Updated January 2018

Commercial Musculoskeletal Codes

Investigational or Non-Covered Spine Surgery Pain Management Joint Surgery Codes associated with an Arthrogram CPT Description Commercial Notes Partial excision of posterior vertebral component (eg, spinous 22100 process, lamina or facet) for intrinsic bony lesion, single vertebral segment; cervical

22101 Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; thoracic

22102 Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; lumbar

Partial excision of posterior vertebral component (eg, spinous process, 22103 lamina or facet) for intrinsic bony lesion, single vertebral segment; each additional segment (List separately in addition to code for primary procedure) Partial excision of vertebral body, for intrinsic bony lesion, without 22110 decompression of spinal cord or nerve root(s), single vertebral segment;cervical Partial excision of vertebral body, for intrinsic bony lesion, without 22112 decompression of spinal cord or nerve root(s), single vertebral segment; thoracic Partial excision of vertebral body, for intrinsic bony lesion, without 22114 decompression of spinal cord or nerve root(s), single vertebral segment; lumbar each additional vertebral segment (list separately in addition to code 22116 for primary procedure) Osteotomy of spine, posterior or posterolateral approach, 3 columns, 22206 1 vertebral segment (eg, pedicle/vertebral body subtraction); thoracic Osteotomy of spine, posterior approach, 3 columns, 1 vertebral 22207 segment (eg. Pedicle/vertebral body subtraction);lumbar Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (eg, pedicle/vertebral body subtraction); each 22208 additional vertebral segment (list separately in addition to code for primary procedure) Osteotomy of spine, posterior or posterolateral approach, one 22210 vertebral segment; cervical Osteotomy of spine, posterior or posterolateral approach, 1 vertebral 22212 segment; thoracic Osteotomy of spine, posterior or posterolateral approach, 1 vertebral 22214 segment; lumbar each additional vertebral segment (list separately in addition to code 22216 for primary procedure) Osteotomy of spine, including discectomy anterior approach, single 22220 vertebral segment; cervical Osteotomy of spine, including discectomy, anterior approach, single 22222 vertebral segment; thoracic Osteotomy of spine, including discectomy, anterior approach, single 22224 vertebral segment; lumbar Updated January 2018

Osteotomy of spine, including discectomy, anterior approach, single 22226 vertebral segment; each additional vertebral segment (List separately in addition to code for primary procedure Percutaneous vertebroplasty (bone biopsy included when 22510 performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; cervicothoracic Percutaneous vertebroplasty (bone biopsy included when 22511 performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; lumbosacral Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, 22512 inclusive of all imaging guidance; each additional cervicothoracic or lumbosacral vertebral body (List separately in addition to code for primary procedure) Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using 22513 mechanical device (e.g., kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; thoracic

Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using 22514 mechanical device (e.g., kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; lumbar Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (e.g., kyphoplasty), 1 vertebral body, unilateral or 22515 bilateral cannulation, inclusive of all imaging guidance; each additional thoracic or lumbar vertebral body (List separately in addition to code for primary procedure) Arthrodesis, lateral extracavitary technique, including minimal 22532 discectomy to prepare interspace (other than for decompression); thoracic Arthrodesis, lateral extracavitary technique, including minimal 22533 discectomy to prepare interspace (other than for decompression); lumbar Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); 22534 thoracic or lumbar, each additional vertebral segment (List separately in addition to code for primary procedure) Arthrodesis, anterior transoral or extraoral technique, clivus-C1-C2 22548 (atlas-axis), with or without excision of odontoid process Arthrodesis, anterior interbody, including disc space preparation, 22551 discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2 Arthrodesis, anterior interbody, including disc space prep, 22552 discectomy, osteophytectomy + decompression of spinal cord a Arthrodesis, anterior interbody technique, including minimal 22554 discectomy to prepare interspace (other than for decompression); cervical below C2 Arthrodesis, anterior interbody technique, including minimal 22556 discectomy to prepare interspace (other than for decompression); thoracic Arthrodesis, anterior interbody technique, including minimal 22558 discectomy to prepare interspace (other than for decompression); lumbar Updated January 2018

Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); 22585 each additional interspace (List separately in addition to code for primary procedure) Arthrodesis, pre-sacral interbody technique, including disc space 22586 preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft when performed, L5-S1 interspace

22590 Arthrodesis, posterior technique, craniocervical (occiput-C2) 22595 Arthrodesis, posterior technique, atlas-axis (C1-C2) Arthrodesis, posterior or posterolateral technique, single level; 22600 cervical below C2 segment Arthrodesis, posterior or posterolateral technique, single level; 22610 thoracic (with or without lateral transverse technique) Arthrodesis, posterior or posterolateral technique, single level; 22612 lumbar (with or without lateral transverse technique) Arthrodesis, posterior or posterolateral technique, single level; each 22614 additional vertebral segment (List separately in addition to code for primary procedure) Arthrodesis, posterior interbody technique, including laminectomy 22630 and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for 22632 decompression), single interspace; each additional interspace (List separately in addition to code for primary procedure) Arthrodesis, combined posterior or posterolateral technique with 22633 posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for 22634 decompression), single interspace and segment; each additional interspace and segment (List separately in addition to code for primary procedure) Arthrodesis, posterior, for spinal deformity, with or without cast; up to 22800 6 vertebral segments Arthrodesis, posterior, for spinal deformity, with or without cast; 7 to 22802 12 vertebral segments Arthrodesis, posterior, for spinal deformity, with or without cast; 13 or 22804 more vertebral segments Arthrodesis, anterior, for spinal deformity, with or without cast; 2 to 3 22808 vertebral segments Arthrodesis, anterior, for spinal deformity, with or without cast; 4 to 7 22810 vertebral segments Arthrodesis, anterior, for spinal deformity, with or without cast; 8 or 22812 more vertebral segments Kyphectomy, circumferential exposure of spine and resection of 22818 vertebral segment(s) (including body and posterior elements); single or 2 segments Kyphectomy, circumferential exposure of spine and resection of 22819 vertebral segment(s) (including body and posterior elements); 3 or more segments 22830 Exploration of spinal fusion Updated January 2018

Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial 22840 transarticular screw fixation, sublaminar wiring at C1, facet screw fixation) (List separately in addition to code for primary procedure) Internal spinal fixation by wiring of spinous processes (List 22841 separately in addition to code for primary procedure) Posterior segmental instrumentation (eg, pedicle fixation, dual rods 22842 with multiple hooks and sublaminar wires); 3 to 6 vertebral segments (List separately in addition to code for primary procedure)

Posterior segmental instrumentation (eg, pedicle fixation, dual rods 22843 with multiple hooks and sublaminar wires); 7 to 12 vertebral segments (List separately in addition to code for primary procedure)

Posterior segmental instrumentation (eg, pedicle fixation, dual rods 22844 with multiple hooks and sublaminar wires); 13 or more vertebral segments (List separately in addition to code for primary procedure) Anterior instrumentation; 2 to 3 vertebral segments (List separately 22845 in addition to code for primary procedure) Anterior instrumentation; 4 to 7 vertebral segments (List separately 22846 in addition to code for primary procedure) Anterior instrumentation; 8 or more vertebral segments (List 22847 separately in addition to code for primary procedure) 22849 Reinsertion of spinal fixaton device

Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, 22853 screws, flanges), when performed, to intervertebral disc space in Added 9/1/2017 conjunction with interbody arthrodesis, each interspace (List separately in addition to code for primary procedure)

Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device 22854 anchoring (eg, screws, flanges), when performed, to vertebral Added 9/1/2017 corpectomy(ies) (vertebral body resection, partial or complete) defect, in conjunction with interbody arthrodesis, each contiguous defect (List separately in addition to code for primary procedure)

Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for 22856 nerve root or spinal cord decompression and microdissection); single interspace, cervical

Total disc arthroplasty (artificial disc), anterior approach, including 22857 discectomy to prepare interspace (other than for decompression), single interspace, lumbar Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for 22858 nerve root or spinal cord decompression and microdissection); second level, cervical (List separately in addition to code for primary procedure) Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh, methylmethacrylate) to intervertebral disc space or 22859 Added 9/1/2017 vertebral body defect without interbody arthrodesis, each contiguous defect (List separately in addition to code for primary procedure) Updated January 2018

Revision including replacement of total disc arthroplasty (artificial 22861 disc), anterior approach, single interspace; cervical Revision including replacement of total disc arthroplasty (artificial 22862 disc), anterior approach, single interspace; lumbar Removal of total disc arthroplasty (artificial disc), anterior approach, 22864 single interspace; cervical Removal of total disc arthroplasty (artificial disc), anterior approach, 22865 single interspace; lumbar Added 9/1/2017 Insertion of interlaminar/interspinous process stabilization/distraction Investigational Per 22867 device, without fusion, including image guidance when performed, BCBST Medical with open decompression, lumbar; single level Policy Insertion of interlaminar/interspinous process stabilization/distraction Added 9/1/2017 device, without fusion, including image guidance when performed, Investigational Per 22868 with open decompression, lumbar; second level (List separately in BCBST Medical addition to code for primary procedure) Policy Added 9/1/2017 Insertion of interlaminar/interspinous process stabilization/distraction Investigational Per 22869 device, without open decompression or fusion, including image BCBST Medical guidance when performed, lumbar; single level Policy Insertion of interlaminar/interspinous process stabilization/distraction Added 9/1/2017 device, without open decompression or fusion, including image Investigational Per 22870 guidance when performed, lumbar; second level (List separately in BCBST Medical addition to code for primary procedure) Policy 23031 Incision and drainage, shoulder area; infected bursa Incision, bone cortex (eg, osteomyelitis or bone abscess), shoulder 23035 area Arthrotomy, glenohumeral joint,including exploration, drainage, or 23040 removal of foreign body Arthrotomy, acromioclavicular, sternoclavicular joint, including 23044 exploration, drainage, or removal of foreign body 23065 Biopsy, soft tissue of shoulder area, superficial 23066 Biopsy, soft tissue of shoulder area, deep Excision, tumor, soft tissue of shoulder area, subcutaneous; 3 cm or 23071 greater Excision, tumor soft tissue of shoulder area, subfascial (eg. 23073 Intramuscular) 5 cm or greater Excision, tumor, soft tissue of shoulder area, subcutaneous; less 23075 than 3 cm Excision, tumor, soft tissue of shoulder area, subfascial (eg. 23076 Intramuscular); less than 5 cm Radical resection of tumor (eg. Sarcoma), soft tissue of shoulder 23077 area; less than 5 cm Radical resection of tumor (eg. Sarcoma), soft tissue of shoulder 23078 area; greater than 5 cm 23100 Arthrotomy, glenohumeral joint, including biopsy Arthrotomy, acromioclavicular joint or sternoclavicular joint, including 23101 biopsy and/or excision of torn cartilage Arthrotomy; glenohumeral joint, with synovectomy, with or without 23105 biopsy Arthrotomy; sternoclavicular joint, with synovectomy, with or without 23106 biopsy Arthrotomy, glenohumeral joint, with joint exploration, with or without 23107 removal of loose or foreign body 23120 Claviculectomy; partial 23125 Claviculectomy; total Updated January 2018

Acromioplasty or acrominonectomy, partial with or without 23130 coracoacromial ligament release Excision or curettage of bone cyst or benign tumor of clavicle or 23140 scapula Excision or curettage of bone cyst or benign tumor of clavicle or 23145 scapula; with autograft (includes obtaining graft) Excision or curettage of bone cyst or benign tumor of clavicle or 23146 scapula; with allograft Excision or curettage of bone cyst or benign tumor of proximal 23150 humerus Excision or curettage of bone cyst or benign tumor of proximal 23155 humerus; with autograft (includes obtaining graft) Excision or curettage of bone cyst or benign tumor of proximal 23156 humerus; with allograft 23170 Sequestrectomy (eg., for osteomyelitis or bone abscess), clavicle

23172 Sequestrectomy (eg., for osteomyelitis or bone abscess), scapula Sequestrectomy (eg.,for osteomyelitis or bone abscess), humeral 23174 head to surgical neck Partial excision (craterization, saucerization, or diaphysectomy) bone 23180 (eg. Osteomyelitis), clavicle Partial excision (craterization, saucerization, or diaphysectomy) bone 23182 (eg. Osteomyelitis), scapula Partial excision (craterization, saucerization, or diaphysectomy) bone 23184 (eg, Osteomyelitis), proximal humerus 23190 Ostectomy of scapula, partial (eg, superior medial angle) 23195 Resection, humeral head 23200 Radical resection of tumor; clavicle 23210 Radical resection of tumor; scapula 23220 Radical resection of tumor, proximal humerus 23330 Removal of foreign body, shoulder;subcutaneous Removal of foreign body, shoulder; deep (subfascial or 23333 intramuscular)

23334 Removal of prostheses, includes debridement and synovectomy when performed; humeral or glenoid component

23335 Removal of prostheses, includes debridement and synovectomy when performed; humeral and glenoid component Injection procedure for shoulder arthrography or enhanced CT/MRI 23350 shoulder arthrography 23395 Muscle transfer, any type, shoulder or upper arm; single 23397 Muscle transfer, any type, shoulder or upper arm; multiple 23400 Scapulopexy (eg, Sprengels deformity or for paralysis) 23405 Tenotomy, shoulder area; single tendon 23406 Tenotomy, shoulder area; multiple tendons through same incision Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; 23410 acute Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; 23412 chronic 23415 Coracoacromial ligament release, with or without acromioplasty Reconstruction of complete shoulder (rotator) cuff avulsion, chronic 23420 (includes acromioplasty) 23430 Tenodesis of long tendon of biceps Updated January 2018

23440 Resection or transplantation of long tendon of biceps Capsulorrhaphy, anterior, Putti-Platt procedure or Magnuson type 23450 operation 23455 Capsulorrhaphy, anterior, with labral repair (eg, Bankart procedure) 23460 Capsulorrhaphy, anterior, any type; with bone block 23462 Capsulorrhaphy, anterior, with coracoid process transfer Capsulorrhaphy, glenohumeral joint, posterior, with or without bone 23465 block Capsulorrhaphy, glenohumeral joint, any type multidirectional 23466 instability 23470 Arthroplasty, glenohumeral joint; hemiarthroplasty Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal 23472 humeral replacement (eg, total shoulder)) Revision of total shoulder arthroplasty, including allograft when performed; 23473 humeral or glenoid component Revision of total shoulder arthroplasty, including allograft when performed; 23474 humeral and glenoid component 23480 Osteotomy, clavicle, with or without internal fixation Osteotomy, clavicle, with or without internal fixation; with bone graft 23485 for nonunion or malunion (includes obtaining graft and/or necessary fixation) Prophylactic tratment (nailing, pinning, plating or wiring) with or 23490 without methylemathacrylate; clavicle Prophylactic tratment (nailing, pinning, plating or wiring) with or 23491 without methylemathacrylate; proximal humerus 23800 Arthrodesis, glenohumeral joint 23802 with autogenous graft (includes obtaining graft) 23929 Unlisted procedure, shoulder Incision and drainage, pelvis or hip joint area; deep abscess or 26990 hematoma 26991 Incision and drainage, pelvis or hip joint area; infected bursa Incision, bone cortex, pelvis and/or hip joint (eg, osteomyelitis or 26992 bone abscess) 27000 Tenotomy, adductor of hip, percutaneous (separate procedure) 27001 Tenotomy, adductor of hip, open Tenotomy, adductor, subcutaneous, open, with obturator 27003 neurectomy 27005 Tenotomy, hip flexor(s), open (separate procedure) Tenotomy, abductors and/or extensor(s) of hip, open (separate 27006 procedure) 27025 Fasciotomy, hip or thigh, any type Decompression fasciotomy(ies), pelvic (buttock) compartment(s) (eg, 27027 gluteus medius-minimus, gluteus maximus, iliopsoas, and/or tensor fascia lata muscle), unilateral

27030 Arthrotomy, hip, with drainage (eg, infection) Arthrotomy, hip, including exploration or removal of loose or foreign 27033 body Denervation, hip joint, intrapelvic or extrapelvic intra-articular 27035 branches of sciatic, femoral, or obturator nerves Capsulectomy or capsulotomy, hip, with or without excision of heterotopic bone, with release of hip flexor muscles (ie, gluteus 27036 medius, gluteus minimus, tensor fascia latae, rectus femoris, sartorius, iliopsoas) 27040 Biopsy, soft tissue of pelvis and hip area; superficial Updated January 2018

Biopsy, soft tissue of pelvis and hip area; deep, subfascial or 27041 intramuscular Excision, tumor, soft tissue of pelvis and hip area, subcutaneous; 3 27043 cm or greater Excision, tumor, soft tissue of pelvis and hip area, subfascial (eg, 27045 intramuscular); 5 cm or greater Excision, tumor, soft tissue of pelvis and hip area, subcutaneous; 27047 less than 3 cm Excision, tumor, soft tissue of pelvis and hip area, subfascial (eg, 27048 intramuscular); less than 5 cm Radical resection of tumor (eg, sarcoma), soft tissue of pelvis and 27049 hip area; less than 5 cm 27050 Arthrectomy with biopsy; sacroiliac joint 27052 hip joint 27054 Arthrotomy with synovectomy,hip joint Decompression fasciotomy (ies), pelvic (buttock) compartment(s) (eg, gluteus medius-minimus, gluteus maximus,iliopsoas, and/or 27057 tensor fascia lata muscle), with debridement of nonviable muscle, unilateral Radical resection of tumor (eg,sarcoma), soft tissue of pelvis and 27059 hip area; 5 cm or greater 27060 Excision; ischial bursa 27062 trochanteric bursa or calcification Excision of bone cyst or benign tumor, wing of ilium, symphysis 27065 pubis, or greater trochanter of femur; superficial, includes autograft, when performed 27066 deep, (subfascial), includes autograft when performed 27067 with autograft requiring separate incision Partial excision, wing of ilium, symphysis pubis, or greaer trochanter 27070 of femur, (craterization, saucerization) (eg, ostermyelitis or bone abscess); superficial 27071 deep ( subfascial or intramuscular) Radical resection of tumor; wing or ilium, 1 pubic or ischial ramus or 27075 symphysis pubis ilium, including acetabulum, both pubic rami, or ischium and 27076 acetabulum 27077 innominate bone, total 27078 ischial tuberosity and greater trochanter of femur 27080 Coccygectomy, primary 27086 Removal of foreign body, pelvis or hip; subcutaneous tissue Removal of foreign body, pelvis or hip; deep (subfascial or 27087 intramuscular) 27090 Removal of hip prosthesis;(separate procedure) complicated, including total hip prosthesis, methylmethacrylate with 27091 or without insertion of spacer 27093 Injection procedure for hip arthrography; without anesthesia 27095 Injection procedure for hip arthrography; with anesthesia no longer 27096 Injection procedure for sacroiliac joint, arthrography and/or Investigational as of anesthetic/steroid 9/11/2016 27097 Release or recession, hamstring, proximal 27098 transfer, adductor to ischium Transfer external oblique muscle to greater trochanter including 27100 fascial or tendon extension (graft) Transfer paraspinal muscle to hip (includes fascial or tendon 27105 extension graft) Updated January 2018

27110 Transfer iliopsoas; to greater trochanter femur 27111 Transfert iliopsoas; to femoral neck Hemiarthroplasty, hip, partial (eg, femoral stem prosthesis,bipolar 27125 arthroplasty) Arthroplasty, acetabular and proximal femoral prosthetic 27130 replacement (total hip arthroplasty), with or without autograft or allograft) Conversion of previous hip surgery to total hip arthroplasty, with or 27132 without autograft or allograft Revision of total hip arthroplasty; both components, with or without 27134 autograft or allograft 27137 acetabular component only, with or without autograft or allograft 27138 femoral component only, with or without autograft or allograft Osteotomy and transfer of greater trochanter of femur (separate 27140 procedure) 27146 Osteotomy, iliac, acetabular or innominate bone Osteotomy, iliac, acetabular or innominate bone ; with open 27147 reduction of hip Osteotomy, iliac, acetabular or innominate bone; with femoral 27151 osteotomy Osteotomy, iliac, acetabular or innominate bone; with femoral 27156 osteotomy and open reduction of hip 27158 Osteotomy, pelvis, bilateral (eg, congenital malformation) 27161 Osteotomy, femoral neck (separate procedure) Osteotomy, intertrochanteric or subtrochanteric including internal or 27165 external fixation and/or case Bone graft, femoral head, neck, intertrochanteric or subtrochanteric 27170 area (includes obtaining bone graft) 27175 Treatment of slipped femoral epiphysis; by traction, without reduction Treatment of slipped femoral epiphysis; by single or multiple pinning, 27176 in situ Open treatment of slipped femoral epiphysis; single or multiple 27177 pinning or bone graft (includes obtaining graft) Open treatment of slipped femoral epiphysis; closed manipulation 27178 with single or multiple pinning Open treatment of slipped femoral epiphysis; osteoplasty of femoral 27179 neck (Heyman type procedure) Open treatment of slipped femoral epiphysis; osteotomy and internal 27181 fixation Epiphyseal arrest by epiphysiodesis or stapling, greater trochanter of 27185 femur Prophylactic treatment (nailing, pinning, plating or wiring) with or 27187 without methylmethacrylate, femoral neck and proximal femur

Closed treatment of posterior pelvic ring fracture(s), dislocation(s), diastasis or subluxation of the ilium, sacroiliac joint, and/or sacrum, with or without anterior pelvic ring fracture(s) and/or dislocation(s) of 27198 Added 9/1/2017 the pubic symphysis and/or superior/inferior rami, unilateral or bilateral; with manipulation, requiring more than local anesthesia (ie, general anesthesia, moderate sedation, spinal/epidural)

Arthrodesis, sacroiliac joint, percutaneous or minimally invasive Investigational per 27279 (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixing device BCBST medical policy Updated January 2018

Arthrodesis, open, sacroiliac joint including obtaining bone graft, including Investigational per 27280 instrumentation, when performed BCBST medical policy as of 9/11/2016 27282 Arthrodesis, symphysis pubis (including obtaining graft) 27284 Arthrodesis, hip joint (including obtaining graft) 27286 with subtrochanteric osteotomy 27299 Unlisted procedure, pelvis or hip joint Incision and drainage, deep abscess bursa, or hematoma, thigh or 27301 knee region Incision, deep with opening of bone cortex, femur or knee (eg, 27303 osteomyelitis or bone abscess) 27305 Fasciotomy, iliotibial (tenotomy), open Tenotomy,percutaneous, adductor or hamstring; single tendon 27306 (separate procedure) 27307 multiple tendons arthrotomy, knee, with exploration, drainage, or removal of foreign 27310 body (eg, infection) 27323 Biopsy, soft tissue of thigh or knee area; superficial 27324 deep (subfascial or intramuscular) 27325 Neurectomy, hamstring muscle 27326 Neurectomy, popliteal (gastrocnemius) Excision, tumor, soft tissue of thigh or knee area, subcutaneous; 27327 less than 3 cm Excision, tumor, soft tissue of thigh or knee area, subfascial (eg, 27328 intramuscular); less than 5 cm Radical resection of tumor (eg, sarcoma),soft tissue of thigh or knee 27329 area; less than 5 cm 27330 Arthrotomy, knee; with synovial biopsy only including joint exploration, biopsy, or removal of loose or foreign 27331 bodies Arthrotomy, with excision of semilunar cartilage (meniscectomy) 27332 knee; medial or lateral 27333 medial and lateral 27334 Arthrotomy, with synovectomy, knee; anterior or posterior Arthrotomy, with synovectomy, knee; anterior AND posterior 27335 including popliteal area Excision, tumor, soft tissue of thigh or knee area, subcutaneous; 3 cm or 27337 greater Excision, tumor, soft tissue of thigh or knee area, subfascial (eg, 27339 intramuscular); 5 cm or greater 27340 Excision, prepatellar bursa 27345 Excision of synovial cyst of popliteal space (eg, Baker's cyst) 27347 Excision of lesion of meniscus or capsule (eg, cyst, ganglion), knee 27350 Patellectomy or hemipatellectomy 27355 Excision or curettage of bone cyst or benign tumor of femur; Excision or curettage of bone cyst or benign tumor of femur; with 27356 allograft Excision or curettage of bone cyst or benign tumor of femur; with 27357 autograft (includes obtaining graft Excision or curettage of bone cyst or benign tumor of femur; with 27358 internal fixation (List in addition to code for primary procedure) Updated January 2018

Partial excision (craterization, saucerization, or diaphysectomy) 27360 bone, femur, proximal tibia and/or fibula (eg, osteomyelitis or bone abscess) Radical resection of tumor (eg, sarcoma), soft tissue of thigh or 27364 knee area; 5 cm or greater 27365 Radical resection of tumor, femur or knee 27370 Injection of contrast for knee arthrography 27372 Removal of foreign body, deep, thigh region or knee area 27380 Suture of infrapatellar tendon; primary Suture of infrapatellar tendon; secondary reconstruction, including 27381 fascial or tendon graft 27385 Suture of quadriceps or hamstring muscle rupture; primary Suture of quadriceps or hamstring muscle rupture; secondary 27386 reconstruction, including fascial or tendon graft 27390 Tenotomy, open, hamstring, knee to hip; single tendon 27391 Tenotomy, open, hamstring, knee to hip; multiple tendons, 1 leg

27392 Tenotomy, open, hamstring, knee to hip; multiple tendons, bilateral 27393 Lengthening of hamstring tendon; single tendon 27394 Lengthening of hamstring tendon; multiple tendons, 1 leg 27395 Lengthening of hamstring tendon; multiple tendons, bilateral Transplant or transfer (with muscle redirection or rerouting), thigh 27396 (eg, extensor to flexor); single tendon Transplant or transfer (with muscle redirection or rerouting), thigh 27397 (eg, extensor to flexor); multiple tendons Transfer, tendon or muscle, hamstrings to femur (eg, Egger's type 27400 procedure) 27403 Arthrotomy with meniscus repair, knee 27405 Repair, primary, torn ligament and/or capsule, knee; collateral 27407 Repair, primary, torn ligament and/or capsule, knee; cruciate Repair, primary, torn ligament and/or capsule, knee; collateral and 27409 cruciate ligaments 27412 Autologous chondrocyte implantation, knee 27415 Osteochondral allograft, knee, open Osteochondral autograft(s), knee, open (eg, mosaicplasty) (includes 27416 harvesting of autograft[s]) 27418 Anterior tibial tubercleplasty (eg, Maquet type procedure) 27420 Reconstruction of dislocating patella; (eg, Hauser type procedure) Reconstruction of dislocating patella; with extensor realignment 27422 and/or muscle advancement or release (eg, Campbell, Goldwaite type procedure) 27424 Reconstruction of dislocating patella; with patellectomy 27425 Lateral retinacular release, open 27427 Ligamentous reconstruction (augmentation), knee; extra-articular Ligamentous reconstruction (augmentation), knee; intra-articular 27428 (open) Ligamentous reconstruction (augmentation), knee; intra-articular 27429 (open) and extra-articular 27430 Quadricepsplasty (eg, Bennett or Thompson type) 27435 Capsulotomy, posterior capsular release, knee 27438 Arthroplasty, patella with prosthesis 27440 Arthroplasty, knee tibial plateau Updated January 2018

27441 with debridement and partial synovectomy 27442 Arthroplasty, femoral condyles or tibial plateau(s), knee; 27443 with debridement and partial synovectomy 27445 Arthroplasty, knee, hinge prosthesis (eg, Walldius type) Arthroplasty, knee, condyle and plateau; medial OR lateral 27446 compartment medial AND lateral compartments with or without patella resurfacing 27447 (total knee arthroplasty) 27448 Osteotomy, femur, shaft or supracondylar; without fixation 27450 Osteotomy, femur, shaft or supracondylar; with fixation Osteotomy, multiple, with realignment on intramedullary rod, femoral 27454 shaft (eg, Sofield type procedure) Osteotomy, proximal tibia, including fibular excision or osteotomy 27455 (includes correction of genu varus [bowleg] or genu valgus [knock- knee]); before epiphyseal closure Osteotomy, proximal tibia, including fibular excision or osteotomy 27457 (includes correction of genu varus [bowleg] or genu valgus [knock- knee]); after epiphyseal closure 27465 Osteoplasty, femur; shortening (excluding 64876) 27466 Osteoplasty, femur; lengthening Osteoplasty, femur; combined, lengthening and shortening with 27468 femoral segment transfer Repair, nonunion or malunion, femur, distal to head and neck; 27470 without graft (eg, compression technique) Repair, nonunion or malunion, femur, distal to head and neck; with 27472 iliac or other autogenous bone graft (includes obtaining graft)

27475 Arrest, epiphyseal, any method (eg, epiphysiodesis); distal femur Arrest, epiphyseal, any method (eg, epiphysiodesis); tibia and fibula, 27477 proximal Arrest, epiphyseal, any method (eg, epiphysiodesis); combined distal 27479 femur, proximal tibia and fibula Arrest, hemiepiphyseal, distal femur or proximal tibia or fibula (eg, 27485 genu varus or valgus) Revision of total knee arthroplasty, with or without allograft; one 27486 component 27487 femoral and entire tibial component Removal of prosthesis, including total knee prosthesis, 27488 methylmethacrylate with or without insertion of spacer, knee Prophylactic treatment (nailing, pinning, plating, or wiring) with or 27495 without methylmethacrylate, femur Decompression fasciotomy, thigh and/or knee, 1 compartment 27496 (flexor or extensor or adductor); Decompression fasciotomy, thigh and/or knee, 1 compartment 27497 (flexor or extensor or adductor); with debridement of nonviable muscle and/or nerve Decompression fasciotomy, thigh and/or knee, multiple 27498 compartments; Decompression fasciotomy, thigh and/or knee, multiple 27499 compartments; with debridement of nonviable muscle and/or nerve

27580 Arthrodesis, knee, any technique 27599 Unlisted procedure, femur or knee 27702 Arthroplasty, ankle; with implant (total ankle) Added 9/1/2017 27703 Arthroplasty, ankle; revision, total ankle Added 9/1/2017 Updated January 2018

29805 Arthroscopy, shoulder, diagnostic, with or without synovial biopsy 29806 Arthroscopy, shoulder, surgical; capsulorrhaphy 29807 Arthroscopy, shoulder, surgical; repair of SLAP lesion Arthroscopy, shoulder, surgical; with removal of loose body or 29819 foreign body 29820 Arthroscopy, shoulder, surgical; synovectoy, partial 29821 Arthroscopy, shoulder, surgical; synovectoy, complete 29822 Arthroscopy, shoulder, surgical; debridement, limited 29823 Arthroscopy, shoulder, surgical; debridement, extensive Arthroscopy, shoulder, surgical; distal claviculectomy including distal 29824 articular surface (Mumford procedure) Arthroscopy, shoulder, surgical; with lysis and resection of 29825 adhesions, with or without manipulation Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, 29826 arch) release, when performed (list separately in addition to code for primary procedure) 29827 Arthroscopy, shoulder, surgical; with rotator cuff repair Arthroscopically aided treatment of intercondylar spine(s) and/or 29850 tuberosity fracture(s) of the knee, with or without manipulation; without internal or external fixation (includes arthroscopy)

Arthroscopically aided treatment of intercondylar spine(s) and/or 29851 tuberosity fracture(s) of the knee, with or without manipulation; with internal or external fixation (includes arthroscopy) Arthroscopically aided treatment of tibial fracture, proximal (plateau); 29855 unicondylar, includes internal fixation, when performed (includes arthroscopy) Arthroscopically aided treatment of tibial fracture, proximal (plateau); 29856 bicondylar, includes internal fixation, when performed (includes arthroscopy) Arthroscopy, hip, diagnostic with or without synovial biopsy 29860 (separate procedure) Arthroscopy, hip, surgical; with removal of loose body or foreign 29861 body Arthroscopy, hip, surgical; with debridement/shaving of articular 29862 cartilage (chondroplasty), abrasion arthroplasty, and/or resection of labrum 29863 Arthroscopy, hip, surgical; with synovectomy Arthroscopy, knee, surgical; osteochondral autograft(s) (eg, 29866 mosaicplasty) (includes harvesting of the autograft[s]) Arthroscopy, knee, surgical; osteochondral allograft (eg, 29867 mosaicplasty) Arthroscopy, knee, surgical; meniscal transplantation (includes 29868 arthrotomy for meniscal insertion), medial or lateral Arthroscopy, knee, diagnostic, with or without synovial biopsy 29870 (separate procedure) 29871 Arthroscopy, knee, surgical; for infection, lavage and drainage 29873 Arthroscopy, knee, surgical; with lateral release Arthroscopy, knee, surgical; for removal of loose body or foreign 29874 body (eg, osteochondritis dissecans fragmentation, chondral fragmentation) Arthroscopy, knee, surgical; synovectomy, limited (eg, plica or shelf 29875 resection) (separate procedure) Arthroscopy, knee, surgical; synovectomy, major, 2 or more 29876 compartments (eg, medial or lateral) Updated January 2018

Arthroscopy, knee, surgical; debridement/shaving of articular 29877 cartilage (chondroplasty) Arthroscopy, knee, surgical; abrasion arthroplasty (includes 29879 chondroplasty where necessary) or multiple drilling or microfracture Arthroscopy, knee, surgical; with meniscectomy (medial AND lateral, including any meniscal shaving) including debridement/shaving of 29880 articular cartilage (chondroplasty), same or separate compartment(s), when performed Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral, including any meniscal shaving) including debridement/shaving of 29881 articular cartilage (chondroplasty), same or separate compartment(s), when performed 29882 Arthroscopy, knee, surgical; with meniscus repair (medial OR lateral) Arthroscopy, knee, surgical; with meniscus repair (medial AND 29883 lateral) Arthroscopy, knee, surgical; with lysis of adhesions, with or without 29884 manipulation (separate procedure) Arthroscopy, knee, surgical; drilling for osteochondritis dissecans 29885 with bone grafting, with or without internal fixation (including debridement of base of lesion) Arthroscopy, knee, surgical; drilling for intact osteochondritis 29886 dissecans lesion Arthroscopy, knee, surgical; drilling for intact osteochondritis 29887 dissecans lesion with internal fixation Arthroscopically aided anterior cruciate ligament repair/augmentation 29888 or reconstruction Arthroscopically aided posterior cruciate ligament 29889 repair/augmentation or reconstruction Arthroscopy, hip, surgical; with femoroplasty (ie, treatment of cam 29914 lesion) Arthroscopy, hip, surgical; with acetabuloplasty (ie, treatment of 29915 pincer lesion) 29916 Arthroscopy, hip, surgical; with labral repair Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced 62280 saline solutions), with or without other therapeutic substance; subarachnoid 62281 epidural, cervical or thoracic 62282 epidural, lumbar, sacral (caudal) Aspiration or decompression procedure, percutaneous, of nucleus Investigational per pulposus of intervertebral disc, any method, single or multiple levels, 62287 BCBST medical lumbar (eg, manual or automated percutaneous discectomy, policy percutaneous laser discectomy) 62290 Injection procedure for discography, each level; lumbar 62291 Injection procedure for discography, each level; cervical or thoracic

Injection procedure for chemonucleolysis, including discography, 62292 intervertebral disc, single or multiple levels, lumbar Injection(s), of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other solution), not Added as of 1/1/2017 62320 including neurolytic substances, including needle or catheter CROSSWALKED FROM placement, interlaminar epidural or subarachnoid, cervical or 62310 thoracic; without imaging guidance Updated January 2018

Injection(s), of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other solution), not 62321 including neurolytic substances, including needle or catheter added 1/1/2017 placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (i.e., fluoroscopy or CT) Injection(s), of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other solution), not Added as of 1/1/2017 62322 including neurolytic substances, including needle or catheter CROSSWALKED FROM placement, interlaminar epidural or subarachnoid, lumbar or sacral 62311 (caudal); without imaging guidance Injection(s), of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other solution), not 62323 including neurolytic substances, including needle or catheter added 1/1/2017 placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (i.e., fluoroscopy or CT) Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic Added as of 1/1/2017 62324 substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other CROSSWALKED FROM solution), not including neurolytic substances, interlaminar epidural 62318 or subarachnoid, cervical or thoracic; without imaging guidance Injection(s), of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other solution), not 62325 including neurolytic substances, including needle or catheter added 1/1/2017 placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (i.e., fluoroscopy or CT) Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic Added As of 1/1/2017 substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other 62326 CROSSWALKED FROM solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging 62319 guidance Injection(s), of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other solution), not 62327 including neurolytic substances, including needle or catheter added 1/1/2017 placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (i.e., fluoroscopy or CT) Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an 62350 external pump or implantable reservoir/infusion pump; without laminectomy Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an 62351 external pump or implantable reservoir/infusion pump; with laminectomy 62355 Removal of previously implanted intrathecal or epidural catheter Implantation or replacement of device for intrathecal or epidural drug 62360 infusion; subcutaneous reservoir 62361 non-programmable pump programmable pump, including preparation of pump, with or without 62362 programming Removal of subcutaneous reservoir or pump, previously implanted 62365 for intrathecal or epidural infusion Electronic analysis of programmable, implanted pump for intrathecal 62367 or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); without reprogramming Updated January 2018

Electronic analysis of programmable, implanted pump for intrathecal 62368 or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); with reprogramming Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, 62370 alarm status, drug prescription status); with reprogramming and refill Added 9/1/2017 (requiring skill of a physician or other qualified health care professional)

Endoscopic decompression of spinal cord, nerve root(s), including Added 9/1/2017 62380 laminotomy, partial facetectomy, foraminotomy, discectomy and/or Investigational Per excision of herniated intervertebral disc, 1 interspace, lumbar BCBST Medical Policy

Laminectomy with exploration and/or decompression of spinal cord 63001 and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; cervical

Laminectomy with exploration and/or decompression of spinal cord 63003 and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; thoracic Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or 63005 discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; lumbar, except for spondylolisthesis Laminectomy with exploration and/or decompression of spinal cord 63011 and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; sacral Laminectomy with removal of abnormal facets and/or pars inter- 63012 articularis with decompression of 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 63015 discectomy (eg, spinal stenosis), more than 2 vertebral segments; cervical Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or 63016 discectomy (eg, spinal stenosis), more than 2 vertebral segments; thoracic Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or 63017 discectomy (eg, spinal stenosis), more than 2 vertebral segments; lumbar Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision 63020 of herniated intervertebral disc, including open and endoscopically- assisted approaches; 1 interspace, cervical Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision 63030 of herniated intervertebral disc, including open and endoscopically- assisted approaches; 1 interspace, lumbar Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision 63035 of herniated intervertebral disc, including open and endoscopically- assisted approaches; each additional interspace, cervical or lumbar (List separately in addition to code for primary procedure) Updated January 2018

Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision 63040 of herniated intervertebral disc, reexploration, single interspace; cervical Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision 63042 of herniated intervertebral disc, reexploration, single interspace; lumbar Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision 63043 of herniated intervertebral disc, re-exploration, single interspace; each additional cervical interspace (List separately in addition to code for primary procedure) Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision 63044 of herniated intervertebral disc, re-exploration, single interspace; each additional lumbar interspace (List separately in addition to code for primary procedure) Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve 63045 root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; cervical Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve 63046 root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; thoracic Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve 63047 root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve 63048 root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; each additional segment, cervical, thoracic, or lumbar (List separately in addition to code for primary procedure) Laminoplasty, cervical, with decompression of the spinal cord, 2 or 63050 more vertebral segments; Laminoplasty, cervical, with decompression of the spinal cord, 2 or more vertebral segments; with reconstruction of the posterior bony 63051 elements (including the application of bridging bone graft and non- segmental fixation devices (eg, wire, suture, mini-plates), when performed) Transpedicular approach with decompression of spinal cord, equina 63055 and/or nerve root(s) (eg, herniated intervertebral disc), single segment; thoracic Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single 63056 segment; lumbar (including transfacet, or lateral extraforaminal approach) (eg, far lateral herniated intervertebral disc) Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single 63057 segment; each additional segment, thoracic or lumbar (List separately in addition to code for primary procedure) Costovertebral approach with decompression of spinal cord or nerve 63064 root(s) (eg, herniated intervertebral disc), thoracic; single segment Updated January 2018

Costovertebral approach with decompression of spinal cord or nerve 63066 root(s) (eg, herniated intervertebral disc), thoracic; each additional segment (List separately in addition to code for primary procedure)

Discectomy, anterior, with decompression of spinal cord and/or 63075 nerve root(s), including osteophytectomy; cervical, single interspace

Discectomy, anterior, with decompression of spinal cord and/or 63076 nerve root(s), including osteophytectomy; cervical, each additional interspace (List separately in addition to code for primary procedure)

Discectomy, anterior, with decompression of spinal cord and/or 63077 nerve root(s), including osteophytectomy; thoracic, single interspace

Discectomy, anterior, with decompression of spinal cord and/or 63078 nerve root(s), including osteophytectomy; thoracic, each additional interspace (List separately in addition to code for primary procedure) Vertebral corpectomy (vertebral body resection), partial or complete, 63081 anterior approach with decompression of spinal cord and/or nerve root(s); cervical, single segment Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve 63082 root(s); cervical, each additional segment (List separately in addition to code for primary procedure) Vertebral corpectomy (vertebral body resection), partial or complete, 63085 transthoracic approach with decompression of spinal cord and/or nerve root(s); thoracic, single segment Vertebral corpectomy (vertebral body resection), partial or complete, transthoracic approach with decompression of spinal cord and/or 63086 nerve root(s); thoracic, each additional segment (List separately in addition to code for primary procedure) Vertebral corpectomy (vertebral body resection), partial or complete, combined thoracolumbar approach with decompression of spinal 63087 cord, cauda equina or nerve root(s), lower thoracic or lumbar; single segment Vertebral corpectomy (vertebral body resection), partial or complete, combined thoracolumbar approach with decompression of spinal 63088 cord, cauda equina or nerve root(s), lower thoracic or lumbar; each additional segment (List separately in addition to code for primary procedure) Vertebral corpectomy (vertebral body resection), partial or complete, transperitoneal or retroperitoneal approach with decompression of 63090 spinal cord, cauda equina or nerve root(s), lower thoracic, lumbar, or sacral; single segment Vertebral corpectomy (vertebral body resection), partial or complete, transperitoneal or retroperitoneal approach with decompression of 63091 spinal cord, cauda equina or nerve root(s), lower thoracic, lumbar, or sacral; each additional segment (List separately in addition to code for primary procedure) Vertebral corpectomy (vertebral body resection), partial or complete, lateral extracavitary approach with decompression of spinal cord 63101 and/or nerve root(s) (eg, for tumor or retropulsed bone fragments); thoracic, single segment Vertebral corpectomy (vertebral body resection), partial or complete, lateral extracavitary approach with decompression of spinal cord 63102 and/or nerve root(s) (eg, for tumor or retropulsed bone fragments); lumbar, single segment Updated January 2018

Vertebral corpectomy (vertebral body resection), partial or complete, lateral extracavitary approach with decompression of spinal cord 63103 and/or nerve root(s) (eg, for tumor or retropulsed bone fragments); thoracic or lumbar, each additional segment (List separately in addition to code for primary procedure) Laminectomy with myelotomy (eg, Bischof or DREZ type), cervical, 63170 thoracic, or thoracolumbar Laminectomy with drainage of intramedullary cyst/syrinx; to 63172 subarachnoid space Laminectomy with drainage of intramedullary cyst/syrinx; to 63173 peritoneal or pleural space Laminectomy and section of dentate ligaments, with or without dural 63180 graft, cervical; 1 or 2 segments Laminectomy and section of dentate ligaments, with or without dural 63182 graft, cervical; more than 2 segments 63185 Laminectomy with rhizotomy; 1 or 2 segments 63190 Laminectomy with rhizotomy; more than 2 segments 63191 Laminectomy with section of spinal accessory nerve Laminectomy with cordotomy, with section of 1 spinothalamic tract, 1 63194 stage; cervical Laminectomy with cordotomy, with section of 1 spinothalamic tract, 1 63195 stage; thoracic Laminectomy with cordotomy, with section of both spinothalamic 63196 tracts, 1 stage; cervical Laminectomy with cordotomy, with section of both spinothalamic 63197 tracts, 1 stage; thoracic Laminectomy with cordotomy with section of both spinothalamic 63198 tracts, 2 stages within 14 days; cervical Laminectomy with cordotomy with section of both spinothalamic 63199 tracts, 2 stages within 14 days; thoracic 63200 Laminectomy, with release of tethered spinal cord, lumbar Laminectomy for excision or occlusion of arteriovenous malformation 63250 of spinal cord; cervical Laminectomy for excision or occlusion of arteriovenous malformation 63251 of spinal cord; thoracic Laminectomy for excision or occlusion of arteriovenous malformation 63252 of spinal cord; thoracolumbar Laminectomy for excision or evacuation of intraspinal lesion other 63265 than neoplasm, extradural; cervical Laminectomy for excision or evacuation of intraspinal lesion other 63266 than neoplasm, extradural; thoracic Laminectomy for excision or evacuation of intraspinal lesion other 63267 than neoplasm, extradural; lumbar Laminectomy for excision or evacuation of intraspinal lesion other 63268 than neoplasm, extradural; sacral Laminectomy for excision of intraspinal lesion other than neoplasm, 63270 intradural; cervical Laminectomy for excision of intraspinal lesion other than neoplasm, 63271 intradural; thoracic Laminectomy for excision of intraspinal lesion other than neoplasm, 63272 intradural; lumbar Laminectomy for excision of intraspinal lesion other than neoplasm, 63273 intradural; sacral Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, 63275 cervical Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, 63276 thoracic Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, 63277 lumbar Updated January 2018

Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, 63278 sacral Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, 63280 extramedullary, cervical Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, 63281 extramedullary, thoracic Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, 63282 extramedullary, lumbar Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, 63283 sacral Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, 63285 intramedullary, cervical Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, 63286 intramedullary, thoracic Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, 63287 intramedullary, thoracolumbar Laminectomy for biopsy/excision of intraspinal neoplasm; combined 63290 extradural-intradural lesion, any level Osteoplastic reconstruction of dorsal spinal elements, following 63295 primary intraspinal procedure (List separately in addition to code for primary procedure) Vertebral corpectomy (vertebral body resection), partial or complete, 63300 for excision of intraspinal lesion, single segment; extradural, cervical Vertebral corpectomy (vertebral body resection), partial or complete, 63301 for excision of intraspinal lesion, single segment; extradural, thoracic by transthoracic approach Vertebral corpectomy (vertebral body resection), partial or complete, 63302 for excision of intraspinal lesion, single segment; extradural, thoracic by thoracolumbar approach Vertebral corpectomy (vertebral body resection), partial or complete, 63303 for excision of intraspinal lesion, single segment; extradural, lumbar or sacral by transperitoneal or retroperitoneal approach

Vertebral corpectomy (vertebral body resection), partial or complete, 63304 for excision of intraspinal lesion, single segment; intradural, cervical Vertebral corpectomy (vertebral body resection), partial or complete, 63305 for excision of intraspinal lesion, single segment; intradural, thoracic by transthoracic approach Vertebral corpectomy (vertebral body resection), partial or complete, 63306 for excision of intraspinal lesion, single segment; intradural, thoracic by thoracolumbar approach Vertebral corpectomy (vertebral body resection), partial or complete, 63307 for excision of intraspinal lesion, single segment; intradural, lumbar or sacral by transperitoneal or retroperitoneal approach

Vertebral corpectomy (vertebral body resection), partial or complete, 63308 for excision of intraspinal lesion, single segment; each additional segment (List separately in addition to codes for single segment) Percutaneous implantation of neurostimulator electrode array, 63650 epidural Laminectomy for implantation of neurostimulator electrodes, 63655 plate/paddle, epidural Removal of spinal neurostimulator electrode percutaneous array(s), 63661 including fluoroscopy, when performed Updated January 2018

Removal of spinal neurostimulator electrode plate/paddle(s) placed 63662 via laminotomy or laminectomy, including fluoroscopy, when performed Revision including replacement, when performed, of spinal 63663 neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed Revision including replacement, when performed, of spinal 63664 neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed Insertion or replacement of spinal neurostimulator pulse generator or 63685 receiver, direct or inductive coupling Revision or removal of implanted spinal neurostimulator pulse 63688 generator or receiver Injection, anesthetic agent and/or steroid, transforaminal epidural; 64479 cervical or thoracic, single level Injection, anesthetic agent and/or steroid, transforaminal epidural; 64480 cervical or thoracic, each additional level (List separately in addition to code for primary procedure) Injection, anesthetic agent and/or steroid, transforaminal epidural; 64483 lumbar or sacral, single level Injection, anesthetic agent and/or steroid, transforaminal epidural; 64484 lumbar or sacral, single level Injection(s), diagnostic or therapeutic agent, paravertebral facet 64490 (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image 64491 guidance (fluoroscopy or CT), cervical or thoracic; second level (List separately in addition to code for primary procedure) Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image 64492 guidance (fluoroscopy or CT), cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure) Injection(s), diagnostic or therapeutic agent, paravertebral facet 64493 (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image 64494 guidance (fluoroscopy or CT), lumbar or sacral; second level (List separately in addition to code for primary procedure) Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image 64495 guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure) 64510 Injection, anesthetic agent; stellate ganglion (cervical sympathetic) Injection, anesthetic agent; lumbar or thoracic (paravertebral 64520 sympathetic) 64620 Destruction by neurolytic agent, intercostal nerve Destruction by neurolytic agent, paravertebral facet joint nerve(s), 64633 with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint Updated January 2018

Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each 64634 additional facet joint (List separately in addition to code for primary procedure) Destruction by neurolytic agent, paravertebral facet joint nerve(s), 64635 with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each 64636 additional facet joint (List separately in addition to code for primary procedure) 64999 Unlisted procedure, nervous system Added 9/1/2017 72275 Epidurography, radiological supervision and interpretation Discography, cervical or thoracic, radiological supervision and 72285 interpretation 72295 Discography, lumbar, radiological supervision and interpretation Refilling and maintenance of implantable pump or reservoir for drug 95990 delivery, spinal (intrathecal, epidural) or brain (intraventricular), includes electronic analysis of pump, when performed; Refilling and maintenance of implantable pump or reservoir for drug delivery, spinal (intrathecal, epidural) or brain (intraventricular), 95991 includes electronic analysis of pump, when performed; requiring physician's skill Percutaneous sacral augmentation (sacroplasty), unilateral injection(s), including the use of a balloon or mechanical device, 0200T when used, 1 or more needles, includes imaging guidance and bone biopsy, when performed Percutaneous sacral augmentation (sacroplasty), bilateral injections, 0201T including the use of a balloon or mechanical device, when used, 2 or more needles, includes imaging guidance and bone biopsy, when performed

Posterior vertebral joint(s) arthroplasty (eg, facet joint[s] Investigational per replacement), including facetectomy, laminectomy, foraminotomy, 0202T BCBST medical and vertebral column fixation, injection of bone cement, when policy performed, including fluoroscopy, single level, lumbar spine Injection(s), diagnostic or therapeutic agent, paravertebral facet 0213T (zygapophyseal) joint (or nerves innervating that joint) with Added 9/1/2017 ultrasound guidance, cervical or thoracic; single level second level (list separately in addition to code for primary 0214T procedure) third and any additional level(s) (List separately in addition to code 0215T for primary procedure) Injection(s), diagnostic or therapeutic agent, paravertebral facet 0216T (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; single level second level (list separately in addition to code for primary 0217T procedure) third and any additional level(s) (List separately in addition to code 0218T for primary procedure) Injection(s), anesthetic agent and/or steroid, transforaminal epidural, 0228T with ultrasound guidance, cervical or thoracic; single level each additional level (list separately in addition to code for primary 0229T procedure) Injection(s), anesthetic agent and/or steroid, transforaminal epidural, 0230T with ultrasound guidance, lumbar or sacral; single level Updated January 2018

each additional level (list separately in addition to code for primary 0231T procedure) Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for 0375T nerve root or spinal cord decompression and microdissection) cervical, three or more levels Investigational per G0259 Injection procedure for sacroilliac joint; arthrography BCBST medical policy no longer Injection procedure for sacroilliac joint; provision of anesthetic, G0260 Investigational as of steroid and/or other therapeutic agent, with or without arthrography 9/11/2016 L8680 Implantable neurostimulator electrode, each Patient programmer (external) for use with implantable L8681 programmable neurostimulator pulse generator, replacement only

L8682 Implantable neurostimulator radiofrequency receiver Radiofrequency transmitter (external) for use with implantable L8683 neurostimulator radiofrequency receiver Implantable neurostimulator pulse generator, single array, L8685 rechargeable, includes extension Implantable neurostimulator pulse generator, single array, L8686 nonrechargeable, includes extension Implantable neurostimulator pulse generator, dual array, L8687 rechargeable, includes extension Implantable neurostimulator pulse generator, dual array, L8688 nonrechargeable, includes extension External recharging system for battery (internal) for use with L8689 implantable neurostimulator, replacement only External recharging system for battery (external) for use with L8695 implantable neurostimulator, replacement only Investigational per Diskectomy, anterior, with decompression of spinal cord and/or S2350 BCBST medical nerve root(s), including osteophytectomy; lumbar, single interspace policy Diskectomy, anterior, with decompression of spinal cord and/or Investigational per S2351 nerve root(s), including osteophytectomy; lumbar, each additional BCBST medical interspace (list separately in addition to code for primary procedure) policy