NCCT Procedure Volume Data Form



Complete this form if you received the NCCT mailing sent on April 16, 2012. When completing the form:

• Include all payer volume (Medicare, Medicaid, commercial, self-pay)for the previous 12 months

• Put “N/A” in the volume column if the procedure is not performed at your facility

• Return one form for each facility (do not combine facility data)

• Return the completed form by Tuesday, May 15, 2012

• Email the completed form to: PremeraNCCT@ or fax it to: 425-918-5185 Attn: PIMS

For questions about this form or NCCT, call Physician and Provider Relations at 800-722-4714, option 4.

Location name:      

Address:      

Tax ID:      

Contact name and phone number:      

|Inpatient Treatment Categories |MS-DRG |ICD 9 |Volume |

|Bariatric Surgery - Laparoscopic Gastric Bypass |621 | |      |

|Cardiac Angioplasty - w/ Drug Eluting Stent |247 | |      |

|Cardiac Defibrillator Implant w/o Cardiac Catheterization |227 | |      |

|Coronary Bypass (CABG) w/o Cardiac Catheterization |236 | |      |

|C-Section Delivery |766 + 795 | |      |

|Vaginal Delivery |775 + 795 | |      |

|Hip Replacement |470 |81.51, 81.52 |      |

|Hysterectomy |743 | |      |

|Knee Replacement |470 |81.54 |      |

|Laminectomy - Inpatient |491 | |      |

|Spinal Fusion (Anterior) |473 | |      |

|Spinal Fusion (Posterior) |460 | |      |

|Removal of Plaque Build-Up in the Major Neck (Carotid) Arteries |39 | |      |

|Revision of Total Hip or Total Knee Replacement |468 | |      |

|Removal of Prostate Gland and Surrounding Tissue |708 | |      |

|Partial or Total Removal of Thyroid Gland |627 | |      |

|Outpatient Treatment Categories |CPT Code |Volume |

|ACL Repair by Arthroscopy |29888 |      |

|Back Surgery - Laminectomy |63030, 63047 |       |

|Bariatric Surgery (Lap Band) |43770 |       |

|Bladder Repair For Incontinence (Sling) |57288 |      |

|Breast Biopsy Percutaneous w/Imaging |19102 |      |

|Breast Biopsy w/Device |19103 |      |

|Breast Lumpectomy |19301 |      |

|Bunionectomy |28296, 28292 |      |

|Hammertoe Correction |28285, 28270 |      |

|Carpal Tunnel |64721 |      |

|Cataract Removal |66984 |      |

|Dilation & Curettage - D&C |58120 |      |

|Hernia Inguinal Repair (Age 5+) |49505 |      |

|Knee Arthroscopy with Cartilage Repair |29877, 29880, 29881, 29882 |      |

|Laparoscopic Gall Bladder Removal |47562, 47563 |      |

|Laparoscopic Removal of Ovaries and/or Fallopian Tubes |58661 |      |

|Laparoscopic Tubal Block or Tubal Ligation |58671 |      |

|Left Heart Catheterization |93510, 93452, 93458, 93459 |      |

|Lithotripsy - Fragmenting of Kidney Stones |50590 |      |

|Nasal/Sinus - Corrective Surgery - Septoplasty |30520 |      |

|Nasal/Sinus - Endoscopy - Sinus Surgery |31255, 31237, 31256, 31267, 31276 |      |

|Shoulder Arthroscopy |29826, 29806, 29807, 29822, 29823, 29824 |      |

|Shoulder Arthroscopy with Rotator Cuff Repair |29827 |      |

|Tonsillectomy and/or Adenoidectomy, Under Age 12 |42820, 42825, 42830 |      |

|Tonsillectomy and Adenoidectomy, Over Age 12 |42821, 42826, 42831 |      |

|Tympanostomy and Myringotomy |69420, 69421, 69433, 69436 |      |

|Upper GI Endoscopy |43235 |      |

|Upper GI Endoscopy with Biopsy |43239 |      |

|Bronchoscopy |31622, 31623, 31624, 31625, 31628, 31629 |      |

|Urethra and Bladder Scope |52000 |      |

|Colonoscopy with Removal of Lesion(s) |45385, 45383, 45384 |      |

|Colonoscopy with Biopsy |45380 |       |

|Screening Colonoscopy |45378 |      |

|Hysteroscopy with Removal of Lesion(s) or Uterine Lining |58563 |      |

|Uterine Tissue Sample (Biopsy) |58558 |      |

|Repair of Umbilical Hernia (Age 5+) |49585 |      |

|Spinal Fusion of Neck - Front |22554 |      |

|Bladder Scope with Stent |52332 |      |

|Diagnostic Treatment Categories |CPT Code |Volume |

|CT Angiography, Abdomen w/o & w/ contrast |74175 |      |

|CT Angiography, Head w/o & w/ contrast |70496 |      |

|CT Angiography, Pelvis w/o & w/ contrast |72191 |      |

|Mammogram, Analog Unilateral |77055 (77051) |      |

|Mammogram, Analog Bilateral |77056 (77051) |      |

|Mammogram, Analog Bilateral 2 Views |77057 (77052) |      |

|Mammogram, Digital Screening Bilateral |G0202 (77052) |      |

|Mammogram, Digital Diagnostic Bilateral |G0204 (77051) |       |

|Mammogram, Digital Diagnostic Unilateral |G0206 (77051) |      |

|CT Scan Abdomen w/o contrast |74150 |      |

|CT Scan Abdomen w/ contrast |74160 |      |

|CT Scan Abdomen w/o & w/ contrast |74170 |      |

|CT Scan Head/Brain w/o contrast |70450 |      |

|CT Scan Head/Brain w/ contrast |70460 |      |

|CT Scan Head/Brain w/o & w/ contrast |70470 |      |

|CT Scan Pelvis w/o contrast |72192 |      |

|CT Scan Pelvis w/contrast |72193 |      |

|CT Scan Pelvis w/o & w/ contrast |72194 |      |

|MRI Brain w/o contrast |70551 |      |

|MRI Brain w/ contrast |70552 |      |

|MRI Brain w/o & w/ contrast |70553 |      |

|MRI Lumbar Spine w/ contrast |72149 |      |

|MRI Lumbar Spine w/o contrast |72148 |      |

|MRI Lumbar Spine w/o & w/ contrast |72158 |      |

|MRI Neck Spine w/ contrast |72142 |      |

|MRI Neck Spine w/o contrast |72141 |      |

|MRI Neck Spine w/o & w/ contrast |72156 |      |

|MRI Orbit/Face/Neck w/ contrast |70542 |      |

|MRI Orbit/Face/Neck w/o contrast |70540 |      |

|MRI Orbit/Face/Neck w/o & w/ contrast |70543 |      |

|MRI Spine w/o contrast |72146 |      |

|MRI Spine w/ contrast |72147 |      |

|MRI Spine w/o & w/ contrast |72157 |      |

|MRI Lower Limb w/o contrast |73718 |      |

|MRI Lower Limb w/ contrast |73719 |      |

|MRI Lower Limb w/o & w/ contrast |73720 |      |

|MRI Upper Limb (Other Than Joint) w/o contrast |73218 |      |

|MRI Upper Limb (Other Than Joint) w/ contrast |73219 |      |

|MRI Upper Limb (Other Than Joint) w/o contrast & w/contrast |73220 |      |

|MRI Lower Limb with Joint w/o contrast |73721 |      |

|MRI Lower Limb with Joint w/ contrast |73722 |      |

|MRI Lower Limb with Joint w/o & w/ contrast |73723 |      |

|CT Scan of Mouth, Jaw, and Neck w/o contrast |70486 |      |

|CT Scan of Mouth, Jaw, and Neck w/ contrast |70487 |      |

|CT Scan of Mouth, Jaw, and Neck w/o & w/ contrast |70488 |      |

|CT Scan Chest w/o contrast |71250 |      |

|CT Scan Chest w/ contrast |71260 |      |

|CT Scan Chest w/o & w/ contrast |71270 |      |

|CT Scan of Lumbar Lower Spine w/o contrast |72131 |      |

|CT Scan of Lumbar Lower Spine w/ contrast |72132 |      |

|CT Scan of Lumbar Lower Spine w/o & w/ contrast |72133 |      |

|Bone Density study of Spine or Pelvis |77080 |      |

|Ultrasound of Head and Neck (e.g. Thyroid, Parathyroid, Parotid) |76536 |      |

|Ultrasound of Breast(s) |76645 |      |

|Ultrasound of Abdomen |76700 |      |

|Ultrasound of Pelvis |76856 |      |

|Bone and Joint Scan of Whole Body |78306 |      |

|PET Scan Image from Skull base to Mid-Thigh |78815 |      |

|PET Scan Image of Whole Body |78816 |      |

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