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Home , Acromioplasty, Ankle fusion, Ankle replacement, Arthroplasty, Arthroscopy, Corpectomy

TurningPoint – Procedure Coding and Medical Policy Information

TurningPoint Procedure Code Description Policy ACL Repair 27407 Repair, primary, torn and/or capsule, ; cruciate OR-1013 ACL Repair 27409 Repair, primary, torn ligament and/or capsule, knee; collateral and cruciate OR-1013

ACL Repair 29888 Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction OR-1013 Or Acromionectomy, Partial, With Or Without Coracoacromial Ligament Acromioplasty and Rotator Cuff Repair 23130 OR-1018 Release Acromioplasty and Rotator Cuff Repair 23410 Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; acute OR-1018 Acromioplasty and Rotator Cuff Repair 23412 Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; chronic OR-1018 Acromioplasty and Rotator Cuff Repair 23415 Coracoacromial Ligament Release, With Or Without Acromioplasty OR-1018 Acromioplasty and Rotator Cuff Repair 23420 Reconstruction of complete (rotator) cuff avulsion, chronic (includes acromioplasty) OR-1018 , Shoulder, Surgical; Decompression Of Subacromial Space With Partial Acromioplasty and Rotator Cuff Repair 29826 Acromioplasty, With Coracoacromial Ligament (Ie, Arch) Release, When Performed (List OR-1018 Separately In Addition To Code For Primary Procedure) Acromioplasty and Rotator Cuff Repair 29827 Arthroscopy, shoulder, surgical; with rotator cuff repair OR-1018 Allograft for [BMP] 20930 Allograft, morselized, or placement of osteopromotive material, for spine only OR-1005 Fusion 27870 , ankle, open OR-1030 29899 Arthroscopy, ankle (tibiotalar and fibulotalar ), surgical; with ankle arthrodesis OR-1030 Total disc (artificial disc), anterior approach, including with end plate Cervical Disc Replacement 22856 preparation (includes osteophytectomy for root or decompression and OR-1006 microdissection), single interspace, cervical Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, Cervical Disc Replacement 22861 OR-1006 single interspace; cervical Cervical Disc Replacement 22864 Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical OR-1006 with exploration and/or decompression of spinal cord and/or cauda equina, Cervical Laminectomy and Discectomy 63001 without , or discectomy (eg, ), 1 or 2 vertebral OR-1007 segments; cervical Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, Cervical Laminectomy and Discectomy 63015 without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral OR-1007 segments; cervical (hemilaminectomy), with decompression of (s), including partial Cervical Laminectomy and Discectomy 63020 facetectomy, foraminotomy and/or excision of herniated ; 1 interspace, OR-1007 cervical Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial Cervical Laminectomy and Discectomy 63040 facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, OR-1007 single interspace; cervical Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, Cervical Laminectomy and Discectomy 63043 OR-1007 single interspace; each additional cervical interspace (List separately in addition to code for primary procedure) Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of Cervical Laminectomy and Discectomy 63045 spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single OR-1007 vertebral segment; cervical Cervical Laminectomy and Discectomy 63050 , cervical, with decompression of the spinal cord, 2 or more vertebral segments OR-1007

Laminoplasty, cervical, with decompression of the spinal cord, 2 or more vertebral segments; Cervical Laminectomy and Discectomy 63051 with reconstruction of the posterior bony elements (including the application of bridging OR-1007 graft and non-segmental fixation devices (eg, wire, suture, mini-plates), when performed) Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including Cervical Laminectomy and Discectomy 63075 OR-1007 osteophytectomy; cervical, single interspace Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including Cervical Laminectomy and Discectomy 63076 OR-1007 osteophytectomy; cervical, each additional interspace Laminectomy and section of dentate ligaments, with or without dural graft, cervical; 1 or 2 Cervical Laminectomy and Discectomy 63180 OR-1007 segments Laminectomy and section of dentate ligaments, with or without dural graft, cervical; more than Cervical Laminectomy and Discectomy 63182 OR-1007 2 segments Cervical Laminectomy and Discectomy 63194 Laminectomy with , with section of 1 spinothalamic tract, 1 stage; cervical OR-1007

Cervical Laminectomy and Discectomy 63196 Laminectomy with cordotomy, with section of both spinothalamic tracts, 1 stage; cervical OR-1007 Laminectomy with cordotomy with section of both spinothalamic tracts, 2 stages within 14 Cervical Laminectomy and Discectomy 63198 OR-1007 days; cervical Cervical Laminectomy and Discectomy 63250 Laminectomy for excision or occlusion of arteriovenous malformation of spinal cord; cervical OR-1007 Laminectomy for excision or evacuation of intraspinal lesion other than , extradural; Cervical Laminectomy and Discectomy 63265 OR-1007 cervical Cervical Laminectomy and Discectomy 63270 Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; cervical OR-1007 Cervical Laminectomy and Discectomy 63275 Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, cervical OR-1007

SuperiorHealthPlan.com SHP_20195259C TurningPoint Procedure Code Description Policy Cervical Laminectomy and Discectomy 63280 Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, extramedullary, cervical OR-1007

Cervical Laminectomy and Discectomy 63285 Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, intramedullary, cervical OR-1007 Percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or Cervical Laminectomy and Discectomy 0274T foraminotomy), any method, under indirect image guidance (eg, fluoroscopic, CT), with or OR-1007 without the use of an endoscope, single or multiple levels, unilateral or bilateral; cervical or thoracic Arthrodesis, anterior transoral or extraoral technique, clivus-C1-C2 (atlas-axis), with or without Cervical Spinal Fusion 22548 OR-1012 excision of odontoid process Arthrodesis, anterior interbody, including disc space preparation, discectomy, Cervical Spinal Fusion 22551 OR-1012 osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2

Arthrodesis, anterior interbody, including disc space preparation, discectomy, Cervical Spinal Fusion 22552 osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2, OR-1012 each additional interspace (List separately in addition to code for separate procedure) Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace Cervical Spinal Fusion 22554 OR-1012 (other than for decompression); cervical below C2 Cervical Spinal Fusion 22590 Arthrodesis, posterior technique, craniocervical (occiput-C2) OR-1012 Cervical Spinal Fusion 22595 Arthrodesis, posterior technique, atlas-axis (C1-C2) OR-1012 Cervical Spinal Fusion 22600 Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment OR-1012 Removal of , includes debridement and when performed; humeral and Elbow Replacement 24160 OR-1022 ulnar components Elbow Replacement 24164 Removal of prosthesis, includes debridement and synovectomy when performed; radial head OR-1022 Elbow Replacement 24360 Arthroplasty, elbow; with membrane (e.g., fascial) OR-1022 Elbow Replacement 24361 Arthroplasty, elbow; with distal humeral prosthetic replacement OR-1022 Elbow Replacement 24362 Arthroplasty, elbow; with and fascia lata ligament reconstruction OR-1022 Arthroplasty, elbow; with distal humerus and proximal ulnar prosthetic replacement (e.g., total Elbow Replacement 24363 OR-1022 elbow) Elbow Replacement 24365 Arthroplasty, radial head OR-1022 Elbow Replacement 24366 Arthroplasty, radial head; with implant OR-1022 Revision of total elbow arthroplasty, including allograft when performed; humeral or ulnar Elbow Replacement 24370 OR-1022 component Revision of total elbow arthroplasty, including allograft when performed; humeral and ulnar Elbow Replacement 24371 OR-1022 component Unlisted procedure, or [when specified as open procedure for Femoroacetabular Arthroscopy 27299 OR-1025 femoroacetabular impingement syndrome, other than capsular plication] Femoroacetabular Arthroscopy 29914 Arthroscopy, hip, surgical; with femoroplasty (ie, treatment of cam lesion) OR-1025 Femoroacetabular Arthroscopy 29915 Arthroscopy, hip, surgical; with acetabuloplasty (ie, treatment of pincer lesion) OR-1025 Arthroscopy, hip, surgical; with labral repair [when repair of the labral tear is associated with Femoroacetabular Arthroscopy 29916 OR-1025 FAIS] 29860 Arthroscopy, Hip, Diagnostic With Or Without Synovial Biopsy (Separate Procedure) OR-1031 Hip Arthroscopy 29861 Arthroscopy, Hip, Surgical; With Removal Of Loose Body Or Foreign Body OR-1031 Arthroscopy, Hip, Surgical; With Debridement/Shaving Of Articular (Chondroplasty), Hip Arthroscopy 29862 OR-1031 Abrasion Arthroplasty, And/Or Resection Of Labrum Hip Arthroscopy 29863 Arthroscopy, Hip, Surgical; With Synovectomy OR-1031 27033 , hip, including exploration or removal of loose or foreign body OR-1026 Hip Resurfacing 27125 Hip Hemiarthroplasty, hip, partial (eg, femoral stem prosthesis, bipolar arthroplasty) OR-1026 Partial excision (craterization, saucerization, or diaphysectomy) bone, , proximal Hip Resurfacing 27360 OR-1026 and/or fibula (eg, osteomyelitis or bone abscess Hip Resurfacing S2118 METL-ON-METL TOT HIP RESRFC ACETAB&FEM CMPNT OR-1026 Implantable Infusion Pumps 36260 Insertion of implantable intra-arterial infusion pump (eg, for chemotherapy of liver) OR-1034 Insertion Of Tunneled Centrally Inserted Central Venous Access Device With Subcutaneous Implantable Infusion Pumps 36563 OR-1034 Pump Replacement, Complete, Of A Tunneled Centrally Inserted Central Venous Access Device, Implantable Infusion Pumps 36583 OR-1034 With Subcutaneous Pump, Through Same Venous Access Insertion of subcutaneous reservoir, pump or continuous infusion system for connection to Implantable Infusion Pumps 61215 OR-1034 ventricular catheter Implantation, Revision Or Repositioning Of Tunneled Intrathecal Or Epidural Catheter, For Implantable Infusion Pumps 62350 Long-Term Medication Administration Via An External Pump Or Implantable OR-1034 Reservoir/Infusion Pump; Without Laminectomy Implantation, Revision Or Repositioning Of Tunneled Intrathecal Or Epidural Catheter, For Implantable Infusion Pumps 62351 Long-Term Medication Administration Via An External Pump Or Implantable OR-1034 Reservoir/Infusion Pump; With Laminectomy Implantation Or Replacement Of Device For Intrathecal Or Epidural Drug Infusion; Implantable Infusion Pumps 62360 OR-1034 Subcutaneous Reservoir Implantation Or Replacement Of Device For Intrathecal Or Epidural Drug Infusion; Implantable Infusion Pumps 62361 OR-1034 Nonprogrammable Pump

SuperiorHealthPlan.com SHP_20195259C TurningPoint Procedure Code Description Policy Implantation Or Replacement Of Device For Intrathecal Or Epidural Drug Infusion; Implantable Infusion Pumps 62362 OR-1034 Programmable Pump, Including Preparation Of Pump, With Or Without Programming Removal Of Subcutaneous Reservoir Or Pump, Previously Implanted For Intrathecal Or Implantable Infusion Pumps 62365 OR-1034 Epidural Infusion Electronic Analysis Of Programmable, Implanted Pump For Intrathecal Or Epidural Drug Implantable Infusion Pumps 62367 Infusion (Includes Evaluation Of Reservoir Status, Alarm Status, Drug Prescription Status); OR-1034 Without Reprogramming Or Refil Electronic Analysis Of Programmable, Implanted Pump For Intrathecal Or Epidural Drug Implantable Infusion Pumps 62368 Infusion (Includes Evaluation Of Reservoir Status, Alarm Status, Drug Prescription Status); OR-1034 With Reprogramming Implantable Infusion Pumps C1772 Infusion pump, programmable (implantable) OR-1034 Implantable Infusion Pumps C1891 Infusion pump, nonprogrammable, permanent (implantable) OR-1034 Implantable Infusion Pumps C2626 Infusion pump, nonprogrammable, temporary (implantable) OR-1034 Infusion pump system, implantable, programmable (includes all components, e.g., pump, Implantable Infusion Pumps E0783 OR-1034 catheter, connectors, etc.) Implantable intraspinal (epidural/intrathecal) catheter used with implantable infusion pump, Implantable Infusion Pumps E0785 OR-1034 replacement Implantable programmable infusion pump, replacement (excludes implantable intraspinal Implantable Infusion Pumps E0786 OR-1034 catheter) Knee Arthroscopy 27405 Repair, primary, torn ligament and/or capsule, knee; collateral OR-1029 Knee Arthroscopy 29870 Arthroscopy, knee, diagnostic, with or without synovial biopsy (separate procedure) OR-1029 Knee Arthroscopy 29871 Arthroscopy, knee, surgical; for , lavage and drainage OR-1029 Knee Arthroscopy 29873 Arthroscopy, knee, surgical; with lateral release OR-1029 Arthroscopy, knee, surgical; for removal of loose body or foreign body (eg, osteochondritis Knee Arthroscopy 29874 OR-1029 dissecans fragmentation, chondral fragmentation) Arthroscopy, knee, surgical; synovectomy, limited (eg, plica or shelf resection) (separate Knee Arthroscopy 29875 OR-1029 procedure) Arthroscopy, knee, surgical; synovectomy, major, 2 or more compartments (eg, medial or Knee Arthroscopy 29876 OR-1029 lateral) Knee Arthroscopy 29877 Arthroscopy, knee, surgical; debridement/ shaving or articular cartilage (chondroplasty) OR-1029 Arthroscopy, knee, surgical; abrasion arthroplasty (includes chondroplasty where necessary) Knee Arthroscopy 29879 OR-1029 or multiple drilling or microfracture Arthroscopy, knee, surgical; with meniscectomy (medial AND lateral, including any meniscal Knee Arthroscopy 29880 shaving) including debridement/ shaving of articular cartilage (chondroplasty), same or OR-1029 separate compartment(s), when performed Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral, including any meniscal Knee Arthroscopy 29881 shaving) including debridement/ shaving of articular cartilage (chondroplasty), same or OR-1029 separate compartment(s), when performed Arthroscopy, knee, surgical; with lysis of adhesions, with or without manipulation (separate Knee Arthroscopy 29884 OR-1029 procedure) Arthroscopy, knee, surgical; drilling for osteochondritis dissecans with , with or Knee Arthroscopy 29885 OR-1029 without internal fixaiton (including debridement of base of lesion)

Knee Arthroscopy 29886 Arthroscopy, knee, surgical; drilling for intact osteochondritis dissecans lesion OR-1029 Arthroscopy, knee, surgical; drilling for intact osteochondritis dissecans lesion with internal Knee Arthroscopy 29887 OR-1029 fixation Knee Arthroscopy 29889 ARTHRS AIDED PST CRUCIATE LIGM RPR/AGMNTJ/RCNSTJ OR-1029 Unlisted procedure, arthroscopy [when specified as arthroscopic knee lavage as a separate [unlisted Knee Arthroscopy 29999 procedure] procedure] Arthroscopy, knee, surgical, for removal of loose body, foreign body, debridement/shaving of Knee Arthroscopy G0289 articular cartilage (chondroplasty) at the time of other surgical knee arthroscopy in a different OR-1029 compartment of the same knee Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, Kyphoplasty and Vertebroplasty 22510 OR-1024 unilateral or bilateral injection, inclusive of all imaging guidance; cervicothoracic Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, Kyphoplasty and Vertebroplasty 22511 unilateral or bilateral injection, inclusive of all imaging guidance; lumbosacral [when specified OR-1024 as lumbar] Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, Kyphoplasty and Vertebroplasty 22512 unilateral or bilateral injection, inclusive of all imaging guidance; each additional OR-1024 cervicothoracic or lumbosacral vertebral body [when specified as other than sacral]

Percutaneous , including cavity creation (fracture reduction and bone Kyphoplasty and Vertebroplasty 22513 biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral OR-1024 body, unilateral or bilateral cannulation, inclusive of all imaging guidance; thoracic

Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone Kyphoplasty and Vertebroplasty 22514 biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral OR-1024 body, unilateral or bilateral cannulation, inclusive of all imaging guidance; lumbar

SuperiorHealthPlan.com SHP_20195259C TurningPoint Procedure Code Description Policy Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral Kyphoplasty and Vertebroplasty 22515 OR-1024 body, unilateral or bilateral cannulation, inclusive of all imaging guidance; each additional thoracic or lumbar vertebral body Percutaneous sacral augmentation (sacroplasty), unilateral injection(s), including the use of a Kyphoplasty and Vertebroplasty 0200T OR-1024 balloon or mechanical device, when used, 1 or more needles

Percutaneous sacral augmentation (sacroplasty), bilateral injections, including the use of a Kyphoplasty and Vertebroplasty 0201T OR-1024 balloon or mechanical device, when used, 2 or more needles

Posterior vertebral joint(s) arthroplasty (eg, facet joint[s] replacement), including facetectomy, Kyphoplasty and Vertebroplasty 0202T laminectomy, foraminotomy, and fixation, injection of , when OR-1024 performed, including , single level, lumbar spine [Follows main Laminectomy- Unspecified 63170 Laminectomy with myelotomy (eg, Bischof or DREZ type), cervical, thoracic, or thoracolumbar procedure] [Follows main Laminectomy- Unspecified 63172 Laminectomy with drainage of intramedullary cyst/syrinx; to subarachnoid space procedure] [Follows main Laminectomy- Unspecified 63173 Laminectomy with drainage of intramedullary cyst/syrinx; to peritoneal or pleural space procedure] Laminectomy- Unspecified 63185 Laminectomy with ; 1 or 2 segments [Follows main Laminectomy- Unspecified 63190 Laminectomy with rhizotomy; more than 2 segments [Follows main Laminectomy- Unspecified 63191 Laminectomy with section of spinal accessory nerve [Follows main Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare Lumbar Disc Replacement 22857 OR-1003 interspace (other than for decompression), single interspace, lumbar Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, Lumbar Disc Replacement 22862 OR-1003 single interspace; lumbar Lumbar Disc Replacement 22865 Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace, lumbar OR-1003

Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare Lumbar Disc Replacement 0163T OR-1003 interspace (other than for decompression), each additional interspace, lumbar

Removal of total disc arthroplasty (artificial disc), anterior approach, each additional Lumbar Disc Replacement 0164T OR-1003 interspace, lumbar (List separately in addition to code for primary procedure) Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, Lumbar Disc Replacement 0165T OR-1003 each additional interspace, lumbar Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, any method utilizing needle based technique to remove disc material under fluoroscopic imaging Lumbar Laminectomy, Discectomy, and Laminotomy 62287 OR-1008 or other form of indirect visualization, with the use of an endoscope, with discography and/or epidural injection(s) at the treated level(s), when performed, single or multiple levels, lumbar Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, Lumbar Laminectomy, Discectomy, and Laminotomy 63003 without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral OR-1008 segments; thoracic Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, Lumbar Laminectomy, Discectomy, and Laminotomy 63005 without facetectomy, foraminotomy or discectomy (eg, spinal stenosis) 1 or 2 vertebral OR-1008 segments; lumbar, except for Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, Lumbar Laminectomy, Discectomy, and Laminotomy 63011 without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral OR-1008 segments; sacral Laminectomy with removal of abnormal facets and/or pars interarticularis with decompression Lumbar Laminectomy, Discectomy, and Laminotomy 63012 OR-1008 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, Lumbar Laminectomy, Discectomy, and Laminotomy 63016 without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral OR-1008 segments; thoracic Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, Lumbar Laminectomy, Discectomy, and Laminotomy 63017 without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral OR-1008 segments; lumbar Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial Lumbar Laminectomy, Discectomy, and Laminotomy 63030 facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, OR-1008 lumbar Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial Lumbar Laminectomy, Discectomy, and Laminotomy 63035 facetectomy, foraminotomy and/or excision of herniated intervertebral disc; each additional OR-1008 interspace, cervical or lumbar Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial Lumbar Laminectomy, Discectomy, and Laminotomy 63042 facetectomy, foraminotomy and/or excision of herniated intervertebral disc, re-exploration, OR-1008 single interspace; lumbar Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial Lumbar Laminectomy, Discectomy, and Laminotomy 63044 facetectomy, foraminotomy and/or excision of herniated intervertebral disc, re-exploration, OR-1008 single interspace; each additional lumbar interspace

SuperiorHealthPlan.com SHP_20195259C TurningPoint Procedure Code Description Policy Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of Lumbar Laminectomy, Discectomy, and Laminotomy 63046 spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single OR-1008 vertebral segment; thoracic Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of Lumbar Laminectomy, Discectomy, and Laminotomy 63047 spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single OR-1008 vertebral segment; lumbar Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of Lumbar Laminectomy, Discectomy, and Laminotomy 63048 spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single OR-1008 vertebral segment; each additional segment, cervical, thoracic, or lumbar

Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, Lumbar Laminectomy, Discectomy, and Laminotomy 63056 herniated intervertebral disc), single segment; lumbar (including transfacet, or lateral OR-1008 extraforaminal approach) (eg, far lateral herniated intervertebral disc) Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, Lumbar Laminectomy, Discectomy, and Laminotomy 63057 herniated intervertebral disc), single segment; each additional segment, thoracic or lumbar OR-1008 [when specified as lumbar] Lumbar Laminectomy, Discectomy, and Laminotomy 63200 Laminectomy, with release of tethered spinal cord, lumbar OR-1008 Laminectomy for excision or occlusion of arteriovenous malformation of spinal cord; Lumbar Laminectomy, Discectomy, and Laminotomy 63252 OR-1008 thoracolumbar Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; Lumbar Laminectomy, Discectomy, and Laminotomy 63267 OR-1008 lumbar Lumbar Laminectomy, Discectomy, and Laminotomy 63272 Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; lumbar OR-1008 Lumbar Laminectomy, Discectomy, and Laminotomy 63277 Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, lumbar OR-1008 Lumbar Laminectomy, Discectomy, and Laminotomy 63282 Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, extramedullary, lumbar OR-1008 Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, intramedullary, Lumbar Laminectomy, Discectomy, and Laminotomy 63287 OR-1008 thoracolumbar Laminectomy for biopsy/excision of intraspinal neoplasm; combined extradural-intradural Lumbar Laminectomy, Discectomy, and Laminotomy 63290 OR-1008 lesion, any level [when specified as lumbar] Vertebral (vertebral body resection), partial or complete, for excision of intraspinal Lumbar Laminectomy, Discectomy, and Laminotomy 63303 lesion, single segment; extradural, lumbar or sacral by transperitoneal or retroperitoneal OR-1008 approach Percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or Lumbar Laminectomy, Discectomy, and Laminotomy 0275T OR-1008 foraminotomy), any method, under indirect image guidance (eg, fluoroscopic, CT), with or without the use of an endoscope, single or multiple levels, unilateral or bilateral; lumbar

Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, using Lumbar Laminectomy, Discectomy, and Laminotomy S2348 OR-1008 radiofrequency energy, single or multiple levels, lumbar Diskectomy, anterior, with decompression of spinal cord and/or nerve root(s), including Lumbar Laminectomy, Discectomy, and Laminotomy S2350 OR-1008 osteophytectomy; lumbar, single interspace Diskectomy, anterior, with decompression of spinal cord and/or nerve root(s), including Lumbar Laminectomy, Discectomy, and Laminotomy S2351 osteophytectomy; lumbar, each additional interspace (list separately in addition to code for OR-1008 primary procedure) Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare Lumbar Spinal Fusion 22533 OR-1004 interspace (other than for decompression); lumbar Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace Lumbar Spinal Fusion 22558 OR-1004 (other than for decompression); lumbar Arthrodesis, pre-sacral interbody technique, including disc space preparation, discectomy, Lumbar Spinal Fusion 22586 with posterior instrumentation, with image guidance, includes bone graft when performed, L5- OR-1004 S1 interspace Arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse Lumbar Spinal Fusion 22612 OR-1004 technique, when performed) Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to Lumbar Spinal Fusion 22630 OR-1004 prepare interspace (other than for decompression), single interspace; lumbar

Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique Lumbar Spinal Fusion 22633 including laminectomy and/or discectomy sufficient to prepare interspace (other than for OR-1004 decompression), single interspace and segment; lumbar

Arthrodesis, pre-sacral interbody technique, disc space preparation, discectomy, without Lumbar Spinal Fusion 0195T OR-1004 instrumentation, with image guidance, includes bone graft when performed; L5-S1 interspace

Arthrodesis, pre-sacral interbody technique, disc space preparation, discectomy, without Lumbar Spinal Fusion 0196T OR-1004 instrumentation, with image guidance, includes bone graft when performed; L4-L5 interspace Arthroscopy, knee, surgical; meniscal transplantation (includes arthrotomy for meniscal Meniscal Repair and Allograft Transplantation 29868 OR-1027 insertion), medial or lateral Meniscal Repair and Allograft Transplantation 29882 Arthroscopy, knee, surgical; with repair (medial OR lateral) OR-1027 Meniscal Repair and Allograft Transplantation 29883 Arthroscopy, knee, surgical; with meniscus repair (medial AND lateral) OR-1027 Osteochondral Defect Repair 27412 Autologous chondrocyte implantation, knee OR-1014

SuperiorHealthPlan.com SHP_20195259C TurningPoint Procedure Code Description Policy Osteochondral Defect Repair 27415 Osteochondral allograft, knee, open [when specified as osteochondral allograft] OR-1014

Osteochondral Defect Repair 27416 Osteochondral autograft(s), knee, open (eg, mosaicplasty) includes harvesting of autograft[s]) OR-1014 Arthroscopy, knee, surgical; osteochondral autograft(s) (eg, mosaicplasty) (includes Osteochondral Defect Repair 29866 OR-1014 harvesting of the autograft) Osteochondral Defect Repair 29867 Arthroscopy, knee, surgical; osteochondral allograft (eg, mosaicplasty) OR-1014 Osteochondral Defect Repair J7330 Autologous cultured chondrocytes, implant OR-1014 Osteochondral Defect Repair S2112 Arthroscopy, knee, surgical for harvesting of cartilage (chondrocyte cells) OR-1014 Partial 27437 Arthroplasty, ; without prosthesis OR-1028 Partial Knee Replacement 27438 Arthroplasty, patella; with prosthesis OR-1028 Partial Knee Replacement 27440 Arthroplasty, knee, tibial plateau; OR-1028 Partial Knee Replacement 27441 Arthroplasty, knee, tibial plateau; with debridement and partial synovectomy OR-1028 Partial Knee Replacement 27442 Arthroplasty, femoral condyles or tibial plateau(s), knee; OR-1028 Arthroplasty, femoral condyles or tibial plateau(s), knee; with debridement and partial Partial Knee Replacement 27443 OR-1028 synovectomy Partial Knee Replacement 27446 Arthroplasty, knee, condyle and plateau; medial OR lateral compartment OR-1028 Revision of Total 27090 Removal of hip prothesis OR-1016 Removal of hip prosthesis; complicated, including total hip prosthesis, methylmethacrylate Revision of Total Hip Replacement 27091 OR-1016 with or without insertion of spacer Revision of Total Hip Replacement 27134 Hip Revision of total hip arthroplasty; both components, with or without autograft or allograft OR-1016 Hip Revision of total hip arthroplasty; acetabular component only, with or without autograft or Revision of Total Hip Replacement 27137 OR-1016 allograft Revision of Total Hip Replacement 27138 Hip Revision of total hip arthroplasty; femoral component only, with or without allograft OR-1016 Revision of Total Knee Replacement 27486 Revision of total knee arthroplasty, with or without allograft; 1 component OR-1017 Revision of total knee arthroplasty, with or without allograft; femoral and entire tibial Revision of Total Knee Replacement 27487 OR-1017 component Removal of prosthesis, including total knee prosthesis, methylmethacrylate with or without Revision of Total Knee Replacement 27488 OR-1017 insertion of spacer, knee Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; Sacral Decompression 63268 OR-1038 sacral Sacroiliac Joint Fusion 27280 Arthrodesis, sacroiliac joint (including obtaining graft) OR-1009 Shoulder Fusion 23800 Arthrodesis, glenohumeral joint; OR-1019 Shoulder Fusion 23802 Arthrodesis, glenohumeral joint; with autogenous graft (includes obtaining graft) OR-1019 (Total, Reverse, Revision, Hemi) 23333 Removal of foreign body, shoulder; deep (subfascial or intramuscular) OR-1023 Removal of prosthesis, includes debridement and synovectomy when performed; humeral or Shoulder Replacement (Total, Reverse, Revision, Hemi) 23334 OR-1023 glenoid component Removal of prosthesis, includes debridement and synovectomy when performed; humeral and Shoulder Replacement (Total, Reverse, Revision, Hemi) 23335 OR-1023 glenoid components (eg, total shoulder) Shoulder Replacement (Total, Reverse, Revision, Hemi) 23470 Arthroplasty, glenohumeral joint; hemiarthroplasty OR-1023 Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement Shoulder Replacement (Total, Reverse, Revision, Hemi) 23472 OR-1023 (e.g., total shoulder) Revision of total shoulder arthroplasty, including allograft when performed; humeral or glenoid Shoulder Replacement (Total, Reverse, Revision, Hemi) 23473 OR-1023 component Revision of total shoulder arthroplasty, including allograft when performed; humeral and Shoulder Replacement (Total, Reverse, Revision, Hemi) 23474 OR-1023 glenoid component Open Treatment Of Proximal Humeral (Surgical Or Anatomical Neck) Fracture, Includes Shoulder Replacement (Total, Reverse, Revision, Hemi) 23616 , When Performed, Includes Repair Of Tuberosity(S), When Performed; With OR-1023 Proximal Humeral Prosthetic Replacement Spinal Cord Neurostimulator 63650 Percutaneous implantation of neurostimulator electrode array, epidural OR-1015 Spinal Cord Neurostimulator 63655 Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural OR-1015 Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, Spinal Cord Neurostimulator 63661 OR-1015 when performed Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or Spinal Cord Neurostimulator 63662 OR-1015 laminectomy, including fluoroscopy, when performed Revision including replacement, when performed, of spinal neurostimulator electrode Spinal Cord Neurostimulator 63663 OR-1015 percutaneous array(s), including fluoroscopy, when performed Revision including replacement, when performed, of spinal neurostimulator electrode Spinal Cord Neurostimulator 63664 OR-1015 plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or Spinal Cord Neurostimulator 63685 OR-1015 inductive coupling Spinal Cord Neurostimulator 63688 Revision or removal of implanted spinal neurostimulator pulse generator or receive OR-1015 Spinal Cord Neurostimulator C1767 Generator, neurostimulator (implantable), non-rechargeable OR-1015 Spinal Cord Neurostimulator C1778 Lead, neurostimulator (implantable) OR-1015 Spinal Cord Neurostimulator C1787 Patient programmer, neurostimulator OR-1015 Spinal Cord Neurostimulator C1820 Generator, neurostimulator (implantable), with rechargeable battery and charging system OR-1015

SuperiorHealthPlan.com SHP_20195259C TurningPoint Procedure Code Description Policy Spinal Cord Neurostimulator C1883 Adaptor/extension, pacing lead or neurostimulator lead (implantable) OR-1015 Spinal Cord Neurostimulator C1897 Lead, neurostimulator test kit (implantable) OR-1015 Spinal Cord Neurostimulator L8679 Implantable neurostimulator, pulse generator, any type OR-1015 Spinal Cord Neurostimulator L8680 Implantable neurostimulator electrode, each OR-1015 Patient programmer (external) for use with implantable programmable neurostimulator pulse Spinal Cord Neurostimulator L8681 OR-1015 generator, replacement only Spinal Cord Neurostimulator L8682 Implantable neurostimulator radiofrequency receiver OR-1015 Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency Spinal Cord Neurostimulator L8683 OR-1015 receiver Spinal Cord Neurostimulator L8685 Implantable neurostimulator pulse generator, single array, rechargeable, includes extension OR-1015 Implantable neurostimulator pulse generator, single array, non-rechargeable, includes Spinal Cord Neurostimulator L8686 OR-1015 extension Spinal Cord Neurostimulator L8687 Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension OR-1015 Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes Spinal Cord Neurostimulator L8688 OR-1015 extension External recharging system for battery (internal) for use with implantable neurostimulator, Spinal Cord Neurostimulator L8689 OR-1015 replacement only External recharging system for battery (external) for use with implantable neurostimulator, Spinal Cord Neurostimulator L8695 OR-1015 replacement only Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and Spinal Devices (Facet Implant) 0219T OR-1037 placement of bone graft(s) or synthetic device(s), single level; cervical

Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and Spinal Devices (Facet Implant) 0220T OR-1037 placement of bone graft(s) or synthetic device(s), single level; thoracic

Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and Spinal Devices (Facet Implant) 0221T OR-1037 placement of bone graft(s) or synthetic device(s), single level; lumbar Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and Spinal Devices (Facet Implant) 0222T placement of bone graft(s) or synthetic device(s), single level; each additional vertebral OR-1037 segment Spinal Fusion for 22800 Arthrodesis, posterior, for spinal deformity, with or without cast; up to 6 vertebral segments OR-1020

Spinal Fusion for Scoliosis 22802 Arthrodesis, posterior, for spinal deformity, with or without cast; 7 to 12 vertebral segments OR-1020 Arthrodesis, posterior, for spinal deformity, with or without cast; 13 or more vertebral Spinal Fusion for Scoliosis 22804 OR-1020 segments Spinal Fusion for Scoliosis 22808 Arthrodesis, anterior, for spinal deformity, with or without cast; 2 to 3 vertebral segments OR-1020

Spinal Fusion for Scoliosis 22810 Arthrodesis, anterior, for spinal deformity, with or without cast; 4 to 7 vertebral segments OR-1020

Spinal Fusion for Scoliosis 22812 Arthrodesis, anterior, for spinal deformity, with or without cast; 8 or more vertebral segments OR-1020

Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare [Follows main Spinal Fusion- Unspecified 22534 interspace (other than for decompression); thoracic or lumbar, each additional vertebral procedure] segment (List separately in addition to code for primary procedure) Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace [Follows main Spinal Fusion- Unspecified 22585 (other than for decompression); each additional interspace procedure] Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral [Follows main Spinal Fusion- Unspecified 22614 segment procedure] Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to [Follows main Spinal Fusion- Unspecified 22632 prepare interspace (other than for decompression), single interspace; each additional procedure] interspace Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique [Follows main Spinal Fusion- Unspecified 22634 including laminectomy and/or discectomy sufficient to prepare interspace (other than for procedure] decompression), single interspace and segment; each additional interspace and segment Spinal Fusion- Unspecified 22830 Exploration of spinal fusion [Follows main Spine Non-Specific 20931 Allograft, structural, for spine surgery only [Follows main Autograft for spine surgery only (includes harvesting the graft); local (eg, , spinous [Follows main Spine Non-Specific 20936 process, or laminar fragments) obtained from same incision procedure] Autograft for spine surgery only (includes harvesting the graft); morselized (through separate [Follows main Spine Non-Specific 20937 or fascial incision) procedure] Autograft for spine surgery only (includes harvesting the graft); structural, bicortical or [Follows main Spine Non-Specific 20938 tricortical (through separate skin or fascial incision procedure] Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for [Follows main Spine Non-Specific 22100 intrinsic bony lesion, single vertebral segment; cervical procedure] Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for [Follows main Spine Non-Specific 22101 intrinsic bony lesion, single vertebral segment; thoracic procedure] Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for [Follows main Spine Non-Specific 22102 intrinsic bony lesion, single vertebral segment; lumbar procedure]

SuperiorHealthPlan.com SHP_20195259C TurningPoint Procedure Code Description Policy Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for [Follows main Spine Non-Specific 22103 intrinsic bony lesion, single vertebral segment; each additional segment procedure]

Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal [Follows main Spine Non-Specific 22110 cord or nerve root(s), single vertebral segment; cervical procedure]

Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal [Follows main Spine Non-Specific 22112 cord or nerve root(s), single vertebral segment; thoracic procedure]

Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal [Follows main Spine Non-Specific 22114 cord or nerve root(s), single vertebral segment; lumbar procedure]

Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal [Follows main Spine Non-Specific 22116 cord or nerve root(s), single vertebral segment; each additional vertebral segment procedure] of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (eg, [Follows main Spine Non-Specific 22206 pedicle/vertebral body subtraction); thoracic procedure] Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (eg, [Follows main Spine Non-Specific 22207 pedicle/vertebral body subtraction); lumbar procedure] Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (eg, [Follows main Spine Non-Specific 22208 pedicle/vertebral body subtraction); each additional vertebral segment procedure] [Follows main Spine Non-Specific 22210 Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; cervical procedure] [Follows main Spine Non-Specific 22212 Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; thoracic procedure] [Follows main Spine Non-Specific 22214 Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; lumbar procedure] Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; each [Follows main Spine Non-Specific 22216 additional vertebral segment procedure] Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; [Follows main Spine Non-Specific 22220 cervical procedure] Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; [Follows main Spine Non-Specific 22222 thoracic procedure] Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; [Follows main Spine Non-Specific 22224 lumbar procedure] Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; each [Follows main Spine Non-Specific 22226 additional vertebral segment procedure] Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior [Follows main Spine Non-Specific 22325 approach, 1 fractured or dislocated segment; lumbar procedure] Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior [Follows main Spine Non-Specific 22326 approach, 1 fractured vertebra or dislocated segment; cervical procedure] Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior [Follows main Spine Non-Specific 22327 approach, 1 fractured vertebra or dislocated segment; thoracic procedure] Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior [Follows main Spine Non-Specific 22328 approach, 1 fractured vertebra or dislocated segment; each additional fractured vertebra or procedure] dislocated segment Kyphectomy, circumferential exposure of spine and resection of vertebral segment(s) [Follows main Spine Non-Specific 22818 (including body and posterior elements); single or 2 segments procedure] Kyphectomy, circumferential exposure of spine and resection of vertebral segment(s) [Follows main Spine Non-Specific 22819 (including body and posterior elements); 3 or more segments procedure] Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation [Follows main Spine Non-Specific 22840 across 1 interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet procedure] screw fixation) Spine Non-Specific 22841 Internal spinal fixation by wiring of spinous processes [Follows main Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and [Follows main Spine Non-Specific 22842 sublaminar wires); 3 to 6 vertebral segments procedure] Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and [Follows main Spine Non-Specific 22843 sublaminar wires); 7 to 12 vertebral segments procedure] Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and [Follows main Spine Non-Specific 22844 sublaminar wires); 13 or more vertebral segments procedure] Spine Non-Specific 22845 Anterior instrumentation; 2 to 3 vertebral segments [Follows main Spine Non-Specific 22846 Anterior instrumentation; 4 to 7 vertebral segments [Follows main Spine Non-Specific 22847 Anterior instrumentation; 8 or more vertebral segments [Follows main Pelvic fixation (attachment of caudal end of instrumentation to pelvic bony structures) other [Follows main Spine Non-Specific 22848 than procedure] Spine Non-Specific 22849 Reinsertion of spinal fixation device [Follows main Spine Non-Specific 22850 Removal of posterior nonsegmental instrumentation (eg, Harrington rod) [Follows main Spine Non-Specific 22852 Removal of posterior segmental instrumentation [Follows main Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to intervertebral [Follows main Spine Non-Specific 22853 disc space in conjunction with interbody arthrodesis, each interspace (List separately in procedure] addition to code for primary procedure)

SuperiorHealthPlan.com SHP_20195259C TurningPoint Procedure Code Description Policy Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to [Follows main Spine Non-Specific 22854 vertebral corpectomy(ies) (vertebral body resection, partial or complete) defect, in conjunction procedure] with interbody arthrodesis, each contiguous defect (List separately in addition to code for primary procedure Spine Non-Specific 22855 Removal of anterior instrumentation [Follows main Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh, [Follows main Spine Non-Specific 22859 methylmethacrylate) to intervertebral disc space or vertebral body defect without interbody procedure] arthrodesis, each contiguous defect (List separately in addition to code for primary procedure) Spine Non-Specific 22899 Unlisted procedure, spine [unlisted Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with [Follows main Spine Non-Specific 63081 decompression of spinal cord and/or nerve root(s); cervical, single segment procedure]

Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with [Follows main Spine Non-Specific 63082 decompression of spinal cord and/or nerve root(s); cervical, each additional segment procedure]

Vertebral corpectomy (vertebral body resection), partial or complete, transthoracic approach [Follows main Spine Non-Specific 63085 with decompression of spinal cord and/or nerve root(s); thoracic, single segment procedure]

Vertebral corpectomy (vertebral body resection), partial or complete, transthoracic approach [Follows main Spine Non-Specific 63086 with decompression of spinal cord and/or nerve root(s); thoracic, each additional segment procedure] Vertebral corpectomy (vertebral body resection), partial or complete, combined thoracolumbar [Follows main Spine Non-Specific 63087 approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic or procedure] lumbar; single segment Vertebral corpectomy (vertebral body resection), partial or complete, combined thoracolumbar [Follows main Spine Non-Specific 63088 approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic or procedure] lumbar; each additional segment Vertebral corpectomy (vertebral body resection), partial or complete, transperitoneal or [Follows main Spine Non-Specific 63090 retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), procedure] lower thoracic, lumbar, or sacral; single segment

Vertebral corpectomy (vertebral body resection), partial or complete, transperitoneal or [Follows main Spine Non-Specific 63091 retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), procedure] lower thoracic, lumbar, or sacral; each additional segment Vertebral corpectomy (vertebral body resection), partial or complete, lateral extracavitary [Follows main Spine Non-Specific 63101 approach with decompression of spinal cord and/or nerve root(s) (eg, for tumor or retropulsed procedure] bone fragments); thoracic, single segmen Vertebral corpectomy (vertebral body resection), partial or complete, lateral extracavitary [Follows main Spine Non-Specific 63102 approach with decompression of spinal cord and/or nerve root(s) (eg, for tumor or retropulsed procedure] bone fragments); lumbar, single segment Vertebral corpectomy (vertebral body resection), partial or complete, lateral extracavitary [Follows main Spine Non-Specific 63103 approach with decompression of spinal cord and/or nerve root(s) (eg, for tumor or retropulsed procedure] bone fragments); thoracic or lumbar, each additional segment Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal [Follows main Spine Non-Specific 63300 lesion, single segment; extradural, cervical procedure] Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal [Follows main Spine Non-Specific 63301 lesion, single segment; extradural, thoracic by transthoracic approach procedure]

Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal [Follows main Spine Non-Specific 63302 lesion, single segment; extradural, thoracic by thoracolumbar approach procedure] Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal [Follows main Spine Non-Specific 63304 lesion, single segment; intradural, cervical procedure] Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal [Follows main Spine Non-Specific 63305 lesion, single segment; intradural, thoracic by transthoracic approach procedure]

Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal [Follows main Spine Non-Specific 63306 lesion, single segment; intradural, thoracic by thoracolumbar approach procedure] Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal [Follows main Spine Non-Specific 63307 lesion, single segment; intradural, lumbar or sacral by transperitoneal or retroperitoneal procedure] approach Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal [Follows main Spine Non-Specific 63308 lesion, single segment; each additional segment procedure] Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, Thoracic Laminectomy and Discectomy 63055 OR-1010 herniated intervertebral disc), single segment; thoracic Costovertebral approach with decompression of spinal cord or nerve root(s) (eg, herniated Thoracic Laminectomy and Discectomy 63064 OR-1010 intervertebral disc), thoracic; single segment Costovertebral approach with decompression of spinal cord or nerve root(s) (eg, herniated Thoracic Laminectomy and Discectomy 63066 OR-1010 intervertebral disc), thoracic; each additional segment

SuperiorHealthPlan.com SHP_20195259C TurningPoint Procedure Code Description Policy Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including Thoracic Laminectomy and Discectomy 63077 OR-1010 osteophytectomy; thoracic, single interspace Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including Thoracic Laminectomy and Discectomy 63078 OR-1010 osteophytectomy; thoracic, each additional interspace Thoracic Laminectomy and Discectomy 63195 Laminectomy with cordotomy, with section of 1 spinothalamic tract, 1 stage; thoracic OR-1010

Thoracic Laminectomy and Discectomy 63197 Laminectomy with cordotomy, with section of both spinothalamic tracts, 1 stage; thoracic OR-1010 Laminectomy with cordotomy with section of both spinothalamic tracts, 2 stages within 14 Thoracic Laminectomy and Discectomy 63199 OR-1010 days; thoracic Thoracic Laminectomy and Discectomy 63251 Laminectomy for excision or occlusion of arteriovenous malformation of spinal cord; thoracic OR-1010

Thoracic Laminectomy and Discectomy 63271 Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; thoracic OR-1010

Thoracic Laminectomy and Discectomy 63286 Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, intramedullary, thoracic OR-1010 Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare Thoracic Spinal Fusion 22532 OR-1011 interspace (other than for decompression); thoracic Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace Thoracic Spinal Fusion 22556 OR-1011 (other than for decompression); thoracic Arthrodesis, posterior or posterolateral technique, single level; thoracic (with lateral transverse Thoracic Spinal Fusion 22610 OR-1011 technique, when performed) Total and Revision 27700 Arthroplasty, ankle OR-1021 Total Ankle Replacement and Revision 27702 Arthroplasty, ankle; with implant (total ankle) OR-1021 Total Ankle Replacement and Revision 27703 Arthroplasty, ankle; revision, total ankle OR-1021 Total Ankle Replacement and Revision 27704 Removal of ankle implant OR-1021 Total Hip Replacement 27120 Hip Acetabuloplasty; (eg, Whitman, Colonna, Haygroves, or cup type) OR-1001 Total Hip Replacement 27122 Hip Acetabuloplasty; resection, (eg, Girdlestone procedure) OR-1001 Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), Total Hip Replacement 27130 OR-1001 with or without autograft or allograft Hip Conversion of previous hip surgery to total hip arthroplasty, with or without autograft or Total Hip Replacement 27132 OR-1001 allograft Total Knee Replacement 27445 Arthroplasty, knee, hinge prosthesis (eg, Walldius type) OR-1002 Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without Total Knee Replacement 27447 OR-1002 patella resurfacing (total knee arthroplasty) Fusion 25800 ARTHRODESIS WRIST COMPLETE W/O BONE GRAFT OR-1032 Wrist Fusion 25805 ARTHRODESIS WRIST W/SLIDING GRAFT OR-1032 Wrist Fusion 25810 ARTHRODESIS WRIST W/ILIAC/OTHER AUTOGRAFT OR-1032 Wrist Fusion 25820 ARTHRODESIS WRIST LIMITED W/O BONE GRAFT OR-1032 Wrist Fusion 25825 ARTHRODESIS WRIST LIMITED W/AUTOGRAFT OR-1032 Wrist Replacement 25332 Arthroplasty, wrist, with or without interposition, with or without external or internal fixation OR-1033 Wrist Replacement 25441 Arthroplasty with prosthetic replacement; distal radius OR-1033 Wrist Replacement 25442 Arthroplasty with prosthetic replacement; distal ulna OR-1033 Wrist Replacement 25443 Arthroplasty with prosthetic replacement; scaphoid carpal (navicular) OR-1033 Wrist Replacement 25444 Arthroplasty with prosthetic replacement; lunate OR-1033 Wrist Replacement 25445 Arthroplasty with prosthetic replacement; trapezium OR-1033 Wrist Replacement 25446 Arthroplasty with prosthetic replacement; distal radius and partial or entire carpus (total wrist) OR-1033

SuperiorHealthPlan.com SHP_20195259C