120 12,120 12,120 4,848 7,200 3,880 7,200 Health Care Institution Fee 1,600 9,600 3,780 3,780 3,030 3,030 3,030 1,212 1,800 970 1,800
67005
18,900
15,120
3,780
67010
26,700
21,360
5,340
67015 67036 67038 67039 67040 67041 67042 67043
4,850 23,250 23,250 23,250 23,250 23,250 23,250 23,250
3,880 18,600 18,600 18,600 18,600 18,600 18,600 18,600
970 4,650 4,650 4,650 4,650 4,650 4,650 4,650
67044 67045 67046
23,250 23,250 23,250
18,600 18,600 18,600
4,650 4,650 4,650
Page 23 of 31
67047

Vitrectomy, mechanical, pars plana approach; with removal of choroidal neovascular membrane Vitrectomy, mechanical, pars plana approach; with endodrainage of subretinal hemorrhage (with or without tPA injection) Vitrectomy, mechanical, pars plana approach; with removal of dropped IOL Vitrectomy, mechanical, pars plana approach; with phacofragmentation for dropped lens material Vitrectomy, mechanical, pars plana approach; with internal tamponade with air, gas, silicone oil, perfluorocarbon liquid Vitrectomy, mechanical, pars plana approach; with insertion of scleral fixated intraocular lens, with or without anterior vitrectomy Repair of retinal detachment, one or more sessions; cryotherapy or diathermy, w/ or w/o drainage of subretinal fluid Repair of retinal detachment, one or more sessions; photocoagulation, w/ or w/o drainage of subretinal fluid Repair of retinal detachment; scleral buckling (such as lamellar scleral dissection, imbrication or encircling procedure), w/ or w/o implant, w/ or w/o cryotherapy, photocoagulation, and drainage of subretinal fluid Repair of retinal detachment; w/ vitrectomy, any method, w/ or w/o air or gas tamponade, focal endolaser photocoagulation, cryotherapy, drainage of subretinal fluid, scleral buckling, and/or removal of lens by same technique Repair of retinal detachment; by injection of air or other gas (e.g., pneumatic retinopexy) Repair of retinal detachment; by scleral buckling or vitrectomy, on patient having previous ipsilateral retinal detachment repair(s) using scleral buckling or vitrectomy techniques Release of encircling material (posterior segment) Removal of implanted material, posterior segment; extraocular Removal of implanted material, posterior segment; intraocular Destruction of localized lesion of retina (e.g., maculopathy, choroidopathy, small tumors), one or more sessions; cryotherapy, diathermy H Case Rate C I 23,250 Professional Fee Health Care Institution Fee 4,650
18,600
67048 67049 67050
23,250 23,250 23,250
18,600 18,600 18,600
4,650 4,650 4,650
67051
23,250
18,600
4,650
67052
18,900
15,120
3,780
67101
23,250
18,600
4,650
67105
18,590
14,872
3,718
67107
23,250
18,600
4,650
67108
23,250
18,600
4,650
67110
15,150
12,120
3,030
67112
23,250
18,600
4,650
67115 67120 67121 67208
6,060 6,060 10,490 6,060
4,848 4,848 8,392 4,848
1,212 1,212 2,098 1,212
Page 24 of 31
Destruction of localized lesion of retina (e.g., maculopathy, choroidopathy, small tumors), one or more sessions; photocoagulation (laser or xenon arc) Destruction of localized lesion of retina (e.g., maculopathy, choroidopathy, small tumors), one or more sessions; radiation by implantation of source (includes removal of source) Destruction of localized lesion of choroid (e.g., choroidal neovascularization); photocoagulation (e.g., laser), one or more sessions Destruction of localized lesion of choroid (e.g., choroidal neovascularization); photodynamic therapy (includes intravenous infusions Destruction of localized lesion of choroid (e.g., choroidal neovascularization); transpupillary thermotherapy Destruction of extensive or progressive retinopathy (e.g., diabetic retinopathy), one or more sessions; cryotherapy, diathermy Destruction of extensive or progressive retinopathy (e.g., diabetic retinopathy), one or more sessions; photocoagulation (laser or xenon arc) Scleral reinforcement Strabismus surgery, recession or resection procedure (patient not previously operated on); one horizontal muscle Strabismus surgery, recession or resection procedure (patient not previously operated on); two horizontal muscles Strabismus surgery, recession or resection procedure (patient not previously operated on); one vertical muscle (excluding superior oblique) Strabismus surgery, recession or resection procedure (patient not previously operated on); two or more vertical muscles (excluding superior oblique) Strabismus surgery, any procedure (patient not previously operated on), superior oblique muscle Transposition procedure (e.g., for paretic extraocular muscle), any extraocular muscle (specify) Strabismus surgery on patient w/ previous eye surgery or injury that did not involve the extraocular muscles H Case Rate C I 6,060 Professional Fee Health Care Institution Fee 1,212
67210
4,848
67218
6,060
4,848
1,212
67220
6,060
4,848
1,212
67221
6,060
4,848
1,212
67222
6,060
4,848
1,212
67227
6,060
4,848
1,212
67228 67250 67311
6,060 6,060 5,060
4,848 4,848 4,048
1,212 1,212 1,012
67312
6,060
4,848
1,212
67314
6,060
4,848
1,212
67316
9,000
7,200
1,800
67318
9,000
7,200
1,800
67320
9,000
7,200
1,800
67331
9,000
7,200
1,800
Page 25 of 31
Strabismus surgery on patient w/ scaring of extraocular muscles (e.g., prior ocular injury, strabismus or retinal detachment surgery) or restrictive myopathy (e.g., dysthyroid ophthalmopathy) Strabismus surgery by posterior fixation suture technique, w/ or w/o muscle recession Strabismus surgery involving exploration and/or repair of detached extraocular muscle(s) Release of extensive scar tissue w/o detaching extraocular muscle Chemodenervation of extraocular muscle Orbitotomy w/o bone flap (frontal or transconjunctival approach); for exploration, w/ or w/o biopsy Orbitotomy w/o bone flap (frontal or transconjunctival approach); w/ drainage only Orbitotomy w/o bone flap (frontal or transconjunctival approach); w/ removal of lesion Orbitotomy w/o bone flap (frontal or transconjunctival approach); w/ removal of foreign body Orbitotomy w/o bone flap (frontal or transconjunctival approach); w/ removal of bone for decompression Fine needle aspiration of orbital contents Orbitotomy w/ bone flap or window, lateral approach (e.g., Kroenlein); w/ removal of lesion Orbitotomy w/ bone flap or window, lateral approach (e.g., Kroenlein); w/ removal of foreign body Orbitotomy w/ bone flap or window, lateral approach (e.g., Kroenlein); w/ drainage Orbitotomy w/ bone flap or window, lateral approach (e.g., Kroenlein); w/ removal of bone for decompression Orbital implant (implant outside muscle cone); insertion Orbital implant (implant outside muscle cone); removal or revision Repair of anophthalmic socket; with insertion or removal of orbital implant within muscle cone Repair of anophthalmic socket; with exchange or orbital implant Repair of anophthalmic socket; with exchange of orbital implant and reattachment of muscles Repair of anophthalmic socket; with fornix reconstruction using sutures Repair of anophthalmic socket; with fornix reconstruction using buccal mucosal graft or amnion graft, including harvesting of graft H Case Rate C I 10,970 Professional Fee Health Care Institution Fee
67332
8,776
2,194
67334 67340 67343 67345 67400 67405 67412
5,990 11,330 9,000 4,850 23,250 23,250 23,250
4,792 9,064 7,200 3,880 18,600 18,600 18,600
1,198 2,266 1,800 970 4,650 4,650 4,650
67413
23,250
18,600
4,650
67414 67415 67420 67430 67440 67445 67550 67560 67580 67581 67582 67583 67584
23,250 23,250 23,250 23,250 23,250 23,250 5,480 5,480 6,060 10,490 10,490 10,490 10,490
18,600 18,600 18,600 18,600 18,600 18,600 4,384 4,384 4,848 8,392 8,392 8,392 8,392
4,650 4,650 4,650 4,650 4,650 4,650 1,096 1,096 1,212 2,098 2,098 2,098 2,098
Page 26 of 31
67585

Repair of anophthalmic socket; with revision of implant and fornix reconstruction using sutures Repair of anophthalmic socket; with revision of implant and fornix reconstruction using buccal mucosal graft, or amnion graft (including harvesting of graft) Blepharotomy, drainage of abscess, eyelid Severing of tarsorrhaphy Canthotomy Excision of chalazion Repair of trichiasis; by electroepilation, electrosurgery, cryotherapy or laser surgery Repair of trichiasis; incision of lid margin Repair of trichiasis; incision of lid margin, with free mucous membrane graft Excision of lesion of eyelid (except chalazion) without closure or with simple direct closure Temporary closure of eyelids suture (e.g., frost suture) Construction of intermargin adhesions, median tarsorrhaphy, or canthorrhaphy; Construction of intermargin adhesions, median tarsorrhaphy, or canthorrhaphy; with transportation of tarsal plate Repair of brow ptosis (supraciliary, midforehead or coronal approach) Repair of blepharoptosis; frontalis muscle technique with suture or other material Repair of blepharoptosis; frontalis muscle technique with fascial sling (includes obtaining fascia) Repair of blepharoptosis; (tarso) levator resection or advancement, internal approach Repair of blepharoptosis; (tarso) levator resection or advancement, external approach Repair of blepharoptosis; superior rectus technique with fascial sling (includes obtaining fascia) Repair of blepharoptosis; conjunctivo-tarso-Mullers muscle-levator resection (Fasanella-Servat type) Repair of lid retraction (eyelid recession); without spacer Correction of lagophthalmos, with implantation of upper eyelid load Repair of ectropion; suture Repair of ectropion; thermocauterization Blepharoplasty, excision tarsal wedge Blepharoplasty, extensive (e.g., Kuhnt-Szymanowski or tarsal strip operations) Repair of entropion; suture Repair of entropion; thermocauterization H Case Rate C I 10,490 Professional Fee 8,392 Health Care Institution Fee 2,098
67586 67700 67710 67715 67800 67825 67830 67835 67840 67875 67880 67882 67900 67901 67902 67903 67904 67906
10,490 2,840 2,840 2,840 2,840 2,840 1,820 4,650 2,780 2,840 2,840 4,010 9,000 9,000 10,490 9,000 9,000 9,000
8,392 2,272 2,272 2,272 2,272 2,272 1,456 3,720 2,224 2,272 2,272 3,208 7,200 7,200 8,392 7,200 7,200 7,200
2,098 568 568 568 568 568 364 930 556 568 568 802 1,800 1,800 2,098 1,800 1,800 1,800
67908 67911 67912 67914 67915 67916 67917 67921 67922
9,000 10,700 16,000 4,010 4,010 4,850 6,450 2,840 2,840
7,200 8,560 12,800 3,208 3,208 3,880 5,160 2,272 2,272
1,800 2,140 3,200 802 802 970 1,290 568 568
Page 27 of 31
67923 67924 67930

Blepharoplasty, excision tarsal wedge Blepharoplasty, extensive (e.g., Wheeler operation) Suture of recent wound, eyelid, involving lid margin, tarsus, and/ or palpebral conjunctiva direct closure; partial thickness Suture of recent wound, eyelid, involving lid margin, tarsus, and/ or palpebral conjunctiva direct closure; full thickness Canthoplasty (reconstruction of canthus) Excision and repair of eyelid, involving lid margin, tarsus, conjunctiva, canthus, or full thickness, may include preparation for skin graft or pedicle flap with adjacent tissue transfer or rearrangement; up to onefourth of lid margin Excision and repair of eyelid, involving lid margin, tarsus, conjunctiva, canthus, or full thickness, may include preparation for skin graft or pedicle flap with adjacent tissue transfer or rearrangement; over onefourth of lid margin Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap from opposing eyelid; up to two-thirds of eyelid, one stage or first stage Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap from opposing eyelid; total eyelid, lower, one stage or first stage Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap from opposing eyelid; total eyelid, upper, one stage or first stage Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap from opposing eyelid; second stage Conjunctivoplasty; with conjunctival graft or extensive rearrangement Conjunctivoplasty; with buccal mucous membrane graft (includes obtaining graft) Conjunctivoplasty reconstruction cul-de-sac; with conjunctival graft or extensive rearrangement Conjunctivoplasty reconstruction cul-de-sac; with buccal mucous membrane graft (includes obtaining graft) Repair of symblepharon; conjunctivoplasty, without graft Repair of symblepharon; with free graft conjunctiva or buccal mucous membrane (includes obtaining graft) H Case Rate C 4,850 I 6,450 4,850 Professional Fee 3,880 5,160 3,880 Health Care Institution Fee 970 1,290 970
67935 67950
6,060 6,060
4,848 4,848
1,212 1,212
67961
15,370
12,296
3,074
67966
13,560
10,848
2,712
67971
15,150
12,120
3,030
67973
18,900
15,120
3,780
67974
18,900
15,120
3,780
67975 68320 68325 68326
15,150 5,270 6,060 7,480
12,120 4,216 4,848 5,984
3,030 1,054 1,212 1,496
68328 68330 68335
9,000 7,480 10,970
7,200 5,984 8,776
1,800 1,496 2,194
Page 28 of 31
68340 68360 68362 68371 68400 68420 68440 68500 68520 68530 68540 68550 68700 68705 68720 68745 68750 68760 68770 68811 68815 69310 69320 69400 69405 69420 69421 69433

Repair of symblepharon; division of symblepharon, with or without insertion of conformer or contact lens Conjunctival flap; bridge or partial Conjunctival flap; total (such as Gunderson thin flap or purse string flap) Harvesting conjunctival allograft, living donor Incision, drainage of lacrimal gland Incision, drainage of lacrimal sac (dacryocystostomy) Snip incision of lacrimal punctum Excision of lacrimal gland (dacryoadenectomy), except for tumor Excision of lacrimal sac (dacryocystectomy) Removal of foreign body or dacryolith, lacrimal passages Excision of lacrimal gland tumor; frontal approach Excision of lacrimal gland tumor; involving osteotomy Plastic repair of canaliculi Correction of everted punctum, cautery Dacryocystorhinostomy (fistulization of lacrimal sac to nasal cavity) Conjunctivorhinostomy (fistulization of conjunctiva to nasal cavity); without tube Conjunctivorhinostomy (fistulization of conjunctiva to nasal cavity); with insertion of tube or stent Closure of the lacrimal punctum; by thermocauterization, ligation, or laser surgery Closure of lacrimal fistula Probing of nasolacrimal duct; requiring general anesthesia Probing of nasolacrimal duct; with insertion of tube or stent Reconstruction of external auditory canal (meatoplasty) (e.g., for stenosis due to trauma, infection) Reconstruction external auditory canal for congenital atresia, single stage Eustachian tube inflation, transnasal; w/ catheterization Eustachian tube catheterization, transtympanic Myringotomy including aspiration and/or eustachian tube inflation Myringotomy including aspiration and/or eustachian tube inflation requiring general anesthesia Tympanostomy (requiring insertion of ventilating tube), local or topical anesthesia H Case Rate C I 9,000 5,990 5,990 10,490 2,840 2,840 2,840 6,060 6,060 2,840 9,000 9,000 4,850 1,820 9,000 9,000 10,490 4,010 5,440 4,010 4,850 11,650 11,650 2,906 2,840 2,840 4,010 4,130 Professional Fee Health Care Institution Fee 1,800 1,198 1,198 2,098 568 568 568 1,212 1,212 568 1,800 1,800 970 364 1,800 1,800 2,098 802 1,088 802 970 2,330 2,330 581 568 568 802 826
7,200 4,792 4,792 8,392 2,272 2,272 2,272 4,848 4,848 2,272 7,200 7,200 3,880 1,456 7,200 7,200 8,392 3,208 4,352 3,208 3,880 9,320 9,320 2,325 2,272 2,272 3,208 3,304
Page 29 of 31
69436 69440 69450 69535 69620 69650 69660

Tympanostomy (requiring insertion of ventilating tube), w/ general anesthesia Middle ear exploration through postauricular or ear canal incision Tympanolysis, transcanal Resection temporal bone, external approach Myringoplasty (surgery confined to drumhead and donor area) Stapes mobilization Stapedectomy or stapedotomy w/ reestablishment of ossicular continuity, w/ or w/o use of foreign material; Stapedectomy or stapedotomy w/ reestablishment of ossicular continuity, w/ or w/o use of foreign material; w/ footplate drill out Revision of stapedectomy or stapedotomy Repair oval window fistula Repair round window fistula Mastoid obliteration Tympanic neurectomy Closure postauricular fistula, mastoid Decompression facial nerve, intratemporal; lateral to geniculate ganglion Decompression facial nerve, intratemporal; including medial to geniculate ganglion Suture facial nerve, intratemporal, w/ or w/o graft or decompression; lateral to geniculate ganglion Suture facial nerve, intratemporal, w/ or w/o graft or decompression; including medial to geniculate ganglion Labyrinthotomy, w/ or w/o cryosurgery including other nonexcisional destructive procedures or perfusion of vestbuloactive drugs (single or multiple perfusions); transcanal Labyrinthotomy, w/ or w/o cryosurgery including other nonexcisional destructive procedures or perfusion of vestbuloactive drugs (single or multiple perfusions); w/ mastoidectomy Endolymphatic sac operation; w/o shunt Endolymphatic sac operation; w/ shunt Fenestration semicircular canal Revision fenestration operation Labyrinthectomy; transcanal Labyrinthectomy; w/ mastoidectomy Vestibular nerve section, translabyrinthine approach Cochlear device implantation, w/ or w/o mastoidectomy Vestibular nerve section, transcranial approach H Case Rate C I 4,130 9,000 4,850 23,250 10,490 18,900 19,320 Professional Fee 3,304 7,200 3,880 18,600 8,392 15,120 15,456 Health Care Institution Fee 826 1,800 970 4,650 2,098 3,780 3,864
69661 69662 69666 69667 69670 69676 69700 69720 69725 69740
19,320 19,320 19,320 19,320 15,790 15,150 5,270 15,150 15,150 18,900
15,456 15,456 15,456 15,456 12,632 12,120 4,216 12,120 12,120 15,120
3,864 3,864 3,864 3,864 3,158 3,030 1,054 3,030 3,030 3,780
69745
18,900
15,120
3,780
69801
19,320
15,456
3,864
69802
19,740
15,792
3,948
69805 69806 69820 69840 69905 69910 69915 69930 69950
23,250 26,700 23,250 26,700 23,250 26,700 26,700 27,500 27,500
18,600 21,360 18,600 21,360 18,600 21,360 21,360 22,000 22,000
4,650 5,340 4,650 5,340 4,650 5,340 5,340 5,500 5,500
Page 30 of 31
69955 69960 69970
SECOND CASE RATE

H Case Rate C Total facial nerve decompression and/or repair (may I 27,500 include graft) 26,700 Decompression internal auditory canal 23,250 Removal of tumor, temporal bone *subject to policies contained in PC 17 s 2013
DESCRIPTION
Professional Fee 22,000 21,360 18,600
Health Care Institution Fee 5,500 5,340 4,650
Page 31 of 31

PhilHealth Circular No. 0035, s.2013 Annex 3 List of Medical Conditions and Procedures Allowed As Second Case Rate

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PhilHealth Circular No. 0035, s.2013 Annex 3 List of Medical Conditions and Procedures Allowed As Second Case Rate

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ANNEX 3.

SECOND CASE RATE

Professional Fee 11,400 11,400 11,400 11,400 11,400 11,400 11,400

SECOND CASE RATE DESCRIPTION

O08.5 O08.9 O67.8 O71.0 O71.1 O71.2

4,650 4,650 4,650 4,650 4,650 4,650

2,790 2,790 2,790 2,790 2,790 2,790

1,860 1,860 1,860 1,860 1,860 1,860

SECOND CASE RATE

Professional Fee 2,790 2,790 2,790 2,790 2,790

Health Care Institution Fee 1,860 1,860 1,860 1,860 1,860

O74.8 O75.1 O75.8 O75.9 O87.9 11000 11010

4,650 4,650 4,650 4,650 4,650 10,540 10,540

2,790 2,790 2,790 2,790 2,790 5,040 5,040

1,860 1,860 1,860 1,860 1,860 5,500 5,500

11012 11040 11041 11042 11043

12,120 3,640 3,640 5,680 8,020

6,720 840 840 1,680 2,520

5,400 2,800 2,800 4,000 5,500

SECOND CASE RATE

77789 90935 90945 96408

9,700 4,000 4,000 7,280

4,200 500 500 1,680

5,500 3,500 3,500 5,600

15820 15822 15823 19160

5,060 5,060 5,990 11,000

4,048 4,048 4,792 8,800

1,012 1,012 1,198 2,200

SECOND CASE RATE

Professional Fee 8,800 8,800 8,800 8,800 8,800

Health Care Institution Fee 2,200 2,200 2,200 2,200 2,200

19340 19342 19350 19357 19361 19364 19366 19367

18,900 18,900 15,150 18,900 27,500 27,500 27,500 27,500

15,120 15,120 12,120 15,120 22,000 22,000 22,000 22,000

3,780 3,780 3,030 3,780 5,500 5,500 5,500 5,500

SECOND CASE RATE DESCRIPTION

23620 23630 23650 23660 23665 23670 23675 23680

4,850 11,650 5,270 13,560 5,990 13,560 6,060 13,560

3,880 9,320 4,216 10,848 4,792 10,848 4,848 10,848

970 2,330 1,054 2,712 1,198 2,712 1,212 2,712

23700 23900 23920 24500 24515 24516

4,850 15,150 13,560 5,060 15,370 15,370

3,880 12,120 10,848 4,048 12,296 12,296

970 3,030 2,712 1,012 3,074 3,074

24546 24560 24575

16,000 5,440 9,000

12,800 4,352 7,200

3,200 1,088 1,800

SECOND CASE RATE DESCRIPTION

24587 24600 24615 24620

18,900 5,270 11,650 5,440

15,120 4,216 9,320 4,352

3,780 1,054 2,330 1,088

24640 24650 24665

2,840 5,440 10,490

2,272 4,352 8,392

568 1,088 2,098

24670 24685 24900 24920 24925 24930 24931 25500 25515

5,440 10,970 9,000 6,060 5,480 7,480 7,480 4,850 10,970

4,352 8,776 7,200 4,848 4,384 5,984 5,984 3,880 8,776

1,088 2,194 1,800 1,212 1,096 1,496 1,496 970 2,194

SECOND CASE RATE DESCRIPTION

25530 25545 25560 25574