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Effective March 20, 2001 CPT Codes and Descriptions Only Are Copyright Effective March 20, 2001 NOTICE The five-digit numeric codes and descriptions included in the Medical Reimbursement Schedule are obtained from the Physicians’ Current Procedural Terminology, copyright 1999 by the American Medical Association (CPT). CPT is a listing of descriptive terms and numeric identifying codes and modifiers for reporting medical services and procedures performed by physicians and other health care providers. This publication includes only CPT numeric identifying codes and modifiers for reporting medical services and procedures that were selected by the Louisiana Department of Labor, Office of Workers’ Compensation. Any use of CPT outside the fee schedule should refer to the Physicians’ Current Procedural Terminology, copyright 1999 American Medical Association and any update thereto. These CPT publications contain the complete and most current listing of CPT descriptive terms and numeric identifying codes and modifiers for reporting medical services and procedures. No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of the Physicians’ Current Procedural Terminology, copyright 1999, by the American Medical Association. All rights reserved. *Copyright 2000 Louisiana Department of Labor, Office of Workers’ compensation ™ Maximum Fee Allowance Schedule Office of Workers' Compensation CPT Global Maximum Code Mod Description Days Allowance ----- ---- ---------------------------- ----- -------- 00100 Integ sys head or saliv glands; nos 5 + TM 00102 Plastic repair of cleft lip 6 + TM 00103 Blepharoplasty 5 + TM 00104 Electroconvulsive therapy 4 + TM 00120 Ext, mid, & inner ear inc bx; nos 5 + TM 00124 Otoscopy 4 + TM 00126 Tympanotomy 4 + TM 00140 Procedures on eye nos 5 + TM 00142 Lens surgery 6 + TM 00144 Corneal transplant 6 + TM 00145 Vitrectomy 6 + TM 00147 Iridectomy 6 + TM 00148 Ophthalmoscopy 4 + TM 00160 Nose & accessory sinuses nos 5 + TM 00162 Nose, radical surgery 7 + TM 00164 Nose, biopsy, soft tissue 4 + TM 00170 Intraoral procedures, inc bx nos 5 + TM 00172 Intraoral, repair of cleft palate 6 + TM CPT codes and descriptions only are copyright 1999 American Medical Association 1 Effective March 20, 2001 00174 Intraoral exc retropharyngeal tumor 6 + TM 00176 Intraoral radical surgery 7 + TM 00190 Procedures on facial bones; nos 5 + TM 00192 Facial bones; radical surgery 7 + TM 00210 Intracranial procedures; nos 11 + TM 00212 Subdural taps 5 + TM 00214 Burr holes 9 + TM 00215 Skull fracture 9 + TM 00216 Intracranial vascular procedures 15 + TM 00218 Intracranial proc sitting position 13 + TM 00220 Spinal fluid shunting procedures 10 + TM 00222 Electrocoag intracranial nerve 6 + TM 00300 Integ sys neck, inc subcut tissue 5 + TM 00320 Neck procedures exc integ system 6 + TM 00322 Needle biopsy of thyroid 3 + TM 00350 Major vessels of neck; nos 10 + TM 00352 Major vesels neck; simple ligation 5 + TM 00400 Ant integ system chest; nos 3 + TM 00402 Reconstructive procedures on breast 5 + TM 00404 Radical/mod radical breast 5 + TM 00406 Radical/mod breast w/node dissect 13 + TM 00410 Cardioversion 4 + TM 00450 Clavicle & scapula; nos 5 + TM 00452 Clavicle & scapula; radical surgery 6 + TM 00454 Biopsy of clavicle 3 + TM 00470 Partial rib resection; nos 6 + TM 00472 Thoracoplasty 10 + TM 00474 Rib resection; radical procedures 13 + TM 00500 Procedures on esophagus 15 + TM 00520 Closed chest procedures nos 6 + TM 00522 Needle biopsy of pleura 4 + TM 00524 Pneumocentesis 4 + TM 00528 Mediastinoscopy 8 + TM 00530 Transvenous pacemaker insertion 4 + TM 00532 Access central venous circulation 4 + TM 00534 Transvenous cardioverter/defibrill 7 + TM 00540 Thoracotomy procedures; nos 13 + TM 00542 Decortication 15 + TM 00544 Pleurectomy 15 + TM 00546 Pulmonary resect w/thoracoplasty 15 + TM 00548 Repair trauma trachea/bronchi 15 + TM 00560 Heart, pericardium, w/o pump 15 + TM 00562 Heart, pericardium, w/ pump 20 + TM 00580 Heart, heart/lung transplant 20 + TM 00600 Cervical spine & cord; nos 10 + TM 00604 Post cervical laminectomy sitting 13 + TM 00620 Thoracic spine & cord; nos 10 + TM CPT codes and descriptions only are copyright 1999 American Medical Association 2 Effective March 20, 2001 00622 Thoracolumbar sympathectomy 13 + TM 00630 Procedures in lumbar region; nos 8 + TM 00632 Lumbar sympathectomy 7 + TM 00634 Chemonucleolysis 10 + TM 00670 Extensive spine/cord procedures 13 + TM 00700 Upper anterior abdominal wall nos 3 + TM 00702 Percutaneous liver biopsy 4 + TM 00730 Upper posterior abdominal wall 5 + TM 00740 Upper gi endoscopic procedures 5 + TM 00750 Hernia repairs upper abdomen nos 4 + TM 00752 Lumbar & ventral hernias 6 + TM 00754 Omphalocele 7 + TM 00756 Transabd repair diaphragm hernia 7 + TM 00770 Major abdominal blood vessels 15 + TM 00790 Intraperitoneal proc upper abd; nos 7 + TM 00792 Partial hepatectomy 13 + TM 00794 Pancreatectomy, partial or total 8 + TM 00796 Liver transplant (recipient) 30 + TM 00800 Lower anterior abdominal wall; nos 3 + TM 00802 Panniculectomy 5 + TM 00810 Intestinal endoscopic procedures 5 + TM 00820 Lower posterior abdominal wall 5 + TM 00830 Hernia repairs lower abdomen; nos 4 + TM 00832 Ventral & incisional hernias 6 + TM 00840 Intraperitoneal proc lower abd; nos 6 + TM 00842 Amniocentesis 4 + TM 00844 Abdominoperineal resection 7 + TM 00846 Radical hysterectomy 8 + TM 00848 Pelvic exenteration 8 + TM 00850 Cesarean section 7 + TM 00855 Cesarean hysterectomy 8 + TM 00857 Cont epidural analgesia, c-section 7 + TM 00860 Extraperitoneal proc lower abd; nos 6 + TM 00862 Renal procedures/donor nephrectomy 7 + TM 00863 Radical prostatectomy 7 + TM 00864 Total cystectomy 8 + TM 00865 Radical prostatectomy 7 + TM 00866 Adrenalectomy 10 + TM 00868 Renal transplant (recipient) 10 + TM 00870 Cystolithotomy 5 + TM 00872 Lithotripsy, w/ water bath 7 + TM 00873 Lithotripsy, w/o water bath 5 + TM 00880 Major lower abdominal vessels; nos 15 + TM 00882 Inferior vena cava ligation 10 + TM 00884 Transvenous umbrella insertion 5 + TM 00900 Perineal integumentary system; nos 3 + TM 00902 Anorectal procedure 4 + TM CPT codes and descriptions only are copyright 1999 American Medical Association 3 Effective March 20, 2001 00904 Radical perineal procedure 7 + TM 00906 Vulvectomy 4 + TM 00908 Perineal prostatectomy 6 + TM 00910 Transurethral procedures; nos 3 + TM 00912 Tur bladder tumor(s) 5 + TM 00914 Transurethral resection prostate 5 + TM 00916 Post turp bleeding 5 + TM 00918 Fragment/removal ureteral calculus 5 + TM 00920 Male external genitalia; nos 3 + TM 00922 Seminal vesicles 6 + TM 00924 Undescended testis 4 + TM 00926 Radical orchiectomy, inguinal 4 + TM 00928 Radical orchiectomy, abdominal 6 + TM 00930 Orchiopexy, unilateral or bilateral 4 + TM 00932 Complete amputation of penis 4 + TM 00934 Rad amp penis w/ bil ing lymphad 6 + TM 00936 Rad amp penis w/ bil ing/iliac lymp 8 + TM 00938 Insertion of penile prosthesis 4 + TM 00940 Vaginal procedures; nos 3 + TM 00942 Colpotomy, colpectomy, colporrhaphy 4 + TM 00944 Vaginal hysterectomy 6 + TM 00946 Vaginal delivery 5 + TM 00948 Cervical cerclage 4 + TM 00950 Culdoscopy 5 + TM 00952 Hysteroscopy 4 + TM 00955 Cont epidural analgesia, vag del 5 + TM 01120 Bony pelvis 6 + TM 01130 Body cast application or revision 3 + TM 01140 Interpelviabdominal amputation 15 + TM 01150 Rad proc tumor pelvis, 8 + TM 01160 Closed procedures symphysis pubis 4 + TM 01170 Open proc symphysis pubis/sacroilia 8 + TM 01180 Obturator neurectomy; extrapelvic 3 + TM 01190 Intrapelvic 4 + TM 01200 Closed procedures hip joint 4 + TM 01202 Arthroscopic procedures hip joint 4 + TM 01210 Open procedures hip joint; nos 6 + TM 01212 Hip disarticulation 10 + TM 01214 Total hip replacement or revision 8 + TM 01216 Revision of total hip arthroplasty 10 + TM 01220 Closed procedures upper femur 4 + TM 01230 Open procedures upper femur; nos 6 + TM 01232 Amputation 5 + TM 01234 Radical resection 8 + TM 01250 Nerves, muscles, etc, upper leg 4 + TM 01260 Veins upper leg, including explore 3 + TM 01270 Arteries upper leg, inc bypass; nos 8 + TM CPT codes and descriptions only are copyright 1999 American Medical Association 4 Effective March 20, 2001 01272 Femoral artery ligation 4 + TM 01274 Femoral artery embolectomy 6 + TM 01320 Nerves, muscles, etc, knee 4 + TM 01340 Closed procedures lower femur 4 + TM 01360 Open procedures lower of femur 5 + TM 01380 Closed procedures knee joint 3 + TM 01382 Arthroscopic procedures knee joint 3 + TM 01390 Closed procedures uppr tibia/fibula 3 + TM 01392 Open procedures upper tibia/fibula 4 + TM 01400 Open procedures on knee joint; nos 4 + TM 01402 Total knee replacement 7 + TM 01404 Disarticulation at knee 5 + TM 01420 Cast apply, remove, repair knee 3 + TM 01430 Veins of knee & popliteal area; nos 3 + TM 01432 Arteriovenous fistula 6 + TM 01440 Arteries knee & popliteal area nos 5 + TM 01442 Popliteal thromboendarterectomy 8 + TM 01444 Popliteal excision & graft 8 + TM 01462 Closed proc lwr leg, ankle, & foot 3 + TM 01464 Arthroscopic procedures ankle joint 3 + TM 01470 Nerves, muscles, etc, lower leg 3 + TM 01472 Repair ruptured achilles tendon, 5 + TM 01474 Gastrocnemius recession 5 + TM 01480 Open procedures bones lower leg 3 + TM 01482 Radical resection 4 + TM 01484 Osteotomy/osteoplasty tibia/fibula 4 + TM 01486 Total ankle replacement 7 + TM 01490 Lower leg cast, removal, or repair 3 + TM 01500 Arteries lower leg, inc bypass; nos 8 + TM 01502 Embolectomy, direct or catheter 6 + TM 01520 Veins of lower leg nos 3 + TM 01522 Venous thrombectomy, dir catheter 5 + TM 01610
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