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Clinical Classifications Software for Services and Procedures
The Clinical Classifications Software for Services and Procedures is one in a family of databases and software tools developed as part of the Healthcare Cost and Utilization Project (HCUP), a Federal-State-Industry partnership sponsored by the Agency for Healthcare Research and Quality.
 
 
Clinical Classifications Software for Services and Procedures

The Clinical Classifications Software for Services and Procedures (CCS-Services and Procedures) is one in a family of databases and software tools developed as part of the Healthcare Cost and Utilization Project (HCUP), a Federal-State-Industry partnership sponsored by the Agency for Healthcare Research and Quality. HCUP databases, tools, and software inform decision making at the national, State, and community levels.

The CCS-Services and Procedures is being made available for users who would like to apply the CCS procedure categories to their CPT/HCPCS-based data. We look forward to your comments and suggestions for changes and improvements.

Contents:

CCS-Services and Procedures provides a method for classifying Current Procedural Terminology (CPT®) codes and Healthcare Common Procedure Coding System (HCPCS) codes into clinically meaningful procedure categories. CPT is a proprietary coding system developed by the American Medical Association (AMA) for coding services provided by health care professionals. CPT is also referred to as HCPCS Level I. HCPCS (also referred to as HCPCS Level II) is a supplementary coding system developed by the Centers for Medicare and Medicaid Services (CMS) to account for supplies and services not accounted for in CPT (HCPCS Level I). The procedure categories are identical to the CCS with the addition of specific categories unique to the professional service and supply codes in CPT/HCPCS. CCS-Services and Procedures is current as of 2013 and can be used with any data that include CPT or HCPCS procedure information.

More than 9,000 CPT/HCPCS codes and 6,000 HCPCS codes are collapsed into 244 clinically meaningful categories that may be more useful for presenting descriptive statistics than are individual CPT or HCPCS codes. For example, CCS-Services and Procedures can be used to identify populations for procedure-specific studies or to develop statistical reports providing information (such as charges and length of stay) about relatively specific procedures.

For a list of CCS-Services and Procedures procedure categories, see Table 1.
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The five-character codes included in the Clinical Classifications Software for Services and Procedures are obtained from the Current Procedural Terminology (CPT®), copyright 2013 by the American Medical Association (AMA). CPT is developed by the AMA as a listing of descriptive terms and five–character identifying codes and modifiers for reporting medical services and procedures performed by physicians.

The responsibility for the content of Clinical Classifications Software for Services and Procedures is with the U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality (AHRQ) and no endorsement by the AMA is intended or should be implied. The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in Clinical Classifications Software for Services and Procedures. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. Any use of CPT outside Clinical Classifications Software for Services and Procedures should refer to the most current Current Procedural Terminology which contains the complete and most current listing of CPT codes and descriptive terms. Applicable FARS/DFARS apply.

CPT is a registered trademark of the American Medical Association.

Five character codes in the Clinical Classifications Software for Services and Procedures are also obtained from the Healthcare Common Procedure Coding System (HCPCS).

This tool includes CPT and HCPCS five-character codes. Descriptive terms for individual CPT codes are not included because CPT codes are proprietary; descriptions of individual HCPCS codes are not included as well. Any use of CPT outside CCS-Services and Procedures should refer to the most current (CPT) which contains the complete and most current listings of CPT descriptive terms and five-character identifying codes and modifiers for reporting medical services and procedures.

Certain CPT and HCPCS codes are used to code performance measurement and Medicare-approved demonstration projects; these codes are not included in the CCS-Services and Procedures. For example, a series of HCPCS codes (G8006-G9140) are used to provide information on assessments done for a Medicare-approved demonstration project on patient-reported nausea or vomiting associated with chemotherapy, and are excluded from this classification. The CPT-4 Category II codes are also excluded 0001F-6020F.

Some CCS categories do not include CPT codes because no exact matches were found for these procedures. These categories include 133 (Episiotomy) and 136 (Artificial rupture of membranes to assist delivery).

No fee schedules, basic unit values, relative value guides, conversion factors, or scales are included in any part of CPT or CCS-Services and Procedures.
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The CCS-Services and Procedures consists of one translation table in Comma Separated Values (CSV) File format that creates CCS categories for data sets that contain CPT or HCPCS information. How the translation file is used will depend on the software system being used. For example, if SAS is employed, the translation table could be adapted to create a SAS PROC FORMAT. If SPSS is used, the translation table could be adapted into VALUE LABELS or into a series of recodes.
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The Clinical Classifications Software (CCS) is a tool for clustering patient diagnoses and procedures into a manageable number of clinically meaningful categories, developed at the Agency for Healthcare Research and Quality (AHRQ).

The CCS-Services and Procedures aggregates CPT and HCPCS codes into 244 mutually exclusive categories. Many of the categories represent unique procedure types. Some procedures that occur infrequently are grouped according to body system. Body system categories are further delineated as diagnostic or therapeutic and whether they are considered operating room or non-operating room procedures, according to Diagnosis Related Groups definitions.

The CCS-Services and Procedures contains CPT codes valid at any time between January 1992 and January 2013 and HCPCS codes valid at any time between January 2002 and January 2013.

Process for Assigning CCS Categories to CPT/HCPCS Codes

Two certified clinical coding specialists assigned CPT/HCPCS codes to CCS categories. These assignments were then reviewed by AHRQ staff possessing clinical and administrative data experience. One clinical coding specialist identified the initial assignments, while the second provided assistance with decision making and overall review of the assignments made.

The following iterative process was used to assign CPT/HCPCS codes to CCS categories:
  • Each CPT/HCPCS code was entered into Encoder Pro Professional© (a software application from Ingenix, Inc.)
  • The CPT/HCPCS Crosscoder within the software was used to identify any and all ICD-9-CM procedure codes that might be comparable to the CPT/HCPCS code.
  • Each ICD-9-CM code in the original CCS software was analyzed, in order to understand how the ICD-9-CM codes had been assigned to CCS categories.
  • If there were multiple CCS categories for the comparable ICD-9-CM codes, one that best fits the description of the CPT/HCPCS code was chosen.
  • If there was not one best category, the second coding specialist was consulted to make the determination.
  • Assignments were reviewed by AHRQ staff; questions about assignments were raised.
  • CPT/HCPCS code assignments were reviewed by the coding specialists and reassignments were made.
  • A final review was conducted by AHRQ staff.

Guidelines for Assigning CCS Categories to CPT/HCPCS Codes

In the course of assigning CPT/HCPCS codes to CCS categories, a series of guidelines were developed to ensure consistent code assignments:
  • If the code included two OR procedures, the one that would result in the greatest morbidity, extent of surgery, or resource use took precedence.


  • Examples:

    CPT 43305 Esophagoplasty (plastic repair or reconstruction), cervical approach; with repair of tracheoesophageal fistula.

      Assigned to CCS category

        94    Other OR upper GI therapeutic procedures

      not
        42    Other OR therapeutic procedures on respiratory system and mediastinum


      Because the repair of the esophagus would result in greater morbidity or resource use than the repair of the trachea fistula.

    CPT 31294 Nasal/sinus endoscopy, surgical; with optic nerve decompression

      Assigned to CCS category

        33    Other OR therapeutic procedures on nose, mouth and pharynx

      not
        9    Other OR therapeutic nervous system procedures


      Because the decompression of the nerve is not as great as the surgical procedure to gain entry to the sinus cavity.
  • When a CPT/HCPCS code could be assigned to a more specific category or to a more general category, we opted for the most specific.


  • Example:

    CPT 34451 Thrombectomy, direct or with catheter; vena cava, iliac, femoropopliteal vein, by abdominal and leg incision

      Assigned to CCS category

        60    Embolectomy and endarterectomy of lower limbs

      not
        61    Other OR procedures on vessels other than head and neck


      In a general sense, this procedure fits into CCS category 61; however, a more specific category is available for this procedure to remove a clot in the leg.
  • Codes were assigned to the body system associated with a physician´s specialty.


  • Example:

    CPT 33282 Implantation of patient-activated cardiac event recorder

      Assigned to CCS category

        62    Other diagnostic cardiovascular procedures

      not
        174    Other non-OR therapeutic procedures on skin and breast


      Although the procedure itself includes an incision and dissection down to the subcutaneous tissue to implant the recorder, a cardiologist will most likely be performing this procedure. This categorization scheme enhances agreement in studies that compare inpatient (ICD) and ambulatory surgery (CPT) data.
  • If a CPT/HCPCS code contained both diagnostic and therapeutic components, and the applicable CCS categories were split between these two types of services, the therapeutic aspect took precedence.


  • Examples:

    CPT 22830 Exploration of spinal fusion

      Assigned to CCS category

        161    Other OR therapeutic procedures on bone

      not
        159    Other diagnostic procedures on musculoskeletal system


      Although it may be diagnostic only, therapeutic repair is included in this code if defects are found and corrections are made.

    CPT 29838 Arthroscopy, elbow, surgical; debridement, extensive

      Assigned to CCS category

        162    Other OR therapeutic procedures on joints

      not
        149    Arthroscopy


      Because CCS categories do not allow for multiple assignments, the arthroscopy category is for minor or diagnostic codes only, and this code includes a therapeutic debridement.
  • If there were both operating room (OR) and non-operating room components, the OR category was chosen.


  • Examples:

    CPT 30110 Excision, nasal polyp(s), simple

      Assigned to CCS category

        33    Other OR therapeutic procedures on nose, mouth and pharynx

      not
        32    Other non-OR therapeutic procedures on nose, mouth and pharynx


      Although this is generally performed in the office, it is done in OR as well (e.g., with children or if the polyp is large). However, it is still done with a local anesthetic and may require packing during the first 24 hours.

    CPT 50392 Introduction of intracatheter or catheter into renal pelvis for drainage and/or injection, percutaneous

      Assigned to CCS category

        112    Other OR therapeutic procedures of urinary tract

      not
        111    Other non-OR therapeutic procedures of urinary tract


      This would be an OR procedure because the physician uses radiological guidance to advance the needle toward the renal pelvis.
  • If a CPT/HCPCS code included the phrase "with or without" a specific additional procedure, the code was mapped to the more general category rather than the specific category in order to reduce erroneous categorization of those records that did not include the additional procedure.


  • Example:

    CPT 54300 Plastic operation of penis for straightening of chordee (e.g., hypospadias), with or without mobilization of urethra

      Assigned to CCS category

        118    Other OR therapeutic procedures, male genital

      not
        109    Procedures on the urethra


      The male genital category is chosen because the urethra procedure may or may not take place.
New CCS Categories

The following new CCS categories were added to effectively represent codes specific to CPT and HCPCS.
  232 Anesthesia
  233 Laboratory - Chemistry and Hematology
  234 Pathology
  235 Other Lab
  236 Home Health Services
  237 Ancillary Services
  238 Infertility Services
  239 Transportation - patient, provider, equipment
  240 Medications (Injections, infusions and other forms)
  241 Visual aids and other optical supplies
  242 Hearing devices and audiology supplies
  243 DME and supplies
  244 Gastric bypass and volume reduction


  1. 232 Anesthesia: To capture the increased resource use of anesthesia administered by an anesthesiologist or surgeon. Examples include anesthesia for procedures on spine, perineum, and arthroscopic surgery.


  2. 233 Laboratory - Chemistry and Hematology: Chemistry testing of specimens (i.e., serum, blood, feces) by a physician or a technologist under physician supervision. Examples include basic metabolic panel, blood count, and pulse oximetry. This category is for chemistry and hematology only; all other labs were assigned CCS 235. (Note: Urinalysis tests can be found in CCS 206 Microscopic Exams and CCS 200 Urinary System Measurements.)


  3. 234 Pathology: Anatomic, cytopathology, and surgical pathology services provided by a physician or a technologist under physician supervision. Examples include clinical pathology consult, postmortem exam, Pap smear, and gross and microscopic surgical pathology.


  4. 235 Other Lab: Non-chemistry tests on specimens by a physician or a technologist under physician supervision. This category is used to capture labs outside CCS 233 Chemistry & Hematology. Examples include thyroid panel, drug assays, and antibody tests.


  5. 236 Home Health Services: For evaluation and management services provided in a private residence. Examples include home visits for respiratory therapy, chemotherapy, and counseling.


  6. 237 Ancillary Services: For services performed adjunct to a basic procedure or by an ancillary healthcare worker. Examples include transportation of specimens, medical testimony, and services by a dietitian.


  7. 238 Infertility Services: Includes codes for infertility care such as in vitro fertilization and ovulation induction.


  8. 239 Transportation: For emergency and non-emergency transportation of patients, medical staff, equipment, and tissue.


  9. 240 Medications: For the provision of medications, infusions, injections, and other pharmaceutical services.


  10. 241 Visual aids and other optical supplies: For all optical supplies including eye glasses, lenses, and prosthetics.


  11. 242 Hearing devices and audiology supplies: For supplies related to hearing such as ear molds and impressions, hearing aids, and batteries for hearing aids.


  12. 243 DME and supplies: A miscellaneous category for other forms of durable medical equipment and supplies including power sources and batteries, cables, injectable contrast materials, implantable devices, tissues for transplantations, joint replacement devices, non-ocular prostheses, compression stockings, orthotics, orthopedic devices, casting supplies, tape, continence supplies, wound care kits and supplies, dialysis equipment and solutions, ostomy supplies, catheters and stents, pacemakers and leads, and crutches.


  13. 244 Gastric bypass and volume reduction: For all procedures dealing with gastric bypass and volume reduction, primarily for the purpose of bariatric surgery. (To ensure that all codes relate to obesity surgery, this code should be used in conjunction with diagnosis codes for obesity.)
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Prior to downloading the CCS-Services and Procedures, users must agree to a license agreement with the AMA for using CPT codes.

Click here to access CCS-Services and Procedures

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Questions or comments regarding CCS-Services and Procedures may be directed to HCUP User Support through the following channels:
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1 Incision and excision of CNS
2 Insertion; replacement; or removal of extracranial ventricular shunt
3 Laminectomy; excision intervertebral disc
4 Diagnostic spinal tap
5 Insertion of catheter or spinal stimulator and injection into spinal canal
6 Decompression peripheral nerve
7 Other diagnostic nervous system procedures
8 Other non-OR or closed therapeutic nervous system procedures
9 Other OR therapeutic nervous system procedures
10 Thyroidectomy; partial or complete
11 Diagnostic endocrine procedures
12 Other therapeutic endocrine procedures
13 Corneal transplant
14 Glaucoma procedures
15 Lens and cataract procedures
16 Repair of retinal tear; detachment
17 Destruction of lesion of retina and choroid
18 Diagnostic procedures on eye
19 Other therapeutic procedures on eyelids; conjunctiva; cornea
20 Other intraocular therapeutic procedures
21 Other extraocular muscle and orbit therapeutic procedures
22 Tympanoplasty
23 Myringotomy
24 Mastoidectomy
25 Diagnostic procedures on ear
26 Other therapeutic ear procedures
27 Control of epistaxis
28 Plastic procedures on nose
29 Dental procedures
30 Tonsillectomy and/or adenoidectomy
31 Diagnostic procedures on nose; mouth and pharynx
32 Other non-OR therapeutic procedures on nose; mouth and pharynx
33 Other OR therapeutic procedures on nose; mouth and pharynx
34 Tracheostomy; temporary and permanent
35 Tracheoscopy and laryngoscopy with biopsy
36 Lobectomy or pneumonectomy
37 Diagnostic bronchoscopy and biopsy of bronchus
38 Other diagnostic procedures on lung and bronchus
39 Incision of pleura; thoracentesis; chest drainage
40 Other diagnostic procedures of respiratory tract and mediastinum
41 Other non-OR therapeutic procedures on respiratory system
42 Other OR therapeutic procedures on respiratory system and mediastinum
43 Heart valve procedures
44 Coronary artery bypass graft (CABG)
45 Percutaneous transluminal coronary angioplasty (PTCA)
46 Coronary thrombolysis
47 Diagnostic cardiac catheterization; coronary arteriography
48 Insertion; revision; replacement; removal of cardiac pacemaker or cardioverter/defibrill
49 Other OR heart procedures
50 Extracorporeal circulation auxiliary to open heart procedures
51 Endarterectomy; vessel of head and neck
52 Aortic resection; replacement or anastomosis
53 Varicose vein stripping; lower limb
54 Other vascular catheterization; not heart
55 Peripheral vascular bypass
56 Other vascular bypass and shunt; not heart
57 Creation; revision and removal of arteriovenous fistula or vessel-to-vessel cannula for
58 Hemodialysis
59 Other OR procedures on vessels of head and neck
60 Embolectomy and endarterectomy of lower limbs
61 Other OR procedures on vessels other than head and neck
62 Other diagnostic cardiovascular procedures
63 Other non-OR therapeutic cardiovascular procedures
64 Bone marrow transplant
65 Bone marrow biopsy
66 Procedures on spleen
67 Other therapeutic procedures; hemic and lymphatic system
68 Injection or ligation of esophageal varices
69 Esophageal dilatation
70 Upper gastrointestinal endoscopy; biopsy
71 Gastrostomy; temporary and permanent
72 Colostomy; temporary and permanent
73 Ileostomy and other enterostomy
74 Gastrectomy; partial and total
75 Small bowel resection
76 Colonoscopy and biopsy
77 Proctoscopy and anorectal biopsy
78 Colorectal resection
79 Local excision of large intestine lesion (not endoscopic)
80 Appendectomy
81 Hemorrhoid procedures
82 Endoscopic retrograde cannulation of pancreas (ERCP)
83 Biopsy of liver
84 Cholecystectomy and common duct exploration
85 Inguinal and femoral hernia repair
86 Other hernia repair
87 Laparoscopy (GI only)
88 Abdominal paracentesis
89 Exploratory laparotomy
90 Excision; lysis peritoneal adhesions
91 Peritoneal dialysis
92 Other bowel diagnostic procedures
93 Other non-OR upper GI therapeutic procedures
94 Other OR upper GI therapeutic procedures
95 Other non-OR lower GI therapeutic procedures
96 Other OR lower GI therapeutic procedures
97 Other gastrointestinal diagnostic procedures
98 Other non-OR gastrointestinal therapeutic procedures
99 Other OR gastrointestinal therapeutic procedures
100 Endoscopy and endoscopic biopsy of the urinary tract
101 Transurethral excision; drainage; or removal urinary obstruction
102 Ureteral catheterization
103 Nephrotomy and nephrostomy
104 Nephrectomy; partial or complete
105 Kidney transplant
106 Genitourinary incontinence procedures
107 Extracorporeal lithotripsy; urinary
108 Indwelling catheter
109 Procedures on the urethra
110 Other diagnostic procedures of urinary tract
111 Other non-OR therapeutic procedures of urinary tract
112 Other OR therapeutic procedures of urinary tract
113 Transurethral resection of prostate (TURP)
114 Open prostatectomy
115 Circumcision
116 Diagnostic procedures; male genital
117 Other non-OR therapeutic procedures; male genital
118 Other OR therapeutic procedures; male genital
119 Oophorectomy; unilateral and bilateral
120 Other operations on ovary
121 Ligation or occlusion of fallopian tubes
122 Removal of ectopic pregnancy
123 Other operations on fallopian tubes
124 Hysterectomy; abdominal and vaginal
125 Other excision of cervix and uterus
126 Abortion (termination of pregnancy)
127 Dilatation and curettage (D&C); aspiration after delivery or abortion
128 Diagnostic dilatation and curettage (D&C)
129 Repair of cystocele and rectocele; obliteration of vaginal vault
130 Other diagnostic procedures; female organs
131 Other non-OR therapeutic procedures; female organs
132 Other OR therapeutic procedures; female organs
133 Episiotomy
134 Cesarean section
135 Forceps; vacuum; and breech delivery
136 Artificial rupture of membranes to assist delivery
137 Other procedures to assist delivery
138 Diagnostic amniocentesis
139 Fetal monitoring
140 Repair of current obstetric laceration
141 Other therapeutic obstetrical procedures
142 Partial excision bone
143 Bunionectomy or repair of toe deformities
144 Treatment; facial fracture or dislocation
145 Treatment; fracture or dislocation of radius and ulna
146 Treatment; fracture or dislocation of hip and femur
147 Treatment; fracture or dislocation of lower extremity (other than hip or femur)
148 Other fracture and dislocation procedure
149 Arthroscopy
150 Division of joint capsule; ligament or cartilage
151 Excision of semilunar cartilage of knee
152 Arthroplasty knee
153 Hip replacement; total and partial
154 Arthroplasty other than hip or knee
155 Arthrocentesis
156 Injections and aspirations of muscles; tendons; bursa; joints and soft tissue
157 Amputation of lower extremity
158 Spinal fusion
159 Other diagnostic procedures on musculoskeletal system
160 Other therapeutic procedures on muscles and tendons
161 Other OR therapeutic procedures on bone
162 Other OR therapeutic procedures on joints
163 Other non-OR therapeutic procedures on musculoskeletal system
164 Other OR therapeutic procedures on musculoskeletal system
165 Breast biopsy and other diagnostic procedures on breast
166 Lumpectomy; quadrantectomy of breast
167 Mastectomy
168 Incision and drainage; skin and subcutaneous tissue
169 Debridement of wound; infection or burn
170 Excision of skin lesion
171 Suture of skin and subcutaneous tissue
172 Skin graft
173 Other diagnostic procedures on skin and subcutaneous tissue
174 Other non-OR therapeutic procedures on skin and breast
175 Other OR therapeutic procedures on skin and breast
176 Other organ transplantation
177 Computerized axial tomography (CT) scan head
178 CT scan chest
179 CT scan abdomen
180 Other CT scan
181 Myelogram
182 Mammography
183 Routine chest X-ray
184 Intraoperative cholangiogram
185 Upper gastrointestinal X-ray
186 Lower gastrointestinal X-ray
187 Intravenous pyelogram
188 Cerebral arteriogram
189 Contrast aortogram
190 Contrast arteriogram of femoral and lower extremity arteries
191 Arterio- or venogram (not heart and head)
192 Diagnostic ultrasound of head and neck
193 Diagnostic ultrasound of heart (echocardiogram)
194 Diagnostic ultrasound of gastrointestinal tract
195 Diagnostic ultrasound of urinary tract
196 Diagnostic ultrasound of abdomen or retroperitoneum
197 Other diagnostic ultrasound
198 Magnetic resonance imaging
199 Electroencephalogram (EEG)
200 Nonoperative urinary system measurements
201 Cardiac stress tests
202 Electrocardiogram
203 Electrographic cardiac monitoring
204 Swan-Ganz catheterization for monitoring
205 Arterial blood gases
206 Microscopic examination (bacterial smear; culture; toxicology)
207 Radioisotope bone scan
208 Radioisotope pulmonary scan
209 Radioisotope scan and function studies
210 Other radioisotope scan
211 Therapeutic radiology for cancer treatment
212 Diagnostic physical therapy
213 Physical therapy exercises; manipulation; and other procedures
214 Traction; splints; and other wound care
215 Other physical therapy and rehabilitation
216 Respiratory intubation and mechanical ventilation
217 Other respiratory therapy
218 Psychological and psychiatric evaluation and therapy
219 Alcohol and drug rehabilitation/detoxification
220 Ophthalmologic and otologic diagnosis and treatment
221 Nasogastric tube
222 Blood transfusion
223 Enteral and parenteral nutrition
224 Cancer chemotherapy
225 Conversion of cardiac rhythm
226 Other diagnostic radiology and related techniques
227 Other diagnostic procedures (interview; evaluation; consultation)
228 Prophylactic vaccinations and inoculations
229 Nonoperative removal of foreign body
230 Extracorporeal shock wave lithotripsy; other than urinary
231 Other therapeutic procedures
232 Anesthesia
233 Laboratory - Chemistry and hematology
234 Pathology
235 Other laboratory
236 Home health services
237 Ancillary services
238 Infertility Services
239 Transportation - patient, provider, equipment
240 Medications (Injections, infusions and other forms)
241 Visual aids and other optical supplies
242 Hearing devices and audiology supplies
243 DME and supplies
244 Gastric bypass and volume reduction
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CPT only copyright 2014 American Medical Association. All rights reserved.

Internet Citation: HCUP CCS-Services and Procedures. Healthcare Cost and Utilization Project (HCUP). February 2014. Agency for Healthcare Research and Quality, Rockville, MD. www.hcup-us.ahrq.gov//toolssoftware/ccs_svcsproc/ccssvcproc.jsp.
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