OrthoNet PPA Code List Pain Management and Spine Surgery Procedures AND Effective 01/01/2018 Major Joint and Foot/ Lower Extremity Procedures (Blue Medicare HMO PPO)

CATEGORY PROCCODE PROCEDURE DESCRIPTION Pain Management & Spine Surgery Procedures Spinal Fusion 22510 Perq cervicothoracic inject Spinal Fusion 22511 Perq lumbosacral injection Spinal Fusion 22512 Vertebroplasty addl inject Spinal Fusion 22513 Perq vertebral augmentation Spinal Fusion 22514 Perq vertebral augmentation Spinal Fusion 22515 Perq vertebral augmentation Spinal Fusion 22532 LAT THORAX SPINE FUSION Spinal Fusion 22533 LAT LUMBAR SPINE FUSION Spinal Fusion 22534 LAT THOR/LUMB ADDL SEG Spinal Fusion 22548 NECK SPINE FUSION Spinal Fusion 22551 NECK SPINE FUSE&REMOV BEL C2 Spinal Fusion 22552 ADDL NECK SPINE FUSION Spinal Fusion 22554 NECK SPINE FUSION Spinal Fusion 22556 THORAX SPINE FUSION Spinal Fusion 22558 LUMBAR SPINE FUSION Spinal Fusion 22585 ADDITIONAL SPINAL FUSION Spinal Fusion 22590 SPINE & SKULL SPINAL FUSION Spinal Fusion 22595 NECK SPINAL FUSION Spinal Fusion 22600 NECK SPINE FUSION Spinal Fusion 22610 THORAX SPINE FUSION Spinal Fusion 22612 LUMBAR SPINE FUSION Spinal Fusion 22614 SPINE FUSION, EXTRA SEGMENT Spinal Fusion 22630 LUMBAR SPINE FUSION Spinal Fusion 22632 SPINE FUSION, EXTRA SEGMENT Spinal Fusion 22633 LUMBAR SPINE FUSION COMBINED Spinal Fusion 22634 SPINE FUSION EXTRA SEGMENT Spinal Fusion 22800 FUSION OF SPINE Spinal Fusion 22802 FUSION OF SPINE Spinal Fusion 22804 FUSION OF SPINE Spinal Fusion 22808 FUSION OF SPINE Spinal Fusion 22810 FUSION OF SPINE Spinal Fusion 22812 FUSION OF SPINE Spinal Fusion 22818 KYPHECTOMY, 1-2 SEGMENTS Spinal Fusion 22819 KYPHECTOMY, 3 OR MORE Spinal Fusion 22830 EXPLORATION OF SPINAL FUSION Spinal Fusion 22840 INSERT SPINE FIXATION DEVICE Spinal Fusion 22841 INSERT SPINE FIXATION DEVICE Spinal Fusion 22842 INSERT SPINE FIXATION DEVICE Spinal Fusion 22843 INSERT SPINE FIXATION DEVICE Spinal Fusion 22844 INSERT SPINE FIXATION DEVICE Spinal Fusion 22845 INSERT SPINE FIXATION DEVICE Spinal Fusion 22846 INSERT SPINE FIXATION DEVICE Spinal Fusion 22847 INSERT SPINE FIXATION DEVICE OrthoNet PPA Code List Pain Management and Spine Surgery Procedures AND Effective 01/01/2018 Major Joint and Foot/ Lower Extremity Procedures (Blue Medicare HMO PPO)

Spinal Fusion 22848 INSERT PELV FIXATION DEVICE Spinal Fusion 22849 REINSERT SPINAL FIXATION Spinal Fusion 22850 REMOVE SPINE FIXATION DEVICE Spinal Fusion 22852 REMOVE SPINE FIXATION DEVICE Spinal Fusion 22855 REMOVE SPINE FIXATION DEVICE Spinal Fusion 22856 CERV ARTIFIC DISKECTOMY Spinal Fusion 22864 REMOVE CERV ARTIF DISC Spinal Fusion 22899 SPINE SURGERY PROCEDURE Pain Pump 62350 IMPLANT SPINAL CANAL CATH Pain Pump 62351 IMPLANT SPINAL CANAL CATH Pain Pump 62360 INSERT SPINE INFUSION DEVICE Pain Pump 62361 IMPLANT SPINE INFUSION PUMP Pain Pump 62362 IMPLANT SPINE INFUSION PUMP Decompression Surgery 63001 REMOVAL OF SPINAL LAMINA Decompression Surgery 63003 REMOVAL OF SPINAL LAMINA Decompression Surgery 63005 REMOVAL OF SPINAL LAMINA Decompression Surgery 63011 REMOVAL OF SPINAL LAMINA Decompression Surgery 63012 REMOVAL OF SPINAL LAMINA Decompression Surgery 63015 REMOVAL OF SPINAL LAMINA Decompression Surgery 63016 REMOVAL OF SPINAL LAMINA Decompression Surgery 63017 REMOVAL OF SPINAL LAMINA Decompression Surgery 63020 NECK SPINE DISK SURGERY Decompression Surgery 63030 LOW BACK DISK SURGERY Decompression Surgery 63035 SPINAL DISK SURGERY ADD-ON Decompression Surgery 63040 LAMINOTOMY, SINGLE CERVICAL Decompression Surgery 63042 LAMINOTOMY, SINGLE LUMBAR Decompression Surgery 63043 LAMINOTOMY, ADDL CERVICAL Decompression Surgery 63044 LAMINOTOMY, ADDL LUMBAR Decompression Surgery 63045 REMOVAL OF SPINAL LAMINA Decompression Surgery 63046 REMOVAL OF SPINAL LAMINA Decompression Surgery 63047 REMOVAL OF SPINAL LAMINA Decompression Surgery 63048 REMOVE SPINAL LAMINA ADD-ON Decompression Surgery 63050 CERVICAL LAMINOPLASTY Decompression Surgery 63051 C-LAMINOPLASTY W/GRAFT/PLATE Decompression Surgery 63055 DECOMPRESS SPINAL CORD Decompression Surgery 63056 DECOMPRESS SPINAL CORD Decompression Surgery 63057 DECOMPRESS SPINE CORD ADD-ON Decompression Surgery 63064 DECOMPRESS SPINAL CORD Decompression Surgery 63066 DECOMPRESS SPINE CORD ADD-ON Decompression Surgery 63075 NECK SPINE DISK SURGERY Decompression Surgery 63076 NECK SPINE DISK SURGERY Decompression Surgery 63077 SPINE DISK SURGERY, THORAX Decompression Surgery 63078 SPINE DISK SURGERY, THORAX Decompression Surgery 63081 REMOVAL OF VERTEBRAL BODY Decompression Surgery 63082 REMOVE VERTEBRAL BODY ADD-ON OrthoNet PPA Code List Pain Management and Spine Surgery Procedures AND Effective 01/01/2018 Major Joint and Foot/ Lower Extremity Procedures (Blue Medicare HMO PPO)

Decompression Surgery 63085 REMOVAL OF VERTEBRAL BODY Decompression Surgery 63086 REMOVE VERTEBRAL BODY ADD-ON Decompression Surgery 63087 REMOVAL OF VERTEBRAL BODY Decompression Surgery 63088 REMOVE VERTEBRAL BODY ADD-ON Decompression Surgery 63090 REMOVAL OF VERTEBRAL BODY Decompression Surgery 63091 REMOVE VERTEBRAL BODY ADD-ON Decompression Surgery 63101 REMOVAL OF VERTEBRAL BODY Decompression Surgery 63102 REMOVAL OF VERTEBRAL BODY Decompression Surgery 63103 REMOVE VERTEBRAL BODY ADD-ON Decompression Surgery 63170 INCISE SPINAL CORD TRACT(S) Decompression Surgery 63172 DRAINAGE OF SPINAL CYST Decompression Surgery 63173 DRAINAGE OF SPINAL CYST Decompression Surgery 63180 REVISE SPINAL CORD LIGAMENTS Decompression Surgery 63182 REVISE SPINAL CORD LIGAMENTS Decompression Surgery 63185 INCISE SPINAL COLUMN/NERVES Decompression Surgery 63190 INCISE SPINAL COLUMN/NERVES Decompression Surgery 63191 INCISE SPINAL COLUMN/NERVES Decompression Surgery 63194 INCISE SPINAL COLUMN & CORD Decompression Surgery 63195 INCISE SPINAL COLUMN & CORD Decompression Surgery 63196 INCISE SPINAL COLUMN & CORD Decompression Surgery 63197 INCISE SPINAL COLUMN & CORD Decompression Surgery 63198 INCISE SPINAL COLUMN & CORD Decompression Surgery 63199 INCISE SPINAL COLUMN & CORD Decompression Surgery 63200 RELEASE OF SPINAL CORD Decompression Surgery 63250 REVISE SPINAL CORD VESSELS Decompression Surgery 63251 REVISE SPINAL CORD VESSELS Decompression Surgery 63252 REVISE SPINAL CORD VESSELS Decompression Surgery 63265 EXCISE INTRASPINAL LESION Decompression Surgery 63266 EXCISE INTRASPINAL LESION Decompression Surgery 63267 EXCISE INTRASPINAL LESION Decompression Surgery 63268 EXCISE INTRASPINAL LESION Decompression Surgery 63270 EXCISE INTRASPINAL LESION Decompression Surgery 63271 EXCISE INTRASPINAL LESION Decompression Surgery 63272 EXCISE INTRASPINAL LESION Decompression Surgery 63273 EXCISE INTRASPINAL LESION Decompression Surgery 63275 BIOPSY/EXCISE SPINAL TUMOR Decompression Surgery 63276 BIOPSY/EXCISE SPINAL TUMOR Decompression Surgery 63277 BIOPSY/EXCISE SPINAL TUMOR Decompression Surgery 63278 BIOPSY/EXCISE SPINAL TUMOR Decompression Surgery 63280 BIOPSY/EXCISE SPINAL TUMOR Decompression Surgery 63281 BIOPSY/EXCISE SPINAL TUMOR Decompression Surgery 63282 BIOPSY/EXCISE SPINAL TUMOR Decompression Surgery 63283 BIOPSY/EXCISE SPINAL TUMOR Decompression Surgery 63285 BIOPSY/EXCISE SPINAL TUMOR Decompression Surgery 63286 BIOPSY/EXCISE SPINAL TUMOR OrthoNet PPA Code List Pain Management and Spine Surgery Procedures AND Effective 01/01/2018 Major Joint and Foot/ Lower Extremity Procedures (Blue Medicare HMO PPO)

Decompression Surgery 63287 BIOPSY/EXCISE SPINAL TUMOR Decompression Surgery 63290 BIOPSY/EXCISE SPINAL TUMOR Decompression Surgery 63295 REPAIR OF LAMINECTOMY DEFECT Decompression Surgery 63300 REMOVAL OF VERTEBRAL BODY Decompression Surgery 63301 REMOVAL OF VERTEBRAL BODY Decompression Surgery 63302 REMOVAL OF VERTEBRAL BODY Decompression Surgery 63303 REMOVAL OF VERTEBRAL BODY Decompression Surgery 63304 REMOVAL OF VERTEBRAL BODY Decompression Surgery 63305 REMOVAL OF VERTEBRAL BODY Decompression Surgery 63306 REMOVAL OF VERTEBRAL BODY Decompression Surgery 63307 REMOVAL OF VERTEBRAL BODY Decompression Surgery 63308 REMOVE VERTEBRAL BODY ADD-ON Spinal Cord Stimulator 63650 IMPLANT NEUROELECTRODES Spinal Cord Stimulator 63655 IMPLANT NEUROELECTRODES Spinal Cord Stimulator 63661 REMOVE SPINE ELTRD PERQ ARAY Spinal Cord Stimulator 63662 REMOVE SPINE ELTRD PLATE Spinal Cord Stimulator 63663 REVISE SPINE ELTRD PERQ ARAY Spinal Cord Stimulator 63664 REVISE SPINE ELTRD PLATE Spinal Cord Stimulator 63685 IMPLANT NEURORECEIVER Spinal Cord Stimulator 63688 REVISE/REMOVE NEURORECEIVER Spinal Fusion 0195T ARTHROD PRESAC INTERBODY Spinal Fusion 0196T ARTHROD PRESAC INTERBODY EAC Spinal Fusion 22853 INSJ BIOMCHN DEV INTERVERTEBRAL DSC SPC W/ARTHRD Spinal Fusion 22854 INSJ BIOMCHN DEV VRT CORPECTOMY DEFECT W/ARTHRD Spinal Fusion 22859 INSJ BIOMCHN DEV NTRVRT DISC SPACE W/O ARTHRD Spinal Fusion 22867 INSJ STABLJ DEV W/DCMPRN LUMBAR SINGLE LEVEL Spinal Fusion 22868 INSJ STABLJ DEV W/DCMPRN LUMBAR SECOND LEVEL Spinal Fusion 22869 INSJ STABLJ DEV W/O DCMPRN LUMBAR SINGLE LEVEL Spinal Fusion 22870 INSJ STABLJ DEV W/O DCMPRN LUMBAR SECOND LEVEL Pain Pump 62324 NJX DX/THER SBST INTRLMNR CRV/THRC W/O IMG GDN Pain Pump 62325 NJX DX/THER SBST INTRLMNR CRV/THRC W/IMG GDN Pain Pump 62326 NJX DX/THER SBST INTRLMNR LMBR/SAC W/O IMG GDN Pain Pump 62327 NJX DX/THER SBST INTRLMNR LMBR/SAC W/IMG GDN Decompression Surgery 62380 NDSC DCMPRN SPINAL CORD 1 W/LAMOT NTRSPC LUMBAR Pain Pump E0782 NON-PROGRAMBLE INFUSION PUMP Pain Pump E0783 PROGRAMMABLE INFUSION PUMP Pain Pump E0785 REPLACEMENT IMPL PUMP CATHET Pain Pump E0786 IMPLANTABLE PUMP REPLACEMENT Spinal Cord Stimulator L8679 Imp neurosti pls gn any type Spinal Cord Stimulator L8680 IMPLT NEUROSTIM ELCTR EACH Spinal Cord Stimulator L8682 IMPLT NEUROSTIM RADIOFQ REC Major Joint and Foot/ Lower Extremity Procedures Hip Arthroplasty 27090 REMOVAL OF HIP PROSTHESIS Hip Arthroplasty 27091 REMOVAL OF HIP PROSTHESIS Hip Arthroplasty 27120 RECONSTRUCTION OF HIP SOCKET OrthoNet PPA Code List Pain Management and Spine Surgery Procedures AND Effective 01/01/2018 Major Joint and Foot/ Lower Extremity Procedures (Blue Medicare HMO PPO)

Hip Arthroplasty 27122 RECONSTRUCTION OF HIP SOCKET Hip Arthroplasty 27125 HEMIARTHROPLASTY HIP PARTIAL Hip Arthroplasty 27130 ARTHRP ACETBLR/PROX FEM PROSTC AGRFT/ALGRFT Hip Arthroplasty 27132 CONV PREV HIP TOT HIP ARTHRP W/WO AGRFT/ALGRFT Hip Arthroplasty 27134 REVJ TOT HIP ARTHRP BTH W/WO AGRFT/ALGRFT Hip Arthroplasty 27137 REVJ TOT HIP ARTHRP ACTBLR W/WO AGRFT/ALGRFT Hip Arthroplasty 27138 REVJ TOT HIP ARTHRP FEM ONLY W/WO ALGRFT Hip Arthroscopy 27299 PELVIS/HIP SURGERY UNLISTED Knee Arthroplasty 27437 ARTHROPLASTY PATELLA W/O PROSTHESIS Knee Arthroplasty 27438 ARTHROPLASTY PATELLA W/PROSTHESIS Knee Arthroplasty 27440 ARTHROPLASTY KNEE TIBIAL PLATEAU Knee Arthroplasty 27441 ARTHRP KNEE TIBIAL PLATEAU DBRDMT&PRTL SYNVCT Knee Arthroplasty 27442 ARTHROPLASTY FEM CONDYLES/TIBIAL PLATEAU KNEE Knee Arthroplasty 27443 ARTHRP FEM CONDYLES/TIBL PLATU KNE DBRDMT&PRTL Knee Arthroplasty 27445 ARTHROPLASTY KNEE HINGE PROSTHESIS Knee Arthroplasty 27446 ARTHRP KNEE CONDYLE&PLATEAU MEDIAL/LAT CMPRT Knee Arthroplasty 27447 ARTHRP KNE CONDYLE&PLATU MEDIAL&LAT COMPARTMENTS Knee Arthroplasty 27486 REVISE/REPLACE KNEE JOINT Knee Arthroplasty 27487 REVISE/REPLACE KNEE JOINT Knee Arthroplasty 27488 REMOVAL OF KNEE PROSTHESIS Knee Arthroscopy 27599 KNEE SURGERY PROCEDURE UNLISTED Ankle Surgery 27605 TENOTOMY PRQ ACHILLES TENDON SPX LOCAL ANES Ankle Surgery 27606 TENOTOMY PRQ ACHILLES TENDON SPX GENERAL ANES Ankle Surgery 27615 RAD RESECTION TUMOR SOFT TISSUE LEG/ANKLE <5CM Ankle Surgery 27616 RAD RESCJ TUM SOFT TISSUE LEG/ANKLE 5+CM Ankle Surgery 27620 ARTHRT ANKLE W/JT EXPL +-BX +-RMVL LOOSE/FB Ankle Surgery 27625 ARTHROTOMY W/SYNOVECTOMY ANKLE Ankle Surgery 27626 ARTHROTOMY W/SYNOVECTOMY ANKLE TENOSYNOVECTOMY Ankle Surgery 27647 RADICAL RESECTION OF TUMOR TALUS OR CALCANEUS Ankle Surgery 27650 REPAIR PRIMARY OPEN/PRQ RUPTURED ACHILLES TENDON Ankle Surgery 27652 RPR PRIMARY OPEN/PRQ RUPTURED ACHILLES W/GRAFT Ankle Surgery 27654 REPAIR SECONDARY ACHILLES TENDON +-GRAFT Ankle Surgery 27680 TENOLYSIS FLXR/XTNSR TENDON LEG&/ANKLE 1 EACH Ankle Surgery 27681 TNOLS FLXR/XTNSR TDN LEG&/ANKLE MLT TDN Ankle Surgery 27685 LNGTH/SHRT TDN LEG/ANKLE 1 TDN SPX Ankle Surgery 27686 LNGTH/SHRT TDN LEG/ANKLE MLT TDN SAME INC EA Ankle Surgery 27695 RPR PRIMARY DISRUPTED LIGAMENT ANKLE COLLATERAL Ankle Surgery 27696 RPR PRIM DISRUPTED LIGM ANKLE BTH COLTRL LIGMS Ankle Surgery 27698 REPAIR SECONDARY DISRUPTED LIGAMENT ANKLE COLTRL Ankle Surgery 27700 ARTHROPLASTY ANKLE Ankle Surgery 27702 ARTHROPLASTY ANKLE W/IMPLANT Ankle Surgery 27703 ARTHROPLASTY ANKLE REVISION TOTAL ANKLE Ankle Surgery 27704 REMOVAL ANKLE IMPLANT Ankle Surgery 27870 ARTHRODESIS ANKLE OPEN Foot Surgery 28008 FASCIOTOMY FOOT&/TOE OrthoNet PPA Code List Pain Management and Spine Surgery Procedures AND Effective 01/01/2018 Major Joint and Foot/ Lower Extremity Procedures (Blue Medicare HMO PPO)

Foot Surgery 28010 TENOTOMY PERCUTANEOUS TOE SINGLE TENDON Foot Surgery 28011 TENOTOMY PERCUTANEOUS TOE MULTIPLE TENDON Foot Surgery 28020 ARTHRT W/EXPL DRG/RMVL LOOSE/FB NTRTRSL/TARS JT Foot Surgery 28022 ARTHRT W/EXPL DRG/RMVL LOOSE/FB MTTARPHLNGL JT Foot Surgery 28024 ARTHRT W/EXPL DRG/RMVL LOOSE/FB IPHAL JT Foot Surgery 28046 RAD RESECTION TUMOR SOFT TISSUE FOOT/TOE <3CM Foot Surgery 28055 NEURECTOMY INTRINSIC MUSCULATURE OF FOOT Foot Surgery 28100 EXCISION/CURETTAGE CYST/TUMOR TALUS/CALCANEUS Foot Surgery 28102 EXC/CURTG CST/B9 TUM TALUS/CLCNS W/ILIAC/AGRFT Foot Surgery 28103 EXC/CURETTAGE CYST/TUMOR TALUS/CALCANEUS ALGRFT Foot Surgery 28104 EXC/CURTG CST/B9 TUM TARSAL/METAR Foot Surgery 28106 EXC/CURTG CST/B9 TUM TARSAL/METAR W/ILIAC/AGRFT Foot Surgery 28107 EXC/CURTG CST/B9 TUM TARSAL/METAR W/ALGRFT Foot Surgery 28108 EXC/CURTG CST/B9 TUM PHALANGES FOOT Foot Surgery 28110 OSTECTOMY PRTL 5TH METAR HEAD SPX Foot Surgery 28111 OSTECTOMY COMPLETE 1ST METATARSAL HEAD Foot Surgery 28112 OSTECTOMY COMPLETE OTHER METATARSAL HEAD 2/3/4 Foot Surgery 28113 OSTECTOMY COMPLETE 5TH METATARSAL HEAD Foot Surgery 28114 OSTC COMPL ALL METAR HEADS W/PRTL PROX PHALANGC Foot Surgery 28116 OSTECTOMY TARSAL COALITION Foot Surgery 28118 OSTECTOMY CALCANEUS Foot Surgery 28119 OSTECTOMY CALCANEUS SPUR +-PLNTAR FSCAL RLS Foot Surgery 28120 PRTL EXC B1 TALUS/CALCANEUS Foot Surgery 28122 PRTL EXC B1 TARSAL/METAR B1 XCP TALUS/CALCANEUS Foot Surgery 28124 PRTL EXC B1 PHALANX TOE Foot Surgery 28126 PARTIAL REMOVAL OF TOE Foot Surgery 28130 REMOVAL OF ANKLE BONE Foot Surgery 28140 REMOVAL OF METATARSAL Foot Surgery 28150 REMOVAL OF TOE Foot Surgery 28153 PARTIAL REMOVAL OF TOE Foot Surgery 28160 PARTIAL REMOVAL OF TOE Foot Surgery 28171 RESECT TARSAL TUMOR Foot Surgery 28173 RESECT METATARSAL TUMOR Foot Surgery 28175 RESECT PHALANX OF TOE TUMOR Foot Surgery 28220 TENOLYSIS FLEXOR FOOT SINGLE TENDON Foot Surgery 28222 TENOLYSIS FLEXOR FOOT MULTIPLE TENDONS Foot Surgery 28285 CORRECTION HAMMERTOE Foot Surgery 28300 OSTEOTOMY CALCANEUS +-INTERNAL FIXATION Foot Surgery 28302 OSTEOTOMY TALUS Foot Surgery 28304 OSTEOTOMY TARSAL BONES OTH/THN CALCANEUS/TALUS Foot Surgery 28305 OSTEOT TARSAL OTH/THN CALCANEUS/TALUS W/AGRFT Foot Surgery 28306 OSTEOT +-LNGTH SHRT/CORRJ 1ST METAR Foot Surgery 28307 OSTEOT +-LNGTH SHRT/CORRJ 1ST METAR XCP 1ST TOE Foot Surgery 28308 OSTEOT +-LNGTH SHRT/CORRJ METAR XCP 1ST EA Foot Surgery 28309 OSTEOT +-LNGTH SHRT/ANGULAR CORRJ METAR MLT OrthoNet PPA Code List Pain Management and Spine Surgery Procedures AND Effective 01/01/2018 Major Joint and Foot/ Lower Extremity Procedures (Blue Medicare HMO PPO)

Foot Surgery 28310 OSTEOT SHRT CORRJ PROX PHALANX 1ST TOE Foot Surgery 28312 OSTEOT SHRT CORRJ OTH PHALANGES ANY TOE Foot Surgery 28705 ARTHRODESIS PANTALAR Foot Surgery 28715 ARTHRODESIS TRIPLE Foot Surgery 28725 ARTHRODESIS SUBTALAR Foot Surgery 28730 ARTHRD MIDTARSL/TARS MLT/TRANSVRS Foot Surgery 28735 ARTHRD MIDTARSL/TARS MLT/TRANSVRS W/OSTEOT Foot Surgery 28737 ARTHRD W/TDN LNGTH&ADVMNT TARSL NVCLR-CUNEIFORM Foot Surgery 28740 ARTHRODESIS MIDTARSOMETATARSAL SINGLE JOINT Foot Surgery 28750 ARTHRODESIS GREAT TOE METATARSOPHALANGEAL JOINT Foot Surgery 28755 ARTHRODESIS GREAT TOE INTERPHALANGEAL JOINT Foot Surgery 28760 ARTHRD W/XTNSR HALLUCIS LONGUS TR 1ST METAR NCK Foot Surgery 28800 AMPUTATION FOOT MIDTARSAL Foot Surgery 28805 AMPUTATION FOOT TRANSMETARSAL Foot Surgery 28810 AMPUTATION METATARSAL W/TOE SINGLE Foot Surgery 28820 AMPUTATION TOE METATARSOPHALANGEAL JOINT Foot Surgery 28825 AMPUTATION TOE INTERPHALANGEAL JOINT Shoulder Arthroscopy 29805 ARTHROSCOPY SHOULDER DX W/WO SYNOVIAL BIOPSY SPX Shoulder Arthroscopy 29806 ARTHROSCOPY SHOULDER SURGICAL CAPSULORRHAPHY Shoulder Arthroscopy 29807 ARTHROSCOPY SHOULDER SURGICAL REPAIR SLAP LESION Shoulder Arthroscopy 29819 ARTHROSCOPY SHOULDER SURGICAL REMOVAL LOOSE/FB Shoulder Arthroscopy 29820 ARTHROSCOPY SHOULDER SURG SYNOVECTOMY PARTIAL Shoulder Arthroscopy 29821 ARTHROSCOPY SHOULDER SURG SYNOVECTOMY COMPLETE Shoulder Arthroscopy 29822 ARTHROSCOPY SHOULDER SURG DEBRIDEMENT LIMITED Shoulder Arthroscopy 29823 ARTHROSCOPY SHOULDER SURG DEBRIDEMENT EXTENSIVE Shoulder Arthroscopy 29824 ARTHROSCOPY SHOULDER DISTAL CLAVICULECTOMY Shoulder Arthroscopy 29825 ARTHROSCOPY SHOULDER AHESIOLYSIS W/WO MANIPJ Shoulder Arthroscopy 29826 ARTHROSCOPY SHOULDER W/CORACOACRM LIGMNT RELEASE Shoulder Arthroscopy 29827 ARTHROSCOPY SHOULDER ROTATOR CUFF REPAIR Shoulder Arthroscopy 29828 ARTHROSCOPY SHOULDER BICEPS TENODESIS Elbow Arthroscopy 29830 ARTHROSCOPY ELBOW DIAG W/WO SYNOVIAL BIOPSY SPX Elbow Arthroscopy 29834 ARTHROSCOPY ELBOW SURGICAL W/REMOVAL LOOSE/FB Elbow Arthroscopy 29835 ARTHROSCOPY ELBOW SURGICAL SYNOVECTOMY PARTIAL Elbow Arthroscopy 29836 ARTHROSCOPY ELBOW SURGICAL SYNOVECTOMY COMPLETE Elbow Arthroscopy 29837 ARTHROSCOPY ELBOW SURGICAL DEBRIDEMENT LIMITED Elbow Arthroscopy 29838 ARTHROSCOPY ELBOW SURGICAL DEBRIDEMENT EXTENSIVE Wrist Arthroscopy 29840 ARTHROSCOPY WRIST DIAG W/WO SYNOVIAL BIOPSY SPX Wrist Arthroscopy 29843 ARTHROSCOPY WRIST INFECTION LAVAGE&DRAINAGE Wrist Arthroscopy 29844 ARTHROSCOPY WRIST SURGICAL SYNOVECTOMY PARTIAL Wrist Arthroscopy 29845 ARTHROSCOPY WRIST SURGICAL SYNOVECTOMY COMPLETE Wrist Arthroscopy 29846 ARTHRS WRST EXC&/RPR TRIANG FIBROCART&/JOINT Wrist Arthroscopy 29847 ARTHROSCOPY WRIST SURG INT FIXJ FX/INSTABILITY Wrist Arthroscopy 29848 NDSC WRST SURG W/RLS TRANSVRS CARPL LIGM Hip Arthroscopy 29860 ARTHROSCOPY HIP DIAGNOSTIC W/WO SYNOVIAL BYP SPX Hip Arthroscopy 29861 ARTHROSCOPY HIP SURGICAL W/REMOVAL LOOSE/FB OrthoNet PPA Code List Pain Management and Spine Surgery Procedures AND Effective 01/01/2018 Major Joint and Foot/ Lower Extremity Procedures (Blue Medicare HMO PPO)

Hip Arthroscopy 29862 ARTHRS HIP DEBRIDEMENT/SHAVING ARTICULAR CRTLG Hip Arthroscopy 29863 ARTHROSCOPY HIP SURGICAL W/SYNOVECTOMY Knee Arthroscopy 29866 ARTHROSCOPY KNEE OSTEOCHONDRAL AGRFT MOSAICPLAST Knee Arthroscopy 29867 ARTHROSCOPY KNEE OSTEOCHONDRAL ALLOGRAFT Knee Arthroscopy 29870 ARTHROSCOPY KNEE DIAGNOSTIC W/WO SYNOVIAL BX SPX Knee Arthroscopy 29871 ARTHROSCOPY KNEE INFECTION LAVAGE & DRAINAGE Knee Arthroscopy 29873 ARTHROSCOPY KNEE LATERAL RELEASE Knee Arthroscopy 29874 ARTHROSCOPY KNEE REMOVAL LOOSE/FOREIGN BODY Knee Arthroscopy 29875 ARTHROSCOPY KNEE SYNOVECTOMY LIMITED SPX Knee Arthroscopy 29876 ARTHROSCOPY KNEE SYNOVECTOMY 2/>COMPARTMENTS Knee Arthroscopy 29877 ARTHRS KNEE DEBRIDEMENT/SHAVING ARTCLR CRTLG Knee Arthroscopy 29879 ARTHRS KNEE ABRASION ARTHRP/MLT DRLG/MICROFX Knee Arthroscopy 29880 ARTHRS KNEE W/MENISCECTOMY MED&LAT W/SHAVING Knee Arthroscopy 29881 ARTHRS KNE SURG W/MENISCECTOMY MED/LAT W/SHVG Knee Arthroscopy 29882 ARTHROSCOPY KNEE W/MENISCUS RPR MEDIAL/LATERAL Knee Arthroscopy 29883 ARTHROSCOPY KNEE W/MENISCUS RPR MEDIAL&LATERAL Knee Arthroscopy 29884 ARTHROSCOPY KNEE W/LYSIS ADHESIONS W/WO MANJ SPX Knee Arthroscopy 29885 ARTHRS KNEE DRILL OSTEOCHONDRITIS DISSECANS GRFG Knee Arthroscopy 29886 ARTHRS KNEE DRILLING OSTEOCHOND DISSECANS LESION Knee Arthroscopy 29887 ARTHRS KNEE DRLG OSTEOCHOND DISSECANS INT FIXJ Knee Arthroscopy 29888 ARTHRS AIDED ANT CRUCIATE LIGM RPR/AGMNTJ/RCNSTJ Knee Arthroscopy 29889 ARTHRS AIDED PST CRUCIATE LIGM RPR/AGMNTJ/RCNSTJ Ankle Arthroscopy 29891 ARTHRS ANKLE EXC OSTCHNDRL DFCT W/DRLG DFCT Ankle Arthroscopy 29892 ARTHRS AID RPR LES/TALAR DOME FX/TIBL PLAFOND FX Ankle Arthroscopy 29893 ENDOSCOPIC PLANTAR FASCIOTOMY Ankle Arthroscopy 29894 ARTHROSCOPY ANKLE W/REMOVAL LOOSE/FOREIGN BODY Ankle Arthroscopy 29895 ARTHROSCOPY ANKLE SURGICAL SYNOVECTOMY PARTIAL Ankle Arthroscopy 29897 ARTHROSCOPY ANKLE SURGICAL DEBRIDEMENT LIMITED Ankle Arthroscopy 29898 ARTHROSCOPY ANKLE SURGICAL DEBRIDEMENT EXTENSIVE Ankle Arthroscopy 29899 ARTHROSCOPY ANKLE SURGICAL W/ANKLE ARTHRODESIS Ankle Arthroscopy 29904 ARTHRS SUBTALAR JOINT REMOVE LOOSE/FOREIGN BODY Ankle Arthroscopy 29905 ARTHROSCOPY SUBTALAR JOINT WITH SYNOVECTOMY Ankle Arthroscopy 29906 ARTHROSCOPY SUBTALAR JOINT WITH DEBRIDEMENT Ankle Arthroscopy 29907 ARTHROSCOPY SUBTALAR JOINT SUBTALAR ARTHRODESIS Hip Arthroscopy 29914 ARTHROSCOPY HIP W/FEMOROPLASTY Hip Arthroscopy 29915 ARTHROSCOPY HIP W/ACETABULOPLASTY Hip Arthroscopy 29916 ARTHROSCOPY HIP W/LABRAL REPAIR Hip Arthroplasty 27197 CLSD TX PELVIC RING FX W/O MANIPULATION Hip Arthroplasty 27198 CLSD TX PELVIC RING FX W/MANIPULATION W/ANES Foot Surgery 28291 HALLUX RIGIDUS W/CHEILECTOMY 1ST MP JT W/IMPLT Foot Surgery 28295 CORRJ HALLUX VALGUS W/SESMDC W/PROX METAR OSTEOT