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Procedure Codes Payable As an Inpatient Service When Delivered In

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INDIANA HEALTH COVER A G E PROGRAMS PROVIDER CO D E S E T S Procedure codes payable as an inpatient service when delivered in an inpatient setting for stays of less than 24 hours for DOS on or after July 1, 2014 Procedure Description Code 11005 Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue infection; abdominal wall, with or without fascial closure 11008 Removal of prosthetic material or mesh, abdominal wall for infection (eg, for chronic or recurrent mesh infection or necrotizing soft tissue infection) (list separately in addition to code for primary procedure) 19361 Breast reconstruction with latissimus dorsi flap, without prosthetic implant 21343 Open treatment of depressed frontal sinus fracture 21422 Treatment of palatal or alveolar ridge fractures (Lefort I type); open treatment 22532 Arthrodesis, lateral extracavitary technique, including minimal diskectomy to prepare interspace (other than for decompression); thoracic 22558 Arthrodesis, anterior interbody technique; lumbar, with bone graft 22585 Arthrodesis, ant or antitrl, ea additional interspace (list sep in add to single lvl arthrodesis) 22842 Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segments (list separately in addition to code for primary procedure) 27025 Ober-yount fasciotomy, combined with spica cast, pins in tibia, wedging the cast, etc; unilateral 27450 Osteotomy, femur, shaft or supracondylar, with fixation; unilateral 27472 Repair, nonunion or malunion, femur, distal to head and neck; with iliac or other autogenou (see CPT4 bk) 27535 Open treatment of tibial fracture, proximal (plateau); unicondylar, includes internal fixation, when performed 27536 Open treatment of closed or open tibial fracture, proximal (plateau),with or without inte (see CPT4 bk) 27703 Arthroplasty, ankle; revision, total ankle 31225 Maxillectomy; without orbital exenteration 35221 Repair blood vessels or A-V fistula, direct; intra-abdominal 35616 Bypass graft, with other than vein; subclavian-axillary 37182 Insertion transvenous intrahepatic portosystemic shunt(s) (tips) (includes venous access, hepatic/portal vein cath, portograph w/ hemodynam eval, intrahepatic tract formation/dilatation, stent placement and all assoc imaging guidance and documentation 37215 Transcatheter placement of intravascular stent(s), cervical carotid artery, percutaneous; with distal embolic protection 39545 Imbrication of diaphragm for eventration; paralytic 43327 Esophagogastric fundoplasty partial or complete; laparotomy 43520 Pyloromyotomy, cutting of pyloric muscle(Fredet-Ramstedt type operation) 43840 Gastrorrhaphy, suture of perforated duodenal or gastric ulcer, or injury 1 Effective May 15, 2015 Indiana Health Coverage Programs Procedure Description Code 43880 Closure of gastrocolic fistula 44143 Colectomy, partial; with end colostomy and closure of distal segment (hartmann type procedure) 47361 Management of liver hemorrhage; exploration of hepatic wound, extensive debridem 47550 Biliary endoscopy, intraoperative (choledochoscopy) 50040 Nephrostomy, nephrotomy with drainage 50546 Laparoscopy, surgical; nephrectomy 58520 Hysterorrhaphy, repair of ruptured uterus (nonobstetrical) 58700 Salpingectomy, complete or partial, unilateral or bilateral (separate procedure) 59120 Surgical treatment of ectopic pregnancy; tubal or ovarian, req. sal. and/or ooph., abd. or vag. app 61250 Burr hole(s) or trephine, supratentorial, exploratory, not followed by other surgery; unilateral 63200 Laminectomy, with release of tethered spinal cord, lumbar 63267 Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; lumbar 22846 Anterior instrumentation; 4 to 7 vertebral segments (list separately in addition to code for primary procedure) 35840 Exploration for postoperative hemorrhage or thrombosis; abdomen 38724 Cervical lymphadenectomy (modified radical neck dissection) 44202 Laparoscopy, surgical; enterectomy, resection of small intestine, single resection and anastomosis 44602 Suture of small intestine (enterorrhaphy) for perforated ulcer, diverticulum, wound, injury or rupture; single perforation 58150 Total hysterectomy (corpus and cervix),with or without removal of tubes(s)with or without (see CPT4 bk) 61107 Twist drill hole(s) for subdural, intracerebral, or ventricular puncture; for implanting ventricular catheter, pressure recording device, or other intracerebral monitoring device 63081 Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, single segment 63082 Vertebral corpectomy (vertebral body resection), cervical, each additional segment 33967 Insertion of intra-aortic balloon assist device, percutaneous 22552 Arthrodesis, 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 proced 22845 Anterior instrumentation; 2 to 3 vertebral segments (list separately in addition to code for primary procedure) 00176 Anesthesia for intraoral procedures, including biopsy; radical surgery 00192 Anesthesia for procedures on facial bones or skull; radical surgery (including prognathism) 00211 Anesthesia for intracranial procedures; craniotomy or craniectomy for evacuation of hematoma 00214 Anesthesia for intracranial procedures; burr holes, including ventriculography 00215 Anesthesia for intracranial procedures; cranioplasty or elevation of depressed skull fracture, extradural (simple or compound) 00452 Anesthesia for procedures on clavicle and scapula; radical surgery 00474 Anesthesia for partial rib resection; radical procedures (eg, pectus excavatum) 2 Effective May 15, 2015 Indiana Health Coverage Programs Procedure Description Code 00524 Anesthesia for closed chest procedures; pneumocentesis 00540 Anesthesia for thoracotomy procedures involving lungs, pleura, diaphragm, and mediastinum (including surgical thoracoscopy); not otherwise specified 00542 Anesthesia for thoracotomy procedures involving lungs, pleura, diaphragm, and mediastinum (including surgical thoracoscopy); decortication 00546 Anesthesia for thoracotomy procedures involving lungs, pleura, diaphragm, and mediastinum (including surgical thoracoscopy); pulmonary resection with thoracoplasty 00560 Anesthesia for procedures on heart, pericardial sac, and great vessels of chest; without pump oxygenator 00561 Anesthesia for procedures on heart, pericardial sac, and great vessels of chest; with pump oxygenator, younger than 1 year of age 00562 Anesthesia for procedures on heart, pericardial sac, and great vessels of chest; with pump oxygenator, age 1 year or older, for all non-coronary bypass procedures (eg, valve procedures) or for re-operation for coronary bypass more than 1 month after 00567 Anesthesia for direct coronary artery bypass grafting; with pump oxygenator 00580 Anesthesia for heart transplant or heart/lung transplant 00604 Anesthesia for procedures on cervical spine and cord; procedures with patient in the sitting position 00622 Anesthesia for procedures on thoracic spine and cord; thoracolumbar sympathectomy 00632 Anesthesia for procedures in lumbar region; lumbar sympathectomy 00670 Anesthesia for extensive spine and spinal cord procedures (eg, spinal instrumentation or vascular procedures) 00792 Anesthesia for intraperitoneal procedures in upper abdomen including laparoscopy; partial hepatectomy or management of liver hemorrhage (excluding liver biopsy) 00794 Anesthesia for intraperitoneal procedures in upper abdomen including laparoscopy; pancreatectomy, partial or total (eg, Whipple procedure) 00796 Anesthesia for intraperitoneal procedures in upper abdomen including laparoscopy; liver transplant (recipient) 00802 Anesthesia for procedures on lower anterior abdominal wall; panniculectomy 00844 Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; abdominoperineal resection 00846 Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; radical hysterectomy 00848 Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; pelvic exenteration 00864 Anesthesia for extraperitoneal procedures in lower abdomen, including urinary tract; total cystectomy 00865 Anesthesia for extraperitoneal procedures in lower abdomen, including urinary tract; radical prostatectomy (suprapubic, retropubic) 00866 Anesthesia for extraperitoneal procedures in lower abdomen, including urinary tract; adrenalectomy 00868 Anesthesia for extraperitoneal procedures in lower abdomen, including urinary tract; renal transplant (recipient) 00882 Anesthesia for procedures on major lower abdominal vessels; inferior vena cava ligation 00904 Anesthesia for; radical perineal procedure 00908 Anesthesia for; perineal prostatectomy 3 Effective May 15, 2015 Indiana Health Coverage Programs Procedure Description Code 00932 Anesthesia for procedures on male genitalia (including open urethral procedures); complete amputation of penis 00934 Anesthesia for procedures on male genitalia (including open urethral procedures); radical amputation of penis with bilateral inguinal lymphadenectomy 00936 Anesthesia for procedures on male genitalia (including open urethral procedures); radical amputation of penis with bilateral inguinal and iliac lymphadenectomy 00944 Anesthesia for vaginal
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