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Us Department of Labor, Office of Workers' Compensation Programs U.S. DEPARTMENT OF LABOR, OFFICE OF WORKERS' COMPENSATION PROGRAMS FEE SCHEDULE MODIFIER LEVEL TABLES Effective Date: February 27, 2017 Last Update: February 27, 2017 CPT/HCPCS MOD MOD LEV DESCRIPTION 00100 291 Anest for proced on integ sys - head/or saliv glands 00102 291 Anesthesia for plastic repair of cleft lip 00103 291 Anesthesia for bepharoplasty 00104 291 Anesthesia for electroconvulsive therapy 00120 291 Anest; proc-esternal/middle/inner ear, inc biopsy nos 00124 291 Anesthesia for otoscopy 00126 291 Anesthesia for tympanotomy 00140 291 Anesthesia for procedures on eye; nos 00142 291 Anesthesia for procedures on eye; lens surgery 00144 291 Anest; procedures on eye; corneal transplant 00145 291 Anesthesia for procedures on eye; vitrectomy 00147 291 Anesthesia for iridectomy 00148 291 Anesthesia for procedures on eye; opthalmoscopy 00160 291 Anest; proc-nose and accessory sinuses; nos 00162 291 Anest; proced-nose/accesory sinuses; rad surg 00164 291 Anesth-proced on nose & access sinuses; biop/soft tis 00170 291 Anesthesia for intraoral procedures, incl biopsy; nos 00172 291 Anesth-intraoral proced, w/biop; repair-cleft palate 00174 291 Anest; intraoral pro-w/biop-ex/retropharyngeal tumor 00176 291 Anesth-intraoral proced, w/biopsy; rad surg 00190 291 Anesthesia for procedures on facial bones; nos 00192 291 Anest - proced on facial bones; rad surg 00210 291 Anesthesia for intracranial proacedures nos 00211 291 Anesth, cran surg, hemotoma 00212 291 Anest; intracranial procedures; subdural taps 00214 291 Anesthesia for intracranial procedures; burr holes 00215 291 Anesthesia for skull fracture 00216 291 Anesthesia-intracranial proced; vascular 00218 291 Anesth-intracranial proced, in sitting position 00220 291 Anest - intracranial proced; spinal fluid shunting proc 00222 291 Anest - intracranial proc; electrocoag-cranial nerve 00300 291 Anest; proc-integ sys of neck, incl subcu tissue 00320 291 Anesth neck organ 1 yr/> 00322 291 Anest proced on neck: needle biopsy of thyroid 00350 291 Anesth; proc-on major vessels of neck; nos 00352 291 Anesth-proc on maj vessels of neck; simple ligation 00400 291 Anesth; proc on ant integ sys-chest a/subcu tise 00402 291 Anest; proc-ant integ sys of chest; reconstr on breast 00404 291 Anest; proc-ant integ sys of chest; radical/mod rad; breast 00406 291 Anest; ant integ sys chest; rad/mod rad proc; breast w/node disse 00410 291 Anest; proc ant integ chest; elec convers of arrhythmias 00450 291 Anest; proc-on clavicle and scapula; nos 00454 291 Anesthesia for procedures on clavicle, biopsy 00470 291 Anesthesia for partial rib resection nos 00472 291 Anest; partial rib resection, thoracoplasty (any type) 00474 291 Anesth surgery of rib 00500 291 Anesthesia for all procedures on esophagus 00520 291 Anest for closed chest proc nos 00522 291 Anest - closed chest proced; needle biopsy-pleura 00524 291 Anest for closed chest procedure; pneumocentesis 00528 291 Anes mediascpy & dx thorscpy 00529 291 Anes medscpy&thorscpy 1 lung 00530 291 Anesthesia for permanent transvenous pacemaker insertion 00532 291 Anesthesia for accesss to central venous circula 00534 291 Anest-transven insert/replace-cardioverter/debfib 00537 291 Anest for cardiac electrophysiologic procedures 00539 291 Anest; tracheobronchial reconstruction 00540 291 Anest; thoracot proced-lungs/pleura/dia/media nos 00541 291 Anest; thoracot proced; one lung ventilation 00542 291 Anesth remvl pleura 00546 291 Anesth-thoracot; pul resection w/thoracoplasty 00548 291 Anesth-thoracotomy; repair-trauma to trachea/bronchi 00550 291 Anesthesia for sternal debridement 00560 291 Anest-heart/pericard/great ves-chest; w/o pump oxygenator, ped 00562 291 Anest-heart/pericard/great ves-chest; w/pump oxygenator U.S. DEPARTMENT OF LABOR, OFFICE OF WORKERS' COMPENSATION PROGRAMS FEE SCHEDULE MODIFIER LEVEL TABLES Effective Date: February 27, 2017 Last Update: February 27, 2017 CPT/HCPCS MOD MOD LEV DESCRIPTION 00563 291 Anest-heart/pericard/great ves-chest; w/pump oxyg w/hypotherm 00566 291 Anest for direct coronary artery bypass graft w/out pump oxyg 00567 291 Anesth, cabg w/pump 00580 291 Anesthesia for heart transplant-heart/lung 00600 291 Anesth for proced on cerv spine/cord; nos 00604 291 Anesth-post cerv laminect-sitting position 00620 291 Anesthesia-proced on thoracic spine/cord; nos 00625 291 Anes spine tranthor w/o vent 00626 291 Anes, spine transthor w/vent 00630 291 Anesthesia for procedures in lumbar region (nos) 00632 291 Anesthesia for lumbar sympathectomy 00635 291 Anesth-procedures in lum region; diag/therapeutic lum puncture 00640 291 Anesth-manip of spine; closed proced on spine 00670 291 Anesth-ext spine/spinal cord proced 00700 291 Anesth-proced on upper ant abdom wall; (nos) 00702 291 Anesthesia for percutaneous liver biopsy 00730 291 Anesth-procedures on upper post abdominal wall 00740 291 Anesth-upper gastrointestinal endoscopic proced 00750 291 Anesthesia for hernia repairs in upper abdomen; (nos) 00752 291 Anesth-repair lum/ventral hernias/wound dehiscence 00754 291 Anesth-hernia repairs-up abdomen; omphalocele 00756 291 Anesth-transabdominal repair-diaphragmatic hernia 00770 291 Anesth-all procedures-major abdominal blood ves 00790 291 Anesth-intraperitoneal proced-up abdo, w/laparos nos 00792 291 Anesth-intraperitoneal proced up abdo-partial hepatectomy 00794 291 Anesth-intraperitoneal pro/up abdo; pancreatect/part/tot 00796 291 Anesth-intraperitoneal pro up abdo, shunts/liver transplant 00797 291 Anesth-intraperitoneal pro up abdo, gastric restrict procedure 00800 291 Anesth-pro low ant abdom wall nos 00802 291 Anesth-pro low ant abdom wall; panniculectomy 00810 291 Anesthesia for intestinal endoscopic procedures 00820 291 Anesth-pro on low post abdominal wall 00830 291 Anesthesia for hernia repairs in lower abdomen; (nos) 00832 291 Anesth-hernia repair, ventral & incisional hernias 00840 291 Anesth-intraperitoneal proced low abdo w/laparos; nos 00842 291 Anesthesia for amniocentesis 00844 291 Anesthesia for abdominoperitoneal resection 00846 291 Anesthesia for radical hysterectomy 00848 291 Anesthesia for pelvic exentration 00851 291 Anesthesia for tubal ligation 00860 291 Anesth-extraperitoneal low abdo, w/urinary tract-nos 00862 291 Anesth-renal proced w/upper 1/3 ureter/donor nephrect 00864 291 Aanesthesia for total cystectomy 00865 291 Anest - extraperitoneal proced-lower abd; rad prostatectomy 00866 291 Anesthesia for adrenalectomy 00868 291 Anesthesia for renal transplant (recipient) 00870 291 Anesthesia for cystolithiotomy 00872 291 Anesth-lithotripsy/extracorp shock wave-w/h20 bath 00873 291 Anesth-lithotripsy/extracorp shock wave-w/o h20 bath 00880 291 Anesth-proced on maj low abdom ves; nos 00882 291 Anesth-proced on maj low abdom ves; infer vena cava liga 00902 291 Anesthesia for anorectal procedures 00904 291 Anesthesia for radical perineal procedure 00906 291 Anesthesia for vulvectomy 00908 291 Anesthesia for perineal prostatectomy 00910 291 Anesthesia for transurethral procedures 00912 291 Anesthesia for transurethral resection of bladder 00914 291 Anesthesia for transurethral resection of prostate 00916 291 Anesthesia for post-transurethral resection bleeding 00918 291 Anesthesia for transurethral procedures,w/fragmenta 00920 291 Anesthesia-proced on male genital ext genitalia, nos 00921 291 Anesthesia-vasectomy, unilat/bilateral 00922 291 Anesthesia for procedures on seminal vesicles 00924 291 Anesth-proced on undescended testis, unilat/bilat 00926 291 Anesthesia for radical orchiectomy, inguinal U.S. DEPARTMENT OF LABOR, OFFICE OF WORKERS' COMPENSATION PROGRAMS FEE SCHEDULE MODIFIER LEVEL TABLES Effective Date: February 27, 2017 Last Update: February 27, 2017 CPT/HCPCS MOD MOD LEV DESCRIPTION 00928 291 Anesthesia for radical orchiectomy, abdominal 00930 291 Anesthesia for orchiopexy, unilateral or bilateral 00932 291 Anesthesia for complete amputation of penis 00934 291 Anesth-radical amputat-penis w/bilat ing lymphaden 00936 291 Anesth-rad amputa-penis w/bilat inguinal/iliac lymphaden 00938 291 Anesth-insertion of penile prosthesis-perineal ap 00940 291 Anesth-vaginal procedures, nos 00942 291 Anesth-for colpotomy, colpectomy, colporrhaphy 00944 291 Anesthesia for vaginal hysterectomy 00948 291 Anesthesia for cervical cerclage 00950 291 Anesthesia culdoscopy 00952 291 Anesthesia for hysteroscopy 01112 291 Anesthesia-bone marrow aspiration/biopsy, iliac crest 01120 291 Anesthesia for procedures on bony pelvis 01130 291 Anesthesia for body cast application or revision 01140 291 Anesth for interpelviabdom amputation (hindquarter) 01150 291 Anesth-rad proced tumor of pelvis, ex hindqtr amputation 01160 291 Anesth-closed pro, involv symphysis pubis/sacroiliac jnt 01170 291 Anesth-open pro involv symphysis pubis/sacroiliac jnt 01173 291 Anesth-open repair, FX disrupt 01180 291 Anesthesia for obturator neurectomy, extrapelvic 01190 291 Anesthesia for obturator neurectomy, intrapelvic 01200 291 Anesthesia for all closed procedures involving hip joint 01202 291 Anesthesia for arthroscopic procedures of hip joint 01210 291 Anesthesia for open procedures involving hip joint; (nos) 01212 291 Anesthesia for hip disarticulation 01214 291 Anesthesia for total hip replacement or revision 01215 291 Anesthesia for revision of total hip arthroplasty 01220 291 Anesth-all closed proced involv up 2/3 of femur-nos 01230 291 Anesth-all open proced involv up 2/3 of femur nos 01232 291 Anesth-open proced involv up 2/3 of femur; amputation 01234 291 Anesth-open proced involv up 2/3 of femur; rad resect 01250 291 Anesth-all proced
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