E862

PDF page 730 / T10

# S544 Urethrectomy - radical ............................................................              6         318.35          6
    REPAIR
# S548 Urethral sling...........................................................................        6         409.10          6
# S815 Tension free vaginal tape mid-urethral sling, by any method/
         approach ............................................................................          6         421.65          6
         Payment rules:
         Cystoscopy (Z606) is not eligible for payment with S815 or S548 unless the cystoscopy is
         rendered for suspicion of disease.
    Retropubic urethropexy for stress incontinence
# S549 - primary procedure ..............................................................       6 419.75                          6
# S546 - repeat procedure for failed retropubic or vaginal surgery for
          stress incontinence.............................................................      6 532.00                          7
# E862    - when performed laparoscopically, to S549 or S546
            ........................................................................... add 25%
      Note:
      See also procedures for stress incontinence in Female Genital Surgical Procedures.
# S539 Insertion of artificial urinary sphincter .....................................                  6         832.65          6
# S540 Revision or removal of artificial urinary sphincter ...................                          6         257.05          7

PDF page 744 / V4

FEMALE GENITAL SURGICAL PROCEDURES
VAGINA
                                                                                                        Asst          Surg         Anae
# E862         - when performed laparoscopically, to S760, S813 or S761
                 ........................................................................... add 25%
# S724 Perineorrhaphy (not eligible for payment with delivery or other
         vaginal surgery procedures)...............................................                        8         127.35           8
# S725 Colpocleisis (LeFort or modification) ......................................                        8         300.35           8
# S726 Construction of artificial vagina (see General Preamble GP12)                                       6          I.C             6
    Closure of fistula
# S523 Vesicovaginal..........................................................................             6         848.90           6
# S231 Rectovaginal (any repair)........................................................                   6         338.55           6
# S729 Ureterovaginal ........................................................................             6         560.95           6
# S709 Urethrovaginal ........................................................................             6         374.85           6
    Retropubic Urethropexy
# S549 Primary procedure ..................................................................                6         419.75           6
# S546 Repeat procedure for failed retropubic or vaginal surgery for
          stress incontinence.............................................................                 6         532.00           7
# E862    - when performed laparoscopically, to S549 or S546
            ........................................................................... add 25%
# S815 Tension free vaginal tape mid-urethral sling by any method/
          approach ............................................................................ 6 421.65 6
      Payment rules:
      Cystoscopy (Z606) is not eligible for payment with S815 unless the cystoscopy is rendered for
      suspicion of disease.

PDF page 748 / V8

FEMALE GENITAL SURGICAL PROCEDURES
CORPUS UTERI
                                                                                              Asst        Surg          Anae
# S783       - hysterotomy with tubal interruption.....................................        6          257.05         6
# S754 Diagnostic curettage (with or without cauterization, biopsy of
         cervix removal of polyps, or hysterosalpingography) .........                                     97.20          6
# S764 Myomectomy by any technique except hysteroscopic............                             8         406.90          8
    INCISION OR EXCISION
    Hysterectomy - with or without adnexa (unless otherwise specified)
# S757 - abdominal - total or subtotal ...............................................            8       643.35          8
# S816 - vaginal ................................................................................ 8       643.35          8
# S758       - with anterior and posterior vaginal repair and including
               enterocoele and/or vault prolapse repair when rendered...                        8         733.45          8
# S759       - with anterior or posterior vaginal repair and including
               enterocoele and/or vault prolapse repair when rendered...                        8         655.05          8
# E090        - removal of one or both ovaries with moderate or severe
                endometrosis, to S757, S758 or S759 ....................... add                           260.80
# E862        - when hysterectomy is performed laparoscopically, or with
                laparoscopic assistance, abdominal or vaginal, to S757,
                S758, S759 or S816........................................... add 25%
# S710     - with omentectomy for malignancy ......................................                8  820.40 8
# S763     - radical (Wertheim or Schauta) - includes node dissection .                            8 1081.80 8
# S762     - radical trachelectomy - excluding node dissection .............                       8  801.10 8
# E862       - when performed laparoscopically, to S710, S763, S762
               ........................................................................... add 25%
        Note:
        S722, S760, S812, S813, S738, S741, S745, S747, S780, S781 and S782 are not eligible for
        payment when rendered with S757, S816, S758, S759, S710, S763 or S762.
      [Commentary:
      Hysterectomy (S757, S816) for benign conditions should only be performed when less invasive
      treatments have been found to be unsuccessful or are declined by the patient.]
# S776 Staging pelvic lymphadenectomy for carcinoma (laparoscopic
           or open) .............................................................................. 8 462.30 8
# S781 Staging Para-aortic lymphadenectomy for carcinoma
           (laparoscopic or open) (not eligible for payment when
           rendered with Z578 and/or S776).......................................                  8 431.20 8

PDF page 749 / V9

FEMALE GENITAL SURGICAL PROCEDURES
 FALLOPIAN TUBE
                                                                                               Asst   Surg     Anae
    EXCISION, SUTURE OR REPAIR
    Ectopic pregnancy
# S784 - management by any surgical technique............................                       6     462.20    7
# E852   - with tuboplasty ........................................................... add             49.25
# E860         - diagnostic laparoscopy prior to laparotomy ............... add                       131.45
# S738 Salpingectomy or salpingo-oophorectomy (uni- or bilateral) ..                            8     366.20    8
# S741 Tubal occlusion or interruption for the purpose of sterilization,
         by any method or approach................................................              8     155.70    8
    Tubal plastic operation with/without operating microscope (unilateral or bilateral)
# S735 - fimbriolysis.......................................................................... 6 334.35        6
# S736 - salpingostomy ....................................................................     6 359.55        7
# S739 - fimbriolysis and salpingostomy...........................................              6 434.55        7
# E862    - when performed laparoscopically, to S735, S736 or S739
            ........................................................................... add 25%
    Repair of extensive unilateral or bilateral tubal and peritubal disease
      For infertility, pelvic inflammatory disease or endometriosis with or without laser treatment and
      ureterolysis
# S743 - laparotomy.......................................................................... 8 657.00 8
# E862     - when performed laparoscopically, to S743 ........ add 25%
      Note:
      1.Z737 or E854 are not eligible for payment when rendered same patient same day as S743 by
        any surgeon.
         2.Reconstruction or repair for infertility following previous sterilization is not an insured service.
         3.S162 is only eligible for payment in addition to S743 when records document that a
           transmural intestinal resection was rendered.
    Laparoscopy
# Z552 - without biopsy.....................................................................    6     160.50    6
# Z553 - with biopsy and/or lysis of adhesions and/or removal of
         foreign body and/or cautery of endometrial implants .........                          8     196.65    8
# E855   - with dye injection........................................................ add              25.85
# E857   - with D&C .................................................................... add           78.45
# Z737 Laser treatment of extensive pelvic disease...........................                   8     215.80    8

Master, record 1556. Record Layout PDF, page 1.

E86220110901999999990000000010000000000000000000000000000000000000000000000

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.