E115

PDF page 769 / Y3

REPLACEMENT
    Corneal transplant
# E121 - penetrating .........................................................................      6     740.00    7
# E951   - with artificial prosthesis .............................................. add                   52.40
# E122 - lamellar...............................................................................    6     590.00    7
# E124 Limbal stem cell transplant .....................................................            6     740.00    8
# E123 Division of iris to cornea and/or angle.....................................                       161.75    6
      Payment rules:
      1.E117 is not eligible for payment with E124.
         2.E123 is not eligible for payment with E133, E132, E114, E115, E156 or E157
         3.E121 is eligible for payment for performing DSEK (Descemet's Stripping Endothelial
           Keratoplasty), DMEK (Descemet's Membrane Endothelial Keratoplasty) and DALK (Deep
           Anterior Lamellar Keratoplasty)
         4.E123 is only eligible for payment in addition to E121 under one of the following
           circumstances:
            a.Previous corneal transplantation,
            b.Post-operative corneal melt,
            c.Corneal perforation from trauma or infection, or
            d.Congenital conditions with iris corneal adhesions only when the iris adhesion is
               documented preoperatively and documented in the operative record.
         5.E117 is not eligible for payment with E121.

PDF page 770 / Y4

GLAUCOMA FILTERING PROCEDURES
# E132 Glaucoma filtering procedures ab externo (e.g.
          trabeculectomy, trabeculotomy, deep sclerectomy,
          viscocanalostomy) .............................................................                  6         550.00          6
# E114 Plate and tube glaucoma drainage procedure........................                                  6         840.00          6
# E115 Minimally invasive glaucoma surgery or minimally invasive
          bleb surgery, ab interno or ab externo (e.g. Hydrus stent,
          iStent, Trabectome, Kahook dual blade, canaloplasty, XEN
          Gel Stent, PreserFlo MicroShunt) ......................................                          6         350.00          6
# E110   - with cataract extraction, all types of, by any procedure,
            includes extraction of native lens and insertion of artificial
            intraocular lens (same eye), to E132, E114, E115..... add                                                271.50
# E984   - following previous glaucoma filtering procedure, to E132,
            E114, E115................................................................ add                           137.50
         Payment rules:
         E132 is not eligible for payment for primary lensectomy or bleb repair.

Master, record 944. Record Layout PDF, page 1.

E11520260401999999990000350000000000774600000000000000000095760000000957600

Auxiliary master fields are preserved as raw scaled values. The linked layout calls them zero-filled, but this edition contains non-zero values. They are not presented as final dollar fees or PDF units.