HCPCS Range Miscellaneous Provider Services and Supplies

• 1 Removal of sutures; by a physician other than the physician who originally closed the wound ( S0630 )

• 2 Laser in situ keratomileusis (LASIK) ( S0800 )

• 3 Photorefractive keratectomy (PRK) ( S0810 )

• 4 Phototherapeutic keratectomy (PTK) ( S0812 )

• 5 Deluxe item, patient aware (list in addition to code for basic item) ( S1001 )

• 6 Customized item (list in addition to code for basic item) ( S1002 )

• 7 IV tubing extension set ( S1015 )

• 8 Non-PVC (polyvinyl chloride) intravenous administration set, for use with drugs that are not stable in PVC e.g. paclitaxel ( S1016 )

• 9 Continuous noninvasive glucose monitoring device, purchase (for physician interpretation of data, use CPT® code) ( S1030 )

• 10 Continuous noninvasive glucose monitoring device, rental, including sensor, sensor replacement, and download to monitor (for physician interpretation of data, use CPT® code) ( S1031 )

• 11 Cranial remolding orthosis, pediatric, rigid, with soft interface material, custom fabricated, includes fitting and adjustment(s) ( S1040 )

• 12 Transplantation of small intestine and liver allografts ( S2053 )

• 13 Transplantation of multivisceral organs ( S2054 )

• 14 Harvesting of donor multivisceral organs, with preparation and maintenance of allografts; from cadaver donor ( S2055 )

• 15 Lobar lung transplantation ( S2060 )

• 16 Donor lobectomy (lung) for transplantation, living donor ( S2061 )

• 17 Simultaneous pancreas kidney transplantation ( S2065 )

• 18 Breast reconstruction with gluteal artery perforator (GAP) flap, including harvesting of the flap, microvascular transfer, closure of donor site and shaping the flap into a breast, unilateral ( S2066 )

• 19 Breast reconstruction of a single breast with "stacked" deep inferior epigastric perforator (DIEP) flap(s) and/or gluteal artery perforator (GAP) flap(s), including harvesting of the flap(s), microvascular transfer, closure of donor site(s) and shaping the flap into a breast, unilateral ( S2067 )

• 20 Breast reconstruction with deep inferior epigastric perforator (DIEP) flap or superficial inferior epigastric artery (SIEA) flap, including harvesting of the flap, microvascular transfer, closure of donor site and shaping the flap into a breast, unilateral ( S2068 )

• 21 Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with endoscopic laser treatment of ureteral calculi (includes ureteral catheterization) ( S2070 )

• 22 Laparoscopic esophagomyotomy (Heller type) ( S2079 )

• 23 Laser-assisted uvulopalatoplasty (LAUP) ( S2080 )

• 24 Adjustment of gastric band diameter via subcutaneous port by injection or aspiration of saline ( S2083 )

• 25 Transcatheter occlusion or embolization for tumor destruction, percutaneous, any method, using yttrium-90 microspheres ( S2095 )

• 26 Islet cell tissue transplant from pancreas; allogeneic ( S2102 )

• 27 Adrenal tissue transplant to brain ( S2103 )

• 28 Adoptive immunotherapy i.e. development of specific anti-tumor reactivity (e.g., tumor-infiltrating lymphocyte therapy) per course of treatment ( S2107 )

• 29 Arthroscopy, knee, surgical for harvesting of cartilage (chondrocyte cells) ( S2112 )

• 30 Osteotomy, periacetabular, with internal fixation ( S2115 )

• 31 Arthroereisis, subtalar ( S2117 )

• 32 Metal-on-metal total hip resurfacing, including acetabular and femoral components ( S2118 )

• 33 Low density lipoprotein (LDL) apheresis using heparin-induced extracorporeal LDL precipitation ( S2120 )

• 34 Cord blood harvesting for transplantation, allogeneic ( S2140 )

• 35 Cord blood-derived stem-cell transplantation, allogeneic ( S2142 )

• 36 Bone marrow or blood-derived stem cells (peripheral or umbilical), allogeneic or autologous, harvesting, transplantation, and related complications; including: pheresis and cell preparation/storage; marrow ablative therapy; drugs, supplies, hospitalization with outpatient follow-up; medical/surgical, diagnostic, emergency, and rehabilitative services; and the number of days of pre-and post-transplant care in the global definition ( S2150 )

• 37 Solid organ(s), complete or segmental, single organ or combination of organs; deceased or living donor (s), procurement, transplantation, and related complications; including: drugs; supplies; hospitalization with outpatient follow-up; medical/surgical, diagnostic, emergency, and rehabilitative services, and the number of days of pre- and post-transplant care in the global definition ( S2152 )

• 38 Echosclerotherapy ( S2202 )

• 39 Minimally invasive direct coronary artery bypass surgery involving mini-thoracotomy or mini-sternotomy surgery, performed under direct vision; using arterial graft(s), single coronary arterial graft ( S2205 )

• 40 Minimally invasive direct coronary artery bypass surgery involving mini-thoracotomy or mini-sternotomy surgery, performed under direct vision; using arterial graft(s), two coronary arterial grafts ( S2206 )

• 41 Minimally invasive direct coronary artery bypass surgery involving mini-thoracotomy or mini-sternotomy surgery, performed under direct vision; using venous graft only, single coronary venous graft ( S2207 )

• 42 Minimally invasive direct coronary artery bypass surgery involving mini-thoracotomy or mini-sternotomy surgery, performed under direct vision; using single arterial and venous graft(s), single venous graft ( S2208 )

• 43 Minimally invasive direct coronary artery bypass surgery involving mini-thoracotomy or mini-sternotomy surgery, performed under direct vision; using two arterial grafts and single venous graft ( S2209 )

• 44 Myringotomy, laser-assisted ( S2225 )

• 45 Implantation of magnetic component of semi-implantable hearing device on ossicles in middle ear ( S2230 )

• 46 Implantation of auditory brain stem implant ( S2235 )

• 47 Induced abortion, 17 to 24 weeks ( S2260 )

• 48 Induced abortion, 25 to 28 weeks ( S2265 )

• 49 Induced abortion, 29 to 31 weeks ( S2266 )

• 50 Induced abortion, 32 weeks or greater ( S2267 )

• 51 Arthroscopy, shoulder, surgical; with thermally-induced capsulorrhaphy ( S2300 )

• 52 Hip core decompression ( S2325 )

• 53 Chemodenervation of abductor muscle(s) of vocal cord ( S2340 )

• 54 Chemodenervation of adductor muscle(s) of vocal cord ( S2341 )

• 55 Nasal endoscopy for post-operative debridement following functional endoscopic sinus surgery, nasal and/or sinus cavity(s), unilateral or bilateral ( S2342 )

• 56 Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, using radiofrequency energy, single or multiple levels, lumbar ( S2348 )

• 57 Diskectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; lumbar, single interspace ( S2350 )

• 58 Diskectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; lumbar, each additional interspace (list separately in addition to code for primary procedure) ( S2351 )

• 59 Repair, congenital diaphragmatic hernia in the fetus using temporary tracheal occlusion, procedure performed in utero ( S2400 )

• 60 Repair, urinary tract obstruction in the fetus, procedure performed in utero ( S2401 )

• 61 Repair, congenital cystic adenomatoid malformation in the fetus, procedure performed in utero ( S2402 )

• 62 Repair, extralobar pulmonary sequestration in the fetus, procedure performed in utero ( S2403 )

• 63 Repair, myelomeningocele in the fetus, procedure performed in utero ( S2404 )

• 64 Repair of sacrococcygeal teratoma in the fetus, procedure performed in utero ( S2405 )

• 65 Repair, congenital malformation of fetus, procedure performed in utero, not otherwise classified ( S2409 )

• 66 Fetoscopic laser therapy for treatment of twin-to-twin transfusion syndrome ( S2411 )

• 67 Surgical techniques requiring use of robotic surgical system (list separately in addition to code for primary procedure) ( S2900 )

• 68 Diabetic indicator; retinal eye exam, dilated, bilateral ( S3000 )

• 69 Performance measurement, evaluation of patient self assessment, depression ( S3005 )

• 70 STAT laboratory request (situations other than S3601) ( S3600 )

• 71 Emergency STAT laboratory charge for patient who is homebound or residing in a nursing facility ( S3601 )

• 72 Newborn metabolic screening panel, includes test kit, postage and the laboratory tests specified by the state for inclusion in this panel (e.g., galactose; hemoglobin, electrophoresis; hydroxyprogesterone, 17-D; phenylanine (PKU); and thyroxine, total) ( S3620 )

• 73 Eosinophil count, blood, direct ( S3630 )

• 74 HIV-1 antibody testing of oral mucosal transudate ( S3645 )

• 75 Saliva test, hormone level; during menopause ( S3650 )

• 76 Saliva test, hormone level; to assess preterm labor risk ( S3652 )

• 77 Antisperm antibodies test (immunobead) ( S3655 )

• 78 Gastrointestinal fat absorption study ( S3708 )

• 79 Dose optimization by area under the curve (AUC) analysis, for infusional 5-fluorouracil ( S3722 )

• 80 Artificial pancreas device system (e.g., low glucose suspend (LGS) feature) including continuous glucose monitor, blood glucose device, insulin pump and computer algorithm that communicates with all of the devices ( S1034 )

• 81 Sensor; invasive (e.g., subcutaneous), disposable, for use with artificial pancreas device system ( S1035 )

• 82 Transmitter; external, for use with artificial pancreas device system ( S1036 )

• 83 Receiver (monitor); external, for use with artificial pancreas device system ( S1037 )

• 84 Stent, non-coronary, temporary, with delivery system (propel) ( S1091 )