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Workers' compensation -- HIPAA 835 Health care claim payment/remittance advice



5221.4033 Outpatient limitation for medical/surgical facility fee

Subp. 2b. Procedure codes subject to limitation (table continued ...)

CPT/HCPCS
procedure code
CPT/HCPCS
description
25530 Treat fracture of ulna
25600 Treat fracture radius/ulna
25622 Treat wrist bone fracture
25630 Treat wrist bone fracture
25650 Repair wrist bone fracture
26010 Drainage of finger abscess
26600 Treat metacarpal fracture
26720 Treat finger fracture, each
26725 Treat finger fracture, each
26740 Treat finger fracture, each
28001 Drainage of bursa of foot
28010 Incision of toe tendon
28011 Incision of toe tendons
28022 Exploration of foot joint
28024 Exploration of toe joint
28052 Biopsy of foot joint lining
28108 Removal of toe lesions
28124 Partial removal of toe
28126 Partial removal of toe
28153 Partial removal of toe
28160 Partial removal of toe
28190 Removal of foot foreign body
28220 Release of foot tendon
28230 Incision of foot tendon(s)
28232 Incision of toe tendon
28234 Incision of foot tendon
28270 Release of foot contracture
28272 Release of toe joint, each
28430 Treatment of ankle fracture
28450 Treat midfoot fracture, each
28455 Treat midfoot fracture, each
28470 Treat metatarsal fracture
28475 Treat metatarsal fracture
28490 Treat big toe fracture
28495 Treat big toe fracture
28510 Treatment of toe fracture
28515 Treatment of toe fracture
28530 Treat sesamoid bone fracture
28540 Treat foot dislocation
28570 Treat foot dislocation
28600 Treat foot dislocation
28630 Treat toe dislocation
29015 Application of body cast
29020 Application of body cast
29025 Application of body cast
29035 Application of body cast
29049 Application of shoulder cast
29065 Application of long arm cast
29075 Application of forearm cast
29085 Apply hand/wrist cast
29105 Apply long arm splint
29125 Apply forearm splint
29126 Apply forearm splint
29130 Application of finger splint
29131 Application of finger splint
29200 Strapping of chest
29220 Strapping of low back
29260 Strapping of elbow or wrist
29280 Strapping of hand or finger
29345 Application of long leg cast
29355  Application of long leg cast
29358 Apply long leg cast brace
29365 Application of long leg cast
29405 Apply short leg cast
29425 Apply short leg cast
29435 Apply short leg cast
29440 Addition of walker to cast
29450 Application of leg cast
29515 Application of lower leg splint
29520 Strapping of hip
29530 Strapping of knee
29540 Strapping of ankle
29550 Strapping of toes
29580 Application of paste boot
29590 Application of foot splint
29700 Removal/revision of cast
29705 Removal/revision of cast
29710 Removal/revision of cast
29715 Removal/revision of cast
29720 Repair of body cast
29730 Windowing of cast
29740 Wedging of cast
29750 Wedging of clubfoot cast
29850 Knee arthroscopy/surgery
30000 Drainage of nose lesion
30020 Drainage of nose lesion
30100 Intranasal biopsy
30110 Removal of nose polyp(s)
30200 Injection treatment of nose
30210 Nasal sinus therapy
30220  Insert nasal septal button
30300 Remove nasal foreign body
30901 Control of nosebleed
31000 Irrigation maxillary sinus
31002 Irrigation sphenoid sinus
31505 Diagnostic laryngoscopy
31575 Diagnostic laryngoscopy
31579 Diagnostic laryngoscopy
36000 Place needle in vein
36400 Drawing blood
36405 Drawing blood
36406 Drawing blood
36410 Drawing blood
36430 Blood transfusion service
36450 Exchange transfusion service
36470 Injection therapy of vein
36471 Injection therapy of vein
36510 Insertion of catheter, vein
40490 Biopsy of lip
40800 Drainage of mouth lesion
40804 Removal of foreign body, mouth
40808 Biopsy of mouth lesion
40810 Excision of mouth lesion
40812 Excise/repair mouth lesion
41100 Biopsy of tongue
41108 Biopsy of floor of mouth
41825 Excision of gum lesion
41826 Excision of gum lesion
42100 Biopsy roof of mouth
42330 Removal of salivary stone
42400 Biopsy of salivary stone
42650 Dilation of salivary duct
42660 Dilation of salivary duct
42800 Biopay of throat
45300 Proctosigmoidoscopy
45303 Proctosigmoidoscopy
45330 Sigmoidoscopy, diagnostic
45520 Treatment of rectal prolapse
46083 Incise external hemorrhoid
46221 Ligation of hemorrhoid(s)
46230 Removal of anal tabs
46320 Removal of hemorrhoid clot
46500 Injection into hemorrhoids
46600 Diagnostic anoscopy
46604 Anoscopy and dilation
46606 Anoscopy and biopsy
46614 Anoscopy, control bleeding
46615 Anoscopy
46900 Destruction, anal lesion(s)
46910 Destruction, anal lesion(s)
46916 Cryosurgery, anal lesion(s)
46917 Laser surgery, anal lesion(s)
46934 Destruction of hemorrhoids
46935 Destruction of hemorrhoids
46936 Destruction of hemorrhoids
46940 Treatment of anal fissure
46942 Treatment of anal fissure
46945 Ligation of hemorrhoids
46946 Ligation of hemorrhoids
51700 Irrigation of bladder
51705 Change of bladder tube
51720 Treatment of bladder lesion
52265 Cystoscopy and treatment
53270 Removal of urethra gland
53600 Dilate urethra stricture
53601 Dilate urethra stricture
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