Line Diagnosis Treatment 1 SEVERE/MODERATE HEAD INJURY: HEMATOMA/EDEMA WITH LOSS OF CONSCIOUSNESS (See Guideline Note 1) MEDICAL AND SURGICAL TREATMENT 2 TYPE I DIABETES MELLITUS (Guideline Note 2) MEDICAL THERAPY 3 PERITONITIS AND RETROPERITONEAL INFECTIONS MEDICAL AND SURGICAL TREATMENT 4 ACUTE GLOMERULONEPHRITIS: WITH LESION OF RAPIDLY PROGRESSIVE GLOMERULONEPHRITIS (Guideline Note 2) MEDICAL THERAPY INCLUDING DIALYSIS 5 PNEUMOTHORAX AND HEMOTHORAX "TUBE THORACOSTOMY/THORACOTOMY, MEDICAL THERAPY" 6 COMPLICATED HERNIA WITH OBSTRUCTION AND/OR GANGRENE; UNCOMPLICATED HERNIA IN CHILDREN UNDER AGE 18 REPAIR 7 TORSION OF OVARY "OOPHORECTOMY, OVARIAN CYSTECTOMY" 8 TORSION OF TESTIS "ORCHIECTOMY, REPAIR" 9 ADDISON'S DISEASE MEDICAL THERAPY 10 INJURY TO INTERNAL ORGANS MEDICAL AND SURGICAL TREATMENT 11 FLAIL CHEST MEDICAL AND SURGICAL TREATMENT 12 APPENDICITIS APPENDECTOMY 13 RUPTURED SPLEEN REPAIR/SPLENECTOMY/INCISION 14 TUBERCULOSIS MEDICAL THERAPY 15 "DEEP OPEN WOUND OF NECK, INCLUDING LARYNX; FRACTURE OF LARYNX OR TRACHEA, OPEN" REPAIR 16 "CROUP SYNDROME, EPIGLOTTITIS, ACUTE LARYNGOTRACHEITIS" "MEDICAL THERAPY, INTUBATION, TRACHEOTOMY" 17 "PNEUMOCOCCAL PNEUMONIA, OTHER BACTERIAL PNEUMONIA, BRONCHOPNEUMONIA" MEDICAL THERAPY 18 PERTUSSIS AND DIPTHERIA MEDICAL THERAPY 19 RUPTURE OF PAPILLARY MUSCLE (See Guideline Note 1) MEDICAL AND SURGICAL TREATMENT 20 COAGULATION DEFECTS MEDICAL THERAPY 21 DISSECTING OR RUPTURED AORTIC ANEURYSM (See Guideline Note 1) SURGICAL TREATMENT 22 INJURY TO MAJOR BLOOD VESSELS OF EXTREMITIES LIGATION 23 "INTUSSCEPTION, VOLVULUS, INTESTINAL OBSTRUCTION, AND FOREIGN BODY IN STOMACH, INTESTINES, COLON AND RECTUM" MEDICAL AND SURGICAL TREATMENT 24 NON-DISSECTING ANEURYSM WITHOUT RUPTURE (See Guideline Note 1) SURGICAL TREATMENT 25 RUPTURED VISCUS REPAIR 26 ACUTE BACTERIAL MENINGITIS (See Guideline Note 1) MEDICAL THERAPY 27 "HODGKIN'S DISEASE (See Guideline Notes 2, 3, 4 )" "MEDICAL THERAPY, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY" 28 "ACUTE PYELONEPHRITIS, RENAL AND PERINEPHRIC ABSCESS" MEDICAL AND SURGICAL THREATMENT 29 "ARTERIAL EMBOLISM/THROMBOSIS: ABDOMINAL AORTA, THORACIC AORTA (See Guideline Note 1)" SURGICAL TREATMENT 30 LIVER ABSCESS MEDICAL THERAPY 31 SUBARACHNOID AND INTRACEREBRAL HEMORRHAGE/HEMATOMA; COMPRESSION OF BRAIN (See Guideline Note 1) "BURR HOLES, CRANIECTOMY/CRANIOTOMY" 32 "FOREIGN BODY IN PHARYNX, LARYNX, TRACHEA, BRONCHUS AND ESOPHAGUS" REMOVAL OF FOREIGN BODY 33 NEOPLASMS OF ISLETS OF LANGERHANS EXCISION OF TUMOR 34 NON-DIABETIC HYPOGLYCEMIC COMA MEDICAL THERAPY 35 ACUTE OSTEOMYELITIS (See Guideline Note 1) MEDICAL AND SURGICAL TREATMENT 36 ACUTE MASTOIDITIS "MASTOIDECTOMY, MEDICAL THERAPY" 37 PYOGENIC ARTHRITIS (See Guideline Note 1) MEDICAL AND SURGICAL TREATMENT 38 ACUTE INFLAMMATION OF THE HEART DUE TO RHEUMATIC FEVER (See Guideline Note 1) MEDICAL THERAPY 39 "BUDD-CHIARI SYNDROME, AND OTHER VENOUS EMBOLISM AND THROMBOSIS" THROMBECTOMY/LIGATION 40 "BURN, PARTIAL THICKNESS GREATER THAN 30% OF BODY SURFACE OR WITH VITAL SITE; FULL THICKNESS WITH VITAL SITE, LESS THAN 10% OF BODY SURFACE (See Guideline Note 1)" "FREE SKIN GRAFT, MEDICAL THERAPY" 41 CHOANAL ATRESIA REPAIR OF CHOANAL ATRESIA 42 THROMBOCYTOPENIA MEDICAL AND SURGICAL THREATMENT 43 INTRA-ABDOMINAL ABSCESS "DRAIN ABSCESS, MEDICAL THERAPY" 44 "PERIPHERAL VASCULAR DISEASE, LIMB THREATENING INFECTIONS, AND VASCULAR COMPLICATIONS" MEDICAL AND SURGICAL TREATMENT 45 "RUPTURE BLADDER, NONTRAUMATIC" MEDICAL AND SURGICAL TREATMENT 46 ERYSIPELAS MEDICAL THERAPY 47 SEPTICEMIA MEDICAL THERAPY 48 RICKETTSIAL AND OTHER ARTHROPOD-BORNE DISEASES MEDICAL THERAPY 49 ACUTE ORBITAL CELLULITIS MEDICAL THERAPY 50 ANAPHYLACTIC SHOCK MEDICAL THERAPY 51 DEFORMITIES OF HEAD AND COMPOUND/DEPRESSED FRACTURES OF SKULL (See Guideline Note 1) CRANIOTOMY/CRANIECTOMY 52 "CONGENITAL, PRIMARY, AND SECONDARY SYPHILIS" MEDICAL THERAPY 53 BIRTH CONTROL CONTRACEPTION MANAGEMENT 54 PREGNANCY (See Guideline Note 5) MATERNITY CARE 55 BIRTH OF INFANT NEWBORN CARE 56 ECTOPIC PREGNANCY MEDICAL AND SURGICAL TREATMENT 57 NECROTIZING ENTEROCOLITIS IN FETUS OR NEWBORN MEDICAL THERAPY 58 NEONATAL THYROTOXICOSIS MEDICAL THERAPY 59 OTHER RESPIRATORY CONDITIONS OF FETUS AND NEWBORN MEDICAL THERAPY 60 DRUG REACTIONS AND INTOXICATIONS SPECIFIC TO NEWBORN MEDICAL THERAPY 61 TETANUS NEONATORUM MEDICAL THERAPY 62 HYDROPS FETALIS MEDICAL THERAPY 63 GALACTOSEMIA MEDICAL THERAPY 64 CONGENITAL HYPOTHYROIDISM MEDICAL THERAPY 65 PHENYLKETONURIA (PKU) MEDICAL THERAPY 66 NEONATAL MYASTHENIA GRAVIS MEDICAL THERAPY 67 CONVULSIONS AND OTHER CEREBRAL IRRITABILITY IN NEWBORN MEDICAL THERAPY 68 HEMATOLOGICAL DISORDERS OF FETUS AND NEWBORN MEDICAL THERAPY 69 "CEREBRAL DEPRESSION, COMA, AND OTHER ABNORMAL CEREBRAL SIGNS OF NEWBORN" MEDICAL THERAPY 70 LOW BIRTH WEIGHT (UNDER 2500 GRAMS) MEDICAL THERAPY 71 CONDITIONS INVOLVING THE TEMPERATURE REGULATION OF NEWBORNS MEDICAL THERAPY 72 ADRENAL OR CUTANEOUS HEMORRHAGE OF FETUS OR NEONATE MEDICAL THERAPY 73 OMPHALITIS OF THE NEWBORN AND NEONATAL INFECTIVE MASTITIS MEDICAL THERAPY 74 BIRTH TRAUMA FOR BABY MEDICAL THERAPY 75 "POLYCYTHEMIA NEONATORUM, SYMPTOMATIC" MEDICAL THERAPY 76 ANEMIA OF PREMATURITY OR TRANSIENT NEONATAL NEUTROPENIA MEDICAL THERAPY 77 CONGENITAL ANOMALIES OF DIGESTIVE SYSTEM AND ABDOMINAL WALL EXCLUDING NECROSIS; CHRONIC INTESTINAL PSEUDO-OBSTRUCTION MEDICAL AND SURGICAL TREATMENT 78 CONGENITAL INFECTIOUS DISEASES MEDICAL THERAPY 79 DISORDERS RELATING TO LONG GESTATION AND HIGH BIRTHWEIGHT MEDICAL THERAPY 80 FEEDING PROBLEMS IN NEWBORN MEDICAL THERAPY 81 "HEMOLYTIC DISEASE DUE TO ISOIMMUNIZATION, ANEMIA DUE TO TRANSPLACENTAL HEMORRHAGE, AND FETAL AND NEONATAL JAUNDICE" MEDICAL THERAPY 82 "NEONATAL CONJUNCTIVITIS, DACRYOCYSTITIS AND CANDIDA INFECTION" MEDICAL THERAPY 83 DRUG WITHDRAWAL SYNDROME IN NEWBORN MEDICAL THERAPY 84 "HYPOCALCEMIA, HYPOMAGNESEMIA AND OTHER ENDOCRINE AND METABOLIC DISTURBANCES SPECIFIC TO THE FETUS AND NEWBORN" MEDICAL THERAPY 85 ADRENOGENITAL DISORDERS MEDICAL AND SURGICAL TREATMENT 86 ENCEPHALOCELE; CONGENITAL HYDROCEPHALUS SHUNT 87 SPINA BIFIDA SURGICAL TREATMENT 88 CONGENITAL DISLOCATION OF HIP; COXA VARA AND VALGA (See Guideline Note 1) SURGICAL TREATMENT 89 "SYNDROME OF ""INFANT OF A DIABETIC MOTHER"" AND NEONATAL HYPOGLYCEMIA" MEDICAL THERAPY 90 CONGENITAL CYSTIC LUNG - MILD AND MODERATE "LUNG RESECTION, MEDICAL THERAPY" 91 RUMINATION DISORDER OF INFANCY MEDICAL/PSYCHOTHERAPY 92 STERILIZATION VASECTOMY 93 STERILIZATION TUBAL LIGATION 94 COARCTATION OF THE AORTA (See Guideline Note 1) SURGICAL TREATMENT 95 "ATRIAL SEPTAL DEFECT, PRIMUM (See Guideline Note 1)" REPAIR SEPTAL DEFECT 96 VENTRICULAR SEPTAL DEFECT (See Guideline Note 1) CLOSURE 97 "SUBVALVULAR AORTIC STENOSIS, RIGHT VENTRICULAR INFUNDIBULAR OBSTRUCTION AND OTHER SPECIFIED ANOMALIES OF HEART (See Guideline Note 1)" "RESECTION, REPAIR" 98 "CONGENITAL ANOMALIES OF UPPER ALIMENTARY TRACT, EXCLUDING TONGUE" MEDICAL AND SURGICAL TREATMENT 99 CONGENITAL ANOMALIES OF URINARY SYSTEM RECONSTRUCTION 100 CORONARY ARTERY ANOMALY (See Guideline Note 1) REIMPLANTATION OF CORONARY ARTERY 101 "COMPLETE, CORRECTED AND OTHER TRANSPOSITION OF GREAT VESSELS (See Guideline Note 1)" REPAIR 102 TETRALOGY OF FALLOT (TOF) (See Guideline Note 1) TOTAL REPAIR TETRALOGY 103 PATENT DUCTUS ARTERIOSUS; AORTIC PULMONARY FISTULA (See Guideline Note 1) LIGATION 104 TOTAL ANOMALOUS PULMONARY VENOUS CONNECTION (See Guideline Note 1) COMPLETE REPAIR 105 OTHER AND UNSPECIFIED TYPE ENDOCARDIAL CUSHION DEFECTS (See Guideline Note 1) REPAIR ATRIOVENTRICULAR 106 BILIARY ATRESIA LIVER TRANSPLANT 107 CYSTIC FIBROSIS MEDICAL THERAPY 108 END STAGE RENAL DISEASE RENAL TRANSPLANT 109 CIRRHOSIS OF LIVER OR BILIARY TRACT; BUDD-CHIARI SYNDROME; HEPATIC VEIN THROMBOSIS; INTRAHEPATIC VASCULAR MALFORMATIONS; CAROLI'S DISEASE (See Coding Specification Below) (See Guideline Note 6) "LIVER TRANSPLANT, LIVER-KIDNEY TRANSPLANT" 110 "CLEFT PALATE WITH AIRWAY OBSTRUCTION, PIERRE ROBIN DEFORMITY" "MEDICAL AND SURGICAL TREATMENT, ORTHODONTICS" 111 "MYOCARDITIS (NONVIRAL), PERICARDITIS (NONVIRAL) AND ENDOCARDITIS (See Guideline Note 1)" MEDICAL AND SURGICAL TREATMENT 112 "CERVICAL VERTEBRAL DISLOCATIONS/FRACTURES, OPEN OR CLOSED; OTHER VERTEBRAL DISLOCATIONS/FRACTURES, OPEN; SPINAL CORD INJURIES WITH OR WITHOUT EVIDENCE OF VERTEBRAL INJURY (See Guideline Note 1)" MEDICAL AND SURGICAL TREATMENT 113 "FRACTURE OF PELVIS, OPEN AND CLOSED (See Guideline Note 1)" MEDICAL AND SURGICAL TREATMENT 114 INJURY TO BLOOD VESSELS OF THE THORACIC CAVITY (See Guideline Note 1) REPAIR 115 TOXIC EPIDERMAL NECROLYSIS AND STAPHYLOCOCCAL SCALDED SKIN SYNDROME; STEVENS-JOHNSON SYNDROME; ECZEMA HERPETICUM MEDICAL THERAPY 116 ACQUIRED HEMOLYTIC ANEMIAS MEDICAL THERAPY 117 "ACUTE LEUKEMIAS, MYELODYSPLASTIC SYNDROME (See Guideline Notes 2, 3, 7)" BONE MARROW TRANSPLANT 118 "ACUTE LYMPHOCYTIC LEUKEMIA (CHILD) (See Guideline Notes 2, 3)" "MEDICAL THERAPY, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY" 119 "HODGKIN'S DISEASE (See Guideline Notes 2, 3, 4, 7)" BONE MARROW TRANSPLANT 120 CONSTITUTIONAL APLASTIC ANEMIA MEDICAL THERAPY 121 "OTHER SPECIFIED APLASTIC ANEMIAS (See Guideline Notes 2, 3, 7)" BONE MARROW TRANSPLANT 122 "NON-HODGKIN'S LYMPHOMAS (See Guideline Notes 2, 3, 4, 8)" "MEDICAL THERAPY, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY" 123 "NON-HODGKIN'S LYMPHOMAS (See Guideline Notes 2, 3, 4, 7)" BONE MARROW TRANSPLANT 124 "OSTEOPETROSIS (See Guideline Notes 2, 3, 7)" BONE MARROW RESCUE AND TRANSPLANT 125 HYDATIDIFORM MOLE "D & C, HYSTERECTOMY" 126 ACUTE VASCULAR INSUFFICIENCY OF INTESTINE SURGICAL TREATMENT 127 SHORT BOWEL SYNDROME - AGE 5 OR UNDER (See Guideline Note 6) INTESTINE AND INTESTINE/LIVER TRANSPLANT 128 ADULT RESPIRATORY DISTRESS SYNDROME; RESPIRATORY CONDITIONS DUE TO PHYSICAL AND CHEMICAL AGENTS MEDICAL THERAPY 129 RUPTURE OF LIVER SUTURE/REPAIR 130 "SUBACUTE MENINGITIS (EG. TUBERCULOSIS, CRYPTOCOCCOSIS)" MEDICAL THERAPY 131 OPEN FRACTURE OF EXTREMITIES (See Guideline 1) MEDICAL AND SURGICAL TREATMENT 132 DISEASES OF PHARYNX INCLUDING RETROPHARYNGEAL ABSCESS MEDICAL AND SURGICAL TREATMENT 133 ARTERIAL ANEURYSM OF NECK (See Guideline Note 1) REPAIR 134 "CHRONIC LEUKEMIAS; POLYCYTHEMIA RUBRA VERA (See Guideline Notes 2, 3)" "MEDICAL THERAPY, WHICH INCLUDES CHEMOTHERAPY, RADIATION AND RADIONUCLEIDE THERAPY" 135 HYPOTHERMIA "MEDICAL THERAPY, EXTRACORPOREAL CIRCULATION" 136 BENIGN NEOPLASM OF THE BRAIN "CRANIOTOMY/CRANIECTOMY, LINEAR ACCELERATOR, MEDICAL THERAPY, WHICH INCLUDES RADIATION THERAPY" 137 "MALIGNANT MELANOMA OF SKIN, WHERE TREATMENT WILL RESULT IN A GREATER THAN 5% 5-YEAR SURVIVAL (See Guideline Notes 2, 3, 4)" MEDICAL AND SURGICAL TREATMENT 138 MULTIPLE ENDOCRINE NEOPLASIA THYROIDECTOMY 139 DIABETES INSIPIDUS MEDICAL THERAPY 140 "DISORDERS OF SPINE WITH NEUROLOGIC IMPAIRMENT (See Guideline Notes 1, 9)" MEDICAL AND SURGICAL TREATMENT 141 "PREVENTIVE SERVICES, BIRTH TO 10 YEARS OF AGE (See Prevention Tables)" MEDICAL THERAPY 142 ANOREXIA NERVOSA MEDICAL/PSYCHOTHERAPY 143 REACTIVE ATTACHMENT DISORDER OF INFANCY OR EARLY CHILDHOOD MEDICAL/PSYCHOTHERAPY 144 COARCTATION OF THE AORTA BALLOON DILATION 145 COMPLICATIONS OF A PROCEDURE ALWAYS REQUIRING TREATMENT (See Guideline Note 1) MEDICAL AND SURGICAL TREATMENT 146 "CRUSH INJURIES: TRUNK, UPPER LIMBS, LOWER LIMB INCLUDING BLOOD VESSELS (See Guideline Note 1)" SURGICAL TREATMENT 147 CONGENITAL MITRAL VALVE STENOSIS (See Guideline Note 1) MITRAL VALUE REPLACEMENT 148 COMMON TRUNCUS (See Guideline Note 1) TOTAL REPAIR/REPLANT ARTERY 149 CONGENITAL TRICUSPID ATRESIA AND STENOSIS (See Guideline Note 1) REPAIR 150 BULBUS CORDIS ANOMALIES AND ANOMALIES OF CARDIAC SEPTAL CLOSURE: DOUBLE OUTLET RIGHT VENTRICLE (See Guideline Note 1) SHUNT/REPAIR 151 COMMON VENTRICLE (See Guideline Note 1) TOTAL REPAIR 152 CONGENITAL PULMONARY VALVE ATRESIA (See Guideline Note 1) SHUNT/REPAIR 153 INTERRUPTED AORTIC ARCH (See Guideline Note 1) TRANSVERSE ARCH GRAFT 154 "CONGESTIVE HEART FAILURE, CARDIOMYOPATHY, TRANSPOSITION OF GREAT VESSELS, HYPOPLASTIC LEFT HEART SYNDROME (See Guideline Notes 1, 6)" CARDIAC TRANSPLANT 155 DISORDERS OF BILE DUCT "EXCISION, REPAIR" 156 ASTHMA MEDICAL THERAPY 157 PNEUMONIA DUE TO RESPIRATORY SYNCYTIAL VIRUS IN PERSONS UNDER AGE 3 MEDICAL THERAPY 158 RESPIRATORY FAILURE MEDICAL THERAPY 159 SCHIZOPHRENIC DISORDERS MEDICAL/PSYCHOTHERAPY 160 "MAJOR DEPRESSION, RECURRENT" MEDICAL/PSYCHOTHERAPY 161 BIPOLAR DISORDERS MEDICAL/PSYCHOTHERAPY 162 BURN FULL THICKNESS GREATER THAN 10% OF BODY SURFACE (See Guideline Note 1) "FREE SKIN GRAFT, MEDICAL THERAPY" 163 "DISORDERS OF FLUID, ELECTROLYTE, AND ACID-BASE BALANCE (See Guideline Note 2)" "MEDICAL THERAPY, DIALYSIS" 164 "THYROTOXICOSIS WITH OR WITHOUT GOITER, ENDOCRINE EXOPHTHALMOS; CHRONIC THYROIDITIS" "MEDICAL AND SURGICAL TREATMENT, INCLUDING RADIATION THERAPY" 165 HYPERTENSIVE HEART AND RENAL DISEASE (See Guideline Note 1) MEDICAL THERAPY 166 BENIGN CEREBRAL CYSTS DRAINAGE 167 HIV DISEASE (INCLUDING ACQUIRED IMMUNODEFICIENCY SYNDROME) AND RELATED OPPORTUNISTIC INFECTIONS MEDICAL THERAPY 168 OPPORTUNISTIC INFECTIONS IN IMMUNOCOMPROMISED HOSTS; CANDIDIASIS OF STOMA; PERSONS RECEIVING CONTINUOUS ANTIBIOTIC THERAPY MEDICAL THERAPY 169 EMPYEMA AND ABSCESS OF LUNG MEDICAL AND SURGICAL TREATMENT 170 ANEMIAS DUE TO DISEASE OR TREATMENT AND OTHER APLASTIC ANEMIAS MEDICAL THERAPY 171 MALARIA AND RELAPSING FEVER MEDICAL THERAPY 172 "HEART FAILURE (See Guideline Note 1, 10)" MEDICAL THERAPY 173 "HEREDITARY ANEMIAS, HEMOGLOBINOPATHIES, AND DISORDRES OF THE SPLEEN" MEDICAL THERAPY 174 LIFE-THREATENING CARDIAC ARRHYTHMIAS (See Guideline Note 1) MEDICAL AND SURGICAL TREATMENT 175 END STAGE RENAL DISEASE MEDICAL THERAPY INCLUDING DIALYSIS 176 "ACUTE AND SUBACUTE NECROSIS OF LIVER; SPECIFIED INBORN ERRORS OF METABOLISM (EG. MAPLE SYRUP URINE DISEASE, TYROSINEMIA) (See Guideline Note 6)" LIVER TRANSPLANT 177 "FRACTURE OF HIP, CLOSED (See Guideline Notes 1, 11)" MEDICAL AND SURGICAL TREATMENT 178 HEREDITARY ANGIOEDEMA; ANGIONEUROTIC EDEMA MEDICAL THERAPY 179 "TESTICULAR CANCER (See Guideline Notes 2, 3, 7, 12)" BONE MARROW RESCUE AND TRANSPLANT 180 "CHRONIC NON-LYMPHOCYTIC LEUKEMIA (See Guideline Notes 2, 3, 7)" BONE MARROW TRANSPLANT 181 "PREVENTIVE SERVICES WITH PROVEN EFFECTIVENESS, OVER AGE OF 10 (See Prevention Tables)" MEDICAL THERAPY 182 TOBACCO DEPENDENCE (See Guideline Note 13) MEDICAL THERAPY/BRIEF COUNSELING NOT TO EXCEED 10 FOLLOW-UP VISITS OVER 3 MONTHS 183 PREVENTIVE FOOT CARE IN HIGH RISK PATIENTS MEDICAL AND SURGICAL TREATMENT OF TOENAILS AND HYPERKERATOSES OF FOOT 184 ABUSE OR DEPENDENCE OF PSYCHOACTIVE SUBSTANCE MEDICAL/PSYCHOTHERAPY 185 MAJOR DEPRESSION; SINGLE EPISODE OR MILD MEDICAL/PSYCHOTHERAPY 186 OTHER PSYCHOTIC DISORDERS MEDICAL/PSYCHOTHERAPY 187 ATTENTION DEFICIT DISORDERS WITH HYPERACTIVITY OR UNDIFFERENTIATED MEDICAL/PSYCHOTHERAPY 188 HYPERTENSION AND HYPERTENSIVE DISEASE (See Guideline Note 1) MEDICAL THERAPY 189 "ULCERS, GASTRITIS AND DUODENITIS" MEDICAL THERAPY 190 "CANCER OF THYROID, WHERE TREATMENT WILL RESULT IN A GREATER THAN 5% 5-YEAR SURVIVAL (See Guideline Notes 2, 3)" "MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY" 191 "CANCER OF TESTIS, WHERE TREATMENT WILL RESULT IN A GREATER THAN 5% 5-YEAR SURVIVAL (See Guideline Notes 2, 3)" "MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY" 192 "CANCER OF UTERUS, WHERE TREATMENT WILL RESULT IN A GREATER THAN 5% 5-YEAR SURVIVAL (See Guideline Notes 2, 3)" "MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY" 193 "CANCER OF EYE AND ORBIT, WHERE TREATMENT WILL RESULT IN A GREATER THAN 5% 5-YEAR SURVIVAL (See Guideline Notes 2, 3)" "MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES RADIATION THERAPY" 194 "ULCERS, GI HEMORRHAGE" SURGICAL TREATMENT 195 CONGENITAL STENOSIS AND INSUFFICIENCY OF AORTIC VALVE (See Guideline Note 1) SURGICAL VALVE REPLACEMENT/VALVULOPLASTY 196 "BURN, PARTIAL THICKNESS WITHOUT VITAL SITE, 10-30% OF BODY SURFACE (See Guideline Note 1)" "FREE SKIN GRAFT, MEDICAL THERAPY" 197 "AGRANULOCYTOSIS (See Guideline Notes 2, 3, 7)" BONE MARROW TRANSPLANTATION 198 "CHRONIC GRANULOMATOUS DISEASE (See Guideline Notes 2, 3)" "MEDICAL THERAPY, WHICH INCLUDES RADIATION THERAPY" 199 BOTULISM MEDICAL THERAPY 200 DISORDERS OF AMINO-ACID TRANSPORT AND METABOLISM (NON PKU) MEDICAL THERAPY 201 CHRONIC RESPIRATORY DISEASE ARISING IN THE NEONATAL PERIOD MEDICAL THERAPY 202 GONOCOCCAL INFECTIONS AND OTHER SEXUALLY TRANSMITTED DISEASES MEDICAL THERAPY 203 HERPES SIMPLEX AND HERPES ZOSTER WITH NEUROLOGICAL AND OPHTHALMOLOGICAL COMPLICATIONS MEDICAL THERAPY 204 PNEUMOCYSTIS CARINII PNEUMONIA MEDICAL THERAPY 205 HYPOPLASIA AND DYSPLASIA OF LUNG MEDICAL THERAPY 206 "CARDIOMYOPATHY, HYPERTROPHIC MUSCLE (See Guideline Note 1)" MEDICAL AND SURGICAL TREATMENT 207 GLYCOGENOSIS MEDICAL THERAPY 208 CHRONIC OSTEOMYELITIS (See Guideline Note 1) MEDICAL AND SURGICAL TREATMENT 209 "ACUTE LYMPHOCYTIC LEUKEMIAS (ADULT) AND MULTIPLE MYELOMA (See Guideline Notes 2, 3)" "MEDICAL THERAPY, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY" 210 "MULTIPLE MYELOMA (See Guideline Notes 2, 3, 7)" BONE MARROW TRANSPLANT 211 "PHLEBITIS AND THROMBOPHLEBITIS, DEEP" MEDICAL THERAPY 212 DISEASES OF ENDOCARDIUM (See Guideline Note 1) MEDICAL THERAPY 213 IDEOPATHIC OR VIRAL MYOCARDITIS AND PERICARDITIS (See Guideline Note 1) MEDICAL AND SURGICAL TREATMENT 214 INTRASPINAL AND INTRACRANIAL ABSCESS MEDICAL AND SURGICAL TREATMENT 215 "FRACTURE OF RIBS AND STERNUM, OPEN" MEDICAL AND SURGICAL TREATMENT 216 "NEUROLOGICAL DYSFUNCTION IN BREATHING, EATING, SWALLOWING, BOWEL, OR BLADDER CONTROL CAUSED BY CHRONIC CONDITIONS (See Guideline Note 1)" "MEDICAL AND SURGICAL TREATMENT (EG. G-TUBES, J-TUBES, RESPIRATORS, TRACHEOSTOMY, UROLOGICAL PROCEDURES)" 217 ESOPHAGEAL STRICTURE MEDICAL AND SURGICAL TREATMENT 218 "SPONTANEOUS ABORTION COMPLICATED BY INFECTION AND/OR HEMORRHAGE, MISSED ABORTION" MEDICAL AND SURGICAL TREATMENT 219 TRANSIENT NEPHROTIC SYNDROME WITH LESION OF MINIMAL CHANGE GLOMERULONEPHRITIS (See Guideline Note 2) MEDICAL THERAPY 220 DISORDERS OF PANCREATIC ENDOCRINE SECRETION MEDICAL AND SURGICAL TREATMENT 221 "ERYTHROPLAKIA, LEUKOEDEMA OF MOUTH OR TONGUE" "INCISION/EXCISION, MEDICAL THERAPY" 222 "LEUKOPLAKIA OF ORAL MUCOSA, INCLUDING TONGUE" "INCISION/EXCISION, MEDICAL THERAPY" 223 DYSTROPHY OF VULVA MEDICAL THERAPY 224 "CANCER OF SOFT TISSUE, WHERE TREATMENT WILL RESULT IN A GREATER THAN 5% 5-YEAR SURVIVAL (See Guideline Notes 2, 3)" "MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY" 225 "CANCER OF BREAST, WHERE TREATMENT WILL RESULT IN A GREATER THAN 5% 5-YEAR SURVIVAL (See Codinging Specification Below) (See Guideline Notes 2, 3, 14)" "MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY, RADIATION THERAPY AND BREAST RECONSTRUCTION" 226 "CANCER OF OVARY, WHERE TREATMENT WILL RESULT IN A GREATER THAN 5% 5-YEAR SURVIVAL (See Guideline Notes 2, 3)" "MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY" 227 UNDESCENDED TESTICLE SURGICAL TREATMENT 228 "CANCER OF PENIS AND OTHER MALE GENITAL ORGAN, WHERE TREATMENT WILL RESULT IN A GREATER THAN 5% 5-YEAR SURVIVAL (See Guideline Notes 2, 3)" "MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY" 229 "CANCER OF VAGINA, VULVA AND OTHER FEMALE GENITAL ORGANS, WHERE TREATMENT WILL RESULT IN A GREATER THAN 5% 5-YEAR SURVIVAL (See Guideline Notes 2, 3)" "MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY" 230 "CHORIOCARCINOMA, WHERE TREATMENT WILL RESULT IN A GREATER THAN 5% 5-YEAR SURVIVAL (See Guideline Notes 2, 3)" "MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY" 231 "CANCER OF BONES, WHERE TREATMENT WILL RESULT IN A GREATER THAN 5% 5-YEAR SURVIVAL (See Guideline Notes 1, 2, 3)" "MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY" 232 "CANCER OF BLADDER AND URETER, WHERE TREATMENT WILL RESULT IN A GREATER THAN 5% 5-YEAR SURVIVAL (See Guideline Notes 2, 3)" "MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY" 233 "CANCER OF RETROPERITONEUM, PERITONEUM, OMENTUM AND MESENTERY, WHERE TREATMENT WILL RESULT IN A GREATER THAN 5% 5-YEAR SURVIVAL (See Guideline Notes 2, 3)" "MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY" 234 "CANCER OF ORAL CAVITY, PHARYNX, NOSE AND LARYNX, WHERE TREATMENT WILL RESULT IN A GREATER THAN 5% 5-YEAR SURVIVAL (See Guideline Notes 2, 3)" "MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY" 235 PORTAL VEIN THROMBOSIS MEDICAL AND SURGICAL TREATMENT 236 PARALYTIC ILEUS MEDICAL AND SURGICAL TREATMENT 237 TRAUMATIC AMPUTATION OF LEG(S) (COMPLETE)(PARTIAL) WITH AND WITHOUT COMPLICATION (See Guideline Note 1) MEDICAL AND SURGICAL TREATMENT 238 "TRAUMATIC AMPUTATION OF ARM(S), HAND(S) THUMB(S) AND FINGER(S) (COMPLETE)(PARTIAL) WITH AND WITHOUT COMPLICATION (See Guideline Note 1)" MEDICAL AND SURGICAL TREATMENT 239 IRON DEFICIENCY ANEMIA AND OTHER NUTRITIONAL DEFICIENCIES MEDICAL THERAPY 240 PHYSICAL AND SEXUAL ABUSE INCLUDING RAPE MEDICAL THERAPY 241 ACUTE STRESS DISORDER MEDICAL/PSYCHOTHERAPY 242 SEPARATION ANXIETY DISORDER MEDICAL/PSYCHOTHERAPY 243 PERITONSILLAR ABSCESS "INCISION AND DRAINAGE OF ABSCESS, MEDICAL THERAPY" 244 CANCRUM ORIS MEDICAL THERAPY 245 OCCLUSION AND STENOSIS OF PRECEREBRAL ARTERIES MEDICAL AND SURGICAL TREATMENT 246 ACUTE GLOMERULONEPHRITIS AND OTHER ACUTE RENAL FAILURE (See Guideline Note 2) MEDICAL THERAPY INCLUDING DIALYSIS 247 NEPHROTIC SYNDROME AND OTHER RENAL DISORDERS (See Guideline Note 2) MEDICAL THERAPY INCLUDING DIALYSIS 248 "CYSTICERCOSIS, OTHER CESTODE INFECTION, TRICHINOSIS" MEDICAL THERAPY 249 "POISONING BY INGESTION, INJECTION, AND NON-MEDICINAL AGENTS" MEDICAL THERAPY 250 METABOLIC DISORDERS INCLUDING HYPERLIPIDEMIA MEDICAL THERAPY 251 "HEREDITARY FRUCTOSE INTOLERANCE, INTESTINAL DISACCHARIDASE AND OTHER DEFICIENCIES" MEDICAL THERAPY 252 INTESTINAL MALABSORPTION MEDICAL THERAPY 253 DELIRIUM DUE TO MEDICAL CAUSES MEDICAL THERAPY 254 PERNICIOUS AND SIDEROBLASTIC ANEMIA MEDICAL THERAPY 255 DISSEMINATED INTRAVASCULAR COAGULATION MEDICAL AND SURGICAL TREATMENT 256 DIVERTICULITIS OF COLON "COLON RESECTION, MEDICAL THERAPY" 257 CYST AND PSEUDOCYST OF PANCREAS DRAINAGE OF PANCREATIC CYST 258 ACUTE POLIOMYELITIS (See Guideline Note 1) MEDICAL THERAPY 259 SYSTEMIC SCLEROSIS MEDICAL THERAPY 260 SUBSTANCE-INDUCED DELIRIUM MEDICAL THERAPY 261 "ACUTE AND SUBACUTE ISCHEMIC HEART DISEASE, MYOCARDIAL INFARCTION (See Guideline Notes 1, 15)" MEDICAL AND SURGICAL TREATMENT 262 "TERMINAL ILLNESS REGARDLESS OF DIAGNOSIS (See Guideline Notes 2, 3, 16)" COMFORT CARE 263 ADJUSTMENT DISORDERS MEDICAL/PSYCHOTHERAPY 264 OPPOSITIONAL DEFIANT DISORDER MEDICAL/PSYCHOTHERAPY 265 TOURETTE'S DISORDER AND TIC DISORDERS MEDICAL/PSYCHOTHERAPY 266 "ANAL, RECTAL AND COLONIC POLYPS" EXCISION OF POLYP 267 TRANSIENT CEREBRAL ISCHEMIA MEDICAL THERAPY 268 "DYSPLASIA OF CERVIX AND CERVICAL CARCINOMA IN SITU, CERVICAL CONDYLOMA" MEDICAL AND SURGICAL TREATMENT 269 ANOGENITAL VIRAL WARTS MEDICAL THERAPY 270 "CANCER OF COLON, RECTUM, SMALL INTESTINE AND ANUS, WHERE TREATMENT WILL RESULT IN A GREATER THAN 5% 5-YEAR SURVIVAL (See Guideline Notes 2, 3, 17)" "MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY" 271 "CANCER OF CERVIX, WHERE TREATMENT WILL RESULT IN A GREATER THAN 5% 5-YEAR SURVIVAL (See Guideline Notes 2, 3)" "MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY" 272 "CANCER OF LUNG, BRONCHUS, PLEURA, TRACHEA, MEDIASTINUM AND OTHER RESPIRATORY ORGANS, WHERE TREATMENT WILL RESULT IN A GREATER THAN 5% 5-YEAR SURVIVAL (See Guideline Notes 2, 3, 4)" "MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY" 273 "CANCER OF PROSTATE GLAND, WHERE TREATMENT WILL RESULT IN A GREATER THAN 5% 5-YEAR SURVIVAL (See Guideline Notes 2, 3)" "MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY" 274 "CANCER OF ENDOCRINE SYSTEM, EXCLUDING THYROID, WHERE TREATMENT WILL RESULT IN A GREATER THAN 5% 5-YEAR SURVIVAL; CARCINOID SYNDROME (See Guideline Notes 2, 3)" "MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY" 275 "CANCER OF KIDNEY AND OTHER URINARY ORGANS, WHERE TREATMENT WILL RESULT IN A GREATER THAN 5% 5-YEAR SURVIVAL (See Guideline Notes 2, 3)" "MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY" 276 "CANCER OF STOMACH, WHERE TREATMENT WILL RESULT IN A GREATER THAN 5% 5-YEAR SURVIVAL (See Guideline Notes 2, 3)" "MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY" 277 "CANCER OF BRAIN AND NERVOUS SYSTEM, WHERE TREATMENT WILL RESULT IN A GREATER THAN 5% 5-YEAR SURVIVAL (See Guideline Notes 2, 3)" "LINEAR ACCELERATOR, MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY" 278 ANAEROBIC INFECTIONS REQUIRING HYPERBARIC OXYGEN HYPERBARIC OXYGEN 279 BENIGN NEOPLASM OF PITUITARY GLAND "MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES RADIATION THERAPY" 280 "CUSHING'S SYNDROME; HYPERALDOSTERONISM, OTHER CORTICOADRENAL OVERACTIVITY, MEDULLOADRENAL HYPERFUNCTION" MEDICAL THERAPY/ADRENALECTOMY 281 CHRONIC OBSTRUCTIVE PULMONARY DISEASE MEDICAL THERAPY 282 DISORDERS MINERAL METABOLISM MEDICAL THERAPY 283 INTRACEREBRAL HEMORRHAGE (See Guideline Note 1) MEDICAL THERAPY 284 STROKE (See Guideline Note 1) MEDICAL THERAPY 285 ACUTE PULMONARY HEART DISEASE AND PULMONARY EMBOLI (See Guideline Note 1) MEDICAL AND SURGICAL TREATMENT 286 "DISLOCATION KNEE AND HIP, OPEN (See Guideline Note 1)" SURGICAL TREATMENT 287 "DISLOCATION OF ELBOW, HAND, ANKLE, FOOT, CLAVICLE AND SHOULDER, OPEN (See Guideline Note 1)" SURGICAL TREATMENT 288 ACUTE BRONCHITIS AND BRONCHIOLITIS MEDICAL THERAPY 289 ACUTE PELVIC INFLAMMATORY DISEASE MEDICAL AND SURGICAL TREATMENT 290 URINARY FISTULA SURGICAL TREATMENT 291 ANEURYSM OF PULMONARY ARTERY (See Guideline Note 1) SURGICAL TREATMENT 292 EPILEPSY AND FEBRILE CONVULSIONS MEDICAL THERAPY 293 "REGIONAL ENTERITIS, IDIOPATHIC PROCTOCOLITIS, ULCERATION OF INTESTINE" MEDICAL AND SURGICAL TREATMENT 294 ENTERIC INFECTIONS AND OTHER BACTERIAL FOOD POISONING MEDICAL THERAPY 295 "GIANT CELL ARTERITIS, KAWASAKI DISEASE, HYPERSENSITIVITY ANGIITIS; THROMBOANGIITIS OBLITERANS" MEDICAL THERAPY 296 COMPLICATIONS OF A PROCEDURE USUALLY REQUIRING TREATMENT (See Guideline Note 1) MEDICAL AND SURGICAL TREATMENT 297 TERMINATION OF PREGNANCY (Note: This line item is not priced as part of the list.) INDUCED ABORTION 298 PREVENTIVE DENTAL SERVICES (See Guideline Note 18) CLEANING AND FLUORIDE 299 HEARING LOSS - AGE 5 OR UNDER MEDICAL THERAPY INCLUDING HEARING AIDS 300 SENSORINEURAL HEARING LOSS - AGE 5 OR UNDER (See Guideline Note 19) COCHLEAR IMPLANT 301 POSTTRAUMATIC STRESS DISORDER MEDICAL/PSYCHOTHERAPY 302 OBSESSIVE-COMPULSIVE DISORDERS MEDICAL/PSYCHOTHERAPY 303 BILATERAL ANOMALIES OF EXTERNAL EAR WITH IMPAIRMENT OF HEARING RECONSTRUCT OF EAR CANAL 304 GENERALIZED CONVULSIVE OR PARTIAL EPILEPSY WITHOUT MENTION OF IMPAIRMENT OF CONSCIOUSNESS (See Guideline Note 4) SINGLE FOCAL SURGERY 305 "CANDIDIASIS OF LUNG, DISSEMINATED CANDIDIASIS, CANDIDAL ENDOCARDITIS AND MENINGITIS" MEDICAL THERAPY 306 "COCCIDIOIDOMYCOSIS, HISTOPLASMOSIS, BLASTOMYCOTIC INFECTION, OPPORTUNISTIC AND OTHER MYCOSES" MEDICAL THERAPY 307 TETANUS MEDICAL THERAPY 308 EBSTEIN'S ANOMALY REPAIR SEPTAL DEFECT/VALVULOPLASTY/REPLACEMENT 309 DISSEMINATED INFECTIONS WITH LOCALIZED SITES MEDICAL THERAPY 310 DISEASES AND DISORDERS OF AORTIC VALVE (See Guideline Note 1) "AORTIC VALVE REPLACEMENT, VALVULOPLASTY, MEDICAL THERAPY" 311 TYPE II DIABETES MELLITUS (Guideline Note 2) MEDICAL THERAPY 312 POLYARTERITIS NODOSA AND ALLIED CONDITIONS MEDICAL THERAPY 313 SARCOIDOSIS MEDICAL THERAPY 314 "DERMATOMYOSITIS, POLYMYOSITIS" MEDICAL THERAPY 315 "ATRIAL SEPTAL DEFECT, SECUNDUM (See Guideline Note 1)" REPAIR SEPTAL DEFECT 316 DISEASES OF MITRAL VALVE AND TRICUSPID VALVES (See Guideline Note 1) "VALVULOPLASTY, VALVE REPLACEMENT, MEDICAL THERAPY" 317 ATELECTASIS (COLLAPSE OF LUNG) MEDICAL THERAPY 318 "TOXIC EFFECT OF GASES, FUMES, AND VAPORS REQUIRING HYPERBARIC OXYGEN" HYPERBARIC OXYGEN 319 "ACQUIRED HYPOTHYROIDISM, DYSHORMONOGENIC GOITER" MEDICAL THERAPY 320 CARDIAC ARRHYTHMIAS (See Guideline Note 1) "MEDICAL THERAPY, PACEMAKER" 321 MULTIPLE VALVULAR DISEASE (See Guideline Note 1) SURGICAL TREATMENT 322 TRAUMATIC AMPUTATION OF FOOT/FEET (COMPLETE)(PARTIAL) WITH AND WITHOUT COMPLICATION (See Guideline Note 1) MEDICAL AND SURGICAL TREATMENT 323 BRACHIAL PLEXUS LESIONS MEDICAL THERAPY 324 "SPINAL DEFORMITY, CLINICALLY SIGNIFICANT (See Guideline Note 1, 20)" MEDICAL AND SURGICAL TREATMENT 325 DISORDERS OF PLASMA PROTEIN METABOLISM MEDICAL THERAPY 326 "ACUTE NON-LYMPHOCYTIC LEUKEMIAS (See Guideline Notes 2, 3)" "MEDICAL THERAPY, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY" 327 "CHRONIC RHEUMATIC PERICARDITIS, RHEUMATIC MYOCARDITIS (See Guideline Note 1)" MEDICAL THERAPY 328 ACUTE NECROSIS OF LIVER MEDICAL THERAPY 329 "CHRONIC HEPATITIS, INCLUDING CHRONIC VIRAL HEPATITIS B AND C" MEDICAL THERAPY 330 ACUTE PANCREATITIS MEDICAL THERAPY 331 DERMATOLOGICAL PREMALIGNANT LESIONS AND CARCINOMA IN SITU DESTRUCT/EXCISION/MEDICAL THERAPY 332 ESOPHAGITIS; ESOPHAGEAL AND INTRAESPHAGEAL HERNIAS SURGICAL TREATMENT 333 NEUROLOGICAL DYSFUNCTION IN POSTURE AND MOVEMENT CAUSED BY CHRONIC CONDITIONS (See Guideline Notes 1) MEDICAL AND SURGICAL TREATMENT (EG. DURABLE MEDICAL EQUIPMENT AND ORTHOPEDIC PROCEDURE) 334 ACUTE THYROIDITIS MEDICAL THERAPY 335 "SYSTEMIC LUPUS ERYTHEMATOSUS, OTHER DIFFUSE DISEASES OF CONNECTIVE TISSUE" MEDICAL THERAPY 336 WEGENER'S GRANULOMATOSIS MEDICAL THERAPY 337 PANIC DISORDER; AGORAPHOBIA MEDICAL/PSYCHOTHERAPY 338 "DISORDERS OF ARTERIES, OTHER THAN CAROTID OR CORONARY" MEDICAL AND SURGICAL TREATMENT 339 LEPTOSPIROSIS MEDICAL THERAPY 340 AMEBIASIS MEDICAL THERAPY 341 ZOONOTIC BACTERIAL DISEASES MEDICAL THERAPY 342 FRACTURE OF FACE BONES; INJURY TO OPTIC AND OTHER CRANIAL NERVES SURGICAL TREATMENT 343 BENIGN NEOPLASM OF RESPIRATORY AND INTRATHORACIC ORGANS "LOBECTOMY, MEDICAL THERAPY, WHICH INCLUDES RADIATION THERAPY" 344 DYSTONIA (UNCONTROLLABLE) MEDICAL THERAPY 345 "ATHEROSCLEROSIS, AORTIC AND RENAL" MEDICAL AND SURGICAL TREATMENT 346 "CANCER OF SKIN, EXCLUDING MALIGNANT MELANOMA, WHERE TREATMENT WILL RESULT IN A GREATER THAN 5% 5-YEAR SURVIVAL (See Guideline Notes 2, 3)" MEDICAL AND SURGICAL TREATMENT 347 SLEEP APNEA (See Guideline Note 21) MEDICAL AND SURGICAL TREATMENT 348 LIFE-THREATENING EPISTAXIS SEPTOPLASTY/REPAIR/CONTROL HEMORRHAGE 349 "SIALOADENITIS, ABSCESS, FISTULA OF SALIVARY GLANDS" SURGICAL TREATMENT 350 CHRONIC ULCER OF SKIN MEDICAL AND SURGICAL TREATMENT 351 "ABSCESS AND CELLULITIS, NON-ORBITAL" MEDICAL AND SURGICAL TREATMENT 352 BREAST CYSTS AND OTHER DISORDERS OF THE BREAST MEDICAL AND SURGICAL TREATMENT 353 PILONIDAL CYST WITH ABSCESS MEDICAL AND SURGICAL TREATMENT 354 DENTAL SERVICES (EG. INFECTIONS) (See Guideline Note 22) URGENT AND EMERGENT DENTAL SERVICES 355 ABSCESS OF BURSA OR TENDON INCISION AND DRAINAGE 356 ABSCESS OF PROSTATE "TURP, DRAIN ABSCESS" 357 OTHER ANEURYSM OF PERIPHERAL ARTERY SURGICAL TREATMENT 358 "PYODERMA; PSORIASIS, STAGE III AND IV (See Guideline Note 23)" MEDICAL THERAPY 359 URINARY TRACT CALCULUS "CYSTOURETHROSCOPY WITH FRAGMENTATION OF CALCULUS, MEDICAL THERAPY" 360 "CONDITIONS INVOLVING EXPOSURE TO NATURAL ELEMENTS (EG. LIGHTNING STRIKE, HEATSTROKE)" "MEDICAL THERAPY, BURN TREATMENT" 361 VESICOURETERAL REFLUX "MEDICAL THERAPY, REIMPLANTATION" 362 CALCULUS OF BLADDER OR KIDNEY "OPEN RESECTION, PERCUTANEOUS NEPHROSTOLITHOTOMY, NEPHROLITHOTOMY, LITHOTRIPSY" 363 "CHOLELITHIASIS, CHOLECYSTITIS, COMMON BILIARY DUCT STONE" MEDICAL AND SURGICAL TREATMENT 364 URETERAL STRICTURE OR OBSTRUCTION; HYDRONEPHROSIS; HYDROURETER MEDICAL AND SURGICAL TREATMENT 365 CONGENITAL HYDRONEPHROSIS NEPHRECTOMY/REPAIR 366 "ATHEROSCLEROSIS, PERIPHERAL (See Guideline Note 1)" SURGICAL TREATMENT 367 HYPOPLASTIC LEFT HEART SYNDROME REPAIR 368 CONGENITAL PULMONARY VALVE STENOSIS PULMONARY VALVE REPAIR 369 RHEUMATOID ARTHRITIS AND OTHER INFLAMMATORY POLYARTHROPATHIES (See Guideline Note 1) "MEDICAL THERAPY, INJECTIONS" 370 "RHEUMATOID ARTHRITIS, OSTEOARTHRITIS, OSTEOCHONDRITIS DISSECANS, AND ASEPTIC NECROSIS OF BONE (See Guideline Notes 1, 11)" ARTHROPLASTY/RECONSTRUCTION 371 "CONDUCT DISORDER, AGE 18 OR UNDER (See Guideline Note 24)" MEDICAL/PSYCHOTHERAPY 372 "OVERANXIOUS DISORDER; GENERALIZED ANXIETY DISORDER; ANXIETY DISORDER, UNSPECIFIED" MEDICAL/PSYCHOTHERAPY 373 BULIMIA NERVOSA MEDICAL/PSYCHOTHERAPY 374 ESOPHAGITIS MEDICAL THERAPY 375 DEEP OPEN WOUNDS "REPAIR, SURGICAL TREATMENT" 376 EPIDERMOLYSIS BULLOSA MEDICAL THERAPY 377 CLEFT PALATE AND/OR CLEFT LIP "EXCISION AND REPAIR VESTIBULE OF MOUTH, ORTHODONTICS" 378 TRACHOMA MEDICAL THERAPY 379 "LEPROSY, YAWS, PINTA" MEDICAL THERAPY 380 RHEUMATIC FEVER (See Guideline Note 1) MEDICAL THERAPY 381 "UNSPECIFIED DISEASES DUE TO MYCOBACTERIA, ACTINOMYCOTIC INFECTIONS, AND TOXOPLASMOSIS" MEDICAL THERAPY 382 "ACUTE, SUBACUTE, CHRONIC AND OTHER TYPES OF IRIDOCYCLITIS" MEDICAL THERAPY 383 "BODY INFESTATIONS (EG. LICE, SCABIES)" MEDICAL THERAPY 384 DELUSIONAL DISORDER MEDICAL/PSYCHOTHERAPY 385 RECURRENT EROSION OF THE CORNEA "CORNEAL TATTOO, REMOVAL OF CORNEAL EPITHELIUM; WITH OR WITHOUT CHEMOCAUTERIZATION" 386 "GIARDIASIS, INTESTINAL HELMINTHIASIS" MEDICAL THERAPY 387 HYPHEMA REMOVAL OF BLOOD CLOT 388 WOUND OF EYE GLOBE SURGICAL REPAIR 389 DIABETIC AND OTHER RETINOPATHY LASER SURGERY 390 GLAUCOMA MEDICAL THERAPY 391 PRIMARY AND OTHER ANGLE-CLOSURE GLAUCOMA "IRIDECTOMY, LASER SURGERY" 392 RETINAL TEAR LASER PROPHYLAXIS 393 RETROLENTAL FIBROPLASIA CRYOSURGERY 394 VENOUS TRIBUTARY (BRANCH) OCCLUSION; CENTRAL RETINAL VEIN OCCLUSION LASER SURGERY 395 SICCA SYNDROME; POLYMYALGIA RHEUMATICA MEDICAL AND SURGICAL TREATMENT 396 PURULENT ENDOPHTHALMITIS VITRECTOMY 397 "KERATOCONJUNCTIVITIS, CORNEAL ABSCESS AND NEOVASCULARIZATION" MEDICAL AND SURGICAL TREATMENT 398 SCLERITIS MEDICAL THERAPY 399 APHAKIA AND OTHER DISORDERS OF LENS INTRAOCULAR LENS 400 CORNEAL ULCER; SUPERFICIAL INJURY OF EYE AND ADNEXA CONJUNCTIVAL FLAP; MEDICAL THERAPY 401 GLAUCOMA ASSOCIATED WITH DISORDERS OF THE LENS EXTRACTION OF CATARACT 402 EXOPHTHALMOS AND CYSTS OF THE EYE AND ORBIT SURGICAL TREATMENT 403 PRIMARY AND OPEN ANGLE GLAUCOMA "TRABECULECTOMY, CYCLOCRYOTHERAPY, LASER TRABECULOPLASTY" 404 RUBEOSIS IRIDIS LASER SURGERY 405 SYMPATHETIC UVEITIS AND DEGENERATIVE DISORDERS AND CONDITIONS OF GLOBE ENUCLEATION 406 "CATARACT, EXCLUDING CONGENITAL (See Guideline Note 25)" EXTRACTION OF CATARACT 407 AFTER CATARACT "DISCISSION, LENS CAPSULE" 408 CORNEAL OPACITY AND OTHER DISORDERS OF CORNEA KERATOPLASTY 409 DEGENERATION OF MACULA AND POSTERIOR POLE (See Guideline Note 26) "VITRECTOMY, LASER SURGERY" 410 GONOCOCCAL INFECTION OF EYE MEDICAL THERAPY 411 CHRONIC INFLAMMATORY DISORDER OF ORBIT MEDICAL THERAPY 412 PENETRATING WOUND OF ORBIT MEDICAL AND SURGICAL TREATMENT 413 "RETAINED INTRAOCULAR FOREIGN BODY, MAGNETIC AND NONMAGNETIC" FOREIGN BODY REMOVAL 414 RETINAL DETACHMENT AND OTHER RETINAL DISORDERS "RETINAL REPAIR, VITRECTOMY" 415 VITREOUS DISORDERS VITRECTOMY 416 ENTROPION REPAIR 417 CHRONIC DEPRESSION MEDICAL/PSYCHOTHERAPY 418 SUBSTANCE-INDUCED DELUSIONAL AND MOOD DISORDERS; INTOXICATION MEDICAL/PSYCHOTHERAPY 419 BORDERLINE PERSONALITY DISORDER MEDICAL/PSYCHOTHERAPY 420 SCHIZOTYPAL PERSONALITY DISORDERS MEDICAL/PSYCHOTHERAPY 421 ACUTE OTITIS MEDIA MEDICAL AND SURGICAL TREATMENT 422 SUPERFICIAL INJURIES WITH INFECTION MEDICAL AND SURGICAL TREATMENT 423 "ACROMEGALY AND GIGANTISM, OTHER AND UNSPECIFIED ANTERIOR PITUITARY HYPERFUNCTION, BENIGN NEOPLASM OF THYROID GLAND AND OTHER ENDOCRINE GLANDS" "MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES RADIATION THERAPY" 424 "CONVERSION DISORDER, CHILD" MEDICAL/PSYCHOTHERAPY 425 FUNCTIONAL ENCOPRESIS MEDICAL/PSYCHOTHERAPY 426 AVOIDANT DISORDER OF CHILDHOOD OR ADOLESCENCE; ELECTIVE MUTISM MEDICAL/PSYCHOTHERAPY 427 "PSYCHOLOGICAL FACTORS AGGRAVATING PHYSICAL CONDITION (EG. ASTHMA, CHRONIC GI CONDITIONS, HYPERTENSION)" MEDICAL/PSYCHOTHERAPY 428 "NONINFLAMMATORY DISORDERS AND BENIGN NEOPLASMS OF OVARY, FALLOPIAN TUBES AND UTERUS, OVARIAN CYSTS" MEDICAL AND SURGICAL TREATMENT 429 STREAK OVARIES "OOPHORECTOMY, OVARIAN CYSTECTOMY" 430 UROLOGIC INFECTIONS MEDICAL THERAPY 431 FUNCTIONAL AND MECHANICAL DISORDERS OF THE GENITOURINARY SYSTEM INCLUDING BLADDER OUTLET OBSTRUCTION (See Coding Specification Below) MEDICAL AND SURGICAL TREATMENT 432 GUILLAIN-BARRE SYNDROME (See Guideline Note 1) MEDICAL THERAPY 433 DEFICIENCIES OF CIRCULATING ENZYMES (ALPHA 1-ANTITRYPSIN DEFICIENCY); CYSTIC FIBROSIS; EMPHYSEMA (See Guideline Note 6) HEART-LUNG AND LUNG TRANSPLANTS 434 "RESPIRATORY FAILURE DUE TO PRIMARY PULMONARY HYPERTENSION, PRIMARY PULMONARY FIBROSIS, LYMPHANGIOLEIOMYOMATOSIS, EISENMENGER'S DISEASE (See Guideline Note 6)" HEART-LUNG AND LUNG TRANSPLANTS 435 DIABETES MELLITUS WITH END STAGE RENAL DISEASE (See Coding Specification Below) (See Guideline Note 6) "SIMULTANEOUS PANCREAS/KIDNEY (SPK) TRANSPLANT, PANCREAS AFTER KIDNEY (PAK) TRANSPLANT" 436 "HEREDITARY IMMUNE DEFICIENCIES (See Guideline Notes 2, 3, 7)" BONE MARROW TRANSPLANT 437 "CONSTITUTIONAL APLASTIC ANEMIAS (See Guideline Notes 2, 3, 7)" BONE MARROW TRANSPLANT 438 "ALCOHOLIC FATTY LIVER OR ALCOHOLIC HEPATITIS, CIRRHOSIS OF LIVER" MEDICAL THERAPY 439 VESICULAR FISTULA MEDICAL AND SURGICAL TREATMENT 440 DISORDERS OF PARATHYROID GLAND; BENIGN NEOPLASM OF PARATHYROID GLAND MEDICAL AND SURGICAL TREATMENT 441 "PANHYPOPITUITARISM, IATROGENIC AND OTHER PITUITARY DISORDERS" MEDICAL THERAPY 442 MULTIPLE SCLEROSIS AND OTHER DEMYELINATING DISEASES OF CENTRAL NERVOUS SYSTEM MEDICAL THERAPY 443 HEREDITARY HEMORRHAGIC TELANGIECTASIA EXCISION 444 ARTHROPOD-BORNE VIRAL DISEASES MEDICAL THERAPY 445 LYME DISEASE AND OTHER ARTHROPOD BORNE DISEASES (See Guideline Note 1) MEDICAL THERAPY 446 DYSFUNCTION RESULTING IN LOSS OF ABILITY TO MAXIMIZE LEVEL OF INDEPENDENCE IN SELF-DIRECTED CARE CAUSED BY CHRONIC CONDITIONS THAT CAUSE NEUROLOGICAL DYSFUNCTION (See Guideline Note 1) MEDICAL THERAPY (SHORT TERM REHABILITATION WITH DEFINED GOALS) 447 NEUROLOGICAL DYSFUNCTION IN COMMUNICATION CAUSED BY CHRONIC CONDITIONS (See Guideline Note 1) MEDICAL THERAPY 448 "PARALYSIS OF VOCAL CORDS OR LARYNX, OTHER DISEASES OF LARYNX; ABSCESS, CELLULITIS, AND LEUKOPLAKIA OF VOCAL CORDS (See Coding Specification Below)" INCISION/EXCISION/ENDOSCOPY 449 OTOSCLEROSIS MEDICAL AND SURGICAL TREATMENT 450 MIGRAINE HEADACHES MEDICAL THERAPY 451 FISTULA INVOLVING FEMALE GENITAL TRACT CLOSURE OF FISTULA 452 STREPTOCOCCAL SORE THROAT AND SCARLET FEVER; VINCENT'S DISEASE; HYPERTROPHY OF TONSILS AND ADENOIDS; ULCER OF TONSIL (See Guideline Note 27) "MEDICAL THERAPY, TONSILLECTOMY/ADENOIDECTOMY" 453 EATING DISORDER NOS MEDICAL/PSYCHOTHERAPY 454 DISSOCIATIVE DISORDERS MEDICAL/PSYCHOTHERAPY 455 CHRONIC ORGANIC MENTAL DISORDERS INCLUDING DEMENTIAS CONSULTATION/MEDICATION MANAGEMENT/LIMITED BEHAVIORAL MODIFICATION 456 LYMPHADENITIS MEDICAL AND SURGICAL TREATMENT 457 SPONTANEOUS ABORTION MEDICAL AND SURGICAL TREATMENT 458 MENSTRUAL BLEEDING DISORDERS (See Guideline Note 28) MEDICAL AND SURGICAL TREATMENT 459 DISORDERS INVOLVING THE IMMUNE SYSTEM MEDICAL THERAPY 460 CLOSED FRACTURE OF EXTREMITIES (EXCEPT TOES) (See Guideline Note 1) OPEN OR CLOSED REDUCTION 461 CHRONIC PANCREATITIS MEDICAL THERAPY 462 STRABISMUS AND OTHER DISORDERS OF BINOCULAR EYE MOVEMENTS; CONGENITAL ANOMALIES OF EYE MEDICAL AND SURGICAL TREATMENT 463 "IMPERFORATE HYMEN, ABNORMALITIES OF VAGINAL SEPTUM" SURGICAL TREATMENT 464 CONGENITAL ABSENCE OF VAGINA ARTIFICIAL VAGINA 465 PARKINSON'S DISEASE MEDICAL THERAPY 466 MENIERE'S DISEASE MEDICAL AND SURGICAL TREATMENT 467 STEREOTYPY/HABIT DISORDER AND SELF-ABUSIVE BEHAVIOR DUE TO NEUROLOGICAL DYSFUNCTION CONSULTATION/MEDICATION MANAGEMENT/LIMITED BEHAVIORAL MODIFICATION 468 BULLOUS DERMATOSES OF THE SKIN MEDICAL THERAPY 469 CHOLESTEATOMA; INFECTIONS OF THE PINNA MEDICAL AND SURGICAL TREATMENT 470 ACUTE SINUSITIS (See Guideline Note 29) MEDICAL AND SURGICAL TREATMENT 471 UTERINE LEIOMYOMA (See Guideline Note 30) TOTAL HYSTERECTOMY OR MYOMECTOMY 472 DISLOCATION / DEFORMITY KNEE AND HIP (See Guideline Note 1) SURGICAL TREATMENT 473 "DISLOCATION/DEFORMITY OF ELBOW, HAND, ANKLE, FOOT, JAW, CLAVICLE AND SHOULDER (See Guideline Note 1)" SURGICAL TREATMENT 474 CLOSED DISLOCATIONS/FRACTURES OF NON-CERVICAL VERTEBRAL COLUMN WITHOUT SPINAL CORD INJURY (See Guideline Note 1) MEDICAL AND SURGICAL TREATMENT 475 "ACHALASIA, NON-NEONATAL" MEDICAL AND SURGICAL TREATMENT 476 BRONCHIECTASIS MEDICAL AND SURGICAL TREATMENT 477 OCCUPATIONAL LUNG DISEASES MEDICAL THERAPY 478 PULMONARY FIBROSIS MEDICAL AND SURGICAL TREATMENT 479 "ANOMALIES OF GALLBLADDER, BILE DUCTS, AND LIVER" MEDICAL AND SURGICAL TREATMENT 480 CHRONIC SINUSITIS (See Guideline Note 29) MEDICAL AND SURGICAL TREATMENT 481 PITUITARY DWARFISM MEDICAL THERAPY 482 FOREIGN BODY IN CORNEA AND CONJUNCTIVAL SAC REMOVAL CONJUNCTIVAL FOREIGN BODY 483 GOUT AND CRYSTAL ARTHROPATHIES MEDICAL THERAPY 484 ENDOMETRIOSIS AND ADENOMYOSIS (See Guideline Note 31) MEDICAL AND SURGICAL TREATMENT 485 "OVARIAN DYSFUNCTION, GONADAL DYSGENISIS, MENOPAUSAL MANAGEMENT" "OOPHORECTOMY, ORCHIECTOMY, HORMONAL REPLACEMENT FOR PURPOSES OTHER THAN INFERTILITY" 486 PERIPHERAL NERVE INJURY WITH OPEN WOUND (See Guideline Note 1) NEUROPLASTY 487 MYASTHENIA GRAVIS "MEDICAL THERAPY, THYMECTOMY" 488 "CANCER OF ESOPHAGUS, WHERE TREATMENT WILL RESULT IN A GREATER THAN 5% 5-YEAR SURVIVAL (See Guideline Notes 2, 3, 32)" "MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY" 489 "CANCER OF LIVER, WHERE TREATMENT WILL RESULT IN A GREATER THAN 5% 5-YEAR SURVIVAL (See Guideline Notes 2, 3, 32)" "MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY" 490 "CANCER OF PANCREAS, WHERE TREATMENT WILL RESULT IN A GREATER THAN 5% 5-YEAR SURVIVAL (See Guideline Notes 2, 3, 32)" "MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY" 491 "CANCER OF GALLBLADDER AND OTHER BILIARY, WHERE TREATMENT WILL RESULT IN A GREATER THAN 5% 5-YEAR SURVIVAL (See Guideline Notes 2, 3, 32)" "MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY" 492 NON-MALIGNANT OTITIS EXTERNA MEDICAL THERAPY 493 ESOPHAGEAL VARICES MEDICAL THERAPY/SHUNT/SCLEROTHERAPY 494 EPISCLERITIS MEDICAL THERAPY 495 "DENTAL CONDITIONS (EG. DENTAL CARIES, FRACTURED TOOTH) (See Guideline Note 33)" BASIC RESTORATIVE 496 DENTAL CONDITIONS (EG. SEVERE TOOTH DECAY) (See Guideline Note 34) "STABILIZATION OF PERIODONTAL HEALTH, COMPLEX RESTORATIVE, AND REMOVABLE PROSTHODONTICS" 497 DISORDERS OF REFRACTION AND ACCOMMODATION MEDICAL THERAPY 498 CENTRAL PTERYGIUM "EXCISION OR TRANSPOSITION OF PTERYGIUM WITHOUT GRAFT, RADIATION THERAPY" 499 HEARING LOSS - OVER AGE OF FIVE MEDICAL THERAPY INCLUDING HEARING AIDS 500 OPEN WOUND OF EAR DRUM "TYMPANOPLASTY, MEDICAL THERAPY" 501 SENSORINEURAL HEARING LOSS - OVER AGE OF FIVE (See Guideline Note 35) COCHLEAR IMPLANT 502 SOMATIZATION DISORDER; SOMATOFORM PAIN DISORDER; PREMENSTRUAL TENSION SYNDROMES CONSULTATION/BEHAVIORAL MANAGEMENT 503 TRIGEMINAL AND OTHER NERVE DISORDERS MEDICAL AND SURGICAL TREATMENT 504 "DISRUPTIONS OF THE LIGAMENTS AND TENDONS OF THE ARMS AND LEGS, EXCLUDING THE KNEE, GRADE II AND III (See Guideline Note 1)" REPAIR 505 DISORDERS OF SHOULDER REPAIR/RECONSTRUCTION 506 "INTERNAL DERANGEMENT OF KNEE AND LIGAMENTOUS DISRUPTIONS OF THE KNEE, GRADE II AND III (See Guideline Note 1)" "REPAIR, MEDICAL THERAPY" 507 MALUNION AND NONUNION OF FRACTURE (See Guideline Note 1) SURGICAL TREATMENT 508 "FOREIGN BODY IN UTERUS, VULVA AND VAGINA" MEDICAL AND SURGICAL TREATMENT 509 UTERINE PROLAPSE; CYSTOCELE (See Guideline Note 36) SURGICAL REPAIR 510 OSTEOARTHRITIS AND ALLIED DISORDERS (See Guideline Note 1) "MEDICAL THERAPY, INJECTIONS" 511 METABOLIC BONE DISEASE MEDICAL THERAPY 512 CYSTS OF BARTHOLIN'S GLAND AND VULVA "INCISION AND DRAINAGE, MEDICAL THERAPY" 513 "CERVICITIS, ENDOCERVICITIS, HEMATOMA OF VULVA, AND NONINFLAMMATORY DISORDERS OF THE VAGINA" MEDICAL AND SURGICAL TREATMENT 514 DENTAL CONDITIONS (EG. TOOTH LOSS) (See Guideline Note 37) SPACE MAINTENANCE AND PERIODONTAL MAINTENANCE 515 URINARY INCONTINENCE (See Guideline Note 38) MEDICAL AND SURGICAL TREATMENT 516 HYPOSPADIAS AND EPISPADIAS REPAIR 517 RESIDUAL FOREIGN BODY IN SOFT TISSUE REMOVAL 518 BRANCHIAL CLEFT CYST "EXCISION, MEDICAL THERAPY" 519 PTOSIS (ACQUIRED) WITH VISION IMPAIRMENT PTOSIS REPAIR 520 SIMPLE AND SOCIAL PHOBIAS MEDICAL/PSYCHOTHERAPY 521 PERIPHERAL NERVE ENTRAPMENT MEDICAL AND SURGICAL TREATMENT 522 INCONTINENCE OF FECES MEDICAL AND SURGICAL TREATMENT 523 RECTAL PROLAPSE PARTIAL COLECTOMY 524 BENIGN NEOPLASM OF KIDNEY AND OTHER URINARY ORGANS MEDICAL AND SURGICAL TREATMENT 525 URETHRAL FISTULA "EXCISION, MEDICAL THERAPY" 526 THROMBOSED AND COMPLICATED HEMORRHOIDS "HEMORRHOIDECTOMY, INCISION" 527 "VAGINITIS, TRICHOMONIASIS" MEDICAL THERAPY 528 BALANOPOSTHITIS AND OTHER DISORDERS OF PENIS MEDICAL AND SURGICAL TREATMENT 529 CHRONIC ANAL FISSURE (See Guideline Note 39); ANAL FISTULA "SPHINCTEROTOMY, FISSURECTOMY, FISTULECTOMY, MEDICAL THERAPY" 530 CHRONIC OTITIS MEDIA (See Guideline Note 40) "PE TUBES/ADENOIDECTOMY/TYMPANOPLASTY, MEDICAL THERAPY" 531 ACUTE CONJUNCTIVITIS MEDICAL THERAPY 532 "CERUMEN IMPACTION, FOREIGN BODY IN EAR AND NOSE" REMOVAL OF FOREIGN BODY 533 VERTIGINOUS SYNDROMES AND OTHER DISORDERS OF VESTIBULAR SYSTEM MEDICAL AND SURGICAL TREATMENT 534 UNSPECIFIED URINARY OBSTRUCTION AND BENIGN PROSTATIC HYPERPLASIA WITHOUT OBSTRUCTION MEDICAL THERAPY 535 PHIMOSIS SURGICAL TREATMENT 536 "CONTACT DERMATITIS, ATOPIC DERMATITIS AND OTHER ECZEMA" MEDICAL THERAPY 537 "PSORIASIS, STAGE I AND II (See Guideline Note 41), DERMATOPHYTOSIS: SCALP, HAND, BODY, DEEP-SEATED" MEDICAL THERAPY 538 CYSTIC ACNE MEDICAL AND SURGICAL TREATMENT 539 CLOSED FRACTURE OF GREAT TOE MEDICAL AND SURGICAL TREATMENT 540 SYMPTOMATIC URTICARIA MEDICAL THERAPY 541 "DYSFUNCTION OF NASOLACRIMAL SYSTEM, LACRIMAL SYSTEM LACERATION" MEDICAL AND SURGICAL TREATMENT 542 "NASAL POLYPS, OTHER DISORDERS OF NASAL CAVITY AND SINUSES (See Guideline Note 29)" MEDICAL AND SURGICAL TREATMENT 543 "SIALOLITHIASIS, MUCOCELE, DISTURBANCE OF SALIVARY SECRETION, OTHER AND UNSPECIFIED DISEASES OF SALIVARY GLANDS" MEDICAL AND SURGICAL TREATMENT 544 DENTAL CONDITIONS (EG. BROKEN APPLIANCES) PERIODONTICS AND COMPLEX PROSTHETICS 545 IMPULSE DISORDERS (See Guideline Note 42) MEDICAL/PSYCHOTHERAPY 546 BENIGN NEOPLASM BONE AND ARTICULAR CARTILAGE INCLUDING OSTEOID OSTEOMAS; BENIGN NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE (See Guideline Note 1) MEDICAL AND SURGICAL TREATMENT 547 SEXUAL DYSFUNCTION "PSYCHOTHERAPY, MEDICAL AND SURGICAL TREATMENT" 548 STOMATITIS AND DISEASES OF LIPS "INCISION AND DRAINAGE, MEDICAL THERAPY" 549 "BELL'S PALSY, EXPOSURE KERATOCONJUNCTIVITIS" TARSORRHAPHY 550 HORDEOLUM AND OTHER DEEP INFLAMMATION OF EYELID; CHALAZION "INCISION AND DRAINAGE, MEDICAL THERAPY" 551 "ECTROPION, TRICHIASIS OF EYELID, BENIGN NEOPLASM OF EYELID" ECTROPION REPAIR 552 CHONDROMALACIA (See Guideline Note 1) MEDICAL THERAPY 553 DYSMENORRHEA (See Guideline Note 43) MEDICAL AND SURGICAL TREATMENT 554 SPASTIC DIPLEGIA RHIZOTOMY 555 ATROPHY OF EDENTULOUS ALVEOLAR RIDGE "VESTIBULOPLASTY, GRAFTS, IMPLANTS" 556 DEFORMITIES OF UPPER BODY AND ALL LIMBS REPAIR/REVISION/RECONSTRUCTION/RELOCATION/MEDICAL THERAPY 557 DEFORMITIES OF FOOT FASCIOTOMY/INCISION/REPAIR/ARTHRODESIS 558 PERITONEAL ADHESION SURGICAL TREATMENT 559 "PELVIC PAIN SYNDROME, DYSPAREUNIA (See Guideline Note 44)" MEDICAL AND SURGICAL TREATMENT 560 TENSION HEADACHES MEDICAL THERAPY 561 CHRONIC BRONCHITIS MEDICAL THERAPY 562 DISORDERS OF FUNCTION OF STOMACH AND OTHER FUNCTIONAL DIGESTIVE DISORDERS MEDICAL THERAPY 563 TMJ DISORDER TMJ SPLINTS 564 "URETHRITIS, NON-SEXUALLY TRANSMITTED" MEDICAL THERAPY 565 LESION OF PLANTAR NERVE; PLANTAR FASCIAL FIBROMATOSIS "MEDICAL THERAPY, EXCISION" 566 "GRANULOMA OF MUSCLE, GRANULOMA OF SKIN AND SUBCUTANEOUS TISSUE" REMOVAL OF GRANULOMA 567 "DERMATOPHYTOSIS OF NAIL, GROIN AND FOOT AND OTHER DERMATOMYCOSIS" MEDICAL AND SURGICAL TREATMENT 568 INTERNAL DERANGEMENT OF JOINT OTHER THAN KNEE (See Guideline Note 1) "REPAIR, MEDICAL THERAPY" 569 STENOSIS OF NASOLACRIMAL DUCT (ACQUIRED) DACRYOCYSTORHINOSTOMY 570 PERIPHERAL NERVE DISORDERS SURGICAL TREATMENT 571 CAVUS DEFORMITY OF FOOT; FLAT FOOT; POLYDACTYLY AND SYNDACTYLY OF TOES "MEDICAL THERAPY, ORTHOTIC" 572 PERIPHERAL ENTHESOPATHIES SURGICAL TREATMENT 573 PERIPHERAL ENTHESOPATHIES (See Guideline Note 1) MEDICAL THERAPY 574 DISORDERS OF SOFT TISSUE MEDICAL THERAPY 575 ENOPHTHALMOS ORBITAL IMPLANT 576 MACROMASTIA "SUBCUTANEOUS TOTAL MASTECTOMY, BREAST REDUCTION" 577 "GALACTORRHEA, MASTODYNIA, ATROPHY, BENIGN NEOPLASMS AND UNSPECIFIED DISORDERS OF THE BREAST" MEDICAL AND SURGICAL TREATMENT 578 "ACUTE AND CHRONIC DISORDERS OF SPINE WITHOUT NEUROLOGIC IMPAIRMENT (See Guideline Notes 1, 45)" MEDICAL AND SURGICAL TREATMENT 579 CYSTS OF ORAL SOFT TISSUES INCISION AND DRAINAGE 580 POSTCONCUSSION SYNDROME MEDICAL THERAPY 581 "SIMPLE AND UNSPECIFIED GOITER, NONTOXIC NODULAR GOITER" "MEDICAL THERAPY, THYROIDECTOMY" 582 CONDUCTIVE HEARING LOSS AUDIANT BONE CONDUCTORS 583 CANCER OF LIVER AND INTRAHEPATIC BILE DUCTS (See Guideline Note 6) LIVER TRANSPLANT 584 HYPOTENSION MEDICAL THERAPY 585 "VIRAL HEPATITIS, EXCLUDING CHRONIC VIRAL HEPATITIS B AND VIRAL HEPATITIS C (See Statement of Intent)" MEDICAL THERAPY 586 BENIGN NEOPLASMS OF SKIN AND OTHER SOFT TISSUES MEDICAL THERAPY 587 REDUNDANT PREPUCE ELECTIVE CIRCUMCISION 588 BENIGN NEOPLASMS OF DIGESTIVE SYSTEM SURGICAL TREATMENT 589 OTHER NONINFECTIOUS GASTROENTERITIS AND COLITIS (See Statement of Intent) MEDICAL THERAPY 590 FACTITIOUS DISORDERS CONSULTATION 591 HYPOCHONDRIASIS; SOMATOFORM DISORDER; NOS AND UNDIFFERENTIATED CONSULTATION 592 "CONVERSION DISORDER, ADULT" MEDICAL/PSYCHOTHERAPY 593 "SPINAL DEFORMITY, NOT CLINICALLY SIGNIFICANT (See Guideline Note 46)" "ARTHRODESIS/REPAIR/RECONSTRUCTION, MEDICAL THERAPY" 594 ASYMPTOMATIC URTICARIA MEDICAL THERAPY 595 CIRCUMSCRIBED SCLERODERMA; SENILE PURPURA MEDICAL THERAPY 596 DERMATITIS DUE TO SUBSTANCES TAKEN INTERNALLY MEDICAL THERAPY 597 "ALLERGIC RHINITIS AND CONJUNCTIVITIS, CHRONIC RHINITIS" MEDICAL THERAPY 598 PLEURISY MEDICAL THERAPY 599 CONJUNCTIVAL CYST EXCISION OF CONJUNCTIVAL CYST 600 HEMATOMA OF AURICLE OR PINNA AND HEMATOMA OF EXTERNAL EAR DRAINAGE 601 ACUTE NON-SUPPURATIVE LABYRINTHITIS MEDICAL THERAPY 602 INFECTIOUS MONONUCLEOSIS MEDICAL THERAPY 603 ASEPTIC MENINGITIS (See Statement of Intent) MEDICAL THERAPY 604 CONGENITAL ANOMALIES OF FEMALE GENITAL ORGANS EXCLUDING VAGINA SURGICAL TREATMENT 605 CONGENITAL DEFORMITIES OF KNEE ARTHROSCOPIC REPAIR 606 UNCOMPLICATED HERNIA REPAIR 607 ACUTE ANAL FISSURE "FISSURECTOMY, MEDICAL THERAPY" 608 "CYST OF KIDNEY, ACQUIRED" MEDICAL AND SURGICAL TREATMENT 609 PICA MEDICAL/PSYCHOTHERAPY 610 DISORDERS OF SLEEP WITHOUT SLEEP APNEA MEDICAL THERAPY 611 "CYST, HEMORRHAGE, AND INFARCTION OF THYROID" SURGICAL TREATMENT 612 "DEVIATED NASAL SEPTUM, ACQUIRED DEFORMITY OF NOSE, OTHER DISEASES OF UPPER RESPIRATORY TRACT" EXCISION OF CYST/RHINECTOMY/PROSTHESIS 613 ERYTHEMA MULTIFORME MEDICAL THERAPY 614 HERPES SIMPLEX WITHOUT COMPLICATIONS MEDICAL THERAPY 615 CONGENITAL ANOMALIES OF THE EAR WITHOUT IMPAIRMENT OF HEARING; UNILATERAL ANOMALIES OF THE EAR "OTOPLASTY, REPAIR AND AMPUTATION" 616 BLEPHARITIS MEDICAL THERAPY 617 HYPERTELORISM OF ORBIT ORBITOTOMY 618 "KERATODERMA, ACANTHOSIS NIGRICANS, STRIAE ATROPHICAE, AND OTHER HYPERTROPHIC OR ATROPHIC CONDITIONS OF SKIN" MEDICAL THERAPY 619 LICHEN PLANUS MEDICAL THERAPY 620 OBESITY NUTRITIONAL AND LIFE STYLE COUNSELING 621 MORBID OBESITY GASTROPLASTY 622 CHRONIC DISEASE OF TONSILS AND ADENOIDS TONSILLECTOMY AND ADENOIDECTOMY 623 HYDROCELE "MEDICAL THERAPY, EXCISION" 624 KELOID SCAR; OTHER ABNORMAL GRANULATION TISSUE "INTRALESIONAL INJECTIONS/DESTRUCTION/EXCISION, RADIATION THERAPY" 625 NONINFLAMMATORY DISORDERS OF CERVIX; HYPERTROPHY OF LABIA MEDICAL THERAPY 626 "SPRAINS OF JOINTS AND ADJACENT MUSCLES, GRADE I (See Guideline Note 1)" MEDICAL THERAPY 627 SYNOVITIS AND TENOSYNOVITIS (See Guideline Note 1) MEDICAL THERAPY 628 "OTHER DISORDERS OF SYNOVIUM, TENDON AND BURSA, COSTOCHONDRITIS, AND CHONDRODYSTROPHY" MEDICAL THERAPY 629 "DISEASE OF NAILS, HAIR AND HAIR FOLLICLES" MEDICAL THERAPY 630 "CANDIDIASIS OF MOUTH, SKIN AND NAILS" MEDICAL THERAPY 631 BENIGN LESIONS OF TONGUE EXCISION 632 MINOR BURNS MEDICAL THERAPY 633 MINOR HEAD INJURY: HEMATOMA/EDEMA WITH NO LOSS OF CONSCIOUSNESS MEDICAL THERAPY 634 CONGENITAL DEFORMITY OF KNEE MEDICAL THERAPY 635 "PHLEBITIS AND THROMBOPHLEBITIS, SUPERFICIAL" MEDICAL THERAPY 636 PROLAPSED URETHRAL MUCOSA SURGICAL TREATMENT 637 RUPTURE OF SYNOVIUM REMOVAL OF BAKER'S CYST 638 "PERSONALITY DISORDERS EXCLUDING BORDERLINE, SCHIZOTYPAL AND ANTI-SOCIAL" MEDICAL/PSYCHOTHERAPY 639 "GENDER IDENTIFICATION DISORDER, PARAPHILIAS AND OTHER PSYCHOSEXUAL DISORDERS" MEDICAL/PSYCHOTHERAPY 640 FINGERTIP AVULSION REPAIR WITHOUT PEDICLE GRAFT 641 "ANOMALIES OF RELATIONSHIP OF JAW TO CRANIAL BASE, MAJOR ANOMALIES OF JAW SIZE, OTHER SPECIFIED AND UNSPECIFIED DENTOFACIAL ANOMALIES" "OSTEOPLASTY, MAXILLA/MANDIBLE" 642 CERVICAL RIB SURGICAL TREATMENT 643 GYNECOMASTIA MASTECTOMY 644 "VIRAL, SELF-LIMITING ENCEPHALITIS, MYELITIS AND ENCEPHALOMYELITIS" MEDICAL THERAPY 645 GALLSTONES WITHOUT CHOLECYSTITIS "MEDICAL THERAPY, CHOLECYSTECTOMY" 646 "BENIGN NEOPLASM OF NASAL CAVITIES, MIDDLE EAR AND ACCESSORY SINUSES" "EXCISION, RECONSTRUCTION" 647 ACUTE TONSILLITIS OTHER THAN BETA-STREPTOCOCCAL MEDICAL THERAPY 648 EDEMA AND OTHER CONDITIONS INVOLVING THE INTEGUMENT OF THE FETUS AND NEWBORN MEDICAL THERAPY 649 ACUTE UPPER RESPIRATORY INFECTIONS AND COMMON COLD MEDICAL THERAPY 650 DIAPER RASH MEDICAL THERAPY 651 DISORDERS OF SWEAT GLANDS MEDICAL THERAPY 652 "OTHER VIRAL INFECTIONS, EXCLUDING PNEUMONIA DUE TO RESPIRATORY SYNCYTIAL VIRUS IN PERSONS UNDER AGE 3 (See Statement of Intent)" MEDICAL THERAPY 653 PHARYNGITIS AND LARYNGITIS AND OTHER DISEASES OF VOCAL CORDS MEDICAL THERAPY 654 CORNS AND CALLUSES MEDICAL THERAPY 655 VIRAL WARTS EXCLUDING VENEREAL WARTS "MEDICAL AND SURGICAL TREATMENT, CRYOSURGERY" 656 OLD LACERATION OF CERVIX AND VAGINA MEDICAL THERAPY 657 TONGUE TIE AND OTHER ANOMALIES OF TONGUE "FRENOTOMY, TONGUE TIE" 658 OPEN WOUND OF INTERNAL STRUCTURES OF MOUTH WITHOUT COMPLICATION REPAIR SOFT TISSUES 659 CENTRAL SEROUS RETINOPATHY LASER SURGERY 660 "SEBORRHEIC KERATOSIS, DYSCHROMIA, AND VASCULAR DISORDERS, SCAR CONDITIONS, AND FIBROSIS OF SKIN" MEDICAL AND SURGICAL TREATMENT 661 UNCOMPLICATED HEMORRHOIDS "HEMORRHOIDECTOMY, MEDICAL THERAPY" 662 GANGLION EXCISION 663 "CHRONIC CONJUNCTIVITIS, BLEPHAROCONJUNCTIVITIS" MEDICAL THERAPY 664 "TOXIC ERYTHEMA, ACNE ROSACEA, DISCOID LUPUS" MEDICAL THERAPY 665 PERIPHERAL NERVE DISORDERS MEDICAL THERAPY 666 OTHER COMPLICATIONS OF A PROCEDURE (See Guideline Note 1) MEDICAL AND SURGICAL TREATMENT 667 RAYNAUD'S SYNDROME MEDICAL THERAPY 668 TMJ DISORDERS TMJ SURGERY 669 VARICOSE VEINS OF LOWER EXTREMITIES WITHOUT ULCER OR INFLAMMATION STRIPPING/SCLEROTHERAPY 670 VULVAL VARICES VASCULAR SURGERY 671 CHRONIC PANCREATITIS SURGICAL TREATMENT 672 "CHRONIC PROSTATITIS, OTHER DISORDERS OF PROSTATE" MEDICAL THERAPY 673 MUSCULAR CALCIFICATION AND OSSIFICATION MEDICAL THERAPY 674 "MEDICAL CONDITIONS WHERE TREATMENT OF THE CONDITION WILL NOT RESULT IN A 5% 5 YEAR SURVIVAL (See Guideline Notes 2, 3)" MEDICAL AND SURGICAL TREATMENT 675 AGENESIS OF LUNG MEDICAL THERAPY 676 DISEASE OF CAPILLARIES EXCISION 677 BENIGN POLYPS OF VOCAL CORDS "MEDICAL THERAPY, STRIPPING" 678 "FRACTURES OF RIBS AND STERNUM, CLOSED" MEDICAL THERAPY 679 "CLOSED FRACTURE OF ONE OR MORE PHALANGES OF THE FOOT, NOT INCLUDING THE GREAT TOE" MEDICAL AND SURGICAL TREATMENT 680 DISEASES OF THYMUS GLAND MEDICAL THERAPY 681 DENTAL CONDITIONS WHERE TREATMENT RESULTS IN MARGINAL IMPROVEMENT (See Guideline Note 47) ELECTIVE DENTAL SERVICES 682 ANTI-SOCIAL PERSONALITY DISORDER MEDICAL/PSYCHOTHERAPY 683 SEBACEOUS CYST MEDICAL AND SURGICAL TREATMENT 684 CENTRAL RETINAL ARTERY OCCLUSION PARACENTESIS OF AQUEOUS 685 ORAL APHTHAE MEDICAL THERAPY 686 "SUBLINGUAL, SCROTAL, AND PELVIC VARICES" "VENOUS INJECTION, VASCULAR SURGERY" 687 SUPERFICIAL WOUNDS WITHOUT INFECTION AND CONTUSIONS MEDICAL THERAPY 688 UNSPECIFIED RETINAL VASCULAR OCCLUSION LASER SURGERY 689 BENIGN NEOPLASM OF EXTERNAL FEMALE GENITAL ORGANS EXCISION 690 "BENIGN NEOPLASM OF MALE GENITAL ORGANS: TESTIS, PROSTATE, EPIDIDYMIS" MEDICAL AND SURGICAL TREATMENT 691 XEROSIS MEDICAL THERAPY 692 CONGENITAL CYSTIC LUNG - SEVERE LUNG RESECTION 693 ICHTHYOSIS MEDICAL THERAPY 694 LYMPHEDEMA "MEDICAL THERAPY, OTHER OPERATION ON LYMPH CHANNEL" 695 DERMATOLOGICAL CONDITIONS WITH NO EFFECTIVE TREATMENTS OR NO TREATMENT NECESSARY (See Guideline Note 8) EVALUATION 696 INFECTIOUS DISEASES WITH NO EFFECTIVE TREATMENTS OR NO TREATMENT NECESSARY EVALUATION 697 RESPIRATORY CONDITIONS WITH NO EFFECTIVE TREATMENTS OR NO TREATMENT NECESSARY EVALUATION 698 GENITOURINARY CONDITIONS WITH NO EFFECTIVE TREATMENTS OR NO TREATMENT NECESSARY EVALUATION 699 CARDIOVASCULAR CONDITIONS WITH NO EFFECTIVE TREATMENTS OR NO TREATMENT NECESSARY EVALUATION 700 MUSCULOSKELETAL CONDITIONS WITH NO EFFECTIVE TREATMENTS OR NO TREATMENT NECESSARY EVALUATION 701 INTRACRANIAL CONDITIONS WITH NO EFFECTIVE TREATMENT OR NO TREATMENT NECESSARY EVALUATION 702 SENSORY ORGAN CONDITIONS WITH NO EFFECTIVE TREATMENT OR NO TREATMENT NECESSARY EVALUATION 703 ENDOCRINE AND METABOLIC CONDITIONS WITH NO EFFECTIVE TREATMENT OR NO TREATMENT NECESSARY EVALUATION 704 GASTROINTESTINAL CONDITIONS WITH NO EFFECTIVE TREATMENT OR NO TREATMENT NECESSARY EVALUATION 705 MENTAL DISORDERS WITH NO EFFECTIVE TREATMENTS OR NO TREATMENT NECESSARY EVALUATION 706 NEUROLOGIC CONDITIONS WITH NO EFFECTIVE TREATMENTS OR NO TREATMENT NECESSARY EVALUATION 707 DENTAL CONDITIONS (EG. ORTHODONTICS) COSMETIC DENTAL SERVICES 708 HEPATORENAL SYNDROME MEDICAL THERAPY 709 SPASTIC DYSPHONIA MEDICAL THERAPY 710 DISORDERS OF REFRACTION AND ACCOMODATION RADIAL KERATOTOMY