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An episode of care, also known as an episode, groups all relevant services provided to a patient for a particular condition within a confined time range. An episode of care serves as a unit of accounting as well as a unit of accountability for providers who take on financial risk for the episode. Defining an episode in such a manner helps to identify sources of variation and to standardize care.
An episode of care for Mastectomy, sometimes abbreviated MSTCMY, is a procedural episode. The Mastectomy episode includes services related to the procedure such as a facility stay, anesthesia services, as well as services within the 30-day pre- and 90-day post-operative care time window, such as diagnostic services, (imaging, labs etc.), office visits and ancillary services.
Episode Components
| Triggers | A Mastectomy episode trigger includes an inpatient facility claim with a procedure trigger code in the principal position and a qualifying diagnosis code in the principal position (Table 1). This episode is also triggered by an outpatient facility or professional claim with a procedure trigger code (in any position) and a qualifying diagnosis code (in any position) on the same claim line. |
| Typical Diagnosis | Typical diagnosis codes (ICD 10 DX codes) indicate typical care. Claims with typical diagnosis codes usually associated with an episode help steer services into this episode. However, a relevant procedure code is required on the same claim/claim line for the indicated diagnosis code to be incorporated into the episode. (Table 2) |
| Actionable adverse events (AAE) | Actionable adverse events (AAE) are events that are recognized by diagnosis codes (ICD 10 DX codes) and their timing to indicate potential complications of care. They require a relevant procedure code (ICD 10 PX codes; CPT/HCPCS codes) on the same claim/claim line to assign the claim to the episode. Additional rules are used to identify AAEs in addition to the presence of AAE diagnosis codes. For example, relevant acute inpatient readmission claims are flagged as actionable adverse events regardless of the presence of AAE codes. (Table 3) |
| Relevant Procedure Codes | All relevant services within the timeframe of an episode are included within an episode. These include office visits, emergency room visits, inpatient professional or facility services, labs, radiology or ancillary services. Relevant diagnosis and procedure codes help identify which services are included. Some procedure codes are sufficient to stand alone, while others require typical or actionable adverse event (AAE) diagnosis codes on the same claim/claim line to steer services into the episode. (Tables 4 and 5) |
| Relevant Pharmacy | All relevant pharmacy services are included within an episode. These are identified by National Drug Codes (NDC) on a pharmacy claim and are grouped using the RxNorm grouping classification for ease of assigning them into episodes. (Table 6) |
| SubTypes | Episode subtypes are used to adjust the target price and/or to subset episode type for reporting purposes. They are specific to the episode and identified from the trigger claim or from claims during the look-back period. Examples of Subtype Groups: Resection Regional Lymph Nodes, BreastBilateral Modified Radical MastectomyExcision Unilateral BreastResection Bilateral Breast |
Code Tables
Table 1: Trigger Codes
| Trigger Type | Code Value |
| CPT / HCPCS Triggers | 19301, 19302, 19303, 19304, 19305, 19306, 19307 |
| ICD-10-CM (DX) Qualifying Diagnosis | C50011, C50012, C50019, C50111, C50112, C50119, C50211, C50212, C50219, C50311, C50312, C50319, C50411, C50412, C50419, C50511, C50512, C50519, C50611, C50612, C50619, C50811, C50812, C50819, C50911, C50912, C50919, C7981, D0500, D0501, D0502, D0510, D0511, D0512, D0580, D0581, D0582, D0590, D0591, D0592, D4860, D4861, D4862, D493, N63, N630, N6310, N6311, N6312, N6313, N6314, N6320, N6321, N6322, N6323, N6324, N6331, N6332, N6341, N6342, R920, R921, R922, R928, T8541XA, T8542XA, T8543XA, T8544XA, T8549XA, T85613A, T85623A, T8579XA, T85818A, T8581XA, T85828A, T8582XA, T85838A, T8583XA, T85848A, T8584XA, T85858A, T8585XA, T85868A, T8586XA, T85898A, T8589XA, Z1501, Z4001, Z853 |
| ICD-10-PCS (PX) Triggers | 0H5T0ZZ, 0H5T3ZZ, 0H5T7ZZ, 0H5T8ZZ, 0H5TXZZ, 0H5U0ZZ, 0H5U3ZZ, 0H5U7ZZ, 0H5U8ZZ, 0H5UXZZ, 0H5V0ZZ, 0H5V3ZZ, 0H5V7ZZ, 0H5V8ZZ, 0H5VXZZ, 0HBT0ZZ, 0HBT3ZZ, 0HBT7ZZ, 0HBT8ZZ, 0HBTXZZ, 0HBU0ZZ, 0HBU3ZZ, 0HBU7ZZ, 0HBU8ZZ, 0HBUXZZ, 0HBV0ZZ, 0HBV3ZZ, 0HBV7ZZ, 0HBV8ZZ, 0HBVXZZ, 0HTT0ZZ, 0HTU0ZZ, 0HTV0ZZ |
Table 2: ICD-10 Typical Diagnosis
| Group ID | Group Name | Code Value |
| DXX05345 | Orthostatic Hypotension / Dizziness | I951, R42 |
| DXX0918 | Neoplsm – malignant neoplsm – personal hx – breast | Z853 |
| DXX09182 | Othr – fitting – breast prosthesis | Z4430, Z4431, Z4432, Z45811, Z45812, Z45819 |
| DXX09183 | Othr – other | N650, N651, Z4001, Z9882 |
| DXX09185 | Othr – other aftercare | Z421 |
| DXX09196 | Benign Breast Disease | N6001, N6002, N6009, N6011, N6012, N6019, N6021, N6022, N6029, N6031, N6032, N6039, N61, N610, N611 |
| DXX09197 | Cancer Breast | C50011, C50012, C50019, C50111, C50112, C50119, C50211, C50212, C50219, C50311, C50312, C50319, C50411, C50412, C50419, C50511, C50512, C50519, C50611, C50612, C50619, C50811, C50812, C50819, C50911, C50912, C50919 |
| DXX09198 | Cancer Breast, uncertain behavior | D4860, D4861, D4862, D493 |
| DXX09199 | Carcinoma in situ of breast | D0500, D0501, D0502, D0510, D0511, D0512, D0580, D0581, D0582, D0590, D0591, D0592 |
| DXX09200 | Secondary Cancer to Breast | C7981 |
| DXX0922 | Neoplsm – abnrml findings – breast | N63, R920, R921, R922, R928 |
| DXX0942 | Breast – hypertrophy | N62 |
| DXX0943 | Breast – symptoms | N644, N6451, N6452, N6453, N6459 |
| DXX0948 | Breast – other ds | N641, N642, N6481, N6482, N6489, N649 |
| DXX10110 | Severe Protein Calorie Malnutrition | E45 |
| DXX10119 | Mild-mod malnutrition | E440, E441, E46, E640 |
| DXX10121 | Vitamin, Mineral & Other Nutrl Deficiency | D81818, D81819, E508, E509, E5111, E5112, E512, E518, E519, E52, E530, E531, E538, E539, E54, E559, E560, E561, E568, E569, E58, E59, E60, E610, E611, E612, E613, E614, E615, E616, E617, E618, E619, E630, E631, E638, E639, E641, E642, E648, E649 |
| DXX1343 | Neoplsm – screening – breast | Z1231, Z1239 |
| DXX16293 | Iron deficiency and other anemias | D510, D511, D512, D513, D518, D519, D520, D521, D528, D529, D530, D531, D532, D538, D539 |
| DXX1768 | Secondary malignancies | C792 |
| DXX1963 | Anxiety Disorders | F064 |
| DXX2104 | NS – acute pain – post op | G8918 |
| DXX2352 | Othr – other | Z1501, Z803 |
| DXX2353 | Othr – s/p surgery | Z9010, Z9011, Z9012, Z9013 |
| DXX2360 | Complication of Implanted device, graft | T8544XS |
| DXX2370 | Fever & Chills | R5081, R509, R6883 |
| DXX2377 | Personal history of blood, endocrine, nutritional disorders | Z8639 |
| XX0000 | Ungrouped Codes | N630, N6310, N6311, N6312, N6313, N6314, N6320, N6321, N6322, N6323, N6324, N6331, N6332, N6341, N6342 |
Table 3: ICD-10 Actionable Adverse Events
| Group ID | Group Name | Code Value |
| DXX01384 | Hemorrhagic Stroke | I60, I600, I6000, I6001, I6002, I601, I6010, I6011, I6012, I602, I6020, I6021, I6022, I603, I6030, I6031, I6032, I604, I605, I6050, I6051, I6052, I606, I607, I608, I609, I610, I611, I612, I613, I614, I615, I616, I618, I619, I6200, I6201, I6202, I6203, I621, I629 |
| DXX01385 | Thromboembolic Stroke | I6300, I63011, I63012, I63013, I63019, I6302, I63031, I63032, I63033, I63039, I6309, I6310, I63111, I63112, I63113, I63119, I6312, I63131, I63132, I63133, I63139, I6319, I6320, I63211, I63212, I63213, I63219, I6322, I63231, I63232, I63233, I63239, I6329, I6330, I63311, I63312, I63313, I63319, I63321, I63322, I63323, I63329, I63331, I63332, I63333, I63339, I63341, I63342, I63343, I63349, I6339, I6340, I63411, I63412, I63413, I63419, I63421, I63422, I63423, I63429, I63431, I63432, I63433, I63439, I63441, I63442, I63443, I63449, I6349, I6350, I63511, I63512, I63513, I63519, I63521, I63522, I63523, I63529, I63531, I63532, I63533, I63539, I63541, I63542, I63543, I63549, I6359, I636, I638, I639 |
| DXX01388 | Transient cerebral ischemia, TIA | G450, G451, G452, G458, G459, G460, G461, G462, I67841, I67848 |
| DXX01390 | Coma, persistent vegetative state | E035, G931, G935, G936, R4020, R402110, R402111, R402112, R402113, R402114, R402120, R402121, R402122, R402123, R402124, R402210, R402211, R402212, R402213, R402214, R402220, R402221, R402222, R402223, R402224, R402310, R402311, R402312, R402313, R402314, R402320, R402321, R402322, R402323, R402324, R402340, R402341, R402342, R402343, R402344, R403 |
| DXX01392 | Delirium, Encephalopathy | F05, G92, G9340, G9341, G9349, I674, I6783 |
| DXX04126 | other lung complications | J90, J940, J941, J942, J949, J954, J955, J95811, J95859, J9588, R091 |
| DXX04127 | empyema, lung abscess | J869 |
| DXX04130 | Aspiration Pneumonia | J690, J691, J698 |
| DXX04138 | Viral Pneumonia | B012, J120, J122, J123, J1289, J129 |
| DXX04142 | Respiratory Failure | J80, J9584, J9600, J9601, J9602, J9610, J9611, J9612, J9620, J9621, J9622, J9690, J9691, J9692, R092 |
| DXX04154 | Respiratory Insufficiency | R0681, R0901, R0902, Y654, Z9981 |
| DXX04164 | Chronic Fungal and Other Pneumonias | A70, B390, B391, B392, B440, B7781 |
| DXX04170 | Ventilator Associated Pnuemonia | J95851 |
| DXX04172 | Gram Negative Pneumonia | J155, J156 |
| DXX04173 | MRSA Pneumonia | J15212 |
| DXX04174 | Other Staph Pneumonia | J1520, J15211, J1529 |
| DXX04176 | Resp Failure following trauma / surgery | J951, J952, J953, J95821, J95822 |
| DXX04177 | Ventilator Dependence | Z9911, Z9912 |
| DXX04187 | Other lung problems | J182, J918, J9811, J9819, R063 |
| DXX04188 | Other Bacterial Pneumonia | J158, J159, J17, J188, J189 |
| DXX04189 | Debilitating Viral Pneumonia | J09X1 |
| DXX04190 | Influenza with Pneumonia | J1000, J1001, J1008, J1100, J1108 |
| DXX05264 | arterial thromboembolism | I749 |
| DXX05272 | dic, coagulation, hemorrhagic disorders | D65, D7582 |
| DXX05274 | Transfusion, Infusion related complications | D6951, E8771, R5084, T8029XA, T8030XA, T80310A, T80311A, T80319A, T8039XA, T8040XA, T80410A, T80411A, T80419A, T8049XA, T8051XA, T8059XA, T8061XA, T8069XA, T80818A, T8089XA, T8090XA, T80910A, T80911A, T80919A, T8092XA, T80A0XA, T80A10A, T80A11A, T80A19A, T80A9XA, Y620, Y621, Y623, Y630, Y631, Y640, Y650, Y651 |
| DXX05275 | Phlebitis, Deep vein thrombosis (DVT) | I8000, I8001, I8002, I8003, I8010, I8011, I8012, I8013, I80201, I80202, I80203, I80209, I80211, I80212, I80213, I80219, I80221, I80222, I80223, I80229, I80231, I80232, I80233, I80239, I80291, I80292, I80293, I80299, I803, I809, I821, I82401, I82402, I82403, I82409, I82411, I82412, I82413, I82419, I82421, I82422, I82423, I82429, I82431, I82432, I82433, I82439, I82441, I82442, I82443, I82449, I82491, I82492, I82493, I82499, I824Y1, I824Y2, I824Y3, I824Y9, I824Z1, I824Z2, I824Z3, I824Z9, I82811, I82812, I82813, I82819, I82890, I8290, I87001, I87002, I87003, I87009, I87011, I87012, I87013, I87019, I87021, I87022, I87023, I87029, I87031, I87032, I87033, I87039, I87091, I87092, I87093, I87099 |
| DXX05281 | STEMI | I2101, I2102, I2109, I2111, I2119, I2121, I2129, I213 |
| DXX05289 | Subendocardial infarct | I214 |
| DXX05291 | Recent AMI | I220, I221, I222, I228, I229 |
| DXX05297 | Hypotension / Syncope | I952, I9581, I959, R55 |
| DXX05298 | Fluid Electrolyte Acid Base Problems | E8330, E8339, E8340, E8341, E8342, E8349, E870, E871, E872, E873, E874, E875, E876, E8770, E8779, E878 |
| DXX05299 | Shock / Cardiac Arrest | I462, I468, I469, I4901, I4902, R570, R571, R578, R579, T782XXA, T882XXA, T886XXA |
| DXX05303 | Acute CHF / pulm edema | I5021, I5023, I5031, I5033, I5041, I5043, J810, J811, R0601 |
| DXX05308 | Pulmonary Embolism | I2690, I2692, I2699 |
| DXX05311 | Other Phlebitis, Lymphangitis, varices | I808, I82210, I82290, I82601, I82602, I82603, I82609, I82611, I82612, I82613, I82619, I82621, I82622, I82623, I82629, I82A11, I82A12, I82A13, I82A19, I82B11, I82B12, I82B13, I82B19, I82C11, I82C12, I82C13, I82C19 |
| DXX05320 | Atrial Flutter / Fibrillation | I480, I481, I482, I483, I484, I4891, I4892 |
| DXX05335 | Sinus Node Dysfunction | I498, R001 |
| DXX05336 | Supraventricular Tachyarrhythmias | I471, I492 |
| DXX05339 | Ventricular Arrhythmias | I470, I472 |
| DXX05340 | Other cardiac arrhythmias | I479, I499, R000, R002 |
| DXX05342 | Acute cor pulmonale | I2601, I2602, I2609 |
| DXX05367 | Hypertensive Urgency | I160, I161, I169 |
| DXX05372 | Shock during or following cardiac surgery | I97120, I97121, I97710, I97790 |
| DXX05373 | Shock during or post-procedure | I97711, I97791, I9788, T8110XA, T8111XA, T8112XA, T8119XA |
| DXX05375 | Dehydration | E860, E861, E869 |
| DXX06160 | Gastroenteritis | A080, A0811, A0819, A082, A0831, A0832, A0839, A084, A088, A09, K5289, K529 |
| DXX06305 | C-Difficile Infection | A047 |
| DXX06306 | GI Bleed | K2971, K2981, K2991, K625, K920, K921, K922 |
| DXX06307 | Intestinal Obstruction | K315, K560, K5660, K5669, K567 |
| DXX07110 | Hepatorenal Syndrome | K767 |
| DXX09187 | Wound Infections | A4852, K6811, T814XXA |
| DXX09190 | Wound Dehiscence | T8130XA, T8131XA, T8132XA |
| DXX09191 | Decubitus Ulcer | L89000, L89001, L89002, L89009, L89010, L89011, L89012, L89019, L89020, L89021, L89022, L89029, L89100, L89101, L89102, L89109, L89110, L89111, L89112, L89119, L89120, L89121, L89122, L89129, L89130, L89131, L89132, L89139, L89140, L89141, L89142, L89149, L89150, L89151, L89152, L89159, L89200, L89201, L89202, L89209, L89210, L89211, L89212, L89219, L89220, L89221, L89222, L89229, L89300, L89301, L89302, L89309, L89310, L89311, L89312, L89319, L89320, L89321, L89322, L89329, L8940, L8941, L8942, L8945, L89500, L89501, L89502, L89509, L89510, L89511, L89512, L89519, L89520, L89521, L89522, L89529, L89600, L89601, L89602, L89609, L89610, L89611, L89612, L89619, L89620, L89621, L89622, L89629, L89810, L89811, L89812, L89819, L89890, L89891, L89892, L89899, L8990, L8991, L8992, L8995 |
| DXX09192 | Dermatitis, Urticaria | T7841XA |
| DXX11143 | Urinary Tract Infection | N10, N110, N111, N118, N119, N12, N136, N151, N159, N16, N2884, N2885, N2886, N3000, N3001, N3010, N3011, N3020, N3021, N3030, N3031, N3080, N3081, N3090, N3091, N340, N341, N342, N343, N35111, N35112, N35113, N35114, N35119, N3512, N37, N390, R309 |
| DXX11145 | Urinary Complications | N99520, N99521, N99522, N99523, N99524, N99528, N99530, N99531, N99532, N99533, N99534, N99538, N9981, N9989 |
| DXX11152 | Urinary Frequency & other symptoms | R300, R34 |
| DXX11167 | Acute Kidney Failure | N170, N171, N172, N178, N179, N19, N990 |
| DXX16296 | Hemorrhage | R58, R710 |
| DXX1770 | Complications from chemotherapy | T80810A |
| DXX1846 | Opportunistic Infections | B3781, B395, B399 |
| DXX1849 | Other bacterial infections | A482, A484, A488, A4901, A491, A492, A493, A498, A499, B950, B951, B952, B953, B954, B955, B9561, B957, B958, B960, B961, B963, B964, B965, B966, B967, B9681, B9682, B9689, I76, J200, J201, J202, R899 |
| DXX1850 | MRSA, Drug Resistant Infections | A4902, B9562, Z1610, Z1611, Z1612, Z1619, Z1620, Z1621, Z1622, Z1623, Z1624, Z1629, Z1630, Z1631, Z1632, Z1633, Z16341, Z16342, Z1635, Z1639 |
| DXX1851 | Sepsis | A392, A394, A400, A401, A403, A408, A409, A4101, A4102, A411, A412, A413, A414, A4150, A4151, A4152, A4153, A4159, A4181, A4189, A419, A5486, B007, B377 |
| DXX1852 | Severe Sepsis | A483, R6511, R6520, R6521 |
| DXX1853 | Bacteremia, SIRS, no organ dysfunction | R6510, R7881 |
| DXX1860 | Other Sexually Transmitted Diseases | A5601 |
| DXX19103 | Altered mental status | F060, F061, F062, R400, R401 |
| DXX19105 | Other Mental Disorders | F068 |
| DXX2161 | Complications from Central Line | T80218A, T80219A, T8022XA |
| DXX2164 | Accidental Falls | V00811A, V00811D, V00812A, V00812D, V00818A, V00818D, V00831A, V00831D, W050XXA, W050XXD, W051XXA, W051XXD, W052XXA, W052XXD, W06XXXA, W06XXXD, W07XXXA, W07XXXD, W08XXXA, W08XXXD, W102XXA, W102XXD, W108XXA, W108XXD, W109XXA, W109XXD, W1811XA, W1811XD, W1812XA, W1812XD |
| DXX2171 | Adverse effects of drugs | G4440, G4441, K1232, R502, T360X5A, T360X5D, T361X5A, T361X5D, T362X5A, T362X5D, T363X5A, T363X5D, T364X5A, T364X5D, T365X5A, T365X5D, T366X5A, T366X5D, T367X5A, T367X5D, T368X5A, T368X5D, T3695XA, T3695XD, T370X5A, T370X5D, T371X5A, T371X5D, T372X5A, T372X5D, T373X5A, T373X5D, T374X5A, T374X5D, T375X5A, T375X5D, T378X5A, T378X5D, T3795XA, T3795XD, T380X5A, T380X5D, T381X5A, T381X5D, T382X5A, T382X5D, T383X5A, T383X5D, T384X5A, T384X5D, T385X5A, T385X5D, T386X5A, T386X5D, T387X5A, T387X5D, T38805A, T38805D, T38815A, T38815D, T38895A, T38895D, T38905A, T38905D, T38995A, T38995D, T39015A, T39015D, T39095A, T39095D, T391X5A, T391X5D, T392X5A, T392X5D, T39315A, T39315D, T39395A, T39395D, T394X5A, T394X5D, T398X5A, T398X5D, T3995XA, T3995XD, T400X5A, T400X5D, T402X5A, T402X5D, T403X5A, T403X5D, T404X5A, T404X5D, T40605A, T40605D, T40695A, T40695D, T407X5A, T407X5D, T40905A, T40905D, T40995A, T40995D, T415X5A, T415X5D, T420X5A, T420X5D, T421X5A, T421X5D, T422X5A, T422X5D, T423X5A, T423X5D, T424X5A, T424X5D, T425X5A, T425X5D, T426X5A, T426X5D, T4275XA, T4275XD, T428X5A, T428X5D, T43015A, T43015D, T43025A, T43025D, T431X5A, T431X5D, T43205A, T43205D, T43215A, T43215D, T43225A, T43225D, T43295A, T43295D, T433X5A, T433X5D, T434X5A, T434X5D, T43505A, T43505D, T43595A, T43595D, T43605A, T43605D, T43615A, T43615D, T43625A, T43625D, T43635A, T43635D, T43695A, T43695D, T438X5A, T438X5D, T4395XA, T4395XD, T440X5A, T440X5D, T441X5A, T441X5D, T442X5A, T442X5D, T443X5A, T443X5D, T444X5A, T444X5D, T445X5A, T445X5D, T446X5A, T446X5D, T447X5A, T447X5D, T448X5A, T448X5D, T44905A, T44905D, T44995A, T44995D, T450X5A, T450X5D, T451X5A, T451X5D, T452X5A, T452X5D, T453X5A, T453X5D, T454X5A, T454X5D, T45515A, T45515D, T45525A, T45525D, T45605A, T45605D, T45615A, T45615D, T45625A, T45625D, T45695A, T45695D, T457X5A, T457X5D, T458X5A, T458X5D, T4595XA, T4595XD, T460X5A, T460X5D, T461X5A, T461X5D, T462X5A, T462X5D, T463X5A, T463X5D, T464X5A, T464X5D, T465X5A, T465X5D, T466X5A, T466X5D, T467X5A, T467X5D, T468X5A, T468X5D, T46905A, T46905D, T46995A, T46995D, T470X5A, T470X5D, T471X5A, T471X5D, T472X5A, T472X5D, T473X5A, T473X5D, T474X5A, T474X5D, T475X5A, T475X5D, T476X5A, T476X5D, T477X5A, T477X5D, T478X5A, T478X5D, T4795XA, T4795XD, T480X5A, T480X5D, T481X5A, T481X5D, T48205A, T48205D, T48295A, T48295D, T483X5A, T483X5D, T484X5A, T484X5D, T485X5A, T485X5D, T486X5A, T486X5D, T48905A, T48905D, T48995A, T48995D, T490X5A, T490X5D, T491X5A, T491X5D, T492X5A, T492X5D, T493X5A, T493X5D, T494X5A, T494X5D, T495X5A, T495X5D, T496X5A, T496X5D, T497X5A, T497X5D, T498X5A, T498X5D, T4995XA, T4995XD, T500X5A, T500X5D, T501X5A, T501X5D, T502X5A, T502X5D, T503X5A, T503X5D, T504X5A, T504X5D, T505X5A, T505X5D, T506X5A, T506X5D, T507X5A, T507X5D, T508X5A, T508X5D, T50905A, T50905D, T50995A, T50995D, T50A15A, T50A25A, T50A95A, T50B15A, T50B15D, T50B95A, T50B95D, T50Z15A, T50Z15D, T50Z95A, T50Z95D |
| DXX2175 | Complications of anesthesia | T410X5A, T411X5A, T41205A, T41295A, T413X5A, T4145XA, T883XXA, T884XXA, T8852XA, T8853XA, T8859XA, Y653, Y700, Y701, Y702, Y703, Y708 |
| DXX2360 | Complication of Implanted device, graft | T8541XA, T8542XA, T8543XA, T8544XA, T8549XA, T85613A, T85623A, T8579XA, T85818A, T8581XA, T85828A, T8582XA, T85838A, T8583XA, T85848A, T8584XA, T85858A, T8585XA, T85868A, T8586XA, T85898A, T8589XA |
| DXX2361 | complications of surgical procedures | D7801, D7802, D7811, D7812, D7821, D7822, D7831, D7832, D7833, D7834, E3601, E3602, E3611, E3612, E89810, E89811, E89820, E89821, E89822, E89823, G9731, G9732, G9748, G9749, G9751, G9752, G9761, G9762, G9763, G9764, I97131, I97191, I97410, I97411, I97418, I9742, I9751, I9752, I97610, I97611, I97618, I9762, I97620, I97621, I97622, I97630, I97631, I97638, I97640, I97641, I97648, I9789, J9561, J9562, J9571, J9572, J95830, J95831, J95860, J95861, J95862, J95863, J9589, K9161, K9162, K9171, K9172, K91840, K91841, K91870, K91871, K91872, K91873, K9189, L7601, L7602, L7611, L7612, L7621, L7622, L7631, L7632, L7633, L7634, M96810, M96811, M96820, M96821, M96830, M96831, M96840, M96841, M96842, M96843, N9961, N9962, N9971, N9972, N99820, N99821, N99840, N99841, N99842, N99843, R5082, T81710A, T81711A, T81718A, T81719A, T8172XA, T8182XA, T8189XA, T819XXA, T888XXA, Y626, Y628, Y629, Y652, Y6551, Y6552, Y6553, Y710, Y711, Y712, Y713, Y718, Y720, Y721, Y722, Y723, Y728, Y730, Y731, Y732, Y733, Y738, Y740, Y741, Y742, Y743, Y748, Y750, Y751, Y752, Y753, Y758, Y760, Y761, Y762, Y763, Y768, Y770, Y771, Y772, Y773, Y778, Y780, Y781, Y782, Y783, Y788, Y790, Y791, Y792, Y793, Y798, Y800, Y801, Y802, Y803, Y808, Y810, Y811, Y812, Y813, Y818, Y828, Y829, Y848 |
| DXX2362 | complications of medical care | D7881, D7889, E368, E8989, I973, J95850, L7681, L7682, M9689, R680, T7841XD, T801XXA, T8181XA, T880XXA, T881XXA, T887XXA, T889XXA, Y633, Y635, Y636, Y638, Y639, Y641, Y648, Y649, Y658, Y66, Y69, Y844, Y846, Y847 |
| DXX2395 | Foreign body left during procedure | T81500A, T81501A, T81502A, T81503A, T81504A, T81505A, T81506A, T81507A, T81508A, T81509A, T81510A, T81511A, T81512A, T81513A, T81514A, T81515A, T81516A, T81517A, T81518A, T81519A, T81520A, T81521A, T81522A, T81523A, T81524A, T81525A, T81526A, T81527A, T81528A, T81529A, T81530A, T81531A, T81532A, T81533A, T81534A, T81535A, T81536A, T81537A, T81538A, T81539A, T81590A, T81591A, T81592A, T81593A, T81594A, T81595A, T81596A, T81597A, T81598A, T81599A, T8160XA, T8161XA, T8169XA |
| DXX9910 | HAC 02: Air Embolism | T800XXA |
| DXX9912 | HAC 04: Stage III and IV Pressure Ulcers | L89003, L89004, L89013, L89014, L89023, L89024, L89103, L89104, L89113, L89114, L89123, L89124, L89133, L89134, L89143, L89144, L89153, L89154, L89203, L89204, L89213, L89214, L89223, L89224, L89303, L89304, L89313, L89314, L89323, L89324, L8943, L8944, L89503, L89504, L89513, L89514, L89523, L89524, L89603, L89604, L89613, L89614, L89623, L89624, L89813, L89814, L89893, L89894, L8993, L8994 |
| DXX9914 | HAC 09: Manifestations of Poor Glycemic Control | E15 |
Table 4: ICD-10 Relevant Procedure Codes
| Group ID | Group Name | Code Value |
| PXX03231 | Other therapeutic procedures – 231 | 0WQ0XZZ, 0WQ6XZZ, 0WQKXZZ, 0WQLXZZ, 3E00XGC |
| PXX03235 | Robotic Assisted Procedure | 8E0W0CZ, 8E0W3CZ, 8E0W7CZ, 8E0WXCZ |
| PXX0441 | Other non-OR therapeutic procedures on respiratory system – 041 | 0HQ5XZZ |
| PXX05247 | Computer Assisted Procedure | 8E0WXBF, 8E0WXBG, 8E0WXBH, 8E0WXBZ |
| PXX08160 | Other therapeutic procedures on muscles and tendons – 160 | 0JB00ZZ, 0JB50ZZ, 0JB60ZZ, 0JB70ZZ, 0JB80ZZ, 0JB90ZZ, 0JBB0ZZ, 0JBC0ZZ, 0JBD0ZZ, 0JBF0ZZ, 0JBG0ZZ, 0JBH0ZZ, 0JBN0ZZ, 0JBP0ZZ, 0JBQ0ZZ, 0JBR0ZZ, 0JD00ZZ, 0JD03ZZ, 0JD10ZZ, 0JD13ZZ, 0JD40ZZ, 0JD43ZZ, 0JD50ZZ, 0JD53ZZ, 0JD60ZZ, 0JD63ZZ, 0JD70ZZ, 0JD73ZZ, 0JD80ZZ, 0JD83ZZ, 0JD90ZZ, 0JD93ZZ, 0JDB0ZZ, 0JDB3ZZ, 0JDC0ZZ, 0JDC3ZZ, 0JDD0ZZ, 0JDD3ZZ, 0JDF0ZZ, 0JDF3ZZ, 0JDG0ZZ, 0JDG3ZZ, 0JDH0ZZ, 0JDH3ZZ, 0JDJ0ZZ, 0JDJ3ZZ, 0JDK0ZZ, 0JDK3ZZ, 0JDL0ZZ, 0JDL3ZZ, 0JDM0ZZ, 0JDM3ZZ, 0JDN0ZZ, 0JDN3ZZ, 0JDP0ZZ, 0JDP3ZZ, 0JDQ0ZZ, 0JDQ3ZZ, 0JDR0ZZ, 0JDR3ZZ |
| PXX08164 | Other OR therapeutic procedures on musculoskeletal system – 164 | 0HQBXZZ, 0HQCXZZ, 0HQDXZZ, 0HQEXZZ, 0HQFXZZ, 0HQGXZZ, 0HQHXZZ, 0HQJXZZ, 0HQKXZZ, 0HQLXZZ, 0HQMXZZ, 0HQNXZZ, 0WQ00ZZ, 0WQ03ZZ, 0WQ04ZZ, 0WQK0ZZ, 0WQK3ZZ, 0WQK4ZZ, 0WQL0ZZ, 0WQL3ZZ, 0WQL4ZZ |
| PXX09166 | Lumpectomy, quadrantectomy of breast – 166 | 0HBT7ZZ, 0HBT8ZZ, 0HBTXZZ, 0HBU7ZZ, 0HBU8ZZ, 0HBUXZZ, 0HBV7ZZ, 0HBV8ZZ, 0HBVXZZ |
| PXX09169 | Debridement of wound, infection or burn – 169 | 0HB0XZZ, 0HB1XZZ, 0HB4XZZ, 0HB5XZZ, 0HB6XZZ, 0HB7XZZ, 0HB8XZZ, 0HBAXZZ, 0HBBXZZ, 0HBCXZZ, 0HBDXZZ, 0HBEXZZ, 0HBFXZZ, 0HBGXZZ, 0HBHXZZ, 0HBJXZZ, 0HBKXZZ, 0HBLXZZ, 0HBMXZZ, 0HBNXZZ |
| PXX09171 | Suture of skin and subcutaneous tissue – 171 | 0HQ0XZZ, 0HQ1XZZ, 0HQ8XZZ, 0HQAXZZ, 0HQTXZZ, 0HQUXZZ, 0HQVXZZ |
| PXX09172 | Skin graft – 172 | 0HX5XZZ |
| PXX09174 | Other non-OR therapeutic procedures on skin and breast – 174 | 0H0T3JZ, 0H0U3JZ, 0H0V3JZ, 0H9T30Z, 0H9T3ZZ, 0H9T70Z, 0H9T7ZZ, 0H9T80Z, 0H9T8ZZ, 0H9TXZZ, 0H9U30Z, 0H9U3ZZ, 0H9U70Z, 0H9U7ZZ, 0H9U80Z, 0H9U8ZZ, 0H9UXZZ, 0H9V30Z, 0H9V3ZZ, 0H9V70Z, 0H9V7ZZ, 0H9V80Z, 0H9V8ZZ, 0H9VXZZ, 0H9W30Z, 0H9W3ZZ, 0H9W70Z, 0H9W7ZZ, 0H9W80Z, 0H9W8ZZ, 0H9X30Z, 0H9X3ZZ, 0H9X70Z, 0H9X7ZZ, 0H9X80Z, 0H9X8ZZ, 0HQT0ZZ, 0HQT3ZZ, 0HQU0ZZ, 0HQU3ZZ |
| PXX09175 | Other OR therapeutic procedures on skin and breast – 175 | 0H0T0JZ, 0H0T0KZ, 0H0T0ZZ, 0H0T3KZ, 0H0T3ZZ, 0H0TXZZ, 0H0U0JZ, 0H0U0KZ, 0H0U0ZZ, 0H0U3KZ, 0H0U3ZZ, 0H0UXZZ, 0H0V07Z, 0H0V0JZ, 0H0V0KZ, 0H0V0ZZ, 0H0V37Z, 0H0V3KZ, 0H0V3ZZ, 0H0VXZZ, 0HBY0ZZ, 0HBY3ZZ, 0HBY7ZZ, 0HBY8ZZ, 0HBYXZZ, 0HHT0NZ, 0HHT3NZ, 0HHT7NZ, 0HHT8NZ, 0HHU0NZ, 0HHU3NZ, 0HHU7NZ, 0HHU8NZ, 0HHV0NZ, 0HHV3NZ, 0HHV7NZ, 0HHV8NZ, 0HHW0NZ, 0HHW3NZ, 0HHW7NZ, 0HHW8NZ, 0HHX0NZ, 0HHX3NZ, 0HHX7NZ, 0HHX8NZ, 0HM1XZZ, 0HM4XZZ, 0HM5XZZ, 0HM6XZZ, 0HM7XZZ, 0HM8XZZ, 0HM9XZZ, 0HMAXZZ, 0HMBXZZ, 0HMCXZZ, 0HMDXZZ, 0HMEXZZ, 0HMFXZZ, 0HMGXZZ, 0HMHXZZ, 0HMJXZZ, 0HMKXZZ, 0HMLXZZ, 0HMMXZZ, 0HMNXZZ, 0HMTXZZ, 0HMUXZZ, 0HMVXZZ, 0HMWXZZ, 0HMXXZZ, 0HNQXZZ, 0HNRXZZ, 0HNT0ZZ, 0HNT3ZZ, 0HNT7ZZ, 0HNT8ZZ, 0HNTXZZ, 0HNU0ZZ, 0HNU3ZZ, 0HNU7ZZ, 0HNU8ZZ, 0HNUXZZ, 0HNV0ZZ, 0HNV3ZZ, 0HNV7ZZ, 0HNV8ZZ, 0HNVXZZ, 0HNW0ZZ, 0HNW3ZZ, 0HNW7ZZ, 0HNW8ZZ, 0HNWXZZ, 0HNX0ZZ, 0HNX3ZZ, 0HNX7ZZ, 0HNX8ZZ, 0HNXXZZ, 0HPT0NZ, 0HPT3NZ, 0HPU0NZ, 0HPU3NZ, 0HQT7ZZ, 0HQT8ZZ, 0HQU7ZZ, 0HQU8ZZ, 0HQV0ZZ, 0HQV3ZZ, 0HQV7ZZ, 0HQV8ZZ, 0HQW0ZZ, 0HQW3ZZ, 0HQW7ZZ, 0HQW8ZZ, 0HQWXZZ, 0HQX0ZZ, 0HQX3ZZ, 0HQX7ZZ, 0HQX8ZZ, 0HQXXZZ, 0HQY0ZZ, 0HQY3ZZ, 0HQY7ZZ, 0HQY8ZZ, 0HQYXZZ, 0HRSXJZ, 0HRSXKZ, 0HRT07Z, 0HRT0JZ, 0HRT0KZ, 0HRT37Z, 0HRT3JZ, 0HRT3KZ, 0HRTX7Z, 0HRTXJZ, 0HRTXKZ, 0HRU07Z, 0HRU0JZ, 0HRU0KZ, 0HRU37Z, 0HRU3JZ, 0HRU3KZ, 0HRUX7Z, 0HRUXJZ, 0HRUXKZ, 0HRV07Z, 0HRV0KZ, 0HRV37Z, 0HRV3KZ, 0HRVX7Z, 0HRVXJZ, 0HRVXKZ, 0HRW07Z, 0HRW0JZ, 0HRW0KZ, 0HRW37Z, 0HRW3JZ, 0HRW3KZ, 0HRWX7Z, 0HRWXJZ, 0HRWXKZ, 0HRX07Z, 0HRX0JZ, 0HRX0KZ, 0HRX37Z, 0HRX3JZ, 0HRX3KZ, 0HRXX7Z, 0HRXXJZ, 0HRXXKZ, 0HSWXZZ, 0HSXXZZ, 0HUT07Z, 0HUT0JZ, 0HUT0KZ, 0HUT37Z, 0HUT3JZ, 0HUT3KZ, 0HUT77Z, 0HUT7JZ, 0HUT7KZ, 0HUT87Z, 0HUT8JZ, 0HUT8KZ, 0HUTX7Z, 0HUTXJZ, 0HUTXKZ, 0HUU07Z, 0HUU0JZ, 0HUU0KZ, 0HUU37Z, 0HUU3JZ, 0HUU3KZ, 0HUU77Z, 0HUU7JZ, 0HUU7KZ, 0HUU87Z, 0HUU8JZ, 0HUU8KZ, 0HUUX7Z, 0HUUXJZ, 0HUUXKZ, 0HUV07Z, 0HUV0JZ, 0HUV0KZ, 0HUV37Z, 0HUV3JZ, 0HUV3KZ, 0HUV77Z, 0HUV7JZ, 0HUV7KZ, 0HUV87Z, 0HUV8JZ, 0HUV8KZ, 0HUVX7Z, 0HUVXJZ, 0HUVXKZ, 0HUW07Z, 0HUW0JZ, 0HUW0KZ, 0HUW37Z, 0HUW3JZ, 0HUW3KZ, 0HUW77Z, 0HUW7JZ, 0HUW7KZ, 0HUW87Z, 0HUW8JZ, 0HUW8KZ, 0HUWX7Z, 0HUWXJZ, 0HUWXKZ, 0HUX07Z, 0HUX0JZ, 0HUX0KZ, 0HUX37Z, 0HUX3JZ, 0HUX3KZ, 0HUX77Z, 0HUX7JZ, 0HUX7KZ, 0HUX87Z, 0HUX8JZ, 0HUX8KZ, 0HUXX7Z, 0HUXXJZ, 0HUXXKZ, 0HWT0JZ, 0HWT3JZ, 0HWU0JZ, 0HWU3JZ, 0JH00NZ, 0JH03NZ, 0JH10NZ, 0JH13NZ, 0JH40NZ, 0JH43NZ, 0JH50NZ, 0JH53NZ, 0JH60NZ, 0JH63NZ, 0JH70NZ, 0JH73NZ, 0JH80NZ, 0JH83NZ, 0JH90NZ, 0JH93NZ, 0JHB0NZ, 0JHB3NZ, 0JHC0NZ, 0JHC3NZ, 0JHD0NZ, 0JHD3NZ, 0JHF0NZ, 0JHF3NZ, 0JHG0NZ, 0JHG3NZ, 0JHH0NZ, 0JHH3NZ, 0JHJ0NZ, 0JHJ3NZ, 0JHK0NZ, 0JHK3NZ, 0JHL0NZ, 0JHL3NZ, 0JHM0NZ, 0JHM3NZ, 0JHN0NZ, 0JHN3NZ, 0JHP0NZ, 0JHP3NZ, 0JHQ0NZ, 0JHQ3NZ, 0JHR0NZ, 0JHR3NZ, 0KXH0ZZ, 0KXH4ZZ, 0KXJ0ZZ, 0KXJ4ZZ, 0W0007Z, 0W000JZ, 0W000KZ, 0W000ZZ, 0W0037Z, 0W003JZ, 0W003KZ, 0W003ZZ, 0W0047Z, 0W004JZ, 0W004KZ, 0W004ZZ, 0W0807Z, 0W080JZ, 0W080KZ, 0W080ZZ, 0W0837Z, 0W083JZ, 0W083KZ, 0W083ZZ, 0W0847Z, 0W084JZ, 0W084KZ, 0W084ZZ, 0W0F07Z, 0W0F0JZ, 0W0F0KZ, 0W0F0ZZ, 0W0F37Z, 0W0F3JZ, 0W0F3KZ, 0W0F3ZZ, 0W0F47Z, 0W0F4JZ, 0W0F4KZ, 0W0F4ZZ, 0W0K07Z, 0W0K0JZ, 0W0K0KZ, 0W0K0ZZ, 0W0K37Z, 0W0K3JZ, 0W0K3KZ, 0W0K3ZZ, 0W0K47Z, 0W0K4JZ, 0W0K4KZ, 0W0K4ZZ, 0W0L07Z, 0W0L0JZ, 0W0L0KZ, 0W0L0ZZ, 0W0L37Z, 0W0L3JZ, 0W0L3KZ, 0W0L3ZZ, 0W0L47Z, 0W0L4JZ, 0W0L4KZ, 0W0L4ZZ, 0W0M07Z, 0W0M0JZ, 0W0M0KZ, 0W0M0ZZ, 0W0M37Z, 0W0M3JZ, 0W0M3KZ, 0W0M3ZZ, 0W0M47Z, 0W0M4JZ, 0W0M4KZ, 0W0M4ZZ, 0WM20ZZ, 0WM40ZZ, 0WM50ZZ, 0WM60ZZ, 0WMK0ZZ, 0WML0ZZ, 0WMM0ZZ, 0WQ40ZZ, 0WQ43ZZ, 0WQ44ZZ, 0WQ4XZZ, 0WQ50ZZ, 0WQ53ZZ, 0WQ54ZZ, 0WQ5XZZ, 0WQ60ZZ, 0WQ63ZZ, 0WQ64ZZ, 0WQM0ZZ, 0WQM3ZZ, 0WQM4ZZ, 0WQMXZZ, 0WU00JZ, 0WU00KZ, 0WU04JZ, 0WU04KZ, 0WU20JZ, 0WU20KZ, 0WU24JZ, 0WU24KZ, 0WU60JZ, 0WU60KZ, 0WU64JZ, 0WU64KZ, 0WUK0JZ, 0WUK0KZ, 0WUK4JZ, 0WUK4KZ, 0WUL0JZ, 0WUL0KZ, 0WUL4JZ, 0WUL4KZ, 0WUM0JZ, 0WUM0KZ, 0WUM4JZ, 0WUM4KZ, 0WY20Z0, 0WY20Z1, 0XU20JZ, 0XU20KZ, 0XU24JZ, 0XU24KZ, 0XU30JZ, 0XU30KZ, 0XU34JZ, 0XU34KZ, 0XU40JZ, 0XU40KZ, 0XU44JZ, 0XU44KZ, 0XU50JZ, 0XU50KZ, 0XU54JZ, 0XU54KZ, 0XU60JZ, 0XU60KZ, 0XU64JZ, 0XU64KZ, 0XU70JZ, 0XU70KZ, 0XU74JZ, 0XU74KZ, 0XU80JZ, 0XU80KZ, 0XU84JZ, 0XU84KZ, 0XU90JZ, 0XU90KZ, 0XU94JZ, 0XU94KZ, 0XUB0JZ, 0XUB0KZ, 0XUB4JZ, 0XUB4KZ, 0XUC0JZ, 0XUC0KZ, 0XUC4JZ, 0XUC4KZ, 0XUD0JZ, 0XUD0KZ, 0XUD4JZ, 0XUD4KZ, 0XUF0JZ, 0XUF0KZ, 0XUF4JZ, 0XUF4KZ, 0XUG0JZ, 0XUG0KZ, 0XUG4JZ, 0XUG4KZ, 0XUH0JZ, 0XUH0KZ, 0XUH4JZ, 0XUH4KZ, 0XUJ0JZ, 0XUJ0KZ, 0XUJ4JZ, 0XUJ4KZ, 0XUK0JZ, 0XUK0KZ, 0XUK4JZ, 0XUK4KZ, 0XUL0JZ, 0XUL0KZ, 0XUL4JZ, 0XUL4KZ, 0XUM0JZ, 0XUM0KZ, 0XUM4JZ, 0XUM4KZ, 0XUN0JZ, 0XUN0KZ, 0XUN4JZ, 0XUN4KZ, 0XUP0JZ, 0XUP0KZ, 0XUP4JZ, 0XUP4KZ, 0XUQ0JZ, 0XUQ0KZ, 0XUQ4JZ, 0XUQ4KZ, 0XUR0JZ, 0XUR0KZ, 0XUR4JZ, 0XUR4KZ, 0XUS0JZ, 0XUS0KZ, 0XUS4JZ, 0XUS4KZ, 0XUT0JZ, 0XUT0KZ, 0XUT4JZ, 0XUT4KZ, 0XUV0JZ, 0XUV0KZ, 0XUV4JZ, 0XUV4KZ, 0XUW0JZ, 0XUW0KZ, 0XUW4JZ, 0XUW4KZ, 0YM00ZZ, 0YM10ZZ, 0YU007Z, 0YU00JZ, 0YU00KZ, 0YU047Z, 0YU04JZ, 0YU04KZ, 0YU107Z, 0YU10JZ, 0YU10KZ, 0YU147Z, 0YU14JZ, 0YU14KZ, 0YU907Z, 0YU90JZ, 0YU90KZ, 0YU947Z, 0YU94JZ, 0YU94KZ, 0YUB07Z, 0YUB0JZ, 0YUB0KZ, 0YUB47Z, 0YUB4JZ, 0YUB4KZ, 0YUC07Z, 0YUC0JZ, 0YUC0KZ, 0YUC47Z, 0YUC4JZ, 0YUC4KZ, 0YUD07Z, 0YUD0JZ, 0YUD0KZ, 0YUD47Z, 0YUD4JZ, 0YUD4KZ, 0YUF07Z, 0YUF0JZ, 0YUF0KZ, 0YUF47Z, 0YUF4JZ, 0YUF4KZ, 0YUG07Z, 0YUG0JZ, 0YUG0KZ, 0YUG47Z, 0YUG4JZ, 0YUG4KZ, 0YUH07Z, 0YUH0JZ, 0YUH0KZ, 0YUH47Z, 0YUH4JZ, 0YUH4KZ, 0YUJ07Z, 0YUJ0JZ, 0YUJ0KZ, 0YUJ47Z, 0YUJ4JZ, 0YUJ4KZ, 0YUK07Z, 0YUK0JZ, 0YUK0KZ, 0YUK47Z, 0YUK4JZ, 0YUK4KZ, 0YUL07Z, 0YUL0JZ, 0YUL0KZ, 0YUL47Z, 0YUL4JZ, 0YUL4KZ, 0YUM07Z, 0YUM0JZ, 0YUM0KZ, 0YUM47Z, 0YUM4JZ, 0YUM4KZ, 0YUN07Z, 0YUN0JZ, 0YUN0KZ, 0YUN47Z, 0YUN4JZ, 0YUN4KZ, 0YUP07Z, 0YUP0JZ, 0YUP0KZ, 0YUP47Z, 0YUP4JZ, 0YUP4KZ, 0YUQ07Z, 0YUQ0JZ, 0YUQ0KZ, 0YUQ47Z, 0YUQ4JZ, 0YUQ4KZ, 0YUR07Z, 0YUR0JZ, 0YUR0KZ, 0YUR47Z, 0YUR4JZ, 0YUR4KZ, 0YUS07Z, 0YUS0JZ, 0YUS0KZ, 0YUS47Z, 0YUS4JZ, 0YUS4KZ, 0YUT07Z, 0YUT0JZ, 0YUT0KZ, 0YUT47Z, 0YUT4JZ, 0YUT4KZ, 0YUU07Z, 0YUU0JZ, 0YUU0KZ, 0YUU47Z, 0YUU4JZ, 0YUU4KZ, 0YUV07Z, 0YUV0JZ, 0YUV0KZ, 0YUV47Z, 0YUV4JZ, 0YUV4KZ, 0YUW07Z, 0YUW0JZ, 0YUW0KZ, 0YUW47Z, 0YUW4JZ, 0YUW4KZ, 0YUX07Z, 0YUX0JZ, 0YUX0KZ, 0YUX47Z, 0YUX4JZ, 0YUX4KZ, 0YUY07Z, 0YUY0JZ, 0YUY0KZ, 0YUY47Z, 0YUY4JZ, 0YUY4KZ |
| PXX09182 | Mammography – 182 | BH00ZZZ, BH01ZZZ, BH02ZZZ, BH03ZZZ, BH04ZZZ, BH05ZZZ, BH06ZZZ |
| PXX09183 | Bilateral Modified Radical Mastectomy | 07T90ZZ |
| PXX09188 | Resection Regional Lymph Nodes, Breast | 07T50ZZ, 07T60ZZ, 07T70ZZ, 07T80ZZ |
| PXX09189 | Destruction of Breast Tissue | 0H5T0ZZ, 0H5T3ZZ, 0H5T7ZZ, 0H5T8ZZ, 0H5TXZZ, 0H5U0ZZ, 0H5U3ZZ, 0H5U7ZZ, 0H5U8ZZ, 0H5UXZZ, 0H5V0ZZ, 0H5V3ZZ, 0H5V7ZZ, 0H5V8ZZ, 0H5VXZZ |
| PXX09190 | Excision Unilateral Breast | 0HBT0ZZ, 0HBT3ZZ, 0HBU0ZZ, 0HBU3ZZ |
| PXX09191 | Excision Bilateral Breast | 0HBV0ZZ, 0HBV3ZZ |
| PXX09192 | Resection Unilateral Breast | 0HTT0ZZ, 0HTU0ZZ |
| PXX09193 | Resection Bilateral Breast | 0HTV0ZZ |
| PXX09194 | Resection Thoracic Muscles | 0KTH0ZZ, 0KTJ0ZZ |
Table 5: Relevant Procedure Codes CPT/HCPCS
| Group ID | Group Name | Code Value |
| CT0011 | Breast placement of localization device | 19281, 19282, 19283, 19284, 19285, 19286, 19287, 19288 |
| CT0012 | Breast Implant | C1789 |
| CT0013 | Other Breast Procedures | 19020, 19030, 19105, 19112, 19328, 19330, 19355, 19370, 19371, 19396, 19499 |
| CT0014 | Mastectomy for Gynecomastia | 19300 |
| CT0025 | Preventive Medicine, Care Coordination | 98960, 98961, 98962, 98966, 98967, 98968, 99361, 99362, 99366, 99367, 99368, 99371, 99372, 99373, 99382, 99383, 99384, 99385, 99386, 99387, 99392, 99393, 99394, 99395, 99396, 99397, 99401, 99402, 99403, 99404, 99411, 99412, 99429, 99441, 99442, 99443, 99446, 99447, 99448, 99449, 99499, G0175, G0246, G0406, G0407, G0408, G0425, G0426, G0427, S0220, S0221, S0320 |
| CT0026 | Anesthesia and pain meds | J1960, J2270, J2310, J3010, J3070, S0012, S0092, S0093 |
| CT0082 | Medications for pain | J0592, J1230, J2315 |
| CT0089 | Metabolic Renal Hepatic Chemistry Panel | 80010, 80047, 80048, 80049, 80050, 80051, 80053, 80069, 80074, 80076, 82040, 82247, 82248, 82310, 82330, 82374, 82435, 82565, 82575, 82947, 84132, 84155, 84295, 84450, 84460, 84520, 84550 |
| CT0091 | Physician Services – Outpatient | 99050, 99051, 99053, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99241, 99242, 99243, 99244, 99245, 99271, 99272, 99273, 99274, 99275, 99354, 99355, 99381, 99391, T1015 |
| CT0092 | Physician Services – Inpatient | 99221, 99222, 99223, 99238, 99239, 99252, 99253, 99254, 99255 |
| CT0096 | Subsequent Physician Services Inpatient | 99462 |
| CT01394 | Medications (Injections, infusions and other forms) | C9743, J0695, J0714, J0875, J1443, J7121, J7328, Q2026, Q2027 |
| CT01395 | DME and supplies | Q4161, Q4162, Q4163, Q4164, Q4165, Q9950 |
| CT02387 | Pathology | 81162, 81211, 81212, 81213, 81214, 81215, 81216, 81217, 81432, 81433, 81540 |
| CT04282 | Chest X-Ray | 71010, 71015, 71020, 71021, 71022, 71023, 71030, 71034, 71035 |
| CT05230 | Tests – cardiac stress tests – cardiac stress tests – other | 78491, 78492 |
| CT05308 | Cardiac Stress Test | 78451, 78452, 78453, 78454, 78460, 78461, 78464, 78465, 78472, 78473, 78481, 78483, 93015, 93016, 93017, 93018 |
| CT05385 | Other diagnostic cardiovascular procedures | 93050 |
| CT0743 | Other diagnostic radiology and related techniques | 0422T |
| CT08387 | Insertion of catheter or spinal stimulator and injection into spinal canal | 64461, 64462, 64463 |
| CT09100 | Radical Mastectomy | 19305, 19306 |
| CT09101 | Simple Mastectomy | 19303, 19304 |
| CT0916 | Procedure – other breast – drainage of breast lesion | 19000, 19001 |
| CT09343 | Other diagnostic procedures on skin and subcutaneous tissue | 10035, 10036 |
| CT09349 | MAMMOGRAM | 77055, 77056, 77057, G0202, G0204, G0206, S8080 |
| CT0943 | Procedure – suture – skin – delayed wound closure | 12020, 12021, 13160 |
| CT0944 | Procedure – suture – skin – layer closure of wound | 12031, 12032, 12034, 12035, 12036, 12037 |
| CT0945 | Procedure – suture – skin – complex wound repair | 13100, 13101, 13102 |
| CT0946 | Procedure – graft – skin – skin tissue rearrangement | 14000, 14001 |
| CT0947 | Procedure – graft – skin – skin graft | 15002, 15003, 15004, 15005, 15040, 15100, 15101, 15110, 15111 |
| CT0950 | Procedure – graft – skin – graft material | C9358, Q4100, Q4101, Q4102, Q4103, Q4104, Q4105, Q4106, Q4107, Q4108, Q4110, Q4111 |
| CT0959 | Procedure – other non – or rx – other non – or skin procedures | 15850, 15851, 15852, 97602, S0630 |
| CT0961 | Procedure – other or rx – other or skin procedures | 11970 |
| CT0962 | Procedure – anesthesia | 00400, 00402, 00404, 00406 |
| CT0965 | Other care – wound care | 97597, 97598, 97605, 97606, E0182, E0188, E0189, E0198, E0769, G0281, G0282, S9097 |
| CT0967 | Other care – wound care – electromagnetic therapy | G0295, G0329 |
| CT0971 | Other care – chronic edema – appliance – non – segmental | E0655 |
| CT0983 | Imaging – mri – breast | 77058, 77059, C8903, C8904, C8905, C8906, C8907, C8908 |
| CT0984 | Imaging – us – breast | 76645 |
| CT0986 | Imaging – pet – breast cancer – treatment planning | G0252 |
| CT0989 | Imaging – mammography – bx localization | 77031, 77032 |
| CT0990 | Imaging – mammography – specimen | 76098 |
| CT0992 | Lab – gene expression – breast cancer | S3854 |
| CT0993 | DME – wound therapy | E2402 |
| CT0994 | Prosthetics – implant | L8600 |
| CT0995 | Prosthetics – breast | L8000, L8001, L8002, L8010, L8015, L8020, L8030, L8031, L8032, L8035, L8039 |
| CT0996 | Breast Reconstruction | 19316, 19324, 19325, 19340, 19342, 19350, 19357, 19364, 19366, 19380, S2067 |
| CT0997 | Breast Reconstruction w/deep flap | 19361, 19367, 19368, 19369, S2066, S2068 |
| CT0998 | Lumpectomy / Partial Mastectomy | 19301, 19302 |
| CT0999 | Modified Radical Mastectomy | 19307 |
| CT10295 | Thyroid Function Tests | 84432, 84436, 84437, 84439, 84442, 84443, 84445, 84479, 84480, 84481, 84482 |
| CT1166 | Lab – urinalysis | 81007, 81015 |
| CT1167 | Lab – specimen collection – urine | P9612, P9615 |
| CT1337 | Lab – genetic testing – brac1 | S3818 |
| CT1338 | Lab – genetic testing – brac2 | S3819 |
| CT1339 | Lab – genetic testing – brac1 / brac2 | S3820, S3823 |
| CT14388 | Magnetic resonance imaging | 0159T |
| CT1602 | Procedure – lymphadenectomy | 38740, 38745 |
| CT1603 | Procedure – biopsy / exploration – lymph nodes | 38500, 38505, 38525, 38530 |
| CT1613 | Procedure – heme / lymph – other rx | 36680 |
| CT1620 | Therapy – phlebotomy | 99195 |
| CT16296 | Lipid Level Monitoring | 80061, 82465, 83701, 83704, 84478 |
| CT16297 | Blood Count | 82728, 83540, 83550, 85004, 85007, 85008, 85009, 85013, 85014, 85018, 85025, 85027, 85032, 85041, 85044, 85045, 85046, 85048, 85049, G0306, G0307 |
| CT16298 | Finger stick – Blood Tests | 82948 |
| CT16316 | Blood transfusion | P9070, P9071, P9072 |
| CT1647 | Lab – hematology – blood count | 85055 |
| CT1651 | Lab – immunology | 86300, 86316 |
| CT1826 | Lab – microbiology – microscopic exam | 87205, 87206, 87207, 87209, 87210, 87220 |
| CT1828 | Lab – microbiology | P7001 |
| CT19304 | Psychiatry Services | H0031, S3005 |
| CT19381 | Smoking / Tobacco Cessation | 99406, 99407 |
| CT2009 | Alcohol / Drug Use Screening | 99409 |
| CT23309 | Markers for Inflammation | 85651, 85652 |
| CT2331 | Other care – observation | G0379 |
| CT2338 | Other care – other – education | S9445, S9446 |
| CT23398 | Ancillary Services | 99415, 99416, G9473, G9474, G9475, G9476, G9477, G9478, G9479 |
| CT2341 | Other care – other – exercise classes | S9451 |
| CT2351 | Lab – single mutation analysis | S3822 |
| CT9902 | E & M – consultation | Q3014, T1014 |
| CT9903 | E & M – hospital | 99217, 99218, 99219, 99220, 99231, 99232, 99233, 99234, 99235, 99236, 99291, 99292, 99293, 99294, 99295, 99296, 99298, 99299, 99300, 99465, 99466, 99475, 99481, 99482, G0378, G0390, S0310 |
| CT9904 | E & M – emergency care | 99058, 99281, 99282, 99283, 99284, 99285, G0380, G0381, G0382, G0383, G0384, S9083, S9088 |
| CT9905 | E & M – home visit | 99224, 99225, 99226, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, S0273 |
| CT9906 | E & M – nursing home | 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99318, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337 |
| CT9907 | E & M – prevention | 99420, G0101, S0302, S0610, S0612, S0613 |
| CT9908 | E & M – other | 96040, 99026, 99027, 99056, 99060, 99150, 99170, 99288, 99289, 99290, 99360, 99450, 99455, 99456, 99485, 99486, 99488, S0260, S0265, S9150 |
| CT99107 | Imaging – mri – other | 75559, 75563, C1770, S8035, S8042 |
| CT99109 | Imaging – mri – contrast agent | A9576, A9577, A9578, A9579, A9581, A9583, Q9953, Q9954 |
| CT9911 | Procedure – sedation | 99143, 99144, 99145, 99148, 99149 |
| CT99113 | Imaging – us – guide – biopsy | 76942 |
| CT99135 | Imaging – other imaging – inject / infuse contrast for x-ray | 38792 |
| CT99136 | Imaging – other imaging | 77051, 77052, 77053, 77054 |
| CT99142 | Lab – pathology consultation | 80500, 80502 |
| CT99143 | Lab – chemistry | 82003, 82045, 82140, 82150, 82154, 82157, 82160, 82190, 82205, 82232, 82239, 82240, 82261, 82273, 82306, 82307, 82331, 82340, 82382, 82383, 82384, 82436, 82438, 82487, 82488, 82491, 82492, 82528, 82530, 82533, 82540, 82541, 82542, 82543, 82544, 82570, 82607, 82608, 82626, 82627, 82633, 82634, 82646, 82649, 82651, 82652, 82664, 82666, 82668, 82670, 82671, 82672, 82677, 82679, 82690, 82746, 82747, 82784, 82785, 82787, 82962, 82977, 83001, 83002, 83051, 83069, 83090, 83491, 83498, 83499, 83516, 83518, 83519, 83520, 83528, 83582, 83586, 83593, 83615, 83690, 83727, 83735, 83788, 83789, 83921, 83930, 83935, 84100, 84133, 84134, 84135, 84140, 84143, 84144, 84146, 84150, 84156, 84157, 84160, 84163, 84165, 84166, 84181, 84182, 84233, 84234, 84235, 84238, 84252, 84270, 84300, 84311, 84315, 84402, 84403, 84425, 84466, 84525, 84540, 84545, 84560, 84578, 84580, 84583, 84590, 84591, 84597, 84630, 84681, 84702, 84703, 84704, 84830, 84999 |
| CT99148 | Lab – surgical pathology | 88300, 88302, 88304, 88305, 88307, 88309, 88311, 88312, 88313, 88314, 88318, 88319, 88321, 88323, 88325, 88329, 88331, 88332, 88333, 88334, 88342, 88346, 88347, 88348, 88349, 88355, 88356, 88358, 88360, 88361, 88362, 88365, 88367, 88368, 88371, 88372, 88380, 88381, 88384, 88385, 88386, 88387, 88388, 88399 |
| CT99169 | Lab – specimen collection – blood – venous – venipuncture | 36415, S9529 |
| CT99173 | Lab – specimen collection – specimen handling | 99000 |
| CT99174 | Lab – microscopic – wet mount | Q0111 |
| CT99175 | Lab – microscopic – koh prep | Q0112 |
| CT99191 | Supplies | A4206, A4207, A4208, A4209, A4210, A4211, A4213, A4215, A4216, A4217, A4218, A4244, A4245, A4246, A4247, A4248, A4265, A4280, A4450, A4452, A4455, A4456, A4458, A4461, A4463, A4465, A4470, A4480, A4550, A4561, A4562, A4649, A4651, A4652, A6000, A6010, A6011, A6021, A6022, A6023, A6024, A6025, A6154, A6196, A6197, A6198, A6199, A6203, A6204, A6205, A6206, A6207, A6208, A6209, A6210, A6211, A6212, A6213, A6214, A6215, A6216, A6217, A6218, A6219, A6220, A6221, A6222, A6223, A6224, A6228, A6229, A6230, A6231, A6232, A6233, A6234, A6235, A6236, A6237, A6238, A6239, A6240, A6241, A6242, A6243, A6244, A6245, A6246, A6247, A6248, A6250, A6251, A6252, A6253, A6254, A6255, A6256, A6257, A6258, A6259, A6260, A6261, A6262, A6266, A6402, A6403, A6404, A6407, A6412, A6413, A6441, A6442, A6443, A6444, A6445, A6446, A6447, A6448, A6449, A6450, A6451, A6452, A6453, A6454, A6455, A6456, A6457, A6550, A7000, A7001, A7002, A9282, C1769, C1883, C1894, C9898, J1642, S8415, S8430, S8431, T2028 |
| CT99198 | PQRI | G8440, G8458, G8508, G8540 |
| CT9923 | Procedure – related supplies – graft / repair | C1762, C1763, C1771, C1781, C2615, C9354, Q4112, Q4113, Q4114, Q4115 |
| CT9925 | Procedure – related supplies – resection – morcellator | C1782 |
| CT99309 | Physician Services | 99251 |
| CT99311 | Urine Protein | 81005, 82042, 82043, 82044 |
| CT99314 | Robotic Surgery | S2900 |
| CT99316 | Physician Services – Inpatient | 99356, 99357 |
| CT9933 | Therapy – phototherapy | 96567, 96570, 96571, 96900 |
| CT99392 | Other diagnostic procedures (interview, evaluation, consultation) | G0438, G0439 |
| CT9940 | Therapy – other | 99024, M0075 |
| CT99400 | Advance care planning | 1123F, 1124F, 1157F, 1158F, 4553F, 99497, 99498, S0255, S0257, S0311 |
| CT99401 | Bundled Payment / Medical Home | G9187, S0280, S0281 |
| CT99402 | Care Plan Oversight | 94005, 99339, 99340, 99374, 99375, 99377, 99378, 99379, 99380 |
| CT99403 | Case Management Services | 0518F, 0521F, 5050F, G0162, G0463, G9012, S0250, T1001, T1016, T1017, T2022, T2023, T2024 |
| CT99404 | Case Management Services – Behavioral | 96116, G0503, G0507, H0023, H1011 |
| CT99407 | Case Management Services – Oncology | G9054, S0353, S0354 |
| CT99408 | Chronic Care Management | 99487, 99489 |
| CT99409 | Home Health / Hospice | G0179, G0180, G0181, G0182 |
| CT99410 | Coordinated Care Fees/Services | G9003, G9004, G9011 |
| CT99411 | Medication Therapy Management Services | 99605, 99606, 99607 |
| CT99413 | Personal Care Services | T1019, T1020 |
| CT99414 | Physical therapy / Rehab | 97164, 97168, 97172 |
| CT99415 | Physician Services – Outpatient | 99358, 99359 |
| CT99416 | Procedures and Reporting | 99080, 99090, 99091 |
| CT99417 | Risk Assessment | G9316 |
| CT99418 | Transitional Care Management | 99495, 99496 |
| CT9946 | Rx – analg/antipy/nsaids – nsaids | J1885 |
| CT9947 | Rx – analg/antipy/nsaids – narcotics | J0364, J0595, J0745, J1170, J1810, J2175, J2180, J2271, J2275, J2300, J2410, S0109 |
| CT9949 | Rx – electrolytic, caloric, water – calcium supplements | J0610, J0620 |
| CT9950 | Rx – electrolytic, caloric, water – potassium supp | J3480, S5012 |
| CT9951 | Rx – electrolytic, caloric, water – multi-mineral prep | J7120, S5014 |
| CT9952 | Rx – electrolytic, caloric, water – sodium chlor preps | J7030, J7040, J7050, J7130 |
| CT9953 | Rx – electrolytic, caloric, water – replacement preparations, misc | J7100, J7110 |
| CT9954 | Rx – electrolytic, caloric, water – caloric rx, amino acid prep | J1955 |
| CT9955 | Rx – electrolytic, caloric, water – caloric rx dextrose / rel | J7042, J7060, J7070, S5010, S5011, S5013 |
| CT9956 | Rx – electrolytic, caloric, water – hydration – unspecfied | 90760, 90761, Q0081, S9373, S9374, S9375, S9376, S9377 |
| CT9960 | Rx – miscellaneous rx – anesthetics, local | J0670, J2001, J2400, J2795, S0020 |
| CT9963 | Rx – pharmacy fee | G0333, Q0510, Q0511, Q0512, Q0513, Q0514, S9430 |
| CT9966 | Other care – home care – nursing care | G0128, T1000, T1002, T1003, T1004 |
| CT9967 | Other care – home care – nursing care – rn | G0154 |
| CT9969 | Other care – home care – nursing care – np | S0274 |
| CT9974 | Other care – home care – home health aide | G0156, S9122, T1021 |
| XX0000 | Ungrouped Codes | 0008M, 0061T, 0351T, 0352T, 0353T, 0354T, 33952, 33954, 33958, 33962, 33966, 33984, 37191, 37192, 37193, 37619, 38900, 6030F, 76641, 76642, 77061, 77062, 77063, 81519, 97610, C9443, C9444, C9446, G0279, G0299, G0300, G0472, G0473, G6045, G6046, G8152, G8153, G8154, G8155, G8156, G8157, G8193, G8196, G8204, G8209, G8214, G8217, G8219, G8220, G8221, G8696, G8697, G8698, G8702, G8703, G8704, G8705, G8706, G8707, G8916, G8917, G8918, G8953, G8961, G8962, G8967, G8968, G8969, G8970, G8971, G8972, G9199, G9200, G9201, G9235, G9237, G9298, G9299, G9307, G9308, G9309, G9310, G9311, G9312, G9362, G9363, G9497, G9500, G9501, G9539, G9540, G9541, G9542, G9543, G9544, G9558, G9559, G9560, G9637, G9638, G9642, G9643, G9644, G9645, G9654, G9655, G9656, G9657, G9658, J2274, J2704, Q9974, S0144 |
Table 6: Relevant Typical Drug Groups
| Group ID | Group Name |
| RX001 | contrast media |
| RX002 | diagnostic agents |
| RX0111 | parasympathomimetics |
| RX017 | hypnotics and sedatives |
| RX0320 | cough and cold preparations |
| RX0321 | decongestants and other nasal preparations for topical use |
| RX0324 | throat preparations |
| RX0425 | antihistamines for systemic use |
| RX0426 | Bronchodilators: adrenergics for systemic use |
| RX0427 | drugs for obstructive airway diseases – inhalants |
| RX0429 | other systemic drugs for obstructive airway diseases |
| RX0530 | agents acting on the renin-angiotensin system |
| RX0531 | Agents for hypertensive emergencies |
| RX0534 | Other Anticoagulants |
| RX0535 | beta blocking agents |
| RX0536 | calcium channel blockers |
| RX0538 | diuretics |
| RX0539 | i.v. solutions & additives |
| RX0540 | Nitrates and other antianginals |
| RX0541 | other antihypertensives |
| RX0546 | Antiplatelet agents, thrombin inhibitors |
| RX0547 | Heparin group |
| RX0645 | antacids |
| RX0646 | antidiarrheals intestinal adsorbents |
| RX0647 | antiemetics and antinauseants |
| RX0648 | digestives incl. enzymes |
| RX0649 | drugs for constipation |
| RX0651 | drugs for peptic ulcer and gerd |
| RX0652 | intestinal antiinfectives |
| RX0857 | antiinflammatory and antirheumatic products |
| RX0860 | muscle relaxants |
| RX0861 | opioids |
| RX0862 | other analgesics and antipyretics |
| RX0864 | topical products for joint and muscular pain |
| RX0968 | antibiotics and chemotherapeutics for dermatological use |
| RX0969 | antifungals for dermatological use |
| RX0970 | antipruritics incl. antihistamines anesthetics etc. |
| RX0971 | antiseptics and disinfectants |
| RX0973 | corticosteroids dermatological preparations |
| RX0974 | ectoparasiticides incl. scabicides insecticides and repellents |
| RX0976 | irrigating solutions |
| RX0977 | medicated dressings |
| RX0978 | other dermatological preparations |
| RX0979 | preparations for treatment of wounds and ulcers |
| RX0980 | Moisturizers and skin protective agents |
| RX1083 | antithyroid preparations |
| RX1086 | corticosteroids for systemic use |
| RX1090 | endocrine therapy |
| RX1092 | thyroid preparations |
| RX13101 | other gynecologicals |
| RX13102 | progestogens |
| RX13103 | sex hormones and modulators of the genital system |
| RX1398 | estrogens |
| RX1399 | gonadotropins and other ovulation stimulants |
| RX16106 | iron preparations |
| RX16109 | vitamin b12 and folic acid |
| RX16110 | vitamin k and other hemostatics |
| RX16111 | Agents to stop bleeding |
| RX17112 | Chemoprotective agents in Cancer Treatment |
| RX18117 | antibacterials for systemic use |
| RX18119 | antiinfectives |
| RX18122 | antivirals for systemic use |
| RX19125 | anxiolytics |
| RX23129 | immune sera and immunoglobulins |
| RX23131 | mineral supplements |
| RX23133 | other nutrients |
| RX23134 | vaccines |
| RX23135 | vitamins |
| RX99136 | anesthetics general |
| RX99137 | anesthetics local |
| RX99138 | medical gas |