Beruflich Dokumente
Kultur Dokumente
LIST OF MEDICAL CONDITIONS AND PROCEDURES ALLOWED AS SECOND CASE RATE ICD/RVS CODE
I60.0 I60.1 I60.2 I60.3 I60.4 I60.5 I60.6
DESCRIPTION
Health Care Institution Fee 7,600 7,600 7,600 7,600 7,600 7,600 7,600
I60.7
19,000
11,400
7,600
I60.8 I60.9 I61.0 I61.1 I61.2 I61.3 I61.4 I61.5 I61.6 I61.8 I61.9 I62.0 I62.1 I62.9 I63.0 I63.1 I63.2 I63.3 I63.4
19,000 19,000 19,000 19,000 19,000 19,000 19,000 19,000 19,000 19,000 19,000 19,000 19,000 19,000 14,000 14,000 14,000 14,000 14,000
11,400 11,400 11,400 11,400 11,400 11,400 11,400 11,400 11,400 11,400 11,400 11,400 11,400 11,400 8,400 8,400 8,400 8,400 8,400
7,600 7,600 7,600 7,600 7,600 7,600 7,600 7,600 7,600 7,600 7,600 7,600 7,600 7,600 5,600 5,600 5,600 5,600 5,600
Page 1 of 31
ANNEX 3. LIST OF MEDICAL CONDITIONS AND PROCEDURES ALLOWED AS SECOND CASE RATE ICD/RVS CODE
I63.5
Cerebral infarction due to unspecified occlusion or stenosis of cerebral arteries Cerebral infarction due to cerebral venous I63.6 thrombosis, nonpyogenic I63.8 Other cerebral infarction I63.9 Cerebral infarction, unspecified Other lacunar syndrome in unspecified cerebral I63.9+G46.7* infarction I64 Stroke, not specified as hemorrhage or infarction Acute transmural myocardial infarction of anterior wall [or duration of <4 weeks] KILLIPS stage unspecified; Acute transmural infarction of anterior wall NOS [or duration of <4 weeks] KILLIPS stage unspecified; Acute anteroapical transmural infarction [or Acute transmural myocardial infarction of inferior wall [or duration of <4 weeks] KILLIPS I; Acute transmural infarction of diaphragmatic wall [or duration of <4 weeks] KILLIPS I; Acute transmural infarction of inferior wall NOS [or duration of <4 weeks] Acute transmural myocardial infarction of other sites [or duration of <4 weeks] KILLIPS II; Acute apicallateral transmural infarction [or duration of <4 weeks] KILLIPS II; Acute basal-lateral transmural infarction [or duration of <4 weeks] KILLIPS I Acute transmural myocardial infarction of unspecified site; Transmural myocardial infarction NOS Acute subendocardial myocardial infarction; Nontransmural myocardial infarction NOS Acute myocardial infarction, unspecified [or duration of <4 weeks] KILLIPS I; Acute myocardial infarction NOS [or duration of <4 weeks] KILLIPS I Subsequent myocardial infarction of anterior wall; Acute Subsequent infarction of anterior wall NOS; Acute subsequent infarction of anteroapical wall; Acute subsequent infarction of anterolateral wall; Acute subsequent infarction of anteroseptal wall Subsequent myocardial infarction of inferior wall; Acute subsequent infarction of diaphragmatic wall; Acute subsequent infarction of inferior wall NOS; Acute subsequent infarction of inferolateral wall; Acute subsequent infarction of inferoposterior wall
I21.0
9,450
5,670
3,780
I21.1
9,450
5,670
3,780
I21.2
9,450
5,670
3,780
I21.3
9,450
5,670
3,780
I21.4
9,450
5,670
3,780
I21.9
9,450
5,670
3,780
I22.0
9,450
5,670
3,780
I22.1
9,450
5,670
3,780
Page 2 of 31
ANNEX 3. LIST OF MEDICAL CONDITIONS AND PROCEDURES ALLOWED AS SECOND CASE RATE ICD/RVS CODE SECOND CASE RATE DESCRIPTION
Subsequent myocardial infarction of other sites; Acute myocardial infarction of apical-lateral wall; Acute myocardial infarction of basal-lateral wall; Acute myocardial infarction of high lateral wall; Acute myocardial infarction of lateral wall NOS; Acut Subsequent myocardial infarction of unspecified site Haemopericardium as current complication following acute myocardial infarction Atrial septal defect as current complication following acute myocardial infarction Ventricular septal defect as current complication following acute myocardial infarction Rupture of cardiac wall without haemopericardium as current complication following acute myocardial infarction Rupture of chordae tendineae as current complication following acute myocardial infarction Rupture of papillary muscle as current complication following acute myocardial infarction Other current complications following acute myocardial infarction Dressler's syndrome; Postmyocardial infarction syndrome Embolism following abortion and ectopic and molar pregnancy; Embolism NOS; Air embolism; Amniotic fluid embolism; Blood-clot embolism; Pulmonary embolism; Pyaemic embolism; Septic or septicopyaemic embolism; Soap embolism Metabolic disorders following abortion and ectopic and molar pregnancy Complication following abortion and ectopic and molar pregnancy, unspecified Other intrapartum haemorrhage; Excessive intrapartum haemorrhage Rupture of uterus before on set of labour Rupture of uterus during labour; Rupture of uterus not stated as occuring before onset of labour Post partum inversion of uterus H Case Rate C I 9,450 Professional Fee Health Care Institution Fee
I22.8
5,670
3,780
I22.9
9,450
5,670
3,780
I23.0
9,450
5,670
3,780
I23.1
9,450
5,670
3,780
I23.2
9,450
5,670
3,780
I23.3
9,450
5,670
3,780
I23.4
9,450
5,670
3,780
I23.5
9,450
5,670
3,780
I23.8
9,450
5,670
3,780
I24.1
9,450
5,670
3,780
O08.2
4,650
2,790
1,860
Page 3 of 31
ANNEX 3. LIST OF MEDICAL CONDITIONS AND PROCEDURES ALLOWED AS SECOND CASE RATE ICD/RVS CODE
O71.3 O71.5 O71.7 O71.8 O71.9
DESCRIPTION
O74.0
4,650
2,790
1,860
O74.2
4,650
2,790
1,860
11011
11,980
5,880
6,100
Page 4 of 31
ANNEX 3. LIST OF MEDICAL CONDITIONS AND PROCEDURES ALLOWED AS SECOND CASE RATE ICD/RVS CODE
11044 11720 11721 16010 21627 36430 49080 55250 58600 77401 77401
DESCRIPTION
Professional Fee 2,520 840 1,260 3,360 6,888 840 2,520 1,000 1,000 800 800
Health Care Institution Fee 5,500 2,800 4,300 4,900 5,400 2,800 5,500 3,000 3,000 2,200 1,200
77761
18,000
8,400
9,600
77776
18,000
8,400
9,600
77781
5,680
1,680
4,000
Page 5 of 31
ANNEX 3. LIST OF MEDICAL CONDITIONS AND PROCEDURES ALLOWED AS SECOND CASE RATE ICD/RVS CODE
19162 19180 19182 19200 19220
DESCRIPTION
19240
11,000
8,800
2,200
19369 19370 19371 23515 23520 23530 23532 23540 23550 23552 23570 23585
27,500 15,150 18,900 6,228 5,440 10,490 13,560 4,010 10,970 10,490 4,010 10,490
22,000 12,120 15,120 4,982 4,352 8,392 10,848 3,208 8,776 8,392 3,208 8,392
5,500 3,030 3,780 1,246 1,088 2,098 2,712 802 2,194 2,098 802 2,098
Page 6 of 31
ANNEX 3. LIST OF MEDICAL CONDITIONS AND PROCEDURES ALLOWED AS SECOND CASE RATE ICD/RVS CODE
23600
23615
11,650
9,320
2,330
23616
23,670
18,936
4,734
24530
5,060
4,048
1,012
24545
6,228
4,982
1,246
Page 7 of 31
ANNEX 3. LIST OF MEDICAL CONDITIONS AND PROCEDURES ALLOWED AS SECOND CASE RATE ICD/RVS CODE
24576 24579
24586
11,330
9,064
2,266
24635
10,970
8,776
2,194
24666
13,560
10,848
2,712
Page 8 of 31
ANNEX 3. LIST OF MEDICAL CONDITIONS AND PROCEDURES ALLOWED AS SECOND CASE RATE ICD/RVS CODE
25520
3,880
25525
10,490
8,392
2,098
25526
11,330
9,064
2,266
25575
13,560
10,848
2,712
25600
4,130
3,304
826
25620
11,650
9,320
2,330
25622 25628 25630 25645 25650 25660 25670 25675 25676 25680
4,130 10,910 4,130 10,952 4,220 4,130 9,000 4,130 10,910 4,130
3,304 8,728 3,304 8,762 3,376 3,304 7,200 3,304 8,728 3,304
826 2,182 826 2,190 844 826 1,800 826 2,182 826
Page 9 of 31
ANNEX 3. LIST OF MEDICAL CONDITIONS AND PROCEDURES ALLOWED AS SECOND CASE RATE ICD/RVS CODE
25685 25690 25695 25900 25905 25907 25909 25920 25922 25924 25927 25929 25931 26600 26607 26615 26641 26645 26665
26670
5,270
4,216
1,054
26685
5,270
4,216
1,054
Page 10 of 31
ANNEX 3. LIST OF MEDICAL CONDITIONS AND PROCEDURES ALLOWED AS SECOND CASE RATE ICD/RVS CODE
26740 26746 26750 26765 26770 26785
26910
6,060
4,848
1,212
26951
5,990
4,792
1,198
26952
10,970
8,776
2,194
27178
15,570
12,456
3,114
27179 27181
15,570 18,590
12,456 14,872
3,114 3,718
27215
18,900
15,120
3,780
27217
23,250
18,600
4,650
27218 27220
23,250 15,370
18,600 12,296
4,650 3,074
Page 11 of 31
ANNEX 3. LIST OF MEDICAL CONDITIONS AND PROCEDURES ALLOWED AS SECOND CASE RATE ICD/RVS CODE
27226
27227
20,160
16,128
4,032
27228
23,250
18,600
4,650
27230 27236
11,650 23,250
9,320 18,600
2,330 4,650
27238
11,650
9,320
2,330
27244
23,250
18,600
4,650
27258
15,150
12,120
3,030
27259
18,590
14,872
3,718
Page 12 of 31
ANNEX 3. LIST OF MEDICAL CONDITIONS AND PROCEDURES ALLOWED AS SECOND CASE RATE ICD/RVS CODE
27501 27502
DESCRIPTION
Professional Fee
5,984 7,368
27503
9,210
7,368
1,842
27506
15,370
12,296
3,074
27507 27510
15,370 9,210
12,296 7,368
3,074 1,842
27511
18,590
14,872
3,718
27513
18,900
15,120
3,780
Page 13 of 31
ANNEX 3. LIST OF MEDICAL CONDITIONS AND PROCEDURES ALLOWED AS SECOND CASE RATE ICD/RVS CODE SECOND CASE RATE DESCRIPTION
Open treatment of knee dislocation, w/ or w/o internal or external fixation; w/o primary ligamentous repair or augmentation/reconstruction Open treatment of knee dislocation, w/ or w/o internal or external fixation; w/ primary ligamentous repair Open treatment of knee dislocation, w/ or w/o internal or external fixation; w/ primary ligamentous repair, w/ augmentation/reconstruction Closed treatment of patellar dislocation Open treatment of patellar dislocation, w/ or w/o partial or total patellectomy Amputation, thigh, through femur, any level; Amputation, thigh, through femur, any level; immediate fitting technique including first cast Amputation, thigh, through femur, any level; open, circular (guillotine) Amputation, thigh, through femur, any level; secondary closure or scar revision Amputation, thigh, through femur, any level; reamputaion Disarticulation at knee Closed treatment of tibial shaft fracture (w/ or w/o fibular fracture) Closed treatment of tibial shaft fracture (with or without fibular fracture); with manipulation, with or without skeletal traction Open treatment of tibial shaft fracture (w/ or w/o fibular fracture) w/ plate/screws, w/ or w/o cerclage Open treatment of tibial shaft fracture (w/ or w/o fibular fracture) by intramedullary implant, w/ or w/o interlocking screws and/or cerclage Closed treatment of medial malleolus fracture Open treatment of medial malleolus fracture, w/ or w/o internal or external fixation Closed treatment of proximal fibula or shaft fracture Open treatment of proximal fibula or shaft fracture, w/ or w/o internal or external fixation Closed treatment of distal fibular fracture (lateral malleolus) Open treatment of distal fibular fracture (lateral malleolus), w/ or w/o internal or external fixation w/o manipulation Closed treatment of bimalleolar ankle fracture, (including Potts) Open treatment of bimalleolar ankle fracture, w/ or w/o internal or external fixation Closed treatment of trimalleolar ankle fracture H Case Rate C I 13,560 Professional Fee Health Care Institution Fee 2,712
27556
10,848
27557
13,980
11,184
2,796
27558 27560 27566 27590 27591 27592 27594 27596 27598 27750 27752
18,900 10,490 13,560 15,150 11,650 11,650 5,990 11,330 13,560 6,060 6,060
15,120 8,392 10,848 12,120 9,320 9,320 4,792 9,064 10,848 4,848 4,848
3,780 2,098 2,712 3,030 2,330 2,330 1,198 2,266 2,712 1,212 1,212
27758
11,330
9,064
2,266
27759 27760 27766 27780 27784 27786 27792 27808 27814 27816
13,560 5,480 6,060 5,480 11,330 5,270 10,490 6,450 11,650 11,650
10,848 4,384 4,848 4,384 9,064 4,216 8,392 5,160 9,320 9,320
2,712 1,096 1,212 1,096 2,266 1,054 2,098 1,290 2,330 2,330
Page 14 of 31
ANNEX 3. LIST OF MEDICAL CONDITIONS AND PROCEDURES ALLOWED AS SECOND CASE RATE ICD/RVS CODE SECOND CASE RATE DESCRIPTION
Open treatment of trimalleolar ankle fracture, w/ or w/o internal or external fixation, medial and/or lateral malleolus; w/o fixation of posterior lip Open treatment of trimalleolar ankle fracture, w/ or w/o internal or external fixation, medial and/or lateral malleolus; w/ fixation of posterior lip Closed treatment of fracture of weight bearing articular portion of distal tibia (e.g., pilon or tibial plafond) Open treatment of fracture of weight bearing articular surface/portion of distal tibia (e.g., pilon or tibial plafond), w/ internal or external fixation; of fibula only Open treatment of fracture of weight bearing articular surface/portion of distal tibia (e.g., pilon or tibial plafond), w/ internal or external fixation; of tibia only Open treatment of fracture of weight bearing articular surface/portion of distal tibia (e.g., pilon or tibial plafond), w/ internal or external fixation; of both tibia and fibula Open treatment of distal tibiofibular joint (syndesmosis) disruption, w/ or w/o internal or external fixation Closed treatment of proximal tibiofibular joint dislocation Open treatment of proximal tibiofibular joint dislocation, w/ or w/o internal or external fixation, or w/ excision of proximal fibula Closed treatment of ankle dislocation Open treatment of ankle dislocation, w/ or w/o percutaneous skeletal fixation; w/o repair or internal fixation Open treatment of ankle dislocation, w/ or w/o percutaneous skeletal fixation; w/ repair or internal or external fixation Amputation, leg, through tibia and fibula; Amputation, leg, through tibia and fibula; w/ immediate fitting technique including application of first cast Amputation, leg, through tibia and fibula; open, circular (guillotine) Amputation, leg, through tibia and fibula; secondary closure or scar revision Amputation, leg, through tibia and fibula; reamputation Amputation, ankle, through malleoli of tibia and fibula (Syme, Pirogoff type procedures), w/ plastic closure and resection of nerves Ankle disarticulation H Case Rate C I 11,650 Professional Fee Health Care Institution Fee 2,330
27822
9,320
27823
11,650
9,320
2,330
27824
5,270
4,216
1,054
27826
10,490
8,392
2,098
27827
10,970
8,776
2,194
27828
10,910
8,728
2,182
Page 15 of 31
ANNEX 3. LIST OF MEDICAL CONDITIONS AND PROCEDURES ALLOWED AS SECOND CASE RATE ICD/RVS CODE
28400 28415
28420 28430 28445 28450 28465 28470 28485 28490 28505 28510 28525 28530 28531 28540 28555 28570 28585 28600 28615 28630 28645 28660
11,180 5,480 7,690 5,566 5,060 5,440 5,440 5,060 6,060 5,060 6,060 4,130 5,060 4,130 6,270 5,440 9,000 5,480 9,000 4,130 9,000 5,440
8,944 4,384 6,152 4,453 4,048 4,352 4,352 4,048 4,848 4,048 4,848 3,304 4,048 3,304 5,016 4,352 7,200 4,384 7,200 3,304 7,200 4,352
2,236 1,096 1,538 1,113 1,012 1,088 1,088 1,012 1,212 1,012 1,212 826 1,012 826 1,254 1,088 1,800 1,096 1,800 826 1,800 1,088
Page 16 of 31
ANNEX 3. LIST OF MEDICAL CONDITIONS AND PROCEDURES ALLOWED AS SECOND CASE RATE ICD/RVS CODE
28675 28800 28810 28820 28825 29058 29065 29075 29085 29305 29325 29345 29355 29358 29365 29405 29425 29435 29445 29450 49495 49496 49497 49500
DESCRIPTION
Professional Fee
Health Care Institution Fee 1,800 2,330 1,212 1,800 1,212 556 568 556 556 802 844 802 844 844 802 802 802 802 568 568 2,100 2,100 2,100 2,100
7,200 9,320 4,848 7,200 4,848 2,224 2,272 2,224 2,224 3,208 3,376 3,208 3,376 3,376 3,208 3,208 3,208 3,208 2,272 2,272 8,400 8,400 8,400 8,400
49501
10,500
8,400
2,100
Page 17 of 31
ANNEX 3. LIST OF MEDICAL CONDITIONS AND PROCEDURES ALLOWED AS SECOND CASE RATE ICD/RVS CODE
49509 49520 49521 49522 49525 49540 49550 49553 49554 49555 49557 49558 49560 49561 49562 49565 49566 49567 49590 49650 49651 54520 54530 54535 54550 54560 54600 54620 54640 54650 54670 54680 54690
Page 18 of 31
ANNEX 3. LIST OF MEDICAL CONDITIONS AND PROCEDURES ALLOWED AS SECOND CASE RATE ICD/RVS CODE
54692 61330 61332 61333 61334 65091 65093 65101 65103 65105 65110 65112
65114 65130 65135 65140 65150 65155 65175 65205 65210 65222 65235 65260 65265 65270
19,740 5,480 5,480 5,990 5,990 5,990 4,850 1,820 4,010 4,010 9,000 26,700 27,500 4,010
15,792 4,384 4,384 4,792 4,792 4,792 3,880 1,456 3,208 3,208 7,200 21,360 22,000 3,208
3,948 1,096 1,096 1,198 1,198 1,198 970 364 802 802 1,800 5,340 5,500 802
Page 19 of 31
ANNEX 3. LIST OF MEDICAL CONDITIONS AND PROCEDURES ALLOWED AS SECOND CASE RATE ICD/RVS CODE
65273 65275 65280 65285 65286 65290 65450 65710 65730 65750 65755 65760 65765 65767 65770 65771 65772 65775 65780 65781 65782 65805
DESCRIPTION
Professional Fee 3,208 3,880 8,392 9,320 3,880 3,880 3,208 12,120 12,120 12,120 12,120 7,200 4,216 7,200 12,120 5,984 5,984 5,984 12,120 12,120 12,120 3,208
Health Care Institution Fee 802 970 2,098 2,330 970 970 802 3,030 3,030 3,030 3,030 1,800 1,054 1,800 3,030 1,496 1,496 1,496 3,030 3,030 3,030 802
65810
4,850
3,880
970
Page 20 of 31
ANNEX 3. LIST OF MEDICAL CONDITIONS AND PROCEDURES ALLOWED AS SECOND CASE RATE ICD/RVS CODE
65865
4,216
65870
5,270
4,216
1,054
65875
5,270
4,216
1,054
66172
13,560
10,848
2,712
66180 66185 66220 66225 66500 66505 66600 66605 66625 66630 66680 66682
15,150 15,150 6,060 11,650 5,270 5,270 6,060 9,000 6,060 6,060 9,000 7,480
12,120 12,120 4,848 9,320 4,216 4,216 4,848 7,200 4,848 4,848 7,200 5,984
3,030 3,030 1,212 2,330 1,054 1,054 1,212 1,800 1,212 1,212 1,800 1,496
Page 21 of 31
ANNEX 3. LIST OF MEDICAL CONDITIONS AND PROCEDURES ALLOWED AS SECOND CASE RATE ICD/RVS CODE
66700 66710 66720 66740 66761 66762 66770
66820
6,060
4,848
1,212
66821
4,130
3,304
826
66825
9,000
7,200
1,800
66830
6,060
4,848
1,212
66982
8,000
6,400
1,600
66983*
16,000
6,400
9,600
66984* 66985
16,000 8,000
6,400 6,400
9,600 1,600
Page 22 of 31
ANNEX 3. LIST OF MEDICAL CONDITIONS AND PROCEDURES ALLOWED AS SECOND CASE RATE ICD/RVS CODE
66986 66987* 66991 66992 66993 66994 66995 66996 66997 66998 66999
67005
18,900
15,120
3,780
67010
26,700
21,360
5,340
Page 23 of 31
ANNEX 3. LIST OF MEDICAL CONDITIONS AND PROCEDURES ALLOWED AS SECOND CASE RATE ICD/RVS CODE
67047
18,600
67051
23,250
18,600
4,650
67052
18,900
15,120
3,780
67101
23,250
18,600
4,650
67105
18,590
14,872
3,718
67107
23,250
18,600
4,650
67108
23,250
18,600
4,650
67110
15,150
12,120
3,030
67112
23,250
18,600
4,650
Page 24 of 31
ANNEX 3. LIST OF MEDICAL CONDITIONS AND PROCEDURES ALLOWED AS SECOND CASE RATE ICD/RVS CODE SECOND CASE RATE DESCRIPTION
Destruction of localized lesion of retina (e.g., maculopathy, choroidopathy, small tumors), one or more sessions; photocoagulation (laser or xenon arc) Destruction of localized lesion of retina (e.g., maculopathy, choroidopathy, small tumors), one or more sessions; radiation by implantation of source (includes removal of source) Destruction of localized lesion of choroid (e.g., choroidal neovascularization); photocoagulation (e.g., laser), one or more sessions Destruction of localized lesion of choroid (e.g., choroidal neovascularization); photodynamic therapy (includes intravenous infusions Destruction of localized lesion of choroid (e.g., choroidal neovascularization); transpupillary thermotherapy Destruction of extensive or progressive retinopathy (e.g., diabetic retinopathy), one or more sessions; cryotherapy, diathermy Destruction of extensive or progressive retinopathy (e.g., diabetic retinopathy), one or more sessions; photocoagulation (laser or xenon arc) Scleral reinforcement Strabismus surgery, recession or resection procedure (patient not previously operated on); one horizontal muscle Strabismus surgery, recession or resection procedure (patient not previously operated on); two horizontal muscles Strabismus surgery, recession or resection procedure (patient not previously operated on); one vertical muscle (excluding superior oblique) Strabismus surgery, recession or resection procedure (patient not previously operated on); two or more vertical muscles (excluding superior oblique) Strabismus surgery, any procedure (patient not previously operated on), superior oblique muscle Transposition procedure (e.g., for paretic extraocular muscle), any extraocular muscle (specify) Strabismus surgery on patient w/ previous eye surgery or injury that did not involve the extraocular muscles H Case Rate C I 6,060 Professional Fee Health Care Institution Fee 1,212
67210
4,848
67218
6,060
4,848
1,212
67220
6,060
4,848
1,212
67221
6,060
4,848
1,212
67222
6,060
4,848
1,212
67227
6,060
4,848
1,212
67312
6,060
4,848
1,212
67314
6,060
4,848
1,212
67316
9,000
7,200
1,800
67318
9,000
7,200
1,800
67320
9,000
7,200
1,800
67331
9,000
7,200
1,800
Page 25 of 31
ANNEX 3. LIST OF MEDICAL CONDITIONS AND PROCEDURES ALLOWED AS SECOND CASE RATE ICD/RVS CODE SECOND CASE RATE DESCRIPTION
Strabismus surgery on patient w/ scaring of extraocular muscles (e.g., prior ocular injury, strabismus or retinal detachment surgery) or restrictive myopathy (e.g., dysthyroid ophthalmopathy) Strabismus surgery by posterior fixation suture technique, w/ or w/o muscle recession Strabismus surgery involving exploration and/or repair of detached extraocular muscle(s) Release of extensive scar tissue w/o detaching extraocular muscle Chemodenervation of extraocular muscle Orbitotomy w/o bone flap (frontal or transconjunctival approach); for exploration, w/ or w/o biopsy Orbitotomy w/o bone flap (frontal or transconjunctival approach); w/ drainage only Orbitotomy w/o bone flap (frontal or transconjunctival approach); w/ removal of lesion Orbitotomy w/o bone flap (frontal or transconjunctival approach); w/ removal of foreign body Orbitotomy w/o bone flap (frontal or transconjunctival approach); w/ removal of bone for decompression Fine needle aspiration of orbital contents Orbitotomy w/ bone flap or window, lateral approach (e.g., Kroenlein); w/ removal of lesion Orbitotomy w/ bone flap or window, lateral approach (e.g., Kroenlein); w/ removal of foreign body Orbitotomy w/ bone flap or window, lateral approach (e.g., Kroenlein); w/ drainage Orbitotomy w/ bone flap or window, lateral approach (e.g., Kroenlein); w/ removal of bone for decompression Orbital implant (implant outside muscle cone); insertion Orbital implant (implant outside muscle cone); removal or revision Repair of anophthalmic socket; with insertion or removal of orbital implant within muscle cone Repair of anophthalmic socket; with exchange or orbital implant Repair of anophthalmic socket; with exchange of orbital implant and reattachment of muscles Repair of anophthalmic socket; with fornix reconstruction using sutures Repair of anophthalmic socket; with fornix reconstruction using buccal mucosal graft or amnion graft, including harvesting of graft H Case Rate C I 10,970 Professional Fee Health Care Institution Fee
67332
8,776
2,194
67413
23,250
18,600
4,650
67414 67415 67420 67430 67440 67445 67550 67560 67580 67581 67582 67583 67584
23,250 23,250 23,250 23,250 23,250 23,250 5,480 5,480 6,060 10,490 10,490 10,490 10,490
18,600 18,600 18,600 18,600 18,600 18,600 4,384 4,384 4,848 8,392 8,392 8,392 8,392
4,650 4,650 4,650 4,650 4,650 4,650 1,096 1,096 1,212 2,098 2,098 2,098 2,098
Page 26 of 31
ANNEX 3. LIST OF MEDICAL CONDITIONS AND PROCEDURES ALLOWED AS SECOND CASE RATE ICD/RVS CODE
67585
67586 67700 67710 67715 67800 67825 67830 67835 67840 67875 67880 67882 67900 67901 67902 67903 67904 67906
10,490 2,840 2,840 2,840 2,840 2,840 1,820 4,650 2,780 2,840 2,840 4,010 9,000 9,000 10,490 9,000 9,000 9,000
8,392 2,272 2,272 2,272 2,272 2,272 1,456 3,720 2,224 2,272 2,272 3,208 7,200 7,200 8,392 7,200 7,200 7,200
2,098 568 568 568 568 568 364 930 556 568 568 802 1,800 1,800 2,098 1,800 1,800 1,800
Page 27 of 31
ANNEX 3. LIST OF MEDICAL CONDITIONS AND PROCEDURES ALLOWED AS SECOND CASE RATE ICD/RVS CODE
67923 67924 67930
67935 67950
6,060 6,060
4,848 4,848
1,212 1,212
67961
15,370
12,296
3,074
67966
13,560
10,848
2,712
67971
15,150
12,120
3,030
67973
18,900
15,120
3,780
67974
18,900
15,120
3,780
Page 28 of 31
ANNEX 3. LIST OF MEDICAL CONDITIONS AND PROCEDURES ALLOWED AS SECOND CASE RATE ICD/RVS CODE
68340 68360 68362 68371 68400 68420 68440 68500 68520 68530 68540 68550 68700 68705 68720 68745 68750 68760 68770 68811 68815 69310 69320 69400 69405 69420 69421 69433
7,200 4,792 4,792 8,392 2,272 2,272 2,272 4,848 4,848 2,272 7,200 7,200 3,880 1,456 7,200 7,200 8,392 3,208 4,352 3,208 3,880 9,320 9,320 2,325 2,272 2,272 3,208 3,304
Page 29 of 31
ANNEX 3. LIST OF MEDICAL CONDITIONS AND PROCEDURES ALLOWED AS SECOND CASE RATE ICD/RVS CODE
69436 69440 69450 69535 69620 69650 69660
69661 69662 69666 69667 69670 69676 69700 69720 69725 69740
19,320 19,320 19,320 19,320 15,790 15,150 5,270 15,150 15,150 18,900
15,456 15,456 15,456 15,456 12,632 12,120 4,216 12,120 12,120 15,120
3,864 3,864 3,864 3,864 3,158 3,030 1,054 3,030 3,030 3,780
69745
18,900
15,120
3,780
69801
19,320
15,456
3,864
69802
19,740
15,792
3,948
Page 30 of 31
ANNEX 3. LIST OF MEDICAL CONDITIONS AND PROCEDURES ALLOWED AS SECOND CASE RATE ICD/RVS CODE
69955 69960 69970
DESCRIPTION
Page 31 of 31