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TurningPoint – Procedure Coding and Medical Policy InformationProcedureCodeDescriptionACL Repair27407Repair, primary, torn ligament and/or capsule, knee; cruciateTurningPointPolicyOR-1013ACL Repair27409Repair, primary, torn ligament and/or capsule, knee; collateral and cruciate ligamentsOR-1013ACL Repair29888Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstructionOR-1013Acromioplasty and Rotator Cuff Repair23130Acromioplasty and Rotator Cuff RepairAcromioplasty and Rotator Cuff RepairAcromioplasty and Rotator Cuff Repair234102341223415Acromioplasty Or Acromionectomy, Partial, With Or Without Coracoacromial LigamentReleaseRepair of ruptured musculotendinous cuff (eg, rotator cuff) open; acuteRepair of ruptured musculotendinous cuff (eg, rotator cuff) open; chronicCoracoacromial Ligament Release, With Or Without AcromioplastyAcromioplasty and Rotator Cuff Repair23420Reconstruction of complete shoulder (rotator) cuff avulsion, chronic (includes acromioplasty)Acromioplasty and Rotator Cuff Repair29826Acromioplasty and Rotator Cuff Repair29827Arthroscopy, Shoulder, Surgical; Decompression Of Subacromial Space With PartialAcromioplasty, With Coracoacromial Ligament (Ie, Arch) Release, When Performed (ListSeparately In Addition To Code For Primary Procedure)Arthroscopy, shoulder, surgical; with rotator cuff repairAllograft for Spinal Fusion [BMP]20930Allograft, morselized, or placement of osteopromotive material, for spine surgery onlyOR-1005Ankle Fusion27870Arthrodesis, ankle, openOR-1030Ankle Fusion29899Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; with ankle arthrodesisOR-1030Cervical Disc Replacement22856Cervical Disc Replacement22861Cervical Disc Replacement22864Cervical Laminectomy and Discectomy63001Cervical Laminectomy and Discectomy63015Cervical Laminectomy and Discectomy63020Cervical Laminectomy and Discectomy63040Cervical Laminectomy and Discectomy63043Cervical Laminectomy and Discectomy63045Cervical Laminectomy and Discectomy63050Laminoplasty, cervical, with decompression of the spinal cord, 2 or more vertebral segmentsOR-1007Cervical Laminectomy and Discectomy63051Laminoplasty, cervical, with decompression of the spinal cord, 2 or more vertebral segments;with reconstruction of the posterior bony elements (including the application of bridging bonegraft and non-segmental fixation devices (eg, wire, suture, mini-plates), when performed)OR-1007Cervical Laminectomy and Discectomy63075Cervical Laminectomy and Discectomy63076Cervical Laminectomy and Discectomy63180Cervical Laminectomy and Discectomy63182Cervical Laminectomy and Discectomy63194Laminectomy with cordotomy, with section of 1 spinothalamic tract, 1 stage; cervicalOR-1007Cervical Laminectomy and Discectomy63196Laminectomy with cordotomy, with section of both spinothalamic tracts, 1 stage; cervicalOR-1007Cervical Laminectomy and Discectomy63198Laminectomy with cordotomy with section of both spinothalamic tracts, 2 stages within 14days; cervicalOR-1007Cervical Laminectomy and Discectomy63250Laminectomy for excision or occlusion of arteriovenous malformation of spinal cord; cervicalOR-1007Cervical Laminectomy and Discectomy63265Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural;cervicalOR-1007Cervical Laminectomy and Discectomy63270Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; cervicalOR-1007Cervical Laminectomy and Discectomy63275Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, cervicalOR-1007SuperiorHealthPlan.comSHP 20195259CTotal disc arthroplasty (artificial disc), anterior approach, including discectomy with end platepreparation (includes osteophytectomy for nerve root or spinal cord decompression andmicrodissection), single interspace, cervicalRevision including replacement of total disc arthroplasty (artificial disc), anterior approach,single interspace; OR-1018OR-1006OR-1006Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical OR-1006Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina,without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebralsegments; cervicalLaminectomy with exploration and/or decompression of spinal cord and/or cauda equina,without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebralsegments; cervicalLaminotomy (hemilaminectomy), with decompression of nerve root(s), including partialfacetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace,cervicalLaminotomy (hemilaminectomy), with decompression of nerve root(s), including partialfacetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration,single interspace; cervicalLaminotomy (hemilaminectomy), with decompression of nerve root(s), including partialfacetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration,single interspace; each additional cervical interspace (List separately in addition to code forprimary procedure)Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression ofspinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), singlevertebral segment; cervicalDiscectomy, anterior, with decompression of spinal cord and/or nerve root(s), includingosteophytectomy; cervical, single interspaceDiscectomy, anterior, with decompression of spinal cord and/or nerve root(s), includingosteophytectomy; cervical, each additional interspaceLaminectomy and section of dentate ligaments, with or without dural graft, cervical; 1 or 2segmentsLaminectomy and section of dentate ligaments, with or without dural graft, cervical; more than2 OR-1007OR-1007OR-1007OR-1007
ProcedureCodeDescriptionTurningPointPolicyCervical Laminectomy and Discectomy63280Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, extramedullary, cervicalOR-1007Cervical Laminectomy and Discectomy63285Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, intramedullary, cervicalOR-1007Percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neuralelements, (with or without ligamentous resection, discectomy, facetectomy and/orforaminotomy), any method, under indirect image guidance (eg, fluoroscopic, CT), with orOR-1007without the use of an endoscope, single or multiple levels, unilateral or bilateral; cervical orthoracicArthrodesis, anterior transoral or extraoral technique, clivus-C1-C2 (atlas-axis), with or withoutOR-1012excision of odontoid processCervical Laminectomy and Discectomy0274TCervical Spinal Fusion22548Cervical Spinal Fusion22551Arthrodesis, anterior interbody, including disc space preparation, discectomy,osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2OR-1012Cervical Spinal Fusion22552Arthrodesis, anterior interbody, including disc space preparation, discectomy,osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2,each additional interspace (List separately in addition to code for separate procedure)OR-1012Cervical Spinal Fusion22554Cervical Spinal FusionCervical Spinal Fusion2259022595Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspaceOR-1012(other than for decompression); cervical below C2Arthrodesis, posterior technique, craniocervical (occiput-C2)OR-1012Arthrodesis, posterior technique, atlas-axis (C1-C2)OR-1012Cervical Spinal Fusion22600Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segmentElbow Replacement24160Removal of prosthesis, includes debridement and synovectomy when performed; humeral andOR-1022ulnar componentsElbow Replacement24164Removal of prosthesis, includes debridement and synovectomy when performed; radial headOR-1022Elbow ReplacementElbow ReplacementElbow ow Replacement24363Elbow ReplacementElbow Replacement2436524366Elbow Replacement24370Elbow Replacement24371Femoroacetabular Arthroscopy27299Femoroacetabular ArthroscopyFemoroacetabular Arthroscopy2991429915Femoroacetabular Arthroscopy29916Arthroplasty, elbow; with membrane (e.g., fascial)Arthroplasty, elbow; with distal humeral prosthetic replacementArthroplasty, elbow; with implant and fascia lata ligament reconstructionArthroplasty, elbow; with distal humerus and proximal ulnar prosthetic replacement (e.g., totalelbow)Arthroplasty, radial headArthroplasty, radial head; with implantRevision of total elbow arthroplasty, including allograft when performed; humeral or ulnarcomponentRevision of total elbow arthroplasty, including allograft when performed; humeral and ulnarcomponentUnlisted procedure, pelvis or hip joint [when specified as open procedure forfemoroacetabular impingement syndrome, other than capsular plication]Arthroscopy, hip, surgical; with femoroplasty (ie, treatment of cam lesion)Arthroscopy, hip, surgical; with acetabuloplasty (ie, treatment of pincer lesion)Arthroscopy, hip, surgical; with labral repair [when repair of the labral tear is associated withFAIS]Hip Arthroscopy29860Arthroscopy, Hip, Diagnostic With Or Without Synovial Biopsy (Separate Procedure)OR-1031Hip Arthroscopy29861OR-1031Hip Arthroscopy29862Hip ArthroscopyHip Resurfacing2986327033Arthroscopy, Hip, Surgical; With Removal Of Loose Body Or Foreign BodyArthroscopy, Hip, Surgical; With Debridement/Shaving Of Articular Cartilage (Chondroplasty),Abrasion Arthroplasty, And/Or Resection Of LabrumArthroscopy, Hip, Surgical; With SynovectomyArthrotomy, hip, including exploration or removal of loose or foreign bodyHip Resurfacing27125Hip Hemiarthroplasty, hip, partial (eg, femoral stem prosthesis, bipolar arthroplasty)OR-1026Hip Resurfacing27360Hip ResurfacingS2118Partial excision (craterization, saucerization, or diaphysectomy) bone, femur, proximal tibiaand/or fibula (eg, osteomyelitis or bone abscessMETL-ON-METL TOT HIP RESRFC ACETAB&FEM CMPNTImplantable Infusion Pumps36260Insertion of implantable intra-arterial infusion pump (eg, for chemotherapy of liver)Implantable Infusion Pumps36563Implantable Infusion Pumps36583Implantable Infusion Pumps61215Implantable Infusion Pumps62350Implantable Infusion Pumps62351Implantable Infusion Pumps62360Implantable Infusion Pumps62361SuperiorHealthPlan.comSHP 20195259CInsertion Of Tunneled Centrally Inserted Central Venous Access Device With SubcutaneousPumpReplacement, Complete, Of A Tunneled Centrally Inserted Central Venous Access Device,With Subcutaneous Pump, Through Same Venous AccessInsertion of subcutaneous reservoir, pump or continuous infusion system for connection toventricular catheterImplantation, Revision Or Repositioning Of Tunneled Intrathecal Or Epidural Catheter, ForLong-Term Medication Administration Via An External Pump Or ImplantableReservoir/Infusion Pump; Without LaminectomyImplantation, Revision Or Repositioning Of Tunneled Intrathecal Or Epidural Catheter, ForLong-Term Medication Administration Via An External Pump Or ImplantableReservoir/Infusion Pump; With LaminectomyImplantation Or Replacement Of Device For Intrathecal Or Epidural Drug Infusion;Subcutaneous ReservoirImplantation Or Replacement Of Device For Intrathecal Or Epidural Drug Infusion;Nonprogrammable 4OR-1034OR-1034
ble Infusion Pumps62362Implantation Or Replacement Of Device For Intrathecal Or Epidural Drug Infusion;Programmable Pump, Including Preparation Of Pump, With Or Without ProgrammingOR-1034Implantable Infusion Pumps62365Implantable Infusion Pumps62367Implantable Infusion Pumps62368Implantable Infusion PumpsImplantable Infusion PumpsImplantable Infusion PumpsC1772C1891C2626Implantable Infusion PumpsE0783Implantable Infusion PumpsE0785Implantable Infusion PumpsE0786Knee Arthroscopy27405Removal Of Subcutaneous Reservoir Or Pump, Previously Implanted For Intrathecal OrEpidural InfusionElectronic Analysis Of Programmable, Implanted Pump For Intrathecal Or Epidural DrugInfusion (Includes Evaluation Of Reservoir Status, Alarm Status, Drug Prescription Status);Without Reprogramming Or RefilElectronic Analysis Of Programmable, Implanted Pump For Intrathecal Or Epidural DrugInfusion (Includes Evaluation Of Reservoir Status, Alarm Status, Drug Prescription Status);With ReprogrammingInfusion pump, programmable (implantable)Infusion pump, nonprogrammable, permanent (implantable)Infusion pump, nonprogrammable, temporary (implantable)Infusion pump system, implantable, programmable (includes all components, e.g., pump,catheter, connectors, etc.)Implantable intraspinal (epidural/intrathecal) catheter used with implantable infusion pump,replacementImplantable programmable infusion pump, replacement (excludes implantable intraspinalcatheter)Repair, primary, torn ligament and/or capsule, knee; collateralKnee Arthroscopy29870Arthroscopy, knee, diagnostic, with or without synovial biopsy (separate procedure)OR-1029Knee ArthroscopyKnee Arthroscopy2987129873OR-1029OR-1029Knee Arthroscopy29874Knee Arthroscopy29875Knee Arthroscopy29876Arthroscopy, knee, surgical; for infection, lavage and drainageArthroscopy, knee, surgical; with lateral releaseArthroscopy, knee, surgical; for removal of loose body or foreign body (eg, osteochondritisdissecans fragmentation, chondral fragmentation)Arthroscopy, knee, surgical; synovectomy, limited (eg, plica or shelf resection) (separateprocedure)Arthroscopy, knee, surgical; synovectomy, major, 2 or more compartments (eg, medial orlateral)Knee Arthroscopy29877Arthroscopy, knee, surgical; debridement/ shaving or articular cartilage (chondroplasty)OR-1029Knee Arthroscopy29879Knee Arthroscopy29880Knee Arthroscopy29881Knee Arthroscopy29884Knee Arthroscopy29885Arthroscopy, knee, surgical; drilling for osteochondritis dissecans with bone grafting, with orwithout internal fixaiton (including debridement of base of lesion)OR-1029Knee Arthroscopy29886Arthroscopy, knee, surgical; drilling for intact osteochondritis dissecans lesionOR-1029Knee Arthroscopy29887Knee Arthroscopy29889Knee Arthroscopy29999Knee ArthroscopyG0289Kyphoplasty and Vertebroplasty22510Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body,unilateral or bilateral injection, inclusive of all imaging guidance; cervicothoracicOR-1024Kyphoplasty and Vertebroplasty22511Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body,unilateral or bilateral injection, inclusive of all imaging guidance; lumbosacral [when specifiedas lumbar]OR-1024Kyphoplasty and Vertebroplasty22512Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body,unilateral or bilateral injection, inclusive of all imaging guidance; each additionalcervicothoracic or lumbosacral vertebral body [when specified as other than sacral]OR-1024Kyphoplasty and Vertebroplasty22513Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bonebiopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebralbody, unilateral or bilateral cannulation, inclusive of all imaging guidance; thoracicOR-1024Kyphoplasty and Vertebroplasty22514Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bonebiopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebralbody, unilateral or bilateral cannulation, inclusive of all imaging guidance; lumbarOR-1024SuperiorHealthPlan.comSHP 20195259CArthroscopy, knee, surgical; abrasion arthroplasty (includes chondroplasty where necessary)or multiple drilling or microfractureArthroscopy, knee, surgical; with meniscectomy (medial AND lateral, including any meniscalshaving) including debridement/ shaving of articular cartilage (chondroplasty), same orseparate compartment(s), when performedArthroscopy, knee, surgical; with meniscectomy (medial OR lateral, including any meniscalshaving) including debridement/ shaving of articular cartilage (chondroplasty), same orseparate compartment(s), when performedArthroscopy, knee, surgical; with lysis of adhesions, with or without manipulation (separateprocedure)Arthroscopy, knee, surgical; drilling for intact osteochondritis dissecans lesion with internalfixationARTHRS AIDED PST CRUCIATE LIGM RPR/AGMNTJ/RCNSTJUnlisted procedure, arthroscopy [when specified as arthroscopic knee lavage as a separateprocedure]Arthroscopy, knee, surgical, for removal of loose body, foreign body, debridement/shaving ofarticular cartilage (chondroplasty) at the time of other surgical knee arthroscopy in a differentcompartment of the same edure]OR-1029
CodeDescriptionTurningPointPolicyKyphoplasty and Vertebroplasty22515Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bonebiopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebralbody, unilateral or bilateral cannulation, inclusive of all imaging guidance; each additionalthoracic or lumbar vertebral bodyOR-1024Kyphoplasty and Vertebroplasty0200TPercutaneous sacral augmentation (sacroplasty), unilateral injection(s), including the use of aOR-1024balloon or mechanical device, when used, 1 or more needlesKyphoplasty and Vertebroplasty0201TPercutaneous sacral augmentation (sacroplasty), bilateral injections, including the use of aballoon or mechanical device, when used, 2 or more needlesKyphoplasty and Vertebroplasty0202TPosterior vertebral joint(s) arthroplasty (eg, facet joint[s] replacement), including facetectomy,laminectomy, foraminotomy, and vertebral column fixation, injection of bone cement, whenOR-1024performed, including fluoroscopy, single level, lumbar spineLaminectomy- Unspecified63170Laminectomy with myelotomy (eg, Bischof or DREZ type), cervical, thoracic, or thoracolumbarLaminectomy- Unspecified63172Laminectomy with drainage of intramedullary cyst/syrinx; to subarachnoid spaceLaminectomy- Unspecified63173Laminectomy with drainage of intramedullary cyst/syrinx; to peritoneal or pleural spaceLaminectomy- UnspecifiedLaminectomy- UnspecifiedLaminectomy- Unspecified631856319063191Laminectomy with rhizotomy; 1 or 2 segmentsLaminectomy with rhizotomy; more than 2 segmentsLaminectomy with section of spinal accessory nerveLumbar Disc Replacement22857Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepareinterspace (other than for decompression), single interspace, lumbarOR-1003Lumbar Disc Replacement22862Revision including replacement of total disc arthroplasty (artificial disc), anterior approach,single interspace; lumbarOR-1003Lumbar Disc Replacement22865Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace, lumbar OR-1003Lumbar Disc Replacement0163TTotal disc arthroplasty (artificial disc), anterior approach, including discectomy to prepareinterspace (other than for decompression), each additional interspace, lumbarOR-1003Lumbar Disc Replacement0164TRemoval of total disc arthroplasty (artificial disc), anterior approach, each additionalinterspace, lumbar (List separately in addition to code for primary procedure)OR-1003Lumbar Disc Replacement0165TRevision including replacement of total disc arthroplasty (artificial disc), anterior approach,each additional interspace, lumbarOR-1003Lumbar Laminectomy, Discectomy, and Laminotomy62287Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, anymethod utilizing needle based technique to remove disc material under fluoroscopic imagingor other form of indirect visualization, with the use of an endoscope, with discography and/orepidural injection(s) at the treated level(s), when performed, single or multiple levels, lumbarOR-1008Lumbar Laminectomy, Discectomy, and Laminotomy63003Lumbar Laminectomy, Discectomy, and Laminotomy63005Lumbar Laminectomy, Discectomy, and Laminotomy63011Lumbar Laminectomy, Discectomy, and Laminotomy63012Lumbar Laminectomy, Discectomy, and Laminotomy63016Lumbar Laminectomy, Discectomy, and Laminotomy63017Lumbar Laminectomy, Discectomy, and Laminotomy63030Lumbar Laminectomy, Discectomy, and Laminotomy63035Lumbar Laminectomy, Discectomy, and Laminotomy63042Lumbar Laminectomy, Discectomy, and Laminotomy63044ProcedureSuperiorHealthPlan.comSHP 20195259CLaminectomy with exploration and/or decompression of spinal cord and/or cauda equina,without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebralsegments; thoracicLaminectomy with exploration and/or decompression of spinal cord and/or cauda equina,without facetectomy, foraminotomy or discectomy (eg, spinal stenosis) 1 or 2 vertebralsegments; lumbar, except for spondylolisthesisLaminectomy with exploration and/or decompression of spinal cord and/or cauda equina,without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebralsegments; sacralOR-1024[Follows mainprocedure][Follows mainprocedure][Follows mainprocedure][Follows main[Follows main[Follows mainOR-1008OR-1008OR-1008Laminectomy with removal of abnormal facets and/or pars interarticularis with decompressionOR-1008of cauda equina and nerve roots for spondylolisthesis, lumbar (Gill type procedure)Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina,without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebralsegments; thoracicLaminectomy with exploration and/or decompression of spinal cord and/or cauda equina,without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebralsegments; lumbarLaminotomy (hemilaminectomy), with decompression of nerve root(s), including partialfacetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace,lumbarLaminotomy (hemilaminectomy), with decompression of nerve root(s), including partialfacetectomy, foraminotomy and/or excision of herniated intervertebral disc; each additionalinterspace, cervical or lumbarLaminotomy (hemilaminectomy), with decompression of nerve root(s), including partialfacetectomy, foraminotomy and/or excision of herniated intervertebral disc, re-exploration,single interspace; lumbarLaminotomy (hemilaminectomy), with decompression of nerve root(s), including partialfacetectomy, foraminotomy and/or excision of herniated intervertebral disc, re-exploration,single interspace; each additional lumbar 08
DescriptionTurningPointPolicyProcedureCodeLumbar Laminectomy, Discectomy, and Laminotomy63046Lumbar Laminectomy, Discectomy, and Laminotomy63047Lumbar Laminectomy, Discectomy, and Laminotomy63048Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression ofspinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), singlevertebral segment; each additional segment, cervical, thoracic, or lumbarOR-1008Lumbar Laminectomy, Discectomy, and Laminotomy63056Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg,herniated intervertebral disc), single segment; lumbar (including transfacet, or lateralextraforaminal approach) (eg, far lateral herniated intervertebral disc)OR-1008Lumbar Laminectomy, Discectomy, and Laminotomy63057Lumbar Laminectomy, Discectomy, and Laminotomy63200Lumbar Laminectomy, Discectomy, and Laminotomy63252Lumbar Laminectomy, Discectomy, and Laminotomy63267Lumbar Laminectomy, Discectomy, and Laminotomy63272Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; lumbarOR-1008Lumbar Laminectomy, Discectomy, and Laminotomy63277Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, lumbarOR-1008Lumbar Laminectomy, Discectomy, and Laminotomy63282Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, extramedullary, lumbarOR-1008Lumbar Laminectomy, Discectomy, and Laminotomy63287Lumbar Laminectomy, Discectomy, and Laminotomy63290Lumbar Laminectomy, Discectomy, and Laminotomy63303Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression ofspinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), singlevertebral segment; thoracicLaminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression ofspinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), singlevertebral segment; lumbarTranspedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg,herniated intervertebral disc), single segment; each additional segment, thoracic or lumbar[when specified as lumbar]Laminectomy, with release of tethered spinal cord, lumbarLaminectomy for excision or occlusion of arteriovenous malformation of spinal cord;thoracolumbarLaminectomy for excision or evacuation of intraspinal lesion other than neoplasm, 08OR-1008Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, intramedullary,OR-1008thoracolumbarLaminectomy for biopsy/excision of intraspinal neoplasm; combined extradural-intraduralOR-1008lesion, any level [when specified as lumbar]Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinallesion, single segment; extradural, lumbar or sacral by transperitoneal or retroperitonealOR-1008approachLumbar Laminectomy, Discectomy, and Laminotomy0275TPercutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neuralelements, (with or without ligamentous resection, discectomy, facetectomy and/orforaminotomy), any method, under indirect image guidance (eg, fluoroscopic, CT), with orwithout the use of an endoscope, single or multiple levels, unilateral or bilateral; lumbarLumbar Laminectomy, Discectomy, and LaminotomyS2348Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, usingradiofrequency energy, single or multiple levels, lumbarLumbar Laminectomy, Discectomy, and LaminotomyS2350Lumbar Laminectomy, Discectomy, and LaminotomyS2351Lumbar Spinal Fusion22533Lumbar Spinal Fusion22558Lumbar Spinal Fusion22586Lumbar Spinal Fusion22612Lumbar Spinal Fusion22630Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy toprepare interspace (other than for decompression), single interspace; lumbarLumbar Spinal Fusion22633Arthrodesis, combined posterior or posterolateral technique with posterior interbody techniqueincluding laminectomy and/or discectomy sufficient to prepare interspace (other than forOR-1004decompression), single interspace and segment; lumbarLumbar Spinal Fusion0195TArthrodesis, pre-sacral interbody technique, disc space preparation, discectomy, withoutOR-1004instrumentation, with image guidance, includes bone graft when performed; L5-S1 interspaceLumbar Spinal Fusion0196TArthrodesis, pre-sacral interbody technique, disc space preparation, discectomy, withoutinstrumentation, with image guidance, includes bone graft when performed; L4-L5 interspaceMeniscal Repair and Allograft Transplantation29868Meniscal Repair and Allograft TransplantationMeniscal Repair and Allograft TransplantationOsteochondral Defect Repair298822988327412SuperiorHealthPlan.comSHP 20195259CDiskectomy, anterior, with decompression of spinal cord and/or nerve root(s), includingosteophytectomy; lumbar, single interspaceDiskectomy, anterior, with decompression of spinal cord and/or nerve root(s), includingosteophytectomy; lumbar, each additional interspace (list separately in addition to code forprimary procedure)Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepareinterspace (other than for decompression); lumbarArthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace(other than for decompression); lumbarArthrodesis, pre-sacral interbody technique, including disc space preparation, discectomy,with posterior instrumentation, with image guidance, includes bone graft when performed, L5S1 interspaceArthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transversetechnique, when performed)Arthroscopy, knee, surgical; meniscal transplantation (includes arthrotomy for meniscalinsertion), medial or lateralArthroscopy, knee, surgical; with meniscus repair (medial OR lateral)Arthroscopy, knee, surgical; with meniscus repair (medial AND lateral)Autologous chondrocyte implantation, 14
ndral Defect Repair27415Osteochondral allograft, knee, open [when specified as osteochondral allograft]OR-1014Osteochondral Defect Repair27416Osteochondral autograft(s), knee, open (eg, mosaicplasty) includes harvesting of autograft[s]) OR-1014Osteochondral Defect Repair29866Osteochondral Defect RepairOsteochondral Defect RepairOsteochondral Defect RepairPartial Knee ReplacementPartial Knee ReplacementPartial Knee ReplacementPartial Knee ReplacementPartial Knee 2Partial Knee Replacement27443Partial Knee ReplacementRevision of Total Hip Replacement2744627090Revision of Total Hip Replacement27091Revision of Total Hip Replacement27134Hip Revision of total hip arthroplasty; both components, with or without autograft or allograftOR-1016Revision of Total Hip Replacement27137Hip Revision of total hip arthroplasty; acetabular component only, with
Infusion pump system, implantable, programmable (includes all components, e.g., pump, catheter, connectors, etc.) OR-1034 Implantable Infusion Pumps E0785 Implantable intraspinal (epidural/intrathecal) catheter used with implantable infusion pump, replacement OR-1034 Implantable Infusion Pumps E0786
