E478

PDF page 589 / N9

MUSCULOSKELETAL SYSTEM SURGICAL PROCEDURES
 HAND AND WRIST
                                                                                         Asst   Surg     Anae
    ARTHROSCOPY
# R682 Wrist arthroscopy setup, includes when rendered
         debridement, synovectomy, synovial biopsy, removal of
         loose body(ies) and/or screw, drilling of defect or
         microfracture, and/or wrist ganglion debridement. .............                  6     400.00    7
         Note:
         1.A wrist procedure listed in the Hand and Wrist section of the Schedule performed
           arthroscopically is eligible for payment in addition to R682 if that procedure is not described
           as a component of R682 or described by an E-add-on code to R682.
         2.Arthroscopic E-add-on codes listed below are not eligible for payment in addition to R682
           when the service described by the E-code is a generally accepted component of a procedure
           described in Note #1.
# E479 Arthroscopy of midcarpal and/or distal radio-ulnar joint,
          through separate portals, to R682................................ add                 192.00
# E478 Pinning of osteochondral fragment, to R682 .................... add          251.55
      Note:
      F-prefix fracture procedures are not eligible for payment with E478 for the same fracture.
# E480 Triangular fibrocartilage complex repair, to R682 ............. add                      350.65
# E482 Soft tissue capsular release, for contractures, without bone
         procedure, to R682....................................................... add          251.55
# E483 Synovectomy for inflammatory arthritis requiring a minimum of
          90 minutes to resect, to R682 ...................................... add              326.55
      Payment rules:
      1.Synovectomy less then 90 minutes in duration is included in R682.
         2.Only one of E482 or E483 is eligible for payment same patient same day.

PDF page 596 / N16

MUSCULOSKELETAL SYSTEM SURGICAL PROCEDURES
ELBOW AND FOREARM
                                                                                                       Asst         Surg          Anae
    AMPUTATION
# R613 Through radius and ulna.........................................................                   6         351.05          7
# R614 Elbow disarticulation ...............................................................              6         289.50          6
    ARTHRODESIS
# R466 Elbow ......................................................................................       6         833.45          6
    ARTHROPLASTY
# E564 revision of elbow arthroplasty ................................... add 35%
# R281 Ulna replacement (lower end).................................................                      6         296.90           6
# R288 Implant radial head .................................................................              6         452.00           6
# R499 Removal of total replacement .................................................                     6         402.75           7
# R438 Humeral Prosthesis ................................................................                6         676.90          10
# R486 Complete arthroplasty replacement........................................                          6        1205.95           8
# R510 Interposition arthroplasty ........................................................                6         435.20           7
    ARTHROSCOPY
# R683 Elbow arthroscopy setup, includes when rendered
          debridement, synovectomy, synovial biopsy, removal of
          loose body(ies) and/or screw, drilling of defect or
          microfracture, and/or arthroscopic epicondylar release .....                                    6         400.00          7
         Note:
         1.An elbow procedure listed in the Elbow section of the Schedule performed arthroscopically is
           eligible for payment in addition to R683 if that procedure is not described as a component of
           R683 or described by an E-add-on code to R683.
         2.Arthroscopic E-add-on codes listed below are not eligible for payment in addition to R683
           when the service described by the E-code is a generally accepted component of a procedure
           described in Note #1.
# E478 Pinning of osteochondral fragment, to R683 .................... add                                          251.55
         Note:
         F-prefix fracture procedures are not eligible for payment with E478 for the same fracture.
# E481 Osteochondroplasty (extensive bone and arthrofibrotic tissue
         removal requiring a minimum of 2 hours to resect), to R683
          ..................................................................................... add                 500.00
# E482 Soft tissue capsular release for contractures without bone
         procedure, to R683....................................................... add                              251.55
# E483 Synovectomy for inflammatory arthritis requiring a minimum of
          90 minutes to resect, to R683 ...................................... add 326.55
      Payment rules:
      1.Only one of E481, E482 or E483 is eligible for payment same patient same day.
         2.Synovectomy less then 90 minutes in duration is included in R683.
         3.Osteochondroplasty less than 2 hours in duration is included in R683.

PDF page 603 / N23

Note:
         1.A shoulder procedure listed in the Shoulder section of the Schedule performed
           arthroscopically is eligible for payment in addition to R684 if that procedure is not described
           as a component of R684 or described by an E-add-on code to R684.
         2.Arthroscopic E-add-on codes listed below are not eligible for payment in addition to R684
           when the service described by the E-code is a generally accepted component of a procedure
           described in Note #1.
# E478 Pinning of osteochondral fragment, to R684 .................... add                                 251.55
      Note:
      F-prefix fracture procedures are not eligible for payment with E478 for the same fracture.
# E484 Superior labral anterior posterior (SLAP) repair,
           to R684......................................................................... add 336.65
# E485 Arthroscopic capsular release for frozen shoulder,
          to R684......................................................................... add             240.50
      Payment rules:
      E484 is not eligible for payment in addition to R401.

PDF page 626 / N46

MUSCULOSKELETAL SYSTEM SURGICAL PROCEDURES
KNEE
                                                                              Asst      Surg     Anae
         4.Prior approval may be granted for E494 or E495 in patients with Kellgren-Lawrence grade 3
           or 4 osteoarthritis (see Kohn MD, Sassoon AA, Fernando ND. Classifications in brief:
           Kellgren-Lawrence classification of osteoarthritis. Clin Orthop Relat Res. 2016 Aug;
           474(8):1886-93) if the clinical record supports:
            a.Significant functional impairment caused by an unstable articular chondral flap or
               degenerative meniscal tear which has not responded to a minimum of six months active
               non-surgical treatment; and
            b.the patient is not a current candidate for knee realignment or arthroplasty.]
# E476 Removal of symptomatic loose body(ies) and/or screw ... add                                                 192.00
      Note:
      Removal of iatrogenic loose body(ies) is not eligible for payment.
# E491 Lateral release .................................................................. add                      161.45
# E492 Synovectomy - for diseased synovium, anterior, posterior or
         complete....................................................................... add                       231.30
# E493 Drilling of defect (includes removal of loose body(ies) ..... add                                           251.55
# E478 Pinning of osteochondral fragment ................................... add                                   251.55

PDF page 626 / N46

Note:
         F-prefix fracture procedures are not eligible for payment with E478 for the same fracture.
# E494 Debridement (degenerative cartilage) – substantial
         debridement of 1 or more focal flaps of unstable
         degenerative articular cartilage causing mechanical
         symptoms, includes, when rendered, synovectomy,
         meniscal trimming and/or chondroplasty...................... add                                          299.00
# E498 Debridement (trauma) - substantial debridement of 1 or more
         focal flaps of unstable post-traumatic articular cartilage
         causing mechanical symptoms, includes, when rendered,
         synovectomy, meniscal trimming and/or chondroplasty add                                                   299.00
         Payment rules:
         1.E492 is not eligible for payment in addition to E494 or E498.
         2.E498 is not eligible for payment with R687 or E494.
         3.E494 or E498 are not eligible for payment for the debridement of cartilage flaps for the
           purpose of surgical visualization alone.
         [Commentary:
         When E494 or E495 are claimed with R687, or E498 is claimed with R699 it is recommended
         that the intra-articular pathology be documented with pre- and post-procedural photographic
         images taken during arthroscopy which are archived in the permanent medical record where
         possible.]
# E489 Microfracture and/or abrasion arthroplasty, for cartilage
         deficiency (includes removal of loose body(ies)........... add                                            250.00
# E495 Meniscectomy, partial or total, for symptomatic meniscal tear
         ..................................................................................... add                 240.45

PDF page 633 / N53

MUSCULOSKELETAL SYSTEM SURGICAL PROCEDURES
 FOOT AND ANKLE
                                                                                                     Asst   Surg     Anae
      Metatarsophalyngeal interposition
# R456 - single ..................................................................................    6     144.80    6
# E538    - each additional........................................................... add                   38.00
# R453 Metatarsophalyngeal (Swansons, etc.)...................................                        6     376.60    7
# R454 - multiple ...............................................................................     6     387.00    7
# R500 Removal - prosthesis without replacement.............................                          6     144.80    6
    ARTHROSCOPY
# R688 Ankle arthroscopy setup, includes when rendered
         debridement, synovectomy, removal of loose body(ies) and/
         or screw, drilling of defect or microfracture and/or synovial
         biopsy .................................................................................     6     400.00    7
         Note:
         1.An ankle procedure listed in the Foot and Ankle section of the Schedule performed
           arthroscopically is eligible for payment in addition to R688 if that procedure is not described
           as a component of R688 or described by an E-add-on code to R688.
         2.Arthroscopic E-add-on codes listed below are not eligible for payment in addition to R688
           when the service described by the E-code is a generally accepted component of a procedure
           described in Note #1.
# E477 Arthroscopy of subtalar and/or intratarsal joint(s), through
          separate portals, to R688 ............................................. add                       192.00
# E478 Pinning of osteochondral fragment, to R688 .................... add          251.55
      Note:
      F-prefix fracture procedures are not eligible for payment with E478 for the same fracture.
# E481 Osteochondroplasty (extensive bone and arthrofibrotic tissue
         removal requiring a minimum of 2 hours to resect),
          to R688........................................................................ add               500.00
# E483 Synovectomy for inflammatory arthritis requiring a minimum of
         90 minutes to resect, to R688 ...................................... add                           326.55
# R689 Excision of Os Trigonum (sole procedure).............................. 6 230.00                                7
     Payment rules:
     1.Only one of E481 or E483 is eligible for payment same patient same day.
         2.R688 is not eligible for payment in addition to R689.

Master, record 1175. Record Layout PDF, page 1.

E47820250401999999990000251550000000000000000000000000000000000000000000000

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.