U.S. DEPARTMENT OF LABOR, OFFICE OF WORKERS' COMPENSATION PROGRAMS OWCP MEDICAL FEE SCHEDULE -- Effective August 14, 2015 Anesthesia Procedure Code Base Units Effective Date: August 14, 2015 Formula for calculating maximum allowable: (Time Units + Base Units) x Conversion Factor = Max Allowable BASE © CPT SHORT DESCRIPTION (Refer to AMA CPT ) UNIT Add-on Code 00100 Anest for proced on integ sys - head/or saliv glands 5 00102 Anesthesia for plastic repair of cleft lip 6 00103 Anesthesia for bepharoplasty 5 00104 Anesthesia for electroconvulsive therapy 4 00120 Anest; proc-esternal/middle/inner ear, inc biopsy nos 5 00124 Anesthesia for otoscopy 4 00126 Anesthesia for tympanotomy 4 00140 Anesthesia for procedures on eye; nos 5 00142 Anesthesia for procedures on eye; lens surgery 4 00144 Anest; procedures on eye; corneal transplant 6 00145 Anesthesia for procedures on eye; vitrectomy 6 00147 Anesthesia for iridectomy 4 00148 Anesthesia for procedures on eye; opthalmoscopy 4 00160 Anest; proc-nose and accessory sinuses; nos 5 00162 Anest; proced-nose/accesory sinuses; rad surg 7 00164 Anesth-proced on nose & access sinuses; biop/soft tis 4 00170 Anesthesia for intraoral procedures, incl biopsy; nos 5 00172 Anesth-intraoral proced, w/biop; repair-cleft palate 6 00174 Anest; intraoral pro-w/biop-ex/retropharyngeal tumor 6 00176 Anesth-intraoral proced, w/biopsy; rad surg 7 00190 Anesthesia for procedures on facial bones; nos 5 00192 Anest - proced on facial bones; rad surg 7 00210 Anesthesia for intracranial proacedures nos 11 00211 Anesth, cran surg, hemotoma 10 00212 Anest; intracranial procedures; subdural taps 5 00214 Anesthesia for intracranial procedures; burr holes 9 00215 Anesthesia for skull fracture 9 00216 Anesthesia-intracranial proced; vascular 15 00218 Anesth-intracranial proced, in sitting position 13 00220 Anest - intracranial proced; spinal fluid shunting proc 10 00222 Anest - intracranial proc; electrocoag-cranial nerve 6 00300 Anest; proc-integ sys of neck, incl subcu tissue 5 00320 Anest-proced: esoph/thy/lar/trac/lymph nos 6 00322 Anest proced on neck: needle biopsy of thyroid 3 00350 Anesth; proc-on major vessels of neck; nos 10 00352 Anesth-proc on maj vessels of neck; simple ligation 5 00400 Anesth; proc on ant integ sys-chest a/subcu tise 3 00402 Anest; proc-ant integ sys of chest; reconstr on breast 5 00404 Anest; proc-ant integ sys of chest; radical/mod rad; breast 5 00406 Anest; ant integ sys chest; rad/mod rad proc; breast w/node disse 13 00410 Anest; proc ant integ chest; elec convers of arrhythmias 4 00450 Anest; proc-on clavicle and scapula; nos 5 00452 Anest; proc-clavicle & scapula; rad surg 6 00454 Anesthesia for procedures on clavicle, biopsy 3 00470 Anesthesia for partial rib resection nos 6 00472 Anest; partial rib resection, thoracoplasty (any type) 10 00474 Anesthesia for partial rib resection, radical proced 13 00500 Anesthesia for all procedures on esophagus 15 00520 Anest for closed chest proc nos 6 00522 Anest - closed chest proced; needle biopsy-pleura 4 00524 Anest for closed chest procedure; pneumocentesis 4 00528 Anest for closed chest procedure; mediastinoscopy 8 00529 Anest, closed chest procedure; medi 11 00530 Anesthesia for permanent transvenous pacemaker insertion 4 00532 Anesthesia for accesss to central venous circula 4 00534 Anest-transven insert/replace-cardioverter/debfib 7 00537 Anest for cardiac electrophysiologic procedures 7 00539 Anest; tracheobronchial reconstruction 18 00540 Anest; thoracot proced-lungs/pleura/dia/media nos 12 00541 Anest; thoracot proced; one lung ventilation 15 00542 Anest; thoracotomy procedure - decortication 15 00546 Anesth-thoracot; pul resection w/thoracoplasty 15 00548 Anesth-thoracotomy; repair-trauma to trachea/bronchi 17 00550 Anesthesia for sternal debridement 10 00560 Anesth, heart surg w/o pump 15 00561 Anest-heart/pericard/great ves-chest; w/ pump oxygenator 25 00562 Anest-heart/pericard/great ves-chest; w/pump oxygenator 20 00563 Anest-heart/pericard/great ves-chest; w/pump oxyg w/hypotherm 25 00566 Anest for direct coronary artery bypass graft w/out pump oxyg 25 00567 Anesth, cabg w/pump 18 00580 Anesthesia for heart transplant-heart/lung 20 00600 Anesth for proced on cerv spine/cord; nos 10 00604 Anesth-post cerv laminect-sitting position 13 00620 Anesthesia-proced on thoracic spine/cord; nos 10 00625 Anes spine tranthor w/o vent 13 00626 Anes, spine transthor w/vent 15 00630 Anesthesia for procedures in lumbar region (nos) 8 00632 Anesthesia for lumbar sympathectomy 7 00635 Anesth-procedures in lum region; diag/therapeutic lum puncture 4 00640 Anesth-manip of spine; closed proced on spine 3 00670 Anesth-ext spine/spinal cord proced 13 00700 Anesth-proced on upper ant abdom wall; (nos) 4 00702 Anesthesia for percutaneous liver biopsy 4 00730 Anesth-procedures on upper post abdominal wall 5 00740 Anesth-upper gastrointestinal endoscopic proced 5 00750 Anesthesia for hernia repairs in upper abdomen; (nos) 4 00752 Anesth-repair lum/ventral hernias/wound dehiscence 6 00754 Anesth-hernia repairs-up abdomen; omphalocele 7 00756 Anesth-transabdominal repair-diaphragmatic hernia 7 00770 Anesth-all procedures-major abdominal blood ves 15 00790 Anesth-intraperitoneal proced-up abdo, w/laparos nos 7 00792 Anesth-intraperitoneal proced up abdo-partial hepatectomy 13 00794 Anesth-intraperitoneal pro/up abdo; pancreatect/part/tot 8 00796 Anesth-intraperitoneal pro up abdo, shunts/liver transplant 30 00797 Anesth-intraperitoneal pro up abdo, gastric restrict procedure 11 00800 Anesth-pro low ant abdom wall nos 4 00802 Anesth-pro low ant abdom wall; panniculectomy 5 00810 Anesthesia for intestinal endoscopic procedures 5 00820 Anesth-pro on low post abdominal wall 5 00830 Anesthesia for hernia repairs in lower abdomen; (nos) 4 00832 Anesth-hernia repair, ventral & incisional hernias 6 00840 Anesth-intraperitoneal proced low abdo w/laparos; nos 6 00842 Anesthesia for amniocentesis 4 00844 Anesthesia for abdominoperitoneal resection 7 00846 Anesthesia for radical hysterectomy 8 00848 Anesthesia for pelvic exentration 8 00851 Anesthesia for tubal ligation 6 00860 Anesth-extraperitoneal low abdo, w/urinary tract-nos 6 00862 Anesth-renal proced w/upper 1/3 ureter/donor nephrect 7 00864 Aanesthesia for total cystectomy 8 00865 Anest - extraperitoneal proced-lower abd; rad prostatectomy 7 00866 Anesthesia for adrenalectomy 10 00868 Anesthesia for renal transplant (recipient) 10 00870 Anesthesia for cystolithiotomy 5 00872 Anesth-lithotripsy/extracorp shock wave-w/h20 bath 7 00873 Anesth-lithotripsy/extracorp shock wave-w/o h20 bath 5 00880 Anesth-proced on maj low abdom ves; nos 15 00882 Anesth-proced on maj low abdom ves; infer vena cava liga 10 00902 Anesthesia for anorectal procedures 5 00904 Anesthesia for radical perineal procedure 7 00906 Anesthesia for vulvectomy 4 00908 Anesthesia for perineal prostatectomy 6 00910 Anesthesia for transurethral procedures 3 00912 Anesthesia for transurethral resection of bladder 5 00914 Anesthesia for transurethral resection of prostate 5 00916 Anesthesia for post-transurethral resection bleeding 5 00918 Anesthesia for transurethral procedures,w/fragmenta 5 00920 Anesthesia-proced on male genital ext genitalia, nos 3 00921 Anesthesia-vasectomy, unilat/bilateral 3 00922 Anesthesia for procedures on seminal vesicles 6 00924 Anesth-proced on undescended testis, unilat/bilat 4 00926 Anesthesia for radical orchiectomy, inguinal 4 00928 Anesthesia for radical orchiectomy, abdominal 6 00930 Anesthesia for orchiopexy, unilateral or bilateral 4 00932 Anesthesia for complete amputation of penis 4 00934 Anesth-radical amputat-penis w/bilat ing lymphaden 6 00936 Anesth-rad amputa-penis w/bilat inguinal/iliac lymphaden 8 00938 Anesth-insertion of penile prosthesis-perineal ap 4 00940 Anesth-vaginal procedures, nos 3 00942 Anesth-for colpotomy, colpectomy, colporrhaphy 4 00944 Anesthesia for vaginal hysterectomy 6 00948 Anesthesia for cervical cerclage 4 00950 Anesthesia culdoscopy 5 00952 Anesthesia for hysteroscopy 4 01112 Anesthesia-bone marrow aspiration/biopsy, iliac crest 5 01120 Anesthesia for procedures on bony pelvis 6 01130 Anesthesia for body cast application or revision 3 01140 Anesth for interpelviabdom amputation (hindquarter) 15 01150 Anesth-rad proced tumor of pelvis, ex hindqtr amputation 10 01160 Anesth-closed pro, involv symphysis pubis/sacroiliac jnt 4 01170 Anesth-open pro involv symphysis pubis/sacroiliac jnt 8 01173 Anesth-open repair, FX disrupt 12 01180 Anesthesia for obturator neurectomy, extrapelvic 3 01190 Anesthesia for obturator neurectomy, intrapelvic 4 01200 Anesthesia for all closed procedures involving hip joint 4 01202 Anesthesia for arthroscopic procedures of hip joint 4 01210 Anesthesia for open procedures involving hip joint; (nos) 6 01212 Anesthesia for hip disarticulation 10 01214 Anesthesia for total hip replacement or revision 8 01215 Anesthesia for revision of total hip arthroplasty 10 01220 Anesth-all closed proced involv up 2/3 of femur-nos 4 01230 Anesth-all open proced involv up 2/3 of femur nos 6 01232 Anesth-open proced involv up 2/3 of femur; amputation 5 01234 Anesth-open proced involv up 2/3 of femur; rad resect 8 01250 Anesth-all proced nerves/mus/ten/fasc/bur-up leg 4 01260 Anesth-all proced involv veins of up leg incl exploration 3 01270 Anesth-all pro involv art-up leg, w/bypass graft; nos 8 01272 Anesthesia for femoral artery ligation 4 01274 Anesthesia for femoral artery embolectomy 6 01320 Anest-all proc-nerves/mus/ten/fasc/bur-knee/popliteal area 4 01340 Anesth-for